Medical history - General and specific pathology in dentistry
The medical history is a health questionnaire from which the disease history of a patient must be clear. The dentist takes a medical history to be able to determine whether dental treatments entail health risks.
In addition to the medical history, there is a dental history to chart dental problems. The dental history is described in other chapters. The following is a description of the medical history.
In a healthy patient, any dental treatment is possible without special precautions. If a defect is found, dental treatment may be subject to limitations. This can vary from a slight limitation, such as not treating too long in succession, or taking preventive measures. Sometimes it is decided to only provide emergency assistance. A number of abnormalities are discussed below that must be taken into account during dental treatment.
General abnormalities can be important for dental treatment. It is therefore necessary to ask the patient a number of questions about his health, for example:
- Do you have a heart defect? If yes which one?
- Do you suffer from hyperventilation?
- Have you ever fainted with medical treatment?
- Do you have epilepsy?
- Do you have lung problems?
- Are you allergic? If yes, for what?
- Do you have diabetes?
- Do you have anemia?
- Do you have an increased tendency to bleed?
- Do you have a contagious disease?
- Do you need antibiotics for bloody procedures?
- Are you pregnant?
- Do you use medication? If yes which one?
- Do you smoke?
If the answers show that dental treatment involves risks, the treatment must be carried out in such a way that the risks for the patient are minimized or even avoided altogether.
Heart (valve) abnormalities
Patients with heart (valve) abnormalities can run risks with dental treatment. If aspiration is not performed during the administration of anesthetic fluid, the fluid may enter the bloodstream. If the liquid contains adrenaline, this not only causes a narrowing of the blood vessels but also an increase in the heart rhythm. This can be dangerous in patients with heart problems.
A patient with angina pectoris has pain with a tightness in the chest. The disease falls under the heart conditions. Angina pectoris arises because the coronary arteries are narrowed and allow less blood to pass through. The heart does not get enough oxygen because of this. When an increased effort is required from the heart muscle, the patient may suffer a great deal from this. This can be with physical exertion, but also with stress. Dental treatments can cause stress in a patient. This can increase cardiac activity and cause trouble in some patients.
Patients usually use nitroglycerin tablets to fight an attack. If the patient feels an attack coming, a tablet is placed under the tongue. These tablets must therefore be within reach during treatment. Usually the patient always has these tablets with him. It is advisable to check this before treatment. Sometimes this medicine is present in dental practice. Nitroglycerin has a limited shelf life. It is therefore necessary to regularly check the expiry date of the tablets. Of course, the risk of administering a tablet that is no longer effective should not be run in practice (see figure below).
Classic gesture with angina pectoris.
Patients with (too) high blood pressure (hypertension) are often treated with a blood pressure lowering agent, an antihypertensive agent. The vasoconstrictor adrenaline in the anesthetic fluid and an antihypertensive agent can influence each other's effects. It is therefore important to aspirate during the injection.
Sometimes patients warn that they faint quickly. If this happens, it is very annoying for both the patient, the dentist and the assistant. A number of measures can be taken to prevent someone from fainting:
- Tell the patient what is going to happen and take time for the treatment.
- A calm and self-assured performance by dentist and assistant.
- Ventilate the practice area well to prevent (too) high temperatures and 'odors' from medicines.
- Have the patient go to the toilet for treatment.
- Have the patient take off too warm clothing, such as a jacket, jacket or thick sweater. For men who wear a tie, it is also wise to loosen the tie and the top button of the shirt.
- Tilt the treatment chair far back so that the head receives sufficient blood supply.
- Reduce pain by applying local anesthesia during treatments.
There are a number of chronic respiratory diseases.
- Asthma is a condition of the lungs with periods of shortness of breath, wheezing and coughing. These symptoms are caused by stimuli in the inhaled air.
- Chronic bronchitis causes increased mucus production in the airways. Patients cough and give up mucus.
- With emphysema, the elasticity is from the lung tissue. This disease is getting worse over time. A patient may even be anxious at rest.
A patient with a lung abnormality therefore generally suffers from breathing. The patient will often have a medicine in the form of a spray can or inhaler to use in the event of an attack of the condition. With dental treatment of a lung patient, care must be taken that breathing can continue as normally as possible. The stress associated with dental treatments must also be avoided. In general this can be achieved by:
- Tell the patient what will happen;
- Let the treatment take place in a calm atmosphere;
- Keep the treatment short;
- Give medication in consultation with the doctor.
If the patient feels an anxiety attack coming, treatment should be stopped immediately.
