Avoid Medical Emergencies: Dealing with the Medically Compromised Patient - Part 1

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. Knowing when to and when not to treat a patient is of extreme importance. Today, we'll be reviewing several common medical problems and their potential significance to the practicing dentist. Our guest is Dr. Stanley Malamed. a dentist anesthesiologist and emeritus professor of dentistry at the Herman Ostrow School of Dentistry of USC, formerly the University of Southern California School of Dentistry. Dr. Malamed, it's a pleasure to have you on Dental Talk. Phil, thank you very much. Pleasure to be back. Yeah, and before we begin, I want to thank you for two extraordinary webinars that you presented on Viva Learning. To our audience now, their titles are Preventing Medical Emergencies, Know Your Patient, and the other one is Know Your Patient, Managing the Medically compromised patient. Both of these webinars are available on demand, free of charge. Simply visit vivalearning.com, type in the search field Malamed, M-A-L-A-M-E-D, and you will see the two webinars. I recommend them highly to everyone on your dental team, not just the dentists that are out there. Really important stuff. Also, I would like to thank our sponsor, Health First, for their support in these important CE presentations that Dr. Malamed's been presenting on our program on medical emergencies. For those of you who don't know Health First, they support almost half of all dental offices with emergency medical kits and other devices required for emergency preparedness. It's a great company to get to know. You can check out all their products and services that Health First offers by visiting their website at healthfirst.com. So, Dr. Malamed, why would obesity be a consideration when evaluating a prospective dental patient? Well, let me start out by just defining obesity. And according to the CDC, obesity is a weight that is higher than what is considered healthy for a given height. It's described as either overweight or obesity. And the sad fact is that in 2017, 2018, 42% of people in the United States fell into the obese category. And from 1999 to 2018, that... In 1999, it was 30%. And in 2018, it's 42%. The highest incidence of obesity is in the Midwest and the South. So we have a problem. And what is the problem? Being obese is one thing, but why is that a consideration? Well, along with obesity, or what obesity actually does, it leads to a higher incidence of heart disease, high blood pressure, coronary artery disease, type 2 diabetes, and obstructive sleep apnea, all of which are considerations for the dentist and the dental staff. This increase that you're talking about over, was it 10 years? It was, yeah, 1999 to 2018, so just about 20 years. It's just a remarkable increase in obesity. And I know that's a topic for another podcast, but it's just something that's literally, it seems to me, is a major problem in our country, in the healthcare area. And in the podcast that I did earlier, the United States is the most obese country in the world. And it also has, I think you mentioned in your webinar, we come out close to 50, number 50 in lifespan. Yeah, lifespan, I think it was 46th, 47th cent. I mean, in the United States right now, the average... Life expectancy for both male and female is 78. For a female, it's 81. And for a male, it's 76. We actually lost a year during the pandemic in 2021, but it's 76 for a male and 81 for a female. And that ranks 46th in the world. So for a practitioner, a dental practitioner, a patient comes in, weighs 375 pounds. Okay, I'm just giving you an example. Sure. It's the first time the dentist has seen this patient. They're perspiring. What should be going through the minds of the dental team at this point? Well, you know, let's take a look at something. First thing, the size of that patient and your dental chair. I have actually seen patients who simply could not fit into a dental chair. So there's one problem right there. How would you treat this person? Secondly, thinking of all the medical history this patient is going to present you with, there are going to be problems. I mean, it's an absolute. guarantee breathing problems are given in a patient like that. There is definitely going to be underlying heart disease. They may not even be aware of it, but when you weigh that much, your heart, your part pumps blood to every cell in your body. And if you weigh 350 pounds, that heart is working very hard. Think about this. What if a medical emergency occurred? What if that patient simply fainted? Or what if that patient had a cardiac arrest? How could you possibly do CPR effectively on a patient who is that large? So let me ask you this question. So there's practical considerations based on the chair size, obviously. And we're not talking about, there's not a lot, there are a lot of people that are obese based on the percentages, but we're not talking about a lot of