MODIFICATION OF DENTAL TREATMENT FOR MEDICALLY COMPROMISED PATIENTS

CONDITION RISKS MANAGEMENT

Infective bacterial endocarditis

Congenital heart defects.
Prosthetic heart valves.
History of previous infective
endocarditis.
Cardiac transplantation recipients
who develop cardiac valvulopathy.
Bacteremia valvular dysfunction
CVA.
Focus on prevention: Maintenance of
optimal oral health and hygiene may
reduce the incidence of bacteremia from
daily activities and is more important
than prophylactic antibiotics for reducing
the risk of IE resulting from a dental
procedure. American Heart Association
Minimize frequency, duration, severity of
bacteremias by altering methods of
dental tx.
Pretreatment antimicrobial rinse:
chlorhexidine.
Antibiotic prophylaxis when bacteremia is
anticipated: All dental procedures that
involve manipulation of gingiva or
perforation of oral mucosa.
*Medical consultation may be beneficial,
but dentist decides whether or not the
procedure warrants antibiotic
prophylaxis.
Hypertension Aggravated by emotional stress,
physiologic demands, vasoconstrictors
in dental anesthetics acute crises:
stroke, myocardial infarction.
Hemostasis compromised.
Antihypertensive tx may
orthostatic hypotension.
120/80: Any required dental tx.
120/80 but <140/90: Any required tx &
encourage patient to see physician.
140/90 but <160/100: Any required tx &
encourage patient to see physician.
160/100 but <180/110 Any required tx;
consider intraoperative monitoring. Refer
patient to physician promptly.
180/110 Defer elective treatment. Refer
to physician ASAP; if symptomatic, refer
immediately.
Short morning appts and profound local
anesthesia to reduce stress.
Cautious use of epinephrine in local
anesthetics.
Ischemic heart disease: angina
pectoris, coronary artery disease

Myocardial infarction
History of 1 MI.
Unstable angina.
Patients who take warfarin or
aspirin may have increased bleeding
after trauma or surgical procedures.
Stress of dental treatment may
increase risk of cardiac instability,
arrhythmias, and reinfarction.
Minimize stress: morning appts of short
duration, profound anesthesia,
comfortable chair positioning, oral/N
2
O
sedation.
Pretreatment recording of vital signs.
Limit use of epinephrine in local
anesthetic and retraction cord.
Keep nitroglycerin readily available.
Medical consultation required prior to
treatment of patients with unstable
angina.
Unstable angina / MI within the past 30
days = major cardiac risk: elective care
should be postponed.
Medical consultation required within 1
year of MI & elective dental procedures
deferred for 6 months.
Minimally stressful dental procedures
may be performed 6-12 months after MI
if cardiologist approves.
Persistent angina, elevated BP, other risk
factors require medical consultation
beyond 1 year post MI.
Cardiac arrhythmia Emotional stress/ epinephrine
destabilization of treated or
aggravation of untreated arrhythmias.
Electronic devices may interfere with
function of pacemakers.
Anticoagulant therapy for atrial
fibrillation increased bleeding
tendency.
Minimize stress.
Minimize or avoid epinephrine use if
possible.
Medical consultation advised for
controlled arrhythmias and required for
all patients with rapid/slow/ irregular
pulse.
Patients with atrial fibrillation who are
taking warfarin: If INR is within the
therapeutic range (2.0-3.5), dental
treatment & minor oral surgery can be
performed without stopping warfarin;
more significant surgery or INR >3.5
require medical consult.
Avoid use of electrosurgery / ultrasonic
scalers in patients with pacemakers.
Congestive heart failure Stress of dental tx abrupt
worsening of symptoms resulting in
acute failure, fatal arrhythmia, CVA, or
MI in symptomatic/ decompensated
CHF.
Complex drug regimen oral side
effects.
NSAIDS exacerbation of symptoms.
Fully reclined position orthopnea,
pulmonary edema.

