Periodontal Treatment of Medically Compromised Patients [Autosaved].pptx

Periodontal Treatment of
Medically Compromised Patients
GUIDED BY
DR K REKHA RANI (PROF & HOD)
PRESENTED BY
R ANIL KUMAR PG-III.

CONTENTS
 INTRODUCTION
 DEFINITION
 CARDIOVASCULAR DISEASES
Hypertension.
Ischemic Heart Diseases
Congestive Heart Failure
Cardiac Pacemakers and Implantable
Cardioverter-Defibrillators
Infective Endocarditis
Cerebrovascular Accident
 ENDOCRINE DISORDERS
a. Diabetes
b. Thyroid and Parathyroid Disorders
c. Adrenal Insufficiency.
 ENDOCRINE DISORDERS
a. Diabetes
b. Thyroid and Parathyroid Disorders
c. Adrenal Insufficiency.
 PROSTHETIC JOINT REPLACEMENT
 INFECTIOUS DISEASES
a) Hepatitis
b) HIV and AIDS
 HEMORRHAGIC DISORDERS
a) Coagulation Disorders
b) Thrombocytopenic Purpuras
c) Nonthrombocytopenic Purpuras
d) Blood Dyscrasias
e) Leukemia
f) Agranulocytosis
 RENAL DISEASES
 LIVER DISEASES
 PULMONARY DISEASES
 MEDICATIONS AND CANCER THERAPIES
a) Bisphosphonates
b) Anticoagulant/Antiplatelet Therapy
c) Corticosteroids
d) Immunosuppression and Chemotherapy
e) Radiation Therapy
 CONCLUSION

INTRODUCTION
A large number of patients seeking periodontal care have significant medical conditions,
which alter the treatment plan and therapy provided.
As the age of the average periodontal patient increases in the coming years a greater
number of older and more medically compromised patients will seek dental care.
Identification of potential systemic disorders is a prerequisite to assessing the impact of
such conditions on periodontal care .
The goal of medical history evaluation is to completely assess all physiologic systems and to
identify all prescription and non-prescription medications taken by the patient

 Since the success of periodontal treatment may be
affected by identification and control or
modification of systemic factors, the medical
history comprises the first step in therapy.
 When all potential systemic conditions have been
thoroughly evaluated, the patient may be assigned
a physical status classified on the guidelines of the
American Society of Anesthesiologists (ASA) as
follows:

 Person suffering with medical disorder and may get compromised while treating
other pathology.
DEFINITION

CARDIOVASCULAR DISEASES
 Cardiovascular diseases (CVD) is a broad term used to categorize any abnormal condition
characterized by dysfunction of the heart and blood vessels.

 Hypertension
 Angina pectoris
 Myocardial Infarction
 Previous cardiac bypass surgery
 Previous cerebrovascular accident
 Congestive heart failure
 Presence of cardiac pacemakers
 Infective endocarditis

 Hypertension is an abnormal elevation in arterial pressure that can be fatal if sustained and
untreated.
 Hypertension can be classified as primary or secondary hypertension.
 PRIMARY or ESSENTIAL HYPERTENSION (without an organic cause): Primary
hypertension is the term used for medium to high blood pressure for a long time (chronic)
without a known cause, which is a very common form of hypertension, comprising about 90-
95% of all patients with hypertension.
HYPERTENSION

SECONDARY HYPERTENSION : Hypertension with a well established organic cause which
includes following:
 Renal (parenchymal or renal vascular).
 Endocrine.
 Neurological.
 Others:- polyarteritis, hypercalcemia, drugs (corticosteroids cyclosporine), sleep apnea,
pregnancy toxemia, acute intermittent porphyria.

 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure (JNC 7) provided several revisions to the previous 1997
guidelines

 Antihypertensive drugs are able to induce a series of adverse effects with the oral cavity.
 Patients can present oral manifestations in the form of xerostomia, lichenoid reactions, burning
mouth sensation, loss of taste sensation or gingival hyperplasia, as well as extraoral
manifestations such as sialadenosis.
Oral
manifestations:

• Consult the Physician
• Schedule appointments in the afternoon
• Check the BP before starting the treatment
• No treatment : Systolic BP > 180mm Hg & Diastolic > 110 mm of Hg
Management of a hypertensive patient

• Use LA with an Adrenaline conc of 1:100000 or less.
• Keep the procedure as short as possible.
• Avoid Intraligamentary injections.
• Use conscious sedation in very anxious patients.

• Make sure that the bleeding has stopped completely
before dismissing the patient
• Beware of postural hypotension while adjusting the
dental chair

ISCHEMIC HEART DISEASE
 Ischemic Heart Disease, also known as Corona artery Disease (CAD), is a condition that affects
the supply of blood to the heart.
 The blood vessels are narrowed or blocked due to the deposition of cholesterol on their walls.
 This reduces the supply of oxygen and nutrients to the heart muscles, which is essential for
proper functioning of the heart.

Angina pectoris
 An important indicator of CAD is angina pectoris defined as a syndrome of substernal chest
discomfort, with characteristic quality and duration that is provoked by a exertion or emotional
stress.
 In angina the myocardial oxygen demand exceeds the supply, resulting in temporary
myocardial ischemia.
 Angina pectoris may be of two types: stable and unstable.

 In the case of stable angina, the patient has pain, lasting 5-15 minutes, which is relieved by
administration of nitroglycerin.
 It usually has a trigger, such as physical exercise or exertion, anxiety, or emotional stress, cold
temperatures, or heavy meals.
 In unstable angina, the patient has pain lasting longer than 15 minutes that may not be fully
relieved by administration of nitroglycerin.
 Less common kind of angina includes variant angina, microvascular angina. and atypical
angina.

PRINCIPLES OF PERIODONTAL MANAGEMENT
Consult the physician
Instruct the patient to bring their medication
Discontinue the procedure if the patient becomes fatigued

Anginal attack in dental chair
1. Discontinue periodontal Rx
2. 0.3-0.6mg nitroglycerine sublingually
3. Reassure patient
4. Administer O2
5. If signs & symptoms cease-continue Rx
6. If not administer another dose of nitroglycerine
7. Chest pain not relived by 3 tablets---MI
 Restrictions on use of local anesthetics containing epinephrine are similar to those for the patient
with hypertension.
 In addition, intraosseous injection with epinephrine containing local anesthetics using special
systems.

Acute myocardial infarction (AMI)
 Acute myocardial infarction results due to physical disruption of an atherosclerotic plaque with
subsequent formation of an occluding thrombus, coronary occlusion causing a reduction in
coronary blood flow.
 It is characterized by acute, sudden onset and intense pain, of an oppressive nature, located in
the retrosternal or precordial region, and can radiate to the arms, neck, back, jaw, palate or
tongue.
 Other clinical features that may be seen are intense perspiration, nausea, vomiting, dyspnea and
imminent death sensation, though it can also manifest as sudden loss of consciousness, mental
confusion or weakness.

 It has been recommended that patients should not receive routine dental care for at least 6
months after myocardial infarction.
 This recommendation is 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.
 The acute myocardial infrction if not treated well in time results in congestive heart failure and
death of the patient.
Management of myocardial infraction

Congestive Heart Failure
 Congestive heart failure can be defined as the incapacity of the heart to function properly,
pumping insufficient blood towards the tissues and leading to fluid accumulation with in the
lungs, liver and peripheral tissues.

 The congestive heart failure is the end result of ischemic heart diseases or arterial hypertension.
 Heart failure may be acute or chronic in nature.
 Acute heart failure is triggered by cardiotoxic drugs or coronary occlusion episodes.
 Chronic heart failure, in turn, is associated to the antecedents of arterial hypertension and
ischemic heart diseases.

 The patients will be on various medications hence details should be sought.
 The position of patient during treatment is important, as lying down or recumbent position may
exaggerate the condition.
 Any patients who are having acute episode of breathlessness or on auscultation crepitations or
abnormal sounds are heard then consultation should be sought from the cardiologist or
physician.
 No drug should be discontinued, judicious use of LA with adrenaline should be considered.
These patients are at risk for acute episode of CCF, arrhythmia and hypotension.
Management of CHF.

