DEPARTMENT PERIODONTICS COMPREHENSIVE HISTORY [Type the document subtitle]

OF CASE

[Link]:
Unique registration number is given to each patient to maintain records -to know the details of the patient & treatment done during his/her later visits.

NAME:
Used - For Identification - To Maintain Record - For Communication - Psychological Benefit & - Rapport

AGE:
Certain diseases are more common at certain ages. DISEASES PRESENT AT/SINCE BIRTH: Related to jaw Agnathia Facial hemihypertrophy Macrognathia Cleft palate Facial hemiatrophy Related to lip Double lip Cleft lip

 Commissural pits& fistulae Related to gingival Fibromatosis gingiva Congenital epilus of newborn Related to teeth Pre deciduous dentition Related to TMJ Aplasia or congenital hypoplasia of mandibular condyle

DISEASES COMMONLY SEEN IN INFANCY: Dental lamina cyst of the newborn Fibrous dysplasia of the jaw Infantile cortical hyperostosis of jaw Melanotic ameloblastoma Hemangioma Palatal cyst of the newborn DISEASES COMMONLY SEEN IN CHILDREN & YOUNG ADULTS: Fissured tongue Beningn migratory glossitis Torus palatines Pulp polyp Osteoid osteoma of jaw

 Diseases commonly seen in adults & older patients: Attrition Abrasion Gingival recession Periodontitis Root resorption

SEX:
CERTAIN DISEASES ARE MORE COMMON IN CERTAIN SEX. Common in females
1.

Common in males: Attrition carcinoma of buccal mucosa Caries in deciduous teeth Leukoplakia Perinicious anaemia

Iron deficiency anaemia

2. Diseases of thyroid 3. Sjogrens syndrome 4. Juvenile periodontiis 5. Caries

ADDRESS:

For correspondence Geographical prevalence of dental/oral diseases.

Periodontal diseases more in rural areas. Dental caries in modern industrialized areas

OCCUPATION:
Some diseases are peculiar to certain occupations. Attrition workers exposed to atmosphere of abrasive dust. Abrasion carpenters,shoemakers,tailors. Gingival staining persons working with lead,bismuth & cadmium. Erosion sandblaster Hepatitis-B- dentists,surgeons,blood bank personnel.

To know the financial status ,so that treatment can be varied.

CHIEF COMPLAINT:
o o o o o

Should be recorded in patients own words. It is the reason for which the patient has come to the doctor. It should be given first priority. Should be recorded in chronological order. if few complaints start simultaneously , record them in the order of frequency.

o Probable chief complaints may be

Bleeding gums Staining of teeth Malodour Food impaction Mobility Pain Recession Swollen gums Burning of mouth Questionarre for each of the chief complaint is as follows: For bleeding gums: 1. when does the bleeding start? A. Morning

B. Night C. While brushing 2. Is it associated with pain? 3. Is it associated with bad breath? 4. Does it pain while bleeding? 5. When does it stop? 6. Do you have any bleeding disorders? 7. Do you have any deficient clotting factors? 8. Is it associated with menstrual cycle changes? 9. Is it associated with burning sensation? 10. Where do you notice the bleeding? 11. Did you notice any hormonal changes? 12. What type of brush do you use? 13. What brushing technique do you follow? How do you brush? A. Horizontally B. Vertically C. Cirvacally For gingival recession: 1. How does the recession or apical migration of gingival start? 2. Is it associated with pain/swelling/irritation/inflammation? 3. Is there any plaque/calculus formation? 4. How do you brush? Horizontal/Vertical/Circular 5. How many times do you brush?

6. What type of tooth brush do you use? 7. Is there any bad breath? 8. Is there any change in color in gingival? 9. Is it generalized/localized/front of the teeth/back of the teeth? 10. Is there any mobility? 11. Any abnormal frenal attachments? 12. Any trauma/malpositioning/crowding of teeth? 13. Any orthodontic appliance usage? 14. Any exposure of root surface? For swollen gums: 1. How does the swelling start start? 2. When does it start? 3. Is it associated with pain / abscess? 4. Is it associated with discharge? Pus/blood 5. Is it covering the tooth crown 6. Does all/few teeth are involved 7. Is there any plaque/calculus formation 8. Since how many days the swelling is seen 9. Is it associated with bleeding? 10. Do you have vit-c deficiency? 11. Are you on medication & since how many days? 12. What kind of drugs are you using? 13. Are you hypertensive? If yes on medication

14. Any allergic disorder 15. Any bleeding disease 16. Any color changes of gingival 17. Do you have epilepsy/seizures attack any time? 18. Are you diabetic? If yes-under what treatment is it controlled 19. Do you have habits of chewing pan & tobacco? For mobility: [Link] & duration [Link] gingival inflammation [Link] accumulation of plaque / calculus [Link] trauma from occlusion [Link] periodontal therapy undertaken [Link] parafunctional habits such as bruxism [Link] periapical pathology [Link] pathology of jaw like tumour,cyst etc [Link] traumatic injury to dentoalveolar unit [Link] morphology [Link] & overbite [Link] mobility [Link] [Link] changes[menstrual cycle] [Link] contraceptives [Link]

[Link] systemic diseases [Link] bone loss [Link] grade mobility [Link] tooth mobility/ a segment

For malodour: [Link] pseudohalitosis [Link] long have you been experiencing this problem? [Link]? [Link] putrifaction in oral cavity? [Link] breathing [Link]? [Link]? [Link] dental hygiene? [Link]/starvation? [Link]? [Link][onion/garlic] [Link] [Link] infections? [Link] coating? [Link]? [Link]?

[Link] faulty restorations,retaining food & bacteria? [Link] dentures? [Link] oral pathological lesions like oral cancers/candidiasis? [Link]/cleft palate? [Link] ulcers? [Link] abscess? [Link] infections?sinusitis,rhinitis,tumors [Link] diseases of GIT-hiatus,hernia,carcinomas,GERD etc [Link] pulmonary infections?bronchitis,pneumonia,tuberculosis [Link] Harmonal changes? For food impaction: [Link] occlusal wear? [Link] of proximal contact?periodontal diseases?proximal caries? [Link] congenital morphologic abnormalities of teeth? [Link] constricted restorations? [Link] food impaction? [Link] inflammation with bleeding? [Link] taste? [Link]/recession? [Link] to dig material from teeth? [Link] pain that radiates to the jaw? [Link] abscess? [Link] inflammatory involvement of PDL?

[Link] sensitivity to percussion? [Link] destruction of alveolar bone/bone loss? [Link] caries? [Link] formation? [Link] mobility? [Link] injury to periodontium? [Link] alingnment of teeth? [Link] between the teeth? 21. Facially displaced teeth? [Link] bite & Open bite? [Link] brush trauma? For burning sensation of mouth: [Link] contact allergy? [Link] chronic mechanical trauma? [Link] oral habits like clenching, grinding& chronic tongue thrust? [Link] infections? [Link]? [Link] dysfunction? [Link] tongue? [Link]? [Link] reflux? [Link]? [Link] nevie neuroma?

