Perio

Question 1

Thyroid & parathyroid disorders managment

Answer 1

For thyrotoxicosis , inadequate medical management & poorly contr. patient

• not receive period. treat. until condition stabilized medication such as epinphrines not be given

In patient w history of hyperthyroidism

• be evaluated carefully to determine the level of medical management
• treat in away that limit stress & infection (hyper. may cause tachycardia, arrhythmias, increase cardiac out put, MI)
• medication such as epinphrines s be given w caution to patient ( small amount not cause problem)

Question 2

Adrenal insufficiency (adrenal crises) complication, managment, treatment

Answer 2

Complications associated with corticosteroid use

1. alteration in glucose metabolism (steroid induce diabetes)
2. incresed risk of infection
3. alteration in wound healing
4. osteoporosis
5. skin disorder
6. Suppression of hypothalamic-pituitary –adrenal (HPA) axis Treatment of patient with history of steroid use
7. consultation with physician
8. stress reduction protocol and profound l.anas.may decrease stress associated with therapy & decrease risk of acute AI
9. Rapid assay to determine the degree of adrenal reserve, by measurement of serum cortisol levels 30-60 minutes after IV administration of synthetic corticotropin.
10. For patient use topical corticosteroid , the need for steroid supplementation is not need.
11. The need for corticosteroid prophylaxis depends on the drug used bec. of variance in equivalent doses of corticosteroids (cortison 25mg,hydrocor.20mg,prednison 5mg,prednisolon 5mg)
12. if patient take large dose of>20mg of cortison/day& require stressful period.proce.
    a. double or triple normal steroid dose 1hr before procedure.
13. for patient receive low doses for short periods (i.e., <1month)
    a. no steroid supplementation
14. in emergency situation
    a. increase steroid dose before the procedure may decrease the chance of A A crisis, if emergency treatm. is not needed consultation w phyiscian before treatment

Management of patient in an AA crisis

If acute adrenal insufficiency occur w manifested by; Mental confusion, fatique,& weakness ,nausea & vomiting ,hypertension, syncope, intense abdominal pain, lower back pain, leg pain, loss of consciousness, coma

1. terminate period.treatment.
2. summon medical assistance
3. give oxygen
4. mointor vital sign
5. place patient in supin position
6. administer 100mg of hydrocortisonsodium succinate I.V for 30 sec or IM

Question 3

Treatment for pt with renal failure

Answer 3

1. consultation w patients physician
2. mointor BP( patient in end stage are hypertensive)
3. cheque laboratory value:PTT,PT,bleeding time,platelet count,hematocrit; Blood urea nitrogen if less than 60mg/dl (not treat);& serum creatinine( if less than1.5 mgldl) not treat
4. eliminate areas of oral infection to prevent systemic infection

good OHI should be established ,periodontal treatment should be aimed to eliminate inflammation or infection
 5. Drug that metabolized in kidney shouid not be given (ex. tetracycline, aminoglycoside antib.), acetaminophen may be used for analgesia & diazepam for sedation.

6. local anasth such as lidocaine are generally safe

Renal transplant patient ( they take immunosuppressive drugs which reduce resistance to infection ). 1-hep.B & hep. C screen

determinnation of level of immune system compromise prophylactlic antibiotic & physician consultation before prescribed

Question 4

patient w hemodialysis managment

4. Points

Answer 4

screen for hept.B & hept.C antigens & antibody before any treatment

2. Prophylactic antibiotic to prevent endarteritis of fistula or shunt
3. patient receive heparin anticoagulant on the day of hemodialysis ( treatment S be done the day after dialysis when the effect of heparin subside)
4. protect the hemo. shunt or fistula when patient in dental chair (if in arm; BP reading S be done in the other arm not use limb for injection) if the shunt in leg avoid sit of the patient for more than 1hr & if the perio.proce is long allow patient to walk for a few minute 
 refer patient to phy. If uremic problems develop ( ex. uremic stomatitis) & if oral inf. not resolve



