Professional Documents
Culture Documents
MEDICAL HISTORY
DEN3ICP
HAM
Have you ever stayed in hospital, had an operation or general anaesthetic?
Relays information about overall health and recent/past medical compromisation of the pt
o May impact present OH
o Does pt need referral to medical GP?
o Does GP need to be consulted prior to tx?
Questions to ask:
o What was the reason for the stay?
o How long ago was it?
o Is everything ok now?
Dental implications
o Some surgeries will influence tx planning
Defer elective tx for 3 months:
Myocardial infarction
Coronary bypass surgery
Stent/ prosthetic valve placement
Transplant surgeries
Joint replacement surgeries
AB prophylaxis may need to be considered
LA may be C/I
<6 weeks of myocardial infarctikon
o Pt may be on certain medications/ immunocompromised
Antiplatelets/ anticoagulants bleeding
Cyclosporine gingival hyperplasia, interacts with rifampicin
Have you ever had any serious problems after dental treatment?
1. Further questioning
What happened? Pre-disposition to these problems
How long ago?
How was the problem resolved?
2. Common Issues
Allergies - LA, latex, penicillin (3 most common)
o Ask about symptoms and extent (urticaria – anaphylaxis)
o Refer to GP – to test for true allergy
o Prevention of overnight symptom precipitation early appointment
Post-operative sensitivity
o Choose to line dentine where this is an option
Swelling and pain post extraction
o Consider NSAIDs prior extraction
Alveolar osteitis (dry socket)
o Clot disintegration exposing the alveolar bone lining (lamina dura) to the oral
environment
o Usually 3 – 5 days post op
o Clinical Features:
Visible void in the sockets
Strong dull throbbing ache
Halitosis
o Management:
Irrigation of socket with warm saline solution to remove debris and bacteria
Analgesics/Systemic Antibiotics
Socket dressing with Alvogyl pain relief but delays healing
Contains:
Butamben – anaesthetic
Iodoform - antimicrobial
Eugenol – analgesic
o Prevention:
CHX mouthwash on day and few days after surgery
AB prophylaxis for immunocompromised patient
Identify high risk pt. beforehand
Smoker
Females on oral contraceptives
Good post op instructions AVOID smoking
Osteomyelitis
o Infection of bone generally caused by bacteria
o Delay definitive tx until infection subsides
o Types:
Acute – generally suppurative, early stage of the disease
Chronic – suppurative or non-suppurative after disease is present > 1 month
o Clinical Features:
Fever
Tenderness and swelling
o Complications:
Bone and soft tissue injury
o Management:
Surgical debridement
Long term AB
Severe bleeding
o Identify cause:
Underlying bleeding diathesis
Anticoagulant/antiplatelet therapy
Surgical trauma
o Precautions:
Suctioning
Use of vasoconstrictors in LA
Topical haemostatic agents
Suturing
BRONJ
o Osteonecrosis of the jaw in pt. taking bisphosphonates
o Clinical Features:
Pain
Exposed bone in oral cavity
Draining sinus tract
Soft tissue infection
o Refer to bone disorders below
Osteoradionecrosis
Surgical site infection
o Consider antibiotics if the pt. is immunocompromised
Dental anxiety
o Consider techniques to overcome anxiety
o Empathize, normalise and guide pt. through tx
Relaxation
Imagination
Distraction
Management of Syncope
If pt. is unconscious:
- Cease dental treatment
- Tilt the chair back to horizontal position (head should not be lower than heart)
- Measure pt. blood pressure and pulse rate
- Place the pt. on their side (if pregnant, on their left side)
- Place a cold compress on their forehead
- Generally in vasovagal-type syncope pt. should rapidly return to consciousness
Hyperventilation
Signs/symptoms:
- Shortness of breath
- Light-headedness
- Tingling in the fingers, toes and lips
- Blurred vision and altered consciousness
- Carpopedal spasms of the hands and fingers
Management of hyperventilation:
- Cease dental treatment
- Encourage pt. to slow their breathing
- Get pt. to cup their hands close over, but not obstructing their mouth and nose to rebreathe expired
air
- DO NOT give OXYGEN (prolongs symptoms)
If pt. doesn’t recover rapidly (>5 – 10 mins or carpopedal spams spreads to legs):
- Consider differential dx
o Acute asthma
o Heart failure
o Anaphylaxis
- Call 000
Have you ever had any type of heart disease, heart murmur, HBP, or rheumatic fever?
Heart anatomy:
Flow of blood = vena cava → right atrium → Tricuspid valve → right
ventricle → Pulmonary valve → pulmonary artery → pulmonary veins →
left atrium → mitral valve → left ventricle → aortic valve → aorta →
systemic circuit
CVD
Leading cause of death:
Presents as:
o Angina pectoris
o Acute Myocardial Infarction (MI)
o Cardiac arrest
o Congestive heart failure
Path:
o Atherosclerosis → Damage to wall, commences inflammatory response, cholesterol pushed
into layers of artery, builds in size occluding vessels, cap may rupture triggering
inflammatory cascade and clotting, may completely occlude vessel or clot may dislodge →
MI/Stroke
Risk factors:
o Hypertension
o Hyperlipidaemia
o Diabetes (Type 2)
o Smoking
o Family History
o Other: Obesity, sedentary lifestyles, kidney disease
Heart Failure
o End stage of multiple cardiac diseases → Heart is unable to meet the circulatory needs of
the body
result from any structural or functional cardiac disorder that impairs the ability of
the ventricle to fill with or eject blood
Ischaemic heart disease can cause scarring and damage to the heart muscle so it
can’t pulp as well leading to heart failure
o Right heart failure - peripheral oedema, hepatic congestion and elevated venous pressure
o Left heart failure - breathlessness, pulmonary congestion and dyspnoea
o Causes:
Ischemic Heart Disease
Hypertension
Valvular heart disease
Alcohol
Diabetes
o Clinical Features:
Asymptomatic
Congestive state – oedema in their lungs, legs and ankles.
Low output state
Cardiogenic shock – heart pumping is so impaired that it isn’t delivering oxygen to
the brain
Quick weight gain due to fluid retention
Fatigue
o Dental Implications:
Tx should only be given if condition stable
Short appointments
Do not tolerate horizontal position (need to be placed so that head is higher than
heart)- ask how many pillows they sleep with at night
NSAIDs - avoid as it can worsen heart failure - due to salt and water retention
Arrhythmias
o Causes:
Ischemia
Hyper thyroidism
Alcohol
Idiopathic
o Atrial Fibrillation – common
Problem with the electric conducting system of the heart
Small clots can form and travel to the ventricles and into circulation (possibly
causing a stroke)
Tachyarrhythmia – if prolonged can lead to cardiac arrest
o Dental implication:
Most common reason for use of warfarin or other anti-coagulation
Heart Murmur
o Disturbances of blood flow that are audible – associated with valves that function
abnormally.
o Aetiology
Physiological normal factors
Pathological abnormalities/conditions
Valvular disease
Mitral valve prolapses
o Backflow of blood from the ventricle into the atrium
Rheumatic heart disease
Other
Previous IE
Prosthetic heart valve
Congenital cyanotic heart disease
o Dental Implications:
Warns potential for colonization of damaged valves by blood borne bacteria – may
require AB prophylaxis if murmur associated with high risk condition e.g. complex
cyanotic heart defect, prosthetic heart valve
Rheumatic fever
o Inflammatory disease that follows a Strep. Infection
Antibody production against host-tissues following throat streptococcus pyogenes
infection
o Bacteria: Group A Streptococcus or Streptococcus pyogens
o Can involve the hearts, joints, skin and brain
“RF licks the joints and bites the heart”
o Dental Implications:
ATSI with rheumatic fever at increased risk – require AP
Hypertension
o Abnormal elevation in arterial pressure that can be fatal is sustained and untreated
Consistently raised BP (>140/90) over 3 months.
o Influenced by
Obesity
Alcohol
Physical inactivity
Dietary sodium
o Risk factor for ischaemic heart disease, cerebrovascular accidents and renal failure.
o Classification
Low BP = 90/60 may precipitate syncope
Normal BP = 120/80
Prehypertension = 120-140/80-90
High BP = 140/90
Malignant hypertension = ≥180/110 defer tx
o Issues with chronic high BP
Over time, if the force of the blood flow is chronically high, the arterial walls gets
stretched and damaged. This leads to:
Vascular weakness
Heart failure:
Increased workload on
Heart failure
circulatory system
o Questions to ask:
What was your last BP reading?
Are you taking any medications for HBP?