INFECTIVEENDOCARDITITS(IE)
 IE is an infection of the inner lining of the heart and heart valves.
 The etiology of more than 85% of all IE cases is bacteria, most often Staphylococci, streptococci,
and Enterococci.

 Other bacteria implicated for IE belong to HACEK group of microorganisms( Haemophilus
parainfluenza, H.aphrophilus, H.paraphrophilus, H.influenzae, Actinobacillus
actinomycetemcomitans, Caradiobacterium hominis, Eikenella corrodens, Kingella kingae, and
K.denitrificans). fungi have also been isolated from the IE lesion.
 IE has been classified into acute and suacute types, according to the natural history of the
disease.
 Recently , as the number of endocarditits cases associated with the prosthetic valves has
increased. Therefore, these diseases are also classified into "prosthetic vaIve endocarditis" and
"native valve endocarditis".

Pathogenesis of IE
•Normally, the cardiac valves are resistant to colonization and infection by circulating bacteria.
•But, if there is any mechanical disruption of the endothelium, it results in the exposure of underlying
extracellular matrix proteins, production of tissue factor, and the deposition of fibrin and platelets as
a normal healing process.
•Such nonbacterial thrombotic endocarditis (NBTE) facilitates bacterial adherence and infection.
•The mechanical damage leads to an inflammatory response which results in the formation of micro-
ulcers and micro-thrombi.

The inflammation results in the expression of integrins of the β1 family (very late
antigen) by the endothelial cells. These bind to the circulating fibronectin
S. aureus and some other IE pathogens carry fibronectin-binding proteins on
their surface, facilitating their colonization in that area.
After adhering, S. aureus triggers their active internalization into valve
endothelial cells, where they can either persist and escape host defenses and
antibiotics, or multiply and spread to distant organs.

Antibiotic prophylaxis to prevent infective endocarditis
The American Heart Association first recommended prophylaxis regimen which was issued in
1995 but changes have done and most current recommendations were issued in 2007.

Dental procedures for which antibiotic prophylaxis is recommended:

Regimen for infective endocarditis prophylaxis

Periodontal treatment of an infective endocarditis patient
•As bacteremia is associated with the development of infective endocarditis, the first step during periodontal
treatment is to define a susceptible patient.
•The guidelines provided by AHA describe high-risk patients who are susceptible to the development of
infective endocarditis.
•A history of the medical illness can indicate the risk of development of IE, but if required patient's physician
should be consulted to know the exact status of the disease. The patient should be given oral hygiene
instructions to reduce bacterial load in the oral cavity.
•Once the soft tissue inflammation is controlled, more aggressive oral hygiene may be initiated.
•The aggressive periodontitis cases high levels of Aggregatibacter actinomycetemcomitans. slots et al. {1983)
have recommended tetracycline, 250 mg, four times daily for 14 days to eliminate or reduce their count.
•The recommended antibiotic prophylaxis is then carried out before periodontal treatment.

If the patient is taking oral penicillin for prevention of
rheumatic fever, penicillin-resistant a-hemolytic Streptococci
may be found in the oral cavity. Therefore, the alternate
regimen can be followed.
If the patient is already taking oral penicillin for periodontal
treatment, the IE prophylaxis regimen is changed.
Following steps should be followed during periodontal
treatment of an IE patient,

1. All the periodontal treatments, including periodontal probing, should be carried out
under antibiotic prophylaxis.
2. Chlorhexidine mouth rinses are recommended before all periodontal treatments
because they significantly reduce the presence of bacteria on mucosal surfaces.
3. The number of appointments should be reduced by clubbing different treatments
according to patients need and tolerability.
4. It reduces the chances of developing resistant bacteria Minimum of one week
(preferably 10- 14 days) gap should be kept between the two appointments, but if it
is less than one week, the alternate antibiotic regimen should be selected.

Using the same antibiotic between dental hygiene appointments that are scheduled within a 9-day period increases the risk of resistance and
may reduce the efficacy of the drug.
It should be remembered that if the patient is taking antibiotic following periodontal treatment, the standard prophylactic dose is still
needed before starting the next periodontal treatment during next appointment.
For example, if a patient has been taking amoxicillin 250 mg three times a day for I0 days after periodontal surgery and be/she is
scheduled for next treatment after 7 days following surgery, he/she should be given full 2 gm dose of amoxicillin before starting the
treatment or alternative drug regimen should be chosen such as azithromycin or clindamycin.
During the maintenance phase, the oral hygiene status of the patient should be re-evaluated with an emphasis on oral hygiene reinforcement

CEREBRO VASCULAR ACCIDENT
A cerebrovascular accident (CVA), or stroke, results from ischemic
changes (e.g., cerebral thrombosis caused by an embolus) or
hemorrhagic phenomena.
Hypertension and atherosclerosis are predisposing factors for CVA
and should alert the clinician to evaluate the patient’s medical
history carefully for the possibility of early cerebrovascular
insufficiency and to be aware of symptoms of the disease.

Dental clinicians should treat post-CVA patients with the
following guidelines in mind:
No periodontal therapy (unless for an emergency) should be
performed for 6 months because of the high risk of recurrence
during this period
After 6 months, periodontal therapy may be performed using
short appointments with an emphasis on minimizing stress.
Concentrations of epinephrine greater than 1 : 100,000 are
contraindicated.

Light conscious sedation (inhalation, oral, or parenteral)
may be used for anxious patients.
Stroke patients are frequently placed on oral
anticoagulants.
BP should be monitored carefully.

 The main concern is the requirement of antibiotic prophylaxis before invasive dental procedures.
 After dental procedures (which involve bleeding), bacteremia can be demonstrated in blood within one
minute of the manipulation and is usually greatest five minutes following the procedure.
High incidences of bacteremia are observed in following dental procedures.
PROSTHETIC JOINT REPLACEMENT
 Dental extractions.
 Periodontal procedures, including surgery, subgingival placement of antibiotic fibers/strips, scaling
and root planing, probing, recall maintenance.
 Dental implant placement and replantation of avulsed teeth
 Prophylactic cleaning of teeth or implants, where bleeding is anticipated.

 Antibiotic prophylaxis has been recommended in all the patients with in 2 years of joint replacement.
 The immunosuppressed patients, such as patients with inflammatory arthropathies (rheumatoid arthritis,
systemic lupus erythematosus) or drug/radiation-induced irnmunosuppression should be given antibiotic
prophylaxis.
 Patients with co-morbidities such as previous prosthetic joint infections, malnourishment, hemophilia, HIV
infection, insulin-dependent (Type I) diabetes or malignancy should be given antibiotic prophylaxis.

ENDOCRANIAL CONDITIONS
 Diabetes
 Thyroid disorders
 Parathyroid disorders
 Adrenal insufficiency
 Pregnanancy

DIABETES
 Diabetes mellitus is a metabolic disorder characterized by chronic hyperglycemia with
disturbances of carbohydrate, fat and protein metabolism, resulting from the defects in insulin
secretion, insulin action, or both.
 It is a disease with complex metabolic and vascular components.
 The metabolic component involves the elevation of blood glucose associated with alteration in
lipid protein metabolism resulting from relative or absolute lack of insulin.
 The vascular component includes an accelerated onset of non-specific atherosclerosis and micro-
angiopathy such as nephropathy and retinopathy

If a patient is suspected of having undiagnosed diabetes,
the following procedures should be performed
1. Consult the patient’s physician.
2. Analyze laboratory tests : glycated hemoglobin (HbA1c)
levels, fasting plasma glucose levels, plasma glucose levels
during an oral glucose tolerance test (OGTT) or the random
plasma glucose level.
3. Rule out acute orofacial infection or severe dental
infection;if present, provide emergency care immediately.
4.Establish best possible oral health through nonsurgical
debridement of plaque and calculus; institute oral hygiene
instruction.

