ONLINE CLASS HOSPITAL

DENTISTRY 2 LAB
ORIENTATION 2ND SEMESTER 2020-
2021
M1 – MEDICAL
Lesson 1 – Review of Medical
Abbreviations

RECORDS Lesson 2 – Components of

Medical Records
 LESSON 2 – COMPONENTS
OF MEDICAL RECORDS
A medical record is a collection of data
compiled on a patient to assist in the clinical
care of present and future illness.
As a document, the medical record is not
only a repository of information, it is also a
continuing record which acts as a means of
communication between members of the
health team. A famous maxim concerning the
medical record is: "To be complete, the
medical record must contain sufficient data,
written in sequence of events, to justify the
diagnosis and warrant the treatment and end
results".
 LESSON 2 – COMPONENTS
OF MEDICAL RECORDS
5 Major components of a Medical Record
1. Admission notes
2. Pre-operative notes
3. Operative and Post-Operative Notes
4. Progress notes
5. Discharge notes
 LESSON 2 – COMPONENTS
OF MEDICAL RECORDS
Supporting/Supplemental Components:
1. PHYSICIAN'S ORDER - Are systematic list of instructions by the physician to the
floor staff for the health care plans of the patient throughout his hospitalization.
2. NURSING NOTES - Provide vital information regarding the patient’s status as viewed
by the nurse. ***Nurses are obligated to carry out medical orders but are also authorized
to diagnose & prescribe within the limits of the state nurse practice act.
Nursing Care Plan
 A written guide that organizes information about the patient’s health into one whole information.
 It is a format that nurses has to follow in charting their interventions with the patient.
 It focuses on the actions a nurse has to take to meet his goals for the patient.

3. LABORATORY TEST RESULTS - Contains pertinent information extracted from

blood, urine & sputum analysis, radiographs and other diagnostic tools.
 M2 – CARDIO-
PULMONARY
Lesson 1 – Principles and steps of
CPR

CEREBRAL Lesson 2 – Automated External

Defibrillator

RESUSCITATION
M2 – CARDIO-PULMONARY
CEREBRAL RESUSCITATION
LESSON 1 – PRINCIPLES AND
STEPS OF CPR
 LESSON 1 – PRINCIPLES AND
STEPS OF CPR
Steps of CPR
1. Check area safety
•Is the scene/environment safe?
•Is it safe to do CPR?
•What happened?
2. Check responsiveness
•Tap or gently shake victim
•Ask, “Hey, are you OK?”
•Check:
–Normal breathing?
Agonal breaths are NOT normal; sign of cardiac arrest
–Unresponsive?
 LESSON 1 – PRINCIPLES AND
STEPS OF CPR
3. Call for HELP CHEST COMPRESSIONS
•Ambulance, Emergency services, Doctor
➛100 - 120 per minute or more
•Activates Emergency Medical Service (EMS)
➛30 counts, count aloud, complete chest recoil
•Get AED/Defibrillator
**pulse check
• for TRAINED Healthcare providers only COMPRESSION DEPTH:
• Carotid pulse
• Within 10s only ADULT: At least 2 -2.4 inches (5-6cm),
• Unsure? proceed to CHEST COMPRESSIONS CHILDREN: About 2-2.4 inches (5-6cm)
4. Compression (C-A-B) INFANTS: About 1.5 inches (4cm)
HOW?
•Kneel facing victim’s chest
HAND PLACEMENT:
•Heel of 1 hand at center of chest, other hand on top and fingers
interlaced ADULT: 2 hands, lower half of sternum
•Shoulders over hands, elbows locked, arm straight CHILDREN: 1 or 2 hands, lower half of sternum
•Compress down, release pressure gently INFANTS: 2 fingers, just below nipple line
 LESSON 1 – PRINCIPLES AND
STEPS OF CPR
5. AIRWAY (C-A-B) 6. Breathing (C-A-B)
•Head-tilt, chin-lift maneuver •Maintain airway
• Press down on the forehead while pulling up on the
bony part of the chin with 2-3 fingers of the other •Pinch nose shut
hand
•Open your mouth wide, take a normal breath,
• Tilt the head past a neutral position top open the
airway while avoiding hyperextension of the neck make a tight seal around outside of victim’s
mouth
•Modified Jaw thrust (suspected cervical spine
injury) •Give 2 full breaths (1s breath)
• Put one hand on each side of the patient’s head •Observe chest rise and fall, listen and feel for
with thumbs near the corners of the mouth
escaping air
• Slide fingers into position under the angles of the
patient’s jawbone without moving the head or neck *rescue breath/ventilations
• Thrust the jaw upward without moving the • One-second breath
head/neck to lift the jaw
• 2 rescue breaths per 30 chest compressions
 LESSON 1 – PRINCIPLES AND
STEPS OF CPR
Ventilations or Rescue Breathing 2. Pocket mask
3 Methods: •Creates a barrier between your mouth and the patient’s
1. Mouth-to-mouth mouth and nose
•Open airway past a neutral position using the head-tilt/chin-lift •Protects you from contact with a patient’s blood,
technique vomitus and saliva, and from breathing the air that the
•Pinch the nose shut and make a complete seal over the patient’s patient exhales
mouth your mouth
•steps:
•Give ventilations by blowing into the patient’s mouth • Assemble the mask and valve
• vTake a break between breaths by breaking the seal
• Open airway (head-tilt/chin-lift, from patient’s side)
Variation: Mouth-to-Nose • Place mask over the mouth and nose (bottom must not
•With the head tilted back, close mouth by pushing on the chin extend past the chin)
• Seal the mask
•Seal your mouth around the patient’s nose and breathe into the
• index finger and thumb on the top of the mask above the valve and
nose remaining fingers on the side of the patient’s face
•If possible, open the patient’s mouth between ventilations to • Hand closest to the chest, place thumb along base of the mask while
placing bent index finger under the patient’s chin, lifting the face into
allow air to escape the mask
 LESSON 1 – PRINCIPLES AND
STEPS OF CPR
3.Bag-valve-mask (BVM) resuscitator
•A handheld device used to ventilate patients and administer
higher concentrations of oxygen than a pocket mask
•2 rescuers needed to effectively operate
•steps:
• Assemble the BVM as needed
• Open airway (head-tilt/chin-lift from the top of the patient’s
head)
• Use an E-C hand position
• Both hands around the mask, form an E with the last three fingers, and a
C with the thumb and index finger
• Second rescuer provide ventilations
• Depress bag halfway to deliver between 400-700 mL of volume to make
chest rise
• Give smooth and effortless ventilations (1 second)
• Do not completely deflate the bag
 LESSON 1 – PRINCIPLES AND
STEPS OF CPR
When to STOP CPR HAINES (High Arm IN Endangered Spine)
• You see sign of return of spontaneous circulation •Used in situations in which the patient is suspected of
(movement or breathing) having a head, neck or spinal injury
• AED is ready to analyze the patient’s heart rhythm •Rescuer is alone and must leave the patient

• Other trained rescuers take over
• Presented a valid do not resuscitate (DNR) order
• Too exhausted to continue
• Scene becomes unsafe
Recovery Position (no cervical trauma)
•Rescuer unable to maintain an open and clear airway
(vomit or fluid)
How to: (H.A.IN.E.S)
• Kneel at side of the patient
• Roll patient toward the rescuer
• Place top leg on the other with both knees in a bent position
• Align the arm on top with the upper body

•If the victim is breathing How to: (H.A.IN.E.S) (infant)

