```markdown THE UNIVERSITY OF WESTERN AUSTRALIA | Oral Health Centre of Western Australia Cardiovascular and respiratory disease Bobby Joseph Associate Professor 2026 ``` Bobby Joseph Associate Professor 2026 # Learning Outcomes - Gain an understanding of an overview of cardiovascular and respiratory disease - To recognise the oral manifestations and management of patients with these conditions - To develop an awareness when medically compromised patients should be referred to secondary care - Gain an understanding of an overview of cardiovascular and respiratory disease - To recognise the oral manifestations and management of patients with these conditions - To develop an awareness when medically compromised patients should be referred to secondary care Hypertension (HTN) - In adults, hypertension is defined as a sustained BP of 130 mm Hg or greater or sustained diastolic BP of 80 mm Hg or greater - The American Cardiology Association and the American Heart Association defined BP in 4 stages: normal, elevated, stage 1 and stage 2 - Normal BP is <120/80 - Many patients with high blood pressure are unaware of their disease - Early detection with referral for additional diagnosis and treatment when indicated, can prove to be lifesaving | BP Classification | Systolic BP (mm Hg) | Diastolic BP (mm Hg) | Recommended Follow-Up | | :--- | :--- | :--- | :--- | | **Normal** | <120 | And <80 | Recheck in 2 years. | | | 120–129 | Or <80 | Recheck in 1 year. | | **Hypertension** | | | | | Stage 1 | 130–139 | Or 80–89 | Confirm within 2 months. | | Stage 2 | ≥140 | Or ≥90 | Evaluate or refer to source of care within 1 month. For those with higher BP (e.g., >180/110 mm Hg), evaluate and treat immediately or within 1 week, depending on the clinical situation and complications. | Note: If there is a disparity in category between the systolic and diastolic pressures, the **higher value** determines the stage.  Hypertension (HTN) is a significant health concern characterized by the following: - In adults, hypertension is defined as a sustained systolic blood pressure (BP) of 130 mm Hg or greater or a sustained diastolic BP of 80 mm Hg or greater. - Many patients with high blood pressure are unaware of their disease. - Early detection, followed by referral for diagnosis and treatment, can be lifesaving. The American Cardiology Association and the American Heart Association define blood pressure in four stages. If there is a disparity between systolic and diastolic pressures, the higher value determines the stage. #### Blood Pressure Classification Table | BP Classification | Systolic BP (mm Hg) | Diastolic BP (mm Hg) | Recommended Follow-Up | | :--- | :--- | :--- | :--- | | **Normal** | <120 | And <80 | Recheck in 2 years | | **Elevated** | 120–129 | Or <80 | Recheck in 1 year | | **Hypertension Stage 1** | 130–139 | Or 80–89 | Confirm within 2 months | | **Hypertension Stage 2** | ≥140 | Or ≥90 | Evaluate or refer within 1 month. For BP >180/110 mm Hg, evaluate and treat immediately or within 1 week depending on clinical situation. | A table classifying blood pressure (BP) in adults into four categories: Normal, Elevated, Stage 1 Hypertension, and Stage 2 Hypertension, based on systolic and diastolic BP values. It also provides recommended follow-up actions for each category, such as rechecking within 1-2 years or evaluating within 1 month for higher BP levels. The table includes a note explaining that if there is a disparity between systolic and diastolic categories, the higher value determines the stage. ```markdown Aetiology Primary (essential hypertension) 90% • Patients have no readily identifiable cause • Risk factors: age, family history/genetic predisposition/lifestyle factors Secondary hypertension • 10% is secondary to other underlying medical conditions • Renal diseases (e.g. diabetic nephropathy) • Endocrine conditions (e.g., Cushing syndrome, hyperthyroidism) • Chronic steroid therapy • Drug related • Obstructive sleep apnoea ``` #### Primary (Essential) Hypertension - Accounts for 90% of cases. - Patients have no readily identifiable cause. - Risk factors include age, family history, genetic predisposition, and lifestyle factors. #### Secondary Hypertension - Accounts for 10% of cases and is secondary to underlying medical conditions. - Causes include: - Renal diseases (e.g., diabetic nephropathy) - Endocrine conditions (e.g., Cushing syndrome, hyperthyroidism) - Chronic steroid therapy - Drug-related causes - Obstructive sleep apnoea # Signs and Symptoms of Hypertensive Disease ## Early - Elevated blood pressure readings - Narrowing and sclerosis of retinal arterioles - Headache, Dizziness, Tinnitus ## Advanced ### Eye: - Rupture and hemorrhage of retinal arterioles - Papilledema ### Heart: - Angina pectoris, Left ventricular hypertrophy, Congestive heart failure ### Kidney: - Proteinuria, Renal failure ### Brain: - Dementia, Encephalopathy, Stroke #### Early Signs and Symptoms - Elevated blood pressure readings - Narrowing and sclerosis of retinal arterioles - Headache - Dizziness - Tinnitus #### Advanced Signs and Symptoms - **Eye:** Rupture and hemorrhage of retinal arterioles; papilledema - **Heart:** Angina pectoris, left ventricular hypertrophy, congestive heart failure - **Kidney:** Proteinuria, renal failure - **Brain:** Dementia, encephalopathy, stroke ## Complications of prolonged hypertension - Accelerates atherosclerosis - Increases the risk of cardiovascular, cerebrovascular, renal and eye diseases - Left ventricular hypertrophy, myocardial infarction, heart failure and stroke - Retinal damage, proteinuria, renal failure - Malignant hypertension (BP >200/>130 mmHg) causes retinal haemorrhage - Shortens life by 10-20 years <img src="https://i.imgur.com/1234567.png" alt="Diagram showing the effects of prolonged hypertension on the body, with arrows pointing from 'Stroke', 'Retinopathy', 'Ischaemic heart disease', and 'Nephropathy' to different parts of a human figure." />  Prolonged hypertension leads to several severe health consequences: - Accelerates atherosclerosis. - Increases the risk of cardiovascular, cerebrovascular, renal, and eye diseases, including: - Left ventricular hypertrophy, myocardial infarction, heart failure, and stroke. - Retinal damage, proteinuria, and renal failure. - Malignant hypertension (BP >200/130 mmHg) causes retinal haemorrhage. - Shortens life expectancy by 10–20 years. #### Systemic Effects - Stroke - Retinopathy - Ischaemic heart disease - Nephropathy A diagram illustrating the complications of prolonged hypertension, showing arrows pointing from 'Stroke', 'Retinopathy', 'Ischaemic heart disease', and 'Nephropathy' to corresponding areas on a human figure, highlighting the systemic effects of hypertension. # Classes of antihypertensive drugs - Diuretics- **Chlorothiazide (Diuril®)** - Angiotensin converting enzyme (ACE) inhibitors- **Captopril (Capoten®)** - Angiotensin II receptor blockers- **Candesartan (Atacand®)** - Calcium channel blockers- **Amlodipine (Norvasc®)** - Beta-blockers- **Atenolol (Tenormin®)** - Alpha-blockers- **Prazosin (Minipres®)** Common classes of antihypertensive drugs include: - **Diuretics:** Chlorothiazide (Diuril®) - **Angiotensin converting enzyme (ACE) inhibitors:** Captopril (Capoten®) - **Angiotensin II receptor blockers:** Candesartan (Atacand®) - **Calcium channel blockers:** Amlodipine (Norvasc®) - **Beta-blockers:** Atenolol (Tenormin®) - **Alpha-blockers:** Prazosin (Minipres®) | Condition/Finding | Comment | | --- | --- | | Orthostatic hypotension | Particularly in older patients on multiple medications<br>More with diuretics | | Dry mouth | Several medications particularly Clonidine (Catapres) | | Hypokalemia | Low potassium is a side effect of diuretics<br>Hypokalemia in turn can produce arrhythmia | | Gingival hyperplasia | Calcium channel blockers, particularly Nifedipine (Procardia)<br>Not dose-related but patient-specific. The severity depends on the quality of oral hygiene, frequency of dental prophylaxis, presence of crowded teeth, and defective restorations | | Lichenoid reactions | Several medications | | Cough/taste disturbances | ACE inhibitors; e.g., Captopril is commonly associated with metallic or loss of taste | | Burning mouth | ACE inhibitors | | Angioedema | ACE inhibitors | | Influence on vasoconstrictors | Non-selective beta-blockers (e.g., propranolol) can potentiate the effect of epinephrine and result in acute elevation in blood pressure<br>Limit epinephrine to 2 carpules of 1:100,000 epinephrine (0.036 mg of epinephrine) | | Other considerations | Erythromycin and clarithromycin (but not azithromycin) can exacerbate the hypotensive effect of calcium channel blockers (CCBs) and can result in acute kidney injury.