Dental Management of Medically

Compromised Patients
Sol G. Brotman, DDS, MAGD
2
 Why is a medical history
important in dentistry?
A patient's medical history is a vital part of his or her
dental history and increases the dentist's awareness of
diseases and medication which might interfere with the
patient's dental treatment.

ncbi.nlm.nih.gov/m/pubmed/16729560

3
 Medical/Dental Health History
Health history form
The health history form is the starting point for the practice’s
relationship with the patient. It’s valuable, because it provides
appropriate staff members with information that they need in
order to fulfill their professional obligations.
Patient interaction
Keep in mind that the patient’s interaction with the staff and the
dentist during the health history collection process is at least as
important as the information detailed on the form itself. This
process sets the tone for a positive patient experience for both
new patients and active dental patients of record.
https://success.ada.org/en/practice-management/guidelines-for-practice-
success/gps-managing-professional-risks/medical-dental-health-history

4
 Medical/Dental Health History
An accurate medical/dental health history is vital since:
• It may provide valuable information for the dentist
prior to beginning treatment, especially since certain
medications can influence treatment decisions or
may impact post-operative care instructions.
• It’s also important to recognize that patients who are
current or recovered opioid users may be reluctant to
reveal that aspect of their medical history.

https://success.ada.org/en/practice-management/guidelines-for-practice-
success/gps-managing-professional-risks/medical-dental-health-history

5
Medical/Dental Health History: Updates
Be sure to make a notation in the patient’s record that
indicates the patient was asked about recent health
and medication changes. That notation should include
the date of the discussion and indicate which staff
member(s) initiated the conversation. The record should
then be updated to reflect the new information.

https://success.ada.org/en/practice-management/guidelines-for-practice-
success/gps-managing-professional-risks/medical-dental-health-history

6
 Do dentists have access
to medical records?
If Dentists don't comply with HIPAA rules then they are
audited, they get penalized. Dental records, in paper or
electronic format, are considered Protected Health
Information and are subject to the same federal scrutiny
for privacy and security as full medical records.

https://www.hipaaone.com/2014/07/01/dentists-concerned-hipaa-laws-
security-patient-records/

7
 Medical and Dental Electronic Health
Record Reporting Discrepancies in
Integrated Patient Care
S. Adibi, M. Li, N. Salazar, D. Seferovic, K. Kookal, J.N.
Holland, M. Walji, M.C. Farach-Carson

Journal of Dental Research

https://journals.sagepub.com/doi/abs/10.1177/2380084419879387?journalCode=jcta

8
 Abstract
Introduction
Oral health mirrors systemic health; yet, few clinics
worldwide provide dental care as part of primary
medical care, nor are dental records commonly
integrated with medical records.

https://journals.sagepub.com/doi/abs/10.1177/2380084419879387?journalCode=jcta

9
 Abstract
Results
Of those patients with diabetes,15.1% misreported their
diabetes condition to their dental clinicians, while 29%
of patients with hypertension also misreported. There
was no relationship between sex and misreporting of
hypertension or diabetes, but age significantly affected
reporting of hypertension, with misreporting decreasing
with age.
https://journals.sagepub.com/doi/abs/10.1177/2380084419879387?journalCode=jcta

10
 Abstract
Conclusions
Because these conditions affect treatment planning in
the dental clinic, misreporting of underlying medical
conditions can have negative outcomes for dental
patients. We conclude that policies that support the
integration of medical and dental records would
meaningfully increase the quality of health care
delivered to patients, particularly those dental patients
with underlying medical conditions.
https://journals.sagepub.com/doi/abs/10.1177/2380084419879387?journalCode=jcta

11
 Abstract
Knowledge transfer statement
Our study illustrates an urgent need for policy
innovation within a currently fragmented health care
delivery system. Dental clinicians rely on the accuracy of
health information provided by patients, which we found
was misreported in ~15% to 30% of dental patient
records. An integrated health care system can close
these misreporting gaps. Policies that support the
integration of medical and dental records can improve
the quality of health care delivered, particularly for
dental patients with underlying medical conditions.
https://journals.sagepub.com/doi/abs/10.1177/2380084419879387?journalCode=jcta
12
 The Effects of Oral Health
on Systemic Health
Over the course of a five-year study6, we’ve seen significantly
lower medical costs for members who use their preventive or
periodontal dental services versus those who do not.
Book of business study concluded
medical cost differences between
dental utilizers versus non-utilizers:
• $4,649 PMPY CAD, 30%
difference
• $1,459 PMPY Diabetes, 16%
difference

