Crash Course in Dental Management of The Medically Compromised Patient

CRASH COURSE IN
DENTAL MANAGEMENT OF THE

MEDICALLY COMPROMISED
PATIENT
WWW.DENTISCOPE.ORG
DONE BY : SIMA HABRAWI

EDIT BY : HAIF ALQAHTANI DENTISCOPE 2020
Crash Course in Dental Management of the Medically Compromised Patient
Table of Contents
Medical emergencies ............................................................................................................. 3
Vasovagal syncope .........................................................................................................................3
Orthostatic hypotension .................................................................................................................4
Hypoglycemia ................................................................................................................................4
Hyperglycemia ...............................................................................................................................4
Adrenal crisis .................................................................................................................................5
Myocardial infarction .....................................................................................................................5
Hyperventilation ............................................................................................................................6
Asthma ..........................................................................................................................................6
Forgein body disloged in the throat ................................................................................................6
Bleeding disorders ................................................................................................................. 7
WHO classification of blood loss .....................................................................................................7
What blood tests to order in cases of bleeding disorders .................................................................8
Bleeding type .................................................................................................................................8
Cardiovascular diseases ......................................................................................................... 9
Hypertension [ HTN] .......................................................................................................................9
Local anesthesia ........................................................................................................................... 10
Infective endocarditis ................................................................................................................... 10
Coronary artery disease / Myocardial infarction:........................................................................... 11
MI management in the dental clinic .............................................................................................. 12
Bleeding....................................................................................................................................... 12
3 different protocols used to treat patient with High INR (Taking Oral Anticoagulant ) ................... 12
G6PD & thalassemia ............................................................................................................ 14
G6PD deficiency ........................................................................................................................... 14
Thalassemia .................................................................................................................................14
Pregnancy ........................................................................................................................... 15
Time for dental treatment ............................................................................................................ 15
Emergencies in pregnant women .................................................................................................. 16
Epilepsy ............................................................................................................................... 17
Diabetes .............................................................................................................................. 19
Done By : Sima Habrawi Dentiscope 2020

Edit By : Haif AlQahtani Page 1 of 29
Diabetes Type 1............................................................................................................................ 19

Diabetes type 2 ............................................................................................................................ 19
Diagnosis of diabetes ................................................................................................................... 19
Oral complications of poorly controlled DM .................................................................................. 20
Kidney disease ..................................................................................................................... 22
Chronic kidney disease [ CKD] ....................................................................................................... 22
Liver diseases ...................................................................................................................... 25
Viral hepatitis............................................................................................................................... 25
Patients with alcoholic liver disease .............................................................................................. 26
References........................................................................................................................... 28
Disclaimer ......................................................................................................................... 29

Medical emergencies
Q: where do most medical emergencies occur ? bathrooms, parkings, staircases
• Pt collapses in the clinic → can be due to medical problem or anxiety

• Pt collapses in the parking lot → mostly due to medical condition [ heart attacks]
EMERGENCY SINGS AND SYMPTOMS MANAGEMENT

1- Put the pt in supine/ trenedelenberg
position [ head below the body so
the blood goes to the brain]
Sweating 2- Communicate with the pt [ no
Cold skin response → pt is unconciouss]
VASOVAGAL Dizziness 3- Clear the airway
Pule is weak and thready 4- Look for chest rises and listen for
SYNCOPE Loss of conciousness breathing
5- Check for radial pulse [ at the wrist ]
or carotid pulse [ at the side of the
neck]
Q: what causes vasovagal syncope? The pt feels stressed from the dental procedure or the sight of
needles and the body activates the sympathetic nervous system “ fear or flight response “ which directs
the blood to the muscles , but the pt is laying down so there is not enough venous return to the heart →
poor cardiac output → less blood reaches the brain → syncope
Q: what happens if you keep the pt at upright position after syncope? The pt might die or get brain
damage because the heart cannot pump enough blood to the brain
When the pt becomes unconciouss all of the muscles become flaccid [

including the tongue ] → the tongue drops back into the pharynx →
airway obstruction and further hypoxia
To open the airway in an unconscious pt you do : head tilt + chin lift to

push the mandible forward with the tongue
Q: why shouldn’t you give any pt that just recovered from syncope
anything by mouth ? during unconsciousness, the muscles are still flaccid and they need time to regain
their muscle tone therefore giving anything by mouth can kill the pt by suffocation
Q: what should you do it an unconscious pt vomits ? tilt their head to the side to allow the vomit to
accumulate in the buccal sulcus and suction the vomitus to prevent it from going into the esophagus or
the trachea


1- Put the pt in supine/ trenedelenberg
position [ head below the body so
Dizziness
the blood goes to the brain]
Cold sweat
2- Communicate with the pt [ no
Thready pulse and loss of
response → pt is unconscious]
consciousness
ORTHOSTATIC [ usually pt’s on Beta blockers , eldery
3- Clear the airway
4- Look for chest rises and listen for
HYPOTENSION or pregnant women ] specially after
breathing
long procedures or long time sitting in
5- Check for radial pulse [ at the wrist ]
the waiting room
or carotid pulse [ at the side of the
neck]
Q: what causes orthostatic hypotension ? long sitting or laying down , blood pools in the lower
extremities → poor venous return to the heart [ because of poor muscle contraction]
Q: why do pts on beta blockers get orthostatic hypotension ? because B blockers will dilate the blood
vessels to reduce the blood pressure → decreased VR to the heart
Both vasovagal syncope and orthostatic hypotension will have quick recovery
So your management to any pt that loses consciousness is first to adjust their position to supine or
Trendelenburg → if they recover quickly [ vasovagal attack or orthostatic hypotension ] but if they don’t
recover quickly → check blood glucose [ might be hypoglycemia]