<br>Prolonged use of NSAIDs should be avoided in patients who have hypertension and on antihypertensive drugs. Prolonged NSAIDs use is associated with decreased efficacy of antihypertensive drugs and increased risk for MI and stroke in this population. |  #### Clinical Findings and Drug Side Effects - **Orthostatic hypotension:** Particularly in older patients on multiple medications; more common with diuretics. - **Dry mouth:** Associated with several medications, particularly Clonidine (Catapres). - **Hypokalemia:** Low potassium is a side effect of diuretics, which can produce arrhythmia. - **Gingival hyperplasia:** Associated with Calcium channel blockers, particularly Nifedipine (Procardia). It is patient-specific rather than dose-related; severity depends on oral hygiene, prophylaxis frequency, tooth crowding, and restorations. - **Lichenoid reactions:** Associated with several medications. - **Cough and taste disturbances:** Associated with ACE inhibitors; Captopril is commonly linked to metallic taste or loss of taste. - **Burning mouth and Angioedema:** Associated with ACE inhibitors. #### Drug Interactions and Precautions - **Influence on vasoconstrictors:** Non-selective beta-blockers (e.g., propranolol) can potentiate epinephrine, resulting in acute BP elevation. Limit epinephrine to 2 carpules of 1:100,000 (0.036 mg). - **Antibiotic interactions:** Erythromycin and clarithromycin (but not azithromycin) can exacerbate the hypotensive effect of calcium channel blockers (CCBs) and may result in acute kidney injury. - **NSAID use:** Prolonged use should be avoided as it decreases the efficacy of antihypertensive drugs and increases the risk for MI and stroke in this population. A table titled "Side Effects of Antihypertensive Drugs" listing various conditions or findings such as orthostatic hypotension, dry mouth, hypokalemia, and gingival hyperplasia, along with comments on their causes and associated medications. The table includes details on drug interactions, side effects, and clinical considerations for antihypertensive drugs. # Oral manifestations - No recognized oral manifestations of hypertension - Antihypertensive drugs can cause - Dry mouth (clonidine) - Gingival hyperplasia (calcium channel blockers) - Lichenoid reactions (several medications) - Erythema multiforme - Angioedema - Burning mouth (ACE inhibitors) - Parotid gland swelling (sialadenosis)  While there are no recognized primary oral manifestations of hypertension itself, antihypertensive medications can cause several secondary conditions: - Dry mouth (e.g., clonidine) - Gingival hyperplasia (e.g., calcium channel blockers) - Lichenoid reactions - Erythema multiforme - Angioedema - Burning mouth (e.g., ACE inhibitors) - Parotid gland swelling (sialadenosis) Two clinical photos showing oral manifestations of antihypertensive drug use. The top image displays gingival hyperplasia with enlarged, swollen gums. The bottom image shows a lesion consistent with erythema multiforme or a similar reaction in the oral cavity. # Dental management considerations - Patient evaluation - Review medical history, assess the severity of hypertension - Obtain a medical consultation if the patient has poorly controlled BP - Dry mouth - improve oral hygiene, dietary counselling, sugarless candy or gum, artificial saliva, fluoride application - Drug-induced gingival hyperplasia - Scaling and root planning, increase frequency of dental prophylaxis and oral hygiene instructions, consult physician to assess the possibility of changing the drug - Lichenoid reactions - consult physician to replace medication if possible #### Patient Evaluation and Consultation - Review medical history and assess the severity of hypertension. - Obtain a medical consultation if the patient has poorly controlled BP. #### Management of Oral Side Effects - **Dry mouth:** Improve oral hygiene, provide dietary counselling, recommend sugarless candy/gum, artificial saliva, or fluoride application. - **Drug-induced gingival hyperplasia:** Perform scaling and root planning, increase frequency of dental prophylaxis, and provide oral hygiene instructions. Consult with a physician regarding the possibility of changing the medication. - **Lichenoid reactions:** Consult with a physician to replace the medication if possible. # Key points - Hypertension is undiagnosed, not well controlled in many patients and accompanied by co-morbidities - BP should be routinely assessed in the dental office and assess for signs, symptoms and co-morbidities - BP can be elevated due to dental anxiety and pain, but can be reduced with appropriate measures - Routine dental care can be provided to most patients when anxiety and pain are controlled - LA with 1:100,000 epinephrine is limited to two carpules or fewer - Dental treatment should be deferred when BP is >180/110; these patients should be referred for medical care - Antihypertensive drugs are associated with hyposalivation, xerostomia, dental caries, and fungal infections - Hypertension is often undiagnosed or poorly controlled and frequently accompanied by co-morbidities. - BP should be routinely assessed in the dental office along with signs, symptoms, and co-morbidities. - BP may be elevated due to dental anxiety and pain but can be reduced with appropriate measures. - Routine dental care is safe for most patients when anxiety and pain are controlled. - Local anesthesia with 1:100,000 epinephrine should be limited to two carpules or fewer. - Dental treatment must be deferred if BP is >180/110; these patients require immediate medical referral. - Antihypertensive drugs are associated with hyposalivation, xerostomia, dental caries, and fungal infections. Ischemic Heart Disease (Coronary Artery Disease; IHD; CAD) - A condition marked by a progressive decrease in the blood supply (ischemia) to the heart muscles - Main cause is plaque accumulation (atherosclerosis) in the coronary artery wall - IHD can lead to angina pectoris, myocardial infarction (MI) or sudden cardiac death | Risk Factors for Coronary Atherosclerosis | | | --- | --- | | **Modifiable (Lifestyle Choices)** | **Not Modifiable** | | Hypertension, cigarette smoking | Older age | | Physical inactivity | Male gender | | Diet rich in simple sugars and starches | Family history of cardiovascular disease | | Obesity, insulin resistance, diabetes mellitus | Genetic hyperlipidemia | | Hyperlipidemia | | | Mental stress, depression | | | Infections and systemic inflammation | |   Ischemic Heart Disease (IHD), also known as Coronary Artery Disease (CAD), is a condition marked by a progressive decrease in the blood supply (ischemia) to the heart muscles. #### Pathophysiology and Outcomes - The primary cause is plaque accumulation (atherosclerosis) in the coronary artery wall. - IHD can lead to clinical complications such as angina pectoris, myocardial infarction (MI), or sudden cardiac death. #### Risk Factors for Coronary Atherosclerosis **Modifiable (Lifestyle Choices)** - Hypertension - Cigarette smoking - Physical inactivity - Diet rich in simple sugars and starches - Obesity, insulin resistance, and diabetes mellitus - Hyperlipidemia - Mental stress and depression - Infections and systemic inflammation **Non-Modifiable** - Older age - Male gender - Family history of cardiovascular disease - Genetic hyperlipidemia A table titled 'Risk Factors for