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Introduction

Theborderlinebetweenmedicineanddentistryisnotalwayssharplydefined.Somedentistshavebeen
criticizedforattemptingtopracticemedicinebyextendingtherangeoftheiractivitiesintofields
notcommonlythoughofasdental.However,adistinctionshouldbemadebetweenpracticing
medicineandknowingaboutit.
Thedentallicenseimposesnolimitationsontheamountofknowledgewhichadentistmaysecurefor
hisownprotectionandforbetterdentalcareofhispatients.
Wheneveradentistisindoubtaboutthephysicalstatusofapatientheshouldenlisttheaidofa
physicianthroughconsultationorreferral.Physiciansreactfavorablytothisgestureof
interprofessionalliaisonandwilldevelopthehabitofcallinguponthedentistfordecisionslying
withinhisfield.
Somesystemicdisordersconstituteanabsoluteandsomearelativecontraindicationtosurgery.The
dentistshouldalwayskeepinmindthemaxim"firstofall,donoharm ."
So,abriefpastandfamilyhistoryshouldbeobtained,clinicalexaminationandcarefulvisual
evaluationbasedonadequateknowledgeandskillisanimportantfactorindetecting manyof
implicationsofsystemicdiseasesinthesurgicalpatient.Radiographicexaminationandlaboratory
testsarenecessaryadjunctsindiagnosisandmanagement.

Basic Principles of Medical Emergency Management


Prevention is the most important phase of treating medical emergencies. It must be remembered
howeverthatdespitealleffortsatpreventionEMERG ENCIESwillhappen.
Therearethreestepstopreventionofmedicalemergenciesinthedentaloffice:
1. Medical History
a) Arethereanyrecentchangestohealth?
b) Isthepatientunderthecareofaphysician?
c) Hasthepatienthadanyseriousillnessoropera tion?
d) Doesthepatienthaveanyallergies?
e) Isthepatienttakinganydrugsormedications?Remembertoaskaboutoverthecounter
medicationsaswell.
f) Isthepatientpregnant?
g) Foralreadydiagnoseddisordersmustask:
1. Whendidthepatientdevelopthediseaseorproblem?
2. Howistheproblemcontrolled?
3. Isthereanythingthatmakestheproblemworse?
4. Hasthepatientbeenhospitalizedfortheproblem?
5. Arethereanyrestrictionsonthepatient?

Medical History Algorithm
SAMPLE
(Medical/EMSalgorithmbutbasicprinciplecanbeappliedtodental.)
Symptoms
Allergies
Meds
PreviousHistory
LastIncident
Eventsleadingtoproblem
2. Patient Evaluation
a) Recordvitalsigns.
b) Completedentalexam.
c) Visualinspectionofthepatient
Formulateyourtreatmentplanatthisstage.Determinehowthistreatmentplanrelatestoand
affectsorisaffectedbythefindingsofthemedicalhistoryandevaluation.Obtainmedicalconsults
ifneededatthispoint.Reasonstoob tainamedicalconsultincludedoubtexistsastothepatients
condition,historyofdangerousorsuspicioussignsorsymptoms,historyofuncontrolledillness,
multiplemedications,ASAclass3orhigher.

ASA Physical Status Classification

Class1:Healthypatientwithnosystemicdisease.
Class2:MildSystemicdiseasewithnolimitsonactivity.
Class3:Severesystemicdiseasethatlimitsactivity.
Class4:Incapacitatingsystemicdiseasethatislifethreatening .
Class5:Moribund

3. Staff Training and Preparation
a) Training:Staffneedstohavetheknowledgetoidentifyandcorrectlymanageeach
emergency.
b) Easilyaccessibleemergencyequipmentanddrugs.
c) Coordinationofofficepersonnel.

WhatisadequatePreparation?Guidelinesvarybystateandorgani zation.Ingeneralitis
expectedthatthedoctorwillbeabletoinitiateemergencymanagementandbecapableof
sustainingavictimslifethroughtheapplicationofBasicLifeSupport.Intimesofcrisis
simplicityhaltsconfusion!

Basic Principle of Managing all Medical Emergencies
1. BLS: rememberABCs
2. Placethepatientsupine.
3. Callforassistance.
4. Assurepatientifconcious.
5. Maintainairway.
6. PlacepatientonOxygenasindicatedbynatureofemergency.
7. Monitorvitalsigns.
8. Diagnosenatureofevent.
9. Initiatespecifictreatment
10. Document,Document,Document!

Stress Reduction Protocol for the Anxious Patient
1. Recognizepatientsanxietylevel.
2. Considerusingpre-medicationorsedation
3. Schedulemorningappointments.
4. Minimizewaitingtimeandwatchappointmentlength.
5. Makesuretouseadequatepaincontrol.Thiswillvaryfrompatienttopatient.
6. Monitorvitalsigns.
7. Medicalconsultifrequired.

The most common medical problems that require the dentist to be knowledgeable in
recognition and management during the course of dental treatment :
1-Cardiovasculardiseases,includingtheentirebroadscopeofcardiacandperipheral vascular
disease.
2-Liverdiseases
a.Infections-hepatitis
b.Obstructioncirrhosis,infectionsandextrahepaticcauses,forexample,cholecystitisand
cholelithiasis
3-Endocrinediseases
a.Hyperthyroidism
b.Diabetes
c.Hypoadrenalism
4-Chronicobstructivelungdiseases
a.Emphysema
b.Asthma
5-Renaldiseases
a.InfectionssuchasGlomerulonephritisandpyleonephritis
b.Systemiceffectsofazotemiafrommultiplecauses
c.Managementofthetransplantpatient
6-Hematologicdisorders
a.Leukemia
b.Bleedingdiatheses
7-Centralnervoussystemdisorders
8-Chronicdebilitatingdiseases
9-Iatrogenicdiseases
a.Irradiation
b.Anticoagulation
c.Long-termsteroidtherapy
10-Anyallergicconditions
11-Thedrugsormedicamentstakenbythepatient

Cardiovascular Diseases
Itisobviouslyofgreatimportancetoevaluatethecardiovascularsystempriortosurgery.
Thediseasestobecosideredcanberoughlyclassifiedas:
a. Peripheral vascular or b. Cardiac in origin
Peripheral vascular disease
Themainentitiestobeconsideredwithregardtoperiphe ralvasculardisease:
a.Advancedatherosclerosisb.Hypertension

Hypertension
Blood Pressure

*Thepressureexertedbythebloodagainsttheinteriorwallsofthearterialsystem
*SoundsproducedbyturbulentbloodflowarecalledKorotkoffsounds,aftertheRussian
physicianwhodescribedthistechniquein1905




*Korotkoffsounds:Firstappearan ceofsoundsisthe systolicpressure;thecompletedisappearance
ofsoundsisthe diastolicpressure.
*Prevalenceincreaseswithage;>halfofpeopleoverage65haveHBP
*Systoloicpressurerisesthroughoutlife;diastolicpressurelevelsofforfallsaft erage50
ThehighertheBP,thegreatertheriskofstroke,MI,heartfailure,andkidneydisease
BloodPressureandCardiovascularRisk

*incrementriseof20mmHginsystolicBPor10mmHgindiastolicBP doublestheriskof
cardiovasculardiseaseacrosstheentirerangefrom115/75to185/115mmHg
Forindividualsaged40-70years,each
Lewington,Lancet2002;360:1903-1913
*Hypertensionisaninsidiousdiseaseandmayremaincompletelyasymptomaticformanyyears
Measurementofbloodpressureistheonlymeansofdetection
Target Organ Damage
(occurs after many years of elevated blood pressure)
1-Heart 2-Leftventricularhypertrophy 3-Angina/priorMI
4-Priorcoronaryrevascularization 5-Heartfailure6-Brain
7-StrokeorTIA 8Dementia9-Chronickidneydisease
10-Peripheralarterialdisease 11-Retinopathy
Signs and Symptoms of Hypertensive Disease
Early
Elevatedbloodpressurereadings
Narrowingandsclerosisofretinalarterioles
Headache
Dizziness
Tinnitus
Advanced
Ruptureandhemorrhageofretinalarterioles
Papilledema
Leftventricularhypertrophy
Proteinuria
Congestiveheartfailure
Anginapectoris
Renalfailure
Dementia
Encephalopathy

ClassificationandFollow-upofBloodPressureMeasurementforAdultsAged18YearsorOlder*

Category** SystolicBlood DiastolicBloodPressure Follow-up


Pressure (mmHg) Recommendedfor
(mmHg) DentalPatients
Normal <130 <85 Recheckatrecall(within
2years)
HighNormal 130-139 85-89 Recheckatrecall(within
1year)
Hypertension***:Mild 140-159 90-99 Recheckwithin1month;
(Stage1) ifstillelevatedhave
patientevaluatedby
physicianwithin1month
Hypertension***: 160-179 100-109 Recheckwithin2weeks;
Moderate ifstillelevatedhave
(Stage2) patientevaluatedby
physicianwithin2weeks
Hypertension***:Severe 180-209 110-119 Havepatientevaluatedby
(Stage3) physicianwithin1week
Hypertension***:Very >or=210 >or=120 Havepatientevaluatedby
Severe physicianimmediately
(Stage4)

Dental Considerations

Evaluationofapatientwithhypertension:

Determine:

Timeofdiagnosisofhypertension.
Presentmedication(s)anddosageusedtocontrolhypertensionaswellasanyrecentchangesor
modificationstoantihypertensivemedication(s)ordosage.
Thepresenceofanysystemiccomplicationssecondarytohypertensionincludingretinopathy,
nephropathy,historyofcerebrovasculardisease,orcardiovasculardisease.

PhysicalandDentalExam:

Establishthepatient'sbaselinebloodpressureatthefirstdentalappointment.Twotothree
bloodpressuremeasurementsseparatedbyatleastfiveminutesshouldbetaken ,andthe
resultsaveragedtodeterminethepatient'sbaselinebloodpressure.Thepatient'sbaseline
bloodpressurewillserveasapointofreferencefromwhichtomakedecisionsforthe
emergencymanagementofthepatientshouldacardiovascularoradve rsereactiondevelop
duringdentaltreatment.Thepatient'sbloodpressureshouldbecheckedatallsubsequent
appointmentspriortotheuseofalocalanesthesia.

DentalManagementPrecautions:

Reducestressandanxietyduringdentaltreatment:consider theuseofN 2O-O2inhalation


sedationand/orpremedicationwithoralanti-anxietymedicationssuchasbenzodiazepines.
Donotuselocalanestheticswithvasoconstrictorsinpatientswithuncontrolledorpoorly
controlledhypertension.Thisisdefinedasanypatientwithasystolicbloodpressuregreater
thanorequalto180mmHgand/oradiastolicbloodpressuregreaterthanorequalto100
mmHg.
Forpatientswithcontrolledhypertension,wheretheuseoflocalanestheticswith
vasoconstrictorsisnotcontraindicatedbecauseofpotentialdruginteractions,limitthetotal
doseofvasoconstrictortomaximumof0.04mgofepinephrine(2.2carpulesof2%lidocaine
with1:100,000epinephrine)or0.2mgoflevonordefrin(2.2carpulesof2%carbocainewith
1:20,000levonordefrin).

Additionalprecautions:

o Avoidtheuseofepinephrine-impregnatedgingivalretractioncord.
o Avoidtheuseofvasoconstrictorsfordirecthemostasistocontrollocalbleeding.
o Avoidtheuseofalocalanestheticwithvasoconstrictors forintraligamentaryor
infrabonyinfiltrations.
Avoidstimulatingthegagreflexinpatientswithahistoryofhypertension.

TreatmentPlanningConsiderations:

Therearenospecifictreatmentplanningmodificationsorconsiderationsforpatientswith
controlledhypertension.Noelectivedentalproceduresshouldbeperformedonapatientwith
severeoruncontrolledhypertension.

DentalDrugInteractions:

Concurrentuseoflocalanestheticswithvasoconstrictorsandnon -cardioselectivebeta-
adrenergicblockerscanresultinanacuteelevationofbloodpressureandreflexbradycardia.
Inpatientswithhypertension,alocalanestheticagentwithoutavasoconstrictorshouldbe
used.
Useofalocalanestheticwithavasoconstrictorconcurrentlywithreser pine(Serpasil),
canresultinapossibleprolongedand/orincreasedeffectofthevasoconstrictor.In
addition,theuseofnorepinephrineinpatientstakingmethyldopa(Aldomet)and
guanethidine(Ismelin)mayresultinanincreasedpressoreffectofnorep inephrine,resulting
inhypertensionandanincreasedtendencytodevelopcardiacarrhythmias(guanethidine).
Thisreactionmayalsooccurwhenothervasoconstrictors(e.g.,epinephrine,levonordefrin)
areusedconcurrentlywithmethyldopaorguanethidine.
Nonsteroidalanti-inflammatorydrugs(NSAIDs)decreasetheantihypertensiveefficacyof
diuretics(especiallyloopdiuretics),beta-adrenergicblockers,ACEinhibitors,
hydralazine(Apresoline),prazosin(Minipress),andselectivealpha 2agonists(toalesser
degree).Thepatient'sbloodpressureshouldbemonitoredfrequentlywhenNSAID'sand
theseantihypertensivesareusedconcurrently,especiallyifNSAIDtherapyisnecessary
longerthan5days.

Beta-adrenergicblockersimpairthehepaticmetabolismofamidelocalanestheticsresultingina
possibleincreasedriskoflocalanesthetictoxicitywithhighdoses.Thisreactionusuallywillnot
haveclinicalsignificancegiventheamountsoflocalanesthetictypicallyusedforasingledental
procedure(e.g.,lessthan120mgoflidocaineorequivalent).
Dental Management and Follow-up
Recommendations Based on Blood
Pressure
BloodPressure DentalTreatment Referralto
Recommendation Physician

>120/80 Anyrequired NO

120/80but AnyRequired Encouragepatientto
<140/90 seephysician

140/90but Anyrequired Encouragepatientto
<160/100 seephysician

160/100but Anyrequired; Referpatientto
<180/110 considerintraoperative physicianpromptly
monitoringofBP (within1month)
forupperlevelstage 2

180/110 Deferelective Refertophysicianas
treatment soonaspossible;if
patientis
symptomatic,refer
immediately


Hypotension

Signs and Symptoms of Hypotension


1. Weakness.
2. Diaphoresis.
3. Decreasedlevelofconsciousness.
4. Possiblenauseaandvomiting.

MANAGEMENT OF HYPOTENSION:

Thetreatmentofhypotensionisbasedontreatingtheetiology.Possibleetiologiesinclude
PsychologicalFactors(Stress),OverdoseofMedication,PosturalChanges,Coexisting Disease,
Hypovolemia,AnestheticOverdose,Reflex(Pain),Hypoxemia,andHypercarbia.

