The Systemic Phase of Treatment
Before engaging in active therapy, the dentist must consider what impact the patient’s overall general health may have on the delivery of dental care and how it may affect the outcome of treatment. The systemic phase of treatment provides an opportunity for the dentist to establish and maintain the best possible state of physical health for the patient before, during, and after treatment. The dentist must be aware of the pathophysiology of all the patient’s health problems and the implications that each alone, and in combination, will have for the delivery of dental care. The best and safest method to resolve any acute dental problems must be determined in light of the patient’s overall condition. In addition, the dentist must devise a strategy for managing comprehensive dental treatment in the context of the patient’s general health.
Each patient has his or her own unique set of health issues and dental needs. A core function of the systemic phase is to evaluate the severity and complexity of this set of health issues and to assess how those issues may affect dental treatment. Through this analysis, the dentist determines whether altering, limiting, or even postponing dental treatment will be necessary. At one end of the spectrum is the patient with few, if any, health problems, who takes no medications, and who requires only preventive services and no invasive dental treatment. For such a patient, the systemic phase may consist simply of evaluating vital signs followed by an update of the health history at regular intervals. At the opposite end of the spectrum is the person with multiple health problems for whom many medications have been prescribed and who presents with both urgent and complex dental needs. This patient may require a multifaceted systemic phase of care that includes consultation with the patient’s physician and pharmacist, laboratory testing, possible modification of dental treatment, and careful monitoring of the patient’s health before, during, and after each dental visit. In addition, and of at least equal importance, the dentist also needs to discover, investigate, and document any previously undiagnosed health problems.
Systemic issues are highly variable in their relevance to and impact on the dental treatment plan. Some conditions, such as mitral valve prolapse with regurgitation, will trigger certain automatic modifications antibiotic prophylaxis to prevent bacterial endocarditis to the way dental care is delivered. Conditions such as arthritis or asthma, on the other hand, may or may not have a significant impact on dental treatment, depending on the nature and severity of the disease or condition.
A comprehensive survey of the relationship to dental treatment planning of all major systemic disorders is beyond the scope of this book. Instead the purpose of this chapter is to give the reader an overview of the impact that systemic disease may have on treatment planning and to suggest guidelines for evaluating the patient’s systemic health and for adapting the provision of treatment to the patient with significant health problems. An assessment of the patient’s general health and capacity to withstand the rigors of dental treatment physically and psychologically should be performed at every appointment.
Systemic health has increasing relevance for dental treatment planning because (1) the population of elderly persons, many of them retaining their teeth into old age, continues to increase; and (2) as a result of recent advances in health care, people of all ages who suffer from serious illnesses are more likely to remain active and ambulatory and to have increased life expectancies. Until relatively recently, individuals with such severe systemic illnesses as liver, kidney, or cardiac failure did not seek dental services unless they had an acute dental problem. Nor did the medical profession always appreciate the interrelationships between oral health and overall physical health. Unfortunately the poor prognosis for many systemic conditions provided a rational excuse for patients, physicians, and dentists to place a low priority on achieving and maintaining optimal oral health.
Today, because the outlook for patients with serious systemic problems has improved immensely, greater numbers of persons with serious health problems have favorable long-term prognoses and can be expected to present to dentists’ offices requesting all types of treatment. As a result, dentists must be proficient in obtaining and evaluating each patient’s health history and in determining how to provide dental care in a safe and efficacious manner.
Many more physicians, especially those involved with treating patients with cancer or acquired immunodeficiency syndrome (AIDS), now appreciate the impact that preventing dental problems can have on the overall prognosis for their patients. For those patients who are immunocompromised because of systemic disease or because of immunosuppressive drugs, untreated periodontal disease, deep carious lesions, and pathologic periapical conditions represent potential sources for serious, even life-threatening, infections. Standard medical protocols now usually require patients who will be receiving organ transplants, radiation treatment, chemotherapy, or heart valve replacements to receive a dental evaluation and have any oral disease controlled before undergoing treatment.
The patient’s systemic health is a critical issue for the increasing numbers of dentists practicing in hospital settings. Current trends in U.S. health care reflect increasing use of outpatient care for chronic conditions and increased use of ambulatory surgical care facilities when necessary. As a result, those patients who are hospitalized generally suffer from more serious conditions and have more complex treatment requirements. For these patients, dental pain and infection can be life threatening. Treatment of dental problems for this group can be challenging because hospitalized patients are often significantly debilitated, bedridden, and unable to be treated in a traditional dental setting. Fortunately, practitioners do have ready access to the patient’s medical record and can more easily request and view laboratory tests and consult with the patient’s physician and other health providers.
The need for systemic therapy must be evaluated when the patient first presents for treatment and at every appointment thereafter. Performing this service is important for the well-being of the patient and for overall risk management in the dental practice. The service also discharges a professional responsibility that is inherent in the practice of dentistry as a health care profession.
