Introduction

Theborderlinebetweenmedicineanddentistryisnotalwayssharplydefined.Somedentistshavebeen criticizedforattemptingtopracticemedicinebyextendingtherangeoftheiractivitiesintofields notcommonlythoughofasdental.However,adistinctionshouldbemadebetweenpracticing medicineandknowingaboutit. Thedentallicenseimposesnolimitationsontheamountofknowledgewhichadentistmaysecurefor hisownprotectionandforbetterdentalcareofhispatients. Wheneveradentistisindoubtaboutthephysicalstatusofapatientheshouldenlisttheaidofa physicianthroughconsultationorreferral.Physiciansreactfavorablytothisgestureof interprofessionalliaisonandwilldevelopthehabitofcallinguponthedentistfordecisionslying withinhisfield. Somesystemicdisordersconstituteanabsoluteandsomearelativecontraindicationtosurgery.The dentistshouldalwayskeepinmindthemaxim"firstofall,donoharm ." So,abriefpastandfamilyhistoryshouldbeobtained,clinicalexaminationandcarefulvisual evaluationbasedonadequateknowledgeandskillisanimportantfactorindetecting manyof implicationsofsystemicdiseasesinthesurgicalpatient.Radiographicexaminationandlaboratory testsarenecessaryadjunctsindiagnosisandmanagement.

Prevention is the most important phase of treating medical emergencies. It must be remembered howeverthatdespitealleffortsatpreventionEMERG ENCIESwillhappen. Therearethreestepstopreventionofmedicalemergenciesinthedentaloffice: 1. Medical History a) Arethereanyrecentchangestohealth? b) Isthepatientunderthecareofaphysician? c) Hasthepatienthadanyseriousillnessoropera tion? d) Doesthepatienthaveanyallergies? e) Isthepatienttakinganydrugsormedications?Remembertoaskaboutoverthecounter medicationsaswell. f) Isthepatientpregnant? g) Foralreadydiagnoseddisordersmustask: 1. Whendidthepatientdevelopthediseaseorproblem? 2. Howistheproblemcontrolled? 3. Isthereanythingthatmakestheproblemworse? 4. Hasthepatientbeenhospitalizedfortheproblem? 5. Arethereanyrestrictionsonthepatient? Medical History Algorithm SAMPLE (Medical/EMSalgorithmbutbasicprinciplecanbeappliedtodental.) Symptoms Allergies Meds PreviousHistory LastIncident Eventsleadingtoproblem 2. Patient Evaluation a) Recordvitalsigns. b) Completedentalexam. c) Visualinspectionofthepatient

Basic Principles of Medical Emergency Management

 Formulateyourtreatmentplanatthisstage.Determinehowthistreatmentplanrelatestoand affectsorisaffectedbythefindingsofthemedicalhistoryandevaluation.Obtainmedicalconsults ifneededatthispoint.Reasonstoob tainamedicalconsultincludedoubtexistsastothepatients condition,historyofdangerousorsuspicioussignsorsymptoms,historyofuncontrolledillness, multiplemedications,ASAclass3orhigher. ASA Physical Status Classification Class1:Healthypatientwithnosystemicdisease. Class2:MildSystemicdiseasewithnolimitsonactivity. Class3:Severesystemicdiseasethatlimitsactivity. Class4:Incapacitatingsystemicdiseasethatislifethreatening . Class5:Moribund 3. Staff Training and Preparation a) Training:Staffneedstohavetheknowledgetoidentifyandcorrectlymanageeach emergency. b) Easilyaccessibleemergencyequipmentanddrugs. c) Coordinationofofficepersonnel. WhatisadequatePreparation?Guidelinesvarybystateandorgani zation.Ingeneralitis expectedthatthedoctorwillbeabletoinitiateemergencymanagementandbecapableof sustainingavictimslifethroughtheapplicationofBasicLifeSupport.Intimesofcrisis simplicityhaltsconfusion! Basic Principle of Managing all Medical Emergencies 1. BLS:rememberABCs 2. Placethepatientsupine. 3. Callforassistance. 4. Assurepatientifconcious. 5. Maintainairway. 6. PlacepatientonOxygenasindicatedbynatureofemergency. 7. Monitorvitalsigns. 8. Diagnosenatureofevent. 9. Initiatespecifictreatment 10.Document,Document,Document! Stress Reduction Protocol for the Anxious Patient 1. Recognizepatientsanxietylevel. 2. Considerusingpremedicationorsedation 3. Schedulemorningappointments. 4. Minimizewaitingtimeandwatchappointmentlength. 5. Makesuretouseadequatepaincontrol.Thiswillvaryfrompatienttopatient. 6. Monitorvitalsigns. 7. Medicalconsultifrequired.

The most common medical problems that require the dentist to be knowledgeable in recognition and management during the course of dental treatment :

1Cardiovasculardiseases,includingtheentirebroadscopeofcardiacandperipheral vascular disease. 2Liverdiseases a.Infectionshepatitis b.Obstructioncirrhosis,infectionsandextrahepaticcauses,forexample,cholecystitisand cholelithiasis

 3Endocrinediseases a.Hyperthyroidism b.Diabetes c.Hypoadrenalism 4Chronicobstructivelungdiseases a.Emphysema b.Asthma 5Renaldiseases a.InfectionssuchasGlomerulonephritisandpyleonephritis b.Systemiceffectsofazotemiafrommultiplecauses c.Managementofthetransplantpatient 6Hematologicdisorders a.Leukemia b.Bleedingdiatheses 7Centralnervoussystemdisorders 8Chronicdebilitatingdiseases 9Iatrogenicdiseases a.Irradiation b.Anticoagulation c.Longtermsteroidtherapy 10Anyallergicconditions 11Thedrugsormedicamentstakenbythepatient

Peripheral vascular disease

Itisobviouslyofgreatimportancetoevaluatethecardiovascularsystempriortosurgery. Thediseasestobecosideredcanberoughlyclassifiedas: a. Peripheral vascular or b. Cardiac in origin Themainentitiestobeconsideredwithregardtoperiphe ralvasculardisease: a.Advancedatherosclerosisb.Hypertension Hypertension Blood Pressure *Thepressureexertedbythebloodagainsttheinteriorwallsofthearterialsystem *SoundsproducedbyturbulentbloodflowarecalledKorotkoffsounds,aftertheRussian physicianwhodescribedthistechniquein1905

Cardiovascular Diseases

*Korotkoffsounds:Firstappearan ceofsoundsisthe systolicpressurethecompletedisappearance ofsoundsisthe diastolicpressure. *Prevalenceincreaseswithage>halfofpeopleoverage65haveHBP *Systoloicpressurerisesthroughoutlifediastolicpressurelevelsofforfallsaft erage50 ThehighertheBP,thegreatertheriskofstroke,MI,heartfailure,andkidneydisease

 BloodPressureandCardiovascularRisk *incrementriseof20mmHginsystolicBPor10mmHgindiastolicBP doublestheriskof cardiovasculardiseaseacrosstheentirerangefrom115/75to185/115mmHg Forindividualsaged4070years,each Lewington,Lancet2002360:19031913 *Hypertensionisaninsidiousdiseaseandmayremaincompletelyasymptomaticformanyyears Measurementofbloodpressureistheonlymeansofdetection Target Organ Damage (occurs after many years of elevated blood pressure) 1Heart 2Leftventricularhypertrophy 3Angina/priorMI 4Priorcoronaryrevascularization 5Heartfailure6Brain 7StrokeorTIA 8Dementia9Chronickidneydisease 10Peripheralarterialdisease 11Retinopathy Early Elevatedbloodpressurereadings Narrowingandsclerosisofretinalarterioles Headache Dizziness Tinnitus Advanced Ruptureandhemorrhageofretinalarterioles Papilledema Leftventricularhypertrophy Proteinuria Congestiveheartfailure Anginapectoris Renalfailure Dementia Encephalopathy

Signs and Symptoms of Hypertensive Disease

ClassificationandFollowupofBloodPressureMeasurementforAdultsAged18YearsorOlder* Category** SystolicBlood Pressure (mmHg) <130 130139 140159 DiastolicBloodPressure (mmHg) <85 8589 9099 Followup Recommendedfor DentalPatients Recheckatrecall(within 2years) Recheckatrecall(within 1year) Recheckwithin1month ifstillelevatedhave patientevaluatedby physicianwithin1month Recheckwithin2weeks ifstillelevatedhave patientevaluatedby physicianwithin2weeks Havepatientevaluatedby physicianwithin1week Havepatientevaluatedby physicianimmediately

Normal HighNormal Hypertension***:Mild (Stage1)

Hypertension***: Moderate (Stage2) Hypertension***:Severe (Stage3) Hypertension***:Very Severe

160179

100109

180209 >or=210

110119 >or=120

 (Stage4) Dental Considerations Evaluationofapatientwithhypertension: Determine: Timeofdiagnosisofhypertension. Presentmedication(s)anddosageusedtocontrolhypertensionaswellasanyrecentchangesor modificationstoantihypertensivemedication(s)ordosage. Thepresenceofanysystemiccomplicationssecondarytohypertensionincludingretinopathy, nephropathy,historyofcerebrovasculardisease,orcardiovasculardisease.

PhysicalandDentalExam:

Establishthepatient'sbaselinebloodpressureatthefirstdentalappointment.Twotothree bloodpressuremeasurementsseparatedbyatleastfiveminutesshouldbetaken ,andthe resultsaveragedtodeterminethepatient'sbaselinebloodpressure.Thepatient'sbaseline bloodpressurewillserveasapointofreferencefromwhichtomakedecisionsforthe emergencymanagementofthepatientshouldacardiovascularoradve rsereactiondevelop duringdentaltreatment.Thepatient'sbloodpressureshouldbecheckedatallsubsequent appointmentspriortotheuseofalocalanesthesia.

DentalManagementPrecautions: Reducestressandanxietyduringdentaltreatment:consider theuseofN 2OO2inhalation sedationand/orpremedicationwithoralantianxietymedicationssuchasbenzodiazepines. Donotuselocalanestheticswithvasoconstrictorsinpatientswithuncontrolledorpoorly controlledhypertension.Thisisdefinedasanypatientwithasystolicbloodpressuregreater thanorequalto180mmHgand/oradiastolicbloodpressuregreaterthanorequalto100 mmHg. Forpatientswithcontrolledhypertension,wheretheuseoflocalanestheticswith vasoconstrictorsisnotcontraindicatedbecauseofpotentialdruginteractions,limitthetotal doseofvasoconstrictortomaximumof0.04mgofepinephrine(2.2carpulesof2%lidocaine with1:100,000epinephrine)or0.2mgoflevonordefrin(2.2carpulesof2%carbocainewith 1:20,000levonordefrin).

Additionalprecautions: Avoidtheuseofepinephrineimpregnatedgingivalretractioncord. Avoidtheuseofvasoconstrictorsfordirecthemostasistocontrollocalbleeding. Avoidtheuseofalocalanestheticwithvasoconstrictors forintraligamentaryor infrabonyinfiltrations. Avoidstimulatingthegagreflexinpatientswithahistoryofhypertension.

o o o

TreatmentPlanningConsiderations:

Therearenospecifictreatmentplanningmodificationsorconsiderationsforpatientswith controlledhypertension.Noelectivedentalproceduresshouldbeperformedonapatientwith severeoruncontrolledhypertension.

DentalDrugInteractions:

Concurrentuseoflocalanestheticswithvasoconstrictorsandnon cardioselectivebeta adrenergicblockerscanresultinanacuteelevationofbloodpressureandreflexbradycardia.


Inpatientswithhypertension,alocalanestheticagentwithoutavasoconstrictorshouldbe used.

Useofalocalanestheticwithavasoconstrictorconcurrentlywithreser pine(Serpasil), canresultinapossibleprolongedand/orincreasedeffectofthevasoconstrictor.In addition,theuseofnorepinephrineinpatientstakingmethyldopa(Aldomet)and guanethidine(Ismelin)mayresultinanincreasedpressoreffectofnorep inephrine,resulting inhypertensionandanincreasedtendencytodevelopcardiacarrhythmias(guanethidine). Thisreactionmayalsooccurwhenothervasoconstrictors(e.g.,epinephrine,levonordefrin) areusedconcurrentlywithmethyldopaorguanethidine. Nonsteroidalantiinflammatorydrugs(NSAIDs)decreasetheantihypertensiveefficacyof diuretics(especiallyloopdiuretics),betaadrenergicblockers,ACEinhibitors, hydralazine(Apresoline),prazosin(Minipress),andselectivealpha 2agonists(toalesser degree).Thepatient'sbloodpressureshouldbemonitoredfrequentlywhenNSAID'sand theseantihypertensivesareusedconcurrently,especiallyifNSAIDtherapyisnecessary longerthan5days.

Betaadrenergicblockersimpairthehepaticmetabolismofamidelocalanestheticsresultingina possibleincreasedriskoflocalanesthetictoxicitywithhighdoses.Thisreactionusuallywillnot haveclinicalsignificancegiventheamountsoflocalanesthetictypicallyusedforasingledental procedure(e.g.,lessthan120mgoflidocaineorequivalent).

Dental Management and Followup Recommendations Based on Blood Pressure DentalTreatment Recommendation

BloodPressure

Referralto Physician
NO

>120/80

Anyrequired

120/80but <140/90

AnyRequired

Encouragepatientto seephysician

140/90but <160/100

Anyrequired

Encouragepatientto seephysician

160/100but <180/110

Anyrequired considerintraoperative monitoringofBP forupperlevelstage 2

Referpatientto physicianpromptly (within1month)

180/110

Deferelective treatment

Refertophysicianas soonaspossibleif patientis symptomatic,refer immediately

Hypotension Signs and Symptoms of Hypotension 1. Weakness. 2. Diaphoresis. 3. Decreasedlevelofconsciousness. 4. Possiblenauseaandvomiting.

