3: SPECIFIC PROBLEM AREAS

SPECIFIC PROBLEM AREAS

ACROMEGALY

General aspects

Aetiopathogenesis

GH hypersecretion is usually caused by an eosinophilic adenoma of the anterior pituitary. Other uncommon causes include pancreatic islet cell tumours and some lung endocrine tumours that produce GH stimulating factors.

Clinical presentation

image Excess tissue growth (Fig. 3.1): • supra-orbital ridge (prominent) • nose (broadened) • skin (thickening) • macroglossia • mandible (spaced teeth, prognathism) • hands and feet (large) image Systemic complications due to organ enlargement: • diabetes • hypertension • cardiomyopathy image Local effects of pituitary tumour (headache, visual defects).

Dental management

Risk assessment

Dental management may be complicated by: image visual impairment image cardiomyopathy image cardiac arrhythmias image hypertension image diabetes mellitus image hypopituitarism.

Rarely, acromegalics have Cushing’s syndrome or hyperparathyroidism due to associated multiple endocrine adenoma syndrome.

Pain and anxiety control

General anaesthesia

Kyphosis and other deformities affecting respiration may make general anaesthesia hazardous. The glottic opening may be narrowed and the cords’ mobility reduced. A goitre may further embarrass the airway.

Table 3.1

Key considerations for dental management in acromegaly (see text)

  Management modifications* Comments/possible complications
Risk assessment 2 Blindness, diabetes, hypertension, arrhythmias
Preventive dentistry and education 1 Carpal tunnel syndrome, enlarged tongue
Pain and anxiety control    
 – Local anaesthesia 0  
 – Conscious sedation 0  
 – General anaesthesia 1/4 Kyphosis, narrow glottis
Patient access and positioning    
 – Access to dental office 0  
 – Timing of treatment 1 Sleep apnoea, fatigue
 – Patient positioning 1 Longer dental chair
Treatment modification    
 – Oral surgery 0  
 – Implantology 0  
 – Conservative/Endodontics 0  
 – Fixed prosthetics 0  
 – Removable prosthetics 0  
 – Non-surgical periodontology 0  
 – Surgical periodontology 0  
Hazardous and contraindicated drugs 0  

*0 = No special considerations. 1 = Caution advised. 2 = Specialised medical advice recommended in some cases. 3 = Specialised medical advice mandatory. 4 = Only to be performed in hospital environment. 5 = Should be avoided.

ADDISON’S DISEASE

General aspects

Aetiopathogenesis

image Main cause is autoimmune (sometimes also associated with diabetes, Graves’ disease, pernicious anaemia, vitiligo or hypoparathyroidism), particularly in women image Rare causes include adrenal tuberculosis, histoplasmosis or tumours image Secondary adrenocortical hypofunction may also follow an abrupt withdrawal from systemic corticosteroid therapy.

Clinical presentation

image Low cortisol leads to: • skin and mucosal hyperpigmentation (due to raised ACTH in primary disease; part of ACTH molecule is similar to melanocyte stimulating hormone) (Fig. 3.2) • hypotension (weakness, lethargy, tiredness, collapse) • weight loss image Adrenocortical hypofunction may lead to shock and death if the individual is stressed as, for example, by an operation, infection or trauma.

Dental management

Risk assessment

The danger of dental treatment in a patient with hypoadrenocorticism, especially when undertaking surgery under general anaesthesia, is of precipitating hypotensive collapse. Clinical findings suggestive of acute adrenal insufficiency include weakness, nausea, vomiting, headache and abdominal pain.

Acute adrenal insufficiency is managed as follows: image call for immediate help image lay patient flat with legs raised image give hydrocortisone 200 mg IM image oxygen 10L/min image if IV access can be obtained, give 1 litre dextrose saline image check blood pressure.

