The practice of dentistry continues to evolve, not only in techniques and procedures but also in the types of patients encountered. As a result of advances in medical science, people are living longer and are receiving medical treatment for disorders that were fatal only a few years ago. For example, damaged heart valves are surgically replaced, occluded coronary arteries are surgically bypassed or opened by balloons and stents, organs and bone marrow are transplanted, severe hypertension is medically controlled, and many types of malignancies and immune deficiencies are managed or controlled.
Because of the increasing numbers of dental patients, especially among older adults who have chronic medical problems, dentists must remain knowledgeable about a wide range of medical conditions and drug considerations. Many chronic disorders or their treatments necessitate alterations in the provision of dental treatment. Failure to make appropriate treatment modifications may have serious clinical consequences.
The key to successful dental management of a medically compromised patient is a thorough evaluation of the patient followed by a thoughtful assessment of risk to determine whether a planned procedure can be safely tolerated. The fundamental question that must be addressed is whether the benefit of dental treatment outweighs the risk of a medical complication occurring either during treatment or as a result of treatment. This evaluation begins with a thorough review of the medical history, expanded as necessary by discussion of any relevant issues with the patient, and proceeds to identification of drugs or medications that the patient is taking (or is supposed to be taking), examining the patient for symptoms and signs of disease as well as obtaining vital signs, reviewing current imaging and laboratory test results, and obtaining a medical consultation if needed. All of this information can then be applied to assess the risk for problems related to specific factors identified in the evaluation. This process benefits from the use of a checklist as summarized in Box 1.1 , which illustrates an “ABC”-type format.
Be aware of adverse outcomes that may occur in the management of a patient who has a medical condition.
P: Patient Evaluation and Risk Assessment
Review medical history and engage in direct discussion of relevant issues with the patient.
Identify all medications and drugs being taken or supposed to be taken by the patient.
Examine the patient for signs and symptoms of disease and obtain vital signs.
Review or obtain recent laboratory test results or images required to assess risk.
Obtain a medical consultation if the patient has a poorly controlled or undiagnosed problem or if the patient’s health status is uncertain.
Potential Issues and Questions of Concern
|Antibiotics||Will the patient need antibiotics, either prophylactically or therapeutically? Is the patient currently taking an antibiotic? Is the patient at risk for infection?|
|Analgesics||Is the patient taking aspirin or other NSAIDs that may increase bleeding? Will analgesics be needed after the procedure?|
|Anesthesia||Are there any potential problems or concerns associated with the use or dosage of local anesthetic or with vasoconstrictors?|
|Anxiety||Will the patient need a sedative or anxiolytic?|
|Bleeding||Is abnormal hemostasis a possibility? Is the patient taking medications that can affect bleeding during or after an invasive procedure?|
|Breathing||Does the patient have any difficulty breathing, or is the breathing abnormally fast or slow?|
|Blood pressure||Is the blood pressure well controlled, or is it likely to increase or decrease during dental treatment?|
|Capacity to tolerate care||Does the patient have sufficient functional (cardiovascular) and emotional capacity to withstand the type of dental procedure planned?|
|Chair position||Can the patient tolerate a supine chair position, or is the patient likely to experience difficulty with rapid position changes?|
|Drugs||Are any drugs being taken by the patient or to be administered or prescribed by the dentist associated with relevant drug interactions, adverse effects, or allergies?|
|Devices||Does the patient have prosthetic or therapeutic devices that may require specific considerations in management (e.g., prosthetic heart valve, prosthetic joint, stent, pacemaker, defibrillator, arteriovenous fistula)?|
|Equipment||Are there any potential problems associated with the use of dental equipment (e.g., x-ray machine, electrocautery, oxygen supply, ultrasonic cleaner)? Are monitoring devices such as a pulse oximeter, carbon dioxide monitor, or blood pressure measurement device indicated for use during the dental procedure?|
|Emergencies||Are there any medical urgencies or emergencies that might be anticipated or prevented by modifying care?|
|Follow-up||Is any follow-up care indicated? Should the patient be contacted at home to assess her or his response to treatment?|
NSAID, Nonsteroidal antiinflammatory drug.
