Periodontal management of medically compromised paients/dental courses

PERIODONTAL
MANAGEMENT OF
MEDICALLY
COMPROMISED PATIENTS
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

Background
Cardiovascular Diseases
Ø     Anesthetic Agents
Ø     Hypertension
Ø     Ischemic Heart Disease
Ø     Arrhythmias
Ø     Congestive Heart Failure
Ø     Hypertrophic Cardiomyopathy
Ø  Valvular Heart Disease and infective endocarditis
Ø     Anticoagulant Therapy

• Prosthetic Joint Replacement
• Pulmonary Diseases
• Immunosupression and Chemotherapy
• Radiation Therapy
• Endocrine Disorders
• Diabetes Mellitus
v     Medical Management and Implications
v     Diabetic emergencies
v     Metabolic control of diabetes

• Thyroid Disorders
• Parathyroid Disorders
• Adrenal insufficiency
• Pregnancy
• Hemorrhagic disorders
v     Coagulation disorders
v     Thrombocytopenic purpura
v     Non- Thrombocytopenic purpura

• Blood Dyscrasias
·       Leukemia
·       Agranulocytosis
• Kidney and Liver Diseases
·  Chronic Renal Disease and Hemodialysis
· Chronic Ambulatory Peritoneal Dialysis
·   Liver disease, Organ Transplantation
• Cancer
• Disorders Associated with early periodontal
Destruction

• Infectious Disease
·        Human immunodeficiency virus
Medications Associated with Gingival
Overgrowth
·        Anticonvulsants
·        Cyclosporin
·        Calcium Channel Blocking Agents

• Significant medical conditions, alter the
treatment plan and therapy provided
• Identification
• Evaluation
Medical history comprises the first step in
therapy

• ASA Class I
Normal, Healthy patient without systemic
disease;
• ASA Class II
Patient with mild systemic disease
• ASA Class III
Patient with severe systemic disease that limits
activity but is not incapacitated
• ASA Class IV
Patient with severe systemic disease, which
limits activity and is a constant threat to life.www.indiandentalacademy.com

Depending on the systemic condition medical
consultation may be indicated for ASA Class
II patients and consultations is compulsory
for most of ASA III and ASA IV patients.

CARDIOVASCULAR
DISORDERS

CARDIOVASCULAR
DISORDERS
• most prevalent category of systemic disease
as they increase with age
• primary management goal; hemodynamic
change produced by dental treatment does
not exceed the cardiovascular reserve of the
patient
• by maintaining the patient’s optimum blood
pressure, heart rate, heart rhythm cardiac
output and myocardial oxygen demand

• cardiovascular disorders encountered include ;
• hypertension,
• Ischemic heart disease,
• arrhythmias,
• congestive heart failure,
• Hypertrophic Cardiomyopathy,
• valvular heart disease,
• anticoagulant therapy and
• infective endocarditis.
CARDIOVASCULAR
DISORDERS

• Therefore, for patients with significant
cardiovascular disorders, a protocol may be
followed which includes, shorter
appointments, preferably in the morning
when the patient is well rested and has
greater physical reserve and the use of
profound local anesthesia.
CARDIOVASCULAR
DISORDERS

Anesthetic agents
• The use of local anesthetics with
vasoconstrictors remains controversial
• Two most commonly used vasoconstrictors
are epinephrine and levonordefrin
• Levonordefrin is only 20% as potent as
epinephrine;

• Normal epinephrine release from the adrenal
medulla can increase 20-40 fold during stress,
which may be induced by pain during dental
treatment
patients with cardiovascular disease may be at a
greater risk from massive endogenous
epinephrine release secondary to local anesthetic
than they are from the small amount of
vasoconstrictor used in local anesthetics
Anesthetic agents

• The American Heart Association and
American Dental Association jointly stated in
1964, “ The concentrations of
vasoconstrictors normally used in dental local
anesthetics solutions are not contraindicated
for patients with cardiovascular disease
when administered carefully with preliminary
aspiration”.
Anesthetic agents

• In 1955, N.Y. Heart Association recommended
a maximal dose of 0.2mg of epinephrine to be
given in a single session
• Thus, in order to remain below the
recommended dose, the maximum number of L.
A carpules would be:
• 11 for 1: 100,000 concentrations;
• 5 for 1: 50,000 concentrations.
Anesthetic agents

• Although small amounts of vasoconstrictor
produces little risk for the average patient with
cardiovascular disease, exogenous vasoconstrictors
may be contraindicated in patients with severe
cardiovascular compromise, including unstable
angina, recent myocardial infarction or coronary
artery bypass uncontrolled arrhythmias, severe
hypertension and severe congestive heart failure.
Anesthetic agents

Hypertension
• Among cardiovascular disorders, hypertensions
are the most prevalent, affecting approximately
20% of adults
• an adult patient is considered hypertensive if
the blood pressure exceeds 160/95, while the
pressure between 140/90 and 160/95, is
classified as borderline hypertensive.
• More recently, even 140/90 is considered
hypertensive. www.indiandentalacademy.com

• initial objective of therapy is to identify
previously undiagnosed hypertension.
• If unidentified or undiagnosed, hypertension
may persist and increase in severity, leading
eventually to coronary heart disease, angina,
myocardial infarction or congestive heart
failure. Increased renal pressure may lead to
kidney failure
Hypertension

• Hypertension is divided into primary and
secondary types
• The patient with severe undiagnosed or
uncontrolled hypertension presents a
contraindication to routine periodontal therapy.
• In general, most authors recommend a delay of
elective therapy when blood pressure exceeds
180/100
Hypertension

• severe hypertension :-
should receive emergency dental treatment
only, to include physician consultation,
administration of anxiolytics agents to
reduce stress and anxiety and analgesics for
pain reduction, and transfer to a more
controlled medical environment for further
management.
Hypertension

