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Precautions towards Dental Patients on medications

Dr. Vini Mehta MDS 1st Year

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• Introduction• Classification• Precautions towards Dental Patients --1. Cardiovascular Disorders2. Respiratory Disorders3. Hematologic Disorders4. Endocrine Disorders5. Neurologic Disorders6. Kidney Diseases7. Infectious Diseases8. Certain Drugs • Conclusion• References

CONTENTS

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Introduction

• Each day, millions of patients undergo dental procedures, most commonly restorative, prosthetic, periodontal, endodontic and surgical procedures.

• Many classifications of medications used before, during, and after dental treatment are critical adjuncts in the delivery of dental care.

• Rapid progress in dental pharmacotherapeutics requires that clinicians constantly update knowledge of new drugs, drug interactions and useful therapeutic trends.

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Slide TitleProduct A• Feature 1• Feature 2• Feature 3

Product B• Feature 1• Feature 2• Feature 3

American Society of AnesthesiologistsPhysical Classifications - Translated for Dental Treatment

I normal, healthy; proceed with treatment

II minimal risk, may need medical consult before treatment dependant on condition

III treatment modifications are indicated, need medical consult before treatment

IV threat, delay all unnecessary treatment

V no dental treatment - not expected to survive without major medical treatment

VI Clinically dead

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Precautions towards Dental Patients includes• Cardiovascular Disorders• Respiratory Disorders• Hematologic Disorders• Endocrine Disorders• Neurologic Disorders• Kidney Diseases• Infectious Diseases• Certain Drugs

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Cardiovascular disorders

• Hypertension • Coronary Artery Disease• Myocardial Infarction• Angina Pectoris• Rheumatic heart Fever• Cardiac Arrhythmia

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Hypertension White Collar Hypertension

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Oral Medications Used For Treatment of Hypertension• Diuretics • Beta-Adrenergic Blockers • Alpha-Adrenergic Blockers• Central Acting Inhibitors • Non-Selective alpha & beta Adrenergic • Calcium Channel Blockers • Vasodilators • ACE Inhibitors

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ORAL MANIFESTATION OF HYPERTENSION

There are no recognized manifestations of hypertension but anti-hypertensive drugs can often cause side affects ,such as:

• Xerostomia• Gingival overgrowth• Salivary gland swelling or pain• Paresthesia• Taste alteration

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1. Asymptomatic BP <159/99 mm Hg, no history of target organ disease

• No modifications needed • Can safely be treated in dental setting

2. Asymptomatic BP 160-179/100-109 mm Hg, no history of target organ disease

• Assessment on an individual basis with regard to type of dental procedure

3. Presence of target organ disease or poorly controlled diabetes mellitus

• No elective dental care until BP is controlled

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Coronary Artery Disease

•STRESS, ANXIETY, EXERTION or PAIN can provoke angina

•Short, minimally stressful dental appointments. Late morning appointments

•Excessive dose of LA containing adrenaline to be avoided in patients taking beta blockers •More Common - periodontal disease in pts of CAD.

Dental Aspects :

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Myocardial Infarction

DENTAL ASPECTS :• Dental clinic should have advanced cardiac life support• Use of pulse oximeter to determine the level of

oxygenation• BP , pulse rate & rhythm should be recorded & any

abnormal findings should be addressed. • Premedication with antianxiety drugs and inhalation

nitrous oxide in anxious patients. • Elective procedures esp those requiring GA should be

avoided for atleast 4 wks aftr MI. Consult pt’s physician prior to dental therapy

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Angina Pectoris

Dental Aspects:• Preoprerative glyceryl trinitrate & oral sedation

advised sometimes. • Monitor pulse & B.P. • POST ANGIOPLASTY elective dental care

deffered for 6 months• Patients with BYPASS GRAFTS – anti biotic

cover against infective endocarditis • LA containing adrenaline is contraindicated

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• Prothrombin time or the international normalized ratio (INR) is calculated

-INR ranges from 2.0 – 3.5, procedure can be continued -If INR is < 3.5, anticoagulation therapy should be

discontinued before minor surgical procedures.

• DRUGS used in t/t of angina may cause oral adverse effects like :

-lichenoid reaction - gingival swelling - ulcers

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Rheumatic heart Fever

Dental Aspects :• Dental extractions and local anesthesia in consent

with physician. • The prophylactic use of antibiotics prior to a

dental procedure is now recommended ONLY for those patients with the highest risk of adverse outcome resulting from endocarditis.

• GA should be avoided if essential must be given in hospital.

Rheumatic heart

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Cardiac arrhythmia

ORAL MANIFESTATIONS :

• Procainamide can cause agranulocytosis,oral ulcerations.

• Quinidine-infrequent oral ulcerations• Disopyramide is anticholinergic agent capable

of producing xerostomia. • Verapamil, Enalapril can cause gingival

hyperplasia.

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Respiratory Disorders1) Dental Aspects of Asthma :

• Patients with asthma may be prone to an attack or episode brought on by the stress of dental treatment, or exposure to an allergen like latex.

