Medical conditions that can directly affect the provision of dental care and/or consequences of dental treatment

Medical conditions that can
directly affect the provision
of dental care and/or
consequences of dental
treatment
1

Outline
• Objectives
• Introduction
• Different medical conditions and
dental care
• Conclusion
• References
2

Objectives
–To highlight the medical conditions that
can directly affect the provision of
dental care and/or consequences of
dental treatment.
–To address the conditions under:
cardiovascular disorders, disorders of
the blood, respiratory disorders,
metabolic and endocrine disorders,
neurologic disorders, liver disease,
renal disease
3

Introduction
• There are many medical
conditions that can directly
affect the provision of dental
care and some where the
consequences of dental disease,
or even dental treatment, can be
life threatening. 4

• The definition of a “medically
compromised” patient is not
precise and in this context, it is
interpreted as the presence of
a medical factor which may
have implications for the
provision of dental care.
Paediatric Dentistry, 3rd Edition, by Richard
Welbury and Monty Duggal, 2005
5

• To achieve optimal oral health
for the medically compromised
patient, the dentist and
physician must work closely.
6

• Because many of these
medical conditions are so
complex, additional treatment
time may be needed to
provide these services.
7

• Each patient presents a unique
set of challenges to the dentist,
but achieving a successful
outcome can be a rewarding
experience.
8

Medical conditions
1. Cardiovascular disorders
2. Disorders of the blood
3. Respiratory disorders
4. Metabolic and endocrine disorders
5. Neurologic disorders
6. Liver disease
7. Renal disease
9

Cardiovascular diseases
• Main signs and symptoms
–Chest pain
–Dyspnea
–Cyanosis
–Palpitations
–Syncope
–Edema of ankles
–Cold pale extremities
–Clubbing fingers
–Easy fatigue 10

• Types
–Congenital
•Heart murmurs , ventricular septal
defects, atrial septal defects,
pulmonary stenosis, patent ductus
arteriosus, tetralogy of Fallot,
–Acquired
•Rheumatic fever, diseases of the
myocardium and pericardium,
secondary hypertension
11

- Dental management of cardiovascular
disorders
- Prevent dental disease- OHI, diet
counselling, fluoride therapy, fissure
sealants
–Any active dental disease must be
treated before cardiac surgery
12

–Treatment planning for
cardiovascular patients-
•Antibiotic prophylaxis given before
invasive operative procedures
•Ideally short appointments in
children for maximal cooperation
•Check patient’s platelet count and
prothrombin time before tooth
extraction
13

•No child with symptomatic cardiac
problems should have any routine
dental procedures until details of the
condition have been obtained and
the patient’s physician consulted.
14

•Endodontic treatment only for teeth
with high probability of success like:
–Permanent incisors
–Straight canals
–Closed apices
–Single visit
–Consider potential drug interactions
and remember some of these patients
will be on anticoagulants.
15

Blood disorders
– Bleeding disorders
• Hemophilia
• Von Willebrand’s disease
• Thrombocytopenia
– Blood dyscrasias
• RBC disorders
–Anemia -Iron deficiency anemia, Glucose 6-
Phosphate dehydrogenase deficiency, Sickle cell
anemia,Thalassemia
• WBC disorders
–leukemia
16

17

• Dental management of bleeding
disorders
–Communicate with hematologist
–Find out the diagnosis/aetiology
–NSAIDS alter platelet function and
should not be used.
18

–Acceptable analgesics
•For acute pain – Acetaminophen,
Propoxyphene hydrochloride
•For severe pain – Narcotics –
heroin, morphine, hydrocodone
19

–Care taken while placing intraoral
xrays
–Local anaesthesia infiltrations or
intraligamentous injections unlikely
to cause problems if given carefully
–Regional anaesthesia (mandibular
block) contraindicated as bleeding in
pterygomandibular region may cause
asphyxia
20

–Pulp therapy preferred to
extractions
–Dental extractions or surgery best
managed in hospital setting (use
resorbable sutures if needed)
–Antifibrinolytics – (e-aminocaproic
acid, tranexamic acid) Used as extra
to the factor concentrate
replacement to prevent or control
oral bleeding
21

• High speed vacuum and saliva ejectors used with
caution so that sublingual hematomas don’t occur
• Periphery wax used on impression tray
• Orthodontic treatment possible- be careful wires don’t
lacerate mucosa
• Platelet transfusions are short-lived and if used
prophylactically must be given immediately prior to or
during surgery.
22

Anemia
23

Oral symptoms of anemia
24
–Oral discomfort and/or ulceration
–Glossitis
–Angular cheilitis.

