Dental Management of the Medically Compromised Patient

There is increasing of the importance of oral health to those with medical problems and the hazards in operative intervention.

Patient with special needs and need oral care, may have a profound influence on the dental treatment plane. The most important medical problems include :

Cardiovascular diseases: Any dental procedure that causes injury to the soft tissues or bone can produce a transient bacterimia and in susceptible patient can result in infective endocarditis even minor dental manipulations such as matrix band placement or cleaning the teeth.

Murmur (functional or organic/pathological) Murmurs may indicate existing heart disease that is a risk factor for infective endocarditis following a dental procedure.

Dental management: 1. Identification by history &examination, medical consultation if (functional) treated as normal patient, (pathologic) need prophylactic antibiotic

2. Patients with heart murmurs may have orthopnea and need to be placed in a upright position during dental treatment,

3. The use of a rubber dam may be contraindicated in such patients, because it may restrict their ability to obtain an adequate volume of air, short appointment, mild tranquilizer (2-5)mg diazepam .

Mitral valve prolapsed May be at risk of developing tachycardia, syncope, congestive heart failure and endocarditis. Dental management as with pathologic murmur.

Rheumatic heart diseases Patient how have history of Rh. Fever may have a residual cardiac damage and Rh. heart diseases, these patient need to be given a prophylactic antibiotic cover during dental treatment to prevent infective endocarditis as in patient with pathologic murmur.

Congenital heart diseases Potential problem related to dental care: Infective endocarditis, prolong bleeding, congestive heart failure.

Dental treatment: detection by history and examination, refer for medical consultation, short and morning appointment, prophylactic antibiotic coverage, bleeding time and prothrombine time should be controlled.

Artificial heart valves Potential problem related to dental care: prosthetic valve endocarditis, prolong bleeding (anticoagulants). Dental management: same as with congenital heart diseases.

Heart transplantation Potential problem related to dental care: Infection from suppression of immune response (corticosteroid), excessive bleeding.

Dental treatment: medical consultation, antibiotic prophylaxis (as surgeons recommended), prothrombine time 1½ to 2½ times normal, need for steroids supplemental for stressful dental procedure ( as surgeon recommendation).

Medically correct cardiovascular lesion Potential problem related to dental care: Infective endocarditis, excessive bleeding (anticoagulant).

Dental treatment: medical consultation, 6 months after surgery treat as normal patient, unless foreign material used to correct defect in the heart, antibiotic coverage is indicated.

Dental management within 6 months after heart surgery (artificial heart valves, heart transplantation, correction cardiovascular lesion) just for emergency dental treatment

Hospitalized treatment. Need for steroids supplemental for stressful dental procedure (as surgeon recommendation). Control the bleeding and prothrombin times.

Antibiotic prophylactic: Not allergy to penicillin: 2 gm Ampicillin IM or IV followed by gentamicin 1.5 mg/kg IM or IV 1h. before dental procedure followed by 1 gm penicillin V orally 6h. after loading dose.

Allergic patient: 1g Vancomycin IV infusion over 60 min prior to dental procedure.

Prophylactic antibiotic for patient with RHD. ,congenital H. D Prophylactic antibiotic for patient with RHD.,congenital H.D. ( without surgery correction), mitral valve prolapsed, organic murmur, & for 6 months after artificial heart valves & Heart transplantation .

patient is not allergic to penicillin Amoxicillin, Adults, 2.0 g; children, 50 mg/kg orally one hour before procedure. Cannot use oral medications: Ampicillin, Adults, 2.0 g IM or IV; children, 50 mg/kg IM or IV within 30 minutes before procedure.

Allergic to Penicillin: Clindamycin, Adults, 600 mg; children, 20 mg/kg orally one hour before procedure. Cephalexin or cefadroxil, Adults, 2.0 g; children, 50 mg/kg orally one hour before procedure.

Azithromycin or clarithromycin, Adults, 500 mg; children, 15 mg/kg orally one hour before procedure.

Allergic to Penicillin and Unable to Take Oral Medications: Clindamycin: Adults, 600 mg; children, 15 mg/kg IV one hour before procedure.

Cefazolin: Adults, 1.0 g; children, 25 mg/kg IM or IV within 30 minutes before procedure Cephalexin: Adults, 2.0; children, 50 mg/ kg IM or IV within 30 minutes before procedure

Specific Situations and Circumstances: Occasionally, a patient may be taking an antibiotic when coming to the dentist. If the patient is taking an antibiotic

normally used for endocarditis prophylaxis, it is prudent to select a drug from a different class rather than to increase the dose of the current antibiotic.

Ischemic heart diseases. It's usually caused by decreased coronary blood flow, increased myocardial oxygen demand or both.

Angina pectoris (AP): (stable, unstable) potential dental problems: stress, angina attack, MI, sudden death.

1. Identification & medical consultation, Dental managements: 1. Identification & medical consultation, 2.Short& morning appointment, 3. Semi supine chair position, 4. Patient own sublingual tablet (Nitroglycerin) on hand.

5. Premedication preoperatively 2-5mg diazepam (for stress) & one tablet nitroglycerin. 6. Local anesthesia with 1:100,000 adrenaline aspirate &inject slowly no more than 3 carp..