Thorough medical hx to evaluate patient
for history, signs, or symptoms of CHF.
For patients with symptoms of untreated
or uncontrolled CHF, defer elective dental
care and refer to physician.
For diagnosed and treated CHF: Medical
consultation in severe cases, e.g.
peripheral edema, dyspnea, angina.
Minimize or avoid epinephrine use if
possible. Avoid NSAIDS.
Minimize stress and avoid fully reclined
position.
Chronic obstructive pulmonary
disease
Stress can respiratory compromise.
Patients often have concurrent
hypertension and ischemic heart
disease.

Encourage tobacco cessation.
Before initiating dental care, assess
severity of the patients disease and the
degree to which is has been controlled.
Well controlled patients can be treated
routinely.
Patients displaying shortness of breath at
rest, a productive cough & upper
respiratory infection: defer dental tx until
medical evaluation is completed.
Minimize stress.
Semisupine or upright chair position for
treatment to prevent orthopnea or
feeling of respiratory discomfort.
N
2
O sedation, narcotics and barbiturates
contraindicated.
Use local anesthetics normally.
Medical consultation or treatment in a
hospital setting for severely affected
patients.
Asthma May be stimulated by emotional
stress/ exposure to dust or a specific
allergen.
Drugs to control asthma may
complicate therapeutics.
Identify severity of asthma and avoid
known precipitating factors.
Minimize stress.
Consider N
2
O or oral sedation.
Inhaler with bronchodilator should always
be readily available.
Recognize signs and symptoms of a
severe/ worsening asthma attack &
administer subcutaneous epinephrine
injection if needed.
Aspirin & NSAIDS are contraindicated.
Patients with rare /mild attacks that do
not require continuous medication can be
treated routinely.
Bleeding disorders Even minor dental procedures
uncontrollable hemorrhage.
Many acquired bleeding disorders can
present with few if any obvious clinic
signs.
Anticoagulant therapy typical in
prevention/ management of MI, CVA,
deep vein thrombosis.
Prolonged healing and anemia from
excessive bleeding.
Decreased resistance to infection.

Confirm diagnosis and severity of disease.
Medical consultation with laboratory
evaluation required in all cases if a
bleeding disorder is suspected.
Patients who taking warfarin: Outpatient
anticoagulant therapy may need to be
altered for invasive/ surgical procedures
& medical consult required with
confirmation of INR.
Patients with mild/ moderate hemophilia
usually treated in the dental setting after
obtaining medical consult and confirming
INR.
Patients with severe hemophilia usually
treated in hospital.
Aspirin and NSAIDs should be avoided.
Gastrointestinal diseases Drug regimens: additional analgesics/
antibiotics can severely aggravate
peptic ulcer and gastritis symptoms
and risk of GI bleeding.
Evaluate patient, determine health status,
and confirm that adequate medical care
was received.
Medical consultation with complete
blood counts if poorly controlled or if
medication profile increases patient risk
for anemia, leukopenia or
thrombocytopenia.
Aspirin and NSAIDs should be avoided.
Hepatitis and liver cirrhosis All patients with a history of viral
hepatitis must be managed as though
they are potentially infectious.
Abnormal bleeding is associated with
hepatitis and significant liver damage.
Administration of drugs with minor
hepatotoxic effects can severity of
hepatic damage.
Active hepatitis: No dental treatment
other than urgent care. Refer the patient
with acute hepatitis for medical dx and tx.
Urgent care should be provided only in an
isolated operatory with adherence to
strict standard precautions. Drugs
metabolized by the liver should
be avoided or dosage as advised by the
physician.
If INR >3.5, the potential for severe
postoperative bleeding exists: extensive
surgical procedures should be postponed.
Hx of hepatitis: Most carriers are
unaware.
Consult with physician and evaluation of
hemostatic competence if surgery is
necessary.
Diabetes mellitus Stress can alter metabolic demands
and cause insulin/glucose imbalance.
In extreme instances can diabetic
coma (hyperglycemia) or insulin
shock (hypoglycemia).

Oral complications of poorly
controlled diabetes mellitus:
xerostomia, bacterial, viral, and fungal
infections (e.g.candidiasis);
poor wound healing;
increased incidence and severity of
caries;
gingivitis and periodontal disease;
periapical abscesses; and burning
mouth symptoms.

