Periodontal treatment of medically compromised patients

One of the major challenges faced by dental specialists today is the assessment and management of patients with increasingly complex medical conditions. These medical conditions can alter both the course of the oral disease and the therapy provided. Therefore, it is important for a clinician to identify patient’s medical status to formulate a proper treatment plan. The life expectancy has increased dramatically in past decades. Geriatric patients are much more likely to have a complex medical history and the use of multiple medications. The common medical conditions encountered by the periodontists in daily practice include cardiac diseases, pulmonary diseases, hypertension, diabetes, bleeding disorders, renal disorders, pregnant patients and patients undergoing radiation therapy.

Importance of history taking

A thorough history taking is of prime importance when starting with the management of a patient. Many times patients cannot correlate their medical condition with their dental problems. So, it becomes important to ask the patient relevant questions to obtain an accurate medical history. A well-designed questionnaire can be designed to obtain a proper medical history of the patient. The analysis of information collected achieves three important objectives: enables the monitoring of medical conditions and the evaluation of underlying systemic conditions of which the patient may or may not be aware; provides a basis for determining whether dental treatment might affect the systemic health of the patient; provides an initial starting point for assessing the possible influence of the patient’s systemic health on the patient’s oral health and/or dental treatment 1, 2. In the following discussion, we shall discuss in detail the management of patients with various medical conditions.

Cardiovascular diseases

Cardiovascular diseases (CVD) is a broad term used to categorize any abnormal condition characterized by dysfunction of the heart and blood vessels. There are a number of cardiac conditions which may be present in a patient seeking periodontal treatment.

Hypertension:

Hypertension or high blood pressure is a common cardiovascular disease. It is a major risk factor for ischemic and hemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. The risk associated with increasing blood pressure is continuous, with each 2 mmHg rise in systolic blood pressure associated with a 7% increased risk of mortality from ischemic heart disease and a 10% increased risk of mortality from stroke. Hypertension can be classified as primary or secondary hypertension.

Primary or Essential Hypertension (without an organic cause):

Primary hypertension is the term used for medium to high blood pressure for a long time (chronic) without a known cause, which is a very common form of hypertension, comprising about 90–95% of all patients with hypertension 3.

Secondary Hypertension:

Hypertension with a well established organic cause which includes the following:

  • Renal (parenchyma or renal vascular): Chronic pyelonephritis, acute and chronic glomerulonephritis, polycystic kidney disease, renal vascular stenosis or renal infarction, other severe kidney diseases (arteriolar nephrosclerosis), renin-secreting tumors;
  • Endocrine: Oral contraceptives, adrenal hyperfunction (Cushing’s syndrome, primary aldosteronism, congenital or hereditary adrenogenital syndrome), pheochromocytoma, myxedema, acromegaly, thyroid and parathyroid hyperfunction;
  • Neurological: Psychogenic “diencephalic syndrome,” familiar dysautonomia (Riley-Day), polyneuritis (acute porphyria, lead poisoning), increased intracranial pressure;
  • Others: Coarctation of the aorta, increased intravascular volume (transfusion excessive polycythemia vera), polyarteritis, hypercalcemia, drugs (corticosteroids, cyclosporine), sleep apnea, pregnancy toxemia, acute intermittent porphyria.

The Seventh report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure gave a classification of blood pressure for adults aged ≥18 years 4 (Table 32.1). According to this classification, normal blood pressure is defined as levels <120/80 mm Hg. Systolic blood pressure of 120-139 mmHg or diastolic blood pressure 80-89 mmHg is classified as prehypertension. Hypertension is defined as systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg. Hypertension is divided into two stages.

  • Stage 1 includes patients with systolic blood pressure 140-159 mm Hg or diastolic blood pressure 90-99 mm Hg.
  • Stage 2 includes patients with systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg.

Table 32.1 Classification of blood pressure

Blood pressure classification
Systolic blood pressure (mmHg)
 
Diastolic blood pressure (mmHg)
Normal<120and<80
Prehypertension120-139or80-89
Stage 1 hypertension140-159or90-99
Stage 2 hypertension≥160or≥100

A more elaborate classification of blood pressure is provided by the European Society of Hypertension and the European Society of Cardiology 5 (Table 32.2).

Table 32.2 Classification of blood pressure for adults

Category
Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
Optimal<120<80
Normal120-12980-84
High normal130-13985-89
Grade 1 hypertension (mild)140-15990-99
Grade 2 hypertension (moderate)160-179100-109
Grade 3 hypertension (severe)≥180≥110
Isolated systolic hypertension≥140<90

The diagnosis of hypertension in adults is made when the average of two or more diastolic blood pressure measurements on at least two subsequent visits is ≥90 mm Hg, or when the average of multiple systolic blood pressure readings on two or more subsequent visits is ≥140 mm Hg.

Management of a hypertensive patient:

Once the patient is an established hypertensive, proper precautions should be taken to prevent any complication during periodontal treatment. Before starting any treatment, blood pressure has to be checked. Accurate measurement of blood pressure is important to avoid overdiagnosis or underdiagnosis, as well as overtreatment or undertreatment, of hypertension. The patient should be allowed to sit for 3-5 minutes before taking blood pressure measurements. At least two blood pressure measurements should be taken in the sitting position, spaced 1-2 minutes apart and additional measurements if the first two are quite different. The average of the readings is considered as the baseline. Unless the measurements are extremely high (i.e., systolic pressure >180 mm Hg or diastolic pressure >100 mm Hg), readings should be taken at a minimum of two appointments before referring the patient to a physician.

There is no change in the treatment plan if the systolic blood pressure is <140 mm Hg and diastolic blood pressure is <90 mm Hg. If systolic blood pressure is 140-159 mm Hg and diastolic blood pressure is 90-99 mm Hg, the patient is informed about the findings and is referred to the physician. If systolic blood pressure is 160-179 mm Hg and diastolic blood pressure is 100-109 mm Hg, only selective treatment is done, including routine examination, oral prophylaxis, and restorative procedures. Surgical procedures should be avoided. In the case of severe hypertension with systolic blood pressure ≥ 180 mm Hg and diastolic blood pressure ≥ 110 mm Hg, only emergency treatment is done to alleviate the pain and immediate referral to the physician is recommended.

If the patient is already on antihypertensive drugs, the local anesthetic (LA) agent may interact with these drugs. Interaction of LA with non-selective β-blockers may increase LA toxicity 6. Stress is another important factor which may complicate the dental treatment in hypertensive patients. Patients with cardiovascular diseases have a high risk of complications due to endogenous catecholamines (adrenaline and noradrenaline) released due to pain and stress. These may dramatically increase blood pressure and cardiac output. Various steps that may be taken to minimize stress are,

  • Shorter appointments
  • Good night’s sleep before the appointment
  • Avoiding caffeine before the appointment
  • Eating a regular meal before the appointment
  • Pre-anesthetic medications as needed
  • Make sure that daily dose of anti-hypertesive medication has been taken by the patient
  • Sudden changes in body position should be avoided, as they can cause orthostatic hypotension as a side effect of the blood pressure lowering drugs.

Pain during treatment may also result in the release of endogenous catecholamines. During treatment, pain should be minimized so that the release of endogenous catecholamines is reduced. It must be noted that epinephrine prolongs the action of LA due to its vasoconstriction effect, but LA with vasoconstrictor should be avoided or used in low doses in patients taking non-selective β-blockers or in patients with uncontrolled hypertension. The recommended dose of epinephrine in a patient with cardiac risk is 0.04 mg, which is equal to that containing about two cartridges of LA with 1 : 100000 epinephrine or 4 cartridges with 1 : 200000 epinephrine 7. It is better to measure the blood pressure after administering LA in patients with severe hypertension in case of emergency. Aspiration and slow administration and can prevent undesirable reactions. The contraindications for using LA with epinephrine are severe uncontrolled hypertension, refractory arrhythmias, myocardial infarction or stroke by age less than 6 months, unstable angina, coronary artery bypass graft under 3 months, congestive heart failure, and untreated hyperthyroidism 1.

Management of hypertensive crisis:

The term hypertensive crisis is defined as an elevation of the blood pressure to a degree which is potentially life-threatening and that requires immediate management. It is important to emphasize that the clinical distinction between hypertensive emergencies (crises) and hypertensive urgencies depends on the presence of acute target organ damage, rather than the absolute level of blood pressure. Hypertensive emergencies are those which involve end organ damage such as hypertensive encephalopathy, acute left ventricular failure or pulmonary edema, acute myocardial ischemia, eclampsia, acute renal failure, dissecting aortic aneurysm or symptomatic microangiopathic hemolytic anemia. In hypertensive urgencies, the increase in blood pressure (usually blood pressure greater than 180/110 mmHg) is not associated with any evidence of acute end-organ damage. In female patients during pregnancy, around 10% of them show hypertension and approximately 1-2% undergo a hypertensive crisis. In pregnancy, systolic blood pressure > 160 mm Hg or diastolic blood pressure >110 mm Hg is considered as hypertensive crisis 8.

In the recent past, the most popular agent for the treatment of hypertensive urgencies was short-acting nifedipine, given either sublingually or orally 9. Several severe side effects, however, have been reported with its use 10. These include loss of consciousness, hemiparesis, ECG changes, myocardial infarction and complete heart block 10-12. Other agents with a relatively fast onset of action which can be used for the management of hypertensive urgencies include……….

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Ischemic Heart Disease:

Angina pectoris:

Ischemic Heart Disease, also known as Coronary Artery Disease (CAD), is a condition that affects the supply of blood to the heart. The blood vessels are narrowed or blocked due to the deposition of cholesterol on their walls. This reduces the supply of oxygen and nutrients to the heart muscles, which is essential for proper functioning of the heart. This may eventually result in a portion of the heart being suddenly deprived of its blood supply leading to the death of that area of heart tissue, resulting in a heart attack.

An important indicator of CAD is angina pectoris, defined as a syndrome of substernal chest discomfort, with a characteristic quality and duration that is provoked by exertion or emotional stress, and is relieved by rest or the administration of nitroglycerin. In angina the myocardial oxygen demand exceeds the supply, resulting in temporary myocardial ischemia. Angina pectoris may be of two types: stable and unstable. In the case of stable angina, the patient has pain, lasting 5-15 minutes, which is relieved by administration of nitroglycerin. It usually has a trigger, such as physical exercise or exertion, anxiety, or emotional stress, cold temperatures, or heavy meals. In unstable angina, the patient has pain lasting longer than 15 minutes that may not be fully relieved by administration of nitroglycerin. Less common kind of angina includes variant angina, microvascular angina, and atypical angina.

Acute myocardial infarction (AMI):

Acute myocardial infarction results due to physical disruption of an atherosclerotic plaque with subsequent formation of an occluding thrombus, coronary occlusion causing a reduction in coronary blood flow. This results in ischemia of heart muscles which are supplied by the occluded artery. Myocardial necrosis caused by complete coronary artery occlusion begin to develop after 15-30 min of severe ischemia (no forward or collateral flow) and progresses from the subendocardium to the subepicardium in a time-dependent fashion. The condition is characterized by acute, sudden onset and intense pain, of an oppressive nature, located in the retrosternal or precordial region, and can irradiate to the arms, neck, back, jaw, palate or tongue. Other clinical features that may be seen are intense perspiration, nausea, vomiting, dyspnea and imminent death sensation, though it can also manifest as sudden loss of consciousness, mental confusion or weakness. Another form of AMI may be silent infarctions. Silent infarctions are characterized by an absence of pain, and are more common in elderly individuals, in women and in diabetic patients 14, 15.

AMI can be confirmed by different perspectives related to electrocardiographic (ECG), biochemical, and pathological characteristics. The present guidelines pertain to patients presenting with ischemic symptoms and persistent ST-segment elevation on the ECG. The acute myocardial infarction if not treated well in time results in congestive heart failure and death of the patient.

Congestive heart failure:

Congestive heart failure can be defined as the incapacity of the heart to function properly, pumping insufficient blood towards the tissues and leading to fluid accumulation within the lungs, liver, and peripheral tissues. The congestive heart failure is the end result of ischemic heart diseases or arterial hypertension. Heart failure may be acute or chronic in nature. Acute heart failure is triggered by cardiotoxic drugs or coronary occlusion episodes. The most common causes for this are severe and prolonged arterial hypertension, valve disease, ischemic heart disease and serious pericardial diseases. Chronic heart failure, in turn, is associated to the antecedents of arterial hypertension and ischemic heart disease. Other causes are dilated myocardiopathy, valve disease, alcohol-induced heart disease, cor pulmonale and hypertrophic and restrictive myocardiopathy 16.

Pathophysiology of ischemic heart disease:

Although, many theories exist regarding the development of atherosclerosis, but the response-to-injury hypothesis is currently the most popular, with the initial “injury” occurring at the level of vascular endothelium 17. According to this hypothesis, the initial endothelial damage is caused by hemodynamic forces. These forces are more common at the arterial branches and bifurcations where atherosclerotic plaques usually develop. Endothelial injury is followed by the adherence of platelets, release of platelet-derived growth factor, migration of monocytes into the intima, and migration and proliferation of smooth muscle cells from the media. These result in the production of an atherosclerotic plaque. Repeated episodes of injury result in progressive narrowing of the vascular lumen by a vicious cycle of flow disturbance, endothelial injury, and plaque growth 18.

Periodontal treatment of patients with ischemic heart disease:

 Patients with ischemic heart disease may be stable or unstable. In an unstable patient only elective dental treatment is indicated with medical consultation. Emergency dental care for the unstable patient should be conservative, principally consisting of the use of analgesics and antibiotics. In stable patients, dental treatment can be carried out without mandatory medical consultation. Nitroglycerine is given to patients to treat acute anginal attacks. They should be asked to bring the drug with them during their dental appointments. Use of vasoconstrictor use should be limited, taking care not to exceed 0.04 mg of adrenaline (2 carpules containing 1.8 ml of anesthetic with adrenaline 1: 100,000). The technique of administration of local anesthesia should be accurate, taking care not to inject the solution into a blood vessel. If more local anesthesia has to be administered, it should be provided without a vasoconstrictor 19. To reduce anxiety, premedication can be administered to lessen anxiety and stress (5-10 mg of diazepam the night before and 1-2 hours before treatment). Inhalatory sedation in the form of nitrous oxide / oxygen has also been recommended by some authors 20. To minimize stress during treatment, the same steps are taken as explained for the hypertensive patients. This reduces endogenous catecholamine secretion, thus preventing complications related to vasoconstriction. If the patient is taking anticoagulants, the international normalized ratio (INR) should be ………..

