Medical emergencies in the dental office -Prevention

Implementation of a complete system of physical evaluation for all prospective dental patients could prevent up to 90% of life-threatening situations. The remaining 10% would occur in spite of all preventive efforts.

Evaluation goals

• Determine the patient’s ability to physically/psychologically tolerate the stress involved in the planned treatment.

• Determine whether treatment modifications are required to enable the patient to better tolerate the stress involved in the planned treatment.

• Determine whether the use of sedation is warranted:

  • Determine which sedation technique is most appropriate.
  • Determine whether contraindications exist to any drugs to be used in the planned treatment.

Physical examination

Physical evaluation in dentistry consists–minimally–of the medical history questionnaire, physical examination, and dialogue history.

Medical history questionnaire

There are two basic types: the short-form medical history, and the long-form medical history. Any medical history questionnaire can be extremely valuable or entirely worthless. The ultimate value of the questionnaire resides in the doctor’s ability to interpret the significance of the answers provided and to elicit additional information through dialogue history and physical examination.

For the health history to be of value, patients must (1) be aware of their state of health and of any existing medical conditions and (2) be willing to share this information with their dentist. Most patients will not knowingly deceive their dentist by omitting important information from their medical history questionnaires.

Physical examination

Because the patient-completed medical history questionnaires are not always reliable, the doctor must seek additional sources of information concerning the patient’s physical status. The physical examination provides much of this information. Physical examination in dentistry consists of the following steps:

• Monitoring of vital signs
  • Blood pressure
  • Heart rate (pulse) and rhythm
  • Respiratory rate
  • Temperature
  • Height
  • Weight
    • Body Mass Index
• Visual inspection of the patient
• Functional tests as indicated
• Auscultation, monitoring (via electrocardiogram), and laboratory tests of the heart and lungs as indicated

ASA Physical Status Classification System

• ASA 1: A normal, healthy patient without systemic disease
• ASA 2: A patient with mild systemic disease
• ASA 3: A patient with severe systemic disease
• ASA 4: A patient with an incapacitating systemic disease that is a constant threat to life
• ASA 5: A moribund patient not expected to survive without the operation
• ASA 6: A declared brain-dead patient whose organs are being removed for donor purposes
• ASA E: Emergency operation of any variety, with E preceding the number to indicate the patient’s physical status (for example, ASA E-3)

When the ASA system was adopted for use in a typical outpatient dental setting, the ASA 5 classification was eliminated.

ASA 1

ASA 1 patients are considered normal and healthy. Review of their medical history, physical evaluation, and all other evaluation parameters indicate no obvious abnormalities. Major organs and organ systems—the heart, lungs, liver, kidneys, and CNS—appear to be in good health. ASA 1 patients are able to walk up one flight of stairs or two level city blocks without distress. Physiologically, ASA 1 patients should be able to tolerate whatever stress is associated with their planned dental treatment without added risk of serious complications. Psychologically, such patients also should have little or no difficulty “handling” the planned treatment. Healthy patients with little or no dental anxiety are assigned an ASA 1 classification representing a “green traffic light” for treatment. Treatment modification is usually not required for these patients.

ASA 2

An ASA 2 patient has a mild systemic disease or is a healthy (ASA 1) patient who demonstrates extreme anxiety and fear in the dental environment. ASA 2 patients are able to walk up one flight of stairs or two level city blocks before distress causes them to stop. ASA 2 patients generally are less stress tolerant than ASA 1 patients; however, they still represent a small risk during their dental treatment. Routine (elective) dental care is indicated as long as some thought is given to possible treatment modification or considerations warranted by the patient’s medical condition. Examples of such considerations or modifications include the use of prophylactic antibiotics or sedative techniques, limits on the duration of treatment, and possible medical consultation.

An ASA 2 classification should serve as a “yellow traffic light,” a warning to the doctor to proceed, but with caution. Elective dental care is warranted because of the minimal increase in risk to the patient during therapy. Treatment modifications should be considered.

Examples of ASA 2 conditions/patients include the following:

• Type 2 diabetes (well controlled)
• Epilepsy (well controlled)
• Asthma (well controlled)
• Hyperthyroid or hypothyroid disorders (well controlled) in which patients are under a physician’s care and currently have normal thyroid function (considered euthyroid)
• ASA 1 patients presenting with upper respiratory tract infections
• Healthy (ASA 1) pregnant patient
• Otherwise healthy patients with allergies, especially to drugs
• Otherwise healthy patients with extreme dental fears
• Adults with blood pressures between 140 and 159 mm Hg systolic and/or 90 to 94 mm Hg diastolic
• BMI between 30.0 and 39.9 (assess for presence of comorbidities)

Generally, the ASA 2 patient is able to perform normal activities without experiencing distress (e.g., undue fatigue, dyspnea, or precordial pain).

