Dental management of Medically

Compromised Patients

Dr. Mohamed Zain

A. Lecturer Oral & Maxillofacial Department, Faculty of Dentistry,
Cairo University
 American Society Of Anesthesiologists
(Physical Status Classification System)
ASA I. A healthy patient (no physiologic, physical, or psychological
abnormalities)
ASA II. A patient with mild systemic disease without limitation of daily
activities
ASA III. A patient with severe systemic disease that limits activity but is
not incapacitating
ASA IV. A patient with incapacitating systemic disease that is a constant
threat to life
ASA V. A moribund patient not expected to survive 24 hours with or
without the operation
ASA VI. A brain-dead patient whose organs are being removed for donor
purposes
 Cardiovascular System

1- Ischemic heart diseases

2- Infective endocarditis
3- Hypertension
4- Cardiac arrhythmia
5- Heart failure
 Ischemic Heart Diseases
• Symptomatic coronary atherosclerotic heart disease is referred to as
ischemic heart disease
• Atherosclerosis: The arteries become thicker, less elastic and harder
 Etiology
• Research indicates that the disease is related to a variety of risk factors
including:
1- male gender.
2- older age.
3- family history of cardiovascular disease.
4- hyperlipidemia (increased levels of low density lipoprotein LDL )
5- hypertension: SBP is more related to the incidence of cardiovascular
disease than is DBP
6- cigarette smoking:
It is the most important modifiable risk factor for coronary heart
disease.
7- insulin resistance & diabetes mellitus.
8- physical inactivity & obesity.
9- mental stress & depression.
Pathophysiology
Progression of myocardial necrosis after
coronary artery occlusion
• Angina: sensation of chest pain or squeezing due to insufficient blood
flow to the heart muscles as a result of obstruction or spasm of the
coronary arteries.

• Myocardial infarction: damage to part of the heart muscle due to

occlusion of the blood supply to this part.
 Signs & Symptoms
Stable angina Unstable angina OR MI

site Retrosternal heaviness tightness radiates to neck, left shoulder arm

& lower jaw.

Pain Less severe Intense & severe

duration 5 – 15 min. 30 – 60 min.

Provoked by Physical effort, eating or Pain may occur at rest

stress

Relieved by Rest or nitroglycerin Not relieved by rest or nitroglycerin

 Dental Management
• Consult the patient’s physician.

• For stress/anxiety reduction: Provide oral sedative premedication and/or

inhalation sedation if indicated,
assess pretreatment vital signs and availability of nitroglycerin, and limit
the quantity of vasoconstrictor used.

• Limited use of vasoconstrictor (maximum 0.04 mg epinephrine, 0.20 mg

levonordefrin). (Avoidance of epinephrine-impregnated retraction cord).

• Provide local anesthesia of excellent quality and adequate postoperative

pain control.
• Nitroglycerin tablet or spray should be readily available. Use it as
premedication if needed.

• If the patient is taking aspirin or another platelet aggregation inhibitor,

excessive bleeding is usually manageable by local measures only;
discontinuation of medication is not recommended.

• If patient has a pacemaker or implanted defibrillator, avoid use of

electrosurgery and ultrasonic scalers; antibiotic prophylaxis is not
recommended for these patients.

• Antibiotic prophylaxis is not recommended for patients with a history of

CABG (coronary artery bypass graft, angioplasty, pacemaker or stent.
 Intraoperative Chest Pain Attack
• Stop procedure
• Give nitroglycerin (NG)
If after 5 minutes pain still present, give another NG after measuring BP.
If after 5 more minutes pain still present, give another NG after measuring
BP If pain persists, assume MI in progress:
oCall emergency
oAdminister oxygen
oGive aspirin
oMonitor vital signs
oBe prepared to provide life support
 MI Dental Management
➢After 4-6 weeks of infarction with no symptoms
• as management of stable angina

➢ Before 6 weeks of infarction or Unstable Angina

• Avoid elective care
• For urgent care: conservative treatment; do only what must be done (e.g.
infection or pain management)
• Consultation with physician to help manage
• Use vasoconstrictors cautiously if needed
• Consider treating in outpatient hospital facility or refer to hospital dentistry
 When can I work ?
❖{intermediate risk}
Stable angina or past MI (> 1 month):
Any indicated dental treatment may be provided, taking into
consideration appropriate management considerations.
❖{Major risk}
unstable angina or recent MI (< 1 month):Elective dental care should
be deferred; if care becomes necessary, it should be provided in
consultation with the physician.
• Management may include establishment of an IV line; sedation;
monitoring of electrocardiogram, pulse oximeter, and blood pressure;
oxygen; cautious use of vasoconstrictors; and prophylactic
nitroglycerin.
Infective Endocarditis
❖Definition:
▪ Infective microbial infection.
▪ Endocarditis inflammation of endothelium of heart & heart
valves.

▪ It usually occurs in proximity to congenital or acquired cardiac

defects.
 Classification according to
1- Causative MO.
Streptococcal – staphylococcal – candidal

2- Type of valve that is affected.

Native (NVE) – Prosthetic (PVE)

3- Source of infection.
Community acquired – Hospital acquired - IVDU
 Pathogenesis
• It usually begins with injury or damage to endothelium of heart or
heart valves.

• Then fibrin & platelets adhere to the roughened endothelial surface

forming small clusters or masses (nonbacterial thrombotic
endocarditis) (NBTE).

