Oral Medicine
Posted by John Doe at Dental Assistant on January 1, 1970.
Categories: Dental Secrets
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KIDNEY DISEASE
54. What precautions should be taken before beginning treatment of a patient on dialysis?
Patients typically receive dialysis 3 times/week, usually on a Monday, Wednesday, Friday schedule or a Tuesday, Thursday, Saturday schedule. Dental treatment for a patient on dialysis should be done on the day between dialysis appointments to avoid bleeding difficulties (patients receive the anticoagulant, heparin, on dialysis days). Patients with an arteriovenous shunt should be premedicated to prevent infection of the shunt whenever the risk of transient bacteremia is present.
55. What adjustments in the dosage of oral antibiotics should you make for a patient on renal dialysis who has a dental infection?
| Penicillin | 500 mg orally every 6 hr; dose after hemodialysis |
|---|---|
| Amoxicillin | 500 mg orally every 24 hr; dose after hemodialysis |
| Ampicillin | 250 mg to I g orally every 12-24 hr; dose after hemodialysis |
| Erythromycin | 250 mg orally every 6 hr; not necessary to dose after hemodialysis |
| Clindamycin | 300 mg every 6 hr; not necessary to dose after hemodialysis |
56. What pain medications can be safely prescribed for patients on dialysis?
- Codeine is safe to use in dialysis but may produce more profound sedation. The dose should be titrated beginning with one-half the normal dose for patients on dialysis and one-half to three-fourths the normal dose for patients with severely decreased renal function.
- Acetaminophen is nephrotoxic in overdoses. However, it may be prescribed in patients on dialysis at a dose of 650 mg every 8 hours. For patients with decreased renal function, the regimen should be 650 mg every 6 hours.
- Aspirin should be avoided in patients with severe renal failure and in patients on renal dialysis because of the possibility of potentiating hemorrhagic diathesis.
- Propoxyphene (Darvon) should not be prescribed for a patient on renal dialysis. The active metabolite norpropoxyphene accumulates in patients with end-stage renal disease.
- Meperidine (Demerol) should not be prescribed in patients on renal dialysis. The active metabolite, normeperidine, accumulates and may cause seizures.
57. What changes do you expect to see in the dental radiographs of a patient on renal dialysis?
The most common changes are decreased bone density with a ground-glass appearance, increased bone density in the mandibular molar area compatible with osteosclerosis, loss of lamina aura, subperiosteal cortical bone resorption in the maxillary sinus and the mandibular canal, and brown tumor.
58. What precautions should be taken in treating a patient after renal transplantation?
After renal transplant patients receive immunosuppressive drugs and have an increased susceptibility to infection. Dental infections should be treated aggressively. Prophylactic antibiotics should be considered whenever the risk of bacteremia is present. Erythromycin should not be prescribed for any patient taking cyclosporine.
59. What antibiotic, used often in dentistry, should be avoided in a patient taking cyclo sporine?
Cyclosporine is used to prevent organ rejection in renal, cardiac, and hepatic transplantation and to prevent graft-vs.-host disease in patients with bone marrow transplants. Erythromycin should not be prescribed for patients taking cyclosporine. Erythromycin increases the levels of cyclosporine by decreasing its metabolism.
PULMONARY DISEASE
60. What precautions should be taken in treating a patient with chronic obstructive pulmonary disease (COPD)?
Patients with COPD and a history of hemoptysis should be prescribed drugs with antiplatelet activity (aspirin and nonsteroidals) with caution. Hemoptysis has been reported after the use of aspirin in patients with COPD.
61. What antibiotic should not be prescribed for patients with COPD who take theophylline?
Erythromycin should not be prescribed for patients taking theophylline. Erythromycin decreases the metabolism of theophylline and may cause toxicity.
