Emergency Drug Kit Strategies For The Dental Office

INTRODUCTION
Every dentist should realize that medical emergencies can, do and will happen during the course of practice. These emergencies could be related to dental treatment, patient risk factors or they could occur unexpectedly in the dental environment. A medical emergency could evolve into a life-threatening emergency without proper treatment. It is for these reasons emergency medications should be present in dental offices.

The majority of states require certain emergency medications if the dentist is performing any type of advanced anesthesia, such as minimal and moderate sedation (either oral or intravenous) as well as deep sedation/general anesthesia.

The ADA Council on Scientific Affairs in their 2002 report in the Journal of the American Dental Association, Volume 133, No 3, 364-365 titled “Office Emergencies and Emergency Kits” stated the following:

In designing an emergency drug kit, the Council suggests that the following drugs be included as a minimum: epinephrine 1:1,000 (injectable), histamine-blocker (injectable), oxygen with positive-pressure administration capability, nitroglycerin (sublingual tablet or aerosol spray), bronchodilator (asthma inhaler), sugar and aspirin. Other drugs may be included as the doctor’s training and needs mandate. It is particularly important that the dentist be knowledgeable about the indications, contraindications, dosages and methods of delivery for all items included in the emergency kit. Dentists are also urged to perform continual emergency kit maintenance by replacing soon-to-be-outdated drugs before their expiration. 1

Local anesthesia is the backbone of pain control in dentistry. Dentists realize and know that adverse events can occur before, during or after administration of local anesthesia. Package insert of all local anesthetics clearly illustrates the importance of the dental practitioner having the proper equipment and resuscitative drugs prior to administering any local anesthetic. Here is what the warnings section state:

“DENTAL PRACTITIONERS WHO EMPLOY LOCAL ANESTHETIC AGENTS SHOULD BE WELL VERSED IN DIAGNOSIS AND MANAGEMENT OF EMERGENCIES WHICH MAY ARISE FROM THEIR USE. RESUSCITATIVE EQUIPMENT, OXYGEN AND OTHER RESUSCITATIVE DRUGS SHOULD BE AVAILABLE FOR IMMEDIATE USE.” 3

Emergency Drug Kit Key Facts

1. An emergency drug kit is critical in the dental setting. The ADA states that all dentists should have an emergency drug kit, equipment and knowledge to properly use all items.
2. Emergency drugs, along with their actions and dosages, should be known by the dentist and his or her team.
3. Know how to use your emergency drug kit BEFORE the emergency in your office.
4. Know the location of your emergency drug kit.
5. Develop an emergency drug logbook and review your drugs each month.
6. Never give an expired drug.
7. Know how to administer each emergency drug in your kit.

CANAL Acronym
Medical emergencies happen in dental offices and we must be ready to react and respond. Here is an acronym that could assist you in trying to remember the many emergencies along with the emergency drugs that could potentially be used to treat them.

C = Cardiac

  • Chest pain: oxygen, nitroglycerin
  • Myocardial infarction: oxygen, aspirin
  • Dysrhythmias: ACLS drugs
  • Sudden Cardiac Arrest: AED
  • Ventricular Fibrillation: ACLS drugs

A = Airway

  • Foreign body obstruction: airway techniques
  • Bronchospasm; albuterol, oxygen, epinephrine
  • Larygnospasm: oxygen, succinylcholine
  • Hyperventilation
  • Aspiration/Emesis: airway techniques

N = Neurological

  • Seizures: anticonvulsant
  • Transient ischemic attack
  • Stroke
  • Panic attack: antianxiety agent
  • Anxiety: antianxiety agent

A = Allergic and drug reaction

  • Latex allergy: diphenhydramine
  • Anaphylaxis: epinephrine, diphenhydramine, albuterol, dexamethasone
  • Allergic reaction: diphenhydramine
  • Epinephrine Overdose:
  • Benzodiazepine Overdose: flumazenil
  • Local anesthetic overdose: oxygen
  • Narcotic Overdose: narcan

L = Loss of consciousness

  • Syncope: ammonia
  • Sudden Cardiac Arrest: AED
  • Hypoglycemia: glucose
  • Stroke

Understanding the Actions of the Sympathetic and Parasympathetic Receptor Sites

Heart

Target

Sympathetic (adrenergic)

Parasympathetic (muscarinic)

Cardiac output

β1, (β2): increases

M2: decreases

Sinoatrial node: heart rate (chronotropic)

β1, (β2): increases

M2: decreases

Atrial cardiac muscle: contractility (inotropic)

β1, (β2): increases

M2: decreases

Ventricular cardiac muscle

β1, (β2):
increases contractility (inotropic)
increases cardiac muscle automaticity

---

At atrioventricular node

β1:
increases conduction
increases cardiac muscle automaticity

M2:
decreases conduction
Atrioventricular block


Blood Vessels

Target

Sympathetic (adrenergic)

Parasympathetic (muscarinic)

Vascular smooth muscle

α1: contracts; β2: relaxes

M3: relaxes

Renal artery

α1: constricts

---

Larger coronary arteries

α1 and α2: constricts

---

Smaller coronary arteries

β2:dilates

---

Arteries to viscera

α: constricts

---

Arteries to skin

α: constricts

---

Arteries to brain

α1: constricts

---

Arteries to erectile tissue

α1: constricts

M3: dilates

Arteries to salivary glands

α: constricts

M3: dilates

Hepatic artery

β2: dilates

---

Arteries to skeletal muscle

β2: dilates

---

Veins

α1 and α2: constricts
β2: dilates

---


Other

Target

Sympathetic (adrenergic)