A medical history must be taken for every patient who is to receive dental treatment. Two basic techniques are used to obtain a medical history. The first technique consists of an interview of the patient (medical model), in which the interviewer questions the patient and then records a narrative of the patient’s verbal responses on a blank sheet. The second technique is the use of a questionnaire that the patient fills out. The latter approach is most commonly used in dental practice and is very convenient and efficient. It is important, however, that the medical information acquired in this manner be reviewed by the dentist and discussed or clarified with the patient as appropriate to determine the significance of the findings and any necessary modifications in dental treatment.
Many questionnaires are commercially available in both electronic and hard copy versions. Dentists also may develop or modify questionnaires to meet the specific needs of their individual practices. Although medical history questionnaires may differ in organization and detail, most attempt to elicit information about the same basic medical problems. The following section presents an overview of such medical conditions, organized by body systems, as well as other conditions and factors of relevance, and specifies the rationale for why certain questions are asked and highlights the significance of positive responses on the questionnaire or in the interview. Detailed information concerning most of these medical problems is found in the specific subsequent chapters.
Patients with various forms of cardiovascular disease are especially vulnerable to physical or emotional challenges that may be encountered during dental treatment.
Heart failure is not a disease per se but rather a clinical syndrome complex that results from an underlying cardiovascular problem such as coronary heart disease or hypertension. The underlying cause of the heart failure should be identified and its potential significance assessed. Patients with untreated or symptomatic heart failure are at increased risk for myocardial infarction (MI), arrhythmias, acute heart failure, or sudden death and generally are not candidates for elective dental treatment. Chair position may influence the ability to breathe, with some patients unable to tolerate a supine position. Vasoconstrictors should be avoided in certain circumstances, for example, if a patient has severe heart failure and in patients who take digitalis glycosides (digoxin) because the combination can precipitate arrhythmias (see Chapter 6 ). Stress reduction measures also may be advisable ( Box 1.2 ).
Open communication about fears or concerns
Short appointments (preferably morning)
Preoperative sedation: short-acting benzodiazepine (e.g., triazolam 0.125–0.25 mg) 1 hour before the appointment and possibly the night before the day of the appointment
Intraoperative sedation (N 2 O-O 2 )
Profound local anesthesia: use topical before injection
Adequate operative and postoperative pain control
Patient contacted on evening of the procedure
A history of a heart attack (MI) within the very recent past may preclude elective dental care because during the immediate postinfarction period, patients are at increased risk for reinfarctions, arrhythmias, and heart failure. Patients may be taking medications such as antianginals, anticoagulants, adrenergic blocking agents, calcium channel blockers, antiarrhythmic agents, or digitalis. Some of these drugs may alter the dental management of patients because of potential interactions with vasoconstrictors in local anesthetic, adverse side effects, or other considerations (see Chapter 4 ). Stress and anxiety reduction measures may be advisable (see Box 1.2 ).
Brief substernal pain resulting from myocardial ischemia, commonly provoked by physical activity or emotional stress, is a common and significant symptom of coronary heart disease. Patients with angina, especially unstable or severe angina, are at increased risk for arrhythmias, MI, and sudden death. A variety of vasoactive medications, such as nitroglycerin, β-adrenergic blocking agents, and calcium channel blockers, are used to treat angina. Caution is advised with the use of vasoconstrictors. Stress and anxiety reduction measures may be appropriate (see Box 1.2 ). Patients with unstable or progressive angina are not candidates for elective dental care (see Chapter 4 ).
High Blood Pressure.
Patients with hypertension (blood pressure >140/90 mm Hg) should be identified by history and the diagnosis confirmed by blood pressure measurement. Patients with a history of hypertension should be asked if they are taking or are supposed to be taking antihypertensive medication. Failure to take medication often is the cause of elevated blood pressure in a patient who reports being under treatment for hypertension. Current blood pressure readings and any clinical signs and symptoms that may be associated with severe, uncontrolled hypertension, such as visual changes, dizziness, spontaneous nosebleeds, and headaches, should be noted. Some antihypertensive medications, such as the nonselective β-adrenergic blocking agents, may require caution in the use of vasoconstrictors (see Chapter 3 ). The coadministration of calcium channel blockers with macrolide antibiotics (e.g., erythromycin, clarithromycin) can result in excessive hypotension. Stress and anxiety reduction measures also may be appropriate (see Box 1.2 ). Elective dental care should be deferred for patients with severe, uncontrolled hypertension (blood pressure of ≥180/110 mm Hg) until the condition can be brought under control because they have an increased risk of stroke.
