This document discusses periodontal treatment considerations for medically compromised patients. It covers various medical conditions including cardiovascular diseases like hypertension, ischemic heart disease, and congestive heart failure. It also discusses management of patients with diabetes, thyroid disorders, adrenal insufficiency, and bleeding disorders. For each condition, it provides details on how the condition may impact dental treatment and recommendations for modifying treatment approaches. The goal is to minimize medical risks and stress for patients with underlying health issues requiring periodontal therapy.

1. PERIODONTAL TREATMENT IN MEDICALLY
COMPROMISED PATIENTS
Presented By
Dr. Fariya Ashraf

2.  CARDIOVASCULAR DISEASE
 HYPERTENSION
 ISCHEMIC HEART DISEASE
 CONGESTIVE HEART FAILURE
 INFECTIVE ENDOCARDITIS
 CEREBROVASCULAR ACCIDENT
 ENDOCRINE DISORDER
 DIABETES
 THYROID AND PARATHYROID DISODERS
 ADRENAL INSUFFICIENCY
 HEMORHAGIC DISORDERS
 COAGULATION DISORDERS
 ANTIPLATELET THERAPY
 LEUKEMIA
 RENAL FAILURE
 DIALYSIS
 PULMONARY DISEASE
 ASTHMA
 TUBERCULOSIS
 IMMUNOSUPRESSION AND CHEMOTHERAPY
 RADIATION THERAPY
 XEROSTOMIA
 OSTEORADIONECROSIS
 INFECTIOUS DISEASE
 HEPATITIS
 COVID 19
CONTENT

3. INTRODUCTION
WHAT THE PERIODONTAL TREATMENT HAS TO DO WITH THE
MEDICALLY COMPROMISED PATIENTS?
 Many patients seeking dental care might have significant
medical condition which may alter the course of their oral
disease and therapy provided.
 The therapeutic responsibility of clinician includes identification
of medical problems and consultation with or referral of the
patient to appropriate physician may be indicated
 Older periodontal patients are more likely to have underlying
disease.

4. CARDIOVASCULAR DISEASES
Health histories should be closely scrutinized for cardiovascular problems, including
hypertension, angina pectoris, myocardial infarction (MI), cardiacbypass surgery,
cerebrovascular accident (CVA), congestive heartfailure (CHF), infective endocarditis (IE), and
implanted cardiacpacemakers or automatic cardioverter-defibrillators
In most cases, the patient's physician should be consulted, especially if stressful or prolonged
treatment is anticipated.
Short appointments and a calm, relaxing environment help minimize stress and maintain
hemodynamic stability.

5. HYPERTENSION
 Hypertension, the most common cardiovascular disease, affects more than 50 million American
adults, many of whom are undiagnosed.

6. • Premedicate the evening before dental appointment & after dental t/t (nitrous oxide,
diazepam 5mg night before and 1hr before procedure)
• Schedule appointment during afternoon. Avoid during early morning
• Minimize patient`s waiting time.
• Short appointments
• Clinician should not use a local anaesthetic containing epinephrine > 1: 100000 nor a
vasopressor to control bleeding.
• If patient exhibits anxiety ,use of conscious sedation in conjunction with periodontal
procedure is warranted.

7. The dental office can
play a vital role in the detection of
hypertension and maintenance
care of the patient with
hypertensive disease.
The first dental office
visit should include two BP
readings spaced at least 10
minutes apart, which are averaged
and used as a baseline.
Before the clinician refers a patient to a
physician because of elevated BP, readings
should be taken at a minimum of two
appointments, unless the measurements
extremely high (i.e., systolic pressure
>180 mm Hg or diastolic pressure >100 mm
Hg).

