Medically complex endodontic patients

“Dreams & dedication are a powerful combination”

-William Longgood11/8/2017

1

MEDICALLY

COMPLEX

ENDODONTIC

PATIENTS

Prepared by,

Dr.Sachin Sunny Otta

Rajarajeswari dental college &

hospital, Bangalore

Guided by,

Dr. Vinay Chandra

11/8/2017

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CONTENTS

INTRODUCTION

PRE TREATMENT EVALUATION

CARDIOVASCULAR DISEASES

Hypertension

Ischemic heart diseases

Heart murmurs & valvular disorders

Congestive heart failure

Arrhythmias & cardiac pacemakers

BLEEDING DISORDERS

Anticoagulant therapy & bleeding disorders

Metabolic diseases

Diabetes mellitus

NEUROLOGICAL DISORDERS

Stroke

Epilepsy

RENAL DISORDERS

Renal diseases & dialysis

RESPIRATORY DISORDERS

Asthma

COPD

Tuberculosis

IMMUNITY SYSTEM DISORDERS

HIV

Adrenal crisis & steroid use

LIVER DISORDER

PREGNANCY

ONCOLOGY

Chemotherapy & radiation therapy

HSCT

SOL

PROSTHETIC JOINTS & DEVICES

ALLERGY

LA

Latex

Irrigating solution

Intacanal medicaments, cements & filling materials

CONCLUSION

BIBLIOGRAPHY

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PART 1

INTRODUCTION

PRE TREATMENT EVALUATION

CARDIOVASCULAR DISEASES

Hypertension

Ischemic heart diseases

Heart murmurs & valvular disorders

Congestive heart failure

Arrhythmias & cardiac pacemakers

BLEEDING DISORDERS

Anticoagulant therapy & bleeding

disorders

Metabolic diseases

Diabetes mellitus

NEUROLOGICAL DISORDERS

Stroke

Epilepsy

RENAL DISORDERS

Renal diseases & dialysis

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INTRODUCTION

Goldberger 1990: “When you prepare for an emergency, the

emergency ceases to exist.”

• Medically compromised patients are just like any other

patients, they don’t want to compromise their teeth and

their esthetics.

• Not only has the average life expectancy increased

dramatically over the past 50 years, but our geriatric

patients are much more likely to be partially edentulous,

have complex medical history with multiple medical

problems and use of multiple medications.

• Medically complex conditions are general condition away

from normal & they are not a contraindication for

endodontic treatment.

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PRE-TREATMENT EVALUATION

1. Medical history & patient interview

2. Medication & allergies

3. Previous dental treatment (PDT)

4. Physical examination

5. Relative stress of planned procedure & behaviour

considerations

6. Multi dimensional risk assessment model (MD-RAM)

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MEDICAL HISTORY & PATIENT INTERVIEW:

• “Never treat a stranger” – Sir William Osler

• Failure to recognize a known risk factor & modify treatment accordingly is a major predictor of unsuccessful patient management

• Standard health history questionnaire- do not clearly lead to specific determination of risk for dental treatment

• A written health history supplemented with patient interview

• Disadv: - Reliability of self reported information is questioned

-patient simply forget to report

-patient intentionally omit relevant information due to concern of privacy or failure to understand how the information could be relevant to dental practice

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MEDICATION & ALLERGIES:

• List of medications & allergies should be consistent with the

disclosed medical conditions

• Herbs, dietary supplements, vitamins & other OTC drugs

contribute to complication in dental setting

• Ginkgo biloba,ginger,garlic,ginseng,feverfew & vitamin E inhibit

platelet aggregation

• OTC weight loss products ( Ephedra) can potentiate the effect of

epinephrine & increase the cardiac stress

PREVIOUS DENTAL TREATMENT (PDT):

• Enquire about any problem with PDT

• Explain about any previous negative dental experience or

possible anxiety

• Explain any adverse drug reaction to dental materials or drugs

• Develop a better rapport with patients so that more sensitive

questions can be enquired.11/8/2017

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PHYSICAL EXAMINATION:

• Vital signs should be recorded prior to dental treatment

• Blood Pressure, Heart Rate & Respiratory Rate – essential risk

assessment baseline information for all patients

• Temperature – sign of infection or sign of malaise or toxicity

• Height & Weight – determine drug dosage in pediatric &

geriatric patients & also in assessing unexplained changes in

weight

RELATIVE STRESS OF THE PLANNED PROCEDURE &

BEHAVIORAL CONSIDERATIONS:

• Endodontic treatment is considered as high-stress dental visit

especially for patients with no prior endodontic treatment or

patients with negative experience

• Surgical RCT, presence of acute pain, self reported dental

anxiety or difficulty with previous treatment & lengthy

procedure are expected to increase the stress.

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Modified Dental Anxiety Scale

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• Stress Reduction Protocol:-

Recognize patient’s level of anxiety

Premedicate the patient (Diazepam 5mg night before and 1hr

before procedure)

Schedule appointment during afternoon. Avoid early morning

appointment

Minimize patient`s waiting time.

Short appointments.

