Oral Medicine
Posted by John Doe at Dental Assistant on January 1, 1970.
Categories: Dental Secrets
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ALLERGIC REACTIONS
42. What would you prescribe for the patient who develops a mild soft-tissue swelling of the lips under the rubber dam?
The patient probably has a contact allergic reaction from the Latex. If the reaction is mild (slight swelling with no extension into the oral cavity) and self-limiting, the patient should be given 50 mg of oral diphenhydramine and observed for at least 2 hours for possible delayed reaction. If the reaction is moderate to severe, the patient should be given 50 mg of diphenhydramine, either intramuscularly or intravenously, and closely monitored. Emergency services should be contacted to transport the patient to the emergency department for treatment and observation. With the advent of the epidemic of HIV infection, Latex gloves and condoms are now widely used. Allergic patients should be instructed to inform health care providers of their Latex allergy and referred to an allergist.
43. What should you do if a patient for whom you prescribed the prophylactic antibiotic amoxicillin approximately 1 hour previously reports urticaria, erythema, and pruritus (itching)?
If the reaction is delayed (longer than 1 hour) and limited to the skin, the patient should be given 50 mg of diphenhydramine, intramuscularly or intravenously, then observed for 1-2 hours before being released. If no further reaction occurs, the patient should be given a prescription for 25-50 mg of diphenhydramine to be taken every 6 hours until symptoms are gone.
If the reaction is immediate (less than 1 hour) and limited to the skin, 50 mg of diphenhydramine should be given immediately either intravenously or intramuscularly. The patient should be monitored and emergency services contacted to transport the patient to the emergency department. If other symptoms of allergic reaction occur, such as conjunctivitis, rhinitis, bronchial constriction, or angioedema, 0.3 cc of aqueous 1/1000 epinephrine should be given by subcutaneous or intramuscular injection. The patient should be monitored until emergency services arrive. If the patient becomes hypotensive, an intravenous line should be started with either Ringer's lactate or 5% dextrose/water.
44. What are the signs and symptoms of anaphylaxis? How should it be managed in the dental office?
Anaphylaxis is characterized by bronchospasm, hypotension or shock, and urticaria or angioedema. It is a medical emergency in which death may result from respiratory obstruction,
circulatory failure, or both. With the first indication of anaphylaxis, 0.2-0.5 cc of 1/1000 aqueous epinephrine should be injected subcutaneously or intramuscularly, and emergency services should be contacted. The injection of epinephrine may be repeated every 20-30 minutes, if necessary, for as many as 3 doses. Oxygen at a rate of 4 L!min must be delivered with a face mask. The patient must be continuously monitored, and an intravenous line containing either Ringer's lactate or normal saline should be infused at 100 cc/hour. If the patient becomes hypotensive, the intravenous infusion should be increased. If airway obstruction occurs from edema of the larynx or hypopharynx, a cricothyrotomy must be done. If the airway obstruction is due to bronchospasm, an albuterol or terbutaline nebulizer should be administered or intravenous aminophylline, 6 mg/kg, infused over 20-30 minutes.
HEMATOLOGY/ONCOLOGY
45. What are the normal values for a CBC?
| White blood cell count | Hemoglobin (Hgb) | ||
|---|---|---|---|
| 18 years and older | 4,000-10,000/ml | 18 years and older | |
| 12-17 years | 4,500-13,000/ml | Male | 13.5-18.0 gm/ldl |
| 6 months to 11 years | 4,500-13,500/ml | Female | 11.5-16.4 gm/ldl |
| Red blood cell count | 12-17 years | ||
| 18 years and older | Male and female | 12.0-16.0 gm/dl | |
| Male | 4.5-6.4 M/ml | 6 months to 11 years | |
| Female | 3.9-6.0 M/ml | Male and female | 10.5-14.0 gm/dl |
| 12-17 years | Platelet count (PLT) | ||
| Male and female | 4.1-5.3 M/ml | 8 days and older | 150,000- |
| 6 months to 11 years | 450,000/ml | ||
| Male and female | 3.7-5.3 M/ml | Up to 7 days | 150,000- |
| Hematocrit (Hct) | 350,000/ml | ||
| 18 years and older | |||
| Male | 40-54% | ||
| Female | 36-48% | ||
| 12-17 years | |||
| Male and female | 36-39% | ||
| 6 months to 11 years | |||
| Male and female | 34-45% |
46. What precautions should be taken in providing dental care to a patient with sickle-cell anemia?
- Patients with sickle-cell disease should not receive dental treatment during a crisis, except for the relief of dental pain and treatment of acute dental infections. Dental infections should be treated aggressively; if facial cellulitis develops, the patient should be admitted to the hospital for
treatment. .' - - The patient's physician should be consulted about the patient's cardiovascular status. Myocardial damage secondary to infarctions and iron deposits is common.