8. Ischemic heart disease includes disorders such as angina pectoris and MI. Angina pectoris occurs when
myocardial oxygen demand exceeds supply, resulting in temporary myocardial
ischemia.
Patients with a history of unstable angina pectoris should be treated only for emergencies and
then in consultation with their physician.
Patients with stable angina can undergo elective dental procedures.
Because stress often induces an acute anginal attack, stress reduction is important. Profound local
anesthesia is vital, and conscious sedation may be indicated for anxious patients

9. • Terminate the procedure.
• Place the patient in a semisupine position.
• Administer 100% oxygen.
• Administer sublingual nitroglycerin, preferablythe patient’s own drug (0.32 mg or 0.4 mg);
• use the minimal dose needed for relief to avoid secondary hypotension.
• Monitor vital signs
In patients where angina occur during dental treatment, the following steps should be
taken:

10. Patients with poorly controlled or untreated CHF are not candidates for elective dental
procedures.
CHF is a condition in which the pump function of the heart is unable to supply sufficient
amounts of oxygenated blood to meet the body's needs.

11. Medical management of CHF:
Weight loss
Sodium restriction
Alcohol restriction
Smoking cessation
Regular exercise
Adequate rest
Balanced diet
Non pharmacologic (Conservative) treatment
Pharmacologic treatment
 Long acting ACE inhibitors
 Digoxin (loading dose 0.75-1.25
mg, maintenance dose adjusted
with age, lean body mass and
renal function)
 Diuretics
 Long acting nitrates
 Vasodilators
 Potassium chloride
supplementation (>4.0 mEq/L)
 Metazolone, 5-10 mg every other
day may be added when
furosemide dose exceeds 160
mg/day

12. DENTAL MANAGEMENT
• Poorly controlled or untreated CHF are not candidates for elective
dental procedures.
• For patients with treated CHF, the clinician should consult with the
physician.
• stress reduction with profound local anesthesia
• use of supplemental oxygen should be considered
• Short appointments
• Patients should not be placed in supine position

13. CARDIAC PACEMAKERS AND IMPLANTABLE
CARDIOVERTER-DEFIBRILLATORS
 Cardiac arrhythmias are most often treated with medications, but some are also treated with
implantable pacemakers or automatic cardioverter-defibrillators.
 Consultation with the patient's physician allows determination of the underlying cardiac status, the
type of pacemaker or automatic cardioverter-defibrillator, and any precautionary measures to be
taken.
Automatic cardioverter defibrillators activate without warning when certain
arrhythmias occur. This can endanger the patient during dental treatment
because activation often causes sudden patient movement. Stabilization of the
operating field during periodontal treatment with bite blocks or other devices
can prevent unexpected trauma.

15. Infective endocarditis (IE) is a disease in which microorganisms colonize damage endocardium or heart valves.
Streptococcus viridans,
Eikenella corrodens,
Aggregatibacter
actinomycetemcomitans,
Capnocytophaga, and
Lactobacillus species
IE
ACUTE
FORMS
SUBACUTE
FORM

18. The following guidelines can aid in the development of periodontal treatment plans for
patients susceptible to IE:
 For patients at risk for IE, every effort
should be made to eliminate this infection.
 All periodontal treatment procedures
(including probing) require antibiotic
prophylaxis; gentle oral hygiene methods
are excluded.
 Pretreatment chlorhexidine rinses are
recommended before all procedures,
including periodontal probing,
 When possible, allow at least 7 days
between appointment
 Regular recall appointments, with an
emphasis on oral hygiene reinforcement
and maintenance of periodontal health

20. CEREBROVASCULAR ACCIDENT
Hypertension and atherosclerosis are predisposing factors for CVA and should alert the
clinician to evaluate the patient's medical history carefully
To prevent a repeat stroke, active infections should be treated aggressively, because
even a minor infection can alter blood coagulation and trigger thrombus formation and
ensuing cerebral infarction.
CVA results from ischemic changes or hemorrhagic phenomenon

21. 1. No periodontal therapy should be performed for 6 months
2. After 6 months, periodontal therapy can be performed during short
appointments with an emphasis on minimizing stress.
3. Light conscious sedation can be used for anxious patients.
4. Supplemental oxygen is indicated to maintain thorough cerebral oxygenation.
5. Stroke patients are frequently placed on oral anticoagulants in consultation
with the patient's physician.
6. BP should be monitored carefully.

