Advanced Oral Surgery E-Book

• Herausgeber: Quintessence Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 393

Veröffentlichungsjahr: 2024

Beschreibung

Following on from the recent publication of Basic Oral Surgery comes the perfect book for advanced practitioners who frequently perform oral surgery procedures in their practices and want to update and develop their skills. The book is also aimed at current and prospective specialists in oral and maxillofacial surgery. Like the first volume, Advanced Oral Surgery is designed as an atlas rather than a textbook. In the clinical chapters, particularly, the theoretical content is outlined in short passages of text and follows a similar structure: indications, contraindications, step-by-step clinical procedures, and postoperative controls. This second volume also contains numerous illustrations in the form of series of images and videos linked via QR codes. The content and scope of the book are based on advanced training programs and the range of clinical advanced training in oral surgery provided by university departments.

Leseprobe

ADVANCED ORAL SURGERY

Andreas Filippi | Fabio Saccardin | Sebastian Kühl (eds)

ADVANCED ORAL SURGERY

With contributions by:

Stephan Acham, Daniel Baumhoer, Michael M. Bornstein, Thomas Connert, Dorothea Dagassan-Berndt, Henrik Dommisch, Tobias Fretwurst, Mathieu Gass, Norbert Jakse, Ronald E. Jung, Georgios Kanavakis, Adrian Kasaj, Khaled Mukaddam, Katja Nelson, Puria Parvini, Michael Payer, Martina Schriber, Michael Schwaiger, Frank Schwarz, Bernd Stadlinger, Frank Peter Strietzel, Silvio Valdec, Carlalberta Verna, Jürgen Wallner, Wolfgang Zemann

One book, one tree: In support of reforestation worldwide and to address the climate crisis, for every book sold Quintessence Publishing will plant a tree (https://onetreeplanted.org/).

A video shows more than a series of photographs

Numerous videos are included in this book to illustrate the content and enrich the reading experience. These can easily be played on a smartphone or tablet using the QR code.

Alternatively, the videos can also be accessed via this link: https://video.qvnet.de/b23530/.

A CIP record for this book is available from the British Library.ISBN: 978-1-78698-133-2

Title of original issue: Das große 1 x 1 der OralchirurgieCopyright © 2022 Quintessenz Verlags-GmbH, Berlin, Germany

Quintessenz Verlags-GmbHIfenpfad 2–412107 Berlin, Germany

www.quintessence-publishing.com

Quintessence Publishing Co LtdGrafton Road, New MaldenSurrey KT3 3AB, United Kingdom

www.quintessence-publishing.com

Copyright © 2024 Quintessenz Verlags-GmbHAll rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Translation: Susan Holmes, Brighton, UKEditing, layout, and production: Quintessenz Verlags-GmbH, Berlin, Germany

ISBN: 978-3-86867-692-1Printed and bound in Croatia

Preface

Our book Basic Oral Surgery was published in late 2022. It became clear even during the creation of that first volume that if that book was about “basic” oral surgery, there would need to be a successor. And so we set about creating this book, Advanced Oral Surgery, the content and scope of which is based on advanced training programs and the range of clinical advanced training in oral surgery provided by university departments. The book is aimed at our advanced oral surgery colleagues who frequently perform oral surgery procedures in their practices and want to update or develop their skills as well as current and prospective specialists in oral and maxillofacial surgery.

The editors in the operating room at the dental clinic in Basel before surgery (from left to right): Fabio Saccardin, Andreas Filippi, and Sebastian Kühl.

Like the first volume, Advanced Oral Surgery is not designed as a textbook but as an atlas. Particularly in the clinical chapters, the theoretical content is outlined in short passages of text that all follow a similar structure: indications, contraindications, step-by-step clinical procedures, and postoperative course, together with just a few relevant literature references. These chapters come to life in the series of photographs in the book and the videos linked via QR codes, which can be viewed very easily and almost instantaneously on any up-to-date smartphone or tablet. This significantly expands the scope and value of the book beyond mere static images. We hope that as a result our book will give practitioners more confidence before, during, and after oral surgery interventions. Some redundancies in the content as well as a few contradictory statements by the team of authors drawn from three nations are intentional on the part of the editors.

Our special thanks again go to everyone who has been involved in the creation of this second volume: our co-authors Stephan Acham, Daniel Baumhoer, Michael M. Bornstein, Thomas Connert, Dorothea Dagassan-Berndt, Henrik Dommisch, Tobias Fretwurst, Mathieu Gass, Norbert Jakse, Ronald E. Jung, Georgios Kanavakis, Adrian Kasaj, Khaled Mukaddam, Katja Nelson, Puria Parvini, Michael Payer, Martina Schriber, Michael Schwaiger, Frank Schwarz, Bernd Stadlinger, Frank Strietzel, Silvio Valdec, Carlalberta Verna, Jürgen Wallner, and Wolfgang Zemann.

Our thanks also go to Sabrina Peterer for the cover image, which continues the style of the iconic covers of books by Andreas Filippi; Anita Hattenbach from Quintessence Publishing, Andreas Filippi’s favorite editor for her ever-reliable, incredibly pleasant, and highly professional editing (and that is compared with all the other publishers with whom Andreas Filippi has previously worked); and to all the staff involved at Quintessence Publishing in Berlin.

Finally, thank you to all our colleagues at our really fantastic Department of Oral Surgery at UZB in Basel for your support, your motivation, and your dedication. It is tremendously enjoyable to work with all of you every day.

