MANAGEMENT OF HYPOTENSION:

The treatment of hypotension is based on treating the etiology. Possible

etiologies include Psychological Factors (Stress), Overdose of Medication,
Postural Changes, Coexisting Disease, Hypovolemia, Anesthetic Overdose,
Reflex (Pain), Hypoxemia, and Hypercarbia.

1. Stop dental treatment and remove all foreign objects from the patient’s
mouth.
2. Administer Oxygen.
3. Place patient in semi-recumbent position with legs elevated above the level of
the heart.
4. Monitor and record vital signs, check pulse for rate, rhythm, and character
(Is it strong, weak, thready, etc.)
5. Check level of consciousness.
6. If patient does not respond to the above treatment a major systemic
complication should be considered. Activate EMS at this point. Consider
possible Pulmonary Embolism, Cerebral Vascular Accident (Stroke),
Myocardial Infarction, and Congestive Heart Failure.
7. If Available start IV (18 gauge catheter with Normal Saline.)

Dental Management, Precautions with hypertensive patients:

 Reduce stress and anxiety during dental treatment: consider the use of
N2O-O2 inhalation sedation and/or premedication with oral anti -anxiety
medications such as benzodiazepines.
 Do not use local anesthetics with vasoconstrictors in patients with
uncontrolled or poorly controlled hypertension. This is defined as any
patient with a systolic blood pressure greater than or equal to 180 mmHg
and/or a diastolic blood pressure greater than or equal to 100 mmHg.
 For patients with controlled hypertension, where the use of local
anesthetics with vasoconstrictors is not contraindicated because of
potential drug interactions, limit the total dose of vasoconstrictor to
maximum of 0.04 mg of epinephrine (2.2 carpules of 2% lidocaine with
1:100,000 epinephrine) or 0.2 mg of levonordefrin (2.2 carpules of 2%
carbocaine with 1:20,000 levonordefrin).

Additional precautions:

o Avoid the use of epinephrine-impregnated gingival retraction

cord.
o Avoid the use of vasoconstrictors for direct hemostasis to control
local bleeding.
o Avoid the use of a local anesthetic with vasoconstrictors for
intraligamentary or infrabony infiltrations.
 Avoid stimulating the gag reflex in patients with a history of
hypertension.
Treatment Planning Considerations:

There are no specific treatment planning modifications or considerations for

patients with controlled hypertension. No elective dental procedures should be
performed on a patient with severe or uncontrolled hypertension .

Valvular Heart Disease (Infective Endocarditis)

Prophylactic measures

1- Careful history taking from patients to identify patients at risk

 Patient with history of congenital heart diseases.
 Patients with history of rheumatic fever.
 Patients with prosthetic valvular heart surgery
2- Medical consultation where indivated
3- Antibiotic coverage should be given to the patient immediately preopertatively
and not 24 hours or more preoperatively.
4- Antibiotic drug should be bactericidal, thus tetracycline which are
bacteriostatic are totally unsuitable.
5- Sufficiently high blood level of the drug should be attained and maintained for
a minimum period of 3 days postoperatively.
Patients at risk from infective endocarditis
High risk
 Prosthetic valves
 Previous infective endocarditis
Variable risk
 Congenital heart disease
 Degenerative(calcific) aortic valve disease
 Hypertrophic cardiomyopathy
 Mitral valve prolapse with systolic murmur
 Rheumatic heart disease
 Syphilitic heart disease
 Hurler's syndrome
 Osteogenesis imperfecta
Procedures requiring antimicrobial prophylaxis in persons at risk from
endocarditis
 Tooth extraction
 Oral surgery involving the periodontal tissues
 Periodontal surgery
 Subgingival procedures including scaling
 Intraligamentary injections
 Reimplanation of avulsed teeth
Procedures for which antimicrobial prophylaxis is not recomme nded in
persons at risk for endocarditis
 Exfoliation of primary teeth
 Local anaesthetic injections, other than intraligamentary
 Non-surgical procedures that do not induce bleeding
Choice of prophylactic antibiotic regimen against infective
endocarditis
The recommendations as follow:
1- Patients not requiring a general anesthetic and with no history
of infective endocarditis:
a.(not allergic to nor received a penicillin more than once in the past
month.
Adult dose: 3 g amoxycillin orally befor the operation, taken in the presence of
the dentist or nurse.
Children under 10: one-half the adult dose
Children under 5: a quarter of the adult dose
b. Patient allergic or who have received a penicillin more than once in the
previous month
Adult dose: a single oral dose of clindamycin 600mg can be given one hour
before the dental procedure
Children under 10: one-half the adult dose
Children under 5: a quarter of the adult dose
-Alternatively , 1.5 g erythromycin stearate can be given orally under
supervision 1-2 hour before the dental procedure, followed by asecond dose of
0.5 g 6 hour later.
Children under 10: one-half the adult dose
Children under 5: a quarter of the adult dose

(Patient who have had endocarditis should be managed as in (2)

