CE Course Handout It's (Medically) Complicated Thursday, June 9, 2016 9:30 a.m.-12:30 p.m. Welcome! It’s (Medically) Complicated! Thursday, June 9, 2016 It's (Medically) Complicated ADHA CLL Annual Session, Pittsburgh, PA Thomas A. Viola, R.Ph, C.C.P. [email protected] Lillian J. Caperila, RDH, BSDH, M.Ed. [email protected] 1 Program Objectives Program Objectives Pharmacology Hygiene Plan • Review the prominent disease states found in the • Discuss the changing paradigm in caries prevention medically-complex patient utilizing risk assessments and consideration with • Distinguish between the states of xerostomia and complex polypharmacy patients hyposalivation • Select effective fluoride therapy using calcium & • Recognize the protective functions of saliva and its phosphate in professional and take-home care. role in prevention • Integrate critical thinking skills and implement • Explain and compare disease-induced and medication-induced xerostomia effective patient care strategies considering the most common chronic diseases. © 2014 Viola & Caperila - All Rights Reserved 3 © 2014 Viola & Caperila - All Rights Reserved 4 Case Study Case Study • 57 year-old male • Patient is diabetic and was a • Last recare visit May 2012 former smoker • Generalized advanced • Statins to control cholesterol chronic periodontal • LDL (148); HDL (56) disease • Rx dietary changes • Significant medical history: • Reduced high fructose and • BP is 140/88 carbohydrates • Monitors glucose level • Began walking 3-4 times week for 1-2 miles each day © 2014 Viola & Caperila - All Rights Reserved 5 © 2014 Viola & Caperila - All Rights Reserved 6 Dental History Dental – Periodontal Exam Radiographic survey • Present and missing teeth • Pathology: caries, lesions, restored teeth, tori, root exposure etc… • Periodontal exam: • Probing 6 sites, mobility, recession, furcation involvement, occlusal assessment… • Gingival description • Active bleeding, exudate • Sensitivity, pain • Salivary flow 8 © 2014 Viola & Caperila - All Rights Reserved © 2014 Viola & Caperila - All Rights Reserved Patient Education Plan Clinical Phenotype: Discuss and document… 1. Medical & dental information 2. Oral examination & radiographs • Nutrition assessment • Lifestyle patterns What is missing here in your • Patient’s at-home oral care diagnosis and treatment plan? © 2014 Viola & Caperila - All Rights Reserved 9 © 2012 Thomas A. Viola, R.Ph., C.C.P. All Rights Reserved 10 Pathogenic burden? Salivary Diagnostic Tests: • PerioPath® test • MyPerioProgress ® report © 2014 Viola & Caperila - All Rights Reserved 11 12 CAMBRA: Diagnostics drives treatment Contributory Risk Factors • Scaling & root planing therapy • Antimicrobial mouthrinses • Host modifying medicaments: – Low dose doxycycline hyclate (Periostat™) – Site specific antibiotic (Arestin™, Atridox™) Salivary Diagnostics: How it is changing our approach to diagnosis, risk assessment, and treatment of periodontal disease. Bader H & Arndt H. Ineedceonline: PennWell® publication Feb 2013-Jan 2016. 13 CAMBRA: Caries Management By Risk Assessment CAMBRA: CAMBRA: General Health Factors Clinical Risk Factors: Dental Hygiene Treatment Plan: CAMBRA: updated risks . Recent hospitalization and reason? . General observation of patient’s appearance, gait • Removable partial dentures and cognitive capabilities • History of extensive prosthodontic or restorative therapy . Take vital signs and record/w date • Over 60 years of age . List names of drugs/herbal supplements • Smoking . Record the daily dosage and frequency (compliance?) • Infectious contact . Research the drug list: . side effects . interactions that may alter treatment outcomes Roberts, D. Maragliano, R. Chapman R. Put the Plan into Action, Dimensions of Dental Hygiene, June 2011 © 2014 Viola & Caperila - All Rights Reserved 18 Dental-Specific Pharmacology, Interactions, Drug interaction & oral conditions and Clinical References Apps available for mobile devices Dental-Specific Pharmacology, Interactions, www.AADMD.org/resources/additionalresources and Clinical References Today’s Review of Disease States Economic Burden • Cardiovascular disease • Diabetes • The mean annual spending on adult dental care peaks • Respiratory (COPD) between the ages of 55 to 64 del Aguila et al, 2002 • GERD dental caries account for about half of this spending • Alzheimer's • Parkinson’s • Americans spent an estimated $108 billion on dental • Chemotherapy & Head and services in 2010 Neck Radiation Patients • Projected increase to $180 billion by 2020. Truffer et al 2010 © 2012 Thomas A. Viola, R.Ph., C.C.P. All Rights Reserved 23 Cardiovascular Disease . The function of the cardiovascular system is to supply oxygen via the blood to all areas of the body. This is accomplished