All about examination and management

of all medically compromised patients

in dental clinic

:Done by
Dr. Mohammad Salah Qrea
D.D.S
Al-Quds University Dental Faculty
2009
• There is no doubt that the first dental
appointment is the most important dental
visit, because during this visit we check the
history of the patient clinically, in addition to
several examinations that we always do, so
that we can build our diagnosis and modify
our dental treatment upon this.
What should we do in the first visit?
taking the patient personal data.
Asking the patient about his\her chief complain.
Taking the medical history of the patient.
Taking the dental history of the patient.
Then “ THE EXAMINATION”.
Patients data
Name.
Age.
His\her address, and contact number.
Gender.
Occupation.
Marital status.
 The chief complain
Very important because it will be our main goal of
treatment plan.
History of chief complain:-
1-) the first appearance.
2-) description of PAIN (( onset, intensity, duration,
location, and radiation.))
3-) precipitating and relieving factors of pain.
4-) other symptoms such as fever, chills, lethargy,
weakness,…etc that caused by this chief complain.
Medical history
Review for previous hospitalization.
Review for serious illnesses and systemic diseases.
Review for Blood transfusion.
Review for allergies.
Review for Medications.
Review for Pregnancy.
Review for Habits.
 The examinations
• 1-) dental examination.
• 2-) physical examination.
• 3-) management of medically compromised
status.
DENTAL EXAMINATION
 Teeth
• The number of teeth.
• Alignment of the teeth.
• Caries.
• Periodontal status of the teeth.
• Non carious lesions “ abrasion, attrition,
erosion,…etc”
• And X-rays “ OPT, periapicals, bitewings, and
occlusal.”
 Bony tissues
• Checking the alignment of the mandible
margins, hard palate, and buccal and lingual
sulcus.
• Any bony exostosis or tori.
• Any swelling of tender areas within bone.
 Soft tissues
• Salivary glands “ swelling, tenderness, amount
of saliva, consistency of saliva, and others.”
• Tongue “ movement, papillae, lateral borders,
and ventral surface.”
• Other cheek, soft palate, lips and floor of the
mouth lesions.

• Wait a PowerPoint presentation about “soft tissue lesions” from dr.mohammad

salah qrea always on esnips.
Physical examination
 ?What do we examine
• Vital signs.
• IPPA” inspection, palpation, percussion, and
auscultation.”
• Maxillofacial examination.” TMJ, lymph nodes,
skin, MOM, cranial nerves,…etc”.
TMJ examination
 Anatomy
• The Articulatory System is comprised of three
components: the temporomandibular joints,
the muscles of mastication and the occlusion
(the nature contact between the upper and
lower teeth).
 ...We will examine

• Tenderness to percussion.
• Movement of the jaw, and the range of
movement.
• And sounds from the joint.
 Tenderness to percussion
• A tenderness to palpation implies inflammation,
generally as a result of acute or chronic trauma.
• A finger should be placed in the immediate pre-
auricular area, gently applying pressure on the lateral
pole/head of the condyle while the jaw is closed. The
level of pain and discomfort on each side should be
assessed and compared.
• The little finger should also be placed in the external
auditory meatus, and pressure gently applied
forwards.
Palpation of the pre-auricular area of the
.temporomandibular joint
Palpation of the intra-auricular area of the
temporomandibular joint
 Joint sounds

• There are two sounds:

• 1-) clicks “single explosive noise”.
• 2-) crepitus “continuous 'grating' noise”.
 Clicks
• A joint click probably represents the sudden
distraction of 2 wet surfaces, symptomatic of some
kind of disc displacement.
• The diagnosis of a joint click, and therefore
treatment, varies on whether the click is left, right
or bilateral, painful or painless, consistent or
intermittent. The timing of a click is also significant:
a click heard later in the opening cycle may
represent a greater degree of disc displacement.
• Clicks may frequently be felt as well as heard,
though they are not normally painful.
 Crepitus
• Crepitus is the continuous noise during
movement of the joint, caused by the
articulatory surfaces of the joint being worn.
This occurs most commonly in patients with
degenerative joint disease.
• The joint sounds should be listened to with a
stethoscope, preferably a stereo one, as the
two sides can be more easily compared.
 Range of motion

Movements to be measured are

• Incisal opening - pain free limit
• Incisal opening - maximum (forced)
• Lateral mandibular excursions
• Mandible deviations on pathway of opening
 Incizal opening
• Pain free range means the incizal opening until
the patient feel of pain or be uncomfortable.
• Maximum forced opening, is important
because we can determine the cause of
opening limitation, if pain occur then the
cause is the muscles, but if the physical
obstruction limit the opening then the cause is
disc displacement.
 Lateral Excursions

