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."