1) Periodontal treatment for medically compromised patients requires consultation with physicians and modification based on the patient's condition. 2) Important medical conditions discussed include bleeding disorders, renal disease, liver disease, pulmonary disease, pregnancy, and infectious diseases. 3) For each condition, the document outlines oral manifestations, considerations for treatment, and precautions to minimize health risks.

1. DEPARTMENTOF PERIoDONTics
TOPIC: PERIODONTAL TREATMENT IN
MEDICALLY COMPROMISED AND GEREATRIC
PATIENTS
PRESENTED BY,
GOPIKA SUKUMARAN(INTERN)

2. content
• Introduction
• Types
• Management
• Conclusion
• Reference

3. INTRODUCTION
• 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

4. TYPES
Hemorrhagic disorder
Renal diseases
Liver diseases
Pulmonary dsisease
Infectious diseases
Pregnancy
Medications and cancer therapies

5. Hemorrhagic disorders…..!!!!

6. • Patients with a history of bleeding
problems caused by the disease or
drugs should be managed to minimize
risks of hemorrhage.
• Identification of these patients can be
done by the following methods :
1) Health history
2) Clinical examination
3) Laboratory tests

7. HEMORRHAGIC DISORDERS
ETIOLOGY
• Nonthrombocytopenic purpuras
• Thrombocytopenic purpuras
• Disorders of coagulation
THROMBOCYTOPENIC PURPURA
• Primary

8. THROMBOCYTIC PURPURA

9. NON-THROMBOCYTIC PURPURA
• Vascular wall alteration : infection, chemical, allergy
• Disorder of platelet function
• Genetic defects
• Aspirin, NSAIDs broad-spectrum antibiotic Ampicillin,
Penicillin, Gentamycin, Vancomycin
• Autoimmune disease

10. NON THROMBOCYTIC PURPURA

11. DISORDERS OF COAGULATION
• Inherited : Hemophilia A Christmas disease von Willebrand's Disease
• Acquired : Liver disease Vitamin K deficiency
• Anticoagulation drugs (heparin, coumarin)
• Anemia

13. Evaluation of bleeding disorders
• Take history
• Physical examination
• Screening clinical laboratory tests
• Observation of excessive bleeding following a surgical procedure

14. HISTORY
• Bleeding problems in relatives
• Bleeding problems following operations and tooth extractions
,trauma
• Use of drugs for prevention of coagulation or pain
• Spontaneous bleeding from nose mouth etc..

15. PHYSICAL EXAMINATION
• Jaundice
• Petechiae ：< 0.2 cm
• Purpura ：0.2 cm-1 cm
• Eccymoses ：> 1 cm
• Oral ulcer
• Hyperplasia of gingiva

16. Screening laboratory tests
• Platelet count
• BT (Bleeding Time)
• PT (Prothrombin Time)
• aPTT (active Partial Thrombopastin Time)
• TT (Thrombin Time)

18. ANTICOAGULANTMEDICATION
COUMARIN (VIT K ANATAGONIST)
• Inhibit Vit K action (Factor II,VII,IX,X)
• Duration haft-life 40hrs
• Monitored by PT : INR 1.5-2.5
• Alteration of coumar dosage ( 2-3 days )

19. HEPARIN
• Complex inhibited ( IXa, Xa, XIa, XIIa )
• Used in deep vein thrombosis , renal dialysis
• Rapid onset, Duration 4-6hrs ( given IV )
• Monitoring by aPTT: 50-65 sec
• Discontinue 6 hrs before surgery then reinstituting therapy 6-12hrs post – op
• And protamine sulfate can reverse the effect

20. Aspirin (antiplatelet)
• Inhibit cycloxygenase, TxA2 formation
• Impairs platelet function
• Tests-BT, aPTT
• If tests are abnormal,physcian should be consulted before dental surgery
• Stop aspirin for 5 days, substitute alternative drug in consultation with MD

21. Thrombocytopenia
• Disease in number of circulation platelets
• Idiopathic thrombocytopenia, secondary thrombocytopenia
• TX : is none indicated unless platelets<20000/mm3, or
excessive bleeding
• TX : Steroid, platelet transfusion

22. THROMBOCYTOPENIA

23. VONWILLEBRANDISDISEASE
• Gene mutation on Von Willebrand’s factor; most common Inherited disease
in America ( 1% )
 Type I : 70%-80%, partial loss on quantity
 Type II : poor on quality
 Type III : severe loss on quantity, inactive to DDAVP

