Most of the students find difficulty while handling the medically compromised patients. This seminar presentation will help you in understanding and better handling the medically compromised patients. very is to understand the terminologies and apply to the patients.

1. PERIODONTAL
TREATMENT OF
MEDICALLY
COMPROMISED PATIENT
Guided By-
Dr. Arpita Gur
Professor and HOD
Dept. of Periodontology
Presented By-
Dr. Sameeta (Final year)
Dept. of Periodontology

2. CONTENTS
Introduction
Cardiovascular diseases
•Hypertension
• Ischemic heart diseases
1. Angina
2. Myocardial infarction
•Congestive heart failure (CHF)
• Pacemakers/Defibrillators
•Infective endocarditis
•Cerebrovascular accident
Endocrine disorders
•Diabetes mellitus
•Thyroid and parathyroid disorders
•Adrenal insufficiency

3. Hemorrhagic Disorders
•History
•Clinical examination
•Laboratory tests
•Coagulation disorders
1. Hemophilia A
2. Hemophilia B
3. Von Willebrand’s Disease
Anticoagulation medications
Antiplatelet medications
Thrombocytopenic purpura
Nonthrombocytopenic purpura
Blood dyscrasias
•Leukemia
•Chronic leukemia
•Agranulocytosis

4.  Medications and cancer therapies
 Bisphosphonates
 Corticosteroids
 Immunosuppression and chemotherapy
 Radiation therapy
 Renal diseases
 Liver diseases
 Pulmonary diseases
 Prosthetic Joint Replacement
 Pregnancy
 Infectious disease
 Hepatitis
 HIV and AIDS
 Tuberculosis
 References

5. Clinician’s
Responsibility
Identification
of
Medical
problems
Formulate
treatment
plans
Consultation/
Referral of the
patient
Medico legal
aspects
Better
patient
management
INTRODUCTION

6. CARDIOVASCULAR DISEASES
• Most prevalent and seen usually in older age patients
• History is of paramount importance and should of closely
scrutinized
• Includes;
• Hypertension,
• Angina, Myocardial infarction,
• cerebrovascular accidents,
• congestive heart failure(CHF),
• Pacemakers/Defibrillators
• Infective endocarditis

7. HYPERTENSION(HTN)
• Most common cardiovascular disease.
• Most frequently encountered in periodontal clinical practice.
• Hypertension is classified according to Joint National
Committee (JNC)-7 guidelines.
• JNC-7 guidelines emphasizes the importance of systolic blood
pressure(SBP) than diastolic blood pressure(DBP).

8. JNC-7 GUIDELINES
Pre hypertension
SBP;120-139 mm Hg
DBP; 80-89 mm H g
Stage I Hypertension
SBP; 140-159 mm Hg
DBP; 90-99 mm Hg
Stage II Hypertension
SBP> 160 mm Hg
DBP> 100 mm Hg

9. HTN is not diagnosed on single elevated BP recording but
classification is done on average value of two or more BP
recordings
Hypertension is classified as;
• Primary hypertension:
• Accounts of 95% of HTN
• Does not have any underlying cause or pathology
• Secondary hypertension:
• Accounts of 5% of HTN
• Does have underlying etiology like Renal disease, Endocrine and Neurogenic
disorders

10. Dentist can play significant role in hypertension detection
• First Dental office visit should include two BP readings spaced at
10 minutes interval- Average value of the two values should be
used as BASELINE.
• Before a Dentist refers a patient to physician because of elevated
BP- readings should be taken at minimum two appointments
unless measurements are extremely high(SBP> 180 mm Hg, DBP >
100 mm Hg.

11. Normal (SBP<120 and DBP <80 mm Hg)
No changes in dental treatment.
Pre hypertension ( SBP 120-139 or DPB 80-89 mm Hg )
No changes in dental treatment.
Monitor BP at each appointment.
Stage 1 hypertension( SBP140-159 or DBP 90-99 mm Hg)
Inform patient of findings.
Routine medical consultation/referral.
Monitor BP at each appointment.
No changes in dental treatment; minimize stress.
Stage 2 hypertension SBP ≥160 DBP ≥100 mm Hg
Inform the patient.
Medical consultation/referral.
Monitor BP at each appointment.

