General Considerations In Patients With Cardiovascular Disorders 

The mainstay approach remains stress reduction, use of vasoconstrictors and physician consent when in doubt. Patients with valvular disease have potential risk for infective endocarditis and risk of excessive bleeding in patients on anticoagulant therapy. According to the most recent guidelines, antibiotic prophylaxis is only recommended for dental procedures that involve manipulation of gingival or the periapical tissue. Nonsurgical root canal treatment such as local anesthetic injection, placement of the rubber dam, and instrumentation within the canal system do not place the patient at significant risk for infective endocarditis. The incidence of bacteremia when canal instrumentation does not extend into the periapical tissues is very low, and thUSe, antibiotic prophylaxis is not required.

Endodontic Considerations in Diabetes 

Early morning appointments are  usually preferred for  diabetics since cortisol levels are high and it helps maintain glucose levels. In patients on insulin therapy, appointments should be scheduled so that they do not coincide with peaks of insulin activity, since this is the period of maximal risk of developing hypoglycaemia.Ensuring patient has eaten well before treatment is important. In case of hypoglycaemia, its better to administer patients with glucose or in extreme situations, 1mg glucagon.

Endodontic Treatment in a Pregnant Patient 

Pregnancy does not classify as being medically compromised. In pregnancy, there is suppression of the maternal immune system in response to the fetus, subsequently causing a decrease in cell-mediated immunity, as well as natural killer cell activity. The initial 3 months of pregnancy are considered vital to the growth of the fetus. By the end of the first trimester, the uterine size is not large enough to make sitting on the dental chair uncomfortable, and nausea has generally waned. These make the second trimester an ideal period to undertake endodontic treatment. During the third trimester (29th week until childbirth), although there is no risk to the fetus during this trimester, the pregnant mother may experience an increasing level of discomfort. The supine position poses an increased risk of developing DVT, by compression of the inferior vena cava, leading to venous stasis and clot formation. The ideal position in the dental chair is the left lateral decubitus position with the right buttock and hip elevated by 15degrees.

Patients with Chronic Kidney Disease 

These patients require special considerations for endodontic management because of increased tendency toward bleeding episodes, odontogenic infections, and drug interactions. Nephrotoxic drugs such as tetracyclines and aminoglycosides must be strictly avoided. Antibiotics such as amoxicillin/clavulanate, erythromycin, azithromycin, and analgesics such as paracetamol and ibuprofen do not require any dose alteration for these patients.

Asthma 

Dental materials and products that exacerbate asthma shouldn’t be used. It is essential to advise the patient to bring the inhaler during each dental visit. When antibiotic therapy is indicated, macrolides (i.e., erythromycin, azithromycin, and clarithromycin), ciprofloxacin, and clindamycin should be avoided in patients taking theophylline because of the potential adverse effect of methylxanthine toxicity. NSAID group of medicines, barbiturates, and narcotics should be avoided for all asthmatic patients.

Endodontic Considerations in Patients with Bleeding Disorders 

There are no restrictions regarding the type of local anesthetic used, although those with vasoconstrictors may provide additional local hemostasis. Endodontic treatment is generally low risk for patients with bleeding disorders. Nonsurgical endodontic procedure can be performed without any modification in anticoagulant therapy.

 Article by Dr. Siri P.B.