Pt. should be referred for medical
evaluation if suspected diabetes has not
been diagnosed or is poorly controlled.
Determine type of diabetes and presence
of complications.
All dental procedures can be performed
without special precautions if diabetes is
well-controlled in non-insulin-dependent
or insulin controlled pt.
Insulin controlled pt: Glucose source
should be available and given if
symptoms of insulin reaction occur.
Morning appointments are usually best.
Advise patient to take usual insulin
dosage and normal meals on day of
dental appointment.

If extensive surgery is needed: consult
with patients physician concerning
dietary needs during postoperative
period. Antibiotic prophylaxis can be
considered for patients with brittle
diabetes and those taking high doses of
insulin who have chronic states of oral
infection.

Thyroid disorders Hyperthyroidism: Adverse interaction
with epinephrine, life-threatening cardiac
arrhythmias, complications of underlying
cardiovascular conditions.
Thyrotoxic crisis (thyroid storm) can be
precipitated by infection/surgical
procedures.

Hypothyroidism: CNS depressants,
infection, surgical procedures can
myxedematous coma.
Medical consultation if poorly
controlled or undiagnosed
hyperthyroidism is suspected.

Cautious use of epinephrine in
untreated or poorly treated thyrotoxic
patients.
Well-controlled asymptomatic patients
can be treated routinely.

Avoid CNS depressants, sedatives, or
narcotic analgesics in hypothyroidism.
Adrenal insufficiency Stress may increase adrenal demand
beyond the functional reserve acute
adrenal insufficiency (adrenal crisis).
Patients with hyperadrenalism have an
increased likelihood of hypertension and
osteoporosis, increased risk for peptic
ulcer disease,
delayed healing and may have
increased susceptibility to infection.

Risk of medical complications increases
when major surgical procedures are
performed on patients having low adrenal
reserve.
Factors contributing to the risk of adrenal
crisis during the perioperative
period of oral surgery: type of surgical
procedure, drugs administered, pts
overall health, and extent of pain control.
Determine dose and duration of past or
present corticosterioid tx.
Medical consultation if adrenal
suppression is suspected and dental tx
is moderately or severely stressful.
Pts taking systemic corticosteroids: For
diagnostic and minimally invasive
procedures, have patient take the usual
daily dose. Majority with adrenal
insufficiency may undergo routine
dental tx without need for
supplemental glucocorticoids.
Schedule surgical procedures in the
morning and reduce stress.
For major invasive oral procedures:
consult with physician to determine
corticosteroid supplementation
protocol.
Blood pressure should be taken at
baseline and monitored during dental
appointments.
Aspirin and NSAIDs should be avoided
in long-term steroid users.
Prophylactic antibiotic coverage for
three days may be beneficial if bacterial
infection is a significant possibility.
Pregnancy Stress and potentially toxic drugs/
radiation can adversely affect
development of the fetus. Risk is greatest
during 1st trimester.
Dental treatment may aggravate gag
reflex and symptoms of morning
sickness during 1st trimester, and
abdominal pressure during the
3rd trimester.
Most common oral complication of
2nd trimester is safest period for
necessary dental treatment: minimize
radiographic exposure and drug use.
Focus on controlling active disease.
Elective dental treatment (e.g. full
mouth radiographs, reconstruction,
crown and bridge, and significant
surgery) should be deferred until after
delivery.
Aspirin, NSAIDs, schedule pain
pregnancy is hyperplastic pregnancy
gingivitis. Gestational diabetes mellitus is
associated with increased risk for
periodontal disease.
medications such as hydrocodone, and
sedatives/hypnotics) are specifically
contraindicated. Analgesic of choice
during pregnancy is acetaminophen.
Medical consult required if systemic
medications or invasive procedures are
needed for an infection or other severe
dental problem.
Enforce optimal oral hygiene and
plaque control.
Chronic renal failure Compromised drug metabolism.
Abnormal bleeding in patients on day of
dialysis.
Immunosuppressive medication regimens
in renal transplant patients
vulnerability to infection.

