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:

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

Calcitonin
Located at or below the level of the thyroid cartilage.

Hyperthyroidism
T3 & TSH
Thyroid T4
Dysfunction
Hypothyroidism T3 & TSH
T4
C
A
U
S
E
S

S
Y
M
T
O
M
S
Oral Manifestations:

- If a suspicion of thyroid disease arises for an undiagnosed patient, all elective

Dental Consideration
dental treatment to put on hold untill full medical evaluation.

-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, to form a platelet plug

Hemostasis 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 (Rendu-Osler-Weber syndrome )

‫َتَو ُّسُع الُّش َع ْيرات‬

⮚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 bleeding (.g. during surgery). Aspirin is a common cause of platelet dysfunction
Thrombocytopenia Production (bone marrow failure)

⮚Megaloblastic anaemia ‫َفْقُر الَّد ِم الَّض ْخ ُم اَألرومات‬

⮚Aplastic anaemia (due to drugs [ cytotoxics chloramphenicol] viruses, chemicals or irradiation)

‫ال تنُّسجي‬

⮚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) ‫ِذْئَبٌة ُحماِم َّيٌة‬
⮚post-transfusion purpura Splenomegaly ( to liver failure )
⮚Large transfusion of stored blood (dilution of platelets)
⮚Disseminated intravascular coagulation (DIC)consumption platelets
Thrombasthenia ‫( َو َهُن الُص َ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.

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, ‫اْع ِتَالٌل َخ ْثِر ّي‬

⮚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
 ANEMIA

► 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

► If platelet count is less than 20000

cells/mm³ all dental procedures are
► Physician consultation
contraindicated
► If thrombocytopenia is caused by a reversible

process, dental extractions should be deferred

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 50000-100000 cell/mm³: Platelet count less than 50000 cells/mm³:

► Some clinical bleeding after dental extraction ► Platelets

procedures
transfusion is necessary for dental

► Regional block injection can be done safely ► Platelet count should be optimized prior to local

► Atraumatic removal of 1 or 2 teeth can

proceed (attention to hemostasis)
anesthesia

► Block anesthesia is contraindicated

► Hemostatic local measures
►Always physician 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

HEMOPHILIA A (classic)

Treatment include:

⦿ Physician consultation
doses:
⦿ Hospitalization

⦿ Coverage under factor VIII concentrate ⦿ amicar 5 g orally one hour after extraction and
1 g every hour thereafter for six doses
(best)or

⦿ Fresh frozen plasma ⦿ Tranexamic acid (cyaklokapron) 25 mg/kg

every 6 hours, starting the day prior to dental
⦿ Epsilon- aminocaproic extraction and continued after surgery until

Acid (Amicar) bleeding stopped

⦿ Tranexamic Acid

⦿ Local measures as for thrombocytopenia

 LEUKEMIA

LEUKEMIA REFER TO A NUMBER OF NEOPLASTIC DISESASES OF THE

BLOOD-FORMING ELEMENTS OF THE BODY

GENERAL SYMPTONS: ORAL MANIFESTATIONS:

• Insidious and nonspecific • gingival bleeding

• Fatigue • petechia
ORAL SOFT TISSUE
• Malaise

OR GINGIVAL INFECTION
• Fever

• lymphadenopathy
• PHARINGITIS
 LEUKEMIA

Treatment:
Laboratory findings:

► Anemia ► Chemotherapy
► Bone marrow transplantation
► Leukopenia

► 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
Leukemia
 LYMPHOMAS

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
 LYMPHOMAS

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)
 9. PRERADIATION THERAPY

NOT HEALTHY TEETH IN THE LINE OF RADIATION THERAPY SHOULD

BE REMOVED TO AVOID OSTEORADIONECRISIS

 LIVER DISORDERS

► 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:

1.Abnormalities in Metabolic processes

Drug intolerance
2.Abnormalities in Coagulation.
Possible viral 3.Abnormalities in drug metabolism
causes
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 infection, - Jaundice

-Autoimmune hepatitis - Portal Hypotension

-Hepatoxins - Hepatosplenomegaly

-Idiopatic - Ascites ‫ االستسقاء (تراكم السوائل في جوف البطن‬,‫الحبن‬

 -Minimize Drugs metabolised in liver.
-Avoid hepatoxic drug
Dental
-LA is safe with small doses and least concentration
Management:

⭶ 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:
In Dental Clinic
-Hypoglycemia
Most commonly seizures due to
-Drug induced (lidocaine)
-Acute Head Trauma -Hypoglycemia
-Brain tumors -Hypoxia secondary to syncope
-Brain Abscess -LA overdose
-Stroke -Seizure in epileptic patients
-Meningitis
-Alcohol intoxication
 Epilepsy:

Epilepsy:
Mostly occurs randomly
►A neurologic disorder characterized by sudden, Trigerring factors
transient, recurrent disturbance of brain function
-Missed a dose of antiepileptic drug -
that may or may not be associated with impairment
-Flashing, flickering lights
or loss of consciousness and abnormal movements or - Stress
behavior. - Infection

- Dehydration or starvation
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

Ensure medications have been taken properly relative to dental appointments to

A good Case history:
► minimiz risk of seizure.
– Type

- Severity Ensure proper lighting ( No light directly on eyes)

- Frequency

- 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

► Iffrom
it can be safely done, quickly remove all foreign material
the patient’s mouth

► The chair should be placed in a supine position

► Ifaspiration
possible, turn the patient to their side in order to minimize
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 َخِّدر‬or barbiturates ‫ ُم َهِّدئ‬as they

are respiratory depressants. ‫ُم َخ ِّم د‬

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 & Aldosterone ‫ينتج 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 0.6 – 1.2 mg / 100 ml blood

Elevated BUN ( blood urea nitogen) ( 8-23 mg)

Oral manifestations: Medical Management:

Stomatitis Artificial blood filtration ( dialysis)

Parotitis Kidney transplantation

Urine like odour in 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