Oral Medicine
Posted by John Doe at Dental Assistant on January 1, 1970.
Categories: Dental Secrets
Share
Print
Email-
+5
Vote
7 votes
TREATMENT OF HIV-POSITIVE PATIENTS
21. What are the considerations in treating patients infected with the HIV virus and treated with azidothymidine (AZT)?
AZT is an antiviral widely used in patients infected with the human immunodeficiency virus (HIV). The drug is toxic to the hematopoietic system and may result in anemia, granulocytopenia, or thrombocytopenia. Patients taking AZT should have a CBC every 2 weeks. Before oral surgical procedures, a CBC should be done to determine whether the patient is neutropenic or thrombocytopenic.
22. What is the mechanism of action of the HIV-1 protease inhibitors? What precautions must be taken in treating patients that receive protease inhibitors?
The protease inhibitors represent a major advance in the management of HIV disease. Once HIV- 1 enters a cell, viral RNA undergoes reverse transcription to produce double-stranded DNA. The viral DNA is integrated into the host genome. It is then transcribed and translated by cellular enzymes to produce large, nonfunctional polypeptide chains, known as polyproteins. Polyproteins are assembled and packaged at the cell surface, and then immature virions are produced and released into the plasma. HIV- 1 protease then cleaves the polyproteins into smaller, functional proteins, thereby allowing the virion to mature. In the presence of HIV- 1 protease inhibitors, the virion cannot mature and is rapidly cleared from the system. The major protease inhibitors are reviewed below:
HIV-1 Protease Inhibitors and Precautions for the Dental Practitioner
| MEDICATION | ADVERSE REACTION | INTERACTIONS |
|---|---|---|
| Saquinavir (Invirase) | Nausea, diarrhea, abdominal discomfort, and rash | Avoid drugs that alter the cytochrome P450 activity in the liver because they affect the bioavailability of saquinavir. Ketoconazole inhibits cytochrome P450 and may result in increased plasma levels of saquinavir. |
| Ritonavir (Norvir) | Nausea, vomiting, diarrhea, fatigue, abdominal pain, circumoral paresthesias, taste disturbances, anorexia, elevated triglycerides, creatinine kinase, and transaminases | Use of sedative/hypnotics is contraindicated (e.g., diazepam, midazolam) because of the potential for oversedation. Ritonavir is a powerful inhibitor of cytochrome P450; thus, plasma concentrations of these drugs remain high. Narcotic analgesics, erythromycin, antifungal agents, and corticosteroids must be prescribed with caution for the same reason. NSAIDs may be subject to decreased bioavailability. Ritonavir is formulated in alcohol. Therefore, metronidazole in also contraindicated. |
| Indinavir (Crixivan) | Nephrolithiasis, abdominal discomfort, asymptomatic hyperbilirubinemia | Generally, indinavir is well-tolerated. No significant contraindications. |
| Nelfinavir (Viracept) | Diarrhea, loose stools | No significant contraindications, but more testing is necessary. |
23. A patient with HIV infection requires an oral surgical procedure to remove teeth after severe bone loss due to H1V-related localized periodontitis. What precautions should be taken?
It is estimated that 10-15% of patients with HIV develop immunogenic thrombocytopenic purpura (ITP). The antiplatelet antibodies appear to be found more frequently in advanced stages of the disease. Affected patients should have a CBC before any oral surgical procedure. If the platelets are low (below 150,000), the procedure should be done only after consultation with the patient's physician and with the knowledge that bleeding may be increased. The patient may require platelet transfusions to control postoperative bleeding.
24. Are there any contraindications to restorative dentistry procedures in patients with HIV infection?
If the patient is not neutropenic or thrombocytópenic, there are no contraindications to pre ventive and restorative dental care. In fact, patients should receive aggressive dental care to reduce t oral cavity as a source of infection. They should be placed on a 3-6-month recall to maintain optimal oral health and followed closely for opportunistic infections and HIV-related oral conditions.
CARDIOVASCULAR DISEASE
25. What is the appropriate response if a patient with a history of cardiac disease develops chest pain during a dental procedure?
- Discontinue treatment immediately.