• Mild to moderate hypertension:-
Use of conscious sedation is frequently
recommended during dental treatment to
maintain a stable blood pressure.
Use of anxiolytics will reduce stress-
induced release of endogenous epinephrine
Hypertension

• A wide variety of medications are used including
angiotensin converting enzyme (ACE) inhibitors,
α and β adrenergic blockers, calcium channels
blockers and direct vasodilators.
• Side effects of these drugs are common and
numerous, orthostatic hypotension is common,
and is best managed by allowing patients to
accommodate following uprighting from a supine
treatment position
Hypertension

• The patient on β-adrenergic blocking agent
presents a potential modification to periodontal
therapy
• Epinephrine causes α- adrenergic stimulation and
pts on nonselective β - blockers have a dramatic
rise in blood pressure as epinephrine will not
stimulate the normal compensatory β2
induced
vasodilatation
Hypertension

• The final product is a patient with severe
hypertension and bradycardia, resulting in a
dangerous decrease in vascular perfusion and
possible death
• Several authors have therefore concluded
that it is prudent to avoid use of epinephrine
in patients taking non-selective β- blockers.
Hypertension

Ischemic heart disease
• Psychological or physiological stress may
exacerbate ischemic symptoms.
• Therefore, use of a stress reduction protocol
and profound anesthesia are an integral part of
periodontal therapy for these patients
• Myocardial ischemia is usually caused by
decreased coronary blood flow and increased
myocardial oxygen demand

Angina
• There are three types of angina; stable,
unstable and variant (Prinzmetal’s).

• Stable angina is generally caused by
atherosclerotic narrowing of coronary artery
and presents with infrequent episodes of pain,
usually precipitated by physical exertion or
emotional stress
• Periodontal treatment is altered as follows:
Angina

• shorter appointments,
• use of only small amounts of vasoconstrictors
in local anesthetics,
• and possible indications for pre-operative or
intra-operative sedation.
• Supplemental oxygen delivered via a nasal
cannula may help prevent intra-operative
anginal attacks.
Angina

• The drugs of choice for treatment of an acute
anginal attack are 100% oxygen and sublingual
nitroglycerin .
• The patients may be instructed to bring his/her
own nitroglycerin tablets to each appointment
and nitroglycerin tablets may also be placed in
the periodontist’s emergency kit.
Angina

• Unstable angina occurs when there is a
dramatic increase in the frequency or
severity of anginal attacks or when angina
appears at rest
Angina

• Patients with unstable angina are generally not
candidates for elective periodontal therapy, and
consultation with patients’ physician is generally
indicated.
• If emergency dental care is needed, the
periodontist may consult the physician, provide
pre-operative anxiolytics for stress reduction,
Angina

• Closely monitor the patients hemo-dynamic status
and oxygen saturation before and during
treatment,
• administer supplemental oxygen and provide
intravenous line for possible medications and
administer intra-operative sedative agents.
• The use of vasoconstrictors in patients with
unstable angina is considered to be
contraindicated.
Angina

• Variant angina, or prinzmetal’s angina, usually
occurs at rest and is probably caused by
coronary artery spasm.
• Vascular lesions may exist within the coronary
vessels and predispose to anginal attacks.
• The pain is usually relieved by nitroglycerin.
Angina

MYOCARDIAL INFARCTION
• It has been recommended that patients should
not receive routine dental care for at least 6
months after myocardial infarction.
• based on the fact that the peak mortality rate
following myocardial infarction occurs during
the first year, primarily due to the increased
electrical instability of the myocardium post-
infarction

• During this 6-month period, dental treatment is
limited to managing acute dental needs as
continued pain may potentiate hemo-dynamic
alterations or dangerous cardiac arrhythmias.
• After the 6-month period, dental care may be
instituted with relatively short appointments and
a stress reduction protocol.
MYOCARDIAL INFARCTION

ARRHYTHMIAS
• Arrhythmias are often associated with ischemic
heart disease, congestive heart failure,
increased sympathetic tone or reversible
conditions such as hypoxia or electrolyte
imbalance
• Anti-arrhythmic drugs are commonly used, many
of which have side effects such as gingival
overgrowth or xerostomia, which may impact the
dentition as well as the periodontium

• The use of local anesthetic with
vasoconstrictors is contraindicated in such
patients and periodontal treatment may best be
accomplished in a controlled medical setting
with careful cardiac monitoring.
• some arrhythmias are treated by implantable
pacemakers or automatic defibrillators.
ARRHYTHMIAS

• Older pace makers were unipolar and could be
disrupted by equipments that generated
electromagnetic field like ultrasonic units and
electro-cautery instruments.
• Newer pacemakers are bipolar and not affected by
the small electromagnetic fields
ARRHYTHMIAS

• Automatic defibrillators often activate without
warning, which may cause sudden movement and
may endanger the patients in the dental
setting.
• The periodontist must thus be aware and may
use a bite block to stabilize the operating field
ARRHYTHMIAS

Congestive heart failure
• Congestive heart failure 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
• Patients with untreated congestive heart failure
are not candidates for elective dental procedures.
•

• For patients with treated congestive
heart failure the clinician should
consult with the physician regarding
the following

Medications
· Digitalis
a. Watch for a tendency towards
nausea/vomiting.
b. Watch for increased susceptibility to
dysrythmia.
· Diuretics
a. Watch for susceptibility to
orthostatic hypertension.
b. Know the side effects of the diuretic.

· Dicoumarol
a. Prothrombin time should be 1.5
times normal.
· Analgesics
a. May increase prothrombin time.

2. Degree of control of medical problem.
3. Etiology of the disease process.
4. Presence of or potential for, polycythemia,
thrombocytopenia, or leukopenia in compensation
for inadequate oxygen in arterial system.

