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Dental.EliteCME.com Page i Table of Contents CE for Ohio Dental Professionals All 40 hours CHAPTER 1: CANCER TREATMENT AND ORAL CARE Page 1 only This chapter provides information to dental professionals about steps they can take before, during and after patient cancer treatment to reduce the risk and impact of these often-painful side effects. It is essential that a multidisciplinary approach be used for oral management of the cancer patient $ before, during and after cancer treatment because the medical complexity of these patients affects dental treatment planning, prioritization and timing of dental care. 149 Cancer Treatment and Oral Care Final Exam Page 44 CHAPTER 2: A DENTAL PROFESSIONAL’S FIELD GUIDE TO SUBSTANCE ABUSE Page 45 Upon completion of this course, you will be able to list the most common oral symptoms of illegal What if I Still Have drug use, the most common oral cancerous and precancerous conditions associated with cigarette Questions? smoking, as well as common characteristics and strategies of drug-seeking behavior. No problem, we have several A Dental Professional’s Field Guide to Substance Abuse Final Exam Page 73 options for you to choose from! Online at Dental.EliteCME. CHAPTER 3: MEDICAL EMERGENCIES IN THE DENTAL OFFICE Page 75 com you will see our robust FAQ In this course, we will discuss common emergencies that one might encounter when interacting section that answers many of with dental patients, as well as steps that should be taken to ensure that all of the bases are your questions, simply click FAQ covered, including responsibilities, safety measures, and accident prevention. in the upper right hand corner or Medical Emergencies in the Dental Office Final Exam Page 88 Email us at [email protected] CHAPTER 4: PERIODONTITIS AND SYSTEMIC HEALTH CONDITIONS Page 89 or call us toll free at 1-866-344-

Many health conditions and diseases are impacted by the presence and severity of periodontitis. 0972, Monday - Friday 9:00 am Oral healthcare providers should understand the relationship of disease conditions associated with - 6:00 pm, EST. periodontal disease. Periodontitis and Systemic Health Conditions Final Exam Page 96 CHAPTER 5: SEDATION AND AIRWAY MANAGEMENT IN THE DENTAL OFFICE Page 97

The decision to use sedation to accomplish dental treatment cannot be arrived at lightly. Dentists must review and discuss the many variables. Proper diagnosis and evaluations must be made. An Visit Dental.EliteCME.com to organized, methodical, and systematic approach is necessary to provide quality dental care. view our entire course library and Sedation and Airway Management in the Dental Office Final Exam Page 112 get your CE today! CHAPTER 6: TOPICS IN PEDIATRIC DENTISTRY Page 113

While the dental professional’s primary objective is always to facilitate optimum oral health for the patient through the best prevention and treatment methods, practitioners working with children also have the priority of creating a positive formative experience, placing additional emphasis on establishing a safe, comfortable atmosphere, communicating the importance of proper dental care, PLUS... and paving the way for lifelong positive dental experiences. Lowest Price Guaranteed Topics in Pediatric Dentistry Final Exam Page 139 Serving Professionals Since 1999 CHAPTER 7: UPDATES ON LASER THERAPY IN DENTISTRY AND INTEGRATION IN THE DENTAL OFFICE Page 141 This course will review the latest developments in dental laser application and will provide evidence for its multitude of benefits in general dentistry. It will discuss the practical application and integration of lasers in dental offices. The science behind lasers, and the types of lasers available in the market and their specific dental applications, will also be reviewed. Elite Updates on Laser Therapy in Dentistry and Integration in the Continuing Education Dental Office Final Exam Page 156

©2017. All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Elite Professional Education, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional advice. Elite Professional Education, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Elite Professional Education, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.

Page ii Dental.EliteCME.com Chapter 1: Cancer Treatment and Oral Care

10 CE Hours

By: Elite Staff

Learning objectives ŠŠ List common side effects of cancer treatment that affect the ŠŠ Describe the identification and management of oral mucositis in mouth. patients undergoing cancer treatment. ŠŠ List risk factors for oral cancer that have been associated with its ŠŠ Discuss issues associated with specific types of orofacial pain in increase in recent years. cancer patients, including barriers to effective pain management. ŠŠ Identify oral complication common to both chemotherapy and ŠŠ Discuss treatment protocol for bacterial, fungal and viral infections radiation, and those associated with each treatment alone. and cancer treatment. ŠŠ List the steps of oral care pretreatment for the patient about to ŠŠ Describe the condition and management of oral graft-vs.-host undergo cancer treatment. disease (GVHD). ŠŠ List the steps of oral care during treatment for the patient ŠŠ Describe the causal mechanisms, diagnosis and management of undergoing cancer treatment. biphosphonate-associated osteonecrosis (BON). ŠŠ List the steps of follow-up oral care for the patient after ŠŠ List and distinguish between early vs. late complications of head completing cancer treatment, distinguishing among post- and neck radiation. chemotherapy, radiation and transplant procedures. ŠŠ Describe potential late dental effects of treatment for childhood ŠŠ List oral complications of hematopoietic stem cell transplantation. cancer. ŠŠ List guidelines for management of dentures and orthodontic ŠŠ List questions to ask the medical and radiation oncologists before, appliances in patients receiving high-dose cancer therapy. during and after patient cancer treatment.

Introduction Most people are aware of common side effects of cancer treatment While oral complications may mimic selected systemic disorders, like nausea and hair loss. But many don’t realize that more than unique oral toxicities emerge in the context of specific oral anatomic one-third of people treated for cancer develop complications that structures and their functions. affect the mouth. These problems may interfere with cancer treatment This chapter provides information to dental professionals about and diminish the patient’s quality of life. Head and neck radiation, steps they can take before, during and after patient cancer treatment chemotherapy and blood and marrow transplantation can cause oral to reduce the risk and impact of these often-painful side effects. complications ranging from dry mouth to life-threatening infections. It is essential that a multidisciplinary approach be used for oral Aggressive treatment of malignant disease may produce unavoidable management of the cancer patient before, during and after cancer toxicities to normal cells. The mucosal lining of the gastrointestinal treatment because the medical complexity of these patients affects tract, including the oral mucosa, is a prime target for treatment-related dental treatment planning, prioritization and timing of dental care. toxicity by virtue of its rapid rate of cell turnover. The oral cavity In addition, selected cancer patients (e.g., status post-treatment with is highly susceptible to direct and indirect toxic effects of cancer high-dose head-and-neck radiation) are often at lifelong risk for chemotherapy and ionizing radiation [132]. This risk results from serious complications such as osteoradionecrosis of the mandible. multiple factors, including high rates of cellular turnover for the lining Thus, a multidisciplinary oncology team that includes oncologists, mucosa, a diverse and complex microflora, and trauma to oral tissues oncology nurses and dental generalists and specialists as well as dental during normal oral function [122]. Although changes in soft tissue hygienists, social workers, dieticians and related health professionals structures within the oral cavity presumably reflect the changes that can often achieve highly effective preventive and therapeutic outcomes occur throughout the gastrointestinal tract, this summary focuses on relative to oral complications in these patients. oral complications of anti-neoplastic drugs and radiation therapies.

Organization of the chapter The chapter is divided into the following parts: conditions lead to secondary complications, such as dehydration, ●● Part I: Basics of lip and oral cavity cancers provides statistics dysgeusia, and malnutrition or systemic infection. Additionally, and background for the chapter, including an introduction to radiation of the head and neck can cause irreversible injury, cancer stages and prognoses. resulting in xerostomia, rampant dental caries, trismus, soft tissue ●● Part II: The role of the dental team in cancer care and necrosis and osteonecrosis. treatment discusses strategies for preventing and managing ●● Part IV: Dentists’ oncology – in brief provides a quick complications common to a patient’s cancer treatment, as well as reference on treating patients before, during and after cancer the role of dental professionals before, during and after treatment. treatment, including questions to ask the patient’s oncology team ●● Part III: Types and prevalence of oral complications reviews before cancer treatment begins and a quick reference for oral the most common oral complications related to cancer therapies, complications from cancer treatment. including mucositis, infection, salivary gland dysfunction, taste ●● Part V: Resources for patients provides links to fact sheets and dysfunction and pain. The section also addresses how these further information for distribution to patients.

Dental.EliteCME.com Page 1 ●● Appendix: Levels of evidence is a guide to the level-of-evidence Institute at the National Institutes of Health used in level-of- designations accompanying reference citations throughout this evidence designations. chapter. These designations are intended to help readers assess Unless otherwise stated, this course discusses evidence and practice the strength of the evidence supporting the use of specific issues as they relate to adults. The evidence and application to practice interventions or approaches. This section discusses the formal for children may differ significantly from that for adults. When specific evidence-ranking system developed by the National Cancer information about the care of children is available, it is summarized under its own heading.

Part I: Basics of lip and oral cavity cancers An estimated 40,250 new cases of oral cancer will be diagnosed in the related to human papillomavirus (HPV) infection [6]. About 60 percent United States in 2012, and an estimated 7,850 people will die of the of oral/pharyngeal cancers are moderately advanced (regional stage) disease. This form of cancer accounts for about 3 percent of cancers or metastatic at the time of diagnosis [261]. The estimated annual in men and 1.5 percent of cancers in women [6]. Oral cancer occurs worldwide number of incident oral cancers is about 275,000, with an more frequently in blacks than in whites [214, 261]. The overall approximately 20-fold variation geographically [281]. annual incidence in the United States is about 10.4 per 100,000 men South and Southeast Asia (India, Sri Lanka, Pakistan and Bangladesh), and women; the median age at diagnosis of oral cavity or pharyngeal France and Brazil have particularly high rates. In most countries, men cancer was 62 years from 2003 to 2007 [261]. have higher rates of oral cancer than women (due to tobacco use) Incidence has been falling in men since 1975 and in women since and higher rates of lip cancer (due to sunlight exposure from outdoor 1980. However, incidence has recently been increasing for oral cancers occupations [281].

Risk factors The primary risk factors for oral cancer in American men and women with HPV-16 has been associated with an excess risk of developing are tobacco (including smokeless tobacco) and alcohol use. Infection squamous cell carcinoma of the oropharynx [167].

Evidence of benefit associated with screening There are different methods of screening for oral cancers. Oral cancer An oral examination often includes looking for leukoplakia and occurs in a region of the body that is generally accessible to physical erythroplakia lesions, which can progress to cancer [280, 31]. examination by the patient, the dentist and the physician, and visual One study has shown that direct fluorescence visualization (using examination is the most common method used to detect visible lesions. a simple hand-held device in the operating room) could identify Other methods have been used to augment clinical detection of oral subclinical high-risk fields with cancerous or precancerous changes lesions and include toluidine blue, brush biopsy and fluorescence extending up to 25 mm beyond the primary tumor in 19 of 20 patients staining. undergoing oral surgery for invasive or in situ squamous cell tumors An inspection of the oral cavity is often part of a physical examination [205]. However, this finding has not yet been tested in a screening in a dentist’s or physician’s office. It has been pointed out that high- setting. Data suggest that molecular markers may be useful in the risk individuals visit their medical doctors more frequently than they prognosis of these premalignant oral lesions [206]. visit their dentists. Although physicians are more likely to provide The routine examination of asymptomatic and symptomatic patients risk-factor counseling (such as tobacco cessation), they are less likely can lead to detection of earlier stage cancers and premalignant lesions. than dentists to perform an oral cancer examination [124]. There is no definitive evidence, however, to show that this screening Overall, only a fraction (about 20 percent) of Americans receive an can reduce oral cancer mortality, and there are no randomized oral cancer examination. Black patients, Hispanic patients, and those controlled trials (RCT) in any Western or other low-risk populations who have a lower level of education are less likely to have such an [31, 82, 9, 267, 231]. examination, perhaps because they lack access to medical care [124].

Location The oral cavity extends from the skin-vermilion junctions of the ●● Retromolar trigone. anterior lips to the junction of the hard and soft palates above and ●● Upper gingiva. to the line of circumvallate papillae below and is divided into the ●● Hard palate. following specific areas: The main routes of lymph node drainage are into the first station nodes ●● Lip. (i.e., buccinator, jugulodigastric, submandibular and submental). ●● Anterior two thirds of tongue. Sites close to the midline often drain bilaterally. Second station nodes ●● Buccal mucosa. include the parotid, jugular and the upper and lower posterior cervical ●● Floor of mouth. nodes. ●● Lower gingiva.

Stage and prognosis Early cancers (stage I and stage II) of the lip and oral cavity are highly 5 mm significantly increases the risk of local recurrence and suggests curable by surgery or by radiation therapy, and the choice of treatment that combined modality treatment may be beneficial [115, 204]. is dictated by the anticipated functional and cosmetic results of Advanced cancers (stage III and stage IV) of the lip and oral cavity treatment and by the availability of the particular expertise required of represent a wide spectrum of challenges for the surgeon and radiation the surgeon or radiation oncologist for the individual patient [50, 95, oncologist. Except for patients with small T3 lesions and no regional 277]. The presence of a positive margin or a tumor depth of more than lymph node and no distant metastases or who have no lymph nodes larger than 2 cm in diameter, for whom treatment by radiation therapy

Page 2 Dental.EliteCME.com alone or surgery alone might be appropriate, most patients with stage cancers of the lip, which are highly curable by surgery or by radiation III or stage IV tumors are candidates for treatment by a combination therapy with cure rates of 90 percent to 100 percent. Small cancers of of surgery and radiation therapy [95]. Furthermore, because local the retromolar trigone, hard palate, and upper gingiva are highly curable recurrence or distant metastases are common in this group of patients, by either radiation therapy or surgery with survival rates of as much they should be considered for clinical trials. Such trials evaluate the as 100 percent. Local control rates of as much as 90 percent can be potential role of radiation modifiers or combination chemotherapy achieved with either radiation therapy or surgery in small cancers of the combined with surgery and radiation therapy. anterior tongue, the floor of the mouth and buccal mucosa [276]. Patients with head and neck cancers have an increased chance of Moderately advanced and advanced cancers of the lip also can be developing a second primary tumor of the upper aerodigestive tract controlled effectively by surgery or radiation therapy or a combination [58, 271]. A study has shown that daily treatment of these patients of these. The choice of treatment is generally dictated by the anticipated with moderate doses of isotretinoin (13-cis-retinoic acid) for one year functional and cosmetic results of the treatment. Moderately advanced can significantly reduce the incidence of second tumors. No survival lesions of the retromolar trigone without evidence of spread to cervical advantage has yet been demonstrated, however, in part due to recurrence lymph nodes are usually curable and have shown local control rates of and death from the primary malignancy. An additional trial has shown as much as 90 percent; such lesions of the hard palate, upper gingiva no benefit of retinyl palmitate or retinyl palmitate plus beta-carotene and buccal mucosa have a local control rate of as much as 80 percent. when compared to retinoic acid alone [186] [Level of evidence: 1]. In the absence of clinical evidence of spread to cervical lymph nodes, The rate of curability of cancers of the lip and oral cavity varies moderately advanced lesions of the floor of the mouth and anterior depending on the stage and specific site. Most patients present with early tongue are generally curable with survival rates of as much as 70 percent and 65 percent, respectively [276, 262].

Part II: The role of the dental team in cancer care and treatment With more than 1.4 million new cases of cancer diagnosed each year and quality of life, and affect their ability to complete planned cancer and a shift to outpatient management, you will likely see some of treatment. For some patients, the complications can be so debilitating these patients in your practice. Because cancer and cancer treatment that they may tolerate only lower doses of therapy, postpone scheduled can affect the oral tissues, you need to know about potential oral side treatments, or discontinue treatment entirely. Oral complications can effects. Preexisting or untreated oral disease can also complicate also lead to serious systemic infections. Medically necessary oral care cancer treatment. Your role in patient management can extend benefits before, during and after cancer treatment can prevent or reduce the beyond the oral cavity. incidence and severity of oral complications, enhancing both patient Oral complications from radiation to the head and neck or survival and quality of life. chemotherapy for any malignancy can compromise patients’ health

Oral complications of cancer treatment Oral complications of cancer treatment arise in various forms and ○○ Taste alterations: Changes in taste perception of foods, degrees of severity, depending on the individual and the cancer ranging from unpleasant to tasteless. treatment. Chemotherapy often impairs the function of bone marrow, ○○ Nutritional compromise: Poor nutrition from eating suppressing the formation of white blood cells, red blood cells and difficulties caused by mucositis, dry mouth, dysphagia and loss platelets (myelosuppression). Some cancer treatments are described of taste. as stomatotoxic because they have toxic effects on the oral tissues. ○○ Abnormal dental development: Altered tooth development, Following are lists of side effects common to both chemotherapy and craniofacial growth or skeletal development in children radiation therapy, and complications specific to each type of treatment. secondary to radiotherapy or high doses of chemotherapy You will need to consider the possibility of these complications each before age 9. time you evaluate a patient with cancer. ●● Other complications of chemotherapy. ●● Oral complications common to both chemotherapy and ○○ Neurotoxicity: Persistent, deep aching and burning pain that radiation. mimics a toothache, but for which no dental or mucosal source ○○ Oral mucositis: Inflammation and ulceration of the mucous can be found. This complication is a side effect of certain membranes; can increase the risk for pain, oral and systemic classes of drugs, such as the vinca alkaloids. infection, and nutritional compromise. ○○ Bleeding: Oral bleeding from the decreased platelets and ○○ Infection: Viral, bacterial and fungal; results from clotting factors associated with the effects of therapy on bone myelosuppression, xerostomia or damage to the mucosa from marrow. chemotherapy or radiotherapy. ●● Other complications of radiation therapy. ○○ Xerostomia/salivary gland dysfunction: Dryness of ○○ Radiation caries: Lifelong risk of rampant dental decay the mouth due to thickened, reduced or absent salivary that may begin within three months of completing radiation flow; increases the risk of infection and compromises treatment if changes in either the quality or quantity of saliva speaking, chewing and swallowing. Medications other than persist. chemotherapy can also cause salivary gland dysfunction. ○○ Trismus/tissue fibrosis: Loss of elasticity of masticatory Persistent dry mouth increases the risk for dental caries. muscles that restricts normal ability to open the mouth. ○○ Functional disabilities: Impaired ability to eat, taste, swallow ○○ Osteonecrosis: Blood vessel compromise and necrosis of bone and speak because of mucositis, dry mouth, trismus and exposed to high-dose radiation therapy; results in decreased infection. ability to heal if traumatized.

Who has oral complications? Oral complications occur in virtually all patients receiving radiation nearly 40 percent of patients receiving chemotherapy. Risk for oral for head and neck malignancies, in approximately 80 percent of complications can be classified as low or high: hematopoietic (blood-forming) stem cell transplant recipients, and in

Dental.EliteCME.com Page 3 ●● Lower risk: Patients receiving minimally myelosuppressive or undergoing head and neck radiation for oral, pharyngeal and nonmyelosuppressive chemotherapy. laryngeal cancer. ●● Higher risk: Patients receiving stomatotoxic chemotherapy Some complications occur only during treatment; others, such as resulting in prolonged myelosuppression, including patients xerostomia, may persist for years. Unfortunately, patients with cancer undergoing hematopoietic stem cell transplantation; and patients do not always receive oral care until serious complications develop.

The role of pretreatment oral care A thorough oral evaluation by a knowledgeable dentist before ●● Provides an opportunity for patient education about oral hygiene cancer treatment begins is important to the success of the regimen. during cancer therapy. Pretreatment oral care achieves the following: ●● Improves the quality of life. ●● Reduces the risk and severity of oral complications. ●● Decreases the cost of care. ●● Allows for prompt identification and treatment of existing infections or other problems. With a pretreatment oral evaluation, the dental team can identify and ●● Improves the likelihood that the patient will successfully complete treat problems such as infection, fractured teeth or restorations, or planned cancer treatment. periodontal disease that could contribute to oral complications when ●● Prevents, eliminates or reduces oral pain. cancer therapy begins. The evaluation also establishes baseline data for ●● Minimizes oral infections that could lead to potentially serious comparing the patient’s status in subsequent examinations. systemic infections. Before the exam, you will need to obtain the patient’s cancer diagnosis ●● Prevents or minimizes complications that compromise nutrition. and treatment plan, medical history and dental history. Open ●● Prevents or reduces later incidence of bone necrosis. communication with the patient’s oncologist is essential to ensure ●● Preserves or improves oral health. that each provider has the information necessary to deliver the best possible care.

Evaluation Ideally, a comprehensive oral evaluation should take place one month ●● Consider extracting highly mobile primary teeth in children, and before cancer treatment starts to allow adequate time for recovery from teeth that are expected to exfoliate during treatment. any required invasive dental procedures. The pretreatment evaluation ●● Prescribe an individualized oral hygiene regimen to minimize includes a thorough examination of hard and soft tissues as well as oral complications. Patients undergoing head and neck radiation appropriate radiographs to detect possible sources of infection and therapy should be instructed on the use of supplemental fluoride. pathology. Also take the following steps before cancer treatment begins: ●● Identify and treat existing infections, carious and other Supplemental fluoride compromised teeth, and tissue injury or trauma. Fluoride rinses are not adequate to prevent tooth demineralization. ●● Stabilize or eliminate potential sites of infection. Instead, a high-potency fluoride gel, delivered via custom gel- ●● Extract teeth in the radiation field that are nonrestorable or applicator trays, is recommended. Several days before radiation may pose a future problem to prevent later extraction-induced therapy begins, patients should start a daily 10-minute application osteonecrosis. of a 1.1 percent neutral pH sodium fluoride gel or a 0.4 percent ●● Conduct a prosthodontic evaluation if indicated. If a removable stannous fluoride (unflavored) gel. Patients with porcelain crowns prosthesis is worn, make sure that it is clean and well adapted to or resin or glass ionomer restorations should use a neutral pH the tissue. Instruct the patient not to wear the prosthesis during fluoride. Be sure that the trays cover all tooth structures without treatment, if possible; or at the least, not to wear it at night. irritating the gingival or mucosal tissues. ●● Perform oral prophylaxis if indicated. For patients reluctant to use a tray, a high-potency fluoride gel ●● Time oral surgery to allow at least two weeks for healing should be brushed on the teeth following daily brushing and before radiation therapy begins. For patients receiving radiation flossing. Either 1.1 percent neutral pH sodium or 0.4 percent treatment, this is the best time to consider surgical procedures. stannous fluoride gel is recommended, based on the patient’s type Oral surgery should be performed at least seven to 10 days before of dental restorations. the patient receives myelosuppressive chemotherapy. Medical consultation is indicated before invasive procedures. Patients with radiation-induced salivary gland dysfunction must ●● Remove orthodontic bands and brackets if highly stomatotoxic continue lifelong daily fluoride applications. chemotherapy is planned or if the appliances will be in the radiation field.

Education Patient education is an integral part of the pretreatment evaluation and Advise patients to: should include a discussion of potential oral complications. It is very ●● Brush teeth, gums and tongue gently with an extra-soft toothbrush and important that the dental team impresses on the patient that optimal fluoride toothpaste after every meal and before bed. If brushing hurts, oral hygiene during treatment, adequate nutrition, and avoiding soften the bristles in warm water. tobacco and alcohol can prevent or minimize oral complications. To ●● Floss teeth gently every day. If gums are sore or bleeding, avoid ensure that the patient fully understands what is required, provide those areas but keep flossing other teeth. detailed instructions on specific oral care practices, such as how and ●● Follow instructions for using fluoride gel. when to brush and floss, how to recognize signs of complications, ●● Avoid mouthwashes containing alcohol. and other instructions appropriate for the individual. Patients should ●● Rinse the mouth with a baking soda and salt solution, followed by understand that good oral care during cancer treatment contributes to a plain water rinse several times a day. (Use ¼ teaspoon each of its success. baking soda and salt in 1 quart of warm water.) Omit salt during mucositis.

Page 4 Dental.EliteCME.com ●● Exercise the jaw muscles three times a day to prevent and treat jaw stiffness from radiation. Open and close the mouth as far as Instructions for patients using supplemental possible without causing pain; repeat 20 times. fluoride ●● Avoid candy, gum and soda unless they are sugar-free. If using a tray: ●● Avoid spicy or acidic foods, toothpicks, tobacco products and ●● Place a thin ribbon of fluoride gel in each tray. alcohol. ●● Place the trays on the teeth and leave in place for 10 minutes. If gel ●● Keep the appointment schedule recommended by the dentist. oozes out of the tray, you are using too much. ●● After 10 minutes, remove the trays and spit out any excess gel. Do not rinse. ●● Rinse the applicator trays with water. ●● Do not eat or drink for 30 minutes. If using a brush-on method: ●● After brushing with toothpaste, rinse as usual. ●● Place a thin ribbon of gel on the toothbrush. ●● Brush for two to three minutes. ●● Spit out any excess gel. Do not rinse. ●● Do not eat or drink for 30 minutes.

Oral care during cancer treatment Careful monitoring of oral health is especially important during cancer ○○ Sip water frequently. therapy to prevent, detect and treat complications as soon as possible. ○○ Suck ice chips or sugar-free candy. When treatment is necessary, consult the oncologist before any ○○ Chew sugar-free gum. dental procedure, including dental prophylaxis. ○○ Use a saliva substitute spray or gel or a prescribed saliva ●● Examine the soft tissues for inflammation or infection and evaluate stimulant if appropriate. for plaque levels and dental caries. ○○ Avoid glycerin swabs. ●● Review oral hygiene and oral care protocols; prescribe ●● Take precautions to protect against trauma. antimicrobial therapy as indicated. ●● Provide topical anesthetics or analgesics for oral pain. ●● Provide recommendations for treating dry mouth and other complications:

Other factors to remember Schedule dental work carefully. If oral surgery is required, allow Table 1 at least seven to 10 days of healing before the patient receives Normal complete blood count myelosuppressive chemotherapy. Elective oral surgery should not be Male: 4.7-6.1 million cells/mcL performed for the duration of radiation treatment. Red blood cells Female: 4.2-5.4 million cells/mcL Determine hematologic status. If the patient is receiving Male: 13.8-17.2 gm/dL chemotherapy, have the oncology team conduct blood work 24 hours Hemoglobin before dental treatment to determine whether the patient’s platelet Female: 12.1-15.1 gm/dL count, clotting factors and absolute neutrophil count are sufficient Males: 40.7-50.3 percent Hematocrit to recommend oral treatment. Postpone oral surgery or other oral Female: 36.1-44.3 percent invasive procedures if: 3 ●● Platelet count is less than 75,000/mm3 or abnormal clotting factors Platelets 150,000-400,000/mm are present. White blood cells 4,500-10,000 cells/mcL ●● Absolute neutrophil count is less than 1,000/mm3 (or consider prophylactic antibiotics). Differential white blood cell (WBC) count Consider oral causes of fever. Fever of unknown origin may be Neutrophils (PMNs) 40-60 percent (3000-6000/mm3) related to an oral infection. Remember that oral signs of infection or 3 other complications may be altered by immunosuppression related to Neutrophils (Bands) 0-3 percent (0-300/mm ) chemotherapy. Eosinophils 1-4 percent (50-400/mm3) Evaluate need for antibiotic prophylaxis. If the patient has a Basophils 0.5-1 percent (15-50/mm3) central venous catheter, consult the oncologist to determine whether Lymphocytes 20-40 percent (1200-3000/mm3) antibiotics are needed before any dental treatment to prevent endocarditis (see www.americanheart.org for more detail). Monocytes 2-8 percent (100-600/mm3) Absolute neutrophil count = WBC x ( percent PMNs + percent bands) Source: A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; ©2005. CBC; [updated 2008 Aug 10; cited 2009 July 31]; WBC; [updated 2009 Feb 21; cited 2009 July 31]; [about 4 p.]. Available from: http://www.nlm.nih.gov/medlineplus/ency/ article/003642.htm; http://www.nlm.nih.gov/medlineplus/ency/ article/003643.htm.

Dental.EliteCME.com Page 5 Follow-up oral care Chemotherapy ●● Because of the risk of osteonecrosis, principally in the mandible, Once all complications of chemotherapy have resolved, patients patients should avoid invasive surgical procedures, including may be able to resume their normal dental care schedule. However, extractions that involve irradiated bone. If an invasive procedure is if immune function continues to be compromised, determine the required, use of antibiotics and hyperbaric oxygen therapy before patient’s hematologic status before initiating any dental treatment or and after surgery should be considered. surgery. This is particularly important to remember for patients who ●● Lifelong daily fluoride application, good nutrition and have undergone stem cell transplantation. Ask whether the patient has conscientious oral hygiene are especially important for patients received intravenous bisphosphonate therapy. with salivary gland dysfunction. Radiation therapy ●● Dentures may need to be reconstructed if treatment altered oral Once the patient has completed head and neck radiation therapy and tissues. Some people can never wear dentures again because of acute oral complications have abated, evaluate the patient regularly friable tissues and xerostomia. (every four to eight weeks, for example) for the first six months. ●● Dentists should closely monitor children who have received Thereafter, you can determine a schedule based on the patient’s needs. radiation to craniofacial and dental structures for abnormal growth However, keep in mind that oral complications can continue or emerge and development. long after radiation therapy has ended. ●● Dentists should be mindful about the recurrence of malignancies in patients with oral and head and neck cancers, and thoroughly Points to remember examine all oral mucosal tissues at recall appointments. ●● High-dose radiation treatment carries a lifelong risk of xerostomia, dental caries and osteonecrosis.

Special considerations for hematopoietic stem cell transplant patients The intensive conditioning regimens of transplantation can result in along with the risk of infections. Also, the oral cavity and salivary pronounced immunosuppression, greatly increasing a patient’s risk glands are commonly involved in graft-vs.-host disease in allograft. of mucositis, ulceration, hemorrhage, infection and xerostomia. The This can result in mucosal inflammation, ulceration and xerostomia, complications begin to resolve when hematologic status improves. so continued monitoring is necessary. Careful attention to oral care in Although the complete blood count and differential may be normal, the immediate and long-term, post-transplant period is important to immunosuppression may last for up to a year after the transplant, patients’ overall health.

Part III: Types and prevalence of oral complications The most common oral complications of cancer therapies are continue cancer therapy; treatment is then usually discontinued. These mucositis, infection, salivary gland dysfunction, taste dysfunction and disruptions in dosing caused by oral complications can directly affect pain. These complications can lead to secondary complications, such patient survivorship. as dehydration, dysgeusia and malnutrition. In myelosuppressed cancer Management of oral complications of cancer therapy includes patients, the oral cavity can also be a source of systemic infection. identification of high-risk populations, patient education, initiation Radiation of the head and neck can irreversibly injure oral mucosa, of pretreatment interventions, and timely management of lesions. vasculature, muscle and bone, resulting in xerostomia, rampant dental Assessment of oral status and stabilization of oral disease before caries, trismus, soft tissue necrosis and osteonecrosis. cancer therapy are critical to overall patient care. Care should be both Severe oral toxicities can compromise delivery of optimal cancer preventive and therapeutic to minimize risk for oral and associated therapy protocols. For example, dose reduction or treatment schedule systemic complications. modifications may be necessary to allow for resolution of oral lesions. Frequencies of oral complications vary by cancer therapy; estimates In cases of severe oral morbidity, the patient may no longer be able to are included in Table II. Table II. Prevalence for oral complications with cancer therapies: oral care study group systematic reviews, MASCC/ISOO Complication Reference citation Weighted prevalence Bisphosphonate [163] 6.1 percent for all studies (mean) osteonecrosis Studies with documented follow-up = 13.3 percent Studies with undocumented follow-up = 0.7 percent Epidemiological studies = 1.2 percent Dysgeusia [103] CT only = 56.3 percent (mean) RT only = 66.5 percent (mean) Combined CT and RT = 76 percent (mean) Oral fungal infection [133] Of clinical oral fungal infection (all oral candidiasis): Pretreatment = 7.5 percent During treatment = 39.1 percent Post-treatment = 32.6 percent Of oral candidiasis clinical infection by cancer treatment: During HNC RT = 37.4 percent During CT = 38 percent

Page 6 Dental.EliteCME.com Complication Reference citation Weighted prevalence Oral viral infection [69] In patients treated with CT for hematologic malignancies: Patients with oral ulcerations/sampling oral ulcerations = 49.8 percent Patients sampling oral ulcerations = 33.8 percent Patients sampling independently of the presence of oral ulcerations = 0 percent In patients treated with RT: Patients with RT only/sampling oral ulcerations = 0 percent Patients with RT and adjunctive CT/sampling oral ulcerations = 43.2 percent Dental disease [102] For dental caries in patients treated with cancer therapy: All studies = 28.1 percent CT only = 37.3 percent Post-RT = 24 percent Post-CT and -RT = 21.4 percent Of severe gingivitis in patients undergoing CT = 20.3 percent Of dental infection/abscess in patients undergoing CT = 5.8 percent Osteoradionecrosis [197] In conventional RT = 7.4 percent In IMRT = 5.2 percent In RT and CT = 6.8 percent In brachytherapy = 5.3 percent Trismus [20] For conventional RT = 25.4 percent For IMRT = 5 percent For combined RT and CT = 30.7 percent Oral paina [74] VAS pain level (0–100) in HNC patients: Pretreatment = 12/100 Immediately post-treatment = 33/100 1 month post-treatment = 20/100 EORTC QLQ-C30 pain level (0–100) in HNC patients: Pretreatment = 27/100 3 months post-treatment = 30/100 6 months post-treatment = 23/100 12 months post-treatment = 24/100 Salivary gland [112] Of xerostomia in HNC patients by type of RT: hypofunction and All studies xerostomia Pre-RT = 6 percent During RT = 93 percent 1–3 mo post-RT = 74 percent 3–6 mo post-RT = 79 percent 6-12 mo post-RT = 83 percent 1-2 y post-RT = 78 percent >2 y post-RT = 85 percent Conventional RT Pre-RT = 10 percent During RT = 81 percent 1-3 mo post-RT = 71 percent 3-6 mo post-RT = 83 percent 6-12 mo post-RT = 72 percent 1-2 y post-RT = 84 percent >2 y post-RT = 91 percent IMRT Pre-RT = 12 percent During RT = 100 percent 1-3 mo post-RT = 89 percent 3-6 mo post-RT = 73 percent 6-12 mo post-RT = 90 percent 1-2 y post-RT = 66 percent >2 y post-RT = 68 percent KEY: CT = chemotherapy; EORTC QLQ-C30 = European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30; HNC = head and neck cancer; IMRT = intensity-modulated radiation therapy; MASCC/ISOO = Multinational Association of Supportive Care in Cancer/ International Society of Oral Oncology; RT = radiation therapy; VAS = visual analog scale. aPain is common in patients with HNCs and is reported by approximately half of patients before cancer therapy, by 81 percent during therapy, by 70 percent at the end of therapy, and by 36 percent at six months post-treatment.

Dental.EliteCME.com Page 7 Current deficits Future research targeted at developing technologies is needed to: costs. New technologies could also provide a setting in which novel ●● Reduce incidence and severity of oral mucositis. classes of chemotherapeutic drugs used at increased doses could lead ●● Improve infection management. to enhanced cancer cure rates and durability of disease remission. ●● Protect salivary gland function. A multidisciplinary collaboration is essential for the advancement ●● Minimize risk of chronic sequelae. of basic, clinical and translational research on oral complications of Development of new technologies to prevent cancer therapy-induced current and emerging cancer therapies. The pathobiologic complexity complications, especially oral mucositis, could substantially reduce the of oral complications and the ever-expanding science base of clinical risk of oral pain, oral and systemic infections, and number of days in management require this comprehensive interdisciplinary approach. the hospital; and could improve quality of life and reduce health care Etiopathogenesis Oral complications associated with cancer chemotherapy and radiation dental/periapical, periodontal and mucosal infections; institution of result from complex interactions among multiple factors. The most comprehensive oral hygiene protocols during therapy; and reduction prominent contributors are direct lethal and sublethal damage to oral of other factors that may compromise oral mucosal integrity (e.g., tissues, attenuation of immune and other protective systems, and physical trauma to oral tissues) can reduce frequency and severity of oral interference with normal healing. Principal causes can be attributed to both complications in cancer patients (refer to the sections on Oral and dental direct stomatotoxicity and indirect stomatotoxicity. Direct toxicities are management prior to cancer therapy and Management following cancer initiated via primary injury to oral tissues. Indirect toxicities are caused by therapy for further information) [137]. nonoral toxicities that secondarily affect the oral cavity, including: Complications can be acute (developing during therapy) or ●● Myelosuppression. chronic (developing months to years after therapy). In general, ●● Loss of tissue-based immune cells. cancer chemotherapy causes acute toxicities that resolve following ●● Loss of protective salivary constituents. discontinuation of therapy and recovery of damaged tissues. In contrast, Understanding of mechanisms associated with oral complications radiation protocols typically cause not only acute oral toxicities, but continues to increase. Unfortunately, there are no universally effective induce permanent tissue damage that result in lifelong risk for the patient. agents or protocols to prevent toxicity. Elimination of preexisting Chemotherapy-induced complications Risk factors for oral complications (see Table III on next page) derive oral microflora when local and systemic immune function is concurrently from both direct damage to oral tissues secondary to chemotherapy compromised. Frequency and severity of oral complications are directly and indirect damage due to regional or systemic toxicity. For example, related to extent and type of systemic compromise. therapy-related toxicity to oral mucosa can be exacerbated by colonizing Table III. Oral complications of cancer chemotherapy Complication Direct risk factor Indirect risk factors DIC = disseminated intravascular coagulation; HSV = herpes simplex virus. Oral mucositis Mucosal cytotoxicity. Decreased local/systemic immunity: local infections, Physical/chemical trauma. reactivation of HSV. Oral infections: Viral Decreased systemic immunity. Fungal Decreased oral mucosal and/or systemic immunity. Salivary gland dysfunction. Altered oral flora (decreased bacterial flora). Bacterial Inadequate oral hygiene. Decreased oral mucosal and/or systemic immunity. Mucosal breakdown. Salivary gland dysfunction. Acquired pathogens. Taste dysfunction Taste receptor toxicity. Xerostomia Salivary gland toxicity. Anti-cholinergic drugs. Neuropathies Vinca alkaloid, thalidomide, Anemia, dental hypersensitivity, temporomandibular bortezomib drug use; risk for dysfunction/myofascial pain. specific drug toxicity varies. Dental and skeletal growth and development Specific drug toxicity. Stage of dental and skeletal maturation. (pediatric patients). Gastrointestinal mucositis causing secondary Mucosal cytotoxicity: radiation, Nausea and vomiting. changes in oral status including taste, hygiene chemotherapy. and dietary intake.

Page 8 Dental.EliteCME.com Complication Direct risk factor Indirect risk factors Hemorrhage Oral mucositis. Thrombocytopenia. Physical trauma. Decreased clotting factors (e.g., DIC). Infections (e.g., HSV). Ulcerative oral mucositis occurs in approximately 40 percent of ●● Bleomycin. patients receiving chemotherapy. In approximately 50 percent of ●● The platinum coordination complexes, including cisplatin and these patients, the lesions are severe and require medical intervention, carboplatin. including modification of their cytotoxic cancer therapy. Normal oral Anecdotal evidence suggests that patients who experience mucositis mucosal epithelium is estimated to undergo complete replacement with a specific chemotherapy regimen during the first cycle will every nine to 16 days. Intensive chemotherapy can cause ulcerative typically develop comparable mucositis during subsequent courses of mucositis that initially emerges approximately two weeks after that regimen. initiation of high-dose chemotherapy [249, 133, 234]. Other oral complications typically include infections of the mucosa, Chemotherapy directly impairs replication of basal epithelial cells; dentition/periapices, and periodontium. Prevalence of these infections other factors, including proinflammatory cytokines and metabolic has been substantiated in multiple studies [47, 2, 209, 169]. products of bacteria, may also play a role. The labial mucosa, buccal mucosa, tongue, floor of mouth, and soft palate are more severely Specific criteria for determining risk of infectious flare during affected by chemotherapy than are the attached, heavily keratinized myelosuppression have not been developed. Guidelines for assessment tissues, such as the hard palate and gingiva; this may be caused by primarily address both degree of severity of the chronic lesion and relative rate of epithelial cell turnover among high-risk vs. low-risk whether acute symptoms have recently (i.e., less than 90 days) oral mucosal tissues. Topical cryotherapy may ameliorate mucositis developed. However, chronic asymptomatic periodontitis may also caused by agents such as 5-fluorouracil (5-FU) by reducing vascular represent a focus for systemic infectious complications because delivery of these toxic agents to replicating oral epithelium [219]. bacteria, bacterial cell wall substances and inflammatory cytokines may translocate into the circulation via ulcerated pocket epithelium It is difficult to predict whether a patient will develop mucositis strictly [209]. In addition, poor oral hygiene and periodontitis seem to increase on the basis of the classes of drugs that are administered. Several drugs the prevalence of pulmonary infections in high-risk patients [185]. are associated with propensity to damage oral mucosa: ●● Methotrexate. Resolution of oral toxicity, including mucositis and infection, ●● Doxorubicin. generally coincides with granulocyte recovery. This relationship may ●● 5-FU. be temporally but not causally related. For example, oral mucosal ●● Busulfan. healing in hematopoietic stem cell transplantation patients is only partially dependent on rate of engraftment, especially neutrophils.

Head/neck radiation–induced complications Head and neck radiation can cause a wide spectrum of oral Head and neck radiation can also induce damage that results in complications. Ulcerative oral mucositis is a virtually universal permanent dysfunction of vasculature, connective tissue, salivary toxicity resulting from this treatment; there are clinically significant glands, muscle and bone. Loss of bone vitality occurs: similarities as well as differences compared with oral mucositis caused ●● Secondary to injury to osteocytes, osteoblasts and osteoclasts. by chemotherapy [249]. In addition, oral mucosal toxicity can be ●● From a relative hypoxia due to reduction in vascular supply. increased by use of head and neck radiation together with concurrent These changes can lead to soft tissue necrosis and osteonecrosis that chemotherapy. result in bone exposure, secondary infection and severe pain [169].

Oral complications of radiation therapy ●● Acute complications. ○○ Muscular/cutaneous fibrosis. ○○ Oral mucositis. ○○ Infections: ○○ Infection: ■■ Fungal. ■■ Fungal. ■■ Bacterial. ■■ Bacterial. Unlike chemotherapy, however, radiation damage is anatomically ○○ Salivary gland dysfunction: site-specific; toxicity is localized to irradiated tissue volumes. ■■ Sialadenitis. Degree of damage depends on treatment regimen-related factors, ■■ Xerostomia. including type of radiation utilized, total dose administered, and ○○ Taste dysfunction. field size/fractionation. Radiation-induced damage also differs from ●● Chronic complications. chemotherapy-induced changes in that irradiated tissue tends to ○○ Mucosal fibrosis and atrophy. manifest permanent damage that places the patient at continual risk ○○ Xerostomia. for oral sequelae. The oral tissues are thus more easily damaged by ○○ Dental caries. subsequent toxic drug or radiation exposure, and normal physiologic ○○ Soft tissue necrosis. repair mechanisms are compromised as a result of permanent cellular ○○ Osteonecrosis. damage. ○○ Taste dysfunction: ■■ Dysgeusia. ■■ Ageusia.

Dental.EliteCME.com Page 9 Oral and dental management before cancer therapy Poor oral health has been associated with increased incidence and chemotherapy. Both studies had several flaws, including small sample severity of oral complications in cancer patients, hence the adoption size or the lack of comparison groups [102]. of an aggressive approach to stabilizing oral care before treatment The involvement of a dental team experienced with oral oncology may [248, 78]. Primary preventive measures such as appropriate nutritional reduce the risk of oral complications via either direct examination of intake, effective oral hygiene practices, and early detection of oral the patient or in consultation with the community-based dentist. The lesions are important pretreatment interventions. evaluation should occur as early as possible before treatment [132, There is no universally accepted pre-cancer therapy dental protocol 234]. The examination allows the dentist to determine the status of the because of the lack of clinical trials evaluating the efficacy of a oral cavity before cancer treatment begins and to initiate necessary specific protocol. A systematic review of the literature revealed two interventions that may reduce oral complications during and after that articles on oral care protocols prior to cancer therapy [102]. One study therapy. Ideally, this examination should be performed at least one examined the benefits of a minimal intervention pre-cancer therapy month before the start of cancer treatment to permit adequate healing (mostly chemotherapy) dental protocol, and the other examined the from any required invasive oral procedures. A program of oral hygiene impact of an intensive preventive protocol on patients undergoing should be initiated, with emphasis on maximizing patient compliance on a continuing basis.

Chemotherapy patients Oral evaluation and management of patients scheduled to undergo advise the dentist on the patient’s medical status and oncology myeloablative chemotherapy should occur as early as possible before treatment plan. In turn, the dental team should delineate and initiation of therapy (refer to the list on Oral disease stabilization communicate a plan of care for oral disease management before, before chemotherapy and hematopoietic stem cell transplantation during and after cancer therapy [234]. below). To maximize outcomes, the oncology team should clearly

Oral disease stabilization before chemotherapy and hematopoietic stem cell transplantation ●● Data provided by oncology team to dental providers: ■■ Teeth with pulpal infection. ○○ Underlying disease: ■■ Teeth with periapical infection. ■■ Cancer: type, stage, prognosis. ○○ Periodontal disease status. ■■ Aplastic anemia status, complete blood count (CBC). ○○ Number of teeth requiring extraction. ■■ Other. ○○ Other urgent care required. ○○ Type of transplant: ○○ Time necessary to complete stabilization of oral disease. ■■ Autologous. The overall goal is to complete a comprehensive oral care plan that ■■ Allogeneic donor types: eliminates or stabilizes oral disease that could otherwise produce □□ Matched related and unrelated. complications during or following chemotherapy. Achieving this goal □□ Mismatched related. will most likely reduce risk of oral toxicities with resultant reduced □□ Mismatched unrelated. risk for systemic sequelae, reduced cost of patient care, and enhanced □□ Syngeneic. quality of life. If the patient is unable to receive the medically ■■ Hematopoietic stem cell source: necessary oral care in the community, the oncology team should □□ Bone marrow. assume responsibility for oral management. □□ Peripheral stem cells. □□ Cord blood stem cells. It is important to realize that dental treatment plans need to be realistic ■■ Conditioning regimen: about the type and extent of dental disease and how long it could be □□ Myeloablative. before resumption of routine dental care. For example, teeth with □□ Reduced-intensity conditioning (including minor caries may not need restoration before cancer treatment begins, nonmyeloablative regimens). especially if more conservative disease stabilization strategies can be ■■ Planned date of transplant. used (e.g., aggressive topical fluoride protocols, temporary restorations ■■ Conditioning regimen: or dental sealants). □□ Chemotherapy. Specific interventions are directed to: □□ Total-body irradiation. ●● Mucosal lesions. □□ Radioactive antibodies. ●● Dental caries and endodontic disease. ■■ Current hematologic status and immunologic status. ●● Periodontal disease. ■■ Present medications. ●● Ill-fitting dentures. ■■ Other medical considerations: ●● Orthodontic appliances. □□ Cardiac disease (including murmurs). ●● Temporomandibular dysfunction. □□ Pulmonary disease. ●● Salivary abnormalities. □□ Indwelling venous access line. □□ Coagulation status. Guidelines for dental extractions, endodontic management and related □□ Splenectomy. interventions (see Table IV) can be used as appropriate [286, 184]. ●● Data provided by dental providers to oncology team: Antibiotic prophylaxis prior to invasive oral procedures may be ○○ Dental caries (number of teeth and severity, including warranted in the context of central venous catheters; the current designation of number of teeth that should be treated before American Heart Association (AHA) protocol for infective cancer treatment begins). endocarditis and oral procedures is frequently used for these patients. ○○ Endodontic disease:

Page 10 Dental.EliteCME.com Table IV. Management guidelines on invasive dental procedures Medical status Guideline Comments Patients with chronic AHA prophylactic antibiotic recommendations (low There is no clear scientific proof detailing infectious indwelling venous access risk). risk for these lines following dental procedures. This lines (e.g., Hickman). recommendation is empiric. Neutrophils Order CBC with differential. >2,000/mm3 No prophylactic antibiotics. 1,000-2,000/mm3 AHA prophylactic antibiotic recommendations (low Clinical judgment is critical. If infection is present or risk). unclear, more aggressive antibiotic therapy may be indicated. <1,000/mm3 Amikacin 150 mg/m2 1 h presurgery; Ticarcillin If organisms are known or suspected, appropriate 75 mg/kg IV ½ h presurgery. Repeat both 6 h adjustments should be based on sensitivities. postoperatively. Plateletsa Order platelet count and coagulation tests. >60,000/mm3 No additional support needed. 30,000-60,000/mm3 Platelet transfusions are optional for noninvasive Utilize techniques to promote establishing and maintaining treatment; consider administering preoperatively control of bleeding (i.e., sutures, pressure packs, minimize and 24 hours later for surgical treatment (e.g., dental trauma). extractions). Additional transfusions are based on clinical course. <30,000/mm3 Platelets should be transfused 1 hour before In addition to above, consider using hemostatic procedure; obtain an immediate post-infusion platelet agents (i.e., microfibrillar collagen, topical thrombin). count; transfuse regularly to maintain counts >30,000- Aminocaproic acid may help stabilize nondurable clots. 40,000/mm3 until initial healing has occurred. In Monitor sites carefully. some instances, platelet counts >60,000/mm3 may be required. Key: CBC = complete blood cell count; IV = intravenous. aAssumes that all other coagulation parameters are within normal limits and that platelet counts will be maintained at or above the specified level until initial stabilization/healing has occurred.

Assessment of hematopoietic stem cell transplant patients Stages of assessment have been described for hematopoietic stem Selected conditioning regimens characterized by reduced intensity cell transplant patients (see Table V on next page) [234]. This model for myelosuppression have been used in patients. These regimens provides a useful classification for neutropenic cancer patients in have generally been noted to significantly reduce the severity of oral general. Type, timing and severity of oral complications represent complications early post-transplant, especially for mucositis and the interaction of local and systemic factors that culminate in clinical infection risk. The guidelines listed in Table IV can be adjusted to expression of disease. Correlating oral status with systemic condition reflect these varying degrees of risk, based on the specific conditioning of the patient is thus critically important. regimen to be used.

Dental.EliteCME.com Page 11 Table V. Oral complications of hematopoietic stem cell transplantation Transplant phase Oral complication GVHD = graft-vs.-host disease. Phase I: Preconditioning Oral infections: dental caries, endodontic infections, periodontal disease (gingivitis, periodontitis), mucosal infections (i.e., viral, fungal, bacterial). Gingival leukemic infiltrates. Metastatic cancer. Oral bleeding. Oral ulceration: aphthous ulcers, erythema multiforme. Temporomandibular dysfunction. Phase II: Conditioning neutropenic phase Oropharyngeal mucositis. Oral infections: mucosal infections (i.e., viral, fungal, bacterial), periodontal infections. Hemorrhage. Xerostomia. Taste dysfunction. Neurotoxicity: dental pain, muscle tremor (e.g., jaws, tongue). Temporomandibular dysfunction: jaw pain, headache, joint pain. Phase III: Engraftment hematopoietic Oral infections: mucosal infections (i.e., viral, fungal, bacterial). recovery Acute GVHD. Xerostomia. Hemorrhage. Neurotoxicity: dental pain, muscle tremor (e.g., jaws, tongue). Temporomandibular dysfunction: jaw pain, headache, joint pain. Granulomas/papillomas. Phase IV: Immune reconstitution late post- Oral infections: mucosal infections (i.e., viral, fungal, bacterial). transplant Chronic GVHD. Dental/skeletal growth and development alterations (pediatric patients). Xerostomia. Relapse-related oral lesions. Second malignancies. Phase V: Long-term survival Relapse or second malignancies. Dental/skeletal growth and development alterations. Phase I: Before chemotherapy Oral complications are related to current systemic and oral health, oral patients should be educated about the range and management of oral manifestations of underlying disease, and oral complications of recent complications that may occur during subsequent phases. Baseline oral cancer or other medical therapy. During this period, oral trauma and hygiene instructions should be provided. It is especially important to clinically significant infections, including dental caries, periodontal note whether patients have been treated with bisphosphonates (e.g., disease and pulpal infection, should be eliminated. Additionally, patients with multiple myeloma) and to plan their care accordingly.

Phase II: Neutropenic phase Oral complications arise primarily from direct and indirect the patient may remain at risk for infection, depending on status of stomatotoxicities associated with high-dose chemotherapy or overall immune reconstitution. chemoradiotherapy and their sequelae. Mucositis, xerostomia and those Salivary gland hypofunction/xerostomia secondary to anti-cholinergic lesions related to myelosuppression, thrombocytopenia and anemia drugs and taste dysfunction is initially detected in this phase; the toxicity predominate. This phase is typically the period of high prevalence and typically resolves within two to three months. severity of oral complications. In allogeneic transplant patients, while uncommon, hyperacute graft- Oral mucositis usually begins seven to 10 days after initiation of vs.-host disease (GVHD) can occur and can result in significant oral cytotoxic therapy and remains present for approximately two weeks mucosal inflammation and breakdown that can complicate the oral after cessation of that therapy. Viral, fungal and bacterial infections course for patients. Clinical presentation will often not be sufficiently may arise, with incidence dependent on the use of prophylactic distinct to diagnosis of this lesion. The clinical assessment is typically regimens, oral status prior to chemotherapy, and duration and severity based on the patient experiencing more-severe-than-expected of neutropenia. Frequency of infection declines upon resolution of mucositis that will often not heal within the time line for mucosal mucositis and regeneration of neutrophils. This phenomenon appears recovery with oral mucositis caused by chemotherapy. to be more a temporal relation than a causative one, based on the predominant evidence. Despite the initial marrow recovery, however,

Page 12 Dental.EliteCME.com Phase III: Hematopoietic recovery Frequency and severity of acute oral complications typically begin Mucosal bacterial infections during this phase occur less frequently to decrease approximately three to four weeks after cessation of unless engraftment is delayed or the patient has acute GVHD or is chemotherapy. Healing of ulcerative oral mucositis in the setting of receiving GVHD therapy. Most centers will use systemic infection marrow regeneration contributes to this dynamic. Although immune prophylaxis throughout this period (and, in many instances, longer) reconstitution is developing, oral mucosal immune defenses may not to reduce the risk of infections in general, a practice that positively be optimal. Generally stated, immune reconstitution will take between influences the rate and severity of both systemic and local oral six to nine months for autologous transplant patients and between nine infections. and 12 months for allogeneic transplant patients not developing chronic The hematopoietic stem cell transplant patient represents a unique cohort GVHD. Thus, the patient remains at risk for selected infection, including at this point. For example, risk for acute oral GVHD typically emerges candidal and herpes simplex virus infections. during this time in allogeneic graft recipients.

Phase IV: Immune reconstitution/recovery from systemic toxicity Oral lesions are principally related to chronic conditioning regimen- Risk exists for graft failure, cancer relapse and second malignancies. associated (chemotherapy with or without radiation therapy) toxicity The hematopoietic stem cell transplant patient may develop oral and, in the allogeneic patient, GVHD. Late viral infections and manifestations of chronic GVHD during this period. xerostomia predominate. Mucosal bacterial infections are infrequent unless the patient remains neutropenic or has severe chronic GVHD.

Phase V: Long-term survival Long-term survivors of cancer treated with high-dose chemotherapy xerostomia [112], which is the most frequently reported late oral alone or chemoradiotherapy will generally have few significant complication. Permanent salivary gland dysfunction can occur in permanent oral complications. autologous transplant patients in addition to nonautologous recipients. Risk for radiation-induced chronic complications is related to the total Other significant complications include craniofacial growth and dose and schedule of radiation therapy. Regimens that incorporate total developmental abnormalities in pediatric patients, and emergence of body irradiation may result in permanent salivary gland hypofunction/ second malignancies of the head/neck region.

Oral and dental management after cancer therapy Routine systematic oral hygiene is important for reducing incidence Management of patients undergoing either high-dose chemotherapy and severity of oral sequelae of cancer therapy. The patient must be or upper-mantle radiation share selected common principles. informed of the rationale for the oral hygiene program as well as the These principles are based on baseline oral care (refer to the list potential side effects of cancer chemotherapy and radiation therapy. of suggestions for routine oral hygiene care below) and reduction Effective oral hygiene is important throughout cancer treatment, with of physical trauma to oral mucosa (refer to the list of guidelines emphasis on oral hygiene beginning before treatment starts [234]. for management of dentures and orthodontic appliances in patients receiving high-dose cancer therapy below). Routine oral hygiene care ●● Toothbrushing: [Note: Electric and ultrasonic toothbrushes are ■■ 0.9 percent saline. acceptable if the patient is capable of using them without causing ■■ Sodium bicarbonate solution. trauma.] ■■ 0.9 percent saline plus sodium bicarbonate solution. ○○ Soft nylon-bristled brush (two to three rows). ○○ Use 8 to 12 ounces of rinse, hold a mouthful, and expectorate ○○ Brush two to three times daily with Bass sulcular scrub until total volume is used; repeat every two to four hours or as method. needed to ameliorate discomfort. ○○ Rinse frequently. ●● Fluoride: ○○ Foam toothbrushes: ○○ 1.1 percent neutral sodium fluoride gel. ■■ Use only when use of a regular toothbrush is not feasible. ○○ 0.4 percent stannous fluoride gel. ■■ Use with antimicrobial rinses when routine brushing and ○○ Brush on gel for two to three minutes. flossing are not possible. ○○ Expectorate and rinse mouth gently. ■■ Brush teeth two to three times a day. ○○ Apply once a day. ■■ Rinse frequently. ●● Topical antimicrobial rinses: ○○ Dentifrice: ○○ 0.12 percent to 0.2 percent chlorhexidine oral rinse for ■■ Patient preference, as tolerated. management of acute gingival lesions. □□ (Note: Non-mint-flavored products are typically ○○ Povidone iodine oral rinse. better tolerated than mint-flavored products when oral ○○ Rinse, hold one to two minutes, and expectorate. mucositis or oral graft-vs.-host disease [GVHD] is ○○ Repeat two to four times a day, depending on severity of present). periodontal disease. ■■ Fluoride recommended. Considerable variation exists across institutions in specific nonmedicated ■■ Use 0.9 percent saline or water if toothpaste causes approaches to baseline oral care, given limited published evidence. irritation. Most nonmedicated oral care protocols use topical, frequent (every four ●● Flossing: to six hours) rinsing with 0.9 percent saline. Additional interventions ○○ Once daily. include dental brushing with toothpaste, dental flossing, ice chips ○○ Atraumatic technique with modifications as needed. and sodium bicarbonate rinses. Patient compliance with these agents ●● Bland rinses: ○○ Varieties:

Dental.EliteCME.com Page 13 can be maximized by comprehensive overseeing by the health care substantially reduced prior to high-dose cancer therapy. (Refer to the list professional. of Guidelines for management of dentures and orthodontic appliances in Patients using removable dental prostheses or orthodontic appliances patients receiving high-dose cancer therapy, which follows.) have risk of mucosal injury or infection. This risk can be eliminated or

Guidelines for management of dentures and orthodontic appliances in patients receiving high-dose cancer therapy [234] ●● Minimize denture use during first three weeks post-transplant. ●● Oral rinsing with water or saline three to four times while brushing ○○ Wear dentures only when eating. will further aid in removal of dental plaque dislodged by brushing. ○○ Discontinue use at all other times. ●● Rinses containing alcohol should be avoided. ●● Clean twice a day with a soft brush and rinse well. ●● A toothpaste with a relatively neutral taste should be considered ●● Soak in antimicrobial solutions when not being worn. because the flavoring agents in toothpaste can irritate oral soft ●● Perform routine oral mucosal care procedures three to four times a tissues. day with the oral appliances out of the mouth. ●● Brushes should be air-dried between uses. ●● Leave appliances out of mouth when sleeping and during periods ●● While disinfectants have been suggested, their routine use to clean of significant mouth soreness. brushes has not been proven of value. ●● Dentures may be used to hold medications needed for oral care ●● Ultrasonic toothbrushes may be substituted for manual brushes if (e.g., anti-fungals). patients are properly trained in their use. ●● Discontinue use of removable appliances until oral mucositis has Patients skilled at flossing without traumatizing gingival tissues may healed. continue flossing throughout chemotherapy administration. Flossing ●● Remove orthodontic appliances (e.g., brackets, wires, retainers) allows for interproximal removal of dental bacterial plaque and thus before conditioning. promotes gingival health. As with dental brushing, this intervention Dental brushing and flossing represent simple, cost-effective should be performed under the supervision of professional staff to approaches to bacterial dental plaque control. This strategy is designed ensure its safe administration. to reduce risk of oral soft tissue infection during myeloablation. The oral cavity should be cleaned after meals: Oncology teams at some centers promote their use, while teams at ●● If xerostomia is present, plaque and food debris may accumulate other centers have patients discontinue brushing and flossing when secondary to reduced salivary function, and more frequent hygiene peripheral blood components decrease below defined thresholds (e.g., may be necessary. platelets less than 30,000/mm3). There is no comprehensive evidence ●● Dentures need to be cleaned with denture cleanser every day and base on the optimal approach. Many centers adopt the strategy that the should be brushed and rinsed after meals. benefits of properly performed dental brushing and flossing in reducing ●● Rinsing the oral cavity may not be sufficient for thorough risk of gingival infection outweigh the risks. cleansing of the oral tissues; mechanical plaque removal is often Periodontal infection (gingivitis and periodontitis) increases risk for necessary. oral bleeding; healthy tissues should not bleed. Discontinuing dental ●● Care must be exerted in the use of the varied mechanical hygiene brushing and flossing can increase risk for gingival bleeding, oral aids that are available; dental floss, interproximal brushes, infection and bacteremia. Risk for gingival bleeding and infection, and wooden wedges can injure oral tissues rendered fragile by therefore, is reduced by eliminating gingival infection before therapy chemotherapy. and promoting oral health daily by removing bacterial plaque with ●● Toothettes have limited ability to cleanse the dentition; however, they gentle debridement with a soft or ultra-soft toothbrush during therapy. may be useful for cleaning maxillary/mandibular alveolar ridges of Mechanical plaque control not only promotes gingival health, but it edentulous areas, palate, and tongue. also may decrease risk of exacerbation of oral mucositis secondary to Preventing dryness of the lips to reduce risk for tissue injury is microbial colonization of damaged mucosal surfaces. important. Mouth breathing or xerostomia secondary to anti-cholinergic Dental brushing and flossing should be performed daily under the medications used for nausea management can induce the condition. supervision of professional staff: GVHD of the lips can also contribute to dry lips in allogeneic transplant ●● A soft nylon-bristled toothbrush should be used two to three patients. Lip care products containing petroleum-based oils and waxes times a day with techniques that specifically maintain the gingival can be useful. Lanolin-based creams and ointments may be more portion of the tooth and periodontal sulcus, keeping them free of effective in moisturizing and lubricating the lips and thus protecting bacterial plaque. against trauma. ●● Rinsing the toothbrush in hot water every 15 to 30 seconds during brushing will soften the brush and reduce risk for trauma.

Oral mucositis The terms oral mucositis and stomatitis are often used interchangeably Risk of oral mucositis has historically been characterized by treatment- at the clinical level, but they do not reflect identical processes. based and patient-based variables [13]. The current model of oral ●● Oral mucositis: mucositis involves a complex trajectory of molecular, cellular, ○○ Describes inflammation of oral mucosa resulting from and tissue-based changes. There is increasing evidence of genetic chemotherapeutic agents or ionizing radiation [249, 132, 246]. governance of this injury [79, 239, 284, 94], characterized in part ○○ Typically manifests as erythema or ulcerations. by up-regulation of nuclear factor kappa beta and inflammatory ○○ May be exacerbated by local factors. cytokines (e.g., tumor necrosis factor-alpha) and interleukin-1 in ●● Stomatitis: addition to epithelial basal cell injury. Comprehensive knowledge of ○○ Refers to any inflammatory condition of oral tissue, including the molecular-based causation of the lesion has contributed to targeted mucosa, dentition/periapices, and periodontium. drug development for clinical use [252]. The pipeline of new drugs ○○ Includes infections of oral tissues as well as mucositis. in development (e.g., recombinant human intestinal trefoil factor) [195] may lead to strategic new advances in the ability of clinicians to

Page 14 Dental.EliteCME.com customize the prevention and treatment of oral mucositis in the future Systematic assessment of the oral cavity following treatment permits [196]. early identification of lesions [236, 245, 152, 137, 238]. Oral hygiene Erythematous mucositis typically appears seven to 10 days after and other supportive care measures are important to minimizing the initiation of high-dose cancer therapy. Clinicians should be alert to severity of the lesion. the potential for increased toxicity with escalating dose or treatment In an effort to standardize measurements of mucosal integrity, oral duration in clinical trials that demonstrate gastrointestinal mucosal assessment scales have been developed to grade the level of stomatitis toxicity. High-dose chemotherapy, such as that used in the treatment by characterizing alterations in lips, tongue, mucous membranes, of leukemia and hematopoietic stem cell transplant regimens, gingiva, teeth, pharynx, quality of saliva, and voice [236, 245, 152]. may produce severe mucositis. Mucositis is self-limited when Specific instruments of assessment have been developed to evaluate the uncomplicated by infection and typically heals within two to four observable and functional dimensions of mucositis. These evaluative weeks after cessation of cytotoxic chemotherapy. tools vary in complexity.

Chemotherapy and hematopoietic stem cell transplantation patient – Management of mucositis Oral mucositis in hematopoietic stem cell transplantation patients In one study, opioid analgesic use was also not significantly different produces clinically significant toxicities that require multiprofessional between arms [138]. interventions [71, 72, 134, 198, 223, 247, 250, 265]. The lesion can Evidence from several studies has supported the potential efficacy of increase risk of systemic infection [249], produce clinically significant low-level laser therapy in addition to oral care to decrease the duration pain [202] [Level of evidence: II], and promote oral hemorrhage. It can of chemotherapy-induced oral mucositis in children [129] [Level of also compromise the upper airway such that endotracheal intubation is evidence: I] [233] [Level of evidence: I]. required. Use of total parenteral nutrition is often necessary because of the patient’s inability to receive enteral nutrition. Mucositis management ●● Bland rinses: Once mucositis has developed, its severity and the patient’s ○○ 0.9 percent saline solution. hematologic status govern appropriate oral management. Meticulous ○○ Sodium bicarbonate solution. oral hygiene and palliation of symptoms are essential. Some ○○ 0.9 percent saline/sodium bicarbonate solution. established guidelines for oral care include oral assessments twice ●● Topical anesthetics: daily for hospitalized patients and frequent oral care (minimum of ○○ Lidocaine: viscous, ointments, sprays. every four hours and at bedtime) that increases in frequency as the ○○ Benzocaine: sprays, gels. severity of mucositis increases. ○○ 0.5 percent or 1.0 percent dyclonine hydrochloride (HCl). Oral care protocols generally include atraumatically cleansing the ○○ Diphenhydramine solution. oral mucosa, maintaining lubrication of the lips and oral tissues, ●● Mucosal coating agents: and relieving pain and inflammation. Several health professional ○○ Amphojel. organizations have produced evidence-based oral mucositis guidelines. ○○ Kaopectate. These organizations include but are not limited to the following: ○○ Hydroxypropyl methylcellulose film-forming agents (e.g., ●● Multinational Association of Supportive Care in Cancer/ Zilactin). International Society of Oral Oncology [122]. ○○ Gelclair (approved by the U.S. Food and Drug Administration ●● National Comprehensive Cancer Network [21]. [FDA] as a device). ●● European Society of Medical Oncology [196]. ●● Analgesics: ●● The Cochrane Collaboration [47, 289]. ○○ Benzydamine HCl topical rinse (not approved in the United In many cases, there is similarity in recommendations across the States). organizations. The Cochrane Collaboration, however, uses a meta- ○○ Opioid drugs: oral, intravenous (e.g., bolus, continuous analysis approach and thus provides a unique context for purposes of infusion, patient-controlled analgesia [PCA]), patches, guideline construction. transmucosal. ●● Growth factor (keratinocyte growth factor-1): Palifermin (Kepivance), also known as keratinocyte growth factor-1, ○○ Palifermin (approved by the FDA in December 2004 to decrease has been approved to decrease the incidence and duration of severe oral the incidence and duration of severe oral mucositis in patients mucositis in patients with hematologic cancers undergoing conditioning undergoing high-dose chemotherapy with or without radiation with high-dose chemotherapy, with or without radiation therapy, therapy followed by bone marrow transplant for hematologic followed by hematopoietic stem cell rescue. The standard dosing cancers). regimen is three daily doses before conditioning and three additional daily doses starting on day 0 (day of transplant). Palifermin has also Management of oral mucositis via topical approaches should address been shown in a randomized, placebo-controlled trial to reduce the efficacy, patient acceptance and appropriate dosing. A stepped incidence of oral mucositis in patients with metastatic colorectal cancer approach is typically used, with progression from one level to the next treated with fluorouracil-based chemotherapy [252] [Level of evidence: as follows: I]. In addition, a single dose of palifermin prevented severe oral ●● Bland rinses (e.g., 0.9 percent normal saline and/or sodium mucositis in patients who had sarcoma and were receiving doxorubicin- bicarbonate solutions). based chemotherapy [269] [Level of evidence: I]. ●● Mucosal coating agents (e.g., antacid solutions, kaolin solutions). ●● Water-soluble lubricating agents, including artificial saliva for In two randomized, placebo-controlled trials conducted in head/neck xerostomia. cancer patients undergoing postoperative chemoradiotherapy and in ●● Topical anesthetics (e.g., viscous lidocaine, benzocaine sprays/ patients receiving definitive chemoradiotherapy for locally advanced gels, dyclonine rinses, diphenhydramine solutions). head/neck cancer, intravenous palifermin administered weekly for eight ●● Cellulose film-forming agents for covering localized ulcerative weeks decreased severe oral mucositis [97, 138] [Level of evidence: I], as lesions (e.g., hydroxypropyl cellulose). graded by providers using standard toxicity assessments. Patient-reported outcomes related to mouth and throat soreness and to treatment breaks or Normal saline solution is prepared by adding approximately 1 compliance were not significantly different between arms in either trial. teaspoon of table salt to 32 ounces of water. The solution can be administered at room or refrigerated temperatures, depending on

Dental.EliteCME.com Page 15 patient preference. The patient should rinse and swish approximately The use of compounded topical anesthetic rinses should be considered 1 tablespoon, followed by expectoration; this can be repeated as carefully relative to the cost of compounding these products versus often as necessary to maintain oral comfort. Sodium bicarbonate (1-2 their actual efficacy. tablespoons/quart) can be added, if viscous saliva is present. Saline Irrigation should be performed before topical medication is applied solution can enhance oral lubrication directly as well as by stimulating because removal of debris and saliva allows for better coating of oral salivary glands to increase salivary flow. tissues and prevents material from accumulating. Frequent rinsing A soft toothbrush that is replaced regularly should be used to maintain cleans and lubricates tissues, prevents crusting, and palliates painful oral hygiene [122]. Foam-swab brushes do not effectively clean teeth gingiva and mucosa. and should not be considered a routine substitute for a soft nylon- Systemic analgesics should be administered when topical anesthetic bristled toothbrush; additionally, the rough sponge surface may irritate strategies are not sufficient for clinical relief. Opiates are typically and damage the mucosal surfaces opposite the tooth surfaces being used [202] [Level of evidence: II]; the combination of chronic brushed. indwelling venous catheters and computerized drug administration On the basis of nonoral mucosa wound-healing studies, the repeated pumps to provide PCA has significantly increased the effectiveness use of hydrogen peroxide rinses for daily preventive oral hygiene is not of controlling severe mucositis pain while lowering the dose and recommended, especially if mucositis is present, because of the potential side effects of narcotic analgesics. Nonsteroidal anti-inflammatory for damage to fibroblasts and keratinocytes, which can cause delayed drugs that affect platelet adhesion and damage gastric mucosa are wound healing [175, 16, 263, 19]. Using 3 percent hydrogen peroxide contraindicated, especially if thrombocytopenia is present. diluted 1:1 with water or normal saline to remove hemorrhagic debris Although mucositis continues to be one of the dose-limiting toxicities may be helpful; however, this approach should only be used for one of fluorouracil (5-FU), cryotherapy may be an option for preventing or two days because more extended use may impair timely healing of oral mucositis. Because 5-FU has a short half-life (5-20 minutes), mucosal lesions associated with bleeding [234]. patients are instructed to swish ice chips in their mouths for 30 minutes, Focal topical application of anesthetic agents is preferred over beginning five minutes before 5-FU is administered [219] [Level of widespread oral topical administration, unless the patient requires evidence: I]. Oral cryotherapy has been studied in patients receiving more extensive pain relief. Products such as the following may provide high-dose melphalan conditioning regimens used with transplantation; relief: [166, 180] further research is needed. Many agents and protocols have ●● 2 percent viscous lidocaine. been promoted for management or prevention of mucositis [147, 44, ●● Diphenhydramine solution. 278]. Although not adequately supported by controlled clinical trials, ●● One of the many extemporaneously prepared mixtures combining the allopurinol mouthwash and vitamin E have been cited as agents that following coating agents with topical anesthetics: decrease the severity of mucositis. Prostaglandin E2 was not effective ○○ Milk of magnesia. as a prophylaxis of oral mucositis following bone marrow transplant, ○○ Kaolin with pectin suspension. although studies indicate possible efficacy when prostaglandin E2 is ○○ Mixtures of aluminum. administered via a different dosing protocol. ○○ Magnesium hydroxide suspensions (many antacids).

Orofacial pain in cancer patients Pain in cancer patients may arise from onset of the disease through ●● Physiologic. survivorship and may be [73]: ●● Affective. ●● Caused by the malignant disease. ●● Cognitive. ●● Caused by acute or chronic complications of cancer therapy. ●● Behavioral. ●● Coincidental and unrelated to the cancer. ●● Sociocultural. Cancer pain causes increased morbidity, reduced performance status, Management of head and neck pain and oral pain may be particularly increased anxiety and depression, and diminished quality of life challenging because eating, speech, swallowing, and other motor (QOL). Dimensions of acute and chronic pain include the following: functions of the head and neck and oropharynx are constant pain ●● Sensory. triggers.

Orofacial pain due to cancer Acute and chronic pain in cancer can result from several factors, It is estimated that 45 percent to 80 percent of all cancer patients have including: inadequate pain management. Seventy-five percent to 90 percent of ●● Pain due to malignant disease: patients with terminal or advanced cancer may have pain. Pain may ○○ Local/regional cancer. be present in up to 85 percent of patients with head and neck cancers ○○ Oral involvement in systemic/hematopoietic cancer. (HNCs) at diagnosis. ○○ Metastatic disease. Orofacial pain associated with cancer management is a well- ●● Pain due to treatment: recognized adverse effect of treatment. Pain due to oral mucositis is ○○ Surgery. the most frequently reported patient-related complaint during cancer ○○ Radiation. therapy. Severe and painful mucositis is associated with additional ○○ Chemotherapy. hospital admissions and prolonged periods in hospital, leading to ●● Pain unrelated to malignancy. delayed, interrupted or altered cancer therapy protocols that may affect Pain at diagnosis is often low intensity but typically becomes more prognosis, QOL, and cost of care. Graft-vs.-host disease (GVHD) is frequent and severe with advancing disease. Cancer pain may be a common complication of allogeneic hematopoietic cell transplant caused by local and distant tumor effects. Direct invasion by cancer (HCT), occurring in 25 percent to 70 percent of patients; oral lesions may cause pain and may result from inflammatory and neuropathic are often painful. mechanisms. Effective prevention and management of pain in cancer In addition to HNCs, oral manifestations of leukemia and lymphoma requires knowledge of the factors and mechanisms involved. may cause pain and loss of function. Lymphomas and leukemias may

Page 16 Dental.EliteCME.com induce pain by infiltration of pain-sensitive structures and if secondary undiscovered malignancy in up to 60 percent of patients. Patients oral infection occurs. Multiple myeloma frequently presents with with nasopharyngeal cancer report pain that may be referred to the pain, and when associated with teeth, presents a diagnostic challenge. temporomandibular joint region and masquerade as temporomandibular Intracranial malignancies may give rise to orofacial pain and headache. disorder. Orofacial pain has been reported in patients with a distant Even in diagnosed cancer patients, the prediction of intracranial nonmetastasized cancer, most commonly in the lungs. metastases with new or changed headache is difficult. The mechanism of pain is thought to be involvement of the vagus or Pain may present similarly to classical trigeminal neuralgia. Jaw pain phrenic nerve. Paraneoplastic processes may present with peripheral may be caused by metastatic cancer, and tumors arising from the breast, neuropathies, particularly in patients with lung cancer and lymphoma. prostate, thyroid, lung and kidney have a propensity to spread to bone Neuropathies are commonly reported in patients with malignancy in the head and neck, most commonly seen in the posterior mandible. (1.7 percent to 5.5 percent) because of the direct effects of the tumor, Metastasis in the oral region may be the first indication of a distant paraneoplastic syndromes and treatment-related toxicities.

Orofacial pain due to cancer management The most common acute oral side effect of radiation therapy and to sensory impairment, and more than half of patients experience cancer chemotherapy is oral mucositis. Oral mucositis and associated regional hyperalgesia or allodynia. Pain scores after surgery for HNCs pain are the most distressing symptoms reported by patients receiving are highest for oral cavity cancers, followed by cancers of the larynx head and neck radiation therapy and aggressive neutropenia-inducing and oropharynx. chemotherapy regimens. Combined chemotherapy and radiation At more than six months post-surgery, impairment due to moderate therapy results in increased frequency, severity and duration of to severe pain may be seen in approximately one-third of patients. mucositis. Analgesics and physiotherapy are commonly used in pain management Mucositis pain may interfere with daily activities in approximately in these patients. Long-term HNC survivors (more than three years) one-third of patients, interfering with social activities and mood in continue to suffer from more pain and functional problems. Surgery- more than half. Mucosal pain may persist long after the mucositis related pain involves inflammatory and neuropathic pain mechanisms. resolves. Reports of mucosal sensitivity at one-year follow-up are Post-radiation osteonecrosis and bisphosphonate-associated common, suggesting that chronic symptoms may be related to tissue osteonecrosis are recognized oral complications that may cause pain; change, including epithelial atrophy or neuropathy. clinical presentation may include pain, swelling and bone exposure. Oral Orofacial pain after HNC therapy can be caused by musculoskeletal GVHD represents a local manifestation of a systemic disease post-HCT syndromes, including temporomandibular disorders associated that may result in mucosal and arthritic pain. Viral reactivation of herpes with muscular fibrosis, scar formation, and discontinuity of the jaw. viruses may cause pain. Post-herpetic neuralgia may result in chronic Ablative surgery may lead to tissue defects that may cause significant pain causing painful dysesthesias in the affected area that may persist for loss of orofacial function. Resection of the maxilla and mandible leads years. Treatment of pain in cancer patients Pain is defined as any sensory and emotional experience associated This section discusses evidence and application related to adult with actual or potential tissue damage, or described in terms of such practice, which may differ significantly from pain treatment for damage. Cancer pain can be managed effectively through relatively children. simple means in up to 90 percent of the 8 million Americans who Pain management should be directed at the diagnoses of etiologic have cancer or a history of cancer. Unfortunately, pain associated with factors, pain mechanisms involved, and pain severity. Pain cancer is frequently undertreated [283]. mechanisms in cancer include: Although cancer pain or associated symptoms often cannot be entirely ●● Inflammation. eliminated, appropriate use of available therapies can effectively ○○ Malignant disease. relieve pain in most patients. Pain management improves the patient’s ○○ Complications of treatment. quality of life throughout all stages of the disease. Patients with ○○ Infection. advanced cancer experience multiple concurrent symptoms with ●● Tumor invasion, pressure on structures, or ulceration of mucosal pain; therefore, optimal pain management necessitates a systematic surface. symptom assessment and appropriate management for optimal quality ●● Nociceptive pain. of life [156]. Despite the wide range of available pain management ●● Neuropathic pain. therapies, data are insufficient to guide their use in children, adolescents, older adults and special populations [188].

Management of pain due to oral mucositis Oral mucositis pain is associated with release of proinflammatory Pain experience is influenced by anxiety, depression, sociocultural cytokines and neurotransmitters that activate nociceptors at the site variation, and quality and quantity of sleep. of injury and may be increased by secondary mucosal infection.

Topical approaches for mucosal pain relief Topical anesthetics have a limited duration of effect in mucositis pain have not been subjected to controlled studies. However, these mixtures (15-30 minutes), may sting with application on damaged mucosa, result in dilution of each component, which may limit the therapeutic and affect taste and the gag reflex. Some patients will apply local effect. In addition, various agents in the mix may interact, reducing the anesthetics directly to specific sites of ulceration, but no controlled effect of the components. studies have been reported. Topical benzydamine (not available in the United States), an anti- Topical anesthetics are often mixed with coating and antimicrobial inflammatory and analgesic/anesthetic agent, has been shown in agents such as milk of magnesia, diphenhydramine or nystatin but randomized controlled studies to reduce pain in oral mucositis

Dental.EliteCME.com Page 17 and reduce the need for systemic analgesics [121]. Other topical ●● Topical fentanyl prepared as lozenges administered in a approaches include the following: randomized placebo-controlled study showed relief of oral ●● A single application of topical doxepin, a tricyclic antidepressant, mucositis pain. in cancer patients produces analgesia for four hours or longer [73]. ●● Topical capsaicin has been studied for the control of oral mucositis ○○ Besides producing an extended period of pain relief, pain but is poorly tolerated by patients. Pretreatment initiation of application of topical doxepin to damaged mucosa is not capsaicin may represent an approach to desensitize patients before accompanied by burning. the onset of mucositis. ●● Topical morphine has been shown to be effective for relieving pain Topical coating agents may reduce pain in mucositis. Coating [73], but there is concern about dispensing large volumes of the agents such as sucralfate may have a role to play in mucosal pain medication. management but not in reducing tissue damage. Systemic medications Pain management strategies directed at diagnoses and pain ●● Acupuncture. mechanisms include the following: ●● Psychological approaches: ●● Topical anesthetics/analgesics. ○○ Distraction. ○○ Topical before systemic therapies; if topicals are effective, ○○ Relaxation/imagery. continue while adding systemic analgesics. ○○ Cognitive/behavioral therapy. ●● Systemic analgesics. ○○ Music therapy, drama therapy. ●● Adjuvant medications (muscle relaxants, anti-inflammatories, anti- ○○ Counseling. anxiety medications, anti-depressants, anti-convulsants). ●● Adjuvant therapies (physiotherapy, relaxation, cognitive- Suggestions for the use of opioids in cancer pain include the following: behavioral therapies, counseling). ●● Use the lowest effective dose. ●● Palliative radiation therapy. ●● Base time-contingent prescription on drug characteristics. ●● Provide analgesics for breakthrough pain. Additional and nonpharmacologic pain management techniques in ●● Combine with nonopioid analgesics. oncology include the following: ●● Provide prophylaxis/treatment for constipation. ●● Transcutaneous electrical nerve stimulation. ●● Conduct regular pain assessment and modify management, ●● Cold/moist heat applications. depending on pain control. ●● Hypnosis. ●● Follow steps in World Health Organization (WHO) analgesic ladder.

WHO’s pain ladder

Analgesics should be provided on a time-contingent basis to provide a steady state of analgesia; when needed, medication should be available to manage breakthrough pain. Adjuvant medications such as tricyclic anti-depressants, gabapentin, and other centrally acting pain medications should be considered, particularly in light of the developing understanding of the common neuropathic mechanisms involved in cancer pain [18, 215, 211]. Regular assessment of pain and modification of pain medications are necessary. Transdermal fentanyl is widely used for extended duration therapy in the management of pain in the outpatient setting. Cyclooxygenase-2 (COX-2) is up-regulated in mucositis; therefore, COX-2 inhibitors represent potential agents that may affect pain and evolution of mucositis. Adjuvant medications should be used in addition to analgesics. Patients who experienced neuropathic cancer pain and received amitriptyline in addition to morphine were studied in a randomized controlled trial [155] [Level of evidence: I]. Limited additional analgesic effect and increased drowsiness, confusion and dry mouth The WHO analgesic ladder is a three-step strategy for managing pain in were observed; however, the central actions of amitriptyline may cancer patients [156]. Pain management must be directed at the severity improve sleep. of pain; the lowest dose of strong opioids (step 3 in the WHO ladder) Gabapentin is a voltage-sensitive sodium and calcium channel may be chosen instead of weak opioids for better pain control [68, 18]: blocker that is used for management of a variety of pain conditions If pain occurs, there should be prompt oral administration of drugs and may improve pain control when used in addition to morphine in in the following order: nonopioids (aspirin and paracetamol); cancer patients. Drugs that affect the N-methyl-D-aspartate receptor then, as necessary, mild opioids (codeine); then strong opioids may affect neuropathic pain; gabapentin is one of these and is well such as morphine, until the patient is free of pain. To calm fears tolerated. Other agents that may be used in pain management include and anxiety, additional drugs – “adjuvants” – should be used. To the following: maintain freedom from pain, drugs should be given “by the clock,” ●● Cannabinoids. that is every three to six hours, rather than “on demand.” This ●● Alpha-2 adrenergic receptor agonists. three-step approach of administering the right drug in the right ●● Nicotine. dose at the right time is inexpensive and 80-90 percent effective. ●● Lidocaine. Surgical intervention on appropriate nerves may provide further ●● Ketamine. pain relief if drugs are not wholly effective.

Page 18 Dental.EliteCME.com Addiction in opioid therapy is not generally a concern for cancer State and local laws often restrict the medical use of opioids to relieve patients; the focus should be on escalating to stronger opioids as cancer pain, and third-party payers may not reimburse for noninvasive needed (based on assessment) and using adjuvant approaches to pain-control treatments. Thus, clinicians should work with regulators, provide adequate pain relief. However, the clinician always should be state cancer pain initiatives or other groups to eliminate these health cognizant of potential drug-seeking behavior by the patient. care system barriers to effective pain management. (These and other Tolerance and physical side effects such as constipation, nausea, barriers to effective pain management are listed below.) Changes in vomiting and mental clouding occur with opioids and should be health care delivery may create additional disincentives for clinicians managed prophylactically, if possible. Stool softeners and other to practice effective pain management. approaches to bowel management should be initiated along with The U.S. Food and Drug Administration Amendments Act of 2007 the initial opioid prescription. Adequacy of the approach should be requires manufacturers to provide risk evaluation and mitigation strategies assessed regularly. (REMS) for selected drugs to ensure that benefits outweigh risks. A major component of REMS requires prescribers to obtain training so that these drugs can be safely used. Barriers to effective pain management ●● Problems related to health care professionals: clinical approach outlined below emphasizes a focus on patient ○○ Inadequate knowledge of pain management. involvement. ○○ Poor assessment of pain [28, 260, 224]. Ask about pain regularly. Assess pain and associated symptoms ○○ Concern about regulation of controlled substances. systematically using brief assessment tools. Assessment should include ○○ Fear of patient addiction [260]. discussion about common symptoms experienced by cancer patients ○○ Concern about side effects of analgesics [28, 260]. and how each symptom will be treated [156, 188]. Asking a patient to ○○ Concern about patients becoming tolerant to analgesics. identify his or her most troublesome symptom is also of clinical value ●● Problems related to patients: because the most troublesome symptom is not always the most severe, ○○ Reluctance to report pain. as demonstrated in a survey of 146 patients in the palliative phase of ○○ Concern about distracting physicians from treatment of treatment for lung, gastrointestinal or breast cancer [98]. underlying disease. 1. Believe patient and family reports of pain and what relieves the pain ○○ Fear that pain means disease is worse. (caveats include patients with significant psychological/existential ○○ Concern about not being a “good” patient. distress and patients with cognitive impairment) [3, 224]. ○○ Reluctance to take pain medications. 2. Choose pain-control options appropriate for the patient, family and ○○ Fear of addiction or of being thought of as an addict (this fear setting. may be more pronounced in minority patients) [8]. 3. Deliver interventions in a timely, logical, coordinated fashion. ○○ Worries about unmanageable side effects (such as constipation, 4. Empower patients and their families. Enable patients to control nausea or clouding of thought). their course as much as possible. ○○ Concern about becoming tolerant to pain medications. ○○ Poor adherence to the prescribed analgesic regimen [157]. In summary, effective pain management is best achieved by a team ○○ Financial barriers [260]. approach involving patients, their families and health care providers. ●● Problems related to the health care system: The clinician should: ○○ Low priority given to cancer pain treatment [28]. ●● Initiate prophylactic anti-constipation measures in all patients ○○ Inadequate reimbursement for pain assessment and treatment. (except those with diarrhea) before or during opiate administration. ○○ The most appropriate treatment may not be reimbursed or may (For more information, refer to Constipation and Side Effects be too costly for patients and families [260]. of Opioids at: http://www.cancer.gov/cancertopics/pdq/ ○○ Restrictive regulation of controlled substances. supportivecare/pain/HealthProfessional/Page3#Section_169). ○○ Problems of availability of treatment or access to it. ●● Discuss pain and its management with patients and their families. ○○ Opioids unavailable in the patient’s pharmacy. ●● Encourage patients to be active participants in their care. ○○ Unaffordable medication. ●● Reassure patients who are reluctant to report pain that there are many safe and effective ways to relieve pain. Flexibility is the key to managing cancer pain. As patients vary in ●● Consider the cost of proposed drugs and technologies. diagnosis, stage of disease, responses to pain and interventions, and ●● Share documented pain assessment and management with other personal preferences, so must pain management. The recommended clinicians treating the patient. ●● Know state and local regulations for controlled substances. Nonpharmacologic pain management strategies In randomized trials, hypnosis has been shown to be a useful pain cancer. Pain management requires diagnosis of the various causes and management strategy for cancer patients. Additional psychological mechanisms of pain in cancer patients, and practitioners must obtain techniques such as counseling, distraction, relaxation techniques and regular pain ratings during the treatment of patients with cancer-related other cognitive and behavioral training programs have been described. pain. Because pain is frequently multifactorial, addressing each of the Physical management of orofacial pain includes the use of ice chips dimensions of a patient’s pain can improve pain control. Attention for oral cooling, cold compresses and physical therapy. Acupuncture, should be paid to the patient’s overall medical status and oral status. transcutaneous nerve stimulation, group therapy, self-hypnosis, Appropriate pain treatment requires the recognition and management relaxation, imagery, cognitive behavioral training and massage therapy of side effects of analgesic therapy, especially those induced by opioids have been considered to alleviate pain in cancer patients. Relaxation and adjuvant medications. Use of effective topical pain therapy with and imagery may alleviate pain caused by oral mucositis [73, 121, the initial mucosal injury may allow for reduced duration or reduced 155] [Level of evidence: I] [74]. doses of systemic medications. Awareness of adjuvant approaches In summary, orofacial pain is common in cancer patients and may be to management is essential; both medications and complementary caused by the cancer or its treatment. It is frequently associated with management with evidence of effect should be considered. locoregional cancer, but can also be a sign of systemic and distant

Dental.EliteCME.com Page 19 Infection The multiple protective-barrier functions associated with normal neutrophil count falls below 1,000/mm3, incidence and severity oral mucosa directly affect risk of acute infection. Normal oral of infection rise [88]. Patients with prolonged neutropenia are at mucosa reduces levels of oral microorganisms colonizing the mucosa higher risk of developing serious infectious complications [88, 295]. by shedding the surface layer; it also limits penetration of many Compromised salivary function can elevate risk of infection of oral compounds into the epithelium by maintaining a chemical barrier origin. [253]. Normal salivary gland function promotes mucosal health. Other oral sites, including the dentition, periapices and periodontium, Oral mucositis can be complicated by infection in the can also become acutely infected during myelosuppression secondary immunocompromised patient. Specific organisms may play a role to high-dose chemotherapy [199, 92, 2, 29]. A systematic review of the in up-regulating proinflammatory cytokines via bacterial metabolic MEDLINE/PubMed and EMBASE databases for articles published products such as liposaccharides. Also, oral organisms can disseminate between January 1, 1990, and December 31, 2008, reported (from systemically in the setting of ulcerative oral mucositis and profound, three studies) that the weighted prevalence of dental infection/abscess prolonged neutropenia [253, 234, 59, 123, 220]. during chemotherapy was 5.8 percent (standard of error, 0.009; 95 percent confidence interval [CI], 1.8-9.7) [102]. Dental management Both indigenous oral flora and hospital-acquired pathogens have been before cytoreductive therapy is initiated can substantially reduce the associated with bacteremias and systemic infection. As the absolute risk of these infectious complications [200, 248, 194].

