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Dental management of systemically

compromised patients

Article in International Journal of Clinical Dentistry · September 2012

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International Journal of Clinical Dentistry ISSN: 1939-5833
Volume 5, Number 1 © 2012 Nova Science Publishers, Inc.

DENTAL MANAGEMENT OF SYSTEMICALLY

COMPROMISED PATIENTS

Paulo Sérgio da Silva Santos*,1 and Sérgio Alves de Oliveira Filho2

1
Bauru School of Dentistry, University of São Paulo, Department of Stomatology, Brazil
2
Federal University of Rio Grande do Norte, School of Dentistry,
Oral and Maxillofacial Surgery, Brazil

ABSTRACT
The treatment of oral diseases that individuals with systemic conditions receive has a
direct impact on their overall health and/or medical therapy. The aim of this study was to
determine the profile of care for patients with systemic involvement that required support
in a dental clinic dental hospital. In a retrospective study 1,397 patients at the clinic for
dental patients with special needs were evaluated and treated according to their respective
baseline disease in a general hospital. Patients were divided according to medical
specialties who handed them to undergo general dental procedures based on special
criteria of care for each disease. The medical specialties that requested most of the
consultations for outpatients with special needs were 346 (25%) from General Oncology,
246 (18%) from Onco-Haematology, 209 (15%) from Cardiology and 165 (12%) from
Nephrology. These patients underwent to 1,232 (88%) surgical treatments, 142 (10%)
conventional periodontal treatments, and 26 (2%) other procedures such as laser therapy,
dental restorative treatment and osteoradionecrosis. With these results, we note that the
profile of patients in a clinic Dental Hospital is generated primarily by medical specialties
such as general oncology, onco-hematology, cardiology and organ and tissue
transplantation teams. Surgical procedures were the most frequent in the studied
population, which reflects the poor oral health condition of this group of patients.

Keywords: Hospital Dental Service; Comprehensive Dental Care; Oral Health, Dental Care
for Chronically Ill.

Clinical Significance: To contribute information related to the care of patients with systemic
involvement for dental professionals and related fields.

*
Corresponding author: Paulo Sérgio da Silva Santos, Bauru School of Dentistry, University of São Paulo,
Department of Stomatology. Al. Dr. Octavio Pinheiro Brisolla, 9-75, Bauru-SP, Brazil, Zip Code – 17012-901.
Phone: +55 14 32358000 (8552)
50 Paulo Sérgio da Silva Santos and Sérgio Alves de Oliveira Filho

INTRODUCTION
To provide thorough and safe treatment for medically compromised patients who cannot
tolerate care that is tailored for normorreactive individuals; dentists must carry out more
complex dental treatment for the safety and comfort of the patients. Physically and
emotionally exhausting treatments cannot be tolerated by such patients. Naturally,
systemically compromised patients quickly discover that they cannot withstand the stress of
routine treatment used in conventional dentistry. Therefore, after some unpleasant
experiences, patients will only seek dental support when there is an emergency or when they
have aesthetic concerns, and they abandon elective complete treatment [1].
The treatment of oral diseases that individuals with systemic conditions receive has a
direct impact on their overall health and/or medical therapy, and includes care to control
and/or mitigate pain and infection and the restoration of function. Oral health care is an
integral part of systemic treatment. The aim is to restore overall health and it may also reduce
the costs that would be incurred by treating complications [2].
Hospital Dentistry (HD) professionals believe that hospitals should provide
comprehensive medical services to the public and that dentistry must be included to achieve
this goal. The role of an HD service should be to give support to the medical teams by
diagnosing oral diseases that may be signs of systemic disorders. Furthermore, physicians
should be available to support dentists when facing situations that go beyond their field of
expertise [3].
Hospital services for oral and maxillofacial surgery substantially contribute to the
management and treatment of systemically compromised patients[4]. Absi et al. (1997)
concluded that most patients referred for dental treatment in hospital can receive outpatient
care, after they observed that 70% of referred patients did not require special conditions for
treatment[4].
Epstein et al. (2007) evaluated high complexity medical centers in terms of the resources
that were available for oral assessment and care and the clinical treatment that was carried
out. The study found that the 15 centers whose dental services were assessed provided
treatment for cancer. However, none of the centers requested previous oral assessment prior
to chemotherapy. Dental treatment was provided for sequelae, oral complications and cancer-
related diseases, managed by medical and nursing teams, and only afterwards were the
patients referred to the dental sector for treatment. They noted that 44% of patients who
received hematopoietic stem cell transplantation (HSCT) underwent a prior oral examination,
and only 50% of them had pre-existing complaints and underwent dental consultations. These
results suggest that there may be a significant flaw in the oral care of these patients, which
can affect the outcome of cancer treatment, as well as compromise their quality of life [5].
There is a consensus among international centers for cancer treatment that foci of
infection in the oral cavity are potential sources of systemic infections; including severe
periodontal disease[6] and periapical lesions of endodontic nature. In immunocompromised
patients, these infections can secondarily develop into abscesses, cellulitis or granulomatous
lesions, resulting in sepsis, if not properly treated [7]. These conditions suggest the
importance of the participation of a dentist in multidisciplinary teams so that early diagnosis
and appropriate treatment of oral complications are carried out [8].
 Dental Management in Compromised Patients 51

