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Systemic Disorders and the Mouth
Clues suggesting systemic disease may be found in the mouth and adjacent structures (see Oral Findings in Systemic Disorders). A dentist should consult a physician when a systemic disorder is suspected, when the patient is taking certain drugs (eg, warfarin, bisphosphonates), and when a patient’s ability to withstand general anesthesia or extensive oral surgery must be evaluated. Patients with certain heart valve abnormalities may require antibiotic prophylaxis to help prevent bacterial endocarditis before undergoing certain dental procedures (see Procedures Requiring Antimicrobial Endocarditis Prophylaxis in High-Risk Patients and see Table: Recommended Endocarditis Prophylaxis During Oral-Dental or Respiratory Tract Procedures*).
Oral Findings in Systemic Disorders
Certain medical conditions (and their treatment) predispose patients to dental problems or affect dental care.
People who have disorders that interfere with coagulation (eg, hemophilia, acute leukemia, thrombocytopenia) require medical consultation before undergoing dental procedures that might cause bleeding (eg, extraction, mandibular block). Patients with hemophilia should have clotting factors given before, during, and after an extraction and restorative dentistry requiring local anesthesia (eg, fillings). Most hematologists prefer that patients with hemophilia, especially those who have developed factor inhibitors, receive infiltrative local anesthetics instead of blocks for restorative dentistry. Restorative dentistry can be completed in a dental office after consultation with a hematologist; however, if the patient has inhibitor to factor VIII, the dentistry should be done in a hospital under general anesthesia. Oral surgery should be done in the hospital in consultation with a hematologist. All patients with bleeding disorders should maintain a lifelong routine of regular dental visits, which includes cleanings, fillings, topical fluoride, and preventative sealants, to avoid the need for extractions.
After an MI, dental procedures should be avoided for 6 mo, if possible, to allow damaged myocardium to become less electrically labile. Patients with pulmonary or cardiac disease who require inhalation anesthesia for dental procedures should be hospitalized.
Endocarditis prophylaxis is required before dental procedures only in patients with
Prosthetic cardiac valves or prosthetic material used for cardiac valve repair
Previous history of bacterial endocarditis
Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits; completely repaired congenital heart defect with prosthetic material or device for 6 mo after the procedure; repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device
Completely repaired congenital heart defect with prosthetic material or device (for 6 mo after the procedure)
Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device
Cardiac transplantation recipients with a valvulopathy
The heart is better protected against low-grade bacteremias, which occur in chronic dental conditions, when dental treatment is received (with prophylaxis) than when it is not received. Patients who are to undergo cardiac valve surgery or repair of congenital heart defects should have any necessary dental treatment completed before surgery.
Although probably of marginal benefit, antibiotic prophylaxis is sometimes recommended for patients with hemodialysis shunts and within 2 yr of receipt of a major prosthetic joint (hip, knee, shoulder, elbow). The organisms causing infections at these sites are almost invariably of dermal rather than oral origin.
Epinephrine and levonordefrin are added to local anesthetics to increase the duration of anesthesia. In some cardiovascular patients, excess amounts of these drugs cause arrhythmias, myocardial ischemia, or hypertension. Plain anesthetic can be used for procedures requiring < 45 min, but in longer procedures or where hemostasis is needed, up to 0.04 mg epinephrine (2 dental cartridges with 1:100,000 epinephrine) is considered safe. Generally, no healthy patient should receive > 0.2 mg epinephrine at any one appointment. Absolute contraindications to epinephrine (any dose) are uncontrolled hyperthyroidism; pheochromocytoma; BP > 200 mm Hg systolic or > 115 mm Hg diastolic; uncontrolled arrhythmias despite drug therapy; and unstable angina, MI, or stroke within 6 mo.
Some electrical dental equipment, such as an electrosurgical cautery, a pulp tester, or an ultrasonic scaler, can interfere with early-generation pacemakers.
Extracting a tooth adjacent to a carcinoma of the gingiva, palate, or antrum facilitates invasion of the alveolus (tooth socket) by the tumor. Therefore, a tooth should be extracted only during the course of definitive treatment. In patients with leukemia or agranulocytosis, infection may follow an extraction despite the use of antibiotics.
People with impaired immunity are prone to severe mucosal and periodontal infections by fungi, herpes and other viruses, and, less commonly, bacteria. The infections may cause hemorrhage, delayed healing, or sepsis. Dysplastic or neoplastic oral lesions may develop after a few years of immunosuppression. People with AIDS may develop Kaposi sarcoma, non-Hodgkin lymphoma, hairy leukoplakia, candidiasis, aphthous ulcers, or a rapidly progressive form of periodontal disease.
Dental treatment may be complicated by some endocrine disorders. For example, people with hyperthyroidism may develop tachycardia and excessive anxiety as well as thyroid storm if given epinephrine. Insulin requirements may be reduced on elimination of oral infection in diabetics; insulin dose may require reduction when food intake is limited because of pain after oral surgery. In people with diabetes, hyperglycemia with resultant polyuria may lead to dehydration, resulting in decreased salivary flow (xerostomia), which, along with elevated salivary glucose levels, contributes to caries.
