Dental treatment of patients with epilepsy requires consideration of seizure triggers and medications. Appointments should be scheduled in the morning to avoid nocturnal seizures. Local anesthetics without vasoconstrictors are preferred and barbiturates and narcotics should be avoided due to seizure risk. In the event of a seizure in the dental office, protecting the patient from injury is the priority until the seizure stops.

1. DENTAL MANAGEMENT OF
MEDICALLY COMPLEX PATIENT
PRESENTED BY-
DR. BRATATI DEY (OMR)

2. CONTENTS
Introduction
•Hypertensive patients
•Diabetic patients
•Heart disease and stroke
•Asthma
•Epilepsy
•Parkinson’s disease
•Chronic renal failure
•Facial paralysis
•GI disease
•Liver cirrhosis
•HIV infected patients
•Pregnancy
Dental management of systemic disease
Medical emergency
Conclusion
References

3. INTRODUCTION
There is increasing awareness of
importance of oral health to those with
medical problems & the hazards in
operative intervention.
Persons with special needs are those
whose dental care is complicated by a
medical physical, mental or social
disability.
They may have oral problem that can
affect systemic health & operative
intervention.

4. The “
ABCDEFGHIJKL” of
history taking
A – Anaemia
B – Bleeding tendencies
C – Cardiorespiratory disorders
D – Drug treatment and allergies
E – Endocrine disease
F – Fits & faints
G – Gastrointestinal disorders
H – Hospital admissions
I – Infections
J – Jaundice or liver disease
K – Kidney disease
L – Likelihood of pregnancy

5. DENTAL MANAGEMENT
OF PATIENTS WITH
HYPERTENSION
➢ It is an abnormal elevation in
the blood pressures to a level
grater than 140/90 mmHg.

6. Causes Of Hypertension
Primary hypotension
• Genetic factors
• Lower birth weight
• Obesity
• Alcohol intake
• Sodium intake
• Stress
• Some humoral mechanisms
• Insulin resistance
Secondary hypotension
• Renal cause
• Diabetic nephropathy
• Chronic glomerulonephritis
• Renal vascular disease
• Endocrine diseases
• Adrenal hyperplasia
• Cushing’s syndrome
• Cardiovascular cause
• Drugs

7. Complication of Hypertension
Cerebrovascular disease
Coronary artery disease
Renal failure
Peripheral vascular disease

8. Diagnosis
Diagnosis of hypertensive patients can be
made in three stages

9. Management
of
Hypertension
• Weight reduction, reduction of heavy
alcohol intake, salt restriction, regular
exercise, avoidance of smoking.
General measures of hypertension
• Amlodipine 5-10 mg
• Captopril 50-150 mg
• Atenolol 50mg
• Propanolol (side effect – bronchospasm)
Anti-hypertensive drugs

10. DENTAL MANAGEMENT
PATIENT
No history of
hypertension (record
BP)
Normal BP
Abnormally ↑ BP
(consult physician)
History of
hypertension (record
BP)
Abnormally elevated
BP
Mild
Consult physician &
carry out non
invasive dental
treatment
Moderare
Consult physician
sedation for minor
surgery
Severe
Consult physician
defer for all dental
procedures until the
advice of physician
Normal BP

11. LOCAL ANAESTHETIC
CONTAINING EPINEPHRINE
► It have negligible influence on blood
pressure in hypertensive patients
► It should be avoided to use LA +
vasoconstrictors in uncontrolled
hypertensive patient
► The use of LA with vasopressor is to be
avoided in those patients using
nonselective ᵦ blockers
► Oral bleeding
► Long-term NSAID use to be avoided

12. DENTAL MANAGEMENT OF
THE DIABETIC PATIENTS
▲ Diabetic mellitus is a common
complex metabolic disorder
characterized by abnormalities in
carbohydrates, lipid & protein
metabolism
▲ These abnormalities occur either
from a considerable deficiency of
insulin (Type I DM) or from a target
tissue resistance to its cellular
metabolic effects (Type II DM)
▲ Third type – Gestational diabetes

