DENTAL TREATMENT FOR

THE HANDICAPPED &

MEDICALLY
COMPROMISED PATIENT
 DEFINITION
• WHO  a handicapped person as ‘one who
over an appreciable period is prevented by
physical / mental conditions from full
participation in the normal activities of
their age group including those of social,
recreational, educational / vocational
nature.
• AAPD (1996) – states a person should be
considered ‘DENTALLY HANDICAPPED’ if
pain, infection / lack of dentition affects the
following:-
• Restricts consumption of diet adequate to
support growth and energy needs.

• Delays/alters growth and development.

• inhibits performance of any major life

activity including work, learning,
communication and recreation
 CLASSIFICATION
• A. Frank and Winter
1. Blind / partially sighted
2. deaf / partially deaf
3. maladjusted
4. educationally subnormal
5. physically handicapped
6. epileptic
7. defective of speech
8. Senile
Nowak - 9 categories
• Physically handicapped eg: poliomyelitis,
scoliosis

• Mentally handicapped. e.g.Mental

Retardation

• Congenital defects - cleft lip / palate

• Convulsive disorders - epilepsy

• Communication disorders - blindness

• Systemic disorders - hemophilia /
AIDS

• metabolic disorders - Diabetes

Mellitus

• Osseous Disorders -
Rickets/osteoporosis

• Malignant Disorders - Leukemias

• . For the convenience of management, they can
be categorized into

– Developmentally disabled child

– Medically compromised patient

Agerholm (1975)
– Intrinsic – one from which person cannot
be separated.
– Extrinsic – one from which patient can be
separated eg: social deprivation.
Dental Diseases and Handicapped
Patients
• Poor oral hygiene and increase prevalence
of periodontal disease .

• Prevalence of dental caries – similar to that

of the normal persons, but proportion of
untreated tooth decay is higher due to dental
neglect.
TREATMENT FACTORS TO BE
CONSIDERED
• dentist must carefully assess and evaluate
the patient’s dental needs and his / her
willingness to co-operate.

• Patient – dentist relationship

GOVERNM
DENTIST ENT PATIENT

INTERESTE PARENT/
D PARTY RELATIVE
• 1 Patient Assessment  past Dental, Medical
History and Clinical Examination

– Level of communication and intelligence

– ease of operating can be made.

• the limitations of the patient in mind, a

treatment plan can best suited to the patient.
• Attitude of the parents
– sorrow, guilt, anger and self pity.
– emotionally ,physically and financially tied
up with the patient’s handicapping condition.

– The parents’ attitude

– Fearful parents : afraid that their child will

be unduly hurt.
– ashamed of their child even though aware
of the problem, may not show any concern.
• humiliated when they appear in public with
the child
• kept waiting in the reception area for a long
time, negative opinion on how well you are
able to handle the child’s care.

• Overprotective :certain the dentist will have

difficulty treating their children
• display a lack of confidence directly in front
of the child.
• Attitude of the Society: not well accepted by
the society.
• Dentist’s Attitude: positive one

• Lack of education and experience on the part

of the dentist to deal with such children.
• Fear of the patient
• Feeling incompetent to treat.
• Inability to develop a relationship
• Physical repulsion
• Substandard fees
• Need for special equipment and dental office
architecture.
SUGGESTED PROGRAMMES
• SELF CARE GROUP – those able to brush
their own teeth.
– Need some encouragement and supervision
– Parent /caregiver should see that the routine is
maintained and motivation kept high.
– May require modifications in their tooth brushes
– Weight of toothbrush increased / longer handle
 PARTIAL CARE GROUP
• moderately disable and retarded
• Require close assistance and supervision to
perform routine tasks of everyday living.
• Are unable to understand long term benefits of
brushing.
• When asked to brush, will often brush their
front teeth only.
• require a lot of patience as learning is slow.
• It is often wise to break the task down into
small easy to accomplish steps.
 TOTAL CARE GROUP
• severely disabled, many are profoundly
retarded and confined to wheelchairs.

• will never be able to clean their own teeth

 Home care

• POSITIONING
• a. Standing:- With a larger child, may stand
behind the child and cradle the patients head in
one arm, holding the lower jaw open with the
same hand while brushing / flossing with the
others.
– Mouth props can be used to avoid injury to
the caregiver
• b. Sofa: - sitting on a sofa and having the
patient lie with his head in the caretakers lap.
• c. Lap:- Toddler/small child can often be
easily handled with parent sitting on a chair
without arms. The child is placed across the
parent’s lap with the head hanging down
over one leg slightly to assist in opening
the mouth.

