Internal Medicine and Periodontal Disease

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Internal Medicine and Periodontal Disease

 Internal Medicine and Periodontal Disease

  • Overview of Periodontal Disease (PD)

    • “Periodontal disease is a chronic inflammatory disease, and is linked to other serious health risks.”

    • Systemic disease

      • Current research has linked periodontal disease to a number of systemic diseases.
      • The greatest evidence exists for the connection with diabetes, however numerous associations are being studied and evidence continues to emerge.
      • Some of these possible associations include: heart and lung disease, pre-mature, low-birth weight babies, oral and pancreatic cancers.
      • Scientific evidence also supports the fact that many cases of respiratory infections among the institutionalized originate from oral bacteria.
    • Impact of Periodontal Disease

      • bau mulut
      • resesi → estetika kurang
      • mobilitas→ susah kunyah→ nutrisi kurang

  • PD and Diabetes

    • Diabetes facts

      • Diabetes tipe II meningkat, adanya hubungan kesehatan rongga mulut dan diabetes

      Diabetes mellitus is a clinical syndrome characterized by hyperglycemia (kadar gula berlebih) caused by absolute or relative deficiency of insulin

    • TYPES

      Type I (IDDM) → gakda insulin

      Type II (NIDDM)

      Other types → kehamilan


      • Polyuria→ sering pipis
      • Polydipsia→ haus trus
      • Polyphagia→ banyak makan tapi BB turun
      • Sudden weight loss
      • Wound that won’t heal
      • Blurry vision
      • Numb or tingling hands or feet

      If a patient has any of these symptoms or if a clinician’s index of suspicion is high, lab investigation and physician consultation is indicated



        Casual/non fasting….… > 200 mg/dl

        Fasting …………….. > 126 mg/dl (N..70-100)

        2 prandial .….. > 200 mg/dl (N..<140)


        • HbA1 >7%

        • HbA1c

          <8 % (well controlled diabetes)

          10%(poorly controlled diabetes)

    • Periodontal Disease and Diabetes

      Sangat sering pada orang diabetes, dikatakan komplikasi ke 6 (jaringan periodontal) dan ginjal, jantung

    • Intraoral findings for Diabetes:

      • Dry, burning mouth
      • Gingival proliferation, gingivitis, periodontitis
      • Abnormal wound healing
      • Multiple carious lesions
      • Candida infection – denture sore mouth, angular cheilitis, median rhomboid glossitis
      • Periodontal abscesses
      • Acetone breath
      • Increased salivary viscosity
      • Asymptomatic parotid gland swelling

    • How does periodontal disease affect diabetes?

      • PD : Kadar gula tidak terkontrol→ peningkatan (prod cytokines) inflamasi → insulin resistance
      • mechanisms that explain the increased pathology seen in diabetic patients as a result of periodontal infection:
        • altered vascular physiology
        • reduced immune response
        • particularly protective response by neutrophils
        • reduced ability for tissues to heal
    • DM and Periodontitis -The 2 way relationship

      • Host response

        peningkatan AGE, Hiperglikemi menganggu sintesis kolagen, peningkatan mikro di perio→ cytokin meningkat,

      • Microorganism

        liposakarida meningkat→ meningkatkan insulin resistance


      • Salivary flux reduction
      • High glucose concentration in salivary and GCF

      Development of periodontogenic flora

    • Common microorganism in diabetes

      • Generally in periodontal patients is noticed the presence of
        • Porphyromonas gingivalis
        • Tannerella forsythia
        • Actinobacillus actinomycetemcomitans
      • Sometime, other bacteria, such as
        • Treponema denticola
        • Treponema socranskii
      • DM patients
        • Candida albicans
      • In type 1 DM patients
        • Capnocytophaga spp :most frequent bacteria
        • Porphyromonas gingivalis
        • Prevotella intermedia
      • In type 2 DM patients
        • Capnocytophaga spp. : most frequent bacteria
        • Prevotella intermedia
        • Campylobacter rectus
    • Diabetes and Periodontal Disease

      • Diabetes mellitus
        • Advanced glycation end product formation
        • Deposition of collagen in vessel
        • Reduce blood flow to gingiva
        • Lower resistance to bacteria
      • Periodontal disease
        • toxin production
        • catabolic cascade
        • inflammation
      • increased insulin resistance
      • hyperglycemia
    • Diabetes and Periodontitis