• The lateral movement should be measured

from mid-line to mid-line, the patient moving
the mandible to their maximum extent, from
one side to the other.
• The mandibular deviation:
• 1-) lasting deviation.
• 2-) or tansient deviation.
 Pain Dysfunction Syndrome

• Pain on palpatation of the TMJ

• Pain on palpatation of the associated muscles
• Limitation or deviation of mandibular
movement
• Joint sounds
• Headache
 Osteoarthrosis

• Joint sound due to crepitation (degeneration

within surfaces of the joint or disc)
• Limitation of jaw movement
• Pain - usually located in the immediate pre-
auricular region (not radiating to the
surrounding muscles as with PDS)
 Internal Derangement

• Joint click due to disc displacement or medical

obstruction to mouth opening
• Pain in later stages due to secondary muscle
spasm
 Trauma and dislocation

• External trauma to the face and jaws can often

cause mandibular or condylar fracture or
more commonly traumatic arthritis, but rarely
is a cause of a chronic temporomandibular
disorder. In the absence of an anatomical
defect, dislocation is rare and usually caused
by trauma.
EXAMINATION OF THE OCCLUSION
Occlusion= mandibular movement
• The mandible moves in relative to maxillae in
two virtue of movement:
• 1-) neuromuscular control.
• 2-) and hard tissue guidance.
 Neuromuscular control
• The masticatory muscles is the muscles that
move the mandible during functional and
parafunctional movements.
• Electromypgraphy gives us a clear idea about
these muscles movements.
Individual mandibular muscles
The masseter muscle
Medial pterygoid muscle
Lateral pterygoid
Temporalis muscle
Digastric muscle
Mylohyoid muscle
Suprahyoid, infrahyoid and cervical muscles
 Neural pathways

• Checking for voluntary and non-voluntary

movements, in addition to functional and non-
functional movements.
 Occlusion assessment
• Three questions:
• Static occlusion.
• Does the CO occur in CR?
• Occluzal interferences.
 The guidance systems

• Posterior guidance
• Anterior guidance
Posterior
guidance
Anterior
guidance
LYMPH nodes EXAMINATION
 Palpation

Preauricular - In front of the ear

Postauricular - Behind the ear
Occipital - At the base of the skull
Tonsillar - At the angle of the jaw
Submandibular - Under the jaw on the side
Submental - Under the jaw in the midline
Superficial (Anterior) Cervical - Over and in front of
the sternomastoid muscle
Supraclavicular - In the angle of the sternomastoid
and the clavicle
 …And then
• Note the size and location of any palpable
nodes and whether they were soft or hard,
non-tender or tender, and mobile or fixed.
 The head and face
Look for scars, lumps, rashes, hair loss, or other
.lesions
Look for facial asymmetry, involuntary
.movements, or edema
Palpate to identify any areas of tenderness or
.deformity
 The ears
• Palpate the auricle and mastoid process and
ask the patient for tenderness.
• Inspect the ear canal and middle ear
structures noting any redness, drainage, or
deformity.
 The nose
• Tilt the patient's head back slightly. Ask them
to hold their breath for the next few seconds.
• Inspect the visible nasal structures and note
any swelling, redness, drainage, or deformity.
 Throat
Using a wooden tongue blade and a good light
source, inspect the inside of the patients mouth
including the buccal folds and under the tougue.
Note any ulcers, white patches (leucoplakia), or
.other lesions
If abnormalities are discovered, use a gloved finger
to palpate the anterior structures and floor of the
.mouth
Inspect the posterior oropharynx by depressing the
tongue and asking the patient to say "Ah." Note
.any tonsilar enlargement, redness, or discharge
 The neck
Inspect the neck for asymmetry, scars, or other
.lesions
Palpate the neck to detect areas of tenderness,
.deformity, or masses
 Thyroid Gland
Inspect the neck looking for the thyroid gland. Note
whether it is visible and symmetrical. A visibly enlarged
.thyroid gland is called a goiter
.Move to a position behind the patient
.Identify the cricoid cartilage with the fingers of both hands
Move downward two or three tracheal rings while
.palpating for the isthmus
Move laterally from the midline while palpating for the
.lobes of the thyroid
Note the size, symmetry, and position of the lobes, as well
as the presence of any nodules. The normal gland is often
.not palpable
Thyroid examination
 Facial Tenderness
Ask the patient to tell you if these maneuvers
.causes excessive discomfort or pain
Press upward under both eyebrows with your
.thumbs
Press upward under both maxilla with your
.thumbs
Excessive discomfort on one side or significant
.pain suggests sinusitis
 Sinus Transillumination

