INDIAN DENTAL ACADEMY       Leader in Continuing Dental Educationwww.indiandentalacademy.com
CONTENTS1.    INTRODUCTION2.    CARDIOVASCULAR DISEASES3.    RESPIRATORY DISEASES4.    RENAL DISEASES5.    LIVER DISEASES6...
INTRODUCTION “ Medically compromised patients, are just likeany other patients, they     do not want tocompromise their te...
CARDIOVASCULAR     DISEASES Frequent cause ofdeath in adult life inaffluent societies. Life threatening,sometimes cause ...
COMMON CARDIOVASCULAR PROBLEMS SEEN IN ADULTS1. Ishaemic Heart Disease2. Hypertension3. Congestive Heart Failure4. Infecti...
ISHAEMIC HEART DISEASEAlso called coronary heart disease.Commonest form of heart disease, most important cause of prematu...
DENTAL CONSIDERATIONSI.Dental Management of the patient withunstable angina or with recent myocardialinfarction (< 6 month...
PRETREATMENT HOME Benzodiazepine (10 mg oxazepam or 5 mgdiazepam) night before and one hour beforeappointment. Applicati...
INTRAOPERATIVELY   Use N2O – O2 inhalation sedation. Use pulse oximeter for oxygen    monitoring. Use intravenous benzo...
II.Dental Management of the patient withstable angina or history of myocardialinfarction (6 months or longer). Short appo...
        Stress and anxiety reduction –Diazepam 2 to 5 mg the                   night beforeand/or 2 to5 mg 1 hour beforea...
III.Dental Management of the Dental patient   with history of ischemic heart disease who   develops chest pain1. Stop dent...
b)    If pain not relieved within 5 min.(i)   Take patients B.P and pulse.(ii) If condition is stable give second    nitro...
INFECTIVE ENDOCARDITISPredisposing Lesions :         Rheumatic heart  disease, congenital heart disease, prosthetic  heart...
ANTIBIOTIC    PROPHYLAXIS                 FORINFECTIVE ENDOCARDITISDental Procedure :Amox. 3 g orally 1 hour before surger...
General Anaesthesia and Surgery Amox 1g in 2.5ml of 1% lignocaine I.M pre-operatively and repeat 6 hours later. Allergic t...
Dental Considerations1. Inform adequate - oral hygiene and   emphasize the link between bacteremia   and systemic disorder...
4. Local Degerming        - Iodinated glycerol   solution, Chlorhexidine, Providone – Iodine,   Phenolated solutions.5. An...
8.Incision and drainage - Wait 1 hour after   oral    penicillin, establish drainage through   the root canal whenever pos...
HYPERTENSIONDefined arbitrarily at levels above generallyaccepted normals (120/80) eg. 140/90 at the ageof 20, 160 / 95 at...
CAUSES FOR SECONDARY HYPERTENSIONVascular causes, Renal causes, Endocrinecauses, Adverse reaction to drugs, Toxemiaof preg...
DENTAL CONSIDERATIONS Provide ‘Anxiety – free’ situation.     Establish atmosphere in which patients -    encouraged to ...
 Avoid long or stressful appointments.      Use         premedication          as   needed    (Benzodiazepine such as di...
CONGESTIVE HEART FAILUREState in which heart is not able to pumpadequate amount of blood to meet the demandsof the body.Et...
Class – 1No limitation of physical activity, no dyspnea,fatigue or palpitations with ordinary physicalactivity.Class – IIS...
DENTAL MANAGEMENT1. Patient Evaluationa.Patient with untreated or uncontrolled C.H.F  - avoid elective dental care.b.Patie...
2. Drug consideration Patients taking digitalis use epinephrine (max  0.036 mg epinephrine).     Class III & IV C.C.F – a...
RESPIRATORY DISEASESChronic obstructive pulmonarydisease2 – most common diseases classifiedas COPD.               1. Chron...
DENTAL CONSIDERATIONS Upright chair positionL.A as usual, avoid bilateral mandibular or palatal blocksAvoid use of rubb...
ASTHMAChronic             inflammatorycondition       of           airways,clinically characterized bywide      spread    ...
DENTAL MANAGEMENT1.Identification of patient by history2.Determination of character of asthma.Type of Asthma (Mild, moder...
3.Avoidance of known precipitating factors.4. Medical consultation for severe, active  asthmatic.5. Have patient bring med...
 Avoid barbiturites and narcotics    Avoid erythromycin and ciprofloxacin in      patients taking theophylline7. L.A con...
TUBERCULOSISChronic granulamatous disease caused bymycobacterium tuberculosis which may involveall organs in the body, but...
DENTAL MANAGEMENT1.Patient with active tuberculosis Consultation with physician before treatmentTreatment limited to eme...
2. Patients with past history of tuberculosis Approach with caution, obtain good history  of disease and treatment, appro...
3. Patients with signs or symptom of  tuberculosis Refer to physician and postpone treatment If treatment necessary, tre...
3. Isolation of dental operatory systems.4. Strict aseptic procedures5. Use gloves, gown, mask6. Use of rubber dam when po...
RENAL DISEASESIrreversible deteriorationin renal function – leadsto impairment of theexcretory, metabolic andendocrine fun...
DENTAL MANAGEMENTPotential problemBleeding    tendency,           hypertension,   anemia,intolerance to nephrotoxic drugs ...
Prevention of complications Consultation with physician Pre treatment screening for hematological  disorder (bleeding ti...
 Minimize chances of abnormal bleeding or  infections Aggressive management of infectionOral Complication1. Mucosal pall...
DIALYSISBased on the principle ofosmosis, diffusion andultra filtration across asemi-permeablemembrane.        By thisproc...
IndicationsIncreased plasma urea or creatinine con.,hyperkalemia, fluid over load.     DENTAL CONSIDERATIONSPotential Prob...
