Chapter 032. Oral Manifestations of Disease (Part 9)

Dental Care of Medically Complex Patients Routine dental care (e.g., extraction, scaling and cleaning, tooth restoration, and root canal) is remarkably safe. The most common concerns regarding care of dental patients with medical disease are fear of excessive bleeding for patients on anticoagulants, infection of the heart valves and prosthetic devices from hematogenous seeding of oral flora, and cardiovascular complications resulting from vasopressors used with local anesthetics during dental treatment. Experience confirms that the risks of any of these complications are very low.Patients undergoing tooth extraction or alveolar and gingival surgery rarely experience uncontrolled bleeding when warfarin anticoagulation is...
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Chapter 032. Oral Manifestations of Disease (Part 9) Chapter 032. Oral Manifestations of Disease (Part 9) Dental Care of Medically Complex Patients Routine dental care (e.g., extraction, scaling and cleaning, tooth restoration,and root canal) is remarkably safe. The most common concerns regarding care ofdental patients with medical disease are fear of excessive bleeding for patients onanticoagulants, infection of the heart valves and prosthetic devices fromhematogenous seeding of oral flora, and cardiovascular complications resultingfrom vasopressors used with local anesthetics during dental treatment. Experienceconfirms that the risks of any of these complications are very low. Patients undergoing tooth extraction or alveolar and gingival surgery rarelyexperience uncontrolled bleeding when warfarin anticoagulation is maintainedwithin the therapeutic range currently recommended for prevention of venousthrombosis, atrial fibrillation, or mechanical heart valve. Embolic complicationsand death, however, have been reported during subtherapeutic anticoagulation.Therapeutic anticoagulation should be confirmed before and continued through theprocedure. Likewise, low-dose aspirin (e.g., 81–325 mg) can be safely continued. Patients at high or moderate risk for bacterial endocarditis (Chap. 118)should maintain optimal oral hygiene, including flossing, and have regularprofessional cleaning. Prophylactic antibiotics are recommended for all at-riskpatients who undergo dental and oral procedures likely to cause significantbleeding and bacteremia. Should unexpected bleeding occur, antibiotics givenwithin 2 h following the procedure provide effective prophylaxis. Hematogenous bacterial seeding from oral infection can undoubtedlyproduce late prosthetic joint infection and therefore requires removal of theinfected tissue (e.g., drainage, extraction, root canal) and appropriate antibiotictherapy. However, evidence that late prosthetic joint infection occurs followingroutine dental procedures is lacking. For this reason, antibiotic prophylaxis is notrecommended before dental surgery in patients with orthopedic pins, screws, andplates. It is, however, advised within the first 2 years after joint replacement forpatients who have inflammatory arthropathies, immunosuppression, type 1diabetes mellitus, previous prosthetic joint infection, hemophilia, ormalnourishment. Concern often arises regarding the use of vasoconstrictors in patients withhypertension and heart disease. Vasoconstrictors enhance the depth and durationof local anesthesia, thus reducing the anesthetic dose and potential toxicity. Ifintravascular injection is avoided, 2% lidocaine with 1:100,000 epinephrine(limited to a total of 0.036 mg epinephrine) can be used safely in those withcontrolled hypertension and stable coronary heart disease, arrhythmia, orcongestive heart failure. Precaution should be taken with patients taking tricyclicantidepressants and nonselective beta blockers as these drugs may potentiate theeffect of epinephrine. Elective dental treatments should be postponed for at least 1 month aftermyocardial infarction, after which the risk of reinfarction is low provided thepatient is medically stable (e.g., stable rhythm, stable angina, and free of heartfailure). Patients who have suffered a stroke should have elective dental caredeferred for 6 months. In both situations, effective stress reduction requires goodpain control, including the use of the minimal amount of vasoconstrictor necessaryto provide good hemostasis and local anesthesia. Bisphosphonate therapy can be associated with osteonecrosis of the jaw.Most patients affected have received high dose aminobisphosphonate therapy formultiple myeloma or metastatic breast cancer and have undergone tooth extractionor dental surgery. Intra-oral lesions appear as exposed yellow-white hard bone involving themandible or maxilla. Two-thirds are painful. Patients about to receiveaminobisphosphonate therapy should receive preventive dental care that reducesthe risk of infection and need for future dentoalveolar surgery. Halitosis Halitosis typically emanates from the oral cavity or nasal passages. Volatilesulfur compounds resulting from bacterial decay of food and cellular debrisaccount for the malodor. Periodontal disease, caries, acute forms of gingivitis,poorly fitting dentures, oral abscess, and tongue coating are usual causes. Treatment includes correcting poor hygiene, treating infection, and tonguebrushing. Xerostomia can produce and exacerbate halitosis. Pockets of decay inthe tonsillar crypts, esophageal diverticulum, esophageal stasis (e.g., achalasia,stricture), ...