ASA 3

ASA 3 patients have a severe systemic disease that limits their activity but does not incapacitate them. At rest, ASA 3 patients do not exhibit signs and symptoms of distress and can function normally; however, distress is exhibited when these patients encounter either physiologic or psychological stress. For example, a dental-phobic anginal patient may be normal (no chest pain) in the reception area but develops chest pain when placed in the dental chair. ASA 3 patients are able to negotiate one flight of stairs or two level city blocks, but will have to stop and rest at least once while en route. Like ASA 2 patients, these are “yellow traffic light” patients (e.g., proceed with caution). Elective dental care is not contraindicated, but this patient’s risk during treatment is increased. Serious consideration should be given to the possible use of treatment modifications.

Examples of ASA 3 conditions/patients include the following:

• Angina pectoris (stable)
• Status post–myocardial infarction: more than 6 months prior to dental appointment and with no significant residual signs or symptoms
• Status post–myocardial infarction: less than 6 months prior to dental appointment where the degree of myocardial damage is minimal (requires medical consultation) and with no significant residual signs or symptoms
• Status post-CVA: more than 6 months prior to dental appointment and with minimal residual signs and symptoms
• Type 1 diabetes (well controlled)
• HF with orthopnea and ankle edema
• COPD: emphysema or chronic bronchitis
• Exercise-induced asthma
• Epilepsy (less well controlled)
• Hyperthyroid or hypothyroid disorders (patient is symptomatic)
• Patients who are functionally anephric (renal dialysis patients)
• Adults with blood pressures 160 to 199 mm Hg systolic and/or 95 to 114 mm Hg diastolic
• BMI of 40.0 or greater (may be ASA 3 or 4 depending on presence and severity of comorbidities)

ASA 3 patients can usually perform normal activities without experiencing distress (e.g., undue fatigue, dyspnea, or precordial pain) but will need to stop and rest during an activity should they become distressed.

ASA 4

ASA 4 patients have an incapacitating systemic disease that is a constant threat to their lives. They have severe medical problems that are of greater significance to their health than the planned elective dental treatment. Whenever possible, elective dental care should be postponed until the patient’s medical condition has improved at least to an ASA 3 classification.

ASA 4 patients are unable to walk up one flight of stairs or two level city blocks. Distress is present even at rest. These patients present in the dental office exhibiting clinical signs and symptoms of their underlying disease. An ASA 4 classification should represent a “red traffic light,” a warning that the risk involved in treatment of the patient is too great to permit elective care. The management of dental emergencies, such as infection and pain, should be treated as conservatively as possible in the dental office until the patient’s physical condition improves.

Whenever possible, such emergency dental treatment should be noninvasive, consisting of the prescription of medications such as analgesics for pain and antibiotics or infection. In situations in which immediate intervention is deemed necessary (e.g., incision and drainage, extraction, pulpal extirpation), the patient should receive such care within the confines of an acute care facility (i.e., hospital), if possible, or within the confines of a dental office equipped to recognize and manage emergency situations that might arise. Although hospitalized patients are still at risk, their chance of survival may be greater in the event an acute medical emergency arises as well-trained personnel should be more readily available.

Examples of ASA 4 conditions include the following:

• Unstable angina pectoris (preinfarction angina)
• Myocardial infarction: within the past 6 months
• CVA: within the past 6 months
• Adult blood pressure greater than 200 mm Hg or 115 mm Hg
• Severe HF or COPD (requiring O2 supplementation or confinement in a wheelchair)
• Uncontrolled epilepsy (with a history of hospitalization)
• Uncontrolled type 1 diabetes (with a history of hospitalization)
• BMI of 40.0 or greater (may be ASA 3 or 4 depending on presence and severity of comorbidities)

ASA 5

ASA 5 patients are moribund and are not expected to survive more than 24 hours without the planned surgery. ASA 5 patients almost always are hospitalized (patient located in hospital, nursing home, or hospice facility), terminally ill patients. They may be referred to as DNAR (do not attempt resuscitation) or “no code” patients. Resuscitation efforts are not instituted if respiratory or cardiac arrest occurs. Elective dental treatment definitely is contraindicated; however, emergency care in the realm of palliative treatment (that is, relief of pain and infection) may be necessary. An ASA 5 classification should represent a “red traffic light” for dental care.

