Patients at risk
Introduction :
The dentist is confronted daily with patients with different types of general pathologies.
Any action, whatever its nature, must be adapted to the terrain
– Physiological (pregnancy,…….).
– Pathophysiological (allergy, etc.).
– “therapeutic” (drug interactions) of the patient.
Knowledge of the terrain effectively allows the practitioner to take the necessary precautions in order to preserve the organic and/or functional integrity of his patient.
Inadequate consideration of such history can in some cases lead to potentially fatal accidents.
I- General information and definitions:
1-the risk :
According to LAROUSSE: it is the possibility, probability of a fact, of an event considered as an evil or damage.
2-The risk in dentistry:
Risk is the probability of occurrence of incidents and adverse events, of malfunctions harmful to the person being treated, those around them as well as hospital staff and the establishment itself after exposure to a triggering factor.
3-Notion of patient at medical risk:
Patient with general conditions that may be aggravated by medical procedures and/or prescriptions.
Physiological condition requiring special precautions (age, pregnancy, etc.).
4- ASA Classification:
It is used to measure the impact of a general illness on the patient’s functional status:
■ ASA 1: healthy patient.
■ ASA 2: patient with moderate general illness (balanced diabetes, controlled hypertension, anemia, chronic bronchitis, morbid obesity).
■ ASA 3: patient with a severe general condition that limits activity (angina, COPD, history of MI).
■ ASA 4: patient presenting a pathology with permanent vital risk (heart failure, anuric renal failure).
■ ASA 5: patient whose life expectancy does not exceed 24 hours.
5. Risks to consider in dentistry:
The interview allows us to know whether the patient:
• Presents a physiological particularity: pregnancy, breastfeeding
• Suffers from a pathological condition: allergy, heart disease, etc.
• Is treated with one or more medications.
It is therefore necessary to carry out systematic and careful questioning
and to identify patients at risk in order to adapt the procedure (medical and/or surgical) to their circumstances.
- In practice, always ask yourself 5 questions:
– Risk of infection?
– Risk of bleeding?
– Risk of stress?
– Risk regarding prescriptions? (medication and anesthesia).
– Specific risk specific to the disease?
- Thus, the choice of course of action will be based on the patient’s overall vision.
5.1. Infectious risk
- Potential causes linked to microbiological contamination which can lead to infectious consequences .
- This risk is linked to surgical procedures which can cause the passage of microorganisms into the blood, commonly known as bacteremia .
- The latter will be responsible for unfortunate consequences which can put the vital prognosis of a subject at risk at risk.
- According to the French Agency for the Safety of Health Products in July 2001, a working group proposed to separate the risk of infection into two types :
- Risk A : corresponding to a risk of locally identified infection and/or general infection (septicemia).
- Risk B : corresponding to a risk of infection linked to a secondary location of the bacteria (focal infection).
5.2. The risk of hemorrhage:
Potential causes related to the rupture of the continuity of the vessels causing bleeding that is difficult to control, for example: platelet and coagulation disorder disease.
5.3. The risk of syncopation:
It is the probability of brief, complete and reversible loss of consciousness, following a reduction in oxygenation. Example: ischemic heart disease.
5.4. The risk of contamination:
It is the probability of transmission of a disease from an infected subject to a healthy subject; this contamination can be direct (direct contact) or indirect (pathogenic agent carried by an intermediary).
5.5. Toxic risk:
It is the probability of the appearance of a set of disorders due to the introduction of a substance into the body that is normally well tolerated by it. This toxic effect is due to certain pathology which alters the function of purification or detoxification of poisons in the body, e.g.: nephropathies.
5.6. The risk linked to certain physiological states:
This is the probability of the occurrence of certain disorders, following the taking of certain medications or operative stress during pregnancy, breastfeeding or in the elderly.
II-General concepts of care for at-risk patients:
- Contact the attending physician before undertaking any action likely to worsen the patient’s general state of health.
- Be aware of your general pathology , and thus be able to classify it into a category according to the risk incurred.
- Know the duration , dosage and nature of the drug treatment , to understand the oral repercussions and possible drug interactions linked to the dentist’s prescription.
- Common application of universal rules of hygiene and asepsis linked to the potential risk of contamination.
II- Preliminary biological examinations in dentistry:
Their goal is:
• Confirm a clinical impression: liver damage in an alcoholic patient,……
• Discover a pathological condition unknown to the patient: hepatitis, etc.
• Highlight a pathological condition that the patient had wished not to reveal: AIDS, etc.
There are a number of assessments that need to be taken in order to take the necessary precautions in the face of a disturbed balance sheet.
- Blood test
-FNS blood count:
| Blood count | |
| Hemoglobin | Men: 13 to 18g/dl Women: 12 to 16g/dl |
| Erythrocytes | Men: 4.5 to 6 g/dl Women: 4 to 5.4 g/dl |
| Hematocrit | Men: 40 to 54% Women: 36 to 47% |
| Mean corpuscular volume (MCV) | 85 to 95 µm3 |
| Mean corpuscular hemoglobin concentration (MCHC) | 320 to 360 g/l |
| Mean corpuscular hemoglobin content (MCHC) | 27 to 31 pg |
| Reticulocytes | 25 to 100g/l |
| Blood count: % and white blood cell count | |
| Neutrophil polymorphonuclear cells | 45 to 70%, 1.7 to 7.5g/l |
| Eosinophilic polymorphonuclear leukocytes | 1 to 3%, ˂ 0.5g/l |
| Basophils | ˂ 0.2g/l |
| Lymphocytes | 20 to 40%, 1 to 4g/l |
| Monocytes | 3 to 7%, 0.2 to 1g/l |
| Platelet count | |
| Platelets | 150 to 140g/l |
- Hemostasis assessment:
Platelet count.
INR : Used to measure blood clotting. It explores the extrinsic pathway, it involves the following clotting factors: factor I (fibrinogen), factor II, factor V, factor VII and factor X.
Activated Partial Thromboplastin Time (aPTT): It explores the intrinsic pathway of coagulation, it involves the following coagulation factors: factor VII, factor IX, factor XI and factor XII, it is expressed as a ratio between a control sample and the patient’s blood.
Bleeding time (BT): useful for detecting primary hemostasis pathology: normal ˂ 10 min (Ivy method).
- Inflammatory assessment:
C-reactive protein (CRP): biological marker of inflammation. Normal: ˂ 10 mg/l.
Erythrocyte sedimentation rate (ESR): non-specific measure of inflammation. Normal: age 1/2 in men, age 10/2 in women.
Procalcitonin (PCT): a more specific marker of bacterial inflammation. Normal: ˂0.5 µl/l
- Hepatocellular assessment:
Liver enzymes:
They include:
-Normal gamma glutamyl transferases (GGT): ˂ 26µl/l.
-Normal alkaline phosphatases: 20 to 80 µl/l.
*Increased in cases of cholestasis.
*Can also be a marker of chronic alcohol consumption.
Transaminases (ASAT and ALAT): this is a marker of suffering
hepatocyte. Normal: ˂ 30 to 50 µl/l.
Bilirubin:
It is one of the products resulting from the breakdown of hemoglobin. It circulates in its unconjugated form, mostly bound to albumin. It is conjugated in the liver, allowing its elimination.
Normals:
Total bilirubin: 3 to 10 mg/l.
Conjugated bilirubin: ˂ 2.4 mg/l.
Its increase may be a sign of liver disease or excessive hemolysis.
- Renal assessment:
Normal creatinine:
In women: 5 to 12 mg/l.
