General Medicine and Dental Correlations: Intro to Medicine For the Practicing Dentist PDF

General Medicine and Dental Correlations: Intro to Medicine For the Practicing Dentist Richard D’Innocenzo DMD, MD Clinical Professor Department of Oral & Maxillofacial Surgery August 7, 2023 What We Will Cover Today: • Taking a Medical History • Performing a Head and Neck Exam • Reviewing Pertine...

General Medicine and Dental Correlations: Intro to Medicine For the Practicing Dentist Richard D’Innocenzo DMD, MD Clinical Professor Department of Oral & Maxillofacial Surgery August 7, 2023 What We Will Cover Today: • Taking a Medical History • Performing a Head and Neck Exam • Reviewing Pertinent Lab Work • Health Literacy and Social Determinates of Health While Taking a History Why Do We Need to Learn Medicine? Reasons: • Patients are living longer due to medical advances • May have multiple medical conditions which require adjustments to our dental treatment • May be on multiple medications which could affect oral health or interact with medications we administer or prescribe to our patients • Need to know when we should consult the patient’s PCP (Primary Care Physician) to determine if the patient is medically optimized to undergo treatment • DO NO HARM Improving the Medical Curriculum in Predoctoral Dental Education: Recommendation From the American Association of Oral and Maxillofacial Surgeons Committee on Predoctoral Education and Training Dennis et al, J Oral Maxillofac Surg 75:240-244, 2017 CODA Standards and Biomedical Science Training • Standard 2-14: Graduates must be competent in the application of biomedical science knowledge in the delivery of patient care • The intent: • “Biological science knowledge should be of sufficient depth and scope for graduates to apply advances in modern biology to clinical practice and to integrate new medical knowledge and therapies relevant to oral health care.” Expectations of Dental Graduates • “CPET believes that entry-level graduate dentist should be able to safely treat patients with common medical problems, and that they should understand these problems with enough depth to make independent decisions regarding the dental treatment, delivery of anesthesia, and prescribing medication for such patients” For patients presenting for routine dentistry, the student is expected to: • Identify existing systemic disease processes and understand and be able to explain the basic pathophysiology of the disease(s) • Identify and understand the related medications • Determine whether the patient is stable or unstable (optimum medical management), stratify risk of procedural intervention in light of existing comorbidities and historical exercise tolerance and activity level, and use appropriate medical consultation when indicated • Predict and prepare for medical emergencies that are more likely to occur • Form a general impression of how well the patient will tolerate a surgical or anesthetic intervention J Oral Maxillofac Surg 75;240-244, 2017 Medical History • Biographic Data • CC (Chief Complaint) • HPI (History of Present Illness • PMH (Past Medical History) • PSH (Past Surgical History) • Medications • Allergies • SH (Social History) • ROS (Review of Systems) Medical History • It is the most useful information a clinician can have when deciding whether a patient can safely undergo planned dental therapy • If well done, the physical and laboratory examinations of a patient usually play relatively minor roles in the presurgical evaluation • It should be tailored to each patient Biographic Data • Patient’s full name, address, age, gender, occupation, marital status, and PCP • Assess the patient’s reliability Chief Complaint • In patient’s own words • Helps establish priorities • Clarifies why they desire treatment History of Present Illness (History of Chief Complaint) • Patient to describe the history of the present complaint or illness • It’s first appearance, any changes since the first appearance • Description of pain should include: • • • • • • Onset Quality of the pain Intensity (Grade 0 – 10) Duration (intermittent or constant) location and radiation what worsens or mitigates the pain • Constitutional symptoms: fever, chills, lethargy, anorexia, malaise, and weakness associated with the chief complaint. Medical History • Health History Forms • Baseline Health History Database: hospitalizations, surgeries, illnesses, trauma, medications, allergies, health