Medical MGMT of Dental Patients

Welcome Back to
Another Great Year!
The Medical Management of

Dental Patients
Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Group Group
I. The ASA Classification

Topics of Discussion
I – normal, healthy, ages 5-60
ASA Classifications II – mild systemic disease w/o limits,
Abx Prophylaxis age >60
Top 20 drugs III – moderate-severe systemic
disease, limits activities
Oral Manifestations
IV – severe systemic disease,
Drug Metabolism constant threat to life
Bisphosphonates V – morbid, risk of death w/ in 24hrs or
w/o operation
VI – organ donor

Group Group
ASA Examples Imagine scaling these

babies!!
II – controlled HTN or diabetes
III – stable angina, diabetes w/
systemic sequeale
IV- severe CHF, ESRD

Group Group
Oral Medications 1
Goals of AP
To prevent post-tx microbial
II. Antibiotic Prophylaxis (AP)
complications (local)
To diminish bacterial metastatic

infections (distant)
– Review compliments of Dr. B.C. Muzyka @ LSU

Group Group
Principles of AP Principles of AP
Benefit>risk Choice of abx based on single
Abx must be present in most likely organism to cause
blood/target tissue before infection
organism entry Must be a favorable cost:benefit
Loading dose of abx must be used

Group Group
Potential Harm…
Potential Harm
Incr risk of abx-induced allergy
Incr risk of super infection
Selection of abx resistant micro-
organisms
Encouragement of less meticulous
surgery/dentistry ?

Group Group
Oral Medications 2
Dental Procedures
Extractions (51- Dental prophy (0-
58%) 40%)
Incidence of Bacteremia Perio surg (36- Endo (0-15%)
88%)
Sc/rp (8-80%)

Group Group
Daily Exposure
It’s All Relative….
Brushing (0-26%) Irrigation device
Flossing (20- ( 7-50%)
58%) Toothpicks (20-
Chewing (17- 40%)
51%)

Group Group
Understanding Heart Heart Murmurs

Murmurs
Sounds produced by turbulent blood flow
Physiologic- innocent or functional-No
Abx prophylaxis required
Pathologic- risk for endocarditis- Abx
prophylaxis required
Causes: stenosis- incompetent
valves, vegetations or deformities of
the septa

Group Group
Oral Medications 3
Chain of Events Bacteria
Endothelial Vegetations 2,345 cases from
damage colonized by 1933-1987
Platelet circulating bact → Strep (56.4%)
aggregation thrombosis Staph ( 24.9%)
Fibrin deposit Replication
Nodular sterile Enlargement of
vegetations thrombosis

Group Group
Your Role
Ask pt if he/she
Remember… had a consult w/
MD to determine
It is inappropriate to type and
significance of
prescribe Abx w/o Good murmur
Cause! It is YOUR team’s
obligation to
determine
whether the pt
requires Abx
coverage
Group Group
Your Role as the My Role

Captain
If in doubt,
cover the pt and
then send the pt
to his/her MD to
determine the
pathology
Cianciola & Beach Periodontal

Group
Oral Medications 4
High Risk- Abx Recommended
Prosthetic heart valves
Endocarditis Aortic valve disease

Mitral insufficiency
Prophylaxis Categories
Patent ductus arteriosus

Ventricular septal defect (VSD)
Coarcation of the aorta
Previous episode of endocarditis
Surgically constructed pulmonary shunts

Group Group
Moderate Risk- Abx Negligible Risk- Abx Not

Recommended Recommended
Patent ductus arteriosus Isolated secundum ASD
VSD Surgical repair of ASD
Primary atrial septal defect (ASD) VSD or patent ductus arteriosus w/o
Coarcation of the aorta residua beyond 6mo
Bicuspid aortic valve Previous CABG
Acquired valvular dysfunction (RF) MVP w/o regurgitation
Hypertrophic cardiomyopathy Physiologic HM
MVP w/regurgitation and/or thickened RF w/o valvular dysfunction
leaflets Pacemakers and defibrillators

Group Group
AHA Abx
Recommendations How Can You Help?
Amox 2g PO 1hr prior
($1.50) Good oral hygiene reduces the
Clindamycin 600mg PO likelihood of infective
1hr ($3.88) endocarditis and other
Cephalexin 2g PO 1hr bacteremias in the at risk pts
($2.14)
Azithromycin 500mg PO
1hr ($18)
Clarithromycin 500mg
PO 1hr ($5.10)

Group Group
Oral Medications 5
Prosthetic Joints Life truly is a Beach!
All pts during the 1st 2yrs post-op
Immunocompromised pts
Pts w/ co-morbidities
Previous joint infection
Hemophilia
HIV
Type I Diabetes
Malignancy

Group Group
Drugs 1-10
Vicodin
III. The Top 20 Most Lipitor
Prescribed Drugs…

Synthroid
Atenolol
Amoxicillan
Lisinopril
HCTZ
Furosemide
Albuterol inhaler
Alprazolam (Xanax)- anxiety
Group Group
Drugs 11-20 Heart Disease Meds