Patients suffering from diabetes or diabetes mellitus may have reduced resistance to infections. This is certainly the case if the patient is not properly 'adjusted'. That is why it is better for patients with diabetes to be well-adjusted in procedures where a bacteremia occurs.
Because a diabetic needs to eat small meals at set hours, it is wise to schedule treatment at such a time that the patient can eat at his normal time. A very extensive treatment for a diabetic patient should be avoided, as this can cause problems before using the meal. The best time for an appointment is just after the main meal. The stress of dental treatment can cause a patient with diabetes mellitus to consume more energy than normal. An additional check of blood sugar levels after treatment may be advisable.
Anemia or anaemia is a disorder in which either the hemoglobin level of the blood or the number of erythrocytes (red blood cells) is reduced. The most common form is the Fe deficiency anemia (iron deficiency). Sometimes an unnoticed blood loss or menstruation can cause anemia. The symptoms of a patient suffering from anemia are highly dependent on the speed with which the abnormality occurred. The symptoms of anemia are often:
- Fatigue, weakness and whiteness;
- Shortness of breath after exertion;
- Poor appetite.
With dental treatment of anemia patients it must be taken into account that the general resistance of the patient is reduced. The patient will be or may be extra sensitive to infections. Treatments where there is a high risk of infection and infection, such as extractions or periodontal surgery, can be postponed until the anemia has healed.
Blood coagulation disorders
Deviations in the coagulation of the blood cause problems with bloody procedures. It is therefore necessary that such abnormalities emerge from the case history.
Blood coagulation disorders can occur for a variety of reasons:
- Platelet deficiency. These platelets have a function in blood clotting.
- Congenital coagulation disorder. This is the case with haemophilia patients. Blood coagulation is a very complex process in which all sorts of factors play a role. Haemophilia patients are missing or are deficient in some of these factors. In patients with haemophilia ('bleeding disease'), the after bleeding tendency is so great that a bloody intervention may only take place in a hospital.
- Vitamin K deficiency due to reduced absorption in the gastrointestinal tract. The absorption of vitamin K can be disturbed by gastrointestinal disorders or by the use of anti-infectious agents, which can disrupt the intestinal flora.
- Use of anticoagulants. Patients with an increased risk of thrombosis are treated with anticoagulants or blood thinners. The thrombosis service ensures that the blood clotting of these patients is set up in such a way that the formation of blood clots does not occur within the vascular system. This does, however, have the risk that bleeding does not occur quickly enough in the case of bleeding (such as extraction), with all the associated consequences. In consultation with the treating specialist or the thrombosis service, therefore, blood clotting should be reasonably normal for bloody procedures. The dose of the anticoagulants may need to be temporarily adjusted.
Therefore, if there is any evidence of a blood clotting disorder from the history, this must be taken into account.
After bleeding tendency
It is important that the anamnesis asks about after bleeding tendencies:
- Did the wound bleed for a long time with previous extractions?
- Are after-bleeds customary in the family?
The dentist may also ask about the prevention of nose bleeds or the rapid occurrence of bruising (internal bleeding) in the patient.
If the case history shows that (post-bleeding) bleeding is to be expected, it is advisable to prepare suture material and possibly blood-stinging agents before the operation.
When a patient with toothache comes to the practice and an extraction is necessary, it is wise to ask if he may have used painkillers, and if so, which ones. Pain killers from the salicylate group slow blood clotting. Aspirin is an example of a salicylate.
If the patient's history shows serious blood clotting abnormalities in a patient, it is advisable to contact the patient's doctor to avoid risks.
In patients with an increased tendency to bleed, one must in practice take the certainty into account and after a bloody procedure, properly transfer the wound and possibly use an astringent.
Viral hepatitis (inflammation of the liver, popularly called "jaundice") is a very serious disease that can weaken the patient. The virus is primarily transmitted through blood and blood products. To a lesser extent, the virus enters the body via the oral route or is spread by faeces. The virus can enter the body through the gastrointestinal tract or because it is introduced into the blood stream. Symptoms of hepatitis include: poor appetite, nausea, vomiting, headache, yellowish skin color after a few days, dark-colored urine and light-colored stools. The incubation period is fifteen to twenty days. There are three known forms of hepatitis:
- Hepatitis infectiosa caused by the hepatitis A virus;
- Hepatitis B virus;
- Hepatitis C.