25. HEMOPHILIA
• Sex-linked recessive trait
• Prolong aPTT, normal BT,PT
• Severity of disorder : severe<1%, moderate 1-5%,
mild 6-30%
• TX : Replacement factors, antifibrinilytic agents, steroids

26. HEMOPHILIA

27. HEMOPHILIA-DENTAL MANAGEMENT
• Preventive dentistry
1. Tooth brushing, flossing, rubber cup prophylaxis &topical fluoride,
supragingival scaling without prior replacement therapy
• Pain control
1. Block anesthesia: factor level>50%
2. Avoid aspirin, NSAIDs
• Periodontal therapy
1. No contraindication of probing and supragingival scaling

28. DENTALMANAGEMENTOF BLEEDINGDISORDERS
Replacement therapy :
1. Platelet concentrate : thrombocytopenia ( 1 unit= 30,000/ uL enough for 1 day )
2. Fresh frozen plasma : liver disease, Hemophilia B, vWD type III
3. Factor VIII,IX concentrate : Hemophilia A
( 1 unit /kg can add 2%, so 50 unit /kg add 100% )
4. Factor IX concentrate : Hemophilia B
5. DDAVP : Hemophilia A, vWD type I,II

29. Antifibrinolytic therapy:
1. E-aminocaproic acid (EACA)
2. Tranexamic acid (AMCA, Transamin)

32. RENAL
DISEASES

33. CAUSESOF RENAL FAILURE
• Glomerulonephritis
• Kidney cystic disease
• Renovascular disease
• Drug nephropathy
• Obstructive uropathy
• Hypertension

34. Renal failure result in:
• Severe electrolyte imbalances
• Cardiac arrhythmias
• Pulmonary congestion
• Congestive heart failure
• Prolonged bleeding

36. ORAL MANIFESTATIONSOF RENALDISEASE
• Halitosis
• Altered taste sensation
• Xerostomia
• Gingivitis
• Enamel hypoplasia
• Infections

38. TREATMENT
• Consult the patient’s physician
• Monitor Blood Pressure
(patients in end stage renal failure are usually hypertensive)
• Check laboratory values: PTT, PT, bleeding time, platelet count, blood
urea nitrogen and serum creatinine
• Frequent recall and appointments should be scheduled
• Drugs that are nephrotoxic or metabolized by the kidney should not
be given (eg: tetracycline, aminoglycoside antibiotics)
• Acetaminophen used for analgesia, diazepam for sedation.

39. • The patients who are receiving dialysis requires modification in treatment
planning
MODES OF DIALYSIS:
Intermittent Periodontal Dialysis (IPD)
Chronic ambulatory peritoneal dialysis (CAPD)
Hemodialysis

43. RECOMMENDATIONFOR HEMODIALYSIS
• Screen for Hepatitis B and C antigens antibody before any treatment
• Provide antibiotic prophylaxis
• Periodontal treatment should be provided on the day after dialysis
due to the effects of heparinization
• BP reading should be taken from the other arm.

44. LIVER DISEASES

45. INTRODUCTION
• Liver is the site of production for most of the clotting factors
• Excessive bleeding during or after periodontal treatment may occur
in patients with severe liver disease
• Many drugs are metabolized in the liver. So the liver disease alters
the normal drug metabolism.

46. CAUSESOF LIVER DISEASES
• Drug toxicity
• Cirrhosis
• Viral infections (hepatitis B and C)
• Neoplasms
• Biliary tract disorders

48. ORAL MANIFESTATIONSOF LIVER DISEASE
• Candidiasis
• Angular cheilitis
• Atropic glossitis
• Petechiae
• Lichen planus

49. TREATMENT
• Consultation with the physician concerning current stage of disease,
risk for bleeding, potential drugs to be prescribed during treatment
And required alterations to periodontal therapy.
• Screening for hepatitis B and C
• Check laboratory values for PT and PTT

50. PULMONARY DISEASES

51. INTRODUCTION
• Pulmonary diseases range from obstructive lung diseases
(eg: asthma, emphysema, bronchitis) to restrictive ventilatory
disorders that could
• interfere with effective ventilation
• Acute respiratory distress may be caused by slight airway obstruction
or depression of respiratory function.
• Patients with acute respiratory distress might alter their position in
attempts to improve their ventilatory efficiency
• sed by muscle weakness,scarring,obesity

