1.

Odontological management of the patient with arterial hypertension

Dental considerations • Know meds to avoid interactions
• Reduce stress and anxiety + Avoid long stressful appointments.
• BDZ = 2-5mg at night and 2-5 mg 1 hour before.
• Some clinics have nitrous oxide.
• Slow changes of posture of the patient, slowly elevate the patient after treatment
• Make sure patient doesn’t get up too fast if they have BP problems
• More common to have nausea and vomiting in these patients
Associated oral disease • CCBs gingival hyperplasia e.g. nifedipine
• Diuretics à dry mouth
• Really high BP à bleed more during surgery therefore we wait more after anesthetising so vasoconstrictor work
Lichenoid reactions
• Enalapril ace inhibitor
• Antimalarials
• CCBs
• NSAIDS
classification PA (mmHG) Grupo A (no factors) Grupo B ( Risk factor) Grupo C (CV, pain/diabetes)
130-139/85-89 Lifestyle Lifestyle pharma
140-159/90-99 Lifestyle (12 months) Lifestyle (6 months) pharma
>160/ >100 pharmacotherapy pharmacotherapy pharma
Grades Grade 2 A no Grade 2 B = maximum of 2 Grade 3 = for example, start an endo treatments, and Grade 4 = straight to hospital
restrictions carpools of lidocaine 2% always avoid vasoconstrictor e.g. mepivacaine, or
1/100,000 lidocaine without adrenaline. – very bad situation.
Interactions • NSAIDS à reduce anti-hypertensive effect.
• N and V common
• Anti-hypertensives and barbiturates and sedatives = doctors problem = know and be aware of interaction.
• Orthostatic hypertension
Hypertensive urgency Diazepam 5-10mg Captopril 25-50mg Atenolol 50mg Labetalol 50-100mg SL GTN SL nifedipine
2+ 2+
Patient advice K+ 90mg OD Ca + Mg Stop smoking Reduce salt Increase exercise
Classification 120/80 ideal 120-129/80-84 130-139/85-90 140-159/90-99 160-179/100-109 >180/>110
Ideal 120/80 norm high norm Grade 1 Grade 2 Grade 3
Goal <140/90
Diabetic <130/85
 2. Patient management protocol = kidney pathology
Symptoms • Generalized swelling due to fluid retention
• Metallic flavour of the mouth
• Sensitivity decrease – more important in diabetic patient
• Nausea and vomiting
• Prolonged bleeding, bruising
• Halitosis
• AHT – arterial hypertension.
• Wound delayed cicatrisation (healing) – problems after exos and implants
Protocol Position of the seat,
Dialysis patient = semi reclined
Seat • Pauses during trx
• The patient with chronic renal failure usually presents arterial hypertension
• Monitor the arterial tension on other arm as arterior venous fistula.
• Analgesics = avoid aspirin or any medicine with anti-prostaglandins that induce nephrotoxicity. – increases the chances of
bleeding and is most common in patients under haemodialysis
• Cultures and antibiotic sensitivity against oral infections
Antibiotic • Antibiotic prophylaxis in patients undergoing haemodialysis
• With renal failure, the total dose of antibiotics should be reduced to avoid toxicity.
• Penicillin can be used – e.g. amoxicillin, following formula. E.g. skinny girl 500mg, average normal guy 750mg, 90-100 kg 1gram
of amoxicillin.
• Avoid tetracyclines because of their catabolic effect, nitrogen retention.
• Do not use aminoglycosides or cephalosporins because of their nephrotoxic effect
• Avoid benzylpenicillin and carbenicillin because of its high sodium and potassium content that can produce cardio and
neurotoxic effects.
• Get adequate sleep the night before
stress
• Short appointments
• Dialysis patients should be scheduled the morning after the haemodialysis (heparin 8H)
• Caution with CNS depressant drugs in patients with uremia ( Chronic renal failure)
• Sedation with nitrous oxide, is an excellent anxiolytic and will be accepted by renal patient.
• Use rubber dam for routine treatment
• Antibiotic prophylaxis in immunosuppressed patients 9trsp) or in haemodialysis
• Treat oral infections early to avoid complications
• Adjust the dose of the antibiotics based on GFR.
• Frequent infection and delay in healing.
 • Avoid haemorrhagic treatment at 8h after haemodialysis
• Recent analytic – to check blood levels
• Microfibrillar collagen sponge, topical thrombin and adequate suture in minor surgery.
• Suture for simple extraction e.g. simple suture, x suture, buccal palatal, buccal palatal, then knot in palatine.
Classification Mild Moderate Severe
GFR ml/min 20-50 10-20 <10
CC 0.8-0.6 0.59-0.21 0.2-0.1
Serum creatinine 150-300 300-700 >700
Dose adjustment • Normal dose X patient c. clearance/normal Interval adjustment • Normal interval X normal clearance/patient
clearance clearance
• 500mg (8h) x 0.5/1 = 250mg (the normal dose • 8 X 1/ 0/5 = 16h (the normal interval being 8
being 500mg/8h). hours).
 3.Patients undergoing Organ transplant
bacteraemia in pre- Oral IV
transplante hepatic - Amoxicilinica 2 grams - Ampicillin 2 gr
patients - Metronidazole 500mg (1 h before) - Metronidazole 500mg (1h before)
- Clinical history - Exploration – opg
Pre-transplant - Eliminate septic foci
- Eliminate irritants – ortho, ppr (all must be removed)
- Motivation and hygiene
- Antibiotic profylaxis
- Endo: uni and bi without foci – we only do endo in these cases, rest exo.
- Molar exo
- Not restorable : exo
- 6mm or mobility grade 2: exo (no cx perio nor complicated)
- Infection chronic = exo
- Keep wisdom teeth included without pathology- semi included or with pain = exo
- Premalignant lesions will be removed e.g. leucoplakias.
1-6 months < - major surgery, - Revisions
induction - anastomosis of the - Motivation
DO not Treat these - acute rejection - Control of plaque
- Infection - No urgent treatment – hospital – we do not treat in first 6
- Thrombosis month post transplant
Mask in the waiting room for first 6 months. Mask after if someone other patients have infections
6-12 months - Stable graft - Motivation
maintenance - Immunosuppression but Normal function - Tartarectomia, rapajes
Any bloody - Tri -menstrual revisions - Conservative dentistry – don’t need antibiotics for fillings
procedures give - no exos - Prophylaxis antibiotics
antibiotic - (M, osea 6-9 months) Any bloody procedures give antibiotic prophylaxis!
prophylaxis!

