As a general dentist practicing in Los Angeles, I frequently treat patients dealing with polypharmacy (multiple medications) and various underlying medical conditions. I’m thankful that I not only have my hospital dentistry background to draw from, but also a built-in consultant—my husband, hospitalist Dr. Michael Flagg—to offer guidance.
Recognizing that most dental providers don’t have the luxury of this direct access to medical expertise, I sat down with him for an honest conversation. I wanted to uncover the key things he believes dental providers should know from the medical side. Here’s an unfiltered perspective straight from a hospital physician.
Dr. Lisa Chan: With more dentists moving away from prescribing opioids and using NSAIDs more frequently, are you seeing an increase in adverse side effects from NSAIDs?
Dr. Michael Flagg: Definitely, especially when there’s a lack of communication about a patient’s existing medications. One recent case was a dentist who prescribed Motrin after a dental procedure, not realizing the patient was already taking Celecoxib, another NSAID. This led to severe gastrointestinal bleeding, and the patient ended up needing a transfusion of three units of blood. It’s a perfect example of how easily things can go wrong, but also how preventable something can be.
Dental providers should ask about all current medications, not just the obvious ones like blood thinners, bisphosphonates, or hypertension medications. They also need to recognize both the brand and generic names of NSAIDs to avoid dangerous side effects when prescribing more than one NSAID.
Beyond that, there are certain red flags that should stop dentists from prescribing NSAIDs altogether. If a patient has a history of gastrointestinal bleeding, is on blood thinners, follows an aspirin regimen, or has moderate to severe kidney disease, NSAIDs can pose serious risks. In those cases, other pain management options should be explored.
If there’s ever any uncertainty, I suggest checking a trusted resource such as the Digital Drug Handbook, which is dentistry-specific and can flag potential interactions and suggest when a physician consult is needed. The fact that it’s all online makes it quick and easy to access, and it can help clear up a lot of the guesswork. If there’s still any doubt, don’t hesitate to call the physician.
LC: What are some precautions dental providers should take for patients with heart and/or respiratory problems?
MF: There are some key precautions to keep in mind. For instance, with patients who have COPD, you might need to provide supplemental oxygen during a procedure, especially if sedation is involved. Consult with their physician beforehand to ensure their oxygen needs are addressed and to avoid any risks, such as hypoxia. If a patient checks COPD or emphysema on their medical history, ask if they use oxygen, even if it’s on a PRN basis. These patients often have a barrel chest appearance, and you’ll want to monitor their oxygen levels throughout the procedure using a pulse oximeter. If their oxygen level drops to 92 or below, you’ll want to provide supplemental oxygen.
However, with severe COPD patients, too much oxygen can actually suppress respiration, so you’ll need to check with their pulmonologist before treatment. Patients with conditions such as CHF or COPD may also struggle with lying flat for extended periods. In these cases, work with their physician to figure out how long they can safely stay in a reclined position.
Taking these extra steps, such as adjusting the treatment plan and referencing epinephrine guidelines, can make a huge difference in ensuring patient comfort and safety during procedures.
When it comes to heart issues, if someone has recently had a heart attack (myocardial infarction), the general rule is to wait about six months before moving forward with elective dental treatments. That said, it’s always best to consult their physician first, as the waiting period could be shorter depending on the patient’s recovery and specific condition.
LC: One last question for now: Do you have any tips to ensure a patient is properly handled when we need to send them to the emergency room?
MF: Communication between dentists and other health-care providers is key, especially when you’re sending a patient to the ER. Physicians really appreciate it when dentists send a note or email with the patient that explains why they’re being referred. For instance, some dentists have stopped prescribing narcotics and instead refer patients to urgent care or the ER for pain management. In those cases, it’s helpful to give the patient a note that includes your contact information and clearly explains the need for stronger pain medication. This helps prevent any misunderstandings and avoids the patient being mistaken for someone who’s inappropriately seeking opioids.
The same approach applies when referring a patient to the ER to rule out serious conditions such as Ludwig’s angina, which requires immediate attention. By either contacting the ER ahead of time or sending a detailed note with the patient, you can help avoid unnecessary delays and ensure the person is seen quickly rather than having to wait hours in the ER. Clear communication goes a long way in making sure your patient gets the right care as soon as possible.
My conversation with Dr. Flagg highlights the essential role that strong collaboration between dentists and physicians plays in managing patients with complex medical conditions. Effective communication bridges the gap between medical and dental care and ensures patients receive safe and comprehensive treatment.
At the heart of our efforts is our mission to end smile denial, which focuses on breaking down the barriers that prevent medically complex patients from accessing necessary dental care. Too often, misunderstandings about medications or medical conditions lead to delays or even denial of critical dental treatments. By working closely with physicians, we can ensure that patients receive the care they need without unnecessary complications.
Disclaimer: The opinions and views expressed by Dr. Michael Flagg are his own and do not necessarily represent the opinions of any organization he’s a part of. The information provided in this article is for general informational purposes and should not be construed as medical or dental advice. Always consult with appropriate health-care professionals for specific medical concerns or treatment options.
