Perio Case History 21l5a

DEPARTMENT PERIODONTICS

OF

COMPREHENSIVE HISTORY

CASE

[Type the document subtitle]

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 1.

Iron deficiency anaemia

Common in males: Attrition

2. Diseases of thyroid

carcinoma of buccal mucosa

3. Sjogrens syndrome

Caries in deciduous teeth

4. Juvenile periodontiis

Leukoplakia

5. Caries

Perinicious anaemia

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 & cium. • Erosion – sandblaster • Hepatitis-B- dentists,surgeons,blood bank personnel.

•

To know the financial status ,so that treatment can be varied.

CHIEF COMPLAINT: o

Should be recorded in patient’s own words.

o

It is the reason for which the patient has come to the doctor.

o

It should be given first priority.

o

Should be recorded in chronological order.

o

if few complaints start simultaneously , record them in the order of frequency.

o Probable chief complaints may be

 Bleeding gums  Staining of teeth  Malodour  Food impaction  Mobility  Pain  Recession  Swollen gums  Burning of mouth Questionarre 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? 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 ?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 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 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, migrating] • Localization behaviour • Concomitant neurological signs

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

Past dental history: -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 history: 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 example—obese 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: o

Note frequency of habit per day

o Frequency of brushing per day o Length of time that patient the had the habit in years.

Extra oral examination:  Temporo mandibular t 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 - 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: Gingival Pocket(pseudo pocket): This type of pocket is formed by gingival enlargement without destruction of underlying periodontal status.

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 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  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 Grade1 : 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:  Grade1 : Incipient or early stage.pocket is suprabony or primarily affects soft tissues.radiographic changes not present.  Grade2 : Can effect one or more furcations of same tooth.’’cul-de-sac‘’ with definite horizontal component.R/E-may or may not depict.  Grade3 : Bone is not attached to the dome of furcation.may be filled with soft tissue.R/Eradiolucent area in the crotch of the tooth.

 Grade4 : Inter-dental 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 doesn’t 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 it’s 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 CONTROL

SUGGESTED

TO

IMPROVE

DIABETES

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 ctthrombocytopenic 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: Gingival Pocket (Pseudo Pocket): This type of pocket is formed by gingival enlargement without destruction of underlying periodontal status.

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 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  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 tissues.radiographic changes not present.

is

suprabony

or

primarily

affects

soft

 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 mucosa,frenula,muscle

mucogingival junction and attachments,vestibular

its

relationship to fornices,floor

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

the

gingiva,alveolar of mouth.

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 contraceptives: 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 mouth wash twice daily. IN INFECTIVE ENDOCARRDITIS PT’S 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[NSAID’s]

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

oral hygiene reinforcement

Professional recalls

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

Gingival enlargement regresses

Maintain good oral hygiene Maintain professional recalls

revaluation

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

1st treated ANUG then proceed

oral hygiene reinforcement

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

flap surgery

GINGIVAL ENLARGEMENT IN PREGNANCY Treatment requires elimination of all local irritants responsible for the gingival changes Marginal and interdental gingival enlargement enlargement

Scaling and curettage, oral hygiene instructions and root planning, oral hygieneinstructions

Tumor like gingival

surgical excision, scaling

ENLARGEMENT IN PUBERTY: 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

Scalingand root planning Oral hygiene, chlorhexidine

more fibrotic

shrinkage does not occur after scaling and root planning

Surgery indicated

Gingivectomy

flap surgery

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

No therapy

SYMPTOMATIC

erosive or ulcerative

Rule out superimposed candidisis if +ve use anti fungal drugs

Periodic exam

Topical steroids

Intra lesional steroids for Large chronic ulcers

Resolution

No Resolution

Wean off and moniter

Refer to dermatologist [retinoids,dapsone,cyclosporines, photopheresis ]