•To maintain open airway
• Roll the patient onto his side
• Cross the legs first, then the shoulders
• Position infant face-down along the forearm
• Support infant’s head and neck with your other hand while
keeping infant’s mouth and nose clear
• Keep head and neck slightly lower than the chest
 LESSON 2 – AUTOMATED
EXTERNAL DEFIBRILLATOR
Also known as Automated External Defibrillator
(AED), Implantable Cardioverter Defibrillator
(ICD), Wearable Cardioverter Defibrillator (WCD)
Defibrillators are devices that restore a normal
heartbeat by sending an electric pulse or shock to
the heart. They are used to prevent or correct an
arrhythmia, a heartbeat that is uneven or that is too
slow or too fast. Defibrillators can also restore the
heart’s beating if the heart suddenly stops.
Different types of defibrillators work in different
ways. Automated external defibrillators (AEDs),
which are in many public spaces, were developed
to save the lives of people experiencing sudden
cardiac arrest. Even untrained bystanders can use
these devices in an emergency.
 LESSON 2 – AUTOMATED
EXTERNAL DEFIBRILLATOR
When to use AED?
A person whose heart stops from sudden cardiac arrest
must get help within 10 minutes to survive. Fainting is
usually the first sign of sudden cardiac arrest. If you think
someone may be in cardiac arrest, try the following steps:
If you see a person faint or if you find a person already
unconscious, first confirm that the person cannot respond.
The person may not move, or his or her movements may
look like a seizure.
You can shout at or gently shake the person to make sure
he or she is not sleeping, but never shake an infant or
young child. Instead, you can gently pinch the child to try
to wake him or her up.
Check the person’s breathing and pulse. If the person is
not breathing and has no pulse or has an irregular
heartbeat, prepare to use the AED as soon as possible.
 LESSON 2 – AUTOMATED
EXTERNAL DEFIBRILLATOR
How to use an AED?

Even someone without special training can respond in an
emergency by following the instructions relayed by the device.
If someone is having sudden cardiac arrest, using an AED and
giving CPR can save that person’s life. When using an AED:

Call EMS or have someone else call EMS. If two rescuers are
present, one can provide CPR while the other calls EMS and
gets the AED.

Make sure the area around the person is clear; touching the
person could interfere with the AED’s reading of the person’s
heart.

If an electric pulse or shock is needed to restore a normal
rhythm, the AED uses voice prompts to tell you when and how
to give the shock, and electrodes deliver it. Some AEDs can
deliver more than one shock with increasing energy.

The device may instruct you to start CPR again after
delivering the shock.
 Lesson 1 – Classification of

M3 – COPD
COPD

Lesson 2 – Diagnosis and Tx

Lesson 3 – Dental Management

 LESSON 1 –
CLASSIFICATION OF COPD
Chronic Obstructive Pulmonary Disease or COPD is a
chronic, slowly progressive, irreversible disease characterized
by obstruction of airflow from the lungs.
There are two common types of COPD, namely Chronic
bronchitis; also known as Blue Bloater and emphysema; also
known as Pink Puffer.
In Chronic bronchitis, the bronchial tubes become inflamed
and narrowed and your lungs produce more mucus which
further blocks the narrowed tube, while in emphysema the
alveoli of the lungs are destroyed as a result of damaging
exposure to cigarette smoke and other irritants like air
pollution and workplace exposure to dust, smoke or fumes.
In rare cases, a genetic condition called alpha-1 antitrypsin
deficiency may cause COPD. People with this condition have
a low level of alpha-1 antitrypsin protein which causes lung
damage and COPD if exposed to smoke or other lung irritants.
LESSON 2 – DIAGNOSIS
AND TX
 LESSON 2 – DIAGNOSIS AND
TX
Diagnosis of COPD  
1.Spirometry which is the confirmatory test for COPD is used to
measures how deeply a person can breathe and how fast air can
move into and out of the lungs.
2.Chest X-ray. A chest X-ray can show emphysema, one of the
main causes of COPD, and can also rule out other lung problems
or heart failure.
3.CT scan. A CT scan of your lungs can help detect emphysema
and used to screen for lung cancer.
4.Arterial blood gas analysis. This blood test measures how
well the lungs are bringing oxygen into your blood and
removing carbon dioxide.
5.Laboratory tests. These may be used to determine the cause of
your symptoms or rule out other conditions.
 LESSON 2 – DIAGNOSIS AND
TX
Treatment
There are ranges of treatment options to manage Chronic Obstructive
Pulmonary Disease (COPD). Many are directed at aiding the airways to keep
them open as much as possible, help with mucus clearance, and decrease
inflammation.
Pulmonary Rehabilitation
Pulmonary rehabilitation programs typically combine education, exercise
training, nutrition advice, and counseling. It gives hope for rebuilding strength
and enjoying a fuller, more active life
Supplemental Oxygen
Oxygen might be prescribed if the lungs are not getting enough oxygen to your
blood. Patient with COPD needs extra or supplemental oxygen to perform ADL
or activities of daily living, from digesting food to doing household chores.
Surgery
Some people with very severe COPD symptoms may have a hard time
breathing all of the time. In some of these cases, doctors may suggest lung
surgery to improve breathing but not everyone is a candidate for lung surgery.
 LESSON 2 – DIAGNOSIS AND
TX
MEDICATION
Bronchodilator
Bronchodilators relax the muscles around the airways which helps to keep them open and
makes breathing easier. Most bronchodilators are often delivered through an inhaler or
can be nebulized so you breathe the medicine straight into your lungs. 

Anti-Inflammatory
Decreasing inflammation leads to less swelling and mucus production in the airways and
that makes it easier to breathe. These medicines are known as corticosteroids, which can
have serious side effects, such as weight gain, diabetes, osteoporosis, cataracts, and
increased risk of infection so they must be monitored carefully.

Antibiotics
People with COPD do experience flare-ups with more coughing, more mucus, and more
shortness of breath. This is often caused by bacterial or viral infections.

Anticholinergics
 These relax the muscle bands that tighten around the airways. This action opens the
airways, letting more air in and out of the lungs to improve breathing. Anticholinergics
also help clear mucus from the lungs. As the airways open, the mucus moves more freely
and can, therefore, be coughed out more easily.
LESSON 3 – DENTAL
MANAGEMENT
 LESSON 3 – DENTAL
MANAGEMENT
1.Assess the severity of the patient’s disease and its control.
2.Review the history of evidence of concurrent coronary
heart disease or hypertension and take appropriate
precautions.
3.If the patient is on steroids, consider supplemental
steroids.
4.Avoid dental treatment if the upper respiratory infection is
present.
5.Treat the patient in an upright chair position/semi-supine.
6.Use local anesthetic as usual. The use of bilateral
mandibular blocks or bilateral palatal blocks can cause
unpleasant airway constriction sensation in some patients.
7.Avoid the use of rubber dam in severe disease.
8.Use pulse oximetry to monitor oxygen saturation, consider
low flow (2 to 3L/min) supplemental oxygen when oxygen
saturation drops below 95percent.
1.Avoid nitrous oxide-oxygen inhalation sedation with
severe COPD because the gas may accumulate in the air
spaces of the diseased lung.
2.General anesthesia is given when absolutely essential. I/V
barbiturates are absolutely contraindicated.
3.Consider low dose oral diazepam or other benzodiazepines
(these are respiratory depressants and also may cause oral
dryness).
4.Avoid the use of barbiturates and narcotics since they are
respiratory depressants.
5.Antihistamines and anticholinergics are generally not used
because of their drying properties and the resultant increase
of mucous tenacity.
6.Avoid erythromycin, macrolide antibiotics (azithromycin)
and ciprofloxacin for patients taking theophylline, since
these can retard the metabolism of theophylline, resulting
in theophylline toxicity.
7.Do not use outpatient general anesthesia.
 Lesson 1 – Oral Manifestations of