Treatment of diabetes
Essential components of the treatment for diabetes include diabetes self-management education and support,
lifestyle interventions and pharmacological management. There are a number of anti-diabetic agents available
these days.

Periodontal treatment of diabetic patients
The first step in the treatment of a diabetic patient is asking about the medical history of the
patient and assessment of glycemic control of the patient at the initial appointment.
If the patient is an uncontrolled diabetic the dental treatment is delayed possible if until good
metabolic control is achieved.
The patient should be asked about the recent blood glucose levels and frequency of
hypoglycemic episodes.
The dosage, frequency of intake and time of administration of the anti-diabetic drugs should
be noted.
If the patient is scheduled for any surgical procedure, the insulin or the anti-diabetic drug dosage
may be adjusted with the consultation of the physician.

Scheduling the visits of the patient
•It is important to note that most of the complications during the treatment of a diabetic patient are
due to hypoglycemia and not hyperglycemia.
•If the patient has a complication due to hyperglycemia, which is not confirmed, the initial treatment
is same as that of hypoglycemia
•Reason being, hyperglycemia does not cause any life-threatening complication, but hypoglycemia
can result in a life-threatening situation.
•Keeping all these factors in mind the visits of the patient are scheduled.
•In general, morning appointments are suitable for a diabetic patient because the endogenous
corticosteroid levels are generally high at this time which increases the blood glucose level.
•If the patient is taking insulin, the visits should be arranged in such a way that the treatment time
does not coincide with the peak activity of insulin.

.
Diet
The patient should take normal diet and medications before
the appointment
If the patient skips the breakfast owing to the dental
appointment, but still takes anti-diabetic medications, the risk
of hypoglycemia increases.
If procedures like conscious sedation are planned, the patient
is asked to alter the diet.
The dosage of medications may also be altered in consultation
with the physician.

 Depending on the diabetic history of the patient, dentist may require the blood glucose level
estimation prior to the initiation of treatment.
 Various commercial blood glucose monitors are available in the market, which provide accurate
levels of blood glucose.
 If the blood glucose level of the patient is 200 mg/ dl, an intravenous infusion of I0% dextrose in
half normal saline is initiated, and rapid- acting insulin is administered subcutaneously.
 The blood glucose levels are checked and if found between I 00 and 200 mg/dl the invasive
dental procedure can be performed safely.
Estimation of blood glucose level before the procedure:

Precautions during the treatment of diabetic Patient
 As already stated, most of the complications during the treatment of a diabetic patient are due to
hypoglycemic, the peak activity of the insulin or other anti-diabetic drugs should be determined to avoid the
risk of hypoglycemia.

Post-treatment precautions
One of the major problems associated with uncontrolled diabetes
mellitus is delayed wound healing.
Tissues are more, prone to infections during the hyperglycemic
state.
Therefore, the antibiotic cover is necessary for these patients to
prevent infections.
If it is anticipated that the patient’s diet may be affected by
treatment , the dosage of the antidiabetic drugs or insulin should
be readjusted in consultation with the patient’s physician

•Thyroid is a small butterfly-shaped gland thar lies just
under the skin below Adam's apple in the neck. It secretes
hormone that help lo regulate the body's metabolism.
•There are two main thyroid homones: T3 (triiodothyronine)
and T4 (thyroxine).
•T3 is the more active form of the hormone, and T4 is
converted into T3 by the body as needed.
•Most of T3 and T4 are bound to proteins in the bloodstream.
•The hyper and hypothyroidism are two common
dysfunctions of the thyroid gland.
THYROID DYSFUNCTION

Thyroid
function
tests
include
Thyroid-
stimulating
hormone
(TSH) test
T4 tests
T3 tests
Thyroid-
stimulating
immunoglob
ulin (TSI) test
Antithyroid
antibody test
also called the
thyroid
Peroxidase
antibody
(TPOab) test
Thyroid function tests (TFTs) are used to evaluate thyroid Status.

Clinical features of hyper and hypothyroidism:

Chandna S, Bathla M. Oral manifestations of thyroid disorders and its management. Indian J Endocr Metab 2011;15:S113-6

Periodontal treatment of patients with hypothyroidism
•Hypothyroidism results in increased subcutaneous mucopolysaccharides accumulation due to decrease in their degradation
•It may decrease the ability of small blood vessels to constrict when cut and may result in increased bleeding from infiltrated tissues,
including mucosa and skin
•In hypothyroidism patients, the wound healing is delayed due to decreased metabolic activity in fibroblasts. The delayed wound healing is
more susceptible to infection.
•So, the antibiotic cover is given to prevent any kind of infection.
•Hypothyroidism is associated with increased risk of susceptibility to cardiovascular diseases from arteriosclerosis and elevated LDL.
•If the patient has atrial fibrillation then he or she might require antibiotic prophylaxis before invasive procedures, depending on underlying
cause of atrial fibrillation.
•An antiseptic that includes iodine (such as Povidone), can increase the risk of thyroiditis or hypothyroidism in these patients, so should be
avoided.
•Along with this many drug interactions should be considered in patients taking thyroxine.

Periodontal treatment of patients with hyperthyroidism
Patients with hyperthyroidism show increased heart rate and blood pressure due to the effects of thyroid hormone on sympathetic nervous
system activity.
The blood pressure should be monitored before starting any surgical treatment and longer hemostatic agents may also be used to control
bleeding
propylthiouracil (PTU) is an anti-thyroid drug which has anti-vitamin K activity and can cause hypoprothrombmemia and bleeding. So
patients taking PTU must be carefully evaluated before surgery.
Acetylsalicylic acid (ASA) interferes with the protein binding of T4 and T3, there by increasing their free form. It may worsen the
symptoms of thyrotoxicosis therefore, combination analgesics containing acetylsalicylic acid (ASA) are contraindicated in patient with
hyperthyroidism
The use of local anesthesia with epinephrine warrants special consideration while treating the patients with hyperthyroidism.
The use of epinephrine or other pressor amines (in local anesthesia or gingival retraction cord. or to control bleeding) must be avoided in
the untreated or poorly treated thyrotoxic patient.
The symptoms of thyrotoxic crisis (thyroid storm) include restlessness, fever, tachycardia, pulmonary edema, tremor, sweating, and finally
coma and death. If this situation is faced during periodontal treatment, the treatment is stopped. The patient is cooled with the help of cold
towels or ice packs and given an injection of hydrocortisone ( 100-300mg).
An intravenous line is established and dextrose solution is given to cope With continuously high metabolic demand. Vital signs must be
monitored and cardiopulmonary resuscitation initiated, if necessary. Immediate medical assistance should be sought. If available,
antithyroid drugs and potassium iodide may be started

PARATHYROID GLAND DISORDERS
•The parathyroid glands are derived from the ectoderm of the gland pharyngeal pouches.
•In Humans usually four parathyroid glands are Present, variably located on the back of the thyroid gland.
•The superior parathyroid glands develop from the fourth pharyngeal pouch and are therefore referred to as parathyroid IV .
•The inferior parathyroid glands are derived from the third Pharyngeal pouch and are also referred to as “parathyroid III”.
•The major function of the parathyroid glands is to maintain the body's calcium and phosphate levels.
•Parathyroid glands secrete parathyroid hormone (PTH) which in association with calcitonin (secreted from the thyroid gland) has key role in
regulating the amount of calcium in the blood and within the bones.
•PTH plays an important role in tooth development and bone mineralization and increases bone resorption. It's coordinated action on the
bones, kidney and intestine increases the flow of calcium into the extracellular fluid and increases its concentration in the blood.
•The parathyroid disorders are of two types, one where the parathyroid is overactive (hyperparathyroidism), and another where the
parathyroid is under- or hypoactive (hypoparathyroidism).

