Dental recommendations for preventing complications in patients with chronic conditions health partners research foundation edent study
Dental Recommendations for Preventing Complications in Patients with Chronic Conditions Health Partners Research Foundation eDent Study Health Partners Research Foundation (HPRF) has recently received a grant from The Agency for Health Research and Quality to improve quality and safety of dental care for patients with chronic illness. This project hopes to improve patient outcomes by increasing HealthPartner dentists awareness and clinical decision-making for patients with chronic conditions by identifying problems and providing the dental recommendations. The study will evaluate the effectiveness of simple alert reminders to the dentist and/or patient that special dental care is needed because of the presence of a chronic condition to reduce complications during care. The patient's electronic medical record will be used to identify patients with chronic illnesses. The project will utilize the electronic dental record to provide an alert and information to dentists and a personal health record to provide an alert and information to patients about their condition. The four chronic conditions include congestive heart failure, chronic obstructive pulmonary disease, diabetes mellitus, conditions or medications causing xerostomia. I. Congestive heart failure (CHF) represents a symptom complex that can be caused by a number of specific disease processes. The three most common causes of CHF are hypertensive disease (the dominant cause, preceding cardiac failure in 75% of cases), cardiac valvular disease, coronary artherosclerotic heart disease and its complications. Other causes include thyrotoxicosis, rheumatic fever, congenital heart disease, severe anemia, chronic obstructive lung disease, and pulmonary hypertension.1-3 Congestive heart failure is one of the most common causes of death in the U.S.1,4-5 Of the over 2 million Americans with CHF,50% will die within 5 years. Patients with CHF need special attention during dental care including avoiding procedures that can strain the heart, use of adequate pain control, monitoring blood pressure, shortened visits, and a cautious eye to possible complications. They also need special attention regarding preventing oral infections and periodontal disease that may contribute to further cardiac problems. Table 1. Recommendations for Dental Patients with Congestive Heart Failure Potential Problems Oral Manifestations Assessment for Prevention of Problems Treatment Planning Related to Dental Care 1. Sudden death resulting 1. Infection 1. Detection of classification of patient for heart Dentist Recommendations: from cardiac arrest or failure for quick assessment and possible referral to physician and no routine dental In patients under good medical Table 1. Recommendations for Dental Patients with Congestive Heart Failure Potential Problems Oral Manifestations Assessment for Prevention of Problems Treatment Planning Related to Dental Care care until patient under good medical management with no management (class I or II but caution for complications, any indicated 3. Cerebrovascular class III and contraindicated for class IV until dental care can be performed; 1. For class I or II patients, 2. Patients need to be under good medical maximum 0.036 mg 5. Drug related management and the cause of heart failure epinephrine or 0.20 mg 5. Infective endocarditis if and any other complications must be levonordefrin to be used; heart failure is caused controlled prior routine dental care including: vasoconstrictors avoided in by rheumatic heart class III or IV patients. disease, congenital lesions heart disease, etc 2. Patients with shorter visits b. Valvular disease (rheumatic heart and in semi-supine or upright 6. Breathing difficulty disease) with premedication position during treatment to 7. Drug side effects decrease collection of fluid in c. Congenital heart disease d. Myocardial infarction 3. Monitor blood pressure and hypotension (diuretics, e. Renal failure Appointment terminated if patient becomes fatigued or f. Thyrotoxicosis b. Arrhythmias (digoxin, overdosage) g. Chronic obstructive lung disease 4. Regular Oral Hygiene visits (1 c. Nausea, vomiting (digoxin, vasodilators) 3. Assessment of oral manifestations of disease. Patient Recommendations; 4. Assess for adverse events from medication 1. Alert the dentist of the a. Digitalis—patient more prone to nausea 2. Maintain good oral hygiene b. Anticoagulants—dosage should be 3. Monitor their symptoms that reduced so that prothrombin time is 2.5 times may suggest complications Table 1. Recommendations for Dental Patients with Congestive Heart Failure Potential Problems Oral Manifestations Assessment for Prevention of Problems Treatment Planning Related to Dental Care normal value or less (INR of 3.5 or less) and inform dentist prior to (takes 3 or 4 days). Check prothrombin time and during appointment in medical history c. Antidysrhythmic agents (see cardiac d. Antihypertensive agents (see e. Avoidance of outpatient general *ACC/AHA Classification of Chronic Heart Failure. I. High risk for developing heart failure, Hypertension, diabetes mellitus, CAD,family history of cardiomyopathy. II. Asymptomatic heart failure, previous MI, LV dysfunction, valvular heart disease III. Symptomatic