related habits, last medical check up. • Family History • Should be updated on a yearly basis Contemporary Oral & Maxillofacial Surgery, Hupp, Ellis, Tucker Contemporary Oral & Maxillofacial Surgery, Hupp, Ellis, Tucker Past Surgical History (PSH) • Prior Surgeries: • What surgeries where performed? • When were they performed? • Complications associated with the surgery? • Excessive bleeding • Infection • Type of anesthesia and were there any anesthetic complications? • • • • Local anesthesia, IV sedation, or General Anesthesia Allergic reaction? Post operative nausea or vomiting Difficulty “waking up” Medications: • May provide information regarding their medical condition(s) • Do they affect the patient’s oral health? • Will they alter our treatment of the patient? • Will they interact with our local anesthetics or vasoconstrictors • If the patient will be sedated, are the medications compatible • Will there be an interaction with medications we may prescribe Medications • Medication • How long have they been on the medication • Dose, any change in the dose • When do they take the medication Allergies • Was it a true allergy vs. side effect • What type of allergic reaction did they have • Avoid administering or prescribing these medications to the patient • If no medication allergies: NKDA (No Known Drug Allergies) Family History (FH) • Helps identify whether a patient is at a higher risk for a disease • Provide early warning signs of disease • Help recommend/reinforce lifestyle changes for the patient Family History • History of any Chronic Disease • • • • • • Heart disease Hypertension (HTN) Diabetes (DM) Asthma Renal Disease Autoimmune Disease • History of Cancer • History of Bleeding Disorder • History of Mental Health Condition Social History (SH) • Any alcohol use (ETOH) • Type, how much and how often • Tobacco use • Type of tobacco, how much, how often and for how long • Legal Recreational Drugs • Type, how much, how often, last used • Illegal Recreational Drugs • Type, how often, last used • Use of Prescription Medications for non-medical conditions • Type, how often, last used Screening ASK: Alcohol & Drug Screening • 1. Do you sometimes drink beer, wine, or other alcoholic beverages? • If yes: How many times in the past year have you had 5 or more(men under 65)/4 or more(women & men 65+) drinks in a day?* • 2.How may times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?* • If yes, which drugs? * If the response for either question is one or more times, ASSESS use for severity using CAGE/CAGE-AID, then ADVISE the patient ASSESS: CAGE • 1. Have you ever felt you should CUT DOWN on your drinking or drug use? • 2. Have people ANNOYED you by criticizing your drinking or drug use? • 3. Have you ever felt bad or GUILITY about your drinking or drug use? • 4. Have you ever had a drink or used drugs first thing in the morning (EYE OPENER) to steady your nerves or get rid of a hangover? Positive = 2+ ADVISE ADVISE • Provide personalized feedback and state your concern • • • • Ask permission to give feedback Discuss your screening and assessment findings Link unhealthy substance use to any known or potential risks/consequences Ask for patient’s reaction to feedback ADVISE • Make a nonjudgmental yet explicit recommendation for change in behavior • Cut back to lower risk amounts • Further assessment and discussion with their PCP • Positive CAGE • Adverse consequences from substance abuse • Known meds that interact with or medical conditions that are worsened with substance abuse • Pregnant or trying to conceive NIDA Quick Screen – Online http://www.opioidrisk.com Screen, then Intervene: Advise, Assess, Assist and Arrange Brief Intervention • Ask permission to have a short discussion about the screening results • Advise: Provide medical advice about the patient’s drug use • Assess the patient’s readiness to quit • Assist patient in making a change • Arrange specialty assessment, drug treatment, follow-up visit Refer patients as appropriate • Because the screening does not provide a diagnosis of abuse or dependence, refer high-risk patients for a full assessment • For moderate-risk patients and low-risk patients with special concerns, use clinical judgment to determine whether additional assessment is necessary Review of Systems (ROS) • It is a sequential, comprehensive method of eliciting patient symptoms on an organ system basis. • It