2022 Medical Consults

MEDICAL CONSULTS
The Medically Complex Patients

J.R. Macajoux
SAFEGUARD AGAINST MEDICAL
ERRORS
Advances in health care & technology means complex patients are:
 living longer!
 leading more productive lives ? Living longer!
 seeking care in outpatient settings- from multiple offices and doctors and specialist
 More severe disease states- new meds/Therapies
 disease states may be affected by over the counter meds or home remedies medicaments
 systemic effects of vasoconstrictors
 Potential adverse reactions and recommendations to minimize untoward events

DISEASE CLASSIFICATIONS
Heart Disease- Circulation

Respiratory Disease-Lung and right heart
Kidney and Liver Disease- renal/Hepatic
Diabetes Mellitus-immune and excretion
Thyroid Disease- Metabolism and immune
HIV-Immune
Anaplasia
CARDIOVASCULAR DISEASES
Hypertension- Muscle/Conduction
Ischemic Heart Disease –Circulation/ Rhythm
Cerebrovascular Accident-Blockage
Cardiac Arrhythmia/ Muscle or conduction
Congestive Heart Failure-multi factorial
CARDIOVASCULAR DISEASE
Hypertension- is when the Blood pressure is greater than 130/80
Postpone dental therapy
 Stage III hypertension is BP 180+/110+ refer to ER
 Stage ll hypertension is 140 -159+/90- 99 refer to MD or Primary
 Stage l Hypertension is 140-159/90+ Med consult for additional

control measures
SYMPTOMS OF HYPERTENSION
 headaches
 failing vision-blurry
 ringing in ears
 Dizziness- lack of balance
 Weakness -arms and hands
 tingling of hands and feet

HYPERTENSION
In case of emergency dental treatment
 Obtain medical consult 140-175/90-95

 Limit LA 2% lido w/ 1:100,000 epi to 1-2 carpules
 No retraction cord with epi / and no intralig or intrabony injections
 Stage II hypertension (BP = 160-179/100-109) no therapy(treatment)
DISEASE STATES
Ischemic Heart Disease/Cerebrovascular Accident- requires consent and

recommendations- Emergency dental treatment only
 Pain elimination - 1-2 carpules - 2% lidocain w/ 1:100,000 epi (0.018 to 0.036 mg of epi) is of
little significance in most hypertensive patients
 1-2 carpules of LA w/ epi- vasoconstrictors lower risk of endogenous catecholamine release
 Stable angina
 1-2 carpules of LA w/ epi limited treatment

 Cardiac Arrhythmia- consult is needed and vasoconstrictors are not recommended
CONDUCTION - PROBLEMS
Abnormal heart rhythm-ECG
 Symptoms include:
 Palpitations
 Dizziness
 Syncope
 Chest pain
 Difficulty breathing
CEREBROVASCULAR ACCIDENT - STROKE
Defer dental treatment if:
 Stroke episode within 6 months
 Ongoing TIAs- Transient Ischemic attack
 Emergency dental treatment - consult physician
 6+ months after stroke - less than 2 carpules with epi

CARDIAC ARRHYTHMIA - CONTINUED
Vasoconstrictors contraindicated for:
 Patients with severe arrhythmias

 Patients with an arrhythmia refractory to treatment
 No intraligamentary or intraosseous injections
CONGESTIVE HEART FAILURE (CHF)
Signs and symptoms include the following: NEED CONSULT
 Rapid, shallow breathing followed by apnea (Cheyne-Stokes resp)

 Heart murmur
 Arrhythmia-ECG
 Edema
 Clubbing of fingers
CHF - CONTINUED
 Dental Tx contraindicated when uncontrolled or untreated
 Routine dental Tx okay if well-controlled
 Vasoconstrictor limited to 2 carpules
 Medication interactions
 Digoxin - may produce arrhythmia
 Nitroglycerin - may diminish effects of vasoconstrictor and shorten duration of anesthesia
 Medical consultation and monitor vital signs-Stroke volume

PULMONARY DISEASE
 Asthma-Note last attack and medication dosage/ Last hospitalization
 LA w/ vasoconstrictor safe with mild asthmatics-Tidal volumes
 Chronic Obstructive Pulmonary Disease (COPD) - bronchitis & emphysema
 No contraindication to LA w/ vasoconstrictor (may require dosage modification

if co-existing cardiovascular disease, no sedation with Nitrous Oxide
 Mandibular and palatal blocks (rubber dam too) may create sensation of
airway obstruction
RENAL DISEASE & HEPATIC DISEASE
 Med consult- MCV and GFR- Caucasian/Afro American lab values

 Amide anesthetics (Lido) metabolized by liver & excreted by kidneys
 Keep dosages to a minimum and increase LA intervals
 Medical consultations required prior to dental Tx
 Meds- Motrin is contra indicated
DIABETES MELLITUS-A1C
 Vasoconstrictors oppose action of insulin
 Epi increases gluconeogenesis & glycogen breakdown – hyperglycemia
 Well-controlled diabetics tolerate vasoconstrictors - no special precautions
 1-3 carpules of LA w/ epi increased risk w/ unstable diabetics
 A1C of 5 and below is well controlled and needs no special treatment.
 Treatment including placement of implant is not contra indicated.

