Management of patients with systemic disease

MANAGEMENT OF
PATIENTS WITH SYSTEMIC
DISEASE
Dr. Saleh Bakry
Assistant Professor of Oral and Maxillofacial Surgery

ASA CLASSIFICATION FOR DETERMINATION OF MEDICAL
RISK (AMERICAN SOCIETY OF ANESTHESIOLOGIST)
1. ASA I: Normal healthy patient without systemic disease (green light to work).
 Can tolerate stress involved in dental treatment.
 Treatment modification Usually not necessary.

2. ASA II: Mild systemic condition or disease, who can perform normal activity without
distress (Well controlled Diabetic, Well controlled asthma, ASA I with anxiety).
 Represent minimal risk during dental treatment.
 Routine dental treatment with minor modifications:
 Short early appointments
 Antibiotic prophylaxis
 Sedation

3. ASA III: Severe systemic disease limiting the activity but not incapacitating (stable
angina, 6 mos. Post – MI, 6 mos. Post – CVA, COPD)
 Elective Dental Treatment is not Contraindicated.
 Treatment Modification is Required:
 Reduce Stress.
 Sedation.
 Short Appointments.

4. ASA IV: Severe, incapacitating systemic uncontrolled disease (Unstable angina, M I
within 6 months, CVA within 6 months, BP ≥180 / ≥ 110, Uncontrolled diabetic).
 Elective dental care should be postponed.
 Emergency dental care only:
 Rx only to control pain and infection
 Other treatment in hospital (I&D, extraction)
 Sedation

ASA CLASSIFICATION FOR DETERMINATION OF MEDICAL RISK
(AMERICAN SOCIETY OF ANESTHESIOLOGIST)
5. ASA V: Hospitalized patient not expected to survive more than 24 hours (End stage renal
disease, End stage hepatic disease, Terminal cancer, End stage infectious disease).
 Elective treatment definitely contraindicated
 Emergency care only to relieve pain

HOW COULD YOU REDUCE PERIOPERATIVE RISKS
1. MEDICAL CONSULTATION
 Necessary in case of ASA IV and ASA V.
 Give the physician as much information as possible.
2. ANXIETY REDUCTION PROTOCOL
 Stress is the body response to any kind of demand or threat.
 When stressed adrenal gland  produce 0.28 mg of epinephrine/min.  increase
heart rate and blood flow and increase respiration rate and blood glucose level.

A. Moderate:
 Try to hide their face.
 Cold, sweaty palm.
 Altered facial expression.
 Bruxism.
B. Severe
 Express their fears.
 Tremors.
 Tipping feet or fingers.
 Fainting.
 Increase in heart and respiratory
rate
2. ANXIETY REDUCTION PROTOCOL
RECOGNITION OF ANXIETY (STRESS):

3. ANXIETY (STRESS) REDUCTION PROTOCOL
A. BEFORE APPOINTMENT:
 Hypnotic agent to promote sleep on night before surgery. (optional) e.g., 60 mg
phenobarbitone (sominal)
 Sedative agents to decrease anxiety on morning of surgery (optional) e.g., 5–10 mg
diazepam (Valium)
 Morning appointment and schedule so that the reception room time is minimized.

B. DURING APPOINTMENT:
 Pharmacological means:
 Premedicate one hour before dental appointment as needed (5-10 mg diazepam or
1.5-3 mg bromazepam).
 Intraoperative sedation (N2O2-O2).
 L.A of sufficient potency and duration.

B. DURING APPOINTMENT:
 Non- Pharmacological means:
 Verbal reassurances.
 No surprise.
 Surgical instrument out of the patient sight.
 No unnecessary noise.
 Relaxing background music.

C. AFTER APPOINTMENT:
 Clear verbal and written instruction.
 Patient information on expected postsurgical sequel.
 Effective analgesics.
 Doctor phone number to call in emergency.
 Call the patient at evening after surgery to follow up.