Prevention of ComplicationsConsultation with physicianNo dental treatment until off dialysis machine for atleast 4 hours...
LIVER DISEASESViral Hepatitis Characterized by diffuse inflammation of the liver. Several viruses can cause the syndrome...
DENTAL CONSIDERATIONSPotential problem related to dental care Dentist can be infected by infectious patient’s Patients o...
Prevention of Complications1.Patients with active Hepatitis Consultation with physicianTreatment on emergency basis only...
C. If blood transfusion related, probably HCV or HBV.D. If type in determinate, radioimmunoassay for HBV surface antigen (...
Urgent Dental Care for the patient with acutehepatitisConsult with physician – patient status andplanned dental treatmentI...
 Adhere to strict universal precautions Use isolated operatory. Minimize use of drugs metabolized by liver. Use rubber...
DENTAL DRUGS METABOLIZED                PRIMARILY BY LIVER1.      Local Anaesthetic               – Lidocaine,     Bupivac...
ALCOHOLIC LIVER DISEASE Chronic consumption of alcohol leads to three distinctive forms of liver disease.1. Hepatic steato...
DENTAL CONSIDERATIONSPotential problem related to dental care       Bleeding tendencies       Unpredictable drug metabol...
2. Consultation with physician to verify currentstatus3. Laboratory screening – complete blood  count, bleeding time, thro...
Oral ComplicationsBleeding,     Ecchymoses,                 Petechia,   Glossitis,Angular        cheilosis,            Imp...
GASTROINTESTINAL      DISEASESUlcer  –     Peptic     ulcer,Duodenal ulcer, Gastric ulcer.           www.indiandentalacade...
Peptic Ulcer – Imbalance between theaggressive action of acid pepsin secretion andthe normal defenses of the gastric mucos...
DENTAL CONSIDERATIONSPotential problem related to dental care1.Aspirin and NSAIDS cause injury to intestinal  mucosa.2.Dur...
Treatment plan ModificationsReduce stressful environmentOral Complications1.Rare-enamel dissolution      associated   with...
ENDOCRINE AND METABOLIC DISEASESDIABETES MELLITUSMetabolic     disorder   characterized byhyperglycemia with or without gl...
ClassificationType – 1 : IDDMType – 2 : NIDDMType – 3 : Malnutrition related, Pancreaticdisease, Hormonal disease, drug in...
Dental ConsiderationsPotential problem related to dental care1. In uncontrolled diabetic patientsa. Infection, b. Poor wou...
Prevention of Complications1. Detection by  a) History b) Clinical findings c) Screening    blood glucose level2. Referral...
4.Patient receiving insulin – prevent insulin  reactiona.Advise eating    normal   meals      before  appointments.b.Sched...
Oral ComplicationsAccelerated periodontal diseases, xerostomia,Poor healing, Infection, oral ulcerations,Candidiasis, Numb...
Hyper thyroidism : Persistent elevation of the synthesis and release of thyroid hormones (T4 & T3)Causes :(1) Toxic diffus...
DENTAL CONSIDERATIONS   Potential problem related to dental care :1. Thyrotoxic crises – precipitated in untreated   or in...
3. Thyrotoxicosis    increases   risk   for   hypertension, angina, MI, CHF and severe   arrhythmias.Prevention of Complic...
4. Avoidance of epinephrine and amines in   untreated or incompletely treated patients5. Recognition of early stages of th...
Oral complications :1. Extensive dental caries2. Premature loss of deciduous teeth and early   eruption of permanent teeth...
BLEEDING DISORDERSPurpura – Purplishdiscolouration of the skinand mucous membranes due to spontaneousextravasation of bloo...
Non thrombocytopenic PurpuraNot Mediated through changes in bloodplatelets, but rather through alterations in thecapillari...
Dental ConsiderationsPotential problem related to dental careProlonged bleedingPrevention of complications1. Identificatio...
4. Local measures to control blood loss –microfibrillar collagen, topical thrombin.5. Prophylactic antibiotic for patients...
Oral ComplicationsSpontaneous bleeding, prolonged             bleeding,Petechia, Ecchymoses, Hematomos                  HE...
Types1.Hemophilia – A (Classic Hemophilia) – Deffactor VIII2.Hemophilia – B (Christmas disease) – Deffactor IX3.Hemophilia...
Prevention of complications1.Identification of patients –a) History Bleeding problems in relatives Excessive bleeding fo...
2.Consultation and referral for diagnosis and  treatment before dental procedures3.Replacement options – Fresh flow frozen...
Treatment plan modifications1.No dental procedures unless patient prepared  based on consultation with hematologist.2.Avoi...
4.RCT can be carried out without special  precautions – special care to avoid  instrumentation and filling beyond the apex...
7.High speed vacuum aspirators an saliva  ejectors should be used with caution to avoid  hematomas. Trauma can be minimize...
VON WILLE BRAND’S DISEASE                       Hemorrhage of 2 weeks                       duration from the tongue      ...
Dental ConsiderationsPotential problemExcessive bleedingPrevention of complications1.Identification for patienta)History o...
c) Screening test – Bleeding time2.Consultation and referral for diagnosis and  treatment before procedures3.Avoid aspirin...
Treatment plan modifications1.Regardless     the      severity            of    the   disease, endodontic        treatment...
Fixative in the form of formocresol         then   applied    Treatment continue at subsequent      appointment       un...
NEUROLOGIC DISORDERSEpilepsy :     Functionally characterized by abnormalrecurrent excessive electrical discharge ofcerebr...
DENTAL CONSIDERATIONSPotential problems related to dental care :•   Occurrence of generalized tonic- clonicseizure in dent...
Prevention of complications• Identification of patient by history.   (a) Type of Seizure (b) Age at time of onset   (c)   ...
2. Provide normal care – patients with well   controlled seizure pose no management   problem.3. Questionable history or p...
5. Patients    taking      valproic acid or   carbamazepine – have bleeding tendencies   because of platelet interference6...
