Screening and medical evaluation of adults: contraindications for invasive dental procedures

Implant and preprosthetic surgeries aim to restore normal anatomical contours, function, comfort, esthetics, and oral health. Systemic screening of a patient prior to implant and/or biomaterial insertion is critical to patient well being and success of the surgical procedure(s). It is no longer appropriate to limit the general contraindications to the malfunction of major organs and systems and not consider the devastating long-term effects of an unhealthy lifestyle (smoking, inadequate diet, etc.). Modern standards of care should not systematically exclude patients with relative or marginal health conditions without exploring the possibilities of improving and stabilizing those conditions. Based on the classification of the American Society of Anesthesiology, a number of absolute and relative contraindications are presented. Treatments are proposed for optimizing some marginal health conditions and stabilizing unbalanced physiological function prior to surgery. A knowledge of the fundamentals of internal medicine is an important prerequisite for predictable implant and preprosthetic surgery. This paper reflects the opinion of a physician and dentist who has been actively involved in implant and preprosthetic surgery for the past quarter of a century in both private and university hospital practice.

The psychopathology, medical management and dental implications of schizophrenia

BACKGROUND

Schizophrenia is a psychiatric illness characterized by thought disturbances, bizarre behaviors and cognitive impairments that may diminish a person's abilities in the areas of social relations, school or work and self-care. The onset of the disorder typically occurs between the late teens and mid-30s. Advanced dental disease is seen frequently in patients with schizophrenia for several reasons: the disease impairs these patients' ability to plan and perform oral hygiene procedures; some of the antipsychotic medications they take have adverse orofacial effects such as xerostomia; and these patients sometimes have limited access to treatment because of a paucity of financial resources and adequate number of dentists comfortable in providing care. The recent introduction of more effective medications has permitted the majority of patients to receive their psychiatric care from community-based providers rather than in the hospital. Consequently, dentists in the private sector also are being called on more frequently to care for these people.

CONCLUSIONS

Dentists cognizant of the signs and symptoms of schizophrenia are likely to feel more secure in treating patients with schizophrenia and more confident when obtaining consultative advice from the patients' psychiatrists. Dentists usually can provide a full range of services to such patients, can enhance these patients' self-esteem and can contribute to the psychotherapeutic aspect of management.

CLINICAL IMPLICATIONS

To effectively provide treatment to patients with schizophrenia, dentists must be familiar with the disease process so that they can communicate effectively with the patient, the treating psychiatrist and family members who serve as caregivers. In addition, dental treatment may need to be modified because of the patient's impaired ability to think logically, the local and systemic effects of psychiatric medications, and adverse interactions between these drugs and medications used in dentistry.

Diet medications and valvular hearl disease: the current evidence

Since 1997, the appetite suppressant drugs fenfluramine-phentermine (fen-phen) and dexfenfluramine have been associated with the development of valvular heart disease. As a result, the drugs have been withdrawn from the market and interim recommendations for evaluation and treatment of exposed patients were issued. However, subsequent studies showed lower prevalence rates for valve abnormalities than were initially reported, and the possibility of such drug-induced lesions resolving has been raised. This article reviews relevant evidence and discusses concerns for the dental practitioner.

Dental fear in a special needs clinic population of persons with disabilities

This study reports findings from a survey of dental fear in a special needs dental clinic population. Subjects were recruited from the University of Washington's Dental Education in Care of Persons With Disabilities (DECOD) clinical program (n = 132). Dental fears were assessed using the Kleinknecht Dental Report. Fear levels were examined among patients with differing categories of primary disabilities and between genders, races and educational levels. Some level of dental fear was reported by 43.2% of the respondents, indicating that dental fear may be an important factor in dental care for this population. Gender and educational level were significantly associated with fear levels (both p < 0.05). Significant differences in fear levels were found between individuals with differing classes of disability. Accompanying caregivers also were interviewed (n = 72) to allow for a comparison of patient and caregiver perceptions. Both patient and caregiver were interviewed whenever possible to create paired reports. Generally, caregivers significantly overestimated fear levels compared with patients (p < 0.01). However, when scores were compared in matched caregiver-patient analyses, the fear scores were not significantly different, indicating that caregivers accurately estimated their client's level of dental fear. A regression model including disability group, gender, and years of education was significant for predicting fear level as measured by the Kleinknecht survey (p = 0.02). We conclude that dental fear may be a significant, though little understood problem for a population of persons with disabilities as well as for their oral care providers, and that further investigation is needed.

