A patient's medical history is a vital part of his or her dental history and increases
the dentist's awareness of diseases and medication which might interfere with the
patient's dental treatment.This requires a medical and dental history to be filled
out and then reviewed; to; know what the patient wants,; needs and what their limitations
There are certain medical conditions that need to be checked with that medications
so that proper treatment can be performed.Heart disease in the past, means that
you require antibiotics before undertaking any dental treatment, to check; bleeding.
The reason being that oral bacteria are released into your blood stream during your
dental treatment. These bacteria thrive; in the damaged heart tissue, causing harm.
Ensure that your patient carries his puffer incase he\she is suffering from asthma.
Many heart patients use nitro-glycerine when stressed and this should be easily
available. Allergies to medications, which can be life-threatening and uncontrolled
high blood pressure, may cause serious consequences.
Cardiovascular diseases affect a large section of the population. A wide array of
medication; are used to treat such disorders. However the primary mechanisms involve
the renin- angiotensin system mediated via renal mechanisms and nervous system control
via adrenergic supply.
Prior to performing any dental procedure on a patient with a cardiovascular disease,
a base line recording and evaluation of patients blood pressure and heart rate is
Patients medication regimen should be recorded and updated. It is important that
these patients take their medications at scheduled times, irrespective of dental
appointment, to minimize the possibility of intra operative hypertension or tachycardia.
Many of these drugs can cause orthostatic hypotension. Dentists should have the
patient sit up in the dental chair for 1- 3 minutes after being in a supine position
and monitor the patient while he/she is standing.
Use of epinephrine in local anaesthetics should be kept minimum and extra care while
aspirating; must be taken to avoid intravascular injections. It has been recommended
that no more than 40Ug (0.04mg or approximately two 1.8 cubic- centimeter cartridge
of local anaesthetic with 1:100,000 epinephrine) should be used for successive dental
aneasthetic injections in cardiovascular patients. Additional injections with epinephrine
can be given after 5- 10 minutes provided the base vital signs are satisfactory.
Use of gingival retraction cord with epinephrine is absolutely contraindicated in
Consultation with patients physician is essential for patients on anticoagulants,
before dental procedures involving bleeding.
Used in cardiac dysrhythmia, hypertension and other cardiac diseases.
Common examples of antiarrhythmic drugs: Disopyramide, phosphate, Quinidine, Procainmide,
Mexilitene, Verapamil, Diltiazam.
Most of the Class I and Class II patient may rarely cause luekopenia, thrombocytopenia
or agranulocytosis. Consider medication-induced adverse effects if gingival bleeding
or infection occurs.
- Quinidine and amiodarone can cause bitter or altered taste.
These drugs are used to treat CCF and certain dyrrthymia such as atrial fibrillation.
Common drugs used in this; group are: Digoxin.
- Increased gag reflex is possible.
The patients anticoagulant status as well as the need for endocarditis prophylaxis
should be evaluated.
Patients taking sublingual nitroglycerine should have this medication available
at all dental appointments.
Most of the gastrointestinal drugs do not have any contradictions for dental patients.
Patients suffering from Crohn's disease may have increase incidence of certain microbial
infection, delayed healing and increased tendency for gingival bleeding. This action
may be due to effects of sulfasalazine taken during the course of the disease.
The dentist should be aware if the patient is taking a drug for nausea and vomiting.
If the patient is receiving the drug for cancer therapy, he or she may require palliative
treatment for stomatitis.
Patient with cancer may be taking opioids, so the dentist should not prescribe additional
drug for pain without reviewing patient's medication profile.
The dentist should avoid procedures and drugs that promote nausea and vomiting.
An increased gag reflex makes it difficult for the patient to undergo dental procedures.
- Take complete health history.
List medications patient is taking. Know their effects, side effects, potential
for drug interaction and any specific oral effects.
Schedule proper frequency of oral hygiene and provide good oral hygiene instruction
to ensure healthy periodontal tissue and teeth.
Insure proper dental lighting (no light should shine directly in the eyes).
Insure medications have been taken properly relative to dental appointments to minimise
risk of seizure.
Perform proper periodontal and surgical treatment of gingival hyperplasia to minimise
damage to teeth and supporting structures and to maintain proper aesthetics.
