Management of medically

compromised patients in
the dental office

Dr. Samy mounir

B.Ch.D/M.Sc/Ph.D
Lecturer OMFS. MSA University.
“Dentist is no longer
treating teeth in
patients, but rather
treating patients who
have teeth”
The oral cavity is a common site for the
early manifestations of many
systemic diseases.
Importance
Recognition of existing medical condition enable
the dentist for :
 Adequate preparation.
 Premedication.
 Prophylaxis.
 Adjustment.
 Prepare for any adverse effects.
 Postoperative consideration to control.
 Bleeding.
 Infection.
Patients classification
ASA Classification for Determination of
Medical Risk (American Society of
Anesthesiologist)
 ASA I: Normal patient.
 ASA II: Mild to moderate systemic disease.
 ASA III: Severe systemic diseases limiting patient’s
activity.
 ASA IV: Severe systemic disease threatening the
patient’s life.
 ASA V: Morbid patient.
Treatment options
1- Office treatment
ASA type I
ASA type II
2-Hospitalization
ASA type III
3-Hospitalization & emergency treatment only
ASA type IV
4-Hospitalization and palliative treatment
ASA type V
 Stress reduction protocol
A)Measures before appointment
1-Arrange for morning appointment

2-Hypnotics may be prescribed to the patient on the night before

surgery (optional)

3-Avoid long reception waiting period

B)Measures during appointment

1-Frequent verbal assurance of the patient

2-surgical instruments away from the pt sight

3-Adequate and profound anethesia prior any

surgical maneuvers

4-Inform the pt ahead before any step (donot surprise

the patient)

5-Adequate control of bleeding

c)Measures after the appointment

1-Clear postoperative instructions

2-inform the patient about the possible post operative

complications

3-Effective analgesics to control postoperative pain

4-An emergency phone no. is given to the patient

5-The surgeon may make a call for the patient at the nigth of
surgery for any unexpected postoperative complaint
Reviewing the patient’s general health
should appraise the following:

1- Cardiovascular diseases.
2- Respiratory difficulties.
3- Endocrine imbalance.
4- Metabolic deficiencies.
5- Neurologic diseases.
6- Haemorrhagic problems.
7- Blood Dyscrasias.
8- Allergic conditions.
1. CARDIOVASCULAR DISEASES
Cardiovascular diseases:

 Hypertension.
 Ischemic Heart Disease.
 Congestive Heart Failure.
 Infective Endocarditis.
 Cardiac Arrhythmias
1. HYPERTENSION
 The cardiac output and the peripheral
resistance maintain normal blood pressure.
Alterations in one of these factors lead to
hypertension.
Types:
 Primary hypertension (idiopathic or
essential)
– which accounts for 2/3 of hypertensive pts.
 Secondary hypertension
– caused by renal disease, adrenocrtical insufficiency,
C.N.S lesion. This type accounts for 1/3 of
hypertensive patients.
Classification of Hypertension
 Diastolic pressure
– <85 Normal
– 85-89 High normal 90-104 Mild
– 105-114 Moderate >115 High
 Systolic pressure
– < 140 Normal
– 140-159 Borderline
– >160 Hypertension of old age
Symptoms of Hypertension
 Asymptomatic
 Ringing ears
 Nose bleeding
 Dizziness
 Odontalgia
 Occipital headache
Complications of Hypertension

 Cerebral hemorrhage.
 Ischemic heart disease.
 Renal failure and heart failure.
Dental Considerations of Hypertension

 Stress reduction protocol.

 Minimal amount of VC
 Avoid rapid or intra vascular injection
 Postural hypotension may occure as a side effect of
anti hypertenstion drugs
 Xerostomia and oral ulceration may be present as a
side effrct to hypotensive drugs
 1:100.000 VC concentrations is used till 2 carpules.
 On emergency basis a patient with poorly controlled
hypertension should be hospitalized & local
haemostatic measures are taken to avoid
postoperative hemorrhage.
 2. ISCHEAMIC HEART DISEASES

 Occur as a result of imbalance between the oxygen

consumption & oxygen supply of the heart muscle.
 It is manifested clinically as:
1- Brief pain (1 to 3 minutes) =Angina pectoris,
(temporary coronary insufficiency).

