MANAGEMENT OF THE MEDICALLY COMPLEX DENTAL PATIENT

Brent Hutson, D. D. S., M. S.Director of Clinical ProsthodonticsBaylor College of Dentistry – Texas A&M University Health Science Center

ASA Classifications ASA I—

Healthy patient free of organic disease ASA II—

Pt. With mild systemic Dz. That does not limit activity (smoking, obesity,controlled HTN)

ASA III— Pt with severe systemic Dz that limits

activity, but not incapacitated (past MI, CHF, COPD)

ASA IV— Pt with incapacitating Dz that is a constant

threat to life (acute MI, organ failure) ASA V—

Moribund pt not expected to survive 24 hrs with or without surgery

Never treat a stranger…

Some exceptions Some reasons Risk vs. reward

The Patient’s Chief Complaint

Should be recorded in the patient’s own words

Usually relates to one of the following categories Comfort (pain, sensitivity, swelling…) Function Social (taste/odor…) Appearance

Medical/Dental HistoryExam and Interview Documentation of the current state of the

patient Documentation of where pathology

resides Facilitates the development of a

relationship Provides an opportunity for

undisclosed ‘problems’ to surface It’s the law

Subtle Observations

Inactive or prior history of periodontal disease or issues…

Diagnostic Process

Exam/interview Radiographs Diagnostic tests Pt. consent and approval

The Consent Process…

Not just a form, but a process Originates from the legal community

Tort of battery Blanchard v. Kellum, 975 S.W.2d 522 (Te

nn. 1998).

Must be written (the law) but must also include discussion (Texas)

Affords an opportunity for communication and abatement of misunderstanding issues

Not fool proof, and no guarantees

Barriers to H&P/Consent Process Lack of attention to detail Compartmentalization Production! Scheduling/Patient load Honest mistakes

Take home message…

“Problems encountered during or after treatment can often be traced to errors and omissions during history taking and initial examination. An inexperienced clinician may plunge into the treatment phase before collecting sufficient diagnostic information that helps predict likely pitfalls.” Rosenstiel

Now on to the good stuff!

Why are so many people taking so much medicine? Research and development Diagnostic thresholds Therapeutic criteria Marketing

Are there to many lifeguards on the gene pool? People are living longer People with historically terminal

illness

AHA Prophylaxis Review

Dental Procedures in Which Endocarditis Prophylaxis Is Recommended for High Risk Patients: All dental procedures that involve

manipulation of gingival tissue or the Periapical region of teeth or perforation of the oral mucosa.*

AHA Prophylaxis Review

*The following procedures and events do not need prophylaxis: Routine anesthetic injections through non-infected

tissue Dental radiographs Placement of removable prosthodontic or

orthodontic appliances Shedding of deciduous teeth Bleeding from trauma to the lips/oral mucosa

What conditions warrant premedication?Yes… No…

Prosthetic valve PMH of IE PMH/Hx of congenital

heart disease Cardiac

transplantation

MVP PMH of Rheumatic

Fever Generic Murmur

Prophylaxis Review Orthopedics

Not indicated for Patients with: Pins, plates and Screws

Decision Should be Based on Type of Dental Procedure

Patient’s Medical History Considered Generally- Medically Compromised with Total Joint

Medical Consultation is Always Advised

Write narrative/questions here

Corticosteroid Therapy

Long term vs. short term Oral, parenteral, topical

COPD/asthma, arthritis, oncology, some dermatological conditions

Some allergy conditions Inhaled and topical

Some dermatological conditions Allergies (respiratory, contact) Some short term pulmonary conditions

Side Effects of Short-Term Corticosteroids

Sleep disturbance Increased appetite Weight gain Psychological effects, including

increased or decreased energy Rare but more worrisome side effects of

a short course corticosteroids include: mania, psychosis, heart failure, peptic ulceration, diabetes and aseptic necrosis of the hip.

