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DEPARTMENT OF PERIODONTICS

COMPREHENSIVE CASE HISTORY


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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: Iron deficiency anaemia Diseases of thyroid Sjogrens syndrome Juvenile periodontiis Caries 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. common in males: Attrition carcinoma of buccal mucosa Caries in deciduous teeth Leukoplakia Perinicious anaemia

-to know the financial status ,so that treatment can be varied. CHIEF COMPLAINT: -should be recorded in patients own words. -it is the reason for which the patient has come to the doctor. -it should be given first priority. -should be recorded in chronological order. -if few complaints start simultaneously,record them in the order of frequency. Probable chief complaints may be Bleeding gums Staining of teeth Malodour Food impaction Mobility Pain Recession Swollen gums Burning of mouth Questionare 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? 5.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 Anatomical location where it is felt. Origin & mode of onset. Intensity of pain Nature of painburning,throbbing etc Progression of pain Duration of pain Movement of pain[radiating,referred,migrati ng] Localization behaviour Concomitant neurological signs Past dental history:

Swelling Duration Mode of onset Symptoms Progress of swelling Associated features Impairment function recurrence

Ulcer mode of onset pain discharge[serum,pus,blood] associated diseases

-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 HISTROY: 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 EXAMPLEOBESE 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: -NOTE FREQUENCY OF HABIT PER DAY - FREQUENCY OF BRUSHING PER DAY - 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 CONSISTENCY - 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. II. III. SIMPLE POCKET COMPOUND POCKET 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
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/Eradiolucent 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 MILLERS CLASSIFICATION CLASS 1;marginal tissue recession that doesnt 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 ITS 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. V. VI. SIMPLE POCKET COMPOUND POCKET 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/Eradiolucent 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 contra captives- 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 mouthwash twice daily.

IN INFECTIVE ENDOCARRDITIS PTS 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[NSAIDs] 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 Professional recalls

oral hygiene reinforcement chlorhexidine gluconate rinses Scaling and root planning Possible drug substitution Professional recalls

Gingival enlargement regresses

revaluation

Maintain good oral hygiene Maintain professional recalls

enlargement persists

Periodontal surgery indicated

Small areas of enlargement Absence of osseous defects

large areas of enlargement presence of osseous defects

Leukemic gingival enlargement

Only gingival enlargement

gingival enlagement with superimposed ANUG

oral hygiene reinforcement

1st 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 No osseous defects

enlargement >6 teeth osseous defects

Gingivectomy GINGIVAL ENLARGEMENT IN PREGNANCY

flap surgery

Treatment requires elimination of all local irritants responsible for the gingival changes Marginal and interdental gingival enlargement enlargement tumor like gingival

Scaling and curettage, oral hygiene instructions and root planning, oral hygieneinstructions ENLARGEMENT IN PUBERTY:

surgical excision, scaling

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 Oral hygiene, chlorhexidine

shrinkage does not occur after scaling and root planning

Surgery indicated

Gingivectomy surgery

flap

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 superimposed candidisis if +ve use anti fungal drugs

rule out

Periodic exam

topical steroids

Intra lesional steroids for Large chronic ulcers

Resolution

no resolution

Wean off and moniter dermatologist[retinoids,dapsone,cyclosporines,photopheresis ]

refer to

TREATMENT OF CICATRICIAL PENPHIGOID:

CICATRICIAL PEMPHIGOID

Asymptomatic

mild to moderate

severe

Plaque control dermatologist

topical steroids

refer to

Prednisolone dapsone No resolution [dapsone,methotrexate,cyclosporins, cytophosphamide,azathioprine]

DIAGNOSIS OF PEMPHIGUS VULGARIS

REFER TO DERMOTOLIST

Primary treatment treatment Prednisolone [azathioprine,cyclophaspamide,cyclosporines,photopheresis,methyl trexate]

secondary

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 1 therapy or non surgical phase therapy Scaling and planning and planning

PHASE 1 scaling

Phase 4 therapy or maintenance phases therapy or maintenance

PHASE 4

SUPRABONY POCKETS POCKETS PHASE 1 THERAPY PHASE 1 Therapy with gingival

INTRABONY

SCALING AND ROOT PLANNING 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 Reevaluated 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 exhibit attachment Exhibit attachment loss and bone loss TREATMENT PLAN

when more than 30% of sites and bone loss

PHASE 1 THERAPY OR NON SURGICAL PHASE

Scaling and root planning

Phase 4 maintenance phase

AGGRESSIVE PERIODONTITIS

LOCALIZED PROGRESSIVE

GENERALIZED TREATMENT PLAN

RAPIDLY

NONSURGICAL THERAPY IT INCLUDES Pt education COMBINATION Phase 1 therapy scaling and rootplanning regular recall osseus walls phase 4

SURGICAL

ANTIMICROBIAL

RESECTIVE THERAPY To eliminate or reduce pockets depths

REGENERATIVE Intra bony defects and vertical bone defects with multiple

not done in horizonrtal early diagnosis cases shows better results moderate to severe cases poor prognosis bone loss

