2017

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. feels faint:

- Cease dental treatment
- Tilt the chair back to horizontal position or get them to lie down (the head should not be lower than
the heart)
- Raise the pt. legs slightly
- Assess consciousness by talking to the pt.

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

If pt. does not gain consciousness:

- Consider other causes of syncope or collapse
- Call 000
- Institute BLS
- Maintain treatment until pt. regains consciousness or assistance arrives

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

 Ischaemic heart disease

o Decrease in blood supply to part of heart – heart muscle  function or dies
o Due to narrowing of coronary arteries → artheroscleotic plaques
o Manifestations:
 Angina
 Stable angina - pain from physical effort or stress; pain transient (<10 minutes)
and subsides with rest
 Classically central, tightness/heaviness, radiates to the jaw, neck or arm (left)
 Exacerbated by exercise and relieved with rest
 Some patients (particularly diabetics) can have no pain, atypical pain,
shortness of breath, sweating or light headedness.
 Acute Coronary Syndrome (MI)
 Symptoms similar - more severe
 No relief of symptoms
o Dental Implications:
 Possibly on antiplatelet/ anticoagulant drugs → increased risk of bleeding
 Do not stop any preventative medications (aspirin) - risk of attack
 Defer elective treatment 3 months post MI, stent placement or heart surgery
(coronary bypass)
 Those with previous history of Angina → bring glyceryl trinitrate spray.
 Short appointments → use relaxation techniques and consider sedation
 Periodontal disease is a risk factor for CVD (inconclusive)
  Those with diabetes may experience no symptoms of MI !!! → WHY?
 Drug interactions of adrenaline and beta blockers → acute exacerbation in
hypertension
 May experience some degree of cardiac failure - ask how many pillows they sleep
with - assess tolerance to supine position
Cardiac arrest
 Due to ventricular tachycardia, ventricular fibrillation or electromechanical dissociation
 Pt. loses consciousness → no pulse, no respiration

Management of cardiac arrest

- Cease dental treatment
- Call 000
- Institute BLS (DRSABCD) → Maintain tx until pt. regains consciousness or assistance arrives

Management of angina or ACS

Symptoms:
 Retrosternal cardiac chest pain
 Radiating pain to neck, jaw or arm
 Shortness of breath or lightheadedness
 Chest tightness - elephant sitting on the chest

If chest pain occurs in a pt. With hx of angina:

- Cease dental treatment
- Measure BP and pulse rate - assess consciousness
- Shorten the attack:
o GTN spray 400ug sublingually - repeat every 5 minutes - mx. Of 1200ug (3 sprays)
o GTN tablet 600ug sublingually - repeat every 5 minutes - mx. Of 1800ug (3 times)
- Ask pt. To sit or lie down - esp. If using GTN due to risk of hypotension
- If patient recovers, do not proceed with treatment
- If pain persists for more than 10 minutes, despite 2 doses, administer 3rd dose and manage as severe and
new chest pain.
If chest pain is severe and new:
- Call 000
- Provide oxygen
- Give aspirin 300mg chewed or dissolved before swallowing
- Monitor vitals and reassure them until assistance arrives
- If unconscious - administer BLS (DRSABCD)

 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

 Valvular Heart Disease

o Disease caused by narrowing (stenotic) or leaky valve (regurgitant)
o Aetiologies:
 Degenerative
 Calcific
 Rheumatic fever
 Congenital – bicuspid aortic valve, mitral valve prolapse
o Clinical manifestations:
 Asymptomatic – most
 Incidental cardiac murmur
 Heart failure – fluid retention, exercise intolerance
 Arrhythmias
 IE
o Dental Implications:
 Maybe on Anti-coagulants, arrhythmias
 IE risk

 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

 risk of aneurysm and

 risk of rupture
hamorrhagic stroke
  Vascular scarring

Formation of tiny Formation of scar

tissue which acts as MI or ischaemic
tears in blood nidus for debris
Aetherosclerosis
stroke
vessel such as cholesterol

