Deals with the oral manifestations and dental management of patients with different neuromuscular diseases.

1. Dr. Vibhuti Kaul

2. INTRODUCTION

5. CEREBROVASCULAR DISEASE

6. • CVA is a focal neurologic disorder
caused by destruction of brain
substance as a result of intracerebral
hemorrhage, thrombsis, embolism, or
vascular insufficiency.
• Also known as stroke, cerebral
apoplexy, and “brain attack”.

8. CLINICAL MANIFESTATIONS OF
CVAs
INFARCTION
• Gradual onset of signs and symptoms
• TIA frequently preceding
• Headache, usually mild
• Neurologic signs and symptoms
• Transient monocular blindness-TIA
EMBOLISM
• Abrupt onset of signs and symptoms
• Mild headache preceding neurologic signs and symptoms
HEMORRHAGE
• Abrupt onset of signs and symptoms
• Sudden, violent headache
• Nausea and vomiting
• Chills and sweating
• Dizziness and vertigo
• Neurologic signs and symptoms
• Loss of consciousness

9. PATHOPHYSIOLOGY
The following 2 important factors work
together to produce a CVA:
1. The brain’s continual requirement for
large amounts of O2 and energy
substrate.
2. The inability of the brain to expand
within its confining bony space, the
cranium.

10. Basal Ganglia haemorrhage with
intraventricular extension

11. Small cortical haemorrhage

12. Large hemorrhage with mass effects

13. MANAGEMENT
• Discontinuation of the dental procedure,
activation of dental office emergency team
• P (position)- Semi-Fowler position
• A-B-C
• D (definitive care)
– Activation of emergency medical service (EMS)
– Monitoring of vital signs
– Management of signs and symptoms
– Administration of O2

14. SEMI-FOWLER POSITION

15. Oral Health Considerations
• Pts on anticoagulant therapy may have a
predisposition to excessive bleeding, obtain
coagulation profiles
• Xerostomia (S/E of medications) -> higher caries rate
• Meticulous oral hygiene, freq recalls, saliva
substitutes, and fluoride application
• Pts with weakness in the muscles of the orofacial area
may have poor control of oral secretions, a reduced
gag reflex, and changes in their ability to masticate,
leading to poor nutrition

16. Oral Health Considerations
• In general, dental treatment should not
present major problems for most
poststroke patients.
• Careful history taking, checking of blood
pressure prior to treatment, avoidance of
lengthy appointments, and general
reassurance are all important factors in
the provision of dental treatment for
patients with a history of stroke.

17. MULTIPLE SCLEROSIS

18. Multiple Sclerosis
relapsing remitting
autoimmune
inflammatory
demyelinating disease
of the central nervous
system

19. Photomicrograph from demyelinating plaque
showing perivascular cuffing of blood vessel
by lymphocytes

21. T2 image T1 image with gadolinium enhancement

22. Oral manifestations & considerations
• Dysarthria, paresthesia, numbness of the
orofacial structures, or trigeminal neuralgia
may be one of the first signs of MS
• Scanning speech
• Myokymia of perioral or periorbital muscles
occurring during waking hours only

23. Dental Management
• Appointments should be short & in the
morning to reduce likelihood of a relapse
• Some pts require physical assistance
because of muscle weakness
• LA can be administered w/o concern
• Conscious sedation/GA- likely to exacerbate
symptoms
• Pt may be on corticosteroids- HPA
suppression

24. Dental Management
• MS can incapacitate some pts and make
good oral hygiene practices impossible. In
this instance, a relative/nurse should be
apprised about the importance of daily home
care.
• Placement of FPD/RPD should be based not
only on the oral findings, but also on the
physical ability of the patient to maintain oral
health.

25. AMYOTROPHIC LATERAL
SCLEROSIS

26. • Amyotrophic lateral sclerosis (ALS),
also known as Lou Gehrig disease
and motor neuron disease, belongs to
a group of degenerative diseases
affecting both the upper and the lower
motor neurons of the central nervous
system

27. • The degenerative changes of ALS
can be seen in the corticospinal tracts
(upper motor neurons), the motorcells
of the brainstem, and the anterior
horn cells of the spinal cord (lower
motor neurons).

