Dental management of medically

compromised patients
 Syllabus of oral medicine II
 

1. Introduction to oral medicine 2

2. Dental management of the medically compromised patient
3. Pathophyiology of Hemostasis
4. Bleeding and Clotting Disorders
5. Salivary Gland Diseases and xerostomia
6. Temporomandibular Disorders
7. Orofacial Pain
8. Gingival lesions
9. Palatal lesions
10. Drugs in dentistry
11. HIV associated lesions
12. Premalignant lesions and Oropharyngeal Cancer
 
Learning resources
 
-Burket’s oral medicine -CAWSON’S Essentials of oral
Diagnosis and treatment 12th edition pathology and oral medicine 8th edition
 
:Systemic diseases include

Cardiovascular diseases .1
Respiratory diseases .2
liver diseases .3
Endocrine diseases .4
Renal diseases .5
Neurogenic diseases .6
Sexually transmitted diseases .7
Blood diseases .8
Pregnancy & breast feeding .9
COMMON CARDIOVASCULAR PROBLEMS SEEN IN
ADULTS

Ischemic Heart Disease -1

Hypertension .2
Congestive Heart Failure .3
Infective Endocarditis .4
 Ischemic heart disease
Caused mainly by Atherosclerosis of Coronary Artery
Cardiovascular Disease
Risk factor of Atherosclerosis
Smoking–
Hypertension–
Diabetes mellitus–

It includes
Angina pectoris–
Myocardial infarction–
Heart failure & Arrhythmia–
 ISCHEMIC HEART DISEASE
I- Angina Pectoris
Typical angina , Atypical angina Cardiovascular Disease
Stable Angina , Unstable angina
Heavy’, ‘tight’ or ‘gripping chest pain
Typically, central/retrosternal
Mild ache to most severe that provokes sweating and fear
Associated breathlessness

Antiplatelet therapy
Low-dose (75 mg) aspirin–
Clopidogrel (Plavix) (75 mg daily)–
:Anti-anginal drug treatment
Nitrates–
-Calcium channel blockers
β-blockers–
 Myocardial infarction (MI)
Patients have increased risk for : Reinfarctions , arrhythmias ,
Heart failure

Patients on medications such as:

Antiangina
Anti-platelets
Antihypertensive drugs
antiarrhythmia agents
 DENTAL MANAGEMENT OF PATIENTS
WITH ISCHEMIC HEART DISEASE

Patients with angina pectoris

unstable or progressive angina are not candidates for elective dental
care
:Stable angina
After consultations and extramessurments

– Patient with MI

Before 4-6 weeks after mycardial infarction

only emergency procedures in the hospital

After 6 months
All dental procedure and minor surgeries can be done safely
DENTAL MANAGEMENT IN PATIENTS WITH ISCHEMIC
HEART DISEASE
I- Consultation with physician Cardiovascular Disease
Taking medication as usual at the day of procedure -2

Nitroglycerine tablets sublingually before procedure -3

be ready to take in case chest pain develops
Premedication for anxious patients -4
)mg of diazepam the night before and 1-2 hours before treatment 5-10(

:If surgery is needed

Antiplatelet patient

Aspirin , plavix : local hemostatic measures

Anticoagulated patient → determine INR on the day of treatment

Chairside Management
Oxygen should be available
Brief visits (less than 30 minutes) -
- Nitroglycerine must be available
Avoiding early morning hours and late afternoon hours -
Periodic monitoring of vital signs -
Patient in semi-supine position -

Anesthesia -
There are no absolute contraindications to the use of vasoconstrictors in dental
anesthetics for cardiovascular patients , since epinephrine is an endogenously
produced

Injection given very slowly

Aspiration is a MUST
) not to inject into a blood vessel(

A maximum of two carpules with vasoconstrictor

If anesthetic reinforcement is needed: anesthesia without vasoconstrictor

Discontinuation procedure if patient become fatigue -

,If the patient develops chest pain during dental treatment
The procedure should STOP immediately
Cardiovascular Disease
Sublingual nitrite tablet