23. • Diabetes mellitus (DM) is a disease of glucose, fat, and protein metabolism resulting from
impaired insulin secretion, varying degrees of insulin resistance, or both.
• Stress increases body resistance to insulin and so patients may develop hyperglycemia during
treatment.
• Type 2 Diabetics are less prone to complications that develop during treatment as compared to
type 1 which are more prone to ketosis.

24. If a patient is suspected of having undiagnosed
diabetes, the following procedures should be
performed:
1. Consult the patient's physician.
2. Analyse laboratory tests , including fasting
blood glucose and casual glucose test results.
3. Acute orofacial infection or severe dental
infection; if present, provide emergency care
immediately.
4. Establish the best possible oral health through
nonsurgical debridement of plaque and calculus.
Institute oral hygiene instruction. Limit more
advanced care

25. DENTAL THERAPY CONSIDERATIONS
• Advise the patients to take usual insulin dose and to eat normal breakfast before treatment.
• Schedule dental appointments early in the day
• Use of LA without epinephrine
• When periodontal surgery is indicated, it is usually best to limit the size of the surgical
field so that the patient will be comfortable enough to resume a normal diet immediately.
• • For prolonged procedures, intraoperative blood glucose evaluation is advisable.

26. HYPOGLYCEMIA
Symptoms may include:
• Sweating, tachycardia (sympathetic overactivity)
• Weakness, dizziness
• Pale, moist skin ,and cold skin (in contrast to hyperglycemia)
• Shallow respiration
• Headache ,anxiety
• Altered consciousness

27. • Terminate dental procedure
• Position the patient
• Administer 15 gms of oral carbohydrate
• No improvement – administer parentral carbohydrate or glucagon if
available or intravenous dextrose.
• Observe patient atleast for 1 hour before discharging
MANAGEMENT (CONSCIOUS PATIENT)

28. • Terminate dental procedure
• Position patient in supine patient
• BLS
• Summon medical assistance
• Definitive management (50%dextrose iv, 1mg glucagon im, sc).
HYPOGLYCEMIA (UNCONSCIOUS PATIENT)

29. Guidelines for periodontal care in diabetes patients for medical
and dental professionals and recommendations for
patients/the public.
Guideline A
[Suggested Guidelines for physicians and other medical
health professions for Use in Diabetes Practice]
Because of the increased risk for developing periodontitis in patients with diabetes
the following recommendations are made:
 Patients with diabetes should be told that periodontal disease risk is increased
by diabetes.
 As part of their initial evaluation, patients with type 1, type 2 and gestational
diabetes (GDM) should receive a thorough oral examination, which includes a
comprehensive periodontal examination.

 For all newly diagnosed type 1 and type 2 diabetes patients, subsequent
periodontal examinations should occur (as directed by the dental professionals)
as part of their ongoing management of diabetes

30. Guideline B [Suggested guidelines for use in dental practice]
Chapple, I. L. C., & Genco, R. (2013). Diabetes and periodontal diseases:
consensus report of the Joint EFP/AAP Workshop on Periodontitis and
Systemic Diseases. Journal of Periodontology, 84(4-s), S106–S11

31. Symptoms may include:
• Increased fatigue
• Dizziness
• Drowsiness
• Headaches
• Blurred vision
• Irritability
• Intense thirst
• Increased urination
• Involuntary weight loss
• Excessive hunger
HYPERGLYCEMIA

32. MANAGEMENT OF HYPERGLYCEMIC PATIENT (UNCONSCIOUS PATIENT)
• Terminate dental procedure
• Position the patient
• BLS
• Summon medical assistance
• IV infusion (5% dextrose and water)
• Administer oxygen
• Transport to hospital

33. Periodontal therapy requires minimal alterations for the patient with adequately managed thyroid
disease.
Patients with thyrotoxicosis and those with inadequate medical management should not receive
periodontal therapy until their condition is stabilized
Patients with a history of hyperthyroidism should be carefully evaluated to determine the level of
medical management, and they should be treated in a way that limits stress and infection.

