5.7 - Management of Patient/Visitor Emergencies and Patient Safety

There is always the possibility, however slight, that a medical emergency may arise. The following constitutes a standard protocol for the initial management of all medical emergencies:

1. Position the patient properly (varies with the type of emergency) and make sure they are breathing. Ensure that airway and circulation are adequate. Be prepared to administer basic life support and cardiopulmonary resuscitation (CPR) as necessary.
2. Dial 911, monitor vital signs (pulse, respiratory rate, and blood pressure), and assess the level of consciousness.
3. Notify both the attending faculty and the Director of Compliance by calling 1-3083 or 405.473.6064. The supervising clinic faculty must remain with the person needing emergency treatment, as they are responsible for the life support of the person until appropriate help arrives.
4. Obtain a medical emergency cart.
5. Complete an Emergency Treatment Record form located in the emergency cart.

1. If you suspect the visitor/patient is having a cardiac arrest (not breathing and/or no pulse), CPR should be instituted immediately and a bystander should retrieve the Automatic External Defibrillator (AED) from the nearest location (South hallway on 1^st floor and north hallway on floors 2-5).  Notify the clinic faculty.
2. The student/resident will Call 911, Campus Police will ask the following questions: 
   a.  Nature of emergency
   b.  Identify the College
   c.  The floor 
   d.  The room/clinic number
3. Remain on the telephone until the EMS arrives.
4. Send someone to the 1st-floor main entrance to meet the EMS.
5. Inform the Director of Compliance by calling 1-3083 or 405-473-6064 as soon as possible.
6. Document the specifics of the emergency and the actions taken in the patient’s electronic health record (EHR). Document all medications dispensed, dosage, route, and time on the Emergency Treatment Record (see Section 5.2.12) located in the medical emergency cart. Give a copy to EMS when they arrive and keep a copy for our records. This will be scanned into the EHR.
7. Following proper disposition of the emergency, the healthcare provider (student, staff, resident, or faculty), and the attending faculty member must prepare a detailed report of the incident including names, dates, times, circumstances of occurrence, treatment rendered, condition of the patient, and final disposition of the case on a Clinical Incident Reporting Form (see Section 5.2.12). Provide this report to the Director of Patient Relations and Director of Compliance. A copy of the report will be forwarded to the Dean’s Office.
8. Suppose a patient reports an adverse incident to the healthcare provider or the patient service coordinator (PSC) by telephone during off-hours. In that case, the incident needs to be documented in the patient’s EHR and reported to the Director of Compliance the following business day. 
9. Neither the healthcare provider nor the faculty involved should make any statements to the patient regarding the final disposition of any medical, ambulance, and treatment fees. All documentation will be forwarded to the OUHSC Office of Risk Management, which will assist the visitor with additional questions.

Report all accidents or medical events, whether emergency or non-emergency in nature. Call 911, if necessary, and report the incident to the Director of Compliance (DOC) in Room 234, by calling 405-271-3083.

If an accident (for example; falling down the stairs or falling in or around the building) occurs to a visitor or patient not involved in dental treatment, contact the DOC and/or the Campus Police at 405-271-4911 to investigate.

Examples of an accident or incidents while providing treatment are:
a.  Cutting patient lip/tongue
b.  Wrong site surgery/procedure

1. Procedures to follow are:
   a.  Alert your supervising faculty
   b.  Call the Office of Compliance for assistance at ext. 1-3083 or 46876. If unavailable, call the Director of Patient Relations at 34031.
2. Document on Clinical Incident Reporting Form.
3. The form goes to the Office of Quality Assurance and Compliance, Room 238.
4. The Director of Compliance will assist in providing appropriate emergency care if the patient needs it.

The Director of Quality Assurance and Patient Relations will help provide an appropriate administrative response to the incident. 