1. Stopdentaltreatmentandremoveallforeignobjectsfromthepatientsmouth.
2. AdministerOxygen.
3. Placepatientinsemi-recumbentpositionwithlegselevatedabovetheleveloftheheart.
4. Monitorandrecordvitalsigns,checkpulseforrate,rhythm,andcharacter(Isitstrong,weak,
thready,etc.)
5. Checklevelofconsciousness.
6. Ifpatientdoesnotrespondtotheabovetreatmentamajorsystemiccomplicationshouldbe
considered.ActivateEMSatthispoint.ConsiderpossiblePulmonaryEmbolism,Cerebral
VascularAccident(Stroke),MyocardialInfarction,andCongestiveHeartFailure.
7. IfAvailablestartIV(18gaugecatheterwithNormalSaline.)

Valvular Heart Disease (Infective Endocarditis)

*Occursinpatientwithpre-exisitingvalvularheartdiseaseeithercongenitaloracquired.The
causativemicroorganisms(Streptococcus Viridans)enterthecirculationwhenbleedingoccures
duringextractionofteethorevenduringgin givalsurgery.Whithoutadequateantibioticcoverage,the
microorganismwilladheretotheroughenedordamagedareasoftheheart.Inflammationthenresults
formingplateletadhesionsandcrumblingvegetations.Thefragmentsarecarriedinthecirculation as
emboli.
Clinical Features
Theseareofincidiousonset,whichoftencausesdelayindiagnosis.Severalbloodculturesareoften
requiredtoconfirmthediagnosis.
1- Signsandsymptomsofsepticemia
2- Changingheartmurmurs
3- Fingerclubbingandnailbedhemorrhages
4- Otheremboliccomplicationse.g.hematuria
5- Endresultmaybecardiacfailureanddeath
Prognosis
Untiltheadventofantibiotics,thediseasewasinvariablyfatal
Prophylactic measures:
1-Carefulhistorytakingfrompatientstoidentifypatientsa trisk
Patientwithhistoryofcongenitalheartdiseases.
Patientswithhistoryofrheumaticfever.
Patientswithprostheticvalvularheartsurgery
2-Medicalconsultationwhereindivated
3-Antibioticcoverageshouldbegiventothepatientimmediatelypr eopertativelyandnot24hoursor
morepreoperatively.
4-Antibioticdrugshouldbebactericidal,thustetracyclinewhicharebacteriostaticaretotally
unsuitable.
5-Sufficientlyhighbloodlevelofthedrugshouldbeattainedandmaintainedforaminimu mperiod
of3dayspostoperatively.
Patients at risk from infective endocarditis
High risk
Prostheticvalves
Previousinfectiveendocarditis
Variable risk
Congenitalheartdisease
Degenerative(calcific)aorticvalvedisease
Hypertrophiccardiomyopathy
Mitralvalveprolapsewithsystolicmurmur
Rheumaticheartdisease
Syphiliticheartdisease
Hurler'ssyndrome
Osteogenesisimperfecta
Procedures requiring antimicrobial prophylaxis in persons at risk from endocarditis
Toothextraction
Oralsurgeryinvolvingtheperiodontaltissues
Periodontalsurgery
Subgingivalproceduresincludingscaling
Intraligamentaryinjections
Reimplanationofavulsedteeth
Procedures for which antimicrobial prophylaxis is not recommended in persons a t risk for
endocarditis
Exfoliationofprimaryteeth
Localanaestheticinjections,otherthanintraligamentary
Non-surgicalproceduresthatdonotinducebleeding
Choice of prophylactic antibiotic regimen against infective endocarditis
Therecommendationsasfollow:
1- Patients not requiring a general anesthetic and with no history of infective
endocarditis:
a.(not allergic to nor received a penicillin more than once in the past month.
Adult dose:3gamoxycillinorallybefortheoperation,takeninthepresenceofthedentistornurse .
Children under 10:one-halftheadultdose
Children under 5:aquarteroftheadultdose
b. Patient allergic or who have received a penicillin more than once in the previous month
Adult dose:asingleoraldoseofclindamycin600mgcanbegivenonehourbeforethedental
procedure
Children under 10:one-halftheadultdose
Children under 5:aquarteroftheadultdose
-Alternatively,1.5gerythromycinstearatecanbegivenorallyundersupervision1-2hourbeforethe
dentalprocedure,followedbyaseconddoseof0.5g6hourlater.
Children under 10:one-halftheadultdose
Children under 5:aquarteroftheadultdose

(Patient who have had endocarditis should be managed as in (2) below:


2-Treatment under general anaesthesia- patient with natural valve dise ase and no
history no history of infective endocarditis, but not allergic to nor received a penicillin
more than once in the past month :
Amoxicillin1gI.M.orI.V.in2.5mlof1percentlignocainebeforeinductionplus0.5gofamoxycillin
orally5hourlater.
Alternatively,3gofamoxycillinmaybegivenbymouth4hoursbeforeinductionandrepeatedas
soonaspossibleafterinduction,iftheanesthetistagrees.
3-Treatment under general anaesthesia patients with prosthetic valves or previous
endocarditis, not allergic to nor have had a penicillin more than once within the past
month:
Amoxycilline1gI.M.in2.5mlof1percentlignocaineoramoxycillin1gI.V..plusgentamicin120mg
I.M.orI.V.immediatelybeforeinduction.Afurther0.5gofamoxycillinshouldbegivenorally6houe
later.
Patientallergicorwhohavereceivedapenicillinemorethanonceinthepreviousmonth:Vancomycin
1gbyI.V.infusionover100minfollowedby120mgofgentamicinI.V.beforeinduction.
Alternatively,I.Vteicoplanin400mgplusgentamicin120mgmaybegivenatinduction,orI.V.
clindamycin300mgmaybegiven10minutesbeforeinductionfollowedbyoralclindamycin150mg
after6hours.
4- Patients who have had a previous attack of infective endocarditis (irrespective of
the type of anaestlietic) but not allergic to nor received a penicillin more than once in
the past month:
Amoxycilline1gI.M.in2.5mlof1percentlignocainoramoxycillin1gI.V.plusgentamicin120mg
I.M.orI.V.immediatelybeforedentalprocedure.Afurther0.5gofamoxycillinshouldbegivenorally
6houelater.
Patientallergicorwhohavereceivedapenicillinemorethanonceinthepreviousmonth:Vancomycin
1gbyI.V.infusionover100minfollowedby120mgofgentamicinI.V.beforeinductionor
Alternatively,I.Vteicoplanin400mg.
The reason different cover is given for those who are going to have a general
anaesthetic is that:
Parenteraladministrationremovestheriskofvomiting
Itisnotfeasibletogivesuchlarged oses(3g)odamoxycillineforexamplebyinjection,henceit
hastosupplementedwithgentamicin.
Additional measures
1- Applicationofanantisepticsuchas10percentpovidone-iodine.0.5percent.chlorhexidineor
tinctureofiodinetothegingivalcrevicebeforethedentalproceduremayreducetheseverityof
anyresultingbacteraemiaandmayusefullysupplementantibioticprophylaxisinthoseatrisk.
chlorhexidinemouthrinsesappearnottobehelpfulinthisrespect.
2- Gooddentalhealthshouldreducethefrequencyandseverityofanybacteraemiasandalso
reducetheneedforextraction.
3- Itisessentialthat,evenwhenantibioticcoverhasbeengiven,patientsatriskshouldbe
instructedtoreportanyunexplainedillness.Infectiveendocarditisis oftenexceedingly
insidiousinoriginandcandevelop2ormoremonthsaftertheoperation,whichmighthave
precipitatedit.Latediagnosisconsiderablyincreaseboththemortalityordisabilityamong
survivors.
4- Patientsatriskshouldcarryawarningcardtobe showntotheirdentisttoindicatethedanger
ofinfectiveendocarditisandtheneedforantibioticprophylaxis.
Treatment:
1- Bedrest.
2- Intenseprolongedantibiotictherapybaseduponbloodcultureandsensitivitytestfor 6week.
3- Treatmentofcomplicationsofembolismorcardiacfailureastheyarise.

Ischemic Heart Disease

Coronary Heart Disease: Myocardial Ischemia

Decreasedbloodsupply(andthusoxygen)tothemyocardiumthatcanresultinacutecoronary
syndromes:
Anginapectoris
Myocardialinfarction
Suddendeath(duetofatalarrhythmias)
PathophysiologyofAtheromatousPlaques
Depositionofcholesterolintheintimaandsmoothmuscle
Proliferationofsurroundingfibroustissueandsmoothmuscle
Internalbulgingofvesselwithnarrowingofthelumenlimitingbloodandoxygensupply
resultinginischemiaand/orarrhythmias
Roughsurfacescanruptureandcausebloodclotsandemboliresultinginvesselocclusion

Spectrum of the Atherosclerotic Process
CoronaryArteries(angina,MI,suddendeath)
CerebralArteries(stroke)
PeripheralArteries(claudication)


Angina Pectoris
Briefsub-sternalpain
Self-limitingwithcessationofprecipitatingevent
Precipitatedbyexercise,stress,eating,sex,etc
Mayoccuratrestorwhileasleep
Clinical Patterns of Angina Pecto ris

Stable-painpatternandcharacteristicsrelativelyunchangedoverpastseveralmonths(better
prognosis)
Unstable-painpatternchanginginoccurrence,frequency,intensity,
orduration(poorerprognosis);MIpending
Medical Management of Angina
Medications
nitrates
betablockers
calciumchannelblockers
anti-plateletagents
antihyperlipidemics
Surgery
Percutaneoustransluminalcoronaryangioplasty/balloonangioplasty/stent
Coronaryarterybypassgraft(CABG)
Dental Considerations: Nitrates
VasoconstrictorInteractions:
Noclinicallysignificantinteractions
OralManifestations:
topicalburningatsiteofcontact
OtherConsiderations:
orthostatichypotensionandheadachepossiblefollowingadministration
Dental Considerations: Beta Blockers
Whilethereisapotentialforanenhancedhypertensiveeffectofepinephrineinapatienttaking
anonselectivebetablocker,itisclinicallyunlikelythatsuchareactionwilloccur
Ifapatientistakinganonselectivebetablocker(e.g.propanolol,sotolol),itisprudenttolimit
the amount of epinephrine administered to that found in two carpules of 1:100,000
concentration(0.036mg)
Inpatientstakingacardioselectivebetablocker(e.g.metropolol),nolimitationsarerequired
Dental Considerations: Calcium Channel Blockers
Therearenosignificantdruginteractionsreported
Gingivalhyperplasiacanoccurinpatientstakingcalciumchannelblockers;closemonitoring
andencouragementofoptimaloralhygieneisnecessary
Dental Considerations: Antiplatelet Agents
With a single agent (e.g. aspirin, Plavix), expect some increased perioperative and/or
postoperativebleedingbutitisnotusuallyclinicallysignificantandcanbemanagedbylocal
measuressuchaspressure,suturing,stents,etc.;pr eoperativewithdrawalisnotjustified
Thecombinationofaspirinwithotherinhibitorsofplateletaggregationincreasesthechances
for significant bleeding; depending upon extent of surgery, it is advisable to discuss the
risk/benefitoftemporarydiscontinuationwiththephysician
Dental Considerations:
HMG-CoA Reductase Inhibitors
ThecombinationoftheHMG-CoAreductaseinhibitorswitherythromycinorclarithromycin
(CYP3A4inhibitors)maybeassociatedwithanincreasedriskofadversedrugeffects on
muscle(rhabdomyolosis)andkidney(acuterenalfailure)
AvoidconcurrentuseofHMG-CoAreductaseinhibitorswitherythromycinorclarithromycin.
Dental Considerations
Balloon Angioplasty / Stent
Theseproceduresarenotassociatedwithanincreasedriskofbacterialendocarditisor
endarteritis.Therefore,antibioticsarenotrecommendedfollowingaballoonangioplastynor
aretheyrecommendedforpatientswithastent.

Dental Considerations:
Coronary Artery By-Pass Graft (CABG)
TheCABGdoesnotincreasetheriskforBE,thereforeantibioticprophylaxisisnotrecommended
Post-MyocardialInfarction
MI,Coronary,HeartAttack
Infarction-anareaofnecrosisintissueduetoischemiaresultingfromobstructionofbloodflow
Dental Management Correlate
Electivedentalcareisokifithasbeenlongerthan 4-6weekssincetheMIandthepatientdoes
notreportanyischemicsymptoms.
Ifthereisanydoubtorquestion,consultwiththecardiologist.
Drug Therapy:
Warfarin (Coumadin)
Action: inhibits vitamin K which is a precursor for clotting factors II, VII, IX and X
Dental treatment, including minor surgery, is unlikely to be problematic if INR is within the
therapeutic range
Dental Management:
Stable Angina/Post-MI >4-6 weeks
Minimizetimeinwaitingroom
Short,morningappointments
Preop,intra-op,andpost-opvitalsigns
Pre-medicationasneeded
anxiolytic(triazolam;oxazepam);nightbeforeand1hourbefore
Havenitroglycerinavailablemayconsiderusingprophylacticaly
Usepulseoximetertoassuregoodbreathingandoxygenation
Nitrousoxide/oxygenintraoperatively(ifneeded)
Excellent local anesthesia - use epinephrine, if needed, in limited amount (max 0.04mg) or
levonordefrin(max.0.20mg)
Avoidepinephrineinretractioncord
Dental Management:
Unstable Angina or MI < 3 months
Avoid elective care
For urgent care: be as conservative as possible; do only what must be done (e.g.
infection control, pain management)
Consultation with physician to help manage
Consider treating in outpatient hospital facility or refer to hospital dentistry
ECG, pulse oximetry, IV line
Use vasoconstrictors cautiously if needed
Intraoperative Chest Pain
Stopprocedure
Givenitroglycerin
Ifafter5minutespainstillpresent,giveanothernitroglycerin
Ifafter5moreminutespainstillpresent,giveanothernitroglycerin
Ifpainpersists,assumeMIinprogressandactivatetheEMS
Giveaspirintablettochewandswallow
Monitorvitalsigns,administeroxygen,and
bepreparedtoprovidelifesupport
Periodontal Disease and Coronary Heart Disease
ThereappearstobeanassociationbetweenPDandCHD;exactrelationshipunclear
Possiblyrelatedtotheinflammatoryeffectsofbacterialproducts,i.e.endotoxins,LPS;effect
onendothelium;clotformation
Possiblynocause-effectrelationshipatall
Studiesareunderwaytomoreclearlydefinethisrelationship
Heart Failure
Astatewherethemyocardiumcannotmaintainthenormalcirculation,andthuscausecardiacfailure.
Either the left side or the right side of the heart may fail first, but eventually both sides will be
involved.
Common causes:
1- Hypertension.
2- Pulmonarydiseases.
3- Ischemicheartdiseases.
4- Vavularheartdiseases.
Sings and Symptoms:
1- Rapidfatigue.
2- Breathlessness.
3- Edemaoftheankle.
4- Nonreproductivecough.
5- Prominentlargeveinsintheneck
Mostofthesepatientsareambulatoryandreceivingtheirmedications,mostlikelycardiacglycosides
andtheiractivityisrestricted.
Precautions:
1- Medicalconsultation.
2- Shouldbetreatedwithcautiontoavoidtachycardiathatmayexaggeratethealreadyexisting
condition.
3- Preoperativesedationplusgoodpaincontrolshouldbemaintained.
4- TheuseofV.C.inL.A.shouldbekeptatminimum.
5- Periodiccheck-upofpulserateduringsurgery:Inasignificantriseofpulseratearestperiod
isrequiredoritmaybenecessarytoterminatethedentalappointment.

