DEPARTMENT OF PERIODONTICS

COMPREHENSIVE CASE
HISTORY
[Type the document subtitle]
O.P.NUM:
Unique registration number is given to each patient to maintain records

-to know the details of the patient & treatment done during his/her later visits.

NAME:
Used

- For Identification

- To Maintain Record

- For Communication

- Psychological Benefit &

- Rapport

AGE:
Certain diseases are more common at certain ages.

DISEASES PRESENT AT/SINCE BIRTH:

 Related to jaw
 Agnathia
 Facial hemihypertrophy
 Macrognathia
 Cleft palate
 Facial hemiatrophy
 Related to lip
 Double lip
 Cleft lip
 Commissural pits& fistulae
 Related to gingival
 Fibromatosis gingiva
 Congenital epilus of newborn
 Related to teeth
 Pre deciduous dentition
  Related to TMJ
 Aplasia or congenital hypoplasia of mandibular condyle

DISEASES COMMONLY SEEN IN INFANCY:

 Dental lamina cyst of the newborn

 Fibrous dysplasia of the jaw
 Infantile cortical hyperostosis of jaw
 Melanotic ameloblastoma
 Hemangioma
 Palatal cyst of the newborn

DISEASES COMMONLY SEEN IN CHILDREN & YOUNG ADULTS:

 Fissured tongue
 Beningn migratory glossitis
 Torus palatines
 Pulp polyp
 Osteoid osteoma of jaw
 Diseases commonly seen in adults & older patients:
 Attrition
 Abrasion
 Gingival recession
 Periodontitis
 Root resorption
SEX:
CERTAIN DISEASES ARE MORE COMMON IN CERTAIN SEX.

Common in females Common in males:

1. Iron deficiency anaemia Attrition

2. Diseases of thyroid carcinoma of buccal mucosa
3. Sjogrens syndrome Caries in deciduous teeth
4. Juvenile periodontiis Leukoplakia
5. Caries Perinicious anaemia

ADDRESS:
 For correspondence
 Geographical prevalence of dental/oral diseases.
 Periodontal diseases – more in rural areas.
 Dental caries – in modern industrialized areas

OCCUPATION:
 Some diseases are peculiar to certain occupations.
 Attrition – workers exposed to atmosphere of abrasive dust.
 Abrasion – carpenters,shoemakers,tailors.
 Gingival staining – persons working with lead,bismuth & cadmium.
 Erosion – sandblaster
 Hepatitis-B- dentists,surgeons,blood bank personnel.
 To know the financial status ,so that treatment can be varied.
CHIEF COMPLAINT:
o Should be recorded in patient’s own words.
o It is the reason for which the patient has come to the doctor.
o It should be given first priority.
o Should be recorded in chronological order.
o if few complaints start simultaneously , record them in the order of
frequency.
o Probable chief complaints may be

 Bleeding gums
 Staining of teeth
 Malodour
 Food impaction
 Mobility
 Pain
 Recession
 Swollen gums
 Burning of mouth

Questionarre for each of the chief complaint is as follows:

For bleeding gums:

1. when does the bleeding start?

A. Morning

B. Night

C. While brushing

2. Is it associated with pain?

3. Is it associated with bad breath?

4. Does it pain while bleeding?

5. When does it stop?

6. Do you have any bleeding disorders?

7. Do you have any deficient clotting factors?

8. Is it associated with menstrual cycle changes?

9. Is it associated with burning sensation?

10. Where do you notice the bleeding?

11. Did you notice any hormonal changes?

12. What type of brush do you use?

13. What brushing technique do you follow?

How do you brush? A. Horizontally

B. Vertically

C. Cirvacally

For gingival recession:

1. How does the recession or apical migration of gingival start?

2. Is it associated with pain/swelling/irritation/inflammation?

3. Is there any plaque/calculus formation?

4. How do you brush? Horizontal/Vertical/Circular

5. How many times do you brush?

6. What type of tooth brush do you use?

7. Is there any bad breath?

8. Is there any change in color in gingival?

9. Is it generalized/localized/front of the teeth/back of the teeth?

10. Is there any mobility?

11. Any abnormal frenal attachments?

12. Any trauma/malpositioning/crowding of teeth?

13. Any orthodontic appliance usage?

14. Any exposure of root surface?

For swollen gums:

1. How does the swelling start start?

2. When does it start?

3. Is it associated with pain / abscess?

4. Is it associated with discharge? Pus/blood

5. Is it covering the tooth crown

6. Does all/few teeth are involved

7. Is there any plaque/calculus formation

8. Since how many days the swelling is seen

9. Is it associated with bleeding?

10. Do you have ‘vit-c’ deficiency?

11. Are you on medication & since how many days?

12. What kind of drugs are you using?

13. Are you hypertensive? If yes on medication

14. Any allergic disorder

15. Any bleeding disease

16. Any color changes of gingival

17. Do you have epilepsy/seizures attack any time?

18. Are you diabetic? If yes-under what treatment is it controlled

19. Do you have habits of chewing pan & tobacco?

For mobility:
1.Onset & duration

2.Any gingival inflammation

3.Any accumulation of plaque / calculus

4.Any trauma from occlusion

5.Any periodontal therapy undertaken

6.Any parafunctional habits such as bruxism

7.Any periapical pathology

8.Any pathology of jaw like tumour,cyst etc…

9.Any traumatic injury to dentoalveolar unit

10.Tooth morphology

11.Overjet & overbite

12.Implant mobility

13.Age

14.Harmonal changes[menstrual cycle]

15.Oral contraceptives

16.Pregnancy

17.Any systemic diseases

18.Any bone loss

19.Which grade mobility

20.Single tooth mobility/ a segment

For malodour:
1.Any pseudohalitosis

2.How long have you been experiencing this problem?

3.Anyhalitophobia?

4.Any putrifaction in oral cavity?

5.Mouth breathing

6.Medication?

7.Ageing?

8.Poor dental hygiene?

9.Fasting/starvation?

10.Tobbaco?

11.Foods[onion/garlic]

12.Alcohol

13.Periodontal infections?

14.Tongue coating?

15.Stomatitis?

16.Xerostomia?

17.Any faulty restorations,retaining food & bacteria?

18.Unclean dentures?

19.Any oral pathological lesions like oral cancers/candidiasis?

20.Parotitis/cleft palate?

21.Apthous ulcers?

22.Dental abscess?

23.Nasal infections?sinusitis,rhinitis,tumors
24.Any diseases of GIT-hiatus,hernia,carcinomas,GERD etc…

25.Any pulmonary infections?bronchitis,pneumonia,tuberculosis

26.Any Harmonal changes?

For food impaction:

1.Uneven occlusal wear?

2.Loss of proximal contact?periodontal diseases?proximal caries?

