Rehab Tarek Elsharkawy

Ph.D. Medical College of Georgia, USA

Prof. of Oral and Maxillofacial Surgery
Faculty of Dentistry
Cairo University
 Systemic diseases

1. Cardiovascular diseases 7. Immunological diseases

8. Hematologic diseases
2. Pulmonary diseases
9. Pregnancy & breast feeding
3. Gastrointestinal diseases
10. Psychiatric disorders
4. Endocrine diseases
11. Geriatric patients
5. Genitourinary diseases
12. Organ and bone
6. Neurologic diseases
marrow transplantation
 Infective endocarditis
Def: Infective endocarditis (IE) is a microbial infection of the
endocardium or the heart valves that most often occurs in proximity
to congenital or acquired cardiac defects.

Acquired defects: valvular disease, rheumatic heart disease,

atherosclerosis, prosthetic valve, or open heart surgery.

Congenital defects: Tetralogy of fallot.

IE is caused by bacteria (streptococci and staphylococci) and fungi.

IE is a disease of significant morbidity and mortality that is difficult

to treat; therefore, emphasis directed toward prevention.
 IE: PATHOPHYSIOLOGY
1.Injury or damage to an endothelial surface (cardiac
valve, anatomic defect or prosthesis).

2.Fibrin and platelets then adhere to the roughened

endothelial surface and form small sterile masses.

3.If transient bacteremia occurs bacteria can be seeded into

and adhere to the mass.
 IE: PATHOPHYSIOLOGY
4. Additional platelets and fibrin are then deposited onto the
surface and protect the bacteria that undergo rapid
multiplication within the protection of the vegetative mass.

5. Bacteria are slowly and continually released from the

vegetations and shed into the bloodstream, resulting in a
continuous bacteremia.

6. Fragments of the friable vegetations break off and embolize

to distant sites, resulting in infarction, stroke or infection.
 IE Who needs prophylaxis
1. A prosthetic heart valve or who have had a heart valve
repaired with prosthetic material. (Anticoagulant)
2. Previous infective endocarditis
3. A heart transplant with abnormal heart valve function
4. Congenital heart defects (CHD)
• Unrepaired Cyanotic CHD
• Completely repaired CHD with prosthetic material or
device during the first 6 months.
• Repaired CHD with residual defects at the site
 IE: Dental procedures for which
prophylaxis is recommended
All dental procedures that involve:
1. manipulation of the gingival tissue.
2. manipulation of the periapical region of teeth.
3. perforation of the oral mucosa.
 IE: Dental procedures for which
prophylaxis is recommended
All dental procedures Except:
Routine anesthetic injection through non infected tissue.
Dental radiograph.
Removable prosthesis
Orthodontic appliances
Shedding of deciduous teeth
Bleeding from trauma to lip or oral mucosa.
 Prophylactic Regimens for a Dental Procedure
AHA recommendations
Situation Agent Regimen 30-60 min before
procedure
Adults Children
Oral Amoxicillin 2g 50mg/kg
Parentral Ampicillin 2g IM or IV 50mg/kgIM or
IV*

Penicillin Clindamycin 600mg 20mg/kg

allergy oral

Penicillin Clindamycin 600mg IM or 20mg/kg IM or IV

allergy IV
parentral
 IE: Patients already on antibiotics
 Patients already on penicillin or amoxicillin antibiotics for
eradication of other infection or for long term prevention of
rheumatic fever are likely to have resistant group of
streptococci.

 They should either :

Take clindamycin , azithromycin, or clarithromycin.
Avoid cephalosporins because of the cross resistance.
Wait for 10 days after completion of antibiotic therapy before
taking the usual regimen of prophylatic antibiotic.
 IE Coinfection in a premedicated pateint
 Use the same antibiotic for premedication (2g
Amoxicillin PO 1 hr before treatment)
 Use same amoxicillin 500 mg tid /5 days starting 6
hours after the first dose.
 Change the prophylaxis antibiotic for the visits planned
in the next 3 weeks because bacteria will become
resistant after the 5 days treatment course.
 Go back to amoxicillin premedication after 3 weeks.
 Other option is to use clindamycin for treatment of the
infection and keep amoxicillin for the prophylaxis
 IE
NB:
 Antibiotic should be Bactericidal not bactriostatic
 Use antiseptic mouth wash.
 Atraumatic procedure
 VC with the LA to decrease bacteremia.
 ANGINA PECTORIS
Def: It is obstruction of the arterial supply to the
myocardium.

Age: It occurs in men above 40 years.

Caused by progressive narrowing or spasm of one or more

of the coronary arteries leading to imbalance between
coronary blood flow & myocardial oxygen demand
(myocardial ischemia).
 ANGINA PECTORIS
 Underlying causes:

 Coronary artery spasm

 Congenital abnormalities

 Atherosclerosis (it is the

thickening of the internal layer of
the arterial wall caused by the
accumulation of lipid plaques).
 ANGINA PECTORIS
Clinical pic:
 Sub-sternal heavy, squeezing pain or tightness in the mid-
chest region.
 It may radiate into the left shoulder and arm to the neck or
lower jaw.
 The patient complains of being unable to breath.

