Systemic Treatment (Phase)

🩺 What is the Systemic Phase of Treatment?

The systemic phase is the initial part of treatment planning where the dentist must assess a patient’s overall general health before engaging in any active dental therapy.

The primary goal is to evaluate the severity and complexity of a patient’s existing health issues and then create a strategy to manage their dental care safely within that context. This phase is designed to ensure the patient is in the best possible state of physical health before, during, and after their dental treatment.

This phase has become increasingly important as the elderly population, which often retains its teeth, continues to grow, and as medical advances allow people with serious illnesses to live longer and seek dental care.

Why the Systemic Phase is Performed

There are four main reasons for conducting a thorough systemic phase evaluation:

1. Recognize Undiagnosed Disease: To identify signs and symptoms of systemic conditions the patient may not be aware of (like hypertension or diabetes) and refer them to a physician for evaluation.
2. Modify Dental Treatment: To determine if dental treatment needs to be limited or altered based on the patient’s systemic findings.
3. Prevent Emergencies: To avoid potential medical emergencies in the dental office that could be triggered by stress or dental procedures.
4. Prevent Complications: To prevent serious postoperative issues, such as infection or bleeding, that could arise from dental treatment.

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How the Systemic Evaluation is Conducted

The evaluation is typically performed using two main methods:

1. Review of General Health History

This involves a thorough analysis of the patient’s health questionnaire and a direct interview. Key areas of focus include:

• Medications: Documenting all prescription drugs, over-the-counter products, and herbal supplements. This helps identify the indications for each drug and any potential side effects relevant to dentistry, such as xerostomia (dry mouth) or an increased risk of bleeding.

• Allergies: Identifying and documenting any true allergies to drugs (like penicillin) or dental materials (like latex).

• Past Hospitalizations: Noting any past surgeries or hospital stays, such as for cancer treatment or joint replacements, which may require specific precautions.

2. Physical Evaluation

This involves direct observation and measurement:

• Vital Signs: Blood pressure is one of the most common abnormalities detected. It should be measured and recorded at every patient appointment.

• Visual Inspection: Observing the patient’s general appearance, including their gait, posture, and skin color, can offer clues to undiagnosed systemic problems.

• Oral Examination: The head, neck, and oral cavity are examined for physical signs of systemic disease. Examples include:

  • Tooth Erosion: May suggest gastroesophageal reflux disease (GERD) or bulimia.

  • Gingival Hyperplasia: Can be a local reaction to certain cardiac, seizure, or cancer chemotherapy drugs.

  • Oral Yeast Infection: May indicate decreased immunity, such as in poorly controlled diabetes or AIDS.

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ASA Physical Status Classification

A key tool used during the systemic phase is the American Society of Anesthesiologists (ASA) Physical Status Classification system. This system helps estimate the patient’s medical risk. A dentist may require a medical consultation before treating a patient in ASA category III or IV.

ASA Class	Description	Examples
I	Normal healthy person
II	A patient with mild systemic disease or a significant health risk factor	Well-controlled diabetes (DM), well-controlled hypertension (HTN), asthma, pregnancy, smoker, extreme anxiety
III	A patient with moderate to severe systemic disease that limits activity but is not incapacitating	Stable angina, post-myocardial infarction (MI), poorly controlled HTN, massive obesity, symptomatic respiratory disease
IV	A patient with severe, life-threatening systemic disease	Unstable angina, liver failure, severe congestive heart failure (CCF), end-stage renal disease

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Key Actions and Outcomes of the Systemic Phase

Based on the findings from the history and physical evaluation, the dentist will implement one or more of the following systemic procedures:

• Consultation with a Physician

  This may be done to request an evaluation for a suspected condition (like hypertension), to get clarification on a patient’s current medical status and medications, or to have a collegial discussion about the risks and benefits of a proposed dental plan.

• Postponing or Limiting Treatment

  In some cases, dental treatment must be postponed or limited. For example, elective dental treatment should be deferred for a patient with a blood pressure reading of $\ge 180/110$ mmHg or a patient with uncontrolled hypertension or unstable angina.

• Stress and Anxiety Management

  This is a critical intervention, especially for patients with cardiac disease, diabetes, or severe anxiety. Techniques include:

  • Scheduling short appointments, often in the morning.

  • Discussing the treatment plan to familiarize the patient with procedures and alleviate fear.

  • Considering the use of nitrous oxide, antianxiety medications, or conscious sedation.

• Prescribing or Altering Medication

  This is done to manage pain or, more commonly, to prevent infection.

  • Antibiotic Prophylaxis: This is recommended for patients with specific high-risk cardiac conditions, such as prosthetic heart valves, a history of infective endocarditis, or certain congenital heart defects. Prophylaxis is given before dental procedures that involve manipulating gingival tissue or the periapical region of teeth.

  • Pain Control: Care is taken to select appropriate pain medications. For example, aspirin must be avoided in patients taking anticoagulants like warfarin.

• Positioning the Patient in the Dental Chair

  A patient’s chair position may need to be modified.

  • Patients with conditions like congestive heart failure or emphysema may not tolerate being fully reclined.

  • Women in the last trimester of pregnancy are often more comfortable turned slightly to the side.

  • The chair should be raised slowly at the end of an appointment to prevent orthostatic hypotension (faintness upon sitting up).

Checklist for systemic Phase

Systemic Phase Checklist

• Do I need to modify my treatment to prevent a medical emergency or other complications?
• Does the patient have any significant allergies?
• Is there a risk of a medical emergency during dental treatment?
• Is there an increased risk of bleeding?
• Is there an increased risk of perioperative infection?

Medications

• Are there significant oral and systemic side effects to be aware of?
• Are there any interactions with drugs that are prescribed, recommended, or administered by a dentist?
• Do I need information from the patient’s healthcare provider? How will this alter my treatment plan?
• Does the patient’s medical condition affect their risk for oral disease?