Systemic Pre-Phase

10.1055/b-0034-56517

Systemic Pre-Phase

  • Systemic Problems

  • Systemic Risks

The purpose of the systemic pre-phase is to protect both the patient and the clinician by ascertaining any general systemic risks associated with the patient.

It is critically important that infectious, above all viral diseases (Herpes, Hepatitis B and C, HIV infection) be detected and/or diagnosed: Every patient may harbor such diseases! It is therefore necessary to employ the usual hygiene measures for all dental examinations and treatments, e.g., gloves, mask and protective eyewear.

Individuals with severe systemic diseases (see ASA Classification, p.212) can seldom be treated periodontally under the rubric “comprehensive therapy.” Usually these patients can only be treated with limited “emergency” measures, and with the participation of the patient’s physician.

Special precautionary measures are indicated with patients who suffer from multiple maladies, and most particularly with patients who are susceptible to the life-threatening danger of infectious endocarditis (Reichart & Philipsen 1999).

With non-life-threatening diseases, dental therapy should be planned in collaboration with the physician or internist, who may prescribe appropriate medications (polypharmacy); these should be checked for possible drug interactions with other agents prescribed by the dentist, as well as the possibility of undesired adverse effects (cf., gingival hyperplasia; pp.121–124).

Thanks to modern medicine, many of our patients lead the normal life of a healthy person. The possibility of injuring such patients during dental treatment must be ruled out (allergies, anticoagulants, hypertension, hypercholesterolemia).

Genetic and hereditary risks must be assessed, and decisions made concerning the individual patient’s treatability or non-treatability (uncontrolled Diabetes mellitus; smokers).

This chapter presents the following discussions:

  • The patient—ASA classification

  • Cardiovascular diseases—“blood thinning”

  • Bacteremia—prevention of infectious endocarditis

  • Endocarditis prevention—antibiotics

  • Diabetes mellitus—risk factor for periodontitis

  • For the smoking risk factor—information, tobacco cessation program

Evaluation—Can the Patient be Safely Treated?

Before initiating any dental treatment, the relevant medical history provided by a “new” patient must be carefully checked, regardless of whether comprehensive therapy is anticipated or only an emergency procedure. Of particular importance are serious diseases or conditions, such as:

  • Cardiovascular diseases

  • Pulmonary diseases

  • Renal diseases

  • Endocrine diseases

  • Compromised immune response

  • Psychological/psychiatric conditions

Acute situations should be thoroughly discussed before treatment; these include allergies, anaphylactic reactions, but also patient fear of the treatment or even fear of the injection needle.

The dental team must be systematically prepared for emergency situations. Corresponding checklists, supplies and devices must be at hand (emergency kit, materials for cardiopulmonary resuscitation, and perhaps even a defibrillator). The classification by the American Society of Anesthesiologists (ASA) helps to establish the physical status of a diseased patient (ASA Classes I–VI; Fig. 453)

453 ASA Classification of Patients—Health Status Normally, only patients in Classes I and II are treated in the private dental practice, and in rare cases Class III. In the latter case, active collaboration and cooperation with the patient’s treating physician is highly recommended.

Medical Risk Factor—“Blood Thinning”

Patients with cardiac and circulatory diseases (post-myocardial infarction, Angina pectoris etc.) or other conditions (e.g., post-surgical condition, dialysis patients, thrombosis prophylaxis etc.) usually take anticoagulants:

• Short-term therapy:

Heparin

• Long-term prophylaxis:

Aspirin derivatives

• Long-term therapy:

Cumarin derivatives (e.g., Warfarin)

In order to avoid life-threatening hemorrhage, the patient’s actual “Quick-time” (Cumarin) must be assessed. A Quick value of ≥ 30% usually does not affect dental or oral surgical procedures, but values between 15 and 25% demand consultation with the treating physician.

  • The effect of blood-thinning medications is enhanced by non-steroidal anti-inflammatory agents such as salicylate, mefenamine acids, tetracycline, metronidazol and sulfonamides (Scully & Wolff 2002).

  • Their effects will be reduced by barbiturates, glucocorticoids, alcohol, and foodstuffs with a high vitamin-K content.

The antidote for Cumarin is vitamin K; there is no antidote for the rapidly metabolized heparin. If necessary the patient may stop taking this medication for a short period of time.

454 Coagulation—Tests of Blood Thinning Because the results vary greatly, the old Quick-Test will be abandoned in the near future. It will be replaced by the INR blood thinning test (“International normalized ratio”) which provides constant values and ease of use by the patient! Therapeutic bandwidth: INR values of 2.5–4.5, depending upon the risk status of the patient

Bacteremia—Endocarditis Prophylaxis

Transient bacteremia is a natural, daily occurring situation (chewing, tooth brushing). In healthy persons, oral bacteria that enter the blood stream are efficiently eliminated by the host defense system.