1. CONGESTIVE HEART FAILURE
Is defined as the inability of the myocardium to pump enough blood to satisfy the needs
of the body.
TREATMENT
 Digitalis (Digoxin) used to increase heart contractility.
 Some medication for management of CHF have adverse interaction with AAA drugs
(Analgesics, anesthetics, antibiotics)

MANAGEMENT
1. Assess the medical risk.
2. Use anxiety-reduction protocol.
3. Avoid supine position.
4. Administer supplemental O2.
5. Provide profound local anesthesia and limit epinephrine use to 0.04 mg.
6. G.A should be avoided.

MANAGEMENT
7. Avoid use with patient on digitalis:
 Epinephrine  increase contractility  increase cardiac arrhythmia  ventricular
fibrillation and death.
 Any pressor amines (in gingival retraction cord or local hemostatic agent) to control
bleeding due to the presence of epinephrine.
 NSAID including aspirin  decrease renal clearance of digitalis  increase serum
level of digitalis  toxicity.
 NSAID replace the digitalis  decrease its absorption  decrease its effect.

MANAGEMENT
8. Use with patient on digitalis:
 Plain anesthesia.
 Acetaminophen (paracetamol) as analgesics.
 Penicillin or cephalosporin or clindamycin as antibiotics.

2. ANGINA PECTORIS
Narrowing or spasm of one more of the coronary arteries causing ischemia of the
myocardium.
PREDISPOSING FACTORS:
 Fatigue.
 Extreme stress.
 Rich meal.
 Subsides within 2–5 min after rest and the use of vasodilators.

2. ANGINA PECTORIS
Characteristics of A P.:
 Sudden onset of pain may be localized or may radiate to the arms, shoulder, or
neck.
 Patient complains of substernal discomfort or feeling of fullness or pressure on
the chest.

2. ANGINA PECTORIS
TYPES
STABLE ANGINA (ASA III) UNSTABLE ANGINA (ASAIV)
The last attack is more than 6 months Recent angina within 1 month or intervals between
attacks are several weeks (4-6 weeks)
Symptoms precipitated:
1. Activity
2. Fatigue.
3. Extreme stress.
4. Rich meal.
It occurs at rest or with minimal exertion
Respond to rest or administration of sublingual
nitroglycerin within 2-5 min.
It is severe and of new onset and occurs with a
crescendo pattern.

2. ANGINA PECTORIS
MANAGEMENT
1. Patient Evaluation/Risk Assessment
 Stable angina (ASA III).
 Unstable angina (ASA IV).
2. Obtain medical consultation (ASA IV).
4. Have nitroglycerin tablets readily available.
5. Provide profound local anesthesia and limit epinephrine use to .04 mg during a single
visit.

2. ANGINA PECTORIS
MANAGEMENT
6. Levonordefrin is only 1/6th (15%) as effective as Epinephrine, therefore, using a ratio of
1:20,000 Levonordefrin is like using a ratio of 1:120,000 of Epinephrine.
7. Limit epinephrine use to 0.04 mg (2 carpules) for cardiovascular diseases.
8. Monitor vital signs and maintain verbal contact.

2. ANGINA PECTORIS
IF PATIENT WITH STABLE ANGINA EXPERIENCES CHEST PAIN DURING DENTAL
TREATMENT:
1. Stop the procedure.
2. Administration of sublingual nitroglycerin (one dose every 5 minutes) up to maximum 3
doses until the pain relieved.
 After 5 min. of the 1st dose, if there is still pain, measure the blood pressure:
 If systolic less than 100  no sublingual tablet
 If systolic more than 100  sublingual tablet and wait for 5 min.

2. ANGINA PECTORIS
TREATMENT:
 After another 5 min, measure the blood pressure:
 If systolic less than 100  no sublingual tablet
 If systolic more than 100  sublingual tablet and wait for 5 min.
 After another 5 min repeat the cycle and maximum number of doses are 3 doses only
 because more than 3 doses, the nitroglycerin  severe vasodilation and severe
hypotension  reflex tachycardia  ischemic myocardial infarction.

