 An acute inflammatory disease which occurs as a

sequel to infections caused by group A streptococci.

 Principally involves heart, joints, skin, nervous system,
& subcutaneous tissues.
 Can occur at any age, most commonly between 6 & 15
yrs of age
 Condition can be fatal in the acute stage or can lead to
chronic rheumatic heart disease due to scarring of the
valves.
 Initial symptoms fever, nausea, anorexia, lethargy, &
arthralgia.
 JOHN’S CRITERIA

MAJOR CRITERIA MINOR CRITERIA

carditis fever
polyarthritis arthralgia
chorea Previous history of
rheumatic fever or
rheumatic heart disease
Erythema marginatum Raised ESR
Subcutaneous nodules Prolonged P-R interval on
ECG
 The diagnosis is based on:
 Two or more major criteria
 One major with 2 or more minor criteria
 In both cases, there should be evidence of positive
previous streptococcal infection.
 Blood examination: leucocytosis, raised ESR
 Bacteriological tests: throat swab culture
 Chest X ray- cardiomegaly
 ECG
 Echocardiography
 Bed rest- prolonged rest of 2-6 weeks.
 Salicylates- large doses of aspirin (60 mg/kg/day)
divided into 6 doses may provide symptomatic relief
of arthritis in children.
 Corticosteroids: prednisolone 1-2 mg/kg/day in
divided doses till ESR falls down.
 Antibiotics: benzathine penicillin (1.2 million units)
im on diagnosis, followed by once a week for 3
weeks.
 Follow up.
 Careful dental evaluation is needed and required dental
treatment should be completed before surgery.
 Preventive dental program should be implemented.
 Decrease the incidence of postoperative endocarditis
from oral sources.
 Consultation with cardiologist
 Ab prophylaxis
 Dental treatment should be completed within 3-4 weeks
of planned surgery to allow healing & return of normal
microflora.
 Prior to treatment, complete medical history
should be elicited and consultation with the
child’s cardiologist is necessary to determine the
child’s ability to tolerate the planned dental
treatment, complications that can arise and Ab
prophylaxis to be given.
 Pulp therapy of primary teeth is not

recommended due to high risk of chronic

infection.

 Instead, extraction of offending tooth and its

replacement with a space maintainer is

advocated (distal shoe is not advocated)

 In permanent dentition, endodontic therapy may be

undertaken after a careful evaluation and case selection

(a tooth with poor prognosis is better removed)

 Oral sedation & nitrous oxide analgesia may be

beneficial in reducing anxiety and minimizing risk.

 Orthodontic treatment should be done under Ab

prophylaxis, especially band placement & removal.

 In pts who are on anticoagulant therapy,
hematological monitoring and cessation of
anticoagulant therapy are important before any dental
surgery is undertaken.
Children suffering from severe, debilitating, heart
disease requiring extensive dental work up should be
treated in a hospital under general anesthesia.
 It is a microbial infection of mural
endocardium, a heart valve or valves
(native or prosthetic) or lining of a blood
vessel, or a congenital defect (septal
defect).
 It may be acute or subacute.
 Ab prophylaxis may be given in infective endocarditis
patients for those dental procedures which are likely to
induce gingival bleeding like scaling, incision &
drainage, intraligamentary injections.

 Dental procedures that do not require prophylaxis

include those which may not induce gingival or
mucosal bleeding, such as simple orthodontic
appliances, filling above the gum line
Prophylaxis recommended Prophylaxis not recommended

Dental extractions Restorative dentistry

(operative/prosthodontic)

Endodontic instrumentation or LA injections (nonligamentary)

surgery beyond apex

Subgingival placement of Ab fibres Intracanal endodontic treatment;

or strips. post placement and build up.

Intraligamentary LA injection Placement of rubber dams

Dental implant placement Postoperative suture removal

 Given by American Heart
Association
 Adults: Amoxicillin 2 g orally, 1 hr
before procedure
 Children 50 mg/kg, orally, 1 hr
before procedure.
 This is for patients allergic to penicillin:
 Adults:
 Clindamycin 600mg orally 1 hr before procedure or
Cephalexin or Cefadroxil 2 g orally 1 hr before procedure
or Azithromycin or Clarithromycin 500 mg orally 1 hr
before procedure.
 In children:
 Clindamycin 10 mg/kg 1 hr before procedure, then half dose
6 hours after initial dose
Or
Cephalexin or Cefadroxil 50 mg/kg orally 1 hr before
procedure
Or
Azithromycin or clarithromycin 15 mg/kg orally 1 hr before
procedure.

