The medical–endo interface and patients with special needs
The health and well-being of an individual is influenced by factors as diverse as their genetic make-up, environment, nutrition and interaction with society. These factors all play a part in the physical, psychological, social, cultural and spiritual aspects of the well-being of the individual. Healthcare workers in general should have an awareness of the complex interplay between such factors and their potential influence on the outcome of any health-improving measure. Those involved in the direct delivery of any intervention that may impinge on these factors should understand the nature of the broadest effect of that intervention. Oral healthcare is perceived by many in the general healthcare profession to play only a small part in the overall well-being of the individual. The truth, however, is that oral and dental problems may influence and, in turn, be influenced by the overall well-being of the individual. Management of oral and dental health is therefore, no less important than management of the overall health of people. It requires a broad-based appreciation of life (including, social, cultural, individual, psychological and spiritual contexts) in parallel with the biological and clinical knowledge and skills necessary to deal with diseases of the pulp and periradicular tissues. The dentist must, therefore, be both an oral physician and surgeon.
The western world has experienced a dramatic improvement in living standards and conditions over the last 50 years to the point that life spans have increased to between 80 and 100 years. Such individuals are also maintaining their dentitions for longer into their old age with the consequence of increasing wear and tear problems associated with their teeth. Paradoxically, these figures are juxtaposed with those indicating an increase in life-style dependent diseases, such as obesity, diabetes, cardiovascular disease and cancer.
The dentist must therefore, be cognizant of the patient’s overall and endodontic needs, where appropriate care is provided. The dentist must know how to make an overall assessment of the patient and understand how endodontic care may need to be modified or adjusted to meet the patient’s needs. Endodontic care must be delivered within the confines of a specific treatment plan which is patient centred, realistic and flexible. Careful assessment and treatment planning will take account of factors, such as patient access, general health, medical conditions and prognosis, medication and therapeutics, previous standards of oral hygiene and includes the skills of the dental team required to deliver care. Treatment plans should be modified by an individual’s ability to cooperate with treatment, which may fluctuate, but should retain the overall physical and psychological well-being of the patient as the prime consideration.
The majority of patients have treatment under local anaesthesia within a general dental practice setting, with a smaller group requiring more specialized services, particularly for more complex treatment or management. Inhalation sedation and intravenous sedation are indicated as the next line of treatment when an individual is unable to cooperate for care with local analgesia because of anxiety, learning or physical disability. For some patients, sedation will be insufficient to manage necessary care and treatment under general anaesthesia is indicated.
The completion of an up-to-date and accurate medical history is an essential prerequisite to both treatment planning and the delivery of dental care. It should be remembered that “a good history is taken, not given” and the dentist should actively engage with the patient, or those who care for the patient, rather than simply request for a medical history form to be completed. It is not unusual for patients to be reluctant to divulge aspects of their medical condition, i.e. the presence of blood-borne viruses, until trust is established between the patient and the dental team. It is therefore, in everyone’s best interest that relationship building between patient and clinician is established as quickly as possible.
History taking also allows the dental team to examine the patient’s physical appearance, behaviour and speech. The patient’s physical appearance can not only provide an indication of any underlying medical condition and its severity, but also provides important information regarding their self-esteem, ability to self-care or the level of care they are receiving. The ability to cooperate for the dental examination can often be accurately assessed by their behaviour but may give sufficient time for an apprehensive patient to relax sufficiently to proceed. The patient’s capacity to consent for dental treatment can be also assessed. If another person attends with the patient, it is important to establish their relationship to the patient. In those patients who have a visual or hearing disability, every opportunity should be given to assure an effective means of communication is established via additional techniques, such as bold text, braille, lip reading, sign language and the block alphabet. Patients who have difficulty speaking, often as a result of an underlying neurological condition, should be given the necessary time to respond to the questions being asked if frustration is to be avoided.
Particularly with patients who have special needs, or patients who are being considered for treatment under conscious sedation or general anaesthesia, a significant amount of information needs to be gathered out-with the confines of a pretyped medical history form or consultation. The dental team needs to establish where the patient lives and who provides care for the patient, the nature of the care (i.e. tooth brushing, personal hygiene) and when is the care provided. Does the patient have any contact with friends or relatives? Are their contact details available? Does the patient have a support group, social worker or an Independent Mental Capacity Advocate (IMCA).
If medical or dental treatment has been provided previously, then this can provide important information for future care. Where and how did the patient access their care? Was transportation required and of what type? Were specific appointment times scheduled and how was the care delivered? Was postoperative care required? Who provided that care and in what setting? Was the treatment successful and would that method be suitable for the current treatment planned?
It is highly desirable that all medical colleagues are actively aware of any planned treatment under general anaesthesia for patients with a profound learning disability. Often, additional examinations and invasive procedures, such as blood tests (which could otherwise prove impossible), can be completed at the same time as the dental treatment.
