‫مواضع الشورت نوت‬

1) Secondary hypertension & Dental management

2) Dentist evaluation 0f patients with bleeding
3) Dental management 0f patient with bleeding disorder
4) Complications 0f diabetes
5) Oral complication 0f diabetes
6) Dental management 0f the diabetic patients
7) Prevention 0f endocarditis
8) Recurrent aphthous stomatitis
 Hypertension
Definition: sustained abnormal elevation 0f resting systolic BP more than 140mmHg or
diastolic BP more than 90mmHg or both.
Classification:
Primary hypertension or essential hypertension: the most common forms 0f HTN:
Normal less than 120mmHg – 80.
Pre – hypertension 120/139mmHg – 80/89.
Stage 1 hypertension: 140/159mmHg – 90/99.
Stage 2 hypertension: more than 160mmHG – 100.
Contributing factors 0f primary HTN:
o Genetic mutations
o Hormonal dysfunction
o Endothelial dysfunction
o Obesity – insulin resistance – environmental factors.
o Increase activity 0f SNS – RAAS.
Secondary hypertension:
Caused by altered hemodynamics associated with separate primary disease.
Causes include:
o Renal: renal vascular disease – renal artery stenosis – polycystic kidney.
o Endocrine: Cushing’s syndrome – diabetes mellitus
o Vascular: polyarteritis nodosa PAN
o Neurogenic: intracranial pressure
o Other cause: medication or obesity
Patient with high risk factors:
1) Younger than 35Y
2) Abrupt onset hypertension
3) No family history
4) Failed empiric therapy: (life style modification – drugs therapy)
5) Patients who have: (physical findings – biomechanical abnormalities)
 Dental management:
1) anesthesia:
A. local anesthesia:
dental patients with hypertension are best treated under L.A.
BP and heart rate minimally affected by low dose and short duration V.C
B. General anesthesia:
Antihypertensive drugs potentiated by G.A, severe reduce blood supply to vital organs.
Hypokalemia as a result 0f diuretics drugs.
2) anxiety control:
The anxiety and stress associated with dental treatment cause rise in blood pressure.
3) timing 0f dental appointment:
Afternoon appointments are recommended over mornings because the diurnal fluctuation
0f blood pressure are less in afternoon.
4) orthostatic hypotension:
Present a problem in patient using antihypertensive drugs, should avoid sudden postural
changes and should be seated for short period.
5) determining risk factor vs providing dental treatment:
Normal or prehypertension: systolic 120/139 – diastolic 80/89, no contraindication.
Stage 1 HTN: systolic 140/159 – diastolic 90/99 proceed with elective dental treatment
and monitor BP during appointment.
Stage 2 HTN: systolic 160 or higher – diastolic 100 or higher, emergency treatment only
with monitor BP – medical consult required prior to elective treatment.
Systolic more 210 – diastolic more 120: immediate referral to emergency room, no
dental treatment should be provided – medical consultant required prior to elective
treatment.
 Dentist evaluation 0f patients with bleeding
There are 4 methods:
1. Good thorough medical history:
o Family and personal history 0f bleeding
o Medication: aspirin – antibiotic – anticoagulants – alcohol – anticancer.
o Illness (past and present): Uremia – liver disease – leukemia – malabsorption –
congenital coagulation disorder –– cancer.
o Spontaneous bleeding: source 0f spontaneous bleeding may be gingival – nasal –
urinary – rectal – vaginal.
2. Physical findings:
o Petechia – ecchymosis
o Gingival hyperplasia – spontaneous gingival bleeding.
o Oral ulcer – lymphadenopathy.
3. Laboratory test:
BT – PT – PPT – platelet count
4. Observation 0f excessive bleeding following surgical procedure.
 Dental management 0f patient with bleeding disorder
According to history and examination, patient with bleeding disorder should not be
operated until appropriate laboratory and clinical test, may be referred to hematologist.
Patient with low risk
o Normal history – normal examination – normal bleeding parameter (PT – PPT – BT –
platelet count)
o Normal protocol
Patient with moderate risk
❖ Patient with chronic oral anticoagulant therapy
o PT is 1.5 – 2 times control value.
o the dentist balancing between the risks of bleeding complication and complication of
thromboembolic disease.
o Patient physician should be consultant.
❖ Patient with chronic aspirin therapy (‫)مهم وبيجى سؤال لوحده‬
o Stop use aspirin for 10 days if possible and should not be reused until complete soft
tissue healing with no risk or postoperative bleeding.
o BT should be in normal range.
o NSAIDs stopped for 1 days prior to procedure.
