Esthetics in Function E-Book

Marcelo A. Calamita

• Herausgeber: Quintessence Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 878

Veröffentlichungsjahr: 2023

Beschreibung

The esthetic harmony and effectiveness of occlusal function are integrated and are in constant movement in the search for balance. This book, written by a top expert in the field, is about the preservation and enhancement of smile esthetics. The richly illustrated content aims to enhance the clinician's understanding of the static and dynamic principles that act on a patient's stomatognathic system. The main themes of the book – treatment planning and occlusion – are inseparable factors for the success of every restorative treatment. It is only from a complete understanding of the varied and complex relationships between these aspects that the clinician can diagnose and treat a patient with a pragmatic and effective long-term approach. In a clear and uncomplicated manner, the book presents protocols containing all the relevant aspects related to the topic so that excellent results can be obtained with consistency and predictability. The content is based on an extensive literature review and contains the best-quality scientific evidence available at the time of publication, accompanied by the author's valuable commentary and notes.

Leseprobe

ESTHETICSINFUNCTION

INTEGRATING OCCLUSAL PRINCIPLES INTO SMILE DESIGN

MARCELO A. CALAMITA

One book, one tree: In support of reforestation worldwide and to address the climate crisis, for every book sold Quintessence Publishing will plant a tree (https://onetreeplanted.org/).

Title of original issue:

Estética em Função, Integrando os Princípos Oclusais na Construção do Sorriso

Copyright © 2022 Editora Napoleão Ltda., 2022

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A CIP record for this book is available from the British Library.

ISBN: 978-3-86867-684-6

Copyright © 2023

Quintessenz Verlags-GmbH

All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher.

Translation: Luisa Cassiano, Denmark

Editing, layout, and production: Quintessenz Verlags-GmbH, Berlin, Germany

Dedication / Acknowledgments

Dedication

To my beloved wife Luciana: this work would not have come to fruition without the unwavering support you have graciously bestowed upon me. Your boundless love has been the driving force behind my endeavors, propelling me forward even in the face of challenges. Your love has nurtured my soul, allowing me to grow and flourish in ways I never thought possible.

To my precious children Rafael, Julia, and Leonardo: you have brought a profound and purposeful significance to my life. Your presence has been the catalyst for my personal development, and I am forever grateful for the boundless love and joy you bring to my world.

Acknowledgments

This work is the culmination of a lifetime of dedicated studies, relentless practice, and profound contemplation, nurtured by the invaluable teachings and thought-provoking questions from my beloved family, esteemed professors, colleagues, and students. Each of these enriching relationships has played a pivotal role in shaping me, both as a human being and as a professional. Their unwavering support and constructive influence have earned my eternal gratitude!

For the preparation of this book, I would like to give special thanks to:

The coauthors, Felipe Miguel Pinto Saliba, Christian Coachman, José ­Roberto Santana de Moura Junior, Guilherme Cabral, Alexandre Carvalho Teixeira, Eduardo Rodrigues Fregnani, and Wanessa Miranda-Silva for the priceless quality of the work carried out.

To those who donated their precious time and added academic value to this work, being Professors Robert Gray Coachman, Ivo Contin, ­Paulo Vinícius Soares, Leandro Hilgert, Julio Cesar Joly, Marcos Cesar Pitta, Adalberto de Paula Souza Jr, Gustavo Giordani, Simony Kataoka, Milton Missaka, ­Estevam Augusto Bonfante, Celso Orth, and Maria Luiza de ­Moraes ­Oliveira.

To all the dental laboratory technicians who worked alongside me with determination to exceed the expectations of each patient and who have helped me learn the techniques, possibilities, and limitations of each approach. I would especially like to mention CDT Christian Coachman, CDT Edson Silva, and CDT Diogo Meris Fidêncio, with whom I have had a close collaboration for many years.

To the meticulous work of Editora Napoleão / Quintessence Publishing, with their tireless teams in the pursuit of excellence, namely proofreader Marise Ferreira Zappa, illustrator Daniel Guimarães, graphic designer Deoclesio Alessandro Ferro, and work coordinator Fernando Custódio, in addition to the directors William Napoleon and Leonardo Napoleon.

There is a piece of all of you in these pages!

MARCELO A. CALAMITA

FOREWORD ~ MICHAEL COHEN

You are about to embark on an extraordinary clinical journey that will change the way you think about treating patients. There is no better guide than Dr. Marcelo Calamita as you travel this path. This master clinician and extraordinary educator possesses a generosity of spirit and a caring nature that is second to none.

Indeed, what makes Esthetics in Function so unique among dental tomes is that it clearly depicts Dr. Calamita’s mindset and broad-based treatment philosophy that includes strong interpersonal communications skills, a deep sensitivity to patient needs, and the ability to provide the necessary emotional support, all of which are essential but often missing components in achieving overall treatment success.

With his precise analytical skills and meticulous approach to comprehensive care, Dr. Calamita brings a fresh approach to diagnosis and treatment planning and a new clarity to the kinds of methodologies that can lead to more predictable treatment outcomes. In short, this book will guide dentists in becoming more capable clinicians, with their patients being the true beneficiaries.

With the wealth of resources made available through university education, postgraduate courses, study clubs, dental seminars, and the internet, clinicians are now able to quickly access a vast amount of information that can assist in diagnosis and treatment planning. However, many still have difficulty in recognizing occlusal dysfunction and incorporating the remedies effectively into a comprehensive treatment plan. One of the great strengths of this publication is its focus on the importance of thoroughly understanding the principles of occlusion and occlusal disharmonies as a prerequisite to achieving optimal smile esthetics and successful restorative outcomes.

As founder of Seattle Study Club and editor of two textbooks on interdis­ciplinary treatment planning, I have devoted much of my professional life to providing practicing dentists a university-like continuing education experience and making an essential connection between aspiring practitioners and top educators such as Dr. Calamita. These clinicians may have their own unique practice philosophies, but the common thread between them is that they have an insatiable thirst for knowledge and want to provide the highest-quality patient care.

However, as dentists become increasingly confident in interdisciplinary and multiphased treatment discussions, there is also a greater need for a systematic approach as new levels of understanding and technology are reached. Dr. Morton Amsterdam (considered the “Father” of Periodontal Prosthesis) has been referenced repeatedly over the years as having proposed that there are many options or ways to treatment plan a case, but there is only one correct diagnosis. The closer we come to attaining an accurate diagnosis, the more successful and sustainable the treatment.

In this regard, Esthetics in Function helps clinicians in improving their diag­nostic acuity and then prepares them to proceed with a “customized” treatment plan in concert with their patient’s wishes.

Dr. Calamita also addresses many of the challenges that still remain for those committed to implementing a comprehensive treatment approach:

Where to begin in establishing a meaningful comprehensive treatment plan;

How to develop an organized, reproducible, and effective way that predictably leads to an accurate case diagnosis;

Understanding how occlusal dysfunction can affect restorative treatment outcomes and incorporating solutions into the overall treatment plan; and

Once a case diagnosis has been established, how the interdisciplinary team can work together in developing a treatment plan that will best serve both the treatment team’s abilities and the patient’s desires.

Esthetics in Function is a welcome addition to the body of knowledge that currently exists regarding the often-overlooked relationship between occlusion and esthetics. There is no question in my mind that it will be a much-referenced publication for years to come.