• d. Wheelchair patients – Similar to

standing position
 Plaque Control
• 0.2% Chlorhexidine gluconate
gel/solution/VARNISH.
• gauze dipped in 0.2% Chlorhexidine
gluconate / toothbrush dipped in F mouthrinse.
• Brushing technique – Horizontal scrub.
• Electric toothbrushes and using the patient’s
hand to custom design a handle has yielded
good results.
 DIET AND NUTRITION
• Restrict sweet foods/drinks to mealtimes
• Limit sweet foods/ drinks to 3 times a day.
• Keep food and drink clear of bedtime by
about an hour.
• ask for sugar free medication
• Remember – carbonated drinks are
erosive
 Fluorides/
Preventive Restorations
• SYSTEMIC
• TOPICAL
• P & F sealants
• SSC

• Regular professional supervision

 BEHAVIOUR MANAGEMENT
• fear things that we do not understand.
• mentally retarded understands even less
• show specific fear / intolerance
• maternal anxiety plays an important role in
development of fear.
• T.S.D technique
• HOME should not be used
 Physical restraints
• means of behaviour control.
• never be used as a means of punishment.
• informed and give consent
• understanding of the type of restraints used
and reason for their use.
• GA.
 Aids For Maintaining The Mouth
Open
• Wrapped tongue blade

• Molt mouth prop

• Finger guard / inter occlusal thimble

• Rubber bite blocks

 PHYSICAL RESTRAINTS
• Papoose board
– Simple to store and use
– Available in various sizes
– Has attached head stabilizers
– Reusable
– Does not always fit contours of chair
– patients diaphragm is covered pretracheal
stethoscope is necessary
– hyperthermia if restrained too long.
 Bed sheet / Triangular sheet
patient to sit upright

– Need for straps to maintain the patients position

in the chair
– Difficult to use in small patient
– Possibility of airway impingement, should the
patient slip downwards unnoticed.
– Hyperthermia
 Pedi wrap
• does not have a head support / backboard
• Allows some movement while still confining
the patient
• Mesh net fabric allows better ventilation
• Decrease chances of developing hyperthermia.

• Requires straps to maintain body position and

supervision to prevent the patient from rolling
out of the chair
 ‘Bean bag’ dental chair insert

Developed to help comfortably accommodate

the hypotonic and severely spastic person
who needs more support and less restraining
in the dental environment.

Washable and reusable and one size fits all

• Safety belt
• Extra assistant
 Extremities
• Posey straps
• Head – forearm and body support
• Velcro straps
• Head positioner
• Towel and Tape
• Plastic Bowl
• Extra assistant
 Mental retardation
• AAMD: “Sub Average general intellectual
functioning which originates during the
developmental period & is associated with
impairment in adaptive behavior”.

• IQ = mental age/chronologic age* 100

 Aetiology
• Maternal/fetal rubella
• Cretinism
• Birth injuries
• Hypoxia
• Hypoglycemia
• Poisoning
• Cerebral infection: meningitis
 IQ CLASSIFICATION GUIDE
IQ RANGE GRADE
ABOVE 140 VERY SUPERIOR
120-139 SUPERIOR
110-119 HIGH AVERAGE
90-109 AVERAGE
80-89 LOW AVERAGE
70-79 BORDERLINE
<69 MR
 MR CLASSIFICATION
• Previously  IQ less than 25-idiots
• IQ of 25-50 – imbeciles
• IQ of 50-70 – morons
 IQ
School Special
Degree of MR Classifi Communication requirements for
WIS cation dental care
SB
C-R

Able to speak Treat as normal

Educa well enough for child, mild sedation/
69-
Mild 67-52 ble MR most N2O-O2 analgesia
55
(EMR) communication
needs may be beneficial

Vocabulary and
language skills
Mild to moderate
Traina such that child
54- Sedation, restrain
Moderate 51-36 ble MR can
40 to,+ve
(TMR) communicate at
reinforcement, GA
a basic level
with others

Mute/ Mild to moderate

Non-
communicate in Sedation, restrain
Severe/ profound 35 39 trainab
grunts, little/ no to, +ve
le
communication reinforcement, GA

SB – Stanford – Binnet General Intelligence test.

WISC-R – Wechsler Intelligence scale for children – Revised
 AAMD classification
Mildly/ Educable mental retardation (EMR)
• IQ 69-55
• educational programmes are simplified
versions of regular school programmes
• literacy & skills necessary for employment
• Moderately / trainable mental retardation
(TMR)
IQ- 54-40
• Severely retarded
IQ 39-25
• Profoundly Retarded
IQ<25
 Dental problems
• Anomalies of facial structure
• Eruption
• Malocclusion
• Enamel hypoplasia
• Higher prevalence of dental caries /pdl
disease
• Poor oral hygiene/diet
 Dental Treatment
• Assess degree of MR
• socially, intellectually and emotionally
immature and has a very short attention
span, is restless and hyperactive.
• Schedule patient early in day
• Give brief tour of operatory and introduce
staff
• Keep appointments short and gradually
proceed to more difficult procedures.
• Use simple terms
• Give only 1 instruction at a time /
• complement
• pay attention to gestures.
 DOWN SYNDROME
• Dr.John Langdon Down.

• Most common chromosomal aberration with a

1 in 600 births.

