Mechanism of Systemic Disease

In the act of extracting teeth, the operator must first ensure the general condition of the
patient, ready or not to take action. That readiness, can be assessed from a psychological state
(tense, scared, or ordinary), a systemic state (controlled or not), a history of the disease, and
also a history of treatment.
The initial examination, greatly determines the success rate of treatment. Because the
patient's condition is abnormal, it can make exodonization difficult. One of them is the
presence of uncontrolled systemic abnormalities, then it can arise as a result of perioperative
and postoperative complications. Some systemic diseases that can complicate exodontic
actions include:
1. Hypertension
2. Diabetes Mellitus
3. Cardivascular disease
4. Hyperthyroidism
5. Chronic Kidney Failure
6. Chronic liver disease
7. Asthma

1. HYPERTENSION

Definition:

Hypertension also referred to as high blood pressure (HTN or HPN) is a medical condition in
which continuous high blood pressure or according to JNC-7 (Joint National Committee)
hypertension is a constant increase in arterial blood pressure, which results in oxygen and
nutrient supply, which carried by the blocked blood to the tissues of the body in need.
In current usage, the word "hypertension" usually refers to systemic (arterial hypertension).
While other types are pulmonary hypertension which involves the circulation of the lungs.
Classification of Adult Blood Pressure

Classification SISTOL (mmHg) DIASTOL (mmHg)

Normal < 130 < 85
Normal (Slight High) 130-139 85-89
Stadium 1 (Low Hypertension ) 140-159 90-99
Stadium 2 (Hypertension) 160-179 100-109
Stadium 3 (High Hypertension) 180-209 110-119
Stadium 4 ≥ 210 ≥120
(Maligna Hypertension)

Pathophysiology:

a. Essential hypertension (primary hypnosis) is idiopathic, which is unclear. Affected by age,

sex, smoking, cholesterol, weight.

b. Secondary hypertension. Influenced by drugs, kidney disease, endocrine disease (diabetes

mellitus, thyroid, Cushing).

Clinical Symptoms and Signs:

Usually without causing symptoms (asymptomatic). However, it is usually accompanied by

several clinical signs, namely: prosimal dizziness, sweating, tachycardia, palpitations.
The physical signs that are seen, including:
 
• Restlessness
• Easy to get angry
• Reddish face
• Slow
• Obesity
• Frequent tremors
• Difficulty sleeping
• Easy to get tired
• Nosebleeds
• Ear buzzing
• Eyes are dizzy
• Ginggiva and xerostomia enlargement (due to consumption of antihypertensive drugs)

Diagnosis:

Diagnosis can be done by doing:

a. Anamnesa
b. Examination of symptoms and clinical signs
c. Blood pressure checks (according to the table above)

Therapy:

Treatment of hypertension is broadly divided into 2 types, namely: 2

1. Non-pharmacological treatments include:

a. Low salt / cholesterol / saturated fat diet
b. Reducing salt intake in the body. Advice on reducing salt, must pay attention to sufferers'
eating habits. Drastic reduction in salt intake will be difficult to implement. This method of
treatment should not be used as a single treatment, but is better used as a complement to
pharmacological treatment.
c. Create a relaxed state. Various relaxation methods such as meditation, yoga or hypnosis
can control the nervous system which can eventually lower blood pressure.
d. Do sports such as aerobic exercise or brisk walking for 30-45 minutes 3-4 times a week.
e. Stop smoking and reduce alcohol consumption

2. Treatment with drugs (pharmacological)

Antihypertensive drugs. There are many types of antihypertensive drugs currently circulating.
For the selection of the right drug, you should contact the doctor.

a. Diuretics
Medicines such as diuretics work by removing body fluids (through urine) so that the volume
of fluid in the body decreases which results in a lighter pumping of the heart. The example of
the medicine is Hydrochlorothiazide.

b. Sympathetic Inhibitors
This group of drugs works by inhibiting sympathetic nerve activity (nerves that work when
we move). Examples of drugs are: Methyldopa, Clonidine and Reserpin.

c. Betabloker.
The mechanism of action of this anti-hypertension drug is through a reduction in heart
pumping power. Betabloker types are not recommended for patients who have been known to
have respiratory disorders such as bronchial asthma. Examples of drugs are: Metoprolol,
Propranolol and Atenolol. In patients with diabetes mellitus, care must be taken, because it
can mask the symptoms of hypoglycemia (a condition in which blood sugar levels drop to
very low which can cause harm to the sufferer). In older people there are symptoms of
bronchospasm (narrowing of the respiratory tract) so that the administration of the drug must
be careful.

