What is the importance of taking a

MEDICAL HISTORY?
• INTRODUCTION:
Why should I bother a medical history?
Evaluation of patient’s medical status:
Reasons for Evaluation.
Components of Evaluation.

• MEDICAL HISTORY:
Importance.
Evaluation goals.
Medical history questionnaire.
 EVALUATION AND MANAGEMENT OF THE PATIENTS
WITH VARIOUS SYSTEMIC DISEASES.
• CARDIOVASCULAR SYSTEM:
Hypertension.
Coronary heart disease.
Angina Pectoris.
Myocardial Infarction.
Congestive Heart Failure.
Arrhythmia.
Patients at risk for Bacterial Endocarditis.
- Bacterial Endocarditis.
- Patients undergoing Cardiac Surgery.
- Patient who has undergone Cardiac Surgery.
• PATIENTS WITH PULMONARY DISEASE.
Asthma.
Chronic Obstructive Pulmonary Disease.
Tuberculosis.
• PATIENTS WITH GASTROINTESTINAL DISEASE:
Peptic Ulcer Disease.
Hepatitis.
• PATIENTS WITH ENDOCRINE DISEASE AND
MANAGEMNET OF PREGNANT PATIENT:
Diabetes Mellitus.
Thyroid disorders.
Pregnancy.
• PATIENTS WITH NEUROLOGICAL DISEASE:
Seizure Disorders.
• PATIENTS WITH CHRONIC RENAL FAILURE, DIALYSIS &
TRANSPLANTATION.
• ACQUIRED IMMUNO DEFICIENCY SYNDROME.
• CONCLUSION.
• REFERENCES.
Why should I bother a MEDICAL
HISTORY?
• “Dentists are now concerned not with the treatment of teeth in patients but the
treatment of patients who have teeth”.
MORRIS 1967

• The objective of the medical history and patient assessment is to determine

whether the patient is fit to undergo dental treatment and whether any drug or
anesthesia is contraindicated.

• NO PATIENT SHOULD SUFFER ANY DETORIATION OF HEALTH AS A

RESULT OF DENTAL TREATMENT.
• THE PREVALENCEOF MEDICAL DISORDERS THAT MIGHT AFFECT
DENTAL TREATMENT IS RELATIVELY HIGH.

• Mc Lundie et. al. (1969) for example, found that of the 2500 patients attending
the conservative or prosthetic departments of a dental hospital, 34% gave a
history of prolonged bleeding and 48% had respiratory disorders.

• Among 4785 dental patients, 8% were known to be hypertensive, but

measurements of the blood pressure at the dental clinic showed a further 7% were
hypertensive (Halpern, 1975).

• Blood and urine glucose levels may be abnormal in 5% or more of dental patients
(Falace, 1978) and screening may detect unsuspected diabetes mellitus.
• It is therefore essential to establish as clearly as possible within the practical
limitations of dental practice, the presence and significance of medical problems
likely to affect dental treatment.

• Good preoperative assessment endeavors to anticipate and prevent trouble.

• Morbidity and mortality following minor dental operations is even less excusable
than that caused by more serious surgery.
 EVALUATION OF PATIENTS MEDICAL STATUS:

The history and physical examination produce a comprehensive evaluation of the

patient’s medical status.

Every practicing dentist and the auxiliary staff are responsible for identifying any
patient who may be a potential medical risk by performing a comprehensive
pretreatment physical evaluation.
 REASONS FOR EVALUATION:

1) To identify patients with undetected systemic disease that could be a serious

threat to the life of the patient or that could be complicated by dental treatment.
2) To identify patients who are taking drugs or medication that could be potentiated
by drugs prescribed by the dentist, that would complicate dental therapy, or that
may serve as a clue to an underlying systemic disease that the patient has omitted
from the history.
3) To allow the dentist to modify the treatment plan in light of any systemic disease
the patient may have or any drug he may be taking.
4) To protect the dentist and the patient from any malpractice (or allegations
thereof).
5) To enable the dentist to select and confer with a medical consultant about a
patient’s possible systemic problems.
6) To help establish a good patient-doctor relationship by showing the patients that
the dentist is interested in them as individuals and that the dentist is concerned
about their overall well being.
 Goals for physical evaluation:

 Determine the patient’s ability to physically tolerate the stress involved in the
planned treatment.

 Determine the patient’s ability to psychologically tolerate the stress involved in

the planned treatment.

 Determine whether treatment modifications are required to enable the patient to

better tolerate the stress involved in the planned treatment.

 Determine whether the use of psycho sedation is warranted.

a) determine which sedation technique is most appropriate.
b) determine whether contraindications exist to any of the drugs to be used in
planned treatment.
 Importance of PHYSICAL EVALUATION:

• According to Mc Carthy, a complete system of physical evaluation for all

prospective dental patients can prevent approximately 90% of the life threatening
situations.

• Goldberg stated, “when you prepare for the emergency, the emergency ceases to
exist”.

• Prior knowledge of a patient’s physical condition enables the doctor to

incorporate modifications into the planned dental treatment. In other words, “To
be forewarned is to be forearmed”.
• Many if not most patients with preexisting medical conditions are less able to
tolerate the usual levels of stress associated with dental treatment. These
patients are more likely to undergo acute exacerbations of their preexisting
condition when exposed to such stress.

• Although most patients are able to tolerate dental treatment, the doctor must
determine before treatment begins,
1) The potential problem.
2) The level of severity.
3) The potential effect of the planned dental treatment.

The medically compromised patient also benefits from treatment modifications

aimed at the minimization of stress.
 Components of Evaluation.

Medical history.
Physical evaluation.
Laboratory status (if indicated).
Medical/dental consultation or referral.
 Medical History:
• The most useful aspect of assessment is the medical history. This must be
accurate and also concise and systematically applied in order to ensure that the
maximum success is derived.
• Many such systems are available.
• In one such system the history is reduced to eleven routine questions (A to L) as
follows.
Anemia
Bleeding disorders.
Cardio respiratory disorders.
Drug treatment and allergies.
Endocrine disorders.
Fits or faints.
Gastrointestinal disorders.
Hospital admissions and attendances.
Jaundice or liver disease.
Kidney disorders.
Likelihood of pregnancy.
• Two basic methods for obtaining a medical history
are :
THE MEDICAL HISTORY QUESTIONNAIRE and
THE PERSONAL DIALOGUE INTERVIEW.
 MEDICAL HISTORY QUESTIONNAIRE:

- It is a legitimate method of securing data if used in conjunction with a dialogue.

- It may help a patient recall frequently used medications or various symptoms of
the disease.
- The questionnaire component also can assist the dentist in ascertaining which
areas in the dialogue history to emphasize and explore further.
- More importantly a completed and dated form, signed by the patient may be used
as evidence in any possible malpractice litigation.
• Many questionnaire forms are available. Most of them are simply
modifications of
 The American Dental Association (ADA) SHORT FORM
MEDICAL HISTORY and
 The ADA LONG FORM MEDICAL HISTORY.
 MEDICAL HISTORY QUESTIONNAIRE:

1) Are you having pain or discomfort at this time? Y N

2) Do you feel very nervous about having dental
treatment? Y N
3) Have you ever had a bad experience in a dental
office? Y N
4) Have you been hospitalized during the past 2 years? Y N
5) Have you been under the care of a medical doctor
during the past 2 years? Y N
6) Have you taken any medicine or drugs during the
past two years? Y N
7) Are you allergic to (that is, experiencing itching,
rashes, swelling of the hands, feet or eyes) or made
sick by penicillin, aspirin, codeine or any drugs or
medication? Y N
8) Have you ever had any excessive bleeding requiring
special treatment? Y N
9) circle any of the following that you have had or have
at present
Heart Failure Heart surgery
Heart disease or attack Artificial joint
Angina pectoris Anemia
High blood pressure Stroke
Heart murmur
Kidney trouble
Rheumatic fever
Congenital heart lesions Ulcers
Scarlet fever Emphysema
Artificial heart valve Cough
Heart pacemaker Tuberculosis
Asthma Liver disease
Hay fever Yellow jaundice
Sinus trouble Blood transfusion
Allergies Drug addiction
Diabetes Hemophilia
Thyroid disease Venal disease (syphilis, gonorrhea)
X Ray or cobalt treatment Cold sores
Chemotherapy(cancer/leukemia) Genital Herpes
Arthritis Epilepsy or seizures
Rheumatism Fainting or dizzy spells
Cortisone medicine Nervousness
Glaucoma Psychiatric treatment
Pain in jaws or joints Sickle cell disease
AIDS Bruise early.
Hepatitis A
Hepatitis B
10) When you walk upstairs or take a walk, do you ever
have to stop because of pain in your chest, shortness
of breath, or extreme fatigue? Y N
11) Do your ankles swell during the day? Y N
12) Do you use more than two pillows to sleep? Y N
13) Have you lost or gained more than 10 pounds in the
last year? Y N
14) Do you ever awaken short of breath? Y N
15) Are you on a special diet? Y N
16) Has your medical doctor ever said you have a cancer
or tumor? Y N
17) Do you have any disease, condition, or problem not
listed here? Y N
18) WOMEN Are you pregnant now? Y N
Are you practicing birth control? Y N
Do you anticipate becoming pregnant? Y N

To the best of my knowledge, all the preceding answers are true and
correct. If I have any change in my health, or if my medicines
change, I will inform the doctor of dentistry at the
next appointment with out fail

Date: Faculty signature Signature of Patient,

Parent or Guardian
 Updating the questionnaire

1) Have you experienced any change in your general health since the last visit?
2) Are you under the care of a medical doctor? If so, what is the condition being
treated?
3) Are you currently taking any drugs or medications?

If any of these questions elicits a positive response, a detailed dialogue history

should follow.
• Although the medical history questionnaire is extremely important in the overall
assessment of a patient’s physical status, it does have some limitations.
• For health history to be valuable, patients must
1) Be aware of their own states of health and any medical condition and
2) Be willing to share this information with the dentist.

• Most patients do not knowingly deceive the dentist by omitting important

information from their medical history questionnaire, but such cases have been
recorded.

• The more likely cause of unintentional misinformation is that the patient is

unaware that a problem exists.

• Because of these problems, patient-completed questionnaire is not always

reliable, the doctor must seek additional sources for information concerning the
patient’s physical status.
 A PERSONAL HISTORY ELICITED BY
DIALOGUE:

- To evaluate the patient’s mental status in a nonthreatening atmosphere.

- To evaluate patient’s present health status, medical history, allergies, medications

and the like.

- To determine the patient’s physical and emotional ability to tolerate dental

treatment.

- To identify any condition that might compromise the patients wellbeing during
therapy.