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During the treatment, if the patient develops chest pain administration of nitroglycerine (0.4-0.8 mg) is recommended (Figure 32.1). Nasal oxygen supply, 3 liters/minute should be immediately established. If the pain subsides and the patient improves, the treatment can be continued otherwise the procedure is postponed. If the pain does not subside within next five minutes, another sublingual tablet should be administered. But, if the pain does not subside even after 15 minutes of onset, myocardial infarction has to be suspected and the patient must be transferred to a hospital immediately.

Figure 32.1 Management of an ischemic heart episode during dental treatment

Management of an ischemic heart disease

Infective endocarditis (IE):

IE is an infection of the inner lining of the heart and the heart valves. The etiology of more than 85% of all IE cases is bacteria, most often staphylococci, streptococci, and enterococci 23. Other bacteria implicated for IE belong to HACEK group of microorganisms (Haemophilus parainfluenza, H. aphrophilus, H. paraphrophilus, H. influenzae, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae, and K. denitrificans). Fungi have also been isolated from the IE lesions. IE has been classified into acute and subacute types, according to the natural history of the disease. Recently, as the number of cases with valve replacement surgery is increasing, the number of endocarditis cases associated with the prosthetic valves has increased. Therefore, these diseases are also classified into “prosthetic valve endocarditis” and “native valve endocarditis”.

Pathogenesis of IE:

Normally, the cardiac valves are resistant to colonization and infection by circulating bacteria. But, if there is any mechanical disruption of the endothelium, it results in the exposure of underlying extracellular matrix proteins, production of tissue factor, and the deposition of fibrin and platelets as a normal healing process. Such nonbacterial thrombotic endocarditis (NBTE) facilitates bacterial adherence and infection. There are many reasons for the mechanical damage to the cardiac valves including, turbulent blood flow, electrodes or catheters, inflammation (as in rheumatic carditis), or degenerative changes in elderly individuals. The mechanical damage leads to an inflammatory response which results in the formation of micro-ulcers and micro-thrombi. The inflammation results in……..

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Antibiotic prophylaxis to prevent infective endocarditis:

The bloodstream is sterile under normal conditions. The introduction of bacteria into the bloodstream is necessary for an intracardiac infection to occur. Any dental treatment which involves bleeding may result in bacteremia. It must be noted that not only the surgical procedures but non-surgical procedures have also been reported to cause bacteriemia. These include the administration of local anesthesia 26, periodontal probing 27, dental prophylaxis 28, scaling and root planing 29, and even daily tooth brushing 30 and flossing 31.

To reduce the risk of IE following dental procedures, prophylactic measures have been developed. The principal preventive measure recommended is the use of prophylactic antibiotics before certain dental procedures in patients identified as at risk. The American Heart Association first recommended prophylaxis regimen which was issued in 1955 but changes have done and most current recommendations were issued in 2007 32. Table 32.3 describes the American Heart Association guidelines for the identification of patients who may require prophylaxis for infective endocarditis before dental procedures.

Table 32.3 American Heart Association guidelines for the identification of patients who may require prophylaxis for infective endocarditis before dental procedures

High risk
• Prosthetic cardiac valve
• Previous infective endocarditis
• Congenital heart disease (CHD), if 1 of the 3 conditions listed below is present:
1. Unrepaired cyanotic CHD, including palliative shunts and conduits
2. Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
3. Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization).
• Cardiac transplantation recipients who develop cardiac valvulopathy.

Dental procedures for which antibiotic prophylaxis is recommended:

According to the American Heart Association (2007), following dental procedures require antibiotic prophylaxis,

Manipulation of gingival, periodontal and periapical tissues; incision of mucosa including:

  • Surgery
  • Periodontal procedures
  • Endodontic instrumentation beyond the apex or apical surgery
  • Subgingival placement of antibiotic fibers or strips
  • Initial placement of orthodontic bands, but not brackets
  • Intraligamentary local anesthetic injections
  • Prophylactic cleaning of teeth or implants where bleeding is anticipated

Excluding: Local anesthetic placement (unless through the site of infection).

Regimens for infective endocarditis prophylaxis:

The American Heart Association (2007) has specified the antibiotic regimen for prophylaxis of infective endocarditis. The Table 32.4 describes the AHA regimens for infective endocarditis prophylaxis.

Table 32.4 American Heart Association regimens for infective endocarditis prophylaxis 32

Patient group
Antibiotic
Route
Adult Dose
Timing before procedure
Standard general prophylaxis for patients at riskAmoxicillinOral2 g1 hour
Unable to take oral medicationAmpicillinIV or IM2 gWithin 30 minutes
Allergic to penicillin/ amoxicillin/ampicillinClindamycinOral600 mg1 hour
Cephalexin or cefadroxilOral2 g1 hour
Azithromycin or clarithromycinOral500 mg1 hour
Allergic to penicillin/ amoxicillin/ampicillin and unable to take oral medicationsClindamycinIV600 mgWithin 30 minutes
CefazolinIV1 gmWithin 30 minutes

Periodontal treatment of an infective endocarditis patient:

As bacteremia is associated with the development of infective endocarditis, the first step during periodontal treatment is to define a susceptible patient. The guidelines provided by American Heart Association 32 describe high-risk patients who are susceptible to the development of infective endocarditis. A history of the medical illness can indicate the risk of development of IE, but if required patient’s physician should be consulted to know the exact status of the disease. The patient should be given oral hygiene instructions to reduce bacterial load in the oral cavity. The patient should be asked to avoid vigorous mouth rinsing or tooth brushing to minimize chances of bleeding and hence bacteriemia. Once the soft tissue inflammation is controlled, more aggressive oral hygiene may be initiated. The aggressive periodontitis cases have high levels of aggregatibacter actinomycetemcomitans. Slots et al. (1983) 33 have recommended tetracycline, 250 mg, four times daily for 14 days to eliminate or reduce their count. The recommended antibiotic prophylaxis is then carried out before periodontal treatment.

If the patient is taking oral penicillin for prevention of rheumatic fever, penicillin-resistant α-hemolytic streptococci may be found in the oral cavity. Therefore, the alternate regimen can be followed. If the patient is already taking oral penicillin for periodontal treatment, the IE prophylaxis regimen is changed. Following steps should be followed during periodontal treatment of an IE patient,

  • All the periodontal treatments, including periodontal probing, should be carried out under antibiotic prophylaxis.
  • Chlorhexidine mouth rinses are recommended before all periodontal treatments because they significantly reduce the presence of bacteria on mucosal surfaces 34.
  • The number of appointments should be reduced by clubbing different treatments according to patients need and tolerability 35. It reduces the chances of developing resistant bacteria. Minimum of one week (preferably 10-14 days) gap should be kept between the two appointments, but if it is less than one week, the alternate antibiotic regimen should be selected (Table 32.5). Using the same antibiotic between dental hygiene appointments that are scheduled within a 9-day period increases the risk of resistance and may reduce the efficacy of the drug.
  • It should be remembered that if the patient is taking antibiotic following periodontal treatment, the standard prophylactic dose is still needed before starting the next periodontal treatment during next appointment. Reason being, the regular antibiotic dosage is not adequate to prevent the development of IE. For example, if a patient has been taking amoxicillin 250 mg three times a day for 10 days after periodontal surgery and he/she is scheduled for next treatment after 7 days following surgery, he/she should be given full 2 gram dose of amoxicillin before starting the treatment or alternative drug regimen should be chosen such as azithromycin or clindamycin.
  • During the maintenance phase, the oral hygiene status of the patient should be re-evaluated with an emphasis on oral hygiene reinforcement.

Table 32.5 Antibiotic prophylaxis recommendations for adults at risk for IE who require multiple dental hygiene appointments within a 9-day period 32

Appointment
Antibiotic
FirstAmoxicillin 2gm
Second (2-4 days later)Macrolide (clarithromycin or azithromycin) 500 mg
Third (2-4 days later)Clindamycin 600 mg
Fourth (2-4 days later)Amoxicillin or cephalexin 2.0 g
Fifth (2-4 days later)Macrolide

Patients with cardiac pacemakers and cardioverter-defibrillators:

Different types of cardiovascular implantable electronic devices, chiefly implantable cardiac pacemakers and implantable cardioverter- defibrillators, are used to treat a variety of electrical cardiac defects, including bradyarrhythmia, ventricular tachycardia, and fibrillation; they are also used in patients with complete heart block 36, 37. Use of such devices has significantly reduced mortality rates among patients with a history of life-threatening ventricular arrhythmia, and they are becoming more commonplace in the general population. A cardiac pacemaker is a device that regulates heartbeat. It is a small device sealed in a metal case consisting of a pulse generator, which produces an electrical impulse that is sent directly to the cardiac muscles via plastic-coated wires, and a long-lasting battery 38. A pacemaker is usually implanted under the skin in the chest wall. The different types of implantable pacemakers are as follows:

  • Fixed Rate Pacemaker: This type of pacemakers is intended for patients with permanent heart blocks.
  • Demand Pacemaker: These pacemakers have gradually replaced the fixed rate pacemakers because they avoid the competition between the heart’s natural rhythm and the pacemaker rhythm.
  • R wave Triggered Pacemaker: This type of pacemaker is meant for patients who generally have heart block with occasional heart sinus rhythm.
  • Ventricular Inhibited or R-wave Blocked Pacemaker: This type of pacemaker is meant for patients who generally have sinus rhythm with occasional heart block.
  • Atrial Triggered Pacemaker: This is a type of pacemaker that detects the atrial depolarization and starts the pulse forming circuits after a delay so that the impulse to the ventricles is delivered after a suitable PR interval.
  • Dual Chamber Pacemaker: These devices are commonly capable of treating the majority of those patients who suffer from diseases of the sino-atrial node by providing atrial stimulation whenever needed.

Implantable cardioverter – defibrillators are similar to pacemakers, in that both devices are designed to monitor the heart rate continuously. When ventricular tachycardia or fibrillation is detected, the cardioverter–defibrillator delivers a precisely calibrated shock to stop the abnormal electrical activity and restore the normal heart rate 36.

Pacemakers and other implanted cardiac devices are sensitive to strong electromagnetic signals that may temporarily interfere with function. The initially designed pacemakers and other implanted cardiac devices were not……..

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Management of patients with pacemakers and cardioverter-defibrillators:

All the patients who have been implanted with pacemakers and cardioverter-defibrillators should be asked to bring the details about the device. The manufacturer of the device, model number, serial number, date of implantation and mode of operation of the device should be documented in the patient’s record. Based on the current evidence, it is recommended that use of magnetostrictive ultrasonic equipments should be avoided on or near the individuals with implantable cardiac pacemakers or cardioverter-defibrillators 38. Electrosurgical units also cause marked interference with the functioning of these devices. The piezoelectric ultrasonic scaler devices can be used safely in these patients 38, 40. Care should be taken not to place electrical cords over the client’s chest or operate the magnetostrictive handpiece within 6 inches of the implanted cardiac device. Other devices which are considered safe with pacemakers and cardioverter – defibrillators are dental handpieces; composite curing lights and sonic scalers. Dental radiographs can also be taken safely in the presence of these devices.

Cerebrovascular accident (CVA):

The cerebrovascular system provides an uninterrupted blood supply to the brain for its proper functioning. Any interruption or impairment in cerebral blood flow results in impaired cerebral function. In approximately 80 % of the patients, impaired cerebral blood flow is due to occlusion of the vascular supply to the brain. The remaining 20% of the patients have impaired blood flow due to hemorrhage in the brain. The interruption of blood flow to the brain may be transient, resulting in transient ischemic attack (TIA), or may be permanent, resulting in a cerebrovascular accident or “stroke”.

Dental treatment in patients with cerebrovascular accident (CVA):

The dental treatment of a stroke patient should be done, keeping the following points in mind,

  • First and foremost is the history of stroke. The history of the past strokes needs to be elicited to identify the date of stroke, seriousness, treatment, and disabilities. Blood pressure should be checked and should be under control during the entire treatment.
  • Only emergency dental treatment is allowed within six months after stroke because of the high risk of recurrence during this period. The treatment should be performed carefully with the consultation of the neurologist.
  • Shorter appointments should be kept with an emphasis on minimizing stress. A profound anesthesia should be achieved before starting the treatment. The minimum effective dose of the local anesthetic agent should be used and concentrations of epinephrine greater than 1:100,000 are contraindicated.
  • After 6 months of stroke, the routine dental treatment can be carried out. These patients are put on anti-coagulant therapy. So, procedures which involve bleeding, such as tooth extraction, pulpectomy, subgingival scaling, periodontal surgery should be done after stopping the anticoagulant Anticoagulant drugs like heparin should be stopped at least 6-12 hours before treatment. Six hours after bleeding, when blood clots are built up, heparin systemic treatment can be resumed 41. If any other anti-coagulant has been prescribed to the patient, it should be stopped and international normalized ratio (INR) should be evaluated before the treatment is initiated. As already stated, if it is upto 2.5, a minor surgical procedure can be done with local hemostasis 19, 22.
  • For very anxious patients light conscious sedation may be used.
  • In the case of persistent local hemorrhage, the operator should be ready with hemostatic medication and cautery. The blood pressure should be continuously monitored and oxygen supply unit should be kept ready.
  • Metronidazole and tetracycline should be avoided since they may affect blood clotting.
  • If the stroke patient has minor physical disabilities, the use of electric toothbrushes, oral irrigation and prophylaxis using chlorhexidine should be advised to the patient.
  • Patients with paralysis of oro-facial muscles have difficulty in cleaning teeth due to loss of sensitivity of tissues, flaccid muscles and asymmetrically positioned tongue. Also, dysphagia may present, causing accumulation of food residues on the teeth, tongue, and oral mucosa. In such cases, the patient must learn to keep the teeth and oral cavity clean or should accept others help to do so. 

Prosthetic joint replacement:

In patients with prosthetic joint replacements, the main concern is the requirement of antibiotic prophylaxis before invasive dental procedures. There is substantial soundly-based scientific literature confirming bacteremia after various dental treatments 42, 43. After dental procedures (which involve bleeding), bacteremia can be demonstrated in blood within one minute of the manipulation and is usually greatest five minutes following the procedure. General dental treatment such as local anesthetic injection, fillings, impressions and dentures do not cause significant bacteremia above that which occur in normal chewing or tooth brushing 44. High incidences of bacteremia are observed in following dental procedures,

  • Dental extractions,
  • Periodontal procedures, including surgery, subgingival placement of antibiotic fibers/strips, scaling and root planing, probing, recall maintenance,
  • Dental implant placement and replantation of avulsed teeth,
  • Endodontic (root canal) instrumentation or surgery, only beyond the apex,
  • Initial placement of orthodontic bands, but not brackets,
  • Intraligamentary and intraosseous local anesthetic injections, and
  • Prophylactic cleaning of teeth or implants, where bleeding is anticipated.