.Darken the room as much as possible

Place a bright otoscope or other point light
.source on the maxilla
Ask the patient to open their mouth and look for
.an orange glow on the hard palate
A decreased or absent glow suggests that the
.sinus is filled with something other than air
 The skin
Sore that never fully heals
Translucent growth with rolled edges
Brown or black streak underneath a nail
Cluster of slow-growing, shiny pink or red lesions
Waxy-feeling scar
Flat or slightly depressed lesion that feels hard
to the touch
 The eyes
• Inspection: discoloration, redness, discharge,
lesions, asymmetry, ptosis, exophthalmoses,
lesions, or deformities.
• Corneal Reflections
• Extraocular Movement
Management of medically compromised patients in dental clinic
HEART DISEASES
 Heart diseases in dentistry
• Cardiovascular diseases that should be
managed peri-operatively in dentistry are:
• Hypertension.
• Ischemic heart diseases.
• Dysrythmias.
• infective endocarditis.
• CVA.
• CABG.
 Ischemic heart diseases
”“ angina pectoris
• Brief sub-sternal pain
• Self-limiting with cessation
of precipitating event
• Precipitated by exercise,
stress, eating, sex, etc
• May occur at rest or while
asleep
 Clinical Patterns of Angina Pectoris
• Stable - pain pattern and characteristics
relatively unchanged over past several
months (better prognosis)
• Unstable - pain pattern changing in
occurrence, frequency, intensity, or
duration (poorer prognosis); MI pending
 Dental Management:
Stable Angina/Post-MI >4-6 weeks
• Minimize time in waiting room
• Short, morning appointments
• Measure vital signs.
• Pre-medication as needed
– anxiolytic (triazolam; oxazepam); night before and 1 hour before
– Have nitroglycerin available .
• Use pulse oximeter to assure good breathing and oxygenation
• Nitrous oxide/oxygen intraoperatively (if needed)
• Excellent local anesthesia - use epinephrine, if needed, in
limited amount (max 0.04mg) or levonordefrin (max. 0.20mg)
• Avoid epinephrine in retraction cord
 Dental Management:
Unstable Angina or MI < 3 months
• Avoid elective care
• For urgent care: be as conservative as possible; do
only what must be done (e.g. infection control, pain
management)
• Consultation with physician to help manage
• Consider treating in outpatient hospital facility or
refer to hospital dentistry
• ECG, pulse oximetry, IV line
• Use vasoconstrictors cautiously if needed “see the previous
slide”
 Intraoperative Chest Pain
• Stop procedure
• Give nitroglycerin
• If after 5 minutes pain still present, give another
nitroglycerin
• If after 5 more minutes pain still present, give
another nitroglycerin
• If pain persists, assume MI in progress and
activate the EMS
– Give aspirin tablet to chew and swallow
– Monitor vital signs, administer oxygen, and
be prepared to provide life support
 Medical Management of Angina
• Medications
– nitrates
– beta blockers
– calcium channel blockers
– anti-platelet agents
– antihyperlipidemics
• Surgery
– Percutaneous transluminal coronary angioplasty/
“balloon” angioplasty / stent
– Coronary artery bypass graft (CABG)
 Dental Considerations:
**Nitrates

• Vasoconstrictor Interactions:
– No clinically significant interactions
• Oral Manifestations:
– topical burning at site of contact
• Other Considerations:
– orthostatic hypotension and headache possible
following administration
 Beta Adrenergic Blockers

