Management of medically compromised patients

Introduction
The responsibility of a clinician is not only to identify a particular condition but also to
formulate proper treatment plan. So, in order to do this thorough medical history has to be taken
and if significant findings are unveiled, consultations with or referred of the patient to physician is
required so that not only the patients correctly managed and treated but also the clinician is medico
legally covered.
Understanding these problems will enable the clinician to treat the total patient and not
merely the periodontal reflection of underlying disease
Cardiovascular disease
- Patient’s cardiologist should be consulted.
- Schedule morning appointment.
- Maintain an open, concerned atmosphere during treatment.
- Keep appointment short.

Angina Pectoris
Angina Pectoris is the term used to describe discomfort due to transient myocardial
ischemia and constitutes a clinical syndrome rather than a disease it may occur whenever there is
an, imbalance between myocardial oxygen supply and demand.
Coronary atheroma is by far the most common cause but angina is also a feature of aortic
valve disease, hypertrophic cardio myopathy and some other form of heart disease.

Clinical features
History of pain
Stable angina is characterized by left sided or central chest pain that is precipitated by
exertion and promptly relieved by rest.
Most patients describe a sense of oppression or tightness in the chest – “like a band
around the chest, ‘pain’ may be denied when describing angina, the victim of the closes a hand
around the throat , puts a hand or clenched fist on the sternum or places both hands across the
lower chest. The term ‘angina’ is derived from the Greek word for strangulation and many patients
describe a series of ‘choking ’.
The pain may radiate to the neck or jaw and is often accompanied by discomfort in the arm,
particularly left, the wrist and sometimes the hands.
Symptoms tend to be worse after a meal, in the cold and when walking uphill or against a
strong mind.
Angina that occurs at rest or without provocation is called unstable angina.
Investigation
Resting ECG:
ST segment changes on electro cardiograph, Isotope scanning, coronary arteriography.

Management
Advice to patients.
- Do not smoke
- Aim at ideal body weight
- Regular exercises.
- Avoid severe unaccustomed exertion
- Take sub lingual nitrate before undertaking exertion that may induce angina.

Aspirin
Low dose (75 –300 mg)
Nitrates:
 Causes venous or arteriolar dilatation. Their benefits are due to decrease in the
myocardial oxygen demand and an increase in myocardial O2 supply.
 Sublingual glyceryl trinitrate (GTN) administered from aerosol (400 µg per spray) or a
tablet. 500 µg – relieves anginal attack in 2-3 min.
 β adreno receptor antagonist : lower myocardial O 2 demand by reducing heart rate, BP
and myocardial contractility . Example: propanolol, metoprolol.
 Calcium channel blockers: These drugs inhibit the slow inward current caused by the
entry of extra cellular Ca through the cell membrane of excitable cells, particularly
cardiac and anterior smooth muscle, and lower myocardial O 2 demand by decreasing BP
and myocardial contractility
Surgical treatment
Coronary angioplasty & coronary artery bypass grafting
Dental management
Patients with a H/o unstable angina pectoris should be treated in emergency only. Patients
with stable angina can under go elective dental procedures if proper precautions are taken.
1. Premedication if needed (Diazepam, nitrous oxide - oxygen or a short acting barbiturate
such as pento barbital 30 to 60 mg or seco barbital 60 – 100 mg.
2. Adequate – anesthesia (aspirate frequently and inject slowly).
3. Nitroglycerin premedication sublingually (1/200 grams) 5 minutes before a procedure that
the patient feels is stressful.

The patient’s medication (nitroglycerine) should be readily accessible. Expiration date noted.
 If during a periodontal procedure the patient becomes fatigued or uncomfortable or has a
sudden change in heart system or rate, the procedure should be discontinued as soon as possible.
Emergency medical treatment.
1. Discontinue the periodontal procedure
2. Administer one tablet (0.3 to 0.6 mg) of nitroglycerine sublingually.
3. Reassure the patient and loosen restrictive garments.
4. Administers O2 with the patient in a reclining position
5. If the signs and symptoms cease with in 3 minutes, complete the periodontal procedure if
possible, making sure that the patient comfortable . Terminate the procedure at the earliest
convenient time.

II. Previous cardiac bypass or myocardial infarction

- The physician should be consulted prior to elective dental therapy.
- It is advised that elective therapy not be performed until 6 months after bypass.
- Myocardial infarction is almost always due to the formation of occlusive thrombus at the site
of rupture of an athermatous plaque in a coronary artery.

Clinical features
Pain is the cardinal symptoms. But breathlessness, vomiting and collapse or syncope is
common clinical features
- Pain occurs in the same site on that angina but is very severe and lasts longer often described
as tightness, heaviness or constriction in the chest.
- Prophylactic antibiotics are not needed unless the cardiologist recommends it.
- The cardiologist should inform the dentist regarding the degree of heart damage or arterial
occlusive disease the stability of the patient’s conditions and the potential for infective
endocarditis or graft rejection.

III. Previous Cerebrovascular accident: or stroke

Stroke in uncommon below age of 50 and affects males 1.5 times more than females.
- Stroke may be due cerebral infarction 80% and hemorrhage 20%.
- Risk factors for stroke.
Arterial hypertension, cigarette smoking, diabetes mellitus, hyper lipedimia polycythemia,
thrombocytopenia, high alcohol in take, +ve family history, oral contra ceptive, trauma, cerebral
infarction.
- Occlusion of a major cerebral artery usually leads to infarction.
- Thrombosis at the site of athermatous degeneration in a major cerebral vessel is probably the
commonest mechanism but embolism of thrombotic or athermatous material from the heart or
an extra cranial artery is also frequent.
- Once deprived of blood supply cerebral tissue undergoes infarction with in a few minutes.
Cerebral Hemorrhage.
- Due to subarachanoid bleeding from rupture of an aneurism.
- Subarachanoid hemorrhage may induce secondary arterial spasm and thereby cerebral
infarction.

Classification of stroke
 Complete stroke
- Major
- Minor
 Evolving strokes
 Transient ischemic attach (TIA)

Clinical feature
The majority of the patients exhibit greater or lesser degrees of hemi paresis, dysphagia
with hemi anesthesia.
Strokes affecting the brain stem are more likely to cause loss of consciousness because of
damage to the reticular activating system.

Investigation
CT scanning, angiography, echo cardiography.

Management
Management of acute strokes.
- Careful nursing – avoid pressure sores
- Care of air way – oropharyngeal tube with regular suction.
- Fluid balance – naso gastric feeding and bladder catheterization.
- Physiotherapy
- Speech and occupational therapy

Specific management.
Anticoagulation
If there is a clear persistent embolic source or if feature of strokes are evolving over hours
or days
Edema – reducing agents
Osmotic agents (20% manitol I.V.)
- Limits swelling and brain stem compression
Vasodilating agents
Surgery – Neuro surgical examination of cerebral hematoma. In cerebellar hemorrhage with sec.
Brain – stress compression, urgent surgical drainage of the hematoma may be life saving.

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
because of the high risk of recurrence during this period.
2. After 6 months, periodontal therapy may be performed during short (max 60 minutes)
atraumatic appointments
3. Mild sedation should be used only if the patient is extremely excitable or nervous.
4. LA may be used with caution, aspirate then inject slowly and carefully (not intra
vascularly). The 1989 AAP World Workshop recommended 2 capsules of lidocaine with
epinephrine (1:100000). Others recommend a more of 3 to 5 capsules, depending on
patient’s age and weight.

