medical history seminar 1.pptx

CONTENTS
• INTRODUCTION
• REASONS FOR EVALUATION OF PATIENTS MEDICAL STATUS
• MEDICAL HISTORY
o IMPORTANCE
o EVALUATION GOALS
o MEDICAL HISTORY QUESTIONNAIRE
o IMPORTANCE IN PROSTHODONTICS
• EVALUATION AND MANAGEMENT OF THE PATIENTS WITH VARIOUS SYSTEMIC
DISEASES.

INTRODUCTION
• The objective of the medical history and patient assessment is to determine whether the
patient is fit to undergo dental treatment and whether any drug or anesthesia is
contraindicated.
• NO PATIENT SHOULD SUFFER ANY DETORIATION OF HEALTH AS A RESULT OF
DENTAL TREATMENT.
• It is therefore essential to establish as clearly as possible within the practical limitations of
dental practice, the presence and significance of medical problems likely to affect dental
treatment.

•Good preoperative assessment endeavors to anticipate and prevent trouble.
•Morbidity and mortality following minor dental operations is even less excusable
than that caused by more serious surgery.

REASONS FOR EVALUATION OF PATIENTS MEDICAL
STATUS :
1) To identify patients with undetected systemic disease.
2) To identify patients who are taking drugs or medication.
3) To allow the dentist to modify the treatment plan in light of any systemic disease the
patient may have or any drug he may be taking.

4) To protect the dentist and the patient from any malpractice (or allegations thereof).
5) To enable the dentist to select and confer with a medical consultant.
6) To help establish a good patient-doctor relationship.

Determine the patient’s ability to physically
tolerate the stress involved in the planned
treatment.
Determine the patient’s ability to psychologically
tolerate the stress involved in the planned
treatment.
Determine whether treatment modifications are
required to enable the patient to better tolerate the
stress involved in the planned treatment.
Determine whether the use of psycho sedation is
warranted.
a) determine which sedation technique is most
appropriate.
b) determine whether contraindications exist to
any of the drugs to be used in planned treatment.
GOALS FOR PHYSICAL
EVALUATION

MEDICAL HISTORY
• The most useful aspect of assessment is the medical history. This must be accurate and also concise
and systematically applied in order to ensure that the maximum success is derived.
• Many such systems are available.
• In one such system the history is reduced to eleven routine questions (A to L) as follows.
Anemia
Bleeding disorders.
Cardio respiratory disorders.
Drug treatment and allergies.
Endocrine disorders.
Fits or faints.
Gastrointestinal disorders.
Hospital admissions and attendances.
Jaundice or liver disease.
Kidney disorders.
Likelihood of pregnancy

MEDICAL HISTORY QUETIONNAIRE
- It is a legitimate method of securing data if used in conjunction with a dialogue.
- It may help a patient recall frequently used medications or various symptoms of the
disease.
- The questionnaire component also can assist the dentist in ascertaining which areas in
the dialogue history to emphasize and explore further.
- More importantly a completed and dated form, signed by the patient may be used as
evidence in any possible malpractice litigation.

MEDICAL HISTORY QUETIONNAIRE
1) Are you having pain or discomfort at this time? Y N
2) Do you feel very nervous about having dental
treatment? Y N
3) Have you ever had a bad experience in a dental
office? Y N
4) Have you been hospitalized during the past 2 years? Y N
5) Have you been under the care of a medical doctor
During the past 2 years? Y N
6) have you taken any medicine or drugs during the
past two years? Y N
7) Are you allergic to (that is, experiencing itching,
rashes, swelling of the hands, feet or eyes) or made
sick by penicillin, aspirin, codeine or any drugs or
medication? Y N

• 8) HAVE YOU EVER HAD ANY EXCESSIVE BLEEDING REQUIRING
SPECIAL TREATMENT? Y N
9) CIRCLE ANY OF THE FOLLOWING THAT YOU HAVE HAD OR HAVE
AT PRESENT
• HEART FAILURE
• HEART DISEASE OR ATTACK
• ANGINA PECTORIS
• HIGH BLOOD PRESSURE
• HEART MURMUR
• RHEUMATIC FEVER
• CONGENITAL HEART LESIONS
• SCARLET FEVER
• ARTIFICIAL HEART VALVE
• HEART PACEMAKER
• Heart disease or attack
• Angina pectoris
• High blood pressure
• Heart murmur
• Rheumatic fever
• Congenital heart lesions
• Scarlet fever
• Artificial heart valve
• Heart pacemaker

10) When you walk upstairs or take a walk, do you ever
have to stop because of pain in your chest, shortness
of breath, or extreme fatigue? Y N
11) Do your ankles swell during the day? Y N
12) Do you use more than two pillows to sleep? Y N
13) Have you lost or gained more than 10 pounds in the
last year? Y N
14) Do you ever awaken short of breath? Y N
15) Are you on a special diet? Y N
16) Has your medical doctor ever said you have a cancer
or tumor? Y N

UPDATING THE QUESTIONNAIRE
1) Have you experienced any change in your general health since the last visit?
2) Are you under the care of a medical doctor? If so, what is the condition being
treated?
3) Are you currently taking any drugs or medications?
IF ANY OF THESE QUESTIONS ELICITS A POSITIVE RESPONSE, A DETAILED
DIALOGUE HISTORY SHOULD FOLLOW.

