For Dentists & Students: Management of Medically Compromised Patients in The Dental Chair

Medically compromised patients are those ill people who may or may not tolerate a dental appointment and whom require a modification in the treatment plan depending upon the challenge imposed.

A good thorough medical and drug history of the patient is mandatory and its considered to be a key factor when managing these patients.

These patients include those with:

  1. Bleeding disorders
  2. Heart diseases
  3. Chronic renal failure
  4. Liver diseases
  5. Pulmonary (lung) diseases
  6. Endocrine diseases
  7. Pregnant/lactating mothers
  8. Neurological disorders

In this article, I will be discussing the common diseases or medical conditions that any dentist or student may face during his/her practice and how we should react to it.

  • Bleeding disorders

Any patient with bleeding diseases should be asked about any history of spontaneous and prolonged bleeding along with the types of drugs that the patient is taking.

Hemophilia: is a hereditary bleeding disorder occurs due to deficiency of certain clotting factors.

blood_vessel

The severity of the disease will have to be assessed by the physician before attempting any dental surgical procedure.

The dental management of such patients include:

  1. These patients should be managed under the supervision of their physicians on site. The physician might recommend replacing the deficient clotting factor by IV (Intravenous) infusion provided in the hospital using the Fresh Frozen Plasma or the Fresh Whole Blood by Blood Transfusion.
  2. Clotting factor concentrates should be administered before and after the dental surgery.
  3. Use anti-fibrinolytic agent (tranexamic acid or Epsilon aminocaproic Acid “EACA”) before the surgery for a total of 7 days.
  4. Desmopressin can also be used to increase factor VIII level in some patients with mild to moderate forms of Hemophilia A.
  5. Fibrin glue is used as a local hemostatic measure to control the bleeding in some hospitals to reduce the need for blood transfusions. However, it should not be used in patients whom have never received human derived blood products or those who are receiving a clotting factor replacement therapy with a recombinant factor VIII or IX.
  6. Dental pain can be managed with acetaminophen analgesics (paracetamol). Aspirin should be avoided since it will inhibit platelets aggregation. The prescription of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) should be discussed with patient’s physician.
  7. Prior to giving anesthesia, let the patient rinse with chlorhexidine mouthwash for 2 minutes. An infiltration technique can be done without the need for any factor replacement therapy. The use of Articaine local anesthetic agent will be favorable for both upper and lower teeth because of its excellent bone penetration capacity. Any nerve block injections can be used only after raising clotting factor levels because of increased risk of hematoma in pterygomandibular space that might compromise the airway. This also applies with any lingual injection into an area with a rich plexus of blood vessels.
  8. Any surgery ranging from simple to complex one’s require a replacement therapy, ensure that the oral cavity is properly free from plaque and calculus. The surgery should be carried as atraumatically as possible along with proper suturing of the wound.
  9. If a post-surgical hemorrhage (bleeding) occurs, inspect the site of the bleeding. If there is any evidence of tear in the gingiva or other obvious bleeding points, it should be treated using local measures by applying pressure over it for 5-10 minutes. In case of a simple surgical extraction of a tooth, instruct the patient to bite on a damp gauze for 10 minutes or use a 10% solution of tranexamic acid to dampen the gauze, or use it as a mouthwash if the bleeding is difficult to stop. The patient blood pressure should be monitored as it may increase due to worry and pain. Anti-Microbials such as oral Penicillin V 250mg four times daily given post-operatively for a full course of 7 days to decrease the risk of secondary hemorrhage.
  10. The prevention of any dental problem is an essential component for dental care. Regular dental check up along with advising the patient to thoroughly brush his teeth with a fluoride toothpaste. Fluoride mouth rinses can be used on either daily or weekly basis. Also, the consumption of foods and drinks with a high sugar or acid content should be limited to meal times.

Hypoprothrombinaemia: is a deficiency in prothrombin factor produced by the liver in blood. This condition is seen with newborn babies, patients with obstructive jaundice, and patients in whom the vitamin-K producing organisms have been greatly reduced as a result of protracted therapy with a broad spectrum antibiotics. Patients drug history will have to be obtained as he might be taking oral anticoagulants. These patients are best managed in the hospital.