In certain treatments, there are low incidences of bacteremia and antibiotic prophylaxis should be given in selected circumstances that may create significant bleeding. These procedures include,

Restorative dentistry (operative and prosthodontic) with/without retraction cord

  • Local anesthetic injections (non-intraligamentary and non-intraosseous),
  • Intra-canal endodontic treatment; post-placement and buildup,
  • Placement of rubber dam,
  • Postoperative suture removal,
  • Placement of removable prosthodontic/orthodontic appliances,
  • Taking of oral impressions,
  • Fluoride treatments,
  • Taking of oral radiographs,
  • Orthodontic appliance adjustment, and
  • Restoration of carious (decayed) or missing teeth.

Antibiotic prophylaxis has been recommended in all the patients within 2 years of joint replacement 45. The immunosuppressed patients, such as patients with inflammatory arthropathies (rheumatoid arthritis, systemic lupus erythematosus) or drug/radiation-induced immunosuppression should be given antibiotic prophylaxis. Patients with co-morbidities such as previous prosthetic joint infections, malnourishment, hemophilia, HIV infection, insulin-dependent (Type I) diabetes or malignancy should be given antibiotic prophylaxis 46-52.

Suggested antibiotic prophylaxis regimens:

Table 32.6 describes the antibiotic prophylaxis regimens suggested for these patients 45.

Table 32.6 Suggested antibiotic prophylaxis regimens for prosthetic joint replacement patients*

Patient type
Drug
Dose
Patients not allergic to penicillinCephalexin, cephradine or amoxicillin 2 grams orally 1 hour prior to the dental procedure
Patients not allergic to penicillin and unable to take oral medicationsCefazolin or AmpicillinCefazolin 1 g or ampicillin 2 g intramuscularly or intravenously 1 hour prior to the dental procedure
Patients allergic to penicillinClindamycin 600 mg orally 1 hour prior to the dental procedure
Patients allergic to penicillin and unable to take oral medicationsClindamycin600 mg intravenously 1 hour prior to the dental procedure
* No second doses are recommended for any of these dosing regimens.
 

Endocrinal conditions

Diabetes mellitus:

Diabetes mellitus is a metabolic disorder characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism, resulting from the defects in insulin secretion, insulin action, or both 53. Insulin is a hormone which is produced by the β-cells of the pancreas which controls the blood glucose levels. Diabetes is associated with a range of serious complications which result in reduced quality of life and premature mortality. It is associated with microvascular and macrovascular complications that can cause damage to multiple organ systems in the body. The classical symptoms of marked hyperglycemia include polyuria, polydipsia, weight loss, sometimes with polyphagia, and blurred vision. Long-term complications of diabetes include retinopathy with potential loss of vision; nephropathy leading to renal failure; peripheral neuropathy with risk of foot ulcers, amputations, and Charcot’s joints; and autonomic neuropathy causing gastrointestinal, genitourinary, and cardiovascular symptoms. The uncontrolled diabetic patients usually require periodontal treatment, so a thorough understanding of the disease is essential for a dental health care provider.

Types of diabetes:

Based upon the etiology, diabetes can be classified into the following types,

  1. Type 1 diabetes:

Caused due to β-cell destruction, usually leading to absolute insulin deficiency

  1. Immune-mediated
  2. Idiopathic
  3. Type 2 diabetes:

May range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance.

III. Other specific types:

  1. Genetic defects of β -cell function
  2. Genetic defects in insulin action
  3. Diseases of the exocrine pancreas
  4. Endocrinopathies
  5. Drug or chemical induced
  6. Infections
  7. Uncommon forms of immune-mediated diabetes
  8. Other genetic syndromes sometimes associated with diabetes
  9. Gestational diabetes mellitus

In the present discussion, we shall discuss in detail the most common type of diabetes mellitus i.e. Type 2 diabetes mellitus.

Type 2 diabetes mellitus:

This form of diabetes accounts for 90-95% of diabetic patients. Previously, it was known as non-insulin-dependent diabetes or adult onset diabetes. This disease is caused due to insulin resistance in the liver and skeletal muscle, increased glucose production in the liver, over production of free fatty acids by fat cells and relative insulin deficiency. The insulin secretion decreases with gradual β-cell failure. Other contributing factors for this disease include obesity, age (onset of puberty is associated with increased insulin resistance), lack of physical activity, genetic predisposition, racial/ethnic background (African-American, Native American, Hispanic and Asian/Pacific Islander) and conditions associated with insulin resistance, (e.g., polycystic ovary syndrome).

This form of diabetes frequently goes undiagnosed for many years because the hyperglycemia develops gradually and at earlier stages is often not severe enough for the patient to notice any of the classic symptoms of diabetes. Many times dentists are the first person to suspect the presence of this condition in a patient as uncontrolled diabetic patients usually have gingival inflammation and periodontal breakdown.

Screening of diabetes:

Traditionally, the diagnosis of diabetes has been done by identifying plasma glucose levels. The current diagnostic criteria uses glycated hemoglobin (HbA1c) levels, fasting plasma glucose levels, plasma glucose levels during an oral glucose tolerance test (OGTT) or the random plasma glucose levels to diagnose diabetes. The fasting or random plasma glucose levels confirm the glucose level at a particular point of time when the blood is drawn, but do not give any information about the past glucose levels. The HbA1c reflects the average plasma glucose over the previous eight to 12 weeks 54 because the glucose gets bound to the Hb molecules. HbA1c is formed as a result of the addition of a stable glucose molecule to the N-terminal group of an HbA0 molecule via a nonenzymatic glycation process 55. It is considered a reliable indicator of the glycemic status of previous 3 months 56. Table 32.7 describes the recent criteria suggested for diagnosing diabetes mellitus 57.

Table 32.7 Criteria for the diagnosis of diabetes

Criteria for the diagnosis of diabetes
HbA1c ≥ 6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.*
OR
Fasting plasma glucose (FPG) ≥ 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*
OR
2-h plasma glucose ≥ 200 mg/dl (11.1 mmol/l) during an oral glucose tolerance test (OGTT). The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.*
OR
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dl (11.1 mmol/l).
*In the absence of unequivocal hyperglycemia, criteria 1-3 should be confirmed by repeat testing.

Treatment of diabetes:

Essential components of the treatment for diabetes include diabetes self-management education and support, lifestyle interventions and pharmacological management. There are a number of anti-diabetic agents available these days (Table 32.8, 32.9). There are:

  1. α-glucosidase inhibitors (AGIs)
  • Acarbose
  1. Biguanides
  • Metformin hydrochloride
  1. Dipeptidyl peptidase-4 (DPP-4) Inhibitors
  • Sitagliptin
  • Vildagliptin
  1. Insulin Secretagogues
  • Sulphonylureas
  • Meglitinides
  1. Thiazolidinediones (TZDs)
  • Glitazones
  1. Incretin mimetics
  • Exenatide
  • liraglutide
  1. Insulin

Table 32.8  Non-insulin antidiabetic agents their advantages and disadvantages

Drug class
Route of administration
Advantages
Disadvantages
Sulphonylureas
(Tolbutamide, Tolazamide, Chlorpropamide, Glimepiride, Glyburide, Glipizide
OralAvailable as generic (low cost)Can cause weight gain
Biguanides
(Metformin)
OralEffectively reduces blood glucose, low cost and does not cause weight gainGastrointestinal complaints, contraindicated in patients above 80 yrs of age and those with elevated serum creatinine levels
α-glucosidase inhibitors (AGIs)
(Acarbose)
OralDoes not promote weight gain, safe in patients with renal failureGastrointestinal disturbance, flatulence, diarrhea and comparatively high cost
Thiazolidinediones (TZDs)
(Glitazones)
OralMay preserve β-cells from ongoing destructionCauses fluid retention, stimulates the accumulation of adipose tissue
Meglitinides
(Repaglinide,
Nateglinide)
OralRapid disappearance time results in low risk of hypoglycemia as compared to sulphonylureas Much shorter duration of action as compared to Sulphonylureas thus should be taken before meals, comparatively high cost
Dipeptidyl peptidase-4 (DPP-4) Inhibitors
(Sitagliptin,
Vildagliptin)
OralNo prominent side effect, low risk of hypoglycemiaHigh cost
Incretin mimetics
(Exenatide,
Liraglutide)
OralSuppress glucagon secretion, weight loss, slow gastric emptying, reducing the rate of glucose in the circulation following a meal.High cost

Table 32.9 Insulins used as anti-diabetic agents

Insulins used as anti-diabetic agents
Rapid-acting insulins• Regular insulin (Humulin R, Novolin R)
• Insulin lispro (Humalog)
• Insulin aspart (Novolog)
• Insulin glulisine (Apidra)
• Prompt insulin zinc (Semilente, Slightly slower acting)
Intermediate-acting insulins• Isophane insulin, neutral protamine Hagedorn (NPH) (Humulin N, Novolin N)
• Insulin zinc (Lente)
Long-acting insulins• Extended insulin zinc insulin (Ultralente)
• Insulin glargine (Lantus)
• Insulin detemir (Levemir)

Periodontal treatment of diabetic patients:

The first step in the treatment of a diabetic patient is asking about the medical history of the patient and assessment of glycemic control of the patient at the initial appointment. Patients with well-controlled diabetes can be treated similarly as the non-diabetic individuals. If the patient is an uncontrolled diabetic the dental treatment is delayed if possible until good metabolic control is achieved.

The patient should be asked about the recent blood glucose levels and frequency of hypoglycemic episodes. The dosage, frequency of intake and time of administration of the anti-diabetic drugs should be noted. The drug interactions with various anti-diabetic drugs may alter the blood glucose levels. For example, the hypoglycemic control of sulfonylureas may be altered by drugs that are highly protein-bound, such as salicylates, dicumarol, β-adrenergic blockers, monoamine oxidase inhibitors, sulfonamides and angiotensin converting enzyme inhibitors. On the other hand epinephrine, corticosteroids, thiazides, oral contraceptives, phenytoin, thyroid products and calcium channel-blocking drugs have hyperglycemic effects. If the patient is scheduled for any surgical procedure, the insulin or the anti-diabetic drug dosage may be adjusted with the consultation of the physician.

Scheduling the visits of the patient:

It is important to note that most of the complications during the treatment of a diabetic patient are due to hypoglycemia and not hyperglycemia. If the patient has a complication due to hyperglycemia, which is not confirmed, the initial treatment is same as that of hypoglycemia. Reason being, hyperglycemia does not cause any life threatening complication, but hypoglycemia can result in a life-threatening situation. Keeping all these factors in mind the visits of the patient are scheduled.

In general, morning appointments are suitable for a diabetic patient because the endogenous corticosteroid levels are generally high at this time which increases the blood glucose level. If the patient is taking insulin, the visits should be arranged in such a way that the treatment time does not coincide with peak activity of insulin activity.

Diet:

The patient should take normal diet and medications before the appointment. If the patient skips the breakfast owing to the dental appointment, but still takes anti-diabetic medications, the risk of hypoglycemia increases. If procedures like conscious sedation are planned, the patient is asked to alter the diet. The dosage of medications may also be altered in consultation with the physician.

Estimation of blood glucose level before the procedure:

Depending on the diabetic history of the patient, dentist may require the blood glucose level estimation prior to the initiation of treatment. Various commercial blood glucose monitors are available in the market, which provide accurate levels of blood glucose. If the blood glucose level of the patient is <70 mg/dl, an oral carbohydrate should be given to minimize the risk of hypoglycemia. If blood glucose is >200 mg/ dl, an intravenous infusion of 10% dextrose in half- normal saline is initiated, and rapid- acting insulin is administered subcutaneously. The blood glucose levels are checked and if found between 100 and 200 mg/dl, the invasive dental procedure can be performed safely.

Table 32.10 Symptoms and signs of hypoglycemia

Symptoms
Signs
◦ Anxiety
◦ Shakiness
◦ Increased sweating
◦ Hunger
◦ Tachycardia
◦ Tremors
◦ Altered consciousness (lethargy and obtundation or personality change)
◦ Blood glucose level: < 60 mg/dl

Table 32.11 Treatment of hypoglycemia

Conscious patient
Unconscious patient
Administer 15 gm of simple carbohydrates

Repeat finger-stick glucose test after 15 minutes:
• Blood glucose level > 60 mg/dl: patient should be asked to eat or drink (for example, a sugar-sweetened beverage)
• Blood glucose level < 60 mg/dl: repeat treatment of 15 gm of simple carbohydrates and check blood glucose after 15 minutes. Continue until achieving a blood glucose level > 60 mg/ dl
• Ask the patient to notify his/ her physician
With intravenous access:
• Administer 25-30 ml of 50% dextrose immediately
• Notify the patient’s physician
Without intravenous access:
• Apply glucose gel inside the mouth in a semi obtunded patient or treat with 1 mg of glucagon intramuscularly or subcutaneously
• Repeat the blood glucose test after 15 minutes
• Establish intravenous access and notify the patient’s physician

Precautions during the treatment of diabetic patient:

As already stated, most of the complications during the treatment of a diabetic patient are due to hypoglycemia, the peak activity of the insulin or other anti-diabetic drugs should be determined to avoid the risk of hypoglycemia. The initial signs of hypoglycemia include decreased spontaneity, mood change, hunger, and weakness (Table 32.10). As the condition becomes more severe, the patient may have………

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Complications due to hyperglycemia are uncommon during dental treatment. The ketoacidosis or hyperosmolar nonketotic states in Type I and Type II diabetes, respectively usually have prolonged onset. Therefore, risks associated with the hyperglycemic state are much lower than the hypoglycemic state. As already stated, the clinical presentation of hyperglycemias is very similar to hypoglycemia. If in doubt, it should be treated as a hypoglycemia.