13. GENERAL SIGN & SYMPTOMS
OF DIABETES MELLITUS ▷ Polyurea, Polyphagia,
polydipsia
▷ Weakness & fatigue
▷ Pruritus
▷ Headache
▷ Recent weight gain or loss
▷ Dehydration
▷ Delayed wound healing
▷ Acetone breath

14. COMPLICATIONS
OF DM
■ Retinopathy
■ Atherosclerotic,
cerebrovascular, cardiovascular
& peripheral vascular disease
■ Renal dysfunction
■ Peripheral neuropathies
■ Muscle wasting
■ Ketoacidosis (life threatening
metabolic complication)
■ Obesity

15. ORAL MANIFESTATION
Xerostomia
1
Parotid gland enlargement
2
Oral candidiasis
3
Progressive periodontitis & Increase caries rate
4
Burning mouth
5
Altered taste
6
Oral neuropathies
7

16. DIAGNOSIS OF
DIABETES
❑ Presence of classic symptoms with
hyperglycemia (random plasma glucose
>200 mg/dl)
❑ Fasting plasma glucose > 140 mg/dl or
fasting venous or capillary blood
glucose > 120 mg/dl

17. MEDICAL
MANAGEMENT
❑ Aim – to lower the blood
glucose level & prevent
complication
❑ Insulin inj. (SC), insulin pump
for type I DM
❑ Oral hypoglycemic drugs for
type II DM

18. DENTAL CARE OF
DIABETIC PATIENTS
MAJOR SURGICAL
PROCEDURES
INVASIVE
PROCEDURES
NON-INVASIVE
PROCEDURES
Facial bone fracture
repair
Jaw surgery for tumor
removal
Orthognathic surgery
Extraction
Periodontal surgery
Apical endodontic
surgery
Surgical drainage of
abscesses
Restorative
procedures
Prosthodontic
appliances
Injection of LA
RCT
Orthodontic
procedures
Dental impressions
Routine oral
prophylaxis
Fluoride treatment
IOPA

19. SPECIAL CONSIDERATIONS IN DENTAL TREATMENT
MORNING
APPOINTMENTS
STRESS REDUCTION HYGIENE & RECALL
VISIT
ANTIBIOTICS POST TREATMENT
DIET CONTROL
OTHERS
Short
appointment.
Patients are
more stable in
morning because
most diabetic
regimens
includes
medications
exercise &
breakfast
If necessary
premedication
and analgesic to
control pain
Stress →
endogenous
epinephrine→
mobilization of
glycogen from
liver
→ADDITIONAL
HYPERGLYCEMIA
Diabetic
patients must be
recalled for
complete dental
examination
In severe cases
more frequent
recalls may be
necessary
All diabetic
patients do not
need antibiotic
Only unstable
diabetic patient
need antibiotic
prophylaxis
Amoxicillin 2 g
(500 mg TDS
for 4days)
Clindamycin
600mg (150 mg
QID)
Dietician’s
opinion should
be sought for
patients with
diabetes
Ask to bring
glucometer in
dental clinic
Dentist should
have glucose
tablet ready. A
rapid acting
simple
carbohydrate
should be
available in the
clinic

20. Injection of excess insulin, delayed / mossing meals with usual dose of insulin
Hypoglycemia
Cheak blood glucose level by glucometer
Administer glucose tablet orally
Or 25-30 ml of 50% dextrose/ 1mg glucagon IV or IM

21. HEART DISEASE AND STROKE
▶ With a high prevalence of ischemic
heart disease in the general population
that dental professionals frequently
encounter these condition
▶ Angina is particularly one of the most
common emergencies encountered in
dental practice.
▶ Dental procedure with CVS disease
should be carried out with utmost care.
❑ ISCHAMIC HEART DISEASE
– ANGINA
– MYOCARDIAL INFARCTION
❑ HEART FAILURE

22. ISCHAMIC
HEART
DISEASE
MAJOR RISK FACTORS
⁜ Smoking
⁜ Hypertension
⁜ Older age
⁜ Family history
⁜ Diabetes mellitus
⁜ Hypercholesterolemia