5. Be aware that many post strokes patients have been placed on anticoagulant therapy. If this
is the there
i. Check prothrombin time prior to deep scaling or periodontal surgery.
ii. Consult with the patients physician to adjust the prothrombin time to not greater
than 1.5 times normal and
iii. Remember that anticoagulant have known interactions
6. Know what to do in case of a recurrent CVA.
 Know the signs and symptoms of a CVA
 Terminate the dental treatment.
 Make the patient comfortable in an up right portion of conscious.
 Give O2 only if respiration difficulty develops
 Monitor vital signs
 Summon medical assistance.
 If the patient becomes unconscious, perform basic life support procedure and place the patients
in supine position if CPR is needed.
 Do not give medicines that elicit depression of CNS.

Congestive Heart failure

Describes that state that develops when the heart cannot maintain an adequate cardiac
output or can do so only at the expense of an elevated filling pressure.
CHF begin with left ventricular failure caused by a disproportion because of the
hemodynamic load and the capacity to handle the load.

It may be due to .
 I. A chronic increase in work load (as in hyper tension or in aortic, mitral, pulmonary or
tricuspid vascular disease.
II. direct damage to the myocardium (as in MI or rheumatic fever)
III. To an increase in the body’s energy requirements.

Patients with untreated CHF are not candidates for elective dental procedure. For patients
with treated CHF the clinician should consult with physician regarding the following.

1. Medication
* Digitalis
1. Watch for tending toward name and / or initially
2. watch for increased susceptibility to dry and rthymatic
* Diuretics
1. Watch for a susceptibility to ortho static hypo tension.
2. Known the side effects of prescribed dismetric.
 : Prothrombin time should be 1.5 x
.
2. Degree of control of the medical problem.
3. Etiology of the decrease process.
4. Presence of or potential for polyeythemia, thrombo cytopenia, or leuko perio in compensation
for inadequate O2 in the arterial system.
 Patients may require antibotic coverage if the WBC cannot in law.
 Potential for bleeding problem.
 Do not allow the patients to dehydria.
 Procedure should be short.
 Do not place the patient in flat syringe park
 Supplemental or administration by nasal canulus may be used.
 Stress reduction should be erupted sized.
 Do not use saline rinses, occupy to via absorpt.
 Understand the treatment steps for active developing CHF.
1. Administer 100% O2ly face mask.
2. Positive the patient sitting upright.
3. Record vital signs.
4. Apply rotating torniquets high on the 4 extremities, this is a blood the phlebotomy
procedure that will reduce the total circulating blood release the tourniquet over at a time
for 5 minutes every 30 minutes.
5. Call for medical assistance.
Hypertension
Hypertension (BP greater than 140/90 mm Hg) is the most frequent medical problem.
It is a major risk factor for cardiovascular morbidity and mort ality.
Diagnosis involves a proper and standard procedure for measuring BP.
1. The patient should rest for 5 min prior to BP determination.
2. Arm should be free of restrictive clothing
3. The patient should avoid tobacco for 30 minutes before BP in taken.
4. Cuff size in important the width of the cuff should be 20% wider than the diameter extremity.
5. Deflated cuff in placed 2.5 cm above the antecuboid fossa. Cuff fit should be smooth and for
ever.
6. Examiner pulpates the brachial artery. The bell of the stethoscopes in place over the artery.
7. Take cuff pressure up 30 mm Mg above the post of which palpable radial artery disappears
8. Systolic BP is recorded as first Koeofkoff round diastolic BP in when the sound becomes
muffled and then disappears.
9. Or initial visit, BP should be measured in both arms.
10. Subsequent BP is recorded in the arm with the higher reading if there is more than 10 mm
because discrepancy.

Systobic mm ug Diastolic mm ug

Category
Normal < 130 < 85
High name 130 - 139 85 - 89
Hypertension
Stage – I (Mild) 140 – 159 90 – 99
Stage – II ( Moderate) 160 – 179 100 – 109
Stage – III ( Severe) 180 - 209 110 – 119
Stage – IV ( Very severe) 210 120
- Normal BP increase from 20/45 mm kg in infancyto 480/45 in early childhood and 100/75 in
adolescents.
- If a patients BP is found to be severely elevated (ie 180/110 or gecalin), elective dental
procedure should be postponed until adequate control in achieved.
- Emergency dental procedure should be performed causational and expectatiously in patients
with uncontrolled hypertension in consultation with patient physician.
- BP control during dental procedure may require the intra venous use of mediation such as
nitroglycin sublingual mitroglycin will also produce and transient reduction in BP.
- Medication used to lower BP include diuretics, β-bockers, Ca channel blocks, vasodilation,
angio…. Converting enzyme inhibitors.
- Surgical procedure should be avoided because of the potential for excessive bleeding.
- In testing hypertensive patients, the clinician should not use a LA containing an epinephrine
conc. greater than 1:1,00,000 nor should be vasopressor be used to control local bleeding.
- Saline rinses are contra indicated.
- The clinician should be aware of man side effects of various antihypertensive medication.
- The frequency of episodes of posterial hypertension with or without syncope can be reduce by
eliminating sudden positial charge in the dental class.
The chain should be slowly elevated to an upright position prior to the patients standing up.
- Nousea may also occur see to the use of anti hypertensive medication.
- Vander heydren et al 1989 demonstrated little measurable effect on blood pressure with LA
administration with LA administered in 20 periodontal patients. 19 patients require 3.6 ml of
2% lidocaine with 1:100000 epinephrine. Only one patients required an additional 1.8 ml of
2% lidocane with 1:100000 epinephrine to achieve an adequate inferior a… a block.

Cardiac Pacemakers
 Temporary
 Permanent
The following guidelines.
1. Health history : +ve -> consult patients cardiologic about the proposed periodontal
procedure, associated risk
2. Positioning : The patient should be positioned so as to minimize discomfort from strain on
the lead nines or on the implant site. Pressure should be minimized over the area of the
pacemaker apparatus. Positioning of patient should be determined by their level of cyst.
3. Devices : All line powered devices that come into contact with the patient should be
measured for leakage and all electrically powered dental equipment should be earth
grounded.
4. Limited use of electrical equipment : area ultra source and electro surgical devices. Try to
keep all electrical equipment at least 1 fort (30 um) from the patient.

Infective endocarditis
Infective endocarditis is due to microbial infection of a heart valve (native or prosthetic) or
the lining of a cardiac chamber or blood vessel or a congenital a normally (Example septal
defects).

Causative organisms
Strep Viridian
Strep. Viridians :- (S. mitis, 4 S Sanguis, L.hemolytic strep) are the commensals in the
upper respiratory tract and a common cause of perio infection.
Staph amean : is a common cause of acute endo carditis originating from skin infection,
abscesses or in intra venous drug addition. Other causes of acute endocarditis : Strep phermanion
and Neissemia gonorrhea.

Post operative endocarditis following cardiac surgery etc.

 coagulese –ve straph. (staph. Albens)
 Fungi -> cahdida, aspergillus

Pathophysiology
Endocarditis occurs at sites where the endothelium is damaged by a high pressure jet of
blood. (Venticular septal defect; persistent ductus arteriosus, or reguitilant nitral or aortic value).
Endothelial damage leads to the deposition of platelets and fibrious, with are colonized by blood
borne organisms, creating vegetarian. The award value tissue and presence of fibrin host dyerise
mechanism. Affected valver develop vegetarian compared by organism, fibrin and platelets and
the vegetarian may became large enough to came obstruction or may blade away an embolism.
Extra cardiac manifestation results from embolism or from skin lesions. Mycotic anenysm may
develop in arteries at the site of infected embolism.

