Vol. 119 No.

4 April 2015

Medical conditions and medication use in a U.S. dental school

clinic population
James Guggenheimer, DDS,a Elizabeth A. Bilodeau, DMD, MD, MSEd,b and Steven J. Barket, DMDc

Objectives. The aim of the study was to characterize coexisting medical conditions and medication use in patients treated at a
US dental school in 2010 and to assess their implications on providing dental care.
Study Design. Data on the types and prevalence of self-reported medical conditions and the use of medications were
extracted from the electronic health records of 1797 adult patients and compared against their socioeconomic status (SES).
Results. Within this sample, 8.7% were classified as American Society of Anesthesiologists (ASA) physical status (PS) 1. The
remainder were designated PS 2 to PS 4 for smoking, having one or more medical conditions that ranged from myasthenia
gravis (<1%) to hypertension (24%), or both. Medications for hypertension were the most frequently reported (23%), followed
by more than 40 other classes of drugs.
Conclusions. Dental practitioners must be prepared to treat larger numbers of older patients, whose life expectancies continue
to increase as advances in pharmacotherapeutics and biomedical technologies improve the control of their chronic medical
conditions. (Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:379-384)

A pivotal event in the evolution of dental practice to its
current status as an integral component of modern
health care may have been the 1926 William Gies
Report on Dental Education in the United States and
Canada.1 In this report, Gies criticized the separation
between medicine and dentistry that was attributed to
“.the biological ignorance of many dentists, owing
to deficient education in the medical sciences and in
the requirements of oral medicine..” Dr. Gies then
stated that dentistry “.should be made the health
service equivalent of an oral specialty of medical
practice.” Subsequently, major overhauls in dental
education and clinical training were undertaken,
culminating in our current standards of education and
care, including an increased emphasis on oral
medicine.2
These transitions were accompanied by monumental
developments in medicine, biomedical technology, and
pharmacotherapeutics, which have resulted in the con-
trol of many chronic diseases, particularly in older
adults. This, in turn, has decreased the mortality of the
aging population, prolonged its life expectancy, and
increased the numbers of its “oldest old,” patients over
the age of 85 years.3,4 As a consequence, dental prac-
titioners must now be prepared to treat increasing
numbers of patients with chronic medical conditions
that are managed to variable degrees with an extensive
a
Department of Diagnostic Sciences, University of Pittsburgh, School
of Dental Medicine, Pittsburgh, PA.
b
Assistant Professor, Department of Diagnostic Sciences, University
of Pittsburgh, School of Dental Medicine, Pittsburgh, PA.
c
Bradford Dental Center, Bradford Regional Medical Center, Brad-
ford, PA.
Received for publication Jun 12, 2014; returned for revision Nov 26,
2014; accepted for publication Dec 16, 2014.
Ó 2015 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
http://dx.doi.org/10.1016/j.oooo.2014.12.016
array of new pharmacotherapies or with a variety of
structural or organ replacements. This will be accom-
panied by new concerns with the potential for adverse
interactions between patients’ medical management and
their required dental treatment. Some of these issues
may be complex, and at the outset, new therapeutic
modalities may not be supported by evidenced-based
documentation of their efficacy or potential detri-
mental side effects.
To minimize the likelihood of adverse interactions
between medical management and dental treatment,
providers must routinely undertake a comprehensive
health assessment of their patients, which includes the
patient’s health history, medical conditions, and medi-
cations being taken. Using such information, this study
examined a profile of the types and prevalence of self-
reported medical conditions and medications being
used by patients seeking care in a dental school clinic.
METHODS
Between January and June, 2010, 2693 patients, pri-
marily from Pittsburgh and the surrounding Allegheny
County, presented to the outpatient clinic of the Uni-
versity of Pittsburgh School of Dental Medicine for the
first time for treatment. Patients entered their health
information on a history questionnaire, which included
Statement of Clinical Relevance
Clinical health records of dental patients have
revealed that 76% had at least one medical condi-
tion, were taking a medication, or both. This reflects
the current trend of an aging population with chronic
medical conditions that practitioners must be pre-
pared to manage.

