2. Management of patients in whom dental treatment may need
modification according to their medical condition.
Necessary steps should be taken before & during any dental treatment to
avoid any possible complications, which may occur due to patients
systemic conditions.
4. Hypertension
Problem Precaution
• Stress & anxiety – increased
BP, angina, MI or CVA
• Antihypertensive drugs –
nauseated or hypotensive or
may develop postural
hypotension
• Excessive vasopressors –
increase BP
• Stress, anxiety, duration of procedure – minimized
• Short appointments & friendly atmosphere
• Preoperative reassurance & sedation with 5 mg
diazepam may be helpful
• If over stressed – terminate the treatment
• Low dose epinephrine
• Avoid gingival retraction cords with epinephrine
• Epinephrine + non-selective beta-blockers –
hypertension & cardiac complications
• Epinephrine + TCA – acute hypertensive changes
• Epinephrine + diuretics – dysrhythmias
5. Angina pectoris
Problem Precaution
• Stress & anxiety –
precipitate angina in
dental office
• If not managed properly –
MI may occur
• Sudden death
• Primary concern – prevent recurrence of ischemia or
infarction
• Reduce anxiety & determine vitals prior
• Effective anesthesia is a must
• Dental care – late morning or early noon
• Avoid epinephrine
• Increased HR, BP – terminate the procedure
• 0.3-0.6 mg sublingual nitroglycerin. If pain persists > 3
mins, additional dose up to 3 mg every 5 mins & sought
medical help
• 300 mg chewable Aspirin
• Morphine iv – relieves pain & anxiety
6. Myocardial infarction
Problem Precaution
• Recent history of MI can
precipitate
• Cardiac arrest
• Bleeding tendency
secondary to
anticoagulant
• No routine dental care in first 6 months
• Consult physician before starting dental
care to know the current status
• Avoid gingival retraction cords with
epinephrine
• Terminate appointment if – fatigue, short
of breath or change in pulse rate or
rhythm. Inform physician
7. Rheumatic heart disease/ valvular heart disease
Problem Precaution
• Risk of infective endocarditis from
dental treatment
• Bacteremia can be introduced by
dental treatment
• Antibiotic prophylaxis
8. When to & not to give antibiotic prophylaxis ???
Required Not required
• Extraction
• Periodontal surgery, sub-
gingival scaling & root planning
• Implant
• Tooth reimplantation
• Orthodontic bands
• Endodontic instrumentation
beyond apex
• Periapical surgery
• Intraligamentary injections
• Prophylactic scaling where
bleeding is anticipated
• Operative & prosthodontic procedures without
retraction cord
• LA (non-intraligamentary)
• Intracanal endodontic procedures including post &
core
• Removable prostho & ortho appliance
• Orthodontic appliance adjustments
• Impression taking
• Exfoliation of primary teeth
• Oral radiography
• Fluoride treatment
• Rubber dam placement
9. Antibiotic prophylaxis
Situation Drug Adults Children
• Can take
orally
• Amoxicillin • 2g, 1hr before procedure • 50 mg/ kg, 1 hr before
procedure
• Cannot
take orally
• Ampicillin • 2g, im/ iv, ½ hr before
procedure
• 50 mg/ kg, 1/2 hr before
procedure
• Cefazolin or
Ceftriaxone
• 1 g im/iv, 1/2 hr before
procedure
• 50 mg/ kg, 1/2 hr before
procedure
• Allergy to
penicillin
& can
take orally
• Cephalexin or
Cefadroxil
• 2 g, 1 hr before procedure • 50 mg/ kg, 1 hr before
procedure
• Clindamycin • 600 mg, 1 hr before
procedure
• 20 mg/ kg, 1 hr before
procedure
• Azithromycin
or
Clarithromyci
n
• 500 mg, 1 hr before
procedure
• 15 mg/ kg, 1 hr before
procedure
• Allergy to
penicillin
& cannot
• Cefazolin or
Ceftriaxone
• 1 g im/ iv 1/2 hr before
procedure
• 50 mg/ kg, 1/2 hr before
procedure
• Clindamycin • 600 mg im/ iv, 1 hr before • 20 mg/ kg, 1 hr before
11. Asthma
Problem Precaution
• Dental materials may exacerbate
– pit & fissure sealants, methyl
methacrylate, tooth paste
• Aggravation or worsening of
compromised respiratory
function
• Airway obstruction by dental
procedure
• Sometime it may be a life
threatening medical emergency
• Avoid anxiety
• Advised to bring their regular medication
• Elective dental care must be deferred in severe
cases until they are in a better phase
• Appointments – late morning or later
• Avoid inhalation anesthetics or NSAIDs
• Should not be treated during sickness
• Epinephrine, Clindamycin & Azithromycin –
contraindicated for patients on Theophylline
• Epinephrine + B2 agonist – increase BP &
arrhymias
• Steroid inhalers – oral & pharyngeal thrush
12. Chronic obstructive pulmonary disease
Problem Precaution
• Aggravation or worsening of
compromised respiratory function
• Airway obstruction by dental
procedure
• Avoid long treatment sessions
• Avoid partial airway obstructing
devices – rubber dam
• Avoid Diazepam, Midazolam –
respiratory depression
• Avoid GA
13. Tuberculosis
Problem Precaution
• Infected patients pose risk to
dentist & dental office employees
a) Before treatment:
• Medical evaluation before elective
dental procedures
• Physician consult – if history or
