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MedicalRiskAssessmentoftheDentalPatient:
“Don’tTreataStranger”
October2019
SophiaSaeed,DMDProfessorinResidenceandChairDepartmentofClinicalSciences
SchoolofDentistryUniversityofNevada,LasVegas
LearningObjectives
• Assessapatient’smedicalriskandsuitabilityforelectivedentalcare.
• Discussthemainmedicalconditionsandmedicationsthatimpacttheriskofbleeding,woundhealing,andinfection.
• Determineifmodificationsarenecessarytodentaltreatmentormanagementbasedonthepatient’smedicalstatus.
Resources
• UpToDateà “ScholarlyWikipedia”• Little,JamesW.DentalManagementoftheMedicallyCompromisedPatient,7thEdition.Mosby,2008.VitalBookfile.
• ADAEBD:https://ebd.ada.org/en• JournaloftheAmericanDentalAssociation• RealBodiesexhibit- areviewofanatomy
Guidelines
• Evidence-basedguidelinesareamovingtarget• Sciencechanges• Qualityofarticles???
Assessapatient’smedicalriskandsuitabilityforelectivedentalcare.
WhatisRiskAssessment?
WhatisMedicalRiskAssessment?
AmericanSocietyofAnesthesiologists(ASA)Status
ClevelandClinicwebsite
CariesRiskAssessment
Caries&WhiteSpots
OralHygiene
Fluoride&Xylitol
Diet
SalivaryFlow
Low Moderate High Extreme
MedicalRisk
Assessment
Current/PastConditions+stability
Meds+pastrelevantmeds+compliance
SurgicalHx/Hospitalizations
Allergies
Vitals
Safetoproceed,nomodifications
needed
Safetoproceed,modifications
needed
Proceedwithcaution,urgent
careonlyDefertreatment
Consequences
• Stroke– recentCVA/TIA,elevatedsymptomaticBP
• HeartAttack– elevatedsymptomaticBP
• Aspiration/Pneumonia• Systemicbacteremia/infection(brain,heart,etc.)• Bleeding• Bonyhealing
ModificationstoMgmt orTreatment
• Pre-procedureorprophylacticantibiotics• LAtypesoramount?• Shortappointments?• Stressreductionprotocol• Choiceofdentalmaterials• NoNSAIDsornarcoticsoracetaminophen• RBAoftreatmentoptions(e.g.exts,removableprosth)
• Treatmentsetting- needforphysiologicmonitors?
MedicalHistory
• Visualobservationofpatient• Vitals(mostlyBP)• LastMDvisit• Currentandpastmedicalconditions• Howwell-controlledareconditions
https://www.ahcusaweb.com/ProviderWeb/downloadfs.aspx?category=8&title=3%20&fromsite=1
• Howtomeasureabloodpressureaccurately:https://www.youtube.com/watch?v=gUHALsLeeoM
• ReviewofBPPhysiology:https://youtu.be/diG519dFVNs
MiniMedHx/ROSCardiovascular+Cerebrovascular
Check vitals.Difficultylyingbackward?Abletowalkupaflightofstairs?Angina- cause,carryNTG,howoftenneeded?Sleepw/howmanypillows?MI?CVA?When?Onbloodthinners?
Lungs Difficultylyingbackward?Sleepw/howmanypillows?Abletowalkupaflightofstairs?Hx ofpulmonary embolism?SupplementalO2?ActiveTB?
Kidneys Severelackoffunctionrequiringadjustment ofmeddosing?
Liver ActiveHep?Cirrhosis? Alcoholicliverdisease?Severelackoffunctionrequiringadjustment ofmeddosing?Bleeding?
Diabetes HbA1c?Dailybloodsugarrange?Polyuria, polydypsia?Tingling/neuropathyoffingersandtoes?Visionchanges?LasttimeMDchangedmeds/dosages?
Bone Bisphosphonateuse?Healingpotential 2/2immunecompromise?
Bleeding Too muchfromanti-coagulants?Lowplatelets?Needlabvalues?Hemophilia?vWD?Toothick- stasisandincreasedriskofembolism?
Cancer RadiationTherapy- field,dose,type?Chemotherapy?IVbisphosphonatesinCT(breast&prostatecancer)?Immunestatus?
ImmuneSystem HIV+,s/porganorbone marrowtransplant,cancer,high-dosecorticosteroids,autoimmuneconditions- riskofsystemicinfection
Neurological Coherenceandcomprehension: abilitytounderstand RBA/giveconsent?Movementdisorders?
SurgicalHistory&Hospitalizations
• Pastorplannedsurgeryofmajororgans?• Removalofanymajororgans?• Replacement/transplantofanyorgansorjoints?• Complicationswithsurgeries?• Complicationswithanesthetics?• Overnighthospitalizations?
Medications
• CurrentMeds+Compliance• Psychmeds– “Iseeyouaretaking…..Whatareyoutakingthatfor?”