In humans: 7 to 13.5 mg/l.
Normal urea: 0.1 to 0.5g/l.
An increase in these two markers is a sign of kidney failure.
Renal clearance <60ml/min is also a marker of renal failure.
- Cardiac assessment:
Troponin:
It is a marker of myocardial necrosis.
Normal: ˂ 0.2µg/l.
Its increase allows the diagnosis of a myocardial infarction in the event of chest pain.
- Other constants:
Blood ionogram:
Natremia 135-145mmol/l: its value reflects the state of intracellular hydration.
Potassium 3.5-5 mmol/l: hypo/hyperkalemia can be dangerous due to the risk of heart rhythm disturbance.
Chloremia: 95-105mmol/l.
Normal serum calcium : 2.2 to 2.5 mmol/l.
D-dimers : these are fibrin degradation products, they are used in the diagnosis of deep vein thrombosis or phlebitis and pulmonary embolisms.
III- Patients at risk and OC:
A- Patients at physiological risk:
1- Age: The risk inherent in drug prescription must above all be assessed at both ends of life, that is to say in children and the elderly.
*Child :
The rule for prescribing medication in children is that of Gaubius Cottereau:
-1 to 3 years = 1/6 of the adult dose.
-3 to 7 years = 1/3 of the adult dose.
-7 to 12 years = ½ of the adult dose.
-12 to 17 years = 2/3 of the adult dose.
Many specialties in the form of solutions or syrups are presented with a measuring spoon corresponding to one dose for 5 kg of weight.
*Elderly subject:
Generally speaking, the approach to follow consists of adapting (by reducing) the dosage, using suitable galenic forms and clearly explaining the prescription and the various risks to the patient.
Particularity of drug prescriptions in gerontology
2- Pregnancy and breastfeeding:
*The appropriate time to intervene in pregnant women:
From the 1st to the 3rd month: Only emergency treatments can be performed.
From the 4th to the 7th month: This is the right time to intervene. However, multiple treatments or those requiring follow-up will be postponed until after delivery.
The 8th and 9th months: Only emergency treatments that provide relief will be considered. Sessions will be as short as possible and will take place in a semi-seated position.
*Oral pathologies related to pregnancy
The pathologies that can be observed during pregnancy are:
-Grease-induced gingivitis: the treatment is the same as for normal gingivitis.
-Epulis: granuloma appearing between two teeth, pedunculated or sessile, red, painless and bleeding at the slightest touch. It is advisable to wait until the end of the pregnancy. If it does not regress or if it is bothersome during pregnancy, excision is performed.
-Periodontal diseases, it is therefore recommended to carry out periodontal sanitation.
-Caries lesions, in this case, carry out sealing of the restorations and programming of treatment sessions.
-Erosions: rinsing with sodium bicarbonate, fluoridation and protection tray and scheduling of restoration sessions if loss of substance requires it.
The care of pregnant women does not require any special precautions regarding the provision of care. Possibly:
*Stress:
Stress and anxiety will be minimized by the
-Establishment of a good practitioner-patient relationship.
-Explanation of the procedures and their safety for the fetus.
*Ionizing radiation : we recommend:
-The use of fast printing films.
-The use of the long cone.
-Protection of the pregnant woman by a lead apron.
-Reducing the number of shots to the strict minimum.
-Avoid X-ray examinations, especially during the first trimester.
*Anesthesia:
No analgesic technique used in the dental office is contraindicated.
Concerning the molecules:
-Articaine (Alphacaine®, Ultracaine®, Primacaine®, Septanest®, Bucanest®, Deltazine®, Ubistesine®) should be preferred.
-The use of vasoconstrictors is not contraindicated provided that intravascular injection is avoided.
*Medicinal prescription:
-Antibiotics:
The antibiotic of choice is Penicillin.
First-generation cephalosporins and erythromycin may be
taken.
Tetracyclines should be avoided because they cause:
-Dental dyschromia, cataracts and congenital limb anomalies in newborns.
-Fatty degeneration of liver cells and pancreatic necrosis in pregnant women.
-Anti-inflammatories :
These molecules should be avoided in pregnant women.
Corticosteroids are only administered when life is at risk because they can cause:
– A delay in fetal growth, a possible action on lung maturation and on certain regions of the brain.
-Non-steroidal anti-inflammatory drugs should be avoided during the 2nd and 3rd trimesters of pregnancy because they are responsible for premature closure of the ductus arteriosus, causing cardiac distress in the newborn.
-Painkillers:
In case of pain, Paracetamol remains the molecule of choice.
The use of acetylsalicylic acid, dextropropoxyphene, and codeine derivatives should be avoided.
-Fluoride:
Prescribing fluoride to pregnant women is no longer in vogue. It has been proven that fluoride has no significant effect on the maturation of the unborn child’s dental tissue, but can be used in cases of erosion or vomiting (creation of a fluoridation tray by topical application).
- B- Patients at pathophysiological risk:
B- Patients at pathophysiological risk:
1- Allergic patients:
Allergy is a reaction obtained by the reintroduction of an allergen in a previously sensitized individual.
We distinguish according to their origin:
*Pneumonallergens (allergens penetrating through the respiratory tract).
*Trophoallergens (food allergens).
*Drug allergens.
Clinical signs:
-Simple forms: erythema, a skin rash.
-Severe forms: urticaria and angioedema (Quincke’s edema), anaphylactic shock.
1-a Prevention of allergic risk:
-Exclude prescriptions that include well-known drugs
to be allergens:
- Amidopyrine and noramidopyrine (NSAIDs).
- Ester-linked local anesthetics (parabens or sulfites).
- β-lactams: penicillins and cephalosporins.
-Premedication may be considered if the patient can be monitored, we will call upon:
*Hydroxyzine (Atarax): which exerts a blocking effect on histamine H1 receptors and whose anxiolytic effect is effectively superimposed in these patients who are always anxious.
1-b What to do in the event of an allergic reaction:
*Minor reactions are treated with antihistamines and corticosteroids.
*For major events:
-The SAMU is alerted
-Injection of adrenaline or administration (intravenous) of high doses of fast-acting glucocorticoids such as Soludecadran, Celestène, Betnesol, solupred.
-Pressurized oxygen therapy is recommended along with vascular filling in cases of anaphylactic shock.
1-Heart diseases:
- Classification of heart diseases: They are classified into two main groups:
| High-risk heart disease | Moderate-risk heart disease |
| – Valve prostheses. – Cyanotic congenital heart disease. – History of infective endocarditis | -Valvulopathies. – Non-cyanotic congenital heart diseases except interatrial communication – Obstructive hypertrophic heart diseases (with murmur on auscultation). |
b- The risks incurred:
1- The risk of infection:
- Represented by infective endocarditis.
- It is preceded by bacteremia or fungemia of oral origin.
- 40 to 60% of IE cases are associated with valvular heart disease and 10% are caused by a congenital malformation.
- However, infection of normal valves is not uncommon, being observed in almost one-third (1/3) of IEs
- Action to be taken:
In practice, the precautions to be taken by the practitioner are as follows:
– Obtain the advice of the attending physician.
-Achieve good motivation for oral hygiene.
– Delay any action until the inflammatory state is as low as possible.
– Prescribe antibiotic prophylaxis.
– Reduce the sepsis of the oral cavity before any intervention by using an antiseptic mouthwash.
– Intervene in the least traumatic way possible.
– Avoid intra-ligamentary anesthesia.
– Avoid the iatrogenic creation of infectious foci.
-Respect a minimum interval of 9 to 14 days between each session to avoid the development of bacterial resistance.