Other considerations:-
·  Patients may require antibiotic coverage
if WBC counts is low.
·  Potential for bleeding problems.
·  Do not allow the patients to dehydrate.
·  Procedures should be short.
·Do not place the patient in flat or reclining
position.
Supplemental oxygen administration by nasal
cannulas may be used

• · Stress reduction must be emphasized. If the
patient becomes fatigued or dispensed,
treatment should not begin or procedure
should be discontinued at the first opportune
moment.
• · Do not use saline rinses owing to sodium
absorption.
Understand the treatment steps for active
developing CHFwww.indiandentalacademy.com

If the patient develops an attack of Congestive
Heart failure;
• 1. Administer 100% oxygen by full-face mask.
• 2. Position the patient sitting upright.
• 3. Record vital signs.
• 4. Apply rotating tourniquets high on the four
extremities; www.indiandentalacademy.com

• this is a bloodless phlebotomy
procedure that will
• reduce the total circulating blood
volume; release the tourniquets one
at a time for 5 minutes every 30
minutes

• 5. Reduce the patient’s apprehension
through reassurance.
• 6. Call for medical assistance.

Hypertrophic
Cardiomyopathy
• There is no data relative to risks of
exogenous epinephrine administration in
these subjects; however use of caution in
such administration is appropriate.

Valvular heart disease and
infective endocarditis
• The most important effect of valvular heart
disease on periodontal therapy is the need to
prevent infective endocarditis in affected
patients.
• Certain species of bacteria, including many
found in the oral cavity are more likely than
others to cause infective endocarditis like
alpha hemolytic streptococciwww.indiandentalacademy.com

• Organisms often found in the periodontal
pocket are been increasingly implicated, i.e.
Actinobacillus actinomycetemcomitans,
Eikonella corrodens, Capnocytophaga and
lactobacillus species.
• The 1990 AHA guidelines recommend
antibiotic prophylaxis for patients with:

Prosthetic heart valves.
Previous history of infective endocarditis.
Most congenital cardiac malformations.
Rheumatic and other acquired valvular
dysfunction.
Hypertrophic Cardiomyopathy.
Mitral valve prolapse.

Antibiotic prophylaxis is not recommended for;
• Isolated secundum atrial septal defects.
• Surgical repair without residual beyond 6 months
of secundum atrial septal defect, ventricular
septal defect, or patent ductus arteriosus.
• Previous coronary artery, bypass graft surgery.
• Mitral valve prolapse without regurgitation
(valvular).

• Physiologic, functional or innocent heart
murmurs.
• Previous Kawasaki disease without valvular
dysfunction.
Cardiac pacemakers and implanted
defibrillators

Prophylactic antibiotic regime for dental
extractions or periodontal surgery
• 1.Under local anesthesia
• Patients not allergic to penicillin.
• Ø      Adults: Single dose of amoxycillin 3g by mouth
taken 1hr before procedure.
• Ø      Children 5-10: half adult dose.
Ø      Children under 5: quarter the adult dose.
• Patients allergic to penicillin.
• Ø      Adults: single dose of clindamycin 600mg by
mouth taken 1hr before procedure.
• Ø      Children under 5: quarter the adult dose.

• 2. Under General Anesthesia.
• Patients not allergic to penicillin;
• Ø      Adults: amoxycillin 1g by intramuscular or intravenous
injection at induction then 500mg by mouth 6hr later.
• Ø      Children 5-10: half the adult dose.
• Ø      Children under 5: quarter adult dose.
• Or
• Ø      Adults: Amoxycillin 3g by mouth 4hr before induction
then a further 3g as soon as possible after procedure.
• Ø      Children under 5: quarter adult dose.

• Or
• Ø      Adults: Amoxycillin 3g by mouth and probenecid
1g by mouth 4hr before procedure.
• Special risk patients who should be referred to
hospital;
• Patients not allergic to penicillin;
• Ø      Adults: Amoxycillin 1g by intramuscular or
intravenous injection at induction then 500mg by mouth
6hr later plus 120mg gentamicin by intramuscular or
intravenous route at induction.
• Ø      Children 5-10 yrs: half adult dose amoxycillin plus
gentamicin 2 mg/kg.
• Ø      Children under 5 yrs: quarter adult dose
amoxycillin plus gentamicin 2 mg/kg.www.indiandentalacademy.com

• Patients allergic to penicillin;
• Ø      Adults: Vancomycin 1g by slow intravenous
infusion over atleast 100 min followed by gentamicin
120mg intravenously at induction or 15min before
procedure.
• Ø      Children under 10: Vancomycin 20mg/kg
intravenously plus gentamicin 2mg/kg intravenously.
• Or
• Ø      Adults: Clindamycin 300mg intravenously at least
10min at induction or 15min before procedure then oral
or intravenous clindamycin 150mg 6hr later.
• Ø      Children 5-10 yrs: half the adult dose
• Ø      Children under 5 yrs: quarter adult dose.

• Preventive measures to reduce the risk of
infective endocarditis should consist of the
following:
1. Define the susceptible patients
2. Provide oral hygiene instructions
3. Currently recommended antibiotic prophylaxis
regimens should be practiced in all susceptible
patients

The following guidelines should aid in the
development of periodontal treatment plan
for the patients susceptible to IE:
1. All periodontal treatment procedures
(inducing probing) require antibiotic
prophylaxis
2. In cases of delayed healing, it is prudent to
provide additional doses of antibiotics, in
surgery resorbable sutures may be used.

3. Little and Fallace recommend a
concentrated 5-7 day oral hygiene gross
debridement programme with antibiotic
coverage.