- Must assure the dentist that the treatment may be carried out with relative safety;
if this is not the case, medical consultation must be obtained before instituting any
treatment.
 Considerations in Endodontics:

• Prior to endodontic surgery, identification of all the existing medical

complications and associated drug therapy is necessary.

• Once satisfied that all necessary information is known, an assessment of the risk
status of the patient is made and the requirements for treatment modifications are
determined.

• Treatment modifications involve any alteration from the routine treatment

regimen provided for a normal healthy adult patient.
This may include:
- alteration in drug therapy.
- preoperative and intraoperative sedation or
- the ultimate modification, the decision that the risk factor makes endodontic
surgery contraindicated.
• A common modification of treatment involves pain, anxiety, and stress reduction.

• Although stress reduction procedures are a part of the routine treatment regimen,
many medically compromised patients require more intensive procedures.

• Pain is increased by anxiety and stress and, conversely, anxiety and stress are
generally intensified by pain. The importance of these interrelated elements
should never be underestimated, particularly in medically compromised patients.
 STRESS REDUCTION PROTOCOL:

• The following STRESS REDUCTION PROTOCOL is recommended for

compromised patients who are particularly susceptible to the PAIN-
ANXIETY-STRESS COMPLEX and require endodontic therapy.

1) Instill professional confidence.

2) Avoid or minimize pain.
3) Administer preoperative sedation.
4) Administer intraoperative sedation.
5) Schedule surgery for mornings.
6) Accomplish surgical procedure expeditiously.
7) Avoid surprises.
8) Ensure postsurgical pain, anxiety and stress control.
9) Schedule a postsurgical evaluation appointment.
 DENTAL PROCEDURE CATEGORIES:

NON SURGICAL PROCEDURES:

Type I: examination/ radiographs, oral hygiene instructions, study
model impressions.
Type II: simple operative dentistry, prophylaxis (supragingival),
orthodontics.
Type III: advanced operative dentistry, scaling and root planing
(subgingival), Endodontics.
SURGICAL PROCEDURES:
Type IV: simple extractions, curretage/gingivoplasty.
Type V: multiple extractions, flap surgery or gingivectomy,
extraction of simple bony impaction, apiceoctomy,
simple implant placement.
Type VI: full arch/mouth extractions or flap surgery, extraction of
multiple bony impactions, orthognathic surgery, multiple
implant placement.
CARDIOVASCULAR
SYSTEM
 SYSTEMIC HYPERTENSION

GENERAL INFORMATION:
The WHO defines hypertension as a casual blood pressure higher than 160/96 mm
Hg. Blood pressures between 140/90 and 160/95 mm Hg are categorized as
borderline hypertension, and pressures less than 140/90 mm Hg are considered
normotensive.

o Essential Hypertension: Most hypertensive patients (90-95%) have no medically

detectable cause for their disease.
o Secondary Hypertension: others have known underlying systemic cause (renal,
neurological, endocrine, vascular, or metabolic diseases) in which hypertension is
a secondary complication

Hypertension adversely affects the host by accelerating atherosclerosis.

• Epidemiological studies have demonstrated that untreated moderate hypertension
is associated with increased morbidity and mortality from Cerebrovascular
disease, peripheral vascular disease, renal disease and cardiovascular disease.
Control of hypertension is effective in the prevention of the same.

• Blood pressure levels stay within a fairly normal range with almost all activities
but varies normally so that it generally is lowest at night and highest in mild late
morning.

• Anxiety, pain, exercise and tenseness transiently raise the pressure, where as
relaxation, prolonged bed rest and sleep lower it.
• MEDICAL EVALUATION: Early symptoms of hypertension include headaches,
dizziness, failing vision, tinnitus, and occasional paresthesia (tingling) of the
extremities.
• Sustained hypertension may lead to serious complications including congestive
heart failure, ischemic heart disease, myocardial infarction, Cerebrovascular
accident, and renal failure.

• MEDICAL MANAGEMENT is aimed at achieving a normal or near normal

blood pressure through drug therapy, diet restrictions, weight loss, exercise, and
stress reduction.
• These patients may be taking diuretics, adrenergic blocking agents, vasodilators,
angiotensin-converting enzyme inhibitors, or other antihypertensive drugs.
Additionally, long term hypertensive patients are often receiving several other
drugs for associated disorders (ischemic heart disease, renal impairment, etc.).
 DENTAL EVALUATION:

• DENTISTS should play a major role in the detection of hypertension, because

they routinely see patients for multiple visits and semiannual checkups.

• The dentist should also know how hypertension can complicate dental therapy.

• Poorly controlled hypertension may actually elevate blood pressure during

stressful situations and precipitate angina, congestive heart failure or, rarely a
cerebrovascular event (e.g. stroke, hemorrhage).

• Careful attention to the blood pressure prior to the dental procedure minimizes the
risk of developing these problems.
• A dentist can assess the severity of a patient’s hypertension by means of a
medical history, a physical examination and consultation with patient’s
physician.

• MEDICAL HISTORY: The dentist should determine

1) The time of diagnosis.
2) Past and present treatment.
3) Complications: Cerebrovascular disease
Renal disease
Coronary heart disease.
4) About the types and dosages of current medications and especially more recent
changes in regimen.
 COMMONLY USED ANTIHYPERTENSIVE DRUGS:

1) DIURETICS: 5) ALPHA BLOCKERS:

- Chlorothiazide -Prazosin
- Hydrochlorothiazide -Terazosin
- Furosemide -Doxazosin
2) BETA BLOCKERS:
- Propranalol
6) DIRECT VASODILATORS:
- Metoprolol
-Hydralazine
- Atenolol
-Minoxidil
3) ANGIOTENSIN CONVERTING
ENZYME INHIBITORS: -Guanethidine.
- Captopril
- Enalapril 7) CENTRAL ALPHA II BLOCKERS AND
- Lisinopril OTHER CENTARLLY ACTING DRUGS:
-Clonidine
4) CALCIUM CHANNEL BLOCKERS:
- -Alpha methyl dopa
Nifedepine
- -Reserpine.
Verapamil
- Diltiazem
- Amlodipine
Common side effects of ANTIHYPRTTENSIVE medications:

MEDICATIONS SIDE EFFECTS

Diuretics Dehydration, hypokalemia
Methyldopa Drowsiness, impotence
Propranalol Bronchospasm, Congestive Heart Failure in some patients.

Clonidine Xerostomia, rebound hypertension

Reserpine Sedation, depression
Guanithidine Postural hypertension, diarrhea.
Calcium channel Gingival hyperplasia
blockers

Converting enzyme Chronic cough

inhibitors
• During the initial examination in the dental office, each new patient should have
the blood pressure recorded. All readings in the excess of 140/90 mm Hg should
be repeated at subsequent visits.

• The following categories are reasonable guidelines for the dentist

Normal ----------------------- 120/80 mm Hg

Controlled --------------------- up to 140/ up to 90 mm Hg
Mild Hypertension ----------- 140-160/90-105 mm Hg
Moderate Hypertension -- 160-170/105-115 mm Hg
Severe Hypertension ------ 170-190/115-125 mm Hg
Malignant Hypertension -- severe hypertension
(190+/125+) associated with CNS
symptoms such as blurring of
vision, headache, or
changes in mental status.
 DENTAL MANAGEMENT:

Once the severity of hypertension is established, the dentist may formulate the dental treatment
plan.
Patient

History
No history of hypertension History of hypertension

Blood Pressure Blood Pressure

Normal Systolic > 140 mm Hg Normal Mild (140-160/90-105)

Diastolic > 90 mm Hg medical consultation +/_
sedation for surgery (Type V-VI)
normal Refer to Physician. Normal Moderate (160-170/105-115)
protocol protocol medical consultation +
sedation for minor surgery (Type IV)
hospitalization (Type V- VI)
Severe ( 170-190/115-125)
medical consultation, Type I only
Defer all other care.
 CORONARY HEART DISEASE:

• Coronary Heart Disease is the most common form of heart disease and the single
most important cause of premature death in most of the countries.

• Diseases of the coronary arteries is almost always due to atheroma and its
complications, particularly thrombosis.

• Atherosclerosis is a disease of unknown cause, yet it represents the most common

pathophysiologic etiology of cardiovascular, cerebrovascular, and peripheral
vascular diseases.
• At the tissue level, atherosclerosis is caused by the accumulation of lipids in the
walls of the arteries.

• IMPACT: accumulations of “atheromatous plaques” encroach on the vascular

lumen, limiting the blood flow to the affected organs. These atheromatic plaques
also act as a potential site for thrombosis (blood clot formation) and embolism.
CHD: CLINICAL MANIFESTATIONS AND PATHOLOGY

CLINICAL PROBLEM PATHOLOGY

STABLE ANGINA Ischemia due to fixed atheromatous stenosis of one or more

coronary arteries.

UNSTABLE ANGINA Ischemia caused by dynamic obstruction of a coronary artery due

to plaque rupture with superimposed thrombosis and spasm.

MYOCARDIAL Myocardial necrosis caused by acute occlusion of coronary artery

INFARCTION due to plaque rupture and thrombosis.

HEART FAILURE Myocardial dysfunction due to infarction or ischemia.

ARRHTTHMIA Altered conduction due to ischemia or infarction.

SUDDEN DEATH Ventricular arrhythmia, asystole or massive myocardial infarction.

 ANGINA PECTORIS

GENERAL INFORMATION
 Angina Pectoris is a form of symptomatic ischemic heart disease. The underlying
pathology is a transient myocardial oxygen demand in excess of the available
oxygen supply for the coronary vessels.

 In most of the cases, atherosclerotic obstruction of one or more of the three major
coronary arteries is the causative factor. Less frequently, Angina can result from
excess oxygen demand, limited oxygen carrying capacity of the blood (e. g.
anemia), or inadequate perfusion of the coronary arteries (e. g. hypertension).
 Angina Pectoris literally means “Compression of the chest”.

 A classic case of angina is precipitated by emotional stress or physical exertion

and is relieved by rest.

 During an anginal attack, the typical patient shows signs of anxiety.

 He or she is unable to point exactly to the source of discomfort but often closes
the fist over the sternum in an attempt to describe pain. The pain is often
described as a heavy sensation over the precordial area and can radiate to the
shoulders, arms, or mandible. It is usually of brief duration, lasting 2 or 5 minutes
if the precipitating factor is removed. In contrast, the pain associated with
myocardial infarction is usually more severe.

