BAB
spektrum luas dari "gangguan fisik, perkembangan, mental,
42
KOMPETENSI
BAGIAN VII Individu
Berkebutuhan Khusus
Penyandang Disabilitas
Kathleen B. Muzzin
menantang individu untuk terlibat dalam pola-normal
kehidupan seharihari yang. Hasilnya adalah
pengarusutamaan, yang berarti memasukkan
1. Sebutkan kebijakan legislatif utama yang
menguntungkan penyandang disabilitas.
2. Identifikasi hambatan untuk klien dengan
kebutuhan perawatan kesehatan khusus.
3. Diskusikan nilai harga diri pribadi, termasuk
bagaimana stereotip dan sikap mempengaruhi
penerimaan penyandang disabilitas.
4. Menjelaskan klasifikasi kecacatan, termasuk: •
Membedakan antara kecacatan yang berkembang,
didapat, dan terkait usia.
• Mengidentifikasi masalah penggambaran yang
terkait dengan orang-orang dengan kebutuhan
perawatan kesehatan khusus.
5. Jelaskan alat bantu untuk aktivitas kehidupan sehari-
hari. 6. Jelaskan perangkat perawatan diri oral.
7. Diskusikan pemosisian dan stabilisasi klien. 8.
Jelaskan bagaimana menstabilkan klien selama
pemindahan kursi roda dan perawatan profesional.
9. Diskusikan peluang untuk ahli kesehatan gigi dalam
promosi kesehatan dan advokasi untuk klien
penyandang disabilitas.
Kebutuhan perawatan kesehatan khusus mencakup
sensorik, perilaku, kognitif, dan emosional yang
memerlukan manajemen medis, intervensi perawatan
kesehatan, dan / atau penggunaan layanan atau program
khusus".1 Menurut Biro Sensus Amerika Serikat 2010, 56,7
juta orang Amerika dianggap cacat dan memiliki kebutuhan
perawatan kesehatan khusus (Gambar 42-1).2 Selama 20
tahun ke depan, angka ini diperkirakan akan meningkat
secara signifikan, terutama seiring bertambahnya usia
generasi baby boomer. Kemajuan medis telah mengurangi
kejadian gangguan perkembangan, penyakit masa kanak-
kanak, penyakit menular, dan kondisi kesehatan kronis yang
dapat terjadi di antara populasi penyandang cacat. Banyak
penyandang disabilitas yang kini hidup lebih lama, yang
telah menimbulkan permintaan yang sangat besar akan
layanan kesehatan dan rehabilitasi.
Disabilitas sering dikaitkan dengan orang tua; Namun,
seseorang dapat dinonaktifkan kapan saja selama masa
hidup. Kesalahpahaman umum tentang individu
penyandang disabilitas adalah bahwa mereka sakit,
bergantung pada orang lain, lemah mental dan fisik, atau
tinggal di
lembaga. Pada kenyataannya, sebagian besar individu ini
mampu hidup dalam masyarakat baik sendiri maupun
dengan bantuan. Trennya adalah mentransisikan individu-
individu ini ke dalam komunitas lokal3; normalisasi adalah
proses yang memungkinkan
memisahkan individu dengan kebutuhan khusus ke dalam
aktivitas konvensional. Konsep ini mempromosikan
deinstitusionalisasi orang-orang yang memiliki tantangan
dan memungkinkan mereka untuk hidup dan berfungsi
secara mandiri dengan sedikit atau tanpa bantuan dari
pengasuh.4
Pengarusutamaan adalah tujuan dari penyedia perawatan
dan pendidik jangka panjang yang membantu penyandang
disabilitas.
Pengarusutamaan penyandang disabilitas menciptakan
sejumlah masalah — masalah yang membutuhkan perhatian
dan sumber daya. Individu penyandang disabilitas
menghadapi hambatan terhadap perawatan kesehatan,
pendidikan, dan kesempatan kerja. Akses ke layanan ini
penting bagi orang untuk berfungsi pada tingkat kesehatan
dan kebugaran yang dapat diterima dan untuk menjaga
kemandirian. Jaringan dan organisasi nasional berperan
penting dalam mempengaruhi standar untuk mencapai
kesempatan yang sama bagi penyandang disabilitas.
Legislasi untuk Penyandang Disabilitas
Berbagai kebijakan legislatif memungkinkan penyandang
disabilitas mengakses barang dan jasa serta perawatan
kesehatan; misalnya, Rehabilitation Act of 1973, American
with Disabilities Act (ADA) 1990, Olmstead Decision of
1999, New Freedom Initiative of 2001, dan Affordable Care
Act of 2010 (lihat Tabel Legislasi Disabilitas di Sumber
Online untuk Bab 42 di
http://evolve.elsevier.com/Darby/hygiene). Bagian 504 dari
 Undang-Undang Rehabilitasi tahun 1973 dan ADA
mencapai hasil yang paling signifikan dalam menghilangkan
hambatan bagi penyandang cacat dengan menjamin bahwa
tidak ada orang yang memenuhi syarat yang akan
didiskriminasi dari memperoleh pendidikan, pekerjaan,
layanan sosial, atau perawatan kesehatan karena cacatnya.
The Affordable Care Act of 2010 membuat Patient Bill of
Rights yang memberikan perlindungan terhadap praktik
diskriminasi oleh perusahaan asuransi.kondisi medis yang
sudah ada sebelumnya tidak dapat lagi ditolak
pertanggungannya, dan batas dolar seumur hidup akan
dihapus pada tahun 2014.
Individu penyandang disabilitas denganPernyataan
kebijakan yang paling signifikan mengenai perawatan
kesehatan untuk individu penyandang disabilitas ada di
Healthy People 2020 dan Call to Action to Meningkatkan
Kesehatan dan Kesejahteraan Penyandang Disabilitas. (Silakan
kunjungi bagian Sumber Daya Web di situs web di
http://evolve.elsevier.com/Darby/ hygiene.) Inisiatif ini
mempromosikan kesehatan dan kesejahteraan anak-anak
dan orang dewasa penyandang disabilitas dan memastikan
bahwa mereka memiliki akses ke perawatan kesehatan yang
komprehensif. , memungkinkan mereka untuk menjalani
kehidupan yang penuh dan produktif. Meskipun undang-
undang, peraturan, keputusan pengadilan, dan program
memberikan kesempatan yang sama bagi penyandang
disabilitas, mereka sendiri tidak dapat menjamin kualitas
hidup.

786

Under 15 15 to 24 25 to 44 35.0 53.6 semua fasilitas umum memiliki

BAB 42 n Penyandang Disabilitas
Penghalangdesain bebas
10.8
29.5 787 penghalang. Undang-undang
45 to 54 55 to 64 ini mengharuskan semua
penghalang struktural dan
Untuk penyandang disabilitas
komunikasi disingkirkan dari
yang tinggal di sebuah
area publik dari fasilitas yang
65 to 69 70 to 74 75 to 79 institusi, layanan medis dan
ada (misalnya, di hotel,
perawatan gigi terbatas dapat
restoran, teater, museum, toko
disediakan, tetapi biaya tinggi
ritel, sekolah, bank, dan
0.5 terkait dengan layanan ini,
4.2
fasilitas perawatan kesehatan,
yang biayanya dibebankan
8.4 termasuk kantor dan klinik
kepada keluarga atau negara
gigi) saat pelepasannya.
1.4 bagian. Jika seorang
mudah dicapai. Selain itu,
5.3 penyandang disabilitas berat
10.2 orang yang memiliki,
perlu dilembagakan, biaya
menyewakan, menyewakan,
yang ditanggung keluarga
2.0 atau mengoperasikan tempat
7.3 dapat menguras sumber
akomodasi umum di gedung
11.0 keuangan mereka. Persyaratan
yang ada bertanggung jawab
kelayakan untuk Medicare dan
3.6 untuk memastikan bahwa
13.8 Medicaid membatasi akses
semua penghalang telah
19.7 penduduk yang
disingkirkan. Seringkali,
diarusutamakan ke layanan
6.0 pelepasan penghalang dapat
20.4 perawatan mulut yang
dilakukan dengan membuat
28.7 sebaliknya akan disediakan
sedikit modifikasi fisik pada
dalam pengaturan
6.9 fasilitas. Fasilitas yang bebas
24.7 kelembagaan. Banyak keluarga
42.6 hambatan memungkinkan
memilih untuk merawat
seseorang berfungsi secara
15.4 individu yang sangat cacat di
37.5 mandiri di dalam dan di luar
rumah karena perawatan
lingkungan rumah. Misalnya,
jangka panjang merupakan
bangunan yang berisi lift dan
beban finansial yang terlalu
toilet yang dapat diakses tidak
Membutuhkan bantuan Parah besar.
dianggap benar-benar bebas
disabilitas Semua disabilitas
Arsitektur hambatan jika tidak ada landai
ADA mengamanatkan bahwa atau secara elektronik

80 dan lebih dari 70,5 untuk fasilitas bebas penghalang tersedia

30,2 pintu dioperasikan untuk masuk. Kode dari federal dan sumber daya negara
55,8
bangunan khusus dan standar arsitektur bagian (lihat sumber Web
Gambar 42-1.Prevalensi disabilitas dan kebutuhan bantuan disabilitas dan non-disabilitas rendah dan renovasi mahal.
menurut usia: 2010. Ketika renovasi dilakukan, biaya dibebankan kepada orang
yang lewat, sehingga meningkatkan biaya transportasi.
Biaya perjalanan kemudian menjadi penghalang tambahan
Hambatan Perawatan Kesehatan bagi penyandang disabilitas, yang biasanya berpenghasilan
tetap dan tidak mampu membayar jasa transportasi.
Hambatan Keuangan Ketergantungan pada orang lain untuk transportasi ke dan
Biaya tetap menjadi hambatan utama untuk layanan dari rumah mungkin tidak nyaman bagi penyandang cacat
kesehatan mulut.5 Sumber daya keuangan dibutuhkan untuk atau pengemudi. Ketergantungan pada orang lain ini
memperoleh pendidikan, berpartisipasi dalam program menambah beban pada anggota keluarga atau pengasuh
rehabilitasi, melatih pekerjaan, mencari perumahan yang yang mendampingi penyandang disabilitas.
memadai, menggunakan transportasi dasar, dan bertahan
Sikap Profesional
hidup.negara bagian
Danadan federal gagal untuk menutupi biaya kebutuhan Perawatan Kesehatan Praktisi perawatan kesehatan
setiap orang, memaksa banyak penyandang cacat untuk merupakan penghalang yang signifikan untuk perawatan.
memprioritaskan pengeluaran mereka, seringkali dengan Lebih banyak penyandang disabilitas tinggal di luar
mengorbankan kebutuhan dasar. Kebanyakan penyandang pengaturan kelembagaan;
disabilitas mengandalkan dukungan negara bagian dan 788 BAGIAN VII n Individu dengan Kebutuhan Khusus
federal (misalnya, pembayaran Jaminan Sosial) untuk
menutupi pengeluaran harian. Individu yang mampu
oleh karena itu lebih banyak dari mereka yang perlu dirawat
bekerja mendapatkan upah rendah, dan tingkat
di sektor swasta. Keluhan utama yang dimiliki oleh
pengangguran relatif tinggi.
penyandang disabilitas adalah menemukan praktisi yang
Tanpa dana yang cukup untuk pengeluaran sehari-hari,
bersedia merawat mereka.8 Beberapa praktisi memilih untuk
perawatan kesehatan seringkali terabaikan. Sebagian besar
tidak merawat penyandang disabilitas karena perawatan
tidak mampu membeli asuransi kesehatan swasta dan
Medi dan penggantian Medicaid seringkali tidak setara
bergantung pada penggantian Medicare dan Medicaid
dengan daftar biaya yang biasanya dikenakan.9 Selain itu,
untuk bantuan keuangan. Bagi mereka yang berpenghasilan
waktu ekstra sering dibutuhkan untuk merawat orang-
terbatas tanpa asuransi kesehatan, uang untuk perawatan
orang ini, sehingga waktu dan pendapatan dari merawat
kesehatan adalah pengeluaran sendiri; perawatan kesehatan
orang lain menjadi hilang. Rasa takut untuk berinteraksi
sering dicari berdasarkan krisis, untuk
dengan penyandang disabilitas dan nilai-nilai pribadi yang
keadaan darurat atau pengendalian rasa sakit. Penyandang
bertentangan tentang penyandang disabilitas dapat
disabilitas yang memiliki asuransi kesehatan seringkali
membuat praktisi menghindari perawatan mereka.8
memiliki polis yang tidak memenuhi kebutuhan perawatan
Pelatihan dan pendidikan lanjutan tentang kebutuhan
kesehatan mereka atau tidak memiliki perlindungan untuk
perawatan kesehatan penyandang disabilitas terbatas dan
biaya yang terkait dengan kecacatan mereka.6 Perawatan
tidak memiliki dukungan dari pendanaan negara bagian
mulut sering kali ditolak dan dianggap oleh sebagian besar
dan federal. Akibatnya, banyak praktisi merasa tidak
rencana perawatan kesehatan sebagai layanan medis yang
memenuhi syarat untuk merawat orang-orang ini.
tidak perlu.
Banyak penyedia layanan kesehatan tidak menyadari
bagian dari situs web Evolve di http://evolve.elsevier.com/
hubungan antara mulut dan tubuh (lihat Bab 20) dan gagal
Darby / hygiene).
mengenali penyakit mulut sebagai infeksi yang
Hambatan Transportasihambatan yang membutuhkan perhatian segera. Perawat dan asisten yang
bekerja di institusi untuk penyandang cacat berat mungkin
Salah satusering diabaikan adalah transportasi. Sering kali,
memandang perawatan mulut sebagai prioritas rendah dan
klien penyandang disabilitas harus menempuh jarak yang
tugas yang tidak menyenangkan dan seringkali tidak
jauh untuk melakukan perjalanan ke fasilitas kesehatan yang
7 memasukkan layanan ini ke dalam rencana perawatan klien.
memenuhi syarat dan bersedia merawat mereka.
Transportasi umum seperti kereta bawah tanah, bus, sistem Sikap Klien Cacat
kereta api, dan pesawat terbang memberikan bantuan
Perawatan mulut memiliki arti penting sebagai garis hidup
terbatas kepada penyandang cacat, meskipun peraturan
bagi klien cacat. Misalnya, mulut penting untuk
federal yang mewajibkan modifikasi untuk akses yang lebih
mengunyah, berbicara, mengekspresikan kepribadian,
besar. Menafsirkan jadwal, mencari tarif yang tepat,
menggunakan alat telekomunikasi, bekerja dalam pekerjaan,
menunggu di halte keberangkatan selama cuaca buruk,
dan menggambarkandiri yang positif
menaiki kendaraan yang tepat, dan melacak jumlah
citra. Namun, banyak penyandang disabilitas dan / atau
perhentian bisa menjadi sangat sulit bagi penyandang
pengasuhnya tidak menyadari pentingnya menjaga
disabilitas. Akibatnya, banyak penyandang disabilitas
kesehatan mulut yang baik. Seringkali, perawatan medis
memilih untuk tidak menggunakan transportasi massal
menghabiskan sebagian besar waktu dan uang mereka;
dan lebih memilih tinggal di rumah daripada berisiko
perawatan gigi menjadi prioritas rendah. Beberapa
bepergian. Banyak stasiun dan kendaraan transportasi juga
penyandang cacat, yang tidak menyadari kesehatan mulut,
tetap tidak dapat diakses, sebagian karena rasio penyandang
kurang memiliki motivasi untuk menjaga agar penyakit
mulut bebas. Yang lain merasa bahwa dokter gigi tidak
memahami kerusakan yang mereka alami, yang dapat
menyebabkan pengalaman perawatan gigi yang negatif.
Ahli kesehatan gigi harus menjangkau orang-orang cacat
dan membangun rumah perawatan gigi untuk mereka.
Rumah gigi menyediakan akses bagi individu penyandang
disabilitas ke perawatan gigi yang berkesinambungan,
terkoordinasi, komprehensif, berpusat pada pasien dan
memungkinkan mereka mengakses layanan perawatan
kesehatan mulut khusus.10
Harga Diri Pribadi
Mulut yang sehat dan berfungsi menyiratkan bahwa
individu menghargai kesehatan dan penampilan fisik. Por
trayal positif dari mulut ini berkontribusi pada penerimaan
klien ke dalam masyarakat, harga diri, harga diri, konsep
diri, dan citra diri. Semua orang memiliki prestasi yang
membangun kepercayaan diri dan ketidaksetujuan yang
menurunkan kepercayaan diri. Klien penyandang disabilitas
mengatasi peristiwa kehidupan dengan perilaku yang sama
seperti individu non-difabel; namun, penampilan fisik
penyandang disabilitas dapat mengganggu cara pandang
orang lain, yang pada akhirnya memengaruhi cara mereka
memandang diri sendiri.
Memposisikan penyandang cacat dapat menyebabkan
intimidasi atau kesadaran diri di dekat orang lain. Misalnya,
orang dengan kursi roda secara fisik lebih rendah daripada
mereka yang tidak menggunakan kursi roda; karenanya
orang lain meremehkan mereka saat bercakap-cakap. Orang
yang menggunakan alat bantu (tongkat, kawat gigi, atau alat
bantu jalan) dapat dianggap tidak kompeten atau tidak
dapat berjalan sendiri. Orang-orang yang mengalami
gangguan pendengaran atau penglihatan mungkin
mengalami kesulitan mengikuti percakapan dan oleh karena
itu mungkin dikeluarkan dari grup. Orang dengan tremor
atau gangguan otot lainnya mungkin membutuhkan waktu
lebih lama
untuk berbicara dan dapat dianggap sebagai gangguan
mental oleh mereka yang tidak mau mendengarkan.
Klien penyandang disabilitas adalah individu yang
memiliki kemampuan dan keterbatasan pribadi mereka
sendiri dan beradaptasi dengan kehidupan dengan cara
yang sama seperti orang lain. Oleh karena itu, klien harus
dipandang sebagai individu yang berkontribusi pada
masyarakat meskipun disabilitas dan memiliki kebutuhan
yang sama dengan orang lain.
Mendefinisikan Disabilitas
Menurut ADA Act of 1990, istilah “disabilitas” dikaitkan
dengan batasan dalam aktivitas utama kehidupan. Aktivitas
utama dalam hidupaktivitas yang adalahdapat dilakukan
oleh rata-rata orang dengan sedikit atau tanpa kesulitan
(misalnya, perawatan diri, berjalan, mendengar, melihat,
bernapas, berdiri, berbicara, duduk, belajar, berpikir
, dan berinteraksi dengan orang lain). Amandemen Undang-
Undang ADA tahun 2008 memperluas definisi aktivitas
utama kehidupan untuk juga mencakup operasi fungsi
utama tubuh (misalnya, sistem kekebalan, pertumbuhan sel
normal, dan semua fungsi organ utama). Ini adalah ukuran
terkait usia yang mempertimbangkan
aktivitas yang normal untuk kelompok usia tertentu.
Organisasi Kesehatan Dunia (WHO) mendefinisikan
disabilitas sebagai istilah yang mencakup semua untuk
gangguan, batasan aktivitas, batasan partisipasi, dan faktor
lingkungan.11 Gangguan terjadi sebagai akibat dari patologi,
kecelakaan, atau penyakit dan termasuk kehilangan atau
kelainan apa pun — fisiologis, anatomis, atau mental —
fungsi, yang mungkin permanen atau tidak permanen;
misalnya, gangguan dapat terjadi akibat stroke, yang dapat
menyebabkan hilangnya sensorik, afasia, dan paresis.
Contoh gangguan lainnya termasuk kehilangan anggota
tubuh atau organ tubuh atau anggota tubuh atau pinggul
yang patah. Keterbatasanaktivitas dif ficulty dalam
melakukan aktivitas (misalnya, mengalami kesulitan dengan
kegiatan dasar hidup sehari-hari karena kondisi medis).
Sebuah pembatasan partisipasi adalah ketidakmampuan
untuk terlibat dalam kehidupan sehari-hari keadaan untuk
alasan yang mungkin tidak berada di bawah kendali klien;
misalnya, orang usia kerja dengan kondisi kesehatan yang
parah mungkin mengalami kesulitan mencari pekerjaan
karena lingkungan di tempat kerja (misalnya, kurangnya
akomodasi yang wajar oleh pemberi kerja) atau mungkin
ditolak akses ke pekerjaan karena diskriminasi (sosial
lingkungan Hidup). Definisi WHO memasukkan pandangan
masyarakat tentang disabilitas dan tidak membatasi
disabilitas hanya pada kelainan medis atau biologis.
Memasukkan faktor sosial selanjutnya menentukan dampak
lingkungan terhadap kemampuan klien untuk berfungsi
dalam masyarakat.11
Klasifikasi Disabilitaspenyandang disabilitas
Beberapa metode digunakan untuk mengkategorikan
individu. Standar klasifikasi pemerintah didasarkan pada
kriteria yang diuraikan dalam ADA, yaitu individu
penyandang disabilitas adalah orang yang memenuhi
kriteria berikut: • Memiliki gangguan fisik atau mental
yang secara substansial membatasi satu atau lebih
aktivitas kehidupan utama
• Memiliki catatan tentang hal tersebut penurunan nilai
yang membatasi aktivitas utama kehidupan
• Dianggap memiliki penurunan nilai12
Kriteria ini digunakan untuk menentukan kelayakan
bantuan federal.
Disabilitas (yaitu, kondisi disabilitas) juga dikategorikan
sebagai berikut:
• Kecacatan perkembangan terjadi secara bawaan atau
selama masa perkembangan anak, periode yang
berlangsung sejak lahir hingga usia 22 tahun.13 Kecacatan
perkembangan
umumnya kronis; teruskan sepanjang hidup orang
tersebut; dan muncul sebagai gangguan mental, fisik, atau
gabungan. Individu dengan gangguan perkembangan
mungkin mengalami kesulitan dengan banyak fungsi dan
mungkin terbatas dalam kemampuan mereka untuk
 merawat diri mereka sendiri,
berkomunikasi secara efektif, mempelajari konsep baru,
melakukan ambulasi, atau hidup mandiri.
• Cacat didapat terjadi setelah usia 22 tahun atau
disebabkan oleh penyakit, trauma, atau cedera pada
tubuh.13 Cacat didapat yang umum termasuk
kelumpuhan sumsum tulang belakang akibat kecelakaan
olahraga atau sepeda motor, amputasi anggota tubuh
karena penyakit, dan keterbatasan jangkauan gerak
akibat artritis.
• Disabilitas terkait usia terjadi di kemudian hari, biasanya
di atas usia 65 tahun. Seiring bertambahnya usia, mereka
berisiko lebih tinggi untuk mengembangkan penyakit
kronis, yang pada gilirannya dapat menyebabkan
kecacatan.14 Penyakit kronis termasuk kanker, diabetes,
TABLE 42-1
KlasifikasiCacat
KarakteristikCacat Developmental Disabilities
BAB 42 n Penyandang Cacat 789
penyakit kardiovaskular, arthritis, osteoporosis, dan
penyakit paru obstruktif kronik. Gangguan kognitif,
seperti demensia dan penyakit Alzheimer, serta
kemunduran fisik juga dapat menyebabkan orang lanjut
usia menjadi cacat.
Klasifikasi lain mengelompokkan kecacatan ke dalam
beberapa kategori utama, mengelompokkan gangguan
denganmani yang serupa (perayaanTabel 42-1). Kategori ini
berguna saat mempelajari sekelompok gangguan atau saat
mencoba mengklasifikasikan kondisi klien dengan patologi
oral yang terkait dengan gangguan yang diketahui. Sistem
ini mengkategorikan seseorang berdasarkan status medisnya
dan memberikan sedikit informasi tentang seberapa baik
seseorang dapat mengkompensasi keterbatasan dalam
fungsi sehari-hari.
Status fungsional mungkin merupakan metode yang
paling berguna untuk mengkategorikan disabilitas karena
setiap penyandang disabilitas memiliki kemampuan dan
keterbatasan yang berbeda, terlepas darimedis

gangguan intelektualtermasuk sindrom Down; mencerminkan kesulitan dalam belajar, berpikir kritis, dan
pengembangan keterampilan
Cerebral palsy Gangguan nonprogresif yang disebabkan oleh kerusakan otak baik saat lahir atau sebelum sistem
saraf pusat (SSP) mencapai kematangan
Epilepsi Disebabkan oleh ketidakseimbangan kimiawi di otak; terkait dengan cedera kepala, infeksi, dan gangguan
perkembangan Gangguan
spektrum autisme Disabilitas neurologis seumur hidup dengan keterbatasan dalam komunikasi dan interaksi sosial

Gangguan Sensorik Gangguan

penglihatan Mulai dari perubahan ketajaman penglihatan hingga kebutaan
Gangguan pendengaran Beragam derajat gangguan pendengaran hingga tuli

Gangguan Ortopedi
Paralisis Paling sering dikaitkan dengan stroke
Cedera sumsum tulang belakang Paling sering dikaitkan dengan kecelakaan atau cedera
Ekstremitas hilang Paling sering dikaitkan dengan cedera atau diabetes

Cacat Medis
Penyakit kardiovaskular Hipertensi, penyakit jantung kongestif, angina, penyakit katup Penyakit
autoimun Lupus eritematosus sistemik, asam urat, sindrom Sjögren, skleroderma, rheumatoid arthritis , dan osteoartritis
Infeksi human immunodeficiency virus (HIV) dan didapatnya Infeksi yang menghancurkan sel darah putih, mengakibatkan
sindrom imunodefisiensi (AIDS) kerusakan sistem kekebalan.

Kanker Mulut dan kanker sistemik

Diabetes Ty pe 1 atau tipe 2
 Penyakit pernafasan Tuberkulosis, penyakit paru obstruktif kronik Penyakit ginjal Penyakit
ginjal stadium akhir
Gangguan darah Gangguan perdarahan, kelainan trombosit, anemia sel sabit, anemia lain
790 BAGIAN VII n Individu Berkebutuhan Khusus

TABEL 42-1Cacat—
Klasifikasilanjutan

Karakteristik Cacat

Gangguan Kognitif dan Gangguan Psikiatri

Anoreksia dan bulimia Gangguan makan; ditandai dengan kelaparan diri atau makan berlebihan yang diikuti dengan
muntah yang diinduksi sendiri atau penggunaan diuretik yang berlebihan
Gangguan mood Depresi berat, gangguan bipolar, skizofrenia
Demensia Penyakit Alzheimer, demensia vaskular, penyakit Pick's
Cerebrovascular accident (CVA, stroke) Penyumbatan aliran darah ke otak yang dapat menyebabkan hilangnya
fungsi sebagian atau seluruhnya secara tiba-tiba pada satu sisi tubuh atau kematian
Gangguan penggunaan zat Penyalahgunaan alkohol dan / atau obat-obatan psikoaktif

Gangguan Sistem Saraf Degeneratif PenyakitDegenerasi saraf

Alzheimerdi korteks serebral, mengakibatkan hilangnya memori, berpikir kritis, dan kemampuan penalaran
penyakit Parkinson Degenerasi inti otak dalam, mengakibatkan hilangnya kendali atas gerakan sukarela; tremor,
lambatnya gerakan (bradikinesia); onset bertahap demensia penyakit
Huntington Gangguan dominan autosom yang menyebabkan degenerasi nukleus dalam, kauda, dan putamen;
masalah perilaku dan gerakan otot konstan (chorea)
Ataksia serebelar Status mental normal; perubahan gaya berjalan dan koordinasi
Penyakit neuron motorik dan amyotrophic lateral sclerosis serebral; atrofi otot progresif yang menyebabkan gagal napas;
(ALS) tidak ada kehilangan fungsi mental atau sensorik
Kematian sel di neuron motorik medula spinalis dan korteks
Multiple sclerosis (MS) Kelemahan otot yang ditandai dengan sifat siklik dari progresi Myasthenia gravis
Kelemahan otot di sekitar mata dan tenggorokan; kesulitan menelan Neurofibromatosis Penyakit
dominan autosomal genetik; tumor jinak multipel
Penyakit Creutzfeldt-Jakob Mutasi gen protein prion; degenerasi neuron; kehilangan saraf, pembentukan plak amiloid
dan demensia progresif cepat

Gangguan KomunikasiGangguan
Disartriabicara akibat kelemahan otot yang disebabkan oleh kerusakan sistem saraf pusat atau perifer atau
keduanya; pola bicara cadel.
Apraxia Gangguan bicara yang disebabkan oleh lesi di dalam SSP; gangguan kapasitas untuk memposisikan otot untuk
membentuk pidato;gagap
AphasiaGangguan bahasa yang disebabkan oleh kerusakan neurologis; ketidakmampuan untuk memasukkan pikiran ke
dalam kata-kata atau untuk memahamikata

diagnosisatau tingkat keterlibatan sistem. Status fungsional
menggambarkan seberapa baik klien dapat melakukan
aktivitas dasar dan instruksional kehidupan sehari-hari.
• Kegiatan dasar kehidupan sehari-hari (BADL) termasuk
kegiatan yang diperlukan untuk perawatan pribadi
seperti memberi makan, berpakaian, dandan, mandi, dan
buang air.15
• Kegiatan instrumental dari kehidupan sehari-hari
(IADL) mencakup tugas-tugas yang lebih kompleks yang
diperlukan untuk hidup mandiri (misalnya, menggunakan
telepon, menyiapkan makanan, membersihkan rumah,
mengendarai mobil, atau menggunakan transportasi
umum).15 Setiap individu menghargai kemampuan untuk
hidup mandiri.
Kemandirian fungsional memungkinkan individu untuk
berpartisipasi dalam situasi kehidupan yang bermakna dan
bertujuan;
partisipasi dalam BADL dan IADL sangat penting untuk
kesehatan dan kesejahteraan. Ahli kesehatan gigi yang
mampu meningkatkan kemampuan fungsional klien dan
perilaku kesehatan mulut juga meningkatkan status
fungsional dan kualitas hidup klien.
Gangguan dapat mempengaruhi lima aspek fungsi:
komunikasi, gerakan, kemampuan mental, kesehatan medis,
dan persepsi sensorik. Aspek fungsi ini terbatas; mereka
tidak membahas derajat keparahan atau luas keterlibatan
gangguan, yang dapat menyebabkan berbagai tingkat
keterbatasan fungsional. Tabel 42-2 mengilustrasikan
bagaimana keterbatasan fungsional terkait dengan tingkat
keparahan gangguan menurut empat tingkat keterlibatan.
BAB 42 n Penyandang Disabilitas 791

TABEL 42-2
Tingkat Fungsional untuk Mengkategorikan Disabilitas Berdasarkan Kemampuan Melakukan Aktivitas Dasar Kehidupan
Sehari-hari

Tingkat Gangguan Gerakan Komunikasi Kemampuan Mental Level I

Fungsi mendekati normal Praktisi Tingkat II Upaya ekstra diperlukan untuk

mungkin mengalami kesulitan memahami Klienmungkin berjalan lebih lambat dari penjelasan dan
klien dan sebaliknya. biasanya. kepastian kepada klien.

Simulasi fungsi normal dengan Orang tunarungu mungkin bergerak. daya yang sesuai.
peralatan adaptif, pengobatan, membutuhkan penerjemah. Klien mungkin Klien mungkin menggunakan-
atau Klien dapat membawa teman, memerlukankhusus obatobatan untuk menjaga
metode orang tua, atau pendamping pengaturanuntuk transportasi. keseimbangan emosional atau
untuk membantu komunikasi. Kemungkinan bantuan untuk mungkin memerlukankhusus
Persetujuan klien diperlukan masuk ke kursi perawatan. pendekatanuntuk menerima
untuk memberikan informasi perawatan kebersihan gigi dan
kepada pihak ketiga. gigi.
Level III Petugas atau pengasuh lain
Simulasi fungsi normal dengan mungkin bertanggung jawab
bantuan pihak ketiga atas kebersihan gigi. Dapatkan
Klien akan memiliki wali yang persetujuan klien untuk
sah. memberikan informasi kepada Klien mungkin memilikisah
Praktisi harus memiliki izin wali pihak ketiga. wali yang. Jika demikian,
dan bukti perwalian untuk Akan membutuhkan bantuan praktisi harus memiliki
Level IV perawatan. Pengasuh untuk masuk ke kursi persetujuan wali dan bukti
Simulasi fungsi normal tidak residensial yang bertanggung perawatan. perwalian.
dimungkinkan jawab atas kebersihan gigi
Klien dapat menggunakan harus diberi informasi dan
papan komunikasi, menulis, pendidikan. Kunjungan rumah diperlukan
atau memberi isyarat sebagai Pengaturan harus dapat untuk perawatan kebersihan Klien akan memilikisah
pengganti ucapan. diakses kursi roda; memiliki gigi dan gigi secara rutin. Jika wali yang. Harus memiliki
furnitur yang praktisi tidak dapat izin wali dan bukti perwalian
diatur ulang untuk membuatnya, lihat sumber untuk perawatan.
memungkinkan ruang untuk

Diadaptasi dari Shaffer S, Margon C, Stiefel DJ: Principles of Rehabilitation (Project DECOD), Seattle, 1985, University of
Washington School of Dentistry.

Interaksi dengan Penyandang Disabilitas16 • Seseorang bukanlah penyandang cacat; melainkan

seseorang yang memiliki gangguan. Oleh karena itu,
Hal-hal penting saat mendeskripsikan atau berinteraksi
tidak tepat untuk mengatakan, "Dia adalah kasus
dengan penyandang disabilitas adalah sebagai
sklerosis mul tiple saya." Lebih tepat untuk mengatakan,
berikut:disabilitas
“Ini klien saya, Nyonya Jones. Dia menderita multiple
• Hindari istilah “penyandang”. Istilah ini tidak lagi
sclerosis. ”
digunakan karena konotasi negatifnya.
• Gangguan tidak menimpa karakteristik klien lainnya; oleh
 karena itu, kerusakan harus ditangani hanya jika perlu
atau relevan dengan situasi. Menekankan kerusakan
tanpa alasan harus dihindari.
• Klien dengan disabilitas bukanlah manusia super; belajar
berfungsi sebagai pribadi meskipun ada kekurangan
adalah kelangsungan hidup, bukan tindakan unik yang
membutuhkan bakat khusus. Pencapaian tujuan yang
sensasional oleh orang-orang cacat adalah reaksi yang
umum, seperti dengan mengatakan, "Dia menang atas
ketidakmampuannya untuk berjalan," yang menyiratkan
bahwa klien adalah korban dari gangguan tersebut.
• Istilah sensasional yang menarik emosi, seperti
"bergantung pada tongkat" atau "terikat pada kursi roda", Perangkat Berjalan
tidak tepat dan menyiratkan tingkat ketergantungan
yang salah di pihak klien.
• Penyandang disabilitas belum tentu sakit, terlepas dari
apakah gangguan tersebut disebabkan oleh suatu
penyakit. Tidak tepat untuk menggambarkan klien yang
cacat sebagai "pasien" atau "kasus" kecuali orang tersebut
secara aktif dalam perawatan medis.
• Jangan berasumsi bahwa semua klien yang cacat
membutuhkan bantuan. Alih-alih, tanyakan kepada
klien, "Bagaimana saya bisa membantu Anda?" Individu
dengan disabilitas harus dapat mengarahkan perawatan
mereka dan menginformasikan kepada dokter gigi
tentang jenis bantuan yang mereka perlukan.
• Dokter harus memposisikan diri mereka setinggi mata
saat berbicara dengan klien di kursi roda.
• Saat menyapa klien yang memiliki disabilitas, tawarkan
untuk menjabat tangan mereka. Jika mereka tidak bisa ke klien untuk digunakan. Klien yang cemas mungkin lebih
mengulurkan tangan, mereka akan menyapa Anda suka memegang perangkat sebagai ukuran keamanan.
dengan cara lain.
Masalah penggambaran negatif ditemui melalui kontak
pribadi atau media massa. Misalnya, orang mungkin
792 BAGIAN VII n Individu Berkebutuhan Khusus
mengungkapkan rasa kasihan kepada penyandang
disabilitas tanpa mengenal individu tersebut, atau
ketidakpercayaan saat melihat penyandang disabilitas
menikmati dirinya sendiri “meskipun ia memiliki
disabilitas.” Profesional perawatan kesehatan yang bekerja
dengan klien penyandang disabilitas sering dianggap
memiliki motivasi khusus atau sebagai "benar-benar sabar".
Penggambaran televisi sering kali memperlakukan orang
dewasa yang cacat seperti anak kecil atau orang yang lebih
rendah. Seorang dewasa yang cacat dapat dipanggil dengan
nama depan atau dengan nama belakang ketika situasinya
menentukan gelar yang lebih formal. Contoh lain termasuk
berbicara untuk orang cacat seolah-olah mereka tidak ada
dan berasumsi bahwa mereka tidak dapat membuat
keputusan secara mandiri. Penggambaran negatif harus
dihindari untuk hubungan terapeutik yang positif.
Alat Bantu
Banyak klien memiliki kebutuhan oral yang kompleks yang
terkait langsung dengan kondisi mereka atau dengan obat
yang diminum untuk menstabilkan atau mengendalikan
gejala kondisi mereka. Klien mungkin memerlukan bantuan
khusus dalam mencapai perilaku perawatan
diri yang diperlukan untuk kesehatan dan kesadaran mulut.
Gangguan klien mungkin mendikte kebutuhan alat yang
digunakan untuk mencapai kemandirian dalam fungsi
sehari-hari dan komunikasi. Banyak perangkat tersedia
melalui agen dan agen area; yang lainnya dirancang khusus
untuk klien. Perangkat teknologi digital, seperti tablet
komputer dan video game, juga dimasukkan ke dalam
program pendidikan dan rehabilitasi bagi individu
penyandang disabilitas.17 Ahli kesehatan gigi harus terbiasa
dengan perangkat ini karena penggunaannya dapat
memengaruhi tujuan dan keputusan klien dalam perawatan.
Berbagai perangkat tersedia untuk klien yang mengalami
kesulitan dengan ambulasi. Tongkat, penyangga kaki, kruk,
dan alat bantu jalan adalah alat yang membantu klien
dengan menahan beban tubuh selama gerakan (Gambar 42-
2). Perangkat ini menggantikan fungsi baik secara sepihak
atau bilateral, sangat meningkatkan mobilitas untuk
ambulasi, dan mendukung individu saat mereka berpindah
dari tempat tidur ke kursi. Perangkat berjalan harus tetap
dekat dengan klien. Misalnya, jika ahli kesehatan gigi
memindahkan perangkat, klien harus diberi tahu lokasinya
untuk menghindari perasaan terjebak. Ahli kebersihan gigi
mengambil perangkat saat diperlukan atau atas permintaan
klien dan menyerahkan perangkat langsung
Meskipun tidak ideal, perilaku ini dapat ditoleransi selama
perangkat tidak mengganggu perawatan.
Kursi roda adalah perangkat yang membantu klien yang
memiliki mobilitas terbatas atau tidak memiliki kaki untuk
ambulasi. Kursi roda meningkatkan mobilitas bagi mereka
yang mungkin harus berbaring di tempat tidur atau kursi.
Karena perbaikan dalam desain bangunan, banyak fasilitas
yang dapat diakses sepenuhnya oleh kursi roda, sehingga
memungkinkan klien untuk bergerak dengan bebas tanpa
terhalang oleh keterbatasan fisik saat ambulasi. Klien dapat
dirawat di kursi roda atau dipindahkan ke kursi gigi untuk
perawatan (lihat bagian dan prosedur tentang teknik
pemindahan kursi roda dalam bab ini). Sebagian besar klien
lebih suka mengoperasikan kursi roda itu sendiri; bantuan
harus diberikan hanya atas permintaan mereka.
Perangkat Prostetik Perangkat
prostetik meningkatkan penampilan klien dan
meningkatkan fungsi. Dipasang setelah amputasi, kaki
prostetik meningkatkan ambulasi, lengan prostetik
meningkatkan jangkauan dan rentang gerak, dan tangan
prostetik meningkatkan genggaman. Perangkat lain dapat
menggantikan struktur atau organ karena kelainan bawaan
atau yang telah dikeluarkan karena patologi atau trauma.
Perangkat prostetik dapat dipasang secara permanen
melalui implantasi bedah atau dapat dilepas dan dikenakan
hanya jika diperlukan untuk tujuan fungsional atau
kosmetik. Klien dengan perangkat yang dapat dilepas
 seperti yang dirancang untuk kehilangan struktur wajah
mungkin merasa lebih nyaman saat protese dipasang; oleh
karena itu, pengangkatan harus terjadi hanya selama
penilaian atau saat diindikasikan selama perawatan. Semua
perangkat harus segera diganti setelah prosedur selesai
untuk memastikan kenyamanan dan kemudahan klien.
Privasi harus dijaga saat perangkat prostetik dilepas,
sebaiknya di area tertutup atau ruang pemeriksaan.
Pengobatan awal antibiotik profilaksis diindikasikan
sebelum perawatan kebersihan gigi dapat dimulai untuk
klien dengan penggantian sendi prostetik (lihat Bab 12).
Alat Pendengar Bantu Alat
bantu dengar untuk klien dengan gangguan pendengaran
mendeteksi suara dan membantu memahami ucapan.
Mendengar

A B C
Gambar 42-2.Perangkat berjalan. A, Penggunaan alat bantu jalan sangat meningkatkan mobilitas klien. B, Kruk membantu
klien dengan menahan beban tubuh selama gerakan. C, Canes membantu klien dengan keseimbangan dan mengurangi
beban pada kaki yang berlawanan dengan sisi tempat tongkat dipegang. (Atas perkenan Kathleen Muzzin, Texas A&M
University, Baylor College of Dentistry, Caruth School of Dental Hygiene, Dallas, Texas.)