may reveal undiagnosed medical conditions unknown to the patient. • Should be guided by pertinent answers obtained from the history. • If IV sedation or General Anesthesia planned, the cardiovasular, respiratory, and nervous systems should be reviewed. • Dentist is expected to perform a quick review of the head, ears, eyes, nose, mouth, and throat on every patient. ROS for the Head and Neck Region: • Head • Eyes • Ears • Nose • Throat • “HEENT” Head: Headache is the most common symptom • Typical Questions to ask the patient regarding headache: Is it unilateral or bilateral? Severe with sudden onset, like a thunderclap? Steady or throbbing? Continuous or intermittent? Is there an aura? Is the headache “typical” or is there something different? The Eyes Begin with open-ended questions: “How is your vision?” “Have you had any trouble with your eyes?” Is vision worse during close work or at distances? Is there blurred vision? Is the visual loss bilateral? If it is bilateral, is the onset of visual loss gradual? Are there lights flashing across the field of vision? Does the patient wear glasses? The Ears Opening questions: “How is your hearing?” “Have you had any trouble with your ears?” Does it involve one or both ears? Did it start suddenly or gradually? What are the associated symptoms, if any? Is there any “ringing” in their ears? Do they have any dizziness or vertigo? Complaints of earache, or pain in the ear, are especially common. The Nose and Sinuses Any drainage from the nose? Any nasal congestion, a sense of stuffiness or obstruction? Any sneezing? Do they have loss of smell? Do they have bleeding from the nose? Do they have maxillary tooth pain? If facial pain is present, it is made worse by bending forward? Do they have pressure in their ears? Do they have a fever? The Mouth, Throat, and Neck Do they have any dental pain? Do they have bleeding from the gums? Ask about tendency to bleed or bruise elsewhere. Do they have a sore throat? Do they have a sore tongue? may result from local lesions as well as from systemic illness Do they have hoarseness? This refers to a change in voice quality Causes range from diseases of the larynx to extra- laryngeal lesions that press on the laryngeal nerves Physical Examination • Focuses on the oral cavity and to a lesser degree on the entire maxillofacial region. • Accurate description – not a diagnosis. • Start with vital signs. • Physical evaluation involves: Inspection, Palpation, Percussion and Auscultation. Radial Pulse Physical Evaluation of the Dental Patient: Halstead, Blozis, Drinnan, Gier Pulse • Rate • Rhythm • Character: Form of the individual pulse wave. May have diagnostic value in valvular disease • Volume: Full vs. Weak (“thready”) • Condition of Vessel Wall A Guide to Physical Examination and History Taking: Barbara Bates A Guide to Physical Examination and History Taking: Barbara Bates A Guide to Physical Examination and History Taking: Barbara Bates Korotkov Sounds A Guide to Physical Examination and History Taking: Barbara Bates ASA Classification of Physical Status • ASA I: A normal healthy patient • ASA II: A patient with mild systemic disease or significant health risk factor • ASA III: A patient with severe systemic disease that is not incapacitating • ASA IV: A patient with severe systemic disease that is a constant threat to life • ASA V: A moribund patient who is not expected to survive without the operation • ASA VI: A declared brain-dead patient whose organs are being removed for donor purposes Options For the Practitioner if the Patient is not ASA I or ASA II • Modifying routine tx plans by anxiety reduction measures, pharmacologic anxiety control techniques, increased patient monitoring, or a combination of these • Obtain a Medical Consultation • Refuse to treat patient in the ambulatory setting • Referring the patient to an oral & maxillofacial surgeon Head & Neck Exam Eyes Visual acuity & Visual fields Eyelids Lacrimal apparatus Conjunctiva, sclera, pupils Extraocular muscle movement Fundi Optic disc, retina, and retinal vessels Eyes: Inspection Position and Alignment of the Eyes. Stand in front of the patient and survey the eyes for position and alignment. If one or both eyes seem to protrude, assess them from above Eyebrows. Inspect the eyebrows, noting their fullness, hair distribution, and any scaliness of the underlying skin. Eyelids. Note the position of the lids in relation to