High Risk

Patients
DR . NASHWAN NOMAN
CONSULTANT OF MAXILLOFACIAL SURGERY
Endocrine Disorders
Hyperthyroidism:
Thyroid gland is composed of two elongated
lobes on either side of the trachea.

Secretes:
That are joined by a thin isthmus of thyroid Thyroxin (T4)
tissue. Tri- Iodothryonine (T3)
Calcitonin

Located at or below the level of the thyroid

cartilage.

Hyperthyroidism T3 & TSH

Thyroid T4
Dysfunction T3 & TSH
Hypothyroidism
T4
C
A
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Oral Manifestations:

- If a suspicion of thyroid disease arises for an undiagnosed

patient, all elective dental treatment to put on hold untill full
Dental medical evaluation.
Consideration -Severe hyper function should receive immediate medical
consultation.

-Stress free appointment.

- LA without epinephrine preferred
- avoid epinephrine impregnated gingival retraction cord
Aspirin and other NSAIDs can increase the amount of circulating T 4
, making control of thyroid disease more difficult.
 Vascular phase : vasoconstriction.
Platelet phase : adhesion & aggregation,
Hemostasis to form a platelet plug
Coagulation phase: extrinsic, intrinsic and
common pathways to form a clot.
Bleeding disorders A bleeding tendency can be due to inherited or
acquired problems with vessel integrity, platelet numbers or
function or coagulation defects.
 Vascular disorders Vascular disorders present with easy bruising,
and bleeding into the skin and mucous membranes.
Congenital
 Hereditary haemorrhagic telangiectasia ‫( َت َو ُّس ُع ال ُّش َعيْرات‬Rendu-Osler-
Weber syndrome
 Congenital connective tissue disorders osteogenesis imperfecta,
Ehlers-Danlos disease syndrome, Marfan's syndrome)
Acquired
 Easy bruising syndrome benign and relatively common in women
 Senile purpura (perivascular atrophy)
 Corticosteroid therapy (due to perivascular atrophy)
 Autoimmune disorders (rheumatoid arthritis)
 Vasculitis ( post-infection type III hypersensitivity reactions)
 Severe infections (e.g. meningococcal meningitis, septicaemia)
 Scurvy (vitamin C deficiency
Platelet disorders
present with excessive bruising of skin and mucosae and spontaneous
(e.g. epistaxis, gingival bleeding) or prolonged (e.g. during surgery)
bleeding. Aspirin is a common cause of platelet dysfunction
Thrombocytopenia Production (bone marrow failure)
 Megaloblastic anaemia ‫َف ْق ُر ال َّد ِم الض َّْخ ُم األَرومات‬
 Aplastic ‫ ال تن ُّسجي‬anaemia (due to drugs [ cytotoxics chloramphenicol]
viruses, chemicals or irradiation)
 Tumours infiltrating the bone marrow (including leukaemias and
multiple myeloma)
 Autoimmune (idiopathic ) thrombocytopenia
 Other immune-mediated thrombocytopenias caused by:
 drugs (e.g. heparin may cause a type III hypersensitivity reaction)
 viruses (e.g. HIV)
 Systemic lupus erythematosus (SLE) ‫ِذ ْئ َب ٌة حُما ِمي ٌَّة‬
 post-transfusion purpura Splenomegaly ( to liver failure )
 Large transfusion of stored blood (dilution of platelets)
 Disseminated intravascular coagulation (DIC)consumption platelets
Thrombasthenia ‫( َو َهنُ ال ُص َفيحات‬platelet dysfunction)
 Drugs (lactam antibiotics cytotoxics NSAIDs
 [aspirin thromboxane platelet activation and aggregation])
 Inherited thrombasthenias (Glanzmann's syndrome )
 Myeloproliferative disorders
 Liver disease
 Chronic renal failure (uraemia platelet adhesion)
Management depends on the cause, and may involve
corticosteroids, splenectomy, IV immunoglobulins or
platelets
Coagulation disorders
i) Congenital
-Hemophilia A and B
-von Willebrand’s disease
-Other factor deficiencies (rare)
ii) Acquired
-Liver disease
-Vitamin K deficiency
- Anticoagulants. Hemophilia A - Deficient factor VIII :
Hemophilia B - Deficient factor IX
VWD - platelets and factor VIII
Vitamin K - dependent clotting
factors are factors II, VII, IX, and X,
warfarin prevents the formation of
vit K.
- All factors are made in the liver.
Coagulation disorders
Inherited
 Haemophilia A is an X-linked recessive disorder (it affects
males) characterized by deficiency of clotting factor VIII. It
usually manifests in childhood with bleeding into muscles and
joints.
 Haemophilia B (Christmas disease) is caused by deficiency
of clotting factor IX, is clinically similar to haemophilia A, but
10-fold less frequent.
 von Willebrand's disease (vWD) is caused by deficiency of
von Willebrand factor (vWF), which plays a role in platelet
function and as a carrier for factor VIII and is the most
common coagulation disorder.
 Bleeding is due to low factor VIII, and a platelet defect.
There are several subtypes of vWD, and the clinical features