Membantu memperkuat suara dan hanya efektif jika ada
beberapa kapasitas pendengaran. Alat bantu dengar dapat
dikenakan di telinga luar untuk meningkatkan konduksi
suara (misalnya, alat bantu dengar konvensional) atau
ditanamkan secara operasi di bawah kulit atau di tulang
belakang telinga untuk konduksi telinga bagian dalam
(misalnya, implan koklea atau alat bantu dengar penahan
tulang). Karena banyak orang menyangkal gangguan
pendengaran, beberapa mungkin memiliki alat bantu dengar
tetapi memilih untuk tidak memakai perangkat tersebut
karena kesadaran diri atau rasa malu. Klien ini mungkin
tampak tidak responsif terhadap pertanyaan atau
percakapan. Perilaku seperti itu harus mengingatkan ahli
kesehatan gigi tentang kemungkinan gangguan
pendengaran, dan klien harus ditanyai tentang penggunaan
alat bantu dengar.
Lingkungan mulut dapat menimbulkan gangguan bagi
para penyandang alat bantu dengar. Kedekatan operator
yang dekat atau penempatan alat bantu dengar yang salah
dapat menyebabkannya menjerit; suara bernada tinggi dari
handpiece gigi atau perangkat ultrasonik memicu reaksi ini.
Klien harus diinstruksikan untuk mematikan atau melepas
alat bantu dengar selama perawatan gigi. Klien yang
beradaptasi dengan alat bantu dengar baru sering kali
menolak bantuan tersebut karena "semuanya tampak sangat
berisik". Karena semua suara
diamplifikasi, klien ini mungkin menyadari suara yang
belum pernah mereka dengar sebelumnya atau sudah lama
tidak terdengar, terutama jika gangguan pendengaran itu
bertahap dan tidak diobati. Sebagian besar lingkungan
memiliki kebisingan latar belakang, dan klien dapat
mematikan alat bantu dengar sebelum datang untuk
membuat janji.
Alat bantu dengar lainnya tersedia. Amplifier dapat
digunakan di telepon, televisi, dan radio untuk
meningkatkan volume suara bagi mereka yang mengalami
gangguan pendengaran sebagian. Program televisi teks
tertutup membantu klien tunarungu dengan membaca bibir.
Perangkat telekomunikasi untuk telepon tele mereproduksi
suara dari pemanggil dan mengubahnya menjadi tipe
tertulis yang dapat dibaca dari monitor. Respons yang
diketik mengirimkan pesan kembali ke pemanggil.
Bantuan untuk
Klien Tunanetra yang tunanetra biasanya memakai lensa
korektif untuk meningkatkan penglihatan dan
meningkatkan komunikasi. Jika instruksi perawatan mulut
diberikan kepada klien yang lupa kacamatanya, materi
tertulis dapat disediakan untuk dibaca setelah janji temu.
Bahan-bahan ini harus mengandung cetakan besar dengan
kontras yang memadai. Klien tunanetra sering kali memakai
kacamata hitam untuk melindungi mata dari kepekaan
cahaya. Klien tunanetra membutuhkan bimbingan, terutama
di lingkungan yang tidak dikenal, dan bergantung pada
rangsangan sentuhan untuk memahami lingkungan, sebagai
berikut:
• Klien tunanetra dapat disambut dengan genggaman
tangan ahli kebersihan.
• Untuk menemani klien ke area perawatan, tangan klien Penting juga untuk memberikan waktu respons yang cukup
yang tidak dominan harus diletakkan di bawah siku ahli saat berkomunikasi dengan klien yang menggunakan AAC.
kebersihan, dan klien harus diminta untuk berdiri di Dengan latihan, menjadi relatif mudah untuk memahami
samping tetapi sedikit di belakang ahli kebersihan. dan berkomunikasi dengan klien ini.
• Arahan khusus memandu klien (misalnya, "Ambil tiga
langkah ke depan, lalu belok kanan. Kita akan turun ke
Alat Bantu untuk AlatOrang Lumpuh
lantai yang mulus. Hanya ada satu langkah.").
Eliminasi
• Saat tiba di area perawatan, klien harus diberi tahu lokasi
benda di ruangan (mis., "Kursi tepat di depan Anda, Klien yang lumpuh di bawah pinggang mengalami
sekitar satu kaki dari tempat Anda berdiri sekarang.") kesulitan dengan pembuangan limbah secara normal dan
Izinkan klien untuk rasakan letak dan arah kursi dengan dapat menggunakan kateter untuk
meletakkan tangan klien di atas kursi sambil memberikan
instruksi lisan. Tetap dekat dengan tangan yang
bertumpu di bahu klien menyampaikan kenyamanan dan
perhatian saat klien duduk di kursi.
BAB 42 n Penyandang Disabilitas 793

Klien tunanetra dapat menggunakan tongkat atau anjing

penuntun selama ambulation dan lebih suka menggunakan
alat bantu ini untuk membantu individu lain. Anjing
pemandu diizinkan untuk tetap berada di area perawatan
dan harus diarahkan oleh klien untuk duduk dekat dan
dalam pandangan yang jelas dari klien. Dokter tidak boleh
mencoba untuk membelai anjing pemandu, karena anjing
tersebut mungkin merasa terancam dan mungkin
menyerang siapa saja yang mendekatinya. Selain itu, anjing
Gambar 42-3.Perangkat
pemandu tidak boleh ditinggalkan sendirian di area lain; komunikasi augmentatif dan alternatif yang digunakan
mereka mungkin menjadi cemas jika tidak ada pemiliknya. untuk klien dengan gangguan bicara dan bahasa yang
parah. (Courtesy DynaVox Technologies, Pittsburgh,
Alat Bantu Bicara Alat Pennsylvania.)
bantu bicara membuat ulang suara yang meniru pola bicara 794 BAGIAN VII n Individu dengan Kebutuhan Khusus
normal untuk orang yang pernah menjalani operasi
pengangkatan laring dan tidak bisa mengeluarkan suara
bantuan buang air kecil. Kehati-hatian harus diberikan saat
dari tenggorokan. Alat bicara elektronik yang dipegang di
memindahkan klien dengan kateter agar tidak tertekuk atau
tenggorokan mendeteksi getaran udara yang melewati
terlepas. Juga, klien mungkin memiliki rutinitas usus dan
tenggorokan saat orang tersebut meniru ucapan normal.
kandung kemih untuk mengatur pembuangan limbah. Klien
Perangkat mereproduksi suara yang menyerupai ucapan
harus ditanyai mengenai jadwal eliminasi mereka dan
robot yang dikawinkan secara otomatis. Penggunaan
diinstruksikan untuk menyelesaikan rutinitas usus dan
perangkat ini meningkatkan komunikasi verbal. Terapis
kandung kemih mereka sebelum janji temu.
wicara melatih klien dengan laringec tomies untuk
mengeluarkan udara dari esofagus untuk pembentukan
Perangkat Komunikasi
suara untuk menghasilkan ucapan yang berubah.
Klien yang lumpuh di bawah leher menggunakan berbagai
Komunikasi augmentatif dan alternatif (AAC) adalah
perangkat untuk mencapai BADL, yang sebagian besar
metode komunikasi yang digunakan oleh klien dengan
dirancang oleh terapis okupa atau wicara. Mulut diperlukan
gangguan bicara dan bahasa yang parah (misalnya, sklerosis
untuk mengoperasikan banyak alat ini, yang mengubah
lateral amiotrofik, afasia, apraxia, cedera otak traumatis,
kesehatan dan fungsi struktur mulut. Perangkat yang paling
cerebral palsy). AAC digunakan untuk klien yang tidak
umum digunakan oleh klien tetrapleadalah gicmouthstick,
dapat menggunakan pidato verbal namun mampu secara
batang plastik atau kayu balsa sederhana dengan ujung
kognitif, atau ketika ucapan sangat sulit untuk dipahami.
karet yang ditahan oleh gigi dan bibir (Gambar 42-4).
Klien akan menggunakan, sendiri atau dalam kombinasi,
Mouthsticks dapat digunakan untuk komunikasi, seperti
gerakan, papan komunikasi, gambar,
mengetik di keyboard atau menekan tombol di telepon.
tablet komputer, simbol, atau gambar.18 Misalnya, jika klien
Mouthstick juga digunakan untuk membalik halaman buku,
lapar, dia akan menunjuk ke gambar di ACC seseorang
mengoperasikan komputer, dan menggunakan peralatan
sedang makan. Klien yang menggunakan papan komunikasi
seperti oven microwave dan televisi remote control.
elektronik diprogram oleh ahli patologi wicara-bahasa
Gigi mungkin mengalami trauma oklusal dari tongkat
berdasarkan tingkat fungsinya (Gambar 42-3). Saat merawat
mulut, yang dengan adanya peradangan dan faktor risiko,
klien jenis ini, ahli kebersihan gigi harus mendengarkan
dapat mengakibatkan kerusakan periodontal yang cepat dan
dengan cermat dan mengulangi pesan yang diberikan oleh
kehilangan gigi. Gigi yang sehat secara biologis serta
klien untuk memastikan akurasi dalam pemahaman.
integritas kulit dan selaput lendir sangat penting bagi klien
ini. Tanpa gigi yang sehat dan struktur pendukung, mereka
mungkin tidak dapat memegang tongkat sehingga
kehilangan kemampuan untuk berkomunikasi dan berfungsi
secara mandiri.
Mouthsticks dapat menyebabkan kelelahan otot, trauma
jaringan mulut akibat memasukkan tongkat, kesulitan
memasukkan tanpa bantuan perawat, rasa tidak enak,
ketidaknyamanan sendi tem poromandibular (TMJ), dan
tersedak. Pertimbangan dalam pembuatan peralatan
mouthstick tercantum di Kotak 42-1.
oklusal. Sebuah lubang dibuat di alat dan disesuaikan
untuk tongkat mulut. Ahli terapi okupasi atau wicara
membantu dokterprofesional
gigidengan evaluasi akhir tentang panjang dan desain
tongkat berdasarkan kebutuhan klien.
• Mouthstick dengan bagian yang bergerak di antara lengkungan
rahang atas dan pria dibular. Alat ini digunakan oleh orang
yang tidak bisa menggerakkan kepala atau leher. Ini berisi
tongkat mulut teleskopik yang dipegang pada sambungan
bola-dan-soket di bagian anterior alat dan perangkat rak-
dan-pinion yang dipasang ke sambungan. Otot
pengunyahan digunakan untuk menghasilkan gerakan
vertikal dari batang mulut; lidah mengontrol gerakan lateral
dan fungsi teleskop.19

KOTAK 42-1
A
Alat Mouthstick: Pertimbangan Utama

• Tidak menyebabkan pergerakan gigi

• Stabil saat dipegang di tempat
• Ringan dan nyaman
• Tidak menghambat bicara atau menelan
C • Tidak sesuai dengan pandangan klien
• Memiliki warna netral dan dapat diterima rasa
• Memegang berbagai alat untuk memenuhi
kebutuhan klien dengan baik • Memastikan bahwa
kekuatan menggigit didistribusikan secara merata ke
D sebanyak mungkin gigi dalam lengkungan untuk
B mengurangiperiodontal
kerusakandan kelelahan otot

Fabrikasi mouthstick dimulai dengan impresi alginat

lengkung rahang atas dan rahang bawah klien. Gips gigi
batu dibuat dan dapat digunakan untuk membuat dua jenis
stik mulut yang saat ini tersedia:
• Mouthstick dengan pelindung mulut akrilik. Pelindung mulut
dirancang di atas cetakan batu rahang bawah, kemudian
disesuaikan di mulut klien agar sesuai dan stabilitas

Gambar 42-4.Mouthstick. A, Mouthstick yang dibuat khusus untuk

penderita tetraplegia. B, Mouthstick dibuat sedemikian rupa sehingga gaya menggigit terdistribusi secara merata di seluruh
lengkung rahang atas. C dan D, Lubang di permukaan anterior pelindung mulut juga bisa menampung pensil atau kuas.
(Courtesy Kathleen Muzzin, Texas A&M University, Baylor College of Dentistry, Caruth School of Dental Hygiene, Dallas,
Texas.)
 Sebelum memasukkan salah satu alat, peradangan mulut bersudut untuk jangkauan yang lebih baik agar sesuai di
harus dihilangkan. Pemantauan yang cermat terhadap semua area mulut.
kesesuaian dan penggunaan alat meminimalkan trauma • Kekuatan genggaman. Klien dengan arthritis atau
periodontal dan memastikan manfaat yang optimal bagi gangguan neuromuskuler mengalami kesulitan dalam
klien. memegang alat yang terlalu sempit atau terlalu kecil
(Gambar 42-5). Untuk menilai kekuatan pegangan, klien
Alat Bantu untuk Perlindungan dan
diminta untuk menangkap berbagai ukuran silinder busa.
Fungsi Mulut
Ini lebih fungsional daripada memiliki pegangan klien
Alat bantu untuk perlindungan dan fungsi mulut (misalnya, bola tenis atau softballs. Ukuran lain dari kekuatan
pelindung mulut khusus) digunakan untuk mencegah cengkeraman termasuk menilai kemampuan klien untuk
trauma yang ditimbulkan sendiri oleh klien dengan masalah mempertahankan penutupan jari untuk waktu yang
perilaku atau yang koma. Pelindung mulut khusus lama. The hygienist
BAB 42 n Penyandang Disabilitas 795
berfungsi sebagai berikut:
• Mencegah neuropatologis mengunyah dan trauma yang
ditimbulkan sendiri pada bibir, lidah, dan mukosa bukal •
Melindungi jaringan yang mengalami trauma sehingga
dapat sembuh tanpa cedera lebih lanjut
• Melatih klien untuk berhenti melukai jaringan mulut
Perangkat harus digunakan hanya setelah berkonsultasi
dengan spesialis perilaku.
Klien dengan gangguan neuromuskuler seperti penyakit
Parkinson dan / atau stroke atau klien yang telah menjalani
operasi pengangkatan sebagian tenggorokan atau langit-
langit mungkin mengalami kesulitan dalam berbicara dan
menelan dan memerlukan alat untuk membantu fungsi Gambar
mulut. Lift palatal, alat augmentasi palatal 42-5.Orang dengan artritis mungkin mengalami kesulitan
memegang alat bantu perawatan mulut seperti sikat gigi
, dan obturator adalah alat yang meningkatkan fungsi
atau pembersih interdental. Diindikasikan alat bantu
dengan menciptakan kembali gerakan fisiologis normal dari perawatan diri oral atau sikat gigi listrik atau pembersih
jaringan mulut. Ahli kesehatan gigi yang merawat klien interdental yang dimodifikasi. Tangan kanan klien telah
dengan alat jenis ini harus memantau perubahan pola bicara diperbaiki dengan pembedahan untuk memungkinkan lebih
, kemampuan menelan, dan kebersihan alat. Jika banyak jangkauan gerak. Pada saat pengambilan foto,
penyesuaian perangkat diperlukan, klien harus dirujuk ke tangan kiri belum dirawat. (Atas perkenan Kathleen Muzzin,
prostodontis. Texas A&M University, Baylor College of Dentistry, Caruth
School of Dental Hygiene, Dallas, Texas.)sekuat
Perangkat Perawatan Diri Lisan
Meskipun banyak perangkat memfasilitasi BADL, beberapa
Harus menggenggam tangan klien dengan lembut, minta
perangkat yang ada membantu klien melakukan perilaku
klien untuk menekanmungkin, dan tahan posisi ini
perawatan diri oral secara mandiri. Alternatif kreatif untuk
selama 1 menit. Penilaian ini menentukan kekuatan yang
perangkat kebersihan mulut tradisional dirancang untuk
dibutuhkan untuk memegang perangkat selama jangka
mereka yang memiliki keterbatasan fungsi. Perangkat ini
waktu tertentu. Jika klien tidak dapat menutup jari
harus beradaptasi dengan kebutuhan klien, tingkat keahlian,
selama 1 menit, manset universal, seperti tali Velcro
dan status fungsional.
palmar, mungkin diperlukan untuk memegang
Penilaian Klien perangkat.
• Tingkat keterampilan. Menonton klien mensimulasikan
Ahli kebersihan gigi menilai keterbatasan fisik dan mental
gerakan yang digunakan untuk menyikat gigi, atau
klien yang memengaruhi cara klien beradaptasi dengan
melihat mereka benar-benar menyikat gigi dengan teknik
penggunaan perangkat. • Rentang gerak. Kemampuan
mereka saat ini, digunakan untuk menilai tingkat
klien untuk mencapaimulut
keterampilan. Klien harus didorong untuk melakukan
ronggadengan lengan dan tangan ditentukan. Luasnya
keterampilan seperti menjangkau kuadran kanan atas,
rentang gerak menentukan panjang perangkat yang
menyikat lidah, membersihkan permukaan lingual, dan
diperlukan untuk mengakomodasi keterbatasan fisik
menyikat permukaan wajah gigi anterior. Penting untuk
dalam menjangkau mulut. Misalnya, klien dengan
mencatat apa yang klien mampu lakukan dengan relatif
gangguan otot mungkin dapat menjangkau separuh
mudah dan perilaku apa yang menimbulkan kesulitan
tubuh mereka namun hanya mengangkat lengan hingga
atau kebingungan.
setinggi jantung. Klien seperti itu membutuhkan waktu
• Kemampuan untuk memahami dan mengikuti arahan.
yang lebih lama untuk mengimbangi gerakan terbatas
Kemampuan ini dievaluasi selama penilaian kekuatan
mencapai di atas tingkat jantung. Demikian pula, klien
genggaman. Ahli kebersihan mengajukan sejumlah
yang tidak dapat menekuk siku atau pergelangan tangan
pertanyaan yang cukup untuk menentukan pertanyaan
mungkin mengalami kesulitan menjangkau area tertentu
saya apakah klien mampu menanggapi perintah dan
di rongga mulut dan mungkin memerlukan perangkat
 instruksi verbal secara akurat. Misalnya, klien yang Dagang Medical Corpo ration), yaitu sikat gigi dengan
mengalami gangguan kognitif mungkin mengalami desain khusus yang dapat disambungkan ke alat penghisap
kesulitan dalam menghasilkan respons atas perintah dan di samping tempat tidur (Gambar 42-6).
mungkin memerlukan alat seperti sikat gigi listrik yang Pengukuran penilaian ini bekerja dengan baik dengan klien
menyelesaikan tugas dengan sedikit usaha. yang secara mental dan fisik mampu mempelajari teknik-
• Persepsi tentang apa yang tampaknya mudah atau sulit. teknik teknik perawatan diri; namun, beberapa klien
Umpan balik klien langsung sangat penting untuk mungkin tidak menggerakkan ekstremitas atas mereka sama
penilaian lengkap, dalam hal persepsi klien dapat sekali dan oleh karena itu bergantung pada pengasuh utama
mempengaruhi kepatuhan dengan perangkat apa pun, untuk melakukan perawatan sehari-hari. Wawancara
baik disesuaikan dengan kebutuhan mereka atau tidak. pengasuh penting untuk menilai kesediaan untuk
Klien harus memahami peran mereka dalam penggunaan memberikan perawatan mulut harian, menentukan tingkat
perangkat — strategi motivasi yang mempromosikan keterampilan pengasuh yang ada, dan mengidentifikasi
kepemilikan tanggung jawab atas perilaku perawatan masalah.
diri lisan.
• Status oral saat ini dan teknik perawatan diri oral, jangkauan
Menyesuaikan Perangkat Perawatan Mulut Lisan
pembukaan mulut, dan aktivitas otot-otot mulut, terutama
lidah. Penilaian intraoral memberikan informasi tentang Untuk klien dengan rentang gerak terbatas, adaptasi
kondisi mulut yang ada yang mungkin mendikte terhadap alat bantu perawatan diri oral mungkin
20
kebutuhan akan karakteristik desain perangkat tertentu. diperlukan. Penggaris dan batang plastik, yang tersedia di
Pelebaran rongga mulut dapat dilakukan melalui sebagian besar toko perangkat keras, dapat dipasang ke
penggunaan kerucut atau penekan lidah (menambahkan sikat gigi dan pemegang benang dengan selotip listrik yang
satu di atas setiap hari untuk memperpanjang tebal. Panjang pegangan tambahan memfasilitasi jangkauan
pembukaan mulut). tetapi mungkin membuat penempatan ujung perangkat
796 BAGIAN VII n Individu Berkebutuhan Khusus perawatan diri yang berfungsi di mulut menjadi sulit. Untuk
mengimbangi, sikat gigi dengan ukuran kepala yang
kompak dapat digunakan untuk pemasangan intraoral yang
lebih baik. Pegangan plastik sikat gigi yang ada dapat
ditekuk untuk memiringkan bulu sikat ke arah lengkungan
lengkungan. Untuk menekuk gagang sikat gigi, pegangan
dipegang di atas api atau di bawah air keran panas hingga
lentur.
Untuk membantu klien dengan kekuatan cengkeraman
yang lemah, pegangan perangkat dapat dibuat dengan
berbagai bahan agar sesuai dengan kemampuan penutupan
jari klien. Untuk klien dengan penutupan jari terbatas,
diperlukan pegangan lebar yang besar untuk membantu
pegangan. Gagang sepeda, cetakan styrofoam, dan senyawa
seni dan kerajinan sebagai pegangan alternatif sangat
meningkatkan
kemampuan pelanggan untuk memegang perangkat (Gbr
42-7). Sikat gigi dan pemegang benang dapat dimasukkan ke
dalam barang-barang ini dan diganti bila perlu. Klien yang
mengalami kesulitan dengan koordinasi mungkin
menemukan bahwa pegangan yang ringan sulit untuk
dikelola dan ujung yang berbobot mungkin lebih mudah
ditemukan dan dipegang. Gagang sepeda plastik lebih
disukai karena tersedia dalam berbagai ukuran, tekstur, dan
berat, tidak mahal, dan mudah dibersihkan setelah
digunakan.
Ahli terapi okupasi atau ahli kesehatan gigi bertanggung
Gambar 42-6.Sikat Hisap Mulut Plak-Vac sedang jawab untuk membuat perangkat ini pada awalnya, tetapi
dihubungkan ke perangkat penghisap samping tempat pengasuh harus dilatih untuk membuatnya
tidur di unit perawatan kritis. (Atas perkenan Michelle Bopp,
setelahnya.dibuat
Sekolah Kebersihan Gigi Gene W. Hirschfield, Old
Dominion University, Norfolk, Virginia.)

Orang yang koma atau semikomatosa di rumah sakit

atau fasilitas perawatan tambahan dapat memanfaatkan
sikat gigi seperti Sikat Pengisap Mulut Plak-Vac (Merek

Gambar 42-7khusus.Alat bantu perawatan mulut yang
disesuaikan untuk orang-orang dengan disabilitas fisik.
(Courtesy Kathleen Muzzin, Texas A&M University, Baylor
College of Dentistry, Caruth School of Dental Hygiene,
Dallas, Texas.)
Gambar 42-8.Sikat Gigi Surround dirancang untuk stabilisasi klien dan perangkat pendukung dapat ditemukan
membersihkan permukaan lingual, wajah, dan oklusal pada online di situs web Special Care Dentistry Association
saat yang bersamaan. Perangkat (Courtesy Specialized (http://www.scdaonline.org). Klik pada link ke Publikasi
Care Co, Hampton, New Hampshire.)
Harus dibawa ke setiap janji temu untuk menilai desain,
penggunaan, dan kebutuhan penggantian.
Klien dengan ketangkasan dan koordinasi yang buruk,
dan / atau kemampuan menggenggam yang terbatas,
mendapatkan keuntungan dari sikat gigi listrik dengan
pegangan besar yang dapat digunakan dengan mudah oleh
seorang pengasuh pada klien.
Beberapa produsen memasarkan sikat gigi manual yang
dapat ditekuk dengan tangan tanpa pemanas untuk
meningkatkan akses mulut dan angu lasi. Tempat benang
dan sikat gigi dengan gagang lebar atau dengan desain
pegangan khusus meningkatkan kemampuan
menggenggam klien. Produsen sikat gigi manual lainnya
telah mengkonfigurasi ulang kepala sikat — misalnya,
dengan bulu sikat yang mengelilingi gigi, memungkinkan
klien dan / atau pengasuh untuk menyikat seluruh
permukaan gigi sekaligus (Gambar 42-8). Wadah pasta gigi
dengan dispenser alternatif, seperti tutup dan tuas flip-top,
harus direkomendasikan kepada klien dengan gerakan jari
terbatas karena kekuatan pegangan diperlukan untuk
mengeluarkan pasta gigi. Perangkat irigasi oral adalah alat
bantu tambahan yang sangat baik untuk perawatan diri dan
pengiriman agen antimikroba lokal.
Untuk klien yang tidak dapat memegang perangkat
sendiri, manset universal dapat digunakan untuk bantuan.
Tali, dengan perekat Velcro di mana berbagai perangkat
adaptif dapat dipasang, dipasang di sekitar lengan atau
pergelangan tangan dan bertindak sebagai bidai untuk
stabilisasi. Manset universal dapat disesuaikan untuk
digunakan dengan alat bantu fisioterapi oral. Ahli
kebersihan gigi harus berkonsultasi dengan ahli terapi
okupasi saat merawat klien yang mungkin mendapat
manfaat dari manset universal untuk perangkat perawatan
diri.
Beberapa karakteristik desain perangkat ini antara lain:
• Terbuat dari bahan yang ringan, mudah didapat, murah
dan mudah dibuat; plastik lebih disukai karena tahan
terhadap kerusakan air dan dapat dibersihkan, dibilas,
dan dikeringkan dengan mudah
• Bagian yang dapat diganti (misalnya, pegangan alternatif
yang dibuat pada perangkat harus mudah beradaptasi,
sehingga sikat gigi yang aus dapat diganti tanpa harus
mengganti pegangannya )
• Kemudahan penggunaan dan waktu penyetelan minimal
Pemosisian dan Stabilisasi Klien Klien dengan
gangguan fisik sering kali memiliki masalah dengan
dukungan dan keseimbangan; oleh karena itu penilaian fisik
sebelum perawatan menentukan apakah adaptasi
diperlukan untuk merawat klien dengan aman. Daftar
dan Sumber dan gulir ke bawah ke Panduan Produk SCDA.
Klien dengan masalah neuromuskuler, seperti tremor,
kejang otot, atau respons hiperfleksif, mungkin memerlukan
perangkat bilisasi staf, seperti sabuk pengaman, untuk
membantu tetap dalam posisi tegak dan aman. Perangkat
imobilisasi medis lainnya, seperti papan papoose (Gambar
42-9), tersedia untuk digunakan dengan klien yang
mengalami spastisitas ekstrem atau masalah perilaku parah.
Penggunaan imobilisasi secara rutin harus dibatasi karena
dapat meningkatkan ketidakpercayaan klien dan dapat
mengurangi kemungkinan kerjasama di masa depan.21 Selain
itu, pengekangan fisik telah dikaitkan dengan memar,
gangguan pernapasan
, pneumonia aspirasi, dan selulitis dari pengekangan
ekstremitas. Perangkat imobilisasi atau pendukung juga
harus digunakan dengan hati-hati dengan klien yang rentan
kejang karena perangkat ini harus segera dilepas jika terjadi
kejang. Namun, pada individu tertentu yang
kooperasinya hampir tidak mungkin, perangkat ini
mungkin perlu digunakan pada setiap kunjungan untuk
memberikan perhatian. Risiko dan manfaat menggunakan
segala bentuk imobilisasi harus dijelaskan kepada klien,
orang tua, dan / atau pengasuh, dan persetujuan yang
diinformasikan harus diperoleh dan didokumentasikan
dalam rekam medis klien.21
BAB 42 n Penyandang Cacat 797
Bantal atau handuk gulung juga dapat ditempatkan di
 bawah lutut dan leher klien untuk mencegah kejang otot
dan untuk memberikan dukungan tambahan selama
perawatan.
Untuk mencegah cedera selama perawatan, asisten gigi
atau pemberi perawatan dapat memegang lengan dan kaki
klien dalam posisi yang nyaman. Asisten gigi dapat dengan
mudah mengistirahatkan lengan mereka paling dekat
dengan klien di dada klien, dengan lengan klien terselip di
bawah. Dengan teknik ini, lengan klien dicegah bergerak ke
area kerja jika terjadi refleks otot. Dalam kasus anak yang
sulit untuk tetap duduk di kursi gigi, anak dapat berbaring
di atas orang tuanya, dengan tangan orang tua melingkari
tubuh anak. Praktik ini harus dihentikan di awal perawatan
setelahperilaku
teknik bimbingandan latihan kepercayaan telah dilakukan
dengan anak (Tabel 42-3). Jika klien tidak kooperatif dan
menolak duduk di kursi, orang tua dan pengasuh dapat
meminta klien berbaring di lantai dengan kepala klien di
pangkuan pemberi perawatan sehingga akses yang lebih
baik ke mulut diperoleh. Klien yang sangat agresif dan tidak
bisa diam mungkin membutuhkan obat penenang.
Ahli kebersihan gigi mungkin menemukan kebutuhan
untuk penyangga kepala tambahan dan stabilisasi untuk
klien selama perawatan. Duduk pada posisi jam 12, ahli
kesehatan gigi melingkarkan lengan nondominannya di
sekitar kepala klien dan dengan kuat di bawah dagu untuk
Gambar 42-9.Pengekangan fisik digunakan untuk menjaga
klien yang cacat dalam posisi yang stabil dan aman.
(Courtesy Specialized Care Co, Hampton, New Hampshire.)
798 BAGIAN VII n Individu dengan Kebutuhan Khusus
TABEL 42-3
Teknik Panduan Perilaku
Teknik Deskripsi
Desensitisasi
(penjelasan dan paparan)
Kunjungan pengenalan Memperkenalkan klien pada lingkungan perawatan kesehatan mulut sebelum
memulai perawatan mengurangi rasa takut dan stres. Tell-show-do Demonstrasi memperkuat instruksi
verbal.
Pemodelan Bantuan model langsung atau video dalam pengembangan keterampilan dengan mendemonstrasikan
perilaku atau teknik yang diinginkan. Umpan Balik Umpan balik segera meningkatkan pembelajaran klien dan
stabilisasi. Bantal kecil, gulungan leher, atau seprai mandi
yang digulung juga dapat ditempatkan di kedua sisi kepala
klien untuk dukungan tambahan. Kursi beanbag yang
ditempatkan di kursi gigi dapat memberikan dukungan
tambahan untuk anak-anak penyandang cacat dengan
persendian dan anggota tubuh yang tidak stabil (Gambar 42-
10).
Sandaran kepala, sandaran punggung yang kokoh, sabuk
pengaman, tali dada, penyangga bagasi lateral, dan
pemandu pinggul biasanya digunakan pada kursi roda
untuk membantu klien tetap dalam posisi yang benar di
kursi. Bantal membantu klien yang lumpuh untuk
memberikan dukungan tambahan dan untuk meminimalkan
terjadinya luka tekan (ulkus dekubitus atau dekubiti).
Untuk mengurangi risiko aspirasi, pengasuh tidak boleh
menggunakan obat-obatan atau agen topikal saat klien
telentang. Klien dengan masalah neuromuskuler atau
perilaku dapat menggunakan pasta gigi yang bisa dimakan
sebagai alternatif yang aman.
Selama perawatan, praktisi harus menempatkan klien
dalam posisi duduk atau semi miring untuk mencegah
aspirasi bahan, cairan, atau instrumen. Isolasi bendungan
karet juga mencegah aspirasi bahan gigi; namun,
penggunaan rutin tidak dianjurkan untuk klien yang
mengalami gangguan, terutama pada
Gambar 42-10.Kursi beanbag membantu menopang
anggota tubuh anak-anak yang mengalami gangguan fisik
selama perawatan gigi.
Paparan bertahap ke pengaturan perawatan kesehatan mulut
menanamkan keakraban dengan lingkungan.
 pengembangan keterampilan melalui evaluasi kemajuan dan kinerja.
Pelarian kontingen Menawarkan istirahat singkat dalam pengobatan dan / atau memberikan hadiah positif
berdasarkan periode waktu yang ditentukan untuk perilaku yang baik (misalnya, setelah
menghitung sampai sepuluh, ahli kebersihan memberi tahu klien bahwa mereka diizinkan
untuk menutup mulut dan istirahat).
Penguatan Positif Imbalan memperkuat perilaku dan mendorong pengulangan suatu perilaku; penghargaan termasuk
pujian, hak istimewa, sistem token, dan barang material.
Gangguan Rangsangan audiovisual (mis., Mendengarkan musik melalui headphone atau menonton rekaman video),
mengurangi perilaku tidak kooperatif dengan memberikan rangsangan di mana klien dapat fokus selama perawatan.
Komunikasi Kata dan frasa yang mencerminkan empati, rasa hormat, dan kehangatan meningkatkan interaksi dan
kepercayaan klien-penyedia. Isyarat tangan Izinkan klien yang ketakutan untuk mengangkat tangan sebagai tanda untuk
menghentikan pengobatan; mempromosikan perasaan keselamatan dan keamanan klien.
Komunikasi nonverbal (sentuhan) Klien yang menunjukkan kecemasan ringan hingga sedang
dapat mengambil manfaat dari pernapasan dalam, meditasi,
Relaksasi, hipnosis, sedasi
atau perumpamaan yang dipandu. Pengobatan mungkin
Klien penyandang cacat memiliki kesadaran yang tinggi
diperlukan untuk klien dengan kecemasan, ketakutan, atau
terhadap bahasa tubuh dan ekspresi wajah seseorang.
perilaku tidak kooperatif yang ekstrim.
Sentuhan yang meyakinkan menunjukkan kehangatan dan
pengertian terhadap klien yang gelisah.
Kontrol suara Perubahan volume, kecepatan, dan nada dapat digunakan untuk menarik perhatian klien dan
mempengaruhi perilaku mereka. Ini mengacu pada cara pesan dikirim ke klien.
Cerita sosial Menggambarkan situasi sosial, keterampilan, atau konsep dan perilaku yang diharapkan yang harus
ditampilkan oleh klien. Cerita dapat dibaca oleh klien atau oleh pengasuhnya atau disajikan
melalui pemutar audio atau video atau perangkat lunak komputer.

Data dari Lyons RA: Memahami teknik dukungan perilaku dasar sebagai alternatif sedasi dan anestesi, Spec Care Dentist
29 (1): 39, 2009. Quirmbach LM, Lincoln AJ, Feinberg-Gizzo MJ, dkk: Cerita sosial: mekanisme efektivitas dalam
meningkatkan keterampilan bermain game pada anak-anak yang didiagnosis dengan gangguan spektrum autisme
menggunakan tindakan berulang pretest-posttest desain kelompok kontrol acak, J Autism Dev Disord 39 (2): 299, 2009.

yang memiliki jalan napas terganggu, agresif atau uncoop erative

, atau mengalami kesulitan menelan. Selama perawatan gigi
, penting untuk menggunakan evakuasi yang baik dengan bantuan
asisten gigi, terutama bila terdapat peningkatan air liur
.
To prevent closure of the mandible onto the operator's
fingers, use of a mouth prop is recommended for treating
impaired clients who are seizure prone, have muscle weak
ness, or experience muscle spasms. Standard mouth props
should have one end of the dental floss tied through the hole
at the base of the mouth prop and the other end attached to
the client's napkin clip. This allows the mouth prop to be
pulled quickly from the mouth and prevents swallowing in
the event of an emergency. Larger hand-held mouth props comfortable for the client. The client may be treated in the
also can be used during assisted oral self-care (Figure 42-11). wheelchair if the treatment area is wide enough for position
The client is usually the best source of advice on how to ing the client either alongside or behind the dental chair.
approach positioning and movement. Ideally, all clients Clients who remain in the wheelchair need additional head
should be treated in the dental chair, but on occasion a client support during care, which can be obtained by using a
in a wheelchair may be too weak to transfer into the dental
chair or may require positioning that only the wheelchair
can provide. Some power wheelchairs have seat functions
that recline or tilt for adequate positioning, and this may be
more
Figure 42-11.Clinician using the Open Wide disposable
mouth prop on an adult. (Courtesy Specialized Care Co,
Hampton, New Hampshire.)

the transfer is attempted without verifying whether the
client's perceptions
Figure 42-12.Wheelchair positioned so that the head is
leaning against the back of the dental chair's headrest.
(Courtesy Kathleen Muzzin, Texas A&M University, Baylor
College of Dentistry, Caruth School of Dental Hygiene,
Dallas, Texas.)
portable headrest or by turning the wheelchair around so
that the client's head is leaning against the back of the dental
chair's headrest (Figure 42-12). Treating multiple clients
from this position may cause musculoskeletal problems for
the clinician; therefore clients who cannot be transferred
should be treated early in the day while the hygienist is well
rested. After providing care from a compromised operator
position, the hygienist should break for adequate rest and
muscle stretching before treating another client (see Chapter
11).
Wheelchair Transfer Techniques
Transferring from Wheelchair to Dental Chair
Procedure 42-1 and the corresponding Competency Form
describes transferring the client from the wheelchair to the
dental chair using a one-person lift. Before making the trans
fer, however, the health history must be assessed carefully to
determine the client's current health status, nature of the con
dition that dictates wheelchair use, existing physical
strength, risk of inducing muscle spasms, and areas of the
body that could be injured if the client is moved incorrectly.
In addition, the client should be questioned regarding use of
urinary appliances (catheters and collecting bags) that may
become dislodged during a transfer. A kinked catheter
results in inad equate bladder drainage, causing toxic waste
accumulation, and could trigger an emergency situation. The
client must be asked about use of waste elimination
appliances so that proper care can be taken during the
transfer. The client's physician should be consulted about
specific medical con cerns identified on the health history
assessment before any transfer is attempted.
The client's physical ability to participate with the
transfer is assessed. Many clients who have undergone
physical therapy for their condition may be accustomed to
transfer techniques, especially if they have been taught to
transfer at home by themselves. Some clients have the ability
to assist with the transfer, although they may be unfamiliar
with the actual procedural steps involved. Others may
perceive that they have the physical strength and skills
needed to assist with the transfer when actually they do not
possess these abilities. Misconceptions may be dangerous if
CHAPTER 42 n Persons with Disabilities 799
and abilities are realistic. Also, the client's willingness to
transfer is essential for the dental hygienist to know; in any
transfer procedure the client depends on the practitioner to
some extent, especially during lifting from the wheelchair.
An uncooperative client who overestimates or
underestimates his or her abilities or a client who resists
transfer attempts poses significant management challenges,
as well as increased risks for injury to the client and dental
hygienist.
The client's level of coordination and balance determines
need for assistance with the transfer process. Assistance may
be required from another operator (see Procedure 42-2 and
the corresponding Competency Form) or may be obtained
with the use of a transfer belt or sliding board.
• Transfer belts are straps secured around the client's waist
to provide a place to hold the client in the event that the
person begins to fall during the transfer process. These
are especially useful with clients who have little to no
upper body strength, such as tetraplegics.
• Sliding boards are used to assist the client with fair to
good upper body strength by helping the client slide out
of the wheelchair, across the board, and into the dental
chair. The wheelchair must be positioned beside the
dental chair, and the arms to both chairs must be
removed to accommodate the board. One end of the
board is placed underneath the client, and the other end
is laid across the dental chair. The client uses upper arm
and body strength to move across the board while the
board provides support from underneath the client's legs.
Sliding boards also are useful with clients who are
overweight or are otherwise too difficult for one person to
safely move alone. Transfer belts may be used as an
added precaution during a sliding board transfer.
Operator safety also must be ensured as follows: • The
operator should never attempt to transfer a client alone.
Although the one-person transfer technique requires only
one individual to maneuver the client, an additional person
must be available to provide assistance if needed. The
additional person reduces the risk of falling or injury to the
client during a transfer.
• One operator never should attempt to transfer a client
who is very tall or heavy, especially clients who have no
upper body strength. These clients have a much greater
chance of falling because of their lack of coordination and
balance, and they may injure themselves and the
operator.
• All transfer movements performed by the operator should
be done with feet separated for good balance and knees
bent to protect against back strain.
• All lifting procedures should be performed with the legs,
while keeping the back straight and slightly bent forward
at the waist to prevent muscular back injury to the
operator.
 • While lifting the client from the wheelchair, the operator
should never twist his or her back; twisting may cause
severe muscular back strain and injury. Instead, the opera
tor should move with small steps or pivot to position the
client.
800 SECTION VII n Individuals with Special Needs
Preparation for a Wheelchair Transfer Before
beginning the transfer procedure, the hygienist explains the
steps to reduce client fear. If the client is expected to assist
with the transfer, the client is informed of how and when
assistance is needed. A simulation is helpful before the
actual procedure is performed, especially for clients who

Procedure 42-1 Transferring Client from Wheelchair to Dental Chair Using a

One-Person Lift
STEPS
1. Position transfer belt around client's waist just below
ribcage (Figure 42-13).
2. Insert your hands underneath client's thighs, and gently
slide client forward in wheelchair seat so that client's
buttocks are positioned on front portion of seat. Place
sliding board under client so that one end of board is
underneath client's thighs and other end is laid across
the dental chair (Figure 42-14).
3. Place client's feet together and hold them in place on
either side by your feet. Close your knees or thighs on
the client's knees, thus supporting and stabilizing
client's leg, which allows client to bear some of own
weight during the lift.
4. Place client's arms on his or her lap or on the side of
wheelchair; instruct client to rest the head over your
shoulder so as to look in the opposite direction of the
transfer (Figure 42-15).
5. Grasp client around waist and hold transfer belt
securely between both hands. If there is no transfer belt
available, use an overlapping wrist grasp for greater
stability.
6. Rock gently backward onto your heels and, using your
leg muscles, lift client off seat. Client is now resting
against you, the operator (Figure 42-16).
7. Pivot on your foot closer to the dental chair, and
maneuver client over seat of dental chair. This should be
done in a smooth motion. 8. Lower client onto dental chair
by bending at your knees. Do not release transfer belt
around client until client is securely placed into chair.
9. Release one hand to lift client's legs onto chair while still
supporting client with the other hand. Reposition armrest
of dental chair for client safety.