Parasympathetic (muscarinic)

Platelets

α2: aggregates

---

Mast cells: histamine

β2: inhibits

---


Respiratory System

Target

Sympathetic (adrenergic)

Parasympathetic (muscarinic)

smooth muscles of bronchioles

β2: relaxes (major contribution)
α1: contracts (minor contribution)

M3: contracts


Nervous System

Target

Sympathetic (adrenergic)

Parasympathetic (muscarinic)

Pupil dilator muscle

α1: Relaxes
(causes mydriasis)

M3: contracts circular muscle
(causes miosis)

Ciliary muscle

β2: relaxes
(causes long-range focus)

M3: contracts
(causes short-range focus)


Digestive System

Target

Sympathetic (adrenergic)

Parasympathetic (muscarinic)

Salivary glands: secretions

β: stimulates viscous, amylase secretions
α1: stimulates potassium cation

M3: stimulates watery secretions

Lacrimal glands (tears)

β: stimulates protein secretion

---

Kidney (renin)

β1: secretes

---

Parietal cells

---

M1: Gastric acid secretion

Liver

α1, β2: glycogenolysis, gluconeogenesis

---

Adipose cells

β1, β3: stimulates lipolysis

---

Gastrointestinal (GI)  tract (smooth muscle) motility

α1, α2, β2: decreases

M3, (M1): increases

Sphincters of GI tract

α1, α2, β2: contracts

M3: relaxes

Glands of GI tract

no effect

M3: secretes


Endocrine System

Target

Sympathetic (adrenergic)

Parasympathetic (muscarinic)

Pancreas (islets)

α2: decreases secretion from beta cells, increases secretion from alpha cells

M3 increases stimulation from alpha cells and beta cells

Adrenal medulla

N (nicotinic ACh receptor): secretes epinephrine and norepinephrine

---

Here is a suggested list of the core 8 emergency drugs needed for each dental office along with suggested other emergency medications for those doing advanced anesthesia. Check with your state dental board for the mandatory emergency medications you must have in your office.

Emergency drugs should be available in all dental offices ready to address the medical emergency that they would be used for. These 8 emergency drugs should be the minimum in dental offices. They are:

  • Epinephrine for anaphylaxis, bronchospasm
  • Benadryl for allergic reactions, anaphylaxis
  • Albuterol for asthmatic attack, bronchospasm
  • Nitroglycerin for angina
  • Aspirin for suspected myocardial infarction
  • Glucose source for diabetic emergency (hypoglycemia)
  • Ammonia inhalants for syncope
  • Oxygen as supplemental adjunct

The Core 8 Emergency Drugs

1. ALBUTEROL
DEFINITION—Bronchodilator: stimulates beta-2 adrenergic receptors causing bronchodilation
USE: Bronchospasm (acute asthmatic attack)
DOSAGE: one to 2 puffs per dose
CAUTION: No contraindications to using albuterol in acute episodes of bronchospasm
SUGGESTED STOCK: One albuterol Metered-dose inhaler

2. AMMONIA INHALANTS
DEFINITION: a respiratory stimulant
USE: Syncope/fainting/loss of consciousness
DOSAGE: one to 2 vaporules
SUGGESTED STOCK: One box of ammonia vaporules

3. ASPIRIN
DEFINITION: Antiplatelet—inhibits prostaglandin synthesis and inhibits platelet aggregation irreversibly
USE: Suspected myocardial infarction
DOSAGE: One 325 mg nonenteric, coated aspirin tablet, chewed and swallowed or four-81 mg chewable tablets, chewed and swallowed
CAUTION: Aspirin should not be given to persons who are allergic to it or have active gastrointestinal bleeding
SUGGESTED STOCK: One or 2 packets of chewable 325 mg nonenteric, coated aspirin or four 81-mg chewable tablets

4. DIPHENHYDRAMINE
DEFINITION: Antihistamine—antagonizes histamine at the H-1 receptor, causes sedation and has an anticholinergic effect
USE Allergic reaction/anaphylaxis
DOSE: 50 mg intramuscular or intravenous
CAUTION: No contraindications to giving diphenhydramine during an allergic reaction unless noted allergy or hypersensitivity to diphenhydramine
SUGGESTED STOCK: 1. Two 1-mL ampules or vials of diphenhydramine 50 mg/mL and/or
2. Diphenhydramine hydrochloride capsules 25 mg

5. EPINEPHRINE 1:1,000
DEFINITION: Cardiac stimulant/anaphylaxis—activates alpha and beta-adrenergic receptors increasing heart rate, myocardial contractility, bronchial dilation and decreases peripheral vascular resistance
USE: Anaphylaxis/bronchospasm
DOSAGE: 0.3 mg intramuscular every 5 minutes.
CATUION: No contraindications to giving epinephrine during anaphylaxis
SUGGESTED STOCK: 1. Two autoinjectors of epinephrine in adult form and pediatric form (EpiPen and EpiPen Jr)
2. Two 1-mL ampules or vials of epinephrine 1:1,000

6. GLUCOSE SOURCE
DEFINITION: Antihypoglycemic—increases glucose level for treatment of hypoglycemia
USE: Hypoglycemia
DOSAGE: One tube of glucose gel.
CAUTION: Unconsciousness. Never place anything orally into an unconscious person.
SUGGESTED STOCK: 1. Three tubes of glucose gel (InstaGlucose)
2. Three tubes of glucose tablets