 Attack is precipitated by: Myocardial O2 demands increase

(by exertion, anxiety, or during digestion of a large meal).
 The pain disappears once myocardial work is lowered or O2
supply is increased.
 Medical Management of Stable Angina Pectoris

Nonpharmacologic methods (lifestyle modifications):

 Exercise program;

 Weight control

 Restriction of salt, cholesterol, and saturated fatty acids

 Cessation of smoking;

 Control of exacerbating conditions such as anemia,

hypertension, and hyperthyroidism.
 Medical Management of Stable Angina Pectoris
Pharmacologic management
 Nitrates: Nitroglycerin, Nitrogard, Nitrolingual
(Dry mouth and Orthostatic hypotension, headache)
 Beta blockers Propranolol (Inderal), Nadolol.
(Taste changes and Orthostatic hypotension)
 Calcium channel blockers
 Anti-platelet agents (Increased bleeding but not clinically
significant with daily doses ≤325 mg) Aspirin.
Management of unstable cases of Angina Pectoris
Revascularization
 Coronary angioplasty (baloon angioplasty) with
stinting.
 Management of unstable cases of Angina
Pectoris
Coronary artery bypass grafting:
CABG surgery is an effective means of controlling
symptoms in the management of unstable angina or
in patients whose pain persists despite medical
control
With CABG, a segment of artery or vein is harvested
from a donor site; it is then grafted to the affected
segment of coronary artery, thus bypassing the area
of occlusion
Two primary graft donor sites are used: the
saphenous vein and the internal mammary artery.
 Dental Management of patient with history of
Angina pectoris
 Consult the patient’s physician.
 Use anxiety-reduction protocol
 Nitroglycerin tablet or spray should be readily available. Use
it as premedication if needed.
 Ensure profound local anesthesia.
 Limited use of vasoconstrictor (maximum 0.04 mg
epinephrine, 0.20 mg levonordefrine).
 Avoidance of epinephrine-impregnated retraction cord.
 NB: Antibiotic prophylaxis not recommended for patients
with coronary artery stents or with history of coronary artery
bypass graft (CABG).
 MYOCARDIAL INFARCTION
 It results from occlusion of coronary artery leading to
deficient blood supply to a region of myocardium that results
in a cellular death & necrosis.
 The infarcted area becomes nonfunctional, necrotic and may
lead to dysrhythmias.

 Generally, It is recommended that elective major surgical

procedures be deferred until at least 6 months after infarction

 Recently with the advent of thrombolytic-based treatment

strategies simple oral surgeries can be performed less than 6
months if it is less likely to provoke anxiety.
 MYOCARDIAL INFARCTION
 Dental management:
 Consult the patient’s physician.
 Use anxiety reduction protocol
 Check whether patient is using anticoagulants.
 Nitroglycerin tablet or spray should be available or
used as premedication.
 Ensure profound local anesthesia.
 Limited use of vasoconstrictor and proper aspiration
tech.
 Avoidance of epinephrine-impregnated retraction cord.
 Coronary artery bypass grafting
Dental management:
 Major oral surgical care for patients who have
had CABG is same as for MI.

 Surgery can be done three months after the

CABG.
 Dysrhythmias
Def: Refers to any variation in the normal heart beat.
 Most arrhythmias are of little concern to the dentist;
however, some can produce symptoms, and a few may
be life threatening (precipitated by strong emotion as
anxiety or by various drugs).

Management:
1.Stress reduction protocol.
2.Limited use of vasoconstrictor to 0.04mg.
3.Check if using anticoagulants and manage.
4.Check if patient having pacemaker or intra-cardiac
defibrillator.
 Arrhythmias
 An implantable cardioverter defibrillator (ICD) is a small device that's placed
in the chest to help treat arrhythmias.
 It uses electrical shocks to control life-threatening arrhythmias, especially
those that can cause sudden cardiac arrest (SCA).
 SCA is a condition in which the heart suddenly stops beating and it usually
causes death if it's not treated within minutes.
 Pacemakers give off only low-energy electrical pulses. They're often used to
treat less dangerous heart rhythms.
 Most new ICDs can act as both pacemakers and defibrillators.
 There is no contraindication of surgery for patient with a pacemaker.
 There is no need for antibiotics.
 Defibrillator patients are usually on Anticoagulant
 Avoid Electromagnetic Interference (electrocautery, Ultrasonic scalers,
neuro-stimulators, Cell phones, High-voltage power lines, electric razors).
 CONGESTIVE HEART FAILURE
Def: it is a complex clinical syndrome that may result from
any structural or functional cardiac disorder that impairs
the ability of the ventricle to fill with or eject blood.

May be due to inability of diseased myocardium to pump

sufficient blood to normal body or excessive metabolic
demand placed on a normal heart.

The underlying causes are coronary heart disease,

hypertension, and valvular heart disease. Also
thyrotoxicosis, congenital heart disease, chronic obstructive
lung disease.
 CONGESTIVE HEART FAILURE
Clinical presentation:
 Dyspnea (shortness of breath)
 Fatigue and Exercise intolerance.
 Orthopnea (dyspnea in recumbent position)
 Paroxysmal nocturnal dyspnea (dyspnea that awakens patient
from sleep)
 Acute pulmonary edema (cough)
 Dependent edema (swelling of feet and ankles after standing
or walking)
 Ascites Jaundice
 Cyanosis Weight gain Clubbing of fingers
 Dental management
For patients diagnosed and treated for HF: hospitalization
1. Identify underlying cardiovascular disease and manage
appropriately.
2. For patients taking a digitalis glycoside (Digoxin),
epinephrine should be avoided, if possible, as the
combination can potentially precipitate arrhythmias. A
maximum of 0.04 mg epinephrine.
3.Use anxiety reduction protocol.
4.Consider possible administration of O2.
5. Avoid supine position (Orthopnea).
6.Watch for Orthostatic hypotension, make position or chair
changes slowly, and assist patient into and out of chair.
 HYPERTENSION
Def: Hypertension is chronically elevated blood pressure
more than 140/90 mmHg.
Sever hypertension: Systolic pressure is more than 180
mmHg or diastolic pressure is more than 110 mmHg.
Dental management: Defer any dental work until condition
is controlled.
Why? If BP rises to a serious level it may cause cerebral
accident or myocardial infarction.
Excessive bleeding may also occur.
Moderate hypertension: Systolic pressure is less than 180
mmHg or diastolic pressure is less than 110 mmHg.
 White coat hypertension.
 Medical management
 Life style modifications
 Diuretics (Lasix)………….Dry mouth, orthostatic
hypotension, NSAIDs for long term may reduce its
effect.
 Beta Blockers (BBs) (Inderal)…….Taste changes, limit
VC and avoid long term NSAIDs
 Calcium channel blockers (CCBs)……Gingival
hyperplasia
 HYPERTENSION
Dental management :
1.Monitor the patient’s BP at each visit.

