This document discusses guidelines for providing dental treatment to patients with various medical conditions. It covers cardiovascular diseases like hypertension, ischemic heart disease, congestive heart failure, and infective endocarditis. It also discusses renal disease, liver disease, immunosuppression, pulmonary disease, cerebrovascular accidents, and endocrine disorders like diabetes. For each condition, it provides recommendations on evaluation, risk assessment, medical consultation, anesthesia techniques, appointment length and timing, and post-operative care.

1. GOOD MORNING

3. • CARDIOVASCULAR DISEASES
• Hypertension
• Ischemic Heart Diseases
• Congestive Heart Failure
• Cardiac Pacemakers and Automatic Defibrillators
Infective Endocarditis
• Cerebrovascular Accident
• ENDOCRINE DISORDERS
• Diabetes
• Thyroid and Parathyroid Disorders
• Adrenal Insufficiency

4. • RENAL DISEASES
• LIVER DISEASES
• BLOOD DYSCRASIAS
• IMMUNOSUPPRESSION AND
CHEMOTHERAPY
• RADIATION THERAPY
• PROSTHETIC JOINT REPLACEMENT
• HEMORRHAGIC DISORDERS
•
• INFECTIOUS DISEASES
• PULMONARY DISEASES

5. Hypertension is defined as a systole blood pressure of 140
mm Hg or greater, or a diastolic blood pressure of 90 mm Hg
or greater.
• Hypertension is not diagnosed on a single elevated blood
pressure recording, Rather, classification is based on the
average value of three or more blood pressure readings
taken at three or more appointments.
CARDIOVASCULAR DISEASESCARDIOVASCULAR DISEASES

7. • Periodontal procedures should not be performed until
accurate blood pressure measurements and histories
have been taken to identify those patients with
significant hypertensive disease.
• If a patient is currently receiving antihypertensive
therapy, consultation with the physician may be
warranted regarding the current medical status,
medications, periodontal treatment plan, and patient
management.

8. .
•Morning dental appointments were once suggested for
hypertensive patients.
•Recent evidence indicates that blood pressure
generally increases around awakening and peaks at
mid-morning. Lower blood pressures occur in the
afternoon.

9. • No routine periodontal treatment should be
given to a patient who is hypertensive and
not under medical management.
• For patients with stage 3 hypertension,
treatment should be limited to emergency
care until hypertension is controlled.
• Acute infections may require surgical incision
and drainage, & the surgical field should be
limited because excessive bleeding may be
seen with elevated blood pressures.

11. • When treating hypertensive patients, the clinician should
not use a local anesthetic containing an epinephrine
concentration greater than 1: 100,000, nor should a
vasopressor be used to control local bleeding.
• Local anesthesia without epinephrine may be used for
short procedures (less than 30 minutes).

12. •The smallest possible dose of epinephrine should be
used, and aspiration before injection of local anesthetics
is critical.
•Intraligamentary injection is generally contraindicated
because hemodynamic changes are similar to
intravascular injection.

13. • The clinician should be aware of the many side effects of
various antihypertensive medications.
• Postural hypotension is very common and can be
minimized by slow positional changes in the dental chair.
• Nausea, sedation, oral dryness, lichenoid drug reactions,
and gingival overgrowth are associated with certain
classes of antihypertensive agents .

14. • Angina occurs when myocardial oxygen demand
exceeds supply, resulting in temporary myocardial
ischemia.
• Patients with a history of unstable angina pectoris
should be treated for emergencies only and then in
consultation with the patient's physician.
• Patients with stable angina can undergo elective
dental procedures.

15. • Stress often induces an acute anginal attack, stress
reduction is important.
• Supplemental oxygen delivered via nasal cannula
may also help prevent intraoperative anginal attacks.
• Patients who treat acute anginal attacks with
nitroglycerine should be instructed to bring their
medication to dental appointments.

16. • If the patient becomes,fatigued or uncomfortable or
has a sudden change in heart rhythm or rate during a
periodontal procedure, the procedure should be
discontinued as soon as possible.
1. Discontinue the
periodontal procedure. 2.
Administer one tablet (0.3 to 0.6 mg) of nitroglycerin
sublingually.
3. Reassure the patient and loosen restrictive garments.
4. Administer oxygen with the patient in a
reclined position.