29. • Cramping and fasciculation of the
muscles of the forearm, upper arm,
and shoulder girdle also appear.
• Before long, the triad of atrophic
weakness of the hands and forearms,
light spasticity of the arms and legs,
and generalized hyperreflexia (in the
absence of sensory changes) leaves
little doubt as to the diagnosis.

30. • After some time, the disease affects all
regions, including the muscles of
mastication, facial expression, and tongue,
leading to difficulties in mastication and
speech.
• Dysfunction of the temporomandibular joint
and the development of malocclusion may
also occur as the disease progresses.
• Aspiration pneumonia is the cause of death
in most patients with ALS.

31. Oral manifestations & considerations
• Cranial involvement produces
fasciculations, muscle wasting, &
eventual paralysis of tongue along
with dysphagia & dysphonia
• Initial complaint may be inability to
eat properly or expelling of food into
the nose during swallowing
• The tongue shrinks & fissures along
the dorsal surface become apparent

32. Dental Management
• Physical assistance
• Use of mouth props
• A relative/nurse should provide daily
oral health care
• Complex reconstructive procedures
are C/I due to inability of pt to
maintain good oral hygiene

33. PARKINSONISM

34. • Parkinsonism is a neurodegenerative
disorder characterized by rigidity, tremors,
bradykinesis, and impaired postural reflexes.
• The most common form of parkinsonism is
Parkinson’s disease (paralysis agitans), but
parkinsonism is seen in a variety of disorders
such as postencephalitic parkinsonism,
arteriosclerotic parkinsonism, and post-traumatic
parkinsonism following closed head
injury.

35. ETIOPATHOGENESIS
• In idiopathic parkinsonism, dopamine
depletion due to degeneration of the
dopaminergic nigrostriatal system in the
brainstem leads to an imbalance of
dopamine and acetylcholine,
neurotransmitters that are normally present
in the corpus striatum.
• Symptoms similar to parkinsonism may also
be induced by drugs that cause a reduction
of dopamine in the brain, the most common
of the drugs being phenothiazine derivatives.

36. ETIOPATHOGENESIS
• Although a definite etiology has not
been established, the most likely
explanation is that the disease results
from a combination of accelerated
aging, genetic predisposition, exposure
to toxins, and an abnormality in
oxidative mechanisms

37. Clinical Manifestations
• Tremor, rigidity, bradykinesia, and
postural instability.
• “pill-rolling” tremor
• “masklike” facial appearance
• Abnormalities in oral behavior, such
as purposeless chewing, grinding,
and sucking movements

39. Oral manifestations & considerations
• ↑ Salivation & drooling, angular cheilitis
• Anticholinergic drugs -> xerostomia ->
damage to teeth & PDL, difficulty retaining
dentures, mucosal ulcerations, denture
sores, increased chance of bacterial &
fungal infections.
• Loss of facial expression, difficulty with
mastication, & slow speech that is soft &
fading
• Tremors of the head, lips & tongue

40. Dental Management
• Periodontal recall every 4-6 mo
• Enameloplasty or mouth guard to prevent
irritations to tongue due to tardive
dyskinesia
• Salivary substitutions & topical fluoride Rx
in pts with xerostomia
• Antibacterial rinses & antifungal ointments
to limit microbial Ds

41. Dental Management
• Chair position- 45o to limit muscle rigidity & breathing
difficulties
• At the end of appt- chair should be slowly raised to
prevent orthostatic hypotension
• Physical assistance may be required
• Appointments should be short & relaxing
• N2O sedation helps reduce stress & prevalence of tremors
• IV sedation/GA is a better alternative for pts with severe
l/o control over muscle movement
• Anticholinergics, rubber dam & saliva ejectors enhance
likelihood of successful dental procedures

42. HUNTINGTON’S DISEASE

43. • Huntington’s disease is a hereditary
degenerative disease of the central
nervous system, characterized by
chorea (involuntary movements) and
dementia.