23. ANGINA
₪ Angina pectoris is the most common
& most important symptom of
ischemic heart disease.
₪ This caused by an imbalance
between the myocardial oxygen
supply & demand.
₪ Cardiomyopathies, coronary artery
disease & and aortic stenosis can
also produce angina.
• Patient may be hypertensive, heavy smoker, anaemic or
with high blood cholesterol level
SIGN
• Severe pain described as gripping or crushing
• Pain often radiate to left arm & jaw
• Pain is induced by exercise or stress
• Pain released within 1-2 min by GTN
SYMPTOMS

24. DIAGNOSIS & TREATMENT
DIAGNOSIS
⸎ ECG
⸎ Exercise test (treadmill)
⸎ Radioisotope thallium scanning
⸎ Coronary angiography
TREATMENT
⸎ Identify/ eliminate/ correct risk of
factors
⸎ Drug therapy
▪ Nitrates / GTN to be placed sublingually
▪ β blockers e.g. atenolol 50 mg/daily
▪ Calcium antagonist e. g. nifedepine 10
mg
▪ Coronary angioplasty

25. DENTAL
CONSIDERATIO
N OF ANGINA
▶ At risk patient should be bring their anti
angina medications
▶ Oral nitrates should be kept ready in the clinic
▶ Sublingual GTN or slow release GTN tablet can
be placed in buccal sulcus if attack occurs
▶ The dental treatment should be stop
▶ Oxygen administration if pain persist
▶ If pain disappears & patient feel better &
treatment can be continued

26. DENTAL CONSIDERATIONS
OF MYOCARDIAL
INFARCTION
₪ Minor dental interventions seem to be well-tolerated by
patients with recent uncomplicated MI.
₪ Post MI patients are often on anticoagulants such as
warfarin & aspirin.
₪ Consultation with patient’s cardiologist by the dentist is
essential prior to invasive procedures.
₪ Temporary dose reduction with consultation.

27. DENTAL
MANAGEMENTO
F PATIENT WITH
STABLE ANGINA
OR HISTORY OF
MI
1. Short appointment
2. Pretreatment vital signs
3. Semisupine chair position
4. Patient should bring own supply of nitroglycerin to appointment
5. Stress & anxiety reduction as necessary
6. Consider premedication with nitroglycerin
7. Ensure good pain control, use LA with vasoconstrictor (epinephrine dose 0.036mg)
8. Avoid anticholinergic drugs
9. If patient become fatigue → discontinue all treatment

28. DENTAL MANAGEMENT OF THE
PATIENT WITH UNSTABLE
ANGINA
▶ Avoid elective dental care
▶ For urgent dental needs, consider treating patient in special patient care setting
such as hospital dental clinic
▶ Pretreatment home
▪ BZD (10 mg oxazepam/ 5mg diazepam)
▪ Application of long-acting dermal nitroglycerin
▶ Pretreatment in office
▪ Periodic or continuous monitoring of vital signs
▪ Prophylactic nitroglycerin sublingually before procedure
▶ Intraoperatively
▪ Use N₂o-o₂ inhalation sedation
▪ Use pulse oximeter for o₂

29. DENTAL
MANAGEMENT OF
PATIENT WITH
ISCHAEMIC HEART
DISEASE WHO
DEVELOP CHEST PAIN
1. Stop dental procedure
2. Give patients nitroglycerin tablet under the tongue
3. Administer O₂
a. If pain is relieved within 5 minutes let patient rest &
continue with appoint or terminate appointment.
b. If pain is not relieved within 5 minutes
i. Monitor pulse & BP
ii. If condition is stable → second nitroglycerin →
if pain relieved in 5 minutes→ manage as in 3a
above
iii. Patient condition remains stable but pain
continues → give 3rd nitroglycerin tablet → if
pain is relieved within 5 min manage as 3a
above
iv. If pain is not relieved following 3 nitroglycerin
tablets give within 15 minutes→ or in unstable
condition call emergency facility

30. DENTAL
MANAGEMENT
OF STROKE
STEPS INVOLVED ARE AS FOLLOW
◊ Identification of risk factors
◊ Encourage the patient to control risk factors
◊ Modify dental treatment with previous h/o
stroke
▪ Provide urgent dental care only
▪ Use measures that minimize hemorrhage
▪ Hemostatic agent
◊ Mid morning appointment
◊ Short appointment
◊ Monitor BP
◊ Use minimum amount of anesthetic with
vasoconstrictor

