Resources

Resources for Treating Patients With Medically Complex Problems

Patients seeking dental consultation and care may present with signs and symptoms of undiagnosed medical problems or conditions or may have a significant health history and be under the care of a physician. Current and previous medical illness and use of pharmacologic agents will often affect dental care, particularly when surgical procedures are in the general treatment plan. Dentists will be caring for an aging population whose members are enjoying longer life spans and greater quality of life due to improvements in health care and disease prevention. The degenerative diseases of aging will be more frequently encountered in the dental office and may put the dentist in a quandary with regard to patient management. The explosion of knowledge and increasing detail of information surfacing daily concerning medical conditions can place practitioners at a disadvantage because being knowledgeable about all this new information and how it affects dental practice is simply not feasible. However, up-to-date information on specific conditions is available through publications, consultation, Web sites and chat groups.

The purpose of this article is to inform the practitioner of the availability of those resources that will assist in answering clinical questions regarding dental management of medically complex patients. The clinician may not know where to go to look for current information on relevant subjects. Herein is compiled a list of resources that the dental practitioner can consult when questions arise about managing patients with medical problems.

Dental patients can present with various pathologic conditions that require special consideration. Subjects with atherosclerotic vascular occlusive disease, hypertension, diabetes, chronic liver disease, renal insufficiency, neoplastic disease, neurologic deficits, and infectious diseases are often taking numerous drugs. When contemplating dental treatments, the practitioner will need to review the patient’s medical history and arrive at decisions that will protect the patient from complications. In this scenario, time is not of the essence; the dentist can consult available resources and devise a modification in the dental treatment plan for a later appointment. In the case of medical emergencies, time is critical and there will be no opportunity for consultation. In such instances, the practitioner will have to be well-versed in life support, airway control, and cardiopulmonary resuscitation. The primary resource for medical emergencies arising in the dental office is calling emergency services at 9-1-1.

For the patient with a significant medical history, the dentist has a wide array of resources to consult. The sources available to everyone in practice are listed in Table 1.

Direct consultation with the patient’s physician is always an option when one is concerned about medical problems that affect dental care. Unfortunately, not all physicians are familiar with dental procedures and may not comprehend the significance of the dentist’s concerns. However, there are more than 50 dental schools in the United States, and all of these institutions have a department that includes oral medicine, oral pathology or oral diagnostic sciences. The faculty members in these institutions are often available and willing to consult over the telephone. Some dental schools offer Internet consultation on their Web sites. Interested practitioners need only call the school to acquire the appropriate departmental phone numbers and Web site addresses.

Published texts and articles have always served as the primary resources for information on medical problems as they affect dental practice. The American Academy of Oral Medicine has published The Clinician’s Guide to Treatment of the Medically Compromised Dental Patient and The HIV Patient. A list of these and other publications is given in Table 2. Texts that deal with medical illness and dental practice usually have relatively current recommendations for management. The American Dental Association Council on Access, Prevention, and Interprofessional Relations has published a series of oral health guidelines that are available through ADA catalog sales.

Of course, everything one would ever need or want to know can also be found on the Internet. Web sites with information germane to the dental care of medically complex patients are listed in Table 3. The National Library of Medicine Web sites hosts Grateful Med, a medical and dental publication search engine (http://igm.nlm.nih.gov/). This site is simple to use. It is not necessary to know the exact title of an article to use the system. Rather, the format allows for searches according to subject. There are two boxes that will help the user limit the search to the area of interest (Figure 1). For example, a dentist might be concerned about a potential bleeding disorder in one of his or her patients who is taking coumadin for thromboembolic disease. To access information from the medical literature on this issue, the dentist would type "bleeding disorder" into the first box and designate the box as "subject" The second box will help narrow the search so that retrieval of articles will focus on dental care. To do this, one would type "dental," "dentistry," or "tooth extraction" in the second box and label it as "subject." Once the categories have been selected, the use hits the "perform search" button. After the results are displayed, the user chooses the articles he or she is interested in and clicks on the box that reads "full citation" to peruse the abstract (Figure 2). The user can then download the selected abstracts by clicking the box next to the articles of interest and hitting the "download to disk" button. Choose "download only the records you have selected" and "long records with abstracts" and click on "prepare to download" (Figure 3). Then choose the IGM format and click "download now." This will combine all the selected abstracts into one file that can then be saved onto the user’s hard drive as text and opened with a word processing program. The practitioner will then have the current literature on this subject he or she is researching.