34. Routine periodontal therapy can be provided to patients with parathyroid disease after the
disorder has been identified and the proper medical treatment given.
Patients with hypothyroidism require
careful administration of sedatives and
narcotics because of the potential for
excessive sedation.
Medications such as epinephrine and other
vasopressor amines should be given with
caution to patients with treated
hyperthyroidism, although the small
amounts used in dental anesthetics rarely
cause problems.

35. ADRENAL INSUFFICIENCY
Acute adrenal insufficiency is associated with significant morbidity and mortality rates as a
result of peripheral vascular collapse and cardiac arrest.

36.  Terminate periodontal treatment.
 Summon medical assistance.
 Give oxygen.
 Monitor vital signs.
 Place the patient in a supine position.
 Administer 100 mg of hydrocortisone sodium succinate intravenously over 30
seconds or intramuscularly.
Management of the patient in an acute adrenal
insufficiency crisis is as follows:

37. HEMORRHAGIC DISORDERS

38. • Patients with a history of bleeding problems caused by disease or drugs should be
managed to minimize the risks of hemorrhage.
• Identification of these patients through the health history, clinical examination,
and clinical laboratory tests is paramount.
Health questioning should cover
(1) the history of bleeding after previous surgery or trauma,
(2) past and current drug history,
(3) history of bleeding problems among relatives,
(4) illnesses associated with potential bleeding problems.

39. COAGULATION DISORDERS

40. The clinician should consult the patient's physician before dental treatment to
determine the risk of bleeding and treatment modifications required.
To prevent surgical hemorrhage, a factor VIII level of at least 30% is needed
Parenteral 1-deamino-8-Darginine vasopressin (DDAVP; desmopressin) can be used
to raise factor VIII levels two fold to three fold in patients with mild or moderate
hemophilia.
Hemophilia – B :Surgical therapy requires a factor IX Level of 30% to 50%, which is
usually achieved by administration of purified prothrombin complex concentrate or
factor IX concentrate

41. Periodontal treatment can be performed in patients with these coagulation disorders, provided
that suficient precautions are taken
Probing, scaling, and prophylaxis can usually be done without medical
modiication
More invasive treatment, such as local block anesthesia, root planing, or surgery, dictates
prior physician consultation
Complete wound closure and application of pressure can reduce hemorrhage

42. Dental treatment planning for patients with liver disease should include the following:
1. Physician consultation
2. Laboratory evaluations
3. Conservative, nonsurgical periodontal therapy whenever possible
4. When surgery is required (may require hospitalization)
• International normalized ratio (INR; PT) should be less than 2.0; for simple surgical
procedures, an INR of less than 2.5 is usually safe.
• Platelet count should be more than 80,000/mm3.
Liver disease affects all phases of blood clotting
because most coagulation factors are
synthesized and removed by the liver.

43. THROMBOCYTOPENIC PURPURAS
Thrombocytopenia is defined as a platelet count of less than 100,000/mm3.
Purpuras are hemorrhagic diseases characterized by extravasation of blood into the tissues under the skin
or mucosa, producing spontaneous petechiae or ecchymoses
Periodontal therapy for patients with
thrombocytopenia should be directed toward
reducing inflammation by removing local irritants to
avoid the need for more aggressive therapy.
Scaling and root planing are
usually safe unless the platelet
count is less than 60,000/mm3.
No surgical procedure should be performed unless the platelet count is greater than 80,000/mm3. Platelet
transfusion may be required before surgery

44. NON THROMBOCYTOPENIC PURPURAS
Non thrombocytopenic purpuras result from vascular wall fragility or thrombasthenia (i.e.,
impaired platelet aggregation).
• Treatment consists primarily of direct pressure applied for at least 15 minutes.
• This initial pressure should control the bleeding unless coagulation times are
abnormal or reinjury occurs.
• Surgical therapy should be avoided until the qualitative and quantitative platelet
problems are resolved.

