ALWAYS Medical History Interpretation Key 1 of 12

1. Hospitalization for illness or injury Verify that previous hospitalization for illness or injury are consistent with any other “yes” answers indicated in Medical History Form. Specifically, any previous motor vehicle accident (whiplash injury) or head and neck injury that may alter the occlusion, teeth, TMJ or remaining ridges. 2. An allergic or bad reaction to various substances. Differentiate if the patient has experienced stomach symptoms or has a history of urticaria (hives) or anaphylactoid symptoms (positive evidence the reactions are immunoglobulin E mediated). Any product or material has the potential for adverse effects. • Chlorhexidine gluconate –– The U.S. Food and Drug Administration (FDA) is warning that rare but serious allergic reactions have been reported with the widely used skin antiseptic products containing chlorhexidine gluconate (CHX). Although rare, the number of reports of serious allergic reactions to these products has increased over the last several years. As a result, we are requesting the manufacturers of over-the-counter (OTC) antiseptic products containing chlorhexidine gluconate to add a warning about this risk to the Drug Facts labels (https://www.fda.gov/Drugs/ResourcesForYou/Consumers/ ucm143551.htm). Prescription chlorhexidine gluconate mouthwashes and oral chips used for gum disease already contain a warning about the possibility of serious allergic reactions in their labels. Patients and consumers should stop using the product that contains chlorhexidine gluconate and seek medical attention immediately, or call 911, if they experience symptoms of a serious allergic reaction. These reactions can occur within minutes of exposure. Symptoms include wheezing or difficulty breathing, swelling of the face, hives that can quickly progress to more serious symptoms, severe rash or shock, which is a life-threatening condition that occurs when the body is not getting enough blood flow. • Antibiotic –– Concerns for antibiotic-associated diarrhea and colitis. Highest risk is from clindamycin, followed by amoxicillin, and then cephalosporins. –– Published observational studies show that there is an increased risk of Achilles tendon rupture and Achilles tendinitis (specifically in individuals > 60 years of age) with exposure to fluoroquinolone antibiotic therapy. Those taking concomitant corticosteroids are at increased risk for this adverse event. Several unanswered questions remain with respect to the impact of fluoroquinolones on tendons other than the Achilles – which additional high-risk groups exist, if any, and the impact of dosage and type of fluoroquinolone on the risk of tendon injury, which are all areas of future research. –– Symptoms of fluoroquinolone-related tendinopathy can present within hours of starting treatment or up to 6 months after ceasing treatment, and recovery can be slower and require a less aggressive approach early in rehabilitation than for other types of tendinopathy.

Ref: Adverse Drug Reactions in Dental Practice Ref: Antimicrobial Drugs

View both Additional Three Serious Drug Interactions that Every Dentist Should Know About: Materials in Appendix Contents 1. NSAIDs Mechanism of Action 2. Metronidazole or Fluconazole in Combination with Warfarin 3. Epinephrine with Propranolol 3. Heart problems, or cardiac stent within the last six months • Antibiotic prophylaxis is recommended for patients with heart defects repaired with a prosthetic material or device— whether placed by surgery or catheter intervention—during the first six months after repair. • Multiple unfinished root canals are associated with a higher risk of cardiovascular events. • Periodontal disease caused by high-risk pathogens may be considered a contributory cause of arterial disease. High- risk periodontal pathogens include Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola and Fusobacterium nucleatum. Periodontal disease has also been found to be associated with subclinical arterial stiffness among individuals free of established cardiovascular disease. 4. History of infective endocarditis See the Prevention of Infective Endocarditis Mini Me.

5. Artificial heart valve, repaired heart defect (PFO) Patient may require antibiotic prophylaxis prior to dental treatment. Who is at risk? Guidelines for patient selection remains controversial. Antibiotic prophylaxis is recommended for a small number of people who have specific heart conditions. In 2008, the American Heart Association released guidelines identifying people who might need antibiotic prophylaxis prior to dental care. According to these guidelines, antibiotic prophylaxis should be considered for people with: • Artificial heart valves • A history of an infection of the lining of the heart or heart valves, known as infective endocarditis • A heart transplant in which a problem develops with one of the valves inside the heart • Heart conditions that are present from birth, such as: »» Unrepaired cyanotic congenital heart disease, including people with palliative shunts and conduits; »» Cases in which a heart defect has been repaired, but a residual defect remains at the site or adjacent to the site of the prosthetic patch or prosthetic device used for the repair. Conditions for which antibiotic prophylaxis is no longer recommended include: • Mitral valve prolapse or heart murmur • Rheumatic heart disease • Bicuspid valve disease • Calcified aortic stenosis • Any heart condition present from birth that is not listed above, including ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.