62. What intervention is appropriate for a dental patient who has an asthma attack in the office?
The medical history should provide an indication of the severity of the asthma and the medications that the patient takes for an asthma attack. The symptoms of an acute asthma attack are shortness of breath, wheezing, dyspnea, anxiety, and, with severe attacks, cyanosis. As with all medical emergencies, the first two steps are (1) to discontinue treatment and (2) to remain calm and not increase the patient's anxiety. Patients should be allowed to position themselves for optimal comfort and then placed on oxygen, 2-4 L/min. If patients have their own nebulizer, they should be allowed to use it. If the patient does not have a nebulizer, he or she should be given either a metaproterenol or albuterol nebulizer from the emergency cart or case and take 2 inhalations.
If the symptoms do not subside or increase in severity, emergency services should be contacted; the patient must be closely monitored and given either 0.3-0.5 ml of a 1:1000 solution of epinephrine subcutaneously or intravenous aminophylline, 5.6 mg/kg in 150 ml of either D-5 ½ normal saline or normal saline infused over 30 minutes. (To calculate kg weight, divide the patient's weight in pounds by 2.2.) The dose of epinephrine may be repeated every 30 minutes for as many as 3 doses. Epinephnne should not be used in patients with severe hypertension, severe tachycardia, or cardiac arrhythmias. Aminophylline should not be used in patients who have had theophylline in the past 24 hours.
63. Can nitrous oxide be used safely to sedate a patie with COPD?
Sedation with nitrous oxide should be avoided in patients with COPD. The high flow of oxygen may depress the respiratory drive. Low-flow oxygen via a nasal cannula may be safely used without risk of respiratory depression.
LIVER DISEASE
64. What laboratory blood tests should be ordered for a patient with alcoholic hepatitis?
Alcoholic hepatitis is the most common cause of cirrhosis, which is one of the most common causes of death in the United States. There are a number of concerns in treating the patient with alcoholic hepatitis:
- Increased risk of pen- and postoperative bleeding, secondary to a decrease in vitamin K- dependent coagulation factors
- Qualitative and quantitative effects of alcohol on platelets
- Anemia secondary to dietary deficiencies and/or hemorrhage
Before attempting a surgical procedure, the minimal laboratory tests are PT, PTF, CBC, and bleeding time.
65. What precautions should be taken with patients on anticonvulsant medications?
It is important to obtain a detailed history of the seizure disorder to determine whether the patient is at risk for seizures during dental treatment. Important information includes the type and frequency of seizures, the date of the last seizure, prescribed medications, the last blood test to determine therapeutic ranges, and activities that tend to provoke seizures. For patients taking valproic acid or carbamazepine, periodic tests for liver function should be performed. Blood counts for patients taking carbamazepine and ethosuximide should be done by the patient's physician. Both liver function and blood counts should be checked before any oral surgical procedure is planned.
| MEDICAT10N | ADVERSE REACTIONS | INTERACTIONS |
|---|---|---|
| Valproic acid (Depakote) Heparin |
Prolonged bleeding time, leucopenia, thrombocytopenia | Increased risk of bleeding with aspirin and NSAIDs or warfarin. Additive depression of CNS with other depressants, including narcotic analgesics and sedative/hypnotics. |
| Carbamazepine (Tegretol) | Aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia, leukocytosis | Erythromycin increases levels of carbamazepine and may cause toxicity. |
| Phenytoin (Dilantin) | Aplastic anemia, agranulocytosis, leukopenia, thrombocytopenia | Additive depression of CNS with other depressants, including narcotics and sedative/hypnotics. |
| Phenobarbital | Additive depression of CNS with other depressants, including narcotics and sedative/hypnotics. May increase risk of hepatic toxicity of acetaminophen. | |
| Primidone | Blood dyscrasias, orthostatic hypotension | Additive depression of CNS with other depressants, including narcotics and sedative/hypnotics. |
| Ethosuximide | Aplastic anemia, granulocytosis, leukopenia | Additive depression of CNS with other depressants. |
| Clonazepam | Anemia, thrombocytosis, leukopenia | Additive depression of CNS with other depressants. |
66. What emergency procedures should be taken for a patient having a seizure?
It is important to determine whether the patient has a history of seizure disorder. Any patient who has a seizure in the dental office without a history of seizures must be treated as a medical emergency. The emergency medical service should be contacted as the dentist proceeds with management. There are two stages of a seizure: the ictal phase and the postictal phase. The management of each is described below.