For those patients with conditions that may become progressively debilitating, treatment planning will need to take into account the likely nature and time-frame of any deterioration. This may be unpredictable or impossible for some conditions and can present the dental team with difficult long-term treatment planning decisions.
Cardiovascular disease (CVD) is the commonest cause of adult death in the developed world. Hypertension is persistently raised blood pressure of >140/90 mmHg. Ninety per cent of cases are “essential” with no non-lifestyle causes. A significant number of the population are prescribed antihypertensive medication via the use of diuretics, beta blockers, calcium channel blockers, ACE inhibitors, sympatholytics and vasodilators. Stress, including as a result of dental treatment, may further increase blood pressure leading to a risk of stroke or cardiac arrest. Angina presents as a severe, crushing chest pain. It is the result of impaired blood flow and oxygenation of the heart muscle, usually due to atherosclerosis. Stable angina is usually precipitated by effort and resolves with rest. Unstable angina occurs at rest, with minimal exertion or rapidly increasing severity.
Dental treatment for both conditions can safely be provided under local anaesthesia. However, unstable angina carries a serious risk of myocardial infarction and elective dental treatment should not be carried out. Care should be given to ensure anxiety levels during treatment are minimized and treatment under sedation may be a prudent option for the nervous patient. Intravascular injection of epinephrine-containing local anaesthetic should be avoided and the management of patient on anticoagulants is discussed later in this chapter. Prophylactic glyceryl trinitrate spray has been shown to be effective in the prevention of both hypertension and angina during dental treatment. Routine dental treatment should be avoided where appropriate for at least 6 months following a myocardial infarct with some authors suggesting treatment should be postponed for 1 year, due to the risk of further infarct within this period. Acute dental problems within this timeframe should be managed in close consultation with the cardiologist responsible for the patient’s care.
Infective endocarditis is an infection of the endocardial surface of the heart, which may include damaged heart valves, prosthetic heart valves or ventricular septal defects. In the UK, current guidelines from the National Institute of Clinical Excellence (NICE) recommend that antibiotic prophylaxis is not required for at risk groups as there was insufficient evidence regarding the efficacy of the antibiotic regimen. The updated American Heart Association guidelines (2007), on the other hand, recommend that antibiotic prophylaxis prior to dental procedures be administered to patients with previous infective endocarditis, prosthetic heart valve, cardiac transplantation recipients with cardiac valvulopathy and some patients with congenital heart disease (CHD). Patients with CHD are defined as those with unrepaired cyanotic CHD (including conduits and palliative shunts), repaired CHD with residual defects at or adjacent to the site of a prosthetic patch or device, and completely repaired CHD with device or with prosthetic material in the first 6 months following the procedure. This is because endothelialization of the prosthetic material generally occurs in the 6 months following the procedure. Antibiotic prophylaxis is no longer recommended for any other form of CHD.
Stroke is a generic term for cerebrovascular accident (CVA) resulting in a sudden or rapidly progressing neurological defect, which does not resolve within 24 hours. Stroke is the third highest cause of death in the UK, after ischaemic heart disease and all cancer types combined, with around 150 000 people having a stroke per year.
The effects of stroke principally result in unilateral numbness, weakness and partial or complete paralysis of the arm, leg or face on the contralateral side of the brain. The effects, severity and recovery can be varied. Mobility may become impossible requiring the provision of domiciliary care for dental treatment.
Endodontic treatment may be affected by the provision of anticoagulants. The patient may have difficulty accessing care, particularly if they are wheelchair bound. Communication may be challenging and anxiety, fear or frustration are common emotions for patients who have undergone stroke. Blood pressure should be monitored during treatment and attention given to vasoconstrictor usage in patients who have reduced resiliency of the cardiovascular system. Patients taking antihypertensive medication are at increased risk of postural hypertension and this should be taken into account following prolonged periods in the dental chair.
Acquired bleeding conditions occur as a result of liver disease and platelet disorders or as the result of anticoagulant therapy. Patients with liver failure, alcoholism, renal failure, thrombocytopenia, and chemotherapy will have coagulation and clotting disorders and should not undergo a surgical intervention without liaising with the physician responsible for their care.
Antiplatelet therapy, such as aspirin and clopidogrel, when used in combination, have a synergistic effect impairing platelet function. However, local measures should be adequate to achieve coagulation and the medication should not be stopped prior to a surgical procedure.
Coumarin therapy is most commonly prescribed in the form of the vitamin K antagonist warfarin. Used for the prophylaxis or treatment of deep vein thrombosis, prosthetic heart valves, and people with atrial fibrillation, it prolongs both prothrombin and the activated partial thromboplastin time. The International Normalized Ratio (INR) is used to monitor its effect with a therapeutic range of 2–3 for deep vein thrombosis (DVT) and up to 4.5 for patients with prosthetic heart valves. Patients with an INR of less than 4 can undergo surgery in general dental practice without any warfarin dose adjustment. The patient may bleed more than normal but this should be controlled via local measures. Ideally, the INR should be checked on the day of the procedure.
