Oral Medicine
Posted by John Doe at Dental Assistant on January 1, 1970.
Categories: Dental Secrets
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Now keep this straight: You take the white penicillin tablet every 6 hours and 1 red pill every 2 hours and 1/2 a yellow pill before every meal and 2 speckled orange pills between lunch and dinner followed by 3 green pills before bedtime, unless you have taken the oblong white tablet for pain, then … Any questions? Good luck.
DISORDERS OF HEMOSTASIS
1. How do you screen a patient for potential bleeding problems?
The best screening procedure for a bleeding disorder is a good medical history. If the review of the medical history indicates a bleeding problem, a more detailed history is needed. The following questions are basic:
- Is there a family history of bleeding problems?
- Has bleeding been noted since early childhood, or is the onset relatively recent?
- How many previous episodes have there been?
- What are the circumstances of the bleeding?
- When did the bleeding occur? After minor surgery, such as tonsillectomy or tooth extraction? After falls or participation in contact sports?
- What medications was the patient taking when the bleeding occurred?
- What was the duration of the bleeding episode(s)? Did the episode involve prolonged oozing or a massive hemorrhage?
- Was the bleeding immediate or delayed?
2. What laboratory tests should be ordered if a bleeding problem is suspected?
- Platelet count: normal values = 150,000-450,000
- Prothrombin time (PT): normal value = 10-13.5 seconds
- Partial thromboplastin time (PTT): normal value = 25-36 seconds
- Bleeding time: normal value = < 9 minutes (bleeding time is a nonspecific predictor of platelet function)
Normal values may vary from one laboratory to another. It is important to check the normal values for the laboratory that you use. If any of the tests are abnormal, the patient should be referred to a hematologist for evaluation before treatment is performed.
3. What are the clinical indications for use of 1-deamino-8 vasopressin (DDAVP) in dental patients?
DDAVP (desmopressin) is a synthetic anti diuretic hormone that controls bleeding in patients with type I von Willebrand's disease, platelet defects secondary to uremia related to renal dialysis, and immunologic thrombocytopenic purpura (ITP). The dosage is 0.3 mg/kg. DDAVP should not be used in patients under the age of 2 years; caution is necessary in elderly patients and patients receiving intravenous fluids.
4. When do you use epsilon aminocaproic acid or tranexamic acid?
Epsilon aminocaproic acid (Amicar) and tranexamic acid are antifibrinolytic agents that inhibit activation of plasminogen. They are used to prevent clot lysis in patients with hereditary clotting disorders. For epsilon aminocaproic acid, the dose is 75-100 mg/kg every 6 hours; for tranexamic acid, it is 25 mg/kg every 8 hours.
5. What is the minimal acceptable platelet count for an oral surgical procedure?
Normal platelet count is 150,000-450,000. In general, the minimal count for an oral surgical procedure is 50,000 platelets. However, emergency procedures may be done with as few as 30,000 platelets if the dentist is working closely with the patent's hematologist and uses excellent techniques of tissue management.
6. For a patient taking warfarin (Coumadin), a dental surgical procedure can be done without undue risk of bleeding if the PT is below what value?
Warfarin affects clotting factors II, VII, IX, and X by impairing the conversion of vitamin K to its active form. The normal PT for a healthy patient is 10.0-13.5 seconds with a control of 12 seconds. Oral procedures with a risk of bleeding should not be attempted if the PT is greater than 1½ times the control or above 18 seconds with a control of 12 seconds.
7. Is the bleeding time a good indicator of pen, and post surgical bleeding?
The bleeding time is used to test for platelet function. However, studies have shown no cor relation between blood loss during cardiac or general surgery and prolonged bleeding time. The best indicator of a bleeding problem in the dental patient is a thorough medical history. The bleeding time should be used in patients with no known platelet disorder to help predict the potential for bleeding.
8. Should oral surgical procedures be postponed in patients taking aspirin?
Nonelective oral surgical procedures in the absence of a positive medical history for bleeding should not be postponed because of aspirin therapy, but the surgeon should be aware that bleeding may be exacerbated in a patient with mild platelet defect. However, elective procedures, if at all possible, should be postponed in the patient taking aspirin. Aspirin irreversibly acetylates cyclooxygenase, an enzyme that assists platelet aggregation. The effect is not dose-dependent and lasts for the 7-10-day life span of the platelet.
