CHAPTER 44 DENTAL AND ORAL DISORDERS
Practice of Geriatrics
CHAPTER 44 DENTAL AND ORAL DISORDERS
Kenneth Shay, D.D.S., M.S.
Oral Tissues in the Aged Patient
Oral Function in the Aging Patient
Preventive Dentistry for Older Patients
Assessment of the Oral Cavity
Questions Frequently Raised by Dentists
Oral disease is extremely common in advanced age. In the United States, nearly one third of adults over age 65 have no teeth at all (Fig. 44-1). Although over 90% of edentulous adults use dentures, most denture wearers complain of pain, inadequate function, or some other shortcoming associated with their oral prostheses. Essentially all older adults who retain some or all of their natural teeth have lost some measure of the bony support around the teeth, and a majority at any point in time suffer from active destructive periodontal disease. Dental decay (caries) is as prevalent in older adults as it is in younger ones, and decay of the roots of the teeth is more common in advanced age than at any other time in life.1 Oral disease can be particularly pronounced in institutionalized and dependent elderly, in whom oral care has declined or disappeared along with other daily self-care behaviors.
Figure 44-1 Toothlessness rates in older Americans as reported in 1957, 1971, 1986, and 1993. Data are derived from the following sources: (1) National Center for Health Statistics: Edentulous persons, United States, 1971. Data from the National Health Survey, Vital and Health Statistics 1974, Series 10, No. 89. U. S. Department of Health and Human Services Publication No. (HRA) 74-1516. (2) Miller AJ, Brunelle JA, Carlos JP, et al: Oral Health of United States Adults. NIH Publication No. 87-2868. Washington, DC, U.S. Department of Health and Human Services, National Institutes of Health, 1987. (3) Brunell JA, Marcus SE, Winn DM, Brown LJ: Trends in oral health status of the elderly 1971–1991. J Dent Res 75 (special issue):41, 1996 (Abstract, 192). (4) Douglass CW, Jette AM, Fox CH, et al: Oral health status of the elderly in New England. J Gerontol 48:M39–M46, 1993
Yet oral diseases may be unrecognized or untreated in older people for several reasons. Symptoms of dental decay (sensitivity to hot, cold, and sweets; acute, spontaneous tooth pain) decline and disappear with age. Oral problems may be dismissed by patients or their caregivers as unavoidable or unimportant consequences of aging. The expenses of dental treatment can represent a large part of the fixed or shrinking income of an elder and are not covered by Medicare. Knowledge of a suitable dentist or ability to travel to the dental office can be a significant barrier for a homebound elder or one with limited mobility.2
Oral health is strongly linked to overall health and the quality of an older person’s life. Eating ability and enjoyment of food as well as interpersonal relationships can be strongly impaired by oral disease that affects the functions of chewing, swallowing, tasting, and olfaction. Oral pathogens can significantly impair general health through direct extension of disease or its spread to heart, lungs, joints, or other sites. Finally, many of the nonoral diseases prevalent in advanced age, as well as their treatments, are themselves expressed in the oral cavity through exacerbation of existing conditions or the onset of new ones.3
Physicians who treat older adults must appreciate the importance of oral health to their patients’ general well-being. They must recognize the difference between the few true age changes that affect the mouth and the common diseases or environmental effects that are subject to prevention or treatment. They should encourage the inclusion of preventive dentistry as part of their older patients’ preventive regimens and include appraisal of the mouth in the geriatric assessment. Finally, they should be familiar with common medical questions asked by dentists who treat their older patients.
ORAL TISSUES IN THE AGED PATIENT
The modifications undergone by parts of the oral cavity due strictly to advancing age are relatively minor compared with those that result from accumulated diseases, traumatic incidents, and the management of both.