Clinical features
Sub acute : should be suspected when a patient known to have congenital or valvular heart
disease develops a persistent fever or C/o. unusual tiredness, might awards weight loss or develops
new sign of value dysfunction or heart failure . less after it presents are embolic stroke or
peripheral arterial embolism. Other feature include purpose and fetechial hemorrhage in the skin
and mucous membrane and sphinter hemorrhage under the finger a toe nails.
Osler’s nodes are painful tender swelling at the finger tripe, probably the results of
vasculities. Digital clubbing in the a late sign. The finding of any of these features in patients with
permanent fever or malaria is an indication for re examination for any unrecognized heart disease.

Acute
Usually presents as a severe febrile illness with prominent and charging heart minimum
and petechiae.
Embolic events are common or usual failure may develop rapidly. Abuses may be detected
on echocardiography.

Post operative
 May resemble sub acute or acute endocarditis depending on the virulence of the organism.
The infection usually affects the value injection. Any unesplained fever in a patient. Who has had
heart value surgery should be investigated for possible endo carditis.

Investigation
 Blood culture
 Elevation of the ESR, a monocytic, norno chronic anemia and leucocytomn are common that
not invariable and throbocytoperia may be present. Measurement of C-reactive problem in
more reliable them the ESR in assessing program. Proteinmia may occur and microscopic
hematmia in usually present.
 Echocardiography :- for investing valve damage and for deteching abcess formation.
 Chest radiography shown evidence of cardiac failure and cardio grapy.

Management
To provide adequate preventive measures of IE, periodontitis major concern should be to
reduce the microbial population in the oral cavity.
- Preventive measures to reduce the risk of IE should consist of the fall.
1. Define the susceptible patient : Careful patient history. If in diabetic consult patient
physician
2. Provide oral hygiene instructions

Oral hygiene should initially be limited to growth procedures (ie, oral rinses and gentle tooth
brushing with a soft brush). As gingival health improves, more aggressive oral hygiene may be
initiated. Because dental imagination devices have been implicated in associated with IE their
use should be discouraged in susceptible ind….
3. Currently recommended antibiotic prophylactic regions should be practice with all
susceptible patients.
For most adults, oral administration of 2 g of amonyalbin 1 hr before the dental procedure is
received clindanycin (600 mg 1 hour before the dental procedure) cephalevin / Cefachoscial or
azithrocycin / clarithromycin are recommended in alterations in patients that are allergic to
penicillin.
In or IV antibiotic regimen are prescribed for patients that cannot taken oral medication.
The recommendation are considered adequate for patients that are at high risk from IE.
(Prevention of bacteria endocarditis. Recommendation AMA. Bajani AS, JAMA 1997, circulation
1997)
 Dental procedure creating bacteremia risk
 Dental extraction.
 Implant placement and tooth reimplantation
  Surgical and non surgical periodontal procedure
 Endodontic instrumentation beyond the not open or endo surgery
 Initial placement of ortho bands.
 Intra ligmentary injection
 Prophylarxis when bleeding in expected.
 Sub gingival placement of antibiotic process or streps.
 Dental procedure with low bacteria risk.
 Restorative procedure, with or without retraction cord
 LA injection.
 Placement of rubber dam.
 Suture removal.
 Placement or adjustment of ortho or removable prostho appliances.
 Oral impression.
 Fluoride test.
 Oral radiographs.
 Shedding of periodontal teeth.
4. Periodontal test should be designed for susceptible patients to accommodate their
particular degree of periodontal involvement.

The following guidelines.

 All perio procedure (including probing) require antibiotic prophylaxis.
 In cases of delayed healing it is product to provide additional doses of antibiotics. Also perio
sutures removal may be performed more safely by extending antibiotic coverage to the 5 th or
6th PO day. Alt. Resolve sutures may be use.
 Little and falace recommended a concentration 5-7 days oral hygiene – gotoss debridement
program with antibiotic coverage.
 Dental extraction should be availed and endo treatment in the patients of …. Single
extraction is preferred over multiple extraction is severe perio disease and areas of
periodontal suppuration or dental focus of infection requires elimination
 Prolonged impingment of the gingival tissue on with ligature or tissue retracture should be
avoided
 One day antibiotic coverage shouldbe used with 10-14 das eloping before starting a new
coverage period, if one is needed. An equally acceptable attractive should be to rotates
different antibiotic to minimum the emergence of resistance strain.
 Prior to surgical procedure the gingival tissue should be cleansed. Rising with 0.12%
cehlud….. mouth wash for ….. is recommended before any periodontal procedures.
 All elective dental procedure should be post period until the periodontal tissue approximate
periodontal health.
  Regular recall appointemtn with an emphress on oral hygiene reinforcement and maintainer
of periodontal health are extremely important in their population.

Renal diseases
The most causes of renal failure are glomunlo ruphritis, pyeloneophris, kidney cystic
diseases, reno – vascular disease, drug nephropathy, obstructive uropathy and hypertension.
- Physicians consultation is necessary to determines the stage of the renal failure and the
medical treatment prescribed.
- The patient in chronic renal failure has a progressive disease that my ultimately require renal
transplantation or diagnosis. It is preferable to treat a patient before rather than after transplant
is dialysis.
- The following treatment modality should be followed
1. Consult the patients physician
2. Monitor blood pressure (patients in end stage renal failure are usually hypertensive)
3. Check lab value
Partial thromboplastin time : 12-14 seconds -> def. Of factors II, V, VII and X.
Bleeding time – Less than 8 minutes -> thrombocytopesia, micropathy, Von with brands
disease.
Platelet comb : 150-350 x 109/1
Blood urea nitrogen :-
(De…. If < 60 mg / 100ml)
Scrum creatinium % 1 mg / dl (do not treatment if < 1.5 mg/10 ml
4. Eliminate areas of oral infection
- Oral hygiene should be good
- Perio treatment should aim at providing easy maintainance. All questionable teeth should be
extracted if medical parameter point.
5. Drugs that are nephroton, or metabolized by the kidney should not be given (example
phenacitin, streptocysis tetracycline). Auto….. and acetylsaliytic and may be used with cardia.
The patient who is receiving dialysis:- 3 modes intermittent perit…. Dialysis.
Chronic ambu… per…… dialysis.

Hemodialysis
An lterovenious fistula should be formed usually in the foreum. Due to the increased BP in
the various from the fistula, thus is distensia and thickening of the vein wall with allows the
repetitive insection of need for vascular access for hemodrylysis. Hemodralysis is usually carried
out for 3-5 mm 3 times weekly.
Continuous ambulating perio….. dialysis : in a form of long term dialysis involving
insertion of a permanent intrapertioned …… in to the abdominal cavity. Normally 2 < of sterile
isotemic dialysis fluid on introduced and cyst for a period of appears 6 hrs. the fluid in then
drained and fresh dialysis fluid introduced. This cycle is repeated 4 times daily, during with time
the patient is fully mole and able to undertake normal daily task.
Only hemodralysis patients require special precautions such patients have a high incidence
scrum hepatitis, a high incidence of anemia, and a significant incidence of sec hyper
parathynodism and undergo haparnizala of during hemolysis.

Following recommendation for such patients

1. Screen for hepatitis B surface antigen and antibodies to hepatitis B prior to any treatment.
The HBs Ag appears in the blood take in the incubation period and before the produced phase
of acute type B hepatitis, it may be present for only a few days, disappearing cure before
jaundice has developed, but it last for 3-4 weeks and may persent for up to 5 month. It should
became be sought in such as possible in acute hepatitis.
Antibody to HBs Ag usually appears after about 3-6 month and persists for many years or
perhaps permanently.