• Although the medical history questionnaire is extremely important in the overall
assessment of a patient’s physical status, it does have some limitations.
• For health history to be valuable, patients must
1)Be aware of their own states of health and any medical condition and
2)Be willing to share this information with the dentist.
• Most patients do not knowingly deceive the dentist by omitting important information from
their medical history questionnaire, but such cases have been recorded.
• The more likely cause of unintentional misinformation is that the patient is unaware that
a problem exists.
• Because of these problems, patient-completed questionnaire is not always reliable, the
doctor must seek additional sources for information concerning the patient’s physical
status.

IMPORTANCE OF MEDICAL HITORY IN PROSTHODONTICS
• The prosthodontic procedures should not be planned until the systemic status of the patient is
evaluated.
• Treatment planning is a consideration of all the diagnostic findings, systemic and local which
influence the surgical preparations of the mouth, impression making, maxilla-mandibular relation
records, occlusion, form and material in the teeth. So the dentist must not only be aware of the
systemic factors but also consider them in the treatment plan.

• Some systemic diseases have a direct relation to denture success even though no local
manifestation is apparent.
• Many systemic diseases have a local manifestation with no apparent systemic symptoms and
others have both local and systemic reactions .
• Various systemic diseases play a pivotal role in deciding treatment options in dentistry.
Prosthodontic procedures need to be carefully judged and planned according the systemic status
of the patient. There are various disease that are of concern in prosthodontics.

• When systolic pressure remain elevated above 150mm hg and diastolic pressure remain elevated
above 80mm hg it is considered as hypertension.
• Blood pressure levels stay within a fairly normal range with almost all activities but varies
normally so that it generally is lowest at night and highest in mild late morning.
• Anxiety, pain, exercise and tenseness transiently raise the pressure, where as relaxation, prolonged
bed rest and sleep lower it.
• MEDICAL EVALUATION: early symptoms of hypertension include headaches, dizziness, failing
vision, tinnitus, and occasional paresthesia (tingling) of the extremities.

DENTAL EVALUATION
• Dentists should play a major role in the detection of hypertension, because they
routinely see patients for multiple visits and semiannual checkups.
• The dentist should also know how hypertension can complicate dental therapy.
• Poorly controlled hypertension may actually elevate blood pressure during stressful
situations and precipitate angina, congestive heart failure or, rarely a cerebrovascular
event (eg. Stroke, hemorrhage).
• Careful attention to the blood pressure prior to the dental procedure minimizes the
risk of developing these problems.

COMMONLY USED ANTIHYPERTENSIVE DRUGS:
1) DIURETICS:
- CHLOROTHIAZIDE
- HYDROCHLOROTHIAZIDE
- FUROSEMIDE
2) BETA BLOCKERS:
- PROPRANALOL
- METOPROLOL
- ATENOLOL
3) ANGIOTENSIN CONVERTING ENZYME
INHIBITORS:
- CAPTOPRIL
- ENALAPRIL
- LISINOPRIL
4) CALCIUM CHANNEL BLOCKERS:
- NIFEDEPINE
- VERAPAMIL
- DILTIAZEM
- AMLODIPINE
5) ALPHA BLOCKERS:
-Prazosin
-Terazosin
-Doxazosin
6) DIRECT VASODILATORS:
-Hydralazine
-Minoxidil
-Guanethidine.
7) CENTRAL ALPHA II BLOCKERS AND
OTHER CENTARLLY ACTING DRUGS:
-Clonidine
-Alpha methyl dopa
-Reserpine.

ORAL ADVERSE SIDE EFFECTS OF HYPERTENSIVE DRUGS AND
THEIR MANAGEMENT
DRUG ORALADVERSE SIDE EFFECTS
1. Diuretics Dry mouth, lichenoid reactions
2. Beta blockers Dry mouth , taste changes, lichenoid reactions
3. ACE inhibitors Loss of taste, dry mouth, ulceration, angioedema
4. Calcium channel blockers Gingival enlargement , dry mouth, loss of taste
5. Alpha blockers Dry mouth
6. Direct acting vasodilators Facial flushing, possible increase risk of gingival
bleeding and infection
7. Central acting agents Dry mouth, taste changes, parotid pain

Frequently prescribed drugs cause , XEROSTOMIA
Which cause frequent candida infections, increased periodontal diseases, caries and bacterial
infection caused by loss of protection by saliva
Xerostomia also decreases the valve seal of soft tissue borne removable prosthesis and increases the
risk of abrasions and sore spot.

PROSTHETIC MANAGEMENT
• Communicate with the patient’s physician.
• Reduce patients stress and anxiety.
• Morning appointment
• Short wait in waiting room.
• Reassurance and peaceful environment.

• DENTAL IMPLANT MANAGEMENT:
A stress reducing protocol is indicated for anxiety patients by giving diazepam 5 to 10mg ,night
before a procedure.
Most of the patients undergoing anti hypertensive therapy use NSAID concomitantly. These
drugs have shown to reduce the action of hypertensive agents. So it is recommended that
NSAIDS be limited to short therapy and other analgesics be used .

NSAIDS
• Nsaids, such as ibuprofen, indomethacin or the naproxen, can interact with antihypertensive drugs
( β- bclockers , diuretics, ACE Inhibitors), thereby lowering antihypertensive action.
• Normally, more than 5 days treatment with both types of drugs are required for interaction to
manifest,as a result NSAIDs should not be prescribed for longer than 5 days period.