NOTE: For a member to be considered a ‘dental utilizer,’ they must have

used one preventive or periodontal CDT in the previous 12 months. 13
Patient Evaluation

14
 Patient Evaluation

Clinical
Medical History
Evaluation

Head & Neck Physician

Examination Consultation

15
 Medical History
Current medical conditions

Past medical conditions

Allergies

16
 Medical History
Medications
• Length of time of treatment
• Changes in dosages
• OTC or alternative medications
• Patches or other non-oral routes of
administration
Treatment for current or past
medical conditions
• e.g., radiation, chemotherapy

17
 Clinical Evaluation

General appearance
• Posture
• Asymmetries
• Bruising
• Skin lesions
• Swelling

18
 Clinical Evaluation

Patient responsiveness
• Timing and delays
• Appropriateness
• Voice
• Facial movement and activity
• Pain cues

19
 Clinical Evaluation

Vital signs
• Blood pressure
• Pulse
• Body temperature

20
Head and Neck Examination
Cervical nodes or swelling

TM joint evaluation
• Jaw sounds
• Deviation of mandible on opening
• Range of motion

Oropharyngeal cancer examination

• Include upper pharynx – tonsillar region

21
Head and Neck Examination

Salivary glands

Periodontal

Dental

Radiographic

22
 Physician Consultation
Written versus oral clearances

Referrals for specific concerns

Closing care gaps

23
Coronary Artery Disease and Stroke
(Artherosclerosis)

24
 Demographics
• Most common cause of death in the
US (33%)
• Incidence has been reduced by 50-
60% in past 50 years

25
 Risk Factors
• Male gender
• Age
• Family history
• Hyperlipidemia
• Diet: Total calories, saturated fats,
cholesterol, sugars and salts
26
 Risk Factors
• Hypertension
• Smoking and other tobacco use
• Physical inactivity
• Obesity
• Insulin resistance and diabetes
mellitus
• Mental stress and depression

27
 Markers of Inflammation
• C-reactive protein (CRP)
• Homocysteine
• Fibrinogen
• Lipoproteins (serum lipids)

28
 Conditions (ICD-10)
• Myocardial infarction
• Angina pectoris
• Atherosclerosis
• Cardiac ischemia
• Cerebral infarction
• Arterial occlusion and stenosis
• Embolism and thrombosis
29
 Medication Formulary
Nitrates
• Nitroglycerin and long-acting
nitrates
• Side effects: Dry mouth,
orthostatic hypotension, headache

30
 Medication Formulary
Beta Blockers
• Propranalol (Inderal), Nadolol
(Corgard), Metoprolol (Lopressor),
Atenolol (Tenormin)
• Side effects: taste changes,
orthostatic hypotension
• Dental consideration: reaction with
vasoconstrictors (maximum of 2
carpules with 1:100,000 epinephrine)
31
 Medication Formulary
Calcium Channel Blockers
• Diltiazem (Cardizem), Verapamil
(Calan), Amlodipine (Norvasc)
• Side effects: gingival hyperplasia,
dry mouth
• Dental consideration – avoid
prolonged use of NSAIDs
32
Journal of Human Hypertension 28, 10-14 (2014) R Livada & J Shiloah
https://www.nature.com/articles/jhh201347

33
 Medication Formulary
ACE inhibitors
• Used for heart failure
• All of the …prils

34
 Medication Formulary
Angiotensin Receptor Blockers
• Used for heart failure and high
blood pressure
• Irbesartan (Avapro), Losartan
(Cozaar), Valsartan (Diovan)

35
 Medication Formulary
Anticoagulants
• Aspirin
• Clopidogrel (Plavix)
• Warfarin (Coumadin) Requires INR
testing for range of 2.0 to 3.0
• Dabigatran (Pradaxa)
• Rivaroxaban (Xarelto)
• Aprixaban (Eliquis)

36
 Medication Formulary
Anticoagulants
• Dental consideration: bleeding.
Positive history of excessive
bleeding should have pre-op
testing of PT, aPTT, TT and platelet
counts.