• These agents block either the beta-1 receptors

predominately (cardioselective”CS”) or both the
beta-1 and beta-2 receptors (nonselective”NS”)
• Act as antiarryhthmics, decrease the heart rate,
cardiac output, automaticity, and oxygen demand;
also reduce peripheral resistance
• Examples: propanolol (NS), nadolol (NS), sotolol
(NS), timolol (NS), metoprolol (CS), atenolol (CS)
 Dental Considerations: Beta Blockers
• While there is a potential for an enhanced
hypertensive effect of epinephrine in a patient taking
a nonselective beta blocker, it is clinically unlikely
that such a reaction will occur
• If a patient is taking a nonselective beta blocker (e.g.
propanolol, sotolol), it is prudent to limit the amount
of epinephrine administered to that found in two
carpules of 1:100,000 concentration (0.036mg)
• In patients taking a cardioselective beta blocker (e.g.
metropolol), no limitations are required
 Calcium Channel Blockers
• These agents block the channels that carry slow
inward Ca++ currents in vascular smooth muscle and
cardiac muscle
• Resulting actions include the decrease of conduction
velocity, reduction of automaticity, and coronary and
peripheral arterial dilitation
• These effects lead to an increase of coronary blood
flow and a decrease in myocardial oxygen demand
• Examples: nifedipine, verapamil, diltiazem,
amlodipine
 Dental Considerations: Calcium Channel
Blockers
• There are no
significant drug
interactions reported
• Gingival hyperplasia
can occur in patients
taking calcium channel
blockers; close
monitoring and
encouragement of
optimal oral hygiene is
necessary
 Antiplatelet Agents
• Aspirin
• Clopidogrel (Plavix)
• Ticlopidine (Ticlid)
• Dipyridamole (Persantine)
• ASA+Dipyridamole (Aggrenox)
• Action: Decrease platelet aggregation and
thus decrease chances of thrombus
formation
Dental Considerations: Antiplatelet Agents
• With a single agent (e.g. aspirin, Plavix), expect
some increased bleeding, but it is not usually
clinically significant and can be managed by local
measures such as pressure, suturing, stents, etc.;
preoperative withdrawal is not justified
• The combination of aspirin with other inhibitors of
platelet aggregation increases the chances for
significant bleeding; depending upon extent of
surgery, it is advisable to discuss the risk/benefit of
temporary discontinuation with the physician
 Antihyperlipidemics
• HMG-CoA Reductase Inhibitors
(“statins”)
– Atorvastatin (Lipitor)
– Fluvastatin (Lescol)
– Lovastatin (Mevacor)
– Pravastatin (Pravachol)
– Rosuvastatin (Crestor)
– Simvastatin (Zocor)
• Cholestyramine (Questran)
• Clofibrate (Abitrate; Atromid-S)
• Colestipol (Colestid)
• Gemfibrozil (Lopid)
• Probucol (Lesterol; Lorelco)
 Dental Considerations:
HMG-CoA Reductase Inhibitors
• The combination of the HMG-CoA
reductase inhibitors with erythromycin or
clarithromycin may be associated with an
increased risk of adverse drug effects on
muscle (rhabdomyolosis) and kidney
(acute renal failure).
• Avoid concurrent use of HMG-CoA
reductase inhibitors with erythromycin or
clarithromycin.
 Surgical Treatment
• Percutaneous
Transluminal Coronary
Angioplasty (PTCA)
– balloon expansion
that can provide 90%
dilitation of vessel
lumen
 Stent Placement
• With use of just the
balloon, reocclusion
of the artery can
occur within
months.
• Placement of a stent
delays or prevents
reocclussion
 Dental Considerations
Balloon Angioplasty / Stent
• These procedures are not associated
with an increased risk of bacterial
endocarditis or endarteritis.
Therefore, antibiotics are not
recommended following a balloon
angioplasty nor are they
recommended for patients with a
stent.
 Surgical Treatment
• Coronary Artery By-
Pass Graft (CABG)
• The graft bypasses
the obstruction in the
coronary artery
• Graft sources:
– saphenous vein
– internal mammary
artery
– radial artery
 Dental Considerations: CABG
The CABG does not increase the risk for
endocarditis , therefore antibiotic
prophylaxis is not recommended.
 Post-Myocardial Infarction

“MI”, “Coronary”,
“Heart Attack”

Infarction - an area of
necrosis in tissue due
to ischemia resulting
from obstruction of
blood flow
Sequelae and Complications of Acute MI
• Heart failure
• Angina/infarct extension
• Cardiogenic shock (inadequate
perfusion)
• Ventricular aneurysm and rupture
• Arrhythmias
• Thromboembolism
Medical Management of Acute MI
• Early hospital supportive care (EMS)
• CCU monitoring
• Early use of thrombolytics (Indicated only for use in
patients with ST-segment elevation MI).
• Coronary angioplasty (PTCA)
• Coronary artery by-pass graft (CABG)
• Adjunctive pharmacologic therapy (O2, narcotics,
anxiolytics, beta-blockers, aspirin, heparin, warfarin,
nitrates, calcium-channel blockers, digitalis, ACE
inhibitors)
Clinical Predictors of Risk
• Major Risk:
– Unstable coronary syndromes
• Recent myocardial infarction (< 1 month), with ischemic
symptoms
• Unstable or severe angina
– CCS Class III: marked limitation with ordinary physical
activity; climbing 1 flight of stairs at a normal pace
– CCS Class IV: inability to carry on any physical activity without
pain; may be present at rest
– Significant arrhythmias:
• A-V block
• Symptomatic ventricular arrhthmias
• Supraventricular arrhthmias with uncontrolled ventricular rate
– Severe valvular disease
• Intermediate Risk:
– Mild angina pectoris
• CCS Class I: angina only with strenuous or
rapid or prolonged exertion
• CCS Class II: pain with climbing more than one
flight of stairs at a normal pace
– Previous myocardial infarction (> 1 month) with
no ischemic symptoms
– Compensated (asymptomatic) heart failure
– Insulin-dependent diabetes mellitus
– Renal insufficiency (creatinine > 2.0 mg/dl)
 Dental Management Correlate
• Elective dental care is ok if it has
been longer than 4-6 weeks since
the MI and the patient does not
report any ischemic symptoms.
• If there is any doubt or question,
consult with the cardiologist.
 Drug Therapy:
Warfarin (Coumadin)

