Adult Oral Health

Question 1

Risk Factors for Adult Caries

Answer 1

• High bacterial counts
• Family history of caries
• Frequent consumption of sugar-containing foods and beverages
• Inadequate fluoride
• Poor oral hygiene practices and behaviors
• Low socioeconomic status
• Physical Disabilities (make brushing/oral hygiene more difficulty)
• existing resorations or applicances
• decreased salivary flow/meds

Question 2

Root Caries Etiologies/Preventive Measures/Treatment

Answer 2

Etiology
* In the presence of caries-causing bacteria and a diet high in sugars, caries can develop easily and progress rapidly.
* Roots do not have protective enamel like crowns of teeth, so caries progresses rapidly in the roots.

Preventive Measures & Treatment
* Regular dental visits to remove plaque accumulation and reinforce appropriate home care.
* Lesions can be prevented or arrested using fluoride containing toothpaste, fluoride gels, varnish, or silver diamine fluoride.
* Chlorhexidine-Thymol varnish 1:1 mixture of may be efficacious in prevention of root caries.
* Sucrose-free chewing gum containing xylitol only or xylitol lozenges may be used as adjunctive therapy for adults at higher risk of caries.
* Advanced lesions require restoration or extraction.

Question 3

Gingivitis Sx/Etiology/Preventive Measures/Tx

Answer 3

Gingivitis is characterized by inflammation of the gingiva without destruction of the periodontal ligament or bone, which distinguishes it from periodontitis.

Symptoms
* Mild gum swelling
* Tenderness
* Erythema
* Bleeding gums when brushing
* Bad breath or bad taste in the mouth

Etiology
* Bacteria and food residue (plaque) stick to teeth near the gumline and cause irritation and inflammation of the gums
* Changes in hormone levels as a result of puberty, pregnancy, and diabetes can modify the gingival response to plaque, resulting in increased gingivitis
* Oral foreign bodies such as popcorn kernels are a frequent culprit in acute gum inflammation

Preventive Measures & Treatment
* Effective brushing and flossing
* Regular dental visits to remove plaque accumulation and reinforce appropriate home care

Question 4

Periodontitis Etiology/Preventive Measures/Tx

Answer 4

Periodontitis is the leading cause of tooth loss in adults. 45% of all adults are affected to some degree.

Etiology
Chronic exposure of the periodontal tissues to bacterial plaque causes a chronic inflammation leading to:
* Destruction of the periodontal ligament, loss of supporting bone, tooth loosening, and eventual tooth loss. Bone loss can be halted, but not reversed.
* Smoking, diabetes, HIV, pregnancy, and poor oral hygiene all contribute to the development of periodontitis.
* Some forms of periodontitis are genetic. Individual risk is affected by many factors.

Preventive Measures & Treatment
* Effective brushing and flossing, possible referral to periodontist.
* Cessation of tobacco use.
* Dental referral for deep root scaling (cleaning below the gum surface).
* Initial dental therapy may be nonsurgical, such as deep root scaling (cleaning below the gum surface) and application of local chemotherapeutic agents (e.g. chlorhexidine).
* Moderate to severe periodontitis treatment may include surgical procedures.

Question 5

Teeth Changes with Age

Answer 5

With age, teeth become more yellow due to thinning enamel and dentin showing through.

Teeth also become stained and begin to wear down, a process known as attrition.

Losing teeth is not a normal part of aging. With access to dental care, older adults can keep their teeth throughout their lives.

Question 6

Tooth Loss

Answer 6

Negative Impacts of Tooth Loss
* Difficulty eating
* Inadequate nutritional intake
* Dissatisfaction with facial appearance

Dentures, while not nearly as good as original teeth, can significantly improve quality of life by:
* Providing support and increasing the vertical dimension of the mouth
* Improving appearance
* Making eating easier

Tooth loss is very common in the elderly:
* 30% of elderly have untreated caries
* 25% have lost tooth-supporting structures due to periodontal disease
* Adults over age 65 have an average of 18 remaining teeth
* 25% are completely edentulous
* Medicare does not offer a dental benefit

Question 7

Preventive Steps

Answer 7

Preventive Steps
* Brush and floss regularly
* Avoid frequent snacking on sugary foods, as this increases the acidity of the mouth and accelerates decay
* Use fluoride toothpaste
* Avoid alcohol and tobacco
* Minimize medications with oral effects
* Visit dentist regularly