52. ORAL MANIFESTATIONS:
• Xerostomia
• Gingivitis
• Halitosis
• Candidiasis

53. TREATMENT
• Increased respiratory rate, cyanosis, clubbing of the fingers, chronic
cough, chest pain, hemoptysis, dyspnea and wheezing- need
consultation from the physician and medication details.
Avoid elicitation of respiratory depression or distress.
• Minimize the stress of periodontal appointment
• Patient with emphysema should be treated in the aftenoon
• Avoid medications that cause respiratory depression
(eg: narcotics, sedatives or general anesthetics)

54. • Avoid bilateral mandibular block anesthesia which could cause
increased airway obstruction.
• Position the patient to allow maximal ventilator efficiency
• Keep the patients throat clear and avoid excess periodontal packing
• Do not use equipments that produce aerosol.
eg: ultrasonic scalers
• For asthmatic patient – inhaler should be available
• Infectious patients should not be treated unless the periodontal
procedure is emergency

55. PREGNANCY

56. ORAL MANIFESTATIONS
• Gingivitis
• Pregnancy tumour
• Tooth mobility
• Tooth surface loss

57. AIMOF PERIODONTAL THERAPY
• To minimize the potential inflammatory response related to
pregnancy associated hormonal alterations.
• Plaque control, scaling, root planning, and polishing can be done.
• The second trimester is the safest time to perform treatment.
• The supine position of patient cause obstruction of venacava and
aorta leads to supinehypotensive syndrome.
• Patient should be placed on her left side by elevating the right hip
during treatment.

59. • Appointments should be short and the patient should be allowed to
change the position frequently.
• No medications should be prescribed ideally
• Safer drugs:
Lidocaine, prilocaine, analgesics: paracetamol, antibiotics: amoxicillin

60. INFECTIOUS DISEASES

61. TYPES
• Hepatitis
• HIV
• Tuberculosis

62. HEPATITIS
• Hepatitis A and E are both self-limiting infections with no associated
chronic liver disease.
• Hepatitis B infection may result in chronic liver disease in about 5
10% of infected individuals
• Hepatitis D requires the presence of HBV for its survival
• Hepatitis C is the most serious of all viral hepatitis infection because
of its high chronic infection rate. Only 15% of patients recover
completely; 85% develop chronic HCV infection, which dramatically
increases the risk for cirrhosis, liver Ca. and failure.

63. • Hepatitis G appears as a co-infection with hepatitis A,B or C
• TTV is often present in patients with hepatitis and chronic liver
disease and it is also associated with HCV.

64. GUIDELINESFOR TREATINGHEPATITIS PATIENT
• If the disease is active – do not provide periodontal treatment unless
emergency.
• Patients with history of hepatitis consultation from physician
required
• For recovered HAV or HEV patients perform routine periodontal care.
• Patients with anti HBs positive and HBsAg negative may be treated
routinely.

66. PRECAUTIONS TO BE USED
• If bleeding occurs during or after treatment- measure PT nd Bleeding
time.
• Usage of masks,gloves,eye shields,disposable gowns,disposable
covers,headrest covers,covering light handles,drawer handles and
bracket trays is also essential.
• After treatment all disposable items should be disposed.
• Minimize aerosol production by not using ultrasonic
instrumentation,air syringe or high speed handpieces.

67. • Prerinsing with chlorhexidine gluconate is highly recommended.
• All equipment should be scrubbed and sterilised
• If a percutaneous or permucosal injury occurs during treatment
of a HBV carrier , CDC guidelines recommend administration of
Hepatitis B immune globulin (HBIG)

68. hiv
PERIODONTAL TREATMENT FOR HIV PATIENTS
• HEALTH STATUS
• INFECTION CONTROL MEASURES
• SUPPORTIVE PERIODONTAL THERAPY

69. 1.Healthstatus
• Should be determined from the health history, physical evaluation
and consultation with the patient’s physician.
• Treatment decisions will vary depending on the patient’s state of
health.
• Information should be obtained regarding-
CD4+ T4 lymphocyte level
current viral load
difference from previous counts and load

71. 2. INFECTIONCONTROL MEASURES

72. GOALS OF THERAPY
• Restoration and maintenance of oral health.
• Treatment should be directed toward control of HIV- associated
mucosal diseases such as chronic candidiasis and recurrent oral
ulcerations.
• Effective oral hygiene maintenance
• Conservative, nonsurgical periodontal therapy should be a treatment
option for virtually all HIV patients.
• NUP & NUS can be severely destructive to periodontal structures and
should be treated appropriately.