Side Effects of Long-Term Corticosteroid Therapy

Precipitation or aggravation of diabetes mellitus (high blood sugar).

Increase in circulating blood fat (triglycerides). Redistribution of body fat: moon face, buffalo hump and

truncal obesity. Salt/fluid retention: leg swelling, raised blood pressure,

weight increase and heart failure. Shakiness and tremor. Eye disease, particularly glaucoma (increased intraocular

pressure) and posterior subcapsular cataracts. Psychological effects including insomnia, mood changes,

increased energy, excitement, delirium or depression. Headaches and raised intracranial pressure. Increased susceptibility to infections, via immunosuppressant MAY NEED ADDITIONAL DOSAGE Peri-operatively

Ultimate Outcome of Long Term Corticosteroid Therapy.

Cushing’s Syndrome Weight gain, particularly around

midsection/upper back Fatigue Muscle weakness Rounding face (moon face) Facial flushing Fatty pad or hump between your shoulders

(buffalo hump) Thin and fragile skin that bruises easily Slow healing of cuts, insect bites and infections Depression, anxiety and irritability Thicker or more visible body and facial hair

(hirsutism) High blood pressure

Management of Patients with Liver Disease

Hepatitis A, B, C and Delta

Delta hepatitis occurs as a co-infection with acute hepatitis B/ or super-infection in carriers of hep- B, transmitted parenterally via blood/blood products

Type E- enteric transmitted similar to A Patients with active hepatitis Patients with positive

antibodies/subclinical

Alcoholic Liver Disease

Fatty infiltrate; hepatocytes become engorged with fatty lobules

Alcoholic hepatitis; diffuse inflammatory condition characterized by destructive cellular changes

Cirrhosis; most serious form of alcoholic liver disease, is characterized by progressive fibrosis and abnormal regeneration of liver architecture in response to chronic injury

http://www.brown.edu/Courses/Digital_Path/Liver/fatty_liver.htm

Treatment of Patients with Alcoholic Liver Disease

The absence of ascites dental tx is usually well tolerated (including surgery)

Also look for fat deposits infraorbitally

Petechia, Rhinophyma, Parotid Hypertrophy and peripheral wasting

Patients on “Blood Thinners” Aspirin

Aspirin and NSAIDs (non-steroidal anti-inflammatory

drugs):

Platelet Aggregation Inhibitors (Intrinsic)

Coumadin (Vitamin K) Extrinsic

Aspirin/NSAIDs(non-steroidal anti-inflammatory drugs):

Aspirin's inhibits COX1 in the platelet involved in the formation of chemicals that increase a platelet's ability to cause platelet aggregation. It will inhibit the platelet for its lifespan 7-10 days.

Other NSAIDs (such as ibuprofen) inhibit platelet aggregation in the same way, but the effect is not as long lasting. At this time, aspirin has the longest anti-platelet action in this group of drugs.

Platelet Aggregation Inhibitors -Aspirin

Patients taking aspirin usually tolerate procedures well (including extractions)

The clinician, as always, should evaluate the patients overall presentation

Look for petechiae Geriatrics

Platelet Aggregation Inhibitors - Others

Dipyridamole (Persantine): Mechanism is unclear

Ticlopidine (Ticlid) and Clopidogrel (Plavix): Platelets require a molecule called ADP

to bind to the platelet in order to facilitate aggregation. Studies show that ticlopidine and clopidogrel inhibit the ability of ADP to bind to platelets

Management of patients taking platelet aggregation inhibitors.