 MANAGEMENT OF HYPOTENSION: Thetreatmentofhypotensionisbasedontreatingtheetiology.Possibleetiologiesinclude PsychologicalFactors(Stress),OverdoseofMedication,PosturalChanges,Coexisting Disease, Hypovolemia,AnestheticOverdose,Reflex(Pain),Hypoxemia,andHypercarbia. 1. 2. 3. 4. Stopdentaltreatmentandremoveallforeignobjectsfromthepatientsmouth. AdministerOxygen. Placepatientinsemirecumbentpositionwithlegselevatedabovetheleveloftheheart. Monitorandrecordvitalsigns,checkpulseforrate,rhythm,andcharacter(Isitstrong,weak, thready,etc.) 5. Checklevelofconsciousness. 6. Ifpatientdoesnotrespondtotheabovetreatmentamajorsystemiccomplicationshouldbe considered.ActivateEMSatthispoint.ConsiderpossiblePulmonaryEmbolism,Cerebral VascularAccident(Stroke),MyocardialInfarction,andCongestiveHeartFailure. 7. IfAvailablestartIV(18gaugecatheterwithNormalSaline.) Valvular Heart Disease (Infective Endocarditis) *Occursinpatientwithpreexisitingvalvularheartdiseaseeithercongenitaloracquired.The causativemicroorganisms(Streptococcus Viridans)enterthecirculationwhenbleedingoccures duringextractionofteethorevenduringgin givalsurgery.Whithoutadequateantibioticcoverage,the microorganismwilladheretotheroughenedordamagedareasoftheheart.Inflammationthenresults formingplateletadhesionsandcrumblingvegetations.Thefragmentsarecarriedinthecirculation as emboli. Clinical Features Theseareofincidiousonset,whichoftencausesdelayindiagnosis.Severalbloodculturesareoften requiredtoconfirmthediagnosis. 1 Signsandsymptomsofsepticemia 2 Changingheartmurmurs 3 Fingerclubbingandnailbedhemorrhages 4 Otheremboliccomplicationse.g.hematuria 5 Endresultmaybecardiacfailureanddeath Prognosis Untiltheadventofantibiotics,thediseasewasinvariablyfatal Prophylactic measures: 1Carefulhistorytakingfrompatientstoidentifypatientsa trisk Patientwithhistoryofcongenitalheartdiseases. Patientswithhistoryofrheumaticfever. Patientswithprostheticvalvularheartsurgery 2Medicalconsultationwhereindivated 3Antibioticcoverageshouldbegiventothepatientimmediatelypr eopertativelyandnot24hoursor morepreoperatively. 4Antibioticdrugshouldbebactericidal,thustetracyclinewhicharebacteriostaticaretotally unsuitable. 5Sufficientlyhighbloodlevelofthedrugshouldbeattainedandmaintainedforaminimu mperiod of3dayspostoperatively. Patients at risk from infective endocarditis High risk Prostheticvalves Previousinfectiveendocarditis Variable risk Congenitalheartdisease

 Degenerative(calcific)aorticvalvedisease Hypertrophiccardiomyopathy Mitralvalveprolapsewithsystolicmurmur Rheumaticheartdisease Syphiliticheartdisease Hurler'ssyndrome Osteogenesisimperfecta Procedures requiring antimicrobial prophylaxis in persons at risk from endocarditis Toothextraction Oralsurgeryinvolvingtheperiodontaltissues Periodontalsurgery Subgingivalproceduresincludingscaling Intraligamentaryinjections Reimplanationofavulsedteeth Procedures for which antimicrobial prophylaxis is not recommended in persons a t risk for endocarditis Exfoliationofprimaryteeth Localanaestheticinjections,otherthanintraligamentary Nonsurgicalproceduresthatdonotinducebleeding Choice of prophylactic antibiotic regimen against infective endocarditis Therecommendationsasfollow: 1-Patients not requiring a general anesthetic and with no history of infective endocarditis: a.(not allergic to nor received a penicillin more than once in the past month. Adult dose:3gamoxycillinorallybefortheoperation,takeninthepresenceofthedentistornurse . Children under 10:onehalftheadultdose Children under 5:aquarteroftheadultdose b. Patient allergic or who have received a penicillin more than once in the previous month Adult dose:asingleoraldoseofclindamycin600mgcanbegivenonehourbeforethedental procedure Children under 10:onehalftheadultdose Children under 5:aquarteroftheadultdose Alternatively,1.5gerythromycinstearatecanbegivenorallyundersupervision12hourbeforethe dentalprocedure,followedbyaseconddoseo f0.5g6hourlater. Children under 10:onehalftheadultdose Children under 5:aquarteroftheadultdose (Patient who have had endocarditis should be managed as in (2) below: 2-Treatment under general anaesthesia- patient with natural valve dise ase and no history no history of infective endocarditis, but not allergic to nor received a penicillin more than once in the past month : Amoxicillin1gI.M.orI.V.in2.5mlof1percentlignocainebeforeinductionplus0.5gofamoxycillin orally5hourlater. Alternatively,3gofamoxycillinmaybegivenbymouth4hoursbeforeinductionandrepeatedas soonaspossibleafterinduction,iftheanesthetistagrees. 3-Treatment under general anaesthesia patients with prosthetic valves or previous endocarditis, not allergic to nor have had a penicillin more than once within the past month: Amoxycilline1gI.M.in2.5mlof1percentlignocaineoramoxycillin1gI.V..plusgentamicin120mg I.M.orI.V.immediatelybeforeinduction.Afurther0.5gofam oxycillinshouldbegivenorally6houe later.

 Patientallergicorwhohavereceivedapenicillinemorethanonceinthepreviousmonth:Vancomycin 1gbyI.V.infusionover100minfollowedby120mgofgentamicinI.V.beforeinduction. Alternatively,I.V teicoplanin400mgplusgentamicin120mgmaybegivenatinduction,orI.V. clindamycin300mgmaybegiven10minutesbeforeinductionfollowedbyoralclindamycin150mg after6hours. 4- Patients who have had a previous attack of infective endocarditis (irrespective of the type of anaestlietic) but not allergic to nor received a penicillin more than once in the past month: Amoxycilline1gI.M.in2.5mlof1percentlignocainoramoxycillin1gI.V.plusgentamicin120mg I.M.orI.V.immediatelybefor edentalprocedure.Afurther0.5gofamoxycillinshouldbegivenorally 6houelater. Patientallergicorwhohavereceivedapenicillinemorethanonceinthepreviousmonth:Vancomycin 1gbyI.V.infusionover100minfollowedby120mgofgentamicinI.V.beforeinductionor Alternatively,I.Vteicoplanin400mg. The reason different cover is given for those who are going to have a general anaesthetic is that: Parenteraladministrationremovestheriskofvomiting Itisnotfeasibletogivesuchlarged oses(3g)odamoxycillineforexamplebyinjection,henceit hastosupplementedwithgentamicin.

Additional measures
1 Applicationofanantisepticsuchas10percentpovidoneiodine.0.5percent.chlorhexidineor tinctureofiodinetothegingivalcrevicebeforethedentalproceduremayreducetheseverityof anyresultingbacteraemiaandmayusefullysupplementantibioticprophylaxisinthoseatrisk. chlorhexidinemouthrinsesappearnottobehelpfulinthisrespect. 2 Gooddentalhealthshouldreducethefrequencyandseverityofanybacteraemiasandalso reducetheneedforextraction. 3 Itisessentialthat,evenwhenantibioticcoverhasbeengiven,patientsatriskshouldbe instructedtoreportanyunexplainedillness.Infectiveendocarditisis oftenexceedingly insidiousinoriginandcandevelop2ormoremonthsaftertheoperation,whichmighthave precipitatedit.Latediagnosisconsiderablyincreaseboththemortalityordisabilityamong survivors. 4 Patientsatriskshouldcarryawarningcardtobe showntotheirdentisttoindicatethedanger ofinfectiveendocarditisandtheneedforantibioticprophylaxis. 1 Bedrest. 2 Intenseprolongedantibiotictherapybaseduponbloodcultureandsensitivitytestfor 6week. 3 Treatmentofcomplicationsofembolismorcardiacfailureastheyarise. Ischemic Heart Disease Coronary Heart Disease: Myocardial Ischemia Decreasedbloodsupply(andthusoxygen)tothemyocardiumthatcanresultinacutecoronary syndromes: Anginapectoris Myocardialinfarction Suddendeath(duetofatalarrhythmias) PathophysiologyofAtheromatousPlaques Depositionofcholesterolintheintimaandsmoothmuscle Proliferationofsurroundingfibroustissueandsmoothmuscle Internalbulgingofvesselwithnarrowingofthelumenlimitingbloodandoxygensupply resultinginischemiaand/orarrhythmias Roughsurfacescanruptureandcausebloodclotsandemboliresultinginvesselocclusion

Treatment:

 Spectrum of the Atherosclerotic Process CoronaryArteries(angina,MI,suddendeath) CerebralArteries(stroke) PeripheralArteries(claudication)

Angina Pectoris

Briefsubsternalpain Selflimitingwithcessationofprecipitatingevent Precipitatedbyexercise,stress,eating,sex,etc Mayoccuratrestorwhileasleep Clinical Patterns of Angina Pecto ris Stablepainpatternandcharacteristicsrelativelyunchangedoverpastseveralmonths(better prognosis) Unstablepainpatternchanginginoccurrence,frequency,intensity, orduration(poorerprognosis)MIpending Medical Management of Angina Medications nitrates betablockers calciumchannelblockers antiplateletagents antihyperlipidemics Surgery Percutaneoustransluminalcoronaryangioplasty/balloonangioplasty/stent Coronaryarterybypassgraft(CABG) Dental Considerations: Nitrates VasoconstrictorInteractions: Noclinicallysignificantinteractions OralManifestations: topicalburningatsiteofcontact OtherConsiderations: orthostatichypotensionandheadachepossiblefollowingadministration Dental Considerations: Beta Blockers Whilethereisapotentialforanenhancedhypertensiveeffectofepinephrineinapatienttaking anonselectivebetablocker,itisclinicallyunlikelythatsuchareactionwilloccur

 Ifapatientistakinganonselectivebetablocker(e.g.propanolol,sotolol),itisprudenttolimit the amount of epinephrine administered to that found in two carpules of 1:100,000 concentration(0.036mg) Inpatientstakingacardioselectivebetablocker(e.g.metropolol),nolimitationsarerequired Dental Considerations: Calcium Channel Blockers Therearenosignificantdruginteractionsreported Gingivalhyperplasiacanoccurinpatientstakingcalciumchannelblockersclosemonitoring andencouragementofoptimaloralhygieneisnecessary Dental Considerations: Antiplatelet Agents With a single agent (e.g. aspirin, Plavix), expect some increased perioperative and/or postoperativebleedingbutitisnotusuallyclinicallysignificantandcanbemanagedbylocal measuressuchaspressure,suturing,stents,etc.pr eoperativewithdrawalisnotjustified Thecombinationofaspirinwithotherinhibitorsofplateletaggregationincreasesthechances for significant bleeding depending upon extent of surgery, it is advisable to discuss the risk/benefitoftemporarydiscontinuationwiththephysician Dental Considerations: HMG-CoA Reductase Inhibitors ThecombinationoftheHMGCoAreductaseinhibitorswitherythromycinorclarithromycin (CYP3A4inhibitors)maybeassociatedwithanincreasedriskofadversedrugeffects on muscle(rhabdomyolosis)andkidney(acuterenalfailure) AvoidconcurrentuseofHMGCoAreductaseinhibitorswitherythromycinorclarithromycin. Dental Considerations Balloon Angioplasty / Stent Theseproceduresarenotassociatedwithanincreasedriskofbacterialendocarditisor endarteritis.Therefore,antibioticsarenotrecommendedfollowingaballoonangioplastynor aretheyrecommendedforpatientswithastent. Dental Considerations: Coronary Artery By-Pass Graft (CABG) TheCABGdoesnotincreasetheriskforBE,thereforeantibioticprophylaxisisnotrecommended PostMyocardialInfarction MI,Coronary,HeartAttack Infarctionanareaofnecrosisintissueduetoischemiaresultingfromobstructionofbloodflow Dental Management Correlate Electivedentalcareisokifithasbeenlongerthan 46weekssincetheMIandthepatientdoes notreportanyischemicsymptoms. Ifthereisanydoubtorquestion,consultwiththecardiologist. Drug Therapy: Warfarin (Coumadin) Action: inhibits vitamin K which is a precursor for clotting factors II, VII, IX and X Dental treatment, including minor surgery, is unlikely to be problematic if INR is within the therapeutic range Dental Management: Stable Angina/Post-MI >4-6 weeks Minimizetimeinwaitingroom Short,morningappointments Preop,intraop,andpostopvitalsigns Premedicationasneeded anxiolytic(triazolamoxazepam)nightbeforeand1hourbefore Havenitroglycerinavailablemayconsiderusingprophylacticaly Usepulseoximetertoassuregoodbreathingandoxygenation Nitrousoxide/oxygenintraoperatively(ifneeded)

 Excellent local anesthesia use epinephrine, if needed, in limited amount (max 0.04mg) or levonordefrin(max.0.20mg) Avoidepinephrineinretractioncord Dental Management: Unstable Angina or MI < 3 months Avoid elective care For urgent care: be as conservative as possible do only what must be done (e.g. infection control, pain management) Consultation with physician to help manage Consider treating in outpatient hospital facility or refer to hospital dentistry ECG, pulse oximetry, IV line Use vasoconstrictors cautiously if needed Intraoperative Chest Pain Stopprocedure Givenitroglycerin Ifafter5minutespainstillpresent,giveanothernitroglycerin Ifafter5moreminutespainstillpresent,giveanothernitroglycerin Ifpainpersists,assumeMIinprogressandactivatetheEMS Giveaspirintablettochewandswallow Monitorvitalsigns,administeroxygen,and bepreparedtoprovidelifesupport Periodontal Disease and Coronary Heart Disease ThereappearstobeanassociationbetweenPDandCHDexactrelationshipunclear Possiblyrelatedtotheinflammatoryeffectsofbacterialproducts,i.e.endotoxins,LPSeffect onendotheliumclotformation Possiblynocauseeffectrelationshipatall Studiesareunderwaytomoreclearlydefinethisrelationship Heart Failure Astatewherethemyocardiumcannotmaintainthenormalcirculation,andthuscausecardiacfailure. Either the left side or the right side of the heart may fail first, but eventually both sides will be involved. Common causes: 1 Hypertension. 2 Pulmonarydiseases. 3 Ischemicheartdiseases. 4 Vavularheartdiseases. Sings and Symptoms: 1 Rapidfatigue. 2 Breathlessness. 3 Edemaoftheankle. 4 Nonreproductivecough. 5 Prominentlargeveinsintheneck Mostofthesepatientsareambulatoryandreceivingtheirmedications,mostlikelycardiacglycosides andtheiractivityisrestricted. Precautions: 1 Medicalconsultation. 2 Shouldbetreatedwithcautiontoavoidtachycardiathatmayexaggeratethealreadyexisting condition. 3 Preoperativesedationplusgoodpaincontrolshouldbemaintained. 4 TheuseofV.C.inL.A.shouldbekeptatminimum. 5 Periodiccheckupofpulserateduringsurgery:Inasignificantriseofpulseratearestperiod isrequiredoritmaybenecessarytoterminatethedentalappointment.