44. Clinical Manifestations
• The earliest manifestation of the disease consists of
depression or irritability, coupled with a slowing of
cognition.
• There are subtle changes in coordination and minor
choreiform movements appear.
• The main clinical manifestation is progressively
worsening choreic movements that can be observed
in the face, tongue, and head.
• With time, the hyperkinesia becomes aggravated,and
movements can become violent, with difficulty in
speech and in swallowing

45. Treatment
• There is no cure for Huntington’s
disease; progression cannot be
halted, and treatment is purely
symptomatic.
• Treatment is usually dependent on
dopamine receptor blocking agents
such as haloperidol and
phenothiazines, which temporarily
reduce the hyperkinesis and the
behavior disturbances.

46. Oral Health Considerations
• Dysphagia and choreic movement of
the face and tongue will make dental
treatment especially challenging.
• Sedation with diazepam may be
considered.
• Whenever possible, dentures should
be avoided because of the danger of
fracture or the accidental swallowing
of the dentures

47. CEREBRAL PALSY

48. • The term “cerebral palsy” refers to a group
of disorders with motor manifestations due
to nonprogressive brain damage occurring
before or after birth.
• Anoxia and ischemia during labor have
been implicated, but congenital infections
such as toxoplasmosis, rubella,
Cytomegalovirus disease, herpes simplex,
syphilis, and influenza have also been
associated with CP or mental retardation.

50. Oral manifestations & considerations
• Nonspecific, vary depending upon type of
palsy & degree of motor & mental deficit
• Some patients develop spastic movements
of the tongue whereas others develop
gingival hyperplasia from dilantin therapy
• Malocclusion- due to abnormal muscle
tonicity, narrow maxilla, V-shaped arch
with high palatal vault, labially inclined
maxillary teeth due to constant tongue
thrusting

51. Oral manifestations & considerations
• Dystonia of oral musculature leads to
drooling & abnormal swallowing
• When the upper extremities are severely
involved, oral cleansing is impaired, &
caries & periodontal disease are common
• Mouth breathing worsens these conditions

52. Dental Management
• Before starting Rx, determine IQ & degree of
physical impairment
• Communication should be effective &
thorough
• Pt can be transferred from wheelchair by
sliding a board placed btw wheelchair &
dental chair
• Uncomplicated cerebral palsy pts can
receive routine dental care

53. Dental Management
• Sedation/GA is often necessary in the severely
diseased patients to maintain a stationary
position & to relax the skeletal muscles
• Anxiolytics drugs are helpful- suppress
athetoid & spastic movements
• Drooling is a minor problem- oral evacuation &
4-handed dentistry
• Preventive dental care & parental counseling is
advised
• Concurrent epilepsy is managed accordingly

54. BELL’S PALSY

55. Clinical Manifestation
• Bell’s palsy begins with slight pain around
one ear, followed by an abrupt paralysis of
the muscles on that side of the face.
• The eye on the affected side stays open,
the corner of the mouth drops, and there is
drooling.
• As a result of masseter weakness, food is
retained in both the upper and lower buccal
and labial folds.

56. Clinical Manifestation
• The facial expression changes remarkably,
and the creases of the forehead are
flattened.
• Due to impaired blinking, corneal
ulcerations from foreign bodies can occur.
• Involvement of the chorda tympani nerve
leads to loss of taste perception on the
anterior two-thirds of the tongue and
reduced salivary secretion.