Check blood glucose level
If the pt is conscious → give any source of
oral glucose
Sweating If the pt is unconscious → Do not give
Dizziness anything by mouth !
HYPOGLYCEMIA Increased HR Intravenous glucose – dextrose 50% IV
Pulse is pounding and fast OR
Glucagon 1mg IM
You cannot give epinephrine in the clinic [

only hospital setting]
NOTE : PULSE IS POUNDING AND FAST IN HYOGLYCEMIA BUT WEAK AND THREADY IN SYNCOPE

Confusion and fruit breath Provide only emergency tx and refer to the
HYPERGLYCEMIA hospital

Best area for venipuncture = the dorsum of the hand and wrist – Ginseng Chinese herb acts the same
because it is mostly veins and no arteries [ choose straight , soft , as aspirin causing platelet
elastic veins] do not choose large veins they might be sclerotic disaggregation and blood thinning →
Q: pt is unconscious with normal blood glucose and did not recover if you need to extract ask the pt to
after position adjustment , what might be the cause? Adrenal crisis stop the ginseng for a few days

Pale + sweating Monitor vital signs + administer O2
Nausea and vomiting and abdominal IV line to give corticosteroids [
ADRENAL pain ** hydrocortisone succinate 100 mg ]
CRISIS Thread pulse ** Provide advanced resuscitation and transfer
Pt collapses on the dental chair to the hospital
Adrenal crisis and syncope → weak

Q: what causes an adrenal crisis ? if the pt is taking exogeneous and thready pulse
source of corticosteroids [ like in medications or some types of Hypoglycemia → strong pounding
herbs] the adrenal cortex will stop producing steroids and will pulse with increased HR
undergo atrophy. In cases of stress [ like in dental procedures] the
adrenal cortex cannot produce enough cortisol → pt goes into
adrenal crisis
CUATION: if the pt has skin problems
Cortisone is produced from → adrenal cortex - Daily production of or arthritis or severe asthma →
steroids is 20 mg they are most probably on
corticosteroids and are at risk of
Adrenal gland insufficiency is either :
adrenal crisis
A. Primary → addisons’s disease [ the adrenal cortex produces
enough cortisol for daily need only = 20 mg ]
B. Secondary → pt is taking an exogenous source of corticosteroids in the form of medications or
herbs

Pale + sweating Place pt in upright position
MYOCARDIAL Chest pain Check BP → if the BP is high or normal give
Irregular pulse Nitroglycerin [ NTG ] or aspirin + O2
INFARCTION BP might be normal or high or low Transfer to the hospital
Q: what happens if you place a pt having MI in a supine position? More blood will go to the heart and
eventually to the lungs through the right side → pulmonary edema and hypoventiliation [ because the
alveoli are engorged with blood]
Q: why do you need to check the BP before giving NTG? Because NTG is a very potent vasodilator if the
BP is already low it will drop it even more

Q: why is aspirin a life saving drug in case of MI ? most cases of MI happen due to lack of blood supply
to the coronary arteries because of a blood clot, aspirin given in the first few minutes will prevent the
clot from further progression

Stressed patient
Rapid breathing
Palpitations + dizziness
Stiff fingers ** + hypo calcemic Calm the pt down
tetany Ask the pt to breathe into a paper bag
HYPERVENTILATION [ this will correct the respiratory
In hyperventilation the pt blows off alkalosis]
CO2 resulting in respiratory alkalosis
and the calcium enters into the cells
→ hypocalcemic tetany

Position the patient upright
coughing
Give bronchodilator [O2 +Aminophylline
ASTHMA wheezing **
250mg slow IV / Hydrocortisone sodium
dyspnea
succinate 100mg IV ]

Pt will sense it’s location and catch If the pt is in supine → DO NOT PUT THE PT
FORGEIN BODY their neck or point to an area in the UPRIGHT [ try to remove with tweezers or
DISLOGED IN neck magill’s forceps – max of 2 times]
Pt cannot speak If the pt is well → transfer the pt to the
THE THROAT hospital [ you must accompany the pt ]
If the pt is upright or standing → try back

thrust or abdominal thrust [ you can only try
abdominal thrust once because it uses all of
the air in the lungs]
In vasovagal attack and orthostatic hypotension → position the pt in supine position / Trendelenburg
position
In MI and Asthma → up right position

Bleeding disorders
Bleeding can either be local cause or systemic cause [ bleeding in most healthy patients is due to a local
cause ]
Local causes of hemorrhage originate in either soft tissue or bone.
Soft tissue bleeding:
 Arterial bleeding is bright red and spurting – most commonly injured arteries in Oral surgery =
greater palatine artery + buccal artery
 Venous blood is dark red in color and flows steadily.
 Capillary bleeding is bright red in color and is more of a minimal ooze.
Bone bleeding: from nutrient canals, central vessels [inferior alveolar artery] or from central vascular
lesions (Hemangioma or Vascular malformation).
Hemorrhage classes:
Class 1 Loss of up to 15% of blood volume

No change in vital signs
fluid resuscitation is not usually necessary
Class 2 Loss of 15-30% of total blood volume.
Tachycardia – pale cool skin
Volume resuscitation with crystalloids (Saline solution or Lactated Ringer's solution) is
all that is typically required. Blood transfusion is not typically required.
Class 3 Loss of 30-40% of blood volume.