people that are that big. But anyway, considering that situation. Would it be acceptable for that dental practice to refer that patient out and say, you know, and how do you handle that? That is the problem. I mean, how do you deny a patient care? You know, let me just give you sort of an offhanded example. I've been teaching intravenous sedation since 1973. And I teach it at USC, but now more often at the University of Oregon, up in Portland, Oregon. putting in body mass index, BMI, as a criteria, vital signs, blood pressure, heart rate, respiratory rate. We put in BMI, and our criteria was that we will not treat a patient with IV sedation with a BMI over 40. Now, 40 is defined as morbid obesity. We had patients who had been coming in to see us and being treated for 10, 15 years. And all of a sudden, we now include BMI in our evaluation, and we're telling the patient we can't see you. It's embarrassing. What do you tell them? And my only answer to that was, you're not tall enough for your weight. You have to be eight feet tall in order for us to treat you. It's hard. It is hard. But you think, what is the risk of me treating this patient? You know, things can go wrong. Like I said, you said 350, and that's not an exaggeration, but let's say 250, okay? But if the patient is 250 pounds and is 6'2", that's different than 250 pounds and 5'2". It's all relative. Yeah, and there's a BMI calculator that the office could use on a website. I know the government has one, and they come up with that number. So there are obviously hospital settings where these patients... would be safer to be treated right absolutely and i mean there are in hospital settings and such oversized dental chairs i mean we have in the operating room we have oversized operating tables for patients who are that big right exactly yeah in other words so you have to say and this was a whole premise of my first webinar uh is that you have to know when not to treat a patient you know it's easy to put a patient in a chair and say open your mouth and go to work but We don't want... I teach medical emergencies, and it's the last thing in the world that you want to do is... have to call 911 and have an ambulance come to the office. And basically, you've already saved the patient, hopefully. But you don't want this to happen. So the goal here is to prevent the problems. To know when, not to treat. Right. That's working in your comfort zone and knowing what that zone is. So let's talk about acute asthma. That's another health issue. Bronchospasm is the term, more of a medical term, but it's commonly known as acute asthma. What are some common precipitants of this in the dental office setting? Well, there are two basic types of asthma, and it's basically a 50-50 split between... See, bronchospasm is actually what is happening. The airway, the bronchus, the bronchi are narrowing down, making it extremely difficult for the patient to breathe in and to breathe out. The two types of asthma are allergic asthma and non-allergic asthma. precipitates allergic asthma. It's much more common in children and young adults. Things like, and from the dental perspective, aspirin, non-steroidal anti-inflammatory drugs, and these are our drugs of choice for post -surgical dental pain, the NSAIDs. Sulfites. Now, sulfites are found in every dental anesthetic cartridge, local anesthetic cartridge that contains a vasoconstrictor. So whether it's epinephrine or levonordefrine, It has, it's called an antioxidant. And there are people who are allergic to sulfites. Red wine has it, right? Red wine. Red wine, dried fruits, dried apricots and apples, lots and lots of sulfites on there. So you'd have to be aware of that. In other words, if they have allergic asthma, allergic to NSAIDs, well, and you're doing surgery, you're going to have to somehow modify your post. post-operative pain care. The use of a local anesthetic, which contains a vasoconstrictor on a patient who has a sulfide allergy, it's iffy. And I'm saying it's iffy because even though sulfides produce allergic reactions, most often it's foods, and you said red wines, salad bars, where they spray the food with antioxidants to keep the food looking fresh. There has never been a recorded case of an allergic bronchospasm. produced by a sulfite in a dental cartridge. So yes, sulfite allergy should be a contraindication to using a vasoconstrictor and any anesthetic. But think about it. You're doing surgery. You're not going to get profound pain control for certain for extractions or endodontic procedures using 3% mepivacaine, no epinephrine, 4% cedowness, no epinephrine. So it's risk versus benefit. With the history of all the dental procedures done in a year, it's very rare, right, for a patient to have a real severe asthmatic reaction. Is that the right term, asthmatic reaction? Yeah, or bronchospasm. Bronchospasm, okay. But, you know, so that's the one half of it. Now, the other half of bronchospasm, non-allergic asthma, it's