Oxygen

Take patients B.P and pulse

If the pain fails to subside after 5 minutes, GIVE a second sublingual tablet

If the pain fails to disappear 15 minutes , The patient must transfer to a hospital
center because acute myocardial infarction is suspected
 Cardiovascular Disease
Heart Failure
Heart failure is not a disease per se
Patients with heart failure are at increased risk for
Myocardial infarction (MI)
Arrhythmias
Sudden death

: Dental Management Considerations

Patient at Acute phase are not candidates for elective dental treatment

Patients in upright or at least semi-supine position

unable to tolerate a supine position

Vasoconstrictors should be avoided with patients on (digoxin) because the combination

can precipitate arrhythmia
HYPERTENTION
High Blood Pressure

Patients with hypertension (blood pressure greater than 140/90 mm Hg)

Normal blood pressure is 80/120
Well controlled hypertensive patients has no risk in clinical practice

:Uncontrolled hypertension
BP ≥160/100 mm Hg

.Elevated blood pressure can lead to excessive intra-operative bleeding

Risk of stroke
 Dental management
The patient must take medication as usual on the day of dental treatment
Blood pressure record
if high≥180/110, all procedures are contraindicated

Anxiety and stress protocol

Avoid long or stressful appointments
Dismiss patients if over stressed
Morning visits
A good local anesthetic technique
avoiding intravascular injection -
maximum of two anesthetic carpules with vasoconstrictors -

Avoid rapid posture changes that can leads to Orthostatic hypotension and
Syncope

Caution when using vasoconstrictors in patient taking a nonselective beta-

.blocker
Using gingival cord containing epinephrine is contraindicated
 Arrhythmias
:Conditions
Abnormal pulse rate or rhythm .1
Cardiac pacemaker .2

Elective dental care is not recommended in patients with serious,

symptomatic arrhythmias

: Dental Management Considerations

Consultation .1
Monitoring pulse before treatment .2
Stress reduction protocol .3
Local anesthesia without vasoconstrictor (↑ arryhthmia) .4
Avoid magnetic ultrasonic scaler in case of pacemaker .5
If arrhythmia develops during dental treatment

Stop the procedure

Oxygen

Assessing patient vital signs

body temperature , pulse ,respiratory frequency , blood pressure ( (

Sublingual nitrites If chest pain develop

The patient should be placed in the trendelenburg position

Be ready for basic cardiopulmonary resuscitation and initiation of the

emergency procedure
 Coronary Artery Bypass Graft/Angioplasty/Stent

: Dental Management Considerations

The same precautions for Angina pectoris

Patients with or without placement of a stent

do not require antibiotic Prophylaxis

Antiplatelets drugs
Anticoagulant drug management
monitor INR
Never withdrawal of anticoagulants (risk of thrombosis )(
 Artificial Heart Valve. & congenital Heart Disease

These patients have a high risk for bacterial endocarditis and require
antibiotic prophylaxis for most dental procedures

Patients with prosthetic Joint Replacement

In general, for patients with prosthetic joint implants, prophylactic
antibiotics are not recommended prior to dental procedures to prevent
.prosthetic joint infection

Increased risk for infection of the Prosthetic Joints prosthesis in:

Diabetic patients
Immuno-compromized patients
Patients on immunosuppressive medications
 Updated Guidelines of Antibiotic Prophylaxis 2017

American Heart Association and American College of Cardiology 2017

Endocarditis Prophylaxis Recommended-
Dental extractions .1

Periodontal procedures including surgery, subgingival scaling and root planing .2

Dental implant placement and re-implantation of avulsed teeth -3

Endodontic (root canal) instrumentation or surgery only beyond the apex -4

:Endocarditis Prophylaxis Not Recommended

Restorative dentistry .1
Local anesthetic injections .2
Intracanal endodontic treatment; post and core buildup .3
Placement of rubber dams .4
Postoperative suture removal .5
Taking of oral impressions .6
 Thalassemia & aplastic anemia
Dental management consideration
Postpone surgery if hg concentration is less than 10g/100ml
aplastic anemia: risk of bleeding and infection