heart failure with structural heart disease, dyspnea and fatigue, impaired exercise tolerance IV. Refractory end-stage heart failure
with marked symptoms at rest despite maximal medical therapy
Table 1. Recommendations for Dental Patients with Congestive Heart Failure Potential Problems Oral Manifestations Assessment for Prevention of Problems Treatment Planning Related to Dental Care care until patient under good medical management with no management (class I or II but caution for complications, any indicated 3. Cerebrovascular class III and contraindicated for class IV until dental care can be performed; 1. For class I or II patients, 2. Patients need to be under good medical maximum 0.036 mg 5. Drug related management and the cause of heart failure epinephrine or 0.20 mg 5. Infective endocarditis if and any other complications must be levonordefrin to be used; heart failure is caused controlled prior routine dental care including: vasoconstrictors avoided in by rheumatic heart class III or IV patients. disease, congenital lesions heart disease, etc 2. Patients with shorter visits b. Valvular disease (rheumatic heart and in semi-supine or upright 6. Breathing difficulty disease) with premedication position during treatment to 7. Drug side effects decrease collection of fluid in c. Congenital heart disease d. Myocardial infarction 3. Monitor blood pressure and hypotension (diuretics, e. Renal failure Appointment terminated if patient becomes fatigued or f. Thyrotoxicosis b. Arrhythmias (digoxin, overdosage) g. Chronic obstructive lung disease 4. Regular Oral Hygiene visits (1 c. Nausea, vomiting (digoxin, vasodilators) 3. Assessment of oral manifestations of disease. Patient Recommendations; 4. Assess for adverse events from medication 1. Alert the dentist of the a. Digitalis—patient more prone to nausea 2. Maintain good oral hygiene b. Anticoagulants—dosage should be 3. Monitor their symptoms that reduced so that prothrombin time is 2.5 times may suggest complications Table 1. Recommendations for Dental Patients with Congestive Heart Failure Potential Problems Oral Manifestations Assessment for Prevention of Problems Treatment Planning Related to Dental Care normal value or less (INR of 3.5 or less) and inform dentist prior to (takes 3 or 4 days). Check prothrombin time and during appointment in medical history c. Antidysrhythmic agents (see cardiac d. Antihypertensive agents (see e. Avoidance of outpatient general *ACC/AHA Classification of Chronic Heart Failure. I. High risk for developing heart failure, Hypertension, diabetes mellitus, CAD,
family history of cardiomyopathy. II. Asymptomatic heart failure, previous MI, LV dysfunction, valvular heart disease III. Symptomatic
heart failure with structural heart disease, dyspnea and fatigue, impaired exercise tolerance IV. Refractory end-stage heart failure
with marked symptoms at rest despite maximal medical therapy
II. Chronic Obstructive Pulmonary Disease (COPD) is a slowly progressive disease of the airways that is characterized by a gradual loss of lung function. COPD includes chronic bronchitis, chronic obstructive bronchitis, or emphysema, or combinations of these conditions and can lead to pneumonia, heart disease, and death. They represent the fourth leading cause of death in the U.S with symptoms ranging from chronic cough and sputum production to severe disabling shortness of breath. In some individuals, chronic cough and sputum production are the first signs that they are at risk for developing the airflow obstruction and shortness of breath characteristic of COPD. In others, shortness of breath may be the first indication of the disease. The diagnosis of COPD is confirmed by the presence of airway obstruction on testing with spirometry. Patients with COPD need special attention similar to CHF during dental care including avoiding procedures that can limit breathing, cardiovascular strain, use of adequate pain control, shortened visits, and a cautious eye to possible complications. They also need special attention regarding preventing oral infections and periodontal disease that may contribute to pneumonia and complications.1 Table 2. Chronic Obstructive Pulmonary Disease Potential Problems Oral Manifestations Assessment for Prevention of Treatment Planning Modifications Related to Dental Care Aggravation or worsening 1. Assessment of oral Dentist Recommendations: erythroplakia or manifestations of COPD. respiratory function In patients under good medical management 