Clinical Scenario

A 77‐year‐old woman presents to your dental clinic complaining of mobility problems and discomfort associated with the lower left wisdom tooth. Her symptoms commenced 2 days ago and are especially pronounced when chewing. The painful tooth (#38) serves as an anchor for a removable lower denture that she has been unable to wear since the discomfort started.

Structured Learning

1. The patient is concerned about the lesion you have detected in the left buccal mucosa. She did not know it was there and is very worried that it is cancer, particularly as her sister died due to mouth cancer. What is an appropriate response?
   • Reassure the patient and explain that this is unlikely
   • Include the information below in your discussion
     • The lesion does not have the classic signs of cancer (i.e. speckling, ulceration, induration)
     • There are no additional risk factors (no alcohol/tobacco consumption)
     • It is more likely that the lesion is due to a lichenoid reaction
     • A number of medications can cause this type of lesion
     • Although antihypertensive medications are included in these, the patient is taking a calcium channel blocker (amlodipine), which is not normally associated with this reaction
       

       

     • Hence, the lesion is most likely to be related to the hypoglycaemic agent (metformin)
     • A biopsy can help confirm the diagnosis but is not urgent as the lesion does not look suspicious

2. The patient also complains that her mouth has become increasingly dry over the last 5 years. What could be causing this?
   • Anxiety
   • Secondary to diabetes
   • Secondary to medication: lorazepam (benzodiazepine), amlodipine (calcium channel blocker)
3. Following a discussion, the patient agrees to proceed with dental extraction of #38. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Emotional lability may reduce compliance and ability to cope with dental intervention
     • Emotional distress has also been related to paroxysmal hypertension
   • Medical
     • Hypertension and type 2 diabetes mellitus are both aspects of metabolic syndrome and hence may have shared common aetiological and risk factors; they may also contribute to a worsening of each other’s symptoms
     • Increased risk of hypertensive crisis, orthostatic hypotension and potential increased bleeding tendency
     • Diabetes mellitus is known to be associated with increased risk of infection, impaired wound healing and risk of hypoglycaemia/hyperglycaemia in the dental setting (see Chapter 5.1); it may also result in ‘silent’ heart attacks due to autonomic nerve damage
     • Stress from the dental environment can trigger an anxiety crisis (see Chapter 15.1)
     • Consider the sedative effects of lorazepam
   • Dental
     • Requires an urgent dental extraction (i.e. patient cannot chew)
     • Need for replacement dentures needs to be discussed, taking into account the following factors:
       • Fit of the current dentures is poor
       • Further jeopardised by the loss of a supporting tooth (#38)
       • Previous denture is 10 years old – patient may have difficulty adapting to a new denture
       • Poor prognosis for the remaining teeth
       • Xerostomia can reduce retention and tolerance to a replacement denture
     • Irregular attendance and anxiety may reduce compliance, engagement in improving oral health and engagement in long‐term follow‐up
4. Before commencing the dental procedure, you check the patient’s blood pressure – it is 165/105 mmHg. What is your approach?
   • Do not proceed with treatment
   • Confirm that the patient has taken their antihypertensive medication
   • Repeat the blood pressure measurement after a 5‐minute interval
   • If at 5 minutes the readings are the same or worsen, consult the patient’s physician
   • Be aware that hypertensive urgency (absence of other symptoms)/emergency (symptoms of target organ involvement) occurs when the blood pressure is 180/120 mmHg or greater – this requires immediate medical review/intervention

5. The physician informs you that the patient’s blood pressure is usually well controlled and she has been seen recently for a review. What could have led to the raised readings and what would you do?
   • The patient may not be compliant with her antihypertensive medication, particularly as she is distressed by the recent death of her sister
   • Lifestyle factors may have had an impact (e.g. lack of exercise)
   • The patient has a history of anxiety
   • This coupled with the discussion regarding the buccal lesion and her concern regarding cancer may have caused the elevated readings at the appointment
   • Discuss these factors with the patient
   • Advise further medical review
   • Prescribe medication to control the pain and infection from #38 and rebook an appointment for the dental extraction
6. What should you consider if prescribing an analgesic?
   • The patient is already routinely taking a non‐steroidal anti‐inflammatory drug (dexketoprofen), although this is not controlling her oral pain
   • Non‐steroidal anti‐inflammatory drugs can decrease the activity of antihypertensive drugs (especially angiotensin‐converting enzyme inhibitors and angiotensin II receptor blockers), but there is no evidence of drug interactions with calcium channel antagonists
   • If she requires a rescue analgesic, she should start with paracetamol
7. The patient asks if she can have sedation when the dental extraction is undertaken in the future. What should you consider?
   • If the hypertension and diabetes are well controlled, no technique is contraindicated: nitrous oxide or drug sedation may be employed (e.g. benzodiazepines)
   • However, it is important to consider that the patient is already taking lorazepam (benzodiazepine) daily, and she is 77 years old

General Dental Considerations

Definition

Arterial hypertension is defined as the permanent increase in systolic blood pressure (>140 mmHg), diastolic blood pressure (90 mmHg) or both (in the United States, ≥130/80 mmHg) (Table 8.1.3