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Der Risikopatient in der zahnärztlichen Praxis
Abstract
In the course of his professional work the dentist is increasingly confronted with patients who present with numerous medical risk factors because of the rising age pyramid in the general population. In an overview study, based on most recent publications, the common basic diseases, their treatment, the medications used for this purpose, and the major conclusions drawn from such experience for dental treatment are investigated and presented in a comprehensive way. Based on guidelines worked out on the basis of this information, the purpose of the study is to enable the dentist to confidently handle patients at risk. When faced with threatening situations, the dentist should be able to undertake the right actions, based on well-founded and accurate medical knowledge.
This report discusses the challenges faced by Palestinian women dentists and the opportunities they may have in the near future based on the increasing numbers of enrolled female dental students.
The established correlation between diabetes and periodontal diseases and the increasing prevalence of Type II diabetes in the general population indicate that dental practitioners will probably treat an increasing number of diabetic patients. Despite the fact that there is little scientific evidence to support the concept, it has been generally accepted that treatment for periodontal disease in diabetic patients may reduce insulin requirements and improve metabolic balance. However, to date no one has evaluated the effects of periodontal therapy on the metabolic state of the poorly-controlled diabetic patient. The purpose of this pilot study was to evaluate the effect of controlling gingival inflammation on blood glucose levels as determined by glycosylation of hemoglobin and albumin.
Background. The occupational risk of hepatitis C virus, or HCV, infection in dentistry is very low. Nonetheless, the lack of an effective vaccine, the high rates of chronic infection and the limited effectiveness of treatment may cause concern for dental workers who come into contact with blood in : their daily practices. Description of the Disorder. The authors discuss the natural history, diagnosis and treatment, and patterns of transmission of HCV infection, including the Centers for Disease Control and Prevention's recommendations for management and follow-up of health care workers after occupational exposure to HCV. Clinical Implications, In the absence of an effective vaccine or postexposure prophylaxis, prevention of occupational transmission of HCV in dental settings continues to rely on the use of universal precautions, including barrier precautions and the safe handling of sharp instruments.
PERIODONTAL DISEASES ARE INFECTIONS, and many forms of the disease are associated with specific pathogenic bacteria which colonize the subgingival area. At least two of these microorganisms, Porphyromonas gingivalis and Actinobacillus actinomycetemcomitans, also invade the periodontal tissue and are virulent organisms. Initiation and progression of periodontal infections are clearly modified by local and systemic conditions called risk factors. The local factors include pre-existing disease as evidenced by deep probing depths and plaque retention areas associated with defective restorations. Systemic risk factors recently have been identified by large epidemiologic studies using multifactorial statistical analyses to correct for confounding or associated co-risk factors, Risk factors which we know today as important include diabetes mellitus, especially in individuals in whom metabolic control is poor, and cigarette smoking. These two risk factors markedly affect the initiation and progression of periodontitis, and attempts to manage these factors are now an important component of prevention and treatment of adult periodontitis. Systemic conditions associated with reduced neutrophil numbers or function are also important risk factors in children, juveniles, and young adults. Diseases in which neutrophil dysfunction occurs include the lazy leukocyte syndrome associated with localized juvenile periodontitis, cyclic neutropenia, and congenital neutropenia. Recent studies also point to several potentially important periodontal risk indicators. These include stress and coping behaviors, and osteopenia associated with estrogen deficiency. There are also background determinants associated with periodontal disease including gender (with males having more disease), age (with more disease seen in the elderly), and hereditary factors. The study of risk in periodontal disease is a rapidly emerging field and much is yet to be learned. However, there are at least two significant risk factors-smoking and diabetes-which demand attention in current management of periodontal disease.
Im Kindesalter ist ein angeborener Herzfehler der häufigste prädisponierende Risikofaktor
für eine infektiöse Endokarditis; dies insbesondere vor dem Hintergrund
moderner operativer und katheterinterventioneller Therapieverfahren, die mit dem
Einsatz von Fremdmaterialien wie Herzklappen, Patchmaterial, Gefässstents, Schrittmachersystemen
und anderen Katheterimplantaten verbunden sind. Dadurch haben
sich die Präventionsbemühungen zur Prophylaxe der infektiösen Endokarditis geändert.
