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Dental Management of Medically Compromised Patients Sol G. Brotman, DDS, MAGD 2  Why is a medical history important in dentistry? A patient's medical history is a vital part of his or her dental history and increases the dentist's awareness of diseases and medication which...

Dental Management of Medically Compromised Patients Sol G. Brotman, DDS, MAGD 2  Why is a medical history important in dentistry? A patient's medical history is a vital part of his or her dental history and increases the dentist's awareness of diseases and medication which might interfere with the patient's dental treatment. ncbi.nlm.nih.gov/m/pubmed/16729560 3  Medical/Dental Health History Health history form The health history form is the starting point for the practice’s relationship with the patient. It’s valuable, because it provides appropriate staff members with information that they need in order to fulfill their professional obligations. Patient interaction Keep in mind that the patient’s interaction with the staff and the dentist during the health history collection process is at least as important as the information detailed on the form itself. This process sets the tone for a positive patient experience for both new patients and active dental patients of record. https://success.ada.org/en/practice-management/guidelines-for-practice- success/gps-managing-professional-risks/medical-dental-health-history 4  Medical/Dental Health History An accurate medical/dental health history is vital since: It may provide valuable information for the dentist prior to beginning treatment, especially since certain medications can influence treatment decisions or may impact post-operative care instructions. It’s also important to recognize that patients who are current or recovered opioid users may be reluctant to reveal that aspect of their medical history. https://success.ada.org/en/practice-management/guidelines-for-practice- success/gps-managing-professional-risks/medical-dental-health-history 5 Medical/Dental Health History: Updates Be sure to make a notation in the patient’s record that indicates the patient was asked about recent health and medication changes. That notation should include the date of the discussion and indicate which staff member(s) initiated the conversation. The record should then be updated to reflect the new information. https://success.ada.org/en/practice-management/guidelines-for-practice- success/gps-managing-professional-risks/medical-dental-health-history 6  Do dentists have access to medical records? If Dentists don't comply with HIPAA rules then they are audited, they get penalized. Dental records, in paper or electronic format, are considered Protected Health Information and are subject to the same federal scrutiny for privacy and security as full medical records. https://www.hipaaone.com/2014/07/01/dentists-concerned-hipaa-laws- security-patient-records/ 7  Medical and Dental Electronic Health Record Reporting Discrepancies in Integrated Patient Care S. Adibi, M. Li, N. Salazar, D. Seferovic, K. Kookal, J.N. Holland, M. Walji, M.C. Farach-Carson Journal of Dental Research https://journals.sagepub.com/doi/abs/10.1177/2380084419879387?journalCode=jcta 8  Abstract Introduction Oral health mirrors systemic health; yet, few clinics worldwide provide dental care as part of primary medical care, nor are dental records commonly integrated with medical records. https://journals.sagepub.com/doi/abs/10.1177/2380084419879387?journalCode=jcta 9  Abstract Results Of those patients with diabetes,15.1% misreported their diabetes condition to their dental clinicians, while 29% of patients with hypertension also misreported. There was no relationship between sex and misreporting of hypertension or diabetes, but age significantly affected reporting of hypertension, with misreporting decreasing with age. https://journals.sagepub.com/doi/abs/10.1177/2380084419879387?journalCode=jcta 10  Abstract Conclusions Because these conditions affect treatment planning in the dental clinic, misreporting of underlying medical conditions can have negative outcomes for dental patients. We conclude that policies that support the integration of medical and dental records would meaningfully increase the quality of health care delivered to patients, particularly those dental patients with underlying medical conditions. https://journals.sagepub.com/doi/abs/10.1177/2380084419879387?journalCode=jcta 11  Abstract Knowledge transfer statement Our study illustrates an urgent need for policy innovation within a currently fragmented health care delivery system. Dental clinicians rely on the accuracy of health information provided by patients, which we found was misreported in ~15% to 30% of dental patient records. An integrated health care system can close these misreporting gaps. Policies that support the integration of medical and dental records can improve the quality of health care delivered, particularly for dental patients with underlying medical conditions. https://journals.sagepub.com/doi/abs/10.1177/2380084419879387?journalCode=jcta 12  The Effects of Oral Health on Systemic Health Over the course of a five-year study6, we’ve seen significantly lower medical costs for members who use their preventive or periodontal dental services versus those who do not. Book of business study concluded medical cost differences between dental utilizers versus non-utilizers: $4,649 PMPY CAD, 30% difference $1,459 PMPY Diabetes, 16% difference NOTE: For a member to be considered a ‘dental utilizer,’ they must have used one preventive or periodontal CDT in the previous 12 months. 