18.4 Endocrine, Hepatic, Renal, Pulmonary, Neurological and Psychiatric Conditions in Dental Practice
Key Takeaways
Uncontrolled hyperthyroidism is a reason to defer elective dental care because stress and epinephrine can precipitate a thyroid storm; hypothyroid patients are sensitive to sedatives and opioids.
Most patients on long-term corticosteroids do not need supplementation for routine dental care under local anesthesia, but an adrenal crisis (hypotension, collapse) is treated with hydrocortisone 100 mg intravenously or intramuscularly and emergency transfer.
In liver cirrhosis, expect prolonged INR and thrombocytopenia; limit paracetamol to about 2 g per day, avoid NSAIDs, and reduce sedatives metabolized by the liver.
Lithium levels rise with NSAIDs and metronidazole, tricyclic antidepressants exaggerate the pressor effect of epinephrine, and SSRIs combined with NSAIDs increase bleeding risk.
Bulimia causes palatal erosion of the maxillary anterior teeth (perimylolysis) and parotid enlargement; patients should rinse with water or fluoride after vomiting and delay brushing.
These conditions are individually small parts of the blueprint, but together they generate many "what should the dentist modify?" questions. Focus on the risk, the drug interactions and the oral signs.
Endocrine and Metabolic Disorders
| Condition | Dental risks and signs | Management points |
|---|---|---|
| Hyperthyroidism (uncontrolled) | Tachycardia, anxiety; thyroid storm (fever, tachyarrhythmia, confusion) can follow stress, infection or surgery | Defer elective care until controlled; minimize stress and epinephrine |
| Hypothyroidism | Sensitivity to CNS depressants; congenital form causes macroglossia and delayed eruption | Reduce sedatives and opioids |
| Adrenal insufficiency / long-term corticosteroids | Risk of adrenal crisis under major stress; infection risk, osteoporosis, delayed healing | Routine dentistry under local anesthesia usually needs no extra steroid; consult the physician before major surgery or general anesthesia; treat crisis with hydrocortisone 100 mg IV or IM, oxygen, fluids and emergency transfer |
| Cushing syndrome | Hypertension, diabetes, poor healing | As above |
| Hyperparathyroidism | Loss of lamina dura, brown tumors (giant cell lesions) | Check calcium and parathyroid hormone for giant cell lesions |
| Diabetes | Covered with medically compromised patients |
Pregnancy
- Necessary dental treatment is safe throughout pregnancy; the second trimester is the most comfortable time for elective care.
- In the third trimester avoid the fully supine position (supine hypotensive syndrome from compression of the inferior vena cava); tilt the patient to the left.
- Lidocaine with epinephrine, amoxicillin, paracetamol and clindamycin are commonly used; avoid tetracyclines (tooth staining) and NSAIDs in the third trimester (premature ductus closure).
- Radiographs are taken when needed with standard dose reduction.
- Pregnancy gingivitis and pyogenic granuloma (pregnancy epulis) are common.
Gastrointestinal and Liver Disease
| Condition | Dental relevance |
|---|---|
| Liver cirrhosis | Reduced clotting factors (raised INR) and thrombocytopenia from hypersplenism; impaired drug metabolism. Check INR and platelets; paracetamol up to about 2 g/day; avoid NSAIDs (bleeding, renal injury); reduce benzodiazepines; use amide local anesthetics cautiously |
| Viral hepatitis B and C | Standard precautions; hepatitis B vaccination of staff |
| Gastro-esophageal reflux | Palatal erosion of maxillary teeth and posterior teeth |
| Crohn's disease | Cobblestone mucosa, mucosal tags, linear ulcers, lip swelling (orofacial granulomatosis pattern) |
| Ulcerative colitis | Pyostomatitis vegetans, aphthous ulcers |
| Celiac disease | Enamel defects, aphthous ulcers |
| Peptic ulcer | Avoid NSAIDs and aspirin |
| Peutz-Jeghers syndrome | Perioral melanotic macules with intestinal polyps |
| Gardner syndrome | Jaw osteomas, supernumerary teeth and colonic polyps with high cancer risk |
Genitourinary and Renal Disease
Chronic kidney disease and dialysis are covered with medically compromised patients (schedule care the day after dialysis, protect the fistula arm, adjust renally cleared drugs, avoid NSAIDs). Renal transplant recipients are immunosuppressed (infection risk, cyclosporine gingival enlargement, steroid effects). Renal osteodystrophy can cause loss of lamina dura and giant cell lesions, and uremia causes uremic stomatitis and an ammonia odor.