Brushing & Flossing Techniques
* Brush at least twice a day
* Use a soft toothbrush and focus on the area where the tooth meets the gingiva
* Manual and electric toothbrushes produce comparable oral hygiene results, so the choice should be based on personal preference
* Flossing helps disrupt the formation of plaque below the gum line and between the teeth
* Water flossers and Super Floss(R) are as effective as regular floss for plaque removal. They can be used as an alternative for people with dental appliances, or people with dexterity issues

Question 8

Oral Effects of Meds

Answer 8

• Gingival Hyperplasia: anticonvulsants, methotrexate, cyclosporin, CCBs
• Dental Erosions (due to GERD): progesterone, nitrates, BBs, CCBs
• Dental Caries: sugar containing preps, xerostomia
• Osteonecrosis: bisphosphonates (jaw pain, swelling, infection, loose teeth, pathologic fxs)

Question 9

Gingival Hyperplasia sx/etiology/preventive measures/ tx

Answer 9

Gingival hyperplasia can be associated with poor oral hygiene, underlying systemic disease, or as a medication side effect. Oral hygiene may be impaired by developmental disability or poor manual dexterity as a result of stroke, osteoarthritis of the hands, or Alzheimer’s disease or other dementia.

Symptoms
* Gums or teeth have unsightly gingival enlargement.
* Teeth become hard to clean which puts patients at risk for periodontal disease.
* Periodontitis may occur particularly where there is concurrent gingival inflammation, untreated dental plaque, and poor oral hygiene.

Etiology
* Poor oral hygiene practices
* Drug induced (Phenytoin, Methotrexate, Cyclosporin, Calcium channel blockers)
* Underlying systemic disease (e.g. leukemia) and conditions (e.g. pregnancy)

Preventive Measures & Treatment
* Meticulous oral hygiene
* Regular professional cleanings
* May require gum resection surgery
* Alternative medications may need to be consider

Question 11

Dental Erosion Sx/Etiology/Preventives

Answer 11

Dental erosion occurs when gastric acid erodes dentin and enamel. Patients with bulimia and severe GERD are at great risk for enamel erosions, even at very young ages.

Symptoms
* Teeth become smooth and glassy.
* Pulp exposure causes hot and cold sensitivity.

Etiology
* Bulimia
* Severe gastroesophageal reflux (GERD)
* Acidic drinks
* Medication effects

Preventive Measures
* Rinse with water after reflux or vomiting.
* Do not brush teeth immediately after reflux or vomiting as this may further hasten enamel erosion.

Question 12

Xerostomia Sx/Etiology/Preventives

Answer 12

Symptoms
* Dry mouth
* Changes in taste
* Burning sensation
* Difficulty swallowing and speaking
* Increased caries risk

Etiology
* Medications that can cause xerostomia include: Antihypertensives, Protease inhibitors, Antidepressants, Diuretics, Antihistamines, Others
* Polypharmacy (multiple medication regimen) heightens risk for xerostomia more than a single drug effect.
* Systemic disease and treatment consequences that can lead to this condition include: Sjögren’s syndrome, Head and neck radiation therapy
* Although geriatric patients are likely to have xerostomia, this is not due to aging per se, but instead medications and disease.

Preventive Measures & Treatment
* Change or eliminate medications known to decrease salivary flow.
* Encourage patients to drink water, and avoid alcohol as well as caffeinated or sugary drinks.
* Promote chewing of sugarless gums or candies to induce salivation.
* Recommend use of high concentration topical fluoride products to reduce caries.
* Encourage excellent oral hygiene.
* Ensure regular dental care.
* Recommend use of over-the-counter salivary substitutes for temporary relief. (Be aware they require frequent reapplication.)
* Suggest medications such as pilocarpine hydrochloride (Salagen) and cevimeline hydrochloride (Evoxac). These may be particularly helpful in patients with Sjögren’s syndrome, although side effects are common

Question 13

Illicit Drugs

Answer 13

Alcohol, tobacco, and cannabis use cause oral problems through direct contact, altered immune response, poor blood flow, carcinogenesis, teratogenesis, and accidental trauma. In the case of oral cancers, the effects may be additive when more than one substance is used.