73. 3. SUPPORTIVE PERIODONTAL THERAPY
• Patient should be encouraged to maintain meticulous personal oral
hygiene.
• Recall visits should be conducted at short intervals (2 to 3 months)
• Systemic antibiotic therapy should be administered with caution
• Blood and other medical laboratory tests may be required to
monitor
• The patients overall health status and consultation and coordination
with the patient’s physician are necessary

75. TUBERCULOSIS
• Patients with the tuberculosis should receive only emergency care
following the guidelines.
• The sputum culture for mycobacterium tuberculosis should be done.
• If the results are negative patients may be treated normally.

78. Anticancer drug
• Bisphosphate is used to treat cancer(iv)
• Potential risk factors contribute to the development are steroid
therapy, alcohol, smoking, poor oral hygiene, chemotherapy,
extractions, root canal treatment, periodontal infections, periodontal
surgery and implant surgery.
• Invasive treatment should be avoided.
• Caution and careful consideration of risks must be evaluated for
individuals with a history of talking oral bisphosphonates for periods
longer than 3 years

80. Anticoagulant/antiplatelet therapy
• Discontinue therapy about 3 to 5 (antiplatelet) or 7 to 10
(anticoagulant) days before planned surgical procedures.
• Simple extractions or periodontal surgery can be done without
discontinuation of therapy.
• In case of intraoperative bleeding local measures are sufficient to
control bleeding.

82. corticosteroids
• Administration of corticosteroid is not required in case of
uncomplicated minor surgical procedures.
• Supplementation is indicated in lengthy and major surgical
procedures.

83. chemotherapy
• Should be conservative and palliative.
• The treatment should be done before the day of chemotherapy when
the white cell counts are above 2000/mm3
• Teeth with a poor prognosis should be extracted.
• The clinician should teach the importance of good oral hygiene.
• Antimicrobial rinses such as chlorhexidine is
recommened to prevent secondary infections

85. Radiationtherapy
• Used to treat head and neck tumors.
• Complication includes:
 Mucositis
 Xerostomia
 Trismus
 Radiation caries
 Dysphagia
 Osteoradionecrosis

87. Before radiation therapy:
• Teeth that are restorable or severely periodontally diseased should be
extracted atleast 2 weeks before radiation.
• Extractions should be performed in a manner that allows primary
closure.
• Mucoperiosteal flaps should be elevated and teeth should be
extracted in segments.
• Alveolopasty should be performed allowing no bony spicules to
remain.

88. During radiation therapy:
• Patients should receive weekly prophylaxis
• Oral hygiene instructions.
• Professionally applied fluoride treatments.
• Patient should be instructed to brush daily with a 0.4% stannous fluoride or
1% sodium fluoride gel.

89. After radiation therapy:
• Viscous lidocaine prescribed for painful mucositis
• Salivary substitutes given for xerostomia.
• Radiation caries may be prevented by topical fluoride application daily
and maintenance of good oral hygiene.
• After 3 month recall interview is ideal.
NOTE: Tooth extraction after radiation treatment involves a high risk for
developing OSTEORADIONECROSIS.

90. Conclusion
• In managing medically compromised patients, the clinician should
always obtain a physcian consult before any periodontal treatment.
• Changes in recommendations for medically compromised patients
are continually occurring.
• Dentists should follow the recommendations from the patient’
physician and utilize the appropriate protocol.
• Thus all clinicians need to be cognizant of the systemic implications
of periodontal diseases and their treatment, and should stay up to
date to give the best possible treatment.

91. REFERENCES
1CARRANZA 11TH EDITION
2.DENTAL MANAGEMENT CONSIDERATION FOR DIABETIC
PATIENT.RAJESH ET AL JADA VOL 132,2003
3. TR E A T M E N T O F H E M O P H I L I A MAY 2006 • NOV 40
4.DENTAL CONSIDERATIONS IN CARDIOVASCULAR PATIENTS: A
PRACTICAL PERSPECTIVE SWANTIKA CHAUDHRY A,*, RITIKA
JAISWAL A, SURENDER SACHDEVA ,JANUARY 2016