379
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380 Guggenheimer, Bilodeau and Barket April 2015

a checklist of diseases. It also asked patients to list the Table I. Sociodemographic characteristics of the study
names of all medications (prescription or over-the- patients
counter [OTC]) currently being taken. After a student
reviewed this information with the patient, it was Dental Clinic Allegheny County*
transferred to our electronic health records (EHRs), N % N %
where it was verified by a faculty supervisor. Approval
Men 814 45.3 585,650 47.9
to access the patients’ EHRs was obtained from the Women 983 54.7 637,698 52.1
University’s Institutional Review Board (which granted Age:
“exempt” status) and the University’s Information 18-64 1613 89.8 776,626 79.1
Technology Division. The EHRs were de-identified in
65 184 10.2 205,059 20.9

80 44 2.4 NA
accordance with the privacy and security guidelines of
Range:
the Health Insurance Portability and Accountability Act 18-91
(HIPAA), and the health-related data were retrieved Median age 40
from the first 1797 patients 18 years and older and Mean age: 42.3
entered into a Microsoft Excel program. Insurance/pay status
Medicaid 683 38.0
Patients’ physical status (PS) was based on the
Self-pay 699 38.9
American Society of Anesthesiologists (ASA) classifi- Dental insurance 415 23.1
cation system (of ambulatory patients) as ASA PS 1, 2,
NA, not available.
3, or 4.5 ASA PS 1 included being a nonsmoker, taking *Based on 2010 US census data.7
no medication, and having no allergies. (Smoking was
determined by a self-reported “yes” to currently
smoking cigarettes every day or some days and having Data analysis
smoked 100 or more cigarettes up to the present).6 The Patients were classified and ranked into low or high
remainder of the patients were classified as PS 2 for socioeconomic status (SES) categories by using our
only smoking, and PS 2 to PS 4 for having any three clinic fee-for-service options as surrogate
medical condition, an allergy to a medication or latex, markers. Patients with no insurance whose fees for
or taking a medication. dental care were either “out-of-pocket” (self-pay) (SP)
More frequently used medications were grouped and or were reimbursed by Medicaid (MA) were determined
delineated by class or therapeutic activity. Antihyper- to be in the low SES group.7 The high SES category
tensive agents included diuretics, adrenergic a- or b- patients were those who had an employment-based
antagonists, angiotensin-converting enzyme inhibitors, (commercial) dental insurance (COM).7 Bivariate
calcium channel blockers, or vasodilator agents. Mood analysis using chi-square tests were applied to deter-
modifiers included antidepressant selective serotonin mine associations between medical conditions and be-
reuptake inhibitors, anxiolytics, antipsychotics, tricyclic ing in the low or high SES group. Significant
antidepressants, norepinephrine reuptake inhibitors, and relationships between disease and SES were set at a
phenothiazines. Gastrointestinal agents comprised ant- threshold of P < .01. Odds ratios and 95% confidence
acids, antiulcer therapies, proton pump inhibitors, or a intervals were calculated.
histamine H2-antagonist. Inhalers consisted of bron-
chodilators, corticosteroids, or combinations. Hypo- RESULTS
glycemic agents included insulins and oral antidiabetic The sociodemographic characteristics of the patients are
agents. Cardiac drugs included antiarrhythmics, shown in Table I. Patients’ gender distribution and
digoxin, or nitroglycerin. Anticonvulsants comprised median age were similar to that of Allegheny
drugs used to treat seizures or chronic pain and included County based on the 2010 census.8 The study
gabapentin, phenytoin, carbamazepine, oxcarbazepine, population included 18 patients (1%), the “oldest old”
topiramate, and valproic acid. Central nervous system (>85 years of age).
agents consisted of drugs being used to manage Par- Among the 1797 patients, 156 (8.7%) were classified
kinson disease and Alzheimer disease. These included as ASA PS 1. There were 266 patients (14.8%) who
reversible cholinesterase inhibitors, dopamine agonists, smoked cigarettes but reported having no medical
anticholinergics, and dopamine precursors. Other clas- conditions, no allergies, and taking no medications. The
ses of drugs included anticoagulants (clopidogrel and remaining 1375 (76.5%) were PS 2, 3, or 4 based on
warfarin) and analgesics (acetaminophen and nonste- having one or more medical conditions, a medication or
roidal anti-inflammatory agents). Specific drugs, such latex allergy (Table II), taking at least one of the
as hypolipemic agents, bisphosphonates, muscle re- medications listed in Table III, with or without
laxants, sleep aids, antiallergic agents, and opioids, smoking, or all of these criteria. The classes or names
were not individually identified. of medications being used are listed in Table III. In
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Volume 119, Number 4 Guggenheimer, Bilodeau and Barket 381