3.Any congenital morphologic abnormalities of teeth?

4.Improperly constricted restorations?

5.Lateral food impaction?

6.Gingival inflammation with bleeding?

7.Foul taste?

8.Periodontitis/recession?

9.Urge to dig material from teeth?

10.Any pain that radiates to the jaw?

11.Periodontal abscess?

12.Any inflammatory involvement of PDL?

13.Any sensitivity to percussion?

14.Any destruction of alveolar bone/bone loss?

15.Root caries?

16.Pocket formation?

17.Tooth mobility?

18.Any injury to periodontium?

19.Irregular alingnment of teeth?

20.Spacing between the teeth?

21. Facially displaced teeth?

22.Deep bite & Open bite?

23.Tooth brush trauma?

For burning sensation of mouth:

1.Any contact allergy?

2.Any chronic mechanical trauma?

3.Any oral habits like clenching, grinding& chronic tongue thrust?

4.Any infections?

5.Xerostomia?

6.TMJ dysfunction?

7.Geographic tongue?

8.OSMF?

9.Oesophageal reflux?

10.Angioedema?

11.Acostic nevie neuroma?

12.Nutritional deficiency?-vit-Bcomplex

-folic acid,iron deficiency anaemia

13.Diabetes Mellitus?

14.Psychological disorders?

15.GIT Problems – chronic gastritis,chronic gastric hypoacidity

16.Hypothyroidism?

17.Mild pain with increased intensity throughout the day?

18.Altered taste sensation?

19.Any clinically detectable lesions?

20.Waxing & wanning pattern?

21.Any medication?

22.Estrogen deficiency?

HISTORY OF PRESENT ILLNESS:

Collecting information:

-History from the start of first symptoms to the time of examination

-Can be collected by asking

 When does the problem start?

 What do you notice first?any problems/symptoms related to this
 Did the symptoms get better/worse at any time?
 What had done to treat these symptoms?

Mode of onset – sudden/gradual

-in terms of time-hrs/days/weeks/months

Cause of onset

Duration – since how many days

Progress – intermittent,recurrent,constant,increased/decreased in severity

-aggravating & alleviating factors should be noted

Relapse & remission

Treatment – mode of treatment

Doctor consulted before Negative history

 HISTORY WITH PARTICULTAR REFERENCE

Pain Swelling Ulcer

 Anatomical location  Duration  mode of onset
where it is felt.  Mode of onset  pain
 Origin & mode of  Symptoms  discharge[serum,pus,blood]
onset.  Progress of  associated diseases
 Intensity of pain swelling
 Nature of pain-  Associated
burning,throbbing etc features
 Progression of pain  Impairment
 Duration of pain function
 Movement of  recurrence
pain[radiating,referred,
migrating]
 Localization behaviour
 Concomitant
neurological signs

Past dental history:

-to get the details of previous dental treatment.

-his/her reaction to dentist & the treatment.

By this we can get an idea of importance he gives to good dental treatment & in
persuing a goal of good oral health.
MEDICAL HISTORY:
To assess the patients health status and also it can facilitate for
better diagnosis for the oro facial complaint of the patient.

MEDICAL QUESTIONNAIRE:
1. Systemic problems: whether the patient was suffering from any medical
problems?

If yes ask for

- Duration

- Treatment

- Whether the treatment is beneficial or not

- Medication

- All the diseases suffered by patient pervious to present one

- Particular attention must be given to diseases like diabeties, asthma, bleeding

disorders, hypertension,myocardial infarction,hepatitis b , diptheria, rheumatoid
heart disease, TB & gonorrhea.

2. Chest pain: to know the cardialogical status of the patient

3. Allergy : - whether he has any allergy? Allergy may be due to drug or food

- Patient should be asked about asthma, eczema, utricaria, hayfever &

angioedema etc.

4. Previous hospitalization and indicate the purpose

5. Blood transfusion

6. Accident, operations & fractures should also be noted

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

By taking proper medical history following goals are achieved

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

Family history: very important for many hereditary diseases

Many diseases run in families like hemophilia, diabeties mellitus, hypertension &
heart diseases.

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

2. Oral hygiene and brushing techniques:

Bad oral hygine and improper brushing techniques may lead to dental caries
and periodontal disease, horizontal brushing technique may lead to
cervical abrassion of teeth.

Frequency:
o Note frequency of habit per day
o Frequency of brushing per day
o Length of time that patient the had the habit in years.
Extra oral examination:

 Temporo mandibular joint examination

 Measurement of range of movement
 Normal ranges - maximal mouth opening = 50mm
- Lateral excrusions = 9mm
- Protrusion= 7mm
 Auscultation of TMJ
 Using ‘bell’ of stethoscope or doppler instument
 Magnifies sounds far accurate evaluation
 TMJ palpation
 To evaluate whether condyles are moving symmetrically and detect
any pain, tenderness, clicking or crepitus.
- Pretragus palpation
bilaterally palpate preyragus region with index finger
while patient opens and closes mouth slowly.
- Intra auricular palpation
insert small finger into ear canal and press anteriorly
during movement
- Bimanual palpation/ load testing
patient in supine position with head cradled aginst the
dentists’ arm or abdomen. Place middle fingers under notch on
lower bopder of mandible and exert force upward and thumbs
on chin to exert force downwards.

 Masticatory muscle examination

 Digital palpation
 For trigger points and tenderness
 Masseter palpation
 Bimanual palpation with index fingers – one extraorally and the other
intraorally.
 Squeezing pressure applied intraorally.
 Lateral pterygoid palpation
 Place a finger on each maxillary tuberosity intraorally.
 Offer resistance to patients efforts to protrude the mandible.
 Medial pterygoid palpation
 Run a finger intraorally on the medial side of the mandible on the
floor of the mouth in an antero-posterior direction.
 LYMPH NODE PALPATION
 NODES TO BE EXAMINED:
- Pre auricular
- Post auricular
- Occipital
- Sub mental
- Sub mandibular
- Superficial cervical
- Posterior cervical
- Deep cervical
- Supra clavicular

GINGIVAL STAINS

 COLOUR
- Coral pink
- Bright red
- Magenta
- Pale pink
- Grayish white
- Bluish hue
- Purplish hue
- Black line
 CONTOUR
- Scalloped
- Rolled out
- Thickened
- Denuded
- Irregularly shaped
- Rounded
- Flat with blunt inter dental papillae
 CONSISTENCY
- Firm, resilient
- Soggy, puffy
- Pitting on pressure
- Edematous
- Soft, friable
- Sponge like
- Increase in size with associated inflammatory signs
- Increase in size without any associated inflammatory signs
 TEXTURE
- Stippling/ orange peel appearance
- Loss of stippling
- Shiny
- Smooth
- Peeling
- Leathery
 PERIODONTAL STATUS

THE PERIODONTAL POCKET

DEFINITION: The periodontal pocket is defined as a pathologically deepened

gingival sulcus.