7. NITROGLYCERIN
DEFINITION: Antianginal—stimulates cGMP production which relaxes vascular smooth muscle specifically in the coronary arteries in the presence of an anginal attack
USE: Chest pain (angina)
DOSAGE: The usual dose of nitroglycerin is one sublingual (0.4 mg) tablet or one spray (0.4 mg) from nitroglycerin spray atomizer administered every 5 minutes
CAUTION: Patients with low blood pressure

8. OXYGEN
USE: Almost any type of medical emergency
DOSAGE: At least 2 liters/minute for patient
CAUTION: Do not use with hyperventilation
SUGGESTED STOCK: One portable “E” cylinder of oxygen with regulator and the equipment necessary to deliver O2 to the victim (nasal cannula and ambu-bag)

Additional Medications
Reversal Agent—Benzodiazepine

Flumazenil (Romazicon)—Benzodiazepine Antagonist: Reverses effect of benzodiazepines by inhibiting the gamma amino butyric acid (GABA) receptors

Reversal Agent—Narcotics
Naloxone (Narcan)—Narcotic Antagonist: Reverses the effect of narcotics by competively inhibiting narcotic receptor sites

Injectable AntiConvulsant
Midazolam or diazepam: A benzodiazepine that acts on the inhibitory neurotransmitter GABA, limbic system, hypothalamus and thalamus to produce sedation, anti-anxiety effect and skeletal muscle relaxation

Injectable Antihypoglycemics
Dextrose (50% Dextrose)—Antihypoglycemic: a source of calories and fluid for patients that are not able to take oral fluids in the event of a hypoglycemic reaction
Glucagon (GlucoGen)—Antihypoglycemic: causes a rise in blood glucose levels by promoting hepatic glycogenolysis and gluconeogenesis.

Injectable Anticholinergic
Atropine—Anticholinergic: antagonizes acetylcholine at the muscarinic receptors, increasing the heart rate as well as having an antisialagogue effect.

Injectable Corticosteriod
Hydrocortisone (Solu-Cortef)—Anti-inflammatory: a corticosteroid secreted by the adrenal cortex which has anti-inflammatory, anti-allergic, mineralocorticord activity and stimulates gluconeogenesis.
Dexamethasone – Anti-inflammatory: a corticosteroid secreted by the adrenal cortex which has anti-inflammatory, anti-allergic, glucocorticord activity, and stimulates gluconeogenesis.

Injectable Antihypertensive
Esmolol—Beta-antagonist: is a cardioselective beta1 receptor blocker with rapid onset and a very short duration of action, with no significant intrinsic sympathomimetic or membrane stabilizing activity at therapeutic dosages. It decreases the force and rate of heart contractions by blocking beta-adrenergic receptors of the sympathetic nervous system
Labetolol—Beta-antagonist: is a mixed alpha/beta adrenergic antagonist, which is used to treat high blood pressure.
Hydralazine—is a direct-acting smooth muscle relaxant used to treat hypertension by acting as a vasodilator primarily in arteries and arterioles

Advanced Cardiovascular Life Support and Pediatric Advanced Life Support Emergency Medications:
NOTE: Practitioners may vary on what they carry in their office with these medications as well as the dosing dependent upon the training they received related to advanced cardiovascular life support (ACLS) and pediatric advanced life support (PALS).

Drugs for ventricular fibrillation/pulseless ventricular tachycardia

  • Epinephrine
  • Vasopressin
  • Amiodarone
  • Lidocaine
  • Magnesium

Drugs for asystole and pulseless electrical activity

  • Epinephrine
  • Vasopressin

Drugs for bradycardia

  • Atropine
  • Epinephrine
  • Dopamine

Drugs for tachycardia

  • Adenosine
  • Diltiazem
  • Beta-blockers
  • Amiodarone
  • Digoxin
  • Verapamil
  • Magnesium

Drugs for acute coronary syndrome

  • Oxygen
  • Nitroglycerin
  • Morphine
  • Fibrinolytic therapy
  • Heparin
  • Beta-blockers

Adenosine (Adenocard)—Antiarrhythmic: used for treatment of paroxysmal supraventricular tachycardia by slowing conduction time through the atrioventricular (AV) node as well as interrupting the re-entry pathways through the AV node.

Amiodarone (Cordarone)—Antiarrhythmic: a Class III agent that inhibits adrenergic stimulation which prolongs the action potential, decreases AV conduction and sinus node function which is used for life-threatening recurrent ventricular fibrillation or hemdynamically-unstable ventricular tachycardia.

Atropine (Atropine)—Anticholinergic: antagonizes acetylcholine at the muscarinic receptors, increasing the heart rate as well as having an anti-sialagogue effect.

Lidocaine—Antiarrhythmic: is a Class IB antiarrhythmic drug which is used intravenously for the treatment of ventricular arrhythmias.

Vasopressin (Pitressin)—Antidiuretic hormone: adjunctive treatment used in pulseless ventricular tachycardia/ventricular fibrillation.

Verapamil (Isoptin/Calan)—Antiarrhythmic: used for the treatment of paroxysmal supraventricular tachycardia, atrial flutter and atrial fibrillation.

Development of an Emergency Drug Kit for your Office

Dentists can make their own emergency drug kit.

