ORAL MEDICINE CONSULT IN the clinic :
FOR EACH PATIENT, YOU MUST DETERMINE *:
MEDICAL HISTORY: are there ANY problems, PAST OR PRESENT
MEDICATIONS: significance, dosages, indications, side-effects, pharmacology, interactions, contraindications, etc.
PHYSICAL STATUS: vital signs, GPO
REVIEW of SYSTEMS
HEAD and NECK, INTRAORAL SOFT TISSUE
NEED for ADDITIONAL INFORMATION:
ORAL medicine faculty consult
MEDICAL Consult
SPECIFIC MANAGEMENT PLAN
* USUALLY WITH ORAL MEDICINE FACULTY ASSISTANCE
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AMERICAN SOCIETY of ANESTHESIOLOGY
PHYSICAL STATUS CLASSIFICATION:
ASA PS I: normal : no systemic disease
ASA PS II: mild systemic disease, minor complications, slight modifications
( i.e. Allergies, pregnancy)
ASA PS III: moderately serious systemic disease
potential strict limitations; definite
special considerations( hemophiliac)
ASA PS IV: serious systemic disease; severe limitations; very special considerations ( hospitalization)
( uncontrolled HTN, angina, CHF, diabetes)
THE FOUR MOST IMPORTANT QUESTIONS :
1.) Have you seen an M.D. ? Do you presently ?
when? most recent? why? what was done ? status ?
2.) Have you ever been hospitalized ? operations ? when ?
for what ? clinical course ? complications?
3.) Have you / are you taking medications ?
when ? for what ? ALLERGIES/adverse effects/complications?
4.) How do you feel today ? Has there been ANY recent change in your health status ?
REVIEW of SYSTEMS
Cardiovascular, respiratory, HEENT, nervous, gastrointestinal, immune, endocrine, genitourinary, blood, musculoskeletal, integumentary
SIGNS & SYMPTOMS
PHYSICAL EVALUATION
VITAL SIGNS SIGNS & SYMPTOMS
YOU MAY DETECT some DISEASES BASED ONLY UPON SYMPTOMS.
Most commonly the designation of Medical Alert status, based upon medically compromising conditions with which dental patients present for treatment, is determined by a thorough medical history and physical evaluation and prior to any treatment rendered .
Ordinarily we also request a medical consultation** which may verify this necessity as well as provide management suggestions and details. This should done in concert with ORAL MEDICINE FACULTY>
However, sometimes it is discovered that certain patients have a medical problem AFTER they have been initially and are in other treatment areas. In many cases the decisions made are not appropriate or they are incomplete.
The fundamental rationale for the MED. ALERT determination and designation is attached.
** Medical Alert Status is NOT to be equated with the necessity for medical consultation !!!
The MEDICAL CONSULTATION and documentation of the condition, as well as how the patient should be managed is extremely important and becoming even more necessary with increasing medical technology.
Communication with the patient's physician ( s) will assist in determined the nature and current status of a condition as well as any other pertinent information, potential complications, medications or recommendations for their proper management.
Nelson L. Rhodus, DMD, MPH UNIVERSITY of MINNESOTA
Diplomate, American Board of Oral Medicine Division of Oral Medicine
DENTAL MANAGEMENT of the
MEDICALLY COMPROMISED PATIENT
algorithm
( Considerations which must be assured , presented in a simplified way
by which to determine the dental patient’s physical status
prior to dental management.)
A. antibiotics ( prophylaxis, prone to infections etc.)
anesthetics ( epinephrine)
analgesics
B. bleeding
breathing
blood pressure
bacteremias (infections)
C. complications Medical- systemic-ROS
immunocompromised
oral
cardiac (arrhythmias, arrest,
stress, reserve-output, etc.)
cardiovascular (other...vital signs, etc.)
consciousness
D. drugs (side effects, allergies, adverse reactions, interactions, etc.)
dental management modifications
delayed healing
E. emergency treatment
THE MEDICAL HISTORY
Dr. Nelson L. Rhodus, Director
of Oral Medicine and Oral Diagnosis
Diplomate, American Academy of Oral Medicine
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Primum non nocere.
from the Hippocratic Oath
Essential component of EVERY PATIENT ENCOUNTER !
Usually BASELINE ( initial visit) + UPDATES !
Some update should occur at EACH appointment !
" We must endeavor to find what type of patient has a disease instead of just what disease the patient has ! "
- Sir William Osler
We must realize that health status is dynamic .
( "... the patient that you just saw yesterday may not be the same today!")
Medical History = combination : questionnaire + INTERVIEW
covers DIAGNOSED DISEASES + THEIR CURRENT STATUS
+ DETECTION OF UNDIAGNOSED DISEASE
Medical history questionnaire = comprehensive
questionnaire : Patient can read & understand?
knows and remembers accurately ? fully responds?
follow-up interview = most important areas
INTERVIEW : very important techniques, how the ? is asked
Identify : potential cardiovascular problems ( = #1 !)
( HTN, MI, CHF, arrhythmias, etc.)
potential bleeding problems
potential infections
potential poor healing ( immune)
potential infectious to staff
potential drug interactions( allergy, adverse effects, interactions, etc.)