The periodontium4 is the complex of tissues surrounding the teeth (Fig. 44-2). Colonies of aerobic and anaerobic microorganisms that develop on the teeth near the gum line release endotoxins and stimulate an immune response resulting in a local inflammation, termed gingivitis. Gingivitis is a reversible, edematous, erythematous change localized to the gum tissue near the teeth. Patients may complain of gingival bleeding or minor pain or itching of the gums. Daily removal of the bacterial colonies by brushing or professional debridement normally remedies this condition in a matter of days. In patients taking phenytoin, cyclosporin, or a calcium channel blocking agent, gingivitis may be made worse by a prolific hypertrophic response to the bacterial plaque (Fig. 44-3), in which case surgical reduction of the enlarged gingiva may be required.
Figure 44-2 Terminology of structures of the tooth and periodontium. (From Shay K, Ship JA: The importance of oral health in the older patient. J Am Geriatr Soc 43:1414–1422, 1995.)
Figure 44-3 Gingival overgrowth due to nifedipine. This 69-year-old male had been taking 20 mg of nifedipine TID for 4 months.
Under certain host conditions, particular organisms within the gingival sulcus may trigger a host response that stimulates osteoclast activation. While this process is active, pus may be expressed from the sulcus. If this process occurs repeatedly, the bony support of the affected tooth or teeth becomes affected clinically. Over 95% of Americans aged 65 or over display indications of some present or past periodontitis. The teeth appear to be longer and may be somewhat loosened or may gradually shift position in the mouth. Active periodontal disease is managed by a combination of removal of hopelessly affected teeth, professional scaling, surgical resection of gum tissue to promote easier self-care, and optimal daily oral hygiene.
Periodontal diseases have significant interactions with systemic health. Gingivitis and periodontitis become worse with psychological stress. These oral conditions are often more exaggerated, advanced, and difficult to control in patients with diabetes. It is believed that the chronic infection of periodontitis may interfere with blood glucose control in diabetics with poor glycemic control. Periodontal pathogens are known to colonize the oropharynx and have been implicated in gram-negative pneumonia.
More than 98% of the dentate population carries the organism Streptococcus mutans in the oral cavity. S. mutans metabolizes simple sugars into lactate, resulting in local dissolution of tooth mineral. Dental caries5 occurs in areas where this process has been repeated so often that the dissolution invades the tooth. Older adults experience the same rates of decay of the crowns of teeth as do younger adults, although a greater proportion of this decay affects existing dental restorations rather than previously undiseased surfaces. Due to a lifetime of exposure to periodontal pathogens, most older adults with teeth have parts of the roots exposed to the oral environment, resulting in an increase in root caries with advancing age.
Dental caries appears as light to dark brown, softened spots on the teeth, usually between the teeth, adjacent to the gum, or next to a restoration. As the lesion progresses, frank holes appear, or perhaps a piece of the tooth or filling is actually missing. In older adults, dental caries is seldom accompanied by pain; one true normative age change that affects the oral cavity is the progressive diminution in size and decreased neuronal component of the dental pulp. Epithelial cells lining the dental pulp constantly elaborate an osteoid-like tissue, and the volume of the dental pulp therefore declines with age. Pulp consists of vascular, neuronal, lymphatic, and connective tissues. Aged pulps are characterized by an increase in connective tissue relative to neuronal tissue. The result of these changes is a delayed or omitted report of the oral symptoms of early caries (such as sensitivity or spontaneous pain) that might be more regularly reported by younger patients.
Prevention of dental caries requires daily toothbrushing and is enhanced by exposure to fluoride ion, usually in toothpaste or a fluoride mouth rinse. Management of dental caries consists of removal of the diseased tissue and replacement with a wear-resistant material—a filling or crown. If the caries has progressed to affect the pulp, the pulp chamber must be debrided and filled (a “root canal” treatment) if the tooth is to be retained.
Teeth are lost because of a combination of dental and nondental factors. Periodontal disease can so compromise the support structures of the teeth that extraction is inevitable. Yet although dental caries can destroy the oral component of a tooth, root canal treatment and surgery to expose more of the root area to the oral cavity may allow its restoration. But the considerable expense and elapsed time needed for this approach often result in a decision to extract such a tooth. The fate of a carious tooth is thus the result of the biomedical prognosis and the financial, emotional, and temporal priority that the patient places on it.