MICHAEL COHEN, DDS MSD FACD

Founder of Seattle Study Club

Author / Editor of two bestselling books on Interdisciplinary Treatment Planning (Quintessence Publishing)

FOREWORD ~ CHRISTIAN COACHMAN

I believe that one of the primary shortcuts to success is having the opportunity to interact with true mentors. Even better if these mentors become great friends and partners in life projects.

I have had that privilege. Marcelo is undoubtedly one of the leading names in the exclusive list of people who have directly impacted my career and helped me to become who I am.

Therefore, writing this Foreword fills me with pride and emotion. This happiness is also because I followed the process of creating this book and knew of Marcelo’s immeasurable dedication and passion for this work.

This book is a beautiful tribute to ethical, interdisciplinary, high-performance dentistry. It is the summary of a life dedicated to our profession. It combines tireless research and the pursuit of excellence with the determination never to settle for the mediocre. This work is a gift of a great professional to all of us who are passionate about esthetic–functional rehabilitation. I call it a gift because the focus is on actual teaching, the kind that changes behavior, transforms the complex into the simple, helps in the daily decision-making processes, and allows dentists to positively impact the lives of their patients. It is a realistic book that teaches the scientifically based and the clinically feasible, constituting a manual, a tutorial, and a reasoning guide that only true teachers can create.

I met Marcelo in the early 1990s. I had just started college, and at the time, he was working with my father as a prosthodontist at the Keyes-Coachman Institute, a landmark in interdisciplinary esthetic dentistry. I well remember my father praising Marcelo and his bright future. He became his principal collaborator, not only in patient care but also in developing team workflows. With his unique ability to research, organize, and catalog information, Marcelo helped create pioneering protocols that I use to this day to explain modern dentistry concepts, which was fundamental for developing the DSD (Digital Smile Design) concept.

When I became a dental technician, Marcelo became my second client, only after my father. He bet on me before I became a good professional. The brainstorming we have constantly done resulted in my passion for treatment planning and function. He was also my professor of Dental Prosthesis at college (FOUSP) and encouraged me to discover another passion of mine: teaching. We helped each other to find new and better didactic strategies to express our ideas. The first dental book I ever read, while I was still in college, was the classic on occlusion by Peter Dawson, in which Marcelo was part of the Portuguese translation team.

All of the above shows how important my professional and personal relationship with the author of this work is, to the present day. I perfectly remember the outstanding achievements we enjoyed such as proudly representing Brazilian dentistry with joint lectures on stages of great international congresses such as the Seattle Study Club, International Federation of Esthetic Dentistry, and American Academy of Esthetic Dentistry.

I also remember the numerous congresses we attended together and how Marcelo never missed an opportunity to learn. His excellent notes and the way he ascertains, filters, analyzes, organizes, and complements the information presented are unique, and his summaries are robust. I used to call them the “dental encyclopedia,” and this quality is undoubtedly one of the great reasons why this book will be so valuable.

Every time I show our joint work around the world in my lectures, I always mention: “…this case or concept I developed with my great partner, the brother that dentistry gave me and one of the best prosthodontists I know.”

I say and repeat this with conviction, and each year, this statement becomes more accurate.

Thank you, Marcelo, for your dedication and willingness to share. Thank you for your friendship and teachings. Thank you for this book and for the honor of writing this Foreword.

We continue on this beautiful journey together.

CHRISTIAN COACHMAN, DDS CDT

Author

MARCELO ALEXANDRE CALAMITA

Master’s degree and Doctor in Dental Prosthesis (FOUSP);

Specialist in Dental Prosthetics (CFO);

Courtesy Professor, Department of Restorative Sciences, University of Florida School of Dentistry (USA);

Former Adjunct Professor of Dental Prosthesis at the Universities Braz Cubas (Mogi das Cruzes-SP/Brazil) and University of Guarulhos (Guarulhos-SP/Brazil);

Former President of the Brazilian Society of Esthetic Dentistry (SBOE) and of the Brazilian Academy of Esthetic Dentistry (ABOE);

Current member of the scientific editorial board of the Journal of Esthetic and Restorative Dentistry, in addition to the International Journal of Esthetic Dentistry and the International Journal of Periodontics and Restorative Dentistry (Portuguese editions);

Clinical practice with a focus on Restorative Dentistry since 1988.

Coauthors

Alexandre Carvalho Teixeira

Master’s degree in Periodontics (UERJ);

Specialist in Dental Prosthetics (UERJ);

Professor of the residency course in Fixed Prosthetics at the State University of Rio de Janeiro (UERJ);

Works as a clinician and is co-owner of the Private Clinic CTO (Carvalho Teixeira Odontologia).

Christian Coachman

Dentist (FOUSP) and Dental Prosthesis Technician;

Visiting Professor, Department of Restorative Dentistry, University of Pennsylvania School of Dentistry (USA);

Former Master Ceramist for Team Atlanta (USA);

Founder and CEO of DSD-Digital Smile Design Company;

Director of the DSD Residency clinical course program.

Eduardo Fregnani

Master’s degree in Stomatopathology (UNICAMP);

Doctor in Medical Sciences (AC Camargo Hospital);

Specialist in Endodontics and Oral Pathology.

Felipe Miguel Pinto Saliba

Master’s degree in Dentistry (UERJ);

Specialist in Dental Prosthetics (UNIGRANRIO).

Scientific Director of the Brazilian Institute of Modern Dentistry (IbomRio);

Postgraduate professor (UNIGRANRIO);

DSD Key Opinion Leader.

Guilherme Cabral

Dental Surgeon (FOUSP) and Dental Prosthesis Technician;

Former Master Ceramist for Team Atlanta (USA);

Visiting Professor, Department of Restorative Dentistry, Georgia Regents University School of Dentistry (USA);

Member of the board of applied technology of Revista Prótese News;

Director of the ARTIS Institute – Esthetic Dentistry Training Center (Taubaté-SP).

José Roberto Santana de Moura Junior

Specialist in Restorative Dentistry;

Master’s degree in Dental Prosthetics;

Current President of the Brazilian Society of Esthetic Dentistry (SBOE);

Former President of the International Federation of Esthetic Dentistry (IFED);

Former Director of the Academy of Microscope Enhanced Dentistry (AMED);

Teaches courses and lectures in Brazil and abroad on Esthetic Dentistry and the use of High Magnification in daily practice;

CEO of Instituto ARTIS – Esthetic Dentistry Training Center (Taubaté-SP);

Has worked in private practice since 1983 (Taubaté-SP).

Wanessa Miranda-Silva

Master’s degree and Doctoral student in Health Sciences (Sírio-Libanês Hospital);

Specialist in Endodontics;

Attended a multidisciplinary residency in Oncology.

The search for excellence is a continuous process with no predetermined itinerary or specific destination, and it is related to how we can evolve and offer our best daily.

It is a life purpose that transcends any material good and aspires to achieving a fulfilling life on the personal, professional, and spiritual levels.

“We are what we repeatedly do.

Excellence, then, is not an act, but a habit.”