Effects of Tobacco Use
* Tooth stains
* Altered taste and smell
* Periodontitis
* Xerostomia
* Caries
* Oral, head, and neck cancers
* Congenital anomalies in offspring, such as cleft lip and palate

Effects of Alcohol Use
* Periodontitis
* Xerostomia
* Caries
* Oral and throat cancers
* Fetal alcohol syndrome and effects in offspring.
* Congenital anomalies in offspring, such as cleft lip and palate

Effects of Cannabis Use
* Dental caries
* Increased oral infections
* Xerostomia
* Dysplastic changes and premalignant oral lesions (literature is unclear if cannabis has a direct carcinogenic effect)
* Increase in oral infections (possibly from mild immune suppression effect of marijuana)

Question 14

Substance Use Disorders

Answer 14

Substance use can result in severe oral consequences, some of which are depicted below.

Rapid onset oral devastation is mainly a problem of teens and young adults. Up to 5% of the 12-to-40-year old population report having used methamphetamines.

Research has shown that behavioral factors, such as smoking, consuming sugary beverages, and poor oral hygiene, are more important than direct drug effects.

Symptoms
* Rampant caries, gingival recession, and dental erosion in a young person
* Involves the buccal smooth surfaces, anterior teeth, and gums
* Often accompanied by behavioral changes and sometimes weight loss

Substance use leads to:
* Drug induced xerostomia
* Poor hygiene
* Increased carbohydrate and carbonated beverage consumption
* Teeth grinding
* Direct acid effect of the drug

Treatment
* Dental/oral surgery referral and behavioral health referral

Question 15

Herpes Labialis

Answer 15

Herpes labialis, also known as cold sores, is caused by a reactivation of a latent viral infection.

Symptoms
* Burning, itching, or pain 12–36 hours before eruption
* Vesicles rupture, ulcerate, and crust within 48 hours

Treatment
* Administer topical or systemic antiviral agents, either prophylactically, abortively, or for a full course of treatment.
* Topical 1% pencyclovir cream may help speed healing and reduce pain even if started after the prodrome.
* Oral medications should be initiated during the prodrome to be effective.
* Consider prophylactic antiviral prescription for recurrent outbreaks.

Question 16

Pyogenic Granuloma

Answer 16

Pyogenic granuloma is a rapidly growing, tumor-like lesion that develops as a response to local irritation (e.g., poor hygiene or overhanging restorations) or trauma. Altered hormonal levels in pregnancy increase the incidence and severity of this condition.

Symptoms
* An erythematous, nonpainful, smooth, or lobulated mass that often bleeds when touched
* Usually develops on the gingiva, but less common locations include the lip, tongue, or buccal mucosa
* May be a few millimeters to several centimeters in diameter

Treatment
* Observation and conservative surgical excision are both options
* Recurrence is uncommon unless the lesion is incompletely removed or the source of irritation remains.
* Lesions excised during pregnancy recur more frequently.

Question 17

Oral Ulcerations

Answer 17

Oral ulcerations may be of unknown etiology (aphthous), or associated with a variety of viral or bacterial infections, or in rare instances, drug reactions. In this module, we will address only aphthous ulcers in detail.

Question 18

Aphthous Stomatitis

Answer 18

• Recurrent aphthous stomatitis (RAS), also known as “canker sores,” is an oral ulcerative condition. Although a variety of host and environmental factors have been implicated, including trauma, nutritional deficiencies, and autoimmunity, the precise etiology remains unknown.
• 3 Types: minor (< 7 mm diameter; heal in 10-14 days w/out scarring), Major (>7 mm diameter; may take longer to heal w/ scarring), herpetiform

Symptoms
* Recurring, painful, solitary, or multiple ulcers
* Typically covered by a white to yellow pseudomembrane surrounded by an erythematous halo
* Usually involves nonkeratinizing mucosa (e.g., labial mucosa, buccal mucosa, and ventral tongue)

Preventive Measure/Tx
* Most mild aphthae require no treatment.
* Application of benzocaine paste or gel (Orabase (R)), with or without topical steriods can be used for symptomatic relief.
* Topical treatment with corticosteroids, such as fluocinonide gel or dexamethasone elixir, can promote healing and lessen severity.
* Steroid injection of ulcers or systemic therapy with thalidomide, colchicine, pentoxifylline, or azathioprine may be necessary in severe cases of major aphthae.
* Avoiding trigger foods or sodium lauryl sulfate in toothpaste can help reduce recurrences.
* Celiac disease should be considered in patients with recurrent aphthous ulcers or stomatitis.