Coronary Atherosclerosis' that categorizes risk factors into 'Modifiable (Lifestyle Choices)' and 'Not Modifiable'. The modifiable factors include hypertension, cigarette smoking, physical inactivity, poor diet, obesity, diabetes, hyperlipidemia, mental stress, and infections. The non-modifiable factors include older age, male gender, family history of cardiovascular disease, and genetic hyperlipidemia. A histological photo showing a cross-section of a coronary artery with visible plaque accumulation (atherosclerosis) in the arterial wall, stained in pink and purple, illustrating the structural changes associated with ischemic heart disease. # Clinical Presentation - Chest pain or discomfort (angina) - Weakness, shortness of breath, light headedness, nausea, cold sweat - CVD and CAD warning signs: - Corneal arcus, eyelid xanthomas - Carotid artery calcifications—may show on panoramic radiographs in areas of C3 and C4    #### Symptomatic Presentation - Chest pain or discomfort (angina) - Weakness - Shortness of breath - Lightheadedness - Nausea - Cold sweat #### Clinical Warning Signs - Corneal arcus - Eyelid xanthomas - Carotid artery calcifications: These may be visible on panoramic radiographs, typically located in the areas of the C3 and C4 vertebrae. Close-up photo of an eye showing a corneal arcus, a grayish-white ring around the cornea, which is a warning sign for cardiovascular disease. Close-up photo of an eyelid with a xanthoma, a yellowish deposit of cholesterol, indicating potential cardiovascular risk. Panoramic radiograph showing carotid artery calcifications in the C3 and C4 regions, which may be visible on dental imaging. # Dental management considerations (IHD) - Determine the severity, onset and symptoms of IHD - Stable patients (stable angina)- can receive routine dental care - Unstable patients (unstable angina) and patients who had MI within the previous 30 days - Should not receive elective dental care, - If urgent treatment required: minimal and conservative - Consult with physician to develop a treatment plan - Patients are best treated at a hospital-based clinic or special care facility that offers vital sign monitoring #### Patient Assessment - Determine the severity, onset, and specific symptoms of the patient's Ischemic Heart Disease. #### Treatment Protocols by Stability - **Stable Patients (Stable Angina):** These patients can receive routine dental care. - **Unstable Patients:** This includes those with unstable angina or patients who have experienced a Myocardial Infarction (MI) within the previous 30 days. - Elective dental care should not be provided. - If urgent treatment is required, it must be kept minimal and conservative. - A physician consultation is necessary to develop an appropriate treatment plan. - These patients are best treated at a hospital-based clinic or special care facility that offers continuous vital sign monitoring. # Oral manifestations - Angina is a rare cause of pain in the mandible, teeth or oral tissues - Carotid calcifications can be detected on panoramic images in 1/3rd of patients who have atherosclerosis - Several drugs used by patients have reported oral manifestations - Dry mouth, taste changes, lichenoid lesions, gingival hyperplasia, oral ulcers (nicorandil) - Bleeding may occur with antiplatelet/anticoagulant drugs (e.g. aspirin; warfarin) <img src="https://i.imgur.com/placeholder.jpg" alt="Panoramic dental X-ray showing teeth and jaw structure" /> 15  #### Direct and Radiographic Findings - **Referred Pain:** Angina is a rare cause of pain localized in the mandible, teeth, or oral tissues. - **Radiographic Indicators:** Carotid calcifications can be detected on panoramic images in approximately one-third of patients with atherosclerosis. #### Medication-Related Manifestations Several drugs used to manage IHD have reported oral side effects: - **General Side Effects:** Dry mouth, taste changes, lichenoid lesions, and gingival hyperplasia. - **Nicorandil:** Specifically associated with oral ulcers. - **Antiplatelet/Anticoagulant Drugs:** Increased risk of bleeding may occur with medications such as aspirin or warfarin. Panoramic dental X-ray showing the teeth and jaw structure, illustrating carotid calcifications that can be detected on such images in one-third of patients with atherosclerosis. # Key points: Ischemic Heart Disease - Atherosclerosis and IHD may be asymptomatic or symptomatic - Features suggestive of this disease may appear in the panoramic image - Patients with atherosclerosis may be at risk for angina, MI, and stroke, before, during or after dental treatment - Managing BP, anxiety, pain and limiting the amount of LA with epinephrine will help to reduce adverse outcomes during dental treatment - Routine dental care deferred for patients who have had a MI within 30 days, and those who are unstable and have symptoms of IHD - Dental providers mut be aware of drug interactions in patients with IHD and avoid drugs that may cause adverse interactions - Patients with IHD must be evaluated on a regular basis by the physician #### Disease Progression and Risks - Atherosclerosis and IHD may be either asymptomatic or symptomatic. - Features suggestive of the disease may be identified on panoramic dental images. - Patients with atherosclerosis are at risk for angina, MI, and stroke before, during, or after dental treatment. #### Clinical Management Strategies - Adverse outcomes during dental treatment can be reduced by managing blood pressure, anxiety, and pain, and by limiting the amount of local anesthetic containing epinephrine. - Routine dental care must be deferred for patients who have had an MI within the last 30 days, as well as those who are unstable or symptomatic. #### Provider Responsibilities - Dental providers must be aware of potential drug interactions in patients with IHD and avoid prescribing medications that may cause adverse reactions. - Patients with IHD must be evaluated by their physician on a regular basis. # Infective endocarditis (IE) - Infection caused by microbes that settle on the endothelial surface of the heart valves - Staphylococci aureus, viridans group streptococci (alpha-haemolytic streptococci) - Occurs near congenital or acquired cardiac defects - Results when microbes enter the blood stream and colonize damaged or artificial cardiac valves - Associated with significant morbidity and mortality - Most IE cases related oral microflora are random bacteraemia resulting from routine activities - A very small number of cases are believed to result from dental procedures Infective endocarditis (IE) is a serious condition characterized by the following: #### Pathophysiology and Etiology - Infection caused by microbes that settle on the endothelial surface of the heart valves. - Primary causative agents include *Staphylococci aureus* and viridans group streptococci (alpha-haemolytic streptococci). - The condition occurs near congenital or acquired cardiac defects. - It results when microbes enter the bloodstream and colonize damaged or artificial cardiac valves. #### Clinical Significance and Risk Factors - Associated with significant morbidity and mortality. - Most IE cases related to oral microflora are attributed to random bacteraemia resulting from routine daily activities. - A very small number of cases are believed to result specifically from dental procedures. # Signs and symptoms - Appear within 2 weeks after the initiating bacteraemia - Fever is the most common sign - Heart murmurs in 85% of patients - Immune-complex mediated vasculitis, arthritis, renal damage - Petechiae (skin, conjunctiva, oral mucosa) - Osler nodes (tender red nodules on the pulp of fingers) - Janeway lesions (painless red haemorrhagic macules on the palms and soles) - Splinter haemorrhages (dark-red linear lesions in the nail beds) - Roth spots (oval retinal haemorrhages with small clear centres) - Glomerulonephritis     Signs and symptoms typically appear within 2 weeks after the initiating bacteraemia. #### Common Clinical Findings - **Fever:** The most common