are variable vWF or factor VIII replacement may be necessary
Acquired
 Anticoagulant treatment (with warfarin or heparin) is the
most common cause .
 Vitamin K deficiency (due to malabsorption .treatment with
antibiotics or inadequate stores [e.g. newborns]) leads to
factors II, VII, IX and X.
 Liver disease causes a combination of defects
 Alcohol abuse may damage the liver, and therefore produce
a coagulopathy, ّ‫اعْ ِتالَ ٌل َخ ْث ِري‬
 Hypersplenism , folate deficiency and bone marrow damage,
all of which can impair platelet formation.
 Disseminated intravascular coagulation (DIC) is a
complex condition, where a serious underlying pathology
(e.g. severe sepsis, malignancy, incompatible transfusion,
extensive trauma or surgery)
Anticoagulants
 used in the treatment of acute thrombotic episodes, and as
prophylaxis against thromboses in patients at risk.
Anticoagulant indications
 DVT (deep vein thrombosis) unstable angina, MI, cerebral
and peripheral arterial thrombosis prevention and treatment
 rheumatic heart disease and prosthetic heart valves;
prevention of embolization
 Peri and postoperative prophylaxis of DVT in high-risk
patients
Warfarin
 Warfarin is an anticoagulant given orally as a single daily
dose of 10 mg (usually at night).
 It is a vitamin K antagonist, reducing the liver production of
clotting factors II, VII, IX and X.
 Warfarin needs at least 48 h to reach its maximum effect
 Warfarin is used in outpatients for long-term prophylaxis
against thromboembolism.
 It has a The risk of haemorrhage becomes serious when INR
>8. In such cases, warfarin should be stopped and restarted
when INR <5.
 If there is another risk or evidence of bleeding, give vitamin K
5 mg orally or IV. Fresh frozen plasma may also be needed if
major bleeding occurs.
What is INR?
 The international normalized ratio of prothrombin time.
 Simply means the ratio of the patient PT to normal.
 INR of 1 means the PT time of the patient is the same as
the normal.
 INR of 2 means the PT time of the patient is twice the
normal.
 INR = Patient`s PT
Normal PT
 Prothrombin Time (PT) is normally 12-14 s.
INR – International normalized ratio.
Hematologic Problems
Hereditary coagulopathies .
 Patients with inherited bleeding disorders are usually aware of
their problems, allowing the clinician to take the necessary
precautions before any surgical procedure.
 all patients should be questioned concerning prolonged bleeding
after previous injuries and surgery.
 A history of epistaxis (nosebleeds) easy bruising hematuria
heavy menstrual bleeding
 presurgical laboratory coagulation screening or hematologist
consultation. A PT is used to test the extrinsic pathway factors
(II, V, VII, and X), whereas a PTT is used to detect intrinsic
 To better standardize PT values within and between hospitals,
the INR method was developed. This technique adjusts the
actual PT for variations in agents used to run the test, and the
value is presented as a ratio between the patient’s PT and a
standardized value from the same laboratory.
 Platelet inadequacy usually causes easy bruising and is
evaluated by a bleeding time and platelet count.
 The management of patients with coagulopathies who
require oral surgery depends on the nature of the bleeding
disorder.
 Specific factor deficiencies—such as hemophilia A, B, or C;
or von Willebrand’s disease—are usually managed by the
perioperative administration of coagulation factor
concentrates and by the use of an antifibrinolytic agent such
as aminocaproic acid (Amicar).
 The physician decides the form in which factor replacement
is given, on the basis of the degree of factor deficiency and
on the patient’s history of factor replacement.
 Patients who receive factor replacement sometimes contract
hepatitis virus or HIV. Therefore, appropriate staff protection
measures should be taken during surgery.
Management of Patient with a Coagulopathy*
1. Defer surgery until a hematologist is consulted about the
patient’s management.
2. Have baseline coagulation tests, as indicated (prothrombin time,
partial thromboplastin time, bleeding time, platelet count), and
screening for hepatitis performed.
3. Schedule the surgery in a manner that allows it to be performed
soon after any coagulation-correcting measures have been taken
(after platelet transfusion, factor replacement, or aminocaproic
acid administration).
4. Augment clotting during surgery with the use of topical
coagulation-promoting substances, sutures, and well-placed
pressure packs.
5. Monitor the wound for 2 hours ensure that good initial clot forms
6. Instruct the patient on ways to prevent dislodgment of the clot