Question 5

Liver disease. 
Managment

5 points

Answer 5

1. cons. w patient physi( stage of dis., risk of bleeding, drug to prescribed during treatment.& required alterations to period. Therapy)
2. screening for hepatitis B & C
3. laboratory values for PT, PTT, bleeding time ,platelet count
4. conservative, non surgical periodontal therapy whenever possible
5. if surgery is required ( may require hospitalization international normalized ratio ( INR ;PT) s be generally be less than 2.0 for simple surgical procedure ,INR less than 2.5 is generally safe platelet count s be less than 80,000 lmm3

Question 6

Pulmonary disease managment

Answer 6

1. 
In patient w known pulmonary disease consult w patients physician regarding medication ( antibiotic , steroid , chemotheraputic agents) , degree & severity of pulmonary disease
2. avoid elicitation of respiratory depression by:
   a. decrease stress of periodontal treatment
   b. avoid medication that cause respiratory depression (ex.sedative,anasthesia)
   c. avoid bilateral mandibular block anasthesia , w cause increase air way obstruction
   d. position the patient to allow maximum ventilatory efficiency ( alter the position ; keep the patient throat clear , avoid excess periodontal packing
3. In patient w history of asthma , medication s be available
4. patient w active fungal or bact. respiratory disease s not be treated only for emergency

Question 7

Immuno suppression (IS)& chemotherapy

Answer 7

chemotherapy is cytotoxic to bone marrow, destruction of platelets, red and white blood cells results in thrombocytopenia (platelet count less than 100,000 / mm3), anemia , leukopenia

1. IS individuals at great risk of infection & even minor periodontal infection may be life threatening if immunosuppression is sever`, so the treatment s be directed toward prevention of oral complication that could be life threatening ( the treatment s be conservative & palliative)
2. Evaluate the patient before the initiation of chemotherapy ( extracted of hopeless teeth, thorough debridement of remaining teeth to decrease microbial load )
3. OHI ( teach importance of good oral hygiene )
4. antimicrobial therapy ( chlorhexidine) to prevent 2dry inf. for patient with chemotherapyinduced mucositis
5. Chemotherapy is performed in cycles, each cycle last several days, followed by periods of myelosuppression and recovery , so if periodontal therapy is needed during chemotherapy , it is best done the day before chemotherapy , when WBC counts are relatively high (when WBC counts above 2000/ mm3, granulocyte count of 1000-1500/ mm3 )

Question 8

Radiation

Answer 8

preirradiation

a. initial visit s include panoramic, clinical dental examination , periodontal evaluation & physician consultation.
b. The treatment s commence after physical consultation and the 1st decision should involve extraction for hopeless teeth 2 weeks before radiation. 2. during radiation therapy
a. patient s receive prophylaxis weekly
b. OHI ( instruct patient to brush daily with 0.4% stannous or 1.0% sodium fluoride gel
c. professionally fluoride treatment
d. all remaining teeth s receive debridement ( scaling & root planning )
3. Post radiation therapy consist of :

a. palliative treatment 

i. viscous lidocaine ( painful mucositis)
ii. salivary substitutes for xerostomia
iii. cdaily topical fluoride & oral H.are the best means of prevention radiation caries over time

Question 9

prosthetic joint replacement ( PJR ) managment

And antibiotic regimen

Answer 9

the main treat. for patient w prosthetic joint replacement is the need for prophylaxis antib.

before periodontal therapy Prophylaxis is indicated for all patient win ( 2 years) after joint replace. & for high risk patient (previous prosthetic joint infection).

2. consultation with the orthopedic surgeon before periodontal treatment.