31. DENTAL
MANAGEMENT
OF PATIENTS
WITH ASTHMA
▪ It is a chronic
inflammatory respiratory
disorder characterized by
attacks of wheezing &
breathing difficulty.
▪ This disorder is due to
reversible narrowing of
the airways which is
generally caused by
bronchospasm,
congestion & thickening
of the bronchial lining
/accumulation of mucous.
ASTHMA
EXTRINSIC
Early onset
Atopic
Allergic
INTRINSIC
Late onset
Congenital
Non-atopic

32. FEATURES
◘ There are many factors which can cause
precipitate an attack of asthma (dust, pollen,
fungal spore, food products, nonspecific
factor like cold, exercise, drug).
◘ Sudden in onset.
◘ Wheezing respiration & chest tightness.
◘ SIGNS – tachypnea, prolonged expiration,
tachycardia, restlessness, pulsus paradoxus,
inability to speak.
◘ INVESTIGATION – chest X-Ray, CBC, sputum
examination, pulmonary function test, skin
hypersensitivity & serum IgE level.

33. DENTAL MANAGEMENT
OF ASTHMATIC
PATIENTS
Identification of asthmatic patient
& the assessment of asthma
should include the following
History
➢ Type of asthma (
extrinsic/intrinsic) or by degree
of severity
➢ Precipitating factors &
triggering factors if known
➢ Age & onset
➢ Frequency – time of day/night
➢ How does patient manage
usually
➢ Hospitalization record

34. AVOIDANCE OF
KNOWN
PRECIPITATING
FACTORS
▶ Aspirin containing drugs should be
avoided.
▶ H/o nocturnal attacks of asthma →
appointment late in the morning
▶ LA without epinephrine
▶ Asthmatics + h/o corticosteroid on a long-
term basis → require supplementation for
dental procedure to avoid adrenal
insufficiency.
▶ barbiturates & narcotics to be avoided
▶ Patient taking Theophylline should not
given erythromycin.
Acute asthma if occur in clinic → a short acting
β-adrenergic agonist inhaler is most effective
/ subcutaneous inj. Epinephrine (0.3 – 0.5 mL
1:1000) is very effective.

35. DENTAL MANAGEMENT
OF PATIENTS WITH
HISTORY OF EPILEPSY
₪ Epilepsy is a periodic disturbance in
neurological function with frequent changes in
consciousness which is due to abnormal
excessive electrical discharge within the brain.
₪ During an epileptic seizure, large group of
neurons are activated repetitively.
₪ This cause high voltage spike-and-wave activity
on the ECG which is the electrophysiological
hallmark of epilepsy.

36. CLASSIFICATION
Generalized
epilepsy implying
abnormal electric
activity which is
widespread in the
brain
A simple partial
seizures that
describes a seizure
without loss of
awareness
A complex partial
seizures which
describes a seizure
with loss of
awareness
In clinical practice two main forms of epilepsy are recognized they are
1. Grand mal epilepsy
2. Petit mal epilepsy

37. GRAND MAL EPILEPSY PETIT MAL EPILEPSY
Warning stage – in which a familiar sedation may
occur prior to the occurence of seizures.
Tonic stage – patient falls unconscious often with
an epileptic cry, muscles rigidity & breathing ceases,
blue face, tongue usually bitten
Clonic stage – spasm of the muscles resulting in
violent movements of limbs, frothing at the mouth
& incontinence of urine & faeces
Stage of coma – coma easily pass into deep ordinary
sleep if the patient is not awakened
Duration – 2 min, in severe cases status epilepticus.
This may go for hours, if not control → death may
occur
Minor fits are common in this form
The attacks are more numerous & much briefer
Transient loss of consciousness.
The patient may feel dazed & experience ‘blackout’
& onlookers may not notice anything wrong.
Patient may stay still with a vacant expression.
In this stage, the patient may carry out actions &
procedures of which he/she is unaware
(psychomotor epilepsy)

38. TREATMENT
Treatment Of Epilepsy Includes –
₪ Phenytoin, carbamazepine &
valproate. Chronic use of phenytoin
can cause gingival hyperplasia,
hypertrichosis, osteomalacia, folate
deficiency.
Children not to
cycle on public
roads
Swimming to be
avoided
Working with
moving machinery
not recommended
Adequate sleep is
essential
During fits,
padded gag may be
placed