Treatment plan and design restorations to minimize risk of damaging or displacing
dental restorations or prosthesis during an epileptic seizure.
Request that the patient bring a caregiver to help them. Keep the appointments short--no
more than 45 minutes. Schedule the appointment during the patient's best times,
- Remind the patient of the appointment 24-48 hours ahead of time.
- Avoid treatment plans requiring expensive labour or post procedural care.
- Plan multiple short appointments as opposed to few long appointments.
- Avoid treatments that complicate home care for the patient or caregiver.;
- Use local anesthetics with the shortest possible duration.
Avoid long explanations of the treatment, since patients cannot retain the information
and it will add to their anxiety.
Explain the treatment and post-treatment instructions thoroughly to the caregiver.
Follow up with the caregiver regarding pain or discomfort, increased confusion or
agitation after the visit.
Monitor all the vital signs during the dental visits. Make the patient sit upright
in the dental chair for a minute or 2 after being in the supine position; and then
monitor vital signs in standing position.
- Sedation or general anaesthesia may be required in few cases.
Many of theses drugs cause xerostomia. The dentist should consider them in differential
diagnosis; of; caries, periodontal disease or oral candiasis.
If newly diagnosed mouthing movements are seen, which may indicate a serious medication
side effect, consultation with patient's physician may be appropriate.
The prescription of psychoactive agents by dentist is indicated for a number of
conditions, including acute anxiety associated with dental /oral surgery, management
of bruxism and management of various orofacial pain.
Benzodiazepines are generally regarded as the drugs of choice for oral preoperative
anxiolysis in dental practice.
These drugs have a high margin of safety, especially used in single dose, 30mins-1hr
prior to dental visit.
Bronchial asthma is the most common respiratory disorder encountered by dentist
and it is important that they be well versed with the relevant aspects of the disease.
Asthma is a clinical syndrome characterised by signs and symptoms of intermittent
and potentially reversible airflow limitation related to bronchial and bronchiolar
constriction coupled with hyper-secretion of viscous mucus, superimposed on a background
It can be induced by an allergen or chemical irritant (extrinsic asthma) or by an
intrinsic factor such as an infection or emotional distress (intrinsic asthma).
The American Society of Anaesthesiologists classification of asthma is given in
the table below:
Dental Treatment Modifications
Typical extrinsic or intrinsic asthma
- Easily managed.
- Characterised by infrequent episodes.
- Does not require emergency care or hospitalisation.
- Reduce stress as advised.
- Determine triggering factor.
- Avoid triggering factor.
- Have bronchodilators available during dental treatment.
Exercise- induced asthma
- Often accompanied by fear.
- Patient with Class II asthma usually has history of emergency care or hospitalisation.
Follow ASA II modification.
Administer sedation-inhalation with nitrous oxide, oxygen or oral benzodiazapines
- Signs and symptoms of asthma present at rest.
Obtain medical consultation; before beginning treatment.
Provide only emergency care in clinic.
Defer elective care until respiratory status improves or until patient can be treated
in controlled environment.
COPD; (Chronic Obstructive Pulmonary Disorder) is a major respiratory disorder in
which the bronchial obstruction is irreversible, resulting in severe infections,
cardiac complications and respiratory failure. Respiratory conditions and the use
of inhalants can cause decreased salivation and cause associated problems such as
caries and candidiasis. Therefore patients should be observed for the need of antifungals
and use fluoride rinses.
Stress reduction methods may include the use of medication, especially when complex
procedures are performed.
A semi supine chair position, especially for COPD patients is preferred to prevent;
orthostatic hypotension. Patients should sit for a few minutes upright before being
- Inhalants used by patients should be easily available during the dental appointment.
Patients; on long term steroids are at the risk of stress induced steroid crisis
and increased risk of infections.
With patients using beta-adrenergic agonists, there is a concern of cardiac side
effects such as hypertension and tachycardia.
NSAID's like aspirin and narcotics, are contraindicated in patients with respiratory
conditions, as they may prompt an asthmatic attack.
The most important objective is the prevention of complications.The following principles
apply in this sense:
Identification of the patient based on a thorough clinical history: Disease antecedents,
exploration and laboratory testing for selective identification.