Action: inhibits vitamin K which is a

precursor for clotting factors II, VII,
IX and X
Dental treatment, including minor
surgery, is unlikely to be
problematic if INR is within the
therapeutic range
 Periodontal Disease and Coronary Heart
Disease
• There appears to be an
association between PD and
CHD; exact relationship
unclear
• Possibly related to the
inflammatory effects of
bacterial products, ie
?
endotoxins, LPS; effect on
endothelium; clot formation
• Possibly no cause-effect
relationship at all
• Studies are underway to more
clearly define this relationship
 Hypertension
• Hypertension is a persistently raised blood
pressure resulting from increased peripheral
arteriolar resistance. This condition is also
known as hypertensive cardiovascular disease
and hypertensive heart disease (HHD).
 Dental management of hypertension

• Dental management in hypertensive patients

can be complicated, since any procedure
causing stress can further increase the blood
pressure and can precipitate acute
complications such as a cardiac arrest or a
CVA. Chronic complications of hypertension,
especially impaired renal function, can affect
dental management.
 CLASSIFICATION OF BLOOD PRESSURE IN ADULTS 18 OR OLDER

SYSTOLIC DIASTOLIC

Category Pressure (mm HG) Pressure (mm Hg)

Normal BP < 130 < 85

High Normal BP 130-139 85-89

Hypertension

Stage I 140-159 90-99

Stage II 160-179 100-109

Stage III 180-209 110-119

Stage IV > 210 > 120

From the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The fifth
report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch
Intern Med 153:154-83, 1993
Side effects of some anti-hypertensive
drugs
.Xerostomia
.Gingival overgrowth
.Salivary gland swelling or pain
.Lichenoid drug reactions
.Erythema multiforme
.Taste sense alteration
.And paresthesia
 Anesthesia
( local anesthesia )
• The local anesthesia should be perfect to
reduce anxiety and pain during the procedure.
• No epinephrine should be used with local
anesthesia.
• If we want to use very small doses of
epinephrine we should inject it properly by
using aspirating syringe, avoiding intrabony, or
intralegamentary injections to avoid anxiety
too.
 General anesthesia
• All antihypertensive drugs are potentiated by
general anesthetic agents, especially
barbiturates.
• G.A. agents (such as ,halothane and
isoflurane) tend to reduce the blood pressure
significantly and this may be fatal to the
patients organs that become adapted to raised
blood pressure.
• Hypokalemia as a result of diuretics may be
associated with arrhythmias.
 Anxiety control
• Anxiety reduction protocol.
• Using of sedative agents pre and post
operatively.
• Relative analgesia technique using N2O, can
reduce the blood pressure 10-15 mmHg.
 OTHER DENTAL CONCERNS

• Afternoon appointments are recommended

over mornings.
• Avoiding sudden postural changes, such as
return to sitting position from the supine
operating position.
• Aspirin is now commonly taken by patients
with hypertension.
• Many patients with hypertension develop
systolic heart murmurs, in which case
prophylaxis for endocarditis
Endocrine diseases
 Endocrine diseases
• Diabetes mellitus.
• Adrenal insufficiency.
• Hyperthyroidism.
• Hypothyroidism.
 Diabetes mellitus
• Diabetes mellitus is a disorder characterized
by impairment or destruction of the pancreas'
ability to produce insulin and the resultant
inability of the body to metabolize
carbohydrates, fats, and proteins.
 Clinical presentation
• There are two types of DM:
• Type I Insulin Dependent Diabetes Mellitus,
that occurs under age of 40 years. It is a
severe, acute condition with a sudden onset of
symptoms including: polydipsia, polyuria,
nocturia, polyphagia, loss of weight, loss of
strength, marked irritability, recurrence of bed
wetting, drowsiness, and malaise.
 Type II
• Non-Insulin Dependent Diabetes Mellitus, that
occurs over the age of 40 years.
• The primary manifestations are hyperglycemia,
ketoacidosis, and vascular wall disease contribute
to the inability of uncontrolled diabetic patients to
manage infections and heal wounds.
• Other signs and symptoms relating to the
complications of diabetes are skin lesions,
cataracts, blindness, hypertension, chest pain, and
anemia.
 DENTAL MANAGEMENT