Aristotle (384–322 BC)

CONTENTS

PREFACE

Part 1. The treatment planning process

01. Anamnesis

02. Clinical examination

03. Interdisciplinary treatment planning

04. Selection of restorative materials

05. Treatment plan presentation

06. Control and maintenance

Part 2. Esthetics and function

07. Introduction to functional occlusion

08. Mounting on a semi-adjustable articulator

09. Maxillomandibular relationship

10. Functional guidance

11. Vertical dimension of occlusion

12. Occlusal plane

13. Occlusal adjustment

14. Stabilizing interocclusal splint

Index

PREFACE

Everything in life needs a purpose!

With this statement in mind, I began to reflect on the purpose of the present work. Writing a book takes an immense amount of time, more than we can count. It also includes a need for organization, discipline, and enormous efforts, more than we believe we have. I think it is impossible to predict how challenging and demanding the task of materializing all our studies and experiences in words and images will be.

To fully execute this journey, it will be necessary to make it relevant, practical, and uncomplicated. If the current amount of information is immeas­urable, it is up to me to refine it with care, consistency, and without bias, to make it available in a practical way to our readers. Thus, these pages are based on an extensive literature review and contain the best-quality scientific evidence available at the time of publication, accompanied, when deemed pertinent, by the author’s comments.

This book is not intended to be a closed, complete, or definitive package of information. It suggests an organized system based on a thorough diagnosis that provides rational decision-making and effective personalized treatment planning. The primary objective is to obtain predictability and consistency within a process to be constantly refined according to the abilities of each interdisciplinary team.

The book’s central themes – treatment planning and occlusion – are inseparable factors for the success of any restorative treatment and, why not say, for the reputation of a dental clinic in the long term. However, I often observe that perhaps because these topics are not addressed with the necessary clarity and scope, there remains a deficiency in the understanding and practical application of these concepts by clinicians in general, causing frustrations and failures in dental treatments.

From my perspective, Esthetics in Function refers to the preservation or enhancement of smile esthetics. It is intrinsically connected to understanding static and dynamic functional principles that act on the patient’s stomatognathic system. Therefore, the esthetic harmony and effectiveness of occlusal function are integrated and are in constant movement in the search for balance. It is only from the complete understanding of these varied and complex relationships that the dentist, also a being in continuous evolution, will be able to diagnose and treat the patient with a pragmatic and effective long-term approach.

I tried to make evident the concern in sharing a humanized approach for the broad understanding of the patient that is also practical in applying esthetic, functional, structural, and biologic principles that underlie all treatments. From this point of view, the patient will always be the central focus of attention, and the dentist and their team must do everything to welcome, understand, and treat the patient as comprehensively as possible.

Through these pages, I encourage each professional to develop as complete an understanding of their work system as possible as well as an extensive clinical repertoire that integrates systemic and dental health for the patient’s benefit. The dentist must become a complete being – multimedia and ethical – developing broad competencies, such as, for example, emotional intelligence, interpersonal communication skills, management, and leadership principles, in addition to being aware of the constant technologic advances occurring in our profession.

Finally, my purpose with this book is not to teach anything in particular but to stimulate changes in the reader’s thoughts, feelings, and attitudes based on shared knowledge, experiences, and failures, helping to solidify a path toward excellence and achievement.

Enjoy reading.

MARCELO CALAMITA

Part 1

The Treatment Planning Process

The integration of the patient’s needs and wishes with the biologic, structural, functional, and esthetic aspects of the stomatognathic system

Chapter 1

ANAMNESIS

Introduction

“The most sophisticated and meticulous technique will fail if not based on full knowledge of the patient’s needs, wishes, and expectations through a pragmatic anamnesis, a thorough examination, and a correct diagnosis.”

“It is the dentist’s mission to determine what led the patient to present with that oral health condition at that given moment in their life concerning biologic, structural, functional, and esthetic aspects.”

The practice of outstanding dentistry has as its primary mission the preservation or restoration of the standard of health, comfort, function, and orofacial esthetics. Maximum attention to the anamnesis, clinical examination, diagnosis, and treatment planning processes is needed to achieve these noble goals [Figure 1-01].

[Figure 1-01] Synopsis of the overall context of the anamnesis, clinical examination, diagnosis, and treatment planning process. All the steps mentioned below are interconnected and contribute to developing a complete treatment plan capable of achieving consistent, high-quality results.

Welcoming and greeting the patient

The patient’s first contact with the clinic could be via phone, website, email, social media message, or in person. At this point, the trained receptionist should be kind and helpful, as the initial contact with the patient represents the first impression of the clinic. The receptionist should also ask the patient about the main reason for the appointment, whether there is pain or discomfort, and whether there is a need for urgent care for any other reason. This attitude demonstrates concern for the well-being of the “future” patient and allows the receptionist to gather helpful information for the dentist who will treat the patient. It is also advisable to ask the patient who the clinic should thank for the referral so as to reinforce the interpersonal bonds that facilitate communication.

The day before the appointment, the patient should receive a confirmation call or message (depending on the preference confirmed at the initial contact) as well as other information such as directions to the clinic and where to park a vehicle.

Upon arrival at the clinic, the patient should be warmly welcomed and greeted by the receptionist, who should introduce themselves and offer water, coffee, tea, or anything else in particular. For the comfort of the patient, a selection of varied and updated magazines should be available as well as the Wi-Fi password for internet access [Figure 1-02].

[Figure 1-02] Clinic overview: a warm and comfortable clinic décor has the potential to make the patient feel welcome and at ease.

As soon as the patient settles down, the receptionist should give them a Welcome Form and Medical-Dental Questionnaire [Figure 1-03], briefly explaining how to fill them out and remaining available to help in case of questions.

[Figure 1-03] The purpose of the Welcome Form is to succinctly present particular details of the clinic.

The Medical-Dental Questionnaire should be constantly updated, revised, and customized according to the clinic’s services. It should contain all the critical and significant patient data, avoiding redundant or unnecessary questions and information that is superfluous and irrelevant to treatment planning. Extensive forms are counterproductive and tiring for the patient to fill out. Additional data will be collected by the dentist and added to the back of the questionnaire following the initial conversation with the patient.

Author’s note

I deem it necessary to thank and cite all the principal authors who have helped to build or improve this anamnesis, clinical examination, and treatment planning protocol, which I have used in my clinic for almost 30 years. These authors include Richard Roblee1, Ronald Goldstein2, John Kois3, Frank Spear4, Michael Cohen5, Gerard Chiche6, Lindsey Pankey7, Mauro Fradeani8, Peter Dawson9, Jeffrey Okeson10, Stephen Stefanac11, and Norman Wood12.

Completing the Medical-Dental Questionnaire at the reception will provide the dentist – even before any direct interaction with the patient – with an initial overview of the main concern(s) or other critical factors to be explored during the anamnesis and clinical examination. Its thorough completion has the implicit objective of streamlining and directing the anamnesis, clinical examination, and complementary examinations without losing focus of the human value or of good interpersonal communication. Affirmative responses to open-ended and generic questions will allow the aware clinician to actively review, explore, and complete each question through attentive and empathetic conversation during the initial appointment and to add relevant information to the treatment plan.

Once completed, the Medical-Dental Questionnaire should be folded and placed in an envelope due to the confidential nature of its content.

QR code linking to the Welcome Form and Medical-Dental Questionnaire templates that can be customized.