45. ANTICOAGULANT THERAPY
The recommended level of therapeutic
anticoagulation for most patients is an INR of 2.0 to
3.0, with prosthetic heart valve patients usually in the
2.5 to 3.5 range
The most common cause of
abnormal coagulation may be
drug therapy.
These drugs are vitamin K antagonists that
decrease production of vitamin K–
dependent coagulation factors II, VII, IX, and
X.

47. • The international normalized ratio is a key component in the dental treatment of patients on anti-
coagulation therapy
• When the international normalized ratio is <=3.5, periodontal surgical procedures can be carried
out on these patients in a dental office
• When the international normalized ratio is >3.5, the anticoagulation regimen has to be adjusted
• However, reducing the international normalized ratio value may increase the risk for thrombosis in
patients with other concomitant illnesses such as liver and renal disease, and patients with increased
alcohol consumption

48. ANTIPLATELET MEDICATIONS
Aspirin interferes with normal platelet aggregation and can
result in prolonged bleeding. Because it binds irreversibly to
platelets, the effects of aspirin last at least 4 to 7 days.
Nonsteroidal antiinflammatory drugs (NSAIDs) such as
ibuprofen also inhibit platelet function. Because NSAIDs bind
reversibly, the effect is transitory, lasting only a short time after
the last drug dose.

49. LEUKEMIA
Refer the patient for medical evaluation and treatment.
Before chemotherapy, a complete periodontal treatment plan should be
developed with a physician
During the acute phases of leukemia, patients should receive only
periodontal care.
Oral ulcerations and mucositis are treated with viscous lidocaine.
Oral candidiasis can be treated with nystatin suspension
For patients with chronic leukemia and those in remission, scaling and root planing
can be performed without complication, but periodontal surgery should be
if possible.

50. RENAL DISEASE
Common causes of renal failure:
Glomerulonephritis
Kidney cystic disease
Drug nephropathy
Hypertension
Renal failure may result in :
Severe electrolyte imbalances
Cardiac arrhythmias
Pulmonary congestion
CHF
Prolonged bleeding

51. Because the dental management of patients with renal disease may need to be
drastically altered, physician consultation is necessary to:
 determine the stage of renal disease
 regimen for medical management
 alterations in periodontal therapy.
The patient in CRF has a progressive disease that ultimately may require kidney
transplantation or dialysis. It is preferable to treat the patient before, rather than after,
transplant or dialysis.

52. Treatment modifications should be used:
1. Consult the patient's physician.
2. Monitor blood pressure
3. Check laboratory values:
 Partial thromboplastin time (PTT)
 Prothrombin time (PT)
 Bleeding time
 Platelet count
 Hematocrit
 Blood urea nitrogen (do not treat if <60 mg/dl)
 Serum creatinine (do not treat if < 1.5 mg/dl).

53. 4. Eliminate areas of oral infection to prevent systemic infection.
 Good oral hygiene should be established.
 Periodontal treatment should aim at eliminating inflammation or infection and
providing easy maintenance.
 Questionable teeth should be extracted if medical parameters permit.
 Frequent recall appointments should be scheduled.
5. Drugs considerations:
 Nephrotoxic or metabolized by the kidney should not be given (e.g., Phenacetin,
tetracycline, aminoglycoside antibiotics).
 Acetaminophen may be used for analgesia and diazepam for sedation.
 LA such as lidocaine are generally safe.