Purpose: The increased risk of mortality among people with epilepsy is well documented; people with epilepsy are more likely than the general population to die as a result of an accident. Data about incidence of nonfatal accidents and associated factors are not so readily available, even though such accidents are more common than fatal injuries. We report the proportion of people who sustain various injuries during a seizure and the key variables predicting injury.
Methods: Questionnaires were mailed to an unselected, community‐based population of patients with epilepsy. The questionnaire included clinical and demographic details, previously validated scales of psychosocial well‐being, and questions about seizure‐related injuries.
Results: Of patients who had had at least one seizure during the previous year, 24% sustained at least one head injury, 16% sustained a burn or scald, 10% a dental injury, and 6% some other fracture. Seizure type, seizure severity, and seizure frequency were key predictors of having sustained at least one of these four seizure‐related injuries. Key predictors of budscald were seizure severity, seizure frequency and sex; those of head injury were seizure severity and type; that of dental injury was seizure severity; and those of some other fracture were seizure severity, duration of epilepsy, and three or more drug‐related adverse effects.
Conclusions: These data help identify significant risk factors associated with seizure‐related injuries and so facilitate sensible patient counseling about how the risks of such injuries can be minimized.
Sickle cell anemia is a multisystem disease that can affect the oral region. This article reviews previously reported oral complications associated with this disease and describes the cause of these problems. A case history describes a patient with multiple oral problems after a sickle cell crisis. The diagnostic and management problems of this case are highlighted. The need for a multidisciplinary approach to the care of these patients is emphasized.
Epilepsy is a relatively common problem in children, adults and the elderly. Dentists need to be familiar with the various manifestations of the disease, the anticonvulsant medications (AEDs) the patients are taking, and the complications and side effects of these drugs. In this article the types of seizures and AEDs in common use are described. Guidelines for treatment planning are given. Recommendations are made for managing the patient who has a seizure in the dental office.
Infective endocarditis accounts for 4% of admissions to a specialized unit for grown-up congenital heart patients. This study defines lesions susceptible to infection, antecedent events, organisms, outcome and surgical treatment in a group of such patients.
The grown-up congenital heart disease database was searched for all patients aged 13 years and above with adequate documentation of infective endocarditis retrospectively between 1983-1993 and thereafter between 1993-1996. There were 185 patients (214 episodes) divided into Group I: 128 patients unoperated or palliated and Group II: 57 patients after definitive repair and/or valve repair/replacement. In Group I, the commonest affected sites were ventricular septal defect in 31 (24%), left ventricular outflow tract in 22 (17%) and mitral valve in 17 (13%) and in Group II, left ventricular outflow tract in 20 (35%), repaired Fallot in 11 (19%), and atrioventricular defects in eight (14%). Infective endocarditis was not seen in secundum atrial septal defects before or after closure; in closed ventricular septal defects and ducts without left-sided valve abnormality; in isolated pulmonary stenosis; in unrepaired Ebstein: or after Fontan-type or Mustard operations. Surgery was performed in 39 patients: as an emergency in 17, and for failed medical therapy in 22. Only 87 (41%) of patients had a predisposing event: dental procedure or sepsis were the commonest events in Group I (33%) and cardiac surgery in Group II (50%). Streptococci species were found in 54% of Group I patients and in 45% of Group II. Staphylococci aureus was commoner in Group II (25%) compared to Group I (14%). Mean time from the onset of symptoms to diagnosis was 60 and 29 days in Groups I and II, respectively. Eight (4%) patients died as a result of septicaemia related to emergency or repeated surgery and Staphylococcus aureus infection. Recurrent attacks occurred in 21 (11%) patients.
Reparative surgery does not prevent endocarditis except for closure of a ventricular septal defect and duct. Delay in diagnosis is serious since it contributes to mortality, although the overall mortality % is not high. Specific lesions are not affected so prophylaxis is probably unnecessary in those anomalies.