Norvasc
Zoloft HCTZ, furosemide, triamterene =
Z-Pak diuretics
Toprol XL Lisinopril- After load reducing
Cephalexin agent (ACE inhibitor)
Darvocet Atenolol- β-blocker
Zocor Norvasc, Toprol- Ca2+ channel
Prevacid blocker
Ibuprofen
Zocor- cholesterol lowering agent
Triamterene;HCTZ
Group Group
Oral Medications 6
New Medications Drug References
Why are Med Hx updates important? ADA Guide to Dental Therapeutics
There are about 20-30 new meds www.ada.org/prof/resources/pubs
introduced each year!
Pts are living longer
Drug Information Handbook for
Pts are taking more meds
Dentistry
There are more than 800 generic drugs
There are more than 2,500 brand name
drugs!
DiMatteo 2006

Group Group
Patient Expectations What can Dentists

Prescribe?
Pts expect to be relatively pain-free We are mandated to prescribe
What amount of pts report being meds only for conditions and
dental phobic? diseases w/in our scope of practice
Only 15% Dentists are now writing more Rxn
Despite new meds and techniques, than we did in the past
% has stayed about the same for
the past 15-20yrs
DiMatteo 2006

Group Group
“The survey says…” Moore et al. 2006 Survey

For 3rd molar extractions:
46% use general anesthesia
33% use IV conscious sedation
6% use nitrous oxide
2% use oral sedation
13% local anesthetic alone

Group Group
Oral Medications 7
IV. Drugs and Oral Xerostomia
Manifestations
Antidepressants/antipsychotics
Antihypertensives
Can you hit the
target but still not Antihistamines
win? Anticholinergics
Decongestants

Group Group
Nonspecific Ulcerations Lichen Planus

Antineoplastics (methotrexate)
Barbituates (Phenobarbital)
Dapsone
Salicylates
Sulfonamides
TCN
Direct contact w/ aspirin, peroxide
or phenol
Group Group
Lichen Planus LP Histology

Hyperkeratosis
Band of
inflammatory
infiltrate

Group Group
Oral Medications 8
LP Histology Lichenoid Lesions
Epithelium-R Allopurinol
CT-L Antimalarials
Lymphocytes
attacking
Beta-blockers
Bismuth / Pepto-Bismol
Catopril (ACE inhibitor)
Carbamazepine / Tegretol
Chlorothiazide
Cimetidine / Tagament
Group Group
Please tell us more!

Lichenoid Lesions
Chlorpropamide Sprionolactone
Dapsone Sulfonylureas
Furosemide Streptomycin
Gold salts Tetracycline
Ketoconazole Tolbutamide
Phenithiazine Triprolidine
Cianciola & Beach Periodontal

Group
Erythema-multiforme Erythema-multiforme

Group Group
Oral Medications 9
Erythema-multiforme BMMP Lesion
Like Lesions
Sulfonamides Bullae
Penicillins Ulcers
Pain
Barbituates
Salicylates

Group Group
BMMP and the Eyes BMMP Histology
Subepithelial
clefting
Epi peels away
from CT
Auto Ab vs. the
basement
membrane

Group Group
Pemphigoid-like Lesions Pemphigus Vulgaris

Ibuprofen
Furosemide
Catopril
Clonidine (alpha2-adrenergic for HTN)
Penicillan, sulfonamides
Antimicrobials
Thiol-containing drugs

Group Group
Oral Medications 10
(Insert cute picture here) Pemphigus Vulgaris
Skin or mucosa
Large bullae,
rupture, ulcers
Remission
uncommon
Can be lethal

Group Group
Pemphigus Histology Pemphigus-like Lesions

Stratum Ampicillin Penicillamine
spinosum Catopril Phenonbarbitol
pulled away
Basal cell layer Cephalexin Practolol
still attached to Heroine Propranolol
CT Ibuprofen Rifampin
Intraepithelial
clefting
Tombstone
appearance

Group Group
Lupus Lupus-like lesions

Autoimmune system
attacks organs or cells
Leads to damage and
Carbamazepine Penicillamine
dysfunction
Butterfly rash Chlorpromazine Procainamide
Isoniazid Quinidine
Lithium Reserpine
Methyldopa Streptomycin
Thiouracils

Group Group
Oral Medications 11
Nonspecific Vesiculo-
ulcerative Mucositis Oral Pigmentation
Minocycline
NSAIDs, Naproxen pigmentation
Methyldopa
Penicillamine
Propranolol
Spironolactone
Thiazides
Tolbutamide

Group Group
Oral Pigmentation Pigmentation

Minocycline
pigmentation Antimalarials
Bisulfan
Estrogen
Ketoconazole
Minocycline
Tranquilizers
Zidovudine

Group Group
Gingival Overgrowth Gingival Overgrowth

Group Group
Oral Medications 12
Post-Surgical Gingival Overgrowth
Calcium channel blockers
Cyclosporine
Phenytoin
Sodium valproate

