Case 1: Mr Shake Scaler
Scenario: Mr SS, 29-year-old male with known epilepsy suddenly experiences a generalized tonic-clonic seizure mid-treatment. The dental chair is reclined, and several sharp instruments on the dental tray, operator side
Management:
- Immediate Steps: Remove dangerous instruments, keep the patient supine, follow emergency protocols, clear the airway without force, and call for emergency services.
- Potential Complications: Fractured teeth, soft tissue lacerations, injury to the dental team.
- Prevention: Avoid triggers, schedule appointments when medication is at optimal levels, and maintain regular communication with the patient’s GP. Emphasize meticulous plaque control and schedule regular cleanings (e.g., 3-6 monthly).
Case 2: Ms Seizure Sinus[^15]
Scenario: Ms SS, a 43-year-old female with epilepsy presents with gingival enlargement and bleeding gums. She has been on phenytoin for several years and reports difficulty maintaining oral hygiene
Management:
- Cause of Gingival Enlargement: Phenytoin-induced gingival hyperplasia is a well-known side effect that complicates oral hygiene and increases periodontal disease risk.
- Oral Health Impact: The enlarged gingiva makes plaque control difficult, leading to increased bleeding, inflammation, and potential secondary periodontal problems.
- Treatment Approach: Emphasize meticulous plaque control with modified oral hygiene techniques. Consider referral to periodontist for professional management of gingival hyperplasia.
- Medical Consultation: Liaise with the patient’s GP/neurologist about the severity of the side effect - medication review may be necessary if the gingival hyperplasia significantly impacts oral health and quality of life.
- Ongoing Care: Schedule more frequent professional cleanings (3-4 monthly) and provide intensive oral hygiene education with appropriate aids (interdental brushes, soft toothbrushes).
Case 3: Mr Vertigo Veneer[^16]
Scenario: Mr VV, a 35-year-old male with newly diagnosed epilepsy presents for a check-up. He reports feeling dizzy and having a very dry mouth. He recently started gabapentin
Management:
- Side Effects Recognition: Dizziness, dry mouth, drowsiness, and ataxia are common adverse effects of gabapentinoids (gabapentin).
- Chair Positioning: Assist the patient when getting on and off the dental chair due to dizziness and potential ataxia. Reposition slowly to prevent falls.
- Dry Mouth Management: Educate patient on xerostomia management - recommend sugar-free saliva substitutes, increased hydration, and fluoride treatments to reduce caries risk.
- Procedural Considerations: Drowsiness, dizziness, and potential tremor can interfere with patient cooperation and precision of dental procedures. Consider shorter appointments initially.
- Drug Interactions: Be cautious with other CNS depressants (e.g., benzodiazepines for anxiety) especially since patient has just started medication.
- Timing: Consider deferring complex treatment until patient has stabilized on the new medication and side effects have diminished.
Case 4: Parkinson’s Drug Interaction
Question: Drug interactions - Entacapone + adrenaline: dental relevance?
Answer:
- Mechanism: Entacapone is a COMT (catechol-O-methyltransferase) inhibitor that prevents the breakdown of dopamine and can also affect the metabolism of adrenaline.
- Clinical Concern: Entacapone may increase the risk of tachycardia when combined with adrenaline in local anesthetics due to prolonged adrenaline effects.
- Dental Management:
- Use proper local anesthetic technique with careful aspiration, especially for nerve blocks
- Avoid intravascular injection at all costs
- Consider using the minimum effective dose of adrenaline-containing local anesthetic
- Monitor patient closely for signs of cardiovascular effects (increased heart rate, palpitations)
- Have emergency protocols readily available
Case Studies: Parkinson’s Disease[^24]
Case 1: Mr Dopamine Dentrifice
Scenario: Mr DD, 72 years old, presents for a dental extraction. He has Parkinson’s disease with prominent resting tremor and is currently taking levodopa/carbidopa and entacapone. His caregiver mentions he sometimes feels dizzy when standing up
Management:
- Chair Positioning: Reposition the patient slowly from supine to sitting to prevent orthostatic hypotension.
- Adrenaline in LA: The patient’s medication (e.g., entacapone) may increase the risk of tachycardia with adrenaline. Use proper aspiration technique, especially for blocks, to avoid intravascular injection.
- Medication Timing: Taking PD medication before the appointment helps reduce tremor and rigidity, improving cooperation.
Case 2: Mrs Rigid Root-Canal[^25]
Scenario: Mrs RR is a long-standing Parkinson’s patient on amantadine and benztropine. She complains of dry mouth and difficulty chewing
Management:
- Cause of Xerostomia: Both amantadine and benztropine (anticholinergic) can cause significant dry mouth as common side effects.