Other Internet resources include list-serves and bulletin boards. For example, the Bulletin Board of Oral Pathology has a list-serve that anyone can join. By subscribing to the list, participants will receive all posted messages and can post responses. Oral pathologists and oral medicine specialists utilize the bulletin board to discuss current issues.

These are some of the most helpful references to assist the practitioner in caring for the medically complex patient. In the future, schools and other organizations will no doubt expand the resources available for consultation on all aspects of dental care.

Authors

Lewis Roy Eversole, DDS, MSD, MA, is a professor of pathology and medicine at the UOP School of Dentistry and a head and neck pathology consultant to Pathology Consultants of New Mexico.

William M. Carpenter, DDS, MS, is professor and chairman in the Department of Pathology and Medicine at the University of the Pacific School of Dentistry.

To request a printed copy of this article, please contact/ Lewis Roy Eversole, DDS, MSD, MA, UOP School of Dentistry, 2155 Webster St., San Francisco, CA 94115. Or e-mail the author at leversol@uop.edu.

Table 1. Information Systems for Medically Complex Patients

Direct Consultations

Patient’s treating physician

Oral medicine and oral pathology faculty

Published Data

Dental journals

Textbooks

Monographs and guidelines

Information Technology

Medlar Grateful Med Literature Search

Internet bulletin boards, list-serves, and chat groups

Table 2. Published Resources for Medically Complex Patients

Textbooks

Little JW, Falace DA, et al, Dental Management of the Medically Compromised Patient, 5th ed. Mosby-Year Book, St Louis, 1996.

Eversole LR, A Pocket Guide. WB Saunders Co, Philadelphia, 1996.

Silverman S, Oral Cancer. American Cancer Society Inc and BC Decker Publishing, Ontario, 1998.

Silverman S, Eversole, L, Truelove E, Essentials of Oral Medicine. BC Decker Publishing, Ontario, 2000.

Lynch MA, Brightman VJ, Greenberg MS, Burkett’s Oral Medicine, 9th ed. Lippincott Williams & Wilkins, Philadelphia, 2000.

Coleman GC, Nelson JF, Principles of Oral Diagnosis. Mosby-Year Book, St Louis, 1993.

Bricker SL, Langlais RP, Miller CS, Oral Diagnosis, Medicine and Treatment Planning, 2nd ed. Lea & Febiger, Philadelphia, 1994.

Sonis ST, Fazio RC, Fang L, Principles and Practice of Oral Medicine, 2nd ed. WB Saunders Co, Philadelphia, 1995.

Neidle EA, Yagiela JA, Pharmacology and Therapeutics for Dentistry, 3rd ed. CV Mosby, St Louis, 1989.

Journals

Journal of the American Dental Association

Journal of the California Dental Association

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics

Compendium of Education

Monographs

American Academy of Oral Medicine. Contact Dr. Abraham Reiner, executive coordinator, 159 W. 53rd St., New York, NY 10019-6050

Clinician’s Guide to Treatment of HIV-Infected Patients

Clinician’s Guide to Treatment of Medically Compromised Dental Patients

ADA Oral Health Care Booklets, write Catalog Sales, P.O. Box 776, St. Charles, IL 60174

Cancer Chemotherapy

Cardiovascular Disease

Chemically Dependent Patients

Diabetic Patients

End Stage Renal Disease

Head and Neck Cancer

Hepatic Disease

Physical and Medical Disorders

Women’s Oral Health Issues

Table 3. Internet Resources

Bulletin Board of Oral Pathology -- http://www.sdm.buffalo.edu/bbop/

American Academy of Oral Medicine -- http://www.oralmedicine.com

American Academy of Oral and Maxillofacial Pathology http://www.aaomp.org (under development)

Medline search -- http://igm.nlm.nih.gov/ -- once open, click on "Medline"

Figure 1. Grateful Med search screen.

Figure 2. IGM download action screen.

Figure 3. IGM results screen.