Medical Diseases
Leading cause of death in the U.S.Includes diseases of the heart and blood vessels.
Disease ClassificationAnatomic System
Diseases of pericardium, myocardium, endocardium, heart valves and blood vessels
Etiologic System Diseases by causitive agent includes
infectious agents, atherosclerosis, hypertension, immunologic mehanisms and congenital anomalies
Congenital Heart DiseaseEmbryonic defects
that occur during 1st nine weeks
Accurate patient history to determine nature of lesion and degree of disability
Medical consultMay require premed
Rheumatic Heart DiseaseComplications following rheumatic fever
- affects connective tissue especially heart, its valves and the joints of body
Valves become chronically inflamedPatient may need premedAlways consult physician to verify
necessity of premedication if patient unsure
Infective EndocarditisBacterial invasion of heart valve or
endocardium that occurs in proximity to congenital or acquired defects
Bacteria usually Streptococcus viridans that enters during dental treatment and settles on valve previously damaged
Causes bacteremia-prognosis depends on degree of cardiac damage,valves involved
Prevention of Infective Endocarditis
Antibiotic premedication
Accurate medical history
Patient following approved prophylaxis regimen of antibiotic
HypertensionResults from increased load on the
heart because of high blood pressure
Can lead to enlarged heart, then heart failure
Elevation of blood pressure is symptom of hypertension
HYPERTENSIONPRIMARY
(ESSENTIAL) Hypertension: Etiologic factors unknown-could be diet, obesity, smoking,etc.
90% of people have this type
SECONDARY Hypertension: Specific causes can be identified- increased blood pressure is secondary to major disease - kidney disease,diabetes
10% of people have this type
Ischemic Heart DiseaseCoronary Heart DiseaseCaused by reduction or arrest of
blood supply- usually because of atherosclerosis of the vessel walls
Angina pectoris, myocardial infarction, congestive heart failure
Angina PectorisCoronary arteries unable to supply
sufficient blood to myocardiumResult is pain in chest, mild to severe
crushing pain which radiates from heart to left arm
Unstable angina -increased intensity of attacks,serious sign of impending myocardial infarction
Patients should carry own nitroglycerin
Myocardial InfarctionHeart attack, coronary occlusion, coronary
thrombosisResults from sudden reduction of coronary
blood flowArea affected by zero blood flow is said to
be infarctedNeed to know severity,residual damage,
and time elapsed since attackDental treatment cancelled 6 months
Congestive Heart FailureOccurs when ventricles fail to maintain an
adequate output of blood for the needs of the body
Assess degree of heart failure with help of medical consult and patient information
Patient may not be able to breath if lowered too far back
Administration of O2 may be necessary for dental treatment
Cardiovascular Conditions Contraindicate TreatmentACUTE conditions of
Angina pectoris
Congestive heart failure
Extreme hypertension
Prevention of Infective EndocarditisIdentify high risk patientsProphylactic antibiotic coverage for
appointmentsWorking with patient to improve and
maintain high level of oral health to diminish frequency or severity of bacteremia
Bacteremia lasts only 15 minutes after prophy
Oral Tissue Characteristics Patient health history may not reveal
blood disorders
Oral manifestations of blood disorders are usually exaggerated when there is plaque and local irritating factors
Oral Findings of Blood DisorderGingival bleeding or
history of difficulty in controlling bleeding
Bruises easilyNumerous petechiaeMarked pallor of
mucous membranesAtrophy of tongue
papillae
Acute or chronic infections in mouth that do not respond to treatment
Severe ulcerations gingival that do not respond to treatment
Exaggerated gingival response to local irritants with characteristics of NUG
Normal Blood Composition
55% plasma fluid
45% formed element
Three types of formed elements Erythrocytes - RBC
Leukocytes - WBC
Thrombocytes - Platelets
Functions of Blood CellsRBC’s: sensitive,flexible and change shape
readily; contain hemoglobin- carries O2 to cells
WBC’s: motile so pass into connective tissue; work in CT - phagocytic and immunologic - respond to invasion of microorganisms