Gingival hyperplasia Cyclosporin causes this after 4-5 months.

We try non-surgical - Consult with doctor for different drugs such as tacrolimus.
interventions first - We try non-surgical interventions first
- Then we do surgical intervention e.g. gingivectomy.
If probing depth is 16 mm we minus 2-3 mm, then we cut from that point, where to draw with scalpel how we make cut.
Herpes - Aciclovir cream 5% - 5 times a day - Famciclovir 250mg /8h
- Aciclovir oral – 1,500-4000 mgr/d - Foscarnet 40-60mg/kg/dia
- Aciclovir 8-10 mg/kg/8h iv - Mouthwash of lidocaine and chlorhexidine.

Infections by • 1-6 months up to 45 % suffer from this

Citomegalovirus But over time, rates go down due to lowering of azathioprine (immunosuppression)

Pseudomembranous Nystatin Anforteracain B Miconazole gel 100mg / 4 times

candidiasis - Suspension 100,000 u (4-6/4h) - Suspension 5cc/ 3-4 times a day a day
- Pomada 100,000 u/gr 3 times a day - Bucall pastillas 10mg 4-6 times a day
- Grageas (2 grageas/ 3 times a day Also bicarbonate rinses.
- Tablets vaginales ( 3 times a day

Oral 2 weeks after • Fluconazol Ketoconazol • Itraconazol Amfotericin B

150-200 mg/d 200-500mg/d 100-400 mg/dia 0.5mg/kg a day

Grades Autotransplant : no problem Isotransplant = donor and Allotransplant = same species Xenotransplants = from
immunological/rechazo (teeth, receptor same e.g. twins another species
organs)