Question 19

Geographic Tongue

Answer 19

Geographic tongue, also known as Erythema Migrans or benign migratory glossitis, is of uncertain etiology. Areas of erythema with discrete white borders appear due to atrophy of the filiform papillae. Usually seen on the dorsal surface of the tongue, but other oral sites such as the buccal mucosa may be involved. Geographic tongue is associated with fissured tongue.

Symptoms
* pain/burning (esp w/ spicy foods)
* often asx
* waxes/wanes

Tx
* Normal variant, reassurance only
* Typically no treatment is required.
* Topical steroid gels and antihistamine mouth rinses (e.g., diphenhydramine elixir) can reduce tongue sensitivity.

Question 20

Hairy Tongue

Answer 20

Hairy tongue is an elongation and hypertrophy of filiform papillae. It should not be confused with oral hairy leukoplakia, a viral condition seen in immunocompromised patients. It is associated with tobacco use, poor oral hygiene, and antibiotic use.

Symptoms
* Most patients are asymptomatic.
* Some patients may experience halitosis or altered taste.

Preventive Measures
* Improves with avoidance of tobacco, mouthwashes, and antibiotics.
* Regular tongue brushing with soft toothbrush or tongue scraper may help.

Question 21

Fissured Tongue

Answer 21

Fissured tongue is considered a variant of normal; however, frequency increases with age and xerostomia. It may develop in association with infection, malnutrition, or spontaneously, and is inherited in an autosomal dominant fashion with incomplete penetrance. It can also be associated with Down syndrome, psoriasis, and Sjögren syndrome.

Symptoms
* Fissured tongue usually causes no symptoms.
* Number, depth, and direction of the fissures varies considerably.
* Food debris may lodge between the fissures leading to halitosis and rarely irritation.
* Ten to twenty percent of people with fissured tongue also have geographic tongue.

Preventive Measures
* Tongue brushing is important to remove food trapped in fissures

Question 22

Bony Tori

Answer 22

Tori are benign bony protuberances arising from the cortical plate. They are considered developmental anomalies that are present throughout life, but they often increase in size in adulthood. In the United States, the prevalence of palatal tori is 20-35% of the population, compared to 7-10% for mandibular tori.

Treatment
* Surgical removal is required only if a torus: Affects oral function, Interferes with denture fabrication, Is subject to recurrent trauma or surface ulceration

Question 23

Candidiasis

Answer 23

Oral candidiasis can exhibit a variety of clinical patterns, and is most commonly seen in newborns or the immunocompromised.

• Pseudomembranous Candidiasis: Often referred to as thrush, it is the most common form and may present with a burning sensation.

Other forms of candidiasis:
* Median rhomboid glossitis presents as a well-demarcated, roughly symmetric, red lesion on the midline of the posterior dorsal tongue. It is three times more common in men than women. Causes no symptoms.
* Erythematous candidiasis, also called denture stomatitis, causes localized or generalized red, flat lesions accompanied by a burning sensation. This may result from poor cleansing of dentures and leaving dentures in at bedtime.
* Angular cheilitis, often associated with candidal and staphylococcal infections, is commonly seen in denture wearers.
* Smoking, diabetes, HIV infection, pregnancy, and poor oral hygiene can all contribute to the development of candidiasis.

Treatment:
* Administer topical or systemic antifungal agents.
* If dentures are involved, ensure they are removed at night, properly cleaned, and soaked in liquid antifungal medication.
* New dentures may be needed to improve fit or increase the vertical dimension of the mouth to prevent recurrence.
* In cases of angular cheilitis unresponsive to topical antifungals, topical antibiotics may be needed to cover for staph.

Question 24

Denture Complications

Answer 24

People with dentures often have problems with fit and comfort. Dentures should be replaced every 7-10 years due to bony changes over time.

Clinicians should:
* Remove dentures when performing oral exams to visualize the tissues beneath.
* Counsel patients on proper denture care to avoid complications such as denture sores, mucositis, and denture stomatitis (erythematous candidiasis).

Denture care:
* Remove dentures at night.
* Brush with denture brush or soft toothbrush to remove debris. Denture paste or mild dish soap can be used.
* Place dentures in denture cleanser soaking solution or in water overnight. Rinse thoroughly before replacing in mouth.
* Be aware that some people will require a caregiver to manage this aspect of their oral hygiene

Question 25

Lichen Planus

Answer 25

Oral lichen planus (LP) is a common, chronic inflammatory condition of unknown etiology, which affects 1-2% of adults. Current evidence suggests an immune-mediated mechanism. All age groups may be affected, but adults over 40 years of age predominate with a female-to-male ratio of 1.4:1.

