ONLINE CLASS HOSPITAL

DENTISTRY 2 LEC
ORIENTATION 2ND SEMESTER 2020-
2021
WELCOME TO THE SCHOOL OF
DENTISTRY
VIRTUAL CLASS HOUSE
RULES
GOAL?
 Lesson 1- Definition, Importance, Major and
Accessory Parts of a Medical Record

M1 – MEDICAL Lesson 2 - Review of common hospital

abbreviations and their proper use within the

RECORDS medical record

Lesson 3 - Medico-legal issues and policies of a

medical record
M1 – MEDICAL RECORDS
 LESSON 1- DEFINITION, IMPORTANCE,
MAJOR AND ACCESSORY PARTS OF A
MEDICAL RECORD
A chronological written account of a patient's 5 Major parts of the Medical Record
examination and treatment that includes the patient's
medical history and complaints, the physician's physical 1. Admission notes
findings, the results of diagnostic tests and procedures, 2. Preoperative notes
and medications and therapeutic procedures.                   
3. Operative notes and post operative orders
As a document, the medical record is not only a 4. Progress notes
repository of information, it is also a continuing record
which acts as a means of communication between 5. Discharge notes
members of the health team.
Supporting documents:
A famous maxim concerning the medical record is: "To 1. Orders
be complete, the medical record must contain sufficient
data, written in sequence of events, to justify the 2. Nursing notes
diagnosis and warrant the treatment and end results". 3. Laboratory Results
 LESSON 2 - REVIEW OF COMMON
HOSPITAL ABBREVIATIONS
AND THEIR PROPER USE WITHIN THE
MEDICAL RECORD
 LESSON 3 - MEDICO-LEGAL ISSUES
AND POLICIES OF A MEDICAL RECORD
A Medico-Legal Case can be defined as a
case of injury or ailment, etc., in which
investigations by the law-enforcing agencies
are essential to fix the responsibility regarding
the causation of the injury or ailment.
In any of the medico-legal cases , it is the legal
duty of the treating doctor to report it to the
nearest police station immediately after
completing primary lifesaving medical care.
Quick action by the police also helps to avoid
the destruction of evidence by the treating
physician.
 LESSON 3 - MEDICO-LEGAL
ISSUES AND POLICIES OF A
MEDICAL RECORD
The following cases should be considered as
medico-legal and as such the medical officer is
“duty-bound” to intimate to the police
regarding such cases:
· All cases of injuries and burns ,the circumstances of which suggest
commission of an offense by somebody. (irrespective of suspicion of foul
play)
· All vehicular, factory or other unnatural accident cases specially when
there is a likelihood of patient’s death or grievous hurt.
· Cases of suspected or evident sexual assault.
· Cases of suspected or evident criminal abortion.
· Cases of unconsciousness where its cause is not natural or not clear.
· All cases of suspected or evident poisoning or intoxication.
· Cases referred from a court or otherwise for age estimation.
· Cases brought dead with improper history creating suspicion of an offense.
· Cases of suspected self-infliction of injuries or attempted suicide.
· Any other case not falling under the above categories but has legal
implications.
 LESSON 3 - MEDICO-LEGAL ISSUES
AND POLICIES OF A MEDICAL RECORD
In order to prove that medical
malpractice occurred, the patient must
be able to show all of these things:
· A doctor-patient relationship existed.
· The doctor was negligent.
· The doctor’s negligence caused the injury.
· The injury led to specific damages.
· Failure to diagnose.
· Improper treatment.
· Failure to warn a patient of known risks.
 M2 – HOSPITAL Lesson 1- Hospital Admission

ADMISSION PROCESS Lesson 2 - The Out-patient and In-

patient Admissions
 M2 – HOSPITAL ADMISSION
PROCESS
A patient may be admitted to the hospital in one of
two ways;
Elective admission occurs when a patient is given an
admission appointment by the doctor and hospital for
a surgical procedure or specialized testing that must
take place in the hospital. A patient with complex
medical problems may be admitted to have oro-facial
procedures performed in a hospital dental facility in
which treatment modifications possible only in the
hospital setting can be made.
Nonelective admission occurs when conditions arise
that require immediate attention. This type of
admission is generally routed from the hospital’s
emergency department or referred to the hospital
dental service by private practitioners.
 LESSON 1- HOSPITAL
ADMISSION
ADMITTING DEPARTMENT
-Requests and collects information (for medical record keeping)
-Conveys the first impression of the hospital to the patient
-Disseminates data to ancillary service involved in the patient
case
-Inspires mutual trust and cooperation between patient and
hospital
DUTIES:
a. expediting the admission process
b. maintaining accurate records of patients in the hospital,
including un-admitted patients in the emergency department
c. producing and generating timely and accurate statistical
reports
 LESSON 1- HOSPITAL
TWO types of Admission:
ADMISSION
2. Non-elective admissions
1. Elective admissions

• patient has been given an appointment for surgical procedure or specialized investigations that must • admissions from casualty
take place in the hospital
• usually from the ER
• short stays where patients undergo a surgical procedure (hospital dental service)

why? • based on the process of formal evaluation, database generation, thorough

• for optimal control of therapy and close attention to patient comfort documentation
• closely monitored
• best treatment possible who?

who? a. facial fractures requiring reduction and fixation in the OR

a. Difficult impacted teeth
b. injuries requiring wound care and observation
b. Implant placement
c. odontogenic infections requiring I&D in the OR
c. Complex maxillofacial procedures, including orthognathics and temporomandibular joint surgery
d. oral and maxillofacial conditions requiring administration of fluids or
d. Grafting procedures in which autogenous tissue is harvested from an extraoral site
antibiotics
e. Basic treatment for mentally and emotionally challenged patients and others incapable of tolerating
dental procedures in conventional settings e. rapidly evolving odontogenic infections likely to result in a significant
f. Patients requiring procedures that may cause localized swelling leading to airway compromise
deterioration in the patient’s condition over the next 24 hrs

g. Dental and oral surgical patients with coagulopathies and other medical conditions that may require f. any infections or injuries that have the potential to cause airway compromise
transfusions or intravenous medications
 LESSON 1- HOSPITAL
ADMISSION
3 admitting categories: 3 admitting types:
1.elective 1.private
2.emergency 2.service
3.urgent 3.continuity of care
 LESSON 1- HOSPITAL
ADMISSION
Three Primary elements of admission 3. History and Physical Examination
1. Admitting orders HISTORY
•a full set of orders (diagnostic, therapeutic, routine maintenance •chief complaint
intervention) written by a practitioner on the patient’s chart •HPI
•if expired, must be rewritten •Past medical history
•automatically cancelled if patient undergoes surgery or transferred •Medications
to another service
•Allergies
•ADC VAAN DIMEL (Admit, Diagnosis, Condition, Vital
Sign, Activity, Allergies, Nursing, DIET, IV meds and •Family History
fluids, Medication, Extras, Laboratory studies) •Social History
2. Admitting note •Review of Symptoms
•includes history, results of PE (head, neck, oral), lab test results, PHYSICAL EXAMINATION
radiographic findings, differential diagnosis, plans for treatment
•performed after history taking
•if ELECTIVE:
• consent form signed and attached to chart •comprehensive, emphasis on areas related to CC
• pre-op instructions (NPO), meds to be taken •vital signs
 LESSON 2 - THE OUT-PATIENT
AND IN-PATIENT ADMISSIONS
OUT-PATIENT Admission Criteria for a PROCEDURE:
Ambulatory Admissions
1. physiologic derangements produced by the
•one-day surgery, ambulatory surgery, day surgery, short-stay operation must not require hospital care
surgery
•patients have greater control in scheduling the procedure 2. blood loss must not be great enough to
•insurance feels it reduces costs
require transfusion
•discharge depends more on recovery from anesthesia than the 3. post-operative pain is controllable with safe
procedure doses of oral analgesics
Patient selection guidelines:
4. no risk of airway obstruction
1.ASA physical status
2.Reliability and compliance 5. potential complications must not immobilize
the patient
3.Discharge situation
4.Age
LESSON 2 - THE OUT-PATIENT
AND IN-PATIENT ADMISSIONS
Patient examination requirements: Required forms for admission
•Similar to any operation 1.Hospital forms
1. Medical history
2. Physical examination 2.Patient information forms
3. Laboratory studies
3.Medical history and PE forms
Protocols
4.Informed consent
•patient’s agreement, predetermination of
insurance benefits and preauthorization must
all be in writing
•accepted date of procedure is cleared with the
hospital admission office to permit firm
scheduling
 LESSON 2 - THE OUT-PATIENT
AND IN-PATIENT ADMISSIONS
IN-PATIENT Admission Automatic admissions