This report is confidential, protected by the work product and peer review privilege, and intended to record an incident that may expose the OU College of Dentistry to liability.  The Clinical Incident Reporting Form is prepared in anticipation of litigation and may be discoverable in any future litigation. To protect this privilege, please:

1.   Disclose this report only to the following persons authorized to review it:

Director of Compliance
Director of Patient Relations
Assistant Dean of Clinical Affairs

2.   Do not disclose this document to unauthorized persons (including patients).

3.   Do not mention or place it in the dental record.

4.   Do not photocopy, fax, or duplicate in any form the completed report.

This document will be kept on file in the Office of Quality Assurance and Compliance, Room 238.

The Clinical Incident Reporting Form should be completed in situations where clinic outcomes of treatment are less than desirable. Supervising faculty should assist students in completing this form and signing it prior to submission.  The Office of Quality Assurance and Compliance will keep this document on file at the College of Dentistry.

The Clinical Incident Reporting form is available in all clinics in the Clinic Binder. The “official” Clinic Binder is now available in axiUm. The location is axiUm/Links/Clinic Binder.

INSTRUCTIONS FOR COMPLETING THE CLINICAL INCIDENT REPORTING FORM

A student, practitioner, or faculty member shall complete this report when an incident that causes a negative response by a patient or family member occurs or is suspected to occur.  All sections should be completed as applicable.  

Demographic information:  Please include ALL information regarding the patient record, those people involved, and the clinic in which the incident took place.  Indicate if informed consent was obtained in written or verbal form.

I.   Occurrence: Include a concise description of the incident and the names of any other individuals who witnessed the incident; if additional space is needed, the back of the form may be used.  All written reports should only contain facts and should not include opinions, conclusions, or judgments.

II.  Discovery: Indicate all individuals that acknowledged the incident, including the patient, family members of the patient, or a person escorting the patient.  Provide a description of the information given to this person(s) and indicate whether a prognosis and any follow-up care were discussed.  Be certain to indicate the patient’s understanding of the explanation for the cause of the incident and their satisfaction with that explanation.  If a resolution was proposed to the patient include a description of the terms discussed.

III. Resolution: Indicate who INITIALLY offered reimbursement to the patient. Supervising clinic faculty should indicate who requests reimbursement for approval by Clinic Operations (either Supervising Faculty or the Department Chair). Be certain to indicate in the “Patient’s Comments” any questions or remarks made by the patient in response to the terms of reimbursement. Additionally, a description of any arrangements such as remakes, special arrangements for treatment in other clinics, etc. should be included in the section on “Arrangements Made…”.  “Additional Comments” should include a brief discussion of the patient's concerns regarding how the situation was managed and any remarks that may be the result of a conversation with a family member or person escorting the patient.   

BOTH FACULTY AND STUDENT OR PRACTITIONER MUST SIGN THE REPORT AND DATE OF COMPLETION

A copy of the treatment progress notes from the patient’s dental chart must be attached to the form and returned in an envelope marked CONFIDENTIAL to the Office of Quality Assurance and Compliance, in Room 238.

This form will be available in all clinic faculty offices and should be completed immediately following the incident. 

Upon receipt, the Office of Quality Assurance and Compliance will review this form with the appropriate departmental faculty to determine a course of action and prevent future incident recurrence. Students and faculty should refer any further communication from the patient regarding the incident to the Director of Patient Relations. This report shall be shared with the OUHSC Office of Legal Counsel and the OUHSC Campus Risk Management Office.

1. The College of Dentistry has a Cardiac Science Model G-5 automatic external defibrillator (AED) on each floor.
2. All AEDs contain both adult and pediatric defibrillator pad sensors.
3. The AED on the first floor is found on the southwest brick wall next to the Commons. The AEDs on floors 2, 3, 4, and 5 are found in the north hallway.
4. The Office of Compliance is responsible for testing and maintenance of the AEDs.
5. The Office of Compliance is responsible for sending annual reports to the OUHSC Office of Risk Management.