d. Vasodilator
This class of drugs works directly on blood vessels by relaxing smooth muscle (blood vessel
muscles). Included in this group are: Prasosin, Hidralasin. Side effects that are likely to occur
from administration of this drug are: headache and dizziness.

e. Angiotensin conversion enzyme inhibitors

The way these drugs work is to inhibit the formation of substances Angiotensin II (substances
that can cause an increase in blood pressure). Examples of drugs belonging to this group are
Kaptopril. Side effects that may arise are: dry cough, dizziness, headache and weakness.

f. Calcium antagonists
This class of drugs lowers the heart's pumping power by inhibiting heart contraction
(contractility). Included in this class of drugs are: Nifedipine, Diltiasem and Verapamil. Side
effects that may arise are: constipation, dizziness, headache and vomiting.

g. Angiotensin II Receptor Inhibitors

The way this drug works is by blocking the attachment of Angiotensin II substances to its
receptors which results in a mild heart pumping power. Medicines included in this group is
Valsartan (Diovan). Side effects that may arise are: headache, dizziness, weakness and
nausea.With regular treatment and control, as well as avoiding risk factors for hypertension,
the mortality rate from this disease can be reduced.

Problem:

In patients with hypertension there is a risk of occurring:

a. Bleeding and thrombosis
b. The risk of intravascular injection and adrenaline in local anesthetic drugs enters the blood
vessels, which can cause tachycardia, stroke volume increases, so that blood pressure
becomes high.

Management:
• Use of local anesthetics containing adrenaline needs to be considered, as well as
administration of drugs from NSAID groups.
• Giving sedatives in the form of N20 before treatment only if needed (as anxiety control).
• For hypertensive patients at a high normal level, local anesthetics containing vasoconstrictor
(adrenaline) can be carried out with a ratio of 1: 200000. Or it could also be done by dilution
by mixing 1 ml of 2% product with 1 ml of pure 2% lidocaine.
• Avoid treatment times during rush hour and weather that does not support.
• If necessary dental care should be consulted immediately and surgical treatment carried out
in team work.
1. DIABETES MELLITUS

Definition:
Diabetes mellitus commonly known as diabetes is a disease that is characterized by
hyperglycemia (an increase in blood sugar levels) that is continuous and varied, especially
after eating. All types of diabetes mellitus have similar symptoms and complications at an
advanced level. Hyperglycemia alone can cause dehydration and ketoacidosis.

Classification:

1. DM Type 1:
Absolute insulin deficiency due to pancreatic beta cell deconstruction. The cause can be
autoimmune and also idiopathic.

2. DM Type 2:
Relative insulin deficiency. Because insulin defect is more dominant than insulin resistance
and insulin resistance is more dominant than insulin secretion defect. Differentiated into type
fat and not fat.
Symptoms:

Typical symptoms of people with diabetes mellitus, are:

• Polyuria (frequent urination)
• Polidipsi
• Polyphagia
• BB decreases rapidly without a clear cause
While the symptoms that are not typical of people with diabetes mellitus, are:
• Tingling
• Itching in the genital area
• Infections that are difficult to heal
• An abscess is absent

Blurred vision
• Get tired quickly
• Easily drowsy, etc.

Clinical Signs:
Oral manifestations in diabetics include:
 
• Increasingly widespread gum disease
• Gingivitis
• Candidiasis
• Lichen planus
• mucous ulceration
• Angular cheilosis
• Progressive periodontal disease
• Periodontitis, loss of teeth, wounds are difficult to heal
• Dental mouth infections and diseases
• Caries
• Pain in the tongue
• Dry mouth / xerostomia
• The mouth feels burning
• Disfunction in taste

Diagnosis:
Diagnosis can be done by doing:
a. Anamnesa
b. Examination of symptoms and clinical signs
c. Check blood sugar levels:
• Blood glucose levels at fasting time are more than 120 mg / dl
• Blood glucose levels two hours after eating more than 200 mg / dl

Therapy:
• Low sugar diet
• Giving Insulin
• Anti-diabetic drugs, such as: Tolbutamide, chlorpropamide, tolazamid, glipizid, and
glibenclamide.