Andreas Filippi, Fabio Saccardin,and Sebastian Kühl

Editors’ contact details

Prof Dr Andreas Filippi

Dr Fabio Saccardin

Prof Dr Sebastian Kühl

Department of Oral Surgery

University Center for Dental Medicine Basel UZB

University of Basel

Mattenstr. 40

CH – 4058 Basel, Switzerland

Authors’ contact details

Priv-Doz Dr Stephan Acham

Clinical Department of Oral Surgery and Orthodontics

Department of Dental Medicine and Oral Health

Medical University of Graz

Billrothgasse 4

A – 8010 Graz, Austria

Prof Dr Daniel Baumhoer

Bone Tumor Reference Center and DOESAK Reference Registry

Department of Medical Genetics and Pathology

University Hospital Basel

Schönbeinstr. 40

CH – 4031 Basel, Switzerland

Prof Dr Michael M. Bornstein

Department of Oral Health & Medicine

University Center for Dental Medicine Basel UZB

University of Basel

Mattenstr. 40

CH – 4058 Basel, Switzerland

Priv-Doz Dr Thomas Connert

Department of Periodontology, Endodontology and Cariology

University Center for Dental Medicine Basel UZB

University of Basel

Mattenstr. 40

CH – 4058 Basel, Switzerland

Dr Dorothea Dagassan-Berndt

Center for Dental Imaging

University Center for Dental Medicine Basel UZB

University of Basel

Mattenstr. 40

CH – 4058 Basel, Switzerland

Prof Dr Henrik Dommisch

Department of Periodontology, Oral Medicine and Oral Surgery

CharitéCenter 3 for Oral Health Sciences

Charité – Universitätsmedizin Berlin

Aßmannshauserstr. 4–6

D – 14197 Berlin, Germany

Prof Dr Tobias Fretwurst

Department of Oral and Maxillofacial Surgery/ Translational Implantology

University of Freiburg

Hugstetterstr. 55

D – 79106 Freiburg, Germany

Dr Dr Mathieu Gass

University Clinic for Caniomaxillofacial Surgery

Inselspital, University Hospital Bern

Freiburgstrasse 20

CH – 3010 Bern, Switzerland

Prof Dr Dr Norbert Jakse

Clinical Department of Oral Surgery and Orthodontics

Department of Dental Medicine and Oral Health

Medical University of Graz

Billrothgasse 4

A – 8010 Graz, Austria

Prof Dr Ronald E. Jung, PhD

Department of Reconstructive Dentistry

Center of Dental Medicine UZH

University of Zürich

Plattenstr. 11

CH – 8032 Zürich, Switzerland

Dr Georgios Kanavakis

Department of Pediatric Oral Health and Orthodontics

University Center for Dental Medicine Basel UZB

University of Basel

Mattenstr. 40

CH – 4058 Basel, Switzerland

Prof Dr Dr h c Adrian Kasaj, MSc

Department of Periodontology and Operative Dentistry

University Medical Center

Augustusplatz 2

D – 55131 Mainz, Germany

Dr Khaled Mukaddam

Department of Oral Surgery

University Center for Dental Medicine Basel UZB

University of Basel

Mattenstr. 40

CH – 4058 Basel, Switzerland

Prof Dr Katja Nelson

Department of Oral and Maxillofacial Surgery/ Translational Implantology

University of Freiburg

Hugstetterstr. 55

D – 79106 Freiburg, Germany

Priv-Doz Dr Puria Parvini, MSc MSc

Outpatient Department of Oral Surgery and Implantology

Center of Oral Health (Carolinum)

Johann Wolfgang Goethe University Frankfurt am Main

Theodor-Stern-Kai 7

D – 60596 Frankfurt am Main, Germany

Prof Dr Dr Michael Payer

Clinical Department of Oral Surgery and Orthodontics

University Department of Dental Medicine and Oral Health

Medical University of Graz

Billrothgasse 4

A – 8010 Graz, Austria

Dr Martina Schriber

Department of Oral Health & Medicine

University Center for Dental Medicine Basel UZB

University of Basel

Mattenstr. 40

CH – 4058 Basel, Switzerland

Priv-Doz Dr Dr Dr Michael Schwaiger

Clinical Department of Oral and Maxillofacial Surgery

University Department of Dental Medicine and Oral Health

Medical University of Graz

Auenbruggerplatz 5

A – 8010 Graz, Austria

Prof Dr Frank Schwarz

Outpatient Department of Oral Surgery and Implantology

Center of Oral Health (Carolinum)