2. Provide antibiotic prophylances to prevent endotenstitis of the anteriovenous fistula or

shut.
3. Prevent hypersia.
4. Provide treatment in the day after dialysis when the effects of hepanization have subsided.
5. Establish a long term maintainence system with freqent recall apartment.
6. BP care to protect the dialysis short in fistula when the patient is in the dental chair. If the
short or fistula is placed in the arm, do not c… the limb. Do not use the limb for BP or
infection.

Renal transplantation
The potential for oral and systemic infection in quite high after transplantation because of
the use of immune suppressive drug regi…. – may make the manifestation inflammation.
Occasionally oral cavity in the source of group –ve enterococcal infection (Pseudomaads, protein,
….._ fungal infection (caradic, as perg…) or viral infection (herpes system) all of with can result
in life – threatening systemic sepsis.
Drug often used in dental practice may be retained in blood plasma for prolonged diameter
due to diminished renal function in hemodralysis patients. Therapeutic administration may require
dosage adjustment consulting a physician.
- HBs Ag screening must be due.
- Prophlactic antibiotic ZE may occur in dialysis patients with no evidence of previous cardiac
valunla damage, because dental practitices should renal about for sign and systems of ZE.
Pulmonary disease
Pulmonary disease range from obstructive long diseases (Example : Asthma, Emphys……
bracl….. and …….. obstruction) to restrictive ventilating disorders that are due to muscle
weakness, scaring, obesity or any condition that could interferes with effective long ventilation.
- The clinician should be aware of the sign and symptom of pulmonary disease, such as
increased respiratory rate (normal 12-16 breathin/ min.) central cyanosis : Cyanosis is defined
as a bluish discolouration of the skin and mucous membrane, resulting for an increased amount
of reduced Hb (more than 5’g/dl or of hemoglobin derivatives in the crysillary blood.
- Central cyanosis is due to treated anterial oxygen saturation or the preserve of an abnormal Hb
derivatives.
- Peripheral cyanosis is due to a slowing of blood flow to an area, resulting in greater extraction
of O2 from normally saturated arterial blood. This results from vaso constructs or diminished
peripheral blood flow (decrease cardiac output).
- Clubbing : clubbing is defined as selective bulbom enlargement of the distal segment of a digit,
due to an increase in soft tissue.

Grades Grade I : increase fluctuation of the nail bed.

Grade II : Obliteration of the < between nail and nail bed.
Grade III : Increased curvature of the nail resulting in (normal 160) parrot beak or d…….
appearance.
Grade IV : hypertraptor pulmonary osteo arthropathy, characterized by painful, tender, swelling
of wrists (most common), artitits, elbow and knee.
Chronic cough, chest pain, hemogstrysis, dysprea or orthoprea or wheezing.
Patients with these problem should be referred for medical evaluation and treatment.
Cautions should be taken in the use of ultra rem instrumentation. Brild, retained secretions
that result in partial airway obstruction may, because of their hydrophilic nature, cause complete
obstruction when ultra rem dence ….
Also use of ultra sonic devices may prepared, branchospasis …. To the foreign body
nature and aerosol diabetes.
Acute respiratory distress may be caused by slight airway obstruction or depression of
respiratory function.

Management
1. Identify and refer patients with sign and symptom of pulmonary disease.
2. If known pulmonary disease exists, consult with the physician regarding medication and
the degree and severity of the disease.
 3. Avoid elicitation of the respiratory depression or distress ….. - Minimize the stress
apartment – the patient with ….. should be scheduled in the afternoon, severed his after
sleep to allow for airway clearances.
- Avoid medication that could cause respiratory depression.
- Do not give a bilateral mandibula block, with could care increased airway obstruction.
- Position the patient to allow man, ventilatory efficiency, be careful to prevent physical airway
– obstruction, … the patient throat clear and avoid excess periodontal packing.
4. In patient with a H/o asthma, make same the patients medication in available (example :
Isoproterence 0.25% aerosol ) and several complex dental procedure.
5. Patients with active fungal or bacterial diseases should not be treated unless the periodontal
procedure is in emergency.

Radiation therapy
Radiation therapy along with surgical resection in common in the treatment of head and
neck tumors.
Side effects
Mucositis, dermatitis, xerostosmia, dysphagia, gustatory alteration, radiation causes,
vascular charges, trismus, TMJ degeneration and osteo radio necrosis.
Patients scheduled to receive radiation therapy requires dental consultation. The initial visit
should include panoramic and ZO radiographs, clinical dental examination periodontal evaluation
and physician consultation.
The treatment decision that should be made relates to possible extraction because radiation
can cause side effects that interfere with healing.
For head and neck squmous cell carcinoma, the dose is usually 5000 to 7000 lad to CO60
delivered in a fractionated method (150 to 200 lad over 6 to 7 week course) side effects depends on
the tissue irradiated.

Salivary gland - Xerotomia - parotid most sensitive.

- Saliva becomes extremely viscous or non existent. Decrease in normal salivary cleaning
function, buffering capacity and …… of fluids. Oral bacteria shift to predominately cariogenic
form( S. mutan, Actinocyen).
Other manifestation in the osteo radionecrosis (Occurs in 5 to 10% of patients undergone
radiation therapy). Incidence in more in mandible because of its lack of vascularity and to higher
incidence of carcinoma in mandibular areas. Osseous healing may progress slowly be not at al. A
decrease vascular supply, along with damaged and diminished number of osteocytes and
osteoblasts, any trauma or infection may lead to this condition.
The required extracted should be performed a minimum of 10 days to 2 weeks prior to
initiation of radiation therapy or should not be performed at all. If the perio support is less than ½
the root length, the teeth are non restorable or abcessed and the patients oral hygiene and
motivation are poor, it is recommended that extracted be performed with in the recommended
time.
- Extracted should be performed in a manner that allows patients disease.
- Muco periosteal flaps should be gently elevated, teeth should be extracted in segments, radical
alveolecting should be performed bearing no rough issues specifies to remains and peri closure
should be provided without tension.
- Antibiotics should be prescribed for the initial 7-10 days healing period.
During radiation therapy, the patients should receive weekly fluoride treatment (ie 1 minutes,
APF rims (1.23%) following by a 4 min SuF rinse (1.64%) unless these treatment are initating
to a concurrent mucosities.
Patients should be instructed to brush daily with a SuFgel (0.4%. All remaining teeth
should receive through debridement (SRP). Single restoration should be placed where required.
Ultra sonic instrumentation is not recommended. Full thickness flaps teeth or perio
procedure that could express appears structures should not be performed esp. on mandible post
irridiation care :- consists of palliative treatment. A 3 months recall interval is ideal. Viscous
lido…. May be prescribed to painful mucositis, or salivary substitutes for Xerostomia.
Supportive attitudes

Endocrine disorders
Diabetes :
Diabetes mellitus is a clinical syndrome characterized by hyperglycaemia due to absolute
or relative deficiency of insulin.

