management of medically compromised patients

1. Presented by: Prajjwal Gehlot
Batch 2018
Ruhs college of dental sciences
Jaipur, Rajasthan

2. It includes management of following
conditions:
 Cardiovascular Diseases
 Endocrine Disorders
 Hemorrhagic Disorders
 Renal Diseases
 Liver Diseases
 Pulmonary Diseases
 Pregnancy
 Infectious Diseases

3. Cardiovascular diseases
• Most prevalent and seen usually in older age patients
• History is of paramount importance and should be
actively taken
• Includes;
– Hypertension,
– Angina, Myocardial infarction,
– cerebrovascular accidents,
– congestive heart failure(CHF),
– Pacemakers/Defibrillators
– Infective endocarditis

4. HYPERTENSION
 Most common cardiovascular disease
 Hypertension is classified according to JNC-7 guidelines
 JNC-7 guidelines emphasizes the importance of systolic blood
pressure(SBP) than diastolic blood pressure(DBP)
Pre hypertension
SBP; 120-139 mm Hg DBP; 80-89 mm H g
Stage I Hypertension
SBP; 140-159 mm Hg DBP; 90-99 mm Hg
Stage II Hypertension
SBP > 160 mm Hg DBP > 100 mm Hg

5. Normal (SBP<120 and DBP <80 mm Hg)
No changes in dental treatment.
Pre hypertension ( SBP 120-139 or DPB 80-89 mm Hg )
No changes in dental treatment.
Monitor BP at each appointment.
Stage 1 hypertension( SBP140-159 or DBP 90-99 mm Hg)
Inform patient of findings.
Routine medical consultation/referral.
Monitor BP at each appointment.
No changes in dental treatment; minimize stress.
Stage 2 hypertension SBP ≥160 DBP ≥100 mm Hg
Inform the patient.
Medical consultation/referral.
Monitor BP at each appointment

6. PERIODONTAL CONSIDERATIONS
• Treatment should not be performed until accurate BP
measurements and histories elicited.
• The time of day should be recorded along with the BP
reading
• Patient is currently receiving antihypertensive therapy,
consultation with the physician may be warranted.
• Inform the physician degree of stress, length and
complexity of the procedure.
• Evidence indicates that BP generally increases around
awakening and peaks at midmorning, therefore
afternoon dental appointments should be preferred.

7. • When treating hypertensive patients, the clinician
should not use a local anesthetic containing an
epinephrine concentration greater than 1:100,000 nor
should a vasopressor be used to control local bleeding.
Local anesthesia without epinephrine may be used for
short procedures (<3O minutes).
• Intraligamentary injection is generally contraindicated
because hemodynamic changes are similar to
intravascular injection
• It is prudent to avoid rapid changes in chair
positioning, which may cause postural hypotension.

8. Angina
 Myocardial O2 demands exceeds supply-Transient
Ischemia
 Unstable Angina – Emergency procedures
 Stable Angina- Elective dental procedures
 Stress reduction, Local anesthesia, conscious sedation,
Supplemental oxygen via nasal cannula
 Nitroglycerine tablet (0.3-0.6 mg is given sublingually)
and second tablet is again given at 2-3 minutes if pain
does not subsides
 Third tablet of Nitroglycerine is again given at 5 minutes
and if pain does not subsides- Myocardial Infarction

9. Myocardial infarction (MI)
• The patient is immediately referred to nearest
medical emergency facility
• Dental treatment is deferred for at least 6
months after MI because of increased mortality
during this time
• After 6 months, MI patients can usually be
treated using techniques similar to those for
stable angina patients.
• Cardiac bypass, femoral artery bypass,
angioplasty ;-physician consultation should be
obtained before any dental procedure

10. Congestive Heart Failure (CHF)
• Heart is unable to pump required oxygenated blood to meet body’s
demand
• Elective dental procedures are not indicated in poorly
controlled/untreated CHF due to Risk of sudden death from
ventricular arrhythmia.
• The dental chair should be adjusted to a comfortable level for the
patient rather than placed in a supine position.
• Short appointments, stress reduction with profound local
anesthesia and possibly conscious sedation, and use of
supplemental oxygen should be considered.