M4 – DM DM

Lesson 2 – Dental Management of

Pt. with DM
 LESSON 1 – ORAL
MANIFESTATIONS OF DM
 LESSON 1 – ORAL
MANIFESTATIONS OF DM
 LESSON 2 – DENTAL
MANAGEMENT OF PT.
WITH DM
 LESSON 2 – DENTAL
MANAGEMENT OF PT. WITH DM
• In Non-insulin dependent patient: All procedures can be
performed without special precautions, UNLESS,
complications are present.
• Avoid extractions or surgical procedures in uncontrolled or
poorly controlled diabetes since wound healing is
significantly delayed and the risk of post-operative
infections is high.
• Ensure that the dental procedure does not interfere with the
patient’s dietary intake and the patient takes their regular
dose of insulin or hypoglycemic medication to avoid shock. 
• Morning appointments are usually best.
• When the planned surgery is likely to be associated with
swelling and trismus, the patient should be advised to take a
semisolid and liquid diet.
• If the surgery is expected to significantly hinder food intake,
then the patient is best managed in a hospital  containing local anesthetic solutions. However, in clinical
• Be prepared for hypoglycemic attack at all times. Have
glucose readily available.
• Antibiotic prophylaxis can be considered for patients with
brittle diabetes (i.e. difficult to control, requires high dose of
insulin) and who also have chronic states of oral infection.
• When acute oral infection is present, patients receiving
insulin usually require additional insulin which should be
prescribed by their physician. 
• Non-Insulin controlled patients may need more aggressive
medical management of their diabetes, which may include
insulin during this period.
• Oral infection must be treated with incision and drainage,
antibiotic and extraction.
• Attention must be paid to the patient’s fluid and electrolyte
balance and dietary needs.
• Adrenalin antagonizes the effects of insulin. So,
theoretically it might be best to avoid using adrenaline
practice this precaution may be unnecessary considering the
minute dose used.
 LESSON 2 – DENTAL
MANAGEMENT OF PT. WITH DM
 Lesson 1 – Laboratory and

M5 – HEPATITIS
Diagnostic markers for Hepatitis

Lesson 2 – Dental Management

and Treatment plan for patient
with Hepatitis
 LESSON 1 – LABORATORY AND
DIAGNOSTIC MARKERS FOR HEPATITIS
1.Hepatitis A-E - elevated levels of the following:
1. Serum transaminase
• Aspartate aminotransferase [AST]
• Serum glutamate oxaloacetate
transaminase [SGOT]
• Alanine aminotransferase [ALT]
• Serum glutamate pyruvate transaminase
[SGPT]
2. Serum bilirubin
3. Alkaline phosphatase
4. WBC count (lymphocytosis)
5. Prothrombin time
 LESSON 1 – LABORATORY AND
DIAGNOSTIC MARKERS FOR
1.Hepatitis B
HEPATITIS
1. IgM [immunoglobulin M]
• Indicates acute infection
• Produced during the first 2-6
weeks of infection
2. IgG [immunoglobulin G]
1. Indicates immunity
2. Contributes to
control of the
disease
3. HBSAG [hepatitis B surface antigen]
• Acute or chronic infection
• Patient is infectious
4. Anti HBs [anti-hepatitis B surface
antigen]
• Indicates recovery and
immunity to HBV
• Indicates previous exposure
to HBV, vaccination or HBIg
prophylaxis
5. HBsAg Anti HBc
• Indicates chronic hepatitis
1.
• Ineffective antibody response
HBcAg [hepatitis B core antigen)
• Not secreted during the acute
or chronic phase
• Present only in the liver
• Elicits an antibody response
2. HBeAg [hepatitis B early antigen)
• High infectivity
• Truncated form of HBcAg
secreted into the blood
3. AntiHBe [anti-hepatitis B early
antigen]
• decreased infectivity and
recovery
3.Hepatitis C
3. AntiHCV – Indicates
infectivity
4.Hepatitis E
• AntiHEV – Indicates
recovery
LESSON 1 – LABORATORY AND
DIAGNOSTIC MARKERS FOR
HEPATITIS
Consequence/Sequelae:
1. Recovery
1. immediate for HAV and HEV
2. Persistent infection/carrier state
2. For HBV, HCV and HDV
3. Persistence of low levels of virus in the liver
and serum viral antigens for longer than 6
months without signs of liver disease
4. May persist and progress to chronic acute
hepatitis that may cause liver disease
5. Carriers of HBV and HCV have increased risk
of liver cirrhosis and primary hepatocellular
carcinoma
3. Dual infection
6. E.g. Hepatitis B/D
4. Chronic active hepatitis
1. Characterized by active virus replication in the liver,
HBsAg and HBeAg in the serum, signs and
symptoms of chronic liver disease, persistent
hepatocellular necrosis, and elevated liver enzymes
for longer than 6 months. Chronic liver destruction
and the resulting fibrosis lead to cirrhosis in about
20% of individuals with chronic hepatitis.
5. Fulminant hepatitis
2. Massive hepatocellular destruction and a mortality
rate of about 80%
3. Usually happens with HBV HDV, HCV or HBV
alone
6. Cirrhosis
7. Hepatocellular carcinoma
8. Death
 LESSON 2 – DENTAL MANAGEMENT
AND TREATMENT PLAN FOR PATIENT
WITH HEPATITIS
 LESSON 2 – DENTAL MANAGEMENT
AND TREATMENT PLAN FOR PATIENT
WITH HEPATITIS
Dental Management
1.Identify undiagnosed individuals
2.Patients with active hepatitis
1. No treatment other than urgent care
2. Contact physician immediately
3.Patient with history of Hepatitis
1. Identify carriers
2. Universal precaution for all patients
3. Inoculation of all dental personnel with Hepa vaccine
4.Patient that are Hepatitis carriers
1. Some may have chronic acute hepatitis leading to compromised
liver function and interfere with hemostasis and drug metabolism
2. Consult physician
5.Patients with signs and symptoms of hepatitis
1. Do not treat electively
2. Refer to physician immediately
 LESSON 2 – DENTAL MANAGEMENT
AND TREATMENT PLAN FOR PATIENT
WITH HEPATITIS
Treatment Plan Modifications
1.Completely recovered individuals: no treatment
modification required
2.Chronic Active Hepatitis/Carriers of HBsAg and has
impaired liver function: drugs metabolized by the liver
should be avoided if possible. If not, decrease dose.
Oral Complications
• Potential for abnormal bleeding in cases of significant
liver damage
• Check bleeding parameters such as PT [prothrombin
time]. If >28 sec, may have bleeding complications.
Bleeding time should ideally be <7 min.
 Lesson 1 – Oral Manifestations of

M6 – HYPERTENSION Hypertension

Lesson 2 – Dental Management

and of patient with Hypertension
 LESSON 1 – ORAL MANIFESTATIONS
OF HYPERTENSION
Oral Manifestations Caused by the Adverse
Effects of Antihypertensive Drugs
1. Xerostomia
 Many antihypertensives medications like ACEIs, thiazide diuretics,
loop diuretics, and clonidine are associated with xerostomia. Its
likelihood increases with the number of concomitant medications.
Xerostomia has many consequences, like decay, difficulty in
chewing, swallowing, and speaking, candidiasis, and oral burning
syndrome. Sometimes the feeling is transient and salivary function is
adjusted by the patient itself.
2. Gingival Hyperplasia
It can be caused by calcium channel blockers, with an incidence
ranging from 6 to 83%. The majority of cases are associated with
nifedipine. The effect could be dose related.
3. Lichenoid Reaction
Many antihypertensives (thiazide diuretics, methyldopa, propranolol,
captopril, furosemide, spironolactone, and labetalol) are associated
with oral lichenoid reactions. Clinical forms differ greatly from lichen
planus itself.
 LESSON 1 – ORAL MANIFESTATIONS
OF HYPERTENSION
4. Other Undesirable Effects
ACE inhibitors are associated with cough and loss of taste (ageusia) or
taste alteration (dysgeusia). Dysgeusia has also been reported with
other antihypertensives use, like β-blockers, acetazolamide, and
diltiazem.
5. Facial nerve paralysis
Facial nerve paralysis in hypertension is because of edema or
hemorrhage in the facial canal, but the exact etiology is unknown.
Usually facial nerve paralysis is seen in patients with malignant
hypertension.
7. Periodontitis
Inflammation represents a cornerstone of cardiovascular disease.
Inflammation can contribute to endothelial dysfunction, with
consequent impaired vasodilation ultimately leading to alterations in
the vascular structure.
 LESSON 2 – DENTAL
MANAGEMENT AND OF
PATIENT WITH HYPERTENSION
 LESSON 2 – DENTAL MANAGEMENT
AND OF PATIENT WITH HYPERTENSION
DENTAL MANAGEMENT OF
HYPERTENSIVE PATIENT
• A dental provider must have knowledge of the disease,
know current therapeutic options, and possess the
ability to educate and provide access to care for
patients.
• Management of the patient is mainly based on one’s
judgment as a practitioner.
• Before providing care to these patients, the practitioner
should be able to assess patient health status
• Decisions to treat should be based on the following
factors: baseline blood pressure, urgency of the
procedure, functional and physical status, and time
and invasiveness of the procedure.
• When in doubt, consider medical advice.
 LESSON 2 – DENTAL MANAGEMENT
AND OF PATIENT WITH HYPERTENSION
 LOCAL ANESTHETIC

