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Once all the information has been obtained from the patient’s health history, both oral and written questionnaires, the dental team must evaluate the data and determine if any conditions exist that will affect, alter or delay any necessary dental treatment. The following are conditions that will have some affect on dental treatment:
Need for antibiotic prophylaxis
The American Heart Association (AHA) guidelines from April, 2007 are those currently used to determine the need for and the protocol for antibiotic prophylaxis. The AHA, in conjunction with the American Medical Association and the American Dental Association, reviewed and revised the type of patients that need to be pre-medicated for dental treatment. Each office should consult with the patient’s physician if unsure of recommended antibiotic prophylaxis prescriptions.
Syncope, or fainting, is the most common emergency in the dental office. Patients should be asked if they have ever experienced a fainting episode in a dental office, or at any time in their life. It is most commonly associated with heavy coughing, orthostatic hypotension, and medication. Syncope can happen to any person at any age but most common with geriatric patients.
There are three types of diabetes:
If the patient indicates that they have diabetes, the type must be noted in the history.
Patients with uncontrolled diabetes have low resistance to infection and are prone to periodontal disease. They have poor healing response, including excessive bleeding, and may experience hypoglycemia or hyperglycemia during dental treatment. Patients who are undiagnosed diabetics may report the following symptoms: excessive thirst and hunger, increased urination and in women high birth weight babies.
When reviewing a health history, the following questions should be asked of diabetic patients:
It is advisable to keep sources of sugar on hand for hyper or hypoglycemic episodes. Glucose gel from a pharmacy, granulated sugar or tubes of cake icing can be easily stored and used in the case of an emergency.
When questioning diabetic patients before treatment and you find out they have not eaten or taken their insulin they should be rescheduled. Make sure they understand the importance of these steps to maintain a normal blood sugar level during dental treatment. Additional strategies include keeping appointments short and in the early to mid-morning hours.
Patients who state that they have experienced chest pain, shortness of breath, pain that radiates down their neck or arm, have swollen ankles and/or have high blood pressure are at risk for cardiovascular disease. They may or may not have been diagnosed by a physician. If this patient also indicates that they are a smoker and/or are overweight, the risk is increased. It is recommended that a medical consultation or evaluation be obtained for all patients who indicate some type of cardiovascular disease on their health histories. Additionally, medical consultations should also be obtained for patients who are reporting or exhibiting symptoms of cardiovascular disease, but have not had a definitive diagnosis. Preventing medical crises during dental treatment is the best method of protecting patients who are medically compromised.
Rheumatic heart disease is a result from rheumatic fever and can cause deformities in the heart valves. Some patients will report taking antibiotics on a regular basis. If the patient reports a history of rheumatic fever, the dental practice must consult with the patient’s physician to determine the extent of the heart involvement, in particular whether the patient has valvular damage.
Congenital Heart Defects place the patient at high risk for bacterial endocarditis. Again, a statement from a physician is advisable to determine the type of defect and to verify the need for prophylactic antibiotics.
Coronary Artery Disease (CAD) results from atherosclerosis. Patients may report having been diagnosed with angina pectoris, or having chest pain after some type of physical activity or stress. These patients may be taking several medications, particularly vasodilators like nitroglycerin; or beta-blockers, such as propanolol. The stress of a dental visit may cause an angina attack, therefore it is important to minimize patient stress, maximize patient comfort and make certain that the patient has his/her medications available, particularly nitroglycerin. In addition, it is recommended that local anesthetic without epinephrine or other vasoconstrictors be used for these patients, to avoid further constriction of the blood vessels. Patients with unstable or uncontrolled angina should wait for at least 30 days after their angina is stabilized to receive dental treatment.
Myocardial Infarction (MI) is more commonly known as a heart attack. Patients who have experienced a recent myocardial infarction should not receive any dental treatment for a minimum of 6 months after the heart attack. Most fatalities from MI occur within 3-4 months after the attack. Stress, like that from dental treatment, soon after the attack could cause a rupture in the area of infarct, leading to further health problems and possible death.
