This document provides guidance on dental management of medically compromised children, focusing on those with bleeding disorders like hemophilia. It discusses evaluating coagulation factor levels, using local anesthetics safely, replacing deficient factors, and administering antifibrinolytic drugs to prevent bleeding complications. Minor procedures may require only local measures, while more extensive work like oral surgery demands factor replacement, antifibrinolytics, and close monitoring to safely manage bleeding risks. Prevention through oral hygiene and regular cleanings can reduce need for invasive dental work in these high-risk patients.

2. DENTAL MANAGEMENT OF
MEDICALLY COMPROMISED
CHILD
PRESENTED BY :-
DR. PAWAN K. SINSINWAR

3. Content• Hematologic Disorders
• Hemophilia or Inherited Bleeding
Disorder.
• Blood Transfusion
• Anemia
• Leukemia
• Taking a “Blood Thinner”/Tendency
to Bleed Longer Than Normal
• Cardiovascular Disease
• Heart Failure
• Heart Attack
• Angina Pectoris
• High Blood Pressure
• Heart Murmur
• Mitral Valve Prolapse
• Rheumatic Fever
• Congenital Heart Disease
• Artificial Heart Valve
• Arrhythmias
• Coronary Artery Bypass
Graft/Angioplasty/Stent
• Respiratory Tract Disease
• Allergies or Hives
• Asthma.
• Emphysema/Chronic Bronchitis
• Tuberculosis.
• Sleep Apnea/Snoring
• Endocrine Disease
• Diabetes
• Thyroid Disease
• Genitourinary Tract Disease
• Kidney Failure
• Sexually Transmitted Diseases
• Other Conditions
• Tobacco and Alcohol Use
• Drug Addiction and Substance Abuse
• Tumor and Cancer
• Radiation Therapy and Chemotherapy
• Steroids
• Operations or Hospitalizations

4. Introduction
It is the management of patients in whom the dental treatment
may need modification according to their medical condition
Because the majority of medically compromised patients need
oral healthcare, a working knowledge of the multitude of
medically complex conditions is critical for dental professionals.
This knowledge is necessary to help prevent, minimize, and alert
clinicians to possible adverse side effects potentially associated
with procedures and drugs used in dentistry.

5. To minimize the risk for
potential complications that may
affect the physical health of
medically compromised patients,
an aggressive prevention
oriented program is required.
Each patient presents a unique
set of challenges to the dentist,
but achieving a successful
outcome can be a rewarding
experience.

6. Hemophilia
Deficiency of a procoagulant.
Hemophilia A (classic hemophilia) -Factor VIII,
(antihemophilic factor)
Hemophilia B, (Christmas disease) -Factor IX (plasma
thromboplastin component).
Hemophilia C (Rosenthal’s’disease) Factor XI (plasma
thromboplastin antecedent)

7. Other factor deficiencies, such as those of factors II,
V, and XIII (one case per 1 million population) and
factor VII (one case per 500,000 population) are rare
and are inherited as autosomal recessive traits.

8. TREATMENT
• Replacement of the deficient coagulation factor, through the
use of purified concentrates either manufactured through
recombinant technology or from pooled plasma.
• In the past, whole blood, plasma, or cryoprecipitate was used
for replacement therapy.
• Factor concentrates are advantageous as they are generally
accessible, easily handled and stored, virally inactivated, and
commonly result in consistent hemostatic results.
• The dosage, frequency of administration, and duration of
therapy depend on the activity level required, the half-life of
the procoagulant, the intervention or procedure contemplated,
or the location and severity of the bleeding episode.
• The half-life of factor VIII is approximately 12 hours, whereas
for factor IX it is approximately 18 hours.10

9. FEMALE WITH BLEEDING DISORDERS

10. Von Willebrand Disease
• Patients with Von Wille Brand disease should undergo subtyping to
determine optimal therapy.
• DDAVP may be used to achieve hemostasis in most patients with
type I von Willebrand disease, where type I VWD represents a
quantitative VWF deficiency with intact multimers.
• When DDAVP is used, a test dose should be administered to
document an adequate hemostatic response.
• For patients with less common subtypes of VWD, patients who do
not respond to DDAVP, or patients for whom DDAVP is
inappropriate, or in bleeding events for which DDAVP should not be
used, other therapeutic modalities may be required, including
replacement with exogenous intact VWF through the use of a
concentrate.

11. COMPLICATIONS
Inhibitors are antibodies that neutralize the replaced
coagulation factor and are one of the most severe
complications for patients.
Inhibitors may develop in approximately 28% of
patients with severe factor VIII deficiency and in 3%
to 5% of patients with severe factor IX deficiency.

12. Hemophilic patients with inhibitors pose considerable treatment
challenges and should be managed only in conjunction with a
hemophilia-comprehensive treatment center, because hemostasis
is often difficult to achieve or maintain.

13. Other Complications
Arthritis and
Degenerative joint
disease secondary
to recurrent
bleeding.
Blood-borne viral
infections may
have been
transmitted via
required blood or
blood products.
Hepatitis, including
both B and C and
resultant liver
disease
The human
immunodeficiency
virus (HIV) has
also been a major
source of morbidity
and mortality since
1979.

14. • Approximately 90% of hemophilic patients with severe factor
VIII deficiency and 30% of those with severe factor IX
deficiency who received factor concentrate during the at-risk
period may have become infected with HIV.
• Currently available treatments of factor concentrates made
through recombinant technology or pooled plasma have
effectively eliminated transmission of HIV and hepatitis B and
C.
• Universal precautions should be followed when treating all
hemophilic patients with a history of receiving either factor
concentrate.

15. RISKS TO DENTAL STAFF
• The risk for acquiring hepatitis B virus infection following an
accidental stick with a needle used by a hepatitis B virus
carrier ranges from 6% to 30%, far higher than the risk for
transmission of HIV infection (less than 1%) following a stick
with a needle used by an HIV-infected patient.
• A study by Klein and colleagues demonstrated a less than 0.5%
occupational risk for HIV infection among dental professionals
despite their infrequent compliance with recommended
infection control precautions, frequent occupational exposure
to persons at increased risk for HIV infection, and frequent
accidental parenteral inoculations with sharp instruments.

16. DEVELOPMENT OF A
TREATMENT PLAN
• With recent advances in treatment, most hemophilic patients can receive
outpatient dental care routinely.
• The dentist must be fully aware of the procedures that can be safely
performed and those in which complications may arise.
• The dentist should confer with the patient’s physician and hematologist
to formulate an appropriate treatment plan.
• The dentist should know the specific type of bleeding disorder, the
severity of the disorder, the frequency and treatment of bleeding
episodes, and the patient’s inhibitor status.
• The dentist should discuss with the hematologist the type of anesthetic
anticipated to be administered, the invasiveness of the dental procedure,
the amount of bleeding anticipated, and the time involved in oral wound
healing to help establish an appropriate treatment plan including the need
for replacement and adjunctive therapies.