Circulation 1997
 Most common endocrine disorder of
childhood.
 Inadequate supply of insulin to meet
physiologic needs of the body at a cellular
level.
 Destruction of beta cells of islets of langerhans.
 Juvenile onset diabetes.
 Interaction of genetic, environmental & immunological
factors.
 Beta cells are damaged when genetically predisposed
individuals are subjected to a virus, which induces a
sequence of destructive autoimmune responses.
 5-15%
 Abrupt onset, condition may be unstable and difficult to
control.
 Onset of symptoms is rapid
 1. Classic triad: polyuria,polydipsia &
polyphagia in association with wt loss.
 2. Ketoacidosis: if severe, pt may develop
mental apathy, confusion and may lapse into
coma called “diabetic ketotic coma”
  Reduced salivary flow
 Burning mouth/tongue

 Candidiasis

 Altered taste

 Progressive periodontitis
 Dental caries

 Oral neuropathies
 Parotid enlargement

 Sialosis

 Delayed wound healing

 Increased glucose content in GCF
 Well controlled young diabetic experiences a normal or
even reduced level of dental caries.
 This can be attributed to restriction of sugar &
carbohydrates, effective metabolic control, good oral
hygiene, and regular dental review.
 Elevated salivary glucose & decreased salivary flow in
uncontrolled patients may lead to severe gingivitis &
periodontitis.
 Aimed at implementation of a preventive protocol,
symptomatic relief of any oral manifestations of the
disease & immediate provision of primary care.
 Comprehensive medical history along with
screening tests for diabetes are essential.
 Dental appointments should be short, stress free, as
atraumatic as possible.
 Early morning appointments are preferred and
the patient should eat a normal breakfast before
the appointment.
 Conscious sedation is preferred than deep
sedation.
 If the pt has to go for GA, admit him in the
hospital and insulin regimens should be adjusted
by diabetologist.
 Use of pulp capping & deciduous pulpotomy
procedures is questionable in child with
uncontrolled diabetes.
 Vital pulp therapy may be preferred to a stressful
extraction procedure under LA.
 Non vital tooth with evidence of infection-
extraction is the only treatment of choice.
 Fixed & removable orthodontic appliances may be
preferred, depending on the periodontal health of
the patient.
 Prophylactic Ab may be recommended in use for
surgical procedures.
 Vasoconstrictor drugs with LA to ensure profound
anesthesia are advocated, but excessive adrenaline
dosage is contraindicated.
 Hepatitis is inflammation of the liver
that can result from infectious or non
infectious causes.
Acute viral hepatitis is the most common
form of infectious hepatitis.
Five distinct viruses-typesA,B,C,D and E-
are associated with this disease.
 The American Dental Association and the CDC
recommend that all dental health care workers who
provide patient care receive vaccination against
hepatitis B virus and implement universal
precautions during the care of all dental patients.
PREVENTION THROUGH ACTIVE IMMUNIZATION
Risk for viral hepatitis is reduced by receiving active
immunization.
Currently 2 vaccines are available for HAV.
◦ They are Harivax and Vaqta .
◦ The HepatitisB vaccine have evolved
from first developed in 1982.
◦ The two vaccines licenced for prevention
of HBV infection (EngerixB and
Recombivax HB) are produced by
recombinant DNA technology.
◦ 1 vaccine (TWINRIX) is available for
combination of Hepatitis A and Hepatitis
B.
▪ No dental treatment other than urgent
care should be rendered for a patient with
active hepatitis unless the patient is
clinically and biochemically recovered.
▪ Urgent care should be provided only in an
isolated operatory while adhering to strict
universal precautions.
 Aerosols should be minimized and drugs
metabolized in the liver avoided as much as
possible.
 If surgery is necessary,a preoperative
prothrombin time and bleeding time should
be obtained and any abnormal results
discussed with the physician.
 The dentist should refer the patient with
acute hepatitis for medical diagnosis and
treatment.
 In case of patients with a history of hepatitis
of unknown type is to use the clinical
laboratory to screen for the presence of
HBsAg or anti-HCV.
 Anemia is defined as reduction in the volume
of RBC in the packed cell volume (PCV) or in
the concentration of hemoglobin in
peripheral venous blood.
 Microcytic hypochromic anemia
 Macrocytic anemia
 Pernicious anemia
 Haemolytic anemia
 Aplastic anemia
 Sickle cell anemia
 Causes are
-too much milk less solid
-chronic blood loss in teenage girls
associated with menorrhagia
ORAL MANIFESTATION
-painful atrophic tongue
-angular cheilitis
-pale mucosa
-gingivitis and periodontitis
 Maintenance of oral hygiene
 Supplement iron in diet.
 Symptomatic treatment.
 It is an inherent autosomal,recessive disorder
characterised by a reduced synthesis of one or
more alpha or beta globin chains, leading to a
decreased haemoglobin production .
Clinical features-
 Severe anemia,failure to thrive,poor apetite
 Hepatosplenomegaly,folate deficiency,recurrent
ulcers,growth retardation,jaundice.
 Hemosiderosis due to iron overload following
frequent transfusion.
 Prevention of dental disease.
 Most children can be treated normally under
local anesthesia and nitrous oxide inhalation.
 General anesthesia should be used with care
because of cardiomyopathy, liver and
endocrine complications.
▪ Avoidance of general anesthesia in the
presence of severe, chronic anaemia,
cardiomyopathy.
 Need for Antibiotic prophylaxis.
▪ It is a hereditary blood disorder
characterised by a deficiency of plasma
protien needed for normal clotting.
Haemophilia A-
▪ Haemorrhages from many sites intraorally.