37
 Medication Formulary
Statins
• All of the …..statins
• Dental consideration: increased risk
of organ damage and rhabdomyositis
in conjunction with Erythromcin or
Biaxin
• Many statins interact with certain anti-
fungals
38
 Antibiotic Prophylaxis Prior to
Dental Procedures
• Compared with previous recommendations, there are
currently relatively few patient subpopulations for
whom antibiotic prophylaxis may be indicated prior to
certain dental procedures.
• Infective endocarditis prophylaxis for dental procedures
should be recommended only for patients with
underlying cardiac conditions associated with the
highest risk of adverse outcome from infective
endocarditis. For patients with these underlying
cardiac conditions, prophylaxis is recommended for all
dental procedures that involve manipulation of gingival
tissue or the periapical region of teeth or perforation of
the oral mucosa.

39
https://www.ada.org/en/member-center/oral-health-
topics/antibiotic-prophylaxis

The current infective endocarditis/valvular heart

disease guidelines state that use of preventive
antibiotics before certain dental procedures is
reasonable for patients with:

• Prosthetic cardiac valves, including transcatheter-

implanted prostheses and homografts
• Prosthetic material used for cardiac valve repair,
such as annuloplasty rings and chords
• A history of infective endocarditis

40
https://www.ada.org/en/member-center/oral-health-
topics/antibiotic-prophylaxis

• A cardiac transplant with valve regurgitation due

to a structurally abnormal valve
• Specific congenital (present from birth) heart
disease
• Unrepaired cyanotic congenital heart disease,
including palliative shunts and conduits
• Any repaired congenital heart defect with residual
shunts or valvular regurgitation at the site of or
adjacent to the site of a prosthetic patch or a
prosthetic device

41
 JADA – January , 2015
Volume 146, Issue 1, Pages 11–16.e8
The Use of Prophylactic Antibiotics
Prior to Dental Procedures in
Patients with Prosthetic Joints

42
 JADA – January , 2015
Volume 146, Issue 1, Pages 11–16.e8
Conclusions

Evidence fails to demonstrate an association

between dental procedures and PJI or any
effectiveness for antibiotic prophylaxis. Given this
information in conjunction with the potential harm
from antibiotic use, using antibiotics before dental
procedures is not recommended to prevent PJI.
Additional case-control studies are needed to
increase the level of certainty in the evidence to a
level higher than moderate.

43
Diabetes

44
 Demographics
• US: 30,000,000 diabetics and 70,000,000
prediabetics in 2017.
https://www.cdc.gov/media/releases/2017/p0
718-diabetes-report.html

• Incidence 9% in US and worldwide. Hawaii

11.5%
https://www.stateofobesity.org/diabetes/

• Seventh leading cause of death in US

45
 Diagnostic Criteria for Diabetes
A1C

https://www.diabetes.org/a1c/diagnosis

46
 Diagnostic Criteria for Diabetes
Oral Glucose Tolerance Test

https://www.diabetes.org/a1c/diagnosis

47
 Diagnostic Criteria for Diabetes
Fasting Plasma Glucose

https://www.diabetes.org/a1c/diagnosis

48
 Diagnostic Criteria for Diabetes
Random Plasma Glucose Test
Diabetes is diagnosed at blood
sugar of greater than or equal to 200
mg/dL

https://www.diabetes.org/a1c/diagnosis

49
 Dental Considerations
• Epinephrine can cause blood
glucose to rise
• Steroids will cause blood glucose to
rise
• Gingival and periodontal infections
• Delayed wound healing