2. ANGINA PECTORIS
TREATMENT:
3. Administration of oxygen.
4. If attacks pass, the procedure can be continued after a painless rest of 10-15 min.
5. If the attack prolonged and nitrate don’t help MI is suspected give to the patient 250-325
mg of aspirin to chew while waiting for the ambulance.
6. Aspirin is the first aids of heart attack  antiplatelet as MI is due to obstruction of
coronary artery due to the presence of clot which increase in size by aggregation of
platelets.

3. MYOCARDIAL INFARCTION
Obstruction of one more of the coronary arteries causing ischemia of the myocardium
SYMPTOMS OF MYOCARDIAL INFARCTION
 Burning sensation, pressure, and extreme tightness.
 The pain is more severe compared to that of angina pectoris, lasting longer than 15 min
and does not subside with rest or use of nitrates sublingually.
 Pain usually radiates (as in angina pectoris) to the left shoulder or towards the ulnar
surface of the arm.
 Nausea, vomiting.
 Difficulty in breathing.

MANAGEMENT
 6 mos. Post – MI (ASA III).
 M I within 6 months (ASA IV).
2. Obtain medical consultation (ASA IV).
3. Check if patient is using anticoagulants.

MANAGEMENT
5. Have nitroglycerin available; use prophylactically if physician advises.
6. Provide profound local anesthesia and limit epinephrine use to .04 mg.
7. Monitor vital signs and maintain verbal contact.

4. 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, adrenocortical insufficiency, C.N.S
lesion. This type accounts for 1/3 of hypertensive patients.

4. HYPERTENSION
CLASSIFICATION OF HYPERTENSION

4. HYPERTENSION
MANAGEMENT
1. Patient Evaluation/Risk Assessment.
 Identify the hypertension stage I, II or III
 If the SBP is ≥ 160 mm Hg or the DBP is ≥ 100 mm Hg  obtain medical consultation.
2. Elective dental care should be avoided in patients with blood pressure ≥180/110 (Stage
III hypertension)
3. Use anxiety –reduction protocol.
4. Avoid rapid posture changes.

4. HYPERTENSION
MANAGEMENT
5. Anesthesia:
 Controlled hypertensive patient (ASA II)  minimal risk during dental treatment.
 Stage II hypertension  blood pressure of 160-179/100-109  epinephrine should be
limited to three cartridges (0.054 mg).
 Stage III hypertension  epinephrine should be limited to one to two cartridges of 1:
100,000 solutions (0.018 to 0.036 mg of epinephrine).

4. HYPERTENSION
MANAGEMENT
6. The use of retraction cord with epinephrine and intraligamentary and intrabony injections
should be avoided in these patients.
7. The sublingual administration of nifedipine (Adalat)  myocardial infarction or
cerebrovascular accident  not recommended.
8. Immediate management of hypertension is required intravenous administration of
antihypertensive medication as furosemide (Lasix).

5. PATIENT AT RISK OF INFECTIVE ENDOCARDITIS
 This is defined as a microbial infection of the heart valves or the endocardium
 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
 congenital heart disease.
 Rheumatic heart disease.
 Systemic Lupus Erythematosus.
 Heart murmur.
3. Low degree risk
 Coronary sclerosis.
 Cardiac pacemaker.

DENTAL CONSIDERATIONS IN CASES OF INFECTIVE ENDOCARDITIS
1. Careful history taking to identify patients at risk.
2. Medical consultation.
3. Patients taking anticoagulant therapy → considerations for post-operative bleeding
tendency should be undertaken.
4. Antibiotic coverage just before dental treatment and not 2 or 3 days preoperatively to
avoid the development of resistant bacterial strains.

DENTAL CONSIDERATIONS IN CASES OF INFECTIVE ENDOCARDITIS
5. Improve oral hygiene before dental procedures by the use of antiseptic solutions such
as Povidone-iodine 1% or Chlorhexidine 1% to reduce oral bacteria and subsequent
bacteremia.
6. Local anesthesia with vasoconstrictor is preferable to minimize bacteraemia.