Many patients visit the dental office for maintenance care more frequently than they see a physician for evaluation. All dentists, as health care providers, have the responsibility to be alert for signs of undetected systemic diseases in individual patients. Occasionally, findings from the patient’s vital signs, general appearance, or oral examination are suggestive of a potentially serious physical problem. If, for example, the patient has signs or symptoms suggestive of hypertension, diabetes, hyperthyroidism, or cancer, further investigation is warranted. Once the symptoms or signs of systemic disease are recognized, the dentist is responsible for making a timely referral to an appropriate medical colleague so that treatment can be undertaken.
A number of health problems require the dentist to modify or limit dental treatment for patients. For example, the patient with kidney failure presents several concerns that must be appreciated when providing dental treatment. Dialysis patients have an arteriovenous shunt implanted in one arm to enable regular connection to a dialysis machine. The dentist and staff will want to avoid obtaining blood pressure measurements or placing IV medications in this arm. Infection of the tissue surrounding and connecting to the shunt can lead to septicemia, septic emboli, infective endarteritis, and even infective endocarditis. Although the potential is low for these problems occurring as a result of dental treatment, the dentist will want to consult with the patient’s physician. Dialysis patients receive the drug heparin during dialysis treatment to prevent coagulation of blood in the dialysis machine. To prevent excessive bleeding during dental treatment, the dentist will want to provide treatment the day after dialysis therapy when the effects of the heparin are diminished and the patient is less fatigued. Many more examples of modifying or limiting treatment can be found in the chapters discussing elderly patients and patients with special needs (Chapters 10 and 16).
Although uncommon, life-threatening emergencies can occur in the dental office. Patients who appear to be in relatively good health may have systemic problems that can be aggravated by seemingly routine dental treatment. Emergencies occur with greater frequency in patients with multiple systemic illnesses. A careful review of the patient’s general and dental health history may suggest ways to alter treatment delivery and prevent problems. When adequate precautions are taken, most dental procedures can be provided safely in a general dentistry setting.
The medical emergency dentists most commonly encounter occurs when a patient faints or suffers vasodepressor syncope. This type of fainting may be caused by stress and fear associated with receiving dental treatment or simply by rapid positional changes, such as sitting or standing up quickly. Careful questioning of all new patients regarding their level of dental anxiety and any prior history of syncope may indicate that the practitioner needs to manage the patient’s anxiety or pay close attention to positioning in the dental chair. Other types of medical emergencies seen in dentistry include allergic reactions to drugs and dental materials, chest pain, seizures, and difficulty breathing. In most instances, the dentist can prevent these problems from occurring by carefully reviewing the patient’s health history and modifying dental treatment appropriately.
Most patients expect some minor discomfort after receiving dental treatment. Some procedures, especially those involving oral surgery, routinely have such postoperative sequelae as bleeding, pain, and swelling. Following restorative or endodontic treatment, individual teeth may be sensitive to heat, cold, or chewing pressure. For healthy patients, most of these symptoms are relieved with nonnarcotic analgesics and resolve in a short time.
When the patient’s health is seriously compromised, however, more severe problems can follow dental treatment. Patients with immune system deficiencies, poorly controlled diabetes, or kidney failure may be more susceptible to postoperative infection, and consequently, will experience more severe pain and swelling. Blood loss can be significant when the patient does not have normal clotting mechanisms because of the use of anticoagulant medications or because of failing liver function associated with long-term alcohol use. Mild levels of pain discomfort, normally not a problem in a healthy individual, can create increased stress in an individual who has poor health, exacerbating the consequences of other diseases and conditions.
The practitioner can prevent such severe complications by being knowledgeable about the patient’s general health and the potential for more significant postoperative problems to occur. The patient should be given instructions describing the kinds of discomfort that may occur after treatment and in what kinds of situations the office should be contacted. The dentist may also wish to call the patient at home in the early evening. The use of stress reduction procedures, including prescribing medications to alleviate anxiety, may have additional preventive value. Several of these systemic therapies are discussed in the next section.
To ensure the safe delivery of dental treatment and to minimize postoperative problems, the dentist must be able to recognize when a patient needs or will benefit from systemic phase treatment. The practitioner has two tools available to assist in this endeavor: (1) a thorough review of the general health history and (2) an examination of the patient for signs of systemic disease. Several elements in the general health history can point to concerns that may affect the delivery of dental care. Other significant findings can be drawn from the practitioner’s review of the health questionnaire, including information about any medications that the patient uses regularly. The dentist may detect signs of disease by a systematic evaluation of the patient’s vital signs and overall appearance, including a careful examination of the orofacial structures. This evaluation will always occur at the initial oral examination and at the periodic examination. The competent practitioner will be attentive to changes in the patient’s appearance or general health at each dental visit.