•Local anesthetics are recommended for patients with hypertension because they can decrease pain and increase comfort.
•The selection of a local anesthetic : duration of the procedure the need for hemostasis the required degree of pain control
•Vasoconstrictors added to local anesthetics to aid in hemostatic control and to increase the duration
•Risk of epinephrine: sympathomimetic effect on cardiac β1-receptors.
•Avoid Norepinephrine or levonordefrin, unopposed activation of α1-receptors in HT increase­the duration of the drug’s
effect (activation lead to uncontrolled increases in BP)
•2% lidocaine with 1:100,000 epinephrine most commonly used to achieve the necessary­degree of anesthesia for most
dental situations.
•Maximum recommended dose of local anesthetic solution for hypertension (poorly controlled): two 1.8- ml cartridges
(total dose of 3.6 ml) with 1:100,000 (0.036 mg) epinephrine per appointment.
 CONTRAINDICATIONS: LOCAL ANESTHETICS WITH VASOCONSTRICTORS

•Include severe uncontrolled hypertension

•Caution when administering local anesthetics at dosages higher than recommended
•Should also be aware of the potential interactions between commonly used local anesthetics and antihypertensive drugs
•Lengthy procedures are anticipated, the epinephrine should be diluted to a ratio of 1:200,000.
•Apprehensive, sweating, or nervous patient likely has increased levels of endogenous epinephrine.
•Administration of epinephrine to the nervous or apprehensive stage 2 patient would be contraindicated.
 LESSON 2 – DENTAL
MANAGEMENT AND OF
PATIENT WITH
BLEEDING
HYPERTENSION
• Elevated blood pressure can lead to excessive intraoperative bleeding.
• History of the patient and meds plays a role in deciding when to perform certain procedures.
•Due to a number of different comorbidities, those with hypertension may be taking blood
thinners.
•It is generally recommended that for patients that have an INR value of ≤3 for minor surgery,
anticoagulation is not terminated.
• Aspirin and other antiplatelet drugs, such as Xarelto and Plavix the recommendation is to
continue medication for minor surgery without interruption.
• Various hemostatic agents can be used to help control bleeding.

DRUG CONSIDERATIONS
• Minimal concentration (epinephrine 0.036 mg), aspirate before injection and injection slowly.
•Caution when using vasoconstrictors in patient taking a nonselective beta-blocker.
• Do not use gingival packing material that contains epinephrine.
• Reduce dosage of barbiturates and other sedative (action may enhance by antihypertensive
agent).
• Epinephrine used judiciously with MAO inhibitor.
 Lesson 1 – Fetal Circulation

M7 – CHD Lesson 2 – Etiology, Diagnosis,

and Signs and Symptoms

Lesson 3 – Classification of CHD

LESSON 1 – FETAL
CIRCULATION
 LESSON 2 – ETIOLOGY,
DIAGNOSIS, AND SIGNS AND
SYMPTOMS
 LESSON 2 – ETIOLOGY, DIAGNOSIS,
AND SIGNS AND SYMPTOMS
ETIOLOGY DIAGNOSIS

The etiology of CHD is mainly unknown but •Physical Exam

few factors are seen as its causes and it
includes:
•Viral infections during pregnancy
•Teratogenic effects of drugs
•Maternal insulin dependent diabetes
•Family history
•Genetic factors
•Chromosomal defects
• Palpation
• Auscultation
•Diagnostic Tests
• Echocardiography (ECG)
• Electrocardiogram (EKG)
• Chest X-ray
• Pulse Oximetry
• Cardiac Catheterization
SIGNS AND SYMPTOMS
In general, many congenital heart defects have few or no signs
or symptoms depending on the number, type, and severity of
the defects but as you go through with the module, you will
see the signs and symptoms for each CHD.
 LESSON 3 –
CLASSIFICATION OF CHD
 LESSON 3 –
CLASSIFICATION OF CHD
1.CARDIAC MALPOSITIONS
•The term cardiac malposition indicates that
the heart is abnormally located within the
chest.
• Levocardia - The heart is located in the left
chest.
• Dextrocardia - The heart is located in the right
chest.
• Mesocardia - The heart is located in the middle
of the chest.
 LESSON 3 – CLASSIFICATION OF
CHD
Acyanotic or Late Cyanotic Group
1.VENTRICULAR SEPTAL DEFECT (VSD)
A ventricular septal defect is an abnormal opening in the
heart that forms between the heart's ventricles that allows
oxygen-rich and oxygen-poor blood to mix which causes
the heart to work harder.
TREATMENT
•Medications
• Diuretics – to decrease the amount of fluid in circulation and
in the lungs
• Beta blockers – to keep the heartbeat regular

•Procedures
• Surgical repair - not corrected till 1 year to wait for
spontaneous closure
• Catheter procedure
• Hybrid procedure
 LESSON 3 –
CLASSIFICATION OF CHD
2.ATRIAL SEPTAL DEFECT
An atrial septal defect is an abnormal opening between the heart's upper chambers.
Small defects might be found by chance and never cause a problem. Some small atrial
septal defects close during infancy or early childhood. It usually presents late in life at
about 30 years as a late cyanotic heart disease. The hole increases the amount of blood
that flows through the lungs.
There are several types of atrial septal defects, including:
•This is the most common type of ASD and occurs in the middle of the wall between
the atria (atrial septum).
•This defect occurs in the lower part of the atrial septum and might occur with other
congenital heart problems.
•Sinus venosus. This rare defect usually occurs in the upper part of the atrial septum
and is often associated with other congenital heart problems.
•Coronary sinus. In this rare defect, part of the wall between the coronary sinus —
which is part of the vein system of the heart — and the left atrium is missing.
TREATMENT
•Medical monitoring - many atrial septal defects close on their own during childhood.
For those that don't close, some small atrial septal defects might not require treatment.
•Surgery - Many persistent atrial septal defects eventually require surgery mostly with
medium to large atrial septal defect.
• Cardiac catheterization
• Open-heart surgery
 LESSON 3 – CLASSIFICATION OF
CHD
3.PATENT DUCTUS ARTERIOSUS
Patent ductus arteriosus (PDA) is a persistent opening between the
two major blood vessels leading from the heart, the aorta and the
pulmonary artery. The opening, called the ductus arteriosus, is a
normal part of a baby's circulatory system before birth that usually
closes at the 1st or 2nd day of life.
TREATMENT
Treatment options for a patent ductus arteriosus include
•Monitoring – for premature babies, it may close on its own and for
full-term babies, children and adults who have small PDAs that
aren't causing other health problems, monitoring might be all that's
needed.
•Medications – NSAIDs or PGE2 inhibitor might help to close PDA
in a premature baby.
•Closure by surgery - If medications aren't effective and the
condition is severe or causing complications, surgery might be
recommended.
•Closure by cardiac catheterization – can be used for full-term
babies, children, and adults.
 LESSON 3 –
Cyanotic Group
CLASSIFICATION OF CHD TREATMENT
Surgery is the only effective treatment.
1.TETRALOGY OF FALLOT
• Intracardiac repair
Tetralogy of Fallot is a rare condition caused by a combination of four heart defects that
are present at birth (congenital). • Usually done during the first year after birth and involves several
repairs.
a. Pulmonary valve stenosis - Pulmonary valve stenosis is a narrowing of the pulmonary • In this procedure, the surgeon places a patch over the ventricular septal
valve — the valve that separates the lower right chamber of the heart (right ventricle) defect to close the hole between the lower chambers of the heart
from the main blood vessel leading to the lungs (pulmonary artery).
• Temporary surgery
b. Ventricular septal defect - A ventricular septal defect is a hole (defect) in the wall
(septum) that separates the two lower chambers of the heart • This procedure may be done if your baby was born prematurely or has
pulmonary arteries that are undeveloped.
c. Overriding aorta - In tetralogy of Fallot, the aorta is shifted slightly to the right and lies • In this procedure, the surgeon creates a bypass (shunt) between a large
directly above the ventricular septal defect. In this position the aorta receives blood artery that branches off from the aorta and the pulmonary artery.
from both the right and left ventricles, mixing the oxygen-poor blood from the right
ventricle with the oxygen-rich blood from the left ventricle.