Do you have dental anxiety?
o Signs/symptoms
Pt. may remain asymptomatic
Early signs/symptoms
Only sign is elevated BP measure by sphygmomanometer
Narrowing and sclerosis of retinal arterioles
Headache
Dizziness
Tinnitus
Late signs/symptoms
Fatigue and cold legs
Cognitive decline
Renal failure
Dementia
Encephalopathy
o Dental Implications:
Controlled + stable → no implications
Measure HBP prior to appt. for new pt. or for recall exam using sphyhmomanometer
If >180/100 mmHg, defer tx
May opt to leave cuff around arm throughout tx if elevated
o Concern is acute elevation and stroke or MI
Avoid precipitating a further increase in BP during tx:
Prodromal symptom recognition
Severe long standing pain can cause hypertension
Severe anxiety → increased BP → consider sedatives
Drug interactions of adrenaline and beta blockers → acute exacerbation in
hypertension
A dose of adrenaline has both vasoconstrictor and vasodilation effects. Non-
selective beta blockers as well as adrenaline leads to vasodilation being
blocked leading to unopposed vasoconstriction → acute increase in BP
(200mm/Hg systolic)
LA containing adrenaline → elevate BP (inconclusive)
Can use mepivacaine plain
NSAIDs used with caution → salt and water retention → elevated BP
Avoid Triple Whammy (NSAIDs + diuretic + ACE-inhibitor) - renal failure
INFECTIVE ENDOCARDITIS
Inflammation/infection of
the inner layers of the
heart (endocardial surface),
typically the heart valves
Rare condition
Life threatening =
significant mortality and
morbidity
Symptoms non-specific
o Unexplained fever
– most common
presentation of
endocarditis. CONSIDER AP IN…
o night sweats …Diabetes or renal impairment are at greater risk
o generally unwell …Immunocompromised pt.
o malaise/lethargy … symptoms of endocarditis e.g.
o Other: unexplained fever
Conjunctival petechiae … Periodontal disease risk factor for CVD
Janeway’s lesions …Patients who previously received it and would prefer
Pathogenesis to receive it again
o Damaged or prosthetic heart valves
usually involved, areas of abnormal flow jets from congenital heart defects.
o Mitral valve most often affected.
o Due to Streptococcus viridans (oral commensal) or Staph aureus
Complications
o Regurgitation of the valve because the bacteria can just eat through the valve
o Bacteria can also cause an abscess around the valve. This can lead to heart failure due to the
backflow of blood.
o The bacteria can spread to other places in the body when the valve dislodges. it could go
to the brain and cause stroke or micotic aneurysm
Pathophysiology
1. Injury to endothelium
o E.g. From turbulent bloodflow
2. Formation of non-bacterial thrombus on the surface of a cardiac valve
o Venous blood clot involving fibrin and platelet deposition
3. Bacteremia occurs
o Bacteria enters the blood
o Most dental procedures produce transient bacteremia lasting up to 30 min
4. Bacteria is delivered to the cardiac valve via circulation
5. Bacteria adheres to the initial non-bacterial thrombus
6. Vegetation forms
o This is the characteristic lesion of IE, consisting of bacteria surrounded by a
platelet/fibrin later and attached to the underlying endothelium
7. Further progression of the IE lesion
o Constant bacteremia local infiltration of bacteria causing conduction
abnormalities, abscess, or valve incompetence
o Embolization of the vegetation may cause stroke, heart attack, or paralysis
Antibiotic Prophylaxis
High risk conditions High risk treatments
Prosthetic heart valve Prophylaxis always required
Prosthetic material used for valve repair Extraction
Previous infective endocarditis Periodontal procedures
Congenital heart disease ONLY involving o Surgery
Unrepaired cyanotic defects o Subgingival scaling and root
o Palliative shunts planning
o Conduits Replanting avulsed teeth
Completely repaired defects with Oral surgery
prosthetic material or devices during the o Implants
first 6 months AFTER tx o Apicectomy
o After which the prosthetic material Prophylaxis maybe required if multiple
is endothelialised procedures are conducted, procedure is
Repaired defects with residual defects prolonged or periodontal disease is present
at/adjacent to the site of prosthetic Full periodontal charting
patch or device Intraligamentary and intraosseuous LA
o This inhibits endothelialisation injection
Cardiac transplantation and subsequent Supragingival calculus removal
cardiac valvulopathy Rubber dam placement with clamps
Rheumatic heart disease in Indigenous Restorative matrix band/strip placement
Australians Endodontics beyond AF
Other conditions (AB prophy not routinely Placing orthodontic bands
given, depends on immunosuppressed state) Placing interdental wedges
Diabetes Subgingival placement of retraction
Renal impairment cords, antibiotic fibres/strips
Exhibiting symptoms of IE
AB-prophylaxis regimen
ADULT CHILD
Normal
Amoxycillin 2g orally 1-hour prior 50mg/kg up to 2g
Amoxy/ampicillin 2g IV just prior 50mg/kg up to 2g
Amoxy/ampicillin 2g IM 30mins prior 50mg/kg up to 2g
Penicillin hypersensitivity
Long-term penicillin therapy
Penicillin/beta-lactam AB already taken > once in
the month
Clindamycin 600mg orally 1-hour prior 15mg/kg up to 600mg
Clindamycin 600mg IV >20mins prior 15mg/kg up to 600mg
Lincomycin 600mg IV >1-hour prior 15mg/kg up to 600mg
Teicoplanin 400mg IV just prior 10mg/kg up to 400mg
Teicoplanin 400mg IM 30mins prior 10mg/kg up to 400mg
Cephalexin 2g orally 1-hour prior 50mg/kg up to 2g
Vancomycin 25mg/kg up to 1.5g Child < 12 only; 30mg/kg up to 1.5g
IV, infuse at 10mg/min & Infuse over time of 2-hours
end infusion just before
procedure starts
- PROSTHETIC JOINTS: Used only if there is dental problems within the first 3 months since placement
o But if perious experience should be provided
**Elective treatment should be deferred 3-6 months
ISSUE balance between excessive bleeding due to dentoalveolar surgery if drug is not-stopped VS. risk of a
thromboembolic event if the drug is stopped prior to tx
Thromboembolic event is much more serious!
Excessive bleeding minimised via local measures
Adrenaline containing LA
Insertion of resorbable pack
Suturing
Pressure on site
Stroke
Definition
o A sudden loss of blood flow to the brain causing neural cell death (necrosis)
Classification/aetiology
o Ischaemic
Blood vessels supplying the brain are occluded
Can result in transient ischaemic attack (TIA)
Mini-stroke caused by temporary disturbance in blood supply to localised
area of brain
o T = transient = Lasts ~24 hours
o I = Ischaemic = disturbance in blood supply and lack of oxygen
o A = attack = symptoms and onset are acute
Signs/symptoms
o Numb face, arm, leg unilaterally
o Weakness
o Tingling
o Speech disturbances (<10mins)
o Commonly, a major stroke is preceded by 1-2 TIA’s within several days
of the first attack
o Haemorrhagic
Blood vessels supplying the brain burst accumulation of blood in cranial vault
Presentation
o Varies in accordance with site and size of residual brain deficits
Language disorders
Impaired memory and cognition
Impaired co-ordination
Hemiplegia (half-sided paralysis)
Risk factors:
o Old age
o Hypertension
o Hypocholesteraemia
o Smoking
o Obesity
o Diabetes mellitus
o History of TIA
o Previous stroke
Dental implications:
o Elective dental tx deferred if stroke <6mnths ago
o Motor defects of arm difficulty with OH
Accumulation of plaque on effected side
Electric toothbrushes or water pikster advised
Carer instructed how to aid with OH
o Motor defects of facial muscles compromised function (e.g. mastication, speech)
o Patients with facial nerve weakness accumulate food on affected side and may have
difficulty with denture
Design modifications to dentures including a thickened flange may be implemented.
o Patients with hemiplegia may have difficulty putting on partial dentures as they generally
require both hands
Dentures may be modified to assist with one-handed applications
o Associated with oral ulcerations
o Medications:
Antiplatelets/ anticoagulants DO NOT STOP
Effects on dental health:
Xerostomia increases risk of caries and periodontal disease
Constant sore throat
Dysphagia
Management of Stroke
Cease dental treatment
Call 000
Give oxygen 6L/min
Maintain airway
Monitor patient until assistance arrives
AVOID ASPIRIN unsure whether stroke is haemorrhagic or ischaemic
Epilepsy
Definition
o A group of disorders characterized by chronic and recurrent epileptic seizures which involve
brief episodes of signs or symptoms due to abnormal excessive or repetitive electrical
activity in the brain
Classification
o Generalized vs. partial (one limb only)
o Simple vs. complex (with loss of consciousness)
Aetiology
o Unknown (> 50%)
o Vascular and developmental anomalies, intracranial neoplasms, head trauma (35%)
o Other
Hypoglycaemia
Drug withdrawal
Infection
Genetic conditions
Presentation
o Altered consciousness
o Altered movement
o Cyanosis
o Incontinence
o Oral automatism
Epidemiology
o 3-3.5% experience at some point in life
Considered resolved if:
o Seizure free for ≥10 years, with no medication for 5 years
Dental implications:
o Controlled pt
Check if pt has taken medications
If NOT taken in last 2 days at great risk
Avoid extensive procedures
Consider use of bite block so operator fingers and instruments retrieved if seizure
occurs
Pharmacology
Gingival hyperplasia minimized with good OHI
o Phenytoin
o Valproate
o Carbamazepine
o Epileptic Episode
Signs/symptoms
1/3 pt have an aura prior
Sudden collapse
Tonic phase (30 seconds)
o Loss of consciousness
o Rigidity
o Cyanosis (bluish skin tone due to poor circulation)
Clonic phase (few minutes)
o Jerking movements
o Tongue biting
o Urinary incontinence
Post-seizure
o Gradual return to consciousness
o Headache
o Confusion
Management of Epilepsy
Cease dental treatment
Protect patient from falling of chair and injury
Wait till fitting has subsided
Assess patient consciousness
Maintain airway
Remove any vomitus (if present) from the mouth and pharynx by high-volume suction.
