Dentistry and the medically compromised patient

Cross sectional study on the competence and confidence of dental students and graduates in the management of medically compromised patients and acute medical emergencies

A rapidly aging population means many people have multiple health issues leading to an increased risk of acute medical emergencies. The objective of this study was to evaluate how essential experiential learning is in developing dental graduates' ability to manage medically compromised patients. Three hundred and twenty-seven students and graduates were invited to participate in an online survey to rate their confidence in managing medically compromised patients and acute medical emergencies using a 5-point Likert scale. Competence of knowledge was evaluated using 30 multiple choice questions (MCQs) across six domains. The respondents were also asked whether a theory-only training adequately prepared them to manage medically compromised patients, or whether it must be supplemented with clinical training. Two-hundred and sixty-four responses were collected from 75 undergraduates (UG), 96 junior dental officers (JDO) and 93 senior dental officers (SDO). The UG reported that they infrequently managed medically compromised patients, whereas both the JDO and SDO reported having frequent encounters with these patients. The mean confidence scale in the management of medically compromised patients were 2.62, 3.50 and 3.69 (out of 5), respectively. In contrast, their confidence scale in the management of acute medical emergencies was 2.05, 2.33 and 2.50 (out of 5), respectively. The MCQ scores were 25.51, 26.44 and 26.86 out of 30, respectively. The outcomes of the JDO and SDO were significantly better than the UG (t-tests, p<0.05). All three groups responded that a theory-only training in dental school did not adequately prepare them to manage medically compromised patients. Both the JDO and SDO felt that their clinical work experience better prepared them to manage these patients. Experiential learning from "real-life" clinical experience is an essential component in developing graduates' confidence and competence in the management of medically compromised patients. A dental curriculum with theory-only training in this aspect is inadequate.

Necessity of providing dental care to medically compromised patients in Japan's super-aged society and the way forward

Devising an appropriate dental treatment plan for patients with pre-existing medical conditions is a demanding task. Dentists must consider the sometimes life threatening, interactions between ongoing medical conditions and dental treatment. Stakes are particularly high for the elderly on prescription drugs and other therapies for medical conditions while they seek dental care for advanced oral diseases. Given that Japan is an ageing society, it is crucial to create avenues for medical and dental practitioners to share patient information and collaborate.to,improve care This paper examined trends from demographic data to suggest that there is an impending further rise in the number of medically compromised elderly seeking dental treatment. For patient safety and improved public health, it is important that dental practitioners evaluate the nature and ongoing treatment of pre-existing medical conditions amongst new patients and account for their impact on dedicated and dental status. This paper supports the relevance of comprehensive clinical practice guidelines and the need to train dental practitioners to adopt a multidisciplinary approach to dental care. In order to meet the future needs of an ageing population, the Japanese Society of Dentistry for Medically Compromised Patients needs to take initiative and suggest mechanisms to exchange patient information freely and encourage multidisciplinary dental practices.

Antimicrobial susceptibility pattern of oral viridans group Streptococci in children at risk of infective endocarditis

Infective endocarditis (IE) is an important clinical disease in children with a mortality rate of 11.6%. Prophylaxis with antibiotics is one of the most commonly used methods in children at risk of IE; therefore, the evaluation of antibiotic resistance seems necessary in view of its increasing trend. This study aimed to determine the antibiotic susceptibility pattern of oral viridans group streptococci (VGS) isolated from the dental plaque of children at risk of IE. Fifty-one plaque samples were obtained from children aged 3 to 12 years old in the period from April to July 2018. Samples were obtained with sterile swabs and were transferred to the laboratory in Brain Heart Infusion (BHI) Broth. Samples were immediately cultivated on Columbia blood agar. After identifying VGS, antimicrobial susceptibility test (AST) was performed using Mueller-Hinton agar (MHA) with sheep's blood and E-test strips for selected antibiotics. The minimum inhibitory concentration (MIC) was determined for each isolate and the results were reported as sensitive, intermediate and resistant. Fifty-one VGS bacteria were isolated from children with an average age of 7.3 ± 2.5 years. The highest resistance was observed for azithromycin in 36 (70.6%) isolates and then cefazolin in 35 (68.6%) isolates. The highest susceptibility was observed for amoxicillin in 46 (90.2%) isolates. Based on the findings of this study, amoxicillin is the most effective option for prophylaxis in children. Furthermore, cefazolin should be used with caution because bacteria resistant to this antibiotic can transfer resistance genes to other bacteria.

