MODIFICATION OF DENTAL TREATMENT FOR MEDICALLY COMPROMISED PATIENTS

CONDITION RISKS MANAGEMENT

Infective bacterial endocarditis

Congenital heart defects. Prosthetic heart valves. History of previous infective endocarditis. Cardiac transplantation recipients who develop cardiac valvulopathy. Bacteremia valvular dysfunction CVA.

Focus on prevention: Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for reducing the risk of IE resulting from a dental procedure. American Heart Association Minimize frequency, duration, severity of bacteremias by altering methods of dental tx. Pretreatment antimicrobial rinse: chlorhexidine. Antibiotic prophylaxis when bacteremia is anticipated: All dental procedures that involve manipulation of gingiva or perforation of oral mucosa. *Medical consultation may be beneficial, but dentist decides whether or not the procedure warrants antibiotic prophylaxis.

Hypertension Aggravated by emotional stress, physiologic demands, vasoconstrictors in dental anesthetics acute crises: stroke, myocardial infarction. Hemostasis compromised. Antihypertensive tx may orthostatic hypotension.

120/80: Any required dental tx. 120/80 but

angina. Unstable angina / MI within the past 30 days = major cardiac risk: elective care should be postponed. Medical consultation required within 1 year of MI & elective dental procedures deferred for 6 months. Minimally stressful dental procedures may be performed 6-12 months after MI if cardiologist approves. Persistent angina, elevated BP, other risk factors require medical consultation beyond 1 year post MI.

Cardiac arrhythmia Emotional stress/ epinephrine destabilization of treated or aggravation of untreated arrhythmias. Electronic devices may interfere with function of pacemakers. Anticoagulant therapy for atrial fibrillation increased bleeding tendency.

Minimize stress. Minimize or avoid epinephrine use if possible. Medical consultation advised for controlled arrhythmias and required for all patients with rapid/slow/ irregular pulse. Patients with atrial fibrillation who are taking warfarin: If INR is within the therapeutic range (2.0-3.5), dental treatment & minor oral surgery can be performed without stopping warfarin; more significant surgery or INR >3.5 require medical consult. Avoid use of electrosurgery / ultrasonic scalers in patients with pacemakers.

Congestive heart failure Stress of dental tx abrupt worsening of symptoms resulting in acute failure, fatal arrhythmia, CVA, or MI in symptomatic/ decompensated CHF. Complex drug regimen oral side effects. NSAIDS exacerbation of symptoms. Fully reclined position orthopnea, pulmonary edema.

Thorough medical hx to evaluate patient for history, signs, or symptoms of CHF. For patients with symptoms of untreated or uncontrolled CHF, defer elective dental care and refer to physician. For diagnosed and treated CHF: Medical consultation in severe cases, e.g. peripheral edema, dyspnea, angina. Minimize or avoid epinephrine use if possible. Avoid NSAIDS. Minimize stress and avoid fully reclined position.

Chronic obstructive pulmonary disease

Stress can respiratory compromise. Patients often have concurrent hypertension and ischemic heart disease.

Encourage tobacco cessation. Before initiating dental care, assess severity of the patients disease and the degree to which is has been controlled. Well controlled patients can be treated routinely. Patients displaying shortness of breath at

rest, a productive cough & upper respiratory infection: defer dental tx until medical evaluation is completed. Minimize stress. Semisupine or upright chair position for treatment to prevent orthopnea or feeling of respiratory discomfort. N2O sedation, narcotics and barbiturates contraindicated. Use local anesthetics normally. Medical consultation or treatment in a hospital setting for severely affected patients.

Asthma May be stimulated by emotional stress/ exposure to dust or a specific allergen. Drugs to control asthma may complicate therapeutics.

Identify severity of asthma and avoid known precipitating factors. Minimize stress. Consider N2O or oral sedation. Inhaler with bronchodilator should always be readily available. Recognize signs and symptoms of a severe/ worsening asthma attack & administer subcutaneous epinephrine injection if needed. Aspirin & NSAIDS are contraindicated. Patients with rare /mild attacks that do not require continuous medication can be treated routinely.

Bleeding disorders Even minor dental procedures uncontrollable hemorrhage. Many acquired bleeding disorders can present with few if any obvious clinic signs. Anticoagulant therapy typical in prevention/ management of MI, CVA, deep vein thrombosis. Prolonged healing and anemia from excessive bleeding. Decreased resistance to infection.

