Consultant in Restorative Dentistry and private practitioner Lochana Nanayakkara highlights the importance of dental professionals appreciating the impact that medical conditions like bleeding disorders and endocarditis can have on patients' dental health management.

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How can complicated medical histories impact dental care?

The modern world is faced with many challenges, not least of which is the ever-increasing population. People are living longer and, as such, usually require more healthcare services as they get older. They also often require more complex care as their needs change and their risk of additional health conditions increases.

In dentistry, this translates into greater numbers of people with complicated medical histories. Among the many systemic conditions that we are seeing more and more in our patients is heart disease. For instance, more people are now presenting with a history of conditions like endocarditis than they did ten years ago or so.1,2 This is significant for dentistry because of the link between oral bacteria and endocarditis, which continues to have a mortality rate of around 17%.3 People with inherited bleeding disorders are also living longer due to medical advances. These conditions might influence the types of treatments or medications that someone needs or be associated with greater risks for what may otherwise seem like a simple dental procedure.

People are also retaining their natural teeth for longer, so more treatment will inevitably be required in their lifespan. As clinicians, we have to think about how we can help them maintain function and aesthetics in the long-term. Thanks to modern technology, greater patient access to information and demanding societal pressures, we must also achieve this while meeting the ever-growing patient expectations that we face daily.

What challenges do these conditions create for modern dental professionals?

As medical science evolves, it's beneficial for dental professionals to be aware of the latest advances and international guidelines in the field. The vast majority of patients with complex medical histories, or even with a complicated existing health situation, will present to their general dental practitioner (GDP) for routine dental care. GDPs therefore need to know how various medical conditions could impact a patient's dental health, as well as what dental treatments are most likely to be safe and effective. Whether providing routine care or considering a course of treatment, these factors are likely to affect the management techniques and/or products utilised by the clinician during the primary care of these patients.

Take bleeding disorders as an example. They can be inherited or acquired over time and they render a patient's blood unable to form a proper clot. Common inherited bleeding disorders include haemophilia and von Willebrand disease, which occur when the proteins in the blood (otherwise known as clotting factors) are either missing or ineffective at forming clots.4 The consequences of this regarding any dental treatment that might cause an open wound will depend on the severity of the disorder, but it is clearly a major concern. Even simple procedures like periodontal probing could break the seal between gingiva and bone - the small amount of bleeding that isn't given a second thought with another patient, might be a huge problem for someone with a serious bleeding disorder. Plus, consider the impact for treatments like tooth extractions or implant surgery. In many cases, pre- and post-treatment is recommended with clotting factor concentrate, desmopressin (DDAVP) and/or tranexamic acid.5

In addition, some bleeding disorders can occur due to other health conditions, which might further complicate the patient's situation. For example, bleeding disorders have been associated with anaemia, cirrhosis of the liver, HIV, leukaemia and vitamin K deficiency.6 Some of these may influence dental health in their own right and would therefore need to be investigated and considered.

As such, dentists can - understandably - feel very apprehensive about managing these patients. These are rare conditions so you're not going to see them every day. This makes it more difficult to build experience and confidence in treating affected patients. Further still, due to the challenges of providing dental care for those with bleeding disorders - or endocarditis - whether current or historic, these patients may have had bad experiences in the past. This could have an impact on their cooperation with the dental team, as well as their trust of and compliance with dental health advice given.

Another challenge for GDPs is that they may be confused by recent conflicting guidelines in this field. The debate on antibiotic prophylaxis for the prevention of endocarditis has been ongoing for decades, so it is not surprising that professionals and patients can become frustrated and anxious about the potential implications of having dental treatment in context of the amendment to NICE guidelines. Changing a guideline from 'patients should not be offered antibiotic prophlaxis against infective endocarditis' to 'patients should not routinely be offered…'7 is not helpful!

How can these challenges be overcome?

If dental professionals better understand rarer medical diseases and how they affect dental health, they can be better prepared to deliver quality care to any patient that presents. With knowledge comes confidence, helping clinicians to improve their approach to patients with these types of health conditions. In turn, this will enable clinicians to better manage potential problems by tailoring the patient's dental care accordingly. Of course, prevention is always better than cure, so supporting the patient in maintenance of good oral hygiene is the best way of avoiding complications in the first place. Sometimes, simple strategies can be employed to optimise the patient's oral hygiene.

It is also worth mentioning that while it may seem daunting to treat patients with complex medical conditions or histories, it can also be very rewarding. Dentists play a crucial role in improving these patients' quality of life as careful management and care can have a hugely positive impact on their oral health. In providing this level of care, clinicians can also help build positive patient-practitioner relationships that will ensure patients return time and again for the preventive support they need. It is my hope that I can help GDPs enhance their knowledge and understanding of medical conditions such as bleeding disorders and endocarditis. I wish to empower clinicians to deliver the care these patients need.

Dr Lochana Nanayakkara's lecture in the BDA Theatre at the British Dental Conference and Dentistry Show, entitled 'Bleeding Hearts - How can we make a positive impact?', will explore dental management techniques for patients with inherited bleeding disorders or a history of endocarditis.