below:
2- Treatment under general anaesthesia- patient with natural valve
disease and no history no history of infective endocarditis, but not
allergic to nor received a penicillin more than once in the past month:
Amoxicillin 1 g I.M. or I.V. in 2.5 ml of 1 percent lignocaine before induction
plus 0.5 g of amoxycillin orally 5 hour later.
Alternatively, 3 g of amoxycillin may be given by mouth 4 hours before induction
and repeated as soon as possible after induction, if the anesthetist agrees.
3-Treatment under general anaesthesia – patients with prosthetic
valves or previous endocarditis, not allergic to nor have had a
penicillin more than once within the past month:
Amoxycilline 1 g I.M. in 2.5 ml of 1 percent lignocaine or amoxycillin 1 g I.V..
plus gentamicin 120 mg I.M. or I.V. immediately before induction. A further 0.5
g of amoxycillin should be given orally 6 houe later.
Patient allergic or who have received apenicilline more than once in the previous
month: Vancomycin 1 g by I.V. infusion over 100 min followed by 120 mg of
gentamicin I.V. before induction.
Alternatively, I.V teicoplanin 400 mg plus gentamicin 120 mg may be given at
induction, or I.V. clindamycin 300 mg may be given 10 minutes before induction
followed by oral clindamycin 150 mg after 6 hours.
4- Patients who have had a previous attack of infective endocarditis
(irrespective of the type of anaestlietic) but not allergic to nor
received a penicillin more than once in the past month:
Amoxycilline 1 g I.M. in 2.5 ml of 1 percent lignocain or amoxycillin 1 g I.V. plus
gentamicin 120 mg I.M. or I.V. immediately before dental procedure. A further
0.5 g of amoxycillin should be given orally 6 houe later.
Patient allergic or who have received apenicilline more than once in the previous
month: Vancomycin 1 g by I.V. infusion over 100 min followed by 120 mg of
gentamicin I.V. before induction or Alternatively, I.V teicoplanin 400 mg.
The reason different cover is given for those who are going to have a
general anaesthetic is that:
 Parenteral administration removes the risk of vomiting
 It is not feasible to give such large doses (3g) od amoxycilline for example
by injection, hence it has to supplemented with gentamicin.
Additional measures
1- Application of an antiseptic such as 10 percent povidone-iodine. 0.5
percent. chlorhexidine or tincture of iodine to the gingival crevice before
the dental procedure may reduce the severity of any resulting
bacteraemia and may usefully supplement antibiotic prophylaxis in those
at risk. chlorhexidine mouth rinses appear not to be helpful in this
respect.
2- Good dental health should reduce the frequency and severity of any
bacteraemias and also reduce the need for extraction.
3- It is essential that, even when antibiotic cover has been given, patients at
risk should be instructed to report any u nexplained illness. Infective
endocarditis is often exceedingly insidious in origin and can develop 2 or
more months after the operation, which might have precipitated it. Late
diagnosis considerably increase both the mortality or disability among
survivors.
4- Patients at risk should carry a warning card to be shown to their dentist
to indicate the danger of infective endocarditis and the need for antibiotic
prophylaxis.
Treatment:
1- Bed rest.
2- Intense prolonged antibiotic therapy based upon blood culture and
sensitivity test for 6 week.
3- Treatment of complications of embolism or cardiac failure as they arise.

Ischemic Heart Disease

Coronary Heart Disease: Myocardial Ischemia
Coronary Heart Disease: Myocardial Ischemia

• Decreased blood supply (and thus oxygen) to the myocardium that can
result in acute coronary syndromes:
– Angina pectoris
– Myocardial infarction
– Sudden death (due to fatal arrhythmias)
Pathophysiology of Atheromatous Plaques
• Deposition of cholesterol in the intima and smooth muscle
• Proliferation of surrounding fibrous tissue and smooth muscle
• Internal bulging of vessel with narrowing of the lumen limiting blood and
oxygen supply resulting in ischemia and/or arrhythmias
• Rough surfaces can rupture and cause blood clots and emboli resulting in
vessel occlusion

Spectrum of the Atherosclerotic Process

• Coronary Arteries (angina, MI, sudden death)
• Cerebral Arteries (stroke)
• Peripheral Arteries (claudication)

Angina Pectoris
• Brief sub-sternal pain
• Self-limiting with cessation of precipitating event
• Precipitated by exercise, stress, eating, sex, etc
• May occur at rest or while asleep
Clinical Patterns of Angina Pectoris
• Stable - pain pattern and characteristics relatively unchanged over past
several months (better prognosis)
• Unstable - pain pattern changing in occurrence, frequency, intensity,
or duration (poorer prognosis); MI pending
Medical Management of Angina
• Medications
– nitrates
– beta blockers
– calcium channel blockers
– anti-platelet agents
– antihyperlipidemics
• Surgery
– Percutaneous transluminal coronary angioplasty/ “balloon”
angioplasty / stent
– Coronary artery bypass graft (CABG)
Dental Considerations: Nitrates
• Vasoconstrictor Interactions:
– No clinically significant interactions
• Oral Manifestations:
– topical burning at site of contact
• Other Considerations:
– orthostatic hypotension and headache possible following
administration
Dental Considerations: Beta Blockers
• While there is a potential for an enhanced hypertensive effect of
epinephrine in a patient taking a nonselective beta blocker, it is clinically
unlikely that such a reaction will occur
• If a patient is taking a nonselective beta blocker (e.g. propanolol, sotolol),
it is prudent to limit the amount of epinephrine administered to that
found in two carpules of 1:100,000 concentration (0.036mg)
• In patients taking a cardio selective beta blocker (e.g. metropolol), no
limitations are required
Dental Considerations: Calcium Channel Blockers
• There are no significant drug interactions reported
• Gingival hyperplasia can occur in patients taking calcium channel
blockers; close monitoring and encouragement of optimal oral hygiene is
necessary
Dental Considerations: Antiplatelet Agents
• With a single agent (e.g. aspirin, Plavix), expect some increased
perioperative and/or postoperative bleeding but it is not usually clinically
significant and can be managed by local measures such as pressure,
suturing, stents, etc.; preoperative withdrawal is not justified
• The combination of aspirin with other inhibitors of platelet aggregation
increases the chances for significant bleeding; depending upon extent of
surgery, it is advisable to discuss the risk/benefit of temporary
discontinuation with the physician
Dental Considerations:
HMG-CoA Reductase Inhibitors
 • The combination of the HMG-CoA reductase inhibitors with
erythromycin or clarithromycin (CYP3A4 inhibitors) may be associated
with an increased risk of adverse drug effects on muscle (rhabdomyolosis)
and kidney (acute renal failure)
• Avoid concurrent use of HMG-CoA reductase inhibitors with
erythromycin or clarithromycin.
Dental Considerations
Balloon Angioplasty / Stent
• These procedures are not associated with an increased risk of bacterial
endocarditis or endarteritis. Therefore, antibiotics are not recommended
following a balloon angioplasty nor are they recommended for patients
with a stent.