Appropriate oral health care

The need for patients on long-term steroid treatment to increase their dose of glucocorticoids when undergoing stressful procedures has been the subject of much controversy. In 1998, Nicholson et al reviewed all the available evidence and published new recommendations for steroid cover, where hydrocortisone supplementation is given intravenously. Patients who have taken steroids in excess of 10 mg prednisolone, or equivalent, within the last 3 months, should be considered to have some degree of hypothalamic–pituitary–adrenal (HPA) suppression and will require supplementation. Patients who have not received steroids for more than 3 months are considered to have full recovery of HPA axis and require no supplementation. These guidelines have been adopted by anaesthetists in the UK (see Steroids) and are increasingly used by other specialties, including dentists.

However, the implementation of Nicholson’s guidelines is not universal amongst the dental profession. Some are still using regimens such as doubling the normal daily steroid dose on the day of procedure (Gibson & Ferguson 2004).

Pain and anxiety control

Cortisol levels normally increase in the postoperative period following oral surgical procedures. This increase is blunted by the use of analgesics, strongly suggesting that the increased cortisol levels are a physiological response to pain. Hence in patients with Addison’s disease, postoperative analgesia is extremely important. In view of this, if significant postoperative pain is expected, the patient’s usual steroid dose may be doubled on the following day.

Treatment modification

Most patients undergoing routine dental procedures need no supplemental steroids. However steroid cover is advisable for those patients undergoing surgical procedures, including dental extractions, periodontal surgery and placement of implants. It may also be considered for those patients that are particularly anxious. The guidelines recommended by Nicholson et al in 1998 are outlined below:

Surgery

Delayed healing has been observed after dentoalveolar surgery. Antibiotic prophylaxis is advised before any procedure causing significant bleeding, including oral surgery, implantology and periodontal surgery. Good postoperative pain control is essential. Steroid cover should be considered.

Table 3.2

Key considerations for dental management in Addison’s disease (see text)

  Management modifications* Comments/possible complications
Risk assessment 2 Acute adrenal insufficiency
Appropriate oral health care 2 Consider steroid cover
Preventive dentistry 1 Increased susceptibility to infection
Pain and anxiety control    
 – Local anaesthesia 0  
 – Conscious sedation 0  
 – General anaesthesia 2/4 ACTH and cortisol secretion
Patient access and positioning    
 – Access to dental office 0  
 – Timing of treatment 1 Early morning
 – Patient positioning 0  
Treatment modification    
 – Oral surgery 1 Delayed healing
 – Implantology 1 Delayed healing
 – Conservative/Endodontics 0  
 – Fixed prosthetics 0  
 – Removable prosthetics 0  
 – Non-surgical periodontology 0  
 – Surgical periodontology 1 Delayed healing
Hazardous and contraindicated drugs 0  

*0 = No special considerations. 1 = Caution advised. 2 = Specialised medical advice recommended in some cases. 3 = Specialised medical advice mandatory. 4 = Only to be performed in hospital environment. 5 = Should be avoided.

Further reading

ALCOHOLISM

General aspects

Aetiopathogenesis

Prolonged alcohol abuse causes malnutrition, anaemia, impairment of immune function and other effects, including: image CNS – memory loss, disinhibition image liver – fatty liver, alcoholic hepatitis, cirrhosis image GIT – gastritis, peptic ulcer, pancreatitis image heart – cardiomyopathy, hypertension.