9. Are patients taking non steroidal medications likely to bleed from oral surgical procedures?
Non steroidal anti inflammatory medications produce a transient inhibition of platelet aggregation that is reversed when the drug is cleared from the body. Patients with a preexisting platelet defect may have increased bleeding.
10. If a patient presents with spontaneous gingival bleeding, what diagnostic tests should be ordered?
A patient who presents with spontaneous gingival bleeding without a history of trauma, tooth brushing, flossing, or eating should be assessed for a systemic cause. Etiologies for gingival bleeding include inflammation secondary to localized periodontitis, platelet defect, factor deficiency, hematologic malignancy, and metabolic disorder. A thorough medical history should be obtained, and the following laboratory tests should be ordered: (1) PT, (2) PIT, and (3) complete blood count (CBC).
INDICATIONS FOR PROPHYLACTIC ANTIBIOTICS
11. For what cardiac conditions is prophylaxis for endocarditis recommended in patients receiving dental care?
High-risk category
- Prosthetic cardiac valves, including both bio prosthetic and homo graft valves
- Previous bacterial endocarditis
- Complex cyanotic congenital heart disease (e.g., single ventricle states, transposition of the great arteries, tetra logy of Fallot)
- Surgically constructed systemic pulmonary shunts or conduits
Moderate-risk category
- Most congenital cardiac malformations other than above and below (see next question)
- Acquired valvular dysfunction (e.g., rheumatic heart disease)
- Hypertrophic cardiomyopathy
- Mitral valve prolapse with valvular regurgitation and/or thickened leaflets
12. What cardiac conditions do not require endocarditis prophylaxis? Negligible-risk category (no higher than the general population)
- Isolated secundum atrial septal defect
- Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 months)
- Previous coronary artery bypass graft surgery
- Mitral valve prolapse without valvular regurgitation
- Physiologic, functional, or innocent heart murmurs
- Previous Kawasaki disease without valvular regurgitation
- Previous rheumatic fever without valvular regurgitation
- Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators
13. What are the antibiotics and dosages recommended by the American Heart Association (AHA) for prevention of endocarditis from dental procedures?
The AHA updates its recommendations every few years to reflect new findings. The dentist has an obligation to be aware of the latest recommendations. The patient's well-being is the dentist's responsibility. Even if a physician recommends an alternative prophylactic regimen, the dentist is liable if the patient develops endocarditis and the latest AHA recommendations were not followed.
Standard regimen
Amoxicillin, 2.0 gm orally 1 hr before procedure.
For patients allergic to amoxicillin and penicillin.
Clindamycin, 600 mg orally 1 hr before procedure or Cephalexin* or cefadroxil,* 2.0 gm orally 1 hr before procedure or Azithromycin or clarithromycin, 500 mg orally 1 hr before procedure.
Patients unable to take oral medications
Ampicillin, intravenous or intramuscular administration of 2 gm 30 mm before procedure.
For patients allergic to ampicillin, amoxicillin, and penicillin.
Clindamycin, intravenous administration of 600 mg 30 mm before procedure or Cefazolin,* intravenous or intramuscular administration of 1.0 gm within 30 mm before procedure.
* Cephalosporins should not be used in patients with immediate-type hypersensitivity reaction (urticaria, angioedema. or anaphylaxis) to penicillins.
14. For what dental procedures is antibiotic premedication recommended in patients identified as being at risk for endocarditis?
- Dental extractions
- Periodontal procedures including surgery, scaling and root planing, probing, and recall maintenance
- Dental implant placement and reimplantation of avulsed teeth
- Endodontic (root canal) instrumentation or surgery only beyond the apex
- Subgingival placement of antibiotic fibers or strips
- Initial placement of orthodontic bands but not brackets
- Intraligamentary local anesthetic injections
- Prophylactic cleaning of teeth or implants if bleeding is anticipated
15. For what dental procedures is antibiotic premedication not recommended in patients identified as being at risk for endocarditis?