 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

ANTICOAGULANT AND ANTIPLATELET

 Warfarin
o Inhibits Vitamin K clotting factors  2, 7, 9, 10
o Taken mainly for:
 Most common: Atrial Fibrillation
 DVT  pulmonary embolus
 Stroke Patients
 Prosthetic heart valve
 Secondary prevention of MI
o Dose range 0.5mg – 35mg (average 4-5mg daily)
o Affects prothrombin time  measured as INR (only warfarin effects this part of the
coagulation cascade)
o Issues:
 Warfarin – fluctuating INR (international normalised ratio) so need to check every 24
hrs
 INR around 2.5 – 3.5 with mechanical valve
 Half life – 48-72 hours
o Reversal agents:
 Vit K
 Fresh frozen Plasma (FFP)
 Prothrombin Complex Concentrates (PCC)
o Dental implications:
 Detailed Med hxx before surgery
 Dose regimen
 Stability of INR (international normalised ratio)
o I.e. if score = 2,  blood taking 2x longer to clot
 Underlying medical conditions
o Need for AB-prophy
o Other medications
o Interactions:
 Effects increased by:
 Aspirin
 NSAIDS
o Risk of GI bleeding
o Aspirin competitive binding
 Miconazole
 Tramadol
 Effects reduced by:
 Green tea
 Vit K
 Phenytoin
 Carbamazepine
  Increased metabolism (decreased INR)
 St John’s wort = anti-depressant (herbal)
 Decrease metabolism (increased INR)
 Erythromycin
 Metronidazole
 Decreased absorption = increased toxicity
 Cholestyramine

Management of Patients with Warfarin who require minor oral surgery

- Ask patient for their most recent INR; send them to have a blood test done (within 24 hours):
o INR <2.2 – safe to go ahead with the extraction
o INR 2.2 – 4 – carry out the extraction using 4.8% tranexamic acid
o INR > 4 – do not carry out the procedure as risk of bleeding
 But can be controlled by administration of coagulation factors or platelet transfusions in
consultation with the patient’s physician
Tranexamic acid mouthwash protocol
- Day of surgery:
o Check INR (2.2 – 4)
o Administer AP if needed
o Obtain a bottle of 4.8% tranexamic acid mouthwash
- During Surgery
o After extraction – irrigate socket with tranexamic acid mouthwash
o Fill the socket with loosely packed haemostatic agent
o Place one suture per socket
o Ask the pt. to bite on gauze soaked in tranexamic acid mouthwash
- After Surgery
o Give pt. tranexamic acid mouthwash:
 10 ml rinsed in mouth for 2 minutes, 4 times daily for 2-5 days
o review appointment in 2 days
Drug Dental implications
Aspirin  Mechanism:
(Antiplatelet drug) o Inhibits production of TXA2 (thromboxane A2) which in turn inhibits platelet
activation and aggregation
…COX (cyclo-  Does not usually cause significant bleeding from extraction wounds
oxygenase) inhibitor –  DO NOT STOP without expert advice (there are no indications for stopping aspirin
non-selective however)  warn pt that there is a  risk of bruising/ bleeding if not ceased, but risk is
insignificant vs. risk of thrombosis
 If requires stopping, stop 7 days before procedure and resume 2 days after
Clopidogrel/prasugrel  Irreversible action
(Antiplatelet drug)  Commonly used with aspiring to prevent stent-thrombosis up to 1-year post-stent
placement  premature discontinuation increases risk of stent thrombosis by up to 15%
 DO NOT STOP without expert advice  warn pt that there is a  risk of bruising if not
ceased, but risk is insignificant vs. risk of thrombosis
Warfarin  See ABOVE
(Anticoagulant drug)
Other (NOACS/  DO NOT STOP
DOACS) (new/direct  Consult medical GP before dento-alveolar surgery
oral anticoagulants)  Inhibits factor Xa or thrombin (i.e. factors of the coagulation cascade)
 Types:
o Dipyridamole
o Dabigatran (Pradaxa)
o Enoxaparin
o Rivaroxaban (Xarelto)
OTHER CARDIAC MEDICATIONS
 Thiazide diuretics
o Dry mouth
o Lichenoid reactions
 Beta blockers (lol)
o slows the heart rate and therefore reduce the myocardial oxygen requirement  leads to
increased diastolic time. This means that the muscle is relaxed in diastole where the
increasing filling time allows for better coronary perfusion
o Interacts with adrenaline
o Taste changes
o Lichenoid reactions
 Combined alpha and beta blockers
o Taste changes
 ACE inhibitors (pril)
o inhibit angiotensin converting enzyme  has effect on kidney to reduce salt and water
retention
o Angioedema of lips, face, tongue
o Taste changes
o Oral burning
 Angiotensin receptor blockers (ARB’s)
o Angioedema of lips, face, tongue
 Calcium channel blockers
o Gingival hyperplasia
 Alpha-adrenergic blockers
o Dry mouth
o Taste changes
 Central alpha-adrenergic agonists and other centrally acting drugs
o Dry mouth
o Taste changes
 Direct vasodilators
o Lupus-like oral and skin lesions
o Lymphadenopathy