PROPHYLACTIC REGIMENS FOR ORAL OR DENTAL PROCEDURES
Standard General Prophylaxis:
Amoxicillin Adult 2.0 gm
Child  50 mg/kg.
Orally one hour before procedure
Patient unable to take oral medications:
Ampicillin Adult 2.0 gm IM or IV
Child  50 mg/kg IM or IV
Within 30 minutes before procedure
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.

6. ANEMIA AND OTHER BLOOD DISEASES
 Reduction in the oxygen-carrying capacity of the blood and is defined by a low value for
hemoglobin.
 Normal ♀: 12-16 g / dl and ♂: 14-18 g / dl.
Deficiency Anemia
 Iron deficiency.
 Vitamin B12 or folate deficiency.
 Aplastic anemia.
 Oral Manifestations include: angular stomatitis, atrophic glossitis, soreness of the
tongue.

Hemolytic Anemia
 Hemolytic anemia can be the result of extrinsic factors (e.g. malaria) or problems with
hemoglobin e.g. sickle cell disease, the thalassaemias and glucose 6-phosphate
dehydrogenase deficiency.
 The lifespan of the RBCs ↓ to approximately 20 days
Problems that may arise from anemia during surgical procedures
 Aplastic anemia  increase risk for infections.
 Risk of bleeding.
 Thalassemia  healing retardation

MANAGEMENT
2. Use an anxiety reduction protocol.
3. Avoid barbiturates and strong narcotics; sedation may be obtained with
midazolam
4. LA is the safest method for pain control.
 Avoid articaine and prilocaine which (in over dose) may precipitate
methemoglobinemia.
 GA is contraindicated if Hb is ˂ 10 g / dl.

5. Avoid drugs that can cause hemolysis such as Aspirin and NSAIDs
6. Use local hemostatic measures to control bleeding.

6. LEUKEMIA
Leukemia is a pathologic condition of neoplastic nature, characterized by quantitative and
qualitative defects of circulating white cells.
TWO BASIC PROBLEMS ARISE FROM LEUKEMIA PATIENTS:
 They are thrombocytopenic and neutropenic.
 Their chemotherapy causes bone marrow suppression
THEREFORE, THEY ARE AT RISK OF:
 Bleeding
 infection

6. LEUKEMIA
MANAGEMENT
1. all dental treatment should be completed before the patient becomes
immunosuppressive.
2. Avoidance of nerve block  hematoma formation.
3. Used hemostatic measures to control bleeding.
4. Low risk patients  do not require additional care (ASA II).
5. Moderate risk patients antibiotic prophylaxis + platelet transfusion may be
considered. (ASA III)
6. High risk patients  Postpone the dental treatment (ASA IV).

7. HEMORRHAGIC DIATHESES
 These are pathologic conditions with hemorrhage, which may be spontaneous or the
result of trauma.
CLASSIFICATION
1. Platelets defect:
 Due to either defective numbers or function of the platelets.
 Thrombocytopenia
 Thrombocytosis (thrombocythemia)
 Platelet dysfunction (thrombocytopathia)

2. Coagulation defect:
 Due to deficiency of certain coagulation factors
 Hemophilia A (↓ VIII)
 Hemophilia B (↓ IX)
 Hemophilia C (↓ XI)
3. Blood vessels defect:
 Due to alterations of the vascular wall, especially of the capillaries.
 Congenital such as hereditary telangiectasia.
 Acquired such as allergy, infection, scurvy.

SCREENING LABORATORY TEST FOR DETECTION OF A POTENTIAL BLEEDER
1. Platelet count
 Normal count is 140,000 to 400,000/μL.
 Clinical bleeding problem can occur if count is ˂ 50,000//μL.
2. PT
 Tests extrinsic and common pathways.
 Normal PT is 11 -15 sec.

SCREENING LABORATORY TEST FOR DETECTION OF A POTENTIAL BLEEDER
3. aPTT
 Tests intrinsic and common pathways.
 Normal aPTT is 25 to 35 seconds.
4. TT (Thrombin time)
 Tests ability to form initial clot from fibrinogen.
 Normal TT is 9 to 13 seconds.