• Incidence increases with maternal age (> 40

yrs  1 in 40)

• trisomy of chromosome 21 (92%)

• genotype 47XX-Female/47XY-Male
• 2-4% : mosaic trisomy
• 3-4% : translocation trisomy, material from
one chromosome21 is translocated to
another chromosome
 Clinical features
• CHARECTERISTIC FACIES
• Brachycephaly, widely spaced eyes,
epicanthal folds.
• Clinodactyly (short 5th finger)
• Simian (single palmar creases)
• Congenital cardiac diseases (50%): ASD/
MVP
• Seizure Disorders :5-13%
•
• Myelodysplasia/ defective development of
spinal cord
• Leukemia
• Congenital hypothyroidism
• Hearing loss
• Cataracts
• 12 time higher mortality rate from infectious
diseases: pneumonia
• Chronic RTI/TB
• Multiple immune system defects
• 50 yrs : dementia/alzheimers
 Oral features

• Macroglossia- relative/absolute/fissured.
• Enlarged circumvallate papillae/ filiform
papillae absent
• Lips: thick /dry/fissured
• Poor anterior oral seal/ tongue thrust
• Small maxilla/ enlarged mandible: cl 3
• Cleft lip/palate/bifid uvula/high palate with
horizontal shelves
• Delayed eruption/ vary in shape /hypoplasia
• Congenital absence of teeth
 Dental management
• Learning disability
• Co-operative
• LA / Sedation
• GA : difficulty in intubation due to hypoplastic
midface/respiratory disease:
• Cardiac defects: IE
• Possible atlanto- axial subluxation
• Hep B carriage
• Severe early onset pdl disease
• Defective cell mediated & humoral
immunity: defective phagocytic system
• PREVENTIVE MEASURES
 AUTISM
• 3.4 every 1,000 children ages 3-10

• 1943 Dr. Leo Kanner : early infantile autism .

• varying degrees of impairment in

communication skills, social interactions, and
restricted, repetitive patterns of behavior.
• three times more likely to affect males than
females
• no known cause of autism
• genetic influence
• depression and/or dyslexia in one or both
sides of the family when autism is present.
• virus :Cytolomegalo virus
• measles component of the MMR vaccine and
the pertussis component of the DPT shot, may
cause autism.
• toxins and pollution
 Clinical features
• different from birth
• arching their back away from their caregiver to
avoid physical contact and failing to anticipate
being picked up
• begin to rock and/or bang their head against
the crib
• Milestones ahead/ delayed
• Fall behind after age of 1.5-2
• Self sufficient/introvert
• Want to be left alone/ eye contact is difficult /
extreme resistance to being held
• Little /no attachment to parents
• Relates poorly to parents, well to objects
• Occupied with moving/ shiny objects
• Display affection / anger with a toy
• Impaired language
 Dental management
• Challenge
• Positive reinforcement /TSD
• DESENSITIZATION
• UNUSUAL RESPONSES TO STIMULI
• sensitive to changes in their environment.
• overreact to noise and touch,
• pain and heat may not provoke much reaction
at all.
• same staff, dental operatory, appointment time
to sustain familiarity
• make dental treatment seem less threatening
• Minimize number of distractions.
• reduce unnecessary sights, sounds, odors, or
other stimuli that might be disruptive .
• unusual and unpredictable body movements .
• can jeopardize safety /ability to deliver oral
health care
 CEREBRAL PALSY
• group of non-progressive disorders resulting
from malformation of the motor centers and
pathways of the brain.

• paralysis, weakness and incoordination

• develop either prenatally, during birth / before

the CNS has reached relative maturity (<5 yrs)
 types
• Athetoid/Dyskinetic
• Spastic Cerebral Palsy
• Ataxic Cerebral Palsy
• Rigid
• Mixed Form Cerebral Palsy (combination of
one or more of the above)
 Athetoid/Dyskinetic Cerebral
Palsy
• slow uncontrollable movements
• muscles in legs, hands, feet, and in some
cases face or throat : result in drooling or
grimacing. speech disorders.
• symptoms are most visible during times of
emotional stress invisible during sleep..
• 10-20 per cent of all cases.
• Neck musculature is involved and there is
excessive movement of the head.

• Frequent uncontrolled jaw movements/

bruxism

• Perioral musculature is hypotonic –

mouthbreathing, tongue protrusion and
excessive drooling .

• Chewing, swallowing, speech difficulties

 Spastic Cerebral Palsy
• most common type , 70-80 per cent of all
cases.
• hyper irritability of involved muscles
• tense contracted muscles
• lesion in cerebral cortex
• limited control of neck muscles
• difficulty in maintaining upright posture
• lack of co-ordination of intra-oral, peri-oral
and masticatory musculature.

• impaired chewing, swallowing, excessive

drooling

• persistant spastic tongue thrust.

• Speech impairment
 Ataxic Cerebral Palsy
• very shaky or unsteady movements

• weak sense of balance, poor coordination, and

depth perception in children.

• Disturbances in equilibrium –
stumbling/staggering gait / difficulty in
grasping objects

• 5-10 percent of all cases.

• lesion of cerebellum

• Involved muscles are unable to contract

fully therefore voluntary movements can
only be partially performed.

• longer to complete certain tasks as a result

of such shaky movements and poor
coordination
 Rigid
• constant rigidity  5%

• lesion of basal ganglia

• voluntary movements – slow and stiff

 Mixed Cerebral Palsy
• more than one of the above symptoms are
present and most often include but are not
limited to the combination of athetoid
movements and spasticity.
 Etiology
decreased oxygenation of the developing brain.
– Complication in labour
– meningitis, encephalitis
– Toxemias in pregnancy
– Congenital defects of brain/kernicterus
– Poisoning – drugs/ metals
– Trauma
– Increase correlation between premature birth
and cerebral palsy
 Clinical Features
• Neonatal reflexes persist long after age at
which they normally disappear