Johann Wolfgang Goethe University Frankfurt am Main

Theodor-Stern-Kai 7

D – 60596 Frankfurt am Main, Germany

Prof Dr Dr Bernd Stadlinger

Clinic of Oral Surgery –

Clinic of Cranio-Maxillofacial Surgery

Center of Dental Medicine

University of Zürich

Plattenstr. 11

CH – 8032 Zürich, Switzerland

Priv-Doz Dr Frank Peter Strietzel

Department of Periodontology, Oral Medicine and Oral Surgery

CharitéCenter 3 for Oral Health Sciences

Charité – Universitätsmedizin Berlin

Aßmannshauserstr. 4–6

D – 14197 Berlin, Germany

Priv-Doz Dr Silvio Valdec

Clinic of Oral Surgery –

Clinic of Cranio-Maxillofacial Surgery

Center of Dental Medicine

University of Zürich

Plattenstr. 11

CH – 8032 Zürich, Switzerland

Prof Dr Carlalberta Verna

Department of Pediatric Oral Health and Orthodontics

University Center for Dental Medicine Basel UZB

University of Basel

Mattenstr. 40

CH – 4058 Basel, Switzerland

Priv-Doz Dr Dr Dr Jürgen Wallner

Clinical Department of Oral and Maxillofacial Surgery

University Department of Dental Medicine and Oral Health

Medical University of Graz

Auenbruggerplatz 5

A – 8010 Graz, Austria

Prof Dr Dr Wolfgang Zemann

Clinical Department of Oral and Maxillofacial Surgery

University Department of Dental Medicine and Oral Health

Medical University of Graz

Auenbruggerplatz 5

A – 8010 Graz, Austria

Contents

HISTORY TAKING

1 Complex patient profile in oral surgery

 Martina Schriber, Michael M. Bornstein

SPECIAL EQUIPMENT IN ORAL SURGERY

2 Optical magnifying aids

 Fabio Saccardin, Thomas Connert

3 CO2 laser

 Fabio Saccardin

4 Piezoelectric surgery

 Fabio Saccardin, Sebastian Kühl

5 Cone beam computed tomography

 Dorothea Dagassan-Berndt

BONE-PRESERVING INTERVENTIONS

6 Alveolar stabilization

 Michael Payer, Ronald E. Jung

7 Autologous dental hard tissue

 Puria Parvini, Frank Schwarz

8 Decoronation

 Andreas Filippi

TOOTH-PRESERVING SURGERY

9 Surgical exposure and orthodontic alignment

 Sebastian Kühl

10 Apicoectomy

 Sebastian Kühl, Andreas Filippi

11 Tooth transplantation

 Andreas Filippi

12 Intentional replantation

 Andreas Filippi

13 Transreplantation

 Andreas Filippi

SOFT TISSUE SURGERY

14 Vestibuloplasty and apically repositioned flap

 Mathieu Gass, Tobias Fretwurst, Katja Nelson

15 Autologous soft tissue grafts

 Henrik Dommisch, Frank Peter Strietzel

16 Recession coverage

 Adrian Kasaj

17 Salivary stone removal

 Fabio Saccardin, Sebastian Kühl

HARD TISSUE SURGERY

18 Cystostomy and cystectomy

 Sebastian Kühl, Khaled Mukaddam, Daniel Baumhoer

19 Removal of exostoses

 Silvio Valdec, Bernd Stadlinger

20 Surgical revisions of the alveolar process

 Stephan Acham, Michael Schwaiger, Norbert Jakse, Jürgen Wallner, Wolfgang Zemann

TEMPORARY SKELETAL ANCHORAGE

21 Orthodontic mini-implants

 Sebastian Kühl, Georgios Kanavakis, Carlalberta Verna, Fabio Saccardin

22 Palatal implants

 Sebastian Kühl, Fabio Saccardin, Andreas Filippi

EVIDENCE

23 Evidence-based aspects

 Frank Peter Strietzel, Henrik Dommisch

1 Complex patient profile in oral surgery

Martina Schriber, Michael M. Bornstein

There is often very little separating success from failure in oral surgery, and several factors influence the outcome. Firstly, the skills and experience of the surgeon play a key role. Studies have shown that surgical skills improve with the number of procedures performed, and hence the risk of complications also decreases. Correct patient selection is an equally important factor in the success of oral surgery. In the process, it is crucial to take a thorough general medical history, which helps to avoid local and systemic complications resulting from a surgical procedure. It is the surgeon’s responsibility to give patients a thorough explanation prior to surgery and to gather any general medical information that may be missing. Furthermore, the surgeon needs to assess whether the patient is able to tolerate the procedure under local anesthesia or whether treatment under sedation or general anesthesia is required because of a dental phobia, for example. An oral surgery procedure is successful if attention is paid to patient-specific factors as well as the actual intervention and if medical complications can be avoided.

Importance of history taking

History taking forms the basis on which a diagnosis is made at the start of any medical or dental treatment and is an integral part of the work of medical and dental practitioners. The purpose of history taking is to record all existing or previous illnesses and diagnoses of the cardiovascular system, gastrointestinal tract, metabolic and nervous systems, blood and coagulation system, and musculoskeletal system as well as infectious diseases. Furthermore, patients should specifically be asked whether they have ever experienced intraoperative or postoperative complications such as difficulties during procedures, allergies, bleeding or failure of anesthesia.

Age itself brings with it physiologic changes that have an influence on patient positioning and resilience. In addition, elderly patients frequently have several concomitant diseases and an extensive list of medications. A characteristic of multimorbidity is the simultaneous presence of two or more systemic diseases such as metabolic, cardiovascular, psychosomatic, mental, neuropsychiatric, and gerontopsychiatric conditions as well as combinations of diseases (known as a “cluster”). These illnesses are usually treated or kept under control by patients regularly taking medication. This means they are simultaneously taking many different medications. When a patient is taking five or more prescription medications per day, it is referred to as polypharmacy38. Overprescribing is not uncommon, especially among elderly people who have been taking medication for a long time51. Inappropriate polypharmacy is a relevant problem, particularly for older people, and is associated with negative health consequences46. In 2010, 13% of the population in the USA were aged 65 and older and were receiving 39% of all prescribed medications16,51. In this population group, 68% suffered from two or more chronic illnesses (i.e. multimorbidity). These typically involved high blood pressure (61%), heart disease (32%), arthritis (31%), and diabetes (28%)15.

History taking enables complex patient profiles with multimorbidity and associated polypharmacy to be properly recognized. This can also help to categorize patients into high- and low-risk groups for outpatient oral surgery measures. For polypharmacy and multimorbidity patients, it is therefore advisable to obtain a list of medications and diagnoses routinely from their attending physician. Possible drug interactions can thus be checked and avoided.

Relevant problem areas from general medicine

Increased bleeding tendency

Intraoperative or postoperative bleeding can pose a serious problem in the course of oral surgery procedures (Fig 1-1). When patients have an increased bleeding tendency, a distinction must be made between congenital, acquired, and drug-induced hemorrhagic diatheses.

Fig 1-1 Bleeding 1 day after implant placement with horizontal bone augmentation in the region of the maxillary right first molar in a 55-year-old healthy patient not taking anticoagulants.

Congenital hemorrhagic diathesis

Patients with congenital hemophilia A or B or a deficiency or faulty formation of von Willebrand factor have an increased risk of bleeding. In such cases, it is imperative to consult with the attending hematologist before oral surgery procedures and ideally perform the procedure at a specialist clinic.

Acquired hemorrhagic diathesis

Acquired hemorrhagic diathesis occurs in patients with hepatic, renal, and autoimmune diseases; infectious diseases; and leukemia. Disturbances of liver function such as cirrhosis of the liver can arise in the context of alcohol addiction or as a result of autoimmune and drug-induced hepatitis. In cirrhosis of the liver, the function of the liver is impaired to the extent that clotting factors are no longer formed. It is therefore advisable to obtain preoperative laboratory blood values for clotting factors.

Thrombocytopenia or thrombocyte dysfunction occurs in the context of kidney diseases and malignant bone marrow diseases (leukemias) where the healthy thrombocyte-forming bone marrow is suppressed by the growth of malignant cells.

Thrombocytopenia and thrombocyte dysfunction also occur in association with HIV, hepatitis B and C and Epstein-Barr virus infections, and autoimmune diseases (e.g. systemic lupus erythematosus or rheumatoid arthritis). Prior to oral surgery, the platelet count is particularly significant because in some circumstances the administration of platelet concentrate may be required before the procedure.

Drug-induced hemorrhagic diathesis

Drug-induced hemorrhagic diathesis occurs in patients receiving oral anticoagulants or platelet aggregation inhibitors. More and more patients are taking these drugs, in some cases for life, in order to prevent thromboembolic events. There is still a lack of clarity among physicians and dentists with regard to the preoperative, intraoperative, and postoperative management of these patients, together with a degree of uncertainty on the part of patients. The various groups of anticoagulants (vitamin K antagonists, novel oral anticoagulants, platelet aggregation inhibitors) should be correctly recorded during history taking, and their effects also need to be understood (Table 1-1). In the case of patients taking anticoagulants, potential bleeding risks during the course of oral surgery if anticoagulation is continued must be weighed against possible thromboembolic complications if the medication is suspended, altered or reduced. Patients under oral anticoagulation/platelet aggregation inhibition usually have a very low risk of bleeding complications that cannot be managed with a topical hemostatic agent. No fatality due to blood loss during or as a direct consequence of an oral surgery procedure has been reported in the literature to date. This contrasts with a similarly low but highly significant risk of serious thromboembolic complications with the resulting persistent morbidity or even death in patients with reduced or discontinued anticoagulation therapy in the context of dental procedures62.