12. If systolic BP is <180 mm Hg and diastolic is <110 mm Hg, perform
selective dental care (routine exam, prophylaxis, restorative non surgical
and periodontics);with minimal stress.
If systolic BP ≥ 180 mm Hg or diastolic ≥100 mm Hg, give immediate
medical consultation/referral, and perform emergency dental care only (to
alleviate pain, bleeding, infection)*; with minimal stress.
If BP increases during treatment and not responding to his regular
medication, sodium nitroprusside drip should start to drop the BP. ( Leira
et al. 2022)

13. IF PATIENT IS ON
ANTIHYPERTENSIVE THERAPY
• Consultation with physician for medical status, medications ,
periodontal treatment plan and patient management should
be done.
• Dentist should discuss/inform the physician regarding
estimated degree of stress, length of procedures and
complexity of treatment plan.

14. • Morning dental appointments were once suggested for
hypertensive patients, however recent evidence shows that BP
generally increases around awakening and peak at morning.
• Lower BP levels are seen in afternoon, therefore afternoon
dental appointments should be preferred.
• No routine periodontal treatment should be given to a patient
who is hypertensive and not under medical management.
• Acute infections which require surgical incision and drainage-
surgical field should be limited as excessive bleeding can occur
with elevated BP.

15. • The clinician should not use a local anaesthetic containing
epinephrine concentration greater than 1:100,000 nor should
vasopressor be used to control local bleeding.
• Local anesthesia without epinephrine may be used for short
procedures(<30 minutes).

16. • Administration of LA containing epinephrine to patients
taking Non selective beta blockers(eg Propanolol, Nadolol)
may cause elevated BP.
• Epinephrine containing LA should be used cautiously and
only in very small amounts in patients taking Non-
selective Beta Blockers with careful monitoring of vital
signs.
Epinephrine α adrenegic
stimulation
Vasoconstricion
and
Increased BP

17. CLINICIANS SHOULD BE AWARE OF
MANY SIDE EFFECTS OF VARIOUS
ANTIHYPERTENSIVE MEDICATIONS
LIKE;
• Postural hypertension; can be minimized by slow positional
change in dental chair
• Depression
• Nausea, Sedation, Oral Dryness,
• Lichenoid drug reactions
• Gingival overgrowth

18. ISCHEMIC HEART DISEASE
Angina
– Myocardial O2 demands exceeds supply-Transient
Ischemia
– Stable Angina - Elective dental procedures
– Unstable Angina- Emergency procedures
– Stress reduction, Local anesthesia, conscious sedation-
anxious patient, Supplemental oxygen via nasal cannula.
– Nitroglycerine tablet (0.3-0.6 mg is given sublingually)
and second tablet is again given at 5 minutes if pain does
not subsides
– Third tablet of Nitroglycerine is again given at 5 minutes
and if pain does not subsides- Myocardial Infarction

19. Myocardial Infarction (MI)
• The patient is immediately referred to nearest medical
emergency facility
• Dental treatment is deferred for at least 6 months after MI
because of increased mortality during this time
• Cardiac bypass, femoral artery bypass, angioplasty ;-physician
consultation should be obtained before any dental procedure

20. ELECTIVE THERAPY IN PATIENTS
WITH HISTORY OF MI
Physician should be prior consulted to assess;
heart damage,
arterial occlusive disease,
stability of the patient,
Infection endocarditis or
graft rejection risk.

21. Congestive Heart failure(CHF)
– Heart is unable to pump required oxygenated blood to meet body’s demand.
– Elective dental procedures are not indicated in poorly controlled/untreated
CHF.
– Risk of sudden death from ventricular arrhythmia.
– Medical management of CHF include use of calcium channel blockers,
vasodilators, diuretics, angiotensin converting enzyme inhibitors.

22. • Because of Orthopnea(unable to breathe
unless in upright position) supine position
is avoided.
• Short appointment, stress reduction with
local anesthesia, conscious sedation,
supplemental O2.

23. CARDIAC PACEMAKERS
• Cardiac arrythmia are treated using medications, cardiac
pacemakers/implantable cardioverter.
• Older Pacemakers were unipolar and could be disrupted by dental
instruments like ultrasonic and electro cautery unit.
• Newer pacemakers are Bipolar and are not disrupted by dental
instruments.

