This part 1 lecture to discuss Dental management for Medically Compromised Patients for undergraduate students. Source from therapeutic guideline book.

1. Dental management
for
Medically Compromised Patients
Dr.Haydar Majeed
B.D.S. SEGi Uni

2. • Patients presenting to a general dental practice may have medical
problems or be taking medications that can affect their dental
management.
• Medical emergencies may arise during dental treatment.
• If the patient is not sure what medications they are taking, ask them to
bring in next appointment.
• Crosscheck the medications with the medical history, as there may be
conditions the patient has forgotten to mention or has not disclosed.

3. CARDIOVASCULAR CONDITIONS
• Cardiovascular conditions are common, particularly with increased age.
• Dentists should reinforce strategies (eg smoking cessation) to reduce cardiovascular disease
risk.
• The main dental issues relating to cardiovascular conditions are
• prevention of endocarditis and
• potential problems with anticoagulant and anti platelet drugs.
• Patients may also have a history of hypertension, coronary heart disease or heart failure,
which can affect dental treatment.

4. Potential problems with anticoagulant and antiplatelet
drugs in patients undergoing dentoalveolar surgery
• Many patients with a cardiovascular disorder take anti platelet and/or
anticoagulant drugs.
• The key issue with patients taking an anticoagulant or antiplatelet drug is
• the balance between the increased risk of bleeding from a wound if the drug is not
stopped before surgery and
• the risk of a thromboembolic event if the drug is stopped before surgery.

5. • Ascertain if the patient is taking any anticoagulant or antiplatelet drugs
• which drug(s)
• the current dosage and the indication.
• The most commonly used anticoagulant drug is warfarin.
• Commonly used anti platelet drugs are aspirin.

6. Aspirin
• Antiplatelet therapy with aspirin does not usually cause significant bleeding from
extraction wounds.
• For dentoalveolar surgery (including extractions), there is no indication to
temporarily cease a patient's prescribed regular aspirin.
• Warn patients that they have a slightly higher chance of bruising if aspirin is not
ceased, but the risk is minor compared with the risk of embolism if aspirin is
ceased.
• Local measures can be undertaken to help achieve haemostasis, including
• infiltration of an adrenaline-containing local anaesthetic,
• insertion of a resorbable pack, and
• suturing.

7. • If aspirin is to be ceased (eg for an extensive soft tissue procedure), it should
be stopped at least 7 days before the procedure and restarted 2 days after the
procedure.
• Stopping aspirin for only a few days before the procedure is of no benefit.

8. Warfarin
• It is important that both the patient and their medical practitioner
understand how the patient's warfarin treatment should be managed in
relation to tooth extraction.
• It is not uncommon for patients to reduce their warfarin dose without
consultation or, alternatively, to consult with their medical practitioner who
may (unnecessarily) suggest the traditional course of ceasing anticoagulants
for minor surgery.

9. Management of patients taking warfarin who require minor oral surgery
Before surgery (for all patients)
• Take a detailed medical history including:
- warfarin dose regimen
- stability of INR
- underlying medical conditions and other medications
- need for antibiotic prophylaxis.
Organize blood test for INR within 24 hours before surgery:
- If INR is less than 2.2 and there are no contraindications, proceed with surgery; tranexamic acid
mouthwash is not required.
- If INR is 2.2 to 4.0 , proceed with surgery using the tranexamic acid mouthwash protocol.
- If INR is more than 4.0, do not proceed with surgery and refer patient to their medical
practitioner.
• DO NOT CEASE WARFARIN.

10. Tranexamic acid mouthwash protocol (for patients with INR 2.2 to 4.0)
Day of surgery
• Check INR (INR must be 2.2 to 4.0).
• Administer antibiotic prophylaxis if indicated.
• Obtain a bottle of 4.8% tranexamic acid mouthwash*
During surgery (for extraction of teeth only)
After teeth have been extracted, irrigate sockets with tranexamic acid mouthwash using a disposable syringe.
• Fill the socket with loosely packed haemostatic agent.
Place one suture per socket.
Ask the patient to bite on a gauze pack soaked in tranexamic acid mouthwash.
After surgery
• Give the patient tranexamic acid mouthwash with instructions on use (10ml rinsed in mouth for 2 minutes, 4 times daily for 2 to 5
days).
Arrange review dental appointment for 2 days after the procedure.
Review appointment (2 days after the procedure)
• Check for bleeding, pain, delayed healing or infection, and treat as necessary.
Review the patient again in 1 to 2 weeks to check healing has occurred.

