Cardio issues are changing dentistry, expert says

By Laird Harrison, Senior Editor

September 22, 2008 -- Blood pressure cuffs? Yes. Amoxicillin? Not so much. Dentists must change the way they attend to their patients' cardiovascular health, according to oral medicine specialist Michael Siegel, D.D.S., M.S., who chairs the department of diagnostic sciences at Nova Southeastern University. And the good news is that you can bill for your medical advice.

In particular, he said, guidelines from the National Institutes of Health (NIH) are putting dentists on the front lines in detecting high blood pressure. At the same time, the American Heart Association (AHA) has drastically narrowed the category of patients who need antibiotics before dental procedures.

“Dentists have this sort of paradigm that you can't charge a patient unless you give them some sort of jewelry -- gold, porcelain....”
— Michael Siegel, D.D.S., M.S.

"Dentists and hygienists are now responsible for early detection of hypertension," said Dr. Siegel, citing 2003 NIH guidelines. So dentists or their staff should take their patients' blood pressure regularly. "Get a digital cuff," Dr. Siegel told attendees at the recent California Dental Association Fall Scientific Session. "While you're saying, 'Hello,' and updating their history, push the button."

According to a 2004 report in the Journal of the American Dental Association, the measurement should be taken once a year on all patients (JADA, May 2004, Vol. 135:5, pp. 576-584).

So what do you do when you have the data? If patients have either prehypertension (systolic pressure 120-139 or diastolic 80-89) or stage 1 hypertension (systolic pressure 140-159 or diastolic 90-99), you can treat them but you should recommend they see their doctors about lifestyle changes and medication.

If they have stage 2 hypertension (systolic pressure ≥ 160 or diastolic ≥ 100), "you shouldn't be doing any elective dental care on them," Dr. Siegel said. "These are the people who are going to have a stroke. These people should go to their physicians. You pick up the phone."

Hypertensive patients run a higher risk of many serious diseases. And the condition can pose specific problems to dentists. For example, these patients shouldn't receive too much epinephrine. According to the JADA review, "While there is no official maximum dose for vasoconstrictors when administered with local anesthetic, two to three cartridges of lidocaine with 1:100,000 epinephrine (approximately 0.036-0.054 mg epinephrine) is considered safe in ambulatory patients with all but the most severe CVD [cardiovascular disease]." The review also said that "retraction cords containing epinephrine should be avoided."

Hypertensive patients may also feel dizzy if they get up too quickly from the dental chair. And medications for the condition can cause a wide range of side effects, including xerostomia, gingival overgrowth, lichenoid lesions, increased cough, and loss of taste. ACE inhibitors have been associated with a "scalded mouth" syndrome.

When hypertensive patients present with these problems, Dr. Siegel recommends calling their medical doctors. You can ask, "Is there a drug from another class that will fix this problem?" Fortunately, several classes of drugs are available for the condition.

Dentists need to attend to their own prescriptions as well. Some hypertension drugs may interact with drugs used by dentists; for example nonsteroidal anti-inflammatory drugs (NSAIDs) taken over a long term can weaken some antihypertensive drugs.

Advising patients on these issues can even bring in money, Dr. Siegel said. You can bill dental insurance with the codes 00140 (limited consult), 00150 (moderate consult), or 00160 (high level consult). "Dentists have this sort of paradigm that you can't charge a patient unless you give them some sort of jewelry -- gold, porcelain," he said. But advice can be just as valuable. "Don't give it away."

As for what to charge, he said, know what your overhead is. If your overhead is $50/hour, and the consult takes an hour, charge $150, he advised.

Antibiotics

Another big change is the way dentists no longer need to prescribe antibiotics before treating most patients with a history of heart disease.

For 50 years the AHA has recommended antibiotic prophylaxis for patients at risk of infective endocarditis before dental procedures. But after reviewing the data last year, the AHA -- in consultation with the ADA -- narrowed the number of patients for whom it recommends the antibiotics. The recommendation (JADA, January 1, 2008, Vol. 139:Supplement 1, pp. 3S-24S) now only applies to those who have artificial heart valves, a history of infective endocarditis, certain serious congenital heart conditions (for a list, visit the ADA Web site), or a heart transplant that develops a valve problem.

So dentists just have to ask their patients two questions on this subject: "Have you ever had a heart infection?" and "Have you ever had heart surgery?" If they've had heart surgery, find out if it was for an artificial valve or a congenital heart defect.

In the future, Dr. Siegel speculated, the AHA may end up not recommending antibiotic prophylaxis for anyone because there's no research showing that it prevents infective endocarditis.

The reason for the original recommendation was that dental procedures can introduce bacteria from the mouth into the bloodstream. But more recent research has called into question the threat from this phenomenon. For example, Dr. Siegel cited a study finding that brushing your teeth twice a day for a year would cause 154,000 times more risk of blood-borne bacteria than a single tooth extraction (Pediatric Cardiology, September 1999, Vol. 20:5, pp. 317-325).

"If we're really going to do this right," he said, "everyone in this room should take amoxicillin an hour before brushing."

Similarly, antibiotics aren't necessary for dental procedures when patients have surgical pins, plates, or screws, Dr. Siegel added. If they've had total joint replacement, it's only necessary for the first two years while their bones are healing. "If they've been healthy for the first two years, they don't need it," he said.

Still, old habits die hard, and Dr. Siegel said many dentists and patients have been reluctant to give up the antibiotic habit. But they should, he argued, because antibiotics can cause severe -- even fatal -- side effects. "Give it to them because they need it, don't give it to them just in case," he said.

To emphasize his point, Dr. Siegel showed his audience a gruesome slide of a patient whose face had erupted in blisters from Stevens Johnson syndrome, a side effect of some antibiotics.

"It's like he gargled gasoline, then chased it with a match," he said. Then, to indicate what could happen to dentists who ended up in court, he mimed hanging in a noose.

If medical doctors think antibiotics are called for, Dr. Siegel said, let them write the prescription. "That way if it goes bad, it doesn't end up in your chair."


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