2017 Oregon Dental Conference Course Handout. Renee Watts, DDS Course 8154: Health History Hurdles Friday, April 7 10:30 am - 12 pm

Transcription

1 2017 Oregon Dental Conference Course Handout Renee Watts, DDS Course 8154: Health History Hurdles Friday, April 7 10:30 am - 12 pm

2 Health History Hurdles April 7 th 2017 Renee Watts, DDS, FAGD Renee@ardentcaredental.com Course Objectives Become more comfortable and confident in doing medical history reviews Help your patients get the best care by getting the most accurate information Communicate better with your patients & teammates regarding patients health concerns Better understand how your patients oral and systemic health are related Find reliable places to look to find more information when needed Why? Prevent adverse events & medical emergencies Manage medical emergencies Aid in diagnosis of oral conditions Aid in treatment planning Reduce risks & complications of dental treatment Help patients reduce risk of future dental problems Legal record & risk management To provide the best care to our patients Updating health histories has become more challenging Life expectancy has reached record high & continues to increase Recognition that our oral health & systemic health are interrelated By 2030, 1 in 5 people in the US will be 65 or older More chronic conditions More medications to treat chronic & acute conditions across all age groups When patients ask why you need to know The health of your mouth and your general health are related in many ways. In order to provide you the safest and best care, we want to have an accurate picture of your total health. Obstacles to getting accurate information Forget health events occurred Forget to tell us Forget names Misspell names May not have good understanding of their condition(s) May not understand the question Don't realize how seemingly unrelated conditions can affect their oral health Social embarrassment Don't think we need to know Disease present and undiagnosed

3 *Know what is important to your doctor/practice Key Risks of Dental Treatment Impaired bleeding risk/clotting Susceptibility to infection Drug actions & interactions Ability to tolerate the procedure(s) The answer you receive depends on the question you ask! New Patients May be hesitant to reveal information as relationship is new Incomplete or unanswered questions Be friendly and confident! Communicate with your teammates Communication of admin team with new patients Written & Verbal Ask for clarification when answers unclear or skipped When answers don't correlate Make notes! Confirm condition, names, spelling Historical or present condition? Indicate date! How well controlled is the condition? Controlled with diet, exercise, lifestyle changes? How long they have had their condition "I'm not familiar with that. Tell me about it." How does it affect their life? Spelling matters! Ask your patient Medication list/bottle Look it up Get first and last names of other health care practitioners and/or their locations Brand name vs. generic medication names Unsure about something? Look it up if possible WebMD.com MayoClinic.org Wikipedia Drugs.com Manufacturer's website

4 Nonprofit and foundation websites (American Heart Association, American Diabetes Association, etc.) Government agencies (CDC) Patient Privacy/HIPAA Information kept confidential in recordkeeping & discussion Non-judgmental Attitude of care and concern Information can be shared between health care professionals without a signed release Discussion with family members or friends present also fine Medications & Supplements Which condition are they taking it for? Regularly or as needed? May not be taking recommended medications due to cost, forgetfulness or side effects or intentionally May be taking things not recommended by a health care provider for other reasons Prescription Drug Use Half the US adult population has used at least one Rx drug in the past month 22% report using three or more prescription drugs in the past 30 days 11% report using five or more prescription drugs in the past 30 days May be taking medications short-term or long-term Be familiar with common medications Brand name vs. generic name What condition are they taking it for? Quick reference sheet Look it up online TV & magazine ads Look for clues in the names Clues may be in their names Proscar prostate Lopressor high blood pressure Flonase allergies Flovent asthma Flomax prostate Acyclovir antiviral Norvasc heart disease & high blood pressure

