Complications of ambulatory oral surgery in patients over 65 years of age

AMADO-CUESTA S, VALMASEDA-CASTELLÓN E, BERINI-AYTÉS L, GAY-ESCODA C. COMPLICATIONS OF AMBULATORY ORAL SURGERY IN PATIENTS OVER 65 YEARS OF AGE. MED ORAL 2004;9:253-62.

SUMMARY

Serious systemic disorders such as hypertension, cerebrovascular or heart disease, diabetes and psychiatric problems are common in elderly patients, and lead to the prescription of different drugs. This may in turn influence oral health, and the dentist should be familiarized with these situations when providing dental treatment in elderly patients.
A retrospective study was made of 196 patients over age 65 years to evaluate the type of ambulatory surgery performed under locoregional anesthesia, taking into account the presence of background systemic pathology, multiple drug therapy, oral and dental health, the cause of consultation and the type of anesthesia used, relating these parameters to the development of intra- or postoperative systemic and/or local complications. Some systemic disease was documented in 88% of the patents - hypertension being the most frequent disorder (in 45% of subjects with systemic disease). On the other hand, 78% of the patients used some medication, and 77% presented for hard-tissue treatment (tooth extractions, bone remodeling, etc.); 61% of all treatments comprised the removal of root fragments (54% of all hard-tissue interventions), symptomatic third molars (15%) or other dental inclusions. Only mild or moderate complications were recorded (13%) - either local (n = 25) or systemic (n = 1). No significant relation was observed between the development of intra- or postoperative complications and the type of treatment provided or the medication used by these patients. Only diabetes was associated with a significant increase in intra- and postoperative local complications (p<0.003).

Key words: Geriatric patients, ambulatory surgery, complications.

INTRODUCTION

In most developed countries the proportion of elderly people and their life expectancy is increasing considerably (1). As a result, there is an increase of geriatric patients seeking dental care, which makes it necessary to take certain age-related problems into account when providing dental treatment in this particular population group.

Geriatric patients often present chronic systemic disorders, multiple pathologies and incurable diseases - including arterial hypertension, cerebrovascular accidents, heart disease, diabetes mellitus and mental disorders. In order to treat these problems, elderly patients are usually prescribed different types of drugs, particularly antihistamines, antihypertensive medication, diuretics, anxiolytics, antidepressants, antineoplastic drugs, etc. (2-4).

These systemic diseases and their treatment can in turn influence the oral health of geriatric patients. One of the reasons why dentists are seeing a growing number of elderly patients is because they increasingly retain their own teeth, and an increased presence of caries is therefore observed in positive correlation to advanced age. In some cases, elderly subjects may require surgery for oral pathology. The therapeutic principles and techniques are similar to those used in young patients, and although their repair capacity is generally diminished, it is accepted that final healing in elderly patients is not significantly different to that found in young adults.

The present study was conducted to determine the most common types of surgical treatment in patients over age 65 years seen in an ambulatory oral surgery service, using locoregional anesthesia, with an evaluation of the prevalent systemic disorders and pharmacological treatments in this population group, and correlating the presence of background systemic disease or multiple drug therapy to the development of intra- and postoperative complications.

METHODS

The present retrospective study comprised 196 patients over 65 years of age and consecutively treated under locoregional anesthesia by differents surgeons in an ambulatory setting in the context of the Master of Oral Surgery and Implantology (Dental Clinic, Barcelona University, Spain) over a four-year period (1997-2000).

The following data were evaluated from the individual case histories: age, sex, the presence and type of background systemic pathology, the existence of pharmacological treatment, oral and dental status (including a count of preserved teeth and root remains, the number of periapical lesions, percentage of caries, the presence and type of periodontal disease, and the degree of mandibular bone resorption), the cause of consultation, the treatment provided, the existence of intra- or postoperative complications, and their local or systemic nature.

Bone resorption was evaluated from the orthopantomograph by measuring the height of the mandibular body in the region of the mental foramen. In order to avoid the different magnifications of the X-rays contributed by the patients, the ratio a/(a + b) was calculated, where a = the vertical distance between the alveolar ridge and the mental foramen, and b = the vertical distance between the mental foramen and the mandibular basilar zone. The ratio therefore represents percentage bone height above the mental foramen with respect to the total height of the mandibular body.