 It is often described by the patient as crushing in nature, and is poorly and

incompletely relieved by sublingual nitroglycerin.
 COMMONLY USED DRUGS IN ANGINA PECTORIS:

1) ANTIPLATELET THERAPY- Aspirin

2) ANTI-ANGINAL DRUG TREATMENT-
- NITRATES: reduces myocardial oxygen demand by acting directly on the
vascular smooth muscles to produce venous and arteriolar dilatation.
Nitroglycerin (glyceryl trinitrate), Isosorbide dinitrate.

- BETA BLOCKERS: lower myocardial oxygen demand by reducing heart rate,

blood pressure and myocardial contractility
Atenolol, Metoprolol, Propranolol

- CALCIUM ANTAGONISTS: lower myocardial oxygen demand by reducing

blood pressure and myocardial contractility.
Nefidipine, Nicardapine, Amlodipine.
 COMMON SIDE EFFECTS OF ANGINA PECTORIS
MEDICATIONS:

1) NITROGLYCERIN:
- headache, postural hypotension, tachycardia, tolerance (develops at more than
10 doses/day).
2) LONG ACTING NITRATES:
- Headache, hypotension
3) PROPRANOLOL:
- Bradycardia (heart rate 55-65 per minute is the therapeutic range).
- Precipitates congestive heart failure with borderline ventricular function.
- Aggravation of bronchospasm in patients with mild asthma.
- Rapid Propranalol therapy withdrawal (exacerbation of angina, precipitation of
myocardial infarction).
 DENTAL EVALUATION:

An assessment of the severity of the patient’s angina generally facilitates optimal patient
management.
• The major concern of the dentist in the management of the patient with angina is the
possibility of precipitating an anginal attack during dental procedures.
• MEDICAL HISTORY: The dental evaluation of the patient can be accompanied by
taking a chair side history.
1) General information: presence of these factors must be determined.
- obesity, sedentary life style, psychosocial tension, family history of premature
myocardial infarction.
2) Specific information:
- frequency of angina attacks: (daily, weekly, monthly)
- stability: frequency or severity of attacks changing?
precipitating events less stressful?
- medications: nitroglycerin, long acting nitrates, beta blockers & Ca channel blockers.
- use of medications: recent change in dosage
- presence of other risk factors of ischemic heart disease: smoking,
hypertension, hyperlipidemia, diabetes.
3) Medical consultation:
Additional high risk factors determined by the patient’s
examination:
- left ventricular compromise (clinical evidence of
Congestive heart failure, radiographic evidence of
cardiac enlargement).
- ECG abnormalities (e. g. premature ventricular
contractions, arrhythmias).
 MILD MODERATE ANGINA SEVERE ANGINA
ANGINA
1) FREQUENCY UP TO UP TO 1/WEEK DAILY EPISODES
OF ATTACKS 1/MOnth
2) STABILITY STABLE STABLE UNSTABLE
3) CHANGING None Slight increase over Change in last 6
FREQUENCY previous year or more months.
distant past.
4) ONSET Following Following moderate Following rest,
severe exertion exertion or emotion or decreasing or mild
or emotion. (infrequently) meals emotion or exertion &
meals (frequently)
5) Nitroglycerin Nitroglycerin; long acting Same as moderate
MEDICATIONS nitrates, beta blockers; Ca
channel blockers

6) MEDICAL - - Left ventricular

Consultation compromise, ECG
abnormalities.
 DENTAL MANAGEMENT:

• It is important to know how to treat an acute episode of angina, but the first
priority is to anticipate and avoid attacks.

• Careful assessment of the patient’s angina permits the development of an

integrated medical and dental treatment plan.

• In general, good patient rapport and short appointments minimize the risk of
precipitating angina.
RISK CATEGORY PROCEDURES PROTOCOL
MILD RISK I, II, (II, III) - Normal protocol
(III, IV), V VI - +/- sedation techniques
MODERATE RISK I, (II) - Normal protocol +/- medical consultation.
(II), III, IV - Prophylactic nitroglycerin +/- sedation.
V, VI - Prophylactic nitroglycerin, sedation
techniques +/- hospitalization.

SEVERE RISK I - Normal protocol +/- medical consultation.

II - Prophylactic nitroglycerin +/- sedation.
III, IV -Prophylactic nitroglycerin +/-
sedation +/- hospitalization.
V, VI - Hospitalization; less complex dental
treatment plans recommended.
UNSTABLE - - Dental procedures deferred until their
ANGINA symptoms have been stabilized.
Treatment of ACUTE ANGINAL ATTACK in dental office:

• Patients with angina should be reminded to bring their nitroglycerin tablets to

every appointment and the tablets made accessible to the practitioner.

• SIGNS AND SYMPTOMS:

1) Chest pain +/- radiation – moderate intensity, poorly localized retrosternal pain,
radiation to left arm and shoulder or neck & mandible. Brief duration (2-10 min),
relieved by nitroglycerin.
2) weakness.
3) +/- dyspnea (shortness of breath).
4) apprehension.
5) Increased blood pressure and pulse rate.
6) +/- sweating.
• MANAGEMENT:
1) Stop dental treatment.

2) Recline the patient to 450 angle, lower head position if systolic blood pressure
< 100 mm Hg.

3) Administer nitroglycerin, a tablet is placed under the tongue and symptoms

will usually cease with in 2 to 3 minutes. In the event if pain persists, a second
tablet is administered, and blood pressure and pulse are monitored. If the
patient is stable and continues to have pain, a third tablets is administered.
Failure to respond to three tablets within a 15 minute period, or the presence of
unstable vital signs, indicate the need for immediate medical care and
activation of office emergency life support procedures.
 MYOCARDIAL INFARCTION

• GENERAL INFORMATION:
- Myocardial infarction is irreversible myocardial damage as a result of prolonged
ischemic injury.
- It is most commonly the result of progressive coronary artery disease secondary
to atherosclerosis.
- It affects 1.3% of all patients above age 30 and 10% of all patients above age 40.

• CLINICAL PRESENTATION:
- Severe chest pain is present in the substernal or left precordial area +/- left arm or
jaw radiation.
- Dyspnea, palpitations, nausea and vomiting may also be a part of the presentation.
- A patient with ongoing myocardial injury often appears diaphoretic and in acute
distress.
• COMPLICATIONS:
- These include Arrhythmias, Congestive Heart Failure, and Angina.

- The complications depend on the extent of the injury. Patients with minimal
myocardial injury usually recover with out significant morbidity, where as
patients with large areas of injury are more likely to suffer heart failure and life
threatening arrhythmias.

- Regardless of the extent of injury, a history of MI indicates significant

compromises in the coronary arteries.
 DENTAL EVALUATION:

• Dental evaluation should include a detailed history listing the dates of all the
myocardial infarctions the patient have had. The most recent infarction is of
particular interest, because it largely dictates the feasibility of elective dental
therapy.
• Time interval from the MI as a predictor of surgical risk:
- < 6 months post-MI ----- 18-22% overall mortality with surgery
and general anesthesia.
- 6-12 months post-MI–-- 10%
- > 12 months post-MI---- 5%.

• Presence of other cardiovascular pathology should also be evaluated by asking

the history of complications after MI.
- H/O subsequent chest pain --- Angina.
- H/O dyspnea, orthopnea, PNS, peripheral edema --- CHF.
- H/O palpitations or syncope --- Arrhythmias or
conduction abnormalities.
 DENTAL MANAGEMENT:

• Dental management of the patient with a previous MI depends on the severity

and course of the infarction.

Patients who have undergone an uncomplicated acute MI:

- are able to tolerate procedures (Types I-IV) of short duration at any time following
the event.
- most stressful procedures are postponed until 6 months after the infarct.
1) Physician consultation is suggested.
2) There appears to be no contraindication to use of epinephrine in
concentrations of 1:1,00,000 in LA in these patients. However, protocols to
minimize the use of vasoconstrictors should be employed.
3) Good patient-dentist communication, stress reduction, and monitoring are
essential for the safe management of the post infarct patient.
 Patients who have undergone a complicated myocardial infarction or whose
recovery is unstable
- require a more conservative approach for the first 6 months after the infarction.

- These patients can undergo dental examination (Type I procedures) and urgent,
simple operative procedures (Type II) after consultation with the patient’s
physician.

- All other dental treatments should be deferred until the patient has been stable for
atleast 6 months.

- Patient in this group with a dental emergency should be treated as conservatively

as possible. However, if extraction or surgery is required, the patient’s physician
should be consulted. Stress minimization protocols should be used. If possible the
procedures are best performed in a hospital setting, with constant monitoring.
 Patients who have had MI 6-12 months before proposed dental treatment:
- TYPE I: normal protocol.

- TYPE II, III,IV: can be carried out after consultation with the patient’s physician,
minimization of stress, longer procedures should be divided in to several short
ones, and adjunctive sedation techniques should be used. Midmorning
appointments may be desirable.

- TYPE V, VI: defer if possible, hospitalization recommended. Advanced surgical

procedures should be deferred until the patient will be stable for atleast 12 months
after the MI.
 Patients who have had their most recent MI more than a year ago:
- It is important to remember that these patients still have significant coronary
artery disease despite their stability during the past year.

- They can however, more readily tolerate nonsurgical procedures than patients
with recent MI.
- TYPE I: normal protocol.
- Type II-IV: minimization of stress, sedation techniques.
- TYPE V-VI: medical consultation, +/- hospitalization. Hospital mandatory for
general anesthesia.
• Other considerations:
1) Patients with coronary atherosclerotic disease and a history of MI are usually
placed on anticoagulant therapy with Coumarin-like drugs (Dicumarol,
Warfarin, Panwarfin, Sintrom) and oral anticoagulants (vitamin k,
antimetabolites). Therapy is usually aimed to maintaining a prothrombin time
at 2.5 times normal value (normal -11 to 14sec).
2) Withdrawal of anticoagulant therapy is unnecessary for endodontic surgery. It
is seen that the PT is maintained at 25- 30 seconds.
3) Use strict haemostatic surgical technique.
4) Analgesic therapy for patients on anticoagulant therapy: Aspirin and
acetaminophen should be avoided as these drugs displace coumarin like drugs
from their serum binding sites and increases their level in the blood and posing
the threat of excessive post surgical hemorrhage. Ibuprofen or codeine are the
analgesics of choice.
 CONGESTIVE HEART FAILURE

• GENERAL INFORMATION:
Congestive heart failure is the inability of the heart to deliver adequate supply of
blood to meet metabolic demands.

SIGNIFICANCE:
It indicates significant cardiac dysfunction; stressful procedures are associated with
increased morbidity and mortality, the increase in the risk depends on the severity
of the congestive heart failure. The dentist should therefore be familiar with the
clinical signs and symptoms of Congestive Heart Failure and the possible
precipitating factors. The medications used in CHF can also complicate dental
management of the patient.
 MEDICAL EVALUATION:

• CHF or cardiac decompensation may result from virtually any aberrant cardiac
disease and is a likely complication in most patients with a long cardiovascular
disease history.