Anticoagulant therapy
• Coumarin derivatives such as dicoumarol and warfarin
are Vitamin K inhibitors, which results in depletion of
Vitamin K dependant coagulation factors II, VII and
IX and X.
• Most patients maintain a therapeutic level of
anticoagulation, which results in a PT of 1.5 to 2 times
that of the laboratory control patients

• The prothrombin time (PT) has been expressed as the
ratio of patient’s actual prothrombin time (PT) in seconds
to a control value that varies between laboratories.
• This PT “ratio method” has now been replaced by the
International Normalized Ratio (INR) method

• The INR for patients with normal PT is approximately
1.0.
• The recommended level of anticoagulation for most
patients requiring oral anticoagulant therapy is an INR
of 2.0 to 3.0 but some authors have recommended
values as high as 4.5.
• INR valves of 5.0 or greater indicate a serious risk

• Aspirin and other non-steroidal anti-inflammatory drugs may
dramatically increase the risk of warfarin associated
bleeding.
• Tetracyclines may decrease vitamin K production, interfere
with formation of prothrombin and increase anticoagulation.
• Metronidazole may inhibit coumarin metabolism,
potentiating its anticoagulant effect
• while penicillin may counteract coumarin’s effect.

• Aspirin, an inhibitor of platelet aggregation is often
used to prevent thrombus formation.
• Due to its irreversible binding to platelets, the
effect of aspirin lasts for atleast 4-7 days.
• Aspirin may be discontinued for several days prior
to the dental procedure as periodontal therapy is
expected to induce significant bleeding

Prosthetic joint
replacements

• The primary periodontal treatment considerations
for patients with prosthetic joint replacements
relates to a potential need for antibiotic
prophylaxis prior to therapy
• There is currently no scientific evidence that
prophylactic antibiotics prevent late prosthetic
joint infections, which might occur from transient
bacteremia induced by dental treatment.

• While routine use of prophylactic antibiotics has been
questioned, almost all authors support their use in
“high risk” joint including those with rheumatoid
arthritis, diabetes mellitus, re-operated joints and
those who are on steroids or are immunosuppressed
• From the review of literature it appears that routine
antibiotic prophylaxis for prosthetic joint patients
may not be required before all dental treatment

• Consultation with the patients’ physician is
in the patients’ best interest and may help
in assessing the risk for joint infection
relative to their current dental status and
the type of periodontal treatment planned

Pulmonary diseases

• The periodontal treatment of a patient with
pulmonary disease may require alteration, depending
on the nature and the severity of the respiratory
problem
• The clinician must be aware of the signs and symptoms
of pulmonary disease, such as increased respiratory
rate (the normal rate is 12-16 breaths /min), central
cyanosis, clubbing of the fingers, chronic cough chest
Pulmonary diseases

• Caution should be taken in relation to use of ultrasonic
instrumentation.
• Dried, retained secretions that result in partial
airway obstruction may occur because of their
hydrophilic nature and cause complete obstruction of
the airway if ultrasonics are used.
• Also use of ultrasonic devices may precipitate
bronchospasm owing to foreign body nature of aerosol
droplets.
Pulmonary diseases

• The following management should be used during
periodontal therapy.
• 1. Identify and refer patients with signs and symptoms
of pulmonary disease.
• 2. In patients with known pulmonary disease, consult
with the physician regarding medications and the
degree and severity of pulmonary disease.
• 3. Avoid elicitation of respiratory depression or
distress.
Pulmonary diseases

Minimize the stress of periodontal treatment
Avoid medications that could cause respiratory depression
·Do not give a bilateral mandibular block, which could
cause increased airway obstruction.
· Care should be taken in administering oxygen or nitrous
oxide and use of ultrasonics.
Position the patients to allow for maximum ventilatory
efficiency
Pulmonary diseases

• In patients with history of asthma, make sure
patients medication is available and avoid complex
dental procedures
• Patients with active fungal or bacterial diseases
should not be treated unless the periodontal
procedure is an emergency
Pulmonary diseases

Immunosupression and
Chemotherapy
• Immunosuppressed patients possess impaired host
defenses as a result of an underlying immunodeficiency
or drug administration
• Treatment in these patients should be directed toward
the prevention of oral complications that could be life
threatening.
• The greatest potential for infection occurs during
periods of extreme immunosuppression; therefore
treatment should be consultative and palliative.www.indiandentalacademy.com

Radiation therapy
• The side effects of ionizing radiation include dramatic
perioral changes.
• The extent and severity of dermatitis, mucositis,
xerostomia, dysphagia, gustatory alteration, radiation
caries, vascular changes, trismus, temporomandibular
joint degeneration and periodontal change are
dependant on a myriad of radiation factors;
• the type of radiation used, the fields of irradiation,
the number of ports, the type of tissues in the fields
and the dosage. www.indiandentalacademy.com

• During radiation therapy, patients should receive
weekly fluoride treatment, i.e. a 1-minute acidulated
phosphofluoride rinse (1.23%) followed by 4-minute
stannous fluoride rinse (1.44%) unless these
treatments are irritating to a concurrent mucositis.
• Patients should be instructed to brush daily with
stannous fluoride gel (0.4%).
Radiation therapy

• All remaining teeth should receive thorough
debridement.
• The periodontal ligament has been reported to lose
much of its cellularity and vascularity after radiation
therapy; thus its healing potential is severely
compromised.
• It is important to reinforce the patients’ oral hygiene
and to perform weekly professional plaque removal
Radiation therapy

• An extraction or periodontal disease that progresses
to abscess formation may trigger osteoradionecrosis.
In addition, teeth become brittle
• Post irradiation periodontal care should be limited to
gentle hand instrumentation, oral hygiene
reinforcement and fluoride treatment.
• Ultrasonic instrumentation is not recommended.
Radiation therapy

• Full thickness flap techniques or periodontal
procedures that could expose osseous structures
should not be performed, especially on the
mandible.
• Periodontal care should remain conservative for
the duration of the patients’ life.
Radiation therapy

Endocrine disorders

Diabetes
• The periodontist is particularly concerned with long-
term metabolic control in diabetic patients
• It is generally agreed that the uncontrolled or the
poorly controlled diabetic patients should not receive
elective dental treatment until metabolic control is
established
• The well-controlled diabetic patient can usually be
treated in a manner similar to non-diabetic patients.