Bacterial infection Changes in infection profiles in myelosuppressed cancer patients have ●● Gentle mechanical plaque removal, including dental brushing and occurred over the past three decades. This evolving epidemiology has flossing. been caused by multiple factors, including the use of prophylactic and Pulpal/periapical infections of dental origin can cause complications therapeutic antimicrobial regimens and decreased depth and duration for the chemotherapy patient [200]. Such lesions should be eliminated of myelosuppression via growth factor therapy [169]. Gram-positive before chemotherapy begins. Prechemotherapy endodontic therapy organisms, including viridans streptococci and Enterococci species, are should be completed at least 10 days before chemotherapy begins. associated with systemic infection of oral origin. In addition, gram- Teeth with poor prognoses should be extracted, using the 10-day negative pathogens, including Pseudomonas aeruginosa, Neisseria window as a guide. Specific management guidelines are delineated in species and Escherichia coli, remain of concern. the NIH Consensus Conference statement [200, 248]. Myeloablated cancer patients with chronic periodontal disease may Ill-fitting, removable prosthetic appliances can traumatize oral develop acute periodontal infections, with associated systemic sequelae mucosa and increase the risk of microbial invasion into deeper [234, 199, 92, 2, 209]. Extensive ulceration of sulcular epithelium tissues. Denture-soaking cups can readily become colonized with a associated with periodontal disease is not directly observable yet variety of pathogens, including P. aeruginosa, E. coli, Enterobacter may represent a source of disseminated infection by a wide variety species, Staphylococcus aureus, Klebsiella species and Candida of organisms. Inflammatory signs may be masked by the underlying albicans. Dentures should be evaluated before chemotherapy begins myelosuppression. Thus, neutropenic mouth care protocols that reduce and adjusted as necessary to reduce risk of trauma. Denture-cleansing microbial colonization of the dentition and periodontium are important solutions should be changed daily. In general, dentures should not be during myelosuppression. Topical therapy may include the following: worn when the patient has ulcerative mucositis and is neutropenic (i.e., ●● Oral rinses with 0.12 percent chlorhexidine digluconate. absolute neutrophil count less than 500 cells/mm3). ●● Irrigation with effervescent (peroxide) agents, which may affect anaerobic bacteria colonizing the periodontal pocket.

Fungal infection ●● Candidiasis patients [70, 237]. Patients who wear removable dental ○○ Candidiasis is typically caused by opportunistic overgrowth prostheses (e.g., partial or full denture) should remove them of C. albicans, a normal inhabitant of the oral cavity in a before the oral anti-fungal agents are used. Dentures can also be large proportion of individuals. Several variables contribute treated by soaking them overnight in the anti-fungal solution. to its clinical expression, including drug- or disease-induced ○○ Although topical agents may be helpful for superficial immunosuppression, mucosal injury and salivary compromise. oral candidiasis, systemic agents should be used for In addition, use of antibiotics may alter the oral flora, thereby persistent fungal infections and in patients with significant creating a favorable environment for fungal overgrowth [26]. immunosuppression. Systemic fluconazole is highly effective ○○ A systematic review indicated that the weighted mean for prophylaxis and treatment of oral fungal infections in the prevalence of clinical oral fungal infection during oncology population [133]. chemotherapy is 38 percent [133]. The most common forms ●● Noncandidal fungal infections of intraoral candidiasis reported in oncology patients are ○○ An increasing number of different fungal organisms are pseudomembranous and erythematous candidiasis [179, 76]. being associated with oral infection in immunocompromised Pseudomembranous candidiasis can usually be diagnosed cancer patients, including infection by species of Aspergillus, on the basis of its characteristic clinical appearance and Mucormycosis, and Rhizopus [234, 237]. The clinical may be accompanied by burning pain and taste changes. presentation is not pathognomonic; lesions may appear similar The appearance of erythematous candidiasis is relatively to lesions caused by other oral toxicities. Microbiologic nonspecific, and laboratory testing may be needed to confirm documentation is essential. Systemic therapy must be instituted the diagnosis. It may be accompanied by a burning sensation promptly because of the high risk of morbidity and mortality. of the affected tissues. ○○ Topical oral anti-fungal agents such as nystatin rinse and clotrimazole troches are often used but appear to have variable efficacy in preventing or treating fungal infection in neutropenic

Page 20 Dental.EliteCME.com Viral infections ●● Herpes virus a drug to avoid for routine HSV prophylaxis because of ○○ Herpes group viral infections, including those caused by substantial renal toxicity. oral lesions, can cause a variety of diseases that range from ○○ These guidelines extend beyond the MSG systematic review, mild to serious conditions in patients undergoing treatment which failed to provide sufficient evidence (e.g., regarding for cancer [69]. The severity and impact of these lesions CMV, VZV, and EBV infections) because the evidence and systemic sequelae are directly related to the degree of available is not specific for infections with oral involvement. immunecompromisation of the patient. Comorbid oral conditions The guidelines of these three U.S. societies are in line with the such as mucositis or graft-vs.-host disease can dramatically recommendations of the German Society of Hematology and increase the severity of oral lesions and significantly increase the the European Group for Blood and Marrow Transplantation difficulty of diagnosis. [128]. ○○ In most instances, herpes simplex virus (HSV), varicella- ○○ Early diagnosis and prompt therapy remain hallmarks of zoster virus (VZV), and Epstein-Barr virus (EBV) infections management. Unfortunately, the available literature [69] and result from reactivation of latent virus, while cytomegalovirus the CDC and ASBMT guidelines [41, 259] do not refer to (CMV) infections can result from either reactivation of a latent treatment recommendations once a viral infection is diagnosed. virus, or via a newly acquired virus. The viral infections can As with other infections, risk of systemic dissemination cause oral mucosal lesions. The prevalence of HSV infection and morbidity/mortality increases with degree and duration was found to be higher when oral ulcers existed than when no of immunocompromisation. The infections can be fatal, oral ulcers were present [69]. depending on degree of immunosuppression. ○○ A systematic review was conducted by the Mucositis Study ●● Herpes simplex virus Group (MSG) of the Multinational Association of Supportive ○○ Oral herpetic lesions can range from routine herpes labialis to Care in Cancer/International Society of Oral Oncology severe stomatitis causing large, painful ulcerations throughout [69]. One of the aims of this review was to evaluate studies the mouth. The severity of lesions dramatically increases with conducted since 1989 that considered the prevalence of oral increasing degrees of immunosuppression. The incidence of viral infections. The reported prevalence of oral HSV infection recurrent oral HSV lesions in myelosuppressed cancer patients was 49.8 percent (95 percent CI, 31.3-68.2 percent) among has been considerably reduced with the use of prophylactic neutropenic cancer patients. The prevalence was much lower acyclovir and valacyclovir regimens [139, 212]. Additionally, in head and neck cancer (HNC) patients who were treated the severity and duration of actual HSV lesions have been with radiation therapy (0 percent); however, it rose to 43.2 reduced by anti-viral therapies. percent (95 percent CI, 0-100 percent) in irradiated HNC ○○ Breakthrough infections are uncommon but can occur. While patients who were treated with radiation therapy combined true resistance to anti-virals occurs, clinical infection in the with chemotherapy. This finding is not surprising because face of anti-viral therapy is more likely caused by insufficient neutropenic patients – mainly patients with hematological dosing or compromised gastrointestinal absorption of oral malignancies – develop deeper immunosuppression during acyclovir. The introduction of valacyclovir appears to have cancer treatment than do other groups of cancer patients. reduced the incidence of breakthrough oral HSV infections. However, the addition of chemotherapy to the conventional Topical therapy alone is generally not efficacious in the radiation therapy increased risks for HNC patients. immunocompromised patient. ○○ With the recognition of the increased risk of HSV and VZV ○○ In patients who are not receiving anti-viral prophylaxis, oral reactivation in seropositive patients who are expected to lesions typically emerge concurrent with chemotherapy or become profoundly immunosuppressed during cancer therapy, chemoradiation therapy during the period of most significant prophylaxis with anti-viral medications has drastically reduced immunosuppression (white blood cell nadir). Typically, in HSCT the incidence of disease, primarily in patients receiving high- patients, this represents the period a few days pretransplant dose chemotherapy and undergoing hematopoietic stem cell through day 35 post-transplant. The risk of HSV reactivation transplant (HSCT). The MSG systematic review identified a remains higher than normal until immune reconstitution occurs. series of randomized controlled trials testing various anti- Similar patterns of risk are noted in patients who are receiving viral prophylactic protocols [69]. It concluded that there was high-dose (immunosuppressive) chemotherapy. a significant benefit to using acyclovir to prevent HSV oral ○○ Recurrent oral HSV infections occurring simultaneously infection (at 800 mg/d) [24] [Level of evidence: I]. In addition, with cancer therapy-induced oral mucositis can result in the the systematic review pointed out that HSV reactivation development of extensive, confluent mucosal ulcerations was reported in a similar prevalence whether acyclovir or clinically similar to primary herpetic stomatitis. As such, valacyclovir was prescribed and that the prevention of HSV HSV stomatitis can be confused with cancer therapy- reactivation was achieved in various dosing protocols of induced ulcerative mucositis. Viral cultures from lesions valacyclovir (500 or 1,000 mg/d) [279]. in HSV seropositive patients are essential for accurate ○○ The Centers for Disease Control and Prevention (CDC), diagnoses. Assays that produce more rapid results, including the Infectious Diseases Society of America (IDSA), and the direct immunofluorescence, shell vial testing, and specific American Society for Blood and Marrow Transplantation immunoassay for HSV antigen and biopsy, may also be useful. (ASBMT) have published guidelines for the prevention of ○○ Unlike in myelosuppressed cancer patients, incidence of opportunistic infections in HSCT recipients, which have HSV reactivation in patients undergoing head and neck become a benchmark in this field [41, 259]. This significant radiation is very low [69]. Therefore, HSV prophylaxis in body of literature presents a global perspective on the patients scheduled to receive head and neck radiation is not prevention of viral infections. CDC, IDSA and ASBMT recommended. concluded that acyclovir prophylaxis is recommended for all ●● Varicella-zoster virus HSV seropositive allograft recipients. Valacyclovir instead ○○ VZV infection classically distributes via dermatomes, of acyclovir has been ranked moderately as an effective although the clinical manifestations can be altered in prevention for HSV in HSCT; foscarnet was mentioned as immunocompromised patients, and multiple dermatomes or more widespread distribution of lesions can be seen.

Dental.EliteCME.com Page 21 In patients who are receiving high-dose chemotherapy, patients and solid organ transplant patients. The lesion does orofacial VZV lesions are typically observed several weeks not appear to be clinically significant in chemotherapy after cessation of chemotherapy – unlike HSV, which often recipients, however. In contrast, HSCT patients who are occurs within two to three weeks after chemotherapy is immunocompromised for a prolonged period may be at risk discontinued. For reasons that are not entirely clear, the period of developing EBV-related lymphomas of the head and neck of increased risk of VZV reactivation essentially extends region, especially when T-cell-depleted grafts are used for from approximately three to 12 months post-transplant, allogeneic transplant. As such, risk of EBV infection typically with allogeneic transplant recipients being at highest risk. emerges months after cessation of myeloablative therapy used Acyclovir, valacyclovir and famciclovir are the primary drugs for transplant conditioning. used for treatment [116]. ○○ EBV has been associated with nasopharyngeal carcinomas ●● Cytomegalovirus [130]. After treatment (surgery or radiation therapy), anti- ○○ Oral lesions associated with CMV have been documented EBV antibody titers are often noted to decrease; subsequent in immunocompromised patients, including those who have increases in titers can be associated with recurrence. undergone marrow transplantation [234]. Appearance is ●● Non-herpes group virus infections not pathognomonic and is characterized by multiple mild ○○ Infections caused by non-herpes viruses are more common to moderate ulcerations with irregular margins. The lesions in immunocompromised patients, with the risk of infection initially present during early periods of marrow regeneration apparently increasing with the depth and duration of (e.g., three weeks after chemotherapy is discontinued) and immunosuppression. Oral lesions caused by adenovirus and are characterized by nonspecific pseudomembranous fibrin oral human papilloma virus (HPV) have been described exudate-covered ulcerations with a granulomatous-appearing [234]. Often, patients with increased cutaneous HPV lesions base. Surface swab cultures may yield false-negative results, will demonstrate oral lesions. These lesions can present as perhaps because of viral propensity for infecting endothelial hyperkeratotic verrucoid lesions or as flat acuminata-like cells and fibroblasts, with resulting low levels of free virus. lesions. ○○ Shell vial cultures can enhance identification of CMV, but CMV- ○○ Restoration of immune function will often result in a digression specific immunohistochemical staining of biopsy specimens and possibly the disappearance of the oral mucosal lesions. Laser remains the gold standard. Ganciclovir is the treatment of choice surgery or cryotherapy are typically used to remove oral HPV for acute CMV infection. Improved prophylactic measures lesions when medically or cosmetically required; intralesional have reduced the incidence of both primary and recurrent CMV injections of interferon-alpha may prove effective for recurrent infections [37]. lesions. Infection with Coxsackie viruses can occur but is ●● Epstein-Barr virus generally viewed as uncommon. Although adenovirus infections ○○ EBV is linked to tumor development [118]. In addition, are often implicated as a potential cause of oral lesions, their true oral hairy leukoplakia has been attributed to EBV infection incidence is not known [234]. in immunocompromised patients, as seen in HIV-infected

Hemorrhage Hemorrhage may occur during treatment-induced thrombocytopenia or The degree of health professional oversight of thrombocytopenic coagulopathy and is a concern for patients who are receiving high-dose patients is an important consideration relative to the risk of mechanical chemotherapy or undergoing hematopoietic stem cell transplantation hygiene procedures. With comprehensive monitoring, patients [234]. Spontaneous gingival oozing may occur when platelet counts can often safely use dental brushing and flossing throughout the drop below 20,000/mm3, especially when there is preexisting gingivitis thrombocytopenic episode. Foam brushes are recommended by or periodontitis. Even normal function or routine oral hygiene some practitioners. However, studies have shown that foam brushes (brushing and flossing) can induce gingival oozing in the face of cannot adequately remove dental plaque along gingival margins, thus preexisting gingivitis and periodontitis. promoting gingival infection and bleeding. Although rarely serious, oral bleeds can be of concern to the patient Management of oral bleeds revolves around the use of and family. Oral bleeding may be mild (e.g., petechiae located on vasoconstrictors, clot-forming agents and tissue protectants: the lips, soft palate or floor of the mouth) or severe (e.g., persistent ●● Epinephrine or cocaine can be used topically to reduce blood flow gingival hemorrhage or bleeding from herpes simplex virus ulcers in rates through bleeding vessels. the face of severe thrombocytopenia). ●● Topical thrombin or hemostatic collagen agents can be used to It is not uncommon for oncology patients to be told specifically to not organize and stabilize clots. use toothbrushes and dental floss when their platelet counts drop below ●● Application of mucosal adherent products (including cyanoacrylate 40,000/mm3. This is generally poor advice unless there are extenuating products) help seal bleeding sites and protect organized clots. circumstances. Healthy gingival tissues do not bleed unless traumatized. Patients who tend to form friable and easily dislodged clots will benefit Discontinuation of routine oral hygiene can increase the risk of infection from topical application of aminocaproic acid; in some instances, that could not only promote bleeding but also increase the risk of local intravenous administration can be considered to improve coagulation and systemic infection caused by accumulation of bacterial plaque, and the formation of stable clots. leading to periodontal infections and tissue breakdown. Such issues Application of 3 percent hydrogen peroxide and 0.9 percent saline further support the utility of pre-cancer therapy dental treatments to (1:2 to 1:3 by volume) can aid in wound cleansing and removal of reduce or eliminate gingival or periodontal conditions. superficial blood debris. Care must be taken not to disturb clots, which might promote bleeding [234].

Neurotoxicity Selected classes of chemotherapy, including the vinca alkaloids, associated with peripheral neuropathies that can affect the face and vincristine and vinblastine, can cause direct neurotoxicity. jaw. Deep-seated, throbbing mandibular pain can occur. Because Additionally, drugs such as thalidomide and lenalidomide are this symptom is also consistent with acute dental pulpal disease, it

Page 22 Dental.EliteCME.com is important that a thorough history and oral physical examination they can persist for several months. Topical application of fluorides and be performed when oral pain is present; radiographs and vitality desensitizing toothpaste may ameliorate the discomfort. testing of the dental pulp are typically necessary. After neurotoxicity Patients may experience temporomandibular dysfunction pain is appropriately diagnosed, management includes pain support and involving muscles of mastication, temporomandibular joints, or teeth. patient counseling. The symptom generally resolves within a week of This condition is not unique to cancer patients, and it correlates with discontinuing the causative chemotherapy. stress and dysfunctional habits including bruxism and clenching of Dental hypersensitivity may occasionally arise in patients weeks or the jaws. Stress and sleep dysfunction appear to be the most frequent months after they discontinue chemotherapy. Additionally, it has been etiologic factors. Judicious use of muscle relaxants or anxiety-reducing observed that patients being treated with cyclosporine for treatment agents plus physical therapy (moist heat applications, massage and of graft-vs.-host disease will report increased thermal sensitivity. The gentle stretching) are standard approaches for management. For mechanisms of this response are not known. Fortunately, thermal stimuli patients with a propensity for clenching or bruxism during sleep, are self-resolving after discontinuation or withdrawal of therapy, though customized occlusal splints for use while sleeping may be of value.

Graft-vs.-host disease Patients who have received allogeneic or matched unrelated transplants management of GVHD with systemic therapy will usually see are at risk of developing graft-vs.-host disease (GVHD) [235, 61]. A resolution or significant resolution of this problem. However, in rare related condition referred to as pseudo-GVHD is occasionally reported instances, surgical or chemical techniques to disrupt fibrotic bands can in autologous hematopoietic stem cell transplant recipients. GVHD can be required to improve the oral opening. affect oral tissues and often mimics naturally occurring autoimmune ●● Management of oral GVHD diseases such as erosive lichen planus, pemphigus, scleroderma ○○ Topical steroids: and Sjögren syndrome. Oral GVHD has also been linked to oral ■■ Rinses: dexamethasone elixir (Decadron 0.1 mg/mL). precancerous and malignant lesions [1]. ■■ Gels, creams: Acute GVHD can occur as early as two to three weeks post-transplant; □□ Fluocinonide (Fluonex). mucosal erythema and erosion/ulceration are typical manifestations. □□ Clobetasol (Temovate). Chronic oral GVHD changes can be recognized as early as day 70 □□ Halobetasol (Ultravate). post-transplant [234]. The pattern and types of lesions seen in acute □□ Betamethasone (Celestone). GVHD are also seen in chronic GVHD, but manifestations can also ■■ Powders: Beclomethasone (Beclovent) (inhalers applied to include raised white hyperkeratotic plaques and striae and persistent mucosa). reduced salivary function. Oral symptoms of oral GVHD include ○○ Other topical immunosuppressants: xerostomia and increased sensitivity and pain with spices, alcohols and ■■ Azathioprine rinse (Imuran; 5–10 mg/mL). flavoring agents (especially mint flavors in toothpaste and oral care ■■ Cyclosporin (Neoral). products). Patients may also suffer from odynophagia and dysphagia ○○ Anti-fungals (when concomitant oral fungal infection is due to gastrointestinal involvement [232]. All of these symptoms of documented): GVHD may lead to weight loss and malnutrition [109]. ■■ Topical preparations: □□ Nystatin (Mycostatin). Biopsy of oral mucosa, including both surface epithelium and □□ Clotrimazole (Mycelex). minor labial salivary glands, may be of value in establishing a final □□ Amphotericin solution (Amphocin; in the United diagnosis [144, 290]. Presence of a lymphocytic infiltrate (grade I) States, this is compounded). with epithelial cell necrosis (grade II) provides the diagnostic basis ■■ Systemic agents: for oral GVHD. As clinical criteria for recognition of oral signs and □□ Fluconazole (Diflucan). symptoms of GVHD have become more established, dependence □□ Itraconazole (Sporanox). on the oral biopsy to diagnose oral involvement has lessened. In ■■ PUVA. cases of equivocal examination findings, the biopsy can improve the ○○ Sialogogues: recognition of oral involvement. ■■ Cevimeline (Evoxac). Topical management of mucosal lesions may include steroids, ■■ Pilocarpine (Salagen). azathioprine, or oral psoralen and ultraviolet A (PUVA) therapy (refer ■■ Bethanechol. to the list on Management of oral chronic GVHD, below) [234, 75]. ○○ Topical anesthetics: While topical cyclosporin has been suggested as therapeutically ■■ Lidocaine (Xylocaine). beneficial, its effectiveness is less predictable than that of other ■■ Dyclonine (Dyclone). treatments – which, when coupled with increased cost of care, usually ■■ Diphenhydramine (Benadryl). decreases its utility. The use of FK506 and mycophenolate mofetil ■■ Doxepin (Zonalon). to topically treat oral GVHD remains anecdotal and of uncertain ○○ Dental caries prevention: efficacy. Systemic therapy (e.g., prednisone, budesonide, cyclosporine, ■■ Oral hygiene (dental plaque removal). mycophenolate mofetil and other immunosuppressive agents) is ■■ Fluorides: routinely necessary, primarily to treat the condition. Topical treatment □□ Adult patients: brush-on products, rinses, home-use can be used to specifically manage oral sensitivity and help heal trays. ulcerations. Patients with clinically significant xerostomia may benefit □□ Pediatric patients: brush-on gel (if patient can from pilocarpine (5 mg three or four times a day) or cevimeline (10 dependably expectorate the fluoride gel after mg four times a day) if native salivary gland function remains partially application). [Note: If drinking water does not contain intact. enough fluoride to prevent tooth decay, oral fluoride (e.g., drops or vitamins) should be provided to children Submucosal and dermal fibrosis can occur in persistent cases of younger than 12 years.] chronic GVHD. This scleroderma-like complication can be subtle ■■ Remineralizing solution (calcium phosphate ± fluoride and appear as slight mucosal or skin tightness, or it can progress preparations). to skin thickening and fibrosis. Intraoral submucosal fibrotic bands have been noted to significantly restrict the oral opening. Successful

Dental.EliteCME.com Page 23 Post-transplantation dental treatment Caution should be exercised when considering dental treatment for additionally, bacteremias often occur as a result of dental treatment, transplant patients until immune reconstitution has occurred; the time and their impact can be noticeable. frame for this reconstitution can vary from six months to 12 months. For patients who need urgent or emergency dental treatment, Although hematologic parameters, including complete blood count and prophylactic antibiotics and strategies to reduce the potential influence differential, may be documented as within normal limits, functional of aspirating dental aerosols should be used. Additional administration immune abnormalities may still be present. Patients should not resume of antibiotics should be determined by the patient’s risk of infection routine dental treatment, including dental scaling and polishing, until caused by the presenting condition or as a sequela of treatment. adequate immunologic reconstitution has occurred; this includes recovery from graft-vs.-host disease. The aerosolization of debris Appropriate supportive care – including antibiotics, immunoglobulin and bacteria during the use of ultrasonic or high-speed rotary cutting G administration, adjustment of steroid doses, and platelet transfusions instruments can put the patient at risk for aspiration pneumonia; – should be comprehensively considered before invasive oral procedures are undertaken.

Relapse and second malignancy Gingival infiltrates, oral infection, and bleeding disproportionate to and radiation therapy and alterations in immune function, graft-vs.- local etiology can indicate possible relapsed disease, especially in host disease (GVHD), and GVHD therapy collectively contribute to patients treated for leukemias or lymphomas. Additionally, localized risk of second malignancy. Oral squamous cell carcinoma is the most oral plasmacytomas have been observed in patients relapsing early frequently occurring secondary oral malignancy in transplant patients, post-autologous transplantation for multiple myeloma. Painless with the lips and tongue being the most frequently reported sites. unilateral lymphadenopathy can also represent relapse in patients with ●● Dysgeusia previously treated lymphoma. Lymphoproliferative diseases occurring In stem cell transplant patients, dysgeusia can occur secondary as second primary malignancies post-transplant must be considered for to either chemotherapy/chemoradiation conditioning or graft- soft tissue masses and lymphadenopathy noted in transplant recipients. vs.-host disease. Refer to the section on Conditions affected by Incidence of second malignancy steadily increases as cancer patients both chemotherapy and head/neck radiation in this summary for survive longer post-transplant. Previous exposure to chemotherapy management recommendations.

Oral toxicities not related to chemotherapy or radiation therapy ●● Bisphosphonate-associated osteonecrosis (BON) those of many malignant and nonmalignant diseases. However, ○○ Bisphosphonates are potent inhibitors of osteoclasts. diagnosis and timely interventions not only are lifesaving in They are used in cancer patients with skeletal metastasis, the short term but also may enhance the patient’s compliance including breast, prostate or lung cancer; and in patients with primary and supportive treatments and may improve with multiple myeloma. Bisphosphonates are also used to quality of life [5]. treat hypercalcemia of malignancy. (Refer to section on ○○ When a patient has a refractory, widely disseminated Hypercalcemia, below) Bisphosphonates reduce the risk of malignancy for which specific therapy is no longer being fracture and skeletal pain, improving the quality of life of pursued, the patient may want to consider withholding patients with malignant bone disease [159]. therapy for hypercalcemia. For patients or families who have ○○ Bisphosphonate osteonecrosis (BON) is an oral complication of expressed their wishes regarding end-of-life issues, this may bisphosphonate therapy in cancer patients [162]. First reported in represent a preferred timing or mode of death (as compared 2003 [151, 164], BON is defined as the unexpected appearance with a more prolonged death from advancing metastatic of exposed necrotic bone anywhere in the oral cavity of an disease). This option is best considered long before the onset individual who is receiving a bisphosphonate and who has not of severe hypercalcemia or other metabolic abnormalities that received radiation therapy to the head and neck. The exposed impair cognition, so that the patient may be involved in the bone persists for six to eight weeks despite the provision of decision-making. standard dental care. It is also possible that symptoms of dental ■■ Normal calcium homeostasis or periodontal disease may be present, without visible exposed □□ Hormonal influences bone [5]. The occurrence of BON is based on cases reported Calcium homeostasis is maintained by two hormones, in the literature, and occurrence ranges between 1 percent and parathormone (parathyroid hormone or PTH) and 10 percent for patients receiving the intravenous formulation calcitriol (1,25-dihydroxy vitamin D). Minute- (pamidronate and zoledronic acid) and less than 1 percent for to-minute regulation of serum-ionized calcium is patients taking oral bisphosphonate [288, 126]. regulated by PTH. PTH secretion is stimulated when ●● Hypercalcemia ambient serum-ionized calcium is decreased. PTH ○○ Hypercalcemia is the most common life-threatening metabolic acts on peripheral target cell receptors, increasing disorder associated with neoplastic diseases, occurring in an the efficiency of renal tubular calcium reabsorption. estimated 10 percent to 20 percent of all adults with cancer. In addition, PTH enhances calcium resorption from It also occurs in children with cancer, but with much less mineralized bone and stimulates conversion of vitamin frequency (approximately 0.5 percent-1 percent). Solid tumors D to its active form, calcitriol, which subsequently (such as lung or breast cancer tumors) as well as certain increases intestinal absorption of calcium and hematologic malignancies (particularly multiple myeloma) are phosphorus. Pharmacologic doses of calcitonin act as most frequently associated with hypercalcemia. an antagonist to PTH, lowering serum calcium and ○○ Although early diagnosis followed by hydration and treatment phosphorus and inhibiting bone reabsorption. with agents that decrease serum calcium concentrations ■■ Mechanisms of cancer-associated hypercalcemia (hypocalcemic drugs) can produce symptomatic improvements The fundamental cause of cancer-induced hypercalcemia is within a few days, diagnosis may be complicated because increased bone resorption with calcium mobilization into the symptoms may be insidious at onset and can be confused with extracellular fluid and, secondarily, inadequate renal calcium

Page 24 Dental.EliteCME.com clearance. Two types of cancer-induced hypercalcemia bisphosphonate used. For example, studies in which patient evaluation have been described: osteolytic hypercalcemia and humoral and follow-up are conducted by dental professionals seem to have hypercalcemia. Osteolytic hypercalcemia results from direct an overall prevalence of 7.3 percent, whereas survey studies of large bone destruction by primary or metastatic tumor. Humoral populations of patients have a prevalence of less than 1 percent. If the hypercalcemia is mediated by circulating factors secreted prevalence is calculated on the basis of type of bisphosphonate used, the by malignant cells without evidence of bony disease. It prevalence of cases of BON when a combination of zoledronic acid and is believed that hypercalcemia results from the release of pamidronate is used over the course of therapy can be as high as 24.5 factors by malignant cells that ultimately cause calcium percent [163]. The mandible is affected in approximately 68 percent of reabsorption from bone. cases, the maxilla in about 28 percent of cases, and both jawbones in ■■ Potentiating factors: approximately 4 percent of cases [150]. This complication is exclusively □□ Immobility is associated with an increase in resorption seen in the head and neck area. However, there have been reports of of calcium from bone. Dehydration, anorexia, nausea, evidence of BON in other parts of the head and neck and skeleton [207, and vomiting that exacerbate dehydration reduce renal 125, 143]. calcium excretion. Risk factors for BON include: □□ Hormonal therapy (estrogens, anti-estrogens, ●● Dental extractions [270][Level of evidence: II] [99]. androgens, and progestins) may precipitate ●● Ill-fitting dentures [270]. hypercalcemia. Thiazide diuretics increase renal ●● Intravenous bisphosphonate (zoledronic acid, denosumab) [270, calcium reabsorption and may precipitate or 99] [Level of evidence: I] [163, 255]. exacerbate hypercalcemia. ●● Time on medication [163, 99]. □□ Hematologic malignancies may stimulate osteoclastic ●● Multiple myeloma [163]. bone resorption through the production of cytokines such as TNF-alpha and -beta and interleukin-1 and -6, The incidence of BON may be reduced by the implementation of formerly referred to as osteoclast-activating factor(s). dental preventive measures before bisphosphonate therapy is initiated in solid-tumor patients with bone metastasis [217]. A study evaluating the literature until December 2008 found that the prevalence of BON can vary according to study design and the type of

Diagnosis of BON Diagnosis of BON can be clinically challenging. The two most ●● Occasional: A cancer patient who complains of oral pain and common clinical presentations are as follows: discomfort, but a definitive diagnosis of BON cannot be made ●● Classical: A cancer patient with skeletal metastasis who is receiving because no clinically exposed bone is evident. In these patients, intravenous bisphosphonate therapy and who presents with visible the most likely clinical diagnosis should be addressed first. It necrotic bone in the oral cavity. The site may be infected and is important to recognize that zoledronic acid administration painful; these conditions are the typical reason for referral to a can result in bone pain, including to areas of the head and neck dentist. Pain results both from inflammation of the soft tissues and jaws; this possible etiology for jaw symptoms should be contiguous to the necrotic bone and from infection. Other symptoms considered as additional dental diagnoses are pursued. Routine typically occur in more advanced cases (e.g., paresthesia secondary clinical pulp testing and assessing for signs and symptoms of to local neurologic involvement). Purulent secretion at the exposed periodontal disease (e.g., pocket depths, bone loss, and bleeding on area indicates active infection. Radiographic examination may probing) should be performed. Radiographic examination should demonstrate typical radiolucent and radiopaque areas associated also be conducted. Although not yet definitively confirmed in the with a bone sequestrum. Bone trabeculation may present with literature, the radiographic finding of sclerosing or absence of the a moth-eaten appearance, suggesting ongoing bone destruction. lamina dura of the involved teeth may indicate the early presence Lesions can arise secondary to surgical dental treatments (e.g., of BON [150] [Level of evidence: III]. dental extractions or periodontal surgery), significant dental ●● Endodontic and periodontal therapy should be performed first. infections, or trauma. Alternatively, BON can arise spontaneously, The patient should be advised about the possibility of BON and without any detectable trauma or predisposing treatment. should be educated about oral hygiene procedures. If dental ●● Less common: A cancer patient receiving intravenous extraction is indicated, the possibility of subclinical BON should bisphosphonate therapy who complains of pain that mimics be considered and explained to the patient. Thus, delay or absence periodontal or pulpal pathology. There is no clinically visible of healing post-extraction must be considered as risk for ultimate exposed necrotic bone, but a draining fistula or purulent secretion development of BON. Before the invasive procedure is performed, from the periodontal sulcus may exist. The involved teeth will the risk of excessive bleeding and infection due to bone marrow typically be symptomatic upon palpation and percussion. suppression must be discussed with the patient’s physician, and proper preventive measures should be formulated. Management of BON Confirmed BON with exposed bone in the oral cavity should ●● Amoxicillin and clavulanic acid, 500 mg four times a day for at initially be managed conservatively with local debridement and least 14 days. removal of sharp margins of bone; this reduces the risk of trauma In addition, topical oral therapy can be implemented via 0.12 percent to soft tissue, including the tongue. Systemic antibiotics should be chlorhexidine mouth rinses or tetracycline rinses (62.5 mg/oz) twice a administered when active infection with purulent secretion, swelling day. The need for oral hygiene with meticulous brushing and flossing and inflammation of the surrounding soft tissues, and pain are present. after meals should be emphasized [159, 288, 126, 150, 161, 226]. Initial therapy can be implemented with a single antibiotic, but there is no agreement regarding drug of first choice. Options include: The patient should be reevaluated in two weeks. Systemic antibiotics ●● Amoxicillin, 500 mg four times a day for at least 14 days. can be discontinued when clinical signs and symptoms improve. The ●● Metronidazole, 250 mg three times a day for at least 14 days. local measures should be maintained, however, as part of the routine ●● Clindamycin, 300 mg four times a day for at least 14 days. oral hygiene procedures consisting of brushing and flossing.

Dental.EliteCME.com Page 25 In BON cases refractory to therapy, patients may need to be Furthermore, the use of surgical lasers has also been suggested as maintained on long-term antibiotic therapy. With these patients, a an alternative for BON patients who do not respond to conservative combination of different antibiotic agents such as penicillin and management [273]. metronidazole can be considered. Another possibility is to use Use of hyperbaric oxygen therapy (HBO) to treat cases of established clindamycin or the combination of amoxicillin and clavulanic BON does not appear to be effective [159, 150, 161, 226]. However, acid in place of amoxicillin. When the infectious process extends evidence indicates that HBO in addition to discontinuation of to more critical areas of the head and neck, the patient may need bisphosphonate therapy may benefit patients with BON [84, 85]. hospitalization and intravenous antibiotic therapy, culminating in the need for extensive surgical resection of the affected areas [226]. Another possible approach involves surgical manipulation and uses bone labeling with tetracycline. In this modality, the patient is treated with a Reports suggest that BON can be successfully managed by surgical standard dose of tetracycline a few days presurgery. During the surgery, resection and primary wound closure, especially in cases refractory to when bone is exposed, the Wood’s lamp is shone over the bone. Necrotic conservative therapy [38, 254, 285]. bone does not fluoresce and is removed. The procedure continues until fluorescence is seen, suggesting the presence of vital bone [193].

Discontinuation of bisphosphonate therapy The literature does not support discontinuing bisphosphonate therapy In summary, a potential drug holiday for patients on bisphosphonates to enhance the healing process. Bisphosphonates accumulate in a must be considered in the context of presence or absence of patient’s skeleton and could remain active for several years, especially osteonecrosis. In view of the lack of scientific evidence from in patients who have been treated with an intravenous bisphosphonate randomized controlled studies, risk and benefits of drug discontinuation for longer than a year. There is anecdotal evidence that even with must be determined by the prescribing physician. In patients who are discontinuing zoledronic acid therapy for patients who develop BON, being treated with bisphosphonate therapy and who need invasive the osteonecrotic process clinically progresses and can extend to procedures, there is no scientific information that supports a drug contiguous sites. However, discontinuing bisphosphonate therapy is holiday and that this will prevent the development of BON. In patients advocated by some authors, especially when a procedure to treat BON with osteonecrosis who need invasive procedures, a drug holiday may is planned [288, 150]. be beneficial [63]. On the other hand, there is emerging evidence that Some clinicians believe that discontinuing the drug for patients patients with multiple myeloma and osteonecrosis may be maintained scheduled for surgery to treat the necrotic area may be beneficial, on bisphosphonate therapy without the risk of progression of the although this belief is not supported by scientific study. It is osteonecrotic process [22]. recommended that such a drug holiday be maintained until clinical It is advisable to discuss with the patient’s physician whether evidence of healing is observed [288]. However, controversy discontinuing bisphosphonate therapy will not put the patient’s general surrounds this issue [126] [Level of evidence: IV], and further research health at risk. Obtaining an informed consent from the patient before is needed. execution of the proposed drug discontinuation and therapy is important.

Spontaneous and asymptomatic BON Patients may present with asymptomatic exposed necrotic bone affected sites. In this case, local measures and effective oral hygiene anywhere in the oral cavity, although the mylohyoid plate on the are important, as is systematic reevaluation of the patient to ensure posterior mandible and the mandibular tori are the most frequently resolution.

Effects on quality of life The number of patients who develop BON is small compared with Advanced and nonresponsive infections may require hospitalization the large number of people who take bisphosphonates. However, and intravenous antibiotic therapy [159]. Advanced cases of BON may some lesions can progress to large sizes and cause severe changes in require extensive jawbone resection. Therefore, this adverse effect of a patient’s quality of life. Advanced mandibular lesions, for instance, bisphosphonate therapy may negatively affect quality of life [43]. can cause necrosis of the cortical bone, increasing the risk of fractures.

New trends The discontinuation of tobacco use to favor the healing process ●● A human monoclonal antibody that inhibits the receptor activator has been recommended. However, the role of tobacco and other of nuclear factor kappa beta ligand and is under investigation. comorbidities in the process of BON formation requires further ●● The anti-angiogenic drugs being tested in advanced cancer cases, investigation [150]. Several cases of oral osteonecrosis have been including bevacizumab, sunitinib, and sorafenib. reported with drugs other than bisphosphonates, including the following [160, 291]:

Head/neck radiation patients Head and neck radiation patients are a significant challenge relative to complications of head and neck radiation are more predictable, are both intratherapy and post-therapy oral complications resulting from often more severe, and can lead to permanent tissue changes that put radiation therapy. Unlike the oral complications of chemotherapy the patient at risk for serious chronic complications. that are of shorter duration and significant for only a short period (a few weeks to two months) after the cessation of therapy, the oral

Page 26 Dental.EliteCME.com Preradiation dental evaluation and oral disease stabilization Elimination of oral disease and implementation of oral care protocols gland hypofunction and xerostomia frequently occur post-radiation. designed to maintain maximum oral health must be components of It is thus especially important that preradiation dental care strategies patient assessment and care before radiation therapy begins. During are instituted to reduce the impact of the complications of severely and after radiation therapy, oral management will be dictated by the decreased saliva secretion and the associated high risk of dental caries. following: In addition, some radiation-specific issues emerge: ●● Specific needs of the patient. ●● Radiation injury is oral tissue-specific and dependent on dosage ●● Specifics of the radiation therapy. and portals of therapy. ●● Chronic complications caused by radiation therapy. ●● Radiation-induced oral mucositis typically lasts six to eight weeks, Ongoing oral assessment and treatment of complications are essential versus the approximate five to 14 days observed in chemotherapy because radiation to oral tissues typically conveys a lifelong risk of patients. The extended radiation treatment protocols are chiefly oral complications. In addition, invasive oral procedures can cause responsible for this difference. additional sequelae. Dental care typically needs to be altered because The primary cause of oral cancer is tobacco use; alcohol abuse further of underlying chronic radiation-induced tissue damage. escalates risk. It is therefore critical that head/neck cancer patients Patients should receive a comprehensive oral evaluation several weeks permanently cease tobacco use. before high-dose upper-mantle radiation begins. This timing provides ●● Most patients with smoking-related cancer appear motivated to an appropriate interval for tissue healing in the event that invasive oral quit smoking at the time of cancer diagnosis. procedures, including dental extractions, dental scaling/polishing, and ●● Continued smoking substantially increases the likelihood of endodontic therapy, are necessary. The goal of this evaluation is to recurrence or occurrence of a second cancer in survivors, particularly identify teeth at significant risk of infection and breakdown that would in those who previously received radiation therapy. ultimately require aggressive or invasive dental treatment during or ●● A stepped-care approach to tobacco cessation is recommended, after the radiation that increases the risk of soft tissue necroses and including direct physician advice to quit and provision of basic osteonecroses. The likelihood of these lesions occurring post-radiation information to all patients at each contact during the first month increases over the patient’s lifetime as the risk of significant dental of diagnosis, followed by more intensive pharmacologic treatment disease (restorative, periodontal, and endodontic) increases. Salivary or counseling for those having difficulty quitting or remaining abstinent.

Oral complications of head and neck radiation The oral complications of head and neck radiation can be divided into ●● Chronic complications include the following: two groups on the basis of the usual time of their occurrence: ○○ Mucosal fibrosis and atrophy. ●● Acute complications occurring during therapy. ○○ Decreased saliva secretion and xerostomia [272]. ●● Late complications occurring after radiation therapy has ended. ○○ Accelerated dental caries related to compromised saliva Acute complications include the following: secretion. ●● Oropharyngeal mucositis [272]. ○○ Infections (primarily candidiasis). ●● Sialadenitis and xerostomia. ○○ Tissue necrosis (soft tissue necrosis and osteonecrosis). ●● Infections (primarily candidiasis). ○○ Taste dysfunction (dysgeusia/ageusia). ●● Taste dysfunction. ○○ Muscular and cutaneous fibrosis [272]. ○○ Dysphagia [39]. Occasionally, tissue necrosis can be seen late during therapy, but this is relatively rare.

Management of oral mucositis The etiopathogenesis of mucositis caused by head and neck radiation ●● Because there is generally no risk of bleeding for head and neck appears to be similar but not identical to mucositis caused by high- radiation patients, analgesic treatment begins with nonsteroidal dose chemotherapy [249, 13]. Management strategies described for anti-inflammatory drugs (NSAIDs). chemotherapy/hematopoietic stem cell transplantation are generally ●● As pain increases, NSAIDs are combined with opioids, and applicable to the head/neck radiation patient [60, 241]. (Refer to the patients can be made relatively comfortable. Management of mucositis section for more information.) In one study, Doses for NSAIDs are titrated up to their recommended dosing gabapentin appeared promising in reducing the need for narcotic pain ceiling; on the other hand, opioids are titrated to effective pain relief. medication for patients with head and neck malignancies treated with Systemic analgesics are given by the clock to achieve steady-state radiation therapy [12] [Level of evidence: III]. blood levels to provide adequate pain relief. The extensive duration and severity of radiation mucositis combined Additionally, adjunctive medications are given to provide adjuvant with the treatment of most radiation patients as outpatients results analgesia and manage side effects of NSAIDs and opioids. Zinc in pain management challenges. As mucositis severity increases and supplementation used with radiation therapy may improve mucositis topical pain management strategies become less effective, it becomes and dermatitis [140] [Level of evidence: I]. The use of alcohol-free increasingly necessary to depend on systemic analgesics to manage povidone-iodine mouthwash may reduce the severity and delay the oral radiation mucositis pain [287]: onset of oral mucositis caused by anti-neoplastic radiation therapy [149] [Level of evidence: I].

Early infections A systematic review indicated that the weighted mean prevalence of 37.4 percent and may be significantly higher in patients who receive clinical oral candidiasis during head and neck radiation therapy is concurrent chemotherapy [133].

Dental.EliteCME.com Page 27 Factors promoting clinical fungal infection in this population include: significant xerostomia. Patients who receive topical anti-fungals ●● Hyposalivation resulting from radiation damage to the salivary should be asked to avoid eating, drinking or rinsing for at least 30 glands. minutes after use. Patients with removable dentures should remove ●● Tissue damage caused by radiation-induced oral mucositis. the dentures before using the topical anti-fungals and should also treat ●● Resulting dietary impairment. the dentures to avoid repeat colonization of the oral tissues by fungal ●● Inability to maintain oral hygiene. organisms that are colonizing the dentures. Because these patients are usually not significantly neutropenic, topical For persistent lesions, systemic agents such as fluconazole are very anti-fungal agents such as nystatin rinse/pastilles and clotrimazole effective. troches can be effective. The use of a troche may be limited by

Taste dysfunction As oral and pharyngeal mucosa are exposed to radiation, taste therapy for taste receptors to recover and become functional. Zinc receptors become damaged, and taste discrimination becomes sulfate supplements (220 mg two or three times a day) have been increasingly compromised [176, 296]. After several weeks of radiation reported to help with recovery of the sense of taste [243, 216] [Level therapy, patients commonly complain that they have no sense of taste. of evidence: I]. It will generally take six to eight weeks after the end of radiation

Late complications of head and neck radiation Late oral complications of radiation therapy are chiefly a result of changes are directly related to radiation dosimetry, including total chronic injury to vasculature, salivary glands, mucosa, connective dose, fraction size and duration of treatment. tissue and bone [169, 77, 243, 112]. The types and severity of these

Mucosal lesions Mucosal lesions include epithelial atrophy, reduced vascularization, include loss of acinar cells, alteration in duct epithelium, fibrosis, and and submucosal fibrosis. These changes lead to an atrophic, friable fatty degeneration. Compromised vascularization and remodeling barrier. Fibrosis involving muscle, dermis, and the temporomandibular capacity of bone leads to risk of osteonecrosis. joint results in compromised oral function. Salivary tissue changes

Salivary gland hypofunction and xerostomia Ionizing radiation to salivary glands results in inflammatory and Recovery of salivary gland function is usually incomplete, and the degenerative effects on salivary gland parenchyma, especially serous overall degree of dryness can range from mild to severe. acinar cells. The early salivary gland tissue response to irradiation It should be noted that salivary gland hypofunction and xerostomia results in decreased salivary flow rates within the first week of may also be sequelae of other radiation regimens, e.g., radioactive treatment, and xerostomia (the subjective feeling of oral dryness) iodine treatment of thyroid cancer and preconditioning total body becomes apparent when doses exceed 10 Gy. irradiation in hematopoietic stem cell transplantation for the treatment The degree of dysfunction is related to the radiation dose and volume of hematologic malignancies – although to a much lesser severity of glandular tissue in the radiation field. Doses larger than 54 Gy [106, 53]. are generally considered to induce irreversible dysfunction. Serous Symptoms and signs of salivary gland hypofunction include the parotid glands may be more susceptible to radiation effects than are following: nonserous submandibular, sublingual and minor salivary gland tissues. ●● Xerostomia. Management strategies described for late salivary gland complications ●● Lip dryness/crusting. are generally applicable to the acute complications in the head/neck ●● Fissures at lip commissures. radiation patient. (Refer to the Oral and dental management of the ●● Atrophy of dorsal tongue surface. xerostomic patient section for more information.) ●● Atrophic and fragile oral mucosa. Salivary gland hypofunction (decreased salivary gland secretion) and ●● Difficulties in speech, chewing and swallowing. xerostomia are among the most frequent and severe long-term side ●● Difficulty in wearing dentures (edentulous patients). effects of radiation therapy to the head and neck region. The adverse ●● Oral burning sensation. effects will have a significant impact on a patient’s quality of life in a ●● Taste disturbances. lifelong perspective after radiation treatment [264]. ●● Increased thirst. Xerostomia is caused by salivary gland hypofunction. Saliva is ●● Sensitivity/pain in response to spicy foods and strong flavorings. necessary for the normal execution of oral functions such as taste, Salivary gland tissues that have been excluded from the radiation swallowing and speech. Unstimulated whole salivary flow rates lower portal may become hyperplastic, partially compensating for the than 0.1 mL per minute are considered pathologic low (normal salivary nonfunctional glands at other oral sites. flow rate = 0.3-0.5 mL/min) [110]. Salivary gland hypofunction also alters the mechanical cleansing Late salivary tissue changes induced by radiation therapy include ability and the buffer capacity of the mouth, thereby contributing to a loss of acinar cells, alteration in duct epithelium, fibrosis and fatty high risk of accelerated dental caries (cavities) and periodontal disease. degeneration. The early response to irradiation resulting in markedly Also, the progression of dental caries is accelerated by the reduction in decreased salivary flow rates within the first week of treatment is antimicrobial proteins normally contained in saliva. followed by a further decline in saliva secretion and worsening In summary, salivary gland hypofunction produces the following of xerostomia after radiation therapy (one to three months post- changes in the mouth that collectively cause patient discomfort and treatment), after which salivary secretion and xerostomia gradually increased risk of oral lesions: recover over time (maximum recovery, one to two years post-therapy), depending on the total radiation dose to the gland tissue [110].

Page 28 Dental.EliteCME.com ●● Increase in salivary viscosity, with resultant impaired lubrication ●● Compromise of buffering capacity and salivary pH, with increased of oral tissues. risk for dental caries and erosion. ●● Decrease in flushing/clearance of acid production after sugar ●● Increase in pathogenicity of oral flora. exposure, resulting in demineralization of the teeth and leading to ●● Accumulated bacterial plaque levels caused by patient difficulty dental decay. in maintaining oral hygiene (caused by soreness of oral mucosa or muscular fibrosis/trismus). Oral and dental management of the xerostomic patient Patients who experience salivary gland hypofunction and xerostomia rampant unless preventive measures are instituted. Multiple preventive must maintain excellent oral hygiene to minimize the risk of oral strategies should be considered. lesions. Periodontal disease can be accelerated and caries can become

Oral hygiene protocol Perform systematic oral hygiene at least four times per day (after ●● Rinse with a solution of salt and baking soda four to six times a meals and at bedtime): day (½ teaspoon salt and ½ teaspoon baking soda in 1 cup warm ●● Brush teeth (if soreness of oral mucosa and trismus are present, water) to clean and lubricate the oral tissues and to buffer the oral use small ultrasoft toothbrush). environment. ●● Use a fluoridated toothpaste when brushing. ●● Sip water frequently to rinse the mouth and alleviate mouth dryness. ●● Floss once daily. ●● Avoid foods and liquids with a high sugar content. ●● Apply a prescription-strength fluoride gel at bedtime to prevent caries.

Fluorides Note: Prescription-strength fluorides should be used because Use of topical fluoride has demonstrable benefit in minimizing caries nonprescription fluoride preparations are inadequate for moderate to formation. During radiation treatment, it has been recommended that high risk of dental caries. If drinking water does not contain enough mouth guards be filled with topical 1 percent sodium fluoride gel and fluoride to prevent dental decay, oral fluoride (e.g., drops or vitamins) placed over the upper and lower teeth. The appliances should remain should be provided. in place for five minutes, after which the patient should not eat or drink for 30 minutes. Remineralizing solutions ●● Fluoride and calcium/phosphates. ●● Children: topical and systemic. ●● Topical high-concentration fluorides. ●● Adults: topical.

Prevention of salivary gland hypofunction and xerostomia To prevent or reduce the extent of salivary gland hypofunction and chemotherapy, including reduction of acute or late xerostomia xerostomia, parotid-sparing intensity-modulated radiation therapy in patients with HNC. Studies have reported varying degrees of (IMRT) is recommended as a standard approach in head and neck effectiveness [34, 229] [Level of evidence: I]. One randomized cancer (HNC), if oncologically feasible. In addition, treatment prospective study reported that intravenous amifostine administered should focus on approaches to further reduce the radiation dose to during head and neck radiation therapy reduces the severity and the submandibular and minor salivary glands, which are the major duration of xerostomia two years after amifostine treatment, without contributors to moistening of oral tissues [112]. apparent compromise of locoregional tumor control rates, progression- Another preventive strategy to reduce radiation-induced salivary gland free survival, or overall patient survival [282] [Level of evidence: hypofunction and xerostomia is surgical transfer of one submandibular I]. The intravenous administration of amifostine may cause severe gland to the submental space not included in the radiation portal in adverse effects such as hypotension, vomiting, nausea and allergic selected oropharyngeal and hypopharyngeal/laryngeal cancer patients reaction. These adverse effects might be reduced by subcutaneous [240, 113] [Level of evidence: I]. administration of amifostine. The possible risk of tumor protection by amifostine remains a clinical concern [30]. Amifostine is an organic thiophosphate approved for the protection of normal tissues against the harmful effects of radiation or

Alleviation of xerostomia Treatment of salivary gland hypofunction and xerostomia induced by Sugar-free lozenges, acidic candies or chewing gum may produce radiation therapy is primarily symptomatic. Alleviation of xerostomia transitory relief from xerostomia by stimulating residual capacity of includes frequent sipping or spraying of the oral cavity with water, salivary gland tissue (acidic products can result in demineralization of the use of saliva substitutes, or stimulation of saliva production from the teeth and may not be recommended in dentate patients) [112]. intact salivary glandular tissues by taste/mastication, pharmacological Pilocarpine is the only drug approved by the U.S. Food and Drug sialogogues, or acupuncture [112]. Administration for use as a sialogogue (5-mg tablets of pilocarpine Saliva substitutes or artificial saliva preparations (e.g., oral rinses hydrochloride) for radiation xerostomia. Treatment is initiated at 5 mg or gels containing hydroxyethylcellulose, hydroxypropylcellulose, by mouth three times a day; the dose is then titrated to achieve optimal carboxymethylcellulose, polyglycerylmethacrylate, mucin, or xanthan clinical response and minimize adverse effects. Some patients may gum) are palliative agents that relieve the discomfort of xerostomia by experience increased benefit at higher daily doses; however, incidence temporarily wetting the oral mucosa [112]. of adverse effects increases proportionally with dose. The patient’s evening dose may be increased to 10 mg within one week after starting

Dental.EliteCME.com Page 29 pilocarpine. Subsequently, morning and afternoon doses may also be evidence: I]. It has been indicated that the efficacy of pilocarpine increased to a maximum 10 mg per dose (30 mg/d). Patient tolerance is depends on the radiation dose distributed to the parotid glands during confirmed by allowing seven days between increments. treatment, i.e., in patients in whom the mean parotid dose exceeds The most common adverse effect at clinically useful doses of 40 Gy, pilocarpine may spare parotid gland function and reduce pilocarpine is hyperhidrosis (excessive sweating); its incidence and xerostomia – particularly significant after 12 months [36] [Level of severity are proportional to dosage. Also reported, typically at doses evidence: I]. higher than 5 mg three times a day, are the following: Cevimeline (30 mg three times a day) also appears anecdotally to ●● Nausea. have efficacy in managing radiation-induced xerostomia [42, 114] ●● Chills. [Level of evidence: I]. Although cevimeline is approved for use only ●● Rhinorrhea. in the management of Sjögren syndrome, appropriate clinical trials ●● Vasodilation. are under way, and its efficacy should be established soon. While ●● Increased lacrimation. cevimeline has greater selective affinity for M3 muscarinic receptors ●● Bladder pressure (urinary urgency and frequency). than pilocarpine, whether this can prove advantageous for treating ●● Dizziness. radiation xerostomia remains unclear. ●● Asthenia. Acupuncture appears to offer an intervention for the treatment of ●● Headache. radiation-induced xerostomia in patients with a residual functional ●● Diarrhea. capacity of the salivary glands and is a treatment modality without ●● Dyspepsia. serious adverse effects [25, 183, 45]. Further randomized controlled Pilocarpine usually increases salivary flow within 30 minutes after clinical trials, including sham acupuncture, are warranted. ingestion. Maximal response may occur only after continual use (more Intraoral electrical stimulation devices delivering a low-intensity than eight weeks) [213] [Level of evidence: I]. electrical current to the oral mucosa – thus stimulating salivary gland It has been suggested that pilocarpine given during radiation therapy secretion by innervating afferent neurons of the salivary reflex and may reduce salivary gland impairment and xerostomia both during and efferent neurons (e.g., the lingual nerve) – is under development after treatment. However, in a randomized study of 249 patients with and has been tested, with promising initial results in the palliation of HNC, the concomitant use of pilocarpine during radiation did not have xerostomia [257, 256]. Special considerations appear to be indicated a positive impact on quality of life or patient assessment of salivary when electrostimulation devices are used in head and neck radiation function, despite the maintenance of salivary flow [230] [Level of patients [131] [Level of evidence: I]. Further studies are needed.

Caries The risk of dental caries increases secondary to a number of factors, or chlorhexidine rinses may lead to reduced levels of S. mutans but including shifts to a cariogenic flora, reduced concentrations of not Lactobacilli. Because of adverse drug interactions, fluoride and salivary antimicrobial proteins, and loss of mineralizing components. chlorhexidine dosing should be separated by several hours. (Refer to the Conditions affected by both chemotherapy and head/neck Remineralizing agents, which are high in calcium phosphate and radiation section for more information.) As reported in a systematic fluoride, have demonstrated salutary in vitro and clinical effects. The review, the overall count of decayed, missing or filled teeth (DMFT) intervention may be enhanced by delivering the drug via customized in patients who were post-anti-neoplastic therapy was 9.19 (standard vinyl carriers. This approach extends the contact time of active drug deviation [SD], 7.98; n = 457). The DMFT for patients who were with tooth structure, which leads to increased uptake into enamel. post-radiation therapy was 17.01 (SD, 9.14; n = 157), which was much higher than that in patients who were post-chemotherapy (DMFT, A systematic review of managing dental caries in post-radiation 4.50) [102]. therapy patients produced the following conclusions [102, 29]: ●● Fluoride: The use of fluoride products reduces caries activity in Treatment strategies must be directed to each component of the patients who are post-radiation therapy. The type of fluoride gel or caries process. Optimal oral hygiene must be maintained. Xerostomia fluoride delivery system used did not significantly influence caries should be managed whenever possible via salivary substitutes or activity. replacements. Caries resistance can be enhanced with the use of topical ●● Chlorhexidine: The use of chlorhexidine rinse reduces plaque fluorides and remineralizing agents. Efficacy of topical products may scores and oral streptococcus mutans scores. This reduction was be enhanced by increased contact time on the teeth by application not seen with lactobacillus counts. using vinyl carriers. Patients unable to effectively comply with use of ●● Dental restorative materials: There is evidence suggesting fluoride trays should be instructed to use brush-on gels and rinses. that conventional glass ionomer restorations performed more Increased colonization with Streptococcus mutans and Lactobacillus poorly than did resin-modified glass ionomer, composite resin, species increases caries risk. Culture data can be useful in defining and amalgam restorations in patients who had been treated with level of risk in relation to colonization patterns. Topical fluorides radiation therapy.

Osteoradionecrosis Risk of osteoradionecrosis (ORN) is directly related to radiation dose Pathologic fracture can occur because the compromised bone is unable and volume of tissue irradiated. The unilateral vascular supply to each to appropriately undergo repair at the involved sites. Risk of tissue half of the mandible results in post-radiation ORN most frequently necrosis is in part related to trauma or oral infection; however, idiopathic involving the mandible, compared with the maxilla. Presenting clinical cases can also occur. Patients who have received high-dose radiation to features include: the head and neck are at lifelong risk for ORN, with an overall risk of ●● Pain. approximately 15 percent. ●● Diminished or complete loss of sensation. Ideally, post-radiation management of ORN is based on prevention ●● Fistula. that begins with comprehensive oral and dental care before radiation ●● Infection. therapy begins. The dentition, periodontium, periapices and mucosa should be thoroughly examined to identify oral disease, which could

Page 30 Dental.EliteCME.com lead to serious odontogenic, periodontal or mucosal infections that dives of post-surgical HBO are recommended. Unfortunately, HBO could necessitate surgical therapy post-radiation. Oral disease should technology is not always accessible to patients who might otherwise be eliminated pretreatment. Dentition that exhibits poor prognosis and benefit because of lack of available units and the high price of care. is within high-dose fields should be extracted before radiation therapy A systematic review regarding treatment-dependent frequency, current begins. Ideally, at least seven to 14 days should be allowed for healing management strategies and future studies has been published [197]. A before initiation of radiation; some have suggested allowing up to 21 total of 43 articles published between 1990 and 2008 were reviewed. days. Surgical technique should be as atraumatic as possible and use The weighted prevalence for ORN included the following: primary wound closure. ●● Conventional radiation therapy, 7.4 percent. Patients who develop ORN should be comprehensively managed to: ●● IMRT, 5.1 percent. ●● Eliminate trauma. ●● Chemoradiation therapy, 6.8 percent. ●● Avoid removable dental prosthesis if the denture-bearing area is ●● Brachytherapy, 5.3 percent. within the osteonecrotic field. HBO may contribute a role in management of ORN. However, no ●● Ensure adequate nutritional intake. clear recommendations for the prevention or treatment of ORN could ●● Discontinue tobacco and alcohol use. be established on the basis of the literature reviewed. The review Topical antibiotics (e.g., tetracycline) or antiseptics (e.g., concluded that new cancer treatment modalities such as IMRT and chlorhexidine) may contribute to wound resolution. Wherever concomitant chemoradiation therapy have had minimal effect on possible, coverage of the exposed bone with mucosa should be prevalence of ORN. No studies have systematically addressed the achieved. Analgesics for pain control are often effective. Local impact of ORN on either quality of life or cost of care. Research resection of bone sequestra may be possible. addressing these collective issues is needed. Hyperbaric oxygen therapy (HBO) is recommended for management Partial mandibulectomy may be necessary in severe cases of of ORN, although it has not been universally accepted. HBO has ORN. The mandible can be reconstructed to provide continuity for been reported to increase oxygenation of irradiated tissue, promote esthetics and function. A multidisciplinary cancer team that includes angiogenesis and enhance osteoblast repopulation and fibroblast oncologists, oncology nurses, maxillofacial prosthodontists, general function. HBO is usually prescribed as 20 to 30 dives at 100 percent dentists, hygienists, and physical therapists is appropriate for oxygen and 2 to 2.5 atmospheres of pressure. If surgery is needed, 10 management of these patients.

Tissue necrosis Necrosis and secondary infection of previously irradiated tissue is Soft tissue necrosis can involve any mucosal surface in the mouth, a serious complication for patients who have undergone radiation though nonkeratinized surfaces appear to be at moderately higher risk. therapy for head and neck tumors [243]. Acute effects typically Trauma and injury are often associated with nonhealing soft tissue involve oral mucosa. Chronic changes involving bone and mucosa necrotic lesions, though spontaneous lesions are also reported. Soft are a result of the process of vascular inflammation and scarring that tissue necrosis begins as an ulcerative break in the mucosal surface and in turn result in hypovascular, hypocellular and hypoxic changes. can spread in diameter and depth. Pain will generally become more Infection secondary to tissue injury and osteonecrosis confounds the prominent as soft tissue necrosis becomes worse. Secondary infection process. is a risk.

Mandibular dysfunction Musculoskeletal syndromes may develop secondary to radiation instituted before trismus develops. If clinically significant changes therapy and surgery. Lesions include soft tissue fibrosis, surgically develop, several approaches can be considered, including: induced mandibular discontinuity, and parafunctional habits associated ●● Stabilization of occlusion. with emotional stress caused by cancer and its treatment. Patients can ●● Use of trigger-point injection and other pain management be instructed in physical therapy interventions, such as mandibular strategies. stretching exercises and the use of prosthetic aids designed to reduce ●● Use of muscle relaxants. the severity of fibrosis. It is important that these approaches be ●● Use of tricyclic medications.

Trismus Trismus has been associated with significant morbidity post-radiation Radiation therapy involving the temporomandibular joint, the therapy, with significant health implications, including reduced pterygoid muscles or the masseter muscle is most likely to result in nutrition caused by impaired mastication, difficulty in speaking, and trismus [65]. Tumors related to this type of radiation can appear in the compromised oral hygiene [65]. Limitations in jaw opening have been following locations: reported in 6 percent to 86 percent of patients who received radiation ●● Nasopharynx. to the temporomandibular joint or masseter/pterygoid muscles, with ●● Oral cavity. frequency and severity that are somewhat unpredictable [145]. ●● Oropharynx. The loss of function and range of mandibular motion from ●● Base of tongue. radiation therapy appears to be related to fibrosis in and damage ●● Salivary gland. to the muscles of mastication. Studies have demonstrated that an ●● Maxilla or mandible. abnormal proliferation of fibroblasts is an important initial event The prevalence of trismus increases with increasing doses of radiation, in these reactions. Additionally, there may be scar tissue from and levels in excess of 60 Gy are more likely to cause trismus [264]. radiation therapy or surgery, nerve damage, or a combination of Patients who have been previously irradiated and who are being treated these factors. Regardless of the immediate cause, mandibular for a recurrence appear to be at higher risk of trismus than those who hypomobility will ultimately result in degeneration of both muscle and are receiving their first treatment [64, 293]. This suggests that the effects temporomandibular joint. of radiation are cumulative, even over many years. Radiation-induced trismus may begin toward the end of radiation therapy or at any time during the subsequent 24 months. Limitations in opening the mouth

Dental.EliteCME.com Page 31 often increase slowly over several weeks or months. The condition may Finally, limited mouth opening can result in compromised oral worsen over time or remain the same, or the symptoms may reduce over hygiene. Patients who have undergone radiation therapy involving time, even in the absence of treatment. the salivary glands must maintain excellent oral hygiene to prevent Limited mouth opening frequently results in reduced nutritional status. dental caries. Deficits in oral hygiene can aggravate mucosal and These patients may experience significant weight loss and nutritional dental problems, with the subsequent risk of mandibular ORN. Also, deficits [105]. It is generally accepted that weight loss of more than dental work and other professional oral care measures such as surgery 10 percent of initial body weight is considered significant. This is of can be made more difficult, which might even result in compromised particular importance at a time when the patient is recovering from oncologic follow-up. surgery, chemotherapy or radiation therapy. Additionally, it lowers The weighted prevalence of trismus with conventional radiation is the ability for social eating and thereby increases the risk of social estimated to be 25 percent, but 5 percent with IMRT only. Trismus isolation and decrease in quality of life in patients with HNC. prevalence in studies of chemoradiation is approximately 30 percent [20]. Prevention strategies Early treatment of trismus has the potential to prevent or minimize ●● Screws that are placed between the central incisors. many of the consequences of this condition. If the clinical examination ●● Hydraulic bulbs placed between the teeth. reveals the presence of limited mouth opening and diagnosis These devices range widely in cost. Some devices, such as continuous determines the condition to be trismus, treatment should begin as passive motion devices, must be custom made for each patient; others soon as is practical. As restriction becomes more severe and likely are rented on a daily or weekly basis, at rates of up to several hundred irreversible, the need for treatment becomes more urgent. dollars per week. The least expensive option is the use of tongue Over the years, clinicians have attempted to prevent or treat trismus depressors, which has been used for many years to mobilize the jaw. with a wide array of appliances. These devices include the following: A search of the literature, however, failed to reveal any studies that ●● Cages that fit over the head. demonstrated significant improvement in treating trismus with tongue ●● Heavy springs that fit between the teeth. depressors. Curative approach Some therapeutic interventions seem to show some efficacy in Therabite device [153], and the Dynasplint Trismus System [242]. decreasing the intensity of cancer treatment-related trismus (e.g., However, this proposed efficacy must be confirmed by randomized pentoxifylline [46, 93], Botulinum toxin [96], exercise using the controlled studies, which are lacking in this area.

Recommendations for future research directions Radiation oncology textbooks often fail to mention trismus as a major organ and dermatological injuries, and trismus is not addressed. sequela of radiation therapy for HNC patients, contributing to a lack This should be corrected in future revisions of these scales. of recognition of the prevalence and significance of this condition. Considering the high prevalence of trismus in published studies There has been an ongoing attempt by the Radiation Therapy and the deficits in quality of life associated with trismus, increased Oncology Group and the European Organization for Research and efforts for patient education, prevention and early treatment options Treatment of Cancer to develop LENT (late effects in normal tissue) are warranted. Larger prospective trials that include the prevention morbidity scales. The National Cancer Institute consensus conferences and treatment of trismus are needed to improve management and to introduced the SOMA (subjective, objective, management, analysis) confirm the benefit of IMRT in the reduction of radiation-induced classification for late toxicity. However, both scales are focused on trismus and the quality-of-life and economic impact of this common oral sequela of radiation.

Conditions affected by both chemotherapy and head/neck radiation Salivary gland hypofunction and xerostomia Radiation therapy can damage salivary glands, causing salivary been implicated in causing salivary dysfunction and xerostomia [111]. hypofunction and xerostomia. (Refer to the Oral complications of However, it has not been possible to draw consistent conclusions about head and neck radiation section for more information.) In addition, the effects of cancer chemotherapy on salivary gland function [112]. selected chemotherapeutic agents (singly or in combination) have

Dysphagia Dysphagia and odynophagia are common in cancer patients and can ●● Difficulties with speaking, eating and drinking, or drooling may exist before, during and after treatment: affect mental health and put patients and family members in social ●● Dysphagia predisposes to aspiration and potentially life- isolation. threatening pulmonary complications [177]. All of these problems, plus the patient perception of swallowing ●● Swallowing disorders may lead to unfavorable dietary changes difficulties, significantly decrease health-related quality of life [177, 135]. and decreased oral intake, which may result in dehydration, malnutrition, delayed wound healing and decreased resistance to Dysphagia is most prominent in patients with head and neck cancers infection. but may also develop in patients with other malignancies as a symptom ●● Tube feeding may become necessary, which may further of oropharyngeal or esophageal mucositis or infection. In addition, compromise swallowing. dysphagia can be associated with graft-vs.-host disease. ●● Opioids administered for the management of odynophagia may The prevalence and severity of pretreatment dysphagia associated with cause xerostomia and constipation. head and neck tumors depend on tumor stage and localization [142]. Pretreatment dysphagia is most prevalent in patients with pharyngeal

Page 32 Dental.EliteCME.com and laryngeal cancers [192]. Surgical interventions for head and neck patients. Unfortunately, in head and neck cancer patients treated with tumors result in anatomic or neurologic insults with site-specific chemoradiation, a continuing cascade of inflammatory cytokines patterns of dysphagia [127]. In general, the larger the resection, the triggered by oxidative stress and hypoxia may damage exposed more swallowing function will be impaired. tissues, and dysphagia may develop even years after the completion The severity of radiation-induced dysphagia depends on the following of treatment. Late sequelae that may contribute to chronic dysphagia [203]: include: ●● Total radiation dose. ●● Reduced capillary flow. ●● Fraction size and schedule. ●● Atrophy and necrosis. ●● Target volumes. ●● Lymphedema. ●● Treatment delivery techniques. ●● Neuromuscular fibrosis leading to trismus and stricture formation. ●● Concurrent chemotherapy. ●● Hyposalivation. ●● Genetic factors. ●● Infection. ●● Feeding status (via percutaneous endoscopic gastrostomy [PEG] Successful management of dysphagia requires the following: tube or nil per os [NPO, nothing by mouth]). ●● Interdisciplinary collaboration. ●● Smoking status. ●● Accurate and early diagnostic workup. ●● Psychological coping factors. ●● Effective preventative and therapeutic strategies. Intensified schedules and the use of chemoradiation therapy have ●● An individual approach geared to unique patient characteristics. been shown to improve locoregional control and survival but come Dysphagia- and aspiration-related structures have been identified, at the cost of more severe acute and chronic side effects. Intensity- and minimizing radiation to these bystander tissues results in better modulated radiation therapy (IMRT) has emerged as an effective swallowing outcomes [67]. Because hyposalivation affects swallowing technique to deliver the full radiation dose to the tumor and regions at function, strategies aimed at sparing salivary glands such as IMRT and risk while reducing exposure of surrounding healthy tissues. However, the use of amifostine may improve swallowing outcomes [229, 35]. the preservation of anatomy does not necessarily translate into the A predictive model for persistent swallowing dysfunction following preservation of swallowing function [165]. chemoradiation therapy for head and neck cancer has been developed Mucositis induced by chemoradiation therapy or chemotherapy alone, [135]. Early involvement of a speech and language therapist is critical edema, pain, thickened mucous saliva and hyposalivation, radiation to assess swallow function and aspiration risk and to generate a dermatitis, and infection may all contribute to acute dysphagia. The treatment plan that includes patient education and swallow therapy use of epidermal growth factor inhibitors seems not to be associated [168]. Cooperation with a dietician is important to ensure adequate and with increased mucositis and acute dysphagia [51]. safe nutrition. Prosthodontic interventions may improve swallowing By three months post-treatment, acute clinical effects have largely performance, and patients may benefit from psychological support. resolved, and normal swallowing function starts to return in most Dysgeusia Dysgeusia can be a prominent symptom in patients who are receiving after cessation of cytotoxic therapy. This symptom in general is chemotherapy or head/neck radiation [15, 87]. Etiology is likely reversible, and taste sensation returns to normal in the ensuing months. associated with several factors, including direct neurotoxicity to taste By comparison, however, a total fractionated radiation dose higher buds, xerostomia, infection and psychologic conditioning. In addition, than 3,000 Gy reduces acuity of sweet, sour, bitter and salt tastes. taste dysfunction can be associated with damage caused by graft- Damage to the microvilli and outer surface of the taste cells has been vs.-host disease to the taste perception units. (Refer to the section on proposed as the principal mechanism for loss of the sense of taste. In Graft-vs.-host disease for more information.) many cases, taste acuity returns in two to three months after cessation Patients receiving chemotherapy may experience unpleasant taste of radiation. However, many other patients develop permanent secondary to diffusion of drug into the oral cavity. In addition, hypogeusia. Zinc supplementation (zinc sulfate 220 mg 2 times a day) chemotherapy patients often describe dysgeusia in the early weeks has been reported to be useful in some patients; the overall benefit of this treatment remains unclear [243, 215] [Level of evidence: I]. Nutritional considerations Patients with head and neck cancer are at high risk for nutritional meet their nutritional needs. Almost all patients receiving concurrent problems. Contributing to malnutrition are [218]: chemotherapy and radiation therapy will become fully dependent ●● The malignancy itself. on enteral nutritional support within three to four weeks of therapy. ●● Poor nutrition before diagnosis. Numerous studies have demonstrated the benefit of enteral feedings ●● Complications of surgery, radiation therapy and chemotherapy. initiated at the onset of treatment, before significant weight loss has In cancer patients, loss of appetite can also occur secondary to mucositis, occurred [17, 266]. xerostomia, taste loss, dysphagia, nausea and vomiting. Quality of Oral nutrition is reinstituted after treatment has concluded and the life is compromised as eating becomes more problematic. Oral pain radiated site has adequately healed. Oral nutrition often requires a with eating may lead to selection of foods that do not aggravate the team approach. The assistance of a speech and swallowing therapist oral tissues, often at the expense of adequate nutrition. Nutritional to assess for any swallowing dysfunction resulting from surgery or deficiencies can be minimized by modifying the texture and consistency treatment is often necessary and beneficial in easing the transition of the diet and by adding more frequent meals and snacks to increase back to solid foods. The number of tube feedings can be decreased as calories and protein. Ongoing nutrition assessment and counseling with a patient’s oral intake increases, with tube feeding being discontinued a registered dietitian should be part of the patient’s treatment plan [117]. when 75 percent of a patient’s nutrition needs are being met orally. Many patients who receive radiation therapy alone are able to Although most patients will resume adequate oral intake, many will tolerate soft foods; however, as treatment progresses, most patients continue to experience chronic complications such as taste changes, must transition to liquid diets using high-calorie, high-protein liquid xerostomia and varying degrees of dysphagia that can affect their nutritional supplements, and some may require enteral feeding tubes to nutritional status and quality of life [218, 117].

Dental.EliteCME.com Page 33 Fatigue Cancer patients undergoing high-dose chemotherapy and radiation fewer but increasing data exploring biologic or physiologic correlates. therapy can experience fatigue related to either the disease or its Such correlates have included measures of muscle weakness, maximal treatment [274]. These processes can produce sleep deprivation or oxygen uptake, cytokines and cortisol. metabolic disorders that collectively contribute to compromised oral Fatigue experienced as a side effect of cancer treatment is differentiated status. For example, the fatigued patient will likely have impaired from fatigue experienced by healthy people in their daily lives. Healthy compliance with mouth care protocols designed to otherwise minimize fatigue is frequently described as acute fatigue that is eventually relieved risk of mucosal ulceration, infection and pain. In addition, biochemical by sleep and rest; cancer treatment-related fatigue is categorized as abnormalities are likely involved in many patients. The psychosocial chronic fatigue because it is present over a long period of time, interferes component can also play a major role, with depression contributing to with functioning and is not completely relieved by sleep and rest. overall fatigue. Also, the level of CRF is often disproportionate to the level of activity Fatigue is the most common side effect of cancer treatment with or energy exerted [23]. Although the label chronic fatigue is accurate, chemotherapy, radiation therapy or selected biologic response using this label does not mean that people with cancer who experience modifiers [208]. Cancer treatment-related fatigue generally improves fatigue have chronic fatigue syndrome. Using the phrase chronic fatigue after therapy is completed, but some level of fatigue may persist for can be confusing to both patients and health professionals. Terms such months or years following treatment. Research indicates that for at as cancer fatigue, cancer-related fatigue, and cancer treatment-related least a subset of patients, fatigue may be a significant issue long into fatigue have all been used in the clinical literature, research literature survivorship [27, 11]. and educational materials for patients and the public. Fatigue is also seen as a presenting symptom in cancers that produce Fatigue has a negative impact on all areas of function, including mood, problems such as anemia, endocrine changes and respiratory obstruction physical function, work performance, social interaction, family care and is common in people with advanced cancer who are not receiving [187], cognitive performance, school work, community activities, and active cancer treatment. Cancer treatment-related fatigue is reported in 14 sense of self [201, 90, 87, 52]. percent to 96 percent of patients undergoing cancer treatment [83, 157, Recommendations for fatigue management focus on identifying factors 275, 62, 49, 40] and in 19 percent to 82 percent of patients post-treatment that may be contributing to fatigue. Because the only definitive causal [208, 27]. Several studies have documented significantly worse fatigue in mechanism demonstrated through research to date is chemotherapy- .cancer survivors compared with noncancer populations [208]. induced anemia, most clinical recommendations for managing fatigue Fatigue, like pain, is viewed as a self-perceived state. Patients may caused by something other than chemotherapy-induced anemia rely on describe fatigue as feeling tired, weak, exhausted, lazy, weary, careful development of clinical hypotheses, as outlined in the National worn-out, heavy, slow, or like they do not have any energy or any Comprehensive Cancer Network guidelines on fatigue [174]. The get-up-and-go [14]. Health professionals have included fatigue within only level 1 intervention for CRF at this time is exercise. (Much more concepts such as asthenia, lassitude, malaise, prostration, exercise research is needed to better define fatigue and its trajectory, understand intolerance, lack of energy and weakness. Research on fatigue in its physiology, and determine the best ways to prevent and treat it. people with cancer has included primarily self-reports of fatigue, with Psychosocial Issues Oral complications of cancer, including oral mucositis [66] and avoided in patients with xerostomia and salivary problems. (Refer salivary gland hypofunction/xerostomia, [136] are among the most to the summaries on Adjustment to cancer: anxiety and distress and devastating of both short- and long-term problems encountered by depression for more information.) http://www.cancer.gov/cancertopics/ people with cancer because they affect eating and communication, pdq/supportivecare/adjustment/HealthProfessional the most basic of human activities. Patients with these problems can Supportive care, including education and symptom management, are become withdrawn, socially avoidant and even clinically depressed as important for patients experiencing oral complications from cancer a result of the difficulties and frustrations they encounter living with therapy. It is important to closely monitor each patient’s level of distress, oral complications. ability to cope, and response to treatment. This approach provides When psychotropic drug interventions are employed in the treatment a setting for the health professional to demonstrate concern for the of such patients, it is important that the drugs chosen will improve, patient’s complications and to educate the patient and family caregivers. or at least not worsen, their oral complications. For example, in the Comprehensive, supportive care from staff and family can enhance the treatment of depression, highly anti-cholinergic drugs should be patient’s ability to cope with cancer and its complications.

Special considerations in pediatric populations Altered dental growth and development is a frequent complication in ●● Shortened root length is associated with diminished alveolar long-term cancer survivors who received high-dose chemotherapy and processes, leading to decreased occlusal vertical dimension. head/neck radiation for childhood malignancies [48, 54, 57, 55, 268, ●● Conditioning-induced injury to maxillary and mandibular growth 146, 56, 222]. Radiation doses as low as 4 Gy have been shown to centers can compromise full maturation of the craniofacial cause localized dental defects in humans [86, 91]. complex. Developmental disturbances in children treated before age 12 years Because the changes tend to be symmetric, the effect is not always generally affect size, shape and eruption of teeth as well as craniofacial clinically evident. Cephalometric analysis is typically necessary to development: delineate the scope of the condition. ●● Abnormal tooth formation manifests as decreased crown size, The extent and location of dental and craniofacial anomalies largely shortened and conical shaped roots, and microdontia; on occasion, depend on the age at which cancer therapy was initiated and the complete agenesis may occur. cancer regimen used. Children younger than 5 or 6 years at the time ●● Eruption of teeth can be delayed, including increased frequency of of treatment (particularly those who undergo treatment that involves impacted maxillary canines. concomitant chemotherapy and head and neck radiation) appear to

Page 34 Dental.EliteCME.com have a higher incidence of dental and craniofacial anomalies than do managed orthodontic interventions appears to be increasing; however, older patients or those who undergo only chemotherapy [171, 101]. specific guidelines for management, including optimal force and pace The role and timing of orthodontic treatment for patients who have with which teeth should be moved, remains undefined. The influence transplant-related malocclusions or other alterations of dental growth of growth hormone relative to improved development of maxillary and and development are not fully established. The number of successfully mandibular structures is yet to be comprehensively studied. Such studies may well influence recommendations for orthodontic treatment. Late dental effects of treatment for childhood cancer Both chemotherapy and radiation therapy can cause multiple cosmetic term survivors of childhood cancer [119]. TBI has been linked to the and functional abnormalities of dentition, most predominantly in development of short, V-shaped roots, microdontia, enamel hypoplasia children treated before age 5 years who have not yet developed and premature apical closure [100, 101, 119]. deciduous dentition [4, 100, 101, 119, 120, 190, 191, 148, 104]. Children who undergo bone marrow transplantation with TBI for However, even older prepubertal children are at risk. Developing neuroblastoma are at substantial risk for a spectrum of abnormalities teeth are irradiated in the course of treating head and neck sarcomas, and require close surveillance and appropriate interventions [120]. Hodgkin lymphoma, neuroblastoma, central nervous system leukemia, Salivary gland irradiation incidental to treatment of head and nasopharyngeal cancer, and as a component of total-body irradiation neck malignancies or Hodgkin lymphoma causes a qualitative and (TBI). Doses of 20 Gy to 40 Gy can cause root shortening or abnormal quantitative change in salivary flow, which can be reversible after curvature, dwarfism and hypocalcification [4]. doses of less than 40 Gy but may be irreversible after higher doses, More than 85 percent of survivors of head and neck rhabdomyosarcoma depending on whether sensitizing chemotherapy is also administered who receive radiation doses greater than 40 Gy may have significant [191]. Dental caries are the most problematic consequence. The use dental abnormalities, including mandibular or maxillary hypoplasia, of topical fluoride can dramatically reduce the frequency of caries, increased caries, hypodontia, microdontia, root stunting and xerostomia and saliva substitutes and sialagogues can ameliorate sequelae such as [191, 190]. xerostomia [190]. Chemotherapy for the treatment of leukemia can cause shortening and It has been reported that the incidence of dental visits for childhood thinning of the premolar roots and enamel abnormalities [4, 100]. cancer survivors falls below the American Dental Association’s Childhood Cancer Survivor Study investigators identified age recommendation that all adults visit the dentist annually [148]. These younger than 5 years and increased exposure to cyclophosphamide as findings give health care providers further impetus to encourage significant risk factors for developmental dental abnormalities in long- routine dental and dental hygiene evaluations for survivors of childhood treatment. Table VI. Oral/dental late effects Predisposing therapy Oral/dental effects Health screening/interventions CT = computed tomography; GVHD = graft-vs.-host disease; MRI = magnetic resonance imaging. Any chemotherapy; radiation Dental developmental abnormalities; tooth/ Dental evaluation and cleaning every six months. impacting oral cavity. root agenesis; microdontia; root thinning/ Regular dental care including fluoride applications. shortening; enamel dysplasia. Consultation with orthodontist experienced in management of irradiated childhood cancer survivors. Baseline panorex prior to dental procedures to evaluate root development. Radiation impacting oral cavity. Malocclusion; temporomandibular joint Dental evaluation and cleaning every six months. dysfunction. Regular dental care including fluoride applications. Consultation with orthodontist experienced in management of irradiated childhood cancer survivors. Baseline panorex prior to dental procedures to evaluate root development. Radiation impacting oral Xerostomia/salivary gland dysfunction; Dental evaluation and cleaning every six months. cavity; hematopoietic cell periodontal disease; dental caries; oral Supportive care with saliva substitutes, moistening agents, and transplantation with history of cancer (squamous cell carcinoma). sialogogues (pilocarpine). chronic GVHD. Regular dental care including fluoride applications. Radiation impacting oral cavity Osteoradionecrosis. History: impaired or delayed healing following dental work. (≥40 Gy). Exam: persistent jaw pain, swelling or trismus. Imaging studies (x-ray, CT scan, MRI) may assist in making diagnosis. Surgical biopsy may be needed to confirm diagnosis. Consider hyperbaric oxygen treatments. Management of oral complications in pediatric patients is additionally challenging because of the relatively limited research base directed to oral toxicities. New, comprehensive research studies are thus needed.

Dental.EliteCME.com Page 35 Part IV: Dental oncology – in brief Pre-cancer treatment oral health examination Objectives ○○ Periodontal disease. 1. Conduct evaluation one month, if possible, before cancer treatment ○○ Endodontic disease. begins. ○○ Mucosal lesions. 2. Establish a schedule for dental treatment. 4. Identify and eliminate sources of oral trauma and irritation such as ○○ Complete invasive procedures at least 14 days before head/ ill-fitting dentures, orthodontic bands and other appliances. neck radiation therapy starts; seven to 10 days before 5. Identify and treat potential oral problems within the proposed myelosuppressive chemotherapy. radiation field before radiation treatment begins. ○○ Postpone elective oral surgical procedures until cancer 6. Instruct patients about oral hygiene. treatment is completed. 7. Educate patients on preventing demineralization and dental 3. Identify and treat sites of low-grade and acute oral infections: caries. ○○ Caries.

Head and neck radiation therapy Patients receiving radiation therapy to the head and neck are at risk for ○○ Conduct prosthetic surgery before treatment, since elective developing oral complications. Because of the risk of osteonecrosis surgical procedures are contraindicated on irradiated bone. in irradiated fields, oral surgery should be performed before radiation ●● During radiation therapy treatment begins. ○○ Monitor the patient’s oral hygiene. ●● Before head and neck radiation therapy ○○ Watch for mucositis and infection. ○○ Conduct a pretreatment oral health examination and ○○ Advise against wearing removable appliances during prophylaxis. treatment. ○○ Schedule dental treatment in consultation with the radiation ●● After radiation therapy oncologist. ○○ Recall the patient for prophylaxis and home care evaluation ○○ Extract teeth in the proposed radiation field that may be a every four to eight weeks or as needed for the first six months problem in the future. after cancer treatment. ○○ Prevent tooth demineralization and radiation caries: ○○ Reinforce the importance of optimal oral hygiene. ■■ Fabricate custom gel-applicator trays for the patient. ○○ Monitor the patient for trismus: check for pain or weakness in ■■ Prescribe a 1.1 percent neutral pH sodium fluoride gel or a masticating muscles in the radiation field. Instruct the patient 0.4 percent stannous, unflavored fluoride gel (not fluoride to exercise three times a day, opening and closing the mouth as rinses). far as possible without pain; repeat 20 times. ■■ Use a neutral fluoride for patients with porcelain crowns or ○○ Consult with the oncology team about use of dentures and resin or glass ionomer restorations. other appliances after mucositis subsides. Patients with friable ■■ Be sure that the trays cover all tooth structures without tissues and xerostomia may not be able to wear them again. irritating the gingival or mucosal tissues. ○○ Watch for demineralization and caries. Lifelong, daily ■■ Instruct the patient in home application of fluoride gel. applications of fluoride gel are needed for patients with Several days before radiation therapy begins, the patient xerostomia. should start a daily 10-minute application. ○○ Advise against elective oral surgery on irradiated bone because ■■ Have patients brush with a fluoride gel if using trays is of the risk of osteonecrosis. Tooth extraction, if unavoidable, difficult. should be conservative, using antibiotic coverage and possibly ○○ Allow at least 14 days of healing for any oral surgical hyperbaric oxygen therapy. procedures.

Chemotherapy The oral complications of chemotherapy depend upon the drugs used, ■■ The platelet count is less than 75,000/mm3 or abnormal the dosage, the degree of dental disease, and the use of radiation. clotting factors are present. Chemoradiation therapy carries a significant risk for mucositis. ■■ Absolute neutrophil count is less than 1,000/mm3, or ●● Before chemotherapy consider prophylactic antibiotics (www.americanheart.org/ ○○ Conduct a pretreatment oral health examination and presenter.jhtml?identifier=1200000). prophylaxis. ■■ Check for oral source of viral, bacterial or fungal infection ○○ Schedule dental treatment in consultation with the oncologist. in patients with fever of unknown origin. ○○ Schedule oral surgery at least seven to 10 days before ■■ Encourage consistent oral hygiene measures. myelosuppressive therapy begins. ■■ Consult the oncologist about the need for antibiotic ○○ Consult the oncologist before conducting any oral procedures prophylaxis before any dental procedures in patients with in patients with hematologic cancers; do not conduct central venous catheters. procedures in patients who are immunosuppressed or have ●● After chemotherapy thrombocytopenia. ○○ Place the patient on a dental recall schedule when ●● During chemotherapy chemotherapy is completed and all side effects, including ○○ Consult the oncologist before any dental procedure, immunosuppression, have resolved. including prophylaxis. ○○ Confirm normal hematologic status prior to dental treatment. ○○ Ask the oncologist to order blood work 24 hours before oral ○○ Ask whether the patient has received intravenous surgery or other invasive procedures. Postpone when: bisphosphonate therapy.

Page 36 Dental.EliteCME.com Questions to ask the medical oncologist ●● What is the patient’s complete blood count, including absolute ●● Does the patient have a central venous catheter? neutrophil and platelet counts? ●● What is the scheduled sequence of treatments so that safe dental ●● If an invasive dental procedure needs to be done, are there treatment can be planned? adequate clotting factors? ●● Is radiation therapy also planned?

Questions to ask the radiation oncologist ●● What parts of the mandible/maxilla and salivary glands are in the ●● Has the vascularity of the mandible been previously compromised field of radiation? by surgery? ●● What is the total dose of radiation the patient will receive, and ●● How quickly does the patient need to start radiation treatment? what will be the impact on these areas? ●● Will there be induction chemotherapy with the radiation treatment?