Most systemic diseases have a wide range of severity, complications, pharmacotherapeutics.
" Chance favors the mind that is prepared ! "
- Pasteur
The Goal : Recognize and prevent medical problems!
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MEDICAL ALERT DESIGNATION
IMPORTANT :
MOST medical conditions may necessitate a listing in the PROBLEMS LIST in the dental record. MANY will require a MEDICAL ALERT designation. SOME will require a MEDICAL CONSULTATION. These are SEPARATE distinctions. This may vary EVEN WITH the same medical condition
( i.e. HYPERTENSION : borderline, controlled by medication, undiagnosed or uncontrolled ).
The astute clinician MUST MAKE INDIVIDUAL case by case professional judgments!
Definitions :
MEDICAL ALERT = a "warning sign" of some important, potentially threatening medical problem
MEDICAL - SYSTEMIC a problem category which identifies any type of medical problem/condition for which the dental provider should be aware or make special considerations : these should ALWAYS be identified in the
HEALTH STATUS SUMMARY area of the PODR
MEDICAL CONSULTATION = with the patient's physician when additional diagnostic pertinent information regarding proper management of the patient is needed
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MED. ALERT : ALMOST ALWAYS :
Cardiovascular conditions (59% *) :
(i.e., coronary artery disease: angina pectoris, myocardial infarction, hypertension, congestive heart failure, congenital heart disease, rheumatic heart disease, infective endocarditis, cerebrovascular accident, cardiovascular surgery : coronary bypass, angioplasty, cardiac transplant, etc., valvular disease: mitral valve prolapse, prosthetic heart valves, pacemaker, cardiac arrhythmias, etc.) **
Metabolic conditions ( 11.2%*)
(i.e., diabetes mellitus : Type I and often Type II ; liver disease: cirrhosis, hepatitis, renal disease, thyroid disease, adrenal insufficiency : corticosteriod use, etc.)
Respiratory conditions ( 10.4%*)
(i.e., Chronic obstructive pulmonary disease : asthma, emphysema, chronic bronchitis; tuberculosis, histoplasmosis, other respiratory diseases)
Allergies ( 10.2*%)
(i.e. definitely allergies TO ANY MEDICATION ! In some cases, atopic allergies: hayfever, materials( latex, Ni, Au, environmental, etc.)
Bleeding disorders and blood dyscrasias ( 2.3%*)
(i.e, hemophilia, Christmas disease, leukemia, lymphomas, anemia, etc.)
Joint replacement or other prosthetic device or implant (2.1% *)
( i.e., complete joint replacement, penile implants, etc. )
Cancer (2.1%*)
( i.e., active malignancy, or post-irradiation or chemotherapy or surgery, etc.)
Venereal or sexually transmitted disease ( 2.1% *)
(i.e., syphilis, gonorrhea, AIDS or HIV infection, other)
Autoimmune or rheumatological disease
(i.e., Systemic lupus erythematosus, arthritis, vasculaitis, fibromyalgia, Raynaud's phem., Sjogren's syndrome, etc.)
Other :
( Pregnancy, gastrointestinal disorders, genitourinary disease, chemical dependency, glaucoma, neurological conditions, pyschological disorders, developmental or hereditary conditions, etc.)
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NOTE :
Use of many medications may indicate MEDICAL ALERT which may or may not be for the above conditions. ( i.e. steroids, antidepressants, MAO inhibitors, antibiotics, anticoagulants, etc., etc.)
NOTE :
Certain signs and symptoms of systemic disease without a definitive diagnosis MAY also necessitate a MEDICAL ALERT designation until the definitive status of the condition is found and/or ruled out!
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* % of medically compromising conditions encountered in dentistry
**Many other medical conditions identified MAY necessitate, either a MEDICAL ALERT designation and/or a MEDICAL CONSULTATION with the physician.
Please consult with the Oral Medicine-Diagnosis faculty.
BEHAVIORAL OBJECTIVES
1. Cardiovascular Disease:
a. Understand the pathophysiology of:
i. ischemic heart disease
ii. organic heart disease
iii. congenital heart disease
iv. peripheral vascular disease
v. hypertension
vi. arrhytmias
vii. endocarditis
b. Understand the reasons, effects and contraindications for certain cardiac drugs such as:
propanolol, NGN, isosorbide, quinidine, ASA, digitalis, coumadin, et. al.
c. Understand the recommendations for the utilization of vasoconstricors in dental treatment of the patient with heart disease
d. Describe in detail management of the dental patient who has experienced:
i. angina pectoris
ii. myocardial infarction
iii. cardiac arrest
iv. coronary bypass surgery
e. Outline each step in the evaluation and management of dental patients with a history of heart murmurs.
f. Prescribe management for dental patients at risk for IE and related infections. Includes antibiotic selection, dosage, duration, etc.
g. Describe the management of the dental patient on anticoagulant therapy needing a surgical procedure, cleaning of the teeth, extraction or infection of a local anesthetic.
h. Describe the management of the dental patient with a transplanted heart.