• The patient must always be instructed to bring medication/inhaler to each appointment

Avoid : 1)General anesthesia: leads to hypoxia 2) Analgesics & narcotics: leads to respiratory

depressants

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Chronic Obstructive Pulmonary Disease (COPD)

• COPD may not be able to breathe easily in a supine position or after walking certain distances

• Due to prolonged steroid use to treat COPD, these patients may have candida infections (thrush)

• Patients with COPD may need supplemental oxygen. However, these patients should not be given high levels of oxygen. It is important that the COPD patient do not receive nitrous oxide and oxygen therapy during dental treatment due to their impaired ability to exhale all gases.

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Hematologic Disorders 1)Dental Aspects of Hemophilia: • Patients with hemophilia should have clotting

factors given before, during, and after treatment• Aspirin should never be prescribed coz ,it is a

natural blood thinner and increases bleeding.• Dental treatment, such as extractions, that may

cause bleeding can be risky. Close monitoring by the physician is necessary. Treatment should be confined to specific areas (e.g., one tooth or quadrant at a time)

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2) Dental Aspects of Leukemia

• Leukemia is a type of blood cancer, where there is an overgrowth of white blood cells. These white blood cells may displace red blood cells, used to transport oxygen in the blood.

• These patients may exhibit oral signs. These signs include excessive gingival irritation.

• Patients with leukemia are very prone to periodontal infections

• Chemotherapeutic agents used to treat the disease have many side effects, such as xerostomia

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Endocrine Disorders

Oral Manifestations of Diabetes Mellitus :• Periodontal disease– Microangiopathy altering antigenic challenge.– Increased Ca+ and glucose lead to plaque formation.– Increased collagen breakdown.

• Salivary glands– Xerostomia is common, but reason is unclear.– Tenderness, pain and burning sensation of tongue.

• Dental caries– Increase caries prevalence in adult with diabetes.

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Dental Aspects :• Scheduling of visits

– Morning appt. • Diet

– Ensure that the patient has eaten normally and taken medications • Blood glucose monitoring

– Measured before beginning. (<70 mg/dL)• Prophylactic antibiotics

– Established infection – Pre-operation contamination wound – Major surgery

• During treatment– The most complication of DM occur is hypoglycemia episode.– Hyperglycemia

• After treatment– Infection control

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Thyroid Patients

Hemostasis

Infection

Drug interactions

Thyrotoxic

crisis

Flioride

Stress and

anxiety

anti-thyroid drugs ( PTU ) has

anti-vitamin K

anti-thyroid drugs (Thioaminds)

epinephrine is contraindication

interfere thyroid gland function

Reduction protocol

Dental management

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Neurologic Disorders

• Epileptic patient is scheduled for treatment, the dental team should determine if the patient has taken his medication

• Patients report an aura before experiencing a seizure. Shining a bright light in the patient’s eyes should be avoided

• Patients who are taking oral anticonvulsant medications, such as Dilantin may experience gingival hyperplasia

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Kidney Diseases

• Patients with kidney disease have impaired renal function, which results in accumulation of fluid and waste products

• These patients may experience poor healing and excessive bleeding.

• Consult with the physician regarding side effects of the medications and if there is a need to prescribe drugs for patients whose primary method of excretion or metabolism is kidney.

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Infectious Diseases

Dental Aspects of Hepatitis :• Hepatitis is characterized as an inflammation of the

liver. Dentist should be vaccinated against hepatitis to reduce their risk of infection

• If a patient presents for treatment and reports a combination of fatigue, nausea, fever, dark urine and jaundice, they should be referred for medical treatment.

• When a patient reports a history of hepatitis, consult their physician before drugs are prescribed to note if metabolized by the liver, since liver function may be impaired.

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Management of the different drugs in patients with liver Disease

Contraindicated RecommendedAnesthetics Halothane

ThiopentoneIsofluraneNitrous OxideLocalanesthetics

Analgesics Acetylsalicylic acidIndomethacinIbuprofen

Nitrous Oxide

Antibiotics TetracyclineErythromycinestolateMetronidazole

Localanesthetics

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Drugs• Certain drugs, such as corticosteroids,

immunosuppressants, and antineoplastics, compromise healing and host defenses. When possible, dental procedures should not be done while these drugs are being given

• Many drugs cause dry mouth which is a significant health issue, esp in geriatric patients

• Some antineoplastics cause stomatitis

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•Drugs that interfere with clotting may need to be reduced or stopped before oral surgery. •Patients taking aspirin and clopidogrel should stop taking them 4 days before undergoing dental surgery

•Most patients taking an oral anticoagulant who have a stable INR < 4 do not need to stop the drug before dental surgery because the risk of significant bleeding is very small and the risk of thrombosis may be increased when oral anticoagulants are temporarily stopped.

Anticoagulant OR Antiplatelet Drugs

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Conclusion• The vast array of medications available in dentistry

have done much to improve the health of patients and the quality of dental care.

• A safe and responsible approach to prescribing and administering can minimize, but not eliminate, the occurrence of adverse medication-related events.

• All clinicians should strive to use medications that will combine safety and efficacy

• This will improve the oral health and overall health of each patient

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References

• Davidson’s Principle and Practice of Medicine – 21st Edition

• Burket’s Book of Oral Medicine – 11th Edition• Tripathi, K.D.-Essentials of pharmacology 6th ed• CLINICAL MEDICINE-MURRAY LANGMORE• Emergencies in dental office:Malamed

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