People are increasingly traveling distant and emigrating more often. This increases the chance that patients with hepatitis will be treated in dental practice. However, many people who carry the virus do not feel sick. Such persons are called carriers. One in two hundred people carries the hepatitis virus. Dental staff can also be carriers of the hepatitis virus. There are patients who have an increased risk for hepatitis, namely:
- Sprayers of drugs;
- Kidney dialysis patients;
- Male homosexuals with varying contacts;
- Patients who receive regular blood transfusions.
Dental professionals themselves are also at risk because of their profession. Among the carriers of the hepatitis virus, the virus is constantly multiplying and carried into the bloodstream (especially the hepatitis B virus). In addition, the virus is excreted with the faeces and occurs in the saliva. Vaccination against hepatitis B is mandatory for dentists and dental staff.
AIDS stands for acquired immune deficiency syndrome. It is an acquired disorder in the immune defense, caused by the HIV virus. If this virus invades a human, his defense is disrupted in such a way that relatively innocent germs can cause infections that are difficult to treat. Patients with AIDS symptoms will die within a few years of the first symptoms. The direct cause of death is often pneumonia.
The HIV virus is transmitted through sexual intercourse and blood and blood products. Non-sterile needles are the greatest risk when transmitted via blood. In addition, in the past the HIV virus was transmitted via blood transfusion or via transplantation. An unborn child can become infected by his mother through the placenta. Someone can be infected with the HIV virus without the occurrence of disease symptoms.
The occurrence of reactants in the blood that respond to the virus is indicated by the term seropositive. A large percentage of all untreated HIV-positive people actually get AIDS. It may be clear that apparently healthy people can indeed be HIV positive.
To date, there is no effective treatment. There is no vaccine against AIDS yet. Timely treatment with HIV inhibitors can prevent the HIV infection from having a fatal course in the form of AIDS. As a result, only 1% of HIV-positive people in the Netherlands die from AIDS. Preventing transmission of the virus is now the only method of control.
The herpes simplex virus is located on the skin, mucous membranes, eyes and in the central nervous system. Infection is probably done through the saliva. If one is infected for the first time with the virus (primary infection) then the body will produce antibodies. A primary infection makes someone feel very sick. The virus is then latent. This means that it is present in the body but does not cause any complaints. A secondary infection can occur with a reduction in resistance. For example with fatigue, menstruation, pregnancy, allergy and exposure to sunlight. The recurring blisters mainly occur on the lips (herpes labialis or cold sores).
The thyroid gland produces the hormone thyroxine, which controls the rate of metabolism. In hyperthyroidism or Basedow's disease, the thyroid gland produces too much of this hormone. Patients with this disorder are often nervous and sweat a lot. They also have an irregular heartbeat and increased blood pressure. The latter in particular poses a risk in dental practice. Dental treatments should preferably only be carried out if hormone production has been initiated with medicines.
During bloody procedures (periodontal surgery, rootplaning, extraction), microorganisms always end up in the bloodstream. We call this bacteremia. In normal cases, the body's defenses will ensure that these microorganisms are cleared out within a few hours. Bacteriaemia should be avoided in patients with a history of heart valve defects or acute rheumatism in the anamnesis. Certain bacteria tend to get scars or bumps on the heart valves in this group of patients. Because the bacteria remain stuck, these patients can get an inflammation on the heart valves, an endocarditis. The group of patients with heart (valve) defects should never run this risk. Before starting a bloody procedure, these patients must take antibiotic prophylaxis. This is a high-dose antibiotic that the patient takes one hour before the procedure. Microorganisms that end up in the bloodstream during treatment are controlled.
This shows that it is of utmost importance that the dentist is informed of the existence of heart (valve) abnormalities. The dentist must therefore ask for this; often patients with such an abnormality of their own already come up with this announcement.
Patients with prostheses in their bodies also often have to take antibiotics prophylaxis for bloody procedures. Examples of this are artificial heart valves, artificial vessels, artificial hips and knees.
If antibiotics are to be prescribed, this should preferably be done in consultation with the doctor or specialist treating the patient.
Dental treatments can simply be performed during pregnancy. However, the dentist will have to consider again and again whether a treatment can be postponed for a pregnant woman. Because there is a lot of cell division during the first three months of pregnancy, X-rays are not desirable. Also treatments after which pain relief is needed can sometimes be postponed better. Most painkillers cannot be swallowed during pregnancy. With dental treatment it may be necessary to adjust the position of the treatment chair.
Use of medication
If you ask a patient if he is healthy, he often answers in the affirmative. When asked if he also uses medication, it appears that there is something wrong in the medical field. The demand for medication use is therefore a control question at the end of the case history.
It is also important to know which medicines a patient uses, as these can influence dental treatment; for example, the use of anticoagulants.