the eyeballs. Inspect for the following: ■ Width of the palpebral fissures ■ Edema of the lids ■ Color of the lids ■ Lesions ■ Condition and direction of the eyelashes Also evaluate the adequacy of eyelid closure Extraocular Movements Cardinal directions of gaze Bates Pathways of the light reaction A light beam shining onto one retina causes pupillary constriction in both that eye, termed the direct reaction to light, and in the contralateral eye, the consensual reaction to light. Optic Nerve Oculomotor Nerve Bates Pupillary Reaction to Light • The direct reaction • Pupillary constriction in the same eye • The consensual reaction • Pupillary constriction in the opposite eye Definitions: • Miosis refers to constriction of the pupils • Mydriasis refers to dilation of the pupils • Anisocoria: unequal pupils • Simple anisocoria: difference in pupillary size of 0.04 mm or greater, is seen in approximately 35% of healthy people. If pupillary reactions are normal, anisocoria is considered benign Head & Neck Exam • Skeletal Structures - Facial bones fractures asymmetry - TMJ (Tempromandibular joint) Range of motion Click/Pop/Pain Dislocation Head & Neck Exam • Mouth/Oropharynx -Lips -Tongue -Palate (soft and hard) -Floor of mouth -Buccal mucosa -Buccal vestibule -Teeth Oral Cavity • Lips • Observe color, moisture, lumps, ulcers or cracking • Oral mucosa • Color, ulcers, white patches, and nodules • Gingiva • Color, pigmentation, ulcerations • Roof of Mouth • Color and architecture of the hard palate • Teeth Oral Cavity • Tongue and floor of the mouth • Color, texture, ulcers, lesions. Check symmetry • Pharynx • Soft palate, anterior and posterior pillars, uvula, tonsils • Note color, symmetry, exudate, swelling, ulceration, or tonsillar enlargement • Palpate areas that are suspicious for evidence of induration or tenderness Head & Neck Exam • Palate -Size & shape of oropharyngeal area -Presence of clefts, oro-nasal/oro-antral fistulas -Check for velopharyngeal insufficiency -Common lesions Salivary gland pathology Kaposi’s sarcoma Traumatic ulcers Torus Head & Neck Exam • Lips -Clefts, pits, fissures, ulcers -Check for symmetry, color -Common swellings Fibroma Lymphangioma Hemangioma mucocele Head & Neck Exam • Tongue -Size, shape, color, ulcers/masses, coating, etc -Sensory disturbances (V & IX nerves) -Motor function -Taste (VII & IX nerves) -Common swellings Hemangioma, lymphangioma Malignancy Head & Neck Exam • Floor of mouth -Common swellings Sublingual gland lesions (Ranula) Submandibular gland obstruction (Wharton’s duct) Malignancy Head & Neck Exam • Buccal Mucosa Check for leukoplakic Lesions R/O dysplasia, CA in-situ, Malignancy Parotid Lesions (Stensen’s duct) Other common lesions Hyperkeratosis Lichen planus (Wickham’s striae) Head & Neck Exam • Buccal Vestibule Check for asymmetry Check for leukoplakic lesions Common problems Alveolar ridge height/width Frenum Buccal/vestibular infections of Odontogenic origin Head & Neck Examination • Teeth • Occlusion - Class I - Class II - Class III • Dental and skeletal midlines Head & Neck Exam • Swellings Size and shape Tenderness Consistency/Texture Fixation to structures Rate of growth Color/pigmentation Head & Neck Exam • Inflammatory swelling -Short duration -Tender -Erythematous -Movable • Try to localize source of infection • Cellulitis vs. Abscess Head & Neck Exam • Neoplastic Swellings Longer Duration Rate of growth (benign vs. malignant) Fixed Tender or non-tender Physical Examination of the Head and Neck Head & Neck Exam Head - Occiput to hairline Face - Hairline to mandible Neck - Mandible to clavicle Bates Neck Bates Head & Neck Exam • Head - Hair: Color, Texture, Distribution, Quantity, any pattern loss - Scalp: Lumps or lesions - Skull: General size and contour Bates Head & Neck Exam • The Face: • Note facial expression and contours • Note asymmetry, involuntary movements, edema and masses • The Skin: • Note color, pigmentation, texture, thickness, hair distribution, and lesions Hair • Fine hair: Seen in hyperthyroidism • Coarse hair: Seen in hypothyroidism Scalp • Redness and scaling could indicate seborrheic dermatitis or psoriasis • Soft lumps may be pilar cysts • Pigmented nevi Skull • Enlarged skull may signify hydrocephalus or Paget’s disease of bone • Palpable tenderness or step-offs may be due to head trauma Head & Neck Exam • Nose Asymmetry Septum Turbinates Polyps Smell Assess paranasal sinuses