17. USE OF ANTIFIBRINOLYTIC AGENTS
• Antifibrinolytic agents are an adjunctive therapy for dental
management of patients with bleeding disorders and are
important for prevention or treatment of oral bleeding.
• These agents include -Aminocaproic acid and Tranexamic acid .
• Hemophilic patients form loose, friable clots that may be readily
dislodged or quickly dissolved, especially in the oral cavity
where local fibrinolysis is increased.
• Antifibrinolytics prevent clot lysis within the oral cavity.
• They are often used as an adjunct to factor concentrate
replacement.
• For some dental procedures in which minimal bleeding is
anticipated, they may be used alone.

18. Dosages
• In children, Aminocaproic acid is given immediately before dental
treatment in an initial loading dose of 100 to 200 mg/kg by mouth up to a
maximum total dose of 10 g.
• Subsequently, 50 to 100 mg/kg per dose up to a total maximum dose of 5
g is administered orally every 6 hours for 5 to 7 days.
• Alternatively, for patients of approximately adult size or heavier than 30
kg, a regimen of 3 g by mouth four times daily without a loading dose
may be used.
• The adult and pediatric dosage of Tranexamic acid is 25 mg/kg given
immediately before dental treatment.
• The same dose is continued every 8 hours for 5 to 7 days.

19. Side Effects
The common side effects associated with the use of antifibrinolytics include
headache, nausea, and dry mouth.
These side effects are usually tolerable and, unless severe, do not require
discontinuation of the medication.
Other less common side effects have also been reported.
To avoid thrombosis, Antifibrinolytics should not be used when renal or urinary
tract bleeding is present or when there is any evidence of disseminated
intravascular coagulation.
Repeated use of prothrombin complex concentrate (PCC) or bypassing products
(activated PCC) in patients with inhibitors should also be avoided during a course
of Antifibrinolytic therapy because they may predispose to thrombotic episodes.

20. PAIN CONTROL
If patient apprehension is significant, sedation or nitrous oxide–oxygen
inhalation analgesia and Hypnosis may be considered.
IM injections of hypnotic, tranquilizing, or analgesic agents are contraindicated
due to the risk of hematoma formation.
Analgesics containing aspirin or anti-inflammatory agents (e.g., ibuprofen) may
affect platelet function and should be avoided.
Acute pain of moderate intensity - Acetaminophen.
Propoxyphene hydrochloride analgesic is acceptable.
Severe pain- Narcotic analgesics are indicated.

21. Local Anesthesia
Absence of factor replacement, PDL injections may be used.
Infiltration can generally be administered without pretreatment with
either -Aminocaproic acid or replacement therapy.
If the infiltration injection is into loose connective tissue or a highly
vascularized area, then factor concentrate replacement to achieve a level
of approximately 30% to 40% activity is recommended.

22. Proceed with caution when considering block anesthesia.
The loose, connective, nonfibrous, and highly vascularized tissue at the
sites of IANB and PSA are predisposed to development of a dissecting
hematoma, which potentially may cause airway obstruction and create a
life-threatening bleeding episode.
A minimum of a 40% factor correction is mandatory with block
anesthesia.

23. The dentist must carefully
aspirate to ensure that the
needle has not entered a blood
vessel.
If there is bloody aspirate,
further factor replacement may
be required, and the attending
hematologist should be notified
immediately following the
operative procedure.
All patients should be observed
for development of a hematoma
and immediately referred for
treatment in case hematoma
forms after the administration
of local anesthesia.

24. DENTAL MANAGEMENT
Most hemophilic patients can receive outpatient dental care
routinely.
Maximum treatment should accomplished per visit to minimize the
need for unscheduled factor infusions and hence cost.
Patients with inhibitors are best treated at a center with experience
in dealing with this complication.
The dental procedures used in treating a patient with hemophilia do
not differ significantly from those used for unaffected individuals.

25. Prevention of Dental
Disease
A program that includes
• Tooth brushing, Flossing,
• Topical fluoride exposure,
• Systemic fluoride administration,
• Proper diet and
• Professional examination at regular intervals
are effective measures that prevent dental problems.
Rubber cup prophylaxis and supragingival scaling may be safely
performed without prior factor replacement therapy.

26. Minor bleeding can be readily
controlled with local measures,
such as direct pressure with a
moistened gauze square.
If bleeding persists for several
minutes, the topical application
of bovine thrombin,
microfibrillar collagen and local
fibrin glue may be of value.

27. Periodontal Therapy
Patients who require deep scaling initially undergo supragingival scaling than
tissue should be allowed to heal for 7 to 14 days, as edema and hyperemia
diminish.
Subsequent treatments to remove calculus and irritants therefore decreased
bleeding risk from the tissue.
If subgingival scaling is planned, replacement therapy may be considered,
depending on the amount of anticipated bleeding and the severity of the factor
deficiency.
It is imperative that periodontal patients be placed on a maintenance schedule
for proper management.

28. • An abnormal frenum attachment may cause gingival recession
and pocket formation. Early treatment is indicated
• Frenectomy techniques are surgically acceptable for
hemophilic patients; both factor concentrate replacement and
antifibrinolytic therapy are required before frenum or other
periodontal surgery.
• If a large amount of bleeding is anticipated, should be
performed in a hospital environment, with the requisite
preparation.

29. Restorative Procedures
Most restorative procedures on primary teeth are successfully completed without factor concentrate
replacement using PDL injections of local anesthesia or local infiltration.
Small lesions may be restored using nitrous oxide–oxygen inhalation analgesia alone.
The use of acetaminophen with codeine may also decrease discomfort in the child.
Most operative procedures for adults may also be completed using local infiltration of anesthetic, a
procedure that usually does not require factor concentrate replacement.
If a mandibular block or a posterior superior alveolar injection is anticipated, factor concentrate
replacement to a level of 40% and antifibrinolytic therapy are required before injection.
If factor concentrate replacement is required, all possible restorative treatment should be completed
in one visit to minimize the number of infusions required to complete the restorative treatment plan.

30. • A rubber dam should be used to isolate the operating field and
to retract and protect the cheeks, lips, and tongue.
• A thin rubber dam is preferred because there is a decreased
tendency to torque the rubber dam retainer and cause gingival
tissue abrasion.
• The retainer should be placed carefully so that it is stable.
• Retainers with subgingival extensions should be avoided.
• Wedges and matrices can be used conventionally.
• During proximal preparation, the wedge retracts the papilla,
thus protecting it.
• A properly placed matrix should not cause bleeding.

