Sam Simos, DDS, discusses dental clearance requests from physicians and what your patients need to know about them.
Q: What is a dental clearance?
A: A dental clearance is a written endorsement supplied by a dentist stating that a specified patient’s oral health is satisfactory and without issues. Physicians will often request a dental clearance as a precursory step for patients in need of certain complicated medical procedures such as joint replacement, heart surgery, radiotherapy, etc.
Q: Why is a dental clearance important?
A: The mouth is teeming with bacteria, good and bad, to the extent that simple acts like brushing or flossing can introduce oral bacteria into the bloodstream. Once this occurs, the vascular system essentially becomes a natural thoroughfare for bad bacteria to flock to vulnerable areas of the body, potentially settling in the joints or infecting surgery sites. Patients with periodontal disease are especially susceptible to these risks because they house much more bad bacteria in their mouths than do healthy patients. The hematogenous spread of bad bacteria may result in preoperative and/or postoperative complications that could possibly be life threatening. For this reason, many physicians will refrain from even scheduling the surgery until a dentist has cleared the patient.
Q: What is the current standard for a dental clearance?
A: Unfortunately, there is not yet a universal standard for dental clearance. Until one exists, dentists may adopt the following suggestions in an effort to better preserve their patients’ overall health as well as prevent malpractice lawsuits. First, perform a complete oral evaluation of hard and soft tissue at the time of the clearance request. It is important that the examination be as thorough and up-to-date as possible, regardless of the patient’s dental history. This exam should include a detailed periodontal exam noting bleeding, suppuration, recession, pockets, mobility, and any other pertinent findings. Next, arrange for saliva testing through a reputable laboratory, such as OralDNA (oraldna.com). This test is easily done: Have the patient vigorously swish a saline solution (provided by the testing laboratory) for 30 seconds, and then spit it into a test tube that is sent for evaluation by the laboratory. Depending on the lab, it can take about 48 hours to get a detailed report of the amount and type of bacteria found in the patient’s oral cavity. Finally, make a decision based on all of the findings, and then communicate the verdict to the patient and his or her acting physician.
Q: What is saliva testing, and why is it necessary for a dental clearance?
A: At any time, a dentist may administer an in-office saliva test on a patient and submit the sample for objective analysis. An accredited lab, such as OralDNA, will be able to detect the quality and quantity of bacteria present in the patient’s mouth, and the lab will publish the results as a definitive comparison against acceptable bacterial thresholds. Dentists can use these unbiased concrete numbers to ascertain the patient’s likelihood of developing bacteremia and then ultimately decide whether or not to grant dental clearance or to decline dental clearance until a reduction of the oral bacteria through periodontal procedures can be proven.
Q: What information should I make sure my patients are aware of?
A: Take joint replacement, for example: Getting hip or knee surgery usually does not make your patient initially consider their dental health. They have a lot going on medically and probably have a lot of questions. The important message for them to get from your office is the link between bacteria in the oral environment and the systemic link to that invasive bacteria.
They should know that you will be evaluating their oral condition to help protect them and their new prosthetic from unwanted bacteria that could come from the mouth. The thorough periodontal exam you provide your patient will give you the information necessary to combat any kind of infection that may preclude your patient from having the necessary surgery. You will be communicating with their physician to keep him or her up to speed on the patient’s condition.
It is important for your patient to know that the course of action you take will be dependent on the results of the exam. Also, it is important to have a discussion with your patient regarding the type and potential cost of treatment they can expect if they do not “pass” the periodontal exam. It is also important to give him or her an understanding of the time commitment that will be involved in solving this infectious problem prior to his or her scheduled surgery.
Q: What should a proper dental clearance encompass?
A: There are 2 possible avenues to the submission of a dental clearance. First, if the patient’s evaluation and salivary analysis are unobjectionable, the dentist should provide the physician with a written letter of explicit clearance along with copies of the salivary analysis and periodontal charts. Second, if the patient’s evaluation and/or salivary analysis are unacceptable, then the dentist should promptly notify the physician that the patient is not cleared. The dentist should provide all documentation that supports this decision, such as the substandard salivary analysis and any periodontal exam details. The dentist should then outline a treatment plan, complete with a proposed timeline, so that the physician can accurately plan around any necessary dental work. After dental treatment has concluded, saliva testing will need to be repeated in order to prove efficacy. Finally, furnish the physician with a letter of final clearance, along with all corresponding paperwork, for his or her records.
Dr. Simos maintains private practices in Bolingbrook and Ottawa, Ill. He received his DDS degree at Chicago’s Loyola University and is the founder and president of the Allstar Smiles Learning Center and client facility in Bolingbrook, where he teaches postgraduate courses to practicing dentists on cosmetic dentistry, occlusion, and comprehensive restorative dentistry. He is an internationally recognized lecturer and leader in cosmetic and restorative dentistry. He can be reached via email at firstname.lastname@example.org, via the website allstarsmiles.com, or via the Twitter handle @allstarlc1.