NBDHE - Compromised Pts

🧩 ADL Levels of Functioning (0–III)

• A patient at Level III may need a caregiver to assist with brushing, flossing, or even attending appointments

• Consider ADL level when planning oral hygiene instructions, prosthetics, or follow-ups

Level	Functioning Description	Patient Ability
0 – Independent	Performs activity without help or supervision	No physical or verbal assistance needed
I – Requires Equipment or Setup	Performs activity with assistive device or setup help	May need walker, hearing aid, or help setting up task
II – Requires Supervision or Cueing	Can do activity with verbal reminders or someone nearby	Needs prompting or someone to ensure safety/completion
III – Requires Hands-On Assistance	Needs physical help to complete activity	Caregiver physically assists with the task. Brushing, Flossing.

Fear vs. Anxiety

Term	Definition	Threat Type
Fear	An emotional response to a real, identifiable, and immediate threat	➤ Identified threat (present danger)
Anxiety	A future-oriented, vague, or anticipated emotional response	➤ Anticipated threat (possible danger)

Special Patient Considerations

what are the 2 tobacco cessation medications?

Condition	Key Points
Deaf patients	Do not shout- Face the patient- Use written communication or interpreter as needed
Blind patients	Speak as if on the phone (describe what you're doing)- Do not touch service animal- Guide with verbal cues
Pregnancy	2nd trimester = safest for dental care Use daily topical fluoride only (not systemic). Short appointments. Keep legs uncrossed. Avoid NSAIDs, use Tylenol. Position to the left side with pillow to prevent supine hypotensive syndrome
Tobacco counseling	Follow 5 A’s: Ask, Advise, Assess, Assist, Arrange Cessation: Bupropion (Wellbutrin/Zyban), Chantix (nicotine receptor agonist)
Alcoholism	Avoid nitroglycerin → dangerously low BP Oral petechiae common #1 cause of pancreatitis Avoid acetaminophen (liver risk) Avoid metronidazole → causes severe illness (antabuse-like)
Erectile Dysfunction meds	Viagra, Cialis with nitroglycerin = severe hypotension risk

🍼 Fetal Alcohol Syndrome (FAS) — Overview

Aspect	Key Features
Oral	U-shaped or cleft palate Gingivitis Abnormal tooth eruption, Tooth malformations
Facial	Indistinct philtrum (smooth between nose & upper lip) Thin upper lip- Small eye openings
Behavioral	Hyperactivity Behavioral problems- Learning and attention issues
Other Notes	Dose-dependent (more alcohol exposure = more severe outcomes) Caused by alcohol consumption during pregnancy

Substance Abuse

what drug abuse causes Parkinson’s like tremors?

Type	Key Signs	Dental Considerations
Heroin Depressant	Pinpoint pupils (miosis) Drowsiness ↓ Resp. rate Bradycardia Hypothermia	Methadone (full agonist) used for withdrawal (also causes miosis) Narcan = overdose antidote, antagonist. ↑ Risk: IE, Hep B, HIV
Cocaine Stimulant	Dilated pupils (mydriasis) Euphoria- ↑ BP/HR	No epinephrine (hypertensive crisis) Delay treatment 24 hrs post-use
Methamphetamine Stimulant	Dilated pupils (mydriasis) “Tweaker” behavior Parkinson-like tremors	No epinephrine(hypertensive crisis) Delay treatment 24 hrs Meth mouth: rampant caries, bruxism, xerostomia

Asthma: Clinical & Dental Overview

ASTHMA - no ibuprofen/NSAIDs

Signs/Symptom	Unproductive cough, Recurrent dyspnea, Mouth breathing, Chest holding, Aspiration risk
Inhaler Side Effects	Xerostomia, caries risk, candidiasis
Contraindication	Epinephrine or levonordefrin in LA → sulfites Aspirin & NSAIDs (trigger attacks) Air polishers & ultrasonic scalers (bronchospasm)
Safe Sedation	Nitrous oxide/oxygen: OK for mild - moderate. Avoid in severe asthma. Foggy Mask = pt started breathing
Other Considerations	High-volume evacuation to limit aerosol triggers Status asthmaticus = life-threatening (doesn’t respond to meds)

🫁 COPD Overview (Chronic Obstructive Pulmonary Disease)

COPD: 2 or more diseases; chronic bronchitis + emphysema

• often from smoking, family history, childhood infections, pollution

General Signs	Wheezing, Chronic cough, Chest pain, ↑ Respiratory rate, Airway obstruction
Medications	Bronchodilators, Steroids, Antibiotics
Contraindications	No air polisher or ultrasonic scalers No rubber dam No nitrous oxide/oxygen sedation
Dental Modifications	Short appointments,Tobacco counseling Elevate head of chair, Use high-volume evacuation

Blue Bloater - Chronic Bronchitis

• Cyanotic skin, Chronic productive cough ("smoker's cough")

• Severe dyspnea, Hypoxia.