Oral manifestations of chronic renal
failure: xerostomia, change in
pigmentation, petechiae and ecchymoses
of oral mucosa, osteodystrophy
(radiolucent jaw lesions), uremic
stomatitis.
End stage renal disease: medical
consultation suggested before dental
care is provided. Avoid nephrotoxic
drugs (acetaminophen in high doses,
acyclovir, aspirin, NSAIDs). Avoid dental
treatment if disease is poorly controlled
or advanced.
Optimal time for dental treatment in
hemodialysis patients is on the day
following dialysis.
Prophylactic antibiotic coverage is
generally beneficial.
Screen for bleeding disorder before
surgery (bleeding time, platelet count,
hematocrit, hemoglobin)
Cerebrovascular accident (CVA,
Stroke)
Patients with a history or clinical evidence
of hypertension, CHF, diabetes, previous
stroke or TIA, and advancing age are
predisposed to
Stroke.
Anticoagulant medications may
risk for abnormal bleeding.
Defer elective dental treatment for 6-12
months after a CVA or stroke.
Medical consultation required if history
of CVA.
Pretreatment INR>3.5 requires
consultation with physician to alter
anticoagulant tx. Schedule short, stress-
free, morning appts and N
2
O inhalation
as needed.
Monitor blood pressure and avoid use
of epinephrine.
Epilepsy Stress of dental treatment may induce a
seizure episode, usually in
poorly-controlled epileptic individuals.
Gingival hyperplasia associated with
phenytoin and valproic acid.
Phenytoin, carbamazepine,
and valproic acid can cause bone marrow
suppression, leukopenia,
thrombocytopenia increased incidence
of microbial infection, delayed healing,
and postoperative bleeding.
Determine type and frequency of
seizures, age at onset, use of
medications, frequency of physician
visits, degree of seizure control, date of
last seizure, and any known
precipitating factors.
Medical consultation if seizures are
poorly controlled. Well-controlled
seizures pose no contraindication to
routine dental tx.
Reduce dosage of narcotics in patients
taking CNS depressants.
Propoxyphene and erythromycin should
not be administered to patients who
are taking carbamazepine because of
interference with metabolism.
Gingival hyperplasia managed with
good oral hygiene and occasionally
surgical reduction.
HIV and AIDS Typical infections can progress more
rapidly than usual and will not respond as
favorably to usual tx protocols.
Susceptibility to opportunistic infections
such as candidiasis, pneumonia, HSV.
Thrombocytopenia bleeding tendency.
AIDS: Any oral lesions found should be
diagnosed, then managed by
appropriate local/ systemic treatment
or referred for diagnosis and treatment.
Determine CD4+ lymphocyte count and
viral load.
CD4 count below 200/mm
3
and/or low
neutrophil counts: prophylactic
antibiotic coverage during invasive
dental procedures.
Determine platelet counts if
questionable hemostatic competency.
Prosthetic joint infection Increased risk of hematogenous infection
during transient bacteremias.

High risk:
First 2 years after joint replacement.
Immunocomromised/immunosuppressed.
Insulin-dependent (type 1) diabetes.
Previous prosthetic joint infections.
Malnourishment.
Hemophilia.
Consult with the orthopedic surgeon
regarding risk for a specific patient.

2003 joint advisory statement by ADA
and American Academy of Orthopedic
Surgeons: Scientific evidence does not
support the need for antibiotic
prophylaxis for dental procedures in
patients with pins, plates, screws and
total joint replacement.
Antibiotic prophylaxis should be
considered for some high-risk patients
who are at increased risk for infection
and are undergoing dental procedures
likely to cause significant bleeding. The
dentist should make the final decision
to provide antibiotic prophylaxis.
Radiotherapy and chemotherapy Nausea and vomiting
Mucositis, ulceration, taste alteration
Xerostomia, caries & pulpal necrosis
Tooth sensitivity
Fungal/bacterial/viral infections
Thrombocytopenia
Muscular dysfunction
Osteoradionecrosis
Bisphosphonate associated osteonecrosis
Symptomatic treatment of mucositis
and xerostomia.
Optimal oral hygiene and topical
fluoride.
Evaluate hemostatic function.
Consult with oncologist regarding
surgical procedures in patients with hx
of radiation or chemotherapy with
intravenous bisphosphonates.
oncologist or radiation oncologist.