▪ Mouth lacerations.

▪ Caries and periodontal disease.

▪ Radiographic changes of tooth displacement.

For mild cases: DDVAP( 1 deamino-8 D arginine vasopressin
can be administered IV, SC, IN which improves the Factor VIII activity
▪ Von Willebrand Disease is a hereditary
bleeding disorder resulting from an
abnormality of the Von Willebrand factor
found in plasma,platelets and endothelial
cells.
▪ Impaired formation of platelet plug may
result in bleeding from the skin and
mucosa,bruising,epistaxis,prolonged
bleeding after surgical procedures and
menorrhagia.
 Dental Management
1) Most hemophilic patients can receive
outpatient dental care routinely.
2) Appointments should be arranged so that
maximum treatment should be accomplished
per visit to minimize the need for unsheduled
factor infusions and hence the cost.
3) For patients who require deep scaling first
supraagingival scaling to be done and repeat
after 7-14 days after proper healing.
4) Most intramuscular injections and block
anaesthesia should be avoided.
 If factor concentrate replacement is
required ,all possible restorative treatment
should be completed in one visit itself.
 A pulpotomy or pulpectomy is preferable to
extraction.
 Any surgical procedure needs the
peoperative evaluation and consultation
with a hematologist.
 The use of preformed orthodontic bands
and brackets which can be bonded directly
to the teeth almost totally eliminates
contact of orthodontic appliancesto
gingiva.
 Acquired immuno deficiency syndrome can
be defined as presence of antibodies to
HIV and opportunistic infections.
 Modes of transmission are-
 a) parentral transmission
b) perinatal transmission
c) sexual transmission
d)body fluids
1) Fungal infections like candidiasis –
-angular cheilitis
-hyperplastic
2)Bacterial infections either generalised,
localised or pyogenic
3)Viral infections
-Herpes zoaster
 - Hairy leukoplakia
-Herpetic stomatitis
4)Parotid enlargement with xerostomia
5)Apthous stomatitis
6)Gingival and periodontal lesions like
ANUG and NUP.
7) Linear gingival erythema
8)Cervical lymphadenopathy
1. Consultation with patients physician
to establish current status
2 . Determine if prophylactic antibiotics
are needed to protect patients with
severe immune neutropenia
3. Only immediate treatment needs are
to be rendered for patients with
advanced AIDS.
4. Dental procedures should be provided
in most cases according to patients
wants and needs
1) Candidiasis-Topical and systemic antifungal
agents.
2) Hairy leukoplakia-acyclovir 2.4 to 3 g orally
per day for 2 weeks.
3)Herpes simplex-acyclovir 1 to 1.4g orally per
dayfor 7 to 10 days.
4) Herpes zoster-Treat ment is to be done
promptly to prevent scarring :acyclovir
800mg,orally,5 times per day for 7 to 10
days.
5) Recurrent apthous ulceration-Topical
fluocinonide ointment,0.05% mixed with
Orabase; apply 6 times per day
Dexamethasone alixir 0.5mg/5ml,rinse
and expectorate 2 to 3 times per day
Metronidazole,orally 250mg,four times
per day
6) Xerostomia-Sugarless gum,artificial
saliva,topical fluorides,improvement in
oral hygiene.
7) Necrotizing ulcerative periodontitis-
Debridement ,irrigation with Betadine10%,
0.12% chlorhexidine gluconate mouth rinse,
two times per day.
 Mainly antiviral drugs like
a)Acyclovir 1-2 gm daily orally or IV.
b)Zidovudine (AZT) which attacks virus
through enzyme reverse transcriptase.
c)Dideoxycytosine (ddc) ,Diodeoxyinosis (ddI),
Stavudine(D4T)
d)Protease inhibitors like saquinavir,indinavir
and ritonavir
e) Triple drug therapy combines indinavir with
AZT and 3TC
 A) Transient bacteremia
 B) Irregular fever
 C) Arthralgia
 D) Chorea
 A) Scaling
 B) Intraligamentary injection
 C)Simple orthodontic appliances
 D)Palatal injections
 A) deep sedation.
 B. Inhalation sedation
 C. GA
 D. None of the above
 A. Autism
 B. leukemia
 C. cystic fibrosis
 D. asthama
 A. T Duckett Jones
 B. Michael Glick
 C. Frachon
 D. Glanzmann
 A. both the statement are true
 B. both the statement are false
 C. the first is true and second is false
 D. the first is false and second is true
 A. dyskinetic
 B. ataxic
 C. spastic
 D. mixed
Antibiotic prophylaxis for bacterial
endocarditis with dental manipulation
is to be given
A. 2hrs before the procedure
B. 1hr before the procedure
C. 24 hrs before the procedure
D. 24 hrs after the procedure
For treatment of mild factor VIII deficiency :-
A) 40-50% factor VIII replacement
B) 10-20% factor VIII replacement
C) DDAVP
D) 5-10% factor VIII replacement