Do you have a pacemaker?

 Pacemaker:
o An electrical device that produces electrical impulses to stimulate heart contractions
o Often used to tx:
 Atrial fibrillation
 Bradyarrhythmia
 Ventricular tachycardia
 Dental implications:
o Pt require clearance from their doctor to proceed with dental tx
o Pt should be encouraged to always carry manufacturer’s ID card with them
o Certain dental devices can introduce electromagnetic interference (EMI) by causing single
beat inhibition on pacemakers programmed to unipolar sensing mode.
 Devices found to have an effect:
 Magnetostrictive ultrasonic scalers (e.g. Cavitron, old ferromagnetic
ultrasonic scalers)
 Electrosurgery unit
 Devices found not to have effect:
 Piezoelectric scalers (e.g. EMS)
  EAL
 Electric pulp testers
o Nevertheless, precautions should be taken for pt with pacemakers:
 Keep working end and cabling at least 6 inches from the implanted device
 Do not drape cords over pt chest
o If inhibition occurs:
 Symptoms similar to those experienced prior to device implantation (dizziness, light
headedness etc.)
 Switching off unit will stop the interference  device will automatically re-pace as
usual

Have you ever had heart valve or open heart surgery?

 Jog the pt. memory about any other heart surgeries
o What was the surgery?
o When did you have it?
o Was a prosthetic material used?
 Dental implications
 May need AB-prophy if associated with a high risk condition/surgery
 May need to defer elective tx for 3 months
 If stent placement, sustain clopidogrel and prasugrel for 1 year to avoid thrombosis

Have you ever had a stroke, fits, or epilepsy?

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

Have you had tuberculosis, asthma, or any other lung disease?

 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

 Obstructive sleep apnoea

o Repetitive obstruction of the pharyngeal airway, leading to episodes of
 Apnoea (cessation of breathing)
 Hypopnoea (partial obstruction) during sleep
o Sleep-related breathing disorders actually present a spectrum of clinical entities from mild-
intermittent snoring to severe OAS
o Epidemiology
 4% males
 3% females
o Aetiology
 Anatomically narrowed upper airway, due to risk factors including
 Jaw retrognathia
 Mx. insufficiency
 Excessively large palatine tonsils and lymphoid tissue
 Factors contributing to enlargement of upper airway soft tissues
o Obesity
o Increased neck circumference
o  age
o Male gender
o Alcohol, smoking
o Genetics – craniofacial abnormalities, hypothyroidism, acromegaly
o What soft tissues?
 Soft palate
 Uvula
 Pharyngeal walls
  Soft palate
 Pharyngeal fat pads
o Signs/symptoms
 Most often described by bed partner or parent of a pt
 Snoring
o Most people who snore do NOT have OSA
o Almost all people who have OSA snore
 Snorting, Gasping
 Breath holding
 Daytime sleepiness
o Dental significance
 Multidisciplinary management of OSA
 Dx jaw retrognathia
 Construction of mandibular advancement splints
o Mechanically protrudes the mandible which tightens the muscles of
the upper airway, ensuring that it is patent
o Made of acrylic and worn to hold md teeth forward to open airway
 Health advocating
o Weight reduction
o Smoking cessation
o Avoiding alcohol/drugs influencing sleep
 Increased risk of resp. arrest under GA/sedation