7. Patient with stable angina and develops chest pain give him one sublingual tab. If pain relive terminate the dental procedure if not give another one and monitor vital signs until 15 min otherwise call emergency care.

8. Avoid use of vasopressors to control local bleeding and in gingival cord.

Myocardial infarction: cardiac arrest, MI, AP, congestive heart failure, infective endocardits and electrical interference if pacemaker.

Dental management: No routine dental care until 6 month after MI, dental treatment as for stable angina exept:

1. controlled prothrombin time.( anticoagulant) 2. prophlyctic antibiotic in patient with pacemaker. 3. avoid gag reflex stimulation (digitalis→ nausea &vomiting) 4. Avoid anticholinergic drug such as atropine because of tachycardia

Dental management of patient with unstable angina or recent M.I. 1. Avoid elective dental care (patients have increased susceptibility to repeat infarctions and other cardiovascular complications).

3. Pretreatment medication with valium 5mg. 2. Emergency dental care only on hospital after physician consultation, for pain control (antibiotic for infection, pulpotomy rather than extraction). 3. Pretreatment medication with valium 5mg.

Congestive heart failure: Potential problem to dental care: MI, bleeding, CVA, IEndocarditis.

Dental management: Identification & medical consultation, up righting position to prevent fluid collection in lung, check prothrombine and bleeding times, preoperative antibiotic

, terminate appointment if patient fatigue, avoid gag stimulation, avoid atropine, avoid use of vasopressors to control local bleeding and in gingival cord, management of complications if developed (attack).

10.Cardiac arrhythmaias: Dental management: same as with congestive hard failure with reduce stress.

11. Hypertensive disease: Potential problem related to dental care: Stress and anxiety, increase blood pressure, bleeding, postural hypotension, MI, CVA.

2. Reduce stress and anxiety, short appointment. Dental management: 1. Medical consultation for patient with significant blood pressure elevation. 2. Reduce stress and anxiety, short appointment. 3. local anesthesia with epinephrine 1:100,000, aspirate &inject slowly on more than 3 carp..

5. Avoid orthostatic hypotension by change the chair position slowly. 4. avoid use of vasopressors to control local bleeding and in gingival cord. 5. Avoid orthostatic hypotension by change the chair position slowly.

7. avoid use of barbiturate ( antihypertensive ↑ sedative effect). 6. Avoid gag reflex stimulation (antihypertensive drugs nausea and vomiting). 7. avoid use of barbiturate ( antihypertensive ↑ sedative effect).

12.. Stroke: bleeding, attack Dental management: Identification &medical consultation,reduce stress, short appointment, local anesthesia with epinephrine 1:100,000, aspirate &inject slowly on more than 3 carp

., avoid use of vasopressors to control local bleeding and in gingival cord, controlled bleeding, prothrombin times & blood pressure.

Respiratory Disorders: Asthma 1. identification by history. 2. Emergency treatment should be available during dental procedures. 3. Patients using inhalers should carry their inhalers with them to the clinic. 4. reduce stress & anxiety.

5. avoided use of barbiturates, narcotic, NSAIDs, aspirin, epinephrine or levonordefrin ( containing sulfites). as it may precipitate an asthma attack

7. steroid supplemented as physician recommended. 6. upright position. 7. steroid supplemented as physician recommended. 8. avoid rubber dam. 9. erythromycin avoided theophylline (toxic blood level of theophyllin).

Liver Disorders: Liver cirrhosis - Jaundice Potential complication: bleeding, hepatitis. Dental management:Medical consultation, infection control, avoid drugs metabolized in liver, vit.k 10 mg/day before surgery.

Thyroid Gland Disorder : Hyperthyroidism (Thyrotoxicosis) Potential problem related to dental care: infection, stress, trauma → crisis. Heart failure.

Dental management 1. Detection the patient by history & 2. Referral to medical evaluation. 3. Avoid any dental treatment until good medical control of thyrotoxicosis is achieved (antibiotic for infection, analgesic for pain).

4. For emergency treatment, hospitalize the patient & treated under physician consultation. 5. Avoid use of epinephrine and other presser amine with uncontrolled patient this may lead to heart failure.

6. Patient has significant depression in immune system thus risk for developing infection resulting from dental procedure.

Management of thyroid crises 7. Recognition of early stages of thyrotoxicosis (febrile, abdominal pain, delirious. Management of thyroid crises 1. Cooling with cold towels 2. Hydrocortisone (100-300 mg.) 3. Antithyroid drugs

Renal Diseases: Hemodialysis: bleeding tendencies, hypertension, IE, hepatitis, anemia. Dental management: identify and consultation, elective treatment should be postponed until the day after hemodialysis (heparin),

control bleeding and prothrombin times, avoid drugs metabolized by kidney, AB coverage, HB Ag test.

Renal transplantation: stress ( cortisone), infection, poor wound healing, hepatitis (HB), hypertension (HT).

Dental manegment: physician consultation, steroid supplementation, AB coverage, avoid nephrotoxic drugs, monitor blood pressure, HB Ag test, uncontrolled case hospitalization for sever oral infection treatments.