sign of infection. - **Heart Murmurs:** Present in 85% of patients. #### Immune-Complex Mediated Manifestations These conditions involve vasculitis, arthritis, and renal damage: - **Petechiae:** Found on the skin, conjunctiva, and oral mucosa. - **Osler nodes:** Tender red nodules located on the pulp of fingers. - **Janeway lesions:** Painless red haemorrhagic macules on the palms and soles. - **Splinter haemorrhages:** Dark-red linear lesions found in the nail beds. - **Roth spots:** Oval retinal haemorrhages characterized by small clear centres. - **Glomerulonephritis:** Inflammation of the kidney filters. A close-up photograph of a foot showing petechiae, which are small red or purple spots on the skin, consistent with immune-complex mediated vasculitis. The image is labeled 'Petechiae' and illustrates the skin manifestation described in the text. A photograph of a hand displaying an Osler node, a tender red nodule on the pulp of a finger, as described in the text. The image is labeled 'Osler node' and visually represents the characteristic finding associated with infective endocarditis. A close-up image of a fingernail showing a splinter hemorrhage, a dark-red linear lesion under the nail bed, labeled 'Splinter haemorrhage.' This visual corresponds to the text's description of nail bed involvement in immune-complex mediated conditions. An ophthalmoscopic image of a retina displaying a Roth spot, characterized by an oval retinal hemorrhage with a small clear center, labeled 'Roth spot.' This image illustrates the ocular manifestation of systemic vasculitis. # Antibiotic Prophylaxis Regimens - Antibiotic prophylaxis should be administered in a single dose 30-60 minutes before the procedure - If not administered before the procedure, dosage may be administrated up to 2 hours after the procedure ## American Heart Association Antibiotic Regimens for Dental Procedures: Single Dose 30–60 min Before the Procedure | Situation | Agent | Adults | Children | | --- | --- | --- | --- | | Oral | Amoxicillin | 2 g | 50 mg/kg | | Unable to take oral medication | Ampicillin or Cefazolin or ceftriaxone | 2 g IM or IV | 50 mg/kg IM or IV | | | Cephalexin<sup>a,b</sup> or Azithromycin or clarithromycin | 2 g | 50 mg/kg | | | Or doxycycline | 500 mg | 15 mg/kg | | | | 100 mg | >45 kg, 100 mg | | | | | <45 kg, 4.4 mg/kg | | Allergic to PCNs or ampicillin (oral) | Cefazolin or ceftriaxone<sup>b</sup> | 1 g IM or IV | 50 mg/kg IM or IV | | Allergic to PCNs or ampicillin and unable to take oral medication | Cefazolin or ceftriaxone<sup>b</sup> | 1 g IM or IV | 50 mg/kg IM or IV | <sup>a</sup>Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosing. <sup>b</sup>Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillin or ampicillin. Clindamycin is no longer recommended for antibiotic prophylaxis for a dental procedure. IM, Intramuscular; IV, intravenous; PCN, penicillin.  #### Administration Guidelines - Antibiotic prophylaxis should be administered in a single dose 30–60 minutes before the procedure. - If not administered before the procedure, the dosage may be administered up to 2 hours after the procedure. #### American Heart Association Antibiotic Regimens for Dental Procedures | Situation | Agent | Adults | Children | | :--- | :--- | :--- | :--- | | Oral | Amoxicillin | 2 g | 50 mg/kg | | Unable to take oral medication | Ampicillin OR Cefazolin OR Ceftriaxone | 2 g IM or IV | 50 mg/kg IM or IV | | Allergic to Penicillins or Ampicillin (Oral) | Cephalexin* OR Azithromycin OR Clarithromycin OR Doxycycline | 2 g (Cephalexin/Azithromycin/Clarithromycin) OR 100 mg (Doxycycline) | 50 mg/kg (Cephalexin/Azithromycin/Clarithromycin) OR 15 mg/kg (Clarithromycin) OR >45 kg: 100 mg; <45 kg: 4.4 mg/kg (Doxycycline) | | Allergic to Penicillins or Ampicillin AND unable to take oral medication | Cefazolin OR Ceftriaxone* | 1 g IM or IV | 50 mg/kg IM or IV | #### Important Considerations - *Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosing. - *Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillin or ampicillin. - Clindamycin is no longer recommended for antibiotic prophylaxis for dental procedures. **Abbreviations:** IM, Intramuscular; IV, intravenous; PCN, penicillin. A table detailing the American Heart Association Antibiotic Regimens for Dental Procedures, specifying single dose administration 30-60 minutes before the procedure. It lists various situations such as oral administration, inability to take oral medication, and allergies to penicillins or ampicillin, along with corresponding agents, dosages for adults, and dosages for children. The table includes footnotes explaining additional considerations for cephalosporin use and the discontinuation of clindamycin for prophylaxis. # Infective endocarditis: Key Points - IE is associated with significant morbidity and mortality - IE results when microbes enter the blood stream and colonize damaged or artificial valves - Viridans group streptococci (VGS) in the oral cavity can cause IE because of transient bacteraemia from daily mouth activities and less commonly after dental procedures - Good oral health and regular dental care are important to prevent VGS IE - AHA guidelines recommend antibiotic prophylaxis based on 3 risk factors: (1) underlying cardiac conditions, (2) dental procedure being performed, and (3) oral microbes (VGS) likely to cause bacteraemia - Dental providers must be aware and follow recommended guidelines for antibiotic prophylaxis 20 #### Disease Overview - IE is associated with significant morbidity and mortality. - IE results when microbes enter the bloodstream and colonize damaged or artificial valves. - Viridans group streptococci (VGS) in the oral cavity can cause IE because of transient bacteraemia from daily mouth activities and, less commonly, after dental procedures. #### Prevention and Clinical Responsibility - Good oral health and regular dental care are important to prevent VGS IE. - AHA guidelines recommend antibiotic prophylaxis based on three risk factors: 1. Underlying cardiac conditions. 2. The specific dental procedure being performed. 3. Oral microbes (VGS) likely to cause bacteraemia. - Dental providers must be aware of and follow recommended guidelines for antibiotic prophylaxis. Respiratory Diseases Respiratory Diseases # Asthma - Asthma is a chronic inflammatory disease of the airways marked by reversible episodes of enhanced airway hyperresponsiveness, resulting in recurrent bouts of dyspnea, coughing, and wheezing - Asthma is a multifactorial and heterogeneous disease - Factors that can exacerbate asthma are grouped into one of four categories: - Extrinsic (allergic or atopic) - Intrinsic (idiosyncratic, non-allergic or non-atopic) - Drug induced - Exercise induced Asthma is a chronic inflammatory disease of the airways marked by reversible episodes of enhanced airway hyperresponsiveness, resulting in recurrent bouts of dyspnea, coughing, and wheezing. It is a multifactorial and heterogeneous disease. #### Categories of Exacerbation Factors Factors that can exacerbate asthma are grouped into one of four categories: - Extrinsic (allergic or atopic) - Intrinsic (idiosyncratic, non-allergic or non-atopic) - Drug induced - Exercise induced # Allergic or extrinsic asthma - The most common form; account for 35% of all adult cases - Triggered by inhaled seasonal allergens such as pollens, dust, house mites, animal dander, and irritating fumes (seasonal variations) - Usually is seen in children and young adults - Patients frequently have well-defined allergy history, high IgE levels upon allergen exposure, positive skin tests to numerous allergens, and a family history of allergic conditions - When exposed to an allergen, several inflammatory mediators are secreted resulting in bronchial smooth muscle contraction (bronchoconstriction) and spasm (bronchospasm) - Increased vascular permeability, tissue oedema, mucous secretion #### Allergic or Extrinsic Asthma - The most common form; accounts for 35% of all adult cases. - Triggered by inhaled seasonal allergens such as