• Dental management of anemia
–Tendency to bleed after invasive
dental procedures
–Tests to be taken- Hb, Hematocrit,
WBC, Platelet cell count
25

26

• Dental management of leukemia
–Prevent dental caries as these children at high
risk because of difficulty in taking care of oral
health due to mucositis.
–Oral surveillance
–Topical fluoride therapy, toothbrushing
information
–Chlorhexidine mouthwash 0.12%
–Nystatin 500,000units ‘swish and swallow
–Diet control
–Relieve mucositis- Difflam mouthwash,
Quadragel, ice chips 27Paediatric Dentistry, 3rd Edition, by Richard

–Unless dental emergency, no
operative dental treatment carried
out until child in remission
28

• Once the leukemia is in remission, and after
consulting child’s physician, routine dental care can be
undertaken with following protocol:
1. Hematological information required to assess
bleeding risks
2. Prophylactic antibiotics incase of depressed
neutrophil count
3. Fungal infections treated with amphotericin B,
nystatin, or fluconazole and herpetic infections with
topical and/or systemic acyclovir
4. Regional block anaesthesia contraindicated
29

Respiratory disorders
- Clinical conditions
–Asthma
–Cystic fibrosis
30

• Dental management of asthma
–Dental treatment can cause emotional
stress -> attack
–Child may take puff of their inhaler
before starting dental treatment
–Use analgesics and sedatives with
caution; opioids and sedatives
decrease respiratory drive.
31

–Recently a study has been
published linking dental erosion
with asthma
•Could be due to gastro-
oesophageal reflux in asthmatics
•Or acidic long term medication
•Or to increased consumption of
erosive beverages due to ‘drying’
of oral mucosa by inhalers
•Paediatric Dentistry, 3rd Edition, by Richard Welbury
and Monty Duggal, 2005
•Dental erosion in asthma: a case-control study from
south east Queensland, Sivasithamparam K et al, Aust
Dent J, 2002, Dec;47(4):298-303 32

33

• Dental management of cystic fibrosis
–These children suffer from delayed dental
development, more commonly have
enamel opacities and are more prone to
calculus
–They need to have higher caloric intake
and may have frequent refined
carbohydrate snacks – important priority
group for dental health education and
care
34

–May also have cirrhosis of liver ->
clotting defects -> haemorrhaging
following surgical procedures
–May be prescribed tetracycline to
prevent chest infections -> intrinsic
dental staining
–General anaesthesia should be
avoided
35

Endocrine and metabolic
disorders
• Diabetes mellitus
• Adrenal insufficiency
• Other – thyroid disease, renal
disorders
36

37

• Dental management of diabetes
–Preventive care
–Uncontrolled ->
•Increased glucose concentrations in
saliva, decreased salivary flow ->
dental caries
•Periodontal problems and
susceptibility to infections (Candida
sp)
38

–Dental appointments arranged at
times when blood sugar levels well
controlled; morning immediately
after their insulin injection and a
normal breakfast
39

• General anaesthetics a problem due to
the pre-anaesthetic fasting, so
normally carried out on an in-patient
basis to enable insulin and
carbohydrate to be stabilized
intravenously
40

41

• Dental management of adrenal
insufficiency
–In children, the risks of taking
corticosteroids are greater than
in adults and should only be
used when specifically indicated,
in minimal dosage and for the
shortest time possible.
42

–if child has adrenal insufficiency or
on steroids, any infection or stress
may lead to adrenal crisis
–For routine restorative treatment
no additional steroids are
necessary, but if extractions or
other surgeries planned and/or the
patient is very apprehensive, then
the oral steroid dosage should be
increased.Paediatric Dentistry, 3rd Edition, by Richard
43