39. DENTAL MANAGAMANT OF
THE EPILEPTIC PATIENT
₪ Identify the problem by history taking
ORAL CARE
₪ Undercontrolled patient → no
management problem
₪ Poorly controlled seizures → need
clearance from the physician
₪ Oral care provider should be
knowledgeable of adverse affects of
anticonvulsant drugs (drowsiness,
dizziness, gastrointestinal upset, ataxia,
allergic reactions such as EM)
₪ Patient on valproic acid or
carbamazepine → bleeding tendencies

40. GRANDMAL
SEIZURES
MANAGEMENT
IN DENTAL
CLINIC
MEDICAL EMERGENCY
Place a ligated mouth prop (padded tongue blade) at the beginning
of the oral procedure (do not attempt this during seizures)
Chair back to be in supported supine position
Do not move patient to the clinic floor
Clean the area
Turn this patient to one side in order to avoid aspiration
Do not hold or restrain the patient forcibly
After the seizure, examine traumatic injuries
Discontinue treatment & arrange for transport.

41. DENTAL MANAGEMENT OF PATIENTS WITH
PARKINSON’S DISEASE
▶ Identify the problem
▶ Patient on levodopa often present
postural hypotension
▶ Movement & gait abnormalities being
common, dentist should be careful in
handling these patient
▶ Excessive salivation is common in
parkinsonism due to increased amounts
of acetylcholine & this cause esophageal
dysmobility & inadequate swallowing.
Levodopa cause xerostomia.
▶ Tremors of lips tongue & head are
common, there should be carefully carried
out
▶ Saliva substitution & topical fluoride
treatment is necessary

42. ✓ Semi-reclined (45°) to limit muscle
rigidity & breathing difficulty
✓ Short appoint
✓ Stressful situation must be avoided
✓ Nitrous oxide sedation is useful
✓ No LA restrictions are necessary
✓ Fixed prosthesis is preferred

43. DENTAL MANAGEMENT OF PATIENT WITH CHRONIC RENAL FAILURE
CAUSE SYMPTOMS INVESTIGATIONS TREATMENT
Diabetes
Pyelonephritis
Hypertension
Renal stone
Connective tissue
disorders
Polycystic kidneys
Myeloma
Hypercalcemia
Nausea vomiting &
diarrhea
Drowsiness, twitching
Elevated BP
Pulmonary edema
Anaemia
Pruritus
Nocturia
Polyuria
Peripheral edema
Biochemistry- urea
creatinine, Hypercalcemia
Hyper phosphatemia
Hypoproteinaemia
Symptomatic treatment
Potassium containing foods
to be avoided
Correction of anaemia
Long-term dialysis or kidney
transplantation

44. MANAGEMENT OF PATIENTS
WITH FACIAL PARALYSIS
▶ Damage to the 7th cranial nerve resulting in
facial paralysis.
▶ The neurological level of the damage
determines the clinical picture.
▶ It is important to remember that facial
paralysis is a symptom, not a disease.

45. KEY
FEATURES OF
BELL’S PALSY
1. Drooping corner of the mouth
2. Expressionless face during
conversation
3. Loss of taste
4. Inability of the patient to smile,
whistle, close eye on the involved side
5. Wrinkle forehead
6. Neuritis of facial nerve probably due
to viral infections
7. Prodromal symptom – burning
sensation near ear

46. CLINICAL EXAMINATION
EXAMINATION OF EAR
• In Ramsay Hunt Syndrome vesicular
eruption of herpes zoster
• In Bell’s palsy a reddish line behind
the eardrum suggesting primary
infection
• Burning sensation near the ear
EXAMINATION OF CRANIAL
NERVES
• In multiple sclerosis may involve
other cranial nerves
• Acoustic neuromas also may involve
the acoustic & trigeminal nerves
before involving the facial nerve
EXAMINATION OF FACE,
MOUTH
• Bell’s palsy is the unilateral absence
of motor function of CN VII
• The facial movement should be
assessed on the forehead, around
the eyes, cheek & the mouth

