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CONTENTS

Altered consciousness
DM: hyperglycemia & hypoglycemia
Thyroid gland dysfunction(thyroid
crisis,myxodema coma )
Cerebrovascular accident
Seizures
Anaphylaxis

DIABETES MELLITUS
Is

a most common endocrine


disease.

It

is a group of disease marked by


high levels of blood glucose resulting
from defect in insulin production,
insulin action, or both.

Hypoglycemia

is the most dangerous


complication of diabetes

DIFFERENCE BETWEEN HYPOAND HYPERGLYCEMIC COMA


HYPOGLYCEMIA
Rapid onset
Irritability/aggressiv
eness
Moist skin

Pulse-rapid & full


Blood sugar
reduced
Urine sugar negative

HYPERGLYCEMIA
Slow onset
Drowsiness/disorienta
tion
Dry skin, dry mouth,
deep breathing,
hypotension
Pulse weak
Blood sugar increased
Urine sugar usually
positive

HYPOGLYCEMIA
CLINICAL MANIFESTATION:
Mild
Hunger
Moderate
Nausea
Anxiety
Mood change Sweating
tachycardia
weakness
Poor judgment
Behavior change:
Severe
Hypotension
confusion,
Seizures
uncooperativeness
unconsciousness
4

Management of hypoglycemia
conscious patient

Management of hypoglycemia
unconscious patient

Dental
management of
patient having
thyroid
disorders

THYROID GLAND DYSFUNCTION


HYPERTHYROIDISM (THYROTOXICOSIS)
Heightened thyroid gland activity &
overproduction of thyroid hormone(T4&T3)
Associated with diffuse
Goitre(enlargement of thyroid glandhyperplasia secondary to excessive TSH
level)due to autoimmune disease(Graves
disease)
May lead to Thyroid Storm
(Thyroid crisis)
Mainly seen in females

DENTAL CONSIDERATION

Patients with untreated


hyperthyroidism can be difficult to
deal ,as a result of heightened
anxiety & irritability

Conscious sedation is desirable to


control excessive anxiety

Sympathetic overactivity may lead


to fainting

LA is the main means of pain control

DENTAL CONSIDERATION

Povidone-iodine & similar compounds


should be avoided

Benzodiazepines may potentiate


antithyroid drugs ,so Nitrous oxide
which is more rapidly controllable is
probably safer

Carbimazole causes
agranulocytosis ,which may cause

Main danger is of precipitating Myxedema


coma by the use of sedatives(Diazepam or
Midazolam),Opioid analgesics(Codeine)
,they should be avoided.
LA is used for pain control
Conscious sedation can be carried out
with Nitrous oxide & Oxygen
GA may produce IHD

DENTAL CONSIDERATION
TERMINATE DENTAL
PROCEDURE
P-POSITION THE
PATIENT WITH LEGS
ELEVATED
A-B-C,ASSESS &
PERFORM BLS ,AS
NEEDED
D-DEFINITVE CARE
SUMMON
EMERGENCY
ASSISTANCE
ADMINISTER
OXYGEN

Dental management of
hypothyroid pt
Stable,

well controlled hypothyroid pts do not


need any special precautions for routine dental
treatment under LA

Avoid

routine prescribing of CNS depressants in


severe untreated hypothyroidism for example,
benzodiazepines and narcotic analgesics as they
may result in over-reactions like CNS, CVS and
respiratory over depression. Judicious use in
euthyroid individuals should not be a major
problem

Myxedema

coma (hypothermia, bradycardia,


hypotension) can be precipitated by infections,
surgery, GA and drugs mentioned above

CEREBROVASCULAR
ACCIDENTS
o
o
o
o
o
o

CVA
vascular injury
neurologic impairment
Causes areIntracerebral hemorrhage
Thrombosis
Embolism
Vascular insufficency

causes

TIA

neurologic deficit
complete clinical

resolution
within 24 hours

STROKE

Acc. To WHO
It

is defined as the sudden onset of


neurological deficits due to an
abnormality in cerebral circulation
with the signs and symptoms lasting
for more than 24 hours or longer

Etiology
Atherosclerosis
Cerebral

Atherothromboembolis
m

Thrombus
Cerebral embolus
Embolism from the heart (cardiac origin)
Intracranial hemorrhage
Subarachnoid hemorrhage
Intracranial small vessel disease
Arterial aneurysms
Arterio-venous malformation
Haematological disorders
(haemoglobinopathies, leukemia)

Pathophysiology
Ischemia
irreversible cellular damage
in area of infarction
cerebral edema
elevates ICP
neurological deterioration

PT management
Terminate dental procedure
positon the patient comfortably
basic life support as indicated
monitor vital signs
summon medical assitance
manage sign and symptoms
if bp elevated, semi fowlers positon
adminster oxygen do not admister cns deppresants
symptom persist(CVA OR TIA)
hospitalize patient