The clinical periodontal status of 44 insulin-dependent diabetic children and adolescents and 20 healthy control subjects was compared for a period of approximately 5 years. Fasting blood glucose, fructosamine, and glycosylated hemoglobin (HbA1) values were determined at baseline and 5 years later. The differences in the clinical and laboratory parameters were compared during the study period. The differences between the two groups were also evaluated. The only statistically significant difference observed in the diabetic group was clinical attachment loss (CAL). The CAL was statistically significantly higher in the diabetic group compared to the controls, and a statistically significantly higher in the diabetic group compared to the controls, and a statistically significant positive correlation was observed between the duration of diabetes and CAL. Fructosamine was also correlated with the gingival index in the diabetic group while there was no correlation in the controls. It may be concluded that diabetes modifies the clinical status of the periodontal tissues and increases clinical attachment loss.
The literature on dental surgery in patients receiving oral anticoagulants is reviewed, and methods of managing anticoagulant therapy to minimize the risk of complications are discussed. Although blood loss during and after oral surgery in patients receiving oral anticoagulant drugs can be substantial, research indicates that most bleeding incidents are not serious and can be controlled by local measures. Studies of 241 anticoagulant-treated patients undergoing more than 500 dental extractions during the 1950s and 1960s showed that only 9 had postoperative bleeding. More recent studies indicate that continued anticoagulation can increase the frequency of prolonged bleeding and delay wound healing. An antifibrinolytic mouthwash containing tranexamic acid can effectively suppress postoperative bleeding. Gelatin sponges, oxidized cellulose, and microcrystalline collagen are other useful hemostatic agents. A reduction in the intensity of anticoagulation therapy has been recommended; the prothrombin time should be measured shortly before the procedure in such patients. In many patients the duration of subtherapeutic anticoagulation must be minimized to reduce the possibility of thromboembolism. An option for high-risk patients is to switch them to heparin. Each patient must be evaluated individually, and the level of risk of the dental procedure and the risk of thromboembolism should be taken into account. In patients taking oral anticoagulants who must undergo dental surgery, careful control of the intensity of anticoagulation and improved methods of local hemostasis can minimize the risk of hemorrhagic complications and thromboembolism.
This study was conducted to determine whether a medical history could be an effective means of detecting medical problems in dental patients.
A risk-related patient-administered medical questionnaire was completed by 4,087 patients in 47 dental practices. The data collected were summarized by means of descriptive statistics; the number of medical problems and the relationship between these problems and the age of the patient were analyzed.
In all, 37.2% of these patients reported at least one medical problem. Hypertension, chronic bronchitis, allergies and medication were the items most frequently mentioned. The frequencies of heart disease, hypertension, endocrinologic and neurologic disorders increased with age, while allergies and chronic obstructive pulmonary disease were evenly distributed over the different age groups. The differences between the health of the patients in the various dental practices were not significant.
On the basis of these results, it can be concluded that taking a medical history by means of a patient-administered questionnaire is an effective method of detecting medical problems of dental patients.
The case of a 67-year-old woman, who had been wearing an upper partial removable denture with a cast metal framework made of CoCrMo alloy for years without any problems, is described. After the extraction of a molar tooth a nickel alloy retention was soldered to the framework. Following reinsertion allergic reactions appeared. The soldered joint showed considerable corrosion. After removing the retention and the soldered joint, the allergic reactions disappeared, although an epicutanceous test had revealed a positive reaction to cobalt. This case supports the high corrosion resistance and biocompatibility reported for CoCrMo alloys in the literature and the loss of these properties due to inadequate processing. Furthermore, the case illustrates a true allergic reaction. In contrast to the rather indiscriminate use of the term allergy to describe various vague disorders, this diagnosis should be restricted to clearly identified clinical situations.
McGowan and Tuohy carried out a survey in Belfast in 1968 to identify patients with cardiac lesions susceptible to infective endocarditis. They also asked whether adequate precautions had been taken by the patients' medical and dental advisers in respect of antibiotic cover for dental surgical procedures. This survey has now been repeated in the Belfast and Glasgow Dental Schools. When compared with those of 1968, the results of these recent studies show that while more 'at risk' patients are receiving antibiotic cover for dental surgical procedures there is still room for improvement in the advice given to patients by medical and dental practitioners.