6. Pacemaker or implantable defibrillator Certain dental equipment such as ultrasonic scales, electro surgical units and some light curing units can create electro magnetic interferences and can adversely affect the normal functioning of pacemakers. Dentists should use hand scalers and advise caution when using powered toothbrushes. 7. Orthopedic Implant (Joint Replacement) Controversy still exists regarding antibiotic prophylaxis. The American Association of Orthopedic Surgeons (AAOS) recommends discontinuing prophylactic antibiotics. Antibiotic prophylaxis guidelines have also been developed for people who have orthopedic implants, like artificial joints. In the past, antibiotics were recommended for use within the first two years of anartificial joint placement and for select patients with orthopedic implants after that time. In 2012, however, the American Dental Association (ADA) and the AAOS updated these recommendations. The new guidelines do not recommend routinely prescribing antibiotics for people with artificial joints. As a result, healthcare providers may rely more on case-by-case assessments and consultation with patients to determine when antibiotics are appropriate for people with orthopedic implants. For example, antibiotic prophylaxis might be useful for any of these patients who also have compromised immune systems (due to, for instance, diabetes, rheumatoid arthritis, cancer, chemotherapy and chronic steroid use), which might increase the risk of orthopedic implant infection. There is one documented case of a woman with an orthopedic knee implant who contracted an infection from Streptococcus gordonii after vigorously flossing. Do not recommend an extreme flossing regimen for patients with orthopedic implants. Daily flossing is preferred to reduce chronic inflammation or sudden oral bacterial burden on the body.

8. Rheumatic or Scarlet Fever No need for antibiotic prophylaxis. 9. High or low blood pressure The Bale/Doneen Method has been found to be effective in generating a positive effect on the atherosclerotic disease process by achieving regression of disease in the carotid arteries. Medication – Calcium channel blockers may create a false positive for gingival bleeding. The majority of patients (86.4%) using calcium channel blockers experienced gingival enlargement. Lesions from gingival enlargement can often be managed nonsurgically, however it is best to change medication to prevent this from happening. Low blood pressure could mean a higher risk for syncope. 10. A stroke (taking blood thinners) Evaluate for possible blood thinner medication – prolonged bleeding concerns. Evaluate panorex and/or CBCT scan for evidence of carotid stenoses, >50% of which are associated with an increased risk of stroke, especially in women >60 years. 11. Anemia or other blood disorder Prolonged bleeding concerns. 12. Prolonged bleeding due to a slight cut (INR > 3.5) Consult a physician for patients with an INR > 3.5 for prolonged bleeding concerns. Gingival tissue may bleed with minimal provocation. 13. Pneumonia, Emphysema, Shortness of Breath, Sarcoidosis In the elderly, wearing complete removable dentures while sleeping has a twofold increase in pneumonia. Recommend leaving denture out at night, especially where biofilm management of the denture is not optimized. 14. Chronic Ear Infections, Tuberculosis, Measles, Chicken Pox Active disease requires isolation to reduce transmission. Standard surgical face masks do not protect against TB transmission. More than 80% of children may experience one or more episodes of acute otitis media in the first 3 years of life, and one-third of the pediatric population presents recurrent episodes. Environmental and genetic factors, as well as adenoid hypertrophy, allergic rhinitis and anatomic anomalies of the nasal pyramid all can be involved in the otitis media pathogenesis. Depending on the frequency and severity, treatment can involve pain medications, antibiotics and placement of ventilation tubes. Eustachian tube function/dysfunction can be affected by the functional adequacy of the Tensor Vali Palatini and Levator Veli Palatini muscles, which are anatomically in close proximity to the TMJ and also controlled by cranial nerve V3, which are the same as the muscles of mastication. Dentists should look for recurrent acute otitis media on medical histories in their child patients with malocclusions and make recommendations to the patient’s primary care physician, pediatrician and/or otolaryngologist to consider referring them for orthodontic care. Dental malocclusion in children with recurrent acute otitis media might play a role in the pathogenesis of Eustachian tube dysfunction. In one study, recurrent acute otitis media showed better outcomes in children with dental malocclusion wearing a mandibular repositioning device. Children from the age of three would benefit more from this device. It has also been found that children with otitis media and effusion may benefit from rapid maxillary expansion or ventilation tube placement for release of otitis media and improvement of hearing thresholds levels. Rapid maxillary expansion should be preferred as a first treatment option for children with maxillary constriction and resistance otitis media with effusion. 15. Asthma Check timing of asthmatic attacks and ensure current inhaler is available. Some antiasthmatic agents are known to reduce salivary flow and induce gastroesophageal reflux. There are conflicting studies on whether asthma inhalers directly cause dental erosion. Several studies have found that individuals with asthma regularly using antiasthmatic medication have higher rates of xerostomia, candidiasis, periodontal diseases, caries and lower mouth pH.

16. Breathing or Sleep Problems (i.e., Sleep Apnea, Snoring, Sinus) Children should not snore at all. Risk for sleep apnea and mid-face development concerns. Treatment options for pediatric obstructive sleep apnea syndrome include: • Soft tissue reduction or removal (tonsils, adenoids, turbinates) • Allergy management • Jaw expansion • Myofunctional therapy • Nasal continuous positive airway pressure • Skeletal surgery Adult concerns are also significant. Altered mandibular posturing may result in numerous comorbidities, including occlusion and muscle dysfunction. Mouth breathing may be responsible for a false positive concerning bleeding on probing. Additionally, it has been found that obstructive sleep apnea is associated with higher periodontal indices and local inflammatory parameters such as IL-1β.