In addition, all AED compartments contain Blood Clot kits. The contents of the kit are as follows:

• Bag (TORK) 
• Bear Claw Nitrile Glove, Large 
• Nasopharyngeal Airway 28F with Lubricant 
• HyFin Vent Chest Seal Twin Pack 
• ARS Needle Decompression Kit (14g x 3.25") 
• C-A-T (Combat Application Tourniquet) Blk 
• Z-Fold Combat Gauze 
• S-Rolled Gauze (4.5" x 4.1yard) 
• ETD 6" Emergency Trauma Dressing 
• Trauma Shears (7.25") 
• Polycarbonate Eye Shield 

Red Emergency Carts are available in every student clinic. The Inventory Associates and/or Clinic Assistants complete a Monthly Emergency Cart Checklist (the form is available from the Department of Compliance). The purpose is to identify expired or missing medications and supplies and to replenish oxygen tanks. Each clinic’s checklist is turned in to the Director of Compliance (DOC) for record keeping. The DOC maintains all emergency cart contents for replacement when expired. All expired medications are disposed of according to OUHSC hazardous waste disposal protocol. The emergency carts are equipped with the following items:

Emergency Cart Contents

Albuterol Inhaler
Aspirin 81mg
Diphenhydramine 25mg tablets
Diphenhydramine – 1mL vile IM injectable
Epi-Pen Adult and/or Child
Epinephrine 1:1,000
Insta-Glucose
Naloxone Hydrochloride 2mg
Nitro-lingual tablet 1mg/mL

Glucometer, test strips, and lancets
Oxygen tank
Positive and passive pressure O₂ mask

Airway - adult and child
Alcohol prep pads
2 x 2s in a pouch
Blood Pressure Cuff/Stethoscope
Coban Wrap
Flashlight
Latex free tourniquet
Microshield
Notepad/Pencil
23-gauge needle
5cc syringe
Pocket mask
Scissors
Thermometer - infrared
Tongue blades
Tonsil Suction
Treatment Record

The Emergency Evacuation Plan for the OU College of Dentistry is located on the College of Dentistry website. The Emergency Evacuation Plan provides details on:

• How to exit the building in an emergency.
• Where your muster point is located - 300 feet away from the COD.
• Who to check in with.
• Active Shooter/Threat or Lockdown information.
• Severe weather locations.

Note: The COD does not have fire drills; if you hear an alarm sounding, exit the building and proceed to your muster point. 

This document outlines the parameters that guide decisions relative to the care of patients who present with elevated blood pressure. The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines for blood pressure targets and treatment recommendations were updated as of November 2017:

*Non-compliant w/ therapy or intensify anti-HTN Rx therapy; treat anxiety prn.

GUIDELINES:

All BP measurements and vital signs taken must be recorded in the patient’s electronic health record (EHR) immediately Students are required to measure vital signs at each appointment. 

•    Blood pressure should be measured using a sphygmomanometer and stethoscope or calibrated stand (oscillometric) monitor. Other calibrated oscillometric (electronic) BP measuring devices may be used except for wrist cuffs.
•    Support the arm and make sure the BP cuff is at heart level and the patient is sitting upright with both feet on the floor.
•    If elevated, have patient sit quietly for 5 minutes then remeasure. Consider measuring in both arms and record the higher reading.

• Utilize appropriate stress management protocols. In patients with hypertension who are anxious or fearful, consider use of intraoperative inhalation sedation with nitrous oxide / oxygen.
• Additional appointment management protocols. Avoid rapid position changes to minimize the risk of orthostatic hypotension. For patients with BP measurements greater than 140 / 90, periodic monitoring of BP during treatment, and at the conclusion of the appointment, is advisable.
• Capacity to tolerate care; Hypotensive. Patients with BP measurements below 90/60 should be questioned to determine if treatment may continue. Have or do they:  
• Do you faint, have vertigo, or have blurry vision?
• Do you fall? 
• Have you started a new blood pressure medication or any new medication?
• Have you taken any non-prescribed medications or street drugs?
• Have you been diagnosed with renal disease?
• Have you been diagnosed with congestive heart failure or irregular heartbeat?
• Do you have a well-balanced diet including water intake?
• Is this a normal blood pressure reading for you? 