[Link] deficiency?-vit-Bcomplex -folic acid,iron deficiency anaemia [Link] Mellitus? [Link] disorders? [Link] Problems chronic gastritis,chronic gastric hypoacidity [Link]? [Link] pain with increased intensity throughout the day? [Link] taste sensation? [Link] clinically detectable lesions? [Link] & wanning pattern? [Link] medication? [Link] deficiency? HISTORY OF PRESENT ILLNESS: Collecting information: -History from the start of first symptoms to the time of examination -Can be collected by asking When does the problem start? What do you notice first?any problems/symptoms related to this Did the symptoms get better/worse at any time? What had done to treat these symptoms? Mode of onset sudden/gradual -in terms of time-hrs/days/weeks/months

Cause of onset Duration since how many days Progress intermittent,recurrent,constant,increased/decreased in severity -aggravating & alleviating factors should be noted Relapse & remission Treatment mode of treatment Doctor consulted before Negative history

HISTORY WITH PARTICULTAR REFERENCE

Pain Anatomical location where it is felt. Origin & mode of onset. Intensity of pain Nature of painburning,throbbing etc Progression of pain Duration of pain Movement of pain[radiating,referred, migrating] Localization behaviour Concomitant neurological signs Past dental history:

Swelling Duration Mode of onset Symptoms Progress of swelling Associated features Impairment function recurrence

Ulcer mode of onset pain discharge[serum,pus,blood] associated diseases

-to get the details of previous dental treatment. -his/her reaction to dentist & the treatment. By this we can get an idea of importance he gives to good dental treatment & in persuing a goal of good oral health.

MEDICAL HISTORY: To assess the patients health status and also it can facilitate for better diagnosis for the oro facial complaint of the patient. MEDICAL QUESTIONNAIRE: 1. Systemic problems: whether the patient was suffering from any medical problems?

If yes ask for - Duration - Treatment - Whether the treatment is beneficial or not - Medication - All the diseases suffered by patient pervious to present one - Particular attention must be given to diseases like diabeties, asthma, bleeding disorders, hypertension,myocardial infarction,hepatitis b , diptheria, rheumatoid heart disease, TB & gonorrhea. 2. Chest pain: to know the cardialogical status of the patient 3. Allergy : - whether he has any allergy? Allergy may be due to drug or food - Patient should be asked about asthma, eczema, utricaria, hayfever & angioedema etc. 4. Previous hospitalization and indicate the purpose 5. Blood transfusion 6. Accident, operations & fractures should also be noted

7. Drug history: ask the patient to tell the medication that they are presently taking

By taking proper medical history following goals are achieved 1. Access in diagnosis of oral disease: there are many systemic problems which have oral manifestations. 2. Detection of underlying systemic problems: by taking proper medical histroy we can detect many systemic problems in patient which he is not aware due to negligence. 3. Management of patient: many systemic diseases can change our line of treatment while treating the dental complaint .so we can modify our treatment according to need. 4. Consultation with other professional: dentist may require consultation in following conditions - Known medical problems: consultation is required in patients who have known medical problems and schedule for stressful dental procedures. - Unknown medical problems: in some patients abnormalities are detected while history taking or physical examination or laboratory studies , patient is unaware of this problem. - High risk patient: some patients have high risk for development of particular diseases for exampleobese patients may prone to develop hypertension - Additional information: in patient who requires additional information which may alter dental care assist in the diagnosis of oro facial problems - Consultation letter.

Family history: very important for many hereditary diseases

Many diseases run in families like hemophilia, diabeties mellitus, hypertension & heart diseases. Personal histroy: 1. Habits and addictions: many diseases can correlate with particular habit of patient - Pressure habits: thumb sucking , lip sucking, finger sucking may lead to anterior proclination of maxillary anterior teeth - Tongue thrusting: it may lead to anterior and posterior open bite and proclination of anterior teeth - Mouth breathing : it may lead to anterior marginal gingivitis and caries - Bobby pin opening: seen in teenage girls who open bobby pin with anterior incisors to place them in hair this results in notching of incisors and denudation of labial enamel. - Other habits: nail biting (onacophagia) ,pencil and lip biting lead to proclination of upper anterior and retroclination of lower anterior teeth - Bruxism: may lead to attrition - Tobacco: tobacco prepartions such as khaini ,manipuri tobacco , mishri , pan,snuff , zarda etc should be asked - Smoking: smoking habits such as bidi, chutta, cigarette, dhumthi, hookah etc.. Should be asked - Drinking habit: drinking alcohol, charas, ganja, marijuana etc..

2. Oral hygiene and brushing techniques: Bad oral hygine and improper brushing techniques may lead to dental caries and periodontal disease, horizontal brushing technique may lead to cervical abrassion of teeth. Frequency:
o

Note frequency of habit per day

o Frequency of brushing per day o Length of time that patient the had the habit in years.

Extra oral examination: Temporo mandibular joint examination Measurement of range of movement Normal ranges - maximal mouth opening = 50mm - Lateral excrusions = 9mm - Protrusion= 7mm

Auscultation of TMJ Using bell of stethoscope or doppler instument Magnifies sounds far accurate evaluation

TMJ palpation

 To evaluate whether condyles are moving symmetrically and detect any pain, tenderness, clicking or crepitus. - Pretragus palpation bilaterally palpate preyragus region with index finger while patient opens and closes mouth slowly. - Intra auricular palpation insert small finger into ear canal and press anteriorly during movement - Bimanual palpation/ load testing patient in supine position with head cradled aginst the dentists arm or abdomen. Place middle fingers under notch on lower bopder of mandible and exert force upward and thumbs on chin to exert force downwards.

Masticatory muscle examination Digital palpation For trigger points and tenderness Masseter palpation Bimanual palpation with index fingers one extraorally and the other intraorally. Squeezing pressure applied intraorally. Lateral pterygoid palpation Place a finger on each maxillary tuberosity intraorally. Offer resistance to patients efforts to protrude the mandible. Medial pterygoid palpation

Run a finger intraorally on the medial side of the mandible on the floor of the mouth in an antero-posterior direction.

 LYMPH NODE PALPATION NODES TO BE EXAMINED: - Pre auricular - Post auricular - Occipital - Sub mental - Sub mandibular - Superficial cervical - Posterior cervical - Deep cervical - Supra clavicular GINGIVAL STAINS COLOUR - Coral pink - Bright red - Magenta Pale pink

- Grayish white - Bluish hue - Purplish hue - Black line

 CONTOUR - Scalloped - Rolled out - Thickened - Denuded - Irregularly shaped - Rounded - Flat with blunt inter dental papillae

 CONSISTENCY - Firm, resilient - Soggy, puffy - Pitting on pressure - Edematous - Soft, friable - Sponge like - Increase in size with associated inflammatory signs - Increase in size without any associated inflammatory signs TEXTURE - Stippling/ orange peel appearance - Loss of stippling - Shiny - Smooth - Peeling - Leathery

PERIODONTAL STATUS
THE PERIODONTAL POCKET DEFINITION: The periodontal pocket is defined as a pathologically deepened gingival sulcus. CLASSIFICATION:
Gingival Pocket(pseudo pocket):
This type of pocket is formed by gingival enlargement without destruction of underlying periodontal status.