d. Right ventricular hypertrophy - When the heart's pumping action is overworked, it

causes the muscular wall of the right ventricle to thicken. Over time this might cause
the heart to stiffen, become weak and eventually fail.
 LESSON 3 – CLASSIFICATION OF
CHD
2.TRANSPOSITION OF GREAT ARTERIES
Transposition of the great arteries is a serious but rare
heart defect present at birth, in which the two main
arteries leaving the heart are reversed. The condition is
also called dextro-transposition of the great arteries.
Transposition of the great arteries changes the way
blood circulates through the body, leaving a shortage of
oxygen in blood flowing from the heart to the rest of
the body. Without an adequate supply of oxygen-rich
blood, the body can't function properly and your child
faces serious complications or death without treatment. 
TREATMENT
Transposition of the great arteries is usually detected
either prenatally or within the first hours to weeks of
life. Corrective surgery soon after birth is the usual
treatment for transposition of the great arteries.
3.PERSISTENT TRUNCUS ARTERIOSUS
Truncus arteriosus is a rare heart defect that's present at birth. In this
CHD, one large blood vessel leads out of the heart. Normally, there
are two separate vessels coming out of the heart. In addition, there is
usually a hole — known as a ventricular septal defect — between the
two lower chambers of the heart. As a result of truncus arteriosus,
oxygen-poor blood that should go to the lungs and oxygen-rich
blood that should go to the rest of the body are mixed together. This
creates severe circulatory problems. If left untreated, truncus
arteriosus can be fatal. Surgery to repair truncus arteriosus is
generally successful, especially if the repair occurs before your baby
is one month old.
TREATMENT
•Medications
• Diuretics - Often called water pills, diuretics increase the frequency and
volume of urination, preventing fluid from collecting in the body, which is a
common effect of heart failure.
• Ionotropic agents - This type of medication strengthens the heart's
contractions.
•Surgical Procedures
• Most infants with truncus arteriosus have surgery within the first few weeks
after being born. The exact procedure will depend on your baby's condition.
 LESSON 3 –
CLASSIFICATION OF CHD
4.TRICUSPID ATRESIA AND STENOSIS
Tricuspid atresia is a heart defect present at birth (congenital) in which a valve
(tricuspid valve) between two of the heart's chambers isn't formed. Instead,
there's solid tissue between the chambers, which restricts blood flow and causes
the right lower heart chamber (ventricle) to be underdeveloped. In tricuspid
stenosis, tricuspid valve is narrowed, decreasing the amount of blood that can
flow through it from the right atrium to the lower right heart chamber (right
ventricle).
TREATMENT
Tricuspid atresia is treated with multiple surgeries. Procedures that might be
needed include:
•Atrial septostomy. This creates or enlarges the opening between the heart's
upper chambers to allow more blood to flow from the right atrium to the left
atrium.
•This creates a bypass (shunt) from a main blood vessel leading out of the heart
to the blood vessel leading to the lungs (pulmonary artery), which improves
oxygen levels.
•Pulmonary artery band placement. If there is too much blood flowing to the
lungs from the heart, a surgeon might place a band around the pulmonary artery
to reduce the flow.
•Glenn operation. When babies outgrow the first shunt, they often require this
surgery, which sets the stage for the more-permanent corrective surgery.
 LESSON 3 – CLASSIFICATION OF
CHD
OBSTRUCTIONS 
1.COARCTATION OF AORTA:
Aortic coarctation or narrowing of the aorta  forces your heart to
pump harder to move blood through the aorta. Although the
condition can affect any part of the aorta, the defect is most often
located near a blood vessel called the ductus arteriosus. 
TREATMENT
•Medication
• Not to repair coarctation of the aorta but to control blood pressure before
and after stent placement or surgery.

