• All elective surgical procedures should be postponed until postpartum. Minor/outpatient oral and maxillofacial surgical procedures should follow some basic guidelines.
• The supine position should be avoided for a variety of reasons:to avoid the development of the “supine hypotensive syndrome” in which a supine position causes a decrease in cardiac output, resulting in hypotension, syncope, and decreased uteroplacental perfusion.
• In addition, the supine position may cause a decrease in arterial oxygen tension (PaO2) and increase the incidence of dyspepsia from gastoresophageal reflux secondary to an incompetent lower esophageal sphincter.
• Finally, the supine position poses an increased risk of developing DVT, by compression of the inferior vena cava, leading to venous stasis and clot formation. The ideal position of the gravid patient in the dental chair is the left lateral decubitus position with the right buttock and hip elevated by15°.

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I was happy to see another dental professional post about this topic!

Thank you.

A recent Journal of the American Dental Association report emphasizes that there are several common supplements that dentists should be informed of due to the potential for adverse interactions (July 2013, Vol. 144:7, pp. 788-795).

“Provided that patients are not taking ginkgo, St. John’s wort, evening primrose, or valerian,” the authors explained, “oral healthcare providers can prescribe or administer any of the medications used commonly in dentistry without concern about possible dietary supplement-drug interactions.”

The study authors have professional backgrounds that are well-suited to the topic. Mark Donaldson, RPh, PharmD, is a clinical professor at the University of Montana’s Skaggs School of Pharmacy in Missoula, as well as a clinical assistant professor at Oregon Health and Science University’s School of Dentistry in Portland. Co-author Riva Touger-Decker, PhD, RD, is a professor and director of the New Jersey Dental School’s Division of Nutrition and chair of the University of Medicine and Dentistry of New Jersey’s Department of Nutritional Sciences.

They note that “recognition and avoidance” of dietary supplement-drug interactions is necessary to ensure that dentists keep their patients safe. Seniors in particular are at greater risk; one study reported that people older than 65 are seven times more likely to have an adverse reaction to drug interactions than younger people. The results of another NIH survey that found that 67% of those 50 and older had not discussed complementary and alternative medicine (CAM) with their healthcare provider. In that survey, 42% were not asked about CAMs, while 30% did not know they should broach the subject. Clearly, there are unnecessary risks being taken, along with a need for diligence in having patients disclose what supplements they use, the study authors noted.

Deadly combinations

For their report, they honed in on adverse interactions that had been substantiated with randomized, controlled clinical trials or meta-analyses. Acetaminophen, for example, received a strong recommendation among analgesics for patients taking dietary supplements “because it is not associated with any clinically significant dietary supplement-drug interactions.”

The combination of aspirin and ginkgo or evening primrose, however, was assigned a “D” rating according to the Lexi-Comp clinical database, indicating that a practitioner should “consider therapy modification.” Those two supplements combined with ibuprofen also received a “D” rating.

In the realm of antibiotics, amoxicillin, cephalexin, metronidazole, and penicillin are considered the best choices for patients taking dietary supplements, the authors noted. However, calcium supplements may prevent doxycycline and tetracycline from being absorbed, limiting their effectiveness and earning the combination a “D” rating.

The researchers also cautioned about the use of several sedatives on patients who are taking certain dietary supplements. “Significant interactions exist between St. John’s wort or valerian and the most commonly used benzodiazepines (alprazolam, diazepam, lorazepam, midazolam, and triazolam), as well as zaleplon and zolpidem,” they wrote. The safest alternative for patients requiring a sedative who are taking those supplements is nitrous oxide-oxygen, they noted.

At the end of the day, there were four dietary supplements that had the greatest potential for adverse drug interactions: St. John’s wort, ginkgo, evening primrose, and valerian.

“For a patient who is taking one of these four dietary supplements, the prudent practitioner may ask him or her to stop taking the supplement for at least four half-lives before a dental appointment involving administration of a drug,” the authors stated.

The total number of dental emergency department visits in the United States nearly doubled from 2000 to 2010, according to a study by Thomas Wall, MA, MBA, and Kamyar Nasseh, PhD, from the American Dental Association (ADA), published online in May on the ADA Web site.

