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Oral Surgery Pain Managment adren cort The gold standard test for primary adrenal failure is the: • blood glucose test • ACTH stimulation test • serum creatinine level • BUN test i copyright 6 2013-2014 - Dental Decks ORAL SURGERY & PAIN CONTROL adren cort A person who has been on suppressive doses of steroids will? Select all that apply. • take as long as a year to regain full adrenal cortical function • take as long as a month to regain full adrenal cortical function • may show signs of hyperpigmentation - does not require consultation with a physician prior to surgery 2 copyright © 2012-2013- Dental Decks ORAL SURGERY & PAIN CONTROL • ACTH stimulation test The ACTH stimulation test is performed to examine the response of the adrenal gland to an exogenously administered dose of ACTH. Normal patients have a doubling of the serum Cortisol level after a dose of ACTH. The serum Cortisol level should rise to >20 mg/dL if there is adequate adrenal function. An inadequate response suggests adrenal gland hypofunction. Note: Cosyntropin (Cortrosyn) is an ACTH analogue that stimulates the adrenal gland and its ACTH receptors. About 20 mg of hydrocortisone is secreted by the adrenal cortex daily. During stress, the cortex can increase the output to 200 mg daily. Remember: Patients taking steroids or people with disease of the adrenals will have de­ creased ability to produce more glucocorticoids (hydrocortisone) in times of stress (ex­ tractions). The reason for this is as follows: Secretion of glucocorticoids is stimulated by ACTH, a hormone produced in the anterior pituitary. The pituitary responds to stress by increasing ACTH output and, therefore, glu­ cocorticoid production increases. Arelative lack of glucocorticoids will also increase out­ put of ACTH. An overabundance of circulating systemic steroids will inhibit production of ACTH. Large doses of steroids repress ACTH production, which leads to atrophy of adrenal cortex. • take as long as a year to regain full adrenal cortical function • may show signs of hyperpigmentation The following guidelines may help determine if a patient's adrenal function is suppressed, however, if any doubt exists, consult the patient's physician before performing surgery. Some Guidelines: • People on small doses (5 mg prednisone/day) will have suppression when they have been on the regimen for a month. • People taking the equivalence of 100 mg cortisol/day (20-30 mg prednisone/day) will have ab­ normal cortical function in a week. • Short-term therapy (1-3 days) of even high-dose steroids will not alter adrenal cortical func­ tion. • A person who has been on suppressive doses of steroids will take as long as a year to regain full adrenal cortical function. Patients with adrenal insufficiency are hyperpigmented. This is most noticeable on the buccal and labial mucosa, although other areas such as the gingiva may be involved. The hyperpigmentation is a result of hypersecretion of ACTH, which can stimulate melanocytes to produce pigment. Patients with decreased adrenal gland hormone production experience weakness, weight loss, or­ thostatic hypotension, nausea, and vomiting. Patients with severe adrenal insufficiency cannot in­ crease steroid production in response to stress and in extreme situations may have cardiovascular collapse. It is important that an adrenally insufficient patient have adequate steroid replacement, since the stress of oral surgery can precipitate adrenal crisis. In adrenal crisis, an intravenous or intramuscular injection of hydrocortisone must be given im­ mediately. Supportive treatment of low blood pressure with intravenous fluids is usually neces­ sary. Hospitalization is required for adequate treatment and monitoring. adren cort Patients with glucocorticoid hypersecretion have: • ectopic ACTH Syndrome • MEN I • cushing syndrome • addison disease 3 copyright€>2013-20l4-Dental Decks ORAL SURGERY & PAIN CONTROL adren cort A 52-year-old woman requests removal of a painful mandibular second molar. She tells you that she has not rested for 2 days and nights because of the pain. Her medical history is unremarkable, except that she takes 20 mg of pred­ nisone daily for erythema multiforme. How do you treat this patient? • have patient discontinue the prednisone for 2 days prior to the extraction •give steroid supplementation and remove the tooth with local anesthesia and sedation • instruct the patient to take 3 grams of amoxicillin 1 hour prior to extraction • no special treatment is necessary prior to extraction 4 copyright © 2013-2014 - Dental Decks ORAL SURGERY & PAIN CONTROL • cushing syndrome Cushing syndrome is a hormonal disorder caused by prolonged exposure of the body's tis­ sues to high levels of the hormone Cortisol. This results in characteristic changes in body