Outline Renal disorders Diabetes Mellitus Epilepsy Hematological disorders Respiratory disturbances HIV Cleft lip & Palate

Renal Diseases Renal pathology

Congenital disorders Kidney agenesis Hypoplasia Ectopic kidneys Horseshoe kidneys Cystic kidneys Childhood polycystic kidney disease

Glomerular disorders: Acute glomerulonephritis Rapidly progressive GN Good pasture syndrome Berger disease

Renal tubular disease: Acute tubular necrosis Acute pyelonephritis Effects of uremia on the body CVS Hypertension, Cong CF NEUROLOGIC - fatigue, impaired cognition, irritability, drowsiness, peripheral neuropathy MUSCULOSKELATAL- renal osteodystrophy, growth retardation

HEMATOLOGICAL anemia, bleeding tendency, susc to infections RS pulmonary edema, pluritis GIT nausea, vomiting, anorexia, GI bleeding REPRODUCTIVE delayed puberty, amenorrhea OCULAR retinopathy DERMATOLOGICAL pruritis, yellow skin, brittle hair ENDOCRINE hypothyroidism, hyperparathyroidism METABOLIC hyperglycemia, hyperurecemia, acidosis.

Drop in GFR Progressive Hypertension

Fluid Retention Build up of Metabolites Features Growth retardation is common Palor & Anemia Bleeding tendency due to capillary fragility Thrombocytopenia Anti-coagulant therapy Features Generalized pallor of mucosa Tendency to bleed & prolonged bleeding Chronic marginal gingivitis Bony lesions of jaws resembling giant cell tumours Tetracycline discolouration Caries rate is low in children with end-stage renal disease caused by ammonia released in saliva Uremic stomatitis when serum urea is over 300mg/ml

Teeth calcifying during renal failure will exhibit chronological hypoplasia or hypomineralization - brown or green due to incorporation of blood products such as biliverdin Additional dose of drugs should be given after hemodialysis Management Infections Higher rate Require aggressive ttt of odontogenic infections Hospital admission Surgical drainage Removal of source of infection Adjuvant IV antibiotics Prophylactic antibiotics(?)

Concerns Hypertension Susc for bleeding Optimal time of ttt for children on dialysis Secondary inf with Candida Absence of usual signs of infection Hepatitis carrier state Drug clearance Potassium salts to be avoided hyperkalemia (eg: penicillin) Alternative drugs clindamycin, erythromycin NSAIDS to be avoided LA safe, but vasoconstricter conc should be less Narcotics usually safe, except mepiridine Drugs to be avoided Paracetamol, NSAIDs Penicillin Tetracycline Chloramphenicol

Diabetes mellitus

Impaired insulin secretion or Insulin resistance or Both Diabetes mellitus Type I or Insulin Dependent Diabetes Mellitus (IDDM) Type II or Non insulin Dependent Diabetes Mellitus (NIDDM) Type I or Insulin Dependent Diabetes Mellitus (IDDM) Auto immune destruction of beta cells Accelerated destruction Genetic predisposition Environmental factors Peri natal factors resp distress, cows milk, jaundice Viral infections

Prevalence Type I (1995) 1.8 per 1000 Pathophysiology Clinical DM(>90% destruction) impaired glucose uptake by fat & muscle FPG > 300, post prandial > 500 Polyuria & increased thirst ^plasma fatty acids ^ketoacids &metabolic acidosis

Complications of Diabetes Eye retinopathy Nephropathy Peripheral neuritis

Increased risk of infection

( Elevated pre-op levels >200mg/dl) Neutrophil chemotaxis, phagocytosis, bactericidal activity - compromised Oral manifestations Periodontal disease Increased alveolar bone resorption Inflammatory gingival changes Xerostomia Recurrent intra-oral abscesses Enamel hypocalcifications and hypoplasia Reduced salivary flow increased risk of caries

Altered flora Candida albicans Hemolytic streptococci Staphylococci Management of Diabetic Dental patient

Careful history Current regimen Latest assessment Status of complications Appointment scheduling If delay in usual timing of meal is likely adjust regimen Danger of hypoglycemia Normal meal before dental procedure Glucose source should be readily available

Fasting before GA should be carefully adjusted as hypoglycemia related to anesthesia could be fatal Delayed healing Prophylactic antibiotics

Signs & symptoms of Hypoglycemia Mild Anxiety Sweating Tachycardia

Severe Confusion Seizures Coma Cardiac dysrhythmia

Management Awake or alert patient 15 gm carbohydrate

Uncooperative pt Glucagon 1 mg IM or subcut Oral glucose Or dextrose IV

Unconscious Dextrose50 20-50ml IV

Seizures/Epilepsy Seizures are one of the most commonly encountered neurological disorders. They can manifest as an isolated incident or as a symptom of a condition that requires longterm treatment. When patients experience recurring episodes it is termed as epilepsy. Pathophysiology During a seizure a fundamental brain abnormality results in synchronous, excessive, abnormal electrical discharges of the neurons in the CNS. The manifestation of these discharges is termed seizure. Epidemiology 5 10% of the population will experience atleast one seizure during their lifetime

Atleast 0.5% of them will be diagnosed with epilepsy It is important to know the difference between a single seizure & recurrent seizures ie, epilepsy. Onset extremes of life. Periods of highest incidence - <1yr of age and >75yrs. Classification

According to the International League Against Epilepsy: Partial Generalized Partial seizures Simple partial seizures (pt remains conscious) Complex partial seizures (impaired consciousness) Partial seizures evolving to secondarily generalized seizures Generalized seizures Absence Tonic Clonic Myoclonic Primary generalized tonic-clonic Atonic Common signs Momentary aura Palor Muscle spasm Muscular contractions Altered or loss of consciousness Pupillary dilatation, eyeballs roll upwards Rapid contraction of jaw muscles Drooling Questions when taking history of seizures

1. 2. 3. 4. 5. 6. 7. 8. 9.