Confirm diagnosis and severity of disease. Medical consultation with laboratory evaluation required in all cases if a bleeding disorder is suspected. Patients who taking warfarin: Outpatient anticoagulant therapy may need to be altered for invasive/ surgical procedures & medical consult required with confirmation of INR. Patients with mild/ moderate hemophilia usually treated in the dental setting after obtaining medical consult and confirming INR. Patients with severe hemophilia usually treated in hospital. Aspirin and NSAIDs should be avoided.

Gastrointestinal diseases Drug regimens: additional analgesics/ antibiotics can severely aggravate peptic ulcer and gastritis symptoms and risk of GI bleeding.

Evaluate patient, determine health status, and confirm that adequate medical care was received. Medical consultation with complete blood counts if poorly controlled or if

medication profile increases patient risk for anemia, leukopenia or thrombocytopenia. Aspirin and NSAIDs should be avoided.

Hepatitis and liver cirrhosis All patients with a history of viral hepatitis must be managed as though they are potentially infectious. Abnormal bleeding is associated with hepatitis and significant liver damage. Administration of drugs with minor hepatotoxic effects can severity of hepatic damage.

Active hepatitis: No dental treatment other than urgent care. Refer the patient with acute hepatitis for medical dx and tx. Urgent care should be provided only in an isolated operatory with adherence to strict standard precautions. Drugs metabolized by the liver should be avoided or dosage as advised by the physician. If INR >3.5, the potential for severe postoperative bleeding exists: extensive surgical procedures should be postponed. Hx of hepatitis: Most carriers are unaware. Consult with physician and evaluation of hemostatic competence if surgery is necessary.

Diabetes mellitus Stress can alter metabolic demands and cause insulin/glucose imbalance. In extreme instances can diabetic coma (hyperglycemia) or insulin shock (hypoglycemia). Oral complications of poorly controlled diabetes mellitus: xerostomia, bacterial, viral, and fungal infections (e.g.candidiasis); poor wound healing; increased incidence and severity of caries; gingivitis and periodontal disease; periapical abscesses; and burning mouth symptoms.

Pt. should be referred for medical evaluation if suspected diabetes has not been diagnosed or is poorly controlled. Determine type of diabetes and presence of complications. All dental procedures can be performed without special precautions if diabetes is well-controlled in non-insulin-dependent or insulin controlled pt. Insulin controlled pt: Glucose source should be available and given if symptoms of insulin reaction occur. Morning appointments are usually best. Advise patient to take usual insulin dosage and normal meals on day of dental appointment. If extensive surgery is needed: consult with patients physician concerning dietary needs during postoperative period. Antibiotic prophylaxis can be considered for patients with brittle diabetes and those taking high doses of insulin who have chronic states of oral infection.

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

Medical consultation if poorly controlled or undiagnosed hyperthyroidism is suspected. Cautious use of epinephrine in untreated or poorly treated thyrotoxic patients. Well-controlled asymptomatic patients can be treated routinely. Avoid CNS depressants, sedatives, or narcotic analgesics in hypothyroidism.

Adrenal insufficiency Stress may increase adrenal demand beyond the functional reserve acute adrenal insufficiency (adrenal crisis). Patients with hyperadrenalism have an increased likelihood of hypertension and osteoporosis, increased risk for peptic ulcer disease, delayed healing and may have increased susceptibility to infection. Risk of medical complications increases when major surgical procedures are performed on patients having low adrenal reserve. Factors contributing to the risk of adrenal crisis during the perioperative period of oral surgery: type of surgical procedure, drugs administered, pts overall health, and extent of pain control.

Determine dose and duration of past or present corticosterioid tx. Medical consultation if adrenal suppression is suspected and dental tx is moderately or severely stressful. Pts taking systemic corticosteroids: For diagnostic and minimally invasive procedures, have patient take the usual daily dose. Majority with adrenal insufficiency may undergo routine dental tx without need for supplemental glucocorticoids. Schedule surgical procedures in the morning and reduce stress. For major invasive oral procedures: consult with physician to determine corticosteroid supplementation protocol. Blood pressure should be taken at baseline and monitored during dental appointments. Aspirin and NSAIDs should be avoided in long-term steroid users. Prophylactic antibiotic coverage for three days may be beneficial if bacterial infection is a significant possibility.

Pregnancy Stress and potentially toxic drugs/ radiation can adversely affect development of the fetus. Risk is greatest during 1st trimester. Dental treatment may aggravate gag reflex and symptoms of morning sickness during 1st trimester, and abdominal pressure during the 3rd trimester. Most common oral complication of

2nd trimester is safest period for necessary dental treatment: minimize radiographic exposure and drug use. Focus on controlling active disease. Elective dental treatment (e.g. full mouth radiographs, reconstruction, crown and bridge, and significant surgery) should be deferred until after delivery. Aspirin, NSAIDs, schedule pain

pregnancy is hyperplastic pregnancy gingivitis. Gestational diabetes mellitus is associated with increased risk for periodontal disease.

medications such as hydrocodone, and sedatives/hypnotics) are specifically contraindicated. Analgesic of choice during pregnancy is acetaminophen. Medical consult required if systemic medications or invasive procedures are needed for an infection or other severe dental problem. Enforce optimal oral hygiene and plaque control.

