OUR KNOWLEDGE AT CROSSROADS! DENTAL AND MEDICAL COLLABORATION! DENTAL MEDICINE.

2. PRESENTED BY
DR SHREEJA NAIR AND
DR AYASHA KHATRI

4. DIABETES

5. Parameter Normal Impaoired
glucose
level(Prediab
etic)
Diabetic
Fasting Blood
Sugar(FBS)
70-100 mg/dl 100-125
mg/dl
>126 mg/dl
Post prandial
blood
sugar(PPBS)
<140 mg/dl 140-199
mg/dl
>200 mg/dl
Random
blood
Sugar(RBS)
≥200 mg/dL
with classic
symptoms of
hyperglycemi
a
HbA1C <5.7% 5.7% to 6.4% >6.5%
TREATED AS NON DIABETIC PATIENT
ASK ABOUT:MEDICATION
FOOD INTAKE
MORNING APPOINTMENTS:
Reduced stress level
Increased cortisol level
Prevent
Hypoglycemia
Acceptable
Fasting Blood Sugar <145–180 mg/dl
Random Blood Sugar <234 mg/dl
https://www.diabetes.org/

6. • American College of Endocrinology (ACE),
American Association of Clinical Endocrinologists
and American College of Endocrinology
2016 Outpatient Glucose Monitoring Consensus Statement
• (Gazal, 2019; Gazal, 2018; Byakodi et al., 2017).
Delay dental procedure
Emergency procedures can
be done under antibiotic
coverage.
Poorly controlled
Random Blood Glucose≥234 mg/dl
AMOXICILLIN 500 MG TDS FOR 5 DAYS
Refer to physician

7. 6TH COMPLICATION

8. Blood glucose level
Below 70 mg/dl
HYPOGLYCEMIA
≥240-300 mg/dl
HYPERGLYCEMIA
Above 600 mg/dl
DIABETES
HYPEROSMOLAR
SYNDROME
American diabetes association 2014.

9. SYNCOPE

11. A: Airway: Ensure open airway.
B: Breathing: Check breathing—should be adequate.
C: Circulation: Check carotid pulse—should be adequate.
D: Dispense or administer: Aromatic ammonia
“smelling salts” /spirit
Check pulse
And blood pressure
I.V. 5%-25% DEXTROSE
phenylephrine 10 mg/mL
epinephrine 0.3 to 0.5 mg
I.M.,S.C. or I.V.
Low blood pressure(less than
previous diastolic)
E. Ensure that vital signs, drug administration, and patient responses are properly monitored and recorded.
F: Facilitate next steps in medical and dental care; reassure patient.
Atropine 0.5 mg IV
Repeat dose up to 3 mg additional
vasopressors (dopamine or epinephrine).
Low pulse rate(less than 60/min)
If patient is conscious
and responsive
administer oral glucose
If patient is unconscious
and nonresponsive

12. Hypertension

13. Duration And
Medication
History of
HYPER-
TENSION
Determine associated comorbidity:
CARDIO VASCULAR DISEASE
• DIABETES
• RENAL DAMAGE

14. CONTROL OF PAIN AND ANXIETY
2017 ACC/AHA guidelines
More intensive therapeutic interventions,
may result in a change in the frequency of drug
interactions and adverse effects, including
HYPOTENSIVE EPISODES, during dental care.
WHITE-COAT HYPERTENSION
(WCH) persistently
elevated office blood pressure
in the presence of a normal
blood pressure outside of the
office
Take 2 to 3 reading at frequent intervalAccording to 2017 ACC/AHA guidelines
<180/110 mm Hg
Most dentistry is considered safe up to
these levels.
Minor risk with respect to surgical
procedures and outcomes .
However, practitioners
should be aware that the ACC/AHA
2007 guidelines include a statement
that BP should be brought under
control before any surgery is
performed
≥180/110 mm Hg
HYPERTENSIVE CRISIS
Immediately refered to
physician

15. β blocker
ACE inhibitor
Calcium channel
blockers
𝜶 blocker
Centrally acting
agents
CALCIUM
CHANNEL
BLOCKERs
LICHENOID
β-blockers
ACE inhibitors
Diuretics
Methyldopa

16. RETRACTION CORD
WITH ADRENALINE
• Contraindicated
• Higher concentration
(12 standard cartridge)
Most commonly
used drugs in
dentistry
Antago
nise
Particularly
IBUPROFEN
Textbook of ADA practical guide for medically compromised patient,Aljadhey, (2012)
Lignocain
e
β blocker
increases toxicity
Adrenali
ne
MAXIMUM DOSE: 0.04mg
1:80,000
1:1,00,000
1:2,00,000 – 4 cartridge
2 cartridge
Joint National Committee 7