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 Gram positive organisms Gram negative organisms ANTIBIOTIC FOR CHOICE Amoxicillin clavulanate potassium (augmentin) clindamycin

Nonoral gram negative facultative rods Black pigmented bacteria and spirochetes Provetella intermedia,porphyromonas gingivalis Actinobacillus actinomycetemcomitans

ciprofloxacin metronidazole 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 associated with systemic Such as HIV diseases

Not

Any hematological diseases therapy Like leukaemia debridement with scaling and root Evaluate and treatment of any systemic disease

phase 1 local planning

Phase 1 therapy is followed that is local therapy Debridement of lesions with scaling and root planning Lavage and

phase 4or maintenance

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 in emergency

can undergo EDP restriction of LA containing epinephrin 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 doesnt resolve

continue treatment

second dose of nitroglycerin

monitor

3 doses of nitroglycerin 3 min after 2 dose


nd

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

Consut physician

Untreated Systolic BP>180mm Diastolic BP >110mm Tt should be limited to emergency until it is controlled and no routine perio tt should be given

treated

Local anaesthetic containing epinephrine conc greater than 1;100,000 or vasopressor to be used to control local bleeding

analgesics- for pain antibiotics for infusion

LA without epinephrine may be used for short period of time(<30min)

acute infection-surgical or drainage incision

small doses should be used

surgical field is limited if blood is seen it may rise the BP

intra ligamentary injection is generally contraindicted becoz hemodynamic changes are similar to intravascular injection

anxiety

postural hypertension is reduced by positional changes in chair

INFECTIVE ENDOCARDITIS

Prophylaxis recommended

Prophylaxis not recommended

High risk patients


1. 2. 3. a.

moderate risk patients


1.mitral valve prolapse valvular regurgitation 2.coronary artery bypass graft

Previous history of I.E 1.Acq. vavlular dysfunction Prosthetic heart valves 2.congenital heart malformation Major congenital heart disease 3.hypertrophic cardiomyopathy Tetralogy of fallot 4.mitral valve prolapsed Single ventricular state surgery. b. Transposition of greater artery 3.physiologic,functional c. Surgery constructed sys.pul.shunts

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 (to minimize bacteremia & Improve gingival health)

Recommrnded-Oral rinsus & gentle tooth brushing Not recommended- Oral irrigators(may induce bacteremia)

Antibiotic Regimen

ORAL- Amox-2gm 1hr before procedure(if allergic). 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 PERIODONTITIS+ RESISTANT TO PENCILLINS -Tetracycline-250mg 4 times for 14days.

PERIODONTAL TREATMENT -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 Digioxin Diuretics quidine defibrillators

pacemakers

implanted subcutaneously near

implanted in chest walls

umbilicus

enter heart transversely

have electrodes passing into the heart

older pacemaker unipolar

newer unit bipolar

activate without 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 for 6 months 6 months therapy with short appointments

high risk of recurrence

conc. 1:1,00,000 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 becoz after the therapy they are unable to eat and they may go to hypoglycemic attack If pt is restricted from eating insulin doses should be reduced If procedures are long insulin doses before the treatment may need to be reduc 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 If pt is restricted from eatin insulin doses should be reduced 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 sedatives and narcotics

medical management medical management

no periodontal therapy should limit stress and infection PARATHYROID

Medical history

Routine periodontal treatment

ADRENAL INSUFFICIENCY

Pt taking large doses greater than 20mg corticosteroid per day

pt taking small doses for short periods

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 immuno suppression

Drug administration

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 oforal 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 BT,CT,PT,PTT,INR Tourniquet test

look for petechia and haemorrhagic vesicles

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. 2. 3. 4. Factor ix concentrate Fresh frozen plasma Purified prothrombin complex concentrate 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 Plan should be done Monitor -bleeding time,clotting time Prothrombin time,platelet count Administer antibiotic coverage :

tests for

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 atieast before 10 days

DURING

Acute phase of leukemia

chronic phase

-Patient should receive only emergency Periodontal care -Antibiotic therapy with surgical\ non surgical Debridement -oral ulcerations and mucositis treated with Viscous lidocaine - oral candidiasis treated by Nystatin suspension[100,000/ml 4 times daily] Or clotrimazole Vaginal suppositories[10mg 4/5times daily

- scaling and root planning performed without complication

- if possible periodontal surgery indicated.