The rate of increase in dental emergency room visits outstripped the increase in overall emergency room visits during this period, the researchers found. "This has nothing to do with the recession," Marko Vujicic, PhD, managing vice president of the ADA’s Health Policy Resources Center, told.

To tally dental emergency room visits, the researchers used the National Hospital Ambulatory Medical Care Survey.

To put these visits in the context of overall numbers of dental visits, they used annual dental use data from the Medical Expenditure Panel Survey of the Agency for Healthcare Research and Quality. They found that dental visits as a percentage of total emergency room visits increased from 1.06% in 2000 to 1.65% in 2010, a statistically significant change.

By far the greatest increase came among young adults. As a percentage of all dental visits, emergency room visits by people aged 21 to 34 years increased from 1.5% to 3.0%. The increase among people 35 to 49 years old was from 0.5% to 0.9%. For other age groups, the trend lines were nearly flat.

Young adults may be turning to emergency rooms for dental care because they cannot pay for comprehensive oral care, said Dr. Vujicic, citing previous research.

"The largest percentage that indicate they have financial barriers is the 21- to 34-year-old group," he said.

States, Employers Cutting Benefits

Many states have pared back their adult dental Medicaid benefits; some cover emergency rooms only.

At the same time, many employers are cutting dental benefits, said Dr. Vujicic.

Previous research has shown that a large proportion of dental emergency room visits are for caries and that many of the patients going to emergency rooms for care could be better served in dental offices, the researchers note.

The Affordable Care Act is unlikely to help, the researchers report, because it does not require anyone to purchase dental benefits or make money available for them: It only requires plans in the small-group and individual markets to offer these benefits to children.

The findings in the study echo an earlier report by the Pew Center that also found dental emergency room visits increasing.

"In general, ADA agrees with Pew that [emergency department] visits are increasing and that that’s a problem," Shelly Gehshan, MPP, director of the center’s Children’s Dental Campaign. "There is a big issue with the affordability of dental care."

Gehshan, who was not involved in the ADA study, said 3 policy changes could help with the problem: "I think we need more financing, we need more dental providers, and we need more innovation in the system."

Pew supports a provision of the Affordable Care Act that would have funded demonstration projects using alternative dental providers such as dental therapists in an effort to offer more basic dental care at a lower cost. Congress later blocked funding for the program.

Citing previous research Dr. Vujicic disputed the need for more dental providers: Four of 10 dentists say they could see more patients, he said.

"Dental-Related Emergency Department Visits on the Increase in the United States." ADA Health Policy Resources Center. Published online May 2013.

The study of oral health and kidney disease is new and largely uncharted, according to Vanessa Grubbs, MD, a kidney expert and an assistant professor and pulmonary specialist in the UCSF’s School of Medicine who is focusing on the link between chronic health issues and kidney disease. Establishing the link could change the disease’s treatment approach as well as preventive care in dentistry.

Low-income populations suffer higher rates of both periodontal disease and kidney disease, she noted.

Dr. Grubbs is exploring the possibility that bacteria from periodontal disease puts the kidneys at risk in similar ways it affects the heart, according to the article. Longitudinal research may prove it.

Part of the approach involves tracking the progression of kidney disease in patients who are being treated for periodontal disease in a randomized, controlled study. While two-thirds of these patients with both illnesses will get immediate periodontal care in addition to follow-up treatment, the remaining patients will only get medically necessary dental care, the article noted. The researchers will track kidney function by examining unique biomarkers associated with kidney damage in blood and urine.

Funded by the National Institutes of Health (NIH), the pilot study will track the patients for one year.

Anaphylaxis may include any combination of common signs and symptoms (Table 2). Cutaneous manifestations of anaphylaxis, including urticaria and angioedema, are by far the most common. The respiratory system is commonly involved, producing symptoms such as dyspnea, wheezing, and upper airway obstruction from edema. Gastrointestinal manifestations (e.g., nausea, vomiting, diarrhea, abdominal pain) and cardiovascular manifestations (e.g., dizziness, syncope, hypotension) affect about one third of patients. Headache, rhinitis, substernal pain, pruritus, and seizure occur less frequently.

Symptom onset varies widely but generally occurs within seconds or minutes of exposure. Rarely, anaphylaxis may be delayed for several hours. Anaphylaxis can be protracted, lasting for more than 24 hours, or recur after initial resolution.

TABLE 2
Frequency of Signs and Symptoms