If lasts for >few minutes/ recurrent seizures without recovery of consciousness:
o Call 000
o Maintain airway
o Monitor until pt arrives
Tuberculosis
o A lower respiratory tract infection caused by the bacterium, Mycobacterium tuberculosis
o Transmission: inhalation of airborne droplets (sneezing, coughing, talking)
o Symptoms:
Positive result on tuberculin skin testing
Cough
Fever
Night sweats
Weight loss
Haemoptysis – coughing up blood
Other
Lassitude (physical and mental wariness)
Malaise (general discomfort and illness)
Anorexia
o Risk factors:
Less than 5 yrs and over 60 yrs of age
Chronic lung disease
HIV infection, diabetes, alcoholism
Immunosupressive therapy
o Treatment: slow, 6-12 months
o Dental Implications
Oral manifestation:
TB Osteomtelitis
Bony radiolucency
Scrofula – submand. And cervical lymph nodes enlargement
Often men ~ 30 years
Painful (sometimes painless), deep, irregular ulcer on the dorsum of tongue
o Palate, lips, buccal mucosa, gingiva also potentially affected
Resolution results from tx of TB with anti-tuberculosis drugs
Infection control
If suspected/infected with TB, defer elective treatment as highly infectious
However, if urgent treatment is required – use transmission based
precautions:
o Schedule the patient at the end of the day, as the last patient treated
o Use negative pressure room if possible
o All team members must wear a high efficiency particulate air (HEPA)
mask
o Rubber dam should be used to reduce aerosis
If pt. status is “free of clinically active disease”, treat as normal pt
Pharmacology
Rifampin
o Delayed healing
o Gingival bleeding
Asthma
o Chronic inflammatory disorders of the airways associated with airway hyper-responsiveness
o 10% adults and 11% children
o Symptoms:
Wheezing
Dyspnoea
Chest tightness
Coughing
o Hallmarks:
Airway oedema
Mucous Hypersecretion – lumen obstructed by mucous
Bronchoconstriction
o Aetiology
Intrinsic (non-allergen)
Medication induced
Anxiety
Stress, Smoke, viruses
Exercise
Cold air/ dry air
Extrinsic (allergic)
Inhaled allergens – dust mite allergen, pet dander, pollen
Genetic
o Questions to ask:
How long have you had asthma for?
What triggers your asthma?
Are you taking any medication?
Do you use a spacer?
Did you bring your reliever today?
Are you anxious about treatment today?
o Medications
Preventers
Anti-inflammatory medication preventing release of inflammatory mediators
contributing to narrowing of airways
Include
o Inhaled corticosteroids e.g. Fluticasone
Flixotide = red cap and orange body
Fluticasone only
Seretide = purple
Fluticasone (corticosteroid) + long acting beta 2 agonist
(e.g. salmeterol)
o Long-acting beta-2 agonists e.g. Salmeterol (serevent) = green
o Oral prednisolone
o Steroid:
Pulmicort – steroid
Symbicort: long acting beta 2 agonist + steroid
o Montelukast
Relievers
Act to relax the smooth muscle around the bronchioles, providing instant
relief
Include
o Short-acting beta-2 agonists
e.g. Salbutamol (Ventolin) = blue
o Anticholinergic bronchodilators e.g. Ipratropium (Atrovent)
Block nerve reflexes that cause the airways to constrict,
thereby allowing the airways to remain
o Dental Implications
Be aware of asthma attack management plan
Depending on severity, may avoid use of rubber dam to ensure adequate breathing
Avoid triggering an asthma attack – identify allergens
Ask pt. to bring their inhalers
Anxiety can induce asthma attack
NSAIDs can cause bronchoconstriction in susceptible pts. Paracetamol is the
analgesic and antipyretic of first choice.
10% sensitive to aspirin
o Aspirin exacerbated respiratory disease
Samter’s Triad = asthma, nasal polyps, and aspirin sensitivity
Pt. taking systemic corticosteroids require increased dose if they have adrenal
suppression
IF using inhaled corticosteroid – may develop candida - advise pt. to rinse their
mouth and throat and rinse out inhalation.
Pt. using a metered dose inhaler have additional risk of dysphonia – use spacer
NOTE – Addisonian crisis presents as a progressive hypotension occurring 6 to 12 hours after the dental treatment. The patient
may initially feel faint and then become confused and collapse. Stressful dental treatment should be performed in the morning so
that if an Addisonian crisis occurs, symptoms present while the patient is awake. Otherwise if symptoms precipitate overnight the
result may be death
Management of Acute Asthma
- Cyanosis – life threatening indicator
- Patients with severe asthma might not wheeze!
- Ensure they have their asthma medication (bronchodilator) in case of an attack
- Ensure asthma action plan is on hand
- Consider precipitants and triggers in the practice: stress, fear, allergens
- Keep spacer and asthma medication in the practice
- NSAIDs is contraindicated as it can cause bronchoconstriction, paracetamol is the analgesic of choice.
- Give preventative advice on the use of inhaled corticosteroids as it can cause oral candidiasis.
- Management:
o Identify if mild, moderate or severe:
Mild: can talk in sentences, absence of altered consciousness, no use of accessory muscles,
pulse (<100/min)
Moderate: talks in phrases, some use of accessory muscles, pulse (100-120/min for adults
and 100-200/min for children)
Severe and life threatening: physical exhaustion, altered consciousness, marked use of
accessory muscle and talks in words, pulse (>120/min for adults and >200/min for children)
o Mild asthma attack:
Give 4 puffs of short acting bronchodilator (salbutamol) via a spacer – 1 puff at a time and
take 4 breaths in out of the spacer after each puff
Wait 4 minutes
If not improvement, repeat
If recovered:
Temporise dental state
Make another appointment
When pt. breathing easily – discharge form care
o Moderate or severe:
Call 000
Give oxygen at a flow rate of 6L/min
Give 4 puffs of short acting bronchodilator (salbutamol) every 4 minutes until assistance
arrives.
.
Other considerations VARIATION:
Tx with prednisolone >10mg daily for 3 weeks may If attack is severe, MAY GIVE:
5mg Salbutamol (Ventolin) by nebuliser
induce adrenal suppression
driven by O2
o Dental tx stressful, and adrenal suppression If no response
inability to produce hormones to counter such o Repeat …
stress (can result in adrenal crisis & fainting) o Then every 15-20 mins until
o To counter this, dose of replacement therapy assistance arrives
(corticosteroids) should be increased prior to
appt.
Pharmacology
o Beta-2 agonists
Decreased salivary flow (20-35%)
Decrease plaque pH
Increased prevalence of gingivitis and caries
Increases GOR erosion
o Inhaled corticosteroids
Anti-inflammatory effect causes localized oral immune-deficiency against microbes,
predisposing to Candida albicans proliferation
Oral candidiasis
o Occurs in 5% pt with long-term use
o Prevention
SPACER filters medication straight to the lungs rather than
lingering in the oral cavity
RINSE MOUTH post inhalation
May also result in
Throat irritation
Dysphonia (difficulty speaking)
Subjective xerostomia
o Anticholinergic bronchodilators (often used in combo with other drugs)
Xerostomia
Relationships
o Asthma and Dental caries:
decrease salivary flow caused by beta 2 agonists and increase in Lactobacilli and S.
mutans
fermentable carbohydrates present in anti-asthma medication
increase in frequency of consumption of cariogenic drinks due to excessive thirst
some dry powder inhalers contain surfer so the pt. can tolerate the taste of the drug
o Asthma and Dental erosion:
reduction in buffering capacity and salivary flow rate due to beta 2 agonist
increase in exposure to teeth to acids (acidity of medication, soft drinks and GORD)
certain inhaled beta - 2 - agonist drugs can decrease lower oesophageal sphincter
pressure - associated with GORD
o Asthma and Periodontal disease:
dehydration of alveolar mucosa due to mouth breathing - increase in consumption of
drinks to compensate oral dehydration.
alteration of immune response and increase concentration of IgE in gingival tissue
Decrease in bone mineral density associated with inhaled corticosteroids
o Asthma and Oral candida:
generalised immunosuppressive and anti-inflammatory effects of steroids
higher salivary glucose conc. could promote growth and proliferation of Candida
COPD
o General term for pulmonary disorders characterized by chronic airflow limitation from the
lungs that is not fully reversible
o Combination of:
bronchitis
excessive mucous production and persistent productive cough > 3 months
per year for 3 years
emphysema
dilation and destruction of air spaces distal to the terminal bronchioles –
permanent enlargement of air spaces
o Aetiology
Tobacco smoking
Long term exposure to occupational/environmental pollutants
o Signs/symptoms
Onset normally > 40 years of age
Key indicators
Chronic cough with sputum
Persistent dyspnea worsening with exercise
Chest discomfort
Co-morbidities
CVD
Respiratory infection
Osteoporosis
Fractures
o Dental implications
Avoid placement of pt in horizontal/supine position
Increase dose of corticosteroids prior to appt. if pt has adrenal suppression (may be
induced by prednisolone >10mg daily for 3 weeks)
Avoid use of macrolide AB’s (erythromycin, azithromycin) if pt. being treated with
theophylline
Smoking
Cessation
o 5 As – ask, advice, assess, assist, arrange
o 5 Rs - relevance, risk, rewards, roadblocks, repetition
Increased risk
o Halitosis
o Extrinsic tooth stains
o Nicotinic stomatitis
o PDD
o Premalignant mucosal lesion
o Oral cancer
Do you smoke?