Hypertension is a common condition characterized by high blood pressure. Patients with uncontrolled hypertension are at risk for a stroke (also known as a cerebrovascular accident, CVA), kidney failure, or heart attack. Since stress will increase blood pressure, dental treatment is contraindicated in patients with severe hypertension. Patients presenting with a systolic pressure between 120 to 139 should be advised to monitor their readings for improvement and see their physician for assessment. As a rule, patients with a systolic pressure greater than 160 and/or a diastolic pressure greater than 95 should be referred for medical consultation and treatment and dental treatment should be delayed.
It is relatively common for patients to have undiagnosed hypertension, making it very important for the dental team to monitor patients’ vital signs during their dental visits. A patient who reports having frequent dizziness, nosebleeds or headaches may have high blood pressure and may be in need of medical intervention with antihypertensive drugs and/or diuretics.
Heart Failure (HF) was more commonly known as “congestive heart failure” but the American Heart Association has recently renamed and shortened the title to characterized a broader spectrum of the disease. Patients with congestive heart failure typically have swollen ankles and shortness of breath, due to poor circulation and fluids backing up in the lungs. These patients may indicate that they must sleep upright or with several pillows, in which case, placing them in a supine position in a dental chair may cause them acute distress. HF patients are usually taking one or more diuretic medications to remove fluid, as well as digitalis to strengthen their heart contractions. Supplemental oxygen may be needed for these patients and use of nitrous oxide analgesia is contraindicated.
Patients with kidney disease have impaired renal function, which results in accumulation of fluid and waste products normally excreted by the kidney. Renal problems often result from uncontrolled or undiagnosed diabetes. These patients may experience poor healing and excessive bleeding. They may be receiving dialysis treatments or may have had a kidney transplant. In either case, the patients may be taking medications, such as anticoagulants or immunosuppressive drugs. Consult with the PDR regarding side effects of the medications and with the patient‘s physician if there is a need to prescribe drugs for patients whose primary method of excretion or metabolism is the kidney. The impaired function of the kidney may cause toxic levels of the drug to accumulate in the patient’s tissues.
Seizure disorder is caused by an electrical disturbance in the brain. Any person can experience a seizure in a stressful situation and approximately half of all seizures are considered idiopathic (without known cause.) Epilepsy is a condition commonly associated with a syndrome of associated seizure types.
When a known epileptic patient is scheduled for treatment, the dental team should determine if the patient has taken his anti-seizure medication. These patients should be scheduled for short appointments, when they are well rested. Shining a bright light in the patient‘s eyes should be avoided, since this can sometimes trigger a seizure.
Patients who are taking oral anticonvulsant medications, such as Dilantin®, may experience gingival hyperplasia. Emphasis must be placed on meticulous home care to prevent serious periodontal problems and the increased need for regular dental visits.
Asthma is a chronic respiratory disorder that results in a narrowing of airways. An asthma attack can be triggered in several ways including environmental allergens, medications, or exercise. Patients with asthma may be prone to an attack or episode brought on by the stress of dental treatment. The patient is always instructed to bring his/her medication/inhaler to each appointment. When the health history is reviewed at the beginning of treatment, the patient should have the medication or inhaler readied just in case it is needed.
Chronic Obstructive Pulmonary Disease (COPD)
The two most common forms of COPD are emphysema and chronic bronchitis. Emphysema is the irreversible enlargement of the air sacs in the lungs making it hard to expel all oxygen during breathing. Chronic bronchitis is characterized as the irreversible condition of narrowed airways. Like patients with HF, those with either of these types of COPD may not be able to breathe easily in a supine position or after walking certain distances. Patients with COPD may need supplemental oxygen and often carry their own supply with them. However, these patients should not be given high levels of oxygen, since this disease prevents them from metabolizing it. It is important that the COPD patient not receive nitrous oxide during dental treatment due to their impaired breathing.
