DENTAL MANAGEMENT
&CONSIDERATIONS
FOR MEDICALLY
COMPROMISED PATIENTS
-It is very important to be as the 1st step to ask the patient about his
medical history for the following purposes:-
A-It provides a basis for determining whether dental treatment might
affect the systemic health of the patient.
B-It provides an initial starting point for assessing the possible influence
of the patient’s systemic health on the patient’s oral health and/or
dental treatment.
2-Medical history & systemic condition of the patient:
Self-administered
Health
questionnaire
-Consultations (usually with a patient’s physician) are initiated
when additional medical information is necessary to assess
a patient’s medical status.
- These can be done verbally or in a written format & any
verbal and written communication should be documented in
the patient’s record.
1-Bronchial asthma:-
A-Elective dental procedures should be avoided in all but those whose asthma is well controlled.
B-All dental procedures should be done better in upright dental chair position or semi supine to avoid orthopnea & all prescribed
medications for asthma should be taken before dental appointment.
C-Fluoride supplements should be instituted for all asthmatic patients, particularly those taking
β2-agonists as it may cause xerostomia increasing the incidence of caries.
D-Antifungal medications should be administered as needed, particularly in patients who are taking
inhaled corticosteroids and they should be instructed to rinse mouth after using the inhaler.
E-Avoid dental materials that may precipitate an attack as acrylic appliances should be cured prior to insertion.
F-Dental materials without methyl methacrylate should be considered.
G-Patient should be instructed to bring the inhaler “Albuterol” during dental appointment to control any attack immediately if
occurred.
Oro-pharyngeal candidiasis:- “Common side effect with inhaled
corticosteroids”
-Only 10–20% of the dose from an inhaler actually reaches the lungs, while the rest
remains in the oropharynx.
2-Cardio-vascular disease:
-Primarily , there was a recommendation from the American Heart
Association (AHA) that any cardiac patient should take prophylactic
antibiotic doses before any dental procedure especially those where
there is a direct contact with blood.
-Nowadays , AHA has changed this concept and categorized cardiac
conditions into 2 main groups.
Cardiac conditions requiring antibiotic prophylaxis:
1-Prosthetic cardiac valves.
2-Previous infective endocarditis. 3-Congenital cardiac
malformations. 4-Rheumatic heart disease. 5-Hypertrophic
cardiomyopathy. 6-Mitral valve prolapse with regurgitation.
Cardiac conditions not requiring antibiotic prophylaxis:
1-Previous coronary artery bypass graft surgery.
2-Atrial septal defect.
3-Mitral valve prolapse without regurgitation.
4-Physiologic, functional or innocent heart murmurs.
5-Cardiac pacemakers and implanted defibrillators.
Dental procedures requiring prophylaxis:
All procedures that involve manipulation of gingival tissue or periapical region of the teeth
or perforation of the oral mucosa.
Dental procedures not requiring prophylaxis:
1-Routine anesthetic injections through non infected tissues.
2-Taking radiographs.
3-Placement of removable prosthodontic or orthodontic appliances.
4-Shedding of deciduous teeth.
Needed antibiotic agents with recommended doses:
-Another important item to be considered beside antibiotic prophylaxis
that some of cardiac patients may be under anticoagulant therapy as
a prophylaxis against strokes.
-In routine dental work , there is no problem with such drugs except for
surgical procedures in which they should be stopped and this is permitted
only by the physician if it is allowed to stop the drug or not.
-Permission should not be verbally but it is should be written and signed by
the physician.
Adversee oral side effects associated with common drugs for cardio-
vascular diseases:-
1-Alpha blockers:-
-Xerostomia & lichenoid drug reactions.
2-Beta blockers & ACE inhibitors:-
-Recurrent aphthous stomatitis , lichenoid drug reactions.
3-Calcium channel blockers:-
-Gingival hyperplasia. “drug-induced gingival enlargement”
-Any attempt to replace or exchange any of such drugs should be
decided by the physician only.
3-Peptic or duodental ulcer patients:
-Dentists should avoid administering drugs that exacerbate
ulceration and cause gastrointestinal distress, such as aspirin
and other NSAIDs.