bronchospasm produced by anything other than allergy. You know, and you have what is called exercise-induced asthma. Okay, but the other thing is, how about Dr. Klein? This is your patient, Dr. Klein. Don't take this personally, but I hate going to the dentist. Okay, so fear-induced, stress-induced, fear-induced. Anybody can faint, anybody. An asthmatic can faint, but when an asthmatic is stressed, they're much more likely to have an acute asthmatic attack, which is called bronchospasm. As an anesthesiologist, dentist that you are, would you recommend using nitrous oxide? as a common procedure to calm these patients down if this kind of patient shows up? Phil, I've been saying it for years, that nitrous oxide oxygen sedation should be the starter technique for every dentist. You learned it in dental school. It's been almost 30 years, a little more than 30 years, that COTA, the Council on Dental Accreditation, they accredit dental school. A dental student has to be trained to proficiency before they graduate in the use of nitrous. It is the most used sedation technique out there. Every pediatric dentist uses it. It's over 95% in pediatrics, but it should be used a lot more by the general dentist, the vast majority of us out there. And for an asthmatic, anything that scares them can precipitate the asthmatic attack. Nitrous sedation to me is great. And there's no contraindication, by the way. Anything that has a stinging odor like ammonia would be contraindicated in these patients because it could stimulate bronchospasm. Nitrous oxide, even though there's really no smell to nitrous oxide, but those of you, because I can't smell it, those people who can smell it, they call it sweet air. So it is not going to irritate the bronchi. It's a great sedation technique. You could use oral sedation as well, but nitrous, like I said earlier, I believe is the starter technique for all dentists out there. Right. Tremendous way of managing stress before it actually starts to build up and cause a problem. So the two parts of asthma you identified, what type of asthma should we be concerned with? Is there a rating for someone? Yeah, we always have this ASA classification. So in the ASA, which again, we discussed in detail in the first webinar. So go back and look at that if you haven't heard it. But an ASA-2 is a patient with a mild systemic disease. ASA-3 is more severe and ASA-4 is a red flag. So most asthmatics would fall into the ASA-2 category where they have an occasional asthmatic attack. It's either brought on by physical exertion or I'm talking about the non-allergic type right now. And it's easily handled. They come in with their inhaler. They call it their rescue drug, their bronchodilator. And that's not going to be much of a problem. And in fact, asthma, when I talk about medical emergencies, is one of the two emergencies that I tell the dentist, very easy for you to diagnose and treat for this simple reason. The patient knows they have asthma. So I use the example, the patient's lying in your dental chair in a relatively reclined position. All of a sudden, pushes your hand away and sits up. And you say to the patient, I'll be the patient, Stanley, what's the matter? And the patient will say to you, I'm having an asthmatic attack. They diagnosed it for you because they know what it is. And even if you've never seen an asthmatic attack before, the patient has their own medication with them. And guess what? They're going to medicate themselves. That's a great point, Dr. Malamud, is that in these patients... cases where you know these patients have this risk it's a good idea to make sure they brought it with them by accident they left it at home and now they're in this situation you just described and now they're we're kind of in a bit of a jam here um well but you're not in the jam because one of the eight drugs in our bare bones basic emergency kit is the bronchodilator so in other words we had it there just in case for that reason All right. And yeah, and I'm going to ask you about that later. That's part of the health first system that you recommend. And that's good that you brought that up. Let's talk about cardiovascular a little bit. Sure. Why is monitoring of a patient's blood pressure considered to be standard of care now in dentistry? Well, let's start out with the fact that the number one killer of people worldwide is high blood pressure. I mean, far and away, more than anything else. In the United States, uh if we go by just by aging and our population of course is aging and i'm on the extreme right hand side 75 and above but the incidence of high blood pressure goes up and if you're 65 uh males 70 77 percent of males in this country are classified as hypertensive 75 of females when you get above 75 it goes to 79 of males and 85 of females in many cases it's uh it's not diagnosed in fact when i started it goes back now to 1973 i got involved with the uh in high blood pressure and it was called the silent