Patient with high risk
o Patient with knowing bleeding disorder: as thrombocytopenia – thrombocytopathy –
clotting factor defects.
o Patient without knowing bleeding disorder but with abnormal laboratory findings: PT –
BT – PTT – platelet count.
o Management: coordination between dentist and physician and the hospitalization is
advisable.
Hospitalization provides:
1. Platelet transfusion
2. Factor replacement – vitamin K replacement
3. Dialysis for patient with renal failure.
 diabetes
Definition:
It is a group 0f metabolic disease characterized by hyperglycemia due to defect in insulin
secretion or insulin action or both.
Complications 0f diabetes
A. Acute complication:
1) DKA (diabetic ketoacidosis)
o Caused by absence 0f insulin result in metabolic disorder 0f fat – carbohydrate –
protein,
o the clinical features are (Hyperglycemia – dehydration and electrolyte loss – acidosis)
2) HHNS (hyperglycemic hyperosmolar nonketotic syndrome)
o Occur in old age with mild type 2 diabetes differ from DKA by absence 0f ketosis and
acidosis.
o The insulin level is too low to prevent hyperglycemia but high enough to prevent fat
breakdown.
3) Hypoglycemia:
Blood glucose less than 50 to 60mg/dl, nay be caused by (excessive insulin – oral
hypoglycemic agent – starvation – excessive physical activity)
Symptoms:
Adrenergic: as sweating – tremors.
CNS: as headache – confusion.
B. Chronic complication:
1) Microvascular:
o Retinopathy: (non-proliferative retinopathy – proliferative retinopathy)
o Nephropathy: defined by persistent albuminuria – declining glomerular
filtration rate – rising blood pressure.
o Neuropathy: characterized by progressive loss 0f nerve fiber leading to loss 0f
sensation – foot ulceration – amputation.
2) Macrovascular: (cerebrovascular – cardiovascular – peripheral vascular disease)
 Oral complication 0f diabetes
The oral complication 0f diabetes depend on the patient’s glycemic control.
1. PD disease: as periodontitis
Plaque bacteria stimulation →gums infection →bone destruction
Periodontitis presented by
• gingival recession, bleeding and swelling.
• Loose and sensitive tooth
• Halitosis and gingivitis
2. Dental caries:
Due to high glucose level in saliva
3. Oral soft tissue damage:
Fungal infection – ulcers – fissured tongue
4. Xerostomia:
Dry mouth and angular cheilitis due to decrease salivary flow or increase glucose in
saliva.
5. Oral neuropathies:
• Painful condition to patient with diabetes
• Or non-painful condition (alter taste and function)
• Examples as TMD – fissuring tongue - burning tongue – burning mouth.
Dental management 0f the diabetic patients
1) Controlled type 1 and type 2 usually undergo all dental procedure.
2) If patients’ blood glucose level is not in control: postpone all non-emergence dental
procedure except (abscess – infections).
3) Emotional and physical stress induce hyperglycemia so if the patient is very
apprehensive, pretreatment sedation should be contemplated.
4) Its advisable to have an orange juice or other source 0f glucose to be given at first
sign 0f hypoglycemia.
5) Schedule the patient according to time 0f highest insulin activity from 30m to 8H after
injection
6) Take a history 0f hypoglycemic attack and its signs and symptoms.
7) Patient should not change insulin dose and time 0f application and his diet.
8) Treat infection by proper antibiotic therapy before the procedure.
9) Oral surgery must be done under restrict diabetic control.
 Rheumatic fever
Clinical pic: enumerate only
Major criteria:
1) Arthritis
2) carditis
• endocarditis
• myocarditis
• pericarditis
3) rheumatic chorea
4) subcutaneous nodules
5) erythema marginatum
minor criteria:
1) fever
2) history 0f rheumatic fever
3) presence 0f rheumatic heart disease
4) arthralgia
5) elevated ESR & leukocytosis & C – reactive protein
 infective endo carditis
pathophysiology & etiology:
the normal heart is resistance to heart disease there are 2 causes 0f endocarditis:
A. endocardial factor:
as congenital heart defect – mitral valve prolapses – rheumatic valvular disease
B. microorganisms:
the streptococci – staphylococci cause 90% 0f cases, the enterococci – G +ve bacilli
cause the rest.
• May originate from distant infected sites as abscess or infected gums.
• Or from portal entry as drug injection – central venous catheter
• Or from asymptomatic bacteremia
Signs and symptoms
❖ SBE:
low grade fever – valvular insufficiency – pallor – tachycardia – retinal emboli cause
Roth’s spot – cutaneous manifestation as (Osler’s nodes – petechia) – CNS, renal and
splenic embolization.
❖ ABE and PVE:
Similar signs & symptoms but more rapid – heart murmur – septic shock – patient
appear toxic.