24. IMPLANTABLE CARDIOVERTER
DEFIBRILLATORS
Automatic cardioverter defibrillators could activate
without warning in case of arrhythmia leading to
sudden patient movement so stabilization of
operating field using bite block is recommended to
prevent injury.

25. INFECTIVE ENDOCARDITIS
• Microorganisms (Streptococcus viridans, E corrodens )damage
endocardium or heart valves.
• High risk of developing endocarditis after dental induced
bacteremia.
• Bacteremia may occurs even in the absence of dental procedures,
specially in individuals with poor oral hygiene and significant
periodontal inflammation.

26. – Non streptococcal organisms often found in periodontal pokets
like E. corrodens, A. actinomycentemcomitans, Capnocytophaga,
and lactobacillus species.
– All periodontal procedures require antibiotic prophylaxis except
gentle oral hygiene methods like irrigation.
– Pretreatment chlorhexidine rinse is indicated before all
procedures-reduces microbial load.

27. ANTIBIOTIC PROPHYLAXIS IS GIVEN
PRIOR TO PERIODONTAL PROCEDURES
– Amoxycillin 2gm PO 1 hour before procedure
OR
– Clindamycin 600 mg PO 1 hour before procedure
OR
– Azithromycin 500 mg PO 1 hour before procedure
OR
– Ampicillin 2g IM/IV 30 mins before procedure

28. CEREBROVASCULAR
ACCIDENT(CVA)/STROKE
• CVA results from ischaemic changes in brain due to formation of
emboli or haemorrhage.
• Hypertension and atheroschlerosis are predisposing factors.
• Minor active infection should treat aggressively.
• No Periodontal therapy should be done within 6 month of
episode- High risk of recurrence.

29. CVA/STROKE
• Chlorhexidine rinse aids in plaque control.
• After 6 months periodontal therapy;
• Short appointment,
• Reduce Stress,
• Optimum LA
• Epinephrine greater than 1:100,000 are
contraindicated
• O2 supplement
• BP should be monitored.

30. ENDOCRINE DISORDERS
• Diabetes mellitus
• Thyroid and parathyroid disorders
• Adrenal insufficiency

31. DIABETES MELLITUS
• Types
– Type 1 IDDM
– Type 2 NIDDM
• Symptoms
– Polyphagia, Polydipsia, Polyuria
– Unexplained concurrent weight loss
– Periodontal therapy has limited success in undiagnosed or poorly
controlled diabetes

32. • Diagnostic criteria (at the time)
– Symptoms of diabetes plus casual (non fasting/Random) plasma glucose≥ 200
mg/dl
– Fasting Plasma glucose(FPG) ≥ 126mg/dl
– Normal FPG is 70-110mg/dl.
– HbA1/ HbA1c (long term)
– Glycosylated Hemoglobin (HbA1c) as per *American Diabetes Association
guidelines.
– Normal : 4% - 6%
– good diabetes control: <7%
– Moderate Diabetes control: 7% - 8%
– Action suggested to improve diabetes control: >8%

33. ORAL GLUCOSE TOLERANCE
TEST(OGTT)
– Two hour postprandial glucose >200 mg/dl during on oral glucose
tolerance test(OGTT)- Diagnostic of diabetes
– Normal OGTT <140 mg/dl
*OGTT- 75 gm anhydrous glucose dissolved in
water is given and glucose level assessed after 2
hours.

34. • Guidelines To be observed:
• Glucose level should be monitored regularly.
• Patient with DM should bring glucometer in the dental office and glucose
level should be measured before the procedure.
• If procedure lasts for several hours, beneficial to check the glucose level
during the procedure.
• Even after the procedure, blood glucose can be check again to assess
fluctuations.
• Dental office complication- Hypoglycemia(Blood glucose level< 60 mg/dl).

35. • Keep the appointments before or after periods of peak insulin
activity.
• Diabetic patients on Insulin are at greatest risk of developing
hypoglycemia, followed by those who taking Sulfonylureas
agents.
• Metformin and Thiazolidinediones generally do not cause
hypoglycemia.
• Taking Insulin without eating is primary cause of hypoglycemia.

