CorrectCare

Dental Care for the Medically Compromised Patient
By Mark Szarejko, DDS

Many inmates share two basic problems: poor oral health and one or more chronic medical conditions. The extent of decay and periodontal disease leaves many teeth beyond repair, with their surgical removal the only method of definitive treatment.

Oral surgery patients must be able to withstand the physical and emotional demands that the procedure places on them. But a coexisting medical condition can undermine the dentist’s ability to perform even a minor surgical procedure. And if the patient is taking medications for that condition, the normal intraoperative use of antibiotics, analgesics and local anesthesia may need to be modified.

Before initiating any invasive treatment the dentist must review the medical history with the patient. It may have been many months since the initial physical assessment was completed, so it must be noted if any changes have occurred, if medication dosages have changed or if a new medication has been prescribed. This review should be noted on the chart. If there is any doubt or conflict as to the accuracy of the medical history, the medical director should be contacted.

This article will highlight how the most common medical conditions can affect the delivery of dental treatment.

Hypertension
Hypertension was the most common medical problem among the dental patients in our jail. The concern is that a surgical procedure may trigger anxiety that can cause an already elevated blood pressure to attain levels that could jeopardize cardiovascular health.

Clinical judgments vary as to the blood pressure levels beyond which surgery should not be performed. I use a reading of 160/100, in any combination, as the cutoff where I would defer oral surgery until the readings were lowered. In several cases, patients have been referred to the medical department when their BP remained elevated.

Many local anesthetics contain vasoconstrictors, such as epinephrine or levonordefrin, that benefit the patient during the oral surgery. These compounds decrease systemic absorption of the local anesthetic and prolong its effect, and help to minimize bleeding. However, they also can increase blood pressure, so the least amount possible must be used.

Also, since dental pain can raise blood pressure, preoperative analgesics that do not interact with the blood pressure medications can be prescribed.

Cardiac Disease
Closely related to hypertension is cardiac disease, and many patients present with both. In such cases, the precautions used for both conditions must be followed.

When oral surgery was indicated for patients with cardiac disease, my protocol is to consult with the medical director to determine if the cardiac function is of sufficient quality to withstand the rigors of oral surgery.

Elective dental treatment should be deferred for any patient who has had a heart attack in the past six months. It is during this interval that the chance for a second heart attack is the greatest. Similarly, a patient with unstable angina in which chest pain occurs at rest also is not a candidate for oral surgery because this degree of instability could be a precursor to heart attack.

If pain or infection of dental origin requires dental treatment during the six-month period following a heart attack, it should be done in the office of a practitioner or a hospital-based dental program that can monitor vital signs and can respond to a cardiac emergency. The same is true of patients with uncontrolled cardiac arrhythmias.

Many cardiac patients are on anticoagulant medications such as warfarin, clopidogrel and aspirin. These drugs can prevent a blood clot from forming within the extraction site and the resultant oozing can be difficult to control. The dentist must consult with the prescribing physician before surgery is performed on these patients. Usually, the medications can be discontinued before surgery and resumed the day after. The schedule must be followed exactly as directed by the physician, with appropriate orders made in the prescribing record. To confirm that the patient has discontinued the anticoagulant therapy, the dentist should check with the nursing staff member who dispenses medications before the patient returns for treatment. It is equally important to make sure that dispensing of these medications is resumed.

Care must be taken when prescribing medications for dental problems in patients with cardiac conditions because these patients may be taking several cardiac medications and drug interactions may result.

Liver Disease
Many inmates are infected with hepatitis B or hepatitis C viruses as a result of years of injection drug abuse and alcohol abuse. The latter also leads to cirrhosis. However, problems associated with the liver may manifest with mild or no symptoms.

The liver is an important organ with a multitude of functions. Those that relate to dentistry include drug metabolism and the synthesis of coagulation factors that help enable blood to clot properly at an extraction site. A liver that is cirrhotic or infected with the hepatitis viruses may not be able to perform these functions.

Several local anesthetics, antibiotics and analgesics used in dentistry are metabolized primarily by the liver. Compromised liver function could reduce the ability to clear these drugs from the system. Therefore, a dosage that is usually safe and effective when the liver functions normally can reach levels that constitute a toxic buildup.

Tests that measure liver function and enzyme levels can be used to assess its ability to work properly. A physician should be consulted about the test results to determine if dental treatment, especially oral surgery, and medication regimens should be modified, deferred or changed completely.

It is a rare occasion when a patient who has had a liver transplant can receive dental treatment in a correctional facility. The medical director must be consulted before any invasive procedure is performed. Immunosuppressive medications designed to minimize the chance of host rejection of the transplant and anti-inflammatory medications such as prednisone will impair the patient’s ability to fight infections and will prolong surgical recovery.

Diabetes
The problem of delayed recovery from surgery also applies to patients with diabetes mellitus. This complex disease poses difficulties for patients of all ages. Dental considerations include delayed surgical healing and a higher potential for postoperative infections. Prophylactic antibiotic coverage and postsurgical antibiotic therapy may be needed for these patients.

Insulin-dependent patients should take their normal dosage of insulin and eat their usual allotment on the day of surgery and for their postsurgical course. If eating is difficult due to postoperative pain or the need to avoid surgical sites, liquid supplements can be used to provide nutrition and to maintain the proper blood glucose levels. These levels also should be monitored before the surgery is performed.

It is imperative that diabetes patients understand the dangerous consequences of eating minimally or not at all (because of postoperative pain) while still taking their normal dose of insulin.

Blood glucose levels that are a concern because they are too high or too low before surgery are a reason to defer surgery and to immediately refer these patients to the medical department.

Safety First
Meeting the dental needs of the correctional population in a safe manner requires diligence to identify and monitor any existing medical problems. This discussion has focused on some common medical conditions and their impact on dental treatment. There are numerous other medical problems that affect the inmate population. Each condition must be evaluated and, if necessary, referred to the medical department to determine any treatment modifications that may be needed. Our goal should be to minimize the chance of a dental procedure ending in a medical emergency.

 — About the author: Mark Szarejko, DDS, has practiced in a jail setting in Florida for six years. He will speak on this subject at the 2007 National Conference on Correctional Health Care in Nashville, TN.

[This article first appeared in the Summer 2007 issue of CorrectCare.]