CLASSIFICATION:

1. Gingival Pocket(pseudo pocket):

This type of pocket is formed by gingival enlargement without destruction of underlying periodontal
status.

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

ACCORDING TO INVOLVED TOOTH SURFACES:

I. SIMPLE POCKET

II. COMPOUND POCKET

III. COMPLEX POCKET.

CLINICAL FEATURES:
 Bluish red,thickened marginal gingiva,flaccidity,smooth shiny surface.

 Bluish red vertical zone from the gingival margin to alveolar mucosa.

 Tooth mobility

 Diastema formation

 Symptoms such as localized pain

 Or pain deep in the bone

 Bleeding on probing

 When explored with a probe,inner aspect of periodontal pocket is generally painful

 Pus is expressed on digital pressure application.

TYPES OF POCKETS:
1) SUPRA BONY (Supracrestal or supra alveolar)-in which the bottom of the pocket is coronal to
the underlying alveolar bone.

2) INFRA BONY (Intabony,subcrestal or intra alveolar)-in which bottom of the pocket is apical to
the level of the adjacent alveolar bone.
PATHOLOGICAL TOOTH MIGRATION:

DEFINITION: Pathologic migration refers to tooth displacement that results when the
balance among the factors that maintain physiologic tooth position is disturbed by
periodontal disease.
 Mostly in anterior region

 Can occur in any direction

 Accompanied by mobility and rotation usually

PATHOGENESIS:
1) Weakened periodontal support

2) Changes in the forces exerted on the teeth.

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

Greatest on arising in the morning.

ETIOLOGY:
 Loss of tooth support

 Trauma from occlusion

 Extension of inflammation from gingiva or from the periapex into PDL

 Periodontal surgery

 Pregnancy,use of contraceptives.

 Pathologic processes of jaws that destroy alveolar bone and/or roots of teeth.

GRADING SYSTEM:
NORMAL MOBILITY
Grade1 : Slightly more than normal

Grade2 : Moderately more than normal

Grade3 : Severe mobility,combined with vertical displacement.

FURCATION

Presence of furcation involvement is one clinical finding that can lead to a

diagnosis of advanced periodontits and less favourable prognosis

ETIOLOGY:
 Bacterial plaque-primary factor.

 Local factors-rate of plaque deposition,oral hygiene,allachment loss etc.

DIAGNOSIS: Careful probing to determine presence and extent of furcation

involvement.Trans gingival sounding.

CLASSIFICATION:
 Grade1 : Incipient or early stage.pocket is suprabony or primarily affects soft tissues.radiographic
changes not present.

 Grade2 : Can effect one or more furcations of same tooth.’’cul-de-sac‘’ with definite horizontal
component.R/E-may or may not depict.

 Grade3 : Bone is not attached to the dome of furcation.may be filled with soft tissue.R/E-
radiolucent area in the crotch of the tooth.

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

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

May be localized or generalized.

ETIOLOGY:
 Increase in age

 Faulty tooth brushing technique

 Tooth malposition

 Friction from soft tissues

 Gingival inflammation

 Abnormal frenal attachment

 Smoking

MILLERS CLASSIFICATION

CLASS 1 : Marginal tissue recession that doesn’t extend upto mucogingival junction

CLASS 2 : Marginal tissue recession to or beyond mucogingival junction

CLASS 3 : Marginal tissue recession to or beyond mucogingival junction bone and soft tissue loss
interdentally or malpositioning tooth

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

ATTACHMENT LOSS:
 Increased probing depth and loss of clinical attachment are specific for periodontitis

 Conventional probing-1mm;range 12mm

 Seen in-aggresive periodontitis,chronic periodontitis,refractory periodontitis.

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

 Intra oral periapical radiographs

 Bite wing
 Occlusal

INDICATIONS FOR IOPA

- To visualize periapical region

- In diagnosis of periapical pathology
- To study crown & root length
- To study integrity of lamina dura
- Post surgical evaluation of socket

INDICATIONS FOR BITE-WING RADIOGRAPHS

- To know extent of interproximal caries

- To study height of alveolar bone or assessment of bone mass
- To study occlusion of teeth

OCCLUSAL RADIOGRAPHS

- Covers a larger area than periapical films

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

BLOOD PRESSURE:

 NORMAL < 120/80

 PRE-HYPERTENSION – (120 - 139)/(80-89)
 STAGE 1 HYPERTENSION – (140-159)/(90-99)
 STAGE 2 HYPERTENSION >= 160/100
If normal, pre-hypertensive, stage 1 hypertensive patient continue
dental treatment.
If stage 2 hypertension do not perform any treatment until it’s an
emergency case.
Otherwise go for anti-hypertensive therapy.

DIABETES:

- NORMAL BLOOD SUGAR LEVELS

 FBG – 70-100 MG/DL
 PPBG < 140 MG/DL
 RBS < 160 MG/DL
- GLUCOSE TOLERANCE TEST
 FBS > 100 MG/DL
 1 HR > 160 MG/DL
 2 HRS > 120 MG/DL
THESE GLUCOSE LEVELS WILL CONFIRM DIABETES

- GLYCOSYLATED HAEMOGLOBIN ASSAY (HBA1C)

 4 - 6% NORMAL
 < 7% GOOD DIABETES CONTROL
 7 - 8% MODERATE
 > 8% ACTION SUGGESTED TO IMPROVE DIABETES
CONTROL
RENAL DISEASES:

- Blood urea nitrogen < 60 mg/dl – do not treat

- Serum creatinine < 1.5 mg/dl – do not treat

HAEMORRHAGIC DISEASES:

-COMPLETE BLOOD PICTURE

-NORMAL VALUES:
-BLEEDING TIME – 3-5 MIN.
-PROTHROMBIN TIME – 12-14 SEC
-PARTIAL THROMBOPLASTIN TIME – 20-40 SEC
-HAEMOGLOBIN, HB % :
 MEN – 13-16 GM/DL
 WOMEN – 11-14 GM/DL
- ESR VALUES
 MEN – 0-10 MM 1ST HR WESTERGREN
 WOMEN – 0-20 MM 1ST HR WESTERGREN
- INR LEVELS
 INR < 3 SCALING AND ROOT PLANING CAN BE DONE
SAFELY
 INR < (2-2.25) MINOR SIMPLE EXTRACTIONS CAN BE DONE
- If increased ptt, normal pt,bt- haemophilia
- If low platelet count, prolonged clot retraction time, bt, or slight increase ct-
thrombocytopenic purpura
- If increased wbc count- leukemia
- If decreased hb % - anemia
HEPATITIS:
- HBSAG AND ANTI HBS ANTIBODY TESTS
 if negative but hbv is suspected, order another hbs determination
 if positive patients are probably infective
 if anti hbs positive, may be treated routinely
 if hbsag negative, may be treated routinely
- Bilrubbin levels, urobilinogen levels, sgot/sgpt levels, serum alkaline
phosphatase levels can also be considered.

