The pregnant patient: considerations for dental management and drug use.

The pregnant woman who presents for dental care requires special consideration. This article reviews physiologic changes associated with pregnancy and current considerations for the dental treatment of pregnant dental patients, as well as for pregnant dental professionals. The limitations and safety of commonly used drugs and anesthetics are discussed. Recommendations for prenatal oral counseling are presented.     

Care of the pregnant patient in the dental office.

Attention to a woman's dental health can and should continue throughout pregnancy. The treating dentist must be diligent to the special situations surrounding treating the pregnant patient and the risks involved for both fetus and mother. Undertaking the proper precautions with these patients not only provides the best dental care, but also helps avoid potential complications. Any complication or question that arises with a complicated pregnancy should prompt referral to the patient's obstetrician for further evaluation.     

Adverse drug interactions in dental practice: interactions involving antibiotics. Part II of a series

BACKGROUND: The prudent use of antibiotics is an integral part of dental practice. While these agents generally are considered safe in the dental setting, their use can result in interactions that can lead to serious morbidity in dental patients. METHODS: The faculty of a symposium entitled "Adverse Drug Interactions in Dentistry: Separating the Myths From the Facts" did an extensive literature review on drug interactions. Through this, they were able to establish a significance rating of alleged adverse drug interactions as they relate to dentistry, based on their scientific documentation and severity of effect. The author of this article focused on antibiotics. RESULTS: Most of the reported drug interactions discussed in this article are well-documented by clinical studies. It is particularly important that dentists be aware of the potentially serious and life-threatening interactions of the antibiotics erythromycin, clarithromycin and metronidazole, and of the antifungal agents ketoconazole and itraconazole, with a host of other drugs whose metabolism is impaired by these antimicrobial agents. In contrast, the alleged ability of commonly employed antibiotics to reduce the effectiveness of oral contraceptive agents is not adequately supported by clinical research. It still is recommended, however, that clinicians discuss this possible interaction with their patients, as it might represent a relatively rare event that cannot be discerned in clinical trials. CONCLUSIONS: Potentially serious adverse drug interactions can occur between antimicrobial agents used in dental practice and other drugs patients are taking for a variety of medical conditions. CLINICAL IMPLICATIONS: It is important that dentists stay abreast of potential drug interactions involving antibiotics to avoid serious morbidity among their patients.     

Considerations in the management of the pregnant patient

Traditionally, general dentists have been reluctant to treat pregnant patients due to uncertainty of the risks that might be imposed on both the mother and the fetus. However, preventive, emergency, and routine dental procedures are all suitable during various phases of a pregnancy, with some treatment modifications and initial planning. This article will review some of the physiologic changes and oral pathology associated with pregnancy, and how these alterations affect dental care for the patient. A brief discussion concerning the risks and benefits of radiation, certain medications, and pre-natal fluoride is also given. Additionally, an overview of possible obstetric emergencies that may arise during a general dental appointment is presented with treatment options outlined.     

Considerations for dental care during pregnancy

Traditionally, general dentists have been reluctant to treat pregnant patients due to uncertainty of the risks that might be imposed on both the mother and the fetus. However, preventive, emergency, and routine dental procedures are all suitable during various phases of a pregnancy, with some treatment modifications and initial planning. This article will review some of the physiologic changes and oral pathology associated with pregnancy, and how these alterations affect dental care for the patient. A brief discussion concerning the risks and benefits of radiation, certain medications, and pre-natal fluoride is also given. Additionally, an overview of possible obstetric emergencies that may arise during a general dental appointment is presented with treatment options outlined.     

Local anesthetics and medically complex patients

As the population ages and medical science advances, more and more patients with complex medical histories will be seeking care in private dental practices. This paper will review a variety of disease entities as well as potential drug interactions pertinent to the use of local anesthetic agents in medically complex patients.     

Drug addiction and dental care.

Patients who are addicted to drugs, or are being treated for drug addiction, present a variety of management issues when they attend for dental care. A number of factors are related to the treatment planning and clinical management. Dentists should be aware of these factors in order to manage these patients sensitively and effectively. Important management issues include medical problems associated with drug abuse, dental problems and how drug abuse and its subsequent treatment affect the dentition, behavioural disorders, pain management, and control of cross-infection. People who have recovered from chemical dependency to opiates have special needs, especially in pain management. Establishing a good pre-treatment rapport with the patient will assist the dentist in reducing the need for postoperative analgesics, and will encourage this group of patients to return and obtain needed dental care. The more dental practitioners know about types and patterns of drug abuse and recovery programmes, the more safely this group of patients with special needs can be managed.     

Migraine drug therapy: dental implications

Triptan drugs continue to constitute the major pharmacotherapeutic interventional agents for migraine therapy. Interactions of dental drugs with migraine medications are limited, but their seriousness dictates that dentists be aware of the use of ergot alkaloids, triptans, or other migraine drugs. While many migraine sufferers avoid dental therapy dur ing migraine attacks, the practitioner who is treating a patient who has taken migraine medications must carefully monitor the cardiovascular status of the patient, which may affect the use of vasoconstrictors. Macrolide antibiotics and azole antifungals represent additional drug groups that are prescribed by dentists but which may potentiate the adverse effects of migraine drugs. Migraine patients prefer agents that offer rapid onset of relief and total relief within a couple hours of drug administration; they also prefer therapy that prevents recurrences and does not require "rescue" medications, and, of course, a lack of adverse effects and interactions with other medications. Currently, no single drug or class of drugs offers this ideal combination of actions in all patients.     