Chronic renal failure (CRF) is the consequence of a multitude of diseases that cause permanent destruction of the nephron. Concurrent with renal failure are a host of changes affecting the homeostatic functioning of the individual. This report outlines the pathophysiology of CRF and highlights its effects on surgical manipulation of the oral and maxillofacial region in this patient population. In addition, some of the common physical findings and alterations in blood chemistries frequently observed in these patients are discussed.
This review of the human immunodeficiency virus (HIV) epidemic shows that HIV has had and will have a major impact on dentistry, just as it has had on so many other aspects of medical practice and society. These areas include the prevention of HIV transmission in the dental care workplace, the early and safe care and treatment of those who are infected, and the protection of those who are vulnerable or made more vulnerable because of HIV infection. To do this, the dental professional must be educated about HIV and its diseases, their treatment, and what must be done to prevent HIV transmission. Early recognition and treatment of HIV-related oral diseases have become the norms of practice today. Although more and more dentists face potential exposure to HIV, excellent dental care can be provided while minimizing this risk.
The treatment plan for the pediatric cardiac patient must include the following: 1. A complete medical history that will elicit adequate information with respect to the patient's possible heart condition. 2. Consultation with the family physician, pediatrician and/or cardiologist to learn the specific nature of the defect, specific past history, the child's ability to tolerate stress and anxiety, current medication and any specific recommendations for patient management. 3. Antibiotic prophylaxis, in an effort to prevent endocarditis, for all dental procedures that are likely to result in gingival bleeding, including routine professional cleaning. Application of chlorhexidine may be used as an adjunct to antibiotic prophylaxis, particularly in patients who are at high risk and/or with poor dental hygiene. 4. Prompt and vigorous treatment of all infections, with extraction to be considered as the preferred treatment for endodontically involved primary teeth. 5. A frank and open discussion with the parents and patient, detailing the importance of strict oral hygiene and regular dental care for both the oral and general health of the patient. As important as appropriate antibiotic prophylaxis is to the patient's continued health, it must be stated in summation that the dentist's efforts to foster optimal oral health are perhaps even more significant. Dental manipulation is in no way essential to the genesis of bacteremia, and it must be assumed that frequent showers of organisms are the rule in individuals who neglect their mouths. Perhaps the dentist performs the greatest service for this group when he or she succeeds in significantly modifying their oral hygiene behavior, thus preventing inadvertent septic "suicide".
Cardiovaskular and pulmonary diseases, terminal renal failure, hepatitis B and C as well as the acquired immune deficiency syndrome, hemorrhagic diatheses, diabetes mellitus and hyperthyreosis are the major systemic diseases related to the practice of dentistry and require a modified treatment plan. Dental treatment during pregnancy may involve a risk for the woman and the fetus. The article outlines the most important aspects of interdisciplinary care for medial high-risk patients in the dental practice, refers to further readings and emphasizes the necessity of active continued education in the field of general medicine and specific emergency care.
Successful implementation of guidelines to prevent infective endocarditis (IE) depends upon the dental practitioner being aware of which of his patients are at risk. This was studied by sending a questionnaire to at risk patients and their dentists in the Grampian area. Of 145 respondents (53% response rate) with predisposing cardiac disorders, only 63 reported having seen their dentist in the past 2 years, although for dentate patients 47/61 had seen a dentist in the past 2 years. The dentists of 59 of these cases were then surveyed and replies received in 53 cases. Nineteen had no record of the patient having a cardiac disorder. In only 17 of the remaining cases was information on the cardiac disorder well enough recorded to warrant prophylaxis for at risk procedures. The dentist was usually told of the disorder only by the patient. Sixty-three per cent of dentists felt that communication between them and the patient's doctor was unsatisfactory. It is necessary to improve doctor/patient/dentist communication so that current recommendations on prophylaxis can be implemented to the full. This should be done through the patient's GP or consultant, who should communicate directly with the dentist. Details could also be inserted on warfarin cards and 'cardiac alert cards' expanded.
Prophylactic antibiotic cover for certain oral and dental procedures for patients with artificial joints is a controversial issue. This paper examines the evidence supporting the use of antibiotic cover and concludes that routinely, for the majority of patients with artificial joints, it is not justified. Certain medically compromised patients with artificial joints have a slightly increased risk of infection and, under these circumstances, antibiotic prophylaxis may be justified. The antibiotic recommended for this group is cephradine or in the case of penicillin allergy, clindamycin. Preoperative dental fitness is mandatory for all patients who are to receive artificial joints. This information will be of interest to the oral and maxillofacial surgeon in his own clinical practice, and when giving advice to local general dental practitioners.