• With transient bacteremia, bacteria can be seeded into & adhere to the
mass.
Nonbacterial thrombotic endocarditis (NBTE). Viridans streptococcal endocarditis of mitral valve.
• Bacteria undergo rapid multiplication within the protection of the
vegetative mass.

• Bacteria are slowly and continually released from the vegetations and
shed into the bloodstream resulting in a continuous bacteremia.
 Signs & Symptoms
• Fever.
• New or changing heart murmur.
• Peripheral manifistations of IE due to emboli or immunologic
responses:
1- petechiae of the palpebral conjunctive, the buccal and palatal mucosa
and extremities.
2- Osler’s nodes

3- splinter hemorrhages.
4- Roth spots.

5- splenomegaly.
6- Clubbing of the digits.
 Diagnosis of IE
• Major croteria:
1- Positive blood pictures.
2- evidence of endocardial involvement (positive findings on
echocardiography or presence of new valvular regurgitation.
• Minor criteria:
1- Predisposing heart condition or IV drug use.
2- Fever.
3- vascular phenomena.
4- immunological phenomena.
5- Microbiologic evidence other than positive blood picture.
Definitive diagnosis of IE requires the presence of:

• Two major criteria or

• One major and three minor criteria or
• Fiver minor criteria.
Prescribe antibiotic prophylaxis or not ?
• Dental procedures that involve the manipulation of gingival tissues or
the periapical region of teeth or perforation of the oral mucosa can
produce a bacteremia.
• Bacteremias can also be produced on a daily basis as the result of
tooth brushing, flossing, chewing, or the use of toothpicks or irrigating
devices.
• Although it is unlikely that a single dental procedure–induced
bacteremia will result in infective endocarditis (IE), it is remotely
possible that it can occur.
 Current American Heart Association (AHA)
Recommendations
• IE is much more likely to result from frequent exposure to random
bacteremia associated with daily activities than from bacteremia
caused by a dental procedure.
• Prophylaxis may prevent an exceedingly small number of cases of IE,
if any, in patients who undergo a dental procedure.
• The risk of antibiotic-associated adverse events exceeds the benefit, if
any, from prophylactic antibiotic therapy.
• Maintenance of optimal oral health and hygiene may reduce the
incidence of bacteremia from daily activities and is more important
than prophylactic antibiotics for reducing the risk of IE resulting from
a dental procedure.
 Cardiac Conditions Associated with the Highest Risk of
Adverse Outcomes from Endocarditis for Which Prophylaxis
with Dental Procedures Is Recommended
1- Prosthetic cardiac valve
2- Previous infective endocarditis
3- Congenital heart disease (CHD):
a- Unrepaired cyanotic CHD, including those with palliative
shunts and conduits
b- Completely repaired CHD with prosthetic material or device
by surgery or catheter intervention during the first 6 months
after the procedure†
c- Repaired CHD with residual defects at the site or adjacent
to the site of a prosthetic patch or prosthetic device, which
inhibits endothelialization.
4- Cardiac transplant recipients who develop cardiac valvulopathy.
 Dental Procedures in Patients with Cardiac
Conditions 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
❖ This includes all dental procedures except the following procedures
and events:
1. Routine anesthetic injections through noninfected tissue
2. Taking of dental radiographs
3. Placement of removable prosthodontic or orthodontic appliances
4. Adjustment of orthodontic appliances
5. Shedding of deciduous teeth and bleeding from trauma to the lips or oral
mucosa
 Regimens for dental procedures:
❖ If prophylaxis is required, take a single dose 30 minutes to 1
hour before the procedure:
➢ Standard (oral amoxicillin 2 gm)
➢ Allergic to penicillin (oral cephalexin 2 g, oral clindamycin
600 mg, or azithromycin or
clarithromycin 500 mg).
➢ Unable to take oral medications (intravenous [IV]
or intramuscular [IM] ampicillin, cefazolin, or
ceftriaxone).
 Dental management
• Encourage the maintenance of optimal oral hygiene in all
patients at increased risk for IE.

• Provide antibiotic prophylaxis for only those patients with

the highest risk for adverse outcomes of IE & in dental
procedures that need prophylaxis.
• For patients selected for prophylaxis, perform as much dental
treatment as possible during each coverage period.

• A second antibiotic dose may be indicated if the appointment lasts

longer than 6 hours, or if multiple appointments occur on the same
day.

• For multiple appointments, allow at least 10 days between treatment

sessions so that penicillin-resistant organisms can clear from the oral
flora. If treatment becomes necessary before 10 days have passed,
select one of the alternative antibiotics for prophylaxis.
• Note: Patients with mechanical prosthetic heart valves may have
excessive bleeding following invasive dental procedures as the result
of anticoagulant therapy
• A clinically and pathologically similar infection may occur in the
endothelial lining of an artery, usually adjacent to a vascular defect or
a prosthetic device (e.g., arteriovenous [AV] shunt), is called
Infective Endarteritis
Hypertension
❑ Hypertension is an abnormal elevation in arterial pressure that can be
fatal if sustained and untreated.
 Classification of Blood Pressure (BP) in Adults
and Recommendations for Follow-up
BP classification Systolic BP Diastolic BP Recommended
(mmHg) (mmHg) follow-up
normal < 120 < 80 Recheck in 2
years
Prehypertention 120 – 139 80 – 89 Recheck in 1
year
Stage 1 140 – 159 90 – 99 Confirm within 2
hypertention months
Stage 2 > 160 > 100 Evaluate or refer
hypertention to source of care
within 1 month.
 Definitions
• Systolic pressure: Pressure at the peak of ventricular contraction

• Diastolic pressure: represents the total resting resistance in the

arterial system after passage of the pulsating force produced by
ventricular contraction.