• Medical history:
• Take a thorough medical history concerning
the type of diabetes, and referral of any
patient with cardinal diabetes symptoms to
the physician.
• Well controlled patients with no serious
complications such as renal failure,
hypertension, atherosclerosis,..etc, can
receive any indicated dental treatment.
 Avoiding sugar shock
hypoglycemia

• The most dangerous thing in diabetetic

patients during dental procedure is
hypoglycemic shock, to prevent it do:
• Verify the patient has taken his medication as
usual, and adequate food intake.
• Schedule appointments in the morning.
• A source of sugar, such as orange juice, must
be available in the dental office should the
symptoms of an insulin reaction occur.
 .Oral surgery concerns
IDDM diabetics under periodontal or oral
surgery procedures may be placed on
prophylactic antibiotic therapy during the
.postoperative period to avoid infection
Consultation with a patient's physician is
advisable. The physician may, in fact,
recommend that the patient be treated in a
hospital environment where infection,
bleeding, and dysglycemia can be better
.managed
 Dangers of acute oral infection
• The infection will often cause loss of control of
the diabetic condition, and as a result the
infection is not handled by the body's
defenses as well as it would be in a non-
diabetic patient. The patient's physician
should become a partner in treatment during
this period.
 Oral complications
,Xerostomia
,Infection
,Poor healing
Increased incidence and severity of periodontal
.disease, and Burning mouth syndrome
Diabetic neuropathy may lead to oral symptoms
of tingling, numbness, burning, or pain in the
.oral region
 Oral complications
• These complications are related to:
• Excessive loss of fluids in oral cavity due to
hyper urination.
• Vascular changes in oral tissues.
• Altered Infection response “immunity”.
• And increased sugar concentrations in saliva.
 Potential Drug Interaction
• While patients with well-controlled diabetes
can be given general anesthetics,
management with local anesthetics is
preferable.
• General anesthetics should be used with
caution because they can produce
hyperglycemia.
Asthma
Preventing a sudden episode of airway obstruction
is essential when treating an asthmatic patient
 MANAGEMENT IN DENTAL CARE

• Profound medical history:

Frequency of asthmatic attack
Precipitating agents
Types of pharmacotherapy used
Length of time since an emergency visit owing to
.acute asthma
Elective procedure can be performed in well
controlled patients, but patients with
 .symptoms should be referred to the physician
 Dental materials
• Dental materials that exacerbate asthma are:
• Dentifrices.
• Methylmethacrylates.
• Sulfites.
• Fissure sealants.
• Fluoride trays and cotton roles.
 Dental management
before treatment
.Schedule appointments for late morning or afternoon
• Assess severity of asthmatic condition.
• Consider antibiotic prophylaxis for
immunosuppressed patients
• Consider corticosteroid replacement for adrenally
suppressed patients
• Avoid using dental materials that may elicit an
asthmatic attack
• Have supplemental oxygen and bronchodilators
available in case of acute asthmatic exacerbation
 During treatment
• Use vasoconstrictors judiciously
• Avoid using local anesthetics containing
sodium metabisulfite
• Use rubber dams cautiously
• Avoid eliciting a coughing reflex
• Use techniques to reduce the patient’s stress:
Avoid using barbiturates
Avoid using nitrous oxide in people with severe
asthma.
 After treatment
Be aware that some patients may have an adverse
reaction to nonsteroidal anti inflammatory
.drugs
• Use tetracycline cautiously.
• Avoid use of erythromycin in patients taking
theophylline.
• Avoid use of phenobarbitals in patients taking
theophylline.
• Analgesic of choice for these patients is
acetaminophen.
 Chronic Obstructive Pulmonary Disease
COPD
• Thorough medical history.
• Most of these patients receive theophylline as
bronchodilators “look at this in the previous
slides”.
• And other management process.
 Dental management of COPD
• Well controlled disease.
• Physician consultation.
• Anxiety reduction protocol.
• Oxygen supplements.
• Suggest the presence of adrenal insufficiency.
• Keep the emergency kit near containing
bronchodilator inhalers.
• Scheduling afternoon visits.
Renal failure and renal dialysis
 Dental management of ESRD
• The patients physician should be consulted.
• Screening of hematological disturbances.
• Monitor blood pressure, and use good
infection control protocol.
 Medical considerations for patients
receiving dialysis
• Consult the physician to determine if we need
prophylactic antibiotics or not to prevent
endocarditis.
• Hemodialysis patients must avoid dental care
on the day of dialysis, when they could have
bleeding tendencies. The best time for dental
treatment is the day after hemodialysis.
• Suggest the presence of blood borne infections,
due to blood dialysis.
 Oral complications
• Pallor mucosa due to suggested anemia.
• Loss of lamina dura.
• Bone radiolucency.
• Stomatitis.
• Metallic taste.
• Xerostomia.
 .Potential Drug Interactions