Counselling of patients and their relatives to increase awareness of good oral hygiene
in order to avoid the need for invasive dental care and reduce the number of visits
to the dentist.
Replacement therapy in necessary cases. Replacement may comprise coagulation factors
(haemophilia A, B and Vw disease) or vitamin K (lack of ingestion or poor absorption
and liver disease).
Avoidance of brusque maneuvers during dental treatment in order to prevent oral
mucosal damage that may give rise to post-operative bleeding problems.
In the case of haemophilia, the ideal approach would be to provide dental care in
the specialised haemophilia center by dental surgeons integrated within the team
supervising the patient.
Aspirin and its derivatives are to be avoided as pain treatment instead, paracetamol
is a safe alternative. In the case of the coumarins, the possibility of multiple
interactions with other drugs must be taken into account resulting in either enhancement
of the anticoagulant effect (with the resulting risk of excessive bleeding) or a
reduction of coumarin effects (with the risk of thromboembolic events). Some of
these drugs are often prescribed in dental practice, including antibiotics (amoxicillin
and amoxicillin + clavulanate, ampicillin, azithromycin, erythromycin, rifampicin,
penicillin G, cephalosporins, sulfonamides, metronidazole, chloramphenicol), antifungals
(azoles and griseofulvin), analgesics (aspirin and other nonsteroidal anti-inflammatory
drugs; paracetamol in excess can enhance warfarin action) and psychoactive drugs
(some antihistamines, diazepam).
Controlled type 1 and type 2 diabetic patients usually can undergo all dental treatments
without special precautions.
The dentist must know the type and dose of insulin as well as any other medications
that the patient is taking. They must be aware if the patient has a history of;
hypoglycemia attacks and the accompanying signs and symptoms. The chances of having
a hypoglycemia attack are increased if there have been previous attacks.
In order to avoid an episode of hypoglycemia while undergoing dental treatment it
is advisable to schedule the patient based on the time of highest insulin activity
which varies from 30 minutes to 8 hours after injection depending on the type of
insulin. Therefore, the appointment does not need to be necessarily in the morning.
Consultation with the patient's physician is a must when:
the patient has systemic complications of diabetes such as heart or renal disease.
- the patient has a difficulty to control diabetes or is under high insulin dosage.
the patient has an acute oral infection such as periapical or periodontal abscess.
It is advisable to have in the dental office orange juice or another form of glucose,
to be given to the patient at the first sign of hypoglycemia. Generally a 6 oz.
dose of any fruit juice or any other drink containing carbohydrates will rapidly
reverse the hypoglycemia symptoms.
Infection is a risk for the diabetic patient and can make it more difficult to control
blood glucose levels. If undergoing extensive oral surgery, the dentist may prescribe
antibiotics to minimise the risk of infection. To help the healing process, keep;
blood glucose levels under control before, during and after surgery.
The dentist may recommend a saliva substitute that can be used for relief from dry
mouth discomfort. The dentist may also recommend rinsing with a fluoride mouthrinse
or having a topical application of fluoride at home and in the dental clinic to
help prevent rampant tooth decay.
Androgens, estrogens and progestins are responsible for ;increased; inflammatory
status, causing erythema and an increased tendency towards gingival bleeding. Professional
cleanings and plaque control will minimize their sequelae.
Dental treatment should; be delayed; in patients with hyperthyroidism whose symptoms
are not controlled pharmacologically or surgically.
Antithyroid hormone drugs reduce the production of thyroid hormones, because these
agents have potential to depress the bone marrow, the incidence of microbial infections
can increase, resulting in; delayed healing and gingival bleeding.
The major connective tissue disorders include: Lupus erythmatosus, rheumatoid arthritis,
scleroderma, dermatomyositis, Sjogren syndrome.
Dentist should be suspicious of the possibility of systemic lupus erythematosus
when a women between the age of 15-35 years develops; skin and mucosal leisons associated
with joint pains. The lesions of discoid L.E often respond to topical and intralesional
Dentist treating patients with rheumatoid arthritis must be aware of the drugs prescribed
and their possible side effect on dental treatment. NSAID's can increase bleeding
during surgery. Gold sodium thiomalate can cause oral ulcers.