Anaphylactoid Purpura: is a condition that occurs as a result of a defect in the walls of the capillaries and its characterized by purpura and allergic manifestations such as urticaria (a rash of round, red welts on the skin that itch intensely, sometimes with dangerous swelling, caused by an allergic reaction, typically to specific foods), joints pain and swelling, and angioneurotic edema (is the rapid swelling of the dermis, subcutaneous tissue, mucosa and submucosal tissues).

Anaphylactoid Purpura

Severe hemorrhage may occur when operating on these patients and precautions should be taken.

The Ehlers-Danlos Syndrome: is a hereditary collagen disease presenting primarily as dermatological and joint disorders.

vEDS_type_poster3_2

These patients may undergo routine dental surgery, however, a few precautions should be taken as some forms of this syndrome can predispose to fragile blood vessels, thus a regional nerve block should be avoided to avoid the risk of rupturing the fragile vessels by the needle which can be life-threatening. Serious forms of this syndrome as well can have poor tissue healing and difficulty with retaining sutures in place if oral surgery is needed.

Leukemia: is a pathological condition of neoplastic nature, characterized by quantitative and qualitative defects of circulating white blood cells. These patients should be treated with special care and always under consultation with the patient’s physician.

Leukemia

Regional nerve blocks should be avoided as these patients are at high risk for bleeding, anemia, and infection. The surgery should be carried out as atraumatically as possible with the use of local hemostatic measures to control the bleeding. Platelets infusion or blood transfusion might be needed and antibiotic prophylaxis should be administered.

Anemia: Patients with anemia should have their hemoglobin levels evaluated and must be as near the normal as possible.

Symptoms_of_anemia

Consultation of the patient’s physician is a must prior to the dental treatment. Pain and severe stress during the treatment should be avoided hence, profound anesthesia is recommended. Patients suffering from methemoglobinemia presents a relative contraindication to the use of Articaine and Prilocaine local anesthetic agents. Conscious sedation can be used only with adequate oxygenation with avoidance of deep sedation due of increased risk of hypoxia. In case of Vitamin B12 deficiency, Nitrous Oxide sedation should be avoided since it will interfere with its metabolism. In case of any emergency, a blood transfusion might be necessary and its considered as the ideal way to replace red and white blood cells, and platelets. Antibiotic prophylaxis will have to be prescribed due to increased risk of osteomyelitis in patients with sickle cell anemia.

Thrombocytopenia: is medical condition characterized by a decrease of platelets count in blood which can predispose the patient to excessive unstoppable bleeding. The management of such patients should be under the physician’s supervision and by obtaining a complete blood count test to determine the count of platelets in blood. When giving anesthesia, a local infiltration technique is more preferable and safer than nerve block injections. Nerve block injections should only be given when the platelets count is above 30000. Hemostasis after a tooth extraction is usually adequate if platelets count are above 50000. In case of extensive, complex surgeries, the platelets count should be above 75000. A local hemostatic measures will have to be employed by the use of desmopressin, surgicel, or gelfoam. Conscious sedation can be given but general anesthesia shall only be given in hospitals with expert intubation to avoid the risk of submucous bleeding into the airway.

Von Willebrand’s Disease: is an inherited deficiency in Von Willebrand Factor (vWF). A deficiency in vWF will lead to a deficiency in factor VIII concentration in the blood. It will also lead to a defective platelets adhesion.

Von Willebrands Disease

Managing such patients shall be under consultation of the patient’s physician of whether the treatment can be carried out safely or the patient may require a factor replacement therapy. A local infiltration anesthesia can be generally used safely. Aspirin and NSAIDs should be avoided.

  • Heart Diseases

Hypertension: is an increase in blood pressure. Any patient with hypertension must have his blood pressure assessed at his first dental appointment and prior to any treatment procedure. All present or past medications have to be evaluated. A patient with a long term of hypertension is at high risk of cardiovascular or renal diseases.

HN_BB_Blood_Pressure_5_treat-img_1280x720

Managing these patients in the dental office require the supervision of the patient’s physician. The stress and anxiety should be reduced during the treatment by providing a profound and effective local anesthesia. However, excessive amounts of local anesthesia should not administered. Anxiolytic or sedative drugs can be given 30 minutes – 1 hour before the operation and administered orally. The afternoon appointments is the best time suited for these patients. It shall be noted that controlled hypertensive patients shall not exceed the 0.04 mg maximum dose of vasoconstrictor located in local anesthetic agents.