  • First, know which drugs you will need in your office. Do you need the Core 8 drugs? Do you need more advanced medications such as used in ACLS or PALS protocols? Dentists should be thoroughly knowledgeable on the emergency drugs they have in their office.
  • Second, purchase those drugs and then maintain them in some type of container whether it is a plastic container/box or a metal crash cart.
  • Third, place these emergency medications in ziploc bags or smaller plastic containers with color coded labels for easy identification.
  • Fourth, know the medical emergencies for which these emergency drugs are used for.
  • Finally, develop an emergency drug logbook and keep up with your drugs and their expiration dates.

Note: many dental software programs may already have a “task manager” or you may have Outlook on your computer. You can enter each of your emergency drugs along with their expiration dates so a reminder is sent to you before the actual expired date.

At monthly staff meetings, encourage emergency medications as a regular topic so that area is covered each month and you can prevent your drugs from being expired.

The next several pages of downloadable documents illustrate a suggested source for dentists to use to develop a checklist of emergency drugs they need in their office depending on if they use local anesthesia or a specific type of advanced anesthesia. These can be modified by the individual dentist to the needs of their practice.

DOWNLOADABLE DOCUMENT #1: EMERGENCY DRUGS LIST FOR PRACTITIONERS WHO USED LOCAL ANESTHESIA, MILD SEDATION, MODERATE SEDATION, DEEP SEDATION AND/OR GENERAL ANESTHESIA

DOWNLOADABLE DOCUMENT #2: THE ADULT EMERGENCY CRASH CART. A SUGGESTED LIST OF EMERGENCY EQUIPMENT AND EMERGENCY DRUGS FOR THE DENTIST TREATING ADULTS.  6, 8

DOWNLOADABLE DOCUMENT #3: THE PEDIATRIC EMERGENCY CRASH CART. A SUGGESTED LIST OF EMERGENCY EQUIPMENT AND EMERGENCY DRUGS FOR THE DENTIST 7, 8

DOWNLOADABLE DOCUMENT #4: PREPARATION CHECKLISTS ON EACH MEDICAL EMERGENCY THAT COULD ARISE IN A DENTAL OFFICE. THE PRACTITIONER SHOULD DEVELOP THEIR OWN MEDICAL EMERGENCY ALGORITHMS TO GO ALONG WITH THESE CHECKLISTS OR THEY PURCHASE THEM FROM A VENDOR

DOWNLOADABLE DOCUMENT #5: THE EMERGENCY DRUG TRACKER COMPLIMENTS OF EMERGENCY DRUG RESOURCE; buildyourowndrugkit.com

DOWNLOADABLE DOCUMENT #6: EMERGENCY DRUG LABELS

Conclusion

In conclusion, the emergency drug kit is essential for the practice of dentistry. No practitioner is able to determine when he or she will be faced with a medical emergency that will require the use of emergency drugs. It is for that reason alone, dental healthcare practitioners should stay up-to-date on medical emergencies as well as the drugs used to treat them. Develop a regular protocol to where you and your staff are able to rehearse various emergencies using your emergency drugs. Know their actions along with the route of administration. You and your staff should always know the location of your emergency drugs. Assign a staff member the role of reviewing your emergency drugs each month to prevent expiration of these drugs.

None of us know when our patient’s life may depend on our readiness as well as having the proper emergency drugs.


References

  1. Journal of the American Dental Association, Volume 133, No 3, 364-365 titled “Office Emergencies and Emergency Kits”
  2. Journal of the American Dental Association, May 2010, Supplement on Medical Emergencies
  3. Package Insert on Local Anesthesia, “WARNINGS” section
  4. Wikipedia: Central Nervous System
  5. American Heart Association
  6. Advanced Cardiovascular Life Support (ACLS)
  7. Pediatric Advanced Life Support (PALS)
  8. CRASH CART, SAJITH KUMAR. RN, RM, MScN / Emergency Medicine; www.emergencymedicinemims.com
  9. http://acls-algorithms.com
  10. Emergency Drug Tracker, compliments of Emergency Drug Resource. buildyourowndrugkit.com

Dr. Roberson is a full-time practicing Oral & Maxillofacial Surgeon. He performed his residency in Oral & Maxillofacial Surgery at University Hospital at the University of Cincinnati. Dr. Roberson has dual Board Certifications by the American Board of Oral & Maxillofacial Surgery and the National Dental Board of Anesthesiology. He is a member of the American Association of Oral & Maxillofacial Surgeons, Southeastern Society of Oral & Maxillofacial Surgeons, American Dental Association, American Dental Society of Anesthesiology, Mississippi Dental Association, South Mississippi Dental Association, and the Mississippi Society of Oral & Maxillofacial Surgeons.

An Oral Bisphosphonate Dilemma

INTRODUCTION
Every so often, we have a patient who presents with clinical challenges that need to be handled outside of the usual protocol. So it was with Lucinda, who presented with caries in 2 specific teeth that would normally have been treated by doing extractions. However, the health history showed Fosamax use and, upon further questioning, it was found that she had a history of heavy use of this prescription drug within the last 5 years. Consulting with Dr. Mark Ericson, our oral surgeon, the decision was made not to remove teeth Nos. 3 and 18 because of potential healing problems in the bony socket sites due to the use of Fosamax.

This article will present the case introduced above, demonstrating the alternative treatment that was done, and the current research for deciding upon the course of action outlined below.