17. Ischemic Heart Disease
https://www.healthline.com/health/top-10-deadliest-diseases

18. UPTO 6
MONTHS AFTER
MI ATTACK
AVOID DENTAL
TREATMENT
BECAUSE OF PEAK
MORTALITY RATE
Conservative, targeted
toward PAIN RELIEF, And
INFECTION CONTROL
 Short appointment in
morning
 Semi supine position-
avoid sudden change to
prevent orthostatic
hypotension
Anti-Coagulant
Patient may be of Angina or MI

19. ANTIPLATELET AND
ANTICOAGULANT
THERAPY
Bleeding Time(BT)
Clotting factor(CT)

20. Aspirin
Clopidogrel
Ticlopidine
Prasugrel
Ticagrelor
Continue Discontinue
Do not stop
before
procedure
HIGH RISK
PATIENT
LOW DOSE
ASPIRIN:
75-150 mg
DUAL THERAPY:
ASPIRIN+
CLOPIDOGREL(75-
100 mg)
Consult with
Cardiologist
LOCAL
HEMO-
STATIC
MEASURES
Low High
Thrombotic risk, the bleeding risk
and the invasiveness of each
procedure.
Ada guidelines -2017

21. HEMOSTATIC MEASURES
If major surgery must be performed under emergency conditions,
desmopressin (DDAVP) can be used to reduce the risk of
excessive bleeding in patients taking aspirin
Vitamin K can be used with paitent taking warfarin.
5% Tranexamic acid
mouthwash
4 times daily
For 2 days
Mechanical methods Chemical measures
Pressure pack Astringents and styptics
• Ferric chloride/
Feracrylum
• Silver nitrate
Suture and ligation Gelatin sponge (Abgel)
Electrocautery Oxidised cellulose(surgicel)
Fibrin glue
Adrenaline

22. ANTI
COAGULANT
THERAPY
WARFARIN
DAOA-Directly
Acting Oral
Anticoagulant
1 to 2 days before-creatinine clearance 50 mL/min
3 to 5 days before if the creatinine clearance is less than 50 mL/min
Interprofessional
decision including
the dentist and
DOAC prescriber
Normal
value 1.0
Patient on
therapy:
2.0 to3.0
Check INR
72 hours prior to
Dental surgery
International Normalized Ratio- INR
(a measure of warfarin’s therapeutic index)
<3.5
Minor oral surgical
procedures can be
safely performed
Metronidazole
Erythromycin
Cimetidine
Inhibit warfarin
metabolism
Potentiate anticoagulant
effect
Extensive dental
treatment
Consultation
With the patient’s
physician, making
A decision to withhold
or bridging therapy
DRUG INTERACTION
Alternative medicine
Cephalosporin
Clindamycin

23. Cease
within 3
minutes
•complete the
dental procedure if
possible.
Do not
resolve
within 5
minutes
•administer
another dose of
nitroglycerin
Third
Tablet can
be given 5
minutes
•patient should be
transported to the
emergency
immediately
1 tablet of 0.3 to
0.6 mg of
nitroglycerin
/sorbitrate
Loosen restrictive garments.
Discontinue dental treatment

24. Modern CIEDs
“HERMETICALLY SEALED CASING” and “FILTERS,
REJECTION CIRCUITS, AND BIPOLAR MODES”
Chances of electromagnetic interference is low
Piezoelectric scalers
Safer than
NO RISK
Minor telemetry interference
GREATEST RISK
ada guidelines 2019
If electronic dental devices are used
Distance less than37.5 cm
(~15 inches)
Avoid waving the device
or its cords over the
patient’s pectoral region
Turn off this equipment
when not in use.

25. ANTIBIOTIC PROPHYLAXIS AGAINST INFECTIVE ENDOCARDITIS
Prophylaxis is recommended for
all dental procedures that
involve manipulation of gingival
tissue or the periapical region of
the teeth, or perforation of the
oral mucosa.
Routine anesthetic injections
Taking of radiographs
Placement of removable
prosthodontic or orthodontic
appliances
Adjustment of orthodontic
appliances
Shedding of deciduous teeth
Bleeding from trauma to the
lips or oral mucosa
Prophylaxis not required