2- Prolonged pain (1/2 to one hour or more) =

Myocardial infarction, ( death of cardiac muscle).
A. Angina Pectoris

 Angina pectoris means sever chest pain , it is

considered as a symptom of an ischemic heart
disease rather than a separate entity disease

 angina pectoris developedwhen an extra effort

is required from the mayocarduim while there
is a lack of sufficient blood and oxygen supply
to the heart due to partial occlussion or
narrowing of the CORONARY ARTRIES
Characteristics of Angina pectoris

1. Pain usually developed

secondary to excersice
, stress and after
heavy meals
2. Pain usually described
as sever squeezing
pain localized or may
radiate to the left
arms, shoulder, or
neck.
 B. Myocardial Infarction
"Coronary thrombosis"
"Patient on anticoagulant therapy"

 Is a clinical syndrome caused by deficient coronary

artery blood supply to region of myocardium that
results in cellular death and necrosis.
 Symptoms of Myocardial Infarction

1. Prolonged angina-type pain > 30 minutes.

2. Tachycardia & irregular pulse.
3. Nausea & vomiting.
4. Difficulty in breathing.
5. Complications associated with myocardial
infarction (MI) include shock, heart failure &
cardiac arrest.
6. Skin is cool, pale & moist.
7. Nail beds, mucous membrane are cyanotic.
8. Weak pulse.
Risk factors :

 Family history
 Hypertension
 Diabetis mellitus
 Smoking
 High serum lipids (atherosclrosis)
Dental Therapy Considerations:

1.Stress reduction protocol

2-Patients should have their medication

availble (sublingual nitroglycrin)

3- Avoid dental treatment up to 6 months after

coronary thrombosis (re-infarction & death).

4-oxygen by mask
5.Medical consultation

6- Morphine sulphate is the drug of choice to

relieve pain.
7-patients on anticoagulant therapy ---anticoagulant
is used to reduce the mortality in patient with high
risk of ischemic heart disease
*)Anticoagulant agents are :
1-heparin
2-warfarin (marivan)
3-Asprin (oral most commonly used)

*)medical consultation is required to reduce the

dose of the anticoagulant for patient undergoing
oral surgery to prevent postoperative
hemorrhage

8. Avoid Atropine →tachycardia.

Emergency treatment

1. Termination of dental procedure.

2. Position (P) patient comfortably.
3. A - B - C. (Airway, breathing, Circulation).
4-INFECTIVE ENDOCARDITIS
Introduction
 4. INFECTIVE ENDOCARDITIS

 It is a microbial infection of the

heart valves or the endocardium.
(streptococcus viridans)
 The causitive organism
(streptococcus viridans) enter
the circulation when bleeding
occurs even with minor
gingival treatment..without
antibiotic coverage the bacteria
will adhere to the roughened
or damaged valve
 In patients at risk of infective
endocarditis the micro-organisms
adhere to the damaged areas of the
heart valves forming platelet
adhesions and crumbling vegetations
of platelets and fibrin that may be
carried as emboli in the blood stream.
 Degree of risk:
1- High degree of risk:
- Patients with surgically replaced heart valve.
- Patients with recent surgical repair of a cardiovascular defect.
- Patients with a history of a previous attack of infective
endocarditis
2- Moderate degree risk:
- Most other congenital cardiovascular defects.
- Rheumatic heart disease
- Systemic Lupus Erythematosus
3- Low degree risk
- Coronary sclerosis.
- Cardiac pacemaker.
 Clinical Features of Infective Endocarditis

 Septicemia
 Petechial haemorrhage
in skin & mucous
membranes
 Finger clubbing & nail
bed haemorrhage
 Embolic complications in
the kidneys, brain, eyes
or other organs
 Prophylactic Regimens for Oral or
Dental Procedures

Standard General Prophylaxis:

 Antibiotic covarage
*)the antibiotic should be :
1-Bactercicdal not bacteriostatic
2-starts 30-60min preoperative
3-Maintaned for 3 days postoperative
4-penicillin is the most effective antibiotic
Patient allergic to Penicillin / Amoxicillin /
Ampicillin:
 Clindamycin:
– Adult 600 mg
– Child 20 mg/kg

(Orally one hour before procedure or IV 30 minutes

before procedure)
Ex :
1-loading dose:
600,000 unit penicillin I.M 30-60min preoperative
*)Maintenance dose :
500mg oral penicillin every 6 hrs for 3 days

2-Loading dose :
2gm oral penicillin 30-6-min preoperative
*)Maintenance dose :
500mg oral penicillin every 6 hrs for 3 days
*)patients allergic to penicillin

 Loading dose
1 gm erythromycin 30-60min preoperative
OR
1gm vancomycin by I.V infusion 30-60min
preoertaive

*) *)Maintenance dose :
500mg oral erythromycin every 6 hrs for 3
days
5. CARDIAC ARRHYTHMIAS

Condition
Abnormal pulse rate or rhythm, Pace maker.
Symptoms of Arrhythmia
Palpitation of heart.
Fatigue and dizziness.
Syncope.
Anginal attack & Cardiac arrest
Medical Treatment
Medications, Surgery, Implantation of Cardiac
Pacemaker
Dental Considerations of Arrhythmia

1- Medical consultation.
2- Stress reduction protocol.
3- VC in L.A. are contra­indicated in patients with severe
arrhythmia.
4- Avoid G.A.
5- Electromagnetic radiation in the dental office can
interfere with the pace maker.
6-In case of rapid heart rate → Carotid sinus massage
3 - Endocrine diseases
1 - DIABETES MELLITUS

 DM is a complex disease with a

metabolic and vascular components
 The metabolic component involves
elevated blood glucose with alteration
of lipid –protein metabolism
 The vascular component involves high
risk of atherosclerosis and
microangiopathy
A. Classification of Diabetes
1-Idiopathic, hereditary, Primary
- Insulin Dependent Diabetes IDD Type (I) (T1DM)
- Non-Insulin Dependent Diabetes NIDD Type (II) (T2DM)
2-Glucose intolerance associated with certain conditions (secondary
diabetes)
- Acromegaly
- Hyperthyroidism
- Cancer pancreas
-pregnancy (temporary)
I. Idiopathic diabetes

- The most common type

- Unknown etiology
- Fasting glucose level > 140 m g/dl.
Type (I) IDD Type (II) NIDD

☺ 10% to 20% of ☺ 80% to 90% of

diabetic patients diabetic patients
☺ Common before the ☺ Plasma insulin level is
age of 25 years generally normal or
☺ Plasma insulin level is slightly increased
nearly absent and the ☺ Decrease in number of
cellular receptor sites cellular receptor sites
for insulin are usually for insulin.
normal or increased. ☺ Treatment is usually
☺ Must be treated with by weight reduction,
insulin drugs or insulin.
Diabetic foot
Clinical manifestations

 Polyuria
 Polydepsia
 Polyphagia
 Loss of wiegth
 Peripheral neuritis
 Periodontal disease
Lab investigations

 Normal fasting blood sugar is 80-

120ml blood
 Fasting blood sugar > 140 ……DM
 2hrs p.p blood sugar >160 ……DM
 Glycosolated heamoglobin >5.5 …..DM
Precautions (dental consideration)
 History
-)measure blood sugar level
-)determine the severity of the condition

Uncontrolled diabetic patient are

contraindicated to surgical procedure

-)controlled patients should be treated

after intake of food and the
hypoglycemic drug
 Stress reduction protocol

 Prophylactic antibiotics

 CORBASIL is the most suitable

vasoconstrictor as it has only 1/10 of
the effect of adrenaline in raising
blood sugar level