• Pulse pressure: The difference between diastolic and systolic pressures

• Mean arterial pressure: the sum of the diastolic pressure plus one-
third the pulse pressure. (DP + 1/3 pulse P).
• White coat hypertension: persistantly elevated blood pressure only in
the presence of a health care worker but not elsewhere.
 Signs and Symptoms of Hypertensive
Disease
❖Early
• Elevated blood pressure readings
• Narrowing and sclerosis of retinal arterioles
• Headache
• Dizziness
• Tinnitus
 Signs and Symptoms of Hypertensive
Disease
❖Advanced
• Rupture and hemorrhage of retinal arterioles
• Papilledema (optic disc swelling due to increased intracranial pressure)

• Left ventricular hypertrophy

• Congestive heart failure
• Angina pectoris

• Proteinuria
• Renal failure

• Dementia
• Encephalopathy
 Dental management
recommendations for patients with
hypertension
• Antibiotics: Avoid the use of erythromycin and clarithromycin (not
azithromycin) with calcium channel blockers, because the combination
can enhance hypotension.

• Analgesics: Avoid long-term (>2 weeks) use of NSAIDs, because

these agents may interfere with effectiveness of some antihypertensive
medications.
• Anaesthesia: Modest doses of local anesthetic with 1 : 100,000 or 1 :
200,000 epinephrine (e.g., 1 or 2 carpules) at a given time are of little
clinical consequence in patients with blood pressure <180/110 mm Hg.
Greater quantities may be tolerated reasonably well, but with increased
risk. Levonordefrin should be avoided.

• In patients with uncontrolled hypertension (blood pressure >180/110

mm Hg) the use of epinephrine may be tolerated but should be
discussed with the physician
• Anxiety: Patients with hypertension who are anxious or fearful are
especially good candidates for preoperative oral and/or intraoperative
inhalation sedation.
Apply good stress management protocols.

• Chair position: Avoid rapid position changes owing to possibility of

antihypertensive drug-associated orthostatic hypotension.
 When can I work ?

❖Patients with a blood presure <180/110 mm Hg may receive any

necessary dental treatment.
❖ For patients with a pressure reading >180/110 mm Hg, dental
treatment should be deferred until blood pressure is brought under
control.
❖If urgent or emergency dental treatment is required, it should be done
in as limited and conservative manner as possible.
• Note:
No oral complications are are due to hypertension itself,
however, adverse effects such as dry mouth, taste
changes & oral lesions may be drug related.

Gingival hyperplasia in a patient taking a calcium

channel blocker.
Cardiac Arrhythmias
• Definition:
Any variation in the normal heartbeat, includes disturbances in
rhythm, rate, or the conduction pattern of the heart.
 Signs & symptoms of cardiac
arrhythmias
❖Signs
• Slow heart rate (<60 beats/min)
• Fast heart rate (>100 beats/min)
• Irregular rhythm

❖Symptoms
• Palpitations, fatigue
• Dizziness, syncope, angina
• Congestive heart failure
• Shortness of breath
• Orthopnea
• Peripheral edema
 Dental managenemt
❖For high risk arrhythmias:
1. Elective dental care should be deferred; if care becomes necessary, it
should be provided in consultation with the physician.
2. Management may include establishment of an IV line; sedation;
monitoring of electrocardiogram, pulse oximeter, and blood pressure;
oxygen; and cautious use of vasoconstrictors.
❖For intermediate or low risk arrhyshmias:
Elective dental care may be provided with the following management
considerations:
1. Stress/ anxiety reduction: provide oral sedative premedication and/or
inhalation sedation if indicated; assess pretreatment vital signs.
2. Avoid excessive use of epinephrine (for patients who are taking a
nonselective beta blocker, limit epinephrine to ≤2 cartridges of 1 :
100,000 epinephrine, avoid the use of epinephrine impregnated gingival
retraction cord.
3. provide local anesthesia of excellent quality and postoperative pain
control).
4. For patients who are taking warfarin (Coumadin), the INR should be
3.5 or less before any invasive dental procedure; provide local
measures for hemostasis.
5. For patients with a pacemaker or an implanted defibrillator, avoid the
use of electrosurgery and ultrasonic scalers; antibiotic prophylaxis is
not recommended for these patients.
6. For patients taking digoxin, avoid use of epinephrine because of
increased risk of inducing arrhythmia; be observant for signs of
digoxin toxicity (e.g., hypersalivation).
Heart Failure
• HF is essentially the inability of the heart to supply enough blood
circulation to meet the body’s needs.

• HF represents the end stage of many of the cardiovascular diseases.