Figure 42-13.Transfer belt is placed around the client's client, and the other end is laid across the dental chair.
waist and below the ribcage. (Courtesy Kathleen Muzzin, (Courtesy Kathleen Muzzin, Texas A&M University, Baylor
Texas A&M University, Baylor College of Dentistry, Caruth College of Dentistry, Caruth School of Dental Hygiene; and
School of Dental Hygiene; and Bobi Robles, Baylor Institute Bobi Robles, Baylor Institute for Rehabilitation, Dallas,
for Rehabilitation, Dallas, Texas.) Texas.)
Figure 42-15.Client's hands are placed on side of
wheelchair, and head is positioned on the operator's
shoulder opposite the direction of the trans fer. (Courtesy
Kathleen Muzzin, Texas A&M University, Baylor College of
Dentistry, Caruth School of Dental Hygiene; and Bobi
Robles, Baylor Institute for Rehabilitation, Dallas, Texas.)

Figure 42-

14.One end of the sliding board is placed underneath the

 Figure 42-16.Client is lifted off the wheelchair and
positioned for transfer to the dental chair. (Courtesy
Kathleen Muzzin, Texas A&M University, Baylor College of
Dentistry, Caruth School of Dental Hygiene; and Bobi
Robles, Baylor Institute for Rehabilitation, Dallas, Texas.)

CHAPTER 42 n Persons with Disabilities 801

Procedure 42-2 Transferring Client from Wheelchair to Dental Chair Using a

Two-Person Lift
STEPS
1. First operator stands behind client and reaches around client's
torso
underneath armpits. Operator crosses her or his arms in front
of client
and grasps client's hands at the wrists with opposite hands
(right over
left, left over right). Operator then slides her or his arms down
so that
arms are positioned under the client's ribcage on the abdomen.
Stronger and/or taller of two operators is placed behind client.
2. Second operator is positioned on the far side of the wheelchair
at the
client's knees or thighs. Bending at the knees, operator slides one
arm underneath the client's thighs (approximately midway point) while
other arm is placed slightly above the knees (Figure 42-17).
3. Client is lifted by both operators at a prearranged signal (“1, 2, 3,
lift”). One person coordinates the lift, preferably the operator who is
supporting the client's torso (the operator who is dental chair is replaced.
lifting the most weight) (Figure 42-18).
Figure 42-18.The operator who is supporting the client's
4. Client is lifted in one smooth motion and placed into torso coordi nates the lift. (Courtesy Kathleen Muzzin, Texas
dental chair (Figure 42-19). A&M University, Baylor College of Dentistry, Caruth School
5. Operator holding the legs releases the grasp on the of Dental Hygiene; and Bobi Robles, Baylor Institute for
client and repositions client in chair. Other operator does Rehabilitation, Dallas, Texas.)
not release client until the client is stabilized and arm of
 Figure 42-17.During the two-person transfer, the first portive pillows reduces the incidence of spasms induced by
operator stands behind the wheelchair and the second
operator positions herself at the client's thighs. (Courtesy
802 SECTION VII n Individuals with Special Needs
Kathleen Muzzin, Texas A&M University, Baylor College of
Dentistry, Caruth School of Dental Hygiene; and Bobi
Robles, Baylor Institute for Rehabilitation, Dallas, Texas.) movement. Anxiety also can contribute to spasms; therefore
fear and stress reduction strategies are used before a transfer
is initiated.

have never been transferred. When preparing for a wheel
chair transfer, the hygienist does the following: • Positions
the wheelchair at a slight angle to the dental
chair. The dental chair should be slightly lower than the
wheelchair.
• Positions the wheelchair wheels facing forward and locks
the wheels. This stabilizes the chair and prevents tipping
or slipping during the transfer.
• Places the transfer belt around the client's waist. •
Removes footrests from the chair or folds them back so that
the client's feet do not become caught during the transfer.
The client's feet are placed gently on the floor to prevent
spasm and to position the feet for the transfer. • Removes
arms of both wheelchair and dental chair. If the arm of
dental chair is not removable, then the hygienist positions it
as far back as possible so that it does not inter fere with the
transfer.
Figure 42-19.Client is lifted in one smooth motion and
placed in the dental chair. (Courtesy Kathleen Muzzin,
Texas A&M University, Baylor College of Dentistry, Caruth
School of Dental Hygiene; and Bobi Robles, Baylor
Institute for Rehabilitation, Dallas, Texas.)
Decubitus Ulcers (Pressure Sores)
Individuals who use wheelchairs are prone to decubitus
ulcers. Decubiti form in areas that lack blood flow, such as
on the buttocks and on the backs of thighs. Decubiti can be
extremely painful and become infected easily. The dental
hygienist questions the impaired client during the health
history review about the presence of decubiti. To relieve pres
sure from the skin and prevent decubiti from occurring,
clients must perform weight shifts every 20 minutes. When
clients are transferred into the dental chair, supportive
devices and weight shifts must be incorporated into the
client's appointment plan. Changes in skin integrity are
monitored carefully and discussed with the client's
physician.
Bowel and Bladder Elimination Schedules
Clients who are transferred into the dental chair need to
adhere to their bowel and bladder elimination program. Ade
quate time must be allotted to transfer the client back into
the wheelchair if the client needs to use the restroom during
an appointment. The elimination schedule should be docu
mented in the client's record.

Autonomic Dysreflexia
Any of the aforementioned complications poses a significant
• Checks area for any sharp edges, hazards, obstacles, or
risk for the development of autonomic dysreflexia, a severe
cords that could cause injury during transfer.
condition that can be fatal if untreated. Noxious stimuli,
• Unfastens the client's safety belt. After the belt is removed,
such as urinary backflow or pain from decubitus ulcers,
the operator must support the client to prevent falling. •
leads to the development of dysreflexia, manifested by a
Transfers any special padding underneath the client to the
variety of signs and symptoms. The client may appear
dental chair. The hygienist gently rocks the client forward
disorientated and flushed and exhibit profuse sweating,
while an assistant removes padding from wheelchair and
severe headache, anxiety, and shortness of breath.22 The most
places it onto the dental chair.
characteristic dysreflexia manifestation is an extremely
elevated blood pres sure, which ultimately results in stroke
Complications in Wheelchair (see Chapter 47). The practitioner, alerted to any of these
Transfer Muscle Spasms clinical signs, must stop work immediately, check the client's
Movement may stimulate muscle spasms, and the hygienist blood pressure, and identify the cause of the reaction.
must be prepared to protect the client from injury if spasms Usually, eliminating the cause (such as when a kinked
occur. Continuous spasms are reduced by massaging the catheter is straightened) pro duces an immediate, favorable
affected area or waiting until the muscle relaxes. Use of sup response. Suspicion of dysre
flexia is treated as a severe medical emergency, and
assistance must be summoned immediately. The client
should be placed in an upright position. This position helps
facilitate a drop in blood pressure. Because of the nature of
this risk, it is impera
tive that no client who is transferred to the dental chair be
left unattended.
Transferring from Dental Chair to Wheelchair
When the appointment is completed, the client must be trans
ferred from the dental chair back into the wheelchair. The
same procedures are conducted to move the client, with
special attention given to replacing the padding and
supports underneath the client before seating him or her in
the wheel chair. The chair wheels always must be locked
when the client is transferred back into the wheelchair.
Transfer techniques require practice. Practicing these tech
niques, especially for those who conduct client transfers
infrequently, ensures competence in performing transfer pro
cedures. Physical therapists can help hygienists who are
unfa miliar with providing dental care for clients in
wheelchairs.
Transfer techniques enable hygienists to treat special needs
clients who may otherwise not receive oral care.
Health Promotion and Advocacy
The hygienist supports clients with special healthcare needs
in the healthcare arena and by promoting these clients as con • Impairments occur as a result of pathology, accident, or
tributing members of society. Opportunities abound to work
to improve access to dental hygiene services (eg, participat
ing on councils, on local boards, and in area support groups; • The term “handicap” is no longer used because of its nega
holding leadership positions in organizations; initiating com
munity programs; and contributing to lay and professional • Developmental disabilities occur congenitally or during
communities via speaking engagements and publications).
CLIENT EDUCATION TIPS
• Work with caregivers; physicians; perawat; dietitians; and • Acquired disabilities occur in early adulthood, from
speech, physical, and occupational therapists to identify disease or some type of trauma or injury to the body. • Age-
needs, set goals, and plan client care.
• Provide other healthcare providers with information on
the oral health–systemic health link.
• Clarify information and maximize roles of family and
care givers as healthcare providers for the special needs
client. • Demonstrate methods for modifying and using
oral self care devices to achieve optimal oral health.
LEGAL, ETHICAL, AND SAFETY ISSUES
• Clients with special healthcare needs undergo long-term
care with multiple providers, so oral care interventions
must complement other health services. If the client is
ambulatory, fully functional, and without cognitive
impairment, consent to speak with other caregivers and
providers, as well as permission to proceed with care,
must be obtained directly from the client.
• If client is under the care of a legal guardian, the guardian
must provide informed consent for planned care and con
sultations with other providers.
• Original copies of written correspondence and informa
tion from other care providers are maintained in the cli
ent's dental record.
• Care is taken to ensure client stability during positioning
and transfer; clients never should be left unattended. •
Client is an active participant in all conversations with
caregivers who attend the appointment.
• Some individuals with special needs may become victims
of violence, abuse, or neglect. The hygienist is obliged
ethically to report suspected cases of abuse and neglect to
the proper authorities (see Chapter 60).
KEY CONCEPTS
• Access to healthcare, education, and employment oppor
tunities is essential to achieve an acceptable level of
health and wellness and to maintain as much
independence as possible.
• Oral care is significant for special needs clients because the
mouth is used for mastication, speaking, expressing per
sonality, using telecommunication devices, working at a
job, and portraying a positive self-image.
• Disability is an all-encompassing term for impairments,
activity limitations, participation restrictions, and environ
mental factors.
disease and includes any loss or abnormality of physio
logic, anatomic, or mental function.
tive connotations.
the developmental period of the child and are generally
chronic in nature, continue throughout the life of the indi
vidual, and appear as mental, physical, or combined
impairments.
associated disabilities occur later in life, typically after the
age of 65.
• Assistive devices are used to achieve independence in
daily functions and communication.
• The dental hygienist assesses the client's cognitive aware
ness, ability to ambulate with or without an assistive
device, ability to communicate and interpret information,
and need for caregiver assistance.
• The dental hygienist develops specialized self-care devices
to promote oral health among those with functional
limitations.
• Caregiver interviews assess willingness to provide daily
oral care for the client, determine the existing skill level of
the caregiver, and identify concerns in performing oral
care procedures.
• Most impaired clients can be transferred safely and easily
into the dental chair with proper procedures.
• Autonomic dysreflexia, a life-threatening medical emer
 gency, can be prevented.
• Dental hygienists work with lay and professional com
munities to improve quality of life for citizens with
special needs.
CRITICAL THINKING EXERCISES
1. Form groups of three to practice wheelchair transfers and
client positioning and stabilization techniques. Students
should alternate roles as clients and practitioners.
Practical exercises should include one-person and two-
person lifts and, when possible, a sliding board. Consider
consulting a physical therapist or physical therapy
students for col
laborative learning.
2. Assume the role of an impaired person for several hours,
and complete a set of exercises designed to enhance one's
appreciation of the difficulties associated with conducting
BADLs. Randomly draw from a list that includes hearing
and visual impairment, inability to speak, blindness, and
limited mobility (arm, leg, both legs). Assemble equip
ment and assistive devices for use during these activities
(eg, canes, dark glasses, safety glasses coated with petro
leum jelly, ear plugs, crutches, wheelchairs, splints,
slings, shoe lifts). Consult a physical therapist or physical
therapy students for assistance. While “impaired,”
students should complete a health history form in the
clinical setting, ride in elevators, visit another building to
retrieve a newspaper or beverage, obtain signatures from
faculty in other depart
ments, or purchase supplies from the campus bookstore.
After the exercises, discuss the experiences. (Extreme
caution and care must be taken to plan activities that will
not place the student in danger while “impaired.”
CHAPTER 42 n Persons with Disabilities 803
Students should not be permitted to cross roadways or
other high-traffic areas, to prevent accidental injury. Con
sideration should be given to severely “impaired” stu
dents who may benefit from pairing with a buddy for
assistance or safety. Always inform campus officials
when students will be completing this exercise, to help
ensure student safety and participation by others.)
3. Select a medical condition associated with impairment,
and prepare a dental hygiene care plan tailored to
meeting client needs. Use the care plan approach
presented in Chapter 22. Include information on
population affected, age of onset, rate of onset, rate of 17. Kagohara DM, van der Meer L, Ramdoss S, et al: Using iPods
change or disease pro
gression, need for assistive devices, related medical condi
tions, medications used to manage this condition, oral
manifestations, and special clinical considerations for pro 18.
viding dental hygiene care. Prepare oral presentations
about the care plans, and provide copies of all care plans
to peers as a guide.
4. Design oral self-care devices for the following client condi
tions: inability to grasp and hold; inability to raise hand;
inability to move forearm in a back-and-forth motion.
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 21. Romer M: Consent, restraint, and people with special needs: a
review, Spec Care Dentist 29(1):58, 2009.
22. Milligan J, Lee J, McMillan C, et al: Autonomic dysreflexia. Rek
ognizing a common serious condition in patients with spinal
cord injury, Can Fam Physician 58(8):831, 2012.
ACKNOWLEDGMENT
Pageburst Integrated Resources
As part of your Pageburst Digital Book, you can access the following
Integrated Resources:
Competency Evaluation Forms
Transferring Client from Wheelchair to Dental Chair Using a One-Person Lift
Transferring Client from Wheelchair to Dental Chair Using a Two-Person Lift
Procedure Ordering Exercises
Transferring Client from Wheelchair to Dental Chair Using a One-Person Lift
Transferring Client from Wheelchair to Dental Chair Using a Two-Person Lift
Key Term Flashcards
Procedures Manual
Web Resources
Cardiovas
cular Disease Laura Mueller-
Joseph
COMPETENCIES
1. Discuss cardiovascular disease, including: •
Discuss cardiovascular disease risk factors. •
Critically evaluate the relationship between
cardiovascular disease and periodontal disease. •
Identify signs and symptoms of rheumatic heart
disease, infective endocarditis, valvular heart defects,
hypertension, coronary heart disease, cardiac
arrhythmias, congestive heart failure, and congenital
heart disease.
The author acknowledges Ann Eshenaur Spolarich for her past con
tributions to this chapter.
Refer to the Procedures Manual where rationales are provided for the
steps outlined in the procedures presented in this chapter.
EVOLVE RESOURCES
Please visit http://evolve.elsevier.com/Darby/hygiene
for additional practice and study support tools.
CHAPTER 42 n Persons with Disabilities 804.e1
2. Identify the types of cardiovascular surgery. 3.
Discuss oral manifestations of cardiovascular
medications.
4. Discuss the prevention and management of cardiac
emergencies, including:
• Determine the need for emergency medical care in
clients with coronary heart disease.
• Develop a dental hygiene diagnosis and care plan
for a client with cardiovascular disease.
Penyakit kardiovaskular
Clients presenting with cardiovascular disease have a
unique set of health concerns that may or may not influence
dental hygiene care directly. These clients are considered
individuals with special needs and, depending on their
situation, dental hygiene care plans may have to be altered
to ensure optimal treatment outcomes. Normal
cardiovascular structure and physiology establish the
baseline for discussion of cardiac pathology (Figure 43-1).
Cardiovascular disease (CVD), an alteration of the heart
and/or blood vessels that impairs function, is the leading
cause of death, responsible for 30% of all deaths or 17.3
million people worldwide.1 Projected statistics indicate that
by 2030, 236 million people will develop some form of CVD.
Prevention through management of CVD risk factors
remains important. Risk factors associated with poor
cardiovascular health are listed in Table 43-1.
The American Heart Association notes that periodontal
disease and heart disease share common risk factors such as
diabetes, smoking, and age; however, the association
between these two diseases appears to go beyond their
common risk factors.2,3 Research suggests that chronic
infections, such as periodontitis, may increase one's risk for
CVD.4,5 In recent reports, the American Dental Association
and the American Heart Association have acknowledged
this association and believe more evidence is needed to
establish an indisputable
CHAPTER
(IE), and prophylactic antibiotic premedication before dental
hygiene care is not required.
Etiology
Rheumatic fever is an acute or chronic systemic
inflammatory process characterized by attacks of fever,
polyarthritis, and carditis. The latter eventually may result in
permanent valvu lar heart damage.
Risk Factors
Persons who have had a beta-hemolytic streptococcal pha
ryngeal infection (strep throat) may develop rheumatic fever
within 2 to 3 weeks after initial infection. People with a
history of rheumatic fever are predisposed to RHD because
of the involvement of the heart muscles, resulting in cardiac
valve damage.

43
Disease Process
The most destructive effect of rheumatic fever is carditis, an
inflammation of the cardiac muscle that is found in most
individuals exhibiting signs and symptoms of rheumatic
fever. Carditis may affect the endocardium, myocardium,
pericardium, or heart valves. Valvular damage is responsible
for the familiar organic (nonfunctional) heart murmur associ
ated with rheumatic fever and RHD. The heart murmur is
an irregularity of the auditory heartbeat caused by a
turbulent flow of blood through a valve that has failed to
causative relationship.2,3,6 Changing risk-related behaviors close. Valves most commonly affected are the mitral valve
assists in decreasing the risk and prevalence of heart disease and the aortic valve. Damaged valves are susceptible to
in the population (see Table 43-1). infection that may lead to IE. Severe rheumatic carditis may
cause difficulty in breathing, elevation of diastolic blood
Rheumatic Heart Disease pressure, and increas ing signs of heart failure.
Rheumatic heart disease (RHD) is the cardiac manifestation
of rheumatic fever. Persons with a history of rheumatic fever Prevention
often have valvular heart damage that is affected detrimen RHD prevention requires early diagnosis and treatment of
tally by bacteremia (microorganisms in the bloodstream), streptococcal pharyngeal infections that may lead to
often occurring during dental hygiene care. Persons with a rheumatic fever. Clients need to be informed of the
history of RHD are not at high risk for infective endocarditis importance of early medical diagnosis and treatment for
prevention of this disease.

805
806 SECTION VII n Individuals with Special Needs Right
atrium

Tricuspid valve
Superior
vena cava Right
ventricle

Sinoatrial
(SA) node
(pacemaker)

Pulmonary
veins

Atrioventricular
(AV) node
Inferior Mitral
vena cava (bicuspid)
Aorta valve

Purkinje
Pulmonary fibers
artery

Left
ventricle

Pulmonary
Right and left branches
veins
of AV bundle
(bundle of His)

Figure 43-1.Diagram of the heart. (From Patton KT, Thibodeau GA: Anatomy and physiology, ed 8, St Louis, 2013, Mosby.)

Dental Hygiene Care bacteremia (microorganisms in the bloodstream), is

According to the American Heart Association's Guidelines characterized in most cases by vegetative growths of
for the Prevention of Infective Endocarditis, prophylactic Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus
antibiotic premedication is not required for clients with viridans, and, the most prevalent,
RHD.7 To protect clients from health risks, the care plan must alpha-hemolytic streptococci on heart valves or endocardial
include meticulous oral biofilm control. Good oral health lining. Although staphylococci and streptococci are found in
mainte nance by the client reduces the possibility of the majority of cases, yeast, fungi, and viruses also have
developing a self-inflicted bacteremia during toothbrushing been identified, hence the term infective rather than bacterial.
or interdental cleaning. If untreated, endocarditis is usually fatal; with proper
antibiotic treatment, recovery is possible.
Appointment Guidelines
• Frequent continued-care intervals to maintain good oral Risk Factors
health During invasive dental or dental hygiene therapy (defined
• Client-centered homecare instruction to maintain optimal as procedures that involve manipulation of oral soft tissues,
oral health practices manipulation of the periapical area of teeth, or oral mucosa
• Preprocedural antimicrobial rinse before tissue manipula perforation), a transient bacteremia is produced. Tissue
tion to reduce severity of bacteremia trauma from instrumentation coupled with periodontal
disease status determines the severity of infection. In
Infective Endocarditis addition, a client may create a self-induced bacteremia via
Infective or mastication and daily oral hygiene care. Risk factors for IE
bacterial include clients with a previous history of endocarditis,
endocarditis is artificial heart valves, or serious con genital heart conditions
an infection of and heart transplant patients who develop a problem with a
the endo heart valve.7 Box 12-4 in Chapter 12
cardium, heart delineates risk conditions with the highest risk for adverse
valves, or effects of IE for which antibiotic prophylaxis is
cardiac recommended.
prosthesis
resulting from Disease Process
microbial There are two types of IE, as follows:
invasion. • Acute bacterial endocarditis (ABE) is a severe infection
with a rapid course of action usually caused by
Etiology pathogenic microorganisms, such as S. aureus and S.
IE, caused by the epidermidis, that are capable of producing widespread
formation of a disease.
CHAPTER 43 n Cardiovascular Disease 807

TABLE 43-1
Risk Factors for Cardiovascular Disease

Factors Examples
 Nonmodifiable Risk Factors
Personal Factors
Genetic predisposition or family history Family members have cardiovascular disease; congenital abnormality
Age Pathologic changes within coronary arteries severe enough to cause symptoms appear predominantly in persons
>40 years of age
Race Blacks and Hispanics are more likely to have cardiovascular disease than whites or Pacific Islanders
Gender Men are four times as likely to have coronary heart disease as women up to age 40 years

Disease Patterns
History of anorexia nervosa or bulimia Women <40 years old are at increased risk of developing coronary heart disease
if they have (had) an eating disorder
Past use of fen-phen (fenfluramine and phentermine) May damage heart valves if used longer than 2 months

Modifiable Risk Factors

Personality traits (type A personality) Hard-driving, competitive individuals who worry excessively about
deadlines and consistently overwork
Professional stresses Occupations that impose tremendous responsibility
Oral contraceptive use Women <40 years of age who take oral contraceptives
Tobacco use Smoking and use of smokeless tobacco incr ease risk of coronary heart disease Sedentary
occupation and lifestyle Lack of exercise promotes mental depression and obesity
Diet high in calories, cholesterol, fat, and sodium Overeating and consuming fatty foods promote obesity, lipid
abnormalities, diabetes, metabolic syndrome; high-sodium diet promotes hypertension
Hypertension Individuals with sustained blood pressure of 160/95 mm Hg or higher double their risk of myocardial
infarction
Obesity Weight 30% or more above that considered standard for an individual of a certain height and build
Lipid abnormalities Serum cholesterol >200 mg/100 mL or a fasting triglyceride of >250 mg/100 mL; abnormal level
of C-reactive protein
Diabetes mellitus Fasting blood sugar of >120 mg/dL, or a routine blood sugar level of ≥180 mg/dL increases risk
Periodontal disease Periodontal disease increases chronic systemic inflammation, possibly increasing risk of fatal
cardiovascular disease

• Subacute bacterial endocarditis (SBE) is a slow-moving valvulopa thy in cardiovascular transplantation recipients,
infection with nonspecific clinical features. Affected and pros
persons usually exhibit a continuous low-grade fever, thetic cardiac valves, all require preventive antibiotic therapy
marked weakness, fatigue, weight loss, and joint pain. before procedures that produce bacteremias (see Chapter 12,
Dental and dental hygiene procedures that manipulate Box 12-4 and Tables 12-4 and 12-5).7
soft tissue may be responsible for the development of 808 SECTION VII n Individuals with Special Needs
SBE. As endocarditis progresses, the circulating
microorgan isms attach to the damaged heart valves or
other suscep BOX 43-1
tible areas and proliferate in colonies. This invasion
results in cardiac failure from continued valvular damage Sample Dental Hygiene Care Plan: Client Needs
and embolization (vessel obstruction) owing to Prophylactic Antibiotic Premedication
fragmentation the colonized microorganisms.
Prevention Dental Hygiene Diagnosis
• Protection from health risks: Potential for developing
Clients with conditions that increase their susceptibility to
a resistance to prescribed antibiotic if taken over a
IE, such as previous IE, unrepaired cyanotic congenital heart
period of time
disease (CHD), completely repaired congenital heart defect • Skin and mucous membrane integrity of the head and
with prosthetic material or device within the first 6 months neck
after the procedure, repaired CHD with residual defects at
the site, or adjacent to the site, of a prosthetic patch or Client Goals
prosthetic device (which inhibits endothelialization), cardiac • Schedule invasive procedures so that
 appointments are 9 to 14 days apart
• Reduce gingival bleeding by 80% by last
appointment • Reduce periodontal probing depths by
1 mm by last appointment
Expected Outcomes
• Complete chart of periodontal probing depths
• Dentition and periodontium free from soft and
hard deposits • Root surfaces debrided and
tissue healing observed
• Bleeding index score reduced by 80%
• Periodontal probing depths reduced by at least 1 mm
Dental Hygiene Interventions
• Schedule treatment into three appointments.
Appointment 1
• Probe entire mouth, scale and debride maxilla; oral
biofilm control with toothbrush, interdental cleaning
device, and ADA-accepted antibacterial mouth
rinse.
• Plan for host response time; no treatment for 9 to 14 days.
Appointment 2
• Evaluate tissue on maxillary arch; scale and debride
mandibular arch; oral biofilm control continued;
evaluate and modify self-care regimen as needed.
• Plan for host response time; no treatment for 9 to 14 days.
Appointment 3
• One month after treatment, reassess; evaluate
overall outcome; repeat periodontal probing,
measure gingival bleeding, reevaluate and modify
self-care regimen as needed.
Dental Hygiene Care
The following steps help prevent IE:
• Identify high-risk individuals via the health history and
client questioning.
• Ensure that preventive antibiotic is administered 1 hour
before procedures that produce bacteremias so that
optimal blood levels are established.
• Direct client to use a preprocedural antimicrobial rinse
before tissue manipulation.
• Prevent unnecessary trauma during intraoral procedures
to reduce severity of bacteremia.
• Help client maintain optimal oral health and daily oral
biofilm control to minimize self-induced bacteremias. •
Encourage client to schedule continued-care visits as
needed.
the left atrium to hypertrophy, leading to pulmonary conges
tion and right ventricular failure. If the condition is left
untreated, the person ultimately develops congestive heart
failure (CHF).
Closed Closed
Open Open
Figure 43-2.Diagram of a normal and a prolapsed mitral
valve. (Courtesy Mid-Island Hospital, Bethpage, New York.)
Appointment Guidelines
When a client is taking the prescribed prophylactic antibiotic
regimen, appointment scheduling is affected. (See Chapter
12, Table 12-5.) It is not in the client's best interest to prolong
treatment procedures. If therapeutic scaling and root planing
are necessary, appointments should be scheduled in longer
periods and as close together as possible. The interval
between antibiotic coverage should be 9 to 14 days. If a client
has periodontitis, a care plan may divide invasive
procedures (therapeutic scaling and root planing) into an
organized sequence that allows for 9 to 14 day periods
between prophy lactic antibiotic premedication. The client's
human need for protection from health risks is met by
dividing the invasive treatment appointments into two
separate intervals with a lag time between the appointments.
See Box 43-1.
Valvular Heart Defects
Valvular heart defects (VHDs) result in cardiovascular
damage from malfunctioning heart valves such as the mitral
valve, the aortic valve, or the tricuspid valve (see Figure 43-
1). Mitral valve prolapse (MVP) is one of the most
frequently occurring VHDs. When the left ventricle pumps
blood to the aorta, the mitral valve flops backward
(prolapses) into the left atrium, resulting in MVP. Other
names for MVP are “floppy mitral valve syndrome” and the
“click murmur syndrome,” referring to the sound the valve
makes when it flops back ward (Figure 43-2).
Etiology
VHDs commonly are associated with rheumatic fever but
also may be caused by congenital abnormalities or may
develop after IE.
Disease Process
Valvular malfunction can occur by stenosis, an incomplete
opening of the valve, or regurgitation, a backflow of blood
through the valve because of incomplete closure. When mal
function occurs, the left ventricle hypertrophies to compen
sate for the increased amount of blood. This, in turn, causes
 Echocardiography uses ultrasonic waves to detect heart
size, valvular function, and other structural deformities. The
echocardiogram is the record produced by the evaluation
and used by the physician to diagnosis VHD.
Medical Treatment
Corrective surgery is done for most VHDs. If the valve
cannot be repaired, in most cases prosthetic valves are
available to replace defective valves. For clients with MVP,
surgical treat ment (not always necessary) is aimed at
alleviating symptoms such as palpitations, chest pain,
nervousness, shortness of breath, and dizziness. Medications
are given to control chest pain, slow the heart rate, reduce
palpitations, and/or lower anxiety.
Dental Hygiene Care
To protect the client from health risks, frequent continued
care appointments and meticulous daily oral biofilm control
are necessary. Good oral health maintenance reduces the pos
sibility of developing a self-induced bacteremia from tooth
brushing or interdental cleaning. In cases in which defective
valves are replaced with prosthetic valves, prophylactic anti
biotic premedication is required before dental hygiene care
(see Chapter 12, Boxes 12-4 and 12-5, and Tables 12-4 and 12-
5).
Appointment Guidelines
VHDs require care plan modifications if the client has an
underlying cardiovascular condition or is on anticoagulant
drug therapy. The frequently prescribed anticoagulants—
heparin, warfarin (Coumadin), and indanedione derivatives
— affect the dental hygiene care plan if scaling or root
planing procedures are indicated or if the gingiva bleeds
spontaneously.
Consultation with the client's physician is recommended
to validate the client's current health and medication status.
When the client is taking anticoagulant medication, the
dental hygienist in collaboration with the dentist consults
with the client's physician to determine if a dose reduction
should be made or if it is safer to maintain the prescribed
dosage and use treatment precautions to minimize
hemorrhage.
• Reduction in medication dosage should increase the pro
thrombin time by 2 seconds.
• Normal prothrombin time varies between 11 and 14
seconds.
• Optimal prothrombin time for dental hygiene therapy in
persons taking anticoagulants should be less than 20
seconds on the day of the scheduled procedure.8 For
laboratory consistency, the International Normaliza
tion Ratio (INR) is used to document bleeding time. When
the INR value is used, normal range is less than 1.5, and
routine care can be performed when the INR is 2 to 3.8 Treat
ment of a client on anticoagulant medication includes the
following steps:
• Consult client's physician to verify prothrombin time. •
Scale one area at a time to manage bleeding. • Begin in the
least inflamed area so that bleeding will be minimal.
CHAPTER 43 n Cardiovascular Disease 809
• Periodically check for clotting; discontinue therapy if there
is a long delay in clotting.
• Emphasize importance of daily oral biofilm control for
reduction of disease and associated bleeding during pro
fessional treatment.
Hypertensive Cardiovascular Disease
Hypertensive cardiovascular disease (HCD) or
hypertension is a persistent elevation of the systolic and
diastolic blood pressures at or above 140 mm Hg and 90 mm
Hg, respec tively (see Chapter 13). Half of the 60 million
hypertensive people in the United States are undiagnosed.
Many individu als with diagnosed hypertension are not
treated or are treated inadequately, leaving the client's
condition uncontrolled and the client at risk for other serious
diseases.
Etiology
Hypertension is not considered a disease but rather a
physical finding or symptom. A sustained, elevated blood
pressure affects the heart and leads to HCD, resulting in
heart failure, myocardial infarction (MI), cerebrovascular
accident (stroke), and kidney failure.
Risk Factors
Risk factors for hypertension include family history, race,
stress, obesity, a high dietary intake of saturated fats or
sodium, use of tobacco or oral contraceptives, fast-paced life
style, and age (over age 40). Hypertension is three times
more common in obese persons than in normal-weight
persons. There is a higher incidence of hypertension among
African Americans than American whites.
Disease Process
The two major types of hypertension are as follows: •
Primary hypertension (essential idiopathic hypertension),
with cause unknown, is the most common type, character
ized by a gradual onset or an abrupt onset of short duration.
• Secondary hypertension is the result of an existing disease
of the cardiovascular system, renal system, adrenal
glands, or neurologic system. Because hypertension
usually follows a chronic course, the client may be
asymptomatic. Early clinical signs and symptoms are
occipital headaches, vision changes, ringing ears,
dizziness, and weakness of the hands and feet. As the
condition persists, advanced signs and symptoms can
include hemorrhages, enlargement of the left ventricle,
CHF, angina pectoris, and renal failure. The dental
hygienist refers clients for medical diagnosis if a
hypertensive disorder is suspected.
Prevention
Blood pressure measurement identifies individuals with ele
vated readings possibly indicating undiagnosed heart
disease or hypertensive heart disease (see Chapter 13). Early
identi fication of hypertensive clients minimizes the
occurrence of medical emergencies, helps meet the client's
human need for protection from health risks, and may be
lifesaving for undi agnosed individuals.
 Medical Treatment
Treatment of hypertension aims at lifestyle changes to
reduce risk factors, antihypertensive drug therapy, and/or
correction
810 SECTION VII n Individuals with Special Needs
of the underlying medical condition in the case of secondary
hypertension. The goal is to reduce and maintain the
diastolic pressure level at 90 mm Hg or lower. Some clients
need only to watch their dietary consumption of sodium and
saturated fats; others must reduce daily stress level and alter
their life
style (see Table 43-1). When a client needs drug therapy, peri
odic monitoring is essential. Some drugs may stabilize the
condition temporarily and then an elevation can occur, indi
cating that an alternative drug is needed.
Drugs used for hypertension vary in their method of
action as follows:
• Diuretics—promote renal excretion of water and sodium
ions
• Sympatholytic agents—modify sympathetic nerve activity
• Vasodilators—increase blood vessel size and facilitate
blood flow
Clients receiving hypertensive drug therapy may experi
ence fatigue, gastrointestinal disturbances, nausea, diarrhea,
cramps, xerostomia, orthostatic hypotension with dizziness,
and/or depression (Table 43-2).
Dental Hygiene Care
If the individual's hypertension is uncontrolled, treatment is
postponed until the disorder is regulated. If the client is
being treated with antihypertensive agents and if clinical
blood pressure evaluations are within normal limits, care
Clients with Various Hypertensive Conditions and Appropriate Dental Hygiene Actions
Client with No History of Hypertension, Elevated
Blood Pressure
During assessment, the client reports no history or
symptoms of hyperten sion; however, a blood pressure
reading of 160/100 mm Hg was obtained. One dental
hygiene diagnosis may be an unmet need for protection
from health risks caused by a potential for heart attack or
stroke as evidenced by an elevated blood pressure of
160/100 mm Hg. The dental hygienist should repeat blood
pressure measurements during the assessment phase,
approximately 5 to 10 minutes apart. If after repeated
measurements the diastolic pressure is still more than 100
mm Hg, the appointment should be limited to assessment
and planning; no treatment is implemented. The client must
be referred to the physician of record for medical
consultation and diagnosis. If the client is diagnosed as
nonhypertensive by the physi cian, it can be inferred that
dental care anxiety causes the elevated blood pressure.
Blood pressure must be monitored at each appointment
there after and strategies implemented to minimize stress.
can
BOX 43-2
continue; however, stress and anxiety reduction strategies
and local anesthetic drug modification will reduce the risk
for medical emergencies. Drug considerations for local
anesthetic use in clients with hypertensive heart disease are
based on the careful use of vasopressors (such as
epinephrine), which constrict blood vessels, concentrate the
anesthetic in the desired area, and prevent its dissipation. A
vasopressor side effect is elevation in blood pressure. In
normal persons a slight elevation in blood pressure is
harmless; however, with vasopressors, hypertensive
individuals have increased risk of cerebrovascular accident,
MI, and CHF. Therefore anesthetic agents with vasopressors
are relative contraindications in persons with a history of
hypertension (see Chapter 40). The risk versus the benefit of
using a low concentration of epi nephrine to local anesthetic
agent is considered, and the phy sician of record should be
consulted.
Appointment Guidelines
Care plan considerations for individuals with controlled
hypertension focus on stress reduction strategies (see Chap
ters 10 and 41) and local anesthetic drug modification to
reduce potential for medical emergencies (as discussed in
previous section). Box 43-2 displays cases based on initial
blood pressure measurement and family history
information. Each situation demonstrates appropriate dental
hygiene care modifications to meet a specific human need.
Client Under Treatment for Hypertension During
assessment, the client indicates that he is hypertensive and
under a physician's care. At each visit the hygienist obtains
information on the client's medications and verifies that the
prescribed medication has been taken. Client may have an
unmet need for freedom from fear and stress; therefore the
care plan may include the administration of nitrous oxide–
oxygen analgesia to reduce client anxiety. At each visit the
client's blood pressure is monitored, periodically
remeasured, and recorded.
Client Noncompliant with Hypertension Treatment
Client indicates that she is hypertensive and has
discontinued her recom mended medication because it is
too expensive. Rather, she takes the
medication irregularly based on her symptoms. This client
has uncontrolled hypertension and a need for protection
from health risks. Dental hygiene care is stopped after
assessment and should not resume until her hyper tension
is stabilized. Client is referred to her physician for further
medical evaluation and treatment. Although dental hygiene
 care is postponed, the remaining appointment time can
facilitate the client's need for protection from health risks
via educational strategies directed toward the importance
of controlling hypertension, information about the oral
inflammation and systemic inflammation link, and possible
lethal effects if hypertension is uncontrolled. Throughout the
appointment the client's blood pressure is monitored and
recorded periodically.
Client with Hypertension and Acute Symptoms During
assessment, the client demonstrates hypertension with
diastolic readings greater than 110 mm Hg and symptoms
(eg, headache, dizzi ness, restlessness, decreased level of
consciousness, blurred vision, pal pitations) indicative of
hypertensive cardiovascular disease (HCD). To meet the
client's need for protection from health risks, the client is
referred to his physician for immediate medical consultation
and evaluation. Dental hygiene care is delayed until the
HCD is controlled. Because hypertension can be related to
anxiety and stress, the dental hygienist must determine if
the client needs stress management and, if affirmative, can
reduce apprehension associated with therapy (eg,
encourage client to express fears and concerns, involve
client in goal setting and care planning, explain procedures
completely, obtain informed consent, demonstrate
humanistic behaviors, and discuss apprehensions directly).
CHAPTER 43 n Cardiovascular Disease 811

TABLE 43-2
Commonly Prescribed Cardiovascular Medication

Brand Name Generic Name Indications for Use Oral Implications

Glycosides
Lanoxin Digoxin Congestive heart failure (CHF), atrial fibrillation Excessive salivation, sensitive gag reflex

Diuretics
Diuril Chlorothiazide CHF, hypertension Decreased salivary flow Midamor Amiloride
Lasix Furosemide

Beta Blockers
Tenormin Atenolol Hypertension, angina Xerostomia Inderal Propranolol
Lopressor Metoprolol

Calcium Channel Blockers

Cardizem Diltiazem Hypertension, angina Decreased salivary flow, gingival enlargement Procardia Nifedipine
Calan Verapamil
Vascor Bepridil

ACE (Angiotensin-Converting Enzyme) Inhibitors

Capoten Captopril Hypertension Xerostomia, taste impairment, oral ulceration Vasotec Enalapril
Zestril Lisinopril

Vasodilators
Nitroglycerin Nitroglycerin Angina Burning under tongue

Angiotensin II Receptor Inhibitors

Avapro Irbesartan Hypertension Xerostomia, taste impairment, oral ulceration Losartan Cozaar
Diovan Valsartan