Infectious endocarditis (IE) is a life-threatening disease, an infection of hemodynamically exposed defects (plaque formation on heart valves), usually elicited by oral microorganisms (streptococci).

Depending upon the virulence of the etiologic microbe and the resistance of the patient, various forms of IE can be differentiated (Müller 2001):

  • Acute, infectious forms Sepsis, fever, endocardial destruction; death in less than 6 weeks

  • Acute/Subacute forms Intermediate forms, often elicited by enterococci

  • Subacute forms Slight fever; if untreated, death between 6 weeks and 3 months

  • Chronic forms Symptoms the same as subacute; death in more than 3 months

455 Heart Diseases and Cardiac Defects—Indications for Endocarditis Prophylaxis Within the new wording of the prophylaxis program from the AHA (American Heart Association; Dajani et al. 1997) the risk structure of the heart was newly categorized in three groups: High Risk (red) Moderate Risk (green) Non-elevated Risk Of importance for the hygienist is that the presence of a cardiac pacemaker is not an indication for antibiotic, pre-treatment prophylaxis (but care must be exercised when electronic instruments such as ultrasonic scalers are employed). Left: Individual patient cards from the Swiss Heart Foundation, listing guidelines and dosages for endocarditis prophylaxis. High Risk red → adults yellow → children Moderate Risk green → adult blue → children

Infectious Endocarditis (IE)

A wide variety of microorganisms such as bacteria, mycoplasm, fungi, rickettsia or chlamydia can elicit IE if they enter the bloodstream due to trauma or tissue manipulation. Regions of the cardiovascular system that experience slow blood circulation or a high level of turbulence are particularly susceptible to infections.

The most frequent source of microorganisms that elicit IE is the oral cavity. The primary pathogens are gram-positive streptococci (viridans type), especially Streptococcus sanguis.

In addition to S. aureus and S. epidermis, more and more often one also observes gram-negative bacteria from the oral cavity and the upper respiratory tract that elicit IE; for example, A. actinomycetemcomitans, Hemophilus ssp., Cardiobacterium ssp., Eikenella corrodens, Kingella ssp., Capnocytophaga, Neisseria ssp.

For the protection of IE-endangered patients, bacteriocidal antibiotics of the “penicillin type” (p. 214) are recommended. As early as 1983, J. Slots and others suggested that IE prophylaxis could also include metronidazol (p.287).

Endocarditis Prophylaxis with Antibiotics

According to new guidelines from AHA (Dajani et al. 1997), the prophylactic dose of standard antibiotic (Amoxicillin) was reduced to 2 grams; in addition, no follow-up dose is now recommended; not all other Heart Associations agree.

It is comforting for hygienist to know that most of the, albeit rare, cases of endocarditis do not result from invasive, surgical treatments! Nevertheless: Oral, especially periodontal surgical procedures take place in a highly contaminated area. Expansive and/or deep surgical procedures have almost always been performed with antibiotic prophylaxis. For this reason, recommendations concerning which dental procedures require endocarditis prophylaxis were welcomed (Newman & Winkelhoff 2001).

456 Endocarditis Prophylaxis The standard antibiotic for IE prophylaxis is Amoxicillin. For patients who are allergic to this bacteriocidal broad spectrum penicillin, and/or those who cannot swallow pills, some alternatives are provided. * Maximum children’s dose, depending upon body weight; do not exceed the adult dose! ** Cephalosporine and penicillin must not be used with Type 1 hypersensitivity!

Dental Procedures Carrying the Risk of Bacteremia

Bacteriemia will occur following all dental procedures that elicit bleeding. The endangered patient must be premedicated with the “one-shot” prophylaxis (AHA) before:

  • Periodontal probing (Fig. 457 left).

  • Calculus removal

  • Suture removal, dressing change

  • Intraligamentous anesthesia

  • Tooth extraction, surgical tooth extraction

  • Root tip resection

Bacteriemias of varying frequency and severity also occur after chewing hard foodstuffs (15–50%), during tooth brushing (5–25%), or during oral irrigation (25–40%; according to Neu 1994).

The percentage and number anaerobic species were approximately twice as high in patients with poor oral hygiene and advanced periodontal diseases in comparison to patients with good oral hygiene. Bacteriemia occurs in these patients also, but patients at risk for endocarditis should not abandon mechanical oral hygiene; rather, they should rinse 30 minutes beforehand with chlorhexidine

457 Dental Procedures Requiring Antibiotic Endocarditis Prophylaxis (E-P) For single procedures the prophylaxis measures suggested above are sufficient. If, however, an extended phase of treatment is planned, a longer-lasting (adjunctive) medication must be considered, combined with an intensive intraoral antiseptic regimen (p. 287).
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Jul 2, 2020 | Posted by in Dental Hygiene | Comments Off on Systemic Pre-Phase
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