– asymmetric tonic neck reflex

– tonic labrynthine reflex
– startle reflex
• Mental Retardation – 60%
• Seizure disorders – 30-50%
• hearing and eye disorders – 35%
• Speech disorders – due to lack if control of
speech muscles
• Joint contractures – due to disuse of muscle
groups
 INTRA ORALLY

• Periodontal disease – occurs with greater

frequency due to poor oral hygiene / soft diet /
gingival hyperplasia  due to phenytoin

• Dental caries – data is conflicting

• Malocclusion
• Prevelance is higher

• Protrusion of Maxillary anterior teeth

• Increased overjet / overbite / unilateral

crossbite

• Due to disharmonious relationship between

the extraoral and intra oral musculature.
– Bruxism
• Common
• Leads to loss of vertical dimension and
TMJ disorders
– Trauma
• More susceptible to trauma
• Increased tendency to fall along with
diminished extensor reflex to cushion
the fall
 Dental Management
• Routine dental procedures : accomplished
effectively
• understand and co-operate if dentist takes
time to show and explain each procedure.
• typically WANT TO cooperate but lack of
muscular control makes it difficult for them.
• rubber mouth prop
• support / cradle patient’s head to control
involuntary movements
• Have a preferred comfortable postural state,
positioning of the patient important
• necessitate the dentist’s working in an
uncomfortable position
• Consider treating a patient in a wheelchair, in
the wheel chair itself.
• To minimize startle reflex, avoid abrupt
movements, noises, lights, etc without
forewarning.
• Decrease patient time in chair to decrease
fatigue of involved muscles
• Premedication or GA may be necessary
 EPILEPSY
• Symptom of a brain disorder involving
paroxysmal neuronal discharge causing
recurrent seizures with loss of consciousness

• more than 20 different kinds of seizures,

broadly divided into two main categories:
• Partial seizures
• generalized seizures.
 ETIOLOGY
• IDIOPATHIC
• SYMPTOMATIC/SECONDARY: febrile
seizures
• INTRA CRANIAL CAUSES:
Space occupying lesions, trauma, Vascular defects
• SYSTEMIC CAUSES
Hypoxia, hypoglycemia, inborn errors in
metabolism
Drug overdose/ withdrawal
Grand mal (tonic-clonic ) epilepsy
• Usually begins in childhood
• Aura, loss of consciousness, tonic & clonic
convulsions, prolonged recovery period.
• Aura: mood change/ hyper irritability/
hallucination/headache
• Tonic spasms (<1min)
• Falls to ground
• Face: pale, pupils dilate , head& spine thrown
into extension
• Glottic & respiratory muscle spasm: cyanosis
• Incontinence/ tongue biting
• Clonic phase
• jerking movts of limbs/trunk/tongue/lips
• Salivation/bruxism/tongue biting/vomiting
• Incontinence
• Period of flaccid semi-coma
• Confusion/headaches are common on recovery
(upto 12 hrs)
 Complications
• Trauma
• Respiratory embarrassment/brain damage
• Status epilepticus
 Petit mal seizures
• Minimal/no movements ( blank stare)
• Brief sudden loss of awareness/ conscious
activity
• Frequent recurrence
• Learning difficulties
 Simple partial seizures
• Motor/sensory/behavioral
• Typically remain confined to one area
• Clonic movements of a limb/ group of
muscles
• Clonus may spread to adjacent muscles on the
same side of the body ( Jacksonian epilepsy)
• Abnormal sensations: nausea, sweating, skin
flushing, dilated pupils
 Partial complex seizures/temporal
lobe epilepsy/psychomotor epilepsy
• Automatism/ automatic performance of
complex behaviors : chewing/ facial
grimacing
• Nausea/sweating/skin flushing/ dilated
pupils
• Disorientation/confusion/amnesia/loss of
consciousness
 Dental Management
– Age of onset of 1st seizure?
– How many seizure types does the patient have?
– Frequency of seizures?
– Is the attack preceded by aura? Nature of
aura?
– Does patient induce himself during seizure
attacks?
– Do seizures occur at any particular time of
day?
– Type of medication
– Behavior following seizure
• Since anxiety is a precipitating factor,
premedication with minor tranquilizers can be
considered
– Patients often arrive in a slightly sedated state due
to CNS depressant activity of medications

– Patient should never alter daily medication routine

in either time / dosage on the day of dental
treatment.

– Appointments should occur just after patient has

taken daily medication
 – Fixed appliances are indicated.

– Dilantin causes gingival hyperplasia

• anterior region
• mandibular region
• edentulous areas not affected

• Treatment – gingivectomy
– Meticulous oral hygiene is recommended to
prevent recurrence of hyperplasia
Type of first choice 2nd choice drug
epilepsy drug

Grand mal carbamazepine primidone

/valproic acid

Petit mal Valproic acid clonazepam

/ethosuximide

Partial seizures carbamazepine primidone

 Blindness

• If visual acquity does not exceed 3/60m

in the better eye with correcting lenses

• if visual acquity greater than 3/60 but

accompanied by a visual field of no
greater than 20o.
 Etiology
• Prenatal - tumors, cataracts,
toxoplasmosis TB, rubella, meningitis

• Postnatal - Trauma, Hypertension,

Diabetes Mellitus, premature birth,
glaucoma
 Dental Management
• Complete medical history along with degree
of visual impairment ascertained prior to
treatment.
• Describe office settings, office personnel and
treatment procedures before starting
• Do not grab/move the patient without prior
notice
• Dentist can make use of TASTE / Touch/
smell instead of TSD
• Prolonged immature swallowing pattern

• Poor oral hygiene – unable to visualize

and remove plaque.