11. Other anticoagulant or antiplatelet drugs
• Several other anticoagulant and antiplatelet drugs are available (eg dipyridamole, dabigatran,
enoxaparin, rivaroxaban).
• Dabigatran and rivaroxaban are increasingly used oral anticoagulants but, unlike warfarin, there is
currently no laboratory test to guide treatment and they do not have a specific antidote.
• If a patient is taking an anticoagulant or antiplatelet drug other than aspirin, clopidogrel,
prasugrel and warfarin, do not cease it.
• Consult the patient's medical practitioner before undertaking dentoalveolar surgery (including
extractions).
• In all cases, use local measures to help achieve haemostasis.
• If there is spontaneous bleeding, urgent medical attention is required.

12. Hypertension
• Hypertension is common with increasing age.
• Many drugs are available for the management of hypertension and they are
commonly used in combination.

13. Dental issues
• Hypertension that is controlled and stable is usually not a problem during
dental treatment.
• Check if the patient is taking antiplatelet or anticoagulant drugs.
• Severe longstanding dental pain can increase hypertension, so appropriate
dental treatment should be instituted promptly.
• Severe anxiety associated with dental phobia may increase blood pressure.
• In this circumstance, sedatives should be considered.
• Theoretically, local anaesthetics containing adrenaline may elevate blood
pressure; however, clinically, they have no significant hypertensive effects.

14. • Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with
caution in patients with hypertension as they can cause renal impairment.
• The risk of renal impairment is increased if a patient is taking an NSAID in
combination with a diuretic plus an angiotensin converting enzyme inhibitor
(eg perindopril) or an angiotensin II receptor blocker (eg candesartan).

15. Coronary heart disease
• Dental issues
• The key issue with dental treatment for patients with a history of coronary heart
disease is to ensure that their current condition is stable and they are following their
preventive and/or rehabilitation program.
• Defer elective dental treatment for 3 months after
• myocardial infarction,
• stent placement or
• coronary artery bypass surgery.
• If dental pain or infection occurs within the 3-month period following infarction,
treat it as simply and expediently as possible.

16. • Antibiotic prophylaxis for dental procedures is not required in patients with
coronary stents, unless otherwise indicated.
• Patients with pacemakers and other implantable cardiac devices (eg
implantable cardioverter-defibrillators) do not present a problem during
general dental treatment.
• Interference from dental electronics does not occur with modern implantable
devices, and endocarditis is not a risk as the device is implanted within the
muscle.

17. • A patient who is known to have episodes of angina should be instructed to
bring their medication (eg glyceryl trinitrate GTN spray or tablets) when
presenting for dental treatment.
• Dental treatment should be undertaken in short appointments.
• Use relaxation techniques and consider sedation.
• Ensure effective local anaesthesia, the use of vasoconstrictors with local
anaesthetics is indicated in these patients.

18. Heart failure
• Heart failure is usually a condition of the elderly.
• It can be predominantly left ventricular with pulmonary congestion and
dyspnoea, or predominantly right ventricular with elevated venous pressure,
peripheral oedema and hepatic congestion.
• Usually both coexist in the classical syndrome of congestive or biventricular
heart failure.

19. Dental issues
• Dental treatment should only be undertaken if the patient's heart failure is
stable and should be performed in short appointments.
• Patients with heart failure usually do not tolerate being placed in a horizontal
position and should be placed with their head higher than their heart.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided in
patients with heart failure as they can worsen heart failure.

20. RESPIRATORY CONDITIONS
• The most common and significant respiratory disorder affecting dental
management is ASTHMA.
• Other important respiratory conditions are chronic obstructive pulmonary
disease and obstructive sleep apnoea.

