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Part 1 book “Dental management of the medically compromised patient” has contents: Patient evaluation and risk assessment, infective endocarditis, ischemic heart disease, cardiac arrhythmias, pulmonary disease, sleep-related breathing disorders, gastrointestinal disease, liver disease,… and other contents. TA B L E O F C O N T E N T S Dental Management: A Summary, xiii 19 Allergy, 330 PART I  Patient Evaluation and Risk Assessment, 20 Rheumatologic Disorders, 345 Patient Evaluation and Risk Assessment, PART II  Cardiovascular Disease, 18 21 Organ Transplantation, 370 PART VIII  Hematologic and Oncologic Disease, 389 22 Disorders of Red Blood Cells, 390 Infective Endocarditis, 19 23 Disorders of White Blood Cells, 402 Hypertension, 38 24 Acquired Bleeding and Hypercoagulable Disorders, 428 Ischemic Heart Disease, 53 Cardiac Arrhythmias, 70 25 Congenital Bleeding and Heart Failure (or Congestive Heart Failure), 86 26 Cancer and Oral Care of Patients With PART III  Pulmonary Disease, 100 Pulmonary Disease, 101 Smoking and Tobacco Use Cessation, 128 Sleep-Related Breathing Disorders, 138 PART IV  Gastrointestinal Disease, 150 Hypercoagulable Disorders, 457 Cancer, 480 PART IX  Neurologic, Behavioral, and Psychiatric Disorders, 515 27 Neurologic Disorders, 516 28 Anxiety and Eating Disorders, 544 29 Psychiatric Disorders, 561 30 Drug and Alcohol Abuse, 581 10 Liver Disease, 151 Appendices, 596 11 Gastrointestinal Disease, 176 A Guide to Management of Common Medical Emergencies in the Dental Office, 597 PART V  Genitourinary Disease, 192 12 Chronic Kidney Disease and Dialysis, 193 13 Sexually Transmitted Diseases, 210 PART VI  Endocrine and Metabolic Disease, 229 14 Diabetes Mellitus, 230 15 Adrenal Insufficiency, 255 16 Thyroid Diseases, 268 17 Women’s Health Issues, 288 PART VII  Immunologic Disease, 308 18 AIDS, HIV Infection, and Related Conditions, 309 B Guidelines for Infection Control in Dental Health Care Settings, 606 C Therapeutic Management of Common Oral Lesions, 623 D Drug Interactions of Significance in Dentistry, 639 E Drugs Used in Complementary and Alternative Medicine of Potential Importance in Dentistry, 645 Index, 655 LITTLE AND FALACE’S DENTAL MANAGEMENT of the Medically Compromised Patient YOU’VE JUST PURCHASED MORE THAN A TEXTBOOK! Evolve Student Resources for Little and Falace’s: Dental Management of the Medically Compromised Patient, 9th Edition, include the following: STUDENT RESOURCES: • • • •  nimations A • Three-dimensional animations demonstrate topics such as irregular heartbeats, coronary artery disease, dialysis, diabetes, fetal development, arthritis, chemotherapy, and radiation therapy Mind Maps • Mind Maps for each chapter give visual breakdown of the key information in the chapter, great for quick review or taking notes Printable version of the Dental Management Summary Table • A quick and easy reference table that presents the most important factors to be considered in the management of the medically compromised patient Weblinks • A variety of weblinks for further study and research INSTRUCTOR RESOURCES: • • • • 367-question Test Bank PowerPoint Lecture Slides Image Collection Syllabus Conversion Guide Activate the complete learning experience that comes with each textbook purchase by registering at http://evolve.elsevier.com/Little/compromised/ REGISTER TODAY! You can now purchase Elsevier products on Evolve! Go to evolve.elsevier.com/html/shop-promo.html to search and browse for products 2015v1.0 LITTLE AND FALACE’S DENTAL MANAGEMENT of the Medically Compromised Patient Ninth Edition James W Little, DMD, MS Professor Emeritus University of Minnesota School of Dentistry Minneapolis, Minnesota; Naples, Florida Craig S Miller, DMD, MS Professor of Oral Diagnosis and Oral Medicine Provost Distinguished Service Professor Department of Oral Health Practice Department of Microbiology, Immunology and Genetics The University of Kentucky College of Dentistry and College of Medicine Lexington, Kentucky Nelson L Rhodus, DMD, MPH Morse Distinguished Professor and Director Division of Oral Medicine, Oral Diagnosis and Oral Radiology University of Minnesota School of Dentistry and College of Medicine Minneapolis, Minnesota 3251 Riverport Lane St Louis, Missouri 63043 LITTLE AND FALACE’S DENTAL MANAGEMENT OF THE MEDICALLY COMPROMISED PATIENT, NINTH EDITION ISBN: 9780323443555 Copyright © 2018 by Elsevier, Inc All rights reserved Previous editions copyrighted 2013, 2008, 2002, 1997, 1993, 1988, 1984, and 1980 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein Library of Congress Cataloging-in-Publication Data Names: Little, James W., 1934- author | Miller, Craig S., author | Rhodus,   Nelson L., author Title: Little and Falace’s dental management of the medically compromised   patient / James W Little, Craig S Miller, Nelson L Rhodus Description: Ninth edition | St Louis, Missouri : Elsevier, Inc., [2018] |   