Management of the Hypertensive Dental Patient.

Hypertension is a serious chronic illness that affects more than a third of the world's population. The high prevalence of hypertension coupled with its lack of initial clinical symptoms can make managing a hypertensive patient in a dental setting difficult. The dentist's role in managing hypertensive patients encompasses more than simple treatment modifications. Because of the frequency of dental checkups, dentists play an integral role in the detection of elevated blood pressure and appropriate subsequent referral. As such, it is imperative that dentists are aware of risk factors associated with hypertension to council patients early. In addition, antihypertensive medications pose a risk in dental treatment. Such drugs may produce various oral presentations and interact negatively with drugs commonly prescribed by the dentist. It is critical to recognize these changes and avoid possible interactions. Furthermore, dental treatment can often induce fear and anxiety resulting in an increase in blood pressure; this can further complicate management of patients with pre-existing hypertension. As research and recommendations are constantly changing, dentists must stay informed on how to appropriately administer care. This article is intended to provide the dental team with clear guidelines on the overall management of a hypertensive patient in a dental clinic.

Bell's Palsy: Etiology, Management and Dental Implications.

Bell's palsy is the most common mononeuropathy that causes acute unilateral facial paralysis or paresis. The condition peaks within 72 h and may be associated with numerous signs and symptoms, including post-auricular pain, drooping of the eyelid, loss of taste sensation and decreased lacrimation. Although the etiology of the condition is unknown, inflammation, viral infection, ischemia and anatomy of the facial nerve have all been implicated in the pathophysiology of the disease. Diagnosis and determination of etiology are significant in the early management of this condition. Most incidents resolve spontaneously; however, treatment reduces cases of incomplete recovery and entails the use of corticosteroids, with a possible role for antivirals if a viral etiology is suspected. For patients with incomplete recovery, long-term complications have esthetic, physiological and psychological implications, which greatly affect their quality of life. The purpose of this article is to summarize the current literature on etiology, diagnosis and management of Bell's palsy.

Medical Management, Orofacial Findings, and Dental Care for the Patient with Parkinson's Disease.

Parkinson's disease (PD) is the second most prevalent neurodegenerative disease in North America, next to Alzheimer's disease. Patients who suffer from PD typically present with neuromuscular, cognitive, postural and psychiatric deficits, which make oral hygiene challenging, but extremely important. Although the cardinal signs of PD are movement-related, manifestations in the orofacial complex are ubiquitous. Weakened facial musculature, gaunt appearance, tremors of the tongue, lips and eyes, erratic mandibular movements, bruxism, xerostomia, sialorrhea, dysphagia, dysgeusia and glossitis are examples of the plethora of atypical orofacial findings associated with PD. Further complications, including angular cheilosis, attrition, temporomandibular joint disorders, burning mouth syndrome, hyposmia and hypophonia, may arise as a consequence of these orofacial manifestations. The effects of PD on the orofacial complex may result in poor nutritional habits, which can exacerbate weight loss and contribute to a negative impact on physical, psychosocial and emotional health. Dentists should be able to identify signs of PD systemically, including but not limited to the orofacial region, to optimize the management of PD patients. Here, we report practical recommendations for the medical and dental management of patients with PD in accordance with the most recently published clinical practice guidelines.

Mouthguards in dentistry: Current recommendations for dentists.

Properly fitted mouthguards reduce the risk and severity of orofacial injury, to both hard and soft tissues, preventing thousands of dollars of trauma management. In this review, findings from recent research will be evaluated to discuss the strengths and limitations of the different types of mouthguards, including their indications by sport. Design, ideal dimensions, and other characteristics will also be explored. Additionally, patient education and motivation will be examined, with a focus on the dentist's role in this regard. Finally, in addition to proper oral hygiene, the importance of proper mouthguard maintenance and evaluation will be discussed. This review will therefore be able to act as a guide for dentists looking to provide patients of all ages with personal protective equipment and stay up-to-date on recent developments in this branch of the sports dentistry field.

Diagnosis, Management, and Dental Considerations for the Diabetic Patient.

Current epidemiological data suggest that the prevalence of diabetes in Canada is increasing. Patients with poor glycemic control are more prone to oral manifestations of diabetes, including periodontal disease, salivary gland dysfunction, halitosis, burning mouth sensation, delayed wound healing and increased susceptibility to infections. Diabetic patients are also at risk of experiencing an intraoperative diabetic emergency in the dental office. Therefore, dentists must appreciate and implement important dental management considerations while providing care to diabetic patients. In this article, we discuss the diagnosis, oral findings, dental care and emergency management of diabetic patients.