2. Pulmonary Disease:
a. Understand the pathophysiology of:
i. COPD
ii. Hyperventilation
iii. other respiratory disorders
b. Understand the reasons, effects and contraindications for certain respiratory drugs such as : theophylline, aminphylline, and others
c. Outline in detail the management of the asthmatic patient
3. CNS:
a. Understand the pathophysiology of:
i. Epilepsy
ii. CVA
b. Understand the reasons, effects and contraindications for certain nervous system and psychotropic drugs such as : Phenobarbital, phenytoin, and others
c. Describe in detail the dental management of patients with history of seizures or CVA
4. Endocrine Disorders:
a. Understand the pathophysiology of:
i. Diabetes mellitus
ii. Adrenal insufficiency
iii. Thyroid disease
b. Understand the reasons, effects and contraindications for certain nervous system and psychotropic drugs such as :insulin, synthroid, prednisone, hydrocortisone, tolbutamide, and others
c. Differentiate between IDDM and NIDDM, be able to describe how a patient may be screened for diabetes mellitus
d. Differentiate between the different management techniques ( i.e. diet, insulin, oral, etc. ) for diabetics
e. Describe in detail the routine dental management of the patient with IDDM and when the patient develops acute dental infection
f. Describe in detail the management for insulin shock and diabetic coma
g. Describe in detail the management for thyroid storm
h. Understand the reasons, effects and contraindications for steroids medications
5. Describe in detail the dental management of the pregnant patient:
a. Uncomplicated pregnancy
b. History of abortions and still births
c. Complicated pregnancy
d. Emergency dental treatment, preventive dental procedures, routine dental needs and complex dental restorative procedures
e. Radiographs indicated for the pregnant patient
f. Modification of drug use in the pregnant patient:
i. anesthetics
ii. antibiotics
iii. analgesics
iv. sedatives
6. Liver Disease:
a. Describe in detail the recognition, complications, and dental management for patients with a history of alcohol abuse
b. Describe in detail the recognition, complications, and dental management for patients with a history of viral hepatitis:
i. list the signs and symptoms of acute viral hepatitis
ii. interpret serology tests for HBV, HAV, HCV and HDV infections
c. Describe in detail the recognition and dental management for patients with advanced chronic liver disease
i. be aware of the signs and symptoms or chronic liver failure
ii. be able to interpret the results of screening tests for liver failure
iii. be aware of special management needs for the patient with a transplanted liver
7. Social and Sexually Transmitted Diseases:
a. Describe in detail the clinical manifestations of gonorrhea including oral complications that may occur
b. Describe in detail the clinical manifestations of syphilis including oral complications that may occur
i. primary syphilis
ii. secondary syphilis
iii. latent syphilis
iv. tertiary syphilis
v. congenital syphilis
c. Describe in detail the clinical manifestations of oral and genital herpes
d. Describe in detail the dental management of patients with sexually transmitted diseases
8. AIDS and Related Conditions:
a. Describe the groups of individuals who are considered at increased risk for HIV infection
b. Describe the events that occur following infection with HIV. Include the following conditions and events in proper sequence!
i. flu-like symptoms (seroconversion sickness)
ii. appearance of antibodies to HIV
iii. length of asymptomatic phase
iv. persistent generalized lymphadenopathy
v. AIDS-related complex
vi. AIDS
c. Describe the oral lesions that have been reported to be associated with HIV infection. How are these lesions diagnosed and managed?
i. hairy leukoplakia
ii. candidiasis
iii. Kaposi's sarcoma
iv. non-Hodgkin's lymphoma
v. herpes simplex infections
vi. aphthous stomatitis
vii. HIV-associated gingivitis
viii. HIV-associated periodontitis
ix. necrotizing ulcerative gingivitis and stomatitis
x. herpes zoster
xi. condyloma acuminatum
d. Describe in detail the dental management of the AIDS patient. Include the following:
i. prevention of excessive bleeding
ii. need for prevention of infection
iii. infection control procedures
9. Renal Disease:
a. Describe in detail the recognition and management for
dental patients who have a history of renal disease
b. Define the various levels of therapy along with physical
responses
c. List and describe mechanisms of renal management including dialysis, transplants, etc.
d. Describe the dental management concerns for the patient on renal dialysis and the renal transplant patient
10. Allergies:
a. Describe in detail the recognition and management for dental patients with acute allergies
b. Differentiate and describe in detail management of:
mild, moderate and anaphylactic allergic reactions
c. Differentiate between and describe in detail local
anesthetic toxic overdose vs. local anesthetic allergies
d. Describe the oral lesions that may have an allergic etiology, how they are identified and managed
11. Bleeding Disorders:
a. Describe in detail the recognition and management for dental patients with bleeding disorders (questionnaire, interviewing, history, etc., clinical findings and laboratory screening tests)
b. Differentiate and describe in detail management of: differing types of bleeding disorders
c. Differentiate between and describe in detail local factors in bleeding, coagulation, platelets, etc.
d. Be able to describe several systemic diseases which may involve bleeding tendencies.