PERIODONTAL STATUS
THE PERIODONTAL POCKET

DEFINITION: The periodontal pocket is defined as a pathologically deepened

gingival sulcus.

CLASSIFICATION:

3. Gingival Pocket (Pseudo Pocket):

This type of pocket is formed by gingival enlargement without destruction of underlying periodontal
status.

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

ACCORDING TO INVOLVED TOOTH SURFACES:

IV. SIMPLE POCKET

V. COMPOUND POCKET

VI. COMPLEX POCKET.

CLINICAL FEATURES:
 Bluish red,thickened marginal gingiva,flaccidity,smooth shiny surface.

 Bluish red vertical zone from the gingival margin to alveolar mucosa.

 Tooth mobility

 Diastema formation

 Symptoms such as localized pain

 Or pain deep in the bone

 Bleeding on probing

 When explored with a probe,inner aspect of periodontal pocket is generally painful

 Pus is expressed on digital pressure application.

TYPES OF POCKETS:
3) SUPRA BONY(supracrestal or supra alveolar)-in which the bottom of the pocket is coronal to the
underlying alveolar bone.

4) INFRA BONY(intabony,subcrestal or intra alveolar)-in which bottom of the pocket is apical to

the level of the adjacent alveolar bone.
PATHOLOGICAL TOOTH MIGRATION:

DEFINITION: Pathologic migration refers to tooth displacement that results when the
balance among the factors that maintain physiologic tooth position is disturbed by
periodontal disease.
 Mostly in anterior region

 Can occur in any direction

 Accompanied by mobility and rotation usually

PATHOGENESIS:
3) Weakened periodontal support

4) Changes in the forces exerted on the teeth.

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

Greatest on arising in the morning.

ETIOLOGY:
 Loss of tooth support

 Trauma from occlusion

 Extension of inflammation from gingiva or from the periapex into PDL

 Periodontal surgery

 Pregnancy,use of contraceptives.

 Pathologic processes of jaws that destroy alveolar bone and/or roots of teeth.
GRADING SYSTEM:

NORMAL MOBILITY
GRADE 1:slightly more than normal

GRADE2:moderately more than normal

GRADE3:severe mobility,combined with vertical displacement.

FURCATION: Presence of furcation involvement is one clinical finding that can

lead to a diagnosis of advanced periodontits and less favourable prognosis

ETIOLOGY:
 Bacterial plaque-primary factor.

 Local factors-rate of plaque deposition,oral hygiene,allachment loss etc.

DIAGNOSIS: Careful probing to determine presence and extent of furcation

involvement.Trans gingival sounding.

CLASSIFICATION:
 GRADE 1:incipient or early stage.pocket is suprabony or primarily affects soft
tissues.radiographic changes not present.

 GRADE 2:can effect one or more furcations of same tooth.’’cul-de-sac‘’ with definite horizontal
component.R/E-may or may not depict.

 GRADE 3:bone is not attached to the dome of furcation.may be filled with soft tissue.R/E-
radiolucent area in the crotch of the tooth.

 GRADE 4:interdental bone is destroyed and the soft tissue have receeded apically so that
furcation opening is clinically visible.

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

May be localized or generalized.

ETIOLOGY:
 Increase in age

 Faulty tooth brushing technique

  Tooth malposition

 Friction from soft tissues

 Gingival inflammation

 Abnormal frenal attachment

 Smoking

ATTACHMENT LOSS:
 Increased probing depth and loss of clinical attachment are specific for periodontitis

 Conventional probing-1mm;range 12mm

 Seen in-aggresive periodontitis,chronic periodontitis,refractory periodontitis.

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

GINGIVITIS:

2 SIGNS

1. Incresed crevicular fluid

2. Bleeding on probing.

TREATMENT PLAN:

1. Non surgical[phase I therapy]

1.Limited plaque control instructions

2.Removal of calculus and root planning

3.Correction of restorative and prosthetic irritational factors

4.Excavation of caries and restoration

5.Anti microbial therapy[local or systemic]

6.Occlusal therapy

7. Minor orthodontic therapy

 Maintenance therapy

[Evaluation of response to non surgical phase

Rechecking: gingival inflammation,plaque, calculus and caries]

Surgical phase [if present]

Maintanance therapy

Restorative phase [phase III]

1.Final restoration

2.Fixed and removable prosthodontic appliances

Maintanance therapy[periodic rechecking]

Gingival condition,plaque,calculus

IN FEMALE PATIENTS:

In puberty: Milder gingivitis- scaling, root planning and oral hygiene instructions

Severe gingivitis-anti microbial mouth wash,antibiotic therapy

Menstrual cycle: Anti microbial oral rinses before cyclic inflammation

Pregnancy: Scaling and root planning if necessary

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

WHEN TREATING HYPERTENSIVE PATIENTS:

The clinician should not use a LA containing an epinephrine concentration >1:1,00,000 nor
should a vasopressor be used to control a local bleeding.

LA without epinephrine used for shorter procedures.

IN HEMORRAGIC DISORDERS:

In thrombocytopenic purpura: Scaling & root planning

No surgical procedures unless platelet count is atleast 80,000 cells/mm3.

In leukaemic patients: Scaling & root planning

Through oral hygiene instructions & 0.12% chlorhexidine mouth wash twice daily.

IN INFECTIVE ENDOCARRDITIS PT’S WITH SIGNIFICANT GINGIVAL INFLAMMATION:

Oral hygiene should initially be limited to gentle procedure i.e. oral rinses & tooth brushing with a soft
brush.

Oral irrigators are not recommended because their use may induce bacteremia.

ACUTE NECROTISING ULCERATIVE GINGIVITIS:

1ST VISIT:

Reduce microbial load & remove necrotic tissue

Subgingival scaling & curettage – contraindicated because they extend infection to deeper tissues

Surgical procedures:

Tooth extraction/periodontal therapy is postponed until 4weeks after acute signs & symptoms of NUG
subsided.

Pt instructions:

Avoid tobacco, alcohol.

Rinse with 3% H2O2 & warm water every 2 hrs or with 0.12% chlorhexidine

An analgesics given[NSAID’s]
2ND VISIT:

1 or 2 days after 1st visit

Evaluate the pt

Scaling is performed if necessary

3RD VISIT:

Evaluate the patient

Instruct plaque control procedures

H2O2 mouth wash discontinue use chlorhexidine mouth wash

Scaling and root planning

Additional treatment:

Contouring of gingival

Systemic anti biotics and topical anti microbials

Nutritional supplements.