Table II. Medical conditions in 1797 dental clinic Table III. Medication use in 1797 dental clinic patients
patients N %
Condition N % Antihypertensive agents 409 22.7
Hypertension 435 24.2 Mood modifiers 361 20.1
Mental health 361 20.1 Gastrointestinal agents 208 11.6
Sinus disease 294 16.4 Hypolypemic agents 193 10.7
Penicillin allergy 206 11.5 Inhalers 165 9.2
Asthma 199 11.1 Aspirin 163 9.1
Diabetes 165 9.2 Hypoglycemic agents 131 7.3
Illicit drug use 135 7.5 Hormone replacements 112 6.2
Anemia 125 6.9 Antiallergic agents 88 4.9
History of cancer 100 5.6 Opioids (including methadone) 75 4.2
Cardiac arrhythmia 91 5.1 Anticonvulsants 62 3.5
Joint replacement 60 3.3 Bisphosphonates (oral) 50 2.8
Arthritis 59 3.3 Muscle relaxants 36 2.0
Previous MI 59 3.3 Sleep aids 35 1.9
Latex allergy 59 3.3 Antiretrovirals 29 1.6
Osteoporosis 55 3.3 Clopidogrel (Plavix) 27 1.5
Hepatitis C 55 3.1 Acetaminophen and NSAIDs 25 1.4
Seizure disorder 46 2.5 Central nervous system agents 22 1.2
CVA 39 2.2 Cardiac drugs 21 1.2
Bypass surgery 36 2.0 Warfarin 20 1.1
COPD 34 1.9 Antibiotics 20 1.1
HIV/AIDS 26 1.5 Corticosteroid 18 1.0
Sleep apnea 24 1.3 NSAIDS, nonsteroidal anti-inflammatory drugs.
MI, myocardial infarction; CVA, cerebrovascular accident; COPD, Miscellaneous (<1%): Heparin (enoxaparin), intravenous
chronic obstructive pulmonary disease; HIV/AIDS, human deficiency bisphosphonates (zolendronic acid, pamidronate), antigout medica-
virus/acquired immunodeficiency syndrome. tions (colchicine, allopurinol), anticholinergics and antimuscarinics
Miscellaneous (<1%): Cirrhosis, migraine headaches, chronic pain, (for irritable bowel), antimetabolites and immunosuppressants (anti-
fibromyalgia, heart valve replacement, lupus erythematosus, Alz- rheumatic, anti-rejection, or Crohn disease), antimigraine (acetamin-
heimer disease, Parkinson disease, Huntington disease, Crohn disease, ophen combinations, sympathomimetics; serotonin receptor agonists),
and Von Willebrand disease, end-stage renal disease (dialysis), post- urinary antispasmodics, cannabinoid, nicotine replacement (with-
organ transplantation, sarcoidosis, Sjögren syndrome and Marfan drawal), opioid antagonist, retinoid, nutriceutical, amphetamine
syndrome, endocarditis, irritable bowel syndrome, neurofibromatosis, appetite suppressant, immunomodulator (natalizumab), monoclonal
myasthenia gravis, hemophilia A, trigeminal neuralgia, pulmonary antibody (infliximab), antineoplastics (tamoxifen, trastuzumab, anas-
fibrosis and emboli, multiple sclerosis, muscular dystrophy, amyo- trozole), dopamine receptor antagonist (antiemetic metoclopramide).
trophic lateral sclerosis, thalassemia, glaucoma, gout, pregnancy,
multiple myeloma, and diabetic neuropathy.
reported having a behavioral disorder (52.1%)
(P < .001), a history of use of recreational drugs (76%)
addition to the more commonly used therapeutic agents
(P < .001), or a history of hepatitis C (78.2%)
that were taken by the majority of the patients, this
(P < .001). The associations between the more preva-
EHR review identified 95 entries of miscellaneous
lent and medically significant conditions and patients’
medications that were being used by less than 1% of
SES are summarized in Table IV. Having a mental
our patients. These agents had been prescribed for health condition and use of recreational drugs were
disorders that are uncommon or for which
the only characteristics that were significantly
standardized, effective treatments are not yet
associated with patients in the low SES group.
available. Some examples of the less commonly
prescribed medications are shown at the bottom of
Table III. Discussion
Current smokers were more likely to be in the low The types of medical conditions reported by these pa-
SES group (SP or MA patients) (P < .001) (Table IV). tients were similar to those of similar age in the U.S.
Among the smokers, there were 443 (34.4%) who had a population.9 Medication use paralleled the distribution
smoking-related disease or a sequela. These smoking of the diseases or conditions among these patients
rates ranged from 19% who had undergone bypass (Tables II and III). This was particularly evident for
surgery, 23% who had had a cerebrovascular accident, hypertension and the use of antihypertensives, a
34% with hypertension, 37% who had a previous mental health condition and the use of mood
myocardial infarction (MI), 40% with asthma, to 50% modifiers, diabetes and the use of hypoglycemic
with chronic obstructive pulmonary disease. The agents, osteoporosis and the use of bisphosphonates,
highest smoking rates were found among patients who and treatment of human immunodeficiency virus/
MEDICAL MANAGEMENT AND PHARMACOLOGY UPDATE OOOO
382 Guggenheimer, Bilodeau and Barket April 2015