Clinical presentation

image Alcohol at blood levels above 35 mg/dL (35 mg/100 mL) impairs judgment, while signs of intoxication are clinically obvious at a blood alcohol level above 100 mg/dL, with slurred speech, loss of restraint and ataxia. At a blood alcohol level above 200 mg/dL some people become aggressive. image Thus the acute effects of alcohol are mainly on judgment, concentration and coordination, and are dose-related as shown in Table 3.3 image Earlier signs or symptoms of chronic excessive alcohol drinking include an evasive, truculent, over-boisterous or facetious manner, slurred speech, smell of alcohol on the breath, signs of self-neglect, gastric discomfort (particularly heartburn), anxiety (often with insomnia), or tremor image Later signs or symptoms of chronic excessive alcohol drinking include palpitations and tachycardia, cardiomyopathy, liver disease, malnutrition, peripheral neuropathy, amnesia and confabulation (in Wernicke’s and Korsakoff’s CNS syndromes), cerebellar degeneration with ataxia, or dementia (Fig. 3.3, Table 3.4) image Alcohol can interact with other drugs such as warfarin, paracetamol/acetaminophen, and CNS-active agents such as benzodiazepines.

Table 3.3

Acute effects of alcohol

Blood alcohol level in mg/dL Effect
<100 Dry and decent
100–200 Delighted and devilish
200–300 Delinquent and disgusting
300–400 Dizzy and delirious
400–500 Dazed and dejected
>500 Dead drunk

Table 3.4

Chronic effects of alcohol

  Possible effects Biochemical changes
Cardiac Cardiomyopathy, arrhythmias  
CNS Intoxication Raised blood alcohol
  Dementia Decreased thiamine levels
  Wernicke–Korsakoff syndrome  
Gastric Gastritis  
Haematological Pancytopenia Reduced haemoglobin
  Immune defect Reduced platelet count
    Leukopenia
    Macrocytosis
    Reduced blood clotting factors II, VII, IX, X
Hepatic Hepatitis Raised gamma glutamyl
  Fatty liver (steatosis) transpeptidase
  Cirrhosis Raised other liver enzymes
    Raised bilirubin
    Reduced albumin
Intestinal Malabsorption of glucose and vitamins Reduced folate, thiamine and vitamins B12, A, D, E and K
Oesophageal Gastro-oesophageal reflux disease  
  Mallory–Weiss syndrome (tears from vomiting)  
Pancreatic Pancreatitis Raised serum amylase

Prognosis

The high mortality rate in alcoholism is mainly as a result of road traffic accidents and assaults. After a large alcoholic binge, suppression of protective reflexes, such as the cough reflex, can result in inhalation of vomit, and death.

image Mortality related to alcoholic hepatitis diagnosis is 10-25%, and life quality and expectancy can be affected by diseases including: • liver disease, especially alcohol-induced hepatitis and cirrhosis • nutritional defects • pancreatitis • gastritis and peptic ulcer • immune defects leading to infections, especially pneumonia and tuberculosis, and impaired wound healing • cardiomyopathy • myopathy • brain damage and epilepsy.

image Social difficulties from alcohol misuse can affect the six “Ls”: • law – breach of the criminal, civil and/or professional codes • learning – intellectual difficulties • livelihood – job problems • living – housing problems • lover – interpersonal difficulties of all kinds, husband/wife, partner, employer/employee etc. • lucre (Latin – lucrum = wealth) – money problems.

Oral findings

image The most common oral effect of alcoholism is neglect, leading to advanced caries and periodontal disease image Dental erosion may result from regurgitation image Nocturnal bruxism by reticular system stimulation is common, and may predispose to temporomandibular joint disorders image If there is deficiency of folate or other B complex vitamins (niacin, piridoxine, riboflavine or thiamine), sore mouth, recurrent aphthae, glossitis, dysgeusia, tongue depapillation, dysaesthesia and angular stomatitis may result image Painless, bilateral, parotid gland enlargement due to fat infiltration (sialosis) is frequent in patients with alcoholic cirrhosis image Other orofacial features include a smell of alcohol on the breath, telangiectases and possibly rhinophyma (enlargement of the nose with dilation of follicles and redness and prominent vascularity of the skin, also known as “grog blossom”).

Dental management

Risk assessment

The main relevant medical complications are related to liver cirrhosis, which may delay the metabolism of many drugs, and also result in a bleeding tendency. Problems obtaining valid consent may arise, particularly if the patient is intoxicated.

