GMDC Dental Correlations October 2, 2023 PDF

GMDC: Dental Correlations October 2, 2023 Richard D’Innocenzo DMD, MD Clinical Professor Dept. of Oral & Maxillofacial SurgeryBUGSDM Objectives: • Understand the concept of requesting a medical consultation • Understand the concept of completing a requested consultation • Be able to discuss dental...

GMDC: Dental Correlations October 2, 2023 Richard D’Innocenzo DMD, MD Clinical Professor Dept. of Oral & Maxillofacial SurgeryBUGSDM Objectives: • Understand the concept of requesting a medical consultation • Understand the concept of completing a requested consultation • Be able to discuss dental concerns when treating a patient with • Pulmonary disease • Endocrine disease Consultations • Request for consultations carries different connotations. • Consultant is only expected to render an opinion. • Consultant is expected to perform any test or procedures necessary to act on their opinion. Be clear as to what you want Consultations • Inpatient: • Should be written on standard hospital consultations forms. This may be an electronic record • State the question to be answered • Provide a brief statement of other active problems • Should be answered within 24 hr or sooner Guidelines for Answering Consultations • State the reason for consultation in the opening sentence. • State that the chart has been reviewed and patient examined • Be brief but thorough • Be specific with recommendations • Provide contingency plans • Follow up with verbal contact • Follow patient’s progress Requested Consultation in Hospital • A Patient with severe aortic stenosis has been admitted to the hospital for aortic valve replacement. Please evaluate patient and provide dental clearance prior to valve replacement • State the problem • State chart has been reviewed • List medications/Allergies • Perform an oral evaluation • Make recommendations: • Radiographs • Extractions • etc Consultation • State the problem: • Patient with a history of aortic stenosis. Dental team consulted for preoperative evaluation of patient’s dentition to provided dental clearance prior to having aortic valve replacement • State chart has been reviewed • Chart has been reviewed and patient examined • List medications/Allergies • Hctz, metroprolol, aspirin • Perform an oral evaluation • No trismus noted. No intraoral masses or lesions noted. Patient with multiple crowns in place. Good oral hygiene noted. No abscess noted • Make recommendations: • Patient to be transported to dental if medically stable, to have radiographs taken to rule out periapical pathology and develop a finalized treatment plan. • Does patient require prophylactic antibiotics prior to dental treatment and provide perioperative recommendations Consultation • Patient with a history of aortic stenosis. Dental team consulted for preoperative evaluation of patient’s dentition to provide dental clearance prior to having aortic valve replacement • Chart has been reviewed and patient examined • Medications/Allergies • Hctz, metroprolol, aspirin • NKDA • Oral Exam: • No trismus noted. No intraoral masses or lesions noted. Patient with multiple crowns in place. Good oral hygiene noted. No abscess noted • Recommendations: • Patient to be transported to dental if medically stable, to have radiographs taken to rule out periapical pathology and develop a finalized treatment plan. • Does patient require prophylactic antibiotics prior to dental treatment and provide perioperative recommendations Request to Physician for Medical Consult Medically optimized not medically cleared Improvement in Medical Consultation Responses with a Structured Request Form S. Geist, J. Geist JDE May 2008 Hypothesized: • Consultation requests (CR) in a structured form would lead to better responses • Providing in-service education to clinical faculty would decrease the number of unwarranted CR • DM(Diabetes), HTN(Hypertension), Heart murmur and anticoagulant therapy • The CR should be concise, containing only pertinent and specific questions for the physician to answer • Helps prevent delays in treatment needed due to inappropriate consultation requests and needing to reconsult due to not obtaining the appropriate information The Dentist Who Performs the Procedure is Ultimately Responsible for His or Her Treatment Decisions Conclusion: • The introduction of structured medical consultation request forms for high BP(HTN), heart murmurs, anticoagulant therapy, and DM led to improvements in obtaining the appropriate information provided by physicians Conclusion: • The in-service presentations on how to construct a consultation request and the conditions that require or do not require consultation was not successful • With advancements