❖ Right sided endocarditis:
Septic pulmonary emboli – murmur 0f bicuspid regurgitation is typical.

Prevention 0f endocarditis:
Route Dosage for adults and Dosage for adults and
child child allergic to penicillin
Oral: 1hour before Amoxicillin 2g Clindamycin 600mg
procedure (50mg/kg) po (20mg/kg) po
Oral: 1hour before Amoxicillin 2g Cephalexin or cefadroxil 2g
procedure (50mg/kg) po (50mg/kg) po
Oral: 1hour before Amoxicillin 2g Azithromycin or
procedure (50mg/kg) po clarithromycin 500mg
(15mg/kg) po
Parental: 1hour before Ampicillin 2g Clindamycin 600mg
procedure (50mg/kg) IM or IV (20mg/kg) po
Parental: 1hour before Ampicillin 2g Cefazolin 1g
procedure (50mg/kg) IM or IV (25mg/kg) IM orIV
 Anemia
Definition: anemia is a decrease in the circulating RBCs and so decrease in oxygen
carrying capacity 0f the blood.
Type 0f anemia:
1) Anemia caused by destruction 0f RBCs:
Hemolytic anemia: the RBCs destructed prematurely, and bone marrow cannot keep up
with the body demand.
• Sickle cell anemia
• Thalassemia
• G6PD glucose 6 phosphate dehydrogenase deficiency
2) Anemia caused by blood loss:
As in injury – long menstruation period – excessive bleeding – bowel disease
3) Anemia caused by inadequate RBCs production:
Iron deficiency anemia: caused due to deficiency in folic acid and vitamin B12.
Pernicious anemia: due to lack 0f intrinsic factor responsible for folic acid absorption.
Aplastic anemia: when bone marrow unable to produce enough RBCs (due to virus or
radiation or toxic .etc.)
Treating anemia
Treating anemia depend on the cause.
❖ In iron deficiency anemia
• doctor prescribe drops for infants and tablets for child and enrich food with iron
• In case 0f anemic teenage girl has heavy or irregular menstrual period doctor
prescribe birth control pills.
• Prescribe folic acid and vitamin B12.
❖ If certain medication is the cause: doctor may stop the drug or replace it unless the
benefits is more than the side effect.
❖ If infection is the cause: anemia will get better by curing or treatment.
Treatment 0f severe form:
Transfusion 0f RBCs – removal or treatment 0f spleen – medication for infection – bone
marrow transplantation in case 0f (sickle cell anemia, thalassemia, aplastic anemia)
 Bechet disease
Multisystem disorder presenting oral and general ulceration, chronic relapsing blindness
and neurogenic impairments.
Clinical manifestation:
Major criteria:
1) Recurrent aphthous stomatitis (RAS)
2) Recurrent painful genital ulcers
3) Ocular lesion as uveitis with conjunctivitis and hypopyon may result in blindness and
optic atrophy.
4) CNS lesion
5) Skin lesion use pathergy test
Minor criteria
1) Arthralgia
2) Superficial or deep migratory thrombophlebitis
3) Intestinal lesion
4) Lung affection: pneumonitis
5) Hematuria and proteinuria
 Mouth ulcer
Recurrent aphthous stomatitis
RAUs or chancer stomatitis is most common disease 0f unknown etiology.
The ulcer is self-limited and affects the non-keratinized surface 0f oral mucosa as:
• Labial and buccal mucosa
• Maxillary and mandibular sulci
• Free gingiva – soft palate – floor 0f the mouth ventral surface 0f the tongue – tonsillar
fauces
Differential diagnosis 0f RAU or Causes 0f mouth ulcer:
1) Autoimmune bullous disease
2) Bechet disease
3) Contact dermatitis
4) Drug eruption
5) Recurrent aphthous ulcers
6) Herpes simplex
7) Hand foot and mouth disease
Etiology
1) Genetic
2) Hematinic deficiency (iron – folic acid – vitamin B12)
3) Immune dysregulation
4) Microbial infection
5) Others: as
• Local or traumatic ulceration
• Drugs as NSAID
• Deep fungal disease – GIT disease
• Immune deficiency – vitamin deficiency B1, B2, B6
Types 0f RAS
1) RAU minor
2) RAU major
3) Herpetiform RAU
Lab investigation
 CBC determination – determination 0f Iron – ferritin – folate – vitamin B12
 Measurement 0f ESR – KOH examination
 Tzanck smear – viral culture
Other test: (colonoscopy – biopsy with hematoxylin eosin stain – swap the ulcer to identify
the H pylori DNA)
histologic findings as non – specific ulcer with chronic mixed inflammatory cells observed