• Capacity to tolerate care; Hypertensive. Patients with BP measurements 160 / 100 may receive any necessary dental treatment. For those presenting with BP > 160 / 100, elective dental treatment may be deferred until the BP is brought under better control as confirmed by receipt of a medical clearance from the patient’s primary care physician, internist, or cardiologist. If urgent or emergency dental treatment is determined to be required, proceed with limited and conservative treatment procedures as possible to address the chief complaint and/or relieve acute pain unless the BP is confirmed to be > 180 / 110. At this point, no treatment of any type should be performed without a physician consultation.

NOTE: Superficial surgical procedures, including minor oral and periodontal surgery and non-surgical dental procedures, are classified as low risk. Therefore, it appears that the risk associated with most general, outpatient dental procedures is very low.

TREATMENT CONSIDERATIONS:
Table 2                        CURRENT Values [mm Hg]              Dental Management

*Abnormal pressures should be confirmed by the attending faculty before termination of the appointment. Document in the patient’s chart the cuff placement (ex: right arm), patient position (ex: sitting), interval between readings, and method/s of measurement (ex: stand monitor).
*For borderline values, use professional judgment while taking into consideration patient specific factors such as age and co-morbidities as well as the planned treatment procedures.

• Follow-up considerations: Encourage healthy lifestyle changes, Rx compliance, and self-monitoring when discussing a patient’s level of BP control. Physician follow-up intervals will vary based on the stage of HTN, type of medication(s), level of BP control, and 10-year cardiovascular disease risk assessment.

REFERENCES:

1.    Little, JW, Miller, C, Rhodus, NL. Little & Falace’s Dental Management of the Medically Compromised Patient, 9th Edition, 2018

The following is a summary of the 2007 American Heart Association revision for recommendations for endocarditis antibiotic prophylaxis.

Endocarditis Antibiotic Prophylaxis IS indicated for the following Cardiac Conditions:

• Prosthetic cardiac valves or material+ 
• Previous, relapse, or recurrent infective endocarditis
• Congenital heart disease (CHD)*
  • Unprepared cyanotic CHD, including palliative shunts and conduits.
  • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure.**
  • Repaired CHD with residual effects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization).
• Cardiac transplantation recipients who develop cardiac valvulopathy.

+For patients who have a left ventricular assist device (LVAD): a medical consultation is required.
*Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
**Prophylaxis is recommended because endothelialization of prosthetic material occurs within six months after the procedure.

Dental Procedures Where Endocarditis Prophylaxis IS indicated:

All dental procedures which involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa*.

(See Table below)

Dental Procedures That Do Not Require Endocarditis Prophylaxis:

*The following procedures and events do not need prophylaxis:

• Routine anesthetic injections through non-infected tissue
• Taking dental radiography
• Placement of removable prosthodontics or orthodontic appliances
• Adjustment of orthodontic appliances
• Placement of orthodontic brackets
• Shedding of primary teeth
• Bleeding from trauma to the lips or oral mucosa.

The College of Dentistry’s policy regarding antibiotic prophylaxis for patients with prosthetic joints acknowledges the evidence-based clinical practice guideline (CPG) published in the Journal of the American Dental Association in January, 2015.¹ This CPG is intended to clarify the joint guideline published in December, 2012 by the American Academy of Orthopedic Surgeons (AAOS) and the American Dental Association (ADA).² The policy will be reviewed annually or on an as-needed basis to reflect changes in evidence levels for the practice of antibiotic prophylaxis for patients with prosthetic joints.

