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
 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
 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
 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
P o ste rio r
g u id a n ce
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

 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)
 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
 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
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
 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
 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%
 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
 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
 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
• 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
 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
 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
 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.
C LA S S IFIC A T IO N O F B LO O D P R E S S U R E IN A D U LT S 1 8 O R O LD E R

S Y S T O LIC D IA S T O LIC

C a te g o ry P re ssu re ( m m H G ) P re ssu re ( m m H g )

N o rm a lB P < 130 < 85

H ig h N o rm a lB P 1 3 0 -1 3 9 8 5 -8 9

H yp e rte n sio n

S ta g e I 1 4 0 -1 5 9 9 0 -9 9

S ta g e II 1 6 0 -1 7 9 1 0 0 -1 0 9

S ta g e III 1 8 0 -2 0 9 1 1 0 -1 1 9

S ta g e 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
 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,
 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
 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:
üAvoid using barbiturates
üAvoid 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
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.)
A o rtic va lve e n d o ca rd itis
 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
Situation Agent
Procedure
Regimen-Single dose 30-60
minutes before procedure
Oral Amoxicillin Adults Children
2 gm 50 mg/kg
Unable to take Ampicillin or 2 gm IM or IV 50 mg/kg IM
oral medication cephazolin or 1 gm IM or IV or IV
cephtriaxone
Allergic to Cephalexin* or 2 gm 50 mg/kg
penicillin or Clindamycin or 600 mg 20 mg/kg
ampicillin Azithromycin or 500 mg 15 mg/kg
Oral Clarithromycin 500 mg 15 mg/kg

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

penicillins or cephtriaxone 600 mg IM or IV or IV
ampicillin and Clindamycin 20 mg/kg IM
unable to take phosphate or IV
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
– Defibrillators vascular stents
– LVADs – Vascular grafts,
– Ventriculoatrial including
shunts hemodialysis
– Pledgets – Intra-aortic
balloon pumps
– PDA occlusion
devices – Coronary artery
stents
– ASD and VSD
closure devices – Patches
– Conduits • Venous:
– Patches – Vena cava filters
 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
 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.
 Say no to drugs 