Dental Management of Patients Undergoing Antithrombotic Therapy.

For more than half a century, oral anticoagulant and antiplatelet therapy has been used to decrease the risk of thromboembolism, prolonging the lives of countless patients. Patients taking antithrombotic agents may be at risk of excessive hemorrhage. Dentists commonly see such patients, and this can pose a challenge, as adequate hemostasis is crucial for the success of invasive dental treatment. Many dentists refer these patients, as they lack understanding or fear uncontrollable bleeding during and after surgery. In this clinical review, we discuss the mechanisms of hemostasis, drugs that can interfere with these pathways and how to safely and effectively manage patients who are taking antithrombotic agents. We include which procedures are considered safe, which are riskier in terms of bleeding, what laboratory tests must be reviewed before treatment, drug interactions with commonly prescribed dental drugs, as well as agents that can aid in hemostasis. Although antithrombotics cause an increase in bleeding, there is general consensus that treatment regimens should not be altered before routine dental procedures when the risk of bleeding is moderate to low. Procedures that require drug alterations include extractions of more than 3 teeth, crown lengthening, open-flap surgery, surgical extractions and periodontal surgery.

Pharmacotherapy in Temporomandibular Disorders: A Review.

Temporomandibular disorder (TMD) is a collective term that includes disorders of the temporomandibular joint (TMJ) and of the masticatory muscles and their associated structures. TMDs are characterized by pain, joint sounds and restricted mandibular movement, and drugs are widely used in the management of that pain. Pharmacological agents commonly used for the treatment of TMDs include non-steroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids, muscle relaxants, antidepressants, anticonvulsants and benzodiazepines. In this paper, we discuss these agents and the potential adverse drug reactions and interactions associated with their use. Temporomandibular disorder (TMD) is a collective term used for a number of clinical problems that involve the masticatory muscle complex, the temporomandibular joint (TMJ) and associated structures. TMD is one of the most common disorders in the maxillofacial region. Signs and symptoms of TMD may include pain, impaired jaw function, malocclusion, deviation from the midline on opening or closing the jaw, limited range of motion, joint noises and locking.1 Among other signs and symptoms, headaches and sleep disturbances can appear concomitantly.2 This disorder is most prevalent in people aged 20-40 years.3 Approximately 33% of the population have at least 1 TMD symptom, and 3.6-7.0% of the population have TMD with sufficient severity to seek treatment.3 There is some evidence to suggest that anxiety, stress and other emotional disturbances exacerbate TMD.4 As many as 75% of patients with TMD have a significant psychological abnormality.5 Most TMD symptoms resolve over time, but, for a significant number of patients, this may take a year or more.3 Treatment is directed toward reducing pain and improving function. Many non-invasive therapies, such as self-care, physical therapy and appliance therapy, are commonly used for the treatment of TMD.3 Pharmacological intervention has been used for many years, and the most effective pharmacological agents for the treatment of TMD include analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids, anxiolytics, muscle relaxants, antidepressants, anticonvulsants and benzodiazepines. However, we found only 1 relevant Cochrane study, which included 11 randomized controlled trials of pharmacotherapy for TMD.6 In this article, we review the pharmacology and research supporting the use of a host of pharmacologic agents that have been prescribed for patients who have TMD. The decision to select any of these agents depends on a full understanding of the drug's risks and benefits.

THE INFLUENCE OF SYSTEMIC MEDICATIONS ON OSSEOINTEGRATION OF DENTAL IMPLANTS.

Dental implants are routinely used to treat edentulism. Their success depends on osseointegration, the direct functional and structural interlocking of implant and bone. The osseointegration mechanism is similar to bone remodeling and healing. Thus, chronic use of systemic medications that can interfere with bone turnover and healing may affect osseointegration, resulting in premature implant loss. The aim of this narrative review is to analyze the reported effects of systemic medications on osseointegration.

PHARMACOTHERAPY FOR THE ELDERLY DENTAL PATIENT.

Current demographic data clearly show that the North American population is aging, and projections suggest that the percentage of older people will increase. The elderly often suffer from multiple chronic conditions that affect their quality of life, use of health services, morbidity and mortality. Also, in those of advanced age, the pharmacokinetics and pharmacodynamics of many drugs are altered. Polypharmacy increases the incidence of adverse drug reactions and drug interactions in this population. Thus, the dentist must be continually aware of the pharmacologic status of each patient and consider the likelihood of interactions between drugs prescribed by the dentist, drugs prescribed by the physician and drugs that are self-administered, including over-the-counter medications and natural supplements. In this article, we discuss pharmacokinetic and pharmacodynamic changes in the elderly patient, polypharmacy and the changes in prescribing for our dental patients. Specific emphasis is placed on the drugs commonly prescribed by dentists: local anesthetics, analgesics and antibiotics.