Of special concern are drugs that are primarily

excreted by the kidney or that are nephrotoxic
(tetracycline, acyclovir, acetaminophen,
.aspirin, and NSAlDs)
Certain drugs are removed during hemodialysis
and, therefore, require an additional dose to
.be administered after hemodialysis
 Renal transplant
and other organs
• Preserve the function of transplanted organ.
• Manage the corticosteroids supplements.
• Limit the infections.
• The cyclosporine A an immunosuppressive
drug causes gingival hyperplasia.
• And vital signs should be counted during and
after the operation.
Pregnancy
 Background
• Pregnancy has been considered an
impediment to dental treatment.
• However, preventive, emergency, and routine
dental procedures are all suitable during
various phases of a pregnancy, with some
treatment modifications and initial planning
 Safety increasing
• Try to treat the pregnants during the 2nd
trimester.
• avoid major constructive surgery and
periodontal surgery.
• Radiography become safer due to use of high
speed films, and aprons.
• Ensure elective plaque control and preventive
dental measures.
 General guidelines
• In the first trimester, the dentist should not
perform any elective procedures, with the
exception of emergency dental care.
• Pain and infection should be treated
regardless of the trimester (root canals,
extractions, etc.)
• Routine dental cleaning and plaque control
may be performed during any trimester
• The best time to address active dental disease
(cavities, etc.) during pregnancy is during the
2nd trimester and early part of the 3rd
trimester
• In the 3rd trimester, the dentist should not
perform any elective procedures except
emergency dental care
• Always protect the patient and fetus by using a
lead apron when making radiographs
• Avoid prescribing medications that are
considered a risk by the FDA (see the following table)
• When using a local anesthetic, use one with a
vasoconstrictor
• Avoid nitrous oxide during the first trimester
• Can use Chlorhexidine throughout pregnancy
• Systemic fluoride is not advised – not
considered beneficial
CATEGORIES OF RISK FOR DRUGS DURING PREGNANCY
Category Description
A These drugs are the safest. Well-designed
studies in people show no risks to the
fetus

B Studies in animals show no risk to the

fetus, and no well-designed studies in
.people have been done

C In animal studies, use of the drug resulted

in harm to the fetus, but no information
about how the drug affects the human
.fetus is available

D Evidence shows a risk to the human fetus,

but benefits of the drug may outweigh
.risks in certain situations

X Risk to the fetus has been proved to

.outweigh any possible benefit
Infective endocarditis
 Pathogenesis of IE
• Endothelial damage.
• Non-bacterial thrombotic
endocarditis(NBTE)
• Bacteremia (source??)
• Bacterial colonization of
vegetation
• Additional deposition and
growth of thrombus
• Embolization and bacteremia
 Most Common Pathogens
• Staphylococci account for the majority of
device-related infections
– Coagulase-negative staphylococci
– Staphylococcus aureus
• A minority of infections are caused by:
– Other Gram-negative cocci
– Gram-negative bacilli
– Fungi (e.g. Candida spp.)
Aortic valve endocarditis
 Signs and Symptoms of IE
• Nonspecific: low grade
fever, heart murmur,
night sweats, fatigue.
• Stroke, MI, blindness,
abdominal pain,
petechiae, Osler nodes,
splinter hemorrhages,
Janeway lesions.
 IE Mortality Rates
• 100% fatal if not treated
• With antibiotic treatment, fatality rate:
– NVE (native valve)
• Streptococcus <10%
• Staphylococcus 25-40%
• Gram negatives 75-83%
• Fungi 50-60%
– Late PVE (prosthetic valve) 30-53%
 Dental Procedures and IE:
Conventional Wisdom
• Dental procedures are a source of bacteremias.
• Viridans streptococci (normal oral flora) account for
many cases of BE, therefore, dental procedures are the
source of these bacteria.
• Antibiotic prophylaxis will prevent the development of
endocarditis if given prior to dental procedures to
prevent infective endocarditis.
Prevention of Infective
Endocarditis
Cardiac Conditions with the Highest Risk of Endocarditis for
Which Prophylaxis with Dental Procedures is Recommended

• Prosthetic cardiac valve

• Previous infective endocarditis
• Congenital heart disease (CHD) except for the following:
– Unrepaired cyanotic CHD.
– Completely repaired CHD with prosthetic material or device .
– Repaired CHD with residual defects at the site or adjacent to
the site of a prosthetic patch or prosthetic device which inhibits
endothelialization
• Cardiac transplantation recipients who develop cardiac
valvulopathy
Congenital Cyanotic Heart Disease
 Congenital Heart Defects
That Cause Cyanosis