Planning for the systemic phase of treatment begins with a thorough analysis of the patient’s health history. As discussed in Chapter 1, patients usually complete a health questionnaire when they first visit a dental office and at regular intervals thereafter. The dentist, dental hygienist, or dental assistant then interviews the patient regarding any positive responses. Reviewing the health history with the patient is an important rapport-building exercise. The practitioner must be skillful in asking the patient both open and closed questions, must remain objective, and must be a good listener. Failure to discover important health information can occur for two reasons. First, the patient may accidentally or intentionally fail to report a significant health problem when completing the health questionnaire. The In Clinical Practice box addresses how to improve the accuracy of health questionnaires. Some problems, such as AIDS or sexually transmitted diseases, carry with them a social stigma, making patients reluctant to reveal them to the dentist. Some patients may believe that information about their general health has no relevance to receiving dental treatment or that the questionnaire takes too much time to complete. Still others may not fully understand a health question, answering it incorrectly. Finally, the patient who completely refuses to complete the form may actually be functionally illiterate and unable to read the questionnaire.
The past health history will reveal diseases and conditions that may or may not be significant to the dentist when providing treatment. The clinician must evaluate both the severity of the problem and how recently it occurred. The patient who reports a heart attack less than 1 month ago is at greater risk for having a second attack or a significant episode of arrhythmia during a stressful dental visit than an individual who had an attack 3 years ago. The dentist also will be concerned when the patient reports a history of systemic disease that has now reappeared or is worsening.
Any past problems that have led to damage to a major organ system are highly significant. For instance, the patient who contracted rheumatic fever as a child may have residual heart damage, predisposing the individual to an infection of the heart, infective endocarditis, after certain types of dental treatment. On the other hand, a healthy patient who had syphilis 30 years ago and was treated promptly with antibiotics is probably not at risk for systemic complications during dental treatment.
The practitioner should pay particular attention to any past hospitalizations, including outpatient surgery. Important examples include treatment for cancer, cardiovascular surgery, and placement of prosthetic joints or other artificial body parts. When medical or surgical procedures are part of a patient’s history, the dentist will want to know whether such complications as excessive bleeding and pain, poor healing, or adverse reactions to drugs occurred during treatment. A history of such events should suggest the possibility of similar occurrences associated with dental treatment.
When a potentially life-limiting disease, such as cancer or severe congestive heart failure, has been diagnosed, the long-term prognosis for the patient should be determined because that information may influence decisions regarding which treatment options are most appropriate. For instance, the patient who is being treated for pancreatic cancer may wish to have missing teeth replaced to better chew food or to improve esthetics. Although dental implants may be an ideal long-term solution, a less expensive and immediate solution, such as a provisional removable partial denture, may be more appropriate. It is important to note, however, that the dentist has a professional responsibility to share all reasonable treatment options with any patient, regardless of age, physical condition, or financial status.
In addition to discovering past health problems, the dentist needs to investigate findings related to conditions that are currently present. The systemic health problems of most ambulatory patients relate directly or indirectly to chronic conditions, such as heart and lung disease, diabetes, hypertension, endocrine disorders, anemia, arthritis, or psychological illness. Other problems, more episodic in nature, may not be associated with a chronic disease. Examples include seizure disorders, fainting, and seasonal allergies. Certain habits, such as tobacco use, alcohol consumption, and substance abuse, can influence both systemic and oral health.
An important source of information about the patient’s current health is an evaluation of the drugs he or she is taking on a regular basis. All drugs should be carefully documented and monitored, including prescription drugs, over-the-counter products, health and nutritional supplements, and herbal medicines. Once all the medications have been identified, the dentist should determine the indications for each, consulting a drug reference book or online resource, if necessary. This information should corroborate findings from the health questionnaire and provide some insight into the severity of a particular disease. Occasionally the patient may be taking drugs for conditions not originally identified on the health questionnaire. For example, an elderly patient may report taking furosemide (Lasix) and digoxin (Lanoxin) for a blood pressure problem. The astute dentist will recognize that these drugs also are commonly used to treat congestive heart failure, a much more serious condition.
In addition to recognizing or determining the indications for each of the patient’s medications, the dentist must be aware of their possible side effects. Of particular interest are those side effects that adversely affect oral health or that could cause problems for the patient when receiving dental treatment. For example, aspirin or anticoagulant drugs may promote excessive bleeding during periodontal or oral surgical procedures. Many medications reduce the volume of saliva produced and predispose the patient to increased risk of caries, periodontal disease, and mucosal diseases.