Post-treatment precautions:

One of the major problems associated with uncontrolled diabetes mellitus is delayed wound healing. Tissues are more prone to infections during the hyperglycemic state. Therefore, the antibiotic cover is necessary for these patients to prevent infections. If it is anticipated that the patient’s diet may be affected by treatment, the dosage of the antidiabetic drugs or insulin should be readjusted in consultation with the patient’s physician.  As already stated, salicylates may alter the hypoglycemic control of sulfonylureas and increase insulin secretion and sensitivity resulting in hypoglycemia. Therefore, aspirin-containing compounds should be avoided for post-operative pain control 59.

Thyroid dysfunctions

Thyroid is a small butterfly-shaped gland that lies just under the skin below Adam’s apple in the neck. It secretes hormones that help to regulate the body’s metabolism. There are two main thyroid hormones: T3 (triiodothyronine) and T4 (thyroxine.) T3 is the more active form of the hormone, and T4 is converted into T3 by the body as needed. Most of T3 and T4 are bound to proteins in the bloodstream. The hyper and hypothyroidism are two common dysfunctions of the thyroid gland. An estimated 15% of the general population has abnormalities of thyroid anatomy on physical examination, and an unknown percentage of these do not complete a diagnostic evaluation 60. The oral cavity is adversely affected in these abnormalities of the thyroid.

Thyroid function tests (TFTs) are used to evaluate thyroid status. The thyroid function tests include,

  • Thyroid-stimulating hormone (TSH) test
  • T4 tests
  • T3 test
  • Thyroid-stimulating immunoglobulin (TSI) test
  • Antithyroid antibody test also called the thyroid peroxidase antibody (TPOab) test

Thyroid-stimulating hormone (TSH) test:

Thyroid-stimulating hormone (TSH), or thyrotropin, is produced by the pituitary gland in response to thyrotropin-releasing hormone and stimulates production and secretion of thyroid hormones. Measurement of the TSH serum concentration is the initial test of choice for evaluating thyroid function. The normal range of TSH is between 0.7 milli-International Units per millilitre and 5.3 mIU/mL for adults. The TSH levels are elevated in primary hypothyroidism, decreased in secondary hypothyroidism and elevated in subclinical hypothyroidism. Whereas, low or undetectable TSH levels generally suggest hyperthyroidism. Normal TSH levels in the presence of abnormal T3 or T4 concentrations indicate a non-thyroid pathology. Because TSH is produced when thyroid hormone levels are low in the blood, the increased TSH concentration in hypothyroidism is due to the result of the body’s attempt to produce more thyroid hormone. In hyperthyroidism, because the T3 or T4 levels are high in the blood, TSH levels are low.

T4 Tests:

 The thyroid primarily secretes T4 and only a small amount of T3.  It is found in blood in bound or free forms. The protein bound form is kept in the body as a reserve and is utilized when needed. The free form is the active form of the hormone. High levels of total T4 (bound and free T4) or high level of free T4 suggests hyperthyroidism, and a low level of total T4 or free T4 suggests hypothyroidism.

T3 Test:

If the T4 levels are normal and still it is suspected that the patient may have hyperthyroidism, T3 levels can be tested. The T3 test is not useful in diagnosing hypothyroidism because levels are not reduced until the hypothyroidism is severe.

Thyroid-stimulating immunoglobulin (TSI) test:

Thyroid-stimulating immunoglobulin is an autoantibody present in Graves’ disease. These antibodies stimulate the thyroid hormone in the same way as that by TSH. It causes the excessive secretion of T3 and T4. TSI test detects TSI circulating in the blood. It is done in patients with Grave’s disease and pregnancy.

Antithyroid antibody test:

In Hashimoto’s disease, anti-thyroid antibodies are present in the blood. Two types of antibodies may be present, one which attack the thyroglobulin or another one which attack an enzyme in thyroid cells, called thyroperoxidase.

In association with these basic tests, several other investigations are available to diagnose the thyroid abnormalities. These include an ultrasound of the thyroid, computerized tomography (CT) scan, or nuclear medicine tests.

Clinical features of hyper and hypothyroidism:

Various clinical features associated with hyperthyroidism include the following,

  • Nervousness and irritability
  • Palpitations and tachycardia
  • Heat intolerance or increased sweating
  • Tremor
  • Weight loss or gain
  • Alterations in appetite
  • Frequent bowel movements or diarrhea
  • Dependent lower-extremity edema
  • Sudden paralysis
  • Exertional intolerance and dyspnea
  • Menstrual disturbance (decreased flow)
  • Impaired fertility
  • Mental disturbances
  • Sleep disturbances (including insomnia)
  • Changes in vision, photophobia, eye irritation, diplopia, or exophthalmos

Various clinical features associated with hypothyroidism are,

  • Fatigue
  • Weight gain from fluid retention
  • Dry skin and cold intolerance
  • Yellow skin
  • Coarseness or loss of hair
  • Hoarseness
  • Goiter
  • Reflex delay, relaxation phase
  • Ataxia
  • Constipation
  • Memory and mental impairment
  • Decreased concentration
  • Depression
  • Irregular or heavy menses and infertility
  • Myalgias
  • Hyperlipidemia
  • Bradycardia and hypothermia
  • Myxedema fluid infiltration of tissues

Oral manifestation of hyper and hypothyroidism:

Hyperthyroidism:

Various oral manifestations of hyperthyroidism include, increased susceptibility to caries, periodontal disease, enlargement of extra-glandular thyroid tissue (mainly in the lateral posterior tongue), maxillary or mandibular osteoporosis, accelerated dental eruption 61 and burning mouth syndrome. In Grave’s disease, on extra-oral examination, the enlargement of the thyroid gland can be seen when the patient is in a supine position in the dental chair.

Hypothyroidism:

In children, hypothyroidism is characterized by the presence of thick lips (due to increased accumulation of subcutaneous mucopolysaccharides), large protruding tongue (macroglossia), malocclusion and delayed eruption of teeth. Hypothyroidism also results in altered tooth morphology and delayed wound healing 62.

Management of thyroid dysfunctions:

Treatment of hypothyroidism:

Thyroxine (or levothyroxine) is the current standard thyroid hormone replacement therapy for hypothyroidism. The goal of treatment of primary hypothyroidism is to reverse the symptoms of hypothyroidism by normalizing the blood TSH level.

Treatment of hyperthyroidism:

The treatment of hyperthyroidism includes administration of drugs like β-blockers, antithyroid drugs, radioiodine and surgical treatment of thyroid gland.

Periodontal treatment of patients with thyroid dysfunction:

The first step in the periodontal treatment of a patient with thyroid dysfunction is obtaining correct information about the kind of thyroid dysfunction and medications which the patient is taking. The physician can be consulted to know the present status of the thyroid function.  The thyroid gland should be protected by a thyroid collar while taking patient X-rays. The thyroid is extremely sensitive to radiation, and excessive radiation exposure is a known risk factor for various thyroid conditions.

Periodontal treatment of patients with hypothyroidism:

Hypothyroidism results in increased subcutaneous mucopolysaccharides accumulation due to decrease in their degradation. It may decrease the ability of small blood vessels to constrict when cut and may result in increased bleeding from infiltrated tissues, including mucosa and skin. Local measures to control bleed are required for proper hemostasis 63. In hypothyroidism patients, the wound healing is delayed due to decreased metabolic activity in fibroblasts. The delayed wound healing is more susceptible to infection. So, the antibiotic cover is given to prevent any kind of infection. Hypothyroidism is associated with increased risk of susceptibility to cardiovascular diseases from arteriosclerosis and elevated LDL. If the patient has atrial fibrillation then he or she might require antibiotic prophylaxis before invasive procedures, depending on underlying cause of atrial fibrillation 64.

An antiseptic that includes iodine (such as Povidone), can increase the risk of thyroiditis or hypothyroidism in these patients, so should be avoided. Along with this many drug interactions should be considered in patients taking thyroxine. The metabolism of thyroxine is increased with phenytoin, rifampicin, and carbamazepine. With thyroxine, an increased effect of warfarin sodium is observed.  Because of its gluconeogenic effects, the dosage of oral hypoglycemic agents should be increased.

Central Nervous System (CNS) depressants, sedatives, or narcotic analgesics may cause an exaggerated response in hypothyroid patients. In all patients with severe hypothyroidism, these drugs must be avoided. To avoid any myxedematous complication, patients with severe hypothyroidism should get the medical treatment before dental treatment. If a myxedematous complication occurs during dental treatment, medical assistance should be called.  While waiting for this assistance, 100-300 mg of hydrocortisone can be injected, the patient should be covered to conserve heat, cardiopulmonary resuscitation (CPR) can be applied as indicated.  The patient is given parental levothyroxine and intravenous hypertonic saline and glucose as needed under medical supervision.

Periodontal treatment of patients with hyperthyroidism:

Patients with hyperthyroidism show increased heart rate and blood pressure due to the effects of thyroid hormone on sympathetic nervous system activity. The blood pressure should be monitored before starting any surgical treatment and longer duration of local pressure is required to stop bleeding. Local hemostatic agents may also be used to control bleeding. Propylthiouracil (PTU) is an anti-thyroid drug which has anti-vitamin K activity and can cause hypoprothrombinemia and bleeding. So, patients taking PTU must be carefully evaluated before surgery 65. Acetylsalicylic acid (ASA) interferes with the protein binding of T4 and T3, thereby increasing their free form. It may worsen the symptoms of thyrotoxicosis 66. Therefore, combination analgesics containing acetylsalicylic acid (ASA) are contraindicated in patient with hyperthyroidism. Other nonsteroidal anti-inflammatory drugs (NSAIDs) also have this effect, so should be used with caution.

The use of local anesthesia with epinephrine warrants special consideration while treating the patients with hyperthyroidism. The use of epinephrine or other pressor amines (in local anesthesia or gingival retraction cord, or to control bleeding) must be avoided in……

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The symptoms of thyrotoxic crisis (thyroid storm) include restlessness, fever, tachycardia, pulmonary edema, tremor, sweating, and finally coma and death. If this situation is faced during periodontal treatment, the treatment is stopped. The patient is cooled with the help of cold towels or ice packs and given an injection of hydrocortisone (100-300 mg). An intravenous line is established and dextrose solution is given to cope with continuously high metabolic demand. Vital signs must be monitored, and cardiopulmonary resuscitation initiated, if necessary. Immediate medical assistance should be sought. If available, antithyroid drugs and potassium iodide may be started. The periodontal treatment of the patient is postponed till the medical management of the patient.

Parathyroid gland disorders

The parathyroid glands are derived from the ectoderm of the pharyngeal pouches. In Humans, usually four parathyroid glands are present, variably located on the back of the thyroid gland. The superior parathyroid glands develop from the fourth pharyngeal pouch and are therefore referred to as “parathyroid IV”. The inferior parathyroid glands are derived from the third pharyngeal pouch and are also referred to as “parathyroid III”. The major function of the parathyroid glands is to maintain the body’s calcium and phosphate levels. Parathyroid glands secrete parathyroid hormone (PTH) which in association with calcitonin (secreted from the thyroid gland) has key roles in regulating the amount of calcium in the blood and within the bones. PTH plays an important role in tooth development and bone mineralization and increases bone resorption. It’s coordinated action on the bones, kidney and intestine increases the flow of calcium into the extracellular fluid and increases its concentration in the blood. The parathyroid disorders are of two types, one where the parathyroid is overactive (hyperparathyroidism), and another where the parathyroid is under- or hypoactive (hypoparathyroidism).

Hyperparathyroidism:

The hyperparathyroidism may be primary, secondary or tertiary. The primary hyperparathyroidism is caused due to hyperfunction of one or more parathyroids, usually caused by a tumor (adenoma in 85% of all cases) or hyperplasia of the gland that produces an increase in PTH secretion resulting in hypercalcemia and hypophosphatemia. Secondary hyperthyroidism occurs in patients with intestinal malabsorption syndrome or chronic renal failure, which results in decreased Vit D production or hypocalcemia causing glands to produce a high quantity of PTH. If the secondary hyperparathyroidism persists for a longer duration of time, the parathyroid tissue may become unresponsive to the blood calcium levels, and begin to autonomously release PTH. This is known as tertiary hyperparathyroidism 68.

The oral manifestations of hyperparathyroidism are,

  1. Dental abnormalities:
    1. Widened pulp chambers
    2. Developmental defects
    3. Alterations in dental eruption
    4. Weak teeth
    5. Malocclusions
  2. Brown tumor
  3. Loss of bone density
  4. Soft tissue calcifications

Hypoparathyroidism:

The state of decreased parathyroid activity is known as hypoparathyroidism. This condition is characterized by hypocalcemia and hyperphosphatemia. One common reason for hypoparathyroidism is damage to the glands or their blood supply during thyroid surgery. Some rare genetic syndromes such as DiGeorge syndrome or an autosomal dominant syndrome are also associated with this condition. It may also develop as an isolated entity of unknown etiology, referred to as idiopathic hypoparathyroidism 69.

The oral manifestations of hypoparathyroidism are,

  1. Dental abnormalities:
    1. Enamel hypoplasia in horizontal lines
    2. Poorly calcified dentin
    3. Widened pulp chambers
    4. Dental pulp calcifications
    5. Shortened roots
    6. Hypodontia
    7. Delay or  cessation  of  dental  development
  2. Mandibular tori
  3. Chronic candidiasis
  4. Paresthesia of the tongue or lips
  5. Alteration in facial muscles

Dental management of the patient with parathyroid disorders:

The clinical management of the patients with hyper or hypoparathyroidism does not warrant any special consideration. The hyperparathyroidism patient is more prone to bone fracture due to the decreased mineral content of bones, so care should be taken during surgical procedures. The brown tumor if present should be diagnosed correctly in these patients. On the other hand, hypoparathyroidism patients have low serum calcium. Before performing dental treatment, serum calcium level should be determined. It must be above 8mg/100ml to prevent cardiac arrhythmias, seizures, laryngospasms or bronchospasms. Because of dental abnormalities, these patients are more prone to caries. Proper oral hygiene measures and dietary instructions should be given to these patients to prevent caries.

Adrenal Insufficiency

Adrenal insufficiency (AI) is a……….

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The suppression of the HPA axis is rarely seen in the patients taking the steroid dose for less than 3 weeks. A patient taking 15 mg/day of prednisolone for more than 3 weeks should be suspected of having HPA suppression 75, 76. However, the present evidence says that is very difficult to predict, which patient will develop AI after corticosteroids are discontinued 77.