• CAUSES OF CHF:
Hypertension, coronary atheromatic heart disease, cardiac valvular disease,
congenital heart disease, rheumatic heart disease, chronic obstructive pulmonary
disease and hyperthyroidism.
Myocardial efficiency decreases

blood accumulates in the ventricles

Ventricles dilate and hypertrophy (enlarge heart) to compensate for the early stages
of the disease.

increased ventricular pressure

Transmitted to atria

transmitted peripherally into the pulmonary and systemic venous circulation.

Left ventricular failure usually occurs first, with a rise in pulmonary venous pressure,
followed by right ventricular failure, with a rise in systemic venous pressure
• SYMPTOMS:
In patients with predominant left heart failure, pulmonary symptoms (dyspnea, etc.)
become evident. In patients with predominant right heart failure, congestion
occurs in the abdominal viscera and lower extremities.

LEFT HEART FAILURE:

o Dyspnea (shortness of breath), especially on exertion.
o Orthopnea (shortness of breath with recumbency)
o Paroxysmal nocturnal dyspnea.

RIGHT HEART FAILURE:

o Jugular vein distension.
o Hepatomegaly (enlarged, congested liver).
o Ascites (fluid in peritoneal cavity, with abdominal distension).
o Peripheral edema (swelling of ankles and lower legs).
 MEDICAL EVALUATION:

• Identification of the cause of CHF.

• Assess severity: - symptoms
- ECG (to assess rhythm and evidence of
ischemia or infarction).
- chest X ray (to assess heart size and
pulmonary congestion).
 MEDICAL MANAGEMENT:

• Factors that can precipitate or aggravate failure are eliminated. After the
correction of reversible lesions, treatment of CHF can begin.
1) Management of patients with MILD CHF:
- Bed rest - improves venous return and heart function and is the effective first
step in therapy.
- Salt restriction (4 to 5 g/ day) - designed to minimize salt and volume overload
in patients with marginal cardiac reserve
- A variety of diuretics of varying potency to reduce excess extracellular fluid
and salt & decrease congestion.
2) Management of patients with moderate CHF:
- More potent diuretics.
- Digitalis preparations – in addition to diuretics, cardiac glycosides such as
Digoxin are often used to improve myocardial contractility & improve cardiac
efficiency.
- Vasodilators to control hypertension. (hydralazine, prazosin).
3) Management of patients with severe CHF:
- All of the above
- Addition of afterload reducing agents (converting enzyme inhibitors or
vasodilators).
 Drugs commonly used to treat CHF:

1) DIURETICS:
- Hydrochlorothiazide (HydroDiuril),
- Chlorothiazide (Diuril)
- Furosemide (lasix)
- Spiranolactone (Aldactone)

2) CARDIAC GLYCOSIDES:
- Digoxin (Lanoxin)
- Digitoxin (crystodigin)
- Digitalis

3) VASODILATORS:
- Hydralazine (Apresoline)
- Prazosin (Minipress).
 DENTAL EVALUATION:

• PATIENTS AT LOW RISK:

- H/O mild CHF.
- Asymptomatic on therapy.
- Usually on mild diuretics, with or without cardiac glycosides.

• PATIENTS AT MODERATE RISK:

- H/O moderately severe CHF.
- Asymptomatic at rest, but may have symptoms on exertion.
- Usually on more potent diuretics and cardiac glycosides.

• PATIENTS AT HIGH RISK:

- Symptomatic despite therapy.
- Often on escalating doses of medications, including vasodilators.
- Have other complicating factors such as hypertension, recent or multiple MI,
valvular heart disease, or arrhythmia.
 DENTAL MANAGEMENT:
• GENERAL GUIDELINES:
- Minimization of stress (shorter appointments, adjunctive sedation).
- Limited use of epinephrine.
- The supine position is avoided. A semi recumbent or erect position is
mandatory.
• SPECIFIC GUIDELINES:
RISK PROCEDURE PROTOCOL
CATEGORY S
Low risk I-IV Normal protocol
V-VI Medical consultation +/- sedation

Moderate risk I-IV Normal protocol +/- sedation +/-

hospitalization.
V-VI Medical consultation, recent medical
evaluation; check potassium level of patients
on diuretics.
High risk I-IV Sedation
V-VI Hospitalization, less complex dental treatment
plans recommended.
 DYSRHYTHMIA
• A disturbance of the normal rhythm of the heart is called arrhythmia or
Dysrhythmia.

• The abnormality may arise form disturbances ether in the atria (resulting in atrial
arrhythmias) or the ventricles (resulting in ventricular arrhythmias).

• Arrhythmias may be asymptomatic, detected only by routine examination and

ECG or the patient may have symptoms ranging from palpitations to syncope.
• Arrhythmias are often manifestations of underlying atherosclerotic heart disease.

• Arrhythmias may be exacerbated by the stress and anxiety experienced during the
dental therapy.

• Significant arrhythmias increase the risk of angina, MI, CHF, transient ischemic
attacks or cerebrovascular accident.
• Dysrhythmias are treated by drugs, pacemaking or occasionally implantable
cardiovertors (defibrillators), external cardiac defibrillators, cardioversion or
catheter ablation.

• PACEMAKERS are small implantable electronic devices that stimulate heart to

beat and pace the heart rate when it is too slow (bradycardia).

- In patients with pacemakers, electrosurgery, transcutaneous nerve stimulation are

contraindicated.

- Pacemaker single beat inhibition of little consequence may occasionally be

caused by dental equipment such as piezoelectric ultrasonic scalers and ultrasonic
baths, pulp testers, electronic apex locators, and old X-ray machines.
 BACTERIAL ENDOCARDITIS

• Bacterial endocarditis is a serious infection of the heart valves or the endothelial

surfaces of the heart.

• Because DENTAL MANIPULATION is the LEADING IDENTIFIABLE

CAUSE of transient bacteremia that can result in infectious endocarditis, it is
important for the dentist to understand the pathogenesis of the disease, to be able
to identify the population at risk, and be able to administer appropriate
prophylactic antibiotic therapy.
• Bacterial endocarditis results from bacterial proliferation on altered cardiac
surfaces. Damaged heart valves as a sequela of rheumatic fever, previous
bacterial endocarditis or acquired valvular lesions are the usual predisposing
clinical conditions for bacterial endocarditis. Initially, a sterile platelet-fibrin clot
or thrombus becomes implanted on the damaged surfaces. If bacteria are
introduced (for e. g., by dental products), the thrombus acts as a nidus for
bacterial endocarditis.

• ORAL FLORA AND BACTERIAL ENDOCARDITIS:

Organisms normally found in the oral cavity account for a sizeable proportion of
causative agents of bacterial endocarditis.
- Alpha hemolytic streptococci.
- Enterococci.
- Pnuemococci.
- Staphylococci
- Group A streptococci.
ENTAL MANIPULATIONS CAUSING BACTERIAL ENDOCARDITIS:

• Dental procedures are the leading cause of transient bacteremia that can result in
BE.

• The risk of such orally introduced bacteremias appear to depend on two important
variables:
- The amount of soft tissue trauma induced by dental procedure.
- The degree of pre-existing local inflammatory disease.

• Transient bacteremia has been demonstrated following extraction, gingivectomy,

curettage, prophylaxis, brushing, endodontic manipulation. There are even case
reports of bacterial endocarditis in edentulous patients with dental sores.

• The dentist must assume that any dental manipulation likely to result in gingival
bleeding (even an intraoral examination with mirror and explorer) can lead to
transient bacteremia. Some form of antibiotic prophylaxis should therefore be
used in any patient to be at risk for bacterial endocarditis.
• RATIONALE FOR ANTIBIOTIC PROPHYLAXIS:
- Although there is no direct evidence that antibiotic prophylaxis is effective in
preventing endocarditis in humans, there is adequate evidence that it decreases
the incidence of bacteremia.

- The choice of drugs for prophylaxis is largely empiric. From a theoretic

standpoint, the drugs chosen should be bactericidal and directed at the organisms
commonly found in the oral cavity.

- The drugs should be administered at an appropriate interval prior to the procedure

to ensure maximal blood level at the time of the procedure, and they should be
continued for a period following the procedure to allow adequate time for tissue
healing.
 DENTAL EVALUATION:

• PATIENTS AT MINIMAL RISK WHO DONOT REQUIRE ANTIBIOTIC

PROPHYLAXIS:
- Innocent or functional murmurs.
- Uncomplicated atrial septal defect of secundum type (anatomically high atrial
septal defect).
- Coronary artery bypass graft surgery.
- Mitral valve prolapse without mitral regurgitation.
- Previous rheumatic fever without valvular dysfunction.
• PATIENTS AT SIGNIFICANT RISK:
- Rheumatic valvular disease.
- Mitral valve prolapse and mitral regurgitation.
- Other acquired valvular disease.
- Congenital heart disease.
- Intravascular prosthesis.
- Coarctation of aorta.

• PATIENTS AT HIGH RISK:

- Previous bacterial endocarditis.
- Prosthetic heart valve.
- Systemic pulmonary shunt.
- Recent surgical repair of cardiovascular defect.
 DENTAL MANAGEMENT:

• The selection of the standard regimen or the more stringent alternative regimen
depends on the risks associated with the particular cardiovascular disease and the risk
of bacteremia for a particular procedure and the oral health setting.
• In general standard regimen is sufficient. Alternative regimen should be considered
in high risk patients who are expected to have excessive gingival bleeding.
•SPECIFIC GUIDELINS:

Cardiovascular defect Significant soft tissue Significant soft tissue

Pathology or surgical Pathology or surgical
trauma trauma

Yes No
High risk Alternative regimen Standard regimen
Significant risk Standard regimen Standard regimen
Minimal risk No prophylaxis No prophylaxis
• ENDOCARDITIS PROPHYLAXIS:

RECOMMENDED FOR:
Dental procedures known to induce gingival or mucosal bleeding, including
professional cleaning and injection of intraligamentary anesthetic.

NOT RECOMMENDED FOR:

Dental procedures not likely to induce gingival bleeding
- Simple adjustments of orthodontic appliances,
- Restorations above the gingival margin.
- Injection of local anesthetic – intraoral (except intraligamentary injections).
 PROPHYLAXIS FOR DENTAL PROCEDURES: American Heart
Association

• STANDARD REGIMEN:
Amoxicillin : 3.0 g orally 1 hour before, then 1.5 g, 6 hour after initial dose.