Management of the dental patient with congestive heart failure

This article presents the basic pathophysiology, clinical findings, medical management, and dental management for patients with congestive heart failure. The emphasis is on the role of the dentist in detecting these patients based on history and clinical findings, referring the patient for medical diagnosis and management, and working closely with the physician to develop a dental management plan that will be effective and safe for the patient.

The principles of uncomplicated exodontia: simple steps for safe extractions

This article reviews the basic principles of patient evaluation and surgical techniques to accomplish extraction of teeth in an uncomplicated manner. Also presented are techniques for extraction-site grafting with bioactive glass.

Circulatory dynamics during dental extractions in normal, cardiac and transplant patients

BACKGROUND

The authors conducted a study to evaluate the relationship between the circulatory dynamics of patients with heart disease and these patients' cardiac status when undergoing dental extractions.

METHODS

Subjects with minimal heart disease, or MHD; with severe heart disease, or SHD; or who received a heart transplant, or TRAN; as well as control, or NOR, subjects were enrolled in the study. The authors recorded subjects' systolic blood pressure, or SBP; diastolic blood pressure, or DBP; and heart rate, or HR, while they were under basal conditions and during postanesthesia and dental extraction periods. The authors estimated a general linear model and performed analysis of variance.

RESULTS

Under basal conditions, MHD subjects did not show significantly different mean blood pressure values compared with NOR subjects but did show slightly significantly higher mean HR values. Mean DBP and HR values were significantly higher in SHD and TRAN subjects than in MHD and NOR subjects, while SBP values in SHD subjects were significantly lower than those in MHD, TRAN and NOR subjects. During dental extraction sessions, SBP, DBP and HR mean values increased significantly compared with basal conditions and post-anesthesia periods in MHD and NOR subjects. SHD and TRAN subjects showed no significant time-dependent variation during dental extraction sessions in any circulatory parameter.

CONCLUSIONS

MHD subjects had cardiovascular responses to stress similar to those of NOR subjects, while SHD and TRAN subjects had similar slight and dulled cardiac responses.

CLINICAL IMPLICATIONS

Patients with SHD may not be able to adapt their cardiac performance to an emotional stress such as a dental appointment, while it seems to be easier for MHD and TRAN patients. Managing TRAN patients is relatively easier than managing SHD patients.

Prosthodontic management of a patient with neurological disorders after resection of an acoustic neurinoma: a clinical report

This clinical report describes the treatment of an edentulous patient who had undergone resection of an acoustic neurinoma and subsequently developed neurological problems. A replacement maxillary denture combined with a mandibular denture placed in the neutral zone was selected as the treatment of choice. A simple procedure for recording the neutral zone is presented.

Bloodborne pathogens: current concepts

In the early 1980s, the AIDS hysteria began to gain momentum. As a direct result of this phenomenon, the delivery of dental care changed dramatically. By 1989, most dentists had begun to accept the concept of universal precautions and compliance with infection control recommendations from the Centers for Disease Control and Prevention and the Organization for Safety & Asepsis Procedures. The emergence of bloodborne pathogens from the 1970s has been a significant milestone in the history of the dental profession. Patients infected with human immunodeficiency virus, hepatitis B virus, and hepatitis C virus are commonly encountered in the modern dental practice, and dental providers need to have a thorough knowledge about bloodborne diseases and the dental management of patients presenting with these diseases.