in the medical field, there should be continued efforts to update knowledge and skills in communication with medical professionals in obtaining important medical information so that appropriate clinical decisions can be made Case Presentation • A patient presents to your office for extraction of tooth #19. While observing the patient in the dental chair, the patient appears to be nervous, diaphoretic, thin, with a tremor and exophthalmus. When you review the medical history form that the patient had completed, you note that the patient denies any significant Past Medical History (PMH), except that a “few tests” were ordered by the PCP at a recent well patient visit. What questions would you ask the patient? • Do you have any of the following: • • • • • • • Nervousness Heat intolerance Palpitations Racing heart Fatigue/Weakness Weight loss Increased appetite What is the most common cause of hyperthyroidism? What is the most common cause of hyperthyroidism? • Grave’s Disease • It is an autoimmune disease that produces IgG type of autoantibodies known as Thyroid Stimulating Immunoglobulins (TSIs): They bind to the TSH Receptor in the thyroid gland and causes release of T3 & T4 How is hyperthyroidism treated? How is hyperthyroidism treated? • Antithyroid medication • Methimazole (Tapazole) • Propylthiouracil (PTU) • Inhibits the synthesis of thyroid hormones • Radioactive Iodine Therapy: I131 • Destroys thyroid follicular cells • Avoid in children, pregnancy & breastfeeding • Can lead to hypothyroidism • Subtotal Thyroidectomy • Injury to recurrent laryngeal nerve • Hypoparathyroidism • Hypothyroidism • Propanolol • To treat tachycardia & hypertension What Oral Findings May Be Associated With Hyperthyroidism? • Increased susceptibility to caries • Periodontal disease • Enlargement of extraglandular thyroid tissue • Maxillary or mandibular osteoporosis • Accelerated dental eruption • Burning mouth syndrome Dental Management • Establish the diagnosis of hyperthyroidism • Treatment of hyperthyroidism • Medication • Current medical status: Signs & Symptoms, CV disease, TFTs (Thyroid Function Tests) in last 6-12 months • Concern with agranulocytosis from thioures antithyroid drug therapy • Stress reduction protocol • Short, morning appts, nitrous oxide, sedation, benzos, profound LA, adequate post-op pain control ? Use of epi How Would You Construct a Medical Consultation For This Patient? Let us now assume that the patient has a diagnosis of hyperthyroidism and the patient states they have been treated with medication, which they are still taking. Consultation: • Mrs. Jones is a patient known to you. She has a Past Medical History (PMH) of hyperthyroidism. She requires an extraction of a nonrestorable tooth under LA. Please provide the following: • How long has the patient been on the thyroid medication • Is the patient now eu-thyroid • Recent Thyroid Function Tests (TFTs) • If you request, you should know how to interpret the results • Is the patient medically optimized to undergo the above procedure • Please provide perioperative recommendations Thyroid Storm Thyroid Storm • A life threatening complication represents a sudden and severe exacerbation of the signs and symptoms of hyperthyriodism manifested by fever, restlessness, tachycardia, a-fib, pulmonary edema, tremor, sweating, stupor, and finally coma and death if treatment is not provided Treatment • • • • • • • • • • • Terminate the procedure Activate EMS Provide 100% oxygen Place in comfortable position Acetaminophen for hyperthermia Monitor VS Initiate BLS as indicated Establish IV line: D5LR or NS Dexamethasone 4 mg IV Crystalloid solution (150 ml/hour) Transport to medical facility Case • A 55 y.o. female presents to your office as an emergency appointment with complaint of pain associated with tooth # 30. Clinical and radiographic evaluation reveals a large carious lesion associated tooth # 30. On reviewing the patients PMH, she states that she has been treated for hyperthyroidism. The medication she is presently taking is Synthroid. What thyroid condition does the patient have? Hypothyroidism What questions would you ask the patient and why do you think the patient has this condition? • Patient was previously hyperthyroid • Patient was treated for hyperthyroidism • How was the patient treated? • Any present symptoms? • Now has developed hypothyroidism • Presently taking Synthroid to treat How Does Hypothyroidism Present Clinically? Clinical Presentation/Physical Findings • • • • • • • • Weakness Fatigue Cold intolerance Decreased basal metabolic rate Modest weight gain Decreased memory Slow speech Delayed relaxation of DTRs • • • • • • • • Depressed ventilatory drive Decreased CO Muscle