The aim of this study was to determine the profile of care for patients with systemic
involvement that required support in a dental clinic dental hospital.

METHODS
In a retrospective study patients at the clinic for dental patients with special needs were
evaluated and treated. Patients had been referred by other medical specialists within the
institution itself, according to their respective baseline disease. Over a period of five years, all
assessed patients were included in this study. This study was approved by the Brazilian
National Ethics in Research.
All patients were evaluated by trained dentists using a physical intra-oral and extra-oral
examination. The presence of foci of infection and/or other changes according to patient
complaints was investigated. Radiographic examinations were also carried out (e.g.
panoramic radiograph, extraoral radiographs and CT scans), laboratory exams (biochemical,
hematological and microbiological) whenever necessary and prior to completion of the
procedures, according to the disease groups presented by the patients.
The protocols, defined after clinical assessments and the results of complementary
diagnostic exams consisted of clinical procedures including conventional periodontal
treatment (scaling and root-polishing), restorative dental procedures (permanent restorations
and oral cavity conditioning with glass ionomer cement), surgical procedures (extractions,
biopsies, odontogenic abscess drainage, alveoloplasty, gingivectomy, pre-prosthetic surgery,
apicectomy), treatment of osteoradionecrosis injuries and laser therapy in the prevention and
treatment of chemotherapy or radiation-induced oral mucositis. The procedures were carried
out on an outpatient basis under local anesthetic. In cases of phobia and neurological
impairment, the patient was chemically sedated and medical support was arranged for the
treatment of possible emergency situations.

RESULTS
This study involved 1,397 patients referred by medical specialists. There were no
referrals from outside the institution.
There were 346 (25%) patients referred from General Oncology, 246 (18%) from Onco-
Haematology, 209 (15%) from Cardiology and 165 (12%) from Nephrology. These were the
medical specialties that requested most of the consultations for outpatients with special needs.
To a lesser extent, 84 (6%) patients with coagulopathies, 103 (7%) endocrine abnormalities,
102 (7%) liver disease, 51 (4%) hematological disorders, 30 (2%) neurological disorders, 21
(2 %) immunologic alterations, 19 (1%) infectious diseases, 7 (1%) skin diseases and 11 (1%)
respiratory problems were referred for dental evaluation. The Psychiatry Department referred
three patients, accounting for less than 1% of patients. All patients in the study underwent
clinical and/or surgical procedures on an outpatient basis with dentists who were supervised
by a specialist in dentistry for patients with special needs (Figure 1)
There were 1,232 (88%) surgical treatments, 142 (10%) conventional periodontal
treatments, and 26 (2%) other procedures such as laser therapy, dental restorative treatment
and osteoradionecrosis (Figure 2).
522 Paulo
P Sérgio da
d Silva Santoos and Sérgio Alves
A de Olivveira Filho

Fiigure 1. Patients referred by medical

m specialtyy.

Fiigure 2. Treatm
ments performedd.

Regarding the various suurgical treatmeents, there weere 1,120 extraactions, whichh accounted
foor 91% of surrgeries, follow
wed by 81 (7% %) biopsies annd 31 (2%) other
o procedurres such as
geenvivectomiess, frenectomiees, drainage of
o odontogenicc abscesses annd alveoloplassty (Figure
3)). The medicaal specialties that required the highest number
n of pattients to undeergo dental
exxtractions weere general oncology
o withh 294 (26%) procedures,, 148 (13%)) in onco-
heematology, 19
94 (17%) in caardiology and 112 (10%) in nephrology (F Figure 4).
 Denttal Management in Comprom
mised Patientss 53

Fiigure 3. Surgicaal procedures peerformed.

