Abdul Gani Soulisa

Periodontic Department
Faculty of Dentistry
Trisakti University
11/8/2018 1
Medically Compromised Patient
1. Respiratory Infection
2. Cardiovascular disease - Atherosclerosis
3. Hepatitis
4. HIV

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Overview
1. Periodontal diseases
2. Systemic diseases
3. Manifestation of systemic diseases in periodontal
tissue
4. Management of medically compromised patient

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Session Objectives
 To enable students to:
- Identify the clinical changes in oral tissue as a
manifestation of systemic diseases
- Understand the management of medically
compromised patients during dental treatments

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Assumed Knowledge

 Periodontal tissue
 Familiar with gingival anatomy
 Clinical features of healthy/normal gingiva
 Etiology of periodontal disease
 Classification of periodontal disease

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Periodontal Examination
Clinical
assesment

Health Inflammation

Gingivitis Periodontitis

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 Gingivitis
1. Plaque-Induced Gingival Disease:
III. Gingival diseases modified by medication
I. Gingivitis associated with dental plaque only
A. Without local contributing factors A. Drug induced gingival diseases
B. With local contributing factors 1. Drug influenced gingival enlargement
II. Gingival diseases modified by sistemic factors 2. Drug influenced gingivitis
A. Associated with the endocrine system: a. Oral contraceptive associated
1. Puberty associated gingivitis gingivitis
2. Menstrual cycle- associated gingivitis
b. Other
3. Pregnancy associated :
a. Gingivitis IV. Gingival diseases modified by malnutrition
b. Pyogenic granuloma A. Ascorbic acid deficiency gingivitis
4. Diabetes Mellitus- associated gingivitis B. Other
B. Associted with blood dyscrasias
1. Leukemia - associated gingivitis
2. Other

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 Gingivitis
2. Non-Plaque-Induced Gingival Disease:
IV. Gingival lesions of genetic origin
I. Gingivitis diseases of specific bacterial origin A. Hereditary gingival fibromatosis
A. Neisseria gonorrhoeae
B. Others
B. Treponema pallidum
C. Streptococcus species V. Gingival manifestations of systemic
D. Other
conditions
II. Gingival diseases of viral origin A. Mucocutaneous lesions
A. Herpesvirus infections 1. Lichen planus
1. Primary herpetic gingivostomatitis 2. Pemphigoid
2. Recurrent oral herpes 3. Pemphigus vulgaris
3. Varicella zoster: 4. Erythema multiforme
B. Other
5. Lupus erythematosus
III. Gingival diseases of fungal origin
A. Candida species infections: generalized gingival candidiasis
6. Drug induced
B. Linear gingival erythema 7. Other
C. Histoplasmosis

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Gingivitis
2. Non-Plaque-Induced Gingival Disease:
............ (continue) VI. Traumatic lesions (fractitious, iatrogenic, or
accidental)
B. Allergic reactions A. Chemical injury
1. Dental restorative materials B. Physical injury
a. Mercury C. Thermal injury
b. Nickel VII. Foreign body reactions
c. Acrylic VIII. Not otherwise specified
d. Other
2. Reactions attributable to:
a. Toothpastes or dentrifrices
b. Mouth rinses or mouthwashes
c. Chewing gum additives
d. Foods and additives
3. Other

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Periodontitis
1. Chronic Periodontitis:
- Localized and Generalized
2. Agressive Periodontitis
- Localized and Generalized
3. Periodontitis as a Manisfestation of Systemic Disease
- Hematologic disorders (acquired neutropenia,
leukemias), genetic disorders (familial and cyclic
neutropenia, down syndrome, leukocyte adhesion
deficiency syndrome, papillon-Lefevre syndrome, etc)

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Physiologic Rationale for Cardinal Signs of
Inflammation
Cardinal Signs of Inflammation Physiologic Rationale

Rubor (redness) Increased vascularity

Tumor (swelling) Exudation of fluid
Calor (heat) A combination of increased blood
flow and the release of
inflammatory mediators
Dolor (pain) The stretching of pain receptors
and nerves by the inflammatory
exudates, and by the release of
chemical mediators
Functio laesa (loss of function) A combination of the above effects

(McMahon & Sloan, 2000)

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Oral health is a critical component of total
health
The first-ever Surgeon General’s Report on Oral
Health has called attention to this important
connection and states, that if left untreated, poor
oral health is a “silent X-factor promoting the
onset of life-threatening diseases which are
responsible for the deaths of millions of
Americans each year.”