Blood pressure drops , tachycardia, peripheral hypoperfusion (shock), capillary refill
worsens, and the mental status worsens.
Fluid resuscitation with crystalloid and blood transfusion are usually necessary
Class 4 loss of >40% of circulating blood volume.
Aggressive resuscitation is required to prevent death.
WHO classification of blood loss :

• Grade 0 no bleeding
• Grade 1 petechial bleeding
• Grade 2 mild blood loss (clinically significant)
• Grade 3 gross blood loss, requires transfusion
• Grade 4 debilitating blood loss, retinal or cerebral associated with fatality
• Petechiae： a small (1-2mm) red or purple spot on the body, caused by a minor hemorrhage

• Purpura ： 1 cm red or purple discolorations on the skin caused by bleeding under the skin that
do not blanch on applying pressure.
• Ecchymosis： subcutaneous purpura larger than 1 centimeter or a hematoma
• Hemarthrosis : bleeding in the joints
Blood test Normal count • Warfarin affects PT

Platelet count 140,000 to 400,000/mm3 • Heparin affects aPTT
➢ Thrombocytopenia : < 140,000/mm3
➢ Clinical bleeding problem : <50,000/mm3 PT = Tests extrinsic ( factor VII ) and
➢ Spontaneous bleeding with life common ( I,II,V,X ) pathways
threatening : <20,000/mm3
aPTT= Tests intrinsic and common
Bleeding time 1 to 6 minutes pathway
Prothrombin 11-15sec Management of patients with
time Warfarin therapy increases PT
bleeding disorders :
INR 1 [ you can do surgery up to INR 3 ]
INR = 3-3.5 [ take consultation] Pre-operative blood investigations
aPTT 25-35 sec and preoperative correction of the
Heparin increases aptt underlying deficiency (Replacement of
Thrombin 9 to 13 seconds Clotting factors / platelets)
time
What blood tests to order in cases of bleeding disorders

Condition What tests to order
Aspirin therapy BT + aPTT
Coumarin / warfarin therapy PT
Renal dialysis pts [ heparin ] aPTT
Liver disease BT + PT
Pt is on long term ABX therapy PT
Management
Bleeding type
Primary bleeding [ Pressure, suturing , ligation, electrocautery , local hemostatic agents [ collagen
during surgery] and oxidized cellulose, Tranexamic acid 5%]
Reactionary bleeding [ examination of the surgical wound to identify the site of bleeding
few hours after surgery ] • If bleeding is from bone then the hemostatic agents like bone wax or
gelfoam is usually used.
• If bleeding is from soft tissues then, ligation / cauterization of blood
vessels along with the use of hemostatic agents like surgicel and
suturing of the wound is carried out
Secondary bleeding [ Removal of any debris from the wound surface that promotes infection of the
few days after sugery] wound.
Identify the source of bleeding
Surgical stents can be placed over extraction sockets for stabilization of clot and
prevention of wound contamination.

Cardiovascular diseases
Hypertension [ HTN] : Defined as having systolic blood pressure (SBP) >/= 140mm of Hg or
diastolic blood pressure (DBP) >/= 90mm of Hg
Normal DBP = 80 mmHg

SBP = 120 mmHg
Pre hypertension DBP = 80 -89
SBP= 120-139
Stage 1 HTN DBP = 90 -99
SBP = 140 -159
Stage 2 HTN DBP = 100
SBP = 160
Dental management for patients with controlled hypertension: [ Asymptomatic BP < 140/80 mm Hg]
1- Measure BP at every visit + review the medical history to know if there are any changes in
medications or new medical problems
2- Short morning appointments **
3- Minimize stress **
Dental management of patients with uncontrolled hypertension [Asymptomatic BP 160-179/100-109

mm Hg]
1- periodic intraoperative BP monitoring

2- Emergency care may be accomplished as long as SBP is < 180 mmHg & DBP is < 110 mmHg
3- Terminate appointment if BP rises above 179/109
Dental management of patients with poorly controlled diabetes mellitus [ SBP > 180mmHg and / or
DBP > 110 mmHg]

Abort all dental procedures – Refer the Pt for immediate medical evaluation
Oral manifestations:
There are no recognized manifestations of hypertension but anti-hypertensive drugs can often cause
side affects , such as:
1- Xerostomia
2- Gingival overgrowth
3- Lichenoid drug reactions & Erythema multiforme
4- Taste sense alteration
CAUTION: Most antihypertensive drugs have drug interactions with LA and analgesics:
A. Interaction of LA with nonselective beta-blockers may increase LA toxicity

B. LA with Epinephrine can cause HTN when a patient is taking nonselective b-blockers (propranolol
and nadolol)
C. Long-term use of NSAIDs may antagonize the antihypertensive effect of medications like
diuretics, beta blockers and ACE inhibitors
Local anesthesia:
➢ Epinephrine can be used ONLY in controlled HTN patients
➢ Options in uncontrolled HTN: – Mepivacaine (Scandonest) 3% (with NO vasoconstrictor)
➢ Mepivacaine has a very short effect and can’t be used for long appointments like endo or
surgery because the pt will be in pain + discomfort which will raise their BP. You can give 1
carpule of LA with epinephrine to establish long anesthesia and then continue with
mepivacaine
➢ Retraction cord containing epinephrine should be avoided.
Infective endocarditis
Causative organisms: Staph Aureus, Viridans Streptococci
Q: why do you need to give ABX prophylaxis for IE pts? Invasive dental procedures can introduce
bacteria into the blood which can colonize and grow on the valves
ABX prophylaxis is equal to a DAY DOSE of the ABX , given once - 1 hour before the procedure.
Indications [ patient ] Indications [ procedure]

1- prosthetic cardiac valves [transcatheter- Prophylaxis is recommended for all dental
implanted prostheses and homografts] procedures that involve manipulation of gingival
2- prosthetic material used for cardiac valve tissue or the periapical region of the teeth, or
repair [annuloplasty rings and chords perforation of the oral mucosa
3- history of infective endocarditis
4- Cardiac transplant with valve Prophylaxis is NOT needed for:
regurgitation 1- Injections in non infected sites
5- Unrepaired cyanotic congenital heart 2- Ortho or removable appliance placement
disease, including palliative shunts and 3- Bleeding from trauma to the lip or inside
conduits the mouth