57. House-Brackmann Scale
Grade Definition
I Normal symmetrical function in all areas
II Slight weakness noticeable only on close inspection
Complete eye closure with minimal effort
Slight asymmetry of smile with maximal effort
Synkinesis barely noticeable, contracture, or spasm absent
III Obvious weakness, but not disfiguring
May not be able to lift eyebrow
Complete eye closure and strong but asymmetrical mouth movement
with maximal effort
Obvious, but not disfiguring synkinesis, mass movement or spasm
IV Obvious disfiguring weakness
Inability to lift brow
Incomplete eye closure and asymmetry of mouth with maximal effort
Severe synkinesis, mass movement, spasm
V Motion barely perceptible
Incomplete eye closure, slight movement corner mouth
Synkinesis, contracture, and spasm usually absent
VI No movement, loss of tone, no synkinesis, contracture, or spasm
House, J.W. and Brackmann, D.E. (1985) Facial nerve grading system. Otolaryngol.
Head Neck Surg., 93, 146–147.

58. The most common symptoms of facial
synkinesis include:
• Eye closure with volitional contraction
of mouth muscles
• Midfacial movements with volitional
eye closure
• Neck tightness (Platysmal
contraction) with volitional smiling
• Hyperlacrimation(also called
Crocodile Tears)
Mehta RP, WernickRobinson M, Hadlock TA. (2007). "Validation of the Synkinesis
Assessment Questionnaire.". Laryngoscope. 117 (5): 923–6.

61. TREATMENT
• Spontaneous improvement is generally seen
within 6 months in most cases. However,
15% show incomplete recovery.
• Rx is more likely effective before 72 hrs &
less effective after 7 days.
• Combination of acyclovir 400 mg 5x daily
with prednisolone (40-60 mg daily) for week
is believed to be more effective than steroid
alone.

62. TREATMENT
• Supportive measures include: protecting the
cornea with an eyelid or surgical placement
of gold weights in the upper lid.
• Artificial tear substitutes should be used.
• Bell’s palsy & blepharospasm can be Rxd
with botulinum toxin.
• Physiotherapy

63. GUILLAIN-BARRÉ SYNDROME

64. • Guillain-Barré syndrome (acute idiopathic
polyneuropathy)is an acute symmetrical
ascending polyneuropathy, often
occurring 1 to 3 weeks (and occasionally
up to 8 weeks) after an acute infection.
• The Guillain-Barré syndrome often follows
a non-specific respiratory or
gastrointestinal illness but has also been
described after a few specific infections
(such as with Cytomegalovirus, Epstein-
Barr virus, Enterovirus, Campylobacter
jejuni, or Mycoplasma) and after
immunization.

65. Clinical Manifestations
• The syndrome often begins with myalgia
or paresthesias of the lower limbs,
followed by weakness, which often
ascends to involve abdominal, thoracic,
and upper-limb muscles.
• In severe cases, respiration is
compromised.
• Involvement of the ANS may induce
changes in blood pressure and pulse rate.

66. Clinical Manifestations
• Impaired swallowing or paresthesias ofthe
mouth and face may be early signs of the
disease.
• The seventh cranial nerve is frequently
involved, and bilateral facial weakness is
common.
• Involvement of other cranial nerves may
result in ptosis or facial myokymia.
• Dysarthria, dysphagia and diplopia may
develop in severe cases.

67. Treatment
• The paralysis in Guillain-Barré syndrome may
progress for about 10 days and may then remain
relatively unchanged for about 2 weeks.
• The recovery phase is much slower and may take
from 6 months to 2 years for completion.
• Permanent signs of neurologic damage can persist in
some patients.
• Prednisone is ineffective and may actually affect the
outcome adversely.
• Plasmapheresis is of value; however it is best
performed within the first few days of illness and is
best reserved for clinically severe or rapidly
progressive cases.

69. MYASTHENIA GRAVIS

70. • Myasthenia gravis (MG) is a disease
characterized by progressive muscular
weakness on exertion, secondary to a
disorder at the neuromuscular junction.
• Autoantibodies that combine with and
may destroy the acetylcholine receptor
sites at the neuromuscular junction are
present, preventing the transmission of
nerve impulses to the muscle.