11. Cardiac pacemakers and implantable
cardioverter-defibrillators
 Cardiac arrythmia are treated using cardiac pacemakers or
implantable cardioverter
 Older Pacemakers were unipolar and could be disrupted by dental
instruments like ultrasonic
 Newer pacemakers are Bipolar and are not disrupted by dental
instruments
 Automatic cardioverter defibrillators could activate without warning in
case of arrhythmia leading to sudden patient movement so
stabilization of operating field using bite block is recommended to
prevent injury.

12. INFECTIVE ENDOCARDITIS
 Infective endocarditis (IE) is a disease in which
microorganisms colonize damaged endocardium or heart
valves
 Organisms responsible are α-hemolytic streptococci (e.g.,
Streptococcus viridans).
 Indications for antibiotic prophylaxis-
• Prosthetic cardiac valves and prosthetic material used for
cardiac valve repair
• History of infective endocarditis
• Cardiac transplant with valve regurgitation
• Congenital heart diseases

13. Standard oral regimen
Amoxicillin 2.0 g 30–60 min before procedure
Alternate regimen for patients
Clindamycin 600 mg 30–60 min before procedure
If allergic to amoxicillin or penicillin
Azithromycin or clarithromycin
500 mg 30–60 min before procedure
Recommended Antibiotic Prophylaxis Regimens for
Periodontal procedures in Adults at Risk for Infective
Endocarditis

14. Endocrine disorders
DIABETES
 Types
 Type 1 IDDM
 Type 2 NIDDM
 Symptoms
 Polyphagia, Polydipsia, Polyuria
 Unexplained concurrent weight loss
 Periodontal therapy has limited success in undiagnosed
or poorly controlled diabetes

15. Diagnostic criteria
Symptoms of diabetes plus casual (non fasting) plasma glucose≥ 200 mg/dl
Fasting Plasma glucose(FPG) ≥ 126mg/dl
Normal FPG is 70-110mg/dl.
Glycosylated Hemoglobin (HbA1c) as per *American Diabetes Association
guidelines
Normal : less than5.7%
Pre diabetes: 7.7% to 6.4%
Diabetes: 6.5% and higher
 Glucose level should be monitored regularly
 Patient with DM should bring glucometer in the dental office and
glucose level should be measured before the procedure

16. Hypoglycemia Management
 Diabetic patients on Insulin are at greatest risk of developing
hypoglycemia
 Taking Insulin without eating is primary cause of hypoglycemia
 Hypoglycemic episode; 15 gm oral carbohydrate, 3-4tsp sugar,
candy with 15gm sugar/ 4-6 oz juice
 If patient sedated/unable to drink/eat; 20-30ml of 50% Dextrose
intravenously(12-15gm dextrose) OR 1mg glucagon IV/IM/SC
 Physician consultation

17. Thyroid disorder
 Hyperthyroidism-risk of Thyrotoxicosis
 Hyerthyroidism can cause Tachycardia,
arrythmias,increase cardiac output, myocardial
ischaemia
 Epinephrine and vasopressors should be avoided.
 Hypothyroidism- careful administration of sedatives
because of excessive sedation

18. Adrenal insufficiency
 Significant morbidity and mortality rates as a result of
peripheral vascular collapse and cardiac arrest
 Primary adrenal insufficiency(Addison’s Disease)
 Secondary adrenal insufficiency(Exogenous
glucocortcoids)
 Suppression of HPA(Hypothalamus pituitary axis)
 Impaired Response to stress and increased cortisol
 Acute Adrenal Crisis

19. Clinical Manifestations Adrenal
Insufficiency
 Mental confusion, fatigue and weakness
 Nausea & Vomiting
 Hypertension
 Syncope
 Intense abdominal pain, lowe back pain, and leg pain
 Loss of Consciousness
 Coma

