symposium 2015 handout - saiddentsaiddent.org/admin/images/60071500_1478724519.pdf · • what type...

Medical History, Medications and Your Mouth…Yes, It Matters!

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Overview

• Explain importance of obtaining a thorough health history from each patient before providing dental treatment

• Discuss common medical conditions

– Review important follow up questions

• Highlight most prescribed pharmaceutical classes

– Discuss commonly prescribed medications

• Describe Treatment modifications and dental considerations

– MD consult

– To treat or not to treat?

– Interprofessional collaboration

The Patient Record

• Means of communication

• Coordination of planning

• Continuity of care

• Evaluation of quality of care

• Legal documentation

• Electronic

• Paper

• Clear & concise

• Recorded promptly

• Signed & dated by clinician

If it’s not in the record, it didn’t happen

Medical History

• All patients should have a complete CURRENT medical history on file

• At each appointment:

– Assess patient’s general appearance

– Review medical history with patient

– Take vital signs

– Consult primary physician as needed

Only as good as the source


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Methods of taking a history

• Questionnaire and follow up interview

• Available from ADA or different computer programs

• may be adaptable for specific offices

Tips for establishing rapport

• Sit eye‐to‐eye

• Listen more than talk

• Convey nonjudgmental attitude

• Use normal tone appropriate vocabulary

• Look for clues, share thoughts, ask questions

• Don’t jump to conclusions

• Link info to activities of daily living

What are we concerned about happening?

• Manage bleeding (hemostasis)

• Risk of infection

• Drug interactions

• Patient’s ability to tolerate treatment


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Your patient answers “yes”, now what?

• Positive responses on a history form need clarification

• When were you diagnosed?

• What medications are you taking?

• What kind?

• How many?

• How long?

• How is it managed?

4,327 million prescriptions were dispensed in the U.S. Market in 2014.

2014 Top Therapeutic Classes by Non‐Discounted Spending

Total U.S. Market $ in billion 373.9

1 Oncology 32.6

2 Antidiabetes 32.2

3 Mental Health 23.1

4 Autoimmune 22.2

5 Respiratory 22.0

6 Pain 20.4

7 HIV Antivirals 14.3

8 Multiple Sclerosis 13.8

9 Lipid Regulators 13.7

10 Viral Hepatitis Products 12.3Source: IMS Health, National Prescription Audit, Jan 2015


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2014 Top Therapeutic Classes by Prescription

Total U.S. Market in millions 4,327

1 Antihypertensives 705

2 Mental Health 537

3 Pain 480

4 Antibacterials 267

5 Lipid Regulators 263

6 Antidiabetes 201

7 Nervous System Disorders 179

8 Anti‐Ulcerants 170

9 Respiratory 169

10 Thyroid Therapies 131Source: IMS Health, National Prescription Audit, Jan 2015

2014 Top Therapeutic Classes by Prescription


1 Antihypertensives 705

2 Mental Health 537

3 Pain 480

4 Antibacterials 267

5 Lipid Regulators 263

6 Antidiabetes 201

7 Nervous System Disorders 179

8 Anti‐Ulcerants 170

9 Respiratory 169

10 Thyroid Therapies 131Source: IMS Health, National Prescription Audit, Jan 2015

2014 Top Medicines by Prescription


1 levothyroxine 119.9

2 acetaminophen/hydrocodone 119.2

3 lisinopril 103.7

4 metoprolol 85.3

5 atorvastatin 80.7

6 amlodipine 78.3

7 metformin 76.9

8 omeprazole 75.0

9 simvastatin 72.8

10 albuterol 67.1Source: IMS Health, National Prescription Audit, Jan 2015


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Respiratory Drugs (9)

169 million prescriptions

Respiratory Follow‐up Questions

• Reason for taking medication?

– Asthma, COPD: chronic bronchitis & emphysema

Asthma

• If you use an inhaler, did you bring it to your appointment today?

• What triggers your asthma attacks?

• When was your last attack?

• How was your last attack managed?

Respiratory medications

• Medications are used to stop, control or prevent symptoms.

• Come in various forms: pills, aerosol inhalers, powder inhalers, liquids and injections.

