QUESTION 33
Chronic use of opioids for pain control during pregnancy can result in
1. foetal dependence.
2. premature birth.
3. retardation of the child’s growth.
4. premature closure of the ductus arteriosus.
A. 1, 2, 3
B. 1 and 3
C. 2 and 4
D. 4 only
E. All of the above
Rationale
Chronic use of opioids during pregnancy can result in foetal dependence, premature delivery, and growth retardation.
Acetaminophen is the drug of choice in all stages of pregnancy. It provides effective analgesia in doses of 500 to 1000mg q 4 to 6h, but the total daily dose should not exceed 4000mg.
The use of NSAIDs, including acetylsalicylic acid (ASA) is contraindicated in the third trimester of pregnancy, as they may predispose to ineffective contractions during labour, increased bleeding during delivery, and premature closure of the ductus arteriosus. If acetaminophen is insufficient, opioids may be used in conjunction, provided they are given only for short periods of time. As with pregnancy, acetaminophen is the analgesic of choice for the lactating mother. Opioids may also be used. ASA should be avoided.
The dentist must be mindful that analgesics are the second best means of managing pain. The best means is to remove the cause as quickly as possible.
REFERENCE
Haas, D.A. An update on analgesics for the management of acute postoperative dental pain. J Can Dent Assoc, 8:476-482. 2002.
QUESTION 34
Which of the following may be helpful in the management of a patient, receiving chemotherapy, who has resultant mucositis?
1. Granulocyte “colony stimulating” factor.
2. Viscous lidocaine.
3. Baking soda mouthwash.
4. Use of a soft toothbrush for oral hygiene.
A. 1, 2, 3
B. 1 and 3
C. 2 and 4
D. 4 only
E. All of the above
Rationale
Forty percent of patients receiving chemotherapy will develop significant oral problems. The stomatotoxicity of the agent can be divided into direct and indirect effects. Oral mucosal cells undergo rapid renewal and a chemotherapy agent may cause a reduction in the renewal rate with consequent mucosal atrophy and ulceration. This is one example of direct stomatotoxicity. Clinically, patients experience severe pain and difficulty in swallowing from the ulceration, which generally occurs on the non-keratinized surfaces of the mucosa. Symptomatic treatment using viscous lidocaine and coating agents give some relief. Indirect stomatotoxicity is best exemplified by the effect seen on bone marrow cells, which can result in granulocytopenia and thrombocytopenia. The granulocytopenia opens the way to opportunistic infection, which in the mouth can be bacterial, fungal, viral or mixed. The thrombocytopenia can lead to bleeding because of platelet reduction. Patients may be given a granulocyte “colony stimulating” factor to reduce the duration and extent of mucositis. Xerostomia is a major problem interfering with speech and swallowing, as well as oral hygiene. Patients should be encouraged to use artificial saliva products. They also must maintain as good oral hygiene as possible. A soft brush is recommended, but if brushing is difficult, a soft sponge or gauze may be used to assist in cleaning. Chlorhexidine gluconate mouthwash can also be recommended but, if the alcohol content in it causes too much discomfort, salt or baking soda in water can be useful alternatives.
REFERENCES
1.Ord, R.A., Blanshaert, R.H. Current management of oral cancer. A multidisciplinary approach. JADA 132:19S-29s. 2001.
2.Sung, E.C. Dental management of patients undergoing chemotherapy. CDA Journal 23:55-59, 1995.
QUESTION 35
Risk of displacement of a restoration for a Class V abfraction lesion can best be reduced by use of
A. glass ionomer cement.
B. resin-modified glass ionomer cement.
C. composite resin.
D. compomer.
Rationale
A recent study investigated the use of four tooth-coloured direct restorative materials for cervical cavities. These were glass ionomer cements, resin-modified glass ionomer cements, composite resins, and compomers (polyacid-modified composite resin). Selection of the material was made according to the type of lesion. Results indicated that in caries active dentitions fluoride releasing glass ionomer cement or resin-modified glass ionomer should be used. Erosion and abrasion lesions require acid and wear-resistant materials such as composite resins. Although compomers can also be used, they are particularly recommended for V shaped abfractions since they have a low modulus of elasticity, allowing them to bend with the tooth under functional loading and this lessens the risk of displacement.
REFERENCE
Blunck, V. Improving cervical restorations: A review of materials and techniques. J Adhesive Dent. 3:33-44. 2001.
QUESTION 36
For a patient with mild to moderate cardiovascular disease, a local anaesthetic agent that is epinephrine-free must be used.
For a patient with mild to moderate cardiovascular disease, conscious sedation is beneficial in stress reduction.
A. The first statement is true, the second is false.
B. The first statement is false, the second is true.
C. Both statements are true.
D. Both statements are false.
Rationale
Human studies on the hemodynamic variables after a dental injection of 1.8 to 5.4 ml of 2% lidocaine with 1:100,000 epinephrine have found no significant changes in mean arterial blood pressure or heart rate in healthy patients or in those with mild to moderate cardiovascular disease. It is therefore suggested that those with mild to moderate cardiovascular disease are given the smallest amount of local anaesthetic with vasoconstrictor needed for profound anaesthesia. It is further suggested that use of conscious sedation on such patients is beneficial in stress reduction and should be considered.
Normal epinephrine release from the adrenal medulla can increase 20-40 fold during stress. Such stress may be induced by pain during dental treatment. A patient having a local anaesthetic without a vasoconstrictor frequently has impaired pain control compared to an injection of local anaesthetic with epinephrine. Thus, a patient with cardiovascular disease may be at greater risk when the dentist uses an epinephrine-free local anaesthetic because of stress-released endogenous epinephrine.
REFERENCE
Glick, M. Screening for traditional risk factors for cardiovascular disease. JADA 133:291-300. 2002.
Answers to August 2004 SLSA Quiz
29. D
30. C
31. B
32. D