Normal cortisol levels:

The glucocorticoids are produced in the zona fasciculata of the adrenal cortex under the regulation of the HPA axis. Hypothalamus synthesizes Corticotropin-releasing hormone (CRH) and arginine vasopressin (AVP) which stimulate secretion of adrenocorticotropic hormone (ACTH) from the pituitary gland 78. ACTH acts on renal cortex and cortisols are produced. These are under negative feedback at the level of both the hypothalamus and the pituitary gland 79. It has been estimated that normally around 10 mg/day endogenous cortisol is produced in our body 80, 81. There are cyclic variations in the plasma cortisol concentrations in the course of the 24-hour in a day, being maximum early in the morning and minimum at evening.

Dental management of patients with adrenal insufficiency:

The periodontal treatment of patients with primary or secondary AI is started with a detailed case history and current status of the patient. In patients taking exogenous corticosteroids, the reason of intake should be determined. The primary AI or Addison’s disease results from idiopathic, surgical, or infectious destruction or tumor of the parenchyma of the adrenal gland or infiltration of the cortex by sarcoidosis, tuberculosis or amyloidosis 82. Most of these patients with Addison’s disease are treated with corticosteroids. The AI other than Addison’s disease is most commonly due to exogenous corticosteroid intake. The dosage of the exogenous corticosteroids determines the degree of adrenal suppression. Also, the duration of therapy is important in determining the adrenal suppression. According to the dose of corticosteroids, following degrees of adrenal suppression can be observed 82, 83,

Corticosteroid doses which do not produce adrenal suppression

If the patient is taking < 30mg of hydrocortisone/day it is considered as low-dose corticotherapy. There is no need for corticosteroid supplements both for the long-term and short-term corticoid users because this dose does not cause adrenal suppression. The non-surgical and surgical procedures can be safely carried out without giving the patient any corticosteroid supplements.

Corticosteroid dose which produces adrenal suppression

There is some degree of adrenal suppression in patients who are receiving 30-40 mg of hydrocortisone/day. If the patient is highly anxious, or lengthy dental treatment or surgical procedure is to be performed, we must double the daily dose on the day of treatment. If the postoperative pain is expected, we should also double the daily dose on the first postoperative day.

Patients receiving > 40 mg of hydrocortisone/day are on high-dose corticotherapy. This dosage results in blood levels of corticosteroids, which inhibit the HPA axis.  In patients who are taking high-dose corticotherapy for less than one month, there is transient suppression of the HPA axis. Within 14 days of cessation of the therapy, the endogenous cortisol levels become normal. So, in patients who have discontinued corticosteroid treatment less than 14 days ago, maintenance dose on the day of treatment is required. There is no set protocol for patients who are taking high-dose corticotherapy for more than one month.

Table 32.12 Corticosteroid dose equivalents

Steroid
Equivalent Dose
Betamethasone1.2 mg
Dexamethasone1.5 mg
Methylprednisolone8 mg
Triamcinolone8 mg
Prednisone10 mg
Prednisolone10 mg
Hydrocortisone40 mg
Cortisone50 mg

Table 32.13 Classification of corticosteroids on the basis of their onset of action 84, 85

Glucocorticoid
Approximate equivalent dose (mg)
Half-life (hr)
Short Acting
Cortisone258-12
Hydrocortisone208-12
Intermediate Acting
Methylprednisolone418-36
Prednisolone518-36
Prednisone518-36
Triamcinolone418-36
Long Acting
Betamethasone
Dexamethasone0.6 – 0.7536-54
0.7536-54

Precautions during the treatment:

The plasma cortisol concentration is maximum in the morning, so preferably morning appointment should be given to the patient. The anxiety and emotional stress should be minimized. The treatment should be as painless as possible. Appropriate management of the post-operative pain should be done. Some drug interactions should also be kept in mind. Drugs like phenytoin, barbiturates and rifampicin accelerate glucocorticoid metabolism. Glucocorticoids increase the requirements of insulin, oral antidiabetic drugs, and hypotensive medication.

Adrenal or Addisonian crisis:

Patients with Addison’s disease regularly take corticosteroid replacement drug therapy to compensate for the deficiency of endogenous cortisols due to their inadequate production. Exogenous glucocorticoids can cause adrenal gland suppression and resultant atrophy. With the atrophy of adrenal glands, there is a decreased glucocorticoid response to stress, and this may precipitate an adrenal crisis 86.

As already stated, the cortisol production from the adrenal cortex is under negative feedback. The falling level of cortisol in the blood stimulates the pituitary gland to produce ACTH. During dental treatment, stress stimulates pituitary gland to produce more ACTH, resulting in an even more increase in the production of cortisol. But the patient is already taking exogenous steroids which cause suppression of endogenous cortisol production. Because the body is unable to produce natural cortisol, it fails to respond when higher levels are required. Adrenal crisis may precipitate due to sudden withdrawal of exogenous corticoids, or the existence of situations requiring greater amounts of corticoids than those afforded by replacement therapy. It is due to sudden failure of the adrenal cortex function. The patient may show following signs and symptoms,

  • Pallor
  • Rapid, weak pulse
  • Nausea
  • Vomiting
  • Abdominal pain
  • Hypotension (drop in blood pressure)
  • Loss of consciousness

Prevention is the best management approach for Addisonian crises. The patients who are on long-term corticosteroid treatment should carry a Steroid Treatment Card which carries details of prescriber, drug given, dosage and duration of treatment. It helps in minimizing the risk of precipitation of adrenal crisis.

If adrenal crisis precipitates during dental treatment of the patient, the treatment is terminated and the vital signs of the patient are monitored. The patient is placed in dorsal decubitus position and the medical emergency service is contacted. If the patient is unconscious, maintenance of the airway is of prime importance. The basic life support should be given immediately as soon as the adrenal crisis is anticipated. The patient should be given 100 mg of hydrocortisone sodium succinate intravenously for 30 seconds or intramuscularly, and two hours later, another 100 mg of hydrocortisone dissolved in saline should be given intravenously or intramuscularly 82. The CPR should be started, if necessary.

Hematological conditions

Bleeding disorders:

There are various causes of excessive bleeding  including coagulation factor deficiencies, fibrinolytic defects, vascular disorders and platelet disorders (Figure 32.2). Patients with congenital bleeding disorders have an increased risk of significant bleeding from invasive dental and oral surgery procedures. A thorough knowledge of the blood clotting mechanism is essential for the understanding and management of patients with bleeding disorders. The blood clotting mechanism involves various factors which participate in the formation of blood clot. Coagulation is a property of plasma alone, not of blood cells. Normal clotting time with lee’s white method is 6-17 min. Morawitz in 1904 described the basic mechanism of blood clotting. More than 50 substances that affect blood coagulation have been found in the blood. Most important of these clotting factors are,

  1. Fibrinogen
  2. Prothrombin
  3. Tissue thromboplastin
  4. Calcium
  5. Proaccelerin or labile factor
  6. There is no factor VI
  7. Serum prothrombin conversion accelerator or stable factor
  8. Anti-haemophilic factor (AHF)
  9. Plasma thromboplastin component (Christmas factor)
  10. Stuart factor
  11. Plasma thromboplastin antecedent
  12. Hageman or surface factor
  13. Fibrin stabilizing factor

Figure 32.2 The classification of bleeding disorders

The classification of bleeding disorders

In an area where there is restricted blood flow or an abnormal vessel wall without injury, the initiation of clot formation is by the intrinsic pathway. The initiation of fibrin clot formation in response to injury to the tissue is carried out by extrinsic pathway. Both of these pathways converge in a final common pathway involving the conversion of prothrombin to thrombin and thrombin-catalyzed cleavage of fibrinogen to fibrin.

The congenital bleeding disorders include hemophilia A (classic hemophilia) and B (Christmas disease), von Willebrand disease (vWD) and Factor XI deficiency. Both hemophilia A and B are inherited as an X-linked recessive conditions and share identical clinical manifestations. Out of hemophilia A and B, hemophilia A is more common, accounting for approximately 85% of all the cases of hemophilia (incidence, 1:5,000 live male births), and is characterized by the deficiency of factor VIII. Hemophilia B is characterized by the deficiency of factor IX (incidence, 1:30,000 live male births) 87.

The commonest of the congenital bleeding disorder is vWD and is characterized by a deficient or abnormal plasma protein known as von Willebrand factor (vWF). It is an autosomal dominant condition and affects both males and females. Inherited vWD is subdivided into 3 categories: Types 1 and 3 represent a partial and complete deficiency of vWF, respectively; Type 2 variants represent qualitative abnormalities of vWF (Table 32.14). The most common type of von Willebrand disease (vWD) is Type 1 vWD, which counts for 80% of all vWD patients 88, 89. The management of vWD patients depends on the type of disease. Most of the patients with Type 1 and some Type 2A and 2M patients respond well to desmopressin acetate, a synthetic analog of vasopressin (explained later). Patients with Type 2B and Type 3 vWD, require vWF replacement. The currently available replacement is vWF containing Factor VIII concentrates derived from pooled human plasma which is pasteurized to inactivate viruses 90-92.

Table 32.14 Classification of von Willebrand disease

Type 1
Partial deficiency (80% of those with vWD)
Type 2Qualitative defects
ADecreased function; absent medium and high-molecular-weight multimers
BIncreased affinity for platelet GPIb; decreased high-molecular-weight multimers
MDecreased function; variable multimer pattern
NDecreased affinity for Factor VIII
Type 3Severe deficiency; autosomal recessive

Other congenital factor deficiencies include fibrinogen, Prothrombin, Factor V, Factor VII, Factor X, Factor XI and Factor XIII deficiencies. These are relatively rare factor deficiencies and are treated with fresh frozen plasma or specific factor transfusion.

Specific blood tests to confirm bleeding disorders:

Following investigation are done in bleeding disorders (Table 32.15):

  1. Bleeding time: Time taken for a standardized skin puncture to stop bleeding is calculated. Depending on the method used, it varies from 2-9 minutes. The abnormality is found when there is a defect in platelet number or function (Figure 32.3).
  2. Platelet count: It is obtained from anticoagulated blood using an electronic particle counter. The normal range is 150 to 450 × 103/mm3. Decreased platelet count is associated with bleeding disorders.
  3. Prothrombin time: It measures the adequacy of extrinsic and common coagulation pathway. In this test, the tissue factor is replaced by exogenously added source of tissue thromboplastin eg. brain extract. Calcium ions are provided from outside. Increased PT is present in a deficiency of factor V, VII, X, prothrombin, and It is calculated in seconds.
  4. Partial thromboplastin time: It checks the integrity of intrinsic and common clotting pathway. It is calculated in seconds. Intrinsic pathway requires a contact phase that is provided by the surface of the blood vessels on which surface endothelium is altered. In vitro, it is provided by Kaolin. Cephalin is a substitute for platelet phospholipids. The plasma clotting time is checked. Increased PTT indicates a deficiency of factor I, II, V, VIII, IX, XI, XII. Any of these factors may be deficient when PTT is increased.
  5. Activated partial thromboplastin time (APTT): In APTT, an activator is added that speeds up the clotting time and results in a narrower reference range. The APTT is considered a more sensitive version of the PTT.

Table 32.15 Laboratory tests for bleeding disorders

Test
 
Normal values
Bleeding time (ivy)BT3-7 minutes
Clotting timeCT12-15 Sec.
Prothrombin timePT12 ± 1 Sec.
Activated Partial Thromboplastin TimeAPTT25± 10 Sec.
Platelet count250,000 ± 150,000/mm3

Figure 32.3 Schematic procedure for hematological investigations to identify the cause of excessive bleeding

Diagnosis of bleeding disorders

Periodontal treatment of patients with bleeding disorders:

The bleeding disorders are clinically confirmed by the case history of the patient. Usually, most of the patients are under medical supervision for their condition. Most of the procedures in non-surgical periodontal therapy do not require augmentation of coagulation factor levels. Procedures that require increment in the clotting factor levels (depending on the type of hemophilia and vWD), there may be four therapeutic management options,

  1. Coagulation factor replacement therapy
  2. Release of endogenous factor stores using desmopressin (DDAVP)
  3. Improving clot stability by antifibrinolytic drugs, for example, tranexamic acid
  4. Local hemostatic measures.

Table 32.16 Classification of hemophilia

Severity
Serum levels of factor
Bleeding severity
Mild0.05–0.35 IU/mL or 5% to 35%No spontaneous bleeding; delayed onset bleeding after trauma or surgery or dental extractions
Moderate0.01–0.05 IU/mL or 1% to 5%Bleeding into joints or muscles with minor trauma; excessive bleeding with surgery
Severe< 0.01 IU/mL or < 1%Spontaneous joint, muscle and internal bleeding; excessive bleeding with trauma or surgery
 

Coagulation factor replacement therapy:

The patient may have mild, moderate or severe hemophilia. In mild hemophilia, there is no need for clotting factor replacement. Agents such as desmopressin may be given intravenously, prior to the surgery, to increase the level of factor VIII and vWB factor in the blood. In the case of moderate and severe hemophilia A and B, coagulation factor replacement therapy is the main form of therapy. The concentrate of the deficient factor is administered by intravenous infusion. The dental treatment should be performed within 30 minutes to one hour after infusion of clotting factors because the level of clotting factor in the blood declines with time. The factor administration may be prophylactic (to prevent bleeding) or may be on demand (administered if the bleeding does not stop). The potential problem with plasma-derived factor concentrate transfusion was the transmission of infection. The introduction of recombinant factor replacement therapy has reduced the risk of blood borne infections. The complication associated with the infusion of the factor concentrate is the development of antibodies against the factor. These antibodies negate the effect of factor concentrate.

Release of endogenous factor stores using desmopressin (DDAVP):

Desmopressin (1‐desamino‐8‐d‐arginine vasopressin) is an analog of vasopressin that exerts a substantial hemostatic effect by inducing the release of vWF from its storage sites in endothelial cells. Vasopressin is an anti-diuretic hormone which functions through two receptors, termed V1 and V2, activating different intracellular second messengers. The agonist activity at V2 receptors leads to the rise in intracellular concentrations of cyclic adenosine monophosphate, which in turn induces exocytosis of vWF from its storage sites (i.e., Weibel-Palade bodies of endothelial cells) into the circulation. It also increases the plasma concentration of factor VIII. Desmopressin being an analog of vasopressin, activates only V2 receptors and thus causes the release of vWF into circulation. It shortens the prolonged APTT and the bleeding time. DDAVP (0.3 μg/kg in 50 ml of normal saline) can be administered intravenously (4 μg/ml concentration) one hour pre-procedure as a slow intravenous infusion over 20-30 minutes. It can also be administrated through subcutaneous or intranasal routes.