 All pts should be watched for tehe

posibilty of diabetic coma
Diabetic Comas

– A state of unconsciousness that results from

both hyperglycemia (diabetic coma )or from
hypoglycemia ( insulin shock ).
– The two comas should be differentiated in the
dental practice.
– Hypoglycemic coma is more dangerous than
hyperglycemic coma , because the brain can
only utilize glucose as a source of energy
 Oral manifestations of Diabetes

1. Non-specific.
2. Increased incidence
of gingival and
periodontal disease.
3. Xerostomia
4. Acetone breathing
in advanced stage
of the disease.
5. Denture sore mouth
 Management
Injection of 50ml of glucose IV or even a
50% glucose orally will correct
hypoglycemia and will not cause any
harmful effect if the condition is
hyperglycemia
 High glucose level in blood will
increase the risk of infection as a
result of the following :
1-flourshmint of bacteria
2-decrease the phagocytic power of
neutrophils
3-ketoacidosis decrease chemotaxis
 High glucose level in blood will
interfere with the wound healing as a
result of the following :
1-Atherosclrosis and microangiopathy
decrease the blood flow
2-presence of glycosolated collagen
3-hyperlipidemia interfere with
macrophage function
2. THYROID GLAND
(secretes: T3,T4 and Calcitonin)
1. Hyperthyroidism
(Toxic goiter, Grave's disease)

T3 and T4 in the blood beyond the body requirements.

Signs and Symptoms of Hyperthyroidism
1. Weight loss and increased appetite.
2. Anxiety and emotional instability.
3. Tremors of the hands, tongue and eyelids.
4. Warm moist skin.
5. Profuse sweating and heat intolerance.
6. Palpitation, Tachycardia.
7. Exophthalmos
8. Thyrotoxic crisis can occur spontaneously
or may be precipitated by stress or
vasopressors.
Dental Considerations of Hyperthyroidism
– Stress reduction protocol e.g. premedicate with
5-10 mg diazepam or short acting barbiturate.
– Avoid vasoconstrictor in L.A.

Signs and Symptoms of Thyroid Crisis

– Extreme restlessness.
– Hyperthermia and profuse sweating.
– Marked tachycardia.
– Severe hypotension.
 Management of Thyroid Crisis (unconscious
hyperthyroidism)
– BLS
– Definitive management is concentrated on:
 Decrease body temperature (Cold packs)
 Decrease blood levels of thyroid hormone
(Corticosteroids, antithyroid drugs, IV fluids to
correct dehydration).
– Do not use:
1. Atropine.
2. Use with caution L.A with epinephrine.
3. Prilocaine with felypressin can be given.
2. Hypothyroidism
– Cretinism (childhood hypothyroidism)
– Myxoedema in adults.
 Signs and Symptoms of
hypothyroidism

1. Weight gain.
2. Cold intolerance.
3. Dry skin.
4. Mental retardation.
5. Menstrual disturbances in females.
6. Slow pulse (bradycardia).
 Dental Considerations of Hypothyroidism
– Main danger in hypothyroidism is of precipitating
myxoedema coma by use of sedatives (including
diazepam), opioid analgesics (including codeine),
tranquilizers and general anesthetics.
– These drugs should be avoided or given in low
dose.
– Hypotension, bradycardia, decrease cardiac output
may be associated with hypothyroidism.
– Local anesthesia is preferable to G.A.
Management of myxedema coma

– BLS
– Thyroxin injection
– Steroids
END OF PART I
3. ADRENAL INSUFFICIENCY
(Addison's disease, patients under steroid therapy)

– The adrenal gland cortex secretes two principal

hormones: Aldosterone and cortisol.

– Aldosterone is involved in the maintenance of

sodium, potassium and fluid levels.

– Cortisol is the main glucocorticoid of the body.

 Primary adrenal insufficiency (Addison's disease) is
caused by atrophy or destruction of the adrenal
glands by infection (TB) or malignancy.