Platelets: 1/4 size of RBC’s, active in blood clotting mechanisms, capillary repair
AnemiaReduction of hemoglobin concentration-
which carries O2, hematocrit (fraction of blood occupied by RBC’s)
Causes of anemia - Blood loss:iron deficiency anemia Increased hemolysis(destruction of RBC’s): sickle
cell anemia Diminished production of RBC’s:
nutritional iron deficiency aplastic anemia-bone marrow failure
Characteristics of AnemiaPale and thin skinWeakness,
malaise, easily fatigued
Dyspnea on slight exertion, faintness
Headache, vertigo, tinnitus
Dimness of vision, spots before eyes
Brittle nails with loss of convexity
Treatment ConsiderationsDecreased ability of blood to carry
oxygen throughout body
Fainting may occur more easily
IV sedation must have supplemental O2
Treatment Sickle Cell Hereditary hemolytic
form Occurs primarily in
blacks and mediterranean origin
Concerned with SC crisis-acute stage
Do not treat if in this stage
Treatment Sickle CellPremed if not completely controlledCrisis seen in periods of unusual stress
or when patient does not receive adequate oxygen supply
When SC not controlled patient susceptible to infection
Perio disease may be present even in children
PolycythemiaAn increase in number and
concentrations of RBC’s above normal level
Relative polycythemia- loss of plasma without loss of RBC’s so concentration of RBC’s increased caused by dehydration,diarrhea,repeated
vomiting,sweating or fluid loss from burns
PolycythemiaPrimary polycythemia - actual increase in
number of circulating RBC’s and platelets viscosity of blood increased,which
affects oxygen transport to tissues results from bone disorder
Secondary polycythemia - increase number of RBC’s
causes are hypoxia(high altitudes and diseases or tumors
LeukopeniaDecrease in number of WBC’sResults when cell production can’t keep
pace with the turnover rate or when accelerated rate of removal occurs ( in certain diseases)
Causes are typhoid fever, influenza,malaria, measles, German measles,chronic drug poisoning and radiation
LeukocytosisIncrease in number of circulating WBC’sMay be caused by inflammatory and
infectious states, trauma,exerciseMost extreme cause is Leukemia
Malignant proliferation of WBC’s in bone marrow -results numerous immature WBC’s
Oral complications, more severe tissue response Need shorter appts, good preventive care,
possibly premed
Hemorrhagic DisordersDiseases that have
tendency spontaneous bleeding and/or moderate to excessive bleeding after trauma or surgical procedure
Types due to: abnormalities of
blood capillaries
platelet dysfunction or deficiency
blood clotting defects
Blood Capillary Disorder
Vascular fragility increased which leads to petechial hemorrhages in skin or mucous membranes, includes gingiva
May be caused by severe infections such as typhoid, drug reaction, scurvy
Platelet Deficiency and DysfunctionThrombocytopenia
Lowered number of platelets due to decreased production in bone marrow
Leukemia or vitamin B12 deficiency
Platelet Dysfunction
Interferes with clotting mechanism and leads to prolonged bleeding time
aspirin contraindicated
Blood Clotting Defect
Possible irregularity or disorder is associated with each of the many clotting factors
Examples include Vitamin K deficiency, liver disease, hereditary disorders - Hemophilia A and B
Characteristics of HemophiliaCongenital disorders of the blood
clotting mechanismSeverity variesHemophilia A and B inherited by malesAcceptable minimal surgical level of
the clotting factor is 30% - includes subgingival scaling
Treatment of HemophiliaMust consult patient’s hematologist - they
may need clotting factor replacement therapy before and after appointment
Susceptible to infection-may need premed
Avoid nerve blocks since positive aspiration of blood is great - hematoma
Prosthetic Joint ReplacementReplacement of hips, knees, and
elbows with prosthetic devices is becoming common
Common practice to premedicate to prevent bacteremia
Consultation with orthopedic surgeon essential before proceeding with appt
Pulmonary DiseasesAbnormal condition of the
respiratory system, characterized by cough, chest pain, shortness of breath, sputum production, wheezing
Diseases are Obstructive or Restrictive
ObstructiveResult of an obstacle in airway that
impedes the flow of air, especially during expiration
May be caused by bronchospasms, edema, loss of lung elasticity or thick bronchial secretions