Group Group
V. Drug Metabolism Hepatic Functions

Glucose homeostasis
Vitamin storage (D,A,K,E)
Biotransformation of compounds
Detoxification of drugs, metabolites
and hormones

Group Group
Hepatic Failure Cirrhosis Etiology

Massive liver necrosis 3 categories we see the most:
Cirrhosis Alcohol
Functional failure w/o necrosis Viral Hepatitis
Biliary diseases

Group Group
Oral Medications 13
Alcoholic Liver Disease Alcoholic Liver Disease:
How much does it take?
Steatosis- fatty change (>80%) Males-40g
Usually asymptomatic, reversible Females-lower threshold
Alcoholic hep (10-15%) How many beers?
After an acute bout of drinking 3 beers (15g ETOH each)
May be reversible, may progress How many glasses of wine?
Cirrhosis (10-15%) 2 glasses (18g ETOH each)
Irreversible and lethal if no liver How much liquor?
transplant done
2 drinks (17g ETOH each)
Group Group
This is what happens when

kids have too much! Medical History
Important questions to ask:
Hx of jaundice?
Any liver disease in the family?
Any recent travel (parasites, hep)?
Any exposure to animals/others w/liver

disease?
Sexual Promiscuity-STD, HIV
IDU or nasal drug use?
ETOH habits?
Drugs?

Group Group
Don’t forget to ask about Acetominophen Induced

Acetaminophen use! Liver Toxicity
Susceptibility
“Witch”
patient is Chronic ETOH use
telling the Older age
truth? Use of other CYP-450 inducers
Nutritional status
Key events
Treatment

Group Group
Oral Medications 14
Acetominophen Induced VI. Bisphosphonates
Liver Toxicity
Key events
Rate of toxic metabolites >detox
Cell death via disruption of Ca2+
homeostasis
Treatment
N-acetylcysteine w/in 10hrs
Oral or IV

Group Group
Where to Look for more Osteonecrosis of the

Information: Jaw (ONJ)
AAP web site A condition observed in cancer pts
www.perio.org who undergo invasive procedures
Extractions
Implants

Group Group
Bisphosphonates Osteoporosis
Bone sparing drugs Low or decreasing bone mass
Used to tx osteoporosis and bone Increased risk for bone fractures
cancer Risk factors:
IV tx for cancer pts to decrease Smoking
pain and fracture associated w/ Age
bone cancer Medications
Systemic disease

Group Group
Oral Medications 15
AAP’s Position Who can get ONJ
AAP Clinical Statement on Cancer pts that are:
Bisphosphonates Females
Older
AAP Press Release on Serious
Edentulous regions
Oral Post-surgical Complications
Combo cancer therapy
associated w/ IV Bisphosphonates
Blood dyscrasias / metastatic disease
FDA’s statement may be viewed
Anemia coagulopathy
from this site, too
Surgical dental procedures
Prior infection

Group Group
Treatment Options Bone Loss & Periodontal

Disease
For pts on IV tx, try to avoid A chronic bacterial infection
invasive procedures Releases toxins that cause
Try to tx pt before IV therapy starts redness and inflammation
Toxins damage the bone support
and may → tooth loss
The infection can travel through
the body

Group Group
Periodontal Disease and Review of Topics

its Links
This disease has been linked to other ASA Classifications
inflammatory conditions: Abx Prophylaxis
Cardiovascular disease Top 20 drugs
Diabetes Oral Manifestations
PTLBW babies Drug Metabolism
Bisphosphonates

Group Group
Oral Medications 16
Thank you, it’s been a
whale of a time!
Oral Medications 17

Medical MGMT of Dental Patients

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Welcome Back to

Another Great Year!

The Medical Management of

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

I. The ASA Classification

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

ASA Examples Imagine scaling these

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

To diminish bacterial metastatic

– Review compliments of Dr. B.C. Muzyka @ LSU

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Understanding Heart Heart Murmurs

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Your Role as the My Role

Cianciola & Beach Periodontal

Endocarditis Aortic valve disease

Patent ductus arteriosus

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Moderate Risk- Abx Negligible Risk- Abx Not

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Drugs 11-20 Heart Disease Meds

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Patient Expectations What can Dentists

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

“The survey says…” Moore et al. 2006 Survey

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Nonspecific Ulcerations Lichen Planus

Lichen Planus LP Histology

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Please tell us more!

Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

BMMP and the Eyes BMMP Histology

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Pemphigoid-like Lesions Pemphigus Vulgaris

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Pemphigus Histology Pemphigus-like Lesions

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Lupus Lupus-like lesions

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Oral Pigmentation Pigmentation

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Gingival Overgrowth Gingival Overgrowth

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

V. Drug Metabolism Hepatic Functions

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

Hepatic Failure Cirrhosis Etiology

Functional failure w/o necrosis Viral Hepatitis

Cianciola & Beach Periodontal Cianciola & Beach Periodontal

This is what happens when