Hematopoietic stem cell transplantation Most stem cell transplant patients develop acute oral complications, ●● After transplantation especially patients with graft-vs.-host disease. ○○ Consult the oncologist before any dental procedure, ●● Before transplantation including prophylaxis. ○○ Conduct a pretreatment oral health examination and ○○ Monitor the patient’s oral health for plaque control, tooth prophylaxis. demineralization, dental caries and infection. ○○ Consult the oncologist about scheduling dental treatment. ○○ Watch for infections on the tongue and oral mucosa. Herpes ○○ Schedule oral surgery at least seven to 10 days before simplex and Candida albicans are common oral infections. myelosuppressive therapy begins. ○○ Delay elective oral procedures for one year. ○○ Prevent tooth demineralization and radiation caries: ○○ Follow patients for long-term oral complications. Such ■■ Instruct the patient in home application of fluoride gel (not problems are strong indicators of chronic graft-vs.-host fluoride rinses). disease. ■■ Instruct the patient about an oral hygiene regimen. ○○ Monitor transplant patients carefully for second malignancies in the oral region.

Advice for your patients ●● Brush teeth, gums, and tongue gently with an extra-soft toothbrush ●● Try the following if dry mouth is a problem: and fluoride toothpaste after every meal and at bedtime. If ○○ Sip water frequently. brushing hurts, soften the bristles in warm water. ○○ Suck ice chips or use sugar-free gum or candy. ●● Floss teeth gently every day. If your gums bleed and hurt, avoid ○○ Use saliva substitute spray or gel or a prescribed saliva the areas that are bleeding or sore but keep flossing your other stimulant if appropriate. teeth. ○○ Avoid glycerin swabs. ●● Follow instructions for fluoride gel applications. ○○ Exercise the jaw muscles three times a day to prevent and treat ●● Avoid mouthwashes containing alcohol. jaw stiffness from radiation treatment. ●● Rinse the mouth several times a day with a baking soda and salt ●● Avoid candy, gum and soda unless they are sugar-free. solution, followed by a plain water rinse. Use ¼ teaspoon each of ●● Avoid spicy or acidic foods, toothpicks, tobacco products and baking soda and salt in 1 quart of warm water. Omit salt during alcohol. mucositis.

Special care for children Children receiving chemotherapy or radiation therapy are at risk for ●● Remove orthodontic bands and brackets if highly stomatotoxic the same oral complications as adults. Other actions to consider in chemotherapy is planned or if the appliances will be in the managing pediatric patients include: radiation field. ●● Extract loose primary teeth and teeth expected to exfoliate during ●● Monitor craniofacial and dental structures for abnormal growth cancer treatment. and development.

Dental care for oral complications of cancer treatment Oral mucositis: Culture lesions to identify secondary infection. Complications specific to chemotherapy: Prescribe topical anesthetics and systemic analgesics. Consult ●● Neurotoxicity: Provide analgesics or systemic pain relief. the oncologist about prescribing antimicrobial agents for known ●● Bleeding: Advise the patient to clean teeth thoroughly with a infections. Have the patient avoid rough-textured foods and report oral toothbrush softened in warm water; avoid flossing the areas that problems early. are bleeding but to keep flossing the other teeth. Xerostomia/salivary gland dysfunction: Advise the patient to soften Complications specific to radiation: or thin foods with liquid, chew sugarless gum, or suck ice chips or ●● Demineralization and radiation caries: Prescribe daily fluoride sugar-free hard candies. Suggest using commercial saliva substitutes or gel applications before treatment starts. Continue for the patient’s prescribe a saliva stimulant. lifetime if changes in quality or quantity of saliva persist. Taste changes: Refer to a dietitian. ●● Trismus/tissue fibrosis: Instruct the patient on stretching exercises for the jaw to prevent or reduce the severity of Etched enamel: Advise the patient to rinse the mouth with water and fibrosis. baking soda solution after vomiting to protect enamel. ●● Osteonecrosis: Avoid invasive procedures involving irradiated bone, particularly the mandible.

Dental.EliteCME.com Page 37 Part V: Resources for Patients It is important that your patients understand that chemotherapy and ○○ Tres buenas razones para ver a un dentista ANTES de radiation therapy aimed at the head and neck cause problems in the comenzar el tratamiento contra el cáncer http://www.nidcr.nih. mouth and throat. In its mission to improve oral, dental and craniofacial gov/OralHealth/Topics/CancerTreatment/TresBuenas.htm. health through research, training and sharing information, The National ○○ Illustrated booklet for adults with reading skills at the second Institute of Dental and Craniofacial Research Information Resources grade level or below. It includes reasons to see a dentist before (NIDCR) supplies free information about oral complication of cancer cancer treatment, how to protect the mouth during treatment, treatment for patients in both English and Spanish. Booklets include: and advice on when to call the cancer care team about mouth ●● Chemotherapy and Your Mouth http://www.nidcr.nih.gov/ problems. Self-care tips are also provided. OralHealth/Topics/CancerTreatment/ChemotherapyYourMouth. Materials are available at the links above and online at http://www. htm nidcr.nih.gov, or by contacting the NIDCR Clearinghouse: ○○ La quimioterapia y la boca http://www.nidcr.nih.gov/ National Institute of Dental and Craniofacial Research OralHealth/Topics/CancerTreatment/QuimioterapiaylaBoca. National Oral Health Information Clearinghouse htm 1 NOHIC Way ○○ Discusses how chemotherapy affects the mouth and the Bethesda, MD 20892-3500 importance of seeing a dentist before, during and after Tel: 1-866-232-4528 treatment. Also included are self-care tips for patients to keep Fax: 301- 480-4098 their mouth healthy during treatment. Email: [email protected] ●● Head and Neck Radiation Treatment and Your Mouth http:// www.nidcr.nih.gov/OralHealth/Topics/CancerTreatment/ This information is part of the series Oral Health, Cancer Care, and HeadNeckRadiation.htm You: Fitting the Pieces Together, focused on managing and preventing ○○ La boca y el tratamiento de radiación en la cabeza y el cuello oral complications of cancer treatment. The series was developed by the http://www.nidcr.nih.gov/OralHealth/Topics/CancerTreatment/ National Institute of Dental and Craniofacial Research in partnership SuBoca.htm with the National Cancer Institute, the National Institute of Nursing ○○ Discusses how radiation affects the mouth and the importance Research, and the Centers for Disease Control and Prevention. Related of seeing a dentist before, during and after cancer treatment. resources include: Also included are self-care tips for patients to keep their mouth ●● Chemotherapy and You: Support for People With Cancer http:// healthy during treatment. www.cancer.gov/cancertopics/coping/chemotherapy-and-you. ●● Three Good Reasons to See a Dentist BEFORE Cancer Treatment ●● Eating Hints: Before, During, and After Cancer Treatment http:// http://www.nidcr.nih.gov/OralHealth/Topics/CancerTreatment/ www.cancer.gov/cancertopics/coping/eatinghints. ThreeGoodReasons.htm ●● Follow-up Care After Cancer Treatment http://www.cancer.gov/ ○○ Tres buenas razones para ver a un dentista ANTES de cancertopics/factsheet/Therapy/followup. comenzar el tratamiento contra el cáncer http://www.nidcr.nih. ●● Harms of Smoking and Health Benefits of Quittinghttp://www. gov/OralHealth/Topics/CancerTreatment/TresBuenas.htm. cancer.gov/cancertopics/factsheet/Tobacco/cessation. ○○ Discusses reasons to see a dentist before cancer treatment, how ●● Radiation Therapy and You: Support for People With Cancer to protect the mouth during treatment, and advice on when to http://www.cancer.gov/cancertopics/coping/radiation-therapy-and- call the cancer care team about mouth problems. Self-care tips you. are also provided. ●● Taking Part in Cancer Treatment Research Studies http://www. ●● Three Good Reasons to See a Dentist BEFORE Cancer Treatment cancer.gov/clinicaltrials/learningabout/Taking-Part-in-Cancer- (Pictograph) http://www.nidcr.nih.gov/OralHealth/Topics/ Treatment-Research-Studies. CancerTreatment/ThreeGoodReasonsPicto.htm. ●● What You Need To Know About™ Cancer of the Larynx http:// www.cancer.gov/cancertopics/wyntk/larynx. ●● What You Need To Know About™ Oral Cancer (booklet) http:// www.cancer.gov/cancertopics/wyntk/oral/page1/AllPages. Clinical trials A search engine for clinical trials associated with oral complications of cancer treatment is available at http://www.clinicaltrials.gov/ct2/ results?term=oral%20complications%20of %20cancer%20treatment.

Appendix: Levels of evidence Many reference citations in this chapter are accompanied by a level-of- alone. Depending on perspective, different expert panels, professional evidence designation. These designations are intended to help readers organizations or individual physicians may use different cut-off assess the strength of the evidence supporting the use of specific points on the overall strength of evidence in formulating therapeutic interventions or approaches. The Editorial Board at the National guidelines or in taking action; however, a formal description of the Cancer Institute of the National Institutes of Health uses a formal level of evidence provides a uniform framework for the data, leading evidence ranking system for its level-of-evidence designations. to specific recommendations. Levels of evidence are provided to assist the reader in judging the There are varying levels of evidence on screening, prevention and strength of evidence linked to the reported results of a therapeutic treatment that support a given summary. The summaries are subject strategy. For any given therapy, results of prevention and treatment to modification as new evidence becomes available. The strongest studies can be ranked on each of the following two scales: evidence would be that obtained from a well-designed and well- 1. Strength of the study design. conducted randomized controlled trial. It is not always practical, 2. Strength of the endpoints. however to conduct such a trial to address every question in the fields Together, the two rankings provide a measure of the overall level of of cancer screening, prevention and treatment. evidence. Screening studies are ranked on strength of study design

Page 38 Dental.EliteCME.com Evidence related to screening ●● Screening is a means of accomplishing early detection of disease in symptoms, and this test must be acceptable to patients and society people without symptoms of the disease being sought. in terms of convenience, comfort, risk and cost. ●● Examinations, tests or procedures used in cancer screening are 3. Strong evidence exists that early detection and treatment improve often not definitive but sort out persons suspected of harboring a disease outcomes, particularly disease-specific survival. clinically occult cancer from those in whom a cancer is not likely 4. The harms of screening must be known and acceptable. to be present. 5. Screening must be judged to do more good than harm, considering ●● Diagnosis of disease is made after a workup, biopsy or other all benefits and harms it induces in addition to the cost and cost- tests are completed in pursuing symptoms or following positive effectiveness of the screening program. detection procedures. In descending order of strength of evidence, the levels for screening The five requirements that should be met before it is considered studies are as follows: appropriate to screen for a particular medical condition as part of 1. Evidence obtained from at least one well-designed and well- routine medical practice are as follows: [ Woolf SH: Screening for conducted randomized controlled trial. prostate cancer with prostate-specific antigen. An examination of 2. Evidence obtained from well-designed and well-conducted the evidence. N Engl J Med 333 (21): 1401-5, 1995. Winawer S, nonrandomized controlled trials. Fletcher R, Rex D, et al.: Colorectal cancer screening and surveillance: 3. Evidence obtained from well-designed and well-conducted cohort clinical guidelines and rationale – Update based on new evidence. or case-control analytic studies, preferably from more than one Gastroenterology 124 (2): 544-60, 2003.] center or research group. 1. The medical condition being sought must cause a substantial burden 4. Evidence obtained from multiple time series, with or without of suffering, measured both as mortality and as the frequency and intervention. severity of morbidity and loss of function. 5. Opinions of respected authorities based on clinical experience, 2. A screening test or procedure exists that will detect cancers descriptive studies, or reports of expert committees. earlier in their natural history than when diagnosis is prompted by

Evidence related to cancer prevention Prevention is defined as a reduction in the incidence (or the rate) 4. Evidence obtained from well-designed and well-conducted cohort of new cancer, with the goal of reducing cancer-related morbidity or case-control studies, preferably from more than one center or and mortality. Examples of prevention strategies include smoking research group, that have: cessation, avoidance of excessive exposure to sunlight (ultraviolet) or ○○ A cancer endpoint. ionizing radiation, surgical removal of an at-risk target organ before ■■ Mortality. cancer develops, and use of medications (e.g., tamoxifen for breast ■■ Incidence. cancer risk reduction). ○○ A generally accepted intermediate endpoint (e.g., large For each prevention-related summary of evidence statement, the adenomatous polyps for studies of colorectal cancer associated levels of evidence are listed. In descending order of strength prevention). of evidence, the five levels are as follows: 5. Ecologic (descriptive) studies (e.g., international patterns studies 1. Evidence obtained from at least one well-designed and well- and migration studies) that have: conducted randomized controlled trial that has: ○○ A cancer endpoint. ○○ A cancer endpoint. ■■ Mortality. ■■ Mortality. ■■ Incidence. ■■ Incidence. ○○ A generally accepted intermediate endpoint (e.g., large 2. A generally accepted intermediate endpoint (e.g., large adenomatous polyps for studies of colorectal cancer adenomatous polyps for studies of colorectal cancer prevention). prevention). 3. Evidence obtained from well-designed and well-conducted 6. Opinions of respected authorities based on clinical experience, nonrandomized controlled trials that have: descriptive studies or reports of expert committees (e.g., any of the ○○ A cancer endpoint. above study designs using invalidated surrogate endpoints). ■■ Mortality. In assessing a genetic test (or other method of genetic assessment, ■■ Incidence. including family history), the analytic validity, clinical validity, and ○○ A generally accepted intermediate endpoint (e.g., large clinical utility of the test need to be considered. [Holtzman NA, adenomatous polyps for studies of colorectal cancer Watson MS, eds.: Promoting Safe and Effective Genetic Testing in prevention). the United States: Final Report of the Task Force on Genetic Testing. Baltimore, Md: Johns Hopkins Press, 1998.]

Evidence related to treatment For each treatment-related summary of evidence statement, the c. Carefully assessed quality of life. associated levels of evidence are listed. In descending order of strength d. Indirect surrogates. of evidence, the five levels are as follows: ■■ Disease-free survival. 1. Evidence obtained from randomized controlled trials. ■■ Progression-free survival. 2. Evidence obtained from nonrandomized controlled trials. ■■ Tumor response rate. 3. Evidence obtained from cohort or case-control studies. 4. Evidence from ecological, natural history, or descriptive studies. a. Total mortality (or overall survival from a defined time). 5. Opinions of respected authorities based on clinical experience, b. Cause-specific mortality (or cause-specific mortality from a descriptive studies or reports of expert committees. defined time).

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Dental.EliteCME.com Page 43 Cancer TReatment and Oral Care

Final Examination Questions Select the best answer for each question and mark your answers on the online at Dental.EliteCME.com. 1. More than one-third of people treated for cancer develop 12. Dental brushing and flossing for patients receiving high-dose complications that affect the mouth. cancer therapy should be performed daily under the supervision a. True. of professional staff, and should use a toothpaste with a relatively b. False. neutral taste because flavoring agents in toothpaste can irritate oral 2. Oral cancer accounts for about 3 percent of cancers in men and 1.5 soft tissues. percent of cancers in women. a. True. a. True. b. False. b. False. 13. The terms oral mucositis and stomatitis reflect identical processes. 3. The primary risk factors for oral cancer in American men and a. True. women are tobacco (including smokeless tobacco) and alcohol use. b. False. a. True. 14. Focal topical application of anesthetic agents is preferred over b. False. widespread oral topical administration, unless the patient requires 4. Stage III cancer of the lip and oral cavity is highly curable by more extensive pain relief. either surgery or by radiation therapy alone. a. True. a. True. b. False. b. False. 15. At more than six months post-surgery, impairment due to moderate 5. Oral complications occur in virtually all patients receiving to severe pain may be seen in approximately one-third of patients. radiation for head and neck malignancies. a. True. a. True. b. False. b. False. 16. Addiction to opioid therapy is generally a concern for cancer 6. Fluoride rinses are adequate to prevent tooth demineralization patients. during cancer treatment. a. True. a. True. b. False. b. False. 17. Herpes group viral infections, including those caused by oral 7. It is necessary to consult the dental patient’s oncologist before any lesions, can cause a variety of diseases that range from mild to dental procedure, including dental prophylaxis. serious conditions in patients undergoing treatment for cancer. a. True. a. True. b. False. b. False. 8. Management of oral complications of cancer therapy include 18. Unlike in myelosuppressed cancer patients, incidence of HSV identification of high-risk populations, patient education, initiation reactivation in patients undergoing head and neck radiation is very of pretreatment interventions and timely management of lesions. high. a. True. a. True. b. False. b. False. 9. In general, radiation protocols cause acute toxicities that resolve 19. Spontaneous gingival oozing may occur when platelet counts drop following discontinuation of therapy and recovery of damaged below 40,000/mm3, especially when there is preexisting gingivitis tissues. or periodontitis. a. True. a. True. b. False. b. False. 10. Unlike chemotherapy, radiation damage is anatomically 20. Oral squamous cell carcinoma is the most frequently occurring site-specific. secondary oral malignancy in transplant patients, with the lip and a. True. tongue being the most frequently reported sites. b. False. a. True. 11. Phase III, Hematopoietic recovery, is typically the period of high b. False. prevalence and severity of oral complications. a. True. b. False.

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Page 44 Dental.EliteCME.com Chapter 2: A Dental Professional’s Field Guide to Substance Abuse

7 CE Hours

By: Staff Writer Learning objectives ŠŠ List the most common oral symptoms of illegal drug use. ŠŠ Describe the characteristics associated with meth mouth, including ŠŠ Explain the mechanism and role of neurotransmitters, such as why meth mouth is a misleading term. dopamine, in addiction. ŠŠ Describe the implications of chronic IV drug use on the oral cavity. ŠŠ Distinguish between drinking habits of social alcohol users vs. ŠŠ List the most common sources for nonmedical opioid alcohol-dependent drinkers. prescription drugs. ŠŠ Compare and contrast substance abuse, physical dependence, ŠŠ Describe the physiological effects that most commonly cause and addiction. fatalities with excessive opioid use. ŠŠ Explain how a poor diet and xerostomia, in combination, ŠŠ Define nonmedical use of prescription drugs, according to the U.S. contribute to decay. National Survey on Drug Use and Health. ŠŠ Compare and contrast the hazards of smoking methods such as ŠŠ List strategies for minimizing prescription drug diversion through cigarettes, cigars, and hookahs. responsible prescribing practices. ŠŠ List the most common oral cancerous and precancerous conditions ŠŠ List common characteristics and strategies of drug-seeking behavior. associated with cigarette smoking. ŠŠ Explain the potential drug interactions and contraindications of ŠŠ List the segments of the U.S. population most likely to use anesthesia and sedation for the following types of drug abuse: smokeless tobacco. alcohol, cocaine, methamphetamine, and opioids. ŠŠ List contraindications for patients who are excessive alcohol users ŠŠ Discuss strategies for pain control in opioid addicts or former addicts. and reformed alcoholics. ŠŠ Explain the rationale for drug screening and intervention in the ŠŠ List the oral conditions more common in marijuana smokers. dental office. ŠŠ Describe the oral indications of stimulant abuse. ŠŠ List the bodies of law and legal requirements governing ŠŠ List the potential adverse drug interactions for patients who communication among health care providers regarding use cocaine. substance abuse. ŠŠ Contrast patterns of drug use between designer-drug users and ŠŠ Explain the significance of the5 A’s and SBIRT in substance abuse traditional drug users. intervention.

Introduction Most medical professionals are aware that excessive drug use the oral cavity, the management and clinical implications for these endangers the health of millions of people in the United States. Some patients, and the most effective strategies for intervention and referral. of these abused substances (e.g., tobacco and alcohol) are legal; some This course will teach dental professionals and staff members to (e.g., opioids, codeine, or the anti-anxiety medication, Xanax) are recognize common characteristics of drug abuse to: controlled substances, legally prohibited without a prescription; and ●● Identify patients who are excessive substance users, to protect others (e.g., cocaine or heroin) are generally prohibited for public them from potential drug-related risks during dental treatment (i.e., use. Many of these drugs have highly addictive qualities that greatly contraindications, drug interactions, etc.). increase the risk of their abuse, as well as the potential for many ●● Ensure prescription drugs are not diverted to unintended users. serious diseases and drug-related deaths. The course is divided into five sections: But, not as well known, is that many of the symptoms and effects of ●● Section I: Nature of Substance Abuse and Addiction. substance abuse are exhibited in poor oral health, either as a direct effect ●● Section II: Commonly Abused Legal Substances. of consumption or exposure to the substance, or indirectly, through ●● Section III: Commonly Abused Illegal Substances. multiple compromised body systems. A recent study published in the ●● Section IV: Prescription Drug Abuse. Journal of Substance Abuse Treatment, found a strong association ●● Section V: General Intervention Strategies. between substance abuse and poor oral health, showing increased rates of disease and decay among users of marijuana, heroin, methamphetamine, The specific legal and illegal substances discussed in this prescription pain medication, alcohol, and tobacco, in comparison to course (tobacco, alcohol, marijuana, cocaine, MDMA/ecstasy, nonusers. Those using opioids (pharmaceutical narcotics or heroin) methamphetamine, heroin, and prescription opioids) were selected showed the most extreme and rapid rates of deterioration [1]. for their prevalence and potential for abuse, but there are many more addictive substances that result in poor oral health [2]. Professional dental associations and organizations encourage dentists, hygienists, dental clinicians, and dental office personnel to familiarize Some are customary among specific subcultures or minorities, such themselves with characteristics of drug abuse through professional as khat chewing (common in Yemen), which causes receding gums continuing education. They should learn physical symptoms and with mucosal white lesions; betel nut (Southeast Asia), which stains effects of the most commonly abused drugs on the body—particularly the teeth and gingiva red and is associated with oral cancer; or steroids (athletes use to promote strength and endurance), which cause gingival enlargement. Depending on the population served, a clinician may Dental.EliteCME.com Page 45 encounter a greater incidence of some types of substance abuse among his or her patients than exists among the general population [3][4][5].

Section I: Nature of Substance Abuse and Addiction

Overview According to the U.S. National Survey on Drug Use and Health, about embarrassment or judgment by those seeing the forms, concerns 22 million people aged 12 and older could be classified as substance related to insurance coverage, or general privacy issues [7][8]. abusers or substance-dependent. The majority are dependent on Effective management of patients who abuse drugs or alcohol requires alcohol (about 15 million); with an additional 4 million dependent a keen understanding and awareness of [9]: on one or more illegal drug(s) (or drugs obtained illegally), but not ●● Characteristic symptoms and effects of commonly abused drugs. alcohol; and an additional 3 million dependent on alcohol, as well as at ●● Clinical implications of drug use. least one illegal substance [6]. ●● Effective screening instruments to identify drug abusers. Given the prevalence of substance abuse, it is likely that most dental ●● Potential drug interactions and side effects complicating professionals regularly meet patients who are chemically dependent. procedures or treatment. Dentists who unknowingly treat a patient who is a substance user ●● Potential complications related to a general state of compromised or abuser may be exposing the patient to a higher degree of risk health, weakened immune system, and poor healing ability. and increased potential for adverse effects, even with routine dental ●● Management strategies to address patients who miss appointments, procedures or treatment. exhibit drug-seeking behaviors, or come to an appointment under Identifying substance abusers can be difficult, particularly if you rely the influence of drugs or alcohol. on self-reported medical histories, which are notoriously inaccurate. ●● Dangers of prescribing certain pain medications to opioid abusers, One recent study found almost half of all survey respondents were products with alcohol to alcoholics, or use of any medication or not completely truthful on medical forms due to fear of possible procedure contraindicated in drug users, those in recovery for substance abuse and addiction, and reformed users. ●● The nature of addiction and effective intervention strategies.

Types of drug use and users There are many types of drugs and users. A drug’s potential for Social users rarely show the escalating degree of emotional or physical dependency or addiction differs according to drug type, potency, need for the drug that characterizes a potential substance abuser [10]. frequency of ingestion, methods of production (differences in A primary distinguishing feature of the social user is that he or she is cultivation or processing), and consumption (smoking, injecting), as unlikely to take the types of risks associated with substance abuse, and well as genetic, psychological, and environmental variables associated resists the repetitive behavior that progresses to chronic use. However, with the individual using the substance. Not all users are addicts, nor some long-term social users may escalate to dependency at some point are all addicts obviously dependent on a substance. in their lives. Individuals with a propensity for dependence escalate Alcohol and drug use serves many functions. Early use of many more readily to habitual and/or increasingly risky use. As consumption illegal and legal addictive substances begins in a social environment. of the substance becomes increasingly important, the dependent Young people may try a prohibited substance to achieve a desired individual is willing to assume higher thresholds of risk to continue pharmacological effect, to satisfy a curiosity, take a risk, or because a using the substance. Users go to great lengths to hide their degree of friend or family member shares in the activity. substance use, even as it threatens to destroy jobs and relationships. Many continue to use alcohol and drugs socially. Although casual, Some individuals take a drug for purely recreational purposes, while occasional use characterizes this type of user, the frequency and others use drugs to relieve their physical or emotional pain. The latter amount of drug use may vary widely. Some social usually consume type of substance use is known as self-medication. For those with alcohol or drugs in association with a specific event (a celebration), chronic pain, the initial source is often a valid prescription. Once the time in life (college), or group of friends. Even if the individual uses prescription runs out, the individual will attempt to find other doctors a specific substance on a regular basis, the pattern of use may not be to prescribe the same medication or a similar medication, friends and problematic or potentially abusive. relatives with prescriptions, or turn to black market sources.

Abuse, dependence, and addiction Substance abuse is a disease characterized by maladaptive patterns of drug more of the substance or more potency to achieve the same effects) and consumption that result in damaging consequences for the individual, who withdrawal symptoms, once use of the drug is discontinued. continues to use the substance in the same manner, although it continues While physical dependence and addiction are often used to result in negative repercussions. Substance abuse is characterized interchangeably, they have distinct meanings. Physical dependence is by heavy use, but does not necessarily imply dependence. Physical (or a necessary characteristic of addiction, but addiction also includes a physiological) dependence is indicated by drug tolerance (requiring psychological dependence on the drug. Table 1 contrasts the elements of addiction and dependence [11].

Table 1. Elements of addiction and dependence Addiction Dependence Physical dependence Yes Yes Psychological dependence Yes No Withdrawal symptoms Yes Yes Drug-seeking behavior Yes No

Page 46 Dental.EliteCME.com Physical dependence Physical dependence is an individual’s escalating need for the drug and coworkers, or friends for years before they are found out. Keeping withdrawal effects that appear if he or she stops using the substance. dependence a secret becomes increasingly difficult as it grows. Common characteristics of increasing dependency include failure to Symptoms of withdrawal are a defining feature of physical dependence. fulfill work obligations, inability to change one’s habits, and assuming They typically begin when the user’s blood levels of the substance go increased personal risk due to poor judgment or physical dysfunction. below a certain threshold, with symptoms relieved when the drug levels These behavioral patterns demonstrate the increasing necessity of increase. Users may switch to a similar substance if a preferred drug is getting and using the substance. The individual’s focus and priorities not available, or tolerance increases to a level where the substance no change as these new needs eclipse obligations and responsibilities longer provides a sufficient effect. A substance abuser may use alcohol at work and home. It may be a very long time before dependence one decade and prescription medication the next. Moving from one is discernable to the general public or health care professionals. addictive substance to another over time is referred to as transference [12]. Substance abusers may hide their use from family members,

Addiction Addiction is defined as a progressive illness characterized by long-term uncontrollable cravings for the substance that persist even in the changes to the brain’s structure and function that occur due to repeated face of negative or harmful consequences to the user or others. The use of a substance that can persist long after use is discontinued. The individual may put friends or family members at physical risk (i.e., amount of drug required to cause this change varies by individual. babysitting, driving drunk), or at risk of legal prosecution. Like other Addicts report that the psychological component of addiction can be as chronic diseases, addicts may alternate between relapse and reinitiating powerful as the physical need in its potential to cause relapse [13]. drug use. In some cases, symptoms of withdrawal can be life- If left untreated, addiction can result in disease, disability, or threatening. It is generally accepted that addicts are unable to return to early death. The symptoms of addiction include compulsive or social or occasional use of the abused substance.

How addictive substances produce their effects Drugs are chemicals that alter the way nerve cells in the brain send, occur without the use of drugs. With repeated use, the brain adjusts to receive, and process information. Some drugs, such as marijuana and these surges in dopamine and other neurotransmitters by producing heroin, activate neurons because their chemical structure is similar to less dopamine, or reducing the number of receptors that can receive that of a natural neurotransmitter. This parallel structure allows drugs signals. The drug abuser’s natural reward system diminishes, and the to lock into receptors, activating nerve cells, but acting in a different individual is unable to enjoy things that previously brought him or her manner with different effects than the neurotransmitter they mimic. pleasure. The drug becomes the only way to raise the user’s levels of Amphetamine drugs or cocaine cause nerve cells to release abnormally dopamine, with more of the drug necessary to create the same high, [14]. large amounts of natural neurotransmitters, such as dopamine, or prevent indicating increasing physical dependence their normal recycling. Dopamine is a neurotransmitter responsible for The same mechanisms involved in the development of tolerance can regulating movement, emotion, cognition, motivation, and feelings of eventually lead to profound changes in neurons and brain circuits, with the pleasure (located in the pleasure center of the brain) that are elemental potential to severely compromise the long-term health of the brain. This to the brain’s reward system. The flood of dopamine produces a high or rewiring of the brain triggers irresistible cravings for the drug. If the drug euphoric sensation, reinforcing the drug-taking behavior. This leads to is not available, the individual is likely to exhibit drug-seeking behavior repeated use, paving the way for potential abuse and addiction. and attempt to obtain the drug through any means necessary. Because the need for the drug is positively reinforced by the effects of its consumption Commonly abused drugs may release anywhere from two to 10 times (the high), drug taking becomes a learned reflex. These changes in the the amount of dopamine that would typically be released by the brain brain are associated with an overwhelming need for the drug, which, even under normal circumstances, with a much longer duration than would after years of abstinence, is strong enough to cause relapse.

Section II: Commonly Abused Legal Substances

Tobacco According to the 2010 National Survey on Drug Use and Health, about Even though the health risks associated with tobacco use are well one-third of all individuals in the United States aged 12 years and older documented and publicized, the price has risen precipitously, and it (almost 70 million people) have used at least one form of tobacco. is prohibited in most public and many private spaces, smoking has Cigarette smokers form the largest portion of tobacco smokers (about proven to be a habit with staying power and a persistent following. 58 million people), followed by about 13 million who smoke cigars, 9 Studies suggest the majority of nicotine addicts would like to quit, and million who use smokeless tobacco, and 2 million who smoke pipes [15]. have attempted it at least once [16.1]. Discontinuing tobacco use can be While smoking tobacco (i.e., cigarettes, cigars, hookahs, or pipes) and extremely difficult not only because the user may experience severe smokeless tobacco (i.e., snuff or plug) come from the same processed or potentially dangerous withdrawal systems (nicotine replacement green tobacco leaf, each tobacco product is subject to a different therapies and other commonly prescribed medications are not always curing, aging, and fermentation process. There are more than 4,000 successful in quelling cravings), but also because it requires the different chemical compounds in tobacco, but the concentration of tobacco user to commit to significant, permanent changes in his or her each may vary significantly according to the way it is processed and behavior, priorities, and environment, or risk relapse. other ingredients or flavorings added to the product[16] . The ingredient in tobacco associated with dependence is nicotine. Those who have never felt the grip of nicotine addiction may be perplexed by the behavior of friends who refuse to quit such an obviously dangerous and self-destructive habit.

Dental.EliteCME.com Page 47 Smoking tobacco The 1964 U.S. Surgeon General’s Report on Smoking and Health was one reconstituted tobacco may treat the tobacco with humectants, adhesives, or of the first public documents linking smoking to increased risk of cardiac other potentially hazardous additives [18]. [16.2] and vascular disease . Recent research shows a relationship between Biomarkers such as nicotine, carbon monoxide, hydrogen cyanide, tobacco use and health risks such as increased periodontal disease and benzene, and PAH (polynuclear aromatic hydrocarbons) are many types of cancer, (mouth, pharynx, esophagus, lung, pancreas, and compounds found in body fluids and the exhaled breath of smokers bladder), among other dangerous conditions and disorders [17]. that can be used to assess a smoker’s degree of exposure to the toxic Tobacco smoke, like all smoke, is the result of incomplete combustion and carcinogenic compounds in tobacco smoke. For example, tobacco of the material burned. While most tobacco is equivalent in toxic and smoke contains at least 10 carcinogenic forms of PAH; by measuring carcinogenic compounds (though at varying levels), there are considerable this biomarker in the smoker’s exhaled breath, one can determine the differences in the health risks of each product. For example, cigars and amount exhaled, and the amount remaining in the smoker’s respiratory cigarettes use different qualities of tobacco, are different sizes, and contain tract, which may be as high as 90% in a long-term smoker [19]. other materials smoked with the tobacco, such as the cigar wrapper or According to the International Agency for Research on Cancer (1987), cigarette rolling paper. Tobacco products, with the exception of most some of the most dangerous ingredients found in processed tobaccos standard sized cigars, are flavored with many additives that contain toxic are arsenic, beryllium, chromium, nickel, and cadmium, all of which ingredients inhaled in the smoke. Smokers who use filtered cigarettes are known to be carcinogenic [20]. Other toxic substances include trace or cigars may encounter more flavoring ingredients, as well as the amounts of mercury, lead, and assorted metals, as well as pesticides possibility of industrial plasticizers used to apply filter tips. Products using used in tobacco cultivation, and radioactive elements, such as lead 210 and polonium 210, which are byproducts of phosphate fertilizers [21]. Cigarettes The cigarette is a carefully crafted nicotine delivery system containing Each draw of a cigarette yields 1 mg to 2 mg of nicotine, depending more than 4,000 other chemicals. Once inhaled, nicotine is absorbed on the strength of the draw, with about 10 inhalations per cigarette. through the mucous membrane in the oral cavity and alveolar surface A pack-a-day smoker receives a dosage of about 200 mg of nicotine of the lung. Within 10 seconds of inhalation, nicotine reaches the per day. The vast majority of smokers (about 85% to 90%) use more brain, causing the release of dopamine. Physical effects include the than five cigarettes per day, and exhibit clear symptoms of nicotine release of adrenaline, with a corresponding increase in the smoker’s dependence. In most cases, one a smoker begins the habit, daily respiration and heart rate. Psychological effects associated with consumption increases over a period of years, then levels out [24]. smoking cigarettes include feelings of pleasure, well-being, and a Each year, millions of smokers vow to quit smoking, but more that 85% sense of peace or control. Many cigarette smokers tout its ability to are likely to relapse within 1 week. Most smokers feel the symptoms of energize and relax at the same time. nicotine withdrawal within a few hours of quitting. Cravings to smoke These highly desirable effects dissipate quickly, requiring the individual and symptoms of irritability, depression, anxiety, lack of ability to to repeat the process to reach the dosage of nicotine that allows him concentrate, and insomnia peak after a few days. Most smokers who quit or her to induce or maintain feelings of well-being. If the individual is experience severe withdrawal symptoms for no more than a few weeks, nicotine-dependent, he or she will experience symptoms of withdrawal but some may find symptoms lingering much longer[25] . upon discontinuing use. Nicotine is extremely addictive. Between 35% An important part of smoking cessation is avoiding common triggers and 50% of all people who try a cigarette develop an escalating pattern that make cravings worse and encourage relapse. For some, this might [22]. The level of nicotine dependence among adults is typically of use be the sight of a cigarette, having a cocktail, or socializing at a party. higher in those who had their first smoking experience at a younger age; Behavioral therapies can be useful in identifying these triggers and in general, the younger the person when he or she first smoked, the more addressing them with strategies that strengthen the individual’s resolve likely he or she is to be dependent on nicotine [23]. not to smoke. Nicotine replacement therapies and medications may facilitate smoking cessation in some people. Cigars While the specific origins of the cigar are unknown, they have likely The cigar wrapper, on its own, has the same concentration of been a part of Central American cultures for thousands of years. The hazardous compounds as a typical cigarette, and creates more carbon word cigar is thought to be related to the Mayan word for smoking. monoxide per gram of tobacco burned [28]. In the United States, pipes were the only method of smoking tobacco Cigars vary markedly in size, but most are quite a bit larger than until the late 1700s, when cigars brought from Cuba ignited a demand cigarettes. A traditional cigar contains about 5 g to 15 g of tobacco, for the product. Domestic tobacco production grew in importance and while the majority of cigarettes contain less than one gram. The larger [26]. Cigar sales were relatively popularity throughout the next century size of cigars means more tobacco and longer smoking times, resulting stable for years, expect for a decline in 1913, the year manufactured in extended periods of exposure to substances such as carbon monoxide, cigarettes were introduced; and an increase in 1964, the year that the hydrocarbons, ammonia, and cadmium, as well as tar and nicotine [29]. U.S. Surgeon General’s report on the dangers of cigarette smoking was released. Cigars continue to have a loyal following, however, with cigar Cigars contain varying amounts of nicotine—ranging from the amount smokers comprising a relatively stable 5% of the U.S. population [27]. in one cigarette to one pack of cigarettes—with the nicotine amount directly correlated with the amount of tobacco in the cigar. Nicotine The majority of cigars are made from a single type of wrapped can be absorbed through the lips from both cigars and cigarettes, but air-cured, fermented tobacco. Cigars almost always have higher levels from cigars are absorbed more readily due to the higher (more concentrations of toxins and carcinogens than cigarettes because they alkaline) pH of cigar smoke. Because cigar smokers absorb more tend to be larger, but also because the cigar fermentation process nicotine across the oral mucosa than cigarette smokers, they are able results in smoke that is higher in cancer-causing nitrosomes than to get a sizable dose of nicotine without inhaling the smoke (to get a cigarette smoke, as well as nitrogen oxides and ammonia. similar dosage of nicotine, a cigarette smoker would have to inhale far more smoke, far more deeply into the lungs).

Page 48 Dental.EliteCME.com In fact, nicotine is ingested the entire time an individual’s lips are in number of inhalations, it is actually associated with many of the same contact with the cigar tip, even if the cigar is not lit [30]. risks as cigarette smoking, as well as a few of its own. In general, for cigar and cigarette smokers, the risks of smoke-related diseases are While some believe cigar smoking is associated with a lower risk of [31] disease than cigarette smoking because of differences in the depth and proportional to their exposure to tobacco smoke . Nicotine delivery It is not known how many cigar smokers exhibit symptoms of that cigar smoking may have a lower potential for nicotine dependence. While cigar smokers absorb high levels of nicotine into the addiction than cigarette smoking. Heavy, frequent cigar smoking body by inhalation through the lungs as well as absorption through the significantly increases the potential for addiction. oral mucosa, studies suggest the degree of dependency and addiction is ●● Patterns of use among cigar smokers (infrequent or inconsistent less in cigar smokers than cigarette smokers for these reasons [32]: use, far less average tobacco smoked per day, and lower rates of ●● Delivery systems that distribute nicotine slowly, in low doses, such inhalation) are quite different from those of cigarette smokers, as the nicotine patch, gum, or smokeless tobacco, are associated typically producing less psychological and physical symptoms with fewer, less severe, and a shorter duration of withdrawal of dependence. symptoms. Cigar smoking typically distributes nicotine more ●● Cigar smokers, unlike chronic cigarette smokers, are unlikely to begin slowly than cigarette smoking. smoking until young adulthood. In combination, these factors add up ●● Lower rates of inhalation in cigar smokers and slower (not less) to far less hazardous smoking habits and less risk of addiction. absorption of nicotine through the lining of the mouth suggest

Inhalation and risk of disease Cigar and cigarette smoke share many characteristics, which suggests tissue, which absorbs the smoke’s toxic elements, particularly carbon comparable patterns of disease, but this is not the case. Cigarette and monoxide. Surveys show the majority of cigarette smokers inhale smoke cigar smoking are associated with distinct diseases and degrees of risk into the lungs, while the majority of cigar smokers do not [33.1]. due to differences in patterns of use between the two products. Cigar Tobacco-related cancer accounts for about one-third of all cancer smokers are more likely to be nondaily users of tobacco, and inhale deaths, with smokers showing cancer rates two times as high as those less deeply than cigarette smokers. There are also differences between of nonsmokers. Lung cancer is the main cause of cancer deaths, with [33]. the two products in the composition of smoke nine out of 10 cases of lung cancer associated with cigarette smoking. While the lower pH of cigar smoke makes nicotine absorb more easily Cigarette smokers also show higher mortality rates for coronary heart across the oral mucosa, the lungs more readily absorb the higher (more disease and chronic obstructive pulmonary disease (COPD). Mortality acidic) pH of cigarette smoke. Cigarette smokers must inhale more rates for cigar smoking are primarily associated with cancers of the frequently and deeply to ingest comparable quantities of nicotine as is larynx, oral cavity, and esophagus. Very heavy cigar smokers, or those absorbed through the oral mucosa of cigar smokers. Inhalation increases who inhale deeply, show higher risks for lung and heart disease, with the cigarette smoker’s exposure to tobacco smoke through lung an increased risk for aortic aneurysm [34]. Symptoms and effects Smoking tobacco has been linked to cancers of the mouth, pharynx, Tobacco smoking is one of the most common risk factors for oral larynx, esophagus, lung, stomach, pancreas, cervix, kidney, and cancers, with tobacco smokers showing a rate of oral and pharyngeal bladder. Heavy tobacco smokers exhibit clear indications of the cancers up to 10 times higher than nonsmokers. All cigar and cigarette product’s use, with adverse effects on the oral cavity due to the oral smokers expose their lips, mouth, tongue, throat, and larynx to many tissue’s direct exposure to smoke, and the systemic effects of nicotine, hazardous chemicals in smoke inhalation, resulting in increased among other chemicals [35]. incidence of precancerous and cancerous conditions [37][38]. Exposure to tobacco smoke exacerbates inflammation, dry mouth Smoking is associated with leukoplakia, a precancerous lesion occurring (xerostomia), and vasoconstriction, reducing salivary flow in the mouth in the soft tissue of the mouth that appears as a white patch or piece of and blood supply to the oral tissues. Vasoconstriction and xerostomia plaque, and cannot be removed by scraping. Because leukoplakia is rarely (dry mouth) contribute to the oral conditions most prevalent in heavy painful or irritating, the patient may be unaware of the condition unless smokers, including candidiasis (a fungal infection commonly known he or she seeks professional dental care. Without treatment or smoking as a “yeast” infection or “thrush”), smoker’s keratosis (a potentially cessation, the number of lesions and risk of cancer can increase. cancerous white discoloration, usually caused by heat and seen on the Squamous cell carcinoma is the most common oral cancer linked roof of the mouth), nicotine stomatis (a lesion that typically progresses to cigarette smoking. While it can be found anywhere in the mouth, from keratosis) , and oral cancers. These conditions pose an increased it is most commonly seen on the lateral borders of the tongue, the risk of bone loss and damage to the tooth and gums. Smokers have ventral surface of the tongue, or the floor of the mouth. If detected a much higher incidence of periodontal disease and severe forms of early enough, the prognosis is favorable, but half of those who detect gingivitis than nonsmokers, including acute necrotizing gingivitis and squamous cell carcinoma 2 or more years after its onset will die from necrotizing ulcerative gingivitis (NUG), severe bacterial infections, also the cancer or related complications. known as “trench mouth,” which cause inflamed, swollen, and bleeding gums, and more often require root canal [36]. Statistics show highly elevated rates of tongue cancer for all tobacco smokers, strongly correlated with the total amount of tobacco smoked Tobacco residue trapped on the tongue causes discolored papillae and per day and depth of inhalation. enamel (yellowish to dark brown or black). Food and bacteria stuck to the surface of the tongue inhibit the shedding of dead cells, increasing The risk of esophageal cancer is similar among cigar and cigarette the chance of halitosis. While smokers are prone to xerostomia, smokers, and much greater than among the rate of nonsmokers, but cigar the act of smoking triggers a temporary burst of saliva associated smokers show higher rates of mortality. This is due to a greater build-up with increased calculus production. The excessive stain and calculi of tobacco residue coating the inside of the cigar smokers’ mouth in contribute to increased rates of gum disease. comparison to cigarette smokers. The coating combines with saliva and is swallowed. This carcinogenic mixture travels down the esophagus, increasing tissue exposure and the risk for oral and esophageal cancers. Dental.EliteCME.com Page 49 Management and clinical implications Smokers exhibit a far higher incidence of severe periodontal diseases Because tobacco use is one of the most significant causative and compared with nonsmokers, largely due to the direct effects of smoke contributing factors for oral cancers and periodontal diseases, careful exposure. While periodontal disease is normally indicated by bleeding oral examinations for early symptoms of disease are essential. of the oral tissues upon probing, vasoconstriction in heavy smokers Routine care should include a meticulous oral evaluation and careful inhibits blood flow, so it is important to recognize other indications of documentation, with preventative oral cancer screenings for cancerous periodontal disease, as this inhibited blood flow can be misleading[39] . and precancerous conditions. Early detection techniques and products Recuperation may be delayed in patients who smoke because the include visible light fluorescent wands, toluidine blue staining, vital [41]. reduced blood supply available to the oral tissues causes wounds to staining, DNA-evaluation, and saliva-based oral cancer diagnosis heal more slowly, especially those directly exposed to smoke. Dry The American Dental Association (ADA) advises dentists to follow its sockets are four times more prevalent among smokers after oral standards of care by including a caries evaluation as standard dental surgery than nonsmokers. They are likely to occur when a patient hygiene protocol for patients who are substance abusers. If amenable, returns to smoking too quickly after surgery, interrupting the process patients should be encouraged to describe their smoking habits, oral of blood coagulation (clotting) required for bleeding to stop and hygiene practices, eating habits, or other practices or behavior (such wounds to heal. These are significant factors in postsurgical care, as alcohol consumption) that might increase risk of disease or adverse with smokers treated for periodontal disease experiencing far less effects from dental procedures or treatments[42]. successful treatment results than nonsmokers [40].

The dentist’s role in cessation and intervention Tobacco is a significant risk factor for oral disease. Dental care providers most smokers) can take advantage of tobacco cessation treatment have the opportunity to inform patients about the risks associated with developed specifically for this group[46][47] . tobacco use and refer them to tobacco cessation resources. Although The American Dental Hygienists’ Association (ADHA) established clinicians often ask their patients about their tobacco use as a matter guidelines for a smoking cessation program within the dental office of course, most do not attempt to discuss the possibility of smoking called the Ask.Advise.Refer campaign. A one-page information sheet cessation. In one study, one-third of all teenagers reported their is available at http://doh.sd.gov/prevention/assets/AARposter.pdf). physician counseled them about the dangers of tobacco, but only one- Members of the dental team can refer their patients to telephone- [43]. fifth reported their dentist provided a similar message based tobacco cessation services, accessed through a toll-free number. Research suggests that the limited extent to which dentist are This service provides callers with educational materials, referral implementing recommended guidelines for smoking intervention to treatment programs, and individual counseling by phone [48]. represents a significant missed opportunity to change smoking Detailed information about Ask.Advise.Refer. can be found at http:// behavior, particularly among adolescents. Surveys show the majority smokingcessationleadership.ucsf.edu/Downloads/catolgue/cot10209.pdf of smokers have a desire to quit, and would accept assistance from Other steps that facilitate smoking cessation among patients are: a physician. Dentists should be encouraged to know that a number ●● Availability of nicotine replacement products (e.g., patch, gum, of studies show patients offered cessation services (such as referrals lozenge, inhaler, spray) or prescription medication (e.g., bupropion) to substance abuse treatment professionals) feel increased levels of proven effective in relieving nicotine withdrawal symptoms [49]. satisfaction with their health care provider; and a physician or dentist’s ●● Resources for referrals to counseling services, support groups, and recommendation that a patient stop smoking was associated with [50] [44][45] medical assistance, if necessary . increased attempts by the patient to quit . ●● No lecturing or judgment; patients look to dental professionals to help Dentists have a professional responsibility to address tobacco them stop smoking, but are unlikely to pursue this objective if the dependence with their patients, educate patients about tobacco dental environment feels critical or unreceptive. Training in use of the cessation, and provide support. Failure to do so is a missed opportunity 5 A’s (see Section V for more detail) can educate office personnel and to prevent potential harm to the patient’s oral and general health. Even clinicians about supportive and effective interventions [51]. patients who see a physician or dentist only once a year (typical for Most smokers experience a number of failed attempts before finally quitting the habit [52]. Hookahs Traditional pipe smoking produces much more tar and nicotine per gram many of the same health risks posed by cigarette smoking, including of tobacco than cigarette smoking. Water pipes (also known as bongs) nicotine dependence, periodontal disease, high blood pressure, heart block some of these particles because the user draws smoke through disease, asthma, COPD, and many types of cancer. Among the harmful water in a chamber, which cools and filters it before it inhalation. ingredients that water does not filter out are nicotine, tar, heavy Hookahs are a particular type of water pipe, in which smoke is inhaled metals, carbon monoxide, and a host of other toxins and carcinogenic by mouth through a tube or hose. Hookahs may be communal, with compounds associated with oral cancer, among many other diseases. a number of people sharing one water pipe, and each person drawing Some establishments use charcoal or wood to light the hookah. The smoke through a hose that may or may not be shared with others. smoke produced when these materials combust contains carbon Hookah smoking originated in Persia (now Iran) and India more monoxide and PAH, which have carcinogenic properties, among other than 500 years ago. In the past 20 years, hookahs have become more hazardous compounds [54]. common in the United States, with hookah bars and cafes growing in A study published in the Journal of Periodontology reported that hookah [53]. popularity, especially for young people aged 18 to 25 years smoke might be even more addictive and detrimental to dental health Some users think hookahs are a cleaner, safer, or less addictive than smoking cigarettes. Their research provided strong evidence that alternative to other tobacco smoking methods because the tobacco hookah smokers expose themselves to greater volumes of tobacco is typically fruit-flavored and the smoke is filtered by water. These smoke than cigarette smokers, due to the depth of inhalation and social assumptions are contradicted by a recent World Health Organization context or physical environment of hookah smoking [55]. (WHO) study that found an association between hookah smoking and

Page 50 Dental.EliteCME.com Hookah smokers take long, deep breaths and smoking sessions Additionally, smokers in hookah bars have little control over are relaxed, and may last hours as hookah bars are commonly the the cleanliness of the water pipes. Smokers are at higher risk for evening’s destination. Often, the smoker is sharing a hookah with contracting and spreading communicable diseases through saliva. friends. While smoking a cigarette takes a matter of 10 minutes or Like other smoking methods, hookah smoking is associated with bad so, a session of hookah smoking is likely to last an hour or more, breath and discoloration (yellowing) of the teeth; and like any other significantly increasing the length and amount of exposure to smoke. nicotine delivery system, smoking tobacco with a hookah can lead to According to the WHO study, hookah smokers may inhale the dependence and addiction. equivalent of 100 or more cigarettes’ worth of smoke in a sitting [56]. Smokeless tobacco Smokeless tobacco (also called chewing tobacco or snuff, among other This successful marketing strategy made smokeless tobacco one of terms) is tobacco leaves that are typically sweetened, ground, and/or the fastest growing bad habits in North America. Contributing to its formed into various shapes and textures. In the mid-1980s, during a popularity was the perception that it was safer than smoking cigarettes. precipitous rise in use, it was estimated about 5% of individuals in the In the late-1980s, health professionals, legislators, and parents pressured United States were smokeless tobacco users [57]. The surge in popularity tobacco companies to stop advertising chewing tobacco using athletes, was attributed to aggressive advertising campaigns that recast the image and to produce a public awareness campaign acquainting the general of smokeless tobacco using professional athletes to promote the product. public with the potential dangers of smokeless tobacco [58].

Prevalence and patterns of use Studies using statistics from 2009 to 2011, estimated between 3% are far more likely to be members of the working class (blue-collar) and 3.5% of all individuals in the United States used smokeless than office workers (white-collar)[60] . tobacco, including about 7% of all high school students and 3% of Adults between 18 and 25 years of age show the highest rate of smokeless all middle school students. In most ages, males are more likely to tobacco use among the general public, at slightly more than 5%. Military use than females; however, statistics from middle school students in personnel show the highest incidence of smokeless tobacco use, with one 2009 reported a slightly higher percentage of girls than boys using study estimating more than 12% were current smokeless tobacco users [61]. smokeless tobacco (1% of boys, and 1.5% of girls). Native American men and women, living in Canada and Alaska, show particularly high Studies show these demographic patterns of use are no accident. The rates of smokeless tobacco use [59]. five largest tobacco manufacturers spend vast amounts of money developing smokeless tobacco marketing campaigns targeted to Smokeless tobacco users are predominantly Caucasian males living in specific populations, those considered most susceptible to their the Southern United States. They are between the ages of 10 and 30 message [62]. Not surprisingly, there is significant crossover between years of age and had their first experience with smokeless tobacco at smokeless and smoking tobacco, with more than 40% of smokeless an average age of 19 years. More than 10% started in the 6th grade, tobacco users also smoking cigarette [63]. and more than 25% started in the 8th grade. Smokeless tobacco users

Types of smokeless tobacco The two main types of smokeless tobacco are chewing tobacco and these ground or loose strips of cured tobacco leaves are sweetened and snuff, each of which is sold in many forms. Depending on the product, usually packaged in a pouch. Two other forms of chewing tobacco are tobacco may be pulled from the pouch by hand (in a pinch), as well much less common: (a) a plug is made from compressed cured tobacco as cut or bitten off from a larger piece. The material is placed in the leaves that are combined with sweet syrup and wrapped in a tobacco cheek, and the ball or wad of tobacco is positioned between the teeth leaf and (b) a twist or roll is made of cured flavored tobacco leaves and gum where it is alternatively held, or chewed, over some length twisted or braided together. Together, plug and twist chewing tobaccos of time. Almost immediately after placement in the mouth, nicotine is are favored by about 1% of the smokeless tobacco market. absorbed into the bloodstream through the oral mucosa. Dry snuff is a fire-cured tobacco, processed into a powder, taken in a Most smokeless tobacco users suck or chew on the tobacco, then spit pinch, orally or inhaled through the nose. Its use has been declining for out the saliva containing the tobacco juice, although a small portion is years, and now totals about 1% of the smokeless tobacco market. Most swallowed. Those who hold the tobacco in their mouths for longer periods users are older adults. and swallow more tobacco mixed with saliva increase their exposure to The tobacco industry has introduced a variety of new and innovative the estimated 28 carcinogens (plus nicotine) in smokeless tobacco [64] . smokeless tobacco products in recent years. These items use Snuff comes in both moist and dry forms, but the most popular compressed, processed tobacco leaves to make a dissolvable powder smokeless tobacco by far is moist snuff, comprising about 75% of that can be consumed orally without the need to spit out tobacco residue. the smokeless tobacco market, and a special appeal to young people Products take the form of lozenges, tablets, tabs, strips, and sticks [65]. Moist snuff is made from cured and fermented tobacco leaves [].Tobacco lozenges (not the same as nicotine lozenges, used for smoking processed into fine particles. A pinch (also called a dip or rub) is cessation purposes), look and dissolve in the mouth like hard candy [66]. placed between the cheek or lower lip and gum, commonly in the Snus are a form of smokeless tobacco packaged in a small pouch, which gingival groove (sulcus) and mandibular labial mucosa. Products are is placed into the area between the upper lip and gum. The user keeps attractively packaged in convenient ready-to-use packets resembling the product in place for less than one hour, than discards it. While data tea bags (called sachets). The tobacco remains in the packet, which on these new products are very limited, a recent study estimated that is placed in the mouth. While most forms of snuff used in the United 6% of adults aged 18 years and older in the United States have tried States are oral products, some types of dry snuff are inhaled through dissolvable tobacco products, and more than 5% have tried snus [67]. the nose, but the practice is more common in European countries. The second most popular type of smokeless tobacco, with 22% of the market share, is chewing tobacco. Also known as chew or chaw,

Dental.EliteCME.com Page 51 Symptoms and effects Smokeless tobacco is associated with a number of cancers and Dental caries, especially near the placement site, are common among precancerous conditions of the mouth, including [68]: smokeless tobacco users, in part because the product is sweetened, ●● Pathologic changes of the oral mucosa, indicating an increased risk then held in the mouth against the teeth for an extended period. for cancer of the oral cavity. Decreased saliva flow means the sweetened tobacco residue stays in ●● Leukoplakia, a precancerous lesion of the soft tissue in the mouth the mouth for a longer period of time, rather than washing relatively that consists of a white patch or plaque that cannot be scraped off, rapidly down the esophagus. Studies suggest that smokeless tobacco and can lead to aggressive oral cancers if left unchecked. encourages bacteria growth, including Streptococcus, which is often ●● Verrucous carcinoma, an aggressive form of squamous cell associated with tooth decay [70]. carcinoma that is preceded by severe leukoplakia. In most Quitting smokeless tobacco may result in nicotine withdrawal cases, stopping the habit before the onset of cancer results in the symptoms that include cravings, anger/irritability, anxiety, depression, disappearance of lesions and a return to normal mucosa. or weight gain. Most of these effects are short-term, but can be longer ●● An increased risk of developing complications at the location in or more severe for those who have used heavily for many years. Like the mouth where the patient repeatedly places the tobacco product. cigarettes smokers, those who use smokeless tobacco most frequently Smokeless tobacco is associated with recession of the gums, gum disease, show the most severe patterns of withdrawal. In general, smokeless and tooth decay. Periodontal disease and gingival recession are caused by tobacco withdrawal symptoms are less severe than those experienced irritation of the gum adjacent to the placement site, which usually shows by cigarette smokers, because most smokeless tobacco formulations a higher degree of recession. In most patients, gingival inflammation is deliver nicotine relatively slowly or in low daily doses. indicated by bleeding of the oral tissues upon probing, but heavy nicotine use causes chronic vasoconstriction that inhibits this effect [69].

Management and clinical implications Dental professionals are in a key position to identify smokeless tobacco to the patient, with attention to degree of damage at the location where use, explain its negative health and cosmetic effects, and discuss a tobacco is repeatedly placed against the gum [70]. plan of action for quitting. Young people are likely to have little sense Dental professionals should work with the patient and his or her of the destructive and unattractive results of long-term use. Images of primary care physician, if the patient consents and expresses interest, smokeless-tobacco-related oral cancers, or invasive surgeries required to to develop a plan for nicotine replacement therapy in the form of address them, quickly communicate the potential severity of health risks patches, gum, or lozenges. Many prescription medicines approved for associated with smokeless tobacco. The dental professional should relay nicotine addiction and smoking cessation treatment are likely to help any observable signs of precancerous changes in tissue to the patient. those who use chewing tobacco. Clinicians should take the time to point out the visible indications of use

Identification and intervention Smokeless tobacco users exhibit characteristic oral symptoms that ●● Limit contact with smokeless tobacco users, particularly soon after indicate excessive use, but early signs are not obvious. Questions quitting. Ask those around you to avoid using and avoid going about smokeless tobacco use should be included on the medical history places where others will be using. form, along with questions about smoking tobacco, alcohol, and other ●● Avoid handling smokeless tobacco, having it near you, or in an common addictive substances. accessible location. Avoid activities or people that you associate with using smokeless tobacco, at least temporarily. In recent years, strategies to reduce the rate of smokeless tobacco use in ●● Focus on the negative and positive aspects of not using tobacco, the United States focused primarily on preventing the practice, rather than including financial, health-related, and cosmetic effects. identifying and treating it. But, since many users start at a very young age, ●● Seek counseling. Attend support group meetings and seek a that strategy has been rethought. Smokeless tobacco users suffer relatively referral to a specialist trained in nicotine cessation treatment for few and mild withdrawal systems compared with other types of tobacco smokeless tobacco use. users, suggesting smokeless tobacco users may be particularly good ●● Some find a nonnicotine replacement (usually an herbal blend) candidates for intervention and/or cessation treatment [72]. for smokeless tobacco an effective addition to other therapies, as Both smoking and chewing tobacco are delivery systems for nicotine, it fills in a behavioral gap of habitual actions associated with the creating dependence in the same manner. Although most tobacco practice of chewing tobacco. Using nontobacco dips, or chewing treatment programs were developed for smokers, all address nicotine nonnicotine gum can provide support or comfort even without dependence and addiction, and most can be adapted for patients who nicotine delivery. If gum or another substance is chewed or placed are smokeless tobacco users [73]. in the mouth as a substitute for smokeless tobacco, it should be There are many resources to support patients quitting smokeless sugarless and have ingredients that increase saliva flow. tobacco. A good starting place is the American Cancer Society, which recommends the following strategies for those trying to stop [74]: Alcohol Alcohol is an addictive substance formed by a chemical reaction high financial, emotional, and physical price for their habit, alienating produced when starches and sugars (usually in grains) are combined family and friends, risking loss of employment, and endangering with yeast, and left to ferment. There are many types of alcohol, such themselves and/or others with injudicious behavior. as methyl alcohol (rubbing alcohol) and butanol, but ethyl alcohol Alcohol metabolizes very quickly upon consumption and is rapidly (also called ethanol) is the only form they can be consumed without absorbed into the bloodstream through the stomach and small risk of poisoning (although sufficient amounts of ethanol can be fatal). intestine. Upon reaching the brain, alcohol alters the action of specific Although alcohol is a legal drug, addiction to it can be as severe and neuroreceptor sites, including those for serotonin, GABA (Gamma- dangerous as dependence on many illegal substances. Abusers pay a Aminobutyric acid), and glutamine. The action of alcohol on these

Page 52 Dental.EliteCME.com and other neurotransmitters in the brain’s pleasure center produces the CNS impairment caused by alcohol are slurred speech, blurred vision, characteristic feelings of intoxication associated with alcohol [75]. and poor equilibrium, all familiar signs of drunkenness. Alcohol depresses normal function of the central nervous system (CNS), Alcohol also produces significant effects on the frontal cortex, or outer which controls a number of critical body functions, including regulation layer of the brain. This part of the brain controls conscious thought of motor skills required for speech, muscle coordination, and use of the and judgment. Alcohol use decreases inhibition and increases poor sense organs. The CNS is responsible for assessing information received decision-making, so those under the influence are more likely to through the senses and responding appropriately. Common symptoms of behave differently than if they were sober.

Prevalence and patterns of use Studies of alcohol consumption use the following measurements to ●● Binge drinking is consuming five or more drinks within 2 hours quantify alcohol consumption: a typical drink contains 0.6 oz pure alcohol. for men, and four or more within 4 hours for women. Recent Therefore, one drink = 12 oz of beer, OR 5 oz of wine, OR 1.5 oz (a shot) survey data showed about 23% of persons aged 12 or older in 2012 of 80-proof distilled liquor, such as gin or vodka. While studies vary in the (almost 60 million) reported binge alcohol use in the past month, way they categorize consumption patterns, the following classifications with about half (30 million) reporting binge drinking on a regular [76] are useful in discussing alcohol consumption : basis. A 2006 Centers for Disease Control (CDC) study concluded ●● Problem drinking is primarily identified by the individual that a relatively small number of binge drinkers are responsible for repeatedly acting in an uncharacteristic way under the influence a great majority of the financial, emotional, and physical costs to of alcohol (in a way that he or she would not act if sober). The [77] National Institutes of Health (NIH) report 15% of people living in society caused by alcohol abuse . the United States are problem drinkers. Of this group, 5% to 10% These types of consumption patterns are considered high-risk drinking of men and 3% to 5% of women qualify as alcoholics. behaviors. The National Institute on Alcohol Abuse and Alcoholism ●● Heavy drinking is consuming five or more drinks on the same (NIAAA) estimates about 30% of the U.S. population engage in risky occasion, for 5 or more days of the past 30 days. According to drinking behaviors. one report, 6.5% of the U.S. population aged 12 or older (about 17 million people) drank heavily in the past month.

Distinguishing alcohol abuse, dependence, and addiction (alcoholism) It is estimated about 10% of women and 20% of men in the United Although dependence and addiction are sometimes used interchangeably, States abuse alcohol. Abuse is characterized by a maladaptive pattern there are important differences between them. Physical dependence of alcohol consumption that continues although it produces adverse is indicated by the need to consume increasing amounts of alcohol to consequences for the user. Consumption often begins in the teen years, achieve the same level of effects (tolerance) and by withdrawal symptoms with drinking patterns established by young adulthood. Alcohol abuse if use discontinues. Physical dependence is a necessary component of is characterized by heavy use, but alcohol abusers are not necessarily addiction, but is not itself addiction. Alcohol addiction (alcoholism) is a physically dependent or addicted to alcohol. An alcohol abuser does chronic, progressive disease affecting more than 14 million people in the not necessarily have an increased tolerance for the substance, nor does United States. Addiction differs from physical dependence because it has abstinence from alcohol necessarily cause withdrawal symptoms [78]. a psychological, as well as physical, component [78].

Physical symptoms and effects Excessive alcohol consumption weakens the immune system is more destructive the longer it remains on the teeth. An individual and adversely affects every organ of the body. It contributes to who regular drinks, vomits, and falls asleep or passes out will exhibit malnutrition, neurological disorders, and liver disease, and increases extensive damage from the prolonged exposure to acids and sugars. the risk of cardiovascular disease and cancer. Alcohol-induced Chronic regurgitation of alcohol is associated with severe erosion of irritation of the gastrointestinal (GI) tract causes lesions, hemorrhage, the palatal surface of upper incisors, and lesions in the esophageal and ulceration of the digestive system. Alcohol is associated mucosa at the gastroesophageal junction [8][83][84]. with increased risk for complications in dental and other medical Alcoholics tend to have more inflammation of the gingiva and a procedures due to adverse interactions between alcohol and many higher incidence of dental carries and missing teeth than nonalcoholic [79]. pharmaceutical substances used in treatment individuals. Excessive consumption is associated with significantly Common features of excessive alcohol consumption include [80]: increased rates of chronic inflammatory periodontal disease (CIPD), ●● A coated tongue and significant deposits of plaque and calculi. and deep gingival pocketing, indicative of bone loss. Research suggests ●● Enlarged parotid salivary glands, which is a symptom of potential that alcohol causes inflammation and periodontal disease by increasing liver disease [81]. inflammatory cytokines in the gingival crevice, and weakening neutrophils ●● Xerostomia, which exacerbates the already unhealthy oral that would usually reduce the increased levels of bacteria [85][86]. environment and increases the risk of complications, such as Alcohol abuse is a risk factor for oral cancers, with alcoholics more opportunistic infections or dry sockets after extractions. than 10 times more likely to develop oral squamous cell carcinoma ●● More severe dental erosion than in nonusers due to decreased than the general population. Research suggests that acetaldehyde, salivary secretions. produced when the body metabolizes alcohol, makes mucosal surfaces ●● Symptoms of alcohol-induced bruxism, which causes grinding more vulnerable to carcinogens by attaching to proteins in the oral during REM sleep that is particularly abrasive in combination with cavity that triggers an inflammatory response associated with cancer reduced salivary flow. cell growth. The most common oral cancer sites are on the lips, tongue Severely damaged and decayed enamel and extreme tooth erosion (top and underside), gingiva, and palate [87][88]. may be the result of the patient regurgitating highly acidic vomit on a regular basis, a trait of binge drinkers. Excessive alcohol consumption and vomiting creates an acidic oral environment that

Dental.EliteCME.com Page 53 Management and clinical implications All office and clinic personnel should be able to recognize the signs of injectable/topical anesthetics), or an accidental injury (the patient trips inebriation in patients. Excessive alcohol consumption may be obvious in the bathroom and hits his head on the sink). It is not unheard of for by the smell of alcohol on the breath or a product used to mask it, such a dental office to keep a breath analyzer (Breathalyzer) onsite to test a as mouthwash Alcoholics exhibit hypertrophy of the parotid glands, patient’s alcohol level to ensure treatment is not contraindicated. impaired motor function exhibited in slurred speech or inability to sign Office personnel should be familiar with policies relating to drug and in, poor balance, or inappropriate behavior. Because alcohol can cause alcohol use, as well as the best way to address an intoxicated patient dizziness or light-headedness, as well as disturbed balance, it is a risk without alienating or embarrassing him or her. Testing the patient’s factor for increased falls and fall-related injuries [89]. blood alcohol levels or breath analysis provides conclusive evidence A patient who comes to the appointment in an inebriated state must without having to interrogate the individual, but may be considered be rescheduled and accompanied to his or her home by a responsible far more intrusive. Both may cause the patient to react defensively. person. While this may create awkwardness or potentially offend the Encourage the patient to reschedule, but require him or her to sign patient, it is necessary. Not only is the dental team ethically responsible an agreement that he or she will not consume alcohol for a specified to act in the best interests of the patient, the dental office would be period before and after the next appointment. liable if adverse consequences resulted from treatment (administering

Medical management Many alcoholics suffer from serious tooth decay and gum disorders. excessive amounts of alcohol metabolize amide drugs in such a way Research suggests the increased prevalence and rapid progression that the substance is likely to bypass the injection site, rapidly enter the of dental disease among alcoholics is due not only to the direct bloodstream, and circulate throughout the body. The alcoholic’s blood physical effects of alcohol, but lifestyle choices that increase the risk levels will rise more rapidly and reach dangerous levels more quickly and severity of diseases affecting the oral cavity. Alcohol abusers than a nonusing patient, and fall much more slowly. demonstrate inconsistency in oral hygiene habits, brushing and flossing Attention to repeated dosage is extremely important, as alcoholics are less effectively and consistently than the general population. far more susceptible to overdose reactions than other patients. The patient requires a dose of local anesthesia that produces adequate pain All these factors can contribute to extreme decay, particularly if the relief, but reduces the alcoholic’s greater susceptibility to dangerously patient delays treatment, which is common. high blood levels and potential overdose that are associated with While excessive alcohol consumption weakens the immune system standard administration practices [93][94]: and adversely affects virtually every organ and body system, a primary 1. When administering an initial dose of amide local anesthetic or concern in the clinical treatment of an alcohol abuser are the very benzodiazepine, a normal dose is usually indicated. Monitor the serious complications associated with drug interactions involving patient to ensure no ill effects. alcohol and pharmaceutical substances used in dentistry [90]. 2. Administration of subsequent doses requires monitoring patient blood levels and reducing the dosage amount or extending the The Food and Drug Administration (FDA) recently identified length of the intervals between doses to prevent excessive levels of 50 commonly prescribed drugs with ingredients that interact or the drug from building up in the blood. react with alcohol including analgesics, antibiotics, and sedatives. 3. Use of a vasoconstrictor may assist in providing the desired Reformed alcoholics may be highly susceptible to relapse if exposed effects at the local site without running the risk of excessive to even a small amount of alcohol. Many over-the-counter (OTC) systemic absorption. and prescription drugs, as well as personal hygiene items (such as mouthwash) contain alcohol. Because alcohol (found in antacids, Excessive alcohol use damages the liver and bone marrow, resulting analgesics, antidiarrheals, and tranquilizers) poses such a significant in bleeding disorders and the possibility of spontaneous or excessive risk for individuals in recovery, extreme caution is necessary in bleeding during a dental procedure. If this occurs, stop treatment [92] prescribing medication or recommending oral hygiene products . and apply digital pressure immediately. Liver damage decreases Central nervous system (CNS) depressants, such as sedatives and the body’s ability to store or convert adequate levels of vitamin benzodiazepines (anti-anxiety drugs such as Xanax), should not be K, needed for blood coagulation. This deficiency creates the prescribed to patients who present symptoms of alcohol abuse. The potential for clotting disorders (thrombocytopenia) and associated combined effects of alcohol (a depressant) and narcotics (any drug with risks. Medical evaluation and blood coagulation tests should be sedating effects), or other types of prescription drugs, greatly increase administered, and the findings carefully reviewed before moving the patient’s risk of adverse consequences, such as respiratory failure. forward with further treatment. Acidic drugs, such as aspirin and The use of local anesthetics (particularly amides) and benzodiazepines, nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided as well as other drugs metabolized in the liver, do not act the same in due to increased risk of bleeding in the stomach. Acetaminophens alcohol abusers as they do in other patients. Individuals who consume should be limited to a daily maximum of 4 g (4000 mg) [95].

Routine examination protocol Given the increased risks of disease and contraindications ●● Identify concurrent abuse of tobacco products that worsens associated with alcohol abuse, great caution is required with dental disease and increases the risk of oral cancer. This patients suspected of excessive alcohol consumption, even in additional risk to oral health should be explained to patients who routine procedures or examinations. As a matter of course, patients use both products. If amenable, the dentist can introduce tobacco dependent on alcohol require: or alcohol cessation information. ●● Oral cancer screenings to locate premalignant or malignant lesions ●● Frequent neurological assessment. performed at each dental exam, due to the significantly increased risk ●● Vital signs, including pulse rate and blood pressure, monitored of oral cancer and rapid progression associated with alcohol abuse [96]. throughout the appointment. An irregular pulse or hypertension ●● All patients should be educated about the association between may be indications of alcohol addiction [97]. alcohol abuse and oral cancers, and shown how to self-monitor for ●● Patients should be tested to determine their blood counts, liver potential signs of cancer in the oral cavity. function, and blood clotting ability, before the development of

Page 54 Dental.EliteCME.com a treatment plan, as results may dictate what interventions can to cough if the airways become even partially blocked during proceed without risk to the patient. treatment. Should the patient begin choking, vomit or blood may ●● Special attention to keeping the patient’s airways clear. Alcohol present a serious risk of suffocation [98]. abuse may inhibit the gag reflex, reducing the patient’s ability Identification and intervention Alcoholism is often hidden, undetected, and untreated. The dental Dental personnel should do their best to provide an easy and convenient practitioner is in an ideal position to identify patients who abuse alcohol, way to introduce the patient to resources. If the patient considers it not only for the purpose of ensuring their safety, but as an opportunity to acceptable, dental personnel can discretely send appropriate brochures provide a brief intervention or referral, if the patient is agreeable [99][100]. or referral information home with the patient along with a toothbrush, Usually, patients will not admit they have an alcohol problem, and are floss, or toothpaste sample in a take-home bag. unlikely to provide accurate or reliable information about their past If the patient is amenable, discuss the possibility of working with his or or current drug use on the medical form or in discussion with dental her primary care physician to develop an appropriate treatment program. personnel. The dental office should be stocked with information Discuss the potential benefits of prescription medications that help reduce materials from organizations such as Alcoholics Anonymous (AA) or alcohol cravings [101]. Do not force the patient to take informational Rational Recovery (RR), which provide a range of proven services materials, listen to advice, or receive referrals against his or her will. and support in the form of counseling, support groups, and referrals to medical and nonmedical specialists. Marijuana Marijuana is a species of the Cannabis Sativa plant that contains the Public opinion and the scientific community are divided on the psychoactive chemical tetrahydrocannabinol (THC), found primarily question of marijuana addiction. Some consider marijuana a in the leaves and flowering tops of the plant. Not all strains of cannabis nonaddictive substance; others claim users become emotionally or are grown or used for their THC content. physically dependent on the drug after repeated use. Most agree that Hemp, for example is a variety of cannabis with less than 1% of the effects and level of dependence, if any, are highly variable. THC and a long history of industrial use. Its fiber has been used The U.S. federal government currently prohibits the possession, for thousands of years to make rope, and its seeds and oil are a use, and sale of cannabis containing THC. However, in recent years, nutritional food source. more states are choosing to sanction marijuana for medical and/or [105][106]. With state and national laws at odds, the future Unlike hemp, marijuana is grown primarily for its THC content, which recreational use of marijuana legalization is uncertain. ranges anywhere from 3% to 22% [102]. Marijuana consumption produces feelings of relaxation and joy, and Marijuana has been used medicinally for thousands of years. In the stimulates the appetite. When ingested through smoking or eating, United States, medical marijuana is increasingly used to relieve THC, along with dozens of lesser known psychoactive substances symptoms of autoimmune diseases such as multiple sclerosis and (cannabinoids), rapidly enter the bloodstream and travel to the brain, conditions such as anxiety and depression. Currently, the primary [107]: locking into cannabinoid receptors, and triggering the release of applications of medical marijuana are ●● Controlling nausea and preventing vomiting (chemotherapy). dopamine, which produces the characteristic effects (the high) associated ●● Improving appetite (wasting disease). with the drug. Other common effects of THC use are short-term ●● Managing chronic pain (rheumatoid arthritis). memory lapses, xerostomia, impaired motor skills, and vasodilation ●● Bronchial dilatation/anti-asthmatic (asthma). of the eye vessels (bloodshot eyes). Less common side effects include ●● Reducing intraocular pressure (glaucoma). propensity to paranoia, anxiety, or self-consciousness [103][104].

Prevalence and patterns of use Although federal law currently prohibits marijuana, it is one of the Marijuana is most commonly smoked, but is also consumed in foods and most commonly used illegal drugs in the country. According to the beverages. Most patients find the pain-relieving effects of marijuana are most conservative estimates, more than half of the U.S. population stronger when marijuana is smoked, likely because smoking is a much have used marijuana at some point, and the numbers are growing as more efficient way to absorb THC. Marijuana is commonly smoked in more states regulate its legal sale and use. a hand-rolled cigarette, called a joint, or placed in the bowl of a pipe. Dosage is highly variable due to lack of standardization in the size of a The three most common forms are [108]: ●● Marijuana, the dried leaves and buds of the plant, also known by joint or bowl, but is estimated to measure an average of 0.5 g to 1 g of many other names (pot, weed, dope, etc.). Marijuana is the most marijuana leaves. Smokers who combine tobacco and marijuana in a common and least concentrated form of THC (from 0.5% to 1%). cigarette (called a blunt) will use somewhat less. ●● Hashish (or hash), the resin produced by compressing marijuana When marijuana is smoked, THC passes rapidly from the lungs into the flowers. It contains anywhere from 2% to 20% THC. It is formed bloodstream, then throughout the body, linking with receptors in the into small brown or black lumps or bricks. brain. Eating, rather than smoking marijuana, subjects THC to first-pass ●● Hash oil, a thick liquid extracted from hashish that is the most metabolism by the liver, which results in a 25% lower concentration concentrated form of THC (at 15% to 50%) and is heated to of THC in the bloodstream than smoking the same amount. Unlike produce smoke, which is inhaled. smoking, where the effects of THC are felt almost immediately, the THC is increasingly available in products such as candy and soft initial effects of ingested marijuana may not be felt for up to 2 hours, [109]. drinks and is also available as a prescription pharmaceutical. A and are felt longer than those of smoked marijuana pill form of THC is sometimes preferred for medical applications Other tools used to smoke or consume marijuana include water pipes and because it provides a standardized dose, unlike the amount of THC in vaporizers. Water pipes, or bongs, are very much like hookahs, drawing marijuana, which varies widely, with dosage largely dependent on the smoke through a volume of water, which cools and partially filters it. Like amount and method of consumption. hookahs, bongs may appear deceptively safe, and are commonly assumed to be a less risky way to smoke marijuana. However, this is inaccurate Dental.EliteCME.com Page 55 because although water filters some tar and hazardous particles from wide range of breathing difficulties resulting from chronic or frequent marijuana smoke by water, it is still a health risk. use, including asthma, bronchitis, or COPD [110]. Filtered marijuana smoke contains carcinogens, acts as a bronchial Vaporizers are instruments that apply enough heat to marijuana to produce irritant, and contributes to a diverse range of diseases, just like filtered an inhalable vapor containing THC, but not a sufficiently high temperature cigarettes. Additionally, because the cooled smoke is easier and more that the marijuana burns and produces smoke rather than vapor. Medical comfortable to inhale, it facilitates deeper inhalation and a longer time professionals may recommend using a vaporizer with medical marijuana, holding the smoke in the lungs to maximize THC absorption. These especially if the user’s respiratory health is compromised, because vapor is habits increase exposure to other potentially dangerous components not associated with the health risks of smoke inhalation. in smoke. Those who use bongs to smoke marijuana can experience a

Physical symptoms and effects Marijuana affects multiple body systems, but the majority of its ●● Marijuana smokers show increased rates of caries due to a negative effects are evident in respiratory dysfunction and pulmonary combination of physical effects, such as xerostomia, and disease, usually associated with long-term or heavy use. Chronic behavioral variables, such as neglect of oral health and poor diet. marijuana smokers have symptoms of bronchitis and emphysema, Studies comparing the oral health care habits of marijuana smokers including coughing, wheezing, and mucus production [111]. and nonsmokers suggest that lifestyle choices (inconsistent brushing, infrequent visits to the dentist, and consumption of many Marijuana smoke has many of the same dangerous components as more sugary beverages and foods among smokers), contribute tobacco smoke (carbon monoxide, bronchial irritants, and tar). With significantly to decay and the formation of caries[115] . the exception of nicotine, the primary carcinogens found in tobacco ●● Periodontal disease is likely more prominent among marijuana (hydrocarbons, benzopyrene, and nitrosamines) are found at much smokers than nonsmokers for many of the reasons it is more higher levels in marijuana smoke than equal amounts of tobacco prevalent among tobacco smokers. Data on the specific effects of smoke. A single inhalation from a joint contains three times the tar of tobacco smoke, in part due to the lack of a filtering mechanism. marijuana are limited by the fact that many marijuana smokers Additionally, the deeper inhalation of marijuana smoke leaves more also smoke tobacco, making it difficult to disentangle one set of [116] tar in the respiratory tract. It is estimated that smoking a single joint risk factors from another . is equivalent to five to seven cigarettes in exposure to hazardous ●● Smoking marijuana is associated with oral premalignant lesions, substances and potential for respiratory disease [112]. including leukoplakia and erythroplakia, which result, in part, from exposure of the oral tissues to high temperatures for extended The following oral symptoms and conditions are more common among [113] periods. This increases the likelihood of cellular disruption, causing marijuana smokers than nonsmokers : changes in the composition and appearance of oral tissues [117]. ●● Candida (yeast) is estimated to be more prevalent in marijuana ●● Cannabis stomatitis is a condition found in individuals who users than tobacco users, possibly due to the presence of certain hydrocarbons in marijuana that nourish specific strains of fungi [114]. chew, as well as smoke, marijuana. It is characterized by ●● Chronic users are more prone to oral infections than nonusers, chronic inflammation of the oral epithelium, leukoplakia of the and may have compromised immune response due to marijuana’s buccal mucosa, and hyperkeratosis (a thickening of the tissues). immunosuppressive effects. Continued use increases the patient’s risk for neoplasia. Oral ●● Chronic use is likely to cause some degree of xerostomia, as cancers associated with marijuana typically appear on the tongue well as irritation and swelling of the tissues, dry throat, and or anterior floor of the mouth. redness of the uvula.

Management and clinical implications The dental team should be aware of the following treatment concerns ●● Patients experiencing dental treatment while under the influence of related to patients who use marijuana: marijuana may feel anxiety, discomfort, paranoia, or depression. ●● THC increases the heart rate and causes vasodilation, posing a In unknowingly treating marijuana smokers, dentists may increase their potential risk for blocked arteries (cardiac ischemia), atrial fibrillation patient’s risk for adverse effects or complications. Identifying patients (abnormal heartbeat), or angina (chest pain) due to oxygen-deficient who smoke marijuana is useful as it reduces the potential for unpleasant blood. These patients may need more oxygen than nonusers. surprises. Dental professionals should encourage discussion of marijuana ●● Epinephrine (used in a number of types of local anesthesia), should use by including questions regarding patterns of consumption on the not be administered if there is a possibility of recent marijuana use, medical history form, just as tobacco use is listed. With the increasingly as this can increase the potential for a dangerously increased heart legal status of marijuana, dentists are likely to see more of the conditions rate (tachycardia) or extended duration. identified here, and patients are likely to feel more at ease discussing them. ●● Patients using marijuana are at greater risk for low blood pressure when reclined in the dental chair [118]. ●● A combination of stress and the parasympathetic effects of marijuana may increase the patient’s potential for fainting.

Page 56 Dental.EliteCME.com Section III: Commonly Used Illegal Drugs The National Survey on Drug Use and Health (NSDUH) studies the Illegal drug use among individuals 12 years of age and older. use of prohibited substances in the United States, focusing specifically on the use of marijuana/hashish, cocaine/crack, heroin, hallucinogens, and inhalants. According to data collected in 2010, 22.6 million (almost 9%) of those in the United States aged 12 or older used an illegal substance during the month prior to the survey. The estimated numbers of substance users in each category are presented in the bar chart [119].

Source: 2010 National Survey on Drug Use and Health (NSDUH)

Stimulants Many abused substances are stimulants, which are known for Many stimulant users are polydrug users (more than one drug), as increasing physiological activity, producing an alert and energetic well as polystimulant users. Most stimulants produce a number of “high,” and feelings of well-being. Stimulants may be legal (caffeine) identifying oral effects. In a study of polystimulant use, participants or illegal (MDMA), or legal with a prescription (Ritalin). Other reported the following symptoms and effects: common illegal stimulants are methamphetamine (meth) and cocaine. ●● The most frequent short-term oral health effect of stimulant use was xerosotomia, with 95% reporting frequent dry mouth [122]. Most stimulants have the potential to damage the oral environment ●● 75% reported a need to chew something after ingesting stimulants, due to the physical byproducts of nervous system stimulation and the with about half of all users noticing a tendency to grind and clench behavioral habits of the individual using the substance. teeth, and nearly 40% of all users reporting a habit of biting their Stimulants are associated with bruxism, which can result in cracked cheeks, tongue, or lips after taking the drug. enamel or loosened teeth caused by the user’s stimulant-induced ●● More than half (56%) felt pain or tenderness in the jaw muscle or grinding or clenching. Patients may find some relief with orthodontic jaw joint after using stimulants; 30% felt clicking or popping when interventions such as a biteplate or retainer, to prevent further damage. opening and closing their mouths, with many unable to open their Over time, bruxism can lead to root and gum damage, creating a need mouths completely. for root canal or implants. Grinding is also associated with headaches, ●● About 37% of respondents complained of tooth sensitivity. neck pain, and earaches [120]. ●● Stimulant users showed a distinct pattern of tooth wear, exhibiting Like many other drugs, a common side effect of stimulant use is increased posterior erosion and significant occlusal wear of the xerostomia. While this factor contributes to increased rates of decay, lower first molar. stimulant users are also more likely than nonusers to drink alcohol and ●● More than one-third of participants reported feelings of numbness energy drinks, and choose soda and other sugary beverages to alleviate in their mouths after using stimulants. symptoms of dry mouth or thirst, which further increase the risk for severe tooth decay [121].

Cocaine Cocaine is a powerful and extremely addictive stimulant extracted only by prescription. The continued demand for cocaine and its legal from the leaf of the coca bush, a plant native to parts of South prohibition gave birth to a black market that has thrived ever since. America. Many cultures living in areas with coca bushes have a Two main forms of cocaine are prevalent in the United States: water- practice of chewing the leaves to produce a mild stimulating effect; soluble hydrochloride salt (cocaine hcl) , which takes the form of a white much like caffeine is used in the United States. This form of coca powder or crystals; and water-insoluble cocaine base, more commonly consumption has been a tradition for thousands of years, and is rarely known as crack. Both forms of cocaine begin as the same product and associated with addiction. share a very similar chemical composition. Crack is made from a volume Until 1914, cocaine was a legal commodity in this country, found of partially processed cocaine base removed in an early stage of cocaine in myriad OTC products such as soft drinks and health tonics, and production. It is processed with ammonia, or sodium bicarbonate and considered a necessity in any first-aid kit or medical clinic. Once water, and then heated to extract the hydrochloride, producing a smokable the clearly addictive properties of purified cocaine became apparent, substance. Cocaine hcl is typically consumed through nasal inhalation, products containing cocaine (most famously, Coca Cola) were required permeation of the oral tissues from rubbing it on the gums, or injection. to remove the substance. Cocaine became a controlled substance, sold Water-soluble cocaine base is generally smoked [123].

Dental.EliteCME.com Page 57 Cocaine’s highly addictive properties are related to its ability to Some of the health risks of cocaine use are not necessarily related to increase levels of the neurotransmitter dopamine in the brain. the properties of the coca leaf. Cocaine production is a lengthy process Normally, once dopamine releases, it returns to the same cell, bringing in which the product is likely to move great distances and change a stop to the movement between neurons. Cocaine prevents dopamine hands many times. At each step, there is an opportunity to increase from returning to its original cell, causing excessive amounts of profits by reducing the purity of the product. Many harsh chemicals dopamine to accumulate in the synapse between neurons, which are used to process cocaine, and the drug is often combined, or cut, creates cocaine’s euphoric high. Some of cocaine’s desirable effects with other substances, with little regard to the dangers they pose to are increased energy, alertness, and sociability; elation or euphoria; users. Vendors who sell directly to the user have been known to use and decreased fatigue, need for sleep, and appetite. substances such as cornstarch, talcum powder, or sugar, as well as cheap pharmaceuticals, including anesthetics and amphetamines.

Prevalence and patterns of use Reports from the NSDUH (2008) assess the number of cocaine users in poses a high risk of physical dependence, with a greater propensity for the country at 1.9 million, with more than 350,000 currently using crack. escalation of use, both in frequency and amount consumed. Psychological Overall, men report higher rates of current cocaine use than women. symptoms associated with cocaine binging include irritability, irrational Those reporting the highest rates of cocaine were young men between thinking, restlessness, paranoia, and anxiety [126]. [124] the ages of 18 and 25, totaling about 1.5% of the population . Like other addictive substances, repeated use of cocaine can alter brain Average cocaine doses are estimated to be 20 mg to 100 mg intranasally, function in the short- and long-term. Chronic use is associated with 10 mg to 50 mg intravenously (IV), and 50 mg to 200 mg smoked [125]. increased risk of psychological and physical dependence, and severe Binging, a common pattern of cocaine abuse in which the user consumes health risks. Cocaine users may use other drugs concurrently—users large amounts of cocaine in segments of time ranging from hours to days, may inject a combination of cocaine and heroin, known as a speedball. is likely to result in far larger doses than these averages. This type of use

Physical symptoms and effects Cocaine users are most likely to seek medical help for cardiovascular Cocaine may cause symptoms of digestive distress, such as abdominal symptoms, commonly chest pain [127]. Cocaine increases the heart rate pain and nausea, because it reduces gastric motility, (the rate at and blood pressure, which increases the amount of oxygen needed by which food digests). Users experience a lack of appetite, with some the heart. At the same time, cocaine induces vasoconstriction, which exhibiting signs of malnourishment. Cocaine-induced vasoconstriction decreases the heart’s already suppressed blood and oxygen flow. These and ischemia are causal factors for GI infarction and perforation; factors are associated with increased risk for cardiac arrhythmia, heart colitis; and ulcers of the stomach, pyloric canal, and duodenum [133]. attack, and congestive heart failure in patients with no evidence of heart Common oral health implications of cocaine use include: disease; and increased risk of stroke and seizures in people with no ●● Increased risk of dental caries, resulting from a combination of [128]. Other risks include platelet obvious risk factors for these conditions xerostomia, poor personal oral care, and infrequent or inconsistent aggregation, leading to increased vasoconstriction, vasospasming, blood professional dental care [134]. clot formation (thrombosis), and sudden death. The risk of seizure is ●● Heavy occlusal wear and a cervical abrasion caused by excessive [129][130]. highest within the first 90 minutes after cocaine ingestion clenching and grinding with associated temporomandibular joint Smoked cocaine produces respiratory symptoms similar to other (TMJ) complaints. Gold restorations may show signs of erosion smoked substances, including shortness of breath or wheezing, asthma, from cocaine’s caustic effects. a cough producing mucus, and chest pain. Inhalation of cocaine ●● Dry mouth (and possibly bruxism) contributes to increased levels of microparticles damages the lungs, affecting the pulmonary vascular gingival and periodontal disease. Oral candida infections, angular bed, alveoli, and capillaries, and producing potentially fatal conditions, cheilitis, halitosis, burning mouth, and erosive lichen planus, are more including pulmonary edema or hemorrhage, and scarring of the lung common and progress more rapidly in cocaine users than nonusers. tissue (interstitial disease) [131]. All are conditions exacerbated by dry mouth and poor nutrition [135]. Intranasal cocaine ingestion (snorting) results in a variety of relatively ●● Rubbing cocaine on the gums or inside cheek is associated with mild symptoms including nasal irritation and runny nose, chronic ulcers and oral lesions, and contributes to tooth erosion. Lesions [136]. inflammation of the mucus lining (rhinitis) and sinusitis, loss of sense typically heal normally once use stops ●● Chronic cocaine use by any route of consumption is associated of smell, and nosebleeds. More severe symptoms include difficulty with an increased risk of infection, most commonly viral hepatitis swallowing or oropharyngeal ulcers, while very serious cases of and HIV [137][138]. cocaine abuse involve perforation of the nasal septum and palate. Cocaine-induced vasoconstriction can lead to ischemic necrosis, where the bone dies due to lack of a blood supply [132].