Descriptive study of the patients treated at the clinic "integrated dentistry for patients with special needs" at Complutense University of Madrid (2003-2012)

Objectives: To study clinical and epidemiological characteristics of the patients treated at the clinic “Integrated Dentistry for Patients with Special Needs (Special Care Dentistry)” at Complutense University of Madrid (UCM), as well as to know the dental treatments performed in these patients and the modifications from the usual treatment protocol. The information obtained from the results could also be applied in order to assess the needs of dental students education about this type of patients. Study Design: Medical records review of all the patients referred to the clinic of “Integrated Dentistry for Patients with Special Needs”, performing a retrospective cross-sectional study analyzing their main pathology, ASA risk score (Classification system used by the American Society of Anesthesiologists to estimate the risk posed by the anesthesia for various patient conditions), pharmacological treatment, what kind of dental treatment was necessary, whether the patient was treated or not, and if it was required to change any procedure due to the patient health status (sedation or antibiotic prophylaxis). Results: The number of patients referred to the clinic was 447, of whom 426 were included in this study. Out of them, 52,35 % were men and 47,89 were women, with a mean age of 49,20 years. More frequent pathologies were cardiovascular or cerebrovascular diseases (24,29 %), infectious diseases (12,41%), endocrine diseases (11,66%) and intellectual disability (8,85%). 70’18% of the patients were treated, with sedation being necessary in 9,03% of the cases and antibiotic prophylaxis in 11,70%. Conclusions: Given the high number of patients with some kind of pathology and the amount of medicines that they use, it seems necessary for dentistry students to have a specific training regarding how to handle and treat these patients, so they will be able to provide them the best possible care.

Key words:Patients with special needs, medically compromised patients, dental treatment, special care dentistry.

[Periodontal disease in pediatric rheumatic diseases]

Gingivitis and periodontitis are immunoinflammatory periodontal diseases characterized by chronic localized infections usually associated with insidious inflammation This narrative review discusses periodontal diseases and mechanisms influencing the immune response and autoimmunity in pediatric rheumatic diseases (PRD), particularly juvenile idiopathic arthritis (JIA), childhood-onset systemic lupus erythematosus (C-SLE) and juvenile dermatomyositis (JDM). Gingivitis was more frequently observed in these diseases compared to health controls, whereas periodontitis was a rare finding. In JIA patients, gingivitis and periodontitis were related to mechanical factors, chronic arthritis with functional disability, dysregulation of the immunoinflammatory response, diet and drugs, mainly corticosteroids and cyclosporine. In C-SLE, gingivitis was associated with longer disease period, high doses of corticosteroids, B-cell hyperactivation and immunoglobulin G elevation. There are scarce data on periodontal diseases in JDM population, and a unique gingival pattern, characterized by gingival erythema, capillary dilation and bush-loop formation, was observed in active patients. In conclusion, gingivitis was the most common periodontal disease in PRD. The observed association with disease activity reinforces the need for future studies to determine if resolution of this complication will influence disease course or severity.

Drug interactions in general dental practice--considerations for the dental practitioner

The aim of this article is to explore the diverse and complex nature of pharmacological drug-drug interactions in the general dental practice setting. Using published NHS statistics, this article will highlight medications for common medical conditions that could interact with frequently prescribed drugs by the general dental practitioner.

Outcome of periapical lesions in a rat model of type 2 diabetes: refractoriness to systemic antioxidant therapy

INTRODUCTION

This study evaluated the development of periapical lesions in a rat model of type 2 diabetes and assessed the potential actions of the antioxidant agent tempol in this model.

METHODS

Male Wistar rats were used; they received tap water (N = 5) or a 20% glucose solution (N = 15) during a period of 9 weeks. At the sixth week, periapical lesions were induced on the first mandibular molars, and the animals were subdivided into 4 groups. The subgroup 1 was composed of nondiabetic rats orally receiving saline solution (10 mL/kg). Chronically glucose-fed rats were divided into the following subgroups: (2) saline-treated animals (10 mL/kg by oral route), and animals treated with tempol by gavage at doses of (3) 50 mg/kg or (4) 100 mg/kg. The body weight was monitored thoroughly. After 21 days of apical periodontitis induction, the animals were killed, and the mandibles were collected and submitted to radiographic and histologic analysis. The livers were collected to determine free radicals, and the blood plasma was used to measure insulin levels.