pollens, dust, house mites, animal dander, and irritating fumes (seasonal variations). - Usually seen in children and young adults. - Patients frequently have a well-defined allergy history, high IgE levels upon allergen exposure, positive skin tests to numerous allergens, and a family history of allergic conditions. - When exposed to an allergen, several inflammatory mediators are secreted resulting in: - Bronchial smooth muscle contraction (bronchoconstriction) and spasm (bronchospasm) - Increased vascular permeability - Tissue oedema - Mucous secretion # Intrinsic asthma - Accounts for about 30% of asthma cases and seldom is associated with a family history of allergy or with a known cause - Most common in middle-aged adults (adult onset, over the age of 30) - Patients often have normal IgE levels, negative skin testing, and no history of allergies - Its onset is linked to endogenous factors like emotional stress or GERD - Patients are more likely to develop status asthmaticus - Keep in mind that some patients may have both extrinsic and intrinsic asthma. #### Intrinsic Asthma - Accounts for about 30% of asthma cases and seldom is associated with a family history of allergy or with a known cause. - Most common in middle-aged adults (adult onset, over the age of 30). - Patients often have normal IgE levels, negative skin testing, and no history of allergies. - Onset is linked to endogenous factors like emotional stress or GERD. - Patients are more likely to develop status asthmaticus. - Note: Some patients may have both extrinsic and intrinsic asthma. Drug induced asthma: - Triggered by drugs (aspirin, NSAIDs, betablockers, ACE inhibitors, metabisulphite preservatives) - Aspirin causes bronchonstriction (10% of asthma patients) - Aspirin sensitivity affects 30% asthmatic patients - Metabisulphite preservatives found in epinephrine-containing local anaesthetics Exercise-induced asthma +/- Infection related asthma - Caused or triggered by respiratory infections - Controlled by antimicrobial treatment (bacterial) and supportive care (viral) #### Drug-Induced Asthma - Triggered by drugs such as aspirin, NSAIDs, beta-blockers, ACE inhibitors, and metabisulphite preservatives. - Aspirin causes bronchoconstriction in 10% of asthma patients; aspirin sensitivity affects 30% of asthmatic patients. - Metabisulphite preservatives are found in epinephrine-containing local anaesthetics. #### Exercise-Induced Asthma - Triggered by physical exertion. #### Infection-Related Asthma - Caused or triggered by respiratory infections. - Controlled by antimicrobial treatment (bacterial) and supportive care (viral). # Clinical Presentation - Recurrent episodes of wheezing, dyspnea, cough, and chest tightness - Symptoms are frequently worse at night, early morning, or after exposure to a stimulus - Onset is abrupt, with the peak of symptoms happening within 10-15 minutes - Most episodes are self-limiting; severe attacks needs medical attention - Favourable prognosis when diagnosed in childhood - Condition resolves spontaneously after puberty in young children ## Complications - Acute asthmatic attacks can happen in the dental office; usually self-limiting or respond to inhaler ## Status asthmatics - Serious manifestation of asthma; potentially fatal - Severe and prolonged attack that persists for hours despite therapy - Increased and progressive dyspnea, jugular venous pulsation, cyanosis and pulsus paradoxus (fall in systolic pressure with inspiration) #### Clinical Symptoms - Recurrent episodes of wheezing, dyspnea, cough, and chest tightness. - Symptoms are frequently worse at night, early morning, or after exposure to a stimulus. - Onset is abrupt, with the peak of symptoms happening within 10-15 minutes. - Most episodes are self-limiting; severe attacks need medical attention. - Favourable prognosis when diagnosed in childhood; condition often resolves spontaneously after puberty. #### Complications - Acute asthmatic attacks can happen in the dental office; usually self-limiting or respond to an inhaler. #### Status Asthmaticus - Serious manifestation of asthma; potentially fatal. - Severe and prolonged attack that persists for hours despite therapy. - Characterized by increased and progressive dyspnea, jugular venous pulsation, cyanosis, and pulsus paradoxus (fall in systolic pressure with inspiration). ```markdown # Diagnosis - Diagnosis is based on clinical symptoms and response to therapy - Spirometry before and after administration of a short-acting bronchodilator - Widely applied in diagnosing asthma - Single best test for asthma - If the pulmonary function improves more than 12% following administration of a bronchodilator, this is supportive of the diagnosis - Other - Bronchial provocation (by histamine or methacholine chloride challenge) - Allergy blood and skin tests - Cell counts (to detect neutrophilia or eosinophilia) - Chest radiographs (to exclude other lung diseases) 27 ``` Diagnosis is based on clinical symptoms and response to therapy. #### Spirometry - Widely applied in diagnosing asthma and considered the single best test. - Performed before and after administration of a short-acting bronchodilator. - If pulmonary function improves more than 12% following administration, this is supportive of the diagnosis. #### Other Diagnostic Tools - Bronchial provocation (by histamine or methacholine chloride challenge) - Allergy blood and skin tests - Cell counts (to detect neutrophilia or eosinophilia) - Chest radiographs (to exclude other lung diseases) # Oral Findings - Dry mouth - β2-and anticholinergics can cause dry mouth - Oral Candidiasis - Occurs in 5% of patients who use inhalation steroids for long periods at high dose or frequency - Condition rare if a “spacer” or aerosol-holding chamber is used, mouth rinsed with water after each use - Angina bullosa haemorrhagica - Related to the use of corticosteroids inhalers and trauma - Enamel erosion - β-agonists and theophylline can exacerbate GORD which contributes to erosion of enamel <img src="https://i.imgur.com/placeholder.jpg" alt="Oral Findings Images" />  #### Dry Mouth - β2-agonists and anticholinergics can cause dry mouth. #### Oral Candidiasis - Occurs in 5% of patients who use inhalation steroids for long periods at high dose or frequency. - Condition is rare if a “spacer” or aerosol-holding chamber is used and the mouth is rinsed with water after each use. #### Angina Bullosa Haemorrhagica - Related to the use of corticosteroid inhalers and trauma. #### Enamel Erosion - β-agonists and theophylline can exacerbate GORD (GERD), which contributes to erosion of enamel. Four clinical photographs showing oral findings related to various conditions. The images display cases of oral candidiasis with white patches, angina bullosa haemorrhagica with a blood blister, and enamel erosion with discolored teeth. These photos illustrate the visual manifestations of conditions discussed in the text, including the effects of inhalation steroids and other medications on oral health. # Dental management considerations for patients with a history of asthma - Take a thorough history to determine the severity and stability of the disease - Ask about the type of asthma, adherence to medication, precipitating factors, timing, frequency and severity of attacks - Remind the patient to bring their rescue inhaler to the appointment - Encourage smokers to stop smoking - Obtain medical consultation of asthma is poorly controlled (wheezing or coughing or recent hospitalization - For severe and unstable asthma, consult with the patient's physician, routine dental treatment should be postponed - Take a thorough history to determine the severity and stability of the disease. - Ask about the type of asthma, adherence to medication, precipitating factors, timing, frequency, and severity of attacks. - Remind the patient to bring their rescue inhaler to the appointment. - Encourage smokers to stop smoking. - Obtain medical consultation if asthma is poorly controlled (e.g., wheezing, coughing, or recent hospitalization). - For