 Amoxicillin- Penicillin allergic patients

Erythromycin : erythromycin ethylsuccinate, 1600 mg, or erythromycin Stearate, 1.0
g orally, 2 hours before procedure; then half the dose 6 hour after the initial
dose.
or
Clindamycin : 300 mg orally 1 hour before the procedure, then 150 mg 6 hours after
the initial dose.
 Patients unable to take oral medications (i.e., prior to general anesthesia)
Ampicillin: IV or IM administration of Ampicillin 3.0 g, 30 min before the
procedure, then IV or IM Ampicillin 1.0 g or oral administration of 1.5 g
amoxicillin, 6 hours after the initial dose.

 Ampicillin-Amoxicillin-Penicillin allergic patients unable to take oral

medications:
Clindamycin: IV administration of 300 mg, 30 min before procedure, then IV or oral
administration of 150 mg, 6 hours after the initial dose.
• PATEINTS CONSIDERED HIGH RISK AND NOT CANDIDATES FOR
STANDARD REGIMEN:
Ampicillin, Gentamycin and Amoxicillin:
IV or IM administration of Ampicillin 2.0g + Gentamycin 1.5 mg/kg body weight
(not to exceed 80 mg), 30 min before the procedure followed by Amoxicillin 1.5
g orally, 6 hours after the initial dose; alternatively parenteral regimen may be
repeated 6 hours after initial dose.

 Ampicillin-Amoxicillin-Penicillin allergic patients considered high risk:

Vancomyin: IV administration of 1.0 g over 1 hour, starting 1 hour before procedure;
no repeat dose necessary.
o Other considerations:
1) An additional consideration for IE susceptible patients in implementation of
Chlorhexidine (CH) gluconate mouth rinses several days prior to surgery to
decrease the oral flora population and inhibit plaque formation.
2) In some patients a series of dental procedures may be required. Continuous
antibiotic prophylaxis would result in the emergence of resistant strains.
Therefore, it is recommended that an interval of 7 to 14 days between the
administration of antibiotic prophylaxis measures be observed.
 THE PATIENT UNDERGOING CARDIAC SURGERY

• The dentist may be consulted for the evaluation of the oral health of the patient
who is scheduled to undergo cardiac surgery. The dentist should be integrally
involved in the preoperative care of these patients. A number of cardiac surgical
procedures can increase the risk of developing bacterial endocarditis.

• Because the primary source of transient bacteremia that can result in bacterial
endocarditis is the oral cavity, the oral health of the patient should be optimized
preoperatively, whenever feasible.
INDICATIONS FOR CARDIAC SURGERY:
• CORONARY ARTERY BYPASS GRAFT: Coronary artery disease with angina
or myocardial infarction.
• VALVULAR REPLACEMENT: Vascular stenosis or insufficiency.
• CORRECTION OF CONGENITAL ABNORMALITIES: Atrial septal defect,
Ventricular septal defect, Tetralogy of Fallot, Coarctation of aorta.

RISK CATOGORIES FOR DEVELOPING BE AFTER CARDIAC SURGERY:

• PATIENTS AT LOW RISK: patients with coronary artery bypass graft, patients
with repair of an atrial septal defect of the secundum type.
• PATIENTS AT SIGNIFICANT RISK: patients with correction of congenital
abnormalities (except for uncomplicated atrial septal defects), patients with
valvular replacements.
Patients who are at high risk for developing BE post operatively, should have
aggressive preoperative intervention to minimize the risk.
 DENTAL MANAGEMENT:

• GENERAL GUIDELINES:
Prior to any treatment in preoperative patients, the dentist should be aware of
any underlying cardiac abnormalities and assess the need for antibiotic
prophylaxis.
a) Coronary artery bypass graft – no prophylaxis.
b) Congenital abnormality – standard regimen.
c) Valvular lesions – standard regimen.

- Time constraints and the medical status of the patient may limit therapeutic
options. Dental treatment should be tailored to the needs of the individual
patient.
- Minimize stress: several short appointments, adjunctive sedation techniques.

- Use of epinephrine should be minimized in patients with significant cardiac

disease, especially if arrhythmia is of a concern.
- Hospitalization should be considered for cardiac monitoring, for extensive
dental therapy
• SPECIFIC GUIDELINES:
The dental management of patients undergoing cardiac surgery depends on the
risk of developing postoperative bacterial endocarditis.

- PATIENTS AT LOW RISK:

Acute infections should be eliminated prior to cardiac surgery. Acute abscess,
fistulae, periapical disease and supportive periodontal disease should be
aggressively treated.

- PATIENTS AT SIGNIFICANT RISK:

The primary goal is to eliminate infection quickly before the surgery to minimize
the risk of postoperative BE.
In addition to extraction of acutely infected teeth, any tooth with questionable
prognosis because of pulpal or periodontal disease should also be extracted.
 PATIENTS WHO HAVE UNDERGONE CARDIAC SURGERY

• The patient who has undergone cardiac surgery requires special consideration
prior to the initiation of dental therapy. The two major concerns are the risk of
developing endocarditis and the risk of bleeding secondary to administration of
anticoagulants.

• Different cardiac surgical procedures place the patient at different risks for
bacterial endocarditis, and the types of dental prophylaxis required differs
accordingly.

• Furthermore, some patients may be placed on anticoagulants after the placement

of prosthetic valves and therefore require special intervention.
 MEDICAL EVALUATION:

• Because all patients who have undergone cardiac surgery have had some
compromising cardiac lesions, it is important to be aware of the medical problems
that can persist even after surgery.

• Assess for Angina & Congestive Heart Failure.

• Patients with prosthesis are usually placed on anticoagulants to prevent clot

formation on the prosthesis.
 DENTAL EVALUATION:

• After assessing the patients medical status, the dental evaluation should
determine:
1) The need for antibiotic prophylaxis.
2) The need for adjusting the dosage of anticoagulants.

NEED FOR PROPHYLAXIS:

 Coronary artery bypass graft – no increased risk
In general, patients who have had coronary artery bypass graft are not at
increased risk for the development of BE beyond the immediate postoperative
period and do not need prophylaxis. Even during the first 6 months
immediately after the surgery, when there is ongoing healing of the suture
sites, the risk of developing endocarditis is minimal and prophylaxis is
optional.
 Patients who have had
1) Primary repair of uncomplicated atrial septal defects of the secundum type.
2) Ventricular septal defect repaired without Dacron grafting.
3) Who have had patent ductus arteriosus repaired
Do not require subacute bacterial endocarditis prophylaxis for dental
procedures 6 months or more after the cardiac surgery.

 Patients who have a significant risk of developing bacterial endocarditis and

require prophylaxis are:
- Who have undergone correction of Congenital heart disease.
- Who have undergone vascular repairs with synthetic graft.
- Patients with prosthetic heart valves are at high risk of developing BE and
antibiotic prophylaxis is mandatory.
 DENTAL MANAGEMENT:

• GENERAL GUIDELINES:
# MEDICAL STATUS-
1) Should be optimized by a physician prior to elective dental therapy.
2) Medical consultation, when appropriate.

# MINIMIZATION OF STRESS:
1) Shorter appointments.
2) Adjunctive sedation techniques, when appropriate.

# MINIMIZE THE USE OF EPINEPHRINE.

• SPECIFIC GUIDELINES:
# Patients at no risk of BE ( Coronary artery bypass graft, selected repairs of congenital
lesions with out synthetic grafts – no antibiotic coverage.

# Patients at significant risk of BE (correction of congenital anomaly with synthetic grafts) –

PROCEDURE PROTOCOL
- Patients with minimal - simple dental - standard
inflammatory gingival procedures (types I to III) regimen.
changes undergoing: - requiring dental surgical - standard or
procedures (type IV to VI) alternative
regimen.
- Patients with moderate I to VI dental - standard or
to advanced inflammatory procedures alternative
gingival changes undergoing regimen.
# Patients at high risk of BE (valvular replacements)
- Same protocol as patients with significant risk
- Some patients may be on maintenance oral anticoagulants after the placement of
prosthetic valves. The patients are obviously at high risk for excessive bleeding
unless the anticoagulant is stopped prior to dental treatment. Because the
cessation of anticoagulants may be associated with the formation of clots on the
prosthetic valves, the patient’s physician should be consulted for the adjustment
of anticoagulant therapy.
RESPIRATORY
SYSTEM
 ASTHMA

• Asthma is a disease process in which airway smooth muscle shows an increased

responsiveness to a variety of nonspecific stimuli, which can result in widespread
narrowing of the airway and obstruction to airflow.

• CLINICAL MANIFESTATIONS:
Physical examination of an asthmatic patient during an acute exacerbation often
reveals:
- Tachypnea
- Tachycardia
- Inability to lie flat comfortably
- Use of accessory muscles of respiration and an exaggerated decrease in systolic
blood pressure on inspiration (pulses paradoxus)
- Certain variant forms of asthma require special consideration. Approximately
10% of individuals with asthma demonstrate aspirin hypersensitivity.
• Etiologic factors:
1) Allergens: House dust, animal dander, feathers, animal hair, milk, egg, fish,
fruits, nuts, NSAIDs and some antibiotics.

2) Environmental toxins: ozone (major oxidant generated in photochemical

smog), sulphur dioxide (5ppm) and nitrogen dioxide (1ppm) all induce hyper
responsiveness.

3) Occupational agents: baker’s asthma, western red cedar asthma, meat

wrapper’s asthma.

4) Infections: a viral upper respiratory tract infection is the most common

stimulus that exacerbates asthma and perhaps induces the condition.

5) Modifiers: many factors may worsen the asthmatic condition in individuals

with pre-existing disease. Exercise, hyperventilation of cold, dry air and
emotional factors.
 MEDICAL MANAGEMENT:

• Medical treatment is by drug therapy and avoidance of allergens, when possible,

of known allergens.

• These patients are usually placed on

- bronchodilators, such as theophylline, aminophylline,
- anticholinergics, or
- beta-adrenergic stimulators.
- In severe cases, corticosteroids are sometimes used.

• Inhalation of beta-adrenergic agonists from a metered dose inhaler is the preferred

approach to managing acute asthmatic attacks.
 DENTAL EVALUATION:

• A detailed history is crucial in the evaluation of the patient with asthma.

• Age of onset of symptoms, the frequency and severity of the disease, and the need
for hospitalization should be recorded.
• role of emotional stress in precipitating asthmatic attack, and about aspirin
intolerance.
• medications
- bronchodilators.
- Corticosteroid usage.

• Physical examination:
- Assessment of patient’s respiratory status- patients with shortness of breath,
audible wheezing, and bouts of coughing should not have elective dental
procedures.
- The pulse should also be taken, and an irregular pulse or tachycardia should alert
the dentist to the possibility of excessive medication.
 DENTAL MANAGEMENT:

• THE GOAL OF DENTAL MANAGEMENT OF THE PATIENT WITH

ASTHMA IS TO AVOID PRECIPITATING AN ACUTE ATTACK.