Periodontal Pocket:
This type of pocket occurs with destruction of the surrounding periodontal tissues.

ACCORDING TO INVOLVED TOOTH SURFACES:

I. II. III. SIMPLE POCKET COMPOUND POCKET COMPLEX POCKET.

CLINICAL FEATURES:
Bluish red,thickened marginal gingiva,flaccidity,smooth shiny surface. Bluish red vertical zone from the gingival margin to alveolar mucosa. Tooth mobility Diastema formation Symptoms such as localized pain Or pain deep in the bone Bleeding on probing When explored with a probe,inner aspect of periodontal pocket is generally painful Pus is expressed on digital pressure application.

TYPES OF POCKETS:
1) SUPRA BONY (Supracrestal or supra alveolar)-in which the bottom of the pocket is coronal to the underlying alveolar bone. 2) INFRA BONY (Intabony,subcrestal or intra alveolar)-in which bottom of the pocket is apical to the level of the adjacent alveolar bone.

PATHOLOGICAL TOOTH MIGRATION:

DEFINITION: Pathologic migration refers to tooth displacement that results when the balance among the factors that maintain physiologic tooth position is disturbed by periodontal disease.
Mostly in anterior region Can occur in any direction Accompanied by mobility and rotation usually

PATHOGENESIS:
1) Weakened periodontal support 2) Changes in the forces exerted on the teeth.

TOOTH MOBILITY:
All teeth have slight degree of physiologic mobility. Greatest on arising in the morning.

ETIOLOGY:
Loss of tooth support Trauma from occlusion Extension of inflammation from gingiva or from the periapex into PDL Periodontal surgery Pregnancy,use of contraceptives. Pathologic processes of jaws that destroy alveolar bone and/or roots of teeth.

GRADING SYSTEM:
NORMAL MOBILITY
Grade1 : Slightly more than normal Grade2 : Moderately more than normal Grade3 : Severe mobility,combined with vertical displacement.

FURCATION Presence of furcation involvement is one clinical finding that can lead to a diagnosis of advanced periodontits and less favourable prognosis
ETIOLOGY:
Bacterial plaque-primary factor. Local factors-rate of plaque deposition,oral hygiene,allachment loss etc.

DIAGNOSIS: Careful probing to determine presence and extent of furcation [Link] gingival sounding. CLASSIFICATION:
Grade1 : Incipient or early [Link] is suprabony or primarily affects soft [Link] changes not present. Grade2 : Can effect one or more furcations of same [Link]-de-sac with definite horizontal component.R/E-may or may not depict. Grade3 : Bone is not attached to the dome of [Link] be filled with soft tissue.R/Eradiolucent area in the crotch of the tooth.

 Grade4 : Inter-dental bone is destroyed and the soft tissue have receeded apically so that furcation opening is clinically visible.

GINGIVAL RECESSION:
Exposure of root surface by an apical shift in position of the gingiva.

May be localized or generalized.

ETIOLOGY:
Increase in age Faulty tooth brushing technique Tooth malposition Friction from soft tissues Gingival inflammation Abnormal frenal attachment Smoking MILLERS CLASSIFICATION CLASS 1 CLASS 2 : Marginal tissue recession that doesnt extend upto mucogingival junction : Marginal tissue recession to or beyond mucogingival junction

CLASS 3 : Marginal tissue recession to or beyond mucogingival junction bone and soft tissue loss interdentally or malpositioning tooth CLASS 4 : Marginal tissue recession extend to or beyond the mucogingival junction with severe bone and soft tissue loss interdentally and or severe tooth malposition

ATTACHMENT LOSS:
Increased probing depth and loss of clinical attachment are specific for periodontitis Conventional probing-1mm;range 12mm Seen in-aggresive periodontitis,chronic periodontitis,refractory periodontitis.

MUCOGINGIVAL PROBLEMS:
Mucogingiva includes mucogingival junction and its relationship to the gingiva,alveolar mucosa,frenula,muscle attachments,vestibular fornices,floor of mouth.

INVESTIGATIONS
RADIOGRAPHS: Intra oral periapical radiographs Bite wing Occlusal INDICATIONS FOR IOPA - To visualize periapical region - In diagnosis of periapical pathology - To study crown & root length - To study integrity of lamina dura - Post surgical evaluation of socket INDICATIONS FOR BITE-WING RADIOGRAPHS - To know extent of interproximal caries - To study height of alveolar bone or assessment of bone mass - To study occlusion of teeth OCCLUSAL RADIOGRAPHS - Covers a larger area than periapical films

- Cross-sectional occlusal films allow measurement of buccoblingual dimension of mandible - For planning implants in severely resorbed mandible - To identify expansion of cortical plane in case of any pathology such as cysts

OTHER INVESTIGATIONS
HYPERTENSION: BLOOD PRESSURE: NORMAL < 120/80 PRE-HYPERTENSION (120 - 139)/(80-89) STAGE 1 HYPERTENSION (140-159)/(90-99) STAGE 2 HYPERTENSION >= 160/100 If normal, pre-hypertensive, stage 1 hypertensive patient continue dental treatment. If stage 2 hypertension do not perform any treatment until its an emergency case. Otherwise go for anti-hypertensive therapy. DIABETES: - NORMAL BLOOD SUGAR LEVELS FBG 70-100 MG/DL PPBG < 140 MG/DL RBS < 160 MG/DL - GLUCOSE TOLERANCE TEST FBS > 100 MG/DL 1 HR > 160 MG/DL 2 HRS > 120 MG/DL THESE GLUCOSE LEVELS WILL CONFIRM DIABETES

GLYCOSYLATED HAEMOGLOBIN ASSAY (HBA1C) 4 - 6% NORMAL < 7% GOOD DIABETES CONTROL 7 - 8% MODERATE > 8% ACTION CONTROL SUGGESTED TO IMPROVE DIABETES

RENAL DISEASES: - Blood urea nitrogen < 60 mg/dl do not treat - Serum creatinine < 1.5 mg/dl do not treat HAEMORRHAGIC DISEASES: - COMPLETE BLOOD PICTURE - NORMAL VALUES: - BLEEDING TIME 3-5 MIN. - PROTHROMBIN TIME 12-14 SEC - PARTIAL THROMBOPLASTIN TIME 20-40 SEC - HAEMOGLOBIN, HB % : MEN 13-16 GM/DL WOMEN 11-14 GM/DL - ESR VALUES

MEN 0-10 MM 1ST HR WESTERGREN WOMEN 0-20 MM 1ST HR WESTERGREN

- INR LEVELS INR < 3 SCALING AND ROOT PLANING CAN BE DONE SAFELY INR < (2-2.25) MINOR SIMPLE EXTRACTIONS CAN BE DONE - If increased ptt, normal pt,bt- haemophilia - If low platelet count, prolonged clot retraction time, bt, or slight increase ctthrombocytopenic purpura

- If increased wbc count- leukemia - If decreased hb % - anemia HEPATITIS: - HBSAG AND ANTI HBS ANTIBODY TESTS if negative but hbv is suspected, order another hbs determination if positive patients are probably infective if anti hbs positive, may be treated routinely if hbsag negative, may be treated routinely - Bilrubbin levels, urobilinogen levels, sgot/sgpt levels, serum alkaline phosphatase levels can also be considered.

