Thread by @Gautaamm

#Thread to discuss medical clearance for dental treatment:

A common misconceptions about dental treatment is that it is not affected by a patient's medical history or vice versa.

"Aho daat tar aahe. Tyacha majhya heart attack/knee replacement/diabetes shi kay ghena"

"Its just teeth. What is the connection with a heart attack/knee replacement/diabetes?"

And then there is the issue of getting medical clearance in writing from their specialist doctor.

I will try to cover most common conditions, associated risks and desired clearance!

1) Diabetes:

Where there is sugar, there are bacteria.

Where there is bacteria, there is infection.

Plain and simple.

So a patient with uncontrolled diabetes is a much increased risk for infection.

What is needed:
1) Current labs. Blood Sugar and HbA1C less than 120 days

2) The rule of thumb generallly followed is the blood sugars (Fasting and post meal) need to be under 200 and the A1C under 7 for surgical treatment (extractions/root canals/implants) and under 8 for regular work like fillings/crowns etc.

What the medical clearance should say:

Patient (name specified) is cleared for dental treatment.

The physician might recommend a particular antibiotic or leave that to the dentist, since it's a local infection.

In rare cases, where there is pre existing infection, exceptions

are made. I have treated patients with HbA1C as high as 9 and 10 because waiting for them to come down would have worsened the infection to the point of landing the patient in the hospital.

But ONLY after the physician has cleared the patient IN WRITING!

2) Blood thinners:

These are of two types:
1) Minor ones like Ecosprin or Plavix which block only platelets and hence affect superficial clotting only. The scap or "khapli" that you see on a superficial cut is caused by platelets.

2) Anti Coagulants: These block the ACTUAL

clotting factors and can wreck havoc if not handled well.
Common examples are Warfarin, Xarelto, Eliquis,etc. These can cause internal bleeding during a surgical procedure.

Whether to discontinue or not, is the question. This is a very generational issue.

Over the last decade

or so, the risk of a cardio vascular accident caused by discontinuing blood thinners, specially the first group, has been shown to outweigh the risk of prolonged bleeding from a dental procedure.

The older cardiologists are very reluctant to keep the patient on them during

dental treatment while the younger/more current ones are very comfortable doing so.

Which one a particular cardiologist belongs to is cleared only when he writes the clearance and specifies whether to stop or not.

In the US, I never discontinued the anti platelet group

because I was confident of being able to defend myself in the court of law.

In India, there is a court of law and then there is a court of the physician, not to mention the court of social media.

As such, I defer to the treating cardiologist for the same. A senior one in Pune

has written a letter asking us to proceed with dental treatment for ALL his patients on the anti platelet group without stopping it for any reason.

The proper anti coagulant group has many variables:
-Lab results
-Level of anti coagulants in blood
-Severity of dental condition.

-Risk of bleeding (Nearly zero in root canals/ high in difficult extractions)

In this situation, I definitely defer to the cardiologist.

Typically, the blood thinner is stopped 3/5 days before the procedure and re started a day after.

The clearance should read:

Patient is cleared for dental treatment.

Please proceed without discontinuing blood thinner (name)

OR

Please have patient discontinue BT (Name) X number of days before procedure and restart Y number of days after.

Typically the doctor might advise getting some tests done

post treatment also. Eg.INR etc.

The newer ones like Xarelto are very tricky because there is NO index to measure level of clotting.

3) Cardiac patients:

Till 2007, the list of patients who needed antibiotic prophylaxis was endless. Almost any deviation from normal needed

it.

Then they changed the indications very dramatically. Here are the official guidelines:

The standard regimen is Amox 2 gm 1 hour prior to the appointment or Clindamycin 600 mg in case of Penicillin allergy.

These are rarely an issue as these are clearly defined in black and white and the cardiologists are very clear in their clearance.

"Patient is cleared for dental treatment and should take (Antibiotic) X gms at Y time."

4) Joint replacements:

This is the trickiest!

Till 2015 the guidelines were Antibiotic prophylaxis for the following patients:
-TWO years following replacement
-For life for if the replacement is redone.
-For life for a patient who has had an infection in the replacement.

Then all hell broke loose!

Basically the American Association of Orthopedics stated "No antibiotic prophylaxis needed".