Thrombosis and thrombophlebitis


Athrombusisasolidbloodclotformedwithinavessel:
Etiology:
1- Increasedcoagulabilityofblood
2- Stasisofblood
3- Damagetovesselwallsastrauma,irritantdrugs,andinflammation(phlebitis)
Management of those patients usually by anticoagulant therapy such as (heparin) or (macromar) to
reduce the prothrombin level. Patients on anticoagulant therapy usually bleed excessively following
anysurgicalprocedure.
Precautions:
1- Medical consultation is important before dental surgery. A joint decision between the dental
surgeonandphysicianshouldbeperformedasto:
Decreaseorwithdrawtheanticoagulanttherapy.
Raisetheprothrombinlevelsbyinjectionofvitamink.
Use of local haemostatic measures after surgery such as Gel foam with thrombin or
oxidizedcellulose(Surgicel).
2- Extractionofteethiscontraindicatedifprothrombindeficiencymorethen 20%.

Respiratory Diseases
Asthma Attack

Signs and Symptoms of an Asthma Attack


1. SenseofSuffocation,patientwillsitupliketheyarefightingforair.
2. Pressureortightnessinchest.
3. Non-productivecough.
4. Expiratoryandinspiratorywheezes.
5. Expirationisprolongedandharderthaninspiration.
6. Chestisdistended.
7. ThickStringymucous.Atterminationofaperiodofintensecoughingthepatientwillexpectorate
thismucous.

Severe Asthma Attack


1. Cyanosisofthenailbeds.
2. Perspirationandflushingoftheskin.
3. Useofaccessorymuscleofrespiration:Sternocleidomastoid,andshoulder/abdominalmuscles.
4. Patientmayalsoappearconfusedandagitated.

MANAGEMENT OF AN ASTHMA ATTACK


1. Discontinuedentaltreatment.
2. Placepatientineasiestpositionforthemtobreath.Thisisusuallyuprightwitha rmsoutstretched.
3. AlbuterolInhaler(Proventil)2puffsevery2minutes.
4. Supplementaloxygenat10L/min.
5. Monitorvitalsigns.
6. IfnoimprovementcallEMS.
7. StartIV.
8. ConsiderEpinephrine1:1,000,0.3gevery20minutes.

Dental Treatment Considerations for the Asthmatic Patient


1. TakeagoodMedicalHistorypriortotreatment;determinehowoftenthepatienthasanasthma
attackandwhatprecipitatesit.
2. Considerschedulingmorningappointments.
3. Ifpatientusesaninhalertheyshouldhaveitonhandduringtreatm ent.Considerprophylacticuse
priortotreatment.
Hematologic Diseases
Almostallblooddisordersareofimportancetothedentalsurgeon .
Anemia
Causes of anemia:
A)Deficient,R.B.Cs.production:
Deficiencyofiron,B12,folicacid,vitaminC,protein.
Aplasticanemia.
Marrowinfiltrationasinleukemia,Hodgkin'sdisease,metaplasticcarcinomaandmyeloma.
Symptomatic e.g. anemia of chronic infection, liver disease, kidney disease and collagen-
vasculardisease.
B)LossordestructionofR.B.Cs.:
Hemorrhage.
Hemolyticanemia
1. Congenitalhemoglobinopathy.
2. Sicklecellanemia
3. Thalassemia
4. Auto-immunehemolysis.
Toxicdrugsorchemicalse.g.lead.
Anemicpatientsdonotwithstandbloodlosswell.Furtherbloodlossinanalreadyanemicpatientmay
provokeheartfailureormyocardialinfarction.Postoperativehemorrhageisalsocommoninanemic
patients.
Thecommonoraldisorderofasoretongueinadditiontotheothermanifestationsofanemiaisan
indicationforbloodexaminationandsurgeryshouldbepostponeduntiltheanemiaiscorrected.If
thehemoglobinconcentrationislessthan10g/100ml.ofbloodsurgicalprocedureiscontraindicated.
Reference Ranges for Blood Indicators*
Indicator Men Women
Redbloodcellcount 4.10-5.60(106/L 3.80-5.10(106/L)
Hemoglobin 12.5-17.0(g/dL) 11.5-15.0(g/dL
Hematocrit 36%-50% 34%-44%
*L=microliter;g/dL=gramsperdeciliter
Agranulocytosis (Malignant Leucopenia)
IsaseriousdiseaseinvolvingtheW.B.Cs.Themostcommonknownetiologicfactoristheconti nued
administrationofcertaindrugs,thatincludesulfonamides,chloramphenicol,chlorpromazine,
barbituratesandphenacetin.
Clinical features:
1. Necrotizingulcerationoftheoralmucosa.
2. W.B.Cscountusuallybelow2000cells/cubicml.
Dental prophylaxis:
1. Withdrawanysystemicdrugwhichinduceallergicreactiontothepatient.
2. Incasesthatrequiredprolongedantibiotictherapy,periodiccheck -upofthebloodpictureis
mandatory.
3. Extractionincasesofagranulocytosisiscontraindicatedunlessthedisea seismanagedbyblood
transfusion.
Leukemia
CharacterizedbytheprogressiveoverproductionofimmatureW.B.Cs.intheblood.Oftenthe
earliestsignsofthisfataldiseasearethegingivalbleedingandulceration.
Theresponsibilityofthedentistinrecognizingandreferringpatientsduetoearlydiagnosisofthis
seriousconditionareobvious.Consultationwithphysicianpriortoanydentalproceduresisessential.
Hemorrhagic Disease
Bleedingmaybeduetodefectinplatelets,coagulation,orvessels.
Anycasewithhistoryofprolongedbleedingorpostextractionhemorrhageshouldbethoroughly
investigatedbyahematologistastheremaybeanunderlyingpredispositiontohemorrhage.
Spontaneousgingivalbleedingorrecurrentattackofepistaxismayevokeaserioushemorrhagic
disease.
Disease involving the blood platelets:
1. Thrombocytopeniapurpura.
2. Thrombocytopathicpurpura.
3. Thrombocythemia(Thrombocytosis).

Disease involving the specific blood factors:


1. hemophilia(A,B,C)
2. Pseudohemophilia (vascular hemophilia):
3. parahemophilia
4. hypofibrinogenemia
5. Hypoprothrombinemia
Diseases involving the small vessel:
1. Congenitale.g.hereditaryhemorrhagictelangiectasia.
2. Acquiredsuchas:
Allergicvasculitis.
Infectione.g.meningitisandSABE.
Scurvy.
Cushing'sdisease.
Senilepurpura.
Dental surgery in patients with hemorrhagic diseases:
1. Laboratoryinvestigationsforbleedingtime,clottingtime,andprothrombintimeshouldbe
performedforallcaseswithhistoryofexcessivebleedingafterminorinjuryorwithprevio us
historyofpostextractionhemorrhage.Ifanysignificantalterationexists,thepatientshouldbe
thoroughlyinvestigatedbyahematologistforthepossibleunderlyingcausetohemorrhage.
2. Patientswithhemorrhagediseasesshouldbehospitalizedbefor eanydentalsurgery,even
beforeminorincisororsimpleextraction.
3. Thedeficientfactor(s)shouldbedetectedandcorrectedbythehematologistbeforedental
surgeryandarrangementsforthearrestofpostoperativehemorrhageshouldbecarriedon
suchas:
Freshorstoredwholebloodtransfusion.
Cryofractionsofdifferentbloodcomponents(6majorfractions).
Plasma.
4. Localhemostaticmeasuresshouldbeperformedafterdentalsurgerybyobliterationofthe
dentalsocketwithabsorbablehemostaticmaterialse.g.Gelfoamsoakedwiththrombinor
fibrinogen,oxidizedcellulose(Oxycelorsurgicel),coagulationofhemorrhagicpointsby
electrocoagulationorcryotherapy,suturingofthemucosaandapplicationofastringents
(tannicacid,zincchloride,ferricsubsulfate).
5. Inserioushemorrhagicdiseases,itshouldbekeptinmindthatarrestofhemorrhagedepends
uponthecorrectionofthedeficientfactorandtheroleoflocalmeasureissecondaryandwill
beeffectiveonlyaftercorrectionofthesystemicdefe ct.
6. NerveblockL.A.techniquesofinjectionsarecontraindicatedinpatientswithhemorrhagic
diseasestoavoidthepossibilitiesofinternalhemorrhageandmassivehematomaformation.
7. Severalcasesofhemophiliahavecirculatinganticoagulantfactors(an tibodies)intheirblood,
whichspecificallyinactivatestheAHG.Suchcasesrequiresseveralbloodtransfusion
postoperatively.Thispointshouldbetakeninconsiderationbeforesurgery.
8. Majorsurgicalproceduresshouldbeavoidedwheneverpossibleandthesurgicalinterference
shouldbeatraumaticaspossible.
9. Theoldmethodoftheuseofrubberbandaroundtheneckofthetoothwasprovedtobeof
littlehelpinlooseningthetooth.Onthecontrarybecauseofmechanicalirritationoftherubber
dam,thegingivaltissueswereusuallyfoundtobeinflamedandtherebyincreasepost
extractionbleeding.
10. postoperatively,neverdischargethepatientunlessatleast3dayswithoutbleedinghad
elapsed.
Endocrine Diseases
Diabetes Mellitus

General description.Diabetesmellitusisadisordercharacterizedbyimpairmentordestructionof
thepancreas'abilitytoproduceinsulinandtheresultantinabilityofthebodytometabolize
carbohydrates,fats,andproteins.

Diabetes may occur as a result of:

a"genetic"disorder,
theprimarydestructionofisletcellsbyinflammation,cancer,orsurgery,
anendocrinecondition,or
iatrogenicdiseaseduetotheadministrationofsteroids .

Thepresentdiscussionwillbelimitedtothe"genetic"typeofdiabetes .

Epidemiology.Twotofourpercent(15to20millionpersons)ofthegeneralpopulationintheUShave
diabetesmellitus.Theprevalenceiscurrentlyabout1.89casesper1,000population,butaslife
expectancyincreases,andaspersonswithdiabeteslivelongerduetobettermedicalmanagement,the
numberofcaseswillcontinuetorise. 3-4Adentalpracticeservinganadultpopulationof2,000can
expecttoencounter40-80personswithdiabetes,abouthalfofwhomwillbeunawareoftheir
condition.

Etiology and clinical presentation.Therearetwotypesof"genetic"diabetes:insulin -dependent


diabetesmellitus(IDDM)andnon-insulin-dependentdiabetesmellitus(NIDDM).Whilebothtypes
appeartohaveageneticcomponent,thegeneticroleinNIDDMismuchgrea terthaninIDDM.
Environmentalfactorssuchasviralinfectionsandautoimmunereactionsappeartoplayanimportant
partintheetiologyofIDDM;obesityplaysanimportantbutnotwell -understoodpartintheetiology
ofNIDDM.

AlthoughIDDMisgenerallyfoundinpeopleunder40yearsofage,itcanoccuratanyage.Itisa
severe,acuteconditionwithasuddenonsetofsymptomsincluding:polydipsia,polyuria,nocturia,
polyphagia,lossofweight,lossofstrength,markedirritability,recurrenceofbe dwetting,drowsiness,
andmalaise.

Itsonsetinchildrenisusuallyprecededbyasuddengrowthspurt.Ifuncontrolledbydailyinjections
ofinsulin,IDDMmayresultindeathinamatterofdays,weeks,oratthemost,months.NIDDM
generallyoccursaftertheageof40inobeseindividuals;itsincidenceincreaseswithage.Incontrastto
IDDM,theonsetofsymptomsinNIDDMisusuallyslowandcangoundetectedforyears.Once
diagnosed,however,itcanbecontrolledbyproperdietandweightreduction, usuallywithouttheneed
forinsulin.

Theprimarymanifestationsofdiabeteshyperglycemia,ketoacidosis,andvascularwalldisease
contributetotheinabilityofuncontrolleddiabeticpatientstomanageinfectionsandhealwounds.

Othersignsandsymptomsrelatingtothecomplicationsofdiabetesareskinlesions,cataracts,
blindness,hypertension,chestpain,andanemia.

Treatment.AlthoughpatientswithIDDMrequireinsulintocontroltheirbloodglucoselevel,diet
controlandadequateexercisecanreducetheamountofinsulinneeded.NIDDMisfrequently
controlledbyweightloss,diet,(rigidcontroloftotalcaloriccontent)andphysicalactivity.Whenthese
lifestylechangesfailtoaffecttheblood-glucoselevel,hypoglycemicagentsareused,sometimesin
combinationwithinsulin.Theseagentsappeartostimulatethesecretionofinsulin,increasethe
numberofcellmembraneinsulinreceptors,andimproveinsulinpostreceptoractivity.Therapyisa
highlyindividualprocessandusuallycontinuesthroughoutthepatient'slifetime.