17. 4.If the signs and symptoms cease within 3 minutes,
complete the periodontal procedure if possible,
making sure that the patient is comfortable.
Terminate the procedure at the earliest convenient
time.
5.If the anginal signs and symptoms do not resolve with
this treatment within 2 to 3 minutes, administer
another dose of nitroglycerin, monitor the patient's
vital signs, call his or her physician
6.A third nitroglycerin tablet may be given 3 minutes
after the second. Chest pain that is not relieved by 3
tablets of nitroglycerin indicates likely myocardial
infarction. The patient should be transported to the
nearest emergency medical facility immediately

18. • Congestive heart failure (CHF) 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.
• It may be due to
1.chronic increase in workload.
2.direct damage to the myocardium .
3. an increase in the body's oxygen requirements.

19. • Patients with poorly controlled or untreated congestive
heart failure are not elective for dental procedures.
• These individuals are at risk for sudden death, usually
from ventricular arrhythmias.
• For patients with treated congestive heart failure - consult
with the physician regarding the severity of CHF,
underlying etiology, and current medical management.
• The medications used have potential side effects that
may have an impact on periodontal therapy.

20. • Due to the presence of orthopnea (the 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 and possibly conscious sedation, and
use of supplemental oxygen should be considered.

21. • Infective endocarditis (IE) is a disease in which
microorganisms colonize the damaged endocardium
or heart valves.
• The organisms most commonly encountered in IE are
α hemolytic streptococci .
• However, nonstreptococcal organisms often found in
the periodontal pocket have been increasingly
implicated, including Eikenella
corrodens,A.actinomycetemcomitans,Capnocytophag
a,and Lactobacillus species .

22. • The acute form involves virulent organisms, which
invade normal cardiac tissue, produce septic emboli,
and cause infections that run a rapid, generally fatal
course.
• The subacute form, occurs as a result of colony
formation on damaged endocardium or heart valves
by lowgrade pathogenic organisms;
• The risk for IE varies with the underlying disorder.
• The high-risk category includes patients at high risk of
developing IE after dental-induced bacteremia.
• The moderate-risk category includes patients at
higher risk for IE than the general population.

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
aforementioned susceptible patients. Health questioning
should cover history of all potential categories of risk. If
any doubt exists, the patient's physician should be
consulted.
• 2. Provide oral hygiene instruction.
Oral hygiene should be practiced with methods that
improve gingival health yet minimize bacteremia. In
patients with significant gingival inflammation, oral
hygiene should initially be limited to gentle procedures.

24. 3 . During periodontal treatment, currently recommended
antibiotic prophylaxsis should be practiced with all
susceptible patients
4.Periodontal treatment should be designed for susceptible
patients to accommodate their particular degree of
periodontal involvement .
• Teeth with severe periodontitis and a poor prognosis may
require extraction.

27. • Pacemakers are usually implanted in the chest wall
and enter the heart transvenously.
• Automatic defibrillators are more often implanted
subcutaneously near the umbilicus and have
electrodes passing into the heart transvenously or
directly attached to the epicardium.
• Consultation with the patient's physician.

28. • Automatic defibrillators activate without warning when
certain arrhythmias occur.
• This may endanger the patient during dental
treatment because such activation often causes
sudden patient movement.
• Stabilization of the operating field during periodontal
treatment is necessary.

29. • A cerebrovascular accident (CVA), or stroke, occurs
as a result of ischemic changes (e.g., cerebral
thrombosis or hemorrhagic phenomena.
• Hypertension and atherosclerosis are predisposing
factors to a CVA and should alert the clinician to
evaluate the patient's medical history carefully.
• A physician's referral should precede periodontal
therapy if the signs and symptoms of early
cerebrovascular insufficiency are evident.

30. • To prevent a repeat stroke, active infections should
be treated aggressively because even minor infection
may alter blood coagulation and trigger thrombus
formation and ensuing cerebral infarction.
• Counsel the patient as to the importance of thorough
oral hygiene.
• Post-stroke weakness of the facial area or paralysis of
extremities may make oral hygiene procedures
extremely difficult .
• Modify oral hygiene instruments for ease of use-
consultation with an occupational therapist.
• Long-term chlorhexidine rinses

31. • Patients who are seen after a stroke should be treated
following these guidelines:
1. No periodontal therapy (unless for an
emergency) should be performed for 6 months.
2. After 6 months,
periodontal therapy may be performed using short
appointments with an emphasis on minimizing stress.
Profound local anesthesia should be obtained using the
minimal effective dose of local anesthetic agents.
Concentrations of epinephrine greater than 1: 100,000
are contraindicated.