8. After the seizure – (a) Examine for traumatic   injuries (b) Discontinue treatment, arrange   for patient transport.Tre...
Oral Complications :1. Gingival hyperplasia                 secondary   to   phenytoin (Dilantin)2. Traumatic oral injurie...
AIDS• Characterized by profound impairment of the  immune system.• HIV - has strong affinity for cells of the  immune syst...
• HIV detected in most body fluids – high  quantities only in blood, semen and CSF.• Transmission exclusively by sexual co...
ORAL CANDIDIASISKaposi’s sarcoma               Oral hairy leukoplakia      www.indiandentalacademy.com
DENTAL CONSIDERATIONS1. Consult with physician to establish patients   current status.2. Inform all staff working with AID...
6. Minimize aerosol production – slow speed   handpiece, use air syringe judiciously.7. Provide dental procedures based on...
10. If surgery is necessary – obtain bleeding time    and white blood cell count, platelet    replacement may be needed wi...
CONCLUSION     Patients of today cannot be compared withpatients of the past. They are esthetically moredemanding and have...
REFERENCES Dentistry for medically compromised patients –  James W. Little – 6th Edition. Essentials of safe dentistry f...
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endodontics in medically compromised patients /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in Continuing Dental Educationwww.indiandentalacademy.com
  2. 2. CONTENTS1. INTRODUCTION2. CARDIOVASCULAR DISEASES3. RESPIRATORY DISEASES4. RENAL DISEASES5. LIVER DISEASES6. GASTROINTESTINAL DISEASES7. BLEEDING DISORDERS8. ENDOCRINE AND METABOLIC DISEASES9. NEUROLOGIC DISORDERS10. AIDS AND RELATED CONDITIONS11. CONCLUSION12. REFERENCES www.indiandentalacademy.com
  3. 3. INTRODUCTION “ Medically compromised patients, are just likeany other patients, they do not want tocompromise their teeth and their esthetics”. Relation between medicine and dentistry hasto be understood. Medically compromised dental patient has ageneral health condition away from normal. Medically compromised condition is not acontraindication for endodontic treatment. www.indiandentalacademy.com
  4. 4. CARDIOVASCULAR DISEASES Frequent cause ofdeath in adult life inaffluent societies. Life threatening,sometimes cause littleprovocation duringinception andprogression. Role of dentist is to have sufficientknowledge to react appropriately toemergency. www.indiandentalacademy.com
  5. 5. COMMON CARDIOVASCULAR PROBLEMS SEEN IN ADULTS1. Ishaemic Heart Disease2. Hypertension3. Congestive Heart Failure4. Infective Endocarditis www.indiandentalacademy.com
  6. 6. ISHAEMIC HEART DISEASEAlso called coronary heart disease.Commonest form of heart disease, most important cause of premature death.Pathophysiology – Mismatch between demand and blood supply.Clinical features – Angina, Myocardial infarction www.indiandentalacademy.com
  7. 7. DENTAL CONSIDERATIONSI.Dental Management of the patient withunstable angina or with recent myocardialinfarction (< 6 months).Avoid elective dental careFor urgent dental needs – special patientcare setting such as hospital dental clinic.Consultation with physician. www.indiandentalacademy.com
  8. 8. PRETREATMENT HOME Benzodiazepine (10 mg oxazepam or 5 mgdiazepam) night before and one hour beforeappointment. Application of long acting dermalnitroglycerin.PRETREATMENT IN OFFICE Periodic monitoring of vital signs. Establish and maintain intravenous line. Prophylactic nitroglycerine sublingually www.indiandentalacademy.combefore procedure.
  9. 9. INTRAOPERATIVELY Use N2O – O2 inhalation sedation. Use pulse oximeter for oxygen monitoring. Use intravenous benzodiazepine (Midazolam). Supplemental nitroglycerine sublingually as needed. Ensure excellent pain control with L.A –avoid vasoconstrictors, although smallamount epinephrine (<0.036 mg) may betolerated. www.indiandentalacademy.com
  10. 10. II.Dental Management of the patient withstable angina or history of myocardialinfarction (6 months or longer). Short appointments (Morning preferable). Pretreatment vital signs. Semisupine chair position. Patient should bring on supply of nitroglycerine. www.indiandentalacademy.com
  11. 11.  Stress and anxiety reduction –Diazepam 2 to 5 mg the night beforeand/or 2 to5 mg 1 hour beforeappointment. Good pain control – use L.A withvasoconstrictor (Epinephrine max dose –0.036 mg). If patient becomes fatigue or change inpulse rate or rhythm, discontinuetreatment and reschedule. Patient receiving aspirin, haveincreased bleeding but not usuallyclinically significant. www.indiandentalacademy.com
  12. 12. III.Dental Management of the Dental patient with history of ischemic heart disease who develops chest pain1. Stop dental procedure2. Give nitroglycerine tablet under tongue.3. Administer O2 a) If pain relieved with in 5 min. let patient rest and continue with appointment or terminate appointment and reschedule. www.indiandentalacademy.com
  13. 13. b) If pain not relieved within 5 min.(i) Take patients B.P and pulse.(ii) If condition is stable give second nitroglycerine tablet, if pain relieved within 5 min. manage as in 3a above.(iii) If condition remains stable but pain continues, give third nitroglycerine tablet, if pain relieved within 5 minutes, manage as in 3a above.IV. If pain is not relieved following 3 nitroglycerine tablets given within 15 minutes period or patient become unstable at any time – shift the patient to emergency facility. www.indiandentalacademy.com
  14. 14. INFECTIVE ENDOCARDITISPredisposing Lesions : Rheumatic heart disease, congenital heart disease, prosthetic heart valves, grafts and pacemakers.Organisms : Streptococci, Staphylococci, Pneumococci, Gonococci, Meningococci, Salmonella, E. Coli, Fungi.Precipitating Factors : Dental procedures, abortion, procedures on lower urinary tract, intravenous drugsuse, emergency procedures including IV catheter and infections. www.indiandentalacademy.com