Dental implications of mood disorders

Mood disorders refers to a heterogenous group of mental conditions characterized by extreme exaggeration and disturbance of mood and affect. This article examines major depression and bipolar disorders and how these disorders can affect a patient's dental care. The drugs used to treat these conditions have significant side effects that dentists should be aware of. In addition, important drug interactions can occur as a result of agents used by the dentist. The dentist should refer patients found with signs and symptoms of mood disorders for medical evaluation and treatment. Depressed patients often have poor oral hygiene due to a lack of interest in self-care. Xerostomia occurs due to depression and the drugs used to treat it. The dentist needs to provide an aggressive preventive dental education program for these patients, including the use of artificial salivary products, mouthwashes, and topical fluoride applications, in addition to the treatment of candidiasis when present.     

Impact of drug abuse/dependence on dentists

Drug abuse and dependence are important and complex health problems, and understanding these issues is important for dental patient management. At the same time, dentists, like their patients, could abuse alcohol and other illicit drugs, which would jeopardize their ability to provide optimum dental care. This article reviews important aspects of drug abuse and dependence, risk factors for dentists, the impact of drug abuse on the dental profession, and various treatment options.     

The pregnant patient: considerations in dental care

Although definitely not a disease, pregnancy poses a unique set of circumstances and necessary precautions for the dentist. The hormonal and anatomic changes produce effects that must be accounted for in providing dental care. As pregnancy is a transitory state, many elective dental procedures can be scheduled for completion after the baby is born. Pregnancy, however, does present the potential for dental problems that will require preventive strategies or actual treatment during pregnancy. Many medications commonly used in dentistry are acceptable for use by pregnant patients, particularly in the last two trimesters, but care must be exercised in their selection.     

Beyond warfarin: the new generation of oral anticoagulants and their implications for the management of dental patients

Warfarin has been the primary anticoagulant drug used in the USA for more than 50 years. However, 2 novel types of oral anticoagulants have recently been approved for use in the USA. These are direct thrombin inhibitors (e.g., dabigatran etexilate) and factor Xa inhibitors (e.g., rivaroxaban). Dental health care providers may soon encounter patients who are being prescribed these medications. This article describes the pharmacologic properties and medical uses of these new oral anticoagulants. Also discussed are implications for the management of dental patients being treated with these new oral anticoagulants, including potential interactions with drugs commonly used or prescribed in the course of dental treatment.     

Adolescent pregnancy: a review of dental treatment guidelines

More than 6% of adolescent females become pregnant in the United States per year, yet there is no concise guide for their dental treatment. The principles for medical management of these patients are not unlike those used for adult females, but the higher incidence of complications coupled with social and consent issues make their overall management more complex. Whether treating a pregnant adolescent or an adult, the primary goal is to maintain a safe environment for both the fetus and mother. Untreated dental disease can compromise the health of the mother and unborn child; therefore, dental treatment should not be withheld. In complicated pregnancies, dental practitioners should contact the patient's obstetrician prior to providing treatment or prescribing medication. With proper technique, dental radiographs do not place the fetus at risk and should be taken if they are of potential benefit. Preventive care should be delivered throughout pregnancy, and elective routine care is best delivered during the second trimester.     

Dental management of the pregnant patient

The pregnant patient presents several considerations for providing dental treatment. Among these are that there are two persons involved in the dental treatment of a pregnant woman, the woman and the baby. Each presents a different set of problems. The mother basically presents no difficult problems for dental treatment. She needs to have routine dental treatment provided. All procedures can be done. Because of the fetus, certain precautions in the use of drugs and radiographs must be taken. If it is determined in taking the history that a person may be pregnant and she is not seeing an obstetrician, the dentist should urge her to see one at her earliest convenience. It is well documented that early and good prenatal care decreases the risk to the mother and to the fetus. Diabetes, hypertension, and anemias are frequently associated with pregnancy and produce a threat to the developing fetus. These diseases, along with any other systemic diseases and infections that pose threats to either the mother or the fetus, are normally detected with good prenatal care.     

The use of COX-2 inhibitors for acute dental pain: A second look

BACKGROUND: On the basis of their perceived better safety profile compared with other analgesic agents, cyclo-oxygenase-2 (COX-2) inhibitors have been prescribed frequently as first-line agents to treat acute dental pain. However, recently identified cardiovascular adverse reactions associated with these drugs mandate a reappraisal of their use in dental practice. TYPES OF STUDIES REVIEWED. The authors reviewed 18 clinical studies that evaluated the efficacy of a COX-2 inhibitor for the treatment of acute dental pain. All of the studies used the widely established third-molar surgical extraction model to induce postsurgical inflammatory based pain, and all were randomized, double-blinded and placebo-controlled. However, numerous vagaries in overall study design made direct comparisons difficult. RESULTS: None of the studies established any of the COX-2 inhibitors as clearly better than ibuprofen, the current gold standard for the treatment of surgically induced dental pain. However, in single-dosing scenarios, the COX-2 inhibitor often demonstrated a longer duration of action compared with ibuprofen. CLINCAL IMPLICATIONS: The evidence to date fails to demonstrate any therapeutic advantage to using a COX-2 inhibitor to treat acute dental pain compared with ibuprofen. In the rare event that a COX-2 inhibitor may be appropriate, the clinician must inform the patient of the potential risks, and the drug should be used for the shortest possible time.