Drug protocols for patients with special needs : a review of the literature

There is a great need for dental surgeons to be trained to proceed with patients needing some kind of special care. This study aimed to perform a review of the literature on drug protocols concerning how to treat patients with special needs, within the different areas in which dentists may be engaged. The methodology employed was to review articles dealing with the subjects of diabetes mellitus, chronic renal failure, hemophilia, cardiac patients, which were focused on areas of dentistry. A total of 33 articles were selected. Several specific protocols were found on how to act during a consultation of several systemic diseases or in special cases, in order to achieve success during treatment, to avoid drug interactions or to create emergency situations. It was possible, in some cases, to find a consensus between the sequences or the drug of first choice for patients. Serious errors can occur if a dentist is not capable in serious cases. The creation of a protocol for these patients in the different dental specialties would reduce the number of failed treatments, thus increasing the safety and effectiveness of the treatments. Indexing terms: Dentistry. Pharmacology; Protocols. Disabled persons.


INTRODUCTION
According to the Federal Dental Council, Patients with Special Needs (PSNs) are those who need special care as a result of some deviation from the norm, whether or not they have been specifically identified as such 1 .It is necessary to conceptualize special needs patients taking into account the clarification of the didactics of clinical exercise so that specialized and channelized treatment can be provided 2 .
The prospects of success in any dental treatment depends on the dental surgeon's understanding of the patient, planning which is achieved via a thorough anamnesis 3 .
The American Academy of Pediatric Dentistry reports that PSNs present with changes that create limitations on patients' daily routines.As a result, a monitoring by specialized services is needed as well as permanent care, with the aim of providing social inclusion for this class 4 .
Coming from a biopsychosocial perspective, the World Health Organization created the International Classification of Functioning, Disability and Health (ICF), with the aim of creating a database that, over time, supplies information about these patients between countries and specific regions 5 .
The classification, according to the International Dental Association for Patients with Special Needs (IADH -International Association for Disabilities and Oral Health) divides these patients into 10 classifications that facilitate an understanding of the specific care protocols, which include: 1. Learning difficulties; 2. Physical defects; 3. Congenital defects; 4. Behavioral deviations; 5. Psychic deviations; 6. Sensory and audio-communication deficiencies; 7. Chronic systemic diseases; 8. Endocrine metabolic diseases; 9. Social deviations; 10.Special physiological conditions 6 .
Given this view, the treatment of special needs patients begins with a detailed anamnesis and physical examination.The dental surgeon, in his/her role as health professional, needs to possess not only an understanding related to the diagnosis of the various disorders, but also a knowledge of previous treatments undergone by the patients 7 .Faced with systemic changes, peculiarities should be identified so the treatment can focus on the needs of these individuals 8 .
The aim of this study was to perform a review of the literature in respect of the drug protocols in dentistry used with special needs patients, with the aim of establishing the influence of these drugs and their application in patients with diabetes mellitus, chronic renal insufficiency, hemophilia, cardiomyopathies, anemia or pregnancy.