Anticoagulants
Lovenox Enoxaparin Angina, stent placement, after MI Increased bleeding Coumadin Warfarin
Calciparine Heparin

Antiplatelet Agents
Aspirin Acetylsalicylic acid Angina, after MI Decreases blood clotting Ticlopidine Ticlid
Clopidogrel Plavix

Coronary Heart Disease Coronary heart disease (coronary artery disease or ischemic
heart disease) results from insufficient blood flow from the
coronary arteries into the heart or myocardium. Disorders
associated with this condition are arteriosclerotic heart
disease, angina pectoris, coronary insufficiency, and MI.
Etiology
812 SECTION VII n Individuals with Special Needs
Damaged
endothelium
Fatty
streak
Fibrous
plaque
Complicated
lesion
Figure 43-3.Types of atherosclerotic lesions. (From Debakey M, Grotto A: The living heart, New York, 1977, David McKay.)
occlude the vessel (Figure 43-3). Atherosclerosis usually
develops in high-flow, high-pressure arteries and has been
linked to many risk factors. Other coronary heart disease
causes are congenital abnormalities of the arteries and
changes in the arteries because of infection, autoimmune dis
orders, and coronary embolism (blood clot).
Risk Factors
Coronary heart disease is influenced by systemic risk factors
such as age, gender, race, diet, lifestyle, and environment.
Individuals who are obese, anorectic, bulimic, or physically
inactive or who smoke increase their coronary heart disease
risk (see Table 43-1).
• Age. Being older than 40 is associated with coronary heart
disease. Pathologic changes in the arteries are noticeable
with age, usually producing disease symptoms.
The major cause of coronary heart disease is atherosclerosis,
a narrowing of the lumen of the coronary arteries, thereby
reducing blood flow volume. Narrowing of the lumen occurs
by deposition of fibro-fatty substances containing lipids and
cholesterol. Deposits thicken with time and eventually
Adventitia
Media
Intima
Lipoproteins
Lipid-filled
smooth
muscle cell
Collagen and elastic fibers Lipids
Dead tissue Thrombus
Hemorrhage Calcification Lipids
• Gender. Men are four times more likely to suffer from
coronary heart disease than women up to age 40; after
age 40, prevalence of coronary heart disease among
women
and men is the same. Women younger than 40 years old
are at an increased risk for developing coronary heart
disease if they are taking oral contraceptives or have a
history of anorexia nervosa or bulimia.
• Race. White men and nonwhite women are at a higher risk
for coronary heart disease than nonwhite men and white
women. Researchers are trying to determine the genetic
factors involved; however, a familial connection is
suspected.
• Diet. Populations in which a low-cholesterol, low-fat diet
is consumed have little coronary heart disease; popula
tions in which the diet consists of foods rich in cholesterol
 and saturated fat have a very high rate of coronary heart coro nary heart disease, is a reduction of blood flow through
disease.
• Environment. Coronary heart disease is seven times more infarct is an area of tissue that undergoes necrosis because of
prevalent in North America than in South America, and the elimi nation of blood flow. An MI is also known as a
urban populations are at a higher risk than rural heart attack, coronary occlusion, and coronary thrombosis.
dwellers. Stressful life situations increase an individual's
chance of developing coronary heart disease at an early experienced with angina pectoris; however, the pain usually
age.
• Tobacco use. Cigarette smoking and use of smokeless
tobacco increase an individual's chance of developing
coronary heart disease at an early age.
In addition, research supports an association between
inflammation in the body and coronary heart disease. C-
reactive protein (CRP) levels are used to determine sys temic
inflammation associated with disease including an
individual's risk for cardiovascular disease. Elevated levels
of CRP are key markers of atherosclerosis. Studies have cor
related increased CRP levels with the presence of periodonti
tis.4,5,9 This finding supports other studies that suggest the
presence of periodontis increases one's risk for CVD.10,11
Although the exact link is unclear, evidence suggests that a
relationship exists. Further research is needed to determine a
causal relationship whereby periodontal disease would be
considered a direct risk factor.
Disease Process
Basic manifestations of coronary heart disease are angina
pec toris, MI, and sudden death.
Angina Pectoris
Angina pectoris is the direct result of inadequate oxygen
flow to the myocardium, manifested clinically as a burning,
squeez ing, or crushing tightness in the chest that radiates to
the left arm, neck, and shoulder blade. The person typically
clenches a fist over the chest or rubs the left arm when
describing the pain. When sudden attacks of angina pectoris
follow physical exertion, emotional excitement, or exposure
to cold, and the symptoms are relieved by administration of
nitroglycerin, they are classified as stable angina.
Conversely, unstable angina may occur at rest or during
sleep, and pain is of longer dura
tion and not relieved readily with nitroglycerin. Medical
treatment for angina pectoris has two goals: reduce
myocardial oxygen demand and increase oxygen supply.
Therapy consists primarily of physical rest to decrease
oxygen demand and the administration of nitrates, such as
nitroglycerin, to provide more oxygen. Nitroglycerin (glyc
eryl trinitrate) is a vasodilator that increases blood flow
(oxygen supply) by expanding the arteries. Administration
can be sublingual for immediate absorption, or by nitroglyc
erin pads and patches for time-released medication absorbed
by the skin and into the bloodstream; an overdose can cause
headache. Obstructive lesions that do not respond to drug
therapy may necessitate surgery.
Myocardial Infarction
Myocardial infarction (MI), the second manifestation of
one of the coronary arteries, resulting in an infarct. An
Symptoms associated with MI are similar to those
persists for 12 or more hours and begins as a feeling of indi
gestion. Other manifestations include a feeling of fatigue,
nausea, vomiting, and shortness of breath.
Medical treatment includes combination therapy to reduce
cardiac workloads and increase cardiac output. Cardiac
work load reduction therapies include bed rest, morphine
for pain reduction and sedation, and oxygen if necessary. To
increase
CHAPTER 43 n Cardiovascular Disease 813
cardiac output, therapy for the control and reduction of
cardiac dysrhythmias is recommended (eg, antiarrhythmic
drugs, possibly a cardiac pacemaker). Nitroglycerin can
relieve chest pain and increase cardiac output by
intensifying the blood flow and redistributing blood to the
affected myocardial tissue. Anticoagulants may be used to
thin the blood in an effort to increase blood flow and reduce
the possibility of another MI.
Sudden Death
Sudden death, the last manifestation of coronary heart
disease, occurs during the first 24 to 48 hours after the onset
of symptoms. Most sudden cardiovascular deaths are caused
by ventricular fibrillation. For example, ventricular fibrilla
tion results in ventricular standstill (cardiac arrest) if insuffi
cient blood is pumped into the coronary arteries to supply
the myocardium with oxygen. Biologic death results when
oxygen delivery to the brain is inadequate for 4 to 6 minutes.
Therefore the use of an automated external defibrillator
(AED) (also known as precordial shock) is followed by cardio
pulmonary resuscitation (CPR) to maintain enough blood
oxygen to sustain life. Transportation to the hospital for
emer gency medical care is necessary.
Prevention
Lifestyle behaviors associated with the prevention of coro
nary heart disease are as follows:
• Regular medical checkups
• Healthy diet (eg, reduction in saturated fat and choles
terol; increases in whole grains, fruits, and vegetables) •
Regular physical exercise
• Stress management
• Avoidance of tobacco
• High blood pressure control
• Prevention of periodontal disease
• Knowledge of the warning signs of a heart attack Factors
associated with coronary heart disease must be taken into
consideration when providing nutritional counsel ing to
improve a client's oral health. In facilitating the client's
human need for protection from health risks, the dental
hygienist recognizes the importance of dietary choices
related to coronary heart disease and incorporates that
 knowledge into the nutritional education session (see
Chapter 35). Given that periodontal disease is a risk factor
for coronary heart disease, clients need this information to
make sound decisions about their oral health. Therefore
client education should emphasize the link between oral
disease and systemic disease. By stressing the importance of
oral disease prevention, the dental hygienist promotes active
self-care by the client—for example, teaching self-care
behaviors to maintain oral well ness, encouraging active
participation in formulating goals for care, and facilitating
choices and client decision making.
Dental Hygiene Care
Clients with coronary heart disease are susceptible to angina it is more dangerous to take the individual off the
pectoris and MI.
Angina Pectoris
The client with angina pectoris should be treated in a stress
free environment to meet the client's need for protection
from health risks and freedom from stress. Considerations more efficient as a pump, increasing its volume in relation to
associ ated with angina pectoris include identification of the cardiac output. The most commonly prescribed digitalis
client's condition and frequency of angina attacks. Health
history
814 SECTION VII n Individuals with Special Needs
interview questions to ascertain the stability of the client's
angina are as follows:
1. Do you have chest pain on exertion? At rest?
2. How frequent are your attacks?
3. Is your chest pain relieved promptly with nitroglycerin?
4. How long are your periods of discomfort?
If clients report that their angina has worsened and that
the painful episodes occur more frequently and not only
during exertion, their condition is classified as unstable
angina. These clients should be referred to their physician of
record, and dental hygiene care postponed.
For clients with stable angina, appointments should be
short and preferably scheduled for the morning. The
atmosphere should be friendly and conducive to relaxation.
If the client becomes fatigued or develops significant
changes in pulse rate or rhythm, termination of the
appointment is suggested.
Before care for a client with a history of angina pectoris is
initiated, the client's supply of nitroglycerin should be
placed within reach of the dental hygienist. Potency of
nitroglycerin is lost after 6 months outside of a sealed
container; conse
quently, fresh supplies should be available in the oral care
environment. If an emergency develops, dental hygiene treat
ment is stopped; the client is placed in an upright position,
reassured, and given nitroglycerin sublingually. Emergency
medical services (EMS) should be activated if the client con
tinues to experience pain after administration of
nitroglycerin (see Chapter 10). Vital signs must be monitored
and recorded on the client's record.
Myocardial Infarction
Clients who have a history of MI with no complications do
not require care plan modifications. However, if the MI has
occurred within the past 30 days, dental hygiene therapy
should be postponed until the individual is 30 days or more
postinfarction with no complications and no other risk
factors or ischemic symptoms such as chest pain, shortness
of breath, dizziness, or fatigue. The client's medical status
and dental hygiene treatment plan require medical
consultations if symptoms, risk factors, or complications
persist after 30 days.
Drugs used to treat MI are anticoagulants, digitalis, and
antihypertensive agents. These drugs necessitate care plan
alterations. Anticoagulant drugs increase bleeding time and
may have to be stopped several days before care that
involves tissue manipulation. Some cardiologists believe that
anticoagulant than it is to keep the individual on the drug
and provide care; therefore confirmation from the client's
cardiologist is recommended.
Digitalis, a glycoside, is a drug that increases the contrac
tility of the heart. Improvement in force makes the heart
drug is digoxin (Lanoxin).
Oral health professionals may detect early signs of digi
talis toxicity in clients (ie, anorexia, nausea, vomiting, neu
rologic abnormalities, and facial pain). If digitalis toxicity is
not detected early, cardiac irregularities can develop (eg,
arrhythmias can progress to ventricular fibrillation and
sudden death).
Antihypertensive agents used to control MIs are similar
to those used to control hypertension. These agents do not
influ ence the care plan unless the underlying condition is
uncontrolled.
Clients with coronary heart disease may experience fear,
depression, and disturbances in body image, associated with
a change in lifestyle (eg, dietary restrictions, exercise, and
maintaining low stress). The client's psychologic condition
also may influence oral health.
Emergency situations associated with MI should be
managed by an emergency medical team. Oral health profes
sionals are responsible for monitoring vital signs, administer
ing nitroglycerin, and performing AED and CPR if the client
experiences cardiac arrest. Certification in Basic Life Support
(BLS) should be maintained by all oral health professionals
(see Chapter 10).
Appointment Guidelines
The following steps should be taken for an individual with
coronary heart disease:
• Clarify the stability of the client's angina or symptoms
after 30 days following MI. If uncontrolled, do not treat. If
stable, continue treatment with caution.
• Schedule short morning appointments to help control
environmental stress.
• Use of adequate pain control modalities including nitrous
oxide–oxygen analgesia to reduce stress if no
contraindica tions exist.
• Select interventions that address the client's lifestyle
 changes and periodontal disease status. Atrial Fibrillation.
Atrial fibrillation, a condition of rapid, uneven contractions
Cardiac Dysrhythmias and Arrhythmias Cardiac in the upper chambers of the heart (atrium), is the result of
dysrhythmias and arrhythmias, terms used inter inconsistent impulses through the atrioventricular (AV)
changeably, are dysfunctions of heart rate and rhythm that node transmitted to the ventricles at irregular intervals. The
manifest as heart palpitations. Dysrhythmias may develop in lower chambers (ventricles) cannot contract in response to
normal and diseased hearts. In healthy hearts, arrhythmia the impulses, the contractions become irregular, with a
may be associated with physical and emotional stresses (eg, decreased amount of blood pumped through the body.
exercise, emotional shock) and usually subsides in direct During assessment the pulse rate may appear consistent
response to stimulus reduction. Diseased hearts develop dys with periods of irregular beats. Medical treatment targets the
rhythmias directly associated with the CVD present, most caus ative factors, not the condition itself. CHF, mitral valve
commonly RHD, arteriosclerotic heart disease, or coronary stenosis, and hyperthyroidism may be linked to atrial
artery disease. In some cases a cardiac dysrhythmia may fibrillation.
develop in response to drug toxicities and electrolyte
imbalances. Premature Ventricular Contractions
PVCs are identified easily as pauses in an otherwise normal
Etiology heart rhythm. The pause develops from an abnormal focus
Dysfunction of heart rate and rhythm arises from distur of the ventricle, allowing the ventricle to be at a refractory
bances in nerve impulse formation or nerve impulse conduc (resting) period when the impulse for contraction arrives.
tion and is categorized according to the part of the heart in The feeling of the heart skipping a beat is PVC; these
which it originates. Common dysrhythmias include increase with age and are associated with fatigue, emotional
bradycar dia, tachycardia, atrial fibrillation, premature stress, and excessive use of coffee, alcohol, or tobacco.
ventricular con Recognition of PVCs has significance in the client with
tractions (PVCs), ventricular fibrillation, and heart block. CVD. If five or more PVCs are detected during a 60-second
Cardiac dysrhythmias are medically diagnosed using an pulse examination, medical consultation is recommended
electrocardiogram (ECG) and/or a Holter monitoring strongly. Individuals who are distressed and have five or
system. Electrocardiography, a graphic tracing of the heart's more detectable PVCs per minute may be undergoing an
electri cal activity, determines heart rate, rhythm, and size. acute MI or ventricular fibrillation. The following steps can
Each dysrhythmia is associated with a specific graphic protect the client from health risks:
pattern indicating a definitive medical diagnosis. • Terminate dental hygiene care.
• Place client on oxygen.
Risk Factors • Activate EMS.
See Table 43-1.
Ventricular Fibrillation
Disease Process Ventricular fibrillation, one of the most lethal dysrhythmias,
Bradycardia.
is characterized as an advanced stage of ventricular tachycar
Bradycardia is defined as slowness of the heartbeat as dia with rapid impulse formation and irregular impulse
evidenced by a decline in the pulse rate to less than 60 beats transmission. The heart rate is rapid and disordered and con
tains no rhythm. Immediate medical treatment for
ventricular fibrillation is the use of an AED (precordial
shock) to halt the dysrhythmia, followed by CPR. Electric
per minute (BPM). This normally occurs during sleeping;
current at the time of shock depolarizes the entire
however, severe bradycardia can lead to fainting and convul
myocardium, allowing the cardiac impulses to gain control
sions. If a client has an episode of bradycardia following a
of the heart rate and rhythm. This depolarization should
normal pulse rate of 80 BPM, emergency medical treatment
reestablish cardiac regulation. The
is necessary. This individual may be encountering the initial
symptoms of an acute MI. Emergency medical treatment CHAPTER 43 n Cardiovascular Disease 815
would include discontinuance of the dental hygiene appoint
ment, oxygen administration, and activation of EMS.
person then is placed on drug therapy to maintain
regulation of cardiac rate and rhythm. Without immediate
Takikardia.
medical attention (advanced cardiac life support), blood
Increased heartbeat, termed tachycardia, is associated with
pressure falls to zero, resulting in unconsciousness; death
an abnormally high heart rate, usually greater than 100 BPM.
may occur within 4 minutes.
Tachycardia can increase risk of developing angina pectoris,
acute heart failure, pulmonary edema, and MI if not con
Heart Block
trolled. These conditions are related directly to the amount
Heart block is a dysrhythmia caused by the blocking of
of work the heart is doing and decreased cardiac output.
impulses from the atria to the ventricles at the AV node; it is
Treat ment consists of antiarrhythmic drug therapy to
an interference with the electrical impulses controlling the
control tachycardia and reduce potential of recurrence.
heart muscle. Each of the three forms of heart block is
dangerous; however, third-degree heart block presents the
 greatest danger of cardiac arrest. The three forms are as nonelectrical alternatives to avoid functional interference are
follows: used (eg, hand-activated instruments, tooth desensitization
• First-degree heart block—usually associated with coro with a nonelectronic tech nique, and pulp testing performed
nary artery disease or digitalis drug therapy. The indi by tooth percussion). Addi tional pacemaker protection can
vidual usually is asymptomatic with a normal heart rate be accomplished by placing a lead apron on the client as a
and rhythm. barrier to interrupt electrical interference generated by
• Second-degree heart block—atrial and ventricular rates dental equipment such as the air abrasive system, low- or
are disordered; impulses from the AV node are fully high-speed handpiece, and comput erized periodontal
blocked in irregular patterns. probe. Care should be taken in an open clinical setting where
• Third-degree heart block—blocking of all impulses from electrical dental equipment may be used for an adjacent
the atria at the AV node, resulting in atrial and client.
ventricular dissociation. The ventricles begin beating in Prophylactic antibiotic premedication before dental
response to their biologic pacemaker cells, producing an hygiene care is not recommended after pacemaker implanta
independent heartbeat from the atrium. tion to prevent IE.
Care plan development for the individual with a cardiac
Medical Treatment pacemaker also can be affected by the drugs used to treat the
The cardiac pacemaker, an intracardiac device, is an elec underlying medical condition—anticoagulants and
tronic stimulator used to send electrical currents to the myo antihypertensive agents. Monitoring and assessment of drug
cardium to control or maintain heart rate. Two types of therapy provide information necessary to modify treatment.
pacemakers that control one or both of the heart chambers If the cardiac pacemaker fails or malfunctions during the
are as follows: dental hygiene appointment, the client may experience dif
• Temporary pacemaker—used in emergency situations to ficulty breathing; pusing; a change in the pulse rate; swell
correct ventricular standstill or arrhythmias that are not ing of the legs, ankles, arms, and wrists; and/or chest pain.
responding to other forms of treatment. When this situation arises, do the following:
• Permanent pacemaker—inserted into the body; electrodes 1. Turn off all sources of electrical interference.
are transvenously placed in the endocardium and 2. Activate EMS.
function for 5 to 10 years before battery replacement is 3. Prepare to administer basic life support (BLS) (see
necessary. Two general systems of cardiac pacing for the Chapter 10, Procedure 10-1).
permanent pacemaker are as follows:
• Fixed-rate pacing—based on a preset or fixed impulse Appointment Guidelines
• Demand or standby pacing—operates only when Although uncommon, the older, unshielded pacemaker can
needed to stimulate ventricular contraction; pacemaker be affected by electrical interference in the oral healthcare
contains mechanisms that sense when the client has an setting.
independent heartbeat and stimulates the heart only • Use a lead apron to interrupt electrical interference gener
when the rate deviates from normal (most commonly ated by dental equipment.
used because of its increased sensitivity to the body's • Use manual rather than mechanized procedures to avoid
natural metabolic requirements) electrical interference created by dental equipment. •
Pacemakers vary in their sensitivity to electrical interfer Monitor client and be prepared to administer BLS (see
ence that may alter or cease their function. Newer models, Chapter 10).
bipolar and shielded to protect against interference, do not
require any special consideration during dental hygiene
Congestive Heart Failure
care. The older unipolar pacemaker models are less Congestive heart failure is a syndrome characterized by
protected from electrical interference and can be affected myocardial dysfunction that leads to diminished cardiac
negatively by dental devices and equipment that applies an output or abnormal circulatory congestion. The weakened
electric current. When in doubt, consult the client's heart develops compensatory mechanisms to continue to
cardiologist. function (ie, tachycardia, ventricular dilation, and enlarge
ment of the heart muscle).
Dental Hygiene Care CHF can occur as two independent failures (left-sided
During assessment, the dental hygienist determines the type and right-sided heart failure); however, because the heart
of pacemaker a client has and whether it is shielded from func tions as a closed unit, both pumps must be functioning
electrical interference. Dental devices that apply an electrical prop erly or the heart's efficiency is diminished.
816 SECTION VII n Individuals with Special Needs
Etiology
Causative factors associated with CHF are arteriosclerotic
current directly to the client (eg, ultrasonic scaling systems, heart disease, hypertensive CVD, valvular heart disease, peri
electrodesensitizing equipment, pulp testers, power tooth carditis, circulatory overload, and coronary heart disease.
brushes, and electrosurgery equipment) are likely to cause
interference in unshielded pacemakers. Use of such
equipment even in the proximity of the client with an
unshielded pace maker is contraindicated. Instead, These factors contribute to the gradual failure of the heart by
reducing the inflow of blood to the heart, increasing the with CHF:
inflow to the lungs, obstructing the outflow of blood from • Position client upright to decrease collection of fluid in the
the heart, or damaging the heart muscle itself. lungs.

Risk Factors
See Table 43-1.
• Limit ultrasonic instrumentation use so that unnecessary
Disease Process fluid does not back up in the oral cavity. This fluid reduc
Clients who have left-sided heart failure have difficulty tion minimizes client anxiety and facilitate breathing.
receiving oxygenated blood from the lungs, resulting in • Recommend nutritional counseling to decrease sodium
increased fluid and blood in the lungs, causing dyspnea on intake and alleviate fluid retention.
exertion, shortness of breath on lying supine, cough, and
expectoration. These clients tend to require extra pillows to
Congenital Heart Disease
sleep and cannot be placed in a supine position. Congenital heart disease is an abnormality of the heart's
Right-sided heart failure is associated with the blood structure and function caused by abnormal or disordered
return from the body, resulting in systemic venous heart development before birth. Commonly observed con
congestion and peripheral edema. Clients with right-sided genital heart malformations are ventricular septal defect,
heart failure have feet and ankle edema and often complain atrial septal defect, and patent ductus arteriosus.
of cold hands and feet.
Etiology
Medical Treatment The cause of congenital heart disease is generally unknown;
CHF treatment is related directly to the removal of the cause. however, genetic and environmental factors have been attrib
Usually the corrective therapy associated with the uted to poor intrauterine development. Genetic conditions,
underlying disease eliminates the presence of CHF. Some related to heredity, are apparent in some situations. Environ
patients require additional methods of rehabilitation, such as mental factors are based on the mother's health—for
dietary control, reduced physical activity, and drug therapy example, rubella (German measles) and drug addiction have
(eg, diuretics to reduce salt and water retention and digitalis produced delayed fetal development and growth retardation
to strengthen myocardial contractility). associated with the cardiovascular structure.

Dental Hygiene Care Disease Process and Medical Treatment

Individuals with CHF who are monitored closely by a physi Congenital heart disease is the result of various heart defects
cian do not require a change in conventional dental hygiene that dictate the disease process:
care; however, factors associated with the cause of CHF
should be considered in the care plan. Alterations are based Ventricular Septal Defect
on the causative factors (eg, hypertension, valvular heart A ventricular septal defect—a shunt (opening) in the septum
disease, coronary heart disease, and MI) in association with between the ventricles—allows oxygenated blood from the
the individual's current medical status. left ventricle to flow into the right ventricle (Figure 43-4).
Clients taking digitalis are prone to nausea and vomiting Small defects that close spontaneously or are correctable by
during dental procedures. Therefore procedures that may surgery have a good prognosis. Larger defects that are left
promote gagging should be performed with extra care. In untreated or are irreparable usually result in death from sec
addi tion, the dental hygienist should be aware of any ondary cardiovascular complications. The ventricular septal
underlying heart conditions that are responsible for CHF. defect can be detected by a characteristic heart murmur
These conditions must be evaluated and appropriate audible at birth.
precautions taken.
Alterations in the care plan for a client with left-sided
CHF are related to the human needs for protection from Aorta
health risks and for freedom from fear and stress. Client Pulmonary
positioning must be upright to support breathing. Actions artery
should be taken to minimize distress, and instructions
should reinforce the need for a reduced-sodium diet to Superior
alleviate fluid retention. CHAPTER 43 n Cardiovascular Disease 817
If an emergency arises, medical assistance should be
obtained. The client is usually conscious with difficulty
Clinical manifestations vary with size of defect, infant
breathing. The following treatment is recommended: 1.
age, and the effect of the deviated blood passage on the
Position the person upright to facilitate breathing. 2.
cardiovas cular structure. Large ventricular septal defects
Administer oxygen if necessary.
cause hyper trophy of the ventricles, resulting in CHF.
3. Pantau tanda-tanda vital.
Atrial Septal Defect
Appointment Guidelines
The atrial septal defect—a shunt (opening) between the left
The following steps should be taken when treating clients
and right atria—is responsible for approximately 10% of con
 genital heart defects. The blood volume overload eventually contracture necessary for closure. Patent ductus arteriosus
causes the right atrium to enlarge and the right ventricle to has been linked to rubella syndrome.
dilate (Figure 43-5). Shunting of blood in a patent ductus arteriosus defect is
Usually the client is asymptomatic and the defect goes from the aorta to the pulmonary artery (Figure 43-6). This
undetected; however, in adults, clinical symptoms become type of blood flow results in the recirculation of oxygenated
more pronounced. The client is fatigued easily and short of blood through the lungs. Thus the left atrium and ventricle
breath after mild exertion. Treatment includes have an increased workload from increased pulmonary
cardiovascular repair surgery, observance of developing blood return, which can result in CHF. If the condition is left
atrial arrhythmias, and monitoring of vital signs. untreated, severe obstructive pulmonary vascular disease
may develop.
Patent Ductus Arteriosus Clinical manifestations include respiratory distress,
Patent ductus arteriosus is the most common congenital suscep tibility to respiratory tract infections, and slow motor
heart defect found in adults. During development the fetal develop ment. Treatment consists of surgical correction and
heart contains a blood vessel called the ductus arteriosus. This elimination of symptoms associated with secondary
vessel connects the pulmonary artery to the descending complications.
aorta. Nor
mally after birth the vessel closes. If the vessel fails to close, a
congenital heart defect forms. Failure to close is associated
with premature births and therefore failure of the vessel's
Superior
vena cava Pulmonary veins Inferior
vena cava
Left
Right atrium
atrium

Aorta
Septal Left
defect ventricle Atrial
septal
defect
Inferior
vena cava
Right Right
superior pulmonary atrium
vein
Tricuspid
Right
inferior valve
Right ventricle pulmonary vein
Right
Coronary sinus ventricle
Valve of inferior
vena cava
vena cava

Figure 43- Figure 43-5.Atrial septal defect. (From Bleck E, Nagel D:

4.Ventricular septal defect. (From Bleck E, Nagel D: Physically handi capped children: a medical atlas for
Physically handicapped children: a medical atlas for teachers, ed 2, Needham Heights, Mass, 1982, Allyn and
teachers, ed 2, Needham Heights, Mass, 1982, Allyn and Bacon.)
Bacon.)
818 SECTION VII n Individuals with Special Needs Ductus Arch of
Right
Right
pulmonary
artery

Superior
vena cava
arteriosus
 aorta
pulmonary artery
Arch of
aorta
Ductus
arteriosus
Left
pulmonary
Inferior
vena cava
Figure 43-6.Patent ductus arteriosus defect. (From Bleck E, Nagel D: Physically handicapped children: a medical atlas for
teachers, ed 2, Needham Heights, Mass, 1982, Allyn and Bacon.)
Tetralogy of Fallot
Tetralogy of Fallot is a rare and complex congenital heart
defect generally associated with cyanosis. The defect is com
posed of four congenital abnormalities: ventricular septal
defect, pulmonary stenosis, right ventricular hypertrophy,
and malposition of the aorta. The blood shunts right to left
through the ventricular septal defect, permitting unoxygen
ated blood to mix with oxygenated blood, resulting in cyano
sis. Treatment includes measures to relieve cyanosis and
palliative and corrective surgery.
Dental Hygiene Care
The individual with congenital heart disease does not
require extensive alterations in care. However, the American
Heart Association recommends antibiotic premedication
before dental hygiene procedures to prevent IE in persons
with residual defects following repair, with unrepaired
cyanotic congenital heart defects including palliative shunts,
and during the first 6 months after surgery to correct
congenital defects. Secondary concerns focus on the
management of car diovascular complications, such as CHF
and cardiac dys
rhythmias, resulting from the congenital defect. Dental
hygiene care includes physician consultation to confirm
drug usage and current medical status, prophylactic
antibiotic medication to prevent IE, and assessment of symp
artery Left
pulmonary
artery
Pulmonary
trunk
toms secondary to the disease that may require treatment
alteration. If the individual develops CHF, then care plan
considerations should follow those outlined.
Cardiovascular Surgery
Open-heart surgery is necessary for complex procedures that
need direct visualization of the heart while being performed
(eg, heart transplants, some heart valve replace ments, and
coronary bypass surgery). Open-heart surgery
always is performed with the use of a heart-lung machine
that completely controls cardiopulmonary function, enabling
sur geons to operate for long periods without interfering
with the individual's metabolic needs. Closed-heart surgery
usually is associated with cardiac catheterization.
Types of Cardiovascular Surgery
Angioplasty
The most common type of closed-heart surgery, angioplasty
(also known as percutaneous coronary intervention [PCI]),
involves the use of a catheter (a long, slender tube) with a
tiny balloon at the end that is inserted into the coronary
artery. Specifically, the balloon is inserted into places where
the artery narrows, is inflated to flatten fatty deposits, and is
deflated to allow the increased blood flow to compress and
redistribute the atherosclerotic lesion. This procedure is used
in individuals who have a small atherosclerotic lesion con
 stricting blood flow. If the lesion cannot be corrected by the client susceptible to infection require prophylactic antibiotic
angioplasty procedure, bypass surgery may be necessary. premedication.
Complications from dental hygiene care observed in
Coronary Stent clients who have had cardiovascular surgery are associated
The coronary stent is a mesh-like metal used to open narrow with the drug therapy used rather than the surgery itself.
arteries. Placed in conjunction with PCI procedures, the stent Most postsurgical clients are placed on medication to
maintains the lumen opening in the arteries, allowing blood increase healing, suppress immune response, reduce
to flow freely, thereby reducing angina and potential myocar infection, and/
dial infarctions. or decrease clot formation. Careful evaluation of drug
contra indications and reactions is necessary.
Coronary Bypass Surgery
Coronary bypass surgery, a common procedure to replace Client Who Has Had a Heart Transplant
blocked arteries, is performed by removing part of the leg A major concern of the heart transplant patient is infection
vein or chest artery and then grafting it onto the coronary and transplant rejection. Before care, consultation with the
artery, thereby creating a new passageway for the blood. client's cardiologist is recommended highly to determine if
This type of surgery can be done for more than one artery at additional premedication is indicated. Most transplant
a time and is named accordingly (double-bypass, triple- patients are on long-term preventive antibiotic therapy to
bypass). The control systemic bacteremias. They also are placed on immu
nosuppressant medications such as cyclosporine (Sandim
mune) to reduce the possibility of rejection.

benefits of coronary bypass surgery include relief from Oral Manifestations of

angina, increased tolerance to exercise, improved quality of
life, and extended life span. A person who has had bypass
surgery has no contraindications to dental hygiene therapy.
Valvular Defect Repair
Valvular defect repair or replacement is performed
frequently. Persons with artificial cardiac valves are at high
Cardiovascular Medications
Some medications used in CVD therapy have a profound
effect on the oral cavity. (See Chapter 14 and Table 43-2.)
These medi cations typically include those that treat
hypertension, heart
CHAPTER 43 n Cardiovascular Disease 819

risk for infec tions and IE and must be premedicated with an

antibiotic before dental hygiene care (see Box 43-1 and
Chapter 12, Tables 12-4 and 12-5, and Boxes 12-4, 12-5, and
12-6).
Heart Transplantation
Heart transplantation is a viable option for individuals with
end-stage heart disease in which no other therapeutic inter
vention is considered effective. Although many hospitals
perform cardiac transplantation, the dilemma is finding
donors.
Future goals and implications of heart transplantation
include the development of a safe, reliable, permanent,
totally implantable artificial heart device that allows a
recipient to carry out normal activities. The development of
such a device may increase availability of this life-saving
procedure for eli
gible recipients who at this time await donors.
Dental Hygiene Care
Client Who Has Had Closed-Heart Surgery
No contraindications are associated with dental or dental
hygiene treatment unless the individual is taking anticoagu
lant medication. As in all cardiac-associated situations, con
sultation with the client's cardiologist is recommended.
Client After Open-Heart Surgery
No dental hygiene procedures relate uniquely to the indi
vidual who has had cardiovascular surgery. When in doubt,
the cardiologist is consulted; however, prosthetic valvular
heart replacements and those cardiac surgeries that make the
transplant stabilization, and CHD. Persons taking cardiovas
cular medications should seek regular dental hygiene care
and maintain excellent oral biofilm control to balance their
increased
vulnerability to dental and periodontal diseases. Most
medications for the treatment of hypertension cause
xerostomia, increasing the individual's risk for dental caries
and periodontal disease. Individuals with exposed root sur
faces are at risk for root surface caries and dentinal hypersen
sitivity. Self-administered fluoride therapy, ACP therapy,
and use of saliva substitutes and xylitol products should be
part of the individual's daily self-care regimen to meet the
client's needs. Some calcium channel blockers alter taste
perception, cause drug-influenced gingival enlargement,
and create sali vary gland pain. Immunosuppressants used
for the stabiliza tion of heart transplants increase the
individual's risk for developing periodontal disease or may
exaggerate a pre existing condition, leading to an unmet
need in skin and mucous membrane integrity.
Another dental hygiene diagnosis to consider is a need
for protection from health risks because
immunosuppressants increase risk for developing
opportunistic infections such as candidiasis, herpes simplex,
herpes zoster, necrotizing ulcer
ative gingivitis, and drug-influenced gingival enlargement.
In addition to regular professional dental hygiene care, these
individuals should use an antimicrobial mouth rinse for 30
seconds twice daily as part of their self-care regimen to
reduce oral disease risk.
Persons with a history of heart attack or cerebrovascular
 accident are placed on blood thinners (anticoagulants) to 820 SECTION VII n Individuals with Special Needs
increase blood flow. The side effects are prolonged bleeding
and spontaneous oral bleeding in the presence of infection.
These individuals must maintain a healthy periodontium to Table 43-3 illustrates sample dental hygiene diagnoses for a
reduce periodontal disease risk. client with coronary heart disease.
Planning prevents emergencies and ensures that client
Preventing and Managing needs are the focus of therapeutic interventions. When a care
Cardiac Emergencies plan is developed, attention is given to drug therapies to
The individual with a CVD or cardiovascular symptom or ensure that no contraindications are present and that side
defect is considered high risk—one whose life may be threat effects are identified (see Table 43-2). Tables 43-4 and 43-5
ened by daily activities. These clients have a need for protec can be used when developing care plans for clients with a
tion from health risks because of their increased potential for CVD.
an emergency. The most common physical pain encountered Implementation of care takes into consideration the pos
is chest pain accompanied by difficulty breathing. If the sibility of a medical emergency (see Chapter 10). The most
client complains of physical pain that cannot be alleviated, life-threatening emergency situation is cardiac arrest. Emer
EMS should be activated or 911 called. gency situations require the following steps:
For individuals with angina pectoris, hypertension, previ 1. Contact EMS or call 911.
ous MI, and CHF, the risk for life-threatening medical emer
gencies rises as a result of an increase in fear and stress.
Assessing past responses in oral healthcare situations and TABLE 43-3
monitoring the client's reactions to dental hygiene
procedures are important. Muscular tenseness, perspiration,
and verbal cues indicate a potential emergency, and the
client's need for protection from health risks must be met. 2. Monitor vital signs and state of consciousness.
Individuals with CVD may not take responsibility for 3. Berikan oksigen.
their oral health. Understandably, these individuals fail to 4. Provide BLS.
relate their life-threatening medical condition with oral Other medical emergencies associated with CVD are
disease; however, by increasing a client's awareness that attacks of angina pectoris and MI. Box 43-3 lists actions to be
periodontal disease and the systemic condition are linked, taken.
the dental hygienist may change the client's value system Oral care professionals evaluate the client's current health
and oral health behavior and improve systemic health. status in light of the established client goals. By reviewing
Accurate assessment of the client's personal beliefs, assessment data, dental hygiene diagnoses, care plan, and
behaviors, and values can identify motivators (needs) that interventions used, practitioners can determine where less
may lead to the client's commitment to therapeutic goals and than-desirable outcomes occurred and modify care as neces
priorities. sary. Table 43-6 illustrates an evaluation of dental hygiene
interventions for the care plan in Box 43-1.