• Since stress may result in endogenous epinephrine
release with resultant increase in blood glucose,
appointments should be as stress free as possible.
• Profound anesthesia is a priority and conscious
sedation may be indicated in some cases.
• For most procedures, patients may take their normal
dose insulin or oral hypoglycemic agent as long as they
also continue their normal diet.
Diabetes

• Antibiotics are not necessary for routine periodontal
therapy in, most diabetic patients but may be considered
in the presence of overt infections and before surgical
treatment.
• The anticollagenolytic activity of tetracyclines has proven
effective in decreasing host collagenase activity in
diabetic individuals and these agents offer hope for
future host response modulation.
Diabetes

• Hypoglycemia is the most common medical emergency
likely to be encountered in the periodontal office
during treatment of diabetic patients
• The classic signs and symptoms of hypoglycemia such
as tachycardia, shakiness, agitation and sweating may
not be present immediately prior to a severe
hypoglycemic reaction
Diabetic emergencies

• untreated hypoglycemia may lead to seizures, coma and
death.
• The periodontist should have oral carbohydrates readily
available such as juice, candy, and tubes of cake icing or
soft drinks
• Importantly, periodontal therapy may alter the patient’s
ability to eat during the post-operative period, predisposing
to hypoglycemia

• Hyperglycemia crisis is far less common emergency
and is limited to the uncontrolled IDDM patient.
• It occurs more slowly after a prolonged elevation of
blood glucose ketoacids accumulate, causing
metabolic acidosis, which may lead to coma if
untreated.

• When providing periodontal therapy for the
diabetic patient, an awareness of the onset,
peak of action and duration of action of the
oral hypoglycemic agent or insulin regimen,
which the patient is taking is needed.
• It is generally best to plan periodontal
therapy outside the range of peak drug
activity.

Periodontal management
• Several guidelines should be followed to
ensure diabetes control
1. The clinician should make certain that
prescribed insulin has been taken followed
by a meal. Morning appointments are
preferable.
2. post-operative insulin doses should be
altered

Periodontal management
3. Tissues should be handled as atraumatically as possible.
The anesthetic should contain epinephrine not greater
than 1:100,000. Endogenous epinephrine release may
increase insulin requirements.
4. Diet recommendations should be made to enable the
patient to maintain a proper glucose balance.
5. Antibiotic prophylaxis is recommended if therapy is
extensive
6. Frequent recall appointments and fastidious home oral
care should be stressed.

Insulin
Degree of
Dietary
Short-acting Intermediate Long-acting
Restriction Regular (2-
4hours)
NHP (6-12
hours)
PZI (14-24
hours)
Semilente (2-4
hours)
Lente (6-12
hours)
Ultralente (18-24
hrs)
Minimal None None None
Moderate Stop A.M. Dose ½ a.m. dose med
given, then other
½ dose
½ a.m. dose
Severe Stop A.M. Dose Stop A.M. Dose,
followed by
surgery in 2 hrs
Stop A.M. Dose

Thyroid disorders
• Periodontal therapy requires minimal alterations
in 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
• Hypothyroid patients require careful administration of
sedatives and narcotics because of their diminished inability
to tolerate drugs
Thyroid disorders

Parathyroid disorders
• if hypercalcaemia or hypocalcaemia is present, the
patient may be more prone to cardiac arrhythmias
• Therefore, the dental practitioner must be attuned
to the oral and dental changes that occur with hyper
of hypoparathyroidism to provide astute detection
and referral.

ADRENAL
INSUFFICIENCY
• The periodontist must be aware of the clinical
manifestations and ways of preventing adrenal insufficiency
in patients with a history of Addison’s disease or a patient
with normal adrenal cortices who has been given exogenous
gluocorticosteroids
• adrenal insufficiency is seen in persons who have received
steroid therapy, adrenal suppression occurs as a result of
adreno cortical atrophywww.indiandentalacademy.com

• For the patients who are currently receiving steroid
therapy, the need for corticosteroid prophylaxis
depends on the drug used.
• Most patients with Addison’s disease receive a daily
oral dose of 25.0 to 375 mg of cortisone (equalent to
5.0-75 mg of prednisolone).
• This replaces the normal output of the adrenal
ADRENAL
INSUFFICIENCY

• Little and Falace recommend the following:
• 1. Patients taking low dose (less than 20mg) or high dose
(more than 20 mg) cortisol daily for less than 1 month or
patients on alternate day therapy: No supplementation is
necessary.
• 2. For patients taking large doses (more than 20 mg cortisol
daily) requiring extensive and stressful dental procedures;
double or triple the normal maintenance dose the morning of
the procedure and resume normal dose.
• 3.Patients on topical steroids; generally supplementation is
not required unless there is a prolonged treatment of
extensive areas.
ADRENAL
INSUFFICIENCY

• Malamed’s “rule of twos” –20mg of cortisone or its
equivalent per day, orally or parenterally, given
continuously over 2 weeks or longer and within 2
years of dental therapy should alert the clinician to
suspect adrenal suppression
• The full regeneration of cortical function may occur
within 9-12 months.
ADRENAL
INSUFFICIENCY

• Treatment of the patient in an acute adrenal
insufficiency crisis is as follows:
• 1. Terminate periodontal therapy.
• 2. Summon medical assistance.
• 3. Monitor vital signs.
• 4. Give oxygen.
• 5. Place the patients in a supine position.
• 6.Administer 100mg of hydrocortisone sodium
succinate intravenously over 30 seconds or
ADRENAL
INSUFFICIENCY

• Manifestations of acute adrenal insufficiency
Æ     Mental confusion, fatigue and weakness
Æ     Nausea and/or vomiting
Æ     Hypertension
Æ     Syncope
Æ     Intense abdominal, lower back, and/or leg pain
Æ     Loss of consciousness
Æ     Coma
ADRENAL
INSUFFICIENCY

Pregnancy
• The aim of periodontal therapy for the
pregnant patient is to minimize the potential
exaggerated inflammatory response related
to pregnancy associated hormonal alterations.
• Meticulous plaque control, scaling, root
planning and polishing should be the only non-
emergency periodontal procedures performed

• The second trimester - safest time.
• However, long, stressful appointments, as well as
periodontal surgical procedures, should be delayed until
the postpartum period
• supine hypotensive syndrome; uterine pressure on the
inferior vena cava.
• A fully reclined position should be avoided if possible
Pregnancy

• No medications should be prescribed or
radiographs taken unless the situation is an
emergency.
• The patient’s obstetrician should be consulted
as to whether a drug could cross the placenta
or cause fetal respiratory depression
Pregnancy

Coagulation disorders

• Periodontal care for patients on anti-coagulant
therapy should be altered depending on the
medication used to reduce intra-vascular clotting
• heparin, bishydroxycoumarin (dicoumarol),
warfarin sodium (coumadin), phenindone
derivatives, cylocumarol ethyl biscounmacetate
and aspirin.