The use of antibiotics to prevent infection is a contentious issue in all surgical specialties. Ideally, antibiotic administration should reduce morbidity and mortality. In reality, they may cause drug interactions, allergic and other untoward reactions, and reduce colonisation resistance; this can result in infections with resistant microorganisms. Therefore, when used injudiciously, the patient may suffer more than if antibiotics had not been prescribed. The most effective use of prophylactic antibiotics has been shown to be in short term, high dosage regimens that are active against the common pathogens. To achieve any protective effect, antibiotics must be administered pre-operatively to provide adequate tissue concentrations at the time of surgery.
Infective endocarditis is a serious disease and should be, if possible, prevented. Two risk groups are classified in relation to the patient's underlying cardiac lesions. At high risk are patients with prosthetic valves or with a previous infective endocarditis. Patients with congenital and acquired heart disease, mitral valve prolapse with regurgitation and hypertrophic obstructive cardiomyopathy are at moderate risk. Patients of these two groups should receive antibiotic prophylaxis before dental or surgical procedures that cause bacteremia. For patients at moderate risk a single dose of an orally administered antibiotic should be given one hour before the procedure (e.g. amoxicillin 3 g for procedures of the oropharyngeal, gastrointestinal or genitourinary tract, where the causitive agents of endocarditis are Viridans streptococci or enterococci). Multiple doses are recommended for patients at high risk. The combination of amoxicillin and gentamicin (vancomycin and gentamicin in penicillin-allergic patients) offers the widest margin of safety in high-risk patients.
The causes of tooth and gum disorders during pregnancy and possible prevention measures are discussed. The evaluation of a nation-wide survey comprising 700 pregnant women reflects the women's respective scope of knowledge in respect of mouth and tooth hygiene, 357 of the 700 women included in the investigation had no dental treatment in the course of their pregnancy. 57.7% showed incidence of gingivitis during gestation. 70.9% were not instructed regarding mouth and tooth hygiene in the respective period and 81.7% did not receive any written material on this topic. 41.3% of the respondents did not seek information on matters of mouth and tooth hygiene and 44.3% stated that they felt that their knowledge in these matters was sufficient. When questioned about the causes of the bad state of their teeth, 28.4% stated an actual cause (insufficient tooth hygiene, excessive sugar consumption). 262 (37.4%) suffered from morning sickness, 45% of these women (n = 118) stating that they subsequently brushed their teeth. 45.6% used their toothbrush for a period of six months and 67.9% had no knowledge of fluoride treatment. These findings high-light the need for more information for the prevention of tooth decay and more information on mouth and tooth hygiene during pregnancy. It is suggested to supplement pregnancy guidelines by including two visits to the dentist as an integral part of antenatal checkups.
The purpose of this article is to assist the dental practitioner in making informed decisions concerning the treatment of patients "at risk" for developing infective endocarditis following dental procedures.
Good dental practice requires that a dental practitioner be aware of those medical conditions that might present first with oral manifestations and those for which special considerations are required before dental treatment is rendered. In view of the rapid changes in the understanding and treatment of disease, it is essential that a dentist be current in his knowledge of medicine and be aware of the established and accepted methods of patient management.
Dental extraction in patients receiving long-term oral anticoagulant therapy is a controversial issue. Continuation of anticoagulation exposes the patient to serious hemorrhage, whereas cessation of therapy increases the risk of thromboembolism. Forty patients treated by coumarin underwent 63 tooth extractions, without a change in the therapeutic protocol of anticoagulation. The biologic adhesive Beriplast was used successfully to achieve local hemostasis at the site of the surgical wound. Apart from one patient who had mild oozing, there were no incidences of postsurgical hemorrhage.
The frequency of oral infection complications after cytotoxic chemotherapy and radiochemotherapy is significant, often contributing to serious septic infectious complications. Generally, the more intense the cytotoxic therapy, the more common are the oral infection complications. In the present review, the spectrum of oral infections related to radiation and immunosuppressive therapy are evaluated and the different local and systemic treatment modalities are presented.