Reticular LP
* Appears as white lacy striations or papules bilaterally on the posterior buccal mucosa.
* Other sites, such as the tongue or gingiva, may be involved.
* It is often readily identified clinically.

General LP Symptoms
* Symptoms tend to wax and wane over years.
* Up to two-thirds of patients complain of some sensitivity, especially with erythematous and erosive forms.
* Up to 44% of patients develop extraoral lesions on the flexor surfaces of the extremities, scalp, and nails.
* Up to 25% of women may have genital involvement. Incidence among men is much lower.

Other forms of Oral LP
* Plaque-like white lesions
* Erythematous or atrophic
* Erosive
* Bullous
* Lesions may exhibit mixed types often with zones of tender erythema and painful ulcers, surrounded by peripheral white, radiating striae.
* May present with generalized erythema and ulceration of the gingiva known as desquamative gingivitis.

Treatment
* Asymptomatic patients do not require treatment.
* For symptomatic patients, topical corticosteroid gels or mouth rinses are helpful.
* Lesions not exhibiting classic features may require biopsy for diagnosis.

Question 26

Leukoplakia/Eryhtroplakia

Answer 26

Oral leukoplakia, the best-known premalignant oral lesion, is defined as “a white patch or plaque that cannot be characterized clinically or pathologically as any other disease.” Analogous red lesions are called erythroplakia, and combined red and white lesions are also known as speckled leukoplakia or erythroleukoplakia.

Symptoms
* Leukoplakia and erythroplakia are often subtle and asymptomatic.
* Lesions begin as a white or red patch.
* Progression may lead to slightly elevated plaques.
* Lesions with ulceration are more likely to be cancerous.
* Erythroplakia and speckled leukoplakia are more likely to exhibit dysplasia or carcinoma upon microscopic examination.

Treatment
* All unexplained white lesions in the mouth should be referred to a dentist, oral surgeon, or ENT for evaluation and biopsy.
* Leukoplakia or erythroplakia exhibiting moderate or severe dysplasia should be surgically removed if possible.
* Cryotherapy and laser ablation have been used, although these methods do not allow for tissue preservation and microscopic examination.

Question 27

Oral Cancers

Answer 27

The prevalence of oral cancers increases with age.

Consider the following:
* Ninety percent of oral cancers are squamous cell carcinomas.
* Sixty percent of oral carcinomas are advanced by the time they are detected, and about 1% of patients will have another cancer in a nearby area such as the larynx, esophagus, or lungs.
* Tobacco use and heavy alcohol consumption are the two principal risk factors and are responsible for 75% of oral carcinomas.
* There is a strong etiologic association between HPV and oropharyngeal cancers.
* HPV positive cancers are more frequent in white men, younger populations (52-56 years), and people who do not use tobacco or alcohol.
* The overall five-year survival rate for oral cancer is 50-55%

Question 28

Oral Cancer Tx/Prevention

Answer 28

• Any red or white lesion persisting longer than two weeks warrants referral for biopsy.
• Any mouth sore that won’t heal or bleeds easily; any persistent lump or soreness in the mouth, throat, or tongue; or any difficulty chewing or swallowing warrants further investigation, which includes considering oral cancer as a cause.
• Treatment of oral squamous cell carcinoma is guided by clinical staging and may involve surgical resection, lymph node dissection, radiation therapy, or chemotherapy.
• Long-term follow-up is advised because of the potential for recurrence or development of additional lesions.
• Emerging evidence suggests that vaccination against HPV can help prevent oral cancers. Vaccination can be started at age 9, and is recommended through age 26 for those who were not vaccinated when they were younger

Cancers most commonly develop on the tongue, floor of mouth, and lower lip vermilion.

Question 29

Coordination of Care

Answer 29

By including oral health screening and education in all patients’ care, clinicians should be able to identify those individuals who will likely require professional collaboration as part of their dental care.

These include patients on anticoagulants and patients requiring antibiotic prophylaxis for dental work due to cardiac conditions or implanted devices.

Written communication should be the norm between primary care clinicians and their dental colleagues.

Additionally, clinicians should:
* Actively address and educate patients on oral issues.
* Provide the dental consultant with written diagnosis and treatment recommendations.
* Consider using a standardized referral form for consultations
* Dental referral template is available in the Resources section of this website under Practice Tools tab.

Question 30

Endocarditis Prophylaxis

Answer 30

A systems-based approach is required to care for patients who require antibiotic prophylaxis for oral procedures.