32. • 3. Light conscious sedation may be used for very anxious
patients. Supplemental oxygen is indicated to maintain
thorough cerebral oxygenation.
• 4. Stroke patients are frequently placed on oral
anticoagulants. For procedures that entail significant
bleeding, such as periodontal surgery or tooth extraction,
the anticoagulant regimen often needs adjustment in
consultation with the physician.
• 5. Monitor blood pressure carefully. Recurrence rates for
CVAs are high, as are rates of associated functional
deficits.

33. Diabetes
• If the clinician detects intraoral signs of undiagnosed
or poorly controlled diabetes, a thorough history is
indicated.
• The classic signs of diabetes include polydipsia
,polyuria ,and polyphagia .
• Periodontal therapy has limited success in the
presence of undiagnosed or poorly controlled
diabetes.

35. • 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:
3. Rule out acute
orofacial infection or severe dental infection, and provide
emergency care only until diagnosis is established.
• The level of glycemic control should be established before
initiating periodontal treatment.
• The fasting glucose and casual glucose tests provide
'snapshots" of the blood glucose concentration at the time
the blood was drawn.

36. • Diabetic patients with periodontitis should received oral
hygiene instructions, mechanical debridement to remove
local factors, and regular maintenance.
• An HbAlc of <10% should be established before surgical
treatment is performed.
• Systemic antibiotics are not needed routinely, although
recent evidence indicates that tetracycline antibiotics
in combination with scaling and root planing may
positively influence glycemic control .
• If the patient has poor glycemic control and surgery is
absolutely needed, prophylactic antibiotics may be given.

38. •Many diabetic patients today use glucometers for
immediate blood glucose self-monitoring. These
devices use capillary blood from a simple finger stick to
provide blood glucose readings in a matter of seconds
to minutes.
• Diabetic patients should be asked whether they have
glucometers and how often they use them. Because
these devices provide an instantaneous assessment of
blood glucose, they are highly beneficial in the dental
office environment.

39. • The following guidelines should be observed.
1. Patients should be asked to bring their glucometer
to the dental office at each appointment.
2. Patients should check their blood glucose before
any long procedure to get a baseline level.
3. Patients with blood glucose levels at or below the
lower end of normal before the procedure may
become hypoglycemic intraoperatively.
4. After the procedure, the blood glucose can be
checked again to assess fluctuations over time.
5. Any time the patient feels symptoms of
hypoglycemia, the glucose should be checked
immediately.

40. • The most common dental office complication seen in diabetic
patients taking insulin -hypoglycemia.
• In patients receiving conscious sedation, the warning signs of
an impending hypoglycemic episode may be masked, making
the glucometer one of the best diagnostic aids.
• However, in patients with poor glycemic control who have
prolonged hyperglycemia (high blood glucose levels), a rapid
drop in glucose can precipitate signs and symptoms of
hypoglycemia at levels well above 60 mgldl.
• When planning dental treatment, it is best to schedule
appointments before or after periods of peak insulin activity.

41. • It is absolutely critical that patients eat their normal meal
before dental treatment.
Taking insulin without eating is the primary cause of
hypoglycemia. If the patient is restricted from eating before
treatment ,normal insulin doses will need to be reduced.
• Well-controlled diabetic patients having routine periodontal
treatment may take their normal insulin doses as long as
they also eat their normal meal.
If the procedures are going to be particularly long, the insulin
dose before treatment may need to be reduced.
• If the patient will have dietary restrictions after treatment,
insulin or sulfonylurea dosages may need to be reduced.

42. • Consultation with the patient's physician is prudent .
• When periodontal surgery is indicated, it is usually
best to limit the size of the surgical fields so that the
patient will be comfortable enough to resume a
normal diet immediately.
• Patients taking insulin are at greatest risk, followed by
those on sulfonylurea agents.
• Metformin and thiazolidinediones generally do not
cause hypoglycemia .

