Endocrine disorders continued

  1. Pancreas (insulin)
  2. Thyroid (thyroxin)
  3. Adrenal… produce hormones that prepare the body for stress. I.e. epinephrine... increase heart rate, BP and breathing rate.

Cortisol… makes more glucose available to body cells. *Helps prepare body for stress.

Other hormones produced by adrenals:

  • Regulate the concentration of electrolytes Na/K
  • Produce male and female sex hormones

Cushing’s Disease

  • Hyper secretion of the adrenal gland
  • High bp, high glucose level, osteoporosis, fatigue, edema, decreased immunity
  • A round, full face

Addison’s Disease

  • Severe hypo secretion of the adrenal gland
  • Low bp, low blood glucose, muscle weakness, skin and mucous membrane pigmentation, fatigue
  • Primary insufficiency - due to a destruction of adrenal (Tb, malignancy, fungal infection)
  • Secondary insufficiency – a more common problem resulting from the administration of steroids

Patients on long-term, high doses of steroids are therefore, unable to tolerate stressful incidents and must receive supplementary amounts of steroids just prior to treatment in order to prevent an adrenal crisis.

Adrenal Crisis Symptoms

  • Nausea / vomiting
  • Weakness
  • Headache, dehydration
  • May be fatal

Dentistry for the Pregnant or Lactating Patient

Considerations

  • Treatment timing
  • Use of x-rays
  • Drug administration
  • Local anesthetics
  • Analgesics
  • Antimicrobials
  • Sedatives

With careful attention to the special needs, quality dental care can be provided while the potential risk to mother and child is minimized.

The management of this patient may require alteration in the timing and type of dental treatment but by no means should any necessary treatment be postponed until after partition (birth), Pregnancy is a temporary condition and elective treatment can be delayed. Pain infection and trauma must be treated immediately.

Treatment Timing

The second trimester is the safest period for routine dental care. During the first trimester, organogenesis and the teratogenecity of drugs must be considered. During the later period the patient is easily fatigued and may experience supine hypotensive syndrome.

Dental Radiography

Dental radiography, minimized staff, patient and fetal exposure by use of lead aprons, high speed film, beam collimation and the taking of films only when necessary. X-rays are taken only when it is essential to making a diagnosis and formulating a treatment plan. Use only when necessary and appropriate.

1-2 intraoral films are truly of no significance in terms of radiation effects to the developing fetus… in fact gonadal and fetal radiation is virtually immeasurable

Drug Administration

The principle concern is that a drug may cross the placenta and be toxic or teratogenic to the fetus. Ex. Any drugs which are a respiratory depressant can cause fetal hypoxia. Fortunately, most of the commonly used drugs in dentistry can be given with relative safety.

FDA pregnancy risk factor definitions Categories A – D and category X

The option of not administering any drugs is often not in the patients best interests.

Ideally, the cause of pain is the treatment with local anesthetic and drainage rather than administering analgesics / antimicrobials systemically because the fetus with immature development may not be capable of adequate metabolism and excretion of the drugs.

  1. Local anesthetic
  • Safe to administer while pregnant or nursing
  • Lidocaine and prilocaine category B
  • Mipivacaine category C
  • The low likelihood of systemic absorption of topical preparations minimizes any potential effect on the fetus
  • No adverse fetal effects to the use of vasoconstrictors
  1. Analgesics
  • Acetaminophen has a B rating … the analgesic of choice
  • ASA may result in anemia, hemorrhage and prolonged labour… C rating in the first two trimesters but a D risk factor in the last trimester
  • For lactating patients, use ASA cautiously
  • NSAIDS are very similar to ASA
  • Opioids considered ok in lower therapeutic doses for a short duration
  • Avoid codeine in the first trimester
  • Chronic use can result in fetal dependence, premature birth and growth retardation
  • Codeine and oxycodone are considered safe during lactation
  1. Antimicrobials
  • Not a substitute for local measures
  • Continue to use protocol for prophylactic use
  • One form of erythromycin may cause hepatitis
  • Penicillins are safe
  • Tetracyclines are contraindicated – tooth staining
  • 50% of infants given tetracycline in utero after 14 – 16 weeks of gestation showed tooth discolouration
  • Found in breast milk, may result in allergic reactions and GI upset - > diarrhea
  • the antifungals are safe esp. nystatin but keloconzol is contraindicated during breast feeding
  1. Sedatives
  • N2O is controversial. Teratogenic?
  • Never proven in humans
  • May cause vasoconstriction, hence may reduce blood flow
  • If it has to be given:
  • In the second trimester
  • Less than 30 min
  • At least 50% oxygen

Benzodiazepine use is controversial. A choice especially when used chronically can result in depression and / or dependence in the neonate. Benzodiazepine intake during breast feeding may result in significance sedation of the newborn.