- Restorative dentistry (including restoration of carious teeth and prosthodontic replacement of teeth) with or without retraction cord (clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding)
- Local anesthetic injections (nonintraligamentary)
- Intracanal endodontic treatment (after placement and build-up)
- Placement of rubber dams
- Postoperative suture removal
- Placement of removable prosthodontic or orthodontic appliances
- Making of impressions
- Fluoride treatments
- Intraoral radiographs
- Orthodontic appliance adjustment
- Shedding of primary teeth
16. Should a patient who has had a coronary bypass operation be placed on prophylactic antibiotics before dental treatment?
No evidence indicates that coronary artery bypass graft surgery introduces a risk for endocarditis. Therefore, antibiotic prophylaxis is not needed.
17. What precautions should you take when treating a patient with a central line such as a Hickman or Portacath?
Patients with central venous access are usually receiving intensive antibiotic therapy, chemotherapy, or nutritional support. It is imperative to consult with the patient's physician before performing any dental procedures. If it is determined that the dental procedure is necessary, the patient should receive antibiotic prophylaxis to protect the central venous access line from infection secondary to transient bacteremias. The same antibiotic regimen recommended for the prevention of endocarditis should be prescribed.
18. Should a patient with a prosthetic joint be placed on prophylactic antibiotics before dental treatment?
Case studies support the hematogenous seeding of prosthetic joints. However, it is questionable whether organisms from the oral cavity are a source for late deep infections of prosthetic joints. The decision whether to premedicate should be determined by the dentist's clinical judgment in consultation with the patient's physician or orthopedic surgeon. Patients considered at high risk for developing a late infection of a prosthetic joint should be premedicated. Such patients can be grouped based on predisposing systemic conditions, issues associated with joint prostheses, or presence of acute infection at sites distant to the joint prosthesis.
High-risk Patients with Total Joint Replacements
Predisposing systemic conditions
Rheumatoid arthritis Insulin-dependent diabetes mellitus Systemic lupus erythematosus Hemophilia Disease-, drug-, or radiation-induced immunosuppression Malnourishment.
Issues associated with joint prostheses
First 2 years after joint replacement Loose prosthesis History of replacement of prosthesis History of previous infection of prosthesis.
Acute infection located at distant sites: skin, oral cavity, other.
19. What are the antibiotics and dosages recommended by the American Dental Association and the American Academy of Orthopaedic Surgeons to prevent late joint infections in patients considered to be at high risk?
Standard regimen
Cephalexin* or cephradine* or amoxicillin, 2 gm orally 1 hr before procedure.
For patients allergic to amoxicillin and penicillin.
Clindamycin, 600 mg orally 1 hr before procedure.
Patients unable to take oral medications
Cefazolin,* intravenous or intramuscular administration of 1.0 gm 1 hr before procedure or Ampicillin, intravenous or intramuscular administration of 2.0 gm 1 hr before procedure
For patients allergic to ampicillin, amoxicillin, and penicillin.
Clindamycin, intravenous or intramuscular administration of 600 mg 1 hr before procedure.
* Cephalosporins should not be used in patients with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins.
20. Is it necessary to prescribe prophylactic antibiotics for a patient on renal dialysis?
Patients on dialysis with arteriovenous (AV) shunts should be premedicated before any dental treatment that has the potential of producing a transient bacteremia. The dosages for antibiotic coverage are as follows:
Standard regimen
Amoxicillin, 2.0 gm orally 1 hr before procedure.
For patients allergic to amoxicillin and penicillin
Clindamycin, 600 mg orally 1 hr before procedure or Cephalexin* or cefadroxil,* 2.0 gm orally 1 hr before procedure.
Azithromycin or clarithromycin, 500 mg orally 1 hr before procedure.
Patients unable to take oral medications
Ampicillin, intravenous or intramuscular administration 2.0 gm within 30 mm before procedure.
For patients allergic to ampicillin, anioxicillin, and penicillin
Clindamycin, intravenous administration of 600 mg within 30 mm before procedure or Cefazolin,* intravenous or intramuscular administration of 1.0 gm within 30 mm before procedure.
* Cephalosporins should not be used in patients with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins.
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