    • Impaired Wound healing

    • Normal wound healing

    • Stages of Normal Cutaneous Wound Healing


        • Consult the patient’s physician
        • Analyze lab tests both fasting and casual blood glucose.
        • Rule out acute orofacial infection or severe dental infection; if present, provide emergency care immediately.
        • Establish best possible oral health through non surgical debridement of plaque and calculus, institute oral hygiene instruction, limit more advanced care until diagnosis has been established and good glycemic control obtained.
        • Ask patient to bring his glucometer to dental office on each appointment.
        • Check blood glucose to obtain a baseline level ;
          • Pt with levels at or below the lower end of normal- give carbohydrates before strating procedure
          • High pretreatment glucose levels- consider the recent glycemic control of patient by thorough questioning and recent HbA1c (<7) values.
          • If glycemic control has been poor, postponed the procedure until better glycemic control achieved.
          • Dental procedures safely performed in level < 200mg/dl
          • If procedure is long, check glucose level during procedure to prevent hypoglycemia.
          • Check blood glucose after treatment procedure.
          • Anytime during procedure if patient feels symptoms of hypoglycemia, blood glucose should be checked immediately to prevent severe hypoglycemia , a medical emergency
    • Dental Hygiene Treatment

      • Carefully assess all patients for the signs and symptoms of diabetes
      • Educate diabetic patients about the importance of their personal oral hygiene as well as regular professional care.
      • Actively prevent and aggressively treat periodontal diseases in diabetic patients.

      When planning a dental treatment, it is best to schedule appointments before or after periods of peak insulin activity.

      • Check blood glucose before, during and after procedure.


        • Emergencies from hypoglycemia are rare and usually takes weeks to develop.
        • Glucometer may be used to rule out hyperglycemic emergencies such as diabetic ketoacidosis, a life threatening condition.



          Most common in patients with better glycemic

            • Stop procedure !

            • Check blood glucose

            • Treatment guidelines

              • Provide 15g oral carbohydrate
              • If patient is unable to take food / drink or i sedated
              • Give 25- 30 ml of 50%dextrose IV


            • Give 1 mg of glucagon IV ( causes rapid release of stored glucose from liver)


            • Give 1mg of glucagon IM or subcutaneous

          • Treatment
            • Early treatment
              • administration of oral carbohydrates
                • orange juice
                • candy
                • soft drink
            • Patient remains unresponsive
              • hospital emergency room

          • CAUTIONS
            • Taking insulin without eating is primary cause of hypoglycemia.
            • It is critical that the pt eat their normal meal before dental treatment cz the treatment may render the pt unable to eat for sometime.
            • General guideline “well controlled diabetic pt having routine periodontal therapy may take their normal insulin doses as they also eat their normal meal”.
            • If pt is restricted from eating before treatment or if during long procedures, normal insulin doses will need to be reduced.
            • Likewise if pt is restricted from treatment after treatment , insulin or sulfonyl urea dosages may be reduced.
            • Consult patient’s physician.
            • If PDL surgery is indicated, it is best to limit size of surgical fields so that pt will be comfortable to resume normal diet immediately.
        • Hyperglycemia

          • conscious

            hospital emergency room

          • unconscious

            • basic life support procedure
              • open airway
              • administration of 100% oxygen
            • non glucose- containing intravenous fluids should be administered to prevent vascular collapse
  • PD and Respiratory Disorders

    • The respiratory system

      → rongga hidung, laring, trakea, bronchus, alveori

      → pertukaran di alveolus

      • The respiratory system includes the nasal and oral cavities: the sinuses and larynx as the upper airway, and the trachea, bronchi, bronchioles, and alveoli as the lower airway.
      • The tube which carries the air from the mouth is called the Trachea → divides into two at which point it becomes the Bronchi and divides the air equally to each lung
      • Once the air enters the lungs it passes through a fine spongy structure which contains an extensive network of blood vessels, these vessels bring carbon dioxide into the lungs for removal, and take oxygen from the lungs to the body.
      • This is collectively known as the respiratory system. It deals with the exchange of gases (i.e oxygen & carbon dioxide) in and out of our bodies.