Adrenal gland insufficiency: stress, poor wound healing, infection, HT Adrenal gland insufficiency: stress, poor wound healing, infection, HT. Dental management: 1. Identification & medical consultation, 2. Need for AB coverage & steroid supplementation as physician recommendation.

Neurogenic disorder (epilepsy): Occurrence of generalized attack in dental office Dental management: 1. Identification of epileptic patient by history (type, cause, medication, onset).

2. Dental instrument should be away from the patient to decrease patient's stimulation. 3. Maintain optimum oral hygiene.

5. hospitalized care for uncontrolled case. 4. Problems of drugs taken, Dilantin →gingival hyperplasia, Depakene→ bleeding tendency. 5. hospitalized care for uncontrolled case. 6. be prepared to manage seizure.

Behavioral and Psychiatric Disorders: Schizophrenia, Alzheimer, Abuse. Dental management: 1. Identification & medical consultation, 2. Stress reduction,

3. Significant drug interactions and side effects are associated with tricyclic antidepressants, monoamine oxidase inhibitors, and antianxiety drugs,

4. Consult with the patient's physician is essential before using sedatives, hypnotics, antihistamines, 5.Control infection after dental care, 6. Protection from hepatitis with IV abuse substance patients.

Blood Disease: Leukemia: bleeding, infection, poor wound healing Blood Disease: Leukemia: bleeding, infection, poor wound healing. Dental management: 1. Identification & medical consultation, 2. Control bleeding time, 3. AB coverage, 4. Hospitalized uncontrolled case for emergency dental care.

Sickle cell anemia: crisis Dental management: 1. Identification by history, 2. Avoid use of barbiturate, narcotic, salicylate ( respiratory center suppression→ acidosis→ crisis), 3. Avoid hypoxia, 4. AB for control infection.

Haemophilia: bleeding Dental management: 1. Identification & medical consultation, 2. Control bleeding & prothrombin times, 3. AB coverage, 4. Avoid Intra muscular injections,

, 5. Maintaining healthy gums is very important, 6 , 5. Maintaining healthy gums is very important, 6. Avoid aspirin &NSAIDs, 7. Carry out invasive dental procedures in a hospital. NOTE: local measures for control bleeding should be always found in your clinic (splints, thrombin, microfibrillar collagen).

Pregnancy and Lactation: Potential problem related to dental care: Dental procedure can cause problems to the developing fetus via radiation, drugs, stress and pain, supine position may cause hypotension in late pregnancy.

Dental management: Physician consultation, short painless visit, avoid treatment during 1st and 3rd trimester, avoid give the patient drug unless its necessary after asking her physician, maintain optimum oral hygiene, tetracycline and streptomycin is contraindicated.

AIDS: transmission of disease, infection, bleeding (thrombocytopenia). Dental management: 1.All precaution should be taken ( double masks, double gloves, eye glass and disposable instruments).

3. Bleeding time and platelet count should be ordered. 2. Antibiotic prophylactic to prevent infection in cases where surgery must be performed. 3. Bleeding time and platelet count should be ordered.

Diabetes Mellitus: infection, poor wound healing, MI, renal failure, HT. Dental management: 1. Identification by history, 2.Advise to eat normal meal before appointment, 3. Short &morning appoint., 4. Reduce stress ( ↑ diabetic),

5. Unstable diabetic patient need AB coverage before invasive dental care ( Amoxicillin 2 g. 1h. preoperatively followed by amoxicillin 500 mg. 3 times daily for 4 days.

In penicillin sensitive use Clindamycin 600 mg. 1h In penicillin sensitive use Clindamycin 600 mg. 1h. preoperatively followed by clindamycin 150 mg. 4 times daily for 4 days).

Arthritis & joint prostheses: Rheumatoid arthritis: Joint pain, bleeding tendency (Aspirin, NSAIDs) Dental management: 1. Short appoint., 2. Comfortable chair position, 3. Control bleeding time, 4. Need for steroid supplement discuss with physician.

Joint prostheses: deep infection around joint prosthesis secondary to bacteriamia. Dental management: 1. Identification by history, 2. Comfortable chair position,

3. Steroid supplement according to physician recommended, 4 3. Steroid supplement according to physician recommended, 4. AB coverage as for patient with RH disease, 5. Within 3 months after surgery just for emergency dental care and antibiotic coverage as surgeon recommendation.

Radiation to head and neck: Mucositis, xerostomia, loss of taste, infection, truisms.

Dental management: Before radiation: 1.extracted all non restorable teeth, 2. Restore all carious teeth, 3. Establish good oral hygiene.

During & after radiation thereby: 1 During & after radiation thereby: 1. Examine the soft tissues for inflammation or infection and evaluate for plaque levels and dental caries, 2. Consult the oncologist before any dental procedure,

, 3. Treating dry mouth and other complications by sucking ice chips or sugar-free candy, chewing sugar-free gum, night guard, & fluoride treatment, 4. Take precautions to protect against trauma, 5. AB coverage. 

Patient receive chemotherapy: Dental management: As for radiation therapy in addition to bleeding control (thrombocytopenia).