If the patient is uncontrolled, he/she shall be referred to the hospital or back to their physician in order to get their blood pressure controlled.

Epinephrine containing gingival retraction cord should be avoided because the epinephrine used here is at high concentration and may cause a dramatic increase in blood pressure.

dental_retraction_cord_teethThe use of vasoconstrictor for direct hemostasis should be avoided due to increased risk of rebound hemorrhage. Also, avoid the use of local anesthetics with vasoconstrictors in intraligamentary or infrabony infiltrations because these are very painful and stressful injections for the patient and the rate of absorption of epinephrine equals its IV administration.

When taking an impression, stimulation of gag reflex should be avoided.

dental-impression

It shall be noted down that the use of NSAIDs can decrease the antihypertensive drugs efficacy.

Patients with blood pressure values ranging from 140-160/90-95 mmHg may undergo oral surgery safely. On the other hand, patients with blood pressure values over 190/110 mmHg are not allowed to have a regular dental treatment.

Moving the dental chair from supine position to sitting position and vice versa should be done gradually due to increased risk of orthostatic hypotension seen in patients taking antihypertensive drugs. If the surgery requires a general anesthesia, it shall be done in the hospital with the supervision of their cardiologist.

Congestive Heart Failure: is the inability of the heart to supply enough oxygenated blood to the body tissues and cells.

Congestive-Heart-Failure-Management-Program-03

Patients with untreated congestive heart failure should not undergo any routine dental therapy. These patients are most often prescribed with diuretics, cardiac glycosides such as digoxin, beta-antagonists, or calcium channel antagonists. In addition, patients with chronic atrial fibrillations caused by hypertrophic cardiomyopathy are usually prescribed with Warfarin.

If the patient is well compensated through dietary and drug therapy can safely undergo ambulatory oral surgery. Stress and anxiety should be kept to the minimum and supplemental oxygen supply is helpful. Local anesthetic with a vasoconstrictor can be used safely but the dose shall be minimized with particular importance of aspiration before injection. The appointment should be as shorter and painless as possible. Patients with orthopnea should not be placed in supine position.

If the patient is covered with digitalis which is a drug that can increase the contractility of the heart are prone to nausea and vomiting during the dental treatment. Erythromycin and tetracycline antibiotics should be avoided because they can decrease the count of certain bacterial strains present in gut that are responsible for metabolizing digoxin and hence, can increase the risk of digitalis toxicity.

If pulmonary congestion develops while the patient is in supine chair position, return the chair to the upright position gradually with adequate oxygen supply then refer him to the hospital. If the patient complains of fatigue and weakness, the appointment should be terminated and rescheduled accordingly.

Local anesthetics with 1:100000 epinephrine can be used safely except in patients with severe arrhythmia where they can receive plain Mepivicaine or Prilocaine or Prilocaine with Felypressin. NSAIDs should be avoided in patients receiving Angiotensin Converting Enzyme Inhibitors (ACEI).

Cardiac Arrhythmia: is any periodic variation in the normal rhythm of the heart caused by disturbance of the excitability of the ventricles where its mainly controlled by Sinoatrial (SA) node.

Some of these patients may have a pacemaker in their heart and may be disrupted by any external electromagnetic field such as those generated by powerful magnets including resonance imaging. CT Scan, Ultrasonography, plain radiographs are the safest techniques of obtaining a radiographic image. MRI on the other hand should be avoided. Ultrasonic scalers, Electronic Apex Locators, and Electrocautery should be avoided or kept to a minimum distance of 50 cm between the device the pacemaker.

Epinephrine is contraindicated in all arrhythmias and should be used with caution (by reducing the dose and careful monitoring of the patient). The safest LA (local anesthetics) are plain Mepivicaine or Prilocaine. The use of Bupivicaine should be avoided.

cq5dam.web.1280.1280

These patients may be placed under anticoagulants if they have a history of ischemic heart diseases. Its shall be noted that the American Heart Association states that there is no need for administration of antibiotic prophylaxis in patients with pacemakers.