•follows a specific procedure except for patients coming 1.Emergency/trauma

through the emergency department 2.Mentally handicapped
•admission is to a particular clinical service 3.Physically challenged
•varies per institution 4.Medically compromised
Criteria for admission 5.Immunocompromised
1.requires GA or conscious sedation 6.Nutritionally compromised

2.needs extensive surgical intervention 7.Patients with infectious disease

3.requires extensive general dentistry or oral 8.Patients in at-risk categories

rehabilitation 9.Allergies to LA
4.have other medical indications 10.Requires extensive dental & oral surgical repair
services at a single visit
5.requested elective treatment
 LESSON 2 - THE OUT-PATIENT
AND IN-PATIENT ADMISSIONS
Database Operating Room
•begins with the H&P but also includes test results from a variety of •a formal environment in which behavior is guided by the need to maintain a
diagnostic procedures safe and sterile field
•includes: •surgeons, anesthesiologist, scrub nurse, circulating nurse
• Blood tests
•2 areas: scrub area, sterile field
• Urinalysis
• Radiology Post-operative Period
• Microbiology
•begins after the patient leaves the OR
• Electrocardiogram
• Pulmonary function test •operative note, post-operative orders, pain management, wound care
Differential and Treatment Plan Discharge Criteria
•from H&P and pertinent laboratory tests 1.Normality and stability of VS
•treatment plans discussed with the patient and family before implementation 2.Level of orientation
Preparation for Operative Procedure 3.Ability to tolerates chewing and swallowing
•every patient undergoing a surgical procedure under GA must have an H&P 4.Ability to urinate
•children must be examined by a pediatrician 5.Ability to meet postoperative and daily personal needs
•H&P, informed consent, admitting note, preoperative note, orders, test 6.Subjective readiness for discharge
results, consultations
7.Environment to which the person is being discharged
 Lesson 1- Pain

M3 – PAIN Lesson 2 – Therapeutic

management of pain
 LESSON 1- PAIN
TYPES OF PAIN:
CHRONIC  - From mild to severe; present for
long period of time; often the result of a disease
that may require ongoing treatment.
ACUTE. – Usually severe and short lived; a
signal that your body has been injured.
•Temporary
•Sudden onset
•Localized
•Sharp and severe
•Physical responses: tachycardia, increased bp,
dilated pupils, sweating, pallor
 LESSON 1- PAIN
SOMATIC PAIN VISCERAL PAIN
•A nociceptive pain that includes skin, tissue or •A nociceptive pain that arises from visceral organs.
muscle pain •Poorly localized due to low number of nociceptors
•Located in the skin and deep tissues •Often radiates or referred
•Sharp and localized •Vague and appears like deep pressure
REFERRED PAIN
•Perceived in an area distant from the site of the
stimuli. 
• ex. Injured pancreas causing back pain;  heart attack-
triggering pain in the jaw. 
 LESSON 1- PAIN
PHANTOM PAIN PSYCHOGENIC PAIN
•The perception of a painful, unpleasant •Another name: Psychalgia
sensation in the distribution of the missing or
deafferented body part.  •Physical pain caused, increased, prolonged
by mental, emotional, or behavioral factors.
•It involves the sensation of pain in a part of
the body that is no longer there or has been e.g.  Common types:  Headache,
removed by surgical or accidental stomachache, backache
amputation.
 LESSON 1- PAIN
Another Category of Pain: PERIPHERAL NEUROPATHIC Pain Mechanism
1. Nociceptive Pain – Typically the result of injury.  It is caused by a primary lesion or dysfunction in the
2. Inflammatory Pain – Abnormal inflammation caused by peripheral nervous system (PNS) and involves numerous
inappropriate response by the body’s immune system.  pathophysiological mechanisms associated with altered
nerve functioning and responsiveness.   It includes
3. Neuropathic Pain - Caused by nerve irritation.  hyperexcitability and abnormal impulse generation and
4. Functional Pain – Pain with the obvious origin. mechanical, thermal and chemical sensitivity.
CENTRAL PAIN MECHANISM
MECHANISM OF PAIN Central pain is deeply embodied in the psychophysical
problem of pain.  It is influenced by physical and
NOCICEPTIVE Pain Mechanism
psychological factors.
          Nociceptive pain is associated with the activation of
peripheral receptive terminal of primary afferent neurons in
It is located in the brain and spinal cord.
response to noxious chemical (inflammatory), mechanical It is initiated or caused by primary lesion or dysfunction in
or ischemic stimuli. the central nervous system.
 LESSON 2 – THERAPEUTIC
MANAGEMENT OF PAIN
NON-PHARMACOLOGIC PHARMACOLOGIC PAIN
•It refers to interventions that do not use medications to treat MANAGAMENT
pain.
•Goal: To decrease fear, distress and anxiety, and to reduce Types of Medications:
pain and provide patients with a sense of control. 
1.Non-narcotic analgesics
1.Physical Intervention
•Massage, Positioning, Hot and cold therapy, Acupuncture, 2.Narcotic Analgesics (Opioids)
Transcutaneous Electrical Nerve Stimulation, Progressive
muscle relaxation 3.Serotonin Norepinephrine Re-Uptake
2.Psychological Intervention Inhibitors (SNRIs)
•Cognitive Behavioral Therapy, Mindfulness-based stress 4.Corticosteroids
reduction, Biofeedback, Guided imagery
3.Others 5.Muscle relaxants
•Spirituality/Religion 6.Anesthetic
•Music Therapy
 Lesson 1- BLS

M4 – BLS Lesson 2 – Foreign Body Airway

Obstruction
 LESSON 1- BLS
Emergency Medical Services
• Persons who respond to medical emergencies in
an official capacity
• Dispatchers and responders

Cardiac Arrest
• Cessation of cardiac mechanical activity
• Unresponsiveness, absence of detectable pulse and
apnea (agonal respirations)

Requirements for BLS

• Knowledge and skills in performing CPR
• Use of AED
• Relieving airway obstructions
 LESSON 1- BLS
Chain of SURVIVAL
LINKS of the Chain of survival
1. Recognition and activation of emergency
response system
2. Early CPR
3. Rapid defibrillation
4. Basic and advanced emergency medical
services
5. Advanced life support and post-cardiac arrest
care
 LESSON 1- BLS
STEPS of BLS
1. Check area safety
2. Check unresponsiveness
3. Call for help
4. C-A-B (CPR, Rescue Breaths)
5. AED
6. Wait until help arrives
Cardiopulmonary Resuscitation
High-quality CPR should be performed by
anyone - including bystanders. There are five
critical components:
1. Minimize interruptions in chest compressions
2. Provide compressions of adequate rate and
depth
3. Avoid leaning on the victim between
compressions
4. Ensure proper hand placement
5. Avoid excessive ventilation
 LESSON 1- BLS
When to STOP CPR
• You see sign of return of spontaneous
circulation (movement or breathing)
• AED is ready to analyze the patient’s heart
rhythm
• Other trained rescuers take over
• Presented a valid DNR order
• Too exhausted to continue
• Scene becomes unsafe
LESSON 2 – FOREIGN BODY
AIRWAY OBSTRUCTION
LESSON 2 – FOREIGN BODY
AIRWAY OBSTRUCTION
Causes of Airway Obstruction:
INTRINSIC
• Tongue
• Blood from head and facial injuries
• Regurgitated stomach contents

EXTRINSIC
• Foreign bodies

When NOT to intervene?

When TO INTERVENE?
LESSON 2 – FOREIGN BODY
AIRWAY OBSTRUCTION
Steps for Foreign Body Obstruction
1. Identify the universal distress signal
• Identify yourself
• Tell the victim you know the Heimlich
maneuver
• Ask the person “can you cough/can you
speak?”