13 Patient Evaluation 14  Patient Evaluation Clinical Medical History Evaluation Head & Neck Physician Examination Consultation 15  Medical History Current medical conditions Past medical conditions Allergies 16  Medical History Medications Length of time of treatment Changes in dosages OTC or alternative medications Patches or other non-oral routes of administration Treatment for current or past medical conditions e.g., radiation, chemotherapy 17  Clinical Evaluation General appearance Posture Asymmetries Bruising Skin lesions Swelling 18  Clinical Evaluation Patient responsiveness Timing and delays Appropriateness Voice Facial movement and activity Pain cues 19  Clinical Evaluation Vital signs Blood pressure Pulse Body temperature 20 Head and Neck Examination Cervical nodes or swelling TM joint evaluation Jaw sounds Deviation of mandible on opening Range of motion Oropharyngeal cancer examination Include upper pharynx – tonsillar region 21 Head and Neck Examination Salivary glands Periodontal Dental Radiographic 22  Physician Consultation Written versus oral clearances Referrals for specific concerns Closing care gaps 23 Coronary Artery Disease and Stroke (Artherosclerosis) 24  Demographics Most common cause of death in the US (33%) Incidence has been reduced by 50- 60% in past 50 years 25  Risk Factors Male gender Age Family history Hyperlipidemia Diet: Total calories, saturated fats, cholesterol, sugars and salts 26  Risk Factors Hypertension Smoking and other tobacco use Physical inactivity Obesity Insulin resistance and diabetes mellitus Mental stress and depression 27  Markers of Inflammation C-reactive protein (CRP) Homocysteine Fibrinogen Lipoproteins (serum lipids) 28  Conditions (ICD-10) Myocardial infarction Angina pectoris Atherosclerosis Cardiac ischemia Cerebral infarction Arterial occlusion and stenosis Embolism and thrombosis 29  Medication Formulary Nitrates Nitroglycerin and long-acting nitrates Side effects: Dry mouth, orthostatic hypotension, headache 30  Medication Formulary Beta Blockers Propranalol (Inderal), Nadolol (Corgard), Metoprolol (Lopressor), Atenolol (Tenormin) Side effects: taste changes, orthostatic hypotension Dental consideration: reaction with vasoconstrictors (maximum of 2 carpules with 1:100,000 epinephrine) 31  Medication Formulary Calcium Channel Blockers Diltiazem (Cardizem), Verapamil (Calan), Amlodipine (Norvasc) Side effects: gingival hyperplasia, dry mouth Dental consideration – avoid prolonged use of NSAIDs 32 Journal of Human Hypertension 28, 10-14 (2014) R Livada & J Shiloah https://www.nature.com/articles/jhh201347 33  Medication Formulary ACE inhibitors Used for heart failure All of the …prils 34  Medication Formulary Angiotensin Receptor Blockers Used for heart failure and high blood pressure Irbesartan (Avapro), Losartan (Cozaar), Valsartan (Diovan) 35  Medication Formulary Anticoagulants Aspirin Clopidogrel (Plavix) Warfarin (Coumadin) Requires INR testing for range of 2.0 to 3.0 Dabigatran (Pradaxa) Rivaroxaban (Xarelto) Aprixaban (Eliquis) 36  Medication Formulary Anticoagulants Dental consideration: bleeding. Positive history of excessive bleeding should have pre-op testing of PT, aPTT, TT and platelet counts. 37  Medication Formulary Statins All of the …..statins Dental consideration: increased risk of organ damage and rhabdomyositis in conjunction with Erythromcin or Biaxin Many statins interact with certain anti- fungals 38  Antibiotic Prophylaxis Prior to Dental Procedures Compared with previous recommendations, there are currently relatively few patient subpopulations for whom antibiotic prophylaxis may be indicated prior to certain dental procedures. Infective endocarditis prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. 