6- Repaired congenital heart defect with 4- Shedding of primary teeth

residual shunts or valvular regurgitation
Q: what is the difference between ABX prophylaxis and ABX coverage?
• ABX porphylaxis is a day dose of the ABX given once , 1 hour before the procedure . given for pts
at risk of developing infective endocarditis
• ABX coverage is ABX given for 1 full course or for a week . given for immunocompromised pts or
pts with poor healing.
➢ No association between dental procedures and prosthetic joint infections
Patients with a history of complications associated with joint replacement surgery who are undergoing
dental procedures, prophylactic antibiotics should only be considered after Orthopedic consultation
[the orthopedic will prescribe the ABX not you]
Situation Agent Dose

[ 30- 60 mins before the procedure]
Adult Child
Pt can take oral medication Amoxicillin 2 grams 50 mg / kg
[ general prophylaxis] [ max 2 gram]
Ampicillin 2 grams IV/ IM
Unable to take oral medication Cefazoline 1 gram IV / IM 50 mg / kg IV or IM
Ceftriaxone
Cephalexin 2 grams 50 mg /kg
Clindamycin 600 mg 20 mg / kg
Allergic to penicillin
Azithromycin 500 mg 15 mg / kg
Clarithromycin
Clindamycin 600 mg IV / IM 20 mg / kg IV or IM
Allergic + can’t take oral medication Cefazolin 1 grams 50 mg/kg
Ceftriaxone
Coronary artery disease / Myocardial infarction:

➢ Most important management is to minimize stress [ explain
Angina is the symptom
procedures, distraction techniques , No2 sedation etc.. ]
➢ Prophylactic dose of sublingual nitroglycerin Myocardial infarction is the disease.
• If the pt had a recent MI you need to wait 6 months before
any dental appointment
• Recent Angina attack → wait 30 days
If it is an emergency [ consult physician + give phrophylactic nitroglycerin + limit treatment
to treating acute infection, pain relief or bleeding control]

• If the pt has worsening symptoms → delay elective dental therapy until PROPERLY treated
Myocardial infarction (MI) – heart attack
• Intense and unremitting chest pain for 30-60 mins

• Substernal, and often radiates up to neck, shoulder, jaw and down left arm
• Described as a substernal pressure sensation that also may be characterized as squeezing,
aching, burning, or even sharp pain
• Sometimes, symptom is epigastric discomfort, with a feeling of indigestion or of fullness/gas
MI management in the dental clinic:

1- Terminate all dental treatment
2- Position pt in upright position
3- Give nitroglycerin (NTG) tablet or spray + Administer oxygen + Check pulse & B.P.
4- If pain is relieved → taper O2 over 5 mins
5- If discomfort continues for 3 mins → give 2nd tablet of NTG + monitor
6- If discomfort continues for 3 mins → give 3rd tablet of NTG + monitor
7- If discomfort continues for 3 mins after the 3rd tablet → MI is in progress →transport to the
hospital [ if pain is sever give 2 mg morphine SC or IV]
Bleeding :
Normal INR = 1
3 different protocols used to treat patient with High INR (Taking Oral
Anticoagulant )
1- Warfarin not discontinued (minimizes thromboembolic events &
tranexamic acid (Exacyl) –
increases risk of bleeding after surgery).
antifibrinolytic agent [ local
2- Warfarin discontinued (drug should be discontinued 5 days prior
hemostatic agent]
to surgery, during this period pt is at risk of developing
thromboembolic event but not bleeding).
3- Warfarin discontinued & patient placed on alternative anticoagulant therapy [ low molecular
weight heparin] (thromboembolic event minimized).
If the pt has hemophilia → they need to take the factor at the day of the surgery + 3 days after [ 3
days after extraction the factor levels will be low that’s why pts need to take it at the day of surgery
+ 3 days after surgery]
If the pt’s INR is above 3 you can only give Mepivicaine , using LA with epi will give a false image of
hemostasis → pt will have bleeding after a few hours
NOTE: pts on warfarin will eventually stop bleeding and develop a clot , it just takes longer to
achieve hemostasis .


G6PD & thalassemia

G6PD is common in the UAE and most cases carry the Mediterranean variant, which results in more
severe symptoms than other G6PD variants, due to an unstable enzyme and less than 1% of enzymatic
activity.
G6PD deficiency : a disease that causes premature RBC hemolysis when exposed to oxidative
stressors [stressors can be Fava beans, antibiotics, bacterial or viral infections, etc.] - The
condition presents 1-3 days following the oxidative stress and the resultant hemolysis usually
resolves, without any problems .
Signs and symptoms: Oral changes :

1- Tachycardia + shortness of breath 1- Pale discoloration of the oral mucosa.
2- Dizziness & fatigue 2- Increased susceptibility to infections.
3- Fever 3- Bleeding spontaneously or on
4- Paleness and jaundice slightest provocation.
4- Excessive plaque accumulation.
5- Retarded wound healing
Dental management : In patients with G6PD deficiency, local anaesthesia may induce
methaemoglobinaemia in high doses. most likely caused by prilocaine and benzocaine.
Thalassemia : RBCs have abnormal hemoglobin – treated by blood transfusions every 4-6 weeks
Oral changes :
1- Anemia
2- Low bone mass → malocclusion
3- Hypertelorism [ increased distance between the eyes ]
4- High caries index
5- Mucosal pallor
6- CHIPMUNK FACE
Things to consider in thalassemia pts :
1- Degree of iron overload in the body (consider liver dysfunction, NSAIDS)

2- Chelators administered to the patient (given to chelate iron in pts w frequent transfusions to
minimize iron effect on organs)>> they can cause immunity problems: agranulocytosis &
neutropenia.