RISK SYSTOLIC DIASTOLIC IMPRESSION IMPLANT
PROCEDURE
NORAMAL 130-139 85-89 + SEDATION
STAGE 1 140-159 90-99 + SEDATION
STAGE 2 160-179 100-109 + POSTPONE OF
PROCEDURE
STAGE 3 180-209 110-119 POSTPONE ALL THE
PROCEDURES
STAGE 4 ≥210 ≥120 POSTPONE ALL THE
PROCEDURES

HYPERTENSIVE EMERGENCIES
• HYPERTENSIVE EMERGENCY (>120/210 MM HG)
• EMERGENCY SERVICE SHOULD BE ACTIVATED AND FUROSEMIDE SHOULD BE
ADMINISTERED (40 MG VIA ORAL ROUTE).
• IF THIS PROVES INSUFFICIENT TO RESTORE, CAPTOPRIL SHOULD BE
ADMINISTERED (25MG VIA ORAL ROUTE OR SUBLINGUAL ROUTE)
• IF THE BLOOD PRESSURE FAILS TO DECREASE WITHIN 30 MINUTES AFTER TO
THESE MEASURES,THE PATIENT SHOULD BE REFERRED TO THE NEAREST
HOSPITAL EMERGENCY DEPARTMENT.

LOCAL ANESTHESIA WITH VASOCONSTRITION
• Most antihypertensive drugs have drug interactions with LA (local anaesthetic) and analgesics.
LA toxicity may be increased by interaction of LA with nonselective beta-blockers. The
cardiovascular effects of epinephrine used during dental procedures may be potentiated by the use
of medications such as nonselective beta-blockers (propranolol and nadolol).
• Guidelines recommend decreasing the dose and increasing the time interval between epinephrine
injections. LA with vasoconstrictor should be avoided or used in low doses in patients taking
nonselective beta-blockers or in patients with uncontrolled hypertension.
• Absorbable suture should be avoided with adrenaline.

• Due to higher concentrations of epinephrine (almost 12 standard cartridges) in gingival retraction
cords used for prosthetics impressions and its rapid uptake in circulation, the use of epinephrine
for gingival eviction in patients with cardiovascular disease is contraindicated.
• Hypertensive patients are at an increased risk of developing complications like bleeding and
delayed post operative wound healing. Certain precautions can avoid such complications and
promote successful outcome of the procedures

• Fabricating a complete denture demands utmost care to avoid causing soft tissue abrasion. Certain
antihypertensive drugs are associated with xerostomia which in turn hamper the retention and
stability of the complete dentures.
• For denture wearers, denture adhesives and artificial saliva may aid in the retention of the
prostheses. In such patients artificial salivary lubricants should compensate the effect of
xerostomia for better post-therapy results .

• The sharp edges of the removable partial dentures should be trimmed off. Removable partial
denture should be polished well and preferably should be fabricated with flexible material.
• To minimize gingival bleeding, the margins of the preparation should be kept supragingival.
During treatment, sudden changes in the body position should be avoided, as they can cause
orthostatic hypotension as a side effect of the antihypertensives. Prolonged presence of
xerostomia is conducive to greater carious activity and is therefore extremely hostile to the
margins of cast metal or ceramic restorations. It is mandatory to educate the patients about good
oral hygiene and also to maintain the prosthesis clean.

WHITE COAT HYPERTENSION
• In patients with stage 1 hypertension, BP may also be elevated persistently in the presence of a
health care worker, prticularly a physician.
• When measured elsewhere, including while at work,the BP is not elevated.When this
phenomenon is detected in patients not taking medications, it is referred to as white coat
hypertension.
• Occurs at any age.
• More common in older men and women.

•The patients with chronic heart failure may be at risk for acute exacerbation during
dental procedure. If during a dental procedure a patient experiences acute dyspnea,
certain actions must be taken. The dentist should administer oxygen and ask the
patient to sit upright

•Medication prescribed for congestive heart failure, are classified as three
D’s,digitalis ,diuretics and dilators. Digitalis increases the heart’s pumping action,
diuretics eliminate salt and water, vasodilator dilate the blood vessels so that
pressure decreases and blood can flow more readily.

•Dental implant management:
the patients taking treatment for CHF are prone for digitalis toxicity because the
lethal dose of digitalis is only twice the treatment dose so the dentist should be
familiar with common side effect and should report them to the treating
physician. Gingival hyperplasia similar to caused by dilantin sodium has been
reported to occur around teeth, implants, or superstructure bars of over denture
especially with nifedipine.

•Dental implant management: patients with MIT in preceding 6 months can
have dental examination, but treatment has to postpone if possible for 6 months.
Longer procedures should be segmented into shorter appointments elective
implant procedures should be postponed for at least 12 months following MI.
Hospitalization is an accepted modality for all advanced surgical procedures
regardless of time elapsed after a MI.