Neoplasias Types - associated immunosuppression
- squamous cell carinoma
- linfoproliferativos e.g. linfomas
- Kaposi sarcom
Factors
- Immunosuppression therapy
- Age
- Habits and predispositions
- Episodes of rejection
After changing immunosuppressant drugs e.g.
Kaposi sarcoma went down when doctor
changed medicine to Sirolimus.
 4. Cardiovascular
Rheumatic Antibiotic prophylaxis = except in placement of prosthesis and adjusting orthodontics.
cardiopathy
Antibiotic prophylaxis 2g amoxicillin/cephalexin/ampicillin 30 - 1 h before 600mg clindamycin 500mg azithro/clarithro
Innocent/fuctional increase in the blood flow. – no actual problem, the sound when too much blood going through
murmur • Children of 5 to 7 years
• Pregnant
• Not necessary to give antibiotic profylaxis – but if there is any doubt, we should
Cardiac insufficiency • Beta blockers • Aldosterone blockers
• Diuretics • Calcium channel blockers
• Angiotensin 2 blockers • Digoxin – narrow therapeutic window
Management CI - Check BP
- Position of the patient – can’t lie completely flat as can’t breath properly
Can’t lay them flat - Short appointments
- No rubber damn- 1 or 2 yes but 3 no.

Decompensation of • Cold skin arriving little blood to the skin • Tachycardia – compensation for lack of force
the cardiac • Arterial hypotension - compensation • Tachypnoea –
insufficiency

Grades – cardiac I asymptomatic – treated as II - moderate activity – fatigued III – smooth activity. IV – resting –
insufficiency normal healthy patients – max under these, running/exercise. – we don’t treat these go to
2 carpools normal healthy patients – max 2 URG – during normal activity hospital
carpools
Interactions Clavulanic acid + digoxin à Increases the action of the anticoagulants with the risk of haemorrhage by the alteration of the floral
intestine that inhibits the formation of vitamin k.
Instead we increase the amount of amoxicillin rather than adding clavulanic acid.
Cardiac ischemic Mortality - Age - High level of - Being a man – - Arterial - Tobacco
cardiomyopathy - Diabetes lipids serology. women have hypertension
Coronary hormonal
Risks involved: arteriosclerosis protection
Management of - Short Anesthesia with Avoid retraction Avoid anti- Stick to same - Control stress –
appointment vasoconstrictor cord with adrenalin cholinergic as Anesthesia – due to BDZs –
stable anginal morning! soaked produce tachcardia, preservatives, same
and old stroke 2 carpoules - atropine brand - diazepam 2-5mg,
(+6 months) - Semisupine Doses - Oximetazolina - esocopolamine. - Anesthesia
positon - Tetrahidroxolina without - lorazepam 1mg,
>6 m max of adrenalin inhibits the vasoconstrictor control pain
- Take BP and 0.036 mg muscarinic actions of or with
acetylcholine
heart rate vasoconstrictor

Management of Only urgent cases • BDZs always Angina unstable – Anaesthesia Cafinitrina = has caffeine and nitroglycerine
are treated by us • 10mg nitro-glycerine – this drug is a
unstable angina – we wait for after oxazempam sublingual before
without spasmolytic – makes blood vessels expand
or stroke in less 6 months to do or treatment – brand vasoconstrictor and open more all over the body, avoiding
than 6 months the rest of the • 5mg diazepam name Cafinitrina always. compressive pain.
treatments, only the night before with caffeine
<6 m very urgent • The same 1 hour Caffeine will increase the power of
treatments to do before consult contraction of the heart, will avoid
now. problems of lack of supply of blood to the
heart.
Stent ¨ Never stop treatment of platelet anti-aggregant like Adiro 100mg (300mg or more we speak to cardiologist to reduce the dosage
temporarily only on the days of specific surgery).
¨ Delay non-urgent invasive procedures with risk of bleeding.
Types of stents Metallic stent : 4-6 weeks after angioplasty. Farmacoactive stent: 6-12 months. – coated in medicine.