20. Steroid Prophylaxis
 Administer prophylactic steroid before dental treatment
in patient who are/have taken exogenous steroids
 Physician consultation necessary to evaluate for
supplemental steroid cover before dental procedures in
patient who are/have taken steroids
 No set protocol for steroid prophylaxis

21. Management of Acute Adrenal Insufficiency
 Terminate Dental Procedure
 Call Medical Assistance
 Give Oxygen
 Monitor Vital Signs
 Place patient in Supine position
 Administer 100 mg of Hydrocortisone sodium succinate
intravenously over 30 seconds or intramuscularly

22. Hemorrhagic Disorders
 Bleeding can be due to local as well systemic cause
 Systemic cause should be distinguished from local
cause
 Bleeding disorders
1. History
2. Clinical examination
3. Laboratory diagnosis

23. History
(1) the history of bleeding after previous
surgery or trauma.
(2) past and current drug history
(3) history of bleeding problems among relatives
(4) illnesses associated with potential bleeding
problems.

24. Clinical examination
 Spontaneous gingival bleeding
 Gingival Hyperplasia
 Eechymosis
 Petechiaes
 Hemorrhagic vesicles
 Spider telegiectasia
 Hemarthrosis/Joint bleeding
 Presence of Jaundice

25. Laboratory tests
 Measure Hemostatic, Coagulation,or Lytic Phase of
CLOTTING Mechanism
 Depending on Clues (History and Examination)
regarding Phase involved, includes
 Bleeding Time,
 Complete Blood Count,
 PT, PTT
 Coagulation time (CT)

26. Coagulation disorders
 Hemophilia A
 Hemophilia B
 Von Willebrand’s Disease

27. Hemophilia A
 Deficiency of factor VIII
 Severe Hemophilia: Factor VIII less than 1%
 Moderate Hemophilia: Factor VIII 1-5%
 Mild Hemophilia: Factor VIII 6-30%
 Surgical Hemorrhage is prevented when Factor VIII levels are
atleast 30%
 Parenteral 1-deamino-8-D arginine vasopressin (DDAVP)
/Recombinant Factor VIII are use to increase Factor VIII
levels

28. Hemophilia B or christmas disease
 Deficiency of Factor IX; severity of disease depends on
relative amount of Factor IX
 Surgical therapy;30-50% of Factor IX level
 Haematologist consultation is paramount
 Factor IX levels are increased by administration of
Purified Prothrombin Complex/ Factor IX concentrates

29. Von Willebrand’s Disease
 Deficiency of Von Willebrand factor(VWF)
 VWF mediates adhesion of platelets to injured vessel wall and
essential for Primary Hemostasis
 VWF carries coagulation portion of coagulant portion of
factor VIII in plasma
 It may be discovered as bleeding during dental surgical
procedures
 Treatment Infusion of preoperativeFactor VIII
/Cryoprecipitate/desmopressin

30. Periodontal treatment considerations in
coagulation disorders
 Probing, Scaling, Prophylaxis can be usually done
without medical modifications
 Invasive procedures like-blocks, root planing, surgery
need prior Physician consultation
 Anti hemostatic agents like oxidized cellulose or
purified bovine collagen should be placed over surgical
site

31.  Anti fibrinolytic agent Epsilon-Aminocaproic acid(EACA)
given oral/IV inhibits initial clot dissolution
 Tranexamic acid is potent Antifibrinolytic agent- prevents
excess hemorrhage after surgery
 Tranexamic acid as oral rinse or in combination with systemic
Tranexamic acid prevent given for several days to prevent oral
hemorrhage
 Not all Coagulation disesaes are hereditary .

32. Non Hereditary Coagulation disorder
 Liver diseases affect all phases of clotting disorder
because most coagulation factors are synthesized and
removed by the liver
 Alcohol users, Hepatitis, Liver diseases: Inadequate
Coagulation
 Vitamin K deficiency; due to malabsorption
syndromes, Antibiotics induced alteration of gut flora
that produces vit k.