• 2 main classes of medications

– Bronchodilators: dilate lungs & vessels

– Anti‐inflammatory agents: reduce swelling & mucus production


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Asthma medications

Bronchodilators

• Short‐acting β2 agonist

• Long‐acting β2 agonist

• Anticholinergics

Anti‐inflammatory Agents

• Inhaled corticosteroids

• Oral corticosteroids

• Mast cell stabilizers

• Leukotriene modifiers

Combination medications: Long‐acting β2 agonist + corticosteriod

salmeterol/fluticasone (Advair®)formoterol /budesonide (Symbicort®)

Albuterol /ipatropium bromide combo (Combivent®)

Common Bronchodilators

Class Medication Use

Short‐actingβ2 agonist

Albuterol (Proventil® HFA, Ventolin® HFA)

relief

Levalbuterol (Xoponex® HFA)

Long‐acting Salmeterol (Serevent®) control

β2 agonist Formoterol (Foradil®)

InhaledAnticholinergics

Ipratropium bromide (Atrovent® HFA)

relief

Tiotropium bromide (Spiriva®)

Oral Anticholinergics

Theophylline (Theo‐Dur®, Slo‐Bid® control

Common Anti‐inflammatory AgentsClass Medication Use

Inhaled Beclomethasone (Qvar®) Control

Corticosteroids Fluticasone (Flovent® HFA)

Triamcinolone (Azmacort®)

Oral/IV Prednisone (Deltasone®) Relief/control

Corticosteroids Prednisolone (Prelone®, Orapred®)

Mast Cell Cromolyn sodium (Intal®) Control

Stabilizers Nedocromil sodium (Tilade®)

Leukotriene Montelukast (Singulair®) Control

Modifiers Zafirlukast (Accolate®)


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Bronchodilators: Dental Concerns

β2 agonists

• Xerostomia

• Tachycardia

• Candidiasis (Serevent)

Anticholinergics

• Xerostomia

• Taste alterations

• Increased gastric secretions, gastric reflux

Anti‐inflammatory: Dental Concerns

• Consider MD consult for patients on oralsteroids. May need additional medication (adrenal crisis/immunosuppression)

• Inhaled steroids may cause candidiasis. Instruct patient to rinse after use.

• Drug interactions:

– Use caution with aspirin, NSAIDS & barbiturates can induce bronchospasm

Dental Management• Consider semi supine position

• Have inhaler available for use

• Minimize stress during appointment

• Use of ultrasonics & airpolisher may be contraindicated in patients with compromised respiratory conditions.

• May use nitrous oxide on patients with asthma but contraindicated in those with COPD or emphysema.


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Antidiabetic Agents (6)


Diabetes in the U.S.

• Prevalence: In 2012, 29.1 million Americans, or 9.3% of the population, had diabetes.– Approximately 1.25 million American children and adults have type 1 diabetes.

• Prediabetes: In 2012, 86 million Americans age 20 and older had prediabetes; this is up from 79 million in 2010.

• Deaths: 7th leading cause of death in the U.S. in 2010

National Diabetes Statistics Report, 2014 (released June 10, 2014)

Diabetes Follow‐up Questions• What type of diabetes do you have?

• What medications are you taking?

• What is your Hb A1c?

– Reflects average control over 6‐8wks

• How often do you check your blood sugar? Reflects current control

• Have you been hospitalized during the past year for problems related to your diabetes?

Consider MD consultIf FBG > 200 dl/mm

HbA1c > 8%


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Common Antidiabetic Classes

preprandial

Class Drug

Biguanide Metformin (Glucophage)

Thiazolidinediones Pioglitazone (Actos), Rosiglitazone (Avandia)

Sulfonylureas Glipizide (Glucotrol)

Intermediate/Long Acting Insulin

Insulin NPH (HumuLIN N), Insulin glargine(Lantus)

postprandial

Glinides Repaglinide (Prandin)

Alpha‐glucosidase inhbitors Acarbose (Precose)

Rapid/Short Insulin Insulin lispro(HumaLOG), Insulin aspart(NovoLOG)

GLP‐1 Agonist Exenatide(Byetta)

DPP‐4 Inhibitor Linagliptin (Trajenta), Saxagliptin(Onglyza) Sitagliptin (Januvia)

Side effects: may cause hypoglycemia

http://bloodglucoselevels.net/blood‐glucose‐levels‐chart/

Diabetes: Dental Concerns

• Xerostomia

• Delayed wound healing

• Accelerated periodontal disease

• Opportunistic infections‐candida

• Higher incidence of caries, periodontal disease, and burning mouth syndrome in poorly controlled diabetics


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Dental Management

Schedule early morning appointments and remind patient to:

• Take BGL day of appointment

• Eat a balanced meal within two hours of appointment

• Take medications as scheduled.

