Role of physician in oral health care/prosthodontic courses

INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Introduction
A dental surgeon practicing nowadays encounters a
plethora of patients with medical disorders in his/her
day-to-day practice.
 The successful management of these patients poses a
constant challenge to the dental profession.

Statistics of Medicine OPD
Total No. of patients seen in General Medicine OPD - 1,39,183
Number of Diabetics seen - 10,552 (7.58%)
Number of Hypertensive s- 17,485 (12.5%)
Number of cardiac patients -
(IHD, valvular diseases & arrhythmias) 3,719 (2.6%)
Patients with respiratory diseases -
(COPD, Asthma, TB) 1,406 (1%)
Neuro-psychiatric disorders - 300 (0.21%)

CONTENTS
Cardiovascular system
Respiratory
Diabetes mellitus
Hematologic
CNS

Case study-1
Laxman age 80 years, BP 200/90
R Hemiparesis with global aphasia
CVS, RS normal
ECG LVH, No ST T changes
 S/L Depin 5 mg given prior to extraction
 Stress reduction protocol followed.
 Advised Ditide and Ecosprin

Case study-2
Honnappa 35 yrs
Hypertensive on treatment
BP 160/120
ECG LVH; No evidence of ischemia
 Elective dental treatment deferred
 Advised Amlodepine + Atenolol

DENTAL CONSIDERATIONS IN
HYPERTENSION
Early morning and short appointments
Stress reduction – avoid anxiety; reassurance
 ?? Cap. Depin 5 mg S/L 10 min before treatment,
ECG should be normal.
LA with Adrenaline ?
Postural hypotension due to antihypertensive
agents- do not cause sudden elevation from
supine to upright position.

Ischemic heart disease

Case study 3
• Kalavati age 65 years
• Receiving Monosprin, Atorec, Zabesta AM and
Glycomet OD
• BP 130/90 mm of Hg, FBS 98 mg% PPBS 199mg%
• ECG Lateral wall ischemia
 Advised sub lingual Isosorbide di nitrate 5 mg
before dental extraction

Resting ECG
Exercise stress test
Thallium stress test
Angiography

Risk evaluation for IHD pts:

 Know the problem
 Know the medications
 Plan for emergencies
 Physician’s advice
 Anxiety can precipitate angina.
 Use shorter appointments & morning
appointments
 Consider oral Diazepam 10 mg pre operatively

 Sub-lingual ISORDIL 5mg pre-operatively.
 Patients with CABG do not require antibiotic
cover
 Dental treatment must be done with Lignocaine
and Adrenaline 1: 80,000 which is safe.
 Unstable angina & recent MI ( < 6 m) cases ~
risky.
 Avoid GA up to 6 months after MI.
DENTAL MANAGEMENT

VALVULAR & CONGENITAL HEART
DISEASE
 MS/MR , AS/AR – common valvular diseases
 ASD, VSD,PDA, Fallot’s Tetralogy – common
congenital HD.
 These patients are more prone for CCF,
arrhythmias, T/E and infective endocarditis.

Case study 4
Jayant 35 yrs
RHD MS MR
Needs inf endo prophylaxis
 Tab. Azee 500 mg 1 hour before dental procedure

Case study 5
Kallappa 29 years
Fallot’s tetralogy operated with a patch over the VSD
No cyanosis
Clubbing +
Pulmonary ejection systolic murmur +
No s/o CCF
 Advised Azee 500 mg 1 hour before dental extraction.

Case 6
Mallavva 50 yrs/ F
h/o CCF
On Acitrom 1 mg
PT with INR necessary
 Stop Acitrom for 3 days repeat INR, If less than 1.5,
extraction can be done.
 Acitrom restarted on the next morning.

Normal ECG

ARRHYTHMIAS
A disturbance of the normal rhythm of the heart.
Often a manifestation of atherosclerotic heart disease.
Can be exacerbated by stress & anxiety during dental Rx.
Pt evaluation:
Frequency & severity – pt may say “ skipped beat” or
“palpitations”
Pulse rate and rhythm

Guidelines for Rx
Minimize stress, short procedures with adequate
sedation.
Minimize use of adrenaline
Fainting maybe due to bradycardia, heart blocks or
atrial tachycardias
For patients with pacemakers- electro-surgery and
diathermy major hazard. Pulp testers, ultrasonic
scalars, belt-driven dental motors have a small risk.