• Patients on Warfarin therapy demonstrate
an inhibition of prothrombin or of Vitamin
K dependent factors (factors II, VII, IX
and X).
• It is important to note the duration of
action of warfarin is a minimum of 6 days.
• The periodontal treatment should be
altered as follows:

• 1. Consult the patient’s physician to
determine the nature of the underlying
problem and the degree of required
anticoagulation (The general therapeutic
range is a prothrombin time between 1.5
and 3.0 times normal).

2. Periodontal scaling, surgery and extraction require a
prothrombin time less than 1.5 times normal.
• Physician should be consulted regarding
discontinuation of dicoumarol or reduction of dosage
till the desired prothrombin time is achieved.
• Changes in prothrombin time will not be apparent until
2-3 days after changing dosages.
• A prothrombin time measurement is required on the
day of the procedure. If it is greater than 1.5 times,
cancel the procedure.

• After scaling and curettage, do not dismiss the patient
until bleeding has stopped
• 1. It is preferable to perform segments of the mouth
which may be treated if following precautions are
followed;
Minimize trauma.
Prophylactic antibiotics are recommended to
prevent post-operative infection that may lead to
bleeding.
Use pressure homeostasis.
Attempt to gain closure as close to primary as

• Prior to periodontal pack placement, bleeding should be
stopped by packing cotton pellets inter-proximally and by
applying facial and lingual. pressure with a gauze sponge
• 2. Do not perform scaling or periodontal surgery if the
patient has an acute infection.
• 3. The patient should return in 3-5 days to determine
whether healing is normal. If so, the physician may
resume the patient’s anticoagulant therapy.

• Physicians generally have patients stop
aspirin 7-14 days prior to periodontal
surgery and they measure the bleeding/
platelet counts several times on the day of
the procedure.
• Aspirin should not be prescribed for
patients who are receiving anticoagulant
therapy.

Hereditary Hemophilia
• hemophilia A, hemophilia B and von Willebrand’s
disease.
• The periodontist should consult the patients’ physician
before the dental treatment to determine the risk of
bleeding and treatment modifications required.
• To prevent hemorrhage, at least 30% of factor VIII
levels are requiredwww.indiandentalacademy.com

• Hemophilia B or Christmas disease, results from a
deficiency of factor IX.
• Surgical therapy requires a factors IX level of 30% to
50% and is usually achieved by administration of
purified prothrombin complex concentrates or factors
IX concentrates.

• Von Willebrand’s disease occurs due to
deficiency of von Willebrand’s factor,
which mediates the adhesion of platelets
to the injured vessel wall and is required
for primary homeostasis.

Guidelines
• 1. Consult with the hematologist.
• 2. Hospitalize the patient for surgical procedure.
• 3. Replace coagulation factor.
• 4. Surgical technique: supply antibiotic coverage; perform as
atraumatic procedure as possible, removing all sharp osseous
spicules, treating the soft tissues gingerly and carefully
removing all granulation tissue, obtain maximum
approximation of wound edges, avoiding suture strangulation
and use of resorbable sutures. Topical haemostatic agents
may be applied.

Post-operative follow up: bleeding due to clot
breakdown occurs 3-4 days after surgery, and
pressure hemostasis should be performed only
if adequate replacement factors available to
prevent subcutaneous bleeding from occurring.
Oral hygiene and 3 month maintenance check-
ups are pre-requisites. No aspirin products
should be prescribed
Guidelines

Thrombocytopenic purpura
• Bleeding that is due to a reduced number of
platelets (thrombocytopenia) may be seen
with idiopathic thrombocytopenic purpuras,
radiation therapy, myelosupressive drug
therapy, leukemia or infections.
• Periodontal therapy should be directed
towards reducing local irritants to avoid the
need for more aggressive periodontal
therapy.

• Physician diagnosis and treatment of the platelet
disorder
• Oral hygiene instruction if the number of platelets
is severely decreased, gentle oral hygiene products
and techniques should be used
• Prophylactic treatment of potential abscesses
• No surgical procedures are indicated until the
platelet count is at least 80,000 cells/ mm3
Guidelines

Guidelines
• Surgical procedure can be performed as atraumatic
as possible.
• Stents or thrombin soaked cotton pellets placed
inter-proximally with periodontal dressing should
be utilized to aid in clot formation
• Gentle hydrogen peroxide mouthwashes may aid in
controlling gingival hemorrhage.
• Note that scaling and root planning may be
performed at low platelet levels carefully (30,000
cells/mm3
). www.indiandentalacademy.com

Non-thrombocytopenic
purpuras
• Non-thrombocytopenic purpuras occur as
result of either vascular wall fragility or
platelet dysfunction (thrombasthenia).
• hypersensitivity reactions, chemicals
(phenacetin and aspirin), dysproteinemia,etc.
• uremia, Glanzmann’s disease, aspirin ingestion
and von Willebrand’s disease.