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

Have you ever had hepatitis or any other liver disease?

Liver functions include:

 Filters blood from the gut
 Extracts nutrients and removes toxins
 Metabolizes drugs
 Makes bile
 Makes clotting factors
  Makes glycogen for glucose storage
 Makes proteins

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

Do you currently have, or have been recently exposed to an infectious disease?

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?

Human Immunodeficiency Virus (HIV)

 Definition:
o Viral infection attacking the body’s immune system, namely the CD4 (T-helper) cells,
decreasing the body’s ability to combat simple infections
 Classification:
o HIV seropositive asymptomatic
o HIV-infected, asymptomatic
o AIDS
 Epidemiology:
o 26,000 Australians are HIV-positive
 Transmission:
o Sexual
o Blood to blood = sharing needles
 Risk from needle-stick injury from an infected pt. is 0.3 – 0.45%
o Mother to baby
 Management:
o Anti-retroviral drugs  associated with multiple SE and drug interactions
 Dental Significance
o Infection control
  Pt. are not legally obliged to disclose blood-borne status  we must treat all
blood/bodily fluids as infectious, hence the appropriate infection control and PPE
measure are taken at all times
 Potential for needle-sticks injury
 LA
 Oral surgery instruments
 Endodontic files
o Establishing CD4 and platelet count before performing invasive dental procedure
 Low CD4 count = increased risk of infection, prophylactic AB indicated for
dentoalveolar surgery + liaise with GP
 Low platelet count = Platelet count:
thrombocytopenia, consider platelet
Normal: 150-400 x 109/L
replacement therapy prior to
dentoalveolar surgery + liaise with GP Prolonged bleeding: 100 x 109 /L
o Oral manifestations: Minimal acceptable: 50 x 109 /L
 Candidiasis
REFER: < 50 x 109 /L
 Hairy Leucoplakia
 HIV gingivitis/periodontitis
 Characterized by linear gingival erythema
 NUG
 Kaposi’s Sarcoma
 Non-Hodgkin’s lymphoma
 Salivary gland enlargement
 Perioral paraesthesia (SE of anti-retroviral medication)
 Other viral infections: HSV, HPV

Acquired Immunodeficiency Virus (AIDs)

 Definition:
o Autoimmune syndrome characterized by a CD4 lymphocyte count < 200 cells / mm 3
o Final and most severe stage of HIV
 Aetiology
o HIV
 Management
o See “management” for HIV
 Dental Significance
o See “dental significance” for HIV
o AB-prophy for pt. with significant immunosuppression
 Neutrophil count < 500 μL
o Pt in advanced stages of disease should only receive emergency/preventative dental tx
 Elective tx not indicated
What to do in the case of Needle-stick Injury?

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 – If patient is HBV/HCV/HIV negative, then no follow up is required.

4. Possible treatment if patient is positive for:

a. HBV
 If not already immunized, practitioners should be vaccinated within 24 hours
 Hep B antibodies may be given within 24 hours if practitioner is pregnant or
immunocompromised
b. HCV
 RNA testing 4-6 weeks after exposure
 HCV antibody testing 4-6 months after exposure
 There is no effective passive or active immunoprophylaxis
c. HIV
 HIV antibody testing 6 weeks, 3 months, and 6 months after exposure
 If post-exposure prophylaxis is indicated, commence a 28-day course as soon as
possible with 2-3 anti-retrovirals
5. Counselling and follow up
 Should cover any need for special precautions to prevent secondary infection at work and in
the community

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

What to do in the case of a needle-stick injury at Bendigo Health

1. Immediately
 Wash skin using soap or alcohol-based cleaner
 No squeezing
 First aid measures to treat exposure site
2. Report to manager
 During office hours – contact the infection prevention and control unit
 After hours - contact the emergency department
3. Fill in yellow staff accident report/notice of injury form
4. Contact the infection prevention and control unit for results and follow up
Have you ever undergone neurosurgery (prior to 1982) or growth hormone treatment (prior to 1985)?