stiffness Dry, rough skin Periorbital puffiness Course, dry hair Edema Anemia What are the Oral Manifestations Associated with Hypothyroidism? Hypothyroidism: Oral Findings • Macroglossia • Dysgeusia • Delayed eruption of teeth • Poor periodontal health • Delayed wound healing Dental Treatment Considerations in the Hypothyroid Patient • Well controlled patients: No special precautions needed for routine or emergent dental treatment • During treatment, attention should focus on lethargy, and respiratory rate, which can indicate and uncontrolled state Dental Treatment Considerations in the Hypothyroid Patient • Patients with undiagnosed, untreated, or poorly controlled hypothyroidism: • Elective dental treatment should be deferred • If treating, remain observant to increasing lethargy, bradycardia, and decreased respiratory rate • Surgical procedures should be avoided • Acute orofacial infections should be treated aggressively • Delayed metabolism of CNS depressants When Would You Obtain a Medical Consultation For a Hypothyroid Patient? When to consult: • Patient showing signs and symptoms of poorly controlled hypothyroidism • Patient not sure of what thyroid condition they have • Patient not sure what medication they are taking Consult: • Patient know to you with a history of hypothyroidism who requires an extraction of tooth # 30 under local anesthesia (2% xylocaine with 1:100k epi). Please provide the following: • What medication is the patient taking, the dose, and has there been any recent dosage change • Is the patient eu-thyroid • Recent lab work (TFTs) • Is the patient medically optimized to undergo the above procedure • Please provide perioperative recommendations Case • A 60 y.o. patient with PMH significant for HTN, Chronic cough, and a 35 year history of smoking 2 ppd presents to your office with a portable oxygen tank (Nasal canula at 2 lpm) for an initial oral evaluation • In discussion with the patient, he tells you that he has been diagnosed with COPD • What are some of the clinical signs/physical findings of a patient with COPD? COPD • Insidious onset • Usually presents in the fifth or sixth decade of life – complaints of excessive cough, sputum production, and SOB • Symptoms have often been present for an average of 10 years • Most patients have smoked at least 20 cigarettes per day for 20 or more years before the onset of symptoms “Blue bloater” • Predominately with chronic bronchitis • Bluish-tinged skin color from peripheral cyanosis secondary to chronic hypoxemia and hypercarbia • Peripheral edema • Tachycardia, tachypnea, and chronic cough with production of large amounts of sputum “Pink Puffers” • Predominately emphysema • A cachectic appearance, but pink skin color • Dyspnea manifested by pursed – lip breathing and use of accessory muscles of respiration What is/are the dental significance associated with a patient with COPD? COPD • Efforts must be directed toward the avoidance of anything that could further depress respiration • Since patients with COPD often have coexisting heart disease such as congestive heart failure and/or hypertension, these conditions must also be addressed, if present How would you manage this patient? Dental Management • Evaluation of patient’s medical condition • Dental Evaluation • Assess patient’s current clinical status • Consult with the patient’s physician as needed • Presence and severity of symptoms (dyspnea, orthopnea) • Results of current spirometry, ABG Evaluation • Determine the presence of factors that may exacerbate COPD (URI, etc.) • Check BP and Pulse (Increased could be due to toxic reactions or overdose of a sympathomimetic or anticholingeric bronchodilator, or methylxanthines • Consider dental treatment of high-risk patients in a special care facility: Hospital Clinic Dental • Place patient in a semisupine or upright chair position for treatment • Use of LA is not contraindicated • If patient demonstrating CV side effects secondary to their medications may require a limitation in the use of vasoconstrictor • Use of pulse oximeter to determine oxygen saturation Dental • With severe COPD, the use of a rubber dam may be problematic (oxygen) • Nitrous oxide-oxygen sedation is contraindicated or must be used with caution in patients with emphysema and/or severe COPD (CO2 retainers) • If sedative medications are required, low dose oral benzodiazepines may be used Dental • Narcotic analgesics and barbiturates are used with caution because they are respiratory depressants • Use of macrolide antibiotics, which alter cytochrome P450, may result in elevated serum theophylline levels • Assess the risk for adrenal suppression Medical Consult: • Mr. Jones is known to you and has a PMH significant