Bates • The upper third of the nose is supported by bone • The lower two thirds is supported by cartilage Air enters the nasal cavity by the anterior naris and then passes into a widened area known as the vestibule and on through the narrow nasal passage to the nasopharynx • The medial wall of each nasal cavity is formed by the nasal septum, which is supported by bone and cartilage • It is covered by a mucous membrane • The vestibule is lined with hair-bearing skin, not mucosa • Laterally, the turbinates are present and are covered by highly vascular mucous membrane that protrude into the nasal cavity • Below each turbinate is a groove, or meatus. Each is named according to the turbinate above them Bates • The nasolacrimal duct drains into the inferior meatus • Most of the paranasal sinuses drain into the middle meatus • Their openings are not usually visible • The surface area provided by the turbinates and the mucosal covering them help to provide: Cleansing, humidification, and temperature control of inspired air Nasal Polyps • Pale saclike growths of inflamed tissue that can obstruct the air passages or sinuses • Conditions conducive to polyps: • • • • • Allergic rhinitis Aspirin sensitivity Asthma Chronic sinus infection Cystic fibrosis Paranasal Sinuses • Lined with mucous membranes • Only the frontal and maxillary sinuses are readily accessible to clinical examination Bates • Localized tenderness, along with pain, fever and nasal discharge suggest acute sinusitis Head and Neck Exam • Ears Asymmetry Protrusion Hearing Any lesion/masses Head & Neck Exam • Ulcers -Size -Shape -Margins-rolled, inverted, everted, etc -Etiology Malignant, Aphthous, Trauma, Syphilis, TB, Fungal, viral, Autoimmune, etc Head & Neck Exam • Neck -Lymph nodes -Cervical spine with range of motion -Trachea -Thyroid gland -Carotid pulse Head & Neck Exam Lymph node examination Size Location Texture Tenderness Movable vs. fixed Bates Head & Neck Exam • When reviewing the patient’s medical history, do not just focus on the chief complaint • Do a through medical history (CC, HPI, PMH, PSH, Meds, Allergies, SH, FH) • For any abnormal findings, compare to the contralateral side Other Physical Examination Techniques to be Covered in the Oral Surgery and Pain Control II Courses Eye: Visual acuity & Visual fields Lacrimal apparatus Fundoscopic exam Ear: Otoscopic exam Cardiac Exam Pulmonary Exam Neurologic Exam Extremities Exam Pertinent Labwork Not a new concept • “Laboratory Tests for Dentists” • Oral Surgery, Oral Medicine, Oral Path • Volume 12, Issue 11, November 1959, Pages 1324 -1333; J Peltier • “Brief outline of tests which dentists may be called upon to use” • Hematology (RBC,WBC, Thrombocytes, Differential, Hemoglobin, Hematocrit) Sedimentation rate, Bleeding Time, Clotting time, Capillary Fragility Test, PT, BUN, Total Serum Protein, Serum Glucose, CO2, Cl, Na, K, Ca, Phosphorous, Alkaline Phosphatase, Urinalysis Pertinent Labwork: • CBC with Platelets • Differential Counts • Coagulation Studies • • • • • Prothrombin time (PT) International Normalized Ratio (INR) Partial Thromboplastin Time Platelets Bleeding Time • Electrolytes • Sodium(Na), Potassium (K), Bicarbonate (HCO3), Chloride (Cl) • Markers • Hemoglobin A1c (HbA1C) • C-reactive protein (CRP) Implications of Medical Screenings of Patients Arriving for Dental Treatment: The Results of a Comprehensive Laboratory Screening • Miller C, Westgate P: J Am Dent Assoc. 2014 October; 145(10): 1027 - 1035 Methods: • The authors collected serum, urine and medical histories form 171 patients who arrived for dental treatment as a component of a clinical trial and performed complete blood cell counts, standard blood chemistry panels and urinalysis on the samples Conclusions: • The high frequency of significant abnormal laboratory tests results detected in this time suggest that many patients may be unaware of their medical statuses CBC • Hemoglobin • Hematocrit • Red blood cell (RBC) • White blood cell Hemoglobin • Normal value: Male: 13.5 – 17.5 g/dL Female: 12 to 16 g/dL • Function: Measures oxygen-carrying capacity of blood • Significance: Decreased: hemorrhage, anemia, medications, renal disease, chronic infections and diseases Increased: Polycythemia vera, high attitudes, vigorous exercise, smoking, dehydration Hematocrit • Normal value: Male: 39 – 49% Female: 25 – 45% • Function: Measures relative volume of cells and plasma in blood • Significance: Decreased: hemorrhage, anemia, medications, renal disease, chronic infections and diseases Increased: Polycythemia vera, high attitudes, vigorous exercise, smoking, dehydration Red Blood Cell • Normal value: 4 – 6 million/μL • Male: 4.3 – 5.7 • Female: 3.8 – 5.1 • Function: Measures oxygen-carrying capacity of the blood • Significance: Low: Hemorrhage, anemia High: Polycythemia, heart disease, pulmonary disease White blood cell (WBC) • Normal value: • 1 – 23 months: 6,000 – 14,000/μL • 2 – 9 years: 4,000 – 12,000/μL • 10 – 18 years 4,000 – 10,500/μL • Function: Measures host defense against inflammatory agents • Significance: • Decreased: aplastic anemia, drugs, high attitudes, vigorous exercise, smoking, dehydration, toxicity(chemotheraputic agents), specific infections, ionizing radiation • Increased: inflammation, infection, trauma, toxicity, leukemia, post splenectomy, exercise Differential Counts: • Neutrophils • Lymphocytes • Eosinophils • Basophils • Monocytes Neutrophils • Absolute counts: 1,500 – 8,000/μL • Significance: • Increased in: bacterial infections, hemorrhage, diabetic acidosis • Absolute neutrophil count (ANC) <1,000/μL: patient at increased risk for infection Lymphocytes • Absolute counts: 1,500 – 3,000/μL • Significance: • Increased: Viral and bacteria infections, acute and chronic lymphocytic leukemia, antigen reaction • Decreased: After stress, burns, trauma, uremia and some viral infections Eosinophils • Absolute count: 50 – 250/μL • Significance: • Increased: parasitic and allergic condition, blood dyscrasias, pernicious anemia, malignancy, drugs, Addison’s disease, collagen-vascular diseases • Decreased: after steroid use, ACTH, after stress, Cushing’s syndrome Basophils • Absolute counts: 15 – 50/μL • Significance: • Increased: in types of blood dyscrasias, chronic myeloid leukemia • Decreased: Acute rheumatic fever, lobar pneumonia, after steroid therapy, thyrotoxicosis, stress Monocytes • Absolute counts: 285 – 500/μL • Significance: Hodgkin’s disease, lipid storage disease, recovery from severe infections, monocytic leukemia CBC Hemoglobin White Blood Cells (WBCs) Platelets Hematocrit Coagulation Studies: Prothrombin Time (PT) • Normal value: 11 – 15 sec • Function: Measures extrinsic and common pathways (factors I, II,V, VII and X) • Significance: Prolonged in liver disease, impaired vitamin K production, surgical trauma with blood loss, medications(Coumadin), DIC Partial thromboplastin time (PPT) • Normal value: 20 to 35 sec • Function: Measures intrinsic and common pathways (factors I, II, VIII, IX, X, XI and XII) • Significance: • Increased in hemophilia A, B and C and can be Von Willebrand’s disease Platelets: • Normal value: 150,000 – 400,000/μL • Platelet counts may be normal in number, but abnormal in function • Function: Measures clotting potential • Significance: • Increased in polycythemia, leukemia, severe hemorrhage, leukemia's, myeloproliferative disorders, carcinoma • Decreased in thrombocytopenia, marrow suppressants, burns, leukemias, hypersplenism, thrombotic thrombocytopenic purpura, mononucleosis, cirrhosis, massive transfusion, medications Bleeding Time • Normal value: 2 to 7 minutes • Function: tests platelet and vascular phase, and measures quality of platelets • Significance: Increased in thrombocytopenia, thrombocytopenic purpura, von Willebrand’s Disease, defective platelet function, aspirin therapy International Normalized Ratio (INR) • Normal value: 1 (without anticoagulation therapy) • Function: Measures extrinsic clotting function • Significance: Increased with anticoagulation therapy • INR is calculated as a ratio of the patient’s PT to a control PT • (PT patient/PT control)ISI • ISI: International Sensitively Index Fibrinogen • Normal value: 200 – 400 mg/dL • Function: Measures Factor I • Decreased: DIC, surgery, acute severe bleeding, burns Electrolytes: • Sodium (Na) • Potassium (K) • Bicarbonate (HCO3) • Chloride (Cl) Sodium (Na) • Normal value: 134 -143 mmol/L • Significance: Hyper or Hyponatremia • Increased: Cushing’s syndrome, excessive water loss, diuresis • Decreased: CHF, nephrosis, cirrhosis, inappropriate secretion of ADH Potassium (K) • Normal value: 3.3 – 4.6 mmol/L • Significance: Hyper and hypokalemia • Increased: hemolysis of specimen, renal failure, Addison’s disease, acidosis, dehydration • Decreased: diuretics, decreased intake, vomiting, diarrhea, metabolic