Oral Diagnostics Indication and contraindication of dental treatment relating to general health status

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Oral DiagnosticsIndication and contraindication
of dental treatment relating to general health
status
Dr Bródy Andrea Semmelweis Egyetem Fogorvostudomán
yi Kar Oralis Diagnosztikai Tanszék
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Dentistry is a profession and not a trade
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Factors for the assessment of general health
status

• The known health problems of the patient
• Contraindications and risks caused by used
  medicines
• Estimation of complications and risks, and
  planning the possibilities of prevention
• Evaluation of the complaints and symptoms which
  refer to undiagnosed diseases to improve
  chances for early diagnosis of a serious disease

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Is the information received always realistic?
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No! Because

• The patient had a bad experience earlier and
  doesnt tell us the truth
• Extenuate the earlier treatments or earlier used
  medicines
• Is ashamed of the problem e.g. alcohol abuse,
  or afraid of the consequences e.g. drugs
• Is unable to give us the right information
• No explanation
• Surprising motivation

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Risks relating to general health status

• The general health status could cause a risk for
  the
• patient (e.g. Prosthetic valves, hemophilia),
• environment and the health team (e.g. infective
  diseases)
• for both (e.g. haemophiliac HIV positive
  patient).
• Medical problems Dental
  treatment
• Treatment, used materials
  Disease
• Oral health General
  health

influenced
influenced
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Contraindications relating with general health
status

• Treatment is contraindicated in case of
• Acute infective diseases
• Patient in need of hospitalization
• Mental disorders in need of sedatives
• Severe allergic reaction to earlier dental
  treament with unknown origin

Must find the solution!
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Patients with infectious diseases

• Important to differentiate acute (influenza,
  herpes simplex, etc.) and chronic infections
  (HIV, HBV, HBC, TBC)
• Acute infection postpone the treatment if it is
  possible or choose conservative therapy
• Exception pulpitis, periapical abscess
• Take into consideration applied medicines for the
  basic disease.

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Patients with infectious diseases

• The treatment may not be refused in the event of
  an infectious disease!
• In most cases interaction with an HIV infected
  patients blood or excretion does not lead to
  infection.
• Accepting attitude more information
• In case of an injury it is vital to find the
  serological status of the source of the
  infection.

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Types of exposure

• Pierced or cut injuries with a contaminated
  instrument
• Direct contact between mucosa or damaged skin
  with blood or excretions
• Human bite
• Laboratory infection

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Risks

• The probability of HIV infection in the event of
  exposure is 0.3.
• In connection to HBV and a vulnerable patient it
  is 6-30, to HCV 1.8
• Contact between a small amount of blood and
  intact skin does not carry risk.

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Treatment of a patient with an infectious disease

• Should be called into the dentists surgery as
  the last patient
• Mouth hygiene has increased significance,
  chlorhexidine mouth rinse
• In the event of invasive treatment antibiotic
  prophylaxis may be necessary
• Protective equipment should be worn mask,
  glasses, gloves
• Avoid the use of the turbine and ultrasonic
  depurator if possible
• Disinfection must be performed as usual!!!

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Oral cavity symptoms of HIV viral infection

• Most common symptoms
• Oral candidosis (75 incidence)
• Hairy leukoplakia
• Herpes simplex, Herpes zoster
• Periodontal infections
• HIV gingivitis, necrotizans ulcerative
  gingivitis,
• necrotizans ulcerative periodontitis
• Kaposis sarcoma

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Oral manifestations of humanimmunodeficiency
virus

• Photograph of the interior of the mouth of a
  person suffering from AIDS
• Photograph of the interior of the mouth of a
  person suffering from AIDS

Kaposis sarcoma
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Autoimmune diseases Lupus Vulgaris

• The buccal mucosa, hard palate, and vermilion
  border are the locations most frequently involved
  by lesions, which can be three types (discoid
  lesions, erythematosus lesions, and ulcers) 

Discoid erithematosus laesio
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Autoimmune diseases

• Sjögren syndrome
• Dry mouth
• Inflamed conjunctiva
• Lymph node enlargement

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Cardiovascularis betegségek Cardiovascular
diseases

• High blood pressure, valve disorders, myocadial
  infarction, congestive heart disease, arithmia,
  angina
• Warning symptoms heavy breathing, high blood
  pressure, irregular pulse, periferic oedema,
  cyanosis, chest pain, gingiva hyperplasia, dry
  mouth
• Alpha and Beta blockers, Ca channel blockers,
  diuretics

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• Nifedipine induces gingiva hyperplasia

6 months after the end of the therapy
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Cardiovascular diseases dental aspects

• Pacemaker
• Ultrasonic depurator, electrocauter and apex
  locator may not be used. Depuration with manual
  tools or possibly sonic depurator.

