Dental Implications for Patients

• Most of the gastrointestinal drugs do not have any contradictions for dental patients.
• Patients suffering from Crohn's disease may have increase incidence of certain microbial infection, delayed healing and increased tendency for gingival bleeding. This action may be due to effects of sulfasalazine taken during the course of the disease.
• The dentist should be aware if the patient is taking a drug for nausea and vomiting. If the patient is receiving the drug for cancer therapy, he or she may require palliative treatment for stomatitis.
• Patient with cancer may be taking opioids, so the dentist should not prescribe additional drug for pain without reviewing patient's medication profile.
• The dentist should avoid procedures and drugs that promote nausea and vomiting. An increased gag reflex makes it difficult for the patient to undergo dental procedures.

Special Dental considerations

Anticonvulsant drugs

• Take complete health history.
• List medications patient is taking. Know their effects, side effects, potential for drug interaction and any specific oral effects.
• Schedule proper frequency of oral hygiene and provide good oral hygiene instruction to ensure healthy periodontal tissue and teeth.
• Insure proper dental lighting (no light should shine directly in the eyes).
• Insure medications have been taken properly relative to dental appointments to minimise risk of seizure.
• Perform proper periodontal and surgical treatment of gingival hyperplasia to minimise damage to teeth and supporting structures and to maintain proper aesthetics.
• Treatment plan and design restorations to minimize risk of damaging or displacing dental restorations or prosthesis during an epileptic seizure.

Antimyasthenic and Alzeihmer's type dementia drug

• Request that the patient bring a caregiver to help them. Keep the appointments short--no more than 45 minutes. Schedule the appointment during the patient's best times, usually mornings.
• Remind the patient of the appointment 24-48 hours ahead of time.
• Avoid treatment plans requiring expensive labour or post procedural care.
• Plan multiple short appointments as opposed to few long appointments.
• Avoid treatments that complicate home care for the patient or caregiver.;
• Use local anesthetics with the shortest possible duration.
• Avoid long explanations of the treatment, since patients cannot retain the information and it will add to their anxiety.
• Explain the treatment and post-treatment instructions thoroughly to the caregiver.
• Follow up with the caregiver regarding pain or discomfort, increased confusion or agitation after the visit.

Anti-parkinson drugs

• Monitor all the vital signs during the dental visits. Make the patient sit upright in the dental chair for a minute or 2 after being in the supine position; and then monitor vital signs in standing position.
• Sedation or general anaesthesia may be required in few cases.
• Many of theses drugs cause xerostomia. The dentist should consider them in differential diagnosis; of; caries, periodontal disease or oral candiasis.
• If newly diagnosed mouthing movements are seen, which may indicate a serious medication side effect, consultation with patient's physician may be appropriate.

• The prescription of psychoactive agents by dentist is indicated for a number of conditions, including acute anxiety associated with dental /oral surgery, management of bruxism and management of various orofacial pain.
• Benzodiazepines are generally regarded as the drugs of choice for oral preoperative anxiolysis in dental practice.
• These drugs have a high margin of safety, especially used in single dose, 30mins-1hr prior to dental visit.

Bronchial asthma is the most common respiratory disorder encountered by dentist and it is important that they be well versed with the relevant aspects of the disease.

Asthma is a clinical syndrome characterised by signs and symptoms of intermittent and potentially reversible airflow limitation related to bronchial and bronchiolar constriction coupled with hyper-secretion of viscous mucus, superimposed on a background of inflammation.

It can be induced by an allergen or chemical irritant (extrinsic asthma) or by an intrinsic factor such as an infection or emotional distress (intrinsic asthma).

The American Society of Anaesthesiologists classification of asthma is given in the table below:

Special Dental Considerations

• COPD; (Chronic Obstructive Pulmonary Disorder) is a major respiratory disorder in which the bronchial obstruction is irreversible, resulting in severe infections, cardiac complications and respiratory failure. Respiratory conditions and the use of inhalants can cause decreased salivation and cause associated problems such as caries and candidiasis. Therefore patients should be observed for the need of antifungals and use fluoride rinses.
• Stress reduction methods may include the use of medication, especially when complex procedures are performed.
• A semi supine chair position, especially for COPD patients is preferred to prevent; orthostatic hypotension. Patients should sit for a few minutes upright before being dismissed.
• Inhalants used by patients should be easily available during the dental appointment.
• Patients; on long term steroids are at the risk of stress induced steroid crisis and increased risk of infections.
• With patients using beta-adrenergic agonists, there is a concern of cardiac side effects such as hypertension and tachycardia.
• NSAID's like aspirin and narcotics, are contraindicated in patients with respiratory conditions, as they may prompt an asthmatic attack.