SYMPTOMS
Angina feels like squeezing, pressure, heaviness, tightness
or pain in the chest.
It can be sudden or recur over time.
Pain areas: in the chest, jaw, or neck
Pain types: can be like a clenched fist in the chest or
sudden in the chest
Whole body: dizziness, fatigue, inability to exercise,
light-headedness, or sweating

DENTAL IMPLANT MANAGEMENT:
• Patients with mild angina may undergo must non surgical dental procedures.
• The vital sign has to be monitored during the procedure and the patient in instructed to have
nitroglycerine.
• The implant surgery is performed with nitrous oxide or oral reduction. The use of vasoconstrictors is
limited to 0.04 to 0.05 mg epinephrine.
• Patient with moderate angina should be given nitroglycerine sublingually just before advanced
operative or simple to moderate implant surgery.Antianxiety sedation with supplemental oxygen are
also required.
• Patients with severe angina are limited to examination procedures. Elective implant surgical procedure
is usually not performed on these patients. Medical consultation is required for any of the additional
treatment. Consideration should also be given for administration of oxygen especially in patients with
coexisting pulmonary disease in whom poor oxygen exchange lowers blood oxygen content.

•A proper medical history should be taken to know, which type of diabetes is the
individual suffering from and accordingly plan the treatment.
•The IDDM are more likely to develop glucose imbalance during treatment then
those with NIDDM.
•Glucose drinks should be available if patient complains of symptoms of
hypoglycemia.

•The operator should use an impression technique that will produce maximum
physiologic compatibility of the denture base with supporting structure.
• Careful occlusal correction should be accomplished to remove all interferences.
•The food table should be small and the patient should be given detailed
instructions on eating habits and oral hygiene
• Frequent evaluation of denture is necessary.
• Diabetic patients are prone to develop infections and vascular complication so an
antibiotic prophylaxis before dental surgery to prevent subsequent infection is
advised.

ORAL MANIFESTATIONS AND COMPLICATIONS
• NO SPECIFIC ORAL LESIONS ASSOCIATED WITH DIABETES. HOWEVER, THERE ARE
NUMBER OF PROBLEMS BY PRESENCE OF HYPERGLYCEMIA.
• PERIODONTAL PROBLEMS:
 Increased CA+ and glucose lead to plaque formation.
 Increased collagen breakdown.
• INCREASED RISK OF INFECTION:
 Reason unknown, but macrophage meatbolis altered with inhibition of phogocytosis.
 Peripheral neuropathy and poor peripheal ciculation.
 Immunological defficiency.
 High sugar medium
 Decrease production of antibodies
 Candidal infection are more common and adding effects with xerostomia.

• SALIVARY GLANDS:
 Xerostomia is common, but reason is unclear.
 Tenderness, pain and burning sensation of tongue.
 May cause secondary enlargement of parotid glands with sialosis.
• DENTAL CARIES :
 Increase caries prevalence in adult with diabetes. (Xerostomia, increase saliva glucose.)

• DELAYED HEALING OF WOUNDS:
 Due to microangipathy and utilisation of protien for energy, may retard the repair of tissue.
 Increase prevalence of dry socket.
• MISCELLANEOUS CONDITIONS :
 Neuropathies: may affect cranial nerves( facial).
 Drug side effects: lichenoid reaction may be associated with sulfonylureas (chlopropamide).
 Ulcers

PROSTHODONTIC MANAGEMENT OF DIABETIC DENTAL
PATIENT
1) MEDICAL HISTORY :
Take history and assess glycemic control at initial appointment.
• Glucose levels
• Frequency of hypoglycemic episodes
• Medication, dosage and times.
2) Establishing the levels of glycemic control early in the treatment process:
• Patients recent glycated hb values.

3) STRESS REDUCTION :
• Endogenous production of epinephrine and cortisol increase during stressful situations.
• Profound anesthesia reduces pain and minimizes endogenous epinephrine release.
• Conscious sedation should be considered for extremely anxious patient.
4) Oral hygiene instructions, frequent prophylaxis & monitoring of periodontal health, as there
is increased risk of periodontal disease.
5) Treatment: the use of antibiotics in case of infection and diet modification.

• APPOINTMENT TIMINGS :
• Diabetic patients can receive dental treatment in the morning
. • But, it is generally best to plan dental treatment to occur either before or after periods of peak
insulin activity.
• Greatest risk of hypoglycemia will occur about
A. 30-90 min after injecting lispro insulin.
B. 2 – 3 hours after injecting regular insulin
C. 4-10 hours after injecting lente insulin

DIABETIC EMERGENCIES MANAGEMENT
• The most common diabetic emergency in the dental office is hypoglycemia.
• Signs and symptoms of hypoglycemia include;- confusion , sweating, tremors, agitation, anxiety,
dizziness, tingling or numbness, and tachycardia. Severe hypoglycemia may result in seizures or
loss of consciousness.
• Blood glucose with a glucometer should be checked

If glucometer is not available, condition is treated as hypoglycemic episode and the patient should
be Given approx. 15g of oral carbohydrate.
If patient is unable to take food by mouth i.V line is in place, 25-50 ml of 50% dextrose solution
(D50) or 1mg of glucagon can be given intravenously.
• Signs and symptoms of hypoglycemia should reduce in 10- 15 min.
Marked hyperglycemia: if glucometer is not available, these symptoms must be treated as
hypoglycemia

HYPOGLYCEMIA
• SIGNS & SYMPTOMS OF HYPOGLYCEMIA
• MILD
• Anxiety
• Tachycardia
• Sweating
• SEVERE
• Confusion
• Seizures
•Coma

MANAGEMENT OF HYPOGLYCEMIA
• Terminate all dental procedures
• Alert the patient
• 15 gm carbohydrate( 6 oz orange juice, 4 oz cola, 3-4 teaspoons sugar)
• In case of uncooperative patient, glucagon 1 mg S.C, I.M. Followed by oral glucose supplement
or dextrose50 20- 50 ml I.V.
• The well controlled diabetic is probably at no greater risk of postoperative infection than in non
diabetic. Therefore in routine oral surgical procedures do not require prophylactic antibiotics.
• In poorly controlled diabetic patient, prophylactic antibiotics should be considered.