- Take and record vital signs (blood pressure, pulse, respiration), and question the patient about the pain. Chest pain from ischemia may be either substernal or more diffused. Patients often describe the pain as crushing, pressure, or heavy; it may radiate to the shoulders, arms, neck, or back.
- If the patient has a history of angina and takes nitroglycerin, give the patient either his or her own nitroglycerin or a tablet from your emergency cart. Continue to monitor the patient's vital signs. If the pain does not stop after 3 minutes, give the patient a second dose. If after 3 doses in a 10-minute period the pain does not subside, contact the medical emergency service and have the patient transported to an emergency department to rule out a myocardial infarction.
- If the patient does not have a history of heart disease and persistent chest pain for greater than 2 minutes, the medical emergency service should be contacted and the patient transported to a hospital emergency department for evaluation.
- If the patient is not allergic to aspirin, administer one tablet of aspirin (325 mg) orally. The aspirin acts as an antithrombotic agent.
26. At what blood pressure should elective dental care be postponed?
Elective dental care should be postponed if the systolic blood pressure is> 160 mmHg or the diastolic pressure is> 100 mmHg.
27. At what blood pressure should emergency dental care be postponed and the patient treated palliatively until the blood pressure is controlled?
Emergency dental treatment should be postponed if the systolic pressure is > 180 or the diastolic pressure is > 110. Patients must be referred for care immediately to prevent morbidity if they have either (1) asymptomatic severe hypertension with a systolic pressure > mmHg or diastolic pressure > 130 mmHg or (2) symptomatic hypertension, headache, heart failure, angina, or elevated perioperative blood pressure, with a systolic pressure of > 200 mmHg or diastolic pressure of > 120.
28. How long should dental care be postponed after a heart attack?
Dental treatment in a patient who has had a myocardial infarction should be done only after consultation with the patient's physician. Cintron et al. showed that patients treated within 3 weeks of an uncomplicated myocardial infarction experienced no significant hemodynamic changes or complications related to local anesthesia, vigorous dental prophylaxis, or dental extraction. The general guidelines for a patient without angina or heart failure is to wait 6 months for elective dental care.
29. How do you differentiate between stable and unstable angina?
Unstable angina is characterized by a change in the pattern of pain. The pain occurs with less exertion or at rest, lasts longer, and is less responsive to medication. Dental care for such patients must be postponed and the patient referred to his or her physician immediately for care. Patients are at increased risk for myocardial infarction. If emergency dental care is necessary before the patient is stable, it should be attempted only with cardiac monitoring and sedation.
30. What precautions should be taken in treating a patient with recent onset of angina?
Patients with recent onset of angina less than 30 days' duration are at increased risk for myocardial infarction and sudden death. The angina may not be severe and may occur only with exercise. However, even though symptoms are mild, dental treatment should be postponed until the patient has had a medical evaluation.
31. Is the use of a vasoconstrictor in local anesthetics contraindicated in patients with cardiac disease?
The use of vasoconstnictors is not contraindicated in patients with cardiovascular disease. According to conservative recommendations, epinephrine should not exceed 0.04 mg, which equates to 4 carpules of 1/200,000 or 2 carpules of 1/100,000.
32. Should retraction cord that contains epinephrine be used in a patient with cardiovascular disease?
The concentration of epinephrine in impregnated cord is high, and systemic absorption occurs. Impregnated cord should not be used in patients with cardiac disease, hypertension, or hyperthyroidism. Malamed argues that epinephninecontaining retraction cord should not be used in dental practice.
33. When should vasoconstrictors not be used in either local anesthetic or retraction cord?
Vasoconstrictors should not be used in patients with uncontrolled hypertension or hyperthyroidism. Epinephrine should not be used in dental patients under general anesthesia when either halogenated hydrocarbons or cyclopropane are used for anesthesia.
34. Is it safe to treat a patient who has had a heart transplant in an outpatient dental office?
Dental treatment should be done only after consultation with the patient's cardiologist. If the patient is stable without rejection, there are no contraindications to dental treatment. Such patients do not require prophylactic antibiotics for dental procedures unless the transplanted heart has valvular pathology or the patient is severely immunosuppressed. The patient most likely will be taking prednisone and cyclosporine. For restorative and preventive dental procedures and simple extractions, it is not necessary to increase the corticosteroids. Erythromycin and ketoconazole should not be prescribed for a patient on cyclosponine. Erythromycin and ketoconazole inhibit the metabolism of cyclosponine.