45. • 2. If the patient is unable to take food or drink by mouth,
or if the patient is sedated:
* Give 25 ml to 30 ml of 50% dextrose intravenously, or
* Give 1 mg of glucagon intravenously (glucagon results
in rapid release of stored glucose from the liver), or
Give 1 mg of glucagon intramuscularly (if.no IV access)

46. • Patients with thyrotoxicosis and those with inadequate
medical management should not receive periodontal
therapy until their conditions are stabilized.
• Patients with -hyperthyroidism should be carefully
evaluated to determine the level of medical management -
limit stress and infection.
• Hyperthyroidism may cause tachycardia and other
arrhythmias, increased cardiac output, and myocardial
ischemia.

47. • Medications such as epinephrine and other vasopressor
amines should be given with caution in patients with
treated hyperthyroidism.
• They should not be given to patients with thyrotoxicosis or
poorly controlled thyroid disorders.
• Patients with hypothyroidism require careful administration
of sedatives and narcotics due to the potential for
excessive sedation.

48. • Routine periodontal therapy may be provided to
patients with parathyroid disease.
• Patients who have not received medical care may
have significant renal disease, uremia, and
hypertension.
• If hypercalcemia or hypocalcemia is present, the
patient may be more prone to cardiac arrhythmias.

49. • Acute adrenal insufficiency is associated with
significant morbidity and mortality owing to 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.

51. • The use of systemic corticosteroids is common in allergic,
endocrine, respiratory, joint, intestinal, neurologic, renal,
liver, skin, and connective tissue disorders.
• Significant complications associated with corticosteroid
use -alterations in glucose metabolism ,increased risk of
infection.
• Altered wound healing, osteoporosis, skin disorders,
cataracts, glaucoma, and suppression of the
hypothalamic-pituitary-adrenal (HPA) axis .
• In the normal healthy patient, stress activates the HPA
axis, stimulating increased endogenous cortisol
production by the adrenal glands.

52. • 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 acute adrenal crisis.
• The degree of adrenal suppression depends on the
drugs used, dose, duration of administration, length of
time elapsed since steroid therapy was terminated,
and route of administration.
• It has been common practice in the past to administer
prophylactic systemic steroids before dental treatment
for patients who are taking or recently have taken
exogenous steroids.

53. • Patients taking 5 to 20 mgday prednisolone maintained at
least some adrenal reserve after immediate termination of
steroid therapy.
• Higher doses may suppress the adrenal glands to a
greater degree.
• Although exogenous steroids may suppress normal
adrenal cortisol secretion for an extended period of time,
the ability of the adrenal gland to respond to stress may
return quickly after termination of steroid therapy.

54. • Before treating a patient with a history of recent or current
steroid use, physician consultation is indicated.
• Use of a stress reduction protocol and profound local
anesthesia may help minimize the physical and
psychologic stress associated with therapy and reduce
the risk of acute adrenal crisis.

55. • Topical corticosteroids generally have minimal to no
HPA effect, and steroid supplementation generally is
not required for these patients.
• For the patient currently receiving systemic steroid
therapy, the need for corticosteroid prophylaxis
depends on the drug used because of the variance in
equivalent therapeutic doses.

56. • For patients taking large doses of >20 mg cortisol-
equivalent per day and requiring stressful periodontal
procedures, doubling or tripling the normal steroid dose 1
hour before the procedure is often recommended.
• For those patients on low doses for short periods of time
(i.e., less than 1 month), no supplementation is generally
warranted.
• In an emergency situation, increasing the steroid dose
before the procedure may decrease the chances of acute
adrenal crisis.

57. • 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 30 seconds or
intramuscularly.

58. • The most common causes of renal failure are
glomerulonephritis, pyelonephritis, kidney cystic disease,
renovascular disease, drug nephropathy, obstructive
uropathy, and hypertension.
• Renal failure may result in severe electrolyte imbalances,
cardiac arrhythmias, pulmonary congestion, congestive
heart failure, and prolonged bleeding.
• Physician consultation is necessary.

59. • The patient in chronic renal failure - It is preferable to
treat the patient before, rather than after, transplant or
dialysis.
• The following treatment modifications should be used:
1. Consult the patient's physician.
2. Monitor blood pressure .
3. Check laboratory values:
partial thromboplastin time, prothrombin time, bleeding
time, and platelet count; hematocrit; blood urea nitrogen
and serum creatinine.

60. 4. Eliminate areas of oral infection to prevent systemic
infection.
• Good oral hygiene should be established.
•Periodontal treatment should aim at eliminating
inflammation or infection and providing easy maintenance.
5. Drugs that are nephrotoxic or metabolized by the kidney
should not be given (e.g., phenacetin, tetracycline,
aminoglycoside antibiotics).
• Acetaminophen may be used for
analgesia and diazepam may be used for sedation.