1. Questions to ask?
How long have you smoked for?
How many cigarettes do you smoke a day?
What/how do you smoke? (reverse, pipe, marijuana etc.)
When do you have your first cigarette of the day?
2. Systemic effects risk of:
Lung disease (COPD, pneumonia, lung cancer)
Cancer
Premature skin ageing
Stroke, MI
Sudden death
3. Dental significance
Refer to table below
4. Smoking cessation – the 5 A’s framework
Ask
o “Do you want to quit smoking”
Assess
o Document current tobacco use
Number of cigarettes daily
Time of first cigarette of day
Any previous quit attempts
Advice
o Advocate quitting
Explain benefits
Live longer with quality of life
risk of fatal disease
Decreases wrinkling of skin, dental problems, yellow fingernails, poor
body odour
Food taste
Non-confrontational approach
BMI
Open-ended questions
Affirmation
Reflective listening
Summarize
Assist
o Guide and encourage
o Advocate QUIT-LINE (137 848)
o Advocate getting support from another source e.g. counsellor
Arrange follow-up
o Assess progression
o Relapse common hence motivational interview again
5. Smoking cessation motivation in non-compliant patients – the 5 R’s framework
Relevance
o Ask pt. about how smoking may be personally relevant
Risks
o Ask the pt. about short-term and long-term and environmental risks of continued
use
Rewards
o Ask pt. about perceived benefits/rewards of quitting tobacco use
Roadblocks
o Ask pt. about perceived roadblocks to quitting
Repetition
o Respectfully repeat 5 R’s each visit, providing motivation and information
Condition Description
Squamous Cell Clinically
Carcinoma o EARLY leukoplakia, erythroplakia OR mixed (red + white), painless non-
indurated ulcers
o LATER indurated painful ulcers
o Commonly on lip, tongue, FOM, salivary fauces, retromolar area
Dx
o Radiographically
Radiolucency if bone involvement
o Histologically
Nuclear hyperchromatism
Increased nuclear: cytoplasmic ratio
Mitoses in prickle cell layer
Abnormal mitoses
Loss of polarity of basal cells
Deep cell keratinization
Loss of definition between basal and prickle cells
Diminished intercelluar adherence
Drop-shaped rete pegs
Tx
o Chemotherapy, radiotherapy
o Refer
Leukoplakia Predominantly white lesion that cannot be wiped off/attributed to any disease. There are
different types of leukoplakia, categorized according to their appearance variations:
Homogenous – uniform, not raised
Nodular – slightly raised with erythematous base
Verrucous
Proliferative verrucous
Rare/poorly defined multiple white lesions w/ VERY HIGH malignant risk
Clinically
o Common elderly females
o Initially develop flat leukoplakias that over decades, progress to verrucous
or SC carcinoma; unable to remove surgically & recur
Speckled
Clinically
o White flecks/nodules on atrophic erythematous base
Erythroplakia Predominantly red lesion or plaque with well-defined borders, the texture is soft and
velvety
Clinically
o Commonly on lip, tongue, FOM, salivary fauces, retromolar area
Prognosis
o Carcinoma is found in ~ 40% of these lesions
Nicotinic White hyperkeratotic thickening of palate with red-centred minor mucous gland
Stomatitis umbilicated swellings within
Clinically
o Red scattered inflammatory dots on the palate
o White hyperkeratotic plaques
Tx
o Smoking cessation resolves within weeks
Smoker’s Non-cancerous brown pigmentation often in the gingiva due to toxic substances initiating
Melanosis production of melanin
Clinically
o Black/brown pigmentation of oral tissue, especially the lower gingiva
Dx
o Biopsy if doesn’t heal post-smoking
Tx
o Smoking cessation resolves within 3 months to 3 years post-quitting
Hairy Tongue Elongation of filiform papillae forming thick hair-like fur along dorsal surface
Clinically
o 1/2 cm long, brown-black coloured extensions on dorsum of tongue
Tx
o Scrape hyperplastic papillae; cleanse dorsum w/ toothbrush
Halitosis Oral malodour
Dx
o Subjective measurement
o Smell air from pt. mouth and compare to pt. nose
Tx
o Treat causative factor
Delayed/impaired Nicotine has vasoconstrictive abilities, leading to decreased blood flow and
wound healing therefore influences wound healing
Implant failure Poor healing post-implant surgery
Require sound periodontium which is normally compromised in a pt. smoking
Alveolar osteitis Clot disintegration exposing the alveolar bone lining (lamina dura) to the oral environment
(dry socket) Ensure post-op instructions are given to avoid re-occurrence
Signs/symptoms
o Visible void in the socket
o Strong dull throbbing ache
o Halitosis
Management
o Pain relief until normal healing
o Socket dressing alvogyl for pain relief but delays healing
o Saline to remove bacteria/halitosis
Caries Smoking influences the amount and contents of saliva
Shown to have a significantly higher DMF index vs. non-smokers
Periodontal Pathogenesis:
disease (PDD) o Nicotine: causes gingival blood flow (aid in proliferation of anaerobic
bacteria) and inflammatory cytokines (enhancing tissue breakdown)
Affects the tx outcome after SRP and regenerative periodontal therapy
o Less favourable healing
Less improvement when considering
o Pocket depth reductions & CAL
o Resolution of gingivitis
Lang & Tonetti
o 1-19 cigarettes daily = MODERATE RISK
o >19 cigarettes daily = HIGH RISK
Main dental significance = the potential for drug toxicity, increased bleeding, and transmission of viral
hepatitis.
Hepatitis
Symptoms
o Jaundice
o Abdominal pain and swelling
o Swelling in legs and ankles
o Itchy skin
o Dark urine colour
o Pale stool colour
o Chronic fatigue
o Nausea and vomiting
Questions to ask
o What type of liver disease do you have?
o How long have you had it for?
Types of hepatitis:
o Hepatitis A
Mode of transmission:
Faecal-oral
Contaminated foods
Prevention:
HAV (hep A virus) vaccine available for children >1yo
Signs and symptoms:
Jaundice (70%)
Management:
Generally resolves by itself within 1-2 months if correct self-care, rest and
avoidance of alcohol done
o Hepatitis B
Mode of transmission:
Blood-borne
Sexual
Vertical
Prevention:
HBV vaccine
Avoiding high risk behaviour
Signs and symptoms:
May be asymptomatic
Reactivated during immunocompromised state
Eventually causes
o Chronic cirrhosis
o risk of hepatic cancer
Management:
No cure
Controlled with antiviral drug therapy
o Entecavir (Baraclude®)
o Tenofovir (Viread ®)
o Lamivudine (Zeffix®)
o Adefovir (Hepsera®)
o Hepatitis C
Mode of transmission:
Blood-borne
Sexual
Vertical
Prevention
No vaccine available
Avoid high risk behaviours
Signs and symptoms:
Acute
o Infection < 6 mnths
o Similar to flu
o Jaundice
Chronic
o >6 mnths
o Chronic cirrhosis
o Hepatic cancer
Usually over period of 20 years leads to liver failure
Management:
Course of antiviral therapy
o Sofosbuvir (Sovaldi ®)
If chronic liver failure = liver transplant
incidence of dental caries due to saliva flow
o Hepatitis D
Modes of transmission:
Blood-borne
Sexual
Vertical
Prevention:
Through prevention of Hep B HDV requires HBV to survive
Signs and symptoms:
Clinically resembles HBV
Least common, most severe hep virus
Dental implications:
o Operator and dental staff
Because of mode of transmission, hepatitis B and C (blood-borne) are of the most
significance to the dentist
Everyone in the dental team should be vaccinated against HBV
However, only standard infection control precautions are necessary
Potential for needle stick injury
Dentist may contract blood-borne varieties of hepatitis (B and C)
May occur with:
o LA administration
o Endodontic files
o Oral surgery instruments
Take blood test to confirm
o Patient
Drug metabolism
drug metabolism risk of drug toxicity and hepatotoxicity
o LA – reduce dose (if hepatitis is severe, even 2 cartridges may be too
much)
o Avoid NSAIDs – can cause GIT bleeding, renal impairment
Paracetamol analgesic of choice
However w/ reduced dosage (2-3g/day)
o dose of sedatives
o Consult with GP prior to prescription of antifungals, antibiotics,
sedatives, and analgesics
Abnormal bleeding
Liver damage results in clotting factors
Take platelet count prior to surgery
Consider AB prophylaxis to prevent surgical site infection
Alcoholic Liver Disease (Cirrhosis)
Definition
o A term encompassing liver manifestations of chronic alcohol overconsumption, including
fatty liver, alcoholic hepatitis, and chronic hepatitis with cirrhosis/fibrosis
Signs/symptoms
o Early symptoms include
Fatigue
Poor appetite and weight loss
Nausea
Small red vessels appearing on the skin
o Late symptoms include
Fluid buildup of the legs
Yellow coloured skin, mucous membranes, eyes
Jaundice
Easy bruising and abnormal bleeding
Pale or clay-coloured stools
Dental implications:
o Same as for hepatitis (patient) plus:
Alcohol breath (malodor)
Xerostomia
Increased risk of oral cancer
Bruxism
Parotid enlargement
Petichiae
Glossitis
Angular cheilitis
Impaired healing
Chronic Liver Disease
Signs and symptoms
o Jaundice Yellow pigmentation of tissues, sclerae and
mucosa due to bilirubin deposition
o Spider naevi Small arterial dilations of skin
o Palmar erythema Redness of the palms of the hand
o Finger clubbing Loss of normal angle at nail bed
o Asceites Fluid build-up in abdomen
o Darkened urine
o Weight loss
o Nausea
o Malaise
Dental implications:
o Same as hepatitis (patient)
Liver transplant
o Indicated in end-stage liver disease
o Dental assessment prior to transplant recommended
o Post-operatively patient is immunosuppressed
o Elective dental treatment contraindicated in first 3 months after surgery
o GA must be done in hospital with specialist
From a general perspective, if the pt is the carrier of an infectious disease, they pose risks of spreading the
disease to other patient, the dentist and the dental assistant. It is thus imperative to know of the infectious
state of any patient that comes in the practice.