33. Thrombocytopenia Purpura
 Thrombocytopenia defined as Platelet Counts less than
100,000/cubic mm
 Idiopathic, Radiation, Leukemia,Infections Chemotherapy,
 Purpura-Extravasation of blood into tissues under skin or
mucosa producing small petechiaes or eechymoses(bruises)
 Physician Consultation is mandatory

34.  Periodontal treatment should directed towards reducing
inflammation by removal of local factors
 Scaling and Root Planing are safe with platelet count>
60,000/cubic mm
 Surgical Procedures can only be done with Platelet
counts> 80,000/cubic mm if not then infusion is
required.

35. Renal Diseases
 Renal diseases can result in severe electrolyte imbalance,
cardiac arrhythmias, pulmonary congestion, CHF, and
prolonged bleeding.
So dental management becomes drastically altered
The following treatment modifications should be made:
1. Consult the patient’s physician.
2. Monitor BP; patients in end-stage renal failure are usually
hypertensive.
3. Check laboratory values: PTT, PT, bleeding time, and
platelet count; hematocrit; blood urea nitrogen (do not
treat if <60mg/dL); and serum creatinine (do not treat if
<1.5 mg/dL).

36. 4. Eliminate areas of oral infection to prevent systemic
infection.
• Good oral hygiene should be established.
• Periodontal treatment should aim at eliminating
inflammation or infection.
• Frequent recall appointments should be scheduled.
5. Drugs that are nephrotoxic or metabolized by the
kidney should not be given (e.g.,aminoglycoside
antibiotics)
 paracetamol can be given as analgesic.

37. Patients on dialysis
 Only hemodialysis patients require special precautions
because they have a high incidence of viral hepatitis,
anemia, and prolonged hemorrhage.
Recommendations made for those receiving hemodialysis:
1. Screen for hepatitis B and hepatitis C antigens and
antibodies
before any treatment.
2. Patients receive heparin anticoagulation on the day of
hemodialysis. Periodontal treatment should be provided on
the day after dialysis, when the effects of heparinization have
subsided.

38. 3. The hemodialysis shunt or fistula must be protected
when the patient is on the dental chair
 Excessive bleeding can occur during or after
periodontal treatment because of drug-induced
thrombocytopenia or anticoagulation, or both.

39. Liver diseases
 liver is the site of production of most clotting factors, excessive
bleeding during or after periodontal treatment can occur in
patients with severe liver disease
Treatment recommendations for patients-
1. Consultation with physician concerning the current stage of
disease, risk of bleeding, potential drugs to be prescribed
during treatment, and required alterations to periodontal
therapy
2. Screening for hepatitis B and C
3. Laboratory values for PT and PTT
4. Laboratory values for INR

40. For the liver transplant, Patients take
immunosuppressive drugs that greatly reduce
resistance to infection.
A pretransplantation evaluation is recommended to
determine which teeth can be maintained without risk
of infection.

41. Pulmonary diseases
Pulmonary diseases range from obstructive lung
diseases (e.g., asthma, emphysema, bronchitis) to
restrictive ventilatory disorders caused by muscle
weakness, scarring, obesity, or any condition that can
interfere with effective lung ventilation.
Signs and symptoms of pulmonary disease:
increased respiratory rate, cyanosis, clubbing of the
fingers, chronic cough, chest pain, hemoptysis,
dyspnea or orthopnea, and wheezing.

42. The following guidelines should be used during periodontal
therapy:
1. Identify and refer patients with signs and symptoms of
pulmonary disease to their physician.
2. For patients with known pulmonary disease, consult with their
physician regarding medications (e.g., antibiotics, steroids,
chemotherapeutic agents) and the degree and severity of
pulmonary disease.
3. Avoid elicitation of respiratory depression or distress:
• Minimize the stress of a periodontal appointment.
patient with emphysema should be treated in the afternoon, several hours
after sleep, to allow for airway clearance
• Avoid bilateral mandibular block anesthesia, which could cause
increased airway obstruction.
• Position the patient to allow maximal ventilatory efficiency, be careful to
prevent physical airway obstruction, keep the patient’s throat clear, and
avoid excess periodontal packing.