Use the Epworth Sleepiness Scale. How likely are you to doze off or fall asleep in the situations described below, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you haven’t done some of these things recently, try to work out how they would have affected you. Use the scale below to choose the most appropriate number for each situation:

Situation Chance of Dozing Sitting and Reading Watching TV Sitting, inactive in a public place (e.g. a theater or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic TOTAL

0 = Would never doze SCORE: 1 = Slight chance of dozing 2 = Moderate chance of dozing 0-10 Normal Range 3 = High chance of dozing 10-12 Borderline 12-24 Abnormal

The measurements of obstructive sleep apnea syndrome (OSAS) and sleep bruxism (SB) activity with a validated portable instrument showed a major and significant reduction in respiratory disturbance index and in severe/ moderate SB activity when not wearing a maxillary complete denture during sleep. However, no statistically significant differences were found in OSAS or SB activity in the sleep quality/SB self-report questionnaires. This suggests that the objective improvement was not strong enough to be perceived by patients.

16. Breathing or Sleep Problems (i.e., Sleep Apnea, Snoring, Sinus) (Continued) Is it possible that you have Obstructive Sleep Apnea (OSA)? Please answer the following questions to determine if you might be at risk. Yes No

Do you Snore Loudly (loud enough to be heard through closed doors or Snoring S your bed-partner elbows you for snoring at night)?

Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as Tired T falling asleep during driving or talking to someone)?

Has anyone Observed you Stop Breathing or Choking/Gasping during Observed O your sleep? P Pressure Do you have or are you being treated for High Blood Pressure?

Body Mass Index more than 35 kg/m2? * B Body Mass Index A Age Age older than 50? Neck size large? (Measured around Adams apple) Neck For male, is your shirt collar 17 inches / 43 cm or larger? N For female, is your shirt collar 16 inches / 41 cm or larger? G Gender Gender = Male? For general population OSA - Low Risk : Yes to 0 - 2 questions OSA - Intermediate Risk : Yes to 3 - 4 questions OSA - High Risk : Yes to 5 - 8 questions or Yes to 2 or more of 4 STOP questions + male gender or Yes to 2 or more of 4 STOP questions + BMI > 35kg/m2 or Yes to 2 or more of 4 STOP questions + neck circumference 17 inches / 43 cm in male or 16 inches / 41 cm in female

* Body Mass Index is a simple calculation using a person’s height and weight. The formula is BMI = kg/m2 where kg is a person’s weight in kilograms and m2 is their height in meters squared. To calculate using pounds and inches: 1. Multiply the weight in pounds by 0.45 (the metric conversion factor) 2. Multiply the height in inches by 0.025 (the metric conversion factor) 3. Square the answer from step 2 4. Divide the answer from step 1 by the answer from step 3 A BMI of 25.0 or more is overweight, while the healthy range is 18.5 to 24.9. BMI applies to most adults 18-65 years.

Property of University Health Network, Toronto, Canada. Accessed on STOPBang.ca.

Modified from: 1. Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, Khajehdehi A, Shapiro CM. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008 May;108(5):812-21. 2. Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-Bang score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012 May;108(5):768-75. 3. Chung F, Yang Y, Brown R, Liao P. Alternative scoring models of STOP-bang questionnaire improve specificity to detect undiagnosed obstructive sleep apnea. J Clin Sleep Med. 2014 Sep 15;10(9):951-8.

17. Kidney Disease Findings support the conclusion that edentulous adults are more likely to have chronic kidney disease, and those with a high level of systemic antibody response to one of the major periodontal pathogens are less likely to have chronic kidney disease after controlling for other risk factors. In addition, consider periodontal therapy as a means to contribute to reducing the chronic inflammatory burden in multi- factorial interventions that might include counseling to modify patients’ behavior (e.g., smoking cessation counseling, diet modification, and exercise initiation) and antihypertensive drug therapy directed toward reducing the incidence, progression and complications of chronic kidney disease. 18. Liver Disease Patients with reduced hepatic function may exhibit an abnormally decreased rate of metabolism of amino-amide local anesthetics, resulting in potentially toxic blood levels. All local anesthetics are aminos with an amide side chain except Articaine, which is an amino with an ester side chain (additional concern for pseudocholinesterase deficiency). Dosage levels must therefore be reduced for these patients. 19. Jaundice See 18. Risk for hepatitis. 20. Thyroid, Parathyroid Disease, or Calcium Deficiency Thyroid: Thyroid disease may show oral manifestations such as: • Hyperthyroidism - increased susceptibility to caries, periodontal disease, presence of extra glandular thyroid tissue, accelerated dental eruption (depending on age of onset) and burning mouth syndrome. • Hypothyroidism - salivary gland enlargement, macroglossia, glossitis and delayed dental eruption (depending on age of onset).