• Thick mucus production, Phelgem

• More common in women

• Respiratory acidosis

Pink Puffer - Emphysema

• Pink skin tone, Severe dyspnea, Minimal cough.

• Barrel chest - Over inflation of Aveloli Air Sac

• Pursed-lip breathing

• Weight loss/thin appearance

• More common in older men

• Prolonged expiration

Cystic Fibrosis & Tuberculosis

Cystic Fibrosis (CF)	Details
Cause	Genetic disorder (affects exocrine glands)
Secretions	Thick and sticky (saliva, mucus, sweat, tears)
Respiratory Effects	Mucus buildup → poor gas exchange
Dental Contraindications	No nitrous oxide/oxygen sedation No air polisher or ultrasonic scaler No rubber dam
Oral Considerations	High caries and infection risk due to altered saliva
Transmission	Not contagious

Tuberculosis (TB)	Details
Cause	Bacterial infection (Mycobacterium tuberculosis)
Transmission	Airborne - coughing, sneezing, contaminated dust
Symptoms	Chronic cough, fever, weight loss, hemoptysis
Diagnosis	PPD (Mantoux skin test) = exposure only positive test doesn’t = active Chest X-ray, sputum test for active TB
Staining	Acid-fast stain required (waxy cell-wall resists Gram stain)
Dental Precaution	❌ Do not treat if TB is active
Medication Caution	TB drugs are hepatotoxic (isoniazid, rifampin)

Cardiac Conditions – Comparison Table

Syncope - most common dental emergency

Mitral Regurgitation - fluid buildup in lungs.

Coronary Artery Disease → Angina

180/110 → deferment of treatment.

Condition	Definition / Key Features	Symptoms / Risks	Dental Notes / Contraindications
Cardiac Arrhythmias	Irregular heart rhythm (e.g., Afib)	Irregular HR, cyanosis	No epi Avoid unshielded ultrasonic scalers Postpone if uncontrolled
Congenital Heart Disease	Heart defect present at birth	Cyanosis, clubbing, often in Down syndrome	✅ Medical consult needed ✅ Premed for unrepaired defects
Coronary Heart Disease	Ischemia due to blocked coronary arteries	Angina, MI	✅ Premed may be needed for congenital risks
Angina Pectoris	Temporary oxygen deficiency to heart	Chest pain, indigestion-like discomfort	✅ Nitroglycerin ready ✅ Short, stress-free appointments
Myocardial Infarction	Arrest of blood flow → heart tissue death	Nausea, vomiting, palpitations, ↓ BP	❌ Postpone treatment for 6 months post-MI
Congestive Heart Failure	Pumping failure of one/both ventricles	Shortness of breath, fatigue	✅ Use semi-supine position Digitalis: gag reflex, hypersalivation

Neurologic Disorders – Comparison Table

Condition	Key Features	Clinical Signs	Dental Considerations
Parkinson’s Disease	Imbalance of lack of dopamine & acetylcholine ↑ Typically males, age 40–60	Shuffling gait tremors brandykinsea unblinking eyes	Black box warning meds Short appts Manage tremors/stress
Alzheimer’s Disease	Progressive memory loss, ↓ acetylcholine. Brain atrophy, enlarged ventricles	Disorientation, poor recall, poor oral hygiene	Avoid fluoride & antimicrobials interact with meds Simplify instructions
ADHD	Behavioral disorder (attention, hyperactivity, impulsivity)	Fidgeting, inattentiveness	Mid-morning appts - after med has kicked in. short appts Med: Ritalin (methylphenidate)
Bell’s Palsy	CN VII (Facial nerve) paralysis — often one-sided	Facial drooping, excessive salivation, gingival issues	Protect affected side Oral care difficulty Extra hygiene support

	⚡ Seizure Disorders Summary
Type	Generalized seizure — Idiopathic Grand Mal (Tonic-Clonic) Tonic Phase: Muscle rigidity (stiffening) Clonic Phase: Uncontrolled jerking movements Aura-Often present before seizure as a warning sign
Medications	Phenytoin, Carbamazepine, Valproic acid, Phenobarbital
Contraindications	No nitrous oxide Never place tongue blade or objects between teeth during seizure
Dental Management	Short, stress-free appointments ensure meds taken avoid seizure triggers (stress, hypoglycemia) Emergency protocol ready (oxygen, suction, airway protection) Do not sit patient up during episode.