    • Respiratory disease

      → di udara ada kuman→ nempel rongga mulut→ ada normal flora

      • Gum disease increases bacteria in the mouth
      • Inhaling germ-filled droplets from the mouth and throat into the lungs may cause bacterial infections
      • People suffering from chronic obstructive pulmonary diseases (COPD) typically lack protective systems making it difficult to eliminate bacteria from the lungs
      • Patients with respiratory diseases are more at risk for pneumonia

    • How does periodontal disease affect respiratory health?

      mulut sbg tampungan airway, normal flora klo kbanyakan ntar patogen

      • The oral cavity provides a reservoir of bacteria for lower airway infections.
      • Bacteria from the mouth can form a biofilm on ventilation tubing, thereby inoculating the respiratory tract with oral bacteria.
      • Oral bacteria may also be aspirated by the patient. The severity of the oral disease is correlated with the pathogenicity of the bacteria which may be transmitted.
      • The presence of cariogenic bacteria plus periodontal pathogens have been found to be significant risk factors for aspiration pneumonia.
    • Who is at risk?

      → orang tua, dn tidak terbatas usia

      → biasanya pasien disuruh OH

      Patients at the highest risk for respiratory infection (pneumonia and bronchitis) are institutionalized patients or medically compromised patients with or without respiratory disease who are unable to perform self-oral care.

      Also at risk are hospitalized elderly patients.

      • There is good evidence that mechanical oral hygiene practices reduce the progression or occurrence of respiratory diseases in high-risk elderly people in nursing homes or hospitals. Mechanical oral hygiene practices may prevent the death of about one in 10 elderly residents of nursing homes from health care–associated pneumonia.”
      • This author evaluated 328 articles published from 1996 to 2007 which discussed the results of clinical studies linking oral hygiene to health care–associated pneumonia or respiratory tract infection in elderly people.
    • Dental Hygiene Treatment

      • Meticulous and frequent oral care is critical in preventing these infections.
      • “Oral hygiene intervention significantly reduced occurrence of pneumonia in institutionalized subjects”.
      • Frequent toothbrushing and pre-operative use of 0.12% or 0.2% chlorhexidine mouthrinse or gel reduced nosocomial respiratory tract infecti
    • Sinusitis Related

      → gigi ga kenapa2, nyeri bisa menjalar ke gigi, efek obat pelebar (flu) → mulut kering→ gangguan normal flora

      • Patients complain of tooth ache when they have sinus infections therefore it is important to differentiate between a odontogenic infection and a sinus pain.
      • Chronic sinus infections causes a patient to breath through the mouth leading to dry mouth and is susceptible to gingivitis. Use of decongestants causes dry mouth.
      • Use of antibiotics that patients has been used for another condition, even in increased dosage will not work because the body has gained resistance to it

    • COPD Related (Obstruksi Paru Menahun)

      → paru2 molor (dinding alveoli tipis), biasax pada perokok berat

      COPD refers to chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in which the airways become narrowed.

      • This limits airflow causing shortness of breath.

      • COPD is caused by noxious particles or gas, most commonly from tobacco smoking, which trigger an abnormal inflammatory response in the lung.

      • Oral manifestations of COPD are halitosis, Oral cancer, periodontal infections and tooth stains

      • COPD Facts

        tarik nafas tetap sesak karena alveoli jelek

        ada inflamasi sistemik, partikel biomass (kerja pabrik)

    • Dental management

      • Respiratory Disease

        → asses yg bener, posisi kursi biar bisa napas, selalu pke obat kumur, suction bisa pemicu sesak, tidak menghasilkan aerosol

        • Consultation with patient’s physician before any treatment.
        • Review the patient’s medical history to see the severity of the disease, if they have taken corticosteroids or the medications taken by the patient
        • For asthmatic patients, remind them to bring their inhalers. (45,90)
        • Chair to be in position where patient can breath easily
        • Availability of nitrous oxide or oxygen for patients with upper respiratory infection.
        • Allergy to antibiotics.
        • Advice on using antimicrobial mouth rinse.
        • Avoid triggering a hypersensitive airway by placing cotton rolls and suction tips.
        • Do NOT use equipments that produce aerosols eg. Ultrasonic scalers and polishing because of aspiration risks.
      • stable patient

        • tidak bisa duduk flat
        • inhale o2 dulu
    • Asthmatic Patient


        • Drugs containing aspirin (10-28% of all asthmatics may not tolerate the latter

        • Nonsteroidal antiinflammatory drugs (patients with intrinsic asthma

        • Macrolide antibiotics (erythromycin) in patients treated with theophylline. The serum methylxanthines levels (theophylline) may be increased

        • Opiates

          these can cause respiratory depression and histamine release

        • Local anesthetics: use solutions without adrenalin or levonordefrin, due to the sulfite preservative contents.