Table 1-1 Group of oral anticoagulants modified from the German S3 Guideline on Oral Surgery under oral anticoagulation/platelet aggregation inhibition (as at August 2017) and adapted to the products available in Switzerland.

Group of oral anticoagulants (active ingredients)

Product name in Switzerland

Indications

Plasma half-life

Vitamin K antagonists

Phenprocoumon

Marcoumar

To prevent recurrence of thromboses

Atrial fibrillation

Artificial heart valves and vascular prostheses

Coronary heart disease (CHD)

Marcoumar 50 h

NOACs

DabigatranRivaroxabanApixabanEdoxaban

PradaxaXareltoEliquisLixiana

Primary prevention of venous thromboembolic events after an elective surgical procedure (e.g. artificial knee or hip joint)

Prevention of stroke and systemic embolism in non-valvular atrial fibrillation

Treatment and prevention of (recurrent) deep vein thromboses (DVTs) and pulmonary embolisms (PEs)

Pradaxa 12–17 hXarelto 7–11 hEliquis 8–14 hLixiana 10–14 h

Oral platelet aggregation inhibitors

Acetylsalicylic acid (ASA/aspirin)

Aspirin Cardio

CHD

Prevention of transient ischemic attacks (TIAs) and strokes after TIA or stroke

In peripheral arterial occlusive disease (PAOD) after procedures and to prevent secondary vascular complications such as myocardial infarction, stroke, and vascular death

Aspirin Cardio 15–20 min

Thienopyridines

Clopidogrel Prasugrel

Dual therapy with aspirin in the context of coronary interventions and in acute coronary syndrome

Secondary prevention after ischemic stroke and myocardial infarction

Secondary prevention in cardiovascular diseases as an alternative to aspirin

Clopidogrel 6 hPrasugrel 15 h

h, hours; min, minutes

Typical representatives of indirect anticoagulants are the orally administered vitamin K antagonists (VKAs) (e.g. Marcoumar [phenprocoumon]), coumarin derivatives, and heparins (low molecular weight/fractionated, e.g. Clexane [enoxaparin]; high molecular weight/unfractionated, e.g. Fraxiforte [nadroparin], Fragmin [dalteparin]). The group of VKAs is used for long-term blood dilution primarily in tablet form and inhibits enzymes that are required in vitamin K metabolism for the formation of certain clotting factors. Orally administered VKAs have an onset of action of 48 to 72 hours and a long plasma half-life of approximately 160 hours (Table 1-1). Their action is highly effective but subject to fluctuations due to, for example, certain foods (e.g. cabbage, spinach, parsley), stress, other medications, and sports. The prothrombin time is determined by the international normalized ratio (INR), which is a laboratory value to measure the functional capacity of the extrinsic blood clotting system. Depending on the therapeutic indication, the INR lies between 2 and 3.5. In the case of vitamin K antagonists, therapeutic levels (INR < 4) are possible for oral surgery measures because the risk of postoperative, uncontrollable, life-threatening bleeding is negligible34. As a precaution, however, the INR should be measured on the day of surgery or, if not possible, one day beforehand. From the dentist’s perspective, a target INR below 2.5 would be desirable, provided this is considered possible after consultation with the attending physician.

Heparin anticoagulation is usually only carried out in an in-patient setting, which means a dentist in private practice will hardly ever encounter a patient with heparin in their system. The rapid onset of action and short half-life of 5 to 7 hours are advantages of heparin.

Nowadays, it is accepted that VKAs should not be discontinued or reduced for oral surgery or even bridged with heparin products. One important reason is that adjustment to the appropriate target INR takes several days and is relatively complex and time consuming. Suspension or reduction would carry a considerable risk of a thromboembolic complication6,47. Despite strict hemostatic measures being followed, easily controllable bleeding should nevertheless be anticipated22,34.

The novel direct oral anticoagulants (NOACs) exert their effect by direct interaction with individual clotting factors. Important active ingredients in this group of drugs are dabigatran (e.g. Pradaxa) as a direct thrombin inhibitor as well as edoxaban (e.g. Lixiana), apixaban (e.g. Eliquis), and rivaroxaban (e.g. Xarelto) as factor Xa inhibitors (Table 1-1). Their action is reliable, starts or decreases rapidly, and is rarely subject to fluctuations. The anticoagulant effect cannot be determined routinely in clinical practice but can only be measured by special laboratory tests. For this reason, it is important to ask about the individual bleeding tendency during history taking prior to surgery. What matters is when the last tablet was taken and at what dose as well as identifying the active ingredient28. Antagonization with an antidote is possible for all NOACs. Based on data from general surgery, dabigatran should be discontinued 2 to 3 days prior to surgery with bleeding risks if creatinine clearance is > 50 mL/minute. Early preoperative discontinuation may be advisable if renal function is impaired. The general advice for rivaroxaban is to stop the drug 1 or 2 days prior to invasive procedures, although this approach is disputed28,54,55. Again, based on general surgery data, apixaban should be discontinued more than 2 days and edoxaban 1 to 2 days preoperatively. It is true for all NOACs that they can be resumed after procedures once complete hemostasis has been achieved28. NOACs have not been as thoroughly researched to date as VKAs and most of the recommendations, especially regarding dentistry issues, are therefore based on expert opinions. Even so, it does not seem necessary to suspend NOACs for oral surgery procedures35.

Platelet aggregation inhibitors (PAIs) achieve their effect by an inhibition of platelet function that is induced by various mechanisms, which distinguishes them from other anticoagulants. The best-known active substance in this group is acetylsalicylic acid (aspirin). Thienopyridines (Clopidogrel, Prasugrel) belong to the novel, orally administered active ingredients in this group (Table 1-1). Only specific laboratory tests are able to determine the exact bleeding tendency in a patient taking PAIs. If PAIs are taken in combination with certain nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g. ibuprofen, diclofenac), an increased bleeding tendency is to be expected because these NSAIDs lead to reduced platelet production and hence to thrombocytopenia28,35,54,55.