• PastandPlanned– bisphosphonates- route,lengthoftx,lastuse– RadiationTherapy(RT)- dose,field,typeChemotherapy(CT)- when?IncludingIVbisphos (espbreastandprostatecancer)?
Allergies/AdverseReactions
• Drug/classà reaction• Latexà reaction
PCNà anaphylaxisCodeineà constipationLatexà rash
Social+DentalHistory
• Job/Occupation/Howonespendshis/herdays• Tob/EtOH/Drugs• Behavior• Fear,anxiety,phobias• Previousbaddentalexperiences• Health-relatedbehaviors:oralhygiene,frequencyofaccessingcare,nutrition/diet,compliancewithMDrecommendations/meds
Hypotheticalvs.RealConcerns
Medical>Dental:Safety
• Acuteriskoflife-threateningmedicalevent(e.g.acutelyhighBP)
• Riskofbleedingorinfection>benefitoftreatmentbeingconsidered
• RiskofONJ/MRONJ>benefitofprocedure
• Emergent,Urgent,Elective…
MedicalRisk
Assessment
Current/PastConditions+stability
Meds+pastrelevantmeds+compliance
SurgicalHx/Hospitalizations
Allergies
Vitals
Safetoproceed,nomodifications
needed
Safetoproceed,modifications
needed
Proceedwithcaution,urgent
careonlyDefertreatment
ConferringwithMDs
ConferringwithMDs
ComplexPatient
Consultation
Getmoreinformation
AskspecificQs
Referral Referformedicalcare
“Wecannotabdicateresponsibilityfortreatmentdecisionstophysiciansandstillmaintainthestatusandprivilegeofaprimarycaregiver.”
• “MedicalClearance”fordentalprocedures– OUTDATED– Dotheyknowthesetting?– Dotheyknowtheprocedures?– Doesthisdoanythingforyou,medicolegally?– Doesithelpyouprovidesafercare?
GoodConsults
• Specificinformationaboutpatient• Specificquestionsin“yes/no”formatasoftenaspossible• Specificlabvaluesortestresults• Clarification/opinionintheabsenceofguidelines• Goal:AskONCE,gettheinfoyouneed,makedecision:– Tx w/nomods,tx w/mods,ER(urgent)careonly,toocomplex(risk>benefit)
ExampleMedConsultDearDr.______________,
Iamrequestinginformationregardingourmutualpatient__________(DOB__/___/__)sothatImaysafelyprovidehimdentalcare.Pleasecompletetheformbelowandreturnatyourearliestconvenience.
1. Whatisthestartdateofthepatient’suseofalendronate?_______________2. Hasthepatienttakenanyadditionaloralbisphosphonates?Yes/No3. Ifyes,pleaseprovidethestartdate_________and enddate__________.
Thankyousomuchforyouradditionalattentiontothispatient’scare.
_____________________________(MDsignature)
Sincerely,OralHealthProvider
Consult• More/clarificationofinformation- historyorlabvalues– Currentmeds– Pasthistoryoforalbisphosphonates– PasthistoryofIVbisphosphonates– PasthistoryofH&Nradiationtherapy(RT)– Poorhistorian– HbA1c,INR,CD4,neutrophils…– Previousinfectioninreplacedjoint
• Unclear/noguidelines– s/pOrgantransplant,dialysis,poorlycontrolleddiabetes
Discussthemainmedicalconditionsandmedicationsthatimpacttheriskofbleeding,woundhealing,andinfection.
Determineifmodificationsarenecessarytodentaltreatmentormanagementbasedonthepatient’smedicalstatus.
Bleeding
http://ib.bioninja.com.au/standard-level/topic-6-human-physiology/63-defence-against-infectio/clotting.html
AtRiskforBleeding
• VonWillebrand Disease• Hemophilias• Anticoagulated– Directoralanticoagulants(rivaroxaban,apixaban,dabigatran,edoxaban)
– VitaminKantagonists(INRforwarfarin/coumadin)– Lowmolecularweightheparins (preferredduringpregnancy)
• Lowplatelets
TreatmentinthedentalpracticeofthepatientreceivinganticoagulationtherapyKaplovitch,Ericetal.TheJournaloftheAmericanDentalAssociation,Volume150,Issue7,602- 608
TreatmentinthedentalpracticeofthepatientreceivinganticoagulationtherapyKaplovitch,Ericetal.TheJournaloftheAmericanDentalAssociation,Volume150,Issue7,602- 608
Infection
AtRiskforInfection
• Immunocompromised• Post-transplant(?)• Autoimmuneconditions(?)• ProstheticJoint(?)• Cardiac- AHAguidelines• Dialysis(?)
ProstheticJointInfections(PJIs)
SollecitoTP,etal.Theuseofprophylacticantibioticspriortodentalproceduresinpatientswithprostheticjoints.JADA,146(1).January2015.
