CENTRAL NERVOUS SYSTEM:

Headache and Facial Pain:

Local causes - dental disease, infections (sinusitis)

Psychogenic - tension headache, TMJ dysfunction

Vascular - migraine, migrainous neuralgia, temporal arteritis

Neurological - trigeminal/glossopharyngeal neuralgia, intra-cranial lesions

Misc. - referred cardiac pain, Paget’s disease, raised intracranial pressure.

Cerebro-vascular Accidents:

Hemiplegia - facial palsy

Speech/comprehension difficulty

Impaired mobility/manual dexterity

Hypertension - anticoagulants

Epilepsy:

Dental trauma - mucosal scarring - lacerations to mouth/tongue

Possible contraindication to dentures, complex restorations and some orthodontic therapy

Gingival hyperplasia - phenytoin

Occasional psychiatric problems

Subluxation of TMJ

Depression:

Atypical facial pain

Oral dysaesthesis (burning mouth, sore tongue)

TMJ Dysfunction Syndrome

Down’s Syndrome

Delayed eruption - irregular sequence - morphological variation

Immune defects - periodontal disease

Cardiac defects - infective endocarditis risk

Hep.B risk

Cardio Vascular System:

Heart Disease:

Shortness of breath when supine

Avoid stress - consider sedation or Relative Analgesia

Hypertension and Ischaemic Heart Disease - possible risk of adrenaline in local anaesthesia, dysrythmia (minimum dose)

Angina - ensure patient’s Glyceryl Trinitrate is at hand

Possible use of anticoagulants

Implanted pacemakers - beware ultrasonic scalers and diathermy.

Infective Endocarditis:

Patients at risk - previous episode (high risk)
- rheumatic valvular disease
- prosthetic valves
- congenital cardiac defects

Prophylaxis - ONE hour pre-op amoxycillin 3g. or,
600mg Clindamycin one hour pre-op

Anaemia:

Atrophic glossitis - sore tongue

Predisposition to/exacerbation of candidiasis - angular cheilitis

Apthous stomatitis.

Anticoagulant Therapy:

Surgical risk - extractions under medical supervision

Avoid asprin and other Non Steroid Anti inflammatory drugs (NSAID’s)

Avoid prolonged broad spectrum Antibiotic therapy

Dialysis patients - surgery on the day following dialysis.

Haemophilia:

Surgical risk - extractions planned with medical assessment essential

Bleeding risk - with Intra-muscular injections (inc. Inferior Dental blocks)

Avoid aspirin and other Non Steroid Anti inflammatory drugs (NSAID’s)

Routine dental care - avoid minor trauma

Scaling - AHF cover - preventive advice/procedures important

Hepatitis - AIDS risk

Preventive care.

Respiratory System:

Chronic:

Obstructed airways (COAD) - chronic bronchitis, emphysema

Avoid sedation - Local anaesthesia only

Treat upright

Asthma:

Reduce anxiety - possible RA, but no IV sedation

Avoid aspirin, paracetamol, mefemanic acid (pos. anaphylaxis)

Awareness of other possible allergies eg. penicillin

Bronchdilators - dry mouth

Occasional systemic steroid therapy.

Gastro Intestinal System:

A) Dry mouth:

Causes

Effects:

- discomfort and denture problems
- disturbed taste, speech, swallowing
- tendency to periodontal disease and caries
- tendency to candidiasis/ascending bacterial sialadenitis

Treatment

Peptic Ulceration:

-Avoid erosion of teeth due to regurgitation

-Anaemia

-Avoid NSAID’s

-IV sedation - diazepam activity enhanced by cimetidine.

-Coeliac Disease:

-Apthae - glossitis

-Burning mouth - angular cheilitis.

Crohn’s Disease:

-Mucosal ‘tags’ or ‘cobblestone’ proliferation of mucosa

-Oral ulceration

-Steroid/immunosuppressive therapy.

LIVER:

Obstructive Jaundice:

Cirrhosis:

Surgical risk of bleeding tendency

Anaemia

Impaired drug metabolism

Congenital - green discolouration of teeth - hypoplasia

Hep B Risk:

Known infectious/carrier

IV drug abuse

Homosexual

Geographic risk areas

Institutionalised patients

Chronic use of blood or blood products

Management:

Cross-infection control

Immunisation

Antigen testing.

KIDNEY:

Impaired drug excretion

Hypertension, anaemia, bleeding tendency

Anticoagulant therapy following dialysis

Immunosuppressed/Steroid therapy - transplant patients

Candidiasis

Some drugs are nephrotoxic eg. tetracycline

Infective risk patients.

MUSCULO-SKELETAL:

Rheumatoid Arthritis:

Painful, swollen joints - possible unstable neck

Sjorgren’s Syndrome

Oral drug reactions - lichenoid, oral ulceration

Steroid therapy - immunosuppressive candidiasis

Anaemia.

Paget’s Disease:

Enlargement of alveolar ridges

Hypercementosis/ankylosis of teeth

Difficult and/or traumatic extractions likely with osteomyelitis if appropriate antibiotic therapy is not implemented.

Occasional pulpal calcification.

Diabetes:

Dry mouth

Candidiasis

Lichenoid drug reactions

Poor response to infection

Dental infections may affect control of blood glucose levels

Antimicrobials required for oro-facial infections

Plan appointments and treatment to minimise risk of hypoglycaemia.

Thyrotoxicosis:

Irritable/anxious patient

Tremor, heart failure

Possible risk of dysrhythmia with adrenaline LA

Dental infections – use antimicrobials and drainage to avoid precipitating crisis.

Hypothyroidism:

Slow reactions/cerebration and poor memory

Hypotension, bradycardia

Avoid sedation/codeine.

Pregnancy:

Avoid radiography in 1st and 3rd trimester

Avoid drugs

Dental treatment if necessary in 2nd trimester

‘Pregnancy gingivitis’ and epulides

Supine hypotension

(also check with text before prescribing if mother is breast feeding)

Oral Contraceptives:

Decreased contraceptive effect with certain drug therapy

Possible increased tendency to periodontal disease

Possible increased risk of dry socket

Steroid Therapy:

Masking of disease processes

Opportunistic infections – candidiasis

Impaired healing

Diabetes

Psychosis

Osteoporosis

Peptic Ulceration

Cushinoid features

Prolonged adrenal atrophy – slow withdrawal of therapy essential

Circulatory collapse under stress – Dental treatment?

Supplementary Steroid Cover:

IV hydrocortisone sodium succinate 100-200mg ONE hour pre-op (minor)

or, 20mg prednisolone (4mg dexamethasone) FOUR hours pre-op + FOUR hours post-op.

For more comprehensive information, including General Anaesthetic considerations, refer to text such as:

"Medical Problems in Dentistry" C. Scully & R.A. Cawson 2nd Edition 1987 (Wright, Bristol)