Retention of teeth into advanced age is increasingly common. Today’s elders are far more likely than their predecessors to have been exposed to preventive dental practices earlier in life so that they now carry a larger portion of their natural dentitions into their advanced years. This change is not entirely without problems because the preservation of teeth brings with it the need for their daily care, an obligation that becomes more difficult if skills that depend on visual and manual dexterity are declining.
The absence of a tooth is not a static event. If other teeth remain, extraction is usually followed by a slow anterior migration of the tooth or teeth posterior to the lost one. In some cases, the tooth that opposed the lost one migrates toward the opposite jaw (Fig. 44-4). Areas of the alveolar processes that lack teeth gradually undergo bony resorption. This loss of bone is of most concern to those who lack all their teeth. In such people dentures become progressively more ill-fitting over a period of months or years. Improved fit of the dentures may be possible by modifying the fitting surfaces or by fabricating a new prosthesis, but either option may result in a lower level of function than was possible when the patient possessed a more intact anatomic configuration. Increasingly, those who have lost their teeth and have the means to afford it obtain osseointegrated titanium implants, wherein metallic posts in the edentulous jaws securely anchor a dental prosthesis.
Figure 44-4 When a tooth is lost, the tooth opposing it and the tooth next to it may migrate into the space left behind.
Oral Mucosal Disease
There are three distinct varieties of oral mucosa: the keratinized, tightly bound mucosa surrounding the teeth (gingiva) and covering the hard palate; the loose, parakeratinized alveolar mucosa that covers the inside of the cheeks and lips, floor of the mouth, and ventrum of the tongue; and the specialized mucosa of the dorsum of the tongue. These sites in older persons are subject to a variety of conditions, the most prevalent of which are discussed here.
Traumatic ulceration caused by the use of removable dentures results from food entrapment or eventual poor fit due to the bony resorption described earlier (Fig. 44-5). In extreme cases, an ill-fitting denture can evoke a proliferative tissue response, in which folds of hyperplastic mucosa develop at the border of the denture. Removal of the denture is the most effective management for denture sores; referral to a dentist for assessment and management of the condition must follow to prevent recurrence.
Figure 44-5 Severe denture ulcer due to resorption of the mandibular alveolar ridge and subsequent impingement on the insertion of the mentalis muscle. The denture has been adjusted so that it no longer traumatizes the affected area.
Candidiasis results from local or disseminated pathogenic colonization by a commensal oral yeast. The lesion is most common on the denture-bearing tissues of the maxilla and may be asymptomatic or can present as a persistent unpleasant taste or a burning or itching sensation. The affected mucosa may be diffusely erythematous or may feature small (less than 1 mm) areas of redness or curd-like white plaques that can be removed with gauze, leaving behind a reddened, denuded surface. The condition seems to be due to one or more of the following: ill-fitting dentures; poor denture hygiene; altered salivary flow; or impaired immune response. In many cases, improved daily hygiene and removal of the dentures during sleep is sufficient to resolve the condition. In persistent or recurring cases an antifungal agent such as nystatin, clotrimazole, or fluconazole may be necessary; the denture may also require modification by a dentist. Candidal infection that occurs independent of the use of dental prostheses may indicate a recent shift in the oral microflora (e.g., following a course of antibiotic) or a change in salivary composition due to a medication side effect. Infection that persists despite excellent hygiene and dental and pharmacologic interventions is probably due to an altered host response.
Squamous cell carcinoma of the oral cavity accounts for approximately 3% of new cancers and 2% of cancer deaths annually in the United States. It affects males twice as frequently as females, and 90% of diagnoses are made in patients aged 50 years or older. Smoking, alcohol, and particularly the combination of the two are strong risk factors. Cancerous and precancerous oral lesions appear as asymptomatic white, red, or white and red patches or ulcerations, most commonly on the lip, floor of the mouth, lateral border of the tongue, and oropharynx (Fig. 44-6). Lesions of this description that are not attributable to another obvious cause (such as recent or chronic trauma that resolves when the source of the trauma is removed for 7 to 14 days) must be submitted to biopsy. Five-year survival and degree of morbidity are dramatically improved by early detection and treatment. For this reason, a thorough oral mucosal evaluation must be a routine part of the assessment of every geriatric patient, especially those who are smokers or heavy drinkers.6
Figure 44-6 Squamous cell carcinoma of the lateral border of the tongue. Note the use of gauze to aid retraction and visualization.