Dental Considerations:
Coronary Artery By-Pass Graft (CABG)
The CABG does not increase the risk for BE, therefore antibiotic prophylaxis is
not recommended
Post-Myocardial Infarction
“MI”, “Coronary”, “Heart Attack”
Infarction - an area of necrosis in tissue due to ischemia resulting from
obstruction of blood flow
Dental Management Correlate
• Elective dental care is ok if it has been longer than 4-6 weeks since the MI
and the patient does not report any ischemic symptoms.
• If there is any doubt or question, consult with the cardiologist.
Drug Therapy:
Warfarin (Coumadin)
Action: inhibits vitamin K which is a precursor for clotting factors II,
VII, IX and X
Dental treatment, including minor surgery, is unlikely to be problematic if
INR is within the therapeutic range
Dental Management:
Stable Angina/Post-MI >4-6 weeks
• Minimize time in waiting room
• Short, morning appointments
• Preop, intra-op, and post-op vital signs
• Pre-medication as needed
– anxiolytic (triazolam; oxazepam); night before and 1 hour before
– Have nitroglycerin available – may consider using prophylacticaly
• Use pulse oximeter to assure good breathing and oxygenation
• Nitrous oxide/oxygen intraoperatively (if needed)
• Excellent local anesthesia - use epinephrine, if needed, in limited amount
(max 0.04mg) or levonordefrin (max. 0.20mg)
• Avoid epinephrine in retraction cord
Dental Management:
Unstable Angina or MI < 3 months
• Avoid elective care
 • For urgent care: be as conservative as possible; do only what must
be done (e.g. infection control, pain management)
• Consultation with physician to help manage
• Consider treating in outpatient hospital facility or refer to hospital
dentistry
• ECG, pulse oximetry, IV line
• Use vasoconstrictors cautiously if needed
Intraoperative Chest Pain
• Stop procedure
• Give nitroglycerin
• If after 5 minutes pain still present, give another nitroglycerin
• If after 5 more minutes pain still present, give another nitroglycerin
• If pain persists, assume MI in progress and activate the EMS
– Give aspirin tablet to chew and swallow
– Monitor vital signs, administer oxygen, and
be prepared to provide life support
Periodontal Disease and Coronary Heart Disease
• There appears to be an association between PD and CHD; exact
relationship unclear
• Possibly related to the inflammatory effects of bacterial products, i.e.
endotoxins, LPS; effect on endothelium; clot formation
• Possibly no cause-effect relationship at all
• Studies are underway to more clearly define this relationship
Heart Failure
A state where the myocardium cannot maintain the normal circulation, and thus
cause cardiac failure. Either the left side or the right side of the heart may fail
first, but eventually both sides will be involved.
Common causes:
1- Hypertension.
2- Pulmonary diseases.
3- Ischemic heart diseases.
4- Vavular heart diseases.
Sings and Symptoms:
1- Rapid fatigue.
2- Breathlessness.
3- Edema of the ankle.
4- Non reproductive cough.
5- Prominent large veins in the neck
Most of these patients are ambulatory and receiving their medications, most
likely cardiac glycosides and their activity is restricted.
Precautions:
1- Medical consultation.
2- Should be treated with caution to avoid tachycardia that may exaggerate
the already existing condition.
3- Preoperative sedation plus good pain control should be maintained.
4- The use of V.C. in L.A. should be kept at minimum.
 5- Periodic check-up of pulse rate during surgery: In a significant rise of
pulse rate a rest period is required or it may be necessary to terminate the
dental appointment.

Thrombosis and thrombophlebitis

A thrombus is a solid blood clot formed within a vessel:
Etiology:
1- Increased coagulability of blood
2- Stasis of blood
3- Damage to vessel walls as trauma, irritant drugs, and
inflammation(phlebitis)
Management of those patients usually by anticoagulant therapy such as
(heparin) or (macromar) to reduce the prothrombin level. Patients on
anticoagulant therapy usually bleed excessively following any surgical
procedure.
Precautions:
1- Medical consultation is important before dental surgery. A joint decision
between the dental surgeon and physician should be performed as to:
 Decrease or withdraw the anticoagulant therapy.
 Raise the prothrombin levels by injection of vitamin k.
 Use of local haemostatic measures after surgery such as Gel foam
with thrombin or oxidized cellulose (Surgicel).
2- Extraction of teeth is contraindicated if prothrombin deficiency more
then 20%.

MANAGEMENT OF AN ASTHMA ATTACK

1. Discontinue dental treatment.
2. Place patient in easiest position for them to breath. This is usually upright
with arms outstretched.
3. Albuterol Inhaler (Proventil) 2 puffs every 2 minutes.
4. Supplemental oxygen at 10L/min.
5. Monitor vital signs.
6. If no improvement call EMS.
7. Start IV.
8. Consider Epinephrine 1:1,000, 0.3g every 20 minutes.

Dental Treatment Considerations for the Asthmatic Patient

1. Take a good Medical History prior to treatment; determine how often the
patient has an asthma attack and what precipitates it.
2. Consider scheduling morning appointments.
If patient uses an inhaler they should have it on hand during treatment.
Consider prophylactic use prior to treatment.

Hematologic Diseases
Almost all blood disorders are of importance to the dental surgeon .
Anemia
Causes of anemia:
A) Deficient , R.B.Cs. production:
 Deficiency of iron, B12, folic acid, vitamin C, protein.
 A plastic anemia.
 Marrow infiltration as in leukemia, Hodgkin's disease, metaplastic
carcinoma and myeloma.
 Symptomatic e.g. anemia of chronic infection, liver disease, kidn ey disease
and collagen-vascular disease.
B) Loss or destruction of R.B.Cs.:
 Hemorrhage.
 Hemolytic anemia
1. Congenital hemoglobinopathy.
2. Sickle cell anemia
3. Thalassemia
4. Auto-immune hemolysis.
 Toxic drugs or chemicals e.g. lead.
Anemic patients do not withstand blood loss well. Further blood loss in an
already anemic patient may provoke heart failure or myocardial infarction.
Postoperative hemorrhage is also common in anemic patients.
The common oral disorder of a sore tongue in addition to the other
manifestations of anemia is an indication for blood examination and surgery
should be postponed until the anemia is corrected. If the hemoglobin
concentration is less than 10 g/100ml. of blood surgical procedure is
contraindicated.