Infectious hepatitis C, hepatitis G, and TT virus: review and implications for dentists

In the past 10 years, hepatitis C and G viruses have been identified, and in the last two years a further parenterally transmitted agent, termed TT virus (TTV), has been discovered. These viruses have a worldwide distribution and frequently cause chronic infection. The purpose of this article was to promote an understanding of these viral agents and their relevance in dental practice. Infected patients may develop a chronic carrier state without clinical disease or may develop liver disease, and may have related oral conditions. Dental providers will see a growing number of patients with HCV/HGV and possibly TTV infection. All of these patients require appropriate infection control measures during dental treatment.

Sickle cell anemia and dental caries: a literature review and pilot study

The purpose of this cohort study was to determine whether individuals with sickle cell anemia (SCA) were more susceptible to dental caries than non-sickle-cell control subjects. A review of the literature suggests several reasons why individuals with SCA may be at increased risk. Thirty-five cases of SCA aged 6 years and older were identified from a screening of 15,900 current patient files at the Howard University College of Dentistry Dental Clinic. A total of 140 non-SCA control subjects (four per case), frequency-matched on enrollment period (+/- 5 yrs) and age (+/- 2 yrs if under age 21, or +/- 5 yrs if 21 or over), was selected by a nonbiased method from the same dental clinic files. SCA cases and controls were identical on mean age (30.4 +/- 19 yrs, ranging from 5 to 92 yrs) and were similar in sex distribution (males: 34% of SCA cases, 40% of controls). The mean number of permanent teeth present was very similar for SCA cases and controls (23.4 +/- 6.4 vs. 24.2 +/- 6.4). The mean DMFT was 21% higher in the SCA cases (12.0 +/- 8.4 vs. 9.9 +/- 6.9), and the mean DMFS was 26% higher in the SCA cases (33.0 +/- 32.3 vs. 26.2 +/- 27.7). While there was virtually no difference in DMFS between SCA cases and controls for 6- to 19-year-olds, for subjects aged 20 and older, the DMFS was 30.4% higher in the SCD cases. For all ages, the M component for SCA cases was 40.7% higher, and the D component was 20.0% higher, while the F component was only 3.5% higher than for controls. Untreated decay (the D/D+F surfaces ratio) was 24.4% higher in the SCA cases. The findings from this pilot study suggest that SCA cases have a higher susceptibility to dental caries and/or that SCA patients may have different treatment pathways once caries is detected. While none of the observed differences was statistically significant, these findings were of clinical interest and should be pursued in future large-scale studies.

Management of dental extractions in patients with bleeding disorders

OBJECTIVE

This study evaluated the effectiveness of a protocol to prevent bleeding after dental extraction in patients with hemophilia, von Willebrand's disease (VWD), or platelet disorders.

STUDY DESIGN

Replacement therapy was used in cases involving general anesthesia, and nerve trunk infiltration was used in patients with severe bleeding disorders (severe-to-moderate hemophilia or type 2-3 VWD). Desmopressin was used in good responders with mild hemophilia A, type 1 VWD, and platelet disorders. Local hemostatic measures and antifibrinolytic treatment were used systematically.

RESULTS

Ninety-three patients underwent 103 dental extractions; 2 of these patients had secondary bleeding requiring surgical hemostasis.

CONCLUSION

The indication for replacement therapy depended on the type of anesthesia that was used. Coagulation factor concentrates or desmopressin were necessary to avoid upper airway hematoma with general anesthesia or nerve trunk infiltration. With local anesthesia, substitutive treatment was indicated in patients with severe-to-moderate hemophilia and type 2-3 VWD. Inexpensive desmopressin was effective in those who responded well. Local hemostatic measures and antifibrinolytic treatment were performed systematically.