Angina Pectoris: is a clinical syndrome that is characterized by temporary ischemia in part of or all of the myocardium. Its divided into 3 types:

  1. Stable Angina Pectoris
  2. Unstable Angina Pectoris
  3. Myocardial Infarction

For the first type of angina pectoris, it refers to chest pain that results from a predictable amount of exertion and that respond to Nitroglycerin.

angina-pectoris-charactersThe dental appointment for such patients should as shorter and painless as possible. Morning appointments are more recommended for such patients. A profound local anesthesia is recommended placing in mind not to exceed the maximum recommended dose.

For the second type, it represents a clinical syndrome which is intermediate between stable angina and myocardial infarction. The patient may experience a progressive increase in frequency or severity of pain. The angina may occur at rest after minimal exertion or it may become more resistant to relief by nitrates. These patients should only receive emergency or minimal dental care and only after consultation with their physician. Administration of Vasoconstrictors is contraindicated and hospitals may the most suitable environment for such patients.

When treating patients with stable or unstable angina, their vitals signs should be periodically monitored and a fresh bottle of nitroglycerin tablets or spray must be nearby for use when necessary.

0071-0418-24_1

Myocardial Infarction: occurs when the narrowed coronary arteries become acutely occluded. Affected patients generally report crushing substernal pain frequently with radiation to the neck, jaw, or left arm. It may be accompanied with shortness of breath, anxiety, and nausea. The highest risk of death following acute myocardial infarction occurs during the first 12 hours where the risk of ventricular fibrillation is the greatest.

Signs_and_Symptoms_of_a_Heart_Attack

Managing these patients should be done under the consultation of their physician. Only minimal treatment for acute dental problems is advised within 6 months of an infarction. Beyond that, he/she can be treated in the same way as a patient with angina. Anxiety reduction program should be followed and Nitroglycerin tablets shall be readily available to use when necessary. They can also be used prophylactically when dictated by the patient’s primary care physician. Local anesthetics with epinephrine can be used safely although minimizing the dose will be necessary. Vital signs should be periodically monitored.

Coronary Artery Bypass Grafting: is procedure that involves connecting a healthy artery or vein from the body to a blocked coronary artery.

Blausen_0152_CABG_All

These patients are treated in the same way as a patient with Myocardial Infarction. Before an elective major surgery is performed, 6 months are allowed to elapse. If its necessary however before 6 months, it shall be done under consultation with their physician.

Coronary Angioplasty: is a surgical procedure that involves the induction of balloon tipped catheters into narrowed coronary arteries and stenting arteries to keep it open.

what-is-a-coronary-angioplasty

If the procedure was successful, oral surgery can then be performed soon after with the same precautions used for patients with angina pectoris.

Cerebrovascular Accident (Stroke): Patients with a history of stroke are always susceptible to further neurovascular accidents. They are generally placed on anticoagulants and on anti-hypertensives if they have high blood pressure.

flyer

Before proceeding with any dental procedure, the patient’s baseline neurologic status should be assessed. Anxiety reduction program must be implemented with the vital signs recorded periodically. If pharmacological sedation is necessary, a low concentration of Nitrous Oxide can be used.

Valvular Heart Diseases: is common in individuals of all ages. It results from any pathological processes that can damage or affect the function of these valves such as rheumatic fever, and congenital heart defects. These patients may suffer from valvular stenosis and regurgitations. The dental treatment of a patient with a valvular heart diseases faces 4 major risks:

  1. Heart failure
  2. Significant arrhythmia
  3. Infective endocarditis
  4. Bleeding tendency

Thus any treatment shall take into consideration these 4 risks and the precautions are taken accordingly.

Any dental procedure that involves manipulation of soft tissues resulting in bleeding can produce a transient bacteremia. Blood-borne microorganisms may lodge on damaged and abnormal heart valves, in the endocardium, or in the endothelium, near congenital anatomic defects resulting in Infective endocarditis. Hence, these patients might require antibiotic prophylaxis and they should be administered as well after the oral surgery.

Patients Receiving Anticoagulants should receive a special dental care under the consultation of their physician. The most commonly used drugs are Warfarin, Heparin and Aspirin.