Parathyroid: Parathyroid disease may show oral manifestations such as: Hyperparathyroidism: • Dental abnormalities (dependent on age of onset) – obliteration of pulp chambers by pulp stone, alterations in dental eruption, loosening and drifting of teeth, malocclusions, partial loss of lamina dura, periodontal ligament widening and teeth becoming sensitive to percussion and mastication. • Soft tissue calcifications • Hypercalcemia may result in sialolithiasis • Complaint of vague jaw bone pain • Precautions in surgical treatments should be taken, as patients are at a higher risk of bone fracture. Dentists can assist in the detection of hyperparathyroidism, as the first sign of the disease may be a cyst in the jaw. If a single or multiple radiolucencies are observed on the jaw, the dentist should consider hyperparathyroidism. Hypoparathyroidism: characterized by hypocalcemia • Dental abnormalities (dependent on age of onset) - enamel hypoplasia in horizontal lines, delayed eruption, hypodontia and microdontia, poorly calcified dentin, widened pulp chambers, dental pulp calcifications, shortened roots, malformed roots, delay or cessation of dental development, dental malocclusion, ankylosis and caries. • Chronic candidiasis • Paresthesia of the tongue or lips • Alteration in facial muscles Considerations need to be made during treatment for patients with hypoparathyroidism. These patients are more susceptible to caries, so prevention of caries is critical. Patients’ serum calcium levels should be determined prior to any dental treatment and should be above 8mg/100ml to prevent cardiac arrhythmias, seizures, laryngospasms or bronchospasms.

Calcium Deficiency: Patients that had a calcium deficiency during gestation and childhood may show hypo mineralization defects in enamel and dentin, small tooth size and/or delayed eruption. Patients with a calcium deficiency during adulthood may show signs of osteoporosis in the jaw and alveolar crest. This can be adjusted by calcium supplementation. Loss of alveolar bone, consequent of low calcium levels, can results in loose teeth and tooth loss. It can also result in ill-fitting dentures and less optimal outcomes from oral surgical procedures. 21. Hormone Deficiency Hormones are critical to proper growth and development, and the impact on dental health varies based on the hormone that is deficient. Growth Hormone: Patients that present with a deficiency in growth hormone may have delayed eruption rate, delayed shedding of deciduous teeth, smaller clinical crown of teeth, smaller roots with retarded growth of support apparatus, smaller dental arches, retarded growth of mandible and/or fine wrinkles around the mouth and eyes. Estrogen: Estrogen deficiency may result in bone loss and increased inflammatory processes.

22. High Cholesterol or Taking Statin Drugs Considered associative risk with periodontal disease, high blood pressure, and cardiovascular disease. However, • Statins have been shown to increase calcification and loss of vertical height of the pulp chamber observed in mandibular molars. In addition, this calcification makes endodontic treatment more difficult and with decreased space for blood flow, and may decrease the healing capability of the pulp. • Statins have multiple functions, including anti-Inflammation, the induction of angiogenesis and the improvement of the vascular endothelial cell function. Another important function of statins is that they improve osteoblast function via the BMP-2 pathway and suppress osteoclast function, resulting in enhanced bone formation. There is some thought that they may be able to be used as a pulp capping material. • Long-term treatment with systemically administered statins may have the beneficial effect of protecting against tooth loss. 23. Diabetes

Adequacy of Control of Diabetes Hemoglobin A1c Average Blood Sugar Level of Control < 7% < 140 mg/dL Good 7 – 9% 140-220 mg/dL Fair > 9% > 330 mg/dL Poor (Red Flag)

24. Stomach or Duodenal Ulcer Burning mouth syndrome and chronic aphthous ulcers are a concern for gastrointestinal infection with Helicobacter pylori. 25. Digestive or Eating Disorders (e.g., Celiac Disease, Gastric Reflux, Bulimia, Anorexia) Concerns for GERD: • Ask “Do you have one or more of the following?”: Frequent need to clear your throat, feeling like you’re choking, chronic cough, hoarseness, trouble swallowing, sensation of having a “lump in the throat,” sour or acidic taste in your mouth or recurrent sore throat. • GERD is frequent in children from 6 to 12 years with Obstructive Sleep Apnea Syndrome (OSAS), and us of a proton pump inhibitor treatment may reduce OSAS. • GERD is strongly associated with sleep bruxism and has been shown to directly induce masseter muscle activity, even in the absence of subjective gastrointestinal symptoms. This seems to be related to disruption of sleep created by microarousals. • GERD is more common in infants. Concerns for food allergies, especially cow’s milk. Note: even breastfed babies can acquire a cow’s milk allergy if their mother consumes milk products. This is not to be confused with lactose intolerance (inability to digest the principle sugar in milk). In general, babies do not suffer from lactose intolerance.

