Dental Treatment Considerations for Patients with Medical Conditions
Risk Assessment and Treatment Modification in Dentistry
Risk Assessment
Risk assessment involves evaluating at least four components:
- Nature, severity, and stability of the patient’s medical condition
- Functional capacity of the patient
- Emotional status of the patient
- Type and magnitude of the treatment plan and procedures (invasive or not)
Treatment Modification
Preoperative
- Prophylactic antibiotics prior to certain dental procedures in patients at risk for bacterial endocarditis.
- Ensure food intake before treatment in insulin-dependent diabetic patients.
- For anxious patients with stable angina, prescribe anxiolytic drugs.
- Prior to surgery, determine the INR (international normalized ratio) for patients on anticoagulants.
Intraoperative
- Reduce vasoconstrictor in patients on non-selective beta blockers.
- Administer nitrous oxide/oxygen to anxious, poorly controlled hypertensive patients.
- Use an upright chair position for patients with heart failure.
- Avoid elective radiographs in pregnancy.
- Avoid the use of electrosurgery in patients with a pacemaker.
Postoperative
- For patients on anticoagulants, use extra local measures for hemostasis.
- Administer antibiotics for poorly controlled diabetics after surgery.
- Provide adequate analgesia for patients on chronic steroids.
Risk Assessment Categories
- ASA I: Normal, healthy patient
- ASA II: Patient with mild systemic disease that does not interfere with daily activity, or patient with a significant health risk factor (e.g., smoking, alcohol abuse, gross obesity)
- ASA III: Patient with moderate to severe systemic disease that is not incapacitating but may alter daily activity
- ASA IV: Severe systemic disease that is incapacitating and is a constant threat to life
Possible Issues or Concerns in Risk Assessment
- A: Antibiotic (prophylactic or therapeutic), Anesthesia (type, vasoconstrictor), Anxiety, Allergy
- B: Bleeding
- C: Chair position
- D: Drugs (interaction, adverse effects, side effects, allergies), Devices (prosthetic valves, joints, stents, pacemaker, arteriovenous fistula)
- E: Equipment (X-ray, ultrasonic scaler, electrosurgery, oxygen), Emergencies (potential for occurrence)
Medical Conditions and Dental Considerations
Infective Endocarditis
Definition: A microbial infection of the endothelial surface of the heart or heart valves that most often occurs near congenital or acquired cardiac defects.
Causative factors: Bacteria or fungi
Infective endarteritis: Infection in the endothelial lining of an artery, usually adjacent to a vascular defect (e.g., coarctation of the aorta) or a prosthetic device (e.g., arteriovenous shunt)
Risk factors:
- Age: Middle-aged and elderly persons
- Gender: More common in men than in women
- Underlying conditions: Rheumatic heart disease
- Source of infection: Community-acquired > hospital-acquired > intravenous (IV) drug use
Hypertension
An abnormal elevation in arterial pressure that can be fatal if sustained and untreated.
White coat hypertension: Persistently elevated blood pressure only in the presence of a healthcare worker.
Signs and Symptoms of Hypertensive Disease
Early
- Elevated blood pressure readings
- Narrowing and sclerosis of retinal arterioles
- Headache
- Dizziness
- Tinnitus
Advanced
- Rupture and hemorrhage of retinal arterioles
- Papilledema
- Left ventricular hypertrophy
- Proteinuria
- Congestive heart failure
- Angina pectoris
- Renal failure
- Dementia
- Encephalopathy
Oral Manifestations: No oral complications are due to hypertension itself; however, adverse effects such as dry mouth, taste changes, and oral lesions may be drug-related.
Clinical Predictors of Increased Perioperative Cardiovascular Risk
Major
- Unstable coronary syndromes
- Acute or recent myocardial infarction (*) with evidence of important ischemic risk in clinical symptoms or noninvasive study
- Unstable or severe angina (Canadian Class III or IV)
- Decompensated heart failure
- Significant arrhythmias
- High-grade atrioventricular block
Intermediate
- Mild angina pectoris (Canadian Class I or II)
- Previous myocardial infarction by history or pathological Q waves
- Compensated or prior heart failure
Minor
- Advanced age
- Abnormal ECG (left ventricular hypertrophy, left bundle-branch block, ST-T abnormalities)
- Rhythm other than sinus (e.g., atrial fibrillation)
Management of Patients Being Treated for Hypertension
- Take measures to reduce stress and anxiety.