Management and clinical implications Undisclosed cocaine use increases the potential for adverse outcomes an increased incidence of convulsions in cocaine users [142]. Chronic in even the most routine dental care. Chronic cocaine users have a cocaine use does not appear to increase risks associated with greater propensity to excessive hemorrhage after tooth extraction, general anesthesia, as long as the patient is experiencing normal and a higher risk of orofacial complications such as perforation of cardiovascular function at the time of surgery [143]. [139][140] the nasal septum and palate . Use of cocaine within the 24 hours before dental treatment can The administration of a local anesthetic with vasoconstrictors put the patient at greater risk of cardiovascular complications, (such as those containing epinephrine/ adrenaline) or the use of especially with the use of local anesthetics or adrenaline- epinephrine-impregnated retraction cords, is contraindicated for impregnated retraction cords. Dental offices may require patients to cocaine users, as the drug interaction puts the patient at risk of affirm in writing that they will not use cocaine (or other drugs) for an acute rise in blood pressure that can lead to cardiac arrest [141]. a specified period before and after dental treatment. Patients must Lidocaine use is also contraindicated, as it has been associated with understand that the potential consequences of drug interactions in Page 58 Dental.EliteCME.com dental care can be very dangerous, even fatal. This conversation on the day of the procedure, the patient shows signs of cocaine use, should occur at the time the patient schedules the appointment. If, dental treatment should be postponed.

Identification and intervention Observable physiological effects of very recent cocaine use include Symptoms include musculoskeletal pain, tremors, chills, involuntary increased heart rate, dilated pupils, perspiration, and nausea. movements, such as spasms or tics, depression, anxiety, fatigue, poor Infrequent or moderate cocaine use may be difficult to detect. concentration, lack of enjoyment, severe cocaine craving, hunger, Behavioral and psychological effects of chronic use may be exhibited increased need for sleep, and more lucid dreams. Most users who in erratic demeanor and moods, with effects as diverse as inappropriate quit experience symptoms for 1 or 2 weeks and require no medical grandiosity, panic attacks, paranoia, or delusional thinking. Users intervention to resolve their symptoms. Heavy users experience these may appear agitated or restless, exhibit tremors, spasms or tics, and in symptoms longer, with very severe symptoms, crashing, occurring extreme cases, symptoms of paranoia or hallucinations. Patients may soon after quitting. Crashing frequently involves severe depression and complain of recent insomnia, weight loss, or lack of appetite [144]. suicidal thoughts. It is associated with a greater likelihood of congestive Cocaine users who quit typically experience mild withdrawal symptoms heart failure because it increases the risk of coronary vasospasms, a [146]. that are primarily psychological and rarely pose physical risks [145]. common symptom of stimulant withdrawal Ecstasy (MDMA) MDMA (3-4 methylenedioxymethamphetamine) is a synthetically effects are caused by the MDMA-induced increased activity of three produced drug (referred to as a designer drug) with psychoactive neurotransmitters: serotonin, dopamine, and norepinephrine, which properties, similar in chemical structure to methamphetamine and influence mood and regulate functions such as appetite and sleep. mescaline. Commonly known as ecstasy, MDMA was developed in This amplified neurotransmitter activity increases levels of oxytocin the early 1900s, possibly for use as an appetite suppressant. Its use and vasopressin, hormones identified with feelings of love, trust, was negligible until the 1970s, when it was used in psychotherapy, sexual interest, and sociability. These produce ecstasy’s characteristic although the drug was not formally approved for therapeutic feelings of emotional warmth and empathy toward others, and possible applications. MDMA was largely unknown to the public until the aphrodisiacal qualities [149]. 1980s, when it burst onto the club scene as a party drug that produced MDMA is taken orally, usually as a capsule or tablet. The term, molly feelings of ecstasy, encouraged sociability and friendliness, and (slang for molecular), refers to the pure crystalline powder form of [147]. provided the energy and stamina needed for a night of dancing MDMA, usually sold in capsules. Ecstasy’s effects vary in duration, Ecstasy is one of a number of designer drugs popular among young and depend on the dose and purity of the drug. The effects last an users. These drugs often have stimulant and psychedelics properties and average of 3 to 6 hours, although it is not uncommon for users to take are frequently used recreationally, in a social environment. Designer a second dose of the drug as the effects of the first dose begin to fade. drug abusers show patterns of use very different from those who MDMA is frequently used in combination with other drugs, but rarely abuse traditional drugs, such as heroin or cocaine. In 1985, the Drug with alcohol, as alcohol is believed to diminish its effects. Enforcement Administration (DEA) labeled MDMA a Schedule I Studies of polystimulant abusers show ecstasy abusers are likely to substance; a drug with high abuse potential and no recognized medicinal use other amphetamine-based drugs (polystimulant use), particularly use. Recreational use spiked in the 1990s and continues to rise [148]. methamphetamine (speed), as well as ketamine hydrochloride (ketamine Ecstasy’s popularity is linked to its ability to produce an enhanced or Special K), and barbiturates, but were unlikely to have used heroin [150]. sense of pleasure, well-being, self-confidence, and peace. These

Physical symptoms and effects MDMA has many of the same physical effects as other stimulants MDMA affects oral health in a number of respects. Primary symptoms like cocaine and amphetamines, including increased heart rate and of MDMA consumption include the need to chew, and a strong blood pressure. It poses particular risks for people with circulatory tendency toward bruxism, with severe grinding and clenching soon or coronary disease. MDMA users may experience symptoms such after ingestion. Severe tooth grinders significantly weaken teeth, even as muscle tension, involuntary clenching of the teeth, nausea, blurred exposing the underlying dentine. Occlusal teeth bear the brunt of vision, chills, or sweating. A variety of adverse effects occur after the abrasion and wear showing the greatest degree of severity and number drugs initial euphoria wears off. Symptoms such as sleep disruption, of affected teeth. Those who use the drug with any frequency may drug cravings, depression, or confusion can last as long as a few weeks experience symptoms of TMJ with tenderness, pain, or tension in the depending on amount and frequency of use [151]. jaw muscle or joints during periods of nonuse [154]. MDMA is inconsistently metabolized by the body, creating the MDMA causes dry mouth, with users reporting much greater possibility that dangerous levels will build up in the blood. High consumption of carbonated soft drinks than nonusers. In one study, doses can interfere with the body’s ability to regulate temperature. In MDMA users consumed a mean value of three cans of soda during a rare cases, this can cause hyperthermia, and increase the risk of liver, single MDMA episode. Users taking the drug in the evening are likely kidney, or heart failure [152]. to experience its effects until the following morning [155]. Ecstasy is often contaminated with other substances. Common Ecstasy shares many characteristics of amphetamines and cocaine, additives include ephedrine, dextromethorphan (a cough suppressant), including potential for dependency or addiction. In a recent study, ketamine (a dissociative anesthetics in the same category as nitrous survey respondents who regularly used MDMA reported symptoms of oxide/laughing gas), caffeine, cocaine, methamphetamine, or synthetic dependence, including continued use despite knowledge of physical or cathinones (bath salts). Using these drugs alone or in combination psychological harm, tolerance (or diminished response), and withdrawal. poses serious risks for the user [153]. This is not surprising considering the neurotransmitters activated by MDMA are the same as those targeted by other highly addictive drugs [156].

Dental.EliteCME.com Page 59 Methamphetamine Methamphetamine (meth) is a powerful and highly addictive stimulant treat weight loss, fatigue, and nasal decongestion, among many other that affects the function of neurotransmitters in the brain, altering the uses. Although methamphetamine has a similar chemical composition levels of serotonin, dopamine, and norepinephrine. Meth is a long- to its parent drug, and produces many of the same effects—such acting drug, with users feeling its effects for up to 14 hours. During as feelings of well-being or euphoria, an increased propensity for this time, the individual is energetic, alert, and inclined to physical conversation and physical activity, and a lack of appetite—there are activity, but functionally impaired with limited ability to understand significant, potentially dangerous differences between them[158] . the repercussions of his or her actions. Chronic meth users have little Comparable doses of amphetamine and methamphetamine metabolize or no appetite and may become malnourished or underweight. Crystal in such a way that much greater amounts of meth permeate the brain, methylamphetamine (crystal meth) is a smokable form of meth that with effects estimated to be two times as powerful as amphetamine, [157]. has a very similar chemical structure and produces similar effects and long-lasting consequences far more detrimental to CNS function. Methamphetamine was derived from amphetamine (also known as Both amphetamine and methamphetamine are widely abused substances speed), a drug commonly sold without a prescription in the 1950s to regulated since 1970 under the Controlled Substances Act [159].

Prevalence and patterns of use In the 1980s, the availability, popularity, and prevalence of meth ●● Meth is a relatively good bargain for the user compared to similar surged to new heights, for the following reasons [160]: drugs. It produces an intense sustained high for a period of time ●● Meth was relatively easy to make. Unlike other processed drugs few substances can match for the same money. such as cocaine and heroin, the only necessary ingredient, ●● Meth is considered one of the most highly addictive, commonly ephedrine (or, if not available, pseudoephedrine, a closely related abused drugs. drug) could be found in many OTC cold medications. The other Between 2002 and 2004, the percentage of meth users who were chemicals needed for processing (lye, muriatic and sulfuric acids) dependent on the drug increased more than 30% (from 27.5% could be purchased at a grocery store. to 59.3%). In 2007, the NSDUH reported that about 5% of the U.S. population over 12 years of age (13 million) had used methamphetamine at least once [161].

Physical symptoms and effects Dependence on meth comes with severe costs to a user’s social, ●● Vasoconstriction contributes to the increased risk of periodontal financial, psychological, and physical well-being[162] . The disease by inhibiting the blood supply needed to maintain good mechanism by which meth produces a high progressively depletes oral health. When blood vessels constrict repeatedly due to meth neurotransmitter function, resulting in symptoms of depression and abuse, they can be irreversibly weakened to a point where they [163] physical consequences, including : are unable to deliver sufficient quantities of blood to keep the oral ●● Cardiac dysfunction, including irregular heartbeat or high blood tissues alive (oral necrosis) [168]. pressure, with chronic use associated with hallucinations or a ●● Many users grind or clench their teeth while experiencing the drug’s greater propensity to violence [164]. ●● Long-term meth users may be malnourished or underweight due to effects. Among meth users, signs of bruxism and TMJ are more lack of appetite or concern about the need to eat [165]. common among females than males. Vasoconstriction combined with [169] ●● Meth causes many of the same negative oral effects of other illegal bruxism makes the tooth enamel more fragile and prone to break . drugs, including xerostomia, bruxism, periodontal disease, and ●● Oral ulcerations and infections are common among meth users, oral ulceration. It reduces salivary gland function, causing greater regardless of mode of ingestion. Smoked and snorted meth abrasion and irritation of the tongue and lining of the mouth. exposes the oral cavity to caustic ingredients that irritate and Raw areas can more easily lead to lesions of the oral mucosa and burn oral tissues, leading to ulcers and infection, which are complications such as secondary infections [166]. exacerbated by xerostomia [170]. ●● One-third of meth users reported frequent dryness or cotton mouth, ●● If the drug is snorted, the corrosive chemicals are drawn down with some requiring liquids during meals to facilitate swallowing the nasal passage to the back of the throat, coating the teeth and food. Meth users consume excessive amounts of soft drinks and causing extreme damage to the enamel [171]. other beverages high in sugar, carbohydrates, and calories, due to Recent research provides strong evidence that IV drug use causes the meth-induced sugar cravings and a desire to prolong the high with most severe damage of any route of meth ingestion. IV meth users the stimulating effects of sugar and caffeine [167]. were significantly more likely to be missing teeth than those smoking or inhaling meth, who had much lower rates of dental disease.

Meth mouth Perhaps the most striking feature of meth abuse is the pattern of extreme severe damage, but the most destructive effects are typically associated decay and damage to tooth structure and surfaces, known as meth with the coronal tooth. Decay along the cervical third of the teeth mouth. First documented in 1992, meth mouth refers to the characteristic and labial surfaces can appear black or brown, due to stain or rot. In set of symptoms and physical manifestations of meth abuse seen in the some cases, the level of decay is so severe and so aggravated by other oral cavity. One part of this pattern is the excessive damage evident in symptoms of meth use (such as xerostomia) that teeth may need to be the number of teeth severely decayed, discolored, broken, missing, or extracted, as treatment or restoration is not possible [173]. showing remnants of tooth or roots left behind. In a recent study of meth The extreme pattern of decay seen in meth mouth is a function of a [172]. abusers, almost 23% reported broken or loose teeth number of factors working in combination [174][175]: Because deterioration is so extreme and rapid, even young or short- ●● Methamphetamine is a highly caustic substance produced from a term users may show severe signs of damage. Meth users and former host of hazardous chemicals, such as anhydrous ammonia (found users are more likely to wear (or need) dentures or prosthetics. The in fertilizers), red phosphorus (found on matchboxes), and the pattern of decay is distinct: lingual and buccal surfaces show signs of element lithium-ion (found in batteries). Homemade meth labs

Page 60 Dental.EliteCME.com have been known to add highly corrosive ingredients including drinks and junk food exposes the teeth to high levels of harsh paint thinner, acetone, and battery acid. Other materials commonly acids, which eat away at the tooth if they are not removed by found in meth are muriatic and sulfuric acid, chemicals commonly salivary flow or oral hygiene practices. added to swimming pool water, and the pharmaceutical drug, ●● Excessive grinding of weakened teeth increases the risk of decay, lithium, used to treat bipolar disease [176]. erosion, and fractures. ●● While these substances are poisonous or corrosive in themselves, For many years, there was a consensus in the treatment community the damaged oral environment of a meth abuser increases the that the extreme damage seen in meth mouth was caused by the direct potential for extreme decay and damage. Meth users’ extreme effects of exposure to meth smoke, or meth itself, on the oral cavity. xerostomia adversely affects oral health because there is less Recent research contradicts this assumption, providing strong evidence saliva to neutralize or wash down acids that remain after eating that IV drug use causes the most extreme damage of any route of meth and drinking. The more acidic environment breaks down the tooth ingestion, with IV meth users showing high rates of dental disease and enamel and attacks the gums, causing areas of weakness that are extreme symptoms of meth mouth very similar to those seen in chronic more susceptible to decay. IV users of other drugs, such as heroin [177]. ●● Other elements that contribute to the extreme pattern of decay and damage are behavioral, associated with poor hygiene, diet, lack of Analyzing the relationship between IV drug use and extreme decay is regular dental care, and delay in addressing medical issues until they complicated by the fact that noninjection users become injection users become emergencies. Meth users often have poor oral hygiene habits, as their level of dependence escalates. IV administration is an extremely brushing and flossing their teeth less frequently than nonusers. efficient delivery system, providing the user nearly 100% bioavailability ●● When under the influence of meth, users crave sugary foods and of the drug less than 1 minute after IV administration [178]. beverages, partly due to symptoms of dry mouth. Consuming soft

Management and clinical implications Meth users have a reputation for delay in addressing medical needs, If deep sedation is required, meth users must abstain for several days even if they are in pain for a long time. Research suggests users prior to the appointment [181]. primarily receive dental care in emergency rooms, when the situation Before confirming the appointment, the patient must affirm that he or has become critical, although the issue may have been long-standing. she understands the implications of meth use within the critical period In one study, meth users waited an average of 1.5 years for swollen before the appointment, and provide written assurance, if necessary, or bleeding gums, to 6.5 years for TMJ complaints, before seeking that he or she will abstain for the requisite period. The patient should professional dental care. The same study provided a free dental acknowledge awareness of the increased risk of specific adverse appointment to any participant in the study who wanted one, but no outcomes associated with using meth before or after the procedure. [179]. meth users took advantage of the offer On the day of the appointment, the dental team should pay special Meth users may be more difficult to schedule or contact, come to attention to patient demeanor and behavior for possible symptoms of appointments late, or miss them entirely, and are inconsistent in paying meth use, or use reliable screening techniques to avoid the possibility their bills. Given the dangerous combination of meth-induced oral of adverse drug interactions [182]. symptoms, poor oral hygiene, and lack of professional dental attention, Common behaviors in meth abuse that encourage decay are it is not surprising that a patient can progress from the early stages of consumption of low nutrition, high carbohydrate, high sugar foods periodontal disease to a state of severe damage in a relatively short time. and beverages (especially carbonated soft drinks), hard candies, or Dental management of meth users requires obtaining a thorough other sugary substances held in the mouth; infrequent or ineffective medical history and performing a careful oral examination. Meth users brushing; and bruxism. More than 90% of meth users smoke are unlikely to disclose their substance use, so dental professionals cigarettes. Suggested strategies for reducing harm include providing need to be aware of the physical symptoms and medical risks smoking cessation information, advising the patient to increase his presented by these patients [180]. or her frequency and effectiveness of oral hygiene practices (with If meth use is suspected, extreme care is required in choice and training, if necessary), regular dental check-ups, quitting or reducing administration of local anesthesia. Methamphetamine increases the soft drink consumption, and wearing a mouth guard to reduce tooth [183]. user’s risk for irregular heartbeat, heart attacks, and stroke. Anesthetic erosion and reduce TMJ pain with vasoconstrictors may be ineffective in relieving the patient’s pain, The most important factor in treating the oral effects of and are contraindicated, as are all vasoconstrictors. Injections must be methamphetamine is for the patient to stop using the drug. Therapeutic monitored carefully for adverse effects. If local anesthetic is used, it is treatment cannot combat the continued effects of abuse, which will critical that the patient avoid using meth within the previous 24 hours. eventually cause severe and irreparable damage.

Identification and intervention There is no stereotypical meth user—they come from all walks with meth use that have less obvious indicators, but may be equally of life and use the drug to meet a wide range of needs. Some look dangerous. Meth use may be indicated by TMJ dysfunction, for a recreational high or use it as a sexual aid; others for relief enlargement of the masseter muscle, the characteristic pattern of dental of depression or boredom. Hardworking students and business attrition associated with the drug, and an increased number of caries. professionals may use it to reduce the need to sleep, achieve more in A caries assessment is a recommended screening protocol to identify a day, meet a deadline, or work two jobs. Meth’s ability to keep the undisclosed meth use [184]. user alert and energetic, and reduce the need sleep are initially very Substance abuse research suggests that brief interventions by medical effective in helping users reach their goals. As use escalates, they professionals are surprisingly effective in preventing meth use, become more focused on obtaining and using the drug, with their decreasing the amount and frequency of drug use among users, and original priorities falling by the wayside. providing referrals that facilitate rehabilitation. Intervention may be as Meth users commonly present with multiple dental diseases and simple as mentioning the potential medical risks associated with meth conditions. By detecting early symptoms of use, dental professionals and providing an informational brochure. Most patients are disposed to can play a crucial role in reducing common comorbidities associated listen to dental professionals and consider their recommendations [185].

Dental.EliteCME.com Page 61 The following steps may encourage discussion and/or disclosure of symptoms of paranoia or a propensity to violence. If the meth use [186]: patient appears receptive, discuss the pattern of damage and ●● Warn every patient to avoid using meth, regardless of his or explain that they are characteristic of drug use. If there is any her characteristics. This is important because preconceived possibility of danger to the dental team or patient, adjust the assumptions about meth users can result in missed opportunities to timing and strategy accordingly. identify a patient who uses the drug. A recent study of meth abusers revealed an unexpected finding; ●● If meth is prevalent in the community, mention that fact and ask about 29% were concerned about the appearance of their teeth, with the patient what he or she knows about meth. If the patient appears IV meth users significantly more likely to report cosmetic concerns unaware of the drug or its consequences, provide this information related to oral health than those who smoked meth. This finding in an easily digestible form, such as an information sheet, challenged prevailing assumptions that meth users are largely unaware illustrated by photos of meth mouth. or unconcerned about aesthetic changes resulting from use. Knowing ●● Review clinical and radiograph findings for indications of that many users are not only conscious of, but concerned about, the potentially serious damage to the teeth or mouth that might be unattractive consequences of meth abuse suggests dental professionals related to meth use. Discuss this information with the patient. can appeal to an individual’s desire to appear more attractive and Direct, open-ended questions are most effective in encouraging healthy to motivate or stimulate a patient’s interest in treatment [187]. patients to disclose drug use. Dental clinicians can ask in a direct matter-of-fact way how the teeth came to be in their Understanding the symptoms of meth abuse that make the patient most current condition. emotionally or physically uncomfortable can suggest opportunities ●● Dental professionals should ensure their tone is one of caring for tailoring interventions that address the patient’s priorities and and concern, avoiding any words or actions that might be concerns, to increase the possibility of referral to substance abuse interpreted as judgmental. Long-term meth users may have counseling or treatment programs [188].

Heroin Heroin is a natural opioid derived from morphine, which is extracted effects on opioid receptors in the brain stem, the area that controls from the Asian opium poppy plant. Heroin usually appears as a white critical autonomic, or involuntary, body functions, such as breathing. or brown powder, or a black, sticky substance known as black tar Excessive amounts of heroin can suppress respiration, causing death [190]. heroin. Heroin is an illegal, highly addictive drug. It is both the most After an IV injection of heroin, users report feeling a rush of euphoria, abused and rapid-acting of the opioids. In 2011, 4.2 million Americans aged 12 or older (about 1.6%) reported using heroin at least once in accompanied by dry mouth and a warming or flush of the skin. their lives. It is estimated that about 23% of individuals who use heroin Following this initial high, the user may fall asleep, or remain in a become dependent on it [189]. drowsy wakeful state. Injection provides the greatest intensity and most rapid onset of euphoria (within 7 to 8 seconds). A heroin abuser Heroin can be injected, inhaled by snorting or sniffing, or smoked. All may administer injections multiple times per day. When heroin three routes of administration deliver the drug to the brain very rapidly, which contributes to its health risks and high rates of addiction. Upon is sniffed or smoked, peak effects are usually felt within 10 to 15 entering the brain, heroin is converted back into morphine, which minutes. Smoking and sniffing do not produce the strong initial rush binds to molecules on receptors in the brain and body that mediate the of an injection, but other effects are comparable. Regular heroin use perception of pain. Deaths from overdose are usually related to heroin’s results in tolerance and physical dependence, and produces changes in the brain similar to other highly addictive substances [191].

Physical symptoms and effects Chronic heroin users may develop collapsed veins, infection of the Heroin causes nausea in some, leading to acidic vomiting, which in heart lining and valves, abscesses, constipation and GI cramping, and chronic users produces the extreme degree of tooth erosion found in liver or kidney disease. Pulmonary complications, including various bulimia, or other conditions with frequent vomiting [195]. Chronic heroin types of pneumonia, may result from the generally compromised users exhibit the same oral symptoms referred to collectively as meth health of the user as well as respiratory complication directly related mouth. According to an article in the Journal of the American Dental to drug use. IV use is associated with an increased risk of infectious Association, the term is misleading, as it more directly characterizes diseases like hepatitis and HIV [192]. the consequences of chronic IV drug use. Intravenous heroin users In addition to the effects of the drug itself, street heroin often contains have the same pattern of extreme decay, with a high number of caries, toxic contaminants or additives that can clog blood vessels leading to missing and broken teeth, and increased risk of periodontal disease that the lungs, liver, kidneys, or brain, causing permanent damage to vital characterizes meth mouth. In surveys of IV heroin drug users, up to 70% organs. Although the heroin supply is less adulterated than it once described problems such as teeth snapping off and falling apart [196]. was when supply was more limited, most street heroin is mixed with Like excessive meth users, heroin addicts are also likely to have substances such as sugar, starch, powdered milk, or quinine, or far less periodontal disease and extreme tooth decay along the gum-line, with [193] benign ingredients such as strychnine and other poisons . negative oral conditions aggravated by xerostomia and bruxism. Heroin Users at all stages run the risk of heroin overdose due to the difficulty users are inclined to consume excessive amounts of sugary foods and of assessing the drug’s purity. Pure or uncut heroin can be as much beverages, due to strong cravings for sweets. The resulting build-up of of a danger as hazardous additives, particularly if the user typically acids and bacteria encourages the extremely rapid progression of disease consumes a more adulterated substance. Heroin overdoses result from and decay [197]. Heroin users are likely to delay treatment for very long all forms of ingestion. Users commonly experience slow and shallow periods, even when they are experiencing extremely painful conditions. breathing, convulsions, and, in some cases, coma, before death [194]. In some cases, the analgesic effects of the drug allow the user to postpone treatment far longer than would be possible without the substance [198].

Management and clinical implications Heroin, like other opioids, has the potential for dangerous information about this concern is presented below, in the section interaction with many drugs used in dentistry. More detailed discussing prescription opioid abuse.

Page 62 Dental.EliteCME.com Provide heroin users with information regarding risk factors in their of seeking dental attention regularly. Survey data show that virtually diet (excessive soft drink consumption), dental hygiene habits (the all heroin users also smoke cigarettes, so the dental team may want to need to brush their teeth before going to sleep), and the importance provide tobacco cessation information [199].

Identification and intervention Identification of heroin use follows the same protocol as meth last administration. They include achiness of the bones and muscles, screening. If necessary, a saliva test can be used to conclusively restlessness, perspiration, goose bumps, insomnia, agitation, GI determine if the patient has used heroin. distress, and kicking (resulting in the phrase, kicking the habit). Users experience extreme cravings for the drug, which greatly increase the Perhaps the biggest barrier to quitting heroin is the severe physical potential for relapse[200] dependence that results from chronic use. If a dependent user reduces . Former users may take synthetic opioids such or stops the drug cold turkey (without tapering use), he or she can as methadone and buprenorphine, both used in treatment for heroin experience severe withdrawal symptoms a few hours after the drug’s addiction. These drugs are also associated with certain medical risks, discussed in Section V.

Prescription opioids Opioids are pain relievers derived naturally from the opium poppy, because they directly affect pain receptors in the nervous system, or synthetically from sources that mimic its effects. They are the attaching to receptors in the brain, spinal cord, GI tract, and other source material for many narcotics (drugs that produce sedating organs. Once attached to receptors, opioids trigger a range of effects, effects) including codeine and morphine. All prescription opioids are including reduced pain, increased drowsiness and mental confusion, extremely effective at relieving pain, and have sedating effects due nausea, and constipation. The most significant effects in the context to their depression of CNS function. They are highly habit-forming of abuse are likely the euphoric high, associated with the drug and, if used over long periods, and more commonly abused than any other depending upon the amount of drug taken, shallow respiration, which prescription substances. Some of the most commonly prescribed can prove fatal [202]. opioids are codeine, hydrocodone (e.g., Vicodin), oxycodone (e.g., Those who abuse opioids may seek to intensify their experience by OxyContin, Percocet), and morphine (e.g., Kadian, Avinza) [201]. taking the drug in ways other than prescribed. For example, OxyContin While opioids (such as codeine or morphine) and nonopioids (such is an oral medication used to treat moderate to severe pain through a as acetaminophen or NSAIDs) are both classified as pain relievers, slow, steady release. People who abuse OxyContin may snort or inject opioids are narcotic analgesics, which are much stronger than the it, thereby increasing risk for serious medical complications, including nonnarcotic analgesics, acetaminophen, and NSAIDs. Opioids are overdose. Physical dependence is an almost certain consequence of able to provide a much greater degree of pain relief than nonopioids chronic opioid use [203].

Prevalence and patterns of use Opioid analgesics have many applications in dental care. They are 2 million people in the United States meet the criteria for prescription routinely prescribed for pain following oral surgery, among other opioid abuse or dependence [205]. Those who abuse the drug may change dental procedures, and may be used with anesthetics to provide more their method of ingestion to increase its effects, snorting or injecting it as effective pain management. The number of opioid prescriptions their dependence escalates, or switching to a stronger medication [206]. has risen sharply in recent years, primarily due to their increased Taken in ways other than prescribed, prescription opioids have effects use in chronic pain management. Between 1991 and 2010, opioid similar to heroin. A number of recent studies suggest that prescription prescriptions grew from about 75 million to 209 million. This greater opioids are a frequent precursor to heroin abuse. Almost half of IV heroin availability encouraged more widespread nonmedical use of opioids, users who participated in surveys about their drug use reported abusing [204]. with many doses diverted to those without prescriptions prescription opioids (typically by crushing, snorting, or injecting the It is estimated up to 23% of prescribed opioid doses are used drugs) before trying heroin. Many reported switching to heroin because it nonmedically, or about one of every 25 prescriptions written. Almost was cheaper and easier to obtain than prescription medication [207].

Sources of misused prescription opioids Studies of prescription opioid abuse identified the following sources ●● Almost 10% of users bought the drug from a family member or for nonmedical drug use [208][209]: friend who had leftover drugs from an old prescription. ●● More than half (55.3%) were given the drug by a friend or relative ●● 5% of users took the drug from a friend or family member without without charge. Within this group, 80% of those providing a drug to their knowledge or permission. a nonprescription user obtained the drugs from one prescriber. Data ●● More than 17% used medication they kept from a previous suggest friends and relatives who share their prescription medication prescription for a valid medical complaint. Each of the user’s are primarily motivated by a desire to help the other individual medications were prescribed by one medical professional, as opposed relieve physical pain, rather than provide a recreational high. to multiple prescribers, a common strategy of drug-seeking behavior. ●● Almost 5% purchased the opioid from a dealer.

Physical symptoms and effects As discussed in previous sections, opioid abusers show the highest use can also increase risks due to the effects of opioid abuse on rates of oral decay and disease of all drug users, with the most extreme motivation and decision-making. damage associated with IV administration. Opioids are implicated in a ●● Opioids affect hormonal function (opioid endocrinopathy, or OE) wide range of negative physical effects [210][211]: in both men and women. Hormonal dysfunction can result from ●● Opioid use is linked to the increased incidence of infectious any route of administration. Men are likely to suffer symptoms diseases, including hepatitis and HIV, in those who inject the drug, of sexual dysfunction (such as erectile dysfunction and decreased through use of shared or unsterilized needles. Noninjection drug libido). Serum hormone levels typically return to normal when drug use stops, after withdrawal symptoms resolve.

Dental.EliteCME.com Page 63 ●● Hyperalgia, or increased pain sensitivity, is associated with long- as spinal opioid receptors do not appear to inhibit intestinal term, high-dose opioid use, and is characterized by more acute motility to the same degree as other sites. pain, despite the administration of higher opioid doses. ●● Large amounts of opioids cause liver and kidney damage. ●● Symptoms of GI distress include nausea and vomiting, but ●● CNS depression results in slowed respiration, sleepiness, dizziness, primarily consists of constipation. When taken as directed, slowed unclear thinking, and confusion. Abuse of opioids, alone, with gut motility is an almost guaranteed side effect of opioid ingestion. alcohol, or other drugs, can depress breathing to the point of fatality. Excessive use causes severe constipation, hemorrhoids and rectal The most serious medical complications of opioids are associated pain, bowel obstruction or rupture, among other serious and fatal with its sedating effects. Deaths from unintended prescription opioid effects. Spinal administration may reduce the risk of constipation, overdose are now more than four times what they were in 2000, greater than all the heroin and cocaine deaths combined [212].

Risk of dependency All opioids, like other addictive drugs that trigger the pleasure center Given the need for more of the substance to attain the same results, it of the brain to produce euphoric effects, also produce tolerance in is not surprising that opioid abusers may try to amplify drug effects by those using for an extended period. While prescribing opioids for taking it in ways other than prescribed. Abusers seeking more potency temporary acute pain is safe for most patients, long-term use is a for the same amount of money will snort or inject the drug, or switch high-risk activity that almost certainly leads to addiction. Opioid users to a similar, but less expensive or more available drug. Greater potency experience a very unpleasant crash, when they discontinue use—the or dosage causes increased risk of adverse medical effects, as well as most common symptoms are intense craving for the drug, anxiety, undesirable side effects including dysphoria (feelings of discomfort, depression, and diarrhea. Those who have a pattern of stopping and unhappiness, or restlessness); symptoms of GI distress, such as nausea starting (if a supply is not available, for example), may alternate and vomiting; and potential for severe respiratory distress [214]. between extreme emotional highs and lows [213].

Section IV: Prescription Drug Abuse

Nonmedical use of prescription drugs Prescription drug abuse is the intentional use of a medication that spasm, a twisted ankle on a Saturday). Nonmedical use also includes is not prescribed for the individual using it. The NSDUH considers those with a prescription who use the drug recreationally, for the high, all use of psychotherapeutic drugs without a personal prescription rather than its intended purpose. Psychotherapeutic drugs include nonmedical use, although some of these diverted prescription drugs prescription pain relievers, tranquilizers, stimulants, and sedatives [215]. may legitimately have been used to treat pain (a friend with a back

Prevalence and patterns of use In 2010, about 7 million people were users of psychotherapeutic drugs Survey results from 2011 showed 2.6 million people 12 years of age taken nonmedically (2.7% of the U.S. population). This class of drugs is and older used psychotherapeutics nonmedically for the first time broadly described as those targeting the CNS, including drugs used to treat within the preceding year (about 7,000 new users each day in 2010). psychiatric disorders. The medications most commonly abused are [216]: The average age at which pain relievers were first used nonmedically ●● Pain relievers: 5.1 million. was 20 years. Common reasons an individual might take a prescription ●● Tranquilizers: 2.2 million. drug without a valid prescription include self-medication for emotional ●● Stimulants: 1.1 million. or physical pain, anxiety, sleep disorders, or poor concentration. ●● Sedatives: 0.4 million. Prescription medication may be used to help an individual function Among adolescents, prescription and OTC medications account for more efficiently, postpone sleep so he or she can achieve more in a [218]. most of the commonly abused illegal drugs [217]: day, or stay alert for work or family obligations ●● Nearly one in 12 high school seniors reported nonmedical use of These abused substances complicate dental treatment in many ways. Vicodin; one in 20 reported abuse of OxyContin. Given the intensity of addiction, dentist must be aware that patients ●● When asked how prescription narcotics were obtained for who are substance abusers may be coming in looking for a source of nonmedical use, 70% of 12th graders said they received them from prescription drugs. The next section describes common characteristics a friend or relative. of drug-seeking behavior, and strategies to minimize nonmedical use.

Drug-seeking behavior Substance abuse affects every age group, socioeconomic status, and ●● Claim to be from out of town, or to have left a prescription out of town. ethnicity—there is no reliable profile for prescription drug abuse.All ●● Claim to be in pain or have a history of oral pain, with no observed dental personnel and staff should be aware that the office or clinic reason, and repeatedly request new prescriptions or refills. could be a target for a prescription drug abuser seeking a supply. ●● Request early refills of lost or stolen medications. Users may engage in doctor shopping, visiting multiple medical ●● Claim to be allergic or immune to the effects of all drugs except professionals to obtain as many prescriptions for controlled substances controlled substances. as possible. Dentists should become familiar with common strategies ●● Claim only one type of drug will work. of drug shopping, and think twice about patients who [219][220][221]: If you think a patient is drug or doctor shopping, ask yourself the ●● Appear to time emergency visits when the office is about to close, [222] or contact the dentist by phone after regular office hours or during following questions : weekends or holidays, claiming to be in severe pain and needing ●● How frequently does the patient contact the office or come in immediate relief (asking the doctor to phone in a prescription to for treatment? their local drugstore right away). ●● Does a new patient not want you to talk to his/her former doctor? ●● Have a history of broken appointments, or frequently reschedule ●● Is the patient paying in cash? appointments. ●● Does the patient have a known and valid current and former address?

Page 64 Dental.EliteCME.com ●● Is it often difficult to contact the patient? ●● Does the patient fill prescriptions at more than one or two pharmacies? ●● Has the office ever lost or misplaced prescription pads? ●● Is the patient participating in recommended non pharmaceutical ●● Does the patient ask for drugs by specific name, dosage, and/or therapies as well as the medication for his/her treatment? number? In a survey of dentists in West Virginia, 58% of respondents believed ●● Does the patient have more than one primary care physician? they were the victims of fraud or theft of prescriptions. Dentists ●● Does the patient request the most frequently abused opioids, such as reported patients using the following strategies to obtain drugs: 43% the immediate-release (IR) opioids hydrocodone and oxycodone? pretended to be in pain, 28% claimed their prescriptions were stolen, ●● Does the requested drug have high demand and resale value? 14% forged prescriptions, and 14% found a way to increase the ●● Does the patient have prescriptions from more than one or two number of pills in the prescription [223]. doctors?

Appropriate prescribing practices Overprescribing occurs when prescriptions are written in quantities It is important to note that the need for analgesics varies widely; greater than might be needed to treat the patient’s pain, or are stronger patients with similar health profiles undergoing similar procedures than required for the anticipated degree of pain [224]. In the United may have very different pain management needs. Although the States, IR forms of hydrocodone and oxycodone are the two most recommended dosage of an opioid analgesic, such as hydrocodone frequently abused opioids. Dentists are the second greatest source for with acetaminophen, is between 2 and 3 days for a procedure like these drugs, prescribing 12% of all IR opioids used. The only greater third-molar extraction, some patients legitimately need analgesics for source is family physicians, at a close 15% [225]. up to a week or more [230]. Given the high number of IR opioids prescribed by dentists and the While some flexibility in prescribed amounts is necessary, research has extent of misuse, dentists play a role in minimizing the potential for demonstrated that prolonged pain after surgery is frequently an indication nonmedical use by reducing the excess supply through appropriate of a problem, such as poor healing or infection. A visit to the dentist’s prescription practices. Dentists must apply patient-specific opioid office will facilitate a decision about how to proceed, as the practitioner prescribing practices to ensure adequate pain control, while limiting can assess if and why the patient’s healing is delayed. Dentists should opportunities for abuse and diversion [226]. generally prescribe no more than a few days of medication. Quantities [231]. Available data and peer-reviewed recommendations suggest that lasting a longer period than necessary pose a potential health risk clinicians prescribe no more than the number of doses needed based Dentists have a responsibility to identify patients with substance on ADA recommendations [227]. An ADA survey of 563 practicing abuse issues due to the increased risk of drug interaction or overdose. oral and maxillofacial surgeons in the United States, reported that A patient’s self-reported medical history is unlikely to provide many two-thirds of respondents prescribed between 10 and 20 doses of IR clues of suspected prescription drug abuse, but there should be a opioid analgesics after third-molar extraction. Forty-one percent of section that addresses the issue. Whether or not the patient is a drug respondents said they expected patients to have medication remaining abuser, it is important to know what pain relievers he or she used in the after resolution of their postoperative pain [228]. A 2008 study showed past; how effective they were; and what side effects, if any, occurred. that 72% of respondents who were prescribed an opioid had leftover Even if a patient is not truthful about drug use on the medical history, medication, and 71% of those with leftover medications kept them. it is a good starting point for a discussion about pain medication. Given these statistics, it is easy to see how such a vast number of prescription drugs have found their way into public use [229].

Guidelines for prescription pain control The dental professional should employ the following guidelines in including number and frequency of all prescription refills; and considering the use of controlled substances for pain control [232]: acknowledging the circumstances under which drug therapy may 1. Evaluation of the patient: An appropriate medical history and be discontinued (such as violation of the agreement). Informed dental examination must be conducted and documented in the dental consent must include a description of the planned treatment, and record, which should detail information regarding the nature and address the possible risk of triggering a relapse. intensity of the pain, current and past treatments for pain, underlying 4. Periodic review: At reasonable intervals based on the individual or coexisting diseases or conditions, the effect of the pain on circumstances of the patient, the practitioner should review the physical and psychological function, and history of substance abuse. course of treatment and any new information about the etiology of The dental records should document the presence of one or more the pain. Continuation or modification of therapy should depend recognized dental indications for the use of a controlled substance. on the practitioner’s evaluation of progress toward stated treatment 2. Treatment plan: The written treatment plan should state objectives (such as improvement in the patient’s pain intensity objectives that will be used to determine treatment success, and improved physical and/or psychosocial function, the ability to such as targeted pain relief and improved oral-facial, physical, work, need of health care resources, activities of daily living, and and psychosocial function, and should indicate if any further quality of social life). If treatment goals are not being achieved diagnostic evaluation or other treatments are planned. After despite medication adjustments, the practitioner should reevaluate treatment begins, the dental care practitioner should adjust drug the treatment to determine if it is still appropriate. therapy to the individual patient needs. Other treatment modalities 5. Consultation: The practitioner should be willing to refer the or a rehabilitation program may be necessary depending on the patient for additional evaluation and treatment as necessary to etiology of the pain and the extent to which the pain is associated achieve treatment goals. Special attention should be given to with physical and psychosocial impairment. patients at risk for misusing or diverting their medications for 3. Informed consent: The practitioner should discuss the risks and nonprescription use. Pain management in patients with a history benefits of the use of controlled substances with the patient or of substance abuse or with a comorbid psychiatric disorder may with the patients’ surrogate or guardian if he or she is incompetent require extra care, monitoring, documentation, and consultation or a minor. The patient should receive prescriptions from one with or referral to an expert in the management of such patients. dental care practitioner and one pharmacy, when possible. If the 6. Dental records: The dental clinician should keep accurate and patient has a history of substance abuse, or is currently using, complete records including: the practitioner may employ the use of a written agreement ○○ The medical history and dental examination. between the office and patient, outlining patient responsibilities, ○○ Diagnostic, radiographic, therapeutic, and laboratory results.

Dental.EliteCME.com Page 65 ○○ Evaluations and consultations. dental care practitioners must be licensed in the state and comply ○○ Treatments and treatment objectives. with applicable federal and state regulations. Dental professionals ○○ Discussion of risks and benefits. should refer to The Physician’s Manual of the U.S. DEA (and ○○ Medications (including date, type, dosage, and quantity any relevant documents that may be issued by their state dental prescribed). board) for specific rules governing controlled substances as well ○○ Instructions and agreements. as applicable state regulations. Dental care practitioners are ○○ Periodic reviews. encouraged to use the Automated Prescription System to monitor and report suspected diversions. Records should remain current, be maintained in a recognized 8. Anesthesia: When administering any type of sedation or general SOAP (Subjective, Objective, Assessment, Plan) format, be anesthesia to a patient, dental professionals should refer to accessible, and readily available for review. the ADA’s “Guidelines for the Use of Sedation and General 7. Compliance with controlled substance laws and regulations: Anesthesia by Dentists” and to their State Board of Dentistry’s To prescribe, dispense, or administer controlled substances, the Administrative Rules on sedation and general anesthesia.

Implementing strategies to reduce opioid overprescription Clinicians should be mindful of the inherent abuse potential of opioids, substances the patient is currently prescribed and what has been and comply fully with federal and state regulations regarding the prescribed in the past. Using this technology, local pharmacies and legitimate prescribing and administration of controlled substances by [233]: dental clinicians can identify the doctor prescribing a medication, the ●● Incorporating substance abuse screening into routine practice. pharmacy dispensing it, and a patient’s prescription history [236][237]. ●● Learning the signs and symptoms of substance abuse. Dentists can play a role in minimizing opioid abuse through patient ●● Incorporating standard safeguards for prescribing opioids. education in a number of subject areas [238]. A primary point of concern ●● Educating patients about proper disposal of unused opioids. is the need to convey the dangers of sharing prescription medications ●● Developing a referral network for the treatment of substance with family members or friends. Dental professionals should take the abuse disorders. time to discuss the implication of sharing medications and disposing of Generally, dentists should not prescribe drugs without first examining drugs improperly. the patient and documenting the patient’s condition in his or her dental Explain the environmental repercussions of flushing any medication into record [234]. Requesting a photo ID such as a driver’s license can the toilet or pouring it down a sink. These drugs flow into the nation’s indicate how far an out-of-town patient has traveled to come to the water supply and cannot be filtered out, causing the water supply to office. Patients traveling a significant distance can be asked why they become increasingly medicated. The Office of National Drug Control chose this office rather than one closer to their home [235]. Policy’s guidelines for the disposal of unused or expired prescription drugs instructs patients not to flush prescription drugs down the toilet or In many states, prescription-monitoring programs (PMPs) track drain unless the label or accompanying patient information specifically prescriptions and are able to provide accurate, up-to-date information instructs them to do so. Some areas have established community about the dispensing of controlled substances. Dental professionals can [239] consult these statewide electronic databases to check the controlled prescription drug return programs, which accept donations .

Pain management Because opioid abusers develop a tolerance to the drug’s analgesic involving pain. Nonopioid analgesic agents should be considered the effects, it can be very difficult to manage their dental pain.There are first option in alternative strategies for addressing acute short-term risks and treatment concerns not only for current drug users, but also pain. If appropriate, a long-acting anesthetic, such as bupivacaine, patients in recovery. Patients with histories of substance abuse include can be used to address localized pain for a longer period. NSAID those who currently abuse, former abusers, those in drug-free recovery analgesics can be very effective for postoperative, as well as or rehabilitation, and those in treatment programs that administer prophylactic use, for moderate pain. In studies comparing patients methadone or buprenorphine [240]. If the patient is in recovery for using NSAIDs and opioids following dental impaction surgery, opioid abuse, administering or prescribing an opioid‐containing some patients found ibuprofen and naproxen, taken for an average analgesic can potentially cause relapse [241]. period of 4 to 6 days, as effective as opioid analgesics in addressing It is best for the patient’s welfare if dental professionals can identify postoperative symptoms of sensitivity or pain. Postoperative communication and follow-up with the patient are critical to ensure the current and former users, and determine their status in the recovery [243][244] process. Opioid abuse poses unique challenges for pain management; patient is not experiencing any discomfort or pain . dental professionals must ensure that the analgesic effects of the drug Nonopioid pain relievers, such as NSAIDs, do not produce tolerance or are sufficient, without exposing the patient to any unnecessary risks. It physical dependence and are not associated with abuse or addiction, but is highly recommended that dentists [242]: have an upper threshold where additional medication will not produce ●● Consult with these patients’ primary care physicians or substance additional analgesic effects. This is called the ceiling effect. abuse treatment centers to coordinate treatment. This upper threshold makes nonopioids inappropriate for severe pain in ●● Work with patients’ family members or support networks. This is most people. Opioids do not have a ceiling effect; more taken means more crucial if a family member or other trusted individual is required to pain relief. However, after a point, excessive amounts will likely result dispense controlled medication to the patient. in overdose. When indicated, opioids are an extremely important tool Encourage patients to seek support and professional care in treatment for addressing dental pain, but should not be prescribed indiscriminately, programs before and after dental procedures, especially those especially if a nonopioid analgesic can instead be used [245].

Methadone and buprenorphine Methadone and buprenorphine are prescription drugs primarily known to treat chronic pain; while methadone use is associated with increased as treatments for withdrawal from opioid addiction. Methadone risk of arrhythmia, anecdotal evidence suggests adverse events and maintenance therapy, for example, is one method in which a controlled fatalities associated with its use occur more often among those taking substance is used in combination with therapeutic practices, such as methadone for chronic pain, rather than assistance in recovery [246]. counseling, to control withdrawal symptoms. Both drugs are also used

Page 66 Dental.EliteCME.com A chief concern in treating patients receiving buprenorphine or effects than natural opioids as they do not allow blood opioid levels methadone maintenance therapy is adequately managing their pain to drop between doses, as occurs in natural opioid use. Because the and minimizing risks associated with the drug. An opioid analgesic mouth is deprived of saliva for even longer periods, there is more (including heroin, methadone, or buprenorphine) should never be potential for decay and other adverse effects [248]. combined with alcohol or other prescribed medications. Drugs that Dental professionals can recommend products that relieve dry mouth, pose a high risk of drug interaction include fluvoxamine, which encourage the patient to drink plenty of water, use sugarless gum or increases the patient’s exposure to methadone by inhibiting its candy to increase saliva, tend to personal oral hygiene, and see a dental metabolism, and Lopinavir/ritonavir [247]. professional regularly. While methadone is available in a sugar-free Methadone and buprenorphine are synthetic opioids, and like natural form, the version containing sugar is more commonly used. Dentists opioids, they reduce saliva. It has been suggested that the long-acting can inform patients that methadone syrup is a risk factor for caries that synthetic opioids used in treatment may have even greater damaging can be reduced by switching to a sugarless version of the drug [249].

Section V: General Intervention Strategies

Identification The dental professional must be aware of the signs of substance use, recommends a caries evaluation as standard protocol in patients who are have the knowledge to recognize and treat dental concerns in patients substance abusers or suspected of excessive drug use [251]. who abuse them, and provide the patient with cessation information. Patients may express their concerns to staff members more readily Identifying many kinds of drug abuse can be difficult because patients than to the dentist, so an educated, empathetic, and nonjudgmental are unlikely to be truthful about their drug use or admit to a drug dental team can be key in encouraging disclosure. Dental hygienists, dependency. The most effective screening and intervention strategies who often spend the most time with patients, can integrate screening require the participation of all office and clinic personnel, who should into their practice. Dentists can review this information and discuss the become competent in recognizing potential signs of abuse, especially issue privately with the patient, if necessary. if a patient is under the influence. The patient’s general appearance, As this course has detailed, many drugs are inherently dangerous behavior, and demeanor before and during the appointment should to oral surfaces and/or diminish the immune system, but infrequent provide clues of substance abuse to the trained eye. dental hygiene, poor diet, and other behavioral factors combine to Dental personnel should review the patient’s medical history carefully, increase the patient’s susceptibility to chronic tooth decay, cracked with the understanding that important information may be missing. teeth, gingivitis, or other forms of gum disease. The severity of these Clinicians should be familiar with the oral symptoms of substance conditions is compounded because substance abusers are likely to abuse discussed in this course including the appearance of poor oral delay seeking professional medical attention for as long as possible, health habits, xerostomia, oral infections and lesions, periodontal until the condition becomes too serious or painful to ignore. disease, missing teeth, and severe decay, with a higher incidence of Denial and fear of discovery are significant barriers to identification caries than nonusers. of substance abuse among patients. Most dentists do not consider Comparison studies examining the effects of heroin, methadone, asking patients directly about their illegal drug use or abuse, even amphetamine, and cannabis on the oral cavity show drug users with when behaviors or physical symptoms strongly suggest substance consistently higher numbers of caries compared with nonusers. Data abuse. To the surprise of many medical professionals, the direct show methamphetamine users having an average of nine times as many approach has proven one of the most effective ways to encourage seriously decayed teeth as nonusers; heroin abusers have five times as patients to disclose illegal drug use. There is strong evidence that the many seriously decayed teeth as nonusers; and cocaine abusers have simple act of asking patients with characteristic oral patterns about four times as many seriously decayed teeth as nonusers [250]. The ADA their use or abuse of drugs would identify many more patients with substance abuse disorders [252].

Management and clinical implications If abuse is suspected, management strategies will depend on the patients may behave erratically or inappropriately, and, in very rare individual’s demeanor. If, for example, he or she appears to be under cases, aggressive or violent. These patients will require additional the influence, shows signs of chronic drug use, or asks any questions attention and care. Scheduling should ensure the dental team has regarding drug abuse or addiction, effective clinical management time to accommodate unexpected incidents, as well as complete the would strongly recommend raising the issue in the most caring and following necessary tasks [254]: therapeutic way possible. All dental facilities should have policies and ●● Unhurried review of the medical history, medical consultations, procedures in place for addressing these situations, as well as other and assessment of the patient’s current status. issues that may arise with a chemically dependent patient [253]. ●● Comprehensive monitoring of vital signs (such as blood pressure), Time management is a common concern with patients who abuse before, during, and after, even very routine treatment. drugs. One of the most common, albeit least dangerous, complaints ●● A caries assessment, according to recommended ADA standards of about patients who are excessive drug or alcohol users, is their care for patients with substance abuse disorders. unpredictable behavior and lack of reliability in keeping appointments. Scheduling concerns pale in comparison to the potential medical risks Patients who abuse drugs are more likely to arrive late or miss associated with undisclosed drug use and abuse. Patients with liver appointments without notice. They may be difficult to contact damage due to drug and alcohol abuse have the potential for excessive regarding appointment reminders or outstanding balances. Chemically bleeding. If this occurs, treatment should be stopped and digital dependent patients are likely to consider dental care a very low priority pressure applied immediately. Referral for medical evaluation and unless they are in pain or the situation becomes critical. blood coagulation testing is necessary before treatment can resume. In scheduling the patient’s appointment, staff should allow sufficient Recommended practices for addressing suspected drug use include time for potential delays (a patient may arrive late, or experience a requiring the individual to sign a statement indicating drugs have not complication or adverse event during the procedure). In rare cases, been used within the previous 24 hours and administration of a saliva

Dental.EliteCME.com Page 67 test or urinary drug test (UDT), if necessary, to ensure the patient’s important that the office institute a policy for checking and recording safety during a procedure [255]. the number of prescription pads, who is taking them, and when they Dentists should establish office policies that reduce the potential for are taken. More than one person should be made responsible for illegal prescription drug use, such as reducing prescription leftovers prescription pad oversight to discourage any office worker or clinician [256]. and keeping prescription pads in a secure, locked location. It is with an opportunity to take one

Screening rationale While many dentists feel questions about drug use are intrusive or ●● The vast majority of individuals addicted to drugs and alcohol go unnecessary, there are a number of important benefits to the patient unidentified and untreated by a health care professional. Routine that make screening an important responsibility of the dental team. screening for substance abuse is likely the most effective strategy Support for screening is based on the following rationale: to identify excessive drug use, protect the patient from unnecessary ●● There is a proven association between many types of substance medical risks, or present a possibility for intervention. abuse and adverse health consequences [257]. ●● Research data support the theory that screening and brief ●● Drug abuse is increasingly common; in 2010, an estimated 9% of intervention can significantly reduce substance abuse among those all individuals aged 12 or older in the United States were current who use alcohol and tobacco. There is strong evidence to suggest illegal drug users, with about one in five between the ages of 18 the same benefits of screening and brief intervention would assist and 25 reporting use of an illegal drug in the past month [258]. in identification and intervention of illegal substance abuse, including nonmedical prescription drug use [259]. Screening methods and practices Most medical and health history forms include a section devoted Dental care professionals familiar with the devastating effects of to drug use, but it is estimated that half of patients do not disclose substance abuse on oral health are more likely to participate in information about their history due to feelings of shame, fear of intervention efforts and offer cessation assistance because they see a judgment, and concern about legal prosecution. Because the interaction clear link between the patient’s drug-taking behavior and the painful between commonly abused drugs and those used in professional dental and physically damaging results. care is potentially very hazardous (e.g., cocaine and vasoconstrictors An encouraging finding from a study of participants in substance in local anesthetics), office staff and dental team members must rely abuse treatment noted that patients referred to treatment by their on other clues to ascertain if a patient is using excessive amounts doctors reported improved general and mental health, employment of a drug. All members of the dental team and office staff should and housing status, and less illegal behavior after the intervention. familiarize themselves (ideally through office- or clinic-sponsored Acting in the patient’s best interests to ensure his or her well-being is training) with the signs of drug abuse. In some cases, urine or saliva the dental professional’s ethical obligation and central to all health care drug testing may be necessary to know conclusively if the patient used professions. Learning to talk about drug use with a patient can be the drugs in the critical timeframe before a dental appointment [260]. first step in getting them help. Because dentists frequently develop long-term relationships with Some dentists choose not to ask because they assume the patient does patients, they are in a unique position to assist in public health efforts not seem like a drug user. It is important to note that an individual’s to screen for substance abuse and direct patients to available resources. preconceived notions regarding substance abuse and abusers can inhibit Although brief interventions provide a real possibility for improving his or her ability to recognize actual abuse or addiction in a patient. patient outcomes by addressing excessive drug use, a recent study Excessive drug users can be highly functional, capable individuals, found one-third of all dentists do not ask questions regarding current whose pattern of substance use is known only to the people closest or past substance abuse, missing a crucial opportunity to address a to them. Those who have a family member with a personal history of potential health risk [261]. drug abuse, or are themselves in recovery, are likely to have a special Many dental professionals find it difficult to ask a patient about his awareness or sensitivity to symptoms of addiction. or her illegal drug use. Some dental professionals are concerned In some cases, dentists prefer not to ask about illegal drug use about prying, particularly if he or she does not see a direct connection because they are unsure how to respond to an affirmative answer. The between excessive drug use and potentially adverse consequences. following sections discuss some common intervention strategies. Educational interventions Excessive drug users have long had a reputation for poor oral similar brushing frequency and duration. The drug-using group did hygiene habits, as well as other behaviors that exacerbate the already not benefit from their brushing and flossing practices to the degree negative effect of substance abuse on the teeth and gums. Those the nonusers did, because the counterbalancing effects of xerostomia who experience oral pain may find it excruciating to brush and floss. outweighed the benefits from good oral hygiene. These findings Excessive drug use is likely to minimize or numb the pain, allowing suggest that the combination of less effective dental hygiene habits, the individual to ignore his or her dental condition even longer, until possibly due to impaired motor activity, and reduced saliva flow it progresses to an extreme state [262]. negatively reinforce one another, creating increased oral decay and Because the dental condition of substance abusers often appears neglected, disease among substance abusers. many have hypothesized that drug abusers had little interest or concern in Many drugs stimulate a sweet tooth, leading to consumption of higher maintaining good oral hygiene. Findings from a recent study suggest this levels of refined carbohydrates in snacks, alcoholic beverages, and may not be the case, providing strong evidence that good oral health and soft drinks, which demineralize tooth enamel. The majority of sugary the appearance of teeth are important to alcohol and drug abusers. Data snacks are consumed late in the day, which combined with a lack of also suggest financial/economic factors are a primary reason substance nighttime brushing and flossing before going to sleep, causing rapid abusers do not seek necessary treatment for dental care [263]. build-up of plaque and calculi. The study found that similar oral hygiene habits in drug users If a drug-dependent patient presents for dental treatment and chooses compared with nonusers yielded strikingly different results; alcoholics to discuss his or her current dependency, provide a safe, accepting and drug abusers brushed less effectively than nonusers, despite environment for discussion. Having support materials on hand from Page 68 Dental.EliteCME.com a resource such as Narcotics Anonymous (NA)at http://www.na.org/, It is important for the dental team to provide informational materials can provide a link to that support system. Further communication regarding substance abuse, and support the patient’s efforts to stop using. suggestions are available on the websites for Partnership for a Drug- Educational interventions can include teaching good oral hygiene practices, Free America (http://www.drugfree.org/) and The National Registry of observing the patient brushing and flossing, and suggesting changes in Evidence-based Programs and Practices (NREPP), a searchable online the patient’s diet and routine that might reduce decay. Education is not database of mental health and substance abuse interventions, at http:// just for the patient. Training in effective intervention should include all www.nrepp.samhsa.gov/. (Licensed Alcohol, Tobacco, and Other Drug members of the dental office team, including dentists, hygienists, assistants, (ATOD) treatment facilities are available in most communities [264]). receptionists, and other office and medical personnel. Brief intervention Screening and brief intervention provide an opportunity for A’s create a helpful structure for a brief intervention in the form of a short dental professionals to address drug abuse as early as possible, to conversation, which may be useful in screening for drug use [266]. They are: communicate its risks, and reduce the consequences of excessive use ●● Ask one or more questions related to drug use. for general and dental health. ●● Advise the patient to make a change or quit if drug use is likely to cause the individual’s health to suffer. Studies suggest many more patients are amenable to discussing ●● Assess the patient’s willingness to change his or her behavior. substance abuse with their dentists than are approached with the topic. ●● Assist the patient in making a change or quitting if he or she About half of general dentists provide their patients with tobacco appears amenable. cessation information, but far fewer raise the issue of alcohol or drug ●● Arrange a referral for further assessment and treatment, and/or a dependency. Many dentists hesitate to screen for drug abuse because follow-up appointment, as appropriate. they feel patients will find it unacceptable, although data suggest the majority of patients would welcome screening and referrals for The 5 A’s are widely accepted as the standard for tobacco cessation substance abuse from dental care practitioners. These results suggest interventions, and have proven useful for many other types of that not implementing drug use screening and brief intervention in a substance abuse. In the medical sector, a model for screening, brief dental practice represents a lost opportunity to prevent the potential intervention, referral, and treatment (SBIRT) has proven effective in health risks that are associated with substance abuse [265]. reducing rates of drug and alcohol abuse among patients. The program, In 2000, a study by the U.S. Public Health Service released revised which is integrated with reimbursable insurance Current Procedural clinical practice guidelines, recommending medical professionals Terminology (CPT), Medicare G, and Medicaid coding systems, and health care organizations implement a new treatment model for is intended to make screening for substance abuse a routine part of addressing dependence in a health care setting, known as the The Five medical care. Implementing similarly structured programs in the dental [267]. A’s of Intervention or 5 A’s (ask, advise, assess, assist, arrange). The 5 sector could prove very useful Making referrals Dentists have an ethical obligation to discuss their concerns about Substance Abuse Treatment Facility Locator, at http://findtreatment. substance abuse with their patients and recommend individuals and samhsa.gov, which lists local community treatment centers and organizations that provide the best services and care for the patient. resources[269]. The ADA also provides materials and guidelines for This action is consistent with the ADA’s Principles of Ethics and Code discussing drug use with patients and providing referrals [270]. of Professional Conduct, which states that “dentists shall be obliged When referring a patient to a treatment program or substance abuse to seek consultation, if possible, whenever the welfare of patients will specialist, the practitioner should use the same manner and wording be safeguarded or advanced by using those who have special skills, used to refer them to any other type of specialist: [268]. knowledge and experience” ●● Express and explain concerns. If a drug-using patient presents for dental treatment and wants to ●● Ask the patient if he or she is agreeable to a referral. discuss his or her chemical dependency, it is important to provide a ●● Provide the name of the referral, his or her area of expertise, safe accepting environment. The dental team should make the referral in pertinent information including any charges associated with process as easy and convenient as possible, with an established services, if there is a wait time required for an appointment, referral protocol already in place. Resources for addiction services whether insurance applies, and the best way to contact the include state dental societies, local hospitals, and state governments. individual or schedule an appointment. Clinicians can refer to The Substance Abuse and Mental Health ●● Contact the patient or referral to see if the patient made an Services Administration (SAMHSA) website (http://www.samhsa. appointment. gov/) for treatment and referral recommendations, and SAMHSA’s Communication with other caregivers Communication and collaboration among all health care professionals ●● With whom it will be shared. and family members is the best-case scenario for ensuring the ●● The timeframe for which the authorization is valid. patient’s interests are served. Freedom of information among medical The written approval must be on a privacy authorization form personal is limited by state and federal privacy laws that safeguard the that conforms to all applicable state and federal requirements for confidentiality of patient records and limit the disclosure of protected safeguarding the confidentiality of patient records. health information to other health care professionals treating the patient. Patients who choose not to release personal information to another Current privacy regulations such as the Health Insurance Portability medical professional can put a dentist in an untenable position; the and Accountability Act (HIPAA), United States Code of Federal practitioner is ethically bound to respect the patient’s privacy, but also Regulations, Title 42 (42 C.F.R.), governing confidentiality of professionally obligated to ensure the patient’s physical well-being. substance abuse treatment records, ) and many state laws, require a Specialists who have relatively short-term relationships with patients patient authorizing release of his or her personal information to sign a may not recognize the signs of substance abuse that the family dentist form specifying [271]: knows. The clinician who knows his or her patient is a substance ●● The particular information to be released. abuser and is seeking treatment from an oral or maxillofacial surgeon, ●● The reason for its release.

Dental.EliteCME.com Page 69 but does not disclose this information to the surgeon potentially puts standards, or implementation specifications of the more stringent rule the patient at increased risk of complications and adverse outcomes. (the law more protective of privacy) should apply [274]. If drug or alcohol use exposes the patient to higher rates of risk for In summary, HIPAA provides the following: any treatment or procedure, the dental professional has an obligation ●● It permits widespread sharing of treatment information without to share this information in an appropriate, respectful manner with the consent (with the exception of psychotherapy files). other medical professional. This communication is approved under ●● The substance abuse confidentiality law does not permit sharing HIPAA (45 C.F.R. § 164.502), which states that a health care provider of records relating to substance abuse treatment or rehabilitation can disclose protected health information for treatment purposes [272][273] organizations conducted, regulated, or funded by the federal without patient consent . government, without consent, except within a program or with an C.F.R. § 164.506(c) (1) and (2) Treatment is defined as: entity with administrative control over a program. “… the provision, coordination, or management of health care and ●● Whenever a state law is more protective of privacy than the federal related services by one or more health care providers, including the HIPAA regulations or the federal substance abuse confidentiality coordination or management of health care by a health care provider statute and regulations, the state law takes precedence (the more with a third party; consultation between health care providers stringent law applies). relating to a patient; or the referral of a patient for health care from In nearly all situations, the patient should be informed about and one health care provider to another” (45 C.F.R. § 164.501). authorize communication between his or her health care professionals. In cases where there is a conflict between two applicable laws, such as Sharing information without the patient’s consent should only occur in state and federal regulation of information disclosure, or the privacy very rare cases, when absolutely necessary. law and substance abuse law, HIPAA provides that the requirements, Dental professionals who abuse drugs or alcohol Ten to fifteen percent of dentists are likely to develop a physical It is unethical to practice dentistry while under the influence of dependency on drugs or alcohol at some point in their lives [275]. Other substances that impair the ability to practice. Dentists who have first- clinic and office personnel also have the potential to abuse drugs.To hand knowledge of a colleague’s impairment are obligated to report the clarify and affirm a commitment to a drug-free workplace for patients violation to a dentist assistance program or the state licensing board. The and employees, the facility should have a written policy strictly ADA‘s Principles of Ethics and Code of Professional Conduct states: prohibiting employees from using or being under the influence of “It is unethical for a dentist to practice while abusing controlled alcohol or drugs at work, and stating that any employee engaging in substances, alcohol or other chemical agents which impair the the illegal diversion, sale, possession, or use of a controlled substance ability to practice. All dentists have an ethical obligation to urge may be subject to immediate termination. chemically impaired colleagues to seek treatment. Dentists with Current research in drug abuse and treatment stresses that a punitive first-hand knowledge that a colleague is practicing dentistry when environment is likely to discourage disclosure of illegal activities. so impaired have an ethical responsibility to report such evidence [276].” The policy must recognize drug dependency and alcoholism as health to the professional assistance committee of a dental society problems, and personnel must act accordingly. The office should Services are available in most states for dentists at risk of or commit to providing help to any chemically dependent employee who experiencing impairment. Resources are listed at the ADA website, seeks it, and protect the individual’s position in the same way as an Substance Use Disorders page, at http://www.ada.org/4503.aspx. All employee with any other illness. 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Oral Health Prev Dent 2005;3(3):189-195. 218. Results from the 2009 National Survey on Drug Use and Health; vol 1. 168. Rhodus NL, Little JW. Methampheamine abuse and “meth mouth”. Northwest Dent 2005;84:29,31,33- 219. Gutierrez T, Drash W. Using dentists as dope dealers. “http://articles.cnn.com/2009-07-1/us/dental. 37. doping_1_problem-of-prescription-drug-dentist-painkillers?_s=PM:US”. 169. Shaner JW. Caries associated with methamphetamine abuse. J Mich Dent Assoc 2002 Sept;84(9):42-47. 220. Solaiman T., Drug seekers: protect yourself from patients who abuse pain medications. Hawaii Dent J 170. Peroutka SJ, Newman H, Harris H. Subjective effects of 3,4 methylenedioxy methamphetamine in 2009;40(5):13. recreational users. Neuropsychopharmacology 1988; 1: 273–277 221. Rosse RB, Fay-McCarthy M, Collins JP Jr, Risher-Flowers D, Alim TN, Deutsch SI, Transient 171. Rose, Mark BS, MA, Patterns of methamphetamine abuse and their consequences. J Addict Dis. compulsive foraging behavior associated with crack cocaine use. Am J Psychiatry. 1993;150(1):155. 2002;21(1):21-34. 222. Wentworth RB. What should I do when I suspect a patient may be abusing prescription drugs? JADA 172. Shaner 2008;139(5):623–624. 173. Methamphetamine Abuse Undermines Dental Health Oral Dis. 2009 Jan;15(1):27-37. Epub 2008 Sep 25. 223. Fung EY, Giannini PJ. Implications of drug dependence on dental patient management. Gen Dent 174. Donaldson M, Goodchild JH. Oral health of the methamphetamine abuser (published correction appears 2010;58(3):236–241. in Am J Health Syst Pharm 2006;63(22):2180). Am J Health Syst Pharm 2006;63(21):20178-2082. 224. Moore PA, Nahouraii HS, Zovko JG, Wisniewski SR. Dental therapeutic practice patterns in the U.S., II: 175. Lineberry TW, Bostwick JM. Methamphetamine abuse: a perfect storm of complications. Mayo Clin Proc analgesics, corticosteroids, and antibiotics. Gen Dent 2006;54(3):201–207. January 2006;81(1):77-84 225. Rigoni GC. Drug Utilization for Immediate- and Modified Release Opioids in the US. Silver Spring, Md.: 176. Curtis EK. Meth mouth: A review of methamphetamine abuse and its oral manifestations. General Division of Surveillance, Research & Communication Support, Office of Drug Safety, Food and Drug Dentistry. 2006;54:125–129. [quiz 130] Administration; 2003. www.fda.gov/ohrms/DOCKETS/ac/03/slides/3978S1_05_Rigoni.ppt. 177. Vivek Shetty, DDS, Dr. Larissa J. Mooney, MD, Mr. Corwin M. Zigler, MA. Thomas R. Belin, Debra 226. Savage S, Covington EC, Gilson AM, Gourlay D, Heit HA, Hunt JB. 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Page 72 Dental.EliteCME.com 227. Donaldson M, Goodchild JH. Appropriate analgesic prescribing for the general dentist. Gen Dent 257. Babor, T.F.; McRee, B.G.; Kassebaum, P.A.; Grimaldi, P.L.; Ahmed, and K.;Bray, J.; Screening, brief 2010;58(4):291–297. intervention, and referral to treatment (SBIRT): toward a public health approach to the management of 228. Moore. substance abuse. Substance Abuse. 28: 7-30, 2007. 229. Centers for Disease Control and Prevention Adult use of prescription opioid pain medications: Utah, 258. Madras, B.K. ; Compton, W.M. ; Avula, D. ; Stegbauer, T.; Stein, J.B.; and Clark, W.H. Screening, brief 2008. MMWR Morb Mortal Wkly Rep 2010;59(6):153–157. interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: 230. Biron RT, Hersh EV, Barber HD, Seckinger RJ. A pilot investigation: post-surgical analgesic Comparison at intake and 6 months later. Drug and Alcohol Depend 99: 280-95. 2009.http://www.ncbi. consumption by dental implant patients. Dentistry 1996;16(3):12–13. nlm.nih.gov/pubmed/18929451. 231. Savage. 259. Center for Substance Abuse Treatment. Alcohol Screening and Brief Intervention (SBI) for Trauma 232. Health Care Association of New Jersey (HCANJ)Pain management guideline. Adapted from Health Care Patients: Committee on Trauma Quick Guide, Substance Abuse and Mental Health Services Association of New Jersey (HCANJ). Pain management guideline. Hamilton (NJ):; 2006 Jul 18. 23 p. Administration, DHHS Publication No. (SMA) 07-4266. Washington, DC: U.S. Government Printing http://www.guideline.gov/content.aspx?id=9744. Office, 2007. http://www.samhsa.gov/csatdisasterrecovery/featuredReports/01-alcohol%20SBI%20 233. American Dental Association. ADA Current Policies: Adopted 1954–2009—Substance Use Disorders for%20Trauma%20Patients.pdf (PDF, 7.8MB). Statement on the Use of Opioids in the Treatment of Dental Pain. Chicago: American Dental Association; 260. Humeniuk, R.; Dennington, V.; Ali, R.; and WHO ASSIST Phase III Study Group. The Effectiveness of a 2010:227. Brief Intervention for Illicit Drugs Linked to the ASSIST Screening Test in Primary Health Care Settings: 234. Schulte D . Prescribe pain medication only to patients of record. J Mich Dent Assoc 2010;92(7):16. A Technical Report of Phase III Findings of the WHO ASSIST Randomized Controlled Trial (Draft). 235. O’Neil M, Lilly JK, Lafauci M. A comprehensive checklist for the prevention & management of the drug Geneva, Switzerland, 2008. seeking patient. W Va Med J 2010;106(4 special issue):54–55. 261. Denisco, Richard C. MD, MPH George A. Kenna, PhD, RPh Michael G. O’Neil, PharmD Ronald 236. Wentworth. J. Kulich, PhD Paul A. Moore, DMD, PhD, MPH William T. Kane, DDS, MBA Noshir R. Mehta, 237. Alliance of States With Prescription Monitoring Programs. Status of Prescription Monitoring Programs DMD, MDS, MSElliot V. Hersh, DMD, MS, PhD Nathaniel P. Katz, MD, MS Prevention of (PDMPs). www.pmpalliance.org/pdf/pmpstatusmap2011.pdf prescription opioid abuse; The role of the dentist; The Journal of the American Dental Association, (July 238. Denisco RC, Kenna GA, O’Neil MG, Kulich RJ, Moore PA, Kane WT, Mehta NR, Hersh EV, Katz 1, 2011) 142, 800-810. NP. Graham CH Meechan JG, , Dental management of patients taking methadone. Dent Update. 2005 262. McGrath C, Chan B. Oral health sensations associated with illicit drug abuse. Br Dent J 2005 Feb Oct;32(8):477-8, 481-2, 485. 12;198(3):159-162. 239. Office of National Drug Control Policy. Proper disposal of prescription drugs: Federal guidelines— 263. Khocht, Ahmed , D.D.S. Steven J. Schleifer, M.D. Malvin N. Janal, Ph.D.Katz NP, Adams EH, Chilcoat October 2009. www.whitehousedrugpolicy.gov/publications/pdf/prescrip_disposal.pdf. H, Dental care and oral disease in alcohol-dependent persons , Journal of Substance Abuse Treatment 240. Hersh EV, Kane WT, O’Neil MG, et al. Prescribing recommendations for the treatment of acute pain in Volume 37, Issue 2 , Pages 214-218, September 2009. dentistry. Compend Contin Educ Dent 2011;32(3):22, 24–30. 264. Bullock K. Dental care of patients with substance abuse. Dent Clin North Am 1999;43(3):513–526. 241. Substance Abuse and Mental Health Services Administration, HHS publication SMA 10-4486. 265. Cornuz J, Ghali WA, Di CD, Pecoud A, Paccaud F. Physicians’ attitudes towards prevention: importance 242. Lindroth JE, Herren MC, Falace DA. The management of acute dental pain in the recovering alcoholic. of intervention-specific barriers and physicians’ health habits. Fam Pract. 2000;17(6):535–40. December. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95(4):432–436. 266. Agency for Healthcare Research and Quality, Five Major Steps to Intervention (The “5 A’s”). 243. Hersh EV, Cooper S, Betts N, et al. Single dose and multidose analgesic study of ibuprofen and December 2012. Rockville, MD. http://www.ahrq.gov/professionals/clinicians-providers/guidelines- meclofenamate sodium after third molar surgery. Oral Surg Oral Med Oral Pathol 1993;76(6):680–687. recommendations/tobacco/5steps.html. 244. Donaldson M, Goodchild JH.. 267. Babor. 245. Becker DE. Pain management, part 1: managing acute and postoperative dental pain. Anesth Prog 268. American Dental Association. American Dental Association principles of ethics and code of professional 2010;57(2):67–78. conduct, with official advisory opinions revised to January 2011. Chicago: American Dental Association; 246. Denisco. 2010:5. 247. Nathwani NS, Gallagher JE. Methadone: dental risks and preventive action. Dent Update. 2008 269. Substance Abuse and Mental Health Services Administration. Substance abuse treatment: facility locator. Oct;35(8):542-4, 547-8. http://findtreatment.samhsa.gov/. 248. Office of National Drug Control Policy. National Drug Control Strategy: 2010. Rockville, Md.: Office 270. American Dental Association. Oral health topics: drug use: talking with your patients—dentist version. of National Drug Control Policy; 2010 U.S. Department of Justice, Drug Enforcement Administration, www.ada.org/2663.aspx#talking. Office of Diversion Control. Practitioner’s Manual: An Informational Outline of the Controlled 271. Institute of Medicine (US) Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Substances Act. Washington: U.S. Government printing Office; 2006. Addictive Disorders. Improving the Quality of Health Care for Mental and Substance-Use Conditions: 249. Brondani, Mario, DDS, MSc, PhD and Peter Earl Park, J Dent Hyg Methadone and Oral Health – A Quality Chasm Series. Washington (DC): National Academies Press (US); 2006. Appendix B, Constraints Brief Review Spring 2011 vol. 85 no. 2 92-98. on Sharing Mental Health and Substance-Use Treatment Information Imposed by Federal and State 250. Rees. Medical Records Privacy Laws. https://www.ncbi.nlm.nih.gov/books/NBK19829/. 251. Guzmán-Armstrong, Sandra D.D.S., M.S. and John J. Warren, D.D.S., M.S. Management of High Caries 272. Confidentiality of Alcohol and Substance Abuse Patient Records regulation (42 CFR Part 2)TITLE Risk and High Caries Activity Patients: Rampant Caries Control Program (RCCP) Journal of Dental 42—Public Health Chapter I—Public Health Service, Department of Health And Human Services Education June 1, 2007 vol. 71 no. 6 767-775. Subchapter A—General Provisions Part 2—Confidentiality of Alcohol And Drug Abuse Patient Records 252. Pallasch TJ, Joseph CE. Oral manifestations of drug abuse. J Psychoactive Drug 1987: 19: 375–377. Government Printing Office http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&sid=02b3d31742318b503b8d4 253. Sandler NA. Patients who abuse drugs. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:12- ba0111d0e35&tpl=/ecfrbrowse/Title42/42cfr2_main_02.tpl. 14. 273. he Confidentiality of Alcohol and Drug Abuse Patient Records Regulation and the HIPAA Privacy 254. Shapiro S, Pollack BR, Gallant D. The Oral health of narcotic addicts. J Pub Health Dent Rule: Implications for Alcohol and Substance Abuse Programs U.S.Department of Health and 1970;49(6):1556. Human Services Substance Abuse and Mental Health Services AdministrationCenter for Substance 255. Gourlay DL, Heit HA, Caplan YH. Urine Drug Testing in Clinical Practice: The Art and Science of Abuse Treatment www.samhsa.gov http://www.samhsa.gov/HealthPrivacy/docs/SAMHSAPart2- Patient Care. 4th ed. Stamford, Conn.: PharmaCom Group; 2010. HIPAAComparison2004.pdf. 256. Substance Abuse and Mental Health Services Administration. (2010). Results from the 2009 National 274. 65 Fed. Reg. 82462, 82482–8248; 45 C.F.R. § 160. (42 U.S.C. § 1320d-2(c)(2). Survey on Drug Use and Health: Volume I. Summary of National Findings (Office of Applied Studies, 275. American Dental Association, Substance Use Disorders http://www.ada.org/4503.aspx. NSDUH Series H-38A, HHS Publication No. SMA 10-4586 Findings). Rockville, MD. http://www.oas. 276. American Dental Association. American Dental Association principles of ethics and code of professional samhsa.gov/NSDUH/2k10NSDUH/tabs/Sect1peTabs1to46.htm#Tab1.1A. http://www.oas.samhsa.gov/ conduct, with official advisory opinions revised to January 2011. Chicago: American Dental Association: NSDUH/2k10NSDUH/tabs/Sect1peTabs1to46.htm#Tab1.1B. Principle: Nonmaleficence, 2.D. A DENTAL PROFESSIONAL’S FIELD GUIDE TO SUBSTANCE ABUSE Final Examination Questions Select the best answer for each question and mark your answers on the online at Dental.EliteCME.com.

1. According to the U.S. National Survey on Drug Use and Health, 3. According to the 2010 National Survey on Drug Use and Health, about 22 million people aged 12 and older could be classified as about ______of all individuals in the United States aged substance abusers or substance-dependent. The majority (about 15 12 years and older have used at least one form of tobacco. million) are dependent on: a. One-fifth. a. Alcohol. b. One-quarter. b. Alcohol and one or more illegal drugs. c. One-third. c. One or more illegal drugs, but not alcohol. d. One-half. d. Prescription drugs. 4. Of the millions of smokers who vow to quit smoking each year, 2. One recent study found almost ______of all survey more than ______are likely to relapse within 1 week. respondents were not completely truthful on medical forms due to a. 25%. fear of possible embarrassment or judgment by those seeing the b. 35%. form, concerns related to insurance coverage, or general privacy c. 35%. issues. d. 85%. a. One-fifth. b. One-quarter. c. One-third. d. One-half.

Dental.EliteCME.com Page 73 5. Which of the following groups does not show a higher rate of 13. Which of the following physical effects is not associated with smokeless tobacco use than the general public? cocaine ingestion? a. Caucasian males living in Southern United States, between the a. Vasodilation. ages of 10 and 30 years of age. b. Oral lesions. b. White-collar office workers. c. Excessive hemorrhage after tooth extraction. c. Native American men and women living in Canada and d. Increased number of dental caries. Alaska. d. Military personnel. 14. Which of the following is not contraindicated for patients who use cocaine? 6. ______is the most popular form of smokeless tobacco, a. Local anesthetic with vasoconstrictors. with about 75% of the market. b. Epinephrine-impregnated retraction cords. a. Moist snuff. c. Lidocaine. b. Chewing tobacco. d. General anesthesia for patients with normal cardiovascular c. Dry snuff. function. d. Plug. 15. Which of the following is not slang, or a more common term, for 7. Which of the following is the only type of alcohol than can be the drug, 3-4 methylenedioxymethamphetamine? consumed? a. Ecstasy. a. Methyl. b. MDMA. b. Butanol. c. Meth. c. Ethyl. d. Molly. d. Bethyl. 16. Which of the following is not a physical effect of opioid abuse? 8. Recent survey data showed about ______of people aged a. Hormonal dysfunction. 12 or older report binge drinking on a regular basis. b. Hyperalgia. a. 10 million. c. Diarrhea. b. 30 million. d. Slow respiration due to CNS depression. c. 60 million. d. 80 million. 17. Which of the following psychotherapeutic medications is most commonly abused? 9. Which of the following is not a common physical symptom of a. Stimulants. excessive alcohol consumption? b. Pain relievers. a. A coated tongue and significant deposits of plaque and calculi. c. Tranquilizers. b. Shrunken parotid salivary glands. d. Sedatives. c. Xerostomia. d. Signs of bruxism and tooth erosion. 18. Dentists prescribe ______of all immediate-release (IR) opioid mediation in the United States. 10. Which of the following does not typically pose an elevated risk of a. 6%. complications for the patient who abuses alcohol? b. 10%. a. Central nervous system (CNS) depressants, such as sedatives c. 12%. and narcotics. d. 15%. b. Benzodiazepines. c. Amide-based local anesthetics. 19. A 2008 study of opioid prescriptions showed ______d. Vasoconstrictors. of respondents who were prescribed an opioid had leftover medication. 11. Which of the following hazardous substances can be found in a. 17%. cigarette smoke but not in marijuana smoke? b. 22%. a. Tar. c. 56%. b. Nicotine. d. 72%. c. Nitrosomes. d. Carcinogens. 20. Which of the following is a characteristic of non-opioid analgesics? 12. Which of the following is not a stimulant? a. A ceiling effect. a. Caffeine. b. A high. b. Cocaine. c. Constipation. c. Methamphetamine. d. Physical dependence. d. Benzodiazepine.

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Page 74 Dental.EliteCME.com Chapter 3: Medical Emergencies in the Dental Office

4 CE Hours

By: Elite Staff

Learning objectives ŠŠ Identify medical emergencies that may occur in a dental practice. ŠŠ Describe how to position a patient who is experiencing a medical ŠŠ Recognize symptoms of specific medical conditions. emergency. ŠŠ Describe warning signs that can occur before a medical ŠŠ Define an office emergency action plan. emergency. ŠŠ List essential equipment and medications that should be kept in an ŠŠ Identify situations that should cause a delay in dental care. in-office emergency kit. Introduction Medical emergencies happen every day. They come unexpectedly In this course, we will discuss common emergencies that one might and are something that health care providers never like to experience. encounter when interacting with dental patients as well as steps that As health care professionals, how dental team members manage should be taken to ensure that all of the bases are covered, including emergencies in their offices is crucial. responsibilities, safety measures, and accident prevention. From Because most instances catch people off guard, preparing ahead of time the moment your patient begins having health troubles until the for an emergency is important. An established plan of action, emergency paramedics arrive, there is a crucial window of time where you as the kit and game plan can help the dental office operate at a higher level of health care provider are responsible for their care and well-being. efficiency and care for patients in need.

Common emergencies that occur in a dental practice setting There is a wide range of emergencies that dental professionals have Identifying the warning signs of these medical related emergencies is experienced in their offices. Falls, head trauma, foreign objects in the essential. By being aware of precursors and risks that make patients eye and physical accidents may occur. However, we will limit this susceptible to emergencies, you can refer them to medical services in course to cover medical emergencies that are related to underlying a timely manner. Unfortunately, even with thorough patient screening, health conditions that predispose people to experiencing medical if you work in an office long enough, you will probably have a patient problems. By understanding the signs and symptoms of an emergency experience one or more of the following medical emergencies when as it is occurring, a dental professional can identify the proper method you work in a practice setting. of care, intervention, and if at all possible, prevention of the episode. Cardiovascular arrest and chest pain Chest pain, cardiac arrest or other forms of tightness in the chest are Heart attack symptoms in female patients can include [2]: cause for alarm. While some forms of discomfort may be nothing other ●● Upper body discomfort in the neck, back, jaw and shoulders. than something such as GERD or anxiety, chest pain can be a sign of a ●● Fatigue and weakness due to decreased oxygen flow. serious health condition. ●● Sleep disturbances from a partially blocked airway. ●● Nausea or indigestion because the stomach and heart are sharing The discomfort may not necessarily be a sharp, painful feeling, but similar nerve supplies. the person may instead feel as if his or her chest is being squeezed or ●● Shortness of breath even during a period of rest because of under pressure. Chest pain results from the artery becoming narrow, decreased heart pumping. blocking oxygenated blood from chest muscles and the heart. Quick ●● Anxiety, rapid heartbeat and perspiration. response to heart attack symptoms is important for the life of your patient, because it’s estimated that approximately half of all heart Patients who are experiencing chest pain should be allowed to rest in attack patients will die in the first hours after their attack. any position they find comfortable, which is usually sitting upright. Based on the patient’s health history, determine whether he or she has Classic heart attack symptoms usually include: a history of heart problems. If the patient has never experienced this ●● Chest pain or pressure. type of feeling before, then EMS should be notified so the person can ●● Shortness of breath. be taken to the hospital. ●● Pain or numbness through the arms, shoulders, jaw, neck, back or upper abdomen. Pain that isn’t severe or elevated blood pressure may be angina ●● Nausea. pectoris instead of a myocardial infarction. If the pain continues ●● Perspiration. through the left side of the body, such as the arm, or blood pressure falls sharply below what the patient’s normal baseline value is, then Women may suffer from atypical heart attack symptoms that are unlike the patient is likely experiencing a heart attack. classic symptoms of chest pain experienced by men. They may not have any chest pain at all. Because of the differences in symptoms, If the patient is experiencing a heart attack, you should contact EMS women may take longer to diagnose as having a heart attack. It is immediately. The patient may be given a single dose of aspirin, and then estimated that women have as long as a 15-minute delay in seeking a dose of nitroglycerine from an emergency kit can be administered every care because of the differences in symptoms [1]. five minutes. Some first-time nitroglycerine users may experience low

Dental.EliteCME.com Page 75 blood pressure, so placing them in a supine position can help them relax. An unconscious patient experiencing a cardiovascular attack may The patient may also be placed on a 50:50 nitrous oxide and oxygen exhibit spontaneous breathing. Check the patient’s vital signs and delivery [3]. initiate CPR if necessary until the paramedics arrive and take over the situation.

Loss of consciousness, fainting, syncope Patients may faint for any number of reasons, and that may be the cause for a minute or two before excusing them from the chair. Help patients of more than half of all dental office emergencies. Drug use, seizures, to get up slowly, and caution them to not jolt up quickly from a sitting anxiety or low blood pressure may be the cause. A drop in blood sugar position. may also be to blame, and we will address that separately. Fainting can While some patients prefer to sit with their head dropped between sometimes be caught before it happens by being attentive to patients’ their knees, this may cause them to hurt themselves if they actually do behaviors and vital signs. They may first feel dizzy because of a drop in faint. Instead, place the patient in a supine position to help increase blood pressure. blood flow to the brain and leave the person in the position for several If anxiety is the cause of syncope, patients may need to have nitrous minutes. oxide during their procedure to help them relax. Some patients also Most people typically become alert within one minute after fainting. require an anti-anxiety medication before their visit to be comfortable. If not, then there is most likely a more serious underlying condition. Be sure to explain anything that patients have questions about so they Even after regaining consciousness, the patient should be left in the understand the procedure and are not left with any surprises. Keeping supine position before slowly being placed in an upright position. patients comfortable is of key importance. Reschedule the patient’s treatment for another day. In some cases, patients who get up too quickly after reclining can experience syncope. It is important that all dental patients sit upright

Diabetic syncope/hypoglycemia Diabetic syncope can occur when a patient experiences a drop in blood hypoglycemia occurs, and a rapid drop can bring levels as low as 20- sugar levels and there is not enough glucose in the bloodstream to 30 mg/dl. support metabolic cell functions. Most hypoglycemia will only occur If Type 1 diabetics gives themselves an insulin injection but do in Type 1 diabetics (insulin dependent), but it can also occur in Type II not eat afterward, they may experience hypoglycemia and have a diabetics who are taking hypoglycemic medication. fainting episode. If the patient is still conscious, place him or her Before fainting, people may experience dizziness and confusion. in a comfortable position and give the person something to eat that They also may complain of a headache or behave strangely. It is also contains sugar, such as juice, soda or cake icing. possible that in rare circumstances, a hypoglycemic diabetic may If the patient is unconscious, he or she should be placed in a experience stroke- or seizure-like symptoms. All diabetic patients supine position and be given an injection to raise the blood sugar. should be asked what their blood sugar levels were at their previous If unconscious, EMS should also be notified. It is important to not daily reading before having dental treatment performed to avoid a place anything in an unconscious patient’s mouth because choking or glycemic event during dental treatment. aspiration may occur. The American Diabetes Association suggests the following blood Place the person in a supine position and he or she should typically sugar targets for diabetic adults who are not pregnant [4]: regain consciousness within 60 seconds. If the patient has not regained ●● A1C of 7 percent or eAG 145 mg/dl. consciousness within this window of time, then there is likely a serious ●● 70-130 mg/dl before eating a meal. underlying condition. Begin initiating basic life support steps as ●● Less than 180 mg/dl one to two hours before the next meal. necessary, checking the patient’s airway, breathing and blood circulation. Some diabetics take insulin to lower a high level of blood sugar, If the patient has extremely elevated blood pressure, the person may be and must take food at the time of their injection. This prevents their experiencing a cardiovascular attack instead of diabetic syncope. blood sugar level from becoming too low. Below 80 mg/dl is when To avoid diabetic emergencies in the office, it is best to schedule these patients first thing in the morning, after they have eaten a full meal.