American Dental Hygienists’ Association

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Systemic Disease
 Current research has linked periodontal disease to a number of
systemic diseases.
 The greatest evidence exists for the connection with diabetes,
however numerous associations are being studied and
evidence continues to emerge.
 Some of these possible associations include: heart and lung
disease, pre-mature, low-birth weight babies, oral and
pancreatic cancers.
 Scientific evidence also supports the fact that many cases of
respiratory infections among the institutionalized originate
from oral bacteria.

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“Periodontal disease is a chronic inflammatory disease,
and is linked to other serious health risks.”
 Inflammation
 Osteoporosis
 Heart Disease and Stroke
 Pregnancy Problems
 Diabetes
 Respiratory Diseases

American Academy of Periodontology

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 RESPIRATORY INFECTIONS

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 AVOID
 1. General anesthesia: leads to hypoxia .
 2. Analgesics & narcotics: leads to respiratory
depressants.

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Tuberculosis
- Mycobacterium tuberculosis as the main agent
- Ranking 3rd among the world’s 22 high-burden TB
countries
- Prevalence estimation : 244 per 100,000 population
- More than 70 % of TB patients in Indonesia are still of
productive ages

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 - Another agents are Mycobacterium bovis, and
Mycobacterium africanum.
- M. africanum  There are possibilities of imported
- M. bovis  powdered milk < fresh milk

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 Incubation Period:
 4-12 weeks from the infection to the development of
the primary complex
• The first two year after infection are the highest risk for
developing active disease
• May be dormant for many years and reactivate

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  Transmission Routes: Airborne droplet that produced
by an infectious case during expiratory efforts like
coughing, spitting or sneezing
 factors that may contribute to TB risk:
immunosuppression, travel/migration, Overcrowding,
inadequate nutrition, poor hygiene, occupation, low
socioeconomic status

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 Symptoms:
- Cough more than 2 weeks
- Chest pain
- Nausea
- fever
- Loss weight

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 Transmission and Pathogenesis

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Transmission of
Mycobacterium tuberculosis
 Spread by droplet nuclei
 Immune system usually prevents spread
 Bacteria can remain alive in the lungs for many years
(latent TB infection)

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Risk of TB Transmission in
Dentistry
 Risk in dental settings is low
 Only one documented case of transmission
 Tuberculin skin test conversions among DHP
are rare

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Preventing Transmission of TB in Dental
Settings

 Assess patients for history of TB

 Defer elective dental treatment
 If patient must be treated:
 DHCP should wear face mask
 Separate patient from others/mask/tissue
 Refer to facility with proper TB infection control
precautions

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 Diagnosis of TB

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 Diagnosis of Active TB
 History and epidemiologic clues
Think TB!!!
 Chest X-ray
 Tuberculin skin test
 AFB smear
 AFB culture
 Nucleic acid amplification
Fast but sensitivity poor in smear neg.
 Empiric treatment trial

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 AFB Smear

AFB (shown in red) are tubercle bacilli

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 Cultures
 Use to confirm
diagnosis of TB

 Culture all specimens,

even if smear negative

 Results in 4 to 14 days
when liquid medium
systems used
Colonies of M. tuberculosis
growing on media

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 Testing for
TB Disease and Infection

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 Administering the Tuberculin Skin Test
 Inject intra-dermally:
 0.1 ml of 5 TU PPD tuberculin
 Produce wheal:
 6 mm to 10 mm in diameter
 Do not recap, bend,
or break needles,
or remove needles
from syringes
 Follow universal
precautions for
infection control
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 Reading the Tuberculin Skin Test
 Read reaction:
 48-72 hours
after injection
 Measure only
induration!
 Record reaction
in millimeters