PERIODONTAL STATUS
THE PERIODONTAL POCKET DEFINITION: The periodontal pocket is defined as a pathologically deepened gingival sulcus. CLASSIFICATION:
Gingival Pocket (Pseudo Pocket):
This type of pocket is formed by gingival enlargement without destruction of underlying periodontal status.

Periodontal Pocket:
This type of pocket occurs with destruction of the surrounding periodontal tissues.

ACCORDING TO INVOLVED TOOTH SURFACES:

IV. V. VI. SIMPLE POCKET COMPOUND POCKET COMPLEX POCKET.

CLINICAL FEATURES:
Bluish red,thickened marginal gingiva,flaccidity,smooth shiny surface. Bluish red vertical zone from the gingival margin to alveolar mucosa. Tooth mobility Diastema formation Symptoms such as localized pain Or pain deep in the bone Bleeding on probing When explored with a probe,inner aspect of periodontal pocket is generally painful Pus is expressed on digital pressure application.

TYPES OF POCKETS:
3) SUPRA BONY(supracrestal or supra alveolar)-in which the bottom of the pocket is coronal to the underlying alveolar bone. 4) INFRA BONY(intabony,subcrestal or intra alveolar)-in which bottom of the pocket is apical to the level of the adjacent alveolar bone.

PATHOLOGICAL TOOTH MIGRATION:

DEFINITION: Pathologic migration refers to tooth displacement that results when the balance among the factors that maintain physiologic tooth position is disturbed by periodontal disease.
Mostly in anterior region Can occur in any direction Accompanied by mobility and rotation usually

PATHOGENESIS:
3) Weakened periodontal support 4) Changes in the forces exerted on the teeth.

TOOTH MOBILITY:
All teeth have slight degree of physiologic mobility.

Greatest on arising in the morning.

ETIOLOGY:
Loss of tooth support Trauma from occlusion Extension of inflammation from gingiva or from the periapex into PDL Periodontal surgery Pregnancy,use of contraceptives. Pathologic processes of jaws that destroy alveolar bone and/or roots of teeth.

GRADING SYSTEM:
NORMAL MOBILITY
GRADE 1:slightly more than normal GRADE2:moderately more than normal GRADE3:severe mobility,combined with vertical displacement.

FURCATION: Presence of furcation involvement is one clinical finding that can lead to a diagnosis of advanced periodontits and less favourable prognosis
ETIOLOGY:
Bacterial plaque-primary factor. Local factors-rate of plaque deposition,oral hygiene,allachment loss etc.

DIAGNOSIS: Careful probing to determine presence and extent of furcation [Link] gingival sounding. CLASSIFICATION:
GRADE 1:incipient or early [Link] [Link] changes not present. is suprabony or primarily affects soft

GRADE 2:can effect one or more furcations of same [Link]-de-sac with definite horizontal component.R/E-may or may not depict. GRADE 3:bone is not attached to the dome of [Link] be filled with soft tissue.R/Eradiolucent area in the crotch of the tooth. GRADE 4:interdental bone is destroyed and the soft tissue have receeded apically so that furcation opening is clinically visible.

GINGIVAL RECESSION:
Exposure of root surface by an apical shift in position of the gingiva. May be localized or generalized.

ETIOLOGY:
Increase in age Faulty tooth brushing technique

 Tooth malposition Friction from soft tissues Gingival inflammation Abnormal frenal attachment Smoking

ATTACHMENT LOSS:
Increased probing depth and loss of clinical attachment are specific for periodontitis Conventional probing-1mm;range 12mm Seen in-aggresive periodontitis,chronic periodontitis,refractory periodontitis.

MUCOGINGIVAL PROBLEMS:
Mucogingiva includes mucosa,frenula,muscle GINGIVITIS: 2 SIGNS 1. Incresed crevicular fluid 2. Bleeding on probing. TREATMENT PLAN: 1. Non surgical[phase I therapy] [Link] plaque control instructions [Link] of calculus and root planning [Link] of restorative and prosthetic irritational factors [Link] of caries and restoration [Link] microbial therapy[local or systemic] [Link] therapy 7. Minor orthodontic therapy mucogingival junction and attachments,vestibular its relationship to fornices,floor the gingiva,alveolar of mouth.

Maintenance therapy [Evaluation of response to non surgical phase Rechecking: gingival inflammation,plaque, calculus and caries]

Surgical phase [if present]

Maintanance therapy

Restorative phase [phase III] [Link] restoration [Link] and removable prosthodontic appliances

Maintanance therapy[periodic rechecking] Gingival condition,plaque,calculus IN FEMALE PATIENTS: In puberty: Milder gingivitis- scaling, root planning and oral hygiene instructions Severe gingivitis-anti microbial mouth wash,antibiotic therapy Menstrual cycle: Anti microbial oral rinses before cyclic inflammation Pregnancy: Scaling and root planning if necessary

Patient on oral contraceptives: Oral hygiene program,elimination of local factors,scaling and root planning. Menopause: oral hygiene instructions,brush with extra soft tooth brush With low abrasive content,rinses should have less alcohol content

WHEN TREATING HYPERTENSIVE PATIENTS: The clinician should not use a LA containing an epinephrine concentration >1:1,00,000 nor should a vasopressor be used to control a local bleeding. LA without epinephrine used for shorter procedures. IN HEMORRAGIC DISORDERS: In thrombocytopenic purpura: Scaling & root planning No surgical procedures unless platelet count is atleast 80,000 cells/mm3. In leukaemic patients: Scaling & root planning Through oral hygiene instructions & 0.12% chlorhexidine mouth wash twice daily. IN INFECTIVE ENDOCARRDITIS PTS WITH SIGNIFICANT GINGIVAL INFLAMMATION: Oral hygiene should initially be limited to gentle procedure i.e. oral rinses & tooth brushing with a soft brush. Oral irrigators are not recommended because their use may induce bacteremia. ACUTE NECROTISING ULCERATIVE GINGIVITIS: 1ST VISIT: Reduce microbial load & remove necrotic tissue Subgingival scaling & curettage contraindicated because they extend infection to deeper tissues Surgical procedures: Tooth extraction/periodontal therapy is postponed until 4weeks after acute signs & symptoms of NUG subsided. Pt instructions: Avoid tobacco, alcohol. Rinse with 3% H2O2 & warm water every 2 hrs or with 0.12% chlorhexidine

An analgesics given[NSAIDs]

2ND VISIT: 1 or 2 days after 1st visit Evaluate the pt Scaling is performed if necessary 3RD VISIT: Evaluate the patient Instruct plaque control procedures H2O2 mouth wash discontinue use chlorhexidine mouth wash Scaling and root planning

Additional treatment: Contouring of gingival Systemic anti biotics and topical anti microbials Nutritional supplements.