The most important objective is the prevention of complications.The following principles apply in this sense:

• Identification of the patient based on a thorough clinical history: Disease antecedents, exploration and laboratory testing for selective identification.
• Counselling of patients and their relatives to increase awareness of good oral hygiene in order to avoid the need for invasive dental care and reduce the number of visits to the dentist.
• Replacement therapy in necessary cases. Replacement may comprise coagulation factors (haemophilia A, B and Vw disease) or vitamin K (lack of ingestion or poor absorption and liver disease).
• Avoidance of brusque maneuvers during dental treatment in order to prevent oral mucosal damage that may give rise to post-operative bleeding problems.
• In the case of haemophilia, the ideal approach would be to provide dental care in the specialised haemophilia center by dental surgeons integrated within the team supervising the patient.
• Aspirin and its derivatives are to be avoided as pain treatment instead, paracetamol is a safe alternative. In the case of the coumarins, the possibility of multiple interactions with other drugs must be taken into account resulting in either enhancement of the anticoagulant effect (with the resulting risk of excessive bleeding) or a reduction of coumarin effects (with the risk of thromboembolic events). Some of these drugs are often prescribed in dental practice, including antibiotics (amoxicillin and amoxicillin + clavulanate, ampicillin, azithromycin, erythromycin, rifampicin, penicillin G, cephalosporins, sulfonamides, metronidazole, chloramphenicol), antifungals (azoles and griseofulvin), analgesics (aspirin and other nonsteroidal anti-inflammatory drugs; paracetamol in excess can enhance warfarin action) and psychoactive drugs (some antihistamines, diazepam).

Special dental considerations in; Diabetic patient

• Controlled type 1 and type 2 diabetic patients usually can undergo all dental treatments without special precautions.
• The dentist must know the type and dose of insulin as well as any other medications that the patient is taking. They must be aware if the patient has a history of; hypoglycemia attacks and the accompanying signs and symptoms. The chances of having a hypoglycemia attack are increased if there have been previous attacks.
• In order to avoid an episode of hypoglycemia while undergoing dental treatment it is advisable to schedule the patient based on the time of highest insulin activity which varies from 30 minutes to 8 hours after injection depending on the type of insulin. Therefore, the appointment does not need to be necessarily in the morning.
• Consultation with the patient's physician is a must when:
  • the patient has systemic complications of diabetes such as heart or renal disease.
  • the patient has a difficulty to control diabetes or is under high insulin dosage.
  • the patient has an acute oral infection such as periapical or periodontal abscess.
• It is advisable to have in the dental office orange juice or another form of glucose, to be given to the patient at the first sign of hypoglycemia. Generally a 6 oz. dose of any fruit juice or any other drink containing carbohydrates will rapidly reverse the hypoglycemia symptoms.
• Infection is a risk for the diabetic patient and can make it more difficult to control blood glucose levels. If undergoing extensive oral surgery, the dentist may prescribe antibiotics to minimise the risk of infection. To help the healing process, keep; blood glucose levels under control before, during and after surgery.
• The dentist may recommend a saliva substitute that can be used for relief from dry mouth discomfort. The dentist may also recommend rinsing with a fluoride mouthrinse or having a topical application of fluoride at home and in the dental clinic to help prevent rampant tooth decay.

Special dental considerations in patients on other hormonal and bone metabolic drugs

• Androgens, estrogens and progestins are responsible for ;increased; inflammatory status, causing erythema and an increased tendency towards gingival bleeding. Professional cleanings and plaque control will minimize their sequelae.
• Dental treatment should; be delayed; in patients with hyperthyroidism whose symptoms are not controlled pharmacologically or surgically.
• Antithyroid hormone drugs reduce the production of thyroid hormones, because these agents have potential to depress the bone marrow, the incidence of microbial infections can increase, resulting in; delayed healing and gingival bleeding.

Connective tissue disorders

The major connective tissue disorders include: Lupus erythmatosus, rheumatoid arthritis, scleroderma, dermatomyositis, Sjogren syndrome.

• Dentist should be suspicious of the possibility of systemic lupus erythematosus when a women between the age of 15-35 years develops; skin and mucosal leisons associated with joint pains. The lesions of discoid L.E often respond to topical and intralesional glucocorticoids.
• Dentist treating patients with rheumatoid arthritis must be aware of the drugs prescribed and their possible side effect on dental treatment. NSAID's can increase bleeding during surgery. Gold sodium thiomalate can cause oral ulcers.