Hyperparathyroidism:
The hyperparathyroidism may be primary, secondary or tertiary.
The primary hyperparathyroidism is caused due to hyperfunction of one or more parathyroids, usually
caused by a tumor (adenoma in 85% of all cases) or hyperplasia of the gland that produces an increase
in PTH secretion resulting in hypercalcemia and hypophosphatemia.
Secondary hyperparathyroidism occurs in patients with intestinal malabsorption syndrome or chronic
renal failure, which results in decreased Vit D production or hypocalcemia causing glands to produce a
high quantity of PTH.
If the secondary hyperparathyroidism persists for a longer duration of time, the parathyroid tissue may
become unresponsive to the blood calcium levels, and begin to autonomously release PTH. This is
known as tertiary hyperparathyroidism.
The oral manifestations of are, Dental abnormalities: Widened pulp chambers, Developmental defects,
Alterations in dental eruption, Weak teeth. Malocclusions. Brown tumor, Loss of bone density, Soft
tissue calcifications.

Hypoparathyroidism
•The state of decreased parathyroid activity is known as hypoparathyroidism.
•This condition is characterized by hypocalcemia and hyperphosphatemia.
•One common reason for hypoparathyroidism is damage to the glands their blood supply
during thyroid surgery.
•Some rare genetic syndromes such as DiGeorge syndrome or an autosomal dominant
syndrome are also associated with this condition.
•oral manifestations of hypoparathyroidism are, Dental abnomalities: Enamel hypoplasia
in horizontal Iines., Poorly calcified dentin, Widened pulp chambers, Dental pulp
calcifications, Shortened roots., Hypodontia., Delay or cessation of dental development.
•Mandibular tori.
•Chronic candidiasis
•Paresthesia of the tongue or lips, Alteration in facial muscles.

Dental management of the patient with parathyroid disorders:
The clinical management of the patients with hyper or hypoparathyroidism does not warrant any special consideration
A hyperparathyroidism patient is more prone to bone fracture due to the decreased mineral content of bones, so
care should be taken during surgical procedures. The brown tumor if present should be diagnosed correctly in
these patients.
On the other hand, hypoparathyroidism patients have low serum calcium. Before performing dental treatment,
serum calcium level should be determined
it must be above 8 mg/ 100ml to prevent cardiac arrhythmias, seizures, laryngospasms or bronchospasms.
Because of dental abnormalities, these patients are more prone to caries. Proper oral hygiene measures and dietary
instructions should be given to these patients to prevent caries

Adrenal insufficiency (AI) is a life-threatening disorder that can result from the primary adrenal failure or secondary
adrenal disease due to impairment of the hypothalamicpituitary axis (HPA).
AI can be primary, secondary or iatrogenic.
Addison's disease, the common term for primary AI, occurs when the adrenal glands cannot produce enough of the
adrenal hormones, cortisol and aldosterone.
The clinical manifestations of cortisol deficiency include hypoglycemia, hypotension, asthenia, muscle weakness, anorexia,
nausea, weight loss and diminished resistance to infections and stress.
Secondary AI occurs due to pituitary or hypothalamic dysfunction or failure caused by tumors, irradiation, infiltration,
trauma or surgery.
The Iatrogenic AI is caused by suppression of the HPA axis due to glucocorticoid therapy in pharmacological doses.
The suppression of the HPA axis is rarely seen in the patients taking the steroid dose for less than 3 weeks.
A patient taking 15 mg/ day of prednisolone for more than 3 weeks should be suspected having HPA suppression

Normal cortisol levels:
The glucocorticoids are produced in the zona fasciculata of the
adrenal cortex under the regulation of the HPA axis.
Hypothalamus synthesizes Corticotropin-releasing homone
(CRH) and arginine vasopressin (AVP) which stimulate;
secretion of adrenocorticotropic hormone (ACTH) from the
pituitary gland.
ACTH acts on renal cortex and cortisols are produced. These are
under negative feedback at the level of both the hypothalamus
and t e pituitary gland. It has been estimated that normally
around 10 mg/day endogenous cortisol is produced in our
body.
There are cyclic variations in the plasma cortisol concentration
in the course of the 24 hours in a day, being maximum early in
the morning and minimum at evening.

Dental management of patients with adrenal insufficiency
The periodontal treatment of patients with primary or secondary AI is started with a detailed case history and
current status of the patient.
In patients taking exogenous corticosteroids, the reason of intake should be determined.
The dosage of the exogenous corticosteroids determines the degree of adrenal suppression & Also, the duration
of therapy is important in determining the adrenal suppression.
 If the patient is taking < 30 mg of hydrocortisone/day, it is considered as low-dose corticotherapy.
 There is no need for corticosteroid supplements both for the long-term and short-term corticoid
users because this dose does not cause adrenal suppression.
 The non-surgical and surgical procedures can be safely carried out without giving the patient any
corticosteroid supplements.
Corticosteroid doses which do not produce adrenal suppression

Corticosteroid dose which produces adrenal suppression
 There is some degree of adrenal suppression in patients who are receiving 30-40 mg of
hydrocortisone/day.
 If the patient is highly anxious, or lengthy surgical procedure is to be performed, double the daily dose
on the day of treatment.
 If the postoperative pain is expected, we should also double the daily dose on the first postoperative
day.
Precautions during the treatment
 The plasma cortisol concentration is maximum in the morning. so preferably morning appointment
should be given to the patient, The anxiety an emotional stress should be minimized.
 The treatment should be as painless as possible, appropriate management of the post-operative pain
should be done.
 Some drug interactions should also be kept in mind. Drugs like phenytoin, barbiturates and rifampicin
accelerate glucocorticoid metabolism.

Patients with Addison's disease regularly take corticosteroid replacement drug therapy to compensate for the
deficiency of endogenous cortisols due to their inadequate production. Exogenous glucocorticoids can cause
adrenal gland suppression and resultant atrophy.
With the atrophy of adrenal glands, there is a decreased glucocorticoid response to stress, and this may
precipitate an adrenal crisis.
Adrenal or Addisonian crisis
signs and symptoms,
 Pallor.
 Rapid, weak pulse.
 Nausea.
 Vomiting.
 Abdominal pain.
 Hypotension (drop in blood pressure).
 Loss of consciousness.
Management of the patient in an acute
adrenal insufficiency crisis is as follows
1.Terminate periodontal treatment.
2. Summon medical assistance.
3. Give oxygen.
4. Monitor vital signs.
5. Place the patient in a supine position.
6. Administer 100 mg of hydrocortisone sodium succinate
(Solu-Cortef) intravenously for over 30 s or intramuscularly
and 2 hours later 100mg of hydrocortisone dissolved in
saline and given IV or IM.

 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.
DENTAL MANAGEMENT GUIDELINES DURING PREGNANCY
 it is the period during which complex process of organogenesis takes place. At this stage, the fetus is at risk of developing
developmental defects or teratogenic effects or undergoes abortion.
 Infections, drugs, stress and radiographic examination without suitable precaution can affect the development of fetus.
 prolonged pregnancy induced vomitmg m the first trimester can cause severe chemical erosion in the palatal surface of the
upper incisors.
 The dentist must advice to use baking soda mouth washes to neutralize the acidic_content of saliva
1 trimester (1-12 weeks)
PREGNANCY

 Organogenesis is completed and therefore the risk to the fetus is low.
 Some elective and emergent dentoalveolar procedures are more safely accomplished during the
second trimester.
2 trimester (14th to 28th week):
 Although there is no risk to the fetus during this trimester, the pregnant mother may
experience an increasing level of discomfort.
 Short dental appointments should be scheduled with appropriate positioning while in the
chair to prevent supine hypotension.
 It is safe to perform routine dental treatment in the early part of the third trimester, but from
the middle of the third trimester routine dental treatment should be avoided.
3 trimester (29th week until childbirth):