Reference Ranges for Blood Indicators*

Indicator Men Women
Red blood cell count 4.10-5.60 (×106/µL 3.80-5.10 (×106/µL)
Hemoglobin 12.5-17.0 (g/dL) 11.5-15.0 (g/dL
Hematocrit 36%-50% 34%-44%
*µL=microliter; g/dL=grams per deciliter
Agranulocytosis (Malignant Leucopenia)
Is a serious disease involving the W.B.Cs. The most common known etiologic
factor is the continued administration of certain drugs, that include
sulfonamides, chloramphenicol, chlorpromazine, barbiturates and phenacetin.
Clinical features:
1. Necrotizing ulceration of the oral mucosa.
2. W.B.Cs count usually below 2000 cells/cubic ml.
Dental prophylaxis:
1. Withdraw any systemic drug which induce allergic reaction to the
patient.
2. In cases that required prolonged antibiotic therapy, periodic check -up of
the blood picture is mandatory.
3. Extraction in cases of agranulocytosis is contraindicated unless the
disease is managed by blood transfusion.
Leukemia
Characterized by the progressive over production of immature W.B.Cs. in the
blood. Often the earliest signs of this fatal disease are the gingival bleeding and
ulceration.
The responsibility of the dentist in recognizing and referring patients due to
early diagnosis of this serious condition are obvious. Consultation with physician
prior to any dental procedures is essential.
Hemorrhagic Disease
Bleeding may be due to defect in platelets, coagulation, or vessels.
Any case with history of prolonged bleeding or post extraction hemorrhage
should be thoroughly investigated by a hematologist as there may be an
underlying predisposition to hemorrhage. Spontaneous gingival bleeding or
recurrent attack of epistaxis may evoke a serious hemorrhagic disease.
Disease involving the blood platelets:
1. Thrombocytopenia purpura.
2. Thrombocytopathic purpura.
3. Thrombocythemia(Thrombocytosis).

Disease involving the specific blood factors:

1. hemophilia(A,B,C)
2. Pseudohemophilia (vascular hemophilia):
3. parahemophilia
4. hypofibrinogenemia
5. Hypoprothrombinemia
Diseases involving the small vessel:
1. Congenital e.g. hereditary hemorrhagic telangiectasia.
2. Acquired such as:
 Allergic vasculitis.
 Infection e.g. meningitis and SABE.
 Scurvy.
 Cushing's disease.
 Senile purpura.
Dental surgery in patients with hemorrhagic diseases:
1. Laboratory investigations for bleeding time, clotting time, and
prothrombin time should be performed for all cases with history of
excessive bleeding after minor injury or with previous history of post
extraction hemorrhage. If any significant alteration exists, the patient
should be thoroughly investigated by a hematologist for the possible
underlying cause to hemorrhage.
2. Patients with hemorrhage diseases should be hospitalized before any
dental surgery, even before minor incisor or simple extraction.
3. The deficient factor (s) should be detected and corrected by the
hematologist before dental surgery and arrangements for the arrest of
postoperative hemorrhage should be carried on such as:
 Fresh or stored whole blood transfusion.
 Cryofractions of different blood components (6 major fractions).
 Plasma.
 4. Local hemostatic measures should be performed after dental surgery by
obliteration of the dental socket with absorbable hemostatic materials e.g.
Gelfoam soaked with thrombin or fibrinogen, oxidized cellulose (Oxycel
or surgicel), coagulation of hemorrhagic points by electrocoagulation or
cryotherapy, suturing of the mucosa and application of astringents
(tannic acid, zinc chloride, ferric subsulfate).
5. In serious hemorrhagic diseases, it should be kept in mind that arrest of
hemorrhage depends upon the correction of the deficient factor and the
role of local measure is secondary and will be effective only after
correction of the systemic defect.
6. Nerve block L.A. techniques of injections are contraindicated in patients
with hemorrhagic diseases to avoid the possibilities of internal
hemorrhage and massive hematoma formation.
7. Several cases of hemophilia have circulating anticoagulant factors
(antibodies) in their blood, which specifically inactivates the AHG. Such
cases requires several blood transfusion postoperatively. This point
should be taken in consideration before surgery.
8. Major surgical procedures should be avoided whenever possible and the
surgical interference should be atraumatic as possible.
9. The old method of the use of rubber band around the neck of the tooth
was proved to be of little help in loosening the tooth. On the contrary
because of mechanical irritation of the rubber dam, the gingival tissues
were usually found to be inflamed and thereby increase post extraction
bleeding.
10. post operatively, never discharge the patient unless at least 3 days without
bleeding had elapsed.

Endocrine Diseases
Diabetes Mellitus

DENTAL MANAGEMENT

Medical considerations.

 Take a thorough medical history for all patients diagnosed with diabetes.
 Ascertain the identity of the physician treating the patient and the date o f
the last visit.
 Obtain information concerning the type of diabetes, the severity and
control of the diabetes, and the presence of cardiovascular or neurologic
complications.
 Refer any patient with the cardinal symptoms of diabetes or findings that
suggest diabetes (headache, dry mouth, irritability, repeated skin
infection, blurred vision, paresthesias, progressive periodontal disease,
multiple periodontal abscesses) to a physician for diagnosis and
treatment.
Diabetic patients who are receiving good medical management without serious
complications such as renal disease, hypertension, or coronary atherosclerotic
heart disease, can receive any indicated dental treatment.

Those with serious medical complications may require an altered plan of dental
treatment. When the severity and degree of control of diabetes are not known,
treatment should be limited to palliation.

Food intake and appointment scheduling. To preventing insulin shock from

occurring:

 Verify that the patient has taken medication as usual .