  15. 15. ANTIBIOTIC PROPHYLAXIS FORINFECTIVE ENDOCARDITISDental Procedure :Amox. 3 g orally 1 hour before surgery and 1.5g6 hours later.Allergic to PenicillinErythromycin 1.5 g orally 1 – 2 hour beforesurgery and 0.75 g 6 hours later.Clindamycin 300 mg 1 hour before and 150mg 6hours later. www.indiandentalacademy.com
  16. 16. General Anaesthesia and Surgery Amox 1g in 2.5ml of 1% lignocaine I.M pre-operatively and repeat 6 hours later. Allergic to penicillin Vancomycin 1g IV 1 hour before, plus 120mg gentamicin I.V. www.indiandentalacademy.com
  17. 17. Dental Considerations1. Inform adequate - oral hygiene and emphasize the link between bacteremia and systemic disorders.2. Consult physician – History of cardiac defects3. Discuss with the physician – state of oral hygiene, what procedures are contemplated, extend of bacteremia that can develop. www.indiandentalacademy.com
  18. 18. 4. Local Degerming - Iodinated glycerol solution, Chlorhexidine, Providone – Iodine, Phenolated solutions.5. Antibiotic prophylaxis – Physician should make the final decision.6. Before endodontic procedures – Rinse with antimicrobial agent 5 or 6 times before expectorating.7. Patients with acute periapical abscess – Proceed as above and administer 2g of penicillin orally, establish drainage through the canal. www.indiandentalacademy.com
  19. 19. 8.Incision and drainage - Wait 1 hour after oral penicillin, establish drainage through the root canal whenever possible.9. Non Surgical Endodontic Procedures (Reaming, filing or filling root canals) – produce no detectable bacteremia. Bacteremia that may ensue after placement of rubber dam clamp can be controlled by degerming the gingival sulcus. www.indiandentalacademy.com
  20. 20. HYPERTENSIONDefined arbitrarily at levels above generallyaccepted normals (120/80) eg. 140/90 at the ageof 20, 160 / 95 at the age of 50.TYPES1. Systolic and diastolic pressure2. Primary (Essential) and secondaryhypertension.Primary : Blood pressure elevated without anevident cause.Secondary : Hypertension produced by anidentifiablewww.indiandentalacademy.com cause.
  21. 21. CAUSES FOR SECONDARY HYPERTENSIONVascular causes, Renal causes, Endocrinecauses, Adverse reaction to drugs, Toxemiaof pregnancy.CONTRIBUTORY FACTORS FORPRIMARY HYPERTENSIONGenetic Factors, Psychological stress, Salt andWater intake, Renal Hormones. www.indiandentalacademy.com
  22. 22. DENTAL CONSIDERATIONS Provide ‘Anxiety – free’ situation. Establish atmosphere in which patients - encouraged to express and discuss their fears, concern and question about dental treatment. Blood pressure record www.indiandentalacademy.com
  23. 23.  Avoid long or stressful appointments. Use premedication as needed (Benzodiazepine such as diazepam). Provide gradual change of position to avoid postural hypotension. Avoid stimulating gap reflex. Dismiss patients if over stressed. www.indiandentalacademy.com
  24. 24. CONGESTIVE HEART FAILUREState in which heart is not able to pumpadequate amount of blood to meet the demandsof the body.Etiology - Coronary heart disease,Hypertension, Valvular heart disease,myocarditis, Infective endocarditis, Congenitalheart disease, Pulmonary Hypertension,Pulmonary embolism.Functional classification of heart diseaseGrades the severity of C.H.F.Aid in the dental management of patients. www.indiandentalacademy.com
  25. 25. Class – 1No limitation of physical activity, no dyspnea,fatigue or palpitations with ordinary physicalactivity.Class – IISlight limitation of physical activity, patientshave dyspnea, fatigue or palpitations withordinary physical activity – comfortable at rest.Class – IIIMarket limitations of activity, less than ordinaryphysical activity, results in symptoms –comfortable at rest.Class – IVSymptoms present at rest, any physical excertionexacerbarates symptoms. www.indiandentalacademy.com
  26. 26. DENTAL MANAGEMENT1. Patient Evaluationa.Patient with untreated or uncontrolled C.H.F - avoid elective dental care.b.Patients under medical care for C.H.F –Confirm status with patient or physicianClass I and Class II patients - routine dental careClass III patients - consideration with physician and consider treatment in special care facility (Hospital dental care)Class IV patients – conservatively in special care setting www.indiandentalacademy.com
  27. 27. 2. Drug consideration Patients taking digitalis use epinephrine (max 0.036 mg epinephrine). Class III & IV C.C.F – avoid use of vasoconstrictors3. Use semisupine or upright chair position – per patient comfort.4.Watch for orthostatic hypertension, make position or chair changes slowly.5.Short, stress – free appointments. www.indiandentalacademy.com
  28. 28. RESPIRATORY DISEASESChronic obstructive pulmonarydisease2 – most common diseases classifiedas COPD. 1. Chronic Bronchitis 2. EmphysemaChronic bronchitis - Defined ascough productive of sputum on mostdays of atleast 3 consecutive monthsfor more than 2 successive years.Emphysema – Definedpathologically as dilatation anddestruction of the lung tissue distalto the terminal bronchioles www.indiandentalacademy.com
  29. 29. DENTAL CONSIDERATIONS Upright chair positionL.A as usual, avoid bilateral mandibular or palatal blocksAvoid use of rubber dam in severe diseaseAvoid use of barbiturates, narcotics, antihistamines and anticholinergicsIf patient taking theophylline – avoid erythromycin and ciprofloxacin.Out patients G.A. contraindicated www.indiandentalacademy.com
  30. 30. ASTHMAChronic inflammatorycondition of airways,clinically characterized bywide spread reversiblefunctional narrowing of theairways consisting ofrecurrent episodes ofdyspnea, coughing andwheezing resulting fromhyper irritability of thetracheo bronchial tree. www.indiandentalacademy.com