Respiratory
Diabetes mellitus
Hematologic
CNS

Case study 6
Somanna 60 yrs/M
COPD with OSMF receiving Tiova
Pulse 84/min
BP 150/90
CVS Normal
RS - Bilateral rhonchi
 Inj. Deriphylline 1 amp i.m. before dental treatment
 Avoid NSAIDs after extraction

Dental considerations in COPD
 Treatment deferred in case of acute respiratory infection
 Avoid NSAIDs
 Avoid LA with Adrenaline to prevent arrhythmias.
 Evaluate for adrenal suppression for all pts on steroids
 Avoid drugs that may depress respiratory function-
Nitrous oxide inhalation, sedation, tranquilizers or
narcotics. Non- narcotic analgesics are preferred.

DENTAL CONSIDERATIONS IN ASTHMA
 Patients on steroid inhalers prone to oro-pharyngeal
candidiasis.
 Systemic steroids have their own complications.
 Patients on ipratropium may have dry mouth.
 Erythromycin, Clindamycin, ciprofloxacin are
relatively contraindicated in pts on methyl
xanthines.
 Avoid NSAIDS

Case study 7
Anusuya age 50 years
Known to have DM since 2 years
Receiving Ayurvedic medicine
RBS 520 mg%
 Elective dental treatment postponed
 Patient has been advised Blood urea, S.creatinine,
Lipid profile, FBS and PPBS
 Started on TRIBET 2mg 1+1
 Called back after 15 days

Dental management of DM
 RBS< 200mgs%, FBS< 120mgs%
 Minimize stress- Short mid-morning appointments
 Dietary instructions: Instruct pt to continue normal
dietary intake before the procedure
 Minimize the risk of infection: frequent recall
examinations & prophylaxis, post operative antibiotics
for any surgical procedure

Case study 8
Pavankumar age 21 years
Known case of Hemophilia A
aPTT
Factor VIII levels
 Admitted in Craniofacial unit administered 1130
units Factor VIII before extraction
 Given Inj Tranostat 1 amp i.v. after extraction,
adrenaline pack given and prescribed Tranexamic
acid tablets tid x 4 days.

Case study 9
Khalida age 35 years
c/o generalized weakness and giddiness
o/e pallor of conjunctiva and nails and pale bald
tongue
Hb 6.5 gm%
PS microcytic hypochromic
 Advised Inj. Jectofer 1 amp i.m. on alt days,
 Orofer OD and Alworm 4oo mg hs

Liver disease- Case study 10
Mukesh age 19 years
Operated for DNS 4 years back
HBsAg +
S.Bilirubin 0.4 mg%
SGPT 23 IU/ml
 Fit for dental treatment
 Universal precautions
 Evaluate for bleeding tendencies
 Avoid hepatotoxic drugs.

Respiratory
Endocrine
Hematologic
Liver disease
CNS

Case 11
Munna age 22 years
Known epileptic
Receiving Garoin 1 tab at bedtime and Eptoin 1 in
morning
Last episode 8 months back
 Look for gingival hyperplasia
 Fit for dental treatment

EPILEPSY
High risk:
 h/o seizure in the past 1 month
 k/c/o epilepsy and who has stopped treatment
against medical advice
 Manage stress
 Diazepam / Midazolam 10mg before treatment.
 Psycho sedation – nitrous oxide and oxygen.
 Short appointments
 Be prepared for an emergency.

CONCLUSION
A basic knowledge regarding the underlying medical
condition of a dental patient helps us to reduce the
incidence of medical emergencies in the dental office.
By discovering a systemic problem before any dental
treatment, the dentist can defer treatment until pt can be
checked by a medical consultant or modify dental
treatment.
Oral Medicine dept. in dental colleges could screen dental
patients >40 years for systemic illnesses; PGs in Oral
Medicine maybe posted in General Medicine dept of
Medical colleges for appropriate training.

“We have a hunger of the mind which asks
for knowledge of all around us, and the
more we gain, the more is our desire; the
more we see, the more we are capable of
seeing”….. Maria Mitchell
The hunger for knowledge is
insatiable…
Thank you

Role of physician in oral health care/prosthodontic courses

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