Recommendation 1: There is no need for dental practitioners to routinely administer prophylactic antibiotics prior to dental procedures to prevent infection in patients with orthopedic implants. This recommendation is based on the most current evidence-based science.

Recommendation 2: Dental practitioners should consider premedication under the following circumstances where the patients may be at increased risk for joint infection:

• Previous prosthetic joint infections
• Immunocompromised/immunosuppressed patients:
  • inflammatory arthropathies such as rheumatoid arthritis, systemic lupus erythematosus, etc.
  • Chemotherapy or radiation-induced immunosuppression secondary to malignancies
• AIDS
• Type I or poorly controlled Type II diabetes
• Hemophilia

For patients referred to in Recommendation 2, the patient’s physician (preferably an orthopedic surgeon) should provide input regarding patient management. If the physician desires the patient to receive prophylactic antibiotics the physician should provide the patient with a prescription for the antibiotic of the physician’s choice.

The dental practitioner should not write the prescription.

References:

¹   Sollecito T, Abt E, Lockhart P, et al. "The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients with Prosthetic Joints". JADA 2015;146(1):11-16.

²   American Academy of Orthopaedic Surgeons; American Dental Association. "Prevention of Orthopedic Implant Infection in Patients Undergoing Dental Procedures: Evidence-based Guideline and Evidence Report". Rosemont, IL: American Academy of Orthopedic Surgeons;2012.

When a patient presents for an appointment with an indication for antibiotic premedication and the patient has not taken the antibiotic as prescribed, there is the option of dispensing the antibiotic on-site through the Oral Diagnosis (OD) Division rather than rescheduling the patient. 

• Any antibiotic dispensation must be authorized by supervising faculty. 
• The student will add a new prescription into the eRx module in axiUm containing the drug name, dosage, number of pills/caps, and instructions such as "take all four capsules immediately”.
  • Select the supervising faculty’s name as the provider and select the COD as the pharmacy. 
  • Supervising faculty will log in as eRx user and sign the prescription by choosing “sign don’t send”. 
  • Dental hygiene patients will be entered by OD dental faculty.  
• The student must chart add the appropriate code for the antibiotic they are dispensing and have supervising faculty approve the planned and completed code. There is a fee for on-site dispensing in the student clinics.
  • R9600 Amoxicillin 500 mg x 4 ($6.00) 
  • R9601 Azithromycin 500 mg x 1 ($10.00) 
• The student will go to the OD Clinic to request the antibiotic from OD faculty.
  • You must comply with the recommended waiting period of 30-60 minutes before initiating invasive procedures 
• Students will document in the PTP note the medication, amount, and time the premed was taken by the patient. 
• If the patient is unable to take amoxicillin or azithromycin, the patient will need to be rescheduled and the appointment aborted. 

Things to Know and Remember:

• If premedication is required, there must be a minimum of 10 days between appointments. 
• If a procedure must be scheduled within the 10-day interval, an antibiotic of another class on the regimen should be selected. 
• Repeated treatment sessions require alternative antibiotic regimens at each appointment or at least 4 weeks between treatment sessions. 
• If premedication is indicated and the patient and student doctor/faculty forget or unanticipated bleeding occurs, the antibiotic may be given up to 2 hours following the completion of the procedure. 
• On-site dispensing of antibiotic premedication is not a replacement for providing the patient with a prescription that they should fill at their pharmacy. 
• On-site dispensing is for those times when a patient forgot to take the antibiotic before coming or they did not take the full dosage. 
• There are also instances in which the patient presents for urgent care and is unaware that they need to be premedicated. Ideally, pre-planning should occur and a prescription written or called in for the patient in advance of the appointment. 

The Health and Safety Committee develops guidelines that provide the criteria for the treatment of immune-suppressed patients.  These guidelines as well as clinic workflows can be found in axiUm Links in the Clinic Binder section. 

CRITICAL LAB TEST VALUES - Results are only valid for 6 months from the lab result date. The patient will need to have new labs completed once the results are > 6 months old.