After examining the health questionnaire and medication list, the dentist needs to interview the patient. How severe are the reported health problems? Does the patient see a physician or other heath professional regularly? Are the medications effective in treating the conditions they were prescribed for? Once this information has been gathered, the dentist needs to evaluate whether the patent’s systemic problems present a risk to providing dental care or will adversely affect the prognosis for the proposed dental treatment. The American Society of Anesthesiologists (ASA) has adopted a widely used classification system for estimating patient risk status (Table 5-1). The dentist may require an ASA category III or IV patient to seek medical consultation before treatment. For example, a patient who cannot climb a flight of stairs without resting and complains of occasional chest pain on exertion may be referred to a physician to evaluate for ischemic heart disease.
|ASA I||A normal healthy patient with no evidence of systemic disease|
|ASA II||A patient with mild systemic disease or a significant health risk factor. The patient is able to walk up a flight of stairs or two level city blocks without difficulty.||Well-controlled diabetes, controlled hypertension, history of asthma, mild obesity, pregnancy, smoker, extreme anxiety or fear towards dentistry|
|ASA III||A patient with moderate to severe systemic disease that limits activity but is not incapacitating; the patient can walk up one flight of stairs or two level city blocks, but stops at times because of distress||Stable angina, postmyocardial infarction, poorly controlled hypertension, symptomatic respiratory disease, massive obesity|
|ASA IV||A patient with severe systemic disease that is life threatening; the patient is unable to walk up a flight of stairs or two level city blocks; patient is in distress at rest||Unstable angina, liver failure, severe congestive heart failure, or end-stage renal disease|
Patients should be asked if they have allergies or reactions to drugs or other substances. The dentist is most interested in avoiding reactions to materials commonly used in dentistry. These include allergies or reactions to drugs such as penicillin, erythromycin, aspirin, NSAIDS, codeine, and other narcotics. Some patients are sensitive to latex products and others to certain metals in dental restorations. Patients may report problems with local and topical anesthetics or flavorings used in dentistry. The dentist needs to discern whether the patient has a true allergy, has experienced a side effect or toxic reaction, or just does not care for the product. Once this is determined, a medical alert label or warning message should be prominently displayed in the record. Common medical alert warnings in dentistry include allergies to certain antibiotics and latex products, and the need for antibiotic premedication to prevent bacterial endocarditis.
The dentist has several tools available that can be used to evaluate the patient’s overall physical condition. Obtaining vital signs, the most common of which are blood pressure and pulse rate, represents one objective method. A more subjective but equally valuable approach involves simply evaluating the patient’s appearance, looking at both general physical attributes and, more specifically, at the head and neck area. During this process, the clinician is searching for variations from normal that are not being managed by a physician and that may have significance in a dental setting.
Blood pressure and pulse rate measurements should be obtained at every new patient examination, and subsequently at regular intervals. Many experts recommend routinely taking the blood pressure at every visit in which a local anesthetic or other medicament will be administered. The classification of blood pressure in adults is listed in Table 5-2. The dentist is primarily concerned when the patient has high blood pressure. Low blood pressure measurements (<60 mm Hg, diastolic) may be seen in some individuals, but such measurements usually are not significant unless the patient has other health problems or reports symptoms of light-headedness and fainting. Repeated high blood pressure readings may signify hypertension, a disease that can lead to such serious health problems as heart failure, stroke, and kidney failure. Major risk factors for hypertension include smoking, diabetes, increasing age, gender (higher risk in men and in postmenopausal women), ethnicity, family history of hypertension, and high levels of certain lipids in the blood. With the advent of accurate electronic blood pressure measuring devices, measuring blood pressure and pulse rate has become a relatively easy procedure (Figure 5-1). The interpretation of a high blood pressure measurement can be more difficult. A single high reading may not mean the patient has hypertension. In fact, some patients with normal blood pressure may exhibit high readings because of stress associated with anticipating dental treatment. The dentist will want to confirm the blood pressure reading after 5 to 10 minutes, or at the conclusion of the appointment. It may be appropriate for the dentist to suggest that the patient see a physician regarding Stage 1 and 2 hypertension (see Table 5-2). The dentist may consider postponing elective dental treatment when the patient has Stage 2 hypertension. Patients exhibiting a systolic blood pressure >180 mm Hg or a diastolic pressure >110 mm Hg should be referred to a physician for immediate follow-up.2
Blood Pressure Classification for Adults1
|Classification||Systolic mm Hg||Diastolic mm Hg|
|Stage 1 hypertension||140-159||or 90-99|
|Stage 2 hypertension||≥160||or ≥100|
The pulse rate can be measured either manually or automatically with an electronic blood pressure cuff. An advantage of manual measurement, typically obtained by palpating the radial artery, is that the character of the pulse in terms of regularity and strength can also be detected. The normal heart rate is 60 to 80 beats per minute and is strong in character. High pulse rates, typically in the 80 to 100 beats per minute range, may reflect an anxious patient or one who is under stress, has been smoking, or has just engaged in moderate exercise, such as rushing to the dentist’s office. Individuals who are very physically fit or those who have severe heart problems may demonstrate a pulse rate below 60.