 Verify that the patient has had adequate intake of food.
 Schedule appointments in the morning, since this is a time of high glucose
and low-insulin activity. Afternoon appointments are a time of low -
glucose and high-insulin activity which may predispose the patient to a
hypoglycemic reaction.
 Instruct patients to tell the dentist if at any time during the appointment
they feel symptoms of an insulin reaction occurring. A source of sugar,
such as orange juice, must be available in the dental office shou ld the
symptoms of an insulin reaction occur.

Oral surgery concerns.

 It is important that the total caloric content and the

protein/carbohydrate/fat ratio of the patient's diet remain the same so
control of the disease and proper blood glucose balance ar e maintained.
 IDDM diabetics who are going to receive periodontal or oral surgery
procedures may be placed on prophylactic antibiotic therapy during the
postoperative period to avoid infection.
 Consultation with a patient's physician before conducting extensive
periodontal or oral surgery is advisable. The physician may, in fact,
recommend that the patient be treated in a hospital environment where
infection, bleeding, and dysglycemia can be better managed.

Dangers of acute oral infection. Any diabetic patient with acute dental or
oral infection presents a problem in management. This problem is even more
difficult for patients who take high insulin dosage and those who have IDDM.
The infection will often cause loss of control of the diabetic condition, an d as a
result the infection is not handled by the body's defenses as well as it would be in
a nondiabetic patient. The patient's physician should become a partner in
treatment during this period.

Oral complications. The oral complications of uncontrolled diabetes mellitus

may include:
  Xerostomia,
 Infection,
 Poor healing,
 Increased incidence and severity of periodontal disease, and
 Burning mouth syndrome.
 Diabetic neuropathy may lead to oral symptoms of tingling, numbness,
burning, or pain in the oral region.

Oral findings in patients with uncontrolled diabetes are thought to be related to

excessive loss of fluids through urination, altered response to infection,
microvascular changes, and possibly increased glucose concentrations in saliva.

Early diagnosis and treatment of the diabetic state may allow for regression of
these symptoms, but in long-standing cases the changes may be irreversible.

Potential Drug Interaction. While patients with well-controlled diabetes can be

given general anesthetics, management with local anesthetics is preferable.
General anesthetics should be used with caution because they can produce
hyperglycemia.

Hypoglycemia

MANAGEMENT OF THE HYPOGLYCEMIC PATIENT

1. ABC’s
2. If patient is unconscious or unstable activate EMS.
3. If patient is conscious administer oral carbohydrates (Orange juice, sugar,
candy bar, cake icing.)
4. Unconscious patient administer parenteral carbohydrates if available (50cc of
50% dextrose IV over a period of 2-3 minutes.)
5. Patient should respond within 5 minutes.
6. Never give unconscious patient anything orally!

Dental treatment Considerations

1. Prevention is the key. Take a complete medical history. Especially note a
history of diabetes.
2. In the diabetic patient extra attention should be paid to stress management
and assessing diet.
3. If the patient is on insulin and eating will be impaired by dental treatment
the insulin dose should be decreased accordingly (Medical consult.)

DENTAL MANAGEMENT OF PATIENTS WHO HAVE THYROID

DISEASE

Hypothyroidism. Common oral findings in hypothyroidism include

macroglossia, dysgeusia, delayed eruption, poor periodontal health and delayed
wound healing. Before treating a patient who has a history of thyroid disease, the
dentist should obtain the correct diagnosis and etiology for the thyroid disorder,
as well as past medical complications and medical therapy. Further inquiry
regarding past dental treatment is justified. The condition’s prognosis usually is
given by the time of treatment and patient compliance.

In patients who have hypothyroidism, there is no heightened susceptibility to

infection. They are susceptible to cardiovascular disease from arteriosclerosis
and elevated LDL. Before treating such patients, consult with their primary care
providers who can provide information on their cardiovascular statuses. Patients
who have atrial fibrillation can be on anticoagulation therapy and might require
antibiotic prophylaxis before invasive procedures, depending on the severity of
the arrythmia. If Valvular pathology is present, the need for antibiotic
prophylaxis must be assessed. Drug interactions of l-thyroxine include increased
metabolism due to phenytoin, rifampin and carbamazepine, as well as impaired
absorption with iron sulfate, sucralfate and aluminum hydroxide. When l-
thyroxine is used, it increases the effects of warfarin sodium and, because of its
gluconeogenic effects, the use of oral hypoglycemic agents must be increased.
Concomitant use of tricyclic antidepressants elevates l-thyroxine levels.
Appropriate coagulation tests should be available when the patient is taking an
oral anticoagulant and thyroid hormone replacement therapy. Patients who have
hypothyroidism are sensitive to central nervous system depressants and
barbiturates, so these medications should be used sparingly.

During treatment of diagnosed and medicated patients who have

hypothyroidism, attention should focus on lethargy, which can indicate an
uncontrolled state and become a risk for patients (for example, aspiration of
dental materials), and respiratory rate. It is important to emphasize the
possibility of an iatrogenic hyperthyroid state caused by hormone replacement
therapy used to treat hypothyroidism. Hashimoto’s disease has been reported to
be associated with DM, and patients who have DM might become hyperglycemic
when treated with T 4. When providing dental care to patients who have DM,
attention should focus on complications associated with poor glycemic control,
which may cause decreased healing and heightened susceptibility to infections.

In a literature review, Johnson and colleagues examined the effects of

epinephrine in patients who have hypothyroidism. No significant interaction was
observed in controlled patients who had minimal cardiovascular involvement. In
patients who have cardiovascular disease (for example, congestive heart failure
and atrial fibrillation) or who have uncertain control, local anesthetic and
retraction cord with epinephrine should be used cautiously. People who are on a
stable dosage of hormone replacement for a long time should have no problem
withstanding routine and emergent dental treatment. Hemostasis is not a
concern unless the patient’s cardiovascular status mandates anticoagulation.

For postoperative pain control, narcotic use should be limited, owing to the
heightened susceptibility to these agents.