2. Detection of classification of with no complications, any indicated dental care patient for COPD for quick can be performed. Specific recommendations assessment and possible referral 1. Use shorter visits and upright chair position 3. No routine dental care until patient under good medical 2. Minimize use of bilateral mandibular or palatal 3. Do not use rubber dam in severe disease 4. Use of low-flow oxygen if helpful but do not use nitrous oxide–oxygen sedation in severe emphysema 5. Low-dose oral diazepam is acceptable but avoid barbiturates, narcotics, antihistamines, II. Chronic Obstructive Pulmonary Disease (COPD) is a slowly progressive disease of the airways that is characterized by a gradual loss of lung function. COPD includes chronic bronchitis, chronic obstructive bronchitis, or emphysema, or combinations of these conditions and can lead to pneumonia, heart disease, and death. They represent the fourth leading cause of death in the U.S with symptoms ranging from chronic cough and sputum production to severe disabling shortness of breath. In some individuals, chronic cough and sputum production are the first signs that they are at risk for developing the airflow obstruction and shortness of breath characteristic of COPD. In others, shortness of breath may be the first indication of the disease. The diagnosis of COPD is confirmed by the presence of airway obstruction on testing with spirometry. Patients with COPD need special attention similar to CHF during dental care including avoiding procedures that can limit breathing, cardiovascular strain, use of adequate pain control, shortened visits, and a cautious eye to possible complications. They also need special attention regarding preventing oral infections and periodontal disease that may contribute to pneumonia and complications.1 Table 2. Chronic Obstructive Pulmonary Disease Potential Problems Oral Manifestations Assessment for Prevention of Treatment Planning Modifications Related to Dental Care Aggravation or worsening 1. Assessment of oral Dentist Recommendations: erythroplakia or manifestations of COPD. respiratory function In patients under good medical management 2. Detection of classification of with no complications, any indicated dental care patient for COPD for quick can be performed. Specific recommendations assessment and possible referral 1. Use shorter visits and upright chair position 3. No routine dental care until patient under good medical 2. Minimize use of bilateral mandibular or palatal 3. Do not use rubber dam in severe disease 4. Use of low-flow oxygen if helpful but do not use nitrous oxide–oxygen sedation in severe emphysema 5. Low-dose oral diazepam is acceptable but avoid barbiturates, narcotics, antihistamines, Table 2. Chronic Obstructive Pulmonary Disease Potential Problems Oral Manifestations Assessment for Prevention of Treatment Planning Modifications Related to Dental Care and anticholinergics 6. May need additional steroid dose in patients taking systemic steroids for surgical procedures 7. Avoid macrolide antibiotics (erythromycin, clarithromycin) for patient taking theophylline 8. Outpatient general anesthesia 9. Regular Oral Hygiene visits because of greater risk of oral cancer from smoking (1 per 6 months) Patient Recommendations; 1. Alert the dentist of the medical history. 2. Maintain good oral hygiene. 3. Monitor their symptoms that may suggest complications and inform dentist prior to and during appointment III. Diabetes mellitus is a common disease affecting about 7% of the population and has many concomitant oral manifestations that impact dental care. It is a syndrome of abnormal carbohydrate, fat, and protein metabolism that results in acute and chronic complications due to the absolute or relative lack of insulin. There are three general categories of diabetes: type 1, which results from an absolute insulin deficiency; type 2, which is the result of insulin resistance and an insulin secretory defect; and gestational, a condition of abnormal glucose tolerance during pregnancy. Diabetes develops in people of all ages, although in greater frequency in African-Americans and Hispanics, and prevalence has increased dramatically over the past several decades.2 Approximately one-third of adults with diabetes in the United States are undiagnosed, and preventive care among patients with diabetes falls below national health objective standardsDiagnosis is often made on the basis of a host of systemic and oral signs and symptoms, including oral gingivitis and periodontitis, recurrent oral fungal infections and impaired wound healing. Dental professionals can play an important role in diagnosing and managing patients with diabetes as well as changing their care to consider the risks associated with diabetes. These patients often have xerostomia, increased caries and periodontal disease, candida albicans, oral lichen planus, and burning mouth syndrome.3-5,6-8. Increased