This lecture includes two topics : 1-Chemotherapeutic agents2-Medically compromised pts

*Chemotherapeutic agents*

We'll continue with chemotherapeutic agents and we said these agents are chemical substances provide a clinical therapeutic benefit & divided into :AntisepticsDisinfectantsAnti-plaqueAnti-gingivitisAntibiotics .

** Subginigival irrigation ( slides pg 14)When we advise our pt to rinse using a mouth wash , we don't expect this MW will go more than 1-2 mm beyond the gingival margin , however for such a case we can use an irrigant via canula & we'll reach 7-8mm "pocket penetration" . ** it's very important to know that the benefit we gain from subgingival irrigation is not because of the substance we use during irrigation ! You may use normal saline and it will be very beneficial and u'll have good results So irrigation is good (we need the flushing effect of the technique) whether u used antibiotics, normal saline or whatever. Sometimes in certain cases (Aggressive periodontitis) u may need irrigtion with ab to get good results !** SUbgingival irrigation with ab may help also in (esp.before instrumentation) :1) reducing the incidence of bacteremia.Esp. for pts with high risk for Endocarditis .2)reducing the # of MO in aerosols.** Irrigant solutions used :*)Chlohexidine**) Listerine"2nd line after CHX"***)Tetracycline & Povidone-Iodine*single administration isnot enogh at all ,teach ur pt how to use it at home so he can apply it more times by himself.

CONTROLLED RELEASE AGENTS :Substantivity for sustained & therapeutic dose ; this means these agents provide Prolonged release "sustained" in addition they attemptto maintain drug levels within therapeutic window to avoid potentially hazardous peaks in drug concentration following ingestion .**many devices could be used : fibers , chips , gels & micropheres. These agents will be absorbed and released in the body under specific stimuli/specific period .** mainly used for deep pockets after finishing with conventional treatment -debridement, scaling, root planing ...etc- .. but you should consider that we don't use it if we have many pockets it would be better if u use irrigation with ab for such a case .. so , controlled release agents are used for single deep pocket .** an example for these agents is "Perio chip" which contains 2.5 mg chlorhexidine gluconate. perio chip: (-) PD depths, (+) CAL , (-) bleeding.

HOST MODULATION DRUGS:In general, destruction of the periodontium in periodontal diseases comes directly from (host response) & indirectly from (bacteria) , so to stop the destruction we need to stop the host response effect.An important factor in host response against perio disease >>> Prostaglandins (PGs) production ! PGs are released from macrophages during inflammation causing bone destruction in perio diseases , esp (PGE2).So host modulation drugs are used to stop host response effect & these drugs include :1) NSAIDs : (eg : Aspirin )They mainly inhibit PGs production & slow periodontal bone loss . MOA :

Plasma membrane contains phospholipids , during injury phospholipase A converts these phospholipids into Archidonic acid which helps in releasing Cox1 (responsibe for platlet production) & Cox 2 (responsible for PGs production that induce pain+inflammation+bone resorption)NSAIDs work on inhibiting the production of cox 1 (sothat it is considered as antiplatlet) & inhibit cox 2 (considered as host modulation drug).

2) Tetracyclin : (anti-collagenase)Inhibit the activity of host derived collagenases,gelatinases&elastases .Several types of tetracyclins are available: tetracyclin, Doxycyclin & Minocyclin , same MOA for all of these drugs .Doxycyclin is very important in perio clinics ,it could be applied in many ways such as ;local gels after scaling and root planning this method is called (LDD=local delievry drug), this method isn't considered as host modulation instead they found out that using Doxycyclin in a systemic way with very low concentration 20 mg (Periostat) for a long period will give anti collagenase effect so we control host response effect on tissues. Some studies said that such drugs may induce resistance and others denied that . Still these drugs are very good and commonly used .

* Periodontal treatment in medically compromisedPatients *

In perio we use to treat only patients with teeth, that was before introduction of implants, after implants were introduced perio treatment starts to deal with dentate patients and patients with implants (which in most of the time are older age group), because of that perio treatment is now dealing with all age groups and usually the older patients are susceptible to be medically compromised patients.

The problem is that the vast majority of the killer diseases in the third world countries are the non-communicable chronic diseases(Ex; diabetes , hypertension , renal problems), while in the first world countries it not the same (for example in Japan the infectious diseases are one of the most common causes of death in the old age group ).

So Our Goals in treating medically compromised patients: is to evaluate any source of infection that may compromise successful periodontal therapy and restore optimal oral health and function thorough :1-Medical and dental history "including medications".2- Complete periodontal /dental charting.3- Physician consultation to corroborate medical history and coordinate dental and medical care.4- Arrange treatment initiate preventive therapy.5-Arrange follow up.