Pain and anxiety control

Treatment modification

Because of erratic attendance, and neglect of caries and periodontal disease, only simple restorative procedures should be planned. Consent issues may arise if the patient is intoxicated, particularly if Wernicke’s encephalopathy or Korsakoff’s syndrome is also present. Careful consideration of the patient’s ability to understand and weigh up the information provided is needed, and consent may not be valid on subsequent appointments if the patient is unable to remember the discussion. If available, an escort is desirable as this may improve patient attendance and improve discharge arrangements and care.

Surgery

Two of the most important complications of excessive alcohol intake are maxillofacial trauma and head injuries. Care should be taken when surgery is contemplated, as liver disease causes a bleeding tendency due to a reduction in blood coagulation factors, and some patients may also have thrombocytopenia. Wound healing may be impaired in the severe chronic alcoholic. Indeed, in a series reported in the USA, alcoholism was found to be a common factor in patients with osteomyelitis following jaw fractures. Before providing treatment, laboratory tests including full blood cell count, liver enzyme levels and coagulation screening should be performed and a physician consulted.

Table 3.5

Key considerations for dental management in alcoholism (see text)

  Management modifications* Comments/possible complications
Risk assessment 2 Liver cirrhosis, consent
Preventive dentistry and education 1 Alcoholism screening, oral cancer screening and diet counselling
Pain and anxiety control    
 – Local anaesthesia 1 Tolerance
 – Conscious sedation 1 Additive effect
 – General anaesthesia 5 Resistance, aspiration
Patient access and positioning    
 – Access to dental office 0  
 – Timing of treatment 1 Morning
 – Patient positioning 0  
Treatment modification    
 – Oral surgery 1 Bleeding tendency
 – Implantology 5 Poor risk group
 – Conservative/Endodontics 1 Maintenance compromised
 – Fixed prosthetics 1 Maintenance compromised
 – Removable prosthetics 0  
 – Non-surgical periodontology 1 Maintenance compromised
 – Surgical periodontology 1 Bleeding tendency
Hazardous and contraindicated drugs 2 Sedatives, NSAIDs, metronidazole, cephalosporins

*0 = No special considerations. 1 = Caution advised. 2 = Specialised medical advice recommended in some cases. 3 = Specialised medical advice mandatory. 4 = Only to be performed in hospital environment. 5 = Should be avoided.

ALZHEIMER’S DISEASE

General aspects

image Dementia is a chronic organic brain disease characterised by amnesia (especially for recent events), inability to concentrate, disorientation in time, place or person and intellectual impairment (including loss of normal social awareness) image It has many causes (Table 3.6), the most common being: • Alzheimer’s disease • multi-infarct (vascular) dementia • Lewy body dementia image Dementia is usually seen in old age, and may be mimicked by acute organic brain disease, confusional states, drug-induced disorders and psychiatric disease.

Table 3.6

Causes of dementia

Common causes Uncommon causes
Alcoholism AIDS
Alzheimer’s disease (>60% of all dementia) Brain trauma, haemorrhage or infection
Cortical Lewy body dementia (10%) Creutzfeldt–Jakob disease
Huntington’s chorea Metabolic causes (e.g. hypothyroidism)
Hydrocephalus Pick’s disease (frontal lobar atrophy)
Multi-infarct dementia (25%)  
Tumours  

Dental management

Studies have shown that about 75% of patients with Alzheimer’s disease need dental attention. The stage of the Alzheimer’s disease and the complexity of the dental treatment will decide if the patient can be treated in the dental clinic, at hospital or at home (bed-ridden). Comprehensive oral rehabilitation is best completed as early as possible since the patient’s ability to cooperate during dental treatment diminishes with advancing disease. If long-term care is anticipated, full mouth diagnostic radiographs should be taken and kept for future use. In dentate patients, fabrication of custom mouthguards for fluoride treatment facilitates long-term fluoride therapy, but many people with advanced disease will not tolerate this. The best alternative is more frequent recall visits including prophylaxis and application of topical fluoride. Informed consent is a complex issue in all patients with dementia and requires consultation with the patient’s physician.