-Dentists should be aware that peptic ulcer patients are taking
anticholinergic drugs which often present with xerostomia.
-This may be particularly problematic for denture wearers , so
denture
adhesives and artificial saliva may aid in the retention of these
prostheses.
4-Renal disease:
A-Chronic renal disease:-
-Avoid dental treatment if disease is unstable (poorly controlled or
advanced).
-Screen for bleeding disorder before surgery (bleeding time, platelet
count, hematocrit, hemoglobin).
-Avoid nephrotoxic drugs (acetaminophen in high doses, acyclovir,
aspirin,NSAIDs).
-Assess status of liver function and presence of opportunistic infection in
these patients because of increased risk for carrier state of hepatitis B and
hepatitis C.
-Chronic kidney disease patients have an increased susceptibility
to infection as the result of decreased leukocyte function & leukopenia,
an examination to eliminate oral and dental sources of infections
is recommended.
-When there is significant suppression of leukocyte function,
broad‐spectrum antibiotic prophylaxis is recommended before dental
procedures that may present a risk of infection.
-If residual renal function is diminishing rapidly, elective dental treatment
should be delayed until dialysis is instituted and the patient is medically
stable.
-Bruising after trauma is common, and hematoma formation
should be expected after extraction or periodontal surgery.
-Meticulous surgical technique, primary closure, and local
hemostatic aids such as microfibrillar collagen and oxidized
regenerated cellulose should be used as the standards of care.
B-Hemodialysis patients:-
-Similar to chronic renal disease patients.
-They may develop renal osteodystrophy This condition includes
the following oral signs and symptoms:
1-Tooth mobility.
2-Bone demineralization, decreased trabeculation, “ground
glass” appearance, radiolucent giant cell lesions
(brown tumors).
B-Hemodialysis patients:-
Ground glass appearance
B-Hemodialysis patients:-
-Patients are generally dialyzed according to a regular schedule “every 2
days” & they are heparinized to prevent blood clotting during
the procedure.
-Dental treatment can be performed without increased risk
of bleeding on non-dialysis days when heparin has not been administered
because of the short half‐life of heparin, with 24 h post‐heparinization
being adequate.
-Some centers keep dialysis patients continuously anticoagulated
with warfarin that is why bleeding tendency must be evaluated first.
5-Hematologic disease:
A-G-6-PD deficiency “Favism”:
-Certain drugs as Penicillin & aspirin are linked to cause
hemolysis in these patients, so they are contraindicated to
prescribe.
-Also , dental infection may accelerate the rate of hemolysis
thus it should be avoided and if happened it must be dealt
effectively.
B-Leukemia:-
1.Confirmed using lab .tests (white cell count , differential WBCs ,
hemoglobin or hematocrit level & platelet count.
2-Consultation is mandatory before beginning any dental care.
3-Routine dental care as “scaling & polishing , fluoride applications ….etc.”
are avoided for acute leukemic patients.
4-Controlled leukemic patients can receive only the indicated dental
treatment:-
A-Platelet count 1 day before procedure “scaling and any surgical
procedures”
(Normal= proceed , <50,000= avoid invasive procedures ,
If <40,000= provide platelet replacement.
5-Prophylactic antibiotic should be given 48 hours before dental treatment
and should continue for 1 to 2 days.
Oral lesions accompanied with leukemia:
Leukemic gingival enlargement “one of the early signs”
C-anemia:-
-Antibiotic prophylaxis may be indicated prior to aggressive dental
procedures in poorly controlled Sickle cell anemia to prevent risk of
potential infection.
-Aplastic anemia patients will require consultation with a physician prior to
treatment and possible antibiotic prophylaxis or platelet support for
those with neutropenia or thrombocytopenia,respectively.
C-Hemophilia:-
-Periodontal health is of critical importance for the hemophilia for
2 principal reasons:
(1) hyperemic gingiva contributes to spontaneous and induced gingival
bleeding.
(2) periodontitis is a leading cause of tooth morbidity, necessitating
extraction.
-Severely inflamed and swollen tissues are best treated initially with
chlorhexidine oral rinses or by gross debridement with a cavitron or hand
instruments to allow gingival shrinkage prior to deep scaling.
