Many patients seeking dental care have significant medical conditions that may alter both the course of their dental disease and treatment provided. Successful periodontal treatment includes identification of the patient’s medical problems to formulate proper treatment plans. In managing periodontal therapy in medically compromised patients, the dentist should always obtain a consultation from the patient’s physician, who will determine the necessary precautions that should accompany periodontal treatment. Dentists should follow the recommendations from concerned specialists and utilize the appropriate protocol.
Patients with hypertension enter the dental practice every day. Periodontal procedures should not be performed until accurate readings and history have been taken. Dental treatment for hypertensive patients is generally safe as long as stress is minimized. Lower BP levels occur in the afternoon; therefore afternoon dental appointments may be preferred. Postural hypertension is common and can be minimized by slow positional changes in the dental chair.
Cardiac conditions associated with the highest risk of adverse outcome are infective endocarditis, prosthetic heart valves, congenital heart diseases, etc. Antibiotic prophylaxis is recommended for such patients and patients’ physician should be consulted. Short appointments and calm, relaxing environment help minimize stress and maintain hemodynamic stability. To reduce the number of appointments required and to minimize the risk, numerous procedures can be accomplished at each appointment, depending on the patient’s needs and ability to tolerate dental treatment.
If a patient is known to have diabetes, it is critical that the level of glycemic control be established before initiating periodontal treatment. The diabetic patient requires special precautions before the start of periodontal therapy. Diabetic patients with periodontitis should receive oral hygienic instructions, mechanical debridement to remove local factors, and regular maintenance. Patients should be asked to bring their glucometer to the dental office at each appointment. It is advisable to have such a patient consume some carbohydrate before starting treatment. This is to avoid severe hypoglycemia during the procedure.
Patients with a history of bleeding problems caused by disease or drugs should be managed to minimize the risks of hemorrhage. Thorough history is to be taken. Consult the patient’s physician to determine the nature of underlying medical problem and the degree of anticoagulation required. Careful technique and complete wound closure are paramount.
Pregnancy can change inflammatory reactions to dental plaque in the most dramatic fashion with accentuation of vascular proliferation leading to increased inflammation and a hyperplastic gingival response. A thorough medical history is an imperative component of the periodontal examination, especially in the pregnant patient. Because of immunologic alterations, increased blood volume and fetal interactions, the clinician must diligently and consistently monitor the patient’s medical and periodontal stability. Establishing a healthy oral environment and maintaining optimal oral hygiene levels are primary objectives in the pregnant patient.
A preventive periodontal program consisting of nutritional counseling and rigorous plaque control measures in the dental office and at home should be reinforced. Scaling, polishing and root planing can be performed whenever required. Elective dental care is avoided if possible during the first trimester and third trimester. Prolonged chair time may need to be avoided. Early in the second trimester is the safest period for providing routine dental care. Major periodontal surgery may be postponed until after delivery.
Dental radiography during pregnancy is safe provided high speed film, filtration, collimation, and lead aprons are used. Even with the obvious safety of dental radiography, x rays should be taken selectively during pregnancy and only when necessary and appropriate to aid in the diagnosis and treatment.