Periodontal Treatment on medically compromised patients

PERIODONTAL TREATMENT IN
MEDICALLY COMPROMISED
PATIENTS
presented by
Jhansi IV bds

 CARDIOVASCULAR DISEASE
 HYPERTENSION
INFECTIVE ENDOCARDITIS
 ENDOCRINE DISORDER
 DIABETES
 HEMORHAGIC DISORDERS
 COAGULATION DISORDERS
 ANTIPLATELET THERAPY
 LEUKEMIA
 RENAL FAILURE
 IMMUNOSUPRESSION AND CHEMOTHERAPY
 RADIATION THERAPY
 XEROSTOMIA
 OSTEORADIONECROSIS
 BISPHONATES
CONTENTS

INTRODUCTION
WHAT THE PERIODONTAL TREATMENT HAS TO DO WITH THE
MEDICALLY COMPROMISED PATIENTS?
 Many patients seeking dental care might have significant
medical condition which may alter the course of their oral
disease and therapy provided.
 The therapeutic responsibility of clinician includes
identification of medical problems and consultation with
or referral of the patient to appropriate physician may be
indicated
 Older periodontal patients are more likely to have
underlying disease.

Cardiovascular Diseases
Health histories should be closely scrutinized for cardiovascular problems, including
hypertension, angina pectoris, myocardial infarction (MI), cardiacbypass surgery,
cerebrovascular accident (CVA), congestive heartfailure (CHF), infective endocarditis
(IE), and implanted cardiacpacemakers or automatic cardioverter-defibrillators
In most cases, the patient's physician should be consulted, especially if stressful or
prolonged treatment is anticipated.
Short appointments and a calm, relaxing environment help minimize stress and maintain
hemodynamic stability.

HYPERTENSION
Hypertension, the most
common cardiovascular
disease, affects more than 50
million American
adults, many of whom are
undiagnosed.

STRESS REDUCTION PROTOCOL
• Premedicate the evening before dental appointment & after dental t/t (nitrous oxide,
diazepam 5mg night before and 1hr before procedure)
• Schedule appointment during afternoon. Avoid during early morning
• Minimize patient`s waiting time.
• Short appointments
• Clinician should not use a local anaesthetic containing epinephrine > 1: 100000 nor a
vasopressor to control bleeding.
• If patient exhibits anxiety ,use of conscious sedation in conjunction with periodontal
procedure is warranted.

The dental office can
play a vital role in the detection
of hypertension and
maintenance
care of the patient with
hypertensive disease.
The first dental office
visit should include two BP
readings spaced at least 10
minutes apart, which are
averaged and used as a
baseline.
Before the clinician refers a
patient to a physician because
of elevated BP, readings should
be taken at a minimum of two
appointments, unless the
measurements are extremely
high (i.e., systolic pressure
>180 mm Hg or diastolic
pressure >100 mm Hg).

INFECTIVE ENDOCARDITIS
Infective endocarditis (IE) is a disease in which microorganisms colonize damage endocardium or
heart valves.
Streptococcus viridans,
Eikenella corrodens,
Aggregatibacter
actinomycetemcomitans,
Capnocytophaga, and
Lactobacillus species
IE
ACUTE
FORMS
SUBACUTE
FORM

Periodontal Treatment on medically compromised patients

The following guidelines can aid in the development of periodontal treatment plans for
patients susceptible to IE:
 For patients at risk for IE, every effort
should be made to eliminate this
infection.
 All periodontal treatment procedures
(including probing) require antibiotic
prophylaxis; gentle oral hygiene methods
are excluded.
 Pretreatment chlorhexidine rinses are
recommended before all procedures,
including periodontal probing,
 When possible, allow at least 7 days
between appointment
 Regular recall appointments, with an
emphasis on oral hygiene
reinforcement and maintenance of
periodontal health

DIABETES MELLITUS
• Diabetes mellitus (DM) is a disease of glucose, fat, and protein metabolism resulting
from impaired insulin secretion, varying degrees of insulin resistance, or both.
• Stress increases body resistance to insulin and so patients may develop
hyperglycemia during treatment.
• Type 2 Diabetics are less prone to complications that develop during treatment as
compared to type 1 which are more prone to ketosis.