Succinyl choline causes paralysis and; has anaesthetic or analgesic effects. The
dentist must therefore assure that; sufficient anaesthesia is achieved before performing
Various degree of increased muscle tension in the masseter muscles may develop due
to succinyl choline. In extreme; cases, trismus can occur and make it difficult
to open mouth.
The primary use of spasmolytics in dental office is to relieve anxiety, post-procedural
trismus and muscle spasm of the head, neck; and TMJ disorders.
The anti-anxiety effects of Benzodiazepines, makes it an excellent choice for pre-operative
oral sedation in dental patient.
Hypersalivation has been reported with clonazepam
and this should be considered; when selecting medications for a patient who has
difficulty in controlling salivary flow.
Tizanidine has been associated with visual hallucinations or delusions. Before beginning
dental treatment, the clinician should assess the psychological status of the patient
Before the dentist undertakes any dental procedure involving a patient with cancer,
he/she should; contact the patient's primary care physician regarding the need for
any pre-medication. This includes use of antibiotics to protect against bacteremias.
The dentist's main concern before providing care to a patient receiving chemotherapy
relates to adequate numbers of white blood cells and platelets.The marrow suppression
is usually cyclic and there are periods where risk of infection and bleeding are
Most medications used by dentist to control oral complaints may put an extra burden
on the existing condition. It is important to coordinate medical and dental treatment
to minimize complication to the patient.
Careful clinical and radiographic examination followed by any indicated corrective
procedure are essential to minimise subsequent complications of dental pain, abscess,
poor hygiene and periodontal disease that may occur during cancer treatment.
Extractions and any other pre-radiation surgery should be done with adequate time
allowed for tissue healing. This may take from 14 to 21 days and should be co-ordinated
with; the radiation oncologist to minimise the delay of radiation treatment.
Clinicians also generally recommend that the patient’s remaining dental treatment,
including caries removal, smoothing of any rough or sharp surfaces and calculus
removal be completed before radiation treatment.
The dentist should make standard impressions (using, for example, irreversible hydrocolloid)
of the patient’s remaining dentition to fabricate a fluoride carrier or tray.
To prevent radiation caries, the patient will need to undergo daily fluoride treatments
(e.g. 1 percent neutral sodium fluoride gel in the carrier for five minutes). Therefore,
the carriers should be as comfortable as possible. Carriers are typically made out
of standard thick mouthguard materials such as 5- mm ethylene- vinyl copolymer.
Implants are no longer absolutely contraindicated in irradiated bone, although there
may be decreased success; implant placement can be performed 12 to 18 months after
radiation therapy and when possible, implant supported prostheses should be considered
instead of tissues supported prostheses, since there might be less likelihood of
Extract teeth in the radiation field that are non-restorable or may pose a future
problem, to prevent; extraction-induced; osteoradionecrosis.
Conduct a prosthodontic evaluation if indicated. If a removable prosthesis is worn,
make sure that it is clean and well adapted to the tissue. Instruct the patient
not to wear the prosthesis during treatment, if possible or at the least, not to
wear it at night.
Remove orthodontic bands and brackets if highly stomatotoxic chemotherapy is planned
or if the appliances will be in the radiation field.
Consider extracting highly mobile primary teeth in children and teeth that are expected
to exfoliate during treatment.
Brush teeth, gums and tongue gently with an extra-soft toothbrush and fluoride toothpaste
after every meal and before bed. If brushing hurts, soften the bristles in warm
Floss teeth gently every day. If gums are sore or bleeding, avoid those areas but;
floss other teeth.
- Follow instructions for using fluoride gel.
- Avoid mouthwashes containing alcohol.
Rinse the mouth with; baking soda and salt solution, followed by a plain water rinse
several times a day (Use 1/4 teaspoon each of baking soda and salt in 1 quart of
warm water). Omit salt during mucositis.
Exercise the jaw muscles three times a day to prevent and treat jaw stiffness from
radiation. Open and close the mouth as far as possible without causing pain; repeat
- Avoid candy, gum and soda unless they are sugar-free.
- Avoid spicy or acidic foods, toothpicks, tobacco products and alcohol.
- Keep the appointment schedule recommended by the dentist.