Patients receiving corticosteroids and those with adrenocortical insufficiency may require supplemental corticosteroids during major dental procedures. Patients with Cushing syndrome or who are taking corticosteroids may have alveolar bone loss, delayed wound healing, and increased capillary fragility.
Patients with obstructive sleep apnea who are unable to tolerate treatment with a continuous positive airway pressure (CPAP) or bilevel PAP (BiPAP) mask are sometimes treated with an intraoral device that expands the oropharynx. This treatment is not as effective as CPAP, but more patients tolerate using it.
Certain drugs, such as corticosteroids, immunosuppressants, and antineoplastics, compromise healing and host defenses. When possible, dental procedures should not be done while these drugs are being given.
Many drugs cause dry mouth (xerostomia—see Xerostomia), which is a significant health issue, especially in geriatric patients. Causative drugs often have anticholinergic effects and include certain antidepressants, antipsychotics, diuretics, antihypertensives, anxiolytic and sedative drugs, NSAIDs, antihistamines, and opioid analgesics.
Some antineoplastics (eg, doxorubicin, 5-fluorouracil, bleomycin, dactinomycin, cytosine, arabinoside, methotrexate) cause stomatitis (see Stomatitis), which is worse in patients with preexisting periodontal disease. Before such drugs are prescribed, oral prophylaxis should be completed, and patients should be instructed in proper toothbrushing and flossing.
Drugs that interfere with clotting may need to be reduced or stopped before oral surgery. Patients taking aspirin, NSAIDs, or clopidogrel should stop taking them 4 days before undergoing dental surgery and can resume taking these drugs after bleeding stops. Most patients taking an oral anticoagulant who have a stable INR < 4 do not need to stop the drug before outpatient dental surgery (including extraction) because the risk of significant bleeding is very small and the risk of thrombosis may be increased when oral anticoagulants are temporarily stopped. For people receiving hemodialysis, dental procedures should be done the day after dialysis, when heparinization has subsided.
Phenytoin, cyclosporine, and Ca channel blockers, particularly nifedipine, contribute to gingival hyperplasia. Gingival hyperplasia develops in about 50% of patients taking phenytoin and 25% of patients taking cyclosporine or a Ca channel blocker. However, hyperplasia is minimized with excellent oral hygiene and frequent cleanings by a dentist.
Bisphosphonates can result in antiresorptive agent-induced osteonecrosis of the jaw (ONJ—see Osteonecrosis of the Jaw (ONJ)) after an extraction. ONJ occurs primarily when bisphosphonates are given parenterally to treat bone cancer and to a much lesser extent when they are taken orally to prevent osteoporosis (risk of ONJ about 0.1%). Diligent oral hygiene practices and regular dental care may help lower the risk of ONJ, but there are no validated techniques to determine who is at risk of developing antiresorptive agent–induced ONJ. Stopping bisphosphonate therapy may not lower the risk and may increase the rate of bone loss in people being treated for osteoporosis.
(Caution: Extraction of teeth from irradiated tissues [particularly if the total dose was > 65 Gy, especially in the mandible] is commonly followed by osteoradionecrosis of the jaw. This is a catastrophic complication in which extraction sites break down, frequently sloughing bone and soft tissue. ) Thus, if possible, patients should have any necessary dental treatment completed before undergoing radiation therapy of the head and neck region, with time allowed for healing. Teeth that may not survive should be extracted. Necessary sealants and topical fluoride should be applied. After radiation, extraction should be avoided, if possible, by using dental restorations and root canal treatment instead.
Head and neck radiation often damages salivary glands, causing xerostomia, which promotes caries. Patients must therefore practice lifelong good oral hygiene. A fluoride gel and fluoride mouth rinse should be used daily. Rinsing with 0.12% chlorhexidine for 30 to 60 sec, if tolerated, can be done in the morning and at bedtime. Viscous lidocaine may enable a patient with sensitive oral tissues to brush and floss the teeth and eat. A dentist must be seen at 3-, 4-, or 6-mo intervals, depending on findings at the last examination. Irradiated tissue under dentures is likely to break down, so dentures should be checked and adjusted whenever discomfort is noted. Early caries may also be reversed by Ca phosphopeptides and amorphous Ca phosphate, which can be applied by a dentist or prescribed to a patient for at-home use.
Patients who undergo radiation therapy may develop oral mucosal inflammation and diminished taste as well as trismus due to fibrosis of the masticatory muscles. Trismus may be minimized by such exercises as opening and closing the mouth widely 20 times 3 or 4 times/day. Extractions of teeth in irradiated bone should be avoided (because of possible osteoradionecrosis). Sometimes root canal therapy is done, and the tooth is ground down to the gum line. If extraction is required after radiation, 10 to 20 treatments in a hyperbaric O2 chamber may forestall or prevent osteoradionecrosis.
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