GINGIVAL ENLARGEMENT:

1.Inflammatory gingival enlargement

2.Drug induced

3.Gingival enlargement in pregnancy

4.Gingival enlargement in puberty

5.Leukemic gingival enlargement

 Patient taking drug known to cause gingival enlargement

[anti convulsants,ca channel blockers,immuno suppressants]

Gingival enlargement not present Gingival enlargement present

Oral hygiene reinforcement oral hygiene reinforcement

Professional recalls chlorhexidine gluconate rinses

Scaling and root planning

Possible drug substitution

Professional recalls

Gingival enlargement regresses revaluation

Maintain good oral hygiene Enlargement persists

Maintain professional recalls

 Periodontal surgery indicated

Small areas of enlargement large areas of enlargement

Absence of osseous defects Presence of osseous defects

Leukemic gingival enlargement

Only gingival enlargement gingival enlagement with

superimposed ANUG

oral hygiene reinforcement 1 st treated ANUG then proceed

with gingival enlargement

If regress maintain good oral hygiene if persists after acute symptoms

of ANUG subsided
 Enlargement treated by scaling and root planning

Chlorhexidine mouth wash

Oral hygiene reinforcement,recall

If persists periodontal surgery done

Enlargement of 6 teeth enlargement >6 teeth

No osseous defects osseous defects

Gingivectomy flap surgery

GINGIVAL ENLARGEMENT IN PREGNANCY

Treatment requires elimination of all local irritants responsible for the gingival changes

Marginal and interdental gingival enlargement Tumor like gingival

enlargement

Scaling and curettage, oral hygiene instructions surgical excision, scaling

and root planning, oral hygieneinstructions

ENLARGEMENT IN PUBERTY:

Treated by –scaling and root planning, removal of irritation, plaque control, chlorhexidine rinse

In severe cases- surgical removal

CHRONIC INFLAMMATORY GINGIVAL ENLRGEMENT:

Enlargement whuch is soft and discolored more fibrotic

Scalingand root planning shrinkage does not occur after

Oral hygiene, chlorhexidine scaling and root planning

 Surgery indicated

Gingivectomy flap surgery

DESQUAMATIVE GINGIVITIS:

It is a condition charectarized by the intense erythema, desquamation, ulceration of the free and attached
gingival

It was not a specific entity but a gingival response associated with variety of conditions

TREATMENT OF LICHEN PLANUS:

LICHEN PLANUS

ASYMPTOMATIC SYMPTOMATIC

No therapy erosive or ulcerative Rule out superimposed candidisis if +ve use

anti fungal drugs

Periodic exam Topical steroids

Intra lesional steroids for Large chronic ulcers

Resolution No Resolution
 Wean off and moniter Refer to dermatologist

[retinoids,dapsone,cyclosporines, photopheresis ]

TREATMENT OF CICATRICIAL PENPHIGOID:

CICATRICIAL PEMPHIGOID

Asymptomatic mild to moderate severe

Plaque control Topical steroids Refer to dermatologist

Prednisolone Dapsone

No Resolution

[dapsone,methotrexate,cyclosporins, cytophosphamide,azathioprine]

DIAGNOSIS OF PEMPHIGUS VULGARIS

REFER TO DERMOTOLIST

Primary treatment Secondary treatment

Prednisolone [azathioprine,cyclophaspamide,cyclosporines]
1 PERIODONTAL POCKET
TYPES

1. Gingival pocket

2. Periodontal pocket

Another type of classification of pocket are

1. Suprabony pocket

2. Infra bony pocket

TREATMENT PLAN

GINGIVAL POCKET (PSEUDO POCKET) PERIODONTAL POCKET

Treatment Plan

Phase – I Therapy Phase – I Therapy

Scaling and root planing Scaling and root planing

Phase – 4 Therapy Phase – 4 Therapy

Maintenance phases Maintenance phases

SUPRABONY POCKETS INTRABONYPOCKETS

PHASE 1 THERAPY

PHASE 1 THERAPY
 SCALING AND ROOT

CURETTAGE

PHASE 4 OR MAINTENANCE PHASE

Pocket depth can be reduced or eliminated by periodontal flap surgery

2. PERIODONTAL ABSCESS OR LATERAL ABSCESS OR PARIETAL

ABSCESS

TREATMENT PLAN

EMERGENCY PHASE OR PRELIMINARY PHASE

ACUTE ABSCESS: Before treating a patient with periodontal abscess ,medical

history ,dental history, systemic conditions are noted

Needs for systemic antibiotics in cases

Such as;

1. Fever

2. Cellulitis

3. Deep inaccessible pocket

4. Regional lymphadenopathy

5. Immune compromised patient

ANTIOBIOTIC OPTIONS

1.AMOXILLIN -500mg 3 times daily for 3 days

Re-evaluated after 3 days to determine need for continued or adjusted

antibiotic therapy

2. In cases of pencillin allergy

CLINDAMYCIN is given

300mg 4times daily for 3 days

AZITHROMYCIN OR CLARITHROMYCIN

500mg 4 times daily for 3 days

TRAETMENT OPTIONS

1. Drainage through periodontal pocket retraction or through external

incision
2. Maintenance phase i.e frequent mouth rinsing with warm water or
periodic application of chlorohexidine gluconate either by rinsing or
locally with a cotton tipped applicator
3. In cases of patients who require antibiotics regimen signs and
symptoms usually subsided if not patient is asked to continue
regimen for 24 hrs

CHRONIC ABSCESS

PHASE 1 THERAPY PHASE 2 THERAPY

SCALING AND ROOT PLANNING SURGICAL PHASE

INDICATED IN WHEN DEEEP VERTICAL OR FURCATION DEFECTS ARE
PRESENT

In these cases same antibiotic treatment as acute abscess are given

PERIODONTAL CYST

Antibiotic prophylaxis

Phase 2 or surgical phase

Maintenance phase or phase 4

CHRONIC PERIODONTITIS

Localized periodontitis Generalized periodontitis

When less than 30% of sites when more than 30% of sites attachment

exhibit attachment loss and bone loss and bone loss

TREATMENT PLAN

PHASE 1 THERAPY OR NON SURGICAL PHASE

Scaling and root planning Phase 4 maintenance phase

 AGGRESSIVE PERIODONTITIS

LOCALIZED GENERALIZED RAPIDLY PROGRESSIVE

TREATMENT PLAN

NONSURGICAL SURGICAL ANTIMICROBIAL THERAPY

IT INCLUDES

Pt Education Resective & Regenerative Phase 1 therapy

To eliminate or reduce pockets Scaling and Root planning

And vertical bone defects Regular recall

Depths with multiple osseus walls P hase 4

not done in horizontal bone loss Early diagnosis cases shows better results

Moderate to severe cases poor prognosis

Antimicrobial therapy
 The use of systemic antibiotics was thought to be necessary to eliminate
pathogenic bacteria from tissues
 Several authors have reported success untreating aggressive
periodontitis with systemic antibiotics as adjuncts to standard therapy
Mostly commonly used antimicrobial are

1. TETRACYLCINES-250mg 4 times daily for 1 week it should be given in

conjunction with local mechanical therapy

2. If surgery is indicated ,systemic Tetracyclines should be prescribed and pt

should be instructed to begin taking appproximating 1 hr before surgery

3. DOXYCYCLINE 100mg/day may be used

4. CHLOROHEXIDINE rinses should be used and continued for several weeks

5. MICROBIAL TESTING is done

-specific periodontal pathogens responsible should be identified and appropriate

antibiotics should be given.