  31. 31. DENTAL MANAGEMENT1.Identification of patient by history2.Determination of character of asthma.Type of Asthma (Mild, moderate or severe)Precipitating factorsAge at onsetFrequency, time of day and severity ofattacks. How usually managed Medications being taken Necessity of emergency care www.indiandentalacademy.com
  32. 32. 3.Avoidance of known precipitating factors.4. Medical consultation for severe, active asthmatic.5. Have patient bring medication in haler to every appointment and keep it available.6.Drug considerationsAvoid aspirin containing medications and NSAID (use acetaminophen) www.indiandentalacademy.com
  33. 33.  Avoid barbiturites and narcotics  Avoid erythromycin and ciprofloxacin in patients taking theophylline7. L.A considerations – Elect to avoid solutionscontaining epinephrine because of sulfitepreservative.8. Provision of stress – free environment9. If sedation required, use small doses of oraldiazepam. www.indiandentalacademy.com
  34. 34. TUBERCULOSISChronic granulamatous disease caused bymycobacterium tuberculosis which may involveall organs in the body, but lungs are the mostcommon sites.Systemic EffectsAnorexia, Weight loss,Sleep sweats, evening pyrexiaLocal effectsCough, sputum, haemoptysis www.indiandentalacademy.com
  35. 35. DENTAL MANAGEMENT1.Patient with active tuberculosis Consultation with physician before treatmentTreatment limited to emergency careTreatment with proper isolation, sterilization, mask, gloves, gown, ventilation.Patient under 6 years – treat as normal patient (non infectious) after consultation with physician. www.indiandentalacademy.com
  36. 36. 2. Patients with past history of tuberculosis Approach with caution, obtain good history of disease and treatment, appropriate review of symptoms.Consult with physician and postponed treatment if1.Questionable history of adequate treatment2.Lack of appropriate medical supervision since recovery3.Signs or symptoms of relapse If present status free of clinical disease – treat as normal patient www.indiandentalacademy.com
  37. 37. 3. Patients with signs or symptom of tuberculosis Refer to physician and postpone treatment If treatment necessary, treat as patient with active tuberculosis.4. Emergency careI. If clinical disease present1.Consultation with physician before treatment2.Provide only urgent dental care. www.indiandentalacademy.com
  38. 38. 3. Isolation of dental operatory systems.4. Strict aseptic procedures5. Use gloves, gown, mask6. Use of rubber dam when possible7. Use of slow speed – to minimize aerosol8. Minimize use of air syringe9. Scrubbing and sterilizing of all equipment after useII. Provide normal care only when free of clinical disease www.indiandentalacademy.com
  39. 39. RENAL DISEASESIrreversible deteriorationin renal function – leadsto impairment of theexcretory, metabolic andendocrine functions ofthe kidney which leads todevelopment of theclinical syndromeuraemia. www.indiandentalacademy.com
  40. 40. DENTAL MANAGEMENTPotential problemBleeding tendency, hypertension, anemia,intolerance to nephrotoxic drugs metabolizedby kidney, enhanced susceptibility to infection. www.indiandentalacademy.com
  41. 41. Prevention of complications Consultation with physician Pre treatment screening for hematological disorder (bleeding time, prothrombin time, hemoglobin count, platelet count) Monitoring blood pressure before and during treatment Avoid drugs excreted by kidney or nephrotoxic drugs www.indiandentalacademy.com
  42. 42.  Minimize chances of abnormal bleeding or infections Aggressive management of infectionOral Complication1. Mucosal pallor, xerostomia, metallic taste, amonia breath odor, stomatitis, bone radiolucencies, bleeding tendency www.indiandentalacademy.com
  43. 43. DIALYSISBased on the principle ofosmosis, diffusion andultra filtration across asemi-permeablemembrane. By thisprocedure the metabolitesnormally eliminated by thekidney can be removedfrom blood. www.indiandentalacademy.com
  44. 44. IndicationsIncreased plasma urea or creatinine con.,hyperkalemia, fluid over load. DENTAL CONSIDERATIONSPotential Problems1. Bleeding tendency. 2. Hyper tension. 3.Anemia4.Intolerance to nephrotoxic drugs metabolizedby kidney. 5. Hepatitis (active or carrier) 6.Bacterial endocarditis. www.indiandentalacademy.com
  45. 45. Prevention of ComplicationsConsultation with physicianNo dental treatment until off dialysis machine for atleast 4 hoursPre treatment screening for bleeding disorder (bleeding time, prothrombin time, platelet count, hemoglobin count.Avoid drugs metabolized by kidney or nephrotoxic drugs.Consider antibiotic prophylaxis to minimize bacteriemia.Treatment screening for HBs Ag www.indiandentalacademy.com
  46. 46. LIVER DISEASESViral Hepatitis Characterized by diffuse inflammation of the liver. Several viruses can cause the syndromeFive viruses mainly responsible for the majority of cases – Hepatitis A virus (HAV), Hepatitis B virus (HBV), Hepatitis C virus (HCV), Hepatitis D virus (HDV), Hepatitis E virus (HEV). www.indiandentalacademy.com
  47. 47. DENTAL CONSIDERATIONSPotential problem related to dental care Dentist can be infected by infectious patient’s Patients or Staff can be infected by dentistwith active Hepatitis or who is a carrier. With chronic active Hepatitis may havebleeding tendency or altered drug metabolism www.indiandentalacademy.com
  48. 48. Prevention of Complications1.Patients with active Hepatitis Consultation with physicianTreatment on emergency basis only2. Patients with history of Hepatitis Consultation with physician Probable type determination A. Age at time of infection (HBV uncommon under age 15 years). B. Source of Infection (Food or water, usually HAV or HEV) www.indiandentalacademy.com