2.Anxiety reduction protocol.

3.Avoid rapid posture change because antihypertensive agents

tend to produce orthostatic hypotension.
4.Obtain excellent local anesthesia; OK to use epinephrine in
modest amounts (0.04mg).
5.Use local hemostatic measures in case of bleeding.

6.Avoid the use of Na containing IV fluid replacements.

 Patients on anticoagulants
1. Stroke
2. Myocardial infarction
3. Unstable angina pectoris
4. Deep venous thrombosis
5. Prosthetic valves
6. Thrombotic embolism
 Test Normal values

 Bleeding time 1-6 minutes

 Prothrombin time 11-15 seconds

 Thromboplastin time 25-35 seconds

 Platelet count 150.000-400.000/mm3

 < 50.000/mm3: bleeding

 INR 0,9-1,1
 Aspirin

 Patients who take aspirin (platelet aggregation

antagonist) can expect some increase in bleeding.

 Bleeding time can be assessed before invasive

procedures if desired.

 The platelet function analyzer (PFA)-100 may have

some usefulness.
 Aspirin
Dental management:
1. Low dose effect generally is not clinically significant, and
bleeding may be controlled through local measures.
2. High dose:
 If BT is more than 20 mins defer surgery until the drug have
been stopped for 5 days.
 Consult physician to determine the safety of stopping the
aspirin for several days.
 Take extra measures during and after surgery to help promote
clot formation and retention.
 Restart drug on the day after surgery if no bleeding is present.
Clopidogrel
 Warfrin

 The Coumarin drugs inhibit coagulation by

inhibiting the Vitamin K necessary to the synthesis of
factors II,VII, IX, and X.

 Duration of action: 3-5 days

 Onset of action: 12-24 hours.

 Vitamin K injection reverses the action.

 Warfrin
Management:
1. Consultation with the patient physician.
2. PT to determine level of anticoagulation is very important:
INR less than 3 Dosage doesn’t need to be altered.
INR more than 3 Delay until dosage decreased.
3. Stop Warfarin 2 days before surgery, then check INR again
and proceed with surgery if it dropped to 3.0.
4.Local hemostatic measures generally are adequate to control
bleeding.
6. Restart warfrin on the day of surgery
 1. Heparin Therapy
Heparin activates antithrombin III which then inhibits the
coagulation cascade.
Management :
1. Consultation with the patient physicians to determine
the safety of stopping heparin for the perioperative
period.
2. Defer surgical procedures at least 6 hours after the
heparin has stopped or reverse heparin by Protamine.
3. Restart heparin once a good clot was formed.
Dr. Rehab Elsharkawy 43
Regulation of
the acid- base Renal Functions Synthesis of
balance vitamin D

Preservation
of electrolytic Synthesis of
and volume of rennin
extracellular
liquid

Dr. Rehab Elsharkawy

Filtering waste
Synthesis of Synthesis of
metabolic
prostaglandins erythropoietin
products
44
 Renal disease
Types of renal patients:
 Acute renal failure
 Chronic renal disease CRD
 Patient under dialysis
 Patient after renal transplant

Etiology of Chronic renal disease (CRD):

• Diabetes mellitus
• Arterial hypertension
• Glomerulonephritis.

Dr. Rehab Elsharkawy 45

 Management of patients with renal
insufficiency
 The most important features in these patients are:
 Bleeding tendency
 Hypertension
 Anemia
 Drug intolerance
 Increased susceptibility to infections
 Presence of several oral manifestations associated with either
the disease or its treatment
 Chronic renal disease CRD
Bleeding tendency due to:
 1. Alterations in platelet aggregation (uremia)
 2.The dialysis diminishes platelet count due to
mechanical damage
 3. Heparin anticoagulation during dialysis process.

 Increased susceptibility to infection:

 Kidney- transplanted patients are given a lifelong
immunosuppressive therapy, and therefore more
susceptible to infections (bacterial, viral and candidal
infections) and to the development of malignant
neoplasms
 Renal disease
 Kidney function tests

 In dental practice, the function of the kidneys can be

assessed indirectly through serum creatinine (Cr).

 Normal values of serum Cr are 0.5- 1.4 mg/dl

 In patients with renal insufficiency, Cr is ≥ 1.5 mg/dl.

