1. Periodontal treatment of medically compromised patients requires recognition of underlying medical conditions and formulation of an appropriate treatment plan. 2. Key considerations for patients with cardiovascular diseases like hypertension, ischemic heart diseases, and congestive heart failure include consultation with their physician, use of local anesthetics carefully, keeping procedures short, and monitoring vital signs closely. 3. Management of diabetic patients includes checking blood glucose levels before, during, and after treatment to monitor for hypoglycemia, and consulting their physician about antibiotic premedication for surgical procedures.

2. Periodontal Treatment of Medically
Compromised Patients
P. Satya Gowtham

3. Introduction
• Many patients seeking dental care have significant medical
conditions, that alter the course of their oral disease and therapy.
• Older patients will have greater likelihood of underlying disease.
• Therefore clinician responsibility includes recognition of patient
medical problems and formulation of proper treatment plan.

4. Cardiovascular Diseases

5. Cardiovascular Diseases

6. HYPERTENSION
Most common cardiovascular diseases
If hypertension Un diagnosed
• Leads to CHF,CVA,ANGINA,MI AND KIDNEY FAILURE
• So dentist can play a vital role in detection of hypertension
1)primary or essential
hypertension
• 95 %
• Without underlying pathology
2) secondary hypertension
•5%
•With underlying pathology as
renal disease,endocrine changes
and neurological disorders

7. Classification of adult BP

8. Regardless of the type of hypertension, the following guide- lines should govern the
periodontal management:
1. Consult the physician clearly explaining the nature of periodontal therapy.
2. Schedule the appointments preferably in the afternoons.
3. Check the blood pressure before starting the treatment.
4. No treatment should be provided if the systolic BP is greater than 180mmHg and/or the
diastolic BP is higher than 110 mmHg.
5. Use local anesthetics with an adrenaline (epinephrine)
concentration of 1:100000 or less. Use of anesthetic solu- tions without adrenaline, as was
done in the past, is not recommended since the management of pain and bleed- ing is far
more vital to prevent endogenous secretion of adrenaline. Aspirate before injection to
prevent depositing into a blood vessel.

9. 6. Keep the procedures as short as possible.
7. Avoid intraligamentary injections.
8. Use conscious sedation in very anxious patients.
9. Make sure the bleeding has stopped completely before
dismissing the patient.
10. Beware of postural hypotension while adjusting the dental chair

10. Non selective and selective beta adrenergic
receptor blockers

11. Clinician should aware of many side effects of various anti hypertension
drugs
Common side effects are
• Nausea
• Oral dryness
• Lichenoid drug reaction
• Gingival over growth
• Depression
Note: administration of LA containing epinephrine to patients taking non
selective beta blockers is contraindicated mostly.

12. lschemic Heart Diseases and
Other Cardiovascular Disorders
* when oxygen demand increases more than supply, results in temporary
Myocardial ischemia
* includes
1) angina pectoris
2) MI

13. Angina pectoris
UNSTABLE
ANGINA * irregular on multiple occasions without
predisposing factors
* Treatment only,if emergency
STABLE ANGINA
* Occurs infrequently and a/w exertion
and stress
* Can undergo elective dental precedures

14. Principles of Periodontal Managemen
stress often induces an acute anginal attack, stress reduction is important.
Profound local anesthesia is vital and conscious sedation may be indicated for
anxious patients. Supplemental oxygen delivered by nasal cannula may also
help prevent intraoperative anginal attacks.
1. Consult the patient's physician and obtain the farmer's fitness to undergo
periodontal therapy
2. Instruct the patient to bring their medications, particularly, if they are on
nitroglycerin.
3. Keep the procedures short. Include smaller areas in the mouth for each visit.

15. 4. Discontinue the procedure if the patient becomes fatigued, uncomfortable, or has a
sudden change in heart rhythm or rate during a periodontal procedure, as soon as
pos- sible. A patient who has an anginal episode in the den- tal chair should receive
the following emergency medical treatment:
a. Discontinue the periodontal procedure.
b. Administer one tablet (0.3- 0.6 mg) of nitroglycerin sub lin gually
c. Reassure the patient and loosen restrictive garments.
d. Administer oxygen to the patient in a reclined position.
e. If the signs and symptoms cease within 3min,complete the periodontal procedure
if possible, making sure that the patient is comfortable. Terminate the procedure at the
earliest convenient time.
f. If the anginal signs and symptoms do not resolve with this treatment within 2- 3
min, administer another dose of nitroglycerin, monitor the patient's vital signs, call the
patient's physician, and be ready to accompany the patient to the emergency
department.
g. A third nitroglycerin tablet may be given 3 min after the second. Chest pain that is
not relieved by three tab- lets of nitroglycerin indicates a possible Ml. The patient
should be transported to the nearest emergency medi- cal facility immediately