Fosamax Issues
Patients who have resorptive bone diseases such as osteoporosis (often women) can benefit from the use of oral bisphosphonates (BPs). For the last 11 years, a number of studies have been published that have documented the condition of osteonecrosis of the jaw (ONJ) that is associated with the use of oral BPs; thus called bisphosphonate-related osteonecrosis of the jaw, or BRONJ. From the studies, one can learn how these jaw necroses are tied to the use of BPs (such as Fosamax, risedronate, or alendronate).1

A clinical study important to the dental profession2 documented the healing issue faced when extracting teeth or bone work, namely slow or nonhealing of sockets. When patients have taken BPs for the treatment of osteoporosis, the ability for bone to heal after surgery can be limited. Should nonhealing take place, the patient’s life is affected, which can be a significant issue for the clinician too. The study observed 7 patients who had taken BPs and had extractions, with 6 of the patients having had sequestration during nearly a year of observation, and only 3 had experienced healing. It should be noted that the current standard treatment for BRONJ does not always provide good results.3

BPs have been widely, efficiently, and safely used for the treatment of osteoporosis, malignant hypercalcemia, bone metastasis of solid cancers, and multiple myeloma bone diseases. Accumulating recent reports describe that dental surgery treatments in patients with cancer or osteoporosis who have been receiving intravenous or oral BPs are associated with BRONJ.4

Figure 1. Severe decay in tooth No. 3 that would usually require extraction. Figure 2. Severe decay in tooth No. 18 that would usually require extraction.
Figure 3. Preserved root sealed with glass ionomers (GC Fuji II [GC America]). Figure 4. Acytel resin unilateral partial over preserved root (tooth No. 3). Note: photo was taken after 4 months of wearing the prosthesis.
Figure 5. Tooth No. 18 root preserved with root canal and glass ionomer. Figure 6. Retention preparation in No. 18 before composite resin was placed.

Because BPs can be given to many cancer patients who also have a need for invasive dental care involving bone, it should be noted that ONJ cannot be effectively treated with debridement and antibiotics or even hyperbaric oxygen exposure. To prevent negative outcomes, the clinician must recognize that there are no effective treatments for ONJ. If treatment (such as extraction) is absolutely needed with a patient taking a BP, the treating medical doctor should be contacted about his or her BP delivery.5

A study concerning implant placement for those who were actively taking BPs showed no discernable healing issues. There was no significant difference between groups in the success rates of dental implants at stage-2 surgery (test 93.5%, control 95.5%).6 In another study, new bone formation in extraction sockets, bone area around the implant site, and bone-implant contact were not delayed in the bisphosphonate group.7

One report8 confirmed 2 other patients who experienced osteonecrosis from BP causes were successfully treated with teriparatide, when used as adjunct therapy in ONJ; this is because it has an anabolic effect and presumed role in accelerating bone healing. ONJ is a serious but infrequent condition that has been recently associated with nitrogen-containing bisphosphonate therapy. Teriparatide may be a useful adjunctive therapy when ONJ develops.

Hsiao et al9 found that the results of this preliminary short-term study suggest that patients taking long-term oral BPs can expect a satisfactory outcome with evidence of periradicular healing after conventional root canal treatment. Thus, root canal treatment may be considered a safe and realistic alternative to extraction in patients on bisphosphonate therapy.

The issue facing all dental clinicians is to extract or not to extract a tooth when the patient has been or is taking BPs. Even if the potential for osteonecrosis is small for any given patient, no dentist wants to be responsible for the patient getting this condition, and therefore, hesitancy on the decision to proceed with an extraction would be reasonable.

CASE REPORT
Lucinda presented as a new patient with extensive decay in 2 teeth that would have ordinarily been treated with extractions (Figures 1 and 2).

However, since her medical history included the use of Fosamax during a period of 5 years, it became apparent that extraction could lead to osteonecrosis in one or both sites, even though she reported having stopped taking the drug just prior to this dental visit. The question of an alternative approach seemed vital to getting an outcome that would provide a clinically good result while keeping her healthy.

Figure 7. Glass ionomer in No. 18 prepared for ZAAG (ZEST Anchors) female attachment. Figure 8. ZAAG One-Step Drill (ZEST Anchors) for ZAAG female attachment preparation.
Figure 9. ZAAG attachment cemented into tooth No. 18. Figure 10. ZAAG male attachment placed into female ready for pickup.
Figure 11. Triad VLC Bonding Agent (DENTSPLY Trubyte) placed on lower partial denture for male ZAAG
attachment.
Figure 12. Triad DuaLine dual-cure (self- and light-cured) reline composite material (DENTSPLY Trubyte).
Figure 13. Lower partial denture with the male ZAAG attachment snapped into female in tooth No. 18.

The first course of action was to sever the maxillary bridge at crown No. 5 and to remove the existing crown on No. 3. After determining that the root canals of tooth No. 3 were calcified, the root was sealed with a glass ionomer (GC Fuji II [GC America]) (Figure 3). Since this tooth was without symptoms or swelling, it was determined that the roots could be left at this point. If any symptomology would appear at a later time, that could be dealt with by prescribing antibiotics. (Note: that need has not arisen, as of the writing this article.)

In order to restore the missing teeth, a unilateral partial denture of acytel resin was produced (Figure 4). At this point, this tactic has been successful for the patient.