47. INVESTIGATIONS
1. Baseline hematology & biochemistry
2. Imaging – plain radiograph for mid ear structures, MRI, CT scan
3. Audiometry
4. Schirmer’s test
5. Electrophysiology – electromyography, electroneurography
6. Test for salivary flow is carried as chorda tympani involvement is known to reduce salivary flow

48. ₪ If neoplasms are the causative factors
they are to be surgically removed.
₪ Paralysis following temporal bone
trauma requires decompression of the
nerves
₪ Paralysis secondary to otitis media
require aggressive treatment of
infection
₪ Virally induced facial paralysis treated
conservatively
₪ Idiopathic facial paralysis require
steroid & surgically decompression
₪ Eye care – lubricating eye drops

49. DENTAL MANAGEMENT OF GI DISEASES
Peptic ulcer Crohn’s disease Coeliac disease
DEFINTION
It is used to include both gastric and
duodenal ulceration.
It is believed to result from an
imbalance in HCL production and
defensive factors such as mucus
production, HCO3 secretion and
mucosal resistance.
It is a chronic inflammatory
condition that may affect any part of
the GIT tract from the mouth to the
anus, but has a particular tendency
to affect the terminal ileum and
ascending colon.
It is genetically determined
disease characterized by the
involvement of jejunum due to
hypersensitivity to gluten, a
protein from wheat and other
cereals.
DENTAL
MANAGEMENT
Avoid aspirin containing compounds,
NSAIDS are recommended.
Antibiotics and dietary supplements
to be taken 2 hrs before and 2 hrs
after antacids.
Long term antibiotics can promote
oral fungal infections.
Aspirin and NSAIDS should be
avoided.
Analgesic should be selective.
Adrenal crisis during treatment may
occur if the patient has stopped
steroid recently.
Thorough history concerning food
intake and symptoms provide
clues.
No contraindications for any
treatment.
Oral lesions should be treated
appropriately.

50. DENTAL
MANAGEMENT
OF PATIENTS
WITH
ALCOHOL
ABUSE & LIVER
CIRRHOSIS
Alcohol abuse is a serious public health
problem in the world.
The chronic ingestion of large amounts of
alcohol can give rise to various problem such
as…..
▶ Peripheral neuropathies
▶ Cerebellar degeneration
▶ Esophagitis
▶ Gastritis
▶ Pancreatitis
▶ Malignancy of liver & liver & another
organ
▶ Haemopoietic disorders
▶ Cirrhosis of liver

51. MEDICAL
TREATMENT OF
ALCOHOLIC LIVER
▶ Medical treatment of
alcoholic liver includes
identification of the problem
& then withdrawal from
alcohol
▶ Abrupt withdrawal symptoms
include loss of appetite,
tachycardia, anxiety, insomnia,
delirium

52. Identification Of
The Problem
◆ History
◆ Clinical examination
◆ Alcohol odour on breath
◆ Information from relatives
INVESITGATIONS
◆ Aspartate transaminase (AST or SGOT)
& alanine transaminase (ALT or SGPT)
◆ Bleeding time
◆ Thrombin time
◆ Prothrombin time

53. ORAL
COMPLICATION
OF CHRONIC
ALCOHOLISM
INCLUDES
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆
◆

54. DENTAL MANAGEMENT OF
HIV-INFECTED PATIENT
o Treatment planning for HIV-infected patients should
proceed in the same manner as for the non-infected
patient. Priorities should include:
o Alleviate pain
o Restoration of function
o Prevention of further disease
o Considerations of esthetics

55. DENTAL MANAGEMENT OF
HIV-INFECTED PATIENT
o Antibiotic coverage is not
recommended. The decision to
provide antibiotic coverage should
not be based on HIV status
o A thorough past medical history to
identify tendencies for infections &
complications
o The potential for allergic reactions
increases over time, therefore
judicious use of antibiotics is
warranted.