Chronic renal failure Compromised drug metabolism. Abnormal bleeding in patients on day of dialysis. Immunosuppressive medication regimens in renal transplant patients vulnerability to infection. Oral manifestations of chronic renal failure: xerostomia, change in pigmentation, petechiae and ecchymoses of oral mucosa, osteodystrophy (radiolucent jaw lesions), uremic stomatitis.

End stage renal disease: medical consultation suggested before dental care is provided. Avoid nephrotoxic drugs (acetaminophen in high doses, acyclovir, aspirin, NSAIDs). Avoid dental treatment if disease is poorly controlled or advanced. Optimal time for dental treatment in hemodialysis patients is on the day following dialysis. Prophylactic antibiotic coverage is generally beneficial. Screen for bleeding disorder before surgery (bleeding time, platelet count, hematocrit, hemoglobin)

Cerebrovascular accident (CVA, Stroke)

Patients with a history or clinical evidence of hypertension, CHF, diabetes, previous stroke or TIA, and advancing age are predisposed to Stroke. Anticoagulant medications may risk for abnormal bleeding.

Defer elective dental treatment for 6-12 months after a CVA or stroke. Medical consultation required if history of CVA. Pretreatment INR>3.5 requires consultation with physician to alter anticoagulant tx. Schedule short, stress-free, morning appts and N2O inhalation as needed. Monitor blood pressure and avoid use of epinephrine.

Epilepsy Stress of dental treatment may induce a seizure episode, usually in poorly-controlled epileptic individuals. Gingival hyperplasia associated with phenytoin and valproic acid. Phenytoin, carbamazepine, and valproic acid can cause bone marrow suppression, leukopenia, thrombocytopenia increased incidence of microbial infection, delayed healing, and postoperative bleeding.

Determine type and frequency of seizures, age at onset, use of medications, frequency of physician visits, degree of seizure control, date of last seizure, and any known precipitating factors. Medical consultation if seizures are poorly controlled. Well-controlled seizures pose no contraindication to routine dental tx. Reduce dosage of narcotics in patients taking CNS depressants.

Propoxyphene and erythromycin should not be administered to patients who are taking carbamazepine because of interference with metabolism. Gingival hyperplasia managed with good oral hygiene and occasionally surgical reduction.

HIV and AIDS Typical infections can progress more rapidly than usual and will not respond as favorably to usual tx protocols. Susceptibility to opportunistic infections such as candidiasis, pneumonia, HSV. Thrombocytopenia bleeding tendency.

AIDS: Any oral lesions found should be diagnosed, then managed by appropriate local/ systemic treatment or referred for diagnosis and treatment. Determine CD4+ lymphocyte count and viral load. CD4 count below 200/mm3 and/or low neutrophil counts: prophylactic antibiotic coverage during invasive dental procedures. Determine platelet counts if questionable hemostatic competency.

Prosthetic joint infection Increased risk of hematogenous infection during transient bacteremias. High risk: First 2 years after joint replacement. Immunocomromised/immunosuppressed. Insulin-dependent (type 1) diabetes. Previous prosthetic joint infections. Malnourishment. Hemophilia.

Consult with the orthopedic surgeon regarding risk for a specific patient. 2003 joint advisory statement by ADA and American Academy of Orthopedic Surgeons: Scientific evidence does not support the need for antibiotic prophylaxis for dental procedures in patients with pins, plates, screws and total joint replacement. Antibiotic prophylaxis should be considered for some high-risk patients who are at increased risk for infection and are undergoing dental procedures likely to cause significant bleeding. The dentist should make the final decision to provide antibiotic prophylaxis.

Radiotherapy and chemotherapy Nausea and vomiting Mucositis, ulceration, taste alteration Xerostomia, caries & pulpal necrosis Tooth sensitivity Fungal/bacterial/viral infections Thrombocytopenia Muscular dysfunction Osteoradionecrosis Bisphosphonate associated osteonecrosis

Symptomatic treatment of mucositis and xerostomia. Optimal oral hygiene and topical fluoride. Evaluate hemostatic function. Consult with oncologist regarding surgical procedures in patients with hx of radiation or chemotherapy with intravenous bisphosphonates. oncologist or radiation oncologist.