 Thrombosis and thrombophlebitis Athrombusisasolidbloodclotformedwithinavessel: Etiology: 1 Increasedcoagulabilityofblood 2 Stasisofblood 3 Damagetovesselwallsastrauma,irritantdrugs,andinflammation(phlebitis) Management of those patients usually by anticoagulant therapy such as (heparin) or (macromar) to reduce the prothrombin level. Patients on anticoagulant therapy usually bleed excessively following anysurgicalprocedure. Precautions: 1 Medical consultation is important before dental surgery. A joint decision between the dental surgeonandphysicianshouldbeperformedasto: Decreaseorwithdrawtheanticoagulanttherapy. Raisetheprothrombinlevelsbyinjectionofvitamink. Use of local haemostatic measures after surgery such as Gel foam with thrombin or oxidizedcellulose(Surgicel). 2 Extractionofteethiscontraindicatedifprothrombindeficiencymorethen 20%.

Respiratory Diseases
Asthma Attack Signs and Symptoms of an Asthma Attack 1. SenseofSuffocation,patientwillsitupliketheyarefightingforair. 2. Pressureortightnessinchest. 3. Nonproductivecough. 4. Expiratoryandinspiratorywheezes. 5. Expirationisprolongedandharderthaninspiration. 6. Chestisdistended. 7. ThickStringymucous.Atterminationofaperiodofintensecoughingthepatientwillexpectorate thismucous. Severe Asthma Attack 1. Cyanosisofthenailbeds. 2. Perspirationandflushingoftheskin. 3. Useofaccessorymuscleofrespiration:Sternocleidomastoid,andshoulder/abdominalmuscles. 4. Patientmayalsoappearconfusedandagitated. MANAGEMENT OF AN ASTHMA ATTACK 1. Discontinuedentaltreatment. 2. Placepatientineasiestpositionforthemtobreath.Thisisusuallyuprightwitha rmsoutstretched. 3. AlbuterolInhaler(Proventil)2puffsevery2minutes. 4. Supplementaloxygenat10L/min. 5. Monitorvitalsigns. 6. IfnoimprovementcallEMS. 7. StartIV. 8. ConsiderEpinephrine1:1,000,0.3gevery20minutes. Dental Treatment Considerations for the Asthmatic Patient 1. TakeagoodMedicalHistorypriortotreatmentdeterminehowoftenthepatienthasanasthma attackandwhatprecipitatesit. 2. Considerschedulingmorningappointments. 3. Ifpatientusesaninhalertheyshouldhaveitonhandduringtreatm ent.Considerprophylacticuse priortotreatment.

Almostallblooddisordersareofimportancetothedentalsurgeon . Anemia Causes of anemia: A)Deficient,R.B.Cs.production: Deficiencyofiron,B12,folicacid,vitaminC,protein. Aplasticanemia. Marrowinfiltrationasinleukemia,Hodgkin'sdisease,metaplasticcarcinomaandmyeloma. Symptomatic e.g. anemia of chronic infection, liver disease, kidney disease and collagen vasculardisease. B)LossordestructionofR.B.Cs.: Hemorrhage. Hemolyticanemia 1. Congenitalhemoglobinopathy. 2. Sicklecellanemia 3. Thalassemia 4. Autoimmunehemolysis. Toxicdrugsorchemicalse.g.lead. Anemicpatientsdonotwithstandbloodlosswell.Furtherbloodlossinanalreadyanemicpatientmay provokeheartfailureormyocardialinfarction.Postoperativehemorrhageisalsocommoninanemic patients. Thecommonoraldisorderofasoretongueinadditiontotheothermanifestationsofanemiaisan indicationforbloodexaminationandsurgeryshouldbepostponeduntiltheanemiaiscorrected.If thehemoglobinconcentrationislessthan10g/100ml.ofbloodsurgicalprocedureiscontraindicated. Reference Ranges for Blood Indicators* Indicator Men Women Redbloodcellcount 4.105.60(106/L 3.805.10(106/L) Hemoglobin 12.517.0(g/dL) 11.515.0(g/dL Hematocrit 36%50% 34%44% *L=microliterg/dL=gramsperdeciliter Agranulocytosis (Malignant Leucopenia) IsaseriousdiseaseinvolvingtheW.B.Cs.Themostcommonknownetiologicfactoristheconti nued administrationofcertaindrugs,thatincludesulfonamides,chloramphenicol,chlorpromazine, barbituratesandphenacetin. Clinical features: 1. Necrotizingulcerationoftheoralmucosa. 2. W.B.Cscountusuallybelow2000cells/cubicml. Dental prophylaxis: 1. Withdrawanysystemicdrugwhichinduceallergicreactiontothepatient. 2. Incasesthatrequiredprolongedantibiotictherapy,periodiccheck upofthebloodpictureis mandatory. 3. Extractionincasesofagranulocytosisiscontraindicatedunlessthedisea seismanagedbyblood transfusion. Leukemia CharacterizedbytheprogressiveoverproductionofimmatureW.B.Cs.intheblood.Oftenthe earliestsignsofthisfataldiseasearethegingivalbleedingandulceration. Theresponsibilityofthedentistinrecognizingandreferringpatientsduetoearlydiagnosisofthis seriousconditionareobvious.Consultationwithphysicianpriortoanydentalproceduresisessential. Hemorrhagic Disease Bleedingmaybeduetodefectinplatelets,coagulation,orvessels. Anycasewithhistoryofprolongedbleedingorpostextractionhemorrhageshouldbethoroughly investigatedbyahematologistastheremaybeanunderlyingpredispositiontohemorrhage.

Hematologic Diseases

 Spontaneousgingivalbleedingorrecurrentattackofepistaxismayevokeaserioushemorrhagic disease. Disease involving the blood platelets: 1. Thrombocytopeniapurpura. 2. Thrombocytopathicpurpura. 3. Thrombocythemia(Thrombocytosis). Disease involving the specific blood factors: 1. hemophilia(A,B,C) 2. Pseudohemophilia (vascular hemophilia): 3. parahemophilia 4. hypofibrinogenemia 5. Hypoprothrombinemia Diseases involving the small vessel: 1. Congenitale.g.hereditaryhemorrhagictelangiectasia. 2. Acquiredsuchas: Allergicvasculitis. Infectione.g.meningitisandSABE. Scurvy. Cushing'sdisease. Senilepurpura. Dental surgery in patients with hemorrhagic diseases: 1. Laboratoryinvestigationsforbleedingtime,clottingtime,andprothrombintimeshouldbe performedforallcaseswithhistoryofexcessivebleedingafterminorinjuryorwithprevio us historyofpostextractionhemorrhage.Ifanysignificantalterationexists,thepatientshouldbe thoroughlyinvestigatedbyahematologistforthepossibleunderlyingcausetohemorrhage. 2. Patientswithhemorrhagediseasesshouldbehospitalizedbefor eanydentalsurgery,even beforeminorincisororsimpleextraction. 3. Thedeficientfactor(s)shouldbedetectedandcorrectedbythehematologistbeforedental surgeryandarrangementsforthearrestofpostoperativehemorrhageshouldbecarriedon suchas: Freshorstoredwholebloodtransfusion. Cryofractionsofdifferentbloodcomponents(6majorfractions). Plasma. 4. Localhemostaticmeasuresshouldbeperformedafterdentalsurgerybyobliterationofthe dentalsocketwithabsorbablehemostaticmaterialse.g.Gelfoamsoakedwiththrombinor fibrinogen,oxidizedcellulose(Oxycelorsurgicel),coagulationofhemorrhagicpointsby electrocoagulationorcryotherapy,suturingofthemucosaandapplicationofastringents (tannicacid,zincchloride,ferricsubsulfate). 5. Inserioushemorrhagicdiseases,itshouldbekeptinmindthatarrestofhemorrhagedepends uponthecorrectionofthedeficientfactorandtheroleoflocalmeasureissecondaryandwill beeffectiveonlyaftercorrectionofthesystemicdefe ct. 6. NerveblockL.A.techniquesofinjectionsarecontraindicatedinpatientswithhemorrhagic diseasestoavoidthepossibilitiesofinternalhemorrhageandmassivehematomaformation. 7. Severalcasesofhemophiliahavecirculatinganticoagulantfactors(an tibodies)intheirblood, whichspecificallyinactivatestheAHG.Suchcasesrequiresseveralbloodtransfusion postoperatively.Thispointshouldbetakeninconsiderationbeforesurgery. 8. Majorsurgicalproceduresshouldbeavoidedwheneverpossibleandthesurgicalinterference shouldbeatraumaticaspossible. 9. Theoldmethodoftheuseofrubberbandaroundtheneckofthetoothwasprovedtobeof littlehelpinlooseningthetooth.Onthecontrarybecauseofmechanicalirritationoftherubber dam,thegingivaltissueswereusuallyfoundtobeinflamedandtherebyincreasepost extractionbleeding.

10.postoperatively,neverdischargethepatientunlessatleast3dayswithoutbleedinghad elapsed.

Endocrine Diseases
Diabetes Mellitus General description.Diabetesmellitusisadisordercharacterizedbyimpairmentordestructionof thepancreas'abilitytoproduceinsulinandtheresultantinabilityofthebodytometabolize carbohydrates,fats,andproteins.

Diabetes may occur as a result of:

a"genetic"disorder, theprimarydestructionofisletcellsbyinflammation,cancer,orsurgery, anendocrinecondition,or iatrogenicdiseaseduetotheadministrationofsteroids .

Thepresentdiscussionwillbelimitedtothe"genetic"typeofdiabetes . Epidemiology.Twotofourpercent(15to20millionpersons)ofthegeneralpopulationintheUShave diabetesmellitus.Theprevalenceiscurrentlyabout1.89casesper1,000population,butaslife expectancyincreases,andaspersonswithdiabeteslivelongerduetobettermedicalmanagement,the numberofcaseswillcontinuetorise. 34Adentalpracticeservinganadultpopulationof2,000can expecttoencounter4080personswithdiabetes,abouthalfofwhomwillbeunawareoftheir condition. Etiology and clinical presentation.Therearetwotypesof"genetic"diabetes:insulin dependent diabetesmellitus(IDDM)andnoninsulindependentdiabetesmellitus(NIDDM).Whilebothtypes appeartohaveageneticcomponent,thegeneticroleinNIDDMismuchgrea terthaninIDDM. Environmentalfactorssuchasviralinfectionsandautoimmunereactionsappeartoplayanimportant partintheetiologyofIDDMobesityplaysanimportantbutnotwell understoodpartintheetiology ofNIDDM. AlthoughIDDMisgenerall yfoundinpeopleunder40yearsofage,itcanoccuratanyage.Itisa severe,acuteconditionwithasuddenonsetofsymptomsincluding:polydipsia,polyuria,nocturia, polyphagia,lossofweight,lossofstrength,markedirritability,recurrenceofbe dwetting,drowsiness, andmalaise. Itsonsetinchildrenisusuallyprecededbyasuddengrowthspurt.Ifuncontrolledbydailyinjections ofinsulin,IDDMmayresultindeathinamatterofdays,weeks,oratthemost,months.NIDDM generallyoccursaftertheageof40inobeseindividualsitsincidenceincreaseswithage.Incontrastto IDDM,theonsetofsymptomsinNIDDMisusuallyslowandcangoundetectedforyears.Once diagnosed,however,itcanbecontrolledbyproperdietandweightreduction, usuallywithouttheneed forinsulin. Theprimarymanifestationsofdiabeteshyperglycemia,ketoacidosis,andvascularwalldisease contributetotheinabilityofuncontrolleddiabeticpatientstomanageinfectionsandhealwounds. Othersignsandsymptomsrelatingtothecomplicationsofdiabetesareskinlesions,cataracts, blindness,hypertension,chestpain,andanemia. Treatment.AlthoughpatientswithIDDMrequireinsulintocontroltheirbloodglucoselevel,diet controlandadequateexercisecanreducetheamountofinsulinneeded.NIDDMisfrequently controlledbyweightloss,diet,(rigidcontroloftotalcaloriccontent)andphysicalactivity.Whenthese lifestylechangesfailtoaffectthebloodglucoselevel,hypoglycemicagentsareused,sometimesin

combinationwithinsulin.Theseagentsappeartostimulatethesecretionofinsulin,increasethe numberofcellmembraneinsulinreceptors,andimproveinsulinpostreceptoractivity.Therapyisa highlyindividualprocessandusuallycontinuesthroughoutthepatient'slifetime.