– In case of unexpected bleeding, the antibiotic should be administered within two hours following the procedure.
– The patient presents if fever or other symptoms related to endocarditis appear.
- Treatment :
Rely on appropriate antibiotic therapy for approximately 6 weeks, after detection of the responsible germ by antibiogram.
a- Contraindicated oral and dental procedures (group A and B heart disease):
-Local intra-ligamentary anesthesia.
-Treatment of teeth with necrotic pulp, including resumption of root canal treatment.
-Root amputation.
-Transplantation/reimplantation.
-Periapical surgery.
-Periodontal surgery.
-Implant surgery.
-Preorthodontic surgery of impacted or impacted teeth.
- Invasive oral and dental procedures Antibiotic prophylaxis.
-Installation of the dike.
– Descaling with or without surfacing.
-Survey.
-Dental extractions.
*Healthy tooth.
*Alveolectomy.
*Root separation.
*Included or disincluded tooth. Recommended Optional
*Germectomy.
-Freinectomy.
-Biopsy of the accessory salivary glands.
-Bone surgery.
-Placing rings.
-Orthodontics.
- Non-invasive oral and dental procedures Antibiotic prophylaxis.
-Application of fluoride.
-Sealing of the furrows.
-Coronary restorations on pulped teeth.
-Removal of sutures. Not recommended.
-Installation of removable orthodontic appliances.
-Taking X-rays.
-Non-intraligamentary local anesthesia.
b-Dosage of antibiotic prophylaxis:
| DCI | Dosage | prescription example |
| Amoxicillin | Weight < 60 kg: 2 g Weight > 60 kg: 3 g | -Clamoxyl® dispersible tablet, 1 g – Take 2/3 tablets, 1 hour before the appointment (child 75 mg/kg) |
| Clindamycin | 600 mg | – Dalacin® 300 mg capsules – Take 2 capsules 1 hour before the appointment (child: 15 mg/kg) |
| Pristinamycin | 1000 mg | – Pyostacine® 500 mg tablets – Take 2 tablets, 1 hour before the appointment (child 25 mg/kg) |
2- The risk of hemorrhage:
Heart diseases with a risk of hemorrhage are those whose treatment is based on an antiplatelet, anticoagulant or antifibrinolytic agent:
- Thromboembolic disorders.
- Ischemic heart disease (myocardial infarction, angina).
- History of cardiovascular surgery.
- Valvular heart disease and valve prosthesis wearers.
- Rhythm disorders.
*The main anticoagulants used:
a. Anticoagulants:
– AVKs: administered orally, they have a prolonged effect.
-Heparin: administered intravenously or subcutaneously. It is the most commonly used (2 to 3 injections/day).
The products used are:
-Na heparin (IV)
-Ca heparin (IV) or calciparin
-Ca heparin (SC) or calciparin
-Mg heparin (SC) or cutheparin
b. Antiplatelet agents:
*Products used:
-Acetylsalicylic acid (aspirin).
-Tichlopidine (Ticlid, plavix ).
Action to take:
– Biological monitoring of anticoagulant therapy:
*TP (prothrombin time): it must be at least 30%.
*INR (international normalized ratio):
-INR = patient’s TP, it varies from 1 to 9 control TP
-INR is only reliable for patients on AVK.
-The therapeutic zone for the majority of indications corresponds to an INR between 2 and 3.
*A platelet count may be requested in patients taking antiplatelet drugs.
* Precautions during anesthesia:
-Locoregional anesthesia should be avoided (risk of hematoma).
*Precautions in the context of the prescription:
-Aspirin-based medications and NSAIDs should be avoided, prescribe paracetamol alone or in combination (codeine, dextropropoxyphene).
-Prescribe steroidal anti-inflammatory drugs for 4 days.
-The shots will be taken in the morning at the same time each day.
3- The risk of syncopation:
All cardiac patients can experience syncope except those with pacemakers.
High risk:
– High blood pressure.
– Rhythm disorders.
– Ischemic heart disease.
– Aortic stenosis
Moderate risk:
– Cardiomyopathies.
– Pulmonary embolisms.
– Cyanotic congenital heart disease.
– Heart failure.
2. Clinical manifestations:
-Sudden pallor of the face
-Hot flashes
-Redness and palmar hyperhidrosis
-Slowing down cardiac arrest
-Superficial polypnea
-Tension collapse.
-Loss of consciousness.
Action to take:
- Reassure the patient and give them confidence.
- Minimize the stress and anxiety associated with dental treatment through a non-painful and non-traumatic procedure.
- Sedative premedication if necessary (prescribe Atarax or Sulpérid the day before and on the day of the consultation)
- Avoid anesthetics with vasoconstrictors.
- Perform the procedure preferably in the morning, to avoid the stress of the day, and to ensure that the patient is not fasting.
- Do short sessions
- Caution should be exercised when removing the patient from the supine position (possible orthostatic hypotension).
- Keep the patient under observation for at least 30 minutes after the procedure.
What to do if you faint:
- -Stop the act immediately.
- – Lay the patient on the floor, ensuring that the airways are clear, and monitor the pulse.
- – Perform the first emergency actions (subcutaneous or IV injection of atropine).
- -In case of complications, call the emergency services.
c- Specific actions to take for other high-risk heart diseases:
c-1 Myocardial infarction and angina pectoris:
- In case of myocardial infarction, intervene 6 months later (Do not intervene in case of a recent attack).
- Contact your doctor.
- Careful psychological preparation to reduce stress.
- Have the resuscitation equipment.
- Use of anesthetics without vasoconstrictors.
- Prohibit salicylates or other NSAIDs in patients taking anticoagulants or antiplatelet drugs. Prescribe paracetamol.
- In the event of an angina attack, stop treatment and take trinitrin sublingually, which acts in 1 minute.
- In case of heart attack: specialist evacuation as quickly as possible.
c-2 Acute rheumatic fever:
- Acute rheumatic fever without cardiac involvement: bring the procedure closer to the date of extencillin injection.
- Acute rheumatic fever with valvular involvement: put the patient on antibiotic prophylaxis: Pristinamycin or Clindamycin.
c-3 Heart rhythm disorders:
- Contact the cardiologist.
- Request a hemostasis assessment in patients on anticoagulants.
- Careful psychological preparation to reduce stress.
- Have the resuscitation equipment.
- Use of anesthetics without vasoconstrictors.
- Prohibit salicylates or other NSAIDs in patients taking anticoagulants or antiplatelet drugs. Prescribe paracetamol.
- In case of syncope:
-Stop the act immediately.
– Lay the patient on the floor, ensuring that the airways are clear, and monitor the pulse.
– Perform the first emergency actions (subcutaneous or IV injection of atropine).
-In case of complications, call the emergency services.
- 3- Patients with endocrine disorders:
a- Diabetes mellitus:
What type of diabetes is it?
Type 1 insulin dependent:
■ Pathophysiology: diabetes characterized by an absolute insulin deficiency due to destruction of betapancreatic cells (linked to an autoimmune process of unknown cause). It begins in adolescents or young adults.
■ Patients treated with the combination of:
-Non-insulin treatment = varied diet, regular schedules and carbohydrate intake, physical exercise.
-Insulin treatment = main treatment for type 1 diabetes, lifelong, palliative (Lantus®, Levemir®, Humalog®, Novorapid®, Apidra®, Actrapid®, Lilly® rapid insulin, Insuman®, Ultratard®, Humalog Mix®, Novomix®).
-Self-monitoring of blood sugar: blood sugar around 1 g/L (normal fasting blood sugar according to WHO: < 1.10 g/L).
