Medical Consultations for Dental Patients in 2014

Due to the rising number of dental patients with increasingly more complex medical histories, it has become more important for dentists to evaluate many of these patients’ medical complexities with a medical consultation letter.^1-4 Furthermore, the format of the medical consultation letter by dentists has evolved to become consistent with the format utilized within hospital settings. In the past, many dentists relied upon a dental-medical consultation letter format in which medical conditions were merely checked and the physician was asked for the his or her opinion and clearance regarding the concerns, contraindications, and procedural therapeutic protocols regarding further dental treatment.^3,4

Evaluations of dental school populations have reported greater numbers of medically complex dental patients requiring medical consultations when compared to prior years.^1,2 The number of aged dental patients has increased as the post-World War II baby boom generation has aged throughout time. As a result, a higher number of aged patients, with more complex medical histories, are being seen by general dentists. Furthermore, advances in medical care have led to patients with serious medical conditions such as congestive heart failure and human immunodeficiency virus living longer, and thus presenting as medically complex dental patients for general practitioners^.5-11 Dhanuthai et al¹² reported a prevalence of approximately 12% of patients seeking dental treatment with medically complex conditions in Thailand in 2008. Fernández-Feijoo et al¹³ reported a dental patient prevalence of systemic disease as 35% for public clinic patients and 28% for private system dental patients. They¹³ noted that there was a high prevalence of medical disorders, and of patients receiving polypharmacy among individuals requesting dental care. They concluded that dentists must have adequate training in medical disease and be integrated into the primary care health system in order to prevent and adequately resolve medical complications secondary to dental therapy.

FACTS VERSUS OPINIONS
The critical issue is whether the dentist asks the appropriate questions of the physician in order to gain relevant knowledge of the patient’s individual health issues. Is the patient’s medical condition stable or unstable? What exactly are the therapeutics the patient is presently using? What is the A1c value? What are the results of the blood studies? What is the INR value? It is important for the dentist to gain relevant treatment information rather than to have the physician impart his or her opinions, because many of the physicians’ opinions may be out of date or simply incorrect. Lauber et al¹⁴ surveyed physicians and dentists to determine the recommendations of physicians and dentists with regard to antibiotic prophylaxis. Dentists were correct in selecting first-line drugs 95%, and physicians were correct 71% of the time. With regard to antibiotic prophylaxis and second-line drugs, dentists were correct 84%, and physicians were correct 67% of the time. The study demonstrates that the dentists were more knowledgeable compared to the physicians with regard to this issue.¹⁴

In 1984, Tullman and Redding¹⁵ noted that the general dentist needed to integrate the dental treatment of medically compromised patients within the concept of a general dentistry practice. Therefore, there was a need for general dentists to increase their knowledge of medicine and utilize a consultation form in concert with hospital consultation formats. Throughout time, dental educators, clinicians, and authors have accepted the medical model of communication with regard to the medical consultation letter for dental patients.¹³ The format is as follows:

1. The dentist to provide his or her contact information;

2. A biographical description of the patient and patient particulars such as contact information, the vital signs, and age/birth date, relevant medical history;

3. The patient’s chief complaint (although the chief complaint may be irrelevant in many health consultation scenarios);

4. A description of the dental procedures anticipated and/or the degree of stress associated with such procedures;

5. The specific question to be asked; and

6. Room for the physician to respond to the query.^13,16-22

The basis of this protocol is to allow the dentist to effectively communicate with the physician and to gather (and forward) the information necessary for the dentist to make treatment decisions, and further, to transfer the patient for medical care or change of care when necessary.

THE STANDARD OF CARE
The dentist is responsible for the patient’s health while the patient is under the dentist’s care, and specifically while in the dental operatory. The physician is responsible for the care of his or her patients’ general health; however, as physicians may not necessarily have an understanding of dental procedures and risks, physicians are not specifically responsible for the health of the patient while the patient is undergoing dental therapy. The standard of care is to demonstrate a reasonable effort to communicate with the patient’s physician in order to protect and advance the dental patient’s health. The 3 reasons to write a medical consultation letter for a dental patient are as follows:

1. The patient requires a medical evaluation and/or therapy,

2. The dentist requires specific medical information which may impact upon the patient’s dental treatment, and

3. The dentist requests a change in the patient’s medical therapy in order to benefit the patient’s oral condition.^4,16-22

Furthermore, the dentist has a duty to refer the patient for a medical consultation whenever the medical complexities of the patient exceed the expertise of the dentist.²³