efforts towards oral hygiene are paramount to management. Although diabetes patients are less likely to have regular dental exams, these exams occur more frequently when the dentist is made aware of the patient's diabetes status.9 Table 3 Diabetes Mellitus Potential Problems Oral Manifestations Assessment for Prevention of Problems Treatment Planning Modifications Related to Dental Care 1. In uncontrolled 1. Assessment of oral manifestations Dentist Recommendations: diabetic patients: of diabetes and oral hygiene Infection and poor In well-controlled diabetic patients, no alteration of treatment plan is indicated 2. Detection of patient with diabetes for unless complication of diabetes present 2. Insulin reaction in quick assessment and possible such as hypertension and congestive heart patients treated with referral to physician. This includes Detection using History, Clinical findings, Screening blood glucose 1. Patients receiving insulin—insulin 3. In diabetic patients, level <126 mg% and then Referral reaction prevented by the following: for diagnosis and treatment. complications relating a. Eating of normal meals before Monitoring and control of to cardiovascular hyperglycemia by blood glucose system, eyes, kidneys, 6. Infection moitoring as well as HbA1c b. Scheduling of appointments in and nervous system (angina, myocardial Table 3 Diabetes Mellitus Potential Problems Oral Manifestations Assessment for Prevention of Problems Treatment Planning Modifications Related to Dental Care 7. Oral ulcerations morning or midmorning cerebrovascular accident, renal failure, 3. Drug considerations include the c. Informing the dentist of any peripheral neuropathy symptoms of insulin reaction when they first occur a. Insulin–insulin reaction d. Having sugar available in some congestive heart burning, or pain in b. Hypoglycemic agents—on rare form in case of insulin reaction occasions aplastic anemia 2. Diabetic patients being treated with c. Avoidance of general anesthesia insulin who develop oral infection may in severe diabetics require increase in insulin dosage; consult with physician in addition to aggressive local and systemic management of infection (including antibiotic sensitivity testing) 3. Regular Oral Hygiene visits (1 per 6 Patient Recommendations; 1. Alert the dentist of the medical history. 2. Maintain good oral hygiene. 3. Monitor their symptoms that may suggest complications and inform dentist prior to and during appointment IV. Conditions or medications causing xerostomia. Xerostomia affects approximately 25 percent of the population and, is largely related either to autoimmune salivary gland disease or medication that a patient is currently taking.10 The patient also may experience burning of the tissues, irritation of the tongue, and painful ulcerations. Xerostomia increases susceptibility to caries and also to erosion and dentin hypersensitivity. Many commonly prescribed medications can cause a decrease in salivary function include antihistamines, antidepressants, anti-psychotics, anti-hypertensives, anti-inflammatories, diuretics, sedatives, and narcotics as well as be the result of Sjögren's syndrome, a disorder of the immune system in which white blood cells attack the moisture-producing glands. Various other conditions may cause xerostomia as well, including diabetes, lupus, kidney diseases, stress, anxiety, depression, nutritional deficiencies, and a dysfunction of the immune system, such as caused by HIV/AIDS. Furthermore, cancer radiation therapy on or near the salivary glands can temporarily or permanently damage the salivary glands. Prolonged reduction of saliva can lead to increased decay, as well as mouth ulceration, an increased susceptibility to infection, psychological distress, physical discomfort, and social embarrassment. With xerostomia, there is an increase in dental caries, particularly cervical, proximal, and in the roots; cracking and fissuring of the tongue; frothy saliva; ulceration of oral mucosa; no pooling of saliva in the floor of the mouth; and recurrent oral candida infections. When treating patients with xerostomia, dentists should measure a patient's salivary flow, consider salivary substitutes and over-the-counter salivary mouthwashes, gels, and sprays, and self care suggestions such as drinking more water and chewing gum, A medication review of the dosage or brand of a patient's medication may suggest alternatives that cause less side effects. Other treatment considerations include: the use of Pilocarpine hydrochloride or cevimeline to stimulate the saliva glands, which can increase the production of saliva by up to 40 percent; the use of Amifostine (Ethyol) to protect against xerostomia for patients with head and neck cancer who undergo radiation therapy, and evaluation for candidiasis because of the lack of saliva; and improving the fit of dentures. Table 4. Xerostomia Etiology: radiation therapy or chemotherapy(any) for