  49. 49. C. If blood transfusion related, probably HCV or HBV.D. If type in determinate, radioimmunoassay for HBV surface antigen (HBs Ag) be considered. If HBs Ag positive (carrier) A. Consultation with physician B. Minimize drug metabolized by liver C. Preoperative prothrombin time and bleeding time if chronic active hepatitis. www.indiandentalacademy.com
  50. 50. Urgent Dental Care for the patient with acutehepatitisConsult with physician – patient status andplanned dental treatmentIf surgery necessary – obtain preoperativeprothrombin time and bleeding time, discussabnormal results with physician. www.indiandentalacademy.com
  51. 51.  Adhere to strict universal precautions Use isolated operatory. Minimize use of drugs metabolized by liver. Use rubber dam to minimize contact with saliva and blood. Minimize aerosol production by using slow speed handpiece, use air syringe judiciously www.indiandentalacademy.com
  52. 52. DENTAL DRUGS METABOLIZED PRIMARILY BY LIVER1. Local Anaesthetic – Lidocaine, Bupivacaine, Prilocaine2. Analgesics - Acetaminophen, Aspirin, Ibuprofen3. Sedatives – Diazepam, Barbituraes4. Antibiotics – Ampicillin, Tetracycline www.indiandentalacademy.com
  53. 53. ALCOHOLIC LIVER DISEASE Chronic consumption of alcohol leads to three distinctive forms of liver disease.1. Hepatic steatosis (Fatty liver)2. Alcoholic hepatitis3. Cirrhosis www.indiandentalacademy.com
  54. 54. DENTAL CONSIDERATIONSPotential problem related to dental care Bleeding tendencies Unpredictable drug metabolismPrevention of Complications1. Identification of Alcoholic patientsHistory, Clinical Examination, Detection of odor from breath, information from relatives www.indiandentalacademy.com
  55. 55. 2. Consultation with physician to verify currentstatus3. Laboratory screening – complete blood count, bleeding time, thrombin time, prothrobmin time4. Minimize drugs metabolized by liver5. If screening tests abnormal for surgery – consider antifibrinolytic agents, Vit-K, platelets www.indiandentalacademy.com
  56. 56. Oral ComplicationsBleeding, Ecchymoses, Petechia, Glossitis,Angular cheilosis, Impaired healing,Candidiasis, Alcoholic breath odor, Xerostomia,Bruxism, Dental attrition www.indiandentalacademy.com
  57. 57. GASTROINTESTINAL DISEASESUlcer – Peptic ulcer,Duodenal ulcer, Gastric ulcer. www.indiandentalacademy.com
  58. 58. Peptic Ulcer – Imbalance between theaggressive action of acid pepsin secretion andthe normal defenses of the gastric mucosa.Duodenal Ulcer – Higher mean basal acidoutput than normal.Gastric Ulcer – Exact mechanism not known,unlike peptic and Duodenal ulcer patients haveonly normal or low acid levels www.indiandentalacademy.com
  59. 59. DENTAL CONSIDERATIONSPotential problem related to dental care1.Aspirin and NSAIDS cause injury to intestinal mucosa.2.During or after systemic antibiotic use can cause fungal overgrowth.Prevention of Complications1.Avoid aspirin and NSAID2.Avoid corticosteroids3.Examine oral cavity for signs of fungal overgrowth www.indiandentalacademy.com
  60. 60. Treatment plan ModificationsReduce stressful environmentOral Complications1.Rare-enamel dissolution associated with persistent regurgitation2.Fungal overgrowth3.Rare vitamin B deficiency with omaprazole use. www.indiandentalacademy.com
  61. 61. ENDOCRINE AND METABOLIC DISEASESDIABETES MELLITUSMetabolic disorder characterized byhyperglycemia with or without glycosuriaresulting from an absolute or conditionaldeficiency of insulin.Fasting Plasma Glucose Level - 75-110mg/dlPost – Prandial glucose level - 110-140mg/dl www.indiandentalacademy.com
  62. 62. ClassificationType – 1 : IDDMType – 2 : NIDDMType – 3 : Malnutrition related, Pancreaticdisease, Hormonal disease, drug induced orchemical induced, abnormalities of insulin or itsreceptors, certain genetic syndromes. www.indiandentalacademy.com
  63. 63. Dental ConsiderationsPotential problem related to dental care1. In uncontrolled diabetic patientsa. Infection, b. Poor wound healing2. Patients on insulin – insulin reaction3. In diabetic patient early onset of complication relating to CVS, eyes, kidneys and nervous system (Angina, myocardial infarction, renal failure, hypertension, CHS) www.indiandentalacademy.com
  64. 64. Prevention of Complications1. Detection by a) History b) Clinical findings c) Screening blood glucose level2. Referral for diagnosis and treatment3. Monitor and control of hyper glycemia www.indiandentalacademy.com
  65. 65. 4.Patient receiving insulin – prevent insulin reactiona.Advise eating normal meals before appointments.b.Schedule appointments in morning or mid morning.c. Have sugar in some form to give in case of insulin reaction.d.Advise patient to inform if any symptoms of insulin reaction occur. www.indiandentalacademy.com
  66. 66. Oral ComplicationsAccelerated periodontal diseases, xerostomia,Poor healing, Infection, oral ulcerations,Candidiasis, Numbness, burning or pain in oraltissues. Diabetic Gingivitis www.indiandentalacademy.com
  67. 67. Hyper thyroidism : Persistent elevation of the synthesis and release of thyroid hormones (T4 & T3)Causes :(1) Toxic diffuse goiter (Grave’s disease)(2) Toxic multinodular goiter (Plumme’s disease) (3) Toxic adenoma (4) Acute thyroiditis (5) Iodide induced (6) TSH induced. www.indiandentalacademy.com
  68. 68. DENTAL CONSIDERATIONS Potential problem related to dental care :1. Thyrotoxic crises – precipitated in untreated or incompletely treated patients with (a). infection (b) trauma (c) surgical procedure (d) stress.2. Patients with untreated or incompletely treated thyrotoxicicosis may be very sensitive to epinephrine and other amines. www.indiandentalacademy.com
  69. 69. 3. Thyrotoxicosis increases risk for hypertension, angina, MI, CHF and severe arrhythmias.Prevention of Complications :1. Detection of patients by history and examination findings2. Referral for medical evaluation and treatment.3. Avoidance of dental treatment for patient with thyrotoxicosis until good medical control. www.indiandentalacademy.com