36. HYPOGLYCEMIA
MANAGEMENT
• Terminate the treatment first.
• Blood glucose level should be checked.
• Hypoglycemic episode; 15 gm oral carbohydrate, 3-4tsp sugar, candy
with 15gm sugar/ 4-6 oz juice/ soda.
• If patient sedated/unable to drink/eat; 25-30ml of 50% Dextrose
intravenously(12-15gm dextrose) OR 1mg glucagon IV/IM/SC.
• Physician consultation

37. THYROID DISORDER
• Hyperthyroidism-risk of Thyrotoxicosis- no periodontal therapy.
• Tachycardia, arrythmias, increase cardiac output, myocardial ischaemia.
• Epinephrine and vasopressors should be avoided.
• Hypothyroidism- careful administration of sedatives and narcotics because of excessive
sedation.
• Routine periodontal therapy can be provided to patients with parathyroid disease.

38. ADRENAL INSUFFICIENCY
• Primary adrenal insufficiency(Addison’s Disease)
• Secondary adrenal insufficiency(Exogenous glucocortcoids)
– Suppression of HPA(Hypothalamus pituitary axis)
– Impaired Response to stress and increased cortisol
– Acute Adrenal Crisis

39. CLINICAL MANIFESTATIONS ADRENAL
INSUFFICIENCY;
• Mental confusion, fatigue and weakness
• Nausea & Vomiting
• Hypertension
• Syncope
• Intense abdominal pain, lower back pain, and leg pain
• Loss of Consciousness
• Coma

40. STEROID PROPHYLAXIS
• Administer prophylactic steroid before dental treatment in
patient who are/have taken exogenous steroids.
• Physician consultation necessary to evaluate for supplemental
steroid cover before dental procedures in patient who are/have
taken steroids.
• No set protocol for steroid prophylaxis.

41. MANAGEMENT OF ACUTE
ADRENAL INSUFFICIENCY
• Terminate Dental Procedure
• Call Medical Assistance
• Give Oxygen
• Monitor Vital Signs
• Place patient in Supine position
• Administer 100 mg of Hydrocortisone sodium succinate intravenously
over 30 seconds or intramuscularly.

42. HEMORRHAGIC DISORDERS
OR
BLEEDING DISORDERS

43. BLEEDING DISORDER
Bleeding
Disorders
History
Laboratory
Investigations
Clinical
Examination

44. HISTORY SHOULD COVER;
• History of Bleeding after previous surgery or trauma
• Past and Present drug history
• History of Bleeding in relatives
• Potential bleeding problems

45. CLINICAL EXAMINATION INCLUDES;
– Spontaneous gingival bleeding
– Gingival Hyperplasia
– Eechymosis
– Petechiaes
– Hemorrhagic vesicles
– Spider telegiectasia
– Hemarthrosis/Joint bleeding
– Presence of Jaundice

46. LABORATORY TESTS
– Measure Hemostatic, Coagulation,or Lytic Phase of CLOTTING
Mechanism
– Depending on Clues (History and Examination) regarding Phase
involved, includes
– Bleeding Time,
– Complete Blood Count,
– PT, PTT
– Coagulation time (CT)

47. BLEEDING DISORDERS
CLASSIFIED AS;
• Coagulation disorders
• Thrombocytopenic purpuras
• Non thrombocytopenic purpura

48. COAGULATION DISORDERS
• Hemophilia A
• Hemophilia B
• Von Willebrand’s Disease

49. HEMOPHILIA A
• Deficiency of factor VIII
• Severe Hemophilia: Factor VIII less than 1%
• Moderate Hemophilia: Factor VIII 1-5%
• Mild Hemophilia: Factor VIII 6-30%
• Haematologist consultation is paramount
• To prevent surgical heorrhage Factor VIII levels are atleast 30%.
• Parenteral 1-deamino-8-D arginine vasopressin (DDAVP)
/Recombinant Factor VIII are use to increase Factor VIII levels

50. HEMOPHILIA B OR CHRISTMAS
DISEASE
• Deficiency of Factor IX; severity of disease depends on relative
amount of Factor IX
• Surgical therapy;30-50% of Factor IX level
• Haematologist consultation is paramount
• Factor IX levels are increased by administration of Purified
Prothrombin Complex/ Factor IX concentrates

51. VON WILLEBRAND’S DISEASE;
• Deficiency of Von Willebrand factor(VWF)
• VWF mediates adhesion of platelets to injured vessel wall and essential
for Primary Hemostasis
• VWF carries coagulation portion of factor VIII in plasma
• Go undiagnosed and may be discovered as bleeding during dental
surgical procedures
• Treatment Infusion of preoperative Factor VIII /Cryoprecipitate/DDAVP