Special dental considerations

• Succinyl choline causes paralysis and; has anaesthetic or analgesic effects. The dentist must therefore assure that; sufficient anaesthesia is achieved before performing procedure.
• Various degree of increased muscle tension in the masseter muscles may develop due to succinyl choline. In extreme; cases, trismus can occur and make it difficult to open mouth.
• The primary use of spasmolytics in dental office is to relieve anxiety, post-procedural trismus and muscle spasm of the head, neck; and TMJ disorders.
• The anti-anxiety effects of Benzodiazepines, makes it an excellent choice for pre-operative oral sedation in dental patient.
• Hypersalivation has been reported with clonazepam and this should be considered; when selecting medications for a patient who has difficulty in controlling salivary flow.
• Tizanidine has been associated with visual hallucinations or delusions. Before beginning dental treatment, the clinician should assess the psychological status of the patient taking tizanidine.

Special Considerations

• Before the dentist undertakes any dental procedure involving a patient with cancer, he/she should; contact the patient's primary care physician regarding the need for any pre-medication. This includes use of antibiotics to protect against bacteremias.
• The dentist's main concern before providing care to a patient receiving chemotherapy relates to adequate numbers of white blood cells and platelets.The marrow suppression is usually cyclic and there are periods where risk of infection and bleeding are minimal.
• Most medications used by dentist to control oral complaints may put an extra burden on the existing condition. It is important to coordinate medical and dental treatment to minimize complication to the patient.
• Careful clinical and radiographic examination followed by any indicated corrective procedure are essential to minimise subsequent complications of dental pain, abscess, poor hygiene and periodontal disease that may occur during cancer treatment.
• Extractions and any other pre-radiation surgery should be done with adequate time allowed for tissue healing. This may take from 14 to 21 days and should be co-ordinated with; the radiation oncologist to minimise the delay of radiation treatment.
• Clinicians also generally recommend that the patient’s remaining dental treatment, including caries removal, smoothing of any rough or sharp surfaces and calculus removal be completed before radiation treatment.
• The dentist should make standard impressions (using, for example, irreversible hydrocolloid) of the patient’s remaining dentition to fabricate a fluoride carrier or tray.
• To prevent radiation caries, the patient will need to undergo daily fluoride treatments (e.g. 1 percent neutral sodium fluoride gel in the carrier for five minutes). Therefore, the carriers should be as comfortable as possible. Carriers are typically made out of standard thick mouthguard materials such as 5- mm ethylene- vinyl copolymer.
• Implants are no longer absolutely contraindicated in irradiated bone, although there may be decreased success; implant placement can be performed 12 to 18 months after radiation therapy and when possible, implant supported prostheses should be considered instead of tissues supported prostheses, since there might be less likelihood of soft-tissue trauma.
• Extract teeth in the radiation field that are non-restorable or may pose a future problem, to prevent; extraction-induced; osteoradionecrosis.
• Conduct a prosthodontic evaluation if indicated. If a removable prosthesis is worn, make sure that it is clean and well adapted to the tissue. Instruct the patient not to wear the prosthesis during treatment, if possible or at the least, not to wear it at night.
• Remove orthodontic bands and brackets if highly stomatotoxic chemotherapy is planned or if the appliances will be in the radiation field.
• Consider extracting highly mobile primary teeth in children and teeth that are expected to exfoliate during treatment.

Advise patients to

• Brush teeth, gums and tongue gently with an extra-soft toothbrush and fluoride toothpaste after every meal and before bed. If brushing hurts, soften the bristles in warm water.
• Floss teeth gently every day. If gums are sore or bleeding, avoid those areas but; floss other teeth.
• Follow instructions for using fluoride gel.
• Avoid mouthwashes containing alcohol.
• Rinse the mouth with; baking soda and salt solution, followed by a plain water rinse several times a day (Use 1/4 teaspoon each of baking soda and salt in 1 quart of warm water). Omit salt during mucositis.
• Exercise the jaw muscles three times a day to prevent and treat jaw stiffness from radiation. Open and close the mouth as far as possible without causing pain; repeat 20 times.
• Avoid candy, gum and soda unless they are sugar-free.
• Avoid spicy or acidic foods, toothpicks, tobacco products and alcohol.
• Keep the appointment schedule recommended by the dentist.