If a patient is suspected of having
undiagnosed diabetes, the following
procedures should be performed:
1. Consult the patient's physician.
2. Analyse laboratory tests , including fasting
blood glucose and casual glucose test
results.
3. Acute orofacial infection or severe dental
infection; if present, provide emergency
care immediately.
4. Establish the best possible oral health
through nonsurgical debridement of plaque
and calculus. Institute oral hygiene
instruction. Limit more advanced care

DENTAL THERAPY CONSIDERATIONS
• Advise the patients to take usual insulin dose and to eat normal breakfast before
treatment.
• Schedule dental appointments early in the day
• Use of LA without epinephrine
• When periodontal surgery is indicated, it is usually best to limit the size of the surgical
field so that the patient will be comfortable enough to resume a normal diet
immediately.
• • For prolonged procedures, intraoperative blood glucose evaluation is advisable.

HYPOGLYCEMIA
Symptoms may include:
• Sweating, tachycardia (sympathetic overactivity)
• Weakness, dizziness
• Pale, moist skin ,and cold skin (in contrast to hyperglycemia)
• Shallow respiration
• Headache ,anxiety
• Altered consciousness

• Terminate dental procedure
• Position the patient
• Administer 15 gms of oral carbohydrate
• 3-4 table spoons of sugar
• No improvement – administer parentral carbohydrate or 1mg
glucagon if available or intravenous dextrose.
• Observe patient atleast for 1 hour before discharging
MANAGEMENT (CONSCIOUS PATIENT)

• Position patient in supine patient
• BLS
• Summon medical assistance
• Definitive management (50%dextrose iv, 1mg glucagon im, sc).
HYPOGLYCEMIA (UNCONSCIOUS PATIENT)

Guidelines for periodontal care in diabetes patients for
medical and dental professionals and recommendations
for patients/the public.
Guideline A
[Suggested Guidelines for physicians and other
medical health professions for Use in Diabetes
Practice]
Because of the increased risk for developing periodontitis in patients with
diabetes the following recommendations are made:
 Patients with diabetes should be told that periodontal disease risk is
increased by diabetes.
 As part of their initial evaluation, patients with type 1, type 2 and
gestational diabetes (GDM) should receive a thorough oral examination,
which includes a comprehensive periodontal examination.

 For all newly diagnosed type 1 and type 2 diabetes patients, subsequent
periodontal examinations should occur (as directed by the dental
professionals) as part of their ongoing management of diabetes

Guideline B [Suggested guidelines for use in dental practice]
Chapple, I. L. C., & Genco, R. (2013). Diabetes and periodontal
diseases: consensus report of the Joint EFP/AAP Workshop on
Periodontitis and Systemic Diseases. Journal of Periodontology, 84(4-
s), S106–S11

Symptoms may include:
• Increased fatigue
• Dizziness
• Drowsiness
• Headaches
• Blurred vision
• Irritability
• Intense thirst
• Increased urination
• Involuntary weight loss
• Excessive hunger
HYPERGLYCEMIA

MANAGEMENT OF HYPERGLYCEMIC PATIENT (UNCONSCIOUS
PATIENT)
• Position the patient
• BLS
• Summon medical assistance
• IV infusion (5% dextrose and water)
• Administer oxygen
• Transport to hospital

• Patients with a history of bleeding problems caused by disease or drugs
should be managed to minimize the risks of hemorrhage.
• Identification of these patients through the health history, clinical
examination, and clinical laboratory tests is paramount.
Health questioning should cover
(1) the history of bleeding after previous surgery or trauma,
(2) past and current drug history,
(3) history of bleeding problems among relatives,
(4) illnesses associated with potential bleeding problems.