A heart murmur is caused by turbulence of blood flow that produces vibratory sounds during the beating of the heart. Turbulence may result from physiologic (normal) factors or pathologic abnormalities of the heart valves, vessels, or both. The presence of a heart murmur may be of significance in dental patients because it may be an indication of underlying heart disease. The primary goal is to determine the nature of the heart murmur; consultation with the patient’s physician often is necessary to make this determination. Previously, the American Heart Association (AHA) recommended antibiotic prophylaxis for many patients with heart murmurs caused by valvular disease (e.g., mitral valve prolapse, rheumatic heart disease) in an effort to prevent infective endocarditis; however, current guidelines omit this recommendation on the basis of accumulated scientific evidence. If a murmur is caused by certain specific cardiac conditions (e.g., previous endocarditis, prosthetic heart valve, complex congenital cyanotic heart disease), the AHA continues to recommend antibiotic prophylaxis for most dental procedures (see Chapter 2 ).
Mitral Valve Prolapse.
In mitral valve prolapse (MVP), the leaflets of the mitral valve “prolapse,” or balloon back into, the left atrium during systole. As a result, tight closure of the leaflets may not occur, which can result in leakage or backflow of blood (regurgitation) from the ventricle into the atrium. Not all patients with MVP have regurgitation, however. In past guidelines, the AHA recommended that patients with MVP with regurgitation receive antibiotic prophylaxis for invasive dental procedures to prevent infective endocarditis. However, on the basis of accumulated scientific evidence, current guidelines do not include this recommendation (see Chapter 2 ).
Rheumatic fever is an autoimmune condition that can follow an upper respiratory β-hemolytic streptococcal infection and may lead to damage of the heart valves (rheumatic heart disease). The AHA currently does not recommend antibiotic prophylaxis for patients with a history of this condition (see Chapter 2 ).
Congenital Heart Disease.
Patients with some forms of severe congenital heart disease are at increased risk for infective endocarditis, an infection which can result in significant morbidity and mortality. These are primarily patients with complex cyanotic heart disease (e.g., tetralogy of Fallot) and those who have had an incomplete surgical repair of a congenital defect, with a residual leak. The AHA recommends that these patients receive antibiotic prophylaxis for most dental procedures. For patients with most other types of congenital heart disease, the AHA currently does not recommend antibiotic prophylaxis (see Chapter 2 ).
Artificial Heart Valve.
A diseased valve may be replaced with artificial or prosthetic valves. Such replacement valves are associated with a high risk for development of infective endocarditis, with significant morbidity and mortality. Accordingly, the AHA recommends that all patients with a prosthetic heart valve be given prophylactic antibiotics before most dental procedures (see Chapter 2 ). Patients with an artificial heart valve also may be on anticoagulant medication to prevent blood clots associated with the valve. In such patients, excessive bleeding may be encountered with surgical procedures. It is therefore necessary to determine the level of anticoagulation before any invasive procedure.
Arrhythmias frequently are related to heart failure or ischemic heart disease. Stress, anxiety, physical activity, drugs, and hypoxia are some elements that can precipitate arrhythmias. Vasoconstrictors in local anesthetics should be used cautiously in patients prone to arrhythmias because they may be precipitated by excessive quantities or inadvertent intravascular injections. Stress reduction measures may be appropriate (see Box 1.2 ). Some of these patients take antiarrhythmic drugs, which can cause orthostatic hypotension and adversely interact with vasoconstrictors. Antiarrhythmic drugs can also cause adverse oral health changes. Patients with atrial fibrillation also may be taking anticoagulant or antiplatelet medications, which is associated with increased risk for excessive bleeding with surgical procedures. Patients with certain arrhythmias may require a pacemaker or a defibrillator to regulate or pace heart rhythm by artificial means. Patients with such devices do not require antibiotic prophylaxis. Caution is advised with the use of certain types of electrical equipment (e.g., electrocautery) in patients with pacemakers or defibrillators because of the possibility of intermittent electromagnetic interference with the function of these devices (see Chapter 5 ). Elective dental care is not recommended for patients with severe, symptomatic arrhythmias.