• Hypoplastic teeth. / Trauma to ant teeth.

 Deafness
• Includes individuals who are totally deaf as
well as hearing impaired individuals

• Speech is affected as sound has to be heard

to be repeated

• Decreased ability to communicate

 Etiology
• prenatal – viral infection (rubella and influenza)
– ototoxic drugs
– congenital syphilis
– Heredity.
• Perinatal – toxemia late in pregnancy
– Birth injuries
– Anoxia
– premature birth
– erythroblastosis featalis
Postanatal –
• injuries
• Drugs (streptomycin / Kanamycin/ aspirin)
• Viral infection – measles/mumps /
chickenpox etc
 Dental Management
• poor oral hygiene due to learning difficulty –
hypoplastic teeth.
• Parent should be positioned such that child
can see the parent.
• Use facial expressions, smile, gestures,
physical contact and praise to reassure the
patient.
• Speak directly facing the patient – normal
tone and pace, without slangs
• Adjust hearing aid while using hand piece
as all sounds are amplified .

• TSD / modeling/ (+)ve reinforcement are

effective.

• Sedation and GA for severe behavioral

problems
MANAGEMENT OF MEDICALLY
COMPROMISED PATIENTS

• A medically compromised condition is

where the patient suffers from a systemic
condition which puts him at risk when
regular dental treatment is required.
 Heart Disease
• Congenital /Acquired

• Congenital: 9 in 1000 births

• Absence of treatment 40% die by 5 years

 Congenital Cardiac Disorders
• Cyanotic & acyanotic

• Unknown aetiology

• Congenital rubella/CMV

• Down syndrome
 Congenital heart disorders

Cyanotic Acyanotic
Transposition of great VSD
vessels
Tetralogy of Fallot ASD
Eisenmenger’s syndrome PDA
Tricuspid atresia Aortic stenosis
Pulmonary atresia Coarcation of aorta
 Acyanotic heart disorders
• Left to right shunting of blood

• VSD/ASD

• Clinical features: CHF/ Pulmonary

congestion/ heart murmur/ labored
breathing/ Cardiomegaly
 Cyanotic heart disorders
• Right to left shunting of blood

• Cyanosis on minor exertion

• Hypoxia

• Poor development

• Heart murmurs

• Clubbing of terminal phalanges

• patent ductus arteriosus
(PDA) - occurs during
fetal life
• allows blood to mix
between the pulmonary
artery and the aorta.
• Prior to birth, there is an
open passageway between
the two blood vessels,
which closes soon after
birth. When it does not
close, some blood returns
to the lungs.
• often seen in premature
infants
• atrial septal defect
(ASD) - no
symptoms and
appear healthy.
• if the ASD is large,
permitting a large
amount of blood to
pass through the
right side, symptoms
will be noted.
• VSD:blood from the
left ventricle flows
back into the right
ventricle, due to higher
pressure in the left
ventricle. This causes
an extra volume of
blood to be pumped
into the lungs by the
right ventricle, which
can create congestion in
the lungs.
• Transposition of vessels:
the aorta originates from
the right ventricle, so most
of the blood returning to
the heart from the body is
pumped back out without
first going to the lungs

.
• the pulmonary artery
originates from the left
ventricle, so that most of
the blood returning from
the lungs goes back to the
lungs again
 TETRALOGY OF FALLOT
• ventricular septal defect, that allows blood to pass
from the right ventricle to the left ventricle without
going through the lungs.
• a narrowing (stenosis) at or just beneath the
pulmonary valve that partially blocks the flow of
blood from the right side of the heart to the lungs.
• the right ventricle is more muscular than normal .
• the aorta lies directly over the ventricular septal
defect.
 Coarcation of aorta
• the aorta is narrowed or constricted,
obstructing blood flow to the lower part of the
body and increasing blood pressure above the
constriction.
• no symptoms at birth, but they can develop as
early as the first week after birth.
• If severe symptoms of high blood pressure and
congestive heart failure develop, surgery may
be considered
 Dental Management
• Medical History / consultation with child’s
cardiologist is a must.
• Antibiotic prophylaxis required for those
procedures likely to induce gingival bleeding. I
& D, scaling, intraligamentary injection,
orthodontic band placement require antibiotic
prophylaxis.
• Prophylaxis not required for: Removable
orthodontic appliances, fillings above the gum
line LA injection.
• Pulp therapy of primary teeth is not
recommended, extraction and space
maintainers are preferred
• In permanent teeth – endodontic therapy
after careful case selection may be done.
• Oral sedation and N2O analgesia may be
beneficial in decreasing anxiety.
• Patients on anticoagulant therapy require
hematological monitoring and cessation of
anticoagulant therapy before dental
treatment
Acquired heart disorders
 Rheumatic fever
• Inflammatory disease as a delayed sequelae
to pharyngeal infection with group A
streptococci.( beta –hemolytic str/ Str.
Pyogenes)
• Infection can involve heart, joints, skin,
CNS, subcutaneous tissue
• 6-15 yrs
• Carditis in 50% of patients
 Clinical features/diagnostic criteria

MAJOR MINOR
Carditis pyrexia
polyarthritis arthralgia
Syndhem’s Chorea/St Previous rheumatic fever
Vitus dance
Erythema marginatum ESR & C reactive Protein
raised
Subcutaneous nodules
• Subendocardial inflammation along the lines of
closure of mitral & aortic valve cusps leading
to minute fibrinous vegetations & scarring.

