Dental Extractions and Comorbid Conditions: When to Seek Medical Consultation

Dental Extractions and Comorbid Conditions: When to Seek Medical Consultation

Question. Write down and discuss six common comorbid diseases that you should seek medical consultation for before dental extraction.

Answer.

Comorbidity is the presence of one or more additional disorders or diseases co­occurring with a primary disease or disorder, or the effect of such additional disorders or diseases.

The additional disorder may also be behavioral or mental.

The following are the six comorbid diseases for which one should seek medical consultation before dental extraction:

1. Diabetes mellitus
2. Seizure
3. AIDS
4. Cardiovascular risks
5. Respiratory disorders
6. Blood dyscrasias.

“Understanding the six most common comorbid diseases”

Diabetes Mellitus

There are three types of diabetes: Type I is considered insulin dependent, 5–10% of cases; Type II is when the body does not produce enough insulin and, therefore, diet and medication may be regulated; Gestational diabetes occurs during pregnancy and is reversed after delivery.

If the patient indicates that they have diabetes, the type must be noted in the history.

Patients with uncontrolled diabetes have low resistance to infection and are prone to periodontal disease.

They have poor healing response, including excessive bleeding, and may experience hypoglycemia or hyperglycemia during dental treatment.

Patients who are undiagnosed diabetics may report the following symptoms: excessive thirst and hunger, increased urination, and higher birth weights in babies.

Dental Extractions and Comorbid Conditions: When to Seek Medical Consultation

When reviewing a health history, the following questions should be asked of diabetic patients:

• Is your diabetes well-controlled?
• When is the last time your blood glucose was checked?
• Are you currently taking oral anti­diabetic medicationsor insulin injections?
• When was the last time you ate?
• Did you take your medication on time today?

It is advisable to keep sources of sugar on hand for hyper- or hypoglycemic episodes.

Glucose gel from a pharmacy, granulated sugar packets, honey packets, or tubes of cake icing can be easily stored and used in the case of an emergency.

When questioning diabetic patients before treatment, and you find out they have not eaten or taken their insulin, their appointment should be rescheduled.

Make sure they understand the importance of these steps to maintain a normal blood sugar level during dental treatment.

After approximately 8 hours of fasting, the average range is between 70–99 mg / dL. If they have eaten, an average level should be less that 140 mg / DL.

A strategy for making a dental appointment for a diabetic patient is to keep it short and in the early to mid­morning hours when sugar levels are more stable.

“How do comorbid diseases affect overall health?”

Seizure

Seizure disorder is caused by an electrical disturbance in the brain. Any person can experience a seizure in a stressful situation and approximately half of all seizures are considered idiopathic.

Epilepsy is a condition commonly associated with a syndrome of associated seizure types.

When a known epileptic patient is scheduled for treatment, the dental team should determine, if the patient has taken his / her antiseizure medication.

These patients should be scheduled for short appointments, when they are well rested.

Patients often report an aura before experiencing a seizure.

This aura can be a sound, feeling, or smell.

Shining a bright light in the patient’s eyes should be avoided, since this has been known to trigger a seizure.

Patients who are taking oral anticonvulsant medications, such as Dilantin, Zarontin, or Depacon, may experience gingival hyperplasia.

Emphasis must be placed on meticulous home care to prevent serious periodontal problems and the increased need for regular dental visits.

“Importance of identifying comorbid conditions in patients”

Cardiovascular Risks

Patients who state that they have experienced chest pain, shortness of breath, pain that radiates down their neck or arm, have swollen ankles, and / or have high blood pressure are at risk for cardiovascular disease.

They may or may not have been diagnosed by a physician.

If this patient also indicates that they are a smoker and / or are overweight, the risk is increased.

It is recommended that a medical consultation or evaluation be obtained for all patients who indicate some type of cardiovascular disease on their health histories.

Additionally,medical consultations should also be obtained for patients who are reporting or exhibiting symptoms of cardiovascular disease,but have not had a defiitive diagnosis. Preventing medical crises during dental treatment is the best method of protecting patients who are medically compromised.

Rheumatic heart disease is a result of rheumatic fever and can cause deformities in the heart valves.

Some patients will report taking antibiotics on a regular basis, although this is not a required practice.

