Dental Management of Medically Complex Patients SR Prabhu
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The Medically Compromised Patients: An Overview1

Crispian Scully
 
LEARNING OBJECTIVES
After reading this chapter the student should be able to:
  1. Understand what is meant by: medically compromised patient.
  2. Possess adequate knowledge and skills to collect information pertaining to those medical conditions which are likely to place them at a higher risk of developing complications by receiving invasive dental treatment.
  3. Possess adequate skills of modifying dental treatment to the medically compromised patients as required.
 
INTRODUCTION
There is increasing awareness of the importance of oral health to those with medical problems and the hazards in operative intervention. Persons with special needs are those whose dental care is complicated by a medical, physical, mental or social disability. They may have oral problems that can affect systemic health, and operative intervention such as extractions and surgical procedures in particular can produce major problems.
This chapter aims at providing an overview of the areas that are of particular concern to dental staff, which are the problems associated with:
  • Bleeding tendencies2
  • Cardiac disease
  • Diabetes
  • Drug allergies, use and abuse
  • Fits, faints, behavioural and neuropsychiatric conditions
  • Hepatitis and other transmissible diseases including HIV
  • Immunosuppressive treatment
  • Malignant disease
  • Pregnancy.
A medical history is essential in order:
  • To assess the fitness of the patient for the procedure
  • To decide on the type of pain control required
  • To decide how treatment may need to be modified
  • To warn of any possible emergencies that could arise and to determine any effect on oral health
  • To warn of any possible risk to staff
  • The most relevant conditions are allergies, bleeding tendencies, cardiac disease, immune defects, or where the patient is on drugs acting on the endocrine or central nervous system (CNS)
  • Relevant systemic disease is more common in the elderly, those with disability, and inpatients.
The medical history should be taken in such a fashion to elicit any relevant systemic disease, in particular to identify:
  • A: Anaemia
  • B: Bleeding tendencies
  • C: Cardiorespiratory disorders
  • D: Drug treatment and allergies
  • E: Endocrine diseases
  • F: Fits and faints
  • G: Gastrointestinal disorders
  • H: Hospital admissions and attendances
  • I: Infections
  • J: Jaundice or liver disease
  • K: Kidney disease
  • L: Likelihood of pregnancy, or pregnancy itself.
The history must be reviewed before any surgical procedure or general anaesthetic, and at each new course of dental treatment. Examination of the patient's appearance, behaviour 3and speech, and inspection of the face, neck and hands can also reveal many significant conditions.
Iatrogenic disorders are increasingly encountered, especially inpatients with complex medical or/and surgical problems such as organ transplant recipients. Some diseases are common in certain groups because of lifestyle, such as HIV infection. Some diseases are seen mainly in specific ethnic groups. Infections such as viral hepatitis and some other disorders are found predominantly in persons from the developing world, especially in the tropics but are now being seen increasingly in the developing world in travellers, in migrant populations, and in immunocompromised persons.
 
BLEEDING TENDENCIES
Disorders of haemostasis cause management problems mainly because of prolonged postoperative bleeding, but hypercoagulability and thromboses can be as, or more, life-threatening. About 90 per cent of post-extraction haemorrhage are from local causes:
  • Excessive trauma (to soft tissue in particular)
  • Inflamed mucosa at the extraction site
  • Poor compliance with postoperative instructions
  • Post-extraction interference with the socket, e.g. sucking and tongue pushing
  • Reactive hyperaemia.
    Consult the haematologist before undertaking investigations; bleeding and clotting times are unsatisfactory. Special assays, such as factor VIII clotting activity may well be required. Prothrombin times are reported as per International Normalized Ratio (INR). The INR is the ratio of the patient's one stage prothrombin time to that of controls. A normal healthy patient has an INR of 1.
  • Dental extractions and surgical procedures, including local analgesic injections, can cause problems in anticoagulated patients and persons with coagulation defects or severe thrombocytopenic states. The possibility of viral hepatitis and HIV should always be considered in persons with bleeding tendencies.
 