All variables were subjected to a descriptive statistical analysis. The association between the development of complication and several preoperative variables was analized using the Pearson chi-square test for comparing qualitative variables and the Student t-test and Mann-Whitney U-test for contrasting quantitative variables. Statistical significance was considered for p<0.05. The SPSS version 10.0 statistical package under MS Windows was used throughout.

RESULTS

A representative sample of 196 patients over 65 years of age (70.6 ± 5.0 years (mean ± standard deviation, SD); range 65-85) was studied. Women were slightly more numerous than men (54.1% versus 45.9%, respectively).

-Background systemic disease

Most of the patients (88%) presented some background systemic disorder. The most frequent systemic pathology was arterial hypertension (45% of all subjects with systemic disorders), followed by global bone and joint pathology (arthrosis, arthritis, osteoporosis, etc.)(34%). Heart disease was documented in 20%, and diabetes mellitus in 10% of cases (n = 19). In relation to the latter, type 2 diabetes was considerably more common than type 1 (insulin-dependent) diabetes (68% and 32%, respectively). Other pathologies were recorded in 8% of the patients.

-Medication

The most commonly used drug substances were antiplatelet drugs, diuretics, antihypertensive agents, analgesics, antide-pressants, oral antidiabetic drugs, gastroprotectors, etc. On the other hand, 22% of the patients used no pharmacological treatment, while 21% used a single drug, 18% two drugs, 12% three drugs and 26% used more than three drug substances - i.e., 38% used three or more different drugs (either prescribed or through self-medication).

-Oral and dental health

An average of 14.1 teeth were preserved per patient (range 0-31). In this context, "tooth" was defined when both the root and crown were present. Preservation within the mouth of the root alone was regarded as a root, the average being 1.4 roots per patient (range 0-12).

The mean number of caries (defined as macroscopically and radiologically manifest lesions) was 2.6, with a maximum of 20. On relating the mean caries to the mean number of teeth, 18.4% of all preserved teeth were seen to be caried.

The number of periapical lesions detected by pantomography and periapical X-rays was 0.8 on average, with a maximum of 8.

All patients in the study presented either localized or generalized periodontitis (the latter being the most common presentation, 85%).

Mandibular bone resorption as assessed by the a/(a + b) ratio was 54.7% on average on the right side in males, and 51.0% in females. The corresponding left-side values were 55.4% and 51.6%, respectively.

-Cause of consultation

In order to facilitate systematization of the observed pathology, a distinction was made between oral cavity hard- and soft-tissue treatments. In this context, 79% of the patients presented for hard tissue therapy (extractions, bone remodeling, etc.), while 20% presented for soft tissue treatment (biopsies, exeresis of oral mucosal lesions, etc.). Only 1% consulted for other reasons.

-Type of treatment provided

Three types of treatment were distinguished: hard tissue (teeth and maxillary bone), soft tissue, and combined soft- and hard-tissue interventions. In this context, hard tissue treatment mainly consisted of tooth extractions (accounting for 65% of all surgical operations in the study), comprising root fragments (54% of all hard tissue interventions), symptomatic third molars (15%) or other dental inclusions. The rest of hard tissue interventions consisted of maxillary treatments (bone remodeling, bone cyst or tumor resection; 6% of the total treatments).

In turn, 20% of all interventions were indicated for soft tissue pathology. Seventy-six percent of these procedures consisted of excision biopsies, while 24% were incision biopsies. Most of the treated lesions were benign hyperplasias (75%), followed by leukoplakia (20.1%) and other lesions (2.4%).

Finally, combined soft- and hard-tissue treatment in the same operation was carried out in 10% of cases, e.g., extraction of a third molar with excision of a maxillary cyst.

-Type of locoregional anesthesia used

Most of the 196 operations (73%) were performed under 4% articaine anesthesia with adrenalin 1:100,000 (88.8%) or 1:200,000 (11.2%). Some patients presenting cardiovascular disease or some other condition contraindicating the vasoconstrictor received 3% prilocaine with felipressin at a concentration of 1:1,850,000 (15% of cases) or 3% mepivacaine without vasoconstrictor (6%). A less commonly used anesthetic was 2% lidocaine with adrenalin 1:100,000 (5% of all operations).

-Complications

Of the 196 operations, complications were only observed in 26 cases (13%), and were essentially of a local nature (25 cases, versus a single systemic complication in the form of a postoperative hypertensive episode requiring hospital treatment).