AmericanHeartAssociation
WilsonW,etal.Preventionofinfectiveendocarditis:GuidelinesfromtheAmericanHeartAssociation.JADA,138.June2007.
WoundHealing
AtRiskforPoorWoundHealing
• Bisphosphonates/anti-resorptives• Head&Neckradiationtherapy(RT)• PoorlycontrolledDM• Immunocompromised• Obesity• PoorOH
Brand Name Generic Name Route Approved
Actonel residronate sodium oral 1998Atelvia residronate sodium oral 2010Bonefos clodronate disodium (not US) oral 1985/1992Boniva ibandronate sodium oral 2003Bonviva etidronate disodium oral 2004Didronel etidronate oral 1983
etidronate (g) alendronate sodium oral 2003Fosamax alendronate sodium oral 1995
Fosamax Plus D alendronate sodium/cholecalciferol oral 2005alendronate (g) alendronate sodium oral 2008
Skelid tiludronate disodium oral 1997Aredia pamidronate disodium IV 2001Bonefos clodronate disodium IV 1985/1992
Boniva IV ibandronate sodium IV 2006Reclast zolendroic acid IV 2005/2007Zometa zolendroic acid IV 2001
AdaptedfromHellsteinJW,etal.JADA2011.
Who Rx’s? Diagnosis Route Potency
Primary MDsOsteoporosis,
Osteopenia, Paget’s disease of bone
Oral, Injection Low
EndocrinologistsOsteoporosis,
Osteopenia, Paget’s disease of bone
Oral, Injection Low
Oncologists
Multiple Myeloma, hypercalcemia of
malignancy, treat and reduce risk of bone metastasis in breast
cancer
IV High
OralBisphosphonates-AAOMSPositionPaper
• New-ish drugclassintheUS
OralBisphosphonates-AAOMSPositionPaper
>4yearsoforalbisphosphonates?
2-monthdrugholidaybeforeinvasivedentalprocedure
WhataboutIVbisphosphonates?
M.A.Pogrel,DDS,MD
M.A.Pogrel,DDS,MD
Specifics
• Pacemakers• Riskofstoppingbloodthinners• COPDandO2• Pregnant• H&Ncancer• Drugs:methamphetaminesandcocaine
Pregnancy
OralHealthDuringPregnancyandEarlyChildhood:Evidence-BasedGuidelinesforHealthProfessionals.CDAJournal,Vol 38,No6.June2010.
RadiationTherapy
Traditional IMRT
OtherConsiderations
AbilitytoLieSupineandStill
• CongestiveHeartFailure- NYHAClassification• COPD• GERD• Seizures• RLS(restlesslegsyndrome)• Parkinson’s• Choreas
TreatmentSetting
• Nophysiologicmonitoring(likeEKGandcontinuousBPandO2inoperatingroom)
• Openversusclosedrooms• Availabilityofsedationoptions• Treatmenttakesmonths
OverallMedicalRisk- Framework1• Systemicallystable?• RiskforAcuteMedicalEvent?• Abletoliesupine(andstill)forlengthofappts?• Riskofbacteremia/infection?NeedforAbx?• Riskofbleeding?– Needforfactorprophylaxis?(hemophilia,vwD)– Needforalterationofanti-coagulants?(riskvs.benefit)– Lowplateletcounts
• Healingpotential• AnyreasontohaveanMDconsult?• Necessityoftreatment?• Timelinessoftreatment?
OverallMedicalRisk- Framework2• Anyreasonnottoproceedwith…
– COE/POE– Periodontaltherapyorcariescontrol– Extractions/surgicalprocedures
• Anyotherreasontodelaytreatmentuntilmedicallystable?• AnyreasontohaveanMDconsult?
– Clarificationofdx,meds,orlabvalues– Stabilityofmedicalconditions– Consultationinareasofgray
• Anyothermodificationstocare?– (abx,INR,avoidNSAIDs,shortappts,nitrous?,avoidexts?
sedation?stressreduction?localanesthetic?NTG?Albuterol?Avoidremovable?)
• Abilitytoliesupine?Timelinessoftreatment?
ModificationstoMgmt orTreatment• Pre-procedureorprophylacticantibiotics• LAtypesoramount?• Shortappointments?• Stressreductionprotocol• Choiceofdentalmaterials• NoNSAIDsornarcoticsoracetaminophen• RBAoftreatmentoptions(e.g.exts,removableprosth)
• Treatmentsetting- needforphysiologicmonitors?
“Thesecretofthecareofthepatientiscaringforthepatient.”- FrancisW.Peabody,MD;addressingHarvardMedicalSchoolstudentsin1927
Summary
• Informationneededtoassessapatient’smedicalriskandsuitabilityforelectivedentalcare
• Emergent,Urgent,andElectivedentalcare• Medicalattentionsupersedingdentalneeds• Frameworkforthinkingaboutmedicalrisk