Dental Treatment of the Medically Compromised Corr
By Mark J. Szarejko, DDS, FAGD, CCHP
Posted on February 12, 2012 – After a decade as a full-time staff dentist within a county jail system, I have treated thousands of inmates with acute and chronic dental problems. The typical correctional patient presents with grossly carious teeth which are either not restorable or the cost of restoration upon release is beyond their financial ability. Another common malady among the inmate population is advanced periodontal disease featuring loss of the alveolar bone that supports the teeth and causing advanced tooth mobility which requires extractions. Unfortunately, this population has not used preventive dentistry to their advantage.
Additionally, these patients have neglected their general health and have more medical problems than a comparable segment of the general population. When this trend is coupled with the acute oral problems which emerge due to poor oral health, dentists must consider the patient’s medical problem(s) and any corresponding prescribed medications before dental treatment can be initiated. This article will be a feature some of the most frequently occurring medical problems which I have seen among correctional patients, their impact on the ability to provide dental treatment, and their direct and indirect consequences upon oral health.
Hypertension
Hypertension is the most common chronic illness which afflicts the patients I treat. Although this disease afflicts 50% of patients 65 years of age and older, it is by no means restricted to the geriatric population. It is mandatory to take vital signs on all patients before the initiation of any dental treatment, especially treatment which is invasive. If blood pressure is elevated, a decision must be made whether to defer treatment especially for surgical procedures. The literature suggests treatment deferral at various cutoffs for systolic and diastolic blood pressure ranging from 160 to 180 and 100 to 110 respectively. I use the lower end of both ranges, e.g. 160/100 mm hg, as the point at which I will not proceed with oral surgery. Patients that have elevated blood pressure levels should be referred to the medical department for further evaluation and treatment to controlled levels before proceeding with dental treatment. Additionally, it is essential that vital signs are recorded before any surgical procedure for all patients, not just those know to have hypertension since epinephrine, an endogenous catecholamine, is added to local anesthetics to prolong anesthesia and aid in hemostasis. Epinephrine must be used cautiously in hypertensive and cardiac patients as it can raise the blood pressure.
Cardiovascular Disesase
Cardiac disease is another frequently occurring chronic illness seen in correctional patients. Angina and a history of myocardial infarctions are the most common cardiac ailments among the patients in my experience. Hypertension is a co-morbidity among many of these cardiac patients. Complicating matters further, many patients with ischemic heart disease take anticoagulant medications such as warfarin or antiplatelet medications such as aspirin or clopidogrel. It is imperative that the dentist consult with the medical physician to determine if the degree of cardiac illness precludes the patient’s ability to withstand invasive treatment such as oral surgery. The practice of holding anticoagulant or antiplatelet medications temporarily prior to oral surgery has changed over time. In the past, these medications frequently were held prior to oral surgery; however, in current practice, it is rare to do so. Since the most common reasons for the administration of these medications are ischemic heart disease, cerebrovascular accidents, and blood clots, again the dentist must consult with the medical physician to determine the underlying medical reason for these prescriptions. In the consultation, the dentist must communicate the extent of oral surgery planned as the risk of post-operative bleeding when maintaining patients on anticoagulant or antiplatelet medications must be assessed against the risk of an adverse cardiovascular or cerebrovascular event if these medications are withheld.
For patients taking warfarin, an International Normalizing Ratio (INR) can be used to assess the ability to achieve hemostasis after a surgical procedure. Other recommended laboratory tests are Partial Thromboplastin Time (PTT) and Prothrombin Time (PT) which evaluate intrinsic and extrinsic pathways respectively for their role in the coagulation process and a complete Blood Count (CBC) to determine the number of platelets (normal range: 150,000-450,000 platelets per cubic millimeter of blood). A platelet function analyzer tests the functional ability of the platelets. Collectively these tests can be used to determine a patient’s ability to achieve hemostasis after oral surgery. The only clinician that can alter or temporarily hold any anticoagulant or antiplatelet medication is the patient’s physician. Generally, patients can remain on their normal dose of these medications and proceed with oral surgery without hemostasis complications. Non-steroidal Anti-Inflammatory Drugs (NSAIDS) such as ibuprofen and naproxen can enhance the anticoagulant effect of warfarin and should not be prescribed simultaneously.
Diabetes
Diabetes mellitus is another chronic illness frequently seen among correctional patients. About 90% of the cases involve Type II (non-insulin dependent diabetics) while the remainder are Type I (Insulin-Dependent Diabetics). There is a 50% incidence of diabetes in the geriatric population. Adequate glycemic control is important prior to dental procedures as poor control impairs the chemotactic ability of neutrophils to target pathogenic oral bacteria including those implicated in the development and exacerbation of periodontal disease. Collagen synthesis is also impaired with poor glycemic control and thus prolongs the healing of surgical sites. Patients must be counseled to maintain their normal diet after oral surgery, especially those that are insulin dependent. If these patients take their normal dose of insulin and refrain from eating due to post-surgical pain, hypoglycemia and insulin shock could ensue. Diabetics with recurrent oral infections may need antibiotic prophylaxis prior to oral surgery and post-surgical antibiotics. Brittle diabetics may need surgical procedures performed in an outpatient hospital setting.
HIV/AIDS
Compared to the general population, HIV/AIDS is more prevalent among the correctional population. The progressive immunosuppression caused by HIV subjects these patients to opportunistic oral infections which are AIDS-Defining illnesses as defined by the Centers for Disease Control and Prevention (CDC). Candida albicans is a fungal organism that is a normal component of the oral flora; however, with the decreasing immunocompetence of AIDS patients, it becomes an opportunist pathogen that causes oral candidiasis that can involve the oral cavity, pharynx and even the esophagus. Oral candidiasis afflicts nearly 90% of AIDS patients. Oral surgery must be deferred in these patients as extraction sites can create a portal of systemic fungal dissemination. Systemic antifungal medications may not resolve all of these fungal infections leading to the possibility of fatal outcomes and resistance of these organisms to antifungal medications is a growing concern. The transition from gingivitis to periodontal disease is usually a slowly-progressing process; however, this process can be greatly accelerated in the HIV/AIDS patients. The progression can lead to rapid bone loss with the infective process extending into the adjacent mucosal tissues causing stomatitis and potentially septicemia. Conventional periodontal therapy has limited benefits against this form of periodontal disease with most affected teeth extracted. Some HIV/AIDS patients can develop a cyclic thrombocytopenia so it is essential that a CBC is performed and the platelet count ascertained before any surgical procedure. Most HIV/AIDS patients do not need antibiotic prophylaxis prior to oral surgery.
This discussion should be considered a brief introduction to the relationship between systemic Illnesses and their impact on oral health and the reasons for which dental treatment may need deferral or modification. The small sampling of chronic illnesses listed is far from an exhaustive list of all the illnesses which afflict correctional patients. It does reflect the most common chronic diseases that afflict the correctional patients that I have treated and, in the case of HIV/AIDS, highlights a disease with a much higher incidence in the correctional population compared to the general population. The underlying philosophy of this article is that dental procedures do not start with a tooth or teeth, but rather with a complete understanding of the patient’s unique medical history.