•Surgery
• Resection with end-to-end anastomosis. This method involves removing
the narrowed segment of the aorta (resection) followed by connecting the
two healthy sections of the aorta together (anastomosis).
• Subclavian flap aortoplasty. Left subclavian artery might be used to
expand the narrowed area of the aorta.
• Bypass graft repair.This technique involves bypassing the narrowed area
by inserting a tube called a graft between the portions of the aorta.
• Patch aortoplasty. Treatment of coarctation by cutting across the
narrowed area of the aorta and then attaching a patch of synthetic material
to widen the blood vessel.
 LESSON 3 –
CLASSIFICATION OF CHD
2.AORTIC STENOSIS AND ATRESIA
Aortic valve stenosis or aortic stenosis occurs when the heart's
aortic valve narrows. This narrowing prevents the valve from
opening fully, which reduces or blocks blood flow from your heart
into the main artery to your body (aorta) and onward to the rest of
your body. When the blood flow through the aortic valve is
reduced or blocked, your heart needs to work harder to pump
blood to your body. Eventually, this extra work limits the amount
of blood it can pump, and this can cause symptoms as well as
possibly weaken your heart muscle. It is the most common
anomaly of aorta is congenital bicuspid valve. Not much of
functional significance except predisposes it to calcification.
3 types of congenital aortic stenosis:
1.Valvular: cusps thickened and malformed
2.Subvalvular: thick fibrous ring under the aortic valve
3.Supravalvular: uncommon
Congenital aortic atresia are rare and is incompatible with life. It
is the congenital absence of the normal valvular opening from the
left ventricle of the heart into the aorta.
TREATMENT
Treatment for aortic valve stenosis depends on the
severity of your condition, whether you're experiencing
signs and symptoms, and if your condition is getting
worse.
•Monitoring for mild symptoms
•Surgery for moderate to severe
• Aortic valve repair - Surgeons rarely repair an aortic valve
to treat aortic valve stenosis, and generally aortic valve
stenosis requires aortic valve replacement. To repair an
aortic valve, surgeons may separate valve flaps (cusps)
that have fused.
• Balloon valvuloplasty - A procedure using a long, thin
tube (catheter) to repair a valve with a narrowed opening
(aortic valve stenosis).
• Aortic valve replacement - Surgeons removes the
damaged valve and replaces it with a mechanical valve or
a valve made from cow, pig or human heart tissue
(biological tissue valve).
 LESSON 3 – CLASSIFICATION OF
CHD
3.PULMONARY STENOSIS AND ATRESIA
•  Stenosis
Pulmonary valve stenosis is a condition in which a deformity on or
near your pulmonary valve narrows the pulmonary valve opening
and slows the blood flow. It is the most common form of
obstructive CHD and it occurs as component of Tetralogy of Fallot
or it may be an isolated defect. The pulmonary valve is located
between the lower right heart chamber (right ventricle) and the
pulmonary arteries. Adults occasionally have pulmonary valve
stenosis as a complication of another illness, but mostly, pulmonary
valve stenosis develops before birth as a congenital heart defect.
•Atresia
In pulmonary atresia, the valve that lets blood out of the heart to go
to your or your baby's lungs (pulmonary valve) doesn't form
correctly. Instead of opening and closing to allow blood to travel
from the heart to the lungs, a solid sheet of tissue forms. So blood
can't travel by its normal route to pick up oxygen from the lungs.
Instead, some blood travels to the lungs through other natural
passages within the heart and its arteries. Without treatment,
pulmonary atresia is nearly always fatal.
TREATMENT
•Medication
• IV Prostaglandin.
•Procedures for pulmonary stenosis
• Balloon valvuloplasty - Using the small tube that was threaded through a vein in
your leg to your heart for a cardiac catheterization, your doctor places an
uninflated balloon through the opening of the narrowed pulmonary valve.
• Open-heart surgery - When a balloon valvuloplasty isn't an option, you may
require open-heart surgery. During surgery, doctors either repairs the pulmonary
artery or valve or replaces the valve with an artificial valve.
•Procedures for pulmonary atresia
• Balloon atrial septostomy - A balloon can also be used to enlarge the natural
hole (foramen ovale) in the wall between the upper two chambers of the heart.
• Stent placement – Placing of a rigid tube in the natural connection between the
aorta and pulmonary artery.
• Shunting - Creating a bypass (shunt) from the aorta to the pulmonary arteries
allows for adequate blood flow to the lungs.
• Glenn procedure - In this surgery, one of the large veins that normally returns
blood to the heart is connected directly to the pulmonary artery instead. 
• Fontan procedure - If the right ventricle remains too small to be useful, surgeons
may use a Fontan procedure to create a pathway that allows most, if not all, of
the blood coming to the heart to flow directly into the pulmonary artery.
• Heart transplanst - In some cases, the heart is too damaged to repair and a heart
transplant may be necessary.
 LESSON 3 –
CLASSIFICATION OF CHD
Dental Care for Patients with CHD
1.First step to providing appropriate care is to obtain and document a comprehensive medical and social history of the patient.
2.Where clinically indicated, radiographs should be exposed to augment the clinical examination.
3.Liaison with the family medical practitioner or the cardiology team responsible may be required, prior to providing active treatment.
4.Preventive dentistry in the form of dietary advice, home and office fluoride therapy, and oral hygiene advice can and should be provided for all
patients.
5.This group should receive every appropriate measure in the preventive armamentarium in order to minimize their risk of developing dental caries.
6.Fissure sealant placement may or may not be appropriate, depending on age and cooperation, but should be considered as soon as it is feasible.
7.Placement of resin-modified or conventional glass ionomer sealants may be considered as an interim measure for teeth especially at risk of caries
that are not yet fully erupted, or for children who are unable to tolerate the placement of a conventional resin sealant
8.Should disease occur, identification of potential foci of infection in the mouth is the cornerstone of treatment planning
9.Treatment of dental caries, whether surgical or restorative, must be provided in the context of the risk of IE.
10.Definitive treatment is preferable to temporary or short-to-medium- term solutions.
11.Extraction is generally favored over pulp therapy, especially for the primary dentition. Extractions and other surgical treatment should be carefully
planned and consideration given to potential coagulation problems.
12.Restorative treatment should be definitive, and the placement of stainless steel crowns (SSCs) is often preferable to direct intra- coronal
restorations, especially for carious primary teeth.
13.Appropriate consultation with the cardiac and anesthetic teams at the planning stage forms the basis for minimizing the risks during sedation and
general anesthesia.
 Lesson 1 – Physiologic changes of
pregnancy

M8 – PREGNANCY Lesson 2 – Dental management of

pregnant patient

Lesson 3 – Medications of pregnant

patient in relation to dentistry
 LESSON 1 – PHYSIOLOGIC
CHANGES OF PREGNANCY
Airway changes
•The nasal mucosa is engorged, which means
there is greater resistance to flow
•The upper airway mucosa is oedematous
•There has been weight gain
Respiratory changes
•The diaphragm is pushed up by 4cm
•Tidal volume increases by ~ 30-50%
•Respiratory rate increases to 15-17
•Minute volume increases by 20-50%.
•Chest wall compliance decreases  hydronephrosis" - more so on the right because the right ureter crosses iliac and
•Lung compliance remains the same  •Tubular resorption of urate and glucose decreases
Electrolyte and endocrine changes
•Vasopressin release increases;
•Thus, there is water retention
•In response to a decreased SVR, aldosterone release is increased. This is
the major contributor to the 50% circulating volume expansion
•There is a relative iodine deficiency (the fetus is stealing it all)
•Cortisol secretion is increased, which has implications for all those people
who still do random cortisol levels on their patients
Renal changes
•Renal blood flow increases: the renal arteries are also affected by the fall in
SVRI, and this is mediated by relaxin (which influences endothelial nitric oxide
production).
•GFR increases by as much as 85%
•Urea and creatinine decrease because of this
•Kidneys become enlarged; the renal pelvis dilates and there is a "physiological
ovarian vessels at an angle. This predisposes to pyelonephritis
 LESSON 1 – PHYSIOLOGIC
CHANGES OF PREGNANCY
Gastrointestinal and nutritional changes
•Nausea and vomiting: in 50-90%. 
•esophageal sphincter tone is decreased (aspiration is more likely)
• There is increased intra gastric pressure due to upward displacement
• Gastric emptying is delayed, and is virtually non-existent during labor
•Thiamine supplementation is important, because prolonged hyper
emesis can result in vitamin deficiency.
•Abdominal compartment pressure measurements are going to be
wildly inaccurate.
• There is insulin resistance, particularly later in pregnancy
• Metabolic fuel use favors lipolysis, preserving the glucose and amino
acids for use by the fetus.
• Protein catabolism is decreased
•There is a peak of calcium demand in the third trimester
Haematological changes in the oral cavity 
•The overall trend is towards hyper coagulability. In
the third trimester, coagulation activity is about
double that of normal. 
•Platelet count decreases, particularly in late
pregnancy
• Normal pregnancy is associated with a degree
of enhanced platelet destruction which is
compensated for by increased production
• The destruction takes place in the utero
placental circulation
•Factors V, VII, VIII, IX, X, XII and von Wille brand
factor increase significantly
• Factor VII may increase as much as tenfold.
 LESSON 1 – PHYSIOLOGIC
CHANGES OF PREGNANCY
Changes in the oral cavity
Cavities. These are small, damaged areas in the surface of
your teeth. Being pregnant makes you more likely to have
cavities. You can pass the bacteria that causes cavities to your
baby during pregnancy and after birth. This can cause
problems for your baby’s teeth later in life.
Gingivitis. Gingivitis is inflammation (redness and swelling)
of the gums. If untreated, it can lead to more serious gum
disease.
Signs and symptoms include:
 Redness and swelling
 Tenderness in the gums
 Bleeding of the gums, even when you brush your teeth gently
 Shiny gums
Loose teeth. High levels of the hormones progesterone and
estrogen during pregnancy can temporarily loosen the tissues
and bones that keep your teeth in place. This can make your
teeth loose.
Periodontal disease. If gingivitis is untreated, it can lead to
periodontal disease. This causes serious infection in the gums and
problems with the bones that support the teeth. Your teeth may get
loose, and they may have to be extracted (pulled). Periodontitis
can lead to bacteremia (bacteria in the bloodstream). 
Pregnancy tumors (also called pyogenic granuloma). These
tumors are not cancer. They’re lumps that form on the gums,
usually between teeth. Pregnancy tumors look red and raw, and
they bleed easily. They can be caused by having too much plaque
(a sticky film containing bacteria that forms on teeth). These
tumors usually go away on their own after giving birth. In rare
cases they may need to be removed by your health care provider.
Tooth erosion. If you have vomiting from morning sickness, your
teeth may be exposed to too much stomach acid. This acid can
harm the enamel (the hard surface) of your teeth. Morning
sickness (also called nausea and vomiting of pregnancy or NVP)
is nausea and vomiting that happens during pregnancy, usually in
the first few months.
 LESSON 2 – DENTAL
MANAGEMENT OF PREGNANT
PATIENT
 LESSON 2 – DENTAL MANAGEMENT
OF PREGNANT PATIENT
Signs and symptoms of dental problems include: If you have a dental problem that needs treatment,
•Bad breath make sure your dentist knows that you’re pregnant.
•Loose teeth Depending on your condition, you may be able to
wait for treatment after your baby’s birth.
•Mouth sores or lumps on the gums
Treatments that are safe during pregnancy include:
•New spaces between your teeth
•Receding gums (when your gums pull away from your teeth so you can •Local anesthesia. Anesthesia is medicine that lessens or
see roots of your teeth) or pus along your gumline (where your gums prevents pain. Local anesthesia is used in a specific part
meet your teeth) of the body, like to numb your mouth for a dental
•Gums that are red, swollen, tender or shiny; gums that bleed easily filling or to have a tooth pulled. This medicine is safe
•Toothache or other pain to use during pregnancy. 
LESSON 3 – MEDICATIONS OF
PREGNANT PATIENT IN
RELATION TO DENTISTRY
 LESSON 3 – MEDICATIONS OF
PREGNANT PATIENT IN RELATION TO
DENTISTRY
Safe medications
The most common drugs used by dentists to be safe for use in pregnancy with a few exceptions:
Lidocaine with epinephrine is safe, but as with any patient, proper aspiration to avoid intravascular injection is necessary
for effective anesthesia and to avoid the cardiovascular side effects of epinephrine.
Too rapid heartbeat and systemic vasoconstriction can lead to fetal hypoxia.
Penicillin, clindamycin, and cephalosporins are safe antibiotics and should be prescribed when indicated. Tetracyclines of
any type should be avoided during pregnancy and breastfeeding to avoid any discoloration of the teeth.
Analgesia presents a more difficult decision, but acetaminophen is OK for most patients.
Aspirin and other nonsteroidal, anti-inflammatory drugs (e.g., ibuprofen) should not be prescribed.
For severe pain, oxycodone is considered safe. Codeine, hydrocodone, or propoxyphene are probably safe for a short time.
Nitrous oxide is  probably safe as long as there is oxygen administered as well.
Tooth whitening carbamide bleaching solutions continues to be cautious and it is not recommended during pregnancy.  
Primary prophylaxis is with Amoxicillin 2.0g given orally one hour before the procedure. Penicillin-allergic women can
be treated with Clindamycin 600mg orally.
 Lesson 1 – Oral Manifestations of HIV