7. Avoid prescribing nonsteroidal anti-inflammatory drugs NSAIDs
8. Take precautions against contracting hepatitis during surgery.
 Platelet problems may be quantitative or qualitative.
 Patients with a chronically low platelet count can be given platelet
transfusions. Counts must usually dip below 50,000/mm3 before
abnormal postoperative bleeding occurs.
 If the platelet count is between 20,000/mm3 and 50,000/mm3, the
hematologist may wish to withhold platelet transfusion until
postoperative bleeding becomes a problem. However, platelet
transfusions may be given to patients with counts higher than
50,000/mm3 if a qualitative platelet problem exists.
 Platelet counts under 20,000/mm3 usually require presurgical
platelet transfusion or a delay in surgery until platelet numbers rise.
 Local anesthesia should be given by local infiltration rather than
by field blocks to lessen the likelihood of damaging larger blood
vessels, which can lead to prolonged postinjection bleeding and
hematoma formation.
 Patient should be carefully instructed in ways to avoid dislodging
blood clots once they have formed
Therapeutic anticoagulation.
 administered to patients with thrombogenic implanted
devices such as prosthetic heart valves with thrombogenic
cardiovascular problems such as atrial fibrillation‫ رجفان أذيني‬or
after MI or with a need for extracorporeal blood flow such as
for hemodialysis.
 Patients may also take drugs with anticoagulant properties
such as aspirin, for secondary effect.
 Drugs such as low-dose aspirin do not usually need to be
withdrawn to allow routine surgery.
 Patients taking heparin usually can have their surgery
delayed until the circulating heparin is inactive (6 hours if IV
heparin is given, 24 hours if given subcutaneously).
 Protamine sulfate, which reverses the effects of heparin, can
also be used if emergency oral surgery cannot be deferred
until heparin is naturally inactivated.
 warfarin for anticoagulation and who need elective oral surgery
benefit from close cooperation between patient’s physician dentist.
 Warfarin has a 2- to 3-day delay in the onset of action; therefore,
alterations of warfarin anticoagulant effects appear several days
after the dose is changed.
 The INR is used to gauge the anticoagulant action of warfarin.
Most physicians will allow the INR to drop to about 2 during the
perioperative period, which usually allows sufficient coagulation
for safe surgery.
 Patients should stop taking warfarin 2 or 3 days before the planned
surgery. On the morning of surgery, the INR value should be
checked; if it is between 2 and 3 INR, routine oral surgery can be
performed.
 If the PT is still greater than 3 INR, surgery should be delayed until
the PT approaches 3 INR.
 Surgical wounds should be dressed with thrombogenic substances,
and patient should be given instruction in promotingclot retention.
 Warfarin therapy can be resumed the day of surgery
Management of Patient Whose Blood Is Therapeutically Anticoagulated
Patients Receiving Aspirin or Other Platelet-Inhibiting Drugs
 Consult the patient’s physician to determine the safety of stopping the
anticoagulant drug for several days.
 Defer surgery until the platelet-inhibiting drugs have been stopped for
5 days.
 Take extra measures during and after surgery to help promote clot
formation and retention.
 Restart drug therapy on the day after surgery if no bleeding is present
Patients Receiving Heparin
1. Consult the patient’s physician to determine the safety of
stopping heparin for the perioperative period.
2. Defer surgery until at least 6 hours after the heparin is stopped
or reverse heparin with protamine.
3. Restart heparin once a good clot has formed.
*If the patient’s physician believes it is unsafe to allow the PT to fall, the
patient must be hospitalized for conversion from warfarin to heparin
anticoagulation during the perioperative period.
 Patients Receiving Warfarin (Coumadin)
1. Consult the patient’s physician to determine the safety of
allowing the prothrombin time (PT) to fall to 2.0 to 3.0 INR
(international normalized ratio). May take a few days.*
2. Obtain the baseline PT.
3. (a) If the PT is less than 3.1 INR proceed with surgery and
skip to step 6. (b) If the PT is more than 3.0 INR, go to step 4.
4. Stop warfarin approximately 2 days before surgery.
5. Check the PT daily, and proceed with surgery on the day when
the PT falls to 3.0 INR.
6. Take extra measures during and after surgery to help promote
clot formation and retention.
7. Restart warfarin on the day of surgery.
 Appropriate investigations

