CASE SCENARIO
is requesting to have all of the remaining dentition removed without a diagnosis that indicates the need for this treatment. Appropriate diagnosis is critical to the performance of evidence-based dentistry. The dentist is obligated to educate the patient about the clinical findings and make recommendations that are appropriate to that specific clinical situation. Moreover, the patient’s medical history should raise some “red flags” in the dentist’s mind. When the patient reports that she is receiving intravenous medication to treat her osteoporosis, it would be reasonable to request a medical consultation. It is likely that the patient is receiving intravenous bisphosphonate therapy and is unaware of the dental implications of that treatment. The dental provider must educate the patient about the risks of MRONJ. Additionally, the dentist should recommend avoiding unnecessary dentoalveolar surgery (which includes periodontal surgery and dental implants). Maintenance of the remaining dentition would be the most medically reasonable course of action at this time to prevent MRONJ. Situations like this one can be challenging because the dental professional must contradict the patient’s wishes and educate her concerning what is medically appropriate. This teaching should be thorough and well documented. The patient should be counseled that although her diagnosis does not justify the extraction of healthy teeth, she is at increased risk for MRONJ due to the bisphosphonate therapy she is receiving. Therefore, conservative treatment only should be done at this time. Gingival enlargement has been associated with the use of calcium channel blockers and oral contraceptives and may be addressed by discontinuing or modifying the use of the medication; also, good oral hygiene and professional plaque removal can reduce the severity of this reaction. The severity of oral mucositis, commonly caused by chemotherapeutic agents, can be reduced by good oral hygiene and holding ice chips in the mouth during chemotherapy. The pain associated with this condition can be addressed by several anesthetics, analgesics, and mucosal coating agents. Other drug-related conditions, such as topical agent- induced oral ulceration, fixed drug eruption, and various drug reactions, are typically resolved when the offending medication is stopped. Candidiasis, a type of yeast infection, is treated by antimicrobial or antifungal medications. Hairy leukoplakia, commonly associated with infection by the Epstein-Barr virus, is usually asymptomatic but may be treated with antivirals, if needed. Oral leukoplakia is a premalignant condition and should be monitored for potential transition to malignancy. Xerostomia, or drug-induced dryness of the mouth, is treated by changing medications, avoiding causative substances (e.g., alcohol), and the use of saliva substitutes and oral lubricants. Hypersalivation can result from many factors and should be treated according to the underlying cause. For oral allergic reactions, the causative agent should be identified and eliminated, if possible.
Mary is a 50-year-old female patient who presents to Dr. Sattovia, her local general dentist, with a chief complaint that she would like to have all of her remaining teeth extracted. Mary reports that she is “tired of taking care of her teeth” and thinks it would be better to have them all removed. The patient reports that she has multiple family members who have been long-time denture wearers and they all seem to be happy with their prostheses. Dr. Sattovia reviews Mary’s medical history and learns that Mary has been diagnosed with osteoporosis and goes to the hospital to get, “some IV medication,” monthly to treat the condition. Additionally, Mary reports that she has been smoking 1 to 2 packs of cigarettes per day for the past 30 years and that she drinks 1 to 2 alcoholic drinks per day. Extraoral examination reveals no extraoral swelling or facial abnormalities. Intraoral examination reveals no lesions, ulcerations, or signs of acute infection. Mary is partially edentulous, but the remaining dentition is in good condition. Oral hygiene at this time is fair. There is no mobility noted. However, localized areas of caries are noted. Dr. Sattovia obtains a full mouth series of radiographs. No radiographic signs of periodontal disease or periapical lucencies are noted. Question Should Dr. Sattovia proceed to extract all of the patient’s teeth as requested? Discussion It is important to listen to the patient’s chief complaint; however, it is ultimately up to the dentist to do what is clinically appropriate. In this situation, the patient Conclusion Medication-related damage to soft and hard dental structures can present different levels of severity in patients. More severe damage can interfere with good oral hygiene and cause patient discomfort. This course has been intended to help dental professionals recognize the drugs and medications that have the potential to cause damage to the tissues of the oral cavity and, with this knowledge, provide their patients with the highest level of care. Enamel fluorosis may be evaluated using the Dean fluorosis index and is typically treated by defluoridation of the water and repair of aesthetic blemishes through the use of bleaching, microabrasion veneering, and fixed prosthodontics. Medication-related osteonecrosis of the jaw should be treated according to the recommendations of the American Academy of Oral and Maxillofacial Surgeons, based on the level of severity. Tooth discoloration is common and can result from various factors, both extrinsic and intrinsic, but is rarely serious. Oral mucosa discoloration also may be caused by various factors; however, intrinsic discoloration of the oral mucosa can represent a serious condition such as malignant melanoma or Kaposi sarcoma, and should be evaluated via a full medical and dental history, extraoral and intraoral examinations, and, in some cases, biopsy and laboratory investigations. Black hairy tongue, which results from staining by chromogenic microorganisms related to the use of antibiotics, poor dental hygiene, and smoking, may be resolved by brushing or scraping the tongue, improving oral hygiene, and eliminating potential associated factors.
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