Dental considerations for management of medically compromised 2018

Atef fouda
Maxillofacial surgeon
Cairo university-Egypt.

is a medical condition of impaired kidney function in
which the kidney fail to adequately filter metabolic
wastes from the blood.
Renal failure
Decrease in glomerular filtration rate.
Decrease in or absence of urine production.
Increase of urea and creatinine in the blood.
Protein loss in the urine[Albumin].
Is a process for removing
waste and excess water
from the blood.
Dialysis

•Bleeding tendency,
•Hypertension,
•Anemia,
•Drug intolerance,
• Increased susceptibility to infections.
Dental considerations of the patients with chronic renal
disease.
The most important features in these patients are:

Dental management
Use haemostatic measures.
Measuring blood pressure before treatment.
Avoid prescription of many drugs or unnecessary medications.
Traumatic procedures should be covered with dose adjusted
antibiotics.
Avoid surgery at the day of dialysis [ anti-coagulant].Treat one day
after dialysis.
Consider routine serology for HBV-HCV and HIV.

Peptic ulcer
An ulcer in the stomach is known as a gastric ulcer while that in
the first part of the intestines is known as a duodenal ulcer.
Patients considerations:
•Presence of anemia.
•Antacids medications.
Dental considerations:
Avoid prescription of NSAIDs-Aspirin-Corticosteroids.
Use local haemostatic agents if abnormal bleeding encountered.

Liver
Cholecystectomy
Infective hepatitis.
 Liver cirrhosis.
Hepato-spleno-megaly.
Vitamin K deficiency.
Trans infection.
Drug biotransformation.
Anemia.
Esophageal varices.
Heart failure.
Liver cirrhosis
Hepato-spleno-megaly.
Esophageal varices

Dental management
Aseptic precautions to avoid trans-infection.
Limitations for uses of amide local anesthetics.
Guidelines for management of anemic patients applied.
Restrict use of medications.
Local hemostatic measures.
Avoid erythromycin antibiotic.
In cholecystectomy cases, Vit K supplementation required three
days before surgery.

Bronchial asthma
It is characterized by variable and recurring symptoms of broncho-spasm and
airflow obstruction.
Infection of the upper respiratory tract and stress can worsen the
disease.
Patients treated with inhalers, the inhaler should
be available during treatment visit.
Emergency oxygen in case of hypoxia.
Medications that can cause problems in
asthmatics are aspirin and NSAIDs.
Dental management
Asthma is a common long term inflammatory disease of the lungs.

First trimester
Pregnancy
Pregnancy is typically divided into three trimesters.
The first trimester carries the highest risk of
miscarriage (natural death of embryo or fetus). two-
thirds to three-quarters in various studies) occur during
the first trimester.

First trimester:
Painless, non stressful and atraumatic procedures.
Natural obtundents used for pain relief [eugenol].
Conservative treatment allowed
[scaling-cementation of restoration-impression taking….]
MRI-imaging.
Avoid
x-ray.
Prescription of any medications.
Use of local anesthesia.
Use of any topical dental pharmaceuticals.
[as formocresol, arsenic preparations, topical anesthesia,….etc.]
Allowed
Dental management for pregnant women:

Pregnancy
Second trimester
At this period the fetus condition is stable and most of
the organs are completely formed .
At 28 weeks, more than 90% of babies can survive
outside of the uterus if provided high-quality medical
care.

Second trimester:
Use of local anesthesia with vasoconstrictors.
Painless, non stressful and atraumatic procedures.
Conservative treatment allowed. [root canal-fillings-fixed prosth.]
MRI-imaging.
X-ray using lead shield.
Alcohol free mouthwashes.
Avoid
Use of any toxic dental pharmaceuticals.
Elective long stressful procedures[Impaction odontectomy].
Allowed

Pregnancy
Third trimester
At this period the susceptibility for premature labor increased.

Third trimester:
Use of local anesthesia without vasoconstrictors.
Painless, non stressful, short and atraumatic procedures.
Alcohol free mouthwashes.
Conservative treatment allowed. [root canal-fillings-fixed prosth.]
MRI-imaging.
X-ray using lead shield.
Short duration appointments are better than long visits.
Semi-reclining position preferred.
Avoid
Use of any toxic dental pharmaceuticals.
Elective long stressful procedures[Impaction odontectomy].
Allowed

Avoid dental procedures [even in second trimester]in case of:
1. First time pregnancy.
2. Previous history for miscarriage.
3. Previous history of premature birth.
4. IVF [In vitro fertilization]
5. Artificial insemination.
6. Eclampsia.
7. Women over the age of thirty five.
8. Women who have previously had premature babies or babies
with a birth defect, especially heart or genetic problems
9. Women who have high blood pressure, lupus, diabetes,
asthma, or epilepsy.
10. Women who are pregnant with twins or more.
High risk pregnant women

Gestational diabetes
A woman without diabetes , develops high blood sugar levels
during pregnancy.
Increased insulin resistance.
Etiology
Risk
Requiring a caesarean section.
Babies born to mothers with poorly treated gestational diabetes are at
increased risk of being , having macrosomia , and jaundice.
If untreated, it can result in a stillbirth [fetal death].
Most women with gestational diabetes is treated with a diet, exercise,
and possibly insulin injections.
Dental management:
Combination between management of pregnancy and diabetes
according to the case.