Pregnancy
Time for dental treatment:

• First trimester = week 1-12 [ fetal organ formation – most susceptible to teratogens]
Only provide emergency care
• Second trimester = week 13 -24 [ safest time to deliver dental care ]
• Third trimester = week 25-40 [ only emergency care ]
Q: what is the safest time to do any dental treatment in a pregnant woman ? second trimester
Position of the patient :
• Semi supine or sit up position + Elevate the right hip 10- 12cm
Supine hypotensive syndrome: happens when a pregnant woman lies flat [

supine position]
• Compression of inferior vena cava & aorta

• Decrease venous return to heart
• Decrease uteroplacental perfusion and fetal distress
Symptoms of supine hypotensive syndrome:
1- Sweating, nausea, weakness

2- Sense of air lack **
3- Bradycardia
4- Decrease blood pressure
5- Loss of consciousness
Tx: roll the pt onto their left side
Q: can you take xrays for a pregnant pt ? yes , but with precautions.
Xray precautions in pregnant women:
1- take only xrays that are essential for diagnosis + limit the radiograph to the affected tooth only
2- use lead shield + long cone + collimation
3- be careful while taking essential films to eliminate the need for repeated exposure
Q: which medications are safe to be used in pregnant women ?

• ABX = amoxicillin , penicillin, clindamycin , cephalexin [ FDA group B ] – safe to be used in all
trimesters
• Analgesics = Paracetamol (short term usage) is the analgesic of choice in all trimesters,
ibuprofen [ both FDA group B]

Strong analgesics = Codeine is safe for short term usage, but should be avoided in last trimester
due to fetal respiratory depression and withdrawal symptoms
• Safe LA = Lidocaine, Etidocaine, Prilocaine [ Local anesthesia is not teratogenic, and may be
administered to pregnancy patient in usual clinical doses ] – most common LA in pregnancy is [
lidocaine + vasoconstrictor]
• Vasoconstrictors = no specific contraindication
CAUTION:
• Aspirin is nonteratogenic but may cause maternal and fetal haemorrhage and oral clefts, large
doses during last trimester may cause fetal hypertension, anemia and low birth weight.
• NSAID should be avoided in last trimester due to possible circulatory effects and persistent
pulmonary hypertension.
• Diazepam anticonvulsant [ FDA group D] can cause clefts with prolonged exposure
• Nitrous oxide should not be used in first trimester, and if used in second or third trimesters,
do not use less than 50 % Oxygen
• Large dose of prilocaine are known to cause methemoglobinemia which could cause maternal
& fetal hypoxia
Emergencies in pregnant women

1- Syncope: due to Supine hypotensive syndrome, dehydration, anemia, hypoglycemia and
neurogenic disorder
2- Morning sickness [ enhanced gag reflex ] : pt might aspirate vomit → place
the pt in recumbent position + suction [ if needed do chest compressions]
3- Seizure: pt might aspirate gastric content → hypoxia
A. Control of airway
B. Place pt on her left side
C. Oxygen & suction
D. Transfer to the hospital
4- Bleeding + cramping : PROCEEDS MISCARRIAGE
Place the pt on left site and oxygen, transfer to hospital

Epilepsy
Seizure = sudden intense bursts of electrical impulses in the brain that affect consciousness, sensation
and body movements
An Epileptic is any person who had 2 or more seizures of an idiopathic nature in their life
Seizures
Partial Generalized
Simple (Consciousness is not impaired) Tonic-clonic (grand mal)
Complex (Consciousness is impaired) Myoclonic
Atonic
Absence seizures (petit mal)
Febrile seizure [ in high fever ]: type of generalized tonic-clonic
Tonic - A sustained muscular contraction.
Clonic - Intermittent muscular contractions and relaxation.
Status epilepticus: A seizure lasting more than 5 minutes and is life

threatening, most often a generalized tonic-clonic
Aura: Localized symptom that may be the first part of a seizure:
[Dizziness, head ache, upset stomach ]
Common medications that epileptic patient take [Phenytoin - one of the best tolerated
anticonvulsants, Carbamazepine, Valproic acid, Barbiturates, Succinimide, Benzodiazepines]
Newer anticonvulsants : lamoterigine, gabapentine
Predisposing factures for a seizure:
1- Fatigue & Decreased physical health

2- Alcohol ingestion
3- Emotional stress
4- Flashing lights
5- Menstrual cycle
6- Missed meals
Management: Based on preventing and minimizing occurrence of seizures
The first step in management of an epileptic dental patient is identification [ by a thorough medical
history , ask :
• What medications are you taking?

• What type of seizure do you have & How often do you have a seizure?
• What signals the onset of your seizure?
• How long do your seizures last?

• Have you ever been hospitalized

Gingival hyperplasia is secondary to
The office staff must be sensitive to the embarrassment that many phenytoin (dylantin) therapy
individuals feel after a seizure [ because they might have partial loss
of memory, deep sleep, loss of consciousness and muscoskeletal DD of seizures:
contraction and relaxation → loss of bladder control ] • Epilepsy
Q: while working patient develops a seizure what do you do? • Local Anesthetic Overdose
Reaction
1- Terminate the dental procedure. • Hyperventilation
2- Protect the patient from injury • Cerebrovascular Accident
3- Open the airway / administer oxygen. • Hypoglycemic Reaction
4- Obtain vital signs.
• Syncope
5- Activate the EMS.
6- Anticonvulsant medications I.V.
If you recognize the aura [ or pt informs you ] → stop TX and activate EMS → CABD [ consciousness ,
airway, breathing, definitive treatment]
Seizure persists more than 5 mins → CABD + administer anticonvulsant if available
Intranasal phenytoin [ dylantin] can be given DURING tonic clonic seizure