Type 2 non-insulin dependent:
■ Represents 80 to 90% of diabetes.
■ Pathophysiology: insulin resistance (promoted by android obesity, age and sedentary lifestyle) and relative insulinopenia (insufficient insulin secretion given the level of blood sugar).
■ Patients who can be treated by:
-Physical activity, balanced diet.
-Drug treatment: oral antidiabetics: biguanides (Glucophage®, Stagid®), sulfonamides (Diamicron®, Daonil®, Amarel®), glinides (Novonorm®) aglucosidase inhibitors (Glucor®), glitazones (Actos®, Avandi®), combination of oral antidiabetics (Glucovance®, Avandamet®).
– Insulin therapy combined with oral antidiabetics or exclusively.
- Self-monitoring of blood sugar: blood sugar around 1 g/L (normal fasting blood sugar according to WHO: < 1.10 g/L).
-Diabetes secondary to endocrine pathologies.
-Gestational diabetes: which occurs during pregnancy.
Oral implications:
Diabetes can lead to various oral complications:
-Xerostomia.
– Infections.
-Delayed healing.
-An increase in the frequency and severity of carious lesions.
-An increased risk of candidiasis.
-Gingivitis.
-Periodontitis.
*Precaution in dentistry:
- Make sure of the type of diabetes.
- Is it balanced?
- Balance control in case of uncertainty: glycated hemoglobin (HbA1c) measurement:
-The target for adult diabetics is a value less than or equal to 6.5% (for a healthy subject’s norm ranging from 5.5 or 6%). In the elderly, the target is discussed according to the clinical condition.
-Reflects the balance of the previous 2 to 3 months (7% = average blood sugar of 1.5 g/L; 9% = average blood sugar of 2.1 g/L) = the best indicator of the risk of complications.
– Meaning of HbA1c:
*< 6.5%: good control. Low-risk patient.
* 6.6–8%: quality of control to be interpreted according to the clinical context. Moderate-risk patient.
*> 8%: poor control; therapeutic modification essential. High-risk patient.
– Check blood sugar in the chair: used to assess the risk of hypoglycemia.
Action to take:
*Precautions regarding the treatment followed by the patient:
-The treatment will be carried out in the morning and the patient will be invited to have breakfast.
-If an appointment overlaps the normal meal time, an interruption of care should be considered to allow the patient to eat (usually orange juice is perfectly appropriate).
*Precaution in the context of anesthesia:
The use of vasoconstrictors is not contraindicated. The injection will be done slowly after aspiration.
*Precaution regarding the risk of infection:
Currently, antibiotic prophylaxis is recommended in unbalanced diabetic patients in case of invasive oral-dental procedures, consisting of the prescription of the combination: macrolides-metronidazole or penicillin and metronidazole, antibiotic therapy must be maintained for a longer period (10 days).
*Hypoglycemic discomfort:
-The occurrence of hypoglycemic discomfort is caused by an insufficient blood glucose level (omission of a meal, physical exertion, etc.), and can be precipitated by stress, infection or anxiety.
-Characterized among other things by sweating, marked asthenia, disturbances of consciousness, tremors and tachycardia.
- Action to take:
-Place the patient in the safety lateral decubitus position.
-Free the VAS of any object that could obstruct them and proceed with re-sugaring:
*Conscious patient:
Resugar orally with fast sugars (2 to 4 pieces of sugar, sweet drink), then relay with slow sugars (bread, biscuit).
- Unconscious patient: parenteral (IV) sugar resuscitation 20 to 40 ml of glucose serum.
- In case of significant agitation: subcutaneous or (IM) injection of 1 mg of glucagon.
-In all cases after an episode of hypoglycemia, the insulin dosage and the patient’s feeding methods must be reassessed.
b-Hyperthyroidism:
■ Etiologies:
-Graves’ disease
-Toxic multinodular goiter.
-Toxic adenoma.
- Clinical manifestations:
-Character and mood disorders (nervousness, emotionality, sleep disorders).
– Vasomotor disorders (flushes of redness, sweating, thermophobia).
– Digestive disorders (bulimia, accelerated transit).
-Muscular manifestations (asthenia, cramps).
-Cardiac complications (cardiothyreosis) which are rhythm disorders (fibrillation), more rarely heart or coronary insufficiency.
-Stupor and coma with vascular collapse (severe form).
-Oral manifestations:
*Increased salivary flow.
*Demineralization of alveolar bone.
*Susceptibility to periodontal disease.
*Tongue burns.
*Premature exfoliation of temporary teeth with premature eruption of permanent teeth.
Patients who can be treated by:
-Synthetic antithyroid drugs (NeoMercazole®, Basdène®, Propylthiouracil®).
-Beta-blockers (Avlocardyl®, Sectral®, Tenormine®, Trandate®, etc.).
-Surgical treatment.
– Radioiodine treatment.
- Action to take:
In untreated patients:
*Precaution in the context of anesthesia:
-Anesthetic solutions with vasoconstrictors, gingival retraction cords impregnated with adrenaline and intraligamentary injections are strictly contraindicated (thyrotoxic crisis).
*Precaution regarding the risk of infection:
Antibiotic prophylaxis is recommended for any bloody act.
*Precaution in the context of drug prescription:
Non-narcotic pain medications are not contraindicated.
*Precaution in urgent care:
-Postpone care until the disease is under control.
C. Hypothyroidism:
■ Etiologies:
-Autoimmune (Hashimoto’s thyroiditis).
-Thyroidectomy.
– Radioiodine treatment.
-Medicinal causes…
■ Patients who can be treated with: thyroid hormones (Levothyrox®, Euthyral®).
■ Associated pathologies (autoimmune origin):
-Hematological disorders.
-Anemia.
-Blood clotting disorders (acquired Von Willebrand disease only).
-Adrenal insufficiency.
Oral manifestations:
-Macroglossia.
-Dysgeusia.
-Eruption delays.
-edema and gingival and labial hypertrophy.
- Action to take:
In untreated patients:
-Risk of myxedema (no longer seen at present).
-Postpone care until the disease is under control.
In treated patients:
*Precaution in the context of anesthesia:
-Anesthetic solutions with vasoconstrictors are not contraindicated.
*Precaution regarding the risk of infection:
Antibiotic prophylaxis is recommended for any bloody act.
*Precaution in the context of drug prescription:
Non-narcotic pain medications are not contraindicated.
*Precaution in urgent care:
-Postpone care until the disease is under control.
4- Patients with liver diseases:
a- Liver failure (cirrhosis):
Alcohol is responsible for several liver lesions: steatosis (an accumulation of a fat called triglyceride in the liver cell), hepatocellular necrosis, etc., which then progresses to mutilating fibrosis, causing architectural anarchy of the liver parenchyma leading to established cirrhosis.
Cirrhosis involves parenchymal nodules, sclerosis, intrahepatic circulatory disturbances, and ultimately damage to the entire liver parenchyma. At this stage, liver damage is irreversible.
The patient’s appearance is generally very suggestive and biological examinations
confirm the diagnosis:
-FNS shows frequent anemia , leukopenia and thrombocytopenia .
-Certain dosages such as lowered blood urea and cholesterol levels, the fall in albumin levels and the impairment of certain hemostasis factors (V, VII, IX, X) which will be responsible for the lowering of the prothrombin level, reflect the degree of hepatocellular insufficiency.
b- Viral hepatitis:
These are liver lesions of viral origin characterized by hepatocellular necrosis (localized or extensive) and inflammatory infiltration of the liver.