Side effects are primarily the result of vasodilation and include flushing, tachycardia, hypotension, and headache. Other side effects include hyponatremia (water intoxication in severe cases) resulting from desmopressin’s antidiuretic effects and thrombosis in patients with pre-existing risk factors.

Antifibrinolytic agents:

These agents promote blood coagulation by their anti-fibrinolytic activity. Epsilon-aminocaproic acid (EACA), and the more potent tranexamic acid (TA) are used as anti-fibrinolytic agents. These are analogs of the amino acid lysine. They exert their antifibrinolytic effect by interfering with the binding of plasminogen to fibrin, which is necessary for activation of plasminogen to plasmin. The oral dose of TA is 15-25 mg/kg, which approximates to 1 g for the majority of adults, every 6-8 hours. Its oral administration should be started two hours pre-operatively and should be continued for up to 7-10 days post-procedure.

TA is freely soluble in water, so 10 ml of a 5% solution TA solution can be used as mouthwash just before the oral surgical procedure and should be continued 4 times a day for 5 days after the surgery. The solution should be gently swished inside the mouth for 2-3 minutes and then gently expelled. For children, the oral mouthwash of TA should be used carefully because if it is swallowed, it may exceed the recommended dose.

Local hemostatic measures:

In patient with bleeding disorder, the local hemostatic measures can be used to stop bleeding. Placement of sutures and pressure pack is very helpful in stopping the bleeding. Various local hemostatic agents available include oxidized cellulose, Surgicel®, resorbable gelatin sponge, Gelfoam®, cyanoacrylate tissue adhesives and surgical splints (Table 32.17). It must be remembered that minimum trauma to tissue during the surgical procedure is the key to quick control of bleeding.

Table 32.17 Local hemostatic agents

Brand Name
Mechanism of Action
Precautions
GelfoamAbsorbable gelatin sponge material; provides stable 'scaffold' for clot formationShould not be used under epithelial incisions or flaps, inhibits healing
SurgicelOxidized regenerated cellulose; exerts physical effect rather than physiologicalCan be used safely
Bleed-XHemostatic product containing microporous polysaccharide hemispheres (potato starch); dehydrates blood and accelerates clottingCan be used safely
TisseelFibrin sealant; adhesive action that binds fibrin to the clotTechnique sensitive: requires special attention for preparation; reserved for complex procedures
Cykloapron (Tranexamic acid)Used in the form of a mouthwash after surgical procedures to inhibit postoperative bleeding; can be administered parenterally or as a 4.8% aqueous solution (4 times daily for 1 week)To be used carefully in children. Swallowing the mouthwash may result in increased serum levels than required.
Amicar (Aminocaproic acid) Antifibrinolytic agentNo longer available for topical use

Platelet Disorders:

Platelets are one of the most important components of clotting mechanism. The normal platelet count is 250,000 ± 150,000/mm3.  If the platelet count is less than 100,000 cells/mm3, the condition is known as thrombocytopenia. When the platelet count is below 50,000 cells/mm3 there is excessive bleeding during the surgery and post-operatively. Many different types of platelet disorders are there which may cause defective coagulation. They are broadly classified into various categories on the basis of defects of platelet number (thrombocytopenia) or the function. Thrombocytopenias may be broadly classified as inherited (Figure 32.4) or acquired (Figure 32.5), containing different types of thrombocytopenias under these categories.

Figure 32.4 Various causes of inherited thrombocytopenia

Various causes of inherited therombocytopenia

Figure 32.5 Various causes of acquired therombocytopenia

Various causes of acquired thrombocytopenia

Idiopathic/immune thrombocytopenic purpura (ITP):

ITP is also known as immune thrombocytopenic purpura or primary immune thrombocytopenic purpura. It is a hemorrhagic disorder characterized by abnormally increased destruction of circulating platelets. In this condition, platelets are opsonized by autoreactive antibodies and prematurely destroyed by the reticuloendothelial system. ITP occurs in two distinct clinical forms: an acute self-limiting form seen almost exclusively in children and chronic form mostly observed in adults. The oral findings in this condition are bleeding mucous membranes and petechiae which can be seen in areas most prone to friction.

Non-immunogenic thrombocytopenias:

In this case, there is no immunogenic destruction of platelets but platelet count is reduced due to either less production or more destruction of the platelet. Platelets may have adhesion (Bernard-Soulier syndrome), aggregation (Glanzmann thrombasthenia) or granule defects (Gray platelet syndrome). Many drugs are also known to have significant adverse effects on platelet number and function. Estimates on the incidence of drug-induced thrombocytopenia range 5-40% in patients receiving heparin, to < 1% with other causative agents 93. Other drugs most frequently associated with the development of thrombocytopenia are quinidine, gold and the trimethoprim-sulphamethoxazole 94. Nonsteroidal anti-inflammatory drugs (NSAIDs) attenuate the platelet activity. The most common of these is aspirin, which acetylates COX, thereby blocking thromboxane A2 (TxA2) release from activated platelets.

Periodontal treatment of patients with platelet disorders:

A detailed history of the patient should be recorded with a description of the type of platelet disorder and the medical treatment provided to the patient for the disorder. If the platelet count is > 75,000/mm3, there is no need of additional support, but the operator should be prepared to treat prolonged bleeding by using sutures, hemostatic agents, pressure packs, gelatin foams, and so forth. If the platelet count is 40,000 to 75,000/mm3, platelet transfusions may be considered pre- and 24 hours postoperatively. Localized procedures to manage prolonged bleeding may include sutures, hemostatic agents, pressure packs, and/or gelatin foams. If the platelet count is < 40,000/mm3, only elective dental care should be deferred. Treatment only for relieving pain is rendered and patient’s hematologist is consulted for the hospitalization and platelet transfusion.

The patient should be educated about maintenance of healthy periodontium. If the gingiva is inflamed, it may bleed for a long time in patients with platelet dysfunction. A soft toothbrush is recommended for these patients and a regular assessment of periodontal status is done.

Blood dyscrasias

The hematological malignancies can be grouped into three categories: leukemia, lymphoma and plasma cell tumors. These malignancies may alter bleeding and clotting time, wound healing and may increase susceptibility to infection. Many patients suffering from hematological disorders seek periodontal treatment. A periodontist should be aware of these disorders as well as the protocol followed during the treatment.

Leukemia:

Leukemia is a hematological disorder which is caused by proliferating white blood cell-forming tissues, resulting in a marked increase in circulating immature or abnormal white blood cells. It results from the proliferation of a clone of abnormal hematopoietic cells with impaired differentiation, regulation, and apoptosis (programmed cell death). The multiplication of leukemic cell at the expense of normal hematopoietic cell lines causes marrow failure, depressed blood cell count (cytopenia), and death as a result of infection, bleeding, or both 95. Leukemia is classified based on clinical behavior (acute or chronic) and the primary hematopoietic cell line affected (myeloid or lymphoid). The four principal diagnostic categories are the following 96, 97:

  1. Acute myelogenous leukemia (AML),
  2. Acute lymphocytic leukemia (ALL),
  3. Chronic myelogenous leukemia (CML) and
  4. Chronic lymphocytic leukemia (CLL).

Oral findings:

Patients with leukemia show gingival bleeding, petechiae and ecchymosis due to thrombocytopenia. The severity of these symptoms depend on the platelet count. Less is the platelet count, more severe are these findings. Another important finding is gingival enlargement. It is more common in acute than chronic leukemia. Gingival enlargement is secondary to infiltration of the gingival tissue with leukemic cells. It is characterized by the progressive enlargement of interdental papillae as well as marginal and attached gingiva. Gingiva appears swollen, devoid of stippling and pale red to deep purple in color. Gingival infiltration by leukemic cells also predisposes the patient with leukemia to bleeding 98. Generally, gingival enlargement resolves completely or at least partly with effective leukemia chemotherapy 99, 100. Other findings may include, oral ulcerations, viral infections (e.g. HSV) and oral colonization by Candida albicans 97, 101.

Periodontal treatment of patients with leukemia:

The consultation with the physician treating the malignancy of the patient is must prior to starting the periodontal treatment. Once the condition of the patient is understood, treatment is planned for the patient. Dental treatment of a leukemic patient should be done according to the following criteria 98,

  1. The physician or the oncologist treating the patient should be consulted prior to the initiation of dental treatment.
  2. A detailed case history, thorough periodontal and dental examination and radiographic examination are must before starting the treatment.
  3. Dental treatment should be performed before starting the chemo/radiotherapy.
  4. Patients in long-term remission can undergo dental treatment, while patients with advanced or relapsed disease with reserved prognosis should receive palliative or urgent treatment only.

The main problems in the dental treatment of patients with hematologic malignancies of white cells are:

  1. Tendency to bleed
  2. Increased risk of infection
  • Odontogenic
  • Opportunistic
  1. Anemia
  2. Secondary adrenal insufficiency due to corticosteroids

Tendency to bleed:

As already stated, intraoral bleeding is commonly found in these patients clinically manifested as petechiae and ecchymoses, and occasionally hematoma formation. It is caused due to thrombocytopenia due to suppressed platelet formation. In procedures where bleeding is not anticipated, treatment can generally be provided in even severely thrombocytopenic patients without the need for transfusions. If the surgical procedure has to be performed protocol followed during the treatment of thrombocytopenia (explained previously) is followed.

Increased risk of infection:

The risk of infection in leukemic patients is increased due to compromised lymphocyte function or low neutrophil count. The patient may present with an oral infection, which may be of odontogenic origin or opportunistic.

Odontogenic infections:

Because of compromised immune system, the patient is more prone to have pulpal or periodontal infections. It has been shown that oral prophylaxis, oral hygiene instructions and elimination of oral sources of infection before the initiation of cancer treatment, can significantly reduce the risk of infectious complications 102, 103. The periodontal treatment should be given after evaluation of the platelet (for bleeding tendency) and absolute neutrophil counts (for assessment of immunologic function). The routine periodontal procedures like scaling and curettage should be done under antibiotic cover and chlorhexidine rinses should be prescribed to the patient to prevent any infection.

Opportunistic infections:

These patients are also at a higher risk of developing opportunistic infections like viral and fungal infections. The viral infection may be primary or due to reactivation of the latent virus. Herpes simplex virus (HSV) is the most common viral infection in these patients and typically presents as single or multiple painful ulcerative lesions that may involve any oral mucosal surface. Antiviral therapy is given to treat these infections.

The fungal infection by Candida spp. is common during intensive chemotherapy and in advanced disease. Candidiasis can present as pseudomembranous (most common), erythematous, hyperplastic, or angular cheilitis. The patient is given a topical application of nystatin for 7 to 14 days. In severe cases, 100 to 200 mg/day of fluconazole or itraconazole is given systemically for 7 to 14 days.

Anemia:

The patient may have anemia due to decreased Hb. Patients with severe anemia often complain of easy fatigue and inability to tolerate time-consuming dental treatment. Patient’s oncologist should be consulted regarding this problem and only after appropriate treatment, long dental procedures should be planned.

Secondary adrenal insufficiency due to corticosteroids:

Patients with leukemia are usually on corticosteroid therapy, so there are chances of development of secondary adrenal insufficiency. The dental treatment of these patients should be done only after thorough evaluation of the patient and discussion with the patient’s physician. If during the treatment, the patient shows signs and symptoms of adrenal insufficiency, the treatment protocol is same as discussed for adrenal crisis in the previous section.

Renal diseases

Renal failure is a condition in which the kidneys fail to remove metabolic end-products from the blood and regulate the fluid, electrolyte, and pH balance of the extracellular fluids. Renal failure should be differentiated from renal insufficiency. Renal insufficiency is described as a condition when renal function is abnormal, but capable of sustaining essential bodily functions. Renal function is often quantified by assessing serum creatinine. However, glomerular filtration rate (GFR) is usually accepted as the best overall measure of renal function. Normal GFR values are approximately………..

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The chronic renal failure ends with the reduced number and function of the nephrons; and if not treated results in end-stage renal disease (ESRD). ESRD is characterized by irreversible loss of renal functions and develops a clinical state that requires renal replacement treatments such as dialysis and transplantation to prevent dangerous and life threatening effects of uremia.

Oral manifestations of renal disorders:

In renal diseases, due to diminished function of the kidneys there is an increase in the levels of urea in blood and also in saliva, where it will turn into ammonia. So, these patients have a characteristic halitosis (uremic fetor). This characteristic halitosis is present in about one-third of hemodialyzed patients. It also causes unpleasant, metallic taste in the patient’s mouth. These patients generally complain of altered taste sensation, especially to sweet and acid flavors. Because of increased concentration of urea in saliva, the pH of the saliva changes 106. Some patients also complain of a burning sensation in the lips and tongue, which is proposed to be of neuropathic origin 107. Because these patients are on liquid intake restrictions, the secretion of saliva is reduced, which in association with secondary effects of medication (mainly antihypertensives), is also associated with altered taste perception 106, 108, 109. In renal diseases sometimes there may be decreased synthesis of erythropoietin, which clinically manifests as anemia. It can be clinically seen as paleness of skin and oral mucosa 105.

Renal osteodystrophy is another renal condition which has effects on oral hard and soft tissues. Renal osteodystrophy constitutes a heterogeneous group of metabolic bone disorders that accompany declining GFR. The most common forms of renal osteodystrophy are attributable largely to variations in the plasma levels of parathyroid hormone (PTH). As a result, there are alterations in calcium, phosphorus, and vitamin D metabolism. The condition is characterized by bone demineralization, decreased trabeculation, decreased thickness of cortical bone, ground- glass appearance of bone, metastatic soft- tissue calcifications, radiolucent fibrocystic lesions, radiolucent giant cell lesions, lytic areas of bone, jaw fracture (spontaneous or after dental procedures), abnormal bone healing after extraction, and, sometimes, dental mobility because of loss of tooth-supporting bone 108.

The chronic renal failure, which terminates in ESRD, has been associated with many oral soft and hard tissue manifestations. One major hard tissue oral manifestation is enamel hypoplasia due to a disturbance in enamel formation and mineralization. Other manifestations of chronic kidney disease and hemodialysis therapy are xerostomia, enamel hypoplasia, calcification of root canals, abnormal pH of saliva and abnormal delay in eruption of teeth 109. The uremic stomatitis is one rare finding in ESRD patients. Clinically, it is characterized by the presence of erythematous lesions which are localized or generalized.

