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Oral Diagnostics
Indication and contraindication of dental treatment relating to general health status
Dr Bródy AndreaSemmelweis EgyetemFogorvostudományi KarOralis Diagnosztikai Tanszék
Dentistry is a profession and not a trade
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
Is the information received always realistic?
No! Because:• The patient had a bad experience earlier and
doesn’t 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
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
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!
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.
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 patient’s 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.
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
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.
Treatment of a patient with an infectious disease
• Should be called into the dentist’s 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!!!
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• Kaposi’s sarcoma
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
Kaposi’s sarcoma
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
Autoimmune diseases
Sjögren syndrome
•Dry mouth
• Inflamed conjunctiva
• Lymph node enlargement
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
Nifedipine induces gingiva hyperplasia
6 months after the end of the therapy
Cardiovascular diseases – dental aspects
Pacemaker
Ultrasonic depurator, electrocauter and apex locator may not be used. Depuration with manual tools or possibly sonic depurator.
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
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 < 500/mm3) the patient should be treated with antibiotic prophylaxis.
• Before the treatment chlorhexidine mouth rinse must be administered to avoid bacterial complications.
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)
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!
?
• Extreme amount of plaque in an adult male patient
Candidiasis
Investigation of background disease is necessary!
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
Haematological diseases – haemorrhagic patient
• Vasculopathies• Complications regarding the platelet system• Coagulopathies (inherited, obtained)
Inherited:• Haemostasis disorders (intramuscular
haematomes, GI bleeding)
Obtained:• Heparins, Kumarins, Aspyrin
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
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!
Malignant diseases
• Radiotherapy
• Chemotherapy
• Steroids
Immune compromised status
Bisphosphonate treatment
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)
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
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
Steroids
• Long-term application will harm the operation of the immune system
• They cause osteoporosis
Transplant patients, autoimmune patients, patients with malignant tumor
Eating disorders - bulimia
• Acid erosion on the teeth, the angulus oris, enlarged salivary glands
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
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.