31. • High-speed vacuum and saliva ejectors must be used with
caution so that sublingual hematomas do not occur.
• Care must also be used in the placement of intraoral
radiographic films, particularly in highly vascular
sublingual tissues.
• The preparation of a tooth for a cast crown requires
caution in gingival preparation, as does placement of
retraction cord and impression material.
• Periphery wax is used on the impression tray to prevent
possible intraoral laceration during tray placement.
Undue trauma should be avoided in cementing or
finishing a crown.

32. Pulpal Therapy.
• At times, pulp exposures in primary and permanent teeth may be avoided if carious
dentin is not entirely removed in one procedure (indirect pulp therapy).
• A pulpotomy or pulpectomy is preferable to extraction.
• Most vital pulpotomy and pulpectomy procedures can be successfully completed using
local infiltration anesthesia.
• Nitrous oxide–oxygen inhalation analgesia may also help alleviate discomfort.
• If the pulp of a vital tooth is exposed, an intrapulpal injection may be used safely to
control pain.
• Bleeding from the pulp chamber does not present a significant problem in that it is
readily controlled with pressure from cotton pledgets.
• If pulp tissue is necrotic, local anesthetic is usually unnecessary.

33. Oral Surgery
Preoperative evaluation and postoperative management of the hemophilic patient
undergoing extractions must be coordinated with the hematologist.
The surgical procedure, including the anesthetic technique, the degree of anticipated
surgical trauma, and the expected duration for healing.
The hematologist can then determine the amount and duration of factor concentrate
replacement and adjunctive therapies required for surgery and postoperative
management.
Patients with inhibitors should only be treated in a hospital setting by those
experienced in their management.

34. For simple extractions of erupted permanent teeth and multirooted primary teeth, a
30% to 40% factor correction is administered within 1 hour before dental treatment.
Antifibrinolytic therapy should be started immediately before or after the procedure
and should be continued for 5 to 10 days.
The patient should be placed on a clear liquid diet for the first 72 hours.
For the next week, a soft, pureed diet is recommended.
During this time, the patient should not use straws, metal utensils, pacifiers, or
bottles.
After 10 days, the patient may begin to consume a more normal diet. Specific
postoperative instructions should be provided to the patient and parent.
Factor concentrate is extremely costly, therefore all extractions should be completed
in one appointment if possible.

35. After extractions direct topical application of hemostatic agents, such as thrombin or
microfibrillar collagen hemostat (Avitene), may assist with local hemostasis.
The socket should be packed with an absorbable gelatin sponge (e.g., Gelfoam,
Pharmacia and Upjohn Co., Kalamazoo, MI).
Microfibrillar collagen or topical thrombin or fibrin glue may then be placed in the
wound.
Direct pressure with gauze should then be applied to the area.
Stomahesive may be placed over the wound for additional protection from the oral
environment.
The use of sutures should be avoided unless suturing is expected to markedly enhance
healing, in which case resorbent sutures are recommended.
The patient must be given specific and thorough postoperative instructions.

36. For surgical extractions of impacted, partially erupted, or unerupted teeth, a higher factor
activity level may be targeted before surgery.
The hematologist may also elect to administer factor replacement to the patient
postoperatively.
Antifibrinolytic therapy should be started immediately before or after the procedure and
continued for 7 to 10 days.
For simple extractions of single-rooted primary teeth (i.e., incisors and canines), one
must evaluate the amount of root development present to determine whether factor
replacement therapy is required.
If there is complete root development, factor replacement therapy may be required,
whereas if there is only partial root formation, antifibrinolytic therapy along with local
hemostatic agents may be all that is required.

37. The normal exfoliation of primary teeth does not usually result in bleeding or require
factor replacement.
Bleeding in these circumstances can generally be controlled with direct finger and
gauze pressure maintained for several minutes.
The direct topical application of an adjunctive agent may also help with local
hemostasis.
If there is continuous slow bleeding, antifibrinolytic therapy may be initiated.
In rare circumstances, most commonly when the gingival tissue is repeatedly
traumatized during exfoliation, use of factor replacement therapy may be required.
In this circumstance, dental evaluation should be performed and consideration given
to removal of the exfoliating tooth if repeated trauma cannot be avoided.

38. Surgical Complications
Bleeding may occur 3 to 4 days postoperatively.
Both systemic and local treatment should be used for hemostatic control.
Sufficient replacement factor should be administered to control recurrent bleeding.
It is not prudent to protect a loose clot.
The typical clot in this situation is characterized as a “liver clot” and is dark red, usually
protruding from the surgical site, and often covers the surfaces of several teeth.
Following adequate replacement with factor concentrate, usually to a 30% to 40% activity level,
the abnormal clot should be removed and the area cleansed to help isolate the source of bleeding.
The socket should then be repacked and use of antifibrinolytic agents considered.

39. Antibiotic Prophylaxis
Total joint replacement, is often performed in patients with severe
hemophilia to restore function and alleviate pain associated with
degenerative arthritis due to multiple hemarthroses.
Antibiotic prophylaxis is required before invasive dental procedures.
The American Heart Association recommendations for bacterial endocarditis
prophylaxis, 2007, are commonly followed.
If the patient is immunocompromised because of HIV infection, intravenous
antibiotic prophylaxis may be considered.

40. Orthodontic Treatment
Early recognition of an orthodontic problem is important to eliminate complex orthodontic problems.
Both interceptive and full-banded orthodontics may be performed if required.
Care must be taken in the adaptation and placement of bands to prevent laceration of oral mucosa.
Accidental scratch or minor laceration responds to applied pressure for 5 minutes.
The use of preformed orthodontic bands and brackets
Longer-acting wires and springs require less frequent adjustment of orthodontic appliances.
Oral hygiene is particularly important to avoid inflamed, edematous, and hemorrhagic gingival tissues.
A water irrigating device may be helpful for home dental care.

41. Dental Emergencies
Oral trauma is a common during
childhood.
Management of bleeding injuries,
including hematomas, in patient
with a bleeding disorder require a
combination of factor replacement
and antifibrinolytic therapy, as
well as treatment with local
hemostatic agents.
Blood loss from the oral cavity is
easily underestimated or
overestimated.
The patient’s hemoglobin may be
checked to ensure that the patient
is not anemic in these
circumstances.

