The review and updating of patient medical information is becoming more complex each day. Patients are taking greater amounts of medications, and in many instances, are forgetting the names or conditions these medications are supposed to correct. If it is hard for dental personnel to evaluate patients and their illnesses, imagine what it must be like for those who work in emergency departments where split-second decisions need to be made on a routine basis and can be the difference between life and death.
This article reviews common types of medications that dental patients may be taking and the ramifications such medications have for dental practices.
A QUICK GUIDE TO PATIENT MEDICATIONS
With all the new medications coming out every day, it can be hard to keep up. I work in the emergency department of a busy county hospital, and when patients come in, they are usually carrying a "bag o' meds"‚ Generally, the patients are not very sure what the medications do but can tell you ‚this is my heart pill, this one is my water pill, or I take that one for my nerves when my sons are home. Since we have a very short amount of time to evaluate patients, we have had to stay on top of patients, their possible conditions, and the most likely medications they may be taking. It is easier for us if we think of meds the following way:
Illustration by Nathan Zak
Medications can be grouped by their mechanism or action on the body, such as antihypertensive, antianginal, antidysrhythmics, and so on. As the name implies, antihypertensives are prescribed to stop high blood pressure. Angina is described as a pain in the heart. Therefore, the antianginals are prescribed to stop heart pain. The most common one you may see is nitroglycerine. The small, white pill is generally kept with the patient at all times, so the pills are right there if they have an episode. Nitro, as it is commonly referred to, opens the blood vessels in the heart. Not getting enough oxygen to the heart causes the pain. Some patients may have a chronic problem with the blood vessels constricting or tightening, thus not allowing the oxygenated blood through. Nitro opens up those vessels so the tissue can get what it needs; the problem is that it opens up all the vessels and can cause a drop in blood pressure. In turn, this can lead to a patient passing out if his or her blood pressure is too low to begin with.
Antidysrhythmics work to stop a bad heart rhythm. The heart should pump at a regular, strong rhythm in order to get oxygen to the tissues effectively and carry cellular waste, carbon dioxide, etc back. The heart has to work well in order to keep the rhythm going, and the impulses have to be sent in the right order through the heart in order to accomplish this. If not, you have a dysrhythmia, or bad rhythm. The medications used to work on this slow or block the impulses so they can catch up with the impulses further down, and the heart can pump effectively.
Many patients take a water pill. What the heck is that? Well, its used along with other medications to help the heart be a better pump. When the heart is not working well, or failing, blood can back up in the system. Blood pressure goes up, the vessels cannot stretch any further, blood backs up in the heart, blood pressure goes up, the vessels are maxed out, blood backs up you can see the pattern. The water pill helps draw off any free water or fluid and pushes it toward the kidneys for some filtering and a grand exit. What does this mean for you? Well, the patients on these pills tend to need frequent bathroom breaks, so it could set you off schedule for an extensive procedure.
Here are a few key points about the heart medications: We talked about nitroglycerine (Nitro). As I said, the patients generally have the bottle with them. The pills are kept in a dark bottle for protection from light, so look for a very small, about 1.5-inch tall, dark brown glass bottle. Remember that these pills will cause the blood pressure to drop when taken. That being said, the patients usually have high blood pressure to begin with, but if for some reason it is low, these patients can pass out.
I would suggest that a patient sits down after taking one of these pills; sometimes the chest pain will go away if he or she relaxes. If, however, the patient takes Nitro and does not have relief, I would activate your emergency system (9-1-1). Any chest pain can signal a heart attack and should be evaluated. Moreover, do you really want to manage a patient actively having chest pain in your office?
Antihypertensives lower blood pressure. This is a good thing for people who have high blood pressure. If these same patients have a drop in their pressure either from a medication reaction or as a response to stress in their bodies, the pressure can drop too low, and they can pass out. Patients with a long history of high blood pressure train their bodies to function under this pressure, and a drop to even a blood pressure considered normal for us, ie 130/80, can affect them much like we would be affected by a pressure of 60/40. When the blood pressure is too low and the oxygenated blood is not circulating well, it affects our brain, making us confused or even unconscious. Therefore, the importance of this is that when a normally hypertensive patient becomes confused or passes out and their blood pressure is 130/80, remember that this may not be high enough to perfuse or feed the brain.
Antidysrythmics, which work to correct the impulses in the heart, are important to recognize as well. There are several classifications, but more commonly you will see blockers (beta blockers or calcium channel blockers). Remember that the blockers block or slow the impulse or contraction in the heart to keep it working as well as possible. The names of some of the beta-blocking medications usually end in -lol. Metoprolol, propranolol, labetalol, and esmolol are examples. There are certainly more, but these are commonly used. The names really do not matter as long as you recognize the lol at the end. Keep in mind that they slow or block the impulses. By slowing the impulses, they slow the contractions in the heart. Slowing contractions in the heart will slow the rate that the heart will beat. These patients may not have an increase in their heart rate during a procedure, so if you are monitoring them, they may not show an expected response to pain or stress.
Some examples of calcium channel blockers are nifedipine, diltiazem, verapamil, and felodipine. They also work to slow the impulses but through a different mechanism. The take-home point here is that they will slow contractions or heart rate similar to beta blockers. All of these medications will also lower the blood pressure, so be aware. Some patients only know that they take these pills for their blood pressure or only take them for their heart and do not understand that they act on both.