54. DIALYSIS
• The patient who is receiving dialysis requires
modification in treatment planning.
The three modes dialysis:
 Intermittent peritoneal dialysis (IPD)
 Chronic ambulatory peritoneal dialysis (CAPD)
 Hemodialysis
Hemodialysis patients have :
 High incidence of viral hepatitis
 Anemia
 Prolonged hemorrhage.
The risk for hemorrhage is related to:
 Anticoagulation during dialysis
 Platelet trauma from dialysis
 The uremia that develops with renal failure

55. Recommendations made for those receiving Hemodialysis
1. Screen for hepatitis B and hepatitis C.
2. Antibiotic prophylaxis to prevent endarteritis of the arteriovenous fistula or
shunt.
3. Patients receive heparin anticoagulation on the day of hemodialysis. Therefore,
provide periodontal treatment on the day after dialysis.
4. Protect the hemodialysis shunt or fistula:

56. • Transplant patients take immunosuppressive drugs that greatly reduce resistance to
infection.
• Excessive bleeding may occur during or after periodontal treatment because of drug-
induced thrombocytopenia, anticoagulation, or both.
• Teeth with severe bone and attachment loss, furcation invasion, periodontal abscesses,
or extensive surgical requirements should be extracted, leaving an easily maintainable
dentition.
RENAL TRANSPLANT

57. The following should be considered for the renal transplant recipient:
1. Hepatitis B and C screening
2. Determination of the level of immune system compromise resulting from
antirejection drug therapy
3. Prophylactic antibiotics using AHA recommendations or a speciic regimen
based on physician consultation; not all transplant recipients require antibiotic
coverage, and physician consultation is warranted before prescribing.

58. LIVER DISEASE
1. Consultation with the physician concerning the current
stage of disease, risk of bleeding, potential drugs to be
prescribed during treatment, and required alterations to
periodontal therapy.
2. Screening for hepatitis B and C
3. Laboratory values for PT and PTT
4. Laboratory values for INR

59. PULMONARY DISEASES

60. Asthma is a chronic inflammatory respiratory disease
consisting of recurrent episodes of dyspnea, coughing and
wheezing resulting from hyper responsiveness of
tracheobronchial tree
Overt attacks of asthma may be provoked by:
 Allergens
 Upper respiratory track infections
 Exercise, cold air
 Certain medications (e.g. salicylates, NSAIDS)
 Smoke
 Highly emotional state like anxiety or stress

62. Mild Intermittent:
As needed use of bronchodilator
Mild Persistent:
Anti inflammatory drug
Low dose inhaled corticosteroids
Moderate Persistent
One medium dose inhaled corticosteroid or
Two daily medication: low to medium dose inhaled
corticosteroids & long acting broncodilators.
Severe Persistent
Daily medication: high dose inhaled corticosteroid
+
long acting bronchodilators (Salmeterol, sustained
release theophylline or long acting β2 agonist tab)
+
oral corticosteroids (usually 2 mg/kg total dose <60mg)
MEDICAL MANAGEMENT

63. PERIODONTALMANAGEMENT OF PATIENTSWITH PULMONARY DISEASE:
 Identify and refer patients with signs and symptoms of pulmonary disease to their
physician.
 In patients with known pulmonary disease, consult with their physician regarding
medications (antibiotics, steroids, chemotherapeutic agents) and the degree and
severity of pulmonary disease.

64. • Avoid elicitation of respiratory depression or distress-
• Minimize the stress of a periodontal appointment. The patient with
emphysema should be treated in the afternoon, several hours after sleep,
to allow for airway clearance.
• Avoid medications that could cause respiratory depression (e.g., narcotics,
sedatives, general anesthetics).
• Avoid bilateral mandibular block anesthesia, which could cause increased
airway obstruction.
• Position the patient to allow maximal ventilator efficiency; be careful to
prevent physical airway obstruction; keep the patient's throat clear; and
avoid excess periodontal packing.

66. TUBERCULOSIS
 It’s a major global health problem caused by an infectious and
communicable organism Mycobacterium tuberculi.
 Disease is spread by inhalation of infected droplets and usually
demonstrates a prolonged quiescent period.
 The replication of tubercle bacilli leads to host inflammatory and
granulomatous response and classic pulmonary & systemic
symptoms.