Problem:
a. Loss of metabolic control. Can be caused due to stress, local anesthetic drugs (especially
those containing adrenaline or other vasoconstrictors), and hypoglycemic crises.
b. Increased possibility of infection. Due to the disruption of antibody production caused by a
lack of glycogen, cellular and hormonal immunity of people with diabetes mellitus decreases,
the function of leukocytes is impaired and blood sugar levels are high.
c. Blood clots in people with diabetes mellitus, both type 1 and type 2, are slightly disturbed.
This means that cloating time of patients is not like non-diabetics.
d. Increased bleeding tendency. This is related to vasopathy and infections that often relapse
in the oral mucosa. Bleeding during and after exodonization can usually be controlled
through local treatment.
e. One of the acute complications of diabetes mellitus is the non ketotic hiperosmoler coma.
This disease is caused by high blood sugar levels exceeding 600 mg% which results in
patients being easily shocked.

Management:
• Comprehensive case history information (history).
• Examination of sugar levels before and after the action.
• The addition of insulin is done to prevent shock.
• Local anesthesia without the addition of vasoconstrictor material. Because adrenaline can
increase blood glucose levels.
• In surgery, there is a slight difference between people with type 1 and type 2 diabetes
mellitus. In patients with type 1 diabetes mellitus, insulin therapy must be performed before
surgery, giving insulin injections because the amount of insulin is insufficient. Whereas in
type 2, there is no need for insulin injections.
• Conservative surgery techniques and wound drainage, for example, 30 minutes of tampon
diving after tooth extraction.
• Reducing the likelihood of iatrogenic complications, disorders of blood lipids, increased
blood pressure, hypercoagulation of blood.
• Possibility of antibiotic prophylaxis.
• The act of extracting or operating should be carried out in the morning and after eating,
because at that time the metabolic state is relatively stable.

CARDIOVASCULAR DISEASE

Definition:
Cardiovascular disease is a systemic disease involving the heart and blood vessels. There are
many causes of cardiovascular disease, including: heredity, infectious diseases, unhealthy
lifestyles, smoking, and various other risk factors. Sometimes, dental treatment and the use of
certain drugs can affect the medical condition of patients with cardiovascular disease.

Symptoms:
• Hypoxemia
• Cyanosis
• Clubbing finger on hands and feet
• Polycythemia due to hypoxemia

Clinical signs (intraoral):

• Late and permanent tooth eruptions
• Enamel hypoplasia
• Pulmonary vasodilation
• Teeth appear bluish white
• Caries and periodontal disease

Diagnosis:
Diagnosis can be done by doing:
a. Anamnesa
b. Examination of symptoms and clinical signs

Therapy:
Provision of anti-convulsive drugs, such as: aspirin, heparin, etc.

Problem:
• Circulatory complications, such as bleeding and thrombosis
• Endocarditis infection

Management:
Must avoid the use of vasoconstriction in local anesthesia, because in conjunction with
endogenously released catecholamine, it can cause circulatory complications.
• Be careful in taking dental care.
• Use of antibiotic prophylaxis.
• As for surgery, we recommend that the surgery be performed with an ECG monitor and
accompanied by IV infusion with the intention to immediately find out complications and
perform treatment. This action must be carried out in the hospital so that supervision can be
carried out by an authorized specialist (Test and Wagner, 1992).
• Try as much as possible to reduce patient anxiety during dental treatment. Because people
with severe cardiovascular disease sometimes have medical conditions that are easily
influenced by their emotions.
• It is highly recommended to consult a doctor who has been caring for patients to know
clearly what the patient's current medical conditions are, what drugs are used by the patient,
and what should be avoided during dental treatment in patients with cardiovascular disease.
 
HYPERTIROIDISM

Definition:
Excessive working of the thyroid gland. So that the production of thyroxine becomes
excessive.

Symptoms:
 
• Heat intolerance
• Restlessness
• Tremor
• Excessive sweating
• Muscle weakness
• Diarrhea
• Increased appetite
•Weight loss
• Parents can have fibrillation, angina and congestive heart failure

Clinical Signs:
• Tremor and tachycardia
• Exophtalmos
• Enlarged thyroid gland
• Thin and soft skin
• Hyperactive reflexes

Diagnosis:
Diagnosis can be done by doing:
a. Anamnesa
b. Examination of symptoms and clinical signs
c. Laboratory examination:
- Increased T3 and T4
- Decrease in TSH