Hyperthyroidism. Before treating a patient who has hyperthyroidism, the oral

health care professional needs to be familiar with the oral manifestations of
thyrotoxicosis, including increased susceptibility to caries, periodontal disease,
enlargement of extraglandular thyroid tissue (mainly in the lateral posterior
tongue), maxillary or mandibular osteoporosis, accelerated dental eruption and
burning mouth syndrome (Box 2 ). In patients older than 70 years of age,
hyperthyroidism presents as anorexia and wasting, atrial fibrillation and
congestive heart failure. In young patients, the main manifestation of
hyperthyroidism is Graves’ disease, while middle-aged men and women present
most commonly with toxic nodular goiter. Development of connective-tissue
diseases like Sjögren’s syndrome and systemic lupus erythematosus also should
be considered when evaluating a patient who has a history of Graves’ disease.

Taking a careful history and conducting a thorough physical examination can

indicate to the oral health care professional the level of thyroid hormone control
of the patient. Patients who have hyperthyroidism are susceptible to
cardiovascular disease from the ionotropic and chronotropic effect of the
hormone, which can lead to atrial dysrhythmias. It is important that the dentist
address the cardiac history of these patients. Consulting the patients’ physicians
before performing any invasive procedures is indicated in patients who have
poorly controlled hyperthyroidism. Treatment should be deferred if the patients
present with symptoms of uncontrolled disease. These symptoms include
tachycardia, irregular pulse, sweating, hypertension, tremor, unreliable or vague
history of thyroid disease and management, or neglect to follow physician -
initiated control for more than six months to one year.

A decrease in circulating neutrophils has been reported during thyroid storm

crisis. Dental treatment, however, usually is not a priority in this state.
Susceptibility to infection can increase from drug side effects. People who have
hyperthyroidism and are treated with propyl-thiouracil must be monitored for
possible agranulocytosis or leukopenia as a side effect of therapy. Besides its
leukopenic effects, propylthiouracil can cause sialolith formation and increase
the anticoagulant effects of warfarin. A complete blood count with a differential
will indicate if any medication-induced leukopenia may be present. Aspirin; oral
contraceptives; estrogen; and nonsteroidal anti-inflammatory drugs, or NSAIDs,
may decrease the binding of T 4 to TBG in plasma. This increases the amount of
circulating T 4 and can lead to thyrotoxicosis. Aspirin, glucocortico-steroids,
dopamine and heparin can decrease levels of TSH, complicating a correct
diagnosis of primary or pituitary hyperthyroidism.

The use of epinephrine and other sympathomimetics warrants special

consideration when treating patients who have hyperthyroidism and are taking
nonselective ß-blockers. Epinephrine acts on -adrenergic receptors causing
vasoconstriction and on ß2 receptors causing vasodilation. Nonselective ß-
blockers eliminate the vasodilatory effect, potentiating an -adrenergic increase
in blood pressure. This mechanism applies to any patient who is taking
nonselective ß-blockers, and it is relevant in patients who have hyperthyroidism
because of the possible cardiovascular complications that can arise. Knowledge
of the described interactions should alert the clinician for any possible
complication.

During treatment, heightened awareness toward oral soft- and hard-tissue

manifestations, as described previously, should be emphasized Oral examination
should include inspection and palpation of salivary glands. If the patient does not
have any cardiovascular disease or is not receiving anticoagulation therapy,
hemostatic considerations should not represent a concern for invasive oral
procedures. Management of the patient receiving anticoagulation therapy has
been described in the literature.

Oral health care professionals should recognize the signs and symptoms of a
thyroid storm, as the patient could present for dental care during its initial phase
or when undiagnosed. Patients who have hyperthyroidism have increased levels
of anxiety, and stress or surgery can trigger a thyro-toxic crisis. Epinephrine is
contraindicated, and elective dental care should be deferred for patients who
have hyperthyroidism and exhibit signs or symptoms of thyrotoxicosis. Brief
appointments and stress management are important for patients who have
hyperthyroidism. Treatment should be discontinued if signs or symptoms of a
thyrotoxic crisis develop and access to emergency medical services should be
available.

After treatment, proper postoperative analgesia is indicated. NSAIDs should be

used with caution in the patients who have hyperthyroidism and who take ß-
blockers, as the former can decrease the efficiency of the latter. Pain, however,
can complicate cardiac function in patients who have hyperthyroidism and
symptomatic disease, and alternative pain medications need to be instituted. It is
important that patients continue taking their thyroid medication as prescribed.
If an emergent procedure is needed in the initial weeks of thyroid tre atment,
close work-up with the endocrinologist is needed (Box 3 ).

MANAGEMENT OF SUSPECTED ACUTE ADRENAL INSUFFICIENCY

1. Discontinue all treatment and remove foreign objects from the patients
mouth.
2. Initiate BLS and activate EMS
3. Place patient supine.
4. Monitor and record vital signs.
5. Oxygen at 5-10L/minute.
6. Hydrocortisone 100mg IV (Dexamethasone 4mg) over 30 seconds or IM if
IV not available. Repeat dose every 6 hours for 24 hours. If the patient is
stable then reduce to 50mg (Dexamethasone 4mg) every 6 hours then taper
orally over 4-5 days. Should initiate if there is any suspicion of AAI.
Dental Treatment Considerations

For patients with a history of glucocorticoid therapy use stress reduction

protocols.

The following guidelines can be used to determine if replacement therapy is

indicated This is a change from the old rule of twos based on an article done at
NNDC. It is always a good idea to get a medical consult in such c ases.

If the patient has undergone supraphysiologic (More than 20mg/day)

glucocorticoid therapy that was discontinued more than 30 days prior to the
planned dental treatment no supplementation is required.

If the patients has undergone supraphysiologic glucocorticoid therapy within 30

days of the planned dental procedure considered the patients suppressed and
provide steroid supplementation equivalent to 100mg of cortisol.
If the patient has undergone or is undergoing alternate day dosing schedule
glucocorticoid therapy no supplementation is required but it is best to provide
dental treatment on the off day of the patients dose schedule.
If the patient is currently receiving daily glucocorticoid therapy at a
supraphysiologic level (More than 20mg) supplementation is required. If the
daily dose is subphysiologic supplementation is not required.