Diabetic ketosis Ketosis occurs in diabetics when there isn’t enough insulin to move ●● Thirst. their blood sugars into cells. Fats and protein are used instead, and the ●● Increased urination. result is a buildup of waste in the blood. As a result, blood sugar levels ●● Red, warm skin. increase over a period of time. Predispositions like cardiovascular ●● Dehydration. disease may make even a controlled diabetic likely to suffer from a Because of advanced dehydration, diabetic ketosis can raise blood rise in blood sugar. sugar levels to 300 mg/dl or higher, at which point the patient would Symptoms include: become unconscious. Should this occur, EMS must be notified and ●● Fruity-scented breath. basic life support initiated as needed based on vital signs.

Allergic reactions Allergic reactions are situations that dental professionals are familiar Symptoms of an allergic reaction may include: with because many patients experience allergies to latex gloves. A ●● Hives. patient’s reaction to allergens can range from a mild irritation to a ●● Rash. severe, life-threatening condition. ●● Itchiness. ●● Swelling. ●● Intestinal distress.

Page 76 Dental.EliteCME.com ●● Trouble breathing. ●● Anaphylaxis. ●● Redness of the skin. ●● Loss of consciousness.

Anaphylaxis and loss of consciousness Severe allergic emergencies that result in anaphylaxis (constriction bag-valve-mask. This is a life-threatening condition; if the patient is of the airway and reduction in air flow) can cause a patient to lose beginning to exhibit problems breathing, then EMS should be notified consciousness and go into distress from the lack of oxygen. Oxygen and the patient should be given epinephrine immediately. should be administered using a positive-pressure device such as a

Mild allergies A mild allergic reaction that results in minor symptoms typically watched to ensure that more serious symptoms do not become evident, only calls for the patient to be made comfortable and the delivery of and that vital signs are appropriate. an antihistamine from the emergency drug kit. The patient should be

Examples of allergens There are several everyday allergens found in a dental office, some of ●● Gluten – Contained in some polishing pastes, toothpastes. which may not be obvious. Patients with severe dietary restrictions, ●● Nuts – Found in polishing pastes and brand-specific fluorides. such as abstaining from gluten, nuts and dairy, may be exposed during ●● Milk protein – An ingredient in polishing paste, Recaldent, some a typical visit. gum, and toothpastes. Below is a list of some allergens and where they can be found in the ●● Clove oil – Used to make eugenol, which is found in temporary office: dental cements. ●● Latex – Found in gloves and some equipment. Most people Quick response is important for patients experiencing a severe allergic develop contact dermatitis at the area of their skin that was reaction to something they are sensitive to. An antihistamine can be affected. administered to help block milder symptoms. Patients experiencing ●● Local anesthesia – While rare, some patients may experience a severe reactions must be given a dose of epinephrine from the serious reaction that causes trouble breathing, irregular pulse, and emergency kit, delivered in their thigh or upper arm. Epinephrine is syncope. extremely effective because it prevents further histamine release and ●● Egg protein – Used for general anesthesia delivery. While helps reverse histamine-caused conditions. nitrous oxide does not contain egg protein, it can cause a severe EMS must be notified if the patient is experiencing a severe allergic reaction in some patients because of a similarity in the molecular reaction, and the patient should be placed on oxygen as you monitor compound. vital signs. ●● Fruit flavoring – Found in topical anesthetic.

Respiratory distress Asthma attack All asthmatic patients should be asked about their asthma-related begin to appear cyanotic. Should your patient begin to experience conditions and flare-ups: these symptoms during treatment, put the person into an upright ●● When was their last attack? position. Examine the airway to check for swelling or obstruction and ●● What seems to bring attacks on? record the patient’s vitals. ●● Do they use an emergency inhaler? If so, where is it located? Conscious patients can administer their own drugs (usually albuterol) Asthma affects people of all ages and causes a response that tightens through their inhaler, and then be given oxygen. If they recover in a the airways. Aerosols in the treatment area or fear of dental treatment timely manner, treatment can be continued. may trigger an attack in some people. With patients who use an If the patient has persistent symptoms and requires a second dose of inhaler, have them place it out for easy access during their appointment albuterol, then treatment should be delayed until another day. Should in case of an attack. the patient become unconscious, a bronchodilator and epinephrine Symptoms of an asthma attack include coughing, wheezing and should be delivered while also activating EMS. trouble breathing. Patients may also feel pressure in their chest and

Obstruction From time to time, foreign objects, such as dental supplies, equipment, blockage can lead to a life-threatening situation if the object is not appliances or restorations, may find their way into the patient’s removed. airway. If obstruction is partial, the patient will begin coughing, but If a patient begins to choke, remove all foreign objects from the if obstruction is complete, the patient can become cyanotic and clasp person’s mouth immediately. Allow the patient to forcefully cough, the hands across the throat, which is the universal sign for choking. If which will hopefully open the airway. If the person is unable to cough the patient is able to speak, then obstruction is only partial. A complete or gasp, indicating a completely blocked airway, then abdominal thrusts should be performed. How to perform abdominal thrusts The best way to dislodge an object from a patient’s airway is to which prevents them from talking, gasping or coughing and helps to administer abdominal thrusts (also known as the Heimlich Maneuver.) forcefully remove the object. This is done when the patient has a completely blocked airway, ●● Stand behind the patient.

Dental.EliteCME.com Page 77 ●● Wrap your arms around the person, making a fist and placing your If the patient is unconscious … thumb just above the navel, and grasping the fist with your other ●● Contact EMS. hand. ●● Lay the patient flat on the floor. ●● Slowly make forceful thrusts, moving inward and upward just ●● Open the airway using a head-tilt, chin-lift maneuver. under the rib cage. ●● Perform a finger sweep if the object can be seen. ●● Repeat the thrusts until the foreign object is dislodged. ○○ Never perform a blind finger sweep because this can cause the object to become lodged deeper. ●● Perform appropriate steps of CPR based on the patient’s oxygen flow and pulse. Hyperventilation Severe anxiety or fear of the dentist can trigger hyperventilation, an Hyperventilation is the only emergency seen in the dental office where increased respiratory rate that can be difficult for the patient to control. oxygen delivery is contraindicated. A paper bag for breathing should During the rapid breaths, excessive levels of carbon dioxide are released. be avoided because this can cause elevated carbon dioxide levels. Symptoms such as tingling and numbness may occur, and the patient Communicate with the patient so that the person is aware of his or may become apprehensive. If breaths continue to remain uncontrolled, her breathing speed, and then verbally coach the person into slower spasms or fainting may occur. Thankfully, hyperventilation-induced breaths, one at a time. Under no circumstances should you deliver syncope will typically result in a normal respiratory rate and the patient oxygen to the patient. can regain consciousness.

Seizures If a patient experiences a seizure in your office, it is most likely that control other things, such as muscle control. Some patients can tell the person has a medical history of seizures or epilepsy [5]. It is highly when they are about to experience a seizure, which is called an “aura.” unlikely that someone without a history of seizures will experience one The aura usually involves strange smells, sounds, sensations or while in your care, but you should be prepared nonetheless. hallucinations and can give them a chance to prepare for the seizing Seizures are caused by erratic electrical activity in the brain. These event. After seizing, patients will typically be fatigued or confused. electrical signals can spread over the brain and stimulate areas that

Types of seizures Generalized Status epilepticus These seizures affect both sides of the brain and result in Rarely, seizures occur for a prolonged duration. This type of seizure unconsciousness. Types of generalized seizures include tonic-clonic, describes an ongoing, continuous seizure. myoclonic, absence and atonic. Tonic-clonic (also known as grand Seizing patients should have the immediate area freed of equipment mal) are the most common. Patients who experience this type of or foreign objects that they could come into contact with and possibly seizure should be placed in a supine position and given a head-tilt, harm themselves. Move everything back out of the way and do not chin-lift to open the airway. restrain the patient. All instruments and supplies must be removed Partial from the patient’s mouth to prevent aspiration or trauma. Do not Partial seizures are localized to a specific portion of the brain. attempt to prop the patient’s mouth open in any way or give rescue Consciousness may or may not be lost. They do not last long, but may breaths. spread and cause a generalized seizure [6]. If a relative or caregiver has accompanied the patient to the office, call Non-epileptic the person into the treatment area to find out whether the seizure is These seizures may resemble an epileptic seizure in appearance typical. Most of the time it is only necessary to monitor the patient and and symptoms. While difficult to identify, they differ from epileptic have someone drive him or her home, but if the seizure is severe, it seizures in that non-epileptic seizures are not caused by electrical will be necessary to call EMS. changes in the brain.

Drug overdose Accidental overdose may occur from prescription, over-the-counter, ●● Block injections – Use only an aspirating syringe when delivering or illegal drug use. The patient’s body weight and age must be kept the medication. in mind when administering medication as well as a history of drug ●● Lidocaine – May cause central nervous system toxicity and sensitivities. seizures. Toxicity, unconsciousness and respiratory failure may [8]. There is no antidote available for Lidocaine. Some ethnicities of people may be more susceptible to reactions occur ●● Nitrous oxide – Nausea and vomiting are typical symptoms of from specific drugs. For example, Ethiopian and some North African an N2O overdose [9]. If nitrous levels are too high and oxygen children may experience deadly reactions to the drug codeine [7]. It is important to understand unique sensitivities to particular drugs to deprivation occurs, patients may enter into a deep level of sedation which specific groups are susceptible. and possibly death. ●● General sedation – Problems related to sedation are typically Always administer intravascular medication very slowly. Review the associated with a drug overdose, especially when three or more patient’s health history, including allergies, current medications and any medications are used [10]. recreational drug use, to avoid an adverse reaction. ●● Illegal and prescription drugs – There are approximately 100 [11] ●● IV injected sedation drugs – Should always be administered drug overdose deaths each day in the U.S. . slowly. Begin with only the lowest amount of drug possible to avoid accidentally delivering too high of a dose to the patient.

Page 78 Dental.EliteCME.com If needed, antidote medication from your office emergency supply kit may be administered to a patient. Monitor the person’s vital signs and airway, and contact EMS if the patient does not improve. Bleeding disorder Blood is something that dental professionals deal with each day. When ●● Surgical procedures, such as sinus lifts, dental implants and significant blood loss occurs, it can quickly become an emergency extractions. situation. Patients who hemorrhage should be positioned upright to Patients who take blood thinners should have treatment needs reduce blood flow to the head. Most of the time, firm pressure and care addressed with their physician. Do not instruct the patient to to the local area of bleeding will be enough to control the blood flow. discontinue medication on his or her own. The person’s medical care Severe bleeding may be caused by: provider should make this decision. ●● The patient taking blood thinners close to the time of their If the bleeding is caused by a traumatic injury from a fall (caused by treatment. loss of consciousness or accident), quickly apply pressure to the area. ●● Aspirin use. It is not likely that bleeding will be severe enough to need a tourniquet ●● Trauma to orofacial blood vessels during surgical procedures. in a dental setting, but should you find that it does, apply steady pressure while EMS is notified.

Stroke When the brain experiences a blockage in blood flow, strokes are the Contact EMS immediately if you suspect your patient is experiencing result. Known as a cerebrovascular accident, strokes typically occur a stroke. To determine whether that is happening, act F.A.S.T. [13]: in adults with high blood pressure or hardening of the arteries caused F: Face by a buildup of plaque within them. Blood clots also are a common Ask the person to smile. Does one side of the face droop? cause of stroke, and when the episode occurs, the symptoms are visible A: Arms almost immediately. Most of the time these episodes are short-lived, Ask the person to raise both arms. Does one drift downward? but it is possible that they will continue for a lengthy period. Smaller S: Speech strokes (transient ischemic attacks) are a sign that a more severe attack Ask the person to repeat a simple phrase. Is the speech slurred or may be on its way. strange? Symptoms of stroke include: T: Time ●● Trouble walking. If you observe any of these signs, call 911 immediately. ●● Problems talking or understanding what others are saying. Lay the patient on his or her side and remove all instruments or other ●● Partial paralysis of the face, arm or leg. objects from the person’s mouth to prevent aspiration. If necessary, ●● Difficulty seeing with one or both eyes. you may utilize the suction to prevent the patient from inhaling ●● Headache [12]. material or large quantities of saliva and blood. It is very common for the patient to lose control of some muscles or facial control, so work to keep the person comfortable and calm while waiting for paramedics.

Patient positions and emergency steps The first priority when positioning patients is to ensure their safety environment that they are kept in will depend on what type of medical and comfort. Whether this is by placing them on their back so that emergency is happening. blood flow can quickly reach their head or by relocating surrounding Ultimately, you should keep the patient in a safe and comfortable equipment to preventing a seizing patient from incurring accidental position until the person can be handed off to the care of emergency trauma, it’s important to act quickly. The position of patients and the medical personnel when they arrive.

Supine position Unconscious patients should be placed back into the supine position. flow to the brain, the supine position helps prevent possible oxygen This is the position in the treatment chair where the head is reclined, deficiency. with the legs slightly elevated so they are higher than the head. Placing In medical emergencies, the prime concern should be that there a patient in the supine position will support blood flow to vital organs is enough blood flow and oxygen to the brain[14] . This prevents in the upper body, such as the brain and heart. By supporting blood irreversible brain damage, heart failure and other problems related to the deficiency of oxygenated blood flow.

Upright position Some patients need to be placed in an upright position for comfort administered, or a patient who has asphyxiated something during their and care for their emergency. Examples include a patient who treatment. is experiencing an asthma attack and needs to have albuterol

It’s now the “emergency CAB” There are three essential steps that should be taken after ensuring the the sequence to be airway, breathing and circulation assessments. patient’s positioning and comfort. These are assessing and assisting the However, that year, American Heart Association guidelines changed patient’s circulation, airway, and breathing. this basic life support sequence by placing circulation before airway or Until 2010, most health care providers called a memory aid for these breathing checks. So the memory aid became known as “CAB” instead actions the Emergency ABC’s because the guidelines called for of “ABC.”

Dental.EliteCME.com Page 79 When faced with an emergency situation, perhaps you might By mentally working through the three steps, you can prevent an remember these guidelines for the three key actions and what to do by important step from being missed and thereby possibly risking the creating your own memory aid – for example, you need an “emergency patient’s health. If you were familiar with the emergency ABCs, CAB” (as in a taxi) for this person. remember that circulation is now considered key, and the “C” step should be performed before airway or breathing is assessed.

Circulation The first step in the emergency CAB is circulation. Patients’ pulses the most recent guidelines of the American Heart Association, so be should be checked; for adults, you can check the pulse along the wrist sure to keep your guides current. or neck (alongside of the thyroid cartilage.) Use two fingers next to If chest compressions are necessary, it is important to use proper hand one another to palpate the areas along the radial, brachial or carotid positioning is used so that the compressions will be effective. To find arteries. A child’s pulse may be easier felt beneath the upper arm. the point where pressure should be administered, draw an imaginary When checking patients’ pulses, not only do you want to see what their line between the patient’s nipples and locate the lower portion of the rate per minute is, you should also note whether the rate is regular or sternum directly in the middle. Stack one hand over the other and place irregular, and the quality, that is, if it is weak or strong. A deep pulse the heel of the lower hand over the area of compression. may be found in someone with elevated blood pressure, while weaker Your torso should be positioned so that your arms are directly pulses are found in someone suffering from hypotension. downward, straight into the patient’s chest, not at an angle. Use Normal resting heart rates based on age are [17]: the heel of your hand to press straight downward approximately ●● Newborns 0 to 1 month old: 70-190 beats per minute. two inches, being careful to come back up enough for the chest to ●● Infants 1 to 11 months old: 80-160 beats per minute. completely recoil. ●● Children 1 to 2 years old: 80-130 beats per minute. Repeat chest compressions at a rate of at least 100 compressions per ●● Children 3 to 4 years old: 80-120 beats per minute. minute [18]. For a child, aim to compress their chest by one-third to ●● Children 5 to 6 years old: 75-115 beats per minute. one-half the depth of the chest, also at a rate of 100 compressions per ●● Children 7 to 9 years old: 70-110 beats per minute. minute. The goal of the firm compressions is to simulate a pumping ●● Children 10 years and older, and adults (including seniors): 60-100 heart so that oxygenated blood can flow through the circulatory beats per minute. system, preventing death. ●● Well-trained athletes: 40-60 beats per minute. Compression to breath ratios used in adult CPR are 30:2, meaning that A pulse rate that is too rapid is referred to as tachycardia. Bradychardia 30 compressions are given with a short pause to administer 2 rescue is a pulse rate that is too slow. breaths. For children and infants, a 15:2 ratio is used. If you have checked the patient’s circulation for longer than 10 Because it is easy for the person administering chest compressions to seconds and are unable to detect a pulse, then you should begin become fatigued, two-person CPR can be used. This allows one person performing chest compressions as you were trained in CPR or basic to give chest compressions and the other to deliver rescue breaths, and life support training. Compression rates and ratios with rescue then the pair can switch after several cycles. CPR should be continued breathing continue to be revised almost on an annual basis based on until rescue paramedics arrive and instruct you to allow them to take over. Airway Conscious patients are able to let you know if they are having trouble If a patient is experiencing any signs of obstruction, quickly remove breathing. Patients who are choking typically know how to use the any equipment or materials, such as bite blocks, cotton rolls or other universal choking sign, which is having one hand clasped around the instruments. A finger sweep should not be performed unless there is throat. If the patient can cough, speak and breathe, then there is not a visible debris that the clinician can directly see. If debris is visible, complete airway obstruction. then removal can be attempted. However, if the patient is experiencing anaphylaxis from an allergic Should a patient become unconscious, the dental professional must reaction, the person may have a compressed airway, preventing ensure that the person’s airway is open. The head-tilt, chin-lift that is adequate oxygen intake. Patients who are choking will need to have an used in CPR administration does this. It is extremely important to do abdominal thrust performed to help dislodge a foreign object. this carefully to avoid damage to the spinal cord if accidental trauma has The Red Cross recommends first delivering five back blows with the occurred during the situation. heel of your hand, followed by five abdominal thrusts[15] . This is done To open the airway, the practitioner should position him- or herself by standing behind the patient, wrapping your arms around the person, immediately behind the patient’s head. Gently place the thumbs on putting the thumb side of your fist just above the belly button, grasping the outside of the patient’s jaw and the remaining fingers underneath, the other hand around it and thrusting inward quickly five times. On a softly guiding the mandible forward and up. This opens soft tissues pregnant or obese person, perform the same procedure, but locate your in the back of the mouth so that the airway can operate without hands higher up, over the abdomen. anatomical blockage.

Breathing As soon as the airway has been opened, breathing should be checked. minute [16]. Children tend to breath much faster until they reach A normal respiratory rate for a healthy adult is 12-20 breaths per adolescence.

Page 80 Dental.EliteCME.com As taught in health care provider CPR and lifesaver courses, breathing Age Rate of breaths per minute can be checked using the “look, listen and feel” method. First look at Adult 12-20 the patient’s chest to see whether it is rising and falling as it would Adolescent 12-16 during normal breathing. Place your ear over the patient’s face and listen for sounds of breathing, wheezing, or any airflow. Lastly, as you Elementary 18-30 are bent down listening, feel for any air movement coming out of the Preschooler 22-34 patient’s mouth or nose. Toddler 24-40 Spend no longer than 10 seconds assessing the airway. If signs of breathing are not evident, then rescue breathing should be conducted. Under 1 30-60 Always use a barrier device or a bag-valve-mask device to prevent Patients with asthma or experiencing an allergic reaction may transfer of pathogens or bodily fluids between patients and a care experience wheezing as they attempt to take breaths. Hyperventilating provider. (tachypnea) elevates the respiratory rate, and oxygen intake will be too Administer two rescue breaths and watch to see whether the chest rises high. Bradypnea is when the rate of breathing is lower than normal, and falls with each one before repeating them. Failure of the chest to which prevents adequate oxygen from reaching vital organs and loss of rise or fall is evidence of an obstruction. Be sure to avoid delivering consciousness. too many breaths per minute. See the table above for the normal respiratory rates based on age.

AED/defibrillation use The use of automatic defibrillators has increased the likelihood nipple and to the left of the rib cage. If the patient has an unusually of survival for heart attack victims [18]. AEDs are available for thick amount of chest hair, it may be difficult to get a close connection purchase and can be kept in the office to use in the event of a medical with the skin. In this case, use the enclosed razor to remove excess emergency. They are very user-friendly and simple to use. Many newer hair. If a razor is not available, place the pad on their chest and quickly models will audibly direct the operator on what steps to perform. rip it off before placing it back onto the same area. Previously, AEDs were recommended for children and adults, but their Should the patient have piercing or an implanted device such as a use is now appropriate on all ages, including infants. pacemaker, move the pad at least 1 inch away. Pacemakers typically Upon finding someone unresponsive, first check to see whether the leave a scar in the skin, or are identified by a medical bracelet. person can be woken. Speak loudly to adults and try shaking their After the patient has been prepared, press the AED’s “analyze” button shoulders, or with children, pinch them on the arm or leg. If the patient and follow the voice prompts. Be sure to stay clear of the patient so fails to respond, have someone contact EMS while the other team that the machine can check for any signs of a pulse without being member fetches the AED. Perform necessary CPR steps using the disturbed. If necessary, the AED will alert you that a shock is needed. emergency CAB before the AED arrives. Be sure to stay clear of the patient when the shock is given. No team Once the AED is available, it can be used if the patient’s heart rate members should touch the patient because of they could be shocked. is irregular or absent. To prepare to use the AED, remove any shirts, If everyone is clear, press the “shock” button, wait till the shock has jewelry or underwire bras. Turn on the AED and place the electrode been delivered and then perform two minutes of CPR. After two pads directly on the patient’s dry chest. Although it is highly unlikely minutes, the AED will alert you that it is time to once again analyze that a patient would be in a pool of water in a dental office setting, be the patient’s heart rhythms. Repeat this cycle until EMS arrives. sure that there is no standing water that could act as a conductor and In 2005, the American Heart Association guidelines suggested that spread the shock to other areas. the use of an AED should become a standard of care in all health care The pads should be placed with one over the center right of the chest settings, including dental offices. Using an AED increases the potential just over the nipple, while the second is placed just below the left for resuscitation over traditional CPR.

Preventing a medical emergency Not every medical emergency is preventable, but some can be avoided. conduct a thorough review of the patient’s health history and vital When it comes to treating patients in your office, it is important to signs to identify precursors that may indicate a medical problem.

Reviewing the patient’s health history Regardless of when you last saw a particular patient, a review of aren’t next to the teeth, sometimes people assume it isn’t important medical changes, conditions, risk factors or illnesses should be that you know about it. conducted at every appointment. Some offices do this by using a Even if a patient does not check the box, it is important to ask about drug supplemental form attached to the primary health history form, allergies, current medications, recent hospitalizations and surgeries they providing space to document health updates that should be signed by may have had. Ask them when they last took their medication. Many the patient and dental team member who reviewed it. people spread out their medication for reasons such as cost and therefore Some patients may fail to identify obvious medical procedures and let do not have adequate control over situations like blood pressure and you know halfway during their treatment that they had a knee or heart diabetes. valve replacement two months before. Because these areas of the body

Premedication requirements The American Heart Association has revised its recommendations blood supply to lodge itself or cause an infection in arterial walls and the on antibiotic prophylaxis (premedication) for dental procedures. heart (infective endocarditis). Premedication is used to prevent disrupted oral flora that travels into the

Dental.EliteCME.com Page 81 According to the American Dental Association, the two types of Recent science supports the idea that infective endocarditis is less patients that require premedication include people who: likely to occur in dental patients than previously thought. In the past, ●● Are predisposed to infective endocarditis because of specific heart patients were premedicated with antibiotics even during routine conditions. cleanings if they had a history of mitral valve prolapse, rheumatic ●● Have had joint replacement surgery and also found at risk for heart disease, bicuspid valve disease, calcified aortic stenosis and developing an infection near the prosthetic device. congenital heart defects [19]. It is recommended that people with the following conditions receive Although infective endocarditis should not result in an office emergency, premedication if undergoing more invasive dental procedures: it is worth mentioning because lack of prophylactic care during routine ●● Artificial heart valves. dental procedures can place your patient in a compromising health ●● History of IE. condition. The ADA suggests that, according to research, premedication ●● Heart transplant with a history of valve problems. may not actually prevent the patient’s susceptibility for IE, because ●● Congenital heart problems that are unrepaired or have been regular daily habits such as flossing or brushing can expose the patient to repaired and still have defects or prosthesis. the same conditions as preventive dental procedures.

Remind patients to take or bring their medications Remind patients who have a specific health condition that requires should also bring their nitroglycerin tablets with them. Remind all medications to bring them with them during your confirmation call. patients to take their medication as prescribed to ensure their safety For instance, an asthmatic patient should be reminded to bring an during dental care. inhaler to the appointment. Patients with a history of angina attacks

Recording vital signs Vital signs should be taken at each appointment. With routine vital The patient’s first visit will consist of a “baseline” reading, to which sign documentation, abnormal readings that are not consistent with the all future readings should be compared for consistency and health. patient’s history can easily be identified. If necessary, treatment can be Monitoring these signs at each visit can allow the dental professional deferred and medical referrals made. to identify if a patient is at risk for a medical emergency.

Blood pressure Patients’ blood pressures should be recorded at every dental The American Heart Association has defined the following adult blood appointment, even if the patient was seen just the day before. pressure categories: Traditionally, blood pressure is taken using a standard blood pressure Category Systolic Diastolic cuff and stethoscope, but many offices now prefer to use an electronic cuff. Unfortunately, with an electronic cuff, you may find some minor Normal Under 120 and Under 80 discrepancies in the readings and be unable to detect irregular heartbeats. Hypertension 120-139 or 80-89 When taking patients’ blood pressure, have them sit upright with their High blood pressure, stage 1 140-159 or 90-99 legs uncrossed. Place the cuff on their right arm and ask them to not High blood pressure, stage 2 160 or over or 100 or over speak during the reading. This time can also be useful for monitoring Hypertensive crisis Over 180 or Over 110 their respiratory rate and quality of breaths as well as pulse. Be sure to use the proper-sized cuff; a cuff that is too loose, narrow or wide can In the event that blood pressure falls into the hypertensive crisis result in a false reading. category, emergency care should be sought immediately. All patients whose blood pressure levels measure high enough to fall into stage 2 If you are taking blood pressure using a stethoscope and traditional BP hypertension should have elective dental treatment delayed until after cuff, you should follow the following steps: they receive medical care from their primary care physician [20]. ●● Place the cuff approximately 1 inch above the bend on the inside of the elbow. Blood pressure guidelines for children vary greatly, based on age as ●● Place the diaphragm of the stethoscope above the brachial artery, well as height and weight percentiles, with healthy systolic ranges just below the BP cuff, and hold it in place. never exceeding a reading of 120. Even a slight elevation can be cause ●● With the other hand, use the inflating bulb to begin filling the cuff. for alarm. For example, a 10-year-old female with a systolic reading of ●● Continue filling the cuff 20-30mm of mercury past the point where 134 and a 10-year-old male with a systolic reading of 135 would both the patient’s pulse can no longer be heard or felt. be categorized as having stage 2 hypertension. ●● Slowly release the air using the bulb valve until you hear the first Patients who are anxious may experience higher blood pressure heartbeat in the stethoscope. This number on the dial is recorded as readings while they are at a dental office. If a reading is too elevated, the systolic reading. the practitioner should wait five minutes and take a second reading. ●● Continue releasing air from the cuff until the sounds are no longer If the patient continues to have an elevated blood pressure, proper evident. The last sound is the diastolic reading. measures should be taken for the person’s dental care, and he or she ●● Release all remaining air from the cuff and remove it from the should be referred to a medical provider. When in doubt, contact a patient’s arm. patient’s doctor to determine whether the treatment can be completed.

Pulse and respiratory rates Record patients’ pulse after reviewing their health history. A good Hold the area for 15 more seconds as you also monitor the respiratory time to do this is immediately after recording their blood pressure. rate. Many people will alter their breathing if they are consciously Use two fingers to palpate the wrist for at least 15 to 30 seconds.You aware that someone is checking it. By taking the pulse and respiratory can multiply the pulse by the appropriate amount of time needed for rates consecutively and without telling the patient, you can record their an average number of beats per minute. Document the quality of the normal breath rate. Make a note of the quality of breaths. Are they pulse. Was it strong, weak, or normal? Regular or irregular? slow, normal or fast? Normal, shallow or deep?

Page 82 Dental.EliteCME.com Pulse oximeter use Pulse oximetry use during sedation services can detect conditions Using a pulse oximeter is typically optional, depending on the type such as hypoxemia when no other visible signs are present. They also of sedation services being used, but choosing to invest in this type of effectively monitor oxygen levels in dental patients of all ages. This equipment can protect both patients’ health and the doctor from facing can prevent a low oxygen uptake and possible medical emergency that liabilities. might not otherwise be detected during treatment.

Temperature Most dental offices do not record patients’ temperatures on a Health care providers typically record temperatures using a tympanic/ routine basis. However, doing so can help identify whether they are temporal thermometer, ear canal thermometer, or an oral thermometer. experiencing any type of underlying viral or bacterial infection. Taking If an oral thermometer is used, you will also need to have disposable a patient’s temperature can be done conjunctively with recording covers. Temporal thermometers are easily cleaned, making them their blood pressure, thus not adding any additional chair time to the more convenient, and they give readings that are consistent with oral scheduled appointment. thermometers. Mercury oral thermometers are now considered unsafe The average temperature for healthy individuals is 98.6 degrees for use because accidental breakage of the glass could expose patients Fahrenheit (37.5 degrees Centigrade). A low-grade fever at a to toxic mercury inside of the thermometer. temperature that exceeds 99.6 degrees Fahrenheit is a sign that the patient is battling some type of infection.

Nitrous oxide When patients are using nitrous oxide, never leave them unattended! Only a dentist can administer nitrous oxide. Other staff members, such There are several side effects that can occur very quickly when a patient as a hygienist or dental assistant, are only legally able to monitor the is on nitrous oxide during a routine dental procedure. Nausea may cause patient after the dentist has administered the drug. They can, however, vomiting and a risk for the patient to aspirate some of the debris. lower the concentration of nitrous oxide during the appointment, placing the patient on a higher volume of oxygen. If a patient has a history of vomiting during a procedure using Leaving the patient and stepping out of the room or becoming so N2O, be sure that the nitrous is being administered slowly, in low concentrations. Nausea is more likely if the patient did not have a meal distracted that the patient is being poorly monitored (or not monitored or consumed too heavy of a meal. at all) can compromise the health of the patient, risking oversedation, loss of consciousness and physical harm. An oxygen fail-safe alarm can alert the practitioner when oxygen supply levels are depleted, eliminating the risk of a patient emergency from overexposure to nitrous oxide.

Learn how to recognize an emergency The earlier a medical emergency is recognized, the more time the evident. Some symptoms, such as nausea, chest pain, elevated blood dental team has to respond, call for emergency medical care and begin pressure or irregular pulse, may not be evident unless the patient is addressing the patient’s immediate needs, such as performing basic life asked or special equipment is used. This is why vital signs should be support. recorded at the beginning of the appointment, and repeated within five Visible physical symptoms, such as sweating, paleness, fatigue, change minutes if the readings are irregular. in respiratory rate or vomiting, should be addressed as soon as they are

Make note of existing health conditions It is essential that patients’ health history is updated at every visit and All too often, dental practitioners fall into a repetitive habit of routine. checked for possible health conditions or allergies that the person has Charts do not get checked, and patients are placed at an increased risk experienced in the past. If you know a patient had a heart attack 11 for problems, such as accidentally forgetting to use nitrile gloves on a years ago, ask the person when was the last time he or she saw the patient who has a latex allergy. cardiologist. HIPAA confidentiality restricts what type of information can be placed Perhaps the patient is an epileptic. When was the last seizure? How on the outside of a patient’s chart. It may be useful to put a sticker or severe was it, and what kind of care is the person getting from a red star on the outside of paper charts for patients who have significant medical doctor? Make note of patients who are at risk for medical allergies or medical conditions. emergencies, because they will typically be more likely to experience Electronic charting is very convenient, because most practice one in your office than an overall healthy patient with no medical management software programs will send you a popup alert on concerns. medical conditions as soon as you open the patient’s file.

Consult with the patient’s physician and a drug reference book When in doubt, ask for a medical clearance from patients’ primary care Consult with a drug reference book to note medications and dosages physician before beginning dental treatment. Notify the doctor if you the patient is taking and what they are being taken for. Certain record any abnormal vital signs, such as stage II hypertension, and get medications have a contraindication for other medications, such as a confirmation from the doctor’s office on what treatment restrictions birth control pills or NSAIDs. the patient has been placed on, if any.

Dental.EliteCME.com Page 83 Check to see that patients have taken all of their medications for Ask patients for a current list of medications and dosages at each the day and are not spreading out the dosages for some reason. appointment. Use the office’s physician’s drug reference handbook Inappropriate intake of medications can lead to resistance or ill to note any new medications, side effects and dosages. Ask whether management of their medical conditions. patients are taking any herbal medications or supplements.

Take action As soon as you realize a patient is experiencing an emergency, all action plans in more detail a little further along in this course. Make the treatment should be stopped. If the situation appears to be severe, then patient comfortable, record vital signs, call EMS, and enact basic life follow your office’s emergency action plan. We will discuss emergency support if necessary.

Emergency kit Dental offices should have an emergency medical kit that contains Hopefully, your office will never need to use the emergency medical equipment to perform basic life support (BLS), emergency drugs kit. You can expect to have to discard expired, unused medication and and a defibrillator. All team members should know the location of supplies as you keep the contents up-to-date. It is very important that this emergency kit and how to use all of the included equipment or you do not keep old, expired drugs in your emergency kit. As drugs medication should an emergency arise. expire, they lose their effectiveness, and an emergency situation can Because medications expire, it is important to routinely examine the become more complicated by not knowing what medical measures have emergency kit and document the contents as well as expiration dates. been effective. A log sheet can be part of the office’s monthly checklist, and the Most kits will fit nicely in a very large container, such as a tackle box. responsible staff member should check all of the contents each month to A list or chart of the contents should be inside the box and include be sure there are no leaks, damaged materials, and an ample supply of their proper usage and dosages. Laminating the chart and keeping it emergency drugs. in the top of the kit will ensure that it is not misplaced or overlooked Kits can be purchased from medical supply companies or can be when it is most needed. Some people also find it useful to tape it to the compiled by your office in separate pieces. Your state dental board lid of the kit. may require specific contents, so be sure to check and ensure that you comply with local safety regulations.

Kit contents AED/external defibrillator. This can be kept adjacent to the of oxygen when the patient is conscious and positive pressure is not emergency kit location because most AEDs are large, bulky or may be needed. Place the patient on minimum flow rate of 6 liters per minute. mounted on the wall. Oxygen is administered in almost every medical emergency other than Oxygen delivery device to use during CPR. This may be a bag-mask- hyperventilation. valve device, resuscitation pocket mask or other disposable CPR Sphygmomanometer and stethoscope. Although these pieces of barrier. Barriers prevent practitioners from cross-contaminating bodily equipment should be used routinely in the dental office, having a spare fluids between the patient and themselves, and valve-type devices in the emergency kit that is reserved only for medical emergencies increase the uptake of air by the patient. will prevent the risk or not being able to locate the device during an A nasal cannula along with a portable E cylinder or a nitrous oxide emergency. nasal hood with 100 percent oxygen flow can provide a good source

Essential emergency drugs Epinephrine – Perhaps the most important medication in your entire emergency box; something such as juice would need to be kept in a emergency kit, epinephrine is useful for emergencies with allergic separate refrigerator. reactions, respiratory distress and cardiovascular emergencies. This Nitroglycerine – In the form of a spray or tablet, nitroglycerine is used injectable drug is easily delivered through a preloaded syringe or pen- on patients who are experiencing sharp chest pain and have a history type device. Most people with severe food allergies will keep a device of angina attacks. Patients who take nitroglycerine should bring their such as an EpiPen with them in the event of an exposure. Epinephrine medication with them to their appointment, but people with undiagnosed should be given to asthmatic patients who do not respond to albuterol conditions may experience symptoms of a heart attack and need to have during an attack. nitroglycerine administered to them. The dosage can be given every five Diphenhydramine/histamine-blocker – Also for use with allergic minutes with a total of three dosages. Most nitroglycerine has a shelf life reactions, histamine blockers may be preferred in patients with a milder of only three months after it has been opened. reaction. Injectable antihistamines are for more serious reactions (such Aspirin – A minimal, single dose of 162 mg aspirin should be given as when a patient is experiencing anaphylaxis); orally administered to heart attack victims. It can also be accompanied by nitroglycerine. antihistamines are appropriate for mild allergic responses. Pills should be chewed and then swallowed by the patient. Sugar/glucose – This is for diabetic patients who are experiencing Bronchodilator/Albuterol – This is used when asthmatic patients hypoglycemia from an insulin imbalance. This can be in the form experience an asthma attack or exhibit symptoms of anaphylaxis. of juice, cake icing or soda and should be given to a patient only It is the first medicine of choice for patients who are experiencing if the person is conscious. A tube of icing can easily be kept in the bronchospasm.

Additional emergency medications and equipment In addition to essential medications, if dental offices desire, they may is rurally located and expects a longer response from EMS in the event use other emergency medications. This can come in useful if the office 911 is called.

Page 84 Dental.EliteCME.com Some of these drugs are optional, while others are required by state situations when other narcotics, such as Valium or Versed, have been regulating authorities based on procedures performed in your office. used. For instance, if your office performs general anesthesia or sedative Benzodiazepine – In a water-soluble form, dentists can administer services, then you may be required to keep specific reversal drugs on benzodiazepine (midazolam or lorazepam) intramuscularly to hand for easy access should the patient become over-sedated. patients experiencing status epilepticus [21]. Traditionally, this drug is Airway devices – If your dentist has advanced training in the use of administered through venipuncture, so an alternative form should be devices such as a laryngoscope or endotracheal tube, these devices can used if making it part of your office’s emergency kit. come in useful. Glucagon – Injectable glucagon may be used in the event of a Hydrocortisone – A corticosteroid, hydrocortisone used for hypoglycemic emergency when sugar (glucose) cannot be given orally suppressing anaphylaxis. Unfortunately, the drug has a slow onset, to a patient who is unconscious. It must be delivered intravenously and sometimes taking as long as an hour to become effective. This is not for intramuscular use. medication can also be used to manage an adrenal crisis. Morphine – This is used to treat patients in pain during a heart Naloxone – This is used to reverse respiratory depression associated attack. Use caution when administering this medication to the elderly. with opioids. When opioids are used for sedation, then naloxone is Most dental offices would need to deliver this intramuscularly, but the drug of choice for emergencies because it is a specific opioid intravenous is the method of delivery. antagonist. Naloxone can also be used when there is an overdose of Ephedrine – For management of severe hypotension, ephedrine has specific narcotics (Demerol, morphine) and help reverse any decreased similar effects as epinephrine. Ephedrine has a longer duration than consciousness associated with their use. epinephrine and can last up to 1.5 hours. Flumazenil – This also is used for reversing respiratory sedation and Atropine – Also for the management of hypotension, atropine is used to counteract effects from benzodiazepine because it is a specific appropriate for use when bradycardia is also present. benzodiazepine antagonist. This medicine is also used for overdose

Team preparedness Formal steps must be taken to properly train the office team members practice when paper documentation shows training has been performed on how to respond to an emergency. Doing so not only protects on a consistent basis. patients, but also helps provide legal protection for doctors and their

Appropriate formal training of all staff members Comprehensive training in health care provider CPR and basic life instructions on the use of an AED and other emergency equipment support may be best achieved when the entire team trains together. used during CPR. Most health care provider CPR is typically active for two years and Separate office training should also prepare all team members to know: can be completed through Red Cross or American Heart Association ●● The location and contents of the emergency medical kit. certified providers. Doing this on a frequent basis will maintain all ●● How to administer drugs from the emergency kit if needed. staff member’s certifications and ensure that the office is also fulfilling ●● How to use the emergency kit, such as bag-valve-mask equipment. legal obligations. It also serves as a refresher to team members who ●● How to properly record vital signs, such as pulse, blood pressure, already know how to practice life support. Proper documentation temperature and respiratory rates. should be recorded in a central location. ●● The emergency action plan for the office. No matter what a staff member’s role is in the office, all team members ●● Where emergency oxygen equipment is located and how it is used. are obligated to receive basic life support and CPR training. Each person ●● Which team members hold specific responsibilities in the action will play a key role in an emergency action plan and should serve as plan. backup to team members who are not present or unable to perform ●● When to call paramedics or other emergency numbers, such as an emergency actions for some reason. oral surgeon, local pharmacy and poison control. Formal training will enable staff members to perform one- or two- ●● First aid, such as the care of bleeding, burns and falls. person CPR on both children and adults. The course will also include

Establish an office emergency action plan Perhaps the most important part of managing medical emergencies in immediately. Other words might sound silly but still be effective, the dental office is your office emergency action plan. This plan should such as “apple pie” or “sunburn.” be provided in writing to all employees and reviewed on a routine ●● Act quickly. basis so all parties understand their roles and responsibilities when The faster you respond to a medical emergency, the better. In responding to an emergency. A written team plan can prevent key instances where an AED needs to be used, it has been shown that areas from being overlooked and help the office respond quickly and every minute that passes before artificial defibrillation decreases appropriately based on the circumstances that are occurring. the patient’s survival rate by as high as 10 percent. Good team ●● Have a code word or phrase. communication and an emergency plan that has been enacted, Using a code word or phrase can help alert all of the team practiced and known by all of the team members can help decrease members to the situation without startling other patients or people response time to the patient’s needs. in the waiting room. The word or phrase should sound like ●● Have a play-by-play planned ahead. something that wouldn’t worry anyone, but instantly connects with Written action plans for your emergency routine are essential. the team members. For example, the dentist does not have any They ensure that the entire office knows emergency protocol, sisters, but an emergency phrase could be “Tell Dr. Smith that his which member is responsible for what, and helps emergencies be sister is calling.” Hearing this phrase will alert the doctor as well addressed quicker. When you are preparing your emergency action as the staff that there is an emergency and their attention is needed plan, be sure to include these specific steps:

Dental.EliteCME.com Page 85 ○○ Recognize. ○○ Act. Is your patient experiencing a medical emergency? What While waiting for the response of your other team symptoms or signs cause you to believe that is happening? At members, place the patient in the proper position, including what point should the team members alert the doctor or other administering oxygen, if appropriate. If the patient has brought staff that the emergency plan needs to be enacted? A vital medication along, such as an inhaler or nitroglycerine, locate communication step that is taught in health care provider CPR and administer it immediately. All team members should is having one team member point to another one and say “You then complete their assigned roles in the emergency action dial 911.” This prevents the call from being delayed and mass plan, which will be explained shortly. Contact EMS and alert confusion as a result of multiple people thinking that someone it of the situation as well as any family members who have has already contacted EMS. accompanied the patient to the appointment. If the medical ○○ Communicate. emergency is one that the patient has experienced before, the What will your emergency phrase or keyword be? All team family member’s input is essential. members need to stop whatever they are doing when they hear One member should bring the emergency medical kit as well this phrase. The doctor will come to the area where the patient as an AED if available. Assess the patient’s vital signs and is located and alert the team members if it is appropriate begin basic life support or CPR as necessary, providing backup to alert EMS in addition to already established emergency to other team members when needed. Traditional CPR can be protocols. Everyone should know where emergency equipment very strenuous to a health care provider, so two-man CPR is a is located and where a phone is to dial 911. good way to prevent fatigue.

Assign roles to specific staff members ●● Team member No. 1. ○○ Determine along with team member No. 1 whether it is ○○ Recognize whether the patient is experiencing an emergency. appropriate to contact EMS. If so, verbally confirm that you are ○○ If you suspect a possible emergency, use the code word or going to call 911 and then go directly to the phone and dial 911. phrase to alert the doctor and other staff. If possible, dial from a phone that is not at the reception desk. ○○ Turn off all nitrous oxide and give the patient oxygen unless Be sure to include your office address and the situation you the person is hyperventilating. suspect the patient is experiencing. It can help to keep a business ○○ Administer the patient’s medicine if there is one available, card taped to your phone or desk, because the confusion during such as an inhaler. an emergency could cause a lapse in memory for the office ○○ Place the patient in the appropriate position, supine or upright, address. depending on symptoms. Check vitals. ○○ Stay on the phone with 911 until EMS arrives. Relay any ○○ Ask the patient whether he or she is OK, using a loud voice. information to 911 that other team members present to you. If the patient appears unconscious, attempt to wake the person ●● Team member No. 3. by shaking him or her firmly by the shoulders. Children can be ○○ Respond to team member No. 1’s alarm by immediately pinched or slapped on the arm. fetching the emergency medical kit and AED. Bring these ○○ Inform team member No. 2 to dial 911 by looking at the supplies to the area where the patient is located. person directly and saying, “You – call 911!” ○○ Assist team member No. 1 in recording vitals. ○○ Inform a team member to bring an emergency medical kit and ○○ Prepare AED, if necessary. AED. ○○ Prepare and administer emergency drugs as appropriate. ○○ Administer CPR and basic life support as needed until an ○○ Practice two-rescuer CPR as appropriate until EMS arrives. emergency medical service team arrives. Switch periodically with team member No. 1 to prevent ●● Team member No. 2. rescuer fatigue. ○○ Respond to team member No. 1’s alarm.

Practice makes perfect Practice your emergency plan on a regular basis. Twice per year may you practice an emergency, have team members rotate roles and be adequate. Always have the entire team practice the plan together identify areas that may have been missed or done differently. any time a new team member is added to the staff. Being overly prepared by multiple mock situations can prevent Allowing input and questions can allow for necessary alterations or confusion and improve the team member’s comfort level should clarification when needed so that all are confident in their role.When an actual emergency take place. Panic by team members during an emergency does not help the patient.

Cross-train It is important that more than one person be trained for each rescuer Cross-training also is important when a specific team member is out or role. In addition, a team member should be cross-trained so he or she unavailable. This is yet another reason why all team members should can fulfill two or three different roles if needed. As a result, the office be CPR certified, even if they are never in the actual treatment area team can be more efficient and remind other members if a step is being with the patient. missed.

Page 86 Dental.EliteCME.com Documentation of a patient emergency Detailed record keeping is essential when a patient has experienced a personnel, each step of the way should be carefully outlined in your medical emergency in your office. From the moment the emergency treatment notes. symptoms are observed to when the patient is transferred to EMS

Assess your team’s response Within a day or two of an emergency in the dental office, conduct a All team members should have current health care provider CPR team assessment of the emergency action plan. In this assessment you certification and know their roles in the office emergency plan. This should document all involved team members and their roles in the plan should be reviewed on a regular basis, especially when new staff situation. Ask for the team’s input on each person’s roles in the care of members join the office or job roles change. the patient, allowing an opportunity to determine what changes may be Ultimately, all liability rests on the shoulders of the supervising needed if another medical emergency should arise. dentist. However, licenses and certifications to other staff members, Key points to evaluate should include: such as the hygienist and assistant, are also at risk, placing an added ●● What signs pointed to an emergency? responsibility on those team members. ●● Who first recognized those signs? Emergency care that is reasonable and prudent is at the dentist’s ●● Did the patient’s health history indicate an increased likelihood to discretion. All team members should know what the dentist’s plan experience a medical problem? of action involve, so the office can act as effectively and quickly as ●● What alerts put in place helped detect the emergency, such as notes possible. Simply being ignorant of the law, responsibilities, or a lack of or electronic record warnings? training are a liability for all dental professionals, no matter what their ●● Were there any signals that were missed that could have been role. Until the emergency response team arrives, the sole responsibility avoided? of the patient’s condition lies under the supervision of the dental team. ●● Were the patient’s vital signs recorded? Were they normal? ●● What was the initial reaction to the situation by the involved team Your patients and their families expect that you will provide expert members? medical care that ensures their safety and personal interests. While ●● Could other preventive steps have been taken that could have it can be a scary situation to help a patient during an emergency, avoided the emergency? remaining calm throughout the entire situation and thinking through ●● Did the team follow the emergency action plan as roles were the proper steps can help you make good choices that improve the assigned? safety of your patient. ●● Do these roles need to be altered? Proper precautions should be taken to eliminate medical episodes ●● When was the emergency kit accessed and were the contents while the patient is under your care. Up-to-date medical records, health appropriate for the situation? history screenings and vital signs should be recorded at every single ●● At what point was EMS notified, and how did you decide it was appointment. Neglecting to ask patients about medications they are time to call 911? taking, recording their blood pressure, pulse or documenting blood sugar A team assessment is not an opportunity for judgment or badgering levels can place both patients and dental team members in a dangerous of other team members. It is a serious step that should be taken for situation. the office to efficiently respond to any situations that may arise in the The best way to prepare for a medical emergency is to make future. emergency training part of your annual continuing education for Team members should be given a chance to assess the experience and the entire office. Many times we remember essential parts of our provide input on ways to be more efficient in the future with their responsibilities and emergency plan, but annual refreshers can bring to personal responsibilities. mind key components that are easy to forget. Because dental care providers are licensed health care workers, there Undergoing emergency training as a complete office is an effective way is some legal liability in the way they respond to medical emergencies. to make sure that all staff members are on the same page and understand the weight of their personal responsibilities.

References 1. Concannon, T.; Griffith, J.; Kent, D.; Normand, S,; Newhouse, J; Atkins, J.; Beshansky, J.; Selker, 11. CDC.; Vital Signs: overdoses of prescription opioid pain relievers – United States, 1999-2008; H.; Elapsed time in emergency medical services for patients with cardiac complaints: are some MMWR 2011;60:1-6 patients at greater risk for delay?; American Heart Association; web version available 7/29/13 at 12. Mayo Clinic; Stroke symptoms; Jul 3, 2013. http://circoutcomes.ahajournals.org/content/2/1/9.full 13. 13. National Stroke Association; Warning signs of a stroke.; Jul 25, 2013; www.stroke.org 2. Dolgen, E.; 6 often-missed heart attack symptoms in women.; Huffington Post; Mar 6, 2013. 14. Basic management of medical emergencies: recognizing a patient’s distress.; J Am Dent Assoc.; 3. Homayounfar, SH.; Broomandi, SH.; Evaluation of entonox as an analgesic for relief of pain in 2010 May;141 Suppl 1:20S-4S. patients with acute myocardial infarction.; Iran Heart J2006;7(3):16-19. 15. American Red Cross: Conscious choking.; http://www.redcross.org/flash/brr/English-html/ 4. Checking your blood glucose; American Diabetes Association; Jul 7, 2013. conscious-choking.asp. 5. Bryan, RB; Sullivan, SM; Management of dental patients with seizure disorders.; Dent Clin North 16. Hunger, J; Rawlings-Anderson, K.; Respiratory assessment.; Nursing Standard. Apr 15,2008; Am 2006;50 (4):607-623, vii. 22,41,41-43. 6. Types of Seizures; Epilepsy foundation; Jul 24, 2013; www.epilepsyfoundation.org 17. Pulse; Medline Plus; National Library of Medicine, National Inst. Of Health. http://www.nlm.nih. 7. FDA drug safety communication: codeine use in certain children after tonsillectomy and/or gov/medlineplus/ency/article/003399.htm. adenoidectomy may lead to rare, but life-threatening adverse events or death; Feb 20, 2013; www. 18. American Heart Association; Guidelines for CPR and ECC 2010. fda.gov/drugs/drugsafety/ucm313631.htm 19. Wilson, W., Taubert, K., Gewitz, M.; et. al.; Prevention of infective endocarditis: guidelines from the 8. Sherry, J.; Child deaths from anesthesia; RDH Magazine; Vol 29. Issue 2. American heart Association…; JADA; Jan 2008;139,3S-24S. 9. Guideline on use of nitrous oxide for pediatric dental patients; Council on Clinical Affairs; 2013; 20. Siegal, MA; Medical management guidelines for the provision of dental care.; MedEdPORTAL; www.aapd.org/media/policies_guidelines/g_nitrous.pdf 2012. 10. Cote, CJ; Karl, HW; Notterman, DA; Weinberg, JA, McCloskey, C.; Adverse sedation events in pediatrics: analysis of medications used for sedation. Pediatrics; 2000 Oct;106(4):633-44.

Dental.EliteCME.com Page 87 Medical Emergencies in the Dental Office Final Examination Questions Select the best answer for each question and mark your answers on the online at Dental.EliteCME.com.

1. Which of the following symptoms is not a classic symptom of a 7. Many AEDs: heart attack? a. Use voice prompts. a. Pain through the arms, neck or back. b. Cannot be used on patients with very hairy chests. b. Nausea. c. Are safe to use when the patient is in contact with water. c. Perspiration. d. Are permanently mounted to a wall. d. Vomiting. 8. Which drug in the emergency medical kit is the most important 2. Hypoglycemia occurs when blood sugar levels are: medication to have on hand? a. Below 80 mg/dl. a. Epinephrine. b. Below 180 mg/dl two hours before a meal. b. Glucose. c. Between 70-130 mg/dl just before a meal. c. Nitroglycerine. d. Over 180 mg/dl after a meal. d. Albuterol.

3. Which of the following allergens is not usually found in polishing 9. What method should be used to alert team members that a medical paste? emergency has occurred in the office? a. Gluten. a. Yelling. b. Fruit flavoring. b. Finding the nearest team member. c. Nuts. c. Asking one to call 911. d. Milk protein. d. Using a code word or phrase.

4. To determine whether a patient is likely experiencing a stroke, 10. The best way to prepare for a medical emergency is to: follow the acronym: a. Make emergency training part of your annual continuing a. FAST: Face, arms, speech, time. education for the entire office. b. BRAIN: Breathing, rate, attention, indicators, nervousness. b. Reschedule appointments if the patient isn’t feeling well. c. SIGN: Speed, indicators, gloves, non-mobile. c. Provide antibiotic prophylaxis where appropriate. d. HELP: Heart, eyes, listen, pain. d. Have a code word.

5. Placing a patient in the supine position will: a. Help asphyxiation. b. Support blood flow to the brain. c. Make it easier to perform abdominal thrusts. d. Enable a cleared airway for CPR.

6. A healthy adult has an average respiration rate of: a. 24-40 breaths per minute. b. 30-60 breaths per minute. c. 12-20 breaths per minute. d. 10-30 breaths per minute.

DOH04EDE17

Page 88 Dental.EliteCME.com Chapter 4: Periodontitis and Systemic Health Conditions

2 CE Hours

By: Sharon Boyd, RDH

Learning objectives Upon completion of this course, the learner should be able to: ŠŠ Adapt periodontal patient education to conform to the medical ŠŠ Identify at least five major systemic health conditions that are conditions of the patient. linked in severity with periodontal disease. ŠŠ Record data to monitor the current and future periodontal health of ŠŠ Describe how periodontal disease and certain diseases directly the patient at maintenance appointments. impact the severity of one another. ŠŠ Decide when to make appropriate medical referrals. ŠŠ Relate to patients the significant impact that periodontal disease ŠŠ Observe improvements in the periodontal condition of patients can have on their systemic health condition. who have managed their systemic health conditions. ŠŠ Distinguish whether or not a patient’s periodontal disease severity ŠŠ Adapt maintenance appointments appropriate for periodontal may be linked to a particular systemic health condition. patients that suffer from systemic health complications. ŠŠ Construct an appropriate care plan for managing periodontal disease in patients with systemic medical conditions.

Health Conditions, Disorders, and Diseases Associated with Periodontitis

Introduction Many health conditions and diseases are impacted by the presence and providers give on a daily basis. Research continues to link gum disease severity of periodontitis. Oral healthcare providers should understand with various health conditions each year; thus, patient education plays the relationship of disease conditions associated with periodontal a key role in helping patients prevent or manage related systemic disease. The knowledge of how periodontal disease impacts patients health conditions. should be implemented into the patient education that oral healthcare

Down syndrome According to the National Institute of Dental and Craniofacial Patient education for people with Down syndrome Research (NIDCR), “Periodontal disease is the most significant oral Encouraging independent home care in patients with Down syndrome health problem in people with Down syndrome.” [1] In fact, pediatric is important. Some of these patients are capable of self-care while patients with Down syndrome may present “rapid, destructive” forms others are not, so involving their caregiver is vital. A child may of the disease at a very young age. Due to the extensiveness of the become independent and effective at a home care routine at a much periodontal condition, many individuals with Down syndrome are later age than children without Down syndrome do [2]. Thus, reviewing susceptible to losing their anterior teeth during their teen years. Thus, oral hygiene is vital at each subsequent appointment. preventive dental care and therapy for gum disease is vital. Although Dental professionals should ask patients to demonstrate how periodontal disease is a causative factor in premature tooth loss, it may they brush and floss at home. If patients need to modify their oral be compounded by other Down syndrome-linked factors like conical- hygiene techniques, dental professionals should utilize hands-on shaped tooth roots, bruxism, and malocclusion. A comprehensive care demonstrations with them. If independent oral hygiene is not possible, plan may be necessary to help these patients avoid premature tooth they should review the same step-by-step approach with the caregiver. loss due to these additional factors. Many able-bodied caregivers do not have a comprehensive knowledge Managing periodontal disease in patients with Down syndrome of oral hygiene, which may create a lapse in appropriate prevention. Chlorhexidine rinse is effective when used daily for antimicrobial Dental professionals should not to assume that the caregiver lacks a effects in patients with Down syndrome. However, it may not be grasp of proper preventive dentistry for the patient. possible for these patients to use the antimicrobial rinse, due to lack of Professionals can recommend an electric toothbrush, as this can muscular control or an enlarged tongue. Instead, the chlorhexidine can increase the amount of plaque biofilm removed during brushing. be applied with a toothbrush or even a small spray bottle. A caregiver Flossing with a floss pick or holder will be easier for both patients and may need to assist in the home maintenance process. caregivers. Experts suggest that these patients benefit the most when Unless the patient has unmanaged periodontitis, most people with Down their home oral hygiene routines are conducted at the same time each syndrome only need to be seen on a traditional prophylactic schedule. day, in the same location, using the same methods., Therefore,, helping Due to the severity that juvenile periodontitis may have on younger the patient and their caregiver create a routine is extremely important. patients with Down syndrome, some patients may require a scaling and Because Down syndrome is not a medical condition that can be [2]. root planning (SCRP) as frequently as every three months “reversed” or “improved,” patient education will focus on management of these patients’ oral health habits and care routine rather than management of their syndrome.

Dental.EliteCME.com Page 89 Diabetes Because periodontal disease directly correlates to increased blood Children should not be overlooked when it comes to managing patients sugar levels, management of oral health conditions is significantly with diabetes with diabetes in the dental office. A direct correlation important for patients with diabetes who hope to better manage their also exists between pediatric patients with unmanaged diabetes glucose levels [3]. Likewise, when a person is diabetic, it makes them mellitus and their periodontal health condition [5]. two to three times more susceptible to develop periodontitis than Patient education for people with diabetes [4]. The severity of one condition is often patients without diabetes It is suggested that patients with diabetes should utilize a sonic or dependent on the severity of the other. oscillating electric toothbrush to improve the amount of plaque Other complications associated with the patient’s diabetes may be removal during brushing. Such brushes may also limit the amount of indirectly related, and in general, periodontal disease is considered to be plaque that is retained interproximally, although it does not replace a common “complication of diabetes.” Therefore, patients with diabetes flossing [4]. Oral health professionals should advise their patients to should patients with diabetes be aware of their current oral health and use an over-the-counter antibacterial rinse or prescription rinse as a take proactive measures to prevent periodontal infection, rather than proactive or therapeutic measure on a daily basis. waiting to treat it once it has progressed to an advanced stage. Patients with diabetes will best address their periodontal condition with How periodontitis impacts diabetic health a combination of dedicated oral hygiene and management of their blood The severity of the periodontal condition is also shown to directly sugar levels through medication, diet, and exercise. Treatment of only one correlate to the severity of the diabetic condition. The American or the other may result in an unsuccessful or lengthy recovery process. Academy of Periodontology states that “periodontal disease may make In addition to an increased risk of periodontal disease, other oral health it more difficult for people who have diabetes to control their blood symptoms of diabetes may include xerostomia, increased dental caries, sugar.” Consequently, the severity of periodontal condition impacts candida infections, burning mouth syndrome, lichen planus, and poor the body’s ability to function in people with elevated blood sugar. As a wound healing. If a patient exhibits these symptoms but is unaware result, diabetic periodontal patients are placed “at an increased risk for that he or she could potentially have diabetes, a medical referral is diabetic complications.” appropriate. The dental care provider plays a key role in helping an Managing periodontal disease in patients with diabetes undiagnosed patient seek out medical care. Oral health professionals understand through regular observance just During patient education, oral health professionals should stress how closely the two conditions are linked. Generally, patients with the relationship between unmanaged gum disease and an increase diabetes are more prone to periodontitis, especially if their blood in blood glucose levels. Professionals may also need to provide sugar levels are not under control. Experts recommend appropriate nutritional counseling. periodontal therapy, such as scaling and root planing, followed by maintenance appointments approximately every six months [4]. By providing therapeutic periodontal treatment, most patients with diabetes exhibit improved glycemic control for as long as three months following the procedure.

Hyperparathyroidism Hyperparathyroidism is an excessive production of parathyroid Periodontal charting may be altered if inflammation induces hormone. This hormone impacts the body’s ability to control the pseudopocketing, thus the gingival attachment levels should consider metabolism of calcium. If not addressed, it can eventually lead the distance of the gingival margin to the cementoenamel junction, or to osteoporosis, which the course will address later. Periodontal CEJ, as well as the gingival margin to the clinical attachment. This will health may impact the severity of side effects seen in patients with prevent or at least decrease the likelihood of false pockets from being hyperparathyroidism. recorded in the patients chart. Clinical symptoms of hyperparathyroidism noted during dental exams Patients with hyperparathyroidism should have a bleeding index present themselves predominantly through radiographic images. The recorded during preventive or maintenance appointments. Discussing the mandible may present multilocular radiolucencies and loss of the findings of the bleeding index is an important step in identifying areas of lamina dura. The lamina dura is often described as having a “ground pseudopocketing from those with active periodontal infections. glass” appearance on the radiographic film.[6] Patients may also Patient education for people with hyperparathyroidism experience rapid demineralization of their supporting alveolar bone Oral health professionals should instruct patients to schedule when periodontitis coincides with their health condition. It may also regular appointments in order to monitor the attachment levels of be noted that some patients with hyperparathyroidism exhibit brown their gum tissues. Professionals may also need to recommend oral tumors, malocclusion, and widened pulp chambers. [7] hygiene aids, such as a water flosser, that make it easier to clean Managing periodontal disease in patients with hyperparathyroidism along pseudopockets without causing tissue trauma. Professionals Many patients with hyperparathyroidism present with should advise patients to discuss concerns of gingival hyperplasia pseudopocketing, due to the inflammation of their gingival tissues. with their medical doctor, or the physician that is prescribing their Hyperparathyroidism may also have an impact on the prevalence of hyperparathyroid drug. oral tori, although this has not yet been proven. If the patient does have In addition to the multiple radiographic findings associated with tori or other types of exostosis, this may impact the comfort of patients hyperparathyroidism, patients may also experience accelerated tooth during clinical procedures such as taking radiographs. eruption, an increased susceptibility to tooth decay and burning mouth Due to the impact that hyperparathyroidism can have on loss syndrome. [7] If these conditions are noted clinically, professionals of periodontal bone support, patients must be seen for regular should advise patients to seek a medical consultation. Educating prophylactic appointments and closely supervised for any changes in patients on management of these common side effects can help them connective tissue levels. avoid unnecessary tooth loss or discomfort.

Page 90 Dental.EliteCME.com Cardiovascular diseases Cardiovascular diseases encompass several health conditions involving If a person has elevated subgingival plaque levels, they are at an increased the brain, heart, and circulatory system. Heart disease, stroke, and elevated risk to have both elevated systolic and diastolic blood pressure readings. blood pressure are all examples of cardiovascular conditions shown to [11] It should be noted that certain types of medications, like calcium have a relationship with the presence and severity of periodontal disease. antagonists, could increase the appearance of gingival inflammation or hyperplasia, even if the patient has a healthy periodontium. Heart disease Numerous research studies have proven that heart disease is directly Management of patients with cardiovascular diseases linked with active periodontal disease. The association is attributed Oral health care providers must be aware that gum disease can impact to the body’s inflammatory response triggered by the presence of or aggravate underlying heart conditions. According to the American an infectious periodontal condition [8]. Most experts believe that the Academy of Periodontology, “Patients at risk for infective endocarditis severity of the gum disease directly impacts a person’s likelihood of may require antibiotics prior to dental procedures.” Although this developing heart disease. In fact, patients with gum disease may be is not a blanket guideline for all periodontal patients, those with twice as likely to develop heart disease compared to patients that have identified heart conditions should have their cardiologist coordinate mouths that are free of gum disease [9]. care with their dental provider before having any periodontal Stroke treatment, including a prophylaxis. Like heart disease, stroke has been proven to show a direct correlation Patients with elevated blood pressure levels should be referred to their with the severity of periodontal disease present in dental patients [8]. primary care physician or cardiologist for follow up. In patients with a In fact, patients with severe periodontal disease with subgingival systolic blood pressure over 180 mm Hg or diastolic pressure over 110 pockets greater than 6mm in depth were four times more likely to mm Hg, all dental treatment must be delayed. If readings are as high suffer from cerebral ischemia [10]. This is because periodontal disease as 210 mm Hg (systolic) and 120 mm Hg (diastolic), then emergency is directly linked with an increase in inflammation, which impacts the medical care must be sought [12]. cardiovascular system. Subgingival bacteria have also been shown to Patient education for people with cardiovascular diseases enter into the bloodstream and create lodged pathogens within carotid Patient education should consist of lifestyle changes like a balanced diet plaque of the arterial walls. and adequate physical activity combined with a thorough oral hygiene High blood pressure routine at home. Oral health professionals should ensure that patients Oral health professionals should record patients’ blood pressure understand the link between the amount of oral bacteria and the risk of readings at all patient appointments to identify medical developing or increasing the severity of their cardiovascular condition. emergencies before they occur. It also serves as a screening process Professionals should advise patients to take their medication as for patients with unknown hypertension. As a general rule, patients prescribed, as well as monitor their blood pressure routinely at home. should have a systolic reading of less than 120 mm Hg and a Professionals should ask patients whether or not they have taken their diastolic reading of less than 80 mm Hg. blood pressure medication when they arrive for their appointment.

HIV/AIDS Oral manifestations of HIV/AIDS are usually the very first symptoms Universal precautions mean that professionals treat all patients that are seen in immunocompromised patients. Erythema and punctate as if they have disease. Patients with HIV/AIDS are no different. of the attached gingiva is usually noted, as well as cratering of the Utilizing additional protective equipment over what is already col and the presence of attachment loss. Clefting may also be noted regarded to be proper universal precautions, be it additional layers of along the marginal gingiva. Some of the most widely recognized barriers or personal protective equipment, for these patients alone is oral manifestations include hairy leukoplakia, oral candidiasis, and discrimination toward people with this medical condition. Therefore, Kaposi’s sarcoma [13]. patients with HIV/AIDS should continue to have traditional hygiene Periodontal infection is severe due to the opportunistic infections of instrumentation with ultrasonic or piezo scalers. The Centers for microorganisms caused by the suppression of the immune system Disease Control (CDC) states that “detection of HIV in aerosols [14] would also be uncommon, since the concentration of HIV in blood . An overgrowth of the pathogens is typical, due to suppressed [15] immunity. This leads to colonization of atypical pathogenic bacteria, is generally lower than that of HBV .” Meaning that patients with HIV/AIDS are equally candidates for ultrasonic instrumentation complicating the situation. compared to patients with other types of communicable diseases, such Modern treatments include highly active antiretroviral therapy as HBV (hepatitis B). No additional standard precautions above or (HAART), which has transformed HIV into a manageable condition beyond traditional patients are necessary. for the people impacted by the disease. Patient education for people with HIV/AIDS patients Managing patients with HIV/AIDS Meticulous homecare cannot be stressed enough to these patients, due to Most patients with HIV/AIDS benefit from monthly prophylactic the severity of oral manifestations and the rapid decline of periodontal appointments to prevent rapid destruction of the periodontal tissues. [5] health that is usually seen. Patients must perform traditional brushing If a patient does not yet know that he or she has HIV/AIDS, immediate and flossing habits daily in order to limit bacterial overgrowth. referral is necessary. Oral health professionals must recognize the Some studies suggest that HIV patients treated by antivirals can risk factors and oral symptoms of HIV/AIDS in order to provide experience the virus being “reactivated” by underlying co-infections or appropriate medical referrals in patients that may be unaware that they inflammatory conditions.[16] Thus, managing periodontitis plays a key have the virus. role for these patients. Oral health professionals should inform patients Due to the discomfort caused by oral manifestations of the disease, these that if oral symptoms do not respond appropriately to home care, they patients may require additional steps to keep them comfortable during should schedule more frequent prophylactic dental appointments. prophylactic or periodontal therapies. Professionals may need to use analgesics during the appointment to reduce the extent of discomfort.

Dental.EliteCME.com Page 91 Respiratory diseases The presence of periodontal bacteria can also put patients at increased Managing patients with respiratory diseases risk to develop respiratory diseases or have more severe pneumonia or Decreasing the risk for respiratory diseases begins with a thorough chronic obstructive pulmonary disease (COPD). knowledge of oral hygiene. However, changes in salivary function and Pneumonia viscosity could be a significant risk factor in the patient’s susceptibility Periodontal bacteria, along with other forms of bacteria in the oral toward respiratory illnesses. Dry mouth is fairly common due to changes cavity, have the potential to be aspirated. If lodged in the lungs, in salivary gland function combined with medications that patients may respiratory diseases such as pneumonia have the ability to develop, be taking for health conditions. One bacterium, S. sobrinus, is linked [17] with xerostomia, which is known to be associated with “aspiration especially in individuals who are currently battling periodontitis . As [19] patients age, they become more susceptible to both pneumonia as well pneumonia” in hospitals. Lack of adequate salivary flow also implants a greater number of bacteria that are able to accumulate on the as periodontal disease. When bacteria are found in the lower lung, it mucous membrane linings within the respiratory system. can create inflammation and infection. Education and information on managing xerostomia is important When a person is hospitalized or placed in a nursing facility, studies for patients that are at risk for pneumonia. Oral health professionals have shown that they are generally expected to have a significant should advise patients to drink water frequently and utilize saliva increase in the levels of plaque biofilm in their mouth. If the patient substitute products as needed. is intubated, this may increase the risk of oral bacteria entering into the respiratory system. In one study, dental plaque colonization in Additionally, patients may be given chlorhexidine to reduce their risk of respiratory pathogens was found in four of the five patients who developing pneumonia. One study showed that using chlorhexidine in a acquired pneumonia while in the ICU [18]. hospital setting reduced the incidence of pneumonia within three days [19]. COPD Patient education for people with respiratory diseases Similar studies have shown the correlation between advancement Older or disabled patients that are unable to care for themselves should in periodontal disease and the prevalence of chronic obstructive have caregivers that are educated on limiting the amount of biofilm in pulmonary disorder (COPD). One study noted a trend where “lung the mouth. This includes reviewing home care for removable prosthetics function appeared to diminish as the amount of attachment loss like dentures and partials. Failing to remove the prosthesis for regular increased [18].” It is likely that the role periodontitis plays in COPD is cleaning can allow excess bacteria to accumulate over its surface, quite similar to its relationship with pneumonia. making it possible for pathogens to be aspirated. In addition to managing the care of their removable prosthesis, patients and their caregivers should be properly instructed on toothbrush and flossing techniques.

Osteoporosis Osteoporosis is defined by a bone mineral density of 2.5 standard If patients are taking bisphosphonate therapy, they should be carefully deviations below normal bone density found in young, healthy bone [20]. monitored, as the medication could potentially interfere with repair About 33 percent of all women ages sixty to seventy are impacted by of bone structure in periodontally compromised areas. Other studies osteoporosis, and about 66 percent of women over the age of eighty. suggest that the presence of periodontal disease could impact patients Due to bone loss that can occur through the jaw, osteoporosis holds a placed on a bisphosphonate therapy by contributing to the rapid [17] destruction of bone tissue, or bisphosphonate-related osteonecrosis significant risk to periodontal disease, and vice versa . Loss of bone [22] density throughout the mandible and maxilla caused by osteoporosis of the jaw (BRONJ) . Thus, active periodontal disease could be a contraindication for some types of osteoporosis therapies. can compound the severity of existing periodontal conditions. As a result, patients with periodontitis need to remain on a heightened alert Osteonecrosis of the jaw may be present if the patient exhibits when osteoporosis is present, due to the increased risk of tooth loss. symptoms of tooth mobility, numbness, pain, swelling, or exposed bone. [23] Unfortunately, there is not yet a successful treatment for BRONJ, so Managing patients with osteoporosis patients are usually placed on an antibiotic or anti-inflammatory. In patients who are currently suffering from active or managed periodontal disease with a new diagnosis of osteoporosis, oral health Patient education for people with osteoporosis professionals should place emphasis on the importance of regular If a patient has already been diagnosed with periodontal disease prior prophylactic or periodontal maintenance appointments. Preventive to the diagnosis of osteoporosis, oral health professionals should home care may not be adequate, due to the depth of periodontal emphasize that preventive care and maintenance are vitally important pockets around the teeth. It is important to note that osteoporosis to avoid relapse or accelerated periodontal bone loss. An existing cannot be diagnosed through a conventional radiograph until there is periodontal disease condition could easily progress into something an approximately 50 percent decrease in bone density [20]. more severe, such as tooth loss. Professionals should take special care These patients will be predisposed to additional loss of supporting to monitor the mobility, bone levels, and attachment loss of patients alveolar bone even if they have already successfully managed a with osteoporosis, especially in women taking bisphosphonate drugs. previous periodontal infection. It may be that both the dental provider Professionals should advise these patients to adopt a rigorous home and patient feel that the condition is managed enough to the point hygiene plan each day, and schedule maintenance appointments that proactive measures are not needed. However, osteoporosis is every three to six months, based on periodontal screenings. They “considered a risk factor for periodontal disease progression” due to should also alert patients taking bisphosphonate medications of the the impact that it has on the bone throughout the jaw, regardless of warning signs for BRONJ. whether or not periodontal disease is already present. [21] In general, there is a “greater propensity to lose alveolar bone in subjects with osteoporosis, especially in subjects with preexisting periodontitis.”

Page 92 Dental.EliteCME.com Cancer Having periodontal disease can increase a person’s risk of developing For patients undergoing chemotherapy, an oncologist must always certain types of cancer. According to the American Academy of be consulted prior to prophylactic appointments. The oncologist Periodontology, researchers have found that men with gum disease will need to perform blood work to evaluate the platelet count prior are 49 percent more likely to develop kidney cancer, 54 percent more to determining whether or not certain types of dental treatments likely to develop pancreatic cancer, and 30 percent more likely to (including a prophylaxis) are appropriate. develop blood cancers [17]. Other known cancers directly linked with It is recommended that oral health professionals complete all periodontal disease commonly include oral, esophageal, gastric, and dental treatment prior to starting treatments like chemotherapy or pancreatic cancers [24]. radiotherapy in leukemic patients [28]. These patients will likely Patients with leukemia may exhibit oral manifestations such as experience an increase in bleeding due to malignancies in their white mucosal bleeding, ulceration, petechiae, and diffuse or localized blood cells. Osteonecrosis of the jaw may also be evident. If a patient gingival enlargement [25]. Secondary oral conditions may also include is experiencing advanced disease or relapse, professionals should oral candidiasis, herpes simplex, and bone loss. Some patients with perform only palliative treatment before discussing a plan of care with leukemia also experience an alteration in their sensation of taste. the patient’s oncologist. However, it is important to note that there have been some cases In a child treated with marrow transplants, dental procedures may where the only clinical manifestation of leukemia was the presence [29] [26] need to be delayed for as long as one year afterward . However, of gingival enlargement . Leukemia can lead to the most acute preventive and non-surgical dental appointments are encouraged. form of generalized gingival enlargement [5]. Thus, attention to the periodontium is extremely important when assisting patients in the Patient education for people with cancer screening process for systemic health conditions like that of leukemia. Cancer patients have compromised immune systems, giving them an additional burden when it comes to management of other types Managing patients with cancer of infections such as periodontal disease. Controlling the amount of The National Institute of Dental and Craniofacial Research plaque biofilm can help to limit the severity of cancers like leukemia. recommends extracting teeth within the proposed radiation field (of [5] This is because leukemia manifests when there is a pronounced patients undergoing radiation therapy) that may pose a problem for the inflammatory response, and an increase in gingival swelling and [27]. After radiation therapy, professionals should patient in the future bleeding will be noted. have the patient return for every four to eight weeks for a prophylactic appointment and evaluation. This should continue for the first six Proper oral hygiene education and extremely rigorous prophylactic months after the radiation therapy. maintenance schedule are vital in these patients.

Erectile dysfunction One of the more recent medical conditions found to be linked with This study was conducted on men in their thirties, much younger than periodontal disease is erectile dysfunction (ED.) Approximately 30 million when most adults consider erectile dysfunction to be of a concern. men in America are impacted by ED and it affects men of all age groups. Men may be less likely to seek out preventive dental care than women. Although many experts do not believe that one causes the other, the Although it can seem awkward to screen for ED on medical history existence of gum disease is now considered to be a risk factor in forms, doing so can assist men in managing or reversing their ED men with erectile dysfunction. According to the Journal of Sexual through proper oral health care. Thus, professionals should take Medicine, men with gum disease were three times more likely to suffer appropriate educational steps in order to inform male patients on the from erection problems [30]. A separate study showed that 53 percent of link between the two conditions. men with ED also had severe periodontal disease. An interesting note Patient education for men with erectile dysfunction is that none of those men were smokers and all of them were between If a male patient has indicated he is experiencing ED, during medical the ages of thirty and forty [31]. screening, professionals may recommend placing him on a three- These two conditions are linked the same way that periodontitis is month recall schedule until symptoms improve. If periodontitis is associated with cardiovascular disease: inflammation. If diseased present, professionals should perform necessary scaling and root oral bacteria spread through the cardiovascular system and create planing procedures as necessary. inflammation or damage to the blood vessels, they can also contribute Since this condition may be more uncomfortable for both patients and to erectile disorders. oral healthcare providers to discuss, professionals can consider giving Managing patients with erectile dysfunction their male patients literature on the topic as part of their take-home One study showed that men who received periodontal therapy saw an or welcome packets. Sparking the conversation through educational improvement in their erectile dysfunction within three months. [32] literature or a written screening process may help a male patient feel more comfortable discussing the situation.

Infertility The presence of gum disease can impact a couple’s ability to conceive. Even more significant was another study that showed men who had The presence of periodontal infections can have a direct impact on chronic or aggressive periodontal disease were at a high risk of having diminished fertility. Periodontitis can impact both male and female a very low or even a zero sperm count [35]. With little to no sperm fertility. Thus, professionals should inform patients of the impact that count, it becomes more difficult or impossible for the female partner gum health can have on planning a family in the near or distant future. to conceive. Thus, managing the periodontal condition in the male partner is essential to improving their likelihood in improving sperm Male infertility count, quality, and motility. A correlation exists between the presence of periodontal infections and diminished fertility in men. Deeper periodontal pockets are Female infertility shown to have a positive association with sperm sub-motility in men. A study performed on women hoping to conceive showed a [33] In addition, the overall quality of the semen is also found to be relationship between the length of time that it took for the women diminished in male patients with deep periodontal pockets. to conceive and whether or not periodontal disease was present.

Dental.EliteCME.com Page 93 Women with planned pregnancies generally experienced a pregnancy Managing dental patients battling infertility delayed by approximately two months longer if they had gum disease Management of both male and female patients hoping to conceive compared to pregnancies planned by women with healthy mouths [34]. should follow the recommended method of care for other adults with In some cases, it took women with gum disease longer than twelve periodontal infections. The key is to identify patients who may be months to conceive at all [35]. The study showed that elevated blood trying to conceive and educate them on the relationship between their markers that trigger inflammation were very high in women with oral health and the difficulty that they are experiencing. Health history gum disease. Those same cytokines can trigger inflammation of the updates should make it possible for patients to communicate whether or endometrial lining of the uterus [36]. Thus, the presence of inflammation not this may be a current medical condition that they are struggling with. of the periodontal tissues could be linked with the response within Patient education for people trying to conceive the endometrial lining, making it more difficult for a fertilized egg to Professionals should recommend that these patients maintain periodic implant itself within the uterus. maintenance appointments until their periodontal symptoms are reversed. Professionals should educate patients on proper home oral hygiene methods as appropriate. They should also inform female patients on the risk that periodontal disease can have on their pregnancy duration as well as risks that it poses to their unborn child.

Premature labor and low birth weight infants Due to the increase in pro-inflammatory cytokines, periodontal disease successful in reducing their rates of preterm birth [39]. Those same can impact the health of pregnant women and their unborn child. Two women were also placed on a chlorhexidine rinse after their of the most significant issues are premature labor, and thus, infants treatment. Maintenance appointments were performed ever two to with a low birth weight. three weeks until their delivery date. Studies have shown that pregnant women who had active periodontal Some women may exhibit hormone specific gingivitis only during disease were nearly three times more likely to experience preterm birth their pregnancy, even if they practiced proper oral hygiene habits than women with healthy mouths [37]. That is, before thirty-two weeks up to that point. Dental personnel should competently differentiate gestation. Thus, active gum infections are a significant risk factor for hormonal-induced pregnancy associated gingivitis from tissue complications during a pregnancy. detachment caused by active bacterial induced periodontal disease. It is also believed that periodontal bacteria spread through the gums Patient education for pregnant women into the bloodstream, eventually reaching the fetus [38]. The effect on Pregnant women should be made aware of the significant importance the fetus from this type of cross-infection is not yet known, other than that preventive dental care poses to the success of their pregnancy. the risk it poses to the baby having a lower than average birth weight. Professionals should advise female patients to schedule regular Managing pregnant patients prophylactic appointments during the conception process through In pregnant women with identified periodontal disease, therapeutic early to mid-pregnancy. dental treatment was shown to decrease their risk of early delivery. The Some studies suggest that a large percentage of prenatal women lack women that received periodontal therapy after being diagnosed with the knowledge of what constitutes an oral disease [40]. Thus, patient periodontitis during gestation experienced lower rates of preterm birth education should begin early, and if possible, before conception. The than women who did not receive treatment during their pregnancies [37]. education should include describing signs and symptoms of gingivitis, Scaling and root planing has been safely performed in women periodontal disease, and proper oral hygiene methods. between thirteen to twenty-one weeks gestation and is considered

Conclusion Periodontitis has direct and indirect correlations with diseases and If embarrassment is a factor, then professionals may want to include conditions like diabetes, Down syndrome, hyperparathyroidism, written material inside of a welcome or take-home packet that each and osteoporosis, cancers (including leukemia,) respiratory diseases, every patient receives as a general procedure within the dental practice. erectile dysfunction, heart disease, stroke, HIV/AIDS, infertility, Patients identified at an increased risk relationship should receive premature labor, and low birth weight. The relationships are appropriate treatment plans related to their given health condition. predominantly impacted by the bacterial levels and inflammatory Appropriate referrals, follow up, and patient education can assist conditions that exist due to the presence of periodontal disease. patients in eliminating periodontal disease and decreasing their Screening patients for periodontal disease and performing severity of systemic conditions associated with the infection as comprehensive medical reviews on each patient can identify risk well as tooth loss. In most cases, patients benefit from non-surgical factors that may impact their quality of life. Some conditions may periodontal scaling and root planing (SCRP) along with a higher not seem like those that are traditionally screened for by a dentist, but frequency of prophylactic or periodontal maintenance appointments should not be overlooked. until adequate oral health is achieved.

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American Academy of Periodontology; Diabetes and Periodontal Disease; Retrieved September 25, literature.; J Dentistry 2010; 38(2) p.83-95. 2015 from https://www.perio.org/consumer/diabetes.htm. 25. Chi, A.,DMD, Neville, B., DDS, Krayer, J., DDS, et.al.; Oral Manifestations of Systemic Diseases.; 4. Teeuw, W.J., DDS; Gerdes, V.E.A., PhD; Loos, B., PhD; Effect of Periodontal Treatment on Am Fam Physician. 2010 Dec 1;82(11):1381-1388. Glycemic Control of Patients with diabetes: a systematic review of meta-analysis. Oct 20, 2009. 26. Menezes, L., Roa, J.; Acute myelomonocytic leukemia presenting with gingival enlargement as the 5. Darby, M.L.; Mosby’s Comprehensive Review of Dental Hygiene; 7th edition. only clinical manifestation; J Indian Soc Periodontal. 2012 Oct-Dec; 16(4): 597–601. 6. Fehrenbach, M.J., Weiner, J.; Saunders Review of Dental Hygiene. 2nd edition. 27. National Institute of Dental and Craniofacial Research; Dental Provider’s Oncology Pocket 7. 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American Academy of Periodontology; Men’s sexual health may be linked to periodontal health; 10. Grau, A., et.al.; Periodontal Disease as a Risk Factor for Ischemic Stroke; Retrieved September 25, Retrieved on September 25, 2015 from https://www.perio.org/consumer/erectile_dysfunction. 2015 from http://stroke.ahajournals.org/content/35/2/496.full 31. Paxman, O.; What does gum disease have to do with erectile dysfunction?; Retrieved on September 11. Desvarieux, M., MD, et. al.; Periodontal bacteria and hypertension: The oral infections and 25, 2015 from http://healthland.time.com/2012/12/05/what-does-gum-disease-have-to-do-with- vascular disease epidemiology study; J Hypertens. 2010 Jul; 28(7): 1413–1421. erectile-dysfunction/. 12. Zahedi, S., DDS, Marciniak, R., DMD; The hypertensive patient; Retrieved September 25, 2015 32. Brownstein, J., Treating gum disease may treat erectile dysfunction; Retrieved on September 25, from http://www.oralhealthgroup.com/news/the-hypertensive-patient/1000880285/?&er=NA 2015 from http://www.foxnews.com/health/2012/12/04/treating-gum-disease-may-treat-erectile- 13. Scarlett, M., DMD; Dental Treatment Issues for Patients with HIV/AIDS; Inside Dental Assisting, dysfunction/. May/June; 5(6). 33. Killinger, A., Hain, B., Yaffe, H. et al., Periodontal status of males attending an in vitro fertilization 14. Mataftsi, M., Skoura, L., Sakellari, D.; HIV infection and periodontal diseases: an overview of the clinic; J Clin Periodontol. 2011 Jun;38(6):542-6. post-HAART era.; Oral Diseases (2010) doi:10.1111/j.1601-0825.2010.01727.x 34. Fertility Authority; Dental health matters for fertility; Retrieved on September 25, 2015 from https:// 15. Centers for Disease Control; Bloodborne Pathogens and Aerosols: Infection Control FAQs; Retrieved www.fertilityauthority.com/blogger/claire/2012/3/18/dental-health-matters-fertility. September 25, 2015 from http://www.cdc.gov/oralhealth/infectioncontrol/faq/aerosols.htm. 35. Medical News Today; Women’s Fertility Linked to Oral Health; Retrieved on September 25, 2015 16. Uppoor, A., Nayak, D.; HIV and Periodontal Disease: Redemption or Resurrection; J AIDS Clinic from http://www.medicalnewstoday.com/articles/230568.php Res 2012, 3:7 36. Flanagan, N., 4 things no one tells you about infertility; Retrieved on September 25, 2015 from 17. American Academy of Periodontology; Gum Disease and Other Systemic Diseases; Retrieved on http://www.damemagazine.com/2013/09/23/4-things-no-one-tells-you-about-infertility. September 25, 2015 from https://www.perio.org/consumer/other-systemic-diseases. 37. Boggess, K., MD; Periodontal disease and preterm birth; Retrieved on September 25, 2015 from 18. 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Dental.EliteCME.com Page 95 Periodontitis and Systemic Health Conditions Final Examination Questions Select the best answer for each question and mark your answers on the online at Dental.EliteCME.com.

1. Patient’s with Down syndrome may be more susceptible to 6. What bacteria is linked with xerostomia, and thereby possibly periodontal disease due to _____. “aspiration pneumonia?” a. Blunted roots. a. S. mutans. b. Conical shaped roots. b. S. sobrinus. c. Elevated glucose levels. c. S. aureus. d. Enlarged tongue. d. C. albicans.

2. Due to multilocular radiolucencies of the lamina dura in 7. After radiation therapy, cancer patients may need to return every patients with hyperparathyroidism, radiographs often contain a ______for a prophylactic dental appointment and evaluation. ______appearance. a. One to two weeks. a. Ground glass. b. Four to eight weeks. b. Lacelike. c. Three to four months. c. Webbed. d. Six months. d. Radiopaque. 8. One study showed that men that received periodontal therapy saw 3. Patients with hyperparathyroidism often present which clinical sign? an improvement in their erectile dysfunction within ______. a. Recession. a. Fourteen days. b. Gingival hyperplasia. b. Six months. c. Pseudopocketing. c. Three months. d. Pallor. d. Four weeks.

4. Blood pressure readings over _____ mm Hg systolic should be 9. Men with erectile dysfunction should be placed on a(n) _____ referred to emergency medical personnel. recall schedule. a. 180. a. Three month. b. 250. b. Six month. c. 120. c. As-needed. d. 210. d. One month.

5. Dental plaque colonization in respiratory pathogens were found in 10. Women with periodontal disease are ______times more likely to ____ of five patients who acquired pneumonia while in the ICU. experience preterm birth. a. One. a. Two. b. Two. b. Three. c. Three. c. Four. d. Four. d. Five.

DOH02PSE17

Page 96 Dental.EliteCME.com Chapter 5: Sedation and Airway Management in the Dental Office

5 CE Hours

By: Elite Staff

Learning objectives ŠŠ Explain the definition and different levels of sedation. ŠŠ Discuss the history and physical pre-sedation evaluation. ŠŠ Describe different perceptions and expectations of dental ŠŠ Identify the equipment and monitors necessary for sedation in the providers, patients, and parents. dental office. ŠŠ Discuss additional non-pharmacological behavior management ŠŠ Explain the role of staff members in sedation management. techniques that may be used in conjunction with sedation ŠŠ Define sedation and airway management, including management medications. of complications. ŠŠ Describe the necessary training to obtain sedation permits and ŠŠ Describe the post-sedation monitoring and recovery process. safely provide sedation in the dental office.

Introduction The decision to use sedation to accomplish dental treatment cannot be The definition of the word sedation is to calm or lower the excitement arrived at lightly. Dentists must review and discuss the many variables. level of the nervous system; most likely to complete a medical or Proper diagnosis and evaluations must be made. An organized, dental procedure (Webster 1986). methodical, and systematic approach is necessary to provide quality The goals of sedation in the office are documented in the American dental care. Academy of Pediatric Dentistry Guidelines. They are: The American Dental Association and the American Academy of 1. To guard the welfare and safety of the patient. Pediatric Dentistry have developed guidelines that are the standards 2. To minimize physical discomfort and pain. for sedation in the dental office. The guidelines define the ethical 3. To control anxiety, minimize psychological trauma, and maximize and legal standards the community expects providers to understand the potential for amnesia. and implement to maintain the standard of care in the community. 4. To control behavior and movement to allow safe and high-quality Deviation from these guidelines requires additional documentation. completion of the procedure. 5. To return to the pre-sedation level of consciousness and baseline vitals. Once patients meet these goals, they meet the discharge criteria (AAPD guidelines 2010).