• Have food (balanced nutritional supplement) available if appointment > two hours if needed.

Antihypertensive Agents (1)


Prevalence• 67 million American adults have high blood pressure

– 1 of every 3 adults

• Only about half (47%) have their condition under control

• Nearly 1 of 3 American adults has prehypertion

Source: National Center for Chronic Disease Prevention and Health Promotion, Division for Heart Disease and Stroke Prevention. September 24, 2014


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Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of

High Blood Pressure

Clinicians must work with other healthcare professionals (eg, nurse case managers and other nurses, physician assistants, pharmacists, dentists, registered dietitians, licensed nutritionists, nutrition educators, optometrists, and podiatrists) to influence or reinforce instructions to improve patient lifestyles and BP control.

Chobanian, A., et al. Hypertension (2003)

Antihypertensive Agents

Classes

• ACE Inhibitors

• Angiotension II Receptor Blockers

• Beta Blockers

• Calcium Channel Blockers

• Diuretics

• Aldosterone Antagonists

Conditions Treated

• Angina Pectoris

• Arrhythmias

• Hypertension

• Congestive Heart Disease

• Edema

• Renal Disease

• Migraine Headaches

• Enlarged Prostate

What condition are you taking this for?


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Cardiac Follow‐up Questions

• Congestive Heart Failure– Are you able to lie back in the dental chair?

• Angina Pectoris– Is your angina stable or unstable?

– When was your last attack and how was it managed?

• Stable‐ relieved by rest and/or nitroglycerin

• Unstable‐ changes in pattern, duration, intensity

– Do you carry nitroglycerin?• Place on counter. Can administer 3x in 15 min.

Cardiac Follow‐up QuestionsArrhythmias

• What type of arrhythmias do you have?– Supraventricular: Tachycardia,

premature beats, flutter, A‐fib

– Ventricular: Tachycardia, PVC, V‐fib, Cardiac arrest

Coronary artery bypass graft/ coronary artery stent placement

• Date of surgery/procedure?– Defer elective tx for 1 month

– May be on anticoagulation therapy

Pacemaker or Implantable Cardiac Defibrillator (ICD)

• When was your device placed?

– Defer elective tx for 3 months

– Use piezo over magnetostrictive

Cardiac Follow‐up Questions

• Myocardial Infarction

– When did it occur?

• Defer elective tx for 6 months

• Stroke/TIA

– When did it occur?

• Defer elective tx for 3 months

• Hypertension

– Is it controlled or uncontrolled?

– How often do you monitor it?

– How are you feeling today?

• Defer elective tx if ≥180 and/or ≥ 110 until MD consult


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Cardiac contraindications to dental therapy

Defer treatment:

• Stroke (6 months)

• Recent myocardial infarct (3 months)

• Coronary artery stent placement (1 month)

MD Consult:

• Unstable angina

• Severe congestive heart failure

• Uncontrolled arrhythmias

• Significant uncontrolled hypertension (>180/110)

• INR >3.5

Common Antihypertensive Agents

Generic Class # of rx in mns

Lisinopril (3) ACE‐I 103.7

Metoprolol (4) BB 85.3

Amlodipine (6) CCB 78.3

Hydrochlorothiazide (15) Diuretic 49.1

Furosemide (17) Diuretic 46.5

Losartan (20) ARB 39.5

ACE Inhibitors –prilAR Blockers ‐sartanβ‐Blockers –olol

CC Blockers ‐dipine

Antihypertensives: Dental Concerns


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Dental Management

• Use cardiac dose of epinephrine

–0.04 mg epinephrine ( 2 carpules of 2% lidocaine 1:100,000)

• Be aware of potential for orthostatic hypotension

–Raise chair slowly, wait before dismissing

Anticoagulation Agents

Indications for Anticoagulation or Antiplatelet Therapy

• Patient may tell you they are taking a blood thinner

• Treatment varies from 81mg of aspirin daily to warfarin

Indications:• Prosthetic heart valves• Myocardial Infarction• Treatment and prevention of DVT/PE• Cerebral vascular disease (TIA or stroke)• Stroke prevention in atrial fibrillation (AF) patients


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Mechanism of Action• Prevent formation of a thrombus (blood clot) by interfering with the clotting mechanism of the blood.

