Medical Clearance for Common Dental Procedures.

Medical consultations before dental procedures present opportunities to integrate cross-disciplinary preventive care and improve patient health. This article presents recommendations related to patients with certain medical conditions who are planning to undergo common dental procedures, such as cleanings, extractions, restorations, endodontic procedures, abscess drainage, and mucosal biopsies. Specifically, prophylactic antibiotics are not recommended for preventing prosthetic joint infections or infectious endocarditis except in certain circumstances. Anticoagulation and antiplatelet therapies typically should not be suspended for common dental treatments. Elective dental care should be avoided for six weeks after myocardial infarction or bare-metal stent placement or for six months after drug-eluting stent placement. It is important that any history of antiresorptive or antiangiogenic therapies be communicated to the dentist. Ascites is not an indication for initiating prophylactic antibiotics before dental treatment, and acetaminophen is the analgesic of choice for patients with liver dysfunction or cirrhosis who abstain from alcohol. Nephrotoxic medications should be avoided in patients with chronic kidney disease, and the consultation should include the patient's glomerular filtration rate. Although patients undergoing chemotherapy may receive routine dental care, it should be postponed when possible in those currently undergoing head and neck radiation therapy. A detailed history of head and neck radiation therapy should be provided to the dentist. Multimodal, nonnarcotic analgesia is recommended for managing acute dental pain.

Coccidioidomycosis (Valley Fever) in Primary Care.

Primary pulmonary coccidioidomycosis (valley fever) is caused by inhaling airborne spores of the fungus Coccidioides immitis or Coccidioides posadasii. Residing in or traveling to areas endemic for Coccidioides is required for the diagnosis; no person-to-person or zoonotic contagion occurs. The incidence of coccidioidomycosis is increasing in endemic areas, and it has been identified as the cause of as many as 17% to 29% of all cases of community-acquired pneumonia in some regions. Obtaining a travel history is recommended when evaluating patients with community-acquired pneumonia. Diagnosis usually relies on enzyme immunoassay with immunodiffusion confirmation, but these tests may not be positive for one to three weeks after disease onset. Antifungal agents are not recommended for treatment unless the patient is at risk of or shows signs of complicated or disseminated infection. When antifungals are used, fluconazole and itraconazole are most commonly recommended, except during pregnancy. Treatment may continue for as long as three to 12 months, although lifetime treatment is indicated for patients with coccidioidal meningitis. Monitoring of complement fixation titers and chest radiography is recommended until patients stabilize and symptoms resolve. In patients who are treated with antifungals, complement fixation titers should be followed for at least two years.