ASSOCIATED MICROFLORA ANTIBIOTIC FOR CHOICE

Gram positive organisms Amoxicillin –clavulanate potassium

(augmentin)

Gram negative organisms clindamycin

Nonoral gram negative facultative rods ciprofloxacin

Black pigmented bacteria and metronidazole

spirochetes
Provetella intermedia,porphyromonas
gingivalis
Actinobacillus actinomycetemcomitans
tetracyclines
Metronidazole –amoxicillin
,metronidazole –ciprofloxacin

Porphyrmonas gingivalis azithromycin

 LOCAL DRUG DELIVERY AGENTS –SOLUTIONS.GELS,
FIBERS AND CHIPS
After all the phases completed

Restorative phase and maintenance phase

NECROTISING ULCERTATIVE PERODONTITIS

Associated with systemic diseases Not associated with systemic Such

as HIV diseases

Any hematological diseases Phase 1 therapy

Like leukaemia local debridement with scaling and root planning

Evaluate and treatment of any systemic disease

Phase 1 therapy is followed that is local phase 4or maintenance

therapy

Debridement of lesions with scaling and root planning

Lavage and

Phase 4 therapy or maintenance therapy

Proper oral hygiene instructions

CARDIO VASCULAR DISEASES

ISCHAEMIC HEART DISEASES

ANGINA,

MYOCARDIAL INFARCTION

ANGINA

UNSTABLE STABLE treated acute anginal

attack with nitroglycerin and long

acting forms are used

treated only can undergo EDP restriction of LA containing epinephrin

in emergency stress reduction intraosseous inj of LA should be done

consiously

consult physicain profound LA is vital angina attacks during perio produres

conscious sedation discontinue treatment

supplementation of O2 by cannula Administer 1tab of nitroglycerin

sublingually

Loosening of garments

Administer pt in relaxed position

Signs and symptoms cease in 3 min

 resolving doesn’t resolve

continue treatment second dose of nitroglycerin

monitor

3 doses of nitroglycerin 3 min after

2nd dose

If chest pain persists

Pt is transported to emergency facility

MYOCARDIAL INFARCTION

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

After 6 months using same technique as stable angina pt

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

Consult physician

Prophylactic antibiotics are given

CONGESTIVE HEART FAILURE

Poorly treated Treated CHF

Elective dental procedures Consult physician

To known severity and underlying

etiology are is known

Medication given accordingly

 HYPERTENSION

As long as stress is minimized dental tt is safe

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

Consult physician

Untreated Treated

Systolic BP>180mm

Diastolic BP >110mm

Tt should be limited to Local anaesthetic containing epinephrine

EMERGENCY until it is conc. greater than 1;100,000 or

Vasopressor

Controlled and no routine to be used to control local bleeding

Perio TT should be given

Analgesics- for pain LA without epinephrine may be used for

Antibiotics –for infusion short period of time(<30min)

Acute infection-surgical or small doses should be used

Drainage incision
Surgical field is limited if
Blood is seen it may rise the BP
INFECTIVE ENDOCARDITIS
Prophylaxis recommended
High risk patients
1. Previous history of I.E
2. Prosthetic heart valves
3. Major congenital heart disease
a. Tetralogy of fallot
Single ventricular state
surgery.
b. Transposition of greater artery
c. Surgery constructed sys.pul.shunts
Intraligamentary injection is generally
Contraindicated because hemodynamic
Changes are similar to intravascular
Injection
Anxiety
Postural hypertension is reduced by
positional changes in chair
Prophylaxis not
recommended
moderate risk patients
1.Acq. vavlular dysfunction
2.congenital heart malformation 1.mitral valve prolapse
3.hypertrophic cardiomyopathy valvular regurgitation
4.mitral valve prolapsed 2.coronary artery
bypass graft
3. Physiologic, functional
or innocent murmurs
4.Rheumatic fever
vavular dysfunction
 5. Surgically ASD,VSD
or PPD
6.kawasaki disease
without vavular
dysfunction

PREVENTIVE MEASURES:

Define susceptible patient- medical history

Provide oral hygiene instructions Recommrnded-Oral rinsus & gentle

tooth brushing
(to minimize bacteremia &
Not recommended- Oral
Improve gingival health)
irrigators(may induce bacteremia)

ORAL- Amox-2gm 1hr before procedure(if allergic).

Antibiotic Regimen
Clindamycin-600mg 1hr before procedure.

Or

Azithromycin or Clarithromycin-500mg 1hr before

procedure.

Or

Cetadroxil-2gm 1hr before procedure.

UNABLE TO TAKE ORAL MEDICINE

Ampicillin-2gm IM or IV before 30 min of procedure.

UNABLE TO TAKE ORAL MED. & ALLERGIC TO

PENCILLIN- Clindamycin-6oomg IV before 30min.

Or

Cefazolin-1gm IM or IV before 30min.

EARLY ONSET PERIODONTITIS + RISK OF

PERIODONTAL TREATMENT
PERIODONTITIS+ RESISTANT TO PENCILLINS

-Tetracycline-250mg 4 times for

14days.
 -Periodontitis: Severe-teeth extracted

Less-teeth treated, retained to maintained

-Chlorhexidine rinses

-Restorative sutures & chromic gut

-Antibiotics- used during 1st week of healing

If used dosage not sufficient to prevent IE

& therefore prophylactic antibiotic dosage is

Needed.