 Most common causes of HF
• Coronary heart disease
• Cardiomyopathy (cardiac enlargenemt with impaired systolic function).
• Hypertension
• Valvular heart disease
• Myocarditis
• Infective endocarditis
• Congenital heart disease
• Pulmonary hypertension (right side HF)
• Pulmonary embolism (right side HF)
• Endocrine disease
 NYHA (New York Heart Association)
classification of HF
• Class I : No limitation of physical activity. No dyspnea, fatigue, or
palpitations with ordinary physical activity.
• Class II : Slight limitation of physical activity. Patients experience
fatigue, palpitations, and dyspnea with ordinary physical activity but
are comfortable at rest.
• Class III : Marked limitation of activity. Less than ordinary physical
activity results in symptoms, but patients are comfortable at rest.
• Class IV : Symptoms are present with the patient at rest, and any
physical exertion exacerbates the symptoms.
 Symptoms of HF
1. Dyspnea (perceived shortness of breath)
2. Fatigue and weakness
3. Orthopnea (dyspnea experienced with patient in
recumbent position)
4. Paroxysmal nocturnal dyspnea (dyspnea awakening
patient from sleep)
5. Acute pulmonary edema (cough or progressive
dyspnea)
6. Exercise intolerance (inablility to climb a flight of
stairs)
7- Fatigue (especially muscular)
8- Dependent edema (swelling of feet and ankles after standing or
walking)
9- Report of weight gain or increased abdominal girth (fluid
accumulation; ascites)
10- Right upper quadrant pain (liver congestion)
11- Anorexia, nausea, vomiting, constipation (bowel edema)
12- Hyperventilation followed by apnea during sleep (Cheyne-Stokes
respiration)
 Signs of HF
1. Rapid, shallow breathing
2. Cheyne-Stokes respiration (hyperventilation alternating with apnea)
3. Inspiratory rales (crackles)
4. Enlargement of cardiac silhouette on chest radiograph
5. Increased venous pressure
6. Heart murmur
7. Gallop rhythm
8. Pulsus alternans
9- Distended neck veins (right side HF)
10- Large, tender liver (right side HF)
11- Jaundice (right side HF)
12- Peripheral edema (right side HF)
13- Ascites
14- Cyanosis
15- Weight gain
16- Clubbing of fingers
 Dental management
❖Antibiotics:
• Patients with HF may be more susceptible to infection (leukopenia),
but usually this is not a problem.
• There is no need for antibiotic prophylaxis unless the patient has a
prosthetic heart valve or another cardiac condition (refer to AHA
guidelines).
❖Anesthesia:
• It is very important to achieve and maintain excellent anesthesia in
order to reduce stress and prevent cardiac crisis.
• Use of epinephrine (1 : 100,000) at a dose of no more than 2 carpules
in local anesthetics generally causes no problems, but patients should
be monitored closely.
• Clinicians should provide good postoperative pain control.
• General anesthesia should be avoided.
❖Anxiety:
• Patients with untreated or poorly controlled HF may appear very
anxious and stressed and are at risk for cardiac crisis.
• Use of special anxiety/stress reduction techniques may be indicated.
❖Bleeding:
• Excessive bleeding may occur in the patient with untreated or poorly
controlled HF, because the medical treatment regimen typically
includes anticoagulants (e.g., warfarin, clopidogrel), which are
associated with greater risk for postsurgical bleeding and development
of hypotension.
❖Chair position:
• Positioning usually is not a problem if the patient is under good
medical management; however, a patient who is becoming
hypotensive and syncopal from cardiac stress and pulmonary
congestion may not tolerate the supine position.
❖Drugs:
1- In patients who are taking a nonselective beta blocker, excessive
amounts of epinephrine may cause a dangerous elevation in blood
pressure.
2- The use of epinephrine in patients who are taking digoxin may cause
arrhythmia.
3- Digitalis may result in toxicity, so be on the alert.
 When can I work ?

• Symptomatic Heart Failure (NYHA class III or IV)

Dental treatment should be limited to urgent care only, such as

treatment of acute infection, bleeding, or pain.
• Asymptomatic/Mild Heart Failure
(NYHA class I and II)

Any necessary dental treatment may be provided.

Renal Diseases
 Types of renal patients
1- Acute renal failure: reversible
2- Chronic renal disease CKD
3- Patient under dialysis
4- Patient after renal transplant
 Systemic Effect Of CKD
1. Anemia caused by decreased erythropoietin production and hemolysis
2. Host defense is compromised by nutritional deficiencies, leukocyte
dysfunction, and hypogammaglobulinemia making affected persons more
susceptible to infection.
3. Abnormal bleeding and bruising: petechiae, ecchymosis, oral bleeding
or epistaxis. Due to abnormal platelet aggregation and adhesiveness.
4. Drug intolerance.
5. Presence of several oral manifestations associated with either the
disease or its treatment
6. A variety of bone disorders (renal osteodystrophy): ground-glass
appearance of bone, or radiolucent lesions, or abnormal bone healing
after extraction (sclerosis) , and sometimes dental mobility.
1. Decrease vitamin D production….. decrease absorption of Ca
from GIT and decrease Ca reabsorption from kidney leading to
secondary hyperparathyroidism
• N.B. 3ry hyperparathyroidism
2. Metabolic acidosis: Stimulates bone resorption
 Chronic Renal Disease CRD
Oral Manifestations
1. Altered taste or metallic taste. (Dysgusia) saliva is altered in
composition with higher pH
2. Halitosis (uremic fetor): with Increased serum urea levels increased
salivary urea level, where it will turn into ammonia.
3. Diminished salivary flow: Xerostomia and parotid infections.
4. Candidiasis.
5. Pallor of skin and oral mucosa due to anemia.
6. Petechiae and ecchymosis due to platelet dysfunction.
7. Gingivitis, periodontal disease, and tooth loss
8. Specific osseous changes of the jaws: triad of :
a. Loss of lamina dura
b. Demineralized bone (resulting in a “ground-glass” appearance)
c. Localized and expansile radiolucent jaw lesions (giant cell
granulomas, also called brown tumors)
d. Extraction socket sclerosis.
Chronic Renal Disease CRD Dental Management
Patient Under Conservative Care
1- Anemia
• For elective surgery, erythropoietin and iron supplementation should be
initiated several weeks before surgery to raise hemoglobin to the desired
level
• Transfusion is appropriate to help avoid complications from perioperative
blood loss when hemoglobin levels fall below 8 g/dL in patients undergoing
surgery
2- Increased susceptibility to infection:
• If an orofacial infection occurs, aggressive management with the use of
Incision and drainage, removal of the cause culture and sensitivity testing
and appropriate antibiotics is necessary.
3- The altered bone appearance caused by 2ry hyperparathyroid should
not be mistaken for dental disease.