71. A patient with myasthenia gravis produces autoantibodies to the
acetylcholine receptors on the motor end-plates of muscles.
Binding of acetylcholine is blocked and muscle activation is
inhibited. The autoantibodies also induce complement-mediated
degradation of the acetylcholine receptors, resulting in progressive
weakening of the skeletal muscles.

72. • Patients present with ptosis, diplopia,
difficulty in chewing or swallowing,
respiratory difficulties, limb
weakness, or some combination of
these problems.
• In severe advanced cases,
respiratory difficulty arises.

75. Oral manifestations & considerations
• Dysphagia, dysphonia, dysarthria w/o
concomitant sensory dysfunction
• Pt’s tongue may be supple & flaccid,
with b/l grooves on the dorsal surface
(due to atrophy of tongue
musculature)
• Palatal muscles may be affected,
causing pt to have difficulty in
elevating soft palate

76. Dental Management
• Observe fir weakness of masseter, soft
palatal & glossal muscles
• Chair position- 45o
• Anticholinergic agents & morphine should
be avoided because they increase muscle
weakness
• Sedative agents, narcotics, aminoglycosides
should not be prescribed
• Pts on corticosteroids require physician
consultation prior to dental Rx

77. MUSCULAR DYSTROPHY

78. • Muscular dystrophy (MD) is a genetic
disease characterized by muscle atrophy
that causes severe progressive weakness.
• The various forms of MD are genetically
determined myopathies characterized by
progressive muscular weakness and the
degeneration of muscle fibers.
• The muscular dystrophies are classified
according to mode of inheritance, age at
onset, and clinical features.

80. TYPES
• Duchenne’s MD
• Becker’s MD
• Facioscapulohumeral dystrophy
• Limb-girdle dystrophy
• Oculopharyngeal MD
• Myotonic dystrophy

82. TREATMENT
• All forms of MD are incurable, and no
satisfactory method of retarding the muscle
atrophy exists.
• Corticosteroids have been shown to
decrease the rate of muscle loss, but only in
the short term.
• A physical therapy program will help to delay
the development of joint contractures, and
orthopedic procedures may help to
counteract deformities. The ultimate outcome
in severe forms of the disease is grave.

83. Oral Health Considerations
• Oral and facial signs are prominent in the
facioscapulohumeral and myotonic forms of MD.
• Myotonic-type Ds-> severe atrophy of SCM
• The muscles of facial expression and mastication
are also commonly affected, such that the patient
has difficulty in chewing or in pursing the lips.
• Weakness of the facial muscles and enlargement
of the tongue due to fatty deposits has been
occasionally observed
• Oculopharyngeal Ds-> Dysphagia
• Occlusal abnormalities, macroglossia, anterior
open bite, occasionally TMD

84. SEIZURE DISORDER

85. SEIZURES
• paroxysmal disorder of cerebral
function characterized by an attack
involving changes in the state of
consciousness, motor activity or
sensory phenomenon.

86. TYPE OF SEIZURES

88. Predisposing factors
• Hypoxia, hypoglycaemia,
hypocalcemia, stress, fatigue, missed
meal, alcohol ingestion.

89. MANAGEMENT OF PETIT MAL AND PARTIAL
SEIZURES
Diagnostic clues to presence of
these seizures include:
• Sudden onset of immobility and blank
stare
• Show blinking of eyes
• Short duration
• Rapid recovery

90. Terminate the dental procedure
Position the patient comfortably
Seizure stops seizure continues > 5 min
Reassure patient summon medical assistance
Allow patient to recover basic life support as indicated
and discharge

91. GENERALIZED TONIC CLONIC SEIZURES
Diagnostic clues:
-Prodromal symptoms – marked anxiety
or depression
• Presence of aura prior to loss of
consciousness
• preictal phase- Loss of
consciousness, epileptic cry, increase
in HR and BP upto twice baseline,
apnea