Stent prophylaxis Antibiotic prophylaxis in dental treatments 1st 6m.

<6 weeks = nothing!!!

Metallic stent from 6 weeks to 6 months you have give anti-biotic Farmacoactive stent - must wait up to 1 year – you don’t need
6w – 6m = antibiotic prophylaxis and you can’t do procedures that provoke bleeding in to give antibiotic prophylaxis.
prophylaxis first 6 weeks.

Farmac = no prophy
 Sintrom
2 days before stop sintrom Start LMWH ( 20mg of enoxaparina)
1 day before No sintrom Continue LMWH
Day of the Use tranexamic acid locally, restart sintrom that night Continue LMWH
appointment
2 days after Sintrom continue LMWH continue depending on case – some high risk patients 2-3
days after doctor might say continue only with sintrom
Sintrom after all Before patient with risk of thromboembolism is high, the profilaxis with lmwh it will be mainitained for 3 days after the appointment.

Pacemaker
pacemaker First 6 months of placement – antibiotic prophylaxis
pacemaker - Generator sets - MRI machines
- Welding equipment - Radiation therapy machines for cancer treatment
- Some device used by dentist: ultrasound (curate), electric - Heavy equipment or motors with powerful magnets.
scalpel (tranexamic acid instead as used to stop bleeding/ or
applying pressure) and apex locator (do x-rays old school)
 5. Dental management of pregnant women
1st trimester • 50% spontaneous abortions (due to egg alterations, maternal causes, external aggressions)
• Possible teratogenic effects
• (before 2 weeks of gestation = death of the egg,
• between the 2nd week and 2nd month = important organic defects End of the first trimester = small organic defects).
• 1st trimester reduced arterial hypertension (bradycardia)
2nd trimester • Growth of foetal structures and maturation of organs.
Best time to treat • No teratogenic but toxic effects
• Best trimester for treatments
3rd trimester • Toxic effect
• Maximum size
• Possibility of provoking/advancing labour.
• In third trimester avoid lying the women down, due to hypotensive dorsal decubitus syndrome.
Hypotensive dorsal by compression of the uterus on the vena cava inferior taking down the blood pressure, bradycardia, sweating, nausea, loss of
decubitus syndrome conscience.
Special precaution • Change of habits, change of hours periods of anorexia, and excess apetitie
• Sialorrea
digestive • Nausea and voming common
• By hormones increased oestrogen HCG, progesterone, 1st week
• Immune changes
• Changes in habits; pregnant women eat more - increased carbohydrate intake, increase of salivation, nausea and vomits
respiratory • Increased breathing – tachypnoea
• Dyspnoea ( > in the last week> lying down)
Hormonal gingival and perio
Gestational choasma during second half of pregnancy- brownish colour in eyes and maxilla due to melanocytes increasing ACTH.
Gingivitis • 50-100%
• Starts in 2nd month until 8th month
• Clinically of colour red, increased volume, smooth surface which is bright, random bleeding/
• Papilla hipertroficia and seudobolsas
Immunological • Reduction of T lymphocytes - CD3 and CD4
• Reduction of the response of the cells in the gum> inflammation.
Epulis Gravidico • Clinic = Thickening of the ginigiva (V), in papilla, intense red for being rich in vasos. (increase hemorrhagia) base pedicle o sésil.
• Asymptomatic.
• Gingivs and placa.
• Appear 2nd trimester, decreases in size after pregnancy (no> de 2cm)
• History Similar to pyogenic granuloma, changes of inflammation and hyperplasia. – will cut it around the healthy tissue as
impossible remove with scalpel

Dental precautions Caries

- Relation not nknown.
- Increased cariogenica
Causes - Changes of saliva, hygiene and diet, flora Vomits by reflux
All of these is why they say there are
Doesn’t exist descalcification existed of the calcium when pregnant.

Erosions • Due to hyperemesis.