Dental management for lactating women:
Contra-indicated
Tetracyclines
Radiopharmaceuticals [ dye for C.T scan].
Salicylates [aspirin].
Atropine.
Metronidazole [flagyl].
Indicated but with caution
Paracetamol
Antihistamines
Muscle relaxants.
Corticosteroids.
Quinolons [Cefatriaxone]
Vitamines.
Anesthetics

Chemotherapeutic agents:
Most of them causes nausea and vomiting.
Most of them causes alopecia.
Most of them causes bone marrow suppression.
Commonly used in combination [protocol].
The doses widely varied according to the disease, stage, age, …..etc.
Is a category of cancer treatment drugs. It is a non-specific
intracellular poisons , especially related to inhibiting the process of
cell division [mitosis].
The most common side-effects of chemotherapy is decreased
production of blood cells, hence also [immunosuppression].
Infection.
Bleeding tendency.
Impaired healing.
Risk

Dental management of patients under chemotherapy .
1-Antibiotic coverage for any surgical procedure
starting the day of operation and continue for ten days
post-operative.
2-Massive bone trauma or infection may lead to bone
necrosis and sequestration which is difficult to treat.
3-Bleeding should be controlled by using local
hemostatic measure.
4-Avoid use of NSAIDs to avoid peptic ulcer.

The use of ionizing radiation as part of cancer treatment.
The amount of radiation used in photon radiation therapy is measured
in gray.
solid epithelial tumor requires ranges from 60 to 80 Gy. Preventive
(adjuvant) doses are typically around 45–60 Gy in 1.8–2 Gy fractions
(for head, and neck cancers.)
Tumor cells that are hypoxic (and therefore more radio-resistant) may
re-oxygenate between fractions, improving the tumor cell kill.
Radiation therapy or radiotherapy

Fractionation schedule for adults is 1.8 to 2 Gy per day, five days a
week. In some cancer types, prolongation of the fraction schedule
over too long can allow for the tumor to begin repopulating.
Fractionation
The total dose is fractionated (spread out over time) for several
important reasons.
Fractionation allows normal cells time to recover, while tumor cells
are generally less efficient in repair between fractions.
Fractionation also allows tumor cells that were in a relatively radio-
resistant phase of the cell cycle during one treatment to cycle into a
sensitive phase of the cycle before the next fraction is given.

Risk of Radiation therapy or radiotherapy
Nausea and vomiting.
Damage to the epithelial surfaces.
Mouth, throat and stomach sores.
Swelling related to the irradiated area.
Fibrosis.
Dryness of mouth [Xerostomia].
Osteo-radio-necrosis.

x-rays to treat cancer, beginning in 1896.

2DXRT mainly consists of a single beam of
radiation delivered to the patient from
several directions: often front or back, and
both sides.

Volumetric modulated arc therapy
(VMAT)

Intensity modulated radiotherapy (IMRT)

Brachytherapy (sealed source
radiotherapy)-2005

Risk of dental extraction
Collagen lysis
Induced cellular death
Late tissue repair.
Delayed wound healing.
Prolonged alveolar
bone exposure.
Infection
Osteoradionecrosis.

Is a non-healing, non-septic lesion of bone in which bone
volume and density cannot be maintained by the hypocellular,
hypovascular, hypoxic tissue , which cannot adequately meet its
metabolic demands.
Grossly carious, periodontally hopeless or those teeth
deemed to have poor prognosis for retention beyond twelve
months should be removed prior to the initiation of
radiotherapy.
Osteoradionecrosis [ORN]
26% due to dental extraction.
Prophylaxis[before start of radiotherapy].
Pre-radiation extraction
[at least 10 days before radiation best one month.]

Dental considerations of patients under radiotherapy .
1-Antibiotic coverage for any surgical procedure starting the
day of operation and continue for ten days post-operative.
2-Conservative treatment is preferred than surgical approaches.
3-Massive bone trauma or infection may lead to bone necrosis
and sequestration [Osteo-Radio Necrosis-ORN] which is
difficult to treat.
4-Xerostomia complicate the post-operative course, try to
restore salivary secretion by oral fluids or sialogogues.
[Pilocarpine-chewing gum-ginger]

1-Antibiotic prophylaxis the first dose just before extraction and
continued until wound healing.
2-Alcohol free 0.2% chlorhexidine gluconate mouth wash
recommended before and after extraction.
3-Use of adrenaline free local anesthesia.
4-Minimal trauma during procedure with limited alveoloplasty and
primary wound closure [suturing].
5-After extraction or surgery. Hyperbaric oxygen therapy[HBOT]
prophylaxis protocol.
Surgical management for patients undergo radiation therapy:
Patients at risk of ORN.
Explain condition to the patient.
The same protocol applied to patients undergo post radiation
extraction [within one year].