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 Drugs for Tuberculosis
 First line drugs (active against wild type)
Isoniazid (INH or I)
Rifampin (RIF or R)
Pyrazinamide (PZA or Z)
Ethambutol (EMB or E)
Streptomycin (Strept or S)
 Second line drugs (for drug resistant strains)
- PAS - Capreomycin - Kanamycin
- Ethionamide - Quinolones

www.hopkins-tb.org
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Dental Hygiene Treatment
 Meticulous and frequent oral care is critical in
preventing these infections.
 “Oral hygiene intervention significantly reduced
occurrence of pneumonia in institutionalized
subjects” Scannapieco, FA, Bush, RB, Paju S. Associations between periodontal disease and risk for
nosocomial bacteria pneumonia and chronic obstructive pulmonary disease. A systematic review Ann Periodontal.
2003; 8:1, 54-69.

 Frequent toothbrushing and pre-operative use of

0.12% or 0.2% chlorhexidine mouthrinse or gel
reduced nosocomial respiratory tract infections
Sjorgren P Nilsson E, Forsell M, Johansson O, Hoogstraate J. A systemic review of the preventive effect of oral hygiene on
pneumonia and respiratory tract infection in elderly people in hospitals and nursing homes. J Am Geriatric Soc 2008;
56: 2124-2130

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 Management:
- Recognize the symptoms
- Verify diagnosis
- Refer  eliminate or reduce the inflammation
- Protection and prevention during treatment

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 CARDIOVASCULAR DISEASE

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How does periodontal disease affect
heart disease?
 This association is still being studied, but it is thought
that the C-reactive protein and fibrinogen production is
increased in response to oral inflammation. C- reactive
protein increases clotting and is a marker for heart
disease.

 Risk is increased for diabetic patients and synergistically

increased if the patient is a smoker.

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 Risk Factors
 Hypertension
 High cholesterol
 Obesity
 Cigarette smoking
 Physical inactivity
 Diabetes mellitus
 Kidney disease
 Older age (>55 ♂; > 65 ♀)
 Family history of premature cardiovascular
disease
 Periodontal disease ?
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Etiology
 Fixed
 Age, Male, family history
 Modifiable – strong association
 Dyslipidaemia, smoking, diabetes mellitus, obesity,
hypertension
 Modifiable - weak association
 Lack of exercise, high alcohol consumption, Oral
Contraceptive Pills

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 Non-Modifiable Risk Factor: SEX

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 Non-Modifiable Risk Factor: AGE

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 Non-Modifiable Risk Factor: FAMILY
HISTORY

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 Modifiable Risk Factor: DIABETES

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 Modifiable Risk Factor: SMOKING

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 Modifiable Risk Factor: OBESITY

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 Modifiable Risk Factor: DYSLIPIDEMIA

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 Angina pectoris
 Potential problem related to dental care
1. Stress and anxiety related to dental visit may precipitate angina attack
 Prevention of complication
1. Detection of patient
2. Referral of patient for medical evaluation and treatment
3. Known case with medical treatment for angina
 Stress reduction protocol
 Premedication
 Open and honest communication
 Morning appointments
 Short appointments
 Nitrous oxide - oxygen
 Avoid excessive amounts of epinephrine

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 Treatment
 Stop dental treatment
 Call for help
 Rest, sit up and reassure patient
 Oxygen
 Analgesia (opiate, sublingual nitrate)
 Aspirin
 Thrombolysis
 Primary angioplasty
 Beta-Blockers
 ACE inhibitors
 Prepare for basic life support
 Transport patient to hospital
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 Dental Considerations for IHD
 Common Situations:
 Orthostatic Hypotension due to use of anti-hypertensives (beta
blockers, nitroglycerin…)
 Raise chair slowly
 Allow patient to take his/her time
 Assist patient in standing
 Post-Op Bleeding:
 When patients on Plavix or Aspirin, expect increased bleeding because
of decreased platelet aggregation
 Emergent Situations:
 Possible MI:
 Remember that pain in the jaw may be referred pain from the
myocardium  assess the situation, have good patient history, follow
ABC’s
 Angina:
 In situations of angina pectoris, all operatories should have nitroglycerin
to be placed sublingually
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 Post MI: When to Treat
 Why delay treatment?
 Remember that with an MI there is damage to the heart, be it
severe or minimal that may effect the patient’s daily life
 MI within 1 month  Major Cardiac Risk
 MI within longer then 1 month:
 Stable  routine dental care ok
 Unstable  treat as Major Cardiac Risk
 Older studies suggest high re-infarction rates when surgery
performed within 3 months, 3-6 months… however, this was
abdominal and thoracic surgery under general anesthesia
 New research suggests delaying elective tx for 1 month is advisable.
Emergent care should be done with local anesthetic without
epinephrine and monitoring of vital signs
 When in doubt:

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 Dental Management:
Stable Angina/Post-MI >4-6 weeks
 Minimize time in waiting room
 Short, morning appointments
 Preop, intra-op, and post-op vital signs
 Pre-medication as needed
 anxiolytic (triazolam; oxazepam); night before and 1 hour before
 Have nitroglycerin available – may consider using prophylacticaly
 Use pulse oximeter to assure good breathing and oxygenation
 Oxygen intraoperatively (if needed)
 Excellent local anesthesia - use epinephrine, if needed, in
limited amount (max 0.04mg) or levonordefrin (max. 0.20mg)
 Avoid epinephrine in retraction cord
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Dental Management:
Unstable Angina or MI < 3 months

 Avoid elective care

 For urgent care: be as conservative as possible; do only
what must be done (e.g. infection control, pain
management)
 Consultation with physician to help manage
 Consider treating in outpatient hospital facility or refer to
hospital dentistry

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  When treating patients with Ischemic Heart
Disease or recent MI…
 Use caution and common sense
 When in doubt:

 CONSULT THE CARDIOLOGIST

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Atherosclerosis
- Etiology: unknown, but associated with accumulation
of complex lipid in vascular
- Risk factors for atherosclerosis consist of Major and
Minor risks.
- Major risk: Hipercholesterolemya, Hipertension,
smoking, diabetes mellitus
- Minor risk: lack of exercise, stress, obesity

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Signs and Symptoms
 None: This is referred to as silent
ischemia. Blood to your heart may be
Chest restricted due to CAD, but you don’t feel
None Pain any effects.
 Chest pain: If your coronary arteries
can’t supply enough blood to meet the
oxygen demands of your heart, the result
may be chest pain called angina.
Signs &  Shortness of breath: Some people may
Symptoms not be aware they have CAD until they
develop symptoms of congestive heart
failure- extreme fatigue with exertion,
shortness of breath and swelling in their
feet and ankles.
 Heart attack: Results when an artery to
Shortness Heart your heart muscle becomes completely
Of Breath Attack blocked and the party of your heart
muscles fed by that artery dies.

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Dental Hygiene Treatment
 Educate patients about the importance of maintaining
their oral tissues through home and professional care.
 Dental professionals should always take the patients’
blood pressure before proceeding with treatment. This
is Standard of Care.
 Ask about tobacco use, and incorporate Tobacco
Cessation into the patient’s treatment plan.

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BLOODBORNE DISEASE

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 Question: The greatest risk of
transmission of disease occurs:

A. From the dental healthcare worker to the patient.

B. From the patient to the dental healthcare worker.
C. From one patient to another patient.
D. All transmission routes have the same risk.

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Potential Routes of Transmission of
Bloodborne Pathogens
Patient DHCP

DHCP Patient

Patient Patient

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 CDC http://www.cdc.gov/OralHealth/infectioncontrol/guidelines/ppt.htm
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Wound Care
 Clean wounds with soap and
water
 Do not squeeze
 Flush mucous membranes
with water
 Avoid use of bleach and other
agents caustic to skin

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 Hepatitis D
 Hepatitis D depends on Hepatitis B for
propagation/transmission.
 Hepatitis D infections – usually injection drug users
and hemophiliacs
 Immunization with HBV vaccine confers immunity to
HDV

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 HCV Infection in Dentistry
 Frequency of HCV infection among dentists similar
to that of general population (~ 1-2%)
 No reports of an HCV transmission from infected
dental personnel to patients
 No reports of patient-to-patient transmission of
HCV
 Risk of HCV transmission is very low