16. * Restrictions on use of local anesthetics containing epineph- rine
are similar to those for the patient with hypertension.
* In addition, intraosseous injection with epinephrine-containing
local anesthetics using special systems (eg, Stabident and Fair- fax
Dental) should be done cautiously in patients with isch- emic heart
disease, because it results in transient increases in heart rate and
myocardial oxygen demand.

17. MI
MI is the other category of ischemic heart disease encoun- tered in
dental practice.
Dental treatment is generally deferred for at least 6 months after MI
because peak mortality occurs during this time.
After 6 months, MI patients can usually be treated using techniques
similar to those for a stable angina patient.

18. Congestive Cardiac Failure
* CCF 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 poorly controlled or untreated CCF are not
candidates for elective dental procedures. These individuals are at
risk for sudden death, usually from ventricular arrhythmias.
*For patients with treated CCF, the clinician should consult with the
physician regarding the severity of CCF, underlying etiology, and
current medical management.

19. * Due to the presence of orthopnea (inability to breathe unless in an
upright position) in some CHF patients, the dental chair should be
adjusted to a comfortable level for the patient rather than being placed
in a supine position
* Short appointments
stress reduction with profound local anesthesia
possibly conscious sedation,
use of supplemental oxygen

20. Cardiac Pacemakers and Implantable Cardioverter-
Defibrillators
* Cardiac arrhythmias are treated with implantable pace- makers or
automatic cardioverter-defibrillators.
*Consultation with the patient's physician allows the determination of the
underlying cardiac status, the type of pacemaker or automatic
cardioverter- defibrillator, and any precautionary measures to be taken.
*Older pacemakers were unipolar and could be disrupted by dental
equipment that generated electromagnetic fields, such as ultrasonic and
electrocautery units.
*Newer units are bipolar and are generally not affected by dental
equipment.

21. * Automatic cardioverter-defibrillators activate without warning when cer-
tain arrhythmias occur.
* This may endanger the patient during dental treatment because such
activation often causes sudden patient movement.
* Stabilization of the operating field dur- ing periodontal treatment with bite
blocks or other devices can prevent unexpected trauma.

22. Infective Endocarditis
* previous c/a bacterial endocarditis.
*IE is a disease in which microorganisms colonize the damaged
endocardium or heart valves
* causative agents - alpha haemolytic streptococci and staphylococci
Acute endocarditis
Streptococci and staphylococci -
affects normal cardiac tissue
Sub Acute - affects damaged
endocardium/ heart valves with
low grades.
E.g . Rheumatic endocarditis

23. Preventive measures to reduce the risk of IE should consist of the
following:
1. Define the susceptible patient: A careful medical history will disclose
the previously mentioned susceptible patients.
2. Provide oral-hygiene instruction:Oral hygiene should be practiced with
methods that improve gingival health. In patients with significant gingival
inflammation, oral hygiene should initially be limited to gentle procedures
(ie, oral rinses and gentle toothbrushing with a soft brush) to minimize
bleeding. As gingival health improves, more aggressive oral hygiene
may be initiated.
Oral irrigators are generally not recommended because their use may
induce
bacteremia.

24. 3. During periodontal treatment, currently recommended antibiotic prophylactic regimens
should be practiced with all highrisk patients
In patients who have been receiving continuous oral penicillin for secondary prevention of
rheumatic fever, penicillin resistant a hemolytic Streptococci are occasionally found in the
oral cavity It is therefore recommended that an alternate regimen be followed instead
if the periodontal patient is taking a systemic antibiotic as part of periodontal therapy,
changes in the IE prophylaxis regimen may be indicated.
For example
1) a patient currently taking a penicillin agent after regenerative therapy may be placed on
azithromycin before the next periodontal procedure.
2) Patients with early onset forms of periodontitis often have high levels of A
actinomycetemcomitans in the subgingival plaque. This organism has been associated with
IE and is often resistant to penicillin. Therefore, in patients with aggressive periodontitis who
should be given prophylaxis, Slots et al suggested the use of tetracycline, 250 mg, 4 times
daily for 14 days to eliminate or reduce A actinomycetemcomitans, followed by the
conventional prophylaxis protocol, at the time of dental treatment.