-Deep subgingival scaling and root planning should be performed by
quadrant to reduce gingival area exposed to potential bleeding.
-Rubber dam isolation is advised to minimize the risk of lacerating soft
tissue in the operative field and to avoid creating ecchymoses and
hematomas with high speed evacuators or saliva ejectors.
-Care is required to select a tooth clamp that does not traumatize
the gingiva.
-Matrices, wedges and a hemostatic gingival retraction cord may be used
with caution to protect soft tissues .
-Management of the dental patient on anticoagulant therapy involves
consideration of the degree of anticoagulation achieved as gauged by
the PT/INR & the dental procedure planned:
A-No surgical treatment is recommended for those with an INR of (> 3.5 -
4.0).
B-Minor surgical procedures with minimal anticipated bleeding require
local measures for those with an INR of (<3.5-4.0).
C-Extensive flap surgery or multiple bony extractions may require an INR of
< 1.5.
7-Cancer:
-If head & neck radiation and immunosuppressive chemotherapy are -
scheduled, the following recommendations should be considered:-
A-INDICATORS OF EXTRACTION:
• Grade III mobility.
• Tooth is broken down, nonrestorable, nonfunctional.
• Tooth is associated with an inflammatory condition (e.g., pericoronitis).
B-Extraction guidelines:-
• Perform extraction ideally 3 weeks before initiation of radiation
therapy with minimal trauma.
• For chemotherapy , it should be performed At least 5 days (in
maxilla) & 7 days (in mandible) before.
• Prophylactic antibiotics (cephalosporin) may be used.
C-Endodontic treatment:-
-One should prioritize treatment of infections and extractions,
periodontal care before providing treatment of carious teeth,
root canal therapy, and replacement of faulty restorations.
-Temporary restorations may be placed and some types of
treatment (e.g., cosmetic, prosthodontic, endodontic) can be
delayed when time is limited.
Recommendations for Invasive Oral Procedures in the Cancer Patient
Undergoing Chemotherapy:
-Provide routine care when:
• The patient feels best—generally, (17-20) days after chemotherapy.
• Granulocyte count >2000 cells/mm 3.
• Platelet count >50,000 cells/mm3.
* Consultation with a physician is recommended when values are lower than
indicated here, and there is a need for antibiotic prophylaxis.
Complications of head & neck radiotherapy:-
-Nausea & vomiting.
-Secondary infection (fungal,bacterial,viral).
-Muscular dysfunction.
-Radiation-induced oral ulcers.
-Taste alteration. “after 2nd week”
-Xerostomia. "after 2nd week”
-Oral mucositis. "after 2nd week”
-Radiation caries.”delayed onset”
-Osteoradionecrosis ”delayed onset”
Management of radiotherapy and chemotherapy oral complications:-
A-Oral mucositis :-
-It results from the direct cytotoxic effects of radiation.
-It occurs in up to 40% of patients.
-Develops in non-keratinized mucosa (buccal and labial
mucosa , ventral surface of the tongue).
-Mucositis develops most often between (7-14) days after
chemotherapy is provided.
-It generally subsides 1 to 2 weeks after completion of
treatment.
irregular area of epithelial
necrosis and ulceration of the anterior floor of the mouth
-Patients typically report ulceration, pain, dysphagia, loss of taste, and
difficulty in eating, which increases the risks for oral and systemic infection.
-Treatment regimen:
1-Salt & soda water mouth rinse to keep ulcerated areas as clean as possible.
(1 tsp of each in 1 pint of water)
2-Topical anesthetics to provide pain control.
3-Antimicrobial rinse as Chlorohexidine.
4-Topical corticosteroids as kenacort in orabase.
5-Soft diet.
6-Avoid alcohol , tobacco and irritating foods (e.g.: citrus fruits and juices ,
hot spicy foods).
7-Dentures should be cleaned and soaked with an antimicrobial solution daily
for the prevention of infection
B-Xerostomia:-
-Salivary glands may be affected
due to radiation and causes dry
mouth.