• GENERAL GUIDELINES:
- Minimization of stress.

- Sedation techniques: N2-O-O2 inhalation or diazepam (valium).

- Use of Epinephrine.

- Use of aspirin.

- Use of antibiotics: the use of commonly prescribed antibiotics,

ERYTHROMYCIN and CLINDAMYCIN concurrently with a Methylxanthine
preparation (e. g. Theophylline) is associated with an increased risk of
methylxanthine toxicity. These antibiotics are therefore contraindicated in patients
with asthma who are receiving methylxanthine medication as a bronchodilator.
SPECIFIC GUIDELINES:
1) Symptomatic patients.

2) In asymptomatic patients, a risk categorization based on the history, the list of

medications, and the physical examination can provide some guidelines for dental
treatment.

‡ PATIENTS AT LOW RISK: these patients have rare attacks and are not on
medication. They can be treated with normal operating protocols with special
attention to sedation techniques and minimization of stress.

‡ PATIENTS AT MODERATE RISK: asymptomatic patients on chronic

maintenance therapy are usually on bronchodilators or steroids.
- Patients on bronchodilators
- Patients on chronic steroid therapy
 MANAGEMENT OF PATIENTS WITH ASTHMA FOR
ENDODONTIC SURGERY:

• MEDICAL CONSULTATION:
- Determine status of the disease, associated disorders & drug therapy.
- Advise physician of planned surgical regimen, including administration of drugs.

• IMPLEMENT STRESS REDUCTION PROTOCOL:

- Stress – pain – anxiety complex must be avoided.
- Acetaminophen should be used for analgesic therapy.
- Prescribe 5 mg oral diazepam (valium) the night before and one hour prior to the
surgery.
- Intraoprative sedation with nitrous oxide – oxygen may also be used.
• OTHER CONSIDERATIONS:
- Avoid narcotics, and aspirin and other NSAIDs, which are potential precipitating
agents for acute asthmatic attacks.
- Instruct patient to bring inhaler to each appointment.
- Avoid known precipitating factors such as infection, exercise, and cold
environments.
- Determine if adjustment of corticosteroid medication is indicated.
 CHRONIC OBSTRUCTIVE PULMONARY DISEASE:

• Chronic Obstructive Pulmonary Disease (COPD) is irreversible airway

obstruction and destruction.

• EMPHYSEMA and CHRONIC BRONCHITIS, the two most common forms

of COPD are the result of persistent airway obstruction which resist or obstruct
airflow.
• EMPHYSEMA is a disease affecting the distal airways, causing destruction of
lung parenchyma and loss of elasticity of alveolar walls. This results in
compromise of airflow and collapse of some airways.
- dyspnea, particularly on exertion.
- Coughing and sputum production is scanty.
- As the disease progresses, the patient has tachypnea with minimal exertion, uses
accessory muscles for breathing, and breaths with pursed lips.

• CHRONIC BRONCHITIS is characterized by hypertrophy of and hyper

secretion by the mucous glands of the bronchial tree. Mucus plugging
compromises airways and produces progressive symptoms.
- smoker
- gives a history of chronic, productive cough (atleast 3 months during 2
consecutive years).
- As the disease progresses, the patient develops dyspnea on exertion, hypoxia and
finally CO2 retention.
 DENTAL EVALUATION:

• Evaluation of the patient with COPD is geared toward assessing the severity of
the disease. This can be done by
1) Determining the symptoms.
2) Current medications.
3) Past hospitalizations.

• The medical history includes:

1) History of smoking.
2) Signs of respiratory distress such as wheezing, exertional dyspnea, coughing
and sputum production.
3) The use of medications to control respiratory symptoms.

If a patient has been hospitalized for respiratory difficulties, the physician

should be consulted about the patient’s current status. It is particularly
important to know whether a patient retains CO2, as these patients have severe
disease and are most prone to respiratory failure when oxygen or sedatives are
given.
Based on evaluation patients can be grouped into the following risk categories:
PATIENTS AT LOW RISK:
1) Patients with dyspnea only on significant exertion.
2) Patients with normal blood gases [PCO2- 40mm Hg, PO2- 100mm Hg, pH-
7.40]

DENTAL MANAGEMENT:
1) Normal protocol for all dental procedures (types I-VI).
2) Avoid anything that causes greater demands on the respiratory system ( stress –
pain – anxiety complex, and supine positioning of the patient for treatment.
3) Treat in an upright sitting or very slightly reclining position.
 PATIENTS AT MODERATE RISK:
1) Patients with dyspnea on exertion.
2) Patients on chronic bronchodilator therapy.
3) Patients who have recently used corticosteroids.
4) Patients with hypoxemia [PO2 less than 85mm Hg] but no CO2 retention.

• DENTAL MANAGEMENT:
1) The patient should have a recent medical evaluation and the patients physician
should be consulted. The dentist should discuss the overall treatment plans,
alternatives and the use of local anesthetics, possible sedation techniques and
postoperative analgesics.
2) Patients on bronchodilator therapy deserve special attention.
3) Patients taking theophylline preparations.
4) Patients who are currently on steroids and patients who have had significant
doses of steroids during the past year deserve special attention.
 PATIENTS AT HIGH RISK:
1) Patients with previously unrecognized symptoms of COPD.
2) Patients with acute exacerbation (e. g. acute respiratory infection).
3) Patients with significant dyspnea at rest or cor pulmonale who require chronic
oxygen therapy.
4) Patients with a history of CO2 retention [PCO2 > 45mm Hg].

DENTAL MANAGEMENT:
1) Patients with symptoms suggesting COPD who have not been medically
evaluated, should be referred to their physicians prior to dental procedure.
2) Patients with acute exacerbations of symptoms
3) Patients with severe COPD should be managed with close cooperation with
their physicians.
- Stress should be minimized and short dental sessions should be employed.
- The use of any agent that may depress respiratory function – such as sedatives
(including nitrous oxide), tranquilizers and narcotics- must be discussed with
the patient’s physician. This is particularly true when the patient has a history
of CO2 retention. In most cases non narcotic analgesics are preferred.
4) Patients with cor pulmonale are prone to have arrhythmias.
5) Hospitalization should be considered for moderate to advanced dental surgery
(types V and VI) procedures.
 TUBERCULOSIS

o PRIMARY INFECTION: Mycobacterium tuberculosis generally causes a mild

pulmonary disease including fever, chills, cough and sputum production.
Infected foci form granulomata, which heal by scarring calcification.
It is usually evident on chest radiograph.

o Because oral tuberculosis is highly contagious, it is important for the dentist to

be familiar with the disease and its management to minimize the likelihood of
inadvertent infection.
 DENTAL EVALUATION

• Dental evaluation is directed at the identification of patients with active

disease, particularly those with oral involvement.

• HISTORY:
The medical history should include questions regarding
1) The presence of tuberculosis infection in family members as well as other
possible exposure to the disease.
2) Past infection.
3) Patients with known tuberculosis should be asked about
- The degree of disease involvement
- The type and duration of therapy received.
- The current status of the disease activity.
4) The patient’s physician should be consulted for confirmation.
 ORAL FINDINGS

- Katz found that about 20% of patients with the disease in the lungs had oral
involvement.

- The most common site of oral tuberculosis is the base of the tongue.
- The gingiva, lips, tonsils, tooth sockets and soft palate have also been reported.
- The oral lesions are ulcerative. The ulcers are usually uneven, with jagged,
undermined soft borders. Frequently they are linear. The lesions are painless,
although they have a purulent center.

- Lymphadenopathy is a common finding.

- Lesions may also occur at the corners of the mouth and present as shallow
granulating ulcerations with pebbly surfaces. Such lesions are called CUTIX
ORIFICIALIS.

- Smears of saliva may demonstrate organisms when stained with Ziehl- Neelsen
satin. Cultures are necessary for confirmation of diagnosis.
• Based on detailed history and consultation, patients can be grouped into 3 risk
categories:

PATIENTS AT HIGH RISK:

1) Patients with known tuberculosis showing symptoms of active disease [fever,
chills, night sweats, sputum production, and weight loss].
2) Patients with oral manifestations of tuberculosis.

DENTAL MANAGEMENT:
1) Elective dental care is contraindicated and patient is referred to physician for
further evaluation.
2) Emergency dental care:
- Hospitalization recommended.
- Strict asepsis regimen: gowning, double mask and gloves, and strict adherence
to asepsis techniques are mandatory. Hand pieces that cannot be autoclaved
must be gas sterilized.
• Patients with open pulmonary tuberculosis are thus clearly contagious and dental
treatment is thus deferred until the TB has been treated.
• If this is not possible patients should be treated with special precautions to protect
the respiratory tract against cross infection.
• The aims are :
- To prevent the release of mycobacteria into air.
- To remove any that are present and
- To stop the inhalation by other persons.
• Reduction of splatter and aerosols, by minimizing coughing and avoiding
ultrasonic instruments, and the use of rubber dam are important.
• Improved ventilation, ultraviolet light, new masks and personal respirators are
indicated.
• Mycobacteria are very resistant to disinfectants, so the heat sterilization should be
used wherever possible.
 PATIENTS WITH MODERATE RISK:
1) Patients with positive tuberculin skin test but no evidence of active disease.
2) Patients with chest X ray findings suggestive of prior tuberculosis involvement
but no evidence of active disease.
3) Patients with inadequately treated tuberculosis but no evidence of active
disease.

DENTAL MANAGEMENT:
1) These patients have had tuberculous infection and the disease can be
reactivated. They have no evidence of active infection.
2) Dental procedures can be carried out using appropriate precautions for strict
asepsis.
 PATIENTS WITH LOW RISK:
1) Patients with known tuberculosis who have adequately been treated with no
evidence of active disease.
2) Patients with a history of exposure to tuberculosis but negative skin test and no
evidence of disease involvement.

Dental procedures can be carried out using normal protocol.

GASTROINTESTINAL
SYSTEM
 PEPTIC ULCER DISEASE

• GENERAL INFORMATION:
Peptic ulcer disease is the result of damage to the epithelial lining of the stomach
(gastric ulcer) or the duodenum (duodenal ulcer).

• PATHOPHYSIOLOGY:
Acid erosion of the gastrointestinal mucosa.
Patients with duodenal ulcers classically have:
1) Episodic pain that is usually absent in the early morning and often starts 2 to 3
hours after a meal.
2) It may occasionally awaken the patient at night.
3) The pain is relieved by eating.