Examples of ASA 5 conditions include the following:

• End-stage hepatic disease
• End-stage cancer
• End-stage infectious disease
• End-stage cardiovascular disease
• End-stage respiratory disease

存在发生感染性心内膜炎风险的心脏疾病

存在发生感染性心内膜炎风险的心脏疾病

预防性使用抗生素种类

关于人工关节患者预防性使用抗生素

Dental drug interactions

Dental drug	Interacting drug	Consideration	Action
Local anesthetics (LAs)	Cimetidine, β-adrenergic blockers (propranolol)	Hepatic metabolism of amide LA may be depressed	Use LAs cautiously, especially repeat dosages
	Antidysrhythmics (mexiletine, tocainide)	Additive CNS, CVS depression	Use LAs cautiously—keep dose as low as possible to achieve anesthesia
	CNS depressants, alcohol, antidepressants, antihistamines, benzodiazepines, antipsychotics, centrally acting antihypertensives, muscle relaxants, other LAs, opioids	Possible additive or supra-additive CNS, respiratory depression	Consider limiting maximum dose of LAs, especially with opioids
	Cholinesterase inhibitors, antimyasthenics, antiglaucoma drugs	Antimyasthenic drug dosage may require adjustment because LA inhibits neuromuscular transmission	MD consultation
Vasoconstrictors Epinephrine	α-adrenergic blockers (phenoxybenzamine, prazosin)	Possible hypotensive response following large dose of epinephrine	Use vasoconstrictor cautiously—as low a dose as possible
	Antipsychotics (haloperidol, entacapone)	May enhance systemic actions of vasoconstrictors	Use vasoconstrictor cautiously—as low a dose as possible
	Catecholamine-O-methyltransferase inhibitors (tolcapone, entacapone)	↑ effect of stimulant or vasoconstrictor may occur	Use vasoconstrictor cautiously—as low a dose as possible
	CNS-stimulants (amphetamine, methylphenidate), ergot derivatives (dihydroergotamine, methylsergide)	↑ effects of vasoconstrictors; can result in cardiac arrest	Use vasoconstrictor cautiously—as low a dose as possible
	Cocaine	↑ effects of vasoconstrictors; can result in cardiac arrest	Avoid use of vasoconstrictor in patient under influence of cocaine
	Digitalis glycosides (digoxin, digitoxin)	↑ risk of cardiac dysrhythmias	MD consultation
	Levodopa, thyroid hormones (levothyroxine, liothyronine)	Large doses of either (beyond replacement doses) may ↑ risk of cardiac toxicity	Use vasoconstrictor cautiously—as low a dose as possible
	Tricyclic antidepressants (amitriptyline, doxepin, imipramine)	May enhance systemic effect of vasoconstrictor	Avoid use of levonordefrin or norepinephrine; use epinephrine cautiously—as low a dose as possible
	Nonselective β-blockers (propranolol, nadolol)	May lead to hypertensive responses, especially to epinephrine	Monitor blood pressure after initial LA injection
Benzodiazepines, zolpidem, zaleplon	Alcohol or CNS depressants	Concurrent use may ↑ CNS depressant effects of either agent	Observe for ↑ response to CNS depression; ↓ dose of BZD if necessary
	Chlorpromazine	With zolpidem, zaleplon: concurrent use may prolong elimination half-life of chlorpromazine	Monitor for enhanced BZD response
	Cimetidine	May enhance certain actions of BZD, especially sedation	Monitor for enhanced BZD response
	Disulfiram	May increase CNS depressant action of certain BZD	Monitor for enhanced BZD response
	Erythromycin, clarithromycin, troleandomycin	May ↓ metabolism of certain BZD, ↑ CNS depressant effect	Monitor for enhanced BZD response
	Imipramine	With zolpidem, zaleplon: concurrent use may ↑ drowsiness and risk of anterograde amnesia; may also ↓ peak concentrations of imipramine	Monitor for enhanced BZD response
	Oral contraceptives	May inhibit metabolism of BZD that undergo oxidation	Monitor for enhanced BZD response
	Theophyllines	May antagonize sedative effects of BZD	Monitor for ↓ BZD response
Barbiturates	Acetaminophen	Risk of ↑ hepatotoxicity may exist with large or chronic barbiturate doses	Monitor liver enzymes. Avoid prolonged high dosage use
	Alcohol	Concurrent use may ↑ CNS depressant effects of either agent	Monitor patient for ↑ CNS depressant effects
	Anticoagulants	May ↑ metabolism of anticoagulants, resulting in a ↓ response	Barbiturate therapy should not be started or stopped without considering the possibility of readjustment of the anticoagulant dose