2. Do abdominal thrust
 Heimlich maneuver
 Chest Thrust
 Back blows and chest thrust
LESSON 2 – FOREIGN BODY
AIRWAY OBSTRUCTION
LESSON 2 – FOREIGN BODY
AIRWAY OBSTRUCTION
 LESSON 2 – FOREIGN BODY
AIRWAY OBSTRUCTION
For INFANTS
• Awake, unable to cough, cry, breathe
• 5 back blows and 5 chest thrusts
LESSON 2 – FOREIGN BODY
AIRWAY OBSTRUCTION
 LESSON 2 – FOREIGN BODY
AIRWAY OBSTRUCTION
If becomes UNCONSCIOUS
•Gently guide patient to the floor
•Get astride the victim’s thigh and place
the heel of one hand at approximately the
belly button
•Put your other hand on top and give 5
abdominal thrusts toward the victim’s
nose
If becomes UNRESPONSIVE
•Carefully lower patient to a firm, flat
surface
•Send someone to get an AED
•Begin CPR with chest compression
•Open airway and check person’s mouth
for any visible object
• Use finger sweep motion to remove the
object
• DO NOT perform a blind finger sweep
 Lesson 1- Types, Diagnostics, and

M5A – ASTHMA Medications

Lesson 2 – Dental Management

 LESSON 1- TYPES, DIAGNOSTICS,
AND MEDICATIONS
Types of Asthma:
1. Extrinsic (allergic)- may be precipitated particularly
by allergens like climate, foods, drugs, environmental
pollutants, and airborne substances and is typical
asthma in children. This tends to resolve by adult life
and usually associated with family history.
2. Intrinsic (nonallergic)- appears to relate to mast cell
instability and hyper-responsive airway. It is usually
seen in middle-aged adults and no family history of
asthma. It is associated with emotional stress, exercise,
excitement, and respiratory viral infections such as cold
and flu.
 LESSON 1- TYPES, DIAGNOSTICS,
AND MEDICATIONS
Diagnostics A FeNO test, in patients with allergic or
eosinophilic asthma, is a way to determine how
The diagnosis of asthma begins with a detailed history much lung inflammation is present and how well
and physical examination. A typical history is an inhaled steroids are suppressing this inflammation.
individual with a family history of allergic conditions or
a personal history of allergic rhinitis who experiences Another lung function test is a Methacholine
coughing, wheezing, and difficulty breathing, especially challenge test, also known as a
with exercise, and viral infections.   bronchoprovocation test, which is performed to
The doctor may also carry out a lung function test to evaluate how “reactive” the lungs to things in the
assess how well the lungs are working. A spirometry test environment.
is one example of a lung function test.
Other tests for diagnosis include a skin test that
The doctor will then compare these results with those of can be used to identify a specific allergy.
a person who is similarly aged but who does not have
asthma.
 LESSON 1- TYPES, DIAGNOSTICS,
AND MEDICATIONS
Medications
There are two forms of medication for asthma.
•Controller medications are the most important
because they prevent asthma attacks. When you
use these drugs, your airways are less inflamed
and less likely to react to triggers.
•Quick-relief medications -- also called rescue
medications which relax the muscles around your
airway. 
Long-Term Control Medications
Some of these drugs should be taken daily to get your asthma
under control and keep it that way. Others are taken on an as-
needed basis to reduce the severity of an asthma attack. The most
effective ones stop airway inflammation. The doctor may suggest
combining an inhaled corticosteroid, an anti-inflammatory drug
with other drugs such as:
• Long-acting beta-agonists. 
• Long-acting anticholinergics.
• Tiotropium bromide (Spiriva Respimat)
• Leukotriene modifiers 
• Mast cell stabilizers 
• Theophylline 
• Immunomodulator 
LESSON 2 – DENTAL
MANAGEMENT
 LESSON 2 – DENTAL
MANAGEMENT
1. Detailed history
2. Medical consultation for severe active asthmatic
patients.
3. Elective dental care should be deferred in severe
asthmatics until they are in a better phase.
4. Provide a stress
5. Oral premedication may be accomplished
6. A local anesthetic is preferred and general
anesthesia (GA) is best avoided.
7. If conscious sedation is used nitrous oxide-oxygen is
preferred to I/V sedation.
8. Patients with nocturnal asthma should be scheduled
for late morning appointments.
9. Operatory odorants (e.g. methyl methacrylate) should
be reduced before the patient is treated.
10. Patients are instructed to bring their usual
medication/inhaler for every appointment and keep it
available.
11. The use of pulse oximeter is valuable for
determining the oxygen saturation of the patient.
12. Drug considerations
 LESSON 2 – DENTAL
MANAGEMENT
Management of an Acute Asthmatic Attack
1. Stop the surgical procedure and clear the airway.
2. Seat the patient upright.
3. Take two puffs on their inhaler.
4. Administration of fast-acting bronchodilator
(corticosteroids have delayed onset of action).
5. Provide positive-flow oxygenation.
6. Monitor vital signs.
7. If needed subcutaneous 0.3 to 0.5 ml of adrenalin
(1:1000) is administered.
8. Activating emergency medical system.
M5B – DIABETES Lesson 1- Diabetes, Symptoms, and
Complications

MELLITUS Lesson 2 – Tx and Dental

Management
 LESSON 1- DIABETES, SYMPTOMS,
AND COMPLICATIONS
DIABETES
• Is a chronic disease when the pancreas is no
longer available to make insulin or when the
body cannot make good use of the insulin it
produces.
•According to WHO, diabetes is a “Global
Pandemic”. It is a chronic, metabolic disease
characterized by elevated levels of blood glucose
(or blood sugar) which leads overtime to serious
damage to the heart, blood vessels, eyes, kidneys
and nerves.
• All carbohydrate foods are broken into glucose
in the blood. Insulin helps glucose into the cells.
LESSON 1- DIABETES, SYMPTOMS,
AND COMPLICATIONS
SYMPTOMS:
• Increased hunger
• Increased thirst
• Weight loss • Tiredness

• Frequent urination • Erectile dysfunction (men)

• Blurry vision • Poor muscle strength (men)

• Extreme fatigue • Urinary Tract infections

(women)
• Sores that do not heal or slow
to heal • Yeast infections (women)
• Dry, Itchy skin (women)
LESSON 1- DIABETES, SYMPTOMS,
AND COMPLICATIONS
RISK • Have prediabetes
FACTORS
Type 1 – genetics
Type 2 - increases
when: • Have high blood
• Overweight pressure, high
• Age 45 or older cholesterol, or high
triglycerides
• Have a parent or
sibling with the • Have African
condition American, Hispanic
or Latino American,
• Not physically active Alaska Native,
• Have had gestational Pacific Islander,
diabetes American Indian, or
Asian American
ancestry
 LESSON 1- DIABETES, SYMPTOMS,
AND COMPLICATIONS
Gestational Diabetes - increases when:
•Overweight
•Over age 25
•Had gestational diabetes during a past
pregnancy
•Have given birth to a baby weighing more
than 9 pounds
•Have a family history of type 2 diabetes
•Have polycystic ovary syndrome (PCOS) 
 LESSON 2 – TX AND
DENTAL MANAGEMENT
 LESSON 2 – TX AND DENTAL
MANAGEMENT
TREATMENT
Type 1 diabetes -  INSULIN
Four types of insulin most commonly used.
·Rapid-acting insulin starts to work within 15 minutes and its effects last
for 3 to 4 hours.
·Short-acting insulin starts to work within 30 minutes and lasts 6 to 8
hours.
·Intermediate-acting insulin starts to work within 1 to 2 hours and lasts 12
to 18 hours.
·Long-acting insulin starts to work a few hours after injection and lasts 24
hours or longer.
Type 2 diabetes
·Diet
·Exercise
·Medication
 LESSON 2 – TX AND DENTAL
MANAGEMENT
Types of drug
Alpha-glucosidase inhibitors
Biguanides
DPP-4 inhibitors
Glucagon-like peptides
Meglitinides
SGLT2 inhibitors
Sulfonylureas
Thiazolidinediones
How they work
Slow your body’s breakdown of
sugars and starchy foods
Reduce the amount of glucoseyour
liver makes
Improve your blood sugar without
making it drop too low
Change the way your body produces
insulin
Stimulate your pancreas to release
more insulin
Release more glucose into the urine
Stimulate your pancreas to release
more insulin
Help insulin work better
Example(s)
Acarbose (Precose) and miglitol
(Glyset)
Metformin (Glucophage)
Linagliptin (Tradjenta), saxagliptin
(Onglyza), and sitagliptin (Januvia)
Dulaglutide (Trulicity), exenatide
(Byetta), and liraglutide (Victoza)
Nateglinide (Starlix) and repaglinide
(Prandin)
Canagliflozin (Invokana) and
dapagliflozin (Farxiga)
Glyburide (DiaBeta,
Glynase), glipizide(Glucotrol),
and glimepiride (Amaryl)
Pioglitazone (Actos) and
rosiglitazone (Avandia)
 LESSON 2 – TX AND DENTAL
MANAGEMENT
DENTAL MANAGEMENT:
• 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.  physician.
• 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 environment.
• 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
 
• Noninsulin- 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 patients fluid and electrolyte balance
and dietary needs.
• Adrenalin antagonizes the effects of insulin. So, theoretically it might
be best to avoid using adrenalin containing local anesthetic solutions.
However, in clinical practice this precaution may be
 Lesson 1- Importance of Liver

M5C – HEPATITIS Lesson 2 – What is Hepatitis?