• Stiffening & distortion of heart valves can

cause MS

• IE/ CHF
 Dental management
• Risk of IE in cases of rheumatic carditis

• Level of risk depends upon severity of

defect

• ANTIBIOTIC PROPHYLAXIS
 Infective Bacterial Endocarditis
• Microbial infection of heart valves/
endocardium in proximity to congenital /
acquired cardiac defects.

• Acute: micro organisms of high pathogenecity

attack normal heart causing erosive
destruction of valves.

• Staphylococcus, group A strep, pneumococcus

Primary Reasons for Revision of the IE Prophylaxis
Guidelines

• important than prophylactic antibiotics for a dental

procedure to reduce the risk of IE. IE more likely to
result from frequent exposure to random bacteremias
associated with daily activities.
• Prophylaxis may prevent an exceedingly small
number of cases of IE if any , in individuals who
undergo a dental procedure.
• The risk of antibiotic-associated adverse events
exceeds the benefit, if any, from prophylactic
antibiotic therapy.
• Maintenance of optimal oral health and hygiene may
reduce the incidence of bacteremia from daily
activities and is more
• SBE: Pre existing cardiac defects/ rheumatic
valvular lesions/ prosthetic heart valves
• Viridans streptococci

• Embolization
• Irregular fever ( afternoon/nights)
• Sweating, malaise, anorexia, weight loss,
arthralgia
• Painful fingers, toes, skin lesions
 Endocarditis Prophylactic Regimens for Dental, Oral,
Respiratory Tract, and Esophageal Procedures

Situation Agent Regimen1

Standard Amoxicillin Adults: 2.0 g;
general children 50 mg/kg,
prophylaxis orally 1 h before
procedure

Unable to Ampicillin Adults: 2.0 g IM or

take oral IV; children 50
medications mg/kg IM or IV
within 30 min
before procedure
Patient is Clindamycin Adults: 600 mg;
allergic to or children 20 mg/kg
penicillin orally 1 h before
procedure

Adults: 2 g; children
or 50 mg/kg
Cefadroxil2 or orally 1 h before
cephalexin2 procedure

Adults: 500 mg;

or
children 15 mg/kg
Azithromycin
orally 1 h before
or
procedure
clarithromycin
Allergic to Clindamycin Adults: 600 mg; children 20
penicillin mg/kg
and unable to IV within 30 minutes before
take oral procedure
medications

or Cefazolin2
Adults: 1.0 g; children 25
mg/kg IM or IV within 30
min before procedure
 HEMORRHAGIC DISORDERS
• Platelet / Vascular disorders :characterized by
purpura, i.e. by superficial bleeding with
formation of petechiae and echymosis.

• Coagulation disorders :characterized by severe

bleeding deep in tissue and extensive
hematomas after superficial injury and
prolonged bleeding after surgery / trauma can
be LETHAL
Platelet disorders –
• Thrombocytopenia,
• ITP
• AIDS associated thrombocytopenic,
• Leukemia.
• Von – Willebrand’s disease.
• Drugs – cytotoxic drugs
thrombocytopenia, (Glanzmann’s
syndrome)
Coagulation defects –
• Hemophilia
• Von – Willebrands disease
• Anticoagulants and jaundice
• Rare cause:-
• Aplastic anemia
• CRF (chronic renal failure)
• Multiple myeloma.
 HEMOPHILIA
• Inherited bleeding disorder affecting 1 in
7500 males
• Hemophilia A: deficiency of factor 8
• X linked recessive trait
• Females are carriers
• Hemophilia B: deficiency of factor 9 /plasma
thromboplastin component (christmas
disease)
• Factor 11 deficiency (PTA) : autosomal
recessive trait.
• Von Willebrand disease: deficiency of VWF
found in platelets, megakaryocytes, endothelial
cells.
• Circulates in conjunction with factor 8.
• Platelet adhesion to subendothelium via
collagen: formation of primary platelet plug.
• Bleeding from skin, mucosa , bruising,
epistaxis, prolonged bleeding after surgery
• Hemophilia: bleeding involves muscles &
joints
 classification
• Severe: < 1%; frequent spontaneous
bleeding into joints and muscles.

• Moderate :1-5%;occasional spontaneous

bleeding /minor trauma may initiate
hemorrhage.

