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History and Physical Assessment of the Medically Complex Dental Patient

HISTORY AND PHYSICAL: INTRODUCTION

A medically complex dental patient (MCP) is one who suffers from one or more diseases and who is taking one or more medications for the care of those disease states. The management of the MCP is a multitiered process that requires detailed, organized assessment of several aspects associated with the patient, which can sometimes take more than one dental visit. Every MCP should have a thorough assessment of the medical and dental histories during the first visit. The dentist needs to decide what laboratory tests to obtain from the patient’s primary care physician (PCP) and/or the specialist(s). Evaluation of the tests will help determine the control status level of the patient’s disease states. The dentist also needs to assess the vital organ status; the patient’s American Society of Anesthesiology (ASA) status; the need for stress management; the dental treatment plan; and the final anesthetics, analgesics, and antibiotics (AAAs) that can be safely used during dentistry.

It is important that all pertinent information collected prior to dentistry be incorporated in the patient’s record as a separate “medical consultation” summarized case note. This note can then be referenced any time during patient care and should be updated when there is a change in the health history or the list of medications.

MEASURES ESTABLISHED WITH THE COMPLETE HEALTH HISTORY

The complete health history will provide the following:

• The date of the last physical examination.
• The name, address, and telephone number of the primary care physician (PCP) and the specialists.
• The disease state(s) being managed in the patient.

The control status of disease state(s) is determined by assessment of appropriate laboratory test results, as with diabetes, or by following standard guidelines, as with blood pressure readings.

Diabetes Assessment Example

To assess diabetes, evaluate the fasting blood sugar (FBS), postprandial blood sugar (PPBS), and the HbA1C. The well-controlled patient will have FBS: <120mg/dL; PPBS: <160mg/dL; and HbA1C: <7% (normal: 4–6%).

Hypertension Assessment Example

To evaluate hypertension, assess the blood pressure (BP), and categorize the patient’s BP readings as normal, high-normal, mild, moderate, or severe. Determine the following:

• The presence of symptoms of an as yet undiagnosed condition.
• Whether medical emergencies have occurred in past dental visits.
• Whether the patient requires premedication (at a minimum, successive appointments should be scheduled seven days apart when using the same premedication antibiotic).
• The prescribed, over-the-counter (OTC), or herbal medications the patient is taking.

Always confirm whether the patient is compliant with the medications—never presume! Assess the drug-drug interactions (DDIs) between the drugs that the patient is taking and the anesthetics, analgesics, antibiotics, antivirals, or antifungals (AAAAAs) used or prescribed in the dental setting Many of the drugs typically used in dentistry are substrates, inducers, or inhibitors of the CYP450 enzyme system and can be associated with adverse DDIs. By knowing what drugs your patient takes for the underlying disease states, you can help prevent the occurrence of DDIs by prescribing a drug that does not impact the P450 isoform/enzyme involved in the metabolism of that particular drug.

In addition to the CYP enzyme system, metabolism of certain medications can also be affected by transporter proteins that actively transport medications into and out of cells. ATP-dependent efflux drug transporter P-glycoprotein (P-gp) thus affects how drugs are absorbed, distributed, and eliminated by the body. Many P-gp inhibitors are CYP3A4 inhibitors as well. P-gp and CYP3A4 are present in the gut, and this accounts for why some DDIs occur first in the gastrointestinal tract and then in the liver. Drug interactions occurring through CYP isoenzymes mostly involve the P-glycoprotein (P-gp) transporter system too.

Thus, a thorough assessment of all medications is necessary to prevent adverse reactions or drug-related emergencies during dental treatment. Evaluate every drug by assessing its mechanism of action, what condition(s) it treats, and potential DDIs among the drug and the AAAAAs. Digoxin and theophylline are discussed in the next sections as examples to demonstrate the way drugs should be assessed.

Lanoxin (Digoxin) Assessment

Lanoxin (digoxin) is a cardiac glycoside is used to treat congestive heart failure (CHF) and atrial fibrillation (AF). AF is also called supraventricular arrhythmia.

Lanoxin (Digoxin) Mechanism of Action

Lanoxin (digoxin) binds to and inhibits the magnesium and adenosine triphosphate (ATP) dependent Na+ and K+ ATP-ase, thereby increasing the influx of calcium ions in the cardiac smooth muscle. This increase in calcium ions enhances the myocardial contractility.

Lanoxin (Digoxin) and Local Anesthetics

Ideally, avoid local anesthetics with epinephrine in the presence of digoxin because epinephrine can be counterproductive (Table 2.1). It is safe to use 3% mepivacaine HCL (Carbocaine) or 4% prilocaine HCL (Citanest Plain) instead. However, you may cautiously use the least lipophilic local anesthetic, 4% prilocaine HCL (Citanest Forte) with 1:200,000 epinephrine, maximum two carpules when a local anesthetic with epinephrine is absolutely needed.

Table 2.1 Digoxin and AAAs

Lanoxin (Digoxin) and Analgesics

Avoid aspirin and NSAIDS with digoxin. Aspirin decreases digoxin absorption from the gut and displaces digoxin from the protein binding sites. NSAIDS increase serum digoxin levels by decreasing the renal clearance of digoxin. Use acetaminophen (Tylenol), oxycodone + acetaminophen (Percocet), hydrocodone + acetaminophen (Vicodin), or acetaminophen + 30 mg codeine (Tylenol #3) instead, depending on the needs of the patient and if no contraindications exist to the use of centrally acting pain medications.

Lanoxin (Digoxin) and Antibiotics

Lanoxin (digoxin) is a P-gp substrate and is independent of CYP3A4 action. P-gp inhibits the bioavailability of digoxin and facilitates the renal and biliary secretion of digoxin. Erythromycin or Clarithromycin, when given to patients on chronic digoxin, cause an increase in serum digoxin concentrations, as they are potent P-gp inhibitors.

Azithromycin appears to have little influence on P-gp–mediated digoxin absorption or excretion and would therefore be the safest macrolide to use concurrently with oral digoxin. However, some recent studies have shown that it is best to avoid azithromycin use in patients with underlying cardiac states associated with rhythm issues, myocardial dysfunction, myocardial infarction, angina, cardiac failure, hypertension, hyperlipidemia, diabetes, smoking, obesity, poor diet, and sedentary life style, as azithromycin has been shown to potentially alter cardiac conduction from QTc prolongation and ventricular arrhythmias.

Therefore, avoid macrolides, erythromycin, clarithromycin, and all tetracyclines with digoxin because these drugs increase serum digoxin levels. Use the penicillins, cephalosporins, clindamycin, or azithromycin (when safe to use) instead.

Theophylline (Theo-Dur) Assessment

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