TREATMENT OF CICATRICIAL PENPHIGOID: CICATRICIAL PEMPHIGOID

Asymptomatic

Plaque control

mild to moderate

severe

Topical steroids

Refer to dermatologist

Prednisolone

Dapsone

No Resolution

[dapsone,methotrexate,cyclosporins, cytophosphamide,azathioprine]

DIAGNOSIS OF PEMPHIGUS VULGARIS

REFER TO DERMOTOLIST

Primary treatment

Prednisolone

Secondary treatment

[azathioprine,cyclophaspamide,cyclosporines]

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 – I Therapy Scaling and root planing

Phase – I Therapy Scaling and root planing

Phase – 4 Therapy

Phase – 4 Therapy

Maintenance phases

Maintenance phases

SUPRABONY POCKETS

INTRABONYPOCKETS

PHASE 1 THERAPY PHASE 1 THERAPY

SCALING AND ROOT

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 Re-evaluated 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

SCALING AND ROOT PLANNING

PHASE 2 THERAPY

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

When less than 30% of sites

Generalized periodontitis

when more than 30% of sites attachment

exhibit attachment loss and bone loss

and bone loss

TREATMENT PLAN PHASE 1 THERAPY OR NON SURGICAL PHASE

Scaling and root planning

Phase 4 maintenance phase

AGGRESSIVE PERIODONTITIS

LOCALIZED

GENERALIZED

RAPIDLY PROGRESSIVE

TREATMENT PLAN NONSURGICAL

SURGICAL

ANTIMICROBIAL THERAPY

IT INCLUDES Pt Education

Resective & Regenerative

To eliminate or reduce pockets And vertical bone defects Depths with multiple osseus walls not done in horizontal bone loss

Phase 1 therapy

Scaling and Root planning Regular recall P hase 4 Early diagnosis cases shows better results Moderate to severe cases poor prognosis

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

ANTIBIOTIC FOR CHOICE

Gram positive organisms

Amoxicillin –clavulanate potassium (augmentin)

Gram negative organisms

clindamycin

Nonoral gram negative facultative rods

ciprofloxacin

Black pigmented bacteria and spirochetes

metronidazole

Provetella intermedia,porphyromonas gingivalis

tetracyclines

Actinobacillus actinomycetemcomitans

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

Not associated with systemic Such as HIV diseases

Any hematological diseases Like leukaemia

Phase 1 therapy local debridement with scaling and root planning

Evaluate and treatment of any systemic disease

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

Phase 4 therapy or maintenance therapy

Proper oral hygiene instructions

phase 4or maintenance

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

supplementation of O2 by cannula

discontinue treatment

ister 1tab of nitroglycerin sublingually Loosening of garments ister pt in relaxed position Signs and symptoms cease in 3 min

resolving

continue treatment

doesn’t resolve

second dose of nitroglycerin

monitor

3 doses of 2nd dose

nitroglycerin 3 min after

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 by , femoral artery by , angioplasty , endartectomy are some of the common diseases of IHD

Consult physician Prophylactic antibiotics are given CONGESTIVE HEART FAILURE

Poorly treated

Elective dental procedures

Treated CHF

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

Consult physician

Untreated

Treated

Systolic BP>180mm Diastolic BP >110mm Tt should be limited to EMERGENCY until it is Vasopressor Controlled and no routine

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

Perio TT should be given

Analgesics- for pain Antibiotics –for infusion

Acute infection-surgical or Drainage incision

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

small doses should be used

Surgical field is limited if

Intraligamentary injection is generally

Blood is seen it may rise the BP

Contraindicated because hemodynamic Changes are similar to intravascular Injection

Anxiety

Postural hypertension is reduced by positional changes in chair

INFECTIVE ENDOCARDITIS

Prophylaxis recommended

High risk patients 1.

Prophylaxis not recommended

moderate risk patients

Previous history of I.E

1.Acq. vavlular dysfunction

2. Prosthetic heart valves prolapse

2.congenital heart malformation

3. Major congenital heart disease regurgitation

3.hypertrophic cardiomyopathy

a. Tetralogy of fallot artery Single ventricular state graft surgery.