Symptoms resolve(tia)
follow-up management
Loss of consciousness(cva-hemorrhagic?)
Position patient(supine with legs elevated sligtly)
Basic life support,as indicated
Monitor vital signs
If bp elevated position patient(head/chest slight elevation)
Establish intravenous line ,if avialable
Definitive management(hospitalize patient)

SEIZURES
a paroxysmal disorder of cerebral
function characterized by an attack
involving changes in the state of
consciousness, motor activity or
sensory phenomena; sudden in
onset and usually of brief duration
Excessive discharge of cerebral
neurons

Classification
Partial

seizures

Simple partial seizures


Complex partial seizures
Partial seizures tending to tonic-clonic seizures
Complex seizures tending to tonic-clonic

seizures
Generalized

seizures

Petit mal (absence seizures)


Atypical absence seizures
Myoclonic seizures
Tonic- clonic (grand mal epilepsy)
Atonic seizures

Causes
Primary

/idiopathic/genetic epilepsy

Secondary

epilepsy

Congenital abnormalities
Metabolic and toxic disorders
Head trauma
Tumours and space occupying lesions
Vascular diseases
Degenerative disorders
Infectious diseases

Clinical features
Partial
Petit

seizures

mal seizures

Grand

mal epilepsy

Prodromal phase - aura


Preictal phase epileptic cry and loss of

consciousness
Ictal phase
Tonic component
Clonic component

Postictal phase

Management
PRODROMAL STAGE
procedure

terminate the dental

ICTAL STAGE
position the patient (supine
with legs elevated slighty)
summon medical assitance
protect patient from injury
basic life support as indicated
adminster oxygen
monitor vital singns
seizure contiues more than 5 minutes
basic life support
until assitance
arrives

perform veinpuncture and adminster iv


anticonvulsant
adminster 50%dextroseiv
Definitive management

ANAPHYLAXIS
Allergy is a hypersensitive state acquired
through exposure to a particular allergen, reexposure to which produces a hightened
capacity to react
Types
Type I - Anaphylaxis
Type II - Cytotoxic
Type III - Immune complex
Type IV - Cell mediated or Delayed

Predisposing factors

Antibiotics

Esters

Penicillin

Cephalosporins
Tetracyclins
Sulfonamides

Analgesics

Na metabisulfite

Preservative

NSAIDs

Opiods
Morphine
Codeine
Mepiridine

Procaine
Propoxycaine
Benzocaine
Tetracaine

Antioxidant

Aspirin

Local anaesthetics

Methyl paraben

Anti anxiety drugs


Babiturates

Other agents
Methyl methacrylate

Pathophysiology
Allergen
Sensitizing dose
IgE antibody produced in response to Ag
Mast cell sensitization
Ag destruction
Challenge dose
Ag-Ab reaction
Mast cell degranulation
Release of histamine(chemical mediators of anaphylaxis)
Anaphylaxis

Chemical mediators
Histamine

Vasodilatation, Bronchoconstriction
Increased vascular permeability
Triple response (wheal, flare, flush)

SRS-A

Bronchoconstriction, increased vascular


permeability

ECF-A
Basophil

kallikrins

Prostaglandins
Platelet

activating factors

Clinical manifestations
Skin

reactions

Urticaria pruritis, flushing, warmth


Angioedema periorbital and perioral swelling

Respiratory

reactions

Rhinitis nasal congestion, itching, sneezing


Laryngeal edema dyspnea, hoarseness
Bronchospasm cough, wheezing, tightness

Cardiovascular

reactions

Circulatory collapse tachycardia, hypotension, shock


Dysrhythmias
Cardiac arrest

Management
(Sign and symptom of allergy present)
terminate dental treatment
Positon the patient(supine with legs
elevated)
Basic life support as indicated
Summon medical assitance
Admister epinephrin(sc, IM, IV)
Admister oxygen
Monitor vital sings
Additional drugs
antihistamine,corticosteroid

Definitive

care

1. Adrenaline 1:1000, 0.3-0.5 ml, sc/im (iv)


2. Antihistaminic
a) Chlorpheniramine 10 mg
b) Diphenhydramine 50 mg
3. Steroids
a) Hydrocortisone 100 mg
b) Dexamethasone 8-12 mg
4. Aminophylline (IV bronchodilator)
5. Oxygen 100%, 3-5L/min
6. Fluids 1-2 L
a) Crystalloids
b) Colloids

Prevention
History

of known allergy

History

of previous episode

Which drug was used?


Amount of drug used?
Any other medication?
Duration of effects?
What treatment?

Medical
Allergy

consultation

testing?

REFERENCE

Malamed

Stanley F.; Handbook of


Local Anesthesia; 6th edition; Mosby
Inc. ; 2012
The
Extraction Of Teeth-Geoffrey
L.Howe
Malik Neelima Anil. Text Book of Oral
and Maxillofacial Surgery. 4th edition