Endodontic therapy was done on the lower left second molar (tooth No. 18) by Dr. June Chang to keep it from extraction (Figure 5). Since the patient would now need a removable partial denture, a unilateral type was offered with tooth No. 18 receiving a ZAAG attachment (ZEST Anchors) for distal-end anchorage. Because No. 18 had a temporary restoration after the root canal, because the occlusal height above to No. 15 was limited due to super eruption, and because crown lengthening was ruled out due to the BP issue; the tooth was restored with composite down into the pulp chamber. The preparation can be seen in Figure 6. This restoration allowed for preparation for the ZAAG female attachment placement (Figure 7) using the ZAAG drill (Figure 8) and the actual attachment.

The ZAAG female attachment was cemented into the preparation (Figure 9) using SEcure Cement (Parkell). The male attachment was tried in to evaluate the fit (Figure 10). The unilateral partial denture was primed with Triad VLC Bonding Agent (DENTSPLY Trubyte) (Figure 11), so that the male ZAAG could be “picked up” with Triad DuaLine (DENTSPLY Trubyte) dual-cure reline material (Figure 12). The result was giving the patient a firmly fitting unilateral partial denture, using a tooth that normally would have been extracted. Figure 13 shows the unilateral partial denture with the ZAAG attachment bonded in using Triad DuaLine.

CLOSING COMMENTS
During a dental career, we are sometimes presented with opportunities to be creative, offering the chance for a better outcome for a patient than his or her condition might normally warrant. Having written extensively about and practiced minimally invasive dentistry, this case where the patient presented with a history of BP use for treating osteoporosis required that kind of approach. This compromised situation and the research supporting caution led to the alternate treatment shown. Each subject tooth continues to function well under the partial dentures.


References

  1. Mozzati M, Arata V, Gallesio G. Tooth extraction in osteoporotic patients taking oral bisphosphonates. Osteoporos Int. 2013;24:1707-1712.
  2. Ng AJ, Yue B, Joseph S, et al. Delayed/non-union of upper limb fractures with bisphosphonates: systematic review and recommendations. ANZ J Surg. 2014;84:218-224.
  3. Nomura T, Shibahara T, Uchiyama T, et al. Bisphosphonate-related osteonecrosis of jaw (BRONJ) in Japanese population: a case series of 13 patients at our clinic. Bull Tokyo Dent Coll. 2013;54:117-125.
  4. Yoneda T, Hagino H, Sugimoto T, et al. Bisphosphonate-related osteonecrosis of the jaw: position paper from the Allied Task Force Committee of Japanese Society for Bone and Mineral Research, Japan Osteoporosis Society, Japanese Society of Periodontology, Japanese Society for Oral and Maxillofacial Radiology, and Japanese Society of Oral and Maxillofacial Surgeons. J Bone Miner Metab. 2010;28:365-383.
  5. Urade M. Bisphosphonates and osteonecrosis of the jaws [in Japanese]. Clin Calcium. 2007;17:241-248.
  6. Memon S, Weltman RL, Katancik JA. Oral bisphosphonates: early endosseous dental implant success and crestal bone changes. A retrospective study. Int J Oral Maxillofac Implants. 2012;27:1216-1222.
  7. Kim JH, Park YB, Li Z, et al. Effect of alendronate on healing of extraction sockets and healing around implants. Oral Dis. 2011;17:705-711.
  8. Narongroeknawin P, Danila MI, Humphreys LG Jr, et al. Bisphosphonate-associated osteonecrosis of the jaw, with healing after teriparatide: a review of the literature and a case report. Spec Care Dentist. 2010;30:77-82.
  9. Hsiao A, Glickman G, He J. A retrospective clinical and radiographic study on healing of periradicular lesions in patients taking oral bisphosphonates. J Endod. 2009;35:1525-1528.

Dr. Whitehouse is a founding member and past president (2003 to 2005) of the World Congress of Minimally Invasive Dentistry (MID). He has authored many articles on MID and other clinical issues. He continues to practice 2 days per week after having sold his dental practice in Castro Valley, Calif. He can be reached at (510) 881-1924 or via email at This email address is being protected from spambots. You need JavaScript enabled to view it..

Disclosure: Dr. Whitehouse reports no disclosures.

Reducing Risks of Bacterial Endocarditis from Dental Procedures With Oral Time-Released Xylitol

Introduction

In April 2007, the ADA and its Council on Scientific Affairs published a position paper that provides newly revised guidelines for the prevention of infective endocarditis (IE).1 These guidelines, endorsed by the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Heart Association (AHA), among others, reflected current research assessing dental procedure related bacteremia, endocarditis prevention, and the most common pathogens associated with the condition. The new guidelines reduce the classes of patients for whom antibiotic prophylaxis is recommended because the risk of morbidity resulting from antibiotic use outweighs its probable benefits. However, the guidelines also suggest that dental manipulation of any type may result in the introduction of potentially pathogenic bacteria into the bloodstream. This raises an important question whether less risky approaches to controlling oral bacteria prior to dental procedures and general oral care might be a useful preventative strategy for individuals previously defined as at-risk for IE and where antibiotics are not now recommended. Given this, the following discussion is directed toward a possible new approach for reducing the oral bacteria associated with blood born infection using xylitol incorporated into a time release disk that adheres to the gingiva and/or teeth.