42. THANK YOU

43. SICKLE CELL ANEMIA
• Patients with sickle cell anemia have an autosomal recessive hemolytic disorder that occurs predominantly
in persons of African descent but is also found among Italian, Arabian, Greek, and Indian people.
• Patients with sickle cell anemia produce hemoglobin S instead of the normal hemoglobin A.
• Hemoglobin S has a decreased oxygen-carrying capacity.
• Decreased oxygen tension causes the sickling of cells.
• These patients are susceptible to recurrent acute infections, which result in an “aplastic crisis” caused by
decreased red blood cell production and in subsequent joint and abdominal pain with fever.
• Over time there is a progressive deterioration of cardiac, pulmonary, and renal function.
• Many factors can precipitate a sickle cell crisis, including acidosis, hypoxia, hypothermia, hypotension,
stress, hypovolemia, dehydration, fever, and infection.
• Radiographic changes are associated with sickle cell anemia.
• There is a generalized radiolucency and loss of trabeculae with prominent lamina dura, caused by
increased erythropoietic demands that result in expansion of the marrow spaces.
• Bone growth may be decreased in the mandible, resulting in retrusion, and the teeth may be
hypomineralized.
• Occasionally, patients with sickle cell anemia have infarcts in the jaw, which may be mistaken for a
toothache or osteomyelitis.
• The patients experience dental pain with absence of pathology.

44. • Dental appointments should be short to reduce potential stress on the patient.
• The importance of an aggressive preventive program cannot be understated, and
such a program should have the goal of maintaining excellent oral health and
decreasing the possibility of oral infection.
• Dental treatment should not be initiated during a sickle cell crisis.
• If emergency treatment is necessary during a crisis, only treatment that will make
the patient more comfortable should be provided.
• Patients with sickle cell anemia may have skeletal changes that make orthodontic
treatment beneficial.
• Special care must be taken to avoid tissue irritation, which may induce
bacteremia's, and the disease process may compromise the proposed treatment.
• Careful monitoring is a necessity when proposing elective orthodontic treatment
in patients with sickle cell anemia.

45. • Many patients with sickle cell anemia have defective spleen function or undergo a spleenectomy, which
leaves them more vulnerable to infection because immunoglobulin production is decreased and
phagocytosis of foreign antigens is thus impaired.
• Most patients with sickle cell anemia are taking low-dose daily prophylactic antibiotics, and the need for
additional antibiotics for dental procedures is debatable.
• Some authors have recommended the use of antibiotics for all dental procedures, whereas others
recommend the administration of additional antibiotics when there is obvious dental or periodontal
infection.
• The selection of an antibiotic is usually similar to that in cases of heart defect.
• The use of local anesthetics with a vasoconstrictor is not contraindicated in patients with sickle cell
anemia.
• Some textbooks do recommend against the use of vasoconstrictors, although there is no evidence to
support this practice.
• Similarly, the use of nitrous oxide is not contraindicated in these patients.
• Care must be taken in treating patients with sickle cell anemia to avoid diffusion hypoxia at the completion
of the dental procedure.
• The restoration of teeth, including pulpotomies, is preferable to extraction.
• Pulpectomy in a nonvital tooth is reasonable if the practitioner is fairly confident that the tooth can remain
noninfected. If the tooth is likely to persist as a focus of infection, then extraction is indicated.

46. • The use of general anesthesia for dental procedures must be approached cautiously in consultation with the
hematologist and anesthesiologist.
• Previously, the standard protocol was to perform a direct transfusion (immediate introduction of whole
blood or blood components) or an exchange transfusion (repetitive withdrawal of small amounts of blood
and replacement with donor blood until a large portion of the patient blood has been exchanged) before
general anesthesia.
• The goal of the transfusion is to increase the patient’s hemoglobin level to higher than 10 g/dL and to
decrease the hemoglobin S level below 40%.
• Transfusions do not provide complete protection against venous complications, but they may temporarily
improve the patient’s condition and reduce the hazards of surgery.
• The current thinking is to weigh the risks associated with transfusion prior to anesthesia induction.
Suggested guidelines for performing a prophylactic transfusion before general anesthesia have been
proposed.
• Patients with a hemoglobin level of less than 7 g/dL and a hematocrit of less than 20% may require a
transfusion.
• Pediatric patients are usually less likely to have post-transfusion complications than are adults.
• A high frequency of hospitalizations is indicative of a more severe anemia, and such patients may require
transfusion before surgery.
• Minor surgeries may not require a transfusion.

47. LEUKEMIA• Malignancy is second only to accidents as the leading cause of death
in children.
• Leukemias are hematopoietic malignancies in which there is a
proliferation of abnormal leukocytes in the bone marrow and
dissemination of these cells into the peripheral blood.
• The abnormal leukocytes (blast cells) replace normal cells in bone
marrow and accumulate in other tissues and organs of the body.
• Leukemia is classified according to the morphology of the
predominant abnormal white blood cells in the bone marrow (Table
24-1). These types are further categorized as acute or chronic,
depending on the clinical course and the degree of differentiation, or
maturation, of the predominant abnormal cells.
• In the United States, about 6550 new cases of cancer are diagnosed
each year in children under the age of 15.

48. • Acute leukemia is the most common malignancy in children, with about 2500
new cases diagnosed annually in the United States.
• Thus acute leukemia accounts for about one third of all childhood malignancies;
of these, approximately 80% are lymphocytic (acute lymphocytic leukemia, or
ALL).
• Chronic leukemia in children is rare, accounting for less than 2% of all cases.
• Leukemia affects about one of every 29,000 children each year in the United
States.
• The peak incidence is between 2 and 5 years of age.
• Although the cause of leukemia is unknown, ionizing radiation, certain chemical
agents, and genetic factors have been implicated.
• For example, children with chromosomal abnormalities (Down syndrome and
Bloom syndrome), children with an identical twin who has leukemia, and
children with immunologic disorders have an increased risk for leukemia.

49. • In the US leukemia rates for white children are nearly double
that for black children.48 The clinical manifestations of acute
leukemia are caused by the infiltration of leukemia cells into
tissues and organs.
• Infiltration and proliferation of leukemia cells in the bone
marrow lead to anemia, thrombocytopenia, and
granulocytopenia.
• Because these cytopenias develop gradually, the onset of the
disease is frequently insidious.
• The history at presentation may reveal increased irritability,
lethargy, persistent fever, vague bone pain, and easy bruising.

50. • Some of the more common findings on initial physical
examination are pallor, fever, tachycardia, adenopathy,
hepatosplenomegaly, petechiae, cutaneous bruises, gingival
bleeding, and evidence of infection.
• In approximately 90% of the cases of acute leukemia a
peripheral blood smear reveals anemia and thrombocytopenia.
• In about 65% of cases the white blood cell count is low or
normal, but it may be greater than 50,000 cells/mm3.
• When a new case of leukemia is diagnosed, the patient is
hospitalized and therapy is directed toward stabilizing the
patient physiologically, controlling hemorrhage, identifying
and eliminating infection, evaluating renal and hepatic
functions, and preparing the patient for chemotherapy.