alkalosis Bicarbonate (HCO3) • Normal value: 22 – 29 mmol/L • Function: Reflects acid – base balance • Increased: metabolic alkalosis, respiratory acidosis, severe vomiting, volume contraction • Decreased: metabolic acidosis, respiratory alkalosis, starvation, DKA, toxins, severe diarrhea, drugs Chloride (Cl) • Normal value: 98 – 106 mmol/L • Significance: Increased in renal disease and hypertension • Increased: diarrhea, renal tubular acidosis, medications • Decreased: vomiting, DM with ketoacidosis, renal disease with sodium loss Blood Urea Nitrogen (BUN) • Normal Range: 7 – 20 mg/dL • Significance: • Elevated levels may be related to renal disease, dehydration, burns, medications, high protein diet, CHF, shock, GI bleeding, stress, drugs • Decreased in starvation, liver failure, nephrotic syndrome, over hydration Creatinine (Cr) • Normal levels: 0.7 – 1.3 mg/dL • Significance: Can be used to evaluate kidney function • If elevated: Excessive physical workout, dehydration, increased protein intake, hypertension, diabetic ketoacidosis, excessive creatinine supplements, kidney infections, pre-eclampsia Glucose: • Fasting: 70 – 105 mg/dL • 2 hour post prandial < 120mg/dL • Increased: DM, Cushing’s syndrome, acromegaly, increase epinephrine, acute pancreatitis • Decreased: Pancreatic disorders, extrapancreatic tumors, hepatic disease, endocrine disorders, exogenous insulin, oral hypoglycemics, malnutrition, sepsis Na Cl BUN K Co2 Cr Glucose C-reactive protein (CRP) • Normal value: 0.08 – 1.58 mg/dL • Significance: Increase in infection; indicates an acute phase of inflammatory metabolic response Hemoglobin A1C (HbA1c) • Normal value: < 5.6% • Significance: Increased in hyperglycemia; pre-diabetes: 5.7 – 6.4%; diabetes mellitus: > 6.5% HIV • CD4 count • Normal:400 – 1200 cells/mm3 • Abnormal of Importance: <200 cells/mm3 is an AIDS defining condition HIV • HIV Viral Load • Normal: undectable HIV • Platelet • Hemoglobin • Hematocrit • WBC/ANC Other lab tests • TFTs • LFTs Making Health Literacy Part of Your Dental Practice • ADA • Oral health literacy is the ability to understand and act on health information • Many adults have difficulty comprehending information provided at the dental office: this can lead to poor compliance, errors in taking medications, missed appointments and frequent calls to the office staff • An important component of health literacy is the provider’s ability to communicate clearly and effectively Health literacy of the practice • Initial contact: ask patient about their preferred language and explain the visit • Use plain language forms: are they easy to understand • Identify interpretation needs • Use plain language signs Communication with patients • Show empathy • Use a ”Teach-back” technique • Provide simple, clear instructions • Have the patient explain back to you • If they still have difficulty, try again explaining it in a different way • Implement “Motivational Interviewing” • Ask the patients about their barriers to changing behaviors • Ask what they think they can change and make a plan • Document counseling and follow up next visit • Use of Visual Aids Social Determinants of Health(SDOH) • They are the conditions in the environments where people are born, live, learn, play worship, and age. They affect a wide range of health, functioning, and quality – of – life outcomes and risks • SDOH have a major impact on people’s health, well-being, and quality of life • SDOH also contribute to wide health disparities and inequities SDOH • Economic Stability • Health Care Access and Quality • Social and Community Context • Education Access and Quality • Neighborhood and Built Environment Integrating Social Determinants of Health into Dental Curricula: An Interprofessional Approach Sabato et al Journal of Dental Education March 2018 SDOH Include: • Income • Race/ethnicity • Education level • Work opportunities • Living conditions • Access to health care • Dental students have been taught to take social histories, but have not been well trained to act on patients’ social needs to improve health outcomes • Given the strong relationship between psychological stressors an oral health status, it is important that dental curricula address SDH broadly and in an integrated manner • Health professions trainees need to learn to assess and manage the SDH of their patients to ensure they provide holistic care and promote the highest levels of health outcomes