Sample Dental Hygiene Diagnoses—Client with Coronary Heart Disease Dental Hygiene

Diagnosis Related to As Evidenced by

Protection from health risks: potential for Anxiety area, and left arm pain
myocardial infarction Recent life-threatening medical diagnosis Agitation
Stress Chest, jaw, neck, throat, interscapular
Responsibility for oral health Low value ascribed to oral health Lack of interest in performing daily oral self-care
Potential for health risks: potential for infection Drug therapy (diuretics) taken by client Xerostomia
Biologically sound and functional dentition
History of infective endocarditis Condition indicated on health
history questionnaire
Root caries
Biologically sound and functional TABLE 43-4 saturated fat, and sodium
dentition (nutrition) Dietary restrictions of cholesterol, Obesity, high LDL cholesterol or lipid
blood values
Quick Reference—Signs, Symptoms, and Treatment of Individuals with Cardiovascular Disease Disease Signs and

Symptoms Medical and Surgical T reatment

Rheumatic heart disease Carditis, polyarthritis, chorea, Mitral valve prolapse Palpitations, chest pain, nervousness,
erythema marginatum, subcutaneous nodules, fever shortness of breath, dizziness
Bedrest and medications associated with manifestations
Infective endocarditis Initial high fever, cardiac
decompensation, heart murmur Antibiotic therapy
Valvular heart defects Fatigue, shortness of breath, and
pulmonary edema If defects are left untreated, congestive Valvular repair or replacement with prosthetic heart valve
heart failure
will develop Treatment is not always necessary; aimed at alleviating
symptoms
Cardiac dysrhythmias and arrhythmias minute (BPM) Tachycardia: pulse rate Antiarrhythmic drug therapy or cardiac
Bradycardia: pulse rate <60 beats per >150 BPM pacemaker
Hypertension Headache, fatigue, diminished exercise Antihypertension drug therapy; dietary control of sodium
tolerance, shortness of breath
Coronary (ischemic) heart disease throat, interscapular area, and left arm
Angina pectoris, discomfort in jaw, neck, Bedrest; administration of nitroglycerin

Congestive heart failure Fatigue, weakness, dyspnea, cough, anorexia Treatment directed at the underlying cause
Congenital heart disease Dependent on type of defect Surgery to correct defect

CHAPTER 43 n Cardiovascular Disease 821

TABLE 43-5
Quick Reference—Dental Hygiene Care Implications for Individuals with Cardiovascular Disease

Disease Implications for Dental Hygiene Care Dental Hygiene Actions

Rheumatic heart disease occur when oral disease is present. antibacterial mouth rinse to reduce
Special attention to oral self-care Careful manipulation of soft tissues transient bacteremia
practices; self-inflicted bacteremias may during instrumentation; ADA-accepted
Infective endocarditis Client susceptible to reinfection with disease is present.
transient bacteremia. Careful manipulation of soft tissue; antibacterial mouth rinse
Prophylactic antibiotic premedication is indicated for to reduce transient bacteremia
invasive dental hygiene procedures.
Valvular heart defects Infective endocarditis may occur after
dental hygiene procedures that cause transient bacteremias. If anticoagulant medication is being used and scaling
Clients receiving anticoagulant medication may have procedures are planned, dosage of anticoagulant medication
a prolonged bleeding time. should be discussed with client's cardiologist

Mitral valve prolapse Special attention to oral self-care

practices because self-inflicted bacteremias may occur when Careful manipulation of soft tissues during instrumentation
oral and preprocedural antimicrobial rinsing to reduce transient
bacteremia
Cardiac dysrhythmias and arrhythmias unshielded pacemaker to malfunction. contraindicated
Electrical interference can cause Use of electrical dental equipment is

Hypertension Stress and anxiety about treatment may Use stress reduction strategies; if blood pressure is
increase blood pressure. uncontrolled, dental hygiene care is contraindicated
Coronary (ischemic) heart disease Have nitroglycerin available during to relaxation
Stress and anxiety about treatment may treatment. Implement stress reduction
precipitate angina. strategies; create atmosphere conducive
Congestive heart failure None if person is under appropriate medical care. Keep client in upright position to decrease lung
fluid
 TABLE 43-6
Sample Evaluation of Dental Hygiene Interventions
Client Goals Evaluation Measures Expected Outcomes
Complete invasive dental hygiene 9- to 14-day interval between coverage soft deposits removed
therapy (scaling and root debridement) Appointments scheduled 9-14 days apart
so that antibiotic coverage occurs with a No drug resistance occurring Hard and
By 9/13, reduce gingival bleeding by 90% Document clinical
outcomes using bleeding on probing
By 12/13, reduce periodontal probing depths Document
clinical outcomes using periodontal probing depths and
clinical
attachment levels
BOX 43-3
Basic Steps in a Cardiac Emergency Situation
Minimal to no gingival bleeding on probing
Periodontal probing depths reduced by at least 1 mm Clinical
attachment levels stable
Make certain client is comfortable; loosen restricting
garments, elevate head slightly, provide reassurance.
Angina Pectoris
• Immediately administer nitroglycerin sublingually and
100% oxygen with a face mask or nasal cannula to
prevent disease transmission.* • Monitor vital signs.
*Note: An overdose of nitroglycerin can cause headache.
Myocardial Infarction
• Have client transferred to an emergency facility as soon
as possible. • Apply automated external defibrillator
and/or administer cardiopulmonary resuscitation if
necessary.
• Stay with the client until the physician or
emergency medical technician takes over.
822 SECTION VII n Individuals with Special Needs
Finally, it is important to document in the client record all
components of the dental hygiene process of care. This docu
mentation includes the objective, complete, concise, and accu
rate recording of all collected data, treatment planned and
provided, consultations sought, recommendations made,
and all other information relevant to client care and
treatment. Doing so meets ethical and legal standards and
ensures con tinuity of care by subsequent healthcare
providers.
CLIENT EDUCATION TIPS
• Explain that prophylactic antibiotic premedication must
be taken 1 hour before the scheduled appointment to
achieve optimal blood levels and to reduce the possibility
of infective endocarditis (IE) in persons with the highest
categories of risk for IE (see Chapter 12, Box 12-4).
• Explain that oral health maintenance reduces self-induced
and professionally induced transient bacteremias (preven
tion of IE).
• Explain that reducing gingival inflammation and oral
biofilm is important when taking anticoagulant medication.
• Explain that periodontal disease may increase one's risk
for coronary heart disease.
• Discuss how some forms of cardiovascular disease are
preventable by lifestyle changes such as following a low
sodium, low-fat, low-cholesterol diet that is rich in fruits,
vegetables, and whole grains; getting daily exercise; per
forming stress management; and not using tobacco.
LEGAL, ETHICAL, AND SAFETY ISSUES
• The client with cardiovascular disease (CVD) poses a mal
practice risk if treatment procedures fail to follow the stan
dard of care. Legal issues as a result of a medical
emergency include the following12:
• The original “incident” may subject the practitioner to
liability for causing additional harm (even death)
resulting from (1) later negligent care and treatment of
the original injury, (2) later care and treatment (not
negligent), or (3) later care and treatment when an
inherent risk (eg, infection) is the aftermath.
• If a client with CVD develops chest pain and begins to
feel nauseous and sweat profusely, the provider
should (1) stop dental hygiene care; (2) alert the
dentist; and (3) together with the dentist manage the
immediate emergency situation, which may include
use of the automated external defibrillator and Basic
Life Support.
• If dental hygiene care is continued and the client expe
riences a myocardial infarction, liability charges may
be brought against the practitioner.
• If dental care is performed on a client who was not
appropriately assessed and his or her status is not
docu mented on an acceptable health history form, the
prac titioner could be held responsible for any damage
resulting from care.
• If a client reports a cardiac condition that requires
antibi otic premedication to prevent infective
endocarditis (per American Heart Association
guidelines) and he or she is not premedicated, the
practitioner may be liable for mor bidity and mortality
that develops after treatment.
• Medical emergency situations must be prevented and
 properly managed or a malpractice suit could arise. early periodontitis.
1. Cite implications of MI and anticoagulant medication on
dental hygiene care.
2. What unmet human needs does this client have? 3. Should
KEY CONCEPTS this client receive dental hygiene care? Mengapa atau
mengapa tidak?
• Review health history, dental history, cultural history,
pharmacologic history, and risk factors for systemic and
oral disease as a standard of care; consult with client's
physician or cardiologist as required. 4. If client is treated, should the dental hygiene care plan be
• Periodontal disease may contribute to one's risk for devel altered?
oping cardiovascular disease (CVD) (eg, the inflamma 5. What client education topics need to be addressed?
tory process increases risk for thrombosis development).
• The practitioner must follow the Prevention of Infective Case 2: Documentation of Health History—
Endocarditis guidelines from the American Heart Associa
Client with Coronary Heart Disease
tion and strive to maintain the oral health of clients with Medical Profile: Mrs. J, age 56, was last examined by her
cardiovascular disease. physician in September. On completion of the health history,
• Hypertension can be detected by measuring blood pres you note that Mrs. J has responded “yes” to some questions
sure as part of the dental hygiene assessment. concerning coronary heart disease, experiences chest pain,
• Unstable angina pectoris indicates that a client has increas and carries nitroglycerin. Although the nitroglycerin usually
ing chest pain at rest and during sleep. Clients with unsta helps, she sometimes needs to take two doses.
ble angina are at risk for a possible medical emergency 1. What additional questions should the dental hygienist ask
and should not be treated in the dental setting until Mrs. J?
medical clearance is obtained. 2. What unmet human needs does this client have? 3. Cite
• The drug of choice for a client experiencing angina is nitro implications for dental hygiene care. Menjelaskan. 4.
glycerin, usually administered sublingually. Too much Should the dental hygiene care plan be altered?
nitroglycerin can cause headache. Menjelaskan. 5. The client is at risk for what medical
• Dental hygiene care should be postponed if a client has emergency?
had a myocardial infarction within 30 days of the sched
REFERENSI
uled appointment or if ischemic symptoms persist.
• Cardiac dysrhythmias and arrhythmias are dysfunctions 1. World Health Organization (WHO): World health statistics:
of the heart rate and rhythm and may be detected when annual report, Washington, DC, 2012, WHO.
2. Lockhart P, Bolger A, Papapanou P, et al: Periodontal disease
assessing the client's pulse rate.
and atherosclerotic vascular disease: Dose the evidence support
• Unshielded cardiac pacemakers may be susceptible to
an independent association? AHA Scientific Statement,
interference generated by some dental equipment (eg, Circulation 125:2520, 2012.
ultrasonic scalers, pulp testers, electrodesensitizing equip 3. Bolger A, Papanou P, Osinbowale O: Periodontal disease and
ment, air-abrasion systems, computerized periodontal atherosclerotic vascular disease: Dose the evidence support an
probes, low- or high-speed handpieces). independent association? AHA Scientific Statement, Circulation
• Clients with congestive heart failure have difficulty 125:2520, 2012. Update available at: http://newsroom.heart.org/
breath ing in a supine position. pr/aha/periodontal-disease-and-atherosclerotic-234243.aspx.
• Clients with a history of CVD can be given local anesthetic Accessed May 15, 2012.
agents that contain epinephrine at the minimally safe dose. CHAPTER 43 n Cardiovascular Disease 823
• Anticoagulant medications increase bleeding time. Clients
taking such medications need a medical consultation and
4. Dorn J, Genco R, Grossi S, et al: Periodontal disease and
prothrombin time values within the range of normal before
recurrent cardiovascular events in survivors of myocardial
dental hygiene care is performed. infarction: the Western New York Acute MI Study, J Periodontol
• Clients taking immunosuppressant medication for a heart 81:502-511, 2010.
transplant and calcium channel blockers for hypertension 5. Tonetti M: Periodontitis and risk for atheroscelerosis: an update
are at risk for drug-influenced gingival enlargement. on intervention trials, J Clin Periodontol 36:15, 2009.
• Prevention of CVD requires healthy lifestyles (ie, reduc 6. Berry J: Setting the record straight, ADA News Release.
tion in saturated fat, cholesterol, and sodium intake; Available at: http://www.ada.org/news/7275.aspx. Accessed July
increased exercise; decreased stress; no tobacco use; and 16, 2012.
control of hypertension). 7. Wilson W, Taubert KA, Gewitz M, et al: Prevention of infective
endocarditis. Guidelines from the American Heart Association,
Circulation 116:1736, 2007.
CRITICAL THINKING EXERCISES 8. Pickett F, Gurenlian J: The medical history: clinical implications and
Case 1: Client with History of MI on emergency prevention in dental settings, Baltimore, 2007,
Anticoagulant Therapy Lippincott Williams and Wilkins.
9. Kaptoge S, Di Angelantonio E, Lowe G, et al: Emerging risk
During assessment, the client reports that he had an MI 2 factors collaboration; C-reactive protein concentration and risk
years ago and is taking Coumadin twice daily. The client has of coronary heart disease, stroke, and mortality: an individual
 par ticipant meta-analysis, Lancet 375:132, 2010. compromised patient, Philadelphia, 1989, Saunders.
10. Chopra R, Sudhir P, Shivani M: Comparison of cardiovascular
disease risk in two main forms of periodontitis, J Dental Res
9:74, 2012.
11. Frisbee S, Chambers C, Frisbee J, et al: Association between EVOLVE RESOURCES
dental hygiene, CVD risk factors and systemic inflammation in
Please visit http://evolve.elsevier.com/Darby/hygiene
rural adults, J Dental Hygiene 84:177, 2010.
for additional practice and study support tools.
12. McCarthy F: Essentials of safe dentistry for the medically
CHAPTER 43 n Cardiovascular Disease 823.e1

Pageburst Integrated Resources

As part of your Pageburst Digital Book, you can access the following
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Key Term Flashcards

Diabetes mellitus, which is one of the most widespread dis

CHAPTER
eases, affects approximately 25.8 million adults and children

44
COMPETENCIES
1. Define diabetes and prediabetes, and explain the role
of the dental hygienist in the care of a person with
diabetes.
2. Discuss the classification of diabetes, including: •
Differentiate between type 1 and type 2 diabetes
mellitus in terms of prevalence, characteristics, and
potential complications.
• Explain gestational diabetes and its potential
complications.
• Identify other specific types of diabetes mellitus. 3.
Recognize the pathophysiology of diabetes, including the
signs, symptoms, and oral and systemic complications.
4. Recognize a diabetic emergency, and take appropriate
action for management.
5. Appreciate lifestyle adjustments required by the
individual with diabetes.
6. Explain the dental hygiene process of care for clients
with diabetes mellitus, including:
• Plan appropriate dental hygiene care for an
individual with diabetes mellitus.
• Assist the client in preventing diabetes when risk
factors are present and recommend referral for
screening.
in the United States or about 8.3% of the population. Of
these individuals, more than 7 million are unaware of their
diabe tes. These numbers are increasing substantially with
increas ing obesity. As many as one in three people born in
2000 will develop diabetes.1 Individuals with diabetes face
shortened life spans and the probability of developing acute
and chronic health complications.
Diabetes mellitus is actually a group of disorders charac
terized by hyperglycemia (abnormally increased blood
glucose) that results from defective insulin secretion, defec
tive insulin action, or a combination of both. Chronic hyper
glycemia damages the eyes, kidneys, nerves (neuropathy),
heart, and blood vessels (microangiopathy). The dental
hygienist plays a key role in managing oral disease in
persons with diabetes (Box 44-1).
Pradiabetes
Prediabetes is a condition that precedes type 2 diabetes.
People with prediabetes have blood glucose levels that are
Diabetes Mellitus
Deborah Blythe Bauman
higher than normal but below diagnostic levels. Approxi
mately 10% to 15% of the US population has prediabetes.
Prediabetes is also called impaired glucose tolerance and
impaired fasting glucose, all of which refer to metabolic
 stages that are somewhere between normal glucose homeo
stasis and diabetes (Figure 44-1). People with prediabetes are
at high risk for developing diabetes and cardiovascular
disease. Impaired glucose tolerance and impaired fasting
glucose are associated with abdominal obesity; high triglyc
eride levels, low high-density lipoprotein (ie, “good choles
terol”) levels, or both; and hypertension. Individuals who
are at high risk for developing diabetes can use a variety of
inter ventions that can delay and often prevent diabetes.
Interven tions that have been shown to reduce the
development of
type 2 diabetes by 58% to 71%, include the following: •
Increasing physical activity to include 150 minutes per week
of moderate activity, such as walking
• Targeting a 7% weight reduction
• Reinforcing behaviors with follow-up counseling •
Adding metformin therapy for those with body mass
indices of more than 35 kg/m2 who are less than 60 years old
and for those women with prior gestational diabetes
mellitus; see Oral Hypoglycemic Agents later in this chapter
for more information.
• Obtaining annual monitoring
Prediabetes has no symptoms, so it is important for the
dental hygienist to know the risk factors, to ask questions, to
refer clients for screening, and to encourage clients to make
healthy changes.
Classification of Diabetes
(Table 44-1 and Box 44-2)
The four major clinical types of diabetes mellitus are as
follows2:
• Type 1 diabetes mellitus
• Type 2 diabetes mellitus
• Gestational diabetes mellitus
• Other specific types
Type 1 (Insulin Deficient) Diabetes Mellitus Type
1 diabetes mellitus, which involves about 5% of the adult
diabetic population, commonly presents during child hood
and adolescence, but it can strike at any age. In indi viduals
with type 1 diabetes, the body does not produce insulin.
People who develop type 1 diabetes mellitus are rarely
obese. To survive, people with type 1 diabetes require the
regular lifelong administration of insulin via injection or
pump. The disease results from the destruction of the
pancreatic beta cells by the body's immune system. Genetic

824

predisposition related to the presence of certain human leu
kocyte antigens that influence immune activity directed
against islet cells is essential for type 1 diabetes. Research
studies suggest a genetic origin associated with type 1 and
type 2 diabetes. The role of genetics is weaker in type 1 dia
betes than in type 2 diabetes. Environmental factors, which
are still poorly defined, have been postulated to play a caus
ative role in genetically predisposed individuals. Autoim
mune reactions and environmental factors (eg, viral
infections) have been demonstrated in research. Twin
studies reveal that, if one twin develops type 1 diabetes, the
other twin will develop the disease in approximately 50% of
cases.3
CHAPTER 44 n Diabetes Mellitus 825
Most individuals with type 2 diabetes are obese, and obesity
itself causes some degree of insulin resistance. Individuals
who are not obese by traditional weight criteria may have an
increased percentage of body fat distributed in the
abdominal region. People with type 2 diabetes constitute
approximately 90% to 95% of the diabetic population. Of the
undiagnosed, the vast majority have type 2 diabetes. The
risk of developing type 2 diabetes increases with obesity,
age, lack of physical activity, history of gestational diabetes
mellitus, hyperten sion, and dyslipidemia (ie, abnormal
amounts of blood

id

Type 2
s d o

most common e
N 100 la

Diabetes mg/dL
(Insulin
m
a

form of
er

The Dental 100

t P
s

o
e
e
e

Resistant) diabetes, 6.5% mg/dL

te
r N
b

Hygienist's Diabetes
b

a
P

6.5%
id
a

results from
i

Diabetes BOX 44-1 Role in the 200

la

mg/dL
m

insulin Care of a
Mellitus
r

5.7% 200
resistance and Person
N

Diabetes mg/dL
m

Type 2 r

5.7%
is preventable. with Diabetes 140
diabetes 126
mg/dL er
mg/dL
mellitus, P
s

140
126 e

mg/dL
te

which is the mg/dL

b

• Conduct periodontal risk assessment. emergencies.

• Determine the need for co-management. • Detect undiagnosed and uncontrolled diabetes
• Monitor the pharmacologic history for drug and refer. • Modify dental hygiene care plan on the
interactions with insulin. • Minimize potential risks for basis of client needs. • Monitor the outcomes of
 dental hygiene care (evaluation). Figure 44-1.The arrows demonstrate the progression from
normal to a diagnosis of prediabetes and from prediabetes
to a diagnosis of diabetes. Prediabetes and diabetes can be
identified using any one of three tests: glycosylated
hemoglobin A1c (A1C), fasting plasma glucose (FPG), or oral
glucose tolerance test (OGTT). These tests each have
TABLE 44-1 distinct diagnostic thresholds for the diagnosis. (From the
American Diabetes Association. Avail able at:
Characteristics of Type 1 and Type 2 Diabetes Mellitus
http://www.diabetes.org/diabetes-basics/prevention/pre-
A1C FPG OGTT
diabetes/ diagnosis.html. Accessed April 30, 2013.)

Factor Type 1 Type 2

Age at onset Usually young, but may occur at any age Usually in persons >40 years old, but may occur at any age Type
of onset Usually abrupt Gradual and subtle
Genetic susceptibility Human leukocyte antigen–related DR3, Frequent genetic background; not related to human leukocyte
DR4, and others antigen
Environmental factors Viruses, toxins, autoimmune stimulation Obesity
Islet-cell antibody Present at outset Not observed
Endogenous insulin Minimal or absent Stimulated response is adequate but with delayed secretion or reduced but not
absent
Nutritional status Thin, catabolic state Obese or may be normal Symptoms Thirst, polyuria, polyphagia,
fatigue Frequently none or mild Ketosis Prone at onset or during insulin deficiency Resistant except during
infection or stress Control of diabetes Often difficult, with wide glucose fluctuation Variable; helped by
dietary adherence Dietary management Essential Essential; may suffice for glycemic control Insulin
Required for all Required for about 40% Sulfonylurea Not efficacious Efficacious
Vascular and neurologic complications Seen in majority after ≥5 years of diabetes Frequent
826 SECTION VII n Individuals with Special Needs

BOX 44-2 TABLE 44-2

Diabetes Mellitus
Prediabetes
• Metabolic stage intermediate between normal glucose
homeostasis and diabetes; indicates relatively high
risk for development of diabetes
Type 1 Diabetes Mellitus
• Results from beta-cell destruction, usually
leading to absolute insulin deficiency
A. Immune mediated
B. Idiopathic
Type 2 Diabetes Mellitus
• Ranges from insulin resistance with relative insulin
deficiency to insulin secretion defect with insulin
resistance
Other Specific Types
• Other types of diabetes associated with certain
conditions or syndromes: pancreatic disease,
endocrinopathies, infections, chemical- or
drug-induced disease, genetic defects, genetic
syndromes, insulin-receptor abnormalities, and
others
Gestational Diabetes Mellitus
• Any degree of glucose intolerance with onset or
first recognition during pregnancy
lipids). The frequency of type 2 diabetes varies with racial
and ethnic groups. Ketoacidosis seldom occurs in clients
with type 2 diabetes, but, when it is present, it is associated
with infection. Type 2 diabetes usually goes undiagnosed for
years because hyperglycemia develops gradually without
classic symptoms. It is estimated that people have type 2
diabetes for 10 years before they are clinically diagnosed.
Neverthe less, the risk of developing macrovascular and
microvascular complications (ie, problems in the large and
small blood vessels) is high. Symptoms may be gradual, and
weight loss is uncommon (Table 44-2).
 Persons with type 2 diabetes often respond to weight Lower-extremity amputations
reduction, dietary management, exercise, and oral hypogly
cemic medications. Persons with type 2 diabetes may require
insulin therapy to achieve good control or during illness,
which is an important distinction between insulin-
pregnancy. Therefore diabetic women who become pregnant
dependent and insulin-treated individuals.
do not fall into the GDM classification. High-risk individuals
Type 2 diabetes is recognized as a heterogeneous
include women with the following conditions: • Marked
disorder that results from insulin resistance and insulin
obesity
secretory defects. Type 2 diabetes is predominantly
• Previous GDM
genetically inher ited, and it has no association with
• Strong family history of diabetes
autoimmune beta-cell destruction. In studies, if one twin
• Glucosuria (ie, glucose in the urine)
develops type 2 diabetes, the other twin has a 100% chance
Even in the nondiabetic individual, normal pregnancy
of developing the disease.3 Obesity has a major role in the
affects both fetal and maternal metabolism and exerts a dia
development of type 2 diabe tes, but more research is
betogenic effect. GDM generally reverts after birth because
needed.
the condition is a consequence of the normal anti-insulin
Gestational Diabetes Mellitus effects of pregnancy hormones and the diversion of natural
glucose to the fetus.
Gestational diabetes mellitus (GDM) occurs in 4% of preg
nancies in the United States.4 Clinical characteristics include CHAPTER 44 n Diabetes Mellitus 827
glucose intolerance that has its onset or recognition during
Complications of Diabetes Mellitus
GDM increases the risk of perinatal morbidity and mortal
ity. Maternal complications include an increased rate of cesar
Affected Area Complications and Results

Eyes Retinopathy
Blindness
Cataracts
BOX 44-3
Glaucoma
ean delivery and chronic hypertension. Furthermore,
Kidneys Glomerulonephritis
women with a history of GDM have a 35% to 60% chance of
Chronic dialysis
develop ing diabetes during the next 10 to 20 years. Six
Nephrosclerosis
Kidney transplant weeks or more after pregnancy ends, the woman with GDM
Pyelonephritis should be reclassified as having one of the following:
• Diabetes
Mouth Gingivitis
• Prediabetes
Dental caries
• Normal glucose regulation
Periodontitis
Reproductive system Sexual dysfunction Other Specific Types of Diabetes Mellitus The
Stillbirths category of other specific types of diabetes mellitus is
Miscarriages heterogeneous in nature and includes diabetes in which the
Babies with high birth weights causative relationship is known, such as diabetes mellitus
Congenital defects associated with certain conditions and syndromes (eg,
Neonatal deaths genetic defects of the beta cells, pancreatic disease, endocrine
Skin Xanthoma diabeticorum Pruritus disease, chemical-induced agents, genetic syndromes).
Furunculosis
Limited joint mobility
Pathophysiology of Diabetes
To use glucose, the body must produce insulin. A person
Vascular system Atherosclerosis
with diabetes produces too little insulin or has an inability to
Stroke
use insulin. Insulin, which is an anabolic hormone (ie, it is
Microangiopathy
Heart disease used to build up the body), stimulates the entry of glucose
Large-vessel disease into the cell and enhances fat storage. Without insulin,
Hypertension glucose remains in the bloodstream (hyperglycemia) rather
Myocardial infarction than being stored or used by cells to produce energy.

Peripheral nerves Earliest recognized complication Insulin Deprivation

Erectile dysfunction The net effect of insulin deficiency is that blood glucose con
Somatic neuropathy
centration rises (hyperglycemia). Without insulin, the
Autonomic neuropathy
glucose derived from a meal cannot be used or stored. When
Slowed digestion in stomach
the blood glucose level rises to more than 150 mg/dL, the
Impaired sensation in feet and hands
kidney tubules become incapable of resorption. Glucose
Carpal tunnel syndrome
appears in the urine (glucosuria), taking with it a large
amount of fluid, thereby raising the volume of urine • Unusual thirst
(polyuria) and necessitat ing frequent urination. • Extreme hunger
Dehydration follows, leading to excessive thirst • Unusual weight loss
(polydipsia). Ketoacidosis may follow hyperglycemia when • Irritability
blood glucose levels rise to more than 400 mg/dL (Box 44-3). • Extreme fatigue
Impaired carbohydrate metabolism, which the body Type 2 diabetes mellitus is characterized by its slow
interprets as energy starvation, causes the excessive onset; it includes any of the type 1 symptoms in
addition to the following:
ingestion of food (polyphagia) and necessitates the use of
• Frequent infections
fats and proteins (hyperglycemia progressively gly
• Blurred vision
cates body proteins) to satisfy energy requirements. Keto
• Cuts and bruises that are slow to heal
acids and ketone bodies (acetone) are produced as a result of
• Tingling or numbness in the hands and feet
the catabolism of fatty acids (lipolysis). Ketones accumulate
• Recurring or hard-to-heal skin, gingival, or bladder
in the tissues; they are excreted in the urine (ketonuria) and infections
circulated in the blood (ketonemia), thereby causing a drop
in the pH of the blood and leading to seizures and diabetic
Adapted from the American Diabetes Association: Diabetes
coma. symptoms. Available at: http://www.diabetes.org/diabetes-
basics/symptoms/?loc=DropDownDB-symptoms. Accessed
Clinical Signs and Symptoms November 1, 2012.
Diabetes is characterized by hyperglycemia. In type 1 diabe
tes mellitus, the predominant problem is impaired insulin
production; in type 2 diabetes mellitus, the predominant Indicators of probable diabetes mellitus (ie, the cardinal
problem is the inability to use the insulin produced by the signs of diabetes) include the following:
body. However, a considerable overlap exists with regard to • Polydipsia
the clinical features of the two forms of diabetes. The defi • Polyuria
ciency of insulin action leads to defects in the metabolism of • Polyphagia
carbohydrates, protein, and lipids. In clinical practice, the • Unexplained weight loss
suspicion of diabetes is gleaned from the client's history and • Weakness
physical findings (Box 44-4). Symptoms of marked hyperglycemia also include poly
Signs and Symptoms of Ketoacidosis phagia (eating extreme amounts of food) and blurred vision.
828 SECTION VII n Individuals with Special Needs
Common Cardinal Symptoms
“Fruity” acetone breath
Frequent urination Impairment of growth and susceptibility to certain infections
Excessive thirst may also accompany chronic hyperglycemia. A family
Unusual hunger history of diabetes, obesity, GDM, premature
Weight loss atherosclerosis, and neuropathic disorders also are
Weakness indications of probable diabe
Nausea
tes mellitus. Dental hygienists aware of indications and risk
Dry skin and mucous membranes
factors can refer potentially undiagnosed clients for testing
Flushed facial appearance
(see Figure 44-4 and Boxes 44-5 and 44-6).
Abdominal tenderness
Rapid, deep breathing Chronic Complications
Depressed sensory perception
People with both types of diabetes mellitus show a tendency
for severe, multisystem, long-term complications (see Table
Other Symptoms
44-2), including the following:
Recurrence of bedwetting
• Microvascular and macrovascular disease
Repeated skin infections
Malaise • Diabetic retinopathy with potential vision loss
Drowsiness • Nephropathy leading to renal failure
Headache • Peripheral neuropathy with risk of foot ulcers, amputa
Marked irritability tion, and neuropathic joint disease
• Autonomic neuropathy causing gastrointestinal, genito
urinary, and cardiovascular symptoms as well as sexual
dysfunction
BOX 44-4 • Periodontal disease
Mechanisms thought to cause tissue damage in diabetics
Warning Signs of Diabetes involve alterations in the host immunoinflammatory
response, including altered function of immune cells (ie,
Type 1 diabetes mellitus is characterized by the sudden
neutrophils, monocytes, and macrophages); elevated levels
appearance of the following:
• Frequent urination of tumor necro
sis factor-alpha; alterations in connective tissue metabolism; and neuropathy occurs with both types (see Table 44-2).
and the glycation of tissue proteins forming advanced glyca
tion end products5 and advanced glycation end product–
Diabetes and Periodontal Disease:
modified collagen.5 Individuals with diabetes have an A Two-Way Relationship
increased incidence of atherosclerotic, cardiovascular, For more information about this topic, see Modifiable Risk
peripheral vascu lar, and cerebrovascular disease. Factors in Chapter 19 and all of Chapter 20.
Hypertension, abnormalities Periodontal disease is the sixth most common complica
tion of diabetes. Young adults with diabetes have twice the
periodontal disease risk of those without diabetes. One third
TABLE 44-3 of individuals with diabetes have severe periodontal
disease6 with attachment loss of 5 mm or more.6 Several meta
analyses confirm that periodontal therapy can result in
reduced glycated hemoglobin (A1c) levels. Reduced systemic
in lipoprotein metabolism, and periodontal disease are inflammation seems to be an important determinant in the
7
found in people with diabetes. The emotional and social relationship.
impact of diabetes and the demands of therapy cause
Diabetic Emergencies (see Chapter 10) Individuals
significant unmet human needs in individuals with diabetes
with uncontrolled diabetes increase their risk of the
and their families (Table 44-3). All complications affect
clients with both type 1 and type 2 diabetes, although following medical emergencies:
clinical consequences differ greatly. Generally, kidney and • Coma
eye diseases predominate with type 1 diabetes, • Hypoglycemia
atherosclerotic disease predominates with type 2 disease, • Ketoacidotic hyperglycemia

Some Unmet Human Needs of Persons with Diabetes and Their Effect on Outcomes of Self-Monitoring of Blood
Glucose

Unmet Human Need Client's Feeling Example of Client's Behavioral Response

Protection from health risks I want to be 100% okay. Seeking perfection; therefore records
results as 100% okay.

Responsibility for oral health
Conceptualization and problem solving
Freedom from fear and stress
I want you to be pleased/proud.
I want to be in charge.
I don't want you to punish me.
I don't want you to question or accuse
me.
I don't want to hear if I'm good or bad. I deserve punishment”
don't have diabetes. Avoiding confrontation and criticism;
therefore “I'll give you records that
I don't want to pay attention to diabetes encourage you to leave me alone”
and feel sad. Avoiding judgment; therefore “I'll give
I hate diabetes/I hate how you make me you records that you won't have to
deal with diabetes. comment about”
Aku curang. Expressing denial; therefore “I'll need no
Seeking approval; therefore “I'll give you test”
information that makes you pleased or
Avoiding depression; therefore “I won't
proud”
test so that I won't have to face sadness”
Seeking independence; therefore “I'll give
Expressing resentment or anger;
you records that show what I want you to
therefore “I won't do what you ask me to
see”
do”
Avoiding punishment; therefore “I'll give
Expressing guilt; therefore “I'll hide it”
you records so that you think I don't

Adapted from Skyler JS, Reeves ML: Intensive treatment of type I diabetes mellitus. In Olefsky JM, Sherwin RS, eds:
Diabetes mellitus: management and complications, New York, 1985, Churchill Livingstone.

• Nonketotic hyperosmolar hyperglycemia • Myocardial infarction

• Lactic acidosis • Stroke
• Uremia • Emergency surgery
• Nondiabetic coma The occurrence of stupor or coma in clients with diabetes
• Infection may be the result of several causes. For example, the diabetic
condition may be undiagnosed, or the person with type 1
disease may not have followed the required insulin regimen.
Stress, infection, and an increased level of activity contribute
to an emergency situation.
Hypoglycemia (Box 44-7; Tables 44-4 and 44-5)
Hypoglycemia (ie, a blood glucose concentration of <70 mg/
dL) is the most common metabolic emergency in persons
with type 1 diabetes mellitus; it results from an excess of
insulin and a glucose deficiency in the body. (A blood
glucose concentration of 80 to 120 mg/dL is normal.) Each
year, severe episodes affect approximately 20% of diabetic
indi viduals; minor episodes occur every 2 weeks on average
in each insulin-treated person. In clients with type 2 disease
who are treated with sulfonylurea agents, hypoglycemia is
more common than is generally recognized, and it may be
severe, especially among older persons treated with longer-
acting agents. Hypoglycemia signs and symptoms result
from a lack of glucose in the brain and compensation by the
nervous system for this lack (see Box 44-7). Main causes of
hypogly cemia in persons with type 1 disease are listed in
Table 44-4.
TABLE 44-4
Causes of Hypoglycemia in Individuals with Type 1
Diabetes Mellitus
Factor Cause
Insulin Inappropriate insulin regimens
Day-to-day variability in absorption
Insulin antibodies
Inappropriate site rotation
Factitious hypoglycemia
Renal failure
CHAPTER 44 n Diabetes Mellitus 829
Individuals with diabetes can manage mild
hypoglycemia themselves by ingesting glucose, sweet
drinks, or milk. Between 10 and 20 g of glucose (ie, about the
amount in an 8-ounce glass of 2% fat milk, a 4-ounce glass of
orange juice, three pieces of hard candy, or eight Life Savers
Food Delayed intake Decreased intake
Exercise Increased energy requirements
Increased insulin absorption
Other Impaired counterregulation
Liver disease
Hypoendocrine states
Alcohol
Potentiating drugs
Hypoglycemic unawareness (absence of signs and
symptoms, long-standing diabetes, autonomic
neuropathy)
candies) is generally adequate, although many persons take
consider
ably more because they fear prolonged hypoglycemia. More
severe hypoglycemia can also be treated via the oral
ingestion of carbohydrates, but another person may have to
administer the carbohydrates. If the victim is unconscious,
treatment requires intravenous dextrose solution or an
intramuscular injection of 0.5 mg to 1.0 mg glucagon; this
should be fol
lowed on awakening by oral complex carbohydrates with a
protein source (eg, a small meat or cheese sandwich, cottage
cheese and fruit).
Hyperglycemic Ketoacidotic Coma (Diabetic
Coma) (see Table 44-6 and Box 44-8)
Although the percentage of all diabetic deaths caused by
hyperglycemia ketoacidotic coma has decreased
dramatically from more than 60% during the preinsulin days
to 1% at present, it is still considerable, especially among
younger individuals. Prevention is the best treatment;
however, emer
gency treatment requires hospitalization to correct fluid and
electrolyte imbalances.
Coma that results from absolute insulin deficiency is
found in persons with acute-onset type 1 diabetes in whom
diagno sis was unknown or delayed and in individuals with
known diabetes who discontinued or decreased their insulin
dose for some reason. Coma from a temporary insulin
deficiency may be caused by infection or stressful situations
in which there is an increase in the secretion of anti-insulin
hormones (ie, glucagon, cortisol, and catecholamines; see
Box 44-8). Infec
tion is the most common precipitating factor, and it is
present in more than 50% of all persons with diabetic
ketoacidotic coma.
A series of biochemical events explains the basis of severe
ketoacidosis, the signs and symptoms of which are
presented in Table 44-6. Clear guidelines for maintaining
control should be provided to the diabetic client with
infection to resolve the infection early (Box 44-9).
TABLE 44-5
Hypoglycemia Compared with Hyperglycemia
Signs and Symptoms Hyperglycemia (400-600 mg/dL)
Hypoglycemia (<70 mg/dL)
Onset Rapid (minutes) Slow (days to weeks) Thirst
Absent Increased Nausea and vomiting Absent
Frequent Vision Double Dim
Respirations Normal Difficult; hyperventilation Skin Moist,
pale Hot, dry, flushed Tremors Frequent Absent Blood
pressure Normal Hypotension
830 SECTION VII n Individuals with Special Needs
 TABLE 44-6
Features of Severe Diabetic Ketoacidosis
Features Possible Causes
Symptoms
Thirst Dehydration
Polyuria Hyperglycemia, osmotic dieresis Fatigue
Dehydration, protein loss Weight loss Dehydration,
protein loss, catabolism* Anorexia Depression*
Nausea, vomiting Ketones,* gastric stasis, ileus
Abdominal pain Gastric stasis,* ileus, electrolyte
deficiency*
Muscle cramps Potassium deficiency*
Signs
Hyperventilation Acidemia
Dehydration Osmotic diuresis, vomiting
Tachycardia Dehydration
Hypotension Dehydration, acidemia
Warm, dry skin Acidemia (peripheral vasodilation)
Hypothermia Acidemia-induced peripheral vasodilation
(when infection is present)
months. In addition, the A1c test is the preferred test for pre
Impaired type 2) use insulin only to control
consciousness or coma hyperglycemia; 58% use oral medications take either insulin or oral
Hyperosmolality only, 14% use a combination of insulin
Ketotic breath Hyperketonemia (acetone)
*Indicates speculated or unknown cause.
Diabetic ketoacidosis treatment requires hospitalization
to restore the disturbed metabolic fluid and electrolyte state
to normal. Fluid rehydration (ie, salt and water), insulin,
potas sium, broad-spectrum antibiotic therapy, and the
treatment of precipitating factors are the main elements of
diabetic coma treatment.
Disease Management
Glycemic Control: Self-Monitoring of Blood
Glucose and A1C
The most important aspect of the control of diabetes
mellitus is the self-monitoring of blood glucose with small
automated devices. The frequency of self-monitoring is
highly individualized. Monitoring is done by placing a small
drop of blood on a reagent strip, which is then inserted into
a meter. The meter measures glucose concentration and dis
plays a value of glucose in millimeters per deciliter (mm/dL)
of blood.
The hemoglobin A1c laboratory test (also known as A1C)
is used by the physician to monitor overall glycemic control.
diabetes. An A1c level between 5.9% and 6.4% indicates pre
diabetes; 6.5% or greater indicated diabetes. Abnormal A 1c
levels correlate with glucose intolerance and the
development
of diabetic complications. Each 1% reduction in A1c is associ
ated with significant reductions (ie, 14% to 37%) in the risk
of diabetic complications.2 Thus early diagnosis and good
control are very important. Recommendations for A1c levels
and blood measurements in clients with diabetes are pre
sented in Box 44-10.
Medical Nutrition Therapy
Diet remains the hallmark of diabetes therapy, despite
advances in insulin formulations, insulin delivery systems,
and oral medications. Diabetic diets are designed to provide
appropri ate quantities of food at regular intervals, to supply
daily caloric requirements to help with achieving or
maintaining desirable body weight, and to reduce fat intake
to correct an
unfavorable lipid profile that is conducive to atherosclerosis.
With type 2 diabetes, a reduction in hyperglycemia is
correlated with weight loss. With type 1 diabetes mellitus,
nutritional strategies involve monitoring the percentages of
carbohydrate (ie, 55% to 60% of total calories) and protein
(ie, 12% to 20% of total calories) intake. Meal planning for
diabetics is based on the food exchange list system of the
American Diabetes Association.
Insulin Therapy
More than 20 different insulins are sold in the United States.
Approximately 12% of people with diabetes (either type 1 or
and oral medications, and 16% do not
Hemoglobin A is made during the 120-day life span of a red
blood cell. Blood glucose attaches to hemoglobin A and is
used as a record of blood glucose levels over the prior 3
medication. Persons with type 1 diabetes have essentially no
pancreatic insulin, they are unresponsive to oral
sulfonylurea hypoglycemic agents, and they are prone to
ketosis; they are therefore dependent on lifelong exogenous
insulin administration.
Human insulin and insulin analogues are categorized by
their speed of onset, their peak effect, and their duration;
they are also available in mixture preparations as follows: •
Rapid-acting
• Short-acting
• Intermediate-acting
• Long-acting
Insulin may be injected subcutaneously with an insulin
syringe or a penlike device. Insulin pumps are widely used
to deliver a programmed steady drip of insulin (ie, a basal
rate) under the skin 24 hours a day. The push of a button on
the pump delivers a bolus dose to respond to the number of
carbohydrate grams consumed at a meal. Numerous new
products are awaiting approval from the US Food and Drug
Administration. Table 44-7 illustrates insulin types that may
be used alone or in combination. Dosages, frequency, and
times of administration are highly individualized.
 Oral Hypoglycemic Agents
When the control of hyperglycemia in clients with type 2
diabetes is not achieved with diet and exercise, oral hypogly
TABLE 44-7 Types of Onset of Action Duration (hr)
Peak CHAPTER 44 n Diabetes
Insulin
Effect (hr) Mellitus 831
Type
Pramlintide is also
approved for clients
Rapid-acting
with type 1 diabe tes, but blood glucose is within Clients with
Insulin lispro 5 minutes 1 2 to 4 Insulin aspart
Insulin glulisine
Short-acting
Regular 30 minutes 2 to 3 3 to 6
Intermediate-acting
Neutral protamine Hagedorn 2 to 4 hours 4 to 12 12 to 18
Long-acting
Ultralente 6 to 10 hours 16 to 18 20 to 24 Glargine and
detemir 1 to 2 hours None 24
response to insulin (insulin sensitizers), to slow glucose
digestion, or to decrease glucose production by the liver as
follows:
• Biguanides (metformin [Glucophage]) decrease the
amount of glucose secreted by the liver, decrease
intestinal glucose absorption, and increase insulin action.
Hypogly cemia is not a side effect. Metformin is
contraindicated for people with reduced kidney function.
• Sulfonylureas (glyburide [Glynase, Micronase, Diabeta];
glipizide [Glucotrol]; glimepiride [Amaryl]) increase
insulin secretion. Hypoglycemia and weight gain are
disadvantages.
• Meglitinides (repaglinide [Prandin]; nateglinide [Starlix])
increase insulin secretion in the presence of glucose.
These drugs are taken before each meal.
• Thiazolidinediones (pioglitazone [Actos]; rosiglitazone
[Avandia]) make the body more sensitive to insulin. The
target cell response to insulin is improved, thereby reduc
ing insulin doses.
• Alpha-glucosidase inhibitors (acarbose [Precose]; miglitol
[Glyset]) inhibit enzymes in the small intestines that are
responsible for the digestion of starchy food, thus
delaying carbohydrate metabolism.
• Dipeptidyl peptidase-4 inhibitors (sitagliptin [Januvia];
saxagliptin [Onglyza]) prevent the breakdown of
glucagon like peptide-1 (a naturally occurring
hypoglycemic in the body), thus allowing it to be active
longer.
Injectable Agents for Type 2 Diabetes The
cemic agents are prescribed by an endocrinologist. Generally
oral hypoglycemic agents stimulate the pancreas to secrete
more insulin (insulin secretagogues), to increase the body's
it requires an additional the normal range as a
injection. result of a careful
balance of medication,
Dental Hygiene diet, and exercise. (A
Process of Care blood glucose
Well-controlled diabetes concentration of 80 to
occurs when the client's 120 mg/dL is normal.)
following are injectable agents for the treatment of type 2
diabetes:
• Exenatide (Byetta), which is derived from the saliva of the
Gila monster, stimulates the incretin effect (increased
insulin response), which is diminished in clients with
type 2 diabetes.
• Amylinomimetics (pramlintide [Symlin]) are an analogue
of human amylin, which modulates gastric emptying.
well-controlled diabetes can be treated safely, provided that
their daily routine is not affected. Diabetics with well
controlled disease have a reduced incidence of dental caries.
It is important for dental hygienists to know that only 37% of
people with type 2 diabetes attain an A1c level of less than
7%.8
Infections of any type can cause a profound disturbance
of glycemic control that potentially leads to ketoacidosis and
diabetic coma. When infection is present, counterregulatory
hormone secretion increases (specifically cortisol and gluca
gon), thereby leading to hyperglycemia and increased keto
genesis. Infection is the most common precipitating factor
for severe ketoacidosis. In the client with poorly controlled
dia betes, phagocytic function is impaired, and resistance to
infection is decreased. The prevention of oral diseases and
infections is critical to the client's diabetic control, and poor
diabetic control may aggravate the oral disease status.
Several unmet human needs relate to dental hygiene care for
individuals with diabetes. For example, emotional stress
induced by a dental appointment causes the release of epi
nephrine, which mobilizes glucose from glycogen stored in
the liver. Stress, therefore, can contribute to a hyperglycemic
condition becoming ketoacidotic. Periods of waiting and
treatment time should be minimized to meet the client's
need for freedom from stress.
Diabetes among people who undertake intensive regi
mens of multiple insulin injections and the daily self
monitoring of blood glucose may abruptly become
uncontrolled as a result of an active periodontal infection.
When this is unrecognized, the periodontal infection may
cause the human needs for skin and mucous membrane
integrity and protection from health risks to become compro
mised. Table 44-3 reflects some unmet human needs and
their effect on outcomes of blood glucose self-monitoring.
Figures 44-2 and 44-3 show clinical examples of periodontal
disease in diabetics.
 Assessment
Health History
When obtaining a client's health history, the dental hygienist
questions the client about the signs and symptoms of ketoaci
dosis (see Boxes 44-3 and 44-4) to determine whether an
undi agnosed diabetic condition is present9 or if the client is
at high risk for diabetes (see Boxes 44-5 and 44-6). The
admin istration of the American Diabetes Association's
Diabetes Risk Test is recommended to assist with early
diagnosis. In addition, the Centers for Disease Control and
Prevention rec ommend that dental offices administer the A1c
test or use a blood glucose self-monitoring device to screen
clients who are at risk for prediabetes and to refer them to a
physician when their results confirm higher than normal
ranges.14 Among the aging population, classic symptoms do
not usually manifest. Rather, clinical findings are related to
chronic complications of the disease, such as vascular disor
ders or neuropathic syndromes.