21. Asthma
• Asthma is a chronic inflammatory disorder of the airways associated With airway hyper-responsiveness that leads to
recurrent episodes of
• wheezing,
• breathlessness,
• chest tightness and
• coughing.
• The episodes are usually associated with
• widespread,
• airflow obstruction that is often reversible either spontaneously or with treatment.

22. • Asthma frequently presents in childhood but can occur for the first time at
any age.
• Medications used to control asthma include inhaled corticosteroids (eg
fluticasone), long-acting beta2 agonists (eg salmeterol), oral prednisolone,
montelukast and sodium cromoglycate- these medications are often referred
to as 'PREVENTERS'.
• Acute asthma attacks are treated with short-acting beta2 agonists (eg
salbutamol, terbutaline)- these medications are often referred to as
'RELIEVERS’.

23. Dental issues
• The most important consideration in the dental treatment of patients With
asthma is to avoid triggering an asthma attack during treatment.
• Patients who regularly use inhalers should be advised to bring them to dental
appointments so they can self-medicate if necessary.
• If intravenous sedation or general anaesthesia is required for a dental
procedure in a patient with asthma, it should be administered in a hospital by
a specialist anesthetist.

24. • Patients taking systemic corticosteroids require an increased dose of their
corticosteroid before dental treatment.
• Several drugs (aspirin and other NSAIDs) can cause bronchoconstriction in
susceptible patients with asthma and these should be avoided or used
cautiously.
• Paracetamol is the analgesic and antipyretic of first choice because adverse
reactions are rare and tend to be milder than reactions to NSAIDs.

25. • Patients may develop oral candidosis secondary to the use of inhaled
corticosteroids.
• To reduce the risk of oral candidosis and systemic absorption of
corticosteroids, advise patients to rinse their mouth and throat with water
and spit out after inhalation.

26. Chronic obstructive pulmonary disease
• Chronic obstructive pulmonary disease (COPD) is characterized by airflow
obstruction that is not fully reversible.
• The airflow limitation is usually progressive and associated with an abnormal
inflammatory response of the lungs to noxious particles or gases, most commonly
cigarette smoke.
• COPD is usually a combination of emphysema (where the lung parenchyma is
structurally damaged) and airway damage (with wall thickening and narrowing of
the airway).
• Typically, COPD involves middle-aged or older people, and cigarette smoking is the
major causative factor.

27. Dental issues
• Dental treatment for patients with COPD needs to be modified according to the patient's
condition.
• Patients with severe COPD do not tolerate being placed in a horizontal position.
• Patients taking systemic corticosteroids require an increased dose of the corticosteroid
before dental treatment.
• Smoking cessation is the only intervention that has been shown to improve the natural
history of COPD.
• Patients may develop oral candidosis secondary to the use of inhaled corticosteroids.
• Patients using a metered dose inhaler have the additional risk of dysphonia and should be
advised to use a spacer.

28. Obstructive Sleep Apnoea
• Obstructive sleep apnoea (OSA) affects approximately 4% of males and 2% of
females.
• It is characterized by repetitive obstruction of the pharyngeal airway, leading to
episodes of apnoea (cessation of breathing) or hypopnea (partial obstruction)
during sleep.
• If OSA is not diagnosed and treated appropriately, it may lead to premature
cardiovascular or accidental death.
• Major risk factors in OSA are obesity and facial skeletal retrusion.

29. • Management of OSA includes
• weight reduction,
• smoking cessation,
• avoidance of alcohol and drugs that affect sleep,
• treatment of nasal congestion,
• tonsillectomy,
• changing sleeping position,
• continuous positive airway pressure (CPAP),
• mandibular advancement splints, and
• surgery.

30. Dental issues
• Dentists have an important role in the multidisciplinary management of OSA,
including the diagnosis of facial skeletal retrusion and the construction of
mandibular advancement splints.
• Snoring can occur in isolation or can be a sign of OSA.
• Use of oral devices to treat snoring without sleep laboratory investigations is not
appropriate.
• Patients with OSA have an increased risk of respiratory arrest under sedation or
general anesthesia.
• Any dental procedure requiring sedation or anesthesia should be undertaken in a
hospital with a specialist anesthetist present.