The most frequent local complications were excessive bleeding (38%), with intra- or postoperative hemorrhage (60%) and postoperative hematomas or ecchymosis (40%); inflammation (defined as exaggerated and/or persistent edema or local swelling)(11%); and vestibular or lingual cortical fracture during the extraction of lower third molars (15% of all operations). Other situations recorded were recurrence of the disorder (three of the 26 complications), post-extraction pain syndrome (4%), etc.

No correlation (p>0.05) was found in our study between the development of complications either during or after surgery and the use of multiple drugs, or as regards the surgical technique employed.

As to the presence of background systemic pathology and the development of such complications, a significant correlation was only found with diabetes mellitus (p = 0.003). In this context, 19 of the 26 patients who presented complications suffered diabetes.

DISCUSSION

As the population ages, the proportion of people requiring medical care for mainly chronic and incapacitating systemic diseases increases. A clinical history as detailed and complete as possible, together with adequate examination and complementary studies, informs of the general condition of the geriatric patient and may reveal the existence of certain background systemic alterations that require special consideration before providing dental treatment, as in the present retrospective study (4).

Elderly patients may require surgery to treat different oral problems, and the general therapeutic principles applicable in this population group are essentially similar to those corresponding to patients of any other age. Although healing capacity diminishes with advanced age, the final results are similar to those obtained in young adults (1).

In the United States, 85% of the elderly and 95% of those over age 65 cared for in institutions receive some kind of medication. According to a study conducted in Andalusia (southern Spain) to assess the oral conditions among the elderly, these patients consume an average of 2.8 drugs per individual, the mean number of systemic disorders being 2.3, acording with our results. Most of the subjects in our study (88% of those over age 65 subjected to treatment) presented some systemic disorder requiring the use of various drug substances (5-6).

The elderly increasingly live longer, though they must often cohabit with different chronic illnesses. In our study based on the findings of an ambulatory care University dental clinic, an important prevalence of arterial hypertension was observed (45% of the patients), together with joint or bone pathology (34%), heart disease (20%) and diabetes mellitus (10%). Other studies (9,15,23) have reported similar data: arthritis in 48.4% of patients, arterial hypertension in 30-50%, heart disease in 27.7%, and diabetes in 9.8%. In this sense, the literature shows cardiovascular disorders such as arterial hypertension and heart failure to be the most common systemic problems (48.8%) (22).

Cardiovascular diseases (including hypertension) must be carefully assessed in the geriatric patient, since they constitute the first cause of death in this population group. Indeed, 75% of all deaths among individuals over age 50 are related to arterial hypertension (7).

The systemic pathology found in geriatric patients may lead to increased intraoperative morbidity and mortality, and this surgical risk is in turn dependent upon patient-related factors (systemic pathology), the anesthesia employed, and the surgery performed (technique and duration). Patient age is one of the factors influencing surgical risk, though the causes underlying intraoperative morbidity and mortality are the same in patients over age 65 years and in young adults. Nevertheless, different epidemiological, bacteriological and immunological studies have shown the presence of periodontal disease or caries to indirectly cause an important increase in morbidity and mortality - particularly among older persons, due to the important repercussions of oral health upon the general condition of individuals in general (8).

Systemic effects are to be expected following locoregional anesthesia, as a result of the action of the vasoconstrictor (normally adrenalin) that accompanies the anesthetic substance. These effects are a result of beta-receptor stimulation, which increases cardiac output and blood pressure (particularly systolic pressure, due to the increased heart rate and inotropic effect). However, it should be pointed out that at the habitually administered doses these effects are practically negligible (9). The amount of adrenalin administered with the local anesthetic used in dental practice generally causes no effects other than local vasoconstriction, with an increase in the intensity and duration of the anesthetic action. Failure to elicit this action would produce pain, which would in turn increase endogenous catecholamine levels and thus also blood pressure. In this sense, it is known that the amount of endogenous adrenalin released as a result of patient stress is much greater than that contained in an anesthetic cartridge (10). Therefore, it is more important to secure a good anesthetic effect, even if the solution contains adrenalin, than to risk patient fear and anxiety - which would induce far greater endogenous adrenalin levels than the concentrations produced as a result of the injection of an anesthetic-vasoconstrictor solution. Elderly patients with severely impaired cardiovascular function may be particularly sensitive to vasoconstrictors. Nevertheless, ambulatory oral surgery is not contraindicated in patients with slight to moderate arterial hypertension, provided the latter is adequately controlled and compensated. Hypertensive patients who receive medication and are well controlled can present minimum blood pressure fluctuations no greater than those seen in normotensive individuals, and which do not pose a clinical risk for oral surgery. In any case, it is advisable to discard a vasoconstrictor in those cases where a completely blood-free surgical field is not needed. Furthermore, in the presence of inflammation or infection, a local anesthetic with a low dissociation constant (pKa)(e.g., mepivacaine) is indicated, and when good hemostasia is required, adrenalin at a concentration of 1:200,000 is advisable (8,11).