Oral Complications

  • Pregnancy Gingivitis / Pregnancy Tumors
  • Generalized tooth mobility
  • Dental caries
  • Tooth erosion
  • ‘for every child a tooth’
  • Extrinsic staining due to iron supplements

Management Considerations

  • An emotional time, so be open and honest to reduce stress
  • Plaque control program to reduce the exaggerated inflammatory response
  • Late in pregnancy, short appts, semi-inclined position, pillow under right side and encourage frequent changes in position
  • Emergency care for supine orthostatic hypotension
  • Avoid extensive reconstruction and surgical procedures
  • X-rays only if absolutely necessary
  • Remember pregnancy is temporary

Managing Medical Emergencies in the Dental Office

Life threatening emergencies do occur in the practice of dentistry; it is estimated that we will experience at least one life-threatening crisis during our years of dentistry / DH.

Until now, in this course, we have focused on prevention, but when the emergency occurs, despite our efforts, we must recognize and manage the emergency.

Factors Which Increase the Rate at Which Emergencies Occur

  1. increase in the number of elderly patients
  2. advantages made by medical profession
  3. longer dental appointments
  4. increase in the use of drugs

It is thought that the majority of emergencies were precipitated by the increased stress that is so often present in the patient in the dental environment… results from fear and anxiety and inadequate pain control.

Specific Emergencies

  • unconsciousness
  • altered consciousness
  • seizures
  • respiratory distress
  • allergy
  • chest pain
  • Local anesthetic overdose

Management of emergencies should be based on the concept of simplicity.

5 steps are to be followed in sequence:

  • Position of pt
  • Airway
  • Breathing
  • Circulation
  • Definitive care
  • Diagnosis of problem
  • Drug therapy
  • Seek assistance

Measures taken to ensure preparedness.

  • BLS courses
  • In-office emergency response team
  • Keep well informed about outside emergency assistance
  • Have emergency drugs and equipment available

Specific Emergencies

Unconsciousness

Lack of response to sensory stimulation. Syncope is the most common emergency in dental practice as the fight or flight response directs blood to the skeletal muscles and cerebral blood flow decreases.

Pre-syncope Signs and Symptoms

  • Pallor
  • Nausea
  • Sweating
  • Feeling dizzy
  • Feeling faint
  • Hyperventilation (use verbal sedation)
  • Postural hypotension

Position: supine with feet elevated 10 – 15 degrees.

Airway: head-tilt chin-lift to ensure open airway

Breathing: usually present… if not, give 2 full breaths

Circulation: pulse should be present (usually brachardia) 20 – 30 minutes

Patient usually regains consciousness in 10 – 15 seconds.

Definitive Care:

  • Loosen tight clothing
  • Administer oxygen
  • Aromatic ammonia
  • Postpone treatment, make certain patient doesn’t drive
  • Activation of EMS rarely necessary
  • If unconsciousness is greater than 15 seconds call EMS
  • Poor airway management may lead to seizures
  • Healthy children do not faint

Altered Consciousness; a Conscious Patient Acting Strangely

Causes:

  • Stroke
  • Hyper or hypothyroidism
  • Hypoglycemia and the use of many drugs
  • It is easy to thing that they patient is inebriated but there is no alcohol on breath
  • *severe hypoglycemia may lead to seizures

Position: upright semi-reclined

Airway: no concern

Breathing: adequately maintained by patient

Circulation: no concern

Definitive Care

Check medical history. Is there a medic-alert bracelet? Has patient taken insulin today?

  • Administer sugar orally
  • If everything resolves continue treatment
  • Patient may be dismissed alone
  • If symptoms do not resolve after oral sugar call EMS
  • If consciousness is lost, repeat procedures for the unconscious patient and call EMS

Important Points

  • Never administer oral sugar to an unconscious patient
  • Whenever a diabetic patient exhibits the signs and symptoms listed above assume hypoglycemia and administer sugar rich liquids.

Seizure

Generalized skeletal muscle contractions. Epileptic patients. Local Anesthetic overdose.

Position: unconscious

Airway: usually maintained by patient

Breathing: usually adequate

Circulation: adequately maintained by patient

Definitive Care

  • Activate EMS procedure when seizure begins.
  • Gently protect from injury
  • No restraining patients movement
  • Do not put anything in their mouth

Management of the Post Seizure Phase

Respiratory Distress

A conscious patient having difficulty breathing.

Causes

  • Usually bronchospasm, the acute manifestation of asthma
  • Aspiration of dental restorative material

Management

Position: upright

ABC: adequate

Definitive Care

  • Administer bronchodilator
  • Episode usually terminates
  • Administer oxygen if cyanosis appears

Chest Pain

Causes

  • Angina pectoralis
  • Acute myocardial infarction

Position: upright

Definitive Care

Administer nitroglycerine. Pain alleviated in 1 – 3 minutes. If chest pain is alleviated by nitroglycerine… then returns -> Acute MI

Upright position

Oxygen via nasal cannula

Summon EMS

Administer Nitro

Pain and anxiety control with nitrous and oxygen (35-65%)