43. 4. For a person with a history of asthma, especially if asthma
attacks are frequent, make sure the patient’s medication
(inhaler) is available. The inhaler should be readily accessible
on the countertop in the dental treatment room.
5. Patients with active fungal or bacterial respiratory diseases
should not be treated unless the periodontal procedure is an
emergency.

44. Pregnancy
The aim of periodontal therapy for the pregnant
patient is to minimize the exaggerated inflammatory
response related to pregnancy associated hormonal
alterations.
Meticulous plaque control, scaling, root planing, and
polishing should be the only nonemergency
periodontal procedures performed.
The second trimester is the safest time to perform
treatment.

45. Supine position is avoided As the uterus increases in
size during the second and third trimesters,
obstruction of the vena cava and aorta can occur
resulting as less return of blood to heart.
 Decreasing BP, syncope, and loss of consciousness can
occur. This can be prevented by placing the patient on
her left side or by elevating the right hip 5 to 6 inches
during treatment.
A fully reclined position should be avoided if possible.

46. Left lateral position for pregnant women

47.  Ideally, no medications should be prescribed.
However, analgesics, antibiotics, local anesthetics, and
other drugs may be required during pregnancy,
depending on the patient’s needs
 All drugs should be reviewed for potential adverse
effects on the fetus.

48. Infectious diseases
 Hepatitis
 HIV and AIDS
 Tuberculosis

49. Hepatitis

50.  If the disease is active, do not provide periodontal
therapy unless the situation is an emergency. In an
emergency case, follow the protocol for patients testing
positive for hepatitis B surface antigen (HBsAg).
 For patients with a history of hepatitis, consult the
physician to determine the type of hepatitis, course
and length of the disease, mode of transmission, and
any chronic liver disease or viral carrier state.
 For recovered HAV and HEV patients, perform routine
periodontal care
 For recovered HBV and HDV patients, consult with the
physician and order HBsAg and anti-HBs (i.e.,
antibody to HBV surface antigen) laboratory tests.

51. If a patient with active hepatitis, positive-HBsAg (i.e., HBV carrier) status,
or positive-HCV carrier status requires emergency treatment, use the
following precautions:
 Consult the patient’s physician regarding status.
 If bleeding is likely during or after treatment, measure the PT and
bleeding time. Hepatitis can alter coagulation; change the treatment
accordingly.
 All personnel in clinical contact with the patient should use full barrier
techniques, including masks, gloves, glasses or eye shields, and
disposable gowns.
 Use as many disposable covers as possible, covering light handles,
drawer handles, and bracket trays. Headrest covers should also be used.
 All disposable items should be placed in one lined wastebasket. After
treatment, all disposable covers should be bagged, labeled.

52.  Aseptic technique should be followed at all times.
Minimize aerosol production by not using ultrasonic
instrumentation, air syringe, or high-speed
handpieces; remember that saliva contains a distillate
of the virus. Prerinsing with chlorhexidine gluconate
for 30 seconds is highly recommended.
 When the procedure is completed, all equipment
should be scrubbed and sterilized. If an item cannot
be sterilized or disposed of, it should not be used.

53. HIV AIDS
 Large variations in progression of HIV disease exist,
selecting an appropriate treatment plan depend upon
person health.
 The periodontal treatment plan is influenced by the
patient’s overall systemic health and coincident oral
infections or diseases.
 As with hepatitis, not all HIV-infected patients know that
they are infected when they present for dental treatment.
Individuals with known HIV infection may not admit their
status on the medical history. Every patient receiving
dental treatment should be managed as a potentially
infected person, using universal precautions for all
therapy.

54. Tuberculosis
 The patient with tuberculosis should receive only
emergency care, following the guidelines listed in the
section on hepatitis.
 When medical clearance has been given and sputum
culture results are negative, the patient can be treated
normally.

55. THANK YOU