51. • These interventions proceed while the definitive studies to determine
the exact type of leukemia are undertaken.
• These include performing a bone marrow aspiration to obtain marrow
for microscopic analysis, special cytochemical staining,
immunophenotyping by flow cytometry, and cytogenetic analysis.
• The goal of treatment is to induce and maintain a complete remission,
which is defined as resolution of the physical findings of leukemia
(e.g., adenopathy, hepatosplenomegaly, petechiae) and normalization
of peripheral blood counts and bone marrow (less than 5% blasts).
• A new term minimal residual disease (MRD) has been applied when
using multiple parameter flow cytometry and less than 0.1% blasts
are found.

52. • Remission with MRD is better prognostically than the old
definition of remission.
• The basic principle of treatment of ALL is substantially
different from that of acute myelogenous or
nonlymphocytic leukemia (ANLL).
• In general, the treatment of ANLL is very intense and
results in profound bone marrow hypoplasia, but the
treatment duration is usually short (less than 1 year).
• For ALL, the treatment is less intense but more prolonged
(21⁄2 to 31⁄2 years).

53. • Overall, the treatment regimens vary considerably depending on
prognostic factors and the parameters being evaluated by the
strategists’ cooperative group (e.g., Children’s Oncology Group).
• The initial phase of treatment, induction, incorporates the use of a
combination of antileukemic drugs at staggered intervals during a 4-
week regimen (Table 24-2).
• This combination of drugs should rapidly destroy the leukemic cells,
yet maintain the regenerative potential of the nonmalignant
hematopoietic cells within the bone marrow.
• About 95% of patients with ALL will be in complete remission at day
28 of therapy.
• The second phase of ALL treatment, consolidation, attempts to
consolidate remission and intensify prophylactic central nervous
system (CNS) treatment.

54. • Prevention of CNS relapse uses intrathecally administered chemotherapy (methotrexate with
or without cytosine arabinoside and hydrocortisone) to destroy leukemic cells within the
CNS.
• This chemotherapeutic agent is instilled directly into the lumbar spinal fl uid because most
antileukemic drugs do not readily cross the blood-brain barrier.
• Intensive intrathecal chemotherapy to prevent CNS relapse has replaced cranial irradiation
for patients in the good and intermediate-risk groups of ALL patients.
• However, both cranial irradiation and intrathecal chemotherapy are still used to prevent CNS
relapse in high-risk ALL patients.
• The third phase of treatment, interim maintenance, uses a combination of agents that are
relatively nontoxic and require only monthly visits to the outpatient clinic.
• In most cases, another phase, delayed intensifi cation, follows interim maintenance.
• This serves to intensify antileukemic therapy again after a short period of less intensive
therapy. The addition of a late phase of intensive therapy substantially improves survival in
patients with ALL.

55. • Following delayed intensification, therapy continues for 2 years for girls
and 3 years for boys (maintenance phase), with chemotherapeutic agents
given as in interim maintenance.
• The prognosis for a child with acute leukemia has improved dramatically
over the past several decades.
• Thirty five years ago, there would have been little need to discuss dental
treatment for a child with leukemia because the disease was invariably
fatal, in most cases within 6 months of diagnosis.
• Today, with the development of new and better antileukemia drugs, the
use of intensive combination drug therapy, the incorporation of radiation
therapy, and improvements in diagnostic techniques and general
supportive care, the overall survival for all children with ALL is now
about 80%.
• Pretreatment prognostic factors identify patients who are likely to benefit
from either standard or more intensive therapy.

56. • Factors that identify patients who are likely to benefit from the type of
therapy just outlined, which causes relatively minimal toxicity, are
patient age between 1 and 10 years, a white blood cell count of less than
50,000/mm3, lymphoblast morphology that is not of the Burkitt type,
and the absence of certain cytogenetic abnormalities [t(4;11); t(9;22)]
(also known as the Philadelphia chromosome) or hypoploidy in the
lymphoblast.
• The presence of either the TEL-AML1 fusion [t(12;21)(p13;q22)] or the
simultaneous trisomies of chromosomes 4, 10, and 17 in the
lymphoblasts correlates with an improved prognosis and may qualify
these children for less strenuous therapy.
• Children with ALL who are at particularly high risk are those who are
younger than 1 year of age at diagnosis, have a high white blood cell
count, or have the cytogenetic abnormalities mentioned above.
• More intrusive treatment regimens are used for these patients.

57. • The early response to induction chemotherapy is also a strong predictor of
outcome for patients with ALL.
• Current clinical trials in leukemia are using flow cytometry and molecular
techniques to detect blast cells not visible morphologically in bone marrow
aspirates.
• Quantification of this MRD is being used as an additional tool to direct therapy so
that children can receive risk based adjusted therapy.
• The prognosis for children with acute myelogenous leukemia (AML) has
improved significantly over the past several years, with event-free survivals of
approximately 50% (at 3 years) for children receiving chemotherapy and
somewhat higher percentages for patients undergoing allogeneic hematopoietic
stem cell transplantation from a matched sibling after achieving remission with
chemotherapy.50
• The treatment regimens are intrusive and result in profound bone marrow
suppression.
• These patients have severe prolonged neutropenia, necessitating long
hospitalizations. They often have serious infections and severe mucositis.

58. ORAL MANIFESTATIONS OF
LEUKEMIA
• Pathologic changes in the oral cavity as a result of leukemia occur frequently.
• Oral signs or symptoms suggestive of leukemia have been reported in as many as
75% of adults and 29% of children with leukemia.
• The lower incidence of oral manifestations in children can be attributed in part to
the early age at diagnosis and the high percentage of ALL in the pediatric age
group.
• The incidence of ALL peaks at 3 years of age, when preexisting inflammatory
and degenerative changes are comparatively less frequent.
• Abnormalities in or around the oral cavity occur in all types of leukemia, and in
all age groups.
• However, oral pathoses are more commonly observed in acute leukemias than in
chronic forms of the disease.
• Oral findings suggestive of leukemia are also more common in AML than in
ALL.

59. • The most frequently reported oral abnormalities attributed to the leukemic
process include regional lymphadenopathy, mucous membrane petechiae and
ecchymoses, gingival bleeding, gingival hypertrophy, pallor, and nonspecific
ulcerations.
• Manifestations seen occasionally are cranial nerve palsies, chin and lip
paresthesias, odontalgia, jaw pain, loose teeth, extruded teeth, and gangrenous
stomatitis.
• Each of these findings has been reported in all types of leukemia. Regional
lymphadenopathy is the most frequently reported finding.
• Gingival abnormalities, including hypertrophy and bleeding, are more common in
patients with AML, whereas petechiae and ecchymoses are more common in
those with ALL.
• Like the systemic manifestations of leukemia, oral changes can be attributed to
anemia, granulocytopenia, and thrombocytopenia, all of which result from the
replacement of normal bone marrow elements by undifferentiated blast cells, or
to direct invasion of tissue by these leukemic cells.