UN KNOWN PATIENT Refer physician Tests for leukemia

1.Blood picture: Anemia Platelets WBC severe increased increased moderate normal increased

2. bone marrow examination: Cellularity hyper cellular blastic cells increase serum lysozome . myloid serum B12 vit. B12 hypercellular .lymphatic cells erythrosyte rosttetest

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 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.

indicate agranulocttosis

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 Aspirin is avoided. Blood transfusions are avoided due to risk of transmission. Sharp instrument injury

INDICATIONS Protease inhibitors ex.Indinavir,Nelfinavir Reverse inhibitor

Ex zidovudine l lamivudine,didanosine In cases of candidiasisantifungal are given periodontal diseases: Oral hygiene Plaque removal chlorhexidine metronidazole herpes- anti virals apthous ulcers-corticosteriods

HEPATITIS HEPATITIS A Treated in acute phase HEPATITIS B

Drugs are used cautionly MANAGEMENT

Normal platelet count Normal prothrombin time

if platelet count is low and prothrombin time prolonged

can be treated

risk of transmission of HBs-Ag

but may have bleeding tendency HEPATITIS C

high risk in oral surgeon and periodontitis

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 Tests are positive

HBsaAg positive are infected

Anti HBsAg positive HbsAg negative

But HBV is suspected degree is measure Order another HBs Determination by HBsAg determination

may be treated

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 techniquesincluding 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 Minimize use of aerosols production by not using the ultrasonic instruments 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. No. 1)

CONDITION NORMAL GINGIVA

COLOUR Coral pink(Adults) Pale pink(children) Bluish hue on reddened gingiva

CONTOUR CONSISTENCY Scalloped outline Firm, resilient

2)

GINGIVITIS

Rolled out or rounded

Soggy, puffy Pits on pressure

marginal gingiva SEVERE, ACUTE CHRONIC Red or Bluish red Flat, blunt Interdental papilla Bluish red Diffuse puffiness and softening

3) 4) 5)

GINGIVA IN PUBERTY IN MENSTRUAL CYCLE IN PREGNANCY GINGIVITIS

Edematous Tense; bloated, with exudate release

Bright red to bluish red RASPBERRY appearance Bright red or magenta

GINGIVAL ENLARGEMENT - MARGINAL - TUMOR LIKE

Marginal and inter dental gingiva is edematous, smooth, shiny & pits on pressure Soft friable, smooth, shiny

Dusky red or magenta

6) 7)

MENOPAUSAL GINGIVOSTOMATITIS ADDISONS DISEASE

S. No. 8)

CONDITION

Abnormally pale to red Isolated patches of bluish black to brown COLOUR Discolouration Red (in anterior region) Red Pale pink

Semi firm, smooth, glistening surface with numerous deep red pinpoint markings Dry, shiny fissures in mucobuccal fold

CONTOUR CONSISTENCY

IN MOUTH BREATHERS GINGIVAL ABSCESS DRUG INDUCED

9) 10)

MULBERRY

Edematous (in anterior region), shiny surface Smooth, shiny surface Resilient, minutely

S. No. 11)

ENLARGEMENTS WITH INFLAMMATION WITHOUT INFLAMMATION CONDITION IDIOPATHIC GINGIVAL ENLARGEMENT IN VITAMIN C DEFICIENCY PLASMA CELL GINGIVITIS PYOGENIC GRANULOMA LEUKEMIA

shaped

lobulated surface & tendency to bleed Lobulated

Reddish or bluish COLOUR Pink CONTOUR

CONSISTENCY Firm, leathery, minutely pebbled surface Soft, friable, smooth, shiny Friable, granular Friable/firm Rounding of gingival margin Sponge like, friable, moderately firm

12) 13) 14) 15) 16)

Bluish red Red

17) 18) 19) 20) S. No. 21) 22)

Bright red and purple Bluish red or cyanotic PERNICIOUS ANEMIA Pale SICKLE CELL ANEMIA Pale yellowish APLASTIC ANEMIA pale THROMBOCYTOPENIA purplish WEGENERS Reddish purple GRANULOMATOSIS SARCOIDOSIS Red FIBROMA OF GINGIVA CONDITION COLOUR

Soft, swollen, friable gingiva

Smooth Spherical tumor, soft, vascular, firm, CONTOUR CONSISTENCY nodular Firm or spongy Flattened scaly lesion to thick, irregularly shaped keratinous plaque Shiny, hemorrhagic

PERIPHERAL GIANT CELL GRANULOMA LEUKOPLAKIA

Pink, deep red or purplish hue Grayish white

23)

NECROTIZING

Red

24) 25) 26)

ULCERATIVE GINGIVITIS PERIODONTAL POCKET PRIMARY HERPETIC GINGIVOSTOMATITIS DESQUAMATIVE GINGIVITIS MILD MODERATE SEVERE

Bluish red Red

(marginal gingiva involved) Thickened Flaccid, smooth marginal gingiva shiny surface Edematous, diffuse, shiny

Red Patchy red or gray areas Striking red colour Pale red to magenta Bright red marginal gingiva Fiery red Black line or bluish line which follows the contour of the gingiva

Irregularly shaped Denuded appearance

27) 28)

29) 30)

CHRONIC PERIODONTITIS NECROTIZING ULCERATIVE PERIODONTITIS AGGRESSIVE PERIODONTITIS BISMUTH, ARSENIC,MERCURY, LEAD PIGMENTATION