 Chronic renal disease CRD
Oral manifestations
1. Increased serum urea levels increased salivary urea level
where it will turn into ammonia.
 So uremic individuals have a characteristic halitosis (uremic fetor)
with unpleasant metallic taste.
2. Dry mouth, altered taste sensation, and uremic stomatitis.
3. Anemia skin and mucosa paleness
4. Renal osteodystrophy due to alterations in Ca and ph metabolism and
abnormal metabolism of vitamin D
secondary hyperparathyroidism ground-glass appearance of
bone, radiolucent giant cell lesions, abnormal bone healing after
extraction, and, sometimes, dental mobility.
Management of patients with renal insufficiency
1. Communication with their nephrologist.
2. Before any invasive dental procedure, coagulation profile
should be studied.
3. It is essential to remove any infective foci as soon as
possible. (Aggressively manage orofacial infection)
4. Due to the frequent hypertension, Bl.p. should be
monitored during the procedures.
5. When prescribing drugs, those that are nephrotoxic must
be avoided (tetracyclines, aminoglycosides).
6. The altered bone appearance caused by 2ry
hyperparathyroid should not be mistaken for dental
disease.
 Drugs
 Antibiotics:
 Penicillin (and its derivatives, amoxicillin,
amoxicillin/clavulanate) can be safely used with dose
interval adjustment according to the creatinine levels.
 Clindamycin can be safely used with no dose
modifications
 Metronidazole can be used with no dose modifications
 Analgesics:
 Paracetamol is the best choice.
 Aspirin is contraindicated
 Avoid NSAIDs, if it is important, use Ibuprofen without
dose adjustments.
Renal dialysis
Renal dialysis
 Management of patients under renal
dialysis (peritoneal)

 Patient in peritoneal dialysis do not require special

measures apart from the considerations already
mentioned.
Management of patients under renal dialysis
(Hemodialysis)
1. Prophylactic antibiotic in first 6 months after placement of
synthetic vascular access graft.

2. Avoid compression on the arm with the vascular access and

never use it to measure blood pressure nor administering drugs
intravenously.

3. Treatments with a risk of bleeding must not be performed the

day of hemodialysis. If an emergency treatment must be
performed, use protamine sulphate.

4. Elective oral surgery is best undertaken the day after a dialysis.

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.
 Management of patients under renal
dialysis
5. Request Coagulation profile before planning the surgery
and keep Local hemostatic measures ready.
(CBC, BT, PT, PTT, INR)

6. Some drugs must not be prescribed and some need dose

adjustment. Request the serum Cr to estimate the GFR.
Bone more susceptible to fractures so careful dental
extraction technique to avoid fractures

7. Consider hepatitis B, C and HIV screening. Take hepatitis

procedures anyway.
Renal transplant
 Management of patients with renal transplant
1. Accurate medical history.
2. Defer treatment until transplant surgeon clears patients for dental
care.
3. Avoid the use of nephrotoxic drugs, such as aspirin and NSAI
drugs. (Protect the residual renal function)
4. Monitor blood pressure pre and postoperatively.
5. Consider hepatitis screening.
6. If the patient is under corticosteroids, consider the use of
supplemental corticosteroids.
7. Consider the use of prophylactic antibiotics, for patients taking
immunosuppressive agents.
8. Watch for presence of cyclosporine A-induced gingival
hyperplasia. Emphasize importance of oral hygiene.
 Cyclosporine A-induced gingival hyperplasia
 With regard to GO, when it is severe, a surgical
treatment should be performed (gingivectomy).
 The clinical decision of gingivectomy is based on the
presence of functional or esthetic discomfort.
 Promote good oral hygiene.
 Management of pregnant patient
1. Defer surgery until after delivery if possible.
2. The safest time for dental treatment is the second trimester.
3. Consult patient’s obstetrician if surgery can’t be delayed.
5. Anxiety reduction protocol. Establish a healthy oral
environment and an optimum level of oral hygiene.
6. Avoid dental radiographs and if must be taken, use proper
shielding (lead apron).
7. Avoid the use of drugs with teratogenic potential.
8. Allow the patient to take frequent trips to the rest room.
 Management of pregnant patient
9. Avoid keeping the patient in supine position during late
pregnancy for long time to avoid vena caval compression.
(inferior vena cava syndrome)
 Signs and symptoms of supine
hypotensive syndrome in pregnancy
 Dizziness
 Faintness
Left lateral decubitus position.
 Nausea
 Vomiting
 Dyspnea
 Pallor
 Cyanosis
 Hypotension
 Headache
 Tingling/numbness
 Chest/abdominal pain
 Local anesthesia
 Ideally no drug should be administered during
pregnancy especially during the 1st trimester.

LA administered with epinephrine are considered

relatively safe. Although both the local anesthetic and the
vasoconstrictor cross the placenta, subtoxic threshold
doses have not been shown to cause fetal abnormalities so
it is advisable to limit the dose to the amount required.
Lidocaine and Prilocaine are Safe.
 Drugs
Analgesics.
 The analgesic of choice during pregnancy is acetaminophen.
 Avoid Aspirin and NSAI drugs as they convey:
 1.Risks for early constriction of the ductus arteriosus
 2. Risk for postpartum hemorrhage.
 3. Risk for delayed labor.
 4.If taken by nursing mother may cause rashes, platelet
abnormalities, and bleeding in nursing infants.

Antibiotics.
Penicillins, Amoxicillin, Clindamycin, Metronidazole, are
considered safe for the expectant mother and the developing
child.
 Pregnancy drugs categories
 FDA classified drugs into five categories according to
their level of safety to the fetus during pregnancy:
 Category A well-controlled human studies failed to
demonstrate a risk to the fetus.
 Category B Animal reproduction studies have failed to
demonstrate a risk to the fetus and there are no well-
controlled studies in human.
 Category C Animal studies have shown an adverse
effect on the fetus, but potential benefits may warrant
use of the drug in pregnant women despite potential
risks.
 Pregnancy drugs categories
 Category D There is positive evidence of human fetal
risk based on adverse reaction data, but potential benefits
may warrant use of the drug.