Lesson 3 – Types of Viral Hepatitis

 LESSON 1- IMPORTANCE OF
LIVER
LIVER 
Largest lobed glandular organ in the body
and is located in the upper right quadrant of
the abdomen.
It is made up of 4 lobes; a large right lobe, a
smaller left lobe and small quadrate and
caudate lobes.
It’s the body’s filter and warehouse. Almost
all cells and tissues in the body depend on the
liver.
 LESSON 1- IMPORTANCE OF
LIVER
Functions:
1.Bile formation and secretion
2.Carbohydrate metabolism

3.Fat metabolism 
4.Protein metabolism
5.Removal, excretion, detoxification and
inactivation of drugs, hormones and toxins take
place in the liver
LESSON 2 – WHAT IS
HEPATITIS?
 LESSON 2 – WHAT IS
HEPATITIS?
Hepatitis - Is a general term that means
inflammation of the liver. The Ancient Greek
word hepa refers to the liver, and itis means
inflammation.
Inflammation of the liver has several
possible causes, including:
•Toxins and chemicals such as excessive
amounts of alcohol
•Autoimmune diseases that cause the immune
system to attack healthy tissues in the body
•Fat which may cause fatty liver disease
•Microorganisms, including viruses
Types of Hepatitis:
1.Infectious – Viral infection of the liver
due to acute or chronic viral hepatitis
(HAV, HBV, HCV, HDV, HEV).
2.Non-infectious – Due to excessive or
prolonged use of toxic substances that
are metabolized in the liver (e.g.
acetaminophen, alcohol, halothane,
ketoconazole, methyldopa and
methotrexate) and sometimes due to auto
immune system response in the body.
LESSON 3 – TYPES OF
VIRAL HEPATITIS
LESSON 3 – TYPES OF VIRAL
HEPATITIS
1.Hepatitis A (RNA-Piconavirus)
Transmission: enteric (fecal-oral route)
Often occurs as an epidemic because the reservoir for
infection is frequently a common food or water source
Incubation period:  ̴25 days
Persons of any age may be infected but occurs
primarily in children and young adults
Mild severity
No carrier state
Recovery conveys immunity against infection
Vaccine developed in 1995
 LESSON 3 – TYPES OF VIRAL
HEPATITIS
2. Hepatitis B (DNA-Hepadnavirus)
•Transmission:
• Direct percutaneous inoculation or transfusion of infected blood or products
• Indirect percutaneous introduction of infected blood and blood products
through minute skin cuts or abrasion
• Absorption of infected blood or blood specimen into the mucosal surface of
the mouth or eye
• Absorption of infected secretions like saliva and semen into mucosal
surfaces
• Transfer of infected serum or plasma through inanimate environmental
surfaces

•Fecal transmission does not occur. Airborne droplets not important

•Incubation period:  ̴75 days
•Permucosal and percutaneous inoculation of infectious saliva is
necessary for transmission of the disease
•Compared with Hepatitis A, Hepatitis B tends to have greater
associated morbidity or mortality, especially in the very young and
older patients
 LESSON 3 – TYPES OF VIRAL
HEPATITIS
3.Hepatitis C (RNA-Flaviviridae)
•Transmission: Parenteral (primarily by blood
to blood products)
•Accounts for 90-95% of all cases of post-
transfusion hepatitis infections
•Similar to HBV in behavior and characteristics
•Unprotected sex and perinatal transmission
have not been recognized as significant factors
•Incubation period:  ̴80 days
 LESSON 3 – TYPES OF VIRAL
HEPATITIS
4.Hepatitis D (defective RNA virus)
•Uses the Hepatitis B surface antigen (HBsAg) for its
viral envelope
•Occurs as a co-infection in patients with acute
Hepatitis B and as a super-infection in Hepatitis B
virus carriers
•Transmitted parenterally by infected blood or blood
products
•Frequently associated with more severe fulminant
infections than infection with Hepatitis B alone
(Hepatitis B/D > Hepatitis B)
•Incubation period: ̴35 days
LESSON 3 – TYPES OF VIRAL
HEPATITIS
5.Hepatitis E (non-developed RNA
virus)
•Enterically transmitted Hepatitis
Non-A-Non-B (NANB) virus
•Perinatal transmission possible.
20% fatality rate in pregnant
women in their third trimester
•Incubation period:  ̴40 days
LESSON 3 – TYPES OF VIRAL
HEPATITIS
Clinical Signs and Symptoms:
•Appearances of types A, B, C, D and E
hepatitis are similar
•Characterized by degeneration and
necrosis of liver cells: entire liver
lobule is inflamed
 LESSON 3 – TYPES OF VIRAL
HEPATITIS
Presents in three phases:
1.1st phase – Prodromal phase [pre-icteric]
1. Resembles flu-like symptoms (anorexia, nausea, vomiting, fatigue,
myalgia, malaise, fever). May also demonstrate arthralgia, rash and
angioedema.
2. Symptoms present 1-2 weeks before the onset of jaundice

2.2nd phase – Icteric phase
2. Clinical jaundice (yellowish brown hue of the eyes, skin, oral
mucosa and urine)
3. Some prodromal symptoms may subside but gastrointestinal
symptoms increases
4. 2-8 weeks
5. (+) hepato- and splenomegaly

3.3rd phase – Convalescent/Recovery phase [post-icteric]
3. Symptoms disappear but abnormal liver function and hepatomegaly
may persist
4. Recovery period usually completed  ̴4 months after onset of
jaundice. Hepa B and C have longer recovery periods
 Lesson 1- Diagnosis of

M5D – CONGESTIVE Cardiovascular Disease

HEART DISEASE Lesson 2 – Management of

Cardiovascular Disease
 M5D – CONGESTIVE
HEART
Cardiovascular disease inlcudes:
DISEASE
1.Hypertension
2.Coronary Artery Disease
3.Myocardial Infarction
4.Acute coronary Syndrome
5.Rheumatic heart disease & fever
6.Cardiac Arrhythmia
7.Angina Pectoris
8.Stroke
9.Congenital Cardiovascular Disease
10.Congestive Heart Failure
 LESSON 1- DIAGNOSIS OF
CARDIOVASCULAR DISEASE
 LESSON 1- DIAGNOSIS OF
CARDIOVASCULAR DISEASE
ANALYSIS OF PRESENTING SYMPTOMS
DYSPNEA
CHEYNE-STOKE BREATHING
CYANOSIS
SWELLING OF FEET (PEDAL EDEMA)
RIGHT HYPOCHODRAL PAIN
DECREASED URINE OUTPUT
SYNCOPE
COUGH AND EXPECTORATION
PALPITATION
LESSON 2 – MANAGEMENT OF
CARDIOVASCULAR DISEASE
 LESSON 2 – MANAGEMENT OF
CARDIOVASCULAR DISEASE
CARDIOVASCULAR DISEASES
Cardiovascular diseases are diseases that
involve the heart and blood vessels. In the
Philippines, around 170,000 Filipinos die from
cardiovascular diseases every year making it the
country's greatest cause of mortality.
It is also the leading cause of mortality
worldwide.
 LESSON 2 – MANAGEMENT OF
CARDIOVASCULAR DISEASE
CARDIAC ARRHYTHMIA
• Cardiac arrhythmia or dysrhythmia is a term for any
of a large and heterogeneous group of conditions in
which there is abnormal electrical activity in the
heart.  The heart beat may be too fast or too slow,
and may be regular or irregular.
Oral Manifestations:
• Procainamide - can cause agranulocytosis, oral
ulcerations.
• Quinidine - infrequent oral ulcerations.
• Disopyramide - is anticholinergic agent capable of
producing xerostomia.
• Verapamil & Enalapril - can cause gingival
hyperplasia.
Dental Considerations:
•A proper history to be taken.
•Stress and anxiety be minimized.
•Short appointments
•Use of epinephrine to be minimized.
•Proper chair position is important, SUPINE.
•At end of appointment chair should be raised slowly to minimize orthostatic hypotension.
•Use of vasoconstrictors should be minimized in patients taking digitalis glycosides.
•The equipments like pulp testers, ultrasonic scalers, electrosurgical units, should not be in
close proximity.
•Prophylactic antibiotics before and after treatment in recently placed pacemaker patients.
•Patients who report palpitations or skipped beats must be evaluated by physician.
•Sustained sinus tachycardia above 100 beats/min in resting position is indicative of sinus
tachycardia.
•Dental treatment shd not be carried out in patients with irregular pulse.
•Long use of procainamide can cause a lupus like syndrome.
•Drug like quinidine can cause erythema multiforme.
•CA may be induced by general anesthesia and vagal reflex.
 LESSON 2 – MANAGEMENT
OF CARDIOVASCULAR
DISEASE
CORONARY (ISHAEMIC) ARTERY
DISEASE (CAD)
•Atherosclerosis is the most common cause of CAD.
Dental Management:
•Stress, anxiety, exertion or pain can provoke angina.
•Short, minimally stressful dental appointments.
•Late morning appointments.
•Excessive dose of LA containing adrenaline to be
avoided in patients taking beta blockers.
•More Common - severe dental caries and
periodontal disease in patients of IHD.
LESSON 2 – MANAGEMENT OF
CARDIOVASCULAR DISEASE
ANGINA PECTORIS
•Name given to paroxysms of severe chest pain. It is characterized by
chest pain particularly on exertion, which is relieved by rest and
nitroglycerine medication.