*if your case diagnosis was associated with a medical problem then you have to make more investigations related to that problem like (radio graphs, lab tests . Etc).

medically compromised patients : Cardiovascular diseases Endocrine Disorders Renal Diseases Liver Diseases Pulmonary Diseases Immunosuppression and Chemotherapy Prosthetic Joint Replacement Hemorrhagic Disorders Infectious Diseases

We will start with the Cardiovascular diseases like:

Hypertension.

Cerebrovascular Accident.

Ischemic heart diseases.

Infective Endocarditis

* Hypertension:Hypertensive patients are divided into two types:

-Primary: about 95 % of hypertensive patients are primary type, in this type there will be a problem in the cardiovascular system itself ,that means there is no underlying cause in any other system .

-Secondary: there is an underlying etiology, like: problems in endocrine, renal problems & neurogenic disorders, so to treat hypertension you have to treat the underlying problem, and then hypertension will be resolved.Note:Most of hypertension patients don't know that they have this problem because in early stages of hypertension patient tend to be asymptomatic, so you as a Dentist should be able to diagnose such patients. Recently, there is an increased in number of patients diagnosed with diabetes at dental clinic, so we all have to know how to measure blood pressure & how to make sure this is hypertensive patients or not, and of course one measurement isn't enough.If not identified or diagnosed, and treated. Hypertension may persist and increase in severity, leading eventually to coronary artery disease, angina, myocardial infarction, congestive heart failure, cerebrovascular accident, or kidney failure.Classification of hypertension :

So what are your concerns when you treat a hypertensive patient? A-Stress:As long as you minimize stress, your dental treatment for a hypertensive patient is considered to be generally safe, so How to minimize stress?? *appointment should be as short as possible ,the doctor says not more than one hour .*dont leave blooded gauze in front of the patient. *try to talk to your patient while treating him / her. *It was thought that morning is best time for appointment, however they found that blood pressure will be high after wake up. Blood pressure peaks at midday, so after noon considered being the best time for hypertensive patients.

B- Medication: The antihypertension drugs have many side effects thats should be in our concern like:1. Postural hypotension .2. Depression .3. Nausea .4. Oral dryness .5. Lichenoid drug reactions .6. Gingival overgrowth (phenytoin, cyclosporine, and nifedipine) .7. you have to make sure if your patient is taking any anti coagulant drugs (aspirin warfarin) and you should know how to deal with it before any surgical treatment. C- Local anesthesia: Because epinephrine is a vasoconstrictor it may cause elevation in the blood presser, so the smallest possible dose of epinephrine should be used, if your treatment is less than 30 minutes you can use local anesthesia without epinephrine. It is important to minimize pain (to avoid an increase in endogenous epinephrine). To avoid intravascular injections, aspiration before injection of local anesthetics is critical. Try to give infiltrations, and avoid I.D block.

The record stops here so I add the last pages from the 2009 script

Done by : Hanady al masri Abdallah al- zireeni

"from 2009 script" Infective endocarditits

Old name bacterial endocarditis , but recently they found other microorganism as causative.

Difinition________________________________

Microorganisms colonize the damaged endocardium or heart valves..

aetiology________________________________

a-hemolytic streptococci (e.g., Streptococcus viridans). However, nonstreptococcal organisms often found in the periodontal pocket have been increasingly implicated, including Eikenella corrodens, Actinobacillus actinomycetemcomitans, Capnocytophaga, and Lactobacillus species.

a-hemolytic streptococci present in oral cavity ,but it isn't considered as periodontal pathogen .recently evidence that actinomycetemcomitans are found in infective endocarditits plaque & make embolism and all the problem.

The effect of periodontal treatment starting from probing, scaling, root planning sometimes polishing all these makes transient bacteremia.

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according to American Heart Association (AHA) recommends antibiotic prophylaxis before procedures associated with significant bleeding from hard or soft tissues, periodontal surgery, scaling and Professional teeth cleaning.

Remember!

Prophylactic means treatment before the disease established, cause bleeding need prophylactic .

bacteremia may occur even in the absence of dental procedures

-in patient with poor oral hygiene they have spontaneous bleeding even with breathing

Periodontics and IE:

AHA states that patients who are at risk for IE

Should establish and maintain the best possible oral health to reduce potential sources of bacterial seeding.

According to AHA new guidelines 2007

All Dental procedures that involve manipulation of Gingival tissue or the periapical region of teeth or Perforation of the oral mucosa need prophylactic Antibiotic coverage.

The following procedures and events do not Need prophylaxis:

Routine anesthetic injections through non infected tissue,

Taking dental radiographs,

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Placement of removable prosthodontic or orthodontic appliances,

Adjustment of orthodontic appliances,

Placement of orthodontic brackets, Shedding of deciduous teeth,

Bleeding from trauma to the lips or oral mucosa.