Patient selection for endosseous dental implants: oral and systemic considerations

This paper reviews the literature and discusses patient selection for endosseous dental implants and the effect of systemic and local pathology on the success rate of dental implants. Endosseous dental implants may be preferable to conventional dentures in patients with compromised supporting bone or mucosa, xerostomia, allergy to denture materials, severe gag reflex, susceptibility to candidiasis, diseases affecting orofacial motor function or in patients who demand optimal bite force, esthetics, and phonetics. Conventional dentures or fixed partial prostheses may be preferable to endosseous dental implants in growing and epileptic patients and patients at risk of oral carcinoma, anaphylaxis, severe hemorrhage, steroid crisis, endocarditis, osteoradionecrosis, myocardial infarction, or peri-implantitis. A systematic approach to dental implant patient selection is outlined and centralized reporting of dental implant outcomes is recommended.

Geriatric dentistry. A review for the general dentist

In the 20th century, the oral health of Americans, along with their life expectancy, improved dramatically. The 21st century offers dental professionals the opportunity to help patients maintain their oral health for a lifetime.

A case report of acute heart failure caused by a patient delaying taking his diuretic medication

Acute heart failure is a life-threatening medical emergency, most commonly occurring as an immediate or delayed complication of acute myocardial infarction (AMI), or resulting from severe hypertension or valvular defects (stenosis or incompetence). Occasionally it is caused by patients' non-compliance with medication orders. In this case the patient had a history of three previous AMIs, controlled hypertension, and controlled congestive heart failure (CHF) for which he took two 40 mg frusemide tablets (a very potent oral diuretic) each morning. Because he had experienced bladder discomfort during the latter stages of previous appointments he decided to delay taking the diuretic until after his appointment and acute heart failure ensued.

Effects of dental local anaesthetics in cardiac transplant recipients

OBJECTIVE

To investigate the cardiovascular responses of cardiac transplant recipients to dental local anaesthetic solutions with and without epinephrine (adrenaline).

MATERIALS AND METHODS

A clinical study employing 30 patients (20 cardiac transplant recipients and ten healthy) awaiting gingival or minor oral surgery under local anaesthesia receiving either 4.4 ml lidocaine (lignocaine) with 1:80,000 epinephrine or 4.4 ml 3% prilocaine with 0.031 U/ml felypressin.

RESULTS

Cardiac transplant patients experienced a significant tachycardia 10 minutes after injection of the epinephrine-containing solution. No significant change in heart rate was detected after the injection of an epinephrine-free solution. Blood pressure was not affected. Periodontal surgery did not affect the responses to the local anaesthetics in the transplant recipients.

CONCLUSIONS

The cardiovascular response to dental local anaesthesia in cardiac transplant recipients is governed by the solution injected.

Use of an individual traction prosthesis and distraction osteogenesis to reposition osseointegrated implants in a juvenile with ectodermal dysplasia: a clinical report

This article describes the use of distraction osteogenesis to reposition osseointegrated maxillary implants in an adolescent girl with ectodermal dysplasia and oligodontia. The distraction of 2 osteotomized segments was controlled by a prosthesis fabricated specifically for this purpose.

Implant-supported, long-span fixed partial denture for a scleroderma patient: a clinical report

Scleroderma poses many difficulties and challenges for the treating dentist. Until now, dental implant treatment for patients with scleroderma was limited to either complete overdentures or short-span fixed partial dentures. This clinical report describes the use of modified techniques to fabricate a long-span fixed prosthesis delivered after serial extractions and implant placement.

Spontaneous angioedema of oral cavity after dental impressions

Maxillofacial angioedema is a rare condition encountered by the oral and maxillofacial surgeon. Its significance lies in its potential to partially or totally obstruct the upper airway secondary to acute sudden swelling. In some individuals, angioedema is hereditary; in others, it occurs spontaneously, without warning, as an allergic reaction. The case presented here documents perioral angioedema secondary to dental impressions and reviews its management.