60. • Very high circulating white blood cell numbers in the peripheral blood can lead to stasis in
small vascular channels.
• The subsequent tissue anoxia results in areas of necrosis and ulceration that can readily
become infected by opportunistic oral microorganisms in patients with neutropenia.
• A person with severe thrombocytopenia, having lost the capacity to maintain vascular
integrity, is likely to bleed spontaneously.
• Clinical manifestations are petechiae or ecchymoses of the oral mucosa or frank bleeding
from the gingival sulcus (Figs. 24-3 and 24-4).
• The propensity for gingival bleeding is greatly increased in persons with deficient oral
hygiene, because accumulated plaque and debris are significant local irritants.
• Direct invasion of tissue by an infiltrate of leukemic cells can produce gingival hypertrophy.
Such gingival changes can occur despite excellent oral hygiene.
• Infiltration of leukemic cells along vascular channels can result in strangulation of pulpal
tissue and spontaneous abscess formation as a result of infection or focal areas of
liquefaction necrosis in the dental pulp of clinically and radiographically sound teeth.

61. • In a similar fashion, the teeth may rapidly loosen as a result of necrosis of the periodontal
ligament.
• Skeletal lesions caused by leukemic infiltration of bone are common in childhood leukemia.
• The most common finding is a generalized osteoporosis caused by enlargement of the
Haversian canals and Volkmann canals.
• Osteolytic lesions resulting from focal areas of hemorrhage and necrosis and leading to loss
of trabecular bone are also common.
• Evidence of skeletal lesions is visible on dental radiographs in up to 63% of children with
acute leukemia.
• Manifestations in the jaws include generalized loss of trabeculation, destruction of the crypts
of developing teeth, loss of lamina dura, widening of the periodontal ligament space, and
displacement of teeth and tooth buds (Fig. 24-5).
• Because none of the oral changes is a pathognomonic sign of leukemia and all can be
associated with numerous local or systemic disease processes, a diagnosis of leukemia
cannot be based on oral findings alone.
• Such changes should, however, alert the clinician to the possibility of malignancy as the
underlying cause.

62. DENTAL MANAGEMENT OF
PATIENTS WITH
LEUKEMIA
• Before any dental treatment is administered to a child with
leukemia, the child’s hematologist/oncologist or primary care
physician should be consulted.
• The following information should be ascertained:
• 1. Primary medical diagnosis
• 2. Anticipated clinical course and prognosis
• 3. Present and future therapeutic modalities
• 4. Present general state of health
• 5. Present hematologic status
• It is also important to establish, by consultation with the
patient’s physician, when dental treatment may be most
propitious, and to schedule the patient’s treatment accordingly.

63. • The proposed procedures should be discussed to determine if they are
appropriate.
• For a child whose first remission has not yet been obtained, or one
who is in relapse, all elective dental procedures should be deferred.
• However, it is essential that potential sources of systemic infection
within the oral cavity be controlled or eradicated whenever they are
recognized (e.g., immediate extraction of carious primary teeth with
pulpal involvement).
• Routine preventive, restorative, and surgical procedures can usually
be provided for a patient who is in complete remission yet is
undergoing chemotherapy.
• The time when such procedures may be completed without
complications will depend on the specifi c agents administered and
the time of administration.

64. • Before the appointment— preferably the same day—a blood cell profile (complete blood
count) and platelet count should be taken to confirm that the patient is not unexpectedly at
undue risk for hemorrhage or infection.
• A patient who has been in complete remission for at least 2 years and no longer requires
chemotherapy may be treated in an essentially normal manner.
• A preappointment blood workup is not necessary.
• Pulp therapy on primary teeth is contraindicated in any patient with a history of leukemia.
• Endodontic treatment for permanent teeth is not recommended for any patient with leukemia
who may have a chronic, intermittent suppression of granulocytes.
• Even with the most exacting technique, an area of chronic inflammatory tissue may remain
in the periapical region of endodontically treated teeth.
• An area of low-grade, chronic inflammation in a healthy patient is generally well tolerated,
but in an immunosuppressed, neutropenic patient the same area can act as an anachoretic
focus with devastating sequelae.
• The decision to perform an endodontic procedure on a patient who has been in prolonged
complete remission and who is not undergoing chemotherapy must be made by the dentist.

65. • A platelet level of 100,000/mm3 is adequate for most dental
procedures (Table 24-3).
• Routine preventive and restorative treatment, including
nonblock injections, may be considered when the platelet
count is at least 50,000/mm3.
• With inadequate oral hygiene, unhealthy periodontal tissues,
and the presence of local irritants, hemorrhage from the
gingival sulcus may be observed when platelet counts are
between 20,000 and 50,000/ mm3.
• Such hemorrhaging is usually noted only after manipulation of
the tissues, such as during toothbrushing.
• .

66. • If the platelet count is lower than 20,000/mm3, all the intraoral
mucosal tissues may show clinical evidence of spontaneous
hemorrhaging (e.g., petechiae, ecchymoses, or frank hemorrhage).
• No dental treatment should be performed at such a time without a
preceding prophylactic platelet transfusion.
• Good oral hygiene must be maintained while the platelet count is at
this level, but it may be necessary to discontinue the use of a
toothbrush and to substitute cleaning with moist gauze wipes,
supplemented by frequent saline rinses.
• The absolute neutrophil count (ANC) is an indicator of the host’s
ability to suppress or eliminate infection.
• It is calculated using the following formula:
• ANC (% of neutrophils % of bands) total white x count 100

67. • The clinical significance of the ANC is presented in Table 24-4.
• If the ANC is less than 1000/mm3, elective dental treatment should
be deferred.
• A leukemic patient with a low ANC may require prophylactic broad-
spectrum antibiotic therapy before certain dental procedures.
• The patient’s physician should be consulted regarding the appropriate
drugs and dosages.
• Infection and hemorrhage are the primary causes of death other than
resistant disease or relapse in children with leukemia.
• Therefore the primary objective of dental treatment in a child with
leukemia should be the prevention, control, and eradication of oral
inflammation, hemorrhage, and infection.

68. • Frequently, initial oral manifestations of bleeding or infection are
observed in association with an unhealthy periodontium.
• In patients with leukemia who are neutropenic or who are being treated
with corticosteroids, the true degree of periodontal inflammation or
infection may be masked, because the cardinal signs of inflammation
may not be apparent.
• There is a much greater propensity for gingival bleeding when the
periodontium is unhealthy.
• When oral hygiene is neglected and local irritants are present,
spontaneous hemorrhaging from the gingival sulcus may be observed if
the patient is thrombocytopenic.
• It is imperative that a patient who is diagnosed as having leukemia be
enrolled in a good preventive dental care program in which special
emphasis is placed on the initiation and maintenance of a comprehensive
oral hygiene regimen.