Parental and patient expectations Parents and patients will all have their own perceptions and Here is another example: An oral surgeon is preparing to extract an expectations that need to be discussed before moving forward with impacted third molar. The surgeon makes the pre-sedation diagnosis a discussion of sedation treatment. These differences in expectations of pain that will not be controlled with local anesthesia, and also must be addressed before informed consent can be obtained. believes that access to the surgical site will be improved if the patient For example: A pediatric dentist has a 2-year-old patient present with is sedated. severe early childhood caries, or bottle caries, on the four maxillary So the surgeon plans a deep IV sedation for the dental treatment, anterior incisors, and the teeth are not restorable. The dentist believes achieved by pushing drugs in an IV that will render the patient deeply the pain from extractions can be well managed with local anesthesia, sedated. The drugs also will suppress respiration, so the surgeon and offers a conscious sedation for anterograde amnesia so the patient expects to provide some bag-mask ventilation with oxygen when the will not recall the treatment. This is done in conjunction with local drug bolus initially reaches the central nervous system. anesthesia. A layperson watching this treatment might think the patient was The child still requires protective stabilization, cries, and responds to overdosed and an emergency situation had developed. However, the the physical stimulation of treatment. A parent watching this treatment surgeon has expected this physiologic reaction because it is the desired considers this barbaric and cruel, while the pediatric dentist considers effect of the IV sedation drugs. When the patient starts to breathe on it successful treatment because the child will not recall the extractions. his own, the surgeon will proceed to inject local anesthesia and extract the tooth.

Levels of sedation Sedation treatment is a continuum. Sedation can progress from a mild The dental literature has divided sedation into three levels. These are and conscious state to deep sedation or general anesthesia extremely conscious sedation or moderate sedation, deep sedation, and general quickly. This progression can occur without warning. Dentists must be anesthesia. prepared for sedation to progress at any time because people can react The state of conscious or moderate sedation is defined as a patient differently to the same dose of a sedation medication. Being prepared who is breathing on his own, has protective reflexes intact, and can for this progressive advance is the only option. be aroused with a stimulus. A patient would respond to the statement,

Dental.EliteCME.com Page 97 “Open your eyes!” Most of the time, the route of medication This course will focus on conscious sedation and deep sedation administration will be oral, inhaled, or intramuscular (Pinkham et al rendered to accomplish dental treatment in the office setting. General 1994). anesthesia will not be discussed. The state of deep sedation is defined as a patient who is not breathing Before starting any discussion about sedation with a patient, the dental effectively on his or her own, does not have protective reflexes intact, diagnosis and treatment plan need to be completed. Then pre-sedation and might not be able to be stimulated to respond. Most of the time, diagnosis needs to be clearly defined and explained. the route of medication administration will be through vascular access Dental diagnosis and treatment can include issues such as dental or IV. Sometimes deep sedation cannot be distinguished from general caries, planned dental restorations, the need for extractions, or implant anesthesia (Pinkham et al 1994). placement. When sedation is discussed, other psychological and The state of general anesthesia is defined as a patient in a controlled physiological factors should also be clearly diagnosed. These could state of unconsciousness, accompanied by a loss of protective include pain that cannot be controlled with local anesthesia, anxiety reflexes, including the ability to maintain an airway independently, or dental phobia, behavior issues or acute stress reaction, surgical site and the ability to respond purposely to physical stimulation or verbal access issues, length of time of treatment, quantity of treatment needs, commands (AAPD Guidelines 2010). and many other issues. All of these factors will be considered in the choice of sedation and type of medications to be used.

Necessary non-pharmacological behavior management techniques It is not possible to discuss sedation for overall patient management guardian. It takes time and an investment of personal energy, without including a discussion of non-pharmacological behavior but can be very rewarding when it is successful. However, it is management techniques. These techniques may not be directly used often not realistic because insurance or Medicaid will not pay for during sedation treatment because of the level of consciousness, but additional office visits where very little documented treatment is they will certainly be applied before and after the sedation. accomplished. The process can be very successful when parents Some behavior management techniques are described below. or patients have extensive resources of money and time. Dentists ●● Tell-show-do is a behavior-shaping process that is well described should charge for this series of treatments because it is well in dental literature. It involves giving patients all the information documented as successful in dental literature. necessary about a particular subject, showing them the instruments ●● Protective stabilization or medical immobilization can be used and materials, and demonstrating examples of the sensations. to accomplish many dental procedures. This treatment is especially This needs to include all senses, such as taste, smell, sounds, effective with a healthy pediatric population with a behavior or and touching (push, pull, and vibrations). Honesty and slow cooperation problem. The technique is also very effective with progression are essential for this to work. Trust has to develop certain groups of special-needs patients. Children will certainly cry between the health care provider and patient, and communication and get upset, but their movement can be managed so it does not has to be clear. interfere with dental treatment. ●● Voice control is a behavior management technique in which ○○ Parents or guardians need to have clear expectations about people use their voice to manage behavior. A direct and clear voice how the treatment will be done, and the dentist needs to is necessary; sometimes it is loud, and at other times, it is just identify a method to determine whether the patient is having focused and direct. The tone and pace also can be altered. Short true pain or just very upset. Parents can get very upset seeing and specific instructions are necessary when specific behaviors are their children restrained if their expectations are not clearly desired or mandated. The tone and focus are as important as how discussed. loud a person speaks; the technique is as much a look or changes ○○ To decrease risk, many pediatric and adult dentists require in attitude and tone. This is a precise way to direct behavior. parents or guardians to help place their children into Informed consent is needed before this is used. Some parents protective stabilization devices. And note, it should not be will not be comfortable with this technique, and others will have done as a punishment. Some medical conditions also clearly legitimate issues, such as history of child abuse. This also will be contraindicate the use of such devices, such as osteogenesis ineffective if the patient is hearing impaired. imperfecta or a patient with a history of child abuse. The time ●● Positive reinforcement is the introduction of a reward after a in the device should be minimal, and documentation should be specific behavior. This can range from a prize to verbal affirmation similar to the way sedation is documented on a time record. to a discount of the cost of a dental procedure. Facial expressions ●● Psychological or psychiatric evaluations also are sometimes are also important. The introduction of a positive reward after necessary. Separating the dental diagnosis and mental or a behavior significantly increases the chances of the behavior behavioral diagnosis can help with the treatment. Psychological being repeated in the future. Everybody loves a prize or positive treatment can be effective when the root cause of the phobia or comments! This should be used often in the dental treatment anxiety is explored. Children often can benefit from behavior setting! shaping or modification from a psychologist. Sometimes the ●● Distraction is making the patient’s focus of the attention a treatment is more effective when done by an individual other than different stimulus that is not unpleasant and that keeps the person’s a dental professional. Some phobias are not grounded in reality attention on something other than the treatment, which then can and should be referred for evaluation and treatment (AAPD be accomplished. This can be done with music, movies, and Guidelines 2010). conversation. Many examples of ways to do this can be found in It is important to discuss any of the non-pharmacological management dental literature. Certain songs or smells can change emotional techniques in informed consent discussions with adult patients and states, which can aid greatly in management of a patient. However, parents of minors. Some parents may not approve of more aggressive professionals have to be careful about and aware of rebroadcast techniques, such as voice control. Other parents may have bad laws as well as which movies, songs, and other distractors are memories of management techniques used on them when they were acceptable to unique individuals and cultures. children, such as “hand over mouth,” that are no longer considered ●● Systematic desensitization process is to expose a patient to a acceptable by the American Academy of Pediatric Dentistry. They will treatment, circumstance, people, and environment on a repeated want to be assured such management techniques will not be applied to basis. This process increases the education of the patient or their children or adolescents (AAPD Guidelines 2010).

Page 98 Dental.EliteCME.com In summary, the dental diagnosis and treatment plans need to be explained. When this information is completely documented and a determined, the accompanying psychological and physiological mutual understanding achieved, the options for sedation can be further diagnoses need to be made, and the level of desired sedation planned. explored. Other non-pharmacological management techniques need to be

Selection of patients for in-office sedation Dentist often can make a quick decision on whether patients can be sedation should complete the same processes and checklists. This will sedated in the office based on their presentation, medical history, reduce errors and medical mismanagement, and aid in medical-legal and level of anxiety. Other patients will require a more extensive protection of the providers. evaluation, which could include multiple consultations with medical This section includes in-depth evaluation of the medical history and professionals. The best approach to pre-sedation evaluations is to anesthesia classifications. It also will discuss the relationships of dental use a systematic approach. All patients being considered for in-office and social histories to sedation, and necessary limited physical exams.

The medical history The medical history is more than just a sheet of paper that dentists give an allergic-profile patient or one with allergies to eggs and soybeans to patients to complete before they begin dental treatment. The history (Murphy et al 2011). form gives dentists information and directs or focuses their follow-up Patients also may report being “allergic to anesthesia” if there is a questions to develop a true review of systems. The form is a tool that positive history of malignant hyperthermia in their family. Patients gives dentists a systematic approach to learning about the medical, with mitochondrial diseases or muscular dystrophy diagnoses dental, and social histories of the patient. also sometimes report they are allergic to anesthesia because of When systemic treatment is to be done, such as sedation, the scope of known complications of certain anesthetics with these conditions. the information gathered needs to be expanded. The medical model These patients should be managed in a hospital setting with an is the preferred method of developing a clear understanding of the anesthesiologist. specific conditions and issues of each patient. In the medical world, a Any patient who presents with a highly allergic profile or atypical comprehensive history and physical exam have to be completed when reaction to sedation drugs should be referred to a hospital setting a patient is admitted to the hospital. A history and physical also has to to have treatment under the care of an anesthesiologist. Pay close be completed before any day-surgery or general anesthesia. This same attention to patients who have had anaphylactic-type reactions. These method of information-gathering should be applied in dentistry when patients would be high risk to treat in an office setting with sedation. dentists plan systemic medications and sedation. Current medications taken require the dentist’s review. Below is a Dental offices that offer sedation services need to develop their small list of medications by system and their interactions with dental own pre-sedation evaluation forms. The medical form used in your treatment. All medications a patient takes should be investigated, community hospital or one found through a search on the Internet are and when necessary, the dentist should consult with the prescribing good methods to obtain samples of these history and physical forms. physicians. The number and type of medications will provide extensive The forms can then be altered for the specific needs of the dental information about a patient. practice. Using a version of the same forms used in your medical and dental community will also provide medical-legal protection. Allergy and asthma medications, such as antihistamines, Benadryl, Claritin, Singular, albuterol and QVAR, point to an allergic profile. The medical history will encompass a majority of the information that The frequent use of albuterol or a rescue inhaler is a red flag because it needs to be obtained to safely sedate patients in the office. The history points to a condition that is not well controlled. Daily-inhaled steroids, component must encompass a complete review of the systems. such as QVAR, indicate the management of a chronic respiratory The chief complaint should be captured. It will likely be evaluation problem. Additional asthma medications, emergency room visits, and for dental treatment with sedation. Any additional complaints should hospital stays also are indicators about the control and severity of the obviously be evaluated by the appropriate health care professional disease. This should be addressed and discussed with the health care before elective dental treatment is attempted. professional managing the medical condition. History of any present illness should include any pending dental Frequent use of medications, access to higher levels of medication, treatment that needs sedation to be accomplished. Any transient and multiple medications indicate a patient who may benefit from illness, such as a cold or a virus, should be documented. Any recent being treated in a hospital setting. Most dentists use “having to use attempted treatment or treatment failures should be documented. This the rescue inhaler within the last 30 days” as a marker to not sedate documentation of failed treatment without sedation protects the dentist a patient in the office. Sedation of any patient with the diagnosis from a medical-legal perspective. Any failed sedations should also be of asthma or reactive airway disease that is managed on the above researched and documented. medications should not be done without a consultation with the The allergies section should not be lightly skipped over. A dentist managing physician. needs to take the time to discuss true allergies to medications verses Antibiotics are important to be aware of when discussing sedation adverse drug reactions. Dentists also need to know which drugs are because of the reason why they are prescribed as well as some of their truly not safe options to use with a patient. Allergies to drugs used side effects. Patients with active infections need to have their level of in sedation or emergency situations need to be well understood, and infection, or sepsis, assessed before any treatment is done. If a patient allergies to other reactive substances, such as latex, also need to be is not responding well to the antibiotics, then the level of sepsis could identified. increase. One commonly used drug for sedation and anesthesia is propofol. These patients by definition could have a higher heart rate, or There is evidence in the literature of increased allergy risk with IgE- tachycardia, and an increased need for fluid. If a patient with this kind mediated food allergies and atopy. Egg and soybean allergies are also of progressing infection was made NPO for oral or IV sedation without reported to be an issue with propofol by some studies, but no higher IV maintenance fluids, the patient can go into shock. Patients with risk in others. Most physicians and dentists will not use propofol with active systemic infections require more investigation.

Dental.EliteCME.com Page 99 Antibiotics can also cause serious gastrointestinal issues. Clindamycin were serving as upper airway obstructions. The dentist also needs to is an antibiotic often used to treat dental infections and also is used as be prepared to ventilate the patient if the Valium causes decreased a prophylactic antibiotic for patients with cardiac issues. The drug can respiratory effort or apnea. cause pseudomembranous colitis or a severe form of diarrhea. Regular A consultation with the neurologist is indicated. The dentist needs to diarrhea also can result from a course of clindamycin. The diarrhea can know the level of control of the seizures, frequency, and medications cause dehydration and electrolyte imbalances that make sedation less used, and must be aware of the side effects of the medications. He or safe. she must be comfortable managing a seizure and the complications In general, the reason why a patient is on an antibiotic needs to be of seizure medications if sedation is done in the office. Most of these investigated and the level of infection needs to be assessed. If the patients are going to be treated in a hospital with the appropriate dental diagnosis is not the reason for the medication, then consider medical professionals ready to intervene, if needed. delaying the dental treatment. If the dental diagnosis is the reason for Anticoagulants or “blood thinners”. When a patient presents and the antibiotic, the level of infection must be closely assessed. Any is taking anticoagulants daily, the dentist must ask focused questions. progressive level of symptoms, such as fever, swelling, or tachycardia, The first is why the person is taking the medications. The next should should be assessed before making a patient NPO for dental sedation. be whether there is a history of previous cardiac surgery. The dentist Progression of infection may require the patient to be hospitalized, should follow up with questions about any congenital cardiac issues. possibly given IV maintenance fluids, IV antibiotics, and management These patients will require consultation with the involved cardiac of the patient by an anesthesiologist for sedation. Sedation in the office specialist. should be limited to patients with local infections and no systemic Patients taking aspirin are now thought to be safer if they are left on symptoms of sepsis or shock. the aspirin and the bleeding issues are managed locally, if possible. Office treatment and sedation is appropriate for patients who are Often, laboratory tests are not going to provide much information deemed stable. because with a patient taking aspirin, platelet function tests can be inaccurate for up to a month. Birth control medications require a blunt conversation between the dentist and patient. Many medications will interfere with different A dentist can learn much by interviewing these patients and contraception medications. Each of these should be reviewed completing an exam looking for bruises and hematomas. If there is separately. The dentist should always err on the side of caution and a serious bleeding risk, treatment should be done in a hospital after recommend that other contraceptive methods be used when there is completing a type and cross-match, and the dentist must make sure any doubt. blood is available, if needed. No changes should be made to any of these medications without consulting the specialist managing the Gastrointestinal medications for reflux are numerous and are patient (UKNHS 2011). important to investigate because these patients may be more likely to vomit or have aspiration issues. The level of control and any With patients taking other, more powerful daily anticoagulants, progression of the disease need to be assessed. Uncontrolled reflux is a dentists also must consult with their physicians. Patients on Coumadin red flag for oral or IV sedation in the office. or warfarin may have to have it stopped and bridged with a short- acting drug such as heparin under the close supervision of a physician. Medications that deal with constipation and gut motility are also Emergency treatment may require administration of fresh frozen important to discuss because of possible dehydration and electrolyte plasma or (FFP) if there is not time to complete a heparin bridge. issues. These patients may also move food boluses along the digestive These treatments would likely require hospitalization and close tract more slowly, creating a higher risk that they may not truly physician supervision (Nematullah et al 2011). be NPO even though they followed pre-sedation guidelines. Such patients are at a higher risk for vomiting and aspiration with sedation. Cardiac medications. Very few of these patients are going to Ask many follow-up questions, and always make sure to consult the be candidates for in-office sedation. Patients taking angiotensin- physician. converting enzymes (ACE inhibitors), angiotensin II receptor blockers (or inhibitors), beta blockers, calcium channel blockers, Seizure medications. Patients who take daily seizure medications will diuretics, vasodilators, digitalis preparations, and statins alone or likely be followed by a neurologist. Consultation before any kind of in some combination to manage chronic cardiac disease require an invasive treatment or sedation is indicated. The number of seizures anesthesiologist to manage their care. Some may even need a cardiac and the last seizure are important to know. Other valuable information anesthesia specialist (American Heart 2010). includes whether the patient has ever had or does have life-threatening seizures that require emergency medication, such as Diastat. Has the Blood pressure medications are too numerous to list. But patients person had any recent 911 or emergency room interventions? taking blood pressure medications need focused questions to determine how well they are being managed. The first question to ask is why Seizure medication can affect the metabolism of other medications, their blood pressure is elevated, although a large percentage of people bleeding times, and activity level of the patients. Local anesthetics have elevated blood pressures with no specific cause. Ask how often lower the threshold for seizures, and general anesthetics are the they check their blood pressure, and follow up with their physicians. treatment for seizures. The maximum doses of local anesthetics should never be approached when working with patients on daily seizure Document the range of the best and worst of the blood pressures medications. that the person can recall. The patient’s level of energy and side effects of the medications the person has experienced also should be Seizure medications can affect buffering of acids by saliva glands documented. Finally, the dentist should research the type of medication and lead to a higher caries rate. These patients should be treated more the patient takes, its location of medication action, and metabolism. aggressively for their dental issues. They are not likely to stop taking A consultation with the prescribing physician is indicated before any seizure medications, and thus the high risk of caries in the future will sedation treatment is considered. not go down. Patients with uncontrolled hypertension or recent admission to the If a patient has a seizure, the dentist must be prepared to manage any emergency room with hypertension issues are not candidates for side effects from giving seizure termination medications. For example, sedation in the office. Patients with recent medication changes because if a dentist administers Valium to stop a patient from seizing, he or of side effects and symptoms also are not likely candidates for in office she may have to suction the person’s mouth to remove secretions that sedation.

Page 100 Dental.EliteCME.com Hemophilia factors and other treatments. Patients with known be treated in a hospital setting or their medical home in conjunction bleeding disorders are often well managed. Bleeding associated with with their oncology team. Some of these patients may need blood dental treatment can be well managed with a consultation with the transfusions before or after dental treatment. No sedation or dental hematologist and a hemophilia management plan. treatment should be done without consultation with the oncologist. Pre-treatments for these patients can range from nasal mist drugs to Laboratory values will have to be obtained. IV and oral medications. These patients often are prescribed Amicar, Patients who have completed chemotherapy and are deemed cancer a drug that acts as an inhibitor of fibrinolysis, or clot breakdown, for free will likely now be followed in survivor clinics. These patients still a few days after invasive treatment. Dentists should never attempt to require special considerations. Previous chemotherapy may have been manage treatment or sedation without consulting with the hematologist cardio-toxic. The patient may still not be hemodynamically stable. The managing the case. immune system may not have returned to baseline. Always consult the Special attention should be given to hemophiliacs with inhibitors, oncologist. in which the immune system attacks the artificially introduced Psychiatric drugs. Patients taking drugs for depression or other replacement therapy for the missing coagulation factor. These psychiatric conditions require a consultation with their physician. patients are at a higher level of risk. They should be treated in a Increased dental prevention should be planned because these patients dental home that is located in their medical home. Bleeding issues are at high risk for developing dental disease from side effects of the are likely to result, and the patient is likely to need intervention from medications, including dry mouth. a hematologist, often for several days after completion of the dental Dentists must assess the level of management of the mental illness as treatment. well as the compliance of the patient and understand the interaction of Chemotherapy and cancer treatment medications. Patients who the medication with planned local anesthetics and sedation drugs. The have been diagnosed with cancer currently or in the past have likely dentist also must be knowledgeable about side effects of psychiatric been sedated multiple times and been exposed to many drugs with medications, such as insomnia, increased anxiety, diarrhea, headaches, long-term side effects. Some of the chemotherapies are cardio-toxic dizziness, and weight fluctuation. and have a profound effect on the cardiac output. Medications used to treat psychiatric disorders have varying side Patients in active chemotherapy can have issues with low platelets effects. The more common medications have predictable side effects causing bleeding. No dental treatment should be done without a and interactions with sedation medications. Some of the more exotic consultation and a plan. Dental treatment with a platelet level below medication used to treat conditions such as bipolar disorder can 75,000 will result in excessive bleeding. As the patient heals after the have cardiac side effects. Geodon increases the cardiac Q-T interval, dental treatment, he or she may need a unit of platelets. or causes long Q-T symptoms, and requires a special sedation or Cancer patients in active chemotherapy also can have very low anesthesia plan. Any additional medications that affect the Q-T absolute neutrophil counts, which will have a very negative effect interval, such as the popular anti-nausea medication Zophran, are then on healing from dental treatment. It is well documented in the dental contraindicated. A long list of medications that cannot be given if the literature that treatment with an ANC below 1,000 results in significant Q-T interval is prolonged can be found in the literature. risk of postoperative infections and problems with healing. No elective Sedation can become very complicated when taking these drugs, treatment should be done below this threshold, and any emergency and most likely should be done in a hospital setting (Geodon 2013) treatment done below an ANC of 1,000 should only be done in (Zophran 2013). cooperation with the oncology team managing the patient. Special The take-home message is that all psychiatric medications have documentation of informed consent is necessary. side effects, and they need to be researched and discussed with the The level of hemoglobin and hematocrit can be low in patients actively prescribing physician. Some of these patients are not going to be receiving chemotherapy. Thus, the amount of blood that can be safely candidates for in-office sedation. They also are more likely to have lost as well as the oxygen-carrying capacity of the blood are severely adverse behavior reactions to medications and require more focused limited. Patients with a hemoglobin and hematocrit that are below attention from the staff. The analysis of their potential for risky their normal range require careful consideration. Most will need to behavior lifestyles cannot be ignored.

The summary statement A summary statement can be used to describe patients’ current statement is also a good place to note whether the person’s overall symptoms, mood, or energy level. It can also be used to summarize appearance is one of health, obesity, infection, or any other obvious whether the condition of the patient is improving or deteriorating. This conditions.

HEENT: Hearing, eyes, ears, nose, throat issues Any hearing impairments and corrective treatments should be behavior management techniques to be effective. Having normal documented, such as hearing aids or cochlear implants. Plan to have vision will make most patients more comfortable before and after them in place during some treatment, but possibly turned down or off sedation. Proper management of this issue can lower anxiety levels of when the high-speed handpiece is used because some patients find the patients. sound painful or unpleasant. Voice control, positive reinforcement, Airway issues that involved the nose, mouth, or posterior pharynx and other adjunctive treatments cannot be accomplished if the patient need to be examined and addressed. Sometimes it will be obvious cannot hear the dental team. that a patient has a history of a cleft lip, cleft palate, or a craniofacial Patients with active ear infections have reported more discomfort syndrome. Other times, dentists will have to ask many questions. With with the sounds and vibration of dental treatment. This issue is easily conditions that have an isolated cleft palate, there is a much higher addressed. Most dental treatment can be delayed to accommodate association with syndromes such as 22q deletion. patients with these issues. Watch the patient breathe. Listen for any airway sounds that could This section also should describe corrective vision devices, such as be the result of any kind of obstruction. In summary, any craniofacial contacts or glasses. Patients need to be able to see for some adjunctive syndrome or condition should be considered a red flag. If there is an

Dental.EliteCME.com Page 101 additional corrective surgery history, the risk for complications could Ask whether the patient has ever had a sleep study. Ask whether there be even higher. is evidence of the use of accessory muscle contraction to maintain Patients with a history of speech surgery to correct hyper-nasal speech the airway at night. Ask whether the patient has ever used an assisted require special consideration. The surgeries to correct this are sphincter respiration device at night. pharyngoplasty or pharyngeal flaps. Many of these procedures will be Any patient with a history of airway obstruction or sleep apnea performed on patients with craniofacial diagnoses. requires a consultation with the managing physician. A majority of However, some will be done on patients who have had a deep pharynx these patients with active issues will not be candidates for sedation in or soft palate with inadequate muscle function. These procedures are the dental office. They will require general anesthesia with a controlled surgically created upper airway obstructions that help the soft palate airway. They also will likely have to spend the night after treatment close off the posterior pharynx. These patients have the potential for in surgical observation because they have a high potential for post- upper airway obstruction during and after sedation. They also are operative airway issues. increasing in number across the country and are most likely better Ask whether the patient has had tonsils and adenoids removed. If so, managed in a hospital setting because of the potential for airway then follow-up questions about possible improvements in sleep and the issues. number of ear and throat infections are helpful. Ask questions about The next part of the upper airway examination is to ask about sleep. the anesthesia and any complications. If there are still ongoing issues Ask a blunt and direct question to the patient or accompanying with the tonsils and adenoids, then in-office sedation probably is not a family members about airway sounds at night, or snoring. If the good plan. patient snores, the person may be more likely to have upper airway In summary, you should obtain an airway management history if obstruction issues during and after the sedation. the patient has had issues, and any history of sedation or general anesthesia.

Cardiovascular Congenital cardiac defects and syndromes, chest pain, rhythm issues, The dentist should consult with the managing physician to and progressive cardiovascular diseases call for extensive follow-up determine whether the patient requires antibiotic prophylaxis. The questions when reviewing a person’s medical history. Consultation guidelines have changed, and now much more of the decision to give with the physician is indicated because many of these conditions prophylactic antibiotics is subjective or case-specific. If the physician are so complicated that patients and parents cannot understand them or patient requests antibiotics when they are not necessary according to completely. the guidelines, this should be documented in the chart. Certainly you You need to discuss any congenital conditions, surgeries, or family would face questions about why the person was given the medication histories of cardiovascular problems as well as any current structural, if he or she were to have an allergic reaction to the antibiotic. In functional, or rhythm issues. general, document all deviations from the American Heart Guidelines. The dentist should obtain the normal range for the person’s blood Many patients who were born with congenital cardiac diseases are pressure and inquire about any exercise restrictions or limitations. now living longer and are better medically managed. These patients He or she also should discuss the history of medications and current will continue to increase in number. Always get a consultation when medications with the patient, and understand the overall stability of the treating such a patient because these conditions are often more patient’s cardiac condition. complicated than the person or a family can comprehend. A physician may recommend that a cardiac anesthesiologist perform any sedation if the cardiac issues are significant or not completely repaired.

Pulmonary issues Pulmonary problems are often divided into upper and lower airway Many upper airway obstructions have been discussed in other sections. issues. Croup, laryngospasm, and obstruction by tonsils are upper These include enlarged tonsils, adenoids, obesity, speech surgeries, airway issues. Asthma, bronchitis, and emphysema are some of the foreign bodies or secretions. lower airway issues. Chronic obstructive pulmonary disease (COPD) A laryngospasm is when the vocal cords slam shut and no air can includes emphysema and chronic bronchitis. Smoking and exposure to flow into the lungs. It is a common complication with the induction of secondhand smoke are the cause of a majority of pulmonary issues. anesthesia in children. It can happen with sedation and irritation of the Croup is defined as swelling and mucous buildup of the larynx and vocal folds from dental treatment and is an immediate, life-threatening trachea. Young children have smaller airways and are more affected event. More information will be provided in the management of the by the swelling and mucous. A distinctive bark-like cough develops, airway section. caused by a contagious virus, bacteria, allergies, breathing an irritable A laryngospasm can happen in adults who have uncontrolled reflux. substance, or acid reflux. Patients may describe not being able to breath at all for a few breaths. It usually strikes at night in the fall and winter and can be acute or These patients require consultation with their physician and likely are chronic. It is treated with oxygen, racemic epinephrine and steroids. not good candidates for in-office sedation. However, some patients experience a rebound effect when the racemic Asthma must be well controlled for a patient to be sedated in the epinephrine makes the airway worse after treatment. Therefore, office. A good indicator of this is the number of medications required treatment is done in the hospital or a doctor’s office, and the patient to manage the asthma. Daily medication patients are less well is required to stay for observation afterward. There is risk in doing controlled than those who only occasionally use a rescue inhaler. Most this kind of treatment at home because medical professionals and dentists define well controlled as no emergency occurrences requiring equipment may be needed to manage this situation. emergency room intervention and no rescue inhaler use within the last Croup can be a life-threatening event. No dental sedations should 30 days. Sedation inside these guidelines would require additional be done for at least 30 days after an acute attack, and a physician informed consent documentation. Narcotic use should be avoided in consultation is necessary. these patients because they will cause additional histamine release.

Page 102 Dental.EliteCME.com Diagnosis of acute or chronic bronchitis requires consultation with care within the six-week window requires documentation of the the physician. Many of these patients will not be good candidates for elevated level of risk. Because the patient would risk becoming in-office sedation because they can have issues with lower airway oxygen dependent after treatment and possibly not able to be extubated obstruction and gas exchange. Sedation and dental treatment will after surgery, this elevated risk would be a major component of the likely cause deterioration in their pulmonary status. informed consent for treatment. Chronic bronchitis and emphysema are both forms of COPD. Sedation Even facts about the patient’s birth are important. The last system of and dental treatment will not improve their pulmonary function and a baby to develop is the lungs. When children are borne prematurely, may lead to oxygen dependence. These patients are not likely to be or after less than 40 weeks gestation, they often are diagnosed with sedated in the dental office (Little et al 1993). bronchopulmonary dysplasia or (BPD). The child may have received Any patient who has a history of pneumonia, or more specifically, multiple medications, surfactants, and even been intubated after birth. aspiration pneumonia, should not have sedation or anesthesia This pulmonary history raises the risk for sedation and requires a electively for six weeks. Any decision to sedate a patient for dental consultation with the physician. The risk of pulmonary issues remains with the patient throughout life.

Gastroenterology These issues include GERD (gastroesophageal reflux), anorexia and the patient has a history of ulcerations and bleeding. These patients bulimia, absorption issues, obesity, and gut motility issues. require labs, consultation with their physicians, and a thorough Reflux needs to be well controlled for sedation to be safe. These understanding of the disease before any in-office sedation is done. patients may experience aspiration of stomach contents into the lungs, Obesity is a major issue when discussing sedation. Airway issues will creating pulmonary issues. The dentist must know the number of likely develop because of the extra tissue; such a patient is not likely to medications the patient takes and whether they control symptoms. be able to maintain his or her own airway. Medication doses would be Consultation with the managing physician is necessary if it is more above the suggested maximum if traditional dose/weight calculations than a mild problem. were used. Consultation with physicians may be necessary and include Anorexia and bulimia raises issues with sedation because many an ENT evaluation. of these patients have problems with their electrolytes caused by Patients who are extremely obese should be treated in a hospital excessive vomiting. They also can have acid erosion of the airway and setting. They likely will require observation and even an ICU bed for pharyngeal tissues. With these patients, a dentist should consult with the day of the dental treatment. Proceed with caution, and have blunt the patient’s physician. It’s likely that blood work, including a CBC conversations when obtaining informed consent. and electrolytes, will be necessary. Move forward with caution when Gut motility disease can affect sedation and general anesthesia risk. considering sedation for dental treatment. Patients may follow the suggested NPO guidelines and still have Gut absorption diseases affects the way medications are taken into undigested food they could vomit during the sedation or anesthesia. the body, and the patient may also have hydration and electrolyte Again, consultation with the physician is necessary. Most of these problems. Hemoglobin and hematocrit issues also may be present if patients will not be candidates for sedation in the dental office.

Genitals and urine Issues such as hematuria or dysuria can be important when sedation is acyclovir may be indicated. Other venereal diseases also have oral planned. Hematuria, or blood in the urine, can be an important finding, presentations. and could be a sign of undiagnosed high blood pressure or a sign of Patients need to be as healthy as possible when challenged with pathology. Dysuria could be a sign of a urinary tract infection. Treating sedation and invasive treatment. Any infection or outbreak that makes the infection and delaying the dental sedation is best so the patient will the body weaker can lead to more complications and longer recovery be in a better state of health when challenged with the sedation. times. Patients with a history of venereal disease need to be questioned Females who have a history of excessive bleeding with their menstrual because some conditions like herpes, both oral and genital, may cycle require a consultation with their physician. Labs may need to be surface from the stress of sedation and treatment. Pretreatment with done to make sure the hemoglobin and hematocrit are at acceptable levels for invasive dental treatment.

Pregnancy Anesthesiologists and hospitals not will perform elective general all females who have started their menstrual cycle is an unacceptable anesthesia on a female patient without evidence that she is not risk. Dentists who are not comfortable addressing this issue should not pregnant. This evidence includes the date of their last period or a be sedating these patients. simple pregnancy test done in the office. Not addressing this issue with

Neurological issues Neurological conditions affecting sedation include seizures, cerebral calls. He or she also should ask whether the patient has ever had a life- spinal fluid issues, strokes, and infections. threatening seizure requiring Diastat or Valium. Consultation with the A neurologist should manage seizures. If a patient has a history of one neurologist will be necessary (Malamed 1993). or two febrile seizures associated with an illness and fever, it likely Local anesthetics lower the threshold for seizures, and general will not affect a plan for sedation in the office. Patients with chronic anesthetics are the treatment for seizures. Thus, many of these patients seizures or epilepsy usually will be on medications. will be better served if they are treated in the hospital with general The dentist should gather information about the last seizure, type, anesthesia. duration, intervention (if necessary), emergency room visits, and 911

Dental.EliteCME.com Page 103 It is important to find out whether the patient has any type of shunt or of these patients are going to be candidates for in-office sedation; issues with cerebral spinal fluid. If the patient has a shunt, then he or management of an acute stroke would be much better in a hospital she should have a current shunt series CT scan and regular follow- environment than a dental office. up with the neurosurgeon. No sedation or treatment should be done In patients with a history of viral or bacterial meningitis, any without consultation and a current shunt series. Treatment likely will permanent repercussions need to be assessed. Most of these infections be recommended to be in the hospital. were life-threatening events, and patients will have a great deal of Any history of cerebral vascular accident, or stroke, requires a information to share about these infections. If these patients have few consultation with the physician to assess the risk for future strokes permanent changes and are now healthy, they may be good candidates and the patient’s medications and overall medical health. Not many for sedation in the office.

Endocrine issues Diabetes, thyroid pathology, and adrenal insufficiency can affect For uncontrolled patients, sedation in the office is absolutely sedation and dental treatments. contraindicated (Little et al 1993). Diabetic patients must be very well controlled to be even Hypothyroid patients can have exaggerated responses to CNS considered for sedation in the office. Issues will arise on NPO medications and sedation. They belong in a hospital environment status and managing their blood sugar. It is important to develop (Little et al 1993). an understanding of the range of blood sugars, length of time the Adrenal insufficiency requires consultation from the physician. individual has had the disease, and any known organ damage. Most of Standard guidelines have been developed describing when steroid these patients will require hospital treatment. supplementation is needed. Even after taking precautions, an acute Hyperthyroid patients can develop acute crisis or thyrotoxic crisis. adrenal crisis can result. Treatment is an immediate dose of 4 mg of A dental office is not the place to manage this medical problem. IM dexamethasone and immediate transfer to a medical center. These With patients who are well controlled, a consultation with their patients are not good candidates for sedation in the office (Little et al physician is indicated. Treatment will likely be done in the hospital. 1993).

Skin It’s important to obtain the history of the skin system. Ask the patient learning about the skin condition. A simple question about the healing to describe reactions to allergens and other insults, such as significant of a laceration or hematoma provides information that is valuable. allergic reactions. Healing can also be assessed by looking and Hyper-reactive skin issues are a red flag and need further exploration.

Psychiatric disorders These are being diagnosed more frequently than in the past. Many of the medications will interact with local anesthesia and some Depression, anxiety, bipolar, and schizophrenia are some of these with systemic sedation medications. If the mental disease is significant, conditions, but many patients are able to live a basically normal life a consultation with the physician is indicated. These patients may not when the right medications are prescribed. All of these medications have typical behavior responses to some sedation medications. and medication changes should be documented.

Immune system Diseases of the immune system should be documented. These patients pneumonia that could be fatal. If the patient has a port for regular are likely to have increased healing times and more potential for infusions, the dentist needs to discuss antibiotics needs with the postoperative infections. Consult with the patient’s physician to immunologist. The decision to use the port or start a peripheral IV line discuss antibiotic coverage because side effects of antibiotics need to also should be discussed because there is risk of infection each time a be considered. port is accessed. Many of these patients may not be good candidates Special consideration must be given to these patients. For example, for in-office sedation. any aspiration of fluids during a procedure could lead to an aspiration

Laboratory tests and x-rays The dentist should review lab tests and x-rays and then write a ●● ASA 3 – A patient with severe systemic disease (active wheezing summary of the person’s state of health, including any additional or sickle cell disease). consults or letters from other providers. As health care providers, ●● ASA 4 – A patient with severe systemic disease that is a constant dentists must obtain information from physicians and specialists and threat to life (status asthmaticus). incorporate it into their plan of care. ●● ASA 5 – A moribund patient who is not expected to survive The term “medical clearance” is not acceptable, and it is not without the operation (severe cardiomyopathy requiring a heart acceptable to ask another physician or provider for a clearance. The transplant). dentist must assimilate all information from the medical history, dental ●● ASA 6 – A brain-dead individual whose organs are being harvested history, social history, consults, physical exam, and finally determine for transplant (AAPD Guidelines, 2010). the anesthesia classification (Chester and Glick 2012). The guidelines for sedation in the dental office clearly state that The ASA physical status classification system is used to assess patients who are ASA class I and some in mild class II are good fitness of a case before surgery. In 1963, the American Society of candidates for in-office sedation. Other patients would be best treated Anesthesiologists (ASA) adopted this system. A sixth category was in a hospital with an anesthesia team. There is little medical-legal added later: protection for dentists who choose to sedate patients in their office ●● ASA 1 – A normal healthy patient. who do not meet these criteria. ●● ASA 2 – A patient with mild systemic disease (controlled asthma).

Page 104 Dental.EliteCME.com The complete dental history The complete dental history is developed when patients establish a complete. The risk level stays high for a period of time after the dental home. A dentist doing sedation and dental treatment does not treatment is completed. have to be the dental home for quality treatment to be completed as long as the patient has an established dental home. Postoperative care, dental home care, frequency of care, diet plans, and other risk factors must be planned for in advance. Single office visits, Dental home components include accessibility, and being family where extensive treatment is done with sedation, are only a small centered, continuous, comprehensive, coordinated, compassionate, and component of overall patient care. culturally competent. The dental history should document which dental office is the dental home. The patient will require a post-operative Medications taken need to be addressed if they have dental side check and future preventive care for quality treatment to be completed effects, and the dentist can discuss alternative medications with (Nowak and Cassamassimo 2002). medical providers. Salivary supplements and toothpaste with higher The dental diagnosis and preventive treatment plan should be concentrations of fluoride can be used to offset the elevated risk of dry documented and the dental history summarized. The dentist needs to mouth. know about exposure to fluoride levels. The dentist must discuss medical issues related to higher incidence Use the caries risk assessment tool for pediatric patients. This is a of dental disease and create dental prevention plans that match the forward-looking tool that is designed to increase prevention to match risk level. For example, if cardiac disease has caused reduced cardiac dental risk for future disease. It is based on medical history, dental output and medications for it have a side effect of dry mouth, then the history, socioeconomic factors, education, and level of dental treatment dental professional should tell the patient to increase use of topical needs. fluorides, salivary supplements, and schedule more frequent visits. The most important factor to understand about the caries risk The goal should always be to treat existing disease and make changes assessment is that it does not decrease as soon as the treatment is going forward that will reduce and eliminate the need for future dental treatment. When the disease process is controlled, cosmetic and functional treatment can be safely planned.

The complete social history Many factors of the disease process are better understood and managed Patients who are extremely into fitness, with low body fat and taking when a dental professional has a complete understanding of the dietary supplements, represent the opposite end of the spectrum, but patient’s social history. they also bring a set of unique risk factors to the table. Neither extreme is without issues. The location of the family residence and with whom the patient lives are important to know. This information can help the dental team It is well documented in the dental literature that sometimes when understand what resources are available for prevention and treatment, tongue and other oral piercings are done, high quality “street cocaine” and who might be able to aid in home care. A large difference exists is put on the tissue to be pierced. Cocaine is a powerful vasoconstrictor in patients who are in custody or living in a group home than for an and local anesthetic; it is a drug still used in ENT surgical procedures adolescent from a county club community – although both of these for those desired effects. Medical doctors and dentists working in circumstances can present challenging issues to manage. emergency rooms have learned that when they see complications from oral piercings, such as hematomas or infections, drug screenings It is important to understand the education level of the family because should be done first to accomplish safe treatment. the dentist must communicate information in a way that will be understood and then applied. Conversations about the scientific Local anesthetics can contain epinephrine. If people who have ingested process of the progression of dental caries will be wasted on some cocaine are given local anesthesia with epinephrine, they can develop populations. Other populations want and need extensive information arrhythmias and die. Sometimes bluntly asking difficult questions can about the science to change their behavior. save the life of the patient. A patient who speaks a different language or who cannot read presents A few questions about regular medical care are very important. unique challenges. Dentists have to connect to their patients where Patients who are closely followed by a physician are going to be they are if they are going to change patients’ behavior. managed differently from a patient who uses the local emergency room for most of his medical issues. More education for this patient Understanding patients as people and what they value will help make could direct the patient back to the dental office for care of any this connection. An analysis and documentation of risky behaviors complications and keep him out of the emergency room. can be very powerful because behaviors such as smoking, excessive alcohol intake and recreational drug use will affect decision processes. In summary, taking a few minutes to get to know the patient can be a Extensive tattoos or body piercings tell us more about the patient. powerful tool to make better treatment and prevention decisions. When an invasive procedure including sedation is to be done, a thorough social history can be important to limit treatment complications.

The limited physical exam for dental sedation The limited physical exam includes the overall assessment of the and stressed or relaxed and well-rested? Does being in the dental patient, examination of the airway, examination of potential IV access office make the patient seem more stressed than most other patients? sites, and obtaining vital signs and weight. The level of planned sedation should mesh with the dental treatment The first part of the physical exam is to look closely at the patient. planned and anxiety or behavior issues. Some findings should be readily apparent. Does the patient look tired

Dental.EliteCME.com Page 105 Next, focus on the breathing of the patient. Do you hear any sounds of and have less potential to be difficult. Airway classes 3 and 4 have congestion, coughing, or upper airway obstruction? Does the patient obstructions, such as the tonsils. Sedation in the office setting should use any accessory muscles to breathe? Listen to the lung sounds of the be limited to airways that score a 1 or a 2 (Brodsky 1989). patient in three different lung fields, two in front and at least one on the Is the patient able to have a conversation while the exam is done back. Listen for wheezing or crackles. that is age- and developmentally appropriate? Assess the level of Attach a pulse oximeter lead to the patient and document the oxygen communication while progressing through the exam process. Note any saturation level. If the oxygen saturation is lower than 96 percent, developmental issues not described in the history. the dentist should investigate further before going forward with the Obtain a blood pressure. The dentist must be aware of what a normal sedation. This process gives baseline data as well as desensitizes the blood pressure is for an adult or a child; 120/80 is normal for an adult. patient to the monitors, the sounds, and the overall environment of the The blood pressure of a child varies by age and size; refer to a standard planned sedation. chart or a smart phone app. If you are sedating children, make sure During the physical exam is a good time to select the size of nasal you are aware of their baseline blood pressure and the normal for their trumpet, oral airway, LMA, or intubation tube that would be used age before starting the sedation. If a complication develops, a blood if needed. There are multiple smartphone apps that can do this very pressure alone without baseline data is not as valuable. quickly, but the data returned must match the physical exam. Obtain an accurate patient weight so calculations can be done in Have the patient open wide and look at the person’s range of motion advance for all of the drug doses that could possibly be needed for and maximum opening. Look at the posterior pharynx with a mirror or sedation and any complications. If the patient is overweight or obese, tongue blade. Take a minute to study and visualize the airway. plan the method you’ll use to calculate drug doses. Obese patients Do a standardized airway analysis using the Mallampati system. This can exceed maximums recommended, and some drugs do not have system is used to evaluate the size of the tongue base relative to the research on how obese patients will respond to them. oral cavity and predict potential difficulty with direct laryngoscopy. Look at the arms of the patient to determine whether IV access could There is a chart with four pictures showing progressive obstruction in be difficult. Determine whether there is a history of multiple peripheral the literature. Copying the picture and matching the anatomy of the IVs. Determine whether there is a history of IV access being difficult; patient to the chart would be advisable. Levels 3 and 4 correlate with most patients who are difficult will know that. For dental sedation, difficult mask airways and the presence of obstructive sleep apnea ports or central lines should only be accessed as a last resort because (Mallampati 1985). Sedation in the office should be limited to airway of the risk of infection. Make sure you plan for an IO (interosseous classes 1 and 2. needle) if you think IV access would be difficult in an emergency or The Brodsky airway analysis is an evaluation of the size of the tonsils complication. relative to the airway. A chart with several pictures is included in the Discuss any potential findings with the patient, or if a child, its parents. literature. Copying the picture and matching the anatomy of the patient All relevant findings are part of the informed consent process. to the chart is advisable. Airway scores of 1 and 2 have an open airway

Medication calculations Calculating medications should all be done as dose/weight-dependent. The equipment section should include: The only exception is for obese patients, who are not likely to be ●● LMA and ET tube size selection: candidates for in-office sedation. Other methods, such as using body ○○ Laryngoscope blade. mass index weight for dosing, have been found to be safe for some ○○ Mask size. sedation drugs. However, proceed with caution if sedation is planned ○○ Blood pressure cuff size. on an obese patient in the office. ○○ Oral airway size. The pre-sedation form should include: ○○ Nasal trumpet size. ●● The weight of the patient. ○○ IV needle size. ●● The sedation drugs doses to be given. ●● IV access plan section: ●● Maximum local anesthesia doses that could be given. ○○ Plan for most likely location to obtain an IV. ○○ IO plan. The complications section should include: ●● Reversal drug doses for sedation drugs (Narcan IV for narcotics Patient baseline vitals should include: and flumazenil IV for Versed). ●● Blood pressure and location. ●● Atropine doses IM and IV. ●● Pulse rate and location. ●● Epinephrine doses for IM and IV. ●● Respiratory rate. ●● Succinylcholine doses IV and IM. ●● Oxygen saturation and location. ●● Albuterol doses. Document any additional information that needs to be in the record. ●● Steroid doses (Decadron) IV and IM.

Pre-sedation Patients and parents need to have NPO guidelines explained. Most A discussion about what, if any, medications should be taken the offices will say the patient should have nothing to eat or drink after morning of the sedation with a little water should be very clear. For midnight and clear liquids up to two hours before the sedation. example, most dentists will have patients who take seizure medications The term “clear liquids” needs to be described. Breast milk should take them with a few sips of water the morning of the sedation. not be consumed for usually four hours before the procedure, and for Individuals being sedated need to plan for someone to come with formula, it usually is six hours. Light meals are usually six hours as them. Someone will need to help the patient return home and should well. The instructions must clearly explain that this is done to reduce stay with the patient that day. Leaving a patient who has been sedated aspiration risk. Note that some liquids should be taken up to the time at home alone is not a good plan. limit to prevent dehydration (AAPD Guidelines 2010).

Page 106 Dental.EliteCME.com The person’s diet after the sedation needs to be discussed; patients ●● Bleeding: When patients start to bleed from surgical areas, the first usually will be told to start with clear liquids in small amounts and thing they should do is to hold pressure with gauze. The saturated work their way up to higher-calorie liquids. If the dental treatment was gauze should be saved so they can estimate blood loss if they have invasive, patients should avoid “hot” (flavored), spicy, salty or acidic to call the dentist. If it does not stop or gets worse, they should call foods. Bland and boring is best for the first 24 hours. Patients may the dentist and go to the office or local emergency room. want to have some soft comfort foods, such as ice cream or yogurt, at ●● Pain: Patient should know which pain medications the dentist home. They should plan to not take medications on an empty stomach. would like them to take, how often, and any anticipated side The most likely complications need pre-sedation education: effects. Narcotics can cause histamine release and constipation; ●● Vomiting: Patients who start to vomit should return to the start of ibuprofen products can cause bleeding. Patients need to call their the diet and take small amounts of clear liquids. Then they should dentist if the pain is not well controlled. work their way up to a more substantial diet in small amounts. There needs to be a plan for a post-operative call from the dental office Anti-nausea medications can be prescribed in advance or if the to the patient at a specific phone number a few hours after the sedation, patient calls the dentist with issues. Patients and parents need to and a patient needs to know how to get in touch with the dentist. The know that if it gets progressively worse, they are to call the dentist patient needs to have some degree of understanding of when to call the and will likely have to go to the local emergency room for IV dentist office, when to go to the emergency room, and when it may be fluids and additional medications. necessary to call 911.

The morning of sedation The first thing to do is to confirm that the patient followed the NPO rubber dam or a nitrous oxide inhalation device as part of the sedation guidelines as given in the pre-sedation visit. Next, make sure there are plan. no changes in the patient’s medical, dental, and social histories. Then Re-evaluate the airway. Have the patient open wide, stick out the finally, repeat a quick physical exam. Observe the patient, check the tongue, and use an instrument to depress the tongue. Visualize the airway, give or document any medication changes, and obtain baseline posterior pharynx and analyze and classify the size of the tonsils. vitals. This is an important part of the informed consent. The dentist must be The data obtained from the quick exam should be compared to the able to visualize that there is enough space for air to move to the lungs. data gathered at the pre-sedation visit. The pulse oximeter reading, Both the Mallampati and Brodsky scores should be recorded. airway evaluation, blood pressure, and listening to the lungs also are all important. Any changes should generate follow-up questions, with Summarize all of the data in a systematic way on a pre-sedation their answers documented. Any changes in medical history, including checklist. Using a checklist will ensure safety. new-onset illness and changes in medications or symptoms, should be At this time, the dentist should call a “time out,” when all staff documented. members must stop what they are doing. Using a standardized format, The blood pressure should be taken at the same location where the the entire team must give full attention to the situation, using eye pre-op visit blood pressure was taken. This will make the reading contact and engagement, and do the following: more reliable. Some “white coat” or doctor anxiety is to be expected. 1. Confirm the patient’s name, date of birth, and at least one other However, any significant elevations in blood pressure should be a patient identifier. cause for alarm and a reason to cancel any sedation or treatment. 2. Check the patient’s weight. When children are to be sedated, use a chart to document a normal 3. Discuss any IV access or route of administration of any emergency blood pressure for the age and the blood pressure the patient presents drugs that may have to be given, and make sure a secondary plan with for the sedation. The blood pressure normals of a child should be is clear. documented. 4. Announce the planned treatment. 5. Name the type of sedation planned. The pulse oximeter should be placed on the patient in the same 6. Verify that informed consent has been obtained. location, if possible. The reading should be consistent with previous 7. Discuss allergies and any plans to deal with them, if necessary. documentation of the oxygen saturation at rest. The saturation should 8. Discuss any additional medications, such as antibiotics, that may be at 96-100 percent at rest. Remember that the pulse oximeter is a late be needed. sign of an oxygen deficit. Proceeding with a sedation when the oxygen 9. Discuss any potential complicating issues that could occur, such as saturation is decreased is never a good plan. Special informed consent medical problems, blood loss, and any variations of treatment that would be necessary. may be necessary. Use a stethoscope to listen to the breath sounds of the patient, 10. Ensure that staffers understand emergency protocols and the roles osculating at least three different locations, the back, and the right they will fill. and the left lungs. Any wet sounds or crackles are a sign of fluid in 11. Verify communication methods. the lungs. This fluid could potentially interfere with gas exchange and 12. Declare that the time out is complete and all are ready to proceed. compromise respiration. The timeout should be documented on the sedation monitoring Listen for upper airway and lower airway sounds. Make sure the form or pre-sedation from; failure to do so could result in a patient can breathe through the nose, especially if you plan to use a medical-legal position that is not defendable.

Sedation, airway management, and complications (non-emergencies) This section is about complications and not emergencies because most of the issues that arise during sedation are predictable. Planning for these in advance makes managing them much less of an emergency.

Dental.EliteCME.com Page 107 Sedation Medications for dental sedation can be given per os, IM, IV, to Versed. If respiratory depression becomes an issue, Versed has a and inhaled. Many of them can be given via multiple routes of reversal agent, flumazenil, and it needs to be given IV. administration. Some of the drugs have reversal agents. ●● Valium is a great drug to relax a patient in the dental chair. Planning which drugs to use in combination goes beyond the scope Valium can also be given to a patient having a seizure. The dentist of this course, but many dentists use drug cocktails or regimens they must always be prepared to give bag-mask-assisted ventilation if were trained to use in residency programs or continuing education respiratory depression occurs. classes. Increasing your clinical exposure in varied clinical teaching ●● Propofol is a great IV sedation drug. However, patients who are environments will make you aware of different options for sedation. allergic to eggs, soybeans, and those who have a highly allergic profile are at risk from using it. Dentists must always be prepared for regular sedation drug doses ●● Ketamine is a great drug for IV sedation and also can be given to cause more sedation than desired, and they must be prepared to orally. It can cause post-sedation problems with susceptible manage the side effects of the medications. It is also important to patients, including anxiety, dysphoria, disorientation, flashbacks remember that many of reversal drugs need to be given IV to be and hallucinations. It will increase the heart rate. effective and that many of them do not last as long as the sedation ●● Demerol is a great oral sedation drug when a longer treatment drug. Thus, reversal agents are likely to have to be repeated. That is time is needed. The drug causes histamine release, so it must be another important reason for a time-based record of events. used with caution in asthmatic and other pulmonary patients. If Below is a list of some common sedation drugs used in clinical this happens, respiratory depression can be reversed for about five dentistry and a few clinically relevant facts about each: minutes with IV Narcan. ●● Nitrous oxide is extremely safe. Dry air can irritate airways of ●● Chloral hydrate is an older sedation drug. It can cause respiratory asthma and other pulmonary patients, so it may be contraindicated depression and does not have a reversal agent. The sedation if it cannot be humidified. Individuals deficient in certain folate properties are not thought by many to give a predictable response. chain enzymes may be contraindicated for nitrous oxide use. ●● Fentanyl is a short-acting IV narcotic that is very good at pain ●● Versed is a very safe drug that causes minimal respiratory relief. Respiratory depression can occur as well as histamine depression. However, patients can have adverse reactions to it, and release. IVs can reverse the respiratory depression, but it only lasts if so, should not have it again. This does not mean they are allergic about five minutes.

Airway management Head and body position. Patients should be positioned on their backs Patients’ heads should be positioned in a way that is comfortable, on a hard surface so emergency treatment can be provided. Some but that also maximizes the opening of the airway. Most people use providers have a stiff board they can insert under patients in the dental a position that is similar to the head-tilt, chin-lift position taught in chair, and others plan how they would move them to the floor. CPR CPR. Of course, patients may have to be moved some to gain access to will be ineffective without the patient in a supine position on a hard surgical sites, but maintaining an open airway is a must. surface.

Management of an upper airway obstruction Obstruction with saliva, blood, water from the handpiece, or organs. Do not stop CPR until additional help relieves the dental team. irrigation can quickly develop during treatment. This kind of Make sure a code sheet or sedation record is filled out to document all obstruction can be seen and heard. A dental suction is usually all that medications, efforts, and downtime. The entire resuscitation must be is needed to clear the fluid. Listen for sounds of fluid in the precordial, orderly, with minimal chaos. even when nothing is visible. Deliver oxygen immediately if there is Laryngospasm is another upper airway obstruction. This is when the any significant obstruction. muscles of the vocal folds slam closed because of irritants. It is more The first monitors to alarm the dentist are the precordial stethoscope likely to happen when the patient is an excited state or hiccupping. and the capnograph. Ideally, the secretions would be removed before This represents a true emergency because air will not move at all. Stop you see any oxygen desaturation on the pulse oximeter. everything immediately and mask-bag the patient with 100 percent Obstructions of foreign bodies should never be blindly finger swept. oxygen. Give the spasm just a minute or a few breaths to see whether Suctions and Magill forceps can be used to grab objects. Stridor you can get any air into the lungs. Then give preferably IV or IM may be heard on inspiration, and wheezing on expiration. If partial succinylcholine. The dentist will then have to breathe for the patient blockage of the airway occurs, give oxygen and monitor the patient. until the effect of the drug terminates. Immediately call for local help If the obstruction becomes complete, progress to basic life support, in the office for IVs, drugs, and extra hands. When dentists are out of including the appropriate treatment for the age and size of patient. The their comfort zone in such situations, they should call 911 because this Heimlich maneuver, chest thrust, and back blows may be necessary. can be life-threatening. Make sure to call 911 early. The dentist will see no end-tidal carbon dioxide on the capnograph, After a series of maneuvers to try to dislodge the foreign object, look and hear no breath sounds on the stethoscope. The pulse oximeter will for the object, return to trying to move air with positive pressure, and drop one to three minutes after the patient has stopped getting oxygen be prepared for further decompensation. Plan to advance to chest into the lungs. When there is any significant obstruction, oxygen compressions once oxygen saturation decreases and the heart rate should be immediately and continuously given. Oxygen and bagging decreases to below 30. The oxygen saturation will drop slowly at first the patient should be continuous throughout the process even when and then rapidly after the 80s. The heart rate may initially speed up, drugs are given. but then bradycardia will develop. Poor positioning and lack of regular muscle tone can cause upper When the heart rate reaches about 30, compressions should begin. Do airway obstruction. The tongue can fall back or swell from retractors not wait until zero because emergency drugs do not move when there pushing on it during dental procedures. The tongue can also swell from is no circulation, and no oxygen will reach the brain and other vital fluid and lack of muscular activity when the patient is sedated or from allergic reactions.

Page 108 Dental.EliteCME.com Floppy and enlarged tonsils can obstruct the airway. Fluid in the bag-mask positive-pressure ventilation with an oral airway or nasal posterior areas of the mouth can occlude the airway faster when the trumpet should continue because some air will likely get to the lungs. tonsils are enlarged. Obese patients can also have additional floppy Be prepared for the situation to deteriorate and to execute the tissue, which makes airway management difficult. algorithm for pediatric advanced life support (PALS) or advanced Painful stimulation, such as a sternum or chest rub, can help arouse the cardiac life support (ACLS). Respiratory failure will lead to cardiac patient and increase muscle tone. A nasal trumpet or oral airway with failure in children; in adults, cardiac issues often will be the initial a bag-mask-oxygen positive-pressure system can be extremely helpful factor. to get air moving to the lungs. These may be needed until the patient is In summary, call for help in the office immediately so all other dentists more awake. If the patient cannot be aroused and adequate air cannot and staff come to help. If there is not immediate resolution of the issue, be moved, a more advanced airway may be needed. call 911 and activate the in-office staff plan. Call early and document The next level of airway advancement would be to place an LMA or all events on the sedation record or code sheet. Try to avoid panic intubation tube. The most experienced team member should place the while applying a systematic and organized approach. airway. If there is difficulty progressing to a more advanced airway,

Management of a lower airway obstruction Asthma attack. When an asthma attack starts, breath sounds and Vomiting with possible aspiration pneumonia. At the first sign or respiratory effort will become more labored. The patient will be sounds of vomiting, treatment should be stopped. The patient should wheezing. Stop all treatment immediately. Position the patient for be turned toward the assistant because assistants normally have the comfort and open the airway. Suction any secretions, and put the suction in their hands. Suction everything immediately. Get the patient patient on 100 percent oxygen. Initially, use blow-by oxygen, then on 100 percent oxygen. Listen to the breath sounds in at least two progress to a face mask and finally a bag-mask-oxygen positive- different areas for crackles or wet sounds. Watch the monitors closely. pressure delivery device. If the patient becomes unconscious, an The patient will likely show he or she is moving air, but gas exchange advanced airway may be needed. The most experienced provider may not be occurring. should place the airway. The oxygen level likely will not remain high, but may not fall below Use an albuterol inhaler immediately if the patient can be stimulated the 80s. Give positive-pressure oxygen if needed. Albuterol will help enough to participate. A nebulizer can also be used. It is acceptable to open the airways, and steroids will decrease the inflammation. Be physically stimulate the patient to arouse him enough to make use of ready to give epinephrine if needed. Call 911 to transport the patient the inhaler. Draw up epinephrine and prepare to inject it if there is no to the hospital. The patient will need a chest film and labs to determine improvement. Start an IV because this may be needed for emergency whether aspiration occurred. drugs. COPD, including emphysema and chronic bronchitis. Patients with Make sure the staff calls for office help early and 911 fast if the asthma COPD are not good candidates for in-office sedation. No discussion attack is not immediately resolved. Use your clinical judgment to should be necessary about managing their airways. These patients decide when to call for help. If treatment is not immediately making with chronic pulmonary conditions are difficult for an anesthesiologist improvements in clinical signs, airway sounds, expired carbon dioxide, to manage. There are risks for oxygen dependence, not being able to and the oxygen saturation level, call 911. Even if the patient makes extubate the patient, and overall patient deterioration. Sedation for progress, if he or she looks more labored or tired, still call 911. Prepare elective dental treatment in the office is not an option. to follow the directives for PALS or ACLS. Avoid panic and chaos by staying focused on providing treatment in a systematic methodology.

Common complications occurring during sedation for dental treatment ●● Syncope. The patient faints. Lay the person down, raise the monitors because the reaction can progress. Give antihistamine. legs, and get him or her to move muscles, such as arms and legs, Call 911 early. because this returns blood to the heart. Aromatic ammonia and ●● Allergic reactions with anaphylactic shock symptoms, stimulation should be used. If the patient becomes unresponsive, including laryngeal edema. Stop dental treatment immediately. monitor oxygen, use atropine (if bradycardia), and call 911 for Change to 100 percent oxygen and keep monitors on the patient. help. Give epinephrine, steroids, and antihistamine. Start BLS, PALS, or ●● Local anesthesia toxicity. Stop working, suction, and clear the ACLS. Call 911 immediately. Prepare for the patient to deteriorate. airway. The person may be in an excited state and then exhibit Advanced airways may not pass if the patient has significant depression. Check all monitors. Plan for airway management with laryngeal edema. Bag-mask positive pressure may be the best bag-mask positive pressure, and supportive care. Call 911. Plan for treatment until help arrives. Valium if the patient has a seizure, and be prepared to deal with ●● Hypoglycemia may have developed in a patient who becomes more respiratory depression from the drug. Supportive care will be clammy, cold, and distant. Check the person’s blood sugar with needed until help arrives. a portable device. If sugar is low (below 70-100), give about 15 ●● Seizures. Stop treatment. Suction the airway and position the grams of oral carbohydrate if the person is awake. If the patient person to keep the airway open. Use blow-by oxygen and be ready is not awake, give glucagon IM or IV. Start an IV and consider to bag-mask ventilate. Check all monitors. If the seizure stops, adding 50 percent IV dextrose if needed. Recheck the blood sugar. monitor vitals and call 911. If the seizure does not stop, administer Call 911 early, keep the patient on monitors, and be prepared for Valium, IM most likely or IV if possible. Watch the capnograph the situation to deteriorate. and listen for breath sounds. If apnea or respiratory depression ●● Cardiac arrhythmias and arrest. Stop all dental treatment and occurs, give a few breaths and continue to monitor. Respiratory put the patient on 100 percent oxygen. The dentist doing sedation depression from the medication is normal. Be prepared for the in the office should have either PALS or ACLS training. Attach situation to progress. the AED to the patient, turn it on, and follow the instructions. If an ●● Allergic reactions without airway involvement. Stop all dental EKG is used, look at the rate and the rhythm. Analyze the rhythm treatment. Change to 100 percent oxygen. Keep the patient on all and treat per the PALS or ACLS directives. Make sure you have

Dental.EliteCME.com Page 109 called 911. Be prepared for the patient to deteriorate and prepared Most important for all sedation complications is to stop all dental for airway management and progression to an advanced airway. treatment. Put the patient on 100 percent oxygen and observe the Start an IV. Prepare emergency drugs. Start compressions if the monitors. Make a diagnosis and treat the complication. Re-evaluate heart rate drops to 30. Continue resuscitation efforts until help continuously. Call for help in the office immediately, and call 911 arrives. early. Keep a good record or code sheet that documents an organized progression and escalation of treatment. Avoid chaos and panic by using a systematic approach.

Post-sedation procedure When treatment is complete, the patient may recover in the same place. Post-operative plans should be in place for respiratory issues, treatment room or be moved to a recovery room. The monitors bleeding issues, pain, and dehydration caused by vomiting. should remain in place as well as the trained individuals tasked with Plan for a phone call checkup later that day. Offices that provide monitoring the patient until baseline vitals and behaviors are returned. quality care will check on patients in the afternoon after sedation. The same emergency intervention equipment and staff must be at the This pre-emptive strike will often prevent issues with pain, bleeding, ready to deal with any medical issues. The post-treatment sedation dehydration, and other complications from getting to the point where patient should not be left alone or with family. medical or dental treatment in the emergency room is required. Plans for post-operative issues should have been made in advance, and Sometimes nothing can be done to prevent complications, but good the most obvious or patient-specific complication plans should be in communication and early treatment will always be necessary.

Necessary equipment for the office Sedation treatment requires that you set up an area of the office mask positive-pressure ventilation. Again, they are not tolerated with all the necessary equipment that is immediately accessible. well by awake patients. The environment needs to be patient friendly, but at the same time, ●● Laryngeal mask airways are the first in line of the advanced functional. airways. The size possibly needed should be selected in advance. The equipment listed below is necessary. This means that to be They are relatively easy to place in an unconscious patient with practicing at the standard of care for the community, none of the minimal training. Although they can be very effective, in an equipment described below is optional: emergency situation, bag-mask positive pressure can be just ●● A pulse oximeter. This monitor is used to measure the amount of as effective. Often, calling for help and bagging the patient is saturation of the hemoglobin of the blood. It is considered a late more effective for ventilation when providers do not have much monitor because the oxygen saturation level drops 1-3 minutes experience with advanced airways. Dentists who have these in after a patient stops breathing. The drop in oxygen saturation their office are expected medically and legally to know how to use occurs slowly from the 90s to the 80s and then can drop very low them. very fast because of the oxygen-binding properties of hemoglobin. ●● Intubation tubes and laryngoscopes. Tube size and type of ●● A capnograph is a device that measures end-tidal or expired blade should be selected before the start of any sedation treatment. carbon dioxide. This is an early monitor. Normally, a wave of Intubation skills require regular practice, and calling for help and expired carbon dioxide is visible on the monitor screen. It can bagging the patient often are a better choice for an inexperienced be seen the second a patient stops breathing. This device is a provider. If the office has this equipment, the provider will be relatively new monitor, but is now the standard of care. The expected medically and legally to be able to use it. Connectors for capnograph allows early intervention in airway issues. albuterol inhalers are also necessary. ●● A precordial stethoscope allows the dentist to hear the patient ●● IV fluid and needles to start an IV should be maintained. Check breathing and some heart sounds. This monitor is manual or expiration dates on the fluid. Plan for possible IV sites during without an electronic alarm. When used properly, it is an early the pre-sedation physical exam. Tourniquets and latex-free monitor that is a great aid in detecting airway obstruction. tourniquets should be available. IV access could be very important ●● Blood pressure (manual or automatic) readings are essential. A in an emergency situation, but when the provider is not very baseline number should be recorded as well as what is normal for experienced, calling for help, doing basic CPR, and giving IM the age of the patient. The cuff must be the correct size because injections of emergency drugs may be a better choice. small cuffs give false high readings, and large cuffs will give ●● IO needles or intraosseous needles could be very valuable in low readings. The blood pressure is very important to know and a true emergency situation. These are large needles inserted into manage if the patient develops complications. bone to administer medications. They are very easy to learn to ●● Suction equipment must be available. Dental suction is sufficient place and very effective in emergency situations. most of the time, but medical suctions such as the Yankauer and ●● Magills are large instruments that look like forceps or pliers. They flexible suctions have their place in management of complications. are used to reach down into the airway and grab foreign bodies. Smaller suction tubes to go inside endotracheal and laryngeal mask They can also be used to aid in the insertion of an intubation tube. airway tubes are also needed. ●● Defibrillators, manual or automatic, are necessary. The standard ●● Oral airways are plastic devices that are inserted into the mouth to of care now is that offices should at least have an AED. If an office keep the mouth open and put forward pressure on the tongue. They is going to do more than mild conscious sedation, a defibrillator is are very effective for patients who are upper airway-obstructed indicated. Additional training in PALS or ACLS is necessary. when used in conjunction with bag-mask positive-pressure ●● Bag-mask valve and an oxygen source are necessary. Positive- ventilation. As patients wake up from sedation, they are not well pressure oxygen, a bag, and correctly sized mask are essential and tolerated and cause gagging. should be within arm’s reach of any sedated patient. Connection ●● Nasal trumpets are flexible tubes that can be lubricated and to an oxygen source is necessary before any sedation should be inserted into the nose. They will usually pass one of the nares, started, and the amount of oxygen in the tanks must be verified although both may have to be tried. The tubes are long enough to before starting. Most of the time, for any true complications or get past upper airway obstructions. These work well with bag- emergencies, this will be the preferred method of managing the

Page 110 Dental.EliteCME.com airway. Additional face masks for oxygen delivery are needed as ●● Blood sugar monitoring device and all necessary supplies should well as special connection pieces to deliver albuterol. be available.

Emergency medications ●● Epinephrine. epiPen Jr in the clinic is a quick way of introducing epinephrine into ●● Atropine. the patient without having to draw it up or start an IV. ●● Valium. The expiration dates must be monitored on these medications. ●● Albuterol. Appropriate supplies, such as needles, syringes, saline flushes, IV ●● Steroid. fluids, and IV tubing, also must be maintained. ●● Antihistamine. ●● Sugar or glucagon. It should be clearly stated that most dentists are experts in managing dental treatment – but not medical emergencies. Many dentists There should be a specific plan of how each medication will be given. complete all of their sedation training without ever having to truly If there is more than one possibility, multiple preparations may need manage any serious complications. Keeping emergency treatment to be stored. Epinephrine can be kept in vials that need to be drawn up simple and calling for help are the most important concepts to into syringes to be put into an IV or given IM. Keeping an epiPen and remember.

Sedation permits States require a specific conscious sedation permit, deep sedation The application for a state sedation permit will likely require permit, and general anesthesia permits. No didactic course can prepare completion of a training program, such as a residency, a log of a candidate to do sedation in the office without exposure to clinical sedations completed, and a site visit. sedation treatment. During the application process, the state board will likely send out a Most states will require a candidate to complete a residency program, dentist who is very experienced with sedation in the office to make with a log of sedations the candidate has completed under supervision. sure the site has all of the necessary emergency equipment in place as While in training and shortly thereafter, candidates should keep very well as proper monitoring equipment. The state also will evaluate the detailed information about their involvement with sedations. A location plan for dealing with any emergencies as well as your staffing plan. specific site visit will also likely be necessary. The inspector also will discuss the plan to transfer a patient to a local Other post-graduate continuing education courses are now teaching hospital if complications result. These individuals are charged with sedation. The requirements for each state are different. Most states making sure sedation will be provided at the standard of care in the are requiring didactic training, a log of a certain number of sedations community. completed with supervision, and a site visit to inspect the area where sedation will be done.

Necessary staff training and planning Staff members helping with the care of a sedated dental patient are Other more experienced and educated staff members, such as RNs, very important. The minimal training should include basic CPR and anesthesia staff, and more experienced assistants, should be ready in-office emergency planning. Offices that provide deep sedation may chairside to assist. be required to have additional professionally educated staff present, Record the emergency treatment on a time record or code sheet. depending on the state laws. The office should have a well-organized Emergency medication amounts should have been pre-calculated. and systematic plan for dealing with emergencies. Adjunctive equipment, such as mask size selection, oral airway size, Staff members should know their specific jobs in the event of an nasal trumpet size, blade size on the laryngoscope, and selection of emergency. Someone should call 911 and keep the line open to relay size of LMA or intubation tube, also should have been selected in important information. Another staff member should go outside to flag advance as well as routes of drug injection. down the ambulance or hold the elevators; EMS personnel summoned The dentist should be able to focus on the patient while the staff to help should have no issues finding your office. Easy access to the handles all the other emergency issues. As soon as an emergency is patient should be ensured. announced, staffers should bring emergency equipment to the dentist and patient. All other treatment should stop to stabilize the emergency.

Special note States all have their own specific requirements for permits for life support or adult cardiac life support certifications usually have to conscious and deep sedation or general anesthesia. Most states be maintained. Please refer to the specific laws of your state. will require proof of didactic training, documentation of successful This course alone in no way prepares a dental professional to sedate supervised sedations, and a site visit at the location where sedation patients in their office. will be performed. Advanced levels of training in pediatric advanced

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Dental.EliteCME.com Page 111 ŠŠ Mallampati SR et al: A clinical sign to predict difficult tracheal intubation: A prospective study. Can ŠŠ NIH Consensus Development Conference Statement on Anesthesia and Sedation in the Dental Anaesth Soc J 1985; 32:429-34 Office. J Am Dent assoc 111:90-93, 1985 ŠŠ Moore PA: Monitoring and management: Adult vs. pediatric patients (scientific abstract). Anesth ŠŠ Nowak AJ and Casamassimo PS: The dental home: A primary oral health concept. J AM Dent Assoc Prog 32:168-169, 1985 2002;133(1):93-8 ŠŠ Murphy et al: Allergic Reactions to Propofol in Egg-Allergic Children. Anesth. Analg. July 1, 2011 ŠŠ Pinkham et al. Pediatric Dentistry: Infancy Through adolescence. Second Edition. 106-115, 1994 113: 140-144 ŠŠ United Kingdom National Health Service. Surgical management of the primary care dental patient ŠŠ Nathan JE, West MS: Comparison of chloral hydrate hydroxyzine with and without meperedine for on antiplatelet medication. National Electronic Library of Medicines. Accessed April 27,2011 management of the difficult pediatric patient. J Dent Child 54:437-444, 1987 ŠŠ Webster: New World College Dictionary. Third Edition. p1214, 1986 ŠŠ Nematullah A et al. Dental surgery for patients on anticoagulant therapy with warfarin: a systematic ŠŠ Wilson S: Conscious sedation and pulse oximetry: false alarms? Pediatr Dent 12:228-232, 1990 review and meta-analysis. Journal of the Canadian Dental Association. 2009;75(1):41-41i. Accessed ŠŠ Zophran.com 2013 Zophran.com May 2 2011.

Sedation and Airway Management in the Dental Office

Final Examination Questions Select the best answer for each question and mark your answers on the online at Dental.EliteCME.com.

1. Conscious sedation is defined as when a patient has protective 6. Stridor is a sign of a lower airway obstruction. reflexes functioning, is breathing on his or her own, and can be a. True. aroused with a stimulus. b. False. a. True. b. False. 7. A patient who becomes unresponsive during a syncope episode may require atropine to raise his or her heart rate. 2. Informed consent for sedation does not need to include non- a. True. pharmacological behavior management techniques. b. False. a. True. b. False. 8. Allergic reactions that show no airway issues and some mild skin reactions will most likely be treated with antihistamine. 3. Patients who have highly allergic profiles and a history of an a. True. anaphylactic event normally can be sedated in the office if the b. False. dentist is fully aware of this history. a. True. 9. The primary drugs to treat anaphylactic shock are steroids, oxygen, b. False. alcohol and atropine. a. True. 4. Patients taking daily seizure medications may not be candidates b. False. for in-office sedation based on their history of seizures requiring emergency medical intervention. 10. The dental office staff should be trained in basic CPR and in-office a. True. emergency planning and be informed when sedations and other b. False. higher-risk treatments are being done to provide assistance to the dentist. 5. When managing an upper airway obstruction the capnograph is a a. True. late monitor to signal airway obstruction. b. False. a. True. b. False.

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Page 112 Dental.EliteCME.com Chapter 6: Topics in Pediatric Dentistry

8 CE Hours

By: Elite Staff

Learning objectives ŠŠ Identify the primary ways pediatric dentistry differs from treating ŠŠ List potential risks and contraindications for local anesthesia. adults. ŠŠ Discuss recent findings regarding xylitol and caries risk reduction. ŠŠ List the goals of behavior guidance. ŠŠ List a recommended use for restorative procedures described in ŠŠ List and describe the main components and objectives of the dental this course. consultation. ŠŠ List the clinical examination steps for unfavorable developing ŠŠ List four nonpharmacological behavior guidance strategies and dentition and occlusion. explain what is involved in each method. ŠŠ List the primary objectives for occlusion for each stage of ŠŠ Discuss some of the pros and cons of having parents present dentition. during treatment. ŠŠ Discuss the protocol for supernumerary teeth from infancy to ŠŠ Explain why nitrous oxide is typically preferred over protective young adolescent. stabilization as an advanced behavior guidance strategy. ŠŠ Describe the characteristics, causes and management of ŠŠ List contraindications and potential adverse effects for nitrous odontogenic infections in children. oxide/oxygen inhalation. ŠŠ Discuss the risks associated with excessive antibiotic therapy. ŠŠ List documentation requirements for deep sedation/general anesthesia.

Introduction Pediatric dentistry differs from treating adults in a number of ●● Nitrous oxide use. significant ways. While the dental professional’s primary objective is ●● Local anesthesia use. always to facilitate optimum oral health for the patient through the best ●● Caries risk-assessment and management. prevention and treatment methods, practitioners working with children ●● Restorative dentistry. also have the priority of creating a positive formative experience, ●● Management of the developing dentition and occlusion. placing additional emphasis on establishing a safe, comfortable ●● Oral surgery. atmosphere, communicating the importance of proper dental care, and Throughout the chapter, list items are characterized by the following paving the way for lifelong positive dental experiences. bullet points to note their significance: Recent years have brought changes in best practices for working with ŠŠ Objectives. pediatric patients. This chapter provides updated guidelines for the ++ Indications/recommendations. following practices and procedures specifically related to the child XX Contraindications. patient: * Risks/cautions. ●● Basic behavior guidance strategies. 99 Documentation requirements. ●● Advanced behavior guidance.

Basic behavior guidance strategies for the child patient This section introduces behavior guidance concepts that dental The proper implementation of behavior guidance strategies requires professionals can use to address fear, anxiety or inappropriate an understanding of the scientific principles on which they are based. behavior in young patients during dental procedures. Revised in 2011 But it is more than pure science. Effective behavior guidance requires by the American Association of Pediatric Dentists, it reviews basic not only the appropriate theoretical knowledge, but also the ability communication strategies, including proper implementation of the to implement communication and active listening skills as well as following interventions and practices: empathy, tolerance and flexibility. This section will touch briefly ●● Obtaining informed consent. on these strategies, but much more detailed information is readily ●● Patient communication. available. Effective behavior guidance is a clinical art form and a skill, ●● Tell-Show-Do technique. requiring a solid grounding in both theoretical and practical issues. ●● Voice control. These methods are critical not only because they affect the child and ●● Nonverbal communication. his parent’s attitude toward dentistry, potentially affecting dental care ●● Positive reinforcement. for the rest of his life, but also because they affect your business. ●● Distraction. Obviously, how a dentist interacts with patients greatly influences his ●● Parental presence/absence. or her professional success. Studies suggest that dentists’ technical ●● Nitrous oxide/oxygen inhalation. skills are often judged by their “bedside manner,” or how caring and ●● Protective stabilization. sympathetic they are perceived to be, which is largely a function of ●● Sedation. communication skills. ●● General anesthesia.

Dental.EliteCME.com Page 113 The goals of behavior guidance are to: share in the decision-making process on treatment of their ŠŠ Establish communication. children. ŠŠ Alleviate fear and anxiety. ●● The staff must be trained carefully to support the dentist’s ŠŠ Deliver quality dental care. efforts and welcome the patient and parent into a child-friendly ŠŠ Build a trusting relationship between dentist, child and parent. environment that will facilitate behavior guidance and a positive ŠŠ Promote the child’s positive attitude toward oral/dental health and dental visit. oral health care. ●● Pain management during dental procedures is crucial for To achieve these objectives, dental professionals should implement successful behavior guidance and enhancing positive dental measures that take the following factors into account: attitudes for future visits. Listening to the child and observing ●● The urgency of the child’s dental needs must be considered his or her behavior at the first sign of distress will be helpful in when planning treatment. Deferral or modification of treatment diagnosing the situation and facilitating proper behavior guidance sometimes may be necessary until routine care can be provided techniques. using appropriate behavior guidance techniques. ●● Parents exert a significant influence on the behavior of their ●● All decisions on use of behavior guidance techniques must be children. Educating the parents before their child’s visit may be based upon a benefit vs. risk evaluation. As part of the process of helpful and promote a positive dental experience. obtaining informed consent, the dentist’s recommendations on ●● Dentists should record the patient’s behavior at each visit. This use of techniques (other than communicative guidance) must be will serve as a documentation of past behavior and aid in diagnosis explained to the parents’ understanding and acceptance. Parents for future visits.

Stages of child development Many different theories and categorization of child development exist. 3. Concrete operations: From about 7 to 11 years of age; child Perhaps the most well-known is Piaget’s stage theory, describing the is able to apply logical reasoning, consider another person’s cognitive development of children. Although stages of psychological point of view, and assess more than one aspect of a particular and physical development vary greatly by child, certain qualitative situation. Characterized by concrete thinking. age-associated differences in development can be noted in most 4. Formal operations: Begins at about 11 years of age; logical children. The dental team should be aware of these important abstract thinking develops, allowing the child to consider psychological milestones: different possibilities for action. ●● Motor development ●● Perceptual development Range of movement develops rapidly. By 2 years of age, most Between the ages of 6 and 7 years, a child begins to determine children are capable of walking on their own. Children 6 to 7 years what information merits greater attention and what can be old usually have sufficient coordination to brush their teeth, though ignored. Concentration improves. At this age, dentists can begin it varies greatly by child. Parental supervision of brushing is very to impart dental advice directly to the patient. Because the home important, but critical for younger children, who are likely to miss environment will still be the main source of information, it is areas of the mouth and may swallow large amounts of toothpaste. crucial to explain proper dental care to the patient’s parents so they ●● Cognitive development can guide the effort. Piaget discussed four main stages of cognitive development: ●● Social development 1. Sensorimotor: About 2 years of age; child develops an Fear of strangers is pronounced in many infants at about 8 months understanding that items exist even when not experienced of age, with anxiety separation relatively common for children directly (called “object permanence”). until about 5 years of age, when it declines markedly. 2. Preoperational thought: From about 2 to 7 years of age; child becomes able to predict outcomes (causation). Language develops.

Anxiety A closer study of anxiety is necessary to addressing it in both children age-appropriate explanation before any procedure can reduce patient and adult patients. Kent and Blinkhorn [1991] describe anxiety as anxiety. a “vague unpleasant feeling accompanied by a premonition that The best way to reduce potential for anxiety is to establish an something undesirable is going to happen.” An added dimension effective preventive care program that includes sufficient time during not noted in this definition is that anxiety often manifests itself in or each session for the patient and dental team to develop a trusting motivates behavior, such as avoiding dental appointments. It also is relationship in which the dentist: an additional stress to the dental practitioner, who does not want to ●● Listens to the child. contribute to the anxiety in any way. ●● Addresses any concerns or worries. Children are much more vulnerable and fearful than most adults. They ●● Ensures that treatment is pain-free. are less comfortable in new surroundings and not amenable to rushing. Anxiety and fear are closely related. In many cases, the two terms can Therefore, effective time management is critical. Do not overschedule, be used interchangeably. While anxiety more often stresses feelings of and do your best to see young patients on time. Never attempt to discomfort, fear describes a stronger reaction to a specific event, one complete a clinical task in a short time on an apprehensive patient. that may trigger the flight/fight response. A phobia is intense fear that Poor past experiences and learned anxiety responses from family is egregiously out of proportion to the actual threat. Despite a dental members and friends are common sources of anxiety in children. team’s best efforts, anxiety may persist or escalate, with dental care Additionally, anxiety is often related to uncertainty about what is compromised unless interventions such as pharmacological agents are about to happen. In each of these cases, a relaxed and thorough used.

Page 114 Dental.EliteCME.com Communication strategies/management Communicative management and appropriate use of commands are Rather than being a collection of singular techniques, communicative used universally in pediatric dentistry with both the cooperative management is an ongoing subjective process that becomes an and uncooperative child. In addition to establishing a relationship extension of the personality of the dentist. Associated with this process with the child and allowing for the successful completion of dental are the specific techniques of tell-show-do, voice control, nonverbal procedures, these techniques may help the child develop a positive communication, positive reinforcement and distraction. The dentist attitude toward oral health. Communicative management comprises should consider the cognitive development of the patient as well as a host of techniques that, when integrated, enhance the evolution of a the presence of other communication deficits (e.g., hearing disorder), cooperative patient. when choosing specific communicative management techniques.

The dental consultation This section outlines basic steps for a dental consultation with a child continue to ask them specifically about pain or discomfort as you patient: are working. An excellent strategy that is educational, calming, 1. Greeting: The dentist should greet the child by name. Parents and easy for you is to discuss specifically what you are doing as should be included in the conversation, but the child should be are doing it. your central focus. The greeting should put the child and parents at ○○ At the end of the dental procedure it is helpful to summarize ease. At this point, the child can be invited to sit in the dental chair, what has been done and discuss aftercare. The parents must or the first part of the preliminary talk can occur with the child in a understand the treatment summary because they need to regular seat. understand what was done and to oversee the aftercare. 2. Preliminary discussion: This portion has three main goals: 5. Health education: Because oral health is so dependent on ○○ To assess worries or concerns on behalf of the patient or personal behavior, it is essential that patients learn how to maintain parents. a healthy mouth. Here are some key ways to improve the value of ○○ To make the patient feel comfortable in the clinical advice given to patients and their parents: environment. ○○ Make the advice specific, simple and precise. ○○ To assess the patient’s emotional state. ○○ Provide written information with diagrams for the patient to ■■ Many dentists find it is best to begin by discussing non- take home. dental topics. Record notes for future reference, and ○○ Do not suggest goals that require unrealistic behavioral review notes from siblings or family members to acquaint changes. Instead, encourage patients to change habits or reacquaint yourself with the patient. Information should gradually; i.e., if brushing only once a day, suggest they brush include names of brothers/sisters, school, pets and hobbies. morning and night instead of after every meal. ■■ Ask open-ended question such as “Are you having any ○○ Confirm the information has been understood and not problems or pain with your teeth?” Never phrase the misinterpreted by having the patient repeat it back to you. question to imply a certain answer (such as “You’re not ○○ Offer advice in such a way that the child and parents do not having any problems or pain with your teeth, are you?”). feel threatened or blamed. Really listen to the answer, including any hesitation ○○ To improve oral hygiene, use practical demonstrations rather or uncertainty. Sometimes children have difficulty than theoretical discussions. characterizing or describing what they are experiencing ○○ Reinforce the advice and offer positive reinforcement at because their language skills are not fully developed. Once follow-up visits. you have listened and clarified the answer, probe further ○○ The final portion of this step is goal setting, in which the for more detail, if necessary. You will find that simply dentist briefly discusses the patient’s responsibilities at talking to the patient and taking note of what he or she home and what he or she should try to achieve by the next is saying increases the person’s feelings of control and visit. This discussion clarifies to both children and parents reduces anxiety. what is expected of them to maintain or improve the child’s 3. Preliminary explanation. This section requires the dentist to oral health. Sensitivity for parents’ feelings is important, communicate the clinical or preventive objectives in terms that because they may feel the dentist does not understand their parents and children will understand. It is critical that the dentist is problems or that they are being blamed for their child’s dental able to state the goals of treatment in non-technical language. shortcomings. It is important that goal setting is done in a 4. Dental procedure: This is where the clinical work begins. While cooperative and friendly manner. you cannot carry on a conversation with the patient, you cannot 6. Departure: This appointment is over. The next appointment treat him or her as a passive object, either. The patient should should be scheduled and office business completed. The patient be encouraged to respond with verbal signs. Tell them to let you should be addressed by name and bid goodbye, leaving pain-free know in a specific way if they are in discomfort or pain, but also with a sense of goodwill.

Nonpharmacological strategies to reduce uncertainty and anxiety Most young children have no real sense of what dental treatment 2. Show: Demonstrations for the patient of the visual, auditory, involves before they experience it, and this will raise anxiety levels. olfactory and tactile aspects of the procedure in a carefully defined, Friendly reassurance is enough for some patients, but others will need nonthreatening setting. more structured methods. 3. Do: Without deviating from the explanation and demonstration, Tell-show-do is a technique of verbal and nonverbal communication completion of the procedure. behavior shaping used by many pediatric professionals. The technique The tell-show-do technique is used with communication skills (verbal involves: and nonverbal) and positive reinforcement. The patient should be 1. Tell: Verbal explanations of procedures in phrases appropriate to praised throughout the procedure. the developmental level of the patient.