DIABETES AND PROSTHODONTICS
• Abutment failure.
• Tissue abrasions are more likely in denture wearers.
• Erythematous candidiasis is associated to the use of upper total denture or prosthesis (denture
stomatitis).
• Oral carrier rate and density of C.albicans in denture wearers of diabetic group were higher.
• Increased residual ridge resorption.
• Mucostatic impressions should be made.

DIABETES AND IMPLANT SURGERY
• Implant dentistry is not contraindicated in most diabetics
• Diabetics patients with blood glucose levels of around 100 mg/dl
• Sedative procedures and antibiotics.
• Need for a stress reduction protocol, diet evaluation before after surgery and control of the risk of
infection are all addressed.
• Corticosteroids, often used to decrease edema, swelling and pain may not be used in the
diabetic’s patient.
• Detrimental effects of diabetes on osseointegration can be modified using aminoguanidine
systemically.

Risk Impressions Implant procedure
Mild ≤ 150 mg /d1
+
Sedation, premedication,
Diet and insulin
adjustment
Moderate ≤ 200mg/dl
+
Sedation, premedication,
Diet and insulin
adjustment, hospitalization
Severe > 250mg/d1
+
Postpone elective
procedure.

• Second most common endocrine problem affecting 1% of the general population principally
women.
• The major function of the thyroid gland is the production of hormone thyroxine (T4). Thyroxine
is responsible for the regulation of carbohydrate, protein and lipid metabolism. It also potentiates
the action of other hormones like catecholamines and growth hormone.
• The abnormalities of anterior pituitary gland or the thyroid results in hyperthyroidism (increased
thyroxine) or hypothyroidism (decreased thyroxine)

• Patients with hyperthyroidism are especially sensitive to Catecholamines such as epinephrine
present in local anesthesia And gingival retraction cord- so when exposure to Catecholamines is
coupled with stress an exacerbation of the Symptoms of hyperthyroidism may occur resulting in
CNS Alteration like psychosis, life threatening arrhythmias or Congestive heart failure.
• Patient with hypothyroidism is particularly sensitive to CNS depressant drugs especially narcotics
and sedative drugs such as diazepam of barbiturates. So there, is a risk of respiratory depression
and cardiovascular depression or Collapse in these cases.

DENTAL IMPLANT MANAGEMENT :
• The most common thyroid disorder patient seen in implant dentist is one with
known and treated thyroid disease. So these types of patients without any
symptom can be considered as low risk and a normal protocol can be followed
for implant surgery and prosthodontic appointments.
•The patients with thyroid disorder who has no symptoms but had recently thyroid
function test is considered as moderate risk category. These patients may follow a
normal protocol in addition with stress reduction. The use of epinephrine and
CNS depressant drugs should be limited in moderate to advanced implant
procedures and surgery.

•The patients with symptoms are considered at high risk. Such patients should
have only examination procedures formed and all other treatment is defaced until
the medical and laboratory evaluation confirms controls of disorder.

TUBERCULOSIS
QUESTIONS TO ASK/NECESSARY INFORMATION:
1. WHEN WERE YOU DIAGNOSED?
2. ARE YOU STILL HAVING SYMPTOMS OF
ACTIVE INFECTION, SUCH AS COUGHING, NIGHT SWEATS?
1. WHAT MEDICATIONS HAVE TAKEN AND FOR HOW LONG?
2. HAVE YOU TAKEN THEM AS DIRECTED?

• IT IS AN INFECTIOUS DISEASE THAT USUALLY AFFECTS LUNGS.
• IT IS THE SECOND BIGGEST KILLER.
• TWO KINDS OF TUBERCULOSIS INFECTION:
• LATENT: THE BACTERIA REMAIN IN THE BODY IN AN INACTIVE STATE. THEY
CAUSE NO SYMPTOMS AND ARE NOT CONTAGIOUS, BUT THEY CAN BECOME
ACTIVE.
• ACTIVE: THE BACTERIA DO CAUSE SYMPTOMS AND CAN BE TRANSMITTED TO
OTHERS.

ORAL MANIFESTATION
• ORAL TB LESIONS MAY BE EITHER:
• PRIMARY – LESIONS ARE UNCOMMON SEEN IN YOUNGER PATIENTS AND PRESENT
AS A SINGLE PAINLESS ULCER WITH REGIONAL LYMPH NODE ENLARGEMENT
AND ULCERS OF LONG DURATION.
• SECONDARY – LESIONS ARE COMMON, OFTEN ASSOCIATED WITH PULMONARY
DISEASE, USUALLY PRESENT AS A SINGLE, INDURATED, IRREGULAR, PAINFUL
ULCER COVERED BY INFLMMATORY EXUDATES IN PATIENTS OF ANY AGE GROUP
BUT RELATIVELY MORE COMMON IN MIDDLE-AGED AND ELDERLY PATIENTS.