Aphthous stomatitis affects the alveolar mucosa with isolated painful ulcerations that disappear within 7 to 10 days (Fig. 44-7). Aphthous ulcers have been linked to psychogenic (stress), chemical (usually acidic), and traumatic (e.g., a new toothbrush) stimuli. Herpetic ulcers appear as isolated fluid-filled blisters that burst and coalesce into irregular, denuded, painful patches on the attached tissues of the mouth (Fig. 44-8) and at the vermilion border of the lip. Resolution occurs without treatment in 7 to 10 days but may be accelerated by the use of a topical antiviral agent such as acyclovir. Topical steroid or viscous lidocaine (Xylocaine) agents applied to aphthous or herpetic ulcerations may make eating less uncomfortable.
Figure 44-7 Aphthous ulcer of the alveolar mucosa of the vestibule that arose after the patient ate fresh pineapple.
Figure 44-8 Early stage of Herpes simplex lesion of the hard palate. The blisters will burst and coalesce into a single denuded ulcer.
ORAL FUNCTION IN THE AGING PATIENT
The oral cavity is involved in alimentation, host protection, and communication. Although perfect oral health is not essential for these functions, various disease states may impair a person’s ability to perform them, leading to the further detriment of general health.
With advancing age, people with intact dentition need to chew for a longer period of time and with an increasing number of chewing strokes to achieve the same level of food maceration as they did when they were younger.7 As the number of natural teeth in the dentition declines, the duration and number of chewing strokes continue to increase, and the achievable level of food reduction can no longer match the level attained with an intact dentition. This is true even if missing teeth are replaced with removable dental prostheses. In a person with no natural teeth and complete dentures, chewing efficiency is, on average, about one-sixth that of the intact natural dentition. Numerous studies have demonstrated a correlation between the number of food types avoided and the degree of debility of an individual’s dentition. It may be concluded that persons with symptomatic oral disease or chewing status compromised by tooth loss are at increased risk of inadequate nutritional intake. It does not follow, however, that replacement of the missing teeth will resolve a person’s weight loss or eating disorder.
The duration of the swallowing8 sequence increases with age, although aspiration episodes do not seem to increase in prevalence owing to age alone. Yet disease states that are known to affect swallowing and protection of the airway profoundly, such as stroke and Parkinson’s disease, are more prevalent in the elderly. Studies demonstrate a significant correlation between impaired chewing ability and frequency of aspiration of oral contents. It is prudent to regard patients with neuromuscular disease and oral disability as having an increased risk of aspiration.
The ability to discern the difference between distilled water and water with an extremely diluted salt, sweet, bitter, or sour component (“taste threshold”) remains essentially intact with increasing age.9 Suprathreshold response—the degree of perceived “saltiness” for a given salt stimulus (and likewise for sour, sweet, and bitter)—does diminish with age, raising questions about the role this change may play in one person’s habit of oversalting food or another’s growing fondness for sweets. Taste perception may also be affected by the use of a maxillary denture, which physically covers the palatal taste pores. Numerous medications have potential side effects involving disruption of taste (Table 44-1). Many others can cause diminution of salivary flow (Table 44-2), which interferes with the taste function owing to blocked taste pores or inadequate fluid available for dissolving tastant molecules. Finally, an older person’s complaint of taste impairment may be due to disruption of some other oral sensation, inasmuch as the “flavor” of a food is derived not only from its taste but also from its smell, texture, and temperature.