DENTAL MANAGEMENT
Medical considerations. Takeathoroughmedicalhistoryforallpatientsdiagnosedwithdiabetes. Ascertaintheidentityofthephysiciantreatingthepatientandthedateofthelastvisit. Obtaininformationconcerningthetypeofdiabetes,theseverityandcontrolofthediabetes, andthepresenceofcardiovascularorneurologiccomplications. Referanypatientwiththecardinalsymptomsofdiabetesorfindingsthatsuggestdiabetes (headache,drymouth,irritability,repeatedskininfection,blurredvision,paresthesias, progressiveperiodontaldisease,multipleperiodontalabscesses)toaphysicianfordiagnosis andtreatment.

Diabeticpatientswhoarereceivinggoodmedicalmanagementwithout seriouscomplicationssuchas renaldisease,hypertension,orcoronaryatheroscleroticheartdisease,canreceiveanyindicateddental treatment. Thosewithseriousmedicalcomplicationsmayrequireanalteredplanofdentaltreatment.Whenthe severityanddegreeofcontrolofdiabetesarenotknown,treatmentshouldbelimitedtopalliation. Foodintakeandappointmentscheduling.Topreventinginsulinshockfromoccurring: Verifythatthepatienthastakenmedicationasusual. Verifythatthepatienthashadadequateintakeoffood. Scheduleappointmentsinthemorning,sincethisisatimeofhighglucoseandlow insulin activity.Afternoonappointmentsareatimeoflow glucoseandhighinsulinactivitywhichmay predisposethepatienttoahypoglycemicreaction. Instructpatientstotellthedentistifatanytimeduringtheappointmenttheyfeelsymptomsof aninsulinreactionoccurring.Asourceofsugar,suchasorangejuice,mustbeavailableinthe dentalofficeshouldthesymptomsofaninsu linreactionoccur.

Oral surgery concerns. Itisimportantthatthetotalcaloriccontentandtheprotein/carbohydrate/fatratioofthe patient'sdietremainthesamesocontrolofthediseaseandproperbloodglucosebalanceare maintained. IDDMdiabeticswhoaregoingtoreceiveperiodontalororalsurgeryproceduresmaybeplaced onprophylacticantibiotictherapyduringthepostoperativeperiodtoavoidinfection. Consultationwithapatient'sphysicianbeforeconductingextensiveperiodontalorora lsurgery isadvisable.Thephysicianmay,infact,recommendthatthepatientbetreatedinahospital environmentwhereinfection,bleeding,anddysglycemiacanbebettermanaged.

Dangers of acute oral infection.Anydiabeticpatientwithacutedentalo roralinfectionpresents aprobleminmanagement.Thisproblemisevenmoredifficultforpatientswhotakehighinsulin dosageandthosewhohaveIDDM.Theinfectionwilloftencauselossofcontrolofthediabetic condition,andasaresulttheinfectionisnothandledbythebody'sdefensesaswellasitwouldbeina nondiabeticpatient.Thepatient'sphysicianshouldbecomeapartnerintreatmentduringthisperiod.

 Oral complications.Theoralcomplicationsofuncontrolleddiabetesmellitusmayin clude:

Xerostomia, Infection, Poorhealing, Increasedincidenceandseverityofperiodontaldisease,and Burningmouthsyndrome. Diabeticneuropathymayleadtooralsymptomsoftingling,numbness,burning,orpaininthe oralregion.

Oralfindingsinpatientswithuncontrolleddiabetesarethoughttoberelatedtoexcessivelossoffluids throughurination,alteredresponsetoinfection,microvascularchanges,andpossiblyincreased glucoseconcentrationsinsaliva. Earlydiagnosisandtreatmentofthediabeticstatemayallowforregressionofthesesymptoms,butin longstandingcasesthechangesmaybeirreversible. PotentialDrugInteraction.Whilepatientswithwellcontrolleddiabetescanbegivengeneral anesthetics,managementwithlocalanestheticsispreferable.Generalanestheticsshouldbeusedwith cautionbecausetheycanproducehyperglycemia. Hypoglycemia Hypoglycemiaisdiagnosedwhenbloodglucoselevelsfalltoabnormallylowlevels.Undernormal conditions,thebodymaintainsaverynarrowrangeofbloodglucoselevelsdespitewidevariationsin foodintakeandenergyexpenditure Signs and Symptoms of Hypoglycemia 1. Diminishedcerebralfunctiondecreasedspontaneousconversation,lethargy. 2. Increasedsympathetictonesweating,tachycardia,piloerection. 3. Anxiety. 4. Bizarrebehavior(Likeintoxication.) 5. Rapidprogressionofsymptoms. MANAGEMENT OF THE HYPOGLYCEMIC PATIENT 1. ABCs 2. IfpatientisunconsciousorunstableactivateEMS. 3. Ifpatientisconsciousadministeroralcarbohydrates(O rangejuice,sugar,candybar,cakeicing.) 4. Unconscious patient administer parenteral carbohydrates if available (50cc of 50% dextrose IV overaperiodof23minutes.) 5. Patientshouldrespondwithin5minutes. 6. Nevergiveunconsciouspatientanythingorally! Dental treatment Considerations 1. Preventionisthekey.Takeacompletemedicalhistory.Especiallynoteahistoryofdiabetes. 2. Inthediabeticpatientextraattentionshouldbepaidtostressmanagementandassessingdiet. 3. Ifthepatientisoninsulinandeatingwillbeimpairedbydentaltreatmenttheinsulindoseshould bedecreasedaccordingly(Medicalconsult.) HYPERTHYROIDISM Hyperthyroidism is a condition caused by unregulated production of thyroid hormones. Thyrotoxicosisisaserioussequelaof hyperthyroidismthatcorrespondstoanoverttissueexposure to excesscirculatingthyroidhormones.Itischaracterized bytremor,emotionalinstability,intoleranceto heat, sinus tachycardia, marked chronotropic and ionotropic effects, increased cardiac output (increased susceptibility to congestive heart failure), systolic heart murmur, hypertension, increased

appetite and weight loss. It can be caused by thyroid hyperfunction, metabolic imbalance or extraglandularhormoneproduction. HYPOTHYROIDISM Hypothyroidismisdefinedbyadecreaseinthyroidhormoneproduction andthyroidglandfunction. Itiscausedbysevereirondeficiency, chronicthyroiditis(Hashimotosdisease),lackofstimulation, radioactiveiodinethatcausesfollicledestruction,surgerThisconditioncanbeclassifiedintotwo categories:primary hypothyroidism,inwhichthedefectisintrathyroidorsecondary hypothyroidism, inwhichotherpathologiescancauseanindirect decreaseofcirculatinghormone(forexample, surgicalorpathologicalalterationofthehypothalamus).

 DENTAL MANAGEMENT OF PATIENTS WHO HAVE THYROID DISEASE Hypothyroidism.Commonoralfindingsinhypothyroidismincludemacroglossia, dysgeusia,delayed eruption,poorperiodontalhealthanddelayed woundhealing.Beforetreatingapatientwhohasa historyofthyroiddisease,thedentistshouldobtainthecorrectdiagnosis andetiologyforthethyroid disorder,aswellaspastmedical complicationsandmedicaltherapy.Furtherinquiryregarding past dentaltreatmentisjustified.Theconditionsprognosis usuallyisgivenbythetimeoftreatmentand patientcompliance. Inpatientswhohavehypothyroidism,thereisnoheightened susceptibilitytoinfection.Theyare susceptibletocardiovascular diseasefromarteriosclerosisandelevatedLDL.Beforetreating such patients,consultwiththeirprimarycareproviderswho canprovideinformationontheir cardiovascularstatuses.Patients whohaveatrialfibrillationcanbeonanticoagulationtherapy and mightrequireantibioticprophylaxisbeforeinvasiveprocedures, dependingontheseverityofthe arrythmia.IfValvularpathologyispresent,theneedforantibioticprophylaxismustbeassessed. Drug interactionsoflthyroxineincludeincreasedmetabolism duetophenytoin,rifampinand carbamazepine,aswellasimpaired absorptionwithironsulfate,sucralfateandaluminumhydroxide. Whenlthyroxineisused,itincreasestheeffectsofwarfarin sodiumand,becauseofitsgluconeogenic effects,theuseof oralhypoglycemicagentsmustbeincreased.Concomitantuse oftricyclic antidepressantselevateslthyroxinelevels.Appropriate coagulationtestsshouldbeavailablewhenthe patientistaking anoralanticoagulantandthyroidhormonereplacementtherapy. Patientswhohave hypothyroidismaresensitivetocentralnervous systemdepressantsandbarbiturates,sothese medicationsshouldbeusedsparingly. Duringtreatmentofdiagnosedandmedicatedpatientswhohave hypothyroidism,attentionshould focusonlethargy,whichcan indicateanuncontrolledstateandbecomeariskforpatients (for example,aspirationofdentalmaterials),andrespiratory rate.Itisimportanttoemphasizethe possibilityofaniatrogenic hyperthyroidstatecausedbyhormonereplacementtherapyusedtotreat hypothyroidism.Hashimotosdiseasehasbeen reportedtobeassociatedwithDM,andpatientswho haveDMmightbecomehyperglycemicwhentreatedwithT 4.Whenprovidingdentalcaretopatients whohaveDM,attentionshouldfocus oncomplicationsassociatedwithpoorglycemiccontrol,which maycausedecreasedhealingandheightenedsusceptibilityto infections. Inaliteraturereview,Johnsonandcolleaguesexaminedthe effectsofepinephrineinpatientswho havehypothyroidism.Nosignificantinteractionwasobservedincontrolledpatients whohadminimal cardiovascularinvolvement.Inpatientswho havecardiovasculardisease(forexample,congestive heartfailureandatrialfibrillation)orwhohaveuncertaincontrol,local anestheticandretractioncord withepinephrineshouldbeused cautiously.Peoplewhoareonastabledosageofhormone replacementforalongtimeshouldhavenoproblemwithstandingroutine andemergentdental treatment.Hemostasisisnotaconcernunless thepatientscardiovascularstatusmandates anticoagulation. Forpostoperativepaincontrol,narcoticuseshouldbelimited, owingtotheheightenedsusceptibility totheseagents. Hyperthyroidism.Beforetreatingapatientwhohashyperthyroidism,theoral healthcare professionalneedstobefamiliarwiththeoral manifestationsofthyrotoxicosis,includingincreased susceptibilitytocaries,periodontaldisease,enlargementofextraglandular thyroidtissue(mainlyin thelateralposteriortongue),maxillary ormandibularosteoporosis,accelerateddentaleruption and burningmouthsyndrome(Box2 ).Inpatients olderthan70yearsofage,hyperthyroidismpresentsas anorexiaandwasting,atrial fibrillationandcongestiveheartfailure.Inyoungpatients, themain manifestationofhyperthyroidismisGravesdisease, whilemiddleagedmenandwomenpresentmost commonlywithtoxic nodulargoiter.DevelopmentofconnectivetissuediseaseslikeSjgrens syndromeandsystemiclupuserythematosus alsoshouldbeconsideredwhenevaluatingapatientwho hasahistoryofGravesdisease.

 Takingacarefulhistoryandconductingathoroughphysical examinationcanindicatetotheoral healthcareprofessional thelevelofthyroidhormonecontrolofthepatient.Patients whohave hyperthyroidismaresusceptibletocardiovasculardisease fromtheionotropicandchronotropiceffect ofthehormone, whichcanleadtoatrialdysrhythmias.Itisimportant thatthedentistaddressthe cardiachistoryofthesepatients. Consultingthepatientsphysiciansbeforeperforming anyinvasive proceduresisindicatedinpatientswhohavepoorlycontrolledhyperthyroidism.Treatmentshouldbe deferredifthepatientspresentwithsymptomsofuncontrolleddisease. Thesesymptomsinclude tachycardia,irregularpulse,sweating, hypertension,tremor,unreliableorvaguehistoryofthyroid diseaseandmanagement,orneglecttofollowphysicianinitiated controlformorethansixmonthsto oneyear. Adecreaseincirculatingneutrophilshasbeenreportedduring thyroidstormcrisis.Dentaltreatment, however,usuallyis notapriorityinthisstate.Susceptibilitytoinfectioncan increasefromdrugside effects.Peoplewhohavehyperthyroidism andaretreatedwithpropylthiouracilmustbemonitored forpossibleagranulocytosisorleukopeniaasasideeffectoftherapy. Besidesitsleukopeniceffects, propylthiouracilcancausesialolith formationandincreasetheanticoagulanteffectsofwarfarin. A completebloodcountwithadifferentialwillindicateif anymedicationinducedleukopeniamaybe present.Aspirinoral contraceptivesestrogenandnonsteroidalantiinflammatorydrugs,orNSAIDs, maydecreasethebindingofT 4toTBGinplasma. ThisincreasestheamountofcirculatingT 4andcan leadtothyrotoxicosis.Aspirin,glucocorticosteroids,dopamineand heparincandecreaselevelsof TSH,complicatingacorrectdiagnosis ofprimaryorpituitaryhyperthyroidism. Theuseofepinephrineandothersympathomimeticswarrantsspecial considerationwhentreating patientswhohavehyperthyroidism andaretakingnonselectiveblockers.Epinephrineactson adrenergicreceptorscausingvasoconstrictionandon 2receptorscausingvasodilation.Nonselective blockerseliminatethevasodilatoryeffect,potentiatingan adrenergicincreaseinbloodpressure. Thismechanismappliestoanypatient whoistakingnonselectiveblockers,anditisrelevant in patientswhohavehyperthyroidismbecauseofthepossiblecardiovascularcomplicationsthatcan arise.Knowledgeofthe describedinteractionsshouldalerttheclinicianforanypossible complication. Duringtreatment,heightenedawarenesstowardoralsoftandhardtissuemanifestations,as describedpreviously,shouldbeemphasizedOralexaminationshouldincludeinspection andpalpation ofsalivaryglands.Ifthepatientdoesnothave anycardiovasculardiseaseorisnotreceiving anticoagulation therapy,hemostaticconsiderationsshouldnotrepresentac oncernforinvasiveoral procedures.Managementofthepatientreceiving anticoagulationtherapyhasbeendescribedinthe literature. Oralhealthcareprofessionalsshouldrecognizethesignsand symptomsofathyroidstorm,asthe patientcouldpresentfordentalcareduringitsinitialphaseorwhenundiagnosed.Patients whohave hyperthyroidismhaveincreasedlevelsofanxiety,and stressorsurgerycantriggerathyrotoxiccrisis. Epinephrineiscontraindicated,andelectivedentalcareshouldbedeferredforpatientswhohave hyperthyroidismandexhibitsignsorsymptoms ofthyrotoxicosis.Briefappointmentsandstress managementareimportantforpatientswhohavehyperthyroidism.Treatment shouldbediscontinued ifsignsorsymptomsofathyrotoxic crisisdevelopandaccesstoemergencymedicalservicesshould be available. Aftertreatment,properpostoperativeanalgesiaisindicated. NSAIDsshouldbeusedwithcautionin thepatientswhohave hyperthyroidismandwhotakeblockers,astheformer candecreasethe efficiencyofthelatter.Pain,however,can complicatecardiacfunctioninpatientswhohave hyperthyroidismandsymptomaticdisease,andalternativepainmedicationsneed tobeinstituted.Itis importantthatpatientscontinuetaking theirthyroidmedicationasprescribed.Ifanemergent procedureisneededintheinitialweeksofthyroidtreatment,closework upwiththeendocrinologistis needed(Box3 ).