Consists of 20 sessions, of 90 minutes each, breathing 100%
humidified oxygen at 2.4 atm. absolute pressure, 10 sessions given
before surgery and 10 similar sessions after surgery.
Extractions performed using elevators and forceps under local or
general anesthesia.
Atraumatic procedure.
HBO prophylaxis protocol
[increase oxygen diffusion into tissues , enhance re-vascularisation, limits amount of
nonviable tissues.
Alveoloplasty routinely performed to achieve a
primary mucosal closure with minimal
periostieum reflection.
HBO

Depression is a state of low mood and aversion to activity that can
affect a person's thoughts, behaviour, feelings, and sense of well-
being.
Therapies associated with depression include:
Interferon.
Beta-blockers.
Monoamine oxidase inhibitors (MAOIs) .
Depression

Dental considerations for patients with Depression
Local anesthesia with epinephrine, or norepinephrine if required
must be administered at much lower doses due to potentiation and
prolonged effect of vasoconstrictor.
Patients taking MAOIs develops hypertensive crisis, which
can be fatal.
Psychiatrist consultation prior to any dental treatment for
Patients taking “phenelzine”.
Patients on interferon should be covered with post-operative
antibiotic.

Multiple sclerosis (MS) is a demyelinated disease in which the
insulating covers of nerve cells in the brain and spinal cord are
damaged. This damage disrupts the ability of parts of the nervous
system to communicate, resulting in a range of signs and symptoms,
including physical and mental problems.
Treatment includes:
High doses of corticosteroids.
Interferon.
Multiple sclerosis (MS)

Dental considerations for patients with MS.
Local anesthesia with epinephrine, or norepinephrine if required
must be administered at much lower doses due to potentiation and
prolonged effect of vasoconstrictor.
Patients on interferon should be covered with post-operative
antibiotic.
Use a non-epinephrine anesthesia [plain]. Specific attention should
be paid to heart rate during the procedure.
Patients on corticosteroids should be managed according to
the protocol of corticosteroids.

Epilepsy
Epilepsy is a group of neurological
disease characterized by seizures. Epileptic
seizures are episodes that can vary from brief
and nearly undetectable to long periods of
vigorous shaking.
These episodes can result in physical injuries
including occasionally teeth fracture or tongue
trauma sometimes fractures.

Putting a bite block or tongue depressor in the mouth is not
recommended as it might make the patient vomit.
If a seizure lasts longer than 5 minutes or if there are more than
two seizures in an hour without a return to a normal level of
consciousness between them, it is considered a medical
emergency known as status epilepticus.
Convulsive status epilepticus that does not respond to initial
treatment typically requires admission to the intensive care unit.
Avoidance therapy consists of minimizing or eliminating triggers.
For example, in those who are aware from dental instruments or
equipments , using a small television, or wearing dark glasses may
be useful.
Dental considerations for patients with epilepsy.

Autism is a neuro-developmental disorder characterized by
impaired social interaction, verbal and non-verbal communication
and restricted and repetitive behavior.
Anxiety disorders
Risk of epilepsy
Autism
Dental considerations for Autism:
Child with impaired communication and general anesthesia
required for treating such cases.

diabetes, is a metabolic disease in
which there are high blood sugar levels
over a prolonged period.
Definition:

Increase in Blood
glucose level due to
cell receptor resistance
InsulinGlucagonGlucagon
Increase in Blood
glucose level due to
insulin insufficiency
Increase in Blood
glucose level
Due to
absence of insulin
InsulinGlucagon Insulin
Type IIType I
Diabetes

Gate is a cellular component that
permit passage of specific
substances when stimulated
from the intra-cellular part.
Insulin receptor
When triggered by
insulin a series of
intra-cellular
processes initiated
and ended by gate
opening.
HumanCell Glucose
Insulin hormone

Glucose
5-Concentration inside = Outside
1-Insulin activate the cell receptor
3-Cell membrane gate open
4-Glucose enter the cell
Insulin
6-Cell membrane gate closed
HumanCell
2- cell receptor send intra-
cellular signal to the cell
membrane gate to open

Gate
Insulin
receptor
Insulin resistance.
Result from alteration of receptor
binding of insulin and subsequent
reduction of trans‐membrane
glucose transport.
HumanCell

External insulin
B cell stimulation
Decrease cell receptor
resistance.
decrease the rate at
which glucose is
absorbed from the
gastrointestinal tract.
Types of diabetes
Type I Type II
Diet(1)
(2)
(3)

External insulin
Management of diabetes
Insulin dose is adjusted to replace the
pancreatic secretion.
A Mix between rapid acting and long
acting insulin usually used.
Absence of insulin secretion.
Diabetes type I

B cell stimulation
Management of diabetes
Diet(1)
(2)
(3)
Decrease carbohydrates and
sugar intake require less
insulin.
Stimulation of β–cells increase
the amount of insulin secreted
by pancreas.”Daonil-amaryl”
Decrease the rate at which
glucose is absorbed from the
gastrointestinal tract.”Glucobay”
Modifying pancreatic secretion.
Diabetes type II
Inhibition of glucose
absorption from GIT

Oral hypo-glycaemic agents “metformin*” do not affect
the insulin output.
Mainly used inType II diabetes to increase insulin
sensitivity that resulting in reduced plasma glucose
concentrations by increased glucose uptake by cells.
Could be used inType I diabetes in conjunction with
insulin therapy.
Decrease cell receptor resistance
Diabetes type II
*Cidophage-Glucophage”.