26. Endocrine Disorders

27. Diabetes
* DM is a group of disorders characterise by hyperglycaemia resulting from
defects in insulin production, secretion, insulin action or both
* periodontitis is 6th complication of DM
* 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: fasting blood glucose and casual glucose
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. Limit more advanced
care until diagnosis has been established and a good glycemic control is

28. DIAGNOSTIC CRITERIA
1. Symptoms of diabetes plus casual (nonfasting) plasma glucose >200 mg/dl.
Casual glucose may be drawn at any time of day without regard to time since the
last meal. Classic symptoms of diabetes include polyuria, polydipsia, and
unexplained weight loss.
2. Fasting plasma glucose >126 mg/dl . "Fasting" is defined as no caloric intake
for at least 8 h. (Normal fasting glucose is 70-100 mg/dl.)
3. Two-hour postprandial glucose 2:200 mg/dl during an oral glucose tolerance
test.' The test should be performed using a glucose load containing the equivalent
of 75 gof anhydrous glucose dissolved in water. (Normal 2-h postprandialglucose
is <140 mg/dl.)
Testsfor Diabetesand Metabolic Control
For an undiagnosed or suspected diabetic patient, with or without symptoms, a
glucose tolerance test should be done.
For an already diagnosed patient, the metabolic control is assessed by the
glycosylated hemoglobin assay (HbAlC)

30. Guidelines for Managing a Diabetic Patient in the Dental
Office
1. For a controlled diabetic for a nonsurgical therapy, no anti- biotic premedication
is required. However, before surgical procedures prophylactic antibiotics are
recommended.
2. Patients should be asked to bring their glucometer to the dental office at each
appointment.
3. Patients should check their blood glucose before any long procedure to obtain
a baseline level.
4. If the procedure lasts several hours, it is often beneficial to check the glucose
level during the procedure to ensure that the patient does not become
hypoglycemic.
5. After the procedure, the blood glucose can be checked again to assess
fluctuations over time.
6. If the patient feels symptoms of hypoglycemia during the procedure, blood-
glucose levels should be checked imme- diately. This may prevent onset of
severe hypoglycemia, which is a medical emergency

31. * The most common dental-office complication, seen in diabetic patients
taking insulin, is symptomatic low-blood glucose, or hypoglycemia.
* Hypoglycemia does not usually occur until blood-glucose levels fall below
60 mg/dl
* signs and symptoms of hypoglycaemia are
Shakiness or tremors Confusio n
Agitation and anxiety Sweating
Tachycardia
Dizziness
Feeling of "impending doom" Unconsciousness
Seizures

32. Management
* If hypoglycemia occurs during a dental treatment, therapy should be
immediately terminated. If a glucometer is avail- able, the blood glucose level
should be checked
1. Provide approximately 15 g of oral carbohydrate to the patient:
2. If the patient is unable to take food or drink by mouth, or if the patient is
sedated:
a. Give 25- 30 ml of 50% dextrose intravenous (IV),
which provides 12.5- 15.0 g of dextrose, or
b. Give 1 mg of glucagon IV (glucagon results in rapid
release of stored glucose from the liver), or
c. Give 1 mg of glucagon intramuscularly or subcutane-
ously (if no IV access is present).
As a general guideline, well-controlled diabetic patients, having rou- tine
periodontal treatment, may tahe their normal insulin doses as long as they also
eat their normal meal.

33. Thyroid and Parathyroid Disorders
* Periodontal therapy requires minimal alterations in the patient with adequately managed thyroid
and parathyroid disease.
* Patients with thyrotoxicosis and those with inadequate medical management should not receive
periodontal therapy until their conditions are stabilized.
* Hyperthyroidism may cause tachycardia and other arrhythmias, increased cardiac output, and
myocardial ischemia. Medications, such as epinephrine and other vaso- pressor amines, should
be given with caution in patients with treated hyperthyroidism although the small amounts used in
dental anesthetics rarely cause problems.
* Patients with hypothyroidism require careful administration of sedatives and narcotics because
of the potential for excessive sedation.
* untreated parathyroid patients may have significant renal disease, uremia, and hypertension.
* Also, if hyper- calcemia or hypocalcemia is present, the patient may be more prone to cardiac
arrhythmias.

