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Clues suggesting systemic disease may be found in the mouth and adjacent structures (see Table 1: Approach to the Dental Patient: 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 Table 3: Endocarditis: Procedures Requiring Antimicrobial Endocarditis Prophylaxis in High-Risk Patients and Table 4: Endocarditis: Recommended Endocarditis Prophylaxis During Oral-Dental or Respiratory Tract Procedures*).
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Table 1
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| Oral Findings in Systemic Disorders |
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Oral Manifestation
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Possible Indication
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Candidiasis
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Diabetes, AIDS, other causes of immunosuppression (eg, agranulocytosis, neutropenia, leukemia, immunoglobulin defects, disorders of leukocyte function), antibiotic use
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Atrophic glossitis (a smooth tongue caused by atrophy of filiform papillae)
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Iron deficiency
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Painful atrophy of the oral mucosa and surface of the tongue, sometimes with aphthous ulcers
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Megaloblastic anemias
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Magenta tongue
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Vitamin B12 deficiency
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Darkly pigmented areas (if not a racial characteristic)
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Hemochromatosis, Addison's disease, Peutz-Jeghers syndrome, melanoma (rare, but may be seen on the palate), smoker's melanosis
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Linear, grayish discoloration (lead line) in the gingiva adjacent to teeth
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Lead, silver, or bismuth poisoning
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Violaceous patches
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Kaposi's sarcoma, AIDS
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Keratotic lichenoid patches, sometimes with painful mucosal atrophy
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Graft-vs-host disease if in the mouth of an organ-transplant recipient
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Reddish discoloration of the teeth
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Congenital erythropoietic porphyria
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High, arched soft palate
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Marfan syndrome
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Notched incisors, domed or mulberry molars
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Congenital syphilis
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Hairy leukoplakia (white, vertical folds on lateral border of tongue)
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HIV transforming to AIDS
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Red or reddish purple collections of oral telangiectases
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Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
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Multiple impacted supernumerary teeth and osteomas
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Gardner's syndrome
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Dental Care of Patients With Systemic Disorders
Certain medical conditions (and their treatment) predispose patients to dental problems or affect dental care.
Hematologic disorders
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). Hemophiliacs should have clotting factors given before, during, and after an extraction. Such 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.
Cardiovascular disorders
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
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.
Cancer
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.
Immunosuppression
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's sarcoma, non-Hodgkin lymphoma, hairy leukoplakia, candidiasis, aphthous ulcers, or a rapidly progressive form of periodontal disease.
Endocrine disorders
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's syndrome or who are taking corticosteroids may have alveolar bone loss, delayed wound healing, and increased capillary fragility.
Neurologic disorders
Patients with seizures who require dental appliances should have nonremovable appliances that cannot be swallowed or aspirated. Patients unable to brush or floss effectively may use chlorhexidine 12% rinses in the morning and at bedtime.
Obstructive sleep apnea
Patients with obstructive sleep apnea who are unable to tolerate treatment with a positive airway pressure (CPAP, 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.
Drugs
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.
Some antineoplastics (eg, doxorubicin, 5-fluorouracil, bleomycin, dactinomycin, cytosine, arabinoside, methotrexate) cause 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 doing so 4 days before undergoing dental surgery and can resume taking these drugs after bleeding stops. Warfarin should be stopped 2 to 3 days before oral surgery. PT is obtained; INR of 1.5 is considered safe for surgery. For people receiving hemodialysis, dental procedures should be done the day after dialysis, when heparinization has subsided.
Phenytoin and Ca channel blockers, particularly nifedipine, contribute to gingival hyperplasia; however, this hyperplasia is minimized with excellent oral hygiene and frequent oral prophylaxes (cleanings).
Bisphosphonates, primarily when given parenterally for treatment of bone cancer, and to a much lesser degree when used orally to prevent osteoporosis, can result in osteonecrosis after an extraction (see Osteonecrosis: Osteonecrosis of the Jaw ).
Radiation therapy
C(aution: 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.
Last full review/revision March 2009 by Robert B. Cohen, DMD
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