killer because You cannot feel your blood pressure unless it's too low. You get dizzy when you stand up. And very often, the very, very first sign of having high blood pressure, sadly, is either a stroke or a myocardial infarction. So, yes, not only should a patient have their blood pressure checked by their physician, but people don't go. Men do not go to their physician for annual physicals. They go every four years for the annual physical. Women are much better. They go every year. So we're going to take their blood pressure. And in fact, what I always have recommended is that part of your evaluation of the patient when he or she comes into your dental office at each, at the first visit should be blood pressure. Blood pressure and heart rate are essential. You know, you can talk about respiratory rate, but really, I'm not really kidding around. I'm saying breathing, yes or no. You know, that's really it. But blood pressure, heart rate, and now we're including, of course, the BMI. For each visit, are you recommending the blood pressure be monitored before the procedure is started? And if so, what is that cutoff point where you feel uncomfortable for the typical dentist to go on with treatment? Well, let me give you an example. I go, I haven't practiced dentistry. I've done anesthesia now since 1973. But when I go to the dentist, I go every three months for my root planning and curatage. The hygienist takes my blood pressure. It's done as a routine. And what does it take? A minute or two? So, I mean, ideally, okay, ideally, yeah, I said earlier, just a moment ago, that at that first dental visit, as part of your physical evaluation, blood pressure should be taken. And as you just said, ideally, blood pressure should be taken to start at each dental treatment. If a patient has high blood pressure, and I'll go into some numbers in just a moment, then... really important that that BP be taken at the start of every dental visit. Absolutely. So the point is now, if we're taking blood pressure, what do we do with the numbers? I mean, that really is the important thing. So let me give you some numbers that we talked about in one of our previous webinars. So for an ASA1, and that's a normal, healthy patient, adult patient in the United States, it's a systolic, the upper number under 130. and the diastolic under 80. Now, that's a patient for blood pressure is considered to be normal. An ASA2 for blood pressure is a systolic of 130 to 139 or a diastolic between 80 and 89. Treatable? Absolutely. ASA3, 140 systolic to 199 systolic. or diastolic between 90 and 114. Treatable? Yes. But here, you want to go out of your way to prevent any further elevations in their blood pressure. And that means if there's any anxiety, using sedation, good pain control, okay? trying to modify your treatment to prevent any further elevations in blood pressure. And then we go to the category ASA4, which is our red flag for treatment. And that would be a systolic blood pressure of 200 millimeters of mercury or greater, or 115 millimeters of mercury diastolic or above. And that should be a no treatment patient. So let me just, by the way, I also want to mention that those numbers might vary. So if we have listeners, let's say, Here's how I got those numbers. When I started teaching at USC in the previous century, we started taking blood pressure. And here's the thing. If you take blood pressure, you have to know what to do with it. So I didn't know at what number we shouldn't treat. So what I did is I called up at Los Angeles County Hospital. This is our referral hospital from USC Dental School. And they have a high blood pressure clinic. And I asked them, at what blood pressure would you tell us don't treat the patient? Don't treat them, but send them to us now. Not tomorrow, now. And they said 200 over 115. Now remember, LA is a big city. It's a very busy hospital. So let's say you live in Wichita, Kansas, which I'm assuming will not be as big and busy as Los Angeles. If you're a dental practitioner there and you want to start looking at when not to treat your patient, call up your local hospital or a high blood pressure clinic and ask them that same question. I'm a dentist here in, what I say, Wichita, and I want to know at what blood pressure would you want me to not treat that patient now, but refer them to you. And that number probably will be a little bit lower than our 200 over 115 in Los Angeles. Right. No, that was great that you did that as a young dental student. Just for clarification for our audience, ASA, that pertains to American Society of Anesthesiology, I believe, correct? Yes, it does. And this ASA1234 system has been used in hospitals since the late 1940s to assign a risk category to a patient prior to surgery. Dr. Frank McCarthy and I wrote an article for the American Dental Association back in 1974. And we started, that's what actually established using this in dentistry. And I think most, most graduates from 1980 or 