The concept of the standard of care is often construed as an amorphous notion that is not easily understood. However, the standard of care concept is relatively straightforward. The quick definition of the standard of care is “what the reasonably prudent dentist would be expected to do in the same or similar circumstances.” In 2004, Graskemper²⁴ has expanded this concept and added several points. “Minimum requirements of skill and knowledge must be met regarding the diagnosis and treatment of the patient. The dentist must proceed as a reasonably prudent and competent practitioner, providing, at the very least, ordinary and reasonable care.” Graskemper²⁴ further expounded on the definition of the standard of care as follows: “The standard of care actually is found in the definition of negligence, which is said to have 4 elements, all of which must be met to allow negligence to be found in a malpractice lawsuit. Those 4 elements are as follows: that a duty of care was owed by the dentist to the patient, that the dentist violated the applicable standard of care, that the plaintiff suffered a compensable injury, that such injury was caused in fact and proximately caused by the substandard conduct.”

Graskemper²⁴ offered even further information regarding the standard of care and noted that other sources have other opinions regarding the definition and offered up such alternatives as what the average dentist does, what dentists are taught in dental school, what is presently taught in dental schools, what the dentist can accomplish with an honest effort under the circumstances, what the majority of the dentists are doing in that part of the country, and what specialists in a particular area of expertise related to the task are generally doing under similar circumstances. The situation is even more confusing as most states use a national standard; although a significant minority of the states tend to use a local standard. The definition of standard of care may be different depending upon which state one resides in, and therefore the concept and definition may be difficult to pin down definitively. However, the standard of care generally refers to treatment which is reasonable, and which a similar healthcare provider would have provided within a similar situation.

One of the issues with regard to the gathering of necessary medical information for the treatment of medically complex dental patients is the previous check-off format that was utilized in a number of dental schools and private practices. This check-off format is still utilized by some dentists today, as many dentists tend to stay with a familiar format, particularly those established within their dental education. The many problems with such a format are as follows:

1. This format merely has checks on various medical conditions, and therefore the physician is forced to interpret what he or she perceives to be the relevant information to be imparted to the dentist, which is at best a guess.

2. Even if the form lists the patient’s dental condition and/or the dental procedures scheduled to be performed, it is unlikely that the physician will have an appreciation for the specific level of stress for that individual dental patient.

3. Many physicians are not knowledgeable concerning current medical/dental guidelines and protocols and will often suggest incorrect drug regimens and incorrect medical advice.

The evidence clearly demonstrates that physicians are often ignorant of current protocols and guidelines.^4,14,25,26 Perhaps the biggest problem with such a check-off medical consultation letter format is that it establishes a lack of effort for the dentist within the communication process. It primarily asks the physician to do all the information sharing without much contribution. This format does not require the dentist to formulate exactly what information is important. As such, the patient is placed in a situation in which his or her dentist may not necessarily be informed of critical information necessary to protect his or her health.

Gary and Glick³ discussed the concept of medical clearance, and the misunderstanding of this concept. They reported that many dentists believe that they can limit their liability by requesting medical clearance for their dental patients. They noted that medical clearance does not shift the liability from the dentist to the physician granting the clearance, regarding treatment rendered by the dentist.

IN SUMMARY
The dentist must know and understand the modifications and limitations of dental therapies secondary to the patient’s medical condition. As such, dentists must attain a certain minimum competency of medical understanding that cannot be deferred to physicians.