92. Ictal phase
• tonic phase lasts from 10 to 20 seconds -
dyspnea and cyanosis .
• Clonic phase lasting for 2 to 5 minutes
heavy, stertous breathing, frothing, blood
from mouth, clenched teeth, tongue biting.
Postictal phase
• consciousness returns, urinary and fecal
incontinence due to muscle flaccidity

93. MANAGEMENT
Prodromal stage
Terminate the dental procedure
Ictal stage
Position the patient (supine with legs elevated slightly
Summon medical assistance
Protect patient from injury
Basic life support as indicated
Administer oxygen
Monitor vital signs
Post ictal stage
Basic life support as needed
Reassure patient and allow to recover
Discharge patient

94. MANAGEMENT OF STATUS
EPILEPTICUS
Prodromal stage
Terminate the dental procedure
Ictal stage
Position the patient (supine with legs elevated slightly)
Summon medical assistance
Protect patient from injury
Basic life support as indicated
Administer oxygen
Monitor vital signs
Seizure continues > 5 min
Basic life support perform venipuncture,
until assistance arrives administer iv anticonvulsant
administer 50% dextrose iv
definitive management
( phenytoin (15mg/kg)
Phenobarbital (10 to 15 mg/kg, Neuromuscular blockade with
pancuronium)

95. DENTAL THERAPY CONSIDERATIONS
• Psychologic stress and fatigue tends to increase
the probability of seizure developing. So psycho
sedation should be considered in such patients.
Inhalation sedation with nitrous oxide (upto 20%)
and oxygen is highly recommended.
• BZDs (diazepam, oxazepam, triazolam) are
recommended for adult patients whereas chloral
hydrate, promethazine and hydroxyzine are
suggested for children.

96. Oral manifestations & considerations
• Phenytoin- gingival hyperplasia
• Edentulous pts on phenytoin with ill-fitting
dentures frequently have
inflammatory hyperplasia
• Phenytoin rarely causes folate
deficiency & megaloblastic anemia
which may be associated with oral
aphthae

99. Oral manifestations & considerations
• Tonic-clonic convulsions can result in
traumatic injuries to the oral cavity
• Traumatic purpura & lacerations of
the tongue & buccal mucosa are
common, whereas devitalized teeth
or orofacial fractures may result from
falls
• Intense clenching of the teeth can
result in wear faceting when seizures
are frequent & severe

100. GUIDELINES FOR ORAL HEALTH CARE
OF PATIENTS WITH NEUROMUSCULAR
DISEASE

101. DISEASE RISK CATEGORY
Amyotrophic Lateral sclerosis
Early II
Late II, IV
Cerebral Palsy
Mild to Moderate II/III
Severe: profound retardation, epilepsy IV
Multiple sclerosis II/III
Myasthenia gravis II/III
Parkinson’s disease II/III
Cerebrovascular Accident
1 CVA >6mo earlier with no/minor neurologic deficit II
1 CVA within 6mo with/without neurologic deficit III
>1 CVA within the past year, severely debilitated IV
Bell’s palsy I/II
Trigeminal neuralgia II
Seizure disorder
<1 seizure per month II
>1 seizure per month & not properly controlled by drugs III

102. MEDICAL CONSULTATION
• S/S suggestive of neurologic disease
• Uncertainty of pt’s medical status, severity
of the ds, the level of control
• A systemic condition is uncontrolled or
poorly controlled in a patient who has not
seen the physician within the last year
• Pt is ASA class II or higher
• Corticosteroids have been taken within the
last 12 months

103. MEDICAL CONSULTATION
• The medications and dosage used are not well
known by the pt
• The need for additional medications, a change in
medication to protect the pt’s health during dental
treatment, or any other special precautions, (eg
presence of a bleeding disorder owing to the
anticoagulant effects of drug therapy) is to be
determined
• There are plans for stressful or complex oral surgical
procedures
• Iatrogenic problem arises from dental treatment (eg
Bell’s palsy that persists >6 hrs after dental injection)

104. STRESS REDUCTION/ANXIOLYTIC
GUIDELINES
• A rapport should be established, to reduce
stress and anxiety
• The type of steroid taken, the dose &
duration of pharmacologic treatment should
be ascertained. Physician should be
consulted to determine the need for
additional steroids. This is particularly
critical when stressful or surgical
procedures are planned.