In the West it created an interesting situation where the orthopedic doctors would orally advise the patient to get pre medicated but ask them to get the prescription from the dentist, thereby protecting themselves from a lawsuit either way.

In India, I have come across a range

of regimens. And a range of responses also.

Some recommend the standard Amox 2 mg 1 or 2 hours before regimen. But a lot recommend a 7 day umbrella cover of Augmentin 625 MG starting 3 days before the procedure.

I believe this is the recommendation from either the state or

national level association.

What I do find interesting is the reluctance to give a written clearance to the patient. I am dealing with that right now where the patient has been sent a prescription and a whatsapp message to start it 3 days prior.

The issue is this: IF, and it

is a very BIG if, the patient develops infection in the joint at some point in the near future, will it be blamed on the dental treatment? And if it is, then what defense do I have in the court of law.

The answer is no defense WITHOUT express written clearance, which should

read:

Patient is cleared for dental treatment.

Patient does not need to take any antibiotic prophylaxis (VERY RARE)

OR

Patient should take (antibiotic) of this strength following this regimen. (How soon to start and how long basically).

The issue with the umbrella cover is

that dental treatment is usually prolonged and multi visit. How many weeks does the patient take the antibiotic in that case?

5) Cancer patients:

Typically those with history of cancer don't need any special clearance. A routine note is generally obtained just to be sure

that the labs are current, there is absolutely no chance of an unknow recurrence and to keep the oncologist on board.

The tricky part is recently diagnosed patients who need chemo or radiation, specially in the head neck region.

Chemotherapy reduces your immunity and hence

greatly increases risk of super infection. So carrying out dental treatment during chemo is impossible and hence all treatment needs to be done either before or after chemo.

The risk in waiting is that there can be a flare up mid treatment and now the patient has to endure

the infection till the chemo is done.

The issue with doing the treatment before is that it delays chemo which is life saving.

The issue with head neck radiation is that it causes what is termed as "Osteo radio necrosis" where it kills the blood supply to teeth and they

basically "rot away" for lack of a better word.

Healing is virtually non existent during and after radiation for a while and so the patient has to basically have all his teeth extracted before radiation.

The clearance is often the stumbling block. It is something as simple as

Patient is due for chemo/radiation. Please perform disease control/infection control as patient is unlikely to be able to received dental treatment for X number of weeks/months.

Desired labs should be above/below ABC.

Please provide antibiotic coverage as per this regimen

(Drug/dosage/regimen.

Please provide certificate of dental clearance at the earliest to enable initiating chemo/radiation.

I request ALL oncologists reading this to send any patient likely to need either to the dentist ASAP with this clearance in writing.

2 years ago, I had

to treat a young lady diagnosed with blood cancer as she was going overseas for her treatment. But it had been over 45 days that the bossman had asked for dental clearance which never came.

And then it needed to be done in 2 days. I had to basicaly cancel ALL appointments and

work only on her for 2 days to finish her treatment.

That is not always possible!

6) Osteoporosis patients:

This is where the bones become brittle. There is a wonderful group of drugs called Bisphosphonates which reverse the disease.

But somehow it is terrible for jaw bones

The bone just dies post any surgery like an extraction if the patient is on this group beyond a certain period of time.

Once again, clearance becomes very crucial.

These patients are typically either treated non surgically eg. do root canals on teeth that would typically be

taken out or in an institute.

NO clearance NO treatment for sure.

7) COVID: God knows what the implications of this deadly virus are going to be long term.

I have always asked "Do I send every patient who gives history of COVID for cardiac and respiratory clearance?

I shudder to think.

In conclusion, my request to all medical doctors reading this:

Speak with your dental colleagues and establish a protocol for your patients. Ideally issue them a clearance at time of discharge if you are a surgeon or send a note covering certain conditions

to the local dentists who approach you for the first time (Like the cardiologist and Ecospirin I mentioned above).

Don't give oral clearance and put the dentist in a jam, specially the younger ones.

Patients: The SOLE purpose of a medical clearance is YOUR well being! Please

don't get upset with the dentist for asking for one and not initiating treatment till the proper written clearance is received.

Hope this helps.

Doctors/non medicos please do share this as much as possible and feel free to reach out with any ques!

#Dentist #MedicalClearance