5.7.4 - Patient's Health Safety

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 .