ASA, ASA in conjunction with another medication Generally ASA alone OK ASA plus another PAI; Stop meds x5 days The plavix burn

Consider a “platelet aggregation test” bleeding test

Also may consider PFT “platelet function test”

Patients Taking Anticoagulants (coumadin/warfarin) PT/PTT

Prothrombin time (PT) and partial thromboplastin time (PTT) tests

Reagent Dependent INR

International Normalized Ratio Results from 1-1.5 (+/- 2.0) are

manageable Europeans treat up to 4 Use overlying measures (SURGICEL, Suture

and Pressure)

Hemophilia/Genetic Bleeding Disorders Classic-severe hemophilia A/B will

likely have a history Mild/moderate and moderately

severe likely will not have a history Factor & AMICAR (aminocaproic acid)

von Willebrand’s Disease 3% of the population? described 1926 by Finnish physician Erik von

Willebrand arises from a qualitative or quantitative deficiency of

von Willebrand factor (vWF), a multimeric protein that is required for platelet adhesion

Diabetes Mellitus

insulin-dependent diabetes mellitus (IDDM) Pt’s usually >40, usually have history severe, acute condition with a sudden onset of symptoms including: polydipsia, polyuria,

nocturia, polyphagia, loss of weight, loss of strength, marked irritability, recurrence of bed wetting, drowsiness, and malaise…

non-insulin-dependent diabetes mellitus (NIDDM). May or may not have history generally occurs after the age of 40 in obese individuals;

incidence increases with age Slow/sub-clinical onset, often controlled with diet/weight

control 1Olefsky JM: Diabetes mellitus. In Wyn~aarden JB, Smith LH, eds.

Cecil Textbook of Medicine, 17th ed. Philadelphia: WB Saunders; 1985.

Management of the Diabetic Patient

Manifestations of diabetes Hyperglycemia Ketoacidosis Vascular wall

disease contribute to the

inability of uncontrolled diabetic patients to manage infections and heal wounds

Skin lesions Cataracts/ blindness Hypertension Chest pain Anemia Oral

candidiasis unexplained dry

mouth multiple caries periodontal disease

Dental Management of Diabetic Patients

History/medical consultation prior to invasive tx. Verify medication as usual. Verify adequate intake of food. Schedule appointments in the morning

Time of high glucose and low-insulin activity Afternoon appointments are a time of low-glucose and high-

insulin activity which may predispose the patient to a hypoglycemic reaction.

Instruct patients to tell the dentist if at any time during the appointment they feel symptoms of hypoglycemic reaction occurring.

A source of sugar, such as orange juice, must be available in the clinic should the symptoms of a hypoglycemic reaction occur.

Surgical Considerations for the Diabetic Patient

It is important that the total caloric content and the protein/carbohydrate/fat ratio of the patient's diet remain the same so control of the disease and proper blood glucose balance are maintained.

IDDM diabetics who are going to receive periodontal or oral surgery procedures may be placed on prophylactic antibiotic therapy during the postoperative period to avoid infection.

Lab Considerations

Blood sugar measurement, “D-stick” Hemoglobin A1C

The most widely used clinical test is measurement of glycated hemoglobin (also called A1C, hemoglobin A1C, glycohemoglobin, or HbA1c)

Although the A1C reflects mean blood glucose over the entire 120 day life span of the red blood cell, it correlates best with mean blood glucose over the previous 8 to 12 weeks.

studies have shown that there is a 10% decrease in micro- vascular risk for every 1 % reduction in A1c

Pulmonary Disease

Chronic disease COPD Emphysema ASTHMA Inflammatory pulmonary disease

Acute disease Asthma Acute episode of chronic disease

Dental Management of Asthmatic Patient Hx/Dx/Consultation Working/current inhaler present Avoid triggers/water spray/fumes Drug interactions:

ASA, NSAIDs, and narcotics

Dental Management of COPD Patient Hx – look for co-morbidity No tx if acute presentation Treat in upright/semi-upright position Avoid rubber dam if not well tolerated

Narcotics > Pulmonary Depression Nitrous Oxide (controversial) Avoid Bilateral Mandibular or Palatal

Blocks Pulse oximeter is helpful, consider low flow oxygen Avoid sedatives other than benzodiazepines Drug interactions with COPD medication

Patients with Cardiovascular Disease

Remember Local Anesthetics and Dosages

Treatment After Events Stints (Premedicate?)

