Establishing Dental Treatment Guidelines for Adult Patients with Uncontrolled Hypertension Attending Acute Care.

Transcription

1 Establishing Dental Treatment Guidelines for Adult Patients with Uncontrolled Hypertension Attending Acute Care. John C Comisi, DDS Assistant Professor, MUSC-College of Dental Medicine

2 We all have them in our practices

3 They decline or refuse to have their B.P. taken

4 Managing the patient

5 Can often be a battle

6 HBP - Silent Killer risk of: Heart Disease Stroke

7 Undiagnosed or uncontrolled hypertension is a serious public health concern that affects nearly half of American adults according to a November scientific guideline issued by the American Heart Association. Proper recognition and early treatment of this serious medical condition can help prolong the health and lives of our patients. The dentist's role in screening for hypertension, as part of a comprehensive evaluation and appropriate referral, is very important. Not only does proper screening allow for early detection and treatment, it may also provide oral health care providers an opportunity to educate their patients on the relationship of oral health and overall systemic health. Dr. Craig Ratner, chair of the ADA Council on Dental Practice.

8 Nearly 1/2 of American Adults are a RISK of major health problems due to: HIGH BLOOD PRESSURE American Heart Association

9 Guidelines

10 Readings of 130 as systolic or 80 as diastolic now are considered to have high blood pressure!

11

12 Under New Guidelines Allow Patients to Rest for 5 minutes prior to measuring BP Average at least two readings over two visits (don t react to just one reading) If reading is above 130/8o on the first visit - Follow up with Primary Health Care Provider!

13 Under New Guidelines At first visit - record BP in both arms. Use the arm with higher reading at subsequent visits. Separate repeated measurements by 1-2 minutes Provide BP readings to the patient - verbally and in writing.

14 Why are these guidelines being used?

15 More patients will be diagnosed, and earlier. Dental Professionals will likely be seeing their patients with more BP and other meds. As such, IMPORTANT to understand the side effects of the most common hypertension drugs - ie: calcium channel blockers (amlodipine -> gingival hyperplasia). Will need to educate our patients about these guidelines. Will play an even more important role in this screening, since its are seen more at dental office, then medical office.

16 Dental Management in patients with Hypertension: Challenges and Solutions Clinical, Cosmetic and Investigational Dentistry: 17 October 2016

17 Dental Management in patients with Hypertension: Challenges and Solutions Clinical, Cosmetic and Investigational Dentistry: 17 October 2016

18 Adult Patients with Uncontrolled Hypertension Needing Acute Care.

19 It was once thought that it was just the temporary stress of being at the doctor that caused a spike and that it didn't indicate a bigger problem. White-coat hypertension is not benign," said Dr. Haitham Ahmed, medical director of cardiac rehabilitation at Cleveland Clinic, who was not a part of the study. "If seeing a white coat increases your blood pressure, a lot of other stressors in life are expected to as well.

20

21 It is vital that you are comfortable with identifying disorders associate with hypertension and making decisions about proper treatment planning. This includes: emergent evaluation as needed for treatment outpatient referral followup

22 Obtain BP BEFORE administering local anesthesia! Gives baseline status to identify those medically unstable to undergo treatment.

23 This Provides a safer environment improves overall outcomes

24 - Mercury sphygmomanometers are most accurate - low usage - Aneroid devices - most commonly used in dental offices. Calibration of these devices: at least q6months!

25 The same is true for Automatic Digital devices.

26 While there is no demonstrated direct connection between dental treatment and complications of 1 hypertension, - it is IMPORTANT for Oral Health Care Providers to know the potential risks and complications while those individuals are receiving treatment in the dental practice. J. The assessment and importance of hypertension in the dental setting. Dent Clin Nort

27 Dental Management in patients with Hypertension: Challenges and Solutions Clinical, Cosmetic and Investigational Dentistry: 17 October 2016

28 When any of these signs or symptoms are observed: Consultation with prescribing physician may be indicated if unable to be resolved using other modalities. Evaluation of the medications list and potential side effects may be indicated.

29 There are many factors associated with hypertension crisis, but: Medication noncompliance is one of the 2,3 most significant factors. 2. Pak KJ, Hu T, Fee C, Wang R, Smith M, Bazzano LA. Acute hypertension: a systematic review and appraisal of guidelines. Ochsner J. 2014;1 3. Whalen K, Finkle R, Panavelil TA. Lippincott Illustrated Reviews: Pharmacology. 6th ed. Philadelphia: Wolters Kluwer; 2015.

30 If patients present with elevated BP >180/120 mmhg or an acute rise in blood pressure after a previously normal baseline, consider the following: - neurologic deficits from ischemic or hemorrhagic stroke, - nausea and vomiting associated with hypertensive encephalopathy and increased intracranial pressure, - chest discomfort associated with myocardial ischemia or aortic dissection, - back pain associated with aortic dissection, - dyspnea associated with pulmonary edema.

31 Pregnancy can precipitate/exacerbate severe hypertension - resulting in preeclampsia and risk of eclampsia! LIFE THREATENING!

32 Pharmocologic agents: cocaine amphetamine phencyclidine monoamine oxidase inhibitors Document and Discontinue

33 Recent discontinuation of: Clonidine and other sympatholytic agents can cause significant rise in BP!

34 Epinephrine: The debate

35 Providers who treat patients who are prescribed the drugs previously discussed, should be cautious when administering local anesthesia with added vasoconstrictor.

36 Bleeding High BP can lead to excessive intraoperative bleeding during surgical procedures.

37 BP values and Risk Assessment Readings above 180/110 - ABSOLUTE Cutoff of dental treatment. <180/110 no increased risk for adverse preoperative outcomes. History of hypertensive-related organ damage (MI, strokes, labile angina) use caution, since this BP rule may be too high. Use good judgement in all cases!

38 Metabolic Equivalents (METs) Could be helpful when stratifying the rush associated with treating patients in the dental setting. One MET = 3.5mL oxygen consumed/kg body-mass/minute. Quantifies the ability to perform physical work. Pts. able to perform tasks > 10 METs = LESS RISK of adverse cardiovascular events.

39 Metabolic Equivalents (METs) Dental Management in patients with Hypertension: Challenges and Solutions Clinical, Cosmetic and Investigational Dentistry: 17 October 2016

40 Considerations for treatment MET < 4 divide procedures into Multiple quadrants, retake BP after one quadrant is completed. Injections: use slow technique with aspiration to avoid intravascular injections.

41 When you treat A complete medical history and physical exam helps with a thorough risk assessment. This risk assessment is VITAL before undertaking ANY dental procedure. Know your patient s physical and functional status to help with decision making for treatment. Use SHORT duration morning appointments SlOW position changes. Establish profound local anesthesia prior to beginning treatment.

42 In Conclusion Knowledge: know current therapeutic options. Use good judgement. Assess patient health to be sure they can be safely treated. Make proper decisions based on: baseline BP urgency of procedure functional and physical status Time and invasiveness of the procedure. When in doubt - seek medical advice!

43 The HEALTH of your Patient Always Comes First!!

44 Thank you!!! Establishing Dental Treatment Guidelines for Adult Patients with Uncontrolled Hypertension Attending Acute Care. John C Comisi, DDS Assistant Professor, MUSC-College of Dental Medicine