Diabetes
Diabetes Type 1 = Beta cells of the pancreas is not producing enough insulin
Common complication = ketoacidosis that leads to coma
Diabetes type 2 = the cells of the body are not responding properly to the insulin produced
Common complication = hypoglycemia
Signs and symptoms: Controlled diabetic = did not change

• Polyuria, (especially nocturia) their medication dose or blood sugar
• Polyphagia reading for the past 3 months
• Polydipsia + Dry lips
• Rapid and unexplained body weight loss
• Blurred vision **
Insulin is important because it will allow glucose to be absorbed into the cells of muscles and other
tissues , when insulin is absent or very low [ undiagnosed or uncontrolled diabetic ] the body cannot
absorb the glucose → starts breaking down fat for energy → build up of acids in the blood stream [
ketones] → keto acidosis and fruity smell of the breath
Signs for ketoacidosis develop within 24 hours:
1. Excessive thirst and Frequent urination

2. Nausea / vomiting and abdominal pain
3. Weakness or fatigue + Shortness of breath
4. Fruity-scented breath **
5. Confusion
Diagnosis of diabetes: At least one of the following

1- A fasting (> 8-hour) plasma glucose of > 126 mg/dL on two separate occasions [
ex; measured on a Sunday then measured on a Tuesday]
2- A random plasma glucose of > 200 mg/dL plus symptoms
3- A two-hour postprandial glucose of > 200 mg/dL after a glucose tolerance test
on two separate occasions
NORMAL GLUCOSE RANGE = 80 -120 mg/dl

Diabetes treatment [ type 1 ]:
1- Insulin [ injected subcutaneously] + self-monitoring of blood glucose in the normal range (80–
120 mg/dL).
Higher blood glucose levels (≥ 200 mg/dL) can be tolerated, particularly in the very young pts , if there is
↑ risk of hypoglycemia
2- Routine HbA1c testing (with a goal HbA1c < 8 in children)

3- frequent BP checks, foot checks
4- annual eye exams + microalbuminuria screening
5- lipid profile every 2–5 years
Types of insulin :
1- Regular insulin → lasts up to 8 hours

2- Humalog [ lispro] → lasts up to 8 hours
3- Novolog [Aspart] → quick action within 10- 20 mins and lasts up to 5 hours
4- Levemir [ detemir ] → lasts up to 20 hours
5- Lantus [ glargine]→ lasts up to 14 hours
Both Levemir and lantus do not have peak effect and last long [ up to 20 hours ]
Oral complications of poorly controlled DM :

1- Xerostomia [ caused by the polyuria] + increased incidence and severity of caries
2- Bacterial, viral, and fungal infections (including candidiasis)
3- poor wound healing
4- gingivitis and periodontal disease
5- burning mouth symptoms
Q: what should you ask every diabetic pt ?
1- How much insulin they use, what type & how often they inject themselves each day
2- Whether their diabetes is well-controlled (if so they are more likely to go hypo)
3- What their signs/symptoms of a hypo are (these should be updated regularly)
4- What their HbA1c is
Your goal as a dentist is to prevent insulin shock during the dental appointment
We depend on HBA1C to determine if the pt is well controlled or not. [ you can treat a pt with HBA1c
up to 8 ]
Brittle diabetes [ mostly in type 1] = pt flips between hypo and hyper quickly. Pts being treated with
large doses of insulin have periods of extreme hyperglycemia & hypoglycemia. – such pts are at higher
risk for infection
You can only give emergency tx to a pt with brittle diabetes + Close consultation with the physician is
required before any dental treatment

If diabetes is well-controlled → all dental procedures can be performed without special precautions.
If not well-controlled [can be hyper >200 mg/dl or hypo <70 mg/dl ]→ emergency only
Diabetic pts in general :
1- Give morning appointments

2- usual insulin dosage and normal meals on day of dental appointment
3- pt should inform dentist if symptoms of insulin reaction occur during dental visit
4- Glucose source (orange juice, soda, Glucola) should be available and given to pt if symptoms of
insulin reaction occur
Acute dental or oral infection → leads to loss of glycemic control [ so they should be managed
aggressively by incision and drainage, extraction, warm rinses & AB]
Pts with brittle diabetes may require hospitalization during management of an infection.
Risk for infection in diabetic pts is directly related to fasting blood glucose levels [if fasting blood
glucose level is below 206 mg/100 mL, no increased risk is present]
Epinephrine has an opposite effect to insulin, so blood glucose could rise with the use of epinephrine
→ In diabetic pts, Use Mepivacaine
Advantage of mepivacaine: no toxicity/ allergy , no BP elevation
Disadvantages of mepivacaine : short acting + risk of bleeding
In long procedures → give one lidocaine then continue with mepivacaine
Q: why should you test blood sugar before giving IAN block? Because tingling in lips is sign of ‘hypo’
and it could be mistaken as the normal sign of LA
Periodontal treatment could lead to a mean reduction of 0.4% in HbA1c level - by improving the
diabetes control the periodontal condition may also be positively affected and vice versa
IV sedation : fasting before the appointment (i.e., nothing by mouth after midnight); using only half the
usual insulin dose; and then supplementing with IV glucose during the procedure.