Acute Adrenal Insufficiency

Theadrenalcortexproducesover25differentsteroids.Thesesteroidsarebrokenintothreegroups: sex steroids, mineralocorticoids, and glucocorticoids. Of primary concern in dentistry are the glucocorticoids.Aphysiologicdoseofapproximately20mg/dayofcortisolisproduced.Thisplaysa keyroleinthebodiesabilitytoadapttostress.Cortisolprovidesachemicallinkwithinthecellsofthe bodyallowingregulationofvitalfunctionsincludingbloodpressureandglucoseutilization.

Cortisolproductionistriggeredbyrealorthreatenedstresssuchastrauma,illness,fright,and anesthesia.Inapatientwithsuppressedadrenalfunction afailureofthiscortisolproduction eliminatesthechemicallinktoregulatevitalfunctionsresultinginsuddenshockandpossiblydeath. SuppressedadrenalfunctionorAdrenalFailureisclassifiedaseitherPrimary(Addisonsdisease causedbyDiseasestatessuchasTB,Bacteremia,Carcinoma,andAmyloidosis.)orSecondary(Caused byPituitarydisorder,Hypothalmicdisorders,orSteroidTherapy.) Steroidtherapysuppressesthefunctionoftheadrenalcortexreducingtheproductionofnatural cortisol.Becauseofthissuppressionpatientswhohavebeenonlongtermsteroidtherapylosetheir abilitytorespondtostress.Ifthesepatientsarestressedsymptomsofacuteadrenalinsufficiencymay result. Signs and Symptoms of Acute Adrenal Insuffici ency 1. Mentalconfusion. 2. Muscleweakness. 3. Fatigue. 4. Nauseaandvomiting. 5. Hypotension. 6. Intensepainsinabdomen,lowerback,and/orlegs. 7. Mucocutaneouspigmentation. 8. Hypoglycemia. 9. Hyperkalemia. 10. Increaseheartrate,decreasedbloodpressure. MANAGEMENT OF SUSPECTED ACUTE ADRENAL INSUFFICIENCY 1. Discontinuealltreatmentandremoveforeignobjectsfromthepatientsmouth. 2. InitiateBLSandactivateEMS 3. Placepatientsupine. 4. Monitorandrecordvitalsigns. 5. Oxygenat510L/minute. 6. Hydrocortisone 100mg IV (Dexamethasone 4mg) over 30 seconds or IM if IV not available. Repeat dose every 6 hours for 24 hours. If the patient is stable then reduce to 50mg (Dexamethasone4mg)every6hoursthentaperorallyover45days.Shouldinitiateifthereisany suspicionofAAI.

 Dental Treatment Considerations Forpatientswithahistoryofglucocorticoidtherapyusestressreductionprotocols. ThefollowingguidelinescanbeusedtodetermineifreplacementtherapyisindicatedThisisachange fromtheoldruleoftwosbasedonanarticledoneatNNDC.Itisalwaysagoodideatogetamedical consultinsuchcases. Ifthepatienthasundergonesupraphysiologic(Morethan20mg/day)glucocorticoidtherapythatwas discontinuedmorethan30dayspriortotheplanneddentaltreatmentnosupplementationisrequired. Ifthepatientshasundergonesupraphysiologicglucocorticoidtherapywithin 30daysoftheplanned dentalprocedureconsideredthepatientssuppressedandprovidesteroidsupplementationequivalent to100mgofcortisol. Ifthepatienthasundergoneorisundergoingalternatedaydosingscheduleglucocorticoidtherapyno supplementationisrequiredbutitisbesttoprovidedentaltreatmentontheoffdayofthepatients doseschedule. Ifthepatientiscurrentlyreceivingdailyglucocorticoidtherapyatasupraphysiologiclevel(More than20mg)supplementationisrequired.Ifthedailydoseissubphysiologicsupplementationisnot required.

Liver diseases
VIRAL HEPATITIS General description.Acuteviralhepatitisischaracterizedbydegenerationandnecrosisoflivercells with ballooning degeneration of the hepatocytes. Icterus (jaundice) is commonly associated with hepatitisandiscausedbyanaccumulationofbilirubinintheskin. Acute viral hepatitis is caused by at least five distinct viruses:

Type A hepatitis (formerly called infectious hepatitis) is caused by the hepatitis A virus (HAV), which is an RNAtype virus. Serologic tests for HAV and its antibodies are readily available. Type B hepatitis (formerlycalledserumhepatitis)iscausedbythehepatitisBvirus(HBV), whichisaDNAtypevirus.Serologictestsareavailableforallbutone(HBcAg)ofitsantigen antibodysystems. Delta hepatitis is caused by a defective RNAtype virus that requires the presence of HBV for infection. It can occur as either a coinfection or a superinfection with hepatitis B. The hepatitisdeltavirus(HDV)anditsantibodyanti HDcanbedetectedwithserologictesting. Non A non- Btype C hepatitis was originally a diagnosis of exclusion in posttransfusion hepatitis when serologic markers of types A and B were not present. Serologic tests are now availableforboththeviralantigenanditsantibody. Non- A- non- B- - - type E hepatitis is an enterically transmitted virus, similar to type A. Serologictestsforbothantigenandantibodyhaverecentlybecomeavailable.

Epidemiology. Because the means of transmission overlap and the clinical expression of the various forms of hepatitis are often indistinguishable, no absolute statements can be made regarding epidemiology.However,certainrecurringpatternsofdiseasearerecognizedforeachtype. Hepatitis A is transmitted almost exclusively by fecal contamination of food or water. Because the reservoirfor infections is frequently a common food or water source, hepatitis A often occurs as an epidemic.Transmissionisenhancedbypoorpersonalhygiene,especiallyamongschoolagedchildren andfoodhandlers.

Hepatitis A is a common disease, with serologic evidence of infection in about 40% of urban populations in the US.1 Of importance is the fact that no carrier state is known to exist for it. No vaccineiscurrentlyavailable,andrecoveryusuallyconveysimmunityagainstreinfection. Hepatitis Bmaybetransmittedinanumberofways: direct percutaneous inoculation of infected serum or plasma by needle or transfusion of infectivebloodorbloodproducts indirectpercutaneousintroductionofinfectiveserumorplasmaabsorptionofinfectiveserum orplasma(e.g.,throughmucosalsurfacesofthemouthoreye) absorptionofotherpotentiallyinfectivesecretions(e.g.,salivaorsemen) transferofinfectiveserumorplasmaviainanimateenvironmentalsurfaces

TheroleofsalivainHBVtransmission,exceptbypercutaneousorpermucosalroutes,doesnotappear tobesignificant. 2 Groups at high risk for hepatitis B are:

healthcareworkers(includingdentistsanddentalstaff) hemodialysispatients usersofillicitdrugs homosexuals heterosexualswithmultipleparameters recipientsofbloodtransfusions

The risk of infection is directly related to exposure to blood. This has resulted in a reported past prevalencerateofinfectionamonggeneraldentistsrangingfrom13to30percent,andarateamong oral surgeons as high as 38 percent.35 More recently, the prevalence rate for general dentists was reportedtobe8.89percent. Hepatitis B has greater associated morbidity and mortality than hepatitis A, especially in older patients.AnadditionalsignificantfeatureofhepatitisBistheexistenceofachroniccarrierstatethat canpersistforvariableperiodsafterresolutionofacutedisease.Whilethecarrierrateofdentistsin theUShasdecreased(reflectingtheeffectivenessofprophylacticmeasures),theriskisstillestimated tobethreetotentimesthatofthegeneralpopulation.Itissignificanttonotethatsincemanycasesare mildorsubclinical,mostcarriersareunawarethattheyhavehadhepatitisB. Delta hepatitisoccursonlyasacoinfectionwithacutehepatitisBorasasuperinfectionincarriers of hepatitis B and, therefore, is transmitted parenterally via infected blood or blood products. It is seenprimarilyindrugaddictsandhemophiliacs. NANB hepatitistype C is similar to type B in behavior and characteristics. It is transmitted primarily parenterally and is the major etiologic agent of posttransfusion nonA nonB hepatitis. WhilefortypercentofpatientswithhepatitisChavenoidentifiableriskfactorsforinfection, 7thoseat highriskinclude:

healthcareworkersexposedtoblood illicitdrugusers hemodialysispatients recipientsofwholeblood,bloodcellularcomponents,orplasma

Clinical presentation.Manyofthesignsandsymptomsofacuteviralhepatitisarecommontoviral diseasesandmaybedescribedasflulike.Thisisespeciallytrueintheearlystageofthedisease.There are classically three phases of acute viral hepatitis, each lasting for a certain duration, and each manifestingparticularsymptoms.

 Prodromal (preicteric) phase. Symptoms include anorexia, nausea, vomiting, fatigue, myalgia,malaise,andfever. Icteric phase. Many of the nonspecific prodromal symptoms may subside, but gastrointestinal symptoms may increase. Hepatomegaly and splenomegaly are also frequently seen. Posticteric phase. Symptoms disappear, but hepatomegaly and abnormal liver function valuesmaypersist. Thisphase canlast forweeks ormonths, withrecovery timefor hepatitis typesBandCgenerallybeinglonger.

Treatment.Thereisnospecifictreatmentforacuteviralhepatitis.Therapyisbasicallypalliativeand supportive.Anutritiousandhighcaloriedietisadvisable. DENTAL MANAGEMENT Medical considerations. Since infectious patients cannot necessarily be identified by history, it is necessary to manage all patients as though they are potentially infectious. The Center for Disease ControlandtheAmericanDentalAssociationhavepublishedrecommendationsforinfectioncontrol that have become the standard of care to prevent crossinfection in dental practice. These standards shouldbestrictlyadheredto. Therearefivecategoriesofpatientswithahistoryofhepatitisthatmustbeconsideredbythedentist:

Patients with active hepatitis. No treatment other than urgent care should be rendered to these patients. If a patient is seen with acute hepatitis, the physician should be contacted immediately . Patients with a history of hepatitis .Sinceitisestimatedthattherearebetween 750,000 and 1 million carriers of hepatitisB in the US today,the only practical method of protection from infection is to adopt a strict program of clinical asepsis for all patients. In addition, inoculationofalldentalpersonnelwithhepatitisBvaccineisstronglyurged. Patients at high risk for HBV infection.Patientswhofitintooneormoreofthehighrisk categories should routinely be screened for HBsAg before dental care is provided unless laboratoryevidenceexistsforantiHBs.Whilethismeasuremayseemredundant,itcouldyield informationthatwouldbeofbenefitincertainsituations.Forexample,ifanaccidentalneedle stick or puncture occurs during treatment and the dentist is not vaccinated, it would be of extremeimportancetoknowwhetherthepatientwasHBsAgpositive,whichwoulddictatethe needforvaccination. Patients who are hepatitis carriers.IfapatientisfoundtobeahepatitisBcarrierorto have a history of NANB hepatitis, recommendations from the Center for Disease Control for avoiding transmission of infection should be closely followed. In addition, some hepatitis carriers may have chronic active hepatitis, leading to compromised liver function and interfering with hemostasis and drug metabolism. Physician consultation or laboratory screeningforliverfunctionisadvised. Patients with signs or symptoms of hepatitis . Any patient having signs or symptoms suggestinghepatitisshouldbereferredtoaphysician,andshouldnotbetreated.Ifemergency carebecomesnecessary,itshouldbeprovidedasforthepatientwithacutedisease.

Potential drug interactions . In a completely recovered patient there are no special drug considerations. However, if a patient has chronic active hepatitis or is a carrier of HBsAg and has impaired liver function, drugs metabolized by the liver should be avoided if possible. Although a numberoflocalanesthetics,analgesics,sedatives,andantibioticscommonlyusedindentistryare,in fact, metabolized principally by the liver, these drugs can be used in limited amounts in all but the mostseverecasesofhepaticdisease.

 Oral complications. The only oral complication associated with hepatitis is the potential for abnormalbleedingincasesofsignificantliverdamage.Ifsurgeryisrequired,itisadvisableto: Check the prothrombin time. If it is greater than 35, an injection of vitamin K will usually correcttheproblem.Thisshould,however,bediscussedwiththepatient'sphysician. Monitorthebleedingtimetocheckplateletfunction .Ifitisnotlessthan20minutes,thepatient may require platelet replacement before surgery. This should also be discussed with the patient'sphysician.