Diabetes type II
Diet control
Yes Yes
No Yes
N.S
Management of controlled diabetic patients
Dental treatmentMedication RiskMeal
No

Diabetes type II
Yes
Dental treatmentMedication
Yes
No
Inhibition of glucose
absorption from GIT
Yes
Yes Yes after sugar intake
No No Yes after sugar intake
No Yes Yes
Risk
Slight elevation in
BGL
Hypoglycemia
Hypoglycemia
No
Meal

Diabetes type II
Medications for
β–cells
stimulation*
Dental treatmentMedication Meal
Yes Yes Yes
No Yes Yes
NoYes
No No
Yes after sugar intake
Risk
No
Slight elevation
in BGL
Hypoglycemia
Hypoglycemia

Yes Yes
No
Medication Meal Dental treatment
Yes
Yes Yes
YesNo
No No
Risk
Slight elevation
in BGL
No
No
Slight elevation
in BGL
Yes
Yes
Diabetes type II
Decrease cell receptor
resistance*
*Metformin.

Yes
Medication
Yes
No
No
No
Meal
Yes
Yes
No
Risk
Hyperglycemia
Hypoglycemia
No
Diabetic coma
Yes
Dental treatment
No
No
Diabetes type I
External substitution.
*insulin.

Hypoglycemia in controlled Diabetic patients:
Decrease food intake.
Agitated, sweaty, weakness
Altered consciousness or even lost in extreme cases, leading to
coma, seizures or even brain damage and death.
Increase external insulin dose. [Medication error]
Etiology:
Increase blood glucose consumption [Exercise].
Manifestations:
blood glucose
levels >65 mg/dL

Intake of sugary drinks or food.
Management
glucagon is used when there is stored liver glycogen [as a
glucose source].
in the absence of such stores, glucagon is largely ineffective.
intravenous dextrose is often used when patient unconscious.
Hypoglycemia in controlled Diabetic patients:
N.B.

Stress The ‘stress response’ to surgery
increased secretion of catecholamines, cortisol [Catabolic hormones]
Glycogenolysis
Hyperglycemia in Diabetic patients:
Hyperglycaemia [internal source]
Increase insulin consumptionDecrease insulin level in blood
Glycogen glucose
Etiology: blood glucose levels <300 mg/dl

Fat.
Diabeticketoacidosis[DKA]
ketone bodies
blood's pH
fatty acids
Etiology:
Low insulin levels in blood
Common in “type I” Diabetes
+

Odor of acetone.
Dehydrated.
Electrolyte imbalances.
Glucosurea.
Breathing rapidly and deeply.
Abdominal pain.
Hypotension, shock.
The level of consciousness decrease and progress to coma and death.
Type I < type 2
1-Hospitalization.
2-Monitoring Blood Glucose Level.
3-Insulin.
4-Fluid replacement.
5-Electrolyte balancing.
Management
Manifestations:

Diabetic coma
Severe diabetic hypoglycemia
Severe hyperglycemia, dehydration are
sufficient to cause unconsciousness.
It is frequently precipitated by infection and is
commonly associated with multi‐organ system
dysfunction. Blood glucose concentrations may
be extremely high <600mg/dL.
Hyperosmolar hyperglycemic state (HHS) “ type 2 < type 1 “

Intravenous fluids.
Electrolyte replacement.
Insulin
Plasma glucose level >600 mg/dL
Profound dehydration.
Serum pH >7.30 *
Neurologic signs including sensory or motor
impairments ;seizures, flaccidity, depressed
reflexes, tremors
Hyper viscosity and increased risk of blood clot
formation.
Absence of ketone bodies. *
Signs and symptoms
Management

Chronic complications of diabetes:
Microangiopathy:
Skin ulcers, diabetic foot and gangrene.
Cardiac myopathy :
heart failure.
Nephropathy :
Renal failure.
Neuropathy: sensation impairment and autonomic dysfunction
Retinopathy:
retinal diseases and blindness
Macro vascular:
atherosclerosis and stroke
Myopathy:
muscle fatigue and weakness
Impaired immune response :
respiratory infection and periodontal diseases.
Most of complications is due to macro or micro-angiopathy
Chronic complications of diabetes:

Impaired healing due to:
1-Increase chance for infection [impaired immunity].
2-decrease blood flow [atherosclerosis].
3-decrease regeneration power[decrease blood supply].
Less traumatic procedure.
Post op antibiotic.
General considerations in treatment of diabetic patients

*identify the three-month average plasma glucose concentration.
*

Diabetes insipidus:
Poly urea.
Thirsty with High water intake.
Electrolyte imbalance.
May be confused with diabetes because
some signs and symptoms resemble
diabetes mellitus.

