he state of Utah has a large refugee/new American population that grows annually. Many of these individuals are from Islamic countries and observe Ramadan.  

Ramadan is an Islamic event observed by Muslims worldwide. It occurs during the ninth month of the lunar calendar. In 2023, Ramadan will be observed March 22 through April 21. Ramadan is characterized by fasting from dawn to sunset, during which the consumption of any substance with nutritional value (i.e., food and water) is forbidden. Although certain exemptions, such as medical illness, allow individuals to forego fasting, many people feel an obligation to fast regardless.  

The University of Utah School of Dentistry (SOD) proudly serves Utah’s refugee/new American population. Each year, providers at the SOD are faced with the challenge of providing care to this patient population during Ramadan as patients often halt their treatment for the entire month in order to fast. While this may work with certain patients, it is not a reality for all patients. 

Ramadan-friendly care 

Dental emergencies, oral pain, and completion of various treatments often cannot be postponed. To help, providers have worked with patients and religious leaders to develop Ramadan-friendly means of providing treatment during fasting times.

We share this information with the ultimate hope of empowering fellow dental providers so they too can continue caring for patients during Ramadan.  

The most crucial information that can be shared regarding Ramadan is that missed days can always be made up. If a patient must break their fast for a dental procedure, they can fast for an additional day to make up for the missed day. Furthermore, the critical defining term for which substances can break the patient's fast is nutrition. An example of this is the local anesthetic. While it does enter the body, it possesses no nutritional value; therefore, it will not break the patient's fast.  

Additionally, there is a key distinction between substances entering the patient's mouth and those being swallowed and entering the stomach. Those in the latter category will break the patient's fast. It should be noted that this view may vary patient-to-patient. More orthodox believers may protest water even entering the mouth regardless of the evacuation means present in the dental setting to prevent it from entering the stomach. It is best to discuss the procedure with the patient and obtain informed consent before the visit.  

Procedures that can be performed while a patient is fasting include the following: 

• Restorative treatments 

• Crown preparations 

• Simple extractions 

• Endodontic therapy 

• Removable prosthodontics 

Ramadan dental care do’s and don’ts  

Treatments that cannot be rendered during a fast include periodontal therapy and surgical extractions. The water used during these procedures cannot predictably be prevented from being swallowed by the patient. 

Providers should be aware of the following: 

Anesthetic

• Administration of anesthetic is a necessary component for the majority of dental treatments. Given that local anesthetic does not possess nutritional value, its delivery can be completed without hesitation. The same principles apply to topical anesthetic. The dentist must utilize evacuation to remove any anesthetic that touches the patient's tongue to prevent discomfort from the unpleasant taste. As always, discuss the use of anesthetic before starting treatment and obtain informed consent from the patient. If the patient is hesitant about any fluid entering their mouth or body, there are two options: postpone treatment if possible or inquire if the patient would be comfortable making up the missed day if treatment is of an acute nature. This decision is preferably made before the visit, so chair time is not lost if treatment is postponed.  

Rubber dams

• Using a rubber dam will allow the dentist to provide various dental treatments. However, the provider must ensure that proper and complete isolation is obtained so water is not accidentally swallowed by the patient, thereby breaking their fast. 

• A rubber dam can facilitate providing most direct restorative procedures for fasting patients. When adjusting the final restoration, turn the water down on the high-speed handpiece to a reasonable level and have the assistant provide close evacuation to predictably prevent any water from accidentally being swallowed by the patient.  

• While crown preparations are not typically completed with a rubber dam, during fasting times, they can be used to obtain isolation to prevent water from being swallowed by the patient. Checking for adequate occlusal reduction can be done in one of two ways. Either wait until the majority of the crown preparation is completed, remove the dam and check for occlusal reduction and place the dam back on to refine the preparation, or use a tooth-borne reduction guide to verify reduction without removal of the rubber dam. Final impressions can be taken with PVS material without worry, as patients typically feel the material well and tend not to swallow it. If the impression material is swallowed accidentally, it is not worrisome, as it does not provide any nutritional value to the body. Once again, obtaining informed consent before starting treatment is critical.   

• Endodontic therapy can be rendered following anesthesia delivery. Because using a rubber dam is the standard of care for endodontic procedures, isolation should prevent any water from being accidentally swallowed by the patient. Then, adjust occlusion based on the steps explained above.  

Simple extractions

• Simple extractions are another treatment that can be rendered without introducing water into the patient's mouth. A slight complication, which may arise, is not wetting the gauze placed over the extraction site, which could lead to dislodgment of the clot upon removal. As such, it is recommended that oral surgery only be completed under acute needs to prevent undesired outcomes. Additionally, ample gauze should be given to the patient with instructions to change them out as soon as they feel that the gauze is saturated. The rationale is that the patient might feel the urge to spit out the accumulating blood from the extraction site to avoid swallowing it. Spiting can lead to dislodgement of the clot leading to alveolar osteitis and other complications. Surgical extractions cannot be completed, as ample water must be used for irrigation to prevent damaging the bone from overheating. Swallowing in these cases cannot be predictably prevented.

Talk with patients about their care

Ramadan reminds us to respect the cultural values and traditions of our patients. Our patient’s choice to persist in their beliefs is entirely their own. Our role is to support them by helping provide care that is in line with their beliefs.

If you’re not sure your patient is practicing, or you don’t know to what degree your patient practices, you can:

• Refer to the patient’s documented spiritual preference. Go to: Chart-Review > Miscellaneous Reports > Learning assessment > SPIRITUAL/CULTURL: Any spiritual/cultural practices that affect your care?
• Simply ask your patient for clarification. Check to see if they’re practicing/fasting, and for what purpose. Open dialogue helps you build stronger connections with patients.

Originally published March 2024