Preceded by Little and Falace’s dental management of the medically   compromised patient / James W Little … [et al.] 8th ed., c2013 |   Includes bibliographical references Identifiers: LCCN 2017025872 (print) | LCCN 2017027016 (ebook) | ISBN   9780323443951 (Ebook) | ISBN 9780323443555 (pbk : alk paper) Subjects: | MESH: Dental Care | Dental Care for Chronically Ill | Oral Manifestations Classification: LCC RK55.S53 (ebook) | LCC RK55.S53 (print) | NLM WU 29 | DDC  617.6–dc23 LC record available at https://lccn.loc.gov/2017025872 Senior Content Strategist: Jennifer Flynn-Briggs Senior Content Development Specialist: Diane Chatman Publishing Services Manager: Deepthi Unni Project Manager: Manchu Mohan Designer: Renee Duenow Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 We dedicate this ninth edition to our role model and close friend: Dr Selverio “Sol”/“Bud” Silverman, Jr., MA, DDS In 2014, we lost our dearest colleague: Each of us in dentistry has been truly blessed by Dr Silverman: As a professor of oral medicine at University of California, San Francisco (UCSF) School of Dentistry, for many years, Silverman headed one of UCSF’s oral medicine clinics and was an advocate for prevention and early detection of oral cancer as well as AIDS Silverman was a diplomat of the American Board of Oral Medicine, past president of the Board, and past President of the American Academy of Oral Medicine (AAOM) Dr Silverman was a consultant to the American Dental Association Council on Scientific Affairs and a national spokesperson for the Association He published more than 300 scientific articles, chapters in textbooks, and monographs He received the prestigious Margaret Hay Edwards medal from the American Association for Cancer Education for outstanding contributions UCSF Enumeration on October 16, 2006, yet practiced until his death Deceased August 14, 2014, at 88 years of age Dr Selverio Silverman, Jr., gave back so much to oral medicine profession worldwide and encouraged others around the world and as well as his fellow oral medicine colleges and students at UCSF’s oral medicine clinics yearly, stressing each to become an active member in AAOM Filled with pride and love, Bud exchanged his family stories over the years with each of us “Bud” was a very well-rounded doctor and family man who was filled with pride and love of both his family and his profession Oral medicine educators, doctors, students, and AAOM members should never tire of challenging each other academically because change makes for evolving changes, and teaming up with each other professionally makes for the very best for oral medicine worldwide Giving is better than receiving always Thanks, “Bud,” for giving each of us your very best Dear friend, you shall always be missed Dr “Bud” Silverman, Jr., has written the Foreword for this textbook for the prior last five editions This book serves as a textbook as well as a must-have reference book for every dental office in the United States as well as throughout the world Dr Sol Silverman, Jr., and Dr James W Little were best friends for the past 45+ years Their world was carved with the same great values, yet they practiced and taught oral medicine more than 3250 miles apart Jim and Bud were tethered via phone as they dedicated their lives to oral medicine through their teachings, research, and their own publications and textbooks Each authored oral medicine textbooks as well as massive publications Each had the total support and love of each of their own families, their own university workplace, and fellow members of the AAOM Bud and Jim shared their love of sports by playing tennis, golf, and pick-up basketball into their 80s They kept young by enjoying their daily playtime with their college kids and all their AAOM friends “Bud” Silverman is missed daily by each of us involved with oral medicine Dr James W Little This page intentionally left blank F O R E WO R D It has been said that dental offices of the past were often located upstairs, on second floors, to screen out those who were too infirm to undergo dental treatment Patients able to climb the flight of stairs to the office were considered fit enough to treat Largely because of modern medical care, people today are living and working with medical conditions that in the past might have been disabling or even unsurvivable Statistics from 2012 show that roughly half of noninstitutionalized U.S adults had one or more of 10 chronic medical conditions (hypertension, coronary heart disease, stroke, diabetes, cancer, arthritis, hepatitis, weak or failing kidneys, current asthma, or chronic obstructive pulmonary disease) Almost a quarter (24.3%) had one of these conditions, 13.87% had two, and 11.7% had three or more Approximately one fourth of U.S adults have more than one chronic illness.1 As one might expect, the incidence of chronic illness increases with age A total of 69.5% of U.S adults age 55 to 64 years had one or more of six