832 SECTION VII n Individuals with Special Needs

A B
Figure 44-2.Diabetes and periodontal disease. A, An adult with diabetes (blood glucose level of 400 mg/100 mL). Note the
gingival inflammation, spontane ous bleeding, and edema. B, The same person after 4 days of insulin therapy (glucose level
of <100 mg/100 mL). The gingival tissues have improved in the absence of professional mechanical therapy. (From Newman
MG, Takei HH, Klokkevold PR, Carranza FA, eds: Carranza's clinical periodontology, ed 11, St Louis, 2012, Saunders.)

A B

C
Figure 44-3.Uncontrolled diabetes and periodontal therapy. A, An adult with uncontrolled diabetes. Note the enlarged,
smooth, red gingiva with initial enlargement in the anterior area. B, The same person. Note the inflamed, enlarged area
around teeth #27 to #30. C, Suppurating abscess and facial or maxillary cleft area in a person with uncontrolled diabetes.
(From Newman MG, Takei HH, Klokkevold PR, Carranza FA, eds: Carranza's clinical periodontology, ed 11, St Louis, 2012,
Saunders.)

When the person is a known diabetic, the client and
health history interview should address the following: • The
type of diabetes
• The methods used to control diabetes (eg, medications,
diet, exercise, weight loss)
• The medication schedule and dosages
• The date and results of the last A1c test
• The frequency of self-monitoring of blood glucose
• The fasting blood glucose levels
• The results of self-monitoring (ie, trends as well as those of
the day of the appointment)
• The blood glucose levels 2 hours after meals
• The date of the last hypoglycemia episode
• The date of onset of diabetes
• The regularity of appointments with a physician • Cheilosis
• The six complications of diabetes • Xerostomia
The decision to continue the assessment, consult with a • Glossodynia
physician, or defer treatment and refer the client to a • Enlarged salivary glands
physician should be made on the basis of the client's • Increased glucose in the saliva
responses to questions during the health history and • Fungal infections such as candidiasis (thrush)
pharmacologic assessment (Boxes 44-11, 44-12, and 44-13). • Dental caries
• Periodontal disease
Oral Assessment Diabetes is an important risk factor for periodontal
Intraoral findings may reveal the following conditions that disease. The American Academy of Periodontology
are common in clients with poorly controlled diabetes (Table published a
44-8):
CHAPTER 44 n Diabetes Mellitus 833

TABLE 44-8
Oral Complications of Diabetes Mellitus

Clinical Signs and Symptoms Pathophysiology

Salivary and Oral Changes

Xerostomia Increased fluid loss
Bilateral asymptomatic parotid gland swelling Increased salivary glucose levels
with increased salivary viscosity Compensatory hypertrophy as a result of a decrease in saliva
Increased fatty acid deposition production
Increased dental caries, especially in the cervical region Secondary to xerostomia and salivary glucose
levels Unexplained odontalgia and percussion sensitivity (acute pulpitis) Pulpal arteritis from
microangiopathies Lingual erosion of anterior teeth* Complications of anorexia nervosa and bulimia

Periodontal Changes
Periodontal disease† Induction and accumulation of advanced glycation end products Tooth mobility Loss of
attachment associated with poor glycemic control Rapidly progressive pocket formation Degenerative vascular
changes
Gingival bleeding Microangiopathies
Local factors
Subgingival polyps Cause unknown

Infection and Wound Healing

Slow wound healing (including periapical lesions after Hyperglycemia reduces phagocytic activity Ketoacidosis may
endodontics) and increased susceptibility to infection delay chemotaxis of granulocytes Vascular changes lead to
decreased blood flow Abnormal collagen production
Microangiopathies
Oral ulcers refractory to therapy, especially in association with Neuropathies
a prosthesis
Irritation fibromas Altered wound healing
Increased incidence and prolonged healing of dry socket Degenerative vascular
changes Post-
extraction infection

Tongue Changes
Glossodynia Neuropathic complications Xerostomia
Candidiasis
Median rhomboid glossitis (glossal central papillary atrophy) Candida albicans

Other Changes
Opportunistic infections: Candida albicans and mucormycosis Repeated use of
 antibiotics
Compromised immune
system
Acetone or diabetic breath (seen when the person is close to a Ketoacidotic state
diabetic coma)

Increased incidence of lichen planus (as high as 30%) Compromised immune system

Adapted from Lalla RV, D'Ambrosio JA: Dental management considerations for the patient with diabetes mellitus, J Am Dent
Assoc 132:1425, 2001. *Although this is not a complication of diabetes per se, this pattern is seen when the person wants to
maintain the weight-loss aspect of diabetes while ignoring or tolerating the hyperglycemic side effects. The client may not
be taking proper insulin doses and may not be truthful when asked about this. †Periodontal disease is more common among
people with diabetes. Among young adults, those with diabetes have about twice the risk of those without diabetes. Adults
who were 45 years old or older with poorly controlled diabetes (ie, A1c > 9%) were 2.9 times more likely to have severe
periodontitis than those without diabetes. The likelihood was even greater (ie, 4.6 times greater) among smokers with poorly
controlled diabetes. About one third of people with diabetes have severe periodontal disease that consists of a loss of
attachment (≥5 mm).
834 SECTION VII n Individuals with Special Needs

BOX 44-5
Type 2 Diabetes: Risk Factors and Criteria for the Testing of Asymptomatic Undiagnosed Adults 2

Testing for diabetes should be considered in the following
situations: • Beginning at age 45 years for all adults who are
overweight (ie, body mass index of ≥25 kg/m2*); if results are
normal, testing should be repeated at 3-year intervals.
• At a younger age or more frequently for adults who are
overweight (ie, body mass index of ≥25 kg/m2*) with
additional risk factors: • Physical inactivity
• First-degree relative with diabetes
• Member of a high-risk ethnic population (eg, African
American, Latino, Native American, Asian American,
Pacific Islander) • Delivered a baby weighing >9 lb or
diagnosed with gestational diabetes mellitus
• Hypertensive (≥140/90 mm Hg or receiving
therapy for hypertension)
• High-density lipoprotein cholesterol level of
≤35 mg/dL (0.90 mmol/L) and/or triglyceride
level of ≥250 mg/dL (2.82 mmol/L)
• Polycystic ovary syndrome
• A1c level of ≥5.7%, impaired glucose tolerance, or
impaired fasting glucose on previous testing
• Another clinical condition associated with insulin
resistance (eg, severe obesity, acanthosis nigricans [see
Figure 44-4]) • History of cardiovascular disease
• Those with prediabetes should be tested annually.

A

the neck. B, Acanthosis nigricans affecting the hand. (Courtesy Lana Crawford.)
*At-risk body mass index may be lower in some ethnic groups.
BOX 44-6 comprehensive review of diabetes mellitus and periodontal
Type 2 Diabetes in Children: Risk Factors and
Criteria for Testing2
• Overweight (body mass index of >85th percentile for
age and sex, weight for height >85th percentile, or
weight >120% of ideal for height) plus any two of the
following risk factors:
• Family history of type 2 diabetes in first- or
second-degree relative
• Native American, African American, Latino, Asian
American, or Pacific Islander race or ethnicity
• Signs of insulin resistance or conditions associated
with insulin resistance (eg, acanthosis nigricans,
hypertension,
dyslipidemia, polycystic ovary syndrome, birth
weight low for gestational age)
• Maternal history of diabetes or gestational
diabetes mellitus during the child's gestation
• Age at initiation of testing: 10 years or at onset of
puberty, if puberty occurs at a younger age
• Frequency of testing: every 3 years
BOX 44-7
Identification and Treatment of Hypoglycemia in the Dental Office
Symptoms of Hypoglycemia
Shakiness
Anxiety
Palpitations
Increased sweating
Hunger
Signs of Hypoglycemia
Tremors
Tachycardia
Altered consciousness (lethargy and obtundation or
personality change) Blood glucose level of less than 60
mg/dL
B Figure 44-4. A, Acanthosis nigricans affecting the back of
disease.5 The prevalence and severity of periodontal disease
increase in individuals with both type 1 (insulin deficient)
and type 2 (insulin resistant) forms of diabetes as compared
with individuals without diabetes. Clients with diabetes with
A1c levels of more than 8% have a greater increase in peri
odontal inflammation, attachment loss, and bone loss than
clients with diabetes with A1c levels of less than 8%.10 The
presence of hyperglycemia contributes to enhanced peri
odontal inflammation and alveolar bone loss in clients with
diabetes. Hyperglycemia progressively leads to an increase of
proinflammatory cytokines such as tumor necrosis factor
alpha, interleukin 6, and others that destroy connective tissue
and bone. The chronic increased cytokine levels augment
inflammatory tissue destruction. The control of hyperglyce
mia reduces the level of proinflammatory cytokines. Glyce
mic control is an integral part of the control of periodontal
disease in individuals with diabetes (see Figure 44-2).5
Uncontrolled diabetes increases dental caries risk as a result
of reduced saliva secretion and increased glucose in saliva.
Other oral complications associated with diabetes may
CHAPTER 44 n Diabetes Mellitus 835
General Principles
Treatment should be initiated as soon as possible, and
staff members should not wait for laboratory results or
for a response from a physician.
If the blood glucose levels are extremely low (eg, less than
40 mg/dL), a transfer for medical evaluation may be
needed as blood should be drawn and sent to the
laboratory for accurate blood glucose level
measurement because the precision of glucometers is
low at extremely low blood glucose levels.
Conscious Hypoglycemic Patient
Treat with 15 grams of simple carbohydrates
• One-half can of regular soda
 • 4 ounces of regular fruit juice
• 3 to 4 glucose tablets
Repeat finger-stick glucose test in 15 minutes.
If the blood glucose level is more than 60 mg/dL, the patient
should be
asked to eat a meal if it is close to mealtime. If it is not
close to mealtime, a mixed snack that includes
carbohydrates, proteins, and fat (eg, peanut butter and
jelly sandwich or graham crackers with peanut butter,
or milk and crackers) should be
given to maintain the blood glucose level. A pure
carbohydrate snack will cause the patient to revert
back to hypoglycemia quickly. Proteins and
carbohydrates in the snack provide sustained glucose
release.
If the blood glucose level is less than 60 mg/dL, repeat
treatment of 15 g of simple carbohydrates and check
the blood glucose level in 15 minutes. Continue this
protocol until the blood glucose level is higher than 60
mg/dL and then follow with a mixed snack.
Adapted from Alamo SM, Soriano YJ, Perez MGS: Dental considerations for the patient with diabetes, J Clin Exp Dent 3(1):e25-30, 2011.
BOX 44-8
Causes of Hyperglycemic Ketoacidotic Coma
Absolute Insulin Deficiency
• Newly diagnosed type 1 diabetes with beta-cell
depletion • Incorrect insulin dose (omitted or
decreased)
Relative Insulin Deficiency
• Stress states
• Infection
• Myocardial infarction
• Trauma
• Cerebrovascular accident
Drugs and Endocrine Disorders
• Steroids
• Adrenergic agonists
• Hyperthyroidism
• Pheochromocytoma
• Thiazide diuretics
BOX 44-9
Guidelines for Maintaining Glycemic Control in
Persons with Diabetes Mellitus
• Perform frequent self-monitoring of blood glucose. •
Obtain a regular A1c test twice a year if glycemic control is Postprandial glucose measurements should be made 1 to 2
†
hours after the beginning of the meal, which is generally when
good, four times a year if treatment or control has
the peak level occurs in persons with diabetes.
changed. • If not eating normally, replace carbohydrate
content of meals and snacks with sugar-containing drinks
or milk; ensure adequate fluid intake (2 to 3 L/day).
• If two preceding blood tests show a glucose level of
>200 mg/dL (11.1 mmol/L), contact the physician.
• Test for urine ketones if the blood glucose level is
>300 mg/dL. • If vomiting occurs or if the blood glucose
level is >300 mg/dL in the presence of positive ketones
Ask the patient to discuss the hypoglycemia with his or
her physician who is managing his or her diabetes
mellitus.
Unconscious Hypoglycemic Patient or Patient
Unable to Consume Oral Carbohydrate
With Intravenous Access
Administer 5 to 25 g of 50% dextrose immediately; it will be
followed by quick recovery.
Notify patient's physician immediately.
Without Intravenous Access
Apply glucose gel inside the mouth in a semiobtund patient
or treat with 1 mg of glucagon intramuscularly or
subcutaneously; the patient should regain
consciousness in 15 to 20 minutes.
Repeat the blood glucose test in 15 minutes.
Establish intravenous access and notify the
patient's physician immediately.
for >24 hours, call for urgent medical advice.
836 SECTION VII n Individuals with Special Needs
BOX 44-10
Glycemic Control: Summary of Recommendations for
Adults with Diabetes2
A1c <7.0%*
Preprandial capillary plasma glucose 70 to 130
mg/dL Peak postprandial capillary plasma
glucose† <180 mg/dL
Key Concepts for Setting Glycemic Goals
• Goals should be individualized.
• Children, pregnant women, and elderly clients
require special considerations.
• More or less intense glycemic goals may be
appropriate for certain individuals.
• Postprandial glucose may be targeted if A1c goals
are not met despite preprandial glucose goals
being reached.
*American Diabetes Association: Standards of medical care in
diabetes – 2012. Position statement, Diabetes Care
35(Suppl):4, 2012.
BOX 44-11
Levels of Blood Glucose for Care Planning
• <70 mg/dL: Too low; hypoglycemia. Provide 15 mg
of carbohydrates and wait 15 minutes. If condition
 continues, check with a physician. Risk for
emergency situations.*
• 70 to 79 mg/dL: Monitor at least once during dental
hygiene care appointment to prevent an emergency.
• 80 to 149 mg/dL: Normal levels.
• 150 to 200 mg/dL: Higher levels. Monitor infections,
insulin intake, stress, and food intake.
• >200 mg/dL: Too high; tendency toward
hyperglycemia. Check with physician. Risk for
emergency situations.*
*Indicates that dental hygiene care should not be provided at
these blood glucose levels.
BOX 44-12
When to Refer to a Physician
Refer the client to a physician for diagnosis and
treatment when the client has the following:
• Cardinal signs of diabetes (see Box 44-3)
• Symptoms that suggest diabetes
• Estimated fasting blood glucose level of ≥126
mg/mL • 2-hour postprandial blood glucose
level of ≥200 mg/mL • Long period since client
was last seen by a physician • Frequent
episodes of hypoglycemia
• Diagnosed diabetes plus signs and symptoms of
diabetes (not controlled)
• Type 1 diabetes with extreme hyperglycemia and
hypoglycemia • An infection anywhere in the body
Adapted from Little JW, Falace DA, Miller CS, Rhodus NL: Dental
management of the medically compromised patient, ed 8, St
Louis, 2013, Elsevier.
BOX 44-13
When to Consult with the Client's Physician
• Client has type 1 or 2 diabetes; determine level of
control • Client has complications such as renal
disease or cardiovascular disease
• Client takes insulin
• Client is not under good medical management
• Client is undergoing extensive periodontal or oral–
maxillofacial surgery
Adapted from Little JW, Falace DA, Miller CS, Rhodus NL: Dental ment, and oral biofilm control. However, the removal of
management of the medically compromised patient, ed 8, St
Louis, 2013, Elsevier.
affect nutrition by causing the person to select foods that are ulation and trauma are avoided to minimize the risk of post
easy to chew but nutritionally inadequate.
Diagnosis and Planning
A dental hygiene care plan focuses on the client's unmet be a risk factor in the progression of diabetes. Thorough peri
human needs and allows the clinician to manage risks of odontal therapy is indicated in clients with diabetes and peri
potential diabetic emergencies, thereby protecting the client odontitis to enhance control of both diseases. Evidence also
from health risks. Persons with diabetes may not be under suggests that antimicrobial treatment (specifically systemic
good glycemic control. In a study of 97 patients who entered
a dental clinic, 28 patients were found to be hyperglycemic
(ie, >130 mg/100 mL), and 2 were noted to be hypoglycemic
(ie, <70 mg/100 mL)11 (see Box 44-11). Appointments should
be brief to minimize anxiety and stress and to avoid interfer
ence with medication and eating schedules. Morning
appoint
ments are ideal because most people with diabetes are best
controlled at this time. An hour to an hour and a half after
breakfast is best for appointments to avoid the peak action
time of medication. Regular (short-acting) insulin, which is
often taken in the morning or at each meal, peaks within 2 to
3 hours after the injection. Oral hypoglycemic agents do not
cause peaks.
Therapeutic scaling and periodontal debridement are con
traindicated for people with uncontrolled diabetes (ie, blood
glucose levels of <70 mg/dL or >200 mg/dL)12 (see Box 44-11
and Figure 44-3). Clients should be treated in consultation
and referred to the physician of record for systemic evalua
tion. Dental hygiene care should not begin until the diabetic
condition is controlled. The short-term risk for infections in
persons with diabetes has been shown to increase with
average blood glucose levels of 200 to 230 mg/100 mL.12
When care is planned, interventions are likely to include the
following:
• Emphasis on oral biofilm control
• Health status monitoring
• Nutritional and dietary analysis (see Chapter 35) •
Fluoride and chlorhexidine therapies and the use of xylitol-
containing and amorphous calcium phosphate– containing
products (see Chapter 33)
• Salivary replacement therapy
• A longer initial appointment, a re-evaluation
appointment, and frequent periodontal maintenance
intervals13 • Collaboration with a physician and a certified
diabetes educator
A sample dental hygiene care plan is shown in the
Critical Thinking Exercises section. Other management
concerns are shown in Box 44-14.
Implementation
Therapeutic Scaling and Periodontal Debridement
Gingival and periodontal diseases associated with systemic
factors, which are often found in persons with diabetes, may
not respond well to subgingival scaling, periodontal debride
hard and soft deposits and bacterial toxins from tooth crown
and root surfaces is critical to the prevention of periodontal
infection in people with diabetes. Unnecessary tissue manip
operative infection and poor healing.
Severe periodontitis is associated with an increased risk
of poor glycemic control; therefore severe periodontitis may
subantimicrobial doses of doxycycline [20 mg twice daily])
has the potential to improve glycemic control after scaling
and root debridement in clients with diabetes.15
Increased glucose in gingival crevicular fluid may result
in the proliferation of oral microflora, thus increasing
periodontal disease and dental caries risk. The short-term
(ie, 3 to 4 months) response in the clinical parameters (ie,
probing depths, bleeding on probing, attachment levels,
subgingival
BOX 44-14
CHAPTER 44 n Diabetes Mellitus 837
microbiota) of clients with diabetes to nonsurgical
periodontal therapy appears to be equivalent to the response
seen in clients without diabetes; however, clients with
poorly controlled dia betes have more rapid clinical
attachment loss and a compro mised long-term response. At
5 years after nonsurgical periodontal therapy and surgical
Alterations in the Dental Hygiene Care of Older Adults with Diabetes
Potential Risks Related to Dental Hygiene Care
In older adult with controlled diabetes:
• Infection
• Poor wound healing
In older adult being treated with insulin:
• Insulin reaction
In older adult with poorly controlled diabetes:
• Early onset of complications related to cardiovascular
system, eyes, kidneys, nervous system, angina,
myocardial infarction, cerebrovascular accident, renal
failure, peripheral neuropathy, blindness, hypertension,
or congestive heart failure
Prevention of Medical Complications
Detection via the following:
• Health history
• Clinical findings
• Screening blood sugar
• Referral for medical diagnosis
Older adult receiving insulin:
• Prevent insulin reaction.
• Advise older adults to eat normal meals before
appointments. • Schedule appointments in the
morning or the midmorning. • Advise older adults to
inform you of any symptoms of insulin reactions
when they first occur.
• Have sugar in some form to give if an insulin reaction
occurs. • Older adults with diabetes who are being
Data from Little JW, Falace DA: Dental management of the medically compromised patient, ed 8, St Louis, 2013, Mosby. Table prepared by
Pamela P. Brangan.
838 SECTION VII n Individuals with Special Needs
periodontal treatment in combination with regular
periodontal maintenance therapy, clients with diabetes who
were well controlled had clinical attachment levels similar to
those of clients without diabetes.5
A client with well-controlled diabetes with no evidence of
infection does not require prophylactic antibiotic premedica
tion.10 In fact, antibiotic use in clients with diabetes may lead
to oral or systemic fungal infections. If an infection is present
either preoperatively or postoperatively, antibiotic therapy is
mandatory. Prophylactic antibiotic premedication before
periodontal instrumentation should be considered for the
client with uncontrolled diabetes after consultation with the
client's physician.
Diabetic microangiopathy causes blindness and kidney
disease. Therefore a client who is exhibiting eye disorders
may also have kidney disease. Medications that are excreted
renally may be retained in the body of the client with
diabetes who also has kidney disease, thereby causing toxic
effects. When local anesthetic agents are administered, the
minimal use of vasoconstrictors is required, because
epinephrine is capable of raising blood glucose.
treated with insulin and who develop oral infections may
require an increase in insulin
dosage; consult with a physician in addition to
performing local and systemic aggressive management
of infection. Drug considerations:
• Insulin: insulin reaction
• Hypoglycemic agents: on rare occasions, aplastic anemia
and similar conditions may occur
• In severe diabetics, avoid general anesthesia
Dental Hygiene Care Plan Modifications For older
clients with well-controlled diabetes, no alteration of
dental hygiene care plan is indicated unless complications
of diabetes are present, such as the following:
• Hypertension
• Congestive heart failure
• Myocardial infarction
• Angina
• Renal failure
Oral Complications
• Accelerated periodontal disease
• Periodontal abscesses
• Oral ulcerations and opportunistic infections
• Numbness, burning, or pain in the oral tissues
• Xerostomia
• Glossodynia
• Prolonged healing
Evaluation and Documentation
The periodontal tissues of the client with well-controlled dia
betes respond positively to nonsurgical periodontal therapy.
However, delayed healing may indicate hyperglycemia,
which decreases the normal healing actions of leukocyte
phagocytosis, chemotaxis, and adherence properties. Fre
quent oral assessments, periodontal maintenance, the evalu
ation of the client's response to dental hygiene care, and the
monitoring of diabetic control with current hemoglobin A1c
test results are recommended.
It is important to accurately record all data that are col
lected, the treatment that is planned and provided, and rec
ommendations and other information that are relevant to
client care and treatment. All relevant information and inter
actions between the client and the practitioner need to be
recorded objectively to enhance interprofessional communi
cation and to promote risk management.
CLIENT EDUCATION TIPS
• Relate the client with diabetes' greater risk of infection and
increased healing times to the need for oral biofilm
control.
• Teach the use of daily subgingival irrigation for the target
delivery of an antimicrobial agent or the twice-daily use
of an American Dental Association–accepted
antimicrobial mouth rinse; the use of an antiplaque and
antigingivitis dentifrice; the use of caries-control products
(eg, fluoride mouth rinse, xylitol mints and chewing gum,
calcium- and phosphorus-based products); and the use of
saliva replace ment therapy (eg, artificial saliva, sucking
on ice chips, xylitol gum and mints).
• Discuss the maintenance of dentition for chewing healthy
foods and the fact that diet and nutrition are essential to
diabetes control.
• Emphasize that individuals with diabetes may not tolerate
dentures because of their oral conditions.
• Stress meticulous daily oral biofilm removal as a method
to control oral disease progression and diabetes. Oral
health contributes significantly to long-term systemic
health in the client with diabetes.
LEGAL, ETHICAL, AND SAFETY ISSUES
• Collaborate with the physician when healing is delayed
after periodontal instrumentation.
• Collaborate with a certified diabetes educator, a health
education consultant, or staff at hospital-based diabetes
management centers.
• Dental hygienists can collaborate with diabetes manage
ment centers, for example, by sharing their expertise in
the area of oral disease prevention and by providing
client education, oral health screenings, and referrals.
KEY CONCEPTS
• Many people with diabetes do not know that they have
the condition.
• Type 2 diabetes can be prevented or delayed with actions
taken by the individual who is at risk. Dental hygienists
can make a difference, and resources are available to
help.
• Type 1 diabetes involves about 5% of the diabetic popula
tion. These individuals need to take insulin injections or
use an insulin pump.
• The presence of certain human leukocyte antigens creates
a genetic predisposition for the autoimmune cause of
type 1 diabetes mellitus.
• Type 2 diabetes affects about 90% to 95% of clients with
diabetes. These individuals usually respond well to
weight reduction, dietary management, exercise, and oral
medications.
• Insulin resistance or a defect in insulin secretion is the
cause of type 2 diabetes. The risk of developing type 2
diabetes increases with obesity, age, inactivity, history of
gestational diabetes mellitus (GDM), hypertension, and
dyslipidemia.
• GDM occurs in 4% of pregnancies. Those who are at high
risk include women with obesity, a family history of dia
betes, and previous GDM.
• GDM usually disappears after birth because the condition
is a consequence of the normal anti-insulin effects of preg
nancy hormones and the diversion of natural glucose to
the fetus.
• Without insulin, glucose remains in the blood (hypergly
cemia) rather than being stored or used by the cells to
produce energy. The suspicion of diabetes is gleaned
from a history of symptoms: glucosuria, polyuria,
polydipsia, weight loss, polyphagia, and blurred vision.
• Diabetes mellitus causes severe multisystem, long-term
complications. Kidney and eye diseases predominate
with type 1 diabetes mellitus; atherosclerosis predomi
nates with type 2; peripheral nerve disease occurs with
both.
• Hypoglycemia, which is the most common emergency in
persons with type 1 diabetes mellitus, results from insulin
excess and glucose deficiency.
• Hyperglycemic ketoacidosis requires hospitalization to
correct fluid and electrolyte imbalances.
• Infection is the most common precipitating factor of
hyperglycemic ketoacidosis.
• Well-controlled diabetes occurs when the individual's
blood glucose level is within the normal range as a result
of a careful balance of medication, diet, and exercise.
• Emotional stress (which can be induced in the oral health
care setting) causes a release of epinephrine, which
mobilizes glucose in the body, thereby contributing to a
hyperglycemic condition becoming ketoacidotic.
• The strict application of oral care protocols increases the
chances of achieving good clinical outcomes for individu
als with diabetes.
• Dental hygiene care should not be provided when blood
glucose levels are less than 70 mg/dL or more than 200
mg/dL.
• When administering local anesthetics, it is recommended
to use the lowest dose and lowest concentration of a vaso
constrictor that produces the desired effect, because epi
 nephrine is an insulin antagonist that is capable of raising
the blood glucose level. Monitor the client for signs of
hyperglycemia.
Client with Diabetes
• A client with well-controlled diabetes with no evidence of
infection does not require prophylactic antibiotic
premedication.
CRITICAL THINKING EXERCISES
1. Find evidence-based information on the Internet about
periodontal disease and diabetes that can be used to
educate clients.
2. Review the office emergency kit. What in the emergency
kit would be used if the diabetic client were to become
disoriented and confused and was reporting that he or
she took his or her insulin but did not have time to eat
breakfast?
3. At the local pharmacy, purchase glucose tablets that can
be kept in the treatment areas. When would these glucose
tablets be indicated?
4. Read the following scenario and dental hygiene care plan,
and then answer the questions that follow.
CHAPTER 44 n Diabetes Mellitus 839
5. Consult with the dentist regarding possible systemic
doxy cycline therapy.
6. Monitor the client's oral health behavior through frequent
evaluation.
7. Schedule follow-up evaluation.
Evaluative Statements
1. Client explains the two-way relationship of diabetic
control and periodontal infection. Tujuan terpenuhi.
2. Client demonstrates oral health behavior congruent with
the maintenance of glycemic control. Tujuan terpenuhi. 3.
Client decreases gingival bleeding by 75% to enhance
glycemic control. Tujuan terpenuhi.
DENTAL HYGIENE DIAGNOSIS GOAL OR EXPECTED
BEHAVIOR

Bettie Douman is a 40-year-old sugar test results average 180 mL/dL, and (undernutrition and increased frequency
professional secretary who is employed her 3-month A1c level was 8%. Bettie of carbohydrate consumption)
full-time at a large university. She has walks the family dog at a fast pace every By 2/1, client verbalizes the need for
had type 1 diabetes mellitus for 20 years. evening for 30 minutes. She is adequate nutrition.
Bettie has been using an insulin pump for embarrassed that she has not been careful By 2/1, client participates in dietary
2 years, and this has greatly lowered her about eating counseling.
blood glucose levels. Her 24-hour blood Unmet need for skin and mucous By 4/1, client increases nutrients in the
membrane integrity of the head and neck diet.

a nutritionally balanced diet for the last year and a half.
During Bettie's examination, the dental hygienist notes a low
risk for dental caries and generalized moderate gingival
bleeding on probing, with localized 4- and 5-mm pocket
depths in the molar areas.
• What changes would you make, if any, to the following
dental hygiene care plan?
• What emergency would you prepare for when treating
this client? What steps would you take to prevent this
emergency?
• Develop a detailed self-care plan for this client.
Dental Hygiene Interventions
1. Relate nutritional needs for diabetes control and integrity
of the periodontium.
2. Relate the frequency of eating to the need for oral biofilm
control.
3. Relate the importance of a healthy dentition and periodon
tium to optimal diet consumption and glycemic control. 4.
Design oral biofilm control measures that are consistent with
the client's frequency of carbohydrate consumption. 5. Refer
the client to a certified diabetes educator for dietary
prescription and meal planning.

Evaluative Statements
DENTAL HYGIENE DIAGNOSIS GOAL OR EXPECTED
1. Client reports normal blood glucose levels and 1% point

BEHAVIOR
Unmet need for conceptualization and By 12/1, client verbalizes the role of oral individual dietary pre scription and meal
problem solving infection in glycemic control. plan. Tujuan terpenuhi.
By 1/1, client decreases bleeding points
REFERENSI
Unmet need for responsibility for oral by 75%.
health By 1/1, client reports improvement in 1. Centers for Disease Control and Prevention:

Unmet need for skin and mucous
membrane integrity
By 12/1, client explains the role of oral
biofilm in causing periodontal disease.
hyperglycemia through the control of
periodontal disease.
reduction in A1c tingkat. Tujuan
terpenuhi.
2. Client indicates compliance with
Diabetes data and trends, 2012. Available at:
http://www.cdc.gov/diabetes/
statistics/diabetes_slides.htm. Accessed
November 1, 2012.
2. American Diabetes Association: Executive
summary: Standards of medical care in
diabetes—2012, Diabetes Care 35(Suppl 1):4, 3. Inzucchi SE, Sherwin RS: Type 2 diabetes
2012. mellitus. In Goldman L, Schafer A, eds: Cecil
Dental Hygiene Interventions
1. Present “bleeding gums” as an indicator of a bacterial
infection that further complicates glycemic control;
explain diabetes as a risk factor for periodontal disease.
2. Demonstrate oral biofilm control measures. 3. Discuss
antimicrobial agents for the control of plaque and
inflammation and the technique for their application. 4. Scale
and root debride with ultrasonic and hand instrumentation.
Saunders.
4. Centers for Disease Control and Prevention: National diabetes fact
sheet, national estimates and general information on diabetes and
prediabetes in the United States, 2011. Available at: http://
www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed
October 3, 2012.
5. Mealey BL, Oates TW; American Academy of Periodontology:
Diabetes mellitus and periodontal diseases, J Periodontol 77:1289,
2006.
6. Kidambi S, Patel S: Diabetes mellitus: considerations for den
tistry, J Am Dent Assoc 139(Suppl):8S, 2008.
840 SECTION VII n Individuals with Special Needs
7. Preshaw PM, Alba AL, Herrera D, et al: Periodontitis and diabe
tes: a two-way relationship, Diabetologia 55:21, 2012. 8. Mealey BL:
The interactions between physicians and dentists in managing the
care of patients with diabetes mellitus, J Am Dent Assoc
139(Suppl):4S–7S, 2008.
9. Campbell PR, Shuman D, Bauman DB: ADHA Graduate
Pageburst Integrated Resources
As part of your Pageburst Digital Book, you can access the following
Integrated Resources:
Key Term Flashcards
Web Resources
Cancer
Joan M. Davis
COMPETENCIES
1. Explain terms related to cancer, cancer therapies, and
medicine, ed 24, Philadelphia, 2011,
Student/ Faculty Research Project: health history, J Dent Hyg
67:378, 1993.
10. Engebretson SP, Hey-Hadavi J, Ehrhardt FJ, et al: Gingival cre
vicular fluid levels of interleukin-1β and glycemic control in
patients with chronic periodontitis and type 2 diabetes, J Peri
odontol 75:1203, 2004.
11. Rhodus NL, Vibeto B, Hamamoto DT: Glycemic control in
patients with diabetes mellitus upon admission to a dental
clinic: considerations for dental management, Quintessence Int
36:474, 2005.
12. Little JW, Falace DA, Miller CS, et al: Dental management of the
medically compromised patient, ed 8, St Louis, 2013, Elsevier. 13.
Gurenlian JR, Ball WL, LaFontaine J: Diabetes mellitus: promot ing
collaboration among health care professionals, J Dent Hyg
83(Suppl):3, 2008.
14. Lalla E, Kunzel C, Burkett S, et al: Identification of unrecognized
diabetes and pre-diabetes in a dental setting, J Dent Res 90:855,
2011.
15. Gilowski L, Kondzielnik P, Wiench R, et al: Efficacy of short-
term adjunctive subantimicrobial dose doxycycline in diabetic
patients—randomized study, Oral Dis 18:763, 2012.
EVOLVE RESOURCES
Please visit http://evolve.elsevier.com/Darby/hygiene
for additional practice and study support tools.
CHAPTER 44 n Diabetes Mellitus 840.e1
oral healthcare for the cancer patient.
2. Discuss the incidence and risk factors associated with
cancer and oral cancer.
3. Describe the modes of cancer and oral cancer
therapy.
4. Describe oral considerations of general cancer therapy
and oral complication management.
5. Discuss oral cancer–specific therapies, including the
rationale for bisphosphonate use and the potential for
osteonecrosis.
6. Explain the dental hygiene process of care for clients
with cancer, including development of a dental hygiene
 care plan for clients before, during, and after cancer
therapy.
Today clients who are in need of oral care are living longer
and may very well have survived—or may be currently
coping with—a life-threatening disease such as cancer. The
dental hygienist will need to understand the oral, physical,
and psychologic issues surrounding a client who is currently
battling or who has survived cancer. Cancer is not a single
disease but rather a broad classification of more than 100
types of diseases. The common element in cancer is the
abnor mal and unrestricted growth of cells that can invade
and destroy surrounding normal body tissues, sometimes
spread
ing to other parts of the body. The difference between a
malig nant and a benign neoplasm is that a benign tumor is
usually circumscribed and encapsulated; it usually grows
slowly, and it is composed of cells that resemble the tissue
from which it arises. A malignant neoplasm or cancer not
only infiltrates locally but also has the potential to
metastasize or spread to distant sites. The cells are usually
atypical or dysplastic, and they may not resemble the parent
tissue. The branch of medi
cine that studies and treats cancer is called oncology, and
the physician specialist is an oncologist.
Kanker
Incidence
To many people, a cancer diagnosis evokes immediate fear
of suffering and death. Fortunately there has been a
significant decline in cancer deaths during recent years,
primarily as a result of a decrease in tobacco use and an
increase in cancer screening, early detection, and effective
treatment.1 Figure
45-1 lists the leading types of new cancer cases and deaths
according to the American Cancer Society 2012 estimates. 2 Of
CHAPTER
45
the estimated 577,190 deaths annually from cancer, 173,200
842 SECTION VII n Individuals with Special Needs
Leading Sites of New Cancer Cases and Deaths – 2008 Estimates
Estimated New Cases*
Male 241,740 (29%)
Prostate Lung and bronchus 116,470 (14%)
deaths are caused by tobacco use; another 190,472 deaths are
caused by obesity, poor nutrition, and inactivity; and many
of the remaining deaths are caused by infectious agents and
sun exposure. Although anyone could potentially develop
cancer, approximately 77% of newly diagnosed cancer cases
occur among people who are 55 years old and older. When
cancers are left untreated, they result in significant
morbidity and death. In the United States, only heart disease
causes more deaths in adults.2
Risk Factors
Carcinogenic or cancer-causing influences may be environ
mental, behavioral, viral, or genetic, thus resulting in poten
tial genetic damage. The National Cancer Institute implicates
tobacco use as the single major cause of preventable cancer
deaths. Other environmental carcinogenic agents include
alcohol, chemical exposure, radon, radiation, sunlight, hor
mones, and asbestos. Behavioral factors that could lead to
the development of cancer include tobacco use, alcohol
abuse, an overweight or obese condition, poor nutrition, and
inactivity. There is also evidence that certain viruses (eg,
hepatitis B virus, human immunodeficiency virus, human
papillomavi rus, Helicobacter pylori) may be linked to the
development of cancers, especially cancers of the liver,
nasopharynx, cervix, and lymphatic system.2 Many of these
risk factors could be minimized through behavioral changes
as well as the use of vaccines and antibiotics.
Common Signs and Symptoms
During the early stages, most cancers exhibit no symptoms.
Box 45-1 lists the most common presenting signs and symp
toms of early cancer, which vary depending on cancer type.
Pain is not often a symptom during the early stages of
cancer. A person who has one of the seven common signs of
cancer for more than 2 weeks should see a doctor promptly.
Oral Cancer Incidence and Risk Factors In 2012
the American Cancer Society estimated that approxi mately
40,250 new cases (28,540 men and 11,710 women) of oral or
pharyngeal cancer would be diagnosed in the United States.
Oral cancer incidence rates declined 1% for women and
remained stable in men between 2004 and 2008, primarily as
a result of the decrease in smoking in the United States.
Unfortunately, the incidence of human papillomavirus–
related cancers has increased over the past decade.3 These
cancers are primarily found in the tongue and the oropharyn
geal area (ie, the throat, the back third of the tongue, the soft
palate, the side and back walls of the throat, and the tonsils)
of adults who are less than 45 years old.2
841
Estimated Deaths
Colon and rectum Urinary bladder
73,420 (9%) 55,600 (7%)
Melanoma of the skin 44,250 (5%)
Kidney and renal pelvis 40,250 Non-Hodgkin lymphoma 31,970 12,040 (4%) Uterine corpus
(5%) (4%) 8,010 (3%)
Urinary bladder
Non-Hodgkin lymphoma 38,160 Kidney and renal pelvis 24,520 10,510 (3%) Liver and intrahepatic bile duct
(4%) (3%) 6,570 (2%)
Non-Hodgkin lymphoma 10,320
Oral cavity and pharynx 28,540 Ovary (3%) Pancreas
(3%) 22,280 (3%) Female 22,090 (3%)
Male
Leukemia All sites
Lung and bronchus
26,830 (3%) 848,170 (100%)
Lung and bronchus 72,590 (26%)
Female Pancreas
87,750 (29%)
Breast 21,830 (3%)
Breast Prostate 39,510 (14%)
226,870 (29%) 28,170 (9%) All sites
Colon and rectum 790,740 (100%)
Lung and bronchus 109,690 (14%) Colon and rectum 25,220 (9%) Kidney and renal pelvis 8,650 (3%)
26,470 (9%)
Colon and rectum Pancreas All sites
70,040 (9%) Pancreas 18,540 (7%) 301,820 (100%)
18,850 (6%) Brain and other nervous system
Uterine corpus Ovary 5,980 (2%)
47,130 (6%) Liver and intrahepatic bile duct 15,500 (6%)
13,980 (5%)
Thyroid
Leukemia
43,210 (5%) Leukemia
10,040 (4%) All sites
13,500 (4%)
Melanoma of the skin 32,000 (4%) 275,370 (100%)
Non-Hodgkin lymphoma 8,620
Esophagus (3%)

*Excludes basal and squamous cell skin cancers and in situ carcinoma except urinary bladder.