•Short appointment should be served in series because patient may fatigue easily.
• Position the patient on her left side and not in supine or Trendelenburg position because of discomfort of
remaining in one position for long.
•Advice non-alcoholic mouthwash and neutral sodiumfluoride rinse.
•Advice not to brush right after vomiting to prevent erosions as nausea and vomiting is common in first
trimester
• Ideally, no medications should be prescribed because of toxic or teratogenic effects of therapy on the foetus.
•Use of dental radiographs during pregnancy should be kept to a minimum. When they are required, patient is
covered with a lead apron, thyroid collar and second apron for the back to prevent secondary radiations from
reaching the abdomen
Periodontal Care for Pregnant Women

HEMORRHAGIC DISORDERS
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
Bleeding
time
Prothrombin
time (PT)
Partial thromboplastin
time (PTT)
Complete blood
cell count (CBC)
Tourniquet
test
Coagulation
time

Specific blood tests to confirm bleeding disorders

 A deficiency of each of the thirteen known plasma coagulation factors has been reported, which
may be inherited or acquired.
 qualitative or quantitative defect in a single
coagulation factor.
 two of the most common inherited coagulation
disorders are the sex-(X)-linked disorders—
classic haemophilia or haemophilia A (due to
inherited deficiency of factor VIII), and Christmas
disease or haemophilia B (due to inherited
deficiency of factor IX).
 Another common and related coagulation
disorder, von Willebrand’s disease (due to
inherited defect of von Willebrand’s factor)
Hereditary coagulation disorders Acquired coagulation disorders
 Deficiencies of multiple coagulation factors.
 The most common acquired clotting
abnormalities are: vitamin K deficiency,
coagulation disorder in liver diseases,
fibrinolytic defects and disseminated
intravascular coagulation (DIC)
Coagulation Disorders

TREATMENT:
Probing, scaling, and prophylaxis can usually be done without
medical modification.
More invasive treatment, such as local block anesthesia, root
planing, or surgery, dictate prior physician consultation.
Complete wound closure and application of pressure will
reduce hemorrhage.
Anti hemostatic agents, such as oxidized cellulose or purified
bovine collagen, may be placed over surgical sites or into
extraction sockets

• Not all coagulation diseases are hereditary.
Acquired Type:
• Liver disease
• Renal disease
• Anticoagulant therapy
• Disseminated intravascular coagulation
• Vit k deficiency

1.Physician consultation.
2. Laboratory evaluations: PT, bleeding time, platelet count, and PTT (in patients in later stages of
liver disease).
3. Conservative, nonsurgical periodontal therapy, whenever possible.
4. If surgery is required (may require hospitalization):
 International normalized ratio (INR; PT) should generally be less than 2.0. For simple
surgical procedures, INR less than 2.5 is generally safe.
 Platelet count should be more than 80,000/mm3.
Dental treatment planning for patients with liver
disease should include the following:

Anticoagulant Medications
The most common cause of abnormal coagulation may be drug therapy.
Patients with prosthetic heart valves or histories of MI, CVA, or
thromboembolism are frequently placed on anticoagulant therapy using
coumarin derivatives such as dicumarol and warfarin
The recommended level of therapeutic anticoagulation for most patients is an
INR of 2.0 to 3.0, with prosthetic heart valve patients generally in the 2.5 to 3.5
range

Traditional recommendations for periodontal treatment are as
follows:
•Consult the patient’s physician to determine the nature of the underlying
medical problem and the degree of required anticoagulation
•The procedure to be done determines the acceptable INR.
• the anticoagulant is discontinued for 2 to 3 days before periodontal
treatment (clearance half-life of warfarin is 36 to 42 hours), and the INR is
checked on the day of therapy. If the INR is within the acceptable target
range, the procedure is done and the anticoagulant resumed immediately
aftertreatment.
 Careful technique and complete wound closure are paramount.
 Use of oxidized cellulose, microfibrillar collagen, topical thrombin, and
tranexamic acid should be considered for persistent bleeding

ANTI PLATELET MEDICATIONS
 Aspirin interferes with normal platelet aggregation and can result in prolonged bleeding.
 Because it binds irreversibly to platelets, the effects of aspirin last at least 4 to 7 days.
 Aspirin upto 325 mg per day – no need to discontinue the medication before periodontal
procedures
 Aspirin more than 325 mg per day – should discontinue the therapy 7 to 10 days before
surgical procedures.
 Aspirin should not be prescribed for patients who are receiving anticoagulation therapy or who
have illnesses related to bleeding tendencies.

THROMBOCYTOPENIC PURPURA
 Thrombocytopenia is defined as a platelet count of less than
100,000/mm3
 It may be seen with idiopathic thrombocytopenic purpuras,
radiation therapy, myelosuppressive drug therapy (e.g.,
chemotherapy), leukemia, or infections.
 Purpuras are hemorrhagic diseases characterized by extravasation
of blood into the tissues under the skin or mucosa, producing
spontaneous petechiae (small red patches) or ecchymoses
(bruises).

Periodontal therapy for patients with thrombocytopenic
purpura
•removing local irritants to avoid the need for more aggressive therapy.
•Oral hygiene instructions and frequent maintenance visits
•Scaling and root planing are generally safe unless platelet counts are less than 60,000/mm3
• No surgical procedures should be performed unless the platelet count is greater than
80,000/mm.
•Platelet transfusion may be required before surgery.
•Surgical technique should be as atraumatic as possible, and local hemostatic measures should be
applied.

NON THROMBOCYTOPENIC PURPURAS
 Nonthrombocytopenic purpuras result from either vascular wall fragility or thrombasthenia (impaired
platelet aggregation).
 Vascular wall fragility may result from hypersensitivity reactions, scurvy, infections, chemicals (phenacetin,
aspirin), dysproteinemia, and other causes.
 Thrombasthenia occurs in uremia, Glanzmann’s disease, aspirin ingestion, and von Willebrand’s disease.
 It consists primarily of direct pressure applied for at least 15 minutes.
 This initial pressure should control the bleeding unless coagulation times are abnormal or reinjury occurs.
 Surgical therapy should be avoided until the qualitative and quantitative platelet problems are resolved
Treatment

 Leukemia is a hematological disorder which is caused by proliferating white blood cell-forming
tissues, resulting in a marked increase in circulating immature or abnomalities white blood cells.
 Leukemia is classified based on clinical behavior ( acute or chronic) and the primary
hematopoietic cell line affected (myeloid or lymphoid).
 The four principal diagnostic categories are the following.
I. Acute myelogenous leukemia (AML),
2. Acute lymphocytic leukemia (ALL),
3. Chronic myelogenous leukemia (CML) and
4. Chronic lymphocytic leukemia (CLL).
LEUKEMIA

Oral findings:
•Patients with leukemia show gingival bleeding, petechiae and ecchymosis due to thrombocytopenia.
•The severity of the symptoms depends on the platelet count. Less is the platelet count, more severe are these
findings
•Another important finding is gingival enlargement, It is more common in acute than chronic leukemia.
•Gingival enlargement is secondary to infiltration of the gingival tissue with leukemic cells, It is characterized by the
progressive enlargement of interdental papillae as well as marginal and attached gingiva
•Gingiva appears swollen, devoid of stippling and pale red to deep purple in color.
•Gingival infiltration by leukemic cells also predisposes the patient with leukemia to bleeding.
•Generally gingival enlargement resolves completely or atleast partly with effective leukemia chemotherapy.
•Other findings may include, oral ulcerations, viral infections (e.g.HSV) and oral colonization by Candida albicans.

TREATMENT PLAN FOR LEUKEMIA PATIENTS:
A. Refer the patient for medical evaluation and treatment.
B. Before chemotherapy, a complete periodontal treatment plan should be developed with a
physician.
 Monitor hematologic laboratory values such as bleeding time, coagulation time ,PT and platelet count
 Administer antibiotic coverage before any periodontal treatment
 Extract all hopeless, potentially infectious teeth atleast 10 days before chemotherapy (if systemic
conditions allow)
 Scaling,root planing should be performed
 Topical hemostatic agents can be used
 Twice daily rinsing with 0.12% chlorhexidine gluconate is recommended after oral hygiene
procedures

C. During the acute phases of leukemia, patients should receive only emergency periodontal care.
D. For patients with chronic leukemia and those in remission, scaling and root planing can be
performed without complication, but periodontal surgery should be avoided if possible.
E. Platelet count and bleeding time should be measured on the day of the procedure. If either is
low, postpone the appointment and refer the patient to a physician.