chronic conditions (arthritis, current asthma, cancer, cardiovascular disease, chronic obstructive pulmonary disease, and diabetes), 37.1% had two or more, and 14.4% had three or more For ages 65 years and older, the percentages increase to 85.6%, 56.0%, and 23.1%, respectively Women were more affected than men in all age groups (2008 data).2 Prescription medication is a mainstay of modern health care, and all age groups use them A total of 14.1% of children younger than age 12 years, 17.3% age 12 to 29 years, and almost 20% of adults age 20 to 59 years use a prescription medication Of adults age 60 years and older, roughly a quarter take one or two prescription medications, and almost four of 10 people (36.7%) take five or more prescription medications.3 Almost one quarter of U.S adults older than 65 years have three or more chronic illnesses, and more than one third take five or more medications Nowadays, many patients no longer have “a doctor.” Instead, a patient may see multiple doctors for his or her various conditions, such as a cardiologist for coronary artery disease, an endocrinologist for diabetes, a rheumatologist for arthritis, an oncologist for cancer, a psychiatrist for depression—the list can go on and on This can make medical consultation challenging for the dentist because each specialist focuses on his or her own area and cannot be expected to be knowledgeable about the details of dental diseases and treatments The dentist cannot expect simply to request a “clearance” from one of the patient’s physicians, who may not have a thorough understanding of what the proposed treatment entails It is therefore essential that the dentist understand how patients’ dental diagnoses and planned treatment relate to their medical diagnoses and treatment For example, some patients may take anticoagulants or have bleeding disorders that affect dental surgical options and require special considerations in treatment planning Medical treatments such as head and neck radiation therapy or antiosteoclast medications may impair healing after dental infections or dental surgical procedures, and failure to appreciate and take into account such relationships may put patients at risk for serious complications Some medical conditions, if unstable, may pose a risk of intraoperative medical emergency during dental treatment and may require modification of treatment planning and delivery Organ and hematopoietic transplant recipients are an increasingly large group of patients, and among their considerations is the potential for opportunistic infections and malignancies, which can occur in the oral cavity as well as elsewhere Certain medical problems may themselves adversely affect dental health, such as a patient with physical or cognitive impairment that precludes effective dental hygiene or a patient whose illness or medication produces such profound xerostomia that caries cannot be controlled Medications that a patient is taking may create the potential for interactions that must be considered when the dentist wishes to prescribe or administer a drug In addition, therapeutic effects of medications, such as anticoagulation, or adverse effects, such as xerostomia or mucosal reactions, may bear on dental management Advanced age, or renal, hepatic, or other diseases that alter drug uptake, metabolism, clearance, or response may require dosage adjustments Furthermore, each new drug creates the potential for known or as yet unknown drug interactions and side effects, and adverse effects of older medications continue to be discovered with ongoing use These are just a few examples of common conditions that can impact dental management Although the most complex and seriously ill patients may require specialists to provide their dental care, no dentist will be able to avoid treating patients with medical problems altogether, and all dentists must be prepared for them This book, which has been thoroughly updated in the present edition, provides an excellent overview of pathophysiology and treatment of a broad range of common medical conditions vii viii FOREWORD that will provide the dentist with understanding of the interrelationships between patients’ dental and medical care, as well as information on recommended modifications of treatment delivery Competency in this critical and complex area of dentistry is essential to the safe and effective provision of dental care to an increasingly large part of our population Its importance cannot be overstated John C Robinson, MA, DDS, FAAOM Santa Rosa, California REFERENCES Ward BW, Schiller JS, Goodman RA Multiple chronic conditions among US adults: a 2012 update Prev Chronic Dis 2014;11:130389 CDC/National Center for Health Statistics National Health Interview Survey https://www.cdc.gov/nchs/ health_policy/adult_chronic_conditions.htm Gu Q, Dillon CF, Burt VL Prescription drug use continues to increase: U.S prescription drug data for 2007-2008 NCHS data brief, no 42 