Periodic follow up

PHYSICAL HEALTH STATUS:

• ASA classification for assessing physical health status(McCarthy

and Malamed, 1979)

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ASA physical classification

ASA 1 -A normal healthy patient

Therapy modifications

None (stress reduction as indicated)

ASA 2- A patient with mild systemic disease


Possible stress reduction and other modifications as needed

ASA 3- A patient with a severe systemic disease that limits activity, but is not

incapacitating


Possible strict modifications; stress reduction and medical consultation are priorities

ASA 4- A patient with an incapacitating systemic disease that is a constant threat to life


Minimal emergency care in office (may consist of pharmacologic management only);

hospitalize for stressful elective treatment; medical consultation urged

ASA 5 -A moribund patient who is not expected to survive without the operation


Treatment in the hospital is limited to life support only; for example, airway and

hemorrhage management

ASA 6 -A declared brain-dead patient whose organs are being removed for donor

purposes


Not applicableAmerican Society of Anesthesiologists’ (ASA) health classification system and suggested treatment modifications.

Adapted from Tables 1 and 2, Goodchild J and Glick M.27

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MEDICAL CONSULTATION:

• Phone conversation – advantageous of being immediate & allow

for discovery of additional information & disadvantageous of

increased risk of potential misunderstanding & also lower level of

documentation from medicolegal viewpoint

• Written letter – formal documentation of the communication.

MULTIDIMENSIONAL RISK ASSESSMENT MODEL (MD-RAM):

• Patient’s ability to handle stress decrease proportional to extent

of systemic disease

• MD-RAM help to assist clinician in determining any treatment

modification prior to dental treatment

• 2-d RAM included only severity of disease & procedural stress

for only IHD & COPD (Lapointe et al)

• MD-RAM included physical health status, procedural stress &

psychological status

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MD-RAM inf.1

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MD-RAM inf.2

MD-RAM inf.3

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CARDIO VASCULAR

DISEASES

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HYPERTENSION

GENERAL OVERVIEW:

• Systolic BP greater than or equal to 140mgHg & Diaslotic BP greater

than or equal to 90mg Hg

• 7th JNC report on Prevention,Detection,Evaluation & Treatment of

high BP (2003) added Prehypertension for people with SBP 120-139

and/or DBP 80-89 : greater risk for developing hypertension 11/8/2017

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>

GENERAL GUIDELINES:

210mmHg 120mmHg

180mmHg 110mmHg

160mmHg 100mmHg

120mmHg 80mmHg

SBP DBP

Any dental treatment

can be tolerated

Stress Reduction

Protocol

Medical consultation

& emergency

management of pain

& infection

Emergency medical

evaluation

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ENDODONTIC CONSIDERATIONS

IN HYPERTENSIVE PATIENTS

• Non surgical procedures : LA without vasoconstrictors preferred. When indicated, epinephrine (Lidocaine with 1:100,000 epinephrine) preferred over norepinephrine or levonordefrin due to decreased potential for alpha-1 receptor stimulation

• Surgical procedures: require LA with vasoconstrictor in large quantity.

• The use of LA with vasoconstrictor in patients with CVD is controversial & addressed in JNC 7 report

• Patients with CVD & under medication (MAO inhibitors, non selective beta blockers) shows reduced tolerance for LA with vasoconstrictors (cause LA toxicity)

• Catridgres: limited to 2-3 catridges of LA(0.036-0.054mg epinephrine) except for those with severe CVD

• Long term NSAIDs – antagonise antihypertensive effects of diuretics,beta & alfa blockers, ACE inhibitors.

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• LA with VC should be avoided in:

1. Severe or poorly controlled HTN, arrhythmias that are refractory to treatment

2. MI within past one month

3. Stroke within past 6 months

4. Coronary artery bypass graft within past 3 months

5. Uncontrolled CHF

• Supplemental injection technique: intraosseous(IO) injection with 3% mepivacaine can be used with any medical condition that could reduce tolerance for epinephrine.

• Decrease the dose & increase the time interval between

epinephrine injection.

• Use of gingival retraction cords avoided.

• Racemic epinephrine-impregnated pellets shows

no significant change in BP

• Topical haemostatic agents can also be considered in patients with significant CVD.11/8/2017

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ISCHEMIC HEART DISEASE

GENERAL CONSIDERATIONS:

• Coronary atherosclerotic heart disease that become advanced &

present as ANGINA or HEART FAILURE

1. ANGINA: Chest pain (sudden,aching,squeezing sensation or tightness

in the middle of the chest.

• Precipitated by physical activity or stress & may radiate to arm or jaw

and present as dental or facial pain.

• Stable angina- manageable with rest or medication (ASA II or III)

• Unstable angina- progressive pain or pain at rest (ASA IV). More

chance of perioperative MI.

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ENDODONTIC CONSIDERATIONS IN

ISCHEMIC HEART DISEASE

PATIENTS

• Advise the patient to bring anti-anginal drugs for the treatment (sublingual or other forms of nitrates)

• Monitoring & short appointment with semi-supine chair position

• Oral premedication with anxiolytic drugs(2-5mg diazepam 1 hrbefore)

• Limited use of vasoconstrictors

• Adequate pain management (before & after appointment)

• Possible cardiac monitoring

• Nitrous oxide or oxygen sedation or oral benzodiazipine (triazolam) can reduce stress & increase the effectiveness of LA

• Conscious sedation should be provided by trained provider & another operator providing dental treatment.