If the patient reports a history of rheumatic fever, the dental practice must consult with the patient’s physician to determine the extent of the heart involvement.

This assessment will determine the need for antibiotic prophylaxis.

Congenital heart defects place the patient at high risk for bacterial endocarditis.

Again, a statement from a physician is advisable to determine the type of defect and to verify the need for prophylactic antibiotics.

Coronary artery disease results from atherosclerosis. Patients may report having been diagnosed with angina pectoris, or having chest pain after some type of physical activity or stress.

These patients may be taking several medications, particularly vasodilators such as nitroglycerin; or beta-blockers, such as propanolol.

The stress of a dental visit may cause an angina attck, therefore it is important to minimize patient stress, maximize patient comfort and make certain that the patient has his / her medications available, particularly nitroglycerin.

In addition, it is recommended that local anesthetic without epinephrine or other vasoconstrictors be used for these patients,to avoid further constriction of the blood vessels.

Patients with unstable or uncontrolled angina should wait for at least 30 days after their angina is stabilized to receive dental treatment.

“Common examples of comorbid diseases explained”

Myocardial infarction is more commonly known as a heart attck.

Patients who have experienced a recent myocardial infarction should not receive any dental treatment for a minimum of 6 months after the heart attck.

Most fatalities from myocardial infarction occur within 3–4 months after the attck.

Stressful situations, like dental treatment can cause a rupture in the area of infarct, leading to further health problems and possible death.

Hypertension is a common condition characterized by high blood pressure.

Patients with uncontrolled hypertension are at risk for a stroke, kidney failure, or heart attck.

Since stress will increase blood pressure, dental treatment is contraindicated in patients with severe hypertension.

Patients presenting with a systolic pressure between 120–139 mm Hg should be advised to monitor their readings for improvement and see their physician for assessment.

As a rule, patients with a systolic pressure greater than 160 mm Hg and / or a diastolic pressure greater than 95 mm Hg should be referred for medical consultation and treatment, dental treatment should be delayed.

It is relatively common for patients to have undiagnosed hypertension, making it very important for the dental team to monitor patient’s vital signs during their dental visits.

A patient who reports having frequent dizziness, nosebleeds, or headaches may have high blood pressure and may be in need of medical intervention with antihypertensive drugs and / or diuretics.

Heart failure was more commonly known as “congestive heart failure” but the American Heart Association has recently renamed and shortened the title to characterize a broader spectrum of the disease.

Depending on the type of heart failure,patients will typically have swollen ankles and shortness of breath, due to poor circulation and flids backing up in the lungs.

These patients may indicate that they must sleep upright or with several pillows. In these cases, placing them in a supine position for dental treatment may cause them acute distress.

Heart failure patients are usually taking one or more diuretic medications to remove flid.

Supplemental oxygen may be needed for these patients and use of nitrous oxide analgesia is contraindicated.

Respiratory Disorders

Asthma is a chronic respiratory disorder that results in a narrowing of airways.

An asthma attck can be triggered in several ways including environmental allergens, medications,or exercise.

Patients with asthma may be prone to an attck or episode brought on by the stress of dental treatment, or exposure to an allergen­like latex.

The patient must always be instructed to bring his / her medication / inhaler to each appointment.

When the health history is reviewed at the beginning of treatment, the patient should be able to produce the medication or inhaler just in case it is needed.

Chronic Obstructive Pulmonary Disease (CoPd)

The two most common forms of COPD are emphysema and chronic bronchitis.

Emphysema is the irreversible enlargement of the air sacs in the lungs making it hard to expel all oxygen during breathing.

Chronic bronchitis is characterized as the irreversible condition of narrowed airways.

Like patients with heart failure, those with either of these types of COPD may not be able to breathe easily in a supine position or after walking certain distances.

Due to prolonged steroid use to treat their COPD, these patients may have Candida infections.

Before dental extraction medical consultation of such patients is necessary.

“Hypertension as a common comorbid disease”

Tuberculosis (TB) is a bacterial infection that occurs primarily in the lungs, but can occur in other organ systems in the body.

It is spread through airborne particles, when an infectious patient coughs, sneezes, talks, or sings.

TB is most easily spread in small confied spaces where infectious people share the same airspace with others.