 Category X: Studies in animals or humans have

demonstrated fetal abnormalities and/or positive fetal
risk

 Category N: FDA has not classified this drug.

 Pregnancy tumor

Generalized
pregnancy gingivitis
 Management of patient with hepatic disease

 Liver damage • Glucose homeostasis

(cirrhosis) may result • Protein synthesis
from: • Drug metabolism
 Infection • Coagulation
 Ethanol abuse • Bilirubin formation and
 Malaria excretion
 Vascular congestion • Phagocytizing bacteria
absorbed from the GIT into
the portal vein
 Management of patient with hepatic disease
 1. Order liver function tests (Serum aspartate aminotransferase
(AST or SGOT) and alanine aminotransferase (ALT or SGPT)).
 2. Order coagulation profile ( PT, PTT, INR).
 If PT or PTT more than 1.5 times the normal, or INR more than
3 you should use FFP transfusion to supply the patient with
decreased factors.
 Inject with Vit K.
 3. Screen patients for bleeding disorders with Platelet count
and BT.
 If platelet less than 50000 mm/dl Give Packed platelets.
 Management of patient with hepatic disease
4. Avoid hepatotoxic drugs (Acetaminophen high doses ,
chloramphenicol, NSAIDs)
5. Avoid drugs metabolized by the liver:
 Amide LA
 Analgesics: Aspirin and Ibuprofen.
 Antibiotics: Ampicillin, penicillin, erythromycin,
tetracyclines, metronidazole.
 Safe to use: Acetaminophen, Clindamycin.
6. If patient is given steroids, supplement should be given.
7 Universal infection control precautions.
 NB. Severe liver disease may decrease the production of
pseudocholinesterase necessary for hydrolysis of drugs such
as succinylcholine and ester local anesthetics
 Seizure disorders.
 Seizures can result from:
 Ethanol withdrawal
 High fever
 Hypoglycemia
 Traumatic brain damage
 Or they can be idiopathic.
 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.
 Management of patient with epilepsy
Def: Epilepsy is characterized by chronic recurrent, paroxysmal
changes in neurologic function (seizures), altered
consciousness, or involuntary movements caused by abnormal
electrical activity in the brain.
 Management of patient with epilepsy

1. Well-controlled seizures pose no management problems.

2. If poorly controlled seizures, consultation with physician and

consider treatment under deep sedation.

3. Attention to adverse effects of anticonvulsants: (Drowsiness,

Ataxia, Allergic signs, possibility of bleeding tendency in
patients taking (Tegretol) as the result of platelet interference.

4. Possibility of drug induced gingival hyperplasia in case of

phenytoin (Dilantin) .
 Management of patient with epilepsy
• Management of the seizure

a. Clear the area

b. Turn the patient to the side (to avoid aspiration).

c. Passively restrain

d. Do not attempt to use a tongue blade

• After the seizure

a. Examine for traumatic injuries

b. Discontinue treatment.
 Neurologic Disorders

 Patients being treated with MAO inhibitors may receive

vasoconstrictors within the usual dental dosage.

Patients receiving tricyclic antidepressants are at greater risk for the

development of dysrhythmias with epinephrine administration.
It is recommended that when epinephrine is administered to these
patients, its dose be minimal.
Administration of levonordefrin or norepinephrine is absolutely
contraindicated.
Large doses of vasoconstrictor may induce severe (exaggerated)
responses.
 Diabetes Mellitus
Def: Diabetes is a chronic disease characterized by elevation of
blood glucose that results from relative or absolute lack of
insulin.
 hyperglycemia leads to complications that include
microvascular disease of the kidney and the eye and a variety
of clinical neuropathies.
Etiology:
 Autoimmune disorder
 Primary destruction of islet cells by inflammation,
cancer, or surgery.
 Endocrine condition such as hyperthyroidism
 Following the administration of certain drugs as steroids.
 Diabetes Mellitus
Type I: Type II:
 Pancreatic Beta cells are  Tissue insensitivity to insulin
defective in function leading  Onset is usually adulthood
to absolute insulin
deficiency.  Manifestations: Polyuria,
polydipsia, polyphagia,
 Onset usually before 40.
 Usually not prone to
 Prone to ketoacidosis
ketoacidosis
 Treatment exogenous insulin
 Obesity, Genetics
replacement
 Treatment diet restrictions,
and oral hypoglycemics
 Diagnosis

Manifestations: Oral Manifestations

Polyuria  Xerostomia, increased
Polydipsia caries.
 Opportunistic bacterial,
Polyphagia fungal, viral infection
Weight Loss  Poor Wound Healing
Loss Of Strength  Periodontal Disease
Repeated Skin Infections  Mucositis, ulcers, burning
Blurred Vision mouth syndrome, angular
cheilitis.
Paresthesias.
 Diagnosis

Labs:
Fasting blood glucose above 126mg/dl.
2 hours post prandial above 200mg/dl.
Glycosylated hemoglobin (HbA1c)
 Dental management
 Ask the undiagnosed diabetic about signs and symptoms, family
history.
 Ask the known diabetic about their glucose levels, how they
control their glucose, their last doctor’s visit, and if they are
displaying any symptoms of diabetes now.
 Non–insulin-dependent patient: If diabetes is well-controlled,
all dental procedures can be performed without special
precautions.
 Insulin-controlled patient: If diabetes is well-controlled, all
dental procedures can be performed without special precautions.
 If not well controlled: If fasting glucose levels are less than 70
mg/dl, or more than 200mg/dl defer elective treatment and refer
to physician.
 General guidelines
1. Morning appointments are usually best.