SIGNS AND SYMPTOMS OF PATIENT WITH BLEEDING HISTORY
 Epistaxis.
 Prolonged bleeding after trauma and surgery (>24 hrs).
 Post dental extraction bleeding.
 Petechiae or purpura.
 Easy bruising.

MANAGEMENT OF PATIENT WITH A COAGULOPATHY
1. Scheduling of surgical procedure for morning hours  to control possible
postoperative hemorrhage during the day.
3. Perform coagulation test.
4. Administration of both nerve block anesthesia and local infiltration anesthesia to
control hemorrhage in the area with vasoconstrictors.
5. Nerve block anesthesia should be avoided in hemophilic patients due to the risk
of hematoma formation.

6. Augment clotting during surgery with the use of local hemostatic measures such as:
 local compression with gauze.
 Oxidized Cellulose (oxycel or surgicel).
 Gelatin sponge (gelfoam).
 Hemostatic Collagen e.g. CollaPlug.
 Bone Wax.
 Sutures.

7. Monitor the wound for 2 hours to ensure that a good initial clot forms.
8. Avoid prescribing NSAIDS.
9. Take hepatitis precautions during surgery.

8. PATIENTS RECEIVING ANTICOAGULANTS
 Today, the correct measurement of anticoagulation is based on the INR (International
Normalized Ratio)
 INR = Patient's Prothrombin Time/Normal Prothrombin Time Õ Normal 1.0-1.3
Minor oral surgery Major oral surgery
INR ≥ 3.5 → significant bleeding ≥ 3.5 → significant bleeding
For surgery should be adjusted to ˂ 3.5 should be adjusted to ˂ 3
The most commonly used anticoagulant drugs are coumarin (warfarin) drugs and heparin
drugs, as well as anticoagulant derivatives of acetylsalicylic acid (aspirin).

COUMARIN DRUGS
 Increase the prothrombin time to 2–2.5 times above the normal level (normal range:
11– 12 s).
 So the dose of the anticoagulant should be reduced or even discontinued before
surgery, until the prothrombin time reaches the desired range (1.5 times the normal
level).

HEPARIN DRUGS.
 Heparin is usually only administered to hospitalized patients, because it is given
parenterally.
 Its effect lasts approximately 4–8 h, but it may be prolonged for up to 24 h.
 Heparin may be discontinued at least 4 h before the dental procedure.
ASPIRIN-CONTAINING COMPOUNDS (ASPIRIN).
 Patients who take aspirin for anticoagulant treatment must discontinue its use at least
2–5 days before the surgical procedure and may continue it 24 h later.

THE LABORATORY TESTS FOR PATIENTS UNDER ANTICOAGULANT TREATMENT:
 Prothrombin time, for patients receiving coumarin drugs.
 Partial thromboplastin time, for patients receiving heparin (except for low
molecular weight heparin).
 Bleeding time and prothrombin time, for patients receiving salicylates.

MANAGEMENT OF PATIENT RECEIVING ASPIRIN OR WARFARIN
1. Minor oral surgery + the patient’s INR is ˂ 3.5  no adjustment in the warfarin dosage.
2. Minor oral surgery + the patient’s INR is ˃ 3.5  the dosage be reduced to allow the
INR to fall to ˂ 3.5.
3. Major oral surgery + the patient’s INR ˃ 3  the dosage be reduced to allow the INR to
fall to ˂ 3.
4. Avoid all drugs that may cause bleeding or potentiate the anticoagulation action of
warfarin, such as aspirin and NSAIDs.

MANAGEMENT OF PATIENT RECEIVING ASPIRIN OR WARFARIN
5. Use acetaminophen or metronidazole and erythromycin.
6. Avoid barbiturates and steroids  antagonize the action of warfarin.
7. Apply topical hemostatic agents to control bleeding during and after surgery.
8. Once no significant complications (bleeding, infection, poor healing) has been
observed  the patient resume his usual warfarin dosage.

9. THYROID DYSFUNCTION
 The thyroid gland secretes 3 hormones Triiodothyronine T3, Thyroxin T4, and Calcitonin.
 These thyroid hormones are controlled by hypothalamus pituitary thyroid feedback
system by TSH.