GINGIVAL ENLARGEMENT: [Link] gingival enlargement [Link] induced [Link] enlargement in pregnancy [Link] enlargement in puberty [Link] gingival enlargement

Patient taking drug known to cause gingival enlargement [anti convulsants,ca channel blockers,immuno suppressants]

Gingival enlargement not present

Gingival enlargement present

Oral hygiene reinforcement Professional recalls

oral hygiene reinforcement chlorhexidine gluconate rinses Scaling and root planning Possible drug substitution Professional recalls

Gingival enlargement regresses

revaluation

Maintain good oral hygiene Maintain professional recalls

Enlargement persists

Periodontal surgery indicated

Small areas of enlargement Absence of osseous defects

large areas of enlargement Presence of osseous defects

Leukemic gingival enlargement

Only gingival enlargement

gingival enlagement with superimposed ANUG

oral hygiene reinforcement

1st treated ANUG then proceed with gingival enlargement

If regress maintain good oral hygiene

if persists

after acute symptoms of ANUG subsided

Enlargement treated by scaling and root planning Chlorhexidine mouth wash Oral hygiene reinforcement,recall

If persists periodontal surgery done

Enlargement of 6 teeth No osseous defects

enlargement >6 teeth osseous defects

Gingivectomy GINGIVAL ENLARGEMENT IN PREGNANCY

flap surgery

Treatment requires elimination of all local irritants responsible for the gingival changes Marginal and interdental gingival enlargement enlargement Tumor like gingival

Scaling and curettage, oral hygiene instructions and root planning, oral hygieneinstructions ENLARGEMENT IN PUBERTY:

surgical excision, scaling

Treated by scaling and root planning, removal of irritation, plaque control, chlorhexidine rinse In severe cases- surgical removal CHRONIC INFLAMMATORY GINGIVAL ENLRGEMENT:

Enlargement whuch is soft and discolored

more fibrotic

Scalingand root planning Oral hygiene, chlorhexidine

shrinkage does not occur after scaling and root planning

Surgery indicated

Gingivectomy

flap surgery

DESQUAMATIVE GINGIVITIS: It is a condition charectarized by the intense erythema, desquamation, ulceration of the free and attached gingival It was not a specific entity but a gingival response associated with variety of conditions TREATMENT OF LICHEN PLANUS: LICHEN PLANUS

ASYMPTOMATIC

SYMPTOMATIC

No therapy

erosive or ulcerative

Rule out superimposed candidisis if +ve use anti fungal drugs

Periodic exam

Topical steroids

Intra lesional steroids for Large chronic ulcers

Resolution

No Resolution

Wean off and moniter

Refer to dermatologist [retinoids,dapsone,cyclosporines, photopheresis ]

TREATMENT OF CICATRICIAL PENPHIGOID:

CICATRICIAL PEMPHIGOID

Asymptomatic

mild to moderate

severe

Plaque control

Topical steroids

Refer to dermatologist

Prednisolone

Dapsone

No Resolution

[dapsone,methotrexate,cyclosporins, cytophosphamide,azathioprine]

DIAGNOSIS OF PEMPHIGUS VULGARIS

REFER TO DERMOTOLIST

Primary treatment

Secondary treatment

Prednisolone

[azathioprine,cyclophaspamide,cyclosporines]

1 PERIODONTAL POCKET
TYPES 1. Gingival pocket 2. Periodontal pocket Another type of classification of pocket are 1. Suprabony pocket 2. Infra bony pocket TREATMENT PLAN GINGIVAL POCKET (PSEUDO POCKET) Treatment Plan PERIODONTAL POCKET

Phase I Therapy Scaling and root planing

Phase I Therapy Scaling and root planing

Phase 4 Therapy Maintenance phases

Phase 4 Therapy Maintenance phases

SUPRABONY POCKETS

INTRABONYPOCKETS

PHASE 1 THERAPY PHASE 1 THERAPY

SCALING AND ROOT

CURETTAGE

PHASE 4 OR MAINTENANCE PHASE

Pocket depth can be reduced or eliminated by periodontal flap surgery 2. PERIODONTAL ABSCESS OR LATERAL ABSCESS OR PARIETAL ABSCESS TREATMENT PLAN EMERGENCY PHASE OR PRELIMINARY PHASE ACUTE ABSCESS: Before treating a patient with periodontal abscess ,medical history ,dental history, systemic conditions are noted Needs for systemic antibiotics in cases Such as; 1. Fever 2. Cellulitis 3. Deep inaccessible pocket 4. Regional lymphadenopathy 5. Immune compromised patient

ANTIOBIOTIC OPTIONS [Link] -500mg 3 times daily for 3 days Re-evaluated after 3 days to determine need for continued or adjusted antibiotic therapy 2. In cases of pencillin allergy CLINDAMYCIN is given 300mg 4times daily for 3 days AZITHROMYCIN OR CLARITHROMYCIN 500mg 4 times daily for 3 days TRAETMENT OPTIONS 1. Drainage through periodontal pocket retraction or through external incision 2. Maintenance phase i.e frequent mouth rinsing with warm water or periodic application of chlorohexidine gluconate either by rinsing or locally with a cotton tipped applicator 3. In cases of patients who require antibiotics regimen signs and symptoms usually subsided if not patient is asked to continue regimen for 24 hrs CHRONIC ABSCESS

PHASE 1 THERAPY

PHASE 2 THERAPY

SCALING AND ROOT PLANNING

SURGICAL PHASE

INDICATED IN WHEN DEEEP VERTICAL OR FURCATION DEFECTS ARE PRESENT In these cases same antibiotic treatment as acute abscess are given PERIODONTAL CYST

Antibiotic prophylaxis

Phase 2 or surgical phase

Maintenance phase or phase 4

CHRONIC PERIODONTITIS

Localized periodontitis

Generalized periodontitis

When less than 30% of sites

when more than 30% of sites attachment and bone loss

exhibit attachment loss and bone loss TREATMENT PLAN

PHASE 1 THERAPY OR NON SURGICAL PHASE

Scaling and root planning

Phase 4 maintenance phase

AGGRESSIVE PERIODONTITIS

LOCALIZED

GENERALIZED

RAPIDLY PROGRESSIVE

TREATMENT PLAN NONSURGICAL SURGICAL ANTIMICROBIAL THERAPY

IT INCLUDES Pt Education Resective & Regenerative Phase 1 therapy

To eliminate or reduce pockets And vertical bone defects Depths with multiple osseus walls not done in horizontal bone loss