4- Bleeding tendency:
• Screen for bleeding disorder
• Use local hemostatic measures
• Avoid Antiplatelet agents within 72 hours before surgery
5- Drugs metabolized or excreted by the kidney
• drug dosage needs to be reduced and timing of administration must be
prolonged
• Safe antibiotics: penicillin, clindamycin and metronidazole
• Safe analgesics: paracetamol (avoid aspirin and NSAIDs)
Management of patients under renal dialysis
1. Hemodialysis removes some drugs from the circulating blood; this
may shorten the duration of effect of prescribed medications
(Amoxicillin).
2. The Bone more susceptible to fractures so careful dental extraction
technique to avoid fracture.
3. Consider hepatitis B, C and HIV screening. We take infection
control measures anyway. Check if liver functions are affected.
4. Bleeding tendency due to
1. Diminishes platelet count due to mechanical damage
2. Heparin anticoagulation (The effects last only 3-6 hrs)
❖In case of invasive dental procedures:
• Screening tests, coagulation profile and platelet count
• Start surgery after 12 hours or next day be safe
• Management modifications can be used to reduce the chance of
serious bleeding
• Administering protamine sulfate (by a physician) in case of emergency
the day of hemodialysis.
• After surgery: During the postoperative period, patients should
undergo Heparin free dialysis for at least 24 hours.
 Patients With Renal Transplant
• Consider the use of prophylactic antibiotics, for patients taking
immunosuppressive agents.
• Avoid the use of nephrotoxic drugs, such as aspirin and NSAIDs.
(Protect the residual renal function).
• If the patient is under corticosteroids, consider the use of supplemental
corticosteroids.
• Watch for presence of cyclosporine A- induced gingival hyperplasia
(Gingivictomy could be performed in case of functional or esthetic
discomfort).
Hepatic Disorders
 Oral Clinical Manifestations
• The oral cavity can reflect liver dysfunction in the form Of:
1- Bleeding disorders: petechiae, bruising, gingival bleeding
2- Foetor hepaticus (a characteristic odor of advanced liver disease)
3- Cheilitis
4- Mucosal membrane jaundice
5- Smooth and atrophic tongue
6- Xerostomia
 Management of patient with hepatic disease
❖Avoid hepatotoxic drugs: Acetaminophen high doses,
Chloramphenicol, NSAIDs
❖Avoid drugs metabolized by the liver:
• Analgesics: Aspirin and Ibuprofen.
• Antibiotics: Ampicillin, penicillin, erythromycin, tetracyclines,
metronidazole, Amide LA
❖Safe to use:
• Analgesic: Acetaminophen but may require dose modifications in
advanced cases
• Antibiotics: Clindamycin
❖Universal infection control precautions.
❖Bleeding tendency.
Pregnancy & Breast Feeding
 Treatment timing
• Elective dental care is best avoided during the first trimester because
of the potential vulnerability of the fetus.
• The second trimester is the safest period during which to provide
routine dental care.
• The early part of the third trimester is still a good time to provide
routine dental care.
• After the middle of the third trimester, however, elective dental care is
best postponed.
• This is because of the increasing feeling of discomfort that many
expectant mothers may experience.
 Oral complications & manifistations
1. Pregnancy gingivitis (exaggeration of periodontal disease).

2. Pregnancy tumor (pyogenic granuloma)

3. Tooth mobility.
 Dental radiographs
• The safety of dental radiography has been well established, provided
that features such as fast exposure techniques (e.g., high-speed film or
digital imaging), lead aprons, and thyroid collars are used.

• The American Academy of Pediatrics and the American College of

Obstetricians and Gynecologists have published guidelines stating:
“Diagnostic radiologic procedures should not be performed during
pregnancy unless the information to be obtained from them is
necessary for the care of the patient and cannot be obtained by other
means.”
 Comparative Radiation Exposures
to Fetal or Embryonic Tissues
Source of Radiation Absorbed Exposure (cGy)
• Upper gastrointestinal series 0.330
• Chest radiograph 0.008
• Skull radiograph 0.004
• Daily (cosmic) background 0.0004
radiation.
• Full-mouth dental series 0.oooo1
(18 intraoral radiographs,
D film, lead apron)
 Dental management of pregnancy
❖Antibiotics:
• If antibiotics are required, consult with thephysician.
• Penicillins (including amoxicillin), erythromycin (except in estolate
form), cephalosporins, metronidazole, and clindamycin are generally
considered to be safe.
• The use of tetracycline, including doxycycline is contraindicated
during pregnancy.
❖Analgesics:
• If analgesics are required, consult with the physician.
• Acetaminophen is the drug of choice.
• If other analgesics are required, use with approval of physician.