Warfarin’s mechanism of action involves antagonizing the Vitamin K dependent synthesis of several coagulation factors. It has a delayed onset of action but a prolonged effect of up 72 hours. Its effectiveness is monitored by International Normalized Ratio or as known as INR.

warfarin

Managing Warfarnized patients require the supervision of their physician. The INR should be checked on the day of the operation or, if that is not possible, a day before the operation. If the oral surgery is simple and INR < 3.5, the surgery can be performed without any further risks. A local hemostatic agents can be used to control the bleeding. If the surgery on the other hand is long and complex and INR >3.5, the patient should be treated in the hospital.

Discontinuing any medication or modifying its dose shall be done in coordination with the patient’s physician. The surgical procedure is best carried out in the morning with primary closure of the wound by resorbable sutures. Applying pressure by a gauze saturated with tranexamic acid for 10 minutes can help in hemostasis. If the bleeding is controlled, the patient is dismissed and a follow-up after 7 days is required. A phone number of the office shall be given with instructions to call if post-operative bleeding occurs. Antimicrobials such as oral Penicillin V 250 -500 mg four times daily or Clindamycin (for Penicillin sensitive patients) should be prescribed post-operatively for a full a course of 7 days.

Next is Heparin. Its mechanism of action is that it acts immediately on blood coagulation to block the conversion of fibrinogen to fibrin mainly by inhibiting the thrombin-fibrinogen reaction. The effect of heparin lasts approximately 4-6 hours but it may be prolonged up to 24 hours.

Heparin_Sodium_sample

For a simple uncomplicated oral surgery, Heparinized patients can be treated safely without any interference to the anticoagulant therapy provided that the Activated Partial Thromboplastin Time (APTT) is within the normal therapeutic range. For more advanced surgical procedures, it shall be done under consultation of the patient’s physician.

In patients receiving renal dialysis, the surgery is best carried out in the next day of renal dialysis since the patient will be in the best physiological status and the effect of heparin will be lost.

654px-Hemodialysis-en.svg

Lastly is Aspirin. It shall be noted that aspirin irreversibly impairs platelet aggregation and is used long term in the prevention of cardiovascular events and stoke in patients at risk.

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In the majority of the patients, they will be prescribed with no more than 100 mg of aspirin, if so, and if the surgery is simple and uncomplicated, it can carried out normally without interfering with aspirin treatment. Suturing the wound and packing the surgical area with a resorbable gelatin sponge, oxidized cellulose, or collagen can be carried out if necessary. If the patient is receiving more than 100 mg of aspirin, consultation of the patient’s physician will have to be obtained.

  • Renal Diseases

Chronic Renal Failure: is a clinical syndrome characterized by permanent kidney damage resulting in impaired glomerular or tubular function of the kidney and its strongly associated with a certain disease. Dental management of such patients can be challenging. A special consideration has to be given to avoid drugs that are primarily excreted by the kidney & Nephrotoxic drugs should be avoided as well.

  • Liver Diseases

Any patient with a liver disease present many of challenges during the dental surgery. Because the liver is involved in many functions such the production of clotting factors, metabolizing drugs and many others, a disease in the liver itself can affect the whole body in general. Operators and students shall have their Hepatitis B vaccination taken to decrease the risk of transmission of viral hepatitis.

In general, treatment of these patients shall in the hospital setting, however in some cases, a consultation of the patient’s physician is enough. Depending on the medical history of the patient, the bleeding time must be checked prior to any treatment. Antibiotics prophylaxis is usually suggested since liver dysfunction is most often associated with diminished immune competence. Acetaminophen analgesic is the safest in these patients as other NSAIDs carry the risk of gastrointestinal hemorrhage and other side effects due to poor metabolism of these drugs in the body.

Alcoholic Liver Disease require the patient to have a number of laboratory test obtained and it includes: CBC (Complete Blood Count), Liver Function Test, Bleeding time, and Prothrombin time. These patients are best managed under the supervision of their physicians and they must get their liver to a controlled state before attempting any oral surgical procedures. When administering Paracetamol, inform the patient to avoid alcohol since both of them when combined can result in a number of serious side effects as they are both metabolized through the same enzyme.

alcoholic-fatty-liver-disease

  • Endocrine Diseases

Diabetes Mellitus: is a disorder characterized by impairment or destruction of the pancreas ability to produce insulin.