 Secondary adrenal insufficiency is caused by

deficiency of ACTH from chronic administration of
steroids.
 Predisposing factors:

– Following sudden withdrawal of steroid

hormones.
– Following stress whether physiologic or
pshycologic.
– Following sudden destruction of pituitary
gland.
– Following injury to both adrenal glands by
trauma, infection.
Rule of two's:
Adrenocortical suppression should be suspected if
patient received steroid therapy through two of
the following methods:
1. In a dose of 20 mg or more of cortisone or its
equivalent.
2. Via oral or parenteral route for continuous
period of 2 weeks or longer.
3. Within 2 years of dental therapy.
Clinical manifestations:
 Extreme fatigue.
 Weakness.
 Hypotension with systolic blood pressure
less than 110 mmhg.
 Nausea.
 Vomiting.
 Hypoglycemia.
 Patient on corticosteroids
– Consider SRP and adrenocortical insufficiency and
treat corresponding to stress.
– In minimal stress do not change the dose of
corticosteroids.
– In moderate stress, double the normal dose one day
before surgery and two days after surgery.
– In major stress give 100 mg hydrocortisone 1/2 -1 hr
before surgery, then continue 50mg for 2-3 days
after surgery, followed by 20 mg twice daily for the
next 3-4 days to return to the normal dose at the 7th
postoperative day.
Management:

1. Put patient in shock position

2. Oxygen administration
3. Decadron I.V (4-12mg) or 100-200,g
hydrocortisone, I.V.
4. If blood pressure does not return to normal levels
give Vasopressor drugs such as wyamine
sulfate(I.V.).
5. In case of G.A., poor risk anaesthetic patients
should be hospitalized.
6. Night before surgery give 100mQ,
hydrocortisone IM.
7. Repeat the dose immediately before surgery.
8. Postoperatively
 50 mg hydrocortisone after recovery.

 2 times the normal dose on the second day.

 Normal dose on the third day.
4-LIVER DISEASES
1-Hepatitis • Hepatitis means
inflammation of the liver.
• Primary hepatitis is viral
hepatitis, toxic hepatitis and
drug – induced hepatitis as in
alcoholic liver diseases.
• Secondary hepatitis includes
Syphilis and TB.
 Infective hepatitis (type A)
It is due to contaminated food or water.
 Serum or viral hepatitis (types B or C)
It is usually transmitted by infected blood products,
following blood
Clinical features:Diagnosis
1. Jaundice which is manifested clinically as yellow
discoloration of skin and eyes is usually
considered as a general sign of underlying liver
disease
2. Antigen-antibody marker to diffrentiate between
difrent types of viruse
3. Idntefy patients with high risk as :
a-Hemodyalysis patients
b-multiple blood transfusion
c-Drug abusers
4- High liver enzymes (SGOT , SGPT)
Preventive measures for dentists & other patients
(infection control):
1.use protective barrier technique
Gloves(double gloving is recommended)
Surgical mask
Protective eye wear glasses or plastic face shield
2. Hands thoroughly washed with water and soap after gloves
removal.
3. Use and special care of sharp instruments and needles
4. Extreme care handling
5. Disposable needles and sharp objects should be disposed in
a hard proof container after use. Never recap, bend or
break used needles.
6. Instrument sterilization
 Strict instrument autoclaving
 Cover environmental surface with disposable clean
adhesive tape or aluminum foil & change after each
patient.
 Impressions materials and trays cleaned with tap water
from blood and saliva and disinfected by immersing in
sodium hypochlorite for 15 minutes before sending to the
lab.
 Use sterilizable hand pieces, ultrasonic scalers and
air/water syringes.
 Use freshly prepared 2% glutaraldehyde solution for
instruments which cannot be autoclaved.
 Use disposable instruments and equipments.
LIVER DISEASE

2-Liver Cirrhosis
– This is characterized by hepatic parenchymal
damage with fibrosis and distortion of the
normal lobular pattern of the liver.
– Etiology
 Idiopathic.
 Alcoholism, Bilharziasis.
 Hepatitis.
 Autoimmune liver disease.
Management of mild cirrhosis:

1. Medical consultation
2. It is better to do surgery after controlling prothrombin time,
bleeding and clotting times to be within normal limits. (Pt.
twice normal).
3. Vitamin k administration 10mg/12hrs before and after
surgery.
4. Ester group (procaine) is safer than the non-ester group
(lidocaine) which undergoes biotransformation in the liver,
while the ester is biotransformed by hydrolysis in the plasma.
5. Two carpules of 2% and 1:100.000 V.C can be used safely.
 6-Avoid dental drugs metabolized primarily by the
liver, such as:
 Lidocaine.
 Aspirin.
 NSAID.
 Diazepam and barbiturates.
 Ampicillin and tetracyclines.
 The safe drugs to be used are:
 Paracetamol for pain control
 Clindamycin and flagyl as antimicrobial drugs.
 Procaine as local anaesthetic drug.
5. RENAL FAILIURE
Function of kidney

 Kidney has a biochemical and metaboloic roles

-)Maintain removal of unwanted waste
products from the blood

-)Electrolyte balance

*)Kidney function as an endocrine gland to produce

prostaglandin and erythropoietin
Sequlea of RENAL FAILIURE
1-sever electrolyte imbalance

2-hemorrhagic tendency

3-bone resorption (renal osteodystorophy)

4-Yellow brown pigmentation

5-Hypertension

6-Alteration in WBCs funtion

Lab investigations

 Serum ceriatenin
 Blood urea nitrogen
 Electrolyte measurement (high
potassium and low sodium and
calcium)
 Urine analysis
 Treatment of Renal Failure
 Conservative: This is accomplished by:
– Diet modification with protein and salt restriction.
– Proper fluid and electrolyte adjustments.
– Avoid nephrotoxic drugs.
– Treatment of anemia, infection or other complications.
 Dialysis: Artificial filtration of the blood. Heparin is
administered during the procedure to prevent blood
clotting.
 Kidney Transplantation: Either from a living donor or from
a cadaver.
 Dental Considerations of Renal
Failure Patients
1. Patient under conservative care:
 Medical consultation
 Screen for bleeding disorders or anemia.
 Avoid nephrotoxic drugs including:
– Amino glycosides.
– Aspirin.
– Cephalosporin.
– Penicillin.
– Nonsteroidal anti-inflammatory drugs.
 Safe drugs are:
- Lidocaine.
- Ibubrufen.
- Diazepam.
- Erythromycin.
2. Patient receiving Hemodialysis:
 In addition to the conservative care
recommendations avoid treatment in the
same day of dialysis. (heparin)
 The best time is the day after dialysis.
 Screen for viral hepatitis and treat the patient
as a potential carrier.
3. Patient with renal transplant

 In addition to the conservative recommen­dations,

consider corticosteroid supplementation and
cytotoxic drugs.
Patients on cytotoxic drugs
 They are prone to infection and poor wound healing.
 Prophylactic antibiotic therapy should be given to
minimize bacteraemia and bacterial endocarditis.
 The kidneys are the primary excretory organ for all
local anesthetics agent and their metabolic products so
renal dysfunction delay the elimination of the local
anesthetics agent from the blood leading to overdose
reaction so we must reduce the dose of L.A.
BLOOD DYSCRASIAS
1. Red Blood Cell Disorders
I. Anemia (decrease
in RBC count 4<
million/cm3)
Causes of anemia:
A. Deficient R.B.Cs. production
1. Deficiency of iron, B 12,
folic acid, vitamin C,
protein.
2. Marrow infiltration as in
leukaemia, Hodgkin's
disease.
3. Symptomatic e.g. anemia of
chronic infection, liver
disease, kidney disease.
II. Polycythemia (increase in
RBC count to > 8 million/cm3).
2.White Blood Cell Disorders
A. Leukocytosis, Granulocytosis (increase in
WBCs count > 11.000/cm3)
1. Physiologic leukocytosis in pregnancy,
exercise and emotion.
2. Pathologic leukocytosis: infection,
neoplasm, allergy.
B. Leukopenia, Agranulocytosis (decrease in
WBCs count <4.000/cm3)