Ictal phase
- Place the patient in a supine position away from hard or sharp objects to prevent injury; a carpeted floor is ideal. If the patient is in the dental chair, it is important to protect the patient by moving equipment as far as possible out of the way.
- Airway must be maintained and vital signs monitored during the tonic stage. If suctioning equipment is available, it should be ready with a plastic tip for suctioning secretions to maintain the airway. The patient may experience periods of apnea and develop cyanosis. The head should be extended to establish a patent airway, and oxygen should be administered. Vital signs, pulse, respiration and blood pressure must be monitored throughout the seizure.
- If the ictal phase of the seizure lasts more than 5 minutes, emergency services should be called. Tonic-clonic status epilepticus is a medical emergency. If the dentist is trained to do so, an intravenous line should be initiated, and a dose of 25-50 ml of 50% dextrose should be given immediately in case the cause of the seizure is hypoglycemia. If there is no response, the patient should be given 10 mg of diazepam intravenously over a 2-minute period. The patient's vital signs must be monitored, because the diazepam may cause respiratory depression. The dose of diazepam may be repeated after 10 minutes, if necessary.
Postictal phase
- Once the seizure activity has stopped and the patient enters the postictal phase, it is important to continue to monitor the vital signs and, if necessary, to provide basic life support. If respiratory depression is significant, emergency
- services should be called, the airway maintained, and respiration supported. Blood pressure may be initially depressed but should recover gradually.
- If the patient recovers from the postictal phase without basic life support or other complications, the patient's physician should be contacted, and the patient, if stable, should be discharged from the dental office, accompanied by a responsible adult.
67. What dental considerations must be considered in treating patients with seizure disorders?
Patients taking phenytoin are at risk for gingival hyperplasia. Tissue irritation from orthodontic bands, defective restorations, fractured teeth, plaque, and calculus accelerate the hyperplasia.
The dental practitioner should consider the patient's seizure status. A rubber dam with dental floss tied to the clamp should be used for all restorative dental procedures to enable the rapid removal of materials and instruments from the patient's oral cavity. Fixed prosthetics, when indicated, should be fabricated rather than removable prosthetics. If removable prosthetics are indicated, they should be fabricated with metal for all major connectors. Acrylic partial dentures should be avoided because of the risk of breaking and aspiration during seizure activities. Unilateral partial dentures are contraindicated. Temporary crowns and bridges should be laboratory-cured for strength.
68. What are the common causes of unconsciousness in dental patients?
The most common cause of loss of consciousness in the dental office is syncope. The signs and symptoms are diaphoresis, pallor, and loss of consciousness. Place the patient in the supine position with the feet elevated, monitor vital signs, and give oxygen, 3-4 L/minute, via nasal cannula.
RADIATION THERAPY
69. What are the risk factors for the development of osteoradionecrosis?
Bone exposed to high radiation therapy is hypovascular, hypocellular, and hypoxic tissue. Osteoradionecrosis develops because the radiated tissue is unable to repair itself. The risk for osteoradionecrosis increases as the dose of radiation increases from 5,000 rads to over 8,000 rads. Tissues receiving less than 5,000 rads are at low risk for necrosis. In addition, the risk increases with poor oral health. Oral surgical procedures after radiation therapy place the patient at high risk for developing osteoradionecrosis. Soft-tissue trauma from dentures and oral infections from periodontal disease and dental caries also put the patient at risk.
70. How should the dentist prepare the patient for radiation therapy of the head and neck?
The dentist should consult with the radiotherapist to determine what oral structures will be in the field as well as the maximal radiation dose. If teeth are in the field and the dose is greater than 5,000 rads, periodontally involved teeth and teeth with periapical lucencies should be extracted at least 2 weeks before radiation therapy begins. The dentist should prepare the patient for postradiation xerostomia, provide custom fluoride trays, and prescribe 0.4% stannous fluoride gel to be used for 3-5 minutes twice daily. The patient must he placed on a 2-3month recall schedule. On recall, the teeth must be carefully examined for root caries, and instruction in oral hygiene should be reviewed.
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