The thyroid gland secretes thyroid
hormones.
The thyroid hormones T3 andT4 are
synthesized from iodine and tyrosin .
Hormonal output from the thyroid is
regulated byThyroid Stimulating
Hormone (TSH) secreted from the pituitary
gland.
TSH
T3 andT4
T3 is 3-5 times potent thanT4.
T4 hormone is transferred by plasma proteins
to be utilized by cells for metabolic processes

The thyroid hormones act on nearly every cell
in the body. They act to increase:
The basal metabolic rate
Neural maturation
Bone growth.
Body sensitivity to catecholamines.
Body temperature.
Thyroid hormones

Hyperthyroidism occurs when the gland
produces excessive amounts of thyroid
hormones [Thyrotoxicosis –Toxic goiter].
is a state of insufficient thyroid hormone
production.Worldwide, the most common cause
is due to iodine deficiency.
Hyperthyroidism
Hypothyroidism
Disturbance of thyroid hormones

Estimation of the patient condition
History taking
Hyperthyroidism
Hypothyroidism
Controlled hyperthyroidism*.
Total thyroidectomy [ Absence of parathyroid gland]
Partial thyroidectomy [ Parathyroid gland intact]
Controlled hypothyroidism**
**Eltroxin= Thyroxin =T4
1
2
3
4
5
6
* Carbimazole

Thyroid gland
ThyroxinT4
Bound to plasma protein
cell
T3+tyrosin
Pituitary gland
TSH 2.0 µIU/mL
T3
T4
T3
TSH

Potentiates the effects of catecholamines
(i.e. increases sympathetic activity)
Increases cardiac output.
Increases heart rate
Increases ventilation rate
Increases basal metabolic rate.
Potentiates brain development
Increases metabolism of proteins and carbohydrates
(i.e. they have a catabolic action)
Effects of tri-iodo-thyronine (T3) :

Thyroid storm is a severe form of thyrotoxicosis characterized by
Rapid and often irregular heart beat.
High temperature.
Vomiting.
Mental agitation.
It is a medical emergency and requires hospital care to control the
symptoms rapidly. Even with treatment, death occurs in 20% to
50%.
Beta blockers. [propranolol].
Thyroid storm
Management

Dental management for patients with hyperthyroidism

Parathyroid gland
Small four glands behind the thyroid gland that produce
para-thyroid hormone [PTH]
Importance
Controls Blood calcium level through:
Increases gastrointestinal absorption of vit D
Increases blood calcium levels through
osteoclastic activity of bone.
Increase renal reabsorption of calcium.

Dental management for patients with hypopararthyroidism
Due to calcium disturbance that may
cause cardiac arrhythmia, be sure that
the patient haven’t any signs or
symptoms of cardiac problem.
If you suspect heart beat abnormalities
check for calcium level through
laboratory investigations.
The condition faced in patients with total thyroidectomy

Normal body cortisol* secretion is about 30 mg/day.The normal
rise in plasma adrenocorticotropic hormone (ACTH) and hence
cortisol is in response to the severity of stress.
The adrenal glands are capable of secreting 150 mg of cortisol/day
in response to stress or major surgery.
The normal rise in cortisol secretion after surgery lasts
for about three days.
*Cortisol=same dose of hydrocortisone

also known
as suprarenal glands
Pre-operative considerations
The degree of adrenal suppression
depends on the dose and duration of
steroid treatment.
Establish how much steroid has been
taken and for how long.

also known
as suprarenal glands
Dosages of less than 5 mg prednisolone per day
are not significant and no steroid cover is
required.
10 mg/day or more of prednisolone (or
equivalent) is generally taken as the threshold
dose for 'steroid cover.

Steroid cover is required if taken within
the last three months of the surgery.
This is because adrenal suppression can
occur after only a week and may take as
long as three months to recover.

Patients on corticosteroids at a dose of 10 mg daily or more of
prednisolone (or equivalent*) within the three months preceding
surgery.
who should receive external steroid cover for surgery
*Patients who stopped their steroids more than three
months ago or who are taking 5 mg or less require no
steroid cover.

Protocol for steroid coverage in maxillofacial field for
patients with adrenal insufficiency.
25 mg* hydrocortisone pre-operative and then
resume normal medication postoperatively.
Minor surgery
N.B: Usual treatment dose of steroids should be continued.

25 mg of hydrocortisone Pre-operative.
followed by 25 mg every 8 hours for 24
hours.[total 100-125 mg].
Moderate surgery

50 mg of hydrocortisone Pre-operative followed
by 50 mg every 8 hours for 48-72 hours.
Major surgery
.[total 150mg/day for 2-3 days]

patients receiving <10 mg of prednisolone or
equivalent [>40 mg hydrocortisone ]do not need steroid
cover but should continue with their usual
treatment steroid dosage.
Patients on long-term steroids do not require
supplementary steroid cover for routine dentistry
procedures under local anaesthesia [see protocol].
Infusion is now preferred to bolus dose.
(this avoids excessive doses of steroid with
possible complications).
Remember

Single dose is considered with no harm [even high dose]and can
be used .
Always complications of steroids are related to duration of
therapy.
Abrupt cessation of prolonged high dose leads to adrenal
insufficiency crisis and contra-indicated.
Infection, severe trauma and stress require increase in steroid
demands.
Facts about steroid treatment
In recent years, doses used for steroid cover have been reduced. This is because
excessive doses cause adverse effects such as postoperative infection,
gastrointestinal haemorrhage and delayed wound healing.