Tooth surface loss: causes, management, and prevention.

OBJECTIVES: Tooth wear, also referred to as tooth surface loss, occurs due to causes other than caries. This involves the loss of hard tissues, namely enamel, dentin, and/or cementum. Types of tooth wear/tooth surface loss are abrasion, abfraction, attrition, and erosion. These multifactorial conditions can be caused by factors such as lifestyle, diet, or even habits, and may not be symptomatic. The focus of this article is to provide clinicians with detailed examples and explanations of the causes of tooth loss to aid in early diagnosis. Through early identification, the preventive measures outlined can be implemented to avoid excessive tooth wear. The provision of a treatment flowchart and general treatment recommendations aims to help clinicians determine when to restore these lesions and the most appropriate treatment measures for the four types of wear. METHOD AND MATERIALS: The PubMed (MEDLINE) search engine was used to gather information on teeth restricted to a 5-year period (26 August 2018 to 25 July 2022). Only English-language studies and reviews with the best balance of sensitivity and specificity were considered. A Boolean search of the PubMed dataset was implemented to combine a range of keywords: ("tooth wear" OR tooth attrition OR tooth erosion OR tooth abrasion OR tooth abfraction). Additional articles were selected through Google Scholar. RESULTS: By this process, many articles and studies were obtained, and the 48 most relevant published studies were chosen and used in the current review. CONCLUSION: Tooth wear affects an increasing number of individuals and can have detrimental effects physically, mentally, and emotionally. It is important to stress early diagnosis and management of tooth wear through monitoring, prevention, and treatment where indicated.

Management of Oral Manifestations of Herpes Simplex Virus, Varicella Zoster Virus, and Human Papillomavirus.

Human herpes virus is a family of DNA viruses that includes herpes simplex virus (HSV) and varicella zoster virus (VZV). HSV-1 and HSV-2 are fairly common and result in oral and genital lesions. Recurrent infections of herpes include lesions on the lips resulting in pain and possibly societal stigma, making adequate treatment of these conditions crucial. VZV is the cause of chicken pox and shingles. Acyclovir and other nucleoside analogues have been the gold standard of treatment for HSV and VZV, but newer, more effective treatments are being developed, which is beneficial regarding the issue of resistance to standard antivirals. Human papillomavirus (HPV) is also a DNA virus with different subtypes that result in four common oral benign lesions. The significance and treatments of HSV, VZV, and HPV are discussed, along with certain developing treatments of herpes labialis (HSV).

Dental and medical management of the patient with bipolar disorder.

OBJECTIVE: The objective of this literature review is to understand the appropriate medical management of patients with bipolar disorder (BD) which subsequently can translate into the effective dental management of patients suffering with this illness METHODS: This study was completed using three databases which included PubMed, Google Scholar and Cochrane library. Additionally, relevant dental and medical textbooks were also used to summarize more complex topics regarding BD. Descriptors used to find relevant articles included "Bipolar Disorder", "Adverse drug effects of bipolar medications", and "Orofacial findings with patients with bipolar disorder". A total of 49 relevant articles and textbooks were found which were included in this literature review. RESULTS: BD is a mental illness which affects millions worldwide. It is characterized by alternating episodes of mania and depression. During the manic phase there is an abnormal elevation in mood whereas the depressive episodes consist of the opposite. The medical management of BD involves pharmacotherapy and psychotherapy. Common dental findings in patients with BD include caries, periodontal disease, xerostomia and adverse oral effects from the medications used to manage this illness. CONCLUSION: BD has a significant burden on society and to effectively manage their medical and dental needs, the clinician must be well versed in their illness.

Adverse Events in Pediatric Dental Practice: Survey of Pediatric Dentists in the United States.