Coronary Artery Bypass Graft, Angioplasty, or Stent.
These procedures are performed in patients with coronary heart disease to restore patency to blocked coronary arteries. One of the more common forms of cardiac surgery performed today is coronary artery bypass grafting (CABG). The grafted artery bypasses the occluded portion of the artery. These patients do not require antibiotic prophylaxis. Another method of restoring patency is by means of a balloon catheter, which is inserted into the partially blocked artery; the balloon is then inflated, which compresses the atheromatous plaque against the vessel wall. A metallic mesh stent then may be placed to aid in the maintenance of patency. After stent placement, patients often are prescribed one or more antiplatelet drugs to decrease the risk of blood clots associated with the stents and may therefore be at increased risk for excessive bleeding with surgical procedures. Patients who have had balloon angioplasty with or without placement of a stent do not require antibiotic prophylaxis (see Chapter 4 ).
Hemophilia or Inherited Bleeding Disorder.
Patients with an inherited bleeding disorder such as hemophilia A or B, or von Willebrand disease, are at risk for severe bleeding after any type of dental treatment that causes bleeding, including scaling and root planing. These patients must be identified and managed in cooperation with a physician or hematologist. Patients with severe factor deficiency may require factor replacement before invasive treatment, as well as aggressive postoperative measures to maintain hemostasis (see Chapter 25 ).
Patients with a history of blood transfusions are of concern from at least two aspects. The underlying problem that necessitated a blood transfusion, such as an inherited or acquired bleeding disorder, must be identified, and alterations in the delivery of dental treatment may have to be made. These patients also may be carriers of hepatitis B or C or may have become infected with the human immunodeficiency virus (HIV) and must be identified. Laboratory screening or medical consultation may be appropriate to determine the white blood cell count or status of liver function, and, as always, standard infection control procedures are mandatory (see Chapter 10 , Chapter 18 , Chapter 24 ).
Anemia is associated with a significant reduction in the number of red blood cells or oxygen-carrying capacity of the red blood cells. This condition may result from an underlying pathologic process such as acute or chronic blood loss, decreased production of red blood cells, or hemolysis. Patients with some forms of anemias, such as glucose-6-phosphate dehydrogenase (G6PD) deficiency and sickle cell disease, require dental management modifications. Oral lesions, infections, delayed wound healing, and adverse responses to hypoxia all are potential matters of concern in patients who have anemia (see Chapter 22 ).
Leukemia and Lymphoma
Depending on the type of leukemia or lymphoma, status of the disease, white blood cell count, and type of treatment, some patients may have bleeding problems or delayed healing or may be prone to infection. Gingival enlargement and gingival bleeding can be a sign of leukemia. Adverse effects can result from the use of chemotherapeutic agents and may require dental management modifications (see Chapter 23 ).
Taking a “Blood Thinner” or the Tendency to Bleed Longer Than Normal
A potentially significant problem occurs when a patient has a history of abnormal bleeding or is taking an anticoagulant or an antiplatelet drug. This is of obvious concern, especially if surgical treatment is planned. Information about an episode of unexplained bleeding should be obtained and evaluated. Many reports of abnormal bleeding are more apparent than real; additional questioning or screening laboratory tests may allow the dentist to make this distinction. Patients taking anticoagulant or antiplatelet medication need to be evaluated to determine the risk for postoperative bleeding. Many patients can be treated without alteration of their medication regimens; however, laboratory testing may help to make this determination (see Chapters 24 and 25 ).