of COPD and HTN. He will require routine dental care including scaling and root planning, restorations including crowns, along with possible extractions. Please provide the following: • Confirm medications the patient is presently taking • Has the patient been on steroid medication in the past, what was the dosage, for how long and when was it last used • Can nitrous oxide –oxygen sedation be used to treat the patient to minimize anxiety • Are the use of vasoconstrictors in local anesthetics contraindicated in this patient (2% xylocaine with 1:100k epi) • Is patient medically optimized to undergo the above procedures • Please provide perioperative recommendations Case • 20 y.o. male with PMH significant for asthma, presents to your office with complaint of pain in the left posterior mandible. He states that he has had the pain off and on in the past, and feels that it is due to a wisdom tooth. Presently he denies dysphagia, odynophagia, or SOB(shortness of breathe). He notices no trismus What questions would you have in regards to the patients asthma? Questions? • • • • • • • • • • How long have you had the asthma? Has it improved or gotten worse? When was your last attack? What brought on the attack? What medications are you using? When was the last time you had taken your medications? Any change in medication? Ever admitted to the hospital? Ever intubated? Any Steroid usage? What are the physical findings/clinical presentation? Asthma • Signs & Symptoms vary with severity of the disease but may include: • • • • • • Wheezing Tachycardia Tachypnea Accessory muscle usage with breathing Paradoxical abdominal and diaphragmatic movement on inspiration Pulsus paradoxus • A fall of systolic blood pressure of > 10 mmHg during the inspiratory phase What is the dental significance for the patient with asthma? • Specific oral conditions have been related to the use of asthma medications, including xerostomia, increased caries, and oral pharyngeal candidiasis • The direct effect of medications may also be manifested by soreness of the oral mucosa What medications are used in the treatment of asthma? Medications • Inhaled Beta-2 agonist: Albuterol • Inhaled corticosteriods: Beclomethasone • Systemic corticosteriods: Prednisone • Mast cell stabilizers: Cromolyn • Methylxanthines: Theophylline • Anticholinergics: Ipratropium bromide • Leukotriene modifiers: Montelukast How would you manage this patient? Dental Management • Optimal asthma control is desirable before dental treatment • ASA & NSAIDs should be avoided in aspirin-sensitive asthmatics • Opiates can induce histamine release • Macrolide antibiotics increase theophylline • Sulfite preservatives can precipitate asthmatic attacks Dental Management • Need for stress dose steroids? • Stress alone can trigger an attack • Patient should bring their inhaler with them When would you request a medical consult on a patient with a history of asthma? • Poorly controlled asthma • Patient does not know what medication they are taking for asthma, and is unable to provide this information Case • A 10 year old patient presents to your office for routine dental treatment. When reviewing the patient’s PMH with their parent, it is noted the child has been diagnosed with Cystic Fibrosis Cystic Fibrosis (CF) • Autosomal recessive disorder of exocrine glands primarily affecting the respiratory and gastrointestinal tract • Characterized by abnormally thick secretions from mucous glands, pancreatic insufficiency, COPD, and an increase in the concentration of electrolytes in sweat • Predominate age: Infants, Children, and young adults • Predominant sex: Male=Female Etiology & Pathogenesis • Chromosome mutation results in abnormalities in chloride transport and water flux across the surface of epithelial cells • This affects various organs and causes damage to exocrine tissue • The consequences are recurrent pneumonia, bronchiectasis, atelectasis, DM, biliary cirrhosis, cholelithiasis, internal obstruction, and increased risk for GI malignancies Multiple systems involved • Gastrointestinal (GI) • Pulmonary: hacking cough, viscous secretions, rapid respiratory rate, frequent infections • Reproductive system: sterility • Salt depletion and heat exhaustion occur frequently in warm climates Dental Significance • Major and minor salivary glands are involved • Electrolyte, enzyme, and total protein in saliva are altered • Drying of nasal and maxillary sinus mucosa contributes to chronic mouth breathing • Anterior open bite and enamel hypoplasia have been noted Dental Management • General dental and oral care should be pursued • Nutritional consultation should be requested • Oral hygiene emphasis • Consult with primary physician to