 (PT) It is prolonged in patients, who are on warfarin

anticoagulant therapy, vit. K deficiency or deficiency of
factor V, VII, X, II,I.
 (PTT) It is prolonged in haemophiliacs.
 (BT) It is prolonged in thrombocytopenia, von
Willebrand´disease and platelet dysfunction.
 Coagulation mechanism
 Intrinsic clotting system:.
It will be increased by Heparin, hemophilia A and B.
PTT (Partial Thromboplastin Time) measures the
integrity of the interensic pathways prior to the
activivation of factor X and the activity of factors I,
II, V, VIII, IX, X, XI and XII and fibrinogen.
 Extrinsic clotting system:
The PT (Prothrombin Time) measures the function of
clotting factors V, VII, IX, X, II (prothrombin), and I
(fibrinogen). It will be increased by Warfarin, Vit. K
deficiency, Liver disease. Warfarin blocks vit. K use.
Clinical Evaluation of a Patient with a
Bleeding Disorder
History
 Family history of bleeding problems.
 Prolonged or persistent bleeding following
trivial trauma.
 Medication, e.g. aspirin, warfarin
 Chronic liver, vitamin K deficiency.
 Chronic alcoholism.
 Laboratory Test for Screening
 Bleeding Time 1-5 s. Normal bleeding time by
Ivy method is 2–9 min and by Duke's method
is 1– 3 min.
 hemoglobine 12/15 g/l
 hematocrite 37-47 woman 40-54 man
 Platelet Count (Plt) is normally 150,000-400.000mm3
 Prothrombin Time (PT) is normally 12-14 s.
INR – International normalized ratio.
 Partial Thromboplastin Time (PTT) 30-45 s.
Treatment of bleeding :
 in general the bleeding treatment is :
 * for topical trauma press locally for 5 minute .
 * press with swab cotton with adrenaline solution 5 minute .
 * if blood not stop use trombine powder on the trauma.
 * stitch if the wound is wide only .
 * acrylic plate which we do before operation .
 * blood transfusion fresh blood or dry plasma .
 - vitamin k and c injection .
 - cold compress .
 - tea bags{the tannic acid help to stop the bleeding} it use for the longer
time bleeding 2-3hours .
 *the best way is to be given factor viii before surgical procedures
 stitch must be nonresorable .
important note :
 don't write these analgesic for patient with
bleeding disorder :
 * aspirin .
 * indomethacine .
 * ketoprofine .
if you want to write analgesic you can write :
 * paracetamol .
 * codeine
 Hb (12/15 g/l)
 Hb is important for oxygen
transportation
 anemia may interfer the wound
healing
 elective oral surgery (dental
extraction) is contraindicated in
patients with hb less than 10 g/l
 DENTIST MANAGEMENT OF PATIENT WITH
THROMBOCYTOPENIA
 Physician consultation  If platelet count is less than
 If thrombocytopenia is caused 20000 cells/mm³ all dental
by a reversible process, dental procedures are
extractions should be deferred contraindicated
until the platelet count return
to normal
 If thrombocytopenia is
deemed irreversible the
management is according to
degree of thrombocytopenia
 DENTIST MANAGEMENT OF PATIENT WITH
THROMBOCYTOPENIA
Platelet count between Platelet count less than 50000 cells/mm³:
50000-100000 cell/mm³:  Platelets transfusion is
 Some clinical bleeding after necessary for dental
dental extraction procedures
 Platelet count should be
 Regional block injection can
be done safely optimized prior to local
anesthesia
 Atraumatic removal of 1 or
 Block anesthesia is
2 teeth can proceed contraindicated
(attention to hemostasis)
 Always physician
 Hemostatic local measures
control
 Major surgery under platelet
coverage(Hospital)
 Always physician control
LOCAL MEASURES TO HELP HEMOSTASIS

 COMPRESSIVE PACKING AND

DRESSING
 EXTRA SUTURES
 MICROFIBRILLAR
COLLAGEN HEMOSTAT
 4.8 TRANEXAMIC ACID
MOUTHWASH 10 ml 3-4 TIMES
FOR 7 DAYS
WHAT THE DENTIST DO TO CONTROL BLEEDING
AFTER DENTAL EXTRACTION IN
THROMBOCYTOPENIC PATIENT?