	Oral contraceptives	Reliability may be reduced because of accelerated estrogen metabolism caused by barbiturate induction of hepatic enzymes	Suggest alternative form of birth control
	Doxycycline	Phenobarbital ↓ doxycycline’s half-life and serum levels	Dose of doxycycline may have to be increased
	MAO-I	MAO-I may enhance sedative effects of barbiturates	Consider reduced dosage of barbiturate
	Metronidazole	Antimicrobial effectiveness of metronidazole may be decreased	Dose of metronidazole may have to be increased
	Narcotics	May ↑ toxicity of meperidine and ↓ effect of methadone	Monitor for excessive meperidine effect; dosage of methadone may have to be increased
	Theophylline	Barbiturates ↓ theophylline levels, possibly resulting in ↓ effects	Clinical Key
	Valproic acid	Concurrent use may ↓ metabolism of barbiturates resulting in ↑ plasma concentrations	Monitor for excessive phenobarbital effect
Opioids (used for conscious sedation)	Benzodiazepines	↑ respiratory depression, ↑ recovery time, ↑ risk of hypotension	Titrate dosages and monitor for excessive sedation
	Cimetidine	Actions of opioids may be enhanced resulting in toxicity	If significant CNS depression occurs withdraw the drugs; if warranted administer opioid antagonist such as naloxone
	CNS depressants	↑ CNS depression	Monitor for excess sedation
	Diuretics/antihypertensives	↑ hypotensive effects	Monitor BP
	MAO inhibitors	With meperidine: agitation, seizures, fever, coma, apnea, death	Avoid this combination
	Phenothiazines	↑ or ↓ effects of opioid analgesic drugs. Hypotension may occur when phenothiazine administered with meperidine	Avoid concurrent use of meperidine and phenothiazines
Chloral hydrate	CNS depressants	Concurrent use may ↑ CNS depressant effects of other drug	Monitor for excess CNS depression
	Anticoagulants, coumarin or indandione-derivative	Displacement of anticoagulant from its plasma protein; ↑ anticoagulant effect	Avoid use
	Catecholamine	Large CH doses may sensitize myocardium to catecholamine	Avoid treating CH overdose with catecholamine
Standard opioids (used for postoperative pain management)	Agonist-antagonist drugs (nalbuphine, butorphanol, pentazocine)	Can lead to withdrawal syndrome or loss of analgesic-pain with hypertension, tachycardia	Never prescribe agonist-antagonist opioids with conventional agonist opioids
	Alcohol	Sedative side effects	Advise patients never to drink alcohol when taking opioids
	Amphetamines	With meperidine: hypotension, respiratory collapse	Do not prescribe meperidine if patient taking amphetamines
	Anticholinergics	Constipation	Prescribe opioids only for short periods of time; consider MD consultation
	Antidiarrheals	Constipation	Prescribe opioids only for short periods of time; consider MD consultation
	Antihypertensives and vasodilators	Potentiation of hypotensive effects	Advise patients to notify dentist if hypotension or dizziness occurs
	Barbiturates	Sedative side effects	Alert patient to possible additive side effects and to notify dentist if not tolerated
	CNS depressants	Sedative side effects	Alert patient to possible additive side effects and to notify dentist if not tolerated
	Hydroxyzine	Sedative side effects	Alert patient to possible additive side effects and to notify dentist if not tolerated
	Hypnotics (sedative)	Sedative side effects	Alert patient to possible additive side effects and to notify dentist if not tolerated
	MAO inhibitors	With meperidine: severe hypertension	Avoid prescribing meperidine to patients taking MAO inhibitors; prescribe opioids only for short periods of time; consider MD consultation
	Metoclopramide	Can antagonize metoclopramide	Avoid prescribing two opioids at one time, unless for chronic pain
	Other opioids	Sedative side effects	Avoid prescribing two opioids at one time, unless for chronic pain
NSAIDs	Alcohol	↑ risk of ulceration	Advise patient to avoid if possible
	Oral anticoagulants	↑ risk of bleeding	Advise patient that concurrent use is contraindicated
	Antihypertensives	Effect ↓ by NSAIDs	Monitor BP
	Aspirin	↑ risk of ulceration and bleeding	Advise patient that concurrent use is contraindicated
	NSAIDs other than aspirin	↑ risk of ulceration and bleeding	Avoid this combination
	Corticosteroids	↑ risk of bleeding	Avoid combination, if possible