RESULTS

Type 2 diabetic rats displayed a significant decrease of body weight gain and a slight increase of insulin levels, which were allied to reduced levels of the antioxidant components catalase and reduced glutathione; these alterations were reversed by tempol. Concerning the periapical lesions, neither radiographic nor histologic analysis revealed any significant difference between control and type 2 diabetic rats. In diabetic rats, the apical periodontitis was refractory to tempol treatment.

CONCLUSIONS

The extent and cellularity of periapical lesions in glucose-fed type 2 diabetic rats were similar to those seen in control rats. Despite affecting other parameters related to diabetes, tempol failed to improve the outcome of endodontic lesions in type 2 diabetic animals.

Prevalence of systemic diseases among patients requesting dental consultation in the public and private systems

Objectives: To determine the prevalence and aetiology of systemic disease among patients requesting dental treatment in public and private practice. Study Design: A retrospective analysis was performed of the medical histories of 2000 patients requesting dental treatment during the year 2009. One thousand patients came from the Fontiñas Primary Care Oral and Dental Health Unit of the Galician Health Service (SERGAS), Spain, and the other thousand from a private clinic; both clinics were situated in Santiago de Compostela, La Coruña, Spain. The data collected were the following: demographic data (age and sex), presence or absence of systemic diseases and the nosologic categories, and drug history (type and number of drugs). Results: The prevalence of systemic disease was significantly higher among patients seen in the public system (35.2% in the public system versus 28.1% in the private system; p= 0.003). The differences between the two systems were more marked when considering patients aged under 65 years, particularly with respect to rheumatic and endocrine-metabolic (diabetes) disorders. The prevalence of patients receiving polypharmacy (>4 drugs/day) was significantly higher among patients seen in the public system (5.7% in the public system versus 2.7% in the private system; p= 0.009). Conclusions: There is a high prevalence of medical disorders and of patients receiving polypharmacy among individuals requesting dental care, particularly in the public health system. Dentists must have adequate training in medical disease and must be fully integrated into primary care health teams in order to prevent or adequately resolve complications.

Key words: Dentistry, medical history, systemic disease, polypharmacy.

Surgical treatment of gingival overgrowth with 10 years of follow-up

Background

In some pathological conditions, gingivitis caused by plaque accumulation can be more severe, with the result of an overgrowth. Nevertheless, the overgrowth involves the gingival margin with extension to the inter-dental papilla. The lesion may involve the inter-proximal spaces, and become so extensive that the teeth are displaced and their crowns covered. Severe overgrowth may lead to impairment in aesthetic and masticatory functions, requiring surgical excision of the excessive tissue. Aim of this study is to describe an operative protocol for the surgical treatment of localized gingival overgrowth analyzing the surgical technique, times and follow-up.

Methods

A total of 20 patients were enrolled and underwent initial, non surgical, periodontal treatment and training sessions on home oral hygiene training. The treatment plan involved radical exeresis of the mass followed by positioning of an autograft of connective tissue and keratinized gingiva.

Results

During 10 years of follow-up, all the grafts appeared well vascularized, aesthetically satisfactory, and without relapse.

Conclusions

Periodontal examinations, surgical procedures, and dental hygiene with follow-up are an essential part of the treatment protocol. However, additional effort is needed from the patient. Hopefully, the final treatment result makes it all worthwhile.

Periodontal status and IOTN interventions among young hemophiliacs

Fifty-two young individuals suffering from severe haemophilia A and B volunteered to be compared with school- and college-going students for oral health status description and subsequent management. A total of 244 students (84.42% boys and 15.58% girls) with the age group of 13-23 years were divided into two groups, A and B (controls). The purpose of this study was to increase awareness about evidence-based dental practices by oral examinations followed by comparisons of periodontal health and prevalence of malocclusions among medically compromised students and healthy controls. Results described the oral health in severe haemophilic population to be compromised with combined simplified health index score of 0.50 and Decayed/Modified/Filled Teeth (DMFT) index score of 2.07 when compared with 0.42 and 0.95, respectively, among group B. Although prevalence of malocclusion and orthodontic treatment needs among group A were higher, yet it was not confirmed as a reason for degraded dental and periodontal status. However, spontaneous and/or toothbrush (trauma)-induced gingival bleeding episodes among group A could be explained as factors discouraging oral hygiene maintenance, particularly self-administered measures. Four haemophiliacs presented with symptoms of Temporomandibular Joint Dysfunction Syndrome (TMPDS). Evidence-based oral medicine and clinical practices need to be encouraged and applied to enhance the quality of life among haemophiliacs, particularly in developing world. Dental treatment needs of haemophilic population appear to be greater and maybe incorporated in routine dental practices, at institutional and individual levels.