61. • The patient who is receiving dialysis requires treatment planning
modifications.
• The three modes of dialysis are intermittent peritoneal dialysis
(IPD), continuous ambulatory peritoneal dialysis (CAPD), and
hemodialysis.
• Only hemodialysis patients require special precautions. These
patients have a high incidence of viral hepatitis, anemia, and
prolonged hemorrhage.
• Hemodialysis patients have either an internal arteriovenous
fistula or an external arteriovenous shunt. This shunt is often
located in the arm and must be protected from trauma.

62. • The following recommendation are made for those on
hemodialysis:
1. Screen for hepatitis B and hepatitis C antigens and
antibody before any treatment.
2. Provide antibiotic prophylaxis to prevent
endarteritis of the arterlovenous fistula or shunt.
3. Patients receive heparin
anticoagulation on the day of hemodialysis. Therefore
provide periodontal treatment on the day after dialysis,
when the effects of heparinization have subsided.

63. • 4. Be careful to protect the hemodialysis shunt or fistula
when the patient is in the dental chair. If the shunt or
fistula is placed in the arm, do not cramp the limb; blood
pressure readings should be taken from 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 hour. If appointments last
longer, allow the patient to walk about for a few minutes
and then resume therapy.

64. 5. Refer the patient to the physician
1. if uremic problems develop, such as
uremic stomatitis. 2.if oral infections do
not resolve promptly to prevent systemic dissemination.
• Transplant patients take immunosuppressive drugs that
greatly reduce resistance to infection.
• Excessive bleeding may occur due to drug induced
thrombocytopenia, anticoagulation, or both.

65. .
• Teeth with severe bone and attachment loss, furcation
invasion, periodontal abscesses, or extensive surgical
requirements should be extracted, leaving an easily
maintainable dentition.

66. • In addition to the recommendations for patients with
chronic renal failure, the following should be considered
for the renal transplant patient:
1. Hepatitis B and C screening.
2. Determination of level of
immunocompromise derived from antirejection drug
therapy.
3. Prophylactic antibiotics

67. • Liver diseases may range from mild to complete
failure. Major causes of liver disease include drug
toxicity, cirrhosis, viral infections, neoplasms, and
biliary tract disorders .
• Excessive bleeding during or after periodontal
treatment may occur in patients with severe liver
disease.
• Liver disease alters normal drug metabolism since
many drugs are metabolized in the liver.

68. • Treatment recommendations for patients with liver
disease include the following:
1. Consultation with the physician concerning current
stage of disease, risk for bleeding, potential drugs to
be prescribed during treatment, and required
alterations to periodontal therapy.
2.Screening for hepatitis B and C.
3.Check laboratory
values for prothrombin time and partial thromboplastin
time.

69. • The periodontal treatment of a patient with pulmonary
disease may require alteration depending on the nature
and the severity of the respiratory problem.
• Pulmonary diseases range from obstructive lung diseases
to restrictive ventilatory disorders that are due to muscle
weakness, scarring, obesity, or any condition that could
interfere with effective lung ventilation .

70. • The signs and symptoms of pulmonary disease are
increased respiratory rate, cyanosis, clubbing of the
fingers, chronic cough, chest pain, hemoptysis, dyspnea or
orthopnea, and wheezing.
• Most patients with chronic lung disease may undergo
routine periodontal therapy if they are receiving adequate
medical management.
• Caution should be practiced in relation to any treatment
that may depress respiratory function.

71. • The following guidelines should be used during periodontal
therapy:
1.Identify and refer patients with signs and symptoms of
pulmonary disease to their physicians.
2.In patients with known pulmonary disease,
consult with their physicians regarding medications and the
degree and severity of pulmonary disease.
3.Avoid elicitation of respiratory
depression or distress: Minimize the stress of a periodontal
appointment.

72. • 4.The patient with emphysema should be treated in the
afternoon, several hours after sleep, to allow for airway
clearance.
• Avoid medications that could cause respiratory
depression (e.g., narcotics, sedatives, and general
anesthetics).
• Avoid bilateral mandibular block
anesthesia, which could cause increased airway
obstruction.