34. Adrenal Insufficiency
* most common cause of adrenal insufficiency is chronic therapeutic corticosteroid
administration
* In the normal healthy patient, stress activates the HPA axis, stimulating increased
endogenous cortisol production by the adrenal glands. Exogenous steroids may
suppress the HPA axis and impair the patient's ability to respond to stress with
increased endogenous cortisol production, leading to the potential for an acute
adrenal crisis.
* Acute adrenal insufficiency is associated with significant morbidity and mortality as
a result of peripheral vascular collapse and cardiac arrest.
*the periodontist should be aware of the clinical manifestations and ways of
preventing acute adrenal insufficiency in patients with histories of primary adrenal
insufficiency (Addison disease) or secondary adrenal insufficiency (most often
caused by use of exogenous glucocorticosteroids)

35. Management
* Use of a stress-reduction protocol and profound local anesthesia will
help minimize the physical and psychologic stress associated with
therapy and reduce the risk of an acute adrenal crisis.
1. Terminate periodontal treatment.
2. Summon medical assistance.
3. Administer oxygen.
4. Monitor vital signs.
5. Place the patient in a supine position.
6. Administer 100 mg of hydrocortisone sodium succinate
intramuscularly or IV over 30 s

36. Hemorrhagic Disorders…..!!!!!

37. Patients with a history of bleeding problems caused by disease or drugs
should be managed to minimize risks of hemorrhage.
Identification of these patients can be done by following methods
1) health history
2) clinical examination
3) laboratory tests

38. Coagulation Disorders
The main inherited coagulation disorders include
1) hemophilia A( deficiency of factor 8)
2) hemophilia B( deficiency of factor 9)
3) von-Willebrand disease

39. von-Willebrand disease results from a deficiency of von- Willebrand factor,
which mediates adhesion of platelets to the injured vessel wall and is
required for primary hemostasis. von-Willebrand factor also carries the
coagulant portion of factor Vlll in the plasma.
Management
1) Periodontal treatment may be performed in patients with these
coagulation disorders, provided that sufficient precau- tions are taken.
2) Probing, scaling, and prophylaxis can usually be done without medical
modification.
3) More invasive treat- ments, such as local-block anesthesia, root
planing, or surgery dictate prior physician consultation.
4) During treatment, local measures to ensure clot forma- tion and stability
are of major importance. Complete wound closure and application of
pressure will reduce hemorrhage.

41. 5) Antihemostatic agents, such as oxidized cellulose or purified bovine
collagen, may be placed over surgical sites or into ex- traction sockets.
6) The antifibrinolytic agent £-aminocaproic acid (Amicar), given orally or
via IV, is a potent inhibitor of initial clot dissolution.
7) Tranexamic acid is a more potent antifibnno- lytic agent than Amicar
and has been shown to prevent ex- cessive oral hemorrhage after
periodontal surgery and tooth extraction.
* Liver dis- ease may affect all phases of blood clotting because most co-
agulation factors are synthesized and removed by the liver.
* long term alcohol abusers or chronic hepatitis patients and patients with
vitamin k deficiency often demonstrate inadequate coagulation.

42. Dental-treatment planning for patients with liver disease should include
the following:
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):
a. International normalized ratio (INR; PT) should gener- ally be less
than 2.0. For simple surgical procedures, INR less than 2.5 is generally
safe.
b. Platelet count should be more than 80,000 mm>' .

45. Thrombocytopenic Purpuras
* Thrombocytopenia is defined as a platelet count of less than 100,000
mm3 '
* Purpuras are hemorrhagic diseases characterized by extravasation of
blood into the tissues under the skin or mucosa, producing spontaneous
petechiae (small- red patches) or ecchymoses (bruises).
* Bleeding caused by thrombocytopenia may be seen with
- idiopathic thrombocytopenic purpuras
- radiation therapy
- myelosuppressive drug therapy (eg, chemotherapy)
- leukemia, or infections.

46. Management
* Periodontal therapy for patients with thrombocytopenia should be
directed toward reducing inflammation by removing local irritants to
avoid the need for a more aggressive therapy.
* Oral-hygiene instructions and frequent mainte- nance visits are
paramount.
* 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 mm3 '.
* Platelet transfusion may be required before surgery.
* Surgical technique should be as atraumatic as possible and local
hemostatic measures should be applied.