Complete Blood Count W or W/O Differential:

• White Blood Cell: count <2000 consider premedication with an AHA regimen for invasive procedures or delay elective procedures
• Absolute Neutrophil: (ANC) ≥750 - <1,000/cc-consider premed for invasive procedures to prevent any infection with the regimen.
• Platelets:
  • ≥50,000: no contraindications
  • >20,000 - <50,000: minor treatment including endodontic and restorative treatment
  • ≤20,000: NO TREATMENT!
• Hemoglobin: ≥ 8 g/dL
• Blood Glucose: ≤ 200 mg/dL

CD4 Count – Considerations:

• A normal CD4 count ranges from 500–1,500 cells/mm³.
• Conventional wisdom says there is no level at which dental care cannot be done.

HIV-1 RNA Viral Load - Considerations:

• Does not have an impact on dental treatment planning, modifications would be based on the critical lab values.
• The viral load trends and is usually checked at 3- to 6-month intervals unless the patient is introduced to a new medication and then 2- to 8-weeks post-initial therapy.
• Viral load and CD4 count have a strong association, as one goes up the other goes down.

INR- International Normalized Ratio (prothrombin time):

• As with any patient taking blood thinners, an INR of 2.5-3.5 is ideal for most dental treatments. Full mouth extractions, periodontal surgery, etc. ~ 3.0 or physician consult.
• If planning an invasive procedure, INR should be checked within 24 hours prior to the procedure.

Dental Device Considerations:

• HIV/AIDS: ultrasonic scalers that generate aerosols are okay to use excluding no other respiratory complications i.e., COPD, TB, uncontrolled asthma. Evidence shows a reduced risk of potential exposure to the health care worker with an ultrasonic scaler VS traditional hand instruments that have blades. HIV/AIDS must have blood components for transmission.
• Lasers and electro surge: Contraindicated with patients who present with herpes simplex virus in vesicular stage (HSV) and human papillomavirus (HPV). No evidence exists of aerosolization or inhalation with HIV or HBV. Follow all recommended precautions with lasers. 

Follow Standard Precautions:

• Use standard precautions when working with any patient; everyone is treated the same.
• PPE: All required PPE used with blood and OPIMs for treatment, gown, mask, eyewear, and gloves

Good Clinical Judgment:

Use the above recommendations as general guidelines. This will ensure their safest and most efficient dental care.

References:

Maria Flores, DDS and Peter L. Jacobsen, Ph.D., DDS; Pacific Protocols for the Dental Management of Patients with HIV Disease, 2007

Little, James W, Falace, Donald A.; Dental Management of the Medically Compromised Patient 8^th edition

www.hivdent.org

www.cdc.org

Ryan White (RW) patients receive comprehensive dental care at COD. This program is funded by Federal and State governments through grants. Every RW patient is allotted $2000 for dental treatment. All the patient’s needs are taken care of with the exception of the following:

1. Cosmetic Dentistry
2. Orthodontic Treatment
3. Implant Dentistry

New RW Patient Protocol:

OU Health Infectious Disease Institute (IDI) refers potential RW patients to be screened at the COD. The COD will adhere to the following protocol:

1. IDI will send the patient’s information and initial bloodwork to the QA staff.
2. The QA staff will create a patient chart in axiUm and upload the initial lab results.
3. The Communications Center schedules the initial screening appointment with the Oral Diagnosis clinic.
4. If the patient is accepted into the predoctoral program, they will be assigned to a student.
5. The Communications Center will schedule the initial workup appointment.
6. Students (DS and DH) will work closely with faculty to complete comprehensive dental treatment.

Existing RW Patient Protocol:

All RW patients are required to have updated labs within their axiUm chart prior to receiving treatment. The lab results must be dated within six months of each treatment appointment. If labs are older than six months, they are considered expired and the patient should be contacted, by the student, to have new labs drawn.