Table IV. Distributions of selected medical conditions by socioeconomic status among 1797 dental clinic patients
Total MA or SP COM
Condition N % N % N % Odds ratio 95% CI P value
Smoking 743 41.3 614 82.6 129 17.4 1.777 1.14-2.23 P < .001
Hypertension 435 24.2 333 76.5 102 23.5 0.974 0.75-1.25 P ¼ .84 NS
Mental health 361 20.1 307 85.0 54 15.0 1.909 0.38-0.71 P < .001
Asthma 199 11.1 161 80.9 38 19.1 1.308 0.90-1.89 P ¼ .15 NS
Diabetes 165 9.2 127 77.0 38 23.0 1.308 0.90-1.89 P ¼ .15 NS
Recreational drugs 135 7.5 123 91.0 12 9.0 3.280 1.79-5.99 P < .001
History of cancer 100 5.6 82 82.0 18 18.0 1.391 0.82-2.34 P ¼ .21 NS
Arrhythmia 91 5.1 74 81.3 17 18.7 1.324 0.77-2.27 P ¼ .30 NS
History of MI 59 3.3 47 79.7 12 20.3 1.182 0.62-2.25 P ¼ .60 NS
Hepatitis C 55 3.1 47 85.5 8 14.5 1.79 0.84-3.82 P ¼ .12 NS
Seizure disorder 46 2.5 42 91.3 4 8.7 0.310 0.11-0.88 P ¼ .018 NS
HIV/AIDS 26 1.4 16 61.5 10 38.5 0.474 0.21-1.05 P ¼ .06 NS
MA, medical assistance; SP, self-pay; COM, commercial dental insurance; CI, confidence interval; MI, myocardial infarction; NS, not significant;
HIV/AIDS, human immunodeficiency virus/acquired immunodeficiency syndrome.