Disorders that predispose to stroke such as hypertension and diabetes must be identified so that appropriate management alterations can be made. Elective dental care should be avoided in the immediate post-stroke period because of an increased risk for subsequent strokes. Vasoconstrictors should be used cautiously. Anticoagulant medications and antiplatelet medications can cause excessive bleeding. Stress and anxiety reduction measures may be necessary (see Box 1.2 ). Some stroke victims may have residual paralysis, speech impairment, or other physical impairments that require special dental care or oral hygiene assistance. Calcified atheromatous plaques may be seen in the carotid arteries on panoramic films; the presence of such lesions may be a risk factor for stroke and requires referral to a physician (see Chapter 27 ).
Epilepsy, Seizures, and Convulsions.
A history of epilepsy or grand mal seizures should be identified, and the degree of seizure control should be determined. Specific triggers of seizures (e.g., odors, bright lights) should be identified and avoided. Some medications used to control seizures may affect dental treatment because of drug actions or adverse side effects. For example, gingival overgrowth is a well-recognized adverse effect of diphenylhydantoin (Dilantin). Patients may discontinue the use of anticonvulsant medication without their doctor’s knowledge and thus may be susceptible to seizures during dental treatment. Therefore, verification of patients’ adherence to their medication schedule is important (see Chapter 27 ).
Behavioral Disorders and Psychiatric Treatment.
Patients with a history of a behavioral disorder or psychiatric illness as well as the nature of the problem need to be identified. This information may help explain patients’ unusual, unexpected, or bizarre behavior or complaints such as unexplainable or unusual conditions. Additionally, some psychiatric drugs have the potential to interact adversely with vasoconstrictors in local anesthetics. Psychiatric drugs also may produce adverse oral effects such as hyposalivation or xerostomia. Other adverse drug effects such as dystonia, akathisia, or tardive dyskinesia may complicate dental treatment. Some patients may be excessively anxious or apprehensive about dental treatment, requiring stress reduction measures (see Box 1.2 and Chapters 28 and 29 ).
Stomach or Intestinal Ulcers, Gastritis, and Colitis.
Patients with gastric or intestinal disease should not be given drugs that are directly irritating to the gastrointestinal tract, such as aspirin or nonsteroidal antiinflammatory drugs (NSAIDs). Patients with colitis or a history of colitis may not be able to take certain antibiotics. Many antibiotics can cause a particularly severe form of colitis (i.e., pseudomembranous colitis), and older adults are more susceptible to this condition. Some drugs used to treat gastric or duodenal ulcers may cause dry mouth (see Chapter 11 ).
Hepatitis, Liver Disease, Jaundice, and Cirrhosis.
Patients who have a history of viral hepatitis are of concern in dentistry because they may be asymptomatic carriers of the disease and can transmit it unknowingly to dental personnel or other patients. Of the several types of viral hepatitis, only hepatitis B, C, and D have carrier stages. Fortunately, laboratory tests are available to identify affected patients. Standard infection control measures are mandatory. Patients who have chronic hepatitis (B or C) may develop cirrhosis, with associated impairment of liver function or liver cancer. Impaired liver function may result in prolonged bleeding and less efficient metabolism of certain drugs, including local anesthetics and analgesics (see Chapter 10 ).
Respiratory Tract Disease
Allergies or Hives.
Patients may be allergic to some drugs or materials used in dentistry. Common drug allergens include antibiotics and analgesics. Latex allergy also is common, and in patients so affected, alternative materials such as vinyl or powderless gloves and vinyl dam material should be used to prevent an adverse reaction. True allergy to amide local anesthetics is uncommon. Dentists should procure a history regarding allergy by specifically asking patients how they react to a particular substance. This information will help to distinguish a true allergy from intolerance or an adverse side effect that may have been incorrectly identified as an allergy. Symptoms and signs consistent with allergy include itching, urticaria (hives), rash, swelling, wheezing, angioedema, runny nose, and tearing eyes. Isolated signs and symptoms such as nausea, vomiting, heart palpitations, and fainting generally are not of an allergic origin but rather are manifestations of drug intolerance, adverse side effects, or psychogenic reactions (see Chapter 19 ).
The type of asthma should be identified, as should the drugs taken and any precipitating factors or triggers. Stress may be a precipitating factor and should be minimized when possible (see Box 1.2 ). It often is helpful to ask whether the patient has visited the emergency department for acute treatment of asthma because this historical detail would indicate more severe disease. A patient who uses an albuterol inhaler for treatment of acute attacks should be instructed to bring it to his or her dental appointments (see Chapter 7 ).