Hyattsville, MD, 2010, National Center for Health Statistics CHAPTER 17  Women’s Health Issues radiographs are less than natural daily background radiation It should be noted, however, that maternal thyroid exposure to diagnostic radiation in excess of 0.4 mGy has been associated with a slight decrease in birth weight.28 This finding reinforces the importance of using a thyroid collar on pregnant patients Teratogenicity is also dependent on the gestational age of the fetus at the time of exposure During the organogenesis period (from the end of the 2nd to the 8th week postconception), fetuses are extremely sensitive to the teratogenic effect of ionizing radiation, particularly the central nervous system (CNS) between the 8th and 15th weeks of pregnancy.29 From the 16th to the 25th week, there is a reduction in the radiosensitivity of the CNS and in many of the other organs After the 25th week, the CNS becomes relatively radioresistant, and major fetal malformations and functional anomalies are highly improbable When risks of dental radiography are further assessed during pregnancy, three reports should be kept in mind The first states that the maximum risk attributable to 1 cGy (which is more than 1000 full-mouth series with E-speed film and rectangular collimation or 10%–20% of the threshold dose) of in utero radiation exposure is estimated25 to be approximately 0.1% This is a quantity thousands of times less than the normal anticipated risks of spontaneous abortion, malformation, or genetic disease The risk of a first-generation fetal defect from a dental radiographic examination is estimated to be in billion.28,29 The third report found that the gonadal dose to women, after full-mouth radiography using a lead apron, is less than 0.01 µSv, which is at least 1000-fold below the threshold shown to cause congenital damage to newborns.28,29 These figures indicate that with use of a lead apron, rectangular collimation, and E-speed film or faster techniques, one or two intraoral films are truly of minute significance in terms of radiation effects on a developing fetus In terms that can be explained to a patient, one should consider the following: The gonadal or fetal dose of two periapical dental films (when a lead apron is used) is 700 times less than day of average exposure to natural background radiation in the United States.30,31 Despite the negligible risks of dental radiography, dentists should not be cavalier regarding its use during pregnancy (or at any other time, for that matter) Radiographs should be used selectively and only when necessary and appropriate to aid in diagnosis and treatment Bitewing, panoramic, or selected periapical films are recommended for minimizing patient dose To further reduce the radiation dose, the following measures should be used: rectangular collimation, E-speed or F-speed film or faster techniques (digital imaging reduces radiographic exposure by at least 50% compared with E-speed exposures), lead shielding (abdominal and thyroid collar), high kilovoltage (kV) or constant beams, and an ongoing quality assurance program 293 An additional consideration is the pregnant dental auxiliary or dentist The maximum permissible radiation dose for whole-body exposure of the pregnant dental care worker is 0.005 Gy or 5 mSv per year This is equivalent to the maximum permissible radiation dose of the nonoccupationally exposed public and 10-fold less than the level of occupationally exposed nonpregnant workers (50 mSv).32 The National Council on Radiation Protection and Measurements reports that production of congenital defects is negligible from fetal exposures of 50 mSv.32 To further ensure safety, a pregnant operator should wear a film badge; stand more than feet from the tube head; and position herself at between 90 and 130 degrees of the beam, preferably behind a protective wall (Fig 17.1) When these guidelines are followed, no contraindication to pregnant women operating an x-ray machine occurs However, dentists should familiarize themselves with federal (Code of Federal Regulations, Code 10, Part 20, Section 20.201) and state regulations that would supersede these guidelines Drug Administration Another controversial area in the treatment of pregnant dental patients is drug administration The principal concern is that a drug may cross the placenta and be toxic or teratogenic to the fetus Additionally, any drug that is a respiratory depressant may cause maternal hypoxia, resulting in fetal hypoxia, injury, or death.3 Ideally, drug administration should be avoided during pregnancy, especially during the first trimester However, adhering to this rule is sometimes impossible Actually, 75% of pregnant women in the United States are taking some type of medication.3 Fortunately, most of the commonly used drugs in dental practice can be given during pregnancy with relative safety, although a few exceptions are notable Table 17.3 presents a suggested approach to drug usage