 
Things to Avoid in Patients with Bleeding Tendencies
  • Trauma and surgery: Endodontics may be preferable to surgery
  • Regional local analgesic injections (may bleed into fascial spaces of neck and obstruct airway)
  • Intramuscular injections
  • Drugs causing increased bleeding tendency (e.g. aspirin)
  • Drugs causing gastric bleeding (e.g. aspirin and NSAIDs).4
  • Anticoagulated patients, can have local analgesia and minor surgery such as the relatively atraumatic removal of one or two teeth may generally be carried out safely in general practice with no change in treatment, if test results are within the normal therapeutic range (INR <3).
  • Thrombocytopenic patients need appropriate measures to raise the platelet count (platelet infusions) before surgery. Thrombocytopenia is significant if platelets are below 80 to 100 × 109 per litre. However, local analgesia and minor surgery such as the relatively atraumatic removal of one or two teeth may generally be carried out safely in general practice with no change in treatment, if the platelet count exceeds 50 × 109/L. Postoperatively, a 4.8 per cent tranexamic mouthwash, 10 ml used 4 times a day for 7 days may help.
  • Patients with clotting defects need their bleeding tendency corrected by giving an appropriate blood product rich in the deficient factor before surgery. Factor VIII or cryoprecipitate is used for haemophilia A and von Willebrand's disease, and Factor IX for Christmas disease. Blood products may be used in lower doses if desmopressin and antifibrinolytic drugs such as tranexamic acid are used. In some mild haemophilics, minor oral surgery such as the relatively atraumatic removal of one or two teeth may be possible under desmopressin (DDAVP) cover. In others, factor replacement is necessary. In haemophilia, in all but severe cases, nonsurgical dental treatment can be carried out under antifibrinolytic cover (tranexamic acid), (taking care to maintain urinary flow to avoid urinary blood clot problems) but haematological advice must be sought before other procedures.
 
CARDIAC DISEASE
  • Cardiac patients may become breathless if laid flat (as in the dental chair). Some may have a bleeding tendency because of anticoagulants. Extractions under local anaesthesia can usually be carried out one or two at a time but the trauma and blood loss of multiple extractions should be avoided. Anxiety and pain cause enhanced sympathetic activity. This increases the load on the heart and the risk of angina or dysrrhythmias. A mild premedicant such as 5 mg diazepam orally can be valuable in cardiac patients. Routine dentistry using short appointments is safe for most patients with heart disease unless they are overanxious.
    The evidence that adrenaline in local anaesthetics used in sensible doses (up to 0.04 mg) is a hazard to cardiac patients is little more than theoretical. Local anaesthetics containing noradrenaline are totally contraindicated. Even in normal persons they have caused fatal hypertensive attacks.
    Sedation with nitrous oxide is pleasant and usually acceptable and probably safer than intravenous sedation.5
General anaesthesia (GA) constitutes a risk to many cardiac patients. Particularly hazardous for the following conditions:
  • Myocardial infarction, if recent
  • Angina pectoris, especially of recent origin or unstable
  • Severe hypertension
  • Intractable dyrhythmias (particularly digitalis toxicity)
  • Some congenital heart diseases
  • Oxygen should be kept readily accessible for use in any emergency.
 
 
Ischaemic Heart Disease
Ischaemic heart disease (IHD) is the main problem, and is commonplace in the middle aged and elderly, especially in men. It is generally accepted that:
  • Routine dentistry for most patients with IHD should be undertaken using short appointments and under local analgesia
  • More complex surgical procedures should be carried out in hospital with full cardiac monitoring
  • Elective dental care for patients who have recently had a myocardial infarct should be deferred for at least 3 months, and some recommend 12 months
  • General anaesthesia (GA) is contraindicated within 3 months of a myocardial infarct
  • Patients on digoxin are at special risk of electrocardiographic changes and dysrhythmias after tooth extractions
  • Oxygen and glyceryl trinitrate should be kept readily accessible for use in any emergency.
 