M9 – HIV Infection

Lesson 2 – Dental Management of HIV

infected/AIDS Patients
 LESSON 1 – ORAL MANIFESTATIONS
OF HIV INFECTION
The three principal signs are described:
1. Oral candidiasis: A fungal infection, candidiasis usually presents as
a semi-adherent white plaque on the palate, although glossitis and
angular stomatitis forms are not uncommon. The plaques can be sore,
and they are very common among HIV-positive individuals.

2. Oral hairy leukoplakia: In a study of 375 homosexual males who

either had AIDS or were considered at risk for the disease, 28%
presented with oral hairy leukoplakia. The lesions appeared most
commonly on the lateral surface of the tongue, with wide variation in
the size, severity, and surface characteristics. The condition is highly
predictive of the future development of AIDS.

3. Kaposi’s sarcoma: Kaposi’s sarcoma is diagnostic for AIDS and is

found in some 20%-34% of AIDS patients. The oral cavity may be the
first or only site of the lesion. The most common intraoral site is the
palate. The pathogenesis of the disorder is still not well understood, nor
is its interaction with HIV infection. Treatment is required because of
functional impairment, pain, or bleeding, or for cosmetic reasons.
 LESSON 2 – DENTAL
MANAGEMENT OF HIV
INFECTED/AIDS PATIENTS
 LESSON 2 – DENTAL MANAGEMENT
OF HIV INFECTED/AIDS PATIENTS
The major considerations in the management of HIV/AIDS patients are: Oral Lesions
A.  Possibility of transmission of HIV from the patient to dental surgeon, their Found should be diagnosed and then managed by appropriate
staff and other patients, local and systemic treatment or referred for treatment depending
B.  Determining the current level of CD4 lymphocyte cell count and the level on one’s experience in the management of these lesions.
of immunosuppression,
Surgery
C.  Viral overload and susceptibility of opportunistic infections,
Prophylactic antibiotic should be given before dental extraction
D.  Oral manifestation of AIDS, or surgery because of the depressed immune status and
E.  Drug therapy. Patients who are HIV seropositive but are asymptomatic neutropenia often found in HIV patients. Defer surgery when T-
may receive all indicated dental treatment. cell count is low. Patients with severe thrombocytopenia may
require special precautions before surgery. Aspirin should be
Generally these patients have a CD4 count of more than 400, no significant
immunosuppression or neutropenia or
avoided as it may aggravate any bleeding tendency.
thrombocytopenia.                                                         Some Medications of HIV Infection/AID patients in relation
Special Precautions to dental treatment:
Must be taken to avoid accidental cross infection during dental procedures. 1.Zidovudine
Such precautions should be observed for all cases (universal precautions and
barrier techniques), regardless of whether the patient is in a high–risk 2.Lamivudine
category for HIV or not. This is because in some instances the asymptomatic
patient may be unaware of the disease or otherwise may be concealing their 3.Mycostatin topical
disease. Moreover, it has been found that most HIV carriers and more than 80
percent HBsAg carriers cannot be identified on the basis of recommended 4.Acyclovir
clinical screening procedures.
 LESSON 2 – DENTAL MANAGEMENT
OF HIV INFECTED/AIDS PATIENTS
Dental Treatment and Prevention
Consult with patient’s physician to establish current level of immunocompromise and
acceptable procedures specific to treatment plan
• Rule out significant risk for infection due to immunosuppression associated with
neutropenia by obtaining blood values from a current CBC with Differential. Look
specifically for ANC (absolute neutrophil count) prior to treatment. ANC <1000/mm3
indicates a significant increase of risk for infection and the need for consideration of
prophylactic antibiotics for any dental treatment that potentially can cause bacteremia
or put the patient at risk for aspiration pneumonia.
• Rule out risk for excessive/prolonged bleeding. Thrombocytopenia (low platelet count)
increases risk for bleeding. Platelet count should be obtained and a physician consult is
recommended for patients with a platelet count <60,000. Other factors that can also
contribute to prolonged bleeding time are liver diseases and medications (including
Warfarin and NSAIDS). Obtain INR (International Normalized Ratio) – a value above
2.5 to 3, can require medical interventions if surgeries or invasive treatment is planned.
Ask physician about any other bleeding risk factors.
• Document history of any opportunistic infections.
• Determine the current CD4+ lymphocyte count as this will indicate the current level of
immunosuppression:
• Those with CD4+ cell counts of more than 400 may have reasonable immune
response.
• As CD4 counts drop below 400 there can be a steadily increasing risk for systemic
•Even asymptomatic adults may experience infection after oral manipulation.
Patients with neutropenia, in particular, are prone to infection and
consideration for antibiotic prophylaxis may be indicated for procedures that
place the patient at risk for infection. Risk for infection in association with
dental treatments will still primarily be related to neutrophil count.
• Obtain a complete list of the patient’s medications including non-prescription
agents and supplements.
• Provide dental procedures in accordance with patient’s desires and needs. For
patients with advanced AIDS, render only more urgently needed treatment to
control pain and infection, consistent with the patient’s desires and needs.
•Consider aggressive caries prevention programs for patients with xerostomia
and/or poor oral hygiene including increased frequency of recall, fluoride
varnish application, 1.1% neutral sodium toothpaste/gel or concentrated
calcium/fluoride products.
• As needed for patients with xerostomia:
• Educate on proper oral hygiene (brushing, flossing) and nutrition.
• Recommend brushing teeth with a fluoride containing dentifrice
before bedtime. After brushing, apply neutral 1.1% fluoride gel (e.g.,
Prevident 5000 gel) in trays or by brush for 2 minutes. Instruct patient
to spit out excess gel and NOT to rinse with water, eat or drink before
going to bed.
• Recommend xylitol mints, lozenges, and/or gum to stimulate saliva
production and caries resistance.
 Lesson 1 – Oral manifestations of Cancer