48. Nonthrombocytopenic 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 and aspirin), dysproteinemia, and other
causes.
* Thrombasthenia occurs in uremia, Glanzmann disease, aspirin
ingestion, and von-Willebrand disease.
* Both types of nonthrombocytopenic purpura may result in immediate
bleeding after gingival injury
* Treatment consists primarily of direct pressure applied for at least 15
min.
* Surgical therapy should be avoided until the qualitative and quantitative
platelet problems are resolved.

50. Leukemia
* Altered periodontal treatment for patients with leukemia is based on their enhanced
susceptibility to infections, bleeding tendency, and the effects of chemotherapy.
The treatment plan for leukemia patients is as follows
1. Refer the patient for medical evaluation and treatment. Close cooperation with the
physician is required.
2. Before chemotherapy, a complete periodontal treatment plan should be developed with a
physician
a. Monitor hematologic laboratory values daily: bleedingtime, coagulation time, PT, and
platelet count.
b. Administer antibiotic coverage before any periodontaltreatment because infection is a
major concern.
c. Extract all hopeless, nonmaintainable, or potentially infectious teeth at least 10 days
before the initiation of chemotherapy, if systemic conditions allow.
d. Periodontal debridement (scaling and root planing) should be performed and thorough
oral-hygiene instructions given if the patient's condition allows. Twice daily rinsing with
0.12% chlorhexidine gluconate is recommended after oral-hygiene procedures. Recognize
the potential for bleeding caused by thrombocytopenia. Use pressure and topical hemostatic
agents asindicated.

51. 3. During the acute phases of leukemia, patients should receive only emergency
periodontal care. Any source of potential infection must be eliminated to prevent
systemic dissemination. Antibiotic therapy is frequently the treatmemt of choice,
combined with nonsurgical or surgical debridement as indicated.
4. Oral ulcerations and mucositis are treated palliatively with agents, such as
viscous lidocaine. Systemic antibiotics may be indicated to prevent secondary
infection.
5. Oral candidiasis is common in leukemic patients and can be treated with
nystatin suspensions (100,000 U/ml, 4 times daily) or clotrimazole vaginal
suppositories (10 mg, 4- 5 times daily).
6. For patients with chronic leukemia and those in remissions, scaling and root
planing can be performed without complication, but periodontal surgery should
be avoided if possible.
a. 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
physicia

52. Antiplatelet Medications
* aspirin bind irreversible to platelets and interferes with normal platelet
aggregation and can result in prolonged bleeding.
* In general, patients taking low doses( 325mg) of aspirin daily do not
need to discontinue aspirin therapy before periodontal procedures.
* However, higher doses may increase bleeding time and predispose
the patient to postoperative bleeding.therefore these patients aspirin
may need to be discontinued for 7- 10 days before surgical therapy, in
consultation with the physician.
* Nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen,
also inhibit platelet function

53. Anticoagulant Medications
* The most common cause of abnormal coagulation may be drug
therapy
* These drugs are vitamin K antagonists that decrease production of
vitamin K-dependent coagulation factors II, VII, IX, and X
* The recommended level of therapeutic anticoagulation for most
patients is an INR of 2.0- 3.0, with prosthetic heart valve patients
generally in the 2.5- 3.5 range.
* anticoagulant therapy - coumarin derivatives
dicumarol and warfarin.

54. Traditional recommendations for periodontal treatment are as follows:
1. Consult the patient's physician to determine the nature of the
underlying medical problem and the degree of re- quired anticoagulation.
2. The procedure to be done determines the acceptable INR. Infiltration
anesthesia, scaling, and root planing may be done safely in patients with
an INR <3.0. Block anes- thesia, minor periodontal surgery, and simple
extractions usually require an INR <2.0- 2.5. Complex surgery, mul- tiple
extractions or implant placement may require an INR <1.5- 2.0.