4.mitral valve prolapsed

1.mitral valve valvular 2.coronary by

b. Transposition of greater artery functional

3. Physiologic,

c. Surgery constructed sys.pul.shunts murmurs

or innocent 4.Rheumatic fever vavular dysfunction 5. Surgically ASD,VSD or PPD 6.kawasaki disease without vavular dysfunction

PREVENTIVE

MEASURES:

Define history

patient-

susceptible

medical

ORAL- Amox-2gm 1hr before procedure(if allergic). Clindamycin-600mg 1hr before procedure.

Provide

oral

(to minimize Improve gingival

hygiene Recommrnded-Oral rinsusinstructions & gentle tooth brushing bacteremia & Azithromycin or Clarithromycin-500mg 1hr before procedure. Not recommended- Oral health) Or irrigators(may induce bacteremia) Or

Cetadroxil-2gm 1hr before procedure.

Antibiotic Regimen

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 in chest walls

enter heart transversely

implanted subcutaneously near

umbilicus

have electrodes ing into the heart

Older pacemak

Newer unit bipolar

disrupted by dental equipment that generated

Activate without unipolar

warning when certain arrhythmias occur cause sudden pt movt

not affected by dental equipment

EM fields

CEREBROVASCULAR ACCIDENTS No periodontal therapy

high risk of recurrence

for 6 months

6 months therapy with short appointments

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

Consult physician

diagnosed

well controlled

Analyze laboratory tests

good response

poor controlled

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 because after the therapy they are unable to eat and they may go to hypoglycemic attack o

If pt is restricted from eating insulin doses should be reduced

o

If procedures are long insulin doses before the treatment may need to be reduced

o 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 o If pt is restricted from eatin insulin doses should be reduced o If procedures are long insulin doses before the treatment may need to be reduced

THYROID AND PARATHYROID DISORDERS THYROID

Thyrotoxicosis

Inadequate

hyperthyroidism

hypothyroidism

Determine level of

Medical management. medical management

No periodontal therapy

should limit stress and infection

PARATHYROID

Medical history

Careful istration of sedatives and narcotics

Routine periodontal treatment

ADRENAL INSUFFICIENCY

Pt taking large doses greater than

pt taking small doses for short periods

20mg corticosteroid per day 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

ister 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 Drug istration

:

Immuno suppression

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 of oral 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)

Normal bleeding

spontaneous bleeding

Go for laboratory tests BT,CT,PT,PTT,INR

if BT > 5min( abnormal)

look for petechia and haemorrhagic vesicles

Tourniquet test 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. Factor ix concentrate 2. Fresh frozen plasma 3. Purified prothrombin complex concentrate 4. 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

Chemo therapy

radiation

un known patient

corticosteroids

Before chemo therapy a complete periodontal treatment

refer to physician

tests for

Plan should be done Monitor -bleeding time,clotting time

:

Prothrombin time,platelet count ister antibiotic coverage 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 at least before 10 days

DURING

Acute phase of leukemia

-Patient should receive only emergency planning Periodontal care -Antibiotic therapy with surgical\ non surgical

Chronic phase

- scaling and root performed without complication

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

- if possible periodontal surgery indicated.

UN KNOWN PATIENT – Refer physician Tests for leukemia

1.Blood picture: Anemia

severe

moderate

Platelets

increased

normal

WBC

increased

increased

2. bone marrow examination: Cellularity

hyper cellular

hypercellular

blastic cells

.

myloid

.lymphatic cells increase

serum lysozome

serum B12

erythrosyte rosttetest

vit. B12

acute leukemia

chronic myeloid

lymphatic

chronic leukamia

AGRANULOCYTOSIS[cyclic neutropenia and granulocytosis

Pt. with agranulocytosis

Drug induced

unknown patient

due to other causes

Eliminate those drugs 2000

Both types agranulocttosis 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.

refer to physician

if WBC count <

indicate

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

INDICATIONS

• Aspirin is avoided.