Genetic Syndromes

Syndrome	General Features	Oral Features
Fragile X Syndrome (males)	Intellectual disability behavioral issues	Delayed tooth eruption, unusual tooth shape, high-arched palate, malocclusion, bruxism, speech/swallowing difficulties
Turner Syndrome (females)	Missing X chromosome short stature, delayed puberty	High/narrow palate, malocclusion, micrognathia (small jaw), less common cleft palate/lip
Down Syndrome (Trisomy 21)	Intellectual disability hypotonia	Macroglossia, fissured tongue, taurodontism, increased periodontal disease not increased caries/xerostomia tell-show-do for oral hygiene
Autism		short - frequent appts over explaining → overwhelms pt

Neurologic, Musculoskeletal, and Endocrine Disorders

Condition	Key Features	Dental Considerations
Schizophrenia	↑ Acetylcholine, behavioral instability	↑ Caries risk from xerostomia, avoid loud noises/music in office
Depression	Mood disorder	Tricyclic antidepressants = No epinephrine (risk of cardiac effects)
Multiple Sclerosis	Autoimmune, attacks myelin sheath, muscular weakness. Oral man: paresthesia, facial palsy, trigeminal neuralgia.	May need mobility accommodations, stress management
Musculoskeletal Disorders	Various conditions affecting bones/joints	No ABX pre-med needed for prosthetic joints per current guidelines
Spinal Cord Injury	Depends on injury level (C7, T12, L5, S5)	Severity varies; position appropriately, assess motor skills C4-need help Quadriplegic C5-partial shoulder/elbow movements, no arm movement, needs help brushing C7-full arm movements, partial hand movements. T1-full arm/hand movements.
Cerebral Palsy	Hypoxia at birth, neuromuscular disorder	May present with poor oral hygiene, gingival hyperplasia (from meds), involuntary movements
Diabetes Mellitus 3P’s	Hypoglycemia Too much insulin, no food, excess exercise	Clammy skin, sweating, shaking; give glucose
	Hyperglycemia Too little insulin, infection, steroids	3P’s: Polydipsia - excessive thirst Polyuria - urine Polyphagia - hunger keep warm, give fluids, hospitalize if needed diabetic ketoacidosis: nausea/vomiting, hyperthermia, psychosis leading to dementia (losing memory/acting crazy)
	For uncontrolled diabetics or CVD = 0.04mg epi in LA	5-10% gestational DM turns into type 2 after pregnancy.

Hepatitis, Renal Failure, Addison’s Disease, and Cushing’s Syndrome,

Condition	Key Features	Dental Considerations
Hepatitis	Jaundice may be present, abnormal bleeding, HCWs at high risk for Hep B (needlesticks)	Screen medical history carefully; delay treatment during active infection
	Bloodborne: Hep B, C, D	Must have Hep B to get D. C = most asymptomatic, no vaccine, from chronic liver damage.
	Fecal-oral: Hep A, E	Hep E extremely rare in developed countries. Hep A has vaccine, and doesn’t show past infection, only current.
Renal Failure	Waste buildup, often treated with dialysis	Schedule dental care 24 hrs post-dialysis; avoid BP cuff on fistula/graft arm
Addison’s Disease bronzing	Primary Adrenal insufficiency ↓ steroid production Symptoms (EVERYTHING’S LOW) anorexia, lethargy, weakness, dehydration, hypoglycemia.	Bronzing of skin/mucosa, consult PCP about steroid premed nothing to do with ACTH
Cushing’s Syndrome 3 cardnial signs	↑ Cortisol (hypercortisolism), from excess ACTH Often caused by pituitary tumor or long-term steroid use	Weight gain, moon face, buffalo hump, HTN, bone fractures. Monitor healing, consider stress reduction, increased infection risk 3 Cardnial Signs: dyspepsia - indigestion dysphagia - diff swallowing dysuria - painful urine