1. Toxic reaction to drugs, chemicals and

radiation.
2. Leukemia.
3. Lymphomas
– Hodgkin's disease, usually multifocal in
children.
– Non-Hodgkin's lymphoma, single focus, at any
age associated with AIDS.
– Burkitt's lymphoma, associated with Epstein-
Barr virus, among complications of AIDS.
C. Leukemia
Characterized by the
progressive overproduction
of immature WBCs in the
blood. Often the earliest
signs of this fatal disease
are the gingival bleeding
and ulceration
 Dental consideration in blood
Dyscrasias

1. Dental surgery is contraindicated if

hemoglobin concentration < 8 – 10 gm/ml.
2. Expect delay wound healing in case of
anemia
3. Local haemostatic measures and
prophylactic antibiotic therapy to prevent
post-operative infection.
4. Oral manifestations of WBCs disorder
include gingival bleeding , oral ulceration ,
infection , loosening of teeth
Bleeding disorders

 A)coagulation factor deficiency

-----------------------------------------
-)Hemophilia
It is a hereditary sex linked disease that
occurs only in males
Types

 Hemophilia A : deficiency in plasma

antiheamophilic globulin (factor Viii)
 Heamophilia B (Christmas disease) :
deficiency in plasma thromboplastin
component (factor x)
 Pseudoheamophilia deficiency in
vonwillbrand factor , it affects males
and females
 Platelets abnormalities
ex :>thrombocytopenic purpura
*)blood vessels abnormalioties
-)vitamin c deficiency (scurvy)
-)hereditary hemorrhagic
telangiectasia
Precautions in patients with
hemorrhagic disease

 Patient should be hospitalized

 The deficient factor must be replaced

 Local heamostatic measures (pressure

pack , oxidized cellulose , gel foam)
Presurgical Lab investigations

 Prothrombin time (PT) (Normal level

11-15 seconds)
-)The PT test is used to monitor patients
taking certain medication as well as to
help to diagnose clotting disorders
 Partial throboplastin time (PTT)
(Normal level 25-35 seconds)
-)blood clotting (coagulation) depends
on the action of substances in the
blood called clotting factors.
measuring the (PTT) helps t assess
which specific clotting factors be
missing or defrctive
 Bleeding time (Normal level 1-6
minutes)
-)bleeding time is a test of hemostatsis
(the arrest or stopping of bleeding). It
indicates how well platelets interact
with blood vessel walls to form blood
clots
 INR (International normalized ratio)
(normal ratio for healthy person is 0.9-
1.3)
-)A high INR level such as INR=5
Indicates that there is high chance for
bleeding , where as if the INR=0.5
then there is a high chance of having
a clot
Neurologic Diseases
 2. EPILEPSY (SEIZURE
DISORDER)

Epilepsy comprises a group of

disorders characterized by sensory
and motor abnormalities as well as
loss of consciousness
Epileptical seizure occurrs because
of abnormal electrical charge in
brain
Dental consideration

 Medical consultation
 If the attack occurs :

1-stop the procedure

2-place the patient in post tonsillectomy
position
3-place a tongue blade between the
teeth
4-injection of anti seizure drug eg>
valium
Radiotherapy

 Complications:
----------------------
1-xerostomia
2-oral ulceration
3-Osteoradionecrosis
4-radiation caries
 Precautions
------------------------
1-Before starting radiation
therapy , all oral foci
should be eliminated

2-instruct patient to follow

proper oral hyagine

3-no surgical procedure s

performed at least 6
months following
completion of
treatment to avoid
osteoradionecrosis
PREGNANCY
Dental Considerations in Pregnancy:

1. Dental therapy can be performed in all cases of

uncomplicated (stable) pregnancy and there is no
apparent reason to delay treatment after delivery.

2. The second trimester is the safest period for

routine dental care.

3. Prolonged chair time should be avoided.

4. Avoid dental radiographic examination during

pregnancy particularly in the first trimester.

5. Aspirin, NSAIDs, corticosteroids, tetracycline, and

are generally contra-indicated during pregnancy.
The same precautions should be considered for
breast-feeding mothers as they cross the placenta.