Asthma, bronchitis, emphysemaAsthmatics frequently allergic to aspirin
RestrictiveCaused by conditions that limit lung
expansion by an actual reduction of the volume of inspired air
Increased work to breath and an inefficient exchange of gases
Examples include pulmonary fibrosis or chest deformities
Treatment Considerations for Pulmonary DiseasesSupplemental
oxygen may be necessary
Chair position may be important - allow patient to feel comfortable about breathing
Not suitable for nitrous oxide usage
Asthmatics should have their own medications chairside
Diabetes Mellitus
Genetically heterogenous group of disorders that are characterized by glucose intolerance
Three types of diabetic syndromes:
Type I - Insulin Dependent
Type II - Noninsulin-dependent
Type III - Gestational
Diabetes Type IInsulin dependent
Patient has natural insulin deficiencyPatient depends on insulin for
survivalUsually begins in childhoodAbrupt onset of symptoms
Diabetes Type IINoninsulin dependent
May or may not use insulin for symptom control but do not need it for survival
Slow progression of diseaseTypically begins after 35 - 40 years of
ageObese type - weight control and diet
Diabetes Type IIIGestational
Begins or is noticed during pregnancyAbove average risk of perinatal
complicationsGlucose intolerance may not last past
pregnancy
Function of InsulinHormoneFacilitates conversion of glucose to fat in
adipose tissueSpeeds the conversion of glucose to
glycogen in the liver and musclesFacilitates the transmission of glucose into
cellsSpeeds the oxidation of glucose within the
cells for energy
Effects of Decreased Insulin In diabetes, insulin is decreased in amount
or functionLess glucose is transmitted through cell
walls into the cellsGlucose increases in the circulating blood
until a threshold is reached when glucose spills over into urine
Without glucose in the cells to use for energy, the cells utilize fats
When cells utilize fats….
End products of fat metabolism (ketones) accumulate in the blood
Acidosis results
Acidosis can result in diabetic coma
Insulin ComplicationsInsulin reaction -
hypoglycemia
lowered blood glucose with excess insulin proportion
sudden onset
Diabetic coma - ketoacidosis
Too little insulin with excess ketones in blood
gradual onset
Uncontrolled DiabetesPatient has symptoms known as
Classic TriadExcess urine - polyuria
Excessive thirst - polydipsia
Increased appetite - polyphagia
Uncontrolled Diabetes - Other SymptomsDehydration from fluid lossGeneral weakness,drowsiness,fatigueweight loss from inability to utilize foodselevated blood glucoseglucose in urineslow wound healing, persistent infectionspain and/or numbness in fingers or toeschanges in vision
Infection and DiabetesMore susceptible to infectionFailure to treat an infection increases
severity of diabetic state and intensifies the symptoms
With infection present, insulin requirements increase, infection heals,insulin lowered
Frequently seen infections-urinary tract infections, skin, lungs and oral cavity
DiabetesDiet therapy- eliminate concentrated
carbohydratesAppointment therapy: stress reduction critical- watch stress
level best appt is in morning 1 to 3 hours
after normal breakfast and medication
Diabetes - Appointment ConsiderationsAntibiotic protection may be indicated for
a patient who has history of slow healing from previous scaling or any surgical procedure
May need to recheck tissues one week post-scaling appt for healing response
May want to postpone fluoride application if scaling was difficulty until healing
Diabetes - Progress of Periodontal DiseasePatients with insulin dependent
diabetes have a tendency to develop perio disease - even at early age
Diabetes doesn’t cause disease just decreases resistance to bacteria
Reactive HypoglycemiaLow blood sugar, deficiency of sugar in
bloodTypes: most common following meal,
due to delayed insulin response in some mild maturity onset diabetes after carbo load
alcohol induced, functional ( unknown causes)
Reactive HypoglycemiaSymptoms: lightheadedness,
palpitations, sweating, hunger,nervousness
Symptoms trigger a ripple effect of fatigue, depression, consciousness, convulsions, and coma
Stress intensifies rippleSymptoms relieved by oral glucose
Hypothyroidism & Hyperthyroidism
Most patients will be sensitive to temperature changes.