Patient access and positioning

Treatment modification

Whilst it is still possible to provide dental treatment, it should be planned with the knowledge that the patient will sooner or later become unmanageable for treatment under local analgesia. Later, there is progressive neglect of oral health as a result of forgetting the need or even how to brush the teeth or clean dentures. Dentures are also frequently lost or broken or cannot be inserted or tolerated. Complex dental treatment such as dental implants, which require follow-up and meticulous oral hygiene, are not indicated.

Table 3.7

Key considerations for dental management in Alzheimer’s disease (see text)

  Management modifications* Comments/possible complications
Risk assessment 2 Behaviour control; other systemic diseases; consent
Preventive dentistry 1 Electric toothbrushing; chlorhexidine
Pain and anxiety control    
 – Local anaesthesia 1 Behaviour control;
 – Conscious sedation 1 other systemic diseases
 – General anaesthesia 3/4  
Patient access and positioning    
 – Access to dental office 1 Hip fracture
 – Timing of treatment 1 Morning; carer present
 – Patient positioning 1 Sitting upright
Treatment modification    
 – Oral surgery 1  
 – Implantology 5 Poor oral hygiene
 – Conservative/Endodontics 1 Single procedures
 – Fixed prosthetics 1 Single procedures, early stages
 – Removable prosthetics 1/5 Lost, broken, poorly tolerated
 – Non-surgical periodontology 1  
 – Surgical periodontology 1  
Hazardous and contraindicated drugs 2 Tolerance of sedatives

*0 = No special considerations. 1 = Caution advised. 2 = Specialised medical advice recommended in some cases. 3 = Specialised medical advice mandatory. 4 = Only to be performed in hospital environment. 5 = Should be avoided.

AMPHETAMINE, LSD AND ECSTASY ABUSE

General aspects

The most common drugs of misuse are amphetamines, LSD (lysergic acid diethylamide) and ecstasy (MDMA – 3,4-methylene-dioxymethamphetamine).

image Dextroamphetamine (amphetamine) and methylphenidate are the most representative drugs. Stimulants are prescribed for treating only a few health conditions, including narcolepsy, attention-deficit hyperactivity disorder, and deep depression. Amphetamines are misused or abused for their euphoriant effect, to stave off fatigue in order to continue working and for slimming. image LSD (lysergic acid diethylamide), manufactured from lysergic acid (found in ergot, a fungus that grows on rye and other grains), is a major hallucinogen, considered one of the most potent mood-changing chemicals image MDMA (3,4-methylenedioxymethamphetamine), popularly known as “ecstasy”, is a synthetic, psychoactive drug with sympathomimetic properties, and both stimulant (amphetamine-like) and hallucinogenic (LSD-like) properties.

Pathogenesis

Amphetamines

image These are the main drugs in a group of central stimulants which also includes phenmetrazine, methylphenidate and, to a lesser extent, diethylpropion. They produce a range of effects by stimulating alpha- and beta-adrenergic receptors, increasing the levels of monoamines (which include norepinephrine and dopamine) and thus stimulating the CNS and peripheral nervous system. image Acute amphetamine toxicity causes dry mouth, dilated pupils, tachycardia, aggression, talkativeness, tachypnoea and hallucinations, leading to seizures, hypertension, hyperpyrexia, arrhythmias and collapse image Chronic amphetamine toxicity causes restlessness, hyperactivity, loss of appetite and weight, tremor, repetitive movements, bruxism and picking at the face and extremities image High doses of amphetamines can cause mood swings and psychoses (including hallucinations and paranoia), and can cause respiratory failure and death image Combining use with other drugs such as alcohol can result in nausea, difficulty breathing and unconsciousness.