1. For ongoing treatment, the COD Grant Coordinator will generate an axiUm report for all upcoming appointments scheduled for RW patients.
   • The report is generated each Friday for the upcoming week.
2. The Grant Coordinator will search OU Health's EMR to retrieve current lab results to upload in the RW patient's axiUm chart.
3. If the labs are expired, the assigned student should contact the patient at least five days prior to the appointment to instruct the patient to have new labs drawn.
4. It is the patient's responsibility to contact the IDI clinic, by calling 405-271-6434, to request that a lab script be sent to the OU Health lab so that necessary labs can be drawn. 
   • The COD does not submit lab scripts to the lab for RW patients.
   • The COD does not call the RW patient's physician to request lab scripts for our patients.
5. The COD requires the following lab results:
   1. Complete Blood Count With (or without) Differential
   2. HIV-1 RNA Viral Load
   3. CD4 Count
6. If there are fewer than three required lab results in the OU Health EMR, the COD Grant Coordinator will upload the remaining labs in the patient's axiUm chart.
7. The student should discuss with the faculty to determine if treatment can continue or if all labs are required depending on the procedure to be performed.

Short Notice Appointments Scheduled:

If an RW patient is being seen for an emergency or short notice appointment (placed on the schedule and being seen for treatment in less than five days),  and the RW labs are expired in the patient's axiUm chart, the student will need to contact the Grant Coordinator to search for current labs prior to contacting the patient.

1. The student should send an email, from their OUHSC email account (to prevent a HIPAA violation), to andrea-adams@ouhsc.edu or call extension 45444 (if calling from a COD phone) to request a search of the patient's OU Health EMR for current labs to upload into axiUm. The information needed in the email or via phone call is: 
   • RW Patient’s Name
   • Patient’s DOB
   • Patient’s axiUm chart number
   • Date of the short notice appointment
2. If current labs are available within the patient’s OU Health EMR, they will be uploaded into the patient's axiUm chart.
3. If current labs are not available (expired), the student will then need to contact the patient to have labs drawn or reschedule the appointment until current labs are available in the patient's OU Health EMR.
4. The Grant Coordinator will contact the student with information regarding the status of the labs via email or phone.

• The COD faculty should assist students with interpreting lab results and determining if a patient can be treated for an emergency if current RW labs are not available. 

Diabetes mellitus is a group of metabolic diseases that lead to high levels of blood glucose (hyperglycemia), which occur when the body does not produce any or enough insulin or does not use insulin well. Because diabetes is a relatively common condition, dental providers are likely to encounter it frequently. Oral manifestations of uncontrolled diabetes can include xerostomia; burning sensation in the mouth; impaired/delayed wound healing; increased incidence and severity of infections; secondary infection with candidiasis; parotid salivary gland enlargement; gingivitis; and/or periodontitis.

Types of Diabetes:

Type 1 Diabetes: a chronic autoimmune disease in which the beta cells in the pancreas create little to no insulin, and accounts for 5% to 10% of all diabetes cases.

Type 2 Diabetes: accounts for 85% to 90% or more of diabetes cases and is one of the most common chronic diseases, characterized by decreased response of target tissues to normal levels of insulin, dysregulation of insulin production, or a combination of both.

Prediabetes: when blood glucose levels are higher than normal, but not high enough for a formal diagnosis of diabetes. The person is at increased risk for developing type 2 diabetes, as well as at increased risk for heart disease and stroke. It is estimated that as many as 90% of those with prediabetes are unaware that they have prediabetes.

Gestational diabetes: a state of glucose intolerance that occurs in pregnant women who do not otherwise have diabetes. Occurring in the second half of pregnancy, gestational diabetes is caused by placental hormones and results in insulin resistance and relative insulin deficiency. Although true gestational diabetes resolves during the postpartum period, those who have had gestational diabetes are at increased risk of developing type 2 diabetes later in life.