Patients with gastric ulcers often present with:

1) Epigastric pain radiating to the back.
2) The pain is aggravated by eating.
3) vomit blood (Hematemesis) or pass black tarry stools (Melena).
4) Occasionally protracted vomiting.
• PRECIPITATING FACTORS:
- Aspirin.
- Alcohol.
- NSAID s
- Tobacco
- Caffeine.
- Corticosteroids.
- Emotional stress.
 MEDICAL MANAGEMENT

• Because peptic ulcer disease is the result of acid erosion of the gastrointestinal
mucosa, medical management is designed either to neutralize the acid produced
or to minimize the acid production.
- Diet: foods that may aggravate symptoms may be avoided.
- Antacids: they are given 1 & 3 hours after a meal and before bedtime for maximal
effect [ Amphojel, Di- gel, Gelusil, Mylanta, Riopan, Sucralfate (Carafate)].
- Anticholinergics: used in reducing acid production at night. [Propanthaline (Pro-
Banthine), and Poldine (Nacton)].
- H2- receptor antagonists: block the production of acid by parietal cells of
stomach. [Cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid)].
- Sucralfate (Carafate): coats the stomach and promote healing. Can bind to other
drugs and decrease the bioavailability of them. E. g. tetracycline, phenytoin,
digoxin.
 DENTAL EVALUATION

1) Assess frequency and severity of symptoms.

2) Determine history of complications:
- Bleeding,
- Obstruction,
- Perforation.
3) History of surgery.
4) History of medications:
- Antacids,
- Anticholinergics.
- H2-receptor antagonists.
 DENTAL MANAGEMENT

1) Dental management of the patient with peptic ulcer disease should avoid
aggravation of symptoms. Minimize stress, shorter appointments, consider
adjunctive sedation techniques.

2) The major concern in dental management of the patient with peptic ulcer
disease relates to the complications of the drugs used in the treatment.
- Some antacid preparations such as Di-gel, Gelusil, Maalox, and Mylanta,
contain aluminiun hydroxide that prohibit the effective absorption of
tetracycline.
- Cimetidine - thrombocytopenia.
- Aspirin and NSAIDs – irritation to mucosal lining.
- Anticholinergics – Xerostomia.
 HEPATITIS

• Hepatitis is an acute infection of the liver caused by one of the three viruses,
Hepatitis type A, type B or Type C.
• The majority of patients have symptoms of an acute mild viral illness, but about
5% proceed to develop chronic hepatitis.
• A number of patients become chronic carriers of hepatitis antigen and are
potentially infectious.

An understanding of the various types of viral hepatitis and the common modes of
transmission is important in the prevention of infection.

The dentist is particularly at risk because of exposure to the oral secretions and
blood of potentially infectious patients.
 MODE OF TRANSMISSION OF HEPATITIS

• HEPATITIS A:
- Children and adolescents are more susceptible to infection than adults.
- Transmission: fecal – oral route.

• HEPATITIS B
- Transmission is by parenteral route. Patients with acute hepatitis B infections
have been found to have viral particles in saliva, semen, vaginal secretions, and
breast milk.

• HEPATITIS C:
- Mode of transmission is parenteral, usually secondary to large blood
transmission (in excess of 5 units).
 DENTAL EVALUATION

• Because dentists are exposed to the blood and oral secretions of patients, they are
particularly at risk of contracting hepatitis. The dental evaluation should therefore
identify all patients who are potentially infectious.
• Patients giving a history of malaise, low grade fever, anorexia, nausea and
vomiting should be referred for evaluation.
• Patients with a prior history of hepatitis or jaundice should be carefully evaluated.
• Patients with scleral icterus or jaundice should have dental procedures deferred
and should be referred for further evaluation.
• Laboratory evaluation of an asymptomatic patient with a past history of jaundice
should include determination of liver function, prothrombin time, and hepatitis
antigen.
• Patients with persistent abnormalities in liver function tests or with positive
HBsAg should be referred for further evaluation.
• Based on history, examination, and laboratory profile, the relative risk of
hepatitis insufficiency can be assessed.

PATIENTS AT LOW RISK:

1) Patients with histories of hepatitis A, B or C with normal liver function tests
and negative hepatitis antigen.
2) Patients with history of hepatitis B with normal liver function tests, negative
antigen tests, and positive antibody tests are also not infectious.

- Normal dental protocol with adherence to universal precautions.

 PATIENTS AT HIGH RISK:
1) Patients with positive surface antigen for hepatitis B and C.
2) Patients with abnormal liver function tests.
3) Patients with jaundice and symptoms of viral hepatitis.

DENTAL MANAGEMENT:
1. Deferring of elective dental care until clinical infection has resolved.

2. Appointments scheduled at the end of the day to allow for appropriate

precautions and sterilization.

3. Careful avoidance of exposure to blood and oral secretions.

4. Strict sterilization procedures: autoclave, chemclave, or cold sterilization (in

order of preference) of all instruments including handpeices. Handpeices that
cannot be autoclave should be sterilized with ethylene oxide gas.
5) Use of double gloves and masks, appropriate gowning precautions.

6) Draping all exposed dental equipment where feasible, and wiping all other
surfaces with antiseptic solutions.

7) Minimal use of aerosol instruments (air- water syringe & ultrasonic scalers) to
prevent aerosolization of potentially infective viral particles.

8) Use of disposable items (e. g. impression trays when possible).

9) Inadvertent needle puncture: when the skin is inadvertently punctured with

instruments and other needles, it is important to wash the wound thoroughly,
whenever feasible the patient’s hepatitis surface antigen status should be
determined. If parenteral exposure to blood that is HBsAg-positive has
occurred, the dentist should receive hepatitis B immunoglobulin.
ENDOCRINE
DISEASES
 DIABETES MELLITUS
• Diabetes Mellitus results from an absolute or relative insulin insufficiency caused
either by a low output of insulin from pancreas or by unresponsiveness of
peripheral tissues to insulin.
• Most important risk factor is hereditary.
• Diagnosis is confirmed by the fasting blood glucose level above 120 mg/dl,
Hemoglobin A1C levels as much as 20%.

• MAJOR SYMPTOMS are:

- Polydipsia.
- Polyuria.
- Polyphagia.
- Weight loss.

• Two forms of Diabetes:

- Type I (insulin dependent, ketosis-prone)- juvenile onset
- Type II (non insulin dependent, non ketosis-prone)- adult onset.
• HYPOGLYCEMIA: low blood glucose level as a result of excessive oral
hypoglycemic agents, insulin, or inadequate dietary intake.

• SIGNS AND SYMPTOMS: weakness, nervousness, palpitations and excessive

sweating. Lethargy, agitation and confusion, progressing to seizure and coma.

• TREATMENT:
- In patients with mild symptoms, administration of sugar in the form of candy or
glucose solution such as orange juice.
- Lethargic patients who are unable to take oral fluids are treated with IV
administration of concentrated glucose solution such as 50% dextrose in water
(D50 W).
- Usually patients respond within 3 to 5 min of the administration of glucose.
 DENTAL EVALUATION

1) PATIENTS NOT KNOWN TO HAVE DIABETES MELITUS:

- Ask H/O polyuria, polydypsia, polyphagia and weight loss.
- Patients giving a positive history should be referred either to clinical laboratory
or to their physician.

2) PATIENTS KNOWN TO HAVE DIABETES MELLITUS: ask for

- Form of disease.
- Therapy being employed.
- Adequacy of diabetic control.
- The presence of neurologic, vascular, renal or infectious complications.
- Duration of disease.
- Occurrence of hypoglycemia.
- H/O hospitalizations for ketoacidosis.
- Any change in therapeutic regimen.
1) PATIENTS AT LOW RISK:
- Patients with good metabolic control and on stable medical regimen.
- No H/O ketoacidosis or hypoglycemia.
- No complications of DM.
- Fasting blood glucose level less than 200 mg/dl.
- Hemoglobin A1C level of less than 7%.

- TYPE I – III PROCEDURES: Normal protocol with general guidelines

applicable to the general guidelines applicable to all diabetic patients.
- TYPE IV – VI PROCEDURES: adjunctive sedation techniques, half the
normal dose only if oral intake is expected to be compromised, after
consultation with the physician.
2) PATIENTS AT MODERATE RISK:
- Patients with occasional symptoms but are in reasonable metabolic balance and
on a stable regimen.
- no recent H/O ketoacidosis or hypoglycemia.
- Few complication of DM.
- Fasting blood sugar level less than 250 mg/dl.
- Hemoglobin A1C level of 7 to 9%.

- TYPE I –III: normal protocol, adjunctive sedation technique.

- TYPE IV: possible adjustment of insulin dose after the consultation with
physician.
- TYPE V – VI: possible adjustment of insulin dose after consultation with
patient’s physician. Consider hospitalizations.
3) PATIENTS AT HIGH RISK:
- Patients under poor metabolic control.
- Have multiple complications.
- H/O frequent hypoglycemia or ketoacidosis, and there is often a constant need to
adjust insulin dosages.
- Fasting blood glucose level greater than 250 mg/dl.
- Hemoglobin A1C level greater than 9%.

- TYPE I: normal protocol

- TYPR II – VI: deferred until metabolic status is stabilized. Palliative rather than
extensive restorative interventions; aggressive control of oral infections.
 DENTAL MANAGEMENT

- GENERAL GUIDELINES: the primary goal should be to avoid untoward

metabolic imbalances during the period of dental therapy.
- Diet.
- Oral hypoglycemic agents.
- Insulin therapy.
- Minimization of stress.
- Minimizing the risk of infection.
- Medical consultation.
• Other considerations:
1) Healing is usually retarded.
2) Susceptible to infection.
3) Alteration in blood glucose level as a result of acute infection or during and
after surgical procedures.
4) Avoid epinephrine.
• ORAL FINDINGS IN DIABETES:
- Periodontal disease.
- Xerostomia.
- Recurrent abscesses
- Enamel hypoplasia and hypocalcification- increases frequency of caries.
- Oral flora – candida albicans, hemolytic streptococci, & staphylococci.
- Abnormal eruption patterns.
 THYROID DISORDERS

• The thyroid gland is an endocrine gland located in the neck superior to the
suprasternal notch and inferior to the cricoid cartilage.
• The major function of this gland is the production of the hormone thyroxine,
which is important in the regulation of the metabolic rate of the body and affects
carbohydrate, protein and lipid metabolism. In addition thyroxine potentiates the
action of other hormones, such as catecholamines and growth hormones.
• HYPERTHYROIDISM:
- Excessive production of thyroxine.
- Symptoms: heat intolerance, nervousness, tremor, excessive sweating, muscular
weakness, diarrhoea, increased appetite and weight loss.
- In elderly patients thyroxine may precipitate atrial fibrillation, angina, or
congestive heart failure.
- Thyroid function tests have high serum concentrations of free thyroxine or
triiodothyroxine (T3).