Questions to ask:
Have you seen a doctor?
Have you been diagnosed?
Have you been taking your medications?
1. Immediately
Wash skin using soap or alcohol-based cleaner
No squeezing
First aid measures to treat exposure site
2. Assess the risk
Type of exposure
Type and amount of fluid involved
The infectious status of the patient – direct questioning
3. Test patient and HCW
Test source (patient) for HBV, HCV, and HIV antibodies
Test injured HCW for baseline serum antibody levels to monitor any post exposure
seroconversion
NOTE – There is a balance that must be considered between giving a healthy person a potentially toxic
compound with side effects (prophylactic anti-viral), and the perceived reduction in risk of infection
Do you or any members of your family have a history of Creutzfeldt-Jakob Disease (CJD)?
Definition:
o Invariably fatal human prion (infectious protein) disease belonging to family of transmissible
spongiform encephalopathies (TSE)
Transmissible = infective
Spongiform = brain tissue takes on appearance of sponge (due to formation of a
myriad of tiny holes known as vacuoles)
Encephalopathy = neurodegenerative condition
Epidemiology:
o 1 in 1 million
o Most commonly ages 50-70yo
Manifestations:
o Cognitive impairment
o Ataxia
o Memory loss
o Death
Most fatalities ≤6 months to first manifestations of symptoms
Types:
o Sporadic – most common (85%)
o Familial
o Iatrogenic
Contaminated surgical instruments, dura mater grafts, growth hormone surgery
o Variant
o Kuru – ritualistic tribal cannibalism
Dental implications:
o Transmission of CJD in dental setting is extremely rare
Higher risk in OMFS
o Precautions (as standard sterilisation procedures do NOT remove prions):
Use of disposable instruments
Incinerate any waste
Do you have diabetes?
Definition
o Type 1 = autoimmune destruction of the insulin producing pancreatic beta cells
o Type 2 = abnormally high intake of glucose and fatty acids causing:
Disruption of insulin function
Insulin resistance
Insulin secretory defect
Epidemiology
o About 1-2 million Australians are affected
o Type 1 = 10%
o Type 2 = 90%
Aetiology
o Type 1
Genetic
Autoimmune
Environmental
Viral infections (mumps, rubella, coxsackievirus) may trigger auto-immune
response
Idiopathic
10-15% cases are of unknown aetiology
o Type 2
Genetic
Positive family history risk of 38% if 1 parent, 60% if 2 parents
Environmental
Obesity
Lack of physical inactivity
Aging
o Gestational
Environmental
Obesity
o BGL normally normalize post-pregnancy
Complications
o Metabolic disturbances
Ketoacidosis accumulation of ketones in blood pH disrupts many systems
in body ultimately can lead to coma, swelling of brain, death
o Cardiovascular
Accelerated atherosclerosis
Hypertension
o Eyes
Retinopathy
Cataracts
o Kidney
Nephropathy
Renal failure
o Extremities
Ulceration, gangrene of feet
Amputations
o Neuropathy
Dysphagia
Diarrhoea
Muscle weakness/cramps
Numbness
o Early death
Signs/symptoms
o Polydipsia (abnormally great thirst)
o Polyuria (abnormally large amounts of urine)
Bed-wetting
o Polyphagia (excessive eating/appetite)
o Weight loss
o Loss of strength
o Irritability
o Drowsiness
o Malaise
o Blurred vision
Dx criteria
o If asymptomatic, repeated tests required
o Symptoms present with:
HbA1c ≥ 6.5% (48 mmol/mol OR 7.7 mmol/L)
HbA1c
o ‘Glycated haemoglobin’
o Indicates average blood glucose concentrations over previous 3
months
Fasting glucose ≥7.0 mmol/L
Random glucose ≥11.1 mmol/L
Tx:
o Medications:
Metformin decreases glucose levels by using insulin already in body
Sulfonylureas
May become ineffective after a prolonged use, thus leading to increased risks
of a hypoglycaemic attack
Insulin
DPP4 inhibitors
SGLT2 inhibitors
o Diet control
o Exercise
Dental implications:
o Questions to ask
What type of diabetes do you have?
How long had you had it for?
Are you currently taking any medication for the diabetes? When was the last time
you took your medications?
Inappropriate insulin dose may precipitate a hypo or hyper incident
Did you eat before the appointment?
Forgotten, delayed, or insufficient meals = risk factor for hypo attack
If meal missed, reschedule appointment OR send them out to eat and come
back 30 mins later
What was your last known BGL / HBa1c reading?
BGL (Random Blood Glucose)
o 3.0 – 8.0 mmol/L = Normal (non-diabetic patient)
o < 3.5mmol/L = Treat as hypoglycaemia
o 3.5 – 12.0 mmol/L = Proceed with tx
o > 12 mmol/L = Refer to GP for medication adjustment
HBa1c
o 4-6% = normal
o >6.5% = diabetic
o 7% (53 mmol/mol) = controlled diabetic (target)
o >8% (64 mmol/mol) = uncontrolled diabetic (delayed soft tissue
healing)
o Course of Care
Initial appt.
Determine pt routine
o Determine what destabilises it
Determine dental tx required
Ask pt to bring with them their glucose monitor
Timing of appt.
Midmorning/early afternoon
Remind pt to maintain meals/medications
Avoid extensive tx or long appointments
Tx
Check pt has stuck to routine prior to tx
o If missed meal, reschedule appointment OR send them to eat and
come back 30 mins later
DO NOT give pt glucose; may destabilise routine
If pt feel ill during tx, cease dental tx
o Assess BGL and act accordingly
Ensure pt leaves care feeling fine
o Oral manifestations
Poor wound healing
Increased collagen metabolism negatively affects wound healing
Xerostomia
Related to a diabetic patient’s experience of polyuria and nocturia
Caries
Polyphagia may result in increased carbohydrate intake
Periodontal disease
Impairs the resolution of inflammation and repair, which leads to accelerated
periodontal destruction because of the associated:
o Attenuated immunity
o Altered vascularity, GCF, and collagen metabolism
o Increased glucose substrate for bacterial metabolism
Periodontal implications:
o More severe periodontitis
o In fact, periodontal disease may be one of the first clinical signs of
diabetes
o Higher frequency of abscess
o Poorer response to periodontal therapy
o Periodontitis may cause an increased insulin requirement
o Periodontal therapy may reduce insulin needs (bidirectional
relationship)
Oral candidiasis
Occurs due to induced xerostomia, immunosuppression, and sugar in saliva
Persistent traumatic ulcers
Immunosuppression
Signs and symptoms of hypoglycaemia
Management of Hypoglycaemia
If patient is conscious and cooperative:
o Cease dental treatment
o Give 20-25g of glucose to adult, or if not available, a fast-acting glucose containing food
or drink (e.g. fruit juice, jelly beans). This must be followed by a lower glycaemic load
carbohydrate (e.g. sandwich, dried fruit)
o Keep patient under observation until they feel recovered. Do not allow them to drive
themselves home and strongly advise they seek medical review.