52. PERIODONTAL TREATMENT
CONSIDERATIONS IN COAGULATION
DISORDERS
– Probing, Scaling, Prophylaxis can be usually done without medical
modifications
– Invasive procedures like-blocks, root planing, surgery need prior
Physician consultation
– Anti hemostatic agents like oxidized cellulose or purified bovine
collagen should be placed over surgical site

53. – Anti fibrinolytic agent Epsilon-Aminocaproic acid(EACA) given oral/IV
inhibits initial clot dissolution
– Tranexamic acid is potent Antifibrinolytic agent- prevents excess
hemorrhage after surgery
– Tranexamic acid as oral rinse or in combination with systemic Tranexamic
acid prevent given for several days to prevent oral hemorrhage
– Not all Coagulation disesaes are hereditary .

54. NON HEREDITARY
COAGULATION
• Liver diseases affect all phases of clotting disorder
• Alcohol users, Hepatitis, Liver diseases: Inadequate Coagulation
• Vitamin K deficiency; due to malabsorption syndromes,
Antibiotics induced alteration of gut flora

55. PERIODONTAL SURGERY IN
LIVER DISEASE PATIENT
– Physician consultation
– Laboratory evaluations:
• PT, Bleeding time,
• Platelet Count, and
• PTT(in Patients with later stages of liver diseases)
• Conservative Nonsurgical Periodontal therapy wherever possible
• If Surgery (Hospitilization) required; PT- international normalized ratio (INR)
should be less than 2.
• Simple Surgery PT-INR less than 2.5 is safe

56. ANTICOAGULANT DRUGS
• Anticoagulant therapy(MI,CVA, Prosthetic valves diseases)
• Coumarin derivatives: Dicumarol and Warfarin
• Vitamin K antagonists
• Decrease production of Vitamin K dependent coagulation factors;
II,VII,IX,X
• Recommended level of anticoagulation INR: 2 to 3 for most
patients,
• Patients with Prosthetic valve INR: 2.5 to 3.5

57. PERIODONTAL TREATMENT IN
PATIENTS WITH ANTICOAGULANTS
• Consult Physician
• Infiltration anesthesia, Scaling Root planing can be done INR<3
• Block Anesthesia, Minor Periodontal surgery and extraction INR: 2
to 2.5
• Complex surgeries/Multiple extraction INR:1.5-2
• Discontinuing Anticoagulants before periodontal surgery was
common in past, However it is not recommended by most Physicians
now due to increased risks

58. – Careful technique and complete wound closure
– Application of pressure to minimize hemorrhage
– Use of Oxidized cellulose, Topical thrombin and Tranexamic acid
can be used to prevent bleeding

59. HEPARIN
• Heparin is short term anticoagulation agent given IV/SC,
powerful anticoagulant(duration of action 4 to 8 hours).
• Periodontal treatment is rarely done in patients undergoing
heparin therapy.

60. ANTIPLATELET MEDICATIONS
• Aspirin interferes with normal platelet aggregation and can
cause prolonged bleeding(Affect of Aspirin lasts for 4to 7 days).
• Patient taking low dose Aspirin 325 mg need not to stop before
the procedure.
• Aspirin should not be prescribed to patient undergoing
Anticoagulation therapy

61. THROMBOCYTOPENIC PURPURA
• Thrombocytopenia defined as Platelet Counts less than 100,000/cubic mm
• Idiopathic, Radiation, Leukemia, Infections Chemotherapy,
• Purpura-Extravasation of blood into tissues under skin or mucosa producing
small petechiae or echymoses (bruises)
• Physician Consultation is mandatory

62. • Periodontal treatment should directed towards reducing
inflammation by removal of local factors
• Scaling and Root Planing are safe with platelet count
>60,000/cubic mm
• Surgical Procedures can only be done with Platelet counts
>80,000/cubic mm
• Platelet transfusion may be required before surgery.
• Surgery- atraumatic as possible.

63. NONTHROMBOCYTOPENIC
PURPURA
• It results from vascular wall fragility.
• Vascular wall fragility can result from hypersensitivity
reaction, scurvy, infections.
• Surgical therapy should be avoided.