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Dental aspects

• Stress reduction protocol, control of blood
  pressure
• Patients with stable heart disease receiving
  atraumatic treatment under local anaesthesia can
  receive treatment in the dental surgery.
• After myocadial infarction in the first year
  treat the patient with high attention
• Cardiac events are most likely to occur in the
  early morning patients with cardia disease
  should be treated in the late moring or afternoon
• If it is necessary - anitimicrobial prophylaxis
• Limiting the dosage of the tonogen

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Antibiotikus profilaxis Antibiotic prophylaxis

• A bleeding related intervention often causes
  transien bacteraemia.
• In the event of certain diseases as well as
  patients with neutropenia (neutrophil lt 500/mm3)
  the patient should be treated with antibiotic
  prophylaxis.
• Before the treatment chlorhexidine mouth rinse
  must be administered to avoid bacterial
  complications.

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Antibiotic prophylaxis recommended in the event of

• Congestive cardiac failure, stenosis
• Prosthetic valves
• Intra-, extracardiatic shunt,
• Diseases of the valves (stenosis, insufficiency)
• Endocarditis
• Dialysis, renal diseases,
• Prosthetic joints,
• Immundeficiencies
• Amoxicillin, Clindamycin, Erythromycin
• (UK National Institute completely removing the
  need for antibiotic prophylaxis in relation of
  dentistry)

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Inflammation

• Epicenter Chronic inflammation at a certain
  place in the body. Often comes without symptoms
  as a persistent state.
• The epicentral inflammation can cause
  disseminated infections.
• Periodontal pocket myocardial
  infarction, stroke, premature birth
• Immune compromised patient need high attention!

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?

• Extreme amount of plaque in an adult male patient

Investigation of background disease is necessary!
Candidiasis
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Haematological diseases neutrophil system

• Leukemia the first symptoms show in the mouth
  (Oral manifestations are more common in acute
  leukaemias.)
• Not healing, plaque-covered ulcers, necrotisans
  ulcerative gingivitis, candida infection early
  diagnosis may be life saving!

Ulcer on the lingual mucosa
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Haematological diseases haemorrhagic patient

• Vasculopathies
• Complications regarding the platelet system
• Coagulopathies (inherited, obtained)
• Inherited
• Haemostasis disorders (intramuscular haematomes,
  GI bleeding)
• Obtained
• Heparins, Kumarins, Aspyrin

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Haematological diseases haemorrhagic patient

• Hemophilia-This is a genetic bleeding disorder
  that frequently has oral manifestations.
• Spontaneous gingival bleeding may occur.

Spontaneous bleeding may occur
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Haematological diseases haemorrhagic patient

• The physician has to aim to avoid invasive
  treatment of haemorrhagic patients
• Anaesthesia, subgingival depuration, oral surgery
  treatment factor substitution is necessary
• Team work is important in the case of a
  haemorrhagic patient dentist haematologist,
  laboratory expert
• Tooth extraction may be performed without
  hospitalizing the patient!

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Malignant diseases

• Radiotherapy
• Chemotherapy
• Steroids
• Immune compromised status
• Bisphosphonate treatment

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Bisphosphonates

• Bisphosphonates are analogues of inorganic
  pyrophosphates,which are commonly used in the
  treatment of osteoporosis, metastatic osteolytic
  bone disease and primary resorptive malignancies
  of bone like multiple myeloma. (act on
  osteoclasts)

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Bisphosphonates

• Patients with bone metastasis suffer jaw necrosis
  in 2.8 of the occassions (Aredia, Zometa,
  intravenal use)
• One of the main risk factors of the development
  of necrosis is existing tooth or periodontal
  disease, not properly fitting removable denture,
  dental treatment
• It was caused in most cases by tooth extraction
  and periodontitis

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Bisphosphonates

• Suspension of the bisphosphonate treatment does
  not stop the progress
• Due to the long half life time, even after the
  completion of the treatment the risk of BON
  (bisphosphonate induced osteonecrosis of jaw) is
  still present
• Prevention Prior to starting the treatment all
  dental problems must be eliminated, if possible
  permanent tooth substitutions should be inserted
• Warning signs erithema, ulcer, movable teeth

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Steroids

• Long-term application will harm the operation of
  the immune system
• They cause osteoporosis
• Transplant patients, autoimmune patients,
  patients with malignant tumor

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Eating disorders - bulimia

• Acid erosion on the teeth, the angulus oris,
  enlarged salivary glands

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Additional risks

• Diabetes mellitus severe periodontitis and
  candidosis may draw attention
• - timing of meals must be paid attention
• Pregnancy increased care must be taken when
  prescribing medicine, x-ray examination may only
  be performed if absolutely necessary
• Alcohol abuse, drugs

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Patient assignment and consultation with other
professionals

• Always consult the GP or the doctor treating the
  patient in the event of severe basic disease e.g.
  recent myocardial infarction, coagulopathies,
  immune deficient state
• All documents must be filed and properly taken
  care of.

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Thank you for your attention!
brody.andrea_at_gmail.com