67. DENTAL MANAGEMENT

68. Immunosuppression
and Chemotherapy

69. Immunosuppressed patients have
impaired host defences as a result of an
underlying immunodeficiency or drug
administration (primarily related to organ
transplantation or cancer chemotherapy).
Immunosuppressed individual
are at greatly increased risk for
infection, and even minor
periodontal infections can
become life threatening if
immunosuppression is severe.
Patients receiving bone marrow transplantation require special attention because these patients
receive extremely high-dose chemotherapy and are particularly susceptible to dissemination of
oral infections.
If periodontal therapy is needed during chemotherapy, it is best done it day before
chemotherapy is given, when white blood cell counts are relatively high..

70. Patients scheduled to receive head and neck radiation therapy require dental consultation at the earliest
possible time to reduce the morbidity of known perioral side effects
After consulting the physician, the first decision should involve possible extractions because radiation can
cause side effects that interfere with healing
During radiation therapy, patients should receive weekly prophylaxis, oral hygiene instruction, and
professionally applied fluoride treatments, unless mucositis prevents treatment

71. XEROSTOMIA
 The parotid is the most radiosensitive of the salivary glands; saliva may become extremely
viscous or nonexistent, depending on the dose delivered to the particular gland.
 Xerostomia causes a decrease in:
 the normal salivary cleansing mechanisms
 buffering capacity of saliva
 pH of oral fluids.
 Radiation-induced caries may progress rapidly and primarily affects smooth tooth surfaces
 Salivary substitutes can be given for xerostomia.
 Daily topical fluoride application and oral hygiene are the best means of preventing radiation
caries over time.
 A long-term, 3-month recall interval is idea

72. OSTEORADIONECROSIS
 High-dose radiation therapy results in hypovascularity of irradiated tissues with a reduction in wound-
healing capacity. Most severe among the resulting oral complications is osteoradionecrosis (ORN).
 Decreased vascularity renders the bone less capable of resolving trauma or infection. Such events may
cause severe destruction of bone.
 The risk of ORN continues for the remainder of the patient's life and does not decrease with time.

74. Bisphosphonate medications are primarily used to treat cancer (i.e., intravenous administration) and
osteoporosis (i.e., oral administration)
They act by inhibiting osteoclastic activity, which leads to less bone resorption, remodeling, and turnover
Use of bisphosphonates leads to the development of bisphosphonate-related osteonecrosis of the jaw
(BRONJ).
Clinically, BRONJ manifests as exposed alveolar bone occurring spontaneously or after a dental
procedure

75. Periodontal disease and treatment (especially surgery) poses a risk for patients treated with
bisphosphonates.
Optimal periodontal and oral health should be achieved and maintained for all patients
For individuals treated with intravenous bisphosphonates, invasive treatment, such as extractions,
periodontal surgery, implant surgery, and bone augmentation procedures, should be avoided
Risks must be considered before treatment of individuals
with a history of taking oral bisphosphonates for longer than 3 years

76. PREGNANCY
The aim of periodontal therapy for the pregnant patient is to minimize the exaggerated inflammatory
response related to pregnancy-associated hormonal alterations.
Meticulous plaque control, scaling, root planing, and polishing should be the only nonemergency
periodontal procedures performed.
As the uterus increases in size during the second and third trimesters, obstruction of the vena cava and
aorta can occur if the patient is placed in a supine position. The reduction in return cardiac blood supply can
cause supine hypotensive syndrome, with decreased placental perfusion

78. HEPATITIS
Most hepatitis infections are undiagnosed, the clinician must be aware of high-risk
groups such as renal dialysis patients, health care workers, immunosuppressed
patients, patients who have received multiple blood transfusions, homosexuals,
drug users, and institutionalized patients
Six distinct viruses that cause viral hepatitis have been identiied: hepatitis A, B, C, D, E, G viruses, and TTV
virus

79. Active disease – No periodontal therapy,
For patients with a past h/o hepatitis, consult the
physician to determine the type of hepatitis, course
and length of the disease, mode of transmission, and
any chronic liver disease or viral carrier state.
For recovered HAV or HEV patients, perform
routine periodontal care.