DENTAL MANAGEMENT

Medical considerations. Since infectious patients cannot necessarily be identified

by history, it is necessary to manage all patients as though they are potentially
infectious. The Center for Disease Control and the American Dental Association
have published recommendations for infection control that have become the
standard of care to prevent crossinfection in dental practice. These standards
should be strictly adhered to.

There are five categories of patients with a history of hepatitis that must be
considered by the dentist:

 Patients with active hepatitis. No treatment other than urgent

care should be rendered to these patients. If a patient is s een
with acute hepatitis, the physician should be contacted
immediately.
 Patients with a history of hepatitis . Since it is estimated that there
are between 750,000 and 1 million carriers of hepatitis B in the US today,
the only practical method of protection from infection is to adopt a strict
program of clinical asepsis for all patients. In addition, inoculation of all
dental personnel with hepatitis B vaccine is strongly urged.
 Patients at high risk for HBV infection. Patients who fit into one or
more of the high risk categories should routinely be screened for HBsAg
before dental care is provided unless laboratory evidence exists for anti-
 HBs. While this measure may seem redundant, it could yield information
that would be of benefit in certain situations. For example, if an
accidental needle stick or puncture occurs during treatment and the
dentist is not vaccinated, it would be of extreme importance to know
whether the patient was HBsAg positive, which would dictate the need for
vaccination.
 Patients who are hepatitis carriers. If a patient is found to be a
hepatitis B carrier or to have a history of NANB hepatitis,
recommendations from the Center for Disease Control for avoiding
transmission of infection should be closely followed. In addition, some
hepatitis carriers may have chronic active hepatitis, leading to
compromised liver function and interfering with hemostasis and drug
metabolism. Physician consultation or laboratory screening for liver
function is advised.
 Patients with signs or symptoms of hepatitis. Any patient having
signs or symptoms suggesting hepatitis should be referred to a physician,
and should not be treated. If emergency care becomes necessary, it should
be provided as for the patient with acute disease.

Potential drug interactions. In a completely recovered patient there are no

special drug considerations. However, if a patient has chronic active hepatitis or
is a carrier of HBsAg and has impaired liver function, drugs metabolized by the
liver should be avoided if possible. Although a number of local anesthetics,
analgesics, sedatives, and antibiotics commonly used in dentistry are, in fact,
metabolized principally by the liver, these drugs can be used in limited amounts
in all but the most severe cases of hepatic disease.

Oral complications. The only oral complication associated with hepatitis is the
potential for abnormal bleeding in cases of significant liver damage. If surgery is
required, it is advisable to:

 Check the prothrombin time. If it is greater than 35, an injection of

vitamin K will usually correct the problem. This should, however, be
discussed with the patient's physician.
 Monitor the bleeding time to check platelet function. If it is not less than
20 minutes, the patient may require platelet replacement before surgery.
This should also be discussed with the patient's physician.

ALCOHOLIC LIVER DISEASE

DENTAL MANAGEMENT

Medical considerations. The two major treatment considerations in an

alcoholic patient are:

 bleeding tendencies
  unpredictable metabolism of certain drugs

Dental management must, therefore, begin with detection by history and/or by

clinical examination. When there is a high index of suspicion, a number of
laboratory tests should be ordered for screening purposes:

 CBC with differential

 AST, ALT
 bleeding time
 thrombin time
 prothrombin time

If a patient has a history of alcoholic liver disease or alcohol abuse, the physician
should be consulted to verify:

 the patient's current status

 medications
 laboratory values
 contraindications for medications, surgery, and other treatment

A patient with untreated alcoholic liver disease is not a candidate for elective,
outpatient dental care and should be referred to a physician. Once the patient is
managed medically, dental care may be provided after consultation with the
physician. Bleeding diatheses (as reflected on laboratory tests) should be
managed in consultation with the physician.

Metabolic concerns. Concern about the unpredictable metabolism of drugs is

twofold:

 In mild to moderate alcoholic liver disease, significant enzyme induction

is likely to have occurred, leading to an increased tolerance of sedative
drugs, hypnotic drugs, and general anesthesia. Larger than normal doses
of these medications are thus required to obtain the desired effec ts.
 With more advanced liver destruction, drug metabolism may be
markedly diminished and can lead to an increased or unexpected effect.
Drugs metabolized primarily by the liver (i.e., certain anesthetics,
analgesics, sedatives, and antibiotics) should be used with caution, and
avoided if possible. When used, doses should be adjusted.

Oral complications. Poor oral hygiene and neglect are common findings in
chronic alcoholics. Other abnormalities that may be found are: 4-5

 glossitis
 angular or labial cheilosis
 candidiasis
 gingival bleeding
 oral cancer
 petechiae
 ecchymoses
 jaundiced mucosa
  parotid gland enlargement
 alcohol breath odor
 impaired healing
 bruxism
 dental attrition
 xerostomia

Since alcohol abuse (and tobacco use) are also strong risk factors for the
development of oral cancer, practitioners should be aggressive in detecting
suspicious soft-tissue lesions.

Kidney Diseases
CHRONIC RENAL FAILURE, DIALYSIS AND DENTAL
MANAGEMENT

DENTAL MANAGEMENT

Medical considerations for patients under conservative care. Before dental care
is provided to a patient under conservative management of ESRD, the patient's
physician should be consulted. A joint decision should then be made as to the
setting (inpatient or outpatient) in which this care can safely be provided. If
ESRD is well-controlled, there is generally no problem in providing outpatient
care. When rendering this care:

 Order pretreatment screening for bleeding disorders (bleeding time,

platelet count, hematocrit, hemoglobin).
 Monitor blood pressure.
 Pay meticulous attention to good surgical technique.
 Use universal infection control procedures.

Medical considerations for patients receiving dialysis . The

recommendations for managing a patient receiving hemodialysis are the same as
those for managing a patient under conservative care, with a few additional
considerations:

 The surgically created arteriovenous fistula is potentially susceptible to

infection (endarteritis) resulting from a dentally induced bacteremia and
is a source of infectious emboli that can cause endocarditis. While both
conditions are of low incidence, the patient's managing physician should
determine whether or not to administer prophylactic antibiotics.
 Hemodialysis patients must avoid dental care on the day of dialysis, when
they could have bleeding tendencies. The best time for dental treatment is
the day after hemodialysis.