• Treatment consists primary of direct
pressure applied for atleast 15 minutes.
• This initial pressure should control the
bleeding unless coagulation times are
abnormal or if re-injury occurs .
• Surgical therapy should be avoided unless
the qualitative and quantitative platelet
problems are solved
Non-thrombocytopenic
purpuras

BLOOD DYSCRASIAS

LEUKEMIA
• Enhanced susceptibility to infections and
increased bleeding tendency.
• The treatment plan for these patients is as
follows

• Refer the patient for medical evaluation
and treatment
• Prior to chemotherapy, a complete
periodontal plan should be developed with a
physician
• Monitor hematological laboratory values daily
bleeding time, coagulation time, prothrombin
time, and platelet count.
• Administer antibiotic coverage before any
periodontal treatment
LEUKEMIA

LEUKEMIA
• Extract all hopeless, nonmaintainable, or potentially
infectious teeth, a minimum of 10 days before the
initiation of chemotherapy, if systemic conditions
allow
• Periodontal debridement (scaling and root planing)
should be performed and thorough oral hygiene
instructions should be given
• Twice daily rinsing with 0.12% Chlorhexidine
gluconate is recommended after oral hygiene
procedures

• During the acute phases of leukemia,
patients should receive only emergency
periodontal care.
• In bleeding tendencies,…3% hydrogen
peroxide, pressure for 15-20 minutes
• Treatment should be designed to make the
patient comfortable and to eliminate any
source of systemic toxicity
LEUKEMIA

• Oral moniliasis is common in the leukemic
patient and can be treated with nystatin
suspensions (100,000 U/ml) or vaginal
suppositories.
• In patients with chronic leukemia periodontal
surgery should be avoided if possible.
LEUKEMIA

AGRANULOCYTOSIS
• Treatment should be conservative
• Oral hygiene instruction should include use of
chlorhexidine mouthrinses twice daily
• Scaling and root planing should be performed
carefully under antibiotic protection
• Avoid drugs causing bone marrow supression

KIDNEY AND LIVER
DISEASES

Chronic renal disease and
hemodialysis
• Azotemia, an increase in blood urea nitrogen (BUN),
may be associated with adverse clinical signs and
symptoms to produce uremia.
• Arterial hypotension is the most common
complication of end stage renal disease.
• Congestive heart failure and pulmonary
hypertensions are also seen.
• Cardiac arrhythmia resulting from electrolyte
imbalance is a serious complication in patients with
renal failure

• Bleeding disorders can result from reduced
platelet adhesiveness.
• Immune reactivity is decreased during uremia.
• Management remains a lot controversial and
frankly, DENTAL PROBLEMS REALLY SEEMS
TOO MINOR FOR TREATMENT.
hemodialysis

• Many authors have suggested the use of
prophylactic antibiotics.
• early detection and aggressive management of
infections are essential.
• Thorough examination, prophylaxis, scaling and root
planning and oral hygiene instructions to optimize
periodontal health are usually indicated, thereby
reducing the risk for infection or transient
bacteremias
hemodialysis

hemodialysis
• Dialysis patients may form calculus more rapidly
than healthy individuals possibility due to high
salivary urea and phosphate levels.
• Patients on hemodialysis for end stage renal
disease are at increased risk for hemorrhage
during periodontal therapy, anticoagulation with
heparin, trauma to the platelets, resulting in
thrombocytopenia.

• Hence, patients should be scheduled for
periodontal procedure on the day after
dialysis, so the effects of heparin are no
longer present and uremic metabolites have
been removed.
hemodialysis

• Many drugs should be avoided completely while
others require alteration of dosage.
• Local anesthesia such as lidocaine is generally
safe.
• Antibiotics considered safe include amoxycillin,
erythromycin and clindamycin.
hemodialysis

• Tetracyclines and aminoglycosides should be
avoided.
• Analgesics containing aspirin and phenacetin
should be used very cautiously due to potential
anticoagulant activity and nephrotoxicity,
respectively
hemodialysis

CHRONIC AMBULATORY
PERITONEAL DISEASE (CAPD)
• Dental procedures and subsequent bacteremia
do not generally place the CAPD patient at risk
for infection.
• Some practitioners may however, prefer to use
antibiotics prior to invasive surgical procedures

PERIODONTAL IMPLICATIONS
FOR KIDNEY DISEASE
• Consult the patient’s physician
• Monitor blood pressure (Patients in end stage renal
failure are usually hypertensive).
• Check laboratory values, partial thromboplastin
time, prothrombin time, bleeding time and platelet
count, hematocrit blood urea nitrogen and serum
creatinine.
• Eliminate areas of oral infectionwww.indiandentalacademy.com

FOR KIDNEY DISEASE
• Nephrotoxic drugs and drugs metabolized in kidney
should be avoided. Acetaminophen and
acetylsalicylic may be used with caution
• Screen for hepatitis surface antigen (Hbs Ag) and
antibody to hepatitis B prior to treatment.
• Provide antibiotic prophylaxiswww.indiandentalacademy.com

• Prevent hypoxia
• Perform treatment on the day after
dialysis
• Establish a long term maintenance system
• Refer the patient to physician, if uremic
problems arise
FOR KIDNEY DISEASE

LIVER DISEASE
• End stage liver disease presents several challenges
to the periodontist and these patients are
generally treated with prior consultation with the
physician.
• The liver is the site of production for almost all
clotting factors; thus, excessive bleeding may
occur with invasive dental procedures.
• the liver’s ability to metabolize drugs may be
severely limited www.indiandentalacademy.com

• Drugs commonly used in periodontics including
local anesthetics, narcotics, acetaminophen,
benzodiazepines and numerous antibiotics are
all metabolized in the liver
• the liver patient may have an increased risk of
infection
• Prophylactic antibiotics may be prescribed
LIVER DISEASE

• Protein in the gut is normally converted to ammonia by the
gut flora, with subsequent conversion of ammonia to inert
urea in the liver.
• In liver failure, excess levels of ammonia accumulate in the
blood and may result in hepatic encephalopathy and coma.
• Swallowing of blood during and after periodontal therapy
should be minimized, since blood proteins will not be
metabolized properly.
• Close flap adaptation and dressing are essential in this
regard
LIVER DISEASE