26. One antibiotic
coverage period
Perform as much
dental treatment
as possible
If the
appointment
lasts longer
than 6 hours
and
If multiple
appointments
occur on the
same day
second
antibiotic
dose may be
indicated
For multiple
appointments
(on different
days)
At least 10 days
between
treatment
sessions
If treatment becomes
necessary before it
alternative antibiotics
Penicillin-
resistant
organisms
can “clear”
from the oral
flora
If the dosage of antibiotic is
inadvertently not
administered before the
procedure, the dosage may
be administered up to 2
hours after the procedure

27. PREGNANCY AND
LACTATION

28. Gingivitis
Gingival
hyperplasia
(Pregnancy
tumor)
Dental caries
ORAL PROPHYLAXIS AND EMERGENCY TREATMENT can be done
DENTAL TREATMENT: Not recommended
Greatest risk of
teratogens because of
organogenesis
Fivefold increased Risk
of spontaneous
abortion
FIRST TRIMESTER

29. SECOND TRIMESTER
• It is RELATIVELY SAFE PERIOD for dental
treatment as organogenesis completed.
• Active and elective dental care can be done.
• Management of oral infections can be done .
SAFE AVOIDED
ANTIBIOTICS Amoxicillin,
cephalosporins,
metronidazole,
azithromycin
TETRACYCLINE
clarithromycin
ANALGESIC PARACETAMOL IBUPROFEN &
other
NSAIDS
LOCAL
ANASTHESIA
Lignocaine with
adrenaline
Articaine,Mepiva
caine

30. THIRD TRIMESTER
• FETAL growth continues, more concern ABOUT:
SAFETY AND COMFORT OF MOTHER (chair positioning)
Dental treatment is safe in the EARLY PART OF THE 3rd TRIMESTER,
but after then avoided.
SUPINE POSITION should
AVOIDED
SEMI-
RECLINE
Right Hip
Should Be
Elevated 10
To 12 Cm On
Left Side
SUPINE
HYPOTENSION
SYNDROME
Change
positions more
slowly towards
left
UPCOMING BIRTH PROCESS
(Reduction of Anxiety and Stress, Drugs that affect
the bleeding time-NSAIDS)

31. LACTATION
TETRACYCLINE AND
DOXYCYCLINE: AVOIDED
METRONIDAZOLE:
May give breast milk
unpleasant taste.
ANTIBIOTICS
IBUPROFEN and
PARACETAMOL have the best
documentation on safety
during Breastfeeding.
Aspirin-Avoided.
ANALGESIC

32. CANCER

33. To prepare for cancer
treatment by treating
existing oral problems.
To prevent oral
complications and manage
problems that occur.
To keep teeth and gums
healthy and manage any
long-term side effects of
cancer and its treatment
CANCER

34. Indicators of Extraction
CBCPlatelet count <50,000/mm3
White blood count <2000/µmm
Neutrophil count <1000/µmm
Delay extraction
If mandatory
minimal
trauma and
Prophylactic
antibiotics can
be used.
2 weeks, * Ideally 3 weeks before RADIATION THERAPY
5 days before in maxilla, 7 days before in mandible in
CHEMOTHERAPY
To minimize the risk of osteoradionecrosis
Rankin KB, Jones DL, Redding SW, editors: Oral health care in cancer therapy: a guide for health care
professionals, ed 3, Dallas, Baylor Oral Health Foundation/Cancer Prevention & Research Institute of Texas, 2008.
Multinational Association of Supportive Care in Cancer Guidelines for Management of Mucositis*
Foci of infection like carious or
periodontally affected teeth.

35. AVOID ANY DENTAL TREATMENT IF POSSIBLE
EMERGENCY MANAGEMENT CAN BE DONE
CONSERVATIVELY

36. Acute signs and symptoms OF MUCOSITIS typically
develop during SECOND OR THIRD WEEK of therapy
which may continue for weeks to months following
completion of treatment
.
Oral Mucositis
Infections.
Most Common Oral Complications
Pain.
Salivary Gland Problems
Radiation Caries
Delayed healing
Trismus
Osteoradionecrosis
Xerostomia
• Warm normal saline, Benzydamine, 0.12%-0.2%
Lignocaine gargling should prescribed to treat it.
Patients receiving METHOTREXATE therapy, Systemic
or topical folinic acid (leucovorin calcium) can be
prescribed.
ASPIRIN should be avoided.