Classification
In 1997, the American diabetes association provided the current classification.
 Type I diabetes (formerly, insulin – dependent diabetes).
 Type II diabetes (formerly non insulin – dependent diabtes)
 Gestational diabetes.
 Other types of diabetes
- Genetic defects in B cell function
- Genetic defects in insulin action.
- Parcreatic disease or injuries
- Infections.
- Drug induced or chemical induced diabetes gluco corticoids, thyroid hormone.
- Endocrimopathies :- acromegaly, phenochromocytania, glycagonania, hyper thyroidism,
cushing syndrome.
- Other genetic syndromes.
Mechanism of insulin metabolism.
Food digestion -> increased glucose -> increase insulin secretion

Blood glucose * Muscle increases uptaken glucose

* Muscle and liver stall glucose as glycogen
* Liver prevented from breaking down
glycogen stores into glycose.

Hormonal control of glycermia

Hormonal that rains blood glucose
 Glycogen, (catecholamine (epinephrine), * Growth house
 Thyroid ……. * Glucocortia.. (Cortisol) hormonal that lowers blood glucose
 Insulin

Characteristics of type 1 and type 2 diabetes.

Type 1 Type 2
Age of onset Generally < 30 years Generally in adulthood
Most commonly Thin or normal Obese
Stature
Formly history Common More common
Rapidity of onsets Abrupt Slow
Pathogenesis Auto immunity to β cells Insulin resistance, impaired
insulin recreations, increase
liver glucose production,
Endogeneous insulin None Decreased, normal or
production elevated
Susceptibility to …… High Low (Hyper or molar non
acidosis ketotic acidosis
Treatment may include Diet excesses insulin Diet excesses, oral agents,
insulin.

Classic complication of DM
1. Retinopathy -> blindness
Increases as the elevation of the disease increases. The basement membrane of retinal
capillaries thickness and micro analysis develop. Extravasation of blood from the capillaries
results in Soft and hard exudates formation in the retina. Capillary Acceleration causes retinal
…… -> proliferation of abnormal blood verses and fibration -> called as proliferative retinopathy.
These new vessesls are frangible and liked into the vitreous -> with time leads to blindness.

2. Nephropathy -> renal failure

the measures given, the membrane supporting the capillary loops in the renal giometer,
expands due to increased production of marginal mation proliferation. As the mea… bonement
membrane in glov… capillaries thickness, further decreasing GFR -> excretion of small amounts
of albuium (micro albin…..) -> progression -> macro albinium -> increase renal blood pressure ->
renal failure.

3. Neuropathy – may affect sensory, motor and anatomic nerves. Peripheral sensorimotor
neuropathy in more common – manifesting on membrane in tinghing of toes or teeth -> paresthesia
may disappear -> hyper extension or even anesthesia.
It is sensory ability makes the affected areas lingually prior to injury since the patient is unable to
prescribe painful stimuli – diabetic tool ulcer and alteration in wound healing capacity may lead
gingiva.

4. Macro vascular disease (acclerated atherosclerosis)

Triglycoids levels are often dramatically increased while HDL levels are decreased. LDL
may be named. Hyperglycemia increases the oxidation of LDL and oxidized LAL in much more
allinogenic than the native from.
Thrombin formation in also enhanced in a diabetic patients increased fibr… deposition and
increased platelet aggregation -> formation of micro thrombi -> increased risk of thromb emboli ->
myocardial infarction, stroke, CVA etc.

5. Altered wound healing.

Clinicals signs and symptoms
Classic symptoms -> polydipsia (Excessive thirst), polymia (excessive ……), unexplained
weight loss, and poly phagia (excessive hunger)
Diagram :- 1997, American diabetes association diagnostic parameters

Laboratory methods
1. Symptom of diabetes and casual (manifesting ) plasma glucose > 200 mg / dl. Casual
glucose may be decrease last meal. Classic symptom include – polymia, polydepsia, and
unexplained weight loss.
2. Fasting plasmia glucose > 126 mg / dl fasting is defined as no calanic in taken for at least
8 hrs.
3. 2 hrs post prandial glucose > 200 mg / dl during an oral glucose tolerance test. The test
should be performed using a glucose load containing the equialent of 75 g of only done
glucose dissolved in water.

Categories of fasting plasma glucose (PPG)

1. FPG < 110 mg/dl = normal FG.
2. FPG < 110 mg / dl and < 126 mg / dl = impaired FPG
 3. FPG > 126 mg / dl = provisional diagramming diabetes ( must be confirmed on saline
quest day)

Categories of 2 hr post pradial glucose ( 2 LPG)

1. 2 h PG < 140 mg / dl = normal GT.
2. 2 h PG > 140 mg / dl & < 200 mg /dl = impa….. GT
3. 2 h PG > 200 mg / dl = provisional diagnosis of diabetes.

The fasting and casual glucose tests allow determination of glycosia at the time when the blood
sample in taken. They do not allow evaluation of glycose called over a more extended time
period.

The patients test used for this purpose in glyconyleted Hb assay. Thin test measures amount
of glycose band to the Hb materials on RBC. Glucose binds incredibility to Hb to form glyconyl
did Hb and well remain bond for the life span of the RBC from about 30 – 90 days.
The higher the blood glucose levels over time, the gentic in % of Gly Hb.
2 different time – Hb A1 and Hb AIC test
Normal HB A1C -> less than 6 to 6.5%.
The A B A recommends that diabetic patients they to achieve an target. Hb AIC of < 7%.
Ah Hb AIC 78% suggests that alteration in patients management is needed to improve glyceric
control.
Self blood glucose monitoring devices.
Using a glyco meter, a small sterile lowest in used to create a puncture on the finger. A
days of capillary blood in decrease from the function site and placed on a strip with in inserted in
the glucometer. A reading of capillary whole blood glucose in given in 1-2 minutes.

Dental management
Careful history
H/o polydysia, polymia, polyphagia or recent unexplained weight loss.
 rapid attachment loss and bone loss that are inconsistent with local factors may
indicate an underlying systemic compart to the patients perio indication.
 Enlarged, hemorrhagic gingival tissues and multiple perio abscess.

Undiagnosed diabetic -> lab evaluation and physician consultation.

Previously diagnosed but poorly controlled – manifestation similar to undiagnosed
Dental treatment should limited to emergency cases, referral to the patients physician
should include on description of intra oral findings and a buy outline of the patients dental
treatment needs. The dental practitioner should require evaluation of the patients glycose control
and appropriate medical management prior to the elective dental treatment
The patients with well controlled diabetes with no significant complication can generally
be managed in a fashion with to the need to monitor signs and symptom of hypoglycemia during
treatment.
Stress reduction, diet modification, antibiotic use, changes in medication hygiene, apart
timings.

Stress decrease -> epinephrine and control of increases stressful condition -> increase blood
glucose – allowing patients appear and discomfortment.
Use LA with 1/100 000 epinephrine has minimal effect on the blood glucose, probably due
to them slow absorption and the low conc. and small valves need.

Diet
Perio therapy often requires surgical procedure that may result in mild to moderate post
operatiave discomfort. Modification of patients about maybe needed in a result of compromised
during and swallowing -> consult the physician.

Antibiotics
Antibiotics are not necessary for routine dental treatment in most diabetic patients may be
considered in the prescribe of overset infection. Antibiotic coverage prior to surgical treatment
should be considered in patients with poorly controlled diabetic. Given elective procedures are
generally deferred until adequate glycermic control in achieved, then most of the applies to
emergence situation such as perio and peri apical. Adjunctive antibiotic may also be considered in
the management of the perio disease -> use of systemic tetracycline, CMY, low dose day cycline
etc.

Planing apartment
It is lest to plant dental treatment either before or after periods of peals insulin activity
because hypoglycemic reaction we more likely to occur when insulin levels are high
If the patient take insulin, the dentist should only the exact type. The greatest risk of
hypoglycemia is usually during the tie of peak insulin activity. 30 to 90 min after injection of
regular insulin, 6 to 8 min after MPH injection.
Question regarding the last meal etc should be included.
It ma be infavouable to plan dental apartment to avoid peak insulin activity. In these
instances the dentist simply needs to be aware that patient is at risk for hypoglycemia, assess the
patients protect. Blood glycone level and have a carbohydrates sources ready.
 If the glucose levels are at or area the lower end of normal, the patient may insure some
carbohydrate before starting treatment to avoid hypoglycemia during apartment.
On the other hand, a markedly elevated patient blood glucose (> 300 mg / dl) may suggest
is assessed and improved.

Thyroid and Para thyroid disorders

In adequately managed thyroid or parathyroid disease -> perio therapy requires minimal
alteration. Hyper thyroidism – should be treated in a way that limits stress and infection.
Epinephrine, atrophy

Hypothyroid
And Other pressure …… should be give with ca…
Hypo thyroid and careful administration of sedative. 25% of the dose required for
enthryoid patient is needed for given anesthesia.

Hyper calcium and Hyper calcemia and more …. For cardiac arth… proper referred.

Adrenal in sufficiency
Most commonly admiral insufficiency is seen in persons who have received sternoid
therapy. Adrenal suppression occurs on a result of adreno certical atrophy. May of these patients
course of tolerate the stress caused by dental anxiety, surgical procedure, trauma or infection.
The degree of suppremia depends in the drugs used, the dose, the duration of
administration the length of time ela…. of since the steroid therapy was terminated and route of
administration.
Endocarine consultation is admired.
Proper medical history.
Manifestation of acute adrenal insufficiency.
- Mental confusion, fatigue and weakness.
- Nousea and or vomittly
- Hyper tension
- Syncope.
- Intense abdominal, lower back, and / or leg pain
- Fossea of consciousness
- Conc.

Most patients with Addrsah disease receive a daily oral dose of 25 to 37.5 mg of zostinal
(equivalent to 5 to 7.5 mg of predominates). This replaces the normal output of the adrenal
intra with ranges from 20-30 mg / day.
 Treatment for rhemated arthritis, asthma, dermatologic disease and so further may require
greater doses, with may readily suppress adrenal function of used for long period of time.
Little and Falau recommended the following
1. Patients taking low dose (less than 20 mg) or high dose (more than 20 mg) cartisol daily for
less than 1 month or patients on alternate day therapy. No supplementation is necessary.
2. Patients taking long doses (more than 20 mg cartisol daily) for extensive and stressful
dental procedure; Double or triple the normal maintenance dose the mainly of and 1 hour
before the procedure. These reserve normal dose.
3. Patient on topical steroid -> supplementation not required.

For patients with past history of steroid therapy perio dentist should determines the degree of
adrenal suppressive.
Malaneds “….. of 2’s” – 20 mg of cortisone or its equivalent per day, orally as
parenterally, given continuously over 2 weeks or larger and in 2 years of dental therapy – should
about the clinician to suspect adrenal suppression.
Three regeneration of cortical function may occur with in 9-12 months, but regeneration
after 2 years has also been reported. A minimum 12 months should have passed since the last dose
was take steroid prophylaxis and may be warranted.
Treatment of patient in acute adrenal insufficiency
1. Terminates the perio therapy
2. Summon medical assistance
3. Monitor vital sign.
4. Give O2.
5. Place the patient in a supine patients.
6. Administer 100mg of hydro cortisone sodium … (solu – cortey) IV over 30 sec or IM.

Pregnancy
The 2nd trimester is the safest time to perform treatment. However long, stressful
appointments as well as perio surgical procedure, should be delayed until the post portion period.
Meticular plaque control, scaling, root planning and polishing should be the only non-
emergency period procedure performed.
Decreased BP, syncope and can of consciousness may occur in a result of uterine pressure
on the inferior were carva. Apartments should be short, and the patient should be achieved to
change portion frequently of fully reduced position should be awarded if possible.
No medicine should be prescribed -> te…. No rachographic unless emergency.

Hemorrhagic disorder
Identification requires careful history.
 1. H/o bleeding after pressure surgery a …….
2. Part and present drug history
3. H/o bleeding problem among relabials and firmly bleeding problem.
Bleeding disorders may be classified as coagulation disorders, thrombocyto prove purposes
or non thrombocytopenic purposes.

Lab tests for coagulation and bleeding disorders

Hemostatic

Vascular Platelet Coagulation Lytic

Tests 1. Tornquent 1. Platelet 1. Prothimbin time 1. Englobin
test N : 1 50 000 - 3 00 000 / (measures exist and common clot lysis
minutes pathway function 1, 11, V, VII time
Abnormal : clinical bleeding & X) N : < 90 min.
occurs at <80,000 1mm3. N : 11-14S (depending on lab) Ab > 90 min.
2. BT Ab : 1.5 – 2 times normal.
3. Clot retraction 2. Partial thromboplastic time
4. Complete blood cell …. (measures int. and common
pathway factor III, IX, XI & low
levels of factors I, II, VI, X &
XII)
N : 25 – 40 sec.
Abn: > 1.5 times normal.
3 – clothing time
N – 30-40 mm.
Abn : > 1 hr.
Clinic Vascular wall Thrombocytopence All three test : liver diseases Increase in
al defect. Rule out : Warfarm therapy fibrolytic ….
diseas Rule out : Vascular wall defect Aspirin therapy activity
e Thrombocyto Acute / chronic centence Malab. Syndrome or lay term
associ pesia Aplastic anemia antibiotic therapy
ation Purposes Liver disease Pro thrombin time ;
Telegiectosia Renal dialysis Factors VII def.
Aspirin Partial thromboplastic time
therapy Hemophilosia, renal dialysis
Levlence
Ranal dialysis

Coagulation disorders
-> patients on warfarm therapy
Institution prothrombin or Vit. K dependent factor (II, VII, IX &X). it is important to note
that duration of active of drug is 6 days.
Altered of period treatment
1. Consult the patients physician (the given therapeutic rage in 1.5 – 3 times normal)
2. Perio scaling, surgery and extraction requires a PT UM than 1.5 times normal.
 The physician must be consulted to reduce the days.
 Changes in payment want be apparent until 2 to 3 days after changing dose.
 A PT measurement is required the day of repeaters. It is > 1.5 X normal, council the procedure
and reschedule for 1 to 3 days later. Remeasure the PT on the day of surgery.
3. After scaling and curettage the patient should not be dismissed until bleeding has stopped.
4. Precaution to following : for perio surgery
 Minimize trauma
 Prophylactic antibiotic are recommended to minimize postages infection that may lead to
bleeding.
 Use pressure hemostasis.
 Attempt closure in close to peri as possible.
 There is no contra indication for LA -> potential for been after
 Prior to period pack placement, bleeding should be stopped by packing cotton pellets intra
proximally and applying pressure digitably favourable and lingually. The peri pack may then
be placed over the cotton pellet.
5. Do not perform scaling or perio surgery if the patient has an acute infection.
6. The patient should return 3 to 5 days to delivers if healing is normal. If so, the physician may
reserve the patients adicoagulation therapy.

* Patients or …….. : has war…. Like effect : should be screened for BT & PTT. Physician
generally have patients stages aspirin 7 to 14 days, prior to perio surgery and they measure
bleeding / platelet time. The day of the procedure

* Heparin therapy : Parenteal route : patients duration of active in 4 to 8 hrs but it may last upto 2
hr less.

* Liver disease -> may affect all phone of blood clothing.