- The clinical picture can be mild, even inapparent, or very severe, with associated coagulation disorders and neurological disorders.
- Based on clinical and biological criteria, two forms can be distinguished: acute and chronic.
- Hepatitis is defined as chronic when the hepatic inflammatory process lasts for more than 6 months.
- Viral hepatitis is caused mainly by four types of viruses: A, B, C, D and E.
| Mode of transmission | Prevalence | |
| Hepatitis A | Oral or fecal route | The child and the young adult |
| Hepatitis B | Parenteral routeTransmucosal or transcutaneous route | The chronic form is the most common |
| Hepatitis C | Parenteral route | More than 20 to 30% develop a chronic form |
| Hepatitis D | Superinfection of form B | The chronic form is the most common |
| Hepatitis E | The pregnant woman |
c- Porphyria:
It is the consequence of a deficiency of an enzyme involved in the biosynthesis of heme.
- Action to take:
*Precautions regarding the risk of infection:
-Wearing gloves, masks, goggles and disposable gowns, using a dam, delicate handling of needles and sharp objects and storing them in rigid containers provided for this purpose.
-Avoid high speeds.
-Use of single-use materials
-Sterilization of instruments, appropriate disinfection of work surfaces, identification or marking of contaminated waste.
– Treatments must be fixed at the end of the day.
-It is absolutely essential for healthcare staff to be vaccinated against hepatitis B; the various vaccines provide remarkable protection for around five years.
-Non-immune personnel who are accidentally contaminated may receive hyperimmune Ig against hepatitis B within a period not exceeding 48 hours.
*Precautions during anesthesia:
-The use of local anesthetics with amine function (Lidocaine, Mepivacaine) should be done in low doses, sedation by inhalation of nitrous oxide will be associated with it.
-Halothane should be avoided in general anesthesia.
-The use of vasoconstrictors is not contraindicated.
-The injection will be done slowly after aspiration.
-The equipment must be used carefully to avoid any contamination
accidental injury of the practitioner by tissue breakage.
-The use of local para-amino anesthetics such as procaine is made.
*Precaution regarding hemostasis and coagulation disorders:
Before any type of surgery, check INR, platelets and APTT.
*Precautions in the context of prescription:
-Acetylsalicylic acid and its derivatives, NSAIDs should be avoided.
-All hepatotoxic drugs should be avoided from the prescription: codeine, benzodiazepines, barbiturates, paracetamol, ampicillin and tetracyclines.
-If the use of these molecules is really necessary, the dosage will be reduced and the interval between doses will be increased.
5- Nephropathies:
a- Chronic renal failure:
It results in the progressive and irreversible inability of the kidneys to perform their physiological functions.
*Consequences of chronic renal failure:
-Normocytic normochromic anemia.
-Lymphocytopenia.
-Uremic thrombopathy.
-Renal osteodystrophy.
– Bone mineralization defect (linked to the absence of activation of vitamin D at the kidney level).
-Pronounced bone resorption linked to secondary hyperparathyroidism.
b-Hemodialysis:
-Hemodialysis consists of circulating the patient’s blood in an extracorporeal circuit and passing it through a filter in order to purify it.
-The majority of dialysis patients benefit from three sessions per week (each session lasts 4 hours).
c- Kidney transplant:
-This is the treatment of choice for end-stage renal failure. It involves removing a kidney from a living related donor and transplanting it into the patient to ensure the function of the diseased kidneys.
-Immunosuppressive treatment (cyclosporine and azathioprine) is essential to ensure graft survival .
- Action to take:
*Precaution regarding stress:
-Medicinal sedation based on benzodiazepines or barbiturates as well as preoperative sedation by inhalation of an oxygen-nitrous oxide mixture is not contraindicated in patients with renal failure.
*Precaution in the context of anesthesia:
-The practice of local anesthesia and the use of vasoconstrictors is not contraindicated.
*Precautions regarding the treatment followed by the patient:
-In patients receiving conservative treatment, anti-infectious prophylaxis is recommended, so check whether the patient is receiving anticoagulant treatment for an associated pathology.
-In hemodialysis patients:
*Avoid the transmission of infection, especially viral infections.
*Reduce the risk of bleeding.
-In transplant patients:
*Limit infections to prevent rejection.
*Precautions regarding the risk of bleeding:
Bleeding control will be achieved through the use of local hemostasis techniques:
-Digital compression, topical application of local hemostatic agents, sutures, compression by placing a gutter, application of biological glue.
-For hemodialysis patients, care will be scheduled the day following dialysis or the day before it.
*Precautions regarding the risk of infection:
- Precautions to prevent the transmission of infections:
-Universal hygiene and asepsis measures are required.
-Start vaccinating patients with chronic renal failure if they do not have anti-HBc antibodies, as soon as the creatinine clearance is 60ml/min.
-The use of erythropoietin even before the dialysis stage significantly reduces the frequency of blood transfusions, which limits the transmission of hepatitis C.
- Precautions to prevent infectious complications following procedures performed by the practitioner:
-Prescription of antibiotic prophylaxis: Erythromycin 3 days before and for 5-6 days after the procedure.
- Precautions to maintain satisfactory oral hygiene, prepare the patient for transplantation and treat established manifestations:
- Maintaining oral hygiene has a dual objective:
-Promote the patient’s diet.
-Prevent the development of infectious manifestations.
- Precautions to prepare the patient for transplantation include, after a thorough oral examination, eliminating all established or latent foci. The patient’s motivation and oral hygiene are crucial.
- The treatment of established manifestations depends on their nature:
-The prescription of acyclovir in the context of herpes infections.
-Topical application of nystatin, ketoconazole or cotrimoxazole to treat candidiasis.
-The use of chlorhexidine mouthwashes
*Precautions in the context of drug prescription:
-Antibiotics to be avoided unless absolutely necessary are aminoglycosides
-Antibiotics whose dose must be adapted according to renal function: cephalosporins and their derivatives, tetracyclines, macrolides, sulfonamides, carboxypenicillin, cheidopenicillin.
-Prescribe drugs for saliva elimination (macrolides = erythromycin).
-Prohibit NSAIDs, acetylsalicylic acid and its derivatives.
*Precautions in urgent care:
-If truly urgent care is required, the practitioner’s attention will focus primarily on the risks of infection and hemorrhage.
6- Patients with blood disease:
a- Anemia:
It is a decrease in hemoglobin (men < 13.5 g/dL, women < 11.5
g/dl).
■ Anemia is distinguished:
-Microcytic (MCV < 80 fL):
*Iron deficiency: due to an iron deficiency following chronic bleeding (gynecological, digestive).
*Thalassemia: Hereditary disorder affecting hemoglobin.
-Normocytic (MCV = 80–96 fL):
*Hemolytic anemia (many causes).
*Sickle cell disease.
-Macrocyte (MCV > 96 fL), generally due to a deficiency in vitamin B12 or folate.
■ Oral manifestations: angular cheilitis, glossitis.
■ No special precautions need to be taken with regard to anesthesia, dental care or surgical procedures.
b-Hemophilia:
Affection héréditaire récessive liée au chromosome X, dans laquelle certains facteurs de coagulation sont absents: Fc VIII (hémophilie A) ou en Fc IX (hémophilie B).
*Le degré de sévérité de l’hémophilie :
Hémophilie majeure Fc VIII ou IX < 1 %
Hémophilie modérée Fc VIII et IX entre 1-5 %.