Special precautions are not required for non-surgical endodontic treatment. However, there is a theoretical risk of bleeding into the fascial planes following an inferior alveolar nerve block and, where possible, this should be avoided. If it is unavoidable, an aspirating technique should be used with the injection given slowly to minimize tissue damage. Currently, there are no specific published guidelines regarding the surgical endodontic management of patients undergoing coumarin therapy. Therefore, if there is doubt regarding the management of such a patient then it would be prudent to seek advice from the patient’s haematologist prior to treatment.
Patients who have a poorly controlled INR or an INR>4 and require multiple extractions should be treated in a hospital setting. Non-surgical endodontic treatment should not present a significant bleeding risk. However, the clinician should maintain the highest standards of atraumatic technique, especially with regards to soft-tissue management, apical control (of instruments, as well as irrigants, particularly sodium hypochlorite) and delivery of local anaesthesia. If there is any doubt with regards to patient management, then the advice of the patient’s haematologist should be sought prior to treatment.
Hereditary or congenital bleeding disorders have the potential to cause severe bleeding tendencies. The most common congenital bleeding disorder is von Willebrand’s disease, followed by haemophilia A and haemophilia B.
The rarer haemophilia B is the result of a genetic mutation leading to a deficiency in factor IX. Both types of haemophilia typically manifest in childhood as easy bruising and prolonged bleeding following injury.
Most patients should be able to be managed within a primary care setting in coordination with the patient’s haemophilia with each haematological disorder and individual patient requiring an individual approach. The goal of treatment is to minimize the challenge to the patient by restoring the haemostatic system to acceptable levels and maintaining haemostasis by local and adjunctive levels. This is normally achieved through the delivery of coagulation therapy to raise coagulation factors to near normal levels within 10–12 hours of factor VIII cover and on consecutive days for factor IX.
It has been reported that patients with congenital bleeding disorders are often highly anxious about dental treatment and often delay treatment until they develop significant dental problems. In addition, patients with congenital bleeding disorders may have been exposed to the hepatitis C virus (HCV) from the use of non-inactivated replacement factor concentrates from pooled human blood until 1986, with the presence of HCV having been reported in up to 70% of haemophilia patients.
During endodontic treatment, whether the patient has received prophylactic coagulant cover or not, care must be taken to avoid trauma. As for patients on anticoagulant therapy, apical control via the use of apex locators and careful instrumentation is required. Rubber dam application should be as atraumatic as possible, otherwise it can lead to gingival bleeding, which can be particularly troublesome in patients with vWD.
Local anaesthesia represents a more significant challenge. An inferior alveolar nerve block must only be given after raising the appropriate clotting factors levels via appropriate therapy as there is a risk of haematoma in the retromolar or pterygoid space potentially compromising the airway. Similarly, lingual infiltrations should be avoided without the appropriate factor cover as it risks a significant haematoma. Therefore, alternative anaesthesia via intraligamental or intraosseous techniques should be considered. Buccal infiltration with Articaine may provide sufficient anaesthesia for mandibular molars though not for patients with pulpitis.
Any surgical procedure should be carried out with minimal trauma and the use of both resorbable and non-resorbable sutures has been advocated. Topical haemostatic agents such as tranexamic acid may provide rapid haemostasis. Careful postoperative instructions should include a soft or liquidized diet and the use of a tranexamic acid mouthwash regimen.
Despite all measures, postoperative haemorrhage may still occur occasionally and patients should be instructed to contact their local haemophilia centre in the first instance for further clotting factor infusions.
Chronic obstructive pulmonary disease (COPD) and asthma are the most likely respiratory diseases to be encountered in the dental surgery. COPD encompasses a collection of diseases, including chronic bronchitis, emphysema and chronic airways disease. There are in the region of 900 000 sufferers in England and Wales varying from mild disease through to severe disease with respiratory failure. The majority of disease is smoking related.
Diagnosis is based on history, physical examination and spirometry tests with treatment ranging from inhaled bronchodilators or corticosteroids, through to confinement at home with constant nebulization.
Most patients can cope with dental treatment safely with only minor adjustments to procedures in general dental practice. Where possible, treatment should be delivered under local anaesthetic, due to the risk of respiratory depression during treatment under sedation. It is likely that the patient will have to be treated in an upright position compromising access for endodontic care. Patients who require oxygen therapy should bring sufficient oxygen for the duration of treatment and this should be checked prior to the initiation of care.
Asthma is common, affecting up to 5.4 million people in the UK in 2008. It is a generalized airway obstruction, which is paroxysmal and reversible in the early stages. The obstruction is the result of bronchial mus/>