• Tetrology of Fallot
• Transposition of the great arteries
• Persistent truncus arteriosis
• Tricuspid atresia
• Pulmonary atresia
• Totally anomalous pulmonary venous
connection
• Hypoplastic left heart syndrome
Conditions for which prophylaxis is no longer recommended

• Mitral valve prolapse with regurgitation

• Rheumatic heart disease and other types
of acquired valvular heart disease (e.g.
SLE)
• Ventricular septal defect
• Atrial septal defect
• Hypertrophic cardiomyopathy
 Dental Procedures for Which Endocarditis
Prophylaxis is Recommended

• All dental procedures that involve manipulation

of gingival tissue or the periapical region of
teeth or perforation of the oral mucosa
• Except the following:
– Routine anesthetic injections through non-infected tissue
– Taking dental radiographs
– Placement of removable prosthodontic or orthodontic
appliances
– Adjustment of orthodontic appliances
– Shedding of deciduous teeth and bleeding from trauma to the
lips or oral mucosa
 Regimens for a Dental Procedure
Regimen-Single dose 30-60 minutes
Situation Agent before procedure

Oral Amoxicillin Adults Children

2 gm 50 mg/kg
Unable to take oral Ampicillin or cephazolin or 2 gm IM or IV 50 mg/kg IM or IV
medication cephtriaxone 1 gm IM or IV

Allergic to penicillin Cephalexin* or 2 gm 50 mg/kg

or ampicillin Clindamycin or 600 mg 20 mg/kg
Oral Azithromycin or 500 mg 15 mg/kg
Clarithromycin 500 mg 15 mg/kg

Allergic to Cephazolinn or 1 gm IM or IV 50 mg/kg IM or IV

penicillins or cephtriaxone 600 mg IM or IV 20 mg/kg IM or IV
ampicillin and Clindamycin phosphate
unable to take oral
medication
Whoops! You forgot to give the patient
?the antibiotic. What now
• If the dosage of antibiotic is inadvertently not
administered before the procedure, the
dosage may be administered up to 2 hours
after the procedure. However, the
administration of the dosage after the
procedure should be considered only when
the patient did not receive the pre-procedure
dose.
 For patients already taking penicillin or amoxicillin (e.g.
prevention of acute rheumatic fever, treatment of sinusitis)

• In such cases , due to the likelihood of the

presence of penicillin-resistant bacteria in the
oral flora, the provider should select either
clindamycin, azithromycin, or clarithromycin
for IE prophylaxis for a dental procedure
 Nonvalvular Cardiovascular Device-Related Infections

• Intracardiac: • Arterial:
– Pacemakers – Peripheral vascular
– Defibrillators stents
– LVADs – Vascular grafts,
– Ventriculoatrial including
shunts hemodialysis
– Pledgets – Intra-aortic balloon
– PDA occlusion pumps
devices – Coronary artery
– ASD and VSD closure stents
devices – Patches
– Conduits • Venous:
 Guidelines
• At present, there is no convincing evidence that
microorganisms associated with [dental] procedures
cause infection in nonvalvular cardiovascular devices
at any time after implantation. So that it is not
recommend to give antibiotic prophylaxis.
– Prophylaxis is recommended for patients when they
undergo incision and drainage of infection (e.g. abscess)
 References
• Donald Falace ,Infective Endocarditis Prophylaxis (An Update on the New
American Heart Association Guidelines), April 19,2007.
• S J Davies & R M J Gray, The examination and recording of the occlusion:
why and how, British Dental Journal 191, 291 - 302 (2001).
• Richard Rathe, Examination of the Head and Neck, Copyright: 1996 by
the University of Florida.
• Little JW, Falace DA. Dental Management of the Medically Compromised
Patient. 4th ed. St. Louis, MO: Mosby Year Book, Inc; 1993: 341-360.
• Linda Russell RDH, PhD, CHES  Source: Journal of Dental Hygiene   
2004;78(3):3  Publisher: American Dental Hygienists' Association.
• Little JW, Falace DA. Dental Management of the Medically Compromised
Patient. 4th ed. St Louis, MO: Mosby Year Book, Inc; 1993: 248-257.
• Dr. Jin Y. Kim, Management of Hypertension in Clinical Dentistry.
•   Donald A. Falace, Dental Management of Patients With Ischemic Heart
Disease (Coronary Heart Disease ), University of Kentucky College of
Dentistry, 2007.
 My message
• I made this presentation for all
general dentists to benefit the
practice of dentistry all over the
word, and to save the life and the
quality of life for our patients.

Dr. Mohammad Salah Qrea.

 Say no to drugs 