Usually Cardiologist will advise to wait 6 weeks MI

6 mos. CABG (Cabbage)

3 mos. Coronary Artery Bypass Graft

Various Medications

Risk Assessment

Cardiovascular disease Angina

Stable/unstable Congestive heart failure

Stable/unstable Hypertension

# of meds and level of control

Cancer and Oncology Patients

Generally tolerate procedures and anesthetics well, prior to Oncology (Chemo/Radiation) phase of treatment

Medical Consultation Dental Treatment Should be ‘Phased’

Phase I- Hygienic/Caries Control Phase Phase II- Maintenance Phase Phase III- Restorative Phase

Cancer and Oncology Patients (cont.)

Phase I (Hygienic Phase) Pre-Oncology

(Chemotherapy/Radiation) Aggressively Treat Periodontal Disease Remove Teeth with Questionable

Prognosis Fabricate trays for medicament

delivery Endpoint goal is patient that is free of

dental pathology

Cancer and Oncology Patients (Cont.)

Phase II (Oncology Phase) Palliative and Supportive

Treatment Monitor Patient Closely Be Prepared to Alter/Modify Tx.

Plan Use of LED device to control

oral/pharyngeal mucositis

(KEPIV/ KEPIVANCE™) human keratinocyte growth factor

(KGF)

Use of ‘Magic Gargle’ or viscous lidocaine

Re-consultation with Oncologist is often required

Cancer and Oncology Patients (Cont.)

Phase III- (Restorative Phase) Prognosis Should be Considered Progress from Stabilization Restorations to

Definitive Restorations

Clinical Presentations Cancer/Oncology

Clinical Presentations Cancer/Oncology

Clinical Presentations Cancer/Oncology

Psychiatric Patients

Medical Consultation/Communication

Copus Mentus/Competency Issues Medication Concerns

TCA’s, MAO’s, CNS Depressants Xerostomia

Root Caries, Candida…. Medico/Legal Concerns Focus of Psychosis

Case Report

Psychiatric Patients (Clinical)

Management of the patient on Oral Bisphosphonates

Oral and Intravenous Bisphosphonate-Induced Osteonecrosis of the Jaws. History, Etiology, Prevention, and Treatment Robert E. Marx, DDS

Assessing the Dental Risk… Medical History

History, History, History Which medication taken? What was the dose and frequency? Was there concomitant use of prednisone

or other steroids?

Clinical and Radiographic Examination… Panoramic and periapical films as

indicated Early signs of bisphosphonate toxicity

Generalized sclerosis of the alveolar bone and lamina dura

Widening of the periodontal membrane space

Clinical exam Tooth mobility unrelated to alveolar bone

loss

Laboratory Testing…

CTX bone turnover marker C-terminal cross linking telopeptide Measurement of relative rate of bone

renewal Normal: 300-600 pg/ml Moderate risk of BONJ: 150-299 pg/ml High risk: <100 pg/ml

Prevention of Oral Bisphosphonate Induced Osteonecrosis

Prevention—prior to initiation of agents oral status needs to be fully evaluated and treated

Drug holiday Use of alternative medications for

osteoporosis Raloxifene

Modulator of estrogen receptors rhPTH

What to do with patients already on Oral Agents? Patients on agents for less than 3 years

with no comorbidities No alteration in treatment plan

Patients on agents less than 3 years with comorbidities With MD consultation: stop agent for three

months (+/- CTX testing) Continue drug holiday for three months

postoperatively Informed consent (in writing) very

important

What to do with patients already on Oral Agents? For patients on agents greater than 3

years With MD consultation: discontinue agent

for 3 months preoperatively Continue drug holiday for 3 months

postoperatively CTX test

What to do with an urgent need for surgery? When palliative measures are

insufficient, and a truly urgent situation arises (abscess, intensive pain) you are better off undergoing the procedure than to suffer the consequences of infection/pain persisting