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 Type of Hepatitis
A B C D E

Source of feces blood/ blood/ blood/ feces

virus blood-derived blood-derived blood-derived
body fluids body fluids body fluids

Route of fecal-oral percutaneous percutaneous percutaneous fecal-oral

transmission permucosal permucosal permucosal

Chronic no yes yes yes no

infection

Prevention pre/post- pre/post- blood donor pre/post- ensure safe

exposure exposure screening; exposure drinking
immunization immunization risk behavior immunization; water
modification risk behavior
modification
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 Healthy Liver Cirrhosis Liver

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Hepatitis A
 Incubation period
 30 days on average (range 15-50 days)
 infectious latter half of incubation period while
asymptomatic through 1 week after having jaundice.

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Hepatitis A
• Symptoms
 Nausea  Dark urine
 Loss of appetite  Pale stool
 Vomiting  Jaundice
 Fatigue  Stomach pain
 Fever  Side pain

A person may have all, some or none of these

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 Take and carefully review every patient’s medical history.

 Take and record each patient’s vital signs, especially blood

pressure.

 Carefully conduct the intraoral assessment including oral

cancer screening and periodontal charting and gingival
assessment.

 Provide exceptional care including referrals to the

appropriate medical personnel.

 Stay informed about emerging evidence about the oral-

systemic connection.
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Hepatitis
 Hepatitis A and E are both self-limiting infections with no
associated chronic liver disease.
 Hepatitis B infection may result in chronic liver disease in
about 5 -10% of infected individuals.
 Hepatitis D requires the presence of HBV for its survival.
 Hepatitis C is the most serious of all viral hepatitis
infection because of its high chronic infection rate. Only
15% of patients recover completely; 85% develop chronic
HCV infection, which dramatically increases the risk for
cirrhosis, liver Ca. and failure.

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 If the disease, regardless of type, is active, do not provide
periodontal therapy unless the situation is an emergency.
For recovered HAV or HEV patients, performed routine
periodontal care.
For recovered HBV or HDV patients, consult with the
physician and order HBsAg and antiHBs lab test.
If there are negative but HBV is suspected, order another
HBs determination
HBsAg + carrier
if antiHBs + may be treated routinely
For HCV consult with the physician to determine the
patient’s risk for transmissibility and current status of
chronic liver

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 Hepatitis: if patient with HBsAg+ or active
requires emergency treatment
 Management
- consultation
- if likely bleeding: checking PT, PTT
- wear mask, gloves, glasses, disposable gowns
- all instruments placed on a sheet of aluminum foil
- all disposable items placed in wastebasket
- minimize aerosol production
- all equipments should be scrubbed and sterilized
★NaOCl (1:3) --- 10 min
★handpieces --- autoclaved
- dental chair
★NaOCl (1:3) --- 10 min
★aseptic technique should be practiced
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 HIV INFECTION

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 HIV
(Human Immunodeficiency Virus)
- Barre-Sonoussi and Gallo’s initial description of the
type I (HIV-1) in 1983
- Clavel et al. first described HIV-2 in 1986
- An estimated 40.3 million people were alive with HIV
infection in the world
- 95% of HIV-infected people live in developing
countries

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 New HIV Infections in 2002 by
Age Group

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Modes of HIV/AIDS Transmission

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 Transmission routes:
- Unprotected sexual intercourse with an infected
partner
- Injection or transfusion of contaminated blood (skin
grafts)
- Sharing unsterilized injection equipment that was
previously used by an infected person
- Maternal-fetal transmission (during pregnancy, at
birth, through breastfeeding)

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 Stage 1 - Primary
 Short, flu-like illness - occurs one to six weeks after
infection
 no symptoms at all
 Infected person can infect other people

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 Stage 2 - Asymptomatic
 Lasts for an average of ten years
 This stage is free from symptoms
 There may be swollen glands
 The level of HIV in the blood drops to very low levels
 HIV antibodies are detectable in the blood

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 Stage 3 - Symptomatic
 The symptoms are mild
 The immune system deteriorates
 emergence of opportunistic infections and cancers