9.A. HYPERTHYROIDISM
Hyperthyroidism refers to the excess T3 and T4 in the blood beyond the body requirements.
SIGNS AND SYMPTOMS OF HYPERTHYROIDISM
 Weight loss and increased appetite.
 Anxiety and emotional instability.
 Tremors of the hands, tongue and eyelids.
 Warm moist skin.
 Profuse sweating and heat intolerance.
 Palpitation, Tachycardia.
 Thyrotoxic crisis can occur spontaneously or may be precipitated by stress or
vasopressors.

9.A. HYPERTHYROIDISM
SIGNS AND SYMPTOMS OF THYROID STORM
 Extreme restlessness.
 Hyperthermia and profuse sweating.
 Marked tachycardia.
 tremor, nausea and vomiting.
 diarrhea, abdominal pain.
 Severe hypotension  Death.

9.B. HYPOTHYROIDISM
 Cretinism (childhood hypothyroidism) or Myxoedema in adults.
SIGNS AND SYMPTOMS
 Weight gain.
 Cold intolerance.
 Dry skin.
 Mental retardation.
 Menstrual disturbances in females.
 Slow pulse (bradycardia).

9.B. HYPOTHYROIDISM
SIGNS AND SYMPTOMS OF MYXEDEMA COMA
 Marked bradycardia.
 Hypothermia.
 Seizures and altered mental status.
 Severe hypotension  Death.

DENTAL MANAGEMENT OF PATIENT OF THYROID
DYSFUNCTION
A. BEFORE DENTAL TREATMENT
 Medical Consultation.
 Use stress reduction protocol.
 Patients who have atrial fibrillation can be on anticoagulant therapy and might require
antibiotic prophylaxis before invasive procedures.
 Take blood pressure and heart rate.

DYSFUNCTION
B. DURING TREATMENT FOR HYPERTHYROIDISM ONLY
 Use the least-concentrated of epinephrine.
 If patient take nonselective beta blocker (Inderal)  epinephrine is contraindicated 
↑BP.
 Avoid epinephrine for uncontrolled hyperthyroidism.
 Prilocaine with felypressin (3% Citanest® DENTAL with Octapressin®) is suitable for L.A.

DYSFUNCTION
C. AFTER DENTAL TREATMENT
Hyperthyroidism Hypothyroidism
Control pain Control pain
NSAIDs should also be used with caution in the
patients who have hyperthyroidism and who take
β-blockers.
Caution when prescribing CNS
Depressant as Sedative-hypnotics, Opioid analgesic.
Aspirin should be avoided Caution with pt receiving anticoagulant therapy

10. DIABETES MELLITUS
CLASSIFICATION OF DIABETES
 Insulin Dependent Diabetes IDD Type (I).
 Non-Insulin Dependent Diabetes NIDD Type (II).
DIABETIC COMA
 A state of unconsciousness that results from both hyperglycemia and ketoacidosis or
from hypoglycemia.
 The two comas should be differentiated in the dental practice.

SIGNS AND SYMPTOMS OF HYPOGLYCEMIA
PRECIPITATING FACTORS
 Weight loss.
 Termination of other drug therapy (epinephrine, thyroid, and corticosteroid).
 Decreased food intake.
 Increased hypoglycaemic drug intake.

SIGNS AND SYMPTOMS
 Nervousness or anxiety.
 Sweating, Headaches.
 Irritability or impatience.
 Blurred/impaired vision.
 Tingling or numbness in the lips or tongue.
 Weakness or fatigue.
 Unconsciousness.

Management
1. Position:
 In conscious patient: place in upright sitting position.
 In unconscious patient: place in supine position.
2. A: Airway: Ensure open airway.
3. B: Breathing: Ensure that patient is breathing.
4. C: Circulation: Check pulse and confirm adequate circulation; pulse could be weak.

Management
5. Dispense:
 In conscious patient: Give a drink with high sugar content such as orange juice.
 In unconscious patient: summoning of medical assistance then administer:
 Oxygen.
 5% dextrose in Ringer’s lactate IV.
 Glucagon 1 mg SC or IM (or IV), or epinephrine (for transient relief).