Thyroid & GI Conditions

Condition	Key Features	Dental Considerations
Hypothyroidism	In children: Cretinism In adults: Myxedema Bradycardia, weight gain. Often from Hashimoto’s (autoimmune)	Delayed tooth eruption, sensitive to CNS depressants
Hyperthyroidism	Often from Graves’ disease (autoimmune) Goiter, tachycardia, weight loss Exophthalmos, accelerated eruption	NO epinephrine, monitor vitals, stress management
Goiter	Enlarged thyroid gland May be from Graves’ Iodine deficiency Tumors	Visually noticeable; refer to PCP or endocrinologist
Crohn’s Disease	Autoimmune GI inflammation Symptoms: Diarrhea, malabsorption	May see aphthous ulcers, delayed healing, nutritional deficienci

Connective Tissue Disorders

Condition	Key Features	Dental Considerations
Epidermolysis Bullosa	Hereditary blistering disorder Skin is extremely fragile bullae from minor trauma	Use pillows, blankets to protect; gentle handling during dental care
Osteoarthritis	Age-related joint degeneration Loss of cartilage cushioning	May have limited mobility; ensure comfortable positioning
Rheumatoid Arthritis	Chronic autoimmune disorder Nodules, joint pain, can occur in children	Suggest electric toothbrush, modified handles, shorter appointments
Marfan Syndrome	Hereditary CT disorder affects joints, skeleton, heart Tall stature, long fingers (arachnodactyly)	Oral: High palate, TMJ dysfunction, Class III malocclusion May require ABX premed
Scleroderma	Autoimmune collagen overproduction Raynaud's phenomenon, tight skin	Oral: Xerostomia, limited opening, widened PDL Use hygiene aids, frequent recalls
Ehlers-Danlos Syndrome	defect in the structure of collagen Clinical: unusually loose and weak joints and skin hyperelasticity.	Gorlin sign- ability to touch nose with tongue Weak TMJ Weak mucosa & gingival tissue BOP Early onset of Perio Abnormal tooth morphology

Blood & Genetic Conditions

Condition	Key Features
Sickle Cell Anemia	Crescent/moon-shaped RBCs smooth tongue, hemoglobin defect, severe pain, mucosal pallor, delayed tooth eruption, ABX may be needed. autosomal recessive, carriers often asymptomatic.
Hemophilia A	Factor VIII deficiency. (8) bleeding disorder, X-linked (carried by females, affects males). Factor VIII replacement prior to treatment.
Leukemia	Cancer of WBCs May lead to aplastic anemia, boggy, edematous gingival enlargement, frequent infections. use alcohol-free rinses, fluoride, antimicrobials.
Anemia	Decreased oxygen in RBCs beefy bald red tongue, altered taste. Vitamin B12 deficiency = pernicious anemia.
Reye’s Syndrome	Brain & liver inflammation follows viral infection (flu/chickenpox) aspirin use in children.
Myasthenia Gravis	Muscle weakness drooping eyelids, difficulty swallowing, increased aspiration risk, altered speech. avoid ultrasonic and air polisher.

• HIV/AIDS-Related

• Craniofacial Syndromes

Condition

Key Features

HIV/AIDS

Immunocompromised, ↓ CD4 count, follow physician guidance, frequent recare, fluoride & antimicrobial rinses. Use Ultrasonics, 3-month recall. Avoid the creation of an aerosol. USE high-volume suction, PPE, standard precaution. To reduce infection risk to immunocompromised pt/clinician. Oral signs: Kaposi Sarcoma NUG/NUP Hairy leukoplakia, angular cheilitis, Erythema multiforme (bull's-eye lesions) Recurrent herpes, superinfections.

Condition	Key Features
Treacher Collins Syndrome	Mandibulofacial dysostosis Underdeveloped Zygoma & MANDIBLE. hearing loss, feeding difficulty, cleft palate. (Note: Maxilla is underdeveloped in Turner syndrome).

Stroke types

• other names for strokes: cerebrovascular disease, cerebral infarction, cerebral hemorrhage

Most common overall: Ischemic stroke - 87% of all strokes.

Type	Cause	Onset	Duration	Notes
Thrombotic	Clot forms in brain artery	Gradual	Permanent damage	Common w/ atherosclerosis
Embolic	Clot travels to brain	Sudden	Permanent damage	Often from heart (A-fib)
TIA-Transient Ischemic Attack	Temporary blockage “mini” stroke	Sudden	Resolves < 24 hrs	No damage, but warning

pain in teeth or mouth caused by?

• migraine headaches

• acute maxillary bacterial sinusitis

• leukemia

• acute otitis media

all can cause pain in teeth or mouth.

examples of Atopic Allergies (genetic)

• Allergic rhinitis (hay fever)

• Asthma

• Atopic dermatitis (eczema)

• Food allergies

All atopic allergies are Type 1 reactions (IgE)