Dental Management of the Medically Compromised Patient

1. Dental Management of the Medically Compromised Patient Donald Falace, DMD Professor and Division Chief Oral Diagnosis and Oral Medicine

2. Objectives of the Course • Help you identify patients with various types of medical problems who might be at risk for having problems as a result of dental treatment • Help you to plan and deliver dental treatment in such a way as to avoid or minimize the chances of an adverse event or outcome occurring, thus protecting your patients from injury, disease or adversity. • Help you to avoid litigation, anxiety, sleepless nights and heartache.

3. Instill fear Inflict pain Inject local anesthetic solutions Inject potent vasoconstrictors Cause bleeding Dictate body position Expose to radiation Expose to dental materials Prescribe medicines Alter oral function Alter appearance What do we do in the course of providing dental treatment that can affect the physical and emotional health and well being of a patient?

4. Risk Assessment? Can we provide dental treatment to this patient without endangering their (or our) health and well being? Yes. No problems are anticipated, and treatment can be delivered in the usual manner. Yes. The potential for problems exists, however, modifications can be made in the delivery of treatment that reduces risk to an acceptable level. No. Potential problems exist that are serious enough to make it inadvisable to provide elective dental treatment.

5. Risk Assessment • Physical/Emotional • -stability • -control • -tolerance • -reserve • Dental Procedure • -invasiveness • -trauma • -blood loss • -duration

6. Syncope Mild Allergic Reaction Angina Pectoris Postural Hypotension Seizures Asthmatic Attack Hyperventilation Epinephrine Reaction Insulin Shock Cardiac Arrest Anaphylaxis Myocardial Infarction Most Common Medical Emergencies in Dental Practice Many of these events are preventable, or at least the chances of them occurring can be lessened

7. Identifying the Patient at Risk • Medical history (questionnaire/interview) • Physical examination (general survey, face, eyes, skin, etc) • Laboratory tests (screening, confirmation) • Medical consultation (physician, dentist, pharmacist)

8. Medical History • Printed questionnaire, paper or electronic (patient must be literate, competent, of legal age) • Follow-up dialogue/research; make notes on questionnaire • Use ink - not pencil • Patient, student, and faculty signature, date • Update regularly • Inquire at each appointment about any changes in health or medications since previous appointment and include this in your progress note; “no change in health history” • New questionnaire completed (every 1-2 years)

10. The Medical History – Now What?? • Review the Medical History and note positive responses • Interview the patient to gain more information about those positive responses; write in the margins of the history form • Innocuous or insignificant problems can be disregarded • Potentially significant disorders OR unfamiliar disorders require further thought and/or investigation • YOUR RESONSIBILITY!!

11. Reference Sources: Basic Medical Information • Little,J, Falace,D, Miller,C, Rhodus,N: Dental Management of the Medically Compromised Patient, 6th ed, Mosby, 2002 (~$55) • The Merck Manual (~$35) • Harrison’s Principles of Internal Medicine (~$125) • Cecil’s Textbook of Internal Medicine (~$139) • Internet (PubMed, Medline, eJournals, Google scholar, MD Consult)

12. Reference Sources: Drug Information • Drug Information Handbook for Dentistry (Lexicomp) ~$45 • Physician’s Desk Reference • PDR ~ $95 • OTC drugs • Nutritional supplements • Herbal medications • Facts and Comparisons • Drug Information for the Health Care Provider (USPDI) • Internet

13. Internet Based Websites for Drug Information • Med center library website (Micromedix) • Google scholar • www.ada.org • www.drugs.com • www.factsandcomparisons.com • www.fda.gov/cder/drug/default.htm • www.lexi.com • www.nlm.nih.gov • www.rxlist.com

14. Drug Information • Drug Name (brand and generic) • Drug type or action • Why prescribed • Interactions • Epinephrine • Antibiotics • Analgesics • Sedative/hypnotics • Oral manifestations • Side effects

15. Clinical Examination • General appearance • Behavior • Vital signs • Head and neck • Oral tissues • Radiographs

16. Laboratory Tests • Determine coagulation status (von Willebrand’s, hemophilia) • Determine level of anticoagulation (coumadin) • Screening for blood glucose (periodontal disease, burning mouth) • Screen for infectious disease (hepatitis C, AIDS) • Screening for liver function (hepatitis C, cirrhosis) • Screening for kidney function (renal failure) • Complete blood count with differential [CBC with diff] (burning mouth, unexplained oral lesions)

17. Medical Consultation • Purpose: • Verify or clarify information • Determine risk for doing dental treatment on the patient • Determine if any changes are required in the delivery of dental treatment • Be brief and to the point • Letter, FAX, phone call • Response should attached to or recorded in the patient’s chart

18. Phone Consultation • Often the physician will not be available to talk to you directly • You may instead talk with a nurse or receptionist who will convey what the physician has said or who will tell you what is in the chart • It is mandatory to document this conversation, to include to whom you spoke and what was said • Direct, written confirmation of this consult is advisable for medico-legal reasons • Suggestion: Write a brief summary of the conversation and FAX it to the physician; include a statement to the effect that if they disagree with the summary, they should FAX their correction to you within 24 hours; your FAX should be attached to the chart

19. Medical Consult: Example • Pt History: 24 year old female with a past history of heart murmur but is unsure of current status • Reason for consult: Determine if the patient has a heart murmur and if so, determine if the patient requires antibiotic prophylaxis for invasive dental treatment?

20. Medical Consult: Example • Pt History: 62 year old male with history of symptomatic heart failure; an inability to climb a flight of stairs without getting short of breath or having chest pain • Reason for Consult: Can this patient tolerate routine dental treatment including fillings, and gingival surgery using local anesthetic with 1:100,000 epinephrine?

21. Then, answer this question…. • Are there any potential problems related to the provision of dental care?

22. ABC’s of Problem Identification Antibiotics Anesthesia Anxiety Allergy Bleeding Chair position Drugs Devices Equipment Emergencies

23. Are there any potential problems related to the provision of dental care? • If not, proceed with treatment in the usual manner • If yes, then…

24. Answer this question…. • Are there any potential problems related to the provision of dental care? If yes, then… • How do I need to modify treatment to avoid those problems?

25. Dental Treatment Modifications

26. Examples of Treatment Modifications • Pre-op: • prophylactic antibiotics • sedative • food intake • Intra-op: • upright chair position • minimize or avoid epinephrine • nitrous oxide • hemostasis measures • Post-op: • analgesics • anti-fibrinolytic agent • antibiotics

27. Answer this question…. • Are there any potential problems related to the provision of dental care? • If not, proceed with treatment in the usual manner • If yes, then… • How do I need to modify treatment to avoid those problems? • Are there any oral manifestations related to the disease or it’s treatment?

28. Oral Manifestations • Dry mouth (xerostomia) • Oral ulcerations/lesions • Burning mouth/tongue • Bleeding • Gingival hyperplasia • Fungal/bacterial infections