Accordingly, in our study we used 4% articaine with adrenalin 1:100,000 in 66% of cases, while surgery in patients with cardiovascular disease or any other contraindication for vasoconstrictors was performed administering 3% prilocaine with felipressin at a concentration of 1:1,850,000 (15% of cases) or 3% mepivacaine without vasoconstrictor (6%). As a general rule, vasoconstrictors are not advised in elderly patients with grade III hypertension according to the Malamed classification (12), poorly compensated and recent onset cardiovascular disease (6 months after myocardial infarction or cerebrovascular stroke), patients treated with tricyclic antidepressants or hypotensive beta-blockers (the latter implying the risk of severe hypertensive episodes upon interacting with the catecholamines contained in the anesthetic solution), and in surgery where a dry surgical field is not essential.

Sedative premedication is beneficial for lessening patient anxiety. Furthermore, the use of nitrous oxide, for example, offers the additional advantage of increasing arterial oxygen pressure. According to some authors, sedation is the best way to control endogenous adrenalin levels, and the myocardium may moreover benefit from the increased oxygen supply afforded by nitrous oxide as sedative. This indication is applicable in patients with coronary problems, a history of cerebrovascular events, or in hypertensive individuals. Some studies have even considered this technique to largely reduce the appearance of dysrhythmias (2). On the other hand, the administration of benzodiazepines to ensure anxiolytic action can be useful in ambulatory treatments, though such prescription requires prior approval by the physician treating the background systemic pathology of the patient.

The oral manifestations of diabetes mellitus are relatively frequent. In this sense, an increased incidence of caries has been reported, in part accounted for by the type of diet of these patients. Furthermore, diabetics present a series of specific immune deficiencies which imply an increased vulnerability to infection and poorer wound healing (13-14). Nevertheless, well controlled diabetics show no greater incidence of infections than the general population (15). Although in our study no significant relation was observed between the presence of diabetes mellitus and the prevalence of caries (p = 0.57), an increased presence of inflammatory complications was recorded among these individuals - a phenomenon which could be explained in terms of diabetes-related neutrophil chemotactic alterations.

Furthermore, unlike habitually believed, these patients are not more susceptible to hemorrhagic accidents than non-diabetics, and may even show a hypercoagulative tendency. Other possible disorders associated with diabetes mellitus (e.g., renal failure), and which are often not taken into account, may indeed pose an important risk of intraoperative bleeding (resulting from an associated complication or from the actual renal failure associated with diabetes) (15,16). In our series there were ten cases of bleeding complication, though none of the affected patients were diabetics. The reason for this bleeding may be related to the medication some of the patients were using for their cardiovascular pathology, such as acenocoumarol (Sintrom®) or the prolonged use of nonsteroidal antiinflamma-tory drugs (NSAIDs).

Our study detected no correlation between the development of intra- or postoperative complications and the use of drugs; this is logical to a point, since only concrete drugs are usually associated with specific complications, such as continued corticosteroid therapy and the appearance of postoperative infectious processes, or oral anticoagulants and excessive intra- or postoperative bleeding.

The pharmacological treatment of a systemic disorder may have side effects at oral level (4). Due to the existing multiple disor-ders, many of these patents are seen to receive treatment in the form of tricyclic antidepressants, antihistamines, antihyper-tensive drugs, antineoplastic agents, diuretics and tranquilizers - all of which induce decreased salivary flow as a side effect (3). Approximately 75% of all patients over 65 years of age use drugs which inhibit salivation (7,13). The present study did not evaluate the types of drugs used, but only their number, though since the medication is generally related to the pathology present, the most frequent drugs would appear to be those prescribed for cardiovascular disease. The treatment of arterial hypertension, which often implies a combination of drugs, should be evaluated due to its possible effects upon salivary flow (xerostomia), taste (dysgeusia, particularly characterized by a metallic taste), or the oral mucosa (lichenoid reactions) - as occurs for example with certain diuretics such as the thiazides (4, 8). We observed no significant relation between the presence of hypertension and increased caries (p = 0.84), or an increased number of root fragments in the mouth (p = 0.22), in contrast to what might be suggested by the tendency of these drugs to cause oral dryness and thus an increase in caries - with a resulting rise in the number of root fragments over the long term. An explanation for this lack of an association could be afforded (among other factors) by the fact that many other variables also contribute to the development of caries, in addition to the administration of xerostomia-inducing drug substances.