Figure 45-1.American Cancer Society incidence and deaths by site and sex, 2012 estimates. (From the American Cancer
Society: Cancer facts and figures 2012. Available at:
http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-031941.pdf. Accessed
November 19, 2012.)

BOX 45-1 that is usually painless • Erythroplakia patch (velvety,

Early Signs and Symptoms of Cancer
• Changes in bowel or bladder habits
• A sore that does not heal
• Unusual bleeding or discharge
• A thickening or a lump in the breast or elsewhere
• Indigestion or difficulty swallowing
• Obvious changes in a wart or mole
• A nagging cough or hoarseness
From the American Cancer Society: Cancer facts and figures
2012. Available at:
http://www.cancer.org/acs/groups/content/@epidemiologysurve
ilance/documents/ document/acspc-031941.pdf. Accessed
November 19, 2012.
Approximately 9 out of every 10 oral malignancies are
squamous cell carcinomas, which often manifest as a pain
less swelling or lump in the oral cavity or the pharynx and
larynx area (Box 45-2). The median age of a person with
newly diagnosed oral cancer is 62 years.4 Of the newly diag
nosed cases in 2012, 5440 men and 2410 women were
expected to die from these cancers. The overall 1-year
survival rate for all stages of oral cancer is about 84%, with a
5-year survival
BOX 45-2
Common Signs of Oral Cancer
• A swelling, lump, growth, or area of induration or
hardness anywhere in or about the mouth or neck
deep red)
• Leukoplakia patch (white or red-and-white patch)
• Any sore (ulcer, irritation) that does not heal
after 2 weeks • Repeated bleeding from the
mouth or throat
• Difficulty swallowing or persistent hoarseness
rate of 61%.2 Even though there has been a slight decline in
incidence, oral cancer screening remains a very important
component of dental hygiene care, as do continued efforts to
educate the public about this life-threatening disease.
Specific oral cancer risk factors include the use of all
tobacco products (ie, cigarettes, cigars, pipes, and smokeless
tobacco) and alcohol (Box 45-3). Cigarette smokers have an
approximately tenfold-increased chance of developing squa
mous cell carcinoma as compared with people who have
never smoked.5 The risk of developing any cancer increases
with both the amount and duration of tobacco product use.
BOX 45-3
Oral Cancer Risk Factors
• Use of tobacco
• Prior oral cancer lesion
• Use of alcohol
• Older age
• Frequent sun exposure
 • Low consumption of fruits and vegetables
• Human papillomavirus
From the American Cancer Society: Cancer facts and figures
2012. Available at:
http://www.cancer.org/acs/groups/content/@epidemiologysurve
ilance/documents/ document/acspc-031941.pdf. Accessed
November 19, 2012.
Individuals who smoke and drink alcohol heavily account
for approximately 80% to 90% of oral cancer cases in the
United States.
The prognosis for a specific oral cancer is highly variable
and depends on the stage and location of the disease when it
is first diagnosed. National Cancer Institute data collected
between the years 2002 and 2008 demonstrated that persons
with a small, localized oral squamous cell cancer have an
82% 5-year survival rate as compared with only a 34% rate
among those with late-stage oral cancer. 4 Early detection is
the key to survival. The most common intraoral sites for
squamous cell cancer are the lateral borders and the ventral
surfaces of the tongue, the floor of the mouth, and the
oropharynx. Any of the signs and symptoms that persist for
more than 2 weeks after the removal of potentially irritating
factors or the appli cation of therapeutic measures must be
considered to result from cancer until the condition is
proven benign by biopsy (ie, the surgical removal of all or
part of the lesion) and microscopic evaluation.
Cancer Therapy
Forms of Cancer Therapy
The choice of cancer treatment is dependent on the type and
stage of cancer. Therapy may include one or a combination
of the following: chemotherapy, bone marrow and blood
transplantation, radiation, surgery, hormone therapy, and
immunotherapy. Some cancers respond to a single mode of
treatment, whereas others require multimodal treatment
strategies. The goal of cancer treatment is to remove or
totally destroy the malignant cells in the body.
Unfortunately, treat ments available today are not able to
target only the cancer cells, and normal healthy cells must
sometimes be destroyed during treatment. This may result
in significant psychologic stress as well as physical
morbidity (illness) or death.
Chemotherapy
Chemotherapy is the use of drugs for the treatment of
cancer. Combinations of chemotherapeutic agents have
resulted in significant improvements in the cure rates of
some cancers. Other cancers are not cured by chemotherapy
alone, so toxic drugs are used in combination with surgery,
radiation, or both to destroy rapidly dividing cancer cells
that may spread systemically.
CHAPTER 45 n Cancer 843
The most common complication of chemotherapy is infec
tion. The high risk of infection is a result of myelosuppres
sion, which is the suppression of bone marrow that results
in, among other things, the destruction of white blood cells,
thereby leading to a decreased immune response. Bacterial,
fungal, and viral infections often increase with chemother
apy; these infections affect both local and distant body sites
and lead to potential sepsis and death. Oral infections such
as periodontal disease, pulpal disease, and pericoronal
disease can significantly increase the likelihood of sepsis
occurring if they are not treated before chemotherapy
begins. Other complications of chemotherapy include
electrolyte imbalances, bleeding, hemorrhage, and acute
toxicity from the drugs, including nausea and vomiting,
photosensitivity, central nervous system dysfunction,
alopecia (hair loss), and poor nutritional status.
Chemotherapy is physically demanding, and it also pro
duces a great deal of stress. Individuals who are undergoing
cancer therapy need support from family members, friends,
and caregivers who are good listeners and who encourage
hope.
Bone Marrow and Blood Stem Cell
Transplantation
Bone marrow and blood stem cell transplantation (BMT) is
a therapeutic procedure that is used to treat a variety of
hema tologic diseases, including aplastic anemia, leukemias,
lym phomas, neuroblastoma, and immunodeficiency
diseases. BMT is also used to treat some solid tumors.
BMT begins with the donation of normal bone marrow or
peripheral blood stem cells. The individual with cancer then
goes through a “conditioning phase” during which superle
thal doses of chemotherapy and sometimes total body irra
diation are administered. The goal is to destroy all of the
malignant cells and to suppress the immune system to
permit engraftment of the normal bone marrow. After clients
have been conditioned, the marrow or peripheral blood
stem cells are intravenously infused into their blood. If
engraftment takes place, the cells begin to reproduce new
marrow within 2 to 4 weeks.
A significant problem that exists for clients who receive
marrow or peripheral blood stem cells from another
individual (allogeneic bone marrow transplant) is graft
versus-host disease (GVHD). This disease results from an
immunologic reaction during which the donor cells react
against the host tissue antigens. If this occurs within the first
100 days after transplant, it is called acute GVHD, and it is
characterized by dermatitis, enteritis, and hepatitis. If these
characteristics occur after the first 100 days, it is called
chronic GVHD, and it has manifestations similar to those of
autoimmune disorders. These may include skin diseases,
keratoconjunctivitis, oral mucositis (mucosal edema, inflam
mation, and ulcerations), salivary gland dysfunction or
xerostomia (dry mouth), esophageal and vaginal strictures,
pulmonary insufficiency, intestinal problems, and chronic
liver disease. Both forms of GVHD can result in fatal
infections. To prevent GVHD, various types of immunosup
pressive therapy are used.
During the first 30 days after transplantation, the client
experiences cytotoxic and immunosuppressive oral manifes
tations from the chemoradiotherapy conditioning. These
 may include severe mucositis, ulceration, hemorrhage, therapy and che motherapy, the dental hygienist plays a key role in
infection, helping clients with cancer to understand that good oral hygiene
844 SECTION VII n Individuals with Special Needs
improves clients' quality of life and the likelihood that they will be
and salivary gland dysfunction. Infections during the first 30
days intensify the mucositis and ulcerations, thereby
opening a portal of entry for organisms into the blood.
During the next several months, the client's acute mani dental hygienist reviews toothbrushing, interdental cleaning
festations begin to resolve unless GVHD develops. Common
complaints with GVHD include xerostomia and mucositis.
In addition, there may be evidence of lichen planus–like or
lupus-like lesions, and these may sometimes become erosive.
Generalized atrophy of the mucosa and changes that are con
sistent with scleroderma may be seen. Viral infections,
includ ing herpes simplex virus and fungal infections, are
common.
After the first 100 days after transplantation, persons with
no evidence of GVHD usually do not have any oral com
plaints other than varying degrees of xerostomia. Those
persons with persistent xerostomia may develop rapid tooth
demineralization and oral infections. Patients who are sched
uled for BMT should undergo a thorough oral and dental
evaluation and necessary treatment before transplant. All
potential sources of infection and irritation should be
treated, because chronic asymptomatic oral infections may
become acute during immunosuppression or GVHD and
may lead to sepsis and even death.
Head and Neck Radiation and
Surgical Treatment
Both head and neck radiation and surgical treatment for oral
cancer have unique client care issues that differ somewhat
from chemotherapy and BMT. These specific issues are
addressed later in this chapter. The following section
reviews oral side effects that are common to many cancer
therapies.
Oral Considerations of General
Cancer Therapy
Oral side effects of cancer treatment that result from the unin
tended disruption and destruction of healthy tissue can be
so debilitating that patients may tolerate only lower, less
effective doses of cancer therapy, or they may delay or dis
continue scheduled treatments. Preventing and managing
oral complications helps to support optimal cancer treatment
and enhances patient survival and quality of life. The
National Institutes of Health formally recognized the critical
role that dentists and dental hygienists play in the overall
care of the individual with cancer.6 Dental hygiene care is
critical to the prevention or amelioration of the oral
complications associ ated with all forms of cancer treatment.
All patients receiving radiation for head and neck malig
nancies, 80% of BMT recipients, and 40% of patients
receiving chemotherapy for any malignancy have oral
complications. The risks for oral complications vary with the
treatment regimen (Box 45-4). Some oral complications occur
only during cancer therapy, whereas others, such as
xerostomia and salivary gland dysfunction, may be lifelong
after radia tion therapy. Before, during, and after radiation
care prevents or reduces oral complications, which in turn
able to tolerate optimal doses of cancer treatment (Box 45-5). For
example, the dental hygienist collaborates with the client to
establish an oral self care regimen to protect the mouth
tissues and to minimize oral complications. To that end, the
techniques, and other
BOX 45-4
Risk Levels for Oral Complications
Low Risk
• Patients receiving mildly myelosuppressive
chemotherapy that mildly decreases the immune
system
Moderate Risk
• Patients receiving single-agent or outpatient therapy
High Risk
• Patients undergoing head and neck radiation
for oral and pharyngeal cancer
• Patients receiving stomatotoxic chemotherapy
that results in prolonged myelosuppression
Adapted from the US Department of Health and Human Services,
National Institutes of Health: Oral complications of chemotherapy
and head/neck radiation (PDQ), 2012. Available at:
http://www.cancer.gov/cancertopics/pdq/supportivecare/
oralcomplications/HealthProfessional and
http://www.cancer.gov/cancertopics/pdq/ supportivecare.
Accessed November 19, 2012.
BOX 45-5
Benefits of Good Oral Hygiene Care Before and
During Cancer Therapy
• Reduces the risk and severity of oral complications
• Improves the likelihood that the client will tolerate
optimal doses of cancer treatment
• Prevents oral infections that could lead to potentially
fatal systemic infections
• Prevents or minimizes complications that can
compromise nutrition • Prevents or reduces oral pain
• Prevents or reduces the incidence of bone
necrosis in clients undergoing radiation
• Preserves oral health
• Improves quality of life
Adapted from the US Department of Health and Human Services,
National Institutes of Health: Oral complications of chemotherapy
and head/neck radiation (PDQ), 2012. Available at:
http://www.cancer.gov/cancertopics/pdq/supportivecare/
oralcomplications/HealthProfessional and
http://www.cancer.gov/cancertopics/pdq/ supportivecare.
 Accessed November 19, 2012. potential survival cannot be overemphasized.

Oral Complications of Chemotherapy and Bone

approaches (eg, the use of antimicrobial and fluoride mouth
rinses and fluoride gel) to keep the mouth as moist and clean
as possible to reduce risk of dental caries, oral infection, and
pain (Table 45-1). The importance of the role of the dental
hygienist in enhancing the client's quality of life and
Marrow and Blood Stem Cell Transplantation
Not all chemotherapy protocols result in oral manifestations,
but many have either a direct or indirect effect on the mouth.
Oral problems related to myelosuppression may be signifi
cantly prevented or diminished through aggressive preven
tive dental hygiene interventions. The oral manifestations of
CHAPTER 45 n Cancer 845

TABLE 45-1
Oral Hygiene Products Used During Cancer Therapy

Product Description Indication, Rationale, or Use Precautions

Toothbrushes Several are available with
extra-soft or super-soft bristles:
such as Rx Ultra Suave (PHB,
Inc, www.phbdirect.com,
1-800-676-4025) and Biotene
SuperSoft (Laclede, Inc,
www.laclede.com, 1-877-522-
5333). A child-size brush may
be helpful for clients with
limited mouth opening. Some
brushes are available with
suctioning capabilities.
Floss Unwaxed or waxed versions are
available.
Dentifrices Commercial dentifrices without strong flavoring
agents can be
used. Paste made from baking
soda and water is an
Plaque biofilm removal should be hospital-supplied, hard,
performed after meals when clients are unpolished, bristled
not severely compromised from surgery, toothbrushes. The benefits versus the
chemotherapy, or bone marrow risks of brushing may need to be
transplantation. The tongue must also be assessed for clients with severely
brushed, especially by clients who are compromised conditions.
receiving soft or liquid diets.
Assess the client's dexterity, and assist if
necessary.
Flossing is important for plaque biofilm Discontinue only when the client is at
removal at least once per day. high risk for
Beware of inexpensive, bleeding and bacteremia.
alternative.
These help with plaque biofilm removal. Strong flavoring
agents may intensify mucositis. Fully rinse
baking soda residue from the
oral cavity.

Foam or sponge sticks They are used to cleanse the be dipped in a chlorhexidine soak them in solution; the
These are alternatives to oral cavity only when the client solution for greatest sponge top may fall off the
toothbrushes that are available cannot use a manual efficacy. These sticks may also stick, and the client could
from some medical supply toothbrush because of pain be used to apply topical aspirate it. These products
companies. Some are associated with ulcerated medications. may abrade friable tissue. Do
impregnated with cleaning tissues or when the platelet These sticks do not adequately not use lemon–glycerin swabs,
agents. count is <20,000/mm3. If foam remove plaque biofilm. Do not because they are acidic and
or a sponge is used, it should drying to the tissues.
Gauze Gauze is another alternative to a as a result of pain associated with chloride to 16 oz of water), or baking
toothbrush. Use 2 × 2 or ulcerated soda solution. Wrap the gauze around
4 × 4 squares. tissues or when toothbrushing the finger and cleanse the teeth, tongue,
Gauze is used to cleanse the oral cavity precipitates bleeding. Moisten the gauze and tissues.
only when toothbrushing is not possible in water, saline 0.9% (1 tsp of sodium Gauze does not adequately remove
plaque biofilm.

Baking soda and saline rinse solution made up of 12 tsp of 16 oz of water. used to cleanse the mouth
This is a mucolytic cleansing baking soda, 14 tsp of salt, and An alkaline soothing rinse is every 2 to 4 hours for clients
with mucositis, xerostomia, or rinsing of a painful mouth. content. Instruct the client not Continued
thick secretions or after Rinse the mouth with plain to swallow the solution. This is
emesis. It may be used in an water after use. not to be used by clients on
irrigation bag to assist with the This mixture has a high sodium sodium-restricted diets.
846 SECTION VII n Individuals with Special Needs

TABLE 45-1
Oral Hygiene Products Used During Cancer Therapy—cont'd

Product Description Indication, Rationale, or Use Precautions

Topical anesthetics These palliative Orabase and benzocaine gag reflex, thereby
agents include over-the-counter products (www.colgateprofessional.com), resulting in the aspiration of food. Over-
such as alcohol-free Benadryl which are available over the the-counter agents or rinses may not
mixed in equal parts with a counter at most pharmacies. provide adequate relief from severe oral
coating agent such as Maalox They are used to control the pain ulcerations. The client's oncologist may
to create a rinse. Other agents associated with mucosal ulcerations. prescribe
that are helpful are topical Topical anesthetics may decrease the analgesics or narcotics.

Saliva replacement and www.kingswood-labs.com/ drugs (pilocarpine) for the substitutes to be unacceptable
xerostomia palliation moistir.html, 1-800-968-7772). systemic stimulation of in taste and too expensive.
Saliva substitutes include Dietary guidelines should functional salivary gland tissue Clients should be discouraged
over-the-counter rinses and encourage the intake of and mechanical stimulation from using tobacco products,
gels such as Oral Balance Gel high-moisture foods, oily with xylitol-containing chewing consuming excessive alcohol,
(Laclede, Inc, foods, and sugar- and acid- gum or candy. and using alcohol-containing
www.laclede.com, 1-877-522- free foods. Saliva stimulants They are used for the palliation mouthwash because these
5333) and Moi-Stir (Kingswood include of xerostomia and dysphagia. products promote dry mouth
Labs, pharmacologic prescription Clients may find saliva or may be irritating.

Chlorhexidine gluconate
0.12%
This is a bactericidal mouth rinse. These
are prophylactic or therapeutic mouth
rinses that are used to reduce plaque
biofilm and oral microbes. Rinse for 30
seconds with 1 capful twice daily.
Products that are available in United
States are prepared with alcohol and mayhigh concentration of
be
irritating. This agent should be used only
when mechanical plaque control is
inadequate. It may cause staining of the
teeth, which is removable with dental
prophylaxis. It may also alter taste may intensify mucositis.
perception. Alcohol-free mouthwashes are
available (ie, Biotene,
Commercial
Pro-Health, and Clear Choice).
mouthwashes
These should be heavily diluted with
water.
They may serve as mouth fresheners.
Most commercial mouthwashes have a
BOX 45-6
alcohol or phenol, which can
be very drying and irritating to
tissues unless diluted heavily
with water. Flavoring agents
BOX 45-7
CHAPTER 45 n Cancer 847

Oral Complications of Chemotherapy • Infection

• Bleeding or hemorrhage
• Oral mucositis • Xerostomia or salivary gland dysfunction
• Neurotoxicity • Dental caries or demineralization
 • Altered tooth development
Adapted from the US Department of Health and Human Services,
National Institutes of Health: Oral complications of chemotherapy
and head/neck radiation (PDQ), 2012. Available at:
http://www.cancer.gov/cancertopics/pdq/supportivecare/
oralcomplications/HealthProfessional and
http://www.cancer.gov/cancertopics/pdq/ supportivecare.
Accessed November 19, 2012.
Figur
e 45-2.Radiation mucositis. (From Regezi JA, Sciubba JJ,
Jordan RCK: Oral pathology for clinical pathologic
correlations, ed 6, St Louis, 2012, Saunders.)
chemotherapy listed in Box 45-6 and described in the follow
ing sections are not permanent, but the client will be at risk
for these complications throughout the entire period during
which the drugs are being administered.
Mucositis
Some chemotherapeutic drugs are toxic to the oral mucosa
and cause edema, inflammation, and ulcerations (mucositis)
within a few days after the administration of the drug. Ulcer
ations from chemotherapy and radiation therapy are alike in
their clinical presentation, with red, swollen tissue that later
develops into a yellowish membrane-covered ulcerated
tissue (Figure 45-2). If the tissues do not become secondarily
infected, the ulcerated tissue will heal within a few weeks of
the drug delivery or radiation therapy. Clients with
mucositis report burning, pain, and general discomfort,
which can interfere with talking, swallowing, and obtaining
proper nutrition.
Management
Mucositis may be prevented or lessened in severity by
dental hygiene interventions that create a clean and well-
hydrated oral environment, good nutritional status, and
control of sec ondary infection (Box 45-7). The client should
be encouraged to rinse frequently with sodium bicarbonate
and saline water rinses and with alcohol-free mouth rinses
(see Table 45-1).
Management of Mouth Pain from Mucositis
• Early detection and treatment of oral infection
• Good oral hygiene, including tongue brushing, to
prevent further infection
• Frequent irrigation with 1 tsp of baking soda, 12 tsp
of salt, and 32 oz of water
• Frequent rinsing with sodium bicarbonate
mouth rinses and nonalcoholic mouth rinses (eg,
Biotene, Clear Choice)
• Daily cleaning of dentures and changing of
soaking solution; removal of dentures while
sleeping
• Use of prescribed topical anesthetics with caution
to avoid anesthetizing the soft palate, which could
cause food aspiration; excessive use may
potentiate mucositis
• Use of over-the-counter or prescribed systemic
analgesics if necessary
• Avoidance of irritating or rough-textured foods
• Use of perioral moisturizers as directed by the radiation
oncologist
Adapted from the US Department of Health and Human Services,
National Institutes of Health: Oral complications of chemotherapy
and head/neck radiation (PDQ), 2012. Available at:
http://www.cancer.gov/cancertopics/pdq/supportivecare/
oralcomplications/HealthProfessional and
http://www.cancer.gov/cancertopics/pdq/ supportivecare.
Accessed November 19, 2012.
These rinses soothe and hydrate the inflamed tissues, help
with bacterial plaque biofilm removal, and neutralize pH if
the client is vomiting. Pain management begins with mild
topical anesthetics and may progress to systemic analgesics
and even narcotics.
Neurotoxicity
Some chemotherapeutic agents that are derived from plant
alkaloids (eg, vincristine) are toxic to nerve tissue and may
cause severe, deep, and often bilateral odontogenic-like pain
known as neurotoxicity. When no dental pathology can be
found, the drug may be implicated. The pain subsides
within a few days after the administration of the drug.
Infection
Some chemotherapeutic agents suppress the bone marrow,
thereby resulting in immunosuppression (decreased
immune response) and bleeding problems. During these
periods, the client will be at risk for developing oral
infections (fungal, viral, and bacterial) that may increase the
risk for a systemic infection, especially if there is a break in
mucosal integrity that allows organisms to enter the blood.
Oral infections can result in significant morbidity for the
client who is undergo ing chemotherapy. Oral infections
intensify mucositis, and, with a breach in the oral mucosa,
such infections may lead to septicemia and death in clients
with profound immunosup
pression.5 Inappropriately timed dental and dental hygiene
procedures can result in bacteremia, thereby causing sepsis
and death.
Management
The final decision regarding the safest time to schedule oral
healthcare appointments is made by the oncologist. If
848 SECTION VII n Individuals with Special Needs
necessary, the oncologist may recommend antibiotic prophy
laxis before dental and dental hygiene care. therapy may be given by the oncologist. Adequate bleeding
A potential rationale for antibiotic prophylaxis before times are dependent on the
dental treatment exists when the client has an indwelling
central venous catheter for chemotherapy delivery. Some
individuals begin chemotherapy without a central venous
catheter but have one placed later during therapy. Therefore extent of the oral procedure. The client should also be
each time a client is seen it is necessary to ask if a catheter warned that trauma from improper toothbrushing or a
has been placed since the last appointment, because it may poorly fitting dental prosthesis may initiate bleeding when
become colonized with oral organisms after a dental or platelet levels are low.
dental hygiene procedure. Although no data are currently
Salivary Gland Dysfunction
available to document the absolute need for prophylactic
Not all persons who are undergoing chemotherapy experi
antibiotics in this patient population before dental
ence xerostomia or ropy saliva. However, some clients
procedures, the oncolo gist should be consulted regarding
complain of a dry mouth, thickened secretions, or excessive
what antibiotics may be necessary (see Chapter 14 for a
drooling during chemotherapy. Studies are inconclusive
discussion of antibiotic premedication).
regarding the drugs' effects on the salivary glands; however,
Some cancer centers have clients discontinue toothbrush
persons who complain about salivary dysfunction should be
ing and flossing during severe myelosuppression. This prac
offered palliative measures such as adequate hydration
tice is controversial, however, because there is evidence that
(Table 45-2) to help manage this debilitating and
toothbrushing and flossing during immunosuppression are
uncomfortable side effect and to prevent the further
not detrimental, and a decrease in plaque biofilm and local
exacerbation of other oral complications.
infection reduces the risk for potentially life-threatening sys
temic infection.
Dental Caries
Clients with dentures should be evaluated frequently and
Rampant tooth decay is not directly caused by the toxicity of
encouraged to call the dental office whenever necessary to
chemotherapeutic drugs. However, clients with chronically
seek early intervention for an oral complication or dental
dry mouths or persons who increase their intake of high
related sources of pain, irritation, or dental trauma. Oral
carbohydrate foods in response to eating problems may
tissues may change significantly during chemotherapy as a
experience an increase in caries development. For example,
result of edema, inflammation, ulceration, or weight loss.
children who are chronically ill may be given nighttime
Clients should understand that, when denture irritation
bottle feedings or diets that are high in sugar. During
occurs, the prosthesis should be removed from the mouth to
periods of stress, parents and caregivers may allow an
avoid further trauma. Persons with oral infections may rein
unbalanced diet to avoid additional stress that may be
fect their mouths with poorly cleansed dentures. It is impor
caused by insisting on a healthy diet. Such eating patterns
tant for the client to clean and disinfect the dentures daily
may increase dental caries risk.
and to keep them out of the mouth while sleeping. Denture
soaking solutions must be changed daily, and the soaking Management
container must be cleansed and rinsed thoroughly (see Depending on the severity of the dental caries problem,
Chapter 56). various preventive regimens may be prescribed. A fluoride
rinse or brush-on 1.1% sodium fluoride gel may be adequate.
Hemorrhage
However, if there is evidence of demineralization and if
Myelosuppression from chemotherapy may result in throm
dryness continues for several months, the client may require
bocytopenia (the reduction of clotting factors). Clients with
3
custom-fit gel trays for daily gel application. In addition, in-
platelet counts of less than 50,000/mm may experience oral
office fluoride varnish applications may be beneficial. The
hemorrhaging (bleeding) during invasive dental and dental
dental hygienist educates the client about the importance of
hygiene procedures.5 The occurrence of spontaneous
daily fluoride application, good nutrition, and oral hygiene.
gingival bleeding increases with a platelet count of less than
The dental hygienist also counsels clients and primary care
20,000/ mm3.5 When there is a disruption of the mucosal
givers about cariogenic foods and behaviors and suggests
integrity or the presence of periodontal disease, clients are at
alternatives (see Chapters 33 and 35).
greater risk for bleeding. This fact emphasizes the need for
early debride ment and periodontal maintenance care. Altered Tooth Development
Studies have shown that some chemotherapy drugs given
Management
before the age of 10 years—and especially before the age of 5
When scheduling a client who is undergoing chemotherapy
years—may alter root development.
for a dental hygiene appointment, it is imperative to consult
the oncologist regarding the status of the client's blood Oral Cancer–Specific Therapy
counts and clotting factors to avoid potential bleeding The choice of treatment for oral squamous cell cancer
problems associated with chemotherapy. Generally a depends on the stage of disease at the time of diagnosis. A
platelet count of at least 50,000/mm3 is recommended before small lesion of less than 1 cm may require only surgery or
invasive dental or dental hygiene procedures occur. 6 If a radiation therapy. Larger cancers and especially those that
dental or dental hygiene procedure is absolutely necessary have spread to the lymph nodes in the neck may require
during periods of thrombocytopenia, platelet support
 surgery, radia Radiation therapy employs the use of ionizing radiation,
tion, and chemotherapy. either from external beams or from internally implanted
sources. Radiation therapy may be used by itself for the treat
Head and Neck Radiation ment of oral squamous cell carcinoma when the lesion is
CHAPTER 45 n Cancer 849

TABLE 45-2
Management of Oral Manifestations of Cancer Therapies

Manifestation Prevention Palliative Measures and Management Dental Hygiene Care Guidelines

Mucositis or stomatitis (related hydration and excellent humidifier immunosuppressed during

to direct
effects of radiation
therapy and cytotoxic
chemotherapy)
bacterial plaque control
Gentle tooth and gingival
brushing with extra-soft
toothbrush
Consult with oncologist for
salivary gland stimulant
prescription
chemotherapy
Increased hydration with
water, saliva substitutes, ice
chips, or sugar-free popsicles
Cool-mist humidifiers may be
helpful, especially in dry
environments
Baking soda and water
solutions (1 tsp of baking soda,
2 tsp of salt, and 16 oz of
1

water) may be used as rinses

Salivary gland
dysfunction or
xerostomia (related to direct
radiation
damage to salivary
gland tissue and
possible indirect effect of
chemotherapeutic agents)
Salivary gland
dysfunction is
permanent after
radiation therapy,
whereas function
usually returns after
chemotherapy.
Infection: fungal, viral, and Eliminate use of products with
bacterial (related to
chemotherapy
induced
immunosuppression) Oral
infections may not cause
typical signs
and symptoms.
Candidiasis is common during
radiation
therapy.
These conditions are caused
by the toxicity of the cancer
therapy Early onset and
severity can be minimized by
consistent
or placed in a disposable
Discontinue toothpastes with irrigation bag (let the solution
strong, irritating flavoring flow through the mouth to
agents and replace with baking gently rinse)
soda and water paste Topical anesthetics (see Table
Discontinue alcohol-based 45-1)
rinses, full-strength peroxide,
and
Suggest over-the-counter
saliva substitutes (see
recommendations for clients
with xerostomia)
Stimulate functional salivary
gland tissue by chewing xylitol
gum or a wax bolus
Consult physician for salivary
gland stimulant prescription
Lubricate the lips with balm or
cream (not pure petrolatum)
Increase hydration with water,
ice chips, and high-moisture
foods Thin foods with liquids
irritating foods Recommend the use of a cool-
mist humidifier, especially
alcohol and irritating agents while client is sleeping
Diminish caffeine intake Suggest baking soda and
Discontinue tobacco use water rinsing for ropy saliva
Humidify air with cool-mist Frequent and consistent oral (see
hydration with water, ices, and recommendations for clients
saliva substitutes with mucositis)
Increase bacterial plaque
Oral microbiologic culturing
control Oral infections may be and assessment
unrelenting when the client is
Alert oncologist at first signs of
severely
oral infection
Encourage use of antifungals
that are sugar-free
Do not schedule dental
hygiene procedures while the
client is experiencing oral
ulcerations and pain. To prevent rampant caries, Do not proceed with dental If the client has a central
encourage improved oral hygiene procedures while a venous catheter, the American
hygiene measures, a diet low client has an acute oral Heart Association antibiotic
in sucrose, and fluoride infection. prophylactic protocol should
supplementation (eg, the daily Schedule dental hygiene be followed for invasive dental
use of 1.1% neutral-pH procedures when the client's hygiene procedures, including
sodium fluoride gels for 5 to 10 absolute neutrophil count is dental prophylaxis.
minutes in customized fluoride >1000/mm3.
trays for home use).
Bleeding (related to chemotherapy if not platelet count of >50,000/mm3
induced consistently removed or a blood transfusion.
myelosuppression) Refer to oncologist for management
Bleeding not preventable but bacterial Dental hygiene procedures should be Continued
plaque can exacerbate the complication delayed until the client has a
850 SECTION VII n Individuals with Special Needs

TABLE 45-2
Management of Oral Manifestations of Cancer Therapies—cont'd

Manifestation Prevention Palliative Measures and Management Dental Hygiene Care Guidelines
Rampant dental caries or In-office application of fluoride varnish to Same as prevention measures Encourage
demineralization exposed cementum Dietary guidelines to the participation of client when planning
(related to therapy induced salivary gland discourage frequent snacking on oral
dysfunction) cariogenic foods, sugared beverages, or hygiene homecare, and ensure
Bacterial plaque control acidic beverages (ie, diet sodas with strict adherence by frequent
Frequent oral hydration with water, ices, citric or phosphoric acid) If there is monitoring.
and saliva substitutes Daily 5- to 10- evidence of dental decay despite daily Establish a 2- to 3-month
minute application of 1.1% sodium fluoride application, place client on 2- continued-care interval until the
fluoride gel in custom gel carriers (soft week client demonstrates the ability to
vinyl trays adapted to extend beyond the chlorhexidine regimen and care for his or her teeth and the
cervical line of the teeth) or topical in-office fluoride varnish acute side effects of therapy
fluoride application have resolved.