• Emergency procedure: hospital attached dental practice with cardiologist consent.11/8/2017

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PREDICTORS OF PRE-OPERATIVE RISK:

1. MAJOR PREDICTOR: Recent MI(less than 1 month), unstable

angina,past MI with significant residual damage, decompensated

CHF, significant arrhythmias, severe valvular disease (ASA IV)

2. INTERMEDIATE RISK: Stable angina, past history of

MI(greater than 1 month), with minimal residual myocardial

damage, compensated CHF, diabetes mellitus (ASA II or ASA III)

3. MULTIPLE RISK: Recent MI or unstable angina require medical

consultation & conscious sedation with monitoring.

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HEART MURMURS & VALVULAR

DISEASES


• Obstruction to blood flow (stenosis) or valve incompetence

(regurgitation)

• Patients with rheumatic heart disease,congenital heart disease,

prosthetic heart valves,grafts & pacemakers, IV drug abusers are

prone for infective endocarditis.

• Other risk conditions for IE: recurrent IE, SLE, medications for

weight reduction(dexfenfluramine,fenfluramine-phentermine)

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VALVULAR DISEASE PATIENTS

• Primary consideration for dental treatment: Potential risk of

endocarditis (bacteraemia) & Risk of excessive bleeding in

patients on anticoagulant therapy.

• Non surgical RCT, LA injection, rubber dam placement,

instrumentation within canals do not require antibiotic

prophylaxis.

• Canal instrumentation beyond apex, IL & IO injections &

periapical surgery should receive antibiotic prophylaxis.

AHA

2007

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ANTIBIOTIC PROPHYLAXIS FOR DENTAL PROCEDURES(Wilson et al)

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1 hour before procedure

1 hour before procedure

ANTIBIOTIC PROPHYLAXIS FOR DENTAL PROCEDURES(Wilson et al)

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30 min before procedure

30 min before procedure

• Features to suspect IE for patients following dental treatment:

1. Simultaneous onset of cardiac murmur & unknown fever

persisting for more than 7 days

2. Chills with night time perspiration

3. Reduced appetite, tiredness & discomfort that manifest 2 weeks

post instrumentation or perforation

4. Occurrence of petechiae with pale centre on the skin of flexure

of extremities, supraclavicular site, mucosa of lower conjunctiva

& hard palate.

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CONGESTIVE HEART FAILURE


• 4th most common medical diagnosis of all age groups

• End stage of other cardiac diseases

• Inability of heart to pump blood

• Presenting symptoms: inability to handle stress & anxiety, taking

multiple medication with potential for drug interaction

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ENDODONTIC MANAGEMENT OF

CONGESTIVE HEART FAILURE

• Diagnosis of underlying cause & specific medical consultation &

treatment

• Moderate to advanced CHF –upright chair position

• Risk of orthostatic hypotension while changing the chair position

• Uncompensated CHD –strict medical consultation & avoid

Vasoconstrictors

• Consider treatment in hospital based clinics

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ARRHYTHMIAS & CARDIAC

PACEMAKERS


• Any disturbance in normal rate or rhythm(abnormal impulse

generation)

• Stimulus: dental anxiety associated with treatment

• Presenting symptoms: history of cardiac arrhythmia, irregular

pulse(rapid or slow),syncope,palpitation,dizziness,angina or

dyspnoea

• Digoxin – common medication(narrow therapeutic safety)

• Cardioversion, Pacemakers – advanced treatment modalities

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PATIENTS WITH ARRHYTHMIAS &

PACEMAKERS

• Medical consultation on suspecting the presenting symptoms

• Stress reduction protocol

• Avoid the use of Electronic Apex Locators & Electric Pulp

Testers(traditional)

• Newer EPT have mucosal lip clip (to complete the circuit)that is

hypothesised to be safer

• Safety of new EPT not yet tested.

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BLEEDING

DISORDERS

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ANTICOAGULANT THERAPY &

BLEEDING DISORDERS


• Warfarin(Coumadin),Aspirin,Clopidogrel & Dipyridamole –

commonly prescribed anticoagulants

• Increased risk of bleeding due to inherited bleeding disorders in

which even relatively minor invasive procedure can precipitate a

prolonged bleeding episode.

• Liver diseases

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BLEEDING DISORDER PATIENTS

• Dental pain : paracetamol. Aspirin should not be prescribed.

• Avoiding over instrumentation & periradicular surgeries: best possible

alternative to stop anti-coagulant drugs

• High risk conditions: 1. drug eluting coronary stents placed within 12

months 2. bare metal coronary stent with in 1 month of placement

• PT calculated in International Normalized Ratio(INR) : 2-3.5(for

patient on blood thinning medication. 0.8-1.2 INR for normal

individuals) accepted for elective non surgical endodontic procedure( to

be checked on the day of endodontic therapy) esp. if nerve block is

required

• Physician referral- if invasive procedure required.