Local haemostatic measures

Postoperative antibiotic cover to prevent postoperative
infection

Any invasive procedure in thalassemia patients should be done under

antibiotic cover and immediately after transfusion

Risk of Transmission of viral hepatitis in thalassemic

patients due to repeated transfusion
 Leukemia
: Patients may have
Anemia . neutropenia , Susceptible to infections -1
Thrombocytopenia , bleeding problems -2
Delayed healing -3
Side effect of using of chemotherapeutic agents -4

Dental management and dental examination before

Chemotherapy
Consultation with the oncologist
Elective treatment should be postponed until patient status stable
Dental treatment at this acute stage Directed to the emergency needs
Eliminate infection and trauma

Dental management after Chemotherapy

The most appropriate time after patients' blood counts have recovered, usually
just prior to their next course of chemotherapy
Epilepsy, Seizures, and Convulsions

: Dental Management Considerations

Medical Consultation -1
Postpone surgery until seizures are well controlled .2
Anticonvulsant Premedication .3
Stress reduction protocol .4
Avoid hypoglycemia .5
Avoid long procedures .6

In case of seizures

Stop the procedure and remove all instruments .1

Put patient in supine position .2
Place bite block or tongue blade between teeth .3
 Asthma
Dental Management Considerations
Consultation .1
Stress reduction protocol .2
anesthesia with adrenaline .3
Prophylaxis for adrenal insufficiency (patients taking steroid) .4
Bronchodilator inhaler should be available .5

:In more severe attack

i. Aminophyline 250 mg IV very slowly in the hospital only

ii. Hydrocortisone 100 mg IV very slowly
iii. Oxygen
 DRUGS TO BE AVOIDED IN ASTHMATIC
PATIENTS

Aspirin

Ibuprofen ,diclofenac sodium)) Nonsteroidal antiinflammatory drugs

NSAID

Erythromycine : Macrolide antibiotics

Opiates: Morphine,codaine

These can cause respiratory depression and histamine release

 Thyroid Disease
The use of vasoconstrictors is generally contraindicated in patients with
uncontrolled hyperthyroidism
In rare cases, infection or surgery can initiate a thyroid crisis—a serious medical
emergency

Patients with known hypothyroidism usually are taking a thyroid supplement

and generally pose minimal concern

local anesthetic and retraction cord with epinephrine should be used cautiously but not
contraindicated if patient stable and taking harmone replacement for long time
 Thyroid crisis
Definition serious medical emergency
Exacerbation of hyperthyroidism
Acute, life-threatening, hypermetabolic state
Thyroid storm may be the initial presentation of thyrotoxicosis
Mortality: 20-30%

Symptoms of Thyroid Storm

Increased body temperature
Tachycardia (rapid heart rate)
Heart palpitations
Management of thyroid crises
Heart failure Anti thyroid drugs .1
Pulmonary edema Hydrocortisone .2
Confusion I.V. glucose .3
Oxygen administration .4
Nausea/vomiting Cooling to decrease temp. of body .5
Frequent loose bowel movements
 Diabetes Endocrine Disease

Diabetes is a long-term condition that causes high blood sugar levels

Type 1 Diabetes, Type 2 Diabetes
Complications of diabetes include
Retinopathy , Hypertension ,kidney failure ,susceptible to infection
exaggerated periodontal disease

Hypoglycemia < 80 mg/dl may occur in the dental office due to stress :
severe hypoglycemia , < 60 mg/dl
Dental Management Considerations
Diabetic Patients

The DENTIST must be aware about : The type, severity of disease

If diabetes is controlled or not
Medication
Short morning appointments
Patient must take breakfast and his medication
Generally receive local anesthetics without special precautions
Source of glucose such as an orange juice must be available in the dental office
to avoid hypoglycemic attacks
Prophylactic antibiotics for patients to prevent post-operative infection
Surgery when blood sugar levels are within normal range
 Management of Insulin hypoglycemia
Golden Rule” is that manage the patients as if they are hypoglycemic until proven “
otherwise