	Cyclosporin	Can cause nephrotoxicity	Avoid combination, if possible
	Digitalis	↑ digitalis levels	Avoid combination, if possible
	Diuretics (especially triamterene)	Effects ↓ by NSAIDs	Monitor BP/excessive fluid retention
	Heparin	↑ risk of bleeding	Advise patient that concurrent use is contraindicated
	Oral hypoglycemics	Effect ↑ by NSAIDs	Advise patient to monitor blood glucose carefully
	Lithium	Concentration ↑ by NSAIDs	Contraindicated unless approved by MD, so avoid concurrent use
	Potassium supplements	↑ risk of ulceration	Avoid combination, if possible
	Valproic acid	↑ risk of ulceration and bleeding	Avoid combination, if possible
Penicillins and cephalosporins	Allopurinol	Concurrent use with ampicillin, amoxicillin, or amoxicillin with clavulanic acid ↑ incidence of rashes	Monitor for signs of rash and need to change to other antibiotic
	Oral contraceptives, combined with estrogen and progestin	Sporadic reports of ↓ oral contraceptive effectiveness resulting in unexplained pregnancies	Patient should be advised of the possible ↓ in effectiveness and encouraged to use alternate or additional method of birth control while taking these penicillins
	Probenecid	May ↓ renal tubular secretion of penicillin and cephalosporins resulting in ↑ and prolonged antibiotic blood levels	Monitor patient for any need in adjustment of antibiotic dose
Macrolides	Alfentanil	Prolonged or enhanced respiratory depression with concurrent use of erythromycin	Chronic preoperative and postoperative use of erythromycin contraindicated
	Carbamazepine	↑ risk of ataxia, vertigo, drowsiness, and confusion with concurrent use of erythromycin	If used concurrently, must be done with great caution
	Cyclosporine	↑ immunosuppression and nephrotoxicity with concurrent use of erythromycin or clarithromycin	Concurrent use of these drugs is contraindicated
	Digoxin	Erythromycin can lead to ↑ digoxin blood levels leading to digitalis toxicity with resulting cardiac dysrhythmias	Concurrent use of these drugs is contraindicated
	Felodipine	↑ risk of hypotension, tachycardia, and edema with concurrent use of erythromycin	Concurrent use of these drugs is contraindicated
	Lovastatin	Muscle pain and skeletal muscle injury with concurrent use of erythromycin	Concurrent use of these drugs is contraindicated
	Oral contraceptives with estrogen and progestin	Sporadic reports of ↓ oral contraceptive effectiveness resulting in unexplained pregnancies	Patient should be advised of the possible ↓ in effectiveness and encouraged to use alternate or additional method of taking these macrolides
	Theophylline	↑ risk of tachycardia, cardiac dysrhythmias, tremors, and seizures reported with concurrent use of erythromycin or clarithromycin	Concurrent use of these drugs is contraindicated
	Triazolam or midazolam	Marked ↑ in blood levels of ↑ both BZDs leading to ↑ sedation and duration reported with concurrent use of erythromycin	Concurrent use of these drugs is contraindicated
	Warfarin	Erythromycin and clarithromycin ↓ metabolism of warfarin and may significantly ↑ prothrombin and/or INR times and ↑ risk of serious bleeding in patients receiving anticoagulation therapy	Warfarin dosage adjustments may be necessary during and after therapy, and prothrombin or INR times should be monitored closely
Tetracyclines	Combinations containing any of the following: antacids, calcium, magnesium, aluminum, iron supplements, sodium bicarbonate	Tetracycline molecules chelate divalent and trivalent cations, impairing absorption.	Advise patients against taking these medications within 1–3 h of taking oral tetracycline
	Digoxin	Tetracyclines may lead to digoxin blood levels, leading to digitalis toxicity with resulting cardiac dysrhythmias	Concurrent use of these drugs is contraindicated
	Oral contraceptives: estrogen and progestin combined	Reports of ↓ oral contraceptive effectiveness in women taking tetracyclines resulting in unplanned pregnancy	Patients should be advised of the possible reduction in the effectiveness and encouraged to use an alternate or additional method of contraception while taking tetracyclines