The first appointment in two acts: anamnesis and clinical examination

The first appointment is full of expectations, and the primary goals are to get to know the patient and develop a solid relationship of trust with them. The patient brings with them the anxiety of meeting a dentist with the supposed competence to solve their problems and – fundamentally – recognizing in the person of the dentist someone genuinely concerned with understanding their needs, wishes, priorities, and fears. Lindsey Pankey, one of the great references in the history of dentistry, explains that patients choose their dentists for their skills, care, and judgment. Skills are related to technical attributes, and care and judgment pertain to empathy and wisdom7. Thus, the only thing that is not a guarantee of harmony in this relationship is the professional’s academic credentials [Figure 1-04].

[Figure 1-04] The first appointment is full of expectations. The environment should be peaceful, and the communication process should occur without interruptions. The dentist should make it clear that the purpose is to answer the patient’s questions or help them understand the existing problems.

The anamnesis (from the Greek ana, to bring again, and mnesis, memory) is a structured interview to obtain relevant data from the history of complaints and the development of the disease (the problem) from the patient’s perspective. When performed effectively, the anamnesis is responsible for generating much of the information necessary for the diagnosis and should be complemented by the clinical examination and complementary tests.

The quality of the anamnesis has a direct influence on the treatment, and it is therefore recommended to set aside adequate time for the first appointment. Although it is difficult to determine a specific period because personal histories and clinical cases differ, a one-hour appointment seems to be a good average. The time allocation should be as follows: approximately 20 to 30 minutes (min) for the anamnesis, 20 to 30 min for the clinical examination, and 10 min for finalizing the appointment [Table 1-01].

[Table 1-01] Average estimated time for the first appointment procedures.

First appointment

Procedure

Approximate time (min)

Anamnesis

20 to 30

Clinical examination

20 to 30

Appointment conclusion

10

Dentist-related aspects

Ideally, the anamnesis and clinical examination appointment should be carried out by the dentist responsible for planning and coordinating the treatment. With experience, the dentist will be able to detect the needs and expectations of each patient and, based on the degree of complexity of the findings, define whether the treatment will require other specialists.

The dentist should greet the patient in a friendly and welcoming way. The anamnesis should be performed without interruptions, in a calm environment – preferably non-clinical – where the patient feels less vulnerable. At this point, clear and focused communication is the dentist’s essential tool when facing the patient.

The anamnesis should have a predefined practical script but should also be flexible so that it accommodates the patient’s characteristics and facilitates communication. It should be started in a friendly way, aiming to open up and relax the conversation with, for example, a mention of thanks to the person who referred the patient or sincere affection for a mutual acquaintance.

Based on the Medical-Dental Questionnaire, some critical questions related to the main concern and the history of the problem(s) should be addressed, allowing the patient to explain the reasons that brought them to the clinic. The organized documentation of all the critical data from this questionnaire is recommended. The use of checklists proposed by this author practically eliminates the tendency of failing to analyze all potentially important data for treatment and has been considered essential in all areas of health, significantly reducing the incidence of medical errors13.

Before the patient starts their report, the dentist needs to mention that they will be taking notes of the most critical data while the patient speaks. This statement of intent shows consideration for the patient, who could feel undervalued if, at this sensitive moment, the dentist is taking notes with their head down instead of making eye contact. During the anamnesis, the dentist should speak as little as possible, preferably only if and when requested or questioned, and provide general and brief answers, as the patient will not yet have been objectively examined. Above all, the dentist needs to be interested in the patient’s message rather than try to be interesting.

The patient should be listened to effectively and with affection, without any personal filters or judgments that could increase their feeling of vulnerability14. This moment is potentially loaded with subjective information, feelings, and expectations. The dentist needs to expand the doors of their perception to capture the minimal and subtle nuances of verbal and non-verbal communication, such as tone of voice and body language15, as these can add significant psychologic aspects to the treatment.

It is essential to consider whether the reported problems are relevant and whether the patient has already done anything to treat them. In addition, what the patient expresses regarding previous treatments or dentists is of paramount importance. Individuals who transfer their frustrations or the blame for their problems onto previous dentists need to be evaluated with extra care, as they may represent the type of patient who does not take their responsibilities in the treatment seriously or is not adequately committed or motivated. After listening to the patient carefully, the dentist needs to reflect – with rationality and humility – whether they will be able to overcome such obstacles or expectations.

Emergency cases

Dental emergencies are frequent gateways for new or old patients to return to the clinic. They are usually related to pain, discomfort, infection, or inflammation relief (of endodontic, periodontal, periapical, or traumatic origin, or have to do with temporomandibular disorders [TMDs]), in addition to the immediate resolution of any esthetic problems.

In these cases, the anamnesis and the clinical examination should be short and specifically directed at the patient’s complaint, addressing it with prompt effectiveness. After the temporary or definitive resolution of the emergency, these patients should be educated about the need for an additional appointment for a complete anamnesis and clinical examination. In this context, many patients will comply with these recommendations and continue with treatment, while others will not continue once their urgent needs have been met.

The patient–dentist relationship

The interpersonal aspects of the patient–dentist relationship need to be discussed because they are essential in all phases of treatment. Knowledge of the patient’s emotional and psychosocial dimensions helps the dentist to develop a relationship of mutual trust and broaden the understanding of the treatment’s risks and limitations, in addition to establishing a partnership to achieve and maintain the best long-term results16,17.

Although it is beyond the scope of this book to delve into topics related to psychology or behavioral therapies, since this would be an extensive matter and be subject to multiple interpretations, the dentist should have a basic understanding of the psychologic elements of their interaction with the patient.

More than 80 years ago, the American Dental Educators Association emphasized the need to understand aspects related to patient behavior. Since then, psychiatrists, psychologists, and dentists have been studying how individuals react to the experience of being patients17.

Some classifications of psychologic profiles have been described in the literature17-22. One of the first citations regarding personality types or “moods” of individuals was proposed by Hippocrates (460 to 370 BC)18. In his work, he described four basic temperaments: choleric, sanguine, melancholic, and phlegmatic. This description has been a source of reference for countless other authors throughout history.

A classification of patients’ behavior patterns according to tooth loss and their adaptation to complete dentures is accredited to House17,20,21. According to that author, patients belong to one of four groups – philosophical, exacting, hysterical, and indifferent – according to their psychologic make-up, experiences, difficulties, and expectations. The philosophical patient is rational, sensible, balanced, calm, and accepts the dentist’s diagnosis, treatment, and prognosis recommendations. The exacting patient is methodical, precise, impatient, and may require additional attention and care from the dentist. These patients are concerned about the appearance and efficiency of complete dentures. They are usually dissatisfied with the treatment and reluctant to accept the dentist’s advice, and they request written guarantees. The hysterical patient is erratic, anxious, presents negative behavior about their current condition, and often has unrealistic expectations such as the notion that the denture will function similarly to their teeth. On the other hand, the indifferent patient is apathetic, has low motivation, and is unconcerned about appearance or chewing ability. These patients usually have low adherence to the treatment.

This author has been using a recent classification that, like the one by Hippocrates (to which it may be related), defines four distinct types of personality profiles: director, thinker, socializer, and relater. It offers a pragmatic point of view to understand patients’ psychologic profiles and values and to enhance the communication and collaboration process between the patient and dentist23[Table 1-02].