Diabetes Mellitus
Diabetes mellitus (DM) is characterized by the group of metabolic disorders that correspond to a presentation of hyperglycemia, generated by abnormalities in the action of insulin [9][10] .Etiologically, this disturbance involves three subtypes: Type 1, type 2 and gestational DM 11 .
Diabetic patients present with physiological changes that affect immunological capacity and inflammatory response, increasing the risk of infection 12 .
In patients who have DM, symptoms occur such as polydipsia, polyuria, polyphagia and weight loss.Hyperglycemia generates microcirculatory abnormalities, retinopathy, nephropathy (kidney disease) and peripheral neuropathies.Moreover, they produce disorders in the healing process and a greater tendency to produce cerebrovascular, cardiovascular and lymphatic vessel atherosclerosis 13 .
As far as the oral region is concerned, DM principally triggers periodontal disease and may be considered as the primary vascular complication of diabetes.Clinical trials have shown that individuals with type 2 DM tend to develop a greater prevalence of periodontal abscesses when compared to non-diabetics 14 .In addition to periodontal disease, other oral complications arising from DM include xerostomia, hyposalivation, oral candidiasis, taste disorders, caries and enamel hypoplasia 15 .
Drug prescriptions written by dentists have to be very cautious.Non-steroidal anti-inflammatory drugs (NSAIDs) and cephalexin (a beta-lactam antibiotic) can boost the effects of oral anti-diabetic medication, increasing the risk of hypoglycemia, while steroidal anti-inflammatory drugs (corticoids) can aggravate hyperglycemia.The prescription of these drugs must be scrupulous, it being necessary to contact the team physician in order to establish dosage16.Prolonged use of topical steroids (for a continuous period in excess of two weeks) may result in atrophy of the oral mucosa and secondary candidiasis 17 .The presence of uncontrolled DM is an absolute contraindication to the use of adrenergic vasoconstrictors combined with local anesthetic.In the event of a formal contraindication to the use of adrenergic vasoconstrictors, felypressin is an option 18 .

Hemophilia
Hemophilia is a genetic disturbance marked by prolonged bleeding caused by a reduction or absence of one of the coagulation factors needed to form a blood clot.The disease, caused by the deficiency of the gene that modifies the organism's ability to produce sufficient factors that produce clotting, affects approximately one in every eight thousand people 19 .The two most common forms are hemophilia A, characterized by the quantitative deficiency of factor VIII, also known as classic hemophilia, and hemophilia B, also known as Christmas disease, characterized by a quantitative deficiency of factor IX 20 .
Controlling dental pain in patients with coagulopathies should be done with paracetamol derivatives or dipyrone.Aspirin and its derivatives are contraindicated as a result of its activity that inhibits platelet aggregation.The use of anti-inflammatory drugs in these patients should be restricted because of their antiaggregation effects.The hematologist must be consulted before these are prescribed 21 .
For periodontal treatment, gauze compresses soaked in antifibrinolytics, balls of cotton wool soaked in 10% trichloroacetic acid (TCA), surgical cement and, if necessary, the administration of oral antifibrinolytics, may be used where there is potential bleeding caused by scraping, which can be controlled locally 21 .
In cases of oral surgery, due diligence is required to avoid bigger problems.Correct antihemorrhagic treatment applied at the right moment is sufficient to produce the clot in the tooth extraction wound 22 .The anesthetic injection should be applied slowly, it being necessary to apply coagulation factor in cases of a blockage of the inferior alveolar and lingual nerve, and whenever possible, avoid trunk and block anesthesia, as these may produce hematomas 23 .

Cardiopathies
The term cardiopathy relates to all diseases that affect the heart.These comprise a lack of flow and/or oxygen in the blood that circulates through the heart muscle, causing a blockage in the coronary arterial structure, as a result of atheromas [24][25] .The pathologies that present the greatest risk of impairment are angina pectoris, myocardial infarction, congestive cardiac insufficiency, arrhythmias and bacterial endocarditis 26 .
Cardiopathic patients must receive a more cautious dental treatment.The professional must pay attention to two special care situations: the first is the risk of developing infectious endocarditis, since this requires specific prophylactic measures oriented by the norms for the prevention of infectious endocarditis published by the American Heart Association (AHA) 24 .
It is important to bear in mind the risk of drug interactions, to consider cardiac disease and its seriousness.
In dentistry, lidocaine is regarded as the safest, intermediate duration anesthetic and is therefore considered the reference drug with properties of antiarrythmic, anticonvulsive, anti-inflammatory and antimicrobial therapeutic value.Bupivacaine is recommended for longer procedures, however, it is cardiotoxic as it has an attraction for cardiac fibers, being contraindicated for cardiopathic patients.Prilocaine is the reference drug for use in dentistry as it possesses felypressin as a vasoconstrictor that does not induce blood pressure variations.However, it is rapidly degraded by hepatic amidases [25][26] .
Endocarditis is an infection of the myocardium by bacteria, such as those present in the saliva.The prophylactic regimen of endocarditis, patient risk classification and the procedures requiring antibiotic prophylaxis have been established by the American Heart Association 21.Amoxicillin is the drug of choice as it has few side effects and is very effective against microorganisms that cause endocarditis, the recommendation being a single preoperative dose of 2g by oral administration, 1 hour before the procedure.For those patients who are allergic to penicillin, erythromycin is no longer indicated due to its gastrointestinal side effects.Instead, 600 mg of clindamycin or alternatively other options such as azithromycin, clarithromycin or cephalosporin may be used.For children, the recommended dose is 50 mg/Kg of body weight via oral administration, one hour prior to the procedure [26][27] .