Factors in the Pathogenesis of Infective Endocarditis

The pathogenesis of IE is complex and involves a number of different factors. There must be vessel turbulence leading to platelet deposition and damage to the endothelium of the cardiac valve or surgically constructed pulmonary shunt or conduit, combined with a bacteremia arising from oral trauma with microorganisms that are capable of adhering to the site (typically streptococci, staphylococci, and enterococci), and bacterial proliferation at the site of adherence.2

Multiple studies suggest that procedures such as tooth extraction, periodontal surgery, tooth cleaning and scaling, rubber dam placement, and root canal therapy can cause a bacteremia.‎3-5 Even though there is evidence that bacteremia follows dental treatment and dental hygiene procedures, because of potential allergy, resistance, and cost-effectiveness, among other factors, the counsel restricted the classes of patients for whom short-term antibiotic prophylaxis before dental procedures are recommended. Prevention via systemic antibiotic application is generally discouraged because, in addition to the above, there is a lack of viable supportive research and further, there are contradictory results. Additionally, limited studies assessing topical antiseptic rinses or germicides as a strategy for reducing bacteremia arising from dental procedures suggest that they are not likely to be effective.8,9

To control the risk of IE in patients for whom antibiotic prophylaxis is no longer recommended, the ADA recommends that individuals simply maintain good oral hygiene and avail themselves of professional dental care. The underlying assumption is that good oral hygiene will reduce overall bacterial counts leading in turn to a reduction in the number of bacteria introduced during dental or hygiene procedures. Good oral hygiene includes daily tooth brushing, flossing, and minimizing sugars that feed resident bacteria. While this proposal makes eminent sense, from a public health standpoint it is not all that clear that the majority of people will follow good preventative practices and present for routine dental care. In fact, based on the US Surgeon General’s Report in 2000,10,11 there remains a substantial discrepancy between American children, young adults, and older adults in terms of access to preventative and other dental care services based on ethnicity, income, education, and special needs status. It is estimated that the fastest growing populations in the US (eg, Black, Hispanic) have the highest disease rates and lowest access to dental care12 even in the face of current National Health Insurance Programs.13 In addition, there appears to be considerable disparity between states with respect to implementation of the State Child Health Insurance Program and comparisons of children in states with and without the plan suggesting that there is over a 24% difference in terms of likelihood of preventative care based on this variable alone.14 The issue concerning adults may even be worse. Thus, many people in the US will not receive the preventative training and skills development necessary to satisfy the ADA’s basic requirements for prevention of IE associated with routine home care.

Other Methods to Reduce Oral Bacterial Burden

Among many of the other continuing and unanswered questions in relation to the introduction of bacteria into the bloodstream and potential IE is whether there are low risk methods besides “good oral hygiene” for reducing the overall burden of oral bacteria prior to dental procedures, specifically the bacteria that are known to cause bacteremia and IE, and whether such a reduction in these disease causing bacteria might result in a drop in the incidence of IE and its associated morbidity or mortality, particularly in the aged and disabled. To date, there have been no prospective, controlled, randomized studies to assess these issues. In a review of IE and dental procedures, it is concluded that, given the current evidence regarding pathogenesis and prevention of endocarditis, novel strategies need to be developed as alternatives to current approaches using antibiotic prophylaxis.15

Assuming, as has been suggested by the AHA’s report, that it might be helpful to reduce the oral bacterial burden prior to dental procedures in individuals where antibiotic prophylaxis is not recommended, the literature regarding xylitol, a sugar substitute that occurs widely in nature which can be delivered topically in the mouth, offers a potential means for achieving this end. Specifically, in a number of dental studies addressing control of caries, it has been found that delivery of xylitol in a controlled manner with chewing gum significantly reduces salivary Streptococcus (Streptococcus mutans) counts.16-18 This is of particular significance not only in the arena of public dental health and caries but also because recent research completed by a group of investigators from Japan, with their findings published by the Journal of Clinical Microbiology, has revealed that S mutans (presumed to be derived from the oral cavity) is the most numerous specie in heart valve and atheromatous plaque specimens.19

Use of xylitol chewing gum four or five times per day has been shown to reduce not only S mutans but also Streptococcus salivarius and Streptococcus sanguis,20 and regular consumption by mothers has been shown to reduce mother-child transmission.21 Further, a xylitol induced reduction in bacterial counts has been shown to continue for a prolonged period of time (age 3 to age 6 years) in children studied.22 Xylitol has also demonstrated efficacy in reducing counts of Streptococcus sobrinus, Lactobacillus rhamnosus, Actinomyces viscosus, Porphyromonas gingivalis, and Fusobacterium nucleatum that have been experimentally incorporated into model biofilms,23 in reducing counts of Porphyromonas aeruginosa in maxillary sinus specimens,24 in altering the viability of strep pheumococci responsible for acute otitis media,25 and in altering cytokine expression induced by P gingivalis (one of many bacteria suspected in periodontal disease).26 These as well as other studies provide a potential medical use for xylitol in reducing bacterial counts potentially involved in cardiac disease and suggest an adjunctive application in the management of IE and other infective diseases (eg, sinus infection, middle ear infection, gingivitis, and periodontitis).

Presently, xylitol is primarily delivered via chewing gum.15,27-29 but it has also been incorporated into lozenges and syrup. In a study assessing the effect of xylitol on hunger, xylitol has been put into yogurt,30 and it is also found in other food products.31 However, one of the problems with its incorporation into foods is whether an adequate concentration can be maintained over a long enough time in the mouth to effectively reduce oral bacteria. Delivery of xylitol via gum appears to be effective in this regard. However, xylitol released from gum is dissipated in about 15 minutes,34 new 32 which requires that it be used 5 times or more per day to be effective and be used in larger quantities than desired.