Director: These patients are direct, competitive, often impatient, demanding, and focused on results. They are not there to establish new relationships but instead to effectively solve their problems. They are usually outgoing, assertive, and take risks.

When dealing with these patients, it is essential to demonstrate knowledge and competence and to be punctual, specific, and direct in communication. It is recommended to share critical information so that they actively participate in the decision-making process to reach the most appropriate solutions.

Thinker: These patients are methodical, centering, critical, and generally serious; they are detail-oriented and focused on facts, not on building interpersonal relationships. Unlike directors, they are not impulsive and are averse to taking risks.

These patients need to trust the dentist and recognize the purposes of the treatment. They require detail and time to evaluate treatment options and make decisions based on reason and caution.

Socializer: These patients are outgoing, spontaneous, dynamic, and persuasive. The main difference between them and the directors and thinkers is that they focus on interpersonal relationships and on obtaining social recognition, not on solving tasks.

With these patients, one should maintain a relaxed and friendly atmosphere, ensuring that every detail of the conversation is understood without losing its primary purpose.

Relater: These patients are the friendliest of all the personality types. They are generally tolerant and apathetic. They value their sense of belonging to a group and dislike changes to their routine or interpersonal conflicts. They are indecisive or slow to make decisions because they do not trust easily, but when they do, they are loyal. They are balanced and calm people.

The relater needs a calm and attentive communication process and appreciates safe and conservative alternatives that guarantee comfort and stability.

According to Alessandra and O’Connor23, 80% of people present one or two dominant personality types. Therefore, recognizing the patient’s profile is essential to treating them according to the “Platinum Rule”23, in other words, the way they would like to be treated.

[Table 1-02] Behavioral characteristics associated with different personality profiles23. The dentist should understand the communication process from the patient’s point of view.

Personality profiles

Director

Thinker

Socializer

Relater

Direct

Methodical

Communicative

Tolerant

Competitive

Centering

Spontaneous

Accommodating

Impatient

Critical

Dynamic

Emotional

Demanding

Concerned about details

Unconcerned about details

Indecisive

Goal-oriented

Task-oriented

People-oriented

People-oriented

Outgoing

Serious

Outgoing

Balanced

Assertive

Logical

Persuasive

Calm

Essential aspects of communication

Essential aspects of communication

Essential aspects of communication

Essential aspects of communication

Show knowledge and competence

Develop a relationship of trust

Maintain a relaxed and friendly atmosphere

Relaxed and attentive communication

Objectively specify the main point of the treatment

Emphasize the purposes and logical aspects of the treatment

Ensure that all the key points are understood

Offer safe and conservative alternatives

Be prepared for objections and negotiation

Provide details and give the patient time to decide carefully

Engage the patient without detracting from the purpose of the conversation

Focus on confidence, comfort, and stability

Needs versus WISHES

The patient comes to us with their unique needs, wishes, priorities, and expectations. Needs basically refer to discomfort or pain related to functional, structural, or biologic problems. They may also be due to some esthetic concern such as a fractured tooth or restoration. Wishes are generally related to an improvement in the general condition of the teeth or the appearance of the smile, although in today’s highly competitive world it is not clear whether esthetics is a necessity or a wish due to the preponderant role of self-confidence and self-esteem in the individual’s daily activities.

It is recommended to determine the extent of the patient’s expectations regarding the treatment so that they can be contextualized in relation to the limitations of the different treatment options. In this author’s opinion, the failure to determine and modulate patient expectations is one of the greatest sources of failure and frustration in clinical practice. Patients with high expectations are challenging, but generally ensure that the dentist’s dedication produces personalized work. On the other hand, litigation can result from patients with unrealistic expectations or those with psychosomatic disorders24 due to the difficulty or impossibility on the part of the dentist to meet their expectations.

Needs

Discomfort or pain related to functional, structural, or biologic problems; may also be due to an esthetic concern such as a fractured tooth or restoration

Wishes

Improvement of the general condition of the teeth or appearance of the smile

Expectations

Determined and modulated according to the diagnosis and treatment limitations

Conclusion of the initial appointment

At the end of the initial appointment, after the clinical examination, the dentist should make a didactic summary of the most significant findings, making it clear to the patient that the analysis of the information is still incomplete and that it will be reviewed after the evaluation of the complementary examinations and discussions with the interdisciplinary team during treatment planning. This summary has the primary objective of guiding the patient about their current conditions and presenting a safe path to be followed with the personalized and detailed work of a trained and committed team. At the end, a brief presentation of images of similar cases performed by the dentist and their team allows an opportunity to show the level of professionalism involved and encourages patient motivation [Figure 1-05].

[Figure 1-05] The succinct presentation of clinical cases showing treatments similar to those probably required by the patient increases the patient’s motivation because it allows them to see the quality of the work performed by the dental team.

Before saying goodbye, it is suggested to ask the patient whether there are any questions or special considerations regarding everything that has been discussed up to that point. The second appointment should be scheduled as soon as possible but with sufficient time in between to allow the dentist coordinating the treatment to gather all the data and expert reports and to prepare the preliminary treatment plan(s).

Fees

It is recommended to avoid any mention of the financial aspect of treatment during the first appointment, as all the data from the anamnesis, clinical and radiographic examinations, and models mounted on the articulator have not yet been assessed by the dental team. In addition, the patient is not yet aware of the extent of the problems and possible consequences. If, however, the patient insists, the experienced dentist can provide a rough estimate of the expected financial commitment, using costs from similar cases of patients treated in the past year. At this point, it is important to make it clear that treatment planning is essential to define the exact stages and treatment costs more precisely.

Practical tips to improve communication

A good dentist is not only distinguished by their scientific knowledge or technical expertise. They should understand the patient as unique and communicate with them in an empathetic, kind, and respectful way

Let the patient tell their story: use open-ended questions to get as much information as possible (e.g. What is the main reason for your initial contact? How can I help you?)

Avoid interrupting patient reports: use facilitators during the conversation (I see..., continue...) or clarifiers to check for correct understanding (as I understand it, do you mean...?)

Validate the patient’s point of view and explain in a way that makes sense to them, avoiding technical terms

Do not use words with negative emotional connotations such as loss, grinding, extraction, surgery, cut, pain, blood, etc

Use words with positive emotional connotations such as restoration, health, esthetics, comfort, proven, reliable, durable, safe, modern, etc

Give the patient a sense of co-participation and co-authorship of the treatment by sharing relevant information with them

Demonstrate commitment, concern, and honesty in all your dealings with the patient

Importance of the Medical-Dental Questionnaire

Marcelo Calamita

Eduardo Rodrigues Fregnani and Wanessa Miranda-Silva

As explained above, the Medical-Dental Questionnaire should cover the most frequent medical and dental conditions and be accompanied by a candid conversation about the relevant facts that may emerge during the appointment and that are essential for the proper management of the patient.

It is estimated that 25% to 30% of patients seeking dental treatment25 have at least one potentially relevant systemic issue. For the safety of all involved, the dentist should be prepared to assess and identify situations that require modifications to their conventional conduct. They may be faced, for example, with the need to perform a surgical procedure on a patient with heart disease using anticoagulant medication. Alternatively, they might have a diabetic patient, who, when the diabetes is not controlled, may have altered wound healing capacity in the face of some clinical procedures. Thus, a number of systemic conditions need to be understood in order to take safe and effective preventive measures before, during, and after treatment.