• Mild :5-35%;Significant hemorrhage only

after major trauma
 Clinical features
• Hemarthroses following injuries can lead to
joint damage and crippling.
• Abdominal hemorrhage can simulate acute
abdomen.
• Bleeding in cranium / bladders can be fatal.
• Bleeding in hemophilia stops immediately
after injury but after an hour/more, rapid
blood loss starts and persists.
• Severity of bleeding depends on
• (1) Level of factor VIII and
• (2) Severity of trauma

• DIAGNOSIS –
• Prolonged APTT (activated plasma
thromboplastin time)
• Decreased factor VIII
• Normal PT
• Normal BT
 Management
• Mainstay of therapy – purified concentrate of
the missing factor, extracted from blood
plasma. Life of factor VIII is low, only around
12 hours.
• Use of desmopressin acetate: - IV in mild
hemophiliacs
• Increases factor VIII activity to 300 – 400%
2 hrs after infusion of 0.3 – 0.4 mg/kg body
weight. It induces release of factor VIII that is
normally bound to vascular basement
membrane.
• Σ aminocaproic acid (EACA) used as an
adjunct with factor therapy.
• normal fibrinolytic mechanism but generation
of thrombin necessary for clot formation is
either inadequate/retarded .Loose friable clots
are formed which are easily dislodged. The
fibrinolytic mechanism is effectively inhibited
by EACA allowing more stable clot to form
and retract.
• hypotension / nausea and vomiting.
• replaced by tranexamic acid which is 10 times
more patient than EACA.
 Complication
• 5-20% of hemophiliacs develop inhibitory
antibodies :bleeding episodes are more difficult
to control.
• patients with low titer, effect may be overcome
by high doses of concentrate.
• high titer, effects of inhibitors may be
bypassed through the use of prothrombin
complex concentrate / DDAVP (1- deamino-8
dearginine vasopressin)
• Risk of HIV and Hepatitis B Infection. –
Heat treatment of pooled donor factor
eliminates infectivity of both HIV and
Hepatitis B.
 Dental treatment
• Relief of anxiety : important ;direct
relationship between anxiety and
antifibrinolytic activity
• - N2O – O2 inhalational analgesia /
Hypnosis can be beneficial
• - I.M. injection of hypnotics /
tranquilizers are contraindicated due to risk of
hematoma formation.
• . Intraligamentary injections can be safely used
in the absence of factors replacement.

• Infiltration requires single infusion of factor

replacement. (30%-40%)

• Block is not recommended even with factor

replacement. (40%) + antifibrinolytic therapy.

• Aspirate: if + further factor replacement

• Prevention
• Minor hemorrhages can be controlled with a
moistened gauze pieces
• topical application of bovine thrombin
microfibrillar collagen/ local fibrin glue
Periodontal therapy
• Initially supragingival scaling. After 7- 14
days
• Replacement therapy is required prior to
subgingival scaling
 Restorative Treatment
• Rubber dam : thin

• Retainers with sub gingival extensions to be

avoided

• Care to be taken while placing intraoral film,

high vacuum suction / saliva ejectors
 PULP THERAPY
• Conventional pulp therapy is preferable to
tooth extraction. . Pulpal hemorrhage can
be controlled by pressure
 ORAL SURGERY
• Simple extractions of multi rooted teeth:
• 30-40% factor 1 hour before + antifibrinolytic
activity started immediately before / after the
procedure to be continued for 5 – 10 days)
• topical bovine thrombin/ microfibrillar collagen
• Primary teeth exfoliate without significant
hemorrhaging – sutures should be avoided
wherever possible
• Electrosurgical procedures not
recommended possibility of spontaneous
hemorrhaging several days after such a
procedure when clot lysis normally occurs.

• ANTIBIOTIC PROPHYLAXIS FOR

PATIENTS WITH JOINT REPLACEMENT
 Post Extraction Instructions

• First 72 hours consume only clear, liquid

diet.
• Dairy products are discouraged since they
leave a film residue. –
• Next 10 days consume only a soft diet.
• Can return to normal diet after 10 to 12
days.
ORTHODONTIC TREATMENT
• EARLY RECOGNITION
• FAT
• Careful adaptation of bands
• Longer acting springs & wires
• Oral hygiene maintenance
 Diabetes Mellitus
• most common endocrine disease of
childhood. types:

• Type I – IDDM where there is destruction of

ß cells leading to decreased insulin
production.

• Type II – NIDDM where there is impaired

insulin function .
 Oral Manifestations
• Decreased salivary flow.
• Progressive periodontitis
• Burning mouth / tongue
• Dental caries – Increased / Decreased
• Candidiasis
• Oral neuropathies
• Altered taste
• Parotid enlargement
• Delayed wound healing
• Increased glucose content in GCF
 Dental Management
• Prevention, symptomatic relief, and
immediate provision of primary care
• comprehensive medical history
• appointments should be short / atraumatic /
stress free
• Early appointments, patient should eat normal
breakfast before appointment to prevent
hypoglycemia.
• Conscious – sedation is beneficial.
• Non-vital teeth with evidence of infection are
indicated for extraction .
• LA with vasoconstrictor to ensure profound
anesthesia but excessive adrenalin dosage is
contra indicated to prevent increase in blood
glucose level.
 Medical treatment
• Type I Diabetics
• Insulin is of 3 types
• 1. Short acting (6-8 hours)
• 2. Intermediate acting (18-24hours)
• 3. Long acting (32-36hours)
• - Careful monitoring of blood glucose level.
• -Well balanced nutritious diet high in fiber.
• Type II managed with oral hypoglycemic
agents
 Diabetic Emergencies
Hypoglycemic shock / insulin shock

• Stress /insulin overdose / poor diet etc,

blood glucose level falls below 40mg/dl.