Dental.EliteCME.com Page 115 The objectives of tell-show-do are to: children on a sporadic basis. Distraction, however, is one cognitive ŠŠ Teach the patient important aspects of the dental visit. approach that is very effective with children. This technique attempts ŠŠ Familiarize the patient with the dental setting. to divert attention from the dental procedure to something more ŠŠ Shape the patient’s response to procedures through desensitization pleasant, such as cartoons or video games. Giving the patient a short and well-described expectations. break during a stressful procedure can also be an effective use of Voice control is a controlled alteration of voice volume, tone or pace distraction before considering more advanced behavior guidance to influence and direct the patient’s behavior. Parents unfamiliar with techniques. this possibly aversive technique may benefit from an explanation The objectives of distraction are to: before its use to prevent misunderstanding. ŠŠ Decrease the perception of unpleasantness. Š The objectives of voice control are to: Š Avert negative or avoidance behavior. ŠŠ Gain the patient’s attention and compliance. Modeling – Children learn a great deal about the world by seeing other ŠŠ Avert negative or avoidance behavior. people’s behaviors and its consequences. Children are more inclined to ŠŠ Establish appropriate adult-child roles. behave in ways they see rewarded rather than punished. Modeling is Nonverbal communication is the reinforcement and guidance of a useful way to “show” that a procedure is not to be feared. To do this behavior through appropriate contact, posture, facial expression and requires seeing another child have a good experience with the same body language. procedure. While it’s not necessary to produce a live model (videos of cooperative patients can be useful), older siblings, other family The objectives of nonverbal communication are to: members and even friends can be very helpful in this regard. ŠŠ Enhance the effectiveness of other communicative management techniques. The most effective modeling programs, however, show videos or use ŠŠ Gain or maintain the patient’s attention and compliance. children close in age to the child involved. The model should be shown entering and leaving treatment with no negative effects (although Positive reinforcement is the process of establishing desirable discussion of tenderness or other common symptoms after dental work patient behavior, it is essential to give appropriate feedback. Positive should be discussed). The dentist should praise the patient throughout. reinforcement is an effective technique to reward desired behaviors and thus strengthen the recurrence of those behaviors. Social A note about hand over mouth exercise (HOME): Hand over reinforcers include positive voice modulation, facial expression, verbal mouth exercise has been eliminated from the clinical guidelines of the praise and appropriate physical demonstrations of affection by all American Association of Pediatric Dentistry. This conditioning method members of the dental team. Nonsocial reinforcers include tokens and was originally recommended in 1929 as a last resort for use by dentists toys. to control a child (typically over 3 years old) who would not cooperate while undergoing a dental procedure. It should no longer be used. Distraction – while cognitive approaches are useful in reducing anxiety in adults, it is difficult to implement most of them with

Parental influence on dental treatment Children learn the most basic aspects of life from their parents in a parent’s presence may also divide the child’s attention, taking it away process known as socialization. Fear of dental treatment and patterns from the dentist. Parents in the treatment room noted the following of dental hygiene are typically learned in the family. Because parents potentially obstructive behaviors: are the primary influence in children’s attitudes about oral health care, ●● Repeating orders, creating excess noise and annoyance for the they must be involved in any attempts to shape a child’s dental care dental team or child. habits. Discussion with parents must always use positive reinforcement ●● Becoming an obstacle to the to the development of rapport and avoid anything that may be interpreted as “blaming.” Parents may between the dentist and the child. feel sensitive, threatened or guilty about a child’s compromised dental ●● Interfering with behavioral guidance or communication strategies. health. These emotions result in excuses, and if intense enough, an end ●● Being defensive or taking offense at something said. to the child’s dental visits. ●● Contributing to physical crowding of the dental team. Parental presence/absence – The objectives of parental presence/ A wide diversity exists in practitioner philosophy and parental attitudes absence are for parents to participate in infant examinations about parents’ presence or absence during pediatric dental treatment. and treatment if asked; offer very young children physical and Parental involvement, especially in their children’s health care, has psychological support; and observe the reality of their child’s changed dramatically in recent years. Increasingly, parents expect to treatment. This allows practitioners to achieve the following goals, be with their infants and young children during examinations as well which are necessary to providing therapeutic services: as during treatment. Parents’ desire to be present during their child’s ŠŠ Gain the patient’s attention and improve compliance. treatment should not be interpreted to mean they distrust the dentist ŠŠ Avert negative or avoidance behaviors. in any way. More often, it suggests they are uncomfortable if they ŠŠ Establish appropriate dentist-child roles. visually cannot verify their child’s safety. ŠŠ Enhance effective communication among the dentist, child and It is important to understand the changing emotional needs of parents parent. because of the growth of a latent but natural sense to be protective of ŠŠ Minimize anxiety and achieve a positive dental experience. their children. Practitioners should become accustomed to this added ŠŠ Facilitate rapid informed consent for changes in treatment or involvement of parents and welcome the questions and concerns for behavior guidance. their children. Practitioners must consider parents’ desires and wishes Unfortunately, in some cases, parents are unwilling or unable to extend and be open to a paradigm shift in their own thinking. effective support when asked. Parents may themselves be anxious about dental care and communicate that fear to their children. A

Page 116 Dental.EliteCME.com Advanced behavior guidance Most children can be managed effectively using basic behavior ++ Patients who cannot cooperate because of a lack of psychological guidance strategies. Some children, however, present behavioral or emotional maturity or mental, physical or medical disability. considerations that require more advanced techniques. These children ++ Patients for whom the use of sedation may protect the developing often cannot cooperate because of a lack psychological or emotional psyche or reduce medical risk. maturity or mental, physical or medical disabilities. The use of sedation is contraindicated for: The advanced behavior guidance techniques commonly used and XX The cooperative patient with minimal dental needs. taught in advanced pediatric dental training programs include XX Predisposing medical conditions or physical conditions that would protective stabilization, sedation and general anesthesia. They are make sedation inadvisable. extensions of the overall behavior guidance continuum with the intent General anesthesia is a controlled state of unconsciousness to facilitate the goals of communication, cooperation and delivery of accompanied by a loss of protective reflexes, including the ability quality oral health care in the difficult patient. Skillful diagnosis of to maintain an airway independently and respond purposefully to behavior and safe and effective implementation of these techniques physical stimulation or verbal command. The use of general anesthesia necessitate knowledge and experience that are generally beyond the sometimes is necessary to provide quality dental care for the child. core knowledge students receive during predoctoral dental education. Depending on the patient, this can be done in a hospital or an While most predoctoral programs provide didactic exposure to ambulatory setting, including the dental office. treatment of very young children (i.e., aged birth-2 years), patients The need to diagnose and treat as well as the safety of the patient, with special health care needs, advanced behavior guidance techniques practitioner and staff should be considered for the use of general and hands-on experience are lacking. A minority of programs provides anesthesia. The decision to use general anesthesia must take into educational experiences with these patient populations, but few consideration: provide hands-on exposure to advanced behavior guidance techniques. ●● Alternative behavioral guidance modalities. On average, predoctoral pediatric dentistry programs teach students ●● Dental needs of the patient. to treat children 4 years of age and older who are generally well- ●● The effect on the quality of dental care. behaved and have low levels of caries. Dentists considering the use of ●● The patient’s emotional development. these advanced behavior guidance techniques should seek additional ●● The patient’s medical status. training through a residency program, a graduate program, or an extensive continuing education course that involves both didactic and The goals of general anesthesia are to: experiential mentored training. ŠŠ Provide safe, efficient and effective dental care. ŠŠ Eliminate anxiety. Sedation can be used safely and effectively with patients unable to ŠŠ Reduce untoward movement and reaction to dental treatment. receive dental care for reasons of age or mental, physical or medical ŠŠ Aid in treatment of the young, mentally, physically or medically condition. The need to diagnose and treat as well as the safety of compromised patient. the patient, practitioner and staff should be considered for the use ŠŠ Eliminate the patient’s pain response. of sedation. The decision to use any type of sedation must take into consideration: Prior to the delivery of general anesthesia, appropriate documentation ●● Alternative behavioral guidance modalities. shall address the rationale for use of general anesthesia, informed ●● Dental needs of the patient. consent, instructions provided to the parent, dietary precautions and ●● The effect on the quality of dental care. preoperative health evaluation. Because laws and codes vary from ●● The patient’s emotional development. state to state, minimal requirements for a time-based anesthesia record ●● The patient’s medical and physical considerations. should include: 99 The patient’s heart rate, blood pressure, respiratory rate and The goals of sedation are to: oxygen saturation at specific intervals throughout the procedure ŠŠ Guard the patient’s safety and welfare. and until predetermined discharge criteria have been attained. ŠŠ Minimize physical discomfort and pain. 99 The name, route, site, time, dosage and patient effect of ŠŠ Control anxiety, minimize psychological trauma, and maximize the administered drugs, including local anesthesia. potential for amnesia. 99 Adverse events (if any) and their treatment. ŠŠ Control behavior and movement to allow the safe completion of 99 That discharge criteria have been met, the time and condition the procedure. of the patient at discharge, and into whose care the discharge ŠŠ Return the patient to a state in which safe discharge from medical occurred. supervision, as determined by recognized criteria, is possible. General anesthesia is indicated for: Documentation must include: ++ Patients who cannot cooperate due to a lack of psychological or 99 Informed consent must be obtained from the parent and emotional maturity or mental, physical or medical disability. documented prior to the use of sedation. ++ Patients for whom local anesthesia is ineffective because of acute 99 Instructions and information provided to the parent. infection, anatomic variations or allergy. 99 Health evaluation. ++ The extremely uncooperative, fearful, anxious or 99 A time-based record that includes the name, route, site, time, uncommunicative child or adolescent. dosage and patient effect of administered drugs. ++ Patients requiring significant surgical procedures. 99 The patient’s level of consciousness, responsiveness, heart rate, ++ Patients for whom the use of general anesthesia may protect the blood pressure, respiratory rate and oxygen saturation at the time developing psyche or reduce medical risk. of treatment and until predetermined discharge criteria have been ++ Patients requiring immediate, comprehensive oral/dental care. attained. 99 Adverse events (if any) and their treatment. The use of general anesthesia is contraindicated for: 99 Time and condition of the patient at discharge. XX A healthy, cooperative patient with minimal dental needs. XX Predisposing medical conditions that would make general Sedation is indicated for: anesthesia inadvisable. ++ Fearful, anxious patients for whom basic behavior guidance techniques have not been successful.

Dental.EliteCME.com Page 117 Protective stabilization – The broad definition of protective ŠŠ Facilitate delivery of quality dental treatment. stabilization is the restriction of patient’s freedom of movement, with The patient’s record must include: or without the patient’s permission, to decrease risk of injury while 99 Informed consent for stabilization. allowing safe completion of treatment. The restriction may involve 99 Indication for stabilization. another human, a patient stabilization device, or a combination thereof. 99 Type of stabilization. The use of any type of protective stabilization in the treatment of 99 The duration of application of stabilization. infants, children, adolescents or patients with special health care 99 Behavior evaluation/rating during stabilization. needs is a topic that concerns health care providers, caregivers and Patient stabilization is indicated when: the public. It is rare that a better strategy cannot be found, because ++ Patients require immediate diagnosis or limited treatment and the use of protective stabilization has the potential to produce serious cannot cooperate because of a lack of maturity or mental or consequences, such as physical or psychological harm, loss of dignity physical disability. and violation of a patient’s rights. Stabilization devices placed around ++ The safety of the patient, staff, dentist or parent would be at risk the chest may restrict respirations; they must be used with caution, without the use of protective stabilization. especially for patients with respiratory compromise (e.g., asthma) or ++ Sedated patients require limited stabilization to help reduce who will receive medications (i.e., local anesthetics, sedatives) that untoward movement. can depress respirations. Because of the associated risks and possible consequences of use, the dentist is encouraged to evaluate thoroughly Patient stabilization is contraindicated for: its use on each patient and possible alternatives. Careful, continuous XX Cooperative, non-sedated patients. monitoring of the patient is mandatory during protective stabilization. XX Patients who cannot be immobilized safely because of associated medical or physical conditions. In very rare cases, partial or complete stabilization of the patient may XX Patients who have experienced previous physical or psychological be necessary to protect the patient, practitioner, staff or the parent trauma from protective stabilization (unless no other alternatives from injury while providing dental care. Protective stabilization can are available). be performed by the dentist, staff or parent with or without the aid of XX Non-sedated patients with non-emergent treatment requiring a restrictive device. The dentist always should use the least restrictive lengthy appointments. but safe and effective protective stabilization. The use of a mouth prop in a compliant child is not considered protective stabilization. The following precautions should be taken: * The patient’s medical history must be reviewed carefully to The need to diagnose, treat and protect the safety of the patient, ascertain whether there are any medical conditions (e.g., asthma) practitioner, staff and parent should be considered before the use of that may compromise respiratory function. protective stabilization. The decision to use protective stabilization * Tightness and duration of the stabilization must be monitored and must take into consideration: reassessed at regular intervals. ●● Alternate behavior guidance modalities. * Stabilization around extremities or the chest must not actively ●● Dental needs of the patient. restrict circulation or respiration. ●● The effect on the quality of dental care. * Stabilization should be terminated as soon as possible in a patient ●● The patient’s emotional development. who is experiencing severe stress or hysterics to prevent possible ●● The patient’s emotional and physical considerations. physical or psychological trauma. Protective stabilization, with or without a restrictive device, performed Potential benefits: by the dental team, requires informed consent from a parent. Informed ++ Reduction in pain and anxiety of pediatric dental patients with consent must be obtained and documented in the patient’s record prior special health care needs. to use of protective stabilization. Because of the possible aversive ++ Increase in safety and quality of care for pediatric dental patients. nature of the technique, informed consent also should be obtained ++ Increase in safety of dental staff. before a parent performs protective stabilization during dental procedures. Furthermore, when appropriate, an explanation to the Potential risks: patient about the need for restraint, with an opportunity for the patient * The use of protective stabilization has the potential to produce to respond, should occur. serious consequences, such as physical or psychological harm, loss of dignity and violation of a patient’s rights. Stabilization In the event of an unanticipated reaction to dental treatment, it is devices placed around the chest may restrict respirations; they incumbent upon the practitioner to protect the patient and staff from must be used with caution, especially for patients with respiratory harm. Following immediate intervention to assure safety, if techniques compromise (e.g., asthma) or who will receive medications (i.e., must be altered to continue delivery of care, the dentist must have local anesthetics, sedatives) that can depress respirations. Because informed consent for the alternative methods. of the associated risks and possible consequences of use, the The objectives of patient stabilization are to: dentist is encouraged to evaluate thoroughly its use on each patient ŠŠ Reduce or eliminate untoward movement. and possible alternatives. Careful, continuous monitoring of the ŠŠ Protect patient, staff, dentist, or parent from injury. patient is mandatory during protective stabilization.

Nitrous oxide use and the child patient Nitrous oxide/oxygen inhalation is a safe and effective technique indications, contraindications and additional clinical considerations, to reduce anxiety and enhance effective communication. Its onset revised in 2009 by the American Association of Pediatric Dentists, are of action is rapid, the effects easily are titrated and reversible, and provided here. recovery is rapid and complete. Additionally, nitrous oxide/oxygen This section provides information to help you develop appropriate inhalation mediates a variable degree of analgesia, amnesia and gag practices in the use of nitrous oxide/oxygen analgesia/anxiolysis reflex reduction. for pediatric patients. Indications for use of nitrous oxide/oxygen However, the need to diagnose and treat as well as the safety of the analgesia/anxiolysis include: patient and practitioner should be considered before the use of nitrous ++ A fearful, anxious, or obstreperous patient. oxide/oxygen analgesia/anxiolysis. Detailed information about the ++ Certain patients with special health care needs.

Page 118 Dental.EliteCME.com ++ A patient whose gag reflex interferes with dental care. pulmonary disease, congestive heart failure, sickle cell disease, acute ++ A patient for whom profound local anesthesia cannot be obtained. otitis media, recent tympanic membrane graft, acute severe head ++ A cooperative child undergoing a lengthy dental procedure. injury). Review of the patient’s medical history should be performed before This section examines the following points: making a decision to use nitrous oxide/oxygen analgesia/anxiolysis. Management This assessment should include: ●● Technique of nitrous oxide/oxygen administration. 99 Allergies and previous allergic or adverse drug reactions. ●● Patient monitoring during procedure (patient’s responsiveness, 99 Current medications including dose, time, route, and site of color, respiratory rate and rhythm, spoken responses). administration. ●● Documentation. 99 Diseases, disorders or physical abnormalities and pregnancy status. ○○ Informed consent. 99 Previous hospitalization to include the date and purpose. ○○ Provision of instructions to the parent (regarding pre-treatment Contraindications for use of nitrous oxide/oxygen inhalation may dietary precautions). include: ○○ Recording of indication, dose, flow, procedure duration, post- XX Some chronic obstructive pulmonary diseases. treatment oxygenation procedure. XX Severe emotional disturbances or drug-related dependencies. Facilities/personnel/equipment XX First trimester of pregnancy. ●● Proper gas delivery and fail-safe function. XX Treatment with bleomycin sulfate. ●● Appropriate oxygen concentration. XX Methylenetetrahydrofolate reductase deficiency. ●● Training and certification in basic life support for all clinical Whenever possible, appropriate medical specialists should be personnel. consulted before administering analgesic/anxiolytic agents to patients ●● Periodic review of safety procedures (the office’s emergency with significant underlying medical conditions (e.g., severe obstructive protocol, the emergency drug cart, and simulated exercises to assure proper emergency management response).

Administration technique Nitrous oxide/oxygen must be administered only by appropriately ++ Enhanced communication and patient cooperation. licensed individuals or under the direct supervision thereof, according ++ Raised pain reaction threshold. to state law. The practitioner responsible for the treatment of the ++ Increased tolerance for longer appointments. patient and the administration of analgesic/anxiolytic agents must ++ Aided treatment of the mentally/physically disabled or medically be trained in the use of such agents and techniques and appropriate compromised patient. emergency response. ++ Reduced gagging. Selection of an appropriately sized nasal hood should be made. A flow ++ Potentiated effect of other sedatives. rate of 5 to 6 liters/minute generally is acceptable to most patients. The Potential risks: flow rate can be adjusted after observation of the reservoir bag.The * Some patients fear “losing control” with the use of nitrous oxide. bag should pulsate gently with each breath and should not be either * Claustrophobic patients may find the nasal hood confining and over- or underinflated. Introduction of 100 percent oxygen for 1-2 unpleasant. minutes followed by titration of nitrous oxide in 10 percent intervals * Side effects including nausea, vomiting, headache and is recommended. During nitrous oxide/oxygen analgesia/anxiolysis, disorientation. the concentration of nitrous oxide should not routinely exceed 50 * Although rare, silent regurgitation and subsequent aspiration need percent. Nitrous oxide concentration may be decreased during easier to be considered with nitrous oxide/oxygen sedation. The concern procedures (e.g., restorations) and increased during more stimulating lies in whether pharyngeal-laryngeal reflexes remain intact. ones (e.g., extraction, injection of local anesthetic). * Interference of the nasal hood with injection to anterior maxillary During treatment, it is important to continue the visual monitoring of region. the patient’s respiratory rate and level of consciousness. The effects * Nitrous oxide pollution and potential occupational exposure health of nitrous oxide largely are dependent on psychological reassurance. hazards. Therefore, it is important to continue traditional behavior guidance Contraindications for use of nitrous oxide/oxygen inhalation may techniques during treatment. Once the nitrous oxide flow is terminated, include: 100 percent oxygen should be delivered for three to five minutes.The XX Some chronic obstructive pulmonary diseases. patient must return to pre-treatment responsiveness before discharge. XX Severe emotional disturbances or drug-related dependencies. Potential benefits: XX First trimester of pregnancy. ++ Reduction or elimination of anxiety. XX Treatment with bleomycin sulfate. ++ Reduced movement and reaction to dental treatment. XX Methylenetetrahydrofolate reductase deficiency.

Monitoring The response of patients to commands during procedures responsiveness, color and respiratory rate and rhythm must be performed with anxiolysis/analgesia serves as a guide to their performed. Spoken responses provide an indication that the patient level of consciousness. Clinical observation of the patient must be is breathing. If any other pharmacologic agent is used in addition to done during any dental procedure. During nitrous oxide/oxygen nitrous oxide/oxygen and a local anesthetic, monitoring guidelines for analgesia/anxiolysis, continual clinical observation of the patient’s the appropriate level of sedation must be followed.

Adverse effects of nitrous oxide/oxygen inhalation Nitrous oxide/oxygen analgesia/anxiolysis has an excellent safety a safe and effective agent for providing pharmacological guidance record. When administered by trained personnel on carefully selected of behavior in children. Acute and chronic adverse effects of nitrous patients with appropriate equipment and technique, nitrous oxide is oxide on the patient are rare. Nausea and vomiting are the most

Dental.EliteCME.com Page 119 common adverse effects, occurring in 0.5 percent of patients. A higher Documentation incidence is noted with longer administration of nitrous oxide/oxygen, Informed consent must be obtained from the parent and documented fluctuations in nitrous oxide levels, and increased concentrations of in the patient’s record prior to administration of nitrous oxide/oxygen. nitrous oxide. The practitioner should provide instructions to the parent regarding pre-treatment dietary precautions, if indicated. In addition, the patient’s Fasting is not required for patients undergoing nitrous oxide analgesia/ record should include: anxiolysis. The practitioner, however, may recommend that only a 99 Indication for use of nitrous oxide/oxygen inhalation. light meal be consumed in the two hours prior to the administration 99 Nitrous oxide dosage (i.e., percent nitrous oxide/oxygen and/or of nitrous oxide. Diffusion hypoxia can occur as a result of rapid flow rate). release of nitrous oxide from the blood stream into the alveoli, thereby 99 Duration of the procedure. diluting the concentration of oxygen. This may lead to headache 99 Post-treatment oxygenation procedure. and disorientation and can be avoided by administering 100 percent oxygen after nitrous oxide has been discontinued.

Facilities/personnel/equipment All newly installed facilities for delivering nitrous oxide/oxygen These individuals should participate in periodic review of the office’s must be checked for proper gas delivery and fail-safe function before emergency protocol, the emergency drug cart, and simulated exercises use. Inhalation equipment must have the capacity for delivering 100 to assure proper emergency management response. percent, and never less than 30 percent, oxygen concentration at An emergency cart (kit) must be readily accessible. Emergency a flow rate appropriate to the child’s size. Additionally, inhalation equipment must be able to accommodate children of all ages and equipment must have a fail-safe system that is checked and calibrated sizes. It should include equipment to resuscitate a non-breathing, regularly according to the practitioner’s state laws and regulations. An unconscious patient and provide continuous support until trained in-line oxygen analyzer must be used if nitrous oxide/oxygen delivery emergency personnel arrive. A positive pressure oxygen delivery equipment is capable of delivering more than 70 percent nitrous oxide system capable of administering greater than 90 percent oxygen at a and less than 30 percent oxygen. Equipment must have an appropriate 10 liters/minute flow for at least 60 minutes (650 liters, “E” cylinder) scavenging system (see below). must be available. When a self-inflating bag valve mask device is The practitioner who utilizes nitrous oxide/oxygen analgesia/anxiolysis used for delivering positive pressure oxygen, a 15 liters/minute flow for a pediatric dental patient must possess appropriate training and is recommended. There should be documentation that all emergency skills and have available the proper facilities, personnel and equipment equipment and drugs are checked and maintained on a regularly to manage any reasonably foreseeable emergency. Training and scheduled basis. Where state law mandates equipment and facilities, certification in basic life support are required for all clinical personnel. such statutes should supersede this guideline.

Occupational safety In an effort to reduce occupational health hazards associated with use of effective scavenging systems and periodic evaluation and nitrous oxide, the American Academy of Pediatric Dentistry (AAPD) maintenance of the delivery and scavenging systems. recommends exposure to ambient nitrous oxide be minimized through

Anesthesia personnel and administration This section is meant to assist the dental practitioner who elects to use delivery equipment, appropriate monitors and emergency anesthesia personnel for the administration of deep sedation/general equipment, and medications. anesthesia for pediatric dental patients in a dental office or other 4. Appropriate documentation on the procedure, including: facility outside of an accredited hospital or surgicenter. It describes the ○○ Rationale for sedation/general anesthesia. necessary personnel, facilities, documentation and quality assurance ○○ Informed consent. mechanisms required to provide optimal and responsible pediatric ○○ Instructions to parent. patient care. It considers the following interventions and practices: ○○ Dietary precautions. 1. Training and credentialing of anesthesia personnel for office-based ○○ Preoperative health evaluation. deep sedation/general anesthesia procedures. ○○ Medication prescriptions. 2. Training of the office staff in emergency procedures. ○○ Vital signs. 3. Provision of appropriate facilities that comply with applicable ○○ Recovery. laws, codes and regulations including dental equipment, anesthesia 5. Risk management and quality assurance.

Personnel Office-based deep sedation/general anesthesia techniques require at ●● The anesthesia care provider must be a licensed dental or medical least three individuals. The anesthesia care provider’s responsibilities practitioner with appropriate and current state certification for deep are to administer drugs, or direct their administration, and vigilantly sedation/general anesthesia. observe the patient’s vital signs, airway patency, cardiovascular and ●● The anesthesia care provider must have completed a one- or two- neurological status, and adequacy of ventilation. In addition to the year dental anesthesia residency or its equivalent, as approved by anesthesia care provider, the operating dentist and other staff must be the American Dental Association (ADA), or medical anesthesia trained in emergency procedures. residency, as approved by the American Medical Association It is the obligation of treating practitioners when employing anesthesia (AMA). personnel to administer deep sedation/general anesthesia to verify their ●● The anesthesia care provider currently must be licensed by and in credentials and experience, including: compliance with the laws of the state in which he or she practices. Laws vary from state to state and may supersede any portion of this document.

Page 120 Dental.EliteCME.com ●● If state law permits a certified registered nurse anesthetist or ●● The anesthesia care provider explains potential risks and obtains anesthesia assistant to function under the supervision of a dentist, informed consent for sedation/anesthesia. the dentist is required to have completed training in deep sedation/ Office staff members should understand their additional general anesthesia and be licensed or permitted, as appropriate to responsibilities and special considerations (e.g., loss of protective state law. reflexes) associated with office-based deep sedation/general anesthesia. The dentist and anesthesia care provider must be compliant with the Advanced training in recognition and management of pediatric American Academy of Pediatrics/American Academy of Pediatric emergencies is critical in providing safe sedation and anesthetic care. Dentistry (AAP/AAPD)’s Guideline on Monitoring and Management Although it is appropriate for the most experienced professional of Pediatric Patients During and After Sedation for Diagnostic and (i.e., the anesthesia provider) to assume responsibility in managing Therapeutic Procedures or other appropriate guidelines of the ADA, anesthesia-related emergencies, the operating dentist and clinical staff AMA and their recognized specialties. The recommendations in need to maintain current expertise in basic life support. this document may be exceeded at any time if the change involves An individual experienced in recovery care must be in attendance in improved safety and is evidence-based or supported by currently the recovery facility until the patient, through continual monitoring, accepted practice. exhibits respiratory and cardiovascular stability and appropriate The dentist and anesthesia personnel must work together to increase discharge criteria have been met. patient safety. Effective communication is essential: In addition, the staff of the treating dentist must be well-versed ●● The dentist introduces the concept of deep sedation/general in rescue and emergency protocols (including cardiopulmonary anesthesia to the parent and provides appropriate preoperative resuscitation) and have contact numbers for emergency medical instructions and informational materials. services and ambulance services. Emergency preparedness must be ●● The dentist or his or her designee coordinates medical updated and practiced on a regular basis. consultations when necessary.

Facilities A continuum exists that extends from wakefulness across all levels of For deep sedation, there shall be continuous monitoring of oxygen sedation. Often these levels are not easily differentiated, and patients saturation and heart rate and intermittent time-based recording of may drift through them. When anesthesia care providers are used for respiratory rate and blood pressure. When adequacy of ventilation office-based administration of deep sedation or general anesthesia, is difficult to observe, use of a precordial stethoscope or capnograph the facilities in which the dentist practices must meet the guidelines is encouraged. An electrocardiographic monitor should be readily and appropriate local, state and federal codes for administration of the available for patients undergoing deep sedation. In addition to the deepest possible level of sedation/anesthesia. monitors previously mentioned, a temperature monitor and pediatric Facilities also should comply with applicable laws, codes and defibrillator are required for general anesthesia. regulations on controlled drug storage, fire prevention, building Emergency equipment must be readily accessible and should include construction and occupancy, accommodations for the disabled, suction, drugs necessary for rescue and resuscitation (including 100 occupational safety and health, and disposal of medical waste and percent oxygen capable of being delivered by positive pressure at hazardous waste. The treatment room must accommodate the dentist appropriate flow rates for up to one hour), and age-/size-appropriate and auxiliaries, the patient, the anesthesia care provider, the dental equipment to resuscitate and rescue a nonbreathing or unconscious equipment, and all necessary anesthesia delivery equipment along with pediatric dental patient and provide continuous support while the appropriate monitors and emergency equipment. Expeditious access to patient is being transported to a medical facility. The treatment facility the patient, anesthesia machine (if present), and monitoring equipment should have medications, equipment and protocols available to treat should be available at all times. malignant hyperthermia when triggering agents are used. Recovery Because laws and codes vary from state to state, guidelines presented facilities must be available and suitably equipped. Backup power in this chapter should be followed as the minimum requirements. sufficient to ensure patient safety should be available in case of an emergency.

Documentation Before delivery of deep sedation/general anesthesia, patient safety 99 Recovery: The condition of the patient, that discharge criteria have requires that appropriate documentation shall address rationale been met, time of discharge, and into whose care the discharge for sedation/general anesthesia, informed consent, instructions to occurred must be documented. Requiring the signature of the parent, dietary precautions, preoperative health evaluation, and responsible adult to whom the child has been discharged, verifying any prescriptions along with the instructions given for their use. that he or she has received and understands the post-operative Documentation requires a time-based anesthesia record, including: instructions, is encouraged. 99 Vital signs: Pulse and respiratory rates, blood pressure and oxygen While various business/legal arrangements may exist between the saturation must be monitored and recorded at least every five treating dentist and the anesthesia provider, the dental staff must minutes throughout the procedure and at specific intervals until the maintain all patient records, including time-based anesthesia records, patient has met documented discharge criteria. taking place in the facility, so they are readily available if needed. The 99 Drugs: Name, dose, route, site, time of administration and patient dentist must assure that the anesthesia provider also maintains patient effect of all drugs, including local anesthesia, must be documented. records that are readily available. When anesthetic gases are administered, inspired concentration and duration of inhalation agents and oxygen shall be documented.

Risk management and quality assurance Dentists who use in-office anesthesia care providers must take (ASA) physical status classification. Knowledge, preparation and all necessary measures to minimize risk to patients. The dentist communication between professionals are essential. Before subjecting must be familiar with the American Society of Anesthesiologists a patient to deep sedation/general anesthesia, the patient must undergo

Dental.EliteCME.com Page 121 a preoperative health evaluation. High-risk patients should be treated Unexpected or negative outcomes must be reviewed to monitor the in a facility properly equipped to provide for their care. The dentist quality of services provided. This will decrease risk, allow for open and anesthesia care provider must communicate during treatment and frank discussions, document risk analysis and intervention, and to share concerns about the airway or other details of patient safety. improve the quality of care for the pediatric dental patient. Furthermore, they must work together to develop and document mechanisms of quality assurance.

Local anesthesia use and the child patient Guidelines in this section, revised in 2009 by the American ○○ The anticipated duration of the dental procedure. Association of Pediatric Dentists, are intended to help practitioners ○○ The need for hemorrhage control. make decisions when using local anesthesia to control pain in pediatric ○○ The planned administration of other agents (e.g., nitrous oxide, patients and individuals with special health care needs during the sedative agents, general anesthesia). delivery of oral health care. It considers the following interventions ○○ The practitioner’s knowledge of the anesthetic agent. and practices: ●● Use of vasoconstrictors in local anesthetics is recommended to 1. Topical anesthetics, such as lidocaine and benzocaine. decrease the risk of toxicity of the anesthetic agent, especially 2. Injectable local anesthetics and vasoconstrictors: when treatment extends to two or more quadrants in a single visit. ○○ Lidocaine. ●● In cases of bisulfate allergy, use of a local anesthetic without ○○ Mepivacaine. vasoconstrictor is indicated. Local anesthetic without ○○ Articaine. vasoconstrictor also can be used for shorter treatment needs but ○○ Prilocaine. should be used with caution to minimize the risk of toxicity of the ○○ Bupivacaine. anesthetic agents. ○○ Epinephrine. ●● The established maximum dosage for any anesthetic should not be ○○ Norepinephrine. exceeded. ○○ Levonordefrin. Documentation of local anesthesia 3. Selection of syringes and needles. 99 Documentation must include the type and dosage of local 4. Documentation of local anesthesia administration. anesthetic. Dosage of vasoconstrictors, if any, must be noted (e.g., 5. Supplemental injection techniques: 34 mg lidocaine with 0.017 mg epinephrine or 34 mg lidocaine ○○ Computer-controlled local anesthetic delivery. with 1:100,000 epinephrine). ○○ Periodontal injection techniques (i.e., periodontal ligament 99 Documentation may include the type of injections given (e.g., [PDL], intraligamentary and peridental injection). infiltration, block, intraosseous), needle selection and patient’s ○○ “Needleless” systems. reaction to the injection. ○○ Intraseptal or intrapulpal injection. 99 If the local anesthetic was administered in conjunction with 6. Emergency and complication management. sedative drugs, the doses of all agents must be noted on a time- 7. Administration of local anesthesia with sedation, general based record. anesthesia or nitrous oxide/oxygen analgesia/anxiolysis. 99 In patients for whom the maximum dosage of local anesthetic may The following recommendations are best practices for administering be a concern, the weight should be documented preoperatively. anesthetic agents: 99 Documentation should include that post-injection instructions were Topical anesthetics reviewed with the patient and parent. ●● Topical anesthetic may be used before the injection of a local Local anesthetic complications anesthetic to reduce discomfort associated with needle penetration. * Practitioners who utilize any type of local anesthetic in a pediatric ●● The pharmacological properties of the topical agent should be dental patient must possess appropriate training and skills and have understood. available the proper facilities, personnel and equipment to manage ●● A metered spray is suggested if an aerosol preparation is selected. any reasonably foreseeable emergency. ○○ Systemic absorption of the drugs in topical anesthetics must * Care should be taken to ensure proper needle placement during the be considered when calculating the total amount of anesthetic intraoral administration of local anesthetics. Practitioners should administered. aspirate before every injection and inject slowly. Selection of syringes and needles * After the injection, the doctor, hygienist or assistant should remain ●● For the administration of local dental anesthesia, dentists with the patient while the anesthetic begins to take effect. should select aspirating syringes that meet the American Dental * Residual soft tissue anesthesia should be minimized in pediatric Association (ADA) standards. and special health care needs patients to decrease risk of self- ●● Short needles may be used for any injection in which the thickness inflicted post-operative injuries. of soft tissue is less than 20 mm. A long needle must be used * Practitioners should advise patients and their caregivers about for a deeper injection into soft tissue. Any 23- through 30-gauge appropriate behavioral precautions (e.g., do not bite or suck on needle may be used for intraoral injections because blood can be lip or cheek, do not ingest hot substances) and the possibility of aspirated through all of them. Aspiration can be more difficult, soft tissue trauma following the administration of local anesthesia. however, when smaller-gauge needles are used. An extra-short, Placing a cotton roll in the mucobuccal fold may help prevent 30-gauge is appropriate for infiltration injections. injury, and lubricating the lips with petroleum jelly helps prevent ●● Needles should not be bent if they are to be inserted into soft drying. Practitioners who use phentolamine mesylate injections tissue to a depth of greater than 5 mm or inserted to their hub for to reduce the duration of local anesthesia still should follow these injections to avoid needle breakage. recommendations. Injectable local anesthetic agents ●● Selection of local anesthetic agents should be based upon: ○○ The patient’s medical history and mental/developmental status.

Page 122 Dental.EliteCME.com Supplemental injections to obtain local anesthesia Alternative techniques for the delivery of local anesthesia may be * If a local anesthetic is injected into an area of infection, its onset considered to minimize the dose of anesthetic used, improve patient will be delayed or even prevented. Inserting a needle into an active comfort, and improve successful dental anesthesia. Local anesthesia site of infection may also lead to possible spread of the infection. can be combined with sedation, general anesthesia and nitrous oxide/ * Local anesthetics without vasoconstrictors should be used with oxygen analgesia/anxiolysis with the following provisos: caution because of rapid systemic absorption, which may result in ●● Particular attention should be paid to local anesthetic doses used overdose. in children. To avoid excessive doses for the patient who is going * Compounded topical anesthetics contain high doses of both amide to be sedated, a maximum recommended dose based upon weight and ester agents and are at risk for side effects. The U.S. Food should be calculated. and Drug Administration does not regulate compounded topical ●● The dosage of local anesthetic should not be altered if nitrous anesthetics and recently issued a warning about their use. oxide/oxygen analgesia/anxiolysis is administered. * While rare, needle breakage is a potential risk that occurs most ●● When general anesthesia is employed, local anesthesia may be commonly when a needle is weakened by being bent before used to reduce the maintenance dosage of the anesthetic drugs. insertion into the soft tissues, or in some cases, by patient The anesthesiologist should be informed of the type and dosage of movement after the needle has been inserted. the local anesthetic used. Recovery room personnel also should be Contraindications informed. XX Epinephrine is contraindicated in hyperthyroid patients. Potential benefits XX Levonordefrin and norepinephrine are absolutely contraindicated ++ Appropriate use of local anesthesia in pediatric patients and in patients receiving tricyclic antidepressants because patients with special health care needs prevents pain during dental dysrhythmias may occur (epinephrine dose should be kept to a procedures, builds trust, allays fear and anxiety, and promotes a minimum). positive dental attitude. XX Absolute contraindications for local anesthetics include a Potential risks documented local anesthetic allergy (allergy to one amide does not * Side effects and toxicities of local anesthetics, epinephrine and rule out the use of another amide, but allergy to one ester rules out levonordefrin include central nervous system and cardiovascular use of another ester). toxicity during overdose, allergic reactions, paresthesia and XX A bisulfate preservative is used in local anesthetics containing postoperative soft tissue injury. epinephrine. For patients with an allergy to bisulfates, use of a * An end product of prilocaine metabolism can induce formation local anesthetic without vasoconstrictor is indicated. of methemoglobin, reducing the oxygen carrying capacity of XX Intraosseous techniques may be contraindicated with primary teeth the blood. In patients with subclinical methemoglobinemia or because of potential for damage to developing permanent teeth. with toxic doses (greater than 6mg/kg), prilocaine can induce XX The use of the periodontal ligament injection or intraosseous methemoglobinemia symptoms (e.g., gray or slate blue cyanosis methods is contraindicated in the presence of inflammation or of lips, mucous membranes and nails; respiratory and circulatory infection at the injection site. distress). XX Prilocaine may be contraindicated in patients with * Accidental lip or cheek trauma can occur. methemoglobinemia, sickle cell anemia, anemia, or symptoms of hypoxia or in patients receiving acetaminophen or phenacetin because both medications elevate methemoglobin levels.

Caries risk-assessment and management in the child patient Guidelines on dental caries were revised in 2010 to better help fluoride, dietary and restorative protocols, based upon caries risk and physicians making treatment and diagnostic decisions on prophylaxis, patient compliance.

Data supporting revised recommendations Current caries management protocol is based on results of clinical Guideline Network (SIGN) guideline for the management of caries trials, systematic reviews and expert panel recommendations providing in pre-school children, a Maternal and Child Health Bureau Expert extensive information about diagnostic, preventive and restorative Panel, and the CDC’s fluoride guidelines. treatments. The information presented here comes from the following ●● Guidelines for pit and fissure sealants are based on ADA’s Council sources: on Scientific Affairs recommendations for the use of pit-and- ●● Radiographic diagnostic guidelines are based on the latest fissure sealants. guidelines from the American Dental Association (ADA). ●● Guidelines for the use of xylitol are based on the American ●● Systemic fluoride protocols are based on the Centers for Disease Academy of Pediatric Dentistry (AAPD) oral health policy on use Control and Prevention (CDC) recommendations for using of xylitol in caries prevention, a clinical trial on high caries-risk fluoride. infants and toddlers, and two evidence-based reviews. ●● Guidelines for the use of topical fluoride treatment are based on When data did not appear sufficient or were inconclusive, the ADA’s Council on Scientific Affairs’ recommendations for recommendations were based upon expert or consensus opinion by professionally applied topical fluoride, the Scottish Intercollegiate experienced researchers and clinicians.

Prophylaxis Periodic professional prophylaxis should be performed to: ●● Remove extrinsic stain. ●● Instruct the caregiver and child or adolescent in proper oral ●● Facilitate the examination of hard and soft tissues. hygiene techniques. ●● Introduce dental procedures to the young child and apprehensive ●● Remove microbial plaque and calculus. patient. ●● Polish hard surfaces to minimize the accumulation and retention of plaque.

Dental.EliteCME.com Page 123 In addition to establishing the need for a prophylaxis, the clinician techniques and removing plaque, stain, calculus and the factors that should determine the most appropriate type of prophylaxis for each influence their build-up. patient. The practitioner should select the least aggressive technique Potential benefits that fulfills the goals of the procedure. To minimize loss of the ++ An individualized preventive plan increases the probability of fluoride-rich layer of enamel during polishing, the least abrasive paste good oral health by demonstrating proper oral hygiene methods should be used with light pressure. If a rubber cup/pumice prophylaxis and techniques and removing plaque, stain, calculus, and the is performed, a topical fluoride application is recommended. factors that influence their build-up. A patient’s risk for caries/periodontal disease, as determined by the Potential risks patient’s dental provider, should help determine the interval of the * The use of abrasive toothpastes and whitening products as well as prophylaxis. Patients who exhibit higher risk for developing caries or abrasion during a prophylaxis can remove the acquired pellicle. periodontal disease should have recall visits at intervals more frequent This can have an adverse effect on exposed tooth surfaces by than every six months. This allows increased professional fluoride increasing the chances of enamel loss through exposure to dietary therapy application, microbial monitoring, antimicrobial therapy acids. Furthermore, even though the pellicle begins forming reapplication, and re-evaluating behavioral changes for effectiveness. immediately after it is removed, it may take up to seven days, An individualized preventive plan increases the probability of good possibly longer, to mature fully and offer maximal protection oral health by demonstrating proper oral hygiene methods and against dietary acid.

Xylitol and caries prevention This section provides information to help oral health care professionals Clinicians may consider recommending xylitol use to moderate or high make informed decisions about the use of xylitol-based products in caries-risk patients. Those recommending xylitol should be familiar caries prevention for infants, children and adolescents with moderate with the product labeling and recommend age-appropriate products. or high caries risk. They should routinely reassess (not less than once every six months) a patient for changes in caries-risk status and adjust recommendations accordingly.

Dosage There is accumulating evidence that total daily doses of 3 to 8 grams grams per day. Although tables of clinically effective xylitol containing of xylitol are required for a clinical effect with the currently available products have recently been published, the products are continually delivery methods of syrup, chewing gum and lozenges. Dosing changing. frequency should be a minimum of two times a day, not to exceed 8 Table I: Benefits of prophylaxis options

Plaque removal Stain Calculus Polish/smooth Education of patient/parent Facilitate exam Toothbrush Yes No No No Yes Yes Power brush Yes Yes No No Yes Yes Rubber cup Yes Yes No Yes Yes Yes Hand instruments Yes Yes Yes No Yes Yes Current evidence supports the following recommendations for children at moderate or high caries risk: Table II: Recommended xylitol dosage for children with moderate or high caries risk Age Xylitol product Dosage Less than 4 years old Xylitol syrup* 3-8 grams/day in divided doses 4 years old or greater Age appropriate products such as chewing gum**, mints, lozenges, snack foods 3-8 grams/day in divided doses such as gummy bears. Key to Table II *The American Academy of Pediatrics does not recommend chewing gum use in children less than 4 years of age due to the risk of choking. **The American Academy of Pediatrics does not recommend chewing gum use in children less than 4 years of age because of the risk of choking. Modality Chewing gum has been the predominant modality for xylitol delivery even milk have been studied as delivery vehicles, but they are neither in clinical studies. Studies that have used xylitol-containing mints and well established scientifically nor available commercially at present. hard candies have shown them to be as effective as xylitol-containing A pacifier with a pouch containing slow release xylitol in tablet form, chewing gum. The American Academy of Pediatrics (AAP) does not not yet available in the United States, has shown high salivary xylitol recommend use of chewing gum, mints, or hard candy by children less concentrations and may be a potential delivery vehicle for infants. than 4 years of age because of the risk of choking. Currently, xylitol-containing chewing gum, mints, energy bars and A randomized trial of xylitol syrup (8 g/day) reduced early childhood foods, nasal sprays and oral hygiene products (e.g., mouth rinse, caries by 50 to 70 percent in children 15 to 25 months of age. Another gels, wipes, floss) are commercially available through retail or online study showed that gum or lozenges consumed by children at 5 venues. However, they may not contain the necessary therapeutic level grams total dose per day at about age 10 resulted in 35 to 60 percent xylitol as the only sweetener, or adequate labeling. reductions of tooth decay, with no differences between the delivery Studies using toothpaste formulations with 10 percent xylitol (dose methods. Xylitol-containing gummy bears, other confections and of 0.1 g/brushing) have shown reduction in mutans streptococci (MS)

Page 124 Dental.EliteCME.com levels and caries in children. The toothpastes that were studied are Potential benefits not for sale in the United States. Furthermore, the xylitol-containing ++ Decrease in caries rates, increment or onset. toothpastes that currently are sold in the United States have never been ++ Maternal consumption of xylitol may reduce the acquisition of tested and their formulas differ from those tested. mutans streptococci (MS) and dental caries by their children.

Side effects Parents need to control the amount of xylitol and other polyols that These symptoms usually occur at higher dosages and will subside once their child consumes. Xylitol is safe for children when consumed in xylitol consumption is stopped. To minimize gas and diarrhea, xylitol therapeutic doses for dental caries prevention. Common side effects should be introduced slowly, over a week or more, to acclimate the that may occur with the use of xylitol are gas and osmotic diarrhea. body to the polyol, especially in young children.

Limitations of caries risk assessment guidelines Risk assessment procedures used in medical practice do not have medical providers. Tables III a, III b, and III c are examples of sufficient data to accurately quantitate a person’s disease susceptibility caries management protocols. and allow for preventive measures. Guidelines must recognize that ●● While there is not enough information at present to have treatment can and should be tailored to fit individual needs, depending quantitative caries-risk assessment analyses, estimating children on the patient, practitioner, setting and other factors. Deviations from at low, moderate and high caries risk by a preponderance of risk guidelines may occur and can be justified by differences in individual and protective factors will enable a more evidence-based approach circumstances. Guidelines are designed to produce optimal outcomes, to medical provider referrals as well as establish periodicity and not minimal standards of practice. intensity of diagnostic, preventive, and restorative services. In summary: ●● Clinical management protocols based on a child’s age, caries risk ●● Dental-caries risk assessment, based on a child’s age, biological and level of patient/parent cooperation provide health providers factors, protective factors and clinical findings, should be a routine with criteria and protocols for determining the types and frequency component of new and periodic examinations by oral health and of diagnostic, preventive and restorative care for patient specific management of dental caries. Table IIIa: Sample caries management protocol for 1-2-year-olds

Risk category Diagnostics Interventions Restorative Fluoride Diet Low risk Recall every 6-12 months Twice daily brushing Counseling Surveillance× Baseline mutans streptococci (MS)α Moderate risk, Recall every 6 months Twice daily brushing with fluoridated Counseling Active surveillance€ of incipient parent engaged Baseline MSα toothpasteβ lesions Fluoride supplementsd Professional topical treatment every 6 months Moderate risk, Recall every 6 months Twice daily brushing with fluoridated Counseling, Active surveillance€ of incipient parent not Baseline MSα toothpasteβ with limited lesions engaged Professional topical treatment every expectations 6 months High risk, Recall every 3 months Twice daily brushing with fluoridated Counseling Active surveillance€ of incipient parent engaged Baseline and follow up MSα toothpasteβ lesions Fluoride supplementsd Restore cavitated lesions with Professional topical treatment every interim therapeutic restorations 3 months (ITR)¢ or definitive restorations High risk Recall every 3 months Twice daily brushing with fluoridated Counseling, Active surveillance€ of incipient parent not Baseline and follow up MSα toothpasteβ with limited lesions engaged Professional topical treatment every expectations Restore cavitated lesions with 3 months interim therapeutic restorations¢ or definitive restorations

Dental.EliteCME.com Page 125 Table IIIb: Sample caries management protocol for 3-5-year-olds

Risk category Diagnostics Interventions Restorative Fluoride Diet Sealantsλ Low risk Recall every 6-12 months Twice daily brushing with No Yes Surveillancex Radiographs every 12-24 fluoridated toothpaste¥ months Baseline MSα Moderate risk, Recall every 6 months Twice daily brushing with Counseling Yes Active surveillance€ of parent engaged Radiographs every 6-12 fluoridated toothpaste¥ incipient lesions months Fluoride supplementsd Restoration of cavitated or Baseline MSα Professional topical treatment enlarging lesions every 6 months Moderate risk, Recall every 6 months Twice daily brushing with Counseling, Yes Active surveillance€ of parent not Radiographs every 6-12 fluoridated toothpaste¥ with limited incipient lesions engaged months Professional topical treatment expectations Restoration of cavitated or Baseline MSα every 6 months enlarging lesions High risk, Recall every 3 months Brushing with 0.5 percent Counseling Yes Active surveillance€ of parent engaged Radiographs every 6 fluoride (with caution) incipient lesions months Fluoride supplementsd Restoration of cavitated or Baseline and follow up Professional topical treatment enlarging lesions MSα every 3 months High risk Recall every 3 months Brushing with 0.5 percent Counseling, Yes Restore incipient, cavitated, parent, not Radiographs every 6 fluoride with limited or enlarging lesions engaged months Professional topical treatment expectations Baseline and follow up MSα every 3 months Table IIIc: Sample caries management protocol for 6-year-olds and above

Risk category Diagnostics Interventions Restorative Fluoride Diet Sealantsλ Low risk Recall every 6-12 months Twice daily brushing with fluoridated No Yes Surveillancex Radiographs every 12-24 toothpasteµ months Moderate risk Recall every 6 months Twice daily brushing with fluoridated Counseling Yes Active surveillance€ of patient/parent Radiographs every 6-12 toothpasteµ incipient lesions engaged months Fluoride supplementsd Restoration of cavitated or Professional topical treatment every 6 enlarging lesions months Moderate risk Recall every 6 months Twice daily brushing with toothpasteµ Counseling, Yes Active surveillance€ of patient/parent Radiographs every 6-12 Professional topical treatment every 6 with limited incipient lesions not engaged months months expectations Restoration of cavitated or enlarging lesions High risk Recall every 3 months Brushing with 0.5 percent fluoride Counseling Yes Active surveillance€ of patient/parent Radiographs every 6 Fluoride supplementsd Xylitol incipient lesions engaged months Professional topical treatment every 3 Restoration of cavitated or months enlarging lesions High risk Recall every 3 months Brushing with 0.5 percent fluoride Counseling, Yes Restore incipient, cavitated, patient/parent Radiographs every 6 Professional topical treatment every 3 with limited or enlarging lesions not engaged months months expectations Xylitol Key for Tables IIIa,b, and c α Salivary mutans streptococci bacterial levels. β Parental supervision of a “smear” amount of toothpaste. x Periodic monitoring for signs of caries progression. d Need to consider fluoride levels in drinking water. € Careful monitoring of caries progression and prevention program. ¢ Interim therapeutic restoration. ¥ Parental supervision of a “pea-sized” amount of toothpaste. λ Indicated for teeth with deep fissure anatomy or developmental defects. μ Less concern about the quantity of toothpaste.

Page 126 Dental.EliteCME.com Restorative dentistry and the child patient This section addresses techniques and materials used to treat infants, Restorative treatment is based upon the results of an appropriate clinical children and adolescents with tooth damage from dental caries or examination and is ideally part of a comprehensive treatment plan, traumatic injury, or with dental developmental defects requiring prepared in conjunction with an individually-tailored preventive program. restoration. It will consider success rates (wear resistance, aesthetics, The treatment plan must take the following factors into consideration: strength, function, reduction of sensitivity) for the following ●● Developmental status of the dentition. restorative procedures: ●● Caries-risk assessment. ●● Use of dentin/enamel adhesives. ●● Patient’s oral hygiene. ●● Use of glass ionomer cements. ●● Anticipated parental compliance and likelihood of timely recall. ●● Use of highly-filled resin-based composites. ●● Patient’s ability to cooperate for treatment. ●● Amalgam restorations. ●● Stainless steel crown (SSC) restorations. Tooth preparation should include the removal of caries or improperly ●● Labial resin restoration. developed tooth structure to establish appropriate outline, resistance, ●● Porcelain veneer restoration. retention, and convenience form compatible with the restorative ●● Full-cast metal crown restorations. material to be utilized. Rubber-dam isolation should be utilized when ●● Porcelain-fused-to-metal crown restorations. possible during the preparation and placement of restorative materials. ●● Fixed prosthetic restorations. Restorative treatment can repair or limit the damage from dental ●● Removable prosthetic appliances. caries, protect and preserve the tooth structure, re-establish adequate Pit-and-fissure sealants will be addressed in the next section. function, restore aesthetics (where applicable), and provide ease in maintaining good oral hygiene. Pulp vitality should be maintained wherever possible. Table IV: Best practices for restorative procedures Restorative procedure Best practices Dentin/enamel The dental literature supports the use of tooth bonding adhesives, when used according to the adhesives manufacturer’s instruction unique for each product, as being effective in primary and permanent teeth in enhancing retention of restorations, minimizing microleakage, and reducing sensitivity. Glass ionomer Glass ionomers cements can be recommended as: cements ++ Luting cements ++ Cavity base and liner ++ Class I, II, III, and V restorations in primary teeth ++ Class III and V restorations in permanent teeth in high risk patients or teeth that cannot be isolated ++ Caries control with: ○○ High-risk patients ○○ Restoration repair ○○ Interim therapeutic restorations (ITR) ○○ Alternative (atraumatic) restorative technique (ART) Resin-based Indications composites Resin-based composites are indicated for: ++ Class I pit-and-fissure caries where conservative preventive resin restorations are appropriate ++ Class I caries extending into dentin ++ Class II restorations in primary teeth that do not extend beyond the proximal line angles ++ Class II restorations in permanent teeth that extend approximately one third to one half the buccolingual intercuspal width of the tooth ++ Class III, IV, V restorations in primary and permanent teeth ++ Strip crowns in the primary and permanent dentitions Contraindications Resin-based composites are not the restorations of choice in the following situations: XX Where a tooth cannot be isolated to obtain moisture control XX In individuals needing large multiple surface restorations in the posterior primary dentition XX In high-risk patients who have multiple caries and/or tooth demineralization and who exhibit poor oral hygiene and compliance with daily oral hygiene, and when maintenance is considered unlikely Amalgam restorations Dental amalgam is recommended for: ++ Class I restorations in primary and permanent teeth ++ Class II restorations in primary molars where the preparation does not extend beyond the proximal line angles ++ Class II restorations in permanent molars and premolars ++ Class V restorations in primary and permanent posterior teeth Stainless steel crown SSC restoration is recommended for: (SSC) restoration ●● Children at high risk exhibiting anterior tooth caries and/or molar caries may be treated with SSCs to protect the remaining at-risk tooth surfaces. ●● Children with extensive decay, large lesions, or multiple-surface lesions in primary molars should be treated with SSCs. ●● Strong consideration should be given to the use of SSCs in children who require general anesthesia.

Dental.EliteCME.com Page 127 Labial resin or Veneers may be indicated for the restoration of anterior teeth with fractures, developmental defects, intrinsic porcelain veneer discoloration, and/or other aesthetic conditions. restoration Full-cast or porcelain- Full-cast metal crowns or porcelain-fused-to-metal crown restorations may be utilized in permanent teeth that are fully fused-to-metal crown erupted and the gingival margin is at the adult position for: restoration ++ Teeth having developmental defects, extensive carious or traumatic loss of structure, or endodontic treatment ++ As an abutment for fixed prostheses ++ For restoration of single-tooth implants Fixed prosthetic Fixed prosthetic restorations to replace one or more missing teeth may be indicated to: restorations for ++ Establish aesthetics missing teeth ++ Maintain arch space or integrity in the developing dentition ++ Prevent or correct harmful habits ++ Improve function Removable prosthetic Removable prosthetic appliances may be indicated in the primary, mixed, or permanent dentition when teeth are appliances missing. Removable prosthetic appliances may be utilized to: ++ Maintain space ++ Obturate congenital or acquired defects ++ Establish aesthetics or occlusal function ++ Facilitate infant speech development or feeding Table V: Pit-and-fissure sealant recommendations Topic Recommendation Caries prevention Sealants should be placed in pits and fissures of children’s primary teeth when it is determined that the tooth, or the patient, is at risk of developing caries*† Sealants should be placed on pits and fissures of children’s and adolescents’ permanent teeth when it is determined that the tooth, or the patient, is at risk of developing caries*† Noncavitated carious Pit-and-fissure sealants should be placed on early (noncavitated) carious lesions, as defined in this document, in lesions‡ children, adolescents and young adults to reduce the percentage of lesions that progress† Resin-based versus Resin-based sealants are the first choice of material for dental sealants glass ionomer cement Glass ionomer cement may be used as an interim preventive agent when there are indications for placement of a resin- based sealant but concerns about moisture control may compromise such placement§ Placement techniques A compatible one-bottle bonding agent, which contains both an adhesive and a primer, may be used between the previously acid-etched enamel surface and the sealant material when, in the opinion of the dental professional, the bonding agent would enhance sealant retention in the clinical situation§ Use of available self-etching bonding agents, which do not involve a separate etching step, may provide less retention than the standard acid-etching technique and is not recommended Routine mechanical preparation of enamel before acid etching is not recommended When possible, a four-handed technique should be used for placement of resin-based sealants When possible, a four-handed technique should be used for placement of glass ionomer cement sealants The oral health care professional should monitor and reapply sealants as needed to maximize effectiveness Key to Table V * Change in caries susceptibility can occur. It is important to consider that the risk of developing dental caries exists on a continuum and changes across time as risk factors change. Therefore, clinicians should re-evaluate each patient’s caries risk status periodically. † Clinicians should use recent radiographs, if available, in the decision-making process, but should not obtain radiographs for the sole purpose of placing sealants. Clinicians should consult the American Dental Association/U.S. Food and Drug Administration guidelines on selection criteria for dental radiographs. ‡ “Noncavitated carious lesion” refers to pits and fissures in fully erupted teeth that may display discoloration not due to extrinsic staining, developmental opacities or fluorosis. The discoloration may be confined to the size of a pit or fissure or may extend to the cusp inclines surrounding a pit or fissure. The tooth surface should have no evidence of a shadow indicating dentinal caries, and, if radiographs are available, they should be evaluated to determine that neither the occlusal nor the proximal surfaces have signs of dentinal caries. § These clinical recommendations offer two options for situations in which moisture control, such as with a newly erupted tooth at risk of developing caries, patient compliance, or both, are a concern. These options include use of a glass ionomer cement material or use of a compatible one-bottle bonding agent, which contains both an adhesive and a primer. Clinicians should use their expertise to determine which technique is most appropriate for an individual patient. ¶ Clinicians should consult with the manufacturer of the adhesive and/or sealant to determine material compatibility.

Page 128 Dental.EliteCME.com Pit-and-fissure sealants These clinical recommendations on pit-and-fissure sealants, published Manufacturers’ instructions for sealant placement should be consulted, in 2008 and summarized in Table V, may be useful when considered and a dry field should be maintained during placement. along with the specific characteristics of the case and patient to Potential benefits facilitate clinical decision-making. ++ Appropriate use may help prevent dental caries. Dentists are encouraged to employ caries risk assessment strategies to Potential risks determine whether placement of pit-and-fissure sealants is indicated as * A transient amount of bisphenol-A (BPA) may be detected in the a primary preventive measure. The risk of experiencing dental caries saliva of some patients immediately after initial application of exists on a continuum and changes across time as risk factors change. certain sealants as a result of the action of salivary enzymes on Therefore, caries risk status should be re-evaluated periodically. It bisphenol-dimethacrylate, a component of some sealant materials. includes the following steps: According to research, systemic BPA has not been detected as a Evaluation/risk assessment result of the use of such sealants, and potential estrogenicity at 1. Tooth cleaning and drying. such low levels of exposure has not been documented. 2. Visual examination to detect early noncavitated lesions. 3. Evaluation of patient’s caries risk status. Data was inconclusive for the following techniques: 4. Recent radiographs (but only if available). ●● Two- or four-handed sealant placement technique – The panelists 5. Periodic re-evaluation of patient’s risk status. determined that the systematic reviews and newly identified Prevention studies were insufficient to determine whether use of a four- 1. Bonding agents (total and self-etch systems). handed versus a two-handed technique improves sealant retention 2. Pit-and-fissure sealants, utilizing a four-handed technique. or caries prevention. However, when possible, a four-handed ■■ Resin-based sealants (polymerized by autopolymerization, technique is recommended. photopolymerization using visible light or a combination ●● Enamel preparation techniques – The panelists determined that the of the two processes). systematic reviews and newly identified studies were insufficient ■■ Glass ionomer cements (conventional and resin-modified). to determine whether enamel preparation, including air abrasion or enameloplasty, would improve sealant retention or caries prevention.

Management of the developing dentition and occlusion in the child patient This section provides guidance for the management of the developing 3. Completion of differential diagnosis and diagnostic summary. dentition and occlusion in pediatric dentistry. It discusses the following 4. Completion of a sequential treatment plan. topics: Management/treatment Unfavorable dentofacial development 1. Habit elimination (patient/parent counseling, behavior 1. Hypodontia (congenitally missing teeth). modification techniques, myofunctional therapy, appliance 2. Supernumerary teeth (hyperdontia). therapy, or referral to other providers, such as orthodontists, 3. Ectopic eruption. psychologists, myofunctional therapists and otolaryngologists). 4. Ankylosis. 2. Tooth extraction. 5. Tooth size/arch length discrepancy and crowding. 3. Orthodontical space closing. 6. Crossbites (dental, functional, and skeletal). 4. Placement of prostheses or implants. 7. Malocclusion (class II and class III). 5. Orthodontical alignment of permanent teeth. Assessment/diagnosis 6. Impacted tooth management (elastic or metal orthodontic 1. Clinical examination: separators, distal tipping of permanent molar). ■■ Facial analysis. 7. Space maintenance and space regaining: fixed appliances ■■ Intraoral examination. (e.g., band and loop, crown and loop, passive lingual arch, ■■ Functional analysis. distal shoe, Nance appliance, transpalatal arch) and removable 2. Maintenance of diagnostic records: appliances (e.g., partial dentures, Hawley appliance, lip ■■ Extraoral and intraoral photographs. bumper, headgear). ■■ Diagnostic dental casts. 8. Crossbite correction. ■■ Intraoral and panoramic radiographs. 9. Malocclusion assessment and correction. ■■ Lateral and anterior-posterior cephalograms. 10. Other treatment modalities (interproximal reduction, ■■ Magnetic resonance imaging. restorative bonding, veneers, crowns, implants and ■■ Computed tomography. orthognathic surgery).

Clinical examination, pretreatment records, differential diagnosis, and treatment plan A thorough clinical examination, appropriate pretreatment records, ○○ Assess aesthetics and identify orthopedic and orthodontic differential diagnosis, sequential treatment plan, and progress records interventions that may improve aesthetics and resultant self- are necessary to manage any condition affecting the developing image and emotional development. dentition. ●● Intraoral examination to: Clinical examination should include: ○○ Assess overall oral health status. ●● Facial analysis to: ○○ Determine the functional status of the patient’s occlusion. ○○ Identify adverse transverse growth patterns including ●● Functional analysis to: asymmetries (maxillary and mandibular). ○○ Determine functional factors associated with the malocclusion. ○○ Identify adverse vertical growth patterns. ○○ Detect deleterious habits. ○○ Identify adverse sagittal (anteroposterior) growth patterns and ○○ Detect temporomandibular joint dysfunction, which may dental anteroposterior (AP) occlusal disharmonies. require additional diagnostic procedures.

Dental.EliteCME.com Page 129 Diagnostic records may be needed to assist in the evaluation of the ○○ Establish a baseline growth record for longitudinal assessment patient’s condition and for documentation purposes. Prudent judgment of growth and displacement of the jaws. is exercised to decide the appropriate records required for diagnosis of ●● Other diagnostic views (e.g., magnetic resonance imaging and the clinical condition. Diagnostic records may include: computed tomographic scans) for hard and soft tissue imaging as ●● Extraoral and intraoral photographs to: indicated by history and clinical examination. ○○ Supplement clinical findings with oriented facial and intraoral A differential diagnosis and diagnostic summary are completed to photographs. achieve the following objectives: ○○ Establish a database for documenting facial changes during ●● Establish the relative contributions of the dental and skeletal treatment. structures to the patient’s malocclusion. ●● Diagnostic dental casts to: ●● Prioritize problems in terms of relative severity. ○○ Assess the occlusal relationship. ●● Detect favorable and unfavorable interactions that may result from ○○ Determine arch length requirements for intra-arch tooth size treatment options for each problem area. relationships. ●● Establish short-term and long-term objectives. ○○ Determine arch length requirements for interarch tooth size ●● Summarize the prognosis of treatment for achieving stability, relationships. function and aesthetics. ○○ Determine location and extent of arch asymmetry. ●● Intraoral and panoramic radiographs to: A sequential treatment plan is completed to achieve the following ○○ Establish dental age. objectives: ○○ Assess eruption problems. ●● Establish timing priorities for each phase of therapy. ○○ Estimate the size and presence of unerupted teeth. ●● Establish proper sequence of treatments to achieve short-term and ○○ Identify dental anomalies/pathology. long-term objectives. ●● Lateral and AP cephalograms to: ●● Ensure treatment progress is assessed and biomechanical protocol ○○ Produce a comprehensive cephalometric analysis of the is updated accordingly on a regular basis. relative dental and skeletal components in the anteroposterior, vertical and transverse dimensions.

Stages of development of occlusion Primary dentition stage supernumerary, fused, geminated); tooth size and shape (peg or small Anomalies of primary teeth and eruption may not be evident/ lateral incisors); and positions (e.g., ectopic first permanent molars). diagnosable prior to eruption because the child has not presented Space analysis can be used to evaluate arch length/crowding at the for dental examination, or because a radiographic examination time of incisor eruption. is not possible in a young child. However, evaluation should be Mid-to-late mixed dentition accomplished when feasible. The objectives of evaluation include Ectopic tooth positions should be diagnosed, especially canines, identification of all anomalies of tooth number and size (as previously bicuspids and second permanent molars. noted), anterior and posterior crossbites, and presence of habits along with their dental and skeletal sequelae. Radiographs are taken with Adolescent dentition stage appropriate clinical indicators or based upon risk assessment/history. If not instituted earlier, orthodontic diagnosis and treatment should be planned for Class I crowded, Class II, and Class III malocclusions Early mixed dentition stage as well as posterior and anterior crossbites. Third molars should be Palpation for unerupted teeth should be part of every examination. monitored as to position and space and parents informed. Panoramic, occlusal and periapical radiographs as indicated at the time of eruption of the lower incisors and first permanent molars provide Early adult dentition stage diagnostic information on anomalies of tooth numbers (e.g., missing, Third molars should be evaluated. If orthodontic diagnosis has not been accomplished, recommendations should be made as necessary.

Objectives for each stage At each stage, the objectives of intervention/treatment include of high rates of growth and prevent worsened adverse dental and reducing adverse growth, preventing increasing dental and skeletal skeletal growth. disharmonies, improving aesthetics of the smile and the accompanying ●● Mid-to-late mixed dentition stage positive effects on self-image, and improving the occlusion. Intervention for ectopic teeth may include extractions and space ŠŠ Primary dentition stage maintenance to aid eruption and reduce the risk of need for Habits and posterior crossbites should be diagnosed and addressed surgical bracket placement and orthodontic traction. Intervention as early as feasible. Parents should be informed of findings of for treatment of skeletal disharmonies and crowding may be adverse growth and developing malocclusions. Interventions/ instituted at this stage. treatment can be recommended if diagnosis can be made, treatment ●● Adolescent dentition stage is appropriate and possible, and parents are supportive and desire In full permanent dentition, final orthodontic diagnosis and to have treatment done. treatment can provide the most functional occlusion. ●● Early adult dentition stage ●● Early mixed stage Third molar position or space can be evaluated and, if indicated, Treatment should address: (1) habits, (2) arch length shortage, be removed. Full orthodontic treatment should be recommended if (3) intervention for crowded incisors, (4) intervention for ectopic needed. molars and incisors, (5) holding of leeway space, (6) crossbites, and (7) adverse skeletal growth. Treatment should take advantage

Page 130 Dental.EliteCME.com Treatment considerations The developing dentition should be monitored throughout eruption. Radiographic examination, when appropriate and feasible, should This monitoring at regular clinical examinations should include accompany clinical examination. Diagnosis of anomalies of primary diagnosis of missing, supernumerary, developmentally defective and or permanent tooth development and eruption should be made to fused or geminated teeth; ectopic eruption; and space and tooth loss inform the patient’s parent and to plan and recommend appropriate secondary to caries. intervention. This evaluation is ongoing throughout the developing dentition, at all stages.

Oral habits Management of an oral habit is indicated whenever the habit is techniques, myofunctional therapy, appliance therapy, or referral to associated with unfavorable dentofacial development or adverse other providers, such as orthodontists, psychologists, myofunctional effects on child health, or when there is a reasonable indication that therapists or otolaryngologists. Use of an appliance to manage oral the oral habit will result in unfavorable sequelae in the developing habits is indicated only when the child wants to stop the habit and permanent dentition. Any treatment must be appropriate for the child’s would benefit from a reminder. development, comprehension and ability to cooperate. Habit treatment Treatment is directed toward decreasing or eliminating the habit and modalities include patient/parent counseling, behavior modification minimizing potential deleterious effects on the dentofacial complex.

Congenitally missing teeth With congenitally missing permanent maxillary incisors or mandibular For a congenitally missing premolar, the primary molar either may second premolars, the decision to extract the primary tooth and close be maintained or extracted with subsequent placement of a prosthesis the space orthodontically versus opening the space orthodontically and or orthodontically closing the space. Maintaining the primary second placing a prosthesis or implant depends on many factors. For maxillary molar may cause occlusal problems due to its larger mesiodistal laterals, the dentist may move the maxillary canine mesially and diameter compared to the second premolar. Reducing the width of use the canine as a lateral incisor or create space for a future lateral the second primary molar is a consideration, but root resorption and prosthesis or implant. Factors that influence the decision are (1) patient subsequent exfoliation may occur. age, (2) canine shape, (3) canine position, (4) child’s occlusion and In crowded arches or with multiple missing premolars, extraction amount of crowding, (5) bite depth, and (6) quality and quantity of of the primary molars can be considered, especially in mild Class bone in the edentulous area. Early extraction of the primary canine and III cases. For a single missing premolar, if maintaining the primary lateral may be needed. molar is not possible, placement of a prosthesis or implant should be Opening space for a prosthesis or implant requires less tooth considered. Consultation with an orthodontist and prosthodontist may movement, but the space needs to be maintained with an interim be required. In addition, preserving the primary tooth may be indicated prosthesis, especially if an implant is planned. Moving the canine into in certain cases. the lateral position produces little facial change, but the resultant tooth Treatment is directed toward an aesthetically pleasing occlusion that size discrepancy often does not allow a canine-guided occlusion. functions well for the patient.

Supernumerary teeth (primary, permanent, and mesiodens) Management and treatment of hyperdontia differs if the tooth is of the mesiodens reduces the likelihood that the adjacent normal primary or permanent. Primary supernumerary teeth normally are permanent incisor will erupt on its own, especially if the apex is accommodated into the arch and usually erupt and exfoliate without completed. Inverted conical supernumeraries can be harder to remove complications. Extraction of an unerupted supernumerary tooth during if removal is delayed, as they can migrate deeper into the jaw. the primary dentition usually is not done to allow it to erupt; surgical After removal of the supernumerary, clinical and radiographic follow- extraction of unerupted supernumerary teeth can displace or damage up is indicated in six months to determine whether the normal incisor the permanent incisor. is erupting. If there is no eruption after six to 12 months and sufficient Removal of a mesiodens or other permanent supernumerary incisor space exists, surgical exposure and orthodontic extrusion is needed. results in eruption of the permanent adjacent normal incisor in 75 Removal of supernumerary teeth should facilitate eruption of percent of the cases. Extraction of an unerupted supernumerary permanent teeth and encourage normal alignment. In cases where during the early mixed dentition allows for a normal eruptive force normal alignment or spontaneous eruption does not occur, further and eruption of the permanent adjacent normal incisor. Later removal orthodontic treatment is indicated.

Ectopic eruption Treatment depends on how severe the impaction appears clinically and canine bulge cannot be palpated in the alveolar process and there radiographically. For mildly impacted first permanent molars, where is radiographic overlapping of the canine with the formed root of little of the tooth is impacted under the primary second molar, elastic the lateral during the mixed dentition. Even if the impacted canine or metal orthodontic separators can be placed to wedge the permanent is diagnosed at a later age (11 to 16), if the canine is not horizontal, first molar distally. For more severe impactions, distal tipping of the extraction of the primary canine lessens the severity of the permanent permanent molar is required. Tipping action can be accomplished with canine impaction, and 75 percent will erupt. brass wires, removable appliances using springs, fixed appliances such Extraction of the first primary molar also has been reported to allow as sectional wires with open coil springs, sling shot type appliances, a eruption of first bicuspids and to assist in the eruption of the cuspids. Halterman appliance, or surgical uprighting. This need can be determined from a panoramic radiograph. Bonded Early diagnosis and treatment of impacted maxillary canines can orthodontic treatment normally is required to create space or align lessen the severity of the impaction and may stimulate eruption of the canine. Long-term periodontal health of impacted canines after the canine. Extraction of the primary canine is indicated when the orthodontic treatment is similar to non-impacted canines.

Dental.EliteCME.com Page 131 Treatment of ectopically erupting incisors depends on the etiology. Management of ectopically erupting molars, canines and incisors Extraction of necrotic or over-retained pulpally treated primary should result in improved eruptive positioning of the tooth. In cases incisors is indicated in the early mixed dentition. Removal of where normal alignment does not occur, subsequent comprehensive supernumerary incisors in the early mixed dentition will lessen ectopic orthodontic treatment may be necessary to achieve appropriate arch eruption of an adjacent permanent incisor. After incisor eruption, form and intercuspation. orthodontic treatment involving removable or banded therapy may be needed.

Ankylosis With ankylosis of a primary molar, exfoliation usually occurs crowding. Extraction of these molars can assist in resolving crowded normally. Extraction is recommended if prolonged retention of arches in complex orthodontic cases. Surgical luxation of ankylosed the primary molar is noted. If a severe marginal ridge discrepancy permanent teeth with forced eruption has been described as an develops, extraction should be considered to prevent the adjacent teeth alternative to premature extraction. from tipping and producing space loss. Replacement resorption of Treatment of ankylosis should result in the continuing normal permanent teeth usually results in the loss of the involved tooth. development of the permanent dentition. Or, in the case of replacement Mildly to moderately ankylosed primary molars without permanent resorption of a permanent tooth, appropriate prosthetic replacement successors may be retained and restored to function in arches without should be planned.

Tooth size/arch length discrepancy and crowding Treatment considerations may include: Other treatment modalities may include interproximal reduction, ●● Making space for permanent incisors to erupt and become straight restorative bonding, veneers, crowns, implants and orthognathic naturally through primary canine extraction and space/arch length surgery. maintenance. Well-timed intervention can: ●● Orthodontic alignment of permanent teeth as soon as erupted ●● Prevent crowded incisors. and feasible, expansion and correction of arch length as early as ●● Increase long-term stability of incisor positions. feasible. ●● Decrease ectopic eruption and impaction of permanent canines. ●● Utilizing holding arches in the mixed dentition until all permanent ●● Reduce orthodontic treatment time and sequelae. bicuspids and canines have erupted. ●● Improve gingival health and overall dental health. ●● Extractions of permanent teeth. ●● Maintaining patient’s original arch form.

Space maintenance It is prudent to consider space maintenance when primary teeth are lost The literature on the use of space maintainers specific to the loss of a prematurely. Factors to consider include: particular primary tooth type includes expert opinion, case reports and ●● Specific tooth lost. details of appliance design. Treatment modalities may include: ●● Time elapsed since tooth loss. ●● Fixed appliances (e.g., band and loop, crown and loop, passive ●● Pre-existing occlusion. lingual arch, distal shoe, Nance appliance, transpalatal arch). ●● Favorable space analysis. ●● Removable appliances (e.g., partial dentures, Hawley appliance). ●● Presence and root development of permanent successor. The placement and retention of space-maintaining appliances requires ●● Amount of alveolar bone covering permanent successor. ongoing compliant patient behavior. Follow-up of patients with space ●● Patient’s health status. maintainers is necessary to assess integrity of cement and to evaluate ●● Patient’s cooperative ability. and clean the abutment teeth. The appliance should function until the ●● Active oral habits. succedaneous teeth have erupted into the arch. ●● Oral hygiene. The goal of space maintenance is to prevent loss of arch length, width If a space analysis is required before the placement of a space and perimeter by maintaining the relative position of the existing maintainer, appropriate radiographs and study models should be dentition. considered.

Regaining space Treatment modalities may include fixed appliances or removable The goal of space-regaining intervention is the recovery of lost arch appliances (e.g., Hawley appliance, lip bumper, headgear). Space width and perimeter and improved eruptive position of permanent, loss and dentofacial skeletal development may dictate that space succedaneous teeth. Space regained should be maintained until regaining not be indicated. This should be determined as the result of a adjacent permanent teeth have erupted completely or until a comprehensive analysis. The timing of clinical intervention subsequent subsequent comprehensive orthodontic treatment plan is initiated. to premature loss of a primary molar is critical.

Crossbites (dental, functional, and skeletal) Crossbites should be considered in the context of the patient’s total ++ Redirect skeletal growth. treatment needs. Anterior crossbite correction can: ++ Improve the tooth-to-alveolus relationship. ++ Reduce dental attrition. ++ Increase arch perimeter. ++ Improve dental aesthetic.

Page 132 Dental.EliteCME.com A simple anterior crossbite can be aligned as soon as the condition ●● A combination of these treatment modalities to correct the palatal is noted if there is sufficient space; otherwise, space will need to be constriction. created with the use of fixed appliances, acrylic incline planes, acrylic Fixed or removable palatal expanders can be utilized until midline retainers or expansion appliances, depending how much space is suture fusion occurs. Treatment decisions depend on the: required. ●● Amount and type of movement (tipping versus bodily movement, Posterior crossbite correction can accomplish the same objectives and rotation, or dental versus orthopedic movement). can improve the eruptive position of the succedaneous teeth. Early ●● Space available. correction of unilateral posterior crossbites has been shown to improve ●● AP, transverse and vertical skeletal relationships. functional conditions significantly and largely eliminate morphological ●● Growth status. and positional asymmetries of the mandible. Functional shifts should ●● Patient cooperation. be eliminated as soon as possible with early correction to avoid Patients with crossbites and concomitant Class III skeletal patterns asymmetric growth. Treatment can be completed with: or skeletal asymmetry should receive comprehensive treatment as ●● Equilibration. covered in the Class III malocclusion section. ●● Appliance therapy (fixed or removable). ●● Extractions. Treatment of a crossbite should result in improved intramaxillary alignment and an acceptable interarch occlusion and function.

Class II malocclusion Factors to consider when planning orthodontic intervention for Class Treatment modalities include: (1) extraoral appliances (headgear), (2) II malocclusion are: (1) facial growth pattern, (2) amount of AP functional appliances, (3) fixed appliances, (4) tooth extraction and discrepancy, (3) patient age, (4) projected patient compliance, (5) interarch elastics, and (5) orthodontics with orthognathic surgery. space analysis, (6) anchorage requirements, and (7) patient and parent Treatment of a developing Class II malocclusion should result in an desires. improved overbite, overjet, and intercuspation of posterior teeth and an aesthetic appearance and profile compatible with the patient’s skeletal morphology.

Class III malocclusion Treatment of class III malocclusions is indicated to provide Treatment of a developing class III malocclusion should result in psychosocial benefits for the child patient by reducing or eliminating improved overbite, overjet, and intercuspation of posterior teeth and an facial disfigurement and to reduce the severity of malocclusion by aesthetic appearance and profile compatible with the patient’s skeletal promoting harmonious growth. Early Class III treatment has been morphology. proposed for several years and has been advocated as a necessary tool Potential benefits in contemporary orthodontics. ++ Guidance of eruption and development of the primary, mixed and Factors to consider when planning orthodontic intervention for Class permanent dentitions is an integral component of comprehensive III malocclusion are: (1) facial growth pattern, (2) amount of AP oral health care for all pediatric dental patients. Such guidance discrepancy, (3) patient age, (4) projected patient compliance, (5) should contribute to the development of a permanent dentition space analysis, (6) anchorage (headgear), (7) functional appliances, (8) that is in a stable, functional and aesthetically acceptable fixed appliances, (9) tooth extraction, (10) interarch elastics, and (11) occlusion. Early diagnosis and successful treatment of developing orthodontics with orthognathic surgery. malocclusions can have both short-term and long-term benefits Early class III treatment may provide a more favorable environment while achieving the goals of occlusal harmony and function and for growth and to improve occlusion, function and aesthetics. dentofacial aesthetics. Although early treatment can minimize the malocclusion and Potential risks potentially eliminate future orthognathic surgery, this is not always Adverse effects associated with space maintainers include: possible. Typically, class III patients tend to grow longer and more XX Dislodged, broken and lost appliances. unpredictably and, therefore, surgery combined with orthodontics is XX Plaque accumulation. the best alternative to achieve a satisfactory result for some patients. XX Caries. XX Interference with successor eruption. XX Undesirable tooth.

Oral surgery and the child patient This section provides updated information regarding best practices for ●● Supernumerary teeth and mesiodens. oral surgery and addressing the following topics: ●● Oral lesions in the newborn such as Epstein’s pearls, dental lamina Diseases and disorders: cysts, Bohn’s nodules, and congenital epulis (Neumann’s tumor). ●● Odontogenic infections. ●● Eruption cysts. ●● Erupted teeth needing extraction. ●● Mucocele. ●● Fractured teeth. ●● Oral structural anomalies such as maxillary frenum, mandibular ●● Unerupted and impacted teeth. labial frenum, mandibular lingual frenum/ankyloglossia, and natal and neonatal teeth.

Assessment 1. Physical exam. 3. Radiographic evaluation. 2. Differential diagnosis.

Dental.EliteCME.com Page 133 Treatment 1. Treatment of odontogenic infections and associated complications: 5. Evaluation and management of oral pathologies occurring in the ○○ Pulp therapy. newborn. ○○ Extraction or incision and drainage. 6. Surgical opening of eruption cyst. ○○ Antibiotic therapy. 7. Surgical excision of mucocele and adjacent minor salivary glands. ○○ Hospitalization and referral/consultation with an oral and 8. Frenectomy (for maxillary frenum and mandibular labial and maxillofacial surgeon. lingual frenum) and frenectomy techniques. 2. Extraction of erupted and unerupted teeth. 9. Frenuloplasty and frenectomy (for ankyloglossia). 3. Management of fractured primary tooth roots. 10. Assessment and treatment of Riga-Fede disease. 4. Management of unerupted, impacted, and supernumerary teeth.

Odontogenic infections In children, odontogenic infections may involve more than one tooth teeth, skin, local lymph nodes and salivary glands. Swelling of the and usually are due to carious lesions, periodontal problems, or a lower face more commonly has been associated with dental infection. history of trauma. Untreated odontogenic infections can lead to pain, Most odontogenic infections can be managed with pulp therapy, abscess and cellulitis. As a consequence of this, children are prone to extraction, or incision and drainage. Infections of odontogenic dehydration – especially if they are not eating well because of pain and origin with systemic manifestations (e.g., elevated temperature of malaise. Prompt treatment of the source of infection is important to 102 degrees to 104 degrees F, facial cellulitis, difficulty in breathing control pain and prevent the spread of infection. or swallowing, fatigue, nausea) require antibiotic therapy. Severe With infections of the upper portion of the face, patients usually but rare complications of odontogenic infections include cavernous complain of facial pain, fever and inability to eat or drink. Care must sinus thrombosis and Ludwig’s angina. These conditions can be be taken to rule out sinusitis, because its symptoms may mimic an life threatening and may require immediate hospitalization with odontogenic infection. Occasionally in upper face infections, it may intravenous antibiotics, incision and drainage, and referral/consultation be difficult to find the true cause. Infections of the lower face usually with an oral and maxillofacial surgeon. involve pain, swelling and trismus. They frequently are associated with

Extraction of erupted maxillary and mandibular anterior teeth Most primary and permanent maxillary and mandibular central Radiographic examination is helpful to identify differences in root incisors, lateral incisors, and canines have conical single roots. In most anatomy prior to extraction. Care should be taken to avoid placing any cases, extraction of anterior teeth is accomplished with a rotational force on adjacent teeth that could become luxated or dislodged easily movement because of their single root anatomies. However, there have due to their root anatomy. been reported cases of accessory roots observed in primary canines.

Extraction of erupted maxillary and mandibular molars Primary molars have roots that are smaller in diameter and more completed. Primary molars with roots encircling the successor’s crown divergent than permanent molars. Root fracture in primary molars is may need to be sectioned to protect the permanent tooth’s location. not uncommon because of these characteristics as well as the potential Molar extractions are accomplished by using slow continuous palatal/ weakening of the roots caused by the eruption of their permanent lingual and buccal force allowing for the expansion of the alveolar successors. To avoid inadvertent extraction or dislocation of or trauma bone to accommodate the divergent roots and reduce the risk of root to the permanent successor, careful evaluation of the relationship of fracture. When extracting mandibular molars, care should be taken to the primary roots to the developing succedaneous tooth should be support the mandible to protect the temporomandibular joints from injury.

Fractured primary tooth roots The dilemma to consider when treating a fractured primary tooth root that if the fractured root tip can be removed easily, it should be is that removing the root tip may cause damage to the succedaneous removed. If the root tip is very small, located deep in the socket tooth, while leaving the root tip may increase the chance for situated in close proximity to the permanent successor or unable to be postoperative infection and delay eruption of the permanent successor. retrieved after several attempts, it is best left to be resorbed. Radiographs can assist in the decision process. The literature suggests

Impacted canines Permanent maxillary canines are second to third molars in frequency Extraction of the primary canines is the treatment of choice when of impaction. Early detection of an ectopically erupting canine through malformation or ankylosis is present, when the risk of resorption of the visual inspection, palpation and radiographic examination is important adjacent tooth is evident, or when trying to correct palatally impacted to minimize such an occurrence. Panoramic and periapical films are canines, provided there are normal space conditions and no incisor useful in locating potentially ectopic canines. Routine evaluation of resorption. One study showed that 78 percent of ectopically erupting patients in mid-mixed dentition should involve identifying signs, permanent canines normalized within 12 months after removal of such as lack of canine bulges and asymmetry in pattern of exfoliation. the primary canines; 64 percent normalized when the starting canine Eruption of canines and abnormal angulation or ectopic eruption of position overlapped the lateral incisor by more than half of the developing permanent cuspids can be detected with a radiograph. root and 91 percent normalized when the starting canine position When the cusp tip of the permanent canine is just mesial to or overlapped the lateral incisor by less than half of the root. overlaying the distal half of the long axis of the root of the permanent lateral incisor, canine palatal impaction usually occurs.

Page 134 Dental.EliteCME.com If no improvement in canine position occurs in a year, surgical or permanent maxillary canines, the literature suggests that this can orthodontic treatment was suggested. Although a Cochrane review be considered to minimize complications resulting from impacted yielded a lack of randomized controlled clinical studies to support canines. Consultation between the practitioner and an orthodontist may extraction of primary canines to facilitate eruption of ectopic be useful in the final treatment decision.

Third molars Panoramic or periapical radiographic examination is indicated in third molar removal in adults is safe with minimal complications and late adolescence to assess the presence, position and development of negative effects on the patient’s quality of life. The report showed that third molars. The American Association of Oral and Maxillofacial mandibular third molars exhibited more pathology or abnormalities. Surgeons (AAOMS) recommends that a decision to remove or retain All intraoperative complications (e.g., nerve injury, unexpected third molars should be made before the middle of the third decade. hemorrhage, unplanned transfusion or parenteral drugs, compromised Little controversy surrounds their removal when pathology (e.g., airway, fracture, other injuries to adjacent teeth/structures) occurred cysts or tumors, caries, infection, pericoronitis, periodontal disease, at a frequency of less than 1 percent. Excluding alveolar osteitis, detrimental changes of adjacent teeth or bone) is associated or the postoperative complications (e.g., paresthesia, infection, trismus, tooth is malpositioned or nonfunctional (i.e., an unopposed tooth). A hemorrhage) were similarly low. Factors that increase the risk systematic review of research literature from 1984 to 1999 concluded for complications (e.g., coexisting systemic conditions, location there is no reliable evidence to support the prophylactic removal of of peripheral nerves, history of temporomandibular joint disease, disease-free impacted third molars. Although prophylactic removal of presence of cysts or tumors) and position and inclination of the all impacted or unerupted disease-free third molars is not indicated, molar in question should be assessed. The age of the patient is only a consideration should be given to removal by the third decade when secondary consideration. Referral to an oral and maxillofacial surgeon there is a high probability of disease or pathology or the risks for consultation and subsequent treatment may be indicated. associated with early removal are less than the risks of later removal. When a decision is made to retain impacted third molars, they should Removing the third molars before complete root formation may be be monitored for change in position and development of pathology, surgically prudent. which may necessitate later removal. AAOMS performed an age-related third molar study among board- certified oral and maxillofacial surgeons in 2001 and concluded that

Supernumerary teeth Supernumerary teeth and hyperdontia are terms to describe an excess Complications of supernumerary teeth can include delayed or lack in tooth number. Supernumerary teeth are thought to be related of eruption of the permanent tooth, crowding, resorption of adjacent to disturbances in the initiation and proliferation stages of dental teeth, dentigerous cyst formation, pericoronal space ossification, and development. Although some supernumerary teeth may be syndrome crown resorption. Early diagnosis and appropriately timed treatment associated (e.g., cleidocranial dysplasia) or of familial inheritance are important in the prevention and avoidance of these complications. pattern, most supernumerary teeth occur as isolated events. Because only 25 percent of all mesiodens erupt spontaneously, surgical Supernumerary teeth can occur in either the primary or permanent management often is necessary. A mesiodens that is conical in shape dentition. In 33 percent of the cases, a supernumerary tooth in the and is not inverted has a better chance for eruption than a mesiodens primary dentition is followed by the supernumerary tooth complement that is tubercular in shape and is inverted. The treatment objective for in the permanent dentition. Reports in incidence of supernumerary a nonerupting permanent mesiodens is to minimize eruption problems teeth can be as high as 3 percent, with the permanent dentition being for the permanent incisors. Surgical management will vary depending affected five times more frequently than the primary dentition and on the size, shape and number of supernumeraries and the patient’s males being affected twice as frequently as females. dental development. The treatment objective for a nonerupting Supernumerary teeth will occur 10 times more often in the maxillary primary mesiodens differs in that the removal of these teeth usually arch versus the mandibular arch. Approximately 90 percent of all is not recommended, because the surgical intervention may disrupt or single tooth supernumerary teeth are found in the maxillary arch, with damage the underlying developing permanent teeth. Erupted primary a strong predilection to the anterior region. The maxillary anterior tooth mesiodens typically are left to shed normally upon the eruption midline is the most common site, in which case the supernumerary of the permanent dentition. tooth is known as a mesiodens; the second most common site is Extraction of an unerupted primary or permanent mesiodens is the maxillary molar area, with the tooth known as a paramolar. A recommended during the mixed dentition to allow the normal mesiodens can be suspected if there is an asymmetric eruption pattern eruptive force of the permanent incisor to bring itself into the oral of the maxillary incisors, delayed eruption of the maxillary incisors cavity. Waiting until the adjacent incisors have at least two-thirds with or without any over-retained primary incisors, or ectopic eruption root development will present less risk to the developing teeth but of a maxillary incisor. The diagnosis of a mesiodens can be confirmed still allow spontaneous eruption of the incisors. In 75 percent of the with radiographs, including occlusal, periapical or panoramic films, cases, extraction of the mesiodens during the mixed dentition results or computed tomography. Three-dimensional information needed in spontaneous eruption and alignment of the adjacent teeth. If the to determine the location of the mesiodens or impacted tooth can adjacent teeth do not erupt within six to 12 months, surgical exposure be obtained by taking two periapical radiographs using either two and orthodontic treatment may be necessary to aid their eruption. The projections taken at right angles to one another or the tube shift diagnosing dentist may consider a multidisciplinary approach when technique (buccal object rule or Clark’s rule) or by cone beam treating difficult or complex cases. computed tomography.