Medical-Dental Questionnaire

The primary purpose of this questionnaire is not to carry out an extensive, complete, or definitive review of all possible health issues, the medication used, and the patient’s dental treatment history. Rather, its central objective is to identify the main risk factors that could involve changes to the treatment plan and effective patient care [Figure 1–06; Table 1-03].

[Figure 1-06] The Medical-Dental Questionnaire should contain all the critical issues that have the potential to interfere with the patient’s diagnosis and treatment plan. The receptionist should provide a brief explanation to the patient of how to fill it out and be available in case of questions. This document will be a roadmap for all significant data related to the patient’s medical and dental history. Its understanding and effective use will be the foundation for a successful treatment plan. The patient will fill out the first page, and the dentist the second page.

[Table 1-03]

Summary of the implications of systemic problems on the treatment plan

Systems

Reported problem

Systemic and oral changes Risk of complications

Treatment plan guidelines

CARDIOVASCULAR

Systemic arterial hypertension

a.Risk of bleeding

b.Adverse effects of antihypertensive medications: xerostomia, taste alterations, periodontal disease, and lichenoid lesions

c.Orthostatic postural hypotension

d.Risk of infections by manipulation of gingival and bone tissue (extraction, dental implants, periodontal and periapical surgeries)

1.Referral for medical evaluation

–Anticoagulant: evaluate the indication and risk/benefit of discontinuing the medication prior to surgical procedures and the medical interruption interval

2.Determine the risk of intervention – ASA (American Society of Anesthesiologists) (see Appendix)

–ASA III or IV: analyze the risk/benefit of the therapeutic proposal and the need to use an anesthetic without a vasoconstrictor

3.It is contraindicated to perform procedures if the patient’s blood pressure (BP) > 160/110 mmHg

4.Assess drug interaction:

–Nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce the effectiveness of antihypertensive medications

5.Avoid using gingival retraction cords soaked in epinephrine

6.Pay attention to the positioning of the chair

7.Take steps to control the patient’s anxiety

8.Give preference to morning appointments

9.The anesthetic of choice is prilocaine with felypressin – use a maximum of two carpules per appointment

Myocardial infarction

a.Risk of bleeding

b.Orthostatic postural hypotension

1.Referral for medical evaluation

–Anticoagulant: evaluate the indication and risk/benefit of discontinuing the medication prior to surgical procedures and the medical interruption interval

2.Determine the risk of intervention – ASA (see Appendix)

–ASA III or IV: analyze the risk/benefit of the therapeutic proposal and the need to use an anesthetic without a vasoconstrictor

3.It is contraindicated to perform procedures if the patient’s BP > 160/110 mmHg

4.Assess drug interaction:

–NSAIDs may reduce the effectiveness of antihypertensive medications

5.Avoid using gingival retraction cords soaked in epinephrine

6.Pay attention to the positioning of the chair

7.Take steps to control the patient’s anxiety

8.Give preference to morning appointments

9.The anesthetic of choice is prilocaine with felypressin – use a maximum of two carpules per appointment

10.Assess the temporality of the event

Cardiac insufficiency

a.Risk of bleeding

b.Orthostatic postural hypotension

1.Referral for medical evaluation

–Anticoagulant: evaluate the indication and risk/benefit of discontinuing the medication prior to surgical procedures and the medical interruption interval

2.Determine the risk of intervention – ASA (see Appendix)

–ASA III or IV: analyze the risk/benefit of the therapeutic proposal and the need to use an anesthetic without a vasoconstrictor

3.It is contraindicated to perform procedures if the patient’s BP > 160/110 mmHg

4.Assess drug interaction:

–NSAIDs may reduce the effectiveness of antihypertensive medications

5.Avoid using gingival retraction cords soaked in epinephrine

6.Pay attention to the positioning of the chair

7.Take steps to control the patient’s anxiety

8.Give preference to morning appointments

9.The anesthetic of choice is prilocaine with felypressin – use a maximum of two carpules per appointment

CARDIOVASCULAR

Stroke

Risk of bleeding from anticoagulant and antiplatelet medication

1.Referral for medical evaluation

–Anticoagulant: evaluate the indication and risk/benefit of discontinuing the medication prior to surgical procedures and medication interruption interval

2.Determine the risk of intervention – ASA (see Appendix)

–ASA III or IV: analyze the risk/benefit of the therapeutic proposal and the need to use an anesthetic without a vasoconstrictor

3. It is contraindicated to perform procedures if the patient’s BP > 160/110 mmHg

4. Assess drug interaction:

–NSAIDs may reduce the effectiveness of antihypertensive medications

5.Take steps to control the patient’s anxiety

6.Give preference to morning appointments

7.The anesthetic of choice is prilocaine with felypressin – use a maximum of two carpules per appointment

Heart valve prosthesis

Risk of interference with a pacemaker

1.Referral for medical evaluation

–Anticoagulant: evaluate the indication and risk/benefit of discontinuing the medication prior to surgical procedures and the medical interruption interval

2.Determine the risk of intervention – ASA (see Appendix)

–ASA III or IV: analyze the risk/benefit of the therapeutic proposal and the need to use an anesthetic without a vasoconstrictor

3.Assess drug interaction:

–NSAIDs may reduce the effectiveness of antihypertensive medications

4.Pay attention to the positioning of the dental chair

5.Check the risk of interference related to the type of pacemaker in procedures with an electric scalpel or ultrasound

6.Evaluate the indication of prophylactic antibiotic therapy: 2 grams (g) amoxicillin 30 to 60 minutes (min) prior to the procedure. For penicillin-allergic patients, 600 milligrams (mg) clindamycin, 500 mg azithromycin, or 500 mg clarithromycin are recommended7,8

Congenital heart disease

a.Risk of bleeding

b.Orthostatic postural hypotension

1.Referral for medical evaluation

–Anticoagulant: evaluate the indication and risk/benefit of discontinuing the medication prior to surgical procedures and medication interruption interval

2.Determine the risk of intervention – ASA (see Appendix)

–ASA III or IV: analyze the risk/benefit of the therapeutic proposal and the need to use an anesthetic without a vasoconstrictor

3.Assess drug interaction:

–NSAIDs may reduce the effectiveness of antihypertensive medications

Previous infective endocarditis

a.Risk of bleeding

b.Orthostatic postural hypotension

c.Risk of infections by manipulation of gingival and bone tissue (extraction, dental implant procedures, periodontal and periapical surgeries)

1.Referral for medical evaluation

–Anticoagulant: evaluate the indication and risk/benefit of discontinuing the medication prior to surgical procedures and the medical interruption interval

2.Determine the risk of intervention – ASA (see Appendix)

–ASA III or IV: analyze the risk/benefit of the therapeutic proposal and the need to use an anesthetic without a vasoconstrictor

3.Evaluate drug interaction:

–NSAIDs may reduce the effectiveness of antihypertensive medications

4.Evaluate the indication of prophylactic antibiotic therapy: 2 g amoxicillin 30 to 60 min prior to the procedure. For penicillin-allergic patients, 600 mg clindamycin, 500 mg azithromycin, or 500 mg clarithromycin are recommended7,8