• Go aesthetic treatments – but wait until after pregnant due to inflamed tissues
Perio disease • Etiopatogenia = severe gingivitiss
• Changes > if they have a pre-xisting period disease
• General mobility that reverts after pregnancy.
• Period pathology.
• Premature birth and low weight = increases with perio
General guidance • Pregnancy does not contra indicate dental treatment
• Prevent (educate, reinforce, fluour)
• 2nd and third trimester best period
• No long treatments
• Important to interconsult with gyno
1st trimester • Control plaque – perio consented
• Educate for health – technique and diet
• Cleaning + tartarectomy + polish teeth
• Treatment of urgent cases if necessary
• If you can work but careful with
• Sialorrea, nausea,
• Organogenesis fetal
• No x-rays. . Pulpotomy, then CaOH, with cavit on top.
2nd trimester • Periodic visits
• Treatment of routine
• short sessions
• Avoid long waiting times
• Careful with posture
• Careful within medication.
3rd trimester • Indication in the second trimester
• To increase the weight
X-ray • Benefit/risk
• Dosis absorbed in abdomen similar to the natural radiation
• In general not contraindicated but only if necessary.
• Avoid 1st trisemester
• Leaded apron
• Apparatus homolgados (50-70Kv)
• Films of high velocity radiovisio
• Avoid accumulation of objects that increase x-ray diffusion
• Inspection periodict, filtros colimacion.

Nitrous oxide • Not in first trimester

Varnish and Avoid fluor until 4th month 1-1.5mg – caries cuello
mouthwash

Breast feeding All of the pass into the milk more or less half amoxicillin and paracetamol ok
Pharma Pharmacological low weight molecular they pass to the milk proportion 2-3%/ in blood.
 6. Epileptic patients
Oral manifestation • Xerostomia
• Caries
• Cicatrices in the tongue
• Severe attrition
• Limitation of the apertura of the mouth
• Dry lips
Benzodiazepine • Lorazepam 1 mg the night before and one hour before the intervention
• Diazepam...5mg
Nitrous oxide Avoid increased toxicity in anti-epileptics
Times early in the morning or during the workday, without making you wait excessively + short
Protocol Management in the clinic of the epileptic patient
1. Eliminate triggers factor (light, noises, anxiety)
2. Appointment after taking meds
3. No NSAIDs, increased risk of haemorrhage, metabolism hepatic. NO administering erythromycin or propoxifeno to patients that
take carbamazepine.
4. Put back space edentulous, protesis fixed, metallic posterior and resin in anteriors. Avoid removable dentures. Resin easier to fix
than porcelain.
5. Use mouth openers
Protocol in epileptic - Remove all dental instruments and materials
crisis - Remove removable prosthetic or orthodontic appliances
- Place supine, on the couch or on the floor
- Avoid hitting the head or limbs
- Separate objects with which the patient may be damaged
Specific measures - Place a guedel cannula or rubber wedges in the mouth – we have various sizes, try and insert without putting the fingers in the
mouth
- Place the head to the side
- Aspirate secretions and saliva if possible
- Keep the airway area clear
Therapeutic measures • If the crisis lasts more than 5 minutes
during a seizure • Ensure adequate ventilation - Administer oxygen with mask.
• Administer benzodiazepine:
• Intravenous route: diazepam 10-20 mg in adults 0.1-0.3 mg / kg in children
• Rectal route: diazepam (10-20 mg).
• If epileptic seizures persist after 15 minutes, the patient should be transferred to a Hospital Emergency Department
Action before an • Measures in the postcritical phase of epileptic seizures
epileptic crisis • Monitor respiratory rate
• Assess the degree of wakefulness and orientation
• Administer IV 1 ampoule of 50% glucose
• Administer 100 mg of thiamine IV if alcoholism
• Diazepam effect can be reversed with flumazenil (Anexate)
• Local priests if oral or lingual wound
 7. Oncology
Immediate - soft • MUCOSITIS / DERMITIS – inflammation fo the skin and areas recieveing radio.
tissue – first weeks to • Dysgeusia – alteration in perception of tongue, won’t be able to feel flavours in same way.
months • GLOSODINIA
• XEROSTOMY –
Medium term • CAVITIES – due to lack of saliva
• TRISMUS - FIBROSIS –loose their elasticity and tendons will suffer the same fate. Due to alterations in the muscle will result in
the patient having trismus. Problems opening the mouth and feeding properly. Mainly affecting the pterygoid muscle and
masseters
• DYSPHAGIA – problems swallowing
• MUCosa NECROSIS – mucosa will start to suffer erosions and spontaneous ulcers.
Long term • OSTEONECROSIS – tissue which will be effected in long term, sometimes spontaneous.
• ALT. DENTAL
o AGENESIA
o ALT. CORONAL
o ALT. RADICULARS
GUIDELINES FOR Clinical history systemic pathologies, medication, type of therapy patient will receive and how many sessions, and very important
ACTION ON when will the patient receive radiotherapy!!! – as is time crucical as have to have all treatment finished before the patient starts.