Hepatitis is characterized as an inflammation of the liver. It is a viral disease that appears in several forms. It is referred to as hepatitis A, B, C, D and E. A newer type of virus, non A-E, has been discovered, but not much is known about it at this time. Hepatitis B and C are transmitted through blood or other body fluids, while hepatitis A and E are usually transmitted indirectly through contaminated food and water. Hepatitis D is a piggyback virus that is linked to hepatitis B. Dental health care workers should be vaccinated against hepatitis B, to reduce their risk of infection when treating patients. There is no vaccine for hepatitis C at this time. We are not able to identify every patient who has a potentially infectious disease. And because many patients are not aware that they had hepatitis, and may be carriers, it is important to remember to practice standard precautions.
If a patient presents for treatment and reports that they are fatigued, nauseous, have a fever, dark urine and/or are jaundiced, they should be referred for medical treatment. When a patient reports a history of hepatitis, consult the PDR and their physician if drugs are prescribed that are metabolized by the liver, since liver function may be impaired.
Tuberculosis (TB) is a bacterial infection that occurs primarily in the lungs, but can occur in other organ systems in the body. It is spread through airborne particles, when an infectious patient coughs, sneezes, talks or sings. TB is most easily spread in small confined spaces where infectious people share the same airspace with others. Because TB is highly infectious and its airborne transmission is difficult to control, the CDC has issued specific guidelines to help protect health care workers when treating patients.
These guidelines state the elective (non-emergency) dental treatment should be postponed for patients who are suspected of having infectious TB or who have been identified as active TB cases. If these patients can be referred for treatment in a facility that is specifically designed to treat TB patients (e.g. a hospital setting), it is acceptable for the dental practice to make this referral and not be liable for discriminatory practices.
In addition to asking patients on their health history if they have had tuberculosis, the patients should also be asked if they have experienced any of the following symptoms: night sweats, unexplained fever and/or weight loss or a prolonged or bloody cough. If a patient has experienced any of these symptoms, refer them to a physician for evaluation before proceeding with anything but emergency treatment.
If emergency treatment must be performed on a patient suspected of having infectious tuberculosis, the following precautions should be taken:
- Schedule the patient at the end of the day, as the last patient treated.
- All team members present in the treatment room must wear a HEPA or NIOSH N 95 mask.
- High volume evacuation and dental dam isolation should be used to reduce aerosols.
HIV/AIDS is a viral infection that impairs a patient’s immune system, making the patient highly susceptible to other infectious diseases. It is transmitted through blood and other body fluids, which puts dental health care workers at some risk of infection from treating patients. Again, the practice of universal precautions must be followed, since many patients will not disclose their HIV status for fear of humiliation or rejection. Remember that information about a patient’s HIV status is highly sensitive. The dental team must take every precaution to protect the confidentiality of that patient’s health history. HIV or AIDS patients should be treated the same as otherwise healthy patients.
The Americans with Disabilities Act of 1990 protects people with HIV/AIDS infectious and other diseases from discrimination in employment and delivery of all types of services, including health care. Although some dental health care workers are fearful of treating AIDS patients, it is illegal not to accept them into a dental practice or to refer them to another practice, unless the type of treatment is not performed in that practice. For example, if a general dental practice does not perform periodontal surgeries, it is legal to refer HIV/AIDS patients to a periodontist, since non-HIV or AIDS patients are referred as well. However, if only the patients with HIV or AIDS are referred for periodontal surgery, this would be considered discriminatory.
When treating patients with full blown AIDS, who are typically very immune suppressed, the dental team should take extra precautions to protect the patient from opportunistic infections. These may include wearing sterile surgical gloves rather than non-sterile exam gloves, having the patient use pre-treatment rinse of chlorhexidine gluconate or other mouthwash to prevent bacteremia and using only sterile water for irrigation, rather than from the air/water syringe, which may contain some bacterial contamination.
Anemia is a deficiency of red blood cells, caused by vitamin or iron deficiency or bone marrow problems. An anemic patient may have problems with slow wound healing and excessive bleeding. They may report feeling weak and fatigued, and may appear very pale. If a patient exhibits these symptoms a medical evaluation should be recommended.