56. Antibiotic prophylaxis is required for patients
with the following conditions
Neutropenia –
antibiotic mouth
rinse, such as 0.12%
CHX
In patient with CD4
cells counts< 200 –
for prevention of
pneumocystis
pneumonia
Antibiotic
prophylaxis prior to
dental procedure
for the prevention
of bacterial
endocarditis

57. PAIN &
ANXIETY
CONTROL
◆ HIV infection is not a contraindication for the
use of chemical agents for the control of pain
& anxiety in dental patient.
◆ NITROUS OXIDE – the judicious use of nitrous
oxide & other short acting anti-anxiolytics is
acceptable for the temporary relief
◆ LOCAL ANAESTHETICS – for pain control,
however, bleeding abnormalities are common
in HIV-positive patients → in these condition
deep block injection should be avoided.
◆ NSAID & non-narcotic & narcotic pain relievers
– these are acceptable for postoperative pain
control

58. Preventive
treatment
Periodontal
disease
Endodontic
procedures Oral surgery
Restorative
procedures
Orthodontic
considerations
Maintaining
good oral
hygiene
Routine dental
prophylaxis
Fluoride
treatment
Sealant
Patient
education
Management of NUP
Management of
gingival Erythema –
prophylactic irrigation
with 10% povidine –
iodine solution
followed by 0.12% CHX
gluconate rinse BD for
2 weeks
Appropriate antifungal
medication
Root canal treatment
can be carried out
following standard
procedures and
without antibiotic
prophylaxis.
Prophylactic
antibacterial mouth rinse
especially in patient with
poor oral hygiene →
reduce systemic
bacteremia, prior to
traumatic procedure
For emergency
procedures, the use of
antimicrobial pre
procedural rinse
Routine restorative
procedures, including
operative & fixed &
removable
prosthodontics may
proceed
Non restorable &
periodontally
hopeless teeth
should be removed to
reduce infection
HIV infection is a
contraindication for
orthodontic
treatment

59. DENTAL
MANAGEMENT IN
PREGNANCY
▶ The storm of hormones which is induced during pregnancy causes changes
in the mother’s body and the oral cavity is no exception.
▶ The human mouth is a complex ecosystem housing several bacterial species,
some of which are known to metabolize steroid hormones.
▶ These metabolites aid interspecies aggregation and energy generation and
may also satisfy nutritional requirements.

60. MONITORING A
PREGNANT FEMALE
Ꙩ Weight
Ꙩ Blood pressure
Ꙩ CBC
Ꙩ Urinalysis
Ꙩ Fetal heart sound during later stage
of pregnancy
FOETAL CONCERNS – Fetus is susceptible
to malformation during 1st trimester. A
notable exception to this is the fetal
dentition, which is susceptible to staining
& enamel hypoplasia due to tetracycline &
nutritional deficiency.

61. DENTAL
MANAGEMENT
⸙
⸙
⸙
⸙

62. •
•
•
•
•
•

63. CATEGORY A
Controlled human studies indicate no apparent risk to the
fetus. Possibility of risk to the fetus is remote.
CATEGORY B
Animal studies do not indicate fetal risk. Well-controlled
human studies have failed to demonstrate a risk.
CATEGORY C
Animal studies show an adverse effect on the fetus, but
there are no controlled studies in humans. The benefits
from the use of such drugs may be acceptable.
CATEGORY D
Evidence of human risk, but in certain circumstances the
use of such a drug may be acceptable in pregnant women
despite its potential risk.
CATEGORY X
Risk of use in pregnant women clearly outweighs possible
benefits.

64. TERATOGENICITY
DRUGS ABNORMALITIES
THALIDOMIDE PHOCOMELIA
ANTI CANCER DRUG MULTIPLE DEFECT , FETAL DEATH
TETRACYCLINE
DISCOLORED AND DEFORMED TOOTH
RETARDED BONE GROWTH
PHENYTOIN
CRANIOFACIAL AND LIMB DEFECT
CLEFT LIP, CLEFT PALATE
PHENOBARBITONE VARIOUS MALFORMATIONS
CARBAMAZEPINE SPINA BIFIDA, CNS DEFECT
RETINOIDS VARIOUS ABNORMALITIES
ALCOHOL FETAL ALCOHOL EMBRYOPATHY
BENZODIAZEPINES FLOPPY INFANT SYNDROME