CARDIOVASCULAR

Heart transplant

a.Risk of bleeding

b.Orthostatic postural hypotension

c.Risk of infections by manipulation of gingival and bone tissue (exodontia, dental implants, periodontal and periapical surgeries)

1.Referral for medical evaluation

–Anticoagulant: evaluate the indication and risk/benefit of discontinuing the medication prior to surgical procedures and the medical interruption interval

2.Determine the risk of intervention – ASA (see Appendix)

–ASA III or IV: analyze the risk/benefit of the therapeutic proposal and the need to use an anesthetic without a vasoconstrictor

3.Evaluate drug interaction:

–NSAIDs may reduce the effectiveness of antihypertensive medications

4.Evaluate the indication of prophylactic antibiotic therapy: 2 g amoxicillin 30 to 60 min prior to the procedure. For penicillin-allergic patients, 600 mg clindamycin, 500 mg azithromycin, or 500 mg clarithromycin are recommended7,8

RESPIRATORY

Chronic obstructive disease Bronchitis Emphysema Pneumonia Tuberculosi

–Dyspnea, cough, chest discomfort

–Anxiety and limitation of care

–Smoker: more significant risk for the development of oral and lung cancer; this risk increases when smoking is associated with alcohol consumption

–Educate on risk factors, signs and symptoms of oral cancer

–Assess risk/benefit of dental intervention

–Carry out the treatment in short sessions for the patient’s comfort

–Ensure that the dental chair is in an upright position

–Using rubber dam isolation can worsen symptoms of anxiety

–Take precautions with the indication of conscious sedation and oral benzodiazepines to control the anxiety of these patients due to the risk of severe respiratory failure

Asthma

–Susceptibility to caries, dental biocorrosion, and periodontal disease

–Candidiasis

–Educate on careful oral hygiene

–Monitor using inhalers (corticosteroids) to avoid possible fungal infections; there is a need for oral hydration

–Ask the patient to bring their inhaler to all appointments and pay attention to triggering actions such as anxiety about the procedure

–Avoid prescribing NSAIDs due to their indirect bronchoconstrictor action

–The anesthetic of choice is prilocaine with felypressin

GASTROINTESTINAL

Gastroesophageal reflux

Eating disorders (anorexia and bulimia)

–Tooth wear due to biocorrosion

–Irritation of the oral and pharyngeal mucosa

–Difficulty in wound healing and osseointegration due to the use of proton inhibitor medications

–Assess the need for a referral for medical evaluation to make the differential diagnosis of gastroesophageal reflux disease and eating disorders; monitor signs and symptoms

–Educate on eating habits; avoid citrus and low pH foods; rinse mouth with water and brush teeth 30 min after meals with low-abrasive toothpaste and an extra-soft toothbrush

–Assess the association with dental attrition as it exacerbates tooth wear

–Evaluate therapeutic alternatives during the postsurgical bone remodeling period

–Monitor the healing process

ENDOCRINE/METABOLIC

Hepatitis Cirrhosis

–Influence on the metabolism of some medications or local anesthetics

–Bleeding due to clotting factor deficiency and delayed wound healing due to immunoglobulin deficiency may be present in more severe cases

–Assess the need for antibiotic prophylaxis in cases of tissue manipulation

–Avoid medications that are metabolized in the liver, such as paracetamol, NSAIDs, amoxicillin, metronidazole, tetracycline, and midazolam, in addition to some local anesthetics

–Avoid ester anesthetics

–Articaine appears to be the safest local anesthetic for these patients

Hyperthyroidism

–Systemic changes: tachycardia, intense sweating, angina, and irritability

–Early tooth eruption

–Susceptibility to infections

–Aggressive periodontal disease

–Limited healing and bone fragility

–Referral for medical evaluation

–Referral for orthodontic evaluation, when necessary

–Give oral hygiene instructions and encourage periodic dental follow-up

–Perform postoperative monitoring

–Prioritize the use of prilocaine with felypressin due to sensitivity to adrenaline

HEMATOLOGIC

Hypothyroidism

–Systemic changes: tiredness, cold intolerance, and obesity

–Delay in tooth development and eruption (permanent)

–Changes in craniofacial growth, condylar hypoplasia, or mandibular or maxillary atresia

–Susceptibility to caries and periodontal disease

–Delayed bone repair

–Change in taste sensitivity

–Macroglossia

–May be more sensitive to sedatives and have a low pain threshold

–Referral for medical evaluation

–Referral for evaluation with an orthodontist, when necessary

–Give oral hygiene instructions and encourage periodic dental follow-up

–Perform postoperative monitoring

–Control salivary flow and use emollients

–Prilocaine with felypressin is the most suitable anesthetic for these patients

Hyper-parathyroidism

–Loss of lamina dura around the teeth and changes in the trabecular bone (ground-glass appearance)

–Propensity to develop torus, osteolytic lesions, gingivitis, and associations with autoimmune diseases

–Changes in skeletal development in children

–Risk of drug-induced osteonecrosis of the jaw (ONJ) when using antiresorptives (AR) in its treatment

–Referral for medical evaluation

–Perform adaptation of the oral environment before the introduction of ARs, when possible

–Perform clinical and radiographic follow-up

–Assess the need for antibiotic therapy when surgical intervention is necessary; also perform local maneuvers that favor the healing process

Hypo-parathyroidism

–Presents with failure or delay in tooth eruption, shortening of the roots, enamel hypoplasia, dentin defects, and a propensity to candidiasis

–May experience cramps, muscle weakness, and myalgia caused by the hypocalcemia that accompanies this disorder

–Referral for medical evaluation

–Referral for orthodontic evaluation, when necessary

–Perform clinical and radiographic follow-up

–Give oral hygiene instructions and encourage periodic dental follow-up

Adrenal insufficiency

–Increased risk of fungal infections

–Melanin pigmentation, which may manifest in the form of plaque

–Increased risk of developing neoplasia

–Referral for medical evaluation

–Carry out periodic clinical follow-up

–Assess the need for anxiolytic control in cases of short appointments and an indication of general anesthesia in cases of long interventions for patient comfort and safety

–Question the continued use of corticosteroids in patients with changes in the adrenal glands as this will influence the prescription of steroidal anti-inflammatory drugs

–Prioritize the use of the appropriate local anesthetic, with prilocaine with felypressin being the anesthetic of choice

Diabetes

–Systemic alterations: tachycardia, intense sweating, angina, and irritability; adrenaline sensitivity

–Oral alterations: xerostomia, greater susceptibility to oral infections (candidiasis, angular cheilitis), more aggressive periodontal disease; decompensated patients experience difficulty in repair/healing

–Numbness, burning, or pain in the oral tissue

–Referral for medical evaluation

–Assess glycemic control, patient profile, and therapeutic proposal

–Assess the systemic status with an oral condition as oral manifestations can signal disease severity

–Assess the therapeutic indication/glycemic control/risk of the intervention

–Prioritize the use of prilocaine with felypressin as it is the most suitable anesthetic for these patients

HEMATOLOGIC

Anemia

–Changes in enamel structures can be observed; difficulties in hard and soft tissue repair; changes in bleeding time and increased edema

–Anxiety, fatigue, and drowsiness are common symptoms

–Loss of taste buds on the tongue

–Increased incidence of oral and pharyngeal carcinoma

–Assess the need to discontinue the medication as patients using platelet aggregation inhibitors have a higher risk of bleeding and require additional care such as hemostatic control