Xylitol has also recently been incorporated into a time-release adhering disc called XyliMelts (OraHealth Corporation) that can be adhered to the teeth or adjoining gingiva to time-release 500 mg of xylitol. Xylitol delivered in this manner is very likely to be present in the mouth for longer periods of time (30 to 120 minutes—based on reports from subjects in a pilot study) and may be more tolerated by patients unwilling or unable to chew gum (eg, the edentulous, those with temporomandibular joint disorder or disabilities). XyliMelts can also be used while sleeping, when saliva flow is lowest, potentially increasing the effectiveness of the overall antibacterial action. A similar oral adhering disc called Oramoist (Quantum) designed to adhere to the roof of the mouth and release flavor to stimulate saliva also contains xylitol but the amount of xylitol in each disc is not published by the manufacturer and is likely insignificant.

Studies suggest that a dose of xylitol in the range of 6.5 g per day to 10.3 g per day delivered with chewing gum over 4 or 5 uses per day is sufficient to reduce streptococci levels.27 Studies of quantities of xylitol that must be delivered with the time release discs to achieve the same effect have not been completed. One would expect the required dosage for an equal effect to be significantly lower and the effect of an equal dosage to be significantly greater. A preliminary study (which cannot be cited because of proprietary issues) has apparently shown that only one gram per day delivered over time by XyliMelts can significantly reduce S mutans counts.

While providing the required dosage in gum can be “cumbersome” as one of the above authors has suggested,27 delivery in a dissolving disc adhered to a molar or gingiva in the buccal vestibule is easily accomplished and could make the process considerably more palatable. To achieve an effect equal to 1.3 g of xylitol chewing gum used 5 times per day (6.5 g per day), the manufacturer (OraHealth) of XyliMelts suggests that a time release disc containing one-half g of xylitol should be used at bedtime and “after each meal, at least 4 discs per day,” for a minimum of 2 g per day. Until studies are completed to determine whether this usage is sufficient to obtain optimal reduction of pathogenic bacteria, to be conservative, based on prior chewing gum studies, one could increase the usage to 4 g per day (8 discs). As previously noted, this approach to the delivery of xylitol prior to dental procedures would likely be particularly worthwhile in those with physical or mental disabilities and in frail older people where maintenance of good oral health is often problematic and where bacterial endocarditis can be a significant problem.32,33 new 33,34

New American Heart Association Recommendations

The AHA now recommends antibiotic prophylaxis before dental procedures only in patients with high risk of IE where that risk outweighs the risks of problems from the antibiotics. (The cardiac conditions that present this level of risk include: prosthetic cardiac valves; congenital heart disease including unrepaired cyanotic coronary heart disease (CHD), including palliative shunts and conduits; completely repaired congenital heart defect with prosthetic material or devices, whether placed by surgery or by catheter intervention during the first 6 months after the procedure, repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device; and cardiac transplantation recipients who develop cardiac valvulopathy). Also included are individuals with a previous IE history. However, another problem associated with IE is the presence of comorbid disease. Hence, individuals with diabetes mellitus, immunosuppressive conditions, and kidney disease necessitating dialysis may have an increased risk of morbidity and mortality from IE. And as previously mentioned, disability and age may also confound the risk of developing the condition in susceptible individuals. However, antibiotics are no longer recommended for this cohort of patients.

New Questions for New Technology

Important questions raised by the new technology for time release of xylitol in the mouth are: (1) whether the XyliMelts discs should be used for several days or weeks before undergoing dental procedures; (2) whether this prophylaxis should be recommended for all dental procedures or only those where substantial bleeding is expected; (3) whether this prophylaxis should be recommended for all patients or only those with a moderate risk of IE; and (4) how patients with moderate risk are to be distinguished from patients with low risk. As an initial step in answering these questions, both in vivo and in vitro studies need to be pursued to assess the effect of xylitol delivered by time-release adhering disc on the oral carriage of the previously defined pathogens causing IE. Then additional prospective randomized controlled trials should be considered to assess the efficacy of this delivery system in preventing IE in select patient cohorts. Finally, it would also be useful to assess the effectiveness of xylitol delivered via adhering disc on other conditions identified as also being caused, in part, by the identified bacteria and where other xylitol-based applications have been found to prevent disease (eg, sinusitis, otitis media).29

Conclusion

Given what is now known regarding oral bacteria and their introduction into the bloodstream, until the above questions are answered, it would seem prudent for individuals with previously identified risk factors for IE who are not now prescribed antibiotics to use over-the-counter products including xylitol (eg, XyliMelts, xylitol gum) for as many days as practically achievable (one to 20 days) prior to dental procedures. These products might also be recommended by health care providers other than dentists for individuals who, for varying reasons, are not able to avail themselves of routine dental preventative care and where there is perceived risk.

ACKNOWLEDGEMENT

The author wishes to thank OralHealth Corporation for its support for this article. 


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Jeff Burgess received his DDS from the University of Washington school of Dentistry, Seattle, and his MSD in Oral Medicine from the University of Washington. He completed a 2-year post-doctoral fellowship in the Department of Anesthesiology and the University of Washington Medical Center and served 15 years as a Consultant/Attending at the Medical Center Pain Center. He also practiced general dentistry for 10 years and was a Research and Clinical Research Assistant Professor in the Department of Oral Medicine for 15 years. In addition, he had a private practice in Oral Medicine for 18 years. He has work experience with dental PACS and DICOM. He has been the co-investigator on numerous studies and authored and co-authored multiple chapters in medical and dental texts and articles in peer-reviewed journals.



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