References

1. Rhodus NL, Bakdash MB, Little JW, et al. Implications of the changing medical profile of a dental school patient population. J Am Dent Assoc. 1989;119:414-416.
2. Jainkittivong A, Yeh CK, Guest GF, et al. Evaluation of medical consultations in a predoctoral dental clinic. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;80:409-413.
3. Gary CJ, Glick M. Medical clearance: an issue of professional autonomy, not a crutch. J Am Dent Assoc. 2012;143:1180-1181.
4. Brown RS, Farquharson AA, Pallasch TM. Medical consultations for medically complex dental patients. J Calif Dent Assoc. 2007;35:343-349.
5. Ryan LH, Smith J, Antonucci TC, et al. Cohort differences in the availability of informal caregivers: are the Boomers at risk? Gerontologist. 2012;52:177-188.
6. Lee SJ, Nelson LP, Lin J, et al. Today’s dental student is training for tomorrow’s elderly baby boomer. Spec Care Dentist. 2001;21:95-97.
7. Deedwania PC, Carbajal E. Evidence-based therapy for heart failure. Med Clin North Am. 2012;96:915-931.
8. McLean AT, Wheeler EK, Cameron S, et al. HIV and dentistry in Australia: clinical and legal issues impacting on dental care. Aust Dent J. 2012;57:256-270.
9. Dunlay SM, Roger VL. Living and dying with heart failure: it’s time to talk. Eur Heart J. 2012;33:689-691.
10. Oguntibeju OO. Quality of life of people living with HIV and AIDS and antiretroviral therapy. HIV AIDS (Auckl). 2012;4:117-124.
11. Vance DE, McGuinness T, Musgrove K, et al. Successful aging and the epidemiology of HIV. Clin Interv Aging. 2011;6:181-192.
12. Dhanuthai K, Sappayatosok K, Bijaphala P, et al. Prevalence of medically compromised conditions in dental patients. Med Oral Patol Oral Cir Bucal. 2009;14:E287-E291.
13. Fernández-Feijoo J, Garea-Gorís R, Fernández-Varela M, et al. Prevalence of systemic diseases among patients requesting dental consultation in the public and private systems. Med Oral Patol Oral Cir Bucal. 2012;17:e89-e93.
14. Lauber C, Lalh SS, Grace M, et al. Antibiotic prophylaxis practices in dentistry: a survey of dentists and physicians. J Can Dent Assoc. 2007;73:245.
15. Tullman MJ, Redding SW. Systemic Disease in Dental Treatment. New York, NY: Appleton-Century-Crofts; 1984:1-5.
16. Peterson LJ. Contemporary Oral and Maxillofacial Surgery. 4th ed. St. Louis, MO: Mosby; 2003:704-705.
17. Greenberg MS, Glick M, Ship JA. Burket’s Oral Medicine. 11th ed. Hamilton, Ontario, Canada: BC Decker; 2008.
18. Rhodus NL, Miller CS, eds. Clinician’s Guide: Medically Complex Dental Patients. 3rd ed. Hamilton, Ontario, Canada: BC Decker; 2008:11.
19. Stefanac SJ, Nesbit SP, eds. Treatment Planning in Dentistry. 2nd ed. St. Louis, MO: Mosby; 2006:22-23.
20. Little JW, Falace DA, Miller CS, et al. Dental Management of the Medically Compromised Patient. 6th ed. St. Louis, MO: Mosby; 2002:3-11.
21. Cohen S, Hargreaves KM. Pathways of the Pulp. 9th ed. St. Louis, MO: Mosby; 2006:81-82.
22. Hargreaves KM, Cohen S. Cohen’s Pathways of the Pulp. 10th ed. St. Louis, MO: Mosby; 2011:72.
23. Monahan R. Legal aspects of the doctor-patient relationship. In: Bricker SL, Langlais RP, Miller CS. Oral Diagnosis, Oral Medicine, and Treatment Planning. 2nd ed. Philadelphia, PA: Lea & Febiger; 1994;13-20.
24. Graskemper JP. The standard of care in dentistry: Where did it come from? How has it evolved? J Am Dent Assoc. 2004;135:1149-1155.
25. Nelson CL, Van Blaricum CS. Physician and dentist compliance with American Heart Association guidelines for prevention of bacterial endocarditis. J Am Dent Assoc. 1989;118:169-173.
26. Zadik Y, Galor S, Weinberg I, et al. General physicians’ knowledge of dental operation prophylaxis for infective endocarditis [in Hebrew]. Harefuah. 2007;146:751-754,815.

Dr. Brown is a professor in the department of clinical dentistry at Howard University College of dentistry and a clinical associate professor, department of otolaryngology at Georgetown University Medical Center, Washington, DC. He can be reached at rbrown@howard.edu.

Disclosure: Dr. Brown reports no disclosures.

Mr. Buscemi graduated from Georgetown University with a BS degree in 1976. He received his law degree from Antioch School of Law in Washington, DC in 1980. His law practice is located in Falls Church, Va, and he is licensed to practice law in Virginia, the District of Columbia, and Maryland. He can be reached at buscemilaw@aol.com.

Disclosure: Mr. Buscemi reports no disclosures.

Dr. David graduated with a BS degree from Fordham University in 1973 and from Emory University School of Dentistry with a DDS in 1977. He is presently a medical examiner consultant for the state of Georgia. He is a Diplomate of the American Board of Forensic Odontology and an Academic Fellow of the American Academy of Oral Medicine. Dr. David is a past president of the American Board of Forensic Odontology. He can be reached at tjd214@bellsouth.net.

Disclosure: Dr. David reports no disclosures.