: In mild cases
. life-threatening consequences ,occurs when blood glucose level drops below 60 mg/dL
:Symptoms
Confusion, sweating, tremors, agitation, anxiety, dizziness, tingling or numbness, and
tachycardia
Administration glucose source by sugar or juice orally

: In severe cases
Severe hypoglycemia may result in seizures or loss of consciousness
50ml ,50 % glucose IV
mg glucagon IV OR IM 1
 Adrenal Insufficiency
: Adrenal suppression can be caused by
Addison’s disease
Pituitary or Hypothalamic disease
Prolonged corticosteroid therapy

Adrenal cortical suppression should be suspected if patient Take (RULE OF

TWO)
mg or more of cortisone daily 20 .1
weeks or more 2 .2
within last 2 years .3
Dental management in patients on steroid therapy
Double or triple the dose day before surgery .1
Day of surgery .2
daysNopostoperatively 2 anesthetic
alteration of local .3 use is required for patients with adrenal
insufficiency
Reinstitute normal dose after that .4
 Pregnancy

Best time for the dental procedure is the 2nd trimester

Emergency treatment can be done at any time

Dental procedures harmful dental procedures for pregnant

:female including

Radiographs-1
Drug administration .2
Pain and stress .3
Supine hypotension in late pregnancy .4
: Dental Management Considerations

Consult the obstetrician .1

Short appointments .2

Avoid painful stimuli .3

Avoid placing the patient in supine position .4

Avoid radiographs .5
)used only after 1st trimester WITH necessary use lead apron

LA is more suitable than GA .6

Avoid drugs with teratogenic potential .7

 Paracetamol is the analgesic of choice for all stages

Common safe Antibiotics

Penicillin – Amoxicillin – Cephalexin (B) –Erythromycin, –

Clindamycin
Antibiotics to Avoid during Pregnancy

Doxycycline • Tetracycline • Vancomycin

avoid NSAID 3rd trimester

SAFE Local Anesthetic Use in Pregnancy

Lidocaine (Xylocaine)
Prilocaine
SUPINE HYPOTENSION SYNDROME (Vena Cava
Compression)
.Avoid supine position in late pregnancy

Supine hypotensive syndrome may occur due to obstruction of the

.vena cava and aorta

This may result in reduction in return cardiac blood supply with

decreased placental perfusion

this can be prevented by placing the patient on her left side or simply
by elevating the right hip 5 to 6 inches during treatment
 Liver diseases
:Impaired liver functions leads to

Abnormalities in metabolic processes , drug metabolism.1

Bleeding disorders (Abnormalities in coagulation) .2

Decrease clotting factors, excess fibrinolysis, impaired vitamin (

.)K absorption

Transmission of viral hepatitis .3

Dental management
.Medical consultation-
:Avoid drugs metabolized in liver-
Lidocaine, Mepicaine , Augmentin , Ampicillin ,paracetamol,
Aspirin

Pt , ptt, INR -
) Vit.k ----- 10 mg/day before surgery(

High infection control measures -

 Chronic renal failure
hemodialysis

: Dental Management Considerations

Medical Consultation
High incidence of hepatitis
High incidence of anemia

It is generally preferable to treat patients before rather than after dialysis

Heparin during hemodialysis

Prophylactic antibiotics

Least amount of LA

High infection control measures

 Chronic renal failure/hemodialysis

Avoid prescribing nephrotoxic drugs & drugs that are

excreted through the kidneys

Avoid NSAIDs, asprin

Gentamycin
Tetracyclines, streptomycin, Vancomycin, Acyclovir
antihistamines
Renal Transplant
: Dental Management Considerations
Medical Consultation
and immunosuppresive drugs patient on corticosteroids
Prophylactic antibiotics
High infection control measurement

Avoid nephrotoxic drugs

Erythromycin is contraindicated in patients on cyclosporins
 Malignancies And Cancer
:The main problems in dental treatment of patients with malignancies are

Bleeding tendency

Increased risk of infection

Risk of developing osteonecrosis of the jaw

Anemia

Secondary malignancies and metastasis