64. BLOOD DYSCRASIAS
• Leukemia
• Periodontal treatment in leukemia is altered;
• due to enhanced susceptibility to infections, bleeding tendency,
Chemotherapy complications
• Before Chemotherapy a complete periodontal treatment plan
should be developed with a Physician.
• Medical evaluation by Physician/Haematologist.
• Antibiotic coverage

65. – Extract all hopeless, non restorable infectious teeth before
Chemotherapy.
– Periodontal debridement, 0.12% CHX rinse, Pressure and
Topical agent are indicated.
– Antibiotic therapy
– Oral ulceration, mucositis treated palliatively using viscous
lidocaine
– Oral Candidiasis: Local Nystatin/Clotrimazole

66. CHRONIC LEUKEMIA;
• SRP can be done without complications
but surgery avoided.
• Platelet count and bleeding time should be
done on day of the procedure.
• If low then postpone the appointment.
Refer to Physician

67. AGRANULOCYTOSIS
• Patient with Agranulocytosis(Cyclic Neutropenia and
Granulocytopenia) have increased susceptibility to infection.
• Total WBC reduced and Granular
leukocytes(Neutrophils,Eosinophils,Basophils) are reduced.
• Severe Periodontal Destruction.

68. MANAGEMENT
• Physician Consultation
• Extraction of Severely affected tooth
• Oral Hygiene Instruction
• Use of CHX rinse for plaque control
• Scaling and root planing should be done under antibiotic
prophylaxis

69. MEDICATIONS AND CANCER
THERAPIES
• Cure, manage, or prevent the disease but effect on periodontal
tissues, wound healing or host immune responses.
• 1. Bisphosphonates:
• Treat the cancers and osteoporosis.
• IV bisphosphonates: invasive treatment, extractions, periodontal
surgery, implants- avoided.
• Risk consider: if taking oral bisphosphonates longer than 3 years.

70. • 2. Corticosteroids:
• Risk for secondary adrenal insufficiency.
• hypertension, osteoporosis, peptic ulcers.
• Adrenal insufficiency receives routine dental treatment without
supplemental glucocorticosteroids.
• Lengthy major surgeries: requires supplementation
• Low adrenal function: consultation, steroid supplementation
• Steroid cover is indicated for patients taking >7.5 to 10 mg prednisolone
for longer than 3 months and undergoing periodontal therapy and /or
treatment under general anesthesia (Leira et al. 2022).

71. • 3. Immunosuppression and chemotherapy:
• Impaired host defense , Risk of infection
• Minor periodontal surgery: life-threatening condition.
• Poor prognosis: extraction, debridement to minimize microbial
load
• CHX rinses recommended
• If periodontal Therapy needed during chemotherapy: best
done day before chemotherapy given.
• Coordinate with oncologist.
• Dental treatment: WBC’s >2000/cubic mm.
• Prophylactic administration of antibiotics may ne indicated in patients who are
immunosuppressed (Yago Liera 2022).

72. • 4. Radiation therapy:
• Treatment of head and neck tumors.
• Effects: perioral changes, mucositis, dermatitis, xerostomia,
dysphagia, gustatory alterations, radiation caries, vascular
changes, trismus, TMJ degenerations.
• Patients who receive radiation therapy require dental
consultation at the earliest possible time to reduce the
morbidity of known perioral side effects. (Schiodt M 2002).
• Tooth extraction after radiation therapy high risk of
developing osteoradionecrosis (ORN).

73. • Surgical flap procedure mostly discourage after radiation
therapy.
• Non-restorable and severe periodontal diseased tooth:
extraction
• Brush daily with 0.4%stannous or 1.0% sodium fluoride gel.
• Custom gel trays provide optimum fluoride application
(Vissink A, et al. 2003).
• 3-month recall is ideal.

74. RENAL DISEASES
• Common cause of renal failure are glomerulonephritis,
pyelonephritis, kidney cystic disease, renovascular disease,
drug nephropathy, obstructive uropathy, and hypertension.
• Physician consultation
• Monitor BP
• Eliminate area of oral infection
• Acetaminophen: analgesia & diazepam for sedation
• Lidocaine is safe.

