Читать книгу A Practical Approach to Special Care in Dentistry - Группа авторов - Страница 255

 Treatment should be modified based on the severity of the condition, the medical management in place and the invasiveness of the proposed dental intervention (Table 5.3.1)Table 5.3.1 Dental management considerations.Risk assessmentThese patients may have heightened anxiety and irritabilitySympathetic overactivity may lead to faintingA thyroid storm may be provoked during dental treatment by the stress, or by epinephrine, infection or traumatic surgeryBleeding tendency in patients on propylthiouracilRisk of lymphopenia in patients on propylthiouracilCarbimazole occasionally leads to agranulocytosis, which may cause oral or oropharyngeal ulcerationAlveolar bone osteoporosis may be presentCriteria for referralControlled hyperthyroidism: depending on the comorbidities, dental care can be provided in the local dental clinic settingUncontrolled hyperthyroidism: delay elective dental treatment until the hyperthyroidism has been controlled; if urgent procedures are required, a hospital setting is preferableAccess/positionIf goitre is present, there may be pressure on the airway; consider a semi‐reclined position if this is the caseIf there is a bleeding/infection risk, arrange appointments earlier in the day and weekCommunicationLiaise with endocrinologist/physician if considering urgent dental treatment in a patient with untreated/significant hyperthyroidismSpeech may be affected if there is goitre or if there is any damage to the laryngeal nerves following surgeryConsent/capacityConsider the impact of heightened anxiety on decision making and consentPatients should be warned of the potential local (e.g. bleeding) and systemic complications (thyroid storm)Anaesthesia/sedationLocal anaesthesiaThe risks of giving epinephrine‐containing local anaesthetics in moderate amounts are more theoretical than realIf there is concern, prilocaine with felypressin can be given, but is not known to be saferSedationSedation may be considered since anxiety may precipitate a thyroid crisisNitrous oxide, which is rapidly controllable, is probably safest for dental sedationBenzodiazepines may potentiate antithyroid drugs and are thus contraindicatedAntihistamines such as hydroxyzine may also be usefulGeneral anaesthesiaThe hyperthyroid patient is especially at risk from general anaesthesia because of the risk of precipitating dangerous arrhythmiasAfter hyperthyroidism treatment, the patient is at risk from hypothyroidism; this must be borne in mind if a general anaesthesia is requiredDental treatmentBeforeBehavioural control and techniques to control anxiety are essential in patients with untreated hyperthyroidism requiring urgent dental treatmentDefinitive dental treatment should be delayed until the patient has been rendered euthyroidInvasive/surgical treatment will require specialised medical adviceDuringThe use of topical anaesthesia prior to the local anaesthesia may help pain control and anxietyLocal anaesthesia should be delivered using an aspirating syringe and should include a reduced amount of vasoconstrictor/epinephrineAfterGive patient written postoperative instruction and emergency contact detailsDrug prescriptionBenzodiazepines should be avoidedPovidone‐iodine and similar compounds are best avoided (iodine is taken up by the thyroid)Education/preventionReinforce meticulous oral hygiene and regular dental visits to prevent caries, periodontal disease and need for future extractions