–Choose ester anesthetics or amide anesthetics such as prilocaine

–Antibiotic prophylaxis for invasive procedures in moderate to severe risk patients

CONTAGIOUS INFECTIOUS DISEASES

Sinusitis

–Relationship with periapical problems

–Risk for implantation

–Transient heavy occlusal contacts

–Request relevant imaging tests such as panoramic radiographs and computed tomography (CT) scans of the sinuses

–Infection must be controlled before any procedure in the region, from surgeries to occlusal contact adjustments

AIDS (HIV)

–Susceptibility to opportunistic infections

–Persistent lymphadenopathy

–Leukoplakia, necrotizing ulcerative periodontitis (NUP), and Kaposi’s sarcoma

–Xerostomia, enlarged salivary glands

–Referral for medical evaluation

–Evaluate therapeutic indication in terms of procedure-related risk

–Evaluate the indication of antibiotic prophylaxis in cases of tissue manipulation

RENAL DISORDERS

Chronic renal failure (CRF)

–Susceptibility to infections

–Periodontal disease/necrotizing ulcerative gingivitis (NUG)

–Halitosis

–Unpleasant taste in mouth

–Biocorrosion

–Candidiasis

–Risk of bleeding

–Ulcerative uremic stomatitis

–Referral for medical evaluation

–Perform laboratory and clinical control

–Evaluate the use of antibiotic prophylaxis in cases of tissue manipulation

–Perform local control for hemostasis and monitoring of the healing process

–Avoid medications with renal toxicity such as NSAIDs, acetylsalicylic acid, and tetracyclines

Kidney transplant

–Susceptibility to infections

–Gingival hyperplasia

–Xerostomia

–Susceptibility to caries

–Change in taste

–Referral for medical evaluation

–Perform laboratory and clinical control

–Assess the use of antibiotic prophylaxis in cases of tissue manipulation

–Avoid medications with renal toxicity such as NSAIDs, acetylsalicylic acid, and tetracyclines

–Use lidocaine with epinephrine as the anesthetic of choice

NEUROLOGIC

Dementia

Parkinson’s disease

–Limitation of patient acceptance of treatment

–Adverse drug effects: xerostomia, reduced salivary flow, altered taste, excessive saliva production, swallowing difficulties, bruxism

–Opportunistic oral infections

–Bacterial biofilm accumulation

–Limitation of self-care

–Establish a solid patient–dentist relationship

–Motivate regarding oral hygiene and oral health care

–Prescribe artificial saliva and similar products for xerostomia, when necessary

–Frequent follow-up to minimize damage in the oral cavity

Seizures

–Adverse effects of drug therapy:

–Xerostomia

–Gingival hyperplasia

–Late repair process

–Bleeding

–Infections

–Drug-induced oral erythema multiforme

–Referral for medical evaluation – analyze the frequency and triggering factors of crises and medications used

–Motivate regarding oral hygiene and oral health care

–Prescribe artificial saliva and similar products for xerostomia, when necessary

–Monitor the healing process

–Evaluate antibiotic prophylaxis in procedures with tissue manipulation

–Avoid prescribing propoxyphene and erythromycin in patients using carbamazepine

–Avoid the use of aspirin and NSAIDs in patients using valproic acid

PSYCHIATRIC AND PSYCHOLOGIC DISORDERS

Depression

–Compromised self-care

–Reduction of salivary flow due to adverse drug effects

–Susceptibility to caries and periodontal disease

–Susceptibility to opportunistic infections

–Facial pain syndrome

–Burning mouth syndrome

–Association with increased episodes of bruxism due to the use of selective serotonin reuptake inhibitor medications

–Referral for medical evaluation

–Prescribe artificial saliva and similar products for xerostomia, when necessary

–Prescribe toothpaste with a high concentration of fluoride

–Regular dental follow-up

–The patient–dentist relationship has a direct impact on the patient’s behavior and acceptance of treatment

–When tricyclic and phenothiazine antidepressants are used, the recommendation is to use anesthetics without vasoconstrictors, whenever possible. If vasoconstrictors are required, epinephrine is the vasoconstrictor of choice due to the increased risk of dysrhythmias. There is an absolute contraindication in patients using tricyclic antidepressants for levonordefrin and noradrenaline

NEOPLASTIC DISEASES

Tumors in the head and neck region

–Patients who have undergone head and neck radiotherapy (RT): when undergoing a surgical procedure or when also presenting risk factors (infection, prosthesis trauma, inadequate oral hygiene), such patients are at risk of developing osteoradionecrosis

–Main oral toxicities of chemotherapy (ChT) and RT:

–Mucositis

–Xerostomia

–Change in taste

–Difficulty in swallowing

–Radiation-related carious lesions

–Referral for medical evaluation

–Perform a dental evaluation before the start of cancer treatment, regular dental follow-ups to adapt the oral environment throughout ChT/RT, and after the end of treatment

–Before the start of RT:

–Remove risk factors before ChT and RT

–Carry out adaptation of the oral environment, oral care instructions, and prescription of local care for the management of acute toxicities

–During RT:

–Manage toxicities: photobiomodulation, management of possible opportunistic infections (candidiasis and herpes simplex), and maintenance of local care

–At the end of RT:

–Perform post-RT surgical procedures with a minimally invasive technique; implement local care to induce healing by primary intention; reinforce local care for decontamination

–Assess the need for antibiotic prophylaxis

–In cases of reduced salivary flow: prescribe artificial saliva and toothpaste with a high concentration of fluoride

NEOPLASTIC DISEASES

Bone metastases

Bone neoplasia

–Risk of drug-induced ONJ due to the use of:

–Antiangiogenics (AA) (sunitinib, sorafenib) or antiresorptives (AR) (bisphosphonate, pamidronate, alendronate, zoledronic acid, denosumab)

–Carry out a dental evaluation before the introduction of AA or AR for adequacy of the oral environment

–Carry out regular dental follow-ups throughout the drug therapy and after the end of treatment

–Remove risk factors before starting AA and AR

–Perform post-RT surgical procedures with a minimally invasive technique; implement local care to induce healing by primary intention; reinforce local care for decontamination

–Assess the need for antibiotic prophylaxis

–Carry out regular dental follow-ups

Pregnancy

–The physical and hormonal changes present during pregnancy increase the risk for carious lesions, gingivitis, periodontitis, xerostomia, mobility, and dental biocorrosion

–Restrict elective dental treatments in the first and third trimester of pregnancy

–Avoid prescribing NSAIDs, acetylsalicylic acid, and sedatives

–Prescribe safer medications for the gestational period: paracetamol is the most indicated drug for pain control in these patients. For managing infectious processes, the safest antibiotics are penicillin, clindamycin, and erythromycin. Tetracycline or metronidazole should not be prescribed

–Avoid the use of local anesthetics with adrenaline or a felypressin-type vasoconstrictor due to the action of oxytocin

–Use 2% lidocaine as the anesthetic of choice for this group of patients, with a safe limit dose of two carpules per appointment, as recommended by the FDA

Migraine

–Some symptoms may be similar to and confused with those of TMD

–Referral for medical evaluation

–Investigate severity and frequency

–