Oral complications.
  Pallor of the oral mucosa secondary to anemia.
 Diminished salivary flow, resulting in xerostomia and parotid infections.
 Patients frequently complain of a metallic taste, and the saliva may have a
characteristic ammonia-like odor due to a high urea content.
 In severe renal failure, a stomatitis may be present.
 Loss of lamina dura.
 Demineralized bone.
 Localized radiolucent jaw lesions.

Potential Drug Interactions.

 Of special concern are drugs that are primarily excreted by the kidney or
that are nephrotoxic (tetracycline, acyclovir, acetaminophen, aspirin, and
NSAlDs).
 Certain drugs are removed during hemodialysis and, therefore, require
an additional dose to be administered after hemodialysis.

The Nervous disease convulsive disorders

EPILEPSY AND DENTAL MANAGEMENT

DENTAL MANAGEMENT

Medical considerations. Once an epileptic patient has been identified:

 Learn as much as possible about the seizure history, current medications,

degree of seizure control, and any known precipitating factors.
 Be aware of the adverse effects of anticonsulvants (drowsiness, dizziness,
ataxia, and gastrointestinal upset).
 Render normal routine care to epileptic patients who have attained good
control of their seizures with medication.
 Do not render treatment to patients whose seizure activity does not
respond to anticonvulsants, without prior consultation with the patient's
physician. Such patients may require additional anticonvulsant or
sedative medication, as directed by the physician.

Oral complications. The most significant oral complication seen in epileptic

patients is gingival hyperplasia associated with phenytoin. The anterior labial
surfaces of the maxillary and mandibular gingivae are the most severely affected.
While there is some controversy regarding the effectiveness of oral hygiene in
preventing gingival hyperplasia, most evidence suggests that meticulous oral
hygiene will prevent, or at least, significantly decrease its severity. Good home
care should thus be combined with the removal of irritants such as overhanging
restorations and calculus. Surgical intervention may, however, be required to
reduce hyperplastic tissue interfering with function or appearance.
Dealing with a seizure. Should a patient have a generalized tonic-clonic
convulsion in the dental office, be prepared to deal with it. The primary task of
management is to protect the patient and try to prevent injury.

 Do not attempt to move the patient.

 Place the chair in a supported supine position.
 Turn the patient, if possible, to the side to control the airway and
minimize aspiration of secretions.
 Use passive restraint only to prevent injury from hitting nearby ob jects or
from falling out of the chair.

Potential Drug Interactions.

 Propoxyphene and erythromycin should not be administered to patients

taking carbemazepine because of interference with metabolism of
carbemazepine, which could lead to toxicity.
 Aspirin and NSAIDS should not be administered to patients taking
valproic acid, for they can further decrease platelet aggregation, leading
to hemorrhagic episodes.

SEXUALLY TRANSMITTED DISEASES AND DENTAL

MANAGEMENT
1. GONORRHEA

DENTAL MANAGEMENT

Medical considerations. Due to the specific requirements for disease

transmission and to the disease's rapid response to antibiotics, gonorrhea poses
little threat of disease transmission to the dentist. Whatever care is necessary
should thus be provided.

Oral Complications. The rare presentation of oral gonorrhea is nonspecific and

varied and may range from slight erythema to severe ulceration with a
pseudomembranous coating. The patient may be either asymptomatic or
incapacitated with limitations of oral function. Definitive diagnosis of oral lesions
should be attempted, and the patient should be under the care of a physician.
Treatment of the oral lesions is then symptomatic.

2. SYPHILIS

DENTAL MANAGEMENT

Medical considerations. The lesions of untreated primary and secondary

syphilis are infectious, as is the patient's blood and saliva. Even after treatment
has begun, the effectiveness of therapy cannot be determined except by
conversion of the positive serologic test to negative; this may take a few months
to over a year. Although patients with syphilis should be viewed as potentially
infectious, any necessary dental care may be provided safely.

Oral complications. Syphilitic chancres and mucous patches are usually

painless unless they become secondarily infected. These lesions are highly
infectious, but regress spontaneously with or without antibiotic therapy. As with
gonorrhea, oral treatment is essentially symptomatic.

DENTAL MANAGEMENT GUIDELINES

First trimester (conception to 14th week)
The most critical and rapid cell division and active organogenesis occur between
the second and the eighth
week of postconception. Therefore, the greater risk of susceptibility to stress and
teratogens occurs during this time and 50% to 75% of all spontaneous abortions
occur during this period.
The recommendations are:
1. Educate the patient about maternal oral changes
during pregnancy.
2. Emphasize strict oral hygiene instructions and
thereby plaque control.
3. Limit dental treatment to periodontal prophylaxis
and emergency treatments only.
4. Avoid routine radiographs. Use selectively and when
needed.
Second trimester (14th to 28th week)
Organogenesis is completed and therefore the risk to
the fetus is low. This is the safest period for providing
dental care during pregnancy.
The recommendations are:
1. Oral hygiene, instruction, and plaque control.
2. Scaling, polishing, and curettage may be performed
if necessary.
3. Control of active oral diseases, if any.
4. Elective dental care is safe.
5. Avoid routine radiographs. Use selectively and when
needed.
Third trimester (29th week until childbirth)
Although there is no risk to the fetus during this trimester, the pregnant mother
may experience an
increasing level of discomfort. Short dental appointments should be scheduled
with appropriate positioning while in the chair to prevent supine hypotension. It
is safe to perform routine dental treatment in the early part of the third
trimester, but from the middle of the third trimester
routine dental treatment should be avoided.
The recommendations are:
1. Oral hygiene, instruction, and plaque control.
2. Scaling, polishing, and curettage may be performed
if necessary.
3. Avoid elective dental care during the second half of
the third trimester.
4. Avoid routine radiographs. Use selectively and when needed.