If patient is drowsy, uncooperative or unconscious:
o Cease dental treatment
o Call 000
o If patient is unconscious, institute BLS
Dental implications
- Medications
o Corticosteroids
Tx with oral prednisolone >10mg daily for 3 weeks may induce adrenal suppression
addisonian crisis (to counter this, dose of corticosteroids should be increased
prior to appointment)
o Immunosuppressants
Cyclosporine gingival hyperplasia
o Dialysis
Delay dental treatment for 4 hours post-dialysis (it is best to even wait till day after
to avoid the anti-coagulant effects of heparin increased bleeding)
This is because patients on hemodialysis will take heparin on their dialysis days
If patient receives dialysis via plastic graft, then AB prophylaxis may be indicated
prior to invasive dentoalveolar surgeries
However, if the graft is native, then no AB prophylaxis is required
o Drug excretion
Reduced excretion – liaise with GP and revisit drug dosages
o Drug metabolism
Pt intolerance to drugs metabolised in kidney
NSAIDs avoided for those with mild renal impairment ( water retention) –
paracetamol the drug of choice
o Abnormal bleeding ( erythropoietin production/ platelet dysfunction)
Attention to surgical technique/local haemostatic measures
Adrenaline containing LA
Insertion of resorbable pack
Suturing
Pre-tx screening for haematological state
o Oral manifestations
Mucosal pallor, pigmentation
Xerostomia
Parotid infection
Dysgeusia
Metallic taste
Oral candidiasis
Petichiae and ecchymosis
Enamel hypoplasia
Stomatitis
Loss of lamina dura
Anaemia
…can result due to failure of erythropoietin production by the kidney
Decrease in level of circulating haemoglobin below the normal range
o Male: 125-140 g/L
o Female: 120 g/L
Clinical Features:
o General:
General fatigue
Heart failure
Angina on effort
Pallor
Spoon shaped nails (koilonychia)
Types:
o Microcytic - iron deficiency anaemia due to chronic blood loss (GI or menstrual), inadequate
diet. Rare causes: thalassaemia
o Macrocytic - low vitamin B12/ low folate. Seen in pernicious anaemia, alcohol abuse,
chronic exposure to nitrous oxide.
o Normocytic - due to chronic disease (acute blood loss, haemolytic anaemia, aplastic
anaemia
o Sickle cell anaemia - hereditary condition causing RBCs to ‘sickle’ when exposed to low O2
→ infarctions of bone and brain occur. Avoid prilocaine (potentiated methHb)
Dental Implications:
o Oral:
Oral discomfort/ ulceration
Glossitis
Pallor of oral mucosa - tongue - first sign!
Angular chellitis
o Reduced O2 carrying capacity – poor wound healing
Do you have any joint problems, arthritis or history of joint replacement surgery?
Rheumatoid Arthritis
Definition:
o Autoimmune disease characterised by symmetric inflammation of joints, especially of the
hands, feet, knees
Aetiology:
o Auto-immunity T-cells and antibodies attack synovial joints
o Genetics
o Infectious agents
Questions to ask?
o Which joints are affected?
o Do you have difficulty being placed supine?
o Does it impede in your ability to brush and carry out oral hygiene?
Signs/Symptoms:
o Often symmetric
o Warm, swollen, painful joints
o Joint stiffness
Morning stiffness > 1 hour
o Fatigue/fever
o Spindle shaped PIP joints
o Subluxation of MCP joints
Management:
o Palliative: Immunesuppressants, DMARD’s, NSAID’s, corticosteroids
o Definitive: Joint replacement
Dental Significance:
o Compromised mobility
Manual dexterity for OH
Consider:
o Electric toothbrush
o Floss holders
o Irrigating devices
Involve the guardian/carer
Accessing clinic
Sitting in dental chairs require pillow and/or breaks
o TMJ involvement
15% have radiographic changes at the joint
Symptoms:
Bilateral pre-auricular pain
Decreased opening/mobility
Swelling
Tenderness
Clicking
Crepitus
May result in AOB from progressive bilateral condylar resorption
o Consider chair-time into treatment planning
Removable prosthodontics over complicated crown/bridge
o Medications
DMARDs = Methotrexate
Oral ulceration
Dysguesia
Interacts with NSAIDs methotrexate levels (compete for secretion)
Immunesuppressants
Cyclosporin = gingival hyperplasia
risk of infections Attention to surgical technique/local
Delayed healing & abnormal bleeding haemostatic measures
NSAIDs Adrenaline containing LA
bleeding Insertion of resorbable pack
Oral ulcerations Suturing
Lichenoid reactions
Corticosteroids
Oral prednisolone > 10mg daily for 3 weeks may induce adrenal
suppression addisonian crisis
o Hence dose of corticosteroid should be prior to appointment
o Consider AB-prophy for dento-alveolar surgery if pt. is severely immunocompromised
Liaise with GP
See “Arthroplasty” below
Osteoarthritis
Definition:
o Degeneration of articular cartilage due to progressive wear and tear
Aetiology:
o Wear and tear
o Genetics
o Metabolic factors
o Obesity
Epidemiology:
o 1.6 million Australians affected
Questions to ask?
o What joints are affected?
o Does it impede in your ability to carry out oral hygiene?
Signs/Symptoms:
o Localised pain
Dull ache accompanied by stiffness
Worse in morning < 15 mins/after period of inactivity
o Grafting sensation when using joint
o Painless bony growths on PIP joints
Management:
o Palliative: Paracetamol, NSAIDs, exercise, weight reduction
o Definitive: Joint replacement
Dental Significance:
o Compromised mobility
Manual dexterity for OH
Consider:
o Electric toothbrush
o Floss holders
o Irrigating devices
Involve the guardian/carer
Sitting in dental chairs require pillow and/or breaks
o TMJ involvement
Symptoms:
Unilateral pre-auricular pain
Decreased opening/mobility
Swelling
Tenderness
Clicking
Crepitus
May result in AOB from progressive bilateral condylar resorption
o Consider chair-time into treatment planning
Removable prosthodontics over complicated crown/bridge
o Medications:
NSAIDs Attention to surgical technique/local
bleeding haemostatic measures
Oral ulcerations Adrenaline containing LA
Lichenoid reactions Insertion of resorbable pack
o No AB prophy needed Suturing
See “Arthroplasty” below
Osteoporosis
Definition:
o Disease characterised by decreased bone density due to osteoclastic activity exceeding
osteoblastic activity
Aetiology: Multi-factorial
o Androgen and oestrogen deficiency
Menopause
o Malnutrition
Calcium deficiency
Vit D deficiency
o Lack of exercise
o Genetics
Epidemiology:
o 1.2 million Australians affected
Questions to ask?
o Do you have difficulty undertaking OH?
o What medication are you taking?
Signs/symptoms:
o Bone fractures
o Back pain (collapsed vertebrae)
o Stooped posture
o Loss of height over time
Management:
o Lifestyle changes (SNAP)
Smoking cessation
Nutrition improvement
Alcohol reduction
Persistent exercise
o Medications:
Bisphosphonates
Calcium, Vitamin D
Dental significance:
o Direct effects of condition
risk of jaw fracture
Loss of alveolar ridge
Resorption in edentulous pt’s
Poor healing
o Pt. positioning
Pt. may not be able to hyperextend neck – cervical vertebrae involvement
Use pillows
Adjust chair
o Medications
Calcium
absorption of quinolone AB’s may require larger dose if prescribed
BISPHOSPHONATES – BRONJ (Bisphosphonate related osteonecrosis of Jaw)
Bisphosphonates inhibit osteoclastic bone resorption, hence an overall in
bone turnover
o angiogenesis, causing exposed bone to undergo avascular bone
necrosis
Incidence: 0.8 – 12%
Risk Factors:
o Type (potency), duration and route (IV) of bisphosphonate therapy
Considerations:
o History-taking related to bisphosphonates
Have you received any tx for bone/calcium disorders?
Osteoporosis
Paget’s disease of the bone
Hyperglycaemia
Cancer spread to the bone
Multiple myeloma
Are you taking bisphosphonate medication?
DON’T proceed with exo/bone surgery
Liaise with specialist
o Prior commencement of bisphosphonates
GP should refer for comprehensive dental examination prior
to long-term oral or IV bisphosphonate therapy
Advise GP when pt. is dentally fit
o Perform pulp testing
o Address caries/PPD
Because drug remains in system possibly for 10 years
post-cessation risk of BRONJ severely after the 1st
year of use
o Post commencement of bisphosphonates
Avoid invasive procedures if possible
If unavoidable:
Check pt. C-terminal telopeptide (CTX) concentration
CTX count: (level of bone turnover):
o <70pg/ml, DO NOT proceed
Normal: 400 – 500 pg/ml Refer to GP and/or OMFS
Low risk: > 150 pg/ml May need drug holiday
Medium risk: 70 to 150 pg/ml Restart bisphosphonates 10 days post-
extraction
High risk: <70 pg/ml
Extraction:
o Explain potential risks to pt.
o Attention to surgical procedure (atraumatic)
o Local haemostatic agents
o Adrenaline containing LA
o Resorbable pack
o Suture
Prevention of BRONJ:
o Identification of patients at risk of BRONJ
Detailed medical history to identify past/present history of:
BRONJ
Bisphosphonate therapy
Comprehensive oral/dental examination
Ill-fitting dentures associated with spontaneous
BRONJ
o Careful treatment Planning for patients at-risk of BRONJ
o Risk assessment and current protocol recommendations
o Preventative regimes for dental procedures:
Use of AP for severely immunocompromised pt.