Diabetes is divided into 3 types:

  1. Type 1, or the Juvenile Diabetes Mellitus or Insulin Dependent Diabetes Mellitus
  2. Type 2, or the Noninsulin Dependent Diabetes Mellitus
  3. Gestational Diabetes seen in pregnant women

Diabetes-Symptoms

Managing a diabetic patient requires the operator to obtain a full accurate history of the type of diabetes, the severity and control of the diabetes, and the presence of any cardiovascular or neurologic complications or renal diseases.

Because the most common complication when treating a diabetic patient is the Hypoglycemia, it is best if the surgery is carried out in the morning preferably 1-1.5 hours after breakfast. Stress and anxiety should be reduced to the minimum with shorter and painless appointments as possible. The administration of an anxiolytic medication is recommended in the morning before the surgical procedure. Local anesthesia with a vasoconstrictor and sedation can be safely given as well. Signs of hypoglycemia include, hypotension, drowsiness, nausea, tachycardia, or any other mood changes. When seeing these signs, the treatment is suspended and the chair is returned to supine or trendelenburg position to increase the blood supply to the brain. Giving the patient any source of sugar like chocolate or juices might be beneficial. If the patient loses consciousness a venous access is maintained and an ampule (50 mL) of 50% glucose (dextrose) in water is administered IV over 2-3 minutes.

hypo

To prevent a hypoglycemic shock from occurring, a 3 step approach is maintained:

  1. Verify that the patient has taken his medication as usual.
  2. Verify that the patient has had adequate intake of food.
  3. Schedule appointments in the early morning

It shall be noted that when prescribing any kind of drugs, a consultation of the patient’s physician is essential since the hypoglycemic action of sulphonylureas can be potentiated by aspirin, beta blockers, & ACEI.

If the patient is well controlled by diet and oral hypoglycemic medication, a careful assessment of blood glucose level by using the glucometer is essential.

Diabetic patient doing glucose level blood test using ultra mini glucometer and small drop of blood from finger and test strips isolated on a white background. Device shows 115 mg/dL which is normal
Diabetic patient doing glucose level blood test using ultra mini glucometer and small drop of blood from finger and test strips isolated on a white background. Device shows 115 mg/dL which is normal

The glycosylated hemoglobin blood test is more specific and can give the average measurement of the blood glucose level for 2-3 months, thus it can show whether the patient is controlled or not. Uncontrolled diabetic patient must get his condition back into control with the help of their physician before attempting any oral surgical procedure.

Hyperthyroidism: is condition that results due to excessive circulating amounts of T3 and T4 which is most often caused by Graves disease, thyroid adenoma, and thyroiditis.

The early manifestations of Hyperthyroidism includes excessive sweating, tachycardia, palpitations, weight loss, fine and brittle hair, hyperpigmentations of skin, and exophthalmos.

j2QBr

Managing hyperthyroid patients require a specific dental care. If its suspected from the history and inspection of the patient, the gland should not be palpated as it can trigger the release of thyorid hormone and may lead to thyrotoxicosis. Uncontrolled hyperthyroid patients should be referred for medical evaluation before any oral surgical procedure. These patients are sensitive to epinephrine contained in local anesthetics and gingival retraction cords and thus they should not be administerd until hyperthyroidism is controlled.

It should be well known that the symptoms of hypothyroidism on the other hand include fatigue, constipation, weight gain, hoarseness, headaches, arthralgia (joint pain), menstrual disturbances, edema, dry skin, and brittle hair and fingernails.

Signs_and_symptoms_of_hypothyroidism

Adrenal Insufficiency: is the underproduction of steroid hormones from the adrenal gland. It can happen if the patient is on a long term corticosteroid therapy.

Dental management of such patients require the supervision of the physician and treatment is best carried out in the early morning.

If the surgery is simple like a tooth extraction under a LA and the patient was covered with steroids during the previous 12 months, they can be covered by giving the usual dose in the morning or hydrocortisone 25-50 mg IV immediately pre-operatively.

If steroids however, is currently taken, doubling the oral steroids in the morning or covering them with supplemental oral steroids 2-4 hours pre and post operatively (20-25 mg hydrocortisone or 20 mg prednisolone or 4 mg dexamethasone or hydrocortisone 25-50 mg IV pre-operatively). The normal medication regimen shall be continued normally after the operation.