THE FIRST VISIT OROFACIAL EXPLORATION

o INTRA AND EXTRAORAL INSPECTION AND EXPLORATION–must know what is the state of the oral cavity to eliminate septic areas.
o PALPATION OF ADENOPATHIES
X-RAYS
o PANORAMA–always a panoramic prior to X-rays as all teeth will suffer, sometimes patients
o PERIAPICALESANDBITwings.
PHOTOGRAPHS – prior and post photos
RECENT ANALYTICS
Protocol prior to MOTIVATION. HYGIENE TECHNIQUES – must understand the importance, must buy a water irrigator.
TARTRECTOMY. SCRATCHES (mild EP)
Radio IMPRESSIONS. LEAD SPLINTS.
EXTRACTIONS
o minimum of 21 DAYS BEFORE
o CURET ALVEOLO, REMOVE fragments, SEALANTS, polishing
• ELIMINATE TRAUMATIC FACTORS
• Bigger bags 6mm – Extraction
• Teeth with pulp involvement
o Incisors and canines- Endodontics
o Premolars
§ Periapical focus - Extraction
§ Without focus - Endodontics
o Molars – Extraction
Don’t do re-endos.
Precautions during • HYDRATION. 2-3 L / DAY
radio • Avoid spicy foods and hard foods.
• Not too cold or too hot food.
• Avoid snacks with high sugar content, avoid very salty water.
• Rinse your mouth with warm salt water every 1 to 2 hours as needed. CHX
• Eat candy or chew sugarless gum.
• Use a soft toothbrush.
• Using toothpaste without abrasives.
Grading OF GRADE 0 ----- NORMAL GRADE 1 ------------------ GRADE 2 ----------- GRADE 3 -------------------- GRADE 4 ---------- EXTENSIVE
MUCOSITIS ------- eritema – ERITEMA-ULCERS ----- ULCERS ULCERS
ACCORDING TO red mucosa = no ulcers o MAY EAT SOLIDS o CAN INGEST LIQUIDS o SWALLOWING Impossible
W.H.O.

Mucositis o BLAND DIET

o REMOVE IRRITANTS, PPR, polish teeth edges – as is an irritant for mucosa, avoid sharp teeth.
o AVOID EXTREME TEMPERATURES – avoid extreme cold,heat.
o GOOD HYDRATION
o AVOID TOBACCO AND ALCOHOL
 Mouthwash o Physiological serum (0.9%)
o Aluminum hydroxide
o Peroxide
Diphenhydramine
Chlorhexidine – apply it everyday, throughout all of the trearment of radio. In the gums or any structure in oral cavity.

Topical Lidocaine spray/gel

MUCOSA PROTECTORS o Carbenoxolone (Anti-inflammatory and cytoprotective)
– gels or o Sodium carboxymethyl cellulose 125 mg (viscous solution for oral use)
mouthwashes. To be o Sucralfate
taken in combination o Colloidal bismuth
with chlorhexidine
and nystatin 1st line Triamcinolone – medium potency 0.5% in mouthwash 3 times a day as long as necessary
2nd line Clobetasol proprionate 0.05% 10 times stronger than triamcinolone at this strength.
ADRs = of topical steroids = oral candidiasis.