69. • The use of a soft nylon toothbrush for the removal of plaque is
recommended, even if the patient is thrombocytopenic.
• As long as the gingiva remains in a healthy state and its manipulation by
brushing does not induce significant hemorrhage, it is not appropriate to
discontinue the use of a toothbrush because of the platelet level alone.
The practicality of flossing must be assessed on an individual basis. It is
important that significant local irritants, including orthodontic
appliances, be removed.
• Scaling and subgingival curettage should not necessarily be perceived as
elective dental treatment in all patients.
• This is especially true if the anticipated clinical course may place the
patient at high risk for hemorrhage and infection.
• Patients with classic leukemic gingivitis experience varying degrees of
discomfort. The use of warm saline rinses several times each day may
assist in the relief of symptoms.

70. • Erosive or ulcerative lesions are common in children with leukemia.
• These lesions are often associated with the use of certain
chemotherapeutic agents (see Table 24-2), especially methotrexate
and the anthracycline antibiotics daunomycin and doxorubicin.
• The lesions may be an early indicator of drug toxicity. After
administration of the drug is discontinued and the ANC has
recovered, these lesions usually disappear within a few days.
• Treatment is directed toward the relief of discomfort (Table 24-5).
• In a patient who is granulocytopenic, trauma may result in the
occurrence of ulcerative lesions, especially along the lateral border of
the tongue and buccal mucosa.
• The clinical course of these ulcerations is generally benign, although
the time necessary for healing may be prolonged.

71. • Use of topical obtundents for pain may be the only treatment indicated.
• Infrequently, deep lesions will bleed spontaneously or as a result of
trauma.
• Local measures, such as the topical application of either bovine thrombin
or Avitene, and the placement of an oral adhesive for protection, may be
benefi cial.
• In a patient who is physically debilitated or who is in relapse, septic, and
severely granulocytopenic, ulcerative lesions require close observation.
• Such lesions may serve as a nidus for the proliferation of
microorganisms, which can lead to potentially fatal viral, fungal, or
bacterial infection.
• Therefore specimens from these ulcerative lesions should be cultured and
subsequent sensitivity testing performed, and antibiotic therapy should
be initiated or modifi ed accordingly.

72. • Candidiasis is common in children with leukemia.
• They are especially susceptible to this fungal infection because of
• (1) general physical debilitation,
• (2) immunosuppression,
• (3) prolonged antibiotic therapy,
• (4) chemotherapy, and
• (5) poor oral hygiene.
• The following topical use of nystatin can be particularly beneficial:
• Nystatin oral suspension, 100,000 U/mL
• Swish 5 mL for 5 minutes and then swallow
• Repeat every 6 hours; continue for 48 hours after lesions disappear

73. • In more resistant cases of oral candidiasis, fluconazole
may be useful, administered once daily either orally or
intravenously (in young children 6 mg/kg on day 1, then
3 mg/kg to a maximum of 12 mg/kg per day; in older
children and adults 200 mg on day 1, then 100 mg).
• For patients who are thrombocytopenic or at risk for
intermittent episodes of thrombocytopenia because of
chemotherapy or active disease, the dentist should avoid
prescribing drugs that may alter platelet function, such as
salicylates (aspirin) and nonsteroidal anti-inflammatory
drugs.

74. SOLID TUMORS
• Solid tumors account for approximately half of the cases of
childhood malignancy.
• The most common tumors include brain tumors, lymphoma,
neuroblastoma, Wilms tumor, osteosarcoma, and
rhabdomyosarcoma.
• Because many of the malignancies can involve bone marrow
and their treatment with chemotherapy and radiation can
suppress marrow function, many of the complications seen in
acute leukemia are also seen with these patients.
• Bleeding diatheses and the propensity to infection are the most
notable medical complications seen.
• In general, the dental management of patients with solid
tumors is similar to that of patients with acute leukemia.

75. VIRAL HEPATITIS
• Viral hepatitis is an infection that produces inflammation of liver cells, which may lead to
necrosis or cirrhosis of the liver. Acute hepatitis classically presents with lethargy, loss of
appetite, nausea, vomiting, abdominal pain, and ultimately jaundice. Acute viral hepatitis
may be caused by any of the following: hepatitis A virus (HAV), hepatitis B virus (HBV),
hepatitis delta virus (HDV), and two forms of non-A, non-B hepatitis virus (NANB)—
parenterally transmitted NANB or hepatitis C virus (HCV), and enterically transmitted
• NANB or hepatitis E virus. Infection with hepatitis A virus results in an acute febrile illness
with jaundice, anorexia, nausea, and malaise.
• Most HAV infections in infants and children cause mild, nonspecifi c symptoms without
jaundice. HAV is spread by the fecal-oral route and is endemic in developing areas. Spread
occurs readily in households and day-care centers, where symptomatic illness occurs
primarily among adult contacts of children. No HAV carrier state exists, and the presence of
immunoglobulin G–anti-HAV indicates past infection and lifelong immunity to HAV.
• The risk for transmission in a dental setting is low. Hepatitis B transmission is of major
concern to the dentist. Members of the dental profession assume a risk for acquiring HBV
that is at least three times higher than that in the general population. An additional concern,
beyond that of acquiring HBV, is the potential of becoming an asymptomatic yet infectious
carrier of HBV and of having the capability of transmitting the disease to patients and dental
staff members and family.

76. • HBV is transmitted from person to person by parenteral, percutaneous, or mucous
membrane inoculation. It can be transmitted by the percutaneous introduction of blood,
administration of certain blood products, or direct contact with secretions contaminated with
blood containing HBV. Infection may also result from inoculation of mucous membranes,
including sexual transmission. Wound exudates contain HBV, and open-wound to
openwound contact can transmit infection. There can also be vertical transmission from an
infected mother to her baby, and this frequently leads to chronic infection.
• A medical history is unreliable in identifying patients who have HBV infection, because
approximately 80% of all HBV infections are undiagnosed. However, the medical history is
useful in identifying groups of patients who are at higher risk of being undiagnosed carriers.
Among populations at high risk for HBV infection are patients undergoing hemodialysis,
patients requiring frequent large-volume blood transfusions or administration of clotting
factor concentrates, residents of institutions for the mentally disabled, and users of illicit
injectable drugs. In 2006, an estimated 46,000 people in the United States became infected
with HBV, and an estimated 1.25 million chronically infected people live in the United
States. Overall, chronic liver disease from hepatitis B claims 5000 lives a year in the United
States.39 Chronic active hepatitis develops in more than 25% of carriers and often
progresses to cirrhosis. Furthermore, HBV carriers have a risk of developing primary liver
cancer that is between 12 and 300 times higher than that of uninfected individuals.