73. • 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.
5. Patient with asthma, make sure the patient's medication is
available.
6. Patients with active fungal or bacterial respiratory diseases
should not be treated unless the periodontal procedure is an
emergency.

74. • Immunosuppressed patients have impaired host defenses
as a result of an underlying immunodeficiency or drug
administration .
• Chemotherapy is often cytotoxic to bone marrow,
destruction of platelets and red and white blood cells
results in thrombocytopenia, anemia, and leukopenia.
• Intraorally, bacterial, viral, and fungal infections may
manifest.

75. • Patients receiving bone marrow transplantation -receive
very high dose chemotherapy.
• Treatment in these patients should be directed toward
the prevention of oral complications that could be life
threatening.
• During periods of extreme immunosuppression -
treatment should be conservative and palliative.
• It is always preferable to evaluate the patient before
initiation of chemotherapy.

76. • Teeth having 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.

77. • Chemotherapy is usually performed in cycles
• If periodontal therapy is needed during chemotherapy, it
is best done the day before chemotherapy
• Coordination with the oncologist is critical.
• Dental treatment should be done when white cell
counts are above 2000/mm3
, with an absolute
granulocyte count of 1000 to 1500/mm3.

78. • The extent and severity of mucositis, dermatitis,
xerostomia, dysphagia, gustatory alteration, radiation
caries, vascular changes, trismus, temporomandibular
joint degeneration,
• periodontal change depend on a myriad of radiation
factors: the type of radiation used, fields of irradiation,
number of ports, types of tissues in the fields, and
dosage.

79. • Preirradiation treatment depends on the patient's
prognosis, compliance, and residual dentition in addition to
the fields, dose, and immediacy of radiotherapy.
• The initial visit should include panoramic and intraoral
radiographs, a clinical dental examination, a periodontal
evaluation, and a physician consultation.
• The first decision that should be made relates to possible
extractions because radiation can cause side effects that
interfere with healing.

80. •Tooth extraction after radiation treatment involves a
high risk of developing ORN, and surgical flap
procedures are generally discouraged after radiation.
•Teeth that are nonrestorable or severely periodontally
diseased should be extracted, ideally at least 2 weeks
before radiation.

81. • Periodontal treatment after irradiation may be limited to
nonsurgical forms of therapy.
• During radiation therapy,patients should receive weekly
prophylaxis, oral hygiene instruction, and professionally
applied fluoride treatments unless mucositis prevents
such treatment.
• Patients should be instructed to brush daily with a 0.4%
stannous or 1.0% sodium fluoride gel.
• All remaining teeth should receive thorough
debridement

82. • Postirradiation follow-up consists of palliative
treatment given as indicated.
• Viscous lidocaine may be prescribed.
• Daily topical fluoride application and oral hygiene.
• A long-term, 3-month recall interval is ideal.

83. • Late prosthetic joint infections-might occur from transient
bacteremia.
• Very few reports demonstrate dental treatment as a
source of joint infection.

84. • Prophylaxis is indicated for almost all patients within
the first 2 years after joint replacement and for so-
called "high-risk' patients including those with
previous prosthetic joint infections,
immunosuppression, rheumatoid arthritis, type 1
diabetes, hemophilia, and malnourishment.

85. • Patients with severe periodontal disease or other potential
dental infections are considered by many authors to be
high-risk, and antibiotic prophylaxis may be indicated for
these patients before dental treatment .
• Consultation with the patient's orthopedic surgeon before
periodontal treatment is in the patient's best interest.

87. • The aim of periodontal therapy for the pregnant
patient is to minimize the potential exaggerated
inflammatory response related to pregnancy-
associated hormonal alterations.
• Non emergency 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.

88. • Since the uterus increases in size during the second and
third trimesters, obstruction of the venacava and aorta
may occur if the patient is placed in a supine position.
• This can be prevented by placing the patient on her left
side or simply 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. A fully
reclined position should be avoided if possible.

89. • Other precautions -potential toxic or teratogenic
effects of therapy on the fetus.
• Analgesics, antibiotics, local anesthetics, and other
drugs may be required during pregnancy, depending
on the patient's needs.
• All drugs should be reviewed for potential adverse
effects on the fetus prior to prescribing.