2. Stress reduction protocol to decrease adrenalin to

decrease glycogenolysis.

3. Patient advised to take usual insulin dosage and normal

meals on day of dental appointment.

4. Glucose source should be available and given to the

patient if symptoms of insulin reaction occur.
 General guidelines
5. Consult with patient's physician concerning dietary
needs during postoperative Period if extensive surgery is to
be done.

6. Antibiotic prophylaxis can be considered for patients

with brittle diabetes.

7. Epinephrine in the dental cartridge has a pharmacologic

effect that is opposite to insulin. It is normally tolerated by
most controlled diabetic patients, but Octapressin
vasoconstrictor is better.
 Diabetes and acute infection
 Any patient with diabetes and an acute oral infection
presents a significant management problem .
 Infection often leads to loss of control over the diabetic
condition; as a result, infection is not handled by the body's
defenses as well as it would be in the normal patient.
 Patients with brittle diabetes may require hospitalization
during management of an infection. The patient's physician
should be consulted and should become a partner during this
period.
 Managing the Hypoglycemic Emergency

Manifestations of hypoglycemia:

Hunger, nausea, mood change and weakness.

Sweating, Pale, cold skin.

Tachycardia, Tremor

Headache, Confusion

Hypotension, Seizures, and unconsciousness.

 Managing the Hypoglycemic Emergency

Treatment :

Conscious patient: give oral high caloric carbs..

Unresponsive patient: administer IV dextrose (

50 ml of dextrose over 2-3 mins).
1mg of IM glucagon.
 Adrenal Gland
 Small endocrine gland located bilaterally at the superior
pole of each kidney.
 Each gland contains an outer cortex and an inner medulla.

 The medulla functions as a sympathetic ganglion and

secretes epinephrine.

 The cortex (90%) consists of 3 zones and secretes

Corticosteroids:
 Glucocorticoids: Cortisol and Corticosterone.
Mineralocorticoids: Aldosterone.
Sex Hormones: Androgens.
 Regulation of Cortisol secretion
Hypothalamic-Pituitary-adrenal
axis (HPA)
CNS mediating circadian rhythm
and responses to stress.
Stimulates Hypothalamus 
CRH.

Stimulates Anterior pituitary

gland ACTH

Stimulates Adrenal cortex 

Cortisol
 Regulation of Aldosterone secretion
1. Decrease in intravascular volume and
fall in BP
2. Renal cells secrets renin enzyme
3. Renin enzyme activates angiotensin
4. Angiotensin stimulates the adrenal
cortex to secrete Aldosterone.
5. Aldosterone decrease Na and H2O
excretion.
6. Intravascular volume and BP rise.
7. Negative feedback that inhibits
additional production of Aldosterone.
 Aldosterone
Functions and effects
Aldosterone regulates Na and K levels in the extracellular fluid
(Intravasculaer volume).
It promotes Na and H2O retention and k excretion from the kidneys.

Regulation of secretion:
Increased activity of the Renin-Angiotensin system.
ACTH necessary for secretion but doesn’t control the rate of
secretion.
Increase Na ion concentration.
Increased K ion concentration in the extracellular fluid
 Function of Cortisol
1. Regulation of carbohydrates metabolism.
Balance the effects of insulin.
2. Regulation of fat metabolism. Mobilization of fatty acids
from adipose tissue to the plasma.
3. Regulation of protein metabolism. Reduction of cellular
protein (muscles and lymphoid (immune system inhibition).
4. Maintenance of homeostasis during periods of stress.
 maintenance of vascular reactivity to vasoactive agents
and the maintenance of normal blood pressure and
cardiac output.
Stress: Trauma, infection, intense heat or cold, surgery, any
debilitating disease, pain.
 Adrenal Gland
 Small endocrine gland located bilaterally at the superior
pole of each kidney.
 Each gland contains an outer cortex and an inner medulla.

 The medulla functions as a sympathetic ganglion and

secretes epinephrine.

 The cortex (90%) consists of 3 zones and secretes

Corticosteroids:
 Glucocorticoids: Cortisol and Corticosterone.
Mineralocorticoids: Aldosterone.
Sex Hormones: Androgens.
 Regulation of Cortisol secretion
Hypothalamic-Pituitary-adrenal
axis (HPA)
CNS mediating circadian
rhythm and responses to stress.
Stimulates Hypothalamus 
CRH.

Stimulates Anterior pituitary

gland ACTH

Stimulates Adrenal cortex 

Cortisol
 Regulation of Aldosterone secretion
1. Decrease in intravascular volume and fall in
BP
2. Renal cells secrets renin enzyme
3. Renin enzyme activates angiotensin
4. Angiotensin stimulates the adrenal cortex to
secrete Aldosterone.
5. Aldosterone decrease Na and H2O
excretion.
6. Intravascular volume and BP rise.
7. Negative feedback that inhibits additional
production of Aldosterone.
 Aldosterone
Functions and effects
Aldosterone regulates Na and K levels in the extracellular fluid
(Intravascular volume).
 It promotes Na and H2O retention and k excretion from the
kidneys.