DENTAL MANAGEMENT

Medical considerations.

Takeathoroughmedicalhistoryforallpatientsdiagnosedwithdiabetes.
Ascertaintheidentityofthephysiciantreatingthepatientandthedateofthelastvisit.
Obtaininformationconcerningthetypeofdiabetes,theseverityandcontrolofthediabetes,
andthepresenceofcardiovascularorneurologiccomplications.
Referanypatientwiththecardinalsymptomsofdiabetesorfindingsthatsuggestdiabetes
(headache,drymouth,irritability,repeatedskininfection,blurredvision,paresthesias,
progressiveperiodontaldisease,multipleperiodontalabscesses)toaphysicianfordiagnosis
andtreatment.

Diabeticpatientswhoarereceivinggoodmedicalmanagementwithout seriouscomplicationssuchas
renaldisease,hypertension,orcoronaryatheroscleroticheartdisease,canreceiveanyindicateddental
treatment.

Thosewithseriousmedicalcomplicationsmayrequireanalteredplanofdentaltreatment.Whenthe
severityanddegreeofcontrolofdiabetesarenotknown,treatmentshouldbelimitedtopalliation.

Foodintakeandappointmentscheduling.Topreventinginsulinshockfromoccurring:

Verifythatthepatienthastakenmedicationasusual.
Verifythatthepatienthashadadequateintakeoffood.
Scheduleappointmentsinthemorning,sincethisisatimeofhighglucoseandlow -insulin
activity.Afternoonappointmentsareatimeoflow -glucoseandhigh-insulinactivitywhichmay
predisposethepatienttoahypoglycemicreaction.
Instructpatientstotellthedentistifatanytimeduringtheappointmenttheyfeelsymptomsof
aninsulinreactionoccurring.Asourceofsugar,suchasorangejuice,mustbeavailableinthe
dentalofficeshouldthesymptomsofaninsu linreactionoccur.

Oral surgery concerns.

Itisimportantthatthetotalcaloriccontentandtheprotein/carbohydrate/fatratioofthe
patient'sdietremainthesamesocontrolofthediseaseandproperbloodglucosebalanceare
maintained.
IDDMdiabeticswhoaregoingtoreceiveperiodontalororalsurgeryproceduresmaybeplaced
onprophylacticantibiotictherapyduringthepostoperativeperiodtoavoidinfection.
Consultationwithapatient'sphysicianbeforeconductingextensiveperiodontalorora lsurgery
isadvisable.Thephysicianmay,infact,recommendthatthepatientbetreatedinahospital
environmentwhereinfection,bleeding,anddysglycemiacanbebettermanaged.

Dangers of acute oral infection.Anydiabeticpatientwithacutedentalo roralinfectionpresents


aprobleminmanagement.Thisproblemisevenmoredifficultforpatientswhotakehighinsulin
dosageandthosewhohaveIDDM.Theinfectionwilloftencauselossofcontrolofthediabetic
condition,andasaresulttheinfectionisnothandledbythebody'sdefensesaswellasitwouldbeina
nondiabeticpatient.Thepatient'sphysicianshouldbecomeapartnerintreatmentduringthisperiod.

Oral complications.Theoralcomplicationsofuncontrolleddiabetesmellitusmayin clude:

Xerostomia,
Infection,
Poorhealing,
Increasedincidenceandseverityofperiodontaldisease,and
Burningmouthsyndrome.
Diabeticneuropathymayleadtooralsymptomsoftingling,numbness,burning,orpaininthe
oralregion.

Oralfindingsinpatientswithuncontrolleddiabetesarethoughttoberelatedtoexcessivelossoffluids
throughurination,alteredresponsetoinfection,microvascularchanges,andpossiblyincreased
glucoseconcentrationsinsaliva.

Earlydiagnosisandtreatmentofthediabeticstatemayallowforregressionofthesesymptoms,butin
long-standingcasesthechangesmaybeirreversible.

PotentialDrugInteraction.Whilepatientswithwell-controlleddiabetescanbegivengeneral
anesthetics,managementwithlocalanestheticsispreferable.Generalanestheticsshouldbeusedwith
cautionbecausetheycanproducehyperglycemia.

Hypoglycemia

Hypoglycemiaisdiagnosedwhenbloodglucoselevelsfalltoabnormallylowlevels.Undernormal
conditions,thebodymaintainsaverynarrowrangeofbloodglucoselevelsdespitewidevariationsin
foodintakeandenergyexpenditure

Signs and Symptoms of Hypoglycemia


1. Diminishedcerebralfunction;decreasedspontaneousconversation,lethargy.
2. Increasedsympathetictone;sweating,tachycardia,piloerection.
3. Anxiety.
4. Bizarrebehavior(Likeintoxication.)
5. Rapidprogressionofsymptoms.

MANAGEMENT OF THE HYPOGLYCEMIC PATIENT


1. ABCs
2. IfpatientisunconsciousorunstableactivateEMS.
3. Ifpatientisconsciousadministeroralcarbohydrates(O rangejuice,sugar,candybar,cakeicing.)
4. Unconscious patient administer parenteral carbohydrates if available (50cc of 50% dextrose IV
overaperiodof2-3minutes.)
5. Patientshouldrespondwithin5minutes.
6. Nevergiveunconsciouspatientanythingorally!

Dental treatment Considerations


1. Preventionisthekey.Takeacompletemedicalhistory.Especiallynoteahistoryofdiabetes.
2. Inthediabeticpatientextraattentionshouldbepaidtostressmanagementandassessingdiet.
3. Ifthepatientisoninsulinandeatingwillbeimpairedbydentaltreatmenttheinsulindoseshould
bedecreasedaccordingly(Medicalconsult.)
HYPERTHYROIDISM
Hyperthyroidism is a condition caused by unregulated production of thyroid hormones.
Thyrotoxicosisisaserioussequelaof hyperthyroidismthatcorrespondstoanoverttissueexposure to
excesscirculatingthyroidhormones.Itischaracterized bytremor,emotionalinstability,intoleranceto
heat, sinus tachycardia, marked chronotropic and ionotropic effects, increased cardiac output
(increased susceptibility to congestive heart failure), systolic heart murmur, hypertension, increased
appetite and weight loss. It can be caused by thyroid hyperfunction, metabolic imbalance or
extraglandularhormoneproduction.
HYPOTHYROIDISM
Hypothyroidismisdefinedbyadecreaseinthyroidhormoneproduction andthyroidglandfunction.
Itiscausedbysevereirondeficiency, chronicthyroiditis(Hashimotosdisease),lackofstimulation,
radioactiveiodinethatcausesfollicledestruction,surgerThisconditioncanbeclassifiedintotwo
categories:primary hypothyroidism,inwhichthedefectisintrathyroid;orsecondary hypothyroidism,
inwhichotherpathologiescancauseanindirect decreaseofcirculatinghormone(forexample,
surgicalorpathologicalalterationofthehypothalamus).

DENTAL MANAGEMENT OF PATIENTS WHO HAVE THYROID DISEASE

Hypothyroidism.Commonoralfindingsinhypothyroidismincludemacroglossia, dysgeusia,delayed
eruption,poorperiodontalhealthanddelayed woundhealing.Beforetreatingapatientwhohasa
historyofthyroiddisease,thedentistshouldobtainthecorrectdiagnosis andetiologyforthethyroid
disorder,aswellaspastmedical complicationsandmedicaltherapy.Furtherinquiryregarding past
dentaltreatmentisjustified.Theconditionsprognosis usuallyisgivenbythetimeoftreatmentand
patientcompliance.

Inpatientswhohavehypothyroidism,thereisnoheightened susceptibilitytoinfection.Theyare
susceptibletocardiovascular diseasefromarteriosclerosisandelevatedLDL.Beforetreating such
patients,consultwiththeirprimarycareproviderswho canprovideinformationontheir
cardiovascularstatuses.Patients whohaveatrialfibrillationcanbeonanticoagulationtherapy and
mightrequireantibioticprophylaxisbeforeinvasiveprocedures, dependingontheseverityofthe
arrythmia.IfValvularpathologyispresent,theneedforantibioticprophylaxismustbeassessed. Drug
interactionsofl-thyroxineincludeincreasedmetabolism duetophenytoin,rifampinand
carbamazepine,aswellasimpaired absorptionwithironsulfate,sucralfateandaluminumhydroxide.
Whenl-thyroxineisused,itincreasestheeffectsofwarfarin sodiumand,becauseofitsgluconeogenic
effects,theuseof oralhypoglycemicagentsmustbeincreased.Concomitantuse oftricyclic
antidepressantselevatesl-thyroxinelevels.Appropriate coagulationtestsshouldbeavailablewhenthe
patientistaking anoralanticoagulantandthyroidhormonereplacementtherapy. Patientswhohave
hypothyroidismaresensitivetocentralnervous systemdepressantsandbarbiturates,sothese
medicationsshouldbeusedsparingly.

Duringtreatmentofdiagnosedandmedicatedpatientswhohave hypothyroidism,attentionshould
focusonlethargy,whichcan indicateanuncontrolledstateandbecomeariskforpatients (for
example,aspirationofdentalmaterials),andrespiratory rate.Itisimportanttoemphasizethe
possibilityofaniatrogenic hyperthyroidstatecausedbyhormonereplacementtherapyusedtotreat
hypothyroidism.Hashimotosdiseasehasbeen reportedtobeassociatedwithDM,andpatientswho
haveDMmightbecomehyperglycemicwhentreatedwithT 4.Whenprovidingdentalcaretopatients
whohaveDM,attentionshouldfocus oncomplicationsassociatedwithpoorglycemiccontrol,which
maycausedecreasedhealingandheightenedsusceptibilityto infections.

Inaliteraturereview,Johnsonandcolleaguesexaminedthe effectsofepinephrineinpatientswho
havehypothyroidism.Nosignificantinteractionwasobservedincontrolledpatients whohadminimal
cardiovascularinvolvement.Inpatientswho havecardiovasculardisease(forexample,congestive
heartfailureandatrialfibrillation)orwhohaveuncertaincontrol,local anestheticandretractioncord
withepinephrineshouldbeused cautiously.Peoplewhoareonastabledosageofhormone
replacementforalongtimeshouldhavenoproblemwithstandingroutine andemergentdental
treatment.Hemostasisisnotaconcernunless thepatientscardiovascularstatusmandates
anticoagulation.

Forpostoperativepaincontrol,narcoticuseshouldbelimited, owingtotheheightenedsusceptibility
totheseagents.

Hyperthyroidism.Beforetreatingapatientwhohashyperthyroidism,theoral healthcare
professionalneedstobefamiliarwiththeoral manifestationsofthyrotoxicosis,includingincreased
susceptibilitytocaries,periodontaldisease,enlargementofextraglandular thyroidtissue(mainlyin
thelateralposteriortongue),maxillary ormandibularosteoporosis,accelerateddentaleruption and
burningmouthsyndrome(Box2 ).Inpatientsolderthan70yearsofage,hyperthyroidismpresentsas
anorexiaandwasting,atrial fibrillationandcongestiveheartfailure.Inyoungpatients, themain
manifestationofhyperthyroidismisGravesdisease, whilemiddle-agedmenandwomenpresentmost
commonlywithtoxic nodulargoiter.Developmentofconnective-tissuediseaseslikeSjgrens
syndromeandsystemiclupuserythematosus alsoshouldbeconsideredwhenevaluatingapatientwho
hasahistoryofGravesdisease.
Takingacarefulhistoryandconductingathoroughphysical examinationcanindicatetotheoral
healthcareprofessional thelevelofthyroidhormonecontrolofthepatient.Patients whohave
hyperthyroidismaresusceptibletocardiovasculardisease fromtheionotropicandchronotropiceffect
ofthehormone, whichcanleadtoatrialdysrhythmias.Itisimportant thatthedentistaddressthe
cardiachistoryofthesepatients. Consultingthepatientsphysiciansbeforeperforming anyinvasive
proceduresisindicatedinpatientswhohavepoorlycontrolledhyperthyroidism.Treatmentshouldbe
deferredifthepatientspresentwithsymptomsofuncontrolleddisease. Thesesymptomsinclude
tachycardia,irregularpulse,sweating, hypertension,tremor,unreliableorvaguehistoryofthyroid
diseaseandmanagement,orneglecttofollowphysician-initiated controlformorethansixmonthsto
oneyear.

Adecreaseincirculatingneutrophilshasbeenreportedduring thyroidstormcrisis.Dentaltreatment,
however,usuallyis notapriorityinthisstate.Susceptibilitytoinfectioncan increasefromdrugside
effects.Peoplewhohavehyperthyroidism andaretreatedwithpropyl-thiouracilmustbemonitored
forpossibleagranulocytosisorleukopeniaasasideeffectoftherapy. Besidesitsleukopeniceffects,
propylthiouracilcancausesialolith formationandincreasetheanticoagulanteffectsofwarfarin. A
completebloodcountwithadifferentialwillindicateif anymedication-inducedleukopeniamaybe
present.Aspirin;oral contraceptives;estrogen;andnonsteroidalanti-inflammatorydrugs,orNSAIDs,
maydecreasethebindingofT 4toTBGinplasma. ThisincreasestheamountofcirculatingT 4andcan
leadtothyrotoxicosis.Aspirin,glucocortico-steroids,dopamineand heparincandecreaselevelsof
TSH,complicatingacorrectdiagnosis ofprimaryorpituitaryhyperthyroidism.

Theuseofepinephrineandothersympathomimeticswarrantsspecial considerationwhentreating
patientswhohavehyperthyroidism andaretakingnonselective-blockers.Epinephrineactson -
adrenergicreceptorscausingvasoconstrictionandon 2receptorscausingvasodilation.Nonselective
-blockerseliminatethevasodilatoryeffect,potentiatingan -adrenergicincreaseinbloodpressure.
Thismechanismappliestoanypatient whoistakingnonselective-blockers,anditisrelevant in
patientswhohavehyperthyroidismbecauseofthepossiblecardiovascularcomplicationsthatcan
arise.Knowledgeofthe describedinteractionsshouldalerttheclinicianforanypossible complication.