50
Patient DP. Non smoker age 53

51
Head and Neck Cancers

52
 Estimated New Cancer Cases in US

All Sites 1,372,910 710,040 662,870 1,762,450 870,970 891,480

Oral cavity & pharynx 29,370 19,100 10,270 53,000 38,140 14,860

Tongue 7,660 5,050 2,610 17,060 12,550 4,510

Mouth 10,070 5,370 4,700 14,310 8,430 5,880

Pharynx 8,590 6,520 2,070 17,870 14,450 3,420

Other oral cavity 3,050 2,160 890 3,760 2,710 1,050

53
Estimated New Cancer Deaths in US

All Sites 570,280 295,280 275,000 606,880 321,670 285,210

Oral cavity & pharynx 7,320 4,910 2,410 10,860 7,970 2,890

Tongue 1,730 1,120 610 3,020 2,220 800

Mouth 1,890 1,100 790 2,740 1,800 940

Pharynx 2,130 1,490 640 3,450 2,660 790

Other oral cavity 1,570 1,200 370 1,650 1,290 360

54
 Oral Cancers
• 90% are squamous cell (SCC)
 80% of SCC are related to tobacco,
alcohol and paan (Betel nuts) 2010
 66% are due to degradation of the p53
protein on Chromosome 9
 25% are white, 60% white/red, 33% red,
2% other
 Recurrence rates – Smokers 30%, Non-
smokers 13%

55
 Pretreatment Oral Evaluation
1. Discuss your role and expectations with
the patient:
a. Nausea and vomiting may lead to
tooth erosion
b. Mucositis and ulcerations
c. Taste alterations
d. Fungal, bacterial or viral infections

56
 Pretreatment Oral Evaluation
2. Rule out oral conditions that may worsen
during cancer therapy

3. Provide baseline for oral conditions

4. Identify other lesions, including

metastasis

57
 Pretreatment Oral Evaluation
5. Minimize intraoperative discomfort with
rinses

6. Reduce risk for radiation or other caries

and tooth sensitivity with fluoride varnish,
gel or rinses

7. Xerostomia management
58
Management on Non-Restorable Teeth
1. Extractions three weeks prior to radiation,
one week prior to chemotherapy

2. Submerging roots or root banking

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4556801/

3. Bisphophonates in chemotherapeutic
protocols

59
60
 Oropharyngeal cancers
• Incidence of oropharyngeal HPV:
10% of men, 3.6% women
• HPV is present in 70% of
oropharyngeal cancers

https://www.cdc.gov/cancer/hpv/basic_info/hpv_oropharyngeal.htm

61
 Oropharyngeal cancers
• Variants 16 and 18 are found most
often in oropharyngeal cancers
https://oralcancerfoundation.org/understanding/hpv/hpv-oral-cancer-facts/

• White, non-smoking males age 35

to 55 are most at risk, 4 to 1 over
females
https://www.cancer.gov/types/head-and-neck/patient/adult/oropharyngeal-treatment-
pdq

62
 Oropharyngeal cancers
• Stages 0 – IVC
• Four types of standard treatment are
used:
Surgery
Radiation therapy
Chemotherapy
Targeted therapy

63
 Oropharyngeal cancers
New types of treatment are being
tested in clinical and other trials:
• Immunotherapy
• Radiochemical therapy
• Cryogenics

64
Sjögrens Syndrome

65
 Demographics
• 3% of adult population
• 90% are women
• Second most common
rheumatoid disorder
• 5% or less of normal salivary flow

66
Most Common Clinical Manifestations
• Dental caries
• Candidiasis
• Angular cheilitis
• Dyseusia (distortion of taste)

67
 Moisture and Lubrication
Artificial saliva (Salivart, Biotene,
Pilocarpine)

68
 Soft Tissue Level and Discomfort

• Benedryl
• Maalox or Milk of Magnesia
• Decadron elixir
• Mycelex troches

69
 Caries Prevention
• More frequent dental exams
• Fluoride varnish, gel and 5000
ppm toothpaste

70
Pregnancy

71
 Demographics
• 100% women
• Leading cause of childbirth

72
 Oral Conditions
Pregnancy Gingivitis

https://images.app.goo.gl/qpQxhyRnW6bgeV8y8

73
 Oral Conditions
Pyogenic Granuloma

https://images.app.goo.gl/4nSKskRgUohGMouA8

74
 Oral Conditions
• Increased dental erosion due to
regurgitation
• Increased dental decay due to
poor diet

75
 Medical Correlation
“In this population-based study,
women who did not receive dental
care or have a teeth cleaning during
pregnancy were at slightly higher risk
for preterm delivery after adjustment
for pertinent confounders.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4561173/

76
 The Future is Now
• On May 6, Oregon House Bill 2220 was signed
into law, enabling licensed dentists to prescribe
and administer vaccines.
• The policy is scheduled for implementation in
2020 pending review and protocol design by the
Oregon State Dental Board.
• With its passage, Oregon joins Minnesota and
Illinois as the third state to permit vaccinations in
dental offices. Minnesota and Illinois allow flu
vaccines to be administered.