65. Type Drugs
1st
Trimester
2nd And 3rd
Trimester
Comment
Local
Anesthetics
Lidocaine
Mepivacaine
Bupivacaine
Benzocaine
Yes
Yes
No
Yes
Yes
Yes
No
Yes
First choice anesthetics, fetal bradycardia
Fetal bradycardia
-
Fetal bradycardia
Vasoconstrictors Epinephrine Yes Yes It can produce hypoxia
Analgesics Paracetamol
Codeine
Aspirin
Ibuprofen
Yes
Limited Dose
No
Yes
(Cautiously)
Yes
Limited Dose
No
No
Teratogenic at over dose level
Respiratory distress
Bleeding, prolonged parturition, premature closure of ductus
arteriosus
Same as aspirin
Antibiotics Penicillin
Erythromycin
Tetracyclin
Clindamycin
Cephalosporin
Metronidazole
Yes
Yes
No
No
Yes
No
Yes
Yes
No
No
Yes
No
Safe
Safe except estolate form
Stains teeth, affects bone
Only if alternative dose not exist
Safe only if use as indicated
Carcinogenic
Antifungal Clotrimazole
Ketoconazole
Nystatin
No
No
Yes
Yes With Caution
No
Yes
Poorly absorbed following topical or intravaginal application,
abnormal LFT
-
Safe
Sedative Benzodiazepines
N2o With 50% O2
No
No
No
Possible With
Adequate O2
Cleft lip, neural tube defect
Ensure adequate oxygen intake, female operates avoid chronic
exposure

66. ORAL FINDING IN
PREGNANCY
GINGIVITIS –
Ꙩ Plaque related mild gingivitis to extensive periodontitis is common during pregnancy. This is due to
exaggerated inflammatory response to local irritants mediated by elevated levels of estrogen &
progesterone.
Ꙩ Pyogenic granuloma is seen as a sessile/ pedunculated asymptomatic reddish soft tissue mass (maxillary
anterior) often this lesion causes bleeding.

67. DENTAL CARIES –
▶ An increase in sugar consumption
increases the incident of caries in
pregnant patient.
▶ Regulation of acidic stomach
content can result in erosion of the
teeth.
▶ To neutralize the acid a fluoride
mouthwash can be recommended.
▶ GIC restoration is proffered than
amalgam to restore carious teeth.

68. MEDICAL
EMERGENCY
▲ Bleeding tendencies
▲ Cardiac diseases
▲ Diabetes
▲ Drug allergies use & abuse
▲ Fits, faints, behavioral &
neuropsychiatric condition
▲ Hepatitis & HIV
▲ Immunosuppressive treatment
▲ Malignant disease
▲ Pregnancy

69. CONCLUSION
◌ The links between oral and general health have
been established and the evolution of
understanding of many chronic conditions is
likely to increase the nature of these
interactions.
◌ Special needs dental units, offer patients care
that is appropriate to both their dental and
medical needs and where their medical status
may begin to influence their oral condition or the
way in which treatment is provided.

70. REFERENCES
SR Prabhu, DENTAL MANAGEMENT OF MEDICALLY
COMPLEX PATIENT, 1st edition, 2007
Anil Ghom, Textbook of Oral Medicine, Third edition, page
no. 965-969
Michael Glick, Burket’s Oral Medicine,twelfth edition, page
no. 335-488
Tshering Pem et al, Safe and unsafe drugs during
pregnancy , Journal of Chemical and Pharmaceutical
Research, 2016, 8(3):652-663, ISSN : 0975-7384, CODEN(USA)
: JCPRC5
V K Prajapati et al, Dental Consideration in Pregnancy: A
Review International Journal of Scientific Study | November
2014 | Vol 2 | Issue 8
Mustafa Naseem et al, Oral health challenges in pregnant
women: Recommendations for dental care professionals
REVIEW ARTICLE, The Saudi Journal for Dental Research,
(2016) 7, 138–146
Lim et al, Special Needs Dentistry: Interdisciplinary
Management of Medically-Complex Patients at Hospital-
Based Dental Units in Tasmania, Australia, International
Journal of Medical Research & Health Sciences, 2017, 6(6):
123-131,ISSN No: 2319-5886

71. THANK YOU!
We will digest Coronoavirus! We will defeat
Coronavirus!