Rheumatologic and CT disorders: Dental Management

Question 1

what is the dental management considerations for RA and OA patients?

Answer 1

• generally the same for both (except problems relating to RA meds)
• short dental appointments
• consider physical comfort

Question 2

what are the dental treatment plan modifications for arthritis patients?

Answer 2

• if no physical disabilities no modifications
• if disabilities present: assess extent of the disabilities, assess ability to perform home care, avoid complex procedures, consider removable prosthesis

Question 3

what are the oral complications for arthritis patients and how would you manage them?

Answer 3

• TMJ pain and discomfort
• consider soft food diet, ice/heat face, occlusal appliances, consider surgery for persistent pain

Question 4

what are the dental and oral considerations for salicylate drugs used in arthritis patients?

Answer 4

prolonged bleeding but usually not clinically significant (aspirin)

Question 5

what are the dental and oral considerations for NSAIDs used in arthritis patients?

Answer 5

• prolonged bleeding but usually not clinically significant (ibuprofen, naproxen, diclofenac)
• oral ulcerations, stomatitis

Question 6

what are the dental and oral considerations for COX-2 inhibitors used in arthritis patients?

Answer 6

none

Question 7

what are the dental and oral considerations for TNF-a inhibitors used in arthritis patients?

Answer 7

none

Question 8

what are the dental and oral considerations for systemic glucocorticoids used in arthritis patients?

Answer 8

• adrenal suppression
• masking of oral infection
• impaired healing
  (prednisone)

Question 9

what are the dental and oral considerations for injectable glucocorticoids used in arthritis patients?

Answer 9

• adrenal suppression
• masking of oral infection
• impaired healing

Question 10

what are the dental and oral considerations for antimalarials (DMARDS) used in arthritis patients?

Answer 10

none

Question 11

what are the dental and oral considerations for penicillamine (DMARDs) used in arthritis patients?

Answer 11

none

Question 12

what are the dental and oral considerations for gold compounds (DMARDs) used in arthritis patients?

Answer 12

• increased infection
• delayed healing
• prolonged bleeding
• oral ulcerations

Question 13

what are the dental and oral considerations for sulfasalazine (DMARDs) used in arthritis patients?

Answer 13

• increased infection
• delayed healing
• prolonged bleeding
• intraoral pigmentation

Question 14

what are the dental and oral considerations for immunosuppressives (DMARDs) used in arthritis patients?

Answer 14

• bone marrow suppression
• increased infection
• delayed healing
• prolonged bleeding
• stomatitis

Question 15

what are the clinical practice guidelines for patients with prosthetic joint implants?

Answer 15

prophylactics are not recommended before a dental procedure to prevent prosthetic joint infection
- consider risks of providing care without
- know risks of frequent/widespread infections with antibiotic use

Question 16

what clinical reasoning is there for not administering prophylaxis in prosthetic joint implant patients?

Answer 16

• dental procedures are not associated with infections
• antibiotics before oral care do not prevent infections
• antibiotics can cause anaphylaxis, antibiotic resistance, and opportunistic infections (C. diff)
• benefits do not exceed harm

Question 17

what are the clinical circumstances that may suggest the presence of a significant medical risk in providing dental care WITHOUT antibiotic prophylaxis in prosthetic joint implant patients?

Answer 17

• Immunocompromised Patients: Inflammatory arthropathies: rheumatoid arthritis; systemic lupus erythematosus; disease, drug, or radiation induced immunosuppression
• Other Patients: Insulin-dependent (type 1) diabetes, previous prosthetic joint infections, malnourishment, hemophilia
• The individual patient’s circumstances and preferences should be considered in consultation with the orthopedic surgeon

Question 18

why should antibiotic prophylaxis not be provided in prosthetic joint implant patients with pins, plates, screws and other orthopedic hardware not in the synovial joint?

Answer 18

they are not at increased risk for hematogenous seeding by microorganisms so antibiotic prophylaxis is not recommended

Question 19

what are the clinical treatment considerations for a patient with SLE?

Answer 19

consult with MD for
- status and stability
- extent of systemic manifestations
- hematological profile
- medication list

Question 20

what are the dental treatment plan modifications to consider in a patient with SLE?

Answer 20

• arthritis and myalgia
• adverse drug side effects

Question 21

what are the dental and oral considerations for ASA and NSAIDs used in SLE patients?

Answer 21

prolonged bleeding but not usually clinically significant

Question 22

what are the dental and oral considerations for gold compounds, sulfasalazine and immunosuppressives used in SLE patients?

Answer 22

• bone marrow suppression
• anemia, agranulocytosis, thrombocytopenia
• increased infection risk
• prolonged bleeding

Question 23

what are the dental and oral considerations for corticosteroids used in SLE patients?

Answer 23

• adrenal suppression?
• additional corticosteroids usually not needed for dental procedures

Question 24

what are the hematological considerations for patients with SLE?

Answer 24

• leukopenia is common
• thrombocytopenia
• elevated PTT

Question 25

what are the oral complications and manifestations for patients with SLE?

Answer 25

- oral lesions on lips and mucous membranes - resembles lichen planus or leukoplakia

Question 26

what is the assessment for "dry mouth"?

Answer 26

Simple questions to ask your patient: 1. Do you have difficulty swallowing dry foods? 2. Does your mouth feel dry while eating a meal? 3. Do you sip liquids to aid in swallowing dry food? 4. Does the amount of saliva in your mouth most of the time seem to be too little, too much, or do you not notice it? Positive responses to 1-3 and “too little” are associated with salivary hypofunction

Question 27

what are the steps in sialometry to measure flow rate?

Answer 27

Have patient drool into graduated container for 5 minutes: 1. Unstimulated whole flow (resting) ◦ Without chewing ◦ Normal 1ml/5min 2. Stimulated whole flow ◦ While chewing something (gum, wax) ◦ Normal 5ml/5min 3. Unstimulated whole flow (Sjögren Syndrome) ◦ Without chewing ◦ Less than 0.5ml/5min

Question 28

what are the treatments for salivary hypofunction?

Answer 28

- Pilocarpine HCl (Salagen): used for radiation, xerostomia and Sjögren Syndrome; Take 5 mg tid (3 times daily) - Cevimeline (Evoxac): used for Sjögren Syndrome; Take 30 mg tid

Question 29

what are the contraindications and dose related side effects of Pilocarpine and Cevimeline?

Answer 29

- Contraindications: Uncontrolled asthma, acute iritis, narrow-angle glaucoma - Side Effects: salivation, sweating, nausea, rhinitis