Oral Diagnostics
Indication and contraindication of dental
treatment relating to general health
status
Dr Bródy Andrea
Semmelweis Egyetem
Fogorvostudományi Kar
Oralis Diagnosztikai Tanszék
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 influenced
Treatment, used materials
Oral health
Dental treatment
influenced
Disease
General health
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:
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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 human
immunodeficiency 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.
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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
Investigation of
background
disease is
necessary!
Candidiasis
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.
Thank you for your
attention!
brody.andrea@gmail.com