ALCOHOLIC LIVER DISEASE

General description.Thepathologiceffectsofalcoholonthelivercanresultinthreediseaseentities,which commonlyappearincombination:

With fatty infiltrate , the hepatocytes become engorged with fatty lobules and distended, with enlargement of the entire liver. These changes may occur after only moderate usage of alcoholforabrieftime,andarecompletelyreversible. Alcoholic hepatitis is a diffuse inflammatory condition of the liver characterized by destructive cellular changes. Some of these may be irreversible, thereby leading to necrosis. Whilethisconditioncanbefatalifdamageiswidespread,itisgenerallyreversible. Cirrhosis, the most serious form of alcoholic liver disease, is characterized by progressive fibrosisandabnormalregenerationofliverarchitectureinresponsetochronicinjuryorinsult (i.e., prolonged and heavy use of ethanol). It results in the progressive deterioration of metabolicandexcretoryfunctionsoftheliver,andultimatelyleadstohepaticfailure.

Epidemiology.Itisestimatedthat:

Uptoninetypercentofpeopledrinkalcohol. Fortytofiftypercentofmenhavetemporaryalcoholinducedproblems. Ten percent of men and three to five percent of women develop pervasive and persistent alcoholism.

Alcoholabuseanddependencearenotlimitedtoanyparticulargroup.Allagesandraces,bothsexes, andallsocioeconomiclevelsareaffected. Clinical presentation.

Fatty liver .Therearenoclinicalmanifestationsofafattyliver,andthediagnosisisusually madeincidentallyinconjunctionwithanotherillness. Alcoholic hepatitis .Signsandsymptomsofalcoholichepatitisareoftennonspecificandmay include nausea, vomiting, anorexia, malaise, weight loss, and fever. More specific findings include hepatomegaly, splenomegaly, jaundice, ascites, ankle edema, and spider angiomas. Withadvancingdisease,encephalopathyandhepaticcomamayensue,endingindeath. Cirrhosis. Cirrhosismayremainasymptomaticformanyyears.Hemorrhagefromesophageal varicesisfrequentlytheinitialsign,butascites,spiderangiomas,ankleedema,orjaundicemay also be among the early signs. The hemorrhagic episode may progress to hepatic encephalopathy,coma,anddeath.

Treatment.Thecornerstoneoftreatmentforalcoholicliverdiseaseisabstinencefromalcohol.Other measuresinclude:

strictdietarymodification(highprotein,highcalorie,lowsodiumdiet) fluidrestriction vitaminsupplementation

Anemiaiscorrectedbyironreplacementandfolicacidsupplementation. DENTAL MANAGEMENT Medical considerations.Thetwomajortreatmentconsiderationsinanalcoh olicpatientare:

bleedingtendencies unpredictablemetabolismofcertaindrugs

Dental management must, therefore, begin with detection by history and/or by clinical examination. Whenthereisahighindexofsuspicion,anumberoflaboratorytestsshouldbeorderedforscreening purposes:

CBCwithdifferential AST,ALT bleedingtime thrombintime prothrombintime

Ifapatienthasahistoryofalcoholicliverdiseaseoralcoholabuse,thephysicianshouldbeconsulted toverify:

thepatient'scurrentstatus medications laboratoryvalues contraindicationsformedications,surgery,andothertreatment

Apatientwithuntreatedalcoholicliverdiseaseisnotacandidateforelective,outpatientdentalcare and should be referred to a physician. Once the patient is managed medically, dental care may be provided after consultation with the physician. Bleeding diatheses (as reflected on laboratory tests) shouldbemanagedinconsultationwiththephysician. Metabolic concerns.Concernabouttheunpredictablemetabolismofdrugsistwofold: In mild to moderate alcoholic liver disease, significant enzyme induction is likely to have occurred, leading to an increased tolerance of sedative drugs, hypnotic drugs, and general anesthesia. Larger than normal doses of these medications are thus required to obtain the desiredeffects. Withmoreadvancedliverdestruction,drugmetabolismmaybemarkedlydiminishedandcan leadtoanincreasedorunexpectedeffect.Drugsmetabolizedprimarilybytheliver(i.e.,certain anesthetics,analgesics,sedatives,andantibiotics)shouldbeusedwithcaution,andavoidedif possible.Whenused,dosesshouldbeadjusted.

Oral complications.Poororalhygieneandneglectarecommonfindingsinchronicalcoholics.Other abnormalitiesthatmaybefoundare: 45

glossitis angularorlabialcheilosis candidiasis gingivalbleeding oralcancer petechiae ecchymoses jaundicedmucosa parotidglandenlargement

alcoholbreathodor impairedhealing bruxism dentalattrition xerostomia

Sincealcoholabuse(andtobaccouse)arealsostrongriskfactorsforthedevelopmentoforalcancer, practitionersshouldbeaggressiveindetectingsuspicioussofttissuelesions.

Kidney Diseases
CHRONIC RENAL FAILURE, DIALYSIS AND DENTAL MANAGEMENT General Description. Endstage renal disease (ESRD) is a bilateral, progressive, and chronic deteriorationofnephronsthatresultsinuremiaandultimatelyleadstodeath.Therateofdestruction andtheseverityofdiseasedependontheunderlyingcausativefactors,whichareoftenunknown. Epidemiology.Approximately1.3in10,000populationdevelopESRDannuallythisrateisincreasing byabout10percentperyear,mostrapidlyinpatientsoverage65. Etiology and clinical presentation .SomeofthemorecommonknowncausesofESRDarediabetes, hypertension,glomerulonephritis,polycystickidneydisease,andsystemiclupuserythematosus . Its manifestations are seen in the cardiovascular, gastrointestinal, neuromuscular, hematologic, and dermatologic systems. Cardiovascular manifestations include hypertension, congestive heart failure, pericarditis. Gastrointestinal signs include anorexia, nausea, vomiting, generalized gastroenteritis, pepticulcerdisease,stomatitis,andcandidiasiscanals ooccur. Patients may:

showmentalslownessordepression demonstratemuscularhyperactivity experiencehemorrhagicepisodes,especiallyinthegastrointestinaltract displaypalloroftheskinandmucousmembranes(duetoanemia) display hyperpigmentation of the skin caused by the retention of carotenelike pigments normallyexcretedbythekidney

Conservative care. Conservative care attempts to decrease the retention of nitrogenous waste products and control fluids and electrolyte imbalances by dietary modification (protein restriction) andbycloselymonitoringfluid,sodium,andpotassiumintake.CalciumandvitaminDsupplements arealsoprescribed. Nephrotoxicdrugsoragentsthataremetabolizedprincipallybythekidneyareavoided . Dialysis. As more and more nephrons are destroyed, medical management of ESRD becomes inadequate and artificial filtration of the blood is required in the form of peritoneal dialysis or hemodialysis. Most patients are maintained by hemodialysis. The technique requires the surgical creation of a permanent arteriovenous fistula that is readily accessible to cannulation with a large gaugeneedle.Thepatientis"pluggedin"tothehemodialysismachineatthefistulasite,andbloodis passedthroughthemachine,filte red, andreturnedtothepatient. Treatmentsusuallyrequire 3to 5 hours,andareperformedevery2or3days,dependingonneed. Althoughhemodialysisisalifesavingtechnique,therearecomplicationsassociatedwithit.Theriskof hepatitisBandCandAIDSissignificantbecausepatientshaveusuallyhadmultiplebloodexposures.

Infection of the arteriovenous fistula is also an ongoing concern and can result in septicemia, septic emboli,infectiveendarteritis,orendocarditis.Theprocedureitselfcausesplateletdestruction,thereby aggravatingalreadyexistingbleedingtendencies. DENTAL MANAGEMENT Medical considerations for patients under conservative care. Before dental care is provided to a patientunderconservativemanagementofESRD,thepatient'sphysicianshouldbeconsulted.Ajoint decisionshouldthenbemadeastothesetting(inpatientoroutpatient)inwhichthiscarecansafelybe provided. If ESRD is wellcontrolled, there is generally no problem in providing outpatient care. Whenrenderingthiscare: Orderpretreatmentscreeningforbleedingdisorders(bleedingtime,plateletcount,hematocrit, hemoglobin). Monitorbloodpressure. Paymeticulousattentiontogoodsurgicaltechnique. Useuniversalinfectioncontrolprocedures.

Medical considerations for patients receiving dialysis . Therecommendationsformanaginga patientreceivinghemodialysisarethesameasthoseformanagingapatientunderconservativecare, withafewadditionalconsiderations: Thesurgicallycreatedarteriovenousfistulaispotentiallysusceptibletoinfection(endarteritis) resultingfromadentallyinducedbacteremiaandisasourceofinfectiousembolithatcancause endocarditis. While both conditions are of low incidence, the patient's managing physician shoulddeterminewhetherornottoadministerprophylacticantibiotics. Hemodialysis patients must avoid dental care on the day of dialysis, when they could have bleedingtendencies.Thebesttimefordentaltreatmentisthedayafterhemodialysis.

Oral complications.

Palloroftheoralmucosasecondarytoanemia. Diminishedsalivaryflow,resultinginxerostomiaandparotidinfections. Patients frequently complain of a metallic taste, and the saliva may have a characteristic ammonialikeodorduetoahighureacontent. Insevererenalfailure,astomatitismaybepresent. Lossoflaminadura. Demineralizedbone. Localizedradiolucentjawlesions.

Potential Drug Interactions. Ofspecialconcernaredrugsthatareprimarilyexcretedbythekidneyorthatarenephrotoxic (tetracycline,acyclovir,acetaminophen,aspirin,andNSAlDs). Certaindrugs are removedduring hemodialysis and,therefore, require anadditional dose to beadministeredafterhemodialysis.

The Nervous disease convulsive d isorders

EPILEPSY AND DENTAL MANAGEMENT General description.Epilepsyisatermthatdescribesagroupofdisorderscharacterizedbychronic, recurrent,paroxysmalchangesinneurologicfunction(seizures)thatarecausedbyabnormal electricalactivityinthebrain.Seizuresmayeitherbeaccompaniedbymotormanifestationsor

 manifestedbysensory,cognitiveoremotionalchangesinneurologicfunction.Thisdiscussionwillbe limitedtogeneralizedtonicclonicseizures,sincetheserepresentthemostsevereexpressionof epilepsythatpractitionersarelikelytoencounter. Epidemiology.Itisestimatedthat10%ofthepopulationwillhaveatleastoneepilepticseizureinits lifetimeandthattheoverallincidencerateis0.5%.1Seizuresaremostcommonduringchildhood, withasmanyas4%ofchildrenhavingatleastoneseizureduringthefirst15yearsoflife. Fortunately,mostchildrenoutgrowthis. Etiology and clinical presentation .Commoncausesofepilepsyincludeheadtrauma,intracranial neoplasm,hypoglycemia,drugwithdrawal,andfebrileillness.Formanypatients,however,thereisno knowncause(idiopathicepilepsy).Insuchcases,seizuresaresometimesevokedbyaspecificstimulus suchasflickeringlights,monotonoussounds,music,oraloudnoise. Thepatienthavingageneralizedtonicclonicconvulsion(grandmalseizure)typicallyemitsasudden cry,immediatelylosesconsciousness,exhibitsgeneralizedmusclerigidityfollowedbyclonicactivity consistingofuncoordinatedbeatingmovementsofthelimbsandhead,ceasesmovementandbecomes comatose.Withinafewminutes,thepatientgraduallyreturnstoconsciousnesswithstupor,headache, andconfusion. Treatment. Themedicalmanagementofepilepsyisbasedondrugtherapy.Whilephenytoin (dilantin)ismostcommonlyusedasafirstlineoftreatment,otheranticonvulsantdrugssuchas carbamazepine,phenobarbital,andvalproicacidarealsocommonlyused.

DENTAL MANAGEMENT
Medical considerations.Onceanepilepticpatienthasbeenidentified: Learnasmuchaspossibleabouttheseizurehistory,currentmedications,degreeofseizure control,andanyknownprecipitatingfactors. Beawareoftheadverseeffectsofanticonsulvants(drowsiness,dizziness,ataxia,and gastrointestinalupset). Rendernormalroutinecaretoepilepticpatientswhohaveattainedgoodcontroloftheir seizureswithmedication. Donotrendertreatmenttopatientswhoseseizureactivitydoesnotrespondtoanticonvulsants, withoutpriorconsultationwiththepatient'sphysician.Suchpatientsmayrequireadditional anticonvulsantorsedativemedication,asdirectedbythephysician.

Oral complications.Themostsignificantoralcomplicationseeninepilepticpatientsisgingival hyperplasiaassociatedwithphenytoin.Theanteriorlabialsurfacesofthemaxillaryandmandibular gingivaearethemostseverelyaffected.Whilethereissomecontroversyregardingtheeffectivenessof oralhygieneinpreventinggingivalhyperplasia,mostevidencesuggeststhatmeticulousoralhygiene willprevent,oratleast,significantlydecreaseitsseverity.Goodhomecareshouldthusbecombined withtheremovalofirritantssuchasoverhangingrestorationsandcalculus.Surgicalintervention may,however,berequiredtoreducehyperplastictissueinterferingwithfunctionorappearance. Dealing with a seizure.Shouldapatienthaveageneralizedtonicclonicconvulsioninthedental office,bepreparedtodealwithit.Theprimarytaskofmanagementistoprotectthepatie ntandtryto preventinjury.

Donotattempttomovethepatient. Placethechairinasupportedsupineposition. Turnthepatient,ifpossible,tothesidetocontroltheairwayandminimizeaspirationof secretions.

Usepassiverestraintonlytopreventinjuryfromhittingnearbyobjectsorfromfallingoutof thechair.