Mono-, bi- or triple therapy

For monotherapy with PAIs there is only a weak correlation, if any, with prolonged bleeding tendencies4,26. However, if acetylsalicylic acid is stopped 7 to 10 days before a procedure, the risk of a cardiovascular event increases threefold61. Therefore, it is not advisable to discontinue acetylsalicylic acid prior to oral surgery procedures, although discontinuation might theoretically take place if the risk of thrombosis is low2,4.

Patients who have had stents implanted are commonly given combined therapy with PAIs (known as bitherapy) for several months postoperatively in order to avoid stent thrombosis, but this can result in relevant postoperative bleeding after oral surgery26. Minor oral surgery procedures can take place while bitherapy is continued40. However, elective dental procedures should be postponed, if possible27. In an emergency procedure, antiaggregatory drugs are not suspended, but platelet concentrates, desmopressin, and/or antifibrinolytics are used, if required55. In this situation, topical hemostatic measures yield good results in terms of preventing and managing bleeding complications52.

If a patient is receiving long-term anticoagulation due to atrial fibrillation and needs a stent because of coronary heart disease, triple therapy is used, which means a combination of oral anticoagulation and two PAIs53. The procedure for these patients is identical to that adopted for patients on bitherapy with PAIs.

Oral surgery procedure in patients with increased bleeding tendency

A patient’s hemorrhagic diathesis or risk of bleeding is dependent on the severity of the systemic disease, the nature of the oral surgery procedure (high or low bleeding risk), wound care, and postoperative compliance as well as the life circumstances of the patient. Oral surgery procedures are generally classified as having a low bleeding risk29. Oral surgery procedures with a higher bleeding risk include the treatment of infected wounds and abscesses as well as interventions in the floor of the mouth, the maxillary sinus, and the retromaxillary space34. These factors dictate the choice of oral surgery approach and whether in-patient admission to a specialist clinic is required12. Bridging is currently controversial even for major procedures and can be carried out with heparin in the case of VKAs and NOACs, if need be, but not in the case of PAIs20.

A minimally invasive approach is important for congenital, acquired or drug-induced hemorrhagic diathesis. Oral surgery procedures should ideally be scheduled for early mornings or on weekends. Large wound areas should be avoided, which means the treatment should be planned on a phased basis, if need be. Local anesthetics with vasoconstrictors are subject to the usual contraindications in this group of patients, while increased bleeding (rebound effect) may be expected if the adrenaline effect is diminished. Complete removal of granulation tissue is important when treating sockets in order to prevent postoperative bleeding. The placement of hemostatic agents such as absorbable sponges or cellulose and collagen cones is advisable (Fig 1-2). The overlying suture fixes the material and further reduces the risk of bleeding8,18,26. Physical compression where the patient bites on gauze5 or the provision of preoperatively prepared gingival shields21 are very simple and effective measures. Postoperatively, tranexamic acid is also helpful as an antifibrinolytic mouthwash, which significantly reduces the frequency of bleeding after oral surgery25,58. It is not uncommon for patients taking anticoagulants to develop hematomas, so prophylactic antibiotic administration may be considered (Fig 1-3). It is advisable to consult the attending internal medicine physician or cardiologist when prescribing antibiotics and analgesics in order to avoid drug interactions.

Fig 1-2 Classic hemostat made of absorbable, regenerated cellulose, which can be placed in the socket after a simple tooth extraction, for instance. However, packing the socket should be avoided as it may impair wound healing.

Fig 1-3 A healthy 94-year-old patient with an extensive hematoma on the right sight of her face and neck after surgical extraction of the maxillary right canine.

Cardiovascular diseases

Patients with very poorly controlled high blood pressure have an increased bleeding tendency and a higher risk of myocardial infarction and stroke. For this group of patients, especially those over the age of 60, it is advisable to monitor blood pressure, pulse, and oxygen saturation during the procedure. The appropriate medications (e.g. Nitroglycerin Streuli, oxygen) should be kept ready during surgery on patients known to have angina pectoris. After a recent myocardial infarction, the attending cardiologist should be contacted in the event of imminent treatment. A period of at least 3 months after myocardial infarction is required before elective surgeries are performed. If there is a risk of endocarditis (e.g. patients with heart valve replacement or congenital valve defects), prophylactic antibiotic administration is required before oral surgery or periodontal procedures in accordance with the endocarditis prevention identification card. Local anesthetics containing adrenaline are not contraindicated for patients with cardiovascular diseases, but the dose should be adjusted depending on the disease and medication (e.g. beta blockers). Patients with heart failure should not be treated in the supine position in order to avoid dyspnea49.

Liver diseases

Impairment of liver function occurs in autoimmune or drug-induced hepatitis and alcohol abuse with cirrhosis of the liver and can cause acquired hemorrhagic diathesis, as described above. In liver disease, it is important to bear in mind the increased bleeding tendency as well as the resultant impaired drug metabolism. Therefore, if liver function is impaired, alternative drugs should be chosen that are not broken down in the liver. It is advisable to discuss the drugs being prescribed beforehand with the patient’s attending internal medicine physician.

Kidney diseases

Chronic renal failure, caused for instance by diabetes mellitus, hypertension, pyelonephritis or polycystic kidney disease, leads to an increased bleeding tendency because of thrombocytopenia or thrombocyte dysfunction, increased susceptibility to infection, and altered drug metabolism. Patients with terminal renal failure require hemodialysis, for which they are anticoagulated. Surgery in patients with renal impairment, renal failure or with a history of kidney transplant surgery should routinely be discussed preoperatively with the patient’s general practitioner or nephrologist. Appropriate hemostatic measures should be taken intraoperatively. Postoperatively, infection prophylaxis by means of antibiotic treatment should be considered.

Diabetes mellitus

Type 1 and 2 diabetes are autoimmune diseases. Patients with type 1 diabetes are reliant on taking insulin for their entire lives because the beta cells in the islets of Langerhans of the pancreas are no longer functioning. Patients with type 2 diabetes primarily show a reduced response of the body’s cells to insulin and have beta cells that are limited in their function. Type 2 diabetes is treated by lifestyle changes, weight reduction, insulin administration, and oral antidiabetic drugs. If a patient is known to have type 1 or 2 diabetes, whether this is well controlled should be checked before any oral surgery treatment. The long-term glucose level (HbA1c) is a reliable benchmark and should ideally be below 7%. Patients usually know what their HbA1c value is. If the diabetes is poorly controlled, delayed wound healing and infections are likely. Appointments should be planned for early morning to enable patients with diabetes who are on insulin therapy to stick to their usual mealtimes and insulin doses. The blood sugar level should ideally be measured prior to an oral surgery procedure. During treatment, it is important to watch out for symptoms of hypoglycemia (e.g. agitation, sweating, pale skin, tachycardia, palpitations, tremor, ravenous appetite, vomiting) and react to them promptly. Antibiotic administration should be considered for patients with poorly controlled diabetes or after major oral surgery procedures in order to aid wound healing and avoid infection.