75. • Renal transplant recipient:
• 1. hepatitis B and C screening
• 2. antirejection drug therapy : level of immune system
compromise.
• 3. prophylactic antibiotic

76. LIVER DISEASES
• Causes: drug toxicity cirrhosis, viral infection, neoplasm, and
biliary tract disorder.
• Site of production of clotting factors: severe bleeding
• Recommendations: consultation, screening Hepatitis B&C, PT,
PTT, INR.

77. • LIVER TRANSPLANT RECIPIENT PATIENTS:
• Periodontal infections: life threatening condition
• Pre-transplantations evaluations is necessary
• Severe bone, attachment loss, furcation, abscess, surgical
required : extracted.

78. PULMONARY DISEASES
• From obstructive lung diseases to restrictive ventilatory
disorders.
• Sign & symptoms:
• Increase respiratory rate
• Cyanosis
• clubbing of fingers
• Chronic cough
• Chest pain
• dyspnea, orthopnea
• wheezing

79. • Guidelines:
• Identify patient, consult physician
• Known patient: consult for medication
• Minimize stress
• emphysema: treat in afternoon, several hours after sleep to allow air
clearance.
• Avoid bilateral mandibular block
• Ventilator efficiency, prevent physical airway obstruction
• Asthma: Inhaler should be available.

80. • ASPIRATION PNEUMONIA: (may 2022)
• Depending upon the severity of dysphagia, patient may need
to be kept in upright or semi-supine position of no more than
45 degree if the airway is compromised.
• The airway may be protected with gauze trap.
• In additional frequent breaks during treatment, ultrasonic
scaler should be used with caution with high volume suction
(Curl C et al. 2014)
• It is important to note that some patients will be at risk of
silent aspiration during procedures, without any signs or
symptoms of protective reflexes (Quek HC 2019).

81. PROSTHETIC JOINT REPLACEMENT
• The main treatment consideration for patients with prosthetic joint
replacement is the potential need for antibiotic prophylaxis before
periodontal therapy.
• In 2015, the American Dental Association (ADA) guidelines stated
that prophylactic antibiotics are not recommended before dental
procedures for patients with prosthetic joint implants to prevent
prosthetic joint infections.

82. PREGNANCY
• To minimize the exaggerated inflammatory response related to
pregnancy-associated hormonal alterations.
• Meticulous plaque control, scaling, root planning and polishing should
be the only nonemergency periodontal procedures performed.
• The second trimester is the safest time to perform treatment.
• Long, stressful appointments and periodontal surgical procedures
should be delayed until the postpartum period.

83. • If there is reduction in return cardiac blood supply can cause supine
hypotensive syndrome.
• This can be prevented by placing the patient on her left side or by
elevating the right hip 5 to 6 inches during treatment.
• Appointments should be short, and the patient should be allowed to
change positions frequently.
• Fully reclined positions should be avoided. Ideally, no medications
should be prescribed. Give analgesics, antibiotics and local anesthetics
if required.

84. INFECTIOUS DISEASES
a. Hepatitis
• Guidelines for treating hepatitis patients: if the disease is active, do not
provide periodontal therapy unless situation is an emergency.
• If there is a history of hepatitis, consult the physician. For recovered HAV and
HEV patients, perform routine periodontal care.
• For recovered HBV and HDV patients, consult with physician and order HBsAg
and anti-HBs laboratory tests.
• For HCV patients consult for risk assessment.
• If patient with active hepatitis, positive-HBsAg status; measure bleeding time,
prothrombin time.

85. • All the personnel in clinical contact with patient should use
full barrier techniques, include masks, gloves, glasses or eye
shields, and disposable gowns.
• All disposable items (gauze, saliva, floss, saliva ejectors,
masks, gowns, gloves) should be placed in one line
wastebasket.
• Minimize the aerosol production by avoiding use of ultrasonic
scaling, airway syringe, or high-speed handpiece.
• Prerinsing the chlorhexidine gluconate for 30 seconds is
highly recommended. Equipment should be scrubbed and
sterilize.

86. HIV AND AIDS
• Extensive periodontal treatment plans must be considered in regard to the
patient’s systemic health, prognosis and survival time.
• Awareness of oral disorders associated with HIV infection may allow the
clinician to recognize previously undiagnosed disease or modify treatment
protocols appropriately.
• primary goal should be restoration and maintenance of oral health, comfort
and function.
• Treatment should be directed towards control of HIV- associated mucosal
diseases such as chronic candidiasis and recurrent oral ulcerations.