5 Statins (cholesterol-lowering drugs) atorvastatin (Lipitor) fluvastatin (Lescol, Lescol XL) lovastatin (Mevacor, Altoprev) pravastatin (Pravachol) rosuvastatin (Crestor) simvastatin (Zocor) pitavastatin (Livalo) Over The Counter (OTC) Medications Analgesics Anti-inflammatories Antacids Antidiarrheals Antihistamines Decongestants Sleep aids Antifungals Topical preparations Common OTC Medications Tylenol = acetaminophen Advil/Motrin = ibuprofen Aleve = naproxen Prilosec = omeprazole Zantac = ranitidine Zyrtec = cetirizine Claritin = loratadine Allegra = fexofenadine Dietary Supplements/Complements Over half of Americans take one or more dietary supplements regularly Contain one or more dietary ingredients (including vitamins, minerals, herbs or other botanicals, amino acids, and other substances) or their constituents May be recommended by health practitioner or self-prescribed Some will decrease or increase the effects of other drugs we may prescribe Reporting is poor, however improves with asking specifically Supplement Sidebar 1994 ~4,000 products available 2016 >55,000 products Majority of adults are confident in the safety, quality and effectiveness of supplements >1/3 have not told their physician Some companies supply third party certifications that supplement ingredients are present in the concentrations claimed Responsible for ~23,000 ER visits per year in the US, mostly women Weight loss and energy supplements most common Minimal oversight authority by FDA No safety testing or FDA approval required to market products No requirement to identify potential adverse effects or major drug interactions

6 Quality and active ingredient levels can widely vary People may get higher doses of some compounds than desirable as they may be getting them from multiple sources Most (80%) people unaware of side effects Examine.com Drugs.com Common effects we're concerned with include interference with blood clotting Valerian and melatonin can increase sedative effects when taken with muscle relaxants, sedatives, pain medications St. John's wort has 200 major drug interactions Dietary Supplement Interactions Responsible for majority Garlic Gingko Kava St. John's wort Valerian Bleeding Risk Increases Garlic Gingko Ginger Ginseng Glucosamine Vitamin E Evening Primrose Oil Increased Bleeding Risk has three main causes Systemic health conditions Medications intended to decrease blood clotting (anticoagulants) Supplements Updates for existing or returning patients - be specific Common Questions Has anything changed since we saw you last? Any changes in your health? Are you still taking the same medications? Supplements? Better Questions Is your doctor still Dr.? The last time we saw you was and at that time you were being treated for/taking. Any new conditions or diagnoses since then? Problems with heart, lungs, liver, kidneys, stomach or bleeding? Allergies or sensitivities?

7 Communication with your teammates and doctor You've updated the history...now what? Recorded in chart Verbal handoff Routing slip Intra-office messenger Who else should know? Common Conditions with Dental Health Relationships Diabetes Mellitus A disease characterized by the body's inability to move sugar from the bloodstream into the body's cells Some part of the mechanism used to transport sugars from digestion/bloodstream to the inside of cells where it can be stored and used as energy is not functioning Sugar in bloodstream remains high and this causes problems throughout the body Thickening of the walls of blood vessels Impaired circulation in small vessels Currently affects about 12% of US population (30 million) 1 in 4 of these cases are undiagnosed Type 1 Usually diagnosed in childhood 5-10% of cases Not preventable Autoimmune disorder where the cells of the pancreas that produce insulin are destroyed Transport mechanism of cells works fine, no insulin being produced by the pancreas Insulin-dependent Blood Sugar Type 2 Diagnosed later in life 90-95% of cases Can be delayed or prevented Insulin is produced by the pancreas, receptors on the cells no longer will recognize it and transport sugar into the cell Treatment involves increasing the insulin sensitivity of cells May also become insulin-dependent over time Normal fasting blood sugar <100 Prediabetes Diabetes >125

8 Hemoglobin A1C A measure of blood sugar control used to for monitoring diabetic patients Measures the amount of glucose in the bloodstream that binds to the hemoglobin in our red blood cells Provides a picture of control over the past ninety days Normal is 5.0% Pre-diabetes % Diabetes 6.5+ Goal is below 7% in diabetic patients Oral Effects of Diabetes Increased susceptibility to periodontal disease Increased susceptibility to fungal infections (thrush) Dry mouth Poor wound healing People with diabetes are 3-4x more likely to develop chronic gum disease Periodontal disease that is not controlled makes it more difficult to control blood sugar Poorly controlled blood sugar associated with increased periodontal disease Allergies True Allergies Four types An overreaction of the immune system Symptoms differ depending on exposure Hives, red itchy bumps, skin rash Watery eyes, runny nose Anaphylaxis Other Stuff Avoidance due to other medications or health conditions Bad reaction/association Fainting Nausea/vomiting Interaction or duplication ADA Statement on Antibiotic Premedication - prosthetic joints In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. The practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic use. As part of the evidence-based approach to care, this clinical recommendation should be integrated with the practitioner s professional judgment and the patient s needs and preferences.