Kidney disease
Chronic kidney disease [ CKD] = 3 months of reduced glomerular filtration rate (GFR) and /
or kidney damage.
CKD COMPLICATIONS:
1- Anemia => due to lack Erythropoeitien ↑Po4

2- Hyperkalemia (High Blood Potassium)
3- Hyperphosphatemia ( high serum phosphate levels) / Hypocalcemia ↑ K+
4- Acidemia (the state of low blood pH)
↓PH
5- Low Vit D / Secondary Hyperparathyroidism / renal osteodystrophy
6- Edema [ in extremities] ↓ Ca 2+
7- Uremia (urine in the blood)
CKD pts suffer from :
1- Increased bleeding tendency → screen for bleeding disorders

2- Increased susceptibility to infections → always consult with their physician + avoid dental tx if
disease is unstable
3- Drugs intolerance → avoid drugs metabolized in the kidneys
4- Hypertension → monitor BP before , during and after procedure
Management of pts with CKD:
1- Avoid nephrotoxic drugs (acetaminophen (Tylenol) in high doses, aspirin, non-steroidal anti-
inflammatory drugs)
2- Adjust dosage of drugs metabolized by the kidney according to their GFR or Creatinine
Clearance (88–128 mL/min for healthy women and 97–137 mL/min for healthy men)
3- Aggressively manage orofacial infections with culture and sensitivity tests and antibiotics
Management of pts with end stage renal disease on renal dialysis :
Avoid dental treatment on the day or dialysis [ specially in the first 6 hours ] because the pt will be tired
+ those Pts are also on heparin [ there is risk of bleeding]
Simple procedures can be done one day after dialysis , complicated procedures should be done one day
before dialysis [ so that LA and any toxins produced by the procedure can be eliminated by the dialysis ]
Pts on renal dialysis might be carriers for HIV / Hep C and B
Oral complications of CKD and ESRD:
1- Pallor of oral mucosa (Related to anemia)

2- Pigmentation of oral mucosa [ Red-orange discoloration of the cheeks and mucosa caused by
deposition of carotene-like pigments occurs when renal filtration is decreased]
3- Xerostomia + saliva has ammonia like odor

4- Dysgeusia [ metallic taste in the mouth ]

5- Candidiasis
6- Petechiae and ecchymosis of oral mucosa [ due to bleeding tendancies]
7- Enamel hypoplasia
8- Osteodystrophy (radiolucent jaw lesions)
9- Uremic stomatitis - red, burning mucosa covered with gray exudates and later by frank
ulceration
Uremic frost : white patches caused by urea crystal deposition on

the skin but may be seen on the oral mucosa associated with blood
urea nitrogen (BUN) levels greater than 55 mg/dL
NOTE : CARIES IS NOT A FEATURE BECAUSE THE HIGH UREA IN

SALIVA WILL BUFFER THE ACIDICTY PREVENTING PH DROP AND CARIES
Q: a pt on hemodialysis will undergo extraction , which blood test should you order and what is the
normal range ? since the pt is on Heparin you order aPTT – normal range [ 25- 35 seconds]
Some pts with ESRD will have AVF [Atrio ventricular fistula – a port that is used as access for dialysis]
Managing a pt with AVF: [ those pts have increased risk of bleeding due to physical destruction of
platelets and the use of heparin] – to minimize bleeding :
1- Determine the status of hemostasis by ordering aPTT

2- Providing dental treatment one day after hemodialysis [on the same day of dialysis, patients are
generally fatigued and may have a tendency to bleed due to the activity of heparin that lasts for
6 hours ].
3- Primary closure of wounds using pressure or hemostatic agents such as thrombin, oxidized
cellulose, desmopressin, and tranexamic acid [ antifibrinolytic agent]
4- Perform major surgical procedures on the day after the end of the week of hemodialysis [to
provide additional time for clot retention before dialysis is resumed]
For example if the pt has Monday/ Wednesday/Friday weekly hemodialysis regimen, surgery
performed on Saturday allows an additional day for clot stabilization before hemodialysis is
resumed on Monday of the following week.
Q: do you need to give ABX prophylaxis for a pt with AVF? Justify . NO, because infective endocarditis
occurs in a very small percentage of such patients, guidelines do not recommend ABX prophylaxis
Q: what is your role as a dentist for a pt that will receive kidney transplant ? before transplant achieve
optimal oral hygiene to prevent development of any dental problems after transplant [ the pt cannot
have any dental procedures 6 months after transplants ] + incase of gingival enlargement due to
cyclosporine just maintain oral hygiene and plaque control through scaling

Q: why can’t you do gingivectomy immediately for cyclosporin

Cyslcosporine causes hypertension so
induced enlargements ? because there is a chance it might recede
most pts taking cyclosporine are also
later [ because the pt will not take the drug forever] , all you can do
given nifedipine [ antihypertensive
is maintain OH and plaque control through scaling – unless
drug] which causes a more severe
overgrowth is severe and covering the crowns → then you can
enlargement [ both have synergistic
consider gingivectomy
effect]

Liver diseases
Viral hepatitis and alcoholic liver disease = most common liver disorders
3 things to remember when dealing with liver disease pts :

Sudden weight loss → can lead to fat
1- impaired drug metabolism [ avoid hepatoxic drugs like accumulation in the liver [ fatty liver
NSAIDs, Acetaminophen, Metronidazole, Diazepam] disease]
2- bleeding tendency [ due to decreased production of vit K and
other coagulation factors + thrombocytopenia due to portal
hypertension ]
3- Risk of infections
Viral hepatitis
Viral hepatitis Mode of transmission + notes
fecal contamination of food or water [usually by traveling in an endemic region] or
A
by direct contact with an infected person.
B Percutaneous and permucosal exposure [ sexual activity]
C Blood + blood products [Renal dialysis pts, drug users]
Co infection with Hep B [ more in drug addicts and pt’s with hemophilia – a more
D severe infection than Hep B]
Same mode of transmission as B
Similar to hep A
E
• Most cases of viral hepatitis resolve with no complications The most common hepatitis is Hep B –
• All patients with a history of viral hepatitis must be has a vaccine
managed as though they are potentially infectious [
Dentists are at risk of getting :
isolated room, high volume suction, face mask , double
gloves] Hep B and to a lesser extent Hep C [due to
Patients With Active Hepatitis: exposure to infected blood/body fluid]
1- urgent care only - in an isolated operatory with strict
standard precautions Dentists need periodic retesting of HBsAg
2- Minimize aerosols [ high speed suction + manual [ surface antigen] and HCV RNA
scalers] HBV, HCV, and HDV → can stay and
3- Avoid drugs metabolized by the liver become chronic
• If surgery is necessary → prothrombin time and bleeding
time should be obtained and abnormal results discussed Chronic viral hepatitis increases the risk
with the physician for hepatocellular carcinoma