On this same note, a patient who has had a heart transplant will not show an increase in his or her heart rate as a response to stress. This is due to the severing of a nerve that helps control the rate in order to transplant the heart. I was told of a 70-year-old woman who had been climbing mountains after she received a heart transplant. While a 70-year-old woman climbing mountains is impressive in and of itself, the most impressive part was that no matter how much oxygen her muscles and tissues needed to climb those mountains, her heart rate was not able to vary from about 70 beats per minute. Think about how fast your heart goes when you are running up the stairs when you are late for work. (I'm sure I'm not the only person who runs late.) Think about how your legs burn by the second or third flight of stairs and how your heart is pounding in your ears. Now picture doing that, but your heart will not beat any faster than 70 times a minute, and the oxygen needs to get to your leg muscles. It makes my thighs cramp to think about it. This woman has trained her body to work so effectively in delivering oxygen to her muscles that she can climb mountains! Amazing!
Patients who have pacemakers may not show an increase in heart rate, either. These patients have wires in their chests that send the impulses through the heart. The pacemaker is usually set at a specific rate and may not go above that depending upon its type (too in-depth to discuss here). Therefore, it is important to obtain an accurate history, because your patients may not respond to procedures as you would expect. It could be due to medications or other issues.
We have also found that many of our patients take an aspirin every day for their hearts. Aspirin is sold over the counter, so how bad can it be for you? Well, aspirin works to help the body not form clots. It is commonly given now for people experiencing chest pain. These pains, remember, are because the tissue in the heart is not getting the blood and oxygen it needs. Some-times this is from a clot in the vessel, which aspirin can help dissolve. The problem is that patients who take aspirin regularly can develop bleeding problems. You may perform a simple procedure but have more difficulty than expected controlling the bleeding.
Several other types of medications, such as warfarin (Coumadin) or Plavix, affect bleeding or clotting. New options seem to be coming out every day, but you might want to ask your patient if he or she takes a pill that causes bleeding problems. If you mention Coumadin and the patient tells you that he or she does not take it anymore, find out if the doctor prescribed something else. People that recognize the name Coumadin have either been on it, are on it, or are taking something like it.
PATIENTS WITH DIABETES
As far as diseases go, healthcare professionals are seeing the greatest increase in the number of patients diagnosed with diabetes. Patients with diabetes have problems with the amount of sugar, or glucose, in their bodies. In normal circumstances, the pancreas releases insulin to control the amount of glucose in the system. When we eat items that contain sugar, insulin is released, and the body lowers the amount of sugar floating around. When you eat a bag of candy corn, your body has to release a large amount of insulin to lower the sugar level rapidly, giving you that headache. (I know I am not the only person who has done that!) For patients with diabetes, the pancreas does not release that insulin, and the sugar level can stay elevated, causing all kinds of problems. Disorientation and coma are certainly possible.
Once the diabetes has been diagnosed, the patient either can take insulin by injection or instead may be able to maintain control with pills. Some patients with diabetes are able to control their blood sugars by eating appropriately. The days of candy corn are over, though. Diabetics can run into serious health problems along the way, such as blindness or poor circulation. Diabetics also tend to have a difficult time healing from wounds. Many uncontrolled diabetics have had toes, feet, or legs amputated from poor circulation or wounds that did not heal and became infected. I have seen some patients come in with a horrible diabetic foot that started simply as an ingrown toenail that they tried to fix on their own, and it did not heal. Some surgeons, when evaluating a diabetic patient prior to surgery, automatically add 20 years to the actual age of the patient to estimate a successful outcome.
The main point you need to keep in mind is that diabetics may not heal as well from procedures or may need to be monitored closely if they are kept from eating in preparation for a procedure. If you have diabetic patients, you need to find out if they took their insulin that day and when or if they ate anything. If patients take their insulin or oral medication but do not eat, they may experience a drop in their blood glucose and become confused or even combative. Having a new patient in the waiting area while you tackle a combative patient does not exactly improve your referral rate. The good news is that most patients with diabetes who have had the disease for a while will be able to tell you that their blood sugar is getting low. Some will even carry a glucose tablet to eat when the feeling hits them.
I'm sure that you were told that orange juice is a good option in this situation, but ingesting it will not keep the sugar up for an extended period of time. These patients need to eat. If you have a patient who becomes confused or unconscious, do not attempt to pour sugar, juice, or anything else into the mouth you run the risk of blocking the airway. Activate your emergency system and let emergency personnel check the blood glucose, start an IV, and give medication, if appropriate.
Diabetic patients can also develop problems if the sugar is too high. One serious illness is known as diabetic ketoacidosis (DKA). You may not be interested in checking the patients urine specimen, which is exactly what is done as soon as he or she gets to the hospital. A test strip is dipped into the sample. We look for the amount of sugar in the urine to see if they are spilling or excreting ketones. This problem is very serious, and generally the patients blood glucose is extremely high. One symptom that you may notice without ever having to deal with the patients urine is his or her breath. Some people describe it as smelling fruity, while others describe it as smelling like nail polish remover. These patients need immediate medical attention, as the body does not do well in this state.
I hope I have made the bag o meds a little easier to understand. Every day I come across another medication that I am not aware of, and when I do, I try to use that as an opportunity to look it up and learn about it. Most offices have a Physicians Desk Reference. That is certainly an option, but any of the nursing drug reference books tend to be a little easier to follow. I am not usually too far from one and suggest that your office consider having one at the front desk. Other great references are your local poison control center or pharmacists, who work with the new medications daily and would be able to give you the important information you need. Don't be afraid to ask your patients questions about their medications or why they were prescribed. Changes in their medical history are your responsibility to monitor and can serve to remind patients of the increasing link be-tween the head and the rest of the body.