SIGNS AND SYMPTOMS OF HYPERGLYCEMIA
WARNING SIGNS
 High fever, dehydration
 Weakness, Drowsiness
 Altered mental state
 Headache, Restlessness
 Inability to speak
 Visual problems
 Hallucinations

SIGNS AND SYMPTOMS OF HYPERGLYCEMIA
PREVENTIVE MEASURES
 Recognize warning signs and refer patient immediately
 Very rare emergency in dental office
 The treatment consists of insulin and gradual rehydration with intravenous fluids.

MANAGEMENT OF DIABETES
1. Controlled type 1 and type 2 diabetic patients usually can undergo all dental
treatments without special precautions.
2. Medical Consultation.
3. Presurgical diet and preoperative insulin intake is not changed.
4. Dental procedures are best performed in the morning (1-3hrs after breakfast and
insulin usual dose).
6. Monitor blood pressure, because diabetes is associated with hypertension.

MANAGEMENT OF DIABETES
7. Use the smallest concentration of epinephrine in L.A solution (1:100.000 at least) or
preferably corpasil or octapressin since their effects are only 1/10 of epinephrine in
raising the blood sugar level.
8. Prophylactic antibiotic administration for a day preoperatively and 2-3 day
postoperatively if massive surgery is to be performed.
9. Mild analgesics and sedatives containing acetaminophen (Tylenol) can be used.
10. Corticosteroids must be avoided because of their glycogenolytic action.

11. 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:
 In a dose of 20 mg or more of cortisone or its equivalent.
 Via oral or parenteral route for continuous period of 2 weeks or longer.
 Within 2 years of dental therapy.

MANAGEMENT
2. Use stress reduction protocol.
3. Use barbiturates with caution  increase the metabolism of cortisol and reduce
blood levels of cortisol.
4. Monitor blood pressure.
5. Provide steroid supplementation:

6. Anesthesia
 Use of epinephrine (1: 100,000).
7. Postoperative care
 Provide good postoperative pain control
 Monitored for good fluid balance and adequate blood pressure during the first 24
hours.

12.BRONCHIAL ASTHMA
3. Use stress reduction protocol
 Before Appointment
 Avoid use of barbiturates and narcotics  depress respiration.
 Consider low-dose oral diazepam or another benzodiazepine.
 During Appointment
 Use N2O–O2 inhalation sedation.

12.BRONCHIAL ASTHMA
4. Treatment modification
 Supplemental steroids  the usual morning corticosteroid dose should be taken on
the day of surgical procedures.
 Instruct patient to bring current medication inhaler to every appointment.
 Chair position: Semisupine or better upright position
 Avoid L.A containing epinephrine or levonordefrin because of sulfite preservative that
cause of allergic-type reactions.
 Avoid aspirin or other NSAIDs Ô precipitate asthma attack.

13.LIVER DISEASE
PRECAUTIONARY MEASURE TO PREVENT CROSS INFECTION
1. Using two pairs of disposable gloves.
2. Special protective glasses and disposable surgical mask.
3. Special protective surgical gown and cap covering scalp hair.
4. Great care during the use of the Disposable needles in order to avoid accidental
puncture.
5. Discarding of surgical blades and disposable needles in a rigid sharp container.
6. After the surgical procedure, disinfection of the dental chair, the dentist’s stool,
spittoon with a virus-active disinfectant.

13.LIVER DISEASE
1. LOCAL ANESTHETICS
 Lidocaine (Xylocaine)
 Mepivicaine (Carbocaine)
2. ANALGESICS
 Aspirin
 Acetaminophen (Tylenol,
Datril)
 Codeine
 Meperidine (Demerol)
 Ibuprofen.
3. SEDATIVES
 Diazepam (Valium)
 Barbiturates
4. ANTIBIOTICS
 Ampicillin
 Tetracycline
 Metronidazole
 Vancomyc
DENTAL DRUGS METABOLIZED PRIMARILY BY THE LIVER

13.LIVER DISEASE
MANAGEMENT:
3. Use anxiety/stress reduction techniques as needed, but avoid benzodiazepines.
4. Two carpules of 2% and 1:100.000 Epinephrin can be used safely.
5. Vitamin k administration 10mg/12hrs before and after surgery.