TABLE 44-1 DRUGS THAT INTERFERE WITH TASTE AND SMELL
TABLE 44-2 AGENTS AMONG THE 200 MOST COMMONLY PRESCRIBED DRUGS REPORTED TO HAVE XEROSTOMIA AS A SIDE EFFECT, AND REPORTED XEROSTOMIA PREVALENCES FOR AGENTS FOR WHICH SUCH DATA ARE AVAILABLE
Olfactory function undergoes demonstrable decline with advancing age. Like taste, olfaction may be further affected by medications. It is also impaired by poor oral hygiene and improves if oral hygiene (particularly that of the tongue) improves.
Saliva is essential for the maintenance of oral health.10 It neutralizes acid that promotes caries and remineralizes areas of incipient dissolution. Saliva contains specific antifungal agents and reduces intraoral bacteria through dilution, aggregating factors, and microbicidal enzymes. In the absence of saliva, caries becomes rampant (Fig. 44-9). Salivary mucins reduce intraoral trauma by lubricating the hard and soft tissues and aiding swallowing by facilitating bolus formation.
Figure 44-9 In the absence of adequate saliva, there is little natural defense against dental caries, which then rampantly destroys the teeth.
Reduced salivary flow is a common complaint of older adults. Longitudinal studies, however, have established that salivary flow from the parotid is essentially unchanged with advancing age. There are conflicting findings about submandibular and minor salivary gland output as a function of advancing age, but it is safe to assert that a patient who complains that his mouth has recently become dry is not experiencing a normal change of aging.
Probably the most prevalent cause of a dry mouth is a side effect of one or more medications (see Table 44-2). Management of psychiatric disorders, incontinence, hypertension, cardiac disease, Parkinson’s disease, and pain all commonly involve medications that are xerogenic. Severe salivary gland hypofunction results from therapeutic irradiation given for tumors of the head and neck. Xerostomia may develop from secretions blocking the nasal passages, resulting in mouth breathing. One to three million Americans suffer from Sjögren’s syndrome (see Chapter 39), of which xerostomia is a sentinel symptom. A decrease in saliva has been associated with Alzheimer’s disease, depression, and other diseases as well.
Management of xerostomia begins with its recognition as a potentially reversible disorder. Dental referral is imperative to institute an optimal preventive regimen that includes frequent recall, dietary counseling, and daily application of fluoride. Elimination of redundant or excessive medications should be followed by attempts to substitute other drugs for potentially xerogenic agents. If manipulation of the drug regimen is impossible or does not solve the problem, some palliation may be possible through the use of salivary substitutes (over-the-counter, aqueous surfactants taken ad lib). In patients with xerostomia due to a nonpharmacologic cause, a prescription of oral pilocarpine may be helpful for those who do not object to the side effects of perspiration and lacrimation. Sugarless hard candies and gum, or frequent sips of water and artificially sweetened drinks are also alternatives. Patients must be educated not to sip sucrose-containing drinks or use sugar-containing gum or candy, which brings about rapid destruction of teeth in a dry mouth (see Fig. 44-9).
PREVENTIVE DENTISTRY FOR OLDER PATIENTS
Most oral problems are related to disease or its treatment and in many cases are preventable wholly or in part. Prevention of oral diseases is a focus of the dental profession, but economic and other barriers may impede many elders, particularly the oldest and most infirm, from seeking needed dental care. The close connection between oral and general health is a compelling reason for physicians to have a working knowledge of preventive dentistry, so they can encourage their older patients to practice these effective and necessary preventive behaviors.
Patients with any number of natural teeth must brush them thoroughly at least daily, ideally after each meal, and always before going to bed (salivary flow is at a minimum during sleep). A soft-bristle brush, directed at a 45-degree angle to the tooth, should be used with a fluoride-containing toothpaste on all surfaces of each tooth and pointed toward the gum line. Dental floss or specialized brushes for cleaning between the teeth are excellent daily adjuncts for patients who can manage them.
Dietary sugar is not in itself deleterious to teeth, but in the presence of plaque each ingestion results in a 20-minute pulse of intraoral acidity. Thus, frequent sweet or starchy snacks, regardless of size, are worse for the dentition than the sum of those foods eaten at once. Frequency of eating is irrelevant to oral health if the mouth is cleaned promptly after each ingestion.