• ORAL TB MAY OCCUR AT ANY LOCATION ON THE ORAL MUCOSA, BUT THE
TONGUE IS MOST COMMONLY AFFECTED.
• OTHER SITES INCLUDE THE PALATE, LIPS, BUCCAL MUCOSA, GINGIVA, PALATINE
TONSIL, AND FLOOR OF THE MOUTH.
• SALIVARY GLANDS, TONSILS, AND UVULAARE ALSO FREQUENTLY INVOLVED.
• THE ORAL LESIONS MAY BE PRESENT IN A VARIETY OF FORMS SUCH AS ULCERS,
NODULES, TUBERCULOMAS AND PERIAPICAL GRANULOMAS.

PRECAUTIONS FOR DENTAL HEALTH CARE
PROFESSIONAL
• Maintenance of proper hand hygiene.
• Personal protective equipment ( eye shields, face masks, headcaps, gloves and surgical gowns)
• Proper sterilization procedures should be followed.
• Standard surgical face masks do not protect against tb transmission; dental healthcare personnel
should use particulate face masks.
• Masks should be changed at regular intervals, inter-appointments
(Between patients) and intra appointments(during patient treatment) if it becomes wet.

• SPREAD BY AEROSOLIZED DROPLETS HIGH RISK TO DENTIST.
• PAST HISTORY OF TB PHYSICIAN’S CONSULTATION IF
CULTURE POSITIVE ONLY EMERGENCY TREATMENT PROVIDED.
• MINIMAL USE OF HIGH SPEED HANDPIECES.
• OPERATING AIR SHOULD BE VENTED OUT (HEPA FILTERED) RECIRCULATION IS
NECESSARY, WITH HIGH VOLUME SUCTION ARE INDICATED FOR CARRYING OUT
ANY PROCEDURE TO MINIMIZE AEROSOL GENERATION.
• ORAL LESIONS MAY MAKE USE OF PROSTHESIS DIFFICULT.

CHRONIC OBSTRUCTIVE PULMONARY
DISEASES

• COPD IS IRREVERSIBLE AIRWAY OBSTRUCTION AND DESTRUCTION.
• THE TWO COMMON FORMS OF COPD ARE : EMPHYSEMA
CHRONIC BRONCHITIS

• THE MEDICAL HISTORY INCLUDES:
1) History of smoking.
2) Signs of respiratory distress such as wheezing, exertional dyspnea, coughing
and sputum production.
3) The use of medications to control respiratory symptoms.
If a patient has been hospitalized for respiratory difficulties, the physician should
be consulted about the patient’s current status. It is particularly important to
know whether a patient retains CO2, as these patients have severe disease and
are most prone to respiratory failure when oxygen or sedatives are given.

BASED ON EVALUATION PATIENTS CAN BE GROUPED INTO THE FOLLOWING
RISK CATEGORIES:
PATIENTS AT LOW RISK:
1) Patients with dyspnea only on significant exertion.
2) Patients with normal blood gases [pco2- 40mm hg, po2- 100mm hg, ph- 7.40]
DENTAL MANAGEMENT:
1) Normal protocol for all dental procedures (types I-VI).
2) Avoid anything that causes greater demands on the respiratory system ( stress – pain – anxiety
complex, and supine positioning of the patient for treatment.
3) Treat in an upright sitting or very slightly reclining position.

PATIENTS AT MODERATE RISK:
• Patients with dyspnea on exertion.
• Patients on chronic bronchodilator therapy.
• Patients who have recently used corticosteroids.
• Patients with hypoxemia [po2 less than 85mm hg] but no CO2 retention.
DENTAL MANAGEMENT:
• The patient should have a recent medical evaluation and the patients physician should be
consulted. The dentist should discuss the overall treatment plans, alternatives and the use of local
anesthetics, possible sedation techniques and postoperative analgesics.
• Patients on bronchodilator therapy deserve special attention.
• Patients taking theophylline preparations.
• Patients who are currently on steroids and patients who have had significant doses of steroids
during the past year deserve special attention.

PATIENTS AT HIGH RISK:
1) Patients with previously unrecognized symptoms of COPD.
2) Patients with acute exacerbation (e. G. Acute respiratory infection).
3) Patients with significant dyspnea at rest or cor pulmonale who require chronic oxygen
therapy.
4) Patients with a history of CO2 retention [PCO2 > 45mm hg].
DENTAL MANAGEMENT:
1) Patients with symptoms suggesting COPD who have not been medically evaluated, should be
referred to their physicians prior to dental procedure.
2) Patients with acute exacerbations of symptoms.

3) Patients with severe COPD should be managed with close cooperation with their physicians.
- Stress should be minimized and short dental sessions should be employed.
- The use of any agent that may depress respiratory function – such as sedatives (including
nitrous oxide), tranquilizers and narcotics- must be discussed with the patient’s physician.
This is particularly true when the patient has a history of CO2 retention. In most cases non
narcotic analgesics are preferred.
4) Patients with cor pulmonale are prone to have arrhythmias.
5) Hospitalization should be considered for moderate to advanced dental surgery (types v and vi)
procedures.

PEPTIC ULCER DISEASE
• GENERAL INFORMATION:
Peptic ulcer disease is the result of damage to the epithelial lining of the stomach (gastric ulcer) or
the duodenum (duodenal ulcer).
• PATHOPHYSIOLOGY:
Acid erosion of the gastrointestinal mucosa.

• PRECIPITATING FACTORS:
- ASPIRIN.
- ALCOHOL.
- NSAID S
- TOBACCO
- CAFFEINE.
- CORTICOSTEROIDS.
- EMOTIONAL STRESS.