Chronic renal insufficiency
This is a progressive disease defined as occurring when the kidneys are unable to perform their normal excretory functions.The byproducts of protein metabolism, such as urea, accumulate in the blood, producing changes in the body's various systems and in the kidneys.The deficiencies end up being life-threatening 28 .
Patients with chronic renal disease have systemic and oral conditions that require special precautions during dental treatment.The medication must be administered with caution and patients subjected to dialysis must receive special attention.Before beginning any dental treatment, the dental surgeon must consult the patient's physician with regard to the specific pecautions [28][29] .
Patients subjected to dialysis are more susceptible to developing infectious processes due to their overall condition, with a probable reduction in the efficiency of the immune system and masking of the signs and symptoms of infection by the drugs employed.These infections are the causes of morbidity and mortality in patients with uremic syndrome and, therefore, antibiotic therapy/prophylaxis should always be prescribed [28][29][30] .
As far as antibiotic prophylaxis in patients with chronic renal insufficiency is concerned, vancomycin is an option for patients not undergoing hemodialysis.The only restriction with this drug is the need to be hospitalized, which is generally recommended for individuals suffering from this abnormality 31 .
Classes of drugs exist that produce gingival hyperplasia, such as nifedipine and cyclosporine, it being necessary to control this via instruction on oral hygiene by means of techniques developed by the dental surgeon, in order to avoid the buildup of bacterial plaque [31][32] .
In addition, it is necessary to take into account the level of nephrotoxicity of drugs such as tetracycline, aspirin, non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen 11,[31][32] .Drugs like ampicillin, cephalexin, amoxicillin and acyclovir require a reduced dose in order to avoid side effects 33 .

CONCLUSION
In the field of dentistry, drug protocols must be performed taking into account the peculiarities of each patient.These characteristics are evidenced by means of a rigorous anamnesis and physical examinations of the patient in the dental surgery itself.It is the dental surgeon's responsibility to understand the various classes of drugs and their functionality and side effects in individuals with special needs.

Collaborators
LL SOUZA, conception and design, acquisition of data, statistical analysis, drafting the article, revising the article critically for important intellectual content, final approval of the version to be published.MAM NASCIMENTO, conception and design, acquisition of data, statistical analysis, drafting the article, revising the article critically for important intellectual content, final approval of the version to be published.RL LIMA, conception and design, acquisition of data, statistical analysis, drafting the article, revising the article critically for important intellectual content, final approval of the version to be published.LNR OLIVEIRA, conception and design, acquisition of data, statistical analysis, drafting the article, revising the article critically for important intellectual content, final approval of the version to be published.ALS RAMOS, conception and design, acquisition of data, statistical analysis, drafting the article, revising the article critically for important intellectual content, final approval of the version to be published.GBF MARQUES, conception and design, acquisition of data, statistical analysis, drafting the article, revising the article critically for important intellectual content, final approval of the version to be published.ACFR PROENÇA, conception and design, acquisition of data, statistical analysis, drafting the article, revising the article critically for important intellectual content, final approval of the version to be published.EN PEDREIRA, conception and design, revising the article critically for important intellectual content, final approval of the version to be published.