• If patient not allergic to pencillin—-o amoxicillin or cephalexin,cepfradine 2gr orally 1hr before treat
• if patient allergic to pencillin o clindamycin 600mg orally 1hr before treat
• if patient not allergic to pencillin but unable to take oral drug o Cephazoline 1gr or ampecillin 2gr( IM, IV ) 1hr before treat
• if patient allergic to pencillin& unable to take oral medication o Clindamycin 600mg ( IV ) 1hr. Before dental procedure

Question 10

Pregnancy

Answer 10

2. short appointment ( avoid long stressful appointment ) and allow the patient to change position frequently
3. l.anasth. can be used, also antibiotic, analgesic and other drug, but avoid drug that that are toxic or teratogenic effect on the fetus.
4. plague control, scaling , root planning & polishing s be the only none emergency periodontal procedure performed . Surgical procedure s be delayed after delivery
5. place the patient on the left side or by elevate the right hip 6 inch during treat.( to avoid supine hypotension syndrome)

Question 11

Leukemia

6 points 4X2 devision

Answer 11

refer the patient for medical evaluation and treatment

2. before chemotherapy , complete periodontal treatment should be developed with a physician
   a. mointor hematologic lab. test daily , bleeding time, coagulation time, PT, platelet count
   b. antibiotic coverage before any periodontal treat.
   c. extract all hopeless teeth 10 days before chemotherapy
   d. periodontal treatment sc. and root planning and thorough OHI given if patients condition allows. rinsing twice-daily with 0.12 % CHX after oral hygiene procedures , use pressure & topical hemostatic agent .
3. IN acute phase of the leukemia , patient receive emergency periodontal care only. Any source of infection s be eliminated to prevent systemic dissemination.Antibiotic therapy ,combined with nonsurgical or surgical debridement.
4. oral ulceration or mucositis can be treated palliatively w agents such viscous lidocaine , antib also given to prevent 2dry infection
5. oral candidiasis w common in leukemic patient ( nystatin suspension (100,000 U/ml) 4 times daily or clotrimazole suppositoris (10 mg) 5 times daily
6. in chronic leukemia
   a. scaling and root plan. can be performed without complication but avoid surgery
   b. platelet count & bleeding time S be measured on the day of procedure, if low stop the treatment and refer patient to the physician

Question 12

Guidelines for treating hepatitis patients:

Answer 12

1. If the disease, regardless of type, is active, do not provide periodontal therapy unless the situation is an emergency.
2. For patients with a past history of hepatitis, consult the physician to determine the type, course and length of the disease, mode of transmission, and any chronic liver disease or viral carrier state.
3. For recovered HAV or HEV patients, perform routine periodontal care.
4. For recovered HBV and HDV patients, consult with the physician and order HBsAg and anti–HBs laboratory tests.
5. For HCV patients, consult with the physician to determine the patient’s risk for transmissibility and current status of chronic liver disease.
6. If a patient with active hepatitis, positive-HBsAg ( HBV carrier) status, or positive-HCV carrier status requires emergency treatment, use the following precautions:
   a. Consult the patient’s physician regarding status.
   b. If bleeding is likely during or after treatment, measure PT and bleeding time. Hepatitis may alter coagulation;change treatment accordingly.
   c. All personnel in clinical contact with the patient should use full barrier technique.
   d. use many disposable covers for covering of light handle,head rest ,and bracket trays
   e. Aseptic technique s be followed at all items.minimize aerosol production by not using ultrasonic scaler, air syringe,or high speed handpieces. Prerinsing with chlorehexidene gluconate for 30 sec.
   f. When the procedure is completed, all equipment s be scrubbed and sterilized

Question 13

Guidelines for treating Tuberculosis patients (Tb):

Answer 13

1. The patient with tuberculosis should receive only emergency care.
2. If patient has completed chemotherapy, patient’s physician should be consulted (infectivity and the results of sputum cultures for Mycobacterium tuberculosis).
3. When sputum culture results are negative, these patients may be treated normally.
4. 5Any patient who gives a history of poor medical follow-up ( e.g., lack of yearly chest radiographs ) or shows signs or symptoms indicative of tuberculosis should be referred for medical evaluation.
5. Adequate treatment of tuberculosis requires a minimum of 18 months, and thorough posttreatment follow-up should include: chest radiographs, sputum cultures, review of the patient’s symptoms by the physician at least every 12 months.