Therapy:
Pharmacological hyperthyroidism management using four groups of drugs, namely: a)
antithyroid drugs, b) iodide transport inhibitors, c) iodide in large doses suppresses the
function of the thyroid gland, d) radioactive iodine which damages the cells of the thyroid
gland. Antithyroid drugs work by inhibiting the binding (incorporation) of iodine in TBG
(thyroxine binding globulin) so that it will inhibit the secretion of TSH (Thyreoid Stimulating
Hormone) resulting in reduced production or secretion of thyroid hormones. Antithyroid is
used for: [1]
a. maintain remission in strauma with tirotoksikkosis
b. controlling hormone levels in patients who get radioactive iodine
c. ahead of thyroid removal (Anonim, 2000).
The drugs including antithyroid drugs are Propiltiourasil, Methimazole, Karbimazol and
Tiamazole.
Beta-adrenergic receptor antagonist. This drug is to reduce symptoms of hypothyroidism.
Example: Propanolol
Problem:
Risk of thyroid crisis

Management:
• Avoid adding adrenaline to the administration of local anesthetics, because there is an
endogenous release of adrenaline so that it can cause a thyrotoxic crisis.

ASMA
Definition:
Asthma is defined as a chronic inflammatory disease of the respiratory tract which is
characterized by an increase in the tracheobronchial branch response to repeated stimuli.
Asthma is a disappearing disease, with acute exacerbations spreading. Generally the time of a
short attack, occurs between several minutes to several hours, and clinically the patient can
recover completely after the attack. Although rare, acute attacks can cause death

Classification:
Asthma is divided into two types, namely bronchial and cardial asthma. Patients with
bronchial asthma, hypersensitivity and hyperactivity to external stimuli, such as house dust,
animal hair, smoke, and other allergens. Symptoms of emergence are very sudden, so that
asthma disorders can come suddenly. If you don't get help as soon as possible, the risk of
death can come. Bronchial asthma disorders can also arise due to inflammation which results
in narrowing of the lower respiratory tract. This constriction is due to wrinkling of the smooth
muscles of the respiratory tract, swelling of the mucous membranes, and the formation of
excessive mucus deposits. While asthma that arises due to a heart abnormality is called
cardial asthma. Cardial asthma symptoms usually occur at night, accompanied by severe
shortness of breath. This event is called nocturnal paroxymul dyspnea. It usually occurs when
the patient is sleeping.
Clinical Symptoms and Signs:
Symptoms and clinical signs are strongly influenced by the severity of asthma suffered. It
could be that an asthma sufferer almost shows no specific symptoms at all, on the other hand
there are also very clear symptoms. Symptoms and signs include:
• Cough
• Shortness of breath (dyspnea) especially when exhaling (expiration)
• Wheezing
Shallow and fast breathing
• Ronkhi
• Retraction of the chest wall
• Respiratory nostrils (indicating that all muscles have been used
respiratory aids in an effort to overcome the shortness that occurs)
• Thoracic hyperinflation (chest like a barrel)
Usually in patients who are free of attack no clinical symptoms are found, but at the time of
the attack the patient appears to breathe fast and deeply, agitated, sits propping forward, and
without the respiratory aids working hard.

Diagnosis:
Asthma can be diagnosed through the following method (www.nature.com):
(a) A device called a 'peak flow meter' can be used to diagnose asthma. Peak flow meters can
measure how much, and how fast air can be released from the lungs / pulmo. This tool can
also be used to determine what type of therapy is most suitable for asthma treatment in each
different case.
(b) Spirometry Tests can measure how well the lung functions, and can provide more
complete information from peak flow meters.
(c) Thoracic cavity X-ray, but this method is somewhat less common.
(d) Allergy tests on the skin, and blood tests, to find out if there are allergies to certain
ingredients.

Therapy:
Therapy for asthma medication is divided into 2 categories, namely quick relief and long-
term control medication.

Quick relief: - Overcome acute exacerbations of asthma

- Short acting beta agonists, anticholinergics and systemic corticosteroids.
- Rapid recovery from acute exacerbations
Long-term control medication:
- inhaled corticosteroids
- cromolyn sodium
- nedocromil
- Long-term beta agonist
- methylxantine
- leukotriene antagonists

Bronchodilator
Is symptomatic treatment of bronchospasm in acute exacerbations of asthma / control of
long-term symptoms: Albuterol, levalbuterol, salmeterol, ipratropium (atrovent),
theophylline.
Leukotriene receptor antagonists
Antagonists are direct from mediators that cause airway inflammation in asthma. Alternative
long-term treatment other than low-dose inhaled corticosteroids: montelukast.