Dental Considerations:
•Preoperative glyceryl trinitrate & oral sedation advised sometimes.
•Dental care carried with minimal anxiety & oxygen saturation
•Monitor pulse & blood pressure
•Post angioplasty elective dental care deferred for 6 months,
emergency dental care in a hospital setting.
•Patients with bypass grafts – anti biotic cover against infective
endocarditis. – local anesthesia containing adrenaline is
contraindicated
•Patients with vascular stents – no antibiotic cover except during 1st 6
week postop for emergency dental care.
•DRUGS used in t/t of angina may cause oral adverse effects.
 LESSON 2 – MANAGEMENT OF
CARDIOVASCULAR DISEASE
MYOCARDIAL INFARCTION
Dental Management:
• Stress reduction protocol.
• Comfortable chair position.
• Pretreatment vital signs.
• Nitroglycerine readily available.
• Limited use of vasoconstrictor.
• Avoid adrenalin impregnated gingival
retraction cord.
• Avoid anticholinergics.
• If coronary artery stent is in place and if it
is more than 24 weeks after placement,
antibiotic prophylaxis is not necessary.
• It is safe to perform procedures under
local anesthesia and sedation whenever
possible since GA may evoke wild
fluctuations in cardiac rhythm that can be
dangerous for the patient with ischemic
heart disease.
• Avoid dental extractions for patients who
had a myocardial infarction or coronary
bypass graft within 6 months.
• Some patients may be on low dose aspirin,
which will cause persistent bleeding from
an extraction wound. In consultation with
patient’s physician it may be stopped 4 to
5 days prior to surgery. If not stopped
strict attention to local hemostasis is
essential to control bleeding.
• Dental surgeon and ancillary staff be
 LESSON 2 – MANAGEMENT OF
CARDIOVASCULAR DISEASE
RHEUMATIC FEVER
•Rheumatic fever is an inflammatory disease that may
develop two to three weeks after a Group A
streptococcal infection. It is believed to be caused by
antibody cross-reactivity and can involve the heart,
joints, skin, and brain. Acute rheumatic fever commonly
appears in children ages 5 through 15, with only 20% of
first time attacks occurring in adults.
Dental Consideration:
•Dental extractions and local anesthesia in consent with
physician.
•The prophylactic use of antibiotics prior to a dental
procedure is now recommended ONLY for those
patients with the highest risk of adverse outcome
resulting from endocarditis.
•GA should be avoided if essential must be given in
hospital.
 LESSON 2 – MANAGEMENT OF
CARDIOVASCULAR DISEASE
RHEUMATIC HEART DISEASE
•History of rheumatic fever during childhood
or adolescence can act as a predisposing
factor for RHD after several years. Its
common sign is murmur due to valvular
damage and later enlargement of heart.
Oral Manifestations:
•Most prominent during acute phase
•Pharyngitis
•Increase oral temperature
•Distended neck veins and a bluish color of
the skin.
Dental Considerations:
•To prevent complication of infective endocarditis, all
dental procedures should be carried under antibiotic
cover.
•Amoxicillin prophylaxis-1 hour before and 6 hours after
the initial dose.
•Good oral hygiene measures, fluoride treatment,
chlorhexidine rinses and routine cleanings to reduce
harmful bacteremias.
•Proper history should be taken to identify history of
rheumatic fever during childhood.
•Suspicious cases should be referred to cardiologist for
cardiac evaluation prior to dental procedures.
•Clindamycin or erythromycin prophylaxis during dental
treatment.
•Elective dental treatment under physician consultation.
 LESSON 2 – MANAGEMENT OF
CARDIOVASCULAR DISEASE
HEART FAILURE
•Heart failure (HF) is a condition in which a
problem with the structure or function of the
heart impairs its ability to supply sufficient
blood flow to meet the body's needs.
Oral Manifestations:
•Distention of the external jugular veins.
•Compensatory polycythemia –ruddy
complexion and bleeding tendencies.
•Abnormal production of clotting factors
•Bleeding can be spontaneous or
extravasational.
Dental Considerations:
• Gingival retraction cords containing
• The dental chair should be kept in partially epinephrine should be avoided
reclining or erect position and patient should
be raised slowly in upright position.
• Supplemental O2 should be available
• Emergency dental care should be
conservative, principally with analgesics and • Rubber dam is contraindicated when it
contributes to breathing difficulty.
antibiotics.
• Appointments should be short • NSAIDS other than aspirin should be avoided
in pts. taking ACE inhibitors.
• Non stressful appointments
• Erythromycin and tetracycline to be avoided
• Patients are best treated in late morning
as they may induce digitalis toxicity
because of epinephrine levels peak in early
morning. • GA is contraindicated in cardiac failure. Until
under control.
• Bupivacaine should be avoided as it is
cardiotoxic. • ACE inhibitors can sometimes cause
erythema multiforme, angioedema or burning
mouth.
• An aspirating syringe should be used to give
local anesthetic
• Antibiotic prophylaxis required for dental
care.
• Epinephrine containing LA should be not
given in large doses to patients taking beta
blockers. • History of recent MI, required delay of
elective dental care for 6 months.
 LESSON 2 – MANAGEMENT OF
CARDIOVASCULAR DISEASE
INFECTIVE ENDOCARDITIS
Infective endocarditis (IE) is caused by microbial infection of heart valves or
endocardium and are most often related to congenital or acquired cardiac defects.
Antibiotic prophylaxis is recommended for all dental procedures that are likely to
cause bleeding. Prophylaxis is designed against alpha-hemolytic streptococci.
These organisms are by far the most common ones found in transient dental
bacteremia.
Patients with the highest risk of infective endocarditis includes three categories:
1.Patients with a prosthetic valve or a prosthetic material used for
cardiac valve repair: these patients have a higher risk of IE, a higher
mortality from IE and more often develop complications of the
disease than patients with native valves and an identical pathogen
2.Patients with previous IE: they also have a greater risk of new IE,
higher mortality and incidence of complications than patients with a
first episode of IE.
3.Patients with congenital heart disease (CHD), in particular those
with complex cyanotic heart disease and those who have post-
operative palliative shunts, conduits, or other prostheses.
 Lesson 1- Pathogenesis, Risk

M5E – factors, Symptoms and

Classification of Hypertension

HYPERTENSION Lesson 2 – Management and

Diagnostic Tests for Hypertension
 LESSON 1- PATHOGENESIS, RISK
FACTORS, SYMPTOMS AND
CLASSIFICATION OF HYPERTENSION
Blood pressure is the force exerted by
circulating blood against the walls of the body’s
arteries, the major blood vessels in the body.
Hypertension is when blood pressure is too high.

Blood pressure is written as two numbers. The

first (systolic) number represents the pressure in
blood vessels when the heart contracts or beats.
The second (diastolic) number represents the
pressure in the vessels when the heart rests
between beats.
 LESSON 1- PATHOGENESIS, RISK
FACTORS, SYMPTOMS AND
CLASSIFICATION OF HYPERTENSION
Pathogenesis of Essential Hypertension  Risk factors for hypertension
Modifiable risk factors include unhealthy diets (excessive salt
There are at least 50 known factors which increase consumption, a diet high in saturated fat and trans fats, low intake of
blood pressure, among which the most important fruits and vegetables), physical inactivity, consumption of tobacco
are: and alcohol, and being overweight or obese.
Non-modifiable risk factors include a family history of
1.Age (over 55 years for men, over 65 years for hypertension, age over 65 years and co-existing diseases such as
women) diabetes or kidney disease.