Hémophilie mineure (fruste) Fc VIII et IX > 5%.
c. Maladie de WILLBRAND:
-Affection héréditaire de transmission autosomique dominante ( dimunition du facteur VII coagulant).
-Elle se traduit cliniquement par des saignements muqueux spontanés ou provoqués (gingivorragies dans 30 à 40 % des cas).
d-Patients atteints d’un désordre leucocytaire non prolifératif
Les désordres leucocytaires non prolifératifs peuvent être classés sur le plan quantitatif en termes d’insuffisance (leucopénie) ou d’excès (leucocytose) et, sur le plan qualitatif en termes d’anomalie fonctionnelle.
e. Leucémie:
Tumeurs malignes des cellules souches hématopoïétiques.
Les leucémies sont classifiées selon leurs manifestations cliniques en forme aiguë et chronique et selon leurs caractéristiques cytologiques en leucémies lymphoïdes (chez l’enfant) et myéloïdes (chez l’adulte).
- Conduite à tenir:
*Précaution à l’égard du risque infectieux:
-Toute source d’infection devra être systématiquement recherchée et éliminée avant qu’une aggravation ne se manifeste.
-Une hygiène buccodentaire rigoureuse sera de rigueur.
-Une prophylaxie anti-infectieuse sera préconisée devant tout actes susceptible d’être à l’origine d’une bactériémie .
-Les mesures universelles d’hygiène et d’asepsie doivent être respectées pour réduire au minimum le risque de transmission croisée de pathologies infectieuses bactériennes et/ou virales.
-Une prophylaxie antifongique sera envisagée chez les patients sévèrement immunodéprimés (10 ml de nystatine à 10 000 unités, 4 fois par jour).
*Précaution à l’égard du risque hémorragique:
–Un bilan d’hémostase (plaquettes, TP, TCK, TS) est indispensable avant tout acte.
-Dans la forme majeure d’hémophilie: un traitement substitutif est nécessaire.
-Les techniques locales d’hémostase (compression, applications topiques d’agents hémostatiques locaux résorbables, application de colle biologique, etc.) doivent être envisagées.
-Dans le cas de manifestations plus conséquentes et/ou d’échec des techniques locales, le praticien traitant sera consulté et une transfusion plaquettaire pourra être envisagée.
*Précaution dans le cadre de l’anesthésie :
-Les anesthésies locorégionales sont formellement contre-indiquées (hématomes).
-Les techniques d’anesthésie locale strictes, administrées lentement et avec utilisation de vasoconstricteurs est recommandée.
*Précaution dans le cadre d’une prescription médicamenteuse :
-La prescription d’acide acétylsalicylique, d’anti-inflammatoires non stéroïdiens est contre-indiquée.
-Attention aux interactions médicamenteuses.
-Hospital care is mandatory when performing surgical procedures: avulsion, etc.
7- Patients with respiratory conditions:
7-1 Asthma:
It is a diffuse and reversible obstruction of the airways. This obstruction results from a constriction due to a particular sensitivity to certain stimuli: allergens, stress, medications.
-Classically two types of asthma are described:
*Extrinsic allergic asthma: it is due to type I (immediate) hypersensitivity phenomena through the use of immunoglobulins E (IgE).
*So-called intrinsic asthma: occurs in adults without evidence of hypersensitivity phenomena.
- Treatment:
-Oral corticosteroids (Cortancyl®, during severe attacks) or inhaled (background treatment): Ventoline® (bronchodilator); Euphylline® (treatment of bronchospasm).
- Action to take:
*Precautions regarding the treatment followed by the patient:
-Ensure that the patient has their aerosol with them during important procedures.
-Patients taking corticosteroid sprays do not require additional corticosteroid coverage while receiving local analgesia.
– Oral corticosteroid therapy: maximum coverage of 60 mg of prednisone on the day of surgery, reducing the dose by 50% per day until the maintenance dose.
-Precautions against stress:
-Prohibit all medications that cause respiratory distress (barbiturates).
-Sedation by inhalation of nitrous oxide is an approach of choice.
– Precautions during anesthesia:
-Local anesthetics are the drugs most likely to induce asthmatic reactions due to the “preservatives” used: parabens and especially sulfites.
-The use of anesthetics with vasoconstrictors is contraindicated in the group of corticosteroid-dependent asthmatics .
– Precautions in the context of drug prescription:
– Acetylsalicylic acid and all other NSAIDs, as well as barbiturates, are contraindicated.
– Paracetamol is strongly indicated in cases of prescription of analgesics.
– Certain antibiotics such as Erythromycin, Clindamycin and Ciprofloxacin are contraindicated in the case of treatment with Theophylline, which promotes its accumulation.
– Macrolides contraindicated with Euphylline®.
-Penicillins can be prescribed in asthmatic patients if there is no hypersensitivity.
– NB:
Due to the breathing difficulties that asthmatic patients may experience when lying on their back, treatment will be provided in a sitting or semi-recumbent position.
8- Patients with neuropsychiatric disorders:
a- Epilepsy:
■ Patients who can be treated by:
*Old antiepileptics: sodium valproate (Dépakine®); barbiturates: phenobarbital (Gardénal®, Alepsal®, Kaneuron®); phenytoin (DiHydan®); carbamazepine (Tégrétol®).
*New antiepileptics: lamotrigine (Lamictal®); oxcarbazepine (Trileptal®); gabapentin (Neurontin®).
- Impact of epileptic seizures on the oral cavity:
-Cracks.
-Coronary fracture with or without pulp exposure.
-Coronoradicular fracture with or without pulp exposure.
-Lesions of the supporting tissues of the teeth: concussion, subluxation, lateral luxation, intrusion, extrusion, expulsion.
– Root fractures of the cervical, middle or apical third.
-Alveolar fracture.
-Fracture of the bone tables.
-Bites of the soft tissues of the oral cavity.
-Gum wounds: laceration, abrasion, contusion.
-Lingual injuries from biting the lateral edges of the tongue.
-Bruise, contusion, scratch,….. cheek.
-Lip injuries.
– Drug-induced gingival hyperplasia linked to phenytoin.
-Hyposialia linked to prolonged use of Benzodiazepines and Carbamazepine.
-Oseomalacia due to the fact that anti-epileptic treatments modify the metabolism of
vitamin D.
-Phenytoin, Sodium Valporate, Carbamazepine are recognized as
responsible for bone marrow aplasia, leukopenia and especially thrombocytopenia.
-Cariesensitivities due to hyposialia and gingival hyperplasia.
- Management of epileptic patients in the dental office:
-Assess the risk of a crisis (possibly contact the attending physician).
*Stress management:
-Psycho-pedagogical approach through the establishment of a relationship of trust
between practitioner and patient.
-Medicinal approach:
Hydroxyzine (ATARAX); adult: 30 to 120mg/day or 15 – 60ml of syrup/day.
child 30 months – 15 years: 1 mg/kg/day.
Benzodiazepines, Diazepam (VALLIUM); adult: 5 to 20 mg/day.
child: 0.5 mg/kg/day.
Conscious sedation by inhalation of MEOPA: Equimolar mixture of oxygen and nitrous oxide.
*Pain management:
-Anesthesia: slow injection, strict extravascular.
-Adrenal solutions not contraindicated.
-Limit to four carpules at 1/200,000.
*Light management:
Care must be taken not to rush the patient with intermittent light stimulations which can trigger a crisis.
*Precautions when prescribing medication:
-Beware of drug interactions: Carbamazepine (Tegretol®) → do not use macrolides because they potentiate the action of Tegretol
-Aspirin interacts with Valproic acid when it is prescribed in high doses.