37. 0.65% Carboxymethylcellulose
(2 ml as frequently as required for
2 weeks)
sugarless gum
buffered citric acid tablets
pilocarpine or cevimeline
SIALOGOGUE
(saliva substitute)
5000 ppm
DAILY ORAL HYGEINE
MAINTAINENCE

38. Occurs even in
teeth not exposed
to radiation
Weaken DEJ
Results in shear
fracturing
Enamel-altered prismatic
structure
Dentine -denatured
collagen
ROOTCANAL TREATMENT PREFERRED OVER
EXTRACTION DUE TO ALTERED PULP VASCULARITY
MATERIAL OF CHOICE

39. INFECTIONS
Nystatin suspension
mouthrinse
Used four times daily
soak dentures
carefully in
hypochlorite or
benzalkonium
chloride
Herpes simplex virus (HSV)
Common in chemotherapy
Uncommon radiation alone
Acyclovir and valcyclovir
GRAM-NEGATIVE BACTERIAL INFECTIONS
may require treatment with GENTAMICIN
OR CARBENICILLIN, as the oral lesions seen
in such infections can be portals for
systemic spread

40. Unless they are
essential for
aesthetics or
function.
Delayed for 12
months or more
after
completion of
radiation
TISSUE BORNE COMPLETE DENTURE
Risk of trauma and OSTEORADIONECROSIS

41. IF INEVITABLE
MINIMAL TRAUMA
Smooth sharp edges of
bone
Avoid reflection of the
periosteum
Number of teeth removed
in a single session should
be limited
 PROPHYLACTIC
ANTIBIOTIC/
 PLATELET-RICH
PLASMA(PRP)/
 STEROIDS
TEETH OUT OF FIELD OR IN
FIELDS LESS THAN 50 GRAY
GRANULOCYTE COUNT >2000 CELLS/µM
PLATELET COUNT >50,000 CELLS/µM
associated with significant bleeding
Safely extract with primary
closure of the socket
GREATER THAN 50 GRAY
Referred to specialist of oncology
17 to 20
days
Consultation With Physician Is
Recommended When Values Are
Lower Than Range

42. INFECTIOUS
DISEASES
HERPES
SIMPLEX
HIV AIDS
TUBERCULOSIS
HEPATITIS B
HEPATITIS C

43. CD4 cell count of ≤ 200
cells/mm3 ± opportunistic
infections, cancers, and
conditions
Asymptomatic patients
with HIV who have CD4
counts >200 cells/mm3
CD 4 COUNTS
CD4/CD8 RATIO
COUNTS < 500
RATIO < 2
• Platelet counts < 50,000/mm3
• Risk for hypercoagulability
• Severe neutropenia < 500 cells/mm3
• Hemoglobin levels < 7.0 g/dL
SERUM albumin <2.5g/dL
hepatic and renal dysfunction
Complete Blood
Count
Renal Function Test
Liver Function Test
LABORATORY INVESTIGATIONS
HUMAN IMMUNODEFICIENCY VIRUS INFECTION

45. DO NOT DENY TREATMENT

46. MANAGEMENT OF THE HIV-INFECTED PEDIATRIC PATIENT
Nutritional Considerations and Dental Management of Children and Adolescents with HIV/AIDS Meenu Mittal, J Clin Pediatr Dent 36(1): 85–92, 2011
ABSOLUTE NEUTROPHIL COUNT
>500/mm3 and PLATELET
COUNT is >20,000/mm3
DO NOT
DEFER THE
TREATMENT

47. SOURCE OF MATERIAL IS BLOOD , BODILY FLUID OR OTHER POTENTIALLY INFECTED MATERIAL OR INSTRUMENT
YES NO
WHAT TYPE OF
EXPOSURE
MUCOUS MEMBRANE OR
SKIN INTEGRITY EXPOSURE
PERCUTANEOUS
EXPOSURE
INTACT SKIN
VOLUME SEVERITY
SMALL VOLUME
AND SHORT
DURATION
LARGE VOLUME
AND LONG
DURATION
LESS SEVERE
SUPERFICIAL
SCRATCH
MORE
SEVERE DEEP
INJURY
PEPNO
PEP
PEP PEP
NO
PEP
NO
PEP
POST EXPOSURE PROPHLAXIS
NACO GUIDELINES 2014

50. CBC
LOW HEMOGLOBIN
NEUTROPENIA
THROMBOCYTOPENIA
LFT
RFT
INR

51. No dental treatment other
than urgent care for acute
viral hepatitis
HEPATITIS
CARRIER
Bleeding is likely during or
after treatment
Precautions and management
of bleeding by local hemostatic
measures must be considered.
2% glutaraldehyde (Cidex)