  70. 70. 4. Avoidance of epinephrine and amines in untreated or incompletely treated patients5. Recognition of early stages of thyrotoxicosis crises. (a) symptoms – Febrile, Abdominal pain.6. Immediate emergency treatment procedures. (a) Immediate medical aid (b) Cool with cold towels. (c) hydrocortisone (100 to 300mg) (d) monitor vital signs. www.indiandentalacademy.com
  71. 71. Oral complications :1. Extensive dental caries2. Premature loss of deciduous teeth and early eruption of permanent teeth. www.indiandentalacademy.com
  72. 72. BLEEDING DISORDERSPurpura – Purplishdiscolouration of the skinand mucous membranes due to spontaneousextravasation of bloodTypes1.Non thrombocytopenic2.Thrombocytopenic – a. Primary (Idiopathic) b.Secondary (Chemicals radiation, leukemia,splenomegaly, drugs – alcohol, thiazidediuretics, estrogens) www.indiandentalacademy.com
  73. 73. Non thrombocytopenic PurpuraNot Mediated through changes in bloodplatelets, but rather through alterations in thecapillaries.ThrombocytopenicPurpuraPlatelet count is usuallyless than 60,000 per cubicmm.Prolong bleeding time, Drug induced thrombocytopenia –normal coagulation time sublingual mucosal hemorrhage www.indiandentalacademy.com
  74. 74. Dental ConsiderationsPotential problem related to dental careProlonged bleedingPrevention of complications1. Identification of Patients•History, b) Examination findings, c) Screeningtests – Bleeding time, platelet count.2. Referral and Consultation with Hematologist3. Correction of underlying problem orreplacement therapy before surgery www.indiandentalacademy.com
  75. 75. 4. Local measures to control blood loss –microfibrillar collagen, topical thrombin.5. Prophylactic antibiotic for patients beingtreated with steroids6. Avoid aspirin, aspirin containing compoundsand NSAIDS – use acetaminophenTreatment plan modificationsNo dental procedures unless replacement ofplatelets before procedure or underlyingproblem has been corrected www.indiandentalacademy.com
  76. 76. Oral ComplicationsSpontaneous bleeding, prolonged bleeding,Petechia, Ecchymoses, Hematomos HEMOPHILIAProlonged coagulation time,normal bleeding time,Hemorrhagic tendenciesHereditarywww.indiandentalacademy.com the X-Chromosome defect carried by
  77. 77. Types1.Hemophilia – A (Classic Hemophilia) – Deffactor VIII2.Hemophilia – B (Christmas disease) – Deffactor IX3.Hemophilia – C – Def factor XIDental considerationsPotential ProblemExcessive bleeding following dental procedures www.indiandentalacademy.com
  78. 78. Prevention of complications1.Identification of patients –a) History Bleeding problems in relatives Excessive bleeding following trauma or surgery.b) Examination findings Ecchymosis Dissecting hematomas www.indiandentalacademy.com
  79. 79. 2.Consultation and referral for diagnosis and treatment before dental procedures3.Replacement options – Fresh flow frozen plasma, factor VIII concentrates.4.Local measures to control bleeding – microfibrillar collagen, topical thrombin etc.5.Prophylactic antibiotic to prevent post operative infections6.Avoid aspirin, aspirin containing compounds and NSAIDs www.indiandentalacademy.com
  80. 80. Treatment plan modifications1.No dental procedures unless patient prepared based on consultation with hematologist.2.Avoid aspirin, aspirin containing compounds and NSAID’s use acetaminophen.3.Use fluorides, fissure sealants dietary advice and regular dental inspection from an early age www.indiandentalacademy.com
  81. 81. 4.RCT can be carried out without special precautions – special care to avoid instrumentation and filling beyond the apex. In severe hemophilia bleeding from the pulp and periapical tissues can be persistent and trouble some.5.Careful application of matrix band – not to cut periodontal tissue.6. Rubber dam is helpful to protect the mucosa, but clamp must be applied carefully. www.indiandentalacademy.com
  82. 82. 7.High speed vacuum aspirators an saliva ejectors should be used with caution to avoid hematomas. Trauma can be minimized by resting it on a Gauze swab.Oral Complications1.Spontaneous bleeding, 2. Prolonged bleeding, 3. Petechia, 4. Hematoma, 5. Oral lesions associated with HIV infection in patients who received infected replacement products www.indiandentalacademy.com
  83. 83. VON WILLE BRAND’S DISEASE Hemorrhage of 2 weeks duration from the tongue with severe Von Wille Brand’s DiseaseExcessive bleeding, normal platelet count,normal clotting time, normal prothrombin time -prolonged bleeding timeHereditary disease–Qualitative and quantitativeabnormalities in factor VIII www.indiandentalacademy.com
  84. 84. Dental ConsiderationsPotential problemExcessive bleedingPrevention of complications1.Identification for patienta)History of bleeding problems in relatives or following surgery or traumab)Examination findings – Petechia, Hematomas www.indiandentalacademy.com
  85. 85. c) Screening test – Bleeding time2.Consultation and referral for diagnosis and treatment before procedures3.Avoid aspirin containing compounds and NSAID’s4.Prophylactic antibiotic5.Replacement options – Fresh frozen plasma, special factor VIII con.6.Local measures – Gel form with thrombin etc. www.indiandentalacademy.com
  86. 86. Treatment plan modifications1.Regardless the severity of the disease, endodontic treatment is preferable to extraction.2.Weine suggests stepwise management of these cases. Pulp tissue removed until pain is elicited www.indiandentalacademy.com
  87. 87. Fixative in the form of formocresol then applied Treatment continue at subsequent appointment until total pulp extirpation accomplished.3. Patient can be treated in the normal dental setting – after initial factor replacement providedwww.indiandentalacademy.com by the hematologist.