Corticosteroids
The drug of choice for the treatment of chronic asthma and prevention of acute exacerbations
of asthma. Some inhaled corticosteroids used in asthma: beclomethasone, budenoside,
turbuhaler, flunisolide, fluticasone, triamcinolone.

Mast cell stabilizer

Prevents the release of mediators from mast cells that cause airway inflammation and
bronchospasm. Indicated for maintenance therapy for mild to moderate asthma: cromolyn

Therapy for cardial asthma (heart failure):

1) Treatment of Arrhythmia:
- Anti Arrhythmia: Diuretics, ACE inhibitors, Beta blockers, etc.
- Heart pacemaker
2) Surgical Treatment
3) Heart Transplant
4) Metabolic treatment
Problem:
• The patient has difficulty breathing.

Management:
• Anamnesa about drug allergies.
• Avoid using drugs that stimulate allergic reactions in patients.
• If the patient has an asthma attack, then: (Rylander, 1997)
(a) Immediately use a reliever inhaler with a spacer.
(b) Sit and relax, don't sleep on your back.
(c) Wait 5-10 minutes, if the asthma attack does not subside too, use an inhaler reliever every
1 minute, for 5 minutes, until the asthma attack subsides.
(d) If the asthma attack still does not subside, call an ambulance immediately, and keep using
the 1x reliever inhaler every minute.

CHRONIC KIDNEY FAILURE

Definition:
Kidney Failure is a disease in which kidney organ function decreases until finally it is no
longer able to work at all in terms of filtering the body's electrolyte disposal, maintaining
fluid balance and body chemicals such as sodium and potassium in the blood or urine
production.
Clinical symptoms and signs:
• Hypertonia
• Limp, no energy, appetite, nausea, vomiting, swelling, reduced urine, itching, shortness of
breath, pallor / anemia.
• Urinary abnormalities: Protein, Erythrocytes, Lekocytes. Abnormalities from the Lab.
others: Creatinine blood rises, Hb drops, Urine: protein is always positive
Diagnosis:
Diagnosis can be done by doing:
a. Anamnesa
b. Examination of symptoms and clinical signs
c. Blood and urine tests will be found:
• Increased levels of urea and creatinine
Anemia
• Acidosis (increased blood acidity)
• Hypocalcemia (decreased calcium levels)
• Hyperphosphatemia (increased phosphate level)
• Increased levels of parathyroid hormone
• Decreased vitamin D levels
• Normal or slightly increased potassium levels
• Analysis of urine shows a variety of abnormalities, such as the discovery of abnormal cells
and high salt concentrations
Problem:
• Drug detoxification disorders
• Trends in bleeding
Management:
• Consider the use of drugs that are excreted by the kidneys. Because of the danger of very
high accumulation.

CHRONIC HEART DISEASE

Definition:
In cases of chronic liver disease, such as liver cirrhosis and hepatitis. Disorders of liver
function occur. And that can increase the likelihood of bleeding.
Symptoms:
• Jaundice, edema, gastric bleeding, mental confusion
• Liver shrinks and is hard, splenomegaly
• Ascites and peripheral edema (enlargement of abdominal pain in the upper right region)
• Skin manifestations: spider angioma / nevi, palmarerythema, skin rash and urticaria
Diagnosis:
Diagnosis can be done by doing:
a. Anamnesa
b. Examination of symptoms and clinical signs
c. Laboratory examination:
- CT scan, ultrasound of the abdomen, biopsihepar
- Liver function tests (SGOT / AST and SGPT / ALT) increase
- The presence of antigens and viral hepatitis antibodies
Problem:
• Drug detoxification disorders
• Trends in bleeding
• Risk of transmission of viral hepatitis infection
Management:
• Examination of liver function, to avoid increased bleeding.
• The use of ester class local anesthetics, to reduce the accumulation of drugs in the liver due
to the considerable breakdown that occurs in the tissues and blood.
• If using amide-type local anesthesia, the maximum dose allowed should be considered as
the maximum dose for today.
• Postponement of care in patients with increased liver function
• For patients with active infections:
- The last nurse's care
- Universal precaution
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Price, Sylvia A. dan Lorraine M. Wilson.1994. Patofisiologi konsep Klinis Proses-Proses
Penyakit Edisi 4.Jakarta: EGC.
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http://www.nature.com/nrd/journal/v3/n10/abs/nrd1524.html