through the contraction of CARDIOVASCULAR DISEASE the heart and actions of the blood vessels. © 2014 Viola & Caperila - All Rights Reserved 25 © 2014 Viola & Caperila - All Rights Reserved 26 Cardiovascular Disease Hypertension Goal of Treatment Drugs Employed . Cardiovascular disease refers to disease of the Reduce plasma volume Diuretics heart and blood vessels that result in this failure. Dilate blood vessels ACEI’s, ARB’s, CCB’s, • Hypertension Alpha-1 Blockers • Coronary Artery Disease Reduce cardiac output • Cardiac Arrhythmia (via SANS) Beta-1 Blockers, • Congestive Heart Failure clonidine © 2014 Viola & Caperila - All Rights Reserved 27 © 2014 Viola & Caperila - All Rights Reserved 28 Coronary Artery Disease Congestive Heart Failure Goal of Treatment Drugs Employed Goal of Treatment Drugs Employed Reduce plasma volume Diuretics Increase coronary artery flow Nitrates, CCB’s Dilate blood vessels ACEI’s, ARB’s, CCB’s Reduce oxygen demand Beta-1 Blockers Reduce contraction rate Beta-1 Blockers Inhibit progression of disease Antihyperlipidemic Agents Increase cardiac contractility Digoxin Prevent thromboembolism Antithromboembolic Agents Prevent thromboembolism Antithromboembolic Agents © 2014 Viola & Caperila - All Rights Reserved 29 30 © 2014 Viola & Caperila - All Rights Reserved The Epinephrine Question Classification of Cholesterol levels Total Cholesterol • The benefit of using epinephrine to achieve profound anesthesia may outweigh the risk in patients with – Under 200 Desirable controlled cardiovascular disease. – 200-239 Borderline high – 240 and above High • Pain-induced stress leads to the release of endogenous epinephrine. • This may exacerbate cardiovascular disease. 31 32 © 2014 Viola & Caperila - All Rights Reserved © 2014 Viola & Caperila - All Rights Reserved Classification of Cholesterol levels Classification of Cholesterol levels LDL Cholesterol HDL Cholesterol • Less than 100 Optimal! • Under 40 Low • 100-129 Near-optimal • Over 60 High • 130-159 Borderline high *Optimal HDL should be >50 for women • 160-189 High Triglycerides • 190 and above Very high • Under 150 Optimal • 150-199 Borderline high • 200 and above High © 2014 Viola & Caperila - All Rights Reserved 33 © 2014 Viola & Caperila - All Rights Reserved 34 Dental Hygiene: Cardiovascular Dental Hygiene: Cardiovascular Observation during examination: • Face, arms or legs: numbness or weakness mainly on one When is best time to schedule this patient? side of body • Brain: confusion, trouble speaking, dizziness, loss of balance, What should be in your office emergency kit? bad headaches At visit – Ask if experienced an MI in past 30 days? • Eyes: trouble seeing from one or both • Stomach: throwing up or urge to • Legs/Body: feeling tired and trouble walking http://www.dentistryiq.com/articles/2013/06/heart-disease-and-stroke-update.html http://www.dentistryiq.com/articles/2013/06/heart-disease-and-stroke-update.html 35 36 Emergency Protocol* Patients with risk factors for coronary heart disease and experience “chest pain” Dental Hygiene: Cardiovascular 1. Take & record vital signs (BP over 180/110 Therapeutic Treatment: contraindicated for treatment that day) • Pain management pre-treatment 2. Administer 0.4mg tab of nitroglycerin sublingually or • 1-2 metered dose of spray (0.3 - 0.6mg) Mechanical removal of biofilm, pathogens 3. Provide Oxygen – flow rate 4 liters/min. to 6 • Altering immune response with selective antibiotics liters/min. via nasal cannula • Treating hypersensitivity – topical fluoride varnish 4. If pain doesn’t subside in 3 minutes, repeat dose of nitroglycerin 5-15 minutes 5. Chest pain that persists after 3 doses is most likely an Take-home agents: MI • Antimicrobial dentifrice/rinses 6. Pain persists – administer a 325 mg uncoated aspirin • Supplemental fluoride & calcium/phosphate products and CALL 911 7. Record all events in patient’s record • Power toothbrush, dental floss, proximal brushes *Tolle & Walters. Strategies for the Safe Treatment of Cardiovascular Patients. Dimensions in Dent Hyg. March 2015 38 37 © 2014 Viola & Caperila. All Rights Reserved Dental Hygiene: Cardiovascular Dental Hygiene: Cardiovascular Treating hypersensitivity: root exposure “dry mouth symptoms” Avoid use of petroleum jelly on lips = causes dehydration Rx: cocoa butter Avoid lemon glycerin swabs or crushing pills in fruit jam to assist in swallowing = dental caries risk If hydrogen peroxide mouthrinse used - must be diluted to neutralize acidity © 2014 Viola & Caperila - All Rights Reserved 39 Morris, D, & Sadowsky, J. Heart-Friendly Oral Health Care. Dimensions in Dent Hygiene. March 2011: Vol. 9, No 3. pp74-79. Dental Hygiene: Cardiovascular Take-home products DIABETES © 2014 Viola & Caperila - All Rights Reserved 41 © 2014