  88. 88. NEUROLOGIC DISORDERSEpilepsy : Functionally characterized by abnormalrecurrent excessive electrical discharge ofcerebral origin. Clinically characterized by loss or excess ofmotor, sensory or autonomic functions with orwithout alteration in consciousness. www.indiandentalacademy.com
  89. 89. DENTAL CONSIDERATIONSPotential problems related to dental care :• Occurrence of generalized tonic- clonicseizure in dental office.• Drug induced leukopenia andthrombocytopenia (phenytoin carbamazepine,valproic acid). www.indiandentalacademy.com
  90. 90. Prevention of complications• Identification of patient by history. (a) Type of Seizure (b) Age at time of onset (c) Cause of seizures (if known) (d) medications (e) Frequency of physician visits (name and Ph.no.) (f) degree of seizure control (g) Frequency of seizures (h) date of last seizures (i) Known precipitating factors. www.indiandentalacademy.com
  91. 91. 2. Provide normal care – patients with well controlled seizure pose no management problem.3. Questionable history or poorly controlled seizures - consultation with physician before treatment may require modification of medication.4. Alert to adverse effects of anticonvulsants - (a) Drowsiness, (b) Slow mentation (c) Dizziness (d) Gastrointestinal upset (e) allergic signs (rash, erythema multiforme) www.indiandentalacademy.com
  92. 92. 5. Patients taking valproic acid or carbamazepine – have bleeding tendencies because of platelet interference6. Preparation to manage grandmal seizure – (a) place a ligated mouth prop at beginning of procedure (b) Chair in supine position.7. Management of seizure – (a) clear area (b) Turn patient to side (to avoid aspiration) (c) Do not attempt to use padded tongue blade. www.indiandentalacademy.com
  93. 93. 8. After the seizure – (a) Examine for traumatic injuries (b) Discontinue treatment, arrange for patient transport.Treatment plan modification :1. Maintenance of optimal oral hygiene2. Surgical reduction of gingival hyperplasia (if indicated).3. Replace missing teeth with fixed prosthesis.4. Choose metal over porcelain when possible www.indiandentalacademy.com
  94. 94. Oral Complications :1. Gingival hyperplasia secondary to phenytoin (Dilantin)2. Traumatic oral injuries www.indiandentalacademy.com
  95. 95. AIDS• Characterized by profound impairment of the immune system.• HIV - has strong affinity for cells of the immune system (T-lymphocytes are mostly affected).• Altered function of T-lymphocytes– increased risk for malignancy and disseminated infection with micro organism.• Increased risk for adverse drug reactions. www.indiandentalacademy.com
  96. 96. • HIV detected in most body fluids – high quantities only in blood, semen and CSF.• Transmission exclusively by sexual contact or exposure to blood or blood products.Oral manifestations :• Oral hairy leukoplakia, Oral candidiasis, Kaposi’s sarcoma, Oral hyper pigmentation, Atypical ulcers and delayed healing, Gingivitis and periodontitis. www.indiandentalacademy.com
  97. 97. ORAL CANDIDIASISKaposi’s sarcoma Oral hairy leukoplakia www.indiandentalacademy.com
  98. 98. DENTAL CONSIDERATIONS1. Consult with physician to establish patients current status.2. Inform all staff working with AIDS patient - relative risks and how they can be minimized.3. Adhere to strict universal precautions.4. Use isolated operatory5. Use rubber dam when possible to minimize contact with saliva and blood. www.indiandentalacademy.com
  99. 99. 6. Minimize aerosol production – slow speed handpiece, use air syringe judiciously.7. Provide dental procedures based on patients wants and needs.8. Render only immediate treatments- patient with advanced AIDs.9. Prophylactic antibiotics – protection of severe neutropenia to avoid post operative infection. www.indiandentalacademy.com
  100. 100. 10. If surgery is necessary – obtain bleeding time and white blood cell count, platelet replacement may be needed with severe thrombo cytopenia.11. Acetominophen should be avoid with patients under Zidovudine (granulocytopenia and anemia associated with zidovudine may be intensified). Aspirin should not given in patients with thrombocytopenia.12. Patient with advanced HIV disease – RCT a slightly increased risk for post operative infections. www.indiandentalacademy.com
  101. 101. CONCLUSION Patients of today cannot be compared withpatients of the past. They are esthetically moredemanding and have access to latest information. Medically compromised patients are notexception. It is the responsibility for the dentistto identify patients with systemic conditions andto provide treatment with some kind ofmodifications. www.indiandentalacademy.com
  102. 102. REFERENCES Dentistry for medically compromised patients – James W. Little – 6th Edition. Essentials of safe dentistry for the medically compromised patient – Frank M. McCarthy. Dental care for the medically compromised patients– Margarret C. Grady. Treatment of patients with medical conditions and complications – DCNA 43(3) July 1999, Milzman DP. Principles and practice of medicine – Davidson’s– 17th Edition. C.R.W. Edwards. Textbook of Oral Medicine – Burket’s – 9th edition www.indiandentalacademy.com – Malcolm A. Lynch.
  103. 103. Thank you for watchingwww.indiandentalacademy.com www.indiandentalacademy.com

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