55. 3. The physician must be consulted about any changes (dis- continuing or
reducing) in anticoagulant dosage until the desired INR is achieved. The
dentist must inform the physician the extent of intraoperative and
postoperative bleeding that is usually expected with the procedures
planned. If the INR is higher than the level at which significant bleeding is
likely to accompany a particular procedure, the physician may change the
anticoagulant therapy. Often, the anticoagulant is discontinued for 2- 3 days
before periodontal treatment (clearance half-life of warfarin is 36- 42 h),
and the INR is checked on the day of therapy. If the INR is within the
acceptable target range, the procedure is performed and the anticoagulant
is resumed immediately after treatment.
4. Careful technique and complete wound closure are para- mount. For all
procedures, application of pressure can minimize hemorrhage. Use of
oxidized cellulose, micro- fibrillar collagen, topical thrombin, and tranexamic
acid should be considered for persistent bleeding.

56. Renal Diseases

57. The following treatment modifications should be used:
1. Consult the patient physician.
2. Monitor BP (patients in end-stage renal failures are usually hypertensive) .
3. Check laboratory values: PTT, PT, bleeding time, and platelet count;
hematocrit; blood-urea nitrogen (do not treat if <60 mg/dl.); and serum creatinine
(do not treat if <1.5 mg/dL).
4. Eliminate areas of oral infection to prevent systemic infections
a. Good oral hygiene should be established.
b. Periodontaltreatmentshouldaimateliminatinginflam- mation or infection
And providing easy maintenance.Questionable teeth should be extracted if
medical Parameters permit.
c. Frequent recall appointments should be scheduled.
5. Drugs that are nephrotoxic or metabolized by the kidney should not be given
(eg, phenacetin, tetracycline, and ami- noglycoside antibiotics). Acetaminophen
may be used for analgesia and diazepam for sedation. Local anesthetics, such
as lidocaine, are generally safe.

58. Dialysis
The three modes of dialysis
1) intermittent peritoneal dialysis (IPD)
2) chronic ambulatory peritoneal dialysis (CAPD)
3) hemodialysis ( require special precautions )
These patients have a high incidence of viral hepatitis, anemia, and
prolonged hemorrhage.
The risk for hemorrhage is related to anticoagulation during dialysis,
platelet trauma from dialysis, and the uremia that develops with renal
failure. Hemodialysis patients have either an internal arteriovenous fistula
or an external arterio- venous shunt. This shunt is often located in the
arm and must be protected from trauma.

59. Thus, in addition to guidelines for patients with chronic renal disease, the
following recommendations are made for those receiving hemodialysis:
1. Screen for hepatitis B and hepatitis C antigens and anti- bodies before
any treatment.
2. Provide antibiotic prophylaxis to prevent endarteritis of the
arteriovenous fistula or shunt. (IPD and CAPD patients do not generally
require prophylactic antibiotics.)
3. Patients receive heparin anticoagulation on the day of h em o d i a l y s
i s . Therefore periodontal treatment should be provided on the day after
dialysis, when the effects of heparinization have subsided. Hemodialysis
treatments are generally performed 3- 4 times a week. (IPD and CAPD
patients are not systemically heparinized; therefore they usually do not
have the potential bleeding problems associated with hemodialysis.)

60. 4. Be careful to protect the hemodialysis shunt or fistula when the patient
is in the dental chair. If the shunt or fis- tula is placed in the arm, do not
cramp the limb; BP read- ings should be takenf rom the other arm. Do not
use the limb for the injection of medication. Patients with leg shunts
should avoid sitting with the leg dependent for longer than 1 h. If
appointments last longer, allow the patient to walk about for a few
minutes, then resume therapy.
5. Refer the patient to the physician if uremic problems de- velop, such as
uremic stomatitis. To prevent systemic dis- semination, refer to the
physician if oral infections do not
promptly resolve.

61. Why periodontal Rx beforeTransplantation
* Many organ transplant centers now include dental examination in their
standard pretransplant protocol.
* Excessive bleeding may occur during or after periodontal treatment
because of drug-induced thrombocytopenia, anticoagulation, or both.
* Transplant patients take immunosuppressive drugs that greatly reduce
resistance to infection.
* Teeth with severe bone and attachment loss, furcation invasion,
periodontal abscesses, or extensive surgical requirements should be
extracted, leaving an easily maintainable dentition before transplantation

62. Pulmonary Diseases

63. Pulmonary diseases range from
* obstructive lung diseases (eg, asthma, emphysema, bronchitis, or acute
obstruction)
* restrictive ventilatory disorders caused by muscle weakness, scarring,
obesity, or any condi- tion that could interfere with effective lung
ventilation.
*Caution should be practiced in relation to any treatment that may
depress respiratory function.