Characteristic symptoms of adrenal crisis are:
•Sudden penetrating pain in the legs, lower back or
abdomen
•Confusion, psychosis, slurred speech
•Severe lethargy
•Convulsions
•Fever fatigue.
•Hyperkalemia (elevated potassium level in the blood)
•Hypercalcemia (elevated calcium level in the blood):
• Hypoglycemia (reduced level of blood glucose)
• Hyponatremia (low sodium level in the blood)
• Hypotension (low blood pressure)
• Hypothyroid (lowT4 level)
• Severe vomiting and diarrhea, resulting in dehydration
• Syncope (loss of consciousness and ability to stand)

Conducting treatment in the morning [high endogenous steroid output].
Control of anxiety and emotional stress [ to decrease body need from
steroids].
Use long acting anesthesia [To control post-operative pain until to be
covered by analgesics.
Prescribe efficient pain killer.
Avoid use of NSAIDs [to avoid gastric problems].
Aseptic surgery and antibiotic prescription [to avoid increase requirements
due to post operative infection].
Routine dental procedures for patients under corticosteroid therapy.
Operative dentistry-Scaling and hygiene measurements-Root canal treatment-
Fixed prothodontics-orthodontic treatment-X-ray.

Examples of conditions likely to have a consequence for surgery and
anaesthesia include:
The risk of underlying disease
There is a wide range of diseases for which corticosteroid
treatment is commonly used. It is important to
remember that these conditions may also carry risk for
surgery.
Bronchial asthma
Rheumatoid arthritis
Glomerulonephritis.
Immune thrombocytopenia.
Malignancy.
Organ transplantation.
Cerebral oedema.
Chemotherapy.
These conditions should be fully assessed pre-operatively.

Atherosclerosis:
Major blood vessels Hypertension.
Coronary artery Angina pectoris.---
heart muscles. Myocardial infarction---
Brain. Stroke----
peripheral vessels Gangrene-----
Renal arteries Hypertension.
The arteries becomes thicker less elastic
and harder.

secondary hypertension
White-Coat Hypertension.
Hypertension
primary or essential hypertension
is classified as:
without an organic cause.
it has a well-established organic cause.

Dental management for patients with hypertension.
Measuring blood pressure before dental procedure .
The maximum limit of blood pressure not greater than
180/100 mmHg.
Short appointments.
The use of effective local anesthesia.
Aspiration before injection of anesthesia.
Avoid stressful [painful] procedures.

Dental management for patients with hypertension.
Dentists should taking into consideration medications that
commonly used during dental visits and affects
hypertension.[NSAIDs-Corticosteroids-Gingival retraction cord]
It is recommended that epinephrine containing local
anesthetics should be limited to two cartridges with
1:100,000 epinephrine. 0.04 mg, which is equal to that
containing about two cartridges of LA with 1 : 100000
epinephrine

The cardinal anatomic changes of the
valve include leaflet thickening and
shortening with thickening of the
tendinous cords.
Chronic rheumatic heart disease
(RHD) is characterized by repeated
inflammation [β-hemolytic
streptococci] with fibrous repair.
Rheumatic heart disease
The majority of morbidity and mortality
associated with rheumatic fever is caused
by its destructive effects on cardiac valve
tissue ended with congestive heart failure.

β-hemolytic
streptococci
Rheumatic fever
Rheumatic
heart disease Congestive
heart failure
Repeated rheumatic fever
Rheumatic heart disease
Patient may receive:
Benzathine benzylpenicillin
Corticosteroids.
Salicylates.
Diuretics.
Beta blockers.
ACE inhibitors.

Dental management for patients with risk of endocarditis.
Rheumatic heart disease
Congenital valve diseases.
Prosthetic valve.
Patients with risk of endocarditis :

Antibiotic prophylaxis regimen
Patients prepared to be operated under GA received the dose by
injection.
For patients whom under oral antibiotic medications, the dose
increased pre-operatively.
Patients under long acting penicillin should be managed
according to the regimen without any modifications.
Patients with concomitant diseases should be managed
accordingly.
The prophylaxis is restricted for cases with suspected
bacteremia.[surgery-exodontia-scaling and gingival treatment]

There are two main coronary arteries; left and
right that run on the surface of the heart,
These relatively narrow vessels are commonly
affected by atherosclerosis and can become
blocked, causing angina or a heart attack.
Angina pectoris
is the sensation of chest
pain , or squeezing, due
to insufficient blood flow
to the heart muscles as a
result of obstruction or
spasm of the coronary
arteries.
angina or a heart attack

A typical presentation of stable angina is that of chest
discomfort and associated symptoms precipitated by some
activity (running, walking, etc.) with minimal or non-existent
symptoms at rest .
Other recognized precipitants of stable angina include cold
weather, heavy meals, and emotional stress.
Stable angina
It has at least one of these three features:
It occurs at rest
usually lasting more than 10 minutes
It is severe with a crescendo pattern.
(i.e. more severe, prolonged, or frequent than before).
Unstable angina
is defined as angina pectoris that worsens.