acquired immunodeficiency syndrome (HIV/AIDS)
with antiretroviral agents.
A literature review of studies similar to the current
investigation found interesting contrasts between our
data and 1500 patients of similar mean age (44.9) sur-
veyed in an academic dental clinic in Minneapolis in
1986.10 Those having any medical condition (76.5 vs.
24.6%), any cardiovascular disease (34.6 vs. 59%),
diabetes (9.2 vs. 6.7%), and a history of cancer (5.6 vs.
2.1%) were particularly noteworthy. These differences
can, in part, be attributed to our inclusion of mental
health disorders (20%) and due to the improvement in
the cardiovascular health of the U.S. population as a
consequence of the reduction in cigarette smoking
since 1970.11 Furthermore, expanded use of aspirin and
warfarin and a number of new agents are now available
to control previously life-threatening MIs, atrial fibrilla-
tion, and occlusive strokes. Overall improvement in the
management of many chronic conditions has enabled
more patients to have access to dental care in conjunction
with an increase in the retention of their natural denti-
tion.12 Our data probably also reflect the increasing
prevalence of asthma and diabetes and advancements in
the treatment of cancer.
A 2000 study of 1041 patients from the dental clinic
at the University of Buffalo13 found that 54% had
systemic diseases, including behavioral disorders.
Although these patients mean age was 10 years older
than our sample (52 vs. 42.3), there were similarities
in the prevalence of hypertension (22 vs. 24%),
cardiac disease (10 vs. 10.4%), use of hypolypemic
agents (10 vs. 10.7%), bronchodilators (7 vs. 9.2%),
hypoglycemic agents (5 vs. 7.3%), and
bisphosphonates (2% vs. 2.8%). These data probably
also reflect similarities in the prevalence of the more
common chronic conditions in the United States as
well as current trends in their pharmacotherapeutic
management. The present study also demonstrates that
the dental practitioner must be able to deal with a
number of health issues that have emerged more
recently, including latex allergy, HIV/AIDS, and the
increased use of bisphosphonates.
In a 2001 study of a number of national health sur-
veys by Miller et al, the authors found that among older
patients, a number of disabling “severe neuropsycho-
logical problems” and “disabilities” would be encoun-
tered, “such as Huntington’s, Parkinson’s or
Alzheimer’s disease.”2 These conditions occurred in
less than 1% of our patients (Table II), but it is
noteworthy that collectively, 22 (1.2%; Table III)
were taking medications currently being used to treat
these disorders. Our patients had early, mild, or
controlled disease and could be treated in an
ambulatory care setting. It can be expected, however,
that with the dramatic growth of the aging population,
there will be an increasing number of these patients
with more advanced diseases. This will generate a
number of management issues, but dental care and
regular assistance with performing routine dental
hygiene procedures will still be required.
The increasing application of the novel therapies for
neurodegenerative diseases is indicative of an evolving
therapeutic armamentarium that continues to improve
the management of an increasing number of chronic
diseases and, in the process, extend patients’ life ex-
pectancies. Improved quality of life for these patients
also allows them to continue to receive dental care.
Although better disease control should enable patients
to continue to be treated in the office setting, dental
practitioners may increasingly encounter a variety of
adverse drug reactions. On the basis of previous expe-
rience, these may include, but are not limited to, oral
ulcerations; mucositis; taste aberrations; lichenoid drug
eruptions; gingival hyperplasia; neuropathies, including
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Volume 119, Number 4
burning mouth or tongue; and candidiasis or other su-
perinfections.2 Furthermore, our patients were taking
multiple categories of pharmacologic agents, more
than half of which have the potential for causing
hyposalivation,14 a common side effect that will
continue to occur as new therapeutic agents come into
use. This will result not only in the multiple
unpleasant symptoms associated with xerostomia,
such as burning mouth and altered taste, but also in
creating an oral environment that is conducive to
increasing the risk for dental caries as well as root
caries and candidiasis.14 It is, therefore, likely that
dental care providers will continue to be challenged
with the management of these complications.
In the 2001 report, Miller et al also addressed the
many implications of the changes in the demographic
characteristics and disease prevalence in the U.S. pop-
ulation and how these may influence the future provi-
sion of oral health care. They predicted that with the
changing profile of the population, the dental practi-
tioner would be confronted by an increased likelihood
of encountering patients with medically related dental
conditions.2 These may arise as a consequence of new
therapies that employ genetic engineering and
bioengineered tissue substitutes, which will enable the
repair or replacement of aging or damaged body
structures. As these emerging technologies continue to
control chronic diseases and extend life expectancy,
they are also likely to improve our ability to restore
or replace oral and dental structures. These parallel
advances in treatment modalities are