Emphysema and Chronic Bronchitis.
Patients with chronic pulmonary diseases such as emphysema and chronic bronchitis must be identified. The use of medications or procedures that might further depress respiratory function or dry or irritate the airway should be avoided. Chair position may be a factor; some patients may not be able to tolerate a supine position. Use of a rubber dam may not be tolerated because of a choking or smothering feeling experienced by the patient. The use of high-flow oxygen should be avoided in patients with severe disease because it can decrease the respiratory drive (see Chapter 7 ). Because cigarette smoking is the most common cause of emphysema and chronic bronchitis, the dentist can provide assistance by offering smoking cessation to the interested patient (see Chapter 8 ).
Patients with a history of tuberculosis (TB) must be identified, and information about the treatment received must be sought. A positive result on skin or blood testing means specifically that the person has at some time been infected with TB, not necessarily that active disease is present. Most patients who have a positive TB test do not develop active disease. A diagnosis of active TB is made by chest radiography, sputum culture, and clinical examination. Persons who have latent TB, who are at increased risk for the development of active disease, may be placed on chemoprophylaxis (e.g., isoniazid) as a preventive measure. Medical treatment for active disease includes the use of multiple medications taken for several months. A history of follow-up medical evaluation is important to detect reactivation of the disease or inadequate treatment. Patients with acquired immunodeficiency syndrome (AIDS) have a high incidence of tuberculosis, so the potential coexistence of these two conditions should be explored (see Chapter 7 ).
Sleep Apnea and Snoring.
Patients with obstructive sleep apnea (OSA) are at increased risk for hypertension, MI, stroke, diabetes, and car crashes and should receive treatment for the disorder. Symptoms and signs include loud snoring, excessive daytime sleepiness, and witnessed breathing cessation during sleep. Patients who present with these symptoms should be referred to a sleep physician specialist for evaluation and then to a clinician who manages OSA. Obesity and large neck circumference are common risk factors for the disease. The gold standard for treatment is positive airway pressure; however, many patients cannot tolerate this modality. Other treatment options include use of oral appliances and various forms of upper airway surgery (see Chapter 9 ).
Many types of arthritis have been identified; the most common of these are osteoarthritis and rheumatoid arthritis. Patients with arthritis may be taking a variety of medications that could influence dental care. NSAIDs, aspirin, corticosteroids, and cytotoxic and immunosuppressive drugs are examples. Tendencies for bleeding and infection should be considered. Chair position may be a factor for physical comfort. Patients with Sjögren syndrome, which may occur with rheumatoid arthritis or independently, have a dry mouth that is often problematic. Patients with Sjögren syndrome also are at increased risk for lymphoma. Patients with arthritis may have problems with manual dexterity and oral hygiene. In addition, patients with arthritis may have involvement of the temporomandibular joints (see Chapter 20 ).
Some patients with artificial joints have been considered to be at risk for infection of the prosthesis subsequent to dental treatment. However, current guidelines do not recommend that prophylactic antibiotics be provided to these patients before any dental treatment that is likely to produce bacteremia (see Chapter 20 ).
Patients with diabetes mellitus must be identified to determine the type of diabetes, how it is being treated, and how well controlled it is. Whereas patients with type 1 diabetes require insulin, type 2 diabetes usually is controlled through diet, oral hypoglycemic agents, or both; however, some patients with type 2 diabetes eventually also require insulin. Those with type 1 diabetes have a greater number of complications and are of greater concern regarding management than are those with type 2 diabetes. Signs and symptoms suggestive of diabetes can be recognized by the dentist and include excessive thirst and hunger, frequent urination, weight loss, and frequent infections. Long-term complications include blindness, hypertension, and kidney failure, each of which also may affect dental management. Understanding the level of control of their diabetes is important. Patients with poorly controlled diabetes typically do not handle infection very well and may have exaggerated periodontal disease. Patients who take insulin are at risk for episodes of hypoglycemia in the dental office if meals are skipped or if stress or infection is present (see Chapter 14 ).