Because TB is highly infectious and its airborne transmission is diffilt to control, CDC has issued specifi guidelines to help protect healthcare workers when treating patients.

In the case of TB, these guidelines state that elective, (nonemergency) dental treatment should be postponed for patients who have or are suspected of having an active, infectious TB case.

If these patients can be referred for treatment in a facility that is specifially designed to treat TB patients (e.g. a hospital settng), it is acceptable for the dental practice to make this referral and not be liable for discriminatory practices.

“Role of diabetes in comorbidity management”

In addition to asking patients on their health history if they have had TB, the patients should also be asked if they have experienced any of the following symptoms: night sweats,unexplained fever, weight loss, or a prolonged or bloody cough.

If a patient has experienced any of these symptoms, refer them to a physician for evaluation before proceeding with anything but emergency palliative treatment.

If emergency treatment must be performed on a patient suspected of having infectious TB, the following precautions should be taken:

• Schedule the patient at the end of the day, as the last patient treated.
• All team members present in the treatment room must wear a HEPA or NIOSH N95 mask.
• High volume evacuation and dental dam isolation must be used to reduce aerosols.

AIDS

AIDS is a viral infection that impairs a patient’s immune system, making the patient highly susceptible to other infectious diseases.

It is transmittd through blood and other body flids, which puts dental healthcare workers at some risk of infection from treating patients.

Again, the practice of standard precautions must be followed, since many patients will not disclose their HIV positive status for fear of humiliation or rejection.

Remember that information about a patient’s HIV positive status is highly sensitive and must be protected.
The dental team must take every precaution to protect the confientiality of that patient’s health history.

“Chronic kidney disease as a comorbid condition”

Although some dental health care workers are fearful of treating AIDS patients, it is illegal not to accept them into a dental practice or to refer them to another practice, unless the type of treatment is not performed in that practice.

For example, if a general dental practice does not perform periodontal surgeries,it is legal to refer HIV positive or AIDS patients to a periodontist,since non­HIV or non­AIDS patients are referred as well.

“Impact of obesity on comorbid conditions”

However, if only the HIV positive or AIDS patients are referred for periodontal surgery, this would be considered discriminatory.

When treating patients with full blown AIDS, who are typically immunosuppressed, the dental team should take extra precautions to protect the patient from opportunistic infections.

These may include wearing sterile surgical gloves rather than non­sterile exam gloves, having the patient use a pre­treatment rinse of chlorhexidine gluconate or other mouthwash to prevent bacteremia, and using only sterile water for irrigation rather than from the air / water syringe, which may contain some bacterial contamination.

Blood Dyscrasias

Anemia is a defiiency of red blood cells, caused by vitamin or iron defiiency or bone marrow problems.

An anemic patient may have problems with slow wound healing and excessive bleeding.

They may report feeling weak and fatigued, and may appear very pale.

If a patient exhibits these symptoms a medical evaluation should be recommended before dental extraction.

Leukemia is a type of blood cancer, where there is an overgrowth of white blood cells.

These white blood cells may displace red blood cells, used to transport oxygen in the blood.

These patients may exhibit oral signs, often before other symptoms of their disease.

“How does cardiovascular disease interact with other illnesses?”

These signs typically include excessive gingival irritation in the absence of other causative agents, such as heavy plaque or calculus.

Patients with leukemia are very prone to infections, including periodontal infections. In addition, the chemotherapeutic agents used to treat the disease have many side effcts, most notably xerostomia (dry mouth).

Consult the treating physician before proceeding with dental treatment.

Hemorrhagic disorders are ailments in which patients experience excessive bleeding, due to a defiiency of clottng factors in their blood.

Common bleeding disorders are hemophilia A and B, factor II, V, VII, X, XII, and von Willebrand’s disease.

A patient with one of these disorders will bruise very easily,may experience spontaneous, excessive bleeding, including unprovoked epistaxis (bleeding from the nose).

Dental treatment, such as extractions, that may cause bleeding can be risky for these patients.

Close monitoring by the physician is necessary before dental extraction.

Extraction should be confied to specifi areas (e.g. one tooth or quadrant at a time) and transfusion with clottng factors may be necessary prior to treatment.

Aspirin must never be prescribed for pain control for these patients, since it is a natural blood thinner and increases bleeding.