1990 on would be familiar with this, including our dental hygiene listeners too. So you talked about high blood pressure doctor, but let's also talk about patients that are coming in with a diastolic of 55 or a systolic of, you know, 90 over 55 or 88. They're functioning. They're not fainting. They feel good. What happens in those situations as far as a dentist is concerned? Well, very, very good. The ideal blood pressure for a human being, for an adult, is the lowest pressure that you can maintain without losing consciousness. If you can function, if your blood pressure is 90 over 60 or 88 over 50 something, and you don't get dizzy when you stand up, you can function normally, that's perfect. Here's the reason. Phil, you want to get life insurance. So the life insurance company sends in to your house a nurse or a paramedic or a retired physician to do a physical exam on you. And one of the things they do is they do blood pressure. Now, the life insurance company wants you to live forever. They want you to pay premiums forever. They don't want you to die prematurely. So I said earlier that the life expectancy for a male in this country is 76 years. but you know what if your blood pressure when they take that exam is elevated slightly you know what your chance of dying is going to be increased you're going to die younger and you pay an extra premium and if your blood pressure is above a certain number you're insurable because they're going to lose the bank they're going to lose they're going to wind up paying your family a lot of money because you died prematurely so that's the importance of it you know but back to back to the lower the lower your blood pressure the longer your life expectancy for every 10 millimeter increase in systolic blood pressure there is and i don't have the number of my right here but there is a decrease in life expectancy this is from actuarial tables millions and millions of people who have had blood pressure exams, they simply higher blood pressure, you die sooner. You covered that really well in your webinar. It was interesting when you said that the systolic or the systole, which is pumping out of the left ventricle, has to actually pump at a greater pressure than the diastolic blood pressure, right? Because the blood ain't going to go anywhere if it doesn't. So for every millimeter of mercury above a base number, the systolic or the systole pump has to be higher than that. And then as you keep moving higher, the left ventricle keeps working harder. So that all makes sense. And that was covered very well. Let me just go back to that. So what we're dealing with is this. So you're right. The diastolic blood pressure is 80. The ventricle, left ventricle, has to get their pressure above 81 millimeters mercury to pump blood out. Okay. What if your diastolic is 90? The muscle of the left ventricle has to work. harder it has to get you know get to 91 millimeters of mercury what happens to muscle when you use it it hypertrophies the heart gets larger and that leads to heart failure because eventually i mean the heart is in a cavity it can't keep on growing forever so that's where the diastolic blood pressure does become very very important but for the practicing dentists as it relates to their routine treatment of these patients if a patient has a history And we can go into that also a little bit about a history of a stroke or history of a heart attack in the last six months and stuff. That's also, these are key things that dentists should know about. But as far as routine treatment, you would say that if a patient has a systolic of under 180, you could still treat them in the office. so i said here in los angeles given the numbers we got now let's go back to my wichita doctor who made that phone call and they said to the doctor 180. yeah they're treatable but what you've got to do now is you what their blood pressure let's say is 178 within treatment limits you want to do whatever you can to prevent any further elevation and what elevates it anxiety elevates blood pressure and ow you missed your block So good pain control and consideration for sedation are the ways to minimize any further increase in that patient's already high blood pressure. Right. And again, when you take somebody's blood pressure in the dental office, it's probably going to be higher than if they were sitting on their living room sofa because they already have the fear of going to the dentist. And that's kind of an acute. rise in systolic, right? Right. That's called white coat hypertension. Yes. And the way you get around that is by repeating the blood pressure three or four times and the patient sort of gets used to what you're doing, but it's called white coat hypertension. Very, very common. This concludes part one of this podcast. To continue to part two, please tap on Avoid Medical Emergencies in Your Office, Dealing with a Medically Compromised Patient, part two. Thanks so much for joining us on Dental Talk.