Potential Drug Interactions. Propoxypheneanderythromycinshouldnotbeadministeredtopatientstakingcarbemazepine becauseofinterferencewithmetabolismofcarbemazepine,whichcouldleadtotoxicity. AspirinandNSAIDSshouldnotbeadministeredtopatientstakingvalproicacid,fortheycan furtherdecreaseplateletaggregation,leadingtohemorrhagicepisodes.

SEXUALLY TRANSMITTED DISEASES AND DENTAL MANAGEMENT

Sexually transmitted diseases (STDs) are a major health problem in the US, varying in their manifestationsfromminorinconvenienceorirritationtoseveredisabilityanddeath.Includedamong this group of diseases are AIDS, gonorrhea, syphilis, chlamydia, genital herpes, hepatitis B, trichomoniasis,lymphogranulomavenereum,chancroid,genitalwarts,andpediculosispubis. Although most STDs have the potential for oral infection and transmission, this discussion will be limited to (1) gonorrhea, (2) syphilis, and (3) genital herpes. Please refer to a separate discussion of AIDSandto"LiverDiseases"foradiscussionofhepatitisB. Sincesomepersonsprovidenohistoryanddemonstratenosignificantsignorsymptomssuggestiveof disease,itisnotpossibletoidentifypotentiallyinfectiouspatients.Itisthusnecessarytomanageall patientsasthoughtheywereinfectious.RecommendationspublishedbytheUSPublicHealthService for controlling infection in dentistry have become the standard for preventing crossinfection. Strict adherencetotheserecommendationswilleliminatethedangerofdiseasetransmissionbetweendentist andpatients. Drug Interactions. There are no adverse interactions between the usual antibiotics or drugs used to treatSTDsandthedrugscommonlyusedindentistry.Nodrugsarecontraindicated. 1. GONORRHEA General description and epidemiology. Gonorrhea is the most commonly reported infectious diseaseintheUS,withover690,000casesrecordedin1990.1Itstransmissionisalmostexclusivelyvia sexual contact, the primary sites of infection are the genitalia, anal canal, and pharynx. Though gonorrheaisseenmorecommonlyin1519yearoldand2024yearoldagegroups,itcanoccuratany age.1Single,black,urbandwellerswithmultiplesexualpartnersareathighrisk.Otherriskfactors includeloweducationallevelandsocioeconomicstatus. Etiology and clinical presentation . Gonorrhea is caused by Neisseria gonorrhoeae, which is a gramnegativediplococcuscommonlyfoundwithinpolymorphonuclearleukocytes.N.gonorrhoeaeis anaerobethatrequireshighhumidityandspecifictemperatureandpHforoptimumgrowth,andis readily killed by drying. It develops resistance to antibiotics rather easily, and many strains have becomeresistanttopenicillinandtetracycline,aswellastootherantibiotics. In men, the most common symptoms include a mucopurulent urethral discharge, pain on urination, urgency,andfrequency,Inwomen,asignificantpercentage(50%)ofcasesmaybeasymptomaticor only minimally symptomatic. Women who are symptomatic may demonstrate vaginal or urethral discharge and dysuria with frequency and urgency. Backache and abdominal pain may also be present. Within the oral cavity the pharynx is most commonly affected. It is usually seen as an asymptomaticinfectionwithdiffuse,nonspecificinflammationorasamildsorethroat. Treatment. Infectiousness diminishes rapidly following antibiotic therapy with ceftriaxone and doxycycline.

 DENTAL MANAGEMENT Medical considerations. Due to the specific requirements for disease transmission and to the disease's rapid response to antibiotics, gonorrhea poses little threat of disease transmission to the dentist.Whatevercareisnecessaryshouldthusbeprovided. Oral Complications. The rare presentation of oral gonorrhea is nonspecific and varied and may rangefromslighterythematosevereulcerationwithapseudomembranouscoating.Thepatientmay beeitherasymptomaticorincapacitatedwithlimitationsoforalfunction.Definitivediagnosisoforal lesionsshouldbeattempted,andthepatientshouldbeunderthecareofaphysician.Treatmentofthe orallesionsisthensymptomatic. 2. SYPHILIS General description and epidemiology. Syphilis is the third most frequently reported infectious diseaseintheUS,surpassedonlybygonorrheaandchickenpox.Itismostcommoninages2040its reported incidence is greater in males than females, by more than 2:1.1 Its transmission is predominantlysexualhowever,itcanoccurvianonsexualmeanssuchaskissing,bloodtransfusion, or accidental inoculation with a contaminated needle. Congenital syphilis occurs when the fetus is infectedinuterobyaninfectedmother.Theprimarysiteofsyphiliticinfectionisusuallythegenitalia, althoughprimarylesionsalsooccuronthelips,tongue,finger,nipples,andanus. Etiology and clinical presentation .TheetiologicagentofsyphilisisTreponemapallidum,whichisa slender fragile anaerobic spirochete. It is easily killed by heat, drying, disinfectants, and soap and water. Themanifestationsofsyphilisareclassicallydividedinto5stagesofoccurrence(primary,secondary, latent,tertiary,andcongenital),witheachstagehavingitsowndistinctsignsandsymptomsthatare relatedtotimeandantigenantibodyresponses. Treatment. Syphilis is treated with parenteral longacting benzathine penicillins. When allergy to penicillin is present, oral doxycycline, and oral tetracycline are used. 2 As with gonorrhea proper treatmentrapidlyreversesinfectiousness. DENTAL MANAGEMENT Medical considerations.Thelesionsofuntreatedprimaryandsecondarysyphilisareinfectious,asis thepatient'sbloodandsaliva.Evenaftertreatmenthasbegun,theeffectivenessoftherapycannotbe determinedexceptbyconversionofthepositiveserologictesttonegativethismaytakeafewmonths to over a year. Although patients with syphilis should be viewed as potentially infectious, any necessarydentalcaremaybeprovidedsafely. Oral complications.Syphiliticchancresandmucouspatchesareusuallypainlessunlesstheybecome secondarily infected. These lesions are highly infectious, but regress spontaneously with or without antibiotictherapy.Aswithgonorrhea,oraltreatmentisessentiallysympt omatic. 3. GENITAL HERPES General description and epidemiology. The herpes simplex virus (HSV) is transmitted by direct contact, usually kissing (transfer of infective saliva) or sexual contact. Since it is not a reportable disease,itsincidenceisunknown.However,theCentersforDiseaseControlestimatethatthenumber ofpatientconsultationsforgenitalherpesincreasedfrom 26,000in1966to 423,000in1983.Aswith otherSTDs,thisestimateisprobablyunderstated.

 Etiology and clinical presentation . HSV is classified into two closely related types, HSV1 and HSV2,HSV1isextremelycommon,andisthecausativeagentofmostherpeticinfectionsthatoccur abovethewaist.Mostadultsdemonstrateantibodiestothisvirus.HSV 2isthecausativeagentofmost herpesinfectionsthatoccurbelowthewaist.Whileitistransmittedmainlybysexualcontact,itmay alsobepassedontoanewbornfromaninfectedmother.Althoughtheprimarysiteofoccurrenceof HSV1isabovethewaistandofHSV2isbelowthewaist,eachinfectionmayoccurineithersiteand canbeinoculatedfromonesitetotheother. Lesions of primary genital herpes (and moist areas) in both men and women tend to ulcerate early. Lesions on exposed dry areas tend to remain pustular or vesicular and then crust over. Painful regionallymphadenopathyaccompaniestheinfection,alongwithheadache,malaise,andsymptomsof fever. These subside in about 2 weeks, with healing in 35 weeks3. All herpetic lesions are highly infectious,regardlessofthestatetheyarein. Treatment. In that no definitive treatment or cure exists, treatment is of a symptomatic and palliativenature.Acyclovir(zovirax)istheonlydrugthathasbeenshowntobeeffectiveindecreasing viralshedding,durationoflesion,andsymptoms. DENTAL MANAGEMENT Medical considerations.

Intheabsenceoforallesions,anynecessarydentalworkmaybeprovided. If oral lesions are present, elective treatment should be delayed to avoid inadvertent inoculationofadjacentsitesandaerosolordropletinoculationoftheconjunctivaeofeitherthe patient,dentist,ordentalstaff. Aproblemofparticularconcerntodentistsisherpecticinfectionofthenailbeds,contractedby fingercontactwithaherpeticlesionofthelipororalcavityofapatient.Theinfectioniscalled a"herpeticwhitlow"or"herpeticparonychia."Itisserious,debilitating,andrecurrent.

DENTAL MANAGEMENT GUIDELINES First trimester (conception to 14th week) Themostcriticalandrapidcelldivisionandactiveorganogenesisoccurbetweenthesecondandthe eighth weekofpostconception.Therefore,thegreaterriskofsusceptibilitytostressandteratogensoccurs duringthistimeand50%to75%ofallspontaneousabortionsoccurduringthisperiod. The recommendations are: 1.Educatethepatientaboutmaternaloralchanges duringpregnancy. 2.Emphasizestrictoralhygieneinstructionsand therebyplaquecontrol. 3.Limitdentaltreatmenttoperiodontalprophylaxis andemergencytreatmentsonly. 4.Avoidroutineradiographs.Useselectivelyandwhen needed. Second trimester (14th to 28th week) Organogenesisiscompletedandthereforetheriskto thefetusislow.Thisisthesafestperiodforproviding dentalcareduringpregnancy. Therecommendationsare: 1.Oralhygiene,instruction,andplaquecontrol.

Pregnancy

 2.Scaling,polishing,andcurettagemaybeperformed ifnecessary. 3.Controlofactiveoraldiseases,ifany. 4.Electivedentalcareissafe. 5.Avoidroutineradiographs.Useselectivelyandwhen needed. Third trimester (29th week until childbirth) Althoughthereisnorisktothefetusduringthistrimester,thepregnantmothermayexperiencean increasing level of discomfort. Short dental appointments should be scheduled with appropriate positioning while in the chair to prevent supine hypotension. It is safe to perform routine dental treatmentintheearlypartofthethirdtrimester,butfromthemiddleofthethirdtrimester routinedentaltreatmentshouldbeavoided. The recommendations are: 1.Oralhygiene,instruction,andplaquecontrol. 2.Scaling,polishing,andcurettagemaybeperformed ifnecessary. 3.Avoidelectivedentalcareduringthesecondhalfof thethirdtrimester. 4.Avoidroutineradiographs.Useselectivelyandwhen needed.

Drugs
Oxygen 1. Use: Oxygen is the most universally common emergency drug and can be used in every situationexcepthyperventilation. 2. Dose a) NasalCannula:Thepercentoxygendeliveredbynasalcanulaisabout 21%(roomair)+ 4% oxygenforeachliterperminuteflowrateused.Useat24L/minute. b) FaceMask:Thepercentoxygendeliveredbyfacemaskis60%at6L/minuteflowratewitha 10% increase in concentration for each liter per minute increased flow rate. Use at 10 15L/minute. A bag valve mask device with oxygen inlet is best when positive pressure ventilationisrequiredthoughapocketmaskwithoxygeninletcanbeused.

3.Pharmacology:Requiredforaerobicmetabolism 1. Adverse Affects: In the case of a hypoxic patient the hypoxic state is a powerful respiratory stimulant. When Oxygen is delivered the hypoxia is reduced and this can actually cause a decreaseinpulmonaryventilationthatmayneedtobeaugmentedbytherescuer. 2. DrugInteractions:None Epinephrine 1:1,000 Injection 1. Use:Epinephrineisusedtoreversehypotension,bronchospasm,andlaryngealedemathatresult fromanacuteanaphylactoidtypereaction.Alsousedtoreducebronchospasmresultingfroman acuteasthmaticepisodethatisrefractorytoinhalerth erapy. 2. Dose:Suppliedinvials,ampules,orpreloadedsyringesinconcentrationof1:1000,1mg/ml.IV give 0.52.0mg (0.5ml2.0ml) depending on severity of hypotension, titrate to effect repeat in 2 minutesifneeded.IMgive0.3mg(0.3ml)repeatin1020minutesasneeded.

 3. Pharmacology: Causes vasoconstriction that in turn increases blood pressure, heart rate, and forceofcontraction.Alsocausesbronchialdilatation.Reducesthereleaseofhistamine. 4. AdverseEffects a) Cardiovascular:Tachycardia,Tachyarrhythmias,andhypertension. b) CentralNervousSystem:Agitation,headache,andtremors. c) EndocrineSystem:Increasedbloodglucose. d) PregnantFemale:Candecreaseplacentalbloodflow. 5. DrugInteractions:Nasaldecongestants,antihistamines,asthmainhalerswillincreaseincidenceof adverseeffects.Canbeineffectiveifthepatientistakingbeta blockers. Diphenhydramine (Benedryl) 50mg Injection 1. Use: Benedryl is used as treatment to reduce the affects of histamine release that is associated withallergicreactions,anaphylaxis,andacuteasthmaattackprecipitatedbyexogenouscauses. 2. Dose: 50100mg IM or IV. For mild cases of pruritis, urticaria, or erythema an oral dose of 50mgevery6hourscanbeused. 3. Pharmacology:Benedrylisanantihistaminethatblocksthereleaseofhistamineinthebody.It does not prevent the action of the histamine once released and thus must be given quickly. Preventshistamineresponsessuckasbronchospasm,hypotension,rash,andedema. 4.AdverseEffects: a) Cardiovascular:Tachycardia(Fasthearrate.) b) Central Nervous System: CNS depression (Sedative effects including drowsiness, lethargy, andmentalconfusion.) c) Gastrointestinal:Xerostomia(Drymouth.) 5 DrugInteractions:AnydrugscausingCNSdepressionwillincreasethesedative effectsofBenedryl.CanalsoexaggeratethiseffectinotherdrugssuckasAtropine, Antipsychotics,Demerol,andTricyclicAntidepressants. Dexamethasone Sodium Phosphate 4mg/ml 1. Use:Asadjunctivetherapyforallergicananaphylacticreactions.Canbeusedasreplacement therapyforAcuteAdrenalInsufficiency(HydrocortisoneSodiumSuccinateisdrugofchoicebut may depend on what is available in clinic.) The approximate dosage equivalency is 0.75mg Dexamethasoneto20mgHydrocortisone. .DOSE a) AllergicorAnaphylactictypereactions412mgIVorIM. b) AcuteAdrenalInsufficiency10mgIVorIM. 3 Pharmacology: Dexamethasone has a rapid onset and short duration of action. Promotes membrane stabilization and inhibits the release of biochemical mediators of inflammation. Dexamethasoneisapotentantiinflammatoryagent. 4. AdverseEffects:Localizedpainorburningatinjectionsiteifinjectedtoquicklyotherwisenone withshorttermuse.DexamethasonecontainsSodiumBisulfite,whichmaycauseanallergicor anaphylacticreactioninpatientsallergictosulfites.