• Block the formation of clotting factors at various steps along clotting cascade.

Protein C

Protein SWarfarin

Warfarin

Warfarin

RivaroxabanApixaban

Dabigatran

Anticoagulant Follow‐up Questions

• Reasons for taking medication?

• How often monitored?

• Stability of dosage over time?

• Most recent INR value/date?

• Any complications?

• Anticipated time that will be on medication?

INR should be < 3.5 (typically done every 4‐6 weeks)For surgical procedures, consult MD


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International Normalized Ratio

2.0-3.5

Common Anticoagulant/Antiplatelet Agents

• Aspirin• Warfarin (Coumadin)*• Clopidogrel (Plavix)• Dabigatran (Pradaxa)• Apizaban (Eliquis)• Effient (Prasugrel)• Rivaroxaban (Xarelto)

International Normalized Ratio (INR)

• Measures speed of blood clotting

• INR ≤ 3.5 ok for tx

• INR > 3.5MD consult

Prothrombin (PT) Time

• Normal range≈11‐15 seconds

• Safe range‐ 1.5‐2 X normal

• If > 2X normal or PTR > 2.5, consult MD.

Anticoagulants: Dental Concerns

Dental Implications

• Ulcers

• Increased bleeding

• Taste disturbances

Drug interactions

• Aspirin & NSAIDS can effects

• Antibiotics may effects

• Acetaminophen in large doses (9 gm/wk) effects

• Vitamin K will effects

• Do not recommend use of aspirin

• Monitor bleeding


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Antiretroviral Agents

Follow‐up Questions for HIV

• When were you diagnosed?

• Are you taking any specific medications for HIV infection?

• Have you had any bleeding problems?

• Have you had any specific diseases related to HIV infection?

• What are your current blood work results?

MD Consult if:CD4 T cell count ≤ 200/mm3

Neutrophil count ≤ 500/mm3

Platelet count ≤ 50,000

Common HIV MedicationsClass Generic

NameBrand Name

Nucleoside Reverse Zidovudine (azidothymidine, AZT, ZDV) Retrovir

Transcriptase Inhibitors (NRTIs) tenofovir disoproxil fumarate (tenofovirDF, TDF)

Virea

Non‐Nucleoside Reverse Rilpivirine (rilpivirine hydrochloride, RPV) Edurant

Transcriptase Inhibitors (NNRTIs) Nevirapine (ER nevirapine, NVP) Viramune

Protease Inhibitors (PIs) saquinavir (saquinavir mesylate, SQV) Invirase

Fusion Inhibitors Enfuvirtide (T‐20) Fuzeon

Combination HIV Medicines lamivudine and zidovudine (3TC / ZDV) Combivir

abacavir and lamivudine (abacavirsulfate / lamivudine, ABC / 3TC)

Epzicom

Side effects: nausea, vomiting, diarrhea, headache, dizziness, fatigue, fever, muscle pain


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HIV: Dental Concerns

Oral manifestations:

• candida infections

• viral infections

• hairy leukoplakia

• Kaposi sarcoma

• Major aphthous ulcers

• Poor healing response

• Necrotizing ulcerative periodontitis

Dental Management

• If patient has HIV infection but has had no medical problems, no special precautions are needed.

• If patient has signs and symptoms of immunosuppression, refer to protocols for patients with immunosuppression.

• Review patient’s medications and any dental medications that may be used, to insure no drug interaction.

References

• Little, Falace. The dental management of the medically compromised patient. 8th edition. Mosby, 2012.

• Rhodus, Miller. Clinicians guide: the medically complex dental patients. Third edition B.C. Decker, 2008.

• The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure ‐ Complete Report

• http://www.hivdent.org/ • http://www.heart.org/HEARTORG/ • http://www.diabetes.org/ • http://www.cdc.gov/

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