 ADDITIONAL PLATELET TRANSFUSION IS

NECESSARY (Physician consultation)
 TRANEXAMIC ACID TOPICALLY
 4.8 % TRANEXAMIC ACID MOUTHWASH, 10 ml
THREE TO FOUR TIMES A DAY FOR THREE TO
SEVEN DAYS
HEMOPHILIA A (classic)
Treatment include:
 Physician consultation
doses:
 Hospitalization
 amicar 5 g orally one hour
 Coverage under factor VIII
after extraction and 1 g every
concentrate (best)or
hour thereafter for six doses
 Fresh frozen plasma
 Tranexamic acid
 Epsilon- aminocaproic (cyaklokapron) 25 mg/kg
Acid (Amicar) every 6 hours, starting the
day prior to dental extraction
 Tranexamic Acid
and continued after surgery
 Local measures as for until bleeding stopped
thrombocytopenia
LEUKEMIA REFER TO A NUMBER OF
NEOPLASTIC DISESASES OF THE BLOOD-
FORMING ELEMENTS OF THE BODY
ORAL MANIFESTATIONS:
GENERAL
SYMPTONS: • gingival bleeding
• Insidious and • petechia
nonspecific ORAL SOFT TISSUE
• Fatigue OR GINGIVAL INFECTION
• Malaise • lymphadenopathy
• Fever • PHARINGITIS
Laboratory findings: Treatment:
 Chemotherapy
 Anemia
 Bone marrow
 Leukopenia
transplantation
 Neutropenia
 Thrombocytopenia
 Presence of blast forms in
the peripheral blood
 Bone marrow biopsy
(definitive diagnosis)
ACCORDING TO ORAL SURGICAL TREATMENT
THE prevention of infection and bleeding are the
major consideration

DENTAL MANAGEMENT:
 Physician consultation
 Elective dental extraction
are contraindicated
 When the patient is compensated
do the extraction
 Advisable the use of antibiotic
 Are malignancies of lymphoreticular origin
that most often involve the lymph nodes
 The most frequent is
Hodking’s disease
 The chemotherapy and
radiotherapy used in the
treatment usually affect the
mouth
 Children treated may have
altered growth and
development of head and neck
 oral surgery risk:
 during the chemotherapy or radiotherapy elective dental
extraction are contraindicated
 when the patient is compensated do dental extraction
 physician consultation
 keep in mind complications relating with radiotherapy
(osteoradionecrosis)
NOT HEALTHY TEETH IN THE LINE OF RADIATION
THERAPY SHOULD
BE REMOVED TO AVOID OSTEORADIONECRISIS
 acute viral hepatitis: all dental procederus should be
deferred until the active infection resolves
 chronic hepatitis: if there alteration in liver function
tests, platelet count pt and ptt . dental extractions should
be deferred
 cirrhosis: if there alteration in liver function tests,
platelet count pt and ptt dental extractions should be
deferred
 physician consultation is very important
 Hepatic Disorders:

Liver Disease cannot be ignored because of

Bleeding
tendencies

Impaired Liver Functions Leads to:

Drug 1. Abnormalities in Metabolic
Possible intolerance processes
viral 2. Abnormalities in Coagulation.
causes 3. Abnormalities in drug metabolism
Hepatic Disorders: Liver Cirrhosis:

Cirrhosis is a condition in which the liver does not function

properly due to long-term damage. This damage is characterized
by the replacement of normal liver tissue by scar tissue.

Causes: Signs & Symptoms

- Alcoholism - Bleeding tendency
- hepatitis B & C - Jaundice
infection, - Portal Hypotension
- Autoimmune hepatitis - Hepatosplenomegaly
- Hepatoxins - Ascites ‫ االستسقاء‬,‫الحبن‬
- Idiopatic ‫(تراكم السوائل في جوف البطن‬
- Jaundice
 -Minimize Drugs metabolised
in liver.
Dental
-Avoid hepatoxic drug
Management:
-LA is safe with small doses and
least concentration
- Medical Consultation
- Liver function test
- Coagulation screening profile
- Regulation of the bleeding
tendency
I. blood transfusion prior to
surgery if needed
II. Vit K injection 10 mg 1 hour
before and after surgery
Liver Hepatitis

 Condition :
- Inflammation of the liver cells
 Etiology :
1. primary Hepatitis
i. Viral hepatitis
ii. Toxic hepatitis
iii. Drug induced hepatitis
2. Secondary hepatitis
i. Syphilis
ii. TB
iii. Infective mononycleosis
Dental Management of liver
patients
 Protection for the practitioner:
- Difficult to identify carriers of HBV,
HCV, HDV. Most carriers are
unaware that they had hepatitis.