Dental treatment planning should include
1. Lab evaluation : PT, BT, platelet conset, and PTT.
2. Conservation non surgical therapy
3. Evaluation of clinical synoptic such as jaundice in microns …. And sclera, clinical bleeding
into tissues, fatigue, increased plasma volume and not loss.
4. GA is usually contra indicated because of the CV improve and improved ability by the liver to
metabolize …..
5. Look for signs of diseases chronic with uncontrolled fibrinolysis (example DIT and
thrombony toperia)
6. If planning surgery (in hospital only)
 Patients should be no more than 1.5 to 2 normal and platelet count should except 80,000
cells /mm3.
 If patient is greater than 2 X normal, Vit K may be effective in reducing it, if not, only smaller
areas of the unable should be treated in patients with advanced liver disease, daily IV doses of
Vit. K (150 mg) maybe tined, but the administration of first whole blood or plasma may also be
required.
 If platelets are low conc. place may be administered.
 Hemophesia.

Hemophibia tests B treatment

Prolonged Normal Treatment
H-A PTT PT Factor VIII cryo ppt,
BT Fresh frozen plasmia
Test whole blood.
HB PTT PT Factor VIII cryo ppt,
Hospitalized Fac IX
ceramic
Van willibrands BT PT Way appt or plasmic
disease PTT Platelet
Variables factors ….
VIII def.

If surgery is needed following precaution

1. Consult physician
2. Hospital of the patient
3. Replace coagulation factors (by dental agent)
4. Surgical teeth : under antibiotic coverage an automatic is possible.

Thrombocytopenic purposes
- Bleeding due to the number of platelets
- Idiopathic thrombocytopenic, radiaton therapy, myelosuppressive drug therapy, b….. or
infection
N -> 2 50 000 + 1 00 000 cell/mm3 spartaeum bleeding occurs at levels of 80,000 to
60,000 cells/mm3.

Management
1. Physician consultation for dry diagnosis and treatment.
2. OH instruction. Gentle OH products shouldbe used.
3. Prophylactic treatment of potential abscesses. Frequent recall appointment are required.
4. No surgical procedure are indicated unless the platelet without is at least 80,000
cells/mm3. the transfusion of platelets can be given before surgery.
 Surgical treatment :- as atraumatic as possible.
 Stents or thrombin soaked culture pellets placed interproximable with perio during should be
utilized to aid in clot termination and to prevent clot disruption.
 Gentle H2O2 mouth wash is may aid in Caholling gingival hemorrhage.
 Close post surgical follow up should ensure.

5. Note that SRP may be carefully performed at low platelet levels (30 000 cells/mm3.

Non thrombocytoperic peripa…

Occurs as a result of either vascular wall fragility – hyper sensitivity reaction, scurvy,
infection, aspirin etc or platelet dysfunction – enemia, Von willibrands disease etc.
Treatment may result in immediate – bleeding after gingival injury.
Treatment consists of direct pressure applied for atleast 15 min. this initial pressure should
control the bleeding. Surgical therapy should be avoided unless the problem is resolved.

Blood dyscrancies
Leukemia
Leukanemia are a gingival of malignant disorders of the hemopoitric tissue
characteristically associated with increased number of primitive white cells (blasts).

Classification
Acute
 Lymphoblastic
 Acute myeloid

Chronic
 hysphetic
 chronic myeloid

Altered period treatment is based on patients susceptibility to infection, bleeding and the
effects of chemo therapy. The treatment plan is an following
1. Refer the patient to the physician for medical evaluation.
2. Prior to chemotherapy
 Monitor BT, CT, PT and platelet count.
 Administer antibiotic coverage before any perio treatment.
 Extract cell hapeters teeth a mixing 10 days before stating chemo therapy.
 Perio debridement should be performed.
OH Instruction :- twice daily rinsing with 0.12% ch…. . if there in the irregular BT, careful
debridement with cotton pellet soaked in 3% H2O2 maybe performed
3. During the acute phases of leukemia patients should receive only emergency perio conc.
* Persistent gingival bleeding usually occurs deep in a perio pocket and should be treated as
follows
1. cleanse the area with 3% H2O2 or 0.12% chlorhemide
2. Careful explores the area and remove any etiological local factors, making every effort to
avoid gingival injury.
3. Release the area with 3% H2O2.
4. Place a cotton pellet evalued in thrombin against the bleeding point.
5. Cover with gauze and apply pressure for 15-20 minutes.
6. If oozing persists after the removal of gauze and pressure, replaces the cotton pellet
(saturated with H2O2 3%) hold poorly and place a period dressing over the area for 24 hrs.

* ANUG -> treatment should be designed to make the patient comfortable and to eliminate a
source of systemic …..
1. Systemic antibiotic
2. Gentle increase and drainage.
3. Cleaning with cotton pellet salinalize with 3% H2O2 or 0.12% chlorhemidium.
* Oral ulceration
1. Topical anesthetic rinses -> viscous lidocaine.
2. Topical protective ointment (Orabase)
3. Sharp initiative areas (bony specific) should be removed.

* Oral membranes – up taken suspension (100,000 U/ml).

4. In patients with chronic leukemia and those in recession SRP canbe performed without
complication perio surgery should be awarded if possible.
* By should be measured on the day of treatment if prolonged postponed the treatment.
* Plaque control and frequent recall visits should receive particular alteration.

Agramdocytosis
There is reduction in total WBC course and a deduction in or disappear of gecular
leukocytes.
Patients with agramdocytosis are more prone for infection. The perio destruction caused by
inflammation in exaggerated, and because treatment should be performed only during periods of
remission of the disease.
Treatment should be …..
OHZ should include use of CHX month uses BID. SRP should be performed carefully
under antibiotic protection.
Drugs implicator to course agramdocytosis should be awarded.
 Normal neuhyshl cut – 3000 to 6000 /mm3.
Third …. Perio – 1000 to 2000 /mm3.
Moderate – 5000 – 1000 /mm3.
Severe - < 500 / mm3.
Agramdocytosis is used when no neutrophils are seen in the peripheral blood scera.

Infection disease
Hepatitis
Hepatitis is divided into Hepatitis A, B, C, D, E and Non A, Non B, Non C Hepatitis.

Hapatitis A mm
- Belongs to the picornavins groups
- Highly infection and spread by feco oral rate
- Since persons incubating or suffering from the disease.
- Children most commonly affected.
- Infection in the community is prevented best by improving social conditions.
- In activated virus vaccine (Hewrise)
- Those at particular risk – Imm protection provided by immune scrum globulin.
- In activation period in – 15 – 20 days.

Hepatitis B virus
- Hepadna virus
- The virus and an excess of its cysula material circulate in the blood, when it can be identified
- Human are the only source of infection.
- Individual incubating or suffering from acute hepatitis are highly infection for at least an long
as the HBs Ag is in the blood
- Asymptomatic individuals and same patients with chronic liver disease have chronic infection
and may carry virus for life.
- Blood in the main source of infection
- Close personal contact, sexual intra course, from mother to child.
- A recabinant hepatitis B vaccine cabining HBs Ag is available (engiene) capable of providing
active immunization in 955 of normal individual.
- Type B hepatitis can be prevented or minimized by IM infection of hyper immune scrum
globbin prepared from blood containing anti HBs.

Hepatitis C Virus
Are PNA containing flam virus.
- Human seen to be the role source of infection. Inculation with blood or blood products is the
best reta…. Mode of from …
- Neither active nor passive protection is available.

Hepatitis and virus

In a RNA containing defective virus requires Hepatitis B virus for replication and has the
same sources and modes of spread on that virus.