Trismus or tissue is Avoid all surgical insult to tissue and bone

temporomandibular disorder
(related to
the direct effect of
radiation on the
muscles of
mastication or the
temporomandibular joint)
Soft-tissue necrosis and
osteoradionecrosis
(related to the direct effect of
radiation on tissue and bone)
Tissue becomes
hypovascular, hypoxic, and
hypocellular;
damage to the bone and soft
permanent.
Daily exercise for muscles of
mastication: instruct the client
to open and close the mouth
20 times without causing pain
to the temporomandibular
joint; this should be repeated
three times a day
All teeth within the field of
radiation that have a poor
lifelong
prognosis should be extracted
14 to 21 days before the
initiation of radiation therapy
irradiated bone throughout the Dental hygiene procedures
client's lifetime may need to be altered for
Same as prevention measures clients with trismus to avoid
Instruct client to encourage exacerbating the associated
further opening of the mouth pain (eg, shortened
by placing increasing numbers appointments or sedation).
of tongue blades between
posterior teeth for several
minutes a day
Establish a frequent and
regular dental hygiene
continued-care interval to
Referral to an oral surgeon for ensure the prevention of
possible hyperbaric oxygen periodontal disease and
therapy and surgical adherence to the oral hygiene
management of the necrotic homecare protocol.
small and superficial and when a surgical procedure would
result in significant functional or cosmetic damage.
Radiation may also be used in combination with
chemotherapy to enhance the chemotherapy's ability to
reduce the tumor or with surgery postoperatively to
eliminate residual disease or preoperatively to reduce the
size of the tumor. Radiation therapy may also be used for the
treatment of other head and neck cancers, including
lymphomas and salivary gland tumors.
Radiation damage to some normal cells (eg, taste buds)
may be acute and may resolve after therapy completion.
Other normal cells that can be affected (eg, salivary gland
cells) may not have the capacity to repair themselves,
thereby resulting in long-term complications. After the first
week of radiation, the client will begin to experience some of
the acute side effects (eg, loss of taste, dry mouth), whereas
other complications may not become evident until later in
the course of radiation therapy.
Oral Side Effects or Complications of
Radiation Therapy
The complications associated with head and neck radiation
will vary among clients, depending on the field of treatment
and the total dose of radiation required. Only the tissues in
the direct field or location of radiation are affected. For
example, a client undergoing lymphoma treatment may
receive only 20 radiation treatments that involve only a
portion of the salivary glands and cervical lymph nodes and
will therefore experience fewer complications than a client
who is undergoing treatment for a squamous cell carcinoma
in the oral cavity. To avoid unnecessarily alarming the client
and to be able to offer sound advice, the dental professional
must establish good communication with the radiation oncol
ogist to understand the anticipated radiation side effects.
The client who is undergoing radiation therapy to the
oral cavity and the salivary glands begins to experience
some side effects after the first week of therapy. Throughout
therapy, it is important to support the client with
suggestions to prevent and reduce side effects or
complications of radiation therapy. These complications are
summarized in Box 45-8 and are described in the following
paragraphs.
Xerostomia and Salivary Gland Dysfunction
Salivary gland exposure to radiation is unavoidable during
treatment for oral cavity and neck tumors, because the
glands are in close proximity to the lymphatic system and
cannot be shielded. Ionizing radiation induces fibrosis and
atrophy of
BOX 45-8
Potential Complications of Radiation to the Head and
Neck Area
Acute
• Xerostomia
• Loss of taste
• Mucositis
• Dysphagia
• Secondary infection
• Trismus
• Impaired nutrition (from xerostomia, pain, and
dysphagia) • Hearing loss
• Fatigue
Chronic
• Xerostomia or salivary gland dysfunction
• Alterations in sense of taste as compared with
preradiation status • Telangiectasia and friable
mucosa
• Continued fungal infections caused by the
lack of saliva • Osteoradionecrosis or soft-
tissue necrosis
• Rampant caries
• Muscle fibrosis, temporomandibular disorder,
and trismus • Altered tooth and jaw
development in children
Adapted from the US Department of Health and Human Services,
National Institutes of Health: Oral complications of chemotherapy
and head/neck radiation (PDQ), 2012. Available at:
http://www.cancer.gov/cancertopics/pdq/supportivecare/
oralcomplications/HealthProfessional and
http://www.cancer.gov/cancertopics/pdq/ sup portivecare.
Accessed November 19, 2012.
CHAPTER 45 n Cancer 851
the salivary gland tissue. Clients begin to experience a
change in their saliva after the first week of radiation. They
first complain of a thickened and ropy saliva, and, as the
treat ments progress, their mouths become drier. The degree
of dryness is dependent on the radiation dose and the extent
of salivary tissue within the radiation field. One study at MD
Anderson Cancer Center demonstrated that persons under
going high doses of radiation therapy to all of the major sali
vary glands experienced a 67% decrease in saliva after 1
week of radiation, a 76% loss after 6 weeks, and a 95% loss 3
years after the completion of radiation.
Xerostomia as a result of thickened, reduced, or absent
salivary flow compromises speaking, chewing, and swallow
ing and increases the risk of impaired nutrition by causing
an inability to eat all foods. Persistent dry mouth also
increases the risk of dental caries and other oral infections.
Because the irradiated salivary glands are permanently
damaged, the change in both the quality and the quantity of
saliva remains. Clients often complain bitterly about the
complications asso
ciated with xerostomia and require ongoing assistance from
the dental team to control symptoms.
Management
Clients who undergo radiation therapy to the neck involving
the submandibular and sublingual salivary glands with only
partial inclusion of the parotid glands complain mostly of a
thick, ropy saliva. These clients benefit greatly from baking
soda and saline water rinses. A baking soda solution is muco
 lytic, which aids in the cleansing and refreshing of the http://www.cancer.gov/cancertopics/pdq/supportivecare/
mouth. A prescribed medication such as pilocarpine can be oralcomplications/HealthProfessional and
http://www.cancer.gov/cancertopics/pdq/ supportivecare.
provided by the oncologist or dentist to help stimulate
Accessed November 19, 2012.
residual salivary gland tissue to produce saliva. In addition,
commercial saliva substitutes are available as over-the-
counter products. Although they be palliative, saliva
substitutes do not contain the protective proteins and may be necessary to avoid weight loss and medical complica
mucoproteins found in saliva, and some clients do not feel tions. If patients do not maintain adequate nutrition during
the cost is justified for the limited relief. In addition, the lips the treatment process, then a stomach tube is surgically
should be lubricated with a mois turizing lip balm or cream placed for liquid feeding at home.
recommended by the radiation oncologist and not with pure
petrolatum, which provides only an occlusive agent and Mucositis, Stomatitis, and Infection
does not moisturize the perioral tissues. These and other If all nonsurgical dental and dental hygiene procedures have
suggestions for the management of a dry mouth are listed in not been accomplished before initiation of radiation, they
Box 45-9. should be done within the first 2 weeks of therapy, before
the onset of mucositis. Usually by the third week of
Alteration of Taste radiation the client begins to experience mucosal
When the tongue is in the field of radiation, the client experi inflammation and pain. Like chemotherapy mucositis, the
ences partial or full taste loss. Loss of taste is an acute effect, mucosa first becomes edematous and inflamed, and then the
and it usually occurs after the first few treatments. Taste tissue becomes thinned; pseudomembranes form, and the
returns a few months after the completion of radiation tissue becomes denuded (see Figure 45-2). As the treatments
therapy, but it may be altered from its preradiation status. progress, small ulcerations may enlarge to become a
Taste loss is a significant side effect that makes radiation confluent and pseudo membranous mucositis. Oncologists
therapy almost intolerable. Eating becomes a chore; clients sometimes schedule a short interruption of therapy to allow
complain that all food tastes like mush or straw. Eating for the regeneration of normal cells. Mucositis can increase
ceases to be a pleasurable activity, and clients must force the risk of severe pain, oral and systemic infection,
themselves to eat to maintain their nutritional status. unpleasant odors, difficulty with talking, and nutritional
compromise. A lack of saliva increases ulceration and
Management
bleeding risk. In addition, the patient may experience
Clients are helped by having someone to listen to their com dysphagia (the inability to swallow) as a result of salivary
plaints. These individuals should be assured that taste dys gland dysfunction and painful ulcerated tissue within the
function is a normal radiation side effect and that taste will radiation field.
return several months after treatment. In addition, clients As a result of the mucositis, secondary oral mucosal infec
should be encouraged to continue eating. The use of nutri tions are common and may intensify the mucosal irritation.
tional liquid substitutes or referral for nutritional counseling The fungal organism Candida albicans is most often impli
852 SECTION VII n Individuals with Special Needs cated, but any organism may be responsible for infection
when the tissues are severely compromised by xerostomia,
mucositis, altered nutrition, and inadequate oral hygiene.
BOX 45-9 Early detection and the treatment of any oral infection are
imperative to prevent the exacerbation of mucositis that may
Recommendations for Clients with Xerostomia
require the interruption of cancer therapy. After all radiation
• Carry bottled water, and sip it often. treatments have been completed, gradual resolution of the
• Use liquids to soften or thin foods.
• Use xylitol gum or xylitol hard candies to help
stimulate saliva flow. • Use over-the-counter saliva
substitutes (see Table 45-1). • Rinse frequently with 14 mucositis can be expected; however, the epithelium under
tsp of baking soda, 18 tsp of salt, and 8 oz of water. goes permanent fibrosis, and the tissue may be thin and
• Let ice chips melt in the mouth. fragile and show evidence of telangiectasia (a vascular
• Suck on sugar-free popsicles. lesion of dilated small blood vessels).
• Humidify rooms with cool-mist humidifiers.
• Avoid highly seasoned foods, tobacco, and the Management
drying effects of alcohol and alcohol-containing Box 45-9 summarizes ways to help clients with mouth pain
products. caused by mucositis. A clean, well-hydrated mouth during
• Ask the dentist or oncologist to prescribe a saliva radiation therapy reduces the severity of mucosal ulceration
stimulant. • Lubricate lips with a moisturizing lip and the risk for oral infection. Toothbrushes are available
balm or cream rather than with pure petrolatum.
that are extra soft and nonabrasive. When the client begins
to experience mucositis, it is necessary to modify oral
Adapted from the US Department of Health and Human Services, hygiene procedures to be nonirritating and atraumatic but
National Institutes of Health: Oral complications of chemotherapy
still ade quate to remove plaque biofilm and thickened
and head/neck radiation (PDQ), 2012. Available at:
saliva. Tooth
brushes should be extra soft, and they may be further e 45-3.Clinical appearance of radiation caries. (Courtesy Dr.
Jonathan A. Ship.)
softened in hot water. The use of commercial toothpastes
with strong flavoring agents may have to be temporarily
discontinued and replaced with the use of a paste made important to prevent mucositis and oral infection. Clients
from baking soda and water. If toothbrushing becomes with dentures should be instructed to leave the dentures out
impossible as a result of painful tissues, the teeth, gingiva, of their mouths as often as possible. If the field of radiation
and tongue may be swabbed with gauze that has been encompasses all of the oral tissues, it may be impossible for
moistened in warm water. Dental flossing should be the client to wear dentures because of significant oral tissue
continued as long as possible and resumed as soon as the changes from edema and inflammation. The client needs to
mucositis resolves. keep the dentures as clean as possible and to store them in a
Sponge-tipped swabs are supplied for oral care to hospi soaking solution that is changed daily to avoid microbial
tals through medical supply companies, but they are not contamination. These clients often eat a soft or liquid diet,
effective for plaque biofilm removal. If their use is necessary and the tongue becomes coated and infected. Therefore,
because of the presence of ulcerated tissue, they should be keeping the mouth well cleansed and the tongue brushed
dipped in a nonalcoholic antimicrobial solution for greatest are extremely important.
efficacy.
Trismus, Tissue Fibrosis, and
All commercial mouthwashes with alcohol or phenol
Temporomandibular Joint Dysfunction
should be avoided because of their drying and irritating
The limited ability to open the mouth known as trismus may
effects. Although half-strength peroxide and water solutions
result from a loss of elasticity of the masticatory muscles or
are sometimes used in hospitals to remove encrusted secre
the temporomandibular joint ligaments after a high dose of
tions or for acute infections, they are not recommended for
radiation. Trismus usually occurs within 3 months after
long-term use, because they are acidic and may alter the
therapy, and it remains a lifelong problem. It can result in
normal oral flora. Frequent mouth rinses with baking soda
significant discomfort, and it can interfere with eating,
and saline water should be suggested. When the mouth is
talking, and post-treatment examination.
too sore to swish the mouth rinse, gentle irrigation of the
mouth with a solution of 1 tsp of baking soda, 1 to 2 tsp of Management
salt, and 32 oz of water can be recommended.
The client who is receiving radiation therapy to the mastica
Chlorhexidine gluconate mouth rinse has not been conclu tion muscles should be placed on an exercise program to
sively shown to be beneficial for reducing oral infections and prevent trismus. The jaw should be exercised three times a
mucositis severity during cancer therapy. Such a rinse, when day by opening and closing the mouth 20 times as wide as
prepared with alcohol, should be evaluated for its antimicro possible without causing pain.
bial benefit versus the irritating effect of the alcohol. Topical
anesthetics and coating agents in addition to the soothing Radiation Caries and Demineralization
bland rinses (see Table 45-1) give temporary relief. All clients Rampant caries and tooth demineralization usually begin
—especially children and their parents—need to be within the first year after radiation therapy unless intensive
cautioned that topical anesthetic agents may anesthetize the oral hygiene and preventive measures are instituted. Figure
soft palate and the epiglottis, potentially causing the aspira 45-3 shows the typical clinical appearance of radiation
tion of food. Excessive use also may increase the mucositis related caries. Enamel demineralization (the loss of minerals
symptoms. Some clients may require systemic analgesics without decay) or rapid decay is a result of changes in both
and sometimes even narcotics to control mucositis pain. the quality and the quantity of saliva after cancer treatment.
During radiation therapy, skin care around the mouth is The decreased salivary flow limits the availability of calcium
directed by the radiation oncologist. Some lip lubricants can and phosphate in the saliva to prevent the natural remineral
increase the effects of the radiation and cause significant ization of the tooth structure and to buffer the acids
radiation dermatitis. Physicians may order specific skin care produced by cariogenic bacteria in the plaque biofilm. With
products during therapy for the relief of symptoms. dry and friable (crumbly) tissues, these clients may change
Clients whose conditions are not compromised are to be to a soft, high-carbohydrate diet, thereby adding to the
scheduled for regular preventive oral healthcare. The role of lifelong risk of rampant dental decay.
the dental hygienist in providing professional mechanical
oral hygiene care and supportive patient education is Management
All clients who are receiving cancericidal doses of radiation
therapy to any of the salivary glands must have custom
CHAPTER 45 n Cancer 853

fluoride trays made for the daily application of a 1.1%

neutral-pH sodium fluoride gel to aid in the prevention of
rampant tooth demineralization. The dental hygienist may
Figur be responsible for making impressions for study models to
fab
ricate the custom tray. Impressions may be sent to a dental surgery or trauma to
laboratory, or the trays may be made in the dental clinic 854 SECTION VII n Individuals with Special Needs
using a vacuum unit. The fluoride trays are made from a soft
vinyl mouth guard material. They should be adapted to
extend slightly above the cervical line of the teeth to include irradiated tissue and bone and those who have dental infec
full coverage of all teeth. The tray edges must be absolutely tion in close proximity to bone that has been compromised
smooth and nonirritating to the client's oral tissues to by radiation. The prevention of osteoradionecrosis by under
prevent soft-tissue breakdown. going dental evaluation and treatment before radiation
The client should begin use of the fluoride trays at the therapy is mandatory. After radiation, the teeth and the peri
initiation of therapy. Clients are instructed to first brush and odontium must be professionally managed at intervals to
floss their teeth and then to place a thin ribbon of the 1.1% ensure excellent oral hygiene, early intervention, and
neutral-pH sodium fluoride gel in each of the trays. They minimal disease. The dental hygienist is an extremely
place the trays on their teeth and leave them in place for 5 to important member of the professional team that manages
10 minutes. After removal, clients rinse the trays well with this poten tially very serious problem.
water but do not rinse the mouth or eat anything for 30
minutes. This fluoride therapy must be done once each day. Hearing Loss and Fatigue
Many clients feel that it is easiest to use the trays when they As treatment progresses, the client becomes more easily
are bathing or showering. In this way, the procedure is fatigued and may require daytime naps. In addition, the
incorporated into a regular daily routine. client may report a partial or total loss of hearing in the ear
There may be a period of time during therapy when on the side of the head being irradiated.
severe mucositis prevents fluoride application with trays.
Management
During this time, the client is encouraged to use
As a result of fatigue, clients may need to cut back on their
nonalcoholic and bland fluoride rinses, to increase the
work schedule and obtain plenty of rest. After radiation
hydration of tissues, and to resume the daily fluoride gel
therapy is completed, hearing and physical energy usually
application as soon as the mucositis resolves.
return.
In addition, dietary habits and daily food consumption
should be discussed to assess the intake of sugar, acidic Surgical Treatment of Oral Cancer
juice, or soda pop (diet soda included). The dental hygienist
Surgery is chosen as the primary treatment when oral cancer
plays a critical role in helping clients to prevent radiation
is small; when the cancer is completely excisable without
caries by educating them about the importance of daily
complication; when the cancer is not sensitive to radiation
fluoride appli
therapy; when the lymph nodes, salivary glands, or bones
cation, good nutrition, and oral hygiene.
are involved; or when there is a recurrence of tumor in an
area that has already received a therapeutic dose of
Altered Tooth and Jaw Development
radiation. The disadvantage of surgery is the sacrifice of
The latent effects of therapeutic radiation therapy on
important func tional oral structures.
children with cancers of the oral cavity and associated
structures vary with the radiation dose and field and the
Potential Complications
child's stage of growth and development. Radiation has the Physical
potential to alter or arrest craniofacial growth and tooth
Acute physical complications after head and neck surgery
development. Older children who receive minimal doses
may include infection; airway obstruction; fistula formation;
may experience only slightly altered root development,
necrosis in the surgical site; impairment of swallowing,
whereas younger children who are treated at an age when
hearing, vision, smell, and speech; and compromised nutri
their jaws and teeth are under development may experience
tional status. Long-term complications include speech
gross malformation of the den tition and may suffer
impair ment, malnutrition from the inability to swallow
significant skeletal deformities.
foods, drooling, malocclusion, temporomandibular
disorders, facial deformity, and chronic pain in the shoulder
Soft-Tissue Necrosis and Osteoradionecrosis
muscles.
Radiation therapy may irreversibly injure the vascularity of
soft tissue and bone, result in the decreased ability to heal if Psychosocial
traumatized, and increase the susceptibility to infection. 6
There may be significant psychosocial problems associated
Osteoradionecrosis is defined as exposed bone that does not
with head and neck surgery because the results of the cancer
respond to treatment over a 6-month period of time as a
and its treatment are often visible and humiliating and can
result of radiation treatment. There is a higher risk of
be psychologically devastating. Physical impairments cannot
osteoradione crosis as the dose of radiation and the volume
be completely disguised by clothing, prostheses, or
of irradiated bone and tissue increase. Nonhealing soft tissue
cosmetics. These surgical defects may result in long-term
or bone may become secondarily infected, and the client
disability, but such problems may be short-term when
may eventually experience intolerable pain and jaw fracture.
reconstructive surgery and rehabilitation are available. In
The mandible appears to be more susceptible than the
today's society, self-image is often equated with body image.
maxilla because of its dense bone and limited blood supply.
As a result, some individuals experience depression,
Clients who are at the greatest risk are those who have
withdrawal and social death, anger, and stigmatization. plan to restore at least partial function and improve cosmetic
Some who are heavy smokers and drinkers experience guilt appear ance. The oral and maxillofacial surgeon, the
because of the associa tion of these addictions with oral maxillofacial prosthodontist, the general dentist, and the
cancer. dental hygienist all may play roles in the initial care
planning.
Management Maxillary defects result in unintelligible speech as a result of
The person who has surgery for oral cancer often requires a nasal voice quality, difficulty eating, thickened nasal and
long postoperative hospital stay. To assist with sinus secretions, and facial disfigurement. Optimal manage
postoperative ment begins at the time of surgery, when the prosthodontist
may place a surgical obturator (a temporary prosthetic
device) to help correct these problems. Approximately 3 to 4
months after surgery, if no complications arise, a permanent
management, a dental hygienist who is working in a
prosthe sis is fabricated. This prosthesis usually allows for
hospital can do the following:
the most effective restoration for the client, because speech,
• Provide in-service programs for nursing staff about oral swallow ing, mastication, and facial contour all can
assessment and oral hygiene care during cancer therapy. • effectively be
Act as a liaison between the surgical and dental teams. •
Facilitate ongoing prosthodontic and oral surgery
consultations.
• Teach clients to insert, remove, and clean the surgical
prosthesis.
• Assess clients' oral tissues for irritation and comfort. •
Teach clients to maintain the oral cavity and all remaining
teeth in optimal condition with frequent gentle cleansing
and hydration. Cleansing and hydration are usually
accomplished with an irrigation bag or bulb syringe, saline
rinses, and gentle debridement with large cotton-tipped Figur
applicators, sponge swabs, or gauze. Care must be taken
when cleansing and suctioning so that new granulation e 45-4.Osteonecrosis of the right mandible in a client with
tissue is not disrupted. metastatic prostate cancer after receiving intravenous
bisphosphonate treatment. (Courtesy Dr. Salvatore
• Encourage clients who have been cleared by the surgeon Ruggiero.)
to take food by mouth to use a spoon to place small bites
of food on the unaffected side of the mouth and as far
back as possible. Forks should be avoided until inci restored with a prosthesis instead of reconstructed with
sions heal. (Immediately after surgery, a client may not be plastic surgery.
able to take food and drink by mouth, at which time a Mandibular defects are often created during oral cancer
tube is placed in the stomach for liquid nutritional surgery. Immediate reconstruction is sometimes possible.
supplementation.) After extensive intraoral surgery, the client may need addi
A client who has had a recent head and neck surgical tional surgical procedures to release the tongue from the
procedure may be in the process of accepting the associated floor of the mouth, to graft skin, to create a vestibule for
facial deformities and functional alterations. Encouragement saliva pooling, and to allow for the extension of denture
to talk about these issues helps the client to move toward flanges. These procedures also help with speech,
acceptance of his or her new body image. It is important for mastication, and swallowing.
the dental hygienist to listen empathetically to the client's After surgical and radiation therapy to the oral cavity,
concerns and fears. Taking time to do so decreases client clients who are partially or fully edentulous require
stress and promotes cooperation with recommendations. It conserva tive prosthetic management. The thinned and
is important to remember that, although the surgical friable tissue, the scarring and fibrosis from surgery, and the
treatment may have removed head and neck tissue, it did lack of lubrica tion and protective qualities of the saliva from
not remove the person of the client. The client, as a whole radiation treat ment make denture placement difficult and
person, has human needs related to oral health and disease. place the client at risk for soft-tissue breakdown and
It is very important to actively listen to the client, to osteoradionecrosis. Some clients are never able to wear
communicate respectfully and with good eye contact, and to dentures. Detailed education, close professional supervision,
interact directly about ways to promote oral health and cope and client acceptance of recommendations are necessary for
with the chal lenges that the surgery has presented. successful prosthetic rehabilitation.
Prosthetic Rehabilitation
Bisphosphonates and Osteonecrosis
Planning for the rehabilitation of the person with head and A potentially painful oral lesion related to a bone-
neck cancer by the dentist begins at the time of medical diag strengthening drug has become an additional concern for
nosis. When a surgical resection creates facial defects and clients who have been diagnosed with multiple myeloma or
oral dysfunction, the client must be assured that there is a
breast, thyroid, lung, or prostate cancer. These individuals patients who are about to receive head and neck radiation
may experience metastatic lesions or tumors that spread to therapy should be followed. Meticulous oral hygiene home
the bones. The cancerous bone lesions can lead to care and professional maintenance during cancer and
hypercalcemia (excess calcium in the blood as a result of bisphosphonate therapy can reduce the number of bacteria
malignancy) and extreme pain, and they can heighten the induced pathologies in the oral cavity, thereby lowering the
potential for bone fractures. To diminish these conditions, risk of developing BRONJ. In addition, the dental hygienist
oncologists often intravenously administer a class of must carefully review the client's health history and explore
medications called bisphosphonates (eg, pamidronate any medications used during or after cancer treatment. Vigi
[Aredia], zoledronic acid [Zometa], clodro lance must be exercised during intraoral and extraoral exami
nate [Bonefos]). These drugs alter or inhibit the ability of nations for evidence of BRONJ ulcers if an intravenous or
osteoclasts to resorb, thereby suppressing bone turnover. As oral form of bisphosphonates has ever been used. The
a result, bisphosphonates stabilize the skeletal matrix and patient must also be informed of the risks associated with
reduce the formation of solid cancerous tumors that are the use of both oral and intravenous bisphosphonates.
attempting to spread from distant sites such as the lungs. 7
Bisphosphonates are also prescribed in pill form (eg, alen
Dental Hygiene Process of Care
dronate [Fosamax], risedronate [Actonel], ibandronate
[Boniva]) to treat osteoporosis and Paget's disease of the The dental hygienist—either as a member of a hospital oncol
bone; they act by increasing bone density. ogy team (see Web Resources) or as a clinician in
A potential side effect of intravenously administered consultation with the oncologist—has the opportunity to
bisphosphonate is a condition called bisphosphonate- prevent or ame liorate many of the oral and systemic
related complications associ ated with cancer treatment by
designing a dental hygiene care plan that promotes a clean
CHAPTER 45 n Cancer 855
and healthy oral cavity. Before the initial dental hygiene care
appointment, consulta tion must be sought with other
osteonecrosis of the jaw (BRONJ). This often painful oral or oncology team members involved in the care of the person
extraoral lesion may resemble an osteoradionecrosis lesion, with cancer. Open and continuous communication with
and it presents as an irregular ulceration with exposed physicians and nurses reduces the risk of providing care that
necrotic bone (Figure 45-4). Bisphosphonate-related bone compromises the client's condition.
death in the mandible and maxilla is believed to occur as a 856 SECTION VII n Individuals with Special Needs
result of the unique conditions to which the oral cavity is
subjected. The mouth, unlike the rest of the body, is con
stantly being assaulted with small traumas through mastica Assessment
tion or poorly fitting dentures as well as oral infection (eg,
The dental hygienist collaborates with the dentist to identify
periodontitis, apical abscesses). When bisphosphonates are
sources of infection that may delay postoperative healing for
administered, they attach to the bone matrix, and they may
a client who is scheduled for surgery of the oral cavity. In
remain in the bone for several years. The presence of this
addition, the pretherapy assessment is also critical for a
drug in the skeletal system prevents the jaw bones from
client who is scheduled for intravenous bisphosphonate
undergo
therapy or radiation therapy of the oral cavity or the salivary
ing the forming and reforming that are necessary for normal
glands. Any part of the maxilla or mandible that will be irra
healing. If traumatized, the bone may then become necrotic
diated is at lifelong risk for the development of osteoradio
and form subsequent lesions. Typical symptoms include
necrosis. Therefore all infections and teeth that cannot be
loose teeth, pain, drainage, swelling, a heavy feeling, and
maintained for the client's lifetime should be identified for
numbness.
removal. Teeth to be extracted include not only those with
Approximately 0.8% to 12% of patients who are receiving
gross caries and refractory periodontal disease but also those
intravenously administered bisphosphonates (and a much
that potentially may not be maintained because of the
smaller number who are using oral bisphosphonates)
client's lack of personal motivation, physical or mental
develop BRONJ. Lesion development risk increases with the
ability, or financial resources.
form, amount, and duration of bisphosphonate use.7 The
Because intraoral infection may spread through the blood
majority of BRONJ lesions are reported to follow invasive
stream and result in sepsis and possibly death during immu
dental pro
nosuppression, all potential sources of irritation that may
cedures such as an extraction or implant placement, but
potentiate mucositis must also be identified and eliminated.
BRONJ has also been reported to develop spontaneously in
The assessment of a potential BMT recipient should identify
limited cases. Unfortunately, other than palliative care, there
any oral problems that may arise within the first year after
currently exists no effective way to treat BRONJ after it has
the transplant, when the client is in an immunosuppressed
formed.
condition.
Management
Client Interview
As with other aspects of cancer treatment, the dental hygien
The client interview provides critical information that influ
ist remains an important treatment team member. In general,
ences future oral hygiene care and dental treatment. Taking
the guidelines developed for the oral and dental care of
time to listen to the client's perceptions decreases client and need to have all surgical procedures performed at least 7
family stress, promotes consistency, encourages cooperation days before periods of immunosuppression, all sources of
among members of the oncology team, and assists the dental infection and irritation removed, and all projected dental
hygienist with assessing the client's human needs that will needs met. For clients who are scheduled for surgery, all oral
shape the dental hygiene process of care. surgical procedures need to be scheduled 14 to 21 days
The client's current oral status and health and dental his before the initiation of radiation therapy involving the oral
tories are reviewed, including frequency of care, dental expe cavity and the salivary glands. Restorative needs should be
riences that were unpleasant or painful, oral self-care habits, cared for before the onset of painful mucositis. Fabrication of
and current attitude and knowledge about the teeth and new dental prostheses is delayed until several months after
mouth. This information assists the dental hygienist with the radia tion therapy ends, when all acute side effects of
planning of dental hygiene care. The interview also reveals radiation have been resolved (Box 45-10).
the client's socioeconomic status and any cultural and ethnic
influences that may affect his or her perceptions of cancer,
health beliefs, coping strategies, social support system,
dietary habits, and ability to adhere to the supportive care. BOX 45-10
Diagnosis Reasons for an Oral Evaluation Before Cancer
Dental hygiene diagnoses identify human needs related to Treatment
direct dental hygiene care before the initiation of cancer • The identification and treatment of existing infections
therapy, during therapy, and after the client has completed and problem teeth
all proposed therapy. As therapy progresses and the client • The elimination of potential sites of infection and
moves through various physical changes and psychosocial trauma (eg, exfoliating teeth in children, partially
stages related to the cancer, the dental hygiene diagnoses erupted third molars, orthodontic bands, ill-fitting
change, and the care plan is continually revised. dentures, fractured teeth or
restorations)
Planning • The construction of oral stents to be worn during
The client who is undergoing cancer therapy or who is expe radiation therapy of the head and neck area
riencing end-stage disease requires a care plan that is • For clients who are scheduled for head and neck
directed toward meeting actual or potential needs associated radiation, the extraction of teeth that may pose a
with the future problem (ie, for the prevention of post-
oral and systemic complications of cancer therapies. Initially, therapy osteoradionecrosis)
when clients are faced with a life-threatening cancer • The construction of custom fluoride gel trays and
instructions regarding their use
diagnosis, they are unable to conceptualize the
• Instructions regarding oral hygiene, nutrition,
and tobacco treatment
• The provision of professional mechanical dental
importance of care beyond their most basic physiologic and hygiene care (ie, oral prophylaxis, periodontal
maintenance, or nonsurgical
survival needs. As these needs appear to be no longer at
periodontal therapy) to reduce periodontal infection
imminent risk, the client often begins to accept the diagnosis,
and to promote periodontal health
and he or she may be capable of participating in supportive
care. Clients in the dental office who have previously had a
positive attitude about their teeth and oral hygiene may
reveal totally different values during times of stress. It Psychosocial I ssues
cannot be assumed that clients involved in cancer therapy The initial client appointment is an important time when
will con tinue the previous level of personal oral hygiene trust and assurance are established. Clients must feel
care. Alter acceptance in a nonjudgmental environment and sense that
natively, it should not be assumed that persons with a their self esteem will be preserved. The client is a “person
seemingly overwhelming cancer diagnosis do not have the living with cancer,” not a “cancer case.” Additional time is
ability to participate in successful rehabilitation. At appropri necessary to allow the client to express feelings. All feelings
ate times, a clear understanding of the oral problems associ should be acknowledged, and anger should not be mitigated
ated with cancer therapy must be effectively communicated too quickly. The dental hygienist encourages the client to
and trust established by mutual participation in the develop participate in care planning, which provides an opportunity
ment of oral health goals. for that client to regain some of the sense of control that was
Oral and Dental Management Before lost to the cancer.
Cancer Therapy
Education
Referral to a Dentist
Adequate time must be allotted for education, because the
Conditions found by the dental hygienist that require diag stress related to a cancer diagnosis can easily impede the
nosis by a dentist should be referred immediately for evalu normal learning process. It is important to engage in the
ation and treatment. Before chemotherapy begins, clients teach ing process with full regard for the client's psychologic
human need status. Clients in a state of denial are not able to
compre hend the importance of preventive oral healthcare
until they begin to accept their cancer and therapy plan.
Others, stressed by the financial burden of medical
treatments, may not place a priority on dental and dental
hygiene treatment when it is compared with their
impending life-saving cancer therapy. Those who are
depressed and who see their prognosis as grave do not value
the importance of long-term dental hygiene care until they
begin to see cause for hope.
Oral Hygiene Instruction and Self-Care
Oral hygiene self-care assistance is important before cancer
therapy initiation to establish good oral hygiene before the
oral tissues are compromised. Disclosing agent use helps
with instruction and helps the client to identify areas that
require closer attention during self-care procedures. This
educational approach also provides an opportunity for the
dental hygien
ist to explain the composition of plaque biofilm and the risk
of oral and systemic infections during cancer therapy. Oral
hygiene technique should be assessed, if possible, and the
client should be assisted with establishing plaque-removal
techniques that will be useful before and during therapy. If a
client is scheduled for therapy that will significantly compro
mise the oral tissues, initial instruction is given verbally and
in print regarding methods for cleansing the mouth in addi
tion to any preventive and palliative products recommended
(see Table 45-1). These methods are then elaborated on
during therapy. Gentle tooth and gingival brushing can
continue during cancer therapy.
Tobacco and Alcohol Cessation Counseling
Usually the oncologist strongly urges the client to stop using
tobacco products and to limit excessive alcohol intake
during cancer therapy. Tobacco treatment and assistance
from the dental hygienist are important (see Chapter 36).
Referral to the national tobacco cessation quitline (1-800-
QUITNOW or http://www.cdc.gov/tobacco/quit_smoking
/index.htmhttp://www.cdc.gov/tobacco/), a local tobacco
treatment program, or a support group may be necessary
and desired by the client.
Nutritional Counseling
A client's nutritional status affects his or her overall response
to cancer therapy and his or her psychologic well-being. The
CHAPTER 45 n Cancer 857
nutritionist on the oncology team assumes primary responsi
bility for monitoring the client's nutritional status and
providing counseling regarding diet selection. The dental
hygienist consults with the nutritionist and educates the
client about diet selection and dietary habits to promote a
clean and healthy oral environment and to reduce caries
development. It is important for the dental hygienist to deter
mine the client's understanding of the relationship of a well
balanced diet to dental caries, periodontal disease, and
infection. When the client is ready psychologically to assimi
late preventive behaviors, the client and the dental hygienist
choose foods that are desirable to the client and that are low
in sugar, acid, and oral retention qualities. The client needs
to understand, however, that it is often difficult during
therapy to eat a well-balanced diet that also contains foods
that promote oral health.
Dental Hygiene Instrumentation
Dental hygiene instrumentation may need to be altered to
accommodate the client's physical condition related to recent
surgery, disease manifestations, and the status of the client's
blood counts and clotting factors. The oncologist is consulted
regarding the safest time to schedule an appointment and
the need for antibiotic prophylaxis before dental hygiene
instrumentation. Overall, dental hygiene care promotes a
clean and well-hydrated oral environment and control of
periodontal disease to reduce the risk of oral infection and
bacteremia.
Fluoride Therapy
When the client is scheduled for radiation therapy to the sali
vary glands or total body irradiation for BMT, custom fluo
ride gel trays are fabricated for daily application of a 1.1%
neutral-pH sodium fluoride gel to prevent rampant dental
caries. Clients who complain of a dry mouth during chemo
therapy require at least a daily fluoride rinse and possibly a
1.1% sodium fluoride toothpaste or gel.
Oral and Dental Care During Cancer Therapy
After therapy is initiated, it is important to continue to
support the client and to understand that most cancer
therapy is physically and psychologically demanding. With
each appointment, the dental hygienist repeats the oral
assessment of the client, updates the client's health history,
and assesses the client's level of disease acceptance and
readiness for new interventions. Clients' anger and
bargaining may be signs of acceptance of the diagnosis and
an attempt by clients to regain control of their own lives.
These times offer the dental hygienist an opportunity to
direct the client's interest to posi tive involvement in oral
self-care and dietary planning. Edu cation during care is
centered on the immediate real and impending
complications of therapy.
Management of Oral Complications
Table 45-2 summarizes dental hygiene interventions that
may prevent or ameliorate the oral complications associated
with radiation therapy and chemotherapy.
After a client who is scheduled to undergo BMT enters
the transplant center, the client is not allowed to leave the
unit until the bone marrow has engrafted and blood counts
have returned to a normal range. Therefore all dental
treatment must be accomplished before the transplant.
858 SECTION VII n Individuals with Special Needs
Nutritional Counseling During Cancer Therapy
The side effects of cancer therapy often result in a high risk
for dental caries. Clients may be placed on a soft and bland
diet or a high-carbohydrate liquid diet as a result of recent
oral surgery or mucositis from therapy. They may also be
encouraged to eat small, frequent meals and snacks to
increase their caloric intake and to counteract nausea and
vomiting. Additional complications arise from a dry mouth
or thick ened saliva, taste dysfunction, the inability to
practice good oral hygiene because of an oral surgical
procedure, or a lack of interest in eating in response to
depression and stress. A severely malnourished client may
be placed on parenteral nutrition, thereby completely
eliminating the mechanical oral cleansing action of foods.
The diets of children who are undergoing cancer therapy
are often a problem because there are so many times when
they are too sick to eat that parents allow them to eat
anything they want when they are feeling well. When
working with the nutritionist, the dental hygienist continues
to emphasize the importance of a well-balanced, low-sugar
diet for the prevention of infection and the promotion of
healing after the insult of therapy.
Clients with mouth pain may be helped by hygienists sug
gesting the use of topical anesthetic or coating agents before
eating (see Table 45-1). In addition, clients with oral ulcer
ations or dry mouth may find it helpful to eat foods that are
high in moisture, or they may thin their food with liquids
and take frequent sips of water while eating. Irritating, hot,
spicy, or acidic foods should be avoided.
Oral and Dental Care After Cancer Therapy
After any kind of cancer therapy, the dental hygienist contin
ues to have an important role in client care. At each client
appointment, the dental hygienist reassesses the client's
human needs related to oral health. Even when clients have
been reassured that their cancer has successfully responded
to therapy, they continue to experience stress, anxiety, and
concern about the possible recurrence of the cancer. Contin
ued education and frequent contact and support are
essential. The dental hygienist tailors the client's oral self-
care to the individual's status and human needs and places
as much responsibility on the client as possible.
After Chemotherapy
After a client has completed the required rounds of chemo
therapy, most of the associated oral manifestations
completely resolve. With full bone marrow recovery, all
problems associ ated with acute cytotoxicity,
immunosuppression, and throm bocytopenia disappear.
After long and intensive chemotherapy, some clients take
months to recover fully and experience chronic oral
infections such as candidiasis and herpetic infec tions.
Continual assistance with oral hygiene is required to prevent
unnecessary infections. The assessment of clients' nutritional
intake is important to determine if they have resumed a
noncariogenic and normal diet.
After Bone Marrow or Blood Stem Cell Transplantation
After clients are released from a transplant unit, they may
have residual effects of the conditioning phase of treatment,
and they may remain susceptible to infections for several
months as a result of immunosuppressive therapy. Some con
tinue to experience xerostomia, which predisposes them to
an
altered oral flora and infections, trauma, and rampant dental
caries. Clients with GVHD may experience additional com
plications that involve thinned and friable mucosa and
mucosal lesions.
The dental hygienist assists the client with establishing
consistent and effective oral hygiene methods that do not
create additional trauma and irritation. Bland rinses, gentle
but thorough and consistent cleansing of the teeth and
tissues, and saliva substitutes are important.
Dental procedures that are deemed necessary are per
formed only after consultation with the oncologist to assess
the client's immune status and his or her need for antibiotic
prophylaxis or platelet support. Elective dental procedures
are delayed until the client has full hematologic function,
which is sometimes up to a year or more after the
completion of cancer treatment. Rampant dental caries from
xerostomia are prevented with the daily application of
fluoride gel in custom fluoride trays.
After Radiation Therapy
Client care after radiation therapy specific to the oral cavity
and salivary glands requires lifelong frequent dental and
dental hygiene maintenance care. Because damage to the sali
vary glands and the jaw bones from cancer radiation therapy
is permanent, clients are at permanent risk for the develop
ment of rampant “radiation caries,” tooth demineralization,
and osteoradionecrosis. Continued-care appointments are
scheduled at intervals to ensure excellent oral hygiene,
sound tooth structure maintenance, and the avoidance of
soft-tissue irritation. The daily use of the custom fluoride
trays with 1.1% neutral-pH sodium fluoride gel for 5 to 10
minutes followed by 30 minutes of abstinence from food and
water must con tinue for the rest of the client's life. If there is
evidence of dental decay despite compliance with daily
fluoride applica tions, the client should be placed on a 2-
week chlorhexidine regimen to decrease cariogenic bacteria
and then scheduled for in-office fluoride varnish
applications. A daily remineral izing gel application may
also be necessary in addition to the daily fluoride gel
application.
With each appointment, the dental hygienist assesses the
client's nutritional status and dietary intake. Adjustments
are made to return the client to a normal and noncariogenic
diet as the acute radiation therapy side effects resolve.
Referral for nutritional counseling may be necessary.
A thorough head and neck assessment for oral cancer and
for the function of the muscles of mastication, the temporo
mandibular joint, and any prosthetic appliances is done at
each appointment. Deficits in the needs for integrity of the
skin and mucous membrane of the head and neck and for a
biologically sound and functional dentition require immedi
ate referral to the dentist. Dental disease in an area of irradi
ated bone is managed as conservatively and as
atraumatically as possible by the dentist; management
sometimes includes antibiotic prophylaxis. If trismus occurs,
treatment consists of introducing tongue blades between the
teeth for several minutes each day and gradually increasing
the number of blades until adequate opening is achieved.
This strategy may be painful, and it requires patience and
perseverance. The dental treatment of osteoradionecrosis is
 conservative but generally requires the conservative surgical
removal of necrotic tissue, antibiotics to prevent infection,
and, ideally, hyperbaric oxygen therapy to stimulate • Approximately 40% to 80% of persons treated for non–
visualization and head and neck malignancies experience oral complications.
new bone growth. When conservative measures fail, surgical individuals who are undergoing cancer therapy. • Head and
resection is usually indicated.
Clients with End-Stage Disease
(see Chapter 61)
Evaluation
Client goals that are planned for dental hygiene care vary
tremendously, depending on the client's human needs assess
ment, disease stage, treatment, and psychologic status. Goals
and outcomes of care are evaluated repeatedly by assessing
clients' responses as they move through the various
treatment phases and make psychologic adjustments to their
disease. Outcomes of care are evaluated on the basis of
whether the planned goals are met, partially met, or unmet.
CLIENT EDUCATION TIPS
• Inform clients about the risk factors for cancer and oral
cancer.
• Assist clients with tobacco use cessation (see Chapter 36).
• Educate clients about the potential oral complications
associated with the type of cancer therapy that they will
undergo and about ways in which such conditions can be
prevented or ameliorated.
• Emphasize the importance of excellent oral hygiene
during cancer therapy. Individualize self-care plans on
the basis of the proposed cancer therapy and the client's
needs.
• Ensure that the client has full knowledge of the long-term
complications associated with oral cancer radiation
therapy and the need to continue preventive measures for
the rest of the client's life.
• Ensure that the client has full knowledge of the long-term
complications associated with the use of oral and intrave
nous bisphosphonate therapy and the need for
meticulous oral care to prevent trauma to the bone.
LEGAL, ETHICAL, AND SAFETY ISSUES
• Always perform a thorough head and neck examination to
screen for oral cancer.
• Inform clients about the potential side effects and compli
cations of various cancer therapies and strategies to
prevent and manage them.
• Coordinate clients' oral healthcare before, during, and
after their cancer therapy.
• Never abandon clients with end-stage cancer. Good oral
health is critical at this time to encourage good oral intake
and to improve quality of life.
KEY CONCEPTS
• Cancer is a term that defines a wide variety of malignant
processes that are usually treated with surgery, chemo
therapy, radiation therapy, or bone marrow or blood
stem cell transplantation.
• Pre-existing oral or dental pathology can adversely affect
the individual who is undergoing cancer therapy. • The
dental hygiene care plan plays a critical role in the care of
neck cancer radiation treatment results in some permanent
oral complications.
CHAPTER 45 n Cancer 859
• Complications associated with radiation to the head and
neck area, systemic chemotherapy, and bone marrow and
blood stem cell transplantation may be prevented or ame
liorated by oral hygiene interventions.
CRITICAL THINKING EXERCISES
CLIENT 1: Mrs. G.
Profile: Mrs. G. is a 45-year-old woman with a soft-palate
lesion and a large mass in the right side of her neck. A
biopsy reveals squamous cell carcinoma. She is scheduled
for surgery followed by unilateral radiation therapy to
the right posterior mandible and maxilla and the lateral
neck.
Chief Complaint: “I need a dental evaluation and dental
hygiene care before starting my cancer therapy.” Dental
History: Her pretherapy radiographic and clinical oral and
dental evaluation reveals no dental caries, generalized
gingivitis, and moderate plaque, calculus, and tobacco
staining.
Social History: The client is single and lives with her parents.
Health History: The client has been diagnosed with squamous
cell carcinoma of the soft palate. She currently takes no
medications, and her blood pressure is within normal
limits.
Oral Health Behavior Assessment: Mrs. G. states that she
brushes her teeth once a day, that she does not use floss,
and that she visits her dentist every year. She takes over-
the-coun ter antacids, chewable vitamin C, and
Aspergum for her sore throat. She has smoked one or two
packs per day for 25 years.
Supplemental Notes: She has dental insurance, she demon
strates sincere interest in and motivation to maintain her
teeth, and she is very interested in tobacco cessation
interventions.
1. What procedures will be included in the dental treatment
plan before radiation therapy?
2. Develop a dental hygiene care plan to be implemented
before radiation therapy.
3. What measures do you suggest to relieve this client's xero
stomia and the pain associated with mucositis? 4. What
dental hygiene interventions and recall schedule are
appropriate for this woman after radiation therapy? 5. What
are the signs and symptoms of osteoradionecrosis? CLIENT
2: Mrs. H.
Profile: Mrs. H. is a 23-year-old woman who has been under
going radiation for Hodgkin's disease.
 Chief Complaint: “I need a dental evaluation and necessary ACKNOWLEDGMENT
treatment before the next phase of my cancer therapy.” The author acknowledges Gerry J. Barker for her past contributions
Social History: She is single and lives alone. to this chapter.
Health History: She is scheduled for an allogeneic bone
marrow transplant for which she will receive total body
irradiation and chemotherapy. She will enter the bone EVOLVE RESOURCES
marrow trans plant unit in 3 weeks. Please visit http://evolve.elsevier.com/Darby/hygiene
Dental History: She had no dental support during her previ for additional practice and study support tools.
ous cancer treatment. Her dental evaluation reveals a
sensitive maxillary premolar with a large carious lesion
and a radiolucent periapical lesion, several areas of mild
demineralization, moderate plaque and calculus, and
chapped lips. No other gross caries or periodontal disease
is evident. There are no impacted teeth or bony lesions
detected by radiographs.
860 SECTION VII n Individuals with Special Needs

Oral Health Behavior Assessment: The client reports that she

brushes her teeth once a day but that she does not use
any interdental cleaning devices.
Supplemental Notes: She has dental insurance, and she
appears motivated to improve her oral hygiene care.
1. What dental treatment and dental hygiene care would be
appropriate for this client before her transplant? 2. Develop
a dental hygiene care plan to be implemented before the
bone marrow transplant.

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