105. STRESS REDUCTION/ANXIOLYTIC
GUIDELINES
• Pt should obtain proper rest the night before
treatment & should reduce work & social
obligations on the day of treatment
• Appointments should be in the morning & kept
short to minimize stress
• BZDs, which have minor CNS depressant activity,
are the anxiolytic/sedative agents of choice
• In pts with cerebral palsy, anxiolytic drugs are
helpful because they limit anxiety & thereby
suppress athetoid & spastic movements.

106. CHAIR POSITION GUIDELINES
• The dental chair should be placed in a
semireclined position (45o) in pts with
Parkinson’s Ds & in pts with Myasthenia
gravis, owing to muscle rigidity & muscle
weakness that can make breathing difficult
in the reclined position

107. CHAIR POSITION GUIDELINES
• At the end of the appointment, chair should
be slowly raised to prevent orthostatic
hypertension.
• Physical assistance maybe required in pts
for transfer to & from the dental chair.

108. ANESTHESIA GUIDELINES
• Local anesthetics are not associated with
an increased risk of seizures & can be
safely used in pts with seizure disorders
• Intraoral local anesthetics should be
administered slowly with aspiration
• In pts with impaired mental capacity, lip
biting after LA administration is a common
postoperative problem

109. ANALGESIA GUIDELINES
• NSAIDs can be used safely in the majority
of pts with neurologic ds. The major
concern is bleeding tendency, which is
most prevalent in pts with cerebrovascular
ds who take anticoagulant drugs.
• Narcotic analgesics may be prescribed;
however, respiratory depressant narcotics
should be used with caution in pts with
neurologic respiratory difficulties.

110. ANTIBIOTIC GUIDELINES
• Culture & sensitivity testing is
recommended whenever oral infection is
present.
• Oral infections should be treated early
• Oral penicillin can be used safely as long
as pt is not hypersensitive to it
• Broad-spectrum antibiotics should be
prescribed with caution in epileptic women
who use oral contraceptives.

111. ANTIBIOTIC GUIDELINES
• In pts with Myasthenia gravis,
aminoglycoside antibiotics which have a
neuromuscular blocking effect, should be
avoided.
• Pts taking immunosuppressant drugs have
an increased risk of oral infection & may
have delayed healing after oral surgical
procedures.

112. AIRWAY MAINTENANCE & GASEOUS
ADMINISTRATION
• Rubber dam is recommended for routine
operative procedures in pts with neurologic
ds esp in pts with drooling problems
• N2O-O2 therapy is an excellent anxiolytic
• Conscious sedation/GA is likely to
exacerbate symptoms of multiple sclerosis
during post-op period
• Outpatient GA is contraindicated in stroke
pts

113. DRUG EFFECTS & INTERACTIONS
GUIDELINES
• Valproic acid inhibits platelet aggregation &
can produce palatal petechiae & abnormal
bleeding
• Carbamazepine can depress bone marrow
leading to bleeding tendencies & increased
incidence of oral infections
• Primidone & Phenobarbital can cause
ataxia, drowsiness & slow cognition.
Additional sedative & respiratory-depressant
drugs should be avoided

114. DRUG EFFECTS & INTERACTIONS
GUIDELINES
• Anticholinergic agents & narcotics should
be avoided as they depress respiration
• Phenytoin-induced gingival hyerplasia may
compromise periodontal health & esthetics
• Levodopa therapy in Parkinson’s may
induce tardive dyskinesia
• Pts with a H/O corticosteroid therapy (Eg
MS, MG) may have adrenal suppression.
Consultation with their physician is
mandatory.