Common Complications:

Three common complications that can occur when glucose levels are not well controlled are hypoglycemia, hyperglycemia, and diabetic ketoacidosis.

Hypoglycemia: a condition in which blood glucose levels drop below normal. For many people with diabetes, this means a blood glucose level of 70 milligrams/deciliter (mg/dL) or less. Although patients with diabetes often recognize signs and symptoms of hypoglycemia and self-intervene before changes in or loss of consciousness occur, staff should be trained to recognize the signs and treat patients accordingly.

Hyperglycemia: occurs when blood glucose levels are abnormally high. This can occur anytime there is not enough insulin in the bloodstream or the body is not using insulin properly.

Diabetic Ketoacidosis: Diabetic ketoacidosis is a serious condition that can develop when there is not enough insulin to help the body adequately use glucose.

(Refer to Table: Symptoms and Treatment for Patients with Diabetes Mellitus)

*NOTE: People who have concomitant kidney disease should not drink orange juice for their 15 grams of carbohydrates because of the high potassium content. Apple, grape, or cranberry juice cocktail are good alternatives.

Monitoring Glucose Levels

Blood-glucose levels can be checked chairside using a drop of blood and a glucometer. Since they are intended for use by multiple individuals, glucometers are designed to facilitate thorough cleaning and disinfection between uses to help prevent the spread of bloodborne pathogens. After each use, the device must be cleaned and disinfected according to the manufacturer’s instructions. After blood is tested, refer to the chart below to determine the correct Treatment Considerations.

HbA1C and Estimated Average Glucose (eAG)

(28.7 x A1C) – 46.7 = eAG mg/dl

A dental provider may want to ask a patient with diabetes questions such as:

• How old were you when you were diagnosed with diabetes and what type of diabetes do you have?
• What medications do you take?
• How do you monitor your blood sugar levels?
• How often do you see your doctor about your diabetes? When was your last visit to the doctor?
• What was your most recent HbA1c (A1C) result?
• Do you ever have episodes of very low (hypoglycemia) or very high blood sugar (hyperglycemia)?
• Do you ever find yourself disoriented, agitated, and anxious for no apparent reason?
• Do you have any mouth sores or discomfort?
• Does your mouth feel dry?
• Do you have any other medical conditions related to your diabetes, such as heart disease, high blood pressure, history of stroke, eye problems, limb numbness, kidney problems, delays in wound healing, or a history of gum disease? Please describe.

Scheduling Considerations

In general, morning appointments are advisable for patients with diabetes since endogenous cortisol levels are typically higher at this time; because cortisol increases blood sugar levels, the risk of hypoglycemia is less. For patients using short- and/or long-acting insulin therapy, appointments should be scheduled so they do not coincide with peak insulin activity, which increases the risk of hypoglycemia. It is important to confirm that the patient has eaten normally prior to the appointment and has taken all scheduled medications. If a procedure is planned with the expectation that the patient will alter normal eating habits ahead of time (e.g., conscious sedation), diabetes medication dosing may need to be modified in consultation with the patient’s physician. Patients with well-controlled diabetes can usually be managed conventionally for most surgical procedures. If the patient’s food consumption will be affected after oral or dental surgery, a plan to balance the patient’s diabetes medications and food intake should be established in advance.

Coordination with the patient’s physician may be necessary to determine the patient’s health status and whether planned dental treatment can be safely and effectively accomplished. Physicians should make laboratory test results available to the dentist upon request, and inform the dentist of any diabetic complications of relevance to the individual patient prior to dental procedures. The physician may need to adjust the patient’s diabetes medication to help ensure sustained metabolic control, before, during, and after surgical procedures. Patients with diabetes should obtain regular medical and dental care, including regular dental visits for a full evaluation of their dental and periodontal condition.

References:

1. American Dental Association, January 2022, Diabetes, ADA.org [online], Available from: https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/diabetes .