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“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
2
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
11/8/2017
3
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
11/8/2017
4
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.
11/8/2017
5
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)
11/8/2017
6
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
11/8/2017
7
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
8
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.
11/8/2017
9
11/8/2017
10
Modified Dental Anxiety Scale
11/8/2017
11
11/8/2017
12
11/8/2017
13
• 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)
11/8/2017
14
ASA physical classification
ASA 1 -A normal healthy patient
Therapy modifications
None (stress reduction as indicated)
ASA 2- A patient with mild systemic disease
Therapy modifications
Possible stress reduction and other modifications as needed
ASA 3- A patient with a severe systemic disease that limits activity, but is not
incapacitating
Therapy modifications
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
Therapy modifications
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
Therapy modifications
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
Therapy modifications
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
11/8/2017
15
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
11/8/2017
16
11/8/2017
17
MD-RAM inf.1
11/8/2017
18
MD-RAM inf.2
MD-RAM inf.3
11/8/2017
19
CARDIO VASCULAR
DISEASES
11/8/2017
20
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
21
>
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
11/8/2017
22
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.
11/8/2017
23
• 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
24
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.
11/8/2017
25
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
26
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.
11/8/2017
27
HEART MURMURS & VALVULAR
DISEASES
GENERAL CONSIDERATIONS:
• 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)
11/8/2017
28
ENDODONTIC CONSIDERATIONS IN
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
11/8/2017
29
11/8/2017
30
ANTIBIOTIC PROPHYLAXIS FOR DENTAL PROCEDURES(Wilson et al)
11/8/2017
31
1 hour before procedure
1 hour before procedure
ANTIBIOTIC PROPHYLAXIS FOR DENTAL PROCEDURES(Wilson et al)
11/8/2017
32
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.
11/8/2017
33
CONGESTIVE HEART FAILURE
GENERAL CONSIDERATIONS:
• 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
11/8/2017
34
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
11/8/2017
35
11/8/2017
36
ARRHYTHMIAS & CARDIAC
PACEMAKERS
GENERAL CONSIDERATIONS:
• 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
11/8/2017
37
11/8/2017
38
ENDODONTIC CONSIDERATIONS IN
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.
11/8/2017
39
BLEEDING
DISORDERS
11/8/2017
40
ANTICOAGULANT THERAPY &
BLEEDING DISORDERS
GENERAL CONSIDERATIONS:
• 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
11/8/2017
41
11/8/2017
42
ENDODONTIC CONSIDERATIONS IN
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
43
• 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
44
• 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.
11/8/2017
45
METABOLIC
DISEASES
11/8/2017
46
DIABETES MELLITUS
GENERAL CONSIDERATIONS:
• 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
11/8/2017
47
ENDODONTIC CONSIDERATIONS
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
48
• 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
11/8/2017
49
NEUROLOGICAL
DISORDERS
11/8/2017
50
STROKE
GENERAL CONSIDERATIONS:
• 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
11/8/2017
51
ENDODONTIC CONSIDERATIONS IN
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
52
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
11/8/2017
53
ENDODONTIC CONSIDERATIONS IN
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
11/8/2017
54
RENAL
DISEASES
11/8/2017
55
RENAL DISEASE & DIALYSIS
GENERAL CONSIDERATIONS:
• 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
11/8/2017
56
ENDODONTIC CONSIDERATIONS
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)
11/8/2017
57
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
11/8/2017
58
RESPIRATORY
DISEASES
11/8/2017
59
ASTHMA
GENERAL CONSIDERATIONS:
• 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
11/8/2017
60
ENDODONTIC CONSIDERATIONS
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
11/8/2017
61
• 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)
11/8/2017
62
• 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
11/8/2017
63
• 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
11/8/2017
64
CHRONIC OBSTRUCTIVE
PULMONARY DISORDER (COPD)
GENERAL CONSIDERATIONS:
• Breathing problem due to constricted airway (chronic
bronchitis,emphysema)
• Cough,dyspnea,sputum,hemoptysis,wheezing or chest pain
11/8/2017
65
ENDODONTIC CONSIDERATIONS
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
11/8/2017
66
TUBERCULOSIS
• Infectious disease spread by bacilli containing airborne droplets
by coughing,sneezing or talking
• Oral manifestations: ulcers, fissures or swelling on dorsum of
tongue
11/8/2017
67
ENDODONTIC CONSIDERATIONS
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
11/8/2017
68
11/8/2017
69
IMMUNITY SYSTEM
DISORDERS11/8/2017
70
HUMAN IMMUNO VIRUS (HIV)
GENERAL CONSIDERATIONS:
• 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
71
ENDODONTIC CONSIDERATIONS IN
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:
11/8/2017
72
11/8/2017
73
11/8/2017
74
ADRENAL SUPPRESSION &
LONG TERM STEROID USE
GENERAL CONSIDERATIONS:
• 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
11/8/2017
75
ENDODONTIC CONSIDERATIONS
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
GENERAL CONSIDERATIONS:
• 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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ENDODONTIC CONSIDERATIONS
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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ENDODONTIC CONSIDERATIONS
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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ENDODONTIC CONSIDERATIONS IN
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
restorable tooth that would otherwise be extracted. Surgical endodontic
procedures avoided.11/8/2017
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ENDODONTIC CONSIDERATIONS IN
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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ENDODONTIC CONSIDERATIONS IN
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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ENDODONTIC CONSIDERATIONS IN
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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