Most people will have had the disease but be under control due to drugs or surgery.
Hypothyroidism & HyperthyroidismHYPO
atrophy of gland less secretions from
thyroid sluggish decreases basal
metabolism
HYPER enlarged gland more secretions
from thyroid increases basal
metabolism nervous
Corticosteroid TherapyHormonal steroidUsed in the management of a wide
variety of diseases including arthritis, allergic diseases, and pemphigus
Corticosteroids depress the natural defensive responses including inflammation and alter connective tissue response to injury
Corticosteroid TherapyIn dentistry, use
corticoids for oral ulcerations, arthritis of TMJ
Usually applied topically for suppression of local inflammation
Treatment considerations: arthritis patients may
be on long term treatment with CS
dental treatment causes stress-need to ascertain if patient has complications with handling stress
Corticosteroid Therapy Treatment Considerations Patient may have high BP, salt and water
retentionTopical applications should be avoided in
patients suffering from diabetes,hyper- tension,peptic ulcer,TB or viral infections
For those on long term therapy, early signs of inflammation will be masked and correct diagnosis may be missed
Oral candidiasis is frequent complication
Allergic ReactionsMild: Characterized by swelling,redness,
itching- delayedSevere: Characterized by respiratory
depression and circulatory system involvement-anaphylaxis-abrupt & immediate
ANY allergies must be fully evaluated before the start of treatment and any drug administration
Mental ConditionsConsiderations for patients on
antianxiety, antipsychotic, or antidepressants
Usually under care of a physicianMay be taking multiple drugs for
management of their disordersSide effects might include xerostomia
and/or lack of mental alertness
EpilepsyFind out type of seizure activity, its
frequency,drugs used to prevent seizures.
Minimize and/or reduce stress level for patient.
Gingiva may be enlarged from medications.
Pharmacological ConsiderationsCENTRAL NERVOUS SYSTEM
DEPRESSANTS: Barbituates:effective sedative and hypnotics -
long acting barbs used fro seizure disorders and mild anxiety
Narcotics: pain control in terminal disease Antianxiety:used in psychiatric treatment Treatment considerations: If patient has been
on medication for a long period of time they will have LESS pain tolerance
Pharmacological ConsiderationsCENTRAL NERVOUS SYSTEM
STIMULANTS: Include antihistamines, diet pills, caffeine,
cocaine Side effects include:
• xerstomia - dry mouth• increase in vital signs• nervousness, talkative
Severe overstimulation can cause heart failure
Cancer PatientsUsually on anti-neoplastic (chemotherapy)
drugs- in combination with surgery, and radiotherapy-may cause oral manifestations side effects
oral ulcerations, mucosal sloughing, necrotic lesionsincreased susceptibility to infections such as
candidiasis due to suppression of normal defense mechanisms
bleeding problems from suppression of blood clotting factors
Cancer PatientsPre-medication may be necessary; consult
oncologist; immune system compromised; will be susceptible to infections
Treatment problems When head and neck area radiated it may cause
necrosis of bone in jaws and rampant caries Oncological treatment
Before: prophy to decrease risk of infectionAfter: fluoride, saliva substitute for xerostomia
Liver DiseaseCaused by:
hepatitis-drug induced,alcoholic,viral
cirrhosis-alcoholic,biliary
infiltrations-glycogen,fat
biliary obstruction severe vascular
diseases
Problems with treatment: serious bleeding
problems may occur;may need replacement of clotting proteins
Reduced capability to metabolize drugs-prolonged blood levels of drugs
Childbearing Age FemalesOral contraceptives: usually mixture
of estrogen and progesteroneTissues may mimic effects of
pregnancy mild inflammation and edema loss of tissue tone spontaneous bleeding tenderness and ulcerations
Alcohol and Drug Addiction PatientsHigher than normal
incidence of liver disease
Increase of valvular damage
May need premedication
Low tolerance for pain
TuberculosisContracted by inhalation of fresh