Patients Who Are Hepatitis Carriers:
1- NO elective dental treatment + refer to a physician Warfarin antagonist = vitamin K

2- Necessary emergency dental in an isolated operatory
and minimal aerosol production with protective If you give Vitamin K you will not interfere
precautions with warfarin
Drugs metabolized in the liver should be considered for diminished Warfarin gets eliminated after 7-10 days
dosage when one or more of the following are present: while Vitamin K works immediately in
case of bleeding in a pt on warfarin
1- Aminotransferase levels [ALT] elevated to greater than 4
times normal values
2- Serum bilirubin > 35 μM/L or 2 mg/dL
Heparin antagonist = protamine sulfate
3- Serum albumin < 35 mg/L
4- Signs of ascites and encephalopathy, and prolonged
bleeding time
NOTE: drug modifications are not required for the patient who has completely recovered from
hepatitis
Patients with alcoholic liver disease

Oral manifestations of alcoholism:
1- Traumatic or unexplained injuries

2- Jaundice
3- Peripheral edema (edematous puffy face)
4- Ecchymoses, petechiae, or prolonged bleeding
5- Poor hygiene and neglect (caries) are prominent oral findings in patients with chronic
alcoholism
6- Nutritional deficiencies → angular or labial cheilitis
7- Vitamin K deficiency → bleeding tendency
8- A sweet, musty breath odor
Dental management of alcoholism pt : [ you major concern is bleeding problem + risk of cancer]
1- Obtain P T,PTT,INR before surgery + have available local haemostatic measures.

2- avoid hepatotoxic drugs
3- Local Anaesthesia of a maximum 2 carpules
4- Avoid Pt swallowing Blood (encephalopathy)
5- monitor oral cancer
** patients with alcoholism may require increased amounts of local anesthetic or the use of additional
anxiolytic procedures


References
▪ Scully, C. (2014). Scully's medical problems in dentistry.

▪ Little, J. W., & Falace, D. A. (1980). Dental management of the medically compromised
patient. St. Louis: C.V. Mosby Co.
▪ Wray L. .The diabetic patient and dental treatment: an update . British Dental Journal
2011; 211: 209-215 .

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CRASH COURSE IN

DENTAL MANAGEMENT OF THE

DONE BY : SIMA HABRAWI

Done By : Sima Habrawi Dentiscope 2020

Diabetes Type 1............................................................................................................................ 19

Done By : Sima Habrawi Dentiscope 2020

• Pt collapses in the clinic → can be due to medical problem or anxiety

EMERGENCY SINGS AND SYMPTOMS MANAGEMENT

When the pt becomes unconciouss all of the muscles become flaccid [

To open the airway in an unconscious pt you do : head tilt + chin lift to

Done By : Sima Habrawi Dentiscope 2020

EMERGENCY SINGS AND SYMPTOMS MANAGEMENT

EMERGENCY SINGS AND SYMPTOMS MANAGEMENT

You cannot give epinephrine in the clinic [

EMERGENCY SINGS AND SYMPTOMS MANAGEMENT

Done By : Sima Habrawi Dentiscope 2020

EMERGENCY SINGS AND SYMPTOMS MANAGEMENT

Adrenal crisis and syncope → weak

EMERGENCY SINGS AND SYMPTOMS MANAGEMENT

Done By : Sima Habrawi Dentiscope 2020

EMERGENCY SINGS AND SYMPTOMS MANAGEMENT

EMERGENCY SINGS AND SYMPTOMS MANAGEMENT

EMERGENCY SINGS AND SYMPTOMS MANAGEMENT

If the pt is upright or standing → try back

In MI and Asthma → up right position

Done By : Sima Habrawi Dentiscope 2020

Local causes of hemorrhage originate in either soft tissue or bone.

Soft tissue bleeding:

 Venous blood is dark red in color and flows steadily.

 Capillary bleeding is bright red in color and is more of a minimal ooze.

Class 1 Loss of up to 15% of blood volume

Class 3 Loss of 30-40% of blood volume.

WHO classification of blood loss :

Done By : Sima Habrawi Dentiscope 2020

Blood test Normal count • Warfarin affects PT

What blood tests to order in cases of bleeding disorders

Done By : Sima Habrawi Dentiscope 2020

Normal DBP = 80 mmHg

Dental management of patients with uncontrolled hypertension [Asymptomatic BP 160-179/100-109

1- periodic intraoperative BP monitoring

Done By : Sima Habrawi Dentiscope 2020

A. Interaction of LA with nonselective beta-blockers may increase LA toxicity

Indications [ patient ] Indications [ procedure]

Done By : Sima Habrawi Dentiscope 2020

6- Repaired congenital heart defect with 4- Shedding of primary teeth

Q: what is the difference between ABX prophylaxis and ABX coverage?

➢ No association between dental procedures and prosthetic joint infections

Situation Agent Dose

Coronary artery disease / Myocardial infarction:

Done By : Sima Habrawi Dentiscope 2020

Myocardial infarction (MI) – heart attack

• Intense and unremitting chest pain for 30-60 mins

MI management in the dental clinic:

Done By : Sima Habrawi Dentiscope 2020

Done By : Sima Habrawi Dentiscope 2020

G6PD & thalassemia

Signs and symptoms: Oral changes :

Things to consider in thalassemia pts :

1- Degree of iron overload in the body (consider liver dysfunction, NSAIDS)