Patients who have a removable denture should keep the prosthesis out of the mouth for at least 6 hours daily to maintain the health of the mucosa. Prostheses should be removed and rinsed after each meal and should be scrubbed with a suitable brush at least daily. They should be soaked in an antimicrobial rinse (either a commercially available agent or a dilute solution of household bleach) for at least 20 minutes several times per week.
Everyone should see a dentist at least twice annually. Patients with one or more natural teeth need to have their teeth thoroughly examined and cleaned professionally. Those at high risk for caries (e.g., those with salivary dysfunction or impaired self-care abilities) may have to be seen at more frequent intervals. Patients who no longer have their natural teeth should receive a mucosal examination and an evaluation of their prosthesis at least annually; those at high risk for oral malignancy (smokers and drinkers) should have a mucosal evaluation performed twice annually.
Because of the importance of regular mucosal evaluation for older patients and because many elders either do not seek or cannot afford dental care, the following section describes the procedure used for oral evaluation.
ASSESSMENT OF THE ORAL CAVITY
Assessment of the oral cavity should begin with a systematic examination of the oral mucosa.11 An easy sequence to remember begins with the lips and cheeks, then the vestibular areas and alveolar ridges, the tongue and floor of the mouth, and finally the hard and soft palates. The examination should be conducted with a strong light, one or two tongue blades, and a gauze sponge for retraction of the tongue. Performed properly, the examination need take no longer than 90 seconds and can easily be quicker for an edentulous patient. The clinician should be alert for areas of ulceration, induration, inflammation, whitening, or reddening of the mucosa.
In examining the lips, the clinician should pay close attention to the vermilion border, where herpetic and malignant lesions are seen most commonly. A cracked, weeping lesion at the corner of the mouth is most commonly due to Candida albicans or riboflavin deficiency. Bluish vascular lesions of the lip are common elsewhere throughout the mouth as well and generally require no treatment. A small (2 to 6 mm) fleshy protuberance high on the inside of the cheek is the duct for the parotid gland.
The vestibules and alveolar ridges cannot be adequately examined until any dentures have been removed. Reddened or ulcerated denture-bearing areas are most likely due to trauma from the denture, and the patient should be urged to seek dental attention. The denture should be kept out of the mouth for at least 72 hours and the area then reexamined; if the lesion has not resolved in this time period it should be biopsied. In the presence of teeth, circular papules on the alveolar ridge that are 1 to 2 mm in diameter may be fistulous tracts from teeth with necrotic pulps—a sign of abscess. Smooth but prominent bony protuberances on either side of the mandible (Fig. 44-10) or maxilla or along the palatal suture are benign osteomas and are no cause for concern.
Figure 44-10 Common benign osseous tumor of the lingual mandible: “torus mandibularis.”
Examination of the tongue requires its retraction. The gauze sponge should be held on the patient’s lower lip and the patient instructed to stick out the tongue. The tongue is then firmly grasped with the gauze and retracted. Switching hands and rotating the tongue to the opposite side will complete the tongue examination. Discrete white, red, or mixed red and white lesions require biopsy if they are not attributable to an obvious cause (e.g., candidal infection or trauma from a sharp tooth). When the lateral borders have been examined, the tongue is released, and the patient is instructed to place the tip of the tongue against the back of the front teeth, allowing visualization of the areas covered by gauze as well as the floor of the mouth. The dorsum is examined last; a depapillated appearance may indicate vitamin B12 deficiency (Fig. 44-11).
Figure 44-11 Depapillated tongue and angular cheilitis due to vitamin B12 deficiency.
In denture wearers, the hard palate is commonly reddened owing to candidiasis. In some patients a disseminated papillary growth is displayed on the palate; this is also due to fungi but requires resection for resolution.
When the mucosal surfaces of the mouth have been examined, the teeth and gums can be assessed for signs of disease: deposits, inflammation, purulence, and mobility. Food debris and bacterial deposits (either hard or soft) are signs of inadequate oral hygiene and must be removed to determine whether dental decay and periodontal disease are present beneath them (Fig. 44-12).