* Standard precaution
* HBN vaccination
* Post exposure prophylaxis
Patients with active Hepatitis

Acute viral hepatitis:

 No dental treatment other than urgent care should be
rendered for a patient with acute viral hepatitis
 Individuals still carry the virus up to 3 months after the
symptoms have disappeared, so any patient with a recent
history of hepatitis B should be treated for dental
emergency problems only

Carriers:
- Low risk Patients
- High Risk Patients
Hepatic Disorders
 The patient with severe liver damage resulting from infectious
disease, ethanol abuse, or vascular or biliary congestion requires
special consideration
 before oral surgery .An alteration of dose or avoidance of drugs
that require hepatic metabolism may be necessary.
 The production of vitamin K–dependent coagulation factors (II,
VII, IX, X) may be depressed in severe liver disease,
 international normalized ratio (INR; prothrombin time [PT]) or
partial thromboplastin time (PTT) may be useful before surgery
 patients with severe liver disease. Portal hypertension caused by
liver disease may also cause hyper splenism a sequestering of
platelets causing thrombocytopenia.
 Patients with severe liver dysfunction may require
hospitalization for dental surgery because their decreased ability
to metabolize the nitrogen in swallowed blood may cause
encephalopathy. ‫إعتالل دماغي‬
Management of Patient with Hepatic Insufficiency
1. Attempt to learn the cause of the liver problem; if the cause
is hepatitis B, take usual precautions.
2. Avoid drugs requiring hepatic metabolism or excretion; if
their use is necessary, modify the dose.
3. Screen patients with severe liver disease for bleeding
disorders by using tests for determining platelet count,
prothrombin time, partial thromboplastin time and bleeding
time.
4. Attempt to avoid situations in which the patient might
swallow large amounts of blood
 Appropriate investigations

 (PT) It is prolonged in patients, who are on warfarin

anticoagulant therapy, vit. K deficiency or deficiency of
factor V, VII, X, II,I.
 (PTT) It is prolonged in haemophiliacs.
 (BT) It is prolonged in thrombocytopenia, von
Willebrand´disease and platelet dysfunction.
 Neurological Disorders
 Seizure:
A Sudden excessive discharge of electrical
activity in the brain that usually causes a
change in behavior.

A symptom of an underlying disorder that affects the brain,

Causes:
- Hypoglycemia In Dental Clinic
- Drug induced (lidocaine) Most commonly seizures due to
- Acute Head Trauma - Hypoglycemia
- Brain tumors - Hypoxia secondary to syncope
- Brain Abscess - LA overdose
- Stroke - Seizure in epileptic patients
- Meningitis
- Alcohol intoxication
 Epilepsy:
Epilepsy:
 A neurologic disorder characterized Mostly occurs randomly
Trigerring factors
by sudden, transient, recurrent
- Missed a dose of antiepileptic drug -
disturbance of brain function that
- Flashing, flickering lights
may or may not be associated with
- Stress
impairment or loss of consciousness - Infection
and abnormal movements or - Dehydration or starvation
behavior.
Why is it concern to dentist
 The main problems in dental care of an
epileptic patient is:
 Convulsion and its sequel
 Drug reactions
 Psychiatric disorders
 Bleeding tendency caused by sodium
valporate
Dental Management of the Epileptic patient

 A good Case history: Ensure medications have been taken properly

– Type relative to dental appointments to minimiz risk
of seizure.
- Severity
- Frequency Ensure proper lighting ( No light directly on
eyes)
- Control
- When Diagnosed
- Last Seizure
- Precipitating factors
- List of medication the patient
is taking
When carrying out dental instrument in a
known epileptic patients- A strong prop should
be used
As much as possible, dental appratus should be
kept away from the working area around the
patient
Steps to minimize risk of injury during an epileptic seizure