- Provide oral sedative premedication and/or inhalation sedation.
- Provide local anesthesia of excellent quality.
- For patients taking a nonselective beta blocker, limit epinephrine to ≤ 2 cartridges of 1:100,000 epinephrine.
- Avoid epinephrine-containing gingival retraction cord.
Atherosclerosis
The most common underlying cause of:
- Coronary heart disease (angina and myocardial infarction [MI])
- Cerebrovascular disease (stroke)
- Peripheral arterial disease (intermittent claudication)
Ischemic Heart Disease Causes
- Atherosclerosis
- Embolism
- Coronary ostial stenosis
- Coronary artery spasm
- Congenital abnormalities
Clinical Presentation
Symptoms
- Chest pain:
- Brief, as in angina pectoris due to temporary ischemia of the myocardium
- Prolonged, as in unstable angina or AMI
Types of Angina
- Stable angina (good prognosis):
- Pain is reproducible and consistent over time.
- Precipitated by physical effort such as walking or climbing stairs but may also occur with eating or stress.
- Relieved by cessation of the precipitating activity, rest, or nitroglycerin.
- Unstable angina (poorer prognosis and often develops into MI within a short time):
- New onset
- Increasing in frequency
- More intense pain than before
- Precipitated by less effort than before, or pain that occurs at rest
- Not readily relieved by nitroglycerin
Management of Angina
- Unstable Angina (major risk): Elective dental care should be deferred; if care becomes necessary, it should be provided in consultation with the physician. Management may include establishing an IV line, sedation, and monitoring of the electrocardiogram.
- Stable Angina (intermediate risk): For stress/anxiety reduction, provide oral sedative premedication and/or inhalation sedation if indicated. Assess pretreatment vital signs and availability of nitroglycerin, and limit the quantity of vasoconstrictor used. For patients taking a nonselective beta blocker, limit epinephrine to ≤ 2 cartridges of 1:100,000 epinephrine.
Treatment Planning for Angina
- Unstable Angina: Dental treatment should be limited to urgent care only, such as treatment of acute infection, bleeding, or pain.
- Stable Angina: Any indicated dental treatment may be provided if appropriate management issues are considered.
Myocardial Infarction (MI)
Irreversible necrosis of heart muscle secondary to prolonged ischemia.
Clinical Signs and Symptoms
- Fatigue
- Chest discomfort
- Palpitations
- Anxiety
- Light-headedness with or without syncope
- Cough
- Wheezing
Oral Manifestations
- No oral complications are due to myocardial infarction.
- Adverse effects such as dry mouth, taste changes, and oral lesions may be drug-related.
- Bleeding may be excessive because of the use of aspirin, other platelet aggregation inhibitors, or Coumadin.
Treatment Planning Modifications for MI
- Recent Myocardial Infarction: Dental treatment should be limited to urgent care only, such as treatment of acute infection, bleeding, or pain.
- Past Myocardial Infarction: Any indicated dental treatment may be provided, taking into consideration appropriate management considerations.
Cardiac Arrhythmias
Any variation in the normal heartbeat, including disturbances of rhythm, rate, or the conduction pattern of the heart.
Signs and Symptoms of Cardiac Arrhythmias
Signs
- Slow heart rate (< 60 beats/min)
- Fast heart rate (> 100 beats/min)
- Irregular rhythm
Symptoms
- Palpitations
- Fatigue
- Dizziness
- Syncope
- Angina
- Congestive heart failure
- Shortness of breath
Treatment Planning Modifications for Arrhythmias
- High-Risk Arrhythmias: Dental treatment should be limited to urgent care only, such as treatment of acute infection, bleeding, or pain.
- All Other Arrhythmias: Any indicated dental treatment may be provided as long as appropriate management issues are considered.