Medication for GERD • Proton pump inhibitors (PPIs) are commonly used in clinical practice for the prevention and treatment of peptic ulcers, gastritis, esophagitis and gastroesophageal reflux. Hypomagnesemia has recently been recognized as a side effect of PPIs. Low magnesium levels may cause symptoms from several systems, some of which being potentially serious, such as tetany, seizures and arrhythmias. It seems that PPIs affect the gastrointestinal absorption of magnesium. Clinicians should be vigilant in order to timely consider and prevent or reverse hypomagnesemia in patients who take PPIs, especially if they are prone to this electrolyte disorder. Systemically administered PPIs impairs bone healing and osseointegration. Burning Mouth Syndrome Possible nutritional deficiency.Evidence of a neurologic problem, vitamin deficiency, viral or fungal etiology, other than biofilm induced gingival inflammation. May be related to an oral pH imbalance. Concerns for low pH and xerostomia. Burning mouth syndrome (BMS) however, is a complicated pain disorder, with various possible underlying mechanisms involving the peripheral and central nervous system and may be associated with less efficient modulation of pain. Predictable treatment modality is not known.

Nutritional Concerns: • The periodontitis phenotype is characterized by hyperinflammation, and oxidative stress is a key orchestration point for the diverse signaling pathways, which control inflammation. Oxidative stress is modulated by diet, as well as by infection. Recent research has demonstrated that subtle shifts in nutritional status are associated independently with the prevalence of periodontitis. Moreover, the results of contemporary animal and human studies have demonstrated the role of specific micronutrients in the modulation of the host’s inflammatory response by reducing inflammatory biomarkers and bone loss.

25. Digestive or Eating Disorders (e.g., Celiac Disease, Gastric Reflux, Bulimia, Anorexia) (Continued) Concerns for Bulimia: • The most important sources of acids are those found in the diet and from the stomach, although industrial sources have been described in the past. • Current evidence suggests that erosion is the most important cause of tooth wear, and if it occurs in combination with abrasion or attrition, the damage will be greater than if these processes occurred independently (Smith and Knight 1984, Jarvinen et at. 1991). • The palatal surface of the upper anterior teeth appears to be the most common site for erosion and is usually associated with acid originating from the stomach (O’Brien 1993), although some researchers have implicated that dietary acids could be important in this region (Milosevic et al. 1997). • The most destructive source of acid is regurgitated gastric juice, which has a pH of about 1, while most dietary acids only reach a pH of around 3 (Bartlett and Smith 1995, Bartlett et al. 1998). • 26% of all Bulimia is first diagnosed in the dental chair. • Children as young as 9 years old are being affected. 26. Osteoporosis/Osteopenia (i.e., taking bisphosphonates) Concerns for medication-related osteonecrosis of the jaw (MRONJ). The American Association of Oral and Maxillofacial Surgeons (AAOMS) Special Committee on Medication- Related Osteonecrosis of the Jaws recommends changing the nomenclature of bisphosphonate-related osteonecrosis of the jaw (BRONJ). The Special Committee favors the term medication-related osteonecrosis of the jaw (MRONJ). The change is justified to accommodate the growing number of osteonecrosis cases involving the maxilla and mandible associated with other antiresorptive (denosumab) and antiangiogenic therapies. New biomarkers, TRACP 5b and the RANKL/OPG ratio may be predictors for MRONJ. See Medication-Related Osseous Necrosis of the Jaw (MRONJ) Mini Me. The effectiveness of therapy regarding MRONJ remains uncertain. Recommended options include the following:

• Surgical versus nonsurgical therapy – The investigators of 4 of the included studies (n = 223) evaluated surgical therapy versus nonsurgical therapy for the treatment of MRONJ. Of these, the investigators of 2 studies reported the superiority of surgical therapy compared with nonsurgical therapy; the investigators of 1 study reported a greater likelihood of condition resolution, and the investigators of another study reported fewer recurrences of the treated lesions. The results of the meta-analysis of the 2 included studies had sufficient data for synthesis; these results support the findings of the aforementioned studies whose investigators had reported significant differences. Compared with medical treatment of local antimicrobials with or without systemic antimicrobials, we found that surgical treatment was associated with higher odds of complete resolution of the condition (2 studies; 76 participants; unadjusted odds ratio [OR], 3.55; 95% confidence interval [CI], 1.12 to 11.19). • Conservative versus aggressive surgical therapy – The investigators of 2 studies (n = 79) evaluated conservative surgery versus aggressive surgery, defined as debridement and resection, respectively. The investigators of 1 of these studies reported that the time to remission was significantly lower in their aggressive surgical therapy cohort compared with no significant differences reported in the study by Lesclous and colleagues. • Bisphosphonate drug holiday – The investigators of 3 studies (n = 113) evaluated the effects of cessation of bisphosphonate therapy on the resolution of MRONJ, of which the investigators of only 1 study reported a significant effect of a drug holiday on the outcome of surgical therapy, indicating significantly greater rates of improvement in the drug holiday cohort. The investigators of all 3 of these studies did not make available the details regarding the length of time the patients had stopped taking bisphosphonates before the intervention. • Early versus delayed surgery – The investigators of 1 study (n = 17) compared the effectiveness of early surgery with that of delayed surgery. They reported no differences in the rate of complete resolution between the 2 groups. • Supplemental hyperbaric oxygen therapy – The investigators of 1 study (n = 46) compared the effectiveness of supplemental hyperbaric oxygen in addition to usual care. They reported significantly higher increases in mucosal coverage but not in full mucosal healing. • Spiramycin versus amoxicillin and clavulanate – The investigators of 1 study (n = 12) compared the effectiveness of spiramycin with that of amoxicillin and clavulanate. They found faster rates of condition resolution in the spiramycin group. • Mucoperiosteal versus mylohyoid flaps – The investigators of 1 study (n = 195) compared the effectiveness of mucoperiosteal with that of mylohyoid flaps for mandibular coverage after debridement. They found that the mylohyoid group had significantly lower rates of recurrence. • Teriparatide versus plasma rich in growth factors – The investigators of 1 study (n = 9) compared the effectiveness of teriparatide with that of plasma rich in growth factors. They reported no difference in the rate of complete resolution between the 2 groups.