Leukemia is a type of blood cancer, where there is an overgrowth of white blood cells. These white blood cells may displace red blood cells, used to transport oxygen in the blood. These patients may exhibit oral signs, often before other symptoms of their disease. These signs typically include excessive gingival irritation in the absence of other causative agents, like heavy plaque or calculus. Patients with leukemia are very prone to infections, including periodontal infections. In addition, the chemotherapeutic agents used to treat the disease have many side effects, most notably, xerostomia or dry mouth. Consult the treating physician before proceeding with treatment. Also consult the PDR for side effects from medications.
Hemorrhagic disorders is a disorder in which patients experience excessive bleeding, due to a deficiency of clotting factors in their blood. Commonly known as hemophilia, these patients will bruise very easily and may experience spontaneous, excessive bleeding. In addition, these patients may have received blood transfusions with blood contaminated with HIV and/or hepatitis B or C. Dental treatment, such as extractions, that may cause bleeding can be risky for these patients. Close monitoring by the physician is necessary. Treatment should be confined to specific areas (e.g. one tooth or quadrant at a time) and transfusion with clotting factors may be necessary prior to treatment. Aspirin containing medications used for pain control must not be prescribed for these patients, since they increase bleeding time.
Allergies are specific body responses to foreign substances. An allergic reaction may be localized or limited to a skin rash or hives, or may be systemic and life-threatening, as in anaphylaxis. Many patients will indicate on their health history that they are allergic to environmental agents, such as pollen and dust. Many are also allergic to medications, such as codeine or penicillin. When prescribing medications, it is important to review the health history and orally question patients about drug allergies.
Latex allergies are becoming more common in dental and medical treatment. Repeated exposure to latex or natural rubber latex (NRL) during dental or medical treatment can cause a patient to become allergic. Again, the reaction may be localized, in which the patient’s lips become itchy or swollen from contact with latex gloves or dental dam material. Some patients, however, can experience a very serious anaphylactic reaction where their entire body responds when exposed to the allergen. The most serious symptom of anaphylaxis is swelling of the tongue, which closes off the patient’s airway. Without medical intervention, particularly without administration of epinephrine, patients can die from anaphylaxis.
A health history should ask questions about any allergies the patient may have, including latex, although some patients may not know that they are latex sensitive. Additional questions on the written questionnaire or oral interview may help to determine if this is the case. Patients should be asked if they have ever experienced stomach cramps, nausea or vomiting after eating bananas, kiwis, water chestnuts or avocados. These foods contain chemicals similar to those in NRL. Also, ask patients if they have ever experienced any itching after handling balloons or after previous visits to the dentist or physician, where the health care providers wore latex gloves.
To safely treat latex allergic patients, all members of the dental team who come in direct contact with the patient should wear non-latex (vinyl or other synthetic material) gloves, and non-latex dental dam should be available if dental dam isolation is used. In addition, the dental team should check all products, such as prophylaxis cups, oxygen masks and other items to determine whether those products contain latex. Latex-free substitutes are available for most products that currently contain latex, and many products are now labeled as “latex free”. Latex allergic patients should be scheduled as early as possible in the work day, before a great deal of latex has become airborne in the office from gloves being put and taken off. Epinephrine auto-injectors, or “epi-pens,” should be located in each treatment room, ready to administer immediately to a patient who begins to exhibit signs of an allergic reaction.
Patient Medications can cause a reaction at any time. Some of the most important information gained from a health history is an accurate list of medications that a patient is currently taking, both prescription and over the counter. However, some patients may not know the names of the medications or not think that it is important to list certain ones. For some elderly patients, it may be advisable to ask the patient to bring all their meds with them, so that an accurate list may be documented. Consult the PDR to identify medications, side effects, precautions, and particularly drug interactions and contraindications.
Most medications have some side effects, many of which appear in or affect the oral cavity. Xerostomia, significantly decreased saliva production, is a common side effect of many heart medications and antihistamines use to treat allergies. Patients taking these medications must be advised about the adverse effects that dry mouth can have on their teeth and oral mucosa, especially if their oral hygiene is lacking. In addition, saliva replacements may need to be prescribed. Patients with systemic diseases, such as liver or kidney disease should not be prescribed medications that are metabolized by the liver or excreted by the kidneys.