2.A family history of premature cardiovascular

disease Symptoms of Hypertension
When symptoms do occur, they can include early morning
3.Smoking headaches, nosebleeds, irregular heart rhythms, vision changes, and
buzzing in the ears. Severe hypertension can cause fatigue, nausea,
4.Increased consumption of alcohol vomiting, confusion, anxiety, chest pain, and muscle tremors.
5.Sedentariness The only way to detect hypertension is to have a health professional
measure blood pressure. Having blood pressure measured is quick
6.Cholesterol rich diet; and painless. Individuals can also measure their own blood pressure
using automated devices, however, an evaluation by a health
7.Coexistence of other diseases (diabetes, obesity, professional is important for assessment of risk and associated
dyslipidemia) conditions.
 LESSON 1- PATHOGENESIS, RISK
FACTORS, SYMPTOMS AND
CLASSIFICATION OF HYPERTENSION
Classification of hypertension according to the JNC7 and JNC8

Stages of hypertension Range for systolic and diastolic blood pressure

Normal blood pressure Systolic <120 mmHg and diastolic <80 mmHg

Prehypertension Systolic 120–139 mmHg or diastolic 80–89 mmHg

Stage 1 hypertension Systolic 140–159 mmHg or diastolic 90–99 mmHg

Stage 2 hypertension Systolic ≥160 mmHg or diastolic ≥100 mmHg

Severe hypertension (diastolic pressure usually >120

Hypertensive urgency
mmHg); no end-organ damage
Severe hypertension (diastolic pressure usually >120
Hypertensive emergency
mmHg); end-organ damage
Elevated blood pressure secondary to fear and
“White coat” hypertension
anxiety from a health care provider
 LESSON 2 –
MANAGEMENT AND
DIAGNOSTIC TESTS FOR
HYPERTENSION
 LESSON 2 – MANAGEMENT AND
DIAGNOSTIC TESTS FOR
HYPERTENSION
NORMAL/ PREHYPERTENSION
No contraindications to elective dental treatment.
 STAGE 1 HTN        
Systolic 140 - 159 or Diastolic 90 - 99
1.Retake and confirm blood pressure.
2.Proceed with elective dental treatment.
3.Monitor BP during appointment.
 STAGE 2 HTN
Systolic 160 or higher or Diastolic 100 or higher
1.Retake and confirm blood pressure.
2.Emergency or non- invasive elective treatment only
3.Monitor BP during appointment.
4.Refer patient to physician for medical evaluation.
5.Medical consult required prior to elective dental treatment.
URGENT
•A blood pressure measurement of 180/110 mmHg is the absolute
cutoff for any dental treatment.
•Studies have shown that there is no increased risk for adverse
perioperative outcomes for patients undergoing treatment with a
blood pressure <180/110mmHg
•For patients who have histories that include previous
hypertensive-related organ damage, (myocardial infarctions,
strokes, or labile angina) this number may be too high to undergo
treatment, even on an emergent basis.
 EMERGENT
Systolic >210 or Diastolic >120
1.Retake and confirm blood pressure with alternate device
2.If blood pressure is unchanged, consider immediate referral of
the patient to a physician or emergency room for evaluation.
3.No treatment of any type
4.Medical consult required prior to any dental treatment.
 LESSON 2 – MANAGEMENT AND
DIAGNOSTIC TESTS FOR
HYPERTENSION
Management of hypertension can be broadly
classified into two categories:
1.Nondrug measures: This include weight reduction, decrease in
salt intake, stopping smoking, stress reduction and stopping oral
contraceptives.
2.Medication: Once commenced, drug therapy is continued for
life. The following broad categories of medication may be used,
sometimes in combination depending on patient’s response:
a. Diuretics—for fluid overload, e.g. chlorothiazide
b. Beta Blockers—to dampen the sympathetic input that
increases the activity of the heart, e.g. propranolol (Inderal)
c. Vasodilators—to decrease peripheral vascular resistance, e.g.
hydralazine.
d. Centrally acting—drugs that compete with neurotransmitter
chemicals of sympathetic nervous system responsible for
increased heart activity, thereby sympathetic mediated increased
heart activity, e.g. methyl dopa (Aldomet)
Precautions to be taken in Hypertensive
Patients
1.Minimize stress levels
2.Avoid adrenaline containing local anesthetic solutions since
adrenalin is a cardiac stimulant, resulting in an untoward increase in
blood pressure or development of an arrhythmia. However this may
have little bearing on well controlled hypertensive patients.
3.Safer to perform procedures under local anesthesia whenever
possible since general anesthesia may evoke wild fluctuations in
blood pressure that can be dangerous. When general anesthesia is
planned inform the anesthetist, who may request further
investigations.
4.Provide gradual changes of position to prevent
postural hypotension
5.Avoid stimulating gag reflex.
6.Dismiss the patient if stress appears excessive.
7.Primary and reactive hemorrhage from the surgical site can be a
problem where there is uncontrolled hypertension.
 Lesson 1- Stages of Pregnancy

M5F – PREGNANT Lesson 2 – Common medical problems and oral

manifestations associated with pregnancy

PATIENT Lesson 3 – Risk factors in Drug Administration

during pregnancy

Lesson 4 – Dental Management Guidelines

 LESSON 1- STAGES OF
PREGNANCY
Changes during pregnancy
1.endocrine changes: causes the most systemic alterations,
there is an increase in production of maternal and placental
hormones
2.neurologic findings:
1st trimester: fatigue, hyperemesis (nausea and vomiting)
syncope and postural hypotension
3rd trimester: increasing fatigue, mild depression
3.cardiovascular changes: slight increase in blood pressure
> blood volume increases approx. 45-50%
> cardiac output increases 20-30%
> tachycardia and heart murmurs
> dyspnea at rest aggravated by a supine position
LESSON 2 – COMMON MEDICAL
PROBLEMS AND ORAL
MANIFESTATIONS ASSOCIATED
WITH PREGNANCY
 LESSON 2 – COMMON MEDICAL
PROBLEMS AND ORAL
MANIFESTATIONS ASSOCIATED WITH
PREGNANCY
COMMON MEDICAL PROBLEMS
DURING PREGNANCY
•Anemia
• fatigue, breathlessness, fainting, palpitations
•pale skin
• Back pain
• Constipation
• Edema
• Eclampsia
• Heartburn
•Hemorrhoids
• Morning sickness
• Sleeping problems
• Varicose veins
 LESSON 2 – COMMON MEDICAL
PROBLEMS AND ORAL
MANIFESTATIONS ASSOCIATED WITH
PREGNANCY
COMMON ORAL MANIFESTATIONS DURING
PREGNANCY
Pregnancy gingivitis and pyogenic granuloma start
around the 2nd month and continues until after parturition
and regresses.
Halitosis and enamel erosion are not uncommon, due to
hypersensitive gag reflex and acid regurgitation from the
stomach
Risk Assessment
During the first trimester the only safe course of action is
to protect the patient as far as possible from infections
and to avoid the use of radiography and drugs,
particularly general anesthetics
In the second and third trimesters the fetus is growing
and maturing but can still be affected by infections, drugs
such as tetracyclines, and possibly other factors
LESSON 3 – RISK FACTORS IN
DRUG ADMINISTRATION
DURING PREGNANCY
LESSON 3 – RISK FACTORS IN DRUG
ADMINISTRATION DURING
PREGNANCY
Drug use
•Drugs may be teratogenic and should be avoided.
• Penicillin is the drug of choice to treat oral infections
• Aspirin and other NSAIDs - cause closure of the ductus arteriosus in utero,
and fetal pulmonary hypertension, as well as delaying or prolonging labor
• Aspirin and other NSAIDs- cause a platelet defect and are best avoided
throughout pregnancy
• Use of analgesics should be minimized during the 1st trimester; if
necessary, paracetamol/acetaminophen is recommended
•Dental treatment, if required, is best carried out during the second
trimester; advanced restorative procedures are probably best postponed
until the periodontal state improves after parturition and prolonged
sessions of treatment are better tolerated
• In the third trimester the supine hypotension syndrome may result if the
patient is laid flat – if this occurs, the patient should be placed on one side
to allow venous return to recover
• In the last month of pregnancy, elective dental care is best avoided as it is
uncomfortable for the patient. Moreover, premature labor or even abortion
may also be ascribed, without justification, to dental treatment.
 LESSON 4 – DENTAL
MANAGEMENT GUIDELINES
 LESSON 4 – DENTAL
MANAGEMENT GUIDELINES
Local anesthetics Dental Management Guidelines
• Anxiety reduction.
• LA with adrenaline are relatively safe with required amount even
though they cross the placental barrier. Lidocaine and prilocaine are • Detailed medical history and consultation with pt’s obstetrician and physician
safer than bupivacaine which causes fetal bradycardia
• Monitoring vital signs.
Radiographs
• Left lateral positioning of the patient to prevent supine hypotensive syndrome during
• Exposing the patient to radiation should be avoided during pregnancy 3rd trimester
because of the stochastic effects especially during the 1st • Preventive program to develop healthy oral environment
• Under unavoidable circumstances exposing pt to dental radiographs • Elimination of periodontal irritants
is considered safe provided precautionary measures in minimizing
radiation are established. (use of lead aprons, F speed films)
 Lesson 1- HIV