Mucositis PAIN:
o ALKALINE SOLUTION (Maalox) + 4 AMPOULES OF A LOCAL ANESTHETIC (2%). o RINSES WITH TWO TABLESPOONS HALF AN HOUR
BEFORE MEALS
o TOPICAL CORTICOIDS, side effects .
Cleaning Cleaning:
o 100ml OFWATER + SALT + BICARBONATE – this avoid the possible over infection of candidiasis.
Cryotherapy 30 minutes to prevent - oral mucositis in patients receiving bolus 5-fluorouracil chemotherapy (II)
Low level laser to prevent oral mucositis in patients receiving HSCT conditioned with high-dose chemotherapy, with or without total body irradiation
therapy (II).
Benzydamine prevent oral mucositis in patients with head and neck cancer receiving moderate dose radiation therapy (up to 50 Gy), without
concomitant chemotherapy (I). A medication used for anti inflammatories and analgesic.
Morphine morphine be used to treat pain due to oral mucositis in patients undergoing HSCT
Transdermal fentanyl treat pain - oral mucositis in patients receiving conventional or high-dose chemotherapy, with or without total body irradiation (III).
2% morphine may be effective to treat pain due to oral mucositis in patients receiving chemoradiation for head and neck cancer (III).
mouthwash
0.5% doxepin mouthwash may be effective to treat pain due to oral mucositis (IV)
XEROSTOMY AND o GLANDULAR DYSFUNCTION IS DEPENDENT DOSE 60-70 grays of radiation, we get this one of the most important side affects of
HYPOSIALIA xerostomia.
o MORE SENSITIVE SERIOUS ACINIS -
o SALIVA DENSA, STICKY, MUCOSA
o ACINOS ATROPHY
o VASCULAR ALTERATIONS
o FIBROSIS
o Tissues are very shiny, massive lack of saliva. The mirror will get completely stuck to mirror.
Xerostomia help o INCREASE LIQUID INTAKE. 2-3 L / day
o SORBITOL BASED CHEWING GUM
o SUBSTITUTES FOR SALIVA. ARTIFICIAL SALIVA
o PILOCARPINA 5mg / 8 hours – the only thing that works, pilocarpine 5mg/8h
o CARBOXIMETILCELULOSA Na (0.5% in aqueous solution)
o LIP BALM – labio protector important to protect lips. Kin hidrat spray.
Osteoradionecrosis Due to....
- DECREASE IN THE NUMBER OF OSTEOCITS
- DECREASE No OF OSTEOBLASTOS
- VASCULAR ALTERATIONS

Exos in patient treated
with radio
• 3 to 6 weeks BEFORE RT – even better to do exos 6 weeks before.
• 8 months to a year AFTER RT – 8-12 months after before we can do exos again.
• Implants 2 years later
• ANESTHESIA WITHOUT VASOCONSTRICTOR (Post.) - before you can, after radio only without adrenalin due to devascularisation.
• CURETEAR ALVEOLO
• SUTURE – after exos
• RESPECT THE PERIOSTIO – If we break or damage it during exos, we get more complications.
• Don’t need to give antibiotics before exo.
• ATB COVERAGE always post – 1 week 700mg amoxic/8 h
• ANTISEPTIC ROUTINE. CHX daily.

How to avoid caries with o ORAL HYGIENE

radio o SEALS
o SODIUM FLUORIDE GEL 1%
o AVOID ACIDS
o Mouthwashes with CLX
o IRRIGATORS (waterpik – this brand) – very very useful
Fungal infections fungal infections

In these temporarily immunosuppressed patients, infections by opportunistic microorganisms are frequent.

We mainly use miconazole patients
In immune depressed patients we have to continue giving it for 2 weeks after

CANDIDA INFECTION

• Miconazole 2% oral gel

o Apply 4 times/ day
• Ketoconazole / 200 mg
o 1 tablet/2 times a day (21days)
• o Fluconazole150mg–50mg/8h

Trismus Physiotherapy and prevention are the best weapons to prevent this pathology. Consistency in exercises will greatly improve your
quality of life.