27. Arthritis Osteoarthritis-concerns for TMJ sounds and/or degredation. Additional concerns in young people for Juvenile Idiopathic Arthritis (JIA). If arthritis compromises manual dexterity, there may be a concern of oral hygiene management. 28. Autoimmune disease (i.e., Rheumatoid Arthritis, Lupus, Scleroderma) Rheumatoid arthritis, Juvenile Idiopathic Arthritis (JIA) and periodontitis appear to share many pathologic features with co- morbidity for periodontal disease and increased risk for peri-implantitis and TMD. 29. Glaucoma Drying agents are contraindicated. Do not use. 30. Contact Lenses Have patient remove contact lenses when any oral drying agent is being used. 31. Head or neck injuries Concerns for TMD shared risk factor (even 1-3 years later). 32. Epilepsy, Convulsions (Seizures) Medication induced (Dilantin) tissue hyperplasia. Some anticonvulsant medication is associated with gingival enlargement. 33. Neurologic Disorders (ADD/ADHD, Prion Disease) Concerns for rapidly progressive, degenerative neurological disorders. Uncontrolled jaw movements are a potential side effect. 34. Viral Infections and Cold Sores Cross contamination. Review toothpaste use concerns for triclosan. 35. Any lumps or swelling in the mouth Usually localized infection. However, concerns for oral cancer, salivary duct blockage or lymph node enlargement must be ruled out. Differentiate by mobility and presence of symptoms. 36. Hives, Skin Rash, Hay Fever Patients with heightened responses (i.e. present with a welt from a mosquito bite) may react adversely to inflammation. 37. STI / STD / HPV Contraindications for Valtrex. Do not take this medicine if you are allergic to valacyclovir or acyclovir (Zovirax). If you have certain conditions, you may need a dose adjustment or special tests to safely take this medication. Before taking Valtrex, tell your doctor if you have: • HIV/AIDS, or other conditions that can weaken the immune system • Kidney disease (or if you are on dialysis) • If you have had a kidney or bone marrow transplant 38. Hepatitis All patients with a history of Hepatitis must be treated as if they are potentially active. HBV has been documented as the most important infectious occupational hazard in the dental profession. Vectors of HBV are blood, saliva and nasopharyngeal secretions, and the greatest concentration of HBV intraorally is in the gingival sulcus. Additionally, periodontal disease, severity of bleeding and bad oral hygiene are said to be associated with the risk of HBV. Blood is often found in the aerosols produced by dental equipment, so extra care should be taken when this equipment is being used. Sharing household items, such as toothbrushes, may put household members at an increased risk of infection. All dental professionals should be immunized against hepatitis virus and use protective equipment such as gloves, head caps, masks, etc. Exposures that may place dental professionals at risk of hepatitis infection include percutaneous injuries (needlestick or cut with a sharp object), contact with potentially infectious blood, tissues or other body fluids and mucus membranes of the eye, nose or mouth or non-intact skin (exposed skin that is chapped, abraded or afflicted with dermatitis). Of these exposures, percutaneous injuries post the greatest risk of transmission.