• Condition develops quickly and

treatment must begin rapidly or else can
be fatal.
 Management
• (1) Administer oral carbohydrates.
• (2) If no recovery with in 2-5 minutes and
patient is unconscious administer:
• a) I.V dextrose (50ml – 5%. concentration)
• b) I.M glucagon (1mg) followed by I.M
epinephrine. (0.5mg of 1:1000 concentration)
• Patient recovers in 5 to 10 minutes give oral
glucose when conscious.
• If patient does net recover, start emergency
procedures
 Diabetic crisis / hyperglycemia
• Blood glucose level goes over 11.1 mmol per
liter.

• develops more slowly than hypoglycemia.

• A diabetic ketoacidosis coma occurs at glucose

levels between 300 and 600mg/dl. And when
ketones are present in urine and blood ph is
below 7.36.
 Management
• maintain open airway
• Administer 100% O2 with IV fluid to prevent
vascular collapse.
• Monitor blood glucose level
• Administer insulin
• Patient recovery is usually slower than for
insulin shock
• Difficult to distinguish between hypoglycemia
and diabetic crisis
• Treat first for hypoglycemia
 AIDS
• Severe defect especially of cell mediated
immunity.

• Susceptibility to an enormous variety of

infections and otherwise rare tumors.

• Transmissible form of Immuno deficiency

 Definition
• as the constellation of opportunistic
infections particularly by Pneumocystis
carinii, and /or Kaposi’s sarcoma or other
tumors, associated with severe immuno
deficiency developing in previously healthy
persons who have had no
immunosuppressive treatment.
 Etiologic agent
• HTLV III virus (Human T cell
lymphotropic Virus Type III)
• LAV (lymphadenopathy virus)
• HTLV IV, ARV (AIDS – related virus)
• These viruses are now termed as human
immunodeficiency viruses (HIV) – HIV1
and HIV2.
 Risk groups
• Male homosexuals, bisexuals – 73.4%
• IV drug abusers – 17.0%
• Transfusion recipients – 1.4%
• Hemophiliacs – 0.7%
 Pathophysiology
HIV attacks T. lymphocytes leading to severe immuno
deficiency due to
• Quantitative abnormalities of T. lymphocytes
• Functional abnormalities of T. lymphocytes
• Functional abnormalities of B. lymphocytes
• Functional abnormalities of Monocytes and
macrophages
• Reversal of T4/T8 ratio (Normally-2, AIDS – 0.5)
• Antilymphocytic antibodies and auto antibodies
especially anti platelet and anticoagulant antibodies
 Pathophysiology
• HIV + T- helper lymphocytes (CD4
antigens)
• Macrophages, neurologic glial cells, colon ,
rectal, some CT cells.
• Latent for 1.5 -11 years > replicate> death
of lymphocytes > release virus into blood
– HIV has been detected in blood, plasma,
semen, saliva, tears, CSF

– Michael Glick et al (1989) – detected HIV

proviral DNA in the dental pulp of
patients with AIDS.
 Clinical features
Opportunistic infections
• 1 Pneumonia / sinusitis – Pneumocystitis
carinii
Aspergillosis
Candidiasis
Staphylococcus aureus etc.

• 2 GIT infections - Cryptosporidiosis

Isospora
Giardiasis
All these infections can lead to chronic weight loss
 3.Meningitis / Encephalitis
4.Mucocutaneous infection –
HSV
HZV
Staphylococcus aureus
Candida & Histoplasmosis
5.Disseminated infection – Adenovirus,
CMV
• . Neoplasms – Kaposi’s sarcoma,
Lymphomas, Squamous cell carcinoma,
Leukemia .

• Other complaints  Encephalopathy, ITP,

lupus erythematosis, seborrhic dermatitis
 DIAGNOSIS
• clinical features and serological findings.

• . WHO has defined pediatric AIDS as an

infant / child presenting with at least a
major criterion along with at least 2 minor
criteria in the absence of any
immunosupression.
 Major features
• Chronic diarrhea of greater than 1 month
• Prolonged fever and
• Weight loss
 Minor Changes
• Oropharyngeal conditions, repeated cough of
greater than 1 month duration.

• Generalized lymphadenopathy

• Generalized dermatitis

• Maternal HIV infection

 Oral Manifestations
• are common and among the first clinical
features to appear, these include
• Cervical lymphadenopathy
• Candidiasis
• Hairy leukoplakia (EBV)
• Kaposi’s sarcoma
Less common ones include:
• Angular cheilitis
• HSV
• HZV
• Venereal warts
• Recurrent ulcers
• Osteomyelitis
• periodontitis
• Parotitis,
• Xerostomia,
• Cranial neuropathies
 Dental precautions
• little scope for HIV transmission
• risk of transmission of HIV by needle –stick
injuries is only 1% (26% for HBV)
• Proper Medical History
• Barriers techniques like –
– eye protection
– disposable mouth mask
– disposable needles
– gloves (double)
– change of clothes
Proper sterilization
• HIV is sensitive to heat
– autoclaving at 121oC for 15 minutes at
1atmospheric pressure
– dry heat at 170oC
– HIV can survive at room temp for 7 days
• Common disinfectants include
– 0.2% Sodium Hypochlorite
– calcium hypochlorite
– 6% H2O2 for more than 30 minutes
– 2% Glutaraldehyde and 6% H2O2 combination
– Sodium dichloroisocyanate
Disinfectant of living tissues
• 2% propanol
• Ethanol
• Iodine