A Strategic Balance: Treating Medically Compromised Patients
Catherine Paulhamus, MA
Patients are returning to the dental chair. But in what shape? Many have avoided the dental office for more than a year. Others have allowed even basic homecare practices to lapse. After constant news about viruses in aerosols, they are still understandably nervous about needing treatment.
Much has changed during this interim, most likely including the patient's medical status. However, a comprehensive medical history (even a review and update) demands time, patience, and communication skills. For dental hygienists facing a surge of patients, time is in short supply, and the extra work needed for long-delayed prophylaxis is already creating problems in the practice schedule. As a recent Los Angeles Times article reported, dental hygienists, who often have personal relationships with patients, are finding that the medical history update is opening up lengthy emotional conversations as patients recap their year and its effect on their oral health.1
However, as patients become more medically complex and pharmaceuticals continue to advance, the dental practice is obligated to assess how these factors may interact to prevent harm. The American Dental Hygienists' Association (ADHA) standards of practice explains in detail the requirements and importance of the health history, beginning with building a rapport between the hygienist and patient. The discussion should take place in a private area that complies with the Health Insurance Portability and Accountability Act (HIPAA). In addition to verifying medical information, the questions should identify the need for physician consultation or any contraindications for treatment. This would include mental health diagnosis, cognitive impairment, behavioral challenges, and functional capacity. The patient's level of ability to withstand a long dental appointment, as well as the need for modified positioning for treatment, should be determined. Laboratory tests (such as current glucose levels) may need to be requested. In addition to confirming the list of medications, including dose and frequency, the pharmacologic history should note any over-the-counter (OTC) drugs or products such as herbs, vitamins, nutritional supplements, and probiotics. The hygienist should also confirm any allergic or adverse reactions.2
A Complex System
As the scope of dental practice increases, practitioners are extending their focus beyond the oral cavity, providing comprehensive examinations for systemic health. In addition, demographics and health status of the patient population are not static. Patients are living longer and seeking more advanced dentistry, such as implants.3 The prevalences of chronic illnesses such as diabetes have increased.4 Advancements in pharmaceuticals have resulted in more patients with more (and different) medications, prescribed by multiple physicians.3 Another change is that this is no longer an issue only for older patients. A new study demonstrates that many younger adult dental patients are taking medications: most likely antidepressants and opioids.5 As explained by the lead author and Director of Regenstrief and IU School of Dentistry Dental Informatics Program, Thankam Thyvalikakath, DMD, PhD, "The number of younger adults on medication really surprised us. Often dentists will assume individuals this age aren't on medications, but these results underscore the importance of paying attention to medical histories of all patients, because medications can play a significant role in oral health."5
Adding to the complexity, medications and medical conditions may affect either oral health or the provision of treatment. While the list is too lengthy to include in this article (and continues to evolve with new research), the potential for interactions requires a high level of awareness and an individualized strategy for the patient. Systemic health care starts with a full-body health history. For example, recommended questions include "cardiovascular, hematologic, neural and sensory, gastrointestinal, respiratory, dermal, mucocutaneous, and musculoskeletal, endocrine, and urinary systems as well as questions related to sexually transmitted diseases, drug use (eg, alcohol, tobacco), allergies, x-ray exposure or treatment, medications, and hospitalizations. Other laboratory tests that may be necessary prior to dental treatment include a complete blood count with differential and tests for hemostasis, hepatitis B and C, and HIV."6
Interactions range from uncomfortable to serious. For example, patients with diabetes who are under stress may experience a hypoglycemic episode in the chair.3 Some prescriptions cause a problem with local anesthesia or with posttreatment pain medication.6 Others have a more direct effect on oral health, as more than 500 medications list xerostomia as a side effect (including 63% of the 200 most-prescribed drugs).7 In all cases, the patient is relying on the healthcare practitioner for an explanation, preventive strategies, and treatment success.
Even if the questionnaire is thorough, patients may not provide accurate or complete information. Often, patients simply indicate "no changes," forgetting an illness or new prescription. They don't remember the names of medications or the dosages. They consider "natural" remedies or OTC medications harmless and don't bother to list them. Unfortunately, in certain situations these omissions can be critical.
Patients may also be reluctant to disclose facts they find uncomfortable: for example, self-medicating with unprescribed or illegal drugs, or even the extent of their alcohol or cannabis use. Some patients may use anti-anxiety medications to calm themselves before an appointment, without advising the dentist. Even a male patient taking an erectile dysfunction medication may not want to admit that fact to a hygienist. Eliciting information from uncooperative patients requires sensitivity, trust, and open communication, while educating them on potential interactions and the need for disclosure.
Mental health is one medical issue that both patients and practitioners may be hesitant to discuss. In a study published in the Journal of Dental Hygiene, the authors explored oral health professionals' knowledge, attitudes, and practices toward patients with depression. Results demonstrated that many oral health professionals do not include a patient's history with depression in their health review, nor do they consider treatment modifications.8 Even if patients have been diagnosed and are being treated, they may not want to disclose this information. On the other hand, the practitioner may feel ill-equipped to discuss mental health without additional education.
Oral health practitioners, aiming to deliver comprehensive, successful treatment, need to balance all aspects of their patients' systemic health. The proportion of "medically compromised" patients is increasing, and with it, the need for more strategic patient management and education-areas in which dental hygienists excel.