Patients with Cardiac Valvular Defects
Patients with cardiac pacemakers can be at risk since the pacemakers can be interfered with by signals from various electrical equipment. The risk from equipment such as ultrasonic scalers or pulp testers is very small. The chief hazards are from electrosurgery and diathermy. However, dental treatment precedes only 10 to 15 per cent of diagnosed cases. Cardiac patients that may need antimicrobial cover to prevent endocarditis include:
  • Prosthetic cardiac valves; these are at special risk
  • Previous history of endocarditis; these are at special risk
  • Congenital cardiac defects
  • Rheumatic heart disease
  • Hypertrophic cardiomyopathy
  • Aortic valve disease (bicuspid valves).6
Prevention of endocarditis depends on giving prophylactic antimicrobials only a few hours preoperatively before extraction, surgery, scaling.
Oral healthcare treatment (including maintaining high levels of oral hygiene) should be completed before any valvular surgery.
It is considered prudent to provide antibiotic cover for endocarditis at-risk patients about to have:
  • Extractions
  • Periodontal surgery
  • Mucogingival flaps raised
  • Scaling
  • Tooth reimplantation
  • Other procedures where there is gingival laceration
  • Orthodontic banding/de-banding.
There is no convincing evidence for the need for antibiotic prophylaxis for most local analgesic injections, or nonsurgical, prosthetic, restorative or other orthodontic procedures.
The current basic recommendations are to use a
  • chlorhexidine mouthwash and, one hour before the dental procedure, a single oral doses of
  • 3 g of amoxycillin (amoxicillin) or, for penicillin-allergic patients,
  • 600 mg of clindamycin.
Patients with a history of previous infective endocarditis require intravenous antibiotic prophylaxis.
 
DIABETES
Diabetes is a common condition of impaired carbohydrate utilisation (impaired glucose tolerance) caused by insulin resistance or deficiency. A random whole blood glucose over 10 mmol/litre or fasting level over about 6.7 mmol/litre usually establishes the diagnosis.
There are two main types of diabetics: juvenile onset and maturity onset. Diabetics need to control their blood glucose levels and thus should have a diet with a constant carbohydrate content. Hypoglycaemic drugs are used for maturity onset diabetics not controllable by diet alone, and insulin is given to juvenile diabetics. The most certain way of assessing control is by serial blood glucose measurements, usually by patients testing using a glucometer, while glycosylated haemoglobin or fructosamine assess long-term control.7
The great danger is hypoglycaemia, because of the risk of brain damage (neuroglycopenia) and hypoglycaemia can rapidly arise if a meal is missed. In contrast, exercise, surgery and infection increase insulin requirements.
To avoid this, it is best to offer dental treatment to diabetics early in the morning.
  • Always err on the side of hyperglycaemia; ensure the patient has breakfast and lunch. Keep a glucose drink readily accessible for use in any emergency
  • Try and treat under local analgesia
  • Always consult the physician before considering general anaesthesia
  • Well-controlled diabetics requiring a simple extraction under GA may be managed under a short GA in the early morning, provided the patient is going to be able to eat normally soon afterwards.
 
DRUG ALLERGIES, USE AND ABUSE
Drug use may influence dental treatment or cause oral adverse reactions. All drugs taken should be checked against a formulary for the type, action, contraindications, potential drug interactions and adverse effects. There are virtually no serious drug interactions with local analgesics used in normal doses.
  • The most serious drug interactions in dentistry are with
    • GA agents
    • Drugs with activity on the CNS
    • Antihypertensive agents.
  • Halothane should not be used repeatedly on any patient.
  • Aspirin may be a hazard in children, persons with a bleeding tendency, peptic ulceration, and diabetes, and those with aspirin allergy.
 
 
Allergic Reactions to Drugs
Allergic reactions to drugs can cause serious life-threatening reactions such as anaphylaxis or angioedema, or merely trivial rashes.
  • Allergic reactions are possible with any drug but are most common with antibiotics (especially penicillin), anaesthetics, analgesics, and antiseptics
  • All allergens should be avoided if possible, and an alternative drug used
  • Penicillin allergy is a real problem though many “allergies” to it are not true allergic responses. A minority of patients may also cross-react with cephalosporins8
  • Iodine sensitivity is a contraindication to the use of iodine-containing preparations such as some radiological contrast media, and povidone iodine
  • Patients and staff may react to dental materials such as resins, latex, and many other materials, including restorative metals and resins
  • Anaphylaxis in response to drugs is one of the most important immediate type reactions.
  • Anaphylaxis is mediated by mast cell degranulation in a type I response to various allergens in susceptible individuals. This leads to vasodilatation and bronchial constriction and thus:
    • Rapid fall in blood pressure, and thus collapse
    • Wheezing
    • Sometimes urticaria
  • This is an emergency. Adrenaline and oxygen should be kept readily accessible for use in any emergency
  • Allergic angioedema is another acute type I response which is potentially lethal as oedema affects the face, and may spread to the tongue and upper airway
  • Hereditary angioedema presents similarly to acute angioedema, but in response to trauma such as dental treatment, and is caused by a defect in the complement control enzyme C1 esterase inhibitor.
 
Drug Use
Drug use may also affect dental care. The most important drugs are the corticosteroids (steroids). Corticosteroids absorbed systemically suppress adrenocortical function for up to 2 years after the steroid treatment. Such patients cannot therefore respond adequately to the stress of trauma, operation or infection, which may cause collapse in adrenal crisis. Thus:
  • Steroids must not be abruptly withdrawn
  • Patients on, or recently on steroids, therefore need steroid supplementation before operations
  • Patients on, or recently on steroids, need supplementation, if there is intercurrent infection or illness
The necessity for these precautions have been challenged recently.
 
Drug Abuse
Drug abuse (chemical dependence or substance abuse) is a widespread problem in most countries, particularly among teenagers and young adults. Crime, violence, social and medical complications are frequently associated. Violent injuries and even death, sexually transmitted diseases, and poor compliance with health care are common in the drug-using population.9
Alcohol and solvent abuse and the use of cannabis are the most common habits, followed by abuse of psychedelics (particularly Ecstasy), heroin, methadone, and cocaine. Organic solvents such as glue are commonly abused by children and teenagers and can cause neurological, respiratory and liver damage. Cardiac effects including dysrhythmias may be fatal.
Injected drug use can be associated with particular problems due to blood-borne infections, notably the hepatitis viruses and HIV, and sometimes infective endocarditis or septicaemia.
Drugs of abuse may
  • Cause behavioural or psychotic reactions leading to accidents, assaults or death
  • Be associated with medical complications that influence dental care (such as blood-borne viral infections).
 
FITS, FAINTS, BEHAVIOURAL AND NEUROPSYCHIATRIC CONDITIONS
Patients with epilepsy or behavioural problems are often otherwise healthy. Access to care is often their greatest difficulty. Psychiatric disorders are common and can significantly influence oral health care, predominantly because of behavioural abnormalities.
  • Patients with epilepsy may sometimes have brain damage or physical disabilities such as cerebral palsy, or have other management problems. Grand mal epileptics may damage themselves, especially the orofacial tissues. Epileptogenic drugs such as methohexitone and enflurane should be avoided. Diazepam should be kept readily accessible for use in any emergency.
  • Anxiety before dental treatment is common but usually manageable with reassurance and, occasionally mild anxiolytics such as short-acting benzodiazepines. Sometimes anxiety is extreme enough to warrant the term “phobia,” when there are symptoms such as terror, rapid breathing, palpitations and agitation. Phobics require psychiatric support sometimes with medication such as buspirone, or a benzodiazepine. Painless dental care and the use of sedation may help.
  • Depressed patients are characterised by lowering of mood and many aspects of activity; sufferers may attempt suicide. Depression may underlie a variety of oral complaints, particularly atypical facial pain and dry mouth. GA is best avoided but local anaesthetics, provided they contain no noradrenaline, can be safely used in patients taking antidepressants. Maniac depression is a psychosis characterised by phases of depression and mania (elation, hyperactivity, flight of ideas, lack of restraint), often requiring psychiatric care. Manic depression is often treated with lithium, which may precipitate dysrhythmias, contraindicating GA, and can cause dry mouth.
  • Eating disorders include anorexia nervosa (slimming disease) and bulimia. These are seen mainly in young females of higher socioeconomic class, who starve themselves into poor health 10and there is a high mortality. Anaemia is common in the eating disorders, and is a contraindication to GA, as is hypokalaemia. Paracetamol has heightened hepatotoxicity in these conditions, and should be avoided.
  • Schizophrenia, a common major psychosis which affects mood, thought, and behaviour, often with illusions, delusions, hallucinations and sometimes paranoia, is controlled with phenothiazines or butyrophenones mainly, and thus dry mouth and extrapyramidal features such as orofacial dyskinesias are common. The acutely disturbed patient may be suffering from such a psychosis, but organic disease such as infections, drug intoxication, or drug withdrawal are other possibilities.
  • Dementia, the loss of intelligence, memory and cognitive functions, usually seen in the elderly, can be caused by vascular disease, HIV, other causes, or is idiopathic (Alzheimer's disease). It leads to general neglect of everything, including health, and thus oral hygiene deteriorates and oral disease increases. Close care and considerable compassion and patience are required.
  • Strokes (cerebrovascular accidents) are common and caused by haemorrhage, thrombosis or embolism, may be lethal, or may leave hemiplegia, facial palsy, speech defects, or other sequelae. Close care and considerable compassion and patience are required.
  • Parkinson's disease is a disease that may be caused by repeated trauma (boxing), drugs, toxins, or infections. Managed mainly with L-dopa and antimuscarinic agents, tremor and drooling can make dental care difficult. Close care and considerable compassion and patience are required.
  • Multiple sclerosis (MS) is a common disorder, often starting in younger adults, in which neurological lesions are disseminated in site and time. Some patients with MS become chairbound. Close care and considerable compassion and patience are required.
  • Autism is a failure in interpersonal relationships, ritualistic behaviour, failed development of language and speech in children of normal appearance and often normal intelligence. Close care and considerable compassion and patience are required.
  • Hyperkinesia in children may result from psychiatric disorders, foods or additives, or drugs. Poor concentration, restlessness, and overactivity are almost uncontrollable. Close care and considerable compassion and patience are required.
 
HEPATITIS AND OTHER TRANSMISSIBLE DISEASES INCLUDING HIV
Oral fluids can contain a range of microorganisms, and saliva and blood can be the vehicle for transmission of a range of agents, especially herpesviruses and hepatitis viruses. There is as yet no evidence of transmission of transmissible spongiform encephalopathies (TSE) by this route.11
  • Serious transmissible infections of established relevance to dentistry include
    • Blood-borne viruses such as human immunodeficiency virus (HIV) and hepatitis viruses
    • Respiratory pathogens, notably tuberculosis.
Serious transmissible infections are most likely in:
  • Injecting drug users
  • Patients who have attended clinics for sexually transmitted diseases
  • Men who have sex with men
  • Prostitutes
  • Vagrants
  • Immunocompromised persons
  • Persons from parts of the developing world.
Infections are transmissible in dentistry unless infection control measures are continually practised. The routine practice adopted for all dental patients must be sufficient to prevent cross-infection (universal precautions). Blood-borne viruses are most readily transmitted by sharps (needlestick) injuries, or use of infected blood, blood products, or tissues.
All members of the dental team have a duty to ensure that all necessary steps are taken to prevent cross-infection, in order to protect their patients, colleagues and themselves.
  • Gloves should be worn routinely by all dentists, students, hygienists and close support dental staff
  • Wash hands before gloving, and after gloves are removed. Cuts and abrasions should be protected with waterproof dressings and/or double gloving as appropriate
  • Gloves must be changed if punctured, and after treatment
  • When aerosols or tooth fragments are generated masks and eye protection should be worn, high volume aspiration used and waste should go into a central drain or sanitary suction unit
  • Clean white coats, or clean surgical gowns must be worn, changed if contaminated and not taken into any food/drink area
  • All 3-in-1 syringe tips, handpieces and ultrasonic scaler tips should be changed after use, and cleaned and autoclaved before refuse
  • Ultrasound scaler handpiece ends, which cannot be sterilised, must be thoroughly cleaned and disinfected before refuse
  • Cling-film should be placed over control buttons, operating light handles, ultrasonic scaler handpieces and 3-in-1 syringe bodies, and changed or decontaminated after every patient
  • Work surfaces should be protected with cling-film or other disposable material and changed after every patient.12
  • All ‘sharps’ must be disposed of in rigid containers
  • Inoculation injuries are the most likely source of cross-infection. Resheathing of needles should be avoided wherever possible
  • When cleaning an operation area or instruments, heavy-duty gloves should be worn.
In the event of accidental injury to operator
  1. Ensure that the accident is not repeated.
  2. Wash the wound.
  3. Test the patient's serum for hepatitis B antigens and enquire about possible HIV positivity.
  4. If the patient's serum is negative, there is probably no problem.
  5. If the patient's serum is positive, consult a microbiologist immediately for advice.
Dental treatment may carry a risk of cross-infection and patients may have problems, including bleeding tendencies, and may be immunocompromised.
  • Liver disease is important because of
    • Bleeding tendencies
    • Drug intolerance, which is a problem mainly in relation to general anaesthesia, but even a small dose of diazepam, may be hazardous. Drugs to be avoided include:
      • Aspirin
      • Carbamazepine
      • Diazepam and other sedatives
      • Erythromycin estolate
      • Halothane; this should never be given within 3 months of a previous halothane anaesthetic, nor repeatedly, nor to patients with unexplained jaundice or pyrexia after exposure to it
      • Ketoconazole
      • MAOI
      • NSAIDs
      • Paracetamol
      • Tetracyclines.
    • Possible viral causes, including hepatitis B virus (HBV), C (HCV), D (HDV), G (HGV) or transfusion transmitted virus (TTV).
Hepatitis B immunisation is recommended for all dental clinical staff. Hepatitis B vaccine is a recombinant vaccine of HBsAg, which gives protective antibody levels after three doses in 85 to 95 per cent of healthy adults for at least 3 years.13
 
IMMUNOSUPPRESSIVE TREATMENT
Iatrogenic immunosuppression is seen in patients on corticosteroids, azathioprine or other agents, but patients after organ transplants are the most severely immunocompromised. Such patients have depressed T lymphocyte responses and are liable mainly to viral and fungal infections, and mycobacterioses. Prophylactic antivirals and antifungals may be indicated in profoundly immunosuppressed persons. Odontogenic infections are potentially life-threatening in these patients, and broad-spectrum cover is needed (such as penicillin plus gentamicin). Dental treatment should be completed well before the transplant operation, if possible.
  • Patients with transplants are, particularly during the immediate postoperative period, liable to present a number of complications to dental treatment; in particular:
    • Need for a corticosteroid cover
    • Liability to infection
    • Bleeding tendency (if on anticoagulants)
    • Gingival hyperplasia if on cyclosporin (and nifedipine).
      Oral health is important as these patients are particularly liable to fungal (candidosis) and viral (herpesvirus) infections.
      Erythromycin is contraindicated since it decreases cyclosporin metabolism and increases its toxicity.
  • Renal transplant patients may also
    • Have a bleeding tendency, usually due to platelet dysfunction.
    • Have impaired drug excretion, a problem mainly when general anaesthesia is contemplated. Consider reducing the dose of most drugs, and avoid
    • NSAIDs (including aspirin)
    • Opioids
    • Aminoglycosides
    • Tetracyclines.
  • Immunosuppressed patients with indwelling peritoneal catheters
    Dental procedures are rarely followed by infection and these rarely involve oral microorganisms. Thus patients do not require antimicrobial prophylaxis before routine dental procedures, unless they have a severe immune defect, there is some other indication or surgery is to be performed.
 
MALIGNANT DISEASES
Malignant tumours in children are mostly leukaemias, lymphomas, CNS tumours, bone tumours, Wilms’ tumours, neuroblastomas or retinoblastomas. Malignant tumours in adults are 14mostly carcinomas of the lung, breast, stomach or colon but oral carcinoma is important in dentistry.
 
 
Leukaemias and Lymphomas
Leukaemias and lymphomas may be complicated by a bleeding tendency, liability to infections, and anaemia. Septicaemias arising from oral sources can be fatal. Cytotoxic chemotherapy, the main treatment for leukaemias, causes stomatitis as can the radiotherapy and bone marrow transplantation which may also be used.
The main oral complications of cytotoxic chemotherapy are infections and ulceration.
Lip cracking, bleeding, xerostomia, and delayed or abnormal dental development may also follow chemotherapy.
The main points in relation to oral health care include:
  • Strict attention to oral hygiene
  • Asepsis
  • Avoidance of aspirin
  • Avoidance of general anaesthesia
  • Platelet infusions to cover surgery.
 
Oral Carcinoma
In the developed world this is mainly a disease of the elderly male who uses tobacco and alcohol. In developing countries it is seen mainly in younger persons using tobacco or betel. Oral carcinoma is treated mainly with surgery, sometimes with radiotherapy.
Surgical treatment of malignant neoplasms in the head and neck is inevitably disfiguring to some degree, but cosmetic results are continually being improved and much can be offered.
Radiotherapy involving the oral tissues may give rise to a range of complications, especially
  • Mucositis; corticosteroid mouthwashes may help ameliorate radiotherapy-induced mucositis and ice cubes may relieve chemotherapy-induced mucositis. Benzydamine rinses may ease discomfort of mucositis and ulceration but opioids may be needed.
  • Xerostomia; predisposing to caries, candidosis and sialadenitis. Salivary substitutes may help relieve symptoms. Pilocarpine may help stimulate salivation. Dietary control and the use of fluorides are necessary to prevent caries. Prophylactic antimicrobials may help minimise fungal infections.
  • Loss of taste15
  • Trismus
  • Endarteritis obliterans; predisposing to osteoradionecrosis. Treatment planning is essential to minimise trauma and infection, and to ensure any surgery is carried out at the optimum time in relation to cancer therapy. Tooth extraction, or other surgical procedures should be done at least one week before radiotherapy is started, because of the risk of serious infection later.
  • Dental and craniofacial maldevelopment.
In patients on cancer therapy, gentle reiteration of oral hygiene instruction and supervision, and scaling and polishing, is not only valuable but is appreciated. Haemorrhage needs the advice of a haematologist. If it is due to thrombocytopenia, a platelet transfusion, plus tranexamic acid might be indicated.
 
PREGNANCY
Spontaneous abortion is most common in the first three months of pregnancy (trimester), a time when not only is the possibility of pregnancy often overlooked but also a time when drugs, infections and irradiation are most likely to cause foetal damage. Damage from these agents may range from subtle anomalies to cardiac or other organ defects, or foetal death. No drug is safe beyond all doubt. Therefore,
  • Drugs (especially aspirin, tetracyclines, co-trimoxazole, retinoids and CNS depressants) and radiation should be avoided whenever possible during pregnancy, particularly the first trimester.
  • Drugs which have been extensively used in pregnant women should be used in preference to newer drugs, and in the smallest effective dose.
  • In general, most dental treatment is best carried out in the 4th to 6th months of pregnancy (second trimester).
  • In the third trimester, avoid GA because of the liability of vomiting and do not lay the patient supine, as this may cause hypotension.
  • Lactating mothers should avoid
    • Aspirin
    • Benzodiazepines and other CNS depressants
    • Co-trimoxazole
    • Tetracyclines.
Pregnancy is the ideal opportunity to begin preventive dental education.
This chapter has been reproduced from: C Scully: The Medically Compromised Patient: In SR Prabhu (Ed): Textbook of Oral Medicine (2004): Oxford University Press.