9 GERD (gastro-esophageal reflux disease) The backward flow of stomach acid into the esophagus Treated due in part to discomfort (chest pain, sour taste) Reduce risk of esophageal inflammation and cancer Untreated GERD oral effects Cardiovascular Diseases An umbrella term that encompasses many conditions of the heart and blood vessels Adults may have more than one cardiovascular condition Periodontal disease and chronic inflammation correlated with CVD May have had surgical and/or pharmacologic treatment Unidentified/undiagnosed disease Hypertension (high blood pressure) Congenital heart diseases Valve defects Coronary artery disease Angina Myocardial infarction Infective endocarditis Arrhythmias Surgical Interventions Coronary artery bypass graft (CABG) Angioplasty Stents in coronary arteries Pacemakers Prosthetic valve replacements Heart transplants When was their surgery & what type of surgery? Medications Several classes of drugs, depending on problem(s) May see oral side effects such as lichenoid drug reaction May bruise/bleed more easily if taking blood thinners Generally more medications indicate increased severity of disease Blood Pressure Systolic Diastolic Normal <120 and <80 Prehypertension or Hypertension >140 or >90

10 Stroke (Cerebrovascular Accident/CVA) Event when blood supply to brain is interrupted Brain cells begin to die quickly Leading cause of serious, long-term disability in U.S. 130,000 deaths per year in U.S. Blockage vs. Bleed Those who survive may have deficits depending on the severity and area of the brain affected Deficits will vary depending on areas and extent of brain damage When did the stroke occur? Muscle weakness, numbness Speech, vision, balance Memory, cognition, emotions What medications are they taking? What activities do they have difficulty with? (Dental home care) Anticoagulant Therapy (blood thinners) Reduce blood clot formation in arteries, veins and lungs Reduce strokes & pulmonary embolism (blood clot in lungs) Atrial Fibrillation Post surgery/heart valve/joint replacement Post-stroke Increase bleeding time/risk INR (Pro time) Aspirin, NSAID s Coumadin (warfarin) Heparin Plavix (clopidogrel) Pradaxa Xarelto Eliquis (apixaban) Garlic, ginseng, ginger, gingko, guarana CoQ10, Vitamin E Prothrombin Time/INR for patients on coumadin/warfarin therapy 1.0 Normal Routine dental treatment generally safe, extensive surgery may be contraindicated >3.5 Dentist and MD should jointly decide management strategy How often do they have this tested? What was their most recent number? Who can we contact for lab values? Lung & Breathing Disorders Asthma Chronic Obstructive Pulmonary Disease (COPD) Chronic bronchitis Emphysema Tuberculosis Cystic Fibrosis Lung cancer Obstructive Sleep Apnea Air exchange & tissue oxygenation reduced chronically or acutely Medications they take?

11 O2? Do they use an inhaler? How often? Dental treatment generally fine for these patients Asthma Some people may have difficulty breathing when fully reclined Prevent acute attack during Tx Have they taken their medication regularly/today? Do they have their inhaler? Reduce triggers if possible Anxiety management Manage acute attack if necessary Rescue inhaler O2 Osteoporosis Risk increased by medical conditions and certain medications Older white and Asian women most affected Lack of weight-bearing exercise Inadequate nutrition Smoking & alcohol increase risk Treated with hormone replacement therapy and/or bisphosphonate drugs Disease where decreased bone strength and mass significantly increase the risk of fractures Often undiagnosed until a fracture occurs 1 in 2 women and 1 in 4 men over age 50 will break a bone due to the disease Review of literature indicates greater propensity to lose alveolar bone in people with osteoporosis Should be considered a risk factor for periodontitis Alzheimer s Disease Progressive deterioration of brain function Etiology includes genetics Seven stages, plateaus between them Medications may help symptoms in some patients Admin team may notice early signs Enlist family members & caregivers help in decision making & consent Dementia An umbrella term for progressive deterioration of multiple brain areas that interferes with daily functioning Difficulty thinking, remembering, reasoning, behavior skills Several causes, Alzheimer's is the most common (~70% of cases) Other less common include vascular, Lewy Body & mixed disorders 10% of people will develop in their lifetime