- Patients with sickle-cell anemia are at increased risk for bacterial infections and should receive prophylactic antibiotics before any dental procedure that may cause a transient bacteremia. The prophylactic antibiotic regimen used for the prevention of endocarditis should be followed. After a surgical procedure, antibiotics (500 mg penicillin VK 4 times/day or erythromycin, 250 mg 4 times/day, for penicillin-allergic patients) should be continued for 7-10 days postoperatively.
47. Can local anesthetic with a vasoconstrictor be used in a patient with sickle-cell disease?
Because of the possibility of impairing local circulation, the use of vasoconstrictors in patients with sickle-cell disease is controversial. It is recommended that the planned dental procedure dictate the choice of local anesthetic. If the planned procedure is a routine, short procedure that can be performed without discomfort by using an anesthetic without a vasoconstrictor, the vasoconstrictor should not be used. However, if the procedure requires long, profound anesthesia, 2% lidocaine with 1/100,000 epinephrine is the anesthetic of choice.
48. Can nitrous oxide be used to help manage anxiety in patients with sickle-cell anemia?
Nitrous oxide can be safely used in patients with sickle-cell anemia as long as the concentration of oxygen is greater than 50%, the flow rate is high, and the patient is able to ventilate adequately.
49. Can a dental infection cause a crisis in a patient with sickle-cell anemia?
Preventive dental care-routine scaling and root planing, topical fluorides, sealants and treatment of dental caries-is important in patients with sickle-cell anemia. The literature reports two cases of a sickle-cell crisis precipitated by periodontal infections.
50. What are the oral symptoms of acute leukemia?
Over 65% of patients with acute leukemia have oral symptoms. The symptoms result from myelosuppression due to the overwhelming numbers of malignant cells in the bone marrow and/or large numbers of circulating immature cells (blasts).
- Symptoms from thrombocytopenia: gingival oozing, petechiae, hematoma, and ecchymosis
- Symptoms from neutropenia: recurrent or unrelenting bacterial infections, lymphadenopathy, oral ulcerations, pharyngitis, and gingival infection
- Symptoms from circulating immature cells (blasts): gingival hyperplasia from blast infiltration
Patients with the above signs or symptoms should be evaluated to rule out a hematologic malignancy. The dentist should consider carefully whether the symptoms can be explained by local factors or are disproportionate to the local factors. If a hematologic malignancy is suspected, a CBC with a differential white cell count should be ordered.
51. Is it safe to extract a tooth in a patient who is receiving chemotherapy?
Dental procedures should be scheduled, if possible, 2 weeks before planned chemotherapy or after the counts begin to recover, usually 14 days for white cells and 21 days for platelets. Dental treatment should be attempted only after consultation and in coordination with the patient's physician and after the patient has had a CBC.
52. What precautions should be taken in treating a patient who has received bone marrow transplantation for a hematologic malignancy?
Dental care should be done only in consultation with the patient's physician. As a rule, elective dental treatment should be postponed for 6 months after transplant. However, emergency dental treatment can be done. If dental care must be done before the recommended postponement, a CBC should be checked and if the results are acceptable (platelets > 50,000 and neutrophils > 500), the patient should be premedicated with the same regimen used for the prevention of endocarditis.
53. What should be done if a patient has enlarged lymph nodes?
Lymphadenopathy may be secondary to a sore throat or upper respiratory infection or the initial presentation of a malignancy. A thorough history and clinical examination help to determine the etiology of the lymphadenopathy.
Patients with lymphadenopathy and an identifiable inflammatory process should be reexamined in 2 weeks to determine whether the lymphadenopathy has responded to treatment. If no inflammatory process can be identified or if the lymphadenopathy does not resolve after treatment, the patient should be referred to a physician for further evaluation and possible biopsy.
| Inflammatory Process | Granulomatous Disease/Neoplasia | |
|---|---|---|
| Onset | Acute | Progressive enlargement |
| Pain on palpation | Tender | Neoplasia: asymptomatic Granulomatous: painful |
| Symmetry | Bilateral for systemic infections Unilateral for localized infections |
Usually unilateral |
| Consistency | Firm, movable | Firm, nonmovable |
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