39 https://www.ada.org/en/member-center/oral-health- topics/antibiotic-prophylaxis The current infective endocarditis/valvular heart disease guidelines state that use of preventive antibiotics before certain dental procedures is reasonable for patients with: Prosthetic cardiac valves, including transcatheter- implanted prostheses and homografts Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords A history of infective endocarditis 40 https://www.ada.org/en/member-center/oral-health- topics/antibiotic-prophylaxis A cardiac transplant with valve regurgitation due to a structurally abnormal valve Specific congenital (present from birth) heart disease Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits Any repaired congenital heart defect with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or a prosthetic device 41  JADA – January , 2015 Volume 146, Issue 1, Pages 11–16.e8 The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients with Prosthetic Joints 42  JADA – January , 2015 Volume 146, Issue 1, Pages 11–16.e8 Conclusions Evidence fails to demonstrate an association between dental procedures and PJI or any effectiveness for antibiotic prophylaxis. Given this information in conjunction with the potential harm from antibiotic use, using antibiotics before dental procedures is not recommended to prevent PJI. Additional case-control studies are needed to increase the level of certainty in the evidence to a level higher than moderate. 43 Diabetes 44  Demographics US: 30,000,000 diabetics and 70,000,000 prediabetics in 2017. https://www.cdc.gov/media/releases/2017/p0 718-diabetes-report.html Incidence 9% in US and worldwide. Hawaii 11.5% https://www.stateofobesity.org/diabetes/ Seventh leading cause of death in US 45  Diagnostic Criteria for Diabetes A1C https://www.diabetes.org/a1c/diagnosis 46  Diagnostic Criteria for Diabetes Oral Glucose Tolerance Test https://www.diabetes.org/a1c/diagnosis 47  Diagnostic Criteria for Diabetes Fasting Plasma Glucose https://www.diabetes.org/a1c/diagnosis 48  Diagnostic Criteria for Diabetes Random Plasma Glucose Test Diabetes is diagnosed at blood sugar of greater than or equal to 200 mg/dL https://www.diabetes.org/a1c/diagnosis 49  Dental Considerations Epinephrine can cause blood glucose to rise Steroids will cause blood glucose to rise Gingival and periodontal infections Delayed wound healing 50 Patient DP. Non smoker age 53 51 Head and Neck Cancers 52  Estimated New Cancer Cases in US All Sites 1,372,910 710,040 662,870 1,762,450 870,970 891,480 Oral cavity & pharynx 29,370 19,100 10,270 53,000 38,140 14,860 Tongue 7,660 5,050 2,610 17,060 12,550 4,510 Mouth 10,070 5,370 4,700 14,310 8,430 5,880 Pharynx 8,590 6,520 2,070 17,870 14,450 3,420 Other oral cavity 3,050 2,160 890 3,760 2,710 1,050 53 Estimated New Cancer Deaths in US All Sites 570,280 295,280 275,000 606,880 321,670 285,210 Oral cavity & pharynx 7,320 4,910 2,410 10,860 7,970 2,890 Tongue 1,730 1,120 610 3,020 2,220 800 Mouth 1,890 1,100 790 2,740 1,800 940 Pharynx 2,130 1,490 640 3,450 2,660 790 Other oral cavity 1,570 1,200 370 1,650 1,290 360 54  Oral Cancers 90% are squamous cell (SCC)  80% of SCC are related to tobacco, alcohol and paan (Betel nuts) 2010  66% are due to degradation of the p53 protein on Chromosome 9  25% are white, 60% white/red, 33% red, 2% other  Recurrence rates – Smokers 30%, Non- smokers 13% 55  Pretreatment Oral Evaluation 1. Discuss your role and expectations with the patient: a. Nausea and vomiting may lead to tooth erosion b. Mucositis and ulcerations c. Taste alterations d. Fungal, bacterial or viral infections 56  Pretreatment Oral Evaluation 2. Rule out oral conditions that may worsen during cancer therapy 3. Provide baseline for oral conditions 4. Identify other lesions, including metastasis 57  Pretreatment Oral Evaluation 5. Minimize intraoperative discomfort with rinses 6. Reduce risk for radiation or other caries and tooth sensitivity with fluoride varnish, gel or rinses 7. Xerostomia management 58 Management on Non-Restorable Teeth 1. Extractions three weeks prior to radiation, one week prior to chemotherapy 2. Submerging roots or root banking https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556801/ 3. Bisphophonates in chemotherapeutic protocols 59 60  Oropharyngeal cancers Incidence of oropharyngeal HPV: 10% of men, 3.6% women HPV is present in 70% of oropharyngeal cancers https://www.cdc.gov/cancer/hpv/basic_info/hpv_oropharyngeal.htm 61  Oropharyngeal cancers Variants 16 and 18 are found most often in oropharyngeal cancers https://oralcancerfoundation.org/understanding/hpv/hpv-oral-cancer-facts/ White, non-smoking males age 35 to 55 are most at risk, 4 to 1 over females https://www.cancer.gov/types/head-and-neck/patient/adult/oropharyngeal-treatment- pdq 62  Oropharyngeal cancers Stages 0 – IVC Four types of standard treatment are used: Surgery Radiation therapy Chemotherapy Targeted therapy 63  Oropharyngeal cancers New types of treatment are being tested in clinical and other trials: Immunotherapy Radiochemical therapy Cryogenics 64 Sjögrens Syndrome 65  Demographics 3% of adult population 90% are women Second most common rheumatoid disorder 5% or less of normal salivary flow 66 Most Common Clinical Manifestations Dental caries Candidiasis Angular cheilitis Dyseusia (distortion of taste) 67  Moisture and Lubrication Artificial saliva (Salivart, Biotene, Pilocarpine) 68  Soft Tissue Level and Discomfort Benedryl Maalox or Milk of Magnesia Decadron elixir Mycelex troches 69  Caries Prevention More frequent dental exams Fluoride varnish, gel and 5000 ppm toothpaste 70 Pregnancy 71  Demographics 100% women Leading cause of childbirth 72  Oral Conditions Pregnancy Gingivitis https://images.app.goo.gl/qpQxhyRnW6bgeV8y8 73  Oral Conditions Pyogenic Granuloma https://images.app.goo.gl/4nSKskRgUohGMouA8 74  Oral Conditions Increased dental erosion due to regurgitation Increased dental decay due to poor diet 75  Medical Correlation “In this population-based study, women who did not receive dental care or have a teeth cleaning during pregnancy were at slightly higher risk for preterm delivery after adjustment for pertinent confounders.