The increased bleeding tendency in renal failure cases is due to decrease in platelet count. It may result due to mechanical damage to platelets during dialysis and use of heparin anticoagulation during the procedure. The oral manifestations of increased bleeding tendency are ecchymosis, petechiae and hemorrhage in the oral mucosa due to minor injury during eating.

Patients with kidney transplant receive immunosuppressants throughout their life. Therefore, these patients are susceptible to infections and to the development of malignant neoplasms 110. The most common finding in patients taking cyclosporine as immunosuppressant is gingival overgrowth. It has been seen that almost 30% of dentate patients taking cyclosporine have gingival overgrowth. If they are taking nifedipine along with cyclosporine, the prevalence of gingival overgrowth increases to 50% 110. Substitution of cyclosporine with other drugs such as tacrolimus, rapamycin or mofetil mycophenolate have been advocated to avoid gingival overgrowth.

Periodontal treatment of patients with renal disorders:

Before initiation of treatment, consultation with the physician is required to know the exact condition of the patient. The renal patients mainly have concerns related to bleeding tendency, hypertension, anemia, drug intolerance, increased susceptibility to infections and gingival overgrowth due to medications used in the treatment of renal disorders and after renal transplant.

Bleeding tendency:

As already described, patients with renal diseases may have increased bleeding tendency. The partial thromboplastin time, prothrombin time, bleeding time, and platelet count is evaluated before initiation of any surgical procedure. If the values are not normal, excessive bleeding may result during the treatment. The International Normalized Ratio (INR) value should be checked. As already stated, minor surgery can be performed with an INR of up to 2.5 21. Complex surgery or multiple extractions may require an INR <1.5.

Various dialysis techniques used today include hemodialysis, peritoneal dialysis, hemofiltration, hemodiafiltration, and intestinal dialysis. Out of these techniques, some require administration of heparin as anticoagulant on the day of dialysis. Therefore, any surgical treatment should be performed one day after dialysis. If an emergency dental treatment needs to be performed on the day of dialysis, protamine sulfate (heparin antagonist) can be administered to block the anticoagulant effect of heparin.

Hypertension:

The patients with ESRD are usually hypertensive. The blood pressure should be controlled with antihypertensive drugs.

Anemia:

As already discussed, a decrease in synthesis of erythropoietin in kidney disorders may result in anemia.  The patient may complain of tiredness and inability to tolerate long dental procedures. The physician should be consulted for the needful treatment and then dental treatment should be carried out.

Drug intolerance:

A major problem with patients with renal disorders is drug intolerance. Many drugs have their metabolism in the kidney, which is hampered during renal diseases. The dosages of the drugs have to be re-adjusted according to renal function. Penicillin and its derivatives (such as amoxicillin), clindamycin and cephalosporins are the preferred antibiotics for these patients. Paracetamol is the drug of choice in NSAID’s. On the basis of creatinine clearance, the dosage of various drugs is established as described in Table 32.18.

Table 32.18 Drug dose adjustment according to creatinine clearance (CC)

Drugs
Normal dose
Dose with CC 10- 50
ml/ min
Dose with CC <10 ml/
min
Antibiotics
Amoxicillin500/ 1000 mg/ 8 h500/ 1000 mg/ 8-12 h500/ 1000 mg/ 12- 24 h
Amoxicillin/clavulanate500/ 875 mg/ 8 hNo need for dose adjustment500/ 875 mg/ 12- 24 h
Penicillin G0.3- 1.2 million IU/ 6-
12 h
50- 100% of the dose every 8- 12 h25- 50% of the dose every 12 h
Clindamycin300 mg/ 8 hNo need for dose adjustmentNo need for dose adjustment
Doxycycline100 mg/ 24 hNo need for dose adjustmentNo need for dose adjustment
Erythromycin250- 500 mg/ 6 hNo need for dose adjustmentNo need for dose adjustment
Metronidazole250- 500 mg/ 6 hEvery 8-12 hEvery 12- 14 h
Azithromycin500 mg/ 24 h, 3 daysNo need for dose adjustmentNo need for dose adjustment
Analgesics
Paracetamol500- 1000 mg/ 4- 6 hNo need for dose adjustmentNo need for dose adjustment
AspirinContraindicated (produces water retention, deterioration of renal function and risk of gastric hemorrhage)
Ibuprofen200- 600 mg/ 4- 6 hNo need for dose adjustmentAvoid
Antifungal
Anfotericin0.3- 1 mg/kg/ 24 hNo need for dose adjustment0.3- 1 mg/ kg/ 24- 48 h
Fluconazol100- 200 mg/ 24 h50- 200 every 24 h50- 100 every 24 h
Local anesthetics
LidocaineRegular dosage and rate of administrationRegular dosage and rate of administrationRegular dosage and rate of administration
MepivacaineRegular dosage and rate of administrationRegular dosage and rate of administrationRegular dosage and rate of administration
Corticosteroids
PrednisoneRegular dosage and rate of administrationRegular dosage and rate of administrationRegular dosage and rate of administration

Susceptibility to infection:

The patients with renal transplant are put on immunosuppressant therapy. It makes them susceptible to infections. Also, long-term corticosteroid intake results in adrenal suppression. When exposed to stressful situations (disease, infection, surgery), adrenal crisis may precipitate in these patients. The management of the adrenal crisis has been discussed under adrenal insufficiency. As dialysis patients are also prone to infections, these patients are at a risk of transmission of HBV, HCV, and HIV infections. Individuals with permanent kidney dialysis shunts should be placed on prophylactic antibiotics using the same protocol as for IE.

Gingival overgrowth:

Gingival overgrowth associated with intake of immunosuppressants and anti-hypertensives is also a common finding in renal transplant patients. A patient with gingival overgrowth should be asked to maintain good oral hygiene. Some reduction in gingival overgrowth can be expected after maintenance of good oral hygiene. A change in the immunosuppressive therapy is an alternative to surgical treatment, but it is not always possible. In the case of severe gingival overgrowth, gingivectomy should be performed.

Liver diseases

Chronic liver disease (CLD) and cirrhosis patients require a special consideration during dental treatment. The most common causes of end-stage liver disease are chronic viral hepatitis B and C, alcohol-related liver disease, autoimmune hepatitis, primary sclerosing cholangitis, primary biliary cirrhosis, steatohepatitis, liver disorders inherited or present at birth, and drug-induced liver damage 111. Damage to the liver has two major impacts on the treatment aspect: bleeding and drug intolerance. Most of the clotting factors are synthesized in the liver, so these patients may have excessive bleeding during invasive dental treatment. Because the liver metabolizes many drugs, its damage may alter the drug metabolism. Re-adjustment of drug dosage is required for these patients.

Increased bleeding due to liver damage:

Liver plays a central role in the clotting process, and acute and chronic liver diseases are invariably associated with coagulation disorders due to multiple causes: decreased synthesis of clotting and inhibitor factors, decreased clearance of activated factors, quantitative and qualitative platelet defects, hyperfibrinolysis, and accelerated intravascular coagulation. The liver produces coagulation Factors I (fibrinogen), II (prothrombin), V, VII, VIII, IX, X, and XI, as well as protein C, protein S and antithrombin. Before any surgical procedure is planned for these patients, appropriate laboratory tests to check bleeding tendency should be performed.

Drug intolerance:

The liver is an important site for metabolism of various drugs (Table 32.19). Liver diseases may result in alterations in the metabolism of these drugs. In mild to moderate liver dysfunction, administration of certain analgesics, antibiotics, and local anesthetics is generally well tolerated. However, in excessive liver damage, certain drugs are avoided.

Table 32.19 Common drugs used in dentistry which are metabolized mainly in the liver

Drug category
Drugs
AntibioticsErythromycin
Clindamycin
Tetracycline
Analgesics Aspirin
Acetaminophen (Paracetamol)
Ibuprofen
Codeine
Meperidine
Antifungals Ketoconazole
Fluconazole
Local anesthetics Lidocaine
Prilocaine
Mepivacaine
Bupivacaine
SedativesDiazepam
Barbiturates

 

In severe liver damage, the dosage of certain drugs should be re-adjusted and certain drugs like erythromycin, metronidazole or tetracyclines must be avoided entirely 112. Penicillin group of drugs can be safely given to these patients. Aminoglycosides can increase the risk of liver toxicity in patients with liver disease, and so should be avoided. Local anesthetics can be safely used, provided the total dosage does not exceed 7 mg/kg, combined with epinephrine 111.

Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with caution or avoided, due to the risk of gastrointestinal bleeding and gastritis usually associated with liver disease. NSAIDs such as acetylsalicylic acid, indomethacin, mefenamic acid and ibuprofen should be avoided in patients with liver damage. Aspirin and acetaminophen (paracetamol) both are metabolized in the liver. In patients with altered hemostasis, aspirin should be avoided. Acetaminophen can be used safely in place of aspirin in these cases 111. Paracetamol should be prescribed cautiously in patients recovering from alcohol abuse because both paracetamol and alcohol are metabolized by the same enzyme (isoenzyme CYP2E1 of the P-450 cytochrome system). So, if the patient consumes alcohol along with paracetamol adverse outcomes may result in 113. The dosage of benzodiazepines should be reduced with the prolonged interval between the dosages owing to delayed metabolism.

Periodontal treatment of patients with liver diseases:

 The physician treating the patient should be consulted regarding liver function. As already stated these patients may have altered coagulation due to reduced levels of clotting factors synthesized in the liver. Before planning for any invasive procedure complete blood count, bleeding time, prothrombin time / international normalized ratio (INR), thrombin time, thromboplastin time and liver biochemistry (SGOT, SGPT, and GGT) should be done 114. In the case where the values are altered and a surgical treatment cannot be performed, only elective treatment to eliminate pain should be done. The emergency treatment should preferably be done in the hospital setting. Once the values return within normal range, a surgical procedure with minimum trauma to the tissues can be performed. Local hemostatic agents can be used to control bleeding. In severe liver damage, antibiotic prophylaxis is recommended since liver dysfunction is associated with diminished immune competence 115.

Pulmonary diseases

Pulmonary diseases are common these days due to increasing air pollution and habits like smoking. The pulmonary diseases may be obstructive or restrictive in nature.  The obstructive pulmonary diseases include emphysema, chronic bronchitis, refractory (non-reversible) asthma, and some forms of bronchiectasis. The restrictive ventilatory disorders are caused due to muscle weakness, scarring, obesity, or any condition that could interfere with effective lung ventilation. The chronic obstructive pulmonary disease (COPD) is an irreversible and slowly progressing disorder characterized by a limitation of airway flow (in some cases partially reversible), resulting from an abnormal pulmonary inflammatory reaction to harmful gasses or particles, particularly tobacco smoke. The examples of COPD include chronic bronchitis, lung emphysema, asthma and acute obstruction.

Chronic obstructive pulmonary disease (COPD):

It is a slowly progressive disease of the airways that is characterized by a gradual loss of lung function. As already stated, COPD includes chronic bronchitis, chronic obstructive bronchitis, or emphysema, or combinations of these conditions and can lead to pneumonia, heart disease, and death. Airflow obstruction and shortness of breath are the initial signs of chronic bronchitis, chronic obstructive bronchitis, or emphysema. Asthma is an important condition which requires special considerations during dental treatment. It is reversible, diffuse stenosis or stricture of the peripheral bronchi, increased responsiveness or sensitivity to different stimuli. A distinction should be made between allergic and non-allergic asthma. Allergic (or extrinsic) asthma is characterized by a family history of asthma, together with an increase in serum IgE titers. These antibodies participate in type I hypersensitivity or immediate sensitivity reactions. The non-allergic asthma is a respiratory disorder manifesting in a heterogeneous group of patients with reversible and recurrent bronchospasm in response to different stimuli such as physical exercise, inhalation of cold air, emotions, exposure to smoke, hypoxemia, stress, gastroesophageal reflux, etc 116.

Periodontal treatment of patients with pulmonary diseases:

Patients with pulmonary disorders requires special precautions during dental treatment to avoid any risk of breath shortness. Shortened visits with adequate pain control are recommended for these patients. Precipitation of an asthmatic attack is a major concern for dentists. It usually precipitates when stress generating procedures like administration of local anesthesia, tooth extraction or dental pulp removal are done. The asthmatic attack is characterized by breathing difficulty (e.g., wheezing, dyspnea) and cough 117. If an asthmatic attack precipitates during dental treatment, the treatment should be suspended. The patient should be raised to a comfortable position. These patients usually carry an inhaler containing β2 agonist with them. It is also an important component of the emergency kit. After establishing a clear airway, inhalatory β2 agonist should be administered. Oxygen is administered through a mask. If the patient does not improve, 1:1000 solution of epinephrine (0.01 mg/kg body weight, with a maximum dose of 0.3 mg) should be administered subcutaneously. The emergency medical service is called and uninterrupted oxygen supply is maintained until the patient breathes normally and/or medical help arrives 117.  Certain drugs are avoided or given with caution in asthmatic patients. These include,

  • Drugs containing aspirin (10-28% of all asthmatics may not tolerate the latter).
  • Nonsteroidal anti-inflammatory drugs (patients with intrinsic asthma).
  • Macrolide antibiotics in patients treated with theophylline.
  • Opiates (cause respiratory depression and histamine release).
  • Local anesthetics (used without adrenaline or levonordefrin, due to the sulfite preservative contents).
  • If the patient is receiving prolonged systemic corticosteroid therapy, supplements may be needed (prior to dental procedures that might cause stress).

The patient may also have a bronchial asthma attack during dental treatment. Anxiety may precipitate a bronchial asthma attack, so all the steps to minimize anxiety should be followed. Administration of antihistamines such as promethazine and diphenhydramine are avoided in these patients as they result in drying effect that can exacerbate the formation of tenacious mucus. Patients are advised to bring their regular medication with them. The management of bronchial asthma attack is similar to an asthmatic attack.

Management of an epileptic patient

Epilepsy is a disease that involves seizures, which are characterized by…………….

123

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Periodontal problems in epileptic patients:

Gingival overgrowth is one common problem faced by patients on phenytoin therapy. Approximately 50% of patients taking phenytoin develop gingival enlargement within 12-24  months  of  initiation  of  treatment 121, 122. For minimal gingival enlargement, maintenance of good oral hygiene has been shown to reduce the enlargement but in severe cases, surgical reduction is needed 123. Valproic acid has been shown to cause direct bone marrow suppression, resulting in impaired wound healing and increased postoperative bleeding and infections. Thrombocytopenia has been reported in 5% to 40% cases taking valproic acid but clinically significant bleeding is uncommon because thrombocytopenia is not so severe 124.