• Clear field visibility – main dilemma faced in patients taking

anticoagulants (LA with VC)

• Replacement of coagulation factors before surgical endodontic therapy11/8/2017

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• Controversies exist in the routine discontinuation of anticoagulants

prior to dental procedure(review in ADA council on Scientific Affairs

& division of Sciences)

• Regardless of the procedure:

1. Consult with patient’s physician

2. INR test on day of surgery

3. Hospitalisation & conversion to heparin therapy(in severe cases)

• Days available for suspension of drugs: Warfarin -2 days prior to

procedure(no bleeding problems noted)

Clopidogrel – less than 5 days (chance of stent thrombosis)

• Newer faces:

1. LMWHs – self administered, high level of anticoagulation, reduced

cost & time

2. Low dose aspirin therapy(<100mg/day) – increase bleeding time &

hence should not be discontinued prior to oral surgery.11/8/2017

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• If the patient has inherited or acquired bleeding disorders:

1. Medical consultation

2. Replacement with deficient coagulation factors

3. Check for impaired liver function,heavy alcoholism or drug

abuse(potentiate bleeding along with antiplatelet medication)

As much as possible, minimal risk endodontic procedure should be

preceded without complete discontinuation of antiplatelet drugs.

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METABOLIC

DISEASES

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DIABETES MELLITUS


• Metabolic disorder characterised by elevated plasma glucose level due to defect in insulin secretion(type 1) or impaired function(type 2) or both

• FBS>125mg/dL (normal- less than 110mg/dL)

• Post prandial(2hrs after)-greater than 140mg/dL

• FBS>110mg/dL<126mg/dL - impaired glucose tolerance (IGT)(pre diabetic state of hyperglycemia associated with CV pathology)

• Glycated Hb – haemoglobin A1c,HbA1c,A1C or Hb1c or HbA1c measure the average plasma glucose over prolonged period of time. Formed by non enzymatic glycation pathway by Hb exposure to plasma glucose.(<6% HbA1c)

• Oral manifestations: severe plaque accumulation,gingivitis,periodontitis,bone loss, chance of infection & poor wound healing

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IN DIABETIC PATIENTS

• ON EXAMINATION:

1. Thorough medical history & blood examination:

FBS<100mg/dL ; PPBS<200mg/dL & HbA1c<7%

2. Cardinal symptoms of DM:

Polyuria,Polydipsia,Polyphagia,Weight loss & weakeness

• Dental appointment should not overlap with or prevent

scheduled meals (morning appointments preferred following

regular diet & medication)

• HYPOGLYCEMIA SYMPTOMS:

1. Mild – anxiety,sweating,tachycardia

2. Severe – mental status change,seizure,coma

• Mx of hypoglycemia – 15gm of oral carbohydrate (6oz orange

juice,3-4 teaspoon of table sugar,5 life savers or 3 glucose or

dextrose tablets)11/8/2017

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• Subconscious/uncooperative patient: 1 mg glucagon s.c/i.m injection

(nausea,vomiting head ache)

• Well controlled diabetic is at no greater risk of postoperative infection

than is non-diabetic

• Routine & surgical procedures can be carried out in well controlled

patients

• Surgery in poorly controlled diabetic patients: antibiotic prophylaxis

with Amoxicillin 500mg bd for 3 days (altered function of neutrophils

in diabetic)

• Risk of hyperglycemia in postoperative period(coz surgery increase

insulin resistance) – prevented by pre operative antibiotic prophylaxis

• Delayed alveolar healing – osteomyelitis

• Any systemic complications should be considered prior to dental

appointment

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NEUROLOGICAL

DISORDERS

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STROKE


• Neurological deficits due to lack of blood flow leading to

deprivation of O2 & glucose in a localized area of brain

• Features: Elevated blood pressure, Slurred speech, loss of motor

control over a portion of body, unilateral facial droop, unilateral

visual changes & headache

• Will be under anticoagulant medication

• Post stroke patients experience depression & behaviour

inappropriate to situation

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STROKE PATIENTS

• Medical history & examination of vitals

• Suspecting any featured attacks – check the vitals & transport the

patient to emergency facility

• Precaution - Patient treated in semi supine position & always use

rubber dam (chance of aspiration due to swallowing abnormalities)

• Post stroke patients – need physician consent for decision on

anticoagulant medications11/8/2017

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SEIZURES

GENERAL CONSIDEARTIONS:

• Temporary involuntary disturbance of brain function that results

in synchronous,excessive,abnormal electric discharge of neurons

in CNS

• Manifestations: motor disturbances, altered feelings, change in

patients level of consciousness

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EPILEPTIC PATIENTS

• Medical history

• Neurologist consent

• Patient who are well controlled with medications – undergo routine endodontic management

• Epileptic attacks:

1. Stop the treatment & remove all instruments from oral cavity & nearby vicinity

2. No direct light

3. Place patient in supine position & low to the ground

4. BLS

• Contraindicated ABs with anti-epileptic medication: penicillins,cephalosporins & carbapenems

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RENAL

DISEASES

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RENAL DISEASE & DIALYSIS


• Chronic Renal Failure – irreversible condition with reduction in

GFR

• Long standing renal failure – End Stage Renal Disease (ESRD)

• Treatment options – Haemodialysis & Renal transplant

• Sudden blood pressure variations are characteristic feature

• Avoid Nephrotoxic drugs – Tetracycline & Aminoglycosides

• Preferred drugs:

1. Antibiotics – amoxicillin/clavulanate,erythromycin,azithromycin

2. Analgesics – paracetamol & ibuprofen

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IN RENAL DISEASE PATIENTS

• For nephritic patients on hemodialysis:

1. No endodontic procedures on the day of haemodialysis (use of

heparin for anticoagulation)

2. Protamine sulfate can be used to block anti coagulant effect

3. High risk of infection & transmission of

hep.B,C & HIV – consider universal precautions

• For Renal transplant patients:

1. Use of antibiotic prophylaxis prior to

endodontic treatment

(patient will be immuno suppressed state

due to medications)

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PART 2

RESPIRATORY DISORDERS

Asthma

COPD

Tuberculosis

IMMUNITY SYSTEM

DISORDERS

HIV

Adrenal crisis & steroid use

LIVER DISORDER

PREGNANCY

ONCOLOGY

Chemotherapy & radiation therapy

HSCT

SOT

PROSTHETIC JOINTS &

DEVICES

ALLERGY

LA

Latex

Irrigating solution

Intacanal medicaments, cements &

filling materials

UNCONSCIOUS PATIENT

CONCLUSION

BIBLIOGRAPHY

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RESPIRATORY

DISEASES

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ASTHMA


• Chronic inflammatory respiratory disorder with recurrent

episodes of chest tightness,coughing,dyspnea & wheezing

resulting from inflammation or hyper responsiveness of

bronchiole tissues

• Exacerbating factors: allergens,URT infections,genetic &

environmental factors,anxiety,depression,stress & nervousness

• Dental materials : dentifrices,fissure sealants,tooth enamel

dust,methyl methacrylate,fluoride rolls & cotton rolls

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IN ASTHMATIC PATIENTS

• Clarify about the type (mild,moderate,severe), frequency of

attack & precipitating factors

• Instruct to bring the inhaler & inform the earliest sign of asthma

to the endodontist

• Possible chance of attack:

1. During & immediately after LA administration

2. Pulp extirpation

3. Improper positioning of suction tips

4. Rubber dam placement

5. Prolonged supine position

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• Precautions:

1. Nitrous oxide sedation for mild to moderate asthma

(Contraindicated in severe asthma - airway irritation)

2. Oral premedication with small doses of short acting

benzodiazepines (Triazolam 0.125-0.5mg 1 hr before)

3. Avoid NSAIDS,barbiturates,narcotics(bronchoconstriction)

4. If patient taking theophylline, do not prescribe Erythromycin or

Ciprofloxacin (toxic levels of theophylline)

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• Acute attack during treatment:

1. Sit upright or lay supine in relaxed position

2. Maintain airway open & administer agonist with inhaler or

nebulizer

3. Provide O2

4. Persisting attacks : administer

Epinephrine 0.01-0.3mg/kg of body weight SC

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• Severe conditions: Procedure to be carried out under physician

consent

• After endodontic treatment:

1. Administer Acetaminophen rather than any other NSAID

(long term/daily/weekly acetaminophen use is associated with more

severe asthma)

• Patients using large dose of systemic corticosteroids (severe asthma):

1. Prophylactic administration of antibiotics to prevent post operative

complications(infection)

2. Corticosteroid replacement therapy to prevent acute adrenal crisis

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CHRONIC OBSTRUCTIVE

PULMONARY DISORDER (COPD)


• Breathing problem due to constricted airway (chronic

bronchitis,emphysema)

• Cough,dyspnea,sputum,hemoptysis,wheezing or chest pain

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IN ‘COPD’ PATIENTS

• Avoid LA containing epinephrine & levonordefin – sulfites induce

asthmatic attacks

• Place patient in semi supine position

• Nitrous oxide should never be used (airway irritation)

• Careful application of rubber dam with administration of humidified

low flow oxygen 2-3L/min

• Avoid AB viz; macrolides(erythromycin), ciprofloxacin,clindamycin in

patients taking theophylline due to potential methylxanthine toxicity

• Acetaminophen & Cox- 2 inhibitor used as analgesic drugs

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TUBERCULOSIS

• Infectious disease spread by bacilli containing airborne droplets

by coughing,sneezing or talking

• Oral manifestations: ulcers, fissures or swelling on dorsum of

tongue

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IN ‘TB’ PATIENTS

• Thorough medical history & any elective procedure should be

delayed until the TB is treated & proves non infectious

• If Under Izoniazid & rifampicin medication – avoid

Acetaminophen due to potential liver damage

• If under Streptomycin medication – avoid Aspirin & muscle

relaxant (ototoxicity & respiratory paralysis respectively)

• Treatment under proper isolation, sterilisation

& universal precautions

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IMMUNITY SYSTEM

DISORDERS11/8/2017

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HUMAN IMMUNO VIRUS (HIV)


• Blood borne retro viral infection transmitted by blood & bodily fluids by intimate sexual contact or parenteral routes

• Best possible treatment to increase life span & the quality of life –Highly Active Anti-Reroviral Therapy (HAART)

3-4 drugs of 2 different classes

Drugs metabolised by same CYP450 enzyme system(CYP34A isoenzyme)