head and neck cancers, stress-depression-anxiety, diabetes, cirrhosis, end stage renal disease, bone marrow transplant, more than 1400 medications (antihistamines, diuretics, antihypertensives, tricylcic antidepressants, etc.), connective tissue diseases (Sjogren's,et.al.), smoking, ethanol intake, mouth breathing Potential Problems Oral Manifestations Prevention and Treatment Treatment Planning Modifications Related to Dental orcheilosis/ angular 1. Salivary testing to Dentist Recommendations cheilitis (75-88) determine saliva 1. At visit; allow patient to drink, sip water and Table 4. Xerostomia Etiology: radiation therapy or chemotherapy(any) for head and neck cancers, stress-depression-anxiety, diabetes, cirrhosis, end stage renal disease, bone marrow transplant, more than 1400 medications (antihistamines, diuretics, antihypertensives, tricylcic antidepressants, etc.), connective tissue diseases (Sjogren's,et.al.), smoking, ethanol intake, mouth breathing Potential Problems Oral Manifestations Prevention and Treatment Treatment Planning Modifications Related to Dental production level mucositis (5-30) 2. Assessment of oral 2. Avoid alcohol, tobacco, coffee and tea manifestations of (caffeine) prior to visit glossodynia (5-45) xerostomia and oral 3. Regular Oral Hygiene visits (1 per 6 months) hygiene compliance dysgeusia (25-75) 4. Improve moisture and lubrication. (continuous 3. Detection of patient dysphagia (10-75) and prn) with products including; with xerostomia for ORAL BALANCE®* (esp. PM) candidiasis (75) quick assessment and possible referral to Rx:PILOCARPINE HCl 2% (Salagen® 5 mg, tid) dental caries (100) Rx: CEVEMILINE HCL (Evoxac ® 30 mg capsules) periodontitis (60-100) MOUTHKOTE® (artificial SALIVA) OPTIMOIST ® (artificial SALIVA) Na-carboxymethylcellulose 0.5% sln. ALIVART ® (artificial SALIVA) 4. Identify and treat soft tissue lesions and soreness with products; BENEDRYL+ MAALOX+NYSTATIN (+/- Carafate®) ELIXER ** if ACUTE, add +/- 2% Lidocaine or DECADRON 0.5mg/5cc Elixir Table 4. Xerostomia Etiology: radiation therapy or chemotherapy(any) for head and neck cancers, stress-depression-anxiety, diabetes, cirrhosis, end stage renal disease, bone marrow transplant, more than 1400 medications (antihistamines, diuretics, antihypertensives, tricylcic antidepressants, etc.), connective tissue diseases (Sjogren's,et.al.), smoking, ethanol intake, mouth breathing Potential Problems Oral Manifestations Prevention and Treatment Treatment Planning Modifications Related to Dental BIOTENE® MOUTHWASH * TRIAMCINOLONE 0.1% in Orabase® (ORABASE-HCA®) MYCELEX® 60 mg troches If LIPS/TONGUE lesions present, use MYCOLOG II ointment Patient Recommendations; 1. Alert the dentist of the medical history. 2. Maintain good oral hygiene and use sugarless candy /gum to stimulate saliva. 3. Avoid alcohol, tobacco, coffee and tea (caffeine) prior to visit 4. 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Source: http://healthit.ahrqdemo.org/sites/default/files/docs/resource/James_Fricton_IQHIT_Q1_HP_Recommendations_for_Preventing_Complications_for_Chronic_Illnesses.pdf
eva-schneider.at
2. Therapien 2.3. Medikamentöse Therapien Medikamente nehmen im Gesamtbehandlungsplan autistischer Störungen eine bedeutende Rolle ein, obwohl die ursächliche Behandlung von Autismus durch Medikamente nach derzeitigem Wissensstand nicht möglich ist. Daher versucht man den Einsatz von Medikamenten auf die Beeinflussung
Purim booklet.indd
Herausgeber und © Deutscher Rabbinerrat Die Geschichte von Purim umfasst eine Reihe von Ereignissen, die sich in einem Zeitraum von 13 Jahren ereigneten. Erst zum Ende hin bemerkten die Juden, dass all die Ereignisse der vergangenen 13 Jahre in Wirklichkeit Teil eines G-ttlichen Plans waren. Sie bemerkten dann, wie G-tt das Wunder in die natürlichen Ereignisse am Palast des König Achaschwerosch eingefädelt hatte.Purim ist die Anerkennung der im Alltag eingebetteten G-ttlichen Wunder.Die Entwicklung jüdischen religiösen Lebens in Deutschland in den vergangenen 30 Jahren ist ein Wunder unserer modernen Zeit. Wo eine schwindende jüdische Gemeinde die Richtung wechselt und zu einer wachsenden religiösen Gesellschaft wird, die danach strebt, jüdisches Leben in vollkommener Harmonie mit den Regeln der Halacha und der jüdischen Tradition zu etablieren.Mit dieser Entwicklung vor Augen, hat der Deutsche Rabbinerrat mit der Herausgabe einer Publikationsreihe „Praktisches Judentum" begonnen, welche als praktisches Handbuch für das Ausüben des Judentums dienen soll.Dieses Handbuch versucht die detaillierten Gesetze von Purim in verständlicher Form darzustellen, da diese einen Bezug zur heutigen Wirklichkeit in Deutschland haben. Details, die nur außerhalb Deutschland relevant sind, wie zum Beispiel das Feiern von Purim in befestigten Städten, wurden ausgelassen.Wir hoffen, dass dieses Handbuch mit ebenso großem Enthusiasmus aufgenommen wird, wie die vorherige Ausgabe.