Scaling and Root planning Regular recall P hase 4 Early diagnosis cases shows better results Moderate to severe cases poor prognosis

Antimicrobial therapy

The use of systemic antibiotics was thought to be necessary to eliminate pathogenic bacteria from tissues

Several authors have reported success untreating aggressive periodontitis with systemic antibiotics as adjuncts to standard therapy

Mostly commonly used antimicrobial are 1. TETRACYLCINES-250mg 4 times daily for 1 week it should be given in conjunction with local mechanical therapy 2. If surgery is indicated ,systemic Tetracyclines should be prescribed and pt should be instructed to begin taking appproximating 1 hr before surgery 3. DOXYCYCLINE 100mg/day may be used 4. CHLOROHEXIDINE rinses should be used and continued for several weeks 5. MICROBIAL TESTING is done -specific periodontal pathogens responsible should be identified and appropriate antibiotics should be given. ASSOCIATED MICROFLORA Gram positive organisms Gram negative organisms Nonoral gram negative facultative rods Black pigmented bacteria and spirochetes Provetella intermedia,porphyromonas gingivalis Actinobacillus actinomycetemcomitans Porphyrmonas gingivalis ANTIBIOTIC FOR CHOICE Amoxicillin clavulanate potassium (augmentin) clindamycin ciprofloxacin metronidazole tetracyclines Metronidazole amoxicillin ,metronidazole ciprofloxacin azithromycin

LOCAL DRUG DELIVERY AGENTS [Link], FIBERS AND CHIPS

After all the phases completed Restorative phase and maintenance phase NECROTISING ULCERTATIVE PERODONTITIS

Associated with systemic diseases

Not associated with systemic Such as HIV diseases

Any hematological diseases Like leukaemia

Phase 1 therapy local debridement with scaling and root planning

Evaluate and treatment of any systemic disease

Phase 1 therapy is followed that is local therapy Debridement of lesions with scaling and root planning Lavage and

phase 4or maintenance

Phase 4 therapy or maintenance therapy

Proper oral hygiene instructions

CARDIO VASCULAR DISEASES ISCHAEMIC HEART DISEASES ANGINA, MYOCARDIAL INFARCTION

ANGINA

UNSTABLE

STABLE

treated acute anginal attack with nitroglycerin and long acting forms are used

treated only in emergency

can undergo EDP restriction of LA containing epinephrin stress reduction intraosseous inj of LA should be done consiously

consult physicain

profound LA is vital

angina attacks during perio produres

conscious sedation

discontinue treatment

supplementation of O2 by cannula

Administer 1tab of nitroglycerin sublingually Loosening of garments Administer pt in relaxed position Signs and symptoms cease in 3 min

resolving

doesnt resolve

continue treatment

second dose of nitroglycerin

monitor

3 doses of 2nd dose

nitroglycerin 3 min after

If chest pain persists

Pt is transported to emergency facility

MYOCARDIAL INFARCTION

Dental tt done after 6 months MI (because peak mortality during 6 months)

After 6 months using same technique as stable angina pt

Cardiac bypass , femoral artery by pass, angioplasty , endartectomy are some of the common diseases of IHD

Consult physician Prophylactic antibiotics are given CONGESTIVE HEART FAILURE

Poorly treated

Treated CHF

Elective dental procedures

Consult physician

To known severity and underlying etiology are is known

Medication given accordingly

HYPERTENSION As long as stress is minimized dental tt is safe

Before consulting a physician should take two readings at two different timings for two different dental visits and takes average

Consult physician

Untreated Systolic BP>180mm Diastolic BP >110mm Tt should be limited to EMERGENCY until it is Vasopressor Controlled and no routine Perio TT should be given

Treated

Local anaesthetic containing epinephrine conc. greater than 1;100,000 or to be used to control local bleeding

Analgesics- for pain Antibiotics for infusion

LA without epinephrine may be used for short period of time(<30min)

Acute infection-surgical or Drainage incision

small doses should be used

Surgical field is limited if Blood is seen it may rise the BP

Intraligamentary injection is generally Contraindicated because hemodynamic Changes are similar to intravascular Injection

Anxiety

Postural hypertension is reduced by positional changes in chair

INFECTIVE ENDOCARDITIS

Prophylaxis recommended

Prophylaxis not recommended

High risk patients

1. Previous history of I.E

moderate risk patients

[Link]. vavlular dysfunction [Link] heart malformation [Link] cardiomyopathy [Link] valve prolapsed [Link] valve valvular [Link] bypass

2. Prosthetic heart valves prolapse 3. Major congenital heart disease regurgitation a. Tetralogy of fallot artery Single ventricular state graft surgery.

b. Transposition of greater artery functional c. Surgery constructed [Link] murmurs

3. Physiologic, or innocent [Link] fever vavular dysfunction 5. Surgically ASD,VSD or PPD [Link] disease without vavular dysfunction

PREVENTIVE Define history susceptible

MEASURES: patientORAL- Amox-2gm 1hr before procedure(if allergic). Clindamycin-600mg 1hr before procedure.

medical

Provide

oral

(to minimize Improve gingival

hygiene & gentle Recommrnded-Oral rinsusinstructions tooth brushing bacteremia & Azithromycin or Clarithromycin-500mg 1hr before procedure. Not recommended- Oral health) Or irrigators(may induce bacteremia)
Or Cetadroxil-2gm 1hr before procedure.

Antibiotic Regimen

UNABLE TO TAKE ORAL MEDICINE Ampicillin-2gm IM or IV before 30 min of procedure. UNABLE TO TAKE ORAL MED. & ALLERGIC TO PENCILLIN- Clindamycin-6oomg IV before 30min. Or Cefazolin-1gm IM or IV before 30min. EARLY ONSET PERIODONTITIS + RISK OF PERIODONTITIS+ RESISTANT TO PENCILLINS -Tetracycline-250mg 4 times for 14days.

PERIODONTAL TREATMENT -Periodontitis: Severe-teeth extracted Less-teeth treated, retained to maintained -Chlorhexidine rinses -Restorative sutures & chromic gut -Antibiotics- used during 1st week of healing If used dosage not sufficient to prevent IE & therefore prophylactic antibiotic dosage is Needed.