Hepatitis E virus
- HEV is an RNA containing virus
- Spreads by feed – oral acute.
- Neither active nor passive protection is available.

Non A, Non B, Non C help viruses

Clinical features
Produced symptoms usually proceed the development of jaundice by a few days to 2
weeks.

Signs and symptoms of acute viral hepatitis

Phase Signs and symptom
Pre ictemic phase Fever, fatigue, Anasexia, Nausea,
Onset is acute in hepatitis A and insidious vomiting, abdominal pain Migalgies.
in B.
Ictemic phase Jaundice, bitimia, increased an…., nausea,
von… abdominal pain, mental depression,
brady cardia.
Post ictemic phase Disappearance of signs and symptoms.
Hepatonegaly may persisted.

Following favourable for treating hepatitis patients.

1. If the disease, regardless of the type is active, do not provide perio therapy, unless the
situation in an emergency.
2. For patients with a past H/o hepatitis, consult the physician to determines type of
hepatitis, cause and length of disease, mode of transmission and required rate test.
3. For recovered type of hepatitis patients, perform routine perio care.
4. For recovered type B – consult the physician and order HBs Ag and anti HBs
determination -> for +ve patients may be treated routinely.
5. If a patient with +ve HbsAg or active hepatitis requires emergency treatment for food
preservation.
 Consult the physician regularly status.
  If bleeding is likely, measure PT and BT, alter treatment accordingly.
 Use full barrier teeth.
 All instruments should be placed on a sheet of Al. food.
 All disposable items should be placed in one lined waste baskets.
 Minimize aerosol production by not may c………………, are syrine, or length speed hand
piece. Prescribing with … in for 30s is recommended.
 When the procedure is completed over equipment should be scheduled and sterilized.
Instrument should be moved while still on the Al. ford to the risk and rinsed with dilute
sodium lypochlorite (1:3) for 10 minutes next they should be scheduled and auto claved.
 The dental chair and unit should be improved done with delute Na Hcl2.
 A… fact should be practiced all the line.
6. Patients who are Hbs Ag –ve maybe blood routinely

STB
The US Public Health Service has categorized STB into – syphilis, granula, herper and
AIDS.

AIDs
- 1st reputed in 1981
- HIV was isolated in 1983.
- The retro virus may take from 6-8 weeks from the time of exposure to procedure measurable
HIV antibodies

Perio treatment
Close advances to the barrier tech.

TB
Should receive emergency care only. If the patient has completed chemo therapy, his or her
physician should be consulted regarding infecting and the results of sputum culture for M.
Tuberculosis when medical clearance has been given and the sputum culture results are –ve, these
patients may be treated normally.
Any patients who given a H/o poor medical follow up or should sign or symptom
indications of TB blood be required to the physician.
Adequate treatment of TB requires a minutes of 18 months and though past treatment
follow up.

References
1. Clinical Periodontology 8th and 9th edition caranza
 2. Periodontal medicine
3. Davidson’s Principle and Practice of Medicine, 17th edition.
4. Periodontal Medicine Perio 2000, Vol. 23, 2000.
5. Human Physiology – Gupta

- Oral lesions in H.V. infection include – oral candidiasis, hairy leukoplakia, extensive aphthous
ulceration and ANUG, linear gingival erythema and NUP.
- Since it is probable that the linear gingival erythema lesion is a precussion for the more
destruction NUP lesion, IIIrd molar principles should be applied in the treatment of these 2
lesions. These principles involves given scaling to remove visible plaque, soft debris and
necrotic tissue when present. Povidone 10 dine irrigation is recommended during this
debridement procedure due to it antiseptic and anesthetic effects. Following this initial
debridement frequent follow up visits are recommended to thoroughly remove the remaining
plaque, calculation and other deposits and to provide plaque control instruments.
- In the case of NUP, this therapeutic approach is important to institute as soon as possible due
to the possibility that the bone and soft tissue necrosis can extend further into the palate and
adjacent tissue leading to the life threatening MOMA conditions.
- Antibiotics should be used with caution due to the risks of over growth of C albican. In order to
prevent the over growth of candida, the generally accepted approach in to use a topical
antigungal agent such as clotrimazole troachea or crystation verginal tablets and systemic
fluconagole in cover of more severe immune suppression.
- Nauon spectrum antibiotics that leave the greater portion of gr +ve flora in tact in order to
prevent candida over growth such on m……. may also be beneficial in the contract of NUP
and LGE.
- Following this debridement, these patients need to the seen for frequent follow up visits in
order to remove residual deposits and to receive a though plaque control regimen.
- CHX based mouth rinses are generally recovered as an effective therapeutic aid in reducing the
acute symptoms of LGE & NUB in and in preventing the recurrence of these lesion.
- Perio surgeries : AAP position paper 1997 on management of cancer patients, it was
recommended not to perform extensive electron perio surgical procedures, if there was severe
immuno suppression to periodontal consideration in the management of the concern patient.
Position paper. JP 1997:68:791-801 T.Rees .
- Of particular concern in performing perio surgery is that a % of HIV infected subjected will
exhibit some degree of thrombocytopenia during the course of their HIV infection. This
depressed platelet count may have an adverse effect on the bleeding and clothing time during
and after perio surgical procedure. It is became recommended that the dental practitioner
obtain necessary information of the HIV patients most current immune and blood status prior
to considering elective surgical procedure.
 Standard oral regimen Ananesthesia 2g 1 hr before procedure
Alternate regimen for Clindamycin 600 mg 1 hr before procedure
patients allergic to common OR
pen, or both Azithomycin or clarthromycin 500 g 1 hr before procedure
OR
Cephalexsis or cefadion 2 g 1 hr before procedure
Patients unable to take oral Anpicillin 2g IM or IV with in 30 min. before
medication procedure
600 mg ZV with in 30 minutes
before procedure
OR 1 g IM or ZV with in 30 minutes
Cefazolin before procedure

Nitroglycerin : For emergency purposes it is awardable as 0.3, 0.4, 0.6 mg sub lingual tablet or a
0.4 mg sublingual spray one important point to be aware of it that the tablets have a short shelf life
of appear. 3 month once the bottle has been opened and the tablets have been exposed to air or
light.

Insulin preparation
Type Onset of activity Peak activity Effective duration
Rapid activity < 15 min. 45 – 90 min. 3 – 4hrs
LISPRO
Short acting 30 minutes 2 – 5 hrs 5 – 8 hrs
Regular
Intermediate 1 –3 hrs. 6 – 12 hrs 16 – 24 hrs
Activity NDH, heute
Neutral protarim Hageforn
Lang acting 4 – 6 hrs. 8 – 20 hrs 24 – 28 hrs.
Ultra leute
Antidiabetic medication
Drug class Genereic (Trade) naves Mech of arch
Sufacy lesion Chlorproparmide (Diabinese) Stimulate
Glipizide (Glucotrol) Insulin secretion
Glyumide (Dia Beta, Micronase)
Glimeripiriole (Assaryl)
Meglitimides Repa glinide (Prandin) Stimulate
Insulin secretion
Biganarides Met fornium (Glucophage) Decrease Glycogenolysis
and hepatic glucose
production
L glycose dose Al arbose (Pre case) Decrease GI absorption
inhibitor Mighitol (Gly set) of carbohydate
Thiazolidinidiaone Rosightongue mallate (Avandih) Enhensive tissue
r Pioghtazone (Actes) sensitivity to insulin

JADA Vol. 132, Oct. 2001