77
 Hawaii Medical and Dental
Statistics
• Hawaii has the highest rate of
childhood dental caries in the US.
• In 2016 there were approximately
3,000 ED visits for preventable
oral health related pathology.
Total cost was $17M or $5,600
per visit.

78
 Oral Health for Total Health
and
HMSA Connected CareSM

Stephanie J Dvoroznak, Program Director

79
Oral Health for Total Health

80
 Overview
Oral Health for Total Health focuses on the HMSA medical and
dental integration. It offers clinically significant enhanced dental
benefits to enrolled members with certain medical conditions that
systemically impact the overall health of those enrolled.
Enhanced dental benefits have demonstrated better health
outcomes and can potentially lower medical and dental costs.
Enhanced dental benefits remove financial barriers, making it easier
than ever to put one’s health first.
• No waiting periods
• No copays or coinsurance: paid at 100% when visiting a
participating provider
• Is not applied towards calendar-year maximum (CYM)
• Benefits are valued over $1,000 per year

81
 Benefits Overview
Oral Health for Total Health Enhanced Dental Benefits Overview

82
 HMSA Connected Care

11/2019 83
 Overview
HMSA Connected Care
• Innovative healthcare management platform

• Designed for patient care management that enhances our

Oral Health for Total Health program

• Real-time system uses information from our primary care

physicians’ patient medical records to deliver a
comprehensive view of each patient’s health status

• Specifically noting the medical and dental measures that

show where attributed patients are healthy vs. deficient in
care – alerting the provider who then can coordinate
outreach and consultation to promote compliance
84
 Dental Measures
HMSA Connected Care Dental Measures
• Preventive Dental Care (Non-OHTH Members)
 Identifies members who have not had a cleaning in the
current calendar year. Obtaining regular cleanings helps to
control oral inflammation and allows the dentist to check for
developing oral health problems that could affect total health.

• Oral health for Total Health Dental Care (OHTH Population)

 Identifies enrolled OHTH members who have not had a dental
cleaning or non-surgical periodontal treatment in the current
calendar year. Obtaining regular treatment helps control oral
inflammation, which is a known risk factor in the control of
diabetes, CAD & stroke, and allows the dentist to check for
developing oral health problems that could affect total health.

85
 Implementation Timeline
• 9/30/2019: Dental Measures released to
PCPs within PTM
• 10/1/2019: Dental Measures pilot begins
• 11/1/2019: Dental Measures pilot ends
• 1/2/2020: Dental measures go-live for all
dentists

86
Dental Patient Registry

87
Viewing Patient Demographics

88
Face Sheet

89
 Cost Containment
Cost containment is an important consideration for the insurer, provider and
patient. With Connected Care, we can help reduce the cost of care by offering
and rendering enhanced dental benefits to members who need them most, and
promote dental utilization by dental providers versus the department.
Over the course of a five-year study,1
there are significantly lower medical costs
for members who use their preventive or
periodontal dental services versus those
who do not use them. The average
medical cost difference between users
versus non-users is $4,649.10 per
member with CAD and $1,459.07 per
diabetic member. This equates to a 30%
difference in medical costs for members
with CAD, and 16% for members with
diabetes.
1HMSA Dental User Medical Cost Trend Average (2013-2017).
 Treating the Whole Patient
Integrated care, incorporating medical and
dental transparency between physician and
dentist, allows for a more comprehensive
approach in addressing the dental health
disparity and facilitating appropriate dental
care versus a medical referral to the
Emergency Department. Facilitating
appropriate dental care is possible through
HMSA Connected Care and your
commitment to treating the whole patient.
91
Questions?

92
Mahalo

93