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Patient with special needs and need oral care, may have a profound influence on the dental treatment plane. The most important medical problems include : 2. Patients with heart murmurs may have orthopnea and need to be placed in a upright position during dental treatment, Mitral valve prolapsed May be at risk of developing tachycardia, syncope, congestive heart failure and endocarditis. Dental management as with pathologic murmur. Rheumatic heart diseases Patient how have history of Rh. Fever may have a residual cardiac damage and Rh. heart diseases, these patient need to be given a prophylactic antibiotic cover during dental treatment to prevent infective endocarditis as in patient with pathologic murmur. Dental treatment: medical consultation, antibiotic prophylaxis (as surgeons recommended), prothrombine time 1½ to 2½ times normal, need for steroids supplemental for stressful dental procedure ( as surgeon recommendation). Antibiotic prophylactic: Not allergy to penicillin: 2 gm Ampicillin IM or IV followed by gentamicin 1.5 mg/kg IM or IV 1h. before dental procedure followed by 1 gm penicillin V orally 6h. after loading dose. Allergic patient: 1g Vancomycin IV infusion over 60 min prior to dental procedure. patient is not allergic to penicillin Amoxicillin, Adults, 2.0 g; children, 50 mg/kg orally one hour before procedure. Cannot use oral medications: Ampicillin, Adults, 2.0 g IM or IV; children, 50 mg/kg IM or IV within 30 minutes before procedure. Allergic to Penicillin: Clindamycin, Adults, 600 mg; children, 20 mg/kg orally one hour before procedure. Cephalexin or cefadroxil, Adults, 2.0 g; children, 50 mg/kg orally one hour before procedure. Azithromycin or clarithromycin, Adults, 500 mg; children, 15 mg/kg orally one hour before procedure. Cefazolin: Adults, 1.0 g; children, 25 mg/kg IM or IV within 30 minutes before procedure Cephalexin: Adults, 2.0; children, 50 mg/ kg IM or IV within 30 minutes before procedure Dental managements: 1. Identification & medical consultation, 2.Short& morning appointment, 3. Semi supine chair position, 4. Patient own sublingual tablet (Nitroglycerin) on hand. 8. Avoid use of vasopressors to control local bleeding and in gingival cord. Dental management of patient with unstable angina or recent M.I. 1. Avoid elective dental care (patients have increased susceptibility to repeat infarctions and other cardiovascular complications). 2. Emergency dental care only on hospital after physician consultation, for pain control (antibiotic for infection, pulpotomy rather than extraction). 3. Pretreatment medication with valium 5mg. Dental management: 1. Medical consultation for patient with significant blood pressure elevation. 2. Reduce stress and anxiety, short appointment. 3. local anesthesia with epinephrine 1:100,000, aspirate &inject slowly on more than 3 carp.. 4. avoid use of vasopressors to control local bleeding and in gingival cord. 5. Avoid orthostatic hypotension by change the chair position slowly. 6. Avoid gag reflex stimulation (antihypertensive drugs nausea and vomiting). 7. avoid use of barbiturate ( antihypertensive ↑ sedative effect). 5. avoided use of barbiturates, narcotic, NSAIDs, aspirin, epinephrine or levonordefrin ( containing sulfites). as it may precipitate an asthma attack 6. upright position. 7. steroid supplemented as physician recommended. 8. avoid rubber dam. 9. erythromycin avoided theophylline (toxic blood level of theophyllin). Thyroid Gland Disorder : Hyperthyroidism (Thyrotoxicosis) Potential problem related to dental care: infection, stress, trauma → crisis. Heart failure. Dental management 1. Detection the patient by history & 2. Referral to medical evaluation. 3. Avoid any dental treatment until good medical control of thyrotoxicosis is achieved (antibiotic for infection, analgesic for pain). 4. For emergency treatment, hospitalize the patient & treated under physician consultation. 5. Avoid use of epinephrine and other presser amine with uncontrolled patient this may lead to heart failure. 6. Patient has significant depression in immune system thus risk for developing infection resulting from dental procedure. control bleeding and prothrombin times, avoid drugs metabolized by kidney, AB coverage, HB Ag test. 2. Dental instrument should be away from the patient to decrease patient's stimulation. 3. Maintain optimum oral hygiene. 3. Significant drug interactions and side effects are associated with tricyclic antidepressants, monoamine oxidase inhibitors, and antianxiety drugs, Haemophilia: bleeding Dental management: 1. Identification & medical consultation, 2. Control bleeding & prothrombin times, 3. AB coverage, 4. Avoid Intra muscular injections, , 5. Maintaining healthy gums is very important, 6. Avoid aspirin &NSAIDs, 7. Carry out invasive dental procedures in a hospital. NOTE: local measures for control bleeding should be always found in your clinic (splints, thrombin, microfibrillar collagen). AIDS: transmission of disease, infection, bleeding (thrombocytopenia). Dental management: 1.All precaution should be taken ( double masks, double gloves, eye glass and disposable instruments). 2. Antibiotic prophylactic to prevent infection in cases where surgery must be performed. 3. Bleeding time and platelet count should be ordered. 5. Unstable diabetic patient need AB coverage before invasive dental care ( Amoxicillin 2 g. 1h. preoperatively followed by amoxicillin 500 mg. 3 times daily for 4 days. In penicillin sensitive use Clindamycin 600 mg. 1h. preoperatively followed by clindamycin 150 mg. 4 times daily for 4 days). Arthritis & joint prostheses: Rheumatoid arthritis: Joint pain, bleeding tendency (Aspirin, NSAIDs) Dental management: 1. Short appoint., 2. Comfortable chair position, 3. Control bleeding time, 4. Need for steroid supplement discuss with physician. Dental management: Before radiation: 1.extracted all non restorable teeth, 2. Restore all carious teeth, 3. Establish good oral hygiene. , 3. Treating dry mouth and other complications by sucking ice chips or sugar-free candy, chewing sugar-free gum, night guard, & fluoride treatment, 4. Take precautions to protect against trauma, 5. AB coverage.