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 Stage 4 - HIV  AIDS

 The immune system

weakens

 The illnesses become

more severe leading to
an AIDS diagnosis

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 - Many infected individuals may have no clinical
manifestations of HIV infection for years (8-20 years or
more)  latency period
- Oral manifestations are among the earliest and most
important indicator
- There are 3 groups of oral manifestations which based
on their intensity and features

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 1). Seven cardinal lesions (oral candidosis, hairy
leukoplakia, Kaposi sarcoma, linear gingiva
erythema, necrotizing ulcerative gingivitis,
necrotizing ulcerative periodontitis, non-Hodgkin
lymphoma)  strongly associated with HIV infection
2). Atypical ulcers, salivary glands diseases, viral
infections (cytomegalovirus, herpes simplex virus,
papillovirus, herpes zoster virus)
3). Diffuse osteomyelitis and squamous cell carcinoma
 rarer than another groups

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  Since the advent of HAART (Highly Active
Antiretroviral Therapy)  The prevalence of all oral
lesions has decreased by more than 30%
 Patients who do not receive ART (Antiretroviral
Therapy) are likely to still have the common oral
features of HIV disease

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 (Leao et al, 2009)
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 (Gennaro et al, 2008)
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 (Gennaro et al, 2008)
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 (Gennaro et al, 2008)
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 (Gennaro et al, 2008)
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 (Gennaro et al, 2008)

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 a. Oral candidosis
 Candida albicans is the predominant yeast that
colonizes the oral cavity of both healthy subjects and
HIV-infected individuals in the developed and
developing world
 oral pseudomembranous candidosis  the most
common fungal infection of HIV disease, associated
with more frequent progression of HIV to AIDS,
used as a clinical marker to define the severity of HIV
infection
 prevalence varying from 1.5 to 56%
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 Severe pseudomembranous candidosis (Thrush)

(Leao et al, 2009)

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 b. Oral hairy leukoplakia
 clinical manifestation of Epstein-Barr virus (EBV)
infection almost exclusively found in patients with
untreated advanced HIV disease
 typically occurs on the lateral border of the tongue
 prevalence varies from 0.42 to 38%

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 Oral hairy leukoplakia

(Leao et al, 2009)

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 c. Oral Kaposi’s sarcoma
 Malignant
 Caused by human herpes virus 8 (HHV-8), which is
transmitted sexually or via blood or saliva
 Oral KS manifests as red to purple macules, papules,
or nodules that may ulcerate and cause local tissue
destruction
 The palate and gingivae are the most commonly
affected intraoral sites

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 Kaposi’s sarcoma of the right buccal vestibule

(Leao et al, 2009)

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 d. Gingiva and periodontal diseases
 Linear gingival erythema, NUG, NUP, and necrotizing
stomatitis

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 Necrotizing ulcerative gingivitis

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 (Gennaro et al, 2008)
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 Management in dental clinic:
- Use disposable instruments
- Always sterilized
- Use hypochloride as an antiseptic for dental unit

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Acquired Immune Deficiency
Syndrome (AIDS)
 Precautions:
- barrier technique
- sharp instruments carefully
- proper sterilization technique
- chlorhexidine oral rinsing
- avoid surgery
★delayed healing response

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Acquired Immune Deficiency
Syndrome (AIDS)
 The Centers for disease control:
- washing clothing in a normal cycle (60~70°C) ,and with
normal bleach followed by machine drying (100°C) will
inactivate AIDS virus
- difficult areas to disinfect should be wrapped with
impervious covering (plastics, aluminum foil).
 conventional hand instrumentation is the choice, and
surgery should be avoided owing to delayed healing
response.
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Why Is Hand Hygiene Important?
 Hands are the most common mode of
pathogen transmission
 Reduce spread of antimicrobial resistance
 Prevent health care-associated infections

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Hands Need to be Cleaned When
 Visibly dirty
 After touching contaminated
objects with bare hands
 Before and after patient
treatment (before glove
placement and after glove
removal)

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Hand Hygiene Definitions
 Handwashing
 Washing hands with plain soap and water
 Antiseptic handwash
 Washing hands with water and soap or other detergents
containing an antiseptic agent
 Alcohol-based handrub
 Rubbing hands with an alcohol-containing preparation
 Surgical antisepsis
 Handwashing with an antiseptic soap or an alcohol-based
handrub before operations by surgical personnel
Efficacy of Hand Hygiene Preparations in
Reduction of Bacteria
Good Better Best