The following questions should be asked and addressed in accordance with the 2007 American Heart Association Guidelines. This process requires collaboration with the patient’s dentist and/or cardiologist.
* Does the patient have a medical condition placing him or her at high risk for endocarditis?
* Does the oral procedure being performed present a substantial risk of bacteremia?
* If the answer to both of the preceding questions is yes, which antibiotic is recommended?

Question 31

Medical Conditions Requiring Prophylaxis

Answer 31

Patients with the following medical conditions require antibiotic prophylaxis for many dental procedures.
* Prosthetic heart valves, including homografts and allografts
* Previous bacterial endocarditis
* Congenital heart disease:
* Unrepaired
* Partially repaired with residual defects
* Completely repaired (first six months only)
* Posttransplant valvulopathy

If repaired defects are expected to remain exposed and not covered by endothelium, then antibiotic prophylaxis is warranted. If prosthetic material used in a repair is expected to become covered with endothelium, antibiotic prophylaxis can cease six months after the repair.

Most patients do NOT require antibiotic prophylaxis

Question 32

Which procedures require prophylaxis?

Answer 32

Procedures requiring prophylaxis include:
* Dental Cleaning
* Tooth extractions
* Periodontal procedures if bleeding anticipated
* Scaling and root planing
* Reimplantation of avulsed teeth
* Root canal treatment beyond the apex
* Initial placement of orthodontic bands (not brackets)
* Intraosseous or intraligamentary injections

Prophylaxis is NOT recommended for the following procedures that occur above the gumline and are not expected to cause bleeding:
* Routine fillings
* Periodontal procedures if bleeding not anticipated
* Simple root canal treatment
* Rubber dam placement
* Suture removal
* Removable appliance placement
* Oral impressions
* Fluoride treatments
* Oral radiographs
* Orthodontic appliance adjustment
* Shedding of primary teeth

Question 33

Endocarditis Prophylaxis Abx Dosing

Answer 33

Amoxicillin: Adults: 2 g; children: 50 mg/kg orally one hour before procedure

If allergic to penicillin, use:
* Clindamycin: Adults: 600 mg; children: 20 mg/kg orally one hour before procedure
* Cephalexin or cefadroxil: Adults: 2 g; children: 50 mg/kg orally one hour before procedure
* Azithromycin or clarithromycin: Adults: 500 mg; children: 15 mg/kg orally one hour before procedure

Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction to penicillins.

Considerations
* A single dose of antibiotic covers the expected period of bacteremia.
* Optimal timing of dose is the 2 hour window before procedure.
* The maximum calculated dose for children should not exceed the adult dose.
* If patients are unable to take oral agents, consult the American Heart Association for the IV or IM recommendations

Question 34

Implanted Med Devices/Abx Prophylaxis

Answer 34

The following medical conditions require antibiotic prophylaxis for dental procedures where bacteremia could occur such as after manipulation of gingiva or the tooth apex or when oral mucosa is perforated:

• Vascular grafts (less than 6 months old)
• Arteriovenous hemodialysis shunts
• Neurosurgical shunts (dependent on type)
• Indwelling vascular catheters
• According to 2015 AAOS-ADA clinical practice guidelines, “for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.”

Antibiotic prophylaxis prior to undergoing dental procedures is NOT required for patients with cardiovascular implantable devices, such as defibrillators or pacemakers.

Question 35

Managing Anticoagulation

Answer 35

Thromboembolism is three times more likely to occur in patients whose anticoagulation is discontinued than in patients whose anticoagulation was continued through routine dental surgery. Primary care communication with dentists prior to procedures in medically complicated individuals on anticoagulants is vital!

Procedural Recommendations
* Cleanings, fillings, and simple extractions can be performed without interrupting anticoagulation (vitamin K antagonists, direct oral anticoagulants (DOACs), and antiplatelet agents)
* If receiving single antiplatelet therapy, dual antiplatelet therapy, or acetylsalicylic acid, dental procedures can be performed without interruption.
* If patients must remain anticoagulated (such as those who have mechanical heart valves) for major oral surgery that carries a high risk of bleeding, a transition to peri-operative heparin should be considered.

Bleeding can be controlled in the following ways:
* Medication: tranexamic acid, epsilon caproic acid mouthwash, topical thrombin
* Pressure: absorbable collagen, Surgicel, Gelfoam, tea bags
* Surgically, if necessary