Duringtreatment,heightenedawarenesstowardoralsoft-andhard-tissuemanifestations,as
describedpreviously,shouldbeemphasizedOralexaminationshouldincludeinspection andpalpation
ofsalivaryglands.Ifthepatientdoesnothave anycardiovasculardiseaseorisnotreceiving
anticoagulation therapy,hemostaticconsiderationsshouldnotrepresentac oncernforinvasiveoral
procedures.Managementofthepatientreceiving anticoagulationtherapyhasbeendescribedinthe
literature.

Oralhealthcareprofessionalsshouldrecognizethesignsand symptomsofathyroidstorm,asthe
patientcouldpresentfordentalcareduringitsinitialphaseorwhenundiagnosed.Patients whohave
hyperthyroidismhaveincreasedlevelsofanxiety,and stressorsurgerycantriggerathyro-toxiccrisis.
Epinephrineiscontraindicated,andelectivedentalcareshouldbedeferredforpatientswhohave
hyperthyroidismandexhibitsignsorsymptoms ofthyrotoxicosis.Briefappointmentsandstress
managementareimportantforpatientswhohavehyperthyroidism.Treatment shouldbediscontinued
ifsignsorsymptomsofathyrotoxic crisisdevelopandaccesstoemergencymedicalservicesshould be
available.

Aftertreatment,properpostoperativeanalgesiaisindicated. NSAIDsshouldbeusedwithcautionin
thepatientswhohave hyperthyroidismandwhotake-blockers,astheformer candecreasethe
efficiencyofthelatter.Pain,however,can complicatecardiacfunctioninpatientswhohave
hyperthyroidismandsymptomaticdisease,andalternativepainmedicationsneed tobeinstituted.Itis
importantthatpatientscontinuetaking theirthyroidmedicationasprescribed.Ifanemergent
procedureisneededintheinitialweeksofthyroidtreatment,closework -upwiththeendocrinologistis
needed(Box3 ).

Acute Adrenal Insufficiency

Theadrenalcortexproducesover25differentsteroids.Thesesteroidsarebrokenintothreegroups:
sex steroids, mineralocorticoids, and glucocorticoids. Of primary concern in dentistry are the
glucocorticoids.Aphysiologicdoseofapproximately20mg/dayofcortisolisproduced.Thisplaysa
keyroleinthebodiesabilitytoadapttostress.Cortisolprovidesachemicallinkwithinthecellsofthe
bodyallowingregulationofvitalfunctionsincludingbloodpressureandglucoseutilization.

Cortisolproductionistriggeredbyrealorthreatenedstresssuchastrauma,illness,fright,and
anesthesia.Inapatientwithsuppressedadrenalfunction afailureofthiscortisolproduction
eliminatesthechemicallinktoregulatevitalfunctionsresultinginsuddenshockandpossiblydeath.
SuppressedadrenalfunctionorAdrenalFailureisclassifiedaseitherPrimary(Addisonsdisease
causedbyDiseasestatessuchasTB,Bacteremia,Carcinoma,andAmyloidosis.)orSecondary(Caused
byPituitarydisorder,Hypothalmicdisorders,orSteroidTherapy.)

Steroidtherapysuppressesthefunctionoftheadrenalcortexreducingtheproductionofnatural
cortisol.Becauseofthissuppressionpatientswhohavebeenonlongtermsteroidtherapylosetheir
abilitytorespondtostress.Ifthesepatientsarestressedsymptomsofacuteadrenalinsufficiencymay
result.

Signs and Symptoms of Acute Adrenal Insuffici ency


1. Mentalconfusion.
2. Muscleweakness.
3. Fatigue.
4. Nauseaandvomiting.
5. Hypotension.
6. Intensepainsinabdomen,lowerback,and/orlegs.
7. Mucocutaneouspigmentation.
8. Hypoglycemia.
9. Hyperkalemia.
10. Increaseheartrate,decreasedbloodpressure.

MANAGEMENT OF SUSPECTED ACUTE ADRENAL INSUFFICIENCY


1. Discontinuealltreatmentandremoveforeignobjectsfromthepatientsmouth.
2. InitiateBLSandactivateEMS
3. Placepatientsupine.
4. Monitorandrecordvitalsigns.
5. Oxygenat5-10L/minute.
6. Hydrocortisone 100mg IV (Dexamethasone 4mg) over 30 seconds or IM if IV not available.
Repeat dose every 6 hours for 24 hours. If the patient is stable then reduce to 50mg
(Dexamethasone4mg)every6hoursthentaperorallyover4-5days.Shouldinitiateifthereisany
suspicionofAAI.












Dental Treatment Considerations

Forpatientswithahistoryofglucocorticoidtherapyusestressreductionprotocols.

ThefollowingguidelinescanbeusedtodetermineifreplacementtherapyisindicatedThisisachange
fromtheoldruleoftwosbasedonanarticledoneatNNDC.Itisalwaysagoodideatogetamedical
consultinsuchcases.

Ifthepatienthasundergonesupraphysiologic(Morethan20mg/day)glucocorticoidtherapythatwas
discontinuedmorethan30dayspriortotheplanneddentaltreatmentnosupplementationisrequired.

Ifthepatientshasundergonesupraphysiologicglucocorticoidtherapywithin 30daysoftheplanned
dentalprocedureconsideredthepatientssuppressedandprovidesteroidsupplementationequivalent
to100mgofcortisol.
Ifthepatienthasundergoneorisundergoingalternatedaydosingscheduleglucocorticoidtherapyno
supplementationisrequiredbutitisbesttoprovidedentaltreatmentontheoffdayofthepatients
doseschedule.
Ifthepatientiscurrentlyreceivingdailyglucocorticoidtherapyatasupraphysiologiclevel(More
than20mg)supplementationisrequired.Ifthedailydoseissubphysiologicsupplementationisnot
required.

Liver diseases

VIRAL HEPATITIS

General description.Acuteviralhepatitisischaracterizedbydegenerationandnecrosisoflivercells
with ballooning degeneration of the hepatocytes. Icterus (jaundice) is commonly associated with
hepatitisandiscausedbyanaccumulationofbilirubinintheskin.

Acute viral hepatitis is caused by at least five distinct viruses:

Type A hepatitis (formerly called infectious hepatitis) is caused by the hepatitis A virus
(HAV), which is an RNA-type virus. Serologic tests for HAV and its antibodies are readily
available.
Type B hepatitis (formerlycalledserum hepatitis)iscausedbythehepatitisBvirus(HBV),
whichisaDNA-typevirus.Serologictestsareavailableforallbutone(HBcAg)ofitsantigen-
antibodysystems.
Delta hepatitis is caused by a defective RNA-type virus that requires the presence of HBV
for infection. It can occur as either a coinfection or a superinfection with hepatitis B. The
hepatitisdeltavirus(HDV)anditsantibodyanti -HDcanbedetectedwithserologictesting.
Non A non- Btype C hepatitis was originally a diagnosis of exclusion in posttransfusion
hepatitis when serologic markers of types A and B were not present. Serologic tests are now
availableforboththeviralantigenanditsantibody.
Non- A- non- B- - - type E hepatitis is an enterically transmitted virus, similar to type A.
Serologictestsforbothantigenandantibodyhaverecentlybecomeavailable.

Epidemiology. Because the means of transmission overlap and the clinical expression of the various
forms of hepatitis are often indistinguishable, no absolute statements can be made regarding
epidemiology.However,certainrecurringpatternsofdiseasearerecognizedforeachtype.

Hepatitis A is transmitted almost exclusively by fecal contamination of food or water. Because the
reservoirfor infections is frequently a common food or water source, hepatitis A often occurs as an
epidemic.Transmissionisenhancedbypoorpersonalhygiene,especiallyamongschool-agedchildren
andfoodhandlers.
Hepatitis A is a common disease, with serologic evidence of infection in about 40% of urban
populations in the US.1 Of importance is the fact that no carrier state is known to exist for it. No
vaccineiscurrentlyavailable,andrecoveryusuallyconveysimmunityagainstreinfection.

Hepatitis Bmaybetransmittedinanumberofways:

direct percutaneous inoculation of infected serum or plasma by needle or transfusion of


infectivebloodorbloodproducts
indirectpercutaneousintroductionofinfectiveserumorplasmaabsorptionofinfectiveserum
orplasma(e.g.,throughmucosalsurfacesofthemouthoreye)
absorptionofotherpotentiallyinfectivesecretions(e.g.,salivaorsemen)
transferofinfectiveserumorplasmaviainanimateenvironmentalsurfaces

TheroleofsalivainHBVtransmission,exceptbypercutaneousorpermucosalroutes,doesnotappear
tobesignificant. 2

Groups at high risk for hepatitis B are:

healthcareworkers(includingdentistsanddentalstaff)
hemodialysispatients
usersofillicitdrugs
homosexuals
heterosexualswithmultipleparameters
recipientsofbloodtransfusions

The risk of infection is directly related to exposure to blood. This has resulted in a reported past
prevalencerateofinfectionamonggeneraldentistsrangingfrom13to30percent,andarateamong
oral surgeons as high as 38 percent.3-5 More recently, the prevalence rate for general dentists was
reportedtobe8.89percent.

Hepatitis B has greater associated morbidity and mortality than hepatitis A, especially in older
patients.AnadditionalsignificantfeatureofhepatitisBistheexistenceofachroniccarrierstatethat
canpersistforvariableperiodsafterresolutionofacutedisease.Whilethecarrierrateofdentistsin
theUShasdecreased(reflectingtheeffectivenessofprophylacticmeasures),theriskisstillestimated
tobethreetotentimesthatofthegeneralpopulation.Itissignificanttonotethatsincemanycasesare
mildorsubclinical,mostcarriersareunawarethattheyhavehadhepatitisB.

Delta hepatitisoccursonlyasacoinfectionwithacutehepatitisBorasasuperinfectionincarriers
of hepatitis B and, therefore, is transmitted parenterally via infected blood or blood products. It is
seenprimarilyindrugaddictsandhemophiliacs.

NANB hepatitistype C is similar to type B in behavior and characteristics. It is transmitted


primarily parenterally and is the major etiologic agent of posttransfusion non-A non-B hepatitis.
WhilefortypercentofpatientswithhepatitisChavenoidentifiableriskfactorsforinfection, 7thoseat
highriskinclude:

healthcareworkersexposedtoblood
illicitdrugusers
hemodialysispatients
recipientsofwholeblood,bloodcellularcomponents,orplasma

Clinical presentation.Manyofthesignsandsymptomsofacuteviralhepatitisarecommontoviral
diseasesandmaybedescribedasflulike.Thisisespeciallytrueintheearlystageofthedisease.There
are classically three phases of acute viral hepatitis, each lasting for a certain duration, and each
manifestingparticularsymptoms.
Prodromal (preicteric) phase. Symptoms include anorexia, nausea, vomiting, fatigue,
myalgia,malaise,andfever.
Icteric phase. Many of the nonspecific prodromal symptoms may subside, but
gastrointestinal symptoms may increase. Hepatomegaly and splenomegaly are also frequently
seen.
Posticteric phase. Symptoms disappear, but hepatomegaly and abnormal liver function
valuesmaypersist. Thisphase canlast forweeks ormonths, withrecovery timefor hepatitis
typesBandCgenerallybeinglonger.

Treatment.Thereisnospecifictreatmentforacuteviralhepatitis.Therapyisbasicallypalliativeand
supportive.Anutritiousandhigh-caloriedietisadvisable.

DENTAL MANAGEMENT

Medical considerations. Since infectious patients cannot necessarily be identified by history, it is


necessary to manage all patients as though they are potentially infectious. The Center for Disease
ControlandtheAmericanDentalAssociationhavepublishedrecommendationsforinfectioncontrol
that have become the standard of care to prevent crossinfection in dental practice. These standards
shouldbestrictlyadheredto.

Therearefivecategoriesofpatientswithahistoryofhepatitisthatmustbeconsideredbythedentist:

Patients with active hepatitis. No treatment other than urgent care should be
rendered to these patients. If a patient is seen with acute hepatitis, the
physician should be contacted immediately .
Patients with a history of hepatitis .Sinceitisestimatedthattherearebetween 750,000
and1 million carriers of hepatitisB in the US today,the only practical method of protection
from infection is to adopt a strict program of clinical asepsis for all patients. In addition,
inoculationofalldentalpersonnelwithhepatitisBvaccineisstronglyurged.
Patients at high risk for HBV infection.Patientswhofitintooneormoreofthehighrisk
categories should routinely be screened for HBsAg before dental care is provided unless
laboratoryevidenceexistsforanti-HBs.Whilethismeasuremayseemredundant,itcouldyield
informationthatwouldbeofbenefitincertainsituations.Forexample,ifanaccidentalneedle
stick or puncture occurs during treatment and the dentist is not vaccinated, it would be of
extremeimportancetoknowwhetherthepatientwasHBsAgpositive,whichwoulddictatethe
needforvaccination.
Patients who are hepatitis carriers.IfapatientisfoundtobeahepatitisBcarrierorto
have a history of NANB hepatitis, recommendations from the Center for Disease Control for
avoiding transmission of infection should be closely followed. In addition, some hepatitis
carriers may have chronic active hepatitis, leading to compromised liver function and
interfering with hemostasis and drug metabolism. Physician consultation or laboratory
screeningforliverfunctionisadvised.
Patients with signs or symptoms of hepatitis . Any patient having signs or symptoms
suggestinghepatitisshouldbereferredtoaphysician,andshouldnotbetreated.Ifemergency
carebecomesnecessary,itshouldbeprovidedasforthepatientwithacutedisease.

Potential drug interactions . In a completely recovered patient there are no special drug
considerations. However, if a patient has chronic active hepatitis or is a carrier of HBsAg and has
impaired liver function, drugs metabolized by the liver should be avoided if possible. Although a
numberoflocalanesthetics,analgesics,sedatives,andantibioticscommonlyusedindentistryare,in
fact, metabolized principally by the liver, these drugs can be used in limited amounts in all but the
mostseverecasesofhepaticdisease.
Oral complications. The only oral complication associated with hepatitis is the potential for
abnormalbleedingincasesofsignificantliverdamage.Ifsurgeryisrequired,itisadvisableto:

Check the prothrombin time. If it is greater than 35, an injection of vitamin K will usually
correcttheproblem.Thisshould,however,bediscussedwiththepatient'sphysician.
Monitorthebleedingtimetocheckplateletfunction .Ifitisnotlessthan20minutes,thepatient
may require platelet replacement before surgery. This should also be discussed with the
patient'sphysician.