M10 – CANCER Lesson 2 – Dental Management

Lesson 3 – Medications of Cancer

patients in relation to dentistry
 LESSON 1 – ORAL
MANIFESTATIONS OF CANCER
SITES OF ORAL CANCER
Many symptoms caused by oral tumors may be due to
other, less serious conditions or other cancers.
• Persistent mouth ulcers that do not heal
• Persistent mouth pain
• A lump or thickening in the cheek
• A white or red patch on the gums, tongue, tonsil, or lining of the mouth
• A sore throat or persistent feeling that something is caught in the throat
• Difficulty in swallowing 
• Difficulty moving the jaw or tongue
• Numbness of the tongue or other area of the mouth
• Jaw swelling that makes dentures hurt or fit poorly
• Loosening of the teeth
• Pain in the teeth or jaw
• Voice changes
• A lump in the neck
• Weight loss
• Persistent bad breath
LESSON 2 – DENTAL
MANAGEMENT
 LESSON 2 – DENTAL
MANAGEMENT
Prior to Cancer Therapy
1.A comprehensive oral assessment is undertaken.
2.Detailed oral hygiene instruction with reinforcement and
elaboration of diet advice is provided in cooperation with the
dietician.
3.Oral hygiene practices are supplemented with the use of a
chlorhexidine mouthwash or dental gel, if there is gingival
disease diagnosed.
4.Impressions of the mouth are taken for study casts to
construct applicator trays and where appropriate for obturator
planning.
5.Carious teeth that can be restored are stabilized with
appropriate restorations.
6.All sharp teeth and restorations are suitably adjusted and
polished.
7.The patient is counseled about denture wear during therapy.
8.Wherever possible, teeth with a dubious prognosis are
removed no less than ten days prior to therapy
9.Orthodontic treatment is discontinued.
During Cancer Therapy
1.The patient receives appropriate support from a dental hygienist.
2.A high standard of oral hygiene is encouraged (including denture hygiene).
3.The use of a chlorhexidine mouthwash, or dental gel, is continued.
4.Those patients receiving radiotherapy, or total body irradiation prior to bone
marrow transplantation, receive a daily fluoride mouthwash to prevent dental
caries and promote enamel remineralization.
5.Children and adults receiving bone marrow transplants often receive Acyclovir as
a prophylaxis if there is a high risk of viral infections. This is usually prescribed
by the oncology team.
6.Antifungal medication is used following detection of oral candida. For children
this should be used routinely as a prophylaxis.
7.Every effort should be made to reduce the severity of the mucositis.
8.Every effort is made to reduce the effect of the xerostomia.
9.Patients are advised that removable prostheses may be left out of the mouth if
there is any evidence of ulceration. They should be examined by a member of the
dental team.
10.When the mouth is too painful for cleaning, the tissues are swabbed with oral
sponges.
11.Foods, drinks and mouthwashes, which irritate the oral mucosa should be
avoided to maintain oral comfort.
12.Dental treatment is avoided wherever possible during therapy.
 LESSON 2 – DENTAL
MANAGEMENT
Following Cancer Therapy
Prevention and Monitoring
1.Growth and development should be closely
monitored for children.
2.Three months oral hygiene review for as long as the
xerostomia continues.
3.Regular and appropriate oral healthcare monitoring
is provided by the designated member of dental staff.
4.Strategies for dealing with xerostomia continue.
5.A remineralizing solution, such as a fluoride
mouthwash continues to be used regularly with
confirmation of compliance.
6.Chlorhexidine gel is applied with applicators.
7.In the event of trismus, jaw exercises are
implemented.
Restorative Dental Care
1.In the event of uncontrolled periodontal disease, vigorous treatment is
initiated. This may involve identification of atypical pathogens.
2.Herpes labialis can be a chronic problem. Topical acyclovir is effective.
3.Restorations are kept simple ensuring acceptable aesthetics and function.
4.Dental extractions if essential, must be performed with appropriate
precautions.
5.Dentures should be avoided wherever possible.
6.Implant stabilization of prostheses and obturators maybe feasible in
some patients.
Requirements for Denture Wearers
1.Removable prostheses are left out at night.
2.Glandosane saliva substitute should be used for edentate patients only.
3.Antifungals are used if a candida infection is diagnosed.
4.Appliance wear is discontinued if the mouth becomes painful.
5.Obturators are reviewed regularly. They may require frequent attention
with adjustment or remake.
LESSON 3 – MEDICATIONS OF
CANCER PATIENTS IN
RELATION TO DENTISTRY
 LESSON 3 – MEDICATIONS OF CANCER
PATIENTS IN RELATION TO DENTISTRY
Pre- irradiation phase
Pre-treatment assessment
1.
A.  Extraction
B. Removal of foci
2. Oral prophylaxis
3. Restorative procedures
4. Initiation of preventive programme
Post-irradiation
Irradiation phase (6-7 wks)
phase(life long) •For patients at higher risk of osteonecrosis of the jaw in whom an
1. Mucositis prevention extraction is indicated, explore all possible alternatives where
Wound
A. Oral rinses/spraying teeth could potentially be retained, e.g. retaining roots in the
healing-
B. Selective elimination of oral flora C.
Discourage denture wearing
absence of infection. Consider seeking advice from secondary
3 wks
D. Pain relief dental care.
2. Relief of oral dryness
•If an extraction or any procedure that impacts on bone is required,
A. Oral rinses
B. Saliva substitute discuss the risks and benefits of treatment with the patient to
C. Sialogogues
D. Mucin
  ensure valid consent before proceeding.
lozenges
•Do not prescribe antibiotics or antiseptic prophylaxis unless
3. Prevention of caries and periodontal disease required for other clinical reasons.
A. Oral hygiene B. Topical fluoride
A. Oral hygiene B.
Topical fluoride
•Refer to secondary dental care if the socket has not healed at eight
weeks.
4. Trismus prevention
A. Monitoring •After treatment:
A. Monitoring mouth opening B.
mouth opening B. • Manage simple denture problems after surgery
Exercises
Exercises
C. Physiotherapy • Alleviate the effects of post-irradiation dry mouth, e.g. preventing caries
C. Physiotherapy
5. Nutritional counseling • Monitor for recurrence, new premalignant lesions and second primary tumors
A. Return to regular • Monitor for cervical metastasis
A. Advices diet • Maintain morale of and provide additional support to patients and their
B. Monitoring body weight C. Artificial B. Adjustment to
feeding individual needs C. relatives
Non-cariogenic diet