severe and unstable asthma, consult with the patient's physician; routine dental treatment should be postponed. # Prevention of an acute asthmatic attack during dental care ## Anxiety - Provide a stress-free environment through the establishment of rapport and openness to reduce the risk of anxiety-induced asthma attacks - If sedation is required, use of nitrous oxide-oxygen inhalation sedation or small doses of a short-acting benzodiazepine (oral diazepam) (or both) is recommended - Avoid barbiturates and narcotics because they can provoke asthmatic attacks in some patients (histamine-releasing drugs), and can depress respiration ## Anaesthesia - Epinephrine-containing local anesthetics are generally not contraindicated - Sodium metabisulfite preservative may elicit asthmatic attacks in susceptible individuals #### Anxiety Management - Provide a stress-free environment through the establishment of rapport and openness to reduce the risk of anxiety-induced asthma attacks. - If sedation is required, use of nitrous oxide-oxygen inhalation sedation or small doses of a short-acting benzodiazepine (oral diazepam) (or both) is recommended. - Avoid barbiturates and narcotics because they can provoke asthmatic attacks in some patients (histamine-releasing drugs) and can depress respiration. #### Anaesthesia - Epinephrine-containing local anesthetics are generally not contraindicated. - Sodium metabisulfite preservative may elicit asthmatic attacks in susceptible individuals. Antibiotics - Avoid prescribing macrolide antibiotics (e.g., erythromycin, azithromycin) or ciprofloxacin to patients who are taking theophylline (raise blood levels) Analgesics - The administration of aspirin to patients with asthma is not advisable because it can provoke asthma attacks in some patients - Avoid aspirin and other NSAIDs in susceptible individuals Drugs - Make sure that the patient has taken their most recent scheduled dose of medication - Check the availability of the rescue inhaler; use it prophylactically in moderate to severe disease - For patients on systemic steroids, provide corticosteroid on the morning of a surgical procedure #### Antibiotics - Avoid prescribing macrolide antibiotics (e.g., erythromycin, azithromycin) or ciprofloxacin to patients who are taking theophylline, as they can raise blood levels. #### Analgesics - The administration of aspirin to patients with asthma is not advisable because it can provoke asthma attacks in some patients. - Avoid aspirin and other NSAIDs in susceptible individuals. #### Medication Adherence and Prophylaxis - Make sure that the patient has taken their most recent scheduled dose of medication. - Check the availability of the rescue inhaler; use it prophylactically in moderate to severe disease. - For patients on systemic steroids, provide corticosteroid on the morning of a surgical procedure. ## Other preventive measures - Patients who have nocturnal asthma should be scheduled for late-morning appointments, when attacks are less likely - Keep away materials with irritating odors (e.g., surface disinfectants, methyl methacrylate, fissure sealants) - Use a dental dam to reduce exposure to irritating particles like tooth-enamel dust and prophy paste - Non-latex gloves and dental dams should be used for latex-sensitive patients - Cold-temperature clinics and surgical rooms should also be avoided - Patients who experience respiratory discomfort when fully reclined should be treated in a semi-supine position #### Environmental and Procedural Measures - Patients who have nocturnal asthma should be scheduled for late-morning appointments, when attacks are less likely. - Keep away materials with irritating odors (e.g., surface disinfectants, methyl methacrylate, fissure sealants). - Use a dental dam to reduce exposure to irritating particles like tooth-enamel dust and prophy paste. - Non-latex gloves and dental dams should be used for latex-sensitive patients. - Cold-temperature clinics and surgical rooms should be avoided. - Patients who experience respiratory discomfort when fully reclined should be treated in a semi-supine position. ```markdown Chronic obstructive pulmonary disease (COPD) - COPD is a general term for pulmonary disorders characterized by chronic and progressive air flow limitation that is irreversible - Linked to exposure to harmful environmental stimuli- cigarette smoke - 2 main diseases: chronic bronchitis and emphysema - Chronic bronchitis: defined as a condition associated with chronic inflammation of the bronchi that produces excessive tracheobronchial mucous production - Emphysema: defined as a permanent enlargement of the air spaces in the lung (distal to the terminal bronchioles) followed by the destruction of the air space (alveolar) walls <img src="https://i.imgur.com/placeholder.png" alt="Comparison of Healthy Lung and Emphysema Lung"> ```  Chronic obstructive pulmonary disease (COPD) is a general term for pulmonary disorders characterized by chronic and progressive air flow limitation that is irreversible. It is primarily linked to exposure to harmful environmental stimuli, most notably cigarette smoke. #### Primary Disease Classifications - **Chronic Bronchitis**: Defined as a condition associated with chronic inflammation of the bronchi that produces excessive tracheobronchial mucous production. - **Emphysema**: Defined as a permanent enlargement of the air spaces in the lung (distal to the terminal bronchioles) followed by the destruction of the air space (alveolar) walls. A comparative diagram showing a healthy lung versus a lung affected by emphysema, illustrating the structural differences such as the enlargement of air spaces and destruction of alveolar walls in emphysema. The diagram is labeled 'Healthy lung' and 'Emphysema' to highlight the contrast. # Aetiology/Pathogenesis ## Cause - Tobacco smoking is the most important cause of COPD - One in five chronic smokers develops COPD - Long-term exposure to occupational and environmental pollutants - Hereditary absence or deficiency of alpha-1 antitrypsin ## Pathogenesis - Chronic exposure to cigarette leads to persistent inflammation, narrowing of small airways, damage the alveolar walls, airflow limitation and obstruction #### Etiological Factors - Tobacco smoking is the most important cause of COPD; approximately one in five chronic smokers develops the condition. - Long-term exposure to occupational and environmental pollutants. - Hereditary absence or deficiency of alpha-1 antitrypsin. #### Pathogenesis Chronic exposure to cigarette smoke leads to: - Persistent inflammation. - Narrowing of small airways. - Damage to the alveolar walls. - Airflow limitation and obstruction. ## Clinical Presentation - Symptoms develop slowly - Chronic cough with sputum (more frequent with chronic bronchitis) - Dyspnoea that is persistent and progressive or worsens with exercise - Patients with chronic bronchitis are described as “blue bloaters”: sedentary, overweight, cyanotic, oedematous and breathless - Patients with emphysema are described as “pink puffers”: enlarges chest walls (barrel-chested appearance), weight loss, severe exertional dyspnoea - Many patients with COPD may exhibit features of both diseases Symptoms of COPD typically develop slowly and include a chronic cough with sputum (more frequent in chronic bronchitis) and dyspnoea that is persistent, progressive, or worsens with exercise. #### Clinical Phenotypes - **Blue Bloaters (Chronic Bronchitis)**: Patients are often sedentary, overweight, cyanotic, oedematous, and breathless. - **Pink Puffers (Emphysema)**: Patients exhibit enlarged chest walls (barrel-chested appearance), weight loss, and severe exertional dyspnoea. Many patients with COPD may exhibit features of both diseases simultaneously. # Oral manifestations - Smoking-related: halitosis, extrinsic tooth stains, nicotine stomatitis, periodontal disease, cancerous and precancerous lesions in chronic smokers - Drug related: dry mouth, caries and oral candidiasis    #### Smoking-Related Manifestations - Halitosis - Extrinsic