87. • Effective oral hygiene maintenance.
• Conservative, nonsurgical periodontal therapy should be
treatment for HIV +patients.
• NUP and NUS can be severely destructive to periodontal
structures and should be treated appropriately.

88. • 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 physician.

89. TUBERCULOSIS
• The patient with tuberculosis should receive only emergency care, following
the guidelines of hepatitis.

90. REFERENCES
1. Smith G: Periodontal ligament injection: evaluation of systemic effect, oral Surg
Oral Med oral pathol 56:571, 1983.
2. Tibbetts LS: Conscious sedation. In Rose LF, Genco RJ, Mealey BL, et al, editors:
Periodontics: medicine, surgery and implants, St. Louis, 2004. Mosby, Elsevier.
3. Muzyka BC, Glick M: The hypertensive Dental patient, J Am Dent Assoc 128:1109-
1120, 1997.
4. Estes NA, 3rd , Weinstock J, Wang PJ, et al: use of antiarrhythmics and implantable
cardio-converter-defibrillators in congestive heart failure, Am J Cardiol 91:45D-52D,
2003.
5. Mealey BL: impact of advances in diabetes care on dental treatment of the diabetic
patient, Compend Contin Educ Dent 19:41-44, 46-48, 50passim; quize 60, 1998.
6. Mealey BL: Diabetes mellitus. In rose LF, Genco RJ, Cohen DW, et al, editors:
Periodontal medicine, Hamilton, ON, Canada, 2000, BC Decker.
7. Mealey BL: Periodontal implications: medically compromised patients, Ann
Periodontol 1:256-321,1996.

91. 8. Patton LL, Ship JA: treatment of patients with bleeding disorders,
Dent Clin north Am 38:465-482, 1994.
9. Pinto A, Glick M: Management of patients with thyroid disease: oral
health considerations, J Am Dent Assoc 133:489-858, 2002.
10. Sherman RG, Lasseter DH: Pharmacologic management of patients
with disease of the endocrine system, Dent Clin Am 40:727-752, 1996.
11.Herman WW, Konzelman JL, Jr, Prisant LM: Current perspectives on
dental patients receiving coumarin anticoagulant therapy, J Am dent
Assoc 128:327-335, 1997.
12. Martinowitz U, mazar AL, Taichrer S, et al: dental extractions for
patients on anticoagulant therapy, oral Surg Oral Med oral pathol
70:274-277, 1990.
13. American Association of Orthopaedic Surgeons: Information
statement: antibiotic prophylaxis for bacteremia in patients with joint
replacements, 2009.
14. American Diabetes Association: 2. Classification and diagnosis of
diabetes, Diabetes Care 40(Suppl 1): S11-S24, 2017.
15. Curl C, Boyle C. Dysphagia and dentistry. Dent Update.
2014;41(5):413-416. 9-20,22.

92. 16. Quek HC, Lee YS. Dentistry consideration for the dysphagic patients:
recognition of condition and management. Proc Singapore Healthc.
2019;28(4):288-292.
17. Royal College of surgeons of England (RCS Eng)/ British Society for
Disability and Oral health (BSDH). The Oral Management of Oncology
patients requiring radiotherapy, chemotherapy and/or Bone Marrow
Transplanataion: Clinical guidelines. RCSEng/BSDH;2018.
18. Poulopoulos AP, padadopoulos P, Andreadis D. Chemotherapy: oral side
effects and dental interventions- a review of the literature. Stomatological
Dis Sci. 2017;1:35-49.
19. Raber-Durlacher JE, Epstein JB, Raber J, et al. periodontal infection in
cancer patients treated with high-dose chemotherapy. Support Care Cancer.
2002;13(4)466-473.
20. Nicolson G, Burrin JM, Hall GM. Peri-operative steroid supplementation.
Anaesthesia. 1998;53(11):1091-1104.
21. GibsonN, Ferguson JW. Steroid cover for dental patients on longterm
steroid medication: proposed clinical guidelines based upon a critical review
of the literature. Br Dent J. 2004;197(11):681-685.
22. Ostuni E: Stroke and the dental patient, J Am Dent Assoc 125:721-727,
1994.