- Oral Complications: Chronic dry mouth increases the risk of dental caries, mucosal irritation, oral infections (candidiasis), and dysphagia (difficulty swallowing).
- Xerostomia Management:
- Recommend sugar-free saliva substitutes and artificial saliva products
- Encourage frequent sips of water and increased overall hydration
- Prescribe high-fluoride toothpaste and consider fluoride varnish applications
- Oral Hygiene: Emphasize meticulous oral hygiene with modified techniques to accommodate motor difficulties
- Medical Liaison: Consider discussing with patient’s GP about the severity of xerostomia side effects, as medication adjustment might be possible
- Nutritional Support: Address chewing difficulties which may affect nutrition and oral health
Management:
- Cause of Xerostomia: Both amantadine and benztropine can cause dry mouth.
- Oral Complications: Chronic dry mouth increases the risk of caries, mucosal irritation, oral infections, and dysphagia.
- Management: Recommend sugar-free saliva substitutes, increased hydration, and meticulous oral hygiene. Consider liaising with her GP about the severity of the side effect.
Case 1: Mr Forgetful Fillings
Scenario: Mr. FF, 78, presents for a routine dental check-up. He has early-stage Alzheimer’s and is currently taking galantamine. His medical history also includes hypertension. He reports dizziness and occasional fainting spells
Management:
- Implications of Galantamine: Dizziness and fainting can complicate patient positioning and tolerance of treatment.
- Adrenaline in LA: Use a correct and slow LA technique with negative aspiration. Use the minimum effective dose and monitor the patient closely.
- Drug Interactions: Avoid prescribing CYP3A4 inhibitors like erythromycin or fluconazole if possible.
Case 2: Ms Confused Composite[^31]
Scenario: Ms CC, 81, with moderate Alzheimer’s disease, is on memantine (an NMDA antagonist). She arrives for an extraction and is visibly confused and agitated. Her caregiver reports recent hallucinations
Management:
- Influence of ADRs: Confusion, agitation, and hallucinations can severely complicate communication and patient cooperation.
- Behavioral Strategies: Use calm communication, give clear and simple instructions, schedule shorter appointments, and involve a familiar caregiver to reduce anxiety.
- Consent: Ensure valid consent is obtained, either from the patient if they are deemed capable or from their legal power of attorney.
-
Case Studies: Psychotropics[^60]
Case 1: Major Depression
Scenario: 45-year-old female on sertraline (SSRI) for major depression presents for routine dental extraction. She complains of dry mouth and occasional dizziness
Management:
- SSRIs commonly cause dry mouth and initial dizziness. Watch for serotonin toxicity if considering tramadol. If the patient is non-compliant with her medication, advise her to see her GP.
Case 2: Schizophrenia[^61]
Scenario: 32-year-old male on haloperidol for schizophrenia complains of dry mouth and tremors; requires scaling and root planning
Management:
- Haloperidol can cause dry mouth, sedation, orthostatic hypotension, and extrapyramidal side effects (EPS) like tremor, which can impair oral hygiene. Monitor for QT prolongation and be cautious with CYP3A4 inhibitors.
Case 3: Bipolar Disorder[^62]
Scenario: 40-year-old male on lithium therapy presents for dental implant surgery. He reports metallic taste and mild tremor
Management:
- Metallic taste and tremor are common with lithium. NSAIDs must be used with extreme caution as they can increase lithium levels and cause toxicity.
Case 4: Anxiety & Sleep Disorders[^63]
Scenario: 28-year-old female on diazepam for short term relief of anxiety requests extraction due to painful tooth
Management:
- Diazepam causes sedation and dizziness. It can also cause dry mouth or hypersalivation (drooling), which can interfere with restorative work. Avoid co-administration with other CNS depressants.
Case 5: ADHD[^64]
Scenario: 15-year-old male treated with methylphenidate for ADHD has dental caries and complains of dry mouth
Management:
- Psychostimulants commonly cause dry mouth, increasing caries risk. There are no major drug interactions of concern for dentists. Management involves meticulous oral hygiene education, regular recalls, and fluoride treatments.
Case 6: Substance Dependence Treatment[^65]
Scenario: 38-year-old male in methadone maintenance therapy for opioid dependence complains of rampant caries and poor oral health
Management:
- Patients on methadone often have high rates of caries and periodontal disease. For pain management, avoid prescribing opioids to prevent relapse; use non-opioid analgesics instead. Be cautious with other CNS depressants and drugs that prolong the QT interval.