• HYPOTHYROIDISM:
- Insufficient production of thyroid hormone.
- Initially the patients complain of fatigue, cold intolerance, weakness and weight
gain. Subsequently hoarseness and impaired mental activity.
- In severe cases there is increasing lethargy, culminating in coma.
 DENTAL EVALUATION

In hyperthyroid patients,
• Catecholamines + stress of the procedure = thyroid storm.
• This emergency situation is characterized by marked exacerbation of the
symptoms of hyperthyroidism, including high fever, major central nervous
system alterations (severe agitation, frank psychosis), vomiting and diarrhoea.
Most importantly there is a high risk of life threatening arrhythmias and/or
congestive cardiac failure.

Hypothyroid patient has preexisting CNS depression and is sensitive to drugs with
CNS depressant side effects.
Severe hypothyroidism – risk of respiratory and cardiovascular depression and/or
collapse.
• Narcotic analgesics.
• Sedatives.
1) PATIENTS AT LOW RISK:
- A patient with known and treated thyroid disease.
- Asymptomatic and normal thyroid function tests within 6 months.

2) PATIENTS AT MODERATE RISK:

- A patient with known hypo/hyperthyroidism who was treated for the same and
may become hypothyroid or hyperthyroid again.
- Any patient who is asymptomatic and has not had a medical evaluation with in
6 months.

3) PATIENTS AT HIGH RISK:

- Any patient who is symptomatic, regardless of the timing of the most recent
medical evaluation.
 DENTAL MANAGEMENT

1) PATIENT’S AT LOW RISK:

- Normal protocol.

2) PATIENT’S AT MODERATE RISK:

- Normal protocol for most of the procedures.
- Avoid the use of vasoconstrictors and minimize the prescription of analgesics
and sedatives.
- For surgical procedures, medical consultation is advisable.

3) PATIENT’S AT HIGH RISK:

- Can undergo only dental examination procedures.
 PREGNANCY
• The pregnant patient requires special attention to dental management. The dental
care for the mother and developmental concerns of the fetus must be considered
carefully before each encounter.

• ORAL CHANGES DURING PREGNANCY:

- Pregnancy gingivitis.
- Pregnancy tumor.
- Erosion of the palatal surface of anterior teeth.
• TIMING OF THE PROCEDURES:
- The trimester approach is safe for both mother and child because it takes into
account the periods of greater risk of harming the developing embryo or fetus.

• Teratogen: any agent that when exposed to the fetus causes permanent alterations
in function or form of the offspring.
eg. Metronidazole, pencillamine, tetracycline, phenytoin
1st trimester is critical as this is the time of organogenesis.

• Trimesters: first trimester.

second trimester.
third trimester.
DRUG 1st trimester 2nd trimester

LA – lidocaine, yes yes

mepivacaine
Analgesics
Aspirin Yes Yes, but avoid in late 3rd
trimester
Acetaminophen Yes Yes
Codeine Yes Yes
Phenacetin No No
Antibiotics
Penicillin Yes Yes
Erythromycin Yes Yes
Tetracycline No No
Streptomycin No No
Sedatives/hypnotics
N2O2 No Yes
Diazepam No No
Barbiturates No no
 SEIZURE DIOSRDERS
• Epilepsy is not a disease but rather a symptom complex, the result of diverse
neural disturbances. Symptoms range from altered consciousness and motor
activity to aberrant sensory phenomena and behavior.

• PETIT MAL EPILEPTIC SEIZURES are usually restricted to children and

consist of sudden, but usually transient, arrest of movements, attention and
speech. Lasts for 10 to 30 sec.

• GRAND MAL EPILEPTIC SEIZURES represent a more severe expression of

the disease and a complicating factor in dental therapy. Generalized seizure
disorder with loss of consciousness and abnormal motor activities. Usually lasts
for 2 to 5 min. urinary and fecal incontinence may be a part of symptom complex.
Postictal phase with confusion and sleepiness may follow.
• SYMPTOMATIC SEIZURES:
Have identifiable underlying disorders. These include tumors, cerebrovascular
disease, and scars from head trauma. Other causes are high grade fever in young
children( febrile seizures), CNS infections, excessive alcohol ingestion.
• IDIOPATHIC SEIZURES:
No identifiable underlying cause.

Drugs commonly used: Phenytoin (Dilantin), phenobarbital, primidone (Mysoline),

carbamazepine (Tegretol), Valporic acid (Depakene).
Side effects: drowsiness, dizziness, ataxia, and GI disturbances.

Precipitating factors: high intake of caffeine in the form of coffee, tea, or colas, or
moderate alcohol consumption, lack of rest and emotional stress.
 DENTAL EVALUATION

Medical history:
1) Type of seizure
2) Medications used and duration of therapy.
3) Frequency of seizures

DENTAL MANAGEMENT:
1) Patients with a past H/O symptomatic epilepsy who has had a correction of the
underlying disorder and is currently asymptomatic and on no medication can
be treated with normal protocol.
2) Patients with poor control of seizures: elective dental therapy should be
deferred.
3) Patients who are stable and on anticonvulsant therapy: dental therapy should be
proceeded with attention to spacific guidelines.
• SPECIFIC GUIDELINES:
1) RISK OF ASPIRATION
- Rubber dam, choice of restorations, temporary restorations.

2) USE OF DRUGS
- Avoid drugs that suppress CNS like sedation and analgesia. Nonnarcotic drugs
should be used.
- Phenytoin and phenobarbitol are potent stimulators for hepatic enzymes
responsible for drug degradation. (tetracycline and doxycycline (vibramycin)
are two commonly used drugs that have accelerated degradation. Use
alternative antibiotics.

3) GINGIVAL HYPERPLASIA
 Acquired
ImmunoDeficiency
Syndrome
• Dentistry is involved at many levels in dealing with the problems with AIDS.

• These include:
- Initial diagnosis.
- Management of oral problems associated with the disease.
- Providing dental care to the patients with AIDS.
 MEDICAL ASPECTS:

- The virus that causes HIV infection has been isolated from almost all body
fluids, although it is found in highest concentration in blood and serum.

- The major routes of transmission or infection are through sexual contact,

shared intravenous needles, transfusions with infected blood, or vertical
transmission from mother to infant.

- Groups at risk include intravenous drug users, homosexual or bisexual men,

sexual partners of patients with HIV, infants of HIV infected mothers, and
hemophiliacs.
• With clinical disease, the patients have a wasting illness with many systemic
manifestations; fatigue, night sweats, fever, chills, anorexia, and weight loss
are common. Laboratory evaluation reveals leukopenia, lymphopenia and
thrombocytopenia. Evaluation of T cell subsets reveals a decreased CD4
count.

• By definition, opportunistic infections and the occurrence of unusual

neoplasms, such as kaposi’s sarcoma, herald the onset of AIDS. Patients
often have progressive swelling, diarrhoea, depression, and apathy and can
progress to dementia, culminating in a vegetative state.

• As disease progresses, multiple organ systems are involved with cutaneous,

oral, pulmonary, cardiac, renal, gastrointestinal, hematologic and neurologic
sequelae.
 Oral manifestations:

1) Mucocutaneous candidiasis:
May be the first manifestation of AIDS.
As in other immunosupressed hosts, the clinical manifestation ranges from the
classic cheese presentation to areas of broad atropic erythema. Although
the palate is most commonly involved, no area of the oral mucosa is
spared.
Controlled with nystatin mouth rinses.

2) Hairy leukoplakia:
Precedes active infection in 35% of patients.
Patients present with nondescript keratotic lesions, usually on the lateral
borders of the tongue.
Lesions are asymptomatic and require no active therapy.
They should be biopsied, especially in individuals with undiagnosed disease.
3) Periodontal changes:
- HIV gingivitis: presents as erythematous lesion that presents from the
marginal gingiva to alveolar mucosa. Typically asymptomatic.
- Condition mimicking ANUG: loss of papillary architecture, marginal
necrosis, soft tissue catering, and loss of gingival attachment. Lesions are
painful and foul swelling. Rapid loss of alveolar bone may accompany the
soft tissue changes.

4) Thrombocytopenia:
Petechiae on the palatal mucosa.
Areas of minor oral trauma are susceptible to hematoma formation.
5) Apthous like ulcerations:
May be seen on any area of movable mucosa.
The lesions present as severe, large painful ulcerations, with or without bands of
surrounding erythema. They linger for long periods.

6) Kaposi’s sarcoma:
Typical lesions present as bluish red or black macules that are asymptomatic.
However, more aggressive lesions of kaposi’s sarcoma may be raised.
If the tumor involves the gingiva, the lesion may become hyperplastic and
overgrow the tooth’s crown.
Bony lesions of kaposi’s sarcoma may produce a swelling of the overlying
normal mucosa, so that the presentation might be confused with periapical
abscess.
Biopsy is required for definitive diagnosis.
7) Intra oral lymphomas:
Patients with AIDS have an increased frequency of intraoral lymphomas, which
may present in various ways.
The most common presentation is that of a rapidly enlarging mass. In some
cases the surface mucosa may be pigmented, but it is often intact. The lesions
are firm to palpation but lack the rock hardness seen in squamous cell
carcinoma.
Diagnosis by biopsy.
Treatment is usually chemotherapy.
 DENTAL EVALUATION

• The state of immunosurpession.

- Clinical history.
- CD4 count > 500 cells/microlitre - reasonable
immunoresponse.
< 500 cells/ microlitre – significant
immunocompromise.
< 200 cells/ microlitre – severe
immunocompromise.
- medications:
Zidovudine, trimethoprin sulfamethaoxazole may cause leukopenia.
pentamidine – hypoglycemia.
- Physicians consent.
 DENTAL MANAGEMENT

• Concern over becoming infected by a patient with AIDS has

been a psychological barrier that has limited access of AIDS
patients to dental and medical care.

• The law is clear that the practitioner cannot

deny a patient care, based on the patient’s HIV
status.

• Dental management of patients with HIV infection requires

consideration of
1) Their immunocompromised status,
2) Their infectivity.
Conclusion
 REFERENCES:

1) Principles and practice of oral medicine , 2nd

edition. Sonis, Fazio, Fang.
2) Internal medicine II edition. Rose and Kay.
3) Medical emergencies in dental office, DCNA,
1995, 39-3
4) Medical emergencies DCNA, 1982, 26-1
5) Medical emergencies in the dental office, 5th
edition . Malamed.
6) Medical problems in dentistry, 5th edition.
Crispian, Scully and Roderick.