80. • For recovered HBV and HDV patients,
1. Consult physician and test HBsAg and anti HBsAg
2. If HBsAg and anti-HBs tests are negative but HBV is suspected, order another
HBs determination.
3. Patients who are HBsAg positive are probably infective (chronic carriers); the
degree of Infectivity is measured by an HBsAg determination.
4. Patients who are anti-HBs positive may be routinely .
5. Patients who are HBsAg negative may be treated routinely.
• For HCV patients, consult with the physician to determine the patient's risk.

81.  If a patient with active hepatitis, use the following precautions:
 Consult patient's physician
 Hepatitis may alter coagulation; change Rx accordingly.
 All personnel use full barrier technique, disposable covers as possible.
 All disposable items (e.g., gauze, floss, saliva ejectors, masks, gowns, gloves)
should be disposed following guidelines of biohazardous waste
 Aseptic technique should be followed
 Minimize aerosol production by not using ultrasonic instrumentation, air syringe,
or high speed handpieces
 Prerinsing with chlorhexidine gluconate for 30 sec
 If an item cannot be sterilized or disposed of, it should not be used.

82. To develop guidelines for dental care provision during the pandemic, the following factors should be
considered:
1. The incubation period of the virus is believed to be up to 14 days; and transmission from asymptomatic
COVID-19 carriers is possible (Bai et al., 2020a, Guan et al., 2020, Lai et al., 2020a).
2. Aerosol and fomite transmission of SARS-CoV-2 is plausible (van Doremalen et al., 2020).
3. It is unclear yet, but COVID-19 recusancy might be possible and some virus strains can be present in
saliva for as long as 29 days (Barzon et al., 2016, Chen et al., 2020a, Zuanazzi et al., 2017).
4. Some confirmed COVID-19 carriers might need urgent dental care at some point.
COVID 19

83. 1. Screening every asymptomatic patient
2. Considering every patient as a potential asymptomatic COVID-19 carrier.
3. Considering recently recovered patients as potential virus carriers for at least 30 days after the
recovery confirmation by a laboratory test
4. Follow minimally invasive procedures.
5. Categorising dental treatment according to the urgency of the required treatment
6. Using contact, and airborne precautions including proper aerosol-generating procedures personal
protective equipment (PPE) for every procedure.
Precautions to be taken include:

85. Alharbi A, Alharbi S, Guidelines for dental care provision during the COVID-19 pandemic Saudi Dent J.
2020;32(4):181-186.

86. Flowchart showing the dental patients screening and categorisation method during the COVID-19 pandemic
as well as the categorisation method of the affected patients after the pandemic.

87. CONCLUSION
 Many patients seeking dental treatment have some specific condition which can alter
the treatment plan of the patient.
 An appropriate management is necessary to avoid any complication which can be
sometimes life threatening.
 While rendering treatment to a medically compromised patients , the periodontist
should be prepared for any complication that might occur.

88. REFERENCES
1. Clinical periodontology – newman carranza ,11th ed, 13th ed
2. Medical problems in dentistry – scully & cawson 4th 5th ed
3. Dental management of medically compromised patient – little, falace 6th ed
4. Periodontics - medicine surgery & implants – rose, mealy, genco, cohen
5. Clinical practice of dental hygienist – wilkins 9th
6. Sedation a guide to patient management - stanley malamed 4th edition

89. 7. Hepatitis- dcna 47;431-447,2003
8. Antibiotic prophylaxis- dcna 46;635-57,2002
9. Cardiac arrhythmias- ooooe 96;659-68,2003
10. Corticosteroid therapy- jada 132;1570-79,2001
11. Oral anticoagulant therapy- jada 134;1492-1497,2003
12. Adverse drug interactions- jada 130;701-9,1999
13. Alharbi A, Alharbi S, Alqaidi S. Guidelines for dental care provision during the COVID-19
pandemic [published online ahead of print, 2020 Apr 7]. Saudi Dent J. 2020;32(4):181-186.
doi:10.1016/j.sdentj.2020.04.001