confirm patient’s status, medical care maintenance and prognosis Case • Your patient, who has been a patient of record for 12 years, presents to your office for his 6 month recall visit. On updating their medical history, the patient relates to you that he has recently been diagnosed with DM. • He questions you: What are some of the oral complications associated with DM? Oral Complications of DM • Xerostomia: 2ndy to salivary gland dysfunction • Increased risk of oral infections • Increased incidence and severity of gingival inflammation, periodontal abscesses, and chronic periodontal disease • Increased incidence and severity of caries • Glossodynia & burning mouth syndrome • Dysgeusia What Types of DM are There? Types of DM • Type 1 • Type 2 • Gestational • Develops in 1-3% of pregnancies in the 3rd trimester • 40-60% chance of developing type 2 DM later in life • Secondary DM Type I • Disordered carbohydrate metabolism and inappropriate hyperglycemia • Due to deficiency of endogenous insulin secretion • Results in end-organ complications including accelerated atherosclerosis, neuropathy, nephropathy, and retinopathy Type 2 • Syndrome of disordered carbohydrate metabolism and inappropriate hyperglycemia • Due to either a deficiency of endogenous insulin secretion and/or a combination of insulin resistance and inadequate insulin secretion to compensate • Results in: accelerated atherosclerosis, neuropathy, nephropathy, and retinopathy What Are The Clinical Manifestations of DM? Clinical Manifestations of DM • Polyuria, Polydipsia, Polyphagia and weight loss • Weakness • Fatigue • Nausea with abdominal discomfort • Blurred vision • Candidal infections • Frequent infections What Lab Tests Could You Order To Check The Patient’s BS Control? Lab Work • Fasting Blood Glucose Level • Glycosylated Hemoglobin (HbA1C): used for monitoring every 3 months Treatment of DM • Diet • Exercise • Oral Agents • Insulin Dental Management • Time of onset • Type of DM • Type of medical management • Adequacy of control (labs, FS) • Presence of Chronic Complications of DM • CV, Neuro, Renal, Retinal, Infection Defer Dental Treatment if the Patient Demonstrates: • Poor control • Symptoms of poor control • Frequent DKA (diabetic ketoacidois), hypoglycemia • Multiple chronic complications of DM • FBS > 250 mg/dl • Glycosylated hemoglobin (HbA1c) level greater than 9% General Considerations • Morning appts best • Last ate, and what was eaten • Perioperative insulin regime • Check FS at chairside • 70-90 mg/dl: give glucose • >200 mg/dl: defer elective tx • Have pt. warn if developing symptoms of hypoglycemia • Consult PCP if more invasive surgery involved • Prophylactic Abx? DM Case • A 55 y.o. patient presents to your office with a history of DM I and HTN. He requires extraction of his remaining 14 teeth due to severe periodontal disease and placement of an immediate dentures. Questions to Ask Patient: • How long have you been diagnosed with DM? • What meds are you taking, and have there been any changes in meds and dosages? • Do you have any complications associated with DM? • Did they eat today? When did they eat? What did they eat? • Did they check their BS today? • Any symptoms of poor control (Polyuria, Polydipsia, Polyphagia) Medical Consult Request: • Mr. C , who is a patient known to you, has a history of DM and HTN. He will require extraction of his remaining teeth under local anesthesia using 2% xylocaine with 1:100k epi. Please provide the following: • • • • What is the patient’s latest HbA1C level and has it been consistent? Is the patient medically optimized to under go the above procedure? Please provide perioperative recommendations After the procedure, the patient’s oral intake may be decreased for the first 3 – 4 days. Patient’s insulin regime may need to be adjusted until oral intake improves. Please provide recommendations/instructions to the patient if required Case • A patient has had a syncope episode each of the last two dental visits after administrating local anesthesia and has not been able to undergo the procedure. • What could you do to help prevent this from happening at his next scheduled visit? Interventions: • Place patient into a supine position before and while administering the local anesthesia • Incorporate a stress reduction protocol • Early morning/short appointments • Use of N2O/O2 Sedation • Anxiety/analgesic • Use of Oral Premedication Would You Obtain a Medical Consult? Would You Obtain A Medical Consult? • May want to request if: • For recommendation of oral premed if patient is medically compromised and on multiple medications • If there is concern that the syncope is not vasovagal • Patient has had episodes outside of the office