❖Anesthesia:
• The usual local anesthetics with vasoconstrictors are safe to use,
provided that care is taken not to exceed the recommended dose.
❖Chair position:
• Patient may not be able to tolerate a supine chair position in third
trimester.
• Supine position may cause difficulty in breathing.
• Supine position may cause hypotension in late 3rd trimester.
Bronchial asthma
• Asthma: it is a common long term inflammatory disease of the lungs.

• It is characterized by variable and recurring symptoms of

bronchospasm and air flow obstruction.

• Infection of the upper respiratory tract and stress can worsen the
disease.
 Dental management
• Patients treated with inhalers, the inhaler should be available during
treatment visit.

• Emergency oxygen in case of hypoxia.

• Medications that can cause problems in asthmatics are aspirin and

NSAIDs.
 Endocrine & Metabolic Diseases
1. Diabetes Mellitus.
2. Adrenal Insufficiency.
3. Thyroid Diseases.
 Diabetes Mellitus
• Definitions:
It is a group of metabolic diseases characterized by:
1. High blood glucose levels (hyperglycemia).
2. Inability to produse and/or use insulin.
 Classification of Diabetes
1. Type 1 DM:
• Mostly in children (Juvenile Onset DM).
• Severe insulin deficiency due to β cell destruction (insulin dependent
IDDM).
• Immune mediated pancreatic β cell destruction in response to an
environmental agent possibly viral in genetically predisposed
patients.
2- Type 2 DM:
• Mostly in adults (Adult Onset DM).
• Insulin resistance hyperinsulinemia to overcome insulin resistance
(non-insulin dependent NIDDM).
• Diabetes appears when hyperinsulinemia can no longer overcome the
insulin resistance & exhaustion of pancreatic β cell occurs insulin
deficiency.
• Mostly in obese patients (80%) with +ve family history associated with
other insulin resistance conditions as hypertension, hypertriglyceridemia,
fatty liver & abdominal obesity (metabolic syndrome).
3- Maturity Onset Diabetes of the Youth (MODY):
• It occurs in young subjects.
• They are usually obese & have +ve family history of DM.
4- Gestational Diabetes:
• Usually in 3rd trimester pregnancy.
• It may recur in subsequent pregnancies or reappear later on even after
years.
5- Other types:
a) Drugs: as glucocorticoids.
b) Endocrinopathies: as Acromegaly, Cushing’s syndrome &
hyperthyroidism.
Pathophysiology
 Complications
1- Metabolic disturbances: ketoacidosis and
hyperosmolar nonketotic coma (type 2
diabetes)
2- Cardiovascular: accelerated atherosclerosis
(coronary heart disease); two thirds have high
blood pressure;
risk for stroke and heart disease death is 2 to
4 times higher among people with DM
3- Eyes: retinopathy, cataracts (clouding of
the lens inside the eye which leads to a
decrease in vision); DM is leading cause of
new cases of blindness among adults
4- Kidney: diabetic nephropathy;
DM is leading cause of renal failure

5- Extremities: ulceration and gangrene of feet; DM is

leading cause of non–accident-related leg and foot
amputations
6- Diabetic neuropathy: dysphagia, gastric distention, diarrhea,
impotence, muscle weakness or cramps, numbness, tingling, deep
burning pain

7- Early death: DM is the seventh leading cause of death in the United

States, most commonly due to cardiovascular disease
 Signs & Symptoms Of Type 1 DM
❖Cardinal signs/symptoms (common): polydipsia, polyuria,
polyphagia, weight loss, loss of strength.

❖Other signs/symptoms: recurrence of bed wetting, repeated skin

infections, marked irritability, headache, drowsiness, malaise, dry
mouth.
 Signs & Symptoms Of Type 2 DM
❖Cardinal signs/symptoms (much less common): polydipsia, polyuria,
polyphagia, weight loss, loss of strength

❖Frequent signs/symptoms: slight weight loss or gain, gastrointestinal

upset, nausea, urination at night, vulvar pruritus, blurred vision,
decreased vision, paresthesias, dry flushed skin, loss of sensation,
impotence, postural hypotension
 Diagnostic criteria for DM by
American Diabetes Association (ADA)
1. FPG ≥126 mg/dL (7.0 mmol/L) on two occasions. Fasting is defined
as no caloric intake for at least 8 hours.
This fasting glucose value is consistently associated with the risk for
retinopathy.
OR
2. Symptoms and signs of diabetes plus casual (random) plasma glucose
concentration ≥200 mg/dL (11.1 mmol/L).
Casual is defined as obtained at any time of day without regard to time
since last meal.
Many patients do not have obvious symptoms.
The cardinal manifestations of diabetes include polyuria, polydipsia,
and unexplained weight loss.
OR
3. 2-hour post-load glucose ≥200 mg/dL (11.1 mmol/L) during an
OGTT. The test should be performed as described by the WHO, using
a glucose load containing the equivalent of 75 g anhydrous glucose
dissolved in water.
OR
4. Glycosylated hemoglobin (HbA1c) (by A1C assay) ≥6.5%
➢Prediabetes:

• Impaired fasting glucose (IFG): 100 – 125 mg/dL

• Impaired glucose tolerance (IGT): 140 – 199 mg/dL
 Medical Management Of DM
❖Type 1 Diabetes ❖Type 2 Diabetes
• Diet and physical activity • Diet and physical activity
• Insulin • Oral hypoglycemic agents
1- Conventional • Insulin plus oral hypoglycemic
2- Multiple injections agents
3- Continuous infusion • Insulin
4- Pancreatic transplantation
 Clinical Detection Of The Patient With
Diabetes

❖Patient with Known Diabetes

1. Detection by history.
2. Establishment of severity of disease and degree of “control”.
❖Patient with Undiagnosed Diabetes
1. History of signs or symptoms of diabetes or its complications
2. High risk for developing diabetes:
a. Presence of diabetes in a parent
b. History of spontaneous abortions or stillbirths
c. Obesity
d. Age older than 40 years
3. Referral or screening test for diabetes
 Dental Management
1- analgesics:
Avoid use of aspirin and other NSAIDs in patients taking
sulfonylureas, because these can worsen hypoglycemia.

2- antibiotics:
Prophylactic antibiotics generally are not required. Antibiotics may be
prescribed for a patient with brittle (very difficult to control) diabetes
for whom an invasive procedure is planned
Manage infections aggressively by:

a) incision and drainage

b) extraction or pulpotomy
c) warm rinses
d) antibiotics.
3- blood pressure:
Monitor blood pressure, because diabetes is associated with
hypertension.

4- cardiovascular:
Confirm cardiovascular status. Beta blocker drugs can exacerbate
hypoglycemia in patients taking sulfonylureas.
5- Drugs:
Patient advised to take usual insulin dosage and normal meals on day of
dental appointment; information confirmed with patient at
appointment.

6- equipment:
Use office glucometer to ensure good glucose control.
7- Emergencies/ Urgencies:
• Advise patient to inform dentist or staff if symptoms of insulin
reaction occur during dental visit.
• Have glucose source (orange juice, soda, cake icing) available; give to
the patient if symptoms of insulin reaction occur.
 Oral manifistations
These manifistations are due to:
1. Increased glucose level in saliva.
2. Fluids loss.
3. Altered response to infections.
4. Microvascular changes.
5. Neuropathies.
1- accelerated periodontal disease.
2- gingival proliferation.
3- xerostomia.
4- periodontal abscesses.
5- poor healing.
6- infection.
7- Oral ulcerations.
8- Candidiasis.
9- Mucormycosis (fungal infection).
10- Numbness, burning or pain in oral tissues.
 When can I work?
❖ In patients with well-controlled diabetes:

No alteration of treatment plan is indicated unless complications of

diabetes are present, such as:
• Hypertension
• Congestive heart failure
• Myocardial infarction
• Angina
• Renal failure
❖ Defer orthodontic and prosthodontic care until periodontal disease is
well controlled.

❖ Avoid periodontal or oral surgery if poor glycemic control.

Adrenal Insuffeicincy
• Adrenal gland consists of 2 different endocrine glands:
1- The inner medulla: secretes catecholamines (epinephrine &
norepinephrine)
2- The outer cortex: secretes steroid hormones
a- Zona glomeruloza mineralocorticoids (aldosterone)
b- Zona fasiculata glucocorticoids (cortisol)
c- Zona reticularis sex hormones (androgens)
Structure Of The Adrenal Gland
 Control Of Glucocorticoid Secretion
Hypothalamus-pituitary-adrenal (HPA) Axis
1. CRH from hypothalamus, stimulates
2. ACTH from anterior pituitary gland.
3. Circadian rhythm of CRH.
4. Stress increases CRH.
5. Cortisol has –ve feedback effect on CRH & ACTH.

❖ Aldosterone secretion is ACTH-independent, it is stimulated by a

fall in renal blood pressure.
 Actions Of Cortisol

1. Gluconeogenesis & decrease glucose utilization by

tissues (anti-insulin effect).
2. Increased glycogen storage by the liver.
3. Protein catabolism in muscles & protein synthesis in liver.
4. Lipolysis.
5. Anti-stress effect.
6. Anti-allergic effect.
7. Anti-inflammatory effect.
 Actions Of Aldosterone

• Elevation of Na⁺ content of ECF promote water retention

elevation of ECF volume.
 Adrenal Disorders

1. Hyperadrenalism (Cushing’s disease).

2. Hypoadrenalism (addison’s disease).
 Etiology Of Adrenal Insufficiency
❖Primary adrenal insufficiency:
progressive destruction of adrenal cortex by:
1- Autoimmune disease.
2- Chronic infectious diseases (TB or HIV).
3- Malignancy.
4- Hemorrhage.
5- Sepsis.
6- Adrenalectomy.
7- Drugs.
8- Genetic mutations.
 Etiology Of Adrenal Insufficiency
❖Secondary adrenal insufficieny:

1- Structural lesions of hypothalamus or pituitary glands.

2- Administration of exogenous corticosteroids.
 Signs & Symptoms Of Addison’s Disease
1- Weakness, fatigue, and abdominal pain.
2- Hyperpigmentation of the skin and mucous membranes.
3- Hypotension & hypoglycemia & myalgia.
4- Anorexia, salt craving, and weight loss.
 Signs & Symptoms Of Cushing’ Syndrome

1- weight gain, a broad and round face (“moon

facies”), a “buffalo hump” on the upper back, and abdominal striae.
2- Hypertension, hirsutism, and acne.
3- Glucose intolerance (e.g., diabetes mellitus)
4- Heart failure.
5- Osteoporosis and & bone fractures.
6- Impaired healing.
7- Psychiatric disorders.
 Adrenal Crisis
• If a patient with Addison’s disease is challenged by stress (e.g., illness,
infection, surgery), an adrenal crisis may be precipitated.

• It includes sunken eyes, profuse sweating, hypotension, weak pulse,

cyanosis, nausea, vomiting, weakness, headache, dehydration, fever,
dyspnea, myalgias, arthralgia, hyponatremia, and eosinophilia.

• If not treated rapidly, the patient may develop hypothermia, severe

hypotension, hypoglycemia, confusion, and circulatory collapse that
can result in death
• An adrenal crisis in a patient with secondary adrenal suppression is
rare and tends not to be as severe as that seen with primary adrenal
insufficiency,
• because aldosterone secretion is normal.
• Thus, hypotension, dehydration, and shock are seldom encountered.
 Management Of Adrenal Crisis
• Intravenous injection of a glucocorticoid—usually a 100-mg
hydrocortisone bolus.
• Intramuscular injection results in slow absorption and is not
preferred for emergency treatment.
• After the initial bolus, 50 mg hydrocortisone is administered IV
slowly every 6 to 8 hours for 24 hrs.
• Fluid replacement, vasopressors, continuous infusion of saline, and
correction of hypoglycemia
 Dental Management
• Analgesics:
Provide good postoperative pain control to avoid adrenal crisis.

• Anxiety:
Use anxiety/stress reduction techniques.
• Blood pressure:
If blood pressure drops below 100/60 mm Hg and the patient is
unresponsive to fluid replacement and vasopressive measures,
administer supplemental steroids.

• Drugs:
Use barbiturates with caution, because they increase the metabolism
of cortisol and reduce blood levels of cortisol.
 Thyroid Diseases
• Pituitary gland secretes the TSH (thyroid stimulating hormone) which
stimulates the thyroid gland to secret the thyroid hormones:
thyroxin T4 & tri-iodothyronine T3
 Functions Of The Thyroxin

1. Increase metabolic rate in all tissues.

2. Increase glucose utilization glycogenolysis.
3. Increase protein catabolism.
4. Stimulate catecholamine receptors esp. in the heart that leads to
increase in HR & force of contraction.
5. Vasodilatation & hyper-dynamic circulation.
 Hyperthyroidism (Thyrotoxicosis)
• Grave’s disease is one type of hyperthyroidism.
• It is an autoimmune disease.
• TSH-R (stim) Ab stimulate thyroid gland to produce T3 & T4 in
excessive amounts.
• Another Ab are directed against the extra-ocular muscles their
swelling (exophthalmos).
• It is more common in females (7:1).
 Sings & Symptoms Of Grave’s Disease
• General:
1. Weight loss in spite of increase apatite.
2. Heat intolerance.
3. Excessive sweating.
4. Warm hands.
• Eye manifistations:
1. Staring look.
2. Exophthalmos.
3. Paralysis of some of eye muscles.
• CNS:
1. Irritability, nervousness & anxiety.
2. Tremors of out stretched hands & of the tongue.
• CVS:
1. Tachycardia (sleeping pulse > 100/ min)
2. Exertional dyspnea.
• GIT:
1. Hyper-defecation (diarrhea).
2. Malabsorption.
• Skin:
1. Pretibial myxoedema: infiltration by myxoedematous tissue,
resulting in non-pitting edema over the skin of the tibia.
 Hypothyroidism (Myxoedema)
• It is failure of thyroid gland to secrete thyroxin.
• It is caused by:
1. 1ry hypothyroidism (autoimmune).
2. After surgical removal.
3. After ttt with radioactive iodine for thyrotoxicosis.
Signs & Symptoms Of Myxoedema

• General:
1. Intolerance to cold.
2. Increased tiredness.
3. Weight gain in spite of decreased apatite.
• Eye & face:
1. Puffiness of the eyelid.
2. Loss of outer 1/3 of eye brow
3. Dry brittle hair.
4. Thickened lips & tongue.
• CVS:
1. Bradycardia.
2. Pericardial effusion.
• CNS:
1. Slow mentality apathy.
• GIT:
1. Decrease apatite.
2. Constipation.
• Infiltration by myxoedematous tissue in:
1. Skin (non-pitting edema)
2. Vocal cords (hoarseness of voice)
3. Tongue (slurred speech)
4. Internal auditory (deafness)
Dental Management Of Hyperthyroid Patient
• Analgesics:
Aspirin and other NSAIDs can increase the amount of circulating T4,
making control of thyroid disease more difficult. Use appropriately.

• Anesthesia:
Avoid using epinephrine in local anesthetics in untreated or poorly
controlled patients.
• Anxiety:
Patients with untreated or poorly controlled disease may appear very
anxious.

• Blood pressure:
Monitor blood pressure as it may be elevated in patients with
untreated or poorly controlled disease.
• Drugs:
The use of epinephrine or other pressor amines (gingival retraction
cords, or to control bleeding) must be avoided in the untreated or
poorly treated thyrotoxic patient.
Common side effects of the antithyroid drugs (methimazole and
propylthiouracil) are rash, pruritus, fever, and arthralgias.
Agranulocytosis and hepatitis are rare but serious complications of the
antithyroid drugs.
Dental Management Of Hypothyroid Patients
• Analgesics:
Avoid CNS depressants such as narcotics, barbiturates. and sedatives
in patients with poorly controlled disease.

• Antibiotics:
Crofloxacin should not be taken simultaneously with levothyroxine,
because the antibiotic appears to decrease absorption of the thyroid
hormone.
• Drugs:
Phenytoin, phenobarbital, carbamazepine, and rifampin should be
used with care, because they increase the metabolism of thyroid
replacement drugs.