 If it can be safely done, quickly

remove all foreign material from the
patient’s mouth

 The chair should be placed in a

supine position

 If possible, turn the patient to their

side in order to minimize aspiration
of foreign bodies or secretions

 Use passive restraint only to prevent

injury that may occur by the patient
hitting nearby objects or to prevent
them from falling out of the chair.
Neurologic Disorders Seizure disorders.
 Patients with a history of seizures should be questioned about
the frequency, type, duration, and sequelae of seizures.
 Seizures can result from ethanol withdrawal high fever
hypoglycemia or traumatic brain damage, or idiopathic.
 dentist should inquire about medications used to control the
seizure disorder, particularly about patient compliance and any
recent measurement of serum levels.
 patient’s physician should be consulted concerning the seizure
history and to establish whether oral surgery should be deferred
for any reason.
 If the seizure disorder is well controlled, standard oral surgical
care can be delivered without any further precautions (except
for the use of an anxiety-reduction protocol;.
 If good control cannot be obtained, the patient should be
referred to an oral-maxillofacial surgeon for treatment under
deep sedation in the office or hospital.
 Ethanol interacts with many of the sedatives used for anxiety
control during oral surgery.The interaction usually potentiates
the level of sedation and suppresses the gag reflex
 ethanol abusers may undergo withdrawal phenomenon in the
perioperative period if they have acutely lowered their daily
ethanol intake before seeking dental care.
 phenomenon may exhibit mild agitation, tremors, seizure,
diaphoresis, or, rarely, delirium tremens with hallucinations,
considerable agitation, and circulatory collapse.
 Patients requiring oral surgery who exhibit signs of severe
alcoholic liver disease or signs of ethanol withdrawal should be
treated in the hospital setting. Liver function tests, a coagulation
profile, and medical consultation before surgery are desirable.
 In patients who can be treated on an outpatient basis, the dose
of drugs metabolized in the liver should be altered, and the
patients should be monitored closely for signs of oversedation
Management of Patient with a
Seizure Disorder
1. Defer surgery until the seizures are well controlled.
2. Consider having serum levels of antiseizure medications
measured if patient compliance is questionable.
3. Use an anxiety-reduction protocol.
4. Take measures to avoid hypoglycemia and fatigue in the patient
Ethanolism (alcoholism).
 Patients volunteering a history of ethanol abuse or in whom
ethanolism is suspected and then confirmed through means
other than history taking require special consideration
 primary problems ethanol abusers have in relation to dental care
are hepatic insufficiency, ethanol and medication interaction,
and withdrawal phenomena
Pulmonary Problems:
Asthma
Asthma is a chronic inflammatory disorder of airways,
causes recurrent episodes of wheezing, breathlessness,
chest tightness and coughing, particularly at night or in
the early morning.

Sign & Symptoms

What happens in Asthama:

• Narrowing of bronchial airways

• Muscle spasm
• Mucosal swelling
• Thick bronchial secretion
• Inflammatory reaction
• Reversible.
 Dental Consideration in Asthmatic patients.

Use Technique to reduce patient stress

Avoid Prolonged Supine positioning
Analgesic of choice : paracetamol
Avoid ibuprofen, Aspirin
Avoid using LA containg Sodium Metabisulfide.

Prophylaxis for adrenal insufficiency, if the patient is under steriod treatment.

 Pulmonary Problems:
Chronic obstructive pulmonary disease (COPD)

A condition in which :
-The lungs have become permanently altered.
-The airways in the lungs are constantly narrowed.
- Chronic inflammation creates difficulty breathing.

COPD causes airway

narrowing, inflammation
and mucous production
 Chronic bronchitis and Emphysema are the two most common
conditions that make up COPD

―Chronic bronchitis" is defined a productive

cough that is present for at least three months
each year for two years.

“Emphysema“ is a chronic, irreversible

disease of the lungs characterized by
abnormal enlargement of air spaces in the
lungs accompanied by destruction of the
tissue lining the walls of the air spaces.
 Dental Consideration

1. Schedule afternoon appointment to allow

for respiratory clearance.

2. Stress reduction protocol

3. Avoid premedication with narcotics ‫م َُخ ِّدر‬

or barbiturates ‫ ُم َه ِّدئ‬as they are respiratory
depressants. ‫م َُخمِّد‬

4. Keep bronchodilator inhaler accessible

5. Place the patient in the dental chair in an

upright position
Dental Consideration

6. Avoid bilateral palatal or mandibular nerve blocks to

avoid the senstaion of respiratory obstructions.

7. Prophylaxis for adrenal insufficiency, if the patient is

under steriod treatment.

8. Avoid antihistaminics & atropine as they lead to dry

mouth and increase mucous production
Pulmonary Problems Asthma.
 When a patient has a history of asthma, the dentist should
first determine, through further problem such as allergic
rhinitis that carries less significance for dental care.
 True asthma involves the episodic narrowing of inflamed
small airways, which produces wheezing and dyspnea as a
result of chemical, infectious, immunologic, or emotional
stimulation, or a combination
 Patients with asthma should be questioned about
precipitating factors, frequency and severity of attacks,
medications used, and response to medications..
 should be questioned about aspirin allergy because of the
relatively high frequency of generalized nonsteroidal anti-
inflammatory drug (NSAID) allergy in those with asthma.
 Patients with severe asthma require xanthine-derived
bronchodilators such as theophylline - corticosteroids.
 Cromolyn may be used to protect against acute attacks, but it is
ineffective once bronchospasm occurs.
 Many patients carry sympathomimetic amines such as epinephrine or
metaproterenol in an aerosol form that can be self administered if
wheezing occurs.
 Oral surgical management patient with asthma involves recognition of
the role of anxiety in bronchospasm initiation and of potential adrenal
suppression in patients receiving corticosteroid therapy.
 Elective oral surgery should be deferred if a respiratory tract infection
or wheezing is present.
 When surgery is performed, an anxiety-reduction protocol should be
followed; if the patient takes steroids, the patient’s consulted about
possible need for corticosteroid augmentation during perioperative
 Nitrous oxide is safe to administer to persons with asthma and is
especially indicated for patients whose asthma is triggered anxiety.
 The patient’s own inhaler should be available during surgery,
 epinephrine and theophylline should be kept in an emergency
 NSAIDs should be avoided because they often precipitate asthma
 Renal Diseases: Renal Failure
Kidney Transplant