12 Xerostomia Increased decay risk Increased sores & fungal infections Difficulty in speaking, chewing, swallowing Difficulty in wearing dentures Increased occlusal wear Health Conditions - xerostomia Sjogren's Syndrome Diabetes Stroke Rheumatoid arthritis Hypertension Alzheimer's Disease Parkinson's Disease Nerve damage from surgery Medications - xerostomia Antidepressants Anti-anxiety drugs Sedatives Pain medications Decongestants & antihistamines Blood pressure medications Drugs to treat asthma Chemotherapy Head/neck radiation

13 Post Course Test Questions 1. We need accurate health histories for dental patients because: a. We want to avoid medical emergencies when possible b. The dentist wants to recommend treatment most appropriate for the patient c. We need documentation of health conditions in case of a board complaint d. All of the above 2. A valid medical history can be obtained from: a. An adult in good general health b. A thirteen year old patient c. An adult whose medical history includes Alzheimer s Disease 3. How often should a patient s medical history be updated? a. Once a year b. Only when they will see the dentist c. When they are scheduled for a surgical procedure d. Every visit 4. Which common medical condition can affect our periodontal health? a. Eczema b. Fungal nail infections c. Diabetes d. Glaucoma 5. Common causes of impaired blood clotting may be: a. Medical conditions b. Medications c. Dietary supplements d. All of the above 6. Medications without oral health effects include: a. Anti-depressants b. Cholesterol-lowering statin drugs c. Anti-coagulant (blood thinning) drugs d. Chronic pain medications Answers: 1. (d) 2. (a) 3. (d) 4. (c) 5. (d) 6. (b)

14 Commonly Prescribed Medications Generic Name Brand Name Primary Use(s) Albuterol (inhaler) Ventolin/Proventil Bronchodilator (asthma) Alendronate Fosamax Osteoporosis Alprazolam Xanax Antianxiety Amlodipine Norvasc Antihypertensive Atorvastatin Lipitor Cholesterol lowering Atenolol Tenormin Antihypertensive, beta-blocker Celecoxib Celebrex Antiarthritic Cetirizine Zyrtec Seasonal allergies Clopidogrel Plavix Antiplatelet agent Dabigatran Pradaxa Anticoagulant Escitalopram Lexapro Antidepressant Esomeprazole Nexium Acid reflux Estrogen Premarin Estrogen replacement Fexofenadine Allegra Antihistamine Fluoxetine Prozac Antidepressant Fluticasone Advair, Flonase Allergies, asthma Furosemide Lasix Diuretic Gabapentin Neurontin Seizures, nerve damage Hydrochlorothiazide (HCTZ) Various brand names Diuretic, anti-hypertensive Hydrocodone/Acetaminophen Vicodin Pain relief Lansoprazole Prevacid Acid reflux Levothyroxine Synthyroid/Levoxyl Thyroid replacement hormone Lisinopril Prinivil, Zestril Antihypertensive Losartan w/hctz Hyzaar Antihypertensive Lorazepam Ativan Antianxiety Metformin Glucophage Lowers blood sugar Metoprolol Toprol, Lopressor Antiangina, antihypertensive Montelukast Singulair Seasonal allergies, asthma

15 Omeprazole Prilosec Acid reflux Pantoprazole Protonix Acid reflux Prednisone Steroid anti-inflammatory Ranitidine Zantac Anti-ulcer Rosuvastatin Crestor Cholesterol lowering Sertraline Zoloft Anti-depressant Simvastatin Zocor Cholesterol lowering Tamsulosin Flomax Prostate disorders Venlafaxine Effexor Antidepressant Verapamil Various brand names Angina, anti-hypertensive Warfarin Coumadin Anticoagulant Zolpidem Ambien Sleep agent Target Lab Values Blood Pressure 120/80mmHg Blood Glucose/Sugar mg/dl A1C % INR (for pts on Warfarin/Coumadin)