Drug competition to bind to same isoenzyme

Increased levels of drug in plasma

Drug toxicity

Resistant HIV strains11/8/2017

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HIV PATIENTS

• Chance of treating HIV patients has increased due to steady state of

new infection annually & longevity from HAART

• Thorough knowledge of the active disease & medications taken by the

patient

• Substitute with another drug if interaction exists

• No modification of proposed procedure unless platelet count <50,000

cells/mm or neutrophil count <1000 cells/mm – but require antibiotic

prophylaxis

• Controversy exist regarding need for antibiotic coverage before

performing surgical treatment

• CDC’s post exposure prophylactic guidelines:

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ADRENAL SUPPRESSION &

LONG TERM STEROID USE


• Adrenal cortex- mineralocoticoids (aldosterone)

- glucocorticoids (cortisol)

{Maintain Fluid Volume}

• Adrenocortical insufficiency – Addison’s disease, pituitary

disease or exogenous corticosteroid (30 mg/day)

• Dental pain, anxiety, stress,infection can initiate adrenal crisis

• Adrenal crisis symptoms: sudden penetrating pain in legs or

lower back, confusion & psychosis, convulsions,fever,syncope

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IN ADRENAL CRISIS CASES

• Supplemental steroids before & after the surgery in patients receiving chronic daily steroid therapy

1. Minor surgical procedures(routine endodontic surgery) – 25 mg hydrocortisone or 5 mg prednisone on day of surgery

2. Moderate risk surgery – 50 to75 mg hydrocortisone on day of surgery & one post operative day

3. Non surgical procedure(non surgical RCT) – case by case basis review

• Rule of thumb: patient who recently discontinued use of exogenous corticosteroids should wait 2 weeks before undergoing surgical procedure

• Patient on alternate day steroid therapy do not require supplementation

• Acute adrenal crisis management – hydrocortisone injection & fluid support

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LIVER

DISEASES

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LIVER DISEASES


• VIRAL HEPATITIS- diffused inflammation of liver

• ALCOHOLIC LIVER DISEASE- hepatic steatosis(fatty

liver),alcoholic hepatitis & cirrhosis

• Dental drugs metabolized by liver :

1. LA – lidocaine,bupivacaine,prilocaine

2. Analgesics – acetaminophen,aspirin,ibuprofen

3. Sedatives – diazepam, barbiturates

4. Antibiotics – ampicillin,tetracycline

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IN LIVER DISEASE PATIENTS

• Oral manifestations: bleeding,glossitis,impaired healing,alcoholic

breath odour,xerostomia,bruxism,attrition

• Oral complication: severe haemorrhage due to reduced hepatic

synthesis of coagulation factors, risk of infection in cirrhosis

patients

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• Preventive measures:

1. Preoperative evaluation of TBC,platelet count,PT or INR to

ensure intact coagulation system

2. Treatment on emergency basis only

3. Physician consultation

• Acute hepatitis requiring urgent dental treatment – consult with

physician regarding patient status & planned dental treatment

Oral

manifestations

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• Antibiotic prophylaxis recommended:

1. h/o spontaneous bacterial peritonitis(SBP)

2. Ascites

3. Or any other medical condition

that would deteriorate SBP condition

• AB prophylaxis for end stage liver disease –

2gm Amoxicillin + 500 mg Metronidazole 1 hr before procedure (oral)

2gm Ampicillin + 500 mg Metronidazole 1 hr before procedure (i.v)

• Alteration of medical dosage based on hepatic compromise require

physician consultation

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• Preventive measures for endodontist:

1. Universal precautions

2. Minimize use of drugs metabolized by liver

3. Use runner dam to minimize contact with saliva or blood

4. Minimize aerosol by using slow speed hand piece

• If screening test abnormal for surgery – consider anti fibrinolytic

agents & vitamin K only after physician consultation

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PREGNANCY

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PREGNANCY- A DYNAMIC

PHYSIOLOGICAL STATE

• Dental practioners with minimal training in gestational medicine

may be hesitant to treat pregnant patients because of their fear of

injuring either mother or unborn child

• Some practioners may withhold care or medications from their

patients, inadvertently causing harm

• Understanding of patients physiologic changes, effect of chronic

infections or illicit drug or alcohol usage is necessary to advise

patients on her options regarding medical & dental care.

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ENDODONTIC DRUG

CONSIDERATIONS IN PREGNANT

PATIENTS

• Drugs used in endodontics: many drugs in dental office

armamentarium are generally safe. Dentist should have

medication reference if question arise regarding a proposed drug

efficacy or safety. Refer to patient’s obstetrician if in case of any

doubt.

1. LA – lidocaine & prilocaine (FDA cat B)

If in case of allergy for lidocaine or prilocaine, Bupivacaine,

mepivacaine(3%) or articaine (FDA cat C)

2. VC – epinephrine or levonorderfin (present in LA) used with

normal precautions taken ie, avoiding injection in blood vessel

& maintaining total dosage of 0.4mg for epinephrine & 0.2mg

for levonorderfin. VC allow for greater depth & duration of LA

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3. AB – Penicillins, erythromycins, azithromycin, metronidazole,

cephalosporins (FDA cat B)

Avoid tertracycline,minocycline & doxycycline (FDA cat D)

4. Analgesics – ‘ not all non steroidal anti inflammatory drugs are safe

for foetus’