Likewise, no association was found between the existence of cardiovascular disease and the appearance of complications in relation to the surgical technique employed (p = 0.157). The usual preventive measures, such as monitorization, the administration of an adequate anesthetic and the provision of anxiolytic premedication (depending on the case and evaluating whether it is truly necessary) are to be strictly observed in the case of patients with this kind of systemic pathology. The adoption of such measures considerably reduces the risk of intra- or postoperative complications - particularly those of a systemic nature.

The dental professional should evaluate the need for buccodental treatment in geriatric patients and must focus priority on problems such as xerostomia, root and coronal caries, periodontal disease, residual crest resorption, the lesions produced by dentures, and stomatitis (among other alterations), since they are the most frequent and conditioning problems in patients belonging to this age group.

Although caries in the elderly are usually long-evolving and are often quite advanced, they can be asymptomatic. Studies addressing dental health and the need for treatment in the institutionalized geriatric population have found the incidence of caries to be greater in men and to increase with age. This is because males preserve a larger number of teeth and show comparatively greater neglect of oral hygiene. In the same way, our patients logically showed a decreasing number of teeth with increasing age, with an average of 16.3 teeth in the mouth among those under age 70, versus 11.8 teeth in patients aged 70 years or older - in coincidence with the findings of other authors (5). However, we observed no relation between patient sex and the degree of edentulism, in contrast to the observations of other investigators who report edentulism to be more frequent in women - though the patient series involved in these reports was rather limited (16,17).

Most elderly individuals are totally edentulous, though the most recent studies show 20% or more to retain some of their natural teeth. The preservation of teeth is closely related to socio-economical factors, and in this sense the economical status of a great majority of elderly persons in Spain is precarious. The frequency of total edentulism in the western world varies from 59-80% of the population over age 65, though in some countries such as Canada the figure is considerably lower (24-55%), and possibly reflects the existence of a higher socio-economical status. In our case, we can not report dates of this theme, although our patients are not a representative serie of all the geriatric patients.

Elderly individuals often present chronic oral disorders such as periodontitis, and bone loss tends to be cumulative and progre-ssive (1,18,19). Although most if not all people over age 65 present mild or moderate periodontitis, only 5-20% suffer severe periodontitis (20-22). In our series all patients over 65 years of age presented periodontitis, and 85% had generalized periodontitis. In any case, this pathology did not influence the appearance of intra- or postoperative complications.

In general, geriatric patients with poor oral hygiene (a majority in almost all studies published in the literature) suffer important bone loss - this condition being more common in men than in women. The index used in our study to assess bone resorption (a/(a + b)) provides an idea of mandibular bone level at the height of the mental foramen, but does not offer an exact evaluation. Indeed, this level depends not only on bone resorption but also on the location of the mental foramen - though in principle all our patients were considered to present a similar location of the foramen.

The jaws suffer progressive atrophy with age similar to that seen in other parts of the skeleton, and in this context tooth extraction always implies a loss of alveolar crest. The degree of such resorption varies among individuals and can be influenced by different factors such as the wearing of dentures, diet, periodontal disease, etc. In patients of similar age, women show greater bone resorption than men (particularly at mandibular level). Endocrine factors also influence alveolar bone resorption. In effect, postmenopausal women with osteoporosis suffer more severe resorption than premenopausal women of the same age.

CONCLUSIONS

Geriatric patients (over 65 years of age) visit our ambulatory oral surgery service mainly for the extraction of root fragments and symptomatic third molars. No significant relation was observed between the development of intra- or postoperative complications and the type of treatment provided or the medication used by these patients. Only diabetes was associated with a significant increase in intra- and postoperative local complications (p<0.003).

A clinical history as detailed and complete as possible is decisive for the surgical management of these patients. Knowing the general condition of the patient, there should be no problems or obstacles for the planning and performance of surgery, and adoption of the required preventive measures with availability of the necessary resources should suffice to control any adverse situation that may arise.

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