ALCOHOLIC LIVER DISEASE

General description.Thepathologiceffectsofalcoholonthelivercanresultinthreediseaseentities,which
commonlyappearincombination:

With fatty infiltrate , the hepatocytes become engorged with fatty lobules and distended,
with enlargement of the entire liver. These changes may occur after only moderate usage of
alcoholforabrieftime,andarecompletelyreversible.
Alcoholic hepatitis is a diffuse inflammatory condition of the liver characterized by
destructive cellular changes. Some of these may be irreversible, thereby leading to necrosis.
Whilethisconditioncanbefatalifdamageiswidespread,itisgenerallyreversible.
Cirrhosis, the most serious form of alcoholic liver disease, is characterized by progressive
fibrosisandabnormalregenerationofliverarchitectureinresponsetochronicinjuryorinsult
(i.e., prolonged and heavy use of ethanol). It results in the progressive deterioration of
metabolicandexcretoryfunctionsoftheliver,andultimatelyleadstohepaticfailure.

Epidemiology.Itisestimatedthat:

Uptoninetypercentofpeopledrinkalcohol.
Fortytofiftypercentofmenhavetemporaryalcohol-inducedproblems.
Ten percent of men and three to five percent of women develop pervasive and persistent
alcoholism.

Alcoholabuseanddependencearenotlimitedtoanyparticulargroup.Allagesandraces,bothsexes,
andallsocioeconomiclevelsareaffected.

Clinical presentation.

Fatty liver .Therearenoclinicalmanifestationsofafattyliver,andthediagnosisisusually


madeincidentallyinconjunctionwithanotherillness.
Alcoholic hepatitis .Signsandsymptomsofalcoholichepatitisareoftennonspecificandmay
include nausea, vomiting, anorexia, malaise, weight loss, and fever. More specific findings
include hepatomegaly, splenomegaly, jaundice, ascites, ankle edema, and spider angiomas.
Withadvancingdisease,encephalopathyandhepaticcomamayensue,endingindeath.
Cirrhosis. Cirrhosismayremainasymptomaticformanyyears.Hemorrhagefromesophageal
varicesisfrequentlytheinitialsign,butascites,spiderangiomas,ankleedema,orjaundicemay
also be among the early signs. The hemorrhagic episode may progress to hepatic
encephalopathy,coma,anddeath.

Treatment.Thecornerstoneoftreatmentforalcoholicliverdiseaseisabstinencefromalcohol.Other
measuresinclude:

strictdietarymodification(high-protein,highcalorie,low-sodiumdiet)
fluidrestriction
vitaminsupplementation
Anemiaiscorrectedbyironreplacementandfolicacidsupplementation.

DENTAL MANAGEMENT

Medical considerations.Thetwomajortreatmentconsiderationsinanalcoh olicpatientare:

bleedingtendencies
unpredictablemetabolismofcertaindrugs

Dental management must, therefore, begin with detection by history and/or by clinical examination.
Whenthereisahighindexofsuspicion,anumberoflaboratorytestsshouldbeorderedforscreening
purposes:

CBCwithdifferential
AST,ALT
bleedingtime
thrombintime
prothrombintime

Ifapatienthasahistoryofalcoholicliverdiseaseoralcoholabuse,thephysicianshouldbeconsulted
toverify:

thepatient'scurrentstatus
medications
laboratoryvalues
contraindicationsformedications,surgery,andothertreatment

Apatientwithuntreatedalcoholicliverdiseaseisnotacandidateforelective,outpatientdentalcare
and should be referred to a physician. Once the patient is managed medically, dental care may be
provided after consultation with the physician. Bleeding diatheses (as reflected on laboratory tests)
shouldbemanagedinconsultationwiththephysician.

Metabolic concerns.Concernabouttheunpredictablemetabolismofdrugsistwofold:

In mild to moderate alcoholic liver disease, significant enzyme induction is likely to have
occurred, leading to an increased tolerance of sedative drugs, hypnotic drugs, and general
anesthesia. Larger than normal doses of these medications are thus required to obtain the
desiredeffects.
Withmoreadvancedliverdestruction,drugmetabolismmaybemarkedlydiminishedandcan
leadtoanincreasedorunexpectedeffect.Drugsmetabolizedprimarilybytheliver(i.e.,certain
anesthetics,analgesics,sedatives,andantibiotics)shouldbeusedwithcaution,andavoidedif
possible.Whenused,dosesshouldbeadjusted.

Oral complications.Poororalhygieneandneglectarecommonfindingsinchronicalcoholics.Other
abnormalitiesthatmaybefoundare: 4-5

glossitis
angularorlabialcheilosis
candidiasis
gingivalbleeding
oralcancer
petechiae
ecchymoses
jaundicedmucosa
parotidglandenlargement
alcoholbreathodor
impairedhealing
bruxism
dentalattrition
xerostomia

Sincealcoholabuse(andtobaccouse)arealsostrongriskfactorsforthedevelopmentoforalcancer,
practitionersshouldbeaggressiveindetectingsuspicioussoft-tissuelesions.

Kidney Diseases
CHRONIC RENAL FAILURE, DIALYSIS AND DENTAL MANAGEMENT

General Description. End-stage renal disease (ESRD) is a bilateral, progressive, and chronic
deteriorationofnephronsthatresultsinuremiaandultimatelyleadstodeath.Therateofdestruction
andtheseverityofdiseasedependontheunderlyingcausativefactors,whichareoftenunknown.

Epidemiology.Approximately1.3in10,000populationdevelopESRDannually;thisrateisincreasing
byabout10percentperyear,mostrapidlyinpatientsoverage65.

Etiology and clinical presentation .SomeofthemorecommonknowncausesofESRDarediabetes,


hypertension,glomerulonephritis,polycystickidneydisease,andsystemiclupuserythematosus .

Its manifestations are seen in the cardiovascular, gastrointestinal, neuromuscular, hematologic, and
dermatologic systems. Cardiovascular manifestations include hypertension, congestive heart failure,
pericarditis. Gastrointestinal signs include anorexia, nausea, vomiting, generalized gastroenteritis,
pepticulcerdisease,stomatitis,andcandidiasiscanals ooccur.

Patients may:

showmentalslownessordepression
demonstratemuscularhyperactivity
experiencehemorrhagicepisodes,especiallyinthegastrointestinaltract
displaypalloroftheskinandmucousmembranes(duetoanemia)
display hyperpigmentation of the skin caused by the retention of carotene-like pigments
normallyexcretedbythekidney

Conservative care. Conservative care attempts to decrease the retention of nitrogenous waste
products and control fluids and electrolyte imbalances by dietary modification (protein restriction)
andbycloselymonitoringfluid,sodium,andpotassiumintake.CalciumandvitaminDsupplements
arealsoprescribed.

Nephrotoxicdrugsoragentsthataremetabolizedprincipallybythekidneyareavoided .

Dialysis. As more and more nephrons are destroyed, medical management of ESRD becomes
inadequate and artificial filtration of the blood is required in the form of peritoneal dialysis or
hemodialysis. Most patients are maintained by hemodialysis. The technique requires the surgical
creation of a permanent arteriovenous fistula that is readily accessible to cannulation with a large-
gaugeneedle.Thepatientis"pluggedin"tothehemodialysismachineatthefistulasite,andbloodis
passedthroughthemachine,filtered, andreturnedtothepatient. Treatmentsusuallyrequire 3to 5
hours,andareperformedevery2or3days,dependingonneed.

Althoughhemodialysisisalifesavingtechnique,therearecomplicationsassociatedwithit.Theriskof
hepatitisBandCandAIDSissignificantbecausepatientshaveusuallyhadmultiplebloodexposures.
Infection of the arteriovenous fistula is also an ongoing concern and can result in septicemia, septic
emboli,infectiveendarteritis,orendocarditis.Theprocedureitselfcausesplateletdestruction,thereby
aggravatingalreadyexistingbleedingtendencies.

DENTAL MANAGEMENT

Medical considerations for patients under conservative care. Before dental care is provided to a
patientunderconservativemanagementofESRD,thepatient'sphysicianshouldbeconsulted.Ajoint
decisionshouldthenbemadeastothesetting(inpatientoroutpatient)inwhichthiscarecansafelybe
provided. If ESRD is well-controlled, there is generally no problem in providing outpatient care.
Whenrenderingthiscare:

Orderpretreatmentscreeningforbleedingdisorders(bleedingtime,plateletcount,hematocrit,
hemoglobin).
Monitorbloodpressure.
Paymeticulousattentiontogoodsurgicaltechnique.
Useuniversalinfectioncontrolprocedures.

Medical considerations for patients receiving dialysis . Therecommendationsformanaginga


patientreceivinghemodialysisarethesameasthoseformanagingapatientunderconservativecare,
withafewadditionalconsiderations:

Thesurgicallycreatedarteriovenousfistulaispotentiallysusceptibletoinfection(endarteritis)
resultingfromadentallyinducedbacteremiaandisasourceofinfectiousembolithatcancause
endocarditis. While both conditions are of low incidence, the patient's managing physician
shoulddeterminewhetherornottoadministerprophylacticantibiotics.
Hemodialysis patients must avoid dental care on the day of dialysis, when they could have
bleedingtendencies.Thebesttimefordentaltreatmentisthedayafterhemodialysis.

Oral complications.

Palloroftheoralmucosasecondarytoanemia.
Diminishedsalivaryflow,resultinginxerostomiaandparotidinfections.
Patients frequently complain of a metallic taste, and the saliva may have a characteristic
ammonia-likeodorduetoahighureacontent.
Insevererenalfailure,astomatitismaybepresent.
Lossoflaminadura.
Demineralizedbone.
Localizedradiolucentjawlesions.

Potential Drug Interactions.

Ofspecialconcernaredrugsthatareprimarilyexcretedbythekidneyorthatarenephrotoxic
(tetracycline,acyclovir,acetaminophen,aspirin,andNSAlDs).
Certaindrugs are removedduring hemodialysis and,therefore, require anadditional dose to
beadministeredafterhemodialysis.

The Nervous disease convulsive d isorders


EPILEPSY AND DENTAL MANAGEMENT

General description.Epilepsyisatermthatdescribesagroupofdisorderscharacterizedbychronic,
recurrent,paroxysmalchangesinneurologicfunction(seizures)thatarecausedbyabnormal
electricalactivityinthebrain.Seizuresmayeitherbeaccompaniedbymotormanifestationsor
manifestedbysensory,cognitiveoremotionalchangesinneurologicfunction.Thisdiscussionwillbe
limitedtogeneralizedtonic-clonicseizures,sincetheserepresentthemostsevereexpressionof
epilepsythatpractitionersarelikelytoencounter.

Epidemiology.Itisestimatedthat10%ofthepopulationwillhaveatleastoneepilepticseizureinits
lifetimeandthattheoverallincidencerateis0.5%.1Seizuresaremostcommonduringchildhood,
withasmanyas4%ofchildrenhavingatleastoneseizureduringthefirst15yearsoflife.
Fortunately,mostchildrenoutgrowthis.

Etiology and clinical presentation .Commoncausesofepilepsyincludeheadtrauma,intracranial


neoplasm,hypoglycemia,drugwithdrawal,andfebrileillness.Formanypatients,however,thereisno
knowncause(idiopathic epilepsy).Insuchcases,seizuresaresometimesevokedbyaspecificstimulus
suchasflickeringlights,monotonoussounds,music,oraloudnoise.

Thepatienthavingageneralizedtonic-clonicconvulsion(grandmalseizure)typicallyemitsasudden
cry,immediatelylosesconsciousness,exhibitsgeneralizedmusclerigidityfollowedbyclonicactivity
consistingofuncoordinatedbeatingmovementsofthelimbsandhead,ceasesmovementandbecomes
comatose.Withinafewminutes,thepatientgraduallyreturnstoconsciousnesswithstupor,headache,
andconfusion.

Treatment. Themedicalmanagementofepilepsyisbasedondrugtherapy.Whilephenytoin
(dilantin)ismostcommonlyusedasafirstlineoftreatment,otheranticonvulsantdrugssuchas
carbamazepine,phenobarbital,andvalproicacidarealsocommonlyused.

DENTAL MANAGEMENT

Medical considerations.Onceanepilepticpatienthasbeenidentified:

Learnasmuchaspossibleabouttheseizurehistory,currentmedications,degreeofseizure
control,andanyknownprecipitatingfactors.
Beawareoftheadverseeffectsofanticonsulvants(drowsiness,dizziness,ataxia,and
gastrointestinalupset).
Rendernormalroutinecaretoepilepticpatientswhohaveattainedgoodcontroloftheir
seizureswithmedication.
Donotrendertreatmenttopatientswhoseseizureactivitydoesnotrespondtoanticonvulsants,
withoutpriorconsultationwiththepatient'sphysician.Suchpatientsmayrequireadditional
anticonvulsantorsedativemedication,asdirectedbythephysician.

Oral complications.Themostsignificantoralcomplicationseeninepilepticpatientsisgingival
hyperplasiaassociatedwithphenytoin.Theanteriorlabialsurfacesofthemaxillaryandmandibular
gingivaearethemostseverelyaffected.Whilethereissomecontroversyregardingtheeffectivenessof
oralhygieneinpreventinggingivalhyperplasia,mostevidencesuggeststhatmeticulousoralhygiene
willprevent,oratleast,significantlydecreaseitsseverity.Goodhomecareshouldthusbecombined
withtheremovalofirritantssuchasoverhangingrestorationsandcalculus.Surgicalintervention
may,however,berequiredtoreducehyperplastictissueinterferingwithfunctionorappearance.

Dealing with a seizure.Shouldapatienthaveageneralizedtonic-clonicconvulsioninthedental


office,bepreparedtodealwithit.Theprimarytaskofmanagementistoprotectthepatie ntandtryto
preventinjury.

Donotattempttomovethepatient.
Placethechairinasupportedsupineposition.
Turnthepatient,ifpossible,tothesidetocontroltheairwayandminimizeaspirationof
secretions.
Usepassiverestraintonlytopreventinjuryfromhittingnearbyobjectsorfromfallingoutof
thechair.