1. Use short appointments (less than one hour), preferably in the morning.
2. Effective local anesthesia is important in order to avoid undue stress during
the appointment.
3. The guidelines for the administration of epinephrine are followed [two
carpules of 1/100000 conc. or 0.04 mg].
4. The use of epinephrine impregnated gingival displacement cord should be
strictly avoided in patients with cardiovascular disease.
5. Prophylactic nitroglycerin has been shown to be effective in the prevention
of angina pectoris during dental treatment.
6. Emergency nitroglycerin patch and oxygen should be available.
Dental management for patients with angina.

Coronary artery stent.
A coronary stent is a
tube shaped device
placed in the coronary
arteries to keep it open.
Drug-eluting stents were designed to lessen the problem
of platelet aggregation, fibrosis and stent renarrowing;
by releasing an anti-proliferative drug
[immunosuppressant drugs] .
Dental management for patients with coronary stent.
Antibiotic prophylaxis during the first three months of stenting.
Atraumatic procedure to avoid hematoma formation.

Myocardial infarction.
Occurs when blood flow stops to
a part of the heart causing
damage to the heart muscle.
Nitroglycerin is not effective.
Aspirin.
ACE inhibitor [relaxation of blood vessels].
Beta blocker.
Anti-coagulant.
Medications.
Problems
Heart attack.
Bleeding.

Dental management for patients with infarction.
1. Don’t stop any medications.
2. Use short appointments.
3. Effective local anesthesia.
6. INR [International-Normalized-Ration] investigated. If INR < 3 proceed with
use of local hemostatic agent. If INR ≥ 3 the anti-coagulant shifted to clexane
for three days with the use of local hemostatic agent.
7. Emergency oxygen should be available.

Cardiac arrhythmia
Or irregular heartbeat, too fast, or too slow.
Tachycardia.
A heart rate that is too fast above 100 beats per minute
Bradycardia
A heart rate that is too slow below 60 beats per minute.
Arrhythmia causes lower blood pressure and dizziness, or
syncope.
Some arrhythmias promote blood clotting within the heart, and
increase risk of embolus and stroke.
Anticoagulant medications and anti-platelet drugs can reduce
the risk of clotting.

Fibrillation “Irregular heart rhythm”
Cardio-Pulmonary –Resuscitation [CPR ] can prolong the
survival of the brain in the lack of a normal pulse, but
defibrillation is the only intervention that can restore a
healthy heart rhythm.
Defibrillation is
performed by applying an
electric shock to the
heart, which resets the
cells, permitting a normal
beat to re-establish itself.

Dental management for patients with arrhythmia.
1. Don’t stop any medications.
2. Use short appointments.
3. Effective local anesthesia is important in order to avoid undue stress during
the appointment.
6. INR [International-Normalized-Ration] investigated. If INR < 3 proceed with
use of local hemostatic agent. If INR ≥ 3 the anti-coagulant shifted to clexane
for three days with the use of local hemostatic agent.
7. Patients with pacemaker, avoid ultrasonic scaler or high magnets[MRI].

congestive heart failure (CHF)
Common causes of heart failure include:
Coronary artery disease.
Myocardial infarction.(heart attack).
High blood pressure.
Atrial fibrillation.
Valvular heart disease.

The left side of the heart is
responsible for receiving oxygen-
rich blood from the lungs and
pumping it forward to the systemic
circulation.
Failure of the left side of the heart
causes blood to back up (be
congested) into the lungs and lead to
insufficient supply of oxygenated
blood.
Severe pulmonary oedema.
Left side heart failure.
LTRT

failure of the right ventricle leads to
congestion of systemic capillaries.
This generates excess fluid
accumulation in the body. This causes
swelling under the skin [peripheral
edema] and causing foot and ankle
swelling.
Right-sided heart failure is often caused by pulmonary
disease which is usually caused by difficulties of the
pulmonary circulation.
Significant liver congestion may result in impaired liver function
and jaundice and even coagulopathy (problems of decreased or
increased blood clotting) may occur.
Right side heart failure.

A number of medications may cause or worsen the disease. This
includes NSAIDS.
The guidelines for the administration of epinephrine are followed
[two carpules of 1/100000 conc. or 0.04 mg].
Etiological disease should be respected during management;
Coronary artery disease, Myocardial infarction.(heart attack), High
blood pressure, Atrial fibrillation and Valvular heart disease.
Dental considerations:.

defined as a decrease in the total amount of red blood cells or
hemoglobin in the blood or lowered ability of the blood to carry
oxygen.
Anemia
Types of anemia
Iron deficiency anemia.
pernicious anemia.
Thalassemias.
Risk of anemia
Increased risk of infection,
Splenomegaly
Heart problems: tachycardia (rapid heartbeat),congestive heart failure and
abnormal heart rhythms.
Altered blood pressure, shortness of breath.

Dental management for patients with anemia.
Suspect ; Syncope, Palpitation and Hyperventilation.
Emergency oxygen should be available.
Traumatic procedures should be covered with antibiotics.
Blood pressure estimation before procedure.
Hemoglobin should be ≥ 9 before surgery.
 The guidelines for the administration of epinephrine are
followed [two carpules of 1/100000 conc. or 0.04 mg].