Purpose: To survey pediatric dentists in the United States regarding adverse events during dental care for children. Methods: A self-administered, anonymous online survey was sent to American Academy of Pediatric Dentistry members (N equals 6,327) using REDCap® software (between October and December 2019). The questionnaire (all items with radio-button numerical categories) included five items surveying pediatric adverse event occurrence and seven demographic items. Annualized occurrences of adverse events in US pediatric dental practices were extrapolated from the data collected. Results: The survey response was 11 percent (n equals 704), with 91 percent of respondents reporting that at least one child experienced an adverse event during dental treatment. The two most prevalent adverse events, each reported by 82 percent of respondents, were self-inflicted trauma to soft tissues after local anesthesia and nausea and vomiting, with annualized estimates of 7,816 and 7,003, respectively. Major adverse events (respiratory depression, cardiovascular depression, neurological damage, death) during pediatric dental treatment were reported by 14 percent of respondents (annualized estimate equals 443). "Wrong" errors (wrong tooth/wrong procedure/wrong patient) were reported by 24 percent of respondents (annualized estimate equals 600). Conclusions: Adverse events during pediatric dental care are of noticeable concern with some (wrong tooth/wrong procedure/wrong patient errors) that can be procedurally mitigated.

Pharmacological Management of the Dentally Anxious Patient.

Dental anxiety is a complex psychological problem in which patients associate negative feelings with the dental experience and is determined clinically through physiological and behavioral presentations. Self-reporting along with questionnaires and patient interviews can indicate the level of a patient's dental anxiety and guide the dentist in determining the appropriate management. Nonpharmacological methods of managing dental anxiety should be exhausted before pharmacological sedative techniques are considered. Nitrous oxide with oxygen is frequently used in the dental setting because of its relative safety, ease of use, and effectiveness for patients with mild to moderate dental anxiety. Oral sedation may be used for moderate to severely anxious patients and most typically consists of the administration of a single benzodiazepine drug prior to the dental appointment. Combination therapy of nitrous oxide with oxygen and oral sedation may be an option to increase the efficacy of both routes of sedation. Conscious intravenous sedation is a viable alternative for practitioners to use if they are adequately trained and certified to do so. Special considerations may apply for sedation of pediatric, elderly, and medically compromised patients and those with cognitive, physical, and/or behavioral disabilities. Sedation guidelines vary regionally, and dental professionals providing sedation must do so only with adequate training and certification as set by their local medical and dental regulatory governing bodies. This article provides a general review of the pharmacological management of dentally anxious patients as seen by a general dentist.

Chlorhexidine in Dentistry: Pharmacology, Uses, and Adverse Effects.

OBJECTIVES: The aim of this work was to review the current uses of chlorhexidine (CHX) in dentistry based on its mechanism of action, whilst highlighting the most effective protocols that render the highest clinical efficacy whilst limiting adverse drug reactions. METHODS: A literature search was conducted using the key words chlorhexidine, mechanism of action, adverse effects, and dentistry using databases in the University of Toronto library system. The titles and abstracts were read, and relevant articles were selected. RESULTS: A total of 1100 publications were identified, 100 were investigated, and 67 of them were used. Out of the 67 selected articles, 12 were reviews on CHX; 5 articles focussed on CHX gels; 13 focussed on CHX mouthwashes; 8 focussed on CHX products; 13 discussed adverse effects associated with CHX; 13 focussed on periodontal pathology and treatment; 6 focussed on implant periodontal and dental surgeries; 7 evaluated effects on caries; 6 looked at the mechanisms of action; and 12 focussed on the antibacterial and antimicrobial impact on the oral biome. There were multiple areas of overlap amongst the articles, and results showed that CHX provides different uses, but mainly as an adjunct to various treatments. Mouthwash was the most superior medium when used in short time spans when mechanical prophylaxis was not possible for the prevention of gingivitis and maintenance of oral hygiene. CHX products are often used in periodontics, post-oral surgical procedures, and as a prophylaxis for multiple invasive procedures with minimal adverse effects. Tooth staining was the most negative adverse effect reported by patients. CONCLUSIONS: CHX's antimicrobial properties make it an ideal prophylactic when mechanical debridement is not possible. CHX mouthwash appears to be more effective compared to gels. Concentrations of 0.12% to 0.2% are recommended; any mouthwash with concentrations above 0.2% will unnecessarily increase the unwanted side effects. CHX is useful amongst various areas of dentistry including oral surgery, periodontics, and even general dentistry. For long-term treatments, especially in periodontitis patients (stage I-III) undergoing nonsurgical treatments, CHX chips are recommended. CHX chips are also recommended as an adjunct to implant debridement in patients with peri-implant mucositis and peri-implantitis over CHX mouthwash and gels.

Drug-Induced Gingival Enlargement: A Review of Diagnosis and Current Treatment Strategies.

Drug-induced gingival enlargement (DIGE) is a biofilm-mediated gingival inflammatory condition associated with pharmacological agents. Specifically, calcium channel blockers, immunosuppressants, and anticonvulsants are among the primary medications associated with DIGE. Modifiable risk factors for DIGE include drug dose and dental biofilm, and the use of concomitant inducing medications. Although the clinical presentation of DIGE depends on these and patient-specific variables, its classical appearance is described as fibrotic, pink, bulbous, or mulberry-shaped overgrowths of the attached gingiva and dental papillae, with no bleeding on probing. The clinical manifestations of DIGE may worsen as the disease increases in severity. Likewise, the treatment strategies become more complex. The dental management of DIGE includes nonsurgical, surgical if necessary, and maintenance therapies. Drug substitutions, which may only be considered in consultation with the patient's family physician or primary healthcare provider, are a form of nonsurgical therapy. DIGE can be extremely debilitating, especially in its advanced stages, and make oral hygiene cumbersome, which translates to poorer oral and periodontal health outcomes. Therefore, DIGE must be properly identified and treated accordingly to re-establish a healthy and maintainable periodontium.

The dental management of the asthmatic patients.

Asthma is the most common chronic respiratory condition characterized by airway inflammation and obstruction. Our increased knowledge and understanding of the etiology and pathogenesis of this condition has widely assisted us in delivering effective therapies. Physicians strive to provide the best treatment modality to achieve symptom-control and minimize the adverse effects of medication use. Nonetheless, patients continue to endure oral complications from the use of asthma medications. As dentists, it is prudent to address these oral complications and promote the oral health of these patients by way of early preventive and therapeutic dental intervention. This must be accomplished by adhering to certain precautionary measures for the sake of avoiding intraoperative problems while optimizing oral care. In this article, we discuss the diagnosis, oral findings, dental care, and emergency management of the asthmatic patients.

Adrenal Insufficiency and Its Implications on Dental Treatment.

Adrenal insufficiency is a rare disease affecting the function of the adrenal glands leading to hormone deficiency. Medical management of these patients often consists of a scheduled regimen of hormone replacement therapies along with patient education on the management of medical emergencies, such as adrenal crisis. The primary goal of the clinician in the dental management of these patients is the minimization of stressful stimuli while being adept and equipped to manage spontaneous occurrences of adrenal crisis. Understanding the pharmacological effects and interactions of these patients' medications is also important in managing their treatment. This article outlines the underlying pathology and clinical manifestation of adrenal insufficiency and underscores specific recommendations for the medical and dental management of such patients to avoid adrenal crisis both inside and outside the clinical setting. The dentist, as one of the primary care providers for these patients, should be able to identify the physical and orofacial signs and symptoms associated with this disorder so that the patient may be diagnosed and treated as best as possible.

Fungal infections in dentistry: Clinical presentations, diagnosis, and treatment alternatives.

Oral candidiasis is a common opportunistic infection that requires knowledge of the various clinical presentations and management strategies for successful treatment. Numerous local and systemic factors contribute to the development of candidiasis, and the infections can range from superficial mucocutaneous overgrowths to invasive bloodstream infections with a high mortality rate. In addition to Candida albicans, various fungal strains have been isolated from the oral cavity, including C. tropicalis, C. glabrata, C. krusei, and many others. Antifungal agents are available in various forms, each with differing indications, dosing regimens, adverse effects, and drug interactions. Some antifungal agents are available as oral suspensions, pastilles, or creams, whereas others are administered systemically in capsule or intravenous form. This review describes the various presentations of oral candidiasis and the diagnostic methods and treatment alternatives, with a specific focus on pharmacologic management. Spectra of activity, mechanisms of action, adverse reactions, drug interactions, and dosing regimens are explored in the context of both topical and systemic pharmacotherapy used to treat candidiasis. Polyenes (nystatin, amphotericin B); azoles (ketoconazole, miconazole, clotrimazole, fluconazole, itraconazole, voriconazole, posaconazole, isavuconazole); and echinocandins (caspofungin, micafungin, anidulafungin) are discussed. Novel approaches in antifungal therapy with the use of probiotics are also reviewed.

Local anaesthesia in dentistry: a review.

Over the past century, there is perhaps no greater contribution to the practice of clinical dentistry than the development and application of local anaesthesia. What were once considered painful procedures have now been made routine by the deposition and action of local anaesthetics. This article will serve as a review of basic pharmacological principles of local anaesthesia, subsequent sequelae that can arise from their use, considerations when using local anaesthetics, and recent advances in the delivery of local anaesthetics.