Epilepsy

The increased stress caused by surgery can trigger a seizure in patients with epilepsy. Patients should be asked about the frequency and intensity of their seizures and the date of their last seizure. If seizures are frequent and poorly controlled by medication, referral to a specialist clinic is advisable, and treatment under sedation or general anesthesia is indicated. In addition, certain antiepileptic drugs belonging to the group of “old antiepileptics” such as those containing the active substance phenytoin cause gingival overgrowth as a side effect. Such changes, previously known as gingival hyperplasia, are nowadays mainly diagnosed in patients with hypertension who are taking calcium channel blockers (e.g. nifedipine-class drugs such as amlodipine) as an antihypertensive active substance (Figs 1-4 to 1-6).

Fig 1-4 Subtle gingival overgrowth, especially in the papillary area, in a 47-year-old patient who is taking a nifedipine drug (calcium channel blocker) daily for hypertension.

Figs 1-5 and 1-6 Generalized gingival overgrowth in the area of the residual dentition in a 56-year-old patient who is taking a nifedipine drug (calcium channel blocker) daily for hypertension. A pronounced increase in substance is very noticeable, especially in the papillary area between the maxillary left canine and first premolar.

Antiresorptive agent-related osteonecrosis of the jaw

A considerable number of adults worldwide are treated with antiresorptive (AR) drugs as a result of various benign and malignant bone metabolism disorders and hypercalcemia. Bisphosphonates (BPs) and monoclonal antibodies such as denosumab (DNO) belong to the group of ARs (Table 1-2). The main indications for AR treatment include multiple myeloma, bone metastases of solid tumors (e.g. breast, prostate or lung carcinomas), osteoporosis (primary and secondary), and Paget’s disease (Table 1-3).

Table 1-2 Antiresorptive drugs from the group of bisphosphonates (BPs) and denosumab (DNO), commonly administered in Switzerland, and novel substances: mammalian target of rapamycin (mTOR) inhibitors, vascular endothelial growth factor (VEGF) inhibitors, tyrosine kinase (TK) inhibitors, multikinase inhibitors.

Active substances

Product name in Switzerland (excluding generics)

Bisphosphonates (BPs)

Alendronic acidAlendronic acid and cholecalciferolIbandronic acidRisedronic acidZoledronic acid

FosamaxFosavanceBonvivaActonelAclastaZometa

Denosumab (DNO)

Denosumab

ProliaXgeva

mTOR inhibitors

EverolimusSirolimusTemsirolimus

AfinitorRapamuneTorisel

VEGF inhibitors

AfliberceptBevacizumabBrolucizumabRanibizumab

EyleaAvastinBeovuLucentis

TK inhibitors

ErlotinibGefitinib

TarcevaIressa

Multikinase inhibitors

SorafenibSunitinib

NexavarSutent

Table 1-3 Risk profiles modified from the S3 Guideline on ARONJ (as at December 2018).

Low risk profile

(range: 0% to 0.5%)

Medium risk profile

(range: > 0.5% to < 1%)

High risk profile

(range: 1% to 21%)

Indication/ Patient group

Primary osteoporosis

In treatment-induced osteoporosisIn secondary osteoporosisAvoidance of skeletal-related eventsComedication with immunomodulators (antirheumatic drugs, including methotrexate)Underlying diseases, treatments or status with impaired wound healing and/or influence on the immune system: diabetes mellitus, anemia, hyperparathyroidism, dialysis, chemotherapy, glucocorticoid therapy, anti-angiogenic therapies, advanced age

For BP:Bone metastasesMultiple myelomacombined with novel substances (mTOR, VEGF, TK inhibitors)

Medication

BP:Oral: including alendronate, ibandronate or risedronateIV: zoledronate 5 mg every 12 months, ibandronate3 mg/3 mL every 3 monthsDNO:SC: DNO medication 60 mg every 6 months

BP:IV: e.g. zoledronate 4 mg every 6 monthsIV: zoledronate once a year or oral BP with comedication with immunomodulators and/or with underlying disease that modifies wound healing or modulates the immune system

BP:IV: e.g. zoledronate 4 mg every 4 weeksDNO:SC: DNO medication 120 mg every 4 weeks

Prevalence with BP medication

0.0%–0.5%BP medication < 4 years: 0.04%BP medication > 4 years: 0.21%

1%

1%–21%

Prevalence with DNO medication

0.13%–0.21%

2%–5%

Prevalence with BP medication and novel substances*

BP combined with TK inhibitor (Nexavar, Sutent): 17%BP combined with VEGF inhibitor (Avastin): 0.9%–2.4%

IV, intravenous; SC, subcutaneous. *Novel substances: mammalian target of rapamycin (mTOR) inhibitors, tyrosine kinase (TK) inhibitors, vascular endothelial growth factor (VEGF) inhibitors.

Numerous clinical trials have shown that ARs lead to a reduced frequency of bone fractures and pain in patients with nononcologic diseases (e.g. osteoporosis). In patients with cancer, AR drugs help to prevent pathologic fractures and to improve quality of life. On the other hand, the side effect of AR agent-related osteonecrosis of the jaw (ARONJ) is relevant (Figs 1-7 and 1-8). ARONJ is a potentially serious disease because it is associated with relevant functional impairments. Event rates of 0.001% to 0.01% are reported in patients with osteoporosis who are taking AR agents (BP and DNO), and 1% to 15% in patients with cancer who are taking AR agents36. As the individual risk profile for ARONJ differs and is dependent on various factors, prophylaxis and prevention should be adapted to the patient’s particular risk profile (Table 1-3). Patients are assigned an individual risk profile (low, medium, high) based on pharmacologic properties, indications, doses administered, frequency, and duration of AR treatment. The patient’s general medical condition as well as existing nicotine use and comedication with agents such as glucocorticosteroids or immunomodulators also play a role. Patients with malignancies receive a much higher AR dose than osteoporosis patients and therefore belong to the high-risk group.