Pulmonary Disease
| Condition | Dental management |
|---|---|
| Asthma | Ask the patient to bring the inhaler; minimize stress; some patients react to aspirin or NSAIDs; sulfite preservative in epinephrine-containing cartridges can trigger sulfite-sensitive asthmatics. Treat an attack with salbutamol (repeated puffs via spacer), oxygen and emergency help if not resolving |
| COPD | Treat semi-upright; avoid respiratory depressants; use low-flow oxygen with caution in CO2 retainers; avoid nitrous oxide in severe emphysema with bullae |
| Tuberculosis | Active pulmonary TB: defer elective care, airborne precautions; treated, non-infectious patients receive normal care |
| Obstructive sleep apnea | Sedation risk; mandibular advancement devices in selected patients |
Neurological Disorders
| Condition | Dental relevance |
|---|---|
| Epilepsy | Know seizure triggers and control; phenytoin gingival enlargement; valproate affects platelets; carbamazepine can cause leukopenia |
| Stroke | Anticoagulants or antiplatelets; dysphagia and aspiration risk; elective care is usually deferred in the early months after a stroke |
| Parkinson disease | Tremor, drooling or xerostomia, orthostatic hypotension (sit up slowly); short appointments when medication is effective |
| Dementia | Capacity and consent, simple preventive plans, involve caregivers |
| Multiple sclerosis | Trigeminal neuralgia may be an early sign |
Behavioral and Psychiatric Disorders
| Condition or drug | Interaction or oral effect |
|---|---|
| Tricyclic antidepressants | Exaggerated pressor response to epinephrine; xerostomia; limit epinephrine dose |
| SSRIs | Bleeding risk increased with NSAIDs and aspirin; bruxism |
| Lithium | NSAIDs and metronidazole raise lithium levels (toxicity); xerostomia |
| Antipsychotics | Xerostomia, tardive dyskinesia; clozapine causes hypersalivation and agranulocytosis |
| Bulimia nervosa | Perimylolysis (palatal erosion of maxillary anterior teeth), parotid enlargement; advise rinsing with water or fluoride after vomiting and delaying brushing |
| Anorexia nervosa | Malnutrition, poor healing |
| Cocaine use | Avoid epinephrine within about 24 hours of use (arrhythmia, hypertensive crisis) |
| Methamphetamine use | Rampant cervical caries ("meth mouth"), xerostomia, bruxism |
| Dental anxiety | Behavioral techniques, nitrous oxide or oral sedation |
Exam Traps
- A patient on lithium given ibuprofen for several days can develop lithium toxicity.
- A pregnant patient lying flat in the third trimester who becomes faint should be rolled to her left side.
- Defer elective treatment in uncontrolled hyperthyroidism; do not simply avoid epinephrine and proceed.
A patient taking lithium for bipolar disorder needs analgesia for several days after an extraction. Which analgesic is preferable?
Ibuprofen 600 mg four times daily, because NSAIDs lower lithium levels
Naproxen, because long-acting NSAIDs never interact with lithium therapy
Diclofenac, because it is the only NSAID that does not affect lithium
Paracetamol, because NSAIDs can raise serum lithium to toxic levels
A 25-year-old woman has smooth, glassy erosion confined to the palatal surfaces of the maxillary anterior teeth and bilateral parotid swelling. Which history is most likely?
Bulimia nervosa with repeated self-induced vomiting
Hypothyroidism with macroglossia and delayed eruption
Bruxism during sleep with attrition of the incisal edges
Excessive consumption of carbonated drinks sipped from a straw
A pregnant patient in her 34th week becomes pale, nauseated and faint while lying flat in the dental chair. What is the immediate management?
Give sublingual nitroglycerin for suspected angina and keep her supine
Give intramuscular epinephrine 0.5 mg for suspected anaphylactic shock
Turn her onto her left side to relieve compression of the inferior vena cava
Lower her head further in the Trendelenburg position and continue treatment
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