for pregnant patients.3-5 Before prescribing or administering a drug to a pregnant patient, the dentist should be familiar with the U.S Food and Drug Administration (FDA) categorization of prescription drugs for pregnancy based on their potential risk of fetal injury.32 These pregnancy risk classification categories, although not without limitations, are meant to aid clinicians and patients in making decisions about drug therapy Counseling should be provided to ensure that women who are pregnant clearly understand the nature and magnitude of the risk associated with a drug In 2008, the FDA announced that it was eliminating the current pregnancy risk classification system due to inadequacies; however, at this time the original system is still in place.32 The current five pregnancy labeling categories are as follows (Fig 17.2): A Controlled studies in humans have failed to demonstrate a risk to the fetus, and the possibility of fetal harm appears remote 294 CHAPTER 17  Women’s Health Issues 135° ft 90° FIG 17.1  Proper operator position during exposure of x-rays B Animal studies have not indicated fetal risk, and human studies have not been conducted; or animal studies have shown a risk, but controlled human studies have not C Animal studies have shown a risk, but controlled human studies have not been conducted, or studies are not available in humans or animals D Positive evidence of human fetal risk exists, but in certain situations, the drug may be used despite its risk X Evidence of fetal abnormalities and fetal risk exists based on human experience, and the risk outweighs any possible benefit of use during pregnancy.3,32 Drugs in categories A or B are preferable for prescribing during pregnancy However, many commonly prescribed drugs used in dentistry fall into category C, and thus the safety of their use is often uncertain Drugs in category C present the greatest difficulty for the dentist and the physician in terms of therapeutic and medicolegal decisions, and therefore, consultation with the physician may be needed3,32 (Fig 17.2) Physicians may advise against the use of some of the approved drugs or conversely may suggest the use of an uncertain or questionable drug The FDA categories are general guidelines and may be incomplete, and therefore, differences in practice are not unusual An example of the occasional use of a questionable drug would be a category C narcotic analgesic for a pregnant patient who is in severe pain Local Anesthetics.  Common local anesthetics (lidocaine, prilocaine) administered with epinephrine are generally considered safe for use during pregnancy.4 Articaine, bupivacaine, and mepivacaine are typically safe, although some caution should be exercised Although both the local anesthetic and the vasoconstrictor cross the placenta, subtoxic threshold doses have not been shown to cause fetal abnormalities Because of adverse effects associated with high levels of local anesthetics, it is important not to exceed the manufacturers recommended maximum dose Some topical anesthetics, including benzocaine, dyclonine, and tetracaine, may be acceptable but used with caution There is no problem with topical lidocaine.3,4 Analgesics.  The analgesic of choice during pregnancy is acetaminophen Aspirin and nonsteroidal antiinflammatory drugs convey risks for constriction of the ductus arteriosus, as well as for postpartum hemorrhage and delayed labor (see Table 17.3).3,34 The risk of these adverse events increases when agents are administered during the third trimester Therefore, it is best to avoid these analgesics (especially in the third trimester) or use them with caution Risk also is more closely associated with prolonged administration, high dosage, and selectively potent antiinflammatory drugs, such as glucocorticoids CHAPTER 17  Women’s Health Issues and indomethacin Most opioids, including codeine, Demerol, and propoxyphene, are associated with multiple congenital defects and should be used cautiously and only if needed.3,34 The safety of hydrocodone and oxycodone is unclear, but because there is no possibility of adverse respiratory effects, it is best to avoid them or use them with caution.3,33-37 Antibiotics.  Penicillins (including amoxicillin), erythromycin (except in estolate form), cephalosporins, metronidazole, and clindamycin are generally considered to be safe for expectant mothers and developing fetuses.34 295 The use of tetracycline, including doxycycline, is contraindicated during pregnancy Tetracyclines bind to hydroxyapatite, causing brown discoloration of teeth, hypoplastic enamel, inhibition of bone growth, and other skeletal abnormalities.3,34 Clarithromycin should be avoided or use with caution.3,34 Antibiotics and Oral Contraceptives. The concern for potential interactions between antibiotics and oral contraceptives requires mention in this chapter This concern arises from the ability of select antibiotics such as rifampin, an antituberculosis