Fig 1-7 A 74-year-old patient with prostate cancer and bone metastases receiving treatment with denosumab (Xgeva). ARONJ in the right mandible in the second premolar to second molar region crestal and distal to the implant in the first premolar region.

Fig 1-8 A 62-year-old patient with breast cancer and bone metastases receiving treatment with denosumab (Xgeva) showing exposed bone areas palatally and marginally in the maxillary left first premolar to first molar region after a dental hygiene session, which corresponds to the clinical picture of ARONJ.

Approximately 1% of BPs are taken orally and 99% are administered intravenously. Long half-lives of 10 to 12 years are reported. The pharmacokinetics of BPs cause a cumulative effect, thereby explaining why the observed event rates increase with the duration of treatment. Unlike BP, DNO is not deposited in the bone. Half-lives of 24 to 26 days and efficacy for up to 5 months are reported for DNO. Therefore, it is assumed that there is no longer a risk of ARONJ after a break of half a year from DNO treatment.

There are some other substances worth mentioning that also pose a risk of osteonecrosis of the jaw (ONJ) or can worsen existing ONJ. These include radium-223 dichloride, which is used in the treatment of prostate carcinoma, and novel substances/small molecules (mTOR, VEGF, and TK inhibitors) that are used in cancer chemotherapy, for instance (Table 1-3). Patients should always be told about their risk profile for ARONJ. Any AR therapy should be preceded by a search for foci of infection, and prophylactic measures should be carried out as well as the eradication of infection and bacterial portals of entry. It is important that the start of osteoporosis therapy is not delayed by dental ONJ prevention because a low ARONJ event rate is present. This applies particularly to osteoporosis patients being treated with oral BP. When DNO is administered, however, it should be borne in mind that an increased risk of ARONJ exists from the first injection due to a rapid onset of action and short half-life. The aim is to complete the prophylactic measures before therapy starts. In oncology patient groups, eradication of infections and bacterial portals of entry in the oral cavity before the start of BP therapy can lower the ARONJ event rate.

If oral surgery is indicated for a patient who has an AR history or is currently receiving AR therapy, an individual risk profile is drawn up on the basis of how long the medication has been taken, the active substance group, and the current dose. The efficacy of a treatment break (drug holiday) with high-dose AR medications remains uncertain41. It is impossible to make any conclusive recommendation for or against a drug holiday prior to oral surgery procedures in patients receiving ongoing AR medication. The decision to suspend the AR therapy is always made in an interdisciplinary manner in consultation with the relevant attending specialists. For oral surgery procedures, perioperative systemic antibiotic administration usually takes place from the day of surgery until follow-up or suture removal and until there are no signs of infection.

Osteoradionecrosis

Osteoradionecrosis (ORN), especially of the mandible, is a serious complication following curative radiotherapy of oropharyngeal and oral cavity carcinomas (Figs 1-9 and 1-10). Around 30 years ago, a review article quoted an ORN incidence of 5% to 15% after doses of between 60 and 72 Gy. More recent studies with modern, slightly accelerated or hyperfractionated treatment regimens with doses of 69 to 81 Gy report a far lower ORN incidence of between < 1% and approximately 6%59. Intensity-modulated radiation therapy (IMRT) is likely to reduce the ORN rate further. In patients with oropharyngeal cancers receiving IMRT, ORN is relatively rare but does continue to occur over 5 years after treatment and the likelihood increases when there are additional risk factors such as smoking and BP medication14.

Figs 1-9 and 1-10 Osteoradionecrosis (ORN) in the posterior region of the right mandible up to the ascending ramus in an 84-year-old patient after radiotherapy for an oral cavity carcinoma.

Especially in the mandible, the risk of ORN after oral surgery is high if the applied radiation doses amounted to more than 40 Gy because the bone damage can persist for a lifetime. The risk of ORN is reduced if anti-infective prophylaxis (e.g. amoxicillin) is initiated not later than 24 hours prior to surgery and is continued for up to 2 weeks postoperatively. Tooth extraction in the formerly radiated field is performed atraumatically, all bone edges are smoothed, and a tight soft tissue coverage should ideally be performed without compromising on vascularization of the local bone, which may result in complications of wound healing. If the masticatory musculature and/or temporomandibular joints were located within the radiation field, trismus can develop even a long time after radiotherapy has been completed, which can additionally complicate the treatment33.

Patients undergoing chemotherapy

Chemotherapy exerts a cytotoxic or cytostatic effect on cells with a high proliferation rate, malignant tumors, and metastases. Cytostatic agents inhibit tumor growth because they influence the replication cycle of the rapidly dividing cancer cells. As cytostatic agents usually do not differentiate between healthy cells in the body and cancer cells, the cells of the hematopoietic bone marrow, the hair follicles, and the epithelial cells of the oral mucosa are also inhibited. Reduced salivary flow, along with oral mucositis, candidiasis (Fig 1-11), a reduced sense of taste, nausea, and vomiting are among the most relevant side effects in patients undergoing or having had cytostatic therapy. Xerostomia and hyposalivation/oligosialia as well as intraoral ulcerations occur as early as the start of chemotherapy, which can have adverse effects on swallowing ability and hence food intake.

Fig 1-11 A 90-year-old patient with oral candidiasis. The patient has bronchial asthma and regularly uses a Symbicort inhaler (combination of sympathomimetic and glucocorticoid). In addition, she suffers from diabetes mellitus.

The bone marrow damage that occurs during ongoing chemotherapy commonly results in myelosuppression, causing a decrease in the number of white blood cells, which particularly affects neutrophilic granulocytes. This means that patients are more susceptible to infection during chemotherapy. Therefore, very good oral hygiene is all the more important. In addition, thrombocytopenia frequently occurs, which in turn can lead to an increased bleeding tendency. Leukemia or lymphoma patients with pancytopenia have a particularly high risk of bacterial dental infections. Patients with leukemia or a lymphoma undergo stem cell transplantation if radiotherapy or chemotherapy have not been successful enough or if they experience a relapse. In this immune situation, chronic periodontitis or apical periodontitis can lead to a systemic infection3. In this patient group, it is therefore advisable to eradicate dental foci of infection if at all possible before the appropriate oncologic treatment, after which close monitoring is important30. Oral surgery treatments should be avoided during ongoing chemotherapy, if at all possible. If there are acute symptoms and invasive oral surgery is unavoidable, the neutrophil granulocyte and platelet counts should be discussed with the attending oncologist. Antibiotic administration is indicated, depending on the findings. Once chemotherapy is completed, the majority of patients are again able to have normal dental treatment.