CONGESTIVE HEART FAILURE

Automatic cardioverter Medications Digioxin Diuretics quidine implanted in chest walls umbilicus pacemakers implanted subcutaneously near defibrillators

enter heart transversely

have electrodes passing into the heart

Older pacemak

Newer unit bipolar

Activate without unipolar

disrupted by dental equipment that generated EM fields

not affected by dental equipment

warning when certain arrhythmias occur cause sudden pt movt

CEREBROVASCULAR ACCIDENTS
No periodontal therapy for 6 months high risk of recurrence

6 months therapy with short appointments

conc. 1:1,00,000 epinephrine contraindicated

LA given

Light conscious sedation given (inhibition oral or parentral)

Oxygen supplements given through cerebral oxygenation

Stroke pt`S O. oral coagulants

Blood pressure carefully monitored

DIABETES MELLITUS
Normal plasma glucose level is >200mg/dl Fasting plasma glucose .>126mg/dl Two hour postprandial glucose.>200mg/dl Normal fasting glucose > 70-100mg/dl Primary test is glycosylated hemoglobin assay 4-6% normal 7%good diabetic 7-8%moderate diabetics >8% action suggested to improve diabetes control Two tests used

HbA1

HbA1c

HbA1c is most often used It reflects blood glucose concentrations over preceding 6-8 weeks It may provide an indication of the potential response to periodontal therapy Treatment plan

Undiagnosed

diagnosed

Consult physician

well controlled

poor controlled

Analyze laboratory tests

good response

poor response

Rule out acute orofacial Infection or severe dental infection

If present emergency care nonsurgical debridement Of plaque and calculus

Oral hygiene instruction If HbA1c is less than 10%

surgical treatment can be done

systemic antibiotics not needed routinely tetracyclines with scaling and root planning is effective if patient has poor glycemic control

surgery is absolutely is needed

pencillins are most often indicated

Frequent reevaluation Before any periodontal therapy pt should be asked to eat because after the therapy they are unable to eat and they may go to hypoglycemic attack
o o

If pt is restricted from eating insulin doses should be reduced If procedures are long insulin doses before the treatment may need to be reduced

o Before any periodontal therapy pt should be asked to eat becoz after the therapy they are unable to eat and they may go to hypoglycemic attack o If pt is restricted from eatin insulin doses should be reduced o If procedures are long insulin doses before the treatment may need to be reduced

THYROID AND PARATHYROID DISORDERS

THYROID

Thyrotoxicosis

hyperthyroidism

hypothyroidism

Inadequate

Determine level of

Careful administration of sedatives and narcotics

Medical management. medical management

No periodontal therapy

should limit stress and infection

PARATHYROID

Medical history

Routine periodontal treatment

ADRENAL INSUFFICIENCY

Pt taking large doses greater than 20mg corticosteroid per day

pt taking small doses for short periods

No supplementation Requiring stressful periodontal Procedures, doubling or tripling the normal dose 1 hr before

ACUTE ADRENAL INSUFFICIENCY CRISIS

Terminate periodontal treatment

Summon medical assistance

Give oxygen

Monitor vital signs

Place pt in supine position

Administer 100mg of hydro corticosine sodium succinate

Intravenously over 30 sec inter muscular TREATMENT OF PATIENTS WITH LIVER DISEASES Treatment recommendations for periodontal problems: 1. Consultation with physician concerning i. ii. iii. iv. Stage of disease. Risk of bleeding. Potential drugs to. be prescribed Required alteration to periodontal treatment.

2. Screening for hepatitis B & C. 3. Prothombin time & partial thromboplastin T. Treatment of patients with pulmonary diseases: 1. Identify & refer patients with signs &symptoms of pulmonary disease to their physicians. 2. Patients with known pulmonary disease a. Consult physician regarding medications. b. Degree & severity of pulmonary disease. c. Avoid elicitation of respiratory depression. i. ii. Minimize stress in periodontal appointment. Avoid medications that cause respiratory depression (narcotics, sedatives, GA)

3. Avoid bilateral mandibular block anaesthesia, which could cause increased airway obstruction. 4. Position of patient to allow maximal ventilatory efficiency. 5. Avoid excessive periodontal packing, keep the patients throat clear.

6.

In patients with history of asthma make sure patients medication (inhaler) is available.

7. In patients with active fungal or bacterial respiratory diseases should not be treated unless it is emergency.

IMMUNO SUPRESSIVE PATIENTS: Organ transplantation Chemo therapy Drug administration Chemo therapy : : Immuno suppression Cyto toxic to bone marrow Destruction of formed elements of blood Thrombocytopenia, leucopenia, anemia. Hence greater risk of infection,dissemination of oral infections.

Treatment: Prevention of oral complications that could be life threatening Conservative and palliative Reduce the microbial load Treatment plan: 1. Extract teeth having poor prognosis 2. Thorough debridement of remaining teeth 3. Antimicrobial rinses esp. in patients with chemotherapy induced mucositis to prevent secondary infection.

RADIATION THERAPY:
During radiation pt.s should receive weekly prophylaxis, oral hygiene instructions, professionally applied fluoride treatment, .dentrifice- 0.4% stannous and 1% sodium fluoride

Pre radiation treatment: 1. examination of non restorable and severly periodontally diseased teeth 2 weeks prior 2.. primary closure of extractions [Link] [Link] surgeries 5. panaromic , intraoral radiograph [Link] dental and periodontal evaluaton Post radiaton follow up: [Link] lidocaine may be prescribed for painful mucositis [Link] substitutes for xerostomia [Link] topical fluoride application and oral hygiene indicated to prevent radiation caries.

HAEMORRAGIC DISORDERS: Patient bleeding

Notice the duration of bleeding

If BT is 3-4 min(normal)

if BT > 5min( abnormal)

Normal bleeding

spontaneous bleeding

Go for laboratory tests BT,CT,PT,PTT,INR Tourniquet test

look for petechia and haemorrhagic vesicles

Go for lab tests Low platelet count ,prolonged clot Retraction time,BT, or slight Increase in CT(Thrombocytopenic purpura)

IN LABORATORY TESTS: IF there is increase in PTT, normal PT,BT IT indicates HAEMOPHILIA A Treatment: 1. Physician consultation 2. Factor viii concentrate 3. Fresh frozen plasma 4. EACA 5. Trans escamic acid If there is increase in PTT, normal PT,BT- HAEMOPHILIA B Treatment: 1. Factor ix concentrate 2. Fresh frozen plasma 3. Purified prothrombin complex concentrate 4. Surgical 30 to 50% of factor viii is needed If increase in BT,PTT,variable factor viii deficiency ,normal PT, platelet count. It indicates von willebrand disease Treated by factor viii concentrate and DDAVP.

In thrombocytopenic purpura: No surgical procedure unless platelet count s atleast 80,000cells/mm3 Prophylactic treatment of potential abscesses

Scaling and root planning performed carefully at low platelet count level.

LEUKAEMIA

Known leukaemic patient

un known patient

Chemo therapy

radiation

corticosteroids

refer to physician

Before chemo therapy a complete periodontal treatment Plan should be done Monitor -bleeding time,clotting time Prothrombin time,platelet count Administer antibiotic coverage

tests for

Periodontal debridement[scaling and root planning] should be done if INR < 3 Thorough oral hygiene instructions given Twice daily rinse with 0.12% chlorohexidine mouth wash Minor simple extractions done if INR < 2-2.5 Multiple extractions if INR< 1.5 -2

Thus extract all hopeless teeth at least before 10 days

DURING

Acute phase of leukemia

Chronic phase

-Patient should receive only emergency planning Periodontal care -Antibiotic therapy with surgical\ non surgical Debridement -oral ulcerations and mucositis treated with Viscous lidocaine - oral candidiasis treated by Nystatin suspension[100,000/ml 4 times daily] Or clotrimazole Vaginal suppositories[10mg 4/5times daily

- scaling and root performed without complication

- if possible periodontal surgery indicated.

UN KNOWN PATIENT Refer physician Tests for leukemia

[Link] picture: Anemia Platelets WBC severe increased increased moderate normal increased

2. bone marrow examination: Cellularity .lymphatic cells increase serum lysozome serum B12 vit. B12 erythrosyte rosttetest hyper cellular blastic cells hypercellular . myloid

acute leukemia lymphatic

chronic myeloid

chronic leukamia

AGRANULOCYTOSIS[cyclic neutropenia and granulocytosis

Pt. with agranulocytosis

unknown patient

Drug induced

due to other causes

refer to physician

Eliminate those drugs 2000

if WBC count <

Both types agranulocttosis Induce periodontal instructions After physician consultation -severely extracted teeth should be extracted -oral hygiene instructions include use of Chlorohexidine rinse daily -scaling and root planning under antibiotic Protection.

indicate

TREATMENT PLAN FOR TUBERCULOSIS: Pt should receive only emergency care. PERIODONTAL TREATMENT

Completed chemotherapy poor medical follow up

Physician consulted

show signs or symptoms evaluated

Systemic culture are made

evaluated

Medical clearance & sputum treated for 18 months minimum Results are negative

Treated normally

post treatment follow up includes 1. Chest radiograph 2. Sputum culture 3. Pts symptoms review by physician atleast every 12 months.

INFECTIOUS DISEASES HIV & AIDS It is endemic Wide range of oral lesions are associated with HIV

CONTRAINDICATIONS Aspirin is avoided. Blood transfusions are avoided due to risk of transmission. Sharp instrument injury

INDICATIONS Protease inhibitors [Link],Nelfinavir Reverse inhibitor

Ex zidovudine l lamivudine,didanosine In cases of candidiasis antifungal are given periodontal diseases: Oral hygiene Plaque removal Chlorhexidine Metronidazole herpes- anti virals apthous ulcers-corticosteriods

HEPATITIS

HEPATITIS A Treated in acute phase HEPATITIS B

Drugs are used cautionly

MANAGEMENT

Normal platelet count Normal prothrombin time

if platelet count is low and prothrombin time prolonged

can be treated

risk of transmission of HBs-Ag

but may have bleeding tendency HEPATITIS C

high risk in oral surgeon and periodontitis

It has been found in saliva and infection has followed a human bite.

TREATMENT PLAN The following guidelines on offered for treating hepatitis pts 1. If disease , regarding of type is active, do not provide periodontal therapy unless situation is an emergency if positive for hepatitis follow the period 2. Past history of hepatitis, consult physician to determine type of hepatitis, course and length of disease, mode of transmission 3. Recurrent HAV, HEV-perform routine periodontal care For recovered HBV ,HDV pts consult physicians and order HBsAg and anti HBs lab tests.

Lab tests

If HBsAg,antiHBs

HBsaAg positive

Anti HBsAg positive HbsAg negative

Tests are positive But HBV is suspected Order another HBs Determination

are infected degree is measure by HBsAg determination may be treated

For HCV pt, consult physician to determine risk of transmissibility and current status of chronic liver disease If pt with active hepatitis ,positive HBsAg status,positive carrier status requires emergency treatment Use following guidelines: 1. Consult physician 2. Measure PT and BT if bleeding occur during procedure
3.

Persons who contact with pts should use a barrier techniques including masks ,gloves, glasses, eyeshields, disposable gowns.

4. Use disposable covers covering light [Link] handle ,bracket trays 5. All disposable items should be placed in waste basket
6.

Aseptic technique should be followed at all time.

7.

Minimize use of aerosols production by not using the ultrasonic instruments.

8. Prerinsing with chlorohexidine gluconate for 30 sec is highly recommmed After the procedure all instruments should be washed and sterilized if an item cant be sterilize it should be disposed S. No. 1) CONDITION Normal Gingiva COLOUR Coral pink(Adults) Pale pink(children) CONTOUR Scalloped outline CONSISTENCY Firm, resilient

2)

Gingivitis severe, acute chronic

Bluish hue on Rolled out or reddened gingiva rounded marginal gingiva Red or Bluish red Flat, blunt Interdental papilla

Soggy, puffy Pits on pressure Diffuse puffiness and softening

3) 4) 5)

gingiva in puberty in menstrual cycle in pregnancy gingivitis

Bluish red

Edematous Tense; bloated, with exudate release

Bright red to bluish red RASPBERRY appearance Bright red or magenta Dusky red or magenta

gingival enlargement - marginal

Marginal and inter dental gingiva is edematous, smooth, shiny & pits on pressure Soft friable, smooth, shiny

- tumor like

Semi firm, smooth,

glistening surface with numerous deep red pinpoint markings 6) 7) menopausal gingivostomatitis addisons disease Abnormally pale to red Isolated patches of bluish black to brown Discolouration 8) in mouth breathers Red (in anterior region) Red Pale pink MULBERRY shaped Edematous (in anterior region), shiny surface Smooth, surface shiny Dry, shiny fissures in mucobuccal fold

9) 10)

gingival abscess drug induced enlargements with inflammation without inflammation

Resilient, minutely lobulated surface & tendency to bleed Lobulated Firm, minutely surface leathery, pebbled

Reddish or bluish 11) idiopathic enlargement gingival Pink

12) 13) 14) 15) 16)

in vitamin c deficiency plasma cell gingivitis pyogenic granuloma leukemia pernicious anemia sickle cell anemia aplastic anemia thrombocytopenia

Bluish red Red Bright red and purple Bluish red cyanotic Pale Pale yellowish Pale Purplish

Soft, friable, smooth, shiny Friable, granular Friable/firm

or Rounding of Sponge like, friable, gingival margin moderately firm

17)

Soft, swollen, friable

gingiva 18) 19) 20) wegeners granulomatosis sarcoidosis fibroma of gingiva Reddish purple Red Smooth Spherical tumor, soft, vascular, firm, Nodular cell Pink, deep red or purplish hue Grayish white Firm or spongy Flattened scaly lesion to thick, irregularly shaped keratinous plaque Shiny, hemorrhagic (marginal gingiva involved) Thickened marginal gingiva Flaccid, smooth shiny surface Edematous, diffuse, shiny Irregularly shaped Denuded appearance

21) 22)

peripheral granuloma leukoplakia

giant

23)

necrotizing gingivitis

ulcerative Red

24)

periodontal pocket

Bluish red

25) 26)

primary gingivostomatitis

herpetic Red

desquamative gingivitis mild moderate severe

Red Patchy red or gray areas Striking red colour Pale red magenta to

27) 28) 29) 30)

chronic periodontitis necrotizing periodontitis

ulcerative Bright red marginal gingiva Fiery red

aggressive periodontitis

bismuth, arsenic,mercury, Black line or lead pigmentation bluish line which follows the

contour gingiva

of

the