77. • For detection of acute or chronic HBV infection, the serologic
test for hepatitis B surface antigen (HepBsAg) is most
commonly used. The antibody to surface antigen (HepBsAb or
anti-HepBsAg) is protective and indicates a resolved natural
infection or successful vaccination. Antibody to the core
antigen (HepBcAb or anti-HepBc) indicates exposure to
natural hepatitis B virus but can be present in either resolved or
chronic infection. The hepatitis Be antigen (HepBeAg) is a
useful marker for infectivity. Patients who test positive for
HepBeAb and HepBsAg are most likely to transmit the
disease. If the patient still shows a positive test result for
HepBsAg 6 months after an acute HBV infection, the patient is
considered to be chronically infected.

78. • The availability of a safe, effective hepatitis B vaccine affords the
dentist and staff additional protection against acquiring HBV
infection. HBV vaccine is recommended for all health care
personnel. The vaccine is derived using recombinant DNA and
therefore does not have the potential to transmit the disease. When
administered in a three-dose injection regimen (0, 1, 6 months), the
recombinant
• DNA vaccine induced protective antibody (anti-HepBs) in 95% to
100% of adults.
• A fulminant type of hepatitis occurs with infection by HDV but only
with coexisting or simultaneous infection with HBV. HDV is
defective in that it requires HBV for outer coat proteins (HepBsAg),
as well as requiring HBV for replication. Transmission is similar to
that of HBV, by parenteral, percutaneous, or mucous membrane
inoculation.

79. • According to Cottone,40 HDV infection occurs in two primary
modes:
• The first is simultaneous infection with HBV and HDV.
• When simultaneous infection occurs, the acute clinical course
of hepatitis often is limited with resolution of both hepatitis B
and HDV infections. The second mode of transmission, acute
delta super-infection, involves those with chronic Hepatitis B
infection. In this
• situation, the patient already has a high titer of circulating
HepBsAg; thus HDV can rapidly replicate. These patients are
more likely to have a serious and possibly acute fulminant
form of hepatitis that more often leads to chronic HDV.

80. • Hepatitis C (formerly known as parenterally transmitted NANB hepatitis) is of
great concern to the dentist, because it can be transmitted by needle stick (risk of
about 1.8% with a range of 0% to 10%) and no immunization is available.
Patients at risk for hepatitis C include those who received blood transfusions or
organ transplants before 1992, those who received clotting factors before 1987,
those on long-term dialysis, and most commonly those who have experimented
with illicit intravenous drugs regardless of how many times or how long ago. Of
those infected, chronic infection develops in 70% to 85%, and chronic liver
disease develops in about 70%. Although only 3% of infected people die of liver
failure, hepatitis C is the leading reason for liver transplantation in adults in the
United States. In 1989, parenterally transmitted NANB was identifi ed as HCV.
Subsequently, three genotypes have been identifi ed. Diagnosis is made by
detection of antibody to hepatitis C virus (anti-HCV) in the serum and can be
confirmed by radioimmunoblot assay. Polymerase chain reaction (PCR) testing
can be done in a qualitative fashion to confirm diagnosis or in a quantitative
fashion to assess response to treatment. Treatment, when indicated, includes
administration of interferon or pegylated interferon with or without ribavirin.
Response rates vary from 50% for type 1 infection to 80% for types 2 and 3.

81. CARDIOVASCULAR
DISEASE

82. Heart Failure
• Heart failure is not a disease per se but rather a clinical syndrome
complex that results from an underlying cardiovascular problem such
as coronary heart disease or hypertension. The underlying cause of
heart failure should be identified and its potential significance
assessed. Patients with untreated or symptomatic heart failure are at
increased risk for myocardial infarction (MI), arrhythmias, acute
heart failure, or sudden death and generally are not candidates for
elective dental treatment.
• Chair position may influence a patient’s ability to breathe, with some
patients unable to tolerate a supine position. Vasoconstrictors should
be avoided, if possible, in patients taking digitalis glycosides
(digoxin) because the combination can precipitate arrhythmias.
• Stress reduction measures also may be advisable

83. Heart Attack
• A history of a heart attack (MI) within the very recent past may
preclude elective dental care because during the immediate
postinfarction period, patients have increased risk for
reinfarctions, arrhythmias, and heart failure. Patients may be
taking medications such as antianginals, anticoagulants,
adrenergic blocking agents, calcium channel blockers,
antiarrhythmic agents, and digitalis. Some of these drugs may
alter the dental management of patients because of potential
interactions with vasoconstrictors in the local anesthetic, drug
adverse effects, or other considerations. Stress and anxiety
reduction measures may be advisable.

84. Angina Pectoris
• Brief substernal pain resulting from myocardial ischemia,
commonly provoked by physical activity or emotional stress, is
a common and significant symptom of coronary heart disease.
Patients with angina, especially unstable angina, are at
increased risk for arrhythmias, MI, and sudden death. A variety
of vasoactive medications, such as nitroglycerin, beta-blocking
agents, and calcium channel blockers, are used to treat angina.
Vasoconstrictors should be used cautiously. Patients with
unstable or progressive angina are not candidates for elective
dental care (see Chapter 4). Stress and anxiety reduction
measures may be appropriate

85. High Blood Pressure
• Patients with hypertension (blood pressure greater than 140/90 mm
Hg) should be identified by history and confirmed by blood pressure
measurement. Patients with a history of hypertension should be asked
if they are taking or are supposed to be taking antihypertensive
medication. Failure to take medication is often the cause of elevated
blood pressure in a patient who reports being under treatment for
high blood pressure.
• Current blood pressure readings and any symptoms that may be
associated with hypertension, such as visual changes, dizziness, and
headaches, should be noted. Some antihypertensive medications,
such as the nonselective beta-blocking agents, may require cautious
use of vasoconstrictors.
• Stress and anxiety reduction measures also may be appropriate (see
Box 1-1). Elective dental care should be deferred for patients with
blood pressure ≥180/110.

86. Heart Murmur
• A heart murmur is caused by turbulence of blood fl ow that produces vibratory
sounds during the beating of the heart. Turbulence may result from physiologic
(normal) factors or pathologic abnormalities of the heart valves, vessels, or both.
The presence of a heart murmur may be of signifi cance in the dental patient in
that it may be an indication of underlying heart disease.
• The primary goal is to determine the nature of the heart murmur; consultation
with the patient’s physician is often necessary to make this determination.
Previously, the
• American Heart Association recommended antibiotic prophylaxis for many
patients with heart murmurs caused by valvular disease (e.g., mitral valve
prolapse, rheumatic heart disease); however, on the basis of accumulated
scientific evidence, recently revised guidelines have omitted this
recommendation. If a murmur is due to a specific cardiac condition (e.g.,
previous endocarditis, prosthetic
• heart valve, complex congenital cyanotic heart disease),
• the American Heart Association recommends antibiotic
• prophylaxis for most dental procedures