• First line analgesic: acetaminophen (FDA cat B) for all 3 trimesters

• For severe pain (narcotic combination): oxycodone(FDA B) &

meperidine,hydrocodone,propoxyphene(FDA C) is safe for short

duration

• Aspirin & Diflusinal in pregnancy causes prolonged gestation &

labour,anemia,increased bleeding potential & premature closure of

ductus arteriosus

• Ibuprofen, ketoprofen & naproxen are contraindicated in 3rd trimester

due to risk of prolonged labour & haemorrhage during delivery

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5. Anxiolytics in dental treatment – Non pharmacological methods

are advised for treating anxiety in dental sitting

• Benzodiazipines(FDA cat C or D) should be administered after

obstetrician consultation

• Traizolam (FDA cat X) is absolutely contraindicated

• Intra nasal nitrous oxide is controversial due to risk of reduced

uterine blood flow or teratogenic effects

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IN PREGNANT PATIENTS

• No contraindications in using necessary diagnostic procedures

viz, appropriate radiographs with normal safety precautions

(beam collimation, high speed films, limited exposure & lead

apron protection)

Average full mouth dental film series expose fetus to 1 X 10-1 rads of

radiation ( far below tetra genic risk to unborn child)

• Pain or infection – invasive endodontic therapy regardless of

patient’s phase of pregnancy

• Elective dental procedure - second trimester

• Sterilization of instruments & proper infection control protocol –

to reduce chance of infection to pregnant patients

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ONCOLOGY

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CANCER CHEMOTHERAPY &

RADIATION THERAPY CASES

• All source of infection & inflammation should be eliminated

before radiation therapy

• Non restorable teeth & that with poor long term periodontal

prognosis should be extracted more than two week prior to

radiation therapy

• Symptomatic non vital teeth can be endodontically treated 1

week before initiation of chemo or radiation therapy

• Antibiotic prophylaxis(AHA) recommended for cancer patients

with indwelling catheters

• Blood examination: Endodontic procedures to be performed if

1. Neutrophil count >2000cells/cubic mm

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• Post Radiation OsteoNecrosis (PRON): arise in bone exposed to high

radiation

• Protocol to reduce PRON:

1. Selection of endodontic therapy over extraction

2. Expert atraumatic surgical procedure

3. LA that contain low concentration of epinephrine

4. Prophylactic antibiotics during period of healing

• Preventive measures to be considered in Bisphosphonate Associated

Osteonecrosis(BON) of Jaw – Non surgical endodontic treatment of non

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HEMATOPOIETIC STEM CELL

TRANSPLANT (HSCT) CASES

• Patient should undergo thorough dental examination & treatment to permit adequate healing before HSCT

• Pre treatment endodontic therapy to be completed at least 10 days prior to initiation of HSCT

• Teeth with poor prognosis - extracted with 10 day window as a guide

• AHA antibiotic prophylaxis – patients with indwelling catheters

• During the HSCT or high dose chemotherapy – aggressive oral hygiene measures to be followed

• Post transplant period (1 year) – patient should not resume routine dental treatment until adequate immunological reconstruction has taken place { aspiration pneumonia due to aerosolization of debris during use of rotary cutting instruments}

• Oncologist consultation for dental treatment 1 year post transplant

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SOLID ORGAN TRANSPLANT CASES

• Consider the patient is in immunosuppressant therapy

• Pre transplant patients – treatment for eradication of dental disease

including endodontic procedures to remove any infection

• Immediate post transplant period – emergency dental procedures

considered if necessary. AHA antibiotic prophylaxis with post

operative antibiotics recommended for invasive procedures

• Transplant rejection – limited dental care should only be given until

stabilization has achieved

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PATIENTS WITH PROSTHETIC

JOINTS & OTHER PROSTHETIC

DEVICES

• Increased risk for developing haematogenous joint infection following dental procedures

• Consultation with orthopaedic surgeon is mandatory

• Antibiotic prophylaxis indicated for:

1. Higher risk dental procedures (endodontic surgeries)

2. With in 2 years following prosthetic joint surgery

3. Who had previous prosthetic joint infections

• AB prophylaxis not indicated for

1. Dental patients with pins,plates,screws & penile or breast implants

2. 2 years after total joint replacement

• Any aggressive orofacial infection should be treated as any other patient with appropriate antibiotics

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Suggested antibiotic prophylaxis regimens for patients with total joint

replacement. Adapted from ADA, AAOS Advisory statement

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HOW TO MANAGE AN UNCONSCIOUS

PATIENT??

REFERRING TERMS:

ANOXIA

COMA – GREEK MEANING DEEP SLEEP

CONSCIOUSNESS –LATIN MEANING AWARE

FAINT

HYPOXIA

SYNCOPE – GREEK TERM SYNKOPE

UNCONSCIOUS

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If the patient collapse in dental chair:

1. Trendelenberg position(head lower than feet)

2. Modified Trendelenberg position(only legs are elevated)

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3. Ammonia vapours- make the patient smell ammonia to bring back

the breathing reflex.

4. Check for vitals

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5. Assessment in emergency: A-B-C-D-E

• AIRWAY- identify foreign body obstruction & stridor

• BREATHING- respiratory rate, use of accessory muscles,

presence of wheeze or cyanosis

• CIRCULATION – assess skin color & temperature, heart rate &

capillary refill time(<2sec)

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• DISABILITY - Assess AVPU (ALERT, respond to

VOICE,respond to PAINFUL stimulus,blood glucose

UNRESPONSIVENESS)

Check finger prick glucose

Do: Give glucose if under 4mmol/l (give 50ml of 50% glucose [or

100ml 20%] IV)

Look: for pupil size and reaction to light; unusual posturing

Feel: for tone in all four limbs and plantar reflexes

• EXPOSURE - To examine the patient properly full exposure of

the body may be necessary. Respect the patient’s dignity and

minimize heat loss.