RENAL DISEASES
 Renal failure can result in severe electrolyte imbalance, cardiac arrhythmias, pulmonary
congestion, CHF, and prolonged bleeding.
 The most common causes of renal failure are glomerulonephritis, pyelonephritis, kidney cystic
disease, renovascular disease, drug nephropathy, obstructive uropathy, and hypertension.

•Renal failure can be chronic or acute.
•Acute renal failure is caused by conditions that produce an acute shut down in renal function.
•chronic renal failure represents the progressive and irreversible destruction of kidney structures.
•Chronic renal failure can result from a number of conditions that cause permanent loss of
nephrons
•The chronic renal failure ends with the reduced number and function of the nephrons; and if not
treated results in end stage renal disease (ESRD).

The following treatment modifications should be used:
 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, hematocrit value.
 Periodontal treatment should aim at eliminating inflammation or infection and frequent recall
appointments should be scheduled
 Drugs that are nephrotoxic or metabolized by the kidney should not be given (eg:
tetracycline,aminoglycoside antibiotics) .

RECOMMENDATION FOR 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.
 Be careful to protect the hemodialysis shunt or fistula when the
patient is in dental chair.
 If the shunt or fistula is placed in the arm do not cramp that limb
and do not use that limb for injection of medication.
 BP reading should be taken from the other arm.

LIVER DISEASES
Liver diseases are very common, and the main underlying causes are viral infections, alcohol abuse and lipid and carbohydrate
metabolic disorders.
Liver diseases are very common and can be classified as acute (characterized by rapid resolution and complete restitution of organ
structure and function once the underlying cause has been eliminated) or chronic (characterized by persistent damage, with
progressively impaired organ function secondary to the increase in liver cell damage)
Liver diseases can also be classified as infectious (hepatitis A, B, C, D and E viruses, infectious mononucleosis, or secondary syphilis
and tuberculosis) or non-infectious (substance abuse such as alcohol and drugs, e.g., paracetamol, halothane, ketoconazole,
methyldopa and methotrexate)
Damage to the liver has two major impacts on the treatment aspect: bleeding and drug intolerance.
Most of the clotting factors are synthesized in the liver, so these patients may have excessive bleeding during invasive dental
treatment. Because the liver metabolizes many drugs, its damage may alter the drug metabolism

Increased bleeding due to liver damage
Liver plays a central role in the clotting process, and acute and chronic liver diseases are invariably
associated with coagulation disorders due to multiple causes: decreased synthesis of clotting and inhibitor
factors, decreased clearance of activated factors, quantitative and qualitative platelet defects,
hyperfibrinolysis, and accelerated intravascular coagulation.
The liver produces coagulation Factors I (fibrinogen), II (prothrombin), V, VII, VIII, IX, X, and XI, as well
as protein C, protein S and antithrombin.
Before any surgical procedure is planned for these patients, appropriate laboratory tests to check bleeding
tendency should be performed.

Drug intolerance
In mild to moderate liver dysfunction, administration of certain analgesics,
antibiotics, and local anesthetics is generally well tolerated. However, in
excessive liver damage, certain drugs are avoided.
In severe liver damage, the dosage of certain drugs should be re-adjusted and
certain drugs like erythromycin, metronidazole or tetracyclines must be
avoided entirely.
Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with caution
or avoided, due to the risk of gastrointestinal bleeding and gastritis usually
associated with liver disease.
Paracetamol should be prescribed cautiously in patients recovering from
alcohol abuse because both paracetamol and alcohol are metabolized by the
same enzyme (isoenzyme CYP2EI of the P-450 cytochrome system). So, if the
patient consumes alcohol along with paracetamol, adverse outcomes may
result in.

Periodontal treatment of patients with liver diseases
The physician treating the patient should be consulted regarding liver function.
Before planning for any invasive procedure complete blood count, bleeding time, prothrombin time/
international normalized ratio (INR), thrombin time, thromboplastin time and liver biochemist (SGOT, SGPT, and
GGT) should be done.
In the case where the values are altered and a surgical treatment cannot be performed, only elective treatment to
eliminate pain should be done.
In severe liver damage, antibiotic prophylaxis is recommended since liver dysfunction is associated with diminished
immune competence.

PULMONARY DISEASES
Pulmonary diseases are common these days due to increasing air pollution and habits like smoking.
The pulmonary diseases may be obstructive or restrictive in nature.
The obstructive pulmonary diseases include emphysema, chronic bronchitis. refractory (non-
reversible) asthma, and some forms of bronchiectasis.
The restrictive ventilatory disorders are caused due to muscle weakness, scarring, obesity, or any
condition that could interfere with effective lung ventilation.
The chronic obstructive pulmonary disease (COPD) is an irreversible and slowly progressing
disorder characterized by a limitation of airway flow (in some cases partially reversible) resulting
from an abnormal pulmonary inflammatory reaction to harmful gasses or particles, particularly
tobacco smoke.

Chronic obstructive pulmonary disease (COPD):
COPD includes chronic bronchitis, chronic obstructive bronchitis or emphysema, or combinations of these conditions and can lead
to pneumonia, heart disease and death.
Airflow obstruction and shortness of breath are the initial signs of chronic bronchitis, chronic obstructive bronchitis, or
emphysema.
Asthma is reversible, diffuse stenosis or stricture of the peripheral bronchi, increased responsiveness or sensitivity to
different stimuli, allergic and non-allergic asthma.
Allergic asthma is characterized by a family history of asthma, together with an increase in serum IgE titers, antibodies
participate in type I hypersensitivity or immediate sensitivity reactions
The non-allergic asthma is a respiratory is reversible and recurrent bronchospam in response to different stimuli such as physical
exercise, inhalation of cold air, emotions, exposure to smoke, hyoxemia, stress, gastroesophageal reflux, etc.

Periodontal treatment of patients with pulmonary diseases
Patients with pulmonary disorders require special precautions during dental treatment to avoid any risk of
breath shortness.
Precipitation of an asthmatic attack is a major concern for dentist, It usually precipitates when stress generating
procedures like administration of local anesthesia, tooth extraction or dental pulp removal are done.
If an asthmatic attack precipitates during dental treatment, the treatment should be suspended. The patient
should be raised to a comfortable position.
After establishing a clear airway, inhalatory β2 agonist should be administered & Oxygen is administered
through a mask.
If the patient does not improve, I:I000 solution of epinephrine (0.01 mg/kg body weight, with a maximum dose
of 0.3 mg) should be administered SC, The emergency medical service is called and uninterrupted oxygen
supply is maintained until the patient breathes normally.
Certain drugs are avoided or given with caution in asthmatic patients. These Aspirin, NSAIDS,
MACROLIDES, OPIATE’S, LA (used without adrenaline).
If the patient is receiving prolonged systemic corticosteroid therapy, supplements may be needed (prior to
dental procedures that might cause stress).

INFECTIOUS DISEASES
Many patients with infectious diseases like human immunodeficiency
virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV)
infections seek periodontal treatment.
Other viruses of concern in the dental office include rubella mumps and
measles viruses; the herpes viruses (herpes simplex virus [HSY] types I
and 2), varicella-zoster, Epstein-Barr virus [EBY], cytomegalovirus; human
papillomaviruses; adenovirus; coxsackieviruses; and the upper respiratory
tract pathogens (influenza A and B viruses, human parvovirus B 19 and
respiratory syncytial virus).