The number of immunocompromised patients has increased during recent years, mainly because of more aggressive anti-cancer treatment and increased survival periods for end-stage cancer patients. Congenital and acquired immunodeficiencies are also more frequently recognized in dental practice due to increased diagnostic knowledge and increased numbers of HIV-infected persons. Oral complications and infections are related to the type and severeness of the immunodeficiency. Low amounts of immunoglobulins are known to play a rôle in many bacterial infections, e.g., upper respiratory tract infections, but have not yet been associated with specific oral conditions. T-cell defects tend to increase susceptibility towards oral infections with fungi and virus, and are also associated with periodontal disease in HIV-infected patients. Defects in the phagocytic system increase the risk of periodontal disease in certain patient groups. Severe granulocytopenia as observed, e.g., in leukemic patients increases the risk of septicemia with oral micro-organisms.
The increase in new clinical materials with questionable biological properties and the corresponding increase in awareness in patients to health hazards from dental materials are two important problems of modern clinical dentistry. Based upon evidence from clinical research the hypersensitivity problems related to the use of silver amalgam and acrylic denture base materials are reviewed to define possible risk groups among dental patients. In silver amalgam therapy the main risk group is patients with contact lesions in the oral mucosa adjacent to the restorations, as this group exhibits a high frequency of skin sensitivity to mercury and other base materials in dental amalgam. Among denture wearers a corresponding risk group has been observed among patients with previous allergic diseases and burning mouth syndrome. In these cases a high incidence of skin sensitivity reactions to denture allergens has been observed, usually to methylmethacrylate monomer and formaldehyde. Some possible pathogenic mechanisms leading to a contact allergy of the oral mucosa in these patient groups are discussed.
An easily mastered safe treatment documentation system is presented. The routine consists of two parts, a comprehensive yet manageable medical history and a treatment modification record. Millions of medically compromised patients may now receive comprehensive care in safety.
Two rate-responsive pacemakers (Activitrax and Sensolog) were tested in order to show up to which extent its function can be disturbed by dental treatment. Inhibition of the pacemaker occurred by switching the electrical dental appliance on and off, or by moving it back and forth. In most cases, inhibition was only evident when the distance between the pacemaker and the electrical appliance was less than 10 cm. The electrome proved to be the most potent source of disturbance, as the function of the pacemaker was totally inhibited when it was switched on and off with a frequency of 1 to 2 Hz and even at a distance of 2.8 meters. During dental treatment--especially osteotomies--vibrations are transferred upon the patient which can cause an increase of the pacing rate.
The use of vasoconstrictors in dentistry has always been a topic of controversy for the medically compromised patient. Over the past few years, dentists have been warned not to use local anesthetics with vasoconstrictors in asthmatic patients. In this article, the authors question the rationale behind these recommendations and explain why the warning should be restricted to steroid-dependent asthmatic patients.
Common oral complications of chemotherapy include mucositis, infections secondary to profound bone marrow aplasia, and gingival bleeding. Mucositis and infections were treated with appropriate antibiotic therapy; a symptomatic tooth was extracted before chemotherapy was begun. Transfusions were performed to obtain adequate platelet levels. A regimen of ticarcillin disodium and gentamicin sulfate is recommended for antibiotic prophylaxis for selected dental procedures.
Management of the dental patient who has a bleeding disorder requires an understanding of the normal hemostatic system and the patient's specific coagulation defect. This patient group can receive quality comprehensive dental care, provided appropriate preoperative planning and evaluation with the patient's physician or hematologist is accomplished. Emphasis should be placed on providing appropriate replacement therapy before the dental procedure, selection of conservative treatment approaches, and use of local hemostatic measures to facilitate hemostasis.
Cardiovascular complications caused by hypertension need to be anticipated during routine dental therapy. Changes in the cardiovascular system before, during, and after treatment were studied for 40 patients undergoing extractions.
Some dental professionals may have concerns about treating patients who have seizure disorders. The authors contend that increased knowledge about seizures and how to manage them may make dental professionals more comfortable. This article reviews the various seizure types, discusses commonly used anticonvulsants and their side effects and outlines some special concerns dentists may have in providing care to these patients.