drug, to reduce plasma levels of TABLE 17.3  Key Medication Considerations During Pregnancy and Breast-Feeding FDA PR* Category Safe During Pregnancy? Safe During Breastfeeding? B C/D C C C C/D B Yes Avoid Use with caution Avoid‡ Use with caution Avoid use in third trimester Use with caution Yes Avoid Yes Yes Use with caution Yes Use with caution Amoxicillin Azithromycin Cephalexin Chlorhexidine (topical) Clarithromycin Clindamycin Clotrimazole (topical) Doxycycline Erythromycin Fluconazole Metronidazole B B B B C B B D B C/D B Yes Yes Yes Yes Use with caution Yes Yes Avoid Yes Yes (single-dose regimens) Yes Nystatin Penicillin Terconazole (topical) Tetracycline C B B D Yes Yes Yes Avoid Yes Yes Yes Yes Use with caution Yes Yes Avoid Use with caution Yes Avoid; may give breast milk an unpleasant taste Yes Yes Yes Avoid C C B C B C C B C Use with caution Use with caution Yes Use with caution Yes Use with caution Yes Yes Use with caution Use with caution Yes Yes Yes Yes Use with caution Yes Yes Use with caution D/X C C Avoid Use with caution Use with caution Avoid Use with caution Yes Agent Analgesics and Antiinflammatories † Acetaminophen Aspirin Codeine Glucocorticoids (dexamethasone, prednisone) Hydrocodone IbuprofenĐ Oxycodone Antibioticsả# Local Anesthetics Articaine Bupivacaine Lidocaine (with or without epinephrine) Mepivacaine (with or without levonordefrin) Prilocaine Benzocaine (topical) Dyclonine (topical) Lidocaine (topical) Tetracaine (topical) Sedatives Benzodiazepines Zaleplon Zolpidem Continued 296 CHAPTER 17  Women’s Health Issues TABLE 17.3  Key Medication Considerations During Pregnancy and Breast-Feeding—cont’d Agent FDA PR* Category Safe During Pregnancy? Safe During Breastfeeding? C B C C C C Steroid and β2-agonist inhalers are safe Yes Use with caution Use with caution Use with caution Use with caution Yes Avoid Yes Use with caution Use with caution Use with caution Emergency Medications Albuterol Diphenhydramine Epinephrine Flumazenil Naloxone Nitroglycerin *FDA PR: U.S Food and Drug Administration Pregnancy Risk See Table for FDA PR category definitions † In the case of combination products (such as oxycodone with acetaminophen), the safety with respect to either pregnancy or breastfeeding is dependent on the highest-risk moiety In the example of oxycodone with acetaminophen, the combination of these two drugs should be used with caution, because the oxycodone moiety carries a higher risk than the acetaminophen moiety ‡ Oral steroids should not be withheld from patients with acute severe asthma § Ibuprofen is representative of all nonsteroidal antiinflammatory drugs In breastfeeding patients, avoid cyclooxygenase selective inhibitors such as celecoxib, as few data regarding their safe use in this population are available, and avoid doses of aspirin higher than 100 milligrams because of risk of platelet dysfunction and Reye syndrome ¶ Antibiotic use during pregnancy: The patient should receive the full adult dose and for the usual length of treatment Serious infections should be treated aggressively Penicillins and cephalosporins are considered safe Use higher-dose regimens (such as cephalexin 500 mg three times per day rather than 250 mg three times per day), as they are cleared from the system more quickly because of the increase in glomerular filtration rate in pregnancy # Antibiotic use during breastfeeding: These agents may cause altered bowel flora and, thus, diarrhea in the baby If the infant develops a fever, the clinician should take into account maternal antibiotic treatment FIG 17.2  Food and Drug Administration Labeling for Drugs Used During Pregnancy and Breastfeeding (2015) circulating oral contraceptives It has been speculated that this interaction also may be seen with other antibiotics; however, studies to date regarding other antibiotics have been less convincing To address this concern, the American Dental Association Council on Scientific Affairs33 issued the following recommendations when prescribing antibiotics to a female patient who takes oral contraceptives: “The dentist should (1) advise the patient of the potential risk of the antibiotic’s reducing the effectiveness of the oral contraceptive, (2) recommend that the patient discuss with her physician the use of an additional nonhormonal means of contraception, [and] (3) advise the patient to maintain compliance with oral contraceptives when concurrently using antibiotics.” The application of these recommendations appears prudent until the findings of larger studies become available In general, dentists should provide treatment for acute infection irrespective of the stage of pregnancy Anxiolytics.  