Infectious diseases

There is a potential risk of infection with every patient contact. The hygiene measures stipulated in practice are adequate to guarantee that staff are protected against the most common infectious diseases such as human immunodeficiency virus (HIV), hepatitis, herpes simplex virus (HSV-1 and HSV-2), and human papillomavirus (HPV). Appropriate vaccinations additionally protect staff against hepatitis A and B, and, ideally, influenza9. As a result of the severe acute respiratory syndrome (SARS)–coronavirus disease (COVID19) pandemic, new additional hygiene measures were introduced in order to minimize contamination in the dental practice. Among these additional measures, the most important involve avoiding shaking hands, social distancing in the practice (waiting and break rooms), and wearing face masks at all times. Disinfectant is provided for patients at the entrance to dental practices, while reception staff are protected with a transparent acrylic screen. Furthermore, indoor ventilation is stepped up.

Since 2002, the number of HIV diagnoses in Switzerland has declined. Most HIV-infected patients in Switzerland are given antiretroviral treatment and hence no longer pose an acute risk of infection10. Nevertheless, with this group of patients, it is advisable to contact their general practitioner or infectiologist to check their immune status and infectiousness (viral load). It is mainly CD4+ lymphocytes that are relevant in HIV-infected patients because certain minimal quantities must be present for adequate immune defense. Neutropenia is also common among HIV-infected individuals. If leukopenia and/or neutropenia are present, prophylactic antibiotic use may be indicated before and at the time of a planned oral surgery procedure. During extraoral and intraoral examination, attention should be paid to any typical HIV-associated cutaneous or oral manifestations that may be present. Examples of such changes are lymphadenopathy, candidiasis, hairy leukoplakia, herpes infections, papillomas, aphthous ulcerations, Kaposi sarcoma or a necrotizing periodontal disease.

Infections with HSV-1 and HSV-2 are common: 70% of the Swiss population carry HSV-1, and 20% carry HSV-2. HSV-1 predominantly leads to infections in the oral and facial area (herpes labialis), and HSV-2 is primarily present in the genital area (herpes genitalis). HSV-1 and HSV-2 are transmitted by mucosal contact, by contact with infected skin or by smear infections. In principle, the prevailing hygiene measures taken in dental practices should provide adequate protection. However, it is advisable to postpone an appointment if a patient has acute labial herpes because contact with blisters and ulcers should be avoided11.

HPVs are sexually transmitted and, although most types of HPV are harmless, they do cause a few cancerous conditions in the throat, pharyngeal, and genital area (cervical cancer). It is estimated that 70% to 80% of sexually active men and women are infected with HPV in the course of their lives, while two-thirds of the infections remain asymptomatic. There are many different types of HPV that infect the skin or mucosa. HPV is involved in the pathogenesis of various benign, exophytically growing tumors (e.g. verruca vulgaris, papillomas, focal epithelial hyperplasia) and is predominantly found on the tongue, soft palate, and lips13.

Switzerland is a low-endemic country for hepatitis B virus (HBV) infection. According to the latest estimates, the viremic prevalence (hepatitis B surface antigen [HBsAg]) is given as 0.44% in the entire population with a low risk, and as 3.6% in those with a high risk. Seroprevalence for hepatitis C virus (HCV) infection (anti-HCV) is given as 0.7% in Switzerland for the entire population with a low risk, according to the latest estimates. HBV and HCV are mainly transmitted via blood but, depending on viral load, can also be detected in other bodily fluids (saliva, sperm, vaginal fluid, urine, tears, breast milk). Transmission of HBV and HCV is largely through sexual contact. However, iatrogenic transmission among health care staff is also possible. One of the sequelae of hepatitis infection is cirrhosis of the liver, which can lead to hemorrhagic diathesis because of the impaired hepatic function9.

Immunosuppressed patients

A distinction is made between endogenous, exogenous, and iatrogenic immunosuppression in the case of immunosuppressed patients.

Endogenous immunosuppression may be the consequence of diseases such as leukemia or a variable immunodeficiency syndrome. Leukemia involves the uncontrolled proliferation of immature white blood cells, which displace the mature white blood cells (leukocytes), red blood cells (erythrocytes), and platelets (thrombocytes). In acute leukemia, due to the lack of mature functioning leukocytes, there is a greater susceptibility to infection and thrombocytopenia, which in turn increases the bleeding tendency. Variable immunodeficiency syndrome is the most common congenital immunodeficiency, in which the affected patients produce too few or no antibodies (IgA, IgM, IgG) because B lymphocytes are usually present but are not fully functioning.

HIV infection is an exogenous form of immunosuppression. Unlike leukemia, in which the body itself produces faulty white blood cells, in HIV infection the virus destroys functioning leukocytes (CD4+ lymphocytes).

The iatrogenic form of immunosuppression is caused by the administration of immunosuppressants, which reduce the body’s immune defense in a variety of ways due to their mechanisms of action. There are various substances that influence the cellular and humoral immune response with a variety of mechanisms of action. Medications containing glucocorticoids or active substances such as cyclophosphamide, azathioprine, methotrexate or tumor necrosis factor (TNF) inhibitors are predominantly immunosuppressive. Immunosuppressants are principally indicated following allogeneic stem cell or organ transplantation, in autoimmune diseases (e.g. connective tissue diseases, chronic inflammatory bowel diseases or rheumatoid arthritis), and for cytostatic therapy. An increased susceptibility to infection is a typical side effect for patients undergoing immunosuppression.

Respiratory diseases

Dental practitioners frequently encounter patients with lung diseases in their practices.

Bronchial asthma and chronic obstructive pulmonary diseases (COPDs) are the most common respiratory conditions. Patients with bronchial asthma often have specific pharmacotherapy as on-demand treatment and usually basic anti-inflammatory therapy. Beta-2 sympathomimetics (e.g. Ventolin, Bricanyl, Symbicort, Seretide) or glucocorticosteroids (Pulmicort, Qvar) are commonly prescribed drugs for inhalation. Patients who regularly inhale glucocorticosteroids frequently develop oral candidiasis (Fig 1-11). Patients are asked to bring along the inhaler they use to any oral surgery treatment. In asthmatic diseases, certain analgesics such as Aspirin Cardio, Novalgin (metamizole), diclofenac or ibuprofen can decrease symptoms.