Periodontal treatment of an epileptic patient:

The major problem that is encountered during periodontal treatment of an epileptic patient is the precipitation of a seizure during treatment. To prevent such a situation dentist must record a detailed history of the condition. The detailed history of the patient should include,

  • The frequency of seizures;
  • The date of the patient’s last seizure;
  • The factors provoking seizures;
  • Whether there is any aura before seizures;
  • The consciousness and respiratory state of the patient during seizures;
  • The physical condition of the patient after a seizure;
  • Whether experiencing an aura always leads to a seizure;
  • The existence of status epilepticus.

The dentist should be able to recognize the early signs of a seizure if it takes place. Precautions should be taken before precipitation of seizure and the patient should be provided with supportive care if it does occur.

Stress is one of the most important factors which can precipitate a seizure attack, so the appointment of the patient should be kept in the early hours of the day. Shorter appointments are scheduled and during treatment, any sudden stimulus such as…..

123

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Management of an epileptic attack:

Many factors are responsible for the precipitation of an epileptic attack, including toothache and oral infections, which make patient uncomfortable, thus provoking an epileptic attack. If an epileptic attack precipitates during dental treatment, then following steps should be taken,

  • Treatment should be terminated and dental tampons, prostheses, and instruments should be removed.
  • Dental chair should be placed in a supported, supine position as near to the floor as possible.
  • The patient should not be restrained in any way and all efforts should be made to prevent any injury to the patient.
  • Any tight clothing the patient is wearing should be loosened.
  • If the patient has an aura, thick gauze tampons should be placed in the patient’s mouth in order to prevent any kind of injury or damage to the tooth.
  • Emergency medical support should be summoned.
  • Some patients fall into a deep sleep after a seizure. They should be monitored closely 129.
  • If the seizure lasts longer than 1 minute or for repeated seizures, administer a 10 mg dose of diazepam intramuscularly (IM) or intravenously (IV), or 5 mg of midazolam, IM or IV 127.
  • After the seizure is over, talk to the patient to evaluate the level of consciousness during the post-ictal phase.
  • The pending dental treatment is postponed to another appointment 118.
  • The patient should be kept under observation until his or her level of awareness is completely restored.
  • A brief intraoral examination is done to rule out any injury caused during a seizure.
  • After the patient regains consciousness, he/she should be sent home, preferably with an attendant.

Infectious diseases

Many patients with infectious diseases like human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections seek periodontal treatment. Other viruses of concern in the dental office include rubella, mumps and measles viruses; the herpes viruses (herpes simplex virus [HSV] types 1 and 2), varicella-zoster, Epstein-Barr virus [EBV], cytomegalovirus; human papillomaviruses; adenovirus; coxsackieviruses; and the upper respiratory tract pathogens (influenza A and B viruses, human parvovirus B19 and respiratory syncytial virus).

Hepatitis Viruses:

Hepatitis of viral origin comprises a heterogeneous group of diseases caused by at least 6 different types of viruses: A, B, C, D, E and G 115. The hepatitis viruses of most concern to dentists are the blood-borne HBV, HCV, and hepatitis D virus (HDV).  Hepatitis A is caused by the hepatitis A virus (HAV), which belongs to the RNA picornavirus family. The virus is transmitted via the enteral (oral-fecal) route. HAV infection is usually an acute, self-limiting disease with no sequelae or chronic disease state. The hepatitis B virus is a small DNA virus that belongs to the Hepadnaviridae family of viruses. The HBV infection may result in chronic liver disease and a chronic carrier state. The virus is transmitted through sexual contact, intravenous drug use and blood transfusions. Oral health care workers are at a risk of transmission of this virus through percutaneous transmission through punctures or cuts with instruments infected from HBV-positive patients, or absorption through the mucosal surfaces (eyes, oral cavity). Transmission through saliva can occur as a result of absorption from mucosal surfaces 115. The hepatitis C virus (HCV), causes chronic liver disease 130, 131. It is a RNA virus, mainly transmitted via the parenteral route from infected blood. Hepatitis D virus (HDV) is an unusual, defective, single-stranded RNA virus. It requires the presence of HBV to replicate. HDV infection develops only in patients who are positive for the hepatitis B surface antigen (HBsAg). Infection may be acquired along with HBV (co-infection) or after HBV infection (superinfection). Hepatitis E virus (HEV) is also associated with the development of liver disease in humans. Hepatitis G virus (HGV), is a lymphotropic human virus that is related to HCV. It has not been convincingly associated with any disease.

Periodontal treatment of hepatitis patients:

While providing oral health care to patients with hepatitis B and C in dental settings, the most important and frequent problems are, the risk of viral contagion on the part of the dental professionals and the rest of the patients (cross-infection), the risk of bleeding in the patients with serious liver disease, and alterations in the metabolism of certain drug substances that increases the risk of toxicity 132. HBV and HCV have been shown to exist on various surfaces in the dental operatory even many days after treating patients positive for hepatitis B and C 133. Appropriate disinfection and sterilization of instruments are very important to prevent transmission of the viruses.  Barriers such as masks, gloves, glasses or eye shields, and disposable gowns should be used by all personnel involved in delivering treatment to the patient. The disposable items used during the treatment of the patient (gauze, floss, saliva ejectors, masks, gowns, gloves, etc.) should be disposed of following the proper guidelines for biohazardous waste disposal. Disposable covers should be used for light handles, drawer handles, and bracket trays etc.

Patients with excessive liver damage due to infection may have altered coagulation, so it is recommended that prothrombin time, bleeding time, INR value or any other test related to blood clotting should be done prior to the treatment. If there are alterations which do not allow surgical treatment to be done, the patient’s physician should be consulted. After values of tests come to normal, the procedure can be carried out.

The patient should be asked to rinse with chlorhexidine mouthwash before starting the treatment. During the treatment, minimal aerosol production should be allowed by avoiding the usage of ultrasonic instrumentation, air syringe, or high-speed handpieces. After completion of the treatment, the instruments used in the procedure should be thoroughly scrubbed and sterilized.

Human immunodeficiency virus (HIV):

The HIV belongs to the retrovirus family. It contains two copies of single-stranded ribonucleic acid (RNA). Following infection of a cell, the viral RNA is converted to deoxyribonucleic acid (DNA). The viral DNA directs the transcription of viral RNA, which is directly incorporated into new viral particles or transcribed into viral proteins and subsequently integrated into newly formed virions 134. The virus is transmitted through body fluids or tissues. Common modes of transmission include unprotected sex, re-using drug-injecting equipment, and vertical transmission from mother to child 135, 136. The main targets for HIV infection are cells in the immune system, particularly CD4 cells, which are helper T-cells, carrying the CD4 surface antigen. The CD4 cells are central in generating an immunological response. Over time, CD4 cell counts decline, which results in immunodeficiency.

Oral manifestation of HIV:

There are various oral conditions associated with HIV. These conditions need to be treated appropriately to improve the quality of life of HIV patients. Oral manifestations are the earliest and most important indicators of HIV infection. Seven cardinal lesions: oral candidiasis, hairy leukoplakia, Kaposi sarcoma, linear gingival erythema, necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis and non-Hodgkin lymphoma are strongly associated with HIV infection and have been identified internationally. Other co-infections and conditions associated with HIV infection, which are significant to oral health care providers include:

  • Syphilis
  • Tuberculosis
  • Persistent generalized lymphadenopathy
  • Gastro-esophageal reflux disease (GORD)

Dental treatment of HIV-infected patients:

The oral lesions associated with HIV have been shown to be the first clinical signs of HIV infection. These early lesions include oral candidiasis, hairy leukoplakia, noma, and herpes zoster. The dentist is often the first person to identify this infection. Early diagnosis is needed for optimal treatment of HIV-related oral lesions, in particular, lesions such as acute necrotizing ulcerative gingivitis and necrotizing ulcerative. The precautions regarding the sterilization and disinfection during the treatment of HIV patient are similar to the treatment of HBV patients as discussed earlier. A detailed description of the management oral lesions in HIV patients has been given in chapter 29 “Management of HIV patients”.

Oral complications of chemotherapy and/or radiotherapy

The oral complications of cancer treatment arise in various forms and degrees of severity, depending on the individual and the cancer treatment provided. Patients on chemotherapy usually have bone marrow suppression resulting in immunosuppression.

The radiation therapy works by damaging the DNA in cancer cells. Since the radiation cannot distinguish between cancer cells and the normal cells the radiation therapy causes side effects 137. Radio-sensitivity of various cells varies according to their activity. The most radiosensitive cells have a high mitotic rate and therefore will undergo many future mitoses and are primitive in differentiation (e.g., basal cells of the oral mucosal membrane and spermatogenic and erythroblastic stem cells). Low radiosensitive cells are highly differentiated and the mature cells will not undergo division (e.g., neurons and striated muscle cells) 137. The radiation dose (Gy), dose rate (Gy/min) and oxygen availability are the factors which determine the extent of cellular damage. Following oral complications are usually found in patients on chemotherapy or radiotherapy,

Complications related to chemotherapy:

Oral mucositis:

It is the inflammation and ulceration of the oral mucosa increasing the risk for pain, oral and systemic infections.

Xerostomia/salivary gland dysfunction:

This is a common finding in these patients due to thickened, reduced, or absent salivary flow. It increases the risk of infection and compromises speaking, chewing, and swallowing.

Infection:

Due to immunosuppression, these patients are prone to viral, bacterial, or fungal infections, which commonly have their manifestations in the oral cavity.

Functional dysfunctions:

These patients have an impaired ability to eat, taste, swallow, and speak because of mucositis, dry mouth, trismus, and infection.

Bleeding tendency:

Bleeding is due to alterations resulting from thrombocytopenia (a consequence of bone marrow aplasia). Clinically, patients may present petechiae, ecchymosis, hematomas or diffuse bleeding in the oral cavity.

Complications related to radiotherapy:

Complications such as oral mucositis, infections, salivary dysfunction (hyposalivation), and taste dysfunction are commonly found in patients on chemo and radiotherapy. Other complications specifically related to radiotherapy are,

Radiation caries:

Patients on radiation therapy are at a risk of rampant dental decay that may begin within 3 months of completing radiation treatment, if changes in either the quality or quantity of saliva persist.

Trismus/tissue fibrosis:

There is a loss of elasticity of masticatory muscles that restricts the normal ability to open the mouth.

Osteoradionecrosis:

Due to high-dose radiation therapy, blood vessel compromise and necrosis of bone exposed occurs which results in decreased ability to heal, if traumatized.

Soft tissue necrosis:

Soft tissue necrosis can involve any mucosal surface in the mouth. Trauma and injury are often associated with non-healing soft tissue necrotic lesions, but spontaneous lesions can also appear.

Periodontal treatment of patients on chemotherapy and/or radiotherapy:

As already stated the patients on chemotherapy and/or radiotherapy demonstrate immunosuppression, which predisposes them to the development of various bacterial, fungal or viral infections. Chemotherapy is usually performed in cycles, with each cycle lasting several days followed by intervening periods of myelosuppression and recovery. So, it is recommended that if periodontal therapy has to be done, it should be done prior to the initiation of chemotherapy. It has been recommended that invasive dental procedures should be done when white cell counts are above 2000/mm3, with an absolute granulocyte count of 1000 to 1500/mm3 (35).

Management of patients on chemotherapy:

Before rendering treatment to the patient, the oncologist should be consulted to determine the current condition of the patient and the type of treatment planned. Complete intra-oral and radiographic examination has to be done to check the status of the dentition, periodontal condition and any periapical pathology and/or bone alterations. All foci of infections should be removed (caries, periodontal infection etc.). If the patient is wearing a denture, it should be checked and readjusted if required. In children, sealing of cracks and fissures in recently erupted molars and premolars is advised. Teeth with poor prognosis (pericoronitis, extensive caries, advanced periodontal disease and periapical disorders) should be removed at least two weeks before chemotherapy. If any major surgical procedure is to be carried out, it should be done 4-6 weeks before chemotherapy. The patient should be advised to maintain a good oral hygiene and oral rinses with 0.12% chlorhexidine are recommended.

During chemotherapy, the patient is usually treated for complications of chemotherapy (mucositis, xerostomia). No elective dental treatment should be carried out during chemotherapy and only emergency dental treatment is done. If any dental emergency is treated during chemotherapy, the drug should be prescribed with caution because antineoplastic agents cause bone marrow suppression to one degree or another, as well as variable liver toxicity, nephrotoxicity, ototoxicity and gastrointestinal disorders.

After the completion of chemotherapy, elective dental treatment can be given to the patient after consulting the oncologist regarding the immunological competence of the patient. Any focus of infection, if present, should be removed and the patient should be examined regularly during the maintenance phase.

Management of patients on radiotherapy:

Before radiotherapy, full mouth examination and X-ray examination are done as discussed in the previous section. The needful treatment is done and the patient is asked to maintain a good oral hygiene. During radiotherapy, the patient should be examined daily or at least at weekly intervals. Patients should be encouraged to drink plenty of water and other fluids. During and following radiotherapy, the teeth may become hypersensitive which could be related to the decreased secretion of saliva and lowered pH of secreted saliva. The topical application of a fluoride gel should be of benefit in reducing these symptoms.

Radiation therapy of the head and neck can cause damage to the vasculature of muscles, leading to trismus of the masticatory muscles and joint capsule. To minimize the effect of radiation on the muscles around the face and the muscles of mastication, a mouth block should be placed during external beam radiation. The patient should also perform stretching exercises at least 3-4 times daily 138.

Denture wearers are advised to remove dentures from the mouth for long periods, at least 8 hours per day. Dentures should be rinsed with the mouth rinse solution before placing them in the mouth. If dentures are required they should be fitted about 4-6 weeks after radiotherapy. Implants can be placed one to one and a half years after radiation therapy with a good knowledge of tissue irradiation fields, the degree of healing and vascularity of the region 139.

Conclusion

Many patients seeking dental treatment have some systemic condition which can alter the treatment plan for the patient. An appropriate management of these patients is essential in order to avoid any complication which can be sometimes life threatening. While rendering treatment to a medically compromised patient, the dentist should always be prepared for any complications that might occur during the treatment as well as their management. A medical emergency kit that contains all the essential drugs used in medical emergencies must be available in a dental setup and the dentist should be well trained to handle any medical emergency if it occurs while providing dental treatment.

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