Protease inhibitors

• Blood transfusions are avoided due to risk of transmission.

ex.Indinavir,Nelfinavir Reverse inhibitor

Sharp instrument injury Ex zidovudine l lamivudine,didanosine In cases of candidiasis antifungal 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

can be treated

if platelet count is low and prothrombin time prolonged

risk of transmission of HBs-Ag

but may have bleeding

high risk in oral surgeon and periodontitis

tendency HEPATITIS C 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

HBsaAg positive

Tests are positive

are infected

But HBV is suspected

degree is measure

Order another HBs

Anti HBsAg positive HbsAg negative

may be treated

by HBsAg determination

Determination 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 with pts should use a barrier techniques including 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.

7.

Minimize use of aerosols production by not using the ultrasonic instruments.

8. 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.

CONDITION

COLOUR

CONTOUR

1)

Normal Gingiva

Coral pink(Adults) Pale pink(children)

2)

Gingivitis

Bluish hue on Rolled out or reddened gingiva rounded marginal gingiva

severe, acute chronic

Red or Bluish red

3)

gingiva in puberty

Bluish red

4)

in menstrual cycle

5)

in pregnancy • gingivitis

• gingival enlargement - marginal

- tumor like

Scalloped outline

Flat, blunt Interdental papilla

CONSISTENCY Firm, resilient

Soggy, puffy Pits on pressure Diffuse puffiness and softening

Edematous Tense; bloated, with exudate release

Bright red to bluish red “RASPBERRY” appearance Bright red or magenta

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

Dusky red or magenta Semi firm, smooth,

glistening surface with numerous deep red pinpoint markings 6)

menopausal gingivostomatitis

Abnormally pale to red

7)

addison’s disease

Isolated patches of bluish black to brown

Dry, shiny fissures in mucobuccal fold

Discolouration 8)

in mouth breathers

Red (in anterior region)

Edematous (in anterior region), shiny surface

9)

gingival abscess

Red

Smooth, surface

10)

drug induced enlargements • with inflammation • without inflammation

Pale pink

“MULBERRY” shaped

Reddish or bluish gingival Pink

shiny

Resilient, minutely lobulated surface & tendency to bleed Lobulated

11)

idiopathic enlargement

Firm, minutely surface

leathery, pebbled

12)

in vitamin ‘c’ deficiency

Bluish red

Soft, friable, smooth, shiny

13)

plasma cell gingivitis

Red

Friable, granular

14)

pyogenic granuloma

Bright red and purple

Friable/firm

15)

leukemia

Bluish red cyanotic

16)

pernicious anemia sickle cell anemia aplastic anemia

Pale Pale yellowish Pale

17)

thrombocytopenia

Purplish

or Rounding of Sponge like, friable, gingival margin moderately firm

Soft, swollen, friable

gingiva 18)

wegeners granulomatosis

Reddish purple

19)

sarcoidosis

Red

20)

fibroma of gingiva

21)

peripheral granuloma

22)

leukoplakia

23)

necrotizing gingivitis

24)

periodontal pocket

25)

primary gingivostomatitis

26)

desquamative gingivitis • mild

Smooth Spherical tumor, soft, vascular, firm, Nodular

giant

cell Pink, deep red or purplish hue

Firm or spongy

Grayish white

Flattened scaly lesion to thick, irregularly shaped keratinous plaque

ulcerative Red

Shiny, hemorrhagic (marginal gingiva involved)

Bluish red

Thickened marginal gingiva

herpetic Red

• moderate • severe

Edematous, diffuse, shiny

Red Patchy red or gray areas Striking red colour Pale red magenta

Flaccid, smooth shiny surface

27)

chronic periodontitis

to

28)

necrotizing periodontitis

29)

aggressive periodontitis

30)

bismuth, arsenic,mercury, Black line or lead pigmentation bluish line which follows the

ulcerative Bright red marginal gingiva Fiery red

Irregularly shaped Denuded appearance

contour gingiva

of

the