-Fluconazole interacts with Phenytoin and Gabapentin which can unbalance the patient’s treatment.
*How to handle a crisis in the chair:
-During convulsions:
-Stop treatment.
-Remove all foreign bodies from the mouth.
– Do not try to grab the tongue, avoid restraining the patient, you must let the crisis happen.
-Prevent a fall or trauma to the patient, place blankets or coverings to cushion the shock.
After the seizures:
-Important things to check are the patient’s breathing and carotid pulse.
-If the patient is breathing:
-Put it in the lateral safety position.
-Ensure freedom of the upper airways.
– Inhale oxygen until consciousness returns: 3l/min for a child and 10l/min for an adult.
-Call the emergency services to report the accident and ensure appropriate medical care for the patient.
-The emergency administration of an antiepileptic is not justified after an isolated seizure. If a second seizure occurs within the following minutes, the administration of Benzodiazepines at the end of the seizure is recommended: injection of Diazepam (Vallium) 10mg IM for an adult and 0.5mg/Kg for a child.
e- Depression:
The disorders are believed to be caused by the depletion of certain neurotransmitters: noradrenaline and serotonin.
Antidepressants are drugs that can restore sufficient levels of norepinephrine and/or serotonin.
They act either by decreasing the inactivation of these neurotransmitters or by blocking their reuptake.
- Consequences of antidepressants in practice:
Adrenaline or noradrenaline cannot be combined with an antidepressant.
exerting a noradrenergic action.
Such an association is contraindicated (risk of a paroxysmal hypertensive crisis which can be fatal).
11- Patients with infectious pathologies with contagious risk:
a- AIDS patients:
AIDS can be defined as a set of opportunistic diseases (pneumocystosis and/or tumors) associated with severe immunodeficiency developing in a previously healthy subject who has not received immunosuppressive treatment.
- Clinical manifestations of HIV infection
- Primary infection is the early, acute phase; it lasts from 1 to 6 weeks after infection.
- The second phase is asymptomatic: it is the latency phase which lasts several years.
- The third ARC phase: is accompanied by symptoms of immune imbalance due to the increase in viral load (plasma viremia) which leads to the appearance of opportunistic infections.
- Oral manifestations:
-Candidiasis.
– Mouth ulcers.
-Herpes.
-Periodontal diseases (GUN, PUN).
-Hairy leukoplakia.
-Kaposi’s sarcoma.
-Non-Hodgkin’s lymphoma.
- Action to take:
*Precautions regarding the risk of infection:
-Depending on the progression of the disease (CD4 and viral load assay).
-They are based on the administration of anti-infectious prophylaxis intended to reduce the risk of postoperative infection.
– Any source of infection will be eliminated.
-Particular attention will be paid to oral hygiene: daily mouthwashes will be recommended.
*Precautions regarding hemorrhagic risk: assess it by INR.
*Precautions when prescribing medication:
-Beware of drug interactions with antiretrovirals.
-Prohibit NSAIDs, acetylsalicylic acid and its derivatives.
*Precautions regarding the risk of transmission: (see hepatitis).
*Precautions in urgent care:
-If truly urgent care is required, all precautions must be observed and attention must be paid to the risk of transmission.
*Recommended protocol in case of exposure:
-Contact the occupational health or prevention service (reporting and support).
-A practitioner who may have been infected with HIV must undergo immediate clinical and serological evaluation.
-After this initial test and in case of seronegativity, a new serology must be carried out at 6 weeks, 12 weeks and 6 months after exposure to determine whether or not there has been transmission.
-A medical evaluation revealing fever, rash, lymphadenopathy occurring within 12 weeks after exposure indicates HIV infection.
-Some centers recommend immediate preventive administration of Zidovudine in subjects who have been exposed.
Dosage : 1200 mg/day (200 mg every 4 hours): for 1 month.
b- Tuberculosis:
It is a contagious systemic disease caused in the vast majority of
cases by Mycobacterium tuberculosis.
*Precautions against stress:
-Short-term care should preferably be carried out in the morning.
-Use of non-respiratory depressant anxiolytics to reduce stress.
-Sedation by inhalation of nitrous oxide is not recommended when the patient is contagious.
*Precautions regarding the risk of infection:
-An interview with the attending physician is crucial to determine whether the patient
is contagious:
After 2 to 3 weeks of anti-tuberculosis treatment or when the sputum is negative, the patient is no longer considered contagious.
In contagious patients, due to the risk of transmission, universal hygiene and asepsis measures must be observed.
*Precautions during anesthesia:
No special precautions to take (local A).
*Precautions regarding the treatment followed by the patient:
-Antituberculosis drugs can cause anemia, leukopenia and thrombocytopenia.
-It is therefore essential to request a bleeding time and a prothrombin level (PT) before any procedure causing bleeding.
*Precautions in the context of the prescription:
As a general rule, medications that metabolize the liver should be avoided.
*Precautions in the context of urgent care:
-Strict aseptic techniques must be followed. (Splashes must be kept to a minimum).
-Minimal use of sprays.
-Truly urgent care will preferably be carried out in a hospital environment in a context of isolation and special ventilation.
c- Rubella:
-Rubella is a viral disease characterized by the appearance of a rash,
of fever and swollen glands.
-The child remains contagious for 8 days after the appearance of skin lesions.
-The diagnosis is difficult because the rash is not very characteristic.
-Rubella does not pose any danger to a child.
-The risks concern the contamination of a pregnant woman and her
fetus (neurological, ocular, cardiac or hearing malformations)
In contagious patients, only urgent care should be provided and
universal hygiene and asepsis measures must be respected.
d- Measles
-Measles, a highly contagious viral disease, is the most common of the diseases
rash accompanied by fever.
-Measles in unvaccinated children and/or those no longer immunized by
antibodies from their mother.
-Measles is contagious 3 to 5 days before the rash appears.
and Up to five days after the rash begins.
In contagious patients, only urgent care should be provided and
universal hygiene and asepsis measures must be respected.
e- Chickenpox:
Chickenpox is transmitted by direct contact.
The contagious period begins 24 to 48 hours before the rash appears and lasts about a week.
The child should avoid being in a community during the period when he or she is contagious.
Chickenpox: a danger for pregnant women and immunocompromised people
In contagious patients, only urgent care should be provided and universal hygiene and asepsis measures should be observed.
f- Scarlet fever:
-Scarlet fever is a highly contagious infectious disease caused by group A streptococcus that affects children between the ages of 5 and 10.
-The tongue is covered with a whitish coating at first and then becomes scarlet red and thick, giving the raspberry color typical of scarlet fever.
-Scarlet fever is contagious 1 day after the first symptoms of angina appear and 2 days after starting antibiotics.
-It is contagious until the scales disappear if antibiotic treatment has not been started.
In contagious patients, only urgent care should be provided and universal hygiene and asepsis measures should be observed.
g- Drug addiction
Drug addiction is a state of intoxication resulting from the repeated intake of toxic medicinal or chemical substances creating a state of psychological and physical dependence.
Drug addiction is not only associated with psychological, nutritional and social complications, it also affects general and oral health.
-It is the cause of many associated problems (behavioral disorders, drug resistance or interaction, hepatitis and AIDS), which can make dental care particularly difficult.
*Precautions regarding stress:
-Sedative premedication is most of the time essential in certain
situations, benzodiazepines are indicated.
-Conscious sedation with nitrous oxide is not recommended due to the fact
that protoxide itself is a source agent of abuse and chronic administration.
*Precautions during anesthesia:
-The amount of local anesthetics should be increased to achieve the desired effect, as these patients have a reduced response to anesthetics.