DENTAL MANAGEMENT
1) Dental management of the patient with peptic ulcer disease should avoid aggravation of
symptoms. Minimize stress, shorter appointments, consider adjunctive sedation techniques.
2) The major concern in dental management of the patient with peptic ulcer disease relates to the
complications of the drugs used in the treatment.
- Some antacid preparations such as di-gel, gelusil, maalox, and mylanta, contain aluminiun
hydroxide that prohibit the effective absorption of tetracycline.
- Cimetidine - thrombocytopenia.
- Aspirin and nsaids – irritation to mucosal lining.
- Anticholinergics – xerostomia.

• HEPATITIS IS AN ACUTE INFECTION OF THE LIVER CAUSED BY ONE OF THE
THREE VIRUSES
Type A Type B
Type C

• THE MAJORITY OF PATIENTS HAVE SYMPTOMS OF AN ACUTE MILD VIRAL
ILLNESS, BUT ABOUT 5% PROCEED TO DEVELOP CHRONIC HEPATITIS.
• A NUMBER OF PATIENTS BECOME CHRONIC CARRIERS OF HEPATITIS ANTIGEN
AND ARE POTENTIALLY INFECTIOUS.
AN UNDERSTANDING OF THE VARIOUS TYPES OF VIRAL HEPATITIS AND THE
COMMON MODES OF TRANSMISSION IS IMPORTANT IN THE PREVENTION OF
INFECTION.
THE DENTIST IS PARTICULARLY AT RISK BECAUSE OF EXPOSURE TO THE ORAL
SECRETIONS AND BLOOD OF POTENTIALLY INFECTIOUS PATIENTS.

MODE OF TRANSMISSION OF HEPATITIS

DENTAL EVALUATION
• Because dentists are exposed to the blood and oral secretions of patients, they are particularly at
risk of contracting hepatitis. The dental evaluation should therefore identify all patients who are
potentially infectious.
• Patients giving a history of malaise, low grade fever, anorexia, nausea and vomiting should be
referred for evaluation.
• Patients with a prior history of hepatitis or jaundice should be carefully evaluated.
• Patients with scleral icterus or jaundice should have dental procedures deferred and should be
referred for further evaluation.
• Based on history, examination, and laboratory profile, the relative risk of hepatitis can be
assessed.

PATIENT AT LOW RISK
Patients with histories of hepatitis A, B or C
with normal liver function tests and
negative hepatitis antigen.
NORMAL DENTAL PROTOCOL WITH ADHERENCE TO UNIVERSAL
PRECAUTIONS.
Patients with history of hepatitis B with
normal liver function tests, negative
antigen tests, and positive antibody tests
are also not infectious.

PATIENTS AT HIGH RISK
Patients with positive surface
antigen for hepatitis B and C. Patients with abnormal
liver function tests.
Patients with jaundice and
symptoms of viral hepatitis.
1. Deferring of elective dental care until clinical infection has resolved.
2. Careful avoidance of exposure to blood and oral secretions.
3. Strict sterilization procedures: autoclave of all instruments including handpieces.
Handpieces that cannot be autoclave should be sterilized with ethylene oxide gas.

5. Use of double gloves and masks, appropriate gowning precautions.
6. Draping all exposed dental equipment where feasible, and wiping all other surfaces with
antiseptic solutions.
7. Minimal use of aerosol instruments (air- water syringe & ultrasonic scalers) to prevent
aerosolization of potentially infective viral particles.
8. Use of disposable items (e. G. Impression trays when possible).
9. Inadvertent needle puncture: when the skin is inadvertently punctured with instruments
and other needles, it is important to wash the wound thoroughly, whenever feasible the
patient’s hepatitis surface antigen status should be determined. If parenteral exposure to
blood that is HBsAg-positive has occurred, the dentist should receive hepatitis B
immunoglobulin.

PREGNANCY
•The pregnant patient requires
special attention to dental
management. The dental care for the
mother and developmental concerns
of the fetus must be considered
carefully before each encounter.

MANAGEMENT DURING DENTAL TREATMENT
• FIRST 3 MONTHS O PREGNANCY:
NO DENTAL TREATMENT EXCEPT EMERGENCIES.
IF DENTAL TREATMENT RENDERED , MINIMUM MEDICATIONS OR TRAUMA.
EDUCATE THE PATIENT ABOUT THE VALUE OF GOOD ORAL HYGIENE.

• SECOND TRIMESTER AN D FIRST HALF OF THIRD:
THIS IS THE APPROPRIATE TIME FOR ALL DENTAL TREATMENT NECESSARY OR
DESIRED DURING THE PREGNANCY.
MINIMIZE DRUG USE INCLUDING OTC DRUG USE.
EMPHASIZE PROPER DENTAL CARE TO MINIMIZE ADVERSE PREGNANCY
OUTCOME.

• LAST HALF OF THIRD TRIMESTER:
NO DENTAL TREATMENT EXCEPT EMERGENCIES.
IF DENTAL TREATMENT RENDERED, MINIMUM MEDICATION O TRAUMA.
IF TREATMENT REQUIRED , BE ALERT FOR SUPINE HYPOTENSIVE
SYNDROME(ALLOW THE PATIENT TO TURN ON HER SIDE)

BE ALERT FOR:
1.) Periodontal problems. Besides the patient’s own risk of bone loss, severe periodontal disease has
been associated with low birth weight pre term babies. Good periodontal health is paramount to
minimizing this risk.
2) Pyogenic granulomas( pregnancy gingivitis)
3) Minimize drug use. Even though there is little risk with most drugs, spontaneous abortions can
occur and concerns about drug used during dental procedures should not enter into concerns about
why abortion occurred.