Plain Soap Antimicrobial Alcohol-based

soap handrub

Source: http://www.cdc.gov/handhygiene/materials.htm

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 Alcohol-based Preparations
Benefits
 Rapid and effective
antimicrobial action
 Improved skin condition
 More accessible than
sinks
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Limitations
 Cannot be used if hands
are visibly soiled
 Store away from high
temperatures or flames
 Hand softeners and glove
powders may “build-up”
112
Special Hand Hygiene Considerations

 Use hand lotions to prevent skin dryness

 Consider compatibility of hand care products with
gloves (e.g., mineral oils and petroleum bases may
cause early glove failure)
 Keep fingernails short
 Avoid artificial nails
 Avoid hand jewelry that may tear gloves

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 Personal Protective
Equipment

 A major component of Standard Precautions

 Protects the skin and mucous membranes from
exposure to infectious materials in spray or
spatter
 Should be removed when leaving treatment
areas

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Masks, Protective Eyewear, Face Shields
 Wear a surgical mask and either eye protection with
solid side shields or a face shield to protect mucous
membranes of the eyes, nose, and mouth
 Change masks between patients
 Clean reusable face protection between patients; if
visibly soiled, clean and disinfect

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 Protective Clothing
 Wear gowns, lab coats, or uniforms
that cover skin and personal
clothing likely to become soiled
with blood, saliva, or infectious
material

 Change if visibly soiled

 Remove all barriers before leaving

the work area

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Gloves
 Minimize the risk of health care personnel
acquiring infections from patients
 Prevent microbial flora from being transmitted
from health care personnel to patients
 Reduce contamination of the hands of health care
personnel by microbial flora that can be
transmitted from one patient to another
 Are not a substitute for handwashing!

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Recommendations for Gloving
 Wear gloves when contact with
blood, saliva, and mucous
membranes is possible
 Remove gloves after patient care
 Wear a new pair of gloves for each
patient

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Recommendations for Gloving
Remove gloves that
are torn, cut or punctured

Do not wash, disinfect

or sterilize gloves for reuse
 Because of the overwhelming
science supporting the “oral-systemic
connection”, patients with these
systemic and oral conditions should
have access to dental hygiene
services on a very routine basis.

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What do you need to know....
1. Review lecture note
2. How to manage medically compromised patient
during dental treatment

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Recommended Textbook
 Gehrig, JSN & Willmand, DE. 2003. Foundations of Periodontics for the
Dental Hygienist. Lippincott Williams & Wilkins, Philadelphia
 Hoag, PM & Pawlak. 1990. Essential of Periodontics. Mosby, New York
 Little, JW., Falace, D., Miller, C., Rhodus, NL. 2013. Dental
Management of Medically Compromised Patient. Mosby, New York.
 Newman, Takei, Klokkevold,Carranza. 2012. Clinical Periodontology,
11th.ed. Saunders, Philadelphia.
 Rateitschak KH, Rateitschak EM, Wolf HF, Hassel TM. 1985. Color
Atlas of Periodontology. Thieme, New York.
 Reddy, S. (2008). Essentials of Clinical Periodontology and
Periodontics. New Delhi: Jaypee Brothers Medical Publishers.

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 References
 Gehrig, JSN & Willmand, DE. 2003. Foundations of Periodontics for the Dental
Hygienist. Lippincott Williams & Wilkins, Philadelphia
 Georgia Dental Hygienist’ Association. The Impact of Dental Hygiene
Treatment on Systemic Disease. 2011
 Little, JW., Falace, D., Miller, C., Rhodus, NL. 2013. Dental Management of
Medically Compromised Patient. Mosby, New York.
 Newman, Takei, Klokkevold,Carranza, 2012. Clinical Periodontology, 11th.ed.
Saunders, Philadelphia.
 Rateitschak KH, Rateitschak EM, Wolf HF, Hassel TM. 1985. Color Atlas of
Periodontology. Thieme, New York.

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