-Some drug addicts are even resistant to general anesthesia.
*Precautions regarding the risk of infection:
Many drug users may have undiagnosed HIV and/or viral hepatitis, which is potentially transmissible to the practitioner, their staff, and other patients. Therefore, universal aseptic and hygiene measures must be observed.
C- Patients at “therapeutic” risk:
1- radiotherapy:
1-1 Pre-radiotherapy recommendations:
Prevent the appearance of:
*Osteoradionecrosis:
– Elimination of dental infectious foci: extraction of irrecoverable teeth, impacted teeth, impacted teeth, teeth with incomplete endodontic treatment or persistent periapical lesion, periodontal sanitation.
-It is recommended to wait 3 weeks between avulsion and irradiation to allow healing.
*Dental caries by fluoroprophylaxis:
Creation of two reservoir-free whitening trays. A fluoride gel (Fluocaril Bifluoré 2000® or Fluodontyl 1350®) is applied to each tray for 5 minutes each day, removing any excess that flows onto the gum.
1-2 After radiotherapy
-Daily fluoridation.
-Treatment of hyposialia:
*Sialogogues, such as pilocarpine (tablets).
*Stimulation by chewing gum.
*Saliva substitutes (secondary saliva).
-Delay the creation and wearing of removable prostheses for 3 to 12 months after stopping radiation (risk of osteomyelitis induced by prosthetic microtrauma).
1-3 Exodontia in the irradiated patient:
- Collection of dose information.
- Precautions:
*Avulsion outside the irradiation field and in a field < 40 gy: usual precautions.
*Avulsion in an irradiation field > 40 gy.
Avoid dental extractions as much as possible: favor conservative care.
-Avoid the combination of vasoconstrictors with local anesthetics during conservative and especially non-conservative care.
-If avulsion is necessary, perform it in a hospital setting with the following precautions:
*Anesthesia without vasoconstrictors (ischemia).
*Antibiotic prophylaxis maintained until the mucosa has healed
*Use alveolar dressings (biological glue).
*Implement very careful site monitoring
*Preventive hyperbaric oxygen therapy recommended by the High Authority of Health.
1-4 Side effects of radiotherapy at the oral level:
Following radiotherapy involving the orofacial sphere, lesions may occur
appear. They may concern:
■ Skin: radiodermatitis, hair follicles are destroyed.
■ Muscles: radiomyositis and muscle sclerosis. This results in trismus that can be treated with repetitive opening exercises (physiotherapy).
■ Salivary glands: hyposialia.
■ Mucous membranes: radioepithelitis, mucositis.
■ Teeth: polycaries due to xerostomia. The teeth may appear ebony in color. This is odontoradionecrosis.
■ Bones: osteoradionecrosis.
2- Chemotherapy:
2-1 Oral care before chemotherapy:
For the treatment of VADS cancers, chemotherapy is always associated with
radiotherapy: same recommendations as for radiotherapy.
When the location is not of interest to the VADS, the oral rehabilitation
is mainly dependent on whether or not the chemotherapy is aplastic.
Hematological assessment:
■ if it is correct: chemotherapy can begin after elimination of the oral infectious foci, if the time before treatment is sufficient. Otherwise, the oncologist is warned of the potential risk.
■ if it is insufficient: delaying chemotherapy and dental treatments.
2-2 Care during chemotherapy
-No surgical procedure is advisable.
-Take into consideration the possibility of neutropenia and/or thrombopenia.
-In case of emergency, treatment should be discussed with the oncologist.
-In any case, it is as conservative as possible.
-Any bloody action must be carried out under antibiotic cover and especially in phase
of remission.
2-3 Side effects of chemotherapy at the oral level:
Chemotherapy mainly causes:
-Mucositis.
-Anomalies in the shape and number of teeth in children.
3- patients on bisphosphonate
- Patients who are candidates for bisphosphonate treatment
* Patients requiring bisphosphonate therapy for malignant pathologies:
■ Oral health assessment + radiological assessment.
■ Only start treatment with biphosphanate if the patient’s clinical condition allows it and once the dental situation has improved:
-Perform the necessary dental care and eliminate all infectious sources.
-Wait for the mucous membranes to heal; if possible, wait for the bones to heal completely (120 days).
* Patients requiring bisphosphonate therapy for osteoporosis/Paget’s disease:
■ Oral health assessment, monitoring of necessary dental care.
■ This care should not delay the initiation of biphosphanate treatment in patients at high risk of fractures.
- Patients treated with bisphosphonates without evidence of osteonecrosis:
*General recommendations before or during treatment with IV or oral bisphosphonate
■ Care available on an outpatient basis or in hospital.
■ Inform the patient of the risk of osteonecrosis and the need for good dental hygiene.
■ Inform the patient of the need to report any tooth mobility or any pain, swelling, or inflammation of the gingival mucosa to their dental surgeon or doctor(s).
*Patients receiving a bisphosphonate for malignant pathologies:
■ Oral health check-up every 4 months.
■ Screening and treatment of infectious foci using the least aggressive procedures possible:
-Without stopping treatment with biphosphanate.
-Under local or locoregional anesthesia, without vasoconstrictor.
-Under antibiotic treatment the day before the extraction and then until complete healing.
-Regulate the alveolar ridge and suture the edges tightly:
-Consider making a periodontal splint to stabilize teeth with stage 1 to 2 mobility, rather than extraction.
-Avoid extraction in the presence of a tooth with decaying caries but without pathological mobility, by carrying out endodontic treatment (cutting the crown of the tooth flush with the gum) and reconstructing the tooth with conventional techniques, taking precautions not to alter the surrounding tissues.
-Contraindicate surgical periodontal treatments.
-Contraindication to implantology. On the other hand, the presence of implants already integrated into the bone structure does not increase the risk of ONJ; they must be preserved.
*Patients receiving a bisphosphonate for osteoporosis/ Paget’s disease:
■ Oral health check-up at least once a year.
■ Perform dental extractions under antibiotic treatment and in the least traumatic way possible.
-Surgery is necessary; a partial thickness flap is preferred to best preserve the vascularization of the underlying bone.
-No contraindication to the placement of a dental implant.
- Patients with proven osteonecrosis
■ They must be referred to a hospital department for maxillofacial surgery, ENT or dentistry.
■ While waiting for hospital treatment:
-Carry out a radiological assessment.
-Avoid any surgical procedure.
-Medically treat the pain.
-Continue strict oral hygiene.
■ Daily rinses using an antiseptic solution (0.1% aqueous chlorhexidine) or prescription of a chlorhexidine gel to be applied to the painful area.
■ Inform the prescribing physician of the complication of biphosphnate treatment. Continuation of biphosphate treatment should be decided on a case-by-case basis by the prescribing physician.
Conclusion :
Every dental surgeon is expected to:
– Know without fail and master all the procedures to follow when dealing with any patient presenting with a high-risk illness.
– Protect yourself from patients who are unaware of their health status while respecting the rules of asepsis.
– Always work in close collaboration with the attending physician through the shuttle form.
– Be aware of any potential drug interactions.
Patients at risk
Wisdom teeth can cause infections if not removed in time.
Dental crowns protect teeth weakened by cavities or fractures.
Inflamed gums can be a sign of gingivitis or periodontitis.
Clear aligners discreetly and comfortably correct teeth.
Modern dental fillings use biocompatible and aesthetic materials.
Interdental brushes remove food debris between teeth.
Adequate hydration helps maintain healthy saliva, which is essential for dental health.