M5G – HIV Lesson 2 – Clinical stages of

HIV
 LESSON 1- HIV
•HIV infects cells in the immune system and the central nervous system
•One of the main type of cells that HIV infects is the T helper
lymphocyte
• These cells play a crucial role in the immune system, by coordinating the actions
of other immune system cells
• A large reduction in the number of T helper cells seriously weakens the immune
system

•HIV infects the T helper cell because it has the protein CD4 on its
surface, which HIV uses to attach itself to the cell before gaining entry
•This is why the T helper cell is sometimes referred to as a CD4+
lymphocyte. Once it has found its way into a cell, HIV produces new
copies of itself, which can then go on to infect other cells
•Over time, HIV infection leads to a severe reduction in the number of T
helper cells available to help fight disease. The number of T helper cells
is measured by having a CD4 test and is referred to as the CD4 count
•It can take several years before the CD4 count declines to the point that
an individual is said to have progressed to AIDS
•HIV infection can generally be broken down into four distinct stages:
primary infection, clinically asymptomatic stage, symptomatic HIV
infection, and progression from HIV to AIDS
 LESSON 1- HIV
•STAGE 1 : Primary HIV infection
• This stage of infection lasts for a few weeks
and is often accompanied by a short flu-like
illness
• In up to about 20% of people the HIV
symptoms are serious enough to consult a
doctor, but the diagnosis of HIV infection is
frequently missed
• During this stage there is a large amount of
HIV in the peripheral blood and the immune
system begins to respond to the virus by
producing HIV antibodies and cytotoxic
lymphocytes
• This process is known as seroconversion
• If an HIV antibody test is done before
seroconversion is complete then it may not be
positive
 LESSON 1- HIV
•STAGE 2 : Clinically asymptomatic stage
• This stage lasts for an average of ten years
and, as its name suggests, is free from major
symptoms, although there may be swollen
glands
• The level of HIV in the peripheral blood
drops to very low levels but people remain
infectious and HIV antibodies are detectable
in the blood, so antibody tests will show a
positive result
• Research has shown that HIV is not dormant
during this stage, but is very active in the
lymph nodes
• A test is available to measure the small
amount of HIV that escapes the lymph nodes
• This test which measures HIV RNA (HIV genetic
material) is referred to as the viral load test, and it
has an important role in the treatment of HIV
infection
 LESSON 1- HIV
•STAGE 3 : Symptomatic HIV infection
• Over time the immune system becomes severely damaged by
HIV
• This is thought to happen for three main reasons:
• The lymph nodes and tissues become damaged or 'burnt out' because of the
years of activity;
• HIV mutates and becomes more pathogenic, in other words stronger and more
varied, leading to more T helper cell destruction;
• The body fails to keep up with replacing the T helper cells that are lost
• As the immune system fails, symptoms develop. Initially many
of the symptoms are mild, but as the immune system deteriorates
the symptoms worsen
• Symptomatic HIV infection is mainly caused by the emergence
of certain opportunistic infections that the immune system
would normally prevent
• This stage of HIV infection is often characterized by multi-
system disease and infections can occur in almost all body
systems
• Treatment for the specific infection is often carried out, but the
underlying cause is the action of HIV as it erodes the immune
system
• Unless HIV itself can be slowed down the symptoms of immune
suppression will continue to worsen
 LESSON 1- HIV
•STAGE 4 : Progression from HIV to AIDS as the
immune system becomes more and more damaged the
individual may develop increasingly severe
opportunistic infections and cancers, leading eventually
to an AIDS diagnosis
•A clinical criteria is used by WHO to diagnose the
progression to AIDS, this differs slightly between adults
and children under five
•In adults and children (5+) the progression to AIDS is
diagnosed when any condition listed in clinical stage 3
or stage 4 is diagnosed and/or the CD4 count is less that
350 cells/mm3
•In children younger than five, an AIDS diagnosis is
based on having any stage 3 or stage 4 condition and/or
a CD4 count of less than between 20 cells/mm3and 30
cells/mm3 depending on the child's age in months
LESSON 2 – CLINICAL
STAGES OF HIV
 LESSON 2 – CLINICAL
STAGES OF HIV
•Clinical Stage I: •Clinical Stage III:
• Asymptomatic • Unexplained* severe weight loss (over 10% of
presumed or measured body weight)**
• Persistent generalized lymphadenopathy
• Unexplained* chronic diarrhea for longer than one
month
•Clinical Stage II:
• Unexplained* persistent fever (intermittent or
• Moderate unexplained* weight loss (under constant for longer than one month)
10% of presumed or measured body weight)**
• Persistent oral candidiasis
• Recurrent respiratory tract infections (sinusitis, • Oral hairy leukoplakia
tonsillitis, otitis media, pharyngitis)
• Pulmonary tuberculosis
• Herpes zoster • Severe bacterial infections (e.g. pneumonia,
• Angular chelitis empyema, pyomyositis, bone or joint infection,
• Recurrent oral ulceration meningitis, bacteremia)
• Acute necrotizing ulcerative stomatitis, gingivitis or
• Papular pruritic eruptions periodontitis
• Seborrhoeic dermatitis • Unexplained* anemia (below 8 g/dl), neutropenia
• Fungal nail infections (below 0.5 billion/l) and/or chronic thrombocytopenia
(below 50 billion/l)
 LESSON 2 – CLINICAL
STAGES OF HIV
•Clinical Stage IV:
• HIV wasting syndrome
• Pneumocystis pneumonia
• Recurrent severe bacterial pneumonia
• Chronic herpes simplex infection (orolabial,
genital or anorectal of more than one month’s
duration or visceral at any site)
• Esophageal candidiasis (or candidiasis of
trachea, bronchi or lungs)
• Extrapulmonary tuberculosis
• Kaposi sarcoma
• Cytomegalovirus infection (retinitis or infection
of other organs)
• Central nervous system toxoplasmosis
• HIV encephalopathy
• Extrapulmonary cryptococcosis including
meningitis
• Disseminated non-tuberculous mycobacteria
infection
• Progressive multifocal leukoencephalopathy
• Chronic cryptosporidiosis
• Chronic isosporiasis
• Disseminated mycosis (extrapulmonary
histoplasmosis, coccidiomycosis)
• Recurrent septicemia (including non-typhoidal
Salmonella)
• Lymphoma (cerebral or B cell non-Hodgkin
• Invasive cervical carcinoma
• Atypical disseminated leishmaniasis
• Symptomatic HIV-associated nephropathy or
HIV-associated cardiomyopathy
 LESSON 2 – CLINICAL
STAGES OF HIV
Enzyme-linked immunosorbent assay (ELISA) is a
labeled immunoassay that is considered the gold standard
of immunoassays. This immunological test is very
sensitive and is used to detect and quantify substances,
including antibodies, antigens, proteins, glycoproteins,
and hormones.
An antibody is a type of protein produced by an
individual’s immune system. This protein type has specific
regions that bind to antigens. An antigen is a protein that
can come from some foreign source and, when bound to
an antibody, induces a cascade of events through the
body’s immune system.
This interaction is utilized in ELISA testing and allows
for identifying specific protein antibodies and antigens,
with only small amounts of a test sample. ELISA testing is
used to diagnose HIV infection, pregnancy tests, and
blood typing, among others.
 LESSON 2 – CLINICAL
STAGES OF HIV
The Western blot assay is a method in which individual proteins
of an HIV-1 lysate are separated according to size by
polyacrylamide gel electrophoresis. The viral proteins are then
transferred onto nitrocellulose paper and reacted with the patient's
serum. Any HIV antibody from the patient's serum is detected by
an antihuman immunoglobulin G (IgG) antibody conjugated with
an enzyme that in the presence of substrate will produce a colored
band. Positive and negative control serum specimens are run
simultaneously to allow identification of viral proteins.
The HIV-1 Western blot (WB), the historic gold standard for
laboratory diagnosis of HIV-1 infection, is no longer part of the
recommended algorithm. The two main reasons for this are the
inability of the WB to detect acute infection and the potential to
misclassify HIV-2 infection as an HIV-1 infection
 Lesson 1- Oral Cancers, clinical features and etiology