–General anaesthesia should be
carried out on an in patient basis
–Consult child’s physician before
prescribing steroids
–Anaesthesists must be aware of
such meds in order to avoid fall in
blood pressure during anaesthesia
or in the immediate post op period.
44

• Dental management of thyroid
disease
–Patient should present no
problems if the as long as they
are medically well controlled,
however contact with the
physician is important
45

Neurologic disorder
• Febrile convulsions
• Epilepsy: most common neurogenic
disorder faced by dentist
46

• Dental management of epilepsy
–Sugar free liquid anti-epileptic
medication
–The possibility of an attack
occurring in dental chair should
be considered
47

–Phenytoin -> gingival enlargement in
about ½ of patients
–A very high standard of oral hygiene
required to minimize the
development of gingival enlargement
–Gingival surgery should never be
contemplated unless oral hygiene is
good
48

–Trauma to anterior teeth usually
encountered
–Reimplantation of avulsed teeth usually
contraindicated in those with severe
learning difficulties
–If prostheses are required then they
should be well retained with clasps and
unlikely to break or be inhaled during
attacks
49

Liver disorders
• Acute liver failure
• Alagille syndrome
• Alpha-1 antitrypsin
deficiency (AATD)
• Autoimmune
hepatitis
• Beckwith-
Wiedemann
syndrome
• Bile acid synthesis
defect
• Biliary atresia
• Budd-Chiari
Syndrome
• Caroli’s disease
• Cirrhosis/chronic
liver failure
• Crigler-Najjar
syndrome
• Cystic fibrosis liver
disease
• Glycogen storage
disease (GSD)
• Hemochromatosis
• Hepatoblastoma
• Hypercholesterolem
ia
• Metabolic diseases
• Nonalcoholic fatty
liver disease
• Organic acidemias
• Primary
hyperoxaluria
• Primary sclerosing
cholangitis
• Progressive familial
intrahepatic
cholestasis
• Tyrosinemia
• Urea cycle defects
• Viral Hepatitis
• Wilson disease
50

51

• Dental management of liver disorders
–Preventive measures
–Strict cross-infection control
–Consult patient’s physician to establish a safe
and adequate treatment plan
–If invasive procedures to be done then prior
coagulation, antibiotic prophylaxis and
hemostasis tests required
–Be cautious when administering drugs
(consult the BNF/DPF) and with
administering local analgesia as liver disease
alters with drug metabolism
–Do not administer general anaesthesia
52

Renal disease
53
• Posterior urethral
valve obstruction
• Fetal hydronephrosis
• Polycystic kidney
disease
• Multicystic kidney
disease
• Renal tubular acidosis
• Wilms tumor
• Glomerulonephritis
• Nephrotic syndrome
• Urinary tract problems
• Hypertension
• Nephritis
• Kidney stones (mostly
in adults)
• UTI

• Signs and symptoms of renal disorders
–Fever
–Edema
–Dysuria
–Increased frequency of urination
–Urine incontinence
–Hematuria
–High blood pressure
54

• Dental management of renal disorders
–Prevent dental diseases- OHI and
education
–Strict cross-infection control
–Consult patient’s physician before
performing dental treatment
–Monitor BP pre-op and post-op
–Treat all infections aggressively and
consider prophylaxis
–Use additional hemostatic measures
55

56

–Be cautious with prescribing drugs
–Never subject these patients to out-
patient general anaesthesia
–Remember veins are precious
–Poor bone density -> frequent
denture adjustments
–Try to perform dental treatment just
after dialysis if possible
57

Conclusion
• Medical conditions have an effect on not only
general health but also oral health. As dental
practitioners it is our sole duty to know the
medical conditions and how to provide dental
care to patients who are suffering from these
medical conditions.
• Oral care is important in enhancing quality of
life, emphasis being put on preventive care.
58

References
• Oxford Handbook of Clinical Dentistry, by
Mitchell, chapter 11 ‘Medicine relevant to
dentistry’.
• Paediatric Dentistry, 3rd Edition, by
Richard Welbury and Monty Duggal, 2005
• Dental erosion in asthma: a case-control
study from south east Queensland,
Sivasithamparam K et al, Aust Dent J,
2002, Dec;47(4):298-303
59

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