Regulation of secretion:
Increased activity of the Renin-Angiotensin system.
ACTH necessary for secretion but doesn’t control the rate of
secretion.
Increase Na ion concentration.
Increased K ion concentration in the extracellular fluid
 Function of Cortisol
1. Regulation of carbohydrates metabolism.
Balance the effects of insulin.
2. Regulation of fat metabolism. Mobilization of fatty acids
from adipose tissue to the plasma.
3. Regulation of protein metabolism. Reduction of cellular
protein (muscles and lymphoid (immune system inhibition).
4. Maintenance of homeostasis during periods of stress.
 maintenance of vascular reactivity to vasoactive agents
and the maintenance of normal blood pressure and
cardiac output.
Stress: Trauma, infection, intense heat or cold, surgery, any
debilitating disease, pain.
 Hypoadrenalism: Etiology
Primary: Destruction of the adrenal cortex.
 Autoimmune, Infection (TB, HIV), Adrenalectomy,
Drugs,
 Malignancy, Hemorrhage (anticoagulants, trauma).
 Secondary:
1. Hypothalamic or Pituitary disease.
2. Administration of exogenous corticosteroids.
Supraphysiologic dose Above 20 mg/day.
Taken daily.
Over long time (more than 2 weeks).
 Hypoadrenalism.
Lack of Cortisol leads to:
1. Failure to maintain normal blood glucose between meals.
2. Impaired fat and protein metabolism.
3. Inability to tolerate stress

Lack of Aldosterone leads to:

Inability to conserve Na and eliminate potassium leading to:
Hypovolemia, hyponatremia, hyperkalemia, and acidosis.
 Hypoadrenalism.
 Weakness.
 Generalized GIT upset with anorexia, nausea, vomiting,
diarrhea, and weight loss.
 Adrenal crisis can be precipitated.

 Hypotension and decreased cardiac output.

 Hypoadrenalism
General Management
Generally the dental procedure better be in the morning 2
hours after taking the dose.
Stress reduction measures are used to decrease anxiety.
Use of nitrous oxide or benzodiazepine sedation may be
helpful.
Blood pressure should be measured before operation and
monitored during and after work.
N.B. Below 100 systolic and 60 diastolic needs corrective
action. Patient positioning, Fluid replacement.
Provide good postop. pain control (analgesics ( NSAIDS) or
long acting L.A. (bupivecaine) or benzodiazepines(
Midazolam) after the surgery.
 Hypoadrenalism
Routine dental treatment
 Routine dental treatment rarely need additional
steroid if on steroids currently (25mg/day).

 If the patient stopped the steroid therapy in less

than 2 weeks then normal daily maintenance dose
should be taken.

 If the patient stopped the steroid therapy in more

than 2 weeks then no dose needed.
 Dental Management
Prevention
Surgical procedure:

1. Instruct the patient to double, triple daily dose on the day

before surgery and day of surgery.
2. On second postop day return to normal dose.
 Dental Management
Prevention

 More than 20 mg of
hydrocortisone or equivalent.
 Oral or parentral.
 For more than 2 weeks
 Within past 2 years
 Thyroid Gland
The thyroid gland secretes 3
hormones
1. Thyroxine (T4)
2. Thriiodothyronine (T3)
3. Calcitonin
 Thyroid Gland
Thyroid hormones have multiple functions
1. They increase metabolic rate (ATP generation)
2. Enhance oxygen consumption
3. Lower cholesterol
4. Potentiate epinephrine
5. Stimulate growth
6. Promote protein, carbohydrates, and lipid metabolism
Calcitonin is involved, with parathyroid hormone and
Vitamin D, in regulating serum calcium and phosphorus
levels and skeletal remodeling.
 Thyroid Disorders
Hyperthyroidism: elevated thyroid function.
Excessive amount of circulating thyroid hormone.
 Graves disease
(diffuse toxic goiter)
 Graves disease is the most common form of
hyperthyroidism.
 It is an autoimmune condition in which
autoantibodies are directed against the
thyroid-stimulating hormone (TSH) receptor.
 As a result, the thyroid gland is
inappropriately stimulated with ensuing gland
enlargement and increase of thyroid hormone
production.
 The disease is classically characterized by the
triad of goiter, exophthalmos, and pretibial
myxedema.
 Hyperthyroid
clinical picture
Nervousness
Fatigue
Palpitation
Rapid heart beats
Weight loss
Heat intolerant
Profuse sweating
Anxiety
Skin is warm, moist, and rosy
Fine hair
Exophtalmus
 Dental management hyperthyroidism
1. No elective treatment should be performed until the patient
has rendered euthyroid
2. The use of epinephrin or other pressor amines (in LA,
retraction cords, or to control bleeding) must be totally
avoided in the untreated or poorly treated patients.
3. Local anesthesia : use LA with octapressin.
4. Avoid General anesthesia for the risk of precipitating
arrhythmias.
5. Antibiotics and analgesics can be
 safely given to hyperthyroid patient until
 medical treatment is provided
 Hypoadrenalism: Etiology

Primary: Destruction of the adrenal cortex.

 Autoimmune, Infection (TB, HIV), Adrenalectomy,
Drugs,
 Malignancy, Hemorrhage (anticoagulants, trauma).
 Secondary:
1. Hypothalamic or Pituitary disease.
2. Administration of exogenous corticosteroids.
Supraphysiologic dose Above 20 mg/day.
Taken daily.
Over long time (more than 2 weeks).
 Hypoadrenalism.
Lack of Cortisol leads to:
1. Failure to maintain normal blood glucose between meals.
2. Impaired fat and protein metabolism.
3. Inability to tolerate stress
Lack of Aldosterone leads to:
Inability to conserve Na and eliminate potassium leading to:
Hypovolemia, hyponatremia, hyperkalemia, and acidosis.
 Weakness.
 Generalized GIT upset with anorexia, nausea, vomiting, diarrhea,
and weight loss.
 Adrenal crisis can be precipitated.
 Hypotension and decreased cardiac output.
 Hypoadrenalism
General Management
 Generally the dental procedure better be in the morning 2
hours after taking the dose.
 Stress reduction measures are used to decrease anxiety.
 Use of nitrous oxide or benzodiazepine sedation may be
helpful.
 Blood pressure should be measured before operation and
monitored during and after work.
N.B. Below 100 systolic and 60 diastolic needs corrective
action. Patient positioning, Fluid replacement.
 Provide good postop. pain control by using analgesics or
long acting L.A. (Bupivecaine) at the end of the procedure.
 Hypoadrenalism
Management in Routine dental treatment
 Routine dental treatment rarely need additional
steroid if on steroids currently (25mg/day).