90. • Penicillins and cephalosporins are category B agents and are
considered safe.
• Erythromycin is also safe-exception of the estolate form -due
to its risk of maternal hepatotoxicity.
• Use of metronidazole-is controversial.
• Amoxicilin/ clavulanate and clindamycin are also category B
agents -generally not used unless specifically indicated.
• Tetracyclines, category D agents, are contraindicated in
pregnant patients due to inhibition of fetal bone growth and
discoloration of teeth .

91. • Acetaminophen is a category B agent and is widely
considered to be the safest analgesic in pregnant
patients .
• Aspirin use is controversial.
• Ibuprofen is a category B agent, but becomes a
category D agent if given in the third trimester.
• Narcotic analgesics are category C agents and should
be used with caution, preferably in consultation with
the physician.

92. • Use of dental radiographs during pregnancy should
be kept to a minimum.
• The small amount of radiation exposure during
diagnostic dental radiography poses little risk to the
fetus as long as the mother is properly shielded .
• The American Dental Association has stated that
normal radiographic guidelines do not need to be
altered because of pregnancy.

93. • Health questioning should cover
(1) History of bleeding after previous surgery or
trauma,
(2) Past and present drug history,
(3) History of bleeding problems among
relatives. (4) Illnesses associated with
potential bleeding problems.

94. • Clinical examinations should detect - jaundice,
ecchymosis, spider telangicetasia, hemarthrosis,
petechiae, hemorrhagic vesicles, spontaneous gingival
bleeding, or gingival hyperplasia.
• Laboratory tests should include - hemostatic, coagulation,
or lytic phases of the clotting mechanism, depending on
clues regarding which phase is involved .
• These tests include bleeding time, tourniquet test,
complete blood cell count, prothrombin time, partial
thromboplastin time, and coagulation time.

95. • Hemophilia A results in a deficiency of coagulation
factor VIII, and the clinical severity of the disorder
depends on the level of factor VIII remaining.
• Severe hemophiliacs with less than 1% of normal
factor VIII levels may have severe bleeding on the
slightest provocation.
• More moderate hemophilics (1% to 5% factor VIII)
have less frequent spontaneous hemorrhage but still
bleed with minimal trauma .
• Mild hemophilics (6% to 30% factor VIII) rarely bleed
spontaneously but may still have hemorrhage after
severe trauma or during surgical procedures

97. • Liver disease may affect all phases of blood clotting
because most coagulation factors are synthesized and
removed by the liver.
• Long-term alcohol abusers or chronic hepatitis patients
often demonstrate inadequate coagulation.
• Coagulation may be impaired by vitamin K deficiency.

98. • The periodontal treatment for patients anti coagulants should
be altered as follows:
• 1. Consult the patient's physician
2.. Infiltration anesthesia, scaling, and root planing may
be done safely in patients with an INR <3.0. Block anesthesia,
minor periodontal surgery, and simple extractions usually
require an INR <2.0. Complex surgery or multiple extractions
may require an INR <1.5.
• 3.The physician should be consulted about discontinuing or
reducing anticoagulant dosage until the desired INR is
achieved.

99. 4. Careful technique and complete wound closure are
paramount. For all procedures, application of
pressure can minimize hemorrhage.
5. Use of oxidized cellulose, microfibrillar collagen,
topical thrombin, and tranexamic acid should be
considered for persistent bleeding.

100. • Thrombocytopenia is defined as a platelet count
<l00,000mm3
• Bleeding due to thromboeytopenia may be seen with
idlopathic thrombcytopenic purpuras, radiation therapy,
myelosuppressive drug therapy ,leukemia, or infections.
• Pupuras are hemorrhagic diseases characterized by
extravasation of blood into the tissues under the skin or
mucosa, producing spontaneous petechiae or echymoses.

101. • Periodontal therapy - reducing inflammation by removing
local irritants to avoid the need for more aggressive
therapy.
• Physician referral Scaling and root planing is generally safe
unless platelet counts are <60,000/mm3
.
• No surgical procedures should be performed unless the
platelet count is >80,000/mm3
.
• Platelet transfusion may be required before surgery.

102. • Nonthrombocytopenic, purpuras occur as a result of either
vascular wall fragility or thrombasthenia.
• The former may result from : hypersensitivity reactions, scurvy,
infections, chemicals (phenacetin and aspirin), dysproteinemia,
and several others. Thrombasthenia occurs in uremia,
Glanzmann's disease, aspirin ingestion, and von Willebrand's
disease.

103. • Treatment 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 unless the
qualitative and quantitative platelet problems are
resolved.