13.LIVER DISEASE
MANAGEMENT:
6. The safe drugs to be used are:
 Paracetamol for pain control
 Clindamycin and flagyl as antimicrobial drugs.
 Procaine as local anesthetic drug.

14. RENAL DISEASE
MANAGEMENT
2. Obtain medical consultation
3. Use anxiety/stress reduction techniques Ô benzodiazepines.
4. Preventive measures to avoid extensive hemorrhage due to hemorrhagic diatheses.
5. Local measures to control bleeding.
6. Use of minimal amounts of vasoconstrictors, because hypertension is usually
observed in chronic renal failure.

14. RENAL DISEASE
MANAGEMENT
7. Use of minimal amounts of local anesthetics in order to avoid toxicity.
8. Aggressively manage orofacial infections with culture and sensitivity testing and
antibiotics.
9. Consider hospitalization for severe infection or major procedures.
10. Avoid nephrotoxic drugs (aminoglycosides, acetaminophen in high doses, acyclovir,
aspirin, and other NSAIDs).

15. HEMODIALYSIS
MANAGEMENT
 The risk of hepatitis B, hepatitis C, and HIV infections is increased because
dialyzers usually are disinfected- not sterilized-between uses.
 Bleeding.
2. Day of appointment
 Avoid dental care on day of treatment.
 best to treat on day after.
3. Avoid Nephrotoxic drugs as well as blood pressure cuff and intravenous medications
in arm with shunt.

16. PREGNANCY
MANAGEMENT IN PREGNANCY:
1. PATIENT EVALUATION/RISK ASSESSMENT
 Evaluate and determine trimester of pregnancy.
 Measuring vital signs.
 Avoid Drugs that cross the placenta.
 Avoid Any drug that is a respiratory depressant  maternal hypoxia  fetal
hypoxia.
 Make only necessary x-ray exposures; use lead apron and thyroid collar.

16. PREGNANCY
2. TREATMENT TIMING:
 Elective dental care is best avoided during the first trimester  potential
vulnerability of the fetus
 The second trimester is the safest period.
 The early part of the third trimester is still a good time to provide routine dental
care.
 After the middle of the third trimester  elective dental care is postponed.

16. PREGNANCY
3. STRESS-REDUCTION PROTOCOL:
 Avoid Sedative-Hypnotics (Barbiturates, Benzodiazepines).
4. CHAIR POSITION:
 Patient may not be able to tolerate a supine chair position in third trimester.

16. PREGNANCY
5. ANESTHESIA:
 The usual local anesthetics with vasoconstrictors are safe to use.
 Mepivacaine, Articaine and Bupivacaine should be used with caution → fetal
bradycardia.
 Lidocaine and Prilocaine are more suitable.

EFFECT OF DENTAL MEDICATION IN PREGNANCY
AND BREAST FEEDING
1. Ideally, no drug should be administered during pregnancy, especially during the first
trimester.
2. Local Anesthetics  discussed before.

AND BREAST FEEDING
3. Analgesics.
 Use acetaminophen.
 Codeine is safe for Lactating mother but not for pregnant patients.
 Aspirin should be avoided, use other NSAIDs.
4. Anxiolytics.
 Avoid Sedative-Hypnotics (Barbiturates, Benzodiazepines).
 Nitrous oxide is safe for lactating mothers.

AND BREAST FEEDING
5. Antibiotics.
 Penicillin (including amoxicillin), erythromycin (except in estolate form),
cephalosporins, metronidazole, and clindamycin are safe for the pregnant mother.
 The use of tetracycline is contraindicated during pregnancy.
 Tetracyclines bind to hydroxyapatite  brown discoloration of teeth  hypoplastic
enamel + inhibition of bone growth.

Management of patients with systemic disease

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