hiatus, including moon facies, truncal obesity, muscular wasting, and hirsutism. Some­ times called "hypercortisolism," it is relatively rare and most commonly affects adults aged 20 to 50. The female-to-male incidence ratio is approximately 5:1. Patients with Cushing syndrome are often hypertensive because of fluid retention. Long- term glucocorticoid excess can result in decreased collagen production, a tendency to bruise easily, poor wound healing, and osteoporosis. They are often at increased risk for infection. Laboratory studies may reveal increased blood glucose levels because of interference with carbohydrate metabolism, and examination of the peripheral blood smear may demon­ strate slight decrease in eosinophil and lymphocyte counts. Important: The patient's cardiovascular status must be evaluated and treated if neces­ sary prior to surgery. Note: The most common cause of Cushing syndrome is a tumor in the pituitary gland. • give steroid supplementation and remove the tooth with local anesthesia and sedation Important: The fear here is that the patient may not have sufficient adrenal cortex secretion (adrenal in­ sufficiency) to withstand the stress of an extraction without taking additional steroids. (This holds true for any patient who has been treated with steroid therapy). Patients with adrenal insufficiency, patients on daily steroid therapy, and patients who have recently fin­ ished a course of steroids should receive steroid supplementation for dental procedures. The concerns about adrenal insufficiency should be raised on the basis of clinical history. In the majority of cases, the dentist should ask: • Is it known that the patient's adrenal glands do not function adequately? • Is the patient on chronic steroid therapy at doses of prednisone higher than 15 mg/day? • Has the patient been on steroid therapy at doses of prednisone higher than 15 mg/day within the last 2 weeks? *** If the answer to any of the above questions is yes, the dentist should assume that the patient will need stress-dose steroids. General guidelines for the management of patients on steroid therapy: • Steroid supplementation in patients who can develop adrenal insufficiency • Early morning appointments • Shorter appointments • Minimize stress • Use sedation techniques when appropriate • Modify dental treatment plan when appropriate • The major goal in these patients is to avoid precipitating of adrenal insufficiency Remember: Erythema multiforme is a hypersensitivity syndrome characterized by polymorphous eruption of skin and mucous membranes. Macules, papules, nodules, vesicles, or bullae and target or ("bull's-eye-shaped") lesions are seen. A severe form of this condition is known as Stevens-Johnson syndrome. These patients may be receiving moderate doses of systemic corticosteroids and therefore may be unable to withstand the stress of an extraction. Consultation with their physician is absolutely nec­ essary before treating these patients. anat Which of the following foramen/location pairings are correct? Select all that apply. • greater palatine foramen/distal to the apex of maxillary 1 st molar • incisive foramen/posterior to the interproximal space of the central incisors • lesser palatine foramen/lateral to the greater palatine foramen copyright O 2013-2014 - Dental Decks ORAL SURGERY & PAIN CONTROL anat The facial nerve carries which of the following? Select all that apply. efferent components • afferent components • sympathetic components • parasympathetic components copyright © 2013-2014 - Dental Decks ORAL SURGERY & PAIN CONTROL • incisive foramen/posterior to the interproximal space of the central incisors The greater palatine foramen is generally located halfway between the gingival margin and mid­ line of the palate, approximately 5 mm anterior to the junction of the hard and soft palate (vibrat­ ing line) distal to the apex of the maxillary second molar. The hard palate is perforated by the following foramina: • The incisive foramen, posterior to the maxillary incisors, transmits the nasopalatine nerves and the terminal branches of the sphenopalatine artery • The greater palatine foramen, is most frequently located distal to the maxillary second molar, transmits the greater palatine vessels and nerve • The lesser palatine foramen, just posterior to the greater palatine foramen, transmits the lesser palatine vessels and nerve Nerves of the palate: • Sensory Innervation to the palate: is supplied by the maxillary (CN V-2) nerve. The ante­ rior part of the hard palate is supplied by the nasopalatine nerve, which passes through the in­ cisive foramen. The posterior part of the hard palate is supplied by the greater palatine nerve which passes through the greater palatine foramen. The soft palate is supplied by the lesser pala­
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