• EXERCISE OF CHEWING MUSCLES--------------à

• OPEN YOUR MOUTH AS MUCH AS POSSIBLE 20 TIMES (6 TIMES A DAY)à

The patient should continue to check regularly and avoid all types of carcinogens (tobacco, alcohol ...)

How long will we see the patient during radiotherapy, we should see them once a week, we can find a really big change from one
week to the next week. Mandatory to see the patient weekly, take pictures and re-assess the mouthwash.
 8. Diabetes
Grades Normal Prediabetes Diabetes
Fasting 70-100mg/dl Fasting 100-125mg/dl >126mg/dl fasting
After 2 hours less than 140mg/dl After 2 hours 140-199mg/dl >200mg/dl after 2 hours

Dental treatment <140mg/dl 140-180mg/dl 180mg/dl<

Treat normal with VC Without VC -
All treatments Big infection, intense pain, trauma – Send to hospital
URGENT cases

HBA 1 c • NORMAL 4.1-5.5% • PREDIABETES between 5.6% and 6.4% • DIABETES greater than 6.5%

More caries lack of saliva + higher amount of glucose in those tissues

Higher perio glucose in the sulcus
Burning mouth synd due to sensitive alteration due to polyneuropathy affecting sensitive nerve terminations
More infections bacterial, fungal, oral infection.
Bidirection badly controlled diabetes = more oral infections. + more infections will affect diabetes
infection
Diabetes V linchen Linchen planus patients we should always ask for diabetes tests in these patients as many times patietns that suffer lichen planus also
planus have diabetes which has not been diagnosed. Strong relation between diabetes and lichen planus also another relation is oral anti-diabetic
medication and lichen planus.
Protocol Hours - morning appointments are recommended since endogenous cortisol levels are generally higher.
Diet – after breakfast
Monitor blood glucose
Anxiolytics: benzodiazepines. Alprazolam, lorazepam.
Antibiotic treatment AFTER extensive surgery (7 days). – ALWAYS give + suture. Not prophylaxtic antibiotic only after ALWAYS.

Signs of Diabetes • dry mouth

• periodontal disease
• Periodontal abscesses
• Scarred healing
• Retarded healing, frequent baceterial and perio infections, polydisya and polyuria.
Hypoglycemia Sweating, Tremor, Anxiety à Blurred vision, Confusion Amnesia à Seizures Coma à death
<60mg/dl
<50mg/dl
monotherapy
capillaries
Hypoglycaemia- History - Low diet, Sudden start, NO Fever, Exercised a lot
Physical exam – moist skin and sweat
OTHER symptoms - Mouth with hypersalivation, Not thirsty, sometimes hungry, NO vomiting, NO Abdominal pain
Fast recovery • Normal BREATH
• BLOOD PRESSURE Normal
• POWERFUL PULSE
• SHAKE YES
• CARBOHYDRATE TREATMENT – sugar, coca cola.
• Quick ANSWER in minutes !!!!!
Hyperglycaemia • HISTORY
- Diet -Insulin
Slow recovery - Gradual start ß
- Fever
• PHYSICAL EXAM
- Dry Skin ß
• OTHER DEMONSTRATIONS
- Dry mouth
- Excessive thirst
- No hunger
- Frequent vomiting
- Frequent abdominal pain
- Doesn’t sweat

• Kussmaul BREATH (fast)

• BREATH Acetone
• Low blood pressure
• Weak PULSE
• SHAKE NO
• Treatment = insulin
• SLOW RESPONSE 6-12 hours à We give lyspro/aspart/glulisina which work in 15 minutes
Renal insufficiency If glomerular filtration (FG) 10-50 mL / minute, administer 75% of the dose and monitor glucose levels.
if glomerular filtration. FG <10 mL / minute, administer between 25-50% of the dose and control glucose levels.

If a patient has both renal insufficiency and diabetes they have to control and adjustment of insulin, so the amount of insulin they need
will be controlled by endocrine. – the worse the renal insufficiency, the less insulin they will have.