CONGESTIVE HEART FAILURE

Automatic cardioverter

Medications defibrillators

 Digioxin
 Diuretics pacemakers implanted subcutaneously near
 quidine

implanted in chest walls umbilicus

enter heart transversely have electrodes passing into the heart

Older pacemak Newer unit bipolar Activate without unipolar

warning when certain

not affected by arrhythmias occur
disrupted by dental dental equipment cause sudden pt movt
equipment that generated

EM fields

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

6 months therapy with conc. 1:1,00,000

short appointments epinephrine contraindicated

LA given

Light conscious sedation given

(inhibition oral or parentral)

Oxygen supplements given – through cerebral oxygenation

Stroke pt`S O. oral coagulants

Blood pressure carefully monitored

DIABETES MELLITUS

Normal plasma glucose level is >200mg/dl

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

HbA1 HbA1c

 HbA1c is most often used

 It reflects blood glucose concentrations over preceding 6-8 weeks
 It may provide an indication of the potential response to periodontal therapy

Treatment plan

Undiagnosed diagnosed

Consult physician well controlled poor controlled

Analyze laboratory tests good response poor response

 Rule out acute orofacial

Infection or severe dental infection

If present emergency care nonsurgical debridement

Of plaque and calculus

Oral hygiene instruction

If HbA1c is less than 10%

surgical treatment can be done

systemic antibiotics not needed routinely

tetracyclines with scaling and root planning is effective

if patient has poor glycemic control

surgery is absolutely is needed

pencillins are most often indicated

Frequent reevaluation Before any periodontal therapy pt should be asked to

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

THYROID AND PARATHYROID DISORDERS

THYROID

Thyrotoxicosis hyperthyroidism hypothyroidism

Inadequate Determine level of Careful administration of

Medical management. medical management sedatives and narcotics

No periodontal therapy should limit stress and

infection

PARATHYROID

Medical history

Routine periodontal treatment

 ADRENAL INSUFFICIENCY

Pt taking large doses greater than pt taking small doses for short periods

20mg corticosteroid per day

No supplementation

Requiring stressful periodontal

Procedures, doubling or tripling

the normal dose 1 hr before

ACUTE ADRENAL INSUFFICIENCY CRISIS

Terminate periodontal treatment

Summon medical assistance

Give oxygen

Monitor vital signs

Place pt in supine position

Administer 100mg of hydro corticosine sodium succinate

 Intravenously over 30 sec inter muscular
TREATMENT OF PATIENTS WITH LIVER DISEASES

Treatment recommendations for periodontal problems:

1. Consultation with physician concerning -

i. Stage of disease.
ii. Risk of bleeding.
iii. Potential drugs to. be prescribed
iv. Required alteration to periodontal treatment.
2. Screening for hepatitis B & C.
3. Prothombin time & partial thromboplastin T.

Treatment of patients with pulmonary diseases:

1. Identify & refer patients with signs &symptoms of pulmonary disease to

their physicians.
2. Patients with known pulmonary disease -
a. Consult physician regarding medications.
b. Degree & severity of pulmonary disease.
c. Avoid elicitation of respiratory depression.
i. Minimize stress in periodontal appointment.
ii. Avoid medications that cause respiratory depression (narcotics,
sedatives, GA)
3. Avoid bilateral mandibular block anaesthesia, which could cause increased
airway obstruction.
4. Position of patient to allow maximal ventilatory efficiency.
5. Avoid excessive periodontal packing, keep the patients throat clear.
6. In patients with history of asthma make sure patients medication (inhaler) is
available.
7. In patients with active fungal or bacterial respiratory diseases should not be
treated unless it is emergency.
IMMUNO SUPRESSIVE PATIENTS:

Organ transplantation

Chemo therapy
Drug administration : Immuno suppression

Chemo therapy : Cyto toxic to bone marrow

Destruction of formed elements of blood

Thrombocytopenia, leucopenia, anemia.

Hence greater risk of infection,dissemination of oral infections.

Treatment: Prevention of oral complications that could be life threatening

Conservative and palliative

Reduce the microbial load

Treatment plan: 1. Extract teeth having poor prognosis

2. Thorough debridement of remaining teeth

3. Antimicrobial rinses esp. in patients with chemotherapy

induced mucositis to prevent secondary infection.

RADIATION THERAPY:
During radiation pt.s should receive weekly prophylaxis, oral hygiene
instructions, professionally applied fluoride treatment,

.dentrifice- 0.4% stannous and 1% sodium fluoride

Pre radiation treatment:

1. examination of non restorable and severly periodontally diseased teeth 2

weeks prior
2.. primary closure of extractions

3.alveolectomy

4.flap surgeries

5. panaromic , intraoral radiograph

6.clinical dental and periodontal evaluaton

Post radiaton follow up:

1.viscous lidocaine may be prescribed for painful mucositis

2.salivary substitutes for xerostomia

3.daily topical fluoride application and oral hygiene indicated to prevent

radiation caries.
HAEMORRAGIC DISORDERS:

Patient bleeding

Notice the duration of bleeding

If BT is 3-4 min(normal) if BT > 5min( abnormal)

Normal bleeding spontaneous bleeding

Go for laboratory tests look for petechia and

BT,CT,PT,PTT,INR haemorrhagic vesicles

Tourniquet test

Go for lab tests

Low platelet count ,prolonged clot

Retraction time,BT, or slight

Increase in CT(Thrombocytopenic purpura)

IN LABORATORY TESTS:

IF there is increase in PTT, normal PT,BT IT indicates HAEMOPHILIA A

Treatment:

1. Physician consultation

2. Factor viii concentrate

3. Fresh frozen plasma

4. EACA

5. Trans escamic acid

If there is increase in PTT, normal PT,BT- HAEMOPHILIA B

Treatment:

1. Factor ix concentrate
2. Fresh frozen plasma
3. Purified prothrombin complex concentrate
4. Surgical 30 to 50% of factor viii is needed

If increase in BT,PTT,variable factor viii deficiency ,normal PT, platelet count.

It indicates von willebrand disease

Treated by factor viii concentrate and DDAVP.

In thrombocytopenic purpura:

No surgical procedure unless platelet count s atleast 80,000cells/mm3

Prophylactic treatment of potential abscesses

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

Known leukaemic patient un known patient

Chemo therapy radiation corticosteroids refer to physician

Before chemo therapy a complete periodontal treatment tests for

Plan should be done

Monitor -bleeding time,clotting time :

Prothrombin time,platelet count

Administer antibiotic coverage

Periodontal debridement[scaling and root planning] should be done if INR < 3

Thorough oral hygiene instructions given

Twice daily rinse with 0.12% chlorohexidine mouth wash

Minor simple extractions done if INR < 2-2.5

Multiple extractions if INR< 1.5 -2

Thus extract all hopeless teeth at least before 10 days

 DURING

Acute phase of leukemia Chronic phase

-Patient should receive only emergency - scaling and root

planning

Periodontal care performed without

-Antibiotic therapy with surgical\ non surgical complication

Debridement

-oral ulcerations and mucositis treated with - if possible periodontal

Viscous lidocaine surgery indicated.