Fiigure 4. Extracttions performedd according to thhe medical speccialty.

DISCUSSION
In 1965, Willis
W definedd a number of o roles for thhe dentist in a hospital ennvironment,
inncluding the trreatment of paain that has ann odontogenicc origin, inform
ming medical staff about
thhe oral health
h of patients and diagnosing oral maniifestations thaat may be inddicative of
syystemic disordders.
54 Paulo Sérgio da Silva Santos and Sérgio Alves de Oliveira Filho

The results of this research demonstrate the need and importance of dentists in a hospital,
working on the support and treatment of various conditions that can affect the oral
environment and need special care, considering the general health of patients that are
systemically compromised [9].
Patients with cancer, onco-hematological, cardiovascular and kidney disorders were most
referred and submitted to surgical procedures, mainly extractions (26%) of teeth that were in
poor condition, with different infectious diseases that could act as primary foci and
compromise medical care.
These patients should be assessed by using a thorough anamnesis, a good physical
examination, and complementary radiographic and laboratory exams. During anamnesis, we
tried to show factors such as underlying diseases, medications and current medical treatment,
which may influence or indicate the completion of clinical or surgical procedures in order to
improve the control of the general health of these patients. The physical examination is
important for the diagnosis of oral diseases that may compromise the overall health of
patients. By using radiographic exams, we could investigate the presence of caries,
periodontal disease, periapical inflammatory lesions and even cysts and tumors that may
negatively affect the individual’s systemic condition and require treatment. Laboratory exams
indicate whether there is adequate control of the underlying disease and whether special care
such as drug interactions, patient's clinical status, pre-and postoperative antibiotic therapy,
restrictions on the use of vasoconstrictors, use of local hemostatic maneuvers or
administration of coagulation factors will be required during treatment.
The possibility of local and systemic complications resulting from inadequate dental
treatment of patients with systemic diseases and the unfamiliarity of most dentists with the
dental approach for these patients, result in a large amount of referrals of patients by the
specialized medics to a specialized dental care hospital, such as to outpatient care for patients
with special needs.

CONCLUSION
With these results, we note that the profile of patients in a clinic Dental Hospital is
generated primarily by medical specialties such as general oncology, onco-hematology,
cardiology and organ and tissue transplantation teams. Surgical procedures were the most
frequent in the studied population, which reflects the poor oral health condition of this group
of patients.
These data suggest the importance of a dental service in hospitals with a multidisciplinary
team, providing a comprehensive service, helping to improve quality of life of patients with
systemic disorders.

ACKNOWLEDGMENTS
We acknowledge and thank the Santa Casa de Misericordia de Sao Paulo for enabling
this research.
 Dental Management in Compromised Patients 55

REFERENCES
[1] McCarthy FM. Recognition, assessment and safe management of the medically
compromised patient in dentistry. Anesth Prog. 1990;37(5):217-22.
[2] Rutkauskas JS. The medical necessity of periodontal care. Periodontol 2000.
2000;23:151-6.
[3] Willis PJ. The role of dentistry in the hospital. J. Am. Dent. Soc. Anesthesiol.
1965;12:40-4.
[4] Absi EG, Satterthwaite J, Shepherd JP, Thomas DW. The appropriateness of referral of
medically compromised dental patients to hospital. Br. J. Oral Maxillofac Surg.
1997;35(2):133-36.
[5] Epstein JB, Parker IR, Epstein MS, Gupta A, Kutis S, Witkowski DM. A survey of
National Cancer Institute-designated comprehensive cancer centers' oral health
supportive care practices and resources in the USA. Support Care Cancer.
2007;15(4):357-62.
[6] Teng YT, Taylor GW, Scannapieco F, Kinane DF, Curtis M, Beck JD, Kogon S.
Periodontal health and systemic disorders. J. Can Dent. Assoc. 2002 ;68(3):188-92.
[7] Munro CL, Grap MJ. Oral health and care in the intensive care unit: state of the science.
Am. J. Crit Care. 2004;13(1):25-33.
[8] Luiz AC, Eduardo FP, Bezinelli LM, Correa L. Oral alterations and oral care in bone
marrow transplant patients: [revision]. Rev. Bras Hematol. Hemoter. 2008; 30(6): 480-
87.
[9] Santos PSS, Mello WR, Wakim RCS, Paschoal MAG. Use of oral rinse with enzymatic
system in patients totally dependent in the intensive care unit. Rev. Bras Ter Int.
2008;20(2):154-9.
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