The clinician should consult the patient's physician before dental treatment
to determine the risk of bleeding and treatment modifications required.
To prevent surgical hemorrhage, a factor VIII level of at least 30% is needed
Parenteral 1-deamino-8-Darginine vasopressin (DDAVP; desmopressin) can
be used to raise factor VIII levels two fold to three fold in patients with mild or
moderate hemophilia.
Hemophilia – B :Surgical therapy requires a factor IX Level of 30% to 50%,
which is usually achieved by administration of purified prothrombin complex
concentrate or factor IX concentrate

Periodontal treatment can be performed in patients with these coagulation disorders,
provided that suficient precautions are taken
Probing, scaling, and prophylaxis can usually be done without medical
modiication
More invasive treatment, such as local block anesthesia, root planing, or surgery,
dictates prior physician consultation
Complete wound closure and application of pressure can reduce
hemorrhage

Dental treatment planning for patients with liver disease should include the following:
1. Physician consultation
2. Laboratory evaluations
3. Conservative, nonsurgical periodontal therapy whenever possible
4. When surgery is required (may require hospitalization)
• International normalized ratio (INR; PT) should be less than 2.0; for simple surgical
procedures, an INR of less than 2.5 is usually safe.
• Platelet count should be more than 80,000/mm3.
Liver disease affects all phases of blood clotting
because most coagulation factors are
synthesized and removed by the liver.

Thrombocytopenic Purpuras
Thrombocytopenia is defined as a platelet count of less than 100,000/mm3.
Purpuras are hemorrhagic diseases characterized by extravasation of blood into the tissues under
the skin or mucosa, producing spontaneous petechiae or ecchymoses
Periodontal therapy for patients with
thrombocytopenia should be directed toward
reducing inflammation by removing local irritants
to avoid the need for more aggressive therapy.
Scaling and root planing are
usually safe unless the platelet
count is less than 60,000/mm3.
No surgical procedure should be performed unless the platelet count is greater than 80,000/mm3.
Platelet transfusion may be required before surgery

Non thrombocytopenic Purpuras
Non thrombocytopenic purpuras result from vascular wall fragility or
thrombasthenia (i.e., impaired platelet aggregation).
• Treatment consists primarily of direct pressure applied for at least 15
minutes.
• This initial pressure should control the bleeding unless coagulation times
are abnormal or reinjury occurs.
• Surgical therapy should be avoided until the qualitative and quantitative
platelet problems are resolved.

ANTICOAGULANT THERAPY
The recommended level of therapeutic
anticoagulation for most patients is an INR of 2.0 to
3.0, with prosthetic heart valve patients usually in
the 2.5 to 3.5 range
The most common cause of
abnormal coagulation may
be drug therapy.
These drugs are vitamin K antagonists
that decrease production of vitamin K–
dependent coagulation factors II, VII, IX,
and X.

Antiplatelet Medications
Aspirin interferes with normal platelet aggregation and
can result in prolonged bleeding. Because it binds
irreversibly to platelets, the effects of aspirin last at least 4
to 7 days.
Nonsteroidal antiinflammatory drugs (NSAIDs) such as
ibuprofen also inhibit platelet function. Because NSAIDs
bind reversibly, the effect is transitory, lasting only a short
time after the last drug dose.

Leukemia
Refer the patient for medical evaluation and treatment.
Before chemotherapy, a complete periodontal treatment plan should
be developed with a physician
During the acute phases of leukemia, patients should receive only
emergency periodontal care.
Oral ulcerations and mucositis are treated with viscous lidocaine.
Oral candidiasis can be treated with nystatin suspension
For patients with chronic leukemia and those in remission, scaling and root
planing can be performed without complication, but periodontal surgery
should be avoided if possible.

RENAL DISEASE
Common causes of renal failure:
Glomerulonephritis
Kidney cystic disease
Drug nephropathy
Hypertension
Renal failure may result in :
Severe electrolyte imbalances
Cardiac arrhythmias
Pulmonary congestion
CHF
Prolonged bleeding

Because the dental management of patients with renal disease may need to be
drastically altered, physician consultation is necessary to:
 determine the stage of renal disease
 regimen for medical management
 alterations in periodontal therapy.
The patient in CRF has a progressive disease that ultimately may require kidney
transplantation or dialysis. It is preferable to treat the patient before, rather than
after, transplant or dialysis.

