Abstract

The aim of this article is to highlight the significance of dental examination and dental prophylaxis before surgery under anaesthesia. A complete dental examination and prophylaxis not only prevents oral sepsis and helps the surgical outcome positively, but also helps in the speedy convalescence post operatively. This article will discuss about the connect between oral and general health, challenges in proceeding with pre surgical dental evaluation and prophylaxis, benefits and possible solutions.

Introduction

The connection between oral health and general health is a well-established one. Various researches prove that dental and periodontal infections act as foci of infection affecting many internal organs. There are multiple challenges like loose teeth, oral sepsis etc. Oral foci of infection remain quiescent and may affect the surgical outcome negatively. This increases the need for additional interventional procedures and extensive usage of medical resources. Due to various reasons, pre surgical dental evaluation and prophylaxis is overlooked perioperatively and not prioritised. Pre surgical dental evaluation is as important as the basic presurgical blood investigations, body weight, hypertension status etc.

Oral – systemic health link

Mouth is the gateway to our body and reflects many inherent systemic changes. A poor dental health leads to poor nutrition and also improper oral phase of digestion (Fig.1). Patient’s recent dental history could be helpful in understanding the existing general health status. Poor oral hygiene may lead to inadequate dietary intake which might lead to weight loss.

Oral health and cardiovascular disease

Poor oral health leads to many periodontal pathologies which plays a role in initiation and development of cardiovascular disease. Evidences also support link between periodontitis and diabetes which is a precursor for most of the cardiovascular disease. Several organisms causing periodontal disease like Porphyromonas gingivalis, Treponema denticola, Streptococcus sanguinus and Aggregatibacter actinomycetemcomitans have been detected within the atherosclerotic plaque found within the blood vessels. (Fig. 2)

Oral health and organ transplant

During and after an organ transplant surgery, patients are usually under immunosuppressant drugs. Existing dental infection may exacerbate due to the immunocompromised state and it could be challenging to render dental treatment. Hence, it is always preferred to eliminate any dental infection and have an oral prophylaxis done preoperatively as a preventive measure.

Oral health and gynaecology

Pregnant women are susceptible to a wide range of oral health conditions that could be harmful to their own health and the health of the fetus. There are many myths about safety of dental care during pregnancy. Due to bad oral health, pregnant women can experience pregnancy gingivitis, pregnancy granuloma (Fig. 3), pregnancy tumours (epulis gravidrum), pre mature delivery, low birth weight, xerostomia and dental erosions. The 2nd trimester is the most appropriate period for delivering dental treatment. Postponing dental treatment closer to parturition is not advisable. Basic oral hygiene measures like brushing twice, flossing should be part of the counselling. Encouraging routine dental check-ups and oral prophylactic treatments before pregnancy will avoid hassles during pregnancy.

Oral health and Cancer patients

Presurgical dental evaluation is very significant in head and neck cancer patients. Preventive dental treatments like coronoplasty of sharp teeth, fluoride treatment, dental caries excavation and restorations will aid the surgical or the radiotherapy plan. Any periodontally compromised teeth needs to be eliminated pre radiotherapy to prevent osteoradionecrosis if intervened during or immediately post radiation. Presurgical dental evaluation would also help in assessing the need for oral surgical obturators post radical resection of the tumours and to plan prosthetic rehabilitation.

Oral health and intensive care patients

Although provision of oral hygiene is considered to be a basic nursing practice, its risk is relegated to a lower priority when caring for a complex intensive care patient. Surgical patients undergoing palliative treatment are particularly prone to oral morbidity that may require specific but simple remedies. Oral hygiene maintenance is integral to prevent VENTILATOR ASSOCIATED PNEUMONIA {VAP} – (Caused by Pseudomonas aeroguinas) in an ICU set up. Many studies showed the presence of microorganisms in the oral cavity, including Enterococcus faecalis, Fusobacterium periodonticum, Streptococcus oralis, Streptococcus sanguinis, Treponema denticola, which were related to increased amounts of bacteria obtained from respiratory tracts of patients with long term use of mechanical ventilation and intubation. ICU patients also suffer from xerostomia which could exacerbate to oral candidiasis. This could affect the surgical outcome adversely. Prevention of oropharyngeal morbidity should be given high clinical and nursing priority. Apart from the nursing oral assessment by Eilers et al (Reference article no. 5), dental opinion has to be sought. Mechanical brushing along with chlorhexidine mouth gargles or swabs should be helpful in maintaining oral hygiene in ICU. (Fig. 4)

Barriers or challenges in Pre surgical dental evaluation and prophylaxis

Surgical health care providers

1. Non availability or lack of access to dental health care providers
2. Lack of awareness about dental diseases and systemic complications
3. Lack of information on conservative methods of dental treatments
4. Difficulty in prioritising dental treatment among the multiple other complications
5. Lack of communication

Patient

1. Fear of unknown or anxiety regarding dental treatments
2. Logistical challenges of an add on procedure
3. Fear of delayed recovery from dental treatment
4. Difficulty in prioritising dental treatment at the juncture of surgery for their primary
complaint
5. Fear of exacerbation of the present disease

Dental health care providers

1. Lack of communication
2. Lack of complete understanding of the challenges of the surgeon
3. Poor overall understanding of the present health and drug status of the patient
4. Meeting the patient day before the surgery with multiple dental issues
5. Difficulty in prioritising and planning conservative management over conventional treatment
methods

A tentative guide to basic presurgical dental treatments

Disclaimer:  The guide could be helpful in decision making by healthcare providers pre– surgically. However, it is important to assess dental and general health status on a case by case basis, communicate and arrive at a safe treatment plan for the patient.

Conclusion

Oral cavity is a readily accessible and visible part of the body, which provides healthcare providers an opportunity to reduce the risk of infections perioperatively. Pre surgical dental evaluation and prophylaxis plays a significant role in surgical outcome and overall wellbeing of the patient postoperatively. Barriers to improve oral care arises many a times due to multiple reasons. Healthcare providers namely the surgeon, nurses and the dentists should together communicate and come up with an optimal plan to ensure the best of oral care which helps in better systemic health. Patients scheduled for major surgeries with untreated dental infections and oral inflammatory process may complicate the perioperative process. Therefore healthcare providers who familiarize themselves with dental complications and systemic well–being of patients are better placed to prevent dental infections and help to improve surgical outcomes and achieve holistic patient care.

References

1. Intraoral infection and oral health in the surgical patient: Need for concern during the perioperative period? Nyle blank and Thomas. M. Halaszynski, Connecticut Medicine, August 2015, 79(1): 19 – 25

2. Necessity of surgical dental foci treatment prior to organ transplantation and heart valve replacement, Jan Rustemeyer and Andreas Bremerich, Clin Oral Invest (2007) 11: 171 – 174

3. Bacteria and bacterial DNA in atherosclerotic plaque and aneurysmal wall biopsies from patients with and without periodontitis, Zahra Armingohar, Jorgen J. Jorgensen and Ingar
Olsen, J. Oral Microniol. 2014, 6: 10.3402

4. Hospital dentistry for intensive care unit patients: a comprehensive review, Mi–Kyoung Jun et al, J. Clin. Med, 202, 10, 3681

5. Development, testing and application of the oral assessment guide, J Eilers et al, Oncol nurs forum, May–Jun1988

Contributors:
1. Dr. Kalyani.P
2. Dr. Janani Rajendran

Dr. U. Rakesh
Consultant Dental Surgeon
Kauvery Hospital Chennai

Dr. Kirthana Rao
Consultant Dental Surgeon
Department of Dental and Maxillofacial Surgery