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4561173/ 76  The Future is Now On May 6, Oregon House Bill 2220 was signed into law, enabling licensed dentists to prescribe and administer vaccines. The policy is scheduled for implementation in 2020 pending review and protocol design by the Oregon State Dental Board. With its passage, Oregon joins Minnesota and Illinois as the third state to permit vaccinations in dental offices. Minnesota and Illinois allow flu vaccines to be administered. 77  Hawaii Medical and Dental Statistics Hawaii has the highest rate of childhood dental caries in the US. In 2016 there were approximately 3,000 ED visits for preventable oral health related pathology. Total cost was $17M or $5,600 per visit. 78  Oral Health for Total Health and HMSA Connected CareSM Stephanie J Dvoroznak, Program Director 79 Oral Health for Total Health 80  Overview Oral Health for Total Health focuses on the HMSA medical and dental integration. It offers clinically significant enhanced dental benefits to enrolled members with certain medical conditions that systemically impact the overall health of those enrolled. Enhanced dental benefits have demonstrated better health outcomes and can potentially lower medical and dental costs. Enhanced dental benefits remove financial barriers, making it easier than ever to put one’s health first. No waiting periods No copays or coinsurance: paid at 100% when visiting a participating provider Is not applied towards calendar-year maximum (CYM) Benefits are valued over $1,000 per year 81  Benefits Overview Oral Health for Total Health Enhanced Dental Benefits Overview 82  HMSA Connected Care 11/2019 83  Overview HMSA Connected Care Innovative healthcare management platform Designed for patient care management that enhances our Oral Health for Total Health program Real-time system uses information from our primary care physicians’ patient medical records to deliver a comprehensive view of each patient’s health status Specifically noting the medical and dental measures that show where attributed patients are healthy vs. deficient in care – alerting the provider who then can coordinate outreach and consultation to promote compliance 84  Dental Measures HMSA Connected Care Dental Measures Preventive Dental Care (Non-OHTH Members)  Identifies members who have not had a cleaning in the current calendar year. Obtaining regular cleanings helps to control oral inflammation and allows the dentist to check for developing oral health problems that could affect total health. Oral health for Total Health Dental Care (OHTH Population)  Identifies enrolled OHTH members who have not had a dental cleaning or non-surgical periodontal treatment in the current calendar year. Obtaining regular treatment helps control oral inflammation, which is a known risk factor in the control of diabetes, CAD & stroke, and allows the dentist to check for developing oral health problems that could affect total health. 85  Implementation Timeline 9/30/2019: Dental Measures released to PCPs within PTM 10/1/2019: Dental Measures pilot begins 11/1/2019: Dental Measures pilot ends 1/2/2020: Dental measures go-live for all dentists 86 Dental Patient Registry 87 Viewing Patient Demographics 88 Face Sheet 89  Cost Containment Cost containment is an important consideration for the insurer, provider and patient. With Connected Care, we can help reduce the cost of care by offering and rendering enhanced dental benefits to members who need them most, and promote dental utilization by dental providers versus the department. Over the course of a five-year study,1 there are significantly lower medical costs for members who use their preventive or periodontal dental services versus those who do not use them. The average medical cost difference between users versus non-users is $4,649.10 per member with CAD and $1,459.07 per diabetic member. This equates to a 30% difference in medical costs for members with CAD, and 16% for members with diabetes. 1HMSA Dental User Medical Cost Trend Average (2013-2017).  Treating the Whole Patient Integrated care, incorporating medical and dental transparency between physician and dentist, allows for a more comprehensive approach in addressing the dental health disparity and facilitating appropriate dental care versus a medical referral to the Emergency Department. Facilitating appropriate dental care is possible through HMSA Connected Care and your commitment to treating the whole patient. 91 Questions? 92 Mahalo 93