        • If the patient is receiving prolonged systemic corticosteroid treatment, supplements may be needed (prior to dental procedures that might cause stress)


        → Hentikan, posisi duduk, kasih o2, semprot bawa sesak, obat adrenalin subkutan

        1. Suspend the dental procedure and raise the patient to a comfortable position.

        2. Establish and keep the airways free, and administer an inhalatory β2 agonist.

        3. Administer oxygen with a mask. If no improvement is observed or the symptoms worsen, administer subcutaneous epinephrine (1:1000 in solution, 0.01 mg/kg body weight, with a maximum dose of 0.3 mg).

        4. Notify the emergency medical service.

        5. Maintain adequate oxygen levels until the patient breathes regularly and/or medical help arrives


        → tertelan: dudukkan pasien, coba dikeluarkan kepalan tangan di epigastric, tekan kearah dalam→ biar batuk/muntah

        1. Raise the patient and instruct him or her to cough forcefully.
        2. If breathing is affected (asphyxia, inspiratory stridor and the need to breathe with accessory muscle support) and vigorous coughing proves ineffective, perform the Heimlich maneuver.
        3. If this likewise proves ineffective, notify the emergency medical service immediately. While waiting for patient transfer, apply vital support measures, including airway permeation by means of a cricothyroidotomy, where necessary.
        4. If the airway is not affected, the swallowed object should be recovered to calm the patient.
        • Ideally, this care should be provided by licensed dental hygienists.
        • Presently, because of restrictive practice regulations in our state, we are unable to provide care in nursing homes and other institutionalized settings without the direct supervision of a dentist.
        • Hygienists can, however, train nursing home personnel to provide this care until such time that a licensed hygienist can be employed by the long term care facility to provide oral care.
  • PD and CVD (Cardiovascular disease

    • Periodontal disease can exacerbate existing heart conditions

    • Patients at risk for infective endocarditis may require antibiotics prior to dental procedures:

      • Prosthetic cardiac valve
      • Previous endocarditis
      • Some types of congenital heart disease
      • Cardiac transplantation recipients with cardiac valvular disease
    • PD and CVD a systematic review

      infeksi gigi berhubungan dengan resiko CDV 1,2

      infeksi jaringan perio→ resiko 3x CDV

      • Relative Risk for Cerebrovascular Disease According to Periodontal Disease Status NHANES I Follow-up

        periodontitis menyebabkan resiko CDV dan stroke 6x, mati 2,1x

    • Proposed role of infection in CHD

    • Inflammatory Pathways in Atherogenesis

      → peningkatan ICAM-1m IL-6→ INFLAMASI di PD dan liver

    • How does periodontal disease affect heart disease?

      → C-rp dan fibrinogen→ marker inflamasi→ berhubungan dengan clotting factor → Heart disease

      • This association is still being studied, but it is thought that the C-reactive protein and fibrinogen production is increased in response to oral inflammation. C- reactive protein increases clotting and is a marker for heart disease.
      • Risk is increased for diabetic patients and synergistically increased if the patient is a smoker.
      • A relationship between periodontal disease and atherosclerotic diseases, including heart disease and stroke, has been established.
      • In a large 14 year study, patients with periodontal disease were 25% more likely to develop coronary heart disease (CHD) than their healthy counterparts.
      • Men under 50 with periodontal disease were 72% more likely to develop CHD
      • Periodontal disease increased risk for both fatal and non-fatal strokes two-fold
    • Definition IHD (Ischemic Heart Disease)

      → kurang darah→ bisa serangan jantung

      " Ischaemia " → an insufficient amount of blood.

      • The coronary arteries are the only source of blood for the heart muscle.

      • If blocked → reduce supply.