Treatment modifications should be used:
1. Consult the patient's physician.
2. Monitor blood pressure
3. Check laboratory values:
 Partial thromboplastin time (PTT)
 Prothrombin time (PT)
 Bleeding time
 Platelet count
 Hematocrit
 Blood urea nitrogen (do not treat if <60 mg/dl)
 Serum creatinine (do not treat if < 1.5 mg/dl).

4. Eliminate areas of oral infection to prevent systemic infection.
 Good oral hygiene should be established.
 Periodontal treatment should aim at eliminating inflammation or infection and
providing easy maintenance.
 Questionable teeth should be extracted if medical parameters permit.
 Frequent recall appointments should be scheduled.
5. Drugs considerations:
 Nephrotoxic or metabolized by the kidney should not be given (e.g., Phenacetin,
tetracycline, aminoglycoside antibiotics).
 Acetaminophen may be used for analgesia and diazepam for sedation.
 LA such as lidocaine are generally safe.

MEDICATION AND CANCER
THERAPIES

XEROSTOMIA
 The parotid is the most radiosensitive of the salivary glands; saliva may become extremely
viscous or nonexistent, depending on the dose delivered to the particular gland.
 Xerostomia causes a decrease in:
 the normal salivary cleansing mechanisms
 buffering capacity of saliva
 pH of oral fluids.
 Radiation-induced caries may progress rapidly and primarily affects smooth tooth surfaces
 Salivary substitutes can be given for xerostomia.
 Daily topical fluoride application and oral hygiene are the best means of preventing radiation
caries over time.
 A long-term, 3-month recall interval is idea

OSTEORADIONECROSIS
 High-dose radiation therapy results in hypovascularity of irradiated tissues with a reduction in wound-
healing capacity. Most severe among the resulting oral complications is osteoradionecrosis (ORN).
 Decreased vascularity renders the bone less capable of resolving trauma or infection. Such events may
cause severe destruction of bone.
 The risk of ORN continues for the remainder of the patient's life and does not decrease with time.

BISPHOSPHONATES
Bisphosphonate medications are primarily used to treat cancer (i.e., intravenous administration)
and osteoporosis (i.e., oral administration)
They act by inhibiting osteoclastic activity, which leads to less bone resorption, remodeling, and
turnover
Use of bisphosphonates leads to the development of bisphosphonate-related osteonecrosis of
the jaw (BRONJ).
Clinically, BRONJ manifests as exposed alveolar bone occurring spontaneously or after a dental
procedure

Periodontal disease and treatment (especially surgery) poses a risk for patients treated
with bisphosphonates.
Optimal periodontal and oral health should be achieved and maintained for all patients
For individuals treated with intravenous bisphosphonates, invasive treatment, such as extractions,
periodontal surgery, implant surgery, and bone augmentation procedures, should be avoided
Risks must be considered before treatment of individuals
with a history of taking oral bisphosphonates for longer than 3
years

Pregnancy
The aim of periodontal therapy for the pregnant patient is to minimize the exaggerated
inflammatory response related to pregnancy-associated hormonal alterations.
Meticulous plaque control, scaling, root planing, and polishing should be the only nonemergency
periodontal procedures performed.
As the uterus increases in size during the second and third trimesters, obstruction of the vena cava
and aorta can occur if the patient is placed in a supine position. The reduction in return cardiac
blood supply can cause supine hypotensive syndrome, with decreased placental perfusion

CONCLUSION
 Many patients seeking dental treatment have some specific condition which
can alter the treatment plan of the patient.
 An appropriate management is necessary to avoid any complication which
can be sometimes life threatening.
 While rendering treatment to a medically compromised patients , the
periodontist should be prepared for any complication that might occur.

REFERENCES
1. Clinical periodontology – newman carranza ,11th ed, 13th
ed

Periodontal Treatment on medically compromised patients

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