tooth stains - Nicotine stomatitis - Periodontal disease - Cancerous and precancerous lesions #### Drug-Related Manifestations - Dry mouth (xerostomia) - Dental caries - Oral candidiasis Close-up photo of oral lesions, showing white patches and red inflamed areas on the oral mucosa, likely representing nicotine stomatitis or other smoking-related changes. Photo of a dental lesion in the oral cavity, showing a tooth with a dark filling and surrounding red, inflamed tissue, possibly indicating caries or periodontal involvement. Photo of oral candidiasis, characterized by white, patchy lesions on the tongue and oral mucosa, consistent with fungal infection. # Dental management considerations for patients with COPD - Assess the severity of the respiratory disease and the degree of control - Take a thorough history and review the systems to determine onset, stage, symptoms, medications and coexisting conditions (hypertension, congestive cardiac failure, respiratory infections) - Assess vital signs (BP, pulse, respiratory rate) - Determine the smoking status and advise smokers to stop smoking - Remind the patient to bring the inhaler (short-acting) to each dental appointment - Obtain medical consultation if the condition is undiagnosed (H/O of smoking, coughing, exertional dyspnoea, cyanosis or frequent respiratory infections) - A patient with shortness of breath at rest, productive cough, URI infection or an oxygen saturation less than 91% is unstable - If the patient has no dyspnoea, oxygen saturation greater than 95%, no URI- stable patient #### Patient Assessment and History - Assess the severity of the respiratory disease and the degree of control. - Take a thorough history and review systems to determine onset, stage, symptoms, medications, and coexisting conditions (e.g., hypertension, congestive cardiac failure, respiratory infections). - Assess vital signs including blood pressure, pulse, and respiratory rate. - Determine smoking status and advise smokers to cease smoking. - Remind the patient to bring their short-acting inhaler to every dental appointment. #### Medical Consultation and Stability Obtain a medical consultation if the condition is undiagnosed (indicated by a history of smoking, coughing, exertional dyspnoea, cyanosis, or frequent respiratory infections). - **Unstable Patient**: Characterized by shortness of breath at rest, productive cough, upper respiratory infection (URI), or oxygen saturation less than 91%. - **Stable Patient**: Characterized by no dyspnoea, oxygen saturation greater than 95%, and no active URI. # Prevention of respiratory depression during dental Tx - Limit epinephrine if significant CVD is present - Avoid bilateral blocks (can cause unpleasant airway constriction sensation) - Avoid macrolide antibiotics (reduce the metabolism of theophylline) - If orthopnoea is present, treat the patient in semi-supine or upright chair position - Avoid the use of rubber dam in patients with severe disease or who mouth-breathe - If sedation medication is required, low dose oral diazepam may be used - Narcotics and barbiturates avoided (depresses respiration) - Anticholinergics and antihistamines used with caution (drying properties and increase in mucous tenacity) - Outpatient GA is contraindicated for most patients with COPD #### Clinical Precautions and Contraindications - **Positioning**: If orthopnoea is present, treat the patient in a semi-supine or upright chair position. - **Local Anaesthesia**: Limit epinephrine if significant cardiovascular disease is present. Avoid bilateral mandibular blocks, as they can cause an unpleasant sensation of airway constriction. - **Equipment**: Avoid the use of rubber dams in patients with severe disease or those who are mouth-breathers. - **Pharmacological Considerations**: - Avoid macrolide antibiotics (they reduce the metabolism of theophylline). - Avoid narcotics and barbiturates (they depress respiration). - Use anticholinergics and antihistamines with caution due to drying properties and increased mucous tenacity. - **Sedation and General Anaesthesia**: - If sedation is required, low-dose oral diazepam may be used. - Outpatient general anaesthesia (GA) is contraindicated for most patients with COPD. Tuberculosis - Chronic infectious disease caused primarily by *Mycobacterium tuberculosis* (acid-fast aerobic, non-motile bacillus) - Transmission occurs through inhalation of infected airborne droplets from a person with active pulmonary TB - Primary TB (primary site is lung, spread to other parts of the body) - Latent TB (90-95% of patients develop) - Healed primary lesions leave a calcified nodule +/- hiliar lymph node) - Bacteria can remain dormant in the nodules for years - Patients asymptomatic and cannot infect others - Secondary TB - 5-10% latent infections can progress to active disease - Common in immunocompromised persons - HIV infection most significant risk factor for developing active TB <img src="https://i.imgur.com/placeholder.jpg" alt="Chest X-ray showing lung lesions indicative of tuberculosis">  Tuberculosis is a chronic infectious disease caused primarily by *Mycobacterium tuberculosis*, an acid-fast aerobic, non-motile bacillus. Transmission occurs through the inhalation of infected airborne droplets from a person with active pulmonary disease. #### Disease Progression and Classification - **Primary TB** - The primary site of infection is the lung, with potential spread to other parts of the body. - **Latent TB** - Develops in 90-95% of patients. - Healed primary lesions leave a calcified nodule, which may include a hilar lymph node. - Bacteria can remain dormant in these nodules for years. - Patients are asymptomatic and cannot infect others. - **Secondary TB** - Occurs when latent infections progress to active disease (5-10% of cases). - Common in immunocompromised persons. - HIV infection is the most significant risk factor for developing active TB. Chest X-ray showing lung lesions indicative of tuberculosis, with arrows pointing to abnormal areas in the upper lobes, consistent with active pulmonary TB. This image illustrates the radiographic findings associated with secondary TB, which can progress from latent infection. ```markdown # Diagnosis - Tuberculin skin test (TST) - Also known as Mantoux test, purified protein derivative (PPD) test - PPD injected under the skin of forearm, after 72 hours, circumference of induration measured (15mm induration is considered positive) - Interferon-gamma release assay (IGRA) - Blood test to determine exposure to *M. tuberculosis* - Can detect recent infections, results available within 24 hours - Cannot differentiate latent TB from active TB ``` #### Diagnostic Testing Methods - **Tuberculin Skin Test (TST)** - Also known as the Mantoux test or purified protein derivative (PPD) test. - PPD is injected under the skin of the forearm. - After 72 hours, the circumference of induration is measured; a 15mm induration is considered positive. - **Interferon-Gamma Release Assay (IGRA)** - A blood test used to determine exposure to *M. tuberculosis*. - Can detect recent infections with results available within 24 hours. - Cannot differentiate between latent TB and active TB. # Dental management - Four infectivity categories (1) active TB, (2) history of TB (3)+ TST or IGRA and (4) signs or symptoms suggestive of TB - Consult with physician before treatment - Provide emergency care in a hospital setting: isolation, sterilization, ventilation and filtration masks (N95; N99; N100) - Rubber dam and high-speed suction should be used to minimize aerosolization of oropharyngeal microbes #### Clinical Management Protocols - Patients are categorized into four infectivity groups: 1. Active TB 2. History of TB 3. Positive TST or IGRA 4. Signs or symptoms suggestive of TB - Consult with a physician before commencing treatment. - Emergency care must be provided in a hospital setting utilizing: - Isolation protocols - Sterilization - Specialized ventilation - Filtration masks (N95, N99, or N100) - Use rubber dams and high-speed suction