39. HIV / AIDS Patients with HIV or AIDS have compromised immune systems, making them more susceptible to infections or other issues in the mouth. The following may be observed in patients with HIV/AIDS: Pediatric patients – salivary gland swelling in one or both parotid glands with or without xerostomia, xerostomia, oral candidiasis, caries, increased susceptibility to viral infections (Herpes simplex, Herpes zoster, Epstein-Barr, HPV), increased risk for infection related to precancerous lesions (Oral Hair Leukoplakia, Oral Warts, Oral Cancer), gingival and periodontal disease (Linear gingival erythema, necrotizing stomatitis, necrotizing ulcerative gingivitis or periodontitis), and dysregulation of calcium homeostatic, bone loss or diabetes mellitus and dyslipidemia (caused by long term use of antiretroviral medications), which may predispose a child to periodontal disease. Adult Patients – xerostomia, necrotizing ulcerative gingivitis or periodontitis, conventional periodontitis and caries (due to combination of periodontal disease, reduced salivary flow and antibodies). All patients should be able to tolerate routine dental care procedures, including oral surgery. Patients should constantly be monitored for disease progression, and any oral manifestations should be treated immediately. Further diseases can be prevented by modifying certain behaviors, such as use of tobacco, alcohol or other drugs that may increase risk of oral abnormalities or complications. HIV and antiretroviral therapies may be associated with abnormal bleeding, glucose intolerance or hyperlipidemia. Other conditions that may require modification of dental treatment are reduced platelet count <60,000 cells/mL, which may affect clotting, or white-blood-cell neutrophil counts <500 cells/mL, which may require antibiotic prophylaxis. However, antibiotic use may predispose patients to adverse drug reactions, superinfection and drug resistant microorganisms, so antibiotics should be used sparingly. All procedures should be conducted to minimize bleeding and avoid bringing oral pathogens into deeper oral spaces. Considerations should always be made to maintain the safety of the dental team while treating patients with infectious diseases. See MH question #47. 40. Tumor, Abnormal Growth A tumor located in a salivary gland will usually present as a large, painless mass in the gland. Tumors located in any of the three salivary glands can cause patients to experience a bad taste in the mouth, difficulty opening the mouth, dry mouth, pain in the face or mouth, swelling of the face or neck under the tongue and/or loss of movement in the affected side of the face. If a patient has a tumor in the oral cavity, a CT scan or MRI should be recommended. A fine needle aspiration biopsy can also be done for further determination. Depending on the tumor, referral to a professional or removal may be recommended. 41. Radiation Therapy Xerostomia. 42. Chemotherapy, Immunosuppressive Medication Concerns for xerostomia and transmission of antibiotic resistant organisms, such as Methicillin Resistant Staphylococcus aureus (MRSA). Immunosuppressive medications can also lead to gingival enlargement. 43. Emotional Difficulties 44. Psychiatric Treatment 45. Antidepressant Medication Patient management issues. Side effects from medications may create movement disorders and xerostomia. Stress is a shared risk factor in periodontal disease progression. Stressful life events can also trigger burning mouth syndrome. Serotonin Reuptake Inhibitors (SSRIs) may increase risk for lack of osseointegration. 46. Alcohol / Recreational drug use Side effects may include movement disorders. Nutritional concerns may be a shared risk factor in the progression of periodontal disease. Any product containing alcohol is contraindicated for those with a history of alcohol dependency. Xerostomia– methamphetamine use. A side effect of ecstacy use is jaw movement disorder. Occurrence of periodontitis, visible plaque, and gingival bleeding has been found to be significantly higher among crack users.. 47. Presently being treated for any other illness Patients that are currently being treated for any type of infectious disease pose a risk of transmission to the entire dental staff. The patient should be carefully evaluated and should be treated only if the infection control protocols of the office will allow treatment without compromising the health and safety of the dental team. In the case of an emergency, dental treatment should be provided in a facility equipped with the capacity for airborne infection isolation. If a patient is believed to have an infectious disease, he or she should be evaluated by a practitioner for further investigation.

48. Aware of a change in your health in the last 24 hours (i.e., fever, chills, new cough, or diarrhea) Concerns for active infectious diseases. 49. Taking medication for weight management Cardiovascular risk. 50. Taking dietary supplements Risk factor for sleep disorder if the medication was for weight-loss. Vitamin C, iron tonic and amino-acid supplements have been implicated in tooth erosion. 51. Often exhausted or fatigued Exhaustion or fatigue may indicate one of several conditions that may affect a patient’s dental treatment. If the exhaustion or fatigue is a result of an immune reaction, the patient should be evaluated for any oral inflammatory burden. NICO (Neuralgia-Inducing Cavitational Osteonecrosis) is one of the jawbone versions of ischemic osteonecrosis, a common disease affecting any bone but with special affinity for those of the hips, knees and face. Chronic infection from NICO’s originating from bacterial colonization of the pulp leads to chronic inflammation of the surrounding bone. The immune system is activated permanently. Inflammatory mediators released by macrophages favor the development or deterioration of chronic inflammations and autoimmune diseases. Chronic exhaustion or fatigue may also be a result of poor sleep quality. The patient should be evaluated for sleep disordered breathing or Obstructive sleep apnea syndrome (OSAS). 52. Experiencing frequent headaches Possible occlusal etiology. 53. A smoker, smoked previously or use smokeless tobacco Risk factor in the progression of periodontal disease (benchmark 10 cigarettes/day). Additional risks include soft tissue management, peri-implantitis, progressive bone loss around implants and root coverage grafting less stable. False negative for bleeding on probing. Smokeless tobacco risk for oral cancer. Cannabis use for up to 20 years is associated with periodontal disease. There have been case reports of e-cigarettes exploding in people’s mouths. These explosions and fires pose unforeseen risks and may cause damage to the dentition and soft tissues of the mouth. 54. Considered a touchy / sensitive person Patient perceived prognosis is reduced, adapted from the Cornell Medical Index. 55. Often unhappy or depressed Related to question 54. Chronic stress may impair osseointegration. 56. Taking birth control pills Historically, patients taking oral contraceptives were at an increased risk for gingival inflammation, due to the increase in the level of progesterone in the body. The duration of use of the oral contraceptive played a large role in the amount of gingival inflammation. However, most birth control doses prescribed now do not contain enough sex hormones to cause this response in patients. Certain medications, such as antibiotics, may lower effectiveness of birth control pills, so it’s important that this is discussed with the patient if an antibiotic prescription is being written. Patients may be at an increased risk for dry socket after tooth removal. According to the June 2016 Journal of the American Dental Association (https://jada.ada.org/article/S0002-8177(16)00066-0/abstract), patients who use oral contraceptives are nearly twice as likely to experience dry socket after a tooth removal, compared to those who do not.