 Neurosurgery prior to 1982

o Surgeons used to graft the dura mater from human remains (high infectivity)
 Growth Hormone prior to 1985
o Surgeons used to extract hormones from pituitary glands (high infectivity)
 Dental implications:
o These individuals may be pre-disposed/carriers of CJD
o Use of disposable instruments
 Sterilisation process ineffective in removing prions

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

Adrenergic symptoms (mediated by the SNS) Neuroglycopenic symptoms (due to altered

brain function)
 Pallor  Hunger
 Sweating  Suboptimal intellectual function
 Shaking  Confusion and inappropriate behavior
 Palpations  Coma
 Feeling of anxiety  Seizures

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

Have you ever had any kidney problems?

Types of problems:
- Renal calculi (kidney stone)
o Stones get stuck any level of urinary tract – extremely painful.
o Calcium stones, uric acid stones, cystic stones, magnesium ammonium phosphate stones
- Glomerulonephritis
o Inflammation of the kidneys due to deposition of immune complexes (IgA) at the glomerular
basement membrane
o Decrease flow in glomerulus  water and sodium retention  increased in blood volume 
hypertension
o Tx = corticosteroids, immunosuppressants
- Acute Renal Failure
o Rapid loss of kidney function
 Pre-renal – hypotension hypovolaemia, shock
 Renal – GN, acute tubulonecrosis, interstitial nephritis, drugs, malignant hypertension
 Post renal – obstruction
o Tx – dialysis
- Chronic Renal failure / Chronic Kidney Disease (CKD)
o Progressive loss of renal function over months or years
 o Results from direct damage to nephrons or from progressive, chronic bilateral deterioration
of nephrons
o Leads to uremia and kidney failure and can lead to death
o Aetiology
 Conditions that destroy nephrons
 Diabetes mellitus
 Hypertension
 Glomerulonephritis
 Polycystic kidney disease
o Symptoms:
 Nausea and vomiting
 Anorexia
 Itch
 Lethargy
 Fluid retention
 Rarely – confusion, hiccups and twitching
o Tx – dialysis

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

Arthroplasty (Joint Replacement)

“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

Are you allergic to any tablets, medicines or latex?

 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

Management of Anaphylactic Attack

Management of Urticaria
 Cease dental tx
 Remove/cease
Cease dental txadministration of allergen
 Assess
Remove/cease
severity administration
of reaction of allergen
 Give oral
o antihistamine
Signs/symptoms present as mentioned ABOVE
o Usea less-sedating antihistamine
Pt history should reveal theduring
naturethe
of day
the response
 Call 000  E.g. Certirizine, desloratadine
o Pt
o If response is poor, add
needs emergency sedating antihistamine at night
admission

 Give IM adrenaline E.g. Cyproheptadine, promethazine
 Refer o
patients with extensive
0.01mg/kg urticaria,
up to 0.5mg or severe
(= 0.5ml urticaria
of 1:1000 involving
solution), eyelids and lips for urgent
for adults/child
medical attention
 Anterolateral thigh
 IF any evidence ofTongue
hypotension + anaphylaxis
o Call000FOM
o 300
o Givemicrograms
IM adrenaline
via pre-loaded auto-injector, for adult; child 10-20kg = 150mg)
 Anterolateral thigh
o Repeat every 3-5mins until response/assistance arrives
 Lay pt flat
 Give high-flow O2
 Be ready to commence CPR
 Record clinical notes including allergen, response and management of the response
Do you have any other medical or disability problems?