o Post-operative review
Management of BRONJ:
o Dx criteria:
Bone area exposed > 8 weeks
No history of radiation to head/neck
Pt. on bisphosphonates
o Signs/symptoms:
Pain
Exposed jaw
Undermined mucosa overlying area
Draining sinus
Soft tissue infection
o Management:
Refer to OMFS
“The current literature does not support the use of prophylactic antibiotics for all patients with prosthetic
joints”
Definition:
o Surgical replacement or reconstruction of a joint using prostheses
Indications:
o Severe arthritis
Osteoarthritis
Rheumatoid arthritis
o Trauma
o Misaligned joint
Higher Risk PATIENT High Risk PROCEDURE
Extensive oral surgery or number of dental extraction ( 5
Pt. on long-term bisphosphonate therapy
teeth)
Surgical extraction of mandibular molar teeth, with risk of
Bisphosphonate therapy related to malignancy
impinging lingual cortical plate/mylohoid ridge
Immunosuppression Surgery with risk of impinging of tori
Current or previous use of high-dose systemic
corticosteroid administration
o Many other reasons
Dental Significance:
o Before placement:
Patient should be referred to a dentist to evaluate dental and oral health
Appropriate treatments to make pt. orally fit
Arrangements for regular dental review
o After placement:
Small risk of infection at the prosthetic site by the haematogenous route
AP not recommended as risk of adverse effects > benefit
Antibiotic toxicity
Allergic reaction
Microbial resistance
Dental problem within 3 months following artificial joint replacement:
Infection with abscess = remove cause, treat aggressively, No AP
Pain = emergency dental treatment for the pain – AP
Non-infective dental problem without pain – defer dental treatment until 3-
6 months after prosthesis replacement
Dental treatment after 3 months:
If normal functioning artificial joint = No AP
Dental treatment for pt. with significant risk factors for artificial joint infection:
Immunocompromised = diabetic, medication, rheumatoid
Non-essential treatment = defer until immunity has stabilized
Essential treatment = consult with orthopaedic surgeon – usually procced
with AP
o AP indicated:
Previous history of artificial joint infection
Established infection of joint
To eliminate any oral cause
Definition
o Abnormal or hypersensitive response of the immune system to a substance introduced into
the body
Aetiology
o Immunological reaction to a non-infectious foreign substance (antigen)
o Involve the humoral or cellular immune system
Type 1 immediate (humoral) = IgE mediated
Type 2 (humoral) = IgG & IgM mediated
Type 3 (humoral) = immune-complex mediated
Type 4 delayed (cellular) = delayed T-cell mediated response
Type 1 diabetes
Contact sensitivity (eczema)
Management
o Antihistamines
o Corticosteroids
Asthma
Contact dermatitis
Dental implications:
o Questions to ask
What sort of reaction do you get?
When was your last exposure?
Do you carry an epipen with you?
Have you been to GP to test for true allergy?
o Nickel, latex, penicillin, and LA are common allergens seen in dental practice
Nickel – orthodontic brackets
Latex – rubber dam, LA plunger (though does not come into contact with pt so
should be ok), gloves, orthodontic bands
Penicillin – antibiotics
Important to remember that there is 10% crossover in allergic response
between Penicillins and Cephalosporins
LA – preservative bisulphite or methyl/propyl paraben
o Non-emergency allergic response/signs/symptoms
Urticaria
Angioedema (swelling)
Chest tightness
Dyspnoea
Rhinorrhoea (runny nose)
o If symptom precipitation occurs:
Cease dental treatment and remove/cease administration of the allergen
Urticaria or rhinorrhoea = provide oral antihistamine
Chest tightness or dyspnoea = ventolin
Angioedema (swelling), reddening across the body, inability to talk = adrenaline
o Prevention
Have EpiPen, adrenaline cartridge, ventolin, and antihistamines available
Schedule morning appointments
Avoid using allergen containing equipment/medication
Thyroid Disorders
Physiology:
o TRH TSH T4 and T3 (active but little produced) made Liver converts T4 to T3 and
T3 to T2 T3 feeds back to hypothalamus and pituitary
Hypothyroidism Hashimoto
o T cells attack the whole thyroid gland
o Symptoms/ signs:
Constipated
sensitive to cold
tired
gaining weight (body stimulating hunger)
decreased immune response
bradycardia
o Oral signs:
Oral candida
Goitre
Enlargement of tongue delayed tooth eruption
Hyperthyroidism Grave’s Disease
o Antibodies stimulating TSH receptor processed as being TSH
o Symptoms/signs:
heart rate
Tremor and Palpitations
Swear - metabolism = core temp
Gut more stimulated = transit time or diarrhea
o Oral signs:
Smooth goitre
Ophthalmopathy – bulgy eyes
Hyperparathyroidism
o Oral signs:
Loss of lamina dura
Central giant cell granuloma
Dental Implications:
o If stable disorder progress with tx
o If unstable disorder defer tx/avoid using adrenaline-containing LA (risk of thyroid crisis)
Thyroid storm
Potentially fatal condition associated with untreated/undertreated
hyperthyroidism abnormally high HR, BP and core body temp
Adrenal disorders
Types:
o Glands produce
Steroid hormones from cortex
Catecholamines from medulla.
o Hypofunction – Addison’s (destruction of adrenal glands – adrenocortical insufficiency)
Hyperpigmentation – dark patches ( ACTH production)
Dental implications:
Adrenal crisis could occur – low cortisol levels = can’t respond to stress
leading to cardiovascular collapse
During dental tx, such as extraction, stress = demand for cortisol BUT
production = adrenal crisis
Long term replacement therapy leads to adrenal glands losing ability to make
steroid themselves = adrenal suppression . The drugs maintain a level of
cortisol and don’t increase with physiological response…
o Tx with corticosteroids doses > 10mg daily for > 3 weeks can cause
adrenal suppression
o Rx = dose should be increased the day before and on the day of dental
tx to stimulate normal increase in glucocorticoid secretion that occurs
in response to stress.
ADRENAL CRISIS
o Progressive hypotension occurring 6-12 hours post tx. Pt. may feel
faint, become confused and collapse
o Procedures should be carried out in the morning so that if crisis
occurs, symptoms presents while the pt. is awake. If at night, while
asleep, could lead to death.
o Hyperfunction – Cushing’s Disease (cortisol production)
Dental Implications:
Thin mucosa = bleed easily
Osteoporosis
Oral candida (increase infection ate)
GORD/Reflux
Transit of gastric contents into oesophagus and into oral cavity
o When food and stomach acids are transferred from the stomach to the small intestine, the
lower esophageal sphincter (LES) contracts to prevent backflow of acid into the oesophagus
– this does not occur in GORD due to weal LES
Common in female
Dental Implications:
o Dental erosion (Perimolysis)
o Increased acidity of the oral environment
o Altered taste
o Halitosis
o Pt. may not be comfortable in fully supine position in dental chair (sphincter loose/faulty so
acid can travel up the oesophagus or lay stagnant causing irritation)
Pharmacology:
o Antacids
Interference with absorption of many drugs ( pH = delayed/decrease absorption):
Fluoride
Metronidazole
Reduce analgesic effect to a level that is non-therapeutic
Neurological disorders
Trigeminal Neuralgia
o Sudden brief and very severe paroxysms of pain on one side of face
o Signs/symptoms:
stabbing or electric shock
Unilateral – distributed in one or more branches of trigeminal nerve
May have residual ache after shock like pain
Specific trigger points may be identified on gingiva
Pain does not wake up from sleep
Pain remit for weeks or months and returns
o Triggers:
Touching face
Cold air
Talking, chewing
Tooth brushing
o Ddx (if pain last for more than few minutes or point of pain in forehead)
Paroxysmal hemicranias
Cluster headache
Atypical facial pain
o Needs to be distinguished from post herpetic pain
o Experiences in < 40 multiple sclerosis
o Management:
Carbamazepine ( effects of Warfarin)
Other drugs: baclofen (muscle relaxant), Phenytoin, sodium valproate
o Dental Implications:
Pt. think they have toothache (pain similar to pulpitis) – check clinically
Questions to ask:
Is the pain consistent with the condition of teeth
Can it be stimulated by soft tissue contact?
Does it interfere with sleep?
What are the effects of diagnostic nerve blocks?
Nerve blocks with long acting LA (bupivacaine) = diagnostic + temp. relief (< pain for
14 days)
Unstable trigeminal neuralgia
Dental treatment may exacerbate pain
o Tx = block the area
Parkinson’s Disease
o Neurodegenerative disease involving the destruction of substantia nigra (major dopamine
producing area in mid brain)
o Symptoms:
Tremor – involuntary trembling
Rigidity – stiffness of muscles
Akinesia – difficulty initiating and maintaining voluntary movement
Postural instability – disturbance in balance and gait
o Dental Implications:
Difficult in OH
Excessive salivation and drooling
Patient may have tremor and find difficulty cooperating during operative treatment.