Written informed consent

Treating Oral Bisphosphonate Induced Osteonecrosis Usually less extensive than

parenteral agents With MD consult DC agent for 1 year

Antibiotics and chlorhexidine rinses Early debridement is contraindicated 60% of lesions the resorption-

sequestration process is complete within 6 months to 1 year

Remainder respond to less aggressive surgical debridement

Orally Administered Bisphosphonates

Brand Name Manufacturer Generic Name

Actonel Procter & Gamble

Pharmaceuticals risedronate

Boniva Roche Laboratories ibandronate

Fosamax Merck & Co. alendronate

Fosamax Plus D

Merck & Co. alendronate

Skelid Sanofi Pharmaceuticals tiludronate

Didronel Procter & Gamble

Pharmaceuticals etidronate

Intravenously Administered Bisphosphonates

Brand Name Manufacturer Generic Name

Aredia Novartis pamidronate

Zometa Novartis zolendronic acid

Bonefos Schering AG clodronate

1 Week Post-Op

6 Weeks Post-Op

Oral Bisphosphonate ONJ Case

Holistic/Environmentally Sensitive

Generally Two Categories Mis/Under-informed

Looking to Vitamins/Minerals/Herbs Poly-Symptomatic Patients

Diagnosis from ‘Alternative Medicine’

Holistic/Environmentally Sensitive E.I. (Environmental Illness)

CS, EMS… American Academy of Environmental Medicine

Medical Consult Consult!!! Psychological/Psychiatric Component

Holistic/Environmentally Sensitive

Appropriate Referral Often Alternative Medical Providers prefer

“Biological Dentist” Appropriate Referral Sequence

Best Time for This Referral is Prior to Treatment Referral After Treatment Raises Concerns

Abandonment Issues Liability for Treatment Rendered

Holistic/Environmentally Sensitive

Excerpt from discussion board: My Brother, who was a patient at the clinic, is having a new bridge installed by

his dentist. Currently he has a temporary bridge held in with adhesive that he is strongly reacting too. Does anyone have any suggestions for less toxic dental products? Our dentist is very open to ideas on how to treat my brother so we are looking for sources and suggestions for less toxic materials. Thanks, JW He needs to go see a biological dentist and let them test him to see what he can

tolerate in his mouth. Then take results back to your dentist. It helped me.

When I come in contact with cable television, electronics, or fluorescent lights, copy machines, magnetic cards, I get a very strange feeling over my body, often tingling in my tongue. Can anyone identify with this strange feeling? I am very concerned about this condition. I have seen a neurologist, but no diagnosis.

With this line of thinking….

Warning this water contains hydrogen which is known to be explosive!

Table salt contains chlorine – a known poison to humans…

“Metal free” Practice

Is it really?

Inorganic components of composite:

1. Quartz - SiO2

2. Borosilicate glass

3. Lithium aluminum silicate

4. Barium aluminum silicate

5. Strontium or zinc glass

And……..

6. Metal oxides – provide color

Ha……..! Metals!

Pregnant Patients

Medical Consult!! Defer Treatment Until 2nd/3rd Trimester Association Between Caries and Premature

Birth Phased (Hygienic Care) Usually Best Specific Medication Concerns

Tetracyclines in the pregnant and nursing ACE inhibitors

Angiotensin-Converting Enzyme Inhibitor Drugs Quinolones (Ciprofloxacin) *NB

Parting shots...

Effects of pregnancy, and organ failure on LA kinetics Renal failure: increases accumulation of metabolic by-

products

Hepatic failure: decreases clearance, increases half-life

Cardiac failure: decreases amide clearance

Pregnancy: increases amide clearance; decreases protein

binding

ABSOLUTE CONTRAINDICATIONS TO LOCAL ANESTHESTIA…

Severe uncontrolled hypertension Refractory arrhythmia MI < 6 months ago Stroke < 6 months ago Unstable angina CABG < 3 months ago Uncontrolled CHF Uncontrolled hyperthyroidism

bhutson@bcd.tamhsc.edu 214-828-8957