When was the condition diagnosed? What were the presenting symptoms? Are there identifiable precipitating circumstances? Do you experience an aura? If so, describe it. How long is a typical seizure? (eyewitnesses) Do you become unconscious during a seizure? Is there a postictal phase? How frequent are your seizures? When was the last event?

10. What medications do you take? 11. Have you had an electroencephalogram & MRI? 12. Has surgery been considered? 13. Is there a history of head trauma, brain tumour or other malformations? Medical & Dental considerations Significantly worse dental condition compared to normal population More evident in patients with poorly controlled tonic-clonic seizures Possible explanations Low soci-economic status Prejudice employment

Dentists role Familiarity with seizure disorders is important to be able to treat without anxiety Not only routine dental care on a long term basis But also in acute situation such as an in-office seizure. Medical consultation is a must. Anxiety-control measures Constantly inform of what is going on Reassure that everything is going well Avoid sudden unexpected movements Nitrous oxide not contraindicated

IV sedation Well-trained staff

Triggering factors Fatigue Stress Alcohol Medication non-compliance Dental lights LA idiopathic causes POA Atleast BLS POA specific to each member of a team Who is to contact emergency medical services At the Onset of seizure stop procedure All instruments should be removed from the oral cavity Mouth prop or bite block to prevent injury to tongue Chair in supine position, low to the ground Patient should be stabilized to prevent injury to herself BLS should begin immediately Vital sign monitors - ECG, pulse-oximeter, BP cuff If seizure last > 5 mins Continue BLS Venupuncture Administer IV anti-convulsant medication benzodiazepines are the drugs of choice. Also lorazepam, diazepam, midazolam. Rule out other medical emergencies that can mimic a seizure, for eg: syncope, myocardial infarction, hypoglycemia, cardiac arrest etc.

Treatment considerations

Fixed appliances or prothesis should be given Metal occlusal surfaces are preferred to ceramic so as to withstand the clenching forces during a seizure Xerostomia flouride applications Phenytoin drowsiness, slurred speech, depressant Drug interaction consideration If GA or IV sedation is considered serum drug levels should be checked for therapeutic, subtherapeutic or above therapeutic serum levels Gingival enlargement - Oral hygiene and plaque removal 3 month recall supra & sub-gingival scaling

Obstructive pulmonary diseases Bronchial asthma, chronic bronchitis, emphysema Dental practitioners should be aware that patients with compromised airway function have diminished overall health and ability to tolerate treatment. Differential diagnosis COPD Bronchial asthma Congestive cardiac failure Sinusitis Acute bronchitis Bronchiectasis Mechanical airway obsruction Vocal cord dysfunction Laryngeal dysfunction Pulmonary infarction or obstruction Pneumonia Neoplasm Prevalence Adults 7.7% Children 8.8%

No of deaths in 2003 4,261 Number affected 20 million Bronchial asthma Reactive airway disease 1 in 10 Recurrent episodes of wheezing, coughing & dyspnoea An attack may last for several mins. Resolves spontaneously or in response to drug therapy. Quiescent periods & acute exacerbations May completely resolve at onset of puberty Genetic component May be associated with allergens, dust, stress, exercise, cold air, certain medications, viral infections etc.

Features of asthma Airway is hyperactive Mechanisms which lead to asthma Bronchial smooth muscle spasm Constriction Inflammation Edema of mucosa Excessive mucous secretion

Differentiating feature rapid resolution of attack with use of inhaled bronchodilater Sequence of events Allergen Antigen-antibody reaction (mast cells)

Release of histamine, vasoactive & chemotactic factors Stimulates mucous production Edema of tissues Leakage of plasma

Bronchioles obstructed Smooth muscle spasm

Oral manifestations Hypoxic states may affect oxygenation of oral tissues. Mouth breathing Xerostomia gingivitis, inc. caries risk, oropharyngeal candidiasis. Anterior gingiva inflammed Skeletal findings increased lower facial height Higher palatal vault Anterior open bite Posterior crossbites Greater overjets Pediatric significance Frequency & severity of attacks Known triggering agents Last hospitalization Medications taken for asthma Dental treatment Awareness of patients level of control over disease Review & discuss medications Avoid triggering factors Anxiety control measures Nitrous oxide sedation mild to moderate asthma Minimize aerosols & exposure to powdery components of dental materials Choice of Drugs Avoid aspirin & NSAIDs Anti-oxidant & preservative component of LA agents can trigger an attack Analgesics of choice acetaminophen & propoxyphene

Avoid narcotics as they cause respiratory depression Emergency during dental care Aspiration prevention Acute asthmatic attack Rescue inhaler readily available If patient does not respond to inhaled bronchodilaters, hospitalization is necessary Parenteral delivery of bronchodilaters when airway is totally obstructed. Signs fatigue, hypoxia, cyanosis, dehydration, peripheral vascular shock, low BP