Motor reflexes impaired – may be in a wheelchair
Multiple Sclerosis
o Demyelination of neurons due to autoimmune destruction
o Symptoms:
Numbness/ tingling
Weakness
Dizziness
Visual loss
Fatigue
Bladder/bowel/ sexual dysfunction
o Dental Implications:
Prednisolone – anti-inflammatory effect – adrenal crisis from dental tx ( dose)
Interferom 1A or 1B – chelitis, xerostomia, gingivitis, candia
Oncology disorders
Head and Neck Cancers
o 6th most common
o Males > Females
o Managed by surgery/ radiotherapy/ chemotherapy
o Risk Factors:
Tobacco
Alcohol
Betel Nut chewing
HPV
Radiation
Poor oral hygiene
o Symptoms:
Hoarseness - persistent or progressive with no obvious explanation
Tongue pain – can also have thickening of the tongue
Dysphagia
Bleeding
Stridor – difficulty breathing
o Dental Implications:
Dentists have responsibility with recognition/diagnosis
Ensure pt dentally fit prior to commencement of radiotherapy
Commence radiotherapy 7-10 days’ post-extractions
Irradiation causes
o Oral pain
o Mucositis
o Reduced salivary flow
If teeth are not able to withstand the ABOVE, they are best extracted
o This is because md extractions post-commencement of radiotherapy
can cause osteoradionecrosis (mx extractions straight-forward)
Do not exo any teeth without specialist advice
Consider conservative options – endo, resto, fluoride
If md exo unavoidable, reduce risk of osteoradionecrosis
(necrosis due to blood supply - nutrients and O2) by using
prophylactic hyperbaric O2 (pressure greater than normal –
allows more O2 to reach damaged area = prevent tissue
damage from blood/ O2 flow)
May be insufficient though liaise with specialist
If osteoradionecrosis occurs, tx involves hyperbaric O2
plus surgery
Consider possibility of cancer recurrence in pt who has had head/neck cancer tx
Chemotherapy
o Cytotoxic drugs used in management of malignancy
Variation of drugs; may be used in combo with corticosteroids
o Can cause mucositis of the entire GI tract
o Dental implications
Ensure pt dentally fit prior to commencement of chemotherapy
Chemotherapy causes
o Mucositis
Direct irradiation to mucosa – erythema and ulceration -
disruption of rapidly dividing cells in oral mucosa
secondary infection common
Tx: benzydamine hydrochloride 0.15%, 10-15 ml rinse, 4-6
times daily
o Reduced salivary flow
Dental tx scheduled between chemotherapy appt.’s
Extraction sockets generally heal well
If taking bisphosphonates, consider BRONJ ABOVE
o Dental Implication:
Referred pain to teeth
May not be able to open mouth too wide – access
Centric occlusion may be painful – complete dentures?
Paget’s Disease
o Disordered bone resorption and production
o High turn over of bone - bone thickening – weak and deformed bone formed
o Dental Implications:
Jaw involvement – mainly maxilla
Bone loss at root – tooth loosening and loss
Bone growth – malocclusion, teeth spreading, hypercementosis
Poor denture fit
Difficult extraction, excess bleeding, osteomyelitis
Fracture
Osteosarcoma rare
o Pharmacology:
Bisphosphonates
Calcitonin – supresses bone resorption but alters absorption of Abx
Psoriasis
o Skin disease marked by red, itchy, scaly patches
o Dental Implications:
Oral mucosal involvement
Gingival erythema
Oral burning
Dental tx may cause flare up with stress/ dental anxiety
Tx:
Methotrexate
o Oral ulceration (reduced if folic acid taken)
o Increased toxicity with other meds e.g. antibiotics, NSAIDs,
corticosteroids
Immunosuppressant – reduced resistance to infection
Cyclosporine – gingival hypertrophy
Sjogren’s syndrome
o Classic triad
Dry eyes
Dry mouth
CT disease – Rheumatoid arthritis
o Infiltration of immune complexes into lacrimal and salivary glands results in destruction and
fibrosis
o Common in females – middle aged
o Dental Implications:
Xerostomia
Decreased salivary secretions
Frothy/ ropey saliva
Lack of saliva pooling in the FoM
Tongue
Dry and fissured tongue
Atrophy of tongue papillae
Buccal mucosa
Dryness
Mouth mirror stick to the mucosa
Red and tender = secondary candidiasis
Fungal infection (decreased cleansing and microbial activity from saliva)
Denture stomatitis
Angular chelitis
Oral candidiasis
Tooth decay (decreased cleansing and microbial activity from saliva)
Cervical caries
Root caries
Parotid swelling, difficulty chewing, biting, opening mouth
Depression
o 5% in general popl and 70% female
o Aetiology:
Genetic predisposition
Serotonin transporter gene involvement
Stressful life events
Side effects of meds
o Symptoms:
Psychological
Depressed mood
Reduced self esteem
Pessimism
Loss of enjoyment
Suicidal thoughts
Somatic
Reduced appetite
Weight change
Disturbed sleep
Fatigue
Loss of libido
o Dental Implications:
Dry mouth from medications
SSRIs / TCAs / MAOIs
Xerostomia
Interact with tramadol serotonin syndrome
o Involves SMARTS:
Shivering
Myoclonus (twitching, jerks)
ANS instability
Rigidity
Temperature increase
Seizures
o So, do not prescribe the opioid tramadol
MAOIs
Contraindicate adrenaline-containing LA
This is because MAOIs inhibit the degradation of adrenaline and therefore
potentiate its effects
Bipolar
o Recurrent disorder – episodes of depression and hypomania/ mania
Risk of suicide
Manic behaviour – outside normal parameters and may become outrageous
o Epidemiology:
1 – 2% of popl – onset early adulthood to late adolescence to late 20s
Comorbid anxiety in about 50% patients and concurrent alcohol or substance abuse
40%
o Genetic influences and biochemical changes particularly involving serotonin have been
documented however biology of bipolar disorder is unclear
o Tx
Lithium
Li+ monovalent ion (like Na+) – substitutes for sodium
o behaves like sodium ions NSAIDs conserve and reabsorption of
sodium lithium and NSAIDs - will get conserved and retained -
toxic
Carbamazepine
Valproic acid
o Dental Implications:
LA interactions:
Not contraindicated with SSRIs or TCAs
MAOI avoided
Issues gaining informed consent
Xerostomia and dry mouth due to disorder and medications
Increased incidence of TMJ pain and atypical facial pain
Somatoform Disorders
o Somatic symptoms not explained by a medical condition and not better diagnosed by
depressive or anxiety mood disorders
o Body dysmorphic disorder
Dental implications:
Be aware of the psychological status of the pt as this affects tx
outcome/planning
o Pt with body dysmorphic disorder will never be satisfied about the
appearance of their teeth, regardless of how much they improve
o Schizophrenia
psychosis characterised by delusion, hallucinations and lack of insight
Dental Implications:
Drug treatment may lead to
o Dry mouth
o Uncontrolled facial movements
o Jaw grinding – can break cusps off, can expose dentine – sensitive teeth
o Impaired pain perception
o Acute dystonia (broken teeth)
o Seizures/ TIA/ Stroke
Often gross neglect leading to increased caries and perio disease
Difficulty with informed consent may present
Usually able to be treated safely in general dental practice
Eating Disorders
o Anorexia
Marked weight loss arising from food avoidance, often in combination with binging,
purging excessive exercise and use of diuretics and/or laxatives
Profound disturbance of body image
Anxiety and depressive symptoms
Amenorrhoea
Aetiology
Unknown . genetic?
Self-perception
Environmental factors
More common in females
Dental Implications:
Tooth erosion due to vomiting
Low body mass may require consideration of drug dose modification
Postural hypotension
o Bulimia
Bulimic patients are usually at or near normal weights but have a fear of fatness
associated with disordered eating behaviour
Recurrent binging and purging
Features
Russell’s sign – callouses on knuckles
o see little scratch marks from the incisors - from trying to induce
vomiting?
Dental Implications:
Perimolysis (acidic erosion of the dentition) – due to vomiting
Loss of vertical dimension (if the erosion is heavily progressed)
Dentinal hypersensitivity
Xerostomia
Halitosis
Redness of pharynx and soft palate
Patient education
o Immediately after vomiting
Avoid brushing teeth
Rinse mouth with water
Use a neutral fluoride or a basic sodium bicarbonate MW
(Peter Mac)
o In general
Consider desensitizing toothpaste, topical fluoride, and CPP-
ACP
Haematological
Types:
o Von willebrand’s disease
o Neutropenia ( neutrophils)
o Thrombocytopenia ( platelet)
o Leukaemia
o Venous Thromboembolism
Bleeding Disorders Concern is LA. The use of deep injections such as inferior alveolar nerve blocks
is contraindicated in patients with bleeding problems unless some form of prophylaxis has been
provided. There is fear of producing a bleed that may track around the pharynx leading to airway
obstruction.
Are you currently taking any medication, or have you taken any in the last 3 months?
Questions to ask?
How many months pregnant are you?
Have you been to the doctor?
Dental Significance:
Defer elective treatment in 1st and 3rd trimester:
o 1st trimester = organogenesis (17-60 days)
o 3rd trimester = may induce labour
Mobility issues:
o Adjust chair height
o Pillows if required
o Place patient slightly on their left – increases blood flow to foetus
LA:
o Articane – least placental barrier permeation
o Do not use LA containing the vasoconstrictor felypressin as it resembles oxytocin and may
stimulate uterine contractions
Prescription of medications:
o Be aware of teratogenic effects of drugs
o Refer to Therapeutic Guidelines – Drug use in pregnancy and breastfeeding p 210-212
Oral Manifestations: