3: Formulating a Management Strategy

Chapter 3

Formulating a Management Strategy

Aim

To outline a systematic approach to history taking, examining, investigating, assimilating and arriving at a diagnosis so that a management strategy, tailored to the individual patient, may be formulated.

Outcome

After reading this chapter the practitioner should have an understanding of:

  • what to look out for in both a patient’s history and medical history

  • what to look out for when conducting both an intraoral and extraoral examination

  • the importance of the patients’ expectations

  • the application of some useful special investigations (Dietary survey tools, Radiographic examination, Study models and intraoral radiographs, salivary tests)

  • behaviour that increases the risk of dental erosion developing

  • the importance of a holistic and individual approach to the management of patients with dental erosion

Making the Diagnosis

The development of dental erosion is insidious. Often it is a member of the dental team who will be the first to discover that the patient has this condition. It is generally not until the integrity of the enamel is breached that a patient will report any symptoms, such as sensitivity of the affected teeth to hot or cold. It is therefore important that the early signs are recognised and acted upon, in consultation with the patient, if the condition is to be prevented from progressing further.

Making a definitive diagnosis to develop a management strategy, tailored to the individual patients needs, involves four principal components:

  • History taking

  • Acquisition of the medical history

  • An extra- and intraoral examination

  • Determining the patients’ expectations.

Each may act as a trigger for a special investigation to acquire further information to assist in the development of the management strategy.

History Taking

It is important to elicite from the patient when and for how long they have been aware of the problem. Typically, the patient will report chipping of the incisal edges, fracture of teeth and alterations in the appearance of anterior teeth, such as greying of the incisal edge following an alteration in translucency as a result of loss of palatal tooth substance. Where dentine has become exposed, pain or sensitivity of the teeth may be reported. This could be upon exposure to hot and cold drinks or even on toothbrushing following the intake of an acidic food.

Acquisition of the Medical History

A comprehensive medical history should always be obtained and recorded. With specific reference to dental erosion, it is important to establish any potential source of intrinsic acid. This could be as a result of an undiagnosed level of gastro-oesophageal reflux, reported by the patient as heartburn or indigestion, arising from either an underlying medical condition (Table 3-1) or as a side-effect of medication (Table 3-2).

Table 3-1 Causes of gastroesophageal reflux and regurgitation
Causes
Incompetence of the gastroesophageal sphincter
Primary

  • idiopathic with or without hiatus hernia secondary

Secondary

  • impairment of the gastroesophageal sphincter by progressive systemic sclerosis, mixed connective tissue disease, and neurogenic disorders (e.g. diabetic and alcoholic polyneuropathia)

  • destruction of the sphincter by surgical resection, myotomie, ballon dilatation or esophagitis

  • neurohormonal induced decrease of gastroesophageal sphincter pressure by drugs (e.g. beta-adrenergics, serotonin, cholecystokinin, diazepam, glukagon), increased estrogen and progesterone (luteal phase of menstrual cycle, pregnancy, intake of oral contraceptives), diet (fatty meals, peppermint, chocolate, coffee, alcohol) or smoking

Increased intraabdominal pressure

  • obesity

  • pregnancy

  • ascites

Increased intragastric volume

  • after meals

  • pyloric spasm

  • obstruction due to peptic ulcer, gastroparesis

  • gastric stasis syndrome

* Reproduced from Scheutzel P. Etiology of dental erosion – intrinsic factors. European Journal of Oral Sciences 1995;104:178–190, by kind permission of the Editor, Journal of Oral Sciences.

Table 3-2 List of drugs that may cause vomiting as a side-effect
List of drugs

Anorectics

Fenfluramine

Amfepramone

Piracetam

Phendimetrazine

Mazindol

Antiallergic drugs and antitussives

Clofedanol

Cranoglycate disodium

Letosteine

Antibiotics

Tetracyclines

Anticonvulsants

Progabide

γ-vinyl-GABA

Buprenorphine

Antifungal drugs

Nystatin

Antihypertensive drugs

Nitroprusside

Clonidine

Anti-inflammatory analgesics and drugs used in gout

Ibuprofen

Indometacin

Phenylbutazone

Piroxicam

Antiprotozoal drugs

Iodoquinol

Emetine

Antipyretic analgesics

Acetylsalicylic acid and related compounds

Central nervous system stimulants

Caffeine

Theophylline and related substances

Doxapram

Euprofylline

Lobeline

Nikethamide

Proproxyphylline

Cytostatic and immunosuppressive drugs

Diuretics

Spironolactone

Thiazide diuretics triamterene

Drugs acting on the peripheral circulation

Buphenine

Co-dergocrine

Isoxsuprine

Drugs affecting automonic function or the extrapyramidal system

Amantadine

Carbidopa

Dopamine

Ergometrine

Ergotamine

Mesulergine

Piribedil

Serotonin

Tyrosine

Drugs increasing dopamine activity

Amantadine

Drugs of abuse

Cannabis nutmeg

Lysergide tetrahydrocannabiol

Gastointestinal drugs

Salazosulfapyridine

Mercaptamine

Pentagastrin

Loperamide

General anesthetics

Cyclopropane

Isoflurane

Hypnotics and sedatives

Benzodiazepines

Chloralhydrate

Ethylchlorrynol

Methaqualone

Immunemodulating agents

Preabanil

Lithium

Gallium nitrate

Gold salts

Iron salts

Selenium

Zinc

Metal antagonists

Dimercaprol

Opioid analgesics

Alfentanil

Buprenorphine

Buturphanol

Ciramadol

Conorfone

Cyclazocine

Dezocine

Nalbuphine

Naloxone

Naltrexone

Pentazocine

Sufentanil

Tramadol

Opioid agonists

Alfentamil

Amantadine

Butorphanol

Ciramadol

Positive inotropic drugs and drugs used in dysarrhythmias

Aprindine

Bretylium

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Jan 9, 2015 | Posted by in Operative Dentistry | Comments Off on 3: Formulating a Management Strategy
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