droplets containing tubercle bacilliPredisposing factors - any
debilitating or immunosuppressive condition-eg. HIV,diabetes.chronic lung disease, alcoholism
Incubation period- up to 6 months
TuberculosisEarly symptoms: low grade fever, loss
of appetite, weight loss, tire easily,slight cough
Later symptoms: definite temperature elevations, night sweats, weakness and persistent cough
Re-infection TB: infection may remain inactive and later produce a recurrence
TuberculosisClinical management:
May have enlarged lymph nodes, ulcers on palate
Chemotherapy can control patients contagious condition
Consult physician to clarify if active- can usually treat patient if they have been on medication for 2-3 weeks
Hepatitis AOccurs most frequently in children
and young adultsMost common transmission is
through close contact in unsanitary conditions (fecal-oral route)
Prevention by universal precautions
Hepatitis BOccurs at any ageVery different disease process than HepAMajor source of HPB from patients with
acute infection and symptomless chronic carriers
Transmitted by blood, other bodily, perinatal transmission
Prevention through immunization
Hepatitis D - DeltaCan only cause infection in presence
of HBV Occurs primarily in persons who
have multiple exposures of HBVTransmission same as HBVMore severe than HBVPrevention is same as HBV
HIV Infected patients have variety of
symptoms since disease has 3 stages
Asymptomatic
AIDS related complex- ARC
AIDS
HIVDamages immune
and neurological system
Transmission via blood,semen,vaginal secretions,breast milk
Patient highly susceptible to infection
Consult physician- may need premed if abnormal white cell, fungslT-cell and/or platelet count
Patient may have opportunistic diseases fungal-candidiasis bacterial-
sinusitis,gingivitis viral- herpes,shingles
HIVNeoplasms-Kaposi’s
sarcoma,squamous cell carcinoma, Non-Hodgkin’s lymphoma
Neurological disturbances- facial palsyUnknown etiological diseases-
recurrent apthous ulcers, delayed wound healing, salivary gland enlargement, xerostomia
Herpes Virus DiseasesVaricella-zoster:
Chicken pox - highly contagious; lesions on trunk
Shingles- painful, burning and itching lesions that may be anywhere on the body
Herpes Virus DiseaseEpstein-Barr virus:Infectious
MononucleosisCharacterized by fever, swollen lymph
nodes and sore throat
Transmitted orally by direct contact and droplets
Herpes Virus DiseasesCytomegalovirus: CMV- Salivary gland
viruses-Occurs congenitally,postnatally, or at any age,
ranges in severity from a slight infection without complications through disease manifested by fever, hepatitis, pneumonitis, and in neonates- severe brain damage resulting in stillbirth or perinatal deaths
60-90% adults have experienced infectionTransmitted by blood transfusion, graft
transplant,sexual transmission,respiratory droplet
Herpes Simplex VirusPrimary herpetic gingivostomatitis-
primary infection may be asymptomatic or with symptoms-usually painful lesions and flu-like symptoms
Herpes labialis (HSV-1) or genital herpes (HSV-2)- cold sores,fever blister, both cause genital and oral-facial infections that can’t be distinguished clinically
Herpes Virus DiseaseHerpes labialis:
Usually triggered by stress, sunlight, illness or trauma
Healing may take 10 days Lesions are infectious and can be
spread to eye, nose and genitals Treat after lesion has burst and dried,
crusted appearance
Herpes Virus DiseaseHerpetic Whitlow: HSV infection of fingers
that results from the virus entering through minor skin abrasions
May be recurrent lesion of HSV-1 or HSV-2
Transmission results from direct contact with a vesicular lesion on patient’s lip or saliva- lesions are infectious and transmissible before appearing
Herpes Virus Diseases
Ocular herpes- HSV-1 or HSV-2 in the eye
Transmission by splashing saliva or fluid from lesion into eye, extension from facial lesion, or during birth
Herpes Virus DiseasesClinician with a
herpetic lesion -
Herpetic Whitlow - direct patient care should be avoided for duration
Herpes Labialis- careful isolation with mask,care that mask does not become moist
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