Lesions of the newborn Oral pathologies occurring in newborn children include Epstein’s percent of newborns. They occur in the median palatal raphe area, as pearls, dental lamina cysts, Bohn’s nodules, and congenital epulis. a result of trapped epithelial remnants along the line of fusion of the Epstein’s pearls are common and found in about 75 percent to 80 palatal halves. Dental lamina cysts, found on the crests of the dental

Dental.EliteCME.com Page 135 ridges, most commonly are seen bilaterally in the region of the first Congenital epulis of the newborn, also known as granular cell tumor primary molars. They result from remnants of the dental lamina. or Neumann’s tumor, is a rare benign tumor seen only in newborns. Bohn’s nodules are remnants of salivary gland epithelium and usually This lesion is typically a protuberant mass arising from the gingival are found on the buccal and lingual aspects of the ridge, away from mucosa. It is most often found on the anterior maxillary ridge. Patients the midline. Epstein’s pearls, Bohn’s nodules, and dental lamina cysts typically present with feeding or respiratory problems. Congenital typically present as asymptomatic 1 mm to 3 mm nodules or papules. epulis has a marked predilection for females at 8:1 to 10:1. Treatment They are smooth, whitish in appearance, and filled with keratin. No normally consists of surgical excision. The newborn usually heals treatment is required; these cysts usually disappear during the first 3 well, and no future complications or treatment should be expected. months of life.

Eruption cyst (eruption hematoma) The eruption cyst is a soft tissue cyst that results from a separation trauma. If trauma is intense, these blood filled lesions sometimes are of the dental follicle from the crown of an erupting tooth. Fluid referred to as eruption hematomas. accumulation occurs within this created follicular space. Eruption cysts Because the tooth erupts through the lesion, no treatment is necessary. most commonly are found in the mandibular molar region. Color of If the cyst does not rupture spontaneously or the lesion becomes these lesions can range from normal to blue-black or brown, depending infected, the roof of the cyst may be opened surgically. on the amount of blood in the cystic fluid. The blood is secondary to

Mucocele The mucocele is a common lesion in children and adolescents resulting rupture. Mucoceles most frequently are observed on the lower lip, from the rupture of a minor salivary gland excretory duct, with usually lateral to the midline. Mucoceles also can be found on the subsequent leakage of mucin into the surrounding connective tissues buccal mucosa, ventral surface of the tongue, retromolar region, and that later may be surrounded in a fibrous capsule. Most mucoceles are floor of the mouth (ranula). well-circumscribed bluish translucent fluctuant swellings (although Superficial mucoceles and some other mucoceles are short-lived deeper and long-standing lesions may range from normal in color to lesions that burst spontaneously, leaving shallow ulcers that heal having a whitish keratinized surface) that are firm to palpation. Local within a few days. Many lesions, however, require treatment to mechanical trauma to the minor salivary gland is often the cause of minimize the risk of recurrence.

Maxillary frenum A prominent maxillary frenum in children, although a common Treatment options can include orthodontics, restorative dentistry, finding, is often a concern, especially when associated with a diastema. surgery, or a combination of these. When a diastema is present, the A comparison of attached frena with and without diastemas found no objectives for treatment involve managing both the diastems or correlation between the height of the frenum attachment and diastema permanent teeth and its cause while maintaining stable results in presence and width. Treatment is suggested when the attachment the future. It is recommended that treatment be delayed until the exerts a traumatic force on the gingival, causing the papilla to blanch permanent incisors and cuspids have erupted and the diastema has had when the upper lip is pulled, or if it causes a diastema to remain after an opportunity to close naturally. If orthodontic treatment is indicated, eruption of the permanent canines. Interference with oral hygiene the frenectomy (complete excision [i.e., removal of the whole measures, aesthetics and psychological reasons are contributing factors frenulum]) should be performed only after the diastema is closed as that relate to treatment of the maxillary frenum. much as possible to achieve stable results. When indicated, a maxillary frenectomy is a fairly simple procedure and can be performed in the office setting.

Mandibular labial frenum A high frenum can sometimes present on the labial aspect of the tissue, which, in turn, can lead to food and plaque accumulation. Early mandibular ridge. This is most often seen in the central incisor area treatment can be considered to prevent subsequent inflammation, and frequently occurs in individuals where the vestibule is shallow. recession, pocket formation, and possible loss of the alveolar bone or The mandibular anterior frenum, as it is known, occasionally inserts tooth. However, if factors causing gingival/periodontal inflammation into the free or marginal gingival tissue. Movements of the lower lip are controlled, the degree of recession and need for treatment cause the frenum to pull on the fibers inserting into the free marginal decreases.

Mandibular lingual frenum/ankyloglossia When indicated, frenuloplasty (various methods to release the tongue and speech. Further evidence is needed to determine the benefit of tie and correct the anatomic situation) or frenectomy (simple cutting of surgical correction of ankyloglossia in resolving speech pathology. the frenulum) may be a successful approach to facilitate breastfeeding; There is limited evidence to show an association between however, there is a need for evidence-based research to determine ankyloglossia and Class III malocclusion. Speculations have indications for treatment. This indicates that there is a need to been made that the abnormal tongue position may affect skeletal standardize a classification system and justify parameters for surgical development. Although there are no clear recommendations in the correction of ankyloglossia among neonates. literature, a complete orthodontic evaluation, diagnosis, and treatment Limitations in tongue mobility and speech pathology have been plan are necessary before any surgical intervention. associated with ankyloglossia. There has been varied opinion among Reports also have been made on the association between frenal health care professionals on the correlation between ankyloglossia and attachment and gingival recession; further clinical evidence, however, speech disorders. Frenuloplasty or frenectomy in conjunction with is warranted to show a clear relationship between these two factors. speech therapy can be a treatment option to improve tongue mobility

Page 136 Dental.EliteCME.com Elimination of plaque-induced gingival inflammation can minimize certain indications for these procedures. A short lingual frenum can gingival recession without any surgical intervention. inhibit tongue movement and create deglutition problems. If there is The significance and management of ankyloglossia are very no improvement in breastfeeding for a child with ankyloglossia after controversial because of the lack of evidence-based studies to non-surgical intervention, frenectomy may be indicated. support frenotomy, frenectomy and frenuloplasty among children and Although there is limited evidence in the literature to promote the adults affected by ankyloglossia. Studies have shown a difference in timing, indication and type of surgical intervention, frenectomy treatment recommendations among speech pathologists, pediatricians, for functional limitations due to severe ankyloglossia should be otolaryngologists, lactation specialists, surgeons, and dental considered on an individual basis. If evaluation shows that function specialists. Most professionals, however, will agree that there are may be improved by surgery, treatment should be considered.

Frenectomy techniques Frenectomy involves surgical incision, establishing hemostasis, and operative working time, the ability to control bleeding quickly, suturing of the wound. Dressing placement or the use of antibiotics reduced pain and discomfort, fewer postoperative complications (e.g., is not necessary. Recommendations include maintaining a soft diet, pain, swelling, infection), and no need for suture removal, as well regular oral hygiene, and analgesics as needed. Although there is as increasing patient acceptance. These procedures require skilled minimal evidence-based research available, the use of laser technology technique and patient management. and electrosurgery for frenectomies have demonstrated a shorter

Natal and neonatal teeth Natal and neonatal teeth can present a challenge when deciding on An important consideration when deciding to extract a natal appropriate treatment. Natal teeth have been defined as those teeth or neonatal tooth is the potential for hemorrhage. Extraction is present at birth, and neonatal teeth are those that erupt during the first contraindicated in newborns due to risk of hemorrhage. Unless 30 days of life. The occurrence of natal and neonatal teeth is rare; the child is at least 10 days old, consultation with the pediatrician the incidence varies from 1:1,000 to 1:30,000. The teeth most often regarding adequate hemostasis may be indicated prior to extraction of affected are the mandibular primary incisors. In most cases, anterior the tooth. natal and neonatal teeth are part of the normal complement of the Potential benefits dentition. Natal or neonatal molars have been identified in the posterior ++ Appropriate management and early treatment of infant, child and region and may be associated with systemic conditions or syndromes adolescent oral health problems and prevention of oral disease. (e.g., Pfieffer syndrome, histiocytosis X). Although many theories exist as to why the teeth erupt prematurely, currently no studies confirm a Potential risks causal relationship with any of the proposed theories. The superficial * Intraoperative complications of third molar removal (e.g., position of the tooth germ associated with a hereditary factor seems to nerve injury, unexpected hemorrhage, unplanned transfusion or be the most accepted possibility. parenteral drugs, compromised airway, fracture, other injuries to adjacent teeth/structures) occurred at a frequency less than 1 If the tooth is not excessively mobile or causing feeding problems, percent. Excluding alveolar osteitis, postoperative complications it should be preserved and maintained in a healthy condition if at all (e.g., paresthesia, infection, trismus, hemorrhage) were similarly possible. Close monitoring is indicated to ensure that the tooth remains low. stable. * Factors that increase the risk for complications (e.g., coexisting Riga-Fede disease is a condition caused by the natal or neonatal tooth systemic conditions, location of peripheral nerves, history of rubbing the ventral surface of the tongue during feeding leading temporomandibular joint disease, presence of cysts or tumors) to ulceration. Failure to diagnose and properly treat this lesion can and position and inclination of the molar in question should be result in dehydration and inadequate nutrient intake for the infant. assessed. Treatment should be conservative and focus on creating round, smooth Contraindications incisal edges. If conservative treatment does not correct the condition, XX Tooth extraction is contraindicated in newborns due to risk of extraction is the treatment of choice. hemorrhage.

Antibiotic therapy and the child patient This section discusses pediatric dental diseases requiring antibiotic 3. Duration of drug therapy. therapy, including oral wounds, dental trauma, orofacial infections 4. Patient education regarding the importance of completing a full and periodontal disease, with the objective of providing guidance in course of antibiotics. the appropriate use of antibiotic therapy in the treatment of these oral 5. Pulpotomy, pulpectomy or tooth extraction (for pulpitis). conditions. It considers the following interventions and practices: 6. Assessment of anesthesia requirements. 1. Antibiotic therapy: 7. Additional birth control measures for patients taking antibiotics ○○ Intravenous. and oral contraceptives. ○○ Intramuscular. Conservative use of antibiotics is indicated to minimize the risk of ○○ Oral. developing resistance to current antibiotic regimens. The following 2. Monitoring of clinical effectiveness of antibiotic therapy: general principles should be adhered to when prescribing antibiotics ○○ Culture and susceptibility testing of isolates from the infective for the pediatric population. site.

Oral wound management Factors related to host risk (e.g., age, systemic illness, malnutrition) Wounds can be classified as clean, potentially contaminated, and type of wound (e.g., laceration, puncture) must be evaluated when or contaminated/dirty. Topical or other antibiotic agents may be determining the risk for infection and subsequent need for antibiotics. required for facial lacerations and intraoral lacerations that appear

Dental.EliteCME.com Page 137 contaminated by extrinsic bacteria, as well as open fractures and joint responsive to the initial drug selection, a culture and susceptibility injury, which are susceptible to increased risk of infection. testing of isolates from the infective site may be indicated. If it is determined that antibiotics would be beneficial to the healing The minimal duration of drug therapy should be limited to five process, the timing of the administration of antibiotics is critical days beyond the point of substantial improvement or resolution of to supplement the natural host resistance in bacterial killing. The signs and symptoms; this is usually a five- to seven-day course of drug should be administered as soon as possible for the best result. treatment dependent upon the specific drug selected. The importance The most effective route of drug administration (intravenous versus of completing a full course of antibiotic must be emphasized. If the intramuscular versus oral) also must be considered. The clinical patient discontinues the antibiotic prematurely, the surviving bacteria effectiveness of the drug must be monitored. If the infection is not can restart an infection that may be resistant to the original antibiotic.

Pulpitis/apical periodontitis/draining sinus tract/localized intraoral swelling Bacteria can gain access to the pulpal tissue through caries, exposed rendered. Antibiotic therapy usually is not indicated if the dental pulp or dentinal tubules, cracks into the dentin, and defective infection is contained within the pulpal tissue or the immediately restorations. If a child presents with acute symptoms of pulpitis, surrounding tissue. In this case, the child will have no systemic signs treatment (i.e., pulpotomy, pulpectomy, or extraction) should be of an infection (i.e., no fever and no facial swelling).

Acute facial swelling of dental origin A child presenting with a facial swelling secondary to a dental treating the involved tooth/teeth. The clinician should consider the infection should receive immediate dental attention. Depending on ability to obtain adequate anesthesia, the severity of the infection, and clinical findings, treatment may consist of treating or extracting the medical status of the child. Intravenous antibiotic therapy and/or the tooth/teeth in question with antibiotic coverage or prescribing referral for medical management may be indicated. antibiotics for several days to contain the spread of infection and then

Dental trauma Local application of an antibiotic to the root surface of an avulsed consideration must be exercised in the systemic use of tetracycline tooth with an open apex and less than 60 minutes extraoral dry time due to the risk of discoloration in the developing permanent dentition. has been recommended, if available, to inhibit external reabsorption Penicillin V can be given as an alternative. The use of topical and aid in pulpal revascularization. Systemic antibiotics have been antibiotics to induce pulpal revascularization in immature non-vital recommended as an adjunctive therapy for avulsed permanent incisors traumatized teeth has been suggested. However, further randomized with an open or closed apex. Tetracycline is the drug of choice, but clinical trials are needed.

Pediatric periodontal diseases In pediatric periodontal diseases (e.g., neutropenias, Papillon-LeFevre some cases, treatment may involve antibiotic therapy. Culture and Syndrome, leukocyte adhesion deficiency), the immune system susceptibility testing of isolates from the involved sites is helpful in is unable to control the growth of periodontal pathogens, and, in guiding the drug selection.

Viral diseases Conditions such as acute primary herpetic gingivostomatitis should not be treated with antibiotic therapy unless there is strong evidence to indicate that a secondary bacterial infection exists.

Oral contraceptive use Whenever an antibiotic is prescribed to a female patient taking oral Potential risks contraceptives to prevent pregnancy, the patient must be advised to * Caution is advised with the concomitant use of antibiotics and oral use additional techniques of birth control during antibiotic therapy and contraceptives as antibiotics may decrease the effectiveness of oral for at least one week beyond the last dose because the antibiotic may contraceptives. render the oral contraceptive ineffective. * Tetracycline can cause discoloration in the developing permanent Rifampicin, tetracycline and penicillin derivatives have been shown dentition. to decrease the effectiveness of oral contraceptives, in some cases, by causing a significant decrease in the plasma concentrations of ethinyl estradiol, causing ovulation in some individuals taking oral contraceptives. Caution is advised with the concomitant use of antibiotics and oral contraceptives. Potential benefits ++ Conservative use of antibiotics may minimize the development of antibiotic resistance.

Bibliography ŠŠ American Academy of Pediatric Dentistry Clinical Affairs Committee-Restorative, Clinical guideline on pediatric restorative dentistry. Chicago (IL): American Academy American Academy of Pediatric Dentistry Council on Clinical Affairs. Guideline of Pediatric Dentistry; 2004. 9 p. on pediatric restorative dentistry. Pediatr Dent 2008-2009;30(7 Suppl):163-9. This ŠŠ Beauchamp J, Caufield PW, Crall JJ, Donly K, Feigal R, Gooch B, Ismail A, Kohn W, guideline updates a previous version: American Academy of Pediatric Dentistry. Siegal M, Simonsen R, American Dental Association Council on Scientific Affairs.

Page 138 Dental.EliteCME.com Evidence-based clinical recommendations for the use of pit-and-fissure sealants: a is based in part on the American Academy of Pediatric Dentistry’s (AAPD’s) Policy report of the American Dental Association Council on Scientific Affairs. J Am Dent Statement on the Use of a Caries-risk Assessment Tool (CAT) for Infants, Children, Assoc 2008 Mar;139(3):257-68. and Adolescents and the American Academy of Periodontics’ (AAP) “Periodontal ŠŠ Council on Clinical Affairs. Guideline on xylitol use in caries prevention. Chicago Diseases in Children and Adolescents.” This guideline updates a previously published (IL): American Academy of Pediatric Dentistry (AAPD); 2011. 4 p. version: American Academy of Pediatric Dentistry. Clinical guideline on the role ŠŠ Guideline on behavior guidance for the pediatric dental patient. Chicago (IL): of dental prophylaxis in pediatric dentistry. Chicago (IL): American Academy of American Academy of Pediatric Dentistry (AAPD); 2011. 13 p. This guideline Pediatric Dentistry; 2003. 3 p. updates a previous version: American Academy of Pediatric Dentistry Clinical Affairs ŠŠ Guideline on use of anesthesia personnel in the administration of office-based deep Committee-Behavior, American Academy of Pediatric Dentistry Council on Clinical sedation/general anesthesia to the pediatric dental patient. Chicago (IL): American Affairs. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent Academy of Pediatric Dentistry (AAPD); 2009. 3 p. This summary updates a previous 2008-2009;30(7 Suppl):125-33. version: Clinical guideline on use of anesthesia-trained personnel in the provision ŠŠ Guideline on caries-risk assessment and management for infants, children and of general anesthesia/deep sedation to the pediatric dental patient. Chicago (IL): adolescents. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2011. American Academy of Pediatric Dentistry; 2001. 2 p. 8 p. This guideline updates a previous version: American Academy of Pediatric ŠŠ Guideline on use of antibiotic therapy for pediatric dental patients. Chicago (IL): Dentistry (AAPD). Policy on use of a caries-risk assessment tool (CAT) for infants, American Academy of Pediatric Dentistry (AAPD); 2009. 3 p. This guideline updates children and adolescents, revised 2006. a previous version: Clinical guideline on appropriate use of antibiotic therapy for ŠŠ Guideline on management of the developing dentition and occlusion in pediatric pediatric dental patients. Chicago (IL): American Academy of Pediatric Dentistry dentistry. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2009. 13 (AAPD); 2005. 3 p. p. This guideline updates a previous version: Clinical guideline on management of ŠŠ Guideline on use of local anesthesia for pediatric dental patients. Chicago (IL): the developing dentition and occlusion in pediatric dentistry. Chicago (IL): American American Academy of Pediatric Dentistry (AAPD); 2009. 7 p. This guideline updates Academy of Pediatric Dentistry (AAPD); 2005. 18 p. a previous version: Clinical guideline on appropriate use of local anesthesia for ŠŠ Guideline on pediatric oral surgery. Chicago (IL): American Academy of Pediatric pediatric dental patients. Chicago (IL): American Academy of Pediatric Dentistry Dentistry (AAPD); 2010. 8 p. This guideline updates a previous version: Guideline (AAPD); 2005. 8 p. on pediatric oral surgery. Chicago (IL): American Academy of Pediatric Dentistry ŠŠ Guideline on use of nitrous oxide for pediatric dental patients. Chicago (IL): American (AAPD); 2005. 9 p. Academy of Pediatric Dentistry (AAPD); 2009. 4 p. This guideline updates a previous ŠŠ Guideline on the role of dental prophylaxis in pediatric dentistry. Chicago (IL): version: Clinical guideline on appropriate use of nitrous oxide for pediatric dental American Academy of Pediatric Dentistry; 2007. 4 p. [18 references] The guideline patients. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2005. 4 p.

Topics in Pediatric Dentistry

Final Examination Questions Select the best answer for each question and mark your answers on the online at Dental.EliteCME.com.

1. Studies suggest that dentists’ technical skills are often judged by 6. HOME is a useful way to “show” that a procedure is not to be their “bedside manner,” or how caring and sympathetic they are feared by showing another child having a good experience with the perceived to be. same procedure. a. True. a. True. b. False. b. False.

2. Which of the following stages of cognitive development discussed 7. Informed consent must be obtained and documented in the by Piaget is characterized by the ability to predict outcomes? patient’s record prior to use of protective stabilization. a. Sensorimotor. a. True. b. Preoperational thought. b. False. c. Concrete operations. d. Formal operations. 8. Before delivery of deep sedation/general anesthesia, oxygen saturation must be monitored and recorded at least every 10 3. Fear of strangers is pronounced in many infants at about 4 months minutes throughout the procedure. of age, with anxiety separation relatively uncommon for children a. True. until about 5 years of age, when it increases markedly. b. False. a. True. b. False. 9. Guidelines for local anesthesia use in children were last revised in 2002. 4. Which of the following is not an effective strategy for reducing a. True. patient anxiety? b. False. a. Attempting to make the appointment as short as possible. b. Providing an age-appropriate explanation before any 10. Practitioners should aspirate before every local anesthetic injection procedure. and inject slowly. c. Listening to the child, and addressing any concerns or worries. a. True. d. Ensuring that treatment is pain-free. b. False.

5. Which of the following activities is not appropriate for the tell- 11. Which of the following is not a contraindication for the use of show-do sequence? supplemental injections to obtain local anesthesia? a. Explaining the procedure in phrases appropriate to the a. Use of a local anesthetic without vasoconstrictor for patients developmental level of the patient. with an allergy to bisulfates. b. Demonstrating the visual, auditory, olfactory and tactile b. Use of epinephrine in hyperthyroid patients. aspects of the procedure for the patient. c. Use of levonordefrin and norepinephrine in patients receiving c. Completing the procedure without deviating from the tricyclic antidepressants. explanation and demonstration. d. Use of the periodontal ligament injection or intraosseous d. Communicating the clinical or preventive objectives of the methods in the presence of inflammation or infection at the treatment to the parents of the patient. injection site.

Dental.EliteCME.com Page 139 12. If a rubber cup/pumice prophylaxis is performed, a topical fluoride 17. Distal tipping should be used for mildly impacted first permanent application is recommended. molars, where little of the tooth is impacted under the primary a. True. second molar. b. False. a. True. b. False. 13. The American Academy of Pediatrics does not recommend chewing gum use in children less than 2 years of age because of 18. There have been reported cases of accessory roots observed in the risk of choking. primary canines. a. True. a. True. b. False. b. False.

14. Children at high risk exhibiting anterior tooth caries and/or molar 19. Seventy-five percent of mesiodens erupt spontaneously. caries may be treated with SSCs to protect the remaining at-risk a. True. tooth surfaces. b. False. a. True. b. False. 20. Which of the following is not a term referring to smooth, whitish cysts, filled with keratin, which require no treatment and usually 15. Which of the following is not a clinical recommendation from a disappear during the first three months of life? study published in 2008 on sealants? a. Bohn’s nodules. a. Routine mechanical preparation of enamel before acid etching b. Epstein’s pearls. is recommended. c. Dental lamina cysts. b. When possible, a four-handed technique should be used for d. Congenital epulis. placement of resin-based sealants. c. Resin-based sealants are the first choice of material for dental sealants. d. Use of available self-etching bonding agents is not recommended.

16. Palpation for unerupted teeth should be part of every examination during the early mixed dentition stage. a. True. b. False.

DOH08PDE17

Page 140 Dental.EliteCME.com Chapter 7: Updates on Laser Therapy in Dentistry and Integration in the Dental Office 4 CE Hours

By: Negar Jamshidi, B.Sc. (Hons1), B.DSc. Learning objectives ŠŠ Describe the basics of laser physics and the mechanism of laser action. ŠŠ List three key applications of lasers in Prosthodontics, and ŠŠ List five uses of laser therapy in orthodontics. describe parameters setting for each laser. ŠŠ List the latest laser technologies available in dentistry, and give ŠŠ List three lasers used in the diagnosis of caries as well as the one example of each application and the advantages compared to limitations and treatments available for TMD. traditional modalities. ŠŠ List the application of lasers in oral surgery. ŠŠ Explain the main application of lasers in each stage of the implant ŠŠ Describe the practical application of lasers in periodontics. process. ŠŠ List three main safety requirements of lasers. ŠŠ Explain five main clinical applications of lasers in restorative ŠŠ Describe practical laser use in pediatric dentistry. dentistry. ŠŠ Discuss ways to integrate lasers into dental practice. Introduction In the last decade alone, the research and application of laser therapy the end of this course, general dental practitioners will be armed with technology in general dentistry has expanded remarkably, heralding knowledge and understanding of how and when to apply laser therapy in lasers as one of the most exciting advances in dental technology. This management of oral diseases as adjunct to or instead of other traditional course will review the latest developments in dental laser application and treatments. Clinicians will also learn to carefully approach laser provide evidence for its multitude of benefits in general dentistry, and application with adequate training and an understanding of the optimal also discuss the practical application and integration of lasers in dental parameters required to achieve specific treatments. It is envisioned that offices. The science behind lasers, and the types of lasers available in this technology will increase the ability to provide quality oral treatment, the market and their specific dental applications will be reviewed. At and in effect, increase the standard of patient care.

Basics of laser physics and mechanism of action “A splendid light has dawned on me...”- Albert Einstein 3. Optical resonator: An optical cavity with excitable atoms that The concept of lasers was first proposed by Einstein in his 1917 paper allows the pumping source to turn it into an oscillation resonator. on the theory of quantum radiation which postulated that light consists 4. Output coupler: I.e. a mirror, that allows partial transmission of of photons with different wave energies which can produce amplified the stored radiation inside the optical cavity. or stimulated particles of powerful light beams [1]. In fact, Einstein won the Noble Prize for describing the concept of radiation photoelectric amplification, not the theory of relativity! It took another 43 years for the first laser to be built by Theodore Maiman in California. The word LASER is an acronym for “Light Amplification by Stimulated Emission of Radiation” and was coined by Gordon Gould in 1957, an independent researcher considered one of the original fathers of laser [2]. Since its inception, laser has found numerous applications in the medical field and there are now growing practical uses for oral and dental-related treatment modalities. The amazing array of amplification mechanisms and the wavelength range of lasers are the drivers for these rapidly expanding dental applications. A laser produces energy in a coherent radiation of one wavelength, in either the infrared, the visible or the ultraviolet part of the electromagnetic spectrum. In Figure 1. Schematic representation of laser mechanism effect, this means that laser light is a single colour (monochromatic) The light for dental laser systems is delivered through an optical fibre and each light wave is identical in physical properties (coherence). The cable which is a hollow articulated arm [2]. The wavelength varies principle mechanism of action of laser involves four main elements [2] between 488nm-10,600nm. Lasers are classified according to the which are represented diagrammatically in Figure 1 : emission type (spontaneous or stimulated emission), output power, 1. Amplifier: An active medium composed of either gas, liquid or active medium (liquid, solid or gas state), target tissue (hard or soft solid molecules in a gas, that amplifies a passing light wave. tissue) and possible biological damage (Class I-IV) which will be 2. Pumping source: An excitation system that allows the active discussed further below [3,4]. medium to turn into an amplifier for electromagnetic radiation.

Update on laser technologies used in dentistry The first laser designed for dental use was introduced in 1989 by an laser application in dentistry began to gain acceptance [5-7]. These American dentist, Dr. Terry Myers, and was intended for commercial applications expanded into the surgical areas of periodontal therapy, use on soft tissues only [4]. It was not until almost 18 years later when implantology, and endodontics [7]. More recent advances into the 3-D

Dental.EliteCME.Com Page 141 capability of lasers has allowed digital impressions using Computer- nm) and the Erbium-Chromium-YSGG (2,780 nm) which have active Assisted Design and Manufacturing (CAD/CAM) technology [8]. mediums of yttrium-aluminium-garnet and solid yttrium-scandium- [10,11] Currently there are more than 24 indications for clinical application garnet, respectively . Due to their high hydroxyapatite and water absorbance properties, both of these lasers are excellent to use for of lasers in dentistry with mounting evidence of the benefits for caries and hard tissue removal [11]. The success rate of these lasers treatment and patient well-being [9]. In this section, the different laser technologies, and their parameters and limitations will be discussed. is also due to their minimal tissue penetration, and hence negligible thermal effects on pulp, as the soft tissue is removed [11]. Of note, The lasers currently used in dentistry are argon, carbon dioxide, there is no need for anaesthetics with an Er-YAG laser during caries erbium (Nd: YAG and Er: YAG), diode, DIAGNOdent, removal. It has less vibration than a high speed drill, which is highly DopplerFlowmetry, chromium (Er, Cr: YSGG), and Low-level satisfying and comfortable for patients [9]. Recent studies have shown Laser Therapy (LLLT). The names of the lasers reflect their active effective reduction of dentinal hypersensitivity using Er-YAG lasers medium contents and states of suspension [7]. Optimal laser parameters with less thermal side effect than CO2 lasers [12,13]. The Er-YAG depend on the target tissue, and involve power output, wavelength, laser also has significant antimicrobial effects and is suitable for use exposure time, and energy quantity [6]. Some of the more common in endodontic treatments. Similarly, the Er-Cr-YSGG laser has no laser applications in dentistry include, but are not limited to, crown thermal effect on pulp and results in excellent bonding properties [14]. lengthening, caries detection, mid-line frenectomy, pain reduction and Diode lasers’ active medium source of emission is a semi-solid hypersensitivity treatment, gingevectomy, and removal of aphthous semiconductor with varying wavelengths in the 800nm-980nm range. ulcers and soft tissue lesions (Table 1). This laser can be safely used for soft tissue surgery including crown An argon laser produces light at the light wavelengths of 488nm blue, lengthening and frenectomy due to its poor absorption by the tooth and 514nm blue-green in an active medium of argon gas with a high structure [3]. current of electrical charge. Due to its poor absorption by hard tissues, The LLLT laser is applied via a light emitting diode (LED) to support the risk of damage to enamel is negligible during soft tissue surgeries. tissue repair and healing, induce analgesic effects, and decrease The main uses of argon lasers are to control haemorrhage during inflammation. Current studies indicate that LLLT is useful in the treatment gingival surgery, and to detect cracks or decay on tooth surfaces [7]. of a plethora of oral conditions and has applications in nearly every dental- The carbon dioxide (CO2) laser is another laser which uses gas as related field. This versatility is due to the mode of LLLT action, as light is active medium. They produce light at about 10,600 nm in the visible absorbed by cell mitochondria with no thermal effect on tissues [15]. range and have very high water and hydroxyapatite absorbance Nd-YAG lasers are the first laser system used in dentistry with an properties compared to other dentistry laser systems [3]. The major advantage of carbon dioxide lasers is that they allow soft tissue active medium of YAG crystal doped with neodymium. It produces surgery with ease and precision. The drawbacks are that the laser is not a wavelength at 1,064 nm which is absorbed only by hard tissue, and [8]. They can also be suitable for hard tissue use, and that it is technique-sensitive. During has great use in surgery and soft tissue removal used to remove some enamel caries and provide good homeostasis application the surrounding tooth structure requires protection [5]. during surgery. The main disadvantage with these lasers is the depth of Erbium lasers are the most frequently used lasers in dentistry. There penetration, which results in a risk of damage to the pulp and possibly are different types of erbium lasers including the Erbium-YAG (2,940 the underlying bone [8,9].

Table 1. Summary of current dental lasers in the market and their main clinical applications Laser type Wavelength Laser characteristics Indication and tissue depth Clinical use

Argon. 488nm, 514nm. Low water absorption. Soft tissue, 1mm. Gingevectomy. CO2. 960nm, 10600nm. High water and Soft tissue, 0.1mm. Oral surgery. hydroxyapatite absorption. Diode. 800-980nm. Poor hard tissue absorption. Soft tissue, 0.1-0.3mm. Crown lengthening, frenectomy, diagnosis and disinfection.

Er-YAG. 1030nm. High water and Soft and hard tissue, 5um. Remove dentinal, enamel/dentin hydroxyapatite absorption. cutting, hypersensitivity.

Potassium-titanyl- 532nm. Low water absorption. Soft tissue. Surgery and periodontal Phosphate. bleaching. Low level lasers 600-1000nm. Low water absorption. Soft tissue. Disinfection, treatment of (LLL). recurrent aphthos ulcer and TMJ disorders. Nd-YAG. 1030nm. High water and Soft tissue, >1mm. Endodontics, disinfection, and hydroxyapatite absorption. selective caries removal.

Laser operation Dental lasers either emit energy in a continuous wave or a free- operate on the free-running pulse mode, where true pulses of ten running pulse. Both carbon dioxide and diode lasers emit energy in thousandths of a second originate from a flash lamp[9] . a continuous wave mode, which continues while the laser remains Laser-tissue interaction activated. The limitations of these lasers include associated thermal Laser-tissue interactions are dependent on the wavelength, laser burn which is abated by using an electronic-controlled or gated-pulse mode of emission, and tissue characteristics [8,9]. The key factor for laser. Laser systems that use Nd-YAG, Er-YAG, and Er,Cr-YSGG Page 142 Dental.EliteCME.Com absorption of light in tissues is wavelength of the light. Generally, In summary, laser-tissue interactions depend on four properties of light pigmented tissues tend to absorb more energy from shorter energy and target tissues [16,17]: wavelengths in the 500-1000 nm range, such as the diode and Nd- ●● Absorption: Tissue characteristics such as pigmentation, and YAG lasers. Tissues with higher water content and apatite crystals presence of chromophores (agents that absorb light) determine absorb energy better in the longer wavelength range (3000 nm-10,600 the amount of energy absorbed. Other factors include the laser nm) which encompasses ER-YAG, Erbium and CO2 wavelengths [9]. emission mode and wavelength, the laser wavelength used, and the Thus the depth of light absorption by target material is an indicator laser emission mode. of the application of the laser: the CO2 laser depth of penetration is ●● Transmission: This effect depends on tissue optical characteristics a maximum of 0.1mm which is capable of sealing blood vessels and and the laser wavelength used. achieving sufficient haemostasis[9] . However, while the Nd-YAG laser ●● Reflection: There are either specular (mirror-image) reflections or is capable of deeper (2-5mm) tissue penetration, the risk of damage to diffuse (different directions) reflections of the light from the target the surrounding tissue increases accordingly [9]. The energy absorbed surface without any effect on the target. from the light is converted to heat, which depending on tissue ●● Scattering: The laser light enters the target tissue across multiple characteristics and the duration of light exposure, may alter the tissue directions, reducing the effect of the laser energy. structure and cause various effects such as carbonization, or in the case of hard tissues, recrystallization [7-9].

Advantages and disadvantages of laser systems The advent of lasers in dentistry carries many benefits. One such the use of lasers in children and pregnant women has been deemed benefit is the removal of a diseased or infected tooth structure while safe and is practiced regularly. not affecting healthy tissues by using the selectivity of their higher The obvious limitation of lasers is their high outlay and ongoing water content. Recent studies have shown that lasers eliminate costs; these costs include training, maintenance, and the time taken microfractures, and compared to high-speed handpieces, have a much to implement laser protocols in the practice. In addition to each [18]. Also there are reports of quicker lower thermal effect on the pulp manufacturer’s in-house training, there are high end courses offered healing of bone tissue after laser-surgical osseous tissue removal. by the Academy of Laser Dentistry (ALD) that support dental teams Notably, it has been shown that lasers used to prepare enamel increase in developing efficiency and skills. There are some limitations in the bonding surface for composites [19]. the delivery system of lasers due to accessibility in the operating One of the main advantages of utilizing a laser is the decreased field. The removal speed of most lasers is slower than a high speed microbial contamination risk in the operating field, especially during drill, but at the same time the damage to healthy tooth structures is cavity preparation. Several studies show that laser post-operative minimal. Another drawback is that erbium lasers cannot interact with healing is rapid and scar formation is diminished [18,20]. Additionally, gold or porcelain materials [18]; although, they are advantageous when removing caries adjacent to these materials.

Table 2. Summary of key benefits and limitations of dental lasers in clinical applications Key benefits for laser application in dentistry Limitations of laser application in dentistry Reduced risk of infection due to bactericidal action. Cost prohibitive in terms of the outlay, maintenance and supplies for the laser. No scar formation and excellent wound healing. Lasers are wavelength specific with different properties. Less requirements for anaesthetics and little to no pain or discomfort Insufficient clinical trials and standardization of protocols for use in during and post operatively. RSTAPT. Control of bleeding and achieving good hemostatic control. Implementation of safety measures for all involved in the operating field and ensuring that staff are supportive and follow safety regulations. Excellent diagnostic tool especially for pulp vitality assessment. Continuing education and ongoing training required for the entire dental staff.

Laser applications in restorative dentistry The traditional procedures for tooth preparation for restorations use and visibility hampered by presence of plaque, and limitations of high or slow speed rotary handpieces which are uncomfortable to radiographs to interproximal tooth decay. Furthermore, development patients and more time consuming because of the requirement to of quantitative methods in dentistry for the detection and monitoring of administer local anesthetics. In restorative dentistry, lasers have a caries have enhanced the reliability of detecting earlier caries lesions, long history of overcoming these limitations, and they have found and allowed quantitative assessment of the progress of the lesion [22]. application in diagnostic and common operative applications such The introduction of caries detection technologies including as caries detection, curing composite restorations, bleaching, cavity laser fluorescence tools such as DIAGNOdent (Kavo), and LED [18]. More recent key applications of preparation and caries removal fluorescence tools such as Spectra Caries Detection Aid System lasers in restorative dentistry areas include using lasers as an adjunct (SCDAS) and Sopro-Life, have vastly improved the early detection to bonding composite restorations, in the removal of defective [23-25] [26] [18, 21] of carious lesions . Recently, Rechmann et al. compared these restorations, and for the treatment of dentin hypersensitivity . technologies and concluded that the sensitivity and specificity of all Caries assessment, diagnosis, and prevention three systems allows them to be utilized as an efficient addition to Generally, the diagnosis of tooth decay or caries involves a visual monitor and diagnose early carious lesions. clinical examination and the use of probes, complemented by bitewing The sensitivity and specificity, respectively, of the systems were radiographs. However, the conventional tools for decay detection are found to be: DIAGNOdent, 87% and 66%; Sopro-Life daylight largely affected by the complexities of tooth morphology, accessibility

Dental.EliteCME.Com Page 143 mode, 95% and 55%, and fluorescence blue mode, 93% and 63%; issues. With lasers, local anaesthesia is not required, and most lasers and SCDA, 92% and 37% [26]. selectively remove infected hard tissue while leaving healthy tooth DIAGNOdent quantitatively measures presence of decay by structure intact. The three most commonly used lasers are from the photodiodes (655nm wavelength). It takes advantage of the differences erbium family and include the ER-YAG (2940 nm), the Er, Cr- in fluorescence emitted by healthy tissues and plaque metabolites.The SGG (780 nm) and Er-YSGG (2790 nm). Each of these provide [35]. Er-YAG lasers have been digital values of fluorescence intensity ranges from zero to ninety- unique applications in tooth ablation demonstrated to be more efficient at removing infected hard tissue nine, and is represented as an audio signal reading as follows (Source: than conventional handpieces, and they stimulate dentin formation and DIAGNOdent, KaVo, Biberac, Germany): exert an antibacterial effect [36] ●● 0-14: healthy occlusal surfaces. . However, some studies have indicated ●● 15-20: enamel caries. a risk of thermal damage to the pulp as a main drawback, despite use [37]. Several more recent studies ●● >21: dentin caries. of water spray during the procedure have demonstrated that adjustments to the pulse repetition rate and There is no correlation between the depth of decay and the signal the power intensity have diminished this thermal alteration to safe reading value [23,27]; however, the DIAGNOdent has been shown to levels for the pulp [37-40]. Although the literature is inundated with be very effective as an adjunct to conventional clinical diagnostic inconsistent reports on the thermal effects of erbium lasers during methods, especially in early detection of occlusal caries [28]. cavity preparation, the emerging evidence on erbium lasers, especially The more recently introduced Sopro-Life (Sopro-Life, La Ciotat, long term dataset, support the clinical use of erbium lasers for tooth [38] France) laser has the extra benefit of magnification, and relies on ablation . The factors that contribute to these inconsistencies are visual assessment with the laser fluorescence device. The output of due to different operator factors including laser parameters (e.g. this system is largely influenced by the presence of calculus, plaque, power intensity), pulse length, light profile, and other parameters prophylactic pastes, and therefore meticulous cleaning of the tooth that ultimately affect the outcome of laser-tissue interaction. Further surface before reading is essential. In addition, fluorosis or stained clinical research on erbium lasers will be required to cement the surfaces on teeth maybe give false positive score, so it is important that position of these lasers in dentistry, and to encourage more clinicians an adequate training session is undertaken before tooth examination to utilize the technology. to increase the sensitivity and specificity of the values[25] . The Another laser with potential in caries removal is the specific CO2-laser Spectra Caries Detection Aid System (SCDAS) utilizes fluorescence system (short-pulsed), also shown to reduce enamel demineralization. technology using light emitting diodes (LED) to project high energy The remarkable efficacy of caries removal by hard tissue ablation and light onto the tooth surface which results in plaque metabolites cavity design precision has been demonstrated with the more recent displaying as red and healthy enamel as green fluoresce[26] . application of Ultra Short Pulsed Laser (USPL) systems which also [41-43] Quantitative light-induced fluorescence (QLF, InspektorTM) lasers are showed minimal side effects . The mechanism of ablation of the the most widely reported diagnostic lasers shown to be more efficient Nd-YVO4-USPL (1064 nm, 8 picosecond duration) in a recent study at early caries detection. They have the added benefit of visual cues, was described as that of a multi-photon process, which is in contrast to and the ability to involve patients in treatment plan [29]. The principle the ER-YAG thermal-mechanism; each exhibited different tissue-laser [41] mechanism involves enamel auto-fluorescence with the excitation of interaction . Thus, the USPL technology offers huge potential for dentin using a blue light of 370 nm which allows detection of lesions as clinical dentistry in efficient and selective caries removal by allowing dark spots on a bright green background. An area with <5% fluorescence for different laser parameter settings to the control ablation rate, hence is considered a demineralized lesion. The QLF system demonstrates minimizing the thermal side effects. excellent reliability and reproducibility as well as sensitivity for early Use of laser in enamel remineralization caries quantification[30] . Similarly, the Sopro-Life camera was developed One of the emerging benefits of lasers in restorative dentistry is their as a potential diagnostic tool for early carious detection [24]. Furthermore, protection of the enamel surface from acid attack and demineralization both of these latest technologies detect active lesions up to a depth of [44-46]. This apparent acid resistance feature of lasers is of particular 500μm on the surface of demineralized tooth area [31,32]. advantage in patients who have difficulty in maintaining an oral One of the most useful diagnostic lasers in restorative dentistry is the hygiene routine, high caries susceptibility, or rampant caries, and/or Laser Doppler Flowmetry (LDF) which was developed to measure those under orthodontic treatment. Recent reports have shown an 87% tooth vitality. Its mechanism of action is dependent on the vascular reduction in the demineralization of enamel surface using specific response of the pulp; red cells scatter light emitted from the LDF with Carbon dioxide (CO2) lasers with a wavelength of 9300-9600 nm and [47,48] a subsequent frequency shift processed as a signal [33]. a short pulsed microsecond setting . The purpose of these caries detection tools is as an adjunct to visual While the exact mechanism of enamel resistance to acid during laser assessment and to enhance the specificity and sensitivity of diagnoses exposure is not clear, there is accumulating evidence to suggest that in general. There are few clinical studies due to the lack of reference the laser may introduce mechanical surface changes to the enamel [49,50] tests with most of the diagnostic tools. The exception is the QLF crystals . Other plausible mechanisms of action are discussed [46] camera, the most widely reported tool, which has been shown to by Karandish et al. in a recent review. Of note, several studies differentiate between caries and adjacent sound enamel accurately and have established that a combination of fluoride application and laser consistently [34]. Therefore, laser fluorescence provides a quantitative exposure significantly reduces carious lesion depth and increases [45,51-53] and non-invasive method for the diagnosis of dental caries, and enamel acid resistance . complements the conventional diagnostic methods. Laser application in management of dentin hypersensitivity Cavity preparation and caries prevention One of the key applications of lasers in restorative dentistry is in The traditional preparation of a cavity first involves application management of dentin hypersensitivity (DH). This condition is of localized anaesthetic to eliminate patient discomfort during the generally due to gingival recession, tooth wear and cracks as well procedure, followed by removal of carious tooth structures using as caries presence. Many lasers are capable of reducing DH and are rotary instruments. The drawback to this conventional method is the essentially divided into two groups: (1) the low-power level lasers, patient discomfort during the entire procedure, from the injection such as Helium-Neon (He-Ne) and Gallium-ALuminumArsenide phase to the drilling noise and vibration stage, combined with the (GaAlAs or diode) lasers; and (2) the middle output power or high- disadvantage of inevitably some healthy tooth structure removal level lasers such as CO2, Er-YAG and Er,Cr-YSGG and Nd-YAG [21,54,55] during the process. The advent of lasers circumvents both of these lasers . The low-power lasers such as the GaALA lasers Page 144 Dental.EliteCME.Com (780, 830 or 900 nm) have been shown to lower pain levels and recently, the diode lasers have also proven to be significantly effective inflammation by suppressed nerve transmission[54] , whereas irradiation in successful direct pulp capping with a long-term prognosis [70]. with higher level lasers such as Nd-YAG and CO2 lasers results in In a recent literature review on the “use of lasers for direct pulp thermal effects leading to complete obliteration of dentinal tubules [55] . capping”, Komabayashi et al. [65], summarizes and illustrates the A recent clinical study showed that a tooth brush with a built-in step-by-step clinical procedures for direct pulp capping with lasers. Low Level Laser was an effective alternative for treatment of DH Clinicians are encouraged to examine this extensive review before [56]. This results were corroborated in another study which found embarking on laser-assisted direct pulp capping for the first time. that application of LLL therapy (685 nm) significantly reduced DH Currently, laser application for direct pulp capping has an incredible compared to a desensitizing agent containing 8% arginine-calcium 90% success rate compared to the 60% rate for conventional methods. carbonate [57]. The use of He-Ne Lasers has a varied efficacy of DH This is a promising future alternative to the current methods and treatment ranging from 5-100%, and there is no consensus among should result in greater long-term success rates and increase the quality studies to draw any conclusions regarding its application [21,54]. On of patient care [66-71]. the other hand, GaALAs lasers for the treatment of DH is well [21] Other applications of lasers in restorative dentistry documented with at least a 50% rate of effectiveness . The use of lasers in etching the enamel has been shown to be The CO2 laser effectiveness in treatment of DH is reportedly in the comparable to the conventional acid-etching method [71,72]. More 59.8%-100% range, but no analgesic effect has been noted [21, 55]. recently, laser etching as an adjunct to the conventional acid-etch method Similarly, the Nd-YAG laser mechanism of DH involves narrowing has been shown to increase tooth-resin adhesion with a significantly of dentinal tubules [58] as well as analgesic effect [59] despite mixed higher bond strength compared to using acid-etch alone [74,75]. [55] reports on its treatment effects in the 5-100% range . In addition, the Another useful application of lasers is in removal or repair of defective combination of Nd-YAG with topical fluoride has been shown to be restorations. Conventional methods using high speed handpieces [60]. quite effective at reducing dentin hypersensitivity have the disadvantage of removing healthy tooth structure which The Er-YAG lasers have a range of treatment effectiveness in the range increases the risk of pulp exposure and undermines the mechanical of 38%-47% , and are shown to enhance the bond strength of common strength of the treated tooth. The advent of USPL technology has desensitizing agents [61]. Furthermore, a recent systematic review of largely overcome these limitations of traditional restoration removal, clinical research concluded that the ER-YAG efficacy in reducing DH and are reportedly effective at removing restorative materials with was markedly higher than GaALA lasers [62]. minimal thermal effects [43]. Further clinical research is required on the In summary, the treatment of DH is essentially directed at inhibiting thermal effects of laser exposure on pulp to confirm their long term pulpal nerve response or limiting displacement of fluid within the dentin effectiveness in restoration removal. tubules. LLLT lasers such as He-Ne (630 nm) or GaAlA lasers (diode) One of the most effective applications of lasers is in the management limit pain stimulus transmission by increasing nerve cell function [55]. of recurrent aphthous ulcers (RAUs), which commonly affect up to Both CO2 and Nd-YAG lasers (1064nm) are capable of stimulating 60% of the general population [76]. These lesions are often painful secondary dentin production and sealing open tubules. There is also oral ulcers that are a result of exposed nerve endings. They are strong evidence indicating that combination of laser therapy and debilitating to the patient without any definitive cure. The challenge in desensitizing agents is very effective in management of DH [63,64]. management of RAUs is to find a resolution in minimal time without [76] Use of lasers in direct pulp capping side effects or patient discomfort . Lasers such as Low-Level Laser Therapy (LLLT) have been suggested as alternative treatment One of the most successful application of lasers in restorative dentistry for management of these ulcers. Several reports have demonstrated is in direct pulp capping. For decades, conventional methods used significant alleviation of RAU symptoms upon application of LLLT. calcium hydroxide-based materials to treat exposed vital pulp once LLLT not only reduced pain but also completely resolved the ulcer in hemostasis and bacterial decontamination had been achieved [65]. less than half the time [77,78]. Since the pathogenesis of RAUs have been Lasers offer the unique opportunity of non-invasive, minimal treatment thought to involve the immune system, a plausible mechanism for of vital exposed pulps with both great success and a proven track the LLLT action is the reduction of inflammatory biomarkers such as record [65]. CO2 laser exposure in direct pulp capping, compared cytokines and interleukin expression [79]. to calcium hydroxide treatment, has been shown to have a clinical In summary, lasers are a more efficient and attractive alternative to success rate of 89% after a 12 month follow-up [66]. Remarkably, Nd- YAG laser treatment of vital pulps in permanent teeth showed a greater conventional dentistry and appears to be effective in a number of than 90% survival rate after 54 months compared to teeth treated with restorative treatments. However, the cost, together with the need for the conventional calcium hydroxide direct pulp capping method [67]. specialised training and ongoing maintenance issues, has hampered More recent clinical studies using Er-YAG lasers in human molar teeth their widespread use among dental professional. Nevertheless, the long achieved a clinical success rate of 93% after two years of pulpotomy term benefits for clinicians include predictable successful treatment treatment [68]. Similarly, clinical evaluation, eight months after Er,Cr- outcomes when correct parameters of laser application together with YSGG laser treatment of vital pulps, indicated positive vitality results sufficient training are applied. The benefits for patient include comfort, with no sign of inflammation in 89% of the cases studied[69] . More reduced pain, and optimal treatment results.

Laser uses in bleaching As discussed earlier, the fundamental components of laser light that absorption (and hence laser wavelength) required to achieve the define its interaction with the target tissue include: the wavelength desirable bleaching efficacy with minimal thermal effects. Of note, emitted by the laser; the density of power of the beam; and the the effect of additives in the bleaching gel and their effect on the operation of laser characteristics, such as a continuous versus pulsed absorption range of photons must be considered when using lasers. delivery system. When the energy emission is low, laser-tissue Bleaching gel can be heated using lasers or special electric heating interactions tend to be optical or a combination of optical effects, devices to enhance bleaching efficiency, as the chemical reaction [80]. When the pulse photochemical effects, or photo-biostimulation occurs faster at higher temperature [82]. In addition, peroxide penetrates energy is increased, photothermic interactions take over, leading dental structures much more efficiently with thermal expansion[80] . The to photoablation [81, 82], an undesirable effect in a bleaching gel [80]. Therefore, when bleaching, it is crucial to consider the level of light Dental.EliteCME.Com Page 145 drawback is that heat can cause enamel dehydration and irreversible remove with bleaching treatments. Near UV Laser heat has been shown pulpal damage [80,81]. to remove such extrinsic stains with added benefit of ablating the [83] The process of the photo-oxidation (molecules in a triplet excited state affected underlying enamel . Intrinsic stains are normally removed with photochemical or photo-thermal bleaching methods. Argon diode becoming oxidized) effect leads to direct photo-bleaching, which is and CO2 lasers have both been used in tooth bleaching. Furthermore, capable of penetrating tooth structure without absorption by water excellent results in bleaching has been shown using potassium– titanyl– or hydroxyapatite. Lasers are more efficient at photo-bleaching due phosphate (KTP) lasers (specific Nd-YAG lasers) that have a wavelength to their high density of light, and are effective at removing extrinsic of 532nm which is visible in the green spectrum. Further studies stains [80,82]. Dental enamel can be stained with coffee, tea, wine and/ or nicotine and these stains are traditionally removed using hydrogen confirmed the safety and validity of KTP lasers for tooth bleaching, peroxide bleaching. In some cases, these extrinsic stains can become and showed significantly more whitening results compared to diode [84]. Noteworthy, photodynamic office bleaching using KTP laser embedded in the outer layer of the enamel which is then difficult to lasers produced improvement in tetracycline discoloration [85].

Laser uses in pediatric dentistry The application of lasers in pediatric dentistry has been by far the clinical studies to standardize use of erbium lasers for hard tissue most active and widest clinical use to date. Lasers offer an attractive ablation without thermal side effects. The reduced vibration and noise alternative to conventional methods as a minimally invasion and the negligible need for local anaesthesia during cavity preparation technology for dental treatment in children. Not only are lasers well- has been reported with successful applications of Er-YAG lasers [95,96]. accepted by children and parents alike, but studies have also indicated In particular, research has demonstrated effective anaesthesia with enhanced cooperation of children during more arduous treatments success rates of 50-75% using pulsed Nd-YAG (660nm) lasers during such as pulp and surgical treatments [86,87]. The most common cavity preparation of primary molar teeth [97]. LLLT is also effective at application of lasers in pediatric dentistry are for caries detection and reducing pain and swelling during eruption of primary or permanent prevention, tooth structure preparation for sealants or restorations, and teeth as well as in instances of soft tissue trauma [98]. [87] pulpotomies as well as numerous soft tissue indications . Pulpotomies are very common treatment procedures in pediatric The American Academy of Pediatric Dentistry (AAPD) has set dentistry. The results of CO2 laser application for vital pulp therapy protocols for the dental specialist on the judicious use of lasers in have shown a 98.1% clinical success rate of treatment after a two pediatric dentistry [88]: year follow-up [99]. Similarly, a recent study using diode lasers for ●● “Recognizes the use of lasers as an alternative and complementary pulpotomy treatment showed a 100% clinical success rate after a 12 method of providing soft and hard tissue dental procedures for infants, month follow up [100]. children, adolescents, and persons with special health care needs. Soft tissue application of lasers in pediatric dentistry include ●● Advocates the dental professional receive additional didactic and gingevectomies, removal of fibromas, gingival hyperplasias, experiential education and training on the use of lasers before mucoceles and aphthous ulcer treatments [87]. The main lasers for soft applying this technology on pediatric dental patients. tissue surgery have been the argon, CO2, and diode lasers, and Nd- ●● Encourages dental professionals to research, implement, and utilize YAG laser systems, especially for coagulations, and decontamination the appropriate laser specific and optimal for the indicated procedure. of the soft tissues [90]. Specific Er-YAG lasers with shorter pulse lengths ●● Endorses use of protective eyewear specific for laser wavelengths modified for soft tissue surgery have also been utilized. Furthermore, during treatment for the dental team, patient, and observers.” lasers can be used to treat traumatic injuries to dental tissues with For diagnosis of caries, the most commonly used laser in pediatric ease, with minimal local anaesthetics and discomfort. Laser Doppler dentistry is the DIAGNOdent laser (655 nm). This laser is effective Flowmetry (LDF) is a reliable and accurate tool used in the assessment for detection of occlusal caries in both deciduous and permanent teeth of pulp vitality and monitoring mobility of traumatized teeth for the [87,89,90]. As described before, the degree of demineralization correlates long term [33]. Also, ER-YAG and Er,Cr-YSGG lasers can be used to with the emitted fluorescence and is quantified as the amount of seal dentinal tubules in traumatized teeth, leading to reduced dentin decay present. The drawback is the lack of efficacy in detection of hypersensitivity [98]. Other applications of lasers for traumatized tissues early enamel lesions; DIAGNOdent is more efficient at diagnosis of include localized application of lasers for facial swelling, soft tissue dentin occlusal caries. Argon lasers (488nm) address this shortcoming trauma, and wounds to reduce associated discomfort and pain [9]. and have been successfully used as diagnostic tool in occlusal and Laser use in pediatric dentistry is on the cusp of becoming the Gold interproximal caries detection; however, they are more efficient in Standard with ever increasing new applications, and refinement of [91]. detecting demineralization in primary rather than permanent teeth the existing ones to address conventional disease with modern non- In addition, Argon lasers are a fantastic adjunct diagnostic tool during invasive technology. Therefore, it is vital for the dental practitioners routine examinations to diagnose caries underneath fissure sealants[92] . and their dental teams to continuously familiarize and educate There is some evidence for the application of argon lasers in enamel themselves on the accumulating clinical evidence and research protection against caries. Especially when combined with topical on safety issues, effectiveness, multiple applications, and more application of fluoride, it has been shown to remarkably decrease the importantly, the laser parameters used for specific dental applications depth of carious lesions [44,93]. Another possible use of a laser system to deliver optimal patient care. is for enameloplasty just before fissure sealant is applied; enamel becomes more acid resistant and bonding is enhanced as the laser complements the use of the acid-etch technique [89]. In pediatric dentistry, accumulating evidence on erbium lasers (Er- YAG and Er,Cr-YSGG) has demonstrated the efficacy of hard tissue ablation with minimal thermal effects [17,89,94]. This is in contrast to some of the research on erbium laser applications for adult teeth. This disparity could be either due to larger clinical samples on primary teeth, or possibly due to laser parameters more carefully set to reduce pulp effects in children. In either case, there is a great need for more

Page 146 Dental.EliteCME.Com Table 3. Laser applications in pediatric dentistry Benefits Limitations Hemostasis achieved during soft tissue surgery. Costly in terms of outlay, and the time to plan and implement laser system in dental office. Selective laser-interaction with infected tissue. More than one laser may be needed for different soft and hard tissue applications requiring specific wavelengths. Enhanced wound healing with reduced need for analgesics. Strict adherence to infection control by all dental team involved is paramount to avoid contaminated aerosols. Bacterial decontamination and disinfection of the localized area. Safety protocols must be followed and individuals involved in the laser vicinity must wear laser specific eye protection. Complementary tool to visual diagnosis for caries detection. Limited diagnostic tool to unrestored surfaces due to fluorescence of the restorative material. Less post-operative discomfort & scarring following soft tissue surgery.

Laser use in periodontics Lasers have been advocated and increasingly used as an adjunct to stimulates acceleration in cellular duplication process without any conventional scale and root planning to overcome limitations with structural or functional changes of the target tissues. periodontal therapies such as non-accessible pockets and delayed Periodontal healing healing following non-surgical periodontal therapy (NSPT). The main Several lines of evidence have demonstrated effective application of concern with lasers is that there is no accepted standardized protocol lasers in regeneration and healing of periodontal tissues [110,111]. The for their use in dental practice, potentiating the risk for adverse events emerging evidence on laser applications in non-surgical periodontal affecting the hard tissue and patient compared to other traditional therapy suggests the use of lasers as adjuncts to conventional modalities. In addition, the wavelength of each laser setting is different mechanical treatments. Recent clinical studies using different and exerts a different effect on the soft and hard tissues, leading to wavelengths confirm that combination laser-mediated therapy is difficulties in comparing lasers and therefore achieving repeatable the most effective approach for optimal treatment outcomes [112-114]. results among studies. Overall, there are very few randomized clinical The combined use of SRP and diode laser therapy has been shown trials and a statistically low number of sample sizes published. A recent to produce the best results in reducing clinical probing depths and systemic review and meta-analysis on NSPT concluded that sufficient attachment loss than laser application alone [112,115]. Similarly, SRP, in evidence only exists for the use of PDT diode lasers as beneficial combination with an Er-YAG laser, treated sites showed significant [101]. However, lasers continue to be beneficial for adjunctive NSPT improvement in reduction of probing depth and attachment level [114]. and are successfully used in other areas of periodontal therapy. Here More recent studies have demonstrated comparable results of SRP in several types of lasers used in periodontal disease treatment with the combination with KTP laser (modified Nd-YAG) therapy supported supportive evidence will be discussed. improvements in all periodontal clinical parameters [116-118]. The KTP The main lasers with periodontal clinical applications include the CO2, laser has been previously shown to be safe to use on root surfaces with diode, and Er-YAG and Er,Cr-YSGG as well as Nd-YAG lasers [102]. minimal thermal effect on vital pulp or periodontal ligament [119]. The applications include: biostimulation; microbial decontamination Soft tissue periodontal laser application of roots and implants; soft tissue surgery; and bone (osseous) surgery One of the many benefits of lasers in periodontal therapy is their [102]. The mechanism of lasers, as mentioned before, are governed application in soft tissue surgery. The very first laser reported to by penetration depth into the target tissue, absorption characteristics have surgical application was the Nd-YAG laser. It was found to including wavelength, and target tissue characteristics. Both CO2 and efficiently control gingival bleeding and bacteraemia as well as erbium families have surface penetration, while the diode and Nd- reduce periodontal pockets [120]. In addition, the Nd-YAG was shown YAG lasers penetrate the target tissue deeply, up to 2-3 millimetres, to be efficient at removal of epithelium pocket linings[121] , which is and suit procedures that require coagulation. In addition, the diode and effective in reduction of probing depths and gingival recession [122]. Nd-YAG lasers are desirable for removal of gingival pigmentation due Both diode and Er-YAG lasers have also demonstrated positive effects to their absorption by the tissue. Owing to their high absorption by in subgingival curettage with significantly improved periodontal water and hydroxyapatite, the erbium family lasers are more ideal for parameters compared to manual instrumentation [123]. efficient bone removal than other lasers[102] . Laser application in bacterial reduction & root surface conditioning The benefits of lasers in periodontal treatment have been shown in Laser applications in periodontal pocket and root surface their control of microbial infection, bacterial reduction [102], efficient decontamination are the most promising adjunct for periodontal removal of subgingival calculus [104], and improvement of periodontal conventional therapy due to their efficient bactericidal effect [9]. regeneration in human with minimal damage to the surrounding tissues Originally, the Nd-YAG laser was found to reduce periodontal [104]. Accumulating evidence supports the effective use of laser therapy pathogens, and later diode laser (980 nm) applications, adjunct in conjunction with traditional treatment modalities to reduce active to ultrasonic scaling, showed a remarkably low prevalence periodontal pathogens, rather than the use of SRP alone [104-106]. This of bacteraemia [124], suggesting a promising application in combination therapy efficacy is mainly due to the complete removal immunocompromised patients [102]. Furthermore, Er-YAG lasers (2940 of the infected sulcular epithelium resulting in improved connective nm) together with diode laser irradiation are proven effective in the [107]. A recent study further corroborated the tissue attachment removal of subgingival calculus without the risk of thermal damage adjunctive use of lasers by demonstrating significant improvement in [125,126] [108] to the vital tooth . Similar studies corroborated these findings by periodontal disease and treating pocket depths of 4-6 mm . using diode lasers to reduce periodontal pathogens in pockets without Laser therapy has been also shown to accelerate the periodontal the need for antibiotic therapy [112]. [109] healing process and attachment . The bio-stimulation effect of laser The application of CO2 lasers in decontamination of root surfaces has therapy has been clearly demonstrated in recent studies. Laser therapy been demonstrated by several clinical reports [127,102], provided that the

Dental.EliteCME.Com Page 147 power setting and parameters stay within a safety range to prevent root laser root conditioning with coronal flap advancement resulted in long- damage [128]. A recently published report found that combined CO2 term tissue stability after 15 years [127].

Laser use in orthodontic treatment Laser use in orthodontics, similar to other fields of dentistry, has seen eliminates the use of hydrofluoric acid as well as the need to repolish rapid growth in diagnosis, imaging, bonding and surgical applications. the porcelain at the bracket de-bonding stage. The key diagnostic applications include caries detection, digital Lasers have the great advantage of decreasing operation time during models, and laser scanning. Laser etching, bonding to porcelain and the de-bonding stage and abolishing all the issues concerned with adhesive curing are other applications. The laser effect extends to conventional ceramic de-bonding methods. The plausible mechanism of bio-modulations such as tooth movement, growth modification, pain lasers during de-bonding is thermal mediated: initial laser heat softens the control, and retention or relapse [129]. bonding agent, which results in the bracket sliding off the enamel [131]. Laser application in diagnosis Laser application in soft tissue surgery In orthodontics, three-dimensional laser scanning has multiple The other useful applications of lasers in orthodontics are in soft applications in diagnosis, growth changes assessment, and in tissue surgery, such as gingival recontouring, frenectomy, fibrotomy, [129]. The advantages of this clinical results after orthognathic surgery exposure of unerupted teeth, ablation of inflamed tissue and gingival technology include auto-calibration and correction, ease of use, and hyperplasia [129,133-135]. The main lasers used for soft tissue application lower costs. Applications include the ability to monitor facial soft are the Nd-YAG lasers [131]. The thermal ablation of tissue via the tissue changes that occur with growth and following orthognathic absorption, melting, and vaporization process is thought to be the surgery, and functional movements of facial muscles [129]. Diagnostic mechanism by which lasers exert effects. Indeed, laser soft tissue dental casts are prepared using 3-D computer-aided design (CAD) ablation is more advantageous than use of a scalpel in terms of systems once the dental model is generated from 3-D graphic accuracy and minimal tissue damage, control of bleeding, ability to information using laser scanning. Digital models not only abolish sterilize the wound area. Lasers reduce the operative time, and provide the need for storage space, but also allow reliable, reproducible, less post-operative discomfort as well as minimal swelling [135-137]. and efficient assessment of arch form, tooth size and tooth-arch discrepancies [130]. Laser scanning is also beneficial for studies of Other applications of laser in orthodontic practice craniofacial abnormalities, assessment of cleft lip and palate, and The most frequently used laser therapy in orthodontics is Low-Level nasal reconstruction procedures. Data from a 3-D laser scanner can Laser Therapy (LLLT), especially for pain relief. The plausible be transformed to produce orthodontic appliances, splints, electronic mechanism of the LLLT analgesic effect is its inhibitory action on pain models, and surgical simulation models. fibres, which decreases action potentials and suppresses neurogenic inflammation[15] . Several reports have indicated that GaAlAs diode [138], Laser Doppler Flowmetry (LDF), aside from its application in Nd-YAG and CO2 laser therapy also exert analgesic effects, decreasing restorative dentistry, is a very useful non-invasive diagnostic tool in pain associated with orthodontic movement [139,140]. Therefore, analgesia- assessment of tooth vitality before and during orthodontic treatment. inducing lasers are beneficial in orthodontic treatment as they are non- In addition, LDF can accurately monitor pulp responses to orthodontic invasive without causing any tissue-related side effects. forces generated by rapid maxillary expansion [131]. Other diagnostic technology includes DIAGNOdent and QFL lasers supporting LLLT has also been shown to stimulate bone regeneration as well as conventional methods in early detection of incipient caries lesions mandible growth, possibly via stimulation of cellular proliferation around orthodontic brackets. and differentiation [15,141]. Similarly, GaAlAs diode lasers have been shown to accelerate bone regeneration during application of a rapid Lasers are great tools for etching to possibly improve resin bonding palatal expansion appliance [142]. Similarly, the combination of retainer and also reduce caries incidence by producing enamel surface that is and LLL therapy has been shown to reduce the retention period due to acid resistant. The mechanism of action is thought to be due to the heat accelerating periodontal tissue remodelling. effect of the laser resulting in an enamel roughness comparable to the acid-etching method [132]. There is no need for water and air application LLLT has also been found to influence rate of tooth movement during laser etching, and more importantly, there is remineralization of during orthodontic treatment phase in animal studies [15]. This could the enamel surface reducing acid attack [129]. possibly be due to the increase of osteoclast formation, resulting in tooth movement, elevation of receptor activator of a nuclear factor Laser application in bonding brackets kappa-B ligand in periodontal ligament, and possibly, stimulation Argon lasers have been shown to not only reduce the frequency of osteogenesis and bone formation on the traction side [129]. The of bracket de-bonding, but also to induce orthodontic resin implications of these research findings are significant for orthodontic polymerization four times faster than conventional curing lights treatment, and it is essential to be aware of optimizing the laser while maintaining a comparable bond strength. While a drawback parameters to achieve positive treatment outcome. However, studies with this laser as a curing light has been cost, this issue has been on the use of laser in tooth movement are controversial, and more largely overcome with the advent of diode-pumped solid-state lasers [131] research is required to determine the optimal laser parameters required . Laser etching is also advantageous for bonding to porcelain as it to achieve tooth movement [15].

Laser applications in prosthodontics The advent of lasers in prosthodontic field has been very encouraging, The greatest impact of laser application in prosthodontics has been leading to increasing laser-integration in specialist clinics. These on aesthetic considerations and functional stability [143]. In fixed technical applications are replacing most of the traditional treatment prosthodontics, soft laser applications such as cosmetic crown procedures [143]. Lasers have numerous applications, especially as lengthening, management of gingival overgrowth and retraction during adjunctive therapy to conventional methods, in prosthodontics with the crown placement and impression taking, are very frequent. In patients more common uses including crown lengthening, soft tissue ablation, with “gummy smile”, erbium lasers have allowed apical lifting of both troughing and veneer removal [144]. While initially, soft tissue lasers soft and hard tissue to achieve an improved and favourable aesthetic were used, with the development of a wider range of wavelengths, result without the risk of damage to adjacent tissues or thermal effects hard tissue lasers took centre stage and are used in tooth preparation [143]. Lasers used in crown lengthening are the CO2 and erbium lasers and bone ablation, among other applications. capable of removing bone without damaging the adjacent cementum Page 148 Dental.EliteCME.Com [143]. Argon lasers are excellent for retraction and hemostasis of beam passing through the porcelain and de-bonding it at the silane- gingival tissue, allowing for accurate impression taking. resin interface [144]. Lasers are also very effective at the removal of gingival overgrowth The applications of hard and soft tissue lasers include ovate pontic prior to re-cementation of a fixed prosthesis. In the aesthetic zone, lasers site preparation, and crown fractures at the gingival margin level. The have the advantage of shaping soft tissue to fabricate ovate pontic for design of pontic is important as part of the final fixed prosthodontic aesthetic improvement. Lasers result in efficient, predictable results with restoration and is particularly critical in the anterior region. To create minimal discomfort and bleeding, which reduces operative time. a natural look, ovate pontic design is sculpted as a depression in the soft tissue using lasers [143]. In the event that the biological width is Gingival laser troughing is more efficient, and allows for better violated, lasers with a hard tissue setting can remove minimal bone visibility of the margins than using retraction cords prior to impression to allow for the 2mm gingiva between the bone and pontic [143]. The taking. Diode lasers have been shown to be effective in tissue application of Er-YAG lasers in crown fractures have been shown to retraction instead of the cord, and show great results in accurate [143] safely ablate bone and expose the fractured edge when crown fracture accessible margins for impression taking . These lasers are also [145] fantastic at recontouring gingiva and removing minor inflamed tissues extends below the bone margin . without any thermal damage to the underlying tissues. There are times In addition to the above applications, lasers are capable of increasing when porcelain veneers are required to be replaced and erbium lasers surface roughness to improve bond strength of the fixed restoration are able to predictably assist in efficient and safe removal of veneers and luting cement. Recently, a study showed the use of CO2 and Er- with minimal harm to the underlying tooth structures [144]. Application YAG lasers enhanced bond strength between the zirconia crown and of lasers in clearing tooth preparation margins by retraction of gingival cement [146]. Of note, laser scanning of casts is becoming increasingly tissue is highly desirable to produce distinct margins for impression, popular among specialists for the creation and design of indirect management of gingival overgrowth during temporization, and final restorations as it is efficient, cost effective in the long term, and more prosthetic restoration placement. comfortable for the patient. Hard tissue lasers have wide applications in prosthodontics such The multiple advantages of hard and soft tissue combination treatment as tooth preparation for crowns and veneers, caries and defective with lasers have facilitated extensive applications, and increased restoration removal, as well as the removal of failed or defective the interest of dental practitioners in integrating the technology into veneers, crowns or bridges [143]. Lasers such as Er-YAG and Er,Cr- dental offices. Not only do patients benefit from less chair time and YSGG have the advantage of removing veneers without any damage comfortable treatment without the need for anaesthetics or sutures, but to the underlying tooth structure. The mechanism of laser involves the the dentist can deliver a predictable and successful outcome by using optimal laser parameters for the specific treatment application.

Laser application in dental implantology Soft tissue lasers such as CO2 and Argons have been shown to been shown to encourage in hard tissue ablation, assist in coagulation be beneficial in soft-tissue peri-implant recontouring, enhancing as well as their soft tissue applications [157]. hemostasis, and decreasing post-operative discomfort and swelling as During implant placement, lasers have been indicated mainly in [147]. Likewise, dental implantology well as increasing wound healing precise flap incision, creation of osteotomy, and guided tissue benefits from hard tissue laser technologies such as Er-YAG and Er,Cr- regeneration. The procedure for predictable bone generation for a YSGG lasers in the early osseointegration phase and in treatment of deficient area follows four principles: wound closure to promote peri-implantitis [102]. Therefore, there are positive indications for both uneventful healing; vascularization of the healing area; space soft and hard tissue laser application in almost all phases of implant creation for bone; and wound stability for blood clot formation [158]. placement, including the post-implant healing stage which will be Research has shown that lasers such as Er-YAG irradiation appear to [102.147-149]. described below stimulate secretion of platelet-derived growth factors which promote Implant dentistry and lasers bone repair and thus enhances healing of the osteotomy sites [159]. Laser applications in implant dentistry includes: prior to and during all There are inconsistent studies on benefits of CO2 (9600nm) lasers stages of implant placement; treatment of peri-implantitis; removal of peri- in bone ablation. While they has been found to be safe when used implant soft tissue; and disinfection of failed implants [147-150]. Both CO2 for decontamination of implant sites [160], previous studies report a and Er,Cr-YSGG lasers have demonstrated effective decontamination risk of thermal damage associated with use of CO2 lasers during of the implant surface and re-osseointegration in pre-clinical studies [151]. irradiation, causing carbonization of the adjacent bone [161]. Therefore, Of particular interest is the CO2 laser application on the implant surface erbium lasers with their water-cooling spray offer a safe and precise which was shown recently to reduce the risk of overheating, a concern bone ablation tool without thermal damage during the initial implant with implant surface melting when using lasers [152]. placement [162]. Nevertheless, during the osteotomy process, just like During the implant placement process, lasers have been shown to be using handpieces, clinicians must exercise caution to avoid thermal [147]. beneficial in decontamination of the site and flap incision, removal damage to the adjacent vascular structures when using lasers of any granulation tissues, and levelling the bone for restoration Once the fixture is in place, bone recontouring may be required to placement [147-150]. Erbium lasers are capable of bacterial reduction level the bone around the implant and allow for accurate impression in the implant site [153], removal of granulation tissue as well as as well as proper seating of the healing abutment, especially when the disinfection of the extraction site without damaging the surrounding immediate implant placement technique is used. Here, the application bone [147]. Lasers, in general, are excellent at hemostasis compared of erbium lasers is ideal, as studies have found erbium lasers to be safe to scalpel blades and are able to reduce discomfort and swelling and posing no risk to the implant surface or causing thermal damage post-surgery. Traditionally, electrosurgical units are used for implant to the adjacent bone area [163]. Studies have shown erbium lasers to be processes, however these units usually induce heat and have thermal precise in bone ablation for accurate placement of healing abutment. damage compared [154] to lasers such as erbium which has water- This prevents later discomfort and swelling associated with placement cooling mechanisms and thereby reduces thermal damaging effect to of final implant restoration[147,148, 163]. In addition, erbium lasers can surrounding bone [155]. In addition, erbium lasers ablate bone and have be applied to minor soft tissue recontourings adjacent to the healing been shown to produce osteotomies with post-operative stability of abutments. The clinical application of erbium lasers for both soft and implants at the two-month mark [156]. Diode laser applications have

Dental.EliteCME.Com Page 149 hard tissue ablations are described and demonstrated in detail by van It has been suggested to approach early peri-implantitis cases (probing As (2015) [148,149]. depths of <5mm and bone loss of <2mm) using non-surgical treatment [180] The renewed interest in diode lasers in more recent years has resulted modalities . The most challenging parts of peri-implantitis treatment are the decontamination of the implant surface, soft tissue ablation, in electrosurgical units being replaced in dental practices owing and long-term maintenance of healthy tissues [181]. While mechanical to diode laser reliability, convenience, affordability and ease of decontamination methods combined with antibiotic therapy have application with dental implants [147,148]. Diode lasers are very safe to use around metals and implants without causing damage to the been used, the side effects of surface damage to the implant and [182,183]. Lasers are reportedly structure of the metal. Laser application in other areas of implant antibiotic resistance have been reported very effective as an adjunct in the decontamination of implants. dentistry include implant site preparation, ablation of excessive tissue The most frequently applied lasers are the CO2, diode and erbium during implant placement, and removal of overlay hard or soft tissue lasers simply because all have antibacterial effects, but also assist in during the uncovering implant stage [147-149]. removal of calculus as well as improving hemostasis [147]. Studies have Another useful laser with an emergent application profile in most areas of shown the combination of traditional modalities with LLL therapy dental implantology is the Low Level Laser with wavelengths in the 655- produces predictable results in dental implant decontamination. Recent 810 nm range [164,165]. These lasers are used for pain reduction and wound studies have indicated that the effect of diode lasers (810 nm) at low healing and exert their therapeutic effects at very low powers without any power (LLLT) combined with conventional therapies is effective at damage to the tissues [166,167]. Several studies have demonstrated that LLL decontaminating implant surfaces as well as in possible stimulation of therapy irradiation resulted in stimulation of osseointegration, increased collagen production [184,185]. Similarly, the CO2 and erbium lasers have bone mineralization, and healing in the early stages of implant placement been shown to be effective at elimination of bacteria from implant as well as improvement in nerve regeneration [168-170]. surfaces provided appropriate laser parameters are used [186]. Lasers also have applications in the implant uncovering stage. While There are cases where the bone loss around an implant is moderate- studies have shown that diode lasers at low settings allow safe severe and a non-surgical option is not feasible. In such instances, uncovering of implant fixtures [171], it has been suggested to use water whether to replace or save the existing implant should be carefully spray intermittently to manage potential thermal effect on the surgical considered. Forum et al. developed a regenerative surgical approach site [157]. Furthermore, diode lasers reduce the number of appointments for treatment of peri-implantitis with encouraging results of no implant due to them decreasing both the need for sutures and the post-operative loss after seven years of follow-up [187]. More recently, studies have healing period. demonstrated that the application of erbium lasers to effectively remove Soft tissue management during the healing phase of implant therapy is the contaminated layer with an optimal laser setting has potential [188,189] possible using diode, CO2 and erbium lasers. Studies have suggested application in surgical approach to peri-implantitis . More clinical Er,Cr-YSGG to be very effective in soft tissue surgery as it showed studies, especially long-term with multiple sessions of laser therapy, are minimal thermal damage compared to diode or CO2 lasers [172,173]. required to establish the application and effectiveness of these lasers [190] Indeed, soft tissue recontouring can save time and effort in the difficult over conventional therapy in peri-implantitis treatment . management of the final restoration process. Despite limited published randomized clinical studies on lasers in dental Peri-implantitis and lasers implantology, there are emerging studies that describe widespread use Despite the great long-term success of implant therapy in replacement in bacterial decontamination of extracted sockets for immediate implant of missing teeth in dentistry [174-176], there are increasing reports of placement, osseous remodelling and osseointegration, surgical flap raise, [147] implant failure either due to inflammation of the soft tissue (mucositis) and uncovering submerged implants to preserve crestal bone . The or the bone (peri-implantitis). These conditions lead to chronic pain, successful laser application in any dental procedure is dependent on infection, bone loss and eventual implant failure if untreated [174, 177,178]. adequate training and education on laser use, especially the application A recent systematic review on peri-implant diseases found a significant of correct parameters specific for the particular procedure as well as [102, 147] incidence of both mucositis and peri-implantitis [178], potentially due safety considerations . to systemic disease (diabetes), smoking, improper implant placement, and/or poor oral hygiene [179].

Laser application in oral surgery The clinical application of lasers in oral surgery includes treatment pain. The advantages of laser therapy include less treatment of oral mucosal lesions, oral cancers, and oral benign lesions. In oral time, less costs compared to radio- or chemo- radiotherapy, and surgery, the most commonly used lasers are the CO2, erbium family, significantly less toxicity[195] . diode and Nd-YAG. There have also been some applications of the Application of lasers in removal of oral benign lesions includes the LLLs in disinfection and wound healing reported [191]. Since most removal of mucoceles which are benign lesions of the minor salivary of the applications are very specialized and out of the scope of this glands that most commonly occur in children on the lower lip. course, only a brief outline of the broad oral surgery applications will Application of erbium and CO2 lasers is demonstrated to effectively be discussed here for the general dental practitioner. remove mucoceles with rapid wound healing and no scaring [86,196]. The most common oral mucosal lesions are oral leucoplakia and lichen Other benign lesions are ranuals, which are traumatic sublingual planus. Treatment of oral leucoplakia, a pre-malignant oral mucosa mucus lesions; they have been reported to be removed by CO2 laser lesion, was demonstrated effectively and safely using CO2 laser therapy treatment safely with minimal recurrence [197]. [192,193] and photodynamic therapy in randomized clinical studies . Oral Laser application in TMD management lichen planus treatment with a diode laser was shown to be effective The most common cause of orofacial pain of non-dental origin is for relief of associated symptoms. In addition, the efficacy of ER-YAG from the Temporomandibular Disorders (TMD) which occur at a lasers in reducing symptoms of oral lichen planus has been reported [194]. prevalence of more than 85% of the population [198]. This dysfunction In oral cancer treatment, clinical studies have reported use of: Nd- is a collection of clinical symptoms involving the temporomandibular YAG lasers for management of lip carcinoma lesions; a specific CO2 joint and its associated structures [198]. It is a debilitating condition (trans-oral) laser for early glottis cancer treatment and soft palate affecting sleep quality, mood and cognition function [199]. The treatment tumours; and diode lasers for healing and reduction in post-operative usually is multidisciplinary and includes a physiotherapist in addition

Page 150 Dental.EliteCME.Com to a general dental practitioner. Traditional modalities used to release of many signalling pathways involved in analgesia, nerve address treatment of TMD frequently involve medication, adjunctive excitability and increased blood circulation [15, 198,199]. Currently, there occlusal splint, physiotherapy, electrotherapy, or manual therapy in is no consensus on the benefits of LLL as therapy for TMD and the combination or individually. The availability of Low Level Laser literature is saturated with conflicting reports that are not consistent Therapy (LLLT) expanded the horizon of treatment options. LLLT has in terms of parameters of the laser application. Further research and been shown to not only reduce pain, but also reduce any associated standardization of treatment parameters is required to clarify the inflammation and swelling[198] . Its mechanism of action is possibly a emerging benefits of LLLT for TMD treatment. result of light penetration in target tissue leading to stimulation and

Laser safety considerations The safety consideration of lasers is an important aspect of providing ●● Class IIIb: Medium-powered lasers. These are dangerous when quality treatment in a safe and efficient manner. It is crucial to be viewed directly regardless of the length of time. aware of the correct operation of the laser equipment and provisions ●● Class IV: High-powered lasers that can cause damage to eyes and must made for the protection of the dental team, patient and operator. skin. Even a reflected or radiated beam is harmful. Appropriate The standards set out by American National Standards Institute and safety measures required. Occupational Safety and Health Administration classifies lasers In summary, when visible or infrared radiation at wavelengths 400- according to their associated risks into four categories [200]: 1400nm are used, directly looking at the laser risks damage to the ●● Class I: Low-powered lasers. These are safe to view. eyes. Therefore, all persons involved in the treatment room must wear ●● Class IIa: Low-powered visible lasers. These do not cause damage the safety goggles normally supplied by the manufacturer. At all times, unless direct eye contact is made with the beam for >1000 seconds. safety protocols associated with the particular laser machine must be ●● Class II: Low-powered visible lasers. These are harmful when followed. Protection of the skin is also required during laser operation viewed directly for <0.25 seconds. at wavelength <400nm to avoid risk of tissue burning. ●● Class IIIa: Medium-powered lasers. These are harmful when viewed directly for >0.25 seconds.

Integration of lasers in the dental practice The integration of lasers just like any other new technology and completed in-house. This is to the benefit of the dental office requires fundamental planning for training, financial outlay, and and the patient in terms of costs, time and efficiency. Suspicious ongoing costs. This planning must also include marketing, including lesions can be biopsied and send for pathology. Tissue contouring introduction of the concept to the existing clients of the practice. The during orthodontic procedure can occur, common fibromas can be investment of time in planning meticulously to address all aspects removed, and operculums over wisdom teeth can be removed for of laser addition to a dental office will assist in achieving a smooth immediate relief. transitional phase in the process of integration. ●● Efficiency in treatment procedures: Most lasers allow for excellent In choosing a laser, the clinical applications that are more commonly bleeding control and reduced use of anaesthetics, saving time to employed in the dental office should be considered, in addition to perform multiple treatment procedures. Restoration of few teeth in space. The indications for investing in a laser system include: different quadrants that have cervical caries and require gingival ●● New treatments offered: Addition of a laser may provide new recontouring can be completed efficiently and ultimately provide opportunities for treatments to the patients which were not available quality patient care. previously. These include crown lengthening, gingevectomy or The success of the integration process is largely dependent on the uncovering tooth for orthodontic bracket bonding. support and active involvement of the dental office team, from ●● Simplified and efficient treatments: Subgingival retraction for inception to implementation. The clinician is responsible for ensuring implant or crown restorations with localised hemostasis resulting training opportunities are made available to all team members in an accurate impression in a timely and cost effective (i.e., and involving the staff in experiencing laser effects first hand. less materials used) manner. Manageable soft tissue surgery Notably, most patients are not only grateful for additional treatment with successful hemostasis and recontouring margins around opportunities that add to their quality of care, but will also increase decayed lesions. Disinfection of aphthous ulcers to reduce patient internal referrals to other patients who seek modern, cutting edge, and discomfort and save treatment time. literally pain-free treatment. ●● External referrals reduced: Depending on the level of clinician experience and training, most procedures referred out can be

Conclusion The dental field is rapidly evolving and the advent of lasers offers There is comprehensive planning involved in integrating lasers including more treatment options (Figure 2). Using lasers as an adjunct to ongoing training, educating the dental team, and marketing and financial specific procedures has not only imparted clinical benefits, but also planning. Ultimately the economics, quality of dentistry on offer, patient increased patient comfort and ease. More and more patients are comfort and financial rewards outweigh the initial time and costs spent technology-savvy, and use online tools to educate themselves, looking for the inclusion of lasers into a dental office. This course highlighted for dental options that are technically advanced and offer a pain-free the mechanism of laser actions, different types and typical application of and comfortable dental experience. Dental practices can effectively lasers in dentistry with a focus on optimal laser parameters for positive integrate lasers as part of their routine dental procedures and offer treatment benefits as well as safety requirements and integration into lasers as an alternative or adjunct treatment for their patients. The dental offices. It also provided a comprehensive update on evidence- most important part of the successful integration and practical use based laser applications in dentistry. The benefits of therapeutic effects is the understanding of the essentials of laser application and safety of lasers are astounding and safe laser implementation should be requirements by clinicians and their dental teams. considered in every dental office.

Dental.EliteCME.Com Page 151 Restorative Periodontics Orthodontics Pediatrics Prosthodontic Oral Surgery - Caries & - Tooth - Caries - Crown - Soft tissue diagnosis & Implantology movement removal & lengthening surgery removal - Eliminate - Bracket diagnosis - Gingivecto- - Apthus ulcer - Dentin periodontal bonding - Anesthesia my treatment hypersensi- pathogens -3D cast - Pulpotomies - Soft tissue - Lichen tivity - Remove models - Pain control surgery planus - Bleaching diseased - Pain relief - Enamel - Hard tissue removal teeth epithilum soft tissue ablation ablation - Direct pulp - Reduce surgery - Veneer cap pocket - Growth removal - Enamel depths modification etching - Soft tissue surgery - Treat peri- implantitis

DENTAL LASERS

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Page 154 Dental.EliteCME.Com Suggested reading list on dental lasers Laser safety Pediatric dentistry American National Standard for Safe Use of Lasers in Health Care 1. Prathima, G. S., Bhadrashetty, D., Babu, S. B. U., & Disha, P. Facilities https://www.lia.org/PDF/Z136_3_s.pdf (2015). Microdentistry with Lasers. Journal of International Oral Comprehensive overview of all lasers in dentistry Health: JIOH, 7(9), 134–137. Koci E, Almas A. Laser application in dentistry: an evidence-based 2. Nazemisalman B, Farsadeghi M, Sokhansanj M. Types of Lasers clinical decision-making update. Pak Oral Dent J. 2009;29(2):409-423. and Their Applications in Pediatric Dentistry. J Lasers Med Sci. 2015;6(3):96-101. Orthodontics 1. Milling Tania, S. D., Sathiasekar, C., Anison, J. J., & Samyukta Periodontics Reddy, B. V. (2015). The extended tentacles of laser - From Romanos, G. (2015). Current concepts in the use of lasers in diagnosis to treatment in orthodontics: An overview. Journal of periodontal and implant dentistry. Journal of Indian Society of Pharmacy & Bio allied Sciences, 7(Suppl 2), S387–S392. Periodontology, 19(5), 490–494. 2. Nalcaci R, Cokakoglu S. Lasers in orthodontics. Eur J Dent 2013; Ulcers 7:119-25 Vale FA, Moreira MS, de Almeida FC, Ramalho KM. (2015). Low- Oral surgery level laser therapy in the treatment of recurrent aphthous ulcers: a Asnaashari M, Zadsirjan S. Application of Laser in Oral Surgery. J systematic review. Scientific World Journal. ; 2015:150412. doi: Lasers Med Sci 2014;5(3):97-107 10.1155/2015/150412. Restorative dentistry TMD 1. Najeeb S, Khurshid Z, Zafar MS, Ajlal S. Applications of Light Shaffer, S. M., Brismée, J.-M., Sizer, P. S., & Courtney, C. A. (2014). Amplification by Stimulated Emission of Radiation (Lasers) for Temporomandibular disorders. Part 2: conservative management. The Restorative Dentistry. Med Princ Pract. (2015): 1-11. Journal of Manual & Manipulative Therapy, 22(1), 13–23. http://doi. 2. Tassery, H., Levallois, B., Terrer, E., Manton, D., Otsuki, M., org/10.1179/2042618613Y.0000000061 Koubi, S., Gugnani, N., Panayotov, I., Jacquot, B., Cuisinier, F. and Rechmann, P. (2013), Use of new minimum intervention dentistry technologies in caries management. Australian Dental Journal, 58: 40–59

Dental.EliteCME.Com Page 155 Updates on laser therapy in dentistry and integration in the dental office Final Examination Questions Select the best answer for each question and mark your answers on the online at Dental.EliteCME.com.

1. Lasers produce a source of energy as a coherent radiation of 7. ______was developed to measure the vitality of the pulp one wavelength in the infrared, visible, or ultraviolet part of the through vascular response. electromagnetic spectrum. a. Quantitative light-induced fluorescence lasers. a. True. b. Magnification. b. False. c. Laser Doppler Flowmetry (LDF). d. Spectra Caries Detection Aid System. 2. The optimal parameters of lasers depend on the target tissue, and involve only the wavelength, exposure time, and energy quantity. 8. ______have been shown to lower pain levels and inflammation a. True. by suppressed nerve transmission. b. False. a. High level lasers. b. Low-power lasers. 3. Due to their high hydroxyapatite and water absorbance properties, c. Pain relievers. ______are excellent to use for caries and hard tissue removal. d. Mid-power lasers. a. Diode lasers. b. LLLT lasers. 9. Strict adherence to ______by all dental team members c. Carbon dioxide lasers. in the vicinity of the laser is paramount to avoid contaminated d. Erbium lasers. aerosols. a. Rules. 4. ______lasers are used for soft tissue surgery, and to remove b. State guidelines. enamel caries as well as providing good homeostasis during c. Ethical codes. ablation. d. Infection control. a. Diode. b. LLLT. 10. Investing in a laser for the dental office will benefit the patient by c. Nd-YAG. reducing time to restore few teeth in different quadrant that have d. Erbium. cervical caries and require gingival recontouring. a. True. 5. Laser-tissue interaction is dependent on the wavelength and mode b. False. of laser emission only. a. True. b. False.

6. ______cannot interact with gold or porcelain material. a. Diode lasers. b. LLLT lasers. c. Erbium lasers. d. Nd-YAG lasers.

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