Thalassemias.
Are inherited blood disorder that can result in the abnormal
formation of haemoglobin.
Iron overload :People with thalassemia can get an overload of iron
in their bodies, either from the disease itself or from frequent
blood transfusions.Too much iron can result in damage to the
heart and liver.
Bone marrow expansion.
Enlarged spleen:The spleen aids in fighting infection and filters
unwanted material, such as old or damaged blood cells.
Thalassemia is often accompanied by the destruction of a large
number of red blood cells and the task of removing these cells
causes the spleen to enlarge

Widening of bone marrow spaces lead to brittle easily fractured
bone during extraction.
Frequent blood transfusion carries the risk of trans-infection.
Spleenomegaly affect platelet count with increased risk for post-
operative bleeding and infection.
Cardiac or liver damage should be taken into consideration.

Thrombocytopenia
Disorder in which there is a relative decrease of platelets.
A normal human platelet count ranges from 150,000 to 450,000
per micro-liter of blood.
Platelet count below 50,000 per micro-liter considered a state of
Thrombocytopenia.
Spontaneous bleeding under the skin and mucous
membrane (pinpoint bleeds=Petechia).

Etiology
2-Increased destruction
1-Decreased production:
Can be due to the following reasons:
Vitamin B or folic acid deficiency.
Leukemia or aplastic anemia.
Liver failure.
Sepsis, systemic viral or bacterial infection.
Can be due to:.
Disseminated intravascular coagulation.
Post-blood transfusion purpura.
Splenomegaly.
Systemic lupus erythematosus.
Zika virus.
Dengue fever.

3-Medication-induced
Corticosteroids.
Spleenectomy.
Methotrexate [chemotherapy].
Interferon.
Valproic acid [Epilepsy].
H2 antagonist [histamine-peptic ulcer].
Treatment

Medication-induced thrombocytopenia
Methotrexate [chemotherapy].
Dental considerations for patients with Thrombocytopenia:
1-Bleeding tendency controlled with platelet transfusion to correct the platelet
count and use of local hemostatic agents.
2-Aspirin should not be prescriped as pain killer.
If the condition due to concomitant disease, both should be managed.
Dental management of patients under chemotherapy .
1-Antibiotic coverage for any surgical procedure starting the day of operation
and continue for ten days post-operative.
4-Avoid use of NSAIDs to avoid peptic ulcer.
medical problem

Dental considerations for patients with Thrombocytopenia:
Bleeding tendency controlled with platelet transfusion to correct
the platelet cound and use of local hemostatic agents.
Asprin should not be prescriped as pain killer.
Patients receiving corticosteroids should be managed according
to the protocol.
Patients condition improved after spleenectomy treated as
normal individuals.
If the condition due to concomitant disease, both should be
managed.

Inherited genetic disorder that impairs the blood clotting. This
results in longer bleeding after injury or more serious internal
bleeding.
Haemophilia
Haemophilia A [Deficient factor VIII] .
Haemophilia B [Deficient factor IX].
Types

Intracranial haemorrhage is a serious medical emergency caused by
the build up of pressure inside the skull. It can cause
disorientation,nausea , loss of consciousness,brain damage and death.
Complications
Deep internal bleeding, e.g. deep-muscle bleeding, leading to
swelling, numbness and pain of a limb.
Joint damage from (haemophilic arthropathy), with severe pain,
disfigurement, and even destruction of the joint and development of
debilitating arthritis.
Trans infection from blood transfusions that are given as treatment.
Adverse reactions to clotting factor treatment, including the
development of an immune inhibitor which renders factor
replacement less effective.

Tranexamic acid or amino caproic acid may be given along with
clotting factors to prevent breakdown of clots.
Hospitalization.
Clotting factors are either given preventively or on-demand.
Preventive use involves the infusion of clotting factor on a
regular schedule in order to keep clotting levels sufficiently
high to prevent spontaneous bleeding episodes.
Medicines which contain aspirin or ibuprofen interfere with
clotting mechanism and should not be prescribed.
In case of temporomandibular joint pain, magnetic resonance
imaging [MRI]required for diagnosis.
Dental considerations for patients with Haemophilia:

is a group of cancers that usually begin in the bone marrow and
result in high numbers of abnormal white blood cells.
Leukemia
Damage to the bone marrow, by way of displacing the normal
bone marrow cells with higher numbers of immature white
blood cells, results in a lack of blood platelets , which are
important in the blood clotting process. This means people with
leukemia may easily bleed excessively, or develop petechiae.
Because leukemia prevents the immune system from working
normally, some patients experience frequent infection sometimes
life-threatening.
Most forms of leukemia are treated with chemotherapy, radiation
or bone marrow transplant.
Risk

Dental considerations for patients with Leukemia:
Bleeding tendency that could be difficult to control. Pre-operative
blood count-use of local hemostatic measures might be beneficial.
Guard against post operative infection by prescribing specific
antibiotics.
Excessive trauma may lead to jaw fractures.
Manage patients treated with chemotherapy and radiation according
to treatment protocol of each one.

Dental considerations for management of medically compromised 2018

Dental considerations for management of medically compromised 2018

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Dental considerations for management of medically compromised 2018