64. The following guidelines should be used during periodontal therapy:
1. Identify and refer patients with signs and symptoms of pulmonary disease to their
physician.
2. In patients with known pulmonary disease, consult with their physician regarding
medications (antibiotics, steroids, and chemotherapeutic agents) and the degree and
severity of pulmonary disease.
3. Avoid elicitation of respiratory depression or distress:
a. Minimize the stress of a periodontal appointment. The patient with emphysema
should be treated in the afternoon, several hours after sleep, to allow for airway
clearan ce.
b. Avoid medications that could cause respiratory depression (eg, narcotics,
sedatives, or general anesthetics).
c. Avoid bilateral mandibular-block anesthesia, which
could cause increased airway obstruction.
d. Position the patient to allow maximal ventilatory efficiency, be careful to prevent
physical airway obstruction, keep the patient's throat clear, and avoid
excess periodontal packing.

66. Tuberculosis
* The patient with tuberculosis should receive only emergency care
* If the patient has completed chemo- therapy, the patient's physician
should be consulted regarding infectivity and the results of sputum
cultures for Mycobacterium tuberculosis.
* Adequate treatment of tuberculosis requires a minimum of 18 months
and thorough posttreat- ment follow-up should include chest radiographs,
sputum cultures, and a review of the patient's symptoms by the physician
at least every 12 months.

67. Hepatitis
* 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 DNA virus known as transfusion-
transmitted virus has recently been identified in cases of acute and
chronic hepatitis.

68. Management
The following guidelines are offered for treating hepatitis patients:
1. If the disease, regardless of type, is active, do not provide periodontal
therapy unless the situation is an emergency. In an emergency case,
follow the protocol for patients posi- tive for hepatitis Bsurface antigen
(HBsAg).
2. For patients with a past history of hepatitis, consult the physician to
determine the type of hepatitis, course and length of the disease, mode of
transmission, and any chronic liver disease or viral carrier state.
3. For recovered HAV or HEV patients, perform routine peri- odontal care.

69. 4. For recovered HBV and HDV patients, consult with the physician and
order HBsAg and anti-HBs (antibody to HBV surface antigen) laboratory
tests.
a. If HBsAg and anti-HBs tests are negative but HBV is suspected, order
another HBs determination.
b. Patients who are HBsAg positive are probably infective (chronic
carriers); the degree of infectivity is measured by an HBsAg determination.
c. Patients who are anti-HBs positive may be treated routinely (they have
antibody to HBsAg).
d. Patients who are HBsAg negative may be treated routinely.
5. For HCV patients, consult with the physician to determine
the patient's risk for transmissibility and current status of
the chronic liver disease.

70. 6. If a patient with active hepatitis, positive-HBsAg (HBV carirer ) status, or positive-
HCV carrier status requires emer- gency treatment, use the following precautions:
a. Consult the patient's physician regarding the status.
b. If bleeding is likely during or after treatment, measure
PT and bleeding time. Hepatitis may alter coagulation; change treatment
accordingly.
c. All personnel in clinical contact with the patient should
use full-barrier technique, including masks, gloves, glasses or eye shields, and
disposable gowns.
d. Use as many disposable covers as possible, covering light handles, drawer
handles, and bracket trays. Head- rest covers should also be used.
e. All disposable items (eg, gauze, floss, saliva ejectors, masks, gowns, or gloves)
should be placed in a one- lined wastebasket. After treatment, these items and all
disposable covers should be bagged, labeled, and dis- posed of, following proper
guidelines for biohazardous waste.
f. Aseptic technique should be followed at all times. Minimize aerosol production by
not using ultrasonic

71. instrumentation, air syringe, or high-speed handpieces; remember that
saliva contains a distillate of the virus. Prerinsing with chlorhexidine
gluconate for 30 s is highly recommended.
g. When the procedure is completed, all equipment should be scrubbed
and sterilized. If an item cannot be sterilized or disposed of, it should not
be used.

72. Conclusion
* in managing medically compromised patients,the clinician should
always obtain a physician consult before any periodontal treatment
* changes in recommendation for medically compromised patients are
continually occurring
* dentists should follow the recommendation from the patient physician
and utilise the appropriate protocol
* thus all clinicians need to be cognizant of the systemic implications of
periodontal disease and their treatment and should stay up to date to
give best possible treatment