 5. Drug Interactions: Possible decreased effects of Dexamethasone in patients taking Phentoin, Phenobarbitol,Ephedrine,andRifampinduetoincreasedmetabolicclearance.Possiblealtered response to anticoagulants. Possible hypokalemia in patients taking potassium depleting diuretics.IncreasedtendencyforgastriculcerationinpatientstakingAspirinorIndomethacin. Mayincreaserequirementforinsulinororalhypoglycemicagentsindiabetics.
Equivalent Doses of Corticosteroids

Cortisone 25mg Hydrocortisone20mg Prednisolone 5mg Prednisone 5mg Methylpredsinilone4mg Triamcinilone4mg Dexamethasone0.75mg Betamethasone0.6mg Aromatic Spirits of Ammonia Ampules 1. Aromatic Ammonia is used to stimulate respiration in the case of syncope or to disrupt respiratorypatterninhyperventilation. 2. Dose:1ampulecrushedwavedunderpatientsnose. 3. Pharmacology:Noxiousodorstimulatestherespiratorycenterofthemedulla. 4. Adverseeffects: a) Cardiovascular:Increasesbloodpressureandheartrate. b) Respiratory:Cancausebronchospasm. 5. DrugInteractions:None. Albuterol Inhaler (Proventil) 1. Use:AlbuterolisusedduringacuteasthmaorAnaphylaxistoreduceorcontrolbronchospasm. 2. Dose:2puffsevery2minutestoamaximumof20puffs.Holdinhalerabout2inchesfrom mouth.Havepatienttaketwodeepbreathsand thenexhaleforcefully.Dispenseonepuffonslow deepinhalation.Holdbreathfor10secondsandrepeat. 3. Pharmacology:AlbuterolisanB2adrenergicdrugthatrelaxesthebronchialsmoothmuscle.It hasrapidonsetanddurationofactionofupto6hours.Alsoreducesthestimulationofmucous production. 4. Adverse Effects: Should be used with caution in patients with cardiovascular disorders especially coronary artery disease, arrhythmias, and hypertension. Also caution with patients havingconvulsivedisorders,hyperthyroidism,andDiabetes.InrarecasesAlbuterolcancausea paradoxicalbronchospasm. 5. Drug Interactions:OtherinhalationbronchodilatorsshouldnotbeusedwithAlbuterol,andif additional adrenergic drugs are given systemically they should be used with caution to avoid cardiovascular effects. Albuterol should also be used with caution on patients who are taking MonoamineOxidaseInhibitorsandTricyclicAntidepressantsastheactionoftheAlbuterolonthe vascular system may be potentiated. Albuterol and BetaBlockers tend to inhibit each other. Albuterolalsotendstolowerserumcalciumandshouldbeusedwithcautioninconjunctionwith otherdrugswiththesameeffect.

 Nitroglycerin 0.4mg Tablets or 0.4mg Metered Dose Spray 1. Use: Nitroglycerin is used to relieve or eliminate chest pain associated with angina pectoris, to differentiatebetweenanginaandamyocardialinfarction. 2. Dose: a) Tablet:1tabletsublinguallyrepeatafter2minutesifnoreliefupto3doses. b) MeteredDoseSpray:1spraysublinguallyrepeatafter2minutesifnoreliefupto3doses. Monitor blood pressure after each dose do not repeat if systolic BP drops below 100. Average drop in BP is 1116 mm Hg after one dose. Patient should be sitting or supine when Nitroglycerineisadministered. 3. Pharmacology:Nitroglycerinisacoronaryandperipheralvasodilatorandassuchhelpsincrease the flow of oxygenated blood to the heart muscle. It also causes venous pooling of blood decreasing venous return to the heart thus improving the pumping efficiency of the heart. Becauseofthisimprovedefficiencymyocardialoxygendemandisdecreased. 4. Adverse Effects: a) Cardiovascular:Rapidheartrate,facialflushing,andorthostatic(Postural)hypotension. b) CentralNervousSystem:Dizzinessandheadache. 5 Drug Interactions: Antihypertensive drugs may exaggerate the hypotensive effect of Nitroglycerine.

Allergic Reaction
Signs and Symptoms of an Allergic Reaction 1. Cutaneousreactionsarethemostcommonoccurrenceandincludeurticarial,exanthematous,and eczemoid reactions. Itching is common and can also find exfoliative dermatitis and bullous dermatosis. 2. Angioedema (Swelling) this varies from localized slight swelling of the lips, eyelids, and face to moreuncomfortableswellingofthemouth,throat,andextremities. 3. Respiratory (Tightness in chest, sneezing, bronchospasm) bronchospasm is a generalized contractionofbronchialsmoothmusclesresultingintherestrictionofairflow.Thismayalsobe accompanied by edema of the bronchiolar mucosa. Bronchospasm is more common with pre existingpulmonarydiseasesuchasasthmaorinfectionbutcanalsobecausedbytheinhalationof aforeignsubstance. 4. Ocularreactionsincludeconjunctivitisandwateringofeyes. 5. Hypotensioncanoccurwithanyallergicreaction. Anaphylaxis:Thisisaseveresystemictypeallergicreactionandisamedicalemergency.Signsand symptomsinclude: 1. Cardiovascular shock including pallor, syncope, palpitations, tachycardia, hypotension, arrythmias,andconvulsions. 2. Respiratory symptoms include sneezing, cough, wheezing, tightness in chest, bronchospasm, laryngospasm. 3. Skiniswarmandflushedwithitching,urticaria,andangioedema. 4. Nausea,vomiting,abdominalcramps,anddiarrheaalsop ossible. Evaluation of Allergic Reactions:Thingstoremember. 1. Skinmanifestationsmayprecedemoreseriouscardiorespiratoryproblems. 2. Recognitionofskinreactionsandearlytreatmentmayabortmoreseriousproblems. 3. Mostimportantfactorisassessingtheseriousnessoftheconditionistherateofonset. 4. Reactionsthatoccurgreaterthanonehouraftertheadministrationoftheallergenwillusuallybe ofanonemergentnature.

 TREATMENT General Treatment 1. ABCs 2. Maintain airway, administer oxygen, and determine possible need for intubation or surgical airway. 3. Monitorvitalsigns. 4. IfinshockputpatientinahorizontalorslightTrendelenburgposition. Mild Reactions 1. Antihistamines usually effective. (Benadryl 50100mg or Cholpheniramine maleate 412 mg PO, IV,orIM.) 2. Identifyandremoveallergen. 3. Followupmedicationsin46hours. Severe Reactions 1. IfavailablestartIVFluids 2. Epinephrineisdrugofchoice.Usuallyprepackaged1:1,000in1mgvialsorsyringe 3. IfIVinplacetitrate1:1,000solutiontoeffect. 4. Ifdropinbloodpressureisminimal,startwith0.5ml(0.5mg.) 5. Ifdropinbloodpressureisseverestartwith2ml(2mg.) 6. Repeatafter2minutesifneeded. 7. IfnoIVuse1:1,000(1mg/CC)IM0.3to0.5mg(0.30.5CC.) 8. Foranadultrepeatthisdos ein10to20minutes. 9. Ifthepatientisintubatedcangiveepinephrineendotracheally 10.IfAsthma,edema,orpruritis(Itching)arepresentcanuseCorticosteroids.Howeverthesedrugs aretoslowactingtobeusedforanemergencysituation. 11.Hydrocortisonesodiumsuccinate(Solucortef)100500mgIVorIM.Dexamethasone (Decadron) 412mgIVorIM. 12.Repeatdoseat1,3,6,and10hoursasindicatedbyseverityofsymptoms. Other Considerations 1. Monitorandrecordvitalsigns. 2. Seizuresarepossibleasaresultofcirculatoryorrespiratoryinsufficiency. 3. Mostseverallergicreactionsrequirehospitalizationandobservationfor24hours.

Vital Signs

Blood Pressure
1. TechniqueforTakingBloodPressure a) Thepatientshouldbeseatedinanuprightpositionwith theirarmattheleveloftheheart. Thearmshouldberelaxed,slightlyflexedandsupportedonahardsurface. b) Placecuffwrappedfirmlyaroundarmwiththecenterofthebladder(Inflatablepartofcuff) overtheBrachialArtery(Somecuffsaremarkedwithanarroworcircleindicatingwhereto placeinrelationtotheartery.)TheBrachialarteryliesinthemedialaspectoftheantecubital fossa.Theloweredgeofthecuffshouldbeplaced1abovetheantecubitalfossa.Itistotight iftwofingerscannotbeplacedundertheloweredgeofthecuffandtolooseitcanbepulledof thearm. c) ForaPalpatorysystolicbloodpressurepalpatethepulseattheradialarteryandinflatecuffto 30mmHgafterthepulsedisappears.Slowlydeflateat23mmHg/seconduntilpulsereturns. ThispointisthePalpatorySystolicBloodPressure.

 d) ForanAusculatorybloodpressureplacethediaphragmofthestethoscopefirmlyonthe medialaspectoftheantecubitalfossa.Donottouchthecuffortubingasthis mayproduce extraneousnoise.Increasethepressureto30mmHgabovethepalpatorysystolicblood pressure.Slowlydeflatethecuffat23mmHg/second.Thefirstsoundheardwillbethe SystolicBloodPressure.Continuetoslowlydeflatethecuff.T hesoundswillbecomemuffled andthepointatwhichtheyceaseistheDiastolicBloodPressure. 2. CommonErrorsinTakingBloodPressures a) Puttingthecuffonthepatienttolooselywillresultinanelevatedreading. b) Useofthewrongsizecuff.Usingacuffthatistoolargewillresultinadepressedreading. Thewidthofthecuffshouldbeapproximately20%greaterthanthediameterofthe extremity. c) Ananxiouspatientcanhaveatransientelevationofthebloodpressure. d) Thepressureintheleftarmi s510mmHghigherthantheright. e) Inrarecasesanausculatorygapmaybepresent.Thisisacompletecessationofsound betweenthesystolicanddiastolicpressures.Thisismostoftenfoundinpatientswithhigh bloodpressurebuthasnorealclinicalsignificance. 3. GeneralInformation a) ThebloodpressureequalsthecardiacoutputXthetotalperipheralresistance b) Theaveragenormalbloodpressurecancalculatedbyadding120+thepatientsage/90orless. c) Waitatleast15secondsbetweenreadingstoallowtrappedbloodinarmtoresumeflow. d) TheSystolicpressureisthepressureinthearterieswhentheheartiscontracting. e) TheDiastolicpressureisthepressureinthearterieswhentheheartisatrest. HeartRate,Rhythm,andQuality 1. Technique a) Themostcommonareastopalpatethepulsearetheradialartery(Ontheventralsurface ofthewristonthethumbside,)thebrachialartery(Onthemedialaspectofthe antecubitalfossa,)andthecarotidartery(Onthelateralaspectoftheneckjustpo sterior totheborderofthestenocleidomastoidmuscle.) b) Usingthetipsoftheindexandmiddlefingerapplygentlepressuretotheareawhereyou wishtopalpatethepulse.Becarefulnottoapplytoomuchpressuresoasnottoocclude theartery. c) Evaluatethreefactors HeartRate:Countthebeatsperminutethisshouldbeforaminimumof30secondsandthencanbe doubled.Aheartrateslowerthan60iscalledbradycardiaandgreaterthan110iscalledtachycardia. Anincreaseinratewithinspirationfollowedbyadecreaseinrate 1. withexpirationiscalledsinusarrhythmia.Thisisfrequentlyseeninadolescentsandis notindicativeofanycardiacabnormality. 2. Rhythm:Therhythmwillbeeitherregularorirregular.Abreakinagenerally regularrhythminwhichalongerthannormalpauseisfollowedbyaresumptionofa regularrhythmisaprematureventricularcontraction(PVC.)Thiscanbeproduced bysmoking,fatigue,stress,medications,alcohol,andanischemic/damaged myocardium.Whenyoufindastrongandweakpulsealternatingthisiscalledpulsus alternans.Thisisseeninsevereleftventricularfailure,severearterialhighblood pressure,andcoronaryarterydisease. 3. Quality:Thepulsequalitycanbecharacterizedasthready,weak ,bounding,orfull.A fullandboundingpulsecanbefoundinseverehypertension.Aweakandthready pulseisindicativeofhypotensionandshock.

RespirationRate
1. Technique a) Monitortherespirationrateimmediatelyaftertakingtheheartrate. b) Leaveyourfingersonthepatientswristwhilecountingrespirations(Theriseandfallofthe patientschest)overaminimumof30seconds. c) Donotletthepatientknowthatyouaremonitoringtheirrespirations,astheymaynotbreathe normally. d) Normalrespirationrateis1218perminute.Aslowratecanbeseenwithnarcotic administration.Anincreasedrespirationrateisseenwithfever,alkalosis,andextreme psychologicalstress.

 AlAzharUniversity FacultyofDentistry OralSurgeryDepartment

By

EhabMohamedElSayedHassan Class(A)