	Warfarin	Tetracycline may ↓ metabolism of warfarin and may significantly ↑ prothrombin and/or INR times and ↑ risk of serious bleeding in patients receiving anticoagulation therapy	Warfarin dosage adjustments may be necessary during and after therapy, and prothrombin or INR times should be monitored closely
Clindamycin	Antidiarrheals	Concurrent use of clindamycin and antidiarrheals containing kaolin or attapulgite may delay absorption of oral clindamycin	If concurrent use of these drugs is necessary, caution and careful spacing of preparations are indicated
	Narcotic analgesics	Concurrent use with clindamycin may lead to ↑ or prolonged respiratory depression or apnea	Concurrent use is contraindicated; otherwise patients should be advised to take absorbent antidiarrheals not less than 2 h before or 3–4 h after taking oral clindamycin
	Neuromuscular blocking agents	Concurrent use with clindamycin may enhance neuromuscular blockade, resulting in skeletal muscle weakness and/or respiratory depression or apnea	Avoid concurrent use; if necessary carefully monitor patient for muscle weakness or respiratory depression
Metronidazole	Alcohol	Combination may produce a disulfiram-like effect, leading to facial flushing, headache, palpitations, and nausea	Concurrent use is contraindicated, and use should be delayed at least 1 day after ingestion of alcohol
	Anticoagulants	Coumarin or indandione-derived anticoagulants may be potentiated by metronidazole resulting in prothrombin or INR times	Anticoagulant adjustments may be necessary in consultation with MD
	Cimetidine, phenobarbital, phenytoin	Hepatic clearance rates may be affected by concurrent use of metronidazole	Concurrent use of these drugs is contraindicated
	Disulfiram	In alcoholic patients, psychotic reactions have been reported in concurrent use to within 2 weeks of use of disulfiram	Concurrent use of these drugs is contraindicated
Ciprofloxacin	Aminophylline, oxtriphylline, or theophylline	Concurrent use of these drugs and ciprofloxacin may result in ↑ risk of theophylline-related toxicity with serious life-threatening reactions	Concurrent use of these drugs is contraindicated
	Antacids containing aluminum, calcium, or magnesium; laxatives containing magnesium	Absorption of ciprofloxacin may be ↓ through chelation by these drugs	Concurrent use of these drugs is contraindicated
	Caffeine	Concurrent use of caffeine and ciprofloxacin may ↓ the metabolism of caffeine resulting in CNS stimulation	Concurrent use of these drugs is contraindicated
	Cyclosporine	Concurrent use of ciprofloxacin has been reported to ↑ serum creatinine and serum cyclosporine concentrations	Cyclosporine concentrations should be monitored and dosage adjustments may be required
	Vitamin or mineral supplements containing ferrous sulfate or zinc	Absorption of ciprofloxacin may be ↓ through chelation by these agents	Concurrent use of these drugs is contraindicated
	Warfarin	Concurrent use of warfarin and ciprofloxacin has been reported to ↑ the anticoagulant effect of warfarin, ↑ the risk of bleeding	The prothrombin time or INR of patients receiving warfarin and ciprofloxacin should be carefully monitored
Trimethoprim and sulfamethoxazole	Coumarin or indanedione-derived anticoagulants	Concurrent use may prolong the patients prothrombin time or INR and lead to bleeding	Prothrombin time or INR of patients concurrently taking these drugs should be monitored carefully
	Hydantoin anticonvulsants	Concurrent use may lead to excessive phenytoin serum levels	Concurrent use of these drugs is contraindicated
	Thiazide diuretics	Elderly patients taking thiazide diuretics have an ↑ risk of thrombocytopenia if these drugs are taken concurrently	If these drugs are taken concurrently, platelet counts and clinical signs of purpura should be carefully monitored

(CVS, cardiovascular system; CNS, central nervous system; BP, blood pressure; BZD, benzodiazepine; CH, chloral hydrate; INR, International Normalized Ratio. Drug-drug interactions of greater clinical significance are italicized and emboldened for emphasis. From Ciancio SG: ADA guide to dental therapeutics, ed 3, Chicago, American Dental Association, Chicago, 2003. Copyright © 2003 American Dental
Association. All rights reserved. Excerpted 2007 with permission.)

牙科患者压力疏解措施

口服镇静催眠药物

(此处需要注意，美国的颌面外科医生经过培训后是可以进行相当于国内麻醉医生的一些操作的，国内颌面外科医生没有这个执业权限)