LSD

image The effects of LSD are unpredictable but prolonged (∼12h), depending on the amount taken, the user’s personality, mood, and expectations, and the surroundings in which the drug is used image Typically, LSD produces several different emotions at once or users swing rapidly from one emotion to another within 30-90 minutes. Synaesthesia, the overflow from one sense to another when, for example, colours are heard, is common. There is often lability of mood, panic (“bad trip”) and delusions of magical powers, such as being able to fly. If taken in a large enough dose, the drug produces delusions and visual hallucinations. The user’s sense of time and self changes. image Many LSD users experience flashbacks, recurrence of certain aspects of a person’s experience, without having taken the drug again. A flashback comes suddenly, often without warning, and may be within a few days or more than a year after LSD use. image The physical effects from LSD are similar to those of catecholamines and include: • dilated pupils • raised body temperature, heart rate and blood pressure • sweating • loss of appetite • sleeplessness • dry mouth • tremors. image Severe adverse effects include terrifying thoughts and feelings and despair, occasionally leading to fatal accidents.

MDMA

image MDMA (ecstasy) affects dopamine-containing neurones that use the chemical serotonin to communicate with other neurones; a decrease in serotonin transporters has been recently demonstrated in the brain of MDMA users by positron emission tomography (PET) image Ecstasy, like amphetamines, produces euphoria and appetite suppression, but is more potently hallucinogenic, possibly because of chemical affinities with mescalin. image It is usually taken by mouth, producing effects after 20-60 minutes image Adverse effects of MDMA are not dose-related, and include: • psychiatric sequelae such as agitation or paranoia • neurological effects such as ataxia and seizures • cardiovascular such as tachycardia, arrhythmias or infarction • renal or hepatic failure • other effects image MDMA users face risks similar to those found with the use of cocaine and amphetamines: • psychological difficulties, including confusion, depression, sleep problems, drug craving, severe anxiety, and paranoia – during and sometimes weeks after taking MDMA • physical symptoms such as muscle tension, involuntary teeth clenching, nausea, blurred vision, rapid eye movement, faintness, and chills or sweating • raised heart rate and blood pressure, a special risk for people with circulatory or heart disease image There is evidence that people who develop a rash that looks like acne after using MDMA may be risking severe side effects, including liver damage, if they continue to use the drug.

Clinical presentation

The most significant risks from drug abuse are behavioural disturbances and psychoses. Intravenous use of these drugs is further complicated by the risk of transmission of infections (HIV, hepatitis B), infective endocarditis or septicaemia.

Findings that may indicate a drug addiction problem include: image Work absenteeism, frequent disappearances from the workplace, making improbable excuses and taking frequent or long trips to the toilet or to the stockroom where drugs are kept image Personality change – mood swings, anxiety, depression, lack of impulse control, suicidal thoughts or gestures, and deteriorating interpersonal relations with colleagues and staff; the user rarely admits errors or accepts blame for errors or oversights image Unreliability in keeping appointments, meeting deadlines, and work performance – which alternates between periods of high and low productivity. Many suffer from mistakes made due to inattention, poor judgment, bad decisions, confusion, memory loss, and difficulty concentrating or recalling details and instructions. Ordinary tasks require greater effort and consume more time. image Progressive deterioration in personal appearance and hygiene, and uncharacteristic deterioration of handwriting and charting image Other common signs are: • tachycardia (amphetamines) • hyperpyrexia (ecstasy) • bruxism – amphetamines or ecstasy • drug-associated diseases • psychosis.

Recognition of individuals who may be abusing drugs is critical. Behavioural problems or drug interactions may interfere with dental treatment. Intravenous drug use (IVDU) is associated with the risk of transmission of infections (HIV, hepatitis B), and complications such as infective endocarditis (which will require antibiotic prophylaxis).

Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 3: SPECIFIC PROBLEM AREAS
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