Potential Drug Interactions.

Propoxypheneanderythromycinshouldnotbeadministeredtopatientstakingcarbemazepine
becauseofinterferencewithmetabolismofcarbemazepine,whichcouldleadtotoxicity.
AspirinandNSAIDSshouldnotbeadministeredtopatientstakingvalproicacid,fortheycan
furtherdecreaseplateletaggregation,leadingtohemorrhagicepisodes.

SEXUALLY TRANSMITTED DISEASES AND DENTAL MANAGEMENT


Sexually transmitted diseases (STDs) are a major health problem in the US, varying in their
manifestationsfromminorinconvenienceorirritationtoseveredisabilityanddeath.Includedamong
this group of diseases are AIDS, gonorrhea, syphilis, chlamydia, genital herpes, hepatitis B,
trichomoniasis,lymphogranulomavenereum,chancroid,genitalwarts,andpediculosispubis.

Although most STDs have the potential for oral infection and transmission, this discussion will be
limited to (1) gonorrhea, (2) syphilis, and (3) genital herpes. Please refer to a separate discussion of
AIDSandto"LiverDiseases"foradiscussionofhepatitisB.

Sincesomepersonsprovidenohistoryanddemonstratenosignificantsignorsymptomssuggestiveof
disease,itisnotpossibletoidentifypotentiallyinfectiouspatients.Itisthusnecessarytomanageall
patientsasthoughtheywereinfectious.RecommendationspublishedbytheUSPublicHealthService
for controlling infection in dentistry have become the standard for preventing cross-infection. Strict
adherencetotheserecommendationswilleliminatethedangerofdiseasetransmissionbetweendentist
andpatients.

Drug Interactions. There are no adverse interactions between the usual antibiotics or drugs used to
treatSTDsandthedrugscommonlyusedindentistry.Nodrugsarecontraindicated.

1. GONORRHEA

General description and epidemiology. Gonorrhea is the most commonly reported infectious
diseaseintheUS,withover690,000casesrecordedin1990.1Itstransmissionisalmostexclusivelyvia
sexual contact, the primary sites of infection are the genitalia, anal canal, and pharynx. Though
gonorrheaisseenmorecommonlyin15-19year-oldand20-24yearoldagegroups,itcanoccuratany
age.1Single,black,urbandwellerswithmultiplesexualpartnersareathighrisk.Otherriskfactors
includeloweducationallevelandsocioeconomicstatus.

Etiology and clinical presentation . Gonorrhea is caused by Neisseria gonorrhoeae, which is a


gram-negativediplococcuscommonlyfoundwithinpolymorphonuclearleukocytes.N. gonorrhoeaeis
anaerobethatrequireshighhumidityandspecifictemperatureandpHforoptimumgrowth,andis
readily killed by drying. It develops resistance to antibiotics rather easily, and many strains have
becomeresistanttopenicillinandtetracycline,aswellastootherantibiotics.

In men, the most common symptoms include a mucopurulent urethral discharge, pain on urination,
urgency,andfrequency,Inwomen,asignificantpercentage(50%)ofcasesmaybeasymptomaticor
only minimally symptomatic. Women who are symptomatic may demonstrate vaginal or urethral
discharge and dysuria with frequency and urgency. Backache and abdominal pain may also be
present. Within the oral cavity the pharynx is most commonly affected. It is usually seen as an
asymptomaticinfectionwithdiffuse,nonspecificinflammationorasamildsorethroat.

Treatment. Infectiousness diminishes rapidly following antibiotic therapy with ceftriaxone and
doxycycline.
DENTAL MANAGEMENT

Medical considerations. Due to the specific requirements for disease transmission and to the
disease's rapid response to antibiotics, gonorrhea poses little threat of disease transmission to the
dentist.Whatevercareisnecessaryshouldthusbeprovided.

Oral Complications. The rare presentation of oral gonorrhea is nonspecific and varied and may
rangefromslighterythematosevereulcerationwithapseudomembranouscoating.Thepatientmay
beeitherasymptomaticorincapacitatedwithlimitationsoforalfunction.Definitivediagnosisoforal
lesionsshouldbeattempted,andthepatientshouldbeunderthecareofaphysician.Treatmentofthe
orallesionsisthensymptomatic.

2. SYPHILIS

General description and epidemiology. Syphilis is the third most frequently reported infectious
diseaseintheUS,surpassedonlybygonorrheaandchickenpox.Itismostcommoninages20-40;its
reported incidence is greater in males than females, by more than 2:1.1 Its transmission is
predominantlysexual;however,itcanoccurvianon-sexualmeanssuchaskissing,bloodtransfusion,
or accidental inoculation with a contaminated needle. Congenital syphilis occurs when the fetus is
infectedinuterobyaninfectedmother.Theprimarysiteofsyphiliticinfectionisusuallythegenitalia,
althoughprimarylesionsalsooccuronthelips,tongue,finger,nipples,andanus.

Etiology and clinical presentation .TheetiologicagentofsyphilisisTreponema pallidum,whichisa


slender fragile anaerobic spirochete. It is easily killed by heat, drying, disinfectants, and soap and
water.

Themanifestationsofsyphilisareclassicallydividedinto5stagesofoccurrence(primary,secondary,
latent,tertiary,andcongenital),witheachstagehavingitsowndistinctsignsandsymptomsthatare
relatedtotimeandantigen-antibodyresponses.

Treatment. Syphilis is treated with parenteral long-acting benzathine penicillins. When allergy to
penicillin is present, oral doxycycline, and oral tetracycline are used. 2 As with gonorrhea proper
treatmentrapidlyreversesinfectiousness.

DENTAL MANAGEMENT

Medical considerations.Thelesionsofuntreatedprimaryandsecondarysyphilisareinfectious,asis
thepatient'sbloodandsaliva.Evenaftertreatmenthasbegun,theeffectivenessoftherapycannotbe
determinedexceptbyconversionofthepositiveserologictesttonegative;thismaytakeafewmonths
to over a year. Although patients with syphilis should be viewed as potentially infectious, any
necessarydentalcaremaybeprovidedsafely.

Oral complications.Syphiliticchancresandmucouspatchesareusuallypainlessunlesstheybecome
secondarily infected. These lesions are highly infectious, but regress spontaneously with or without
antibiotictherapy.Aswithgonorrhea,oraltreatmentisessentiallysympt omatic.

3. GENITAL HERPES

General description and epidemiology. The herpes simplex virus (HSV) is transmitted by direct
contact, usually kissing (transfer of infective saliva) or sexual contact. Since it is not a reportable
disease,itsincidenceisunknown.However,theCentersforDiseaseControlestimatethatthenumber
ofpatientconsultationsforgenitalherpesincreasedfrom 26,000in1966to 423,000in1983.Aswith
otherSTDs,thisestimateisprobablyunderstated.
Etiology and clinical presentation . HSV is classified into two closely related types, HSV-1 and
HSV-2,HSV-1isextremelycommon,andisthecausativeagentofmostherpeticinfectionsthatoccur
abovethewaist.Mostadultsdemonstrateantibodiestothisvirus.HSV -2isthecausativeagentofmost
herpesinfectionsthatoccurbelowthewaist.Whileitistransmittedmainlybysexualcontact,itmay
alsobepassedontoanewbornfromaninfectedmother.Althoughtheprimarysiteofoccurrenceof
HSV-1isabovethewaistandofHSV-2isbelowthewaist,eachinfectionmayoccurineithersiteand
canbeinoculatedfromonesitetotheother.

Lesions of primary genital herpes (and moist areas) in both men and women tend to ulcerate early.
Lesions on exposed dry areas tend to remain pustular or vesicular and then crust over. Painful
regionallymphadenopathyaccompaniestheinfection,alongwithheadache,malaise,andsymptomsof
fever. These subside in about 2 weeks, with healing in 3-5 weeks3. All herpetic lesions are highly
infectious,regardlessofthestatetheyarein.

Treatment. In that no definitive treatment or cure exists, treatment is of a symptomatic and


palliativenature.Acyclovir(zovirax)istheonlydrugthathasbeenshowntobeeffectiveindecreasing
viralshedding,durationoflesion,andsymptoms.

DENTAL MANAGEMENT

Medical considerations.

Intheabsenceoforallesions,anynecessarydentalworkmaybeprovided.

If oral lesions are present, elective treatment should be delayed to avoid inadvertent
inoculationofadjacentsitesandaerosolordropletinoculationoftheconjunctivaeofeitherthe
patient,dentist,ordentalstaff.

Aproblemofparticularconcerntodentistsisherpecticinfectionofthenailbeds,contractedby
fingercontactwithaherpeticlesionofthelipororalcavityofapatient.Theinfectioniscalled
a"herpeticwhitlow"or"herpeticparonychia."Itisserious,debilitating,andrecurrent.

Pregnancy
DENTAL MANAGEMENT GUIDELINES
First trimester (conception to 14th week)
Themostcriticalandrapidcelldivisionandactiveorganogenesisoccurbetweenthesecondandthe
eighth
weekofpostconception.Therefore,thegreaterriskofsusceptibilitytostressandteratogensoccurs
duringthistimeand50%to75%ofallspontaneousabortionsoccurduringthisperiod.
The recommendations are:
1.Educatethepatientaboutmaternaloralchanges
duringpregnancy.
2.Emphasizestrictoralhygieneinstructionsand
therebyplaquecontrol.
3.Limitdentaltreatmenttoperiodontalprophylaxis
andemergencytreatmentsonly.
4.Avoidroutineradiographs.Useselectivelyandwhen
needed.
Second trimester (14th to 28th week)
Organogenesisiscompletedandthereforetheriskto
thefetusislow.Thisisthesafestperiodforproviding
dentalcareduringpregnancy.
Therecommendationsare:
1.Oralhygiene,instruction,andplaquecontrol.
2.Scaling,polishing,andcurettagemaybeperformed
ifnecessary.
3.Controlofactiveoraldiseases,ifany.
4.Electivedentalcareissafe.
5.Avoidroutineradiographs.Useselectivelyandwhen
needed.
Third trimester (29th week until childbirth)
Althoughthereisnorisktothefetusduringthistrimester,thepregnantmothermayexperiencean
increasing level of discomfort. Short dental appointments should be scheduled with appropriate
positioning while in the chair to prevent supine hypotension. It is safe to perform routine dental
treatmentintheearlypartofthethirdtrimester,butfromthemiddleofthethirdtrimester
routinedentaltreatmentshouldbeavoided.
The recommendations are:
1.Oralhygiene,instruction,andplaquecontrol.
2.Scaling,polishing,andcurettagemaybeperformed
ifnecessary.
3.Avoidelectivedentalcareduringthesecondhalfof
thethirdtrimester.
4.Avoidroutineradiographs.Useselectivelyandwhen
needed.

Drugs
Oxygen

1. Use: Oxygen is the most universally common emergency drug and can be used in every
situationexcepthyperventilation.

2. Dose
a) NasalCannula:Thepercentoxygendeliveredbynasalcanulaisabout 21%(roomair)+ 4%
oxygenforeachliterperminuteflowrateused.Useat2-4L/minute.
b) FaceMask:Thepercentoxygendeliveredbyfacemaskis60%at6L/minuteflowratewitha
10% increase in concentration for each liter per minute increased flow rate. Use at 10-
15L/minute. A bag valve mask device with oxygen inlet is best when positive pressure
ventilationisrequiredthoughapocketmaskwithoxygeninletcanbeused.

3.Pharmacology:Requiredforaerobicmetabolism

1. Adverse Affects: In the case of a hypoxic patient the hypoxic state is a powerful respiratory
stimulant. When Oxygen is delivered the hypoxia is reduced and this can actually cause a
decreaseinpulmonaryventilationthatmayneedtobeaugmentedbytherescuer.

2. DrugInteractions:None

Epinephrine 1:1,000 Injection

1. Use:Epinephrineisusedtoreversehypotension,bronchospasm,andlaryngealedemathatresult
fromanacuteanaphylactoidtypereaction.Alsousedtoreducebronchospasmresultingfroman
acuteasthmaticepisodethatisrefractorytoinhalerth erapy.

2. Dose:Suppliedinvials,ampules,orpre-loadedsyringesinconcentrationof1:1000,1mg/ml.IV
give 0.5-2.0mg (0.5ml-2.0ml) depending on severity of hypotension, titrate to effect repeat in 2
minutesifneeded.IMgive0.3mg(0.3ml)repeatin10-20minutesasneeded.

3. Pharmacology: Causes vasoconstriction that in turn increases blood pressure, heart rate, and
forceofcontraction.Alsocausesbronchialdilatation.Reducesthereleaseofhistamine.

4. AdverseEffects
a) Cardiovascular:Tachycardia,Tachyarrhythmias,andhypertension.
b) CentralNervousSystem:Agitation,headache,andtremors.
c) EndocrineSystem:Increasedbloodglucose.
d) PregnantFemale:Candecreaseplacentalbloodflow.

5. DrugInteractions:Nasaldecongestants,antihistamines,asthmainhalerswillincreaseincidenceof
adverseeffects.Canbeineffectiveifthepatientistakingbeta -blockers.

Diphenhydramine (Benedryl) 50mg Injection

1. Use: Benedryl is used as treatment to reduce the affects of histamine release that is associated
withallergicreactions,anaphylaxis,andacuteasthmaattackprecipitatedbyexogenouscauses.

2. Dose: 50-100mg IM or IV. For mild cases of pruritis, urticaria, or erythema an oral dose of
50mgevery6hourscanbeused.

3. Pharmacology:Benedrylisanantihistaminethatblocksthereleaseofhistamineinthebody.It
does not prevent the action of the histamine once released and thus must be given quickly.
Preventshistamineresponsessuckasbronchospasm,hypotension,rash,andedema.

4.AdverseEffects:
a) Cardiovascular:Tachycardia(Fasthearrate.)
b) Central Nervous System: CNS depression (Sedative effects including drowsiness, lethargy,
andmentalconfusion.)
c) Gastrointestinal:Xerostomia(Drymouth.)

5 DrugInteractions:AnydrugscausingCNSdepressionwillincreasethesedative
effectsofBenedryl.CanalsoexaggeratethiseffectinotherdrugssuckasAtropine,
Antipsychotics,Demerol,andTricyclicAntidepressants.