Patients who have uncontrolled hyperthyroidism are potentially hypersensitive to stress and the effects of α 1 -adrenergic sympathomimetics, so the use of vasoconstrictors generally is contraindicated. In rare cases, infection or surgery can initiate a thyroid crisis—a serious medical emergency. These patients also may be easily upset emotionally and intolerant of heat, and they may exhibit tremors. An enlarged thyroid gland and exophthalmos may be present. Patients with known hypothyroidism usually are taking a thyroid supplement; this medication regimen helps to stabilize the body’s thyroid hormone level. Thyroid cancer is a common form of head and neck cancer that often is curable if detected and treated early. Thus, palpation of the thyroid gland during the head and neck examination is important to detect swelling or nodules (see Chapter 16 ).
Genitourinary Tract Disease
Patients with chronic kidney disease or a kidney transplant must be identified. The potential for abnormal drug metabolism, immunosuppressive drug therapy, bleeding problems, hepatitis, infection, high blood pressure, concurrent diabetes, and heart failure must be considered in management (see Chapter 12 ). Certain drugs that are nephrotoxic should be avoided, and several drugs administered by dentists require dosage adjustment when kidney function is low. Patients on hemodialysis do not require antibiotic prophylaxis but do receive heparin, which can prolong bleeding during and after invasive procedures.
Sexually Transmitted Diseases.
A variety of sexually transmitted diseases such as syphilis, gonorrhea, and HIV/AIDS can have manifestations in the oral cavity because of oral–genital contact or secondary to hematogenous dissemination in the blood or immune suppression. The dentist may be the first to identify these conditions. In addition, some sexually transmitted diseases, including HIV infection, hepatitis B and C, and syphilis, can be transmitted to the dentist through direct contact with oral lesions, infectious blood, or improperly sterilized instruments (see Chapter 10 , Chapter 13 , Chapter 18 ).
Other Conditions and Factors
Tobacco and Alcohol Use.
Use of tobacco products is a risk factor associated with cancer, cardiovascular disease, pulmonary disease, and periodontal disease. Patients who use tobacco products should be asked whether they would like to quit and should be encouraged to do so (see Chapter 8 ). The dentist should provide assistance for patients who are interested in smoking cessation. Excessive use of alcohol is a risk factor for periodontal disease, malignancy, and heart disease and may lead to liver disease. The combination of excessive alcohol and tobacco use is a significant risk factor for oral cancer. Alcoholism also can contribute to liver impairment and cirrhosis.
Drug Addiction and Substance Abuse.
Patients who have a history of injected drug use are at increased risk for infectious diseases such as hepatitis B or C, HIV/AIDS, and infective endocarditis. Narcotic and sedative medications should be prescribed with caution, if at all, for these patients because of the risk of triggering a relapse. This caveat also applies to patients who are recovering alcoholics. Vasoconstrictors should be avoided in patients who are cocaine or methamphetamine users because the combination may precipitate arrhythmias, MI, or severe hypertension. Patients who abuse prescription narcotics or other controlled substances may engage in “doctor shopping” and drug-seeking activity (see Chapter 30 ).
Tumors and Cancer.
Patients who have had cancer are at risk for recurrence, so they should be closely monitored. Also, cancer treatment regimens including chemotherapeutic agents or radiation therapy may result in infection, gingival bleeding, oral ulcerations, dry mouth, mucositis, and impaired healing after invasive dental treatment, all of which represent significant management considerations. Patients with a history of intravenous bisphosphonate or antiangiogenic therapy for metastatic bone disease are at risk for medication-related osteonecrosis of the jaw. Invasive procedures should be performed with appropriate caution in these patients (see Chapter 26 ).
Radiation Therapy and Chemotherapy.
Patients with previous radiation treatment to the head, neck, or jaw must be carefully evaluated because radiation can permanently destroy the blood supply to the jaws, leading to osteoradionecrosis after extraction, trauma or procedures that further compromise blood supply to the jaw. Irradiation of the head and neck can destroy the salivary glands, resulting in decreased saliva, increased dental caries, and mucositis. Fibrosis of masticatory muscles resulting in limited mouth opening also may occur. Chemotherapy can produce many undesirable adverse effects, most commonly a severe mucositis; however, such changes resolve with cessation of the chemotherapeutic agents (see Chapter 26 ).