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

Chronic musculoskeletal disorders

 TMJ Pain
o Incidence: Women > men
o Cause:
 Unknown
 Osteoarthritis
 Rheumatoid
 Trauma
 Stress/anxiety  increased tension and bruxism can transfer into TMJ pain
 Poor posture
 Habitual chewing, biting, clenching
o Symptoms:
 Jaw pain and tenderness
 Headache
 Ache in and around ear
 Difficulty or painful chewing
 Clicking or grating sound
 Locking of joint
 Uncomfortable or uneven bite

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

Psychological and psychiatric disorders

 Anxiety Disorders
o Characterised by:
 The emotion of anxiety
 Worrisome thoughts
 Avoidance behaviour
 Somatic symptoms
o Types:
 Phobic
 Panic disorder
 Generalised anxiety disorder
o Clinical features:
  Tachycardia and chest tightness
 Dizziness and hyperventilation
 Diarrhea
 Dry mouth and bruxism
 Myofascial pain – clenching
 Aggression
 Difficulty swallowing
 Lack of concentration
 Reduced pain threshold – some procedures more painful than it actually is.
 Exaggerated response to stimuli
 Sleep loss
o Dental Implications:
 Patient may be aggressive, standoffish, unfriendly, sensitive
 Dry mouth – resultant of anxiety directly, and medication side effects
 Symptoms of hypoglycaemic attack (diabetic event usually tachycardia with paleness
and sweating)
 Tx:
 Communication (sympathise, reassure, explain)
 Sedation – BDZ (diazepam 5-10mg, 1 hour before procedure)
 Relaxation techniques (distraction)
 Drug-dependant/drug-seeking pt may present desiring certain drugs (BDZ)
 Be suspicious of pt who demands analgesics or those presenting good
knowledge about a specific analgesic
 Do not prescribe in the absence of demonstrable disease
 Refer to medical GP

 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?

See DEN3ICP PHARMACOLOGY Notes

Are you pregnant?

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:

Manifestation Pathophysiology Signs/symptoms Management

Pregnancy  Exaggerated  Begins at  OHI

gingivitis inflammatory response interdental/marginal  Debridement
Often initiates in to local irritants gingiva  Savacol (CH)
2nd month of   in oestrogen and  Fiery red and mouthwash if
pregnancy progesterone altering oedematous gingiva cannot brush
fibrinolysis and   Tender to palpation
NOTE: pregnancy capillary dilation  May entail a pyogenic
does not induce (gingival inflammation) granuloma/pregnancy
PPD, but may  Sub-par OHI due to tumour (see below)
modify/worsen morning sickness and
what is already feeling nausea whilst
present. brushing
 Commonly on  OHI
 Benign hyperplastic interdental papilla  Localised
Pyogenic growth in a localised  Localised debridement
granuloma area  Inflamed swelling  May excise if
 See ABOVE   Commonly at the end of doesn’t solve
1st trimester
 Mobility is a sign of  Pregnant pt complaining  OHI
gingival disease, of tooth mobility  Use of
disturbance in multivitamins,
attachment apparatus, NOTE: must assess if there is especially
and mineral changes in underlying reasons for tooth vitamin C
Tooth mobility the lamina dura mobility that are pathological.  Successful
 Vitamin deficiencies delivery of
contribute to this newborn
 Calcium is readily
mobilised from bone to
supply fetal demands
 Non-Carious  Rounding of sharp  Rinse after
irreversible tooth loss angles regurgitation
due to chemical  Dentine cupping or with a
dissolution by acids scooping neutralising
 Hypersensitive gag  Thinned enamel solution e.g.
reflex in combination  Restorations may baking soda,
with morning sickness appear above the tooth water
Dental erosion contributing to surface  pH neutralizing
regurgitation (causing MW such as
halitosis) sodium
bicarbonate
(Peter Mac
MW) or sugar-
free chewing
gum