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‫بسم هللا الرحمن الرحيم‬

MEDICAL PROBLEMs in
DENTISTRY
‫الأمراض العامة في طب الأسنان‬
Dr.Husein Jabi
Maxillofacial Surgeon (M.O.M.S)

Medical History: ‫القصة المرضية‬


- Anemia
- Bleeding disorder
- cardiorespiratory disorder
- Drug teatment and allergies
- Endocrine disorders
- liver disorders
- Kidney disorder
- Pregnancy
- Previous hospitalization of the patient.

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Clinical examination: ‫الفحص السريري‬
-Physical examination:(Cardiovascular system,Respiratory system,Neurological system).
-Examination of patient’s appearance
-Anxity.
-Facial examination(bone deformity,facial movement and sensation)
-Mouth opening.
-Salivary glands.

Laboratory tests: ‫التحاليل المخبرية‬


 Determine coagulation status (von Willebrand’s, Hemophilia):PT,PTT,INR.
 Determine level of anticoagulation (warfarine):INR.
 Screening for blood glucose (periodontal disease, burning mouth):FBS,RBS.
 Screen for infectious disease (hepatitis C, hepatitis B,AIDS)
 Screening for liver function (hepatitis C, cirrhosis):AST,ALT.
 Screening for kidney function(renal failure):Urea, creatinine.
 Complete blood count with differential [CBC with differential] (burning mouth,
unexplained oral lesions).

Medical Consultation ‫الاستشارة الطبية‬


 Purpose:
 Verify or clarify information
 Determine risk for doing dental treatment on the patient
 Determine if any changes are required in the delivery of dental treatment
 Be brief and to the point
 Response should attached to or recorded in the patient’s chart.

Analgesia ‫المسكنات‬
 Acetaminophen (paracetamol):Maximum daily dose : less than 4 gr/day.
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 Non- steroidal anti- infammatory drugs (NSAIDs)
1. Cox-1 inhibitors:(Ibuprofen ,Diclofenac sodium), containdication for: Bronchial
Asthma_Renal disease_Pregnancy_Peplic ulcer_Bleeding
tendency_Allergy_cardiac failiar_Patient on corticosteroid.
2- COX-2 inhibitors:(celecoxib,Meloxicam) prolong (PT,INR),Preferred for Pt with
Peplic ulcer, containdication for cardiac disease.

 Opioids (codeine,tramadol):central action, containdication for: Asthma ,seizures, MAO


inhibitors,Hypothyrodism.

Contraindications of epinephrine(Adrenaline)
‫مضادات استطباب الأدرينالين‬
 Untreated hyperthyroidism (Absolute contraindication).

 Uncontrolled hypertensive patient (Absolute contraindication).

 Hypertensive Pt on Beta-blocker medications.

 Cardiac Pt on Digoxine.

 After radiotherapy to the area.

 Asthmatic Pt who is sensitive to sulphite.

‫ – فرط نشاط الغدة الدرقية الغير منضبط‬2‫ارتفاع الضغط الغير منضبط أو الغير معالج‬-1 : ‫مضادات اإلستطباب القطعية‬

‫مرضى القلب المعالجون‬,‫ارتفاع الضغط المعالج بحاصرات بيتا‬:) ‫مضادات استطباب نسبية (تتبع رأي الطبيب المعالج‬
‫ مريض الربو المتحسس من السولفات‬,‫ بعد عالج شعاعي للعظم المجاور‬, ‫بالديجوكسين‬

Cardiac problems ‫الأمراض القلبية‬


 Consultation with a cardiologist regarding: the need of Antibiotic prophylactic and the
Anticoagulant treatment.

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 Effective painless LA is essential, and an aspirating syringe should be used
 Epinephrine-containing LA should not be given in excessive doses to Pt on beta blockers.
 Citanest(Prilocain&octapresine) is not recommended to be used for cardiac or
hypertensive Pt.
 Assure the patient, Stress free short, late- morning appointments are recommended.
 Antibiotic prophylaxis may be recommended for cardiac patients to prevent infective
endocarditis.

Cardiac conditions which prophylaxis antibiotic is recommended


1. Prosthetic cardiac valve.
2. Previous infective endocarditis.
3. Congenital heart disease (CHD)*
 Unrepaired cyanotic CHD.
 Completely repaired congenital heart defect with prosthetic material during the
first six months after the procedure.
 Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch .
4. Cardiac transplantation recipients who develop cardiac valvulopathy.

Ischemic heart disease (I .H. D) ‫مرض ضعف التروية القلبية‬

 Steress,anxiety,pain, should be minimised.


 The visit for tretment :late morning.
 Aspiration syringe.
 Avoid epinephrine if Pt on Beta blockers.
 If pt on: Aspirin + Plavix (clopidrol), hold one of them for 7 days before the
extraction of teeth
 If Pt has a history of cardiac catheterization & Stent, from more than 6
monthes and he is stable no need antibiotic prophylactic

Angina Pectoris ‫خناق الصدر‬

 Pre – op : Nitroglycerin.
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 During the procedure :Menimal anxity , monitor (BP,Pulse,SPO2) , effictive(LA) , medical
help (O2,Nitroglycerin)should be ready.
 If Pt has chest pain Stop treatment+ Nitroglycerin(S.L)+O2+Sitting upright+check
vital signs pain relief Go home .
pain not relief ask medical help + give Nitroglycerin every 5 min
for 3 doses pain more + syncope + vomiting Myocardial infarction
chew Aspirine 300mg + O2 + Nitrous oxide or Morphin.
 Defer dental procedure 3 monthes after angina attack, and 6 monthes after (M.I).

Congenital heart disease ‫أمراض القلب الخلقية‬


- there is bleeding tendency due to platelate function.
- May need antibiotic prophylactic.

Rhumatic fever(R.H.D) )‫روماتيزم القلب (الحمى الرثوية‬


- there is risk of bleeding due to anticoagulant.
- acute rhumatic fever : emergency dental treatment only.
- No need antibiotic prophylactic.

Heart failiar ‫الفشل القلبي‬

- Dental chair should be erect or reclining only.


- Adrenaline can cause dysrhithmias, so it Should be at minimal dose.
- Avoid Gingival retraction cord.
- O2 ready.
- Avoid Erythromycin & Tetramycine.
- Avoid Non- steroidal anti- infammatory drugs (NSAIs) if Pt on ACE inhibitors.

Hypertention(HTN) ‫ارتفاع ضغط الدم‬


 Medical consultaion if uncontrolled : BP > (160/95)mm/Hg.

 Stable HTN : BP < (140/90)mm/Hg:


1- Reduce (pain,anxity,stress).
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2- late morning appointment.
3- Aspirating syringe .
4- Adrenaline is accepted if BP<(200/115),but it make interaction with B-blockers.
5- Avoid gengival retraction cord with epinephrine.
6- Do not move the dental chair suddenly.

Diabetes mellitus(DM) ‫مرض السكر‬


(type I – type II – gestation)
 The main hazard is hypoglycemia ,give Pt oral Glucose before dental treatment.
 Appiontment :morning after ( breakfast + antidiabetic treatment).
 (L A) with epinephrine is safe.
 Infections should be treated vigorously.
 Avoid : Steroid , Aspirine.
 Oral surgery can be done if blood glucose (RBS) : 120-180 mg/dl (3-5 mmol/l).
 Well-controlled (DM) no need antibiotic prophylactic.
 Poorly controlled (DM) with FBS < 250 mg/dl need consultation, if (ER)surgery: need
antibiotic prophylactic.
 High Glucose level delayed wound healing + phagocyte dysfunction.
 Management of hypoglycemia coma : ‫تدبير اإلغماء بنقص السكر‬
- If the patient is conscious : Glucose 10-20 g is given by mouth.
- If the patient is unconscious: Dextrose 5% (IV) is given intravenous , or Glucagon (IM)
1mg intramuscular.

Systemic corticosteroid therapy ‫المرضى المعالجون بالكورتزون‬


Causes : Autoimmune disease(skin ,blood , gastrointestinal) ,asthma, post trnsplantation.

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Dental aspects: Adrenocortical function may be suppresed if Pt on systemic Pednisolone <7.5
mg Now or more than one month at the last year :
&& Double oral steroid dose in morning, before any dental procedure (conservative dentistry
,extraction, scaling ..) , or Hydrocortisone/50mg ( IV ) preopertive.
&& Avoid : NSAIs or Aspirine peptic ulcer.
&& Antibiotc prophylactic may be indicated , because of impaired wound healing.
&& Management of adrenal crises: Give Hydrocortisone ( IV) 100mg ‫تدبير الصدمة الكظرية‬

Hyperthyrodism ‫فرط نشاط الدرق‬


 Need cosultation if uncontrolled.
 (L A) with epinephrine increase sympathetic over activity Fainting.
 Avoid Povidone-iodine. ‫تجنب استخدام األدرينالين مع المخدر اذا كان الهرمون الدرقي غير منضبط‬
 Management of thyroid crises: Call ambulance to give :Potassium Iodine.

Hypothyrodism ‫قصور الدرق‬


 Avoid : Opiod Alnalgesic(codein,..) and Diazepam Myxoedema coma.
 Avoid Povidone-iodine.
 Avoid (GA).

Hyperparathyrodism ‫فرط نشاط جارات الدرق‬


- Dental treatment is complicated by :
1-Renal disease. 4- Autoimmune disease (DM,Cushing,...) 7- HBV , HCV.
2- Peptic ulcer. 5- Giant-cell lesions (Brown tumors).
3- Bone fragility . 6- dental changes(loss of lamina dura).

 Hypoparathyrodism ‫قصور جارات الدرق‬


Dental treatment is complicated by :

1-Tetany (‫)التكزز‬.
2-Seizurs )‫(اختالجات ال إرادية‬.
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3- DM ( ‫ )مرض السكر‬.
4- Dysrhythmias ( ‫)اضطراب نظم القلب‬.
5-Facial paraesthesia, twitching(Chvostik,s sign)
)‫خدر ورعشة في عضالت الوجه عند لمسها (عالمة تشفوستك‬

Renal failiar ‫الفشل الكلوي‬


Main problems: Bleeding tendency, infection , hypertention,underlying disease.
Dental aspects:
1- Extraction should be day after hemodialysis (H.D).
2-Prophylactic antibiotic need for:(Polycystic Kidney,Periotonieal HD , prosthetic graft , Pt with
transplants). )‫ زرع كلى‬, ‫توصيلة صناعية‬,‫الغسيل البريتواني‬,‫يحتاج مضاد وقائي لحاالت خاصة (داء الكيسات الكلوي‬
3-Avoid : NSAIs,ASA,COX2inhebitors,Gentamycin, Tetracyclin,Opiod.
4- Precaution for infectious disease (HBV,HIV,..).

Sickle cell Anaemia ‫فقر الدم المنجلي‬


 Pt sickle cell triate: Safe
 Pt sickle cell disease:
 1- Avoid prilocaine LA. 2- Avoid Aspirin.
3- Elective surgery can be done if haemolysis is minimal &HBG < 10g/dl.
4- Need prophylactic Antibiotic Pre-Op (Penicilline , Clindamycine) .
‫اذا كانت الحالة مستقرة يمكن عمل الجراحة فموية لكن يحتاج مضاد حيوي وقائي‬
 5-Management of pain crises :O2, Bicarbonate(IV), Red Blood Cells transfusion.

Thalassemias ‫فقر دم البحر الأبيض المتوسط‬


Alpha-Thalassemias : Lethal in infancy .
Beta- Thalassemias : Homozygous(Major):hepatosplenomegaly + severe anaemia +skeletal.
Abnormality.
Hetrerozygotes :No symptoms
Dental aspects :
 Pt may has : HCV,HIV,HBV from blood trasfusion.
 Need Antibiotic prophylactic( immunity ).
‫يحتاج مضاد حيوي وقائي بسبب نقص المناعة الناتج عن مرض الطحال‬
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 LA : safe
 GA :Risk.
 Alveolar bone rarefaction(‫)متخلخل‬,give (Chicken-wire) appearance on X-Ray.
Idiopathic thrombocytopenia purpura ‫نقص الصفيحات الدموية‬
 Clinically : submucosal purpura.
 LA : Safe if PLT < 30x10 /L.
 Minor surgery : Safe if PLT < 50x10 /L.
 Major surgery : Safe if PLT < 75x10 /L.
 Local haemostatic agents: Demopressine,Tranixamic acid,Oxidized regenerated
cellulose(Surgicel) , Collagen.
 Avoid :NSAIs , ASA.(COX2 inhibitor :OK).
Vone Willibrand’s disease
 Avoid :NSAI , ASA.
 LA : local infiltration shoud generally be used.
 Factor VIII,cryoprecipitate and fresh frozen plasma are effective for general
management of the bleeding.
Haemophilia A ‫مرض الناعور‬
 LA : Avoid regional block , lingual infiltration,
(intraligamental ,intraosseous : safe).
 Avoid intamuscular injection.
 Endodontic treatment : avoid instrumentation through the apex .
 Periodontic treatmend: Need Factor VIII level :50-75%
 Extraction: Need Factor VIII level :50-75%
 Minor surgery: Avoid lingual tissue,minimal bone removal, sectioning of tooth, place
surgicel, antibiotic coverage.
Haemophilia B
 Need fctor IX replacement before the surgery.
Warfarine
 Need medical consultation.
 If Pt need simple extraction less than 3 teeth + INR > 3 : local methd hemostasis is
suffice (Suturing, Surgicel,Tranicsamicacid),no need to stop warfarine.
‫ يمكننا القلع دون ايقاف الوارفرين بشرط الخياطة بعد القلع ووضع‬3 ‫اذا كان القلع بسيطا ومعدل التخثر العالمي أقل من‬
‫اسفنج مرقئ في السنخ‬
 If INR more than 3.5 Pt need management in the hospital.
 Avoid : Erythromycine,NSAIs drugs.
 Surgery shoul be with a minimal trauma.
 To stop bleeding :LA with adrenalin,Gauze pad soached with Tranexamic acid press over
socket 15min ,Squeezing the socket edge,Surgicel, sutureing ,if still bleeding consult
Physician for Vit K.
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 ‫ دقيقة ثم نضغط فتحة‬15 ‫إليقاف النزيف نخدر ثم نجعل المريض يعض على شاش مشبع بالترانيكساميك اسيد لمدة‬
‫السنخ باالصبعين ثم ندك االسفنج المرقئ سرجيسيل ونخيط الجرح وفي حال استمرار النزف نستشير الطبيب العام‬
. ‫لحقن فيتامين ك‬

Heparin
 For surgery Need medical consultation.

 For simple extracin > 3 teeth no need to stop heparin.


 Any sugery can be done after 6-8 hour from the last dose of Heparin.
 In emergency Heparin can be reversed by Protamine sulfate
‫ ساعات واذاحدث نزيف يمكن معاكسة مفعول‬6 ‫ اسنان الداعي اليقاف الهيبارين بل نقلع بعد الجرعة ب‬3 ‫لقلع اقل من‬
.‫الهيبارين باعطاء بروتامين سلفات‬
Leukaemias ‫ابيضاض الدم‬
& & Dental problems: (1) bleeding tendency. (2)Susceptability to infection.(3)Pt may has 
HIV,HCV,..infection from blood transfusion. (4)Pt on corticosteroid treatment.
Management: 
1- Hematologest consultation. 
2- Avoid regional LA . 
3- To avoid bleeding use desmopressin(IV). 
4- To avoid infection do not pack the socket. 
5- Avoid : Aspirin , NSAIs.

Lymphoma
 Problems: Anaemia , infection , Corticosteroid therapy,bleeding tendency,
Radiotherapy, cardiac disease , acute Leukaemia , xerostomia.
 Management:
- Avoid regional LA .

Bronchial Asthma ‫الربو القصبي‬


 Avoid anxiety which may precipitate an asthmatic attack.
 Patients are advised to bring their regular medication with them.

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 Elective dental care should be deferred in severe asthmatics until they are in a better
phase.
 Allergy to penicillin may be more frequent.
 Epinephrine, erythromycin, clindamycin and azithromycin are contraindicated for
patients on theophylline
 some asthmatic patients may react to sulphites present as preservatives in it.
 Aspirin and NSAIDs should be avoided as they are considered asthma precipitating
drugs.
‫ تجنب وصف مضادات اإللتهاب غير الستيروئيدية أو األسبرين‬, ‫ تأكد أن البخاخ معه‬, ‫التجهد المريض‬

Liver Disorder ‫أمراض الكبد‬


Probems :potential bleeding, impaired hemostasis , failure of metabolism of many
drugs.
 Investigations : ALT , AST.
 Management:
- Acetaminophen can be used for analgesia in lower than normal doses.
- Aspirin and NSAIDs should be avoided.
- The anti-fungal drug miconazole is contra-indicated if there is hepatic impairment and
fluconazole requires dose reduction.
- Erythromycin, metronidazole and tetracyclines should be avoided.
‫ تجنب مضادات اإللتهاب غير الستيروئيدية‬,‫تأكد من أنزيمات الكبد‬, ‫خطرها يكمن في قابلية النزف وضعف استقالب األدوية‬
‫ واستخدم الباراسيتامول بجرعة منخفضة‬, ‫واألسبرين ومضاد الفطور واألرثروميسين والتتراسيكلين والمترونيدازول‬

Hepatitis B
 Pt should be the last one in the list.
 To avoid bleeding : check (PT , Platelet).
 Prescripe the minimal amount of drugs.
 Avoid scattered drops from the oral cavity (transmision of HBV by saliva is low risk).
 After needle stick injury:allow spontenous bleeding, wash by water, disinfect by Povidon
, the person should receive Hepatitis B immunoglobulin (HBIG) withen 24 hr + the first
dose of the Hepatitis Vaccine .
& Note : 0.0000001 ml from blood plasma serum Virus transmition.

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Pregnancy ‫الحمل‬
 Gynae consultation.
 Avoid giving any drugs if not important,specially if Pt has a history of abortion or her
pregnancy was after a year of failur.
 Dental treatment is best carried out in the second trimester,( short vesits ).
 If the Pt has a syncope avoid supine position , put Pt on the left side.
 LA is safe.
 Avoid :ASA , NSAIDs,Corticosteroids,Codeine.
 If radiologe is issential Pt must wear a lead apron.
 High risk antibiotics: Doxicycline,Tetracycline,Clarythromycine.

Osteoporosis ‫هشاشة العظام‬


If the patient on Bisphosphonate treatment , he my has a bony necrosis after tooth extraction
Precautions :
- If patient on Bisphosphonate (tab) like: (Zolindronic Acid) : stop for 3 monthes before
teeth extraction
- If patient on Bisphosphonate (intravenous) , or he need emergency extraction , give
patient Antibiotic prophylactic prior to the oral surgery
‫يرجى النشر و لا تنسونا من دعائكم‬

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