ORGAN
TRANSPLANTATION
• After transplantation, the patient will remain on
one or more immunosuppressive agents for the rest
of his or her life to prevent organ graft rejection.
• The most common drugs indicate cyclosporin,
azathioprine and steroids
• Azathioprine may cause anemia, leukopenia and
thrombocytopenia secondary to bone marrow
suppression, placing the patient at risk of infection
and bleeding www.indiandentalacademy.com

ORGAN
TRANSPLANTATION
• Long term corticosteroid use is associated
with hypertension, diabetes, mellitus, impaired
healing, and increased potential for infection
• Inherent in all these agents is the increased
risk of infection with a variety of bacteria,
fungi and viruses

• The most common drugs indicate cyclosporin,
azathioprine and steroids
• Blood pressure should be taken at every visit,
since cyclosporin may cause severe renal
damage with secondary hypertension
• Azathioprine may cause anemia, leukopenia and
thrombocytopenia secondary to bone marrow
suppression, placing the patient at risk of
infection and bleeding
ORGAN
TRANSPLANTATION

ORGAN
TRANSPLANTATION
• Immunosuppressive therapy in transplant patients
may reduce the clinical signs of periodontal
inflammation
• Many patients are on oral anticoagulation therapy
while others are taking anti-platelet therapy with
aspirin or dipyridamole

CANCER
• Both chemotherapy and radiation therapy produce
a wide range of oral complications
• The periodontist must consider the clinical and
histo-pathologic diagnosis and staging of the lesion,
goals of cancer therapy and prognosis for a use,
type and dose of cancer therapy to be
administered, size and location of radiation fields
radiation source and immediacy of treatment.

• Chlorhexidine mouth rinses have been shown by
several authors to decrease the severity of
chemotherapy-induced mucositis.
• High dose radiation therapy results in
hypovascularity of irradiated tissues with
reduction in wound healing capacity
• Tooth extraction after radiation treatment
involves a high risk of developing ORN and open
surgical flap procedures are generally avoided
after radiation
CANCER

• Periodontal therapy is mainly directed towards
prevention, identification and treatment of
infection and plays an important role in
maintaining systemic health and improving quality
of life for the patient.
CANCER

DISORDERS ASSOCIATED WITH EARLY
PERIODONTAL DESTRUCTION
• Diseases known to be associated with
periodontitis before puberty include Papillion
Lefevre Syndrome (PLS), hypophosphatasia,
neutropenias, leukemia, histiocytosis, early
onset type I diabetes and acrodynia.

HYPOPHOSPHATASIA
• Hypophosphatasia is a congenital disease characterized
by deficiency of serum alkaline phosphatase, increased
urinary excretion of phosphoethanolamine and defective
bone and tooth mineralization, resulting in cementum
hypophosphatasia or aplasia and premature exfoliation of
primary teeth.
• Periodontal treatment should be planned by selected
extraction, root planning and adequate scaling and most
of these patients respond well to therapy.

PAPILLION-LEFEVRE
SYNDROME
• Papillion Lefevre syndrome (PLS) begins in
childhood and is characterized by palmar-
plantar hyperkeratosis and rapid
periodontal destruction of both the
primary and permanent dentitions.
• Patients also have intracranial
calcifications, retardation of somatic
development and increased susceptibility to
infections.. www.indiandentalacademy.com

• Severe gingival inflammation is present and
alveolar bone resorption occurs in the same order
as tooth eruption.
• PLS patients frequently have altered PMN
chemotaxis, phagocytosis and superoxide
production and sub-gingival sites often contain
high levels of actinobacillus
actinomycetemcomitans
PAPILLION-LEFEVRE
SYNDROME

• Conventional periodontal treatment including
non-surgical and surgical therapy combined with
antibiotics and anti-microbial viruses have been
unsuccessful for most patients with PLS.
• Another approach to the management of PLS
patient, the use of oral retinoid therapy, has
been reported.
PAPILLION-LEFEVRE
SYNDROME

• Nazzaro et al treated three PLS patients having
gingival inflammation and bone loss with synthetic
retinoid acitretin for 16 months.
• After 3 months, gingival inflammation was
markedly reduced while teeth with initially severe
bone loss exfoliated.
• At 16 months teeth that had erupted during
treatment were free of inflammation and bone
levels were stable.
PAPILLION-LEFEVRE
SYNDROME

INFECTIOUS DISEASES
• HUMAN IMMUNODEFICIENCY VIRUS
• The oral lesions associated with HIV disease
include fungal, viral and bacterial infections,
neoplastic disorders, autoimmune lesions, and
other less specific lesions.
• Candidiasis, Erythematous candidiasis, Angular
chelitis, Chronic hyperplastic candidiasis

HUMAN IMMUNODEFICIENCY
VIRUS
• Viral Infections include; Varicella zoster and
recurrent herpes simplex virus infections
• Epstein-Barr virus and Cytomegalovirus
infection are common.
• Kaposi's sarcoma, an endothelial cell malignant
neoplasm is the most common neoplasia
associated with HIV infection

• Necrotizing ulcerative gingivitis (NUG)
and Necrotizing ulcerative periodontitis
(NUP) are commonly seen in patients
with HIV infection.
HUMAN
IMMUNODEFICIENCY VIRUS

MEDICATIONS ASSOCIATED
WITH GINGIVAL OVERGROWTH
• ANTICONVULSANTS
• CYCLOSPORIN
• CALCIUM CHANNEL BLOCKING AGENTS

SUMMARY &
CONCLUSION

References
• Annals of Periodontology 1996.
• Clinical Periodontology – Carranza
• Clinical periodontology and Implant
dentistry – Jan Lindhe
• Antibiotics in Periodontics – Kornman.
• Perio 2000 Special category Patients.

Periodontal management of medically compromised paients/dental courses

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