Kidneys Overview:
- Regulate fluid volume & acid base balance of the plasma
- Excrete nitrogenous waste
- Synthesize erythropoietin ‫ مادة تنظم إنتاج كريات الدم الحمراء‬,‫إريثروبويتين‬
- Drug metabolism
- They are target organs for parathormone & Aldosterone‫ينتج الكظرية‬

― Bones can break, muscles can atrophy, glands can loaf, even the
brain can go to sleep without immediate danger to survival. But –
should kidneys fail…. Neither bone, muscle, nor brain could carry
on‖.
Homer Smith
Clinical features
Loss of weight
Anemia
Hypertension
Congestive heart failure
Acidosis
Pulmonary edema
Elevated serum creatinine 9 0.6 – 1.2 mg / 100 ml blood
Elevated BUN ( blood urea nitogen) ( 8-23 mg)
Oral manifestations: Medical Management:
Stomatitis Artificial blood filtration (
Parotitis dialysis)
Urine like odour in Kidney transplantation
breath
 Renal Hemodialysis:
Dental Management consideration:
 Medical Consultation
 Stress Reduction Protocol
 Avoid drugs excreted through the kidneys
 Avoid nephrotoxic drugs
 Prophylactic antibiotics
 High infection control measures.
 Dental treatment is best carried out on the day after dialysis ( the
effect of heparin worn off, if on same day ( not before 4 hours)
 Least traumatic surgery ( CRF patient have bleeding tendency &
are on anticoagulants )
 Least amount of LA
Renal Transplant

Dental Management consideration

 Medical Consultation
 Stress Reduction Protocol
 Regulation of corticosteroids ( may need steroid
supplements)
 Avoid nephrotoxic drugs
 Prophylactic antibiotics
 High infection control measures ( patients are
immucompromised).
 Carriage of hepatitis is common, patient should be
kept away from sources of infection.
Drug Therapy in Renal
Diseases
Item To be Avoided Preferable

Analgesic Aspirin Paracetamol

NSAIDs
Antibiotics Cephalosporens Erythromycin
Tetracycline Clindamycin
Metronidazole
Anesthesia Procaine Lidocaine
Renal failure.
 Patients with chronic renal failure require periodic renal dialysis.
 Chronic dialysis treatment typically requires the presence of an
arteriovenous shunt ( large, surgically created junction between an
artery and vein) which allows easy vascular access and heparin
administration, allowing blood to move through the dialysis
equipment without clotting.
 The dentist should never use the shunt for venous access except in
a life-threatening emergency.
 Elective oral surgery is best undertaken the day after a dialysis
treatment has been performed. This allows the heparin used during
dialysis to disappear and the patient to be in the best physiologic
status with respect to intravascular volume and metabolic
byproducts.
 Drugs that depend on renal metabolism or excretion should be
avoided or used in modified doses to prevent systemic toxicity.
 Drugs removed during dialysis will also necessitate special dosing
regimens.
 Relatively nephrotoxic drugs such as NSAIDs should also be
avoided in patients with seriously compromised kidneys.
 Because of the higher incidence of hepatitis in patients
undergoing renal dialysis, dentists should take the necessary
precautions
Management of Patient with Renal Insufficiency and Patient
Receiving Hemodialysis
1. Avoid the use of drugs that depend on renal metabolism or
excretion. Modify the dose if such drugs are necessary. Do not use
atrioventricular shunt for giving drugs or taking blood specimens
2. Avoid the use of nephrotoxic drugs such as drugs (NSAIDs).
3. Defer dental care until the day after dialysis has been given.
4. Consult the patient’s physician about the use of prophylactic
antibiotics.
5. Monitor blood pressure and heart rate.
6. Look for signs of secondary hyperparathyroidism.
7. Consider screening for hepatitis B virus before dental treatment.
 DENTIST APPROACH FOR PATIENTS
WITH CHRONIC RENAL INSUFFICIENCY

 If there significant hypertension dental extraction should

be deferred
 The dentist should be aware of the thrombocytopathy
associated with CRI
 Take care with drug that are excreted by the kidneys
 Physician consultation
 DENTAL PROPHYLASIS
IN HEMODIALAYSIS PATIENTS

 In general patients with arteriovenous fistula not require

antibiotic prophylaxis
 Patients with graft and indwelling catheter have a high
risk of infection of the access devices from bacteriemia
and should receive antibiotic prophylaxis