104. • Numerous disorders of red and white blood cells may affect
the course of periodontal therapy.
• Alterations in wound healing, bleeding, tissue appearance,
and susceptibility to infection may occur.

105. • Altered periodontal treatment -enhanced susceptibility
to infections, bleeding tendency, and the effects of
chemotherapy. The treatment plan for these patients
is as follows:
• 1. Refer the patient for medical evaluation
2. Before chemotherapy, a complete
periodontal treatment plan should be developed with
a physician

106. • Monitor hematologic laboratory values daily.
• Extract all hopeless- teeth at least 10 days before the
initiation of chemotherapy.
• Periodontal debridement and thorough oral hygiene
instructions given.
Twice-daily rinsing with 0.12% chlorhexidine gluconate is
recommended after oral hygiene procedures.

107. 3. During the acute phases of leukemia[-only emergency
periodontal care.
4. Oral ulcerations or mucositis are treated palliatively.
5. Oral candidiasis -treated with nystatin
suspensions (100,000 Uml 4 times daily) or clotrimazole
vaginal suppositories (10 mg 4 to 5 times daily) .
6. Patients with chronic leukemia and those in
remission, scaling and root planing can be performed but
periodontal surgery should be avoided.

108. • Periodontal treatment should be done during periods of
disease remission.
• After physician consultation, severely affected teeth should be
extracted.
• Oral hygiene instruction.
• Scaling and root planing should be performed carefully under
antibiotic protection

109. • All periodontal patients should be treated as though they
have an infectious disease.
• Protection of patients, clinicians, and office staff -use
universal) precautions for each and every patient,
maximizing prevention of infection and cross-
contamination.

110. • To date, six distinct viruses causing viral hepatitis have
been identified: hepatitis A, B, C, D, E, and G viruses.
• High risk groups -renal dialysis patients, health care
workers, immunosuppressed patients, patients who
have received multiple blood transfusions,
homosexuals, drug users, and institutionalized patients.

111. • The following guidelines are offered for treating hepatitis
patients:
1 . If the disease, regardless of type, is
active, do not provide periodontal therapy
2. For patients with a past history
of hepatitis, consult the physician
3. For recovered hepatitis A or E
patients, perform routine periodontal care.

112. 4. For recovered hepatitis B and D patients, consult with the
physician and order HBsAG and anti-HB, laboratory
tests.
• Patients who are HBAG positive are probably infective
• Patients who are anti-HB, positive may be treated
routinely
• Patients who are HBsAG negative may be treated
routinely.
5. For hepatitis C patients, consult with the physician.

113. 6. If a patient with active hepatitis, positive HBcAg (HBV
carrier) status or positive HCV carrier status requires
emergency treatment.
• If bleeding is likely during or after treatment, measure
prothrombin time and bleeding time.
• All personnel in clinical contact with the patient should
use full barrier technique.

114. • All disposable items should be placed in one lined
wastebasket.
• Aseptic technique -Minimize aerosol from ultrasonic
instrumentation, air syringe, or high-speed hand
pieces.
Pre rinsing with chlorhexidine gluconate for 30 seconds
is highly recommended.

115. • When the procedure is completed, all equipment should be
scrubbed and sterilized.
If a per cutaneous or per mucosal injury occurs during dental
treatment of a HBV carrier, current Centers Disease Control
and Prevention (CDCP) guidelines recommend
administration of hepatitis B immune globulin (HBIG).
• The HBV vaccine should also be administered if the injured
individual has not previously received it.

116. • HIV-infected patients- unaware of the condition initially.
Individuals with known HIV infection may not admit their
status on the medical history.
• Every patient receiving dental treatment should be managed
as a potentially infected person, using universal precautions
for all therapy.

117. • Extensive periodontal treatment plans must be considered
in light of their relationship to the patient's systemic
health, prognosis, and survival time.
• Few contraindications to routine dental treatment in HIV-
infected patients.
- Periodontal treatment plan influenced by the patient's
overall systemic health.

118. • Physician should be consulted regarding infectivity and the
results of sputum cultures for Mycobacterium tuberculosis.
• When medical clearance has been given -patients may be
treated normally.
• Adequate treatment of tuberculosis requires a minimum of
18 months.
• Any patient who gives a history of poor medical follow-up or
shows signs or symptoms indicative of tuberculosis should
be referred for evaluation.