Figure 44-12 Debris and bacterial deposits impede effective examination of the teeth and gums, and disease is likely to be found beneath.
QUESTIONS FREQUENTLY RAISED BY DENTISTS
As more older Americans retain their teeth, dentists find a growing proportion of their practices devoted to seniors. These older patients generally take more medications and are afflicted by more chronic diseases than dentists’ other patients. Dentists are encouraged to seek guidance from physicians in conjunction with providing dental treatment to patients who have and are being treated for certain medical conditions. The following section addresses three questions frequently asked of physicians by dentists.
Is Antibiotic Prophylaxis Necessary for This Patient?
Bacteremia results from a variety of dental procedures, including tooth extraction, subgingival cleaning, and periodontal surgery (Table 44-3). For several decades it has been recognized that the beta-hemolytic streptococci of the oral cavity are responsible for more than 30% of cases of endocarditis. Patients at risk for bacterial endocarditis because of congenital or acquired cardiac malformations or dysfunction should receive 2.0 g of amoxicillin 1 hour prior to dental treatment that is likely to induce bacteremia.
TABLE 44-3 PREVENTION OF BACTERIAL ENDOCARDITIS IN DENTAL PATIENTS
In patients with major joint arthroplasty, it is now recognized that the risk of bacteremia-induced late joint infection is limited in general. However, antibiotics should still be considered for certain high-risk groups: insulin-dependent diabetics, rheumatoid arthritics, patients taking corticosteroids, and those whose arthroplasty is less than 2 years old. A cephalosporin or amoxicillin regimen has been recommended. Indications for coverage are less clear for xenogenic implants about which there have been no case reports of complications—arteriovenous shunts, ventriculoperitoneal shunts, vascular grafts and filters—and for which there are no published recommendations for antibiotic prophylaxis.
There is also no standard recommendation for treatment of diabetic patients in oral surgery. Empirically, diabetics suffer in a more exaggerated fashion from mucosal and periodontal problems and are more prone to postoperative infections than are nondiabetics. There are no published clinical trials for guidance, but a loading dose (2 g) of amoxicillin (or the equivalent of erythromycin for the penicillin-allergic patient) given 1 hour prior to the procedure is a common prophylactic approach for the historically infection-prone diabetic patient undergoing oral surgery.
Is It Safe to Use Epinephrine-Containing Local Anesthetic for This Patient?
Dentists routinely anesthetize their patients prior to restorative, endodontic, and surgical procedures. The most commonly used local anesthetic solution is 2% lidocaine with 1:100,000 epinephrine, injected from an aspirating syringe in 1.8-mL cartridges. Dentists are cautioned that extreme care should be taken in administering epinephrine to a patient with a history of coronary artery disease or hypertension. An epinephrine dose limit that has received general acceptance is 50 µg per appointment for these patients, which suggests that slightly less than three full cartridges of anesthetic be used in a single sitting.
Elimination of the epinephrine from the anesthetic solution is not generally advised because of the risk of inadequate analgesia. Most authorities agree that endogenous epinephrine release due to breakthrough pain or even preoperative anxiety is a greater risk to the patient than the amount given in a properly administered anesthetic; with an aspirating injection technique, a bolus dose of epinephrine is avoided in any case.
Can This Patient Safely Undergo Dental Treatment So Soon After a Heart Attack (or Stroke)?
A widely disseminated but unsupported guideline within the dental profession is that elective dental treatment should not be performed within 6 months of a patient’s myocardial infarction or stroke. Retrospective investigations suggest that a history of recent myocardial infarction is less relevant to perioperative risk than a multifactorial assessment that also accounts for signs of continued cardiac dysfunction such as unstable angina, pulmonary edema, or underlying valvular disease. Studies of coronary artery disease patients undergoing dental procedures show no greater incidence of electrocardiographic findings indicative of ischemia or threatening arrhythmia than those observed in age- and sex-matched normals.