Treating the Medically Compromised Patient
By Denise Foran, D.D.S.
As dental professionals, all of us at some point in our careers have attended courses, or read literature concerning the treatment and management of the medically compromised patient. I am confident that we are well versed in the challenges we face in caring for patients with systemic diseases. First, we are aware that patients are living longer, and it seems that “dental IQ” has increased over the decades. Seniors are seeking more advanced dentistry, and as a result, they have become a very large part of our practices. Furthermore, advancements in medical treatment and pharmaceuticals have resulted in more patients with significant medical histories and extensive medication lists. As endodontic specialists, we must consider the multifactorial complexities associated with our patient population.
Where shall we begin? From the moment a patient enters the office, valuable information is available to us. What is the patient’s attitude? Is he/she anxious? In pain? Irritable? Do these issues prompt you to question whether this patient is merely apprehensive about dental treatment, or does he/she have an underlying medical condition causing this presentation? One should consider both possibilities and make no assumptions prior to treatment. We know that dental anxiety alone can result in increased blood pressure, syncope, irritability and diaphoresis. However, underlying medical conditions such as hypertension, diabetes and thyroid abnormalities, to list a few, may also be associated with the same manifestations.
Unfortunately, the fact remains that we cannot completely rely on patients to give us an accurate medical history. They may intentionally or inadvertently fail to disclose critical health information. Some patients fail to see the relevance and impact that systemic conditions can have on their dental care and vice versa. For example, a male patient may not disclose that he uses Viagra or other ED medications. Administering nitroglycerin to this patient can lead to a severe hypotensive episode. A thorough review with pointed questions can elucidate a more accurate history and avoid potential complications. A large part of endodontic practice deals with emergency treatment, not routine care, and we are therefore limited in our abilities to appreciate changes in our patients over time. Obtaining and reviewing health histories with patients, while tedious at times, is certainly appropriate and recommended.
A proper clinical examination includes the measurement of vital signs. Often patients are surprised that a dentist is interested in measuring blood pressure, and this creates a timely opportunity for thorough medical history review. While there are no strict contraindications to endodontic treatment for patients with elevated blood pressure readings, it is advisable that elective treatment is deferred for values greater than 180/110 mmHg to minimize risk of an adverse cardiac event. However, any elevated reading warrants a referral to a primary care physician for evaluation and possible treatment.
One of the most common conditions in our patient populations is diabetes. Endodontic treatment can certainly disrupt a patient’s normal routine, and even well-controlled diabetic patients are subject to adverse events. One may simply fail to eat prior to the appointment, and even a minimal amount of stress can result in a hypoglycemic episode. Obviously, having a form of sugar available during treatment is recommended. Furthermore, inquiring about the patient’s current HbA1C levels guides the practitioner in potential treatment modifications, especially when considering surgical options or evaluating the outcome of prior treatment.
Consider how the drugs we administer may affect certain groups of patients.
Local anesthetics: These are generally safe and effective for most patients. For patients diagnosed with cardiovascular disease, we should aim to limit the amount of epinephrine administered to 0.04mg. Although the risk is small, epinephrine may cause a hypertensive event in patients taking non-selective B blockers including carvedilol, propranolol, nadolol and sotolol. Epinephrine may also induce a cardiac arrhythmia in patients taking cardiac glycosides such as digitalis. The use of epinephrine in patients with suspected hyperthyroidism is generally contraindicated. With recreational drug use on the rise, epinephrine should not be used if a patient has used cocaine recently.
Antibiotics: The most common antibiotics used in endodontics include penicillin, amoxicillin, clindamycin and amoxicillin/claveulenic acid (Augmentin). Occasionally, other classes of drugs are used including macrolides, fluroquninolones and tetracyclines. Recently, fluoroquinolones have been singled out for their side effects and thus are not recommended to be used except for advanced disease. In patients with chronic renal disease, it is best to avoid drugs that are eliminated and metabolized by the kidneys. Clindamycin should be considered in the management of endodontic infections in a patient with advanced renal disease.
Analgesics: Aspirin, NSAIDs and acetaminophen (with or without narcotics) are most commonly prescribed. Acetaminophen-containing drugs are generally considered the safest option for patients taking anticoagulants and for patients with end-stage-renal-disease. All of these drugs are metabolized by the liver but are considered safe for patients with mild to moderate liver disease if administered in minimal amounts for short duration.
Oral anxiolytics: If preoperative anxiolytics are indicated, there are a few important things to consider. Patients who are premedicated with any oral sedatives such as diazepam (valium), alprazolam (xanax), or lorazapam (ativan), should be escorted to and from the appointment. Additionally, other CNS altering medications can interact with anxiolytics, resulting in excessive sedation. Lastly, the use of nitrous oxide in these patients must be considered with caution. If a patient is taking any psychotropic drugs, it is best to defer to the physician for appropriate dosing.
In conclusion, it is our duty as specialists to provide the pinnacle of endodontic care for our patients. As modern medicine continues to advance with an aging population, we must remain vigilant and well educated concerning the medical complexities or our patients. As with most things endodontic, the details make the difference!
Dr. Denise Foran, an ABE Diplomate, is director of the post-graduate program in endodontics for the VA New York Harbor Healthcare System. She can be reached at (212) 686-7500 or denise.foran@va.gov.
Works Cited
- Little, James W., Falace, Donald, Miller, Craig, Rhodus, Nelson L. “Little and Falace’s Dental Management of the Medically Compromised Patient.” Elsevier eBook on Intel Education Study, 8th Edition, 2012. https://www.elsevier.com/books/little-and-falaces-dental-management-of-the-medically-compromised-patient/little/978-0-323-08028-6