      • An imbalance between the supply and demand

      • Decreased supply

        Atheroma, thrombosis, spasm, embolus

      • Increased demand

        Anemia, hypertension, high cardiac output (thyrotoxicosis, myocardial hypertrophy

      • Manifestations of Coronary Artery Disease/Ischemic Heart Disease (IHD)

        • Sudden death
        • Heart Attack/Myocardial infarction
        • Acute coronary syndrome
        • Stable/Unstable angina pectoris
        • Heart failure or Arrhythmia
      • Risk factors for Ischaemic heart disease

        • Obesity
        • Genetics
        • Diabetes Mellitus
        • Tobacco Use
        • Latent Life Style (lack of exercise)
        • Hypertension
        • Hypercholesterolemia
        • Age
        • Fixed
          • age
          • Male, +ve family history
        • Modifiable – strong association
          • Dyslipidaemia,
          • smoking,
          • diabetes mellitus,
          • obesity,
          • hypertension
        • Modifiable - weak association
          • Lack of exercise,
          • high alcohol consumption, soft water
    • Angina Pectoris (AP)

      → gejala nyeri dada kiri→ menjalar tangan kiri

      • Symptom not a disease
      • AP is chest discomfort associated with abnormal myocardial function in the absence of myocardial necrosis
      • AP can be Stable or Unstable
        • Stable → membaik saat istirahat

          The pain and pattern of events is unchanged over a period of time (months→ years)

        • Unstable:

          • The pain and pattern is changing, be it in duration, intensity or frequency
          • A Myocardial Infarction waiting to happen
    • Myocardial Infarction

      → PD tertutup lemak/keras

      Partial or total occlusion of one or more of the coronary arteries due to an atheroma, thrombus or emboli resulting in cell death (infarction) of the heart muscle

    • Gejala Serangan Jantung

      • Nyeri dada khas

      • Lokasi

        Dibelakang tulang dada, Dada sebelah kiri

      • Kualitas

        seperti ditekan/ditindih benda berat, dibakar, diremas, ditusuk, diiris, tercekik

      • Penjalaran:

        Leher, Rahang bawah, Bahu, Punggung, pergelangan s/d jari-jari, Ulu hati.

      • Gejala penyerta:

        Rasa sukar hirup/ sesak napas

        Keringat dingin, Pucat

    • Diagnosis

      • Diagnosis ditegakkan, bila: ( 2 dari 3 indikator ) kriteria WHO terpenuhi, yaitu
      1. Keluhan klinis (nyeri dada khas)
      2. Gambaran khas elektrokardiografi (EKG)
      3. Peningkatan kadar enzim jantung : (CK, CKMB dan troponin)
    • Complications of Myocardial Infarctions

      • Infarction leading to inability of the heart to function properly leading to Heart Failur
      • Angina/Pain
      • Cardiogenic shock
      • Ventricular aneurysm and rupture
      • Embolism Formation
      • Arrhythmias → Myocardial Infarctions can lead to Ventricular Fibrillation
    • Ischaemic heart disease Relevance to dentistry

      • IHD is common
      • Subjects with IHD have more severe dental caries and periodontal disease – association or causation?
      • Angina is a cause of pain in the mandible, teeth or other oral tissues
      • Stress provokes ACS!
    • Dental Considerations

      • Assessment and Overall Management
      • Pharmaceuticals
      • Emergency Situations
      • Oral Effects of Pharmaceuticals
      • Antibiotic Prophylaxis
      • Post MI: when to treat
    • RISK

      • Major Risk for Perioperative Procedures:
        • Unstable Angina (getting worse)
        • Recent MI
      • Intermediate Risk for Perioperative Procedures:
        • Stable Angina
        • History of MI
      • Most dental procedures, even surgical procedures fall within the risk of less than 1%
      • Highest risk procedures → those done under general anesthesia
    • Dental Considerations for Ischemic Heart Disease

      • Pharmaceutical Considerations
        • Interaction of NSAIDS with Beta Blockers
        • If patient is taking a non-selective Beta Blockers → limit local anesthetic use (increase in receptors for epinephrine)
        • In uncontrolled hypertensive patients use judgment when giving epinephrine → Carbocaine use encouraged
        • Statins when combined with Erythromycin and Clarithromycin can lead to renal failure and muscle pathology
      • Common Situations:
        • Orthostatic Hypotension due to use of anti-hypertensives (beta blockers, nitroglycerin)
          • Raise chair slowly
          • Allow patient to take his/her time
          • Assist patient in standing
        • Post-Op Bleeding:
          • When patients on Plavix or Aspirin, expect increased bleeding because of decreased platelet aggregation
      • Emergency Situations:
        • Possible MI:

          Remember that pain in the jaw may be referred pain from the myocardium → assess the situation, have good patient history, follow ABC’s

        • Angina:

          In situations of angina pectoris, all operatories should have nitroglycerin to be placed sublingually

        • Chest Pain-MI:

          • STOP PROCEDURE
          • Remove everything from patient’s mouth
          • Give sublingual nitroglycerin
          • Wait 5 minutes → if pain persists, give more nitroglycerin, assume MI
          • Give chewable aspirin → ABC’s
      • Post MI: When to Treat
        • Why delay treatment?
          • Remember that with an MI there is damage to the heart, be it severe or minimal that may effect the patient’s daily life
        • MI within 1 month → Major Cardiac Risk
        • MI within longer then 1 month:
          • Stable → routine dental care ok
          • Unstable → treat as Major Cardiac Risk
        • Delaying elective tx for 1 month is advisable.
        • Emergent care should be done with local anesthetic without epinephrine and monitoring of vital signs
    • Get regular medical checkups.

      • Control your blood pressure
      • Check your cholesterol.
      • Don’t smoke.
      • Exercise regularly.
      • Maintain a healthy weight.
      • Eat a heart-healthy diet
      • Manage stress.
    • Dentistry & Cardiovascular Medicine

      • DIABETES
        • Hypoglycaemia ( Type I)
        • Susceptible to oral infection / poor healing
        • No contraindication to routine dental treatment

        • Drugs may cause oral pathology e.g.Nifedipin

        • Klasifikasi

        • Dental management

          bisa klo dibawah 150/100

          • hati2 calcium blocker
          • bius: gapake epinephrine

        • Pencegahan

          • olahraga
          • jangan merokok
    • Dental Hygiene Treatment

      • Educate patients about the importance of maintaining their oral tissues through home and professional care.
      • Dental professionals should always take the patients’ blood pressure before proceeding with treatment. This is Standard of Care.
      • Ask about tobacco use, and incorporate Tobacco Cessation into the patient’s treatment plan
  • PD and HIV

    • AIDS adalah penyakit defisiensi imun yang disebabkan oleh infeksi virus HIV

    • Pada pasien AIDS, periodontitis dikenal sebagai HIV-periodontitis dimana insidensi kelainan periodontal meningkat seiring memberatnya defisiensi imun

    • HIV-periodontitis memilki gambaran adanya eritema gingiva bebas, gingival attached, dan mukosa alveolar, adanya ulserasi berat pada jaringan lunak dan kerusakan cepat pada periodontal attachments serta tulang

    • Diseases and Conditions causing lesions of oral mucosa: viral


    • Drug Regimen Compliance and Oral Health

      • mulut kering→ memperaparah

      HIV treatment compliance may be impacted by oral pain, xerostomia, dysphagia

    • The Special Importance of Oral Health in HIV Patients

      • Oral lesions in patients with HIV may be particularly large, painful or aggressive

    • HIV-associated oral lesions

      • manifestasi awal di rongga mulut

      Early studies reported that approximately 90% of HIV+ patients will present with at least one oral lesion in the course of their illness.

      Current studies report the prevalence or oral lesions has significantly declined

    • The Special Importance of Oral Health in HIV Patients: Oral Lesions

      LIAT DI PALATUM→ whitish plaque→ HIV

      • Oral lesions may act as markers for seroconversion
      • Oral Lesions may herald decline in immune function
    • Peridontal dan HIV

      • Lokasi tersering di rongga mulut dan jaringan perio
      • deteksi disini drg
      • konsultasi dr spesialis IPD
  • Take Home Messages

    • bagan

      inflamasi→ inflamatory mediator→ c rp dan fibrinogen

    • Hubungan Penyakit Periodontal dengan Kondisi Sistemik

      • Status imunologi dengan kesehatan gigi & mulut Hubungan penyakit gusi dengan Diabetes
      • hub penyakit gusi dan diabetes
      • Penyakit kardiorespirasi dan penyakit periodontal
      • Pengobatan Hipertensi → dry mouth HIV/AIDS dan kondisi rongga mulut
      • Stress, hormon, obat, gizi → kesehatan gigi & mulut
    • Dental managemetn

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