Dexamethasone Sodium Phosphate 4mg/ml

1. Use:Asadjunctivetherapyforallergicananaphylacticreactions.Canbeusedasreplacement
therapyforAcuteAdrenalInsufficiency(HydrocortisoneSodiumSuccinateisdrugofchoicebut
may depend on what is available in clinic.) The approximate dosage equivalency is 0.75mg
Dexamethasoneto20mgHydrocortisone.

.DOSE
a) AllergicorAnaphylactictypereactions4-12mgIVorIM.
b) AcuteAdrenalInsufficiency10mgIVorIM.

3 Pharmacology: Dexamethasone has a rapid onset and short duration of action. Promotes
membrane stabilization and inhibits the release of biochemical mediators of inflammation.
Dexamethasoneisapotentanti-inflammatoryagent.

4. AdverseEffects:Localizedpainorburningatinjectionsiteifinjectedtoquicklyotherwisenone
withshort-termuse.DexamethasonecontainsSodiumBisulfite,whichmaycauseanallergicor
anaphylacticreactioninpatientsallergictosulfites.

5. Drug Interactions: Possible decreased effects of Dexamethasone in patients taking Phentoin,
Phenobarbitol,Ephedrine,andRifampinduetoincreasedmetabolicclearance.Possiblealtered
response to anticoagulants. Possible hypokalemia in patients taking potassium depleting
diuretics.IncreasedtendencyforgastriculcerationinpatientstakingAspirinorIndomethacin.
Mayincreaserequirementforinsulinororalhypoglycemicagentsindiabetics.

Equivalent Doses of Corticosteroids


Cortisone 25mg
Hydrocortisone20mg
Prednisolone 5mg
Prednisone 5mg
Methylpredsinilone4mg
Triamcinilone4mg
Dexamethasone0.75mg
Betamethasone0.6mg

Aromatic Spirits of Ammonia Ampules

1. Aromatic Ammonia is used to stimulate respiration in the case of syncope or to disrupt


respiratorypatterninhyperventilation.
2. Dose:1ampulecrushedwavedunderpatientsnose.
3. Pharmacology:Noxiousodorstimulatestherespiratorycenterofthemedulla.
4. Adverseeffects:
a) Cardiovascular:Increasesbloodpressureandheartrate.
b) Respiratory:Cancausebronchospasm.
5. DrugInteractions:None.
Albuterol Inhaler (Proventil)

1. Use:AlbuterolisusedduringacuteasthmaorAnaphylaxistoreduceorcontrolbronchospasm.

2. Dose:2puffsevery2minutestoamaximumof20puffs.Holdinhalerabout2inchesfrom
mouth.Havepatienttaketwodeepbreathsand thenexhaleforcefully.Dispenseonepuffonslow
deepinhalation.Holdbreathfor10secondsandrepeat.
3. Pharmacology:AlbuterolisanB2-adrenergicdrugthatrelaxesthebronchialsmoothmuscle.It
hasrapidonsetanddurationofactionofupto6hours.Alsoreducesthestimulationofmucous
production.

4. Adverse Effects: Should be used with caution in patients with cardiovascular disorders
especially coronary artery disease, arrhythmias, and hypertension. Also caution with patients
havingconvulsivedisorders,hyperthyroidism,andDiabetes.InrarecasesAlbuterolcancausea
paradoxicalbronchospasm.

5. Drug Interactions:OtherinhalationbronchodilatorsshouldnotbeusedwithAlbuterol,andif
additional adrenergic drugs are given systemically they should be used with caution to avoid
cardiovascular effects. Albuterol should also be used with caution on patients who are taking
MonoamineOxidaseInhibitorsandTricyclicAntidepressantsastheactionoftheAlbuterolonthe
vascular system may be potentiated. Albuterol and Beta-Blockers tend to inhibit each other.
Albuterolalsotendstolowerserumcalciumandshouldbeusedwithcautioninconjunctionwith
otherdrugswiththesameeffect.


Nitroglycerin 0.4mg Tablets or 0.4mg Metered Dose Spray

1. Use: Nitroglycerin is used to relieve or eliminate chest pain associated with angina pectoris, to
differentiatebetweenanginaandamyocardialinfarction.
2. Dose:
a) Tablet:1tabletsublinguallyrepeatafter2minutesifnoreliefupto3doses.
b) MeteredDoseSpray:1spraysublinguallyrepeatafter2minutesifnoreliefupto3doses.

Monitor blood pressure after each dose; do not repeat if systolic BP drops below 100. Average
drop in BP is 11-16 mm Hg after one dose. Patient should be sitting or supine when
Nitroglycerineisadministered.
3. Pharmacology:Nitroglycerinisacoronaryandperipheralvasodilatorandassuchhelpsincrease
the flow of oxygenated blood to the heart muscle. It also causes venous pooling of blood
decreasing venous return to the heart thus improving the pumping efficiency of the heart.
Becauseofthisimprovedefficiencymyocardialoxygendemandisdecreased.
4. Adverse Effects:
a) Cardiovascular:Rapidheartrate,facialflushing,andorthostatic(Postural)hypotension.
b) CentralNervousSystem:Dizzinessandheadache.
5 Drug Interactions: Anti-hypertensive drugs may exaggerate the hypotensive effect of
Nitroglycerine.

Allergic Reaction
Signs and Symptoms of an Allergic Reaction
1. Cutaneousreactionsarethemostcommonoccurrenceandincludeurticarial,exanthematous,and
eczemoid reactions. Itching is common and can also find exfoliative dermatitis and bullous
dermatosis.
2. Angioedema (Swelling) this varies from localized slight swelling of the lips, eyelids, and face to
moreuncomfortableswellingofthemouth,throat,andextremities.
3. Respiratory (Tightness in chest, sneezing, bronchospasm) bronchospasm is a generalized
contractionofbronchialsmoothmusclesresultingintherestrictionofairflow.Thismayalsobe
accompanied by edema of the bronchiolar mucosa. Bronchospasm is more common with pre-
existingpulmonarydiseasesuchasasthmaorinfectionbutcanalsobecausedbytheinhalationof
aforeignsubstance.
4. Ocularreactionsincludeconjunctivitisandwateringofeyes.
5. Hypotensioncanoccurwithanyallergicreaction.

Anaphylaxis:Thisisaseveresystemictypeallergicreactionandisamedicalemergency.Signsand
symptomsinclude:
1. Cardiovascular shock including; pallor, syncope, palpitations, tachycardia, hypotension,
arrythmias,andconvulsions.
2. Respiratory symptoms include; sneezing, cough, wheezing, tightness in chest, bronchospasm,
laryngospasm.
3. Skiniswarmandflushedwithitching,urticaria,andangioedema.
4. Nausea,vomiting,abdominalcramps,anddiarrheaalsop ossible.

Evaluation of Allergic Reactions:Thingstoremember.
1. Skinmanifestationsmayprecedemoreseriouscardiorespiratoryproblems.
2. Recognitionofskinreactionsandearlytreatmentmayabortmoreseriousproblems.
3. Mostimportantfactorisassessingtheseriousnessoftheconditionistherateofonset.
4. Reactionsthatoccurgreaterthanonehouraftertheadministrationoftheallergenwillusuallybe
ofanon-emergentnature.
TREATMENT

General Treatment
1. ABCs
2. Maintain airway, administer oxygen, and determine possible need for intubation or surgical
airway.
3. Monitorvitalsigns.
4. IfinshockputpatientinahorizontalorslightTrendelenburgposition.

Mild Reactions
1. Antihistamines usually effective. (Benadryl 50-100mg or Cholpheniramine maleate 4-12 mg PO,
IV,orIM.)
2. Identifyandremoveallergen.
3. Followupmedicationsin4-6hours.

Severe Reactions
1. IfavailablestartIVFluids
2. Epinephrineisdrugofchoice.Usuallyprepackaged1:1,000in1mgvialsorsyringe
3. IfIVinplacetitrate1:1,000solutiontoeffect.
4. Ifdropinbloodpressureisminimal,startwith0.5ml(0.5mg.)
5. Ifdropinbloodpressureisseverestartwith2ml(2mg.)
6. Repeatafter2minutesifneeded.
7. IfnoIVuse1:1,000(1mg/CC)IM0.3to0.5mg(0.3-0.5CC.)
8. Foranadultrepeatthisdosein10to20minutes.
9. Ifthepatientisintubatedcangiveepinephrineendotracheally
10. IfAsthma,edema,orpruritis(Itching)arepresentcanuseCorticosteroids.Howeverthesedrugs
aretoslowactingtobeusedforanemergencysituation.
11. Hydrocortisonesodiumsuccinate(Solu-cortef)100-500mgIVorIM.Dexamethasone (Decadron)
4-12mgIVorIM.
12. Repeatdoseat1,3,6,and10hoursasindicatedbyseverityofsymptoms.

Other Considerations

1. Monitorandrecordvitalsigns.
2. Seizuresarepossibleasaresultofcirculatoryorrespiratoryinsufficiency.
3. Mostseverallergicreactionsrequirehospitalizationandobservationfor24hours.

Vital Signs

Blood Pressure

1. TechniqueforTakingBloodPressure
a) Thepatientshouldbeseatedinanuprightpositionwith theirarmattheleveloftheheart.
Thearmshouldberelaxed,slightlyflexedandsupportedonahardsurface.
b) Placecuffwrappedfirmlyaroundarmwiththecenterofthebladder(Inflatablepartofcuff)
overtheBrachialArtery(Somecuffsaremarkedwithanarroworcircleindicatingwhereto
placeinrelationtotheartery.)TheBrachialarteryliesinthemedialaspectoftheantecubital
fossa.Theloweredgeofthecuffshouldbeplaced1abovetheantecubitalfossa.Itistotight
iftwofingerscannotbeplacedundertheloweredgeofthecuffandtolooseitcanbepulledof
thearm.
c) ForaPalpatorysystolicbloodpressurepalpatethepulseattheradialarteryandinflatecuffto
30mmHgafterthepulsedisappears.Slowlydeflateat2-3mmHg/seconduntilpulsereturns.
ThispointisthePalpatorySystolicBloodPressure.
d) ForanAusculatorybloodpressureplacethediaphragmofthestethoscopefirmlyonthe
medialaspectoftheantecubitalfossa.Donottouchthecuffortubingasthis mayproduce
extraneousnoise.Increasethepressureto30mmHgabovethepalpatorysystolicblood
pressure.Slowlydeflatethecuffat2-3mmHg/second.Thefirstsoundheardwillbethe
SystolicBloodPressure.Continuetoslowlydeflatethecuff.T hesoundswillbecomemuffled
andthepointatwhichtheyceaseistheDiastolicBloodPressure.

2. CommonErrorsinTakingBloodPressures
a) Puttingthecuffonthepatienttolooselywillresultinanelevatedreading.
b) Useofthewrongsizecuff.Usingacuffthatistoolargewillresultinadepressedreading.
Thewidthofthecuffshouldbeapproximately20%greaterthanthediameterofthe
extremity.
c) Ananxiouspatientcanhaveatransientelevationofthebloodpressure.
d) Thepressureintheleftarmis5-10mmHghigherthantheright.
e) Inrarecasesanausculatorygapmaybepresent.Thisisacompletecessationofsound
betweenthesystolicanddiastolicpressures.Thisismostoftenfoundinpatientswithhigh
bloodpressurebuthasnorealclinicalsignificance.

3. GeneralInformation
a) ThebloodpressureequalsthecardiacoutputXthetotalperipheralresistance
b) Theaveragenormalbloodpressurecancalculatedbyadding120+thepatientsage/90orless.
c) Waitatleast15secondsbetweenreadingstoallowtrappedbloodinarmtoresumeflow.
d) TheSystolicpressureisthepressureinthearterieswhentheheartiscontracting.
e) TheDiastolicpressureisthepressureinthearterieswhentheheartisatrest.


HeartRate,Rhythm,andQuality

1. Technique
a) Themostcommonareastopalpatethepulsearetheradialartery(Ontheventralsurface
ofthewristonthethumbside,)thebrachialartery(Onthemedialaspectofthe
antecubitalfossa,)andthecarotidartery(Onthelateralaspectoftheneckjustpo sterior
totheborderofthestenocleidomastoidmuscle.)
b) Usingthetipsoftheindexandmiddlefingerapplygentlepressuretotheareawhereyou
wishtopalpatethepulse.Becarefulnottoapplytoomuchpressuresoasnottoocclude
theartery.
c) Evaluatethreefactors
HeartRate:Countthebeatsperminutethisshouldbeforaminimumof30secondsandthencanbe
doubled.Aheartrateslowerthan60iscalledbradycardiaandgreaterthan110iscalledtachycardia.
Anincreaseinratewithinspirationfollowedbyadecreaseinrate

1. withexpirationiscalledsinusarrhythmia.Thisisfrequentlyseeninadolescentsandis
notindicativeofanycardiacabnormality.
2. Rhythm:Therhythmwillbeeitherregularorirregular.Abreakinagenerally
regularrhythminwhichalongerthannormalpauseisfollowedbyaresumptionofa
regularrhythmisaprematureventricularcontraction(PVC.)Thiscanbeproduced
bysmoking,fatigue,stress,medications,alcohol,andanischemic/damaged
myocardium.Whenyoufindastrongandweakpulsealternatingthisiscalledpulsus
alternans.Thisisseeninsevereleftventricularfailure,severearterialhighblood
pressure,andcoronaryarterydisease.
3. Quality:Thepulsequalitycanbecharacterizedasthready,weak ,bounding,orfull.A
fullandboundingpulsecanbefoundinseverehypertension.Aweakandthready
pulseisindicativeofhypotensionandshock.


RespirationRate

1. Technique
a) Monitortherespirationrateimmediatelyaftertakingtheheartrate.
b) Leaveyourfingersonthepatientswristwhilecountingrespirations(Theriseandfallofthe
patientschest)overaminimumof30seconds.
c) Donotletthepatientknowthatyouaremonitoringtheirrespirations,astheymaynotbreathe
normally.
d) Normalrespirationrateis12-18perminute.Aslowratecanbeseenwithnarcotic
administration.Anincreasedrespirationrateisseenwithfever,alkalosis,andextreme
psychologicalstress.











































Al-AzharUniversity
FacultyofDentistry
OralSurgeryDepartment

By

EhabMohamedEl-SayedHassan
Class(A)

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