- oral candidiasis treated by

Nystatin suspension[100,000/ml 4 times daily]

Or clotrimazole

Vaginal suppositories[10mg 4/5times daily

UN KNOWN PATIENT – Refer physician

Tests for leukemia

1.Blood picture:

Anemia severe moderate

Platelets increased normal

WBC increased increased

2. bone marrow examination:

Cellularity hyper cellular hypercellular

blastic cells . myloid

.lymphatic cells

increase serum lysozome serum B12 erythrosyte rosttetest

vit. B12

acute leukemia chronic myeloid

lymphatic

chronic leukamia
AGRANULOCYTOSIS[cyclic neutropenia and granulocytosis

Pt. with agranulocytosis unknown patient

Drug induced due to other causes refer to physician

Eliminate those drugs if WBC count <

2000

Both types indicate

agranulocttosis

Induce periodontal instructions

After physician consultation

-severely extracted teeth should be extracted

-oral hygiene instructions include use of

Chlorohexidine rinse daily

-scaling and root planning under antibiotic

Protection.
TREATMENT PLAN FOR TUBERCULOSIS:

Pt should receive only emergency care.

PERIODONTAL TREATMENT

Completed chemotherapy poor medical follow up

Physician consulted show signs or symptoms evaluated

Systemic culture are made evaluated

Medical clearance & sputum treated for 18 months minimum

Results are negative

Treated normally post treatment follow up includes

1. Chest radiograph

2. Sputum culture

3. Pts symptoms review by physician atleast every

12 months.

INFECTIOUS DISEASES

HIV & AIDS

 It is endemic
 Wide range of oral lesions are associated with HIV
CONTRAINDICATIONS INDICATIONS

 Aspirin is avoided. Protease inhibitors

 Blood transfusions are avoided ex.Indinavir,Nelfinavir
due to risk of transmission. Reverse inhibitor
Sharp instrument injury

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

H E PAT I T I S

HEPATITIS A

Treated in acute phase

HEPATITIS B

Drugs are used cautionly

 MANAGEMENT

Normal platelet count if platelet count is low

Normal prothrombin time and prothrombin time prolonged

can be treated risk of transmission of HBs-Ag

but may have bleeding high risk in oral surgeon and periodontitis

tendency

HEPATITIS C

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

TREATMENT PLAN

The following guidelines on offered for treating hepatitis pts

1. If disease , regarding of type is active, do not provide periodontal therapy unless

situation is an emergency if positive for hepatitis follow the period

2. Past history of hepatitis, consult physician to determine type of hepatitis, course

and length of disease, mode of transmission

3. Recurrent HAV, HEV-perform routine periodontal care

For recovered HBV ,HDV pts consult physicians and order HBsAg and anti HBs
lab tests.
 Lab tests

If HBsAg,antiHBs HBsaAg positive Anti HBsAg positive HbsAg negative

Tests are positive are infected

But HBV is suspected degree is measure may be treated

Order another HBs by HBsAg determination

Determination

For HCV pt, consult physician to determine risk of transmissibility and current
status of chronic liver disease

If pt with active hepatitis ,positive HBsAg status,positive carrier status requires

emergency treatment

Use following guidelines:

1. Consult physician
2. Measure PT and BT if bleeding occur during procedure
3. Persons who contact with pts should use a barrier techniques including
masks ,gloves, glasses, eyeshields, disposable gowns.
4. Use disposable covers covering light handles.drawer handle ,bracket trays
5. All disposable items should be placed in waste basket
6. Aseptic technique should be followed at all time.
7. Minimize use of aerosols production by not using the ultrasonic
instruments.
8. Prerinsing with chlorohexidine gluconate for 30 sec is highly recommmed
After the procedure all instruments should be washed and sterilized if an item cant be sterilize it
should be disposed
S.
CONDITION COLOUR CONTOUR CONSISTENCY
No.
1) Normal Gingiva Coral Scalloped Firm, resilient
pink(Adults) outline
Pale
pink(children)
2) Gingivitis Bluish hue on Rolled out or Soggy, puffy
reddened gingiva rounded Pits on pressure
severe, acute marginal
gingiva
Diffuse puffiness
chronic Red or Bluish red and softening
Flat, blunt
Interdental
papilla
3) gingiva in puberty Bluish red Edematous

4) in menstrual cycle Tense; bloated, with

exudate release
5) in pregnancy Bright red to
 gingivitis bluish red Marginal and inter
“RASPBERRY” dental gingiva is
appearance edematous, smooth,
shiny & pits on
 gingival enlargement Bright red or pressure
- marginal magenta Soft friable, smooth,
shiny
Dusky red or
- tumor like magenta
Semi firm, smooth,
glistening surface
with numerous deep
red pinpoint
markings
6) menopausal Abnormally pale Dry, shiny fissures
gingivostomatitis to red in mucobuccal fold
7) addison’s disease Isolated patches
 of bluish black to
brown
Discolouration
8) in mouth breathers Red (in anterior Edematous (in
region) anterior region),
shiny surface
9) gingival abscess Red Smooth, shiny
surface
10) drug induced enlargements Pale pink “MULBERRY” Resilient, minutely
 with inflammation shaped lobulated surface &
 without inflammation tendency to bleed

Reddish or bluish Lobulated

11) idiopathic gingival Pink Firm, leathery,
enlargement minutely pebbled
surface
12) in vitamin ‘c’ deficiency Bluish red Soft, friable, smooth,
shiny
13) plasma cell gingivitis Red Friable, granular
14) pyogenic granuloma Bright red and Friable/firm
purple
15) leukemia Bluish red or Rounding of Sponge like, friable,
cyanotic gingival margin moderately firm
16) pernicious anemia Pale
sickle cell anemia Pale yellowish
aplastic anemia Pale
17) thrombocytopenia Purplish Soft, swollen, friable
gingiva
18) wegeners granulomatosis Reddish purple
19) sarcoidosis Red Smooth
20) fibroma of gingiva Spherical tumor,
soft, vascular, firm,
Nodular
21) peripheral giant cell Pink, deep red or Firm or spongy
 granuloma purplish hue
22) leukoplakia Grayish white Flattened scaly
lesion to thick,
irregularly shaped
keratinous plaque
23) necrotizing ulcerative Red Shiny, hemorrhagic
gingivitis (marginal gingiva
involved)
24) periodontal pocket Bluish red Thickened Flaccid, smooth
marginal shiny surface
gingiva
25) primary herpetic Red Edematous, diffuse,
gingivostomatitis shiny
26) desquamative gingivitis
 mild Red Irregularly
Patchy red or shaped
 moderate gray areas Denuded
Striking red appearance
 severe colour
27) chronic periodontitis Pale red to
magenta
28) necrotizing ulcerative Bright red
periodontitis marginal gingiva
29) aggressive periodontitis Fiery red
30) bismuth, arsenic,mercury, Black line or
lead pigmentation bluish line which
follows the
contour of the
gingiva