Cortisone and prednisone are examples of corticosteroids that are used in the treatment of many inflammatory and autoimmune diseases. These drugs are important because their use can result in adrenal insufficiency and potentially render the patient unable to mount an adequate response to the stress of an infection or invasive dental procedure such as extractions or periodontal surgery. However, in general, most routine, noninvasive dental procedures do not require administration of supplemental steroids (see Chapter 15 ).
Operations or Hospitalizations.
A history of hospitalizations can provide a record of past serious illnesses that may have current significance. For example, a patient may have been hospitalized for cardiac catheterization for ischemic heart disease. Another example is that of a patient who is hospitalized for hepatitis C. In both instances, the patient may or may not have received medical follow-up care for the initial problem, so this aspect of the evaluation may be an effective method of identifying an underlying condition. Information about hospitalizations should include diagnosis, treatment, and complications. If a patient has undergone any operation, the reason for the procedure and any associated untoward events such as an anesthetic emergency, unusual postoperative bleeding, infection, or drug allergy should be ascertained.
Women who are or may be pregnant may need special consideration in dental management. Caution typically is warranted in the taking of radiographs, administration of drugs, and timing of dental treatment. Good oral hygiene is important to maintain during pregnancy for reasons discussed in Chapter 17 .
As part of the medical history, information should be sought regarding the identity of the patient’s physician, why the patient is under medical care, diagnoses, and treatment received. If the reason for seeing a physician was the need for a routine physical examination, the patient should be asked whether any problems were discovered and the date of the examination. The name, address, and phone number of the patient’s physician should be recorded for future reference. A patient who does not have a physician may require a more cautious approach than a patient who sees a physician regularly. This is especially true for the patient who has not seen a physician in several years, because of the possibility of the presence of undiagnosed problems. Understanding the health care the patient is receiving also provides insight into the health of the patient and the priorities that person assigns to health care.
Drugs, Medicines, or Pills
All drugs, medicines, supplements, and pills that a patient is taking or is supposed to be taking should be identified and investigated for actions, adverse side effects, and potential drug interactions (see Appendix D ). The interviewer should specifically mention “drugs, medicines, or pills of any kind” because frequently patients do not list over-the-counter drugs (e.g., aspirin) or herbal medicines (see Appendix E ). The dentist should have a reliable, up-to-date, comprehensive source for drug information, which may be available in print format or through an electronic or web-based resource.
The patient’s list of medications (“drug history”) may provide the only clues to presence of an unreported medical disorder. The patient may have believed that a particular problem was not important enough to mention or may just have omitted the information inadvertently. The patient may nevertheless report taking medication typically prescribed for a disease. For example, a patient with hypertension may fail to report a history of that problem yet may list medications used to treat hypertension. A patient with previously medically managed condition may have discontinued taking a prescribed medication owing to cost or other reasons, and questioning should uncover this possibility.
In addition to asking patients about specific diagnoses, it also is important to ask some screening questions regarding the ability of the patient to engage in normal physical activity (functional capacity). The ability to perform common daily tasks can be expressed in metabolic equivalents of tasks (METs), which quantify the body’s use of oxygen. Thus, the patient’s ability to meet MET levels as determined for specific activities reflects general physical status. A MET is a unit of oxygen consumption; 1 MET equals 3.5 mL of oxygen per kg of body weight per minute at rest. It has been shown that the risk for occurrence of a serious perioperative cardiovascular event (e.g., MI, heart failure) is increased in patients who are unable to meet a 4-MET demand during normal daily activity. Daily activities requiring 4 METs include level walking at 4 miles/hour or climbing a flight of stairs. Activities requiring greater than 10 METs include swimming and singles tennis. An exercise capacity of 10 to 13 METs indicates excellent physical conditioning. Thus, a patient who reports an inability to walk up a flight of stairs without shortness of breath, fatigue, or chest pain may be at increased risk for medical complications during dental treatment, especially when such limitation is combined with other risk factors and the patient is under stress.