Treatment regimen:
-Recommend sugarless lemon
drops , sorbitol-based chewing
gum , buffered solution of
glycerine & water or salivary
substitutes.
(Glandosane
“50ml”……….composed of
Sorbitol + CaCl2 + Kcl+Nacl+Mgcl)
C-Osteoradionecrosis:
-A condition that is characterized by exposed bone that fails to heal (present for 6
months) after high-dose radiation to the jaws.
-Patients determined to be at risk should be provided appropriate preventive
measures to avoid This destructive condition as much as possible to preserve
alveolar and basal bones of the jaws.
D- Bisphosphonate-related osteonecrosis of the jaw “BRONJ”:
-Potentially a very serious oral complication of cancer therapy.
-In patients who develop BRONJ spontaneously, the most common initial complaints are
the sudden presence of intraoral discomfort and the presence of roughness that
may progress to traumatization of oral soft tissues surrounding the area of necrotic bone.
-Treatment strategies have included local surgical debridement, bone curettage, local
irrigation with antibiotics, and hyperbaric oxygen therapy.
a treatment which significantly increases the amount of oxygen available to the
body’s tissues.
This creates an environment that is more conducive to healing certain conditions.
8-Organ transplantation:
-Dental treatment for patients who are preparing for
transplantation or for those who have had a transplant should
be coordinated with the performing physician.
-The physician may consult the patient’s general dentist before
“listing” the patient for the transplantation.
-The nature of this consult is to assure that the patient does not
have any acute (or potentially acute) dental/oral infection that
could complicate the transplantation Process.
A-Immediate post-transplantation period:-
-Due to increased levels of immunosuppression used to avoid rejection during this period,
the dentist should not perform elective dental treatment, and emergency treatment
should be provided only after consultation with the transplantation physician.
B-Stable post-transplantation period:-
-Antibiotic prophylaxis prior to dental treatment is often requested by the transplantation
physician.
-Corticosteroid supplementation may also be required.
-Certain drugs may decrease the levels of immunosuppressive drugs as diclofenac sodium
, diclofenac potassium & erythromycin….so they should not be prescribed.
C-Chronic graft rejection period:-
-For dentists, these patients are often the most complicated to manage
since the organ is failing and the patient is immunosuppressed.
-Only emergency dental treatment is indicated, and the transplantation
physician’s input is essential.
9-Liver diseases:
HCV or HBV:-
-Identification of potential or actual carriers of HBV, HCV, and HDV is
problematic because in most
instances, carriers cannot be identified by history.
-Therefore, all patients with a history of viral hepatitis must be managed as
though they are potentially
infectious.
-No dental treatment other than urgent care (absolutely necessary work) should be
rendered for a patient with active
hepatitis unless the patient is clinically and biochemically recovered.
Drugs metabolized primarily by the liver that should be avoided:
-Aspirin , Ibuprofen . “NSAIDs”
-Ampicillin , tetracycline & metronidazole. “Antibiotics”
-Barbiturates.
--Diazepam (Valium).
HCV or HBV:-
--If surgery is necessary, preoperative prothrombin time (PT) and bleeding time
(BT) should be obtained and abnormal results discussed with the physician.
-the platelet count should be above 50,000 and INR below 2.0–2.5
for surgical procedures.
10-Diabetes Miletus:
-They should also be asked whether they monitor their own blood glucose, by
which method, how often, and the value of the most recent level.
-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.
-Morning appointments are usually best.
-Patient advised to take usual insulin dosage and normal meals on day of dental
appointment; information confirmed when patient comes for appointment.
10-Diabetes Miletus:
-Overall, diabetic patients respond to most dental treatments similarly to the
way
nondiabetic patients respond except for periodontal treatment.
-Well-controlled diabetic patients with periodontitis have positive responses to
nonsurgical therapy & periodontal surgery.
-Uncontrolled diabetics are usually accompanied with poor prognosis.
-Uncontrolled diabetics are liable to develop infected or dry sockets following
extraction.
11-Adrenal disease “Addison’s disease or adrenal insufficiency” :
-Patients with hyperadrenalism have an increased likelihood of hypertension
and osteoporosis and increased risk for peptic ulcer disease.