Management________________________________

Define the susceptible patient. (careful medical history)

Cardiac Conditions Associated for Which we should give Prophylaxis for: (Dr Malek didnt read them but here they are: )

Prosthetic cardiac valve

Previous IE

Congenital heart disease (CHD)

Unrepaired cyanotic CHD, including palliative shunts

Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure

Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)

So for the management we have:

Define the susceptible patient. Provide oral hygiene instruction.

Prophylactic Antibiotics.

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This table shows the types of prophylactic antibiotics and below it are some notes:

Route of administration can be orally, IV, IM or others. The best till now is Amoxicillin (around 2 grams)

If patient is allergic to penicillin we can give other antibiotics like clindamycin or others.

In general we give 2 grams one hour or 30 min before treatment in order to have the antibiotic in reasonable concentration in the blood.

Next in the management of Infective Endocarditis (IE): Eliminate the infection associated with periodontal

disease.

Teeth with severe periodontitis and a poor prognosis may require extraction: (hopeless teeth in those patients are better be extracted)

All periodontal treatment procedures (including probing) require antibiotic prophylaxis

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From now on, in the clinic you can't perform probing before proper history taking and making sure the patient has no risk for IE, only then you can start probing! And you will be responsible for this in the clinic so be careful! And the Dr will be strict about this!

Pretreatment chlorohexidine mouth washes.

Important note: Before you start scaling, ask the dispensary for chlorhexidine mouth wash, dip some gauze in it, and wipe the whole area with it, this way you can reduce up to 80% of the bacteria bulk, by this simple procedure you will also wipe away all the plaque in the area.

Numerous procedures may be accomplished at each appointment.

Post-operative antibiotics: Some times indicated when periodontic surgery is performed, and the patient is still bleeding, so the risk of bacteremia is still there even when the patient leaves, so if we gave him 2 grams pre-op we give him 500 grams prophylactic antibiotic post-op for 2 or 3 days until he comes back to remove the sutures.

It's debatable if removing sutures needs prophylactic antibiotic or not in case of patients at risk of IE.

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We have so far covered hypertension and IE from the cardiovascular diseases, Dr. Malek will provide us with summaries about the rest and he said we should read them as they are important.

Endocrine Disorder

Diabetes Hypoglycemia

Thyroid and Parathyroid Disorders

Adrenal Insufficiency

Diabetes

_______________________

Dr asked a question:

What is the normal fasting blood glucose level? No one answered, and the Dr didn't answer as

well, the references in the internet give many ranges but the most repeatable is (80-110 mg/dL), however the Dr mentioned that we took these things in other courses like medicine and surgery, and that when he asks in the exam he wants the answers to be from what he says and he is not responsible for what we take in other courses. Again you should know these numbers (normal blood glucose level and so on).

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In diabetes we have:

Increased blood glucose level

Absolute or relative deficiency of insulin: Tissues become resistant to insulin due to problems in insulin receptors.

It has two types: insulin dependent and non-insulin dependent.

Now problems are faced in the undiagnosed patients (some research says that more than 50% of the community has diabetes, so the patient should be careful and watch out for signs that can help diagnose diabetic patients).

Intraoral signs of undiagnosed or poorly controlled diabetes Gingivitis

Alveolar bone resorption Xerostomia

Delayed wound healing

Pulpitis in non carious teeth

Burning sensation

Acetone smell in breath (from ketone bodies). Dr said Multiple abscess as well

Thorough history should be taken, and you should concentrate on family history in those patients even if he/she are not diagnosed as a diabetic patients and then you should:

Consult the patient's physician

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Analyze laboratory tests (like fasting blood glucose test or others)

Rule out acute orofacial infection or severe dental infection and multiple abscesses (whenever you see multiple abscesses in the patient's mouth you should directly think about diabetes)

Management of diabetics

o Oral hygiene instructions,

o Mechanical debridement to remove local factors, o Regular maintenance

o Periodontal infection may worsen glycemic control, and should be managed aggressively (we mentioned before that the relation between periodontitis and diabetes are two-way, periodontitis affect diabetes by increasing the resistance for insulin and diabetes on the other hand affects periodontitis and worsens it)

o You should always check HbA1c (border line of HbA1c is 6.5) o Systemic antibiotics are not needed routinely,

o Tetracycline antibiotics in combination with scaling and root planing may positively influence glycemic control (in chronic periodontitis I can give antibiotics for

diabetic patients if it was a severe case)o Prophylactic antibiotics (poor glycemic control )

o Frequent reevaluation after active therapy (to make sure there is no recurrence of the disease)

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During periodontal treatment :

o Check blood glucose before any long procedure to get a baseline level (to avoid hypoglycemia during treatment).

o Patients with blood glucose levels at or below the lower end of normal (70 mg/dl) before the procedure may become hypoglycemic intraoperatively.

o Ask patients to attend to the clinic after having Breakfast.

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