Cortisol_for_injection

If the surgery is intermediate like multiple extractions, minor oral surgery under LA, or oral surgery under general anesthesia and the patient was not covered with steroids during the previous 12 months, coverage with supplemental steroids is only given if large doses of steroids where given by testing the adrenocortical function.

If the patient was covered with steroids during the previous 12 months, giving the usual dose in the morning plus hydrocortisone of 25-50 mg IV pre-operatively and intramuscularly (IM) every 6 hours for 24 hours. The patient shall then continue his normal medication regimen post-operatively.

If the steroids is currently taken, doubling the oral steroids in the morning plus hydrocortisone of 25-50 mg IV pre-operatively and IM every 6 hours for 72 hours. The patient shall continue with his normal medication regimen after the operation.

Adrenal insufficient patients are more prone to infections and osteoporosis and they should be covered with antibiotics.

  • Pregnancy/Lactating Mothers

Although its not a disease state, pregnancy is still a situation in which special considerations are necessary when oral surgery is required.

pregnancy-small

Later pregnancy where 10% of the patients may become hypotensive if laid in supine position due postural hypotension phenomenon, and thus they must be treated in upright position.

A pregnant women should be properly shielded to receive dental x-rays. When drug treatment is unavoidable, penicillin, cephalosporins, erythromycin, and clindamycin are probably considered safe antimicrobials. Paracetamol is the safest oral analgesics to be prescribed. A routine dental treatment under LA is proved to be safe.

  • Respiratory Diseases

Asthma: asthmatic patients presents a considerable risk and challenge during the dental treatment. It shall be noted that if the patient is receiving bronchodilators such as theophylline and corticosteroids, he/she is considered to have a severe asthma. Thus the use of local anesthesia with a vasoconstrictor should be avoided as 10-15% of the patients might be allergic to the sodium bisulphite located in local anesthetics. While patients whom are carrying sympathomimetic amines, such as epinephrine or salbutamol in an aerosol form are considered to have a mild to moderate asthma.

Man about to use asthma inhaler

Anxiety and stress shall be avoided and reduced to the minimum during the dental appointment. Nitrous Oxide sedation is safe to administer in asthmatic patients and is especially indicated in patients whom asthma is triggered by anxiety. The patient own inhaler should be readily available during the surgery and drugs such as Injectable epinephrine and theophylline should be kept in the emergency kit. The use of NSAIDs should be avoided because they often precipitate asthmatic attacks in susceptible individuals.

Patients with Chronic Obstructive Pulmonary Diseases frequently suffers from dyspnea during mild to moderate exertion. They have chronic cough that produces large amounts of thick secretions.

images_248

When managing these patients whom are receiving corticosteroids, the dentist shall consider the use of additional supplementation before the surgery. Sedatives, hypnotics, and narcotics that depresses respiration should be avoided. Patients may need to be kept in an upright position to reduce the secretions of thick mucous. Finally, supplemental oxygen during the surgery should not be administered unless the physician advises it.

  • Neurological Disorders

Epilepsy: is the clinical manifestation of abnormal electrical activity of the brain. Its usually associated with a history of head trauma, intracranial neoplasm, hypoglycemia, and drug withdrawal. Managing these patients require the reduction of stress and anxiety during the dental treatment.

The use of mouth props can be useful in facilitating the suction process and to remove foreign objects which can impair the airway and to avoid trauma during the incident of a seizure.

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When dealing with a seizure, the patient should be kept in a supported supine position and turning him to the side to control the airway and minimize aspirations of secretions. In most of the situations, the seizure will take no more than 1 to 2 minutes. If its taking more than that, administering diazepam of 5 mg/minute should help stop the seizure. Don’t forget to call the emergency department.

First-Aid-for-Seizures3_Page_2


At the end of my article, I hope I have included every possible situation that you might face in your practice. Included with this article is a short video that summarizes everything briefly at a nice, beautiful and a funny way.

If you have benefited from this article, please let me know, it really makes my day after all knowing that I helped in something.

Any questions or concerns or additional situation to add, leave it in the comment section. I read each and every comment.

Haider Maitham, DDS – Bondistry

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