-So blood pressure should be monitored before any dental appointment ,
address any periodontal disease especially severe forms as bone loss here is
accelerated , the same precautions with peptic ulcer patients should be
followed as well.
11-Adrenal disease “Addison’s disease or adrenal insufficiency” :
-Minor oral surgical procedures may need supplemental corticosteroids.
Steroid supplementation guidelines for routine dental procedures:
A-Negligible risk:-
1-Patients daily taking their dose of systemic corticosteroids as prescribed.
B-Mild risk:-
1-Patients daily taking their dose & planned for a minor oral surgery procedure
(e.g.: Few multiple extractions “1-2 teeth” , biopsy & minor periodontal surgery) planned to last
for less than 1 hour. “e.g.: 25 mg hydrocortisone prior to surgery”
C-Moderate-to-major risk:-
1-Patients daily taking their dose & planned for a major oral surgery procedure
(e.g.: quadrant periodontal surgery “6 teeth” , Bony impactions ) planned to last for more than
1 hour.
(The recommended dose is 50-100 mg hydrocortisone prior to the surgery &
the 1st postoperative day)
Oral lesions associated with chronic adrenal insufficiency:
Hyperpigmentation related to hard palate , buccal mucosa & the tongue.
12-Thyroid gland disease:
-Poorly controlled hyperthyroidism is present or suspected, the patient
should not receive elective treatment until the condition is successfully
medically managed.
-In well controlled patients ,treat acute and chronic infection and avoid it
if possible.
-Implement normal procedures and management.
13-Pregnancy:
. Provide accurate periodontal therapy and oral hygiene instructions ,
as there are hormonal changes occurring may increase the incidence of
periodontal diseases.
. Educate the patient: Discuss the importance and benefits of good plaque
control and fluoride.
. Minimize drug use. Drug selection should be based on safety profile, risk
to mother and fetus, and potential for interactions and adverse effects.
. Minimize radiographic exposure.
. Avoid prolonged appointment time in the dental chair
(i.e., risk of supine hypotension).
. The safest time for provision of dental treatment is the second trimester.
Treatment timing during pregnancy:
1st trimester 2nd trimester 3rd trimester
1-Plaque control. All routine dental All routine dental
care can be care can be
2-Scaling , performed performed
curettage &
polishing.
3-Avoid elective
treatment , urgent
care only.
14-HIV:
-Consult whenever possible with the patient's physician to establish current
status; Request CBC if severe thrombocytopenia is present (<50,000),
platelet replacement may be needed before surgical procedures are
performed.
-Determine whether prophylactic antibiotics are needed to protect
patients with severe immune neutropenia (<500 cells/mm 3 ) from
postoperative infection.
-In most cases, provide dental procedures in accordance with
the patient's wants and needs.
15-Rheumatoid arthritis:
-Short appointments whenever possible.
-IF the patient has a joint prosthesis—prophylactic antibiotics are
suggested (cephalosporin or clindamycin).
-Temporomandibular joint pain/dysfunction—sudden occlusal changes
possible:-
A. Decrease jaw function.
B. Soft diet.
C. Moist heat or ice to face/jaw.
D. Occlusal appliance to decrease joint loading.
F. Consideration of surgery for persistent pain or dysfunction.
-The most significant complications associated with RA are drug related :-
-A patient who is taking both aspirin and a corticosteroid may be at
greater risk for bleeding , and determination of pretreatment bleeding
time may be advisable.
16-Systemic lupus erythematosus:
-As in rheumatoid arthritis, drug considerations and adverse effects
are of major importance.
-In patients who are taking corticosteroids or cytotoxins who also have
leukopenia, the use of prophylactic antibiotics for periodontal and oral
surgical procedures may be considered as they are more susceptible to
infection.
-Consultation with the physician about:
A-Extent of systemic manifestations. (e.g.: kidney & heart)
B-Hematologic profile (CBC , PT ,PTT & BT).
-Platelet count (<50,000/mm 3) may result in severe bleeding—consultation with
physician.
-Drug considerations:
-Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs)—bleeding may be
increased but is not usually clinically significant.