Hepatitis viruses
•To date, six distinct viruses causing viral hepatitis have been identified: hepatitis A, B, C, D, E, and G viruses.
• In addition, a single-stranded deoxyribonucleic acid (DNA) virus known as transfusion-transmitted virus has
recently been identified in cases of acute and chronic hepatitis its role as an etiologic agent is still
undetermined.
•These forms of viral hepatitis differ in their virology, epidemiology, and prophylaxis.
•Because the majority of hepatitis infections are undiagnosed, the clinician must be aware of high-risk groups,
such as renal dialysis patients, healthcare workers, immunosuppressed patients, patients who have received
multiple blood transfusions, homosexuals, drug users, and institutionalized patients

Carranza Clinical Periodontology 12 edition

 Prodromal phase: It is of 1–2 weeks; symptoms like anorexia, nausea, malaise and fever occur.
 Icteric phase:(6–8 weeks) anorexia, nausea, vomiting and pain in the right upper quadrant of
abdomen, Hepatomegaly and splenomegaly may also be seen.
 Convalescent(recovery)phase: Symptoms disappear, but abnormal liver function values may persist.
Phases of Hepatitis
 Symptoms: Systemic complaints include malaise, arthralgia, morbilliform skin rash, anorexia,
vomiting and myalgia.
 Signs: Jaundice, darkening of urine, splenomegaly and whitish stools.
 Oral manifestation: Icterus of the oral mucosa, which is seen on the palate and in the sublingual
region.
Clinical Features

GUIDELINES FOR TREATING HEPATITIS PATIENTS
If the disease is active – do not provide periodontal treatment unless the situation is an emergency.
For patients with a past history of hepatitis consultation with the physician is necessary
For recovered HAV or HEV patients perform routine periodontal care.
For recovered HBV and HDV patients order HBsAg and anti HBs (antibody to HBV surface antigen)
laboratory tests.
For HCV patients, consult with the physician to determine the patient’s risk for transmissibility and
current status of chronic liver disease.
If a patient with active hepatitis, positive-HBsAg (HBV carrier) status, or positive-HCV carrier status
requires emergency treatment.

PRECAUTIONS TO BE USED IN THE CASE OF
EMERGENCY TREATMENT
If bleeding occurs during or after treatment,measure PT and Bleeding time.
All personnel in clinical contact with the patient should use full barrier technique, including masks, gloves, glasses or eye shields, and
disposable gowns
All disposable items (e.g., gauze, floss, saliva ejectors, masks, gowns, or gloves) should be placed in one lined wastebasket. After
treatment, these items and all disposable covers should be bagged, labeled, and disposed of, following proper guidelines for
biohazardous waste.
Minimize aerosol production by not using ultrasonic instrumentation, air syringe or high speed handpieces. Prerinsing with
chlorhexidine gluconate is highly recommended
All equipment should be scrubbed and sterilized
If a percutaneous or permucosal injury occurs during treatment of a HBV carrier , CDC guidelines recommend administration of Hepatitis B
immune globulin (HBIG).

 Acquired immunodeficiency syndrome (AIDS) is caused by the human immunodeficiency virus
(HIV) and is characterized by immunosuppression, which leads to a spectrum of clinical
manifestations that include opportunistic infections, secondary neoplasms, and neurologic
manifestations.
 Two genetically distinct populations of viruses known to cause AIDS are HIV-1 and HIV-2.
HIV- 1 is the most common type responsible for AIDS in central Africa and the rest of the world,
and HIV-2 in west Africa and India
ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)

PERIODONTAL TREATMENT FOR HIV PATIENTS:
HEALTH STATUS
INFECTION CONTROL MEASURES
GOALS OF THERAPY
SUPPORTIVE PERIODONTAL
THERAPY

HEALTH STATUS
 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-
i. CD4+ T4 lymphocyte level
ii. current viral load
iii. difference from previous counts and load
iv. H/o of drug abuse, multiple infections
v. present medications

INFECTION CONTROL MEASURES
1. A number of pathogenic microorganisms may be
transmitted in the dental setting and these include:
• Airborne pathogens - tuberculosis
• Blood borne pathogens -HIV, HBV, HCV
• Waterborne pathogens Legionella and Pseudomonas species
• Mucosal/ skin borne pathogens VZV or HSV

GOALS OF THERAPY
Primary goals should be restoration and maintenance of oral health, comfort and function.
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

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 co-ordination with the
patient’s physician are necessary

MEDICATIONS AND CANCER THERAPIES
BISPHOSPHONATES
Bisphosphonate medications are primarily used to treat cancer (IV administration) and osteoporosis
(oral administration).
They act by inhibiting osteoclastic activity, which leads to less bone resorption, less bone remodeling,
and less bone turnover
The use of bisphosphonates in cancer treatment is aimed at preventing the often lethal
imbalance of osteoclastic activity.
In the treatment of osteoporosis, the goal is simply to harness osteoclastic activity to minimize or
prevent bone loss
Individuals treated with high potency, nitrogen-containing bisphosphonates, especially those
administered via IV for cancer treatment (e.g., zoledronate), appear to be at greater risk for BRONJ
than individuals taking oral bisphosphonates for prevention and treatment of osteoporosis

The risk for individuals treated with oral bisphosphonates for a period of less than 3 years appears to be
minimal or zero.
Regular use of oral bisphosphonates for a period greater than 3 years suggests a risk profile that increases
with time and length of use.
Potential risk factors thought to contribute to the development of BRONJ include systemic corticosteroid
therapy, smoking, alcohol, poor oral hygiene, chemotherapy, radiotherapy, diabetes, and hematologic
disease
Reported factors or conditions leading to BRONJ include extractions, root canal treatment, periodontal
infections, periodontal surgery, and dental implant surgery
The bacterial-induced inflammatory process of periodontitis that causes bone resorption can lead to bone
necrosis.
A careful intraoral examination is prudent for all patients treated with bisphosphonate therapy (IV or oral) to
determine whether bone exposures exist and to assess any local conditions that might predispose them to the
development of BRONJ.

 Marx has suggested that a laboratory blood test for the serum C-terminal telopeptide fragment
of type I collagen (CTX) can be used as a means of assessing an individual’s risk of developing
BRONJ.
 Marx reports that lower CTX values are associated with greater risk.

Optimal periodontal/oral health should be achieved
and maintained for all patients.
For individuals treated with IV bisphosphonates,
invasive treatment, such as extractions, periodontal
surgery, implant surgery, and bone augmentation
procedures, should be avoided.
Caution and careful consideration of risks must be
considered before any treatment for individuals with a
history of taking oral bisphosphonates for periods
longer than 3 years.

ANTICOAGULANT /ANTIPLATELET THERAPY
 Antiplatelet and anticoagulant drugs have been associated with
an increase in the bleeding time and risk of postoperative
hemorrhage.
 Because of this, some dentists still recommend the patient to stop
the therapy for at least 3 days before any oral surgical procedure.
 However, stopping the use of these drugs exposes the patient to
vascular problems, with the potential for significant morbidity.

Traditional management of patients on anticoagulant or antiplatelet therapy was to discontinue
therapy about 3 to 5 (antiplatelet) or 7 to 10 (anticoagulant) days before planned surgical procedures
Since there is a increased risk of morbidity/mortality associated with the discontinuation of the
therapy, simple extractions or periodontal surgery can be done without discontinuation of therapy
In the cases of intraoperative bleeding local measures are sufficient to control the bleeding.
In a prospective study of 131 patients undergoing 511 extractions, those whose oral anticoagulant
therapy was reduced 72 hours before surgery to achieve an INR of 1.5 to 2.0 had postoperative
bleeding 10 of 66 patients. Postoperative bleeding occurred in only 6 of 65 patients in the group that
continued the regular dosage of oral anticoagulant therapy.