during procedures to minimize the aerosolization of oropharyngeal microbes. # Dental management - Four infectivity categories (1) active TB, (2) history of TB (3)+ TST or IGRA and (4) signs or symptoms suggestive of TB - Consult with physician before treatment - Provide emergency care in a hospital setting: isolation, sterilization, ventilation and filtration masks (N95; N99; N100) - Rubber dam and high-speed suction should be used to minimize aerosolization of oropharyngeal microbes #### Clinical Management Protocols - Patients are categorized into four infectivity groups: 1. Active TB 2. History of TB 3. Positive TST or IGRA 4. Signs or symptoms suggestive of TB - Consult with a physician before commencing treatment. - Emergency care must be provided in a hospital setting utilizing: - Isolation protocols - Sterilization - Specialized ventilation - Filtration masks (N95, N99, or N100) - Use rubber dams and high-speed suction during procedures to minimize the aerosolization of oropharyngeal microbes. ```html <table> <thead> <tr> <th>Drug</th> <th>Adverse effects</th> <th>Dental consideration</th> </tr> </thead> <tbody> <tr> <td>Isoniazid</td> <td>Hepatotoxicity; elevation in serum aminotransferase in 10-20% of patients</td> <td>Avoid acetaminophen when aminotransferases are elevated; isoniazid increases the concentrations of diazepam</td> </tr> <tr> <td>Rifampicin</td> <td>Hepatotoxicity; leukopenia, jaundice, thrombocytopaenia</td> <td>Infection increased, delayed healing, gingival bleeding; rifampicin decreases serum levels of (diazepam, erythromycin, clarithromycin, fluconazole)</td> </tr> <tr> <td>Streptomycin</td> <td>Ototoxicity</td> <td>Streptomycin and aspirin can interact and cause ototoxicity; avoid concurrent use of aspirin</td> </tr> </tbody> </table> ```  #### Antituberculosis Medication Interactions - **Isoniazid** - **Adverse Effects:** Hepatotoxicity; elevation in serum aminotransferase in 10-20% of patients. - **Dental Considerations:** Avoid acetaminophen when aminotransferases are elevated. Isoniazid increases the concentrations of diazepam. - **Rifampicin** - **Adverse Effects:** Hepatotoxicity, leukopenia, jaundice, and thrombocytopaenia. - **Dental Considerations:** Risk of increased infection, delayed healing, and gingival bleeding. Rifampicin decreases serum levels of diazepam, erythromycin, clarithromycin, and fluconazole. - **Streptomycin** - **Adverse Effects:** Ototoxicity. - **Dental Considerations:** Streptomycin and aspirin can interact to cause ototoxicity; avoid concurrent use of aspirin. A table titled 'Dental treatment considerations with antituberculosis drugs' that lists three drugs—isoniazid, rifampicin, and streptomycin—along with their adverse effects and corresponding dental considerations. The table is organized into three columns: Drug, Adverse effects, and Dental consideration, providing specific clinical guidance for each medication. # Oral findings - Mouth ulceration rare - Chronic, painless, undermined ulcer on the dorsum of tongue (can be indurated with raised margins) - Caused by infected sputum - Granulating gingival lesions also reported - Cervical lymphadenitis, sinus tracts from necrotic lymph node to the skin surface ('collar stud' abscess) - Biopsy (caseating epithelioid granulomas) - Identified in Ziehl-Neelsen stained sections, culture or PCR - Prolonged antibiotic therapy required to clear the infection (isoniazid, rifampicin)    #### Clinical Presentation and Diagnosis - **Oral Lesions** - Mouth ulceration is rare. - When present, it typically appears as a chronic, painless, undermined ulcer on the dorsum of the tongue (may be indurated with raised margins). - These lesions are caused by infected sputum. - Granulating gingival lesions have also been reported. - **Systemic and Lymphatic Involvement** - Cervical lymphadenitis. - Sinus tracts extending from necrotic lymph nodes to the skin surface (known as a 'collar stud' abscess). - **Diagnostic Identification** - Biopsy typically reveals caseating epithelioid granulomas. - Identified via Ziehl-Neelsen stained sections, culture, or PCR. - **Treatment** - Prolonged antibiotic therapy is required to clear the infection (e.g., isoniazid, rifampicin). A close-up photograph showing granulating gingival lesions in the mouth, with visible inflammation and tissue damage around the teeth. A clinical photograph of a patient's neck, illustrating cervical lymphadenitis with a sinus tract and a 'collar stud' abscess on the skin surface. A microscopic image of a biopsy showing caseating epithelioid granulomas, characteristic of a granulomatous infection, stained in purple and pink. # Cystic fibrosis - Autosomal disorder characterised by the build-up of thick, viscous secretions that can damage many organs - Mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene - Affects mostly lung and pancreas - Also affects liver, kidneys, testicles and salivary glands - End-stage lung disease main cause of death - Difficulty in breathing, coughing up mucous - Frequent lung infections, fatty stool, poor growth - Nasal polyps, recurrent sinusitis **Treatment:** - Antibiotics, bronchodilators, mucolytic agents - Oxygen therapy as needed, Chest physiotherapy to loosen mucous - Diet high in protein with pancreatic enzymes and fat-soluble vitamins Cystic fibrosis is an autosomal disorder characterized by the build-up of thick, viscous secretions that can damage many organs. It is caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene. #### Clinical Presentation and Systemic Effects - Primary impact on the lungs and pancreas. - Also affects the liver, kidneys, testicles, and salivary glands. - End-stage lung disease is the main cause of death. - Respiratory symptoms include difficulty in breathing and coughing up mucous. - Other systemic signs include frequent lung infections, fatty stool, poor growth, nasal polyps, and recurrent sinusitis. #### Medical Management - Pharmacological interventions: Antibiotics, bronchodilators, and mucolytic agents. - Respiratory support: Oxygen therapy as needed and chest physiotherapy to loosen mucous. - Nutritional support: Diet high in protein supplemented with pancreatic enzymes and fat-soluble vitamins. # Oral manifestations - Major salivary glands may enlarge and hyposalivation can occur - Delayed dental eruption (due to poor growth) - Higher incidence of enamel defects (due to repeated infections) - Low fat, high carbohydrate diet and dry mouth may predispose to caries - Increased calculus formation (due to higher amount of Ca in saliva) 46 #### Salivary and Developmental Changes - Major salivary glands may enlarge. - Hyposalivation can occur. - Delayed dental eruption, often associated with poor systemic growth. #### Hard Tissue and Oral Health Findings - Higher incidence of enamel defects due to repeated infections. - Increased calculus formation resulting from higher concentrations of calcium in the saliva. - Potential predisposition to dental caries due to a combination of dry mouth and a low-fat, high-carbohydrate diet. ## Dental considerations - Reduced respiratory function, liver disease (bleeding tendency) and diabetes may complicate treatment - Short appointments recommended - Avoid early morning appointment (mucous production) - Patients best treated in upright position - Antimicrobials for oral infections selected carefully since patients are often on long term antibiotic therapy #### Clinical Management and Appointment Planning - Treatment may be complicated by reduced respiratory function, liver disease (which may cause a bleeding tendency), and diabetes. - Short appointments are recommended to accommodate patient limitations. - Avoid early morning appointments due to increased mucous production during those times. - Patients are best treated in an upright position to assist with respiratory comfort. #### Pharmacological Precautions - Antimicrobials for oral infections must be selected carefully, as these patients are often on long-term antibiotic therapy. 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