THYROID DISEASE
 Hyperthyroidism
 Increased metabolic rate - weight loss, exophthalmos, goiter
 Hypertension, arrhythmia, palpitations, chest pain
 Well managed patients - normal amounts of LA w/ epi
 Untreated patients or poorly-controlled patients - CAUTION - avoid
vasoconstrictors/ med consult is needed with recommendations for the use of
anesthetics
 Labs- thyroxin levels
THYROID DISEASE
Hypothyroidism
 Decreased metabolic rate - exaggerated response to depressant effects of LA

 Poorly-controlled patients - myxedema coma from stress of dental care
 Hypothermia, bradycardia, severe hypotension, seizures
 Mild hypothyroidism - low risk of Tx - keep LA to a minimum
 Severe or untreated hypothyroidism - defer elective dental Tx until controlled
Medical consultations
required prior to dental Tx
Go to Med consult H 1
LABS
Related tests: Urine Culture; Urine Protein; BUN; Creatinine; Creatinine Clearance; Urine Albumin; eGFR; Kidney Stone
Analysis; Kidney Stone Risk Panel; Glucose Tests; Renal Panel; Bilirubin
Routine labs are different for different people for different stages of life. However if going to the doc for a basic physical
once a year ... these are usually the panel
Basic:
Glucose, BUN, Creatinine, Na, Cl, K, CO2
Lytes:
Na, K, Cl, CO2 Carbon Dioxide (Bicarbonate) Chloride Potassium Sodium
Liver:
Albumin, AST (SGOT), ALT (SGPT), Total protein, and fractionated bilirubin.
Comprehensive:
Basic, Liver, Ca, Phos minus fractionated bili (Note that Mg and LDH is not included in any panel and must be ordered
separately.)
CBC:
Complete Blood Count including WBC, HGB, HCT. (Must order differential and platelets separately.)
VA:
Chem 7: Albumin.
Bilirubin (total and direct).Alkaline Phosphatase (ALP).Aspartate Aminotransferase (AST).Alanine Aminotransferase (ALT).
Chem 10:
same as Liver plus Ca, PO4, Total protein, LDH

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MEDICAL CONSULTS

The Medically Complex Patients

 leading more productive lives ? Living longer!

 More severe disease states- new meds/Therapies

 systemic effects of vasoconstrictors

 Potential adverse reactions and recommendations to minimize untoward events

Heart Disease- Circulation

Postpone dental therapy

 Stage III hypertension is BP 180+/110+ refer to ER

 Stage ll hypertension is 140 -159+/90- 99 refer to MD or Primary

 Stage l Hypertension is 140-159/90+ Med consult for additional

 Dizziness- lack of balance

 Weakness -arms and hands

 tingling of hands and feet

In case of emergency dental treatment

 Obtain medical consult 140-175/90-95

Ischemic Heart Disease/Cerebrovascular Accident- requires consent and

 1-2 carpules of LA w/ epi- vasoconstrictors lower risk of endogenous catecholamine release

 1-2 carpules of LA w/ epi limited treatment

Abnormal heart rhythm-ECG

Defer dental treatment if:

 Stroke episode within 6 months

 Ongoing TIAs- Transient Ischemic attack

 Emergency dental treatment - consult physician

 6+ months after stroke - less than 2 carpules with epi

 Patients with severe arrhythmias

 Rapid, shallow breathing followed by apnea (Cheyne-Stokes resp)

 Routine dental Tx okay if well-controlled

 Vasoconstrictor limited to 2 carpules

 Digoxin - may produce arrhythmia

 Nitroglycerin - may diminish effects of vasoconstrictor and shorten duration of anesthesia

 Medical consultation and monitor vital signs-Stroke volume

 LA w/ vasoconstrictor safe with mild asthmatics-Tidal volumes

 Chronic Obstructive Pulmonary Disease (COPD) - bronchitis & emphysema

 No contraindication to LA w/ vasoconstrictor (may require dosage modification

 Med consult- MCV and GFR- Caucasian/Afro American lab values

 Vasoconstrictors oppose action of insulin

 Epi increases gluconeogenesis & glycogen breakdown – hyperglycemia

 Well-controlled diabetics tolerate vasoconstrictors - no special precautions

 1-3 carpules of LA w/ epi increased risk w/ unstable diabetics

 A1C of 5 and below is well controlled and needs no special treatment.

 Treatment including placement of implant is not contra indicated.

 Decreased metabolic rate - exaggerated response to depressant effects of LA

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