METABOLIC DISORDERS
35. What precautions do you need to take in treating a patient with insulin-dependent dia betes mellitus (IDDM)?
The major concern for the dental practitioner treating the patient with IDDM is hypoglycemia. It is important to question the patient for changes in insulin dosage, diet, and exercise routine before undertaking any outpatient dental treatment. A decrease in dietary intake or an increase in either the normal insulin dosage or exercise may place the patient at risk for hypoglycemia.
36. What are the symptoms of hypoglycemia?
- Tachycardia 4. Tremulousness
- Palpitations 5. Nausea
- Sweating 6. Hunger The symptoms may progress to coma and convulsions without intervention.
37. What should the dentist be prepared to do for the patient who has a hypoglycemic reaction?
The dental practitioner should have some form of sugar readily available- packets of table sugar, candy, or orange juice. Also available are 3-mg tablets of glucose (Dextrosol). If a patient develops symptoms of hypoglycemia, the dental procedure should be discontinued immediately; if conscious, the patient should be given some form of oral glucose.
If the patient is unconscious, the emergency medical service should be contacted. Then 1 mg of glucagon can be injected intramuscularly, or 50 ml of 50% glucose solution can be given by rapid intravenous infusion. The glucagon injection should restore the patient to a conscious state within 15 minutes; then some form of oral sugar can be given.
38. Is the diabetic patient at greater risk for infection after an oral surgical procedure?
It is important to minimize the risk of infection in diabetic patients. They should have aggressive treatment of dental caries and periodontal disease and then be placed on frequent recall examinations and oral prophylaxis.
After oral surgical procedures, endodontic procedures, and treatment of suppurative periodontitis, diabetic patients should be placed on antibiotics to prevent infection secondary to delayed healing. Antibiotics of choice are potassium phenoxymethyl penicillin, 500 mg, or clindamycin, 150 mg, 4 times/day for 7-10 days.
39. When is it necessary to increase the dose of prednisone in patients taking corticosteroids?
Patients with heart transplants who are on long-term prednisone therapy undergo cardiac biopsy without either intravenous sedation or stress doses of corticosteroids. For restorative dentistry, dental hygiene, mucogingival surgery, and simple extractions, it is not necessary to increase the patient's corticosteroids. However, it is important that the patient has taken the usual dose.
For multiple extractions or extensive mucogingival surgery, the dose of corticosteroids should be doubled on the day of surgery. If the patient is treated in the operating room under general anesthesia, stress level doses of cortisone, 100 mg intravenously or intramuscularly, should be given preoperatively.
40. Should antibiotics be prescribed for oral surgical procedures in patients receiving corticosteroids?
As with the diabetic patient, it is important to minimize the risk of infection in patients taking corticosteroids. Patients on long-term therapy, such as organ transplant recipients, should receive aggressive treatment to eliminate the oral cavity as a source of infection and then be placed on frequent recall examinations and oral prophylaxis.
Patients on corticosteroid therapy should be placed on antibiotic therapy after oral surgical procedures. Antibiotics should be started on the day of the procedure and continued for 5-7 days postoperatively. The antibiotic of choice is potassium phenoxymethyl penicillin, 500 mg 4 times/day. If the patient is allergic to penicillin and not taking cyclosporine, erythromycin, 250 mg 4 times/day for 5- 7 days, should be prescribed. If the patient is allergic to penicillin and taking cyclosporine, clindamycin, 300 mg 3 times/day for 5-7 days, is the antibiotic of choice.
41. What are the clinical symptoms of hypothyroidism? What dental care can be safely provided?
The clinical sym of hypothyroidism are weakness, fatigue, intolerance to cold, changes in weight, constipation, headache, menorrhagia, and dryness of the skin. Dental care should be deferred until after a medical consultation in a patient with or without a history of thyroid disease who experiences a combination of the above signs and symptoms. If the patient is myxedematous, he or she should be treated as a medical emergency and referred immediately for medical care. It is important not to prescribe opiates for palliative treatment of the myxedematous patient. The myxedematous patient may be unusually sensitive and die from normal doses of opiates.
Other articles
You can trackback from your own site.