57. Currently pregnant Hormonal alteration increases the risk for gingival inflammation. • A periodontal pathogen shift creates an oral inflammatory burden, which may increase the risk for pre-term low birth weight delivery. Recommend continuous care appointments at 12 weeks and 24 weeks. Oral inflammatory burden may be associated with pre-term birth. Studies have indicated that the serum responses to a select panel of periodontal pathogens showed some specific relationships to pregnancy outcomes. Mothers who delivered pre-term had significantly lower antibody levels to P. gingivalis during the second trimester than women who delivered at term. In contrast, serum antibodies to F. nucleatum were elevated in women who suffered a fetal loss. Further analyses are needed to examine how the differences in antibody responses between term and pre-term deliveries relate to individual variations in the response to therapy. Pregnancy increases maternal risk for: • Caries, relative to oral imbalance • Xerostomia • Perimylolysis • Slight increase in tooth mobility • Preeclampsia Significant concern has been raised about the adverse effects of mercury on the health and development of babies born to women who are exposed to the substance. While mercury is often absorbed through water and air, it has been found that other significant sources include dental amalgam and seafood, in which seafood was a higher source of mercury than amalgam. Mercury vapor is continuously released from amalgam fillings, with spikes in this release during chewing. There is a mercury testing kit available to measure the level of mercury in the body, which may help the clinician to plan a rational approach for a successful detoxification strategy for the patient. While there are no reported cases of newborns with neurological impairment from the mercury leached from their mother’s amalgam fillings, there are incidences of dentists with chronic occupational exposure to mercury containing amalgams who have a higher incidence of tremors and multiple sclerosis. Additionally, one study found that the negative impact of mercury on oral tissues of rats offspring was due to high mercury levels in their mothers’ blood during pregnancy. Recommend that women should, as much as possible, postpone having dental amalgam filling placed or removed during pregnancy to avoid its harmful effect on the fetus.

Examples of Questions to Add to Health History Based on National Consensus Statement and Relevance of Responses

Questions Relevance of Response When is your due date? How many weeks pregnant To determine the ideal schedule for any treatment; to assess the are you? appropriate diet and oral hygiene counseling; to anticipate the likely clinical changes at clinical examination Do you have any questions or concerns about To explain that many pregnant women and some prenatal healthcare receiving oral healthcare while you are pregnant? providers are confused over the safety and appropriateness of dental care, even when dental problems are encountered Have you received prenatal care? If not, do you To explain the importance of prenatal care and offer assistance in referral need help making an appointment for prenatal to prenatal health professionals in the community, especially those who care? accept Medicare and other public insurance programs Since becoming pregnant, have you been vomiting? To assess risk for acid erosion If so, how often? Also, do you suffer heartburn or have acid reflux into your mouth? Do you have any dietary cravings, fads or food To assess risk for dental caries, acid erosion, and the adequacy of overall aversions? nutrition Are any teeth sensitive to heat or cold, or sweet or To assess risk of acid erosion acidic foods and drinks? Do you have swollen or bleeding gums, a toothache To assess the likelihood of soft-tissue changes, caries or other oral or other problems in your mouth? Have you noticed maladies any changes since becoming pregnant? Are you able to perform your routine oral hygiene To assess if oral hygiene procedures are compromised because of nausea as normal? and vomiting, which are commonly due to morning sickness, and if more intense prevention should be instituted

58. Diagnosed with a prostate disorder Drying agents are contraindicated. Enlargement of the prostate results from increased cell growth in and around the prostate gland. The increased growth can constrict the urethra and decrease urine flow. If a man is already having difficulty, anticholinergic medication (even one dose) can cause retention. If someone has not urinated in about six hours, they will need to go to the hospital and get a catheter put in to drain the urine. There is important preliminary data regarding the potential association between periodontal diseases and benign prostatic diseases. These results warrant further well-designed prospective studies with larger amounts of participants to determine whether this is a coincidence or a direct cause-and-effect relationship between these disorders.