HIV AIDS
• ACQUIRED IMMUNO DEFICIENCY SYNDROME
• EPIDEMIC DISEASE
• ASSOCIATED WITH WIDE RANGE OF ORAL LESIONS LIKE:
 ORAL CANDIDIASIS
 ORAL HAIRY LEUKOPLAKIA
 KAPOSIS SARCOMA
 NUG AND NUP
 RECURRENT APTHOUS ULCERATIONS

• MANY OF THE DENTAL TREATMENTS ARE CONTRAINDICATED IN HIV PATIENTS.
• THE TREATMENT PLAN DEPENDS ON THE OVERALL SYSTEMATIC HEALTH OF THE
PATIENT.
• PRECAUTIONS FOR PREVENTION OF TRANSMISSION.

GUIDELINES FOR PROSTHODONTIC MANAGEMENT OF
SUBJECTS WITH HIV/AIDS
GENERAL MEASURES:
• Create safe and empathetic environment.
• Maintain confidentiality of patients’ information.
• Use standard precautions.
• Provide unbiased treatment.
• Advise regular dental visits.
• Identify and manage oral manifestations of HIV/AIDS.

MEASURES IN PARTICULAR TO PROSTHODONTICS:
• Evaluation of periodontal status of existing dentition during construction of removable and fixed
dentures.
• Evaluation and management of xerostomia.
• Increased maintenance of dentures for prevention of candidiasis.
• Evaluation of temporomandibular joint disorders.
• Precautions during pre-prosthetic and implant surgeries.

INCREASED MAINTENANCE OF DENTURES FOR PREVENTION OF CANDIDIASIS
• Removable partial dentures can act as source of candida species which can not only delay dental
treatment but also predispose them to denture-related stomatitis and improper control of oral lesions
leading to disseminated infections.
• Hence, treatment of oral mucosa as well as the dentures with antifungal to control the spread of fungal
infection and improved maintenance of dentures In HIV patients is of utmost importance.
• Treatment of dentures is done with :
Nystatin powder (50 million U) sprinkled on the tissue contact area of the denture or clotrimazole
cream applied on the undersurface of the dentures 4–5 times in a day.
Severe lesions are treated with systemic antifungal such as fluconazole (200 mg/day, 100 mg daily for
next 7–14 days), itraconazole (100–200 mg/100 ml once a day for 1–2 weeks), and ketoconazole (200–
400 mg/day as a single dose for 7–14 days).
Newer antifungal (e.G.; Echinocandins, second generation triazoles) and natural products are also
being used.

• An in vivo investigation comparing the oral candida population between heat-cured acrylic resin
and nickel-chromium-beryllium alloy in maxillary complete dentures in HIV-infected patients
demonstrated significantly higher colony counts under the acrylic bases.
• This study determined that metal base CD provide an important alternative for edentulous HIV
positive, particularly among those prone to higher incidences of fungal infections.
• Further, it is better to avoid the use of denture adhesives and reliners as these may anchor the
fungal elements to larger extent and contribute to candida infections.

EVALUATION OF TEMPOROMANDIBULAR JOINT
DISORDERS
• Literature reveals that antiretroviral therapy, particularly protease inhibitors (pis) are related to
TMJ arthralgia.
• In this case, stomatologists attributed the temporomandibular disorder (TMD) to problem with
dentures and advised change of dentures. However, the problem did not subside until alternative
medications were prescribed suggesting association of pis with TMD.
• Thus, it is necessary for the prosthodontist dealing with hiv-infected subjects to aware of such a
possibility.

CRITERIA FOR THE DIAGNOSIS OF
RHEUMATOID ARTHRITIS
Signs and Symptoms:
Morning stiffness
Arthritis of three or
more joint areas
Arthritis of hand
joints
Symmetric arthritis
Rheumatoid nodules
Positive Serum
rheumatoid factor
Radiographic
changes

• The temporomandibular joints are frequently affected in this disease. The problem encountered in
the prosthodontic rehabilitation of patients with rheumatoid arthritis of TMJ is
A. CHANGES IN OCCLUSION.
B. JAW RELATION.

CHANGES IN OCCLUSION:
• As the joint tissue are more susceptible to increased loading, the prosthetic reconstruction’s
should be aimed at giving unloading appliances and improve the distribution of occlusal force.
• The removable denture in the lower jaw was not only beneficial for chewing but also for
unloading the diseased joints.
• Treatment should be primarily focused on antirheumatic medications as the prosthetic procedures
do not cure the joint disease and are therefore secondary.

JAW RELATION
• There is a difficulty in recording an acceptable jaw relationship because of the destruction of joint
tissues.
• There is a large distance between the most returned and the intercuspal position i.e., Cr-co. In
such situations a muscularly relaxed and comfortable jaw position should be chosen and tried in
provisional constructions before the permanent rehabilitation is completed.
• Since the disease commonly occurs between acute and chronic stages. The irreversible treatment
like fixed prosthesis should not be given until the disease is cured

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