52. Antibiotic Dose and frequency
Metronidazole 7.5 mg/kg × 1 dose or
500 mg × 1 dose
Clindamycin 300 mg × 1 dose
Ciprofloxacin 250 mg tds × 5 doses
Cefotaxime 1 g i.v. × 1 dose
Halilovic J, Heintz BH. Antibiotic dosing in cirrhosis. American Journal of Health-
System Pharmacy. 2014 Oct 1;71(19):1621-34.
Reduce STRESS
Consider patient
comfort……..
ANTIBIOTICS
AUGMENTIN
ERYTHROMYCIN
AZITHROMYCIN
OFLAOXACIN
LINOFLOAXACINE
KETOCONAZOLE
MINOCYCLINE
SULFAMETHONAZOLE
TRIMETHOPRIM
SALFASALAZIN
SULFONAMIDES
NSAIDS
DICLOFENAC
IBUPROFEN
NIMESULIDE
SULINDAC
MUSCLE RELAXANTS
CHLORZOXAZONE
AVOID HEPATOTOXIC DRUGS
PARACETAMOL
used with
reduced dose.

53. POST EXPOSURE PROPHYLAXIS

55. Herpes cannot be eradicated from body
ANTIVIRAL THERAPY:
If diagnosed within 3 days of onset,
ACYCLOVIR -400mg 5 times daily for 7 days.
PALLIATIVE TREATMENT:
Always keep infected area dry.
INCREASE FLUID INTAKE.
If the condition does
not resolve within 2
weeks, the patient
should be referred
to a physician for
medical consultation
YESNO
ASK FOR THE HISTORY
1. FEVER, FATIGUE
2. TIMING OF APPEARANCE OF
LESION
3. RECENT DENTAL TREATMENT

57. • AIR BORNE / DROPLET INFECTION
• EMERGENCE OF AKT RESISTANT STRAINS
• CAN AFFECT OTHER ORGANS OF THE BODY

58. SIGNS AND SYMPTOMS OF TB
AND/OR
MEDICAL CONDITION PRONE TO TB
(IRRESPECTIVE OF AKT)
NO YES
Isolate the patient and ask the
patient to wear a surgical
mask while consulting and
operator should wear
disposable N-95 respirator to
check the patient
Iseman, Michael D. A clinician's guide to
tuberculosis. Lippincott Williams & Wilkins,
2000.
ASK HISTORY
SIGNS AND SYMPTOMS OF TB
AND/OR
MEDICAL CONDITION PRONE TO TB
(IRRESPECTIVE OF AKT)
NO YES
STANDARD
INFECTION
PROTOCOL
ELECTIVE DENTAL
CARE DEFFERED
UNTILL PATIENT HAS
BEEN DECLARED NON
INFECTIOUS BY
PHYSICIAN

59. LABORATORY REPORTS
AFB SMEAR At least 5000-10,000 organisms
should be present to be positive
AFB Culture
At least 10-100 mycobacterium
should be present for the smear
to be positive
Purified protein
derivative test
(Mantoux test)

60. S Rajasekar, P.L. Ravishankar, G. Balaji Babu. Protocols and guidelines for management of tuberculous patients in dental office - a review. International Journal of Contemporary Medical Research
2017;4(1):159-160.

61. 1. CONSERVATIVE TREATMENT
2. DIALYSIS
HEPARIN!!
Levey, Andrew S., et al. "Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO)." Kidney international 67.6 (2005):
2089-2100.

64. Status epilepticus: This is when you have a seizure that lasts for more than five
minutes or you repeatedly have seizures without completely waking up in between.
This condition can result in brain damage or death.

65. TYPES
ABSENCE SEIZURES

66. • Stress
• Low blood sugar
• Flashing lights e.g. dental chair
light (photo convulsive epilepsy)
• Certain foods, activities, or noises
• Some drugs frequently prescribed
by dentists antibiotics (such as
erythromycin, metronidazole) and
antifungal agents (such as
fluconazole) are known to
interfere with the metabolism of
certain antiepileptic drugs.
Mehmet, Yaltırık, et al. "Management of epileptic patients in dentistry." Surgical Science 3.01 (2012): 47.

67. • Firstly, clear all instruments away from the patient.
• Chair is lowered to the supine position
• Passively restrain only to prevent patient from falling
out of chair or hitting nearby objects.
• Consider use of mouth prop at the beginning of
procedure.
• Maintain the patent airway
• Diazepam 1 mg/kg IV slowly up to 10mg
• Give oxygen
SEIZURES IN DENTAL CHAIR
Gurbuz, Taskin. "Epilepsy and Oral Health." Novel Aspects on Epilepsy. IntechOpen, 2011.

68. THANK YOU