CORTICOSTEROIDS
Patients who habitually use corticosteroids have an increased likelihood of
developing hypertension, osteoporosis, and peptic ulcer disease.
BP should be monitored, and medications that may exacerbate peptic ulceration (e.g.,
acetylsalicylic acid [ASA], NSAIDs) should be avoided.
Stressful events, such as trauma, illness, surgery, emotional upset, or athletic events,
normally increase circulating endogenous cortisol levels through stimulation of the
hypothalamic-pituitary-adrenal (HPA) axis
Pain appears to increase the requirement for cortisol release

•the stress response to minor general and oral surgical procedures conclude that significant increases in cortisol are generally not seen until 1
to 5 hours after surgery and appear to be associated more with postoperative pain and the loss of local anesthesia than with the preoperative
and intraoperative stress of the procedure.
•In fact, the administration of adequate analgesics in the postoperative period can diminish the release (requirement) of cortisol.
•Patients currently taking corticosteroids generally have enough exogenous and endogenous cortisol to handle routine dental procedures if
their usual dose is taken within 2 hours of the planned procedure.
•For most patients, supplemental corticosteroid administration is not required when uncomplicated minor surgical procedures, including
periodontal surgery, are performed with local anesthesia with or without sedation.
•Individuals who may be at risk for adrenal crisis requiring supplementation include those who are undergoing lengthy, major surgical
procedures, those expected to have significant blood loss and those who have extremely low adrenal function.
•Low adrenal function can be identified with an ACTH stimulation test.

Immunosuppression and Chemotherapy
•Immunosuppressed patients have impaired host defenses as
a result of an underlying immunodeficiency or drug
administration (primarily related to organ transplantation or
cancer chemotherapy).
•Because chemotherapy is often cytotoxic to bone marrow,
destruction of platelets and red and white blood cells results
in thrombocytopenia, anemia, and leukopenia.
•.Immunosuppressed individuals are at greatly increased risk
for infection, and even minor periodontal infections can
become life threatening if immunosuppression is severe.

Oral manifestations of chemotherapy
Mucositis
Excessive bleeding following minor trauma
Spontaneous gingival bleeding
Xerostomia
Infection
Poor healing

Management
•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 conservative and palliative.
•It is always preferable to evaluate the patient before initiation of chemotherapy.
•Teeth with a poor prognosis should be extracted, with thorough debridement of remaining teeth
to minimize the microbial load.
•The clinician must teach and emphasize the importance of good oral hygiene.
•Antimicrobial rinses, such as chlorhexidine, are recommended, especially for patients with
chemotherapy-induced mucositis, to prevent secondary infection.

Chemotherapy is usually performed in cycles, with each cycle lasting several
days, followed by intervening periods of myelosuppression and recovery.
If periodontal therapy is needed during chemotherapy, it is best done the
day before chemotherapy is given,when white blood cell counts are
relatively high
Dental treatment should be done when white cell counts are above
2000/mm3with an absolute granulocyte count of 1000 to 1500/mm3

 The use of radiotherapy, alone or in conjunction with surgical resection, is common in the
treatment of head and neck tumors.
 mucositis,
 dermatitis,
 xerostomia,
 dysphagia,
 gustatory alteration,
 radiation caries
 vascular changes,
 trismus,
 temporomandibular joint degeneration,
 periodontal changes
Oral manifestations
RADIATION THERAPY

MANAGEMENT BEFORE RADIATION THERAPY
Teeth that are non 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.
Alveolectomy should be performed allowing no bony spicules to remain and
primary closure should be provided without tension

DURING RADIATION THERAPY
Patients should receive weekly prophylaxis
Oral hygiene instructions.
Professionally applied fluoride treatments.
Patients should be instructed to brush daily with a 0.4 %
stannous fluoride or 1 % sodium fluoride gel
All remaining teeth should receive thorough debridement
(scaling and root planing).

AFTER RADIATION THERAPY
• Viscous lidocaine may be prescribed for painful mucositis
• Salivary substitutes may be given for xerostomia
• Radiation caries may be prevented by topical fluoride application daily and
maintenance of good oral hygiene.
• A 3 month recall interval is ideal.
NOTE : Tooth extraction after the radiation treatment involves a high risk for
developing osteoradionecrosis

..
Many patients seeking dental treatment have some systemic condition which can
alter the treatment plan for the patient.
An appropriate management of these patients is essential in order to avoid any
complication which can be sometimes life threatening
While rendering treatment to a medically compromised patient, the dentist should
always be prepared for any complications that might occur during the treatment as
well as their management.
A medical emergency kit that contains all the essential drugs used in medical
emergencies must be available in a dental setup and the dentist should be well
trained to handle any medical emergency if it occurs while providing dental
treatment
Conclusion

REFERENCES.
 Newman and Carranza's.Clinical Periodontology 12 & 13 edition.
 Scully’s Handbook of MEDICAL PROBLEMS IN DENTISTRY.
 Medical Emergencies in the Dental Office, 7edition by Stanley F. Malamed DDS.
 Textbook of Periodontology and Oral Implantology – Dilip G. Nayak, Ashita Uppoor.
 Brian L. Mealey.Periodontal Implications: Medically Compromised Patients. Ann Periodontol 1996;1:256-321
 Monali Shah,Deepak Dave, Rahul Dave, Ashit Bharwani, Amit Shah . Management of Medically Compromised Patient in
Periodontal Practice: An Overview (Part 1). Adv Hum Biol 2013; 3(1):1-6.
 R.A. Seymour. Dentistry and the medically compromised patient. Surg J R Coli Surg Edinb u«, I August 2003,207-214.
 LOUIS F. ROSE, BARBARA J. STEINBERG & STEVEN L. ATLAS. Periodontal management of the medically compromised
patient. Periodontology 2000, Vol. 9, 1995, 165-1 75.
 Dr Rizwan M Sanadi. Periodontal Treatment of Medically Compromised Patients Author. INTERNATIONAL JOURNAL OF
SCIENTIFIC RESEARCH.ijsr: Volume : 2 | Issue : 5 | May 2013.

 Rachita G Mustilwar et al. MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS IN DENTISTRY –A REVIEW.
INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH. Volume-7 | Issue-4 | April-2018.
 Dr. Musaib Syed. Dental Management of Cardiovascular Compromised Patient: A Review.Journal of Advanced Medical and
Dental Sciences Research |Vol. 9|Issue 6| June 2021.
 Yuya Kawabata et al .Relationship Between Prehypertension/Hypertension and Periodontal Disease: A Prospective Cohort
Study.July 2015American Journal of Hypertension 29(3).
 Eva Munoz Aguilera .Periodontitis is associated with hypertension: a systematic review and meta-analysis . Cardiovascular
Research (2020) 116, 28–39.
 Thomas L. Holland et al. Infective endocarditis. PRIMER. VOLUME 2 | 2016;1-26.
 Shree V. Dhotre. Periodontitis, Bacteremia and Infective Endocarditis: A Review Study. Arch Pediatr Infect Dis. 2017 July;
5(3):e41067.

 Peter B. Lockhart, Michael T. Brennan, Martin Thornhill, Bryan S. Michalowicz, Jenene Noll, Farah K. Bahrani-Mougeot, Howell
C. Sasser. Poor oral hygiene as a risk factor for infective endocarditisrelated bacteremia. Journal of the American Dental
Association, 140(10), 1238-1244.
 D Babu, N Reddy, D Swaroop, K Babu, K Kiran, M Swaminathan. Evaluation Of Bacteremia Following Periodontal Probing In
Gingivitis And Periodontitis Patients.. The Internet Journal of Dental Science. 2009 Volume 9 Number 2.
 Armin J. Grau, Heiko Becher, Christoph M. Ziegler, Christoph Lichy, Florian Buggle, Claudia Kaiser, Rainer Lutz, Stefan
Bültmann, Michael Preusch, Christof E. Dörfer. Periodontal Disease as a Risk Factor for Ischemic Stroke. Stroke. 2004;35:496-501.
 Lafon A, Tala S, Ahossi V, Perrin D, Giroud M, Béjot Y. Association between periodontal disease and non-fatal ischemic stroke: a
casecontrol study. Acta Odontol Scand. 2014 Nov;72(8):687-93

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