Reports of bisphosphonate-associated osteonecrosis of the jaw (BON) associated with the use of Zometa (zolendronic acid) and Aredia (pamidronate) began to surface in 2003. The majority of reported cases have been associated with dental procedures such as tooth extraction; however, less commonly BON appears to occur spontaneously in patients taking these drugs.

Zolendronic acid and pamidronate are intravenous (i.v.) bisphosphonates used to reduce bone pain, hypercalcemia and skeletal complications in patients with multiple myeloma, breast, lung and other cancers and Paget’s disease of bone. Cases of BON have also been associated with the use of the oral bisphosphonates, Fosamax (alendronate), Actonel (risedronate) and Boniva (ibandronate), for the treatment of osteoporosis; however, it is not clear if these patients had other conditions that would put them at risk for developing BON. Clinical Presentation The typical clinical presentation of BON includes pain, soft-tissue swelling and infection, loosening of teeth, drainage, and exposed bone. These symptoms may occur spontaneously, or more commonly, at the site of previous tooth extraction. Patients may also present with feelings of numbness, heaviness and dysesthesias of the jaw. However, BON may remain asymptomatic for weeks or months, and may only become evident after finding exposed bone in the jaw. Dental Management It is important to understand that, based on the information currently available, the risk for developing BON is much higher for cancer patients on i.v. bisphosphonate therapy than the risk for patients on oral bisphosphonate therapy. Therefore, there are different recommendations for dental management of these patients. Further reading. http://jada.ada.org/cgi/content/abstract/137/8/1115

Common allergens include penicillin, latex, aspirin,strawberries, shellfish, and peanuts. Histamine, released by mast cells, produces virtually all the clinical signs and symptoms associated with allergic reactions, including rash, bronchospasm, and vasodilation.

The severity of the allergic reaction depends on how rapidly and where these chemicals are released. Delayed-onset allergies most commonly involve only the skin and are not life-threatening. Immediate-onset allergies are life-threatening, usually involving the respiratory and cardiovascular systems and producing bronchospasm and a drop in blood pressure. This requires immediate emergency management to keep the person alive.

The American Dental Association (ADA) website has  the current requirements from the American Academy of Orthopedic Surgeons (AAOS) and the American Heart Association (AHA), regarding antibiotic prophylaxis prior to dental treatment for patients that may be predisposed to infective endocarditis due to heart conditions or who have had total joint replacement.

www.ada.org/public/topics/antibiotics.asp

www.ada.org/prof/resources/topics/antibiotic.asp

Below I have briefly listed premedication requirements for dental treatment taken from the American Dental Association along with their direct link:

 

The American Heart Association (AHA) states that preventive antibiotics prior to a dental procedure are advised for patients with: 

1.  artificial heart valves

2.  a history of infective endocarditis

3.  certain specific, serious congenital (present from birth) heart conditions, including

• unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
• a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery  or by catheter intervention, during the first six months after the procedure
• any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device

4.  a cardiac transplant that develops a problem in a heart valve.

www.ada.org/public/topics/antibiotics.asp

 

The American Academy of Orthopedic Surgeons(AAOS) states that preventive antibiotics prior to a dental procedure are advised for patients with:

• total joint replacement

www.ada.org/prof/resources/topics/antibiotic.asp

Hypoglycemia, or low blood sugar, is most likely in a diabetic, particularly the type 1 insulin-dependent diabetic. The classic signs and symptoms are that the patient is cold, sweaty, shaking, and mentally disorientated. Many patients, however, do not exhibit these. Therefore, when reviewing the patient's medical history, it is important to ask diabetic patients to list their signs and symptoms.

Before you start dental treatment, ask your patients these questions: "When did you last take your insulin?' and "When did you last eat?" If the patient took insulin and hasn't eaten recently, give the patient some orange juice before you start treatment. Mental confusion or disorientation is often the first signs of hypoglycemia. If a diabetic patient shows either of these signs, stop treatment and apply the PABCD protocol. P. Position Patient A. Airway B. Breathing C. Circulation D. Definitive Care

Medical emergencies can and do occur, not only in your dental office but any place at any time. The entire staff and designated in-office emergency team must be trained, and emergency equipment and drugs must be available and current. The best way to handle an emergency is to start by being prepared.

Imagine you are treating a patient, stop treatment to ask her a question, and find that she is unresponsive. You quickly ask someone to tell the receptionist to call 911 and to bring you the oxygen tank. The oxygen tank finally arrives about 10 minutes later, but is almost empty. You eventually get another oxygen tank from an assistant, but it has no tubing, so there is another delay in getting the patient oxygen. The paramedics finally arrive, but it is too late-the patient is dead. WERE YOU PREPARED? You had the oxygen tank, the emergency kit, and CPR training. You may have thought you were prepared-until the patient died. Emergencies are rare in dental offices. Nonetheless, we must be prepared to manage medical emergencies when they do occur. (Dr. Stanley Malamed)