115. INFECTION-CONTROL GUIDELINES
• Antibiotic prophylaxis & oral antimicrobial rinses
should be considered for used when the pt is
severely immunocompromised
• Normal barrier equipment is mandatory
• Aseptic protocol should be followed
• Contact with blood, saliva, & aerosols should be
minimized by using a rubber dam & high-velocity
evacuation
• Cross-contamination is reduced by wrapping
objects subject to touch & providing for all
instruments required in a single sterile package

116. INFECTION-CONTROL GUIDELINES
• Contaminated instruments should be cleaned of all
bodily fluids before sterilization
• Contaminated disposable supplies should be
discarded in labeled biohazardous bags
• Surfaces should be cleaned & disinfected with the
appropriate disinfectant agents
• Water lines & evacuation system should be
flushed (with disinfectant) when the pt is dismissed
• Sterilize all hand instruments & devices used
during dental care of the patient

117. HEMORRHAGIC DENTAL PROCEDURES
• In pts on warfarin (stroke pts) & on carbamazepine,
CBC, platelet counts, BT, CT, PT, APTT should be
determined before initiating rx
• The dosage of anticoagulant drugs should be
adjusted so the PT & PTT are 1.5 to 2 times normal
control value & the platelet count is above
50,000/mm.
• The physician should be consulted to determine the
need for corticosteroids
• Scrupulous attention should be paid to good surgical
technique & closure
• Local hemostatic agents should be readily available

118. DENTAL EMERGENCIES
Follow normal dental protocol for pts with ASA III
or lower; however, in pts with severe neurologic
ds (ASA IV):
• Pts should receive only emergency rx
• Bleeding is a concern for pts on anticoagulants
• When respiratory difficulties are absent,
narcotic-containing analgesics can be
prescribed
• Severe mental or motor dysfunction mandates
hospitalized dental care

119. MEDICAL EMERGENCIES
Stroke in Evolution
• Recognize the S/S
• Discontinue dental rx & place the pt in a supine
position (Pts with cerebral hemorrhage benefit from a
more upright position)
• Remove all dental equipment from the pt’s mouth &
provide suction to prevent aspiration
• Support the airway
• Monitor respirations, BP & pulse. Administer O2 if
needed
• If symptoms persist >15 mins, call for medical
assistance & begin BLS measures

120. SEIZURES
• Be familiar with the pt’s Hx & recognize S/S
• Place a mouth prop in the pt’s mouth at beginning
of the appointment
• Discontinue dental rx, position the pt such that
little harm can occur
• Cushion the pt’s head & remove all sharp or
breakable equipment from the oral cavity
• Turn the pt to the side, to minimize aspiration of
oral secretions
• Monitor respirations, support the airway, & suction
oral secretions as needed. In case of grand mal
seizure, PP O2 at 5 L/min may be necessary

121. SEIZURES
• If convulsive activity does not cease in 5 min,
administer diazepam up to 10 mg IV, slowly until the
serizure stops
• After the seizure, perform an oral examination to
identify oral lacerations, tooth fractures, & avulsions
• Grand mal seizures are often severe & require
termination of treatment, whereas absence seizures or
focal seizures do not
• Following a severe seizure, discharge the pt with a
responsible adult or admit the pt to the emergency
room for observation by a physician
• Continuous seizure activity for >30 mins w/o recovery
(status epilepticus) mandates emergency transport to
the hospital

122. REFERENCES
• Burket’s Oral Medicine- 11th Ed
• Davidson’s Principles & Practice of Medicine
• Oral Diagnosis, Oral Medicine & Treatment planning- 2nd Ed,
Bricker, Langlais, Miller
• T.B. of Oral Medicine, Oral Diagnostics & Oral Radiology-2nd Ed
Ongole
• House, J.W. and Brackmann, D.E. (1985) Facial nerve grading
system. Otolaryngol. Head Neck Surg., 93, 146–147.
• Mehta RP, WernickRobinson M, Hadlock TA. (2007).
"Validation of the Synkinesis Assessment Questionnaire.".
Laryngoscope. 117 (5): 923–6.
• BMJ 2007;334:201-5