treatment details are unclear
b) During treatment:
• Do dental emergencies only under
controlled environment
15. Peptic, duodenal, gastric ulcers
Problem Precaution
• Stress – increased acid stimulation
& epigastric pain
• Chances of peptic ulcer if NSAIDs
is given
• Avoid drugs that exacerbate
ulceration & cause GI distress
• If patient reacts in a stressful way
sedate before the procedure
• Avoid lengthy procedures
20. Renal failure/ Dialysis
Problem Precaution
• Heparin on dialysis day –
prolonged bleeding if procedure
done on the same day
• High prevalence of arterial
hypertension
• Aspirin, Ibuprofen, Erythromycin
not removed by malfunctioned
kidney
• Renal osteodystrophy –
pathological fractures &
complicate extraction
• Elective dental procedures done during
non-dialysis day & early in dialysis cycle
• Monitor BP pre & post op
• BP cuff not on the dialysis vascular
access arm
• Hemostatic investigations is a must
• Allow to stand/ walk intermittently
• Drugs excreted by kidney – modify
• Investigate for renal osteodystrophy
• Encourage meticulous oral hygiene
21. Renal transplant patient
Problem Precaution
• High prevalence of arterial
hypertension
• Immune suppression due to
immunosuppressants
• Long term steroids – adrenal crises
if drug stopped suddenly or in
stress
• Cyclosporine – gingival overgrowth
• Monitor BP pre & post op
• Hemostatic investigations is a must
• Drugs excreted by kidney – modify
• Antibiotic prophylaxis – if
nephrologist recommends
• Prevent adrenal crisis by –
decreasing stress, supplement
steroids, morning appointments
• Gingival overgrowth – surgical
excision, good oral hygiene & drug
modification
23. Diabetes
Problem Precaution
• Main hazard – hypoglycemia
• Uncontrolled diabetes –
delayed wound healing
• Periodontal disease, dry
mouth, glossitis & candidiasis
• Physician’s consent if:
• Complications like heart/ renal disease
• Difficulty in controlling diabetes in spite
of high insulin dosage
• Check blood sugar level
• Early morning appointments
• Safe to use LA with adrenaline
• Avoid - drugs disturbing diabetic
control
• Orofacial infections – treated
24. Management of hypoglycemia
Condition Treatment
• Awake & can take oral foods • 15 g carbohydrates
• 125-175 mL fruit juice/ soda
• 3-4 tsp sugar
• Hard candy
• Unable to tale oral foods &
has iv line
• 25-50 mL D50 (50% dextrose)/ 1 mg
glucagon
• Unable to tale oral foods & no
iv line
• 1 mg glucagon sc/ im at any body site
25. Hypothyroidism
Problem Precaution
• Tiredness, weakness, difficulty in
concentration, poor memory & intolerance
to cold
• Delayed eruption, short roots, thin lamina
dura
• Mild – exaggerated effect of analgesics &
sedatives in routine doses
• Has pre-existing CNS depression – sensitive
to drugs with CNS depressing side effects
• Increased subcutaneous
mucopolysaccharides – decreased ability of
small vessel to constrict – increased bleeding
• Short appointments
• Warm environment
• Use LA with adrenaline
• Atraumatic procedure
• Avoid Lithium, amiodarone, etc –
induce hypothyroidism
• Uncontrolled – respirator
depression, semi reclined position,
• Narcotics & Sedatives – precipitate
CVS & respiratory depression
26. Hyperthyroidism
Problem Precaution
• Alveolar atrophy in advanced
cases due to osteoporosis
• Increases CVS & RS function
• Infection, trauma, stroke, DKA,
thyroid surgery may precipitate
– thyroid crisis/ storm
• Elective dental care is deferred
• Stress management & short
appointments
• catecholamines + dental stress =
precipitate thyroid storm & exacerbate
underlying CVS pathology
• Epinephrine is contraindicated
• Extended local pressure to arrest bleeding
• NSAIDs – increase circulating T4 &
decrease effect if B-blockers
• Propranolol, KI, anti-thyroid drugs,
27. Hyperparathyroidism
Problem Precaution
• Generalized osteoporosis
• Thinning & loss of cortical bone
• Spontaneous mandibular
fracture
• Brown’s tumor
• Monitor serum Ca level
• Avoid iatrogenic jaw fractures
• Asses bone density
28. Adrenal insufficiency
MANAGEMENT PROTOCOL
Through medical history
Postponing elective dental surgery
Emergency steroid should be readily available
Procedure done early morning
Steroid supplement on the day of surgery
Pain & stress reduction
Long-acting LA
Monitor BP regularly
29. Patient under steroid therapy
MANAGEMENT PROTOCOL
Minimize anxiety
Glucocorticoid level – increased prior to stressful situation
‘RULE OF TWO’ – 20 mg, 2 weeks, 2 times the dose
30. Supplemental corticosteroid
Risk category Procedure Regimen
• Negligible • Non-surgical dental procedures • No supplementation
required
• Mild • Minor oral surgery:
a. Simple extraction
b. Biopsy
• Minor periodontal surgery
• Glucocorticoid target – 25
mg hydrocortisone on the
day of surgery
• Moderate -
major
• Major oral surgery:
• Multiple extractions
• Impaction
• Osseous surgery
• Cancer surgery
• Procedures involving GA
• Procedures involving significant blood
• Glucocorticoid target – 50
– 100 mg on the day of
surgery & 1 post op day