Few anxiolytics are considered safe to use during pregnancy Benzodiazepines, zaleplon, and zolpidem should be avoided However, a single, short-term exposure to nitrous oxide–oxygen (N2O–O2) for less than 35 minutes is not thought to be associated with any human fetal anomalies, including low birth rate.36,37 In contrast, however, chronic occupational exposure to N2O–O2 has been associated with spontaneous abortion and reduced fertility in humans.38 Nitrous oxide may cause inactivation of methionine synthetase and vitamin B12, resulting in altered DNA metabolism that can lead to cellular abnormalities in animals and birth defects Accordingly, the following guidelines are recommended if N2O–O2 is used during pregnancy:36,39 CHAPTER 17  Women’s Health Issues • Use of N2O–O2 inhalation should be minimized to 30 minutes • At least 50% oxygen should be delivered to ensure adequate oxygenation at all times • Appropriate oxygenation should be provided to avoid diffusion hypoxia at the termination of administration • Repeated and prolonged exposures to nitrous oxide are to be prevented • The second and third trimester are safer periods for treatment because organogenesis occurs during the first trimester An additional consideration involves female dentists or dental auxiliaries who are pregnant These individuals should not be exposed to persistent trace levels of nitrous oxide in the operatory The use of appropriate scavenging equipment can help alleviate this problem Female dental health care workers who are chronically exposed to nitrous oxide for more than hours per week, when scavenging equipment is not used, have decreased fertility and increased rates of spontaneous abortion.39 Implementation of National Institute for Occupational Safety and Health recommendations can reduce occupational exposure to nitrous oxide (Box 17.2).39,40 Nursing.  A potential problem arises when a nursing mother requires the administration of a drug in the course of dental treatment The concern is that the administered drug may enter the breast milk and be transferred to the nursing infant, in whom exposure may result in adverse effects BOX 17.2  Control of Nitrous Oxide in the Dental Office During Pregnancy Inspect nitrous oxide equipment and replace defective tubing and parts Check pressure connections for leaks; fix leaks Ensure that mask fits well and is secure Check that the reservoir bag is not over- or underinflated Provide operatory ventilation of 10 or more room air exchanges per hour Use a scavenging system and appropriate mask sizes Vacuum should provide up to 45 L/min Connect and turn on the vacuum pump of the scavenging system before providing nitrous oxide Regularly conduct air sampling Maintain low exposure limits (e.g., 25 ppm*) when pregnant dental health care workers are involved *This limit is a National Institute for Occupational Safety and Health recommendation In contrast, Yagiela65 suggests a timeweighted average lower limit of 100 ppm for an 8-hour workday Modified from McGlothlin JD, Crouch KG, Mickelsen RL: Control of nitrous oxide in dental operatories Cincinnati, OH, 1994, U.S Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Division of Physical Sciences and Engineering, Engineering Control Technology Branch DHHS publication no (NIOSH) 94-129 ETTB report no 166-04 297 Data on which to draw definitive conclusions about drug dosages and effects via breast milk are limited However, retrospective clinical studies and empiric observations, coupled with known pharmacologic pathways, allow recommendations to be made The AAP concludes that “most drugs likely to be prescribed to the nursing mother should have no effect on milk supply or on infant wellbeing.”41 A significant fact is that the amount of drug excreted in the breast milk usually is not more than about 1% to 2% of the maternal dose Therefore, most drugs are of little pharmacologic significance to infants Agreement exists that a few drugs, or categories of drugs, are definitely contraindicated for nursing mothers These include lithium, anticancer drugs, radioactive pharmaceuticals, and phenindione.3,41 Table 17.3 contains recommendations adapted from the AAP regarding the administration of commonly used dental drugs during breastfeeding As with drug use during pregnancy, individual physicians may wish to modify these recommendations, which should be viewed only as general guidelines for treatment In addition to careful drug selection, nursing mothers may take the drug just after breastfeeding and avoid nursing for hours or longer if possible This should result in reduced drug concentrations in the breast milk Treatment Planning Modifications No technical modifications are required for pregnant patients However, full-mouth radiographs, reconstruction, crown and bridge procedures, and significant surgery are best delayed until after pregnancy A prominent gag reflex also may dictate a delay in certain dental procedures Many patients have a concern about mercury exposure from amalgam fillings In 2009,42 the FDA concluded that “although data are limited, existing data not suggest that fetuses are at risk for adverse health effects due to maternal exposure to mercury vapors from dental amalgam.” The FDA does note, however, that “maternal exposures are likely to increase temporarily when new dental amalgams are inserted or existing dental amalgams are removed.” The FDA furthermore concluded that “existing data support a finding that infants are not at risk for adverse health effects from the breast milk of women exposed to mercury vapors from dental amalgams.” Practitioners should be aware, however, that several European countries and Canada have national recommendations advising dentists to limit or avoid the placement and replacement of amalgams during pregnancy As for the risk to dental personnel from exposure to dental amalgam, the FDA concludes that “existing data indicate that dental professionals are generally not at risk for mercury toxicity except when dental amalgams are improperly used, stored, triturated, or handled.” Oral Complications and Manifestations The most common oral complication of pregnancy is pregnancy gingivitis (Fig 17.3) However, the incidence 298 CHAPTER 17  Women’s Health Issues FIG 17.3  Generalized gingivitis (“pregnancy gingivitis”) in a woman in the sixth month of pregnancy FIG 17.4  Pyogenic granuloma (“pregnancy tumor”) occurring during pregnancy of dental caries increases as well This condition results from an exaggerated inflammatory response to local irritants and less than meticulous oral hygiene during periods of increased secretion of estrogen and progesterone and altered fibrinolysis.10 Pregnancy gingivitis begins at the marginal and interdental gingiva, usually in the second month of pregnancy Progression of this condition leads to fiery red and edematous interproximal papillae that are tender to palpation In approximately 1% of gravid women, the hyperplastic response may exacerbate in a localized area, resulting in a pyogenic granuloma or “pregnancy tumor” (Fig 17.4) The most common location for a pyogenic granuloma is the labial aspect of the interdental papilla The lesion is generally asymptomatic; however, tooth brushing may traumatize the lesion and cause bleeding Hyperplastic gingival changes become apparent around the second month and continue until after parturition, at which time the gingival tissues usually regress and return to normal, provided proper oral hygiene measures are implemented and any calculus present is removed.10 Surgical or laser excision is occasionally required if symptoms, bleeding, or interference with mastication dictates Pregnancy does not cause periodontal disease but may modify and worsen what is already present A relationship between dental caries and the physiologic processes of pregnancy has not been demonstrated Caries activity is attributed to the presence of cariogenic bacteria in the mouth, a diet containing fermentable carbohydrates, and poor oral hygiene Control of the carious process through fluoride and chlorhexidine is important because maternal saliva is the primary vehicle for transfer of cariogenic streptococci to the infant.43 Many women are convinced that pregnancy causes tooth loss (i.e., “a tooth for every pregnancy”) or that calcium is withdrawn from the maternal dentition to supply fetal requirements (i.e., “soft teeth”) Calcium is present in the teeth in a stable crystalline form and hence is not available to the systemic circulation to supply a calcium demand However, calcium is readily mobilized from bone to supply these demands Therefore, although calcium supplementation for the purpose of preventing tooth loss or soft teeth is unwarranted, the physician may prescribe calcium to fulfill the general nutritional requirements of the mother and infant Tooth mobility, localized or generalized, is an uncommon finding during pregnancy Mobility is a sign of gingival disease, disturbance of the attachment apparatus, and mineral changes in the lamina dura Because vitamin deficiencies may contribute to this and other congenital problems (e.g., folate deficiency: spina bifida), the dentist, when discussing oral hygiene, should take this opportunity to educate the patient about the benefits of the use of multivitamins Daily removal of local irritants, adequate levels of vitamin C, and delivery of the newborn should result in reversal of tooth mobility Pregnant women often have a hypersensitive gag reflex This, in combination with morning sickness, may contribute to episodes of regurgitation and lead to halitosis and enamel erosion The dentist should advise the patient to rinse after regurgitation with a solution that neutralizes the acid (e.g., baking soda, water) OSTEOPOROSIS Osteoporosis is defined as a skeletal disorder that compromises bone strength, predisposing a person to an increased risk of bone fracture due to inhibited calcium intake and mineral loss According to World Health Organization criteria, osteoporosis occurs when the bone mineral density (BMD) is measured to be 2.5 standard deviations (SDs) less than the average value for young healthy women (a T-score of
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