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Suspecting hypoglycemia-

1mg glucagon i.m

REDUCED CONSCIOUNESS

ALGORITHM- Crispian Scully

ALLERGY

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ALLERGY TO MATERIALS USED

IN ENDODONTIC THERAPY

• ALLERGY is the single most common positive finding on medical

history questionnaire

• Medical questionnaire serves as first stage in screening of allergies

• True allergic reactions: skin rashes, swelling, urticaria, chest

tightness, shortness of breath, rhinorrhoea & conjunctivitis

• Two type of allergic reactions by endodontic materials:

1. Type 1 (immediate or anaphylactic IgE mediated) – after single or

multiple prior exposures

2. Type 4 (delayed or cell mediated) – after 48 to 72 hrs of exposure

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LOCAL ANESTHETICS

• Allergic reactions reported: tachycardia,syncope or general

uneasiness

• Previous experience of LA allergy may induce psychogenic reaction

rather than true allergy

• Potential stimuli for allergy:

1. Sulfite preservative in LA containing epinephrine

2. Latex allergen released from LA catridge(vial stopper & diaphragm)

PRECAUTION:

1. LA without VC (3% mepivacaine)

2. Glass enclosed vials in LA catridges

3. Test dose to be done by the same LA to be used for treatment

• If allergy to all commonly used LA: Inj.1% diphenhydramine with

1:100000 epinephrine(50mg at each appointment) or sedation, GA &

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LATEX

• Natural Rubber Later (NRL) is the most common allergen

• Allergic reaction & adoption of universal precautions coincided

in 1987

• Allergic symptom: urticaria

• Predisposing factors: h/o multiple surgeries,atopy, health care

workers, food allergies are associated with increased risk of NRL

allergy

• Source of latex: rubber dam material, gloves, LA catridges,

rubber mouth prop, rubber tubing, some BP cuffs

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PRECAUTIONS:

1. Non latex gloves & rubber dam materials

2. Scheduling first appointments of the day

3. Prevent extrusion of oburating materials

4. Use of Glass enclosed vials in LA catridges

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IRRIGATING SOLUTIONS

• Sodium hypochlorite (0.5-6%)- canal disinfectant & irrigating

solution in endodontics

• Alternatives to sodium hypochlorite:

1. Sterile saline or water

2. Chlorhexidine(0.2% to 2%)

3. Iodine potassium iodide (2% to 5%)

4. Hydrogen peroxide (3%)

5. Ethylenediamine tetraacetic acid (EDTA, 10% to 17%)

6. Citric acid (10%)

7. MTAD (tetracycline+acid+detergent)

Allergic reactions reported

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INTRACANAL

MEDICAMENTS,CEMENTS & FILLING

MATERIALS

• Formocresol, Formaldehyde, Eugenol, Camphorated phenols, Cresatin-

potential allergens

Alternative: Calcium hydroxide – not allergic

• ZnOE in RC sealers & in RC filling materials (IRM & super EBA) is a

potential allergen

• Formaldehyde or paraformaldehyde containing sealers (N2 paste &

Endometazone) especially when extruded beyond apex stimulate

allergic reaction

• Resin based sealers(AH26 & AHplus) have rare allergic potential

Alternative: Ca(OH) sealers(Sealapex) or GIC sealers(Ketac-Endo)

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• Allergic reaction to gutta percha is seen in patients allergic to

NRL

• GP allergy is seen usually when it has extruded periapically

• Potential allergen in GP may be: barium sulfate, zinc oxide,

waxes & colouring agents

• Newer non GP filling material: Resilon- suspecting some

ingredients same as that of GP

Alternative: MTA

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CONCLUSION

Patients of today cannot be compared with patients of

the past. They are aesthetically more demanding & have

access to latest information. Medically complex patients

are not exception.

Today, endodontists are better equipped with applicable

knowledge of systemic disease & can deliver high

standard of endodontic treatment & at the same time

minimize the potential problems related to general

health of the patients.

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BIBLIOGRAPHY

1. Ingle’s Endodontics – 6th Edition (Chapter 24: The Medically Complex Endodontic Patient)

2. “Endodontic Considerations In A Medically Compromised Patient: An Overview.” Atul Jain,praveenSamant,neeraj Kumar,sonal Sinha,kavita Verma; Asian Journal Of Oral Health & Allied Sciences 2013,volume 3, Issue 2

3. “Endodontic Management Of Patients With Systemic Complications”. Kalaisalvam Rajeswari, DeivanayagamKandaswamy, Soundarajan Karthiek; Journal Of Pharmacy & Bioallied Sciences 2016 Octobet,8(suppl1):S32-S35

4. Medical Problems In Dentistry – 6th Edition; CrispianScully

5. Dentistry For Medically Compromised Patients – 6th

Edition; James.W.Little

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Medically complex endodontic patients

Education

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