 If the patient stopped the steroid therapy in less

than 2 weeks then normal daily maintenance dose
should be taken.

 If the patient stopped the steroid therapy in more

than 2 weeks then no dose needed.
 Hypoadrenalism
Management in Surgical procedure
 If patient was taking corticosteroids at least 20
mg of hydrocortisone for more than 2 weeks
within past year:
1. Instruct the patient to take 60 mg of
hydrocortisone the day before surgery
2. 60 mg of hydrocortisone the morning of surgery.
3. In the first 2 postop days drop the dose to 40mg.
4. Drop the dose to 20 mg for more 2 days.
 Thyroid Gland
The thyroid gland secretes 3
hormones
1. Thyroxine (T4)
2. Thriiodothyronine (T3)
3. Calcitonin
 Thyroid Gland
Thyroid hormones have multiple functions
1. They increase metabolic rate (ATP generation)
2. Enhance oxygen consumption
3. Lower cholesterol
4. Potentiate epinephrine
5. Stimulate growth
6. Promote protein, carbohydrates, and lipid metabolism
Calcitonin is involved, with parathyroid hormone and Vitamin D,
in regulating serum calcium and phosphorus levels and skeletal
remodeling.
 Hyperthyroidism: elevated thyroid function.
Excessive amount of circulating thyroid hormone.
 Graves disease
(diffuse toxic goiter)
 Graves disease is the most common form of hyperthyroidism.
 It is an autoimmune condition in which autoantibodies are
directed against the thyroid-stimulating hormone (TSH)
receptor.
 As a result, the thyroid gland is inappropriately stimulated
with ensuing gland enlargement and increase of thyroid
hormone production.
 The disease is classically characterized by the triad of goiter,
exophthalmos, and pretibial myxedema.
 Hyperthyroid
clinical picture
Nervousness
Fatigue
Palpitation
Rapid heart beats
Weight loss
Heat intolerant
Profuse sweating
Anxiety
Skin is warm, moist, and rosy
Fine hair
Exophtalmus
 Dental management hyperthyroidism
1. No elective treatment should be performed until the patient
has rendered euthyroid
2. The use of epinephrin or other pressor amines (in LA,
retraction cords, or to control bleeding) must be totally
avoided in the untreated or poorly treated patients.
3. Local anesthesia : use LA with octapressin.
4. Avoid General anesthesia for the risk of precipitating
arrhythmias.
5. Antibiotics and analgesics can be
 safely given to hyperthyroid patient until
 medical treatment is provided
Management of asthmatic patient

 True asthma is episodic narrowing of small

airways with wheezing, cough and dyspnea.

 It results from chemical, infectious,

immunological, or emotional stimulation.
 Management of asthmatic patient
1. Defer dental treatment until asthma is well controlled and
patient has no signs of respiratory tract infection.
2. Anxiety reduction protocol.
3. Provide prophylaxis of adrenal insufficiency if patient is or
was taking steroids.
4. Keep a bronchodilator inhaler (theophyllin) easily
accessible. The epinephrin aerosol better also be present.
5. Avoid use of Aspirin and other NSAID drugs because they
often precipitate asthma in susceptible persons.
 Asthma
Bronchial smooth muscles
constriction, complete or
Causes:
partial airway obstruction
and inflammation. Extrinsic: Allergic reaction
(younger people)
Intrinsic: Respiratory
infection (after 35, acute
episodes)
Emotional stress/anxiety
 Asthma
Symptoms:
Mild to Moderate Severe
 Tightness in chest  Intense dyspnea, with
 Nonproductive coughing flaring of nostrils and use
spasms of accessory muscles of
respiration
 Inspiratory and expiratory
wheezing  Cyanosis of mm and nail
beds
 Anxiety
 Minimal breath sounds on
 Tachypnea
auscultation
 Tachycardia
 Flushing of face
 Sweating
 Mental confusion
 Loss of consciousness.
 Asthma
Management
 Upright position, fully sitting comfortable.
 Bronchodilator (Beta-2 agonist metered dose
inhaler , albuterol) (inhaler, 2-6 puffs initially,
repeat in 15-20 minutes).
 Administer oxygen
 Reduce anxiety
 Monitor vitals
 Asthma
Management
Severe bronchospasm: Status asthmaticus
 Activate EMS.
 Epinephrine (beta-1 and 2 agonist) 0.3
ml 1:1000 SC injection

 Glucocorticoids (to relieve the

inflammation) 100-125 mg
methylprednisolone IV
 Hemorrhagic disorders
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).
 Hemorrhagic disorders
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 to ensure that a good
initial clot forms.
6. Instruct the patient on ways to prevent dislodgment of the
clot and on what to do should bleeding restart.
7. Avoid prescribing nonsteroidal anti-inflammatory drugs
(NSAIDs).
8. Take precautions against contracting hepatitis during
surgery.