Endocrine disorders account for approximately 1.5% of all hospital emerg-ency admissions in England; the majority are related to diabetes (Kearney and Dang, 2007). In the dental practice, hypoglycaemia is by far the most likely endocrine disorder to be encountered. Adrenal insuficiency may also occur. The aim of this chapter is to understand the management of endocrine disorders.
The following are CHF symptoms:
1. Orthopnea: Orthopnea is shortness of breath experienced on lying down. Therefore, the patient should always be propped up in bed.
2. Paroxysmal nocturnal dyspnea or “cardiac asthma”: Shortness of breath is experienced hours or minutes after lying in bed.
3. Cough with frothy sputum: Severe CHF compromises cardiac output and this leads to pulmonary congestion or edema. Significant pulmonary congestion causes cough with a frothy sputum expectoration.
Emphysema is a disease state associated with abnormal and permanent enlargement of the air spaces distal to the terminal bronchioles. There is destruction of the walls with or without fibrosis and loss of elastic recoil of the lungs.
The long-standing history of smoking, cough with expectoration, and progressive dyspnea are quite suggestive of emphysema, and spirometry clinches the diagnosis. Emphysema and chronic bronchitis, when present together, constitute COPD.
The hematopoietic stem cell resides predominantly in the bone marrow and, very particularly, in the pelvis and the long bones. The hematopoietic stem cell differentiates and matures to form the three cell lines found in the blood: the white blood cells (WBCs),red blood cells (RBCs), and platelets (Plts). Discussion in this section centers on disease states associated with these cell lines.
Cancers of the mouth, salivary glands, sinuses, nose, throat, and lymph nodes in theneck are designated head and neck cancers. Difficulty swallowing, hoarseness, lesionsin the oral cavity, and lymph node enlargements in the neck are frequently how headand neck cancers present.
Cardiac arrhythmias can be an increase in heart rate, a decrease in heart rate, or anirregularity in heart rate, when compared with normal states. An increased heart ratecan be associated with sinus tachycardia, atrial or supraventricular arrhythmias, and ventricular arrhythmias. When the heart rate is decreased, the patient is said to have bradycardia.
Allergy is an abnormal immune response (usually a type I or type IV hypersensitivity response) to an antigen – a protein or allergen. Many allergies have a hereditary component but the prevalence of allergies appears to be increasing. People who suffer allergies to one type of substance are more likely to suffer allergies to others.
Failure of the circulation for 3–4 minutes (less if the patient is initially hypoxaemic) can lead to irreversible cerebral damage. Restarting the heart following a cardiac arrest may not be possible without adequate reoxygenation (Resuscitation Council (UK), 2011).
Patients who require resuscitation often have airway obstruction, usually secondary to loss of consciousness, but sometimes airway obstruction may be the primary cause of cardiorespiratory arrest (Deakin et al., 2010). Airway obstruction can be subtle and is often undetected by healthcare professionals (Deakin et al., 2010).
It is important to have a systematic approach to an acutely ill patient and to remain calm (Greenwood, 2009). The Resuscitation Council (UK) (2012) recommends undertaking a systematic clinical assessment following the ABCDE approach: pre-empting a medical emergency would allow appropriate help, e.g. ambulance, to be called, hopefully before the patient deteriorates or collapses. As well as monitoring the patient’s vital signs, e.g. respiratory rate, pulse and blood pressure it is also important to be alert to the presence of chest pain, a common pre-cardiac arrest symptom (Resuscitation Council (UK), 2012). The aim of this chapter is to understand the principles of recognition of the acute ill patient following the ABCDE approach.
Therapies that are not currently considered an integral part of conventional allopathic medical practice are termed complementary when used in addition to, and alternative when used instead of, conventional treatments. Such therapies include, but are not limited to, acupuncture, chiropractic, diet fads faith healing, folk medicine, herbal (natural) medicine, homoeopathy, naturopathy, new age healing, massage and music therapy.
This section focuses on acupuncture and herbal medicines, since there is some evidence of efficacy, and increasing use of them by the public.
The use of bisphosphonates is associated with the production of osteonecrosisof the jaws (ONJ). ONJ is defined as exposure of the bone of the jaws that does not heal within 8 weeks after identification by a healthcare worker in a patient taking bisphosphonates. The condition may be a symptomatic or present with pain, soft-tissue swelling and loosening of teeth in addition to exposure of bone.