M5H – CANCER
Lesson 2 – Diagnosis and Treatment Modalities for
Oral Cancers

Lesson 3 - TNM Staging

Lesson 4 - Surgery, Chemotherapy, Radiotherapy and

their effects to Oral Health
 LESSON 1- ORAL CANCERS, CLINICAL
FEATURES AND ETIOLOGY
Squamous Cell Carcinoma (SCCA)is the most frequent malignant neoplasm Pathogenesis:
affecting structures of the oral lining
• Accounts for more than 90% of all malignant lesions in the mouth
• More frequent in male, 5th decade of life Normal Histologic Appearance of Oral mucosa
Clinical Presentation:
Early SCCA often presents as a white patch(leukoplakia), red patch(erythroplakia)
or a mixed white and red patch.
• Ulceration of the mucosal surface
• Exophytic (verrucous or papillary)
• Enlargement of lymph node

Etiologic Agent/ Risk Factors

• Tobacco smoking/chewing
• Alcohol
• Betel nut chewing
• Dietary factors
• Microorganisms, HPV,
• UV light
• Chronic Irritation/ poor oral hygiene
• Genetic susceptibility

Common sites of lesion:

• Tongue- 25- 40% of oral cancer
• Floor of the mouth- 15-20% Histopathologic appearance of oral mucosa
• SCCA of gingiva/buccal mucosa- approx. 15%
• Lip, (Vermillion border)- 25-30%
• Palate 10-20%
 LESSON 1- ORAL CANCERS,
CLINICAL FEATURES AND
ETIOLOGY
Gingival SCCA Histologic Subtypes of SCCA

• Frequently involves mandible than maxilla
• Mainly observed in female than male older than 50yrs
old.
• Gingival SCCA does not show a strong association
with classical risk factors (tobacco use, alcohol)
Normal Histologic appearance of the oral
mucosa:
Classification of SCCA (based on degree of differentiation of the neoplastic
proliferating cells)
Grade 1- Well differentiated- cells are generally large and show distinct cell
membrane, individual cell keratinization, keratin pearls of varying size
Grade 2- moderately differentiated- tumor cells less differentiated, have less
resemblance to squamous cell epithelium
Grade 3- poorly differentiated- proliferation of anaplastic cells, highly
invasive with poor prognosis, high mitotic figures

Other Variants of SCCA

Verrucous Carcinoma- usually found in buccal mucosa or vestibule, slow

growing, well differentiated, growth pattern is more expansile than invasive

Spindle Cell- arises from surface epithelium, usually of the lips, appears as a
proliferation of spindle cells that may be mistaken as sarcoma

Papillary Squamous Cell Ca- resembles verrucous Ca but is less

differentiated and has poorer prognosis

Basaloid Squamous Ca- has predilection to tongue and pharynx

LESSON 2 – DIAGNOSIS
AND TREATMENT
MODALITIES FOR ORAL
CANCERS
 LESSON 1- ORAL CANCERS,
CLINICAL FEATURES AND
Diagnosis
ETIOLOGY
Routine practice:
Brush biopsy
Tissue biopsy
Imaging modalities
LESSON 3 - TNM STAGING
 LESSON 3 - TNM STAGING
Metastasis
•Most frequently develop in the ipsilateral
cervical lymph nodes
•Tumors from the lower lip and floor of the
mouth may initially involve submental nodes
•Involved nodes are usually enlarged, firm and
nontender to palpation
 LESSON 4 - SURGERY,
CHEMOTHERAPY,
RADIOTHERAPY AND
THEIR EFFECTS TO ORAL
 LESSON 4 - SURGERY,
CHEMOTHERAPY,
RADIOTHERAPY AND THEIR
Management EFFECTS TO ORAL HEALTH
Prognosis and Survival Rate
There are 3 recognized treatment modalities for managing head and
neck cancers: Tongue Ca, if localized(no lymph node
 >Surgery involvement), 5-yr survival is >50%.
 >Chemotherapy
 >Radiotherapy Localized Ca of floor of the mouth, survival is
Stage I and Stage II cancers can be managed either by surgery or
>65%.
radiotherapy
Lymph Node metastasis decreases survival rate by
Stage III and IV cancers are managed using combination of about 50%.
radiation therapy and surgery
Surgical Management Lower lip lesions, 5 yr survival rate is 90%.
Surgical treatment aims at complete removal of the primary lesion If surgery is not done immediately after diagnosis,
as well as the metastatic nodes. survival rate of 5 yrs decrease to months to 1 yr.
The extent of resection of lesion depends upon the size and the
adjacent structures that may have been infiltrated. Chemotherapy
> Neck Dissection (Cervical lymphadenectomy). Cytotoxic chemotherapy drugs act mainly by
> Commando surgery - Combined mandibular and neck dissection interaction with the cancer cell DNA or RNA, to
operation inhibit cell division and/or protein synthesis.
 LESSON 4 - SURGERY,
CHEMOTHERAPY,
RADIOTHERAPY AND THEIR
EFFECTS TO ORAL HEALTH
Chemotherapeutic drugs can:
 impair mitosis, or prevent cell division, as in the case of cytotoxic drugs
 target the cancer cells' food source, which consists of the enzymes and
hormones they need to grow
 trigger the suicide of cancer cells, known medically as apoptosis
 stop the growth of new blood vessels that supply a tumor in order to
starve it

Complications/Side Effects
 alopecia
 bone marrow suppression (risk to infection and bleeding tendencies)
 mucositis
 nausea and vomiting
 reproductive function suppression

Common Oral Findings During and After Chemotherapy

 mucositis
 infections
 bleeding
 xerostomia
 craniofacial maldevelopment.
 LESSON 4 - SURGERY,
CHEMOTHERAPY,
RADIOTHERAPY AND THEIR
EFFECTS TO ORAL
Risk assessment HEALTH
Radiotherapy
• Dental screening should be undertaken prior to  • Radiotherapy is the treatment of disease with ionizing
commencement of chemotherapy and the patient’s oral radiation
health stabilized.  • Radiation dose or exposure is measured in units of
• During chemotherapy, only emergency dental treatment absorbed radiation per unit of tissue.
should be performed  • The Gray (Gy) represents 1J/kg of tissue
 • External beam radiotherapy (RTP or DXR) is often used
Dental Management: Treatment modifications
to treat head and neck, and oral cancer.
• Dental treatment preferably should be carried out in the
day(s) before starting a new cytotoxic treatment cycle  • EBRT is now commonly delivered via a medical linear
accelerator or Cobalt-60 unit. These units deposit the
Preventive Dentistry maximum dose beneath the surface, therefore reducing
the dose to the skin
• Strict attention to oral hygiene before, during and after
chemo  • All patients undergoing head and neck irradiation are
immobilized with a neck rest and mask immobilization or
• Caries prevention, dietary control, sealant and Fl with bite block devices.
application
 LESSON 4 - SURGERY,
CHEMOTHERAPY,
RADIOTHERAPY AND THEIR
EFFECTS TO ORAL HEALTH
Oral Findings
Complications of RT often involves the
salivary glands and the mouth
•radiation induced mucositis
•xerostomia
•radiation caries
•infections
•loss of taste
•ORN
•craniofacial defects
•trismus
LESSON 4 - SURGERY, CHEMOTHERAPY, RADIOTHERAPY
AND THEIR EFFECTS TO ORAL HEALTH

Treatment Modifications
1.Prior to RT
• Teeth with poor prognosis should be removed PRIOR to RT.
• An interval of at least 10 days to 2 weeks between extracting the teeth and starting RT is ideal
• No bone should be left exposed in the mouth when RT begins since, once the blood supply is damaged by RT, wound healing is jeopardized.
• Meticulous oral hygiene should be implemented and preventive oral health care instituted

•2. On-Going RT
• During RT, mucosal and salivary gland protection is critical
• amifostine can minimize mucositis and xerostomia
• chlorhexidine mouthwash, 0.2%, helps maintain oral hygiene
• antifungal drugs such as nystatin suspension q4

• 3. Post RT
• If extractions become unavoidable:
• trauma should be kept to a minimum, sharp bone edges removed, and suture carefully
• prophylactic antibiotics from 24–48 hours preop are indicated and continued for at least 4 weeks; clindamycin 300mg q6h is an appropriate antibiotic since it
penetrates bone well
• HBO may be indicated.
• oral hygiene and preventive dental care should be continued
• radiation caries and dental hypersensitivity can be controlled with a non-cariogenic diet, and daily topical fluoride applications (sodium fluoride mouthwash,
stannous fluoride gel or acidulated fluoride phosphate gel)
• salivary substitutes and sialagogues are usually required.