Anaphylaxis is a life-threatening emergency which can occur in the dental practice (Müller et al., 2008). Anaphylaxis in the dental practice is very rare, accounting for approximately 1% of all encountered emergencies (Müller et al., 2008). It may follow the administration of a drug, e.g. local anaesthetic, or exposure to a substance such as latex (Resuscitation Council (UK), 2012a). In the general population, the incidence of anaphylaxis is on the increase (Department of Health, 2006), probably associated with a notable increase in the prevalence of allergic diseases in the last 30 years (Resuscitation Council (UK), 2012a).
Anticoagulation therapy is indicated in the presence of thrombosis formation or whenthere is a risk of thrombosis. Because of its immediate action, intravenous (IV) heparin(standard heparin/unfractionated heparin) is the anticoagulant of choice, and it is usedin a hospitalized setting to stabilize a patient experiencing an acute thrombotic episode.Once the acute state is brought under control, warfarin (Coumadin) is started orally.Coumadin cannot be used at the start of an acute thrombotic episode because of itsslow onset of action and slow achievement of optimal action. IV heparin is with drawn when the therapeutic level of Coumadin is reached and blood thinning can be completely maintained using warfarin (Coumadin). At the time of discharge, the patient is sent home taking only warfarin (Coumadin) to continue with the blood-thinning process.
Defibrillation is the delivery of an electrical current across the myocardium of significant magnitude to depolarise a critical mass of the myocardium simultaneously to enable the restoration of organised electrical activity. A key component in the chain of survival defibrillation is one of only two interventions that have been shown unequivocally to improve long-term survival following a cardiac arrest, the other being basic life support (Resuscitation Council (UK), 2011).
The incidence of maternal cardiac arrest reported in the literature has been variable; it has been cited as 1 in 30000 pregnancies. Recent data from the US Nationwide Inpatient Sample suggest that cardiac arrest occurs in 1:12000 admissions for delivery. Globally, 800 maternal deaths occur daily. Maternal mortality trends in the United States reported by the CDC show a steady increase from 7.2 deaths per 100000 live births in 1987 to 17.8 deaths per 100000 live births in 2009.
TIA is associated with temporary cerebral ischemia due to cerebral vascular spasm. Nopermanent brain damage occurs. Once the spasm is released, the symptoms disappear.The symptoms last for a few seconds to a few minutes, but occasionally they can last fora few hours. Resolution of symptoms occurs within 24 hours. Patients with a history of TIA have a 50–60% chance of progressing to CVA/stroke.
Chronic bronchitis is a disease state where in the patient has had cough with expectoration for two to three months of the year, for at least two successive years. This patient will give a history of using bronchodilators, antibiotics during flare-ups, and oral or injectable corticosteroids during exacerbation of the chronic bronchitis.
Diabetes mellitus is a heterogeneous group of metabolic disorders grouped together due to their common feature of hyperglycemia. The incidence and prevalence of diabetes have increased markedly in recent decades, mostly due to increases in type 2 diabetes rates, which have paralleled the increasing rates of obesity in the developed world during the same time. The increasing prevalence of diabetes is important because of the associated morbidity and mortality and the associated costs, in terms of both the personal cost of decreased quality of life and the economic impact of providing health care to a growing population with a chronic disease and the accompanying loss of productivity.
Seizures are caused because of abnormal electrical discharges in the brain and they canoccur as grand mal seizures, petit mal seizures, or temporallobe seizures. Occurrence of repeat seizures leads to a diagnosis of epilepsy.
A seizure is generalized if the abnormal electrical discharges cross over the midline in the brain. When the seizures involve only a few muscles in the face, arms, or legs, it is a focal seizure. A grand mal seizure or a tonic-clonic seizure is characterized by loss of consciousness with the patient falling down, loss of bowel or bladder control, and rhythmic-to-arrhythmic convulsions.
Rheumatic diseases are chronic conditions that cause significant morbidity and affectthe patient’s quality of life. The patient is often on immunosuppressants to control the underlying inflammation and to improve the long-term outcome of the disease.
It is important to remember that immunosuppressants decrease inflammation but increase the incidence of infections. This increased incidence of infections, coupled withthe poor oral hygiene and increased dental decay found in this population, stresses theimportance of regular dental intervention for these patients.
Pregnancy is a time when women can be motivated to adopt healthy behavior. This is also an opportune time for pregnant women to learn about practices that promote oral health. It is incumbent upon health providers to educate pregnant women about the impact of good oral health on the well‐being of the mother and fetus. Statistics have shown that 56% of women do not have any dental care during pregnancy and that 59% of pregnant women do not receive any counseling on oral health issues. Factors contributing to these statistics include the possibility that ob-gyn providers do not routinely incorporate oral health discussions into their clinical practices, and the fact that some dental providers avoid treating pregnant women because of confusion and misconceptions about the safety and importance of dental treatment during pregnancy. Additional compounding factors include the inability to access dental care by low‐income and underprivileged women.
Chronic obstructive pulmonary disease (COPD) is a disease state associated withirreversible pulmonary damage, progressive airflow limitation, partially obstructedairways, breathing difficulty, and an abnormal inflammatoryresponse. In COPD, thealveoli lose their elasticity, which results in some areas with collapsed airways and someareas with hyperinflated airways. Alveolar damage causes poor air exchange. Additionally, excess mucus production by the mucus-producing cellscauses thickening of theairways and the airway blockade. COPD is most prevalent in the elderly.
Acyclovir and valacyclovir are purine nucleoside analogues and both drugs act againstherpes simplex 1 and 2 (cold sores and genital herpes, respectively), varicella zoster(shingles and chicken pox), and the Epstein-Barr virus (infectious mononucleosis).
Neither acyclovir nor valacyclovir cures the viral infection, but they do decrease thesymptoms and signs associated with the viral infection. Both drugs can be taken with orwithout food, and it is best to take the drug around thesame timeevery day. The elderly patient should be given a lower dose of either drug, compared to the normal, healthy patient.
Angina and myocardial infarction (MI) can occur with involvement of the coronary cir-culation. Hypertension causes narrowing of the coronary arteries, and when the patientis involved in an activity, these narrowed arteries are unable to supply adequate nutrition and oxygenation to the heart, thus leading to angina. Hypertension-associated angina is classic angina and it can be stable or unstable.
Hemophilia A, hemophilia B, and von Willebrand Disease (vWD) are the three mostcommon inherited bleeding disorders. Hemophilia A and hemophilia B (Christmas dis-ease) are x-linked recessive traits that affect only males. Females are often carriers unlessboth parents carry the hemophilia gene. Either hemophilia is often diagnosed in childhood, though mild hemophiliacs may remain undiagnosed until adulthood. Clinical history is often positive for joint hemorrhage (hemarthroses) with joint deformities, gingival hemorrhage, persistent oral bleeding, and bleeding into soft tissues.
The defining characteristics of diabetes, irrespective of the precise etiology, relate to the presence of hyperglycemia. The American Diabetes Association (ADA) has set forth specific criteria for the definition of diabetes. In the ADA guidelines, the following are necessary for the diagnosis of diabetes: (1) hemoglobin A1c (HbA1c) equal to or greater than 6.5% OR (2) fasting plasma glucose equal to or greater than 126 mg/dl OR (3) two-hour plasma glucose equal to or greater than 200 mg/dl during an oral glucose tolerance test (OGTT) (glucose load containing 75 grams anhydrous glucose dissolved in water) OR (4) in a patient with classic symptoms of diabetes or during a hyperglycemic crisis, a random glucose of equal to or greater than 200 mg/dl suffices to diagnose diabetes.
The hypothalamus releases growth hormone-releasing hormone (GHRH), which then stimulates the pituitary gland to produce GH. Secretion of GH by the pituitary into the bloodstream stimulates the liver to produce another hormone called insulin-like growth factor I (IGF-I). IGF-I is what actually causes tissue growth in the body. High levels of IGF-I, in turn, signal the pituitary to reduce GH production.
A medically complex dental patient (MCP) is one who suffers from one or more diseases and who is taking one or more medications for the care of those disease states. The management of the MCP is a multitiered process that requires detailed, organized assessment of several aspects associated with the patient, which can sometimes take more than one dental visit. Every MCP should have a thorough assessment of the medical and dental histories during the first visit. The dentist needs to decide what laboratory tests to obtain from the patient’s primary care physician (PCP) and/or the specialist(s). Evaluation of the tests will help determine the control status level of the patient’s disease states. The dentist also needs to assess the vital organ status; the patient’s American Society of Anesthesiology (ASA) status; the need for stress management; the dental treatment plan; and the final anesthetics, analgesics, and antibiotics (AAAs) that can be safely used during dentistry.
The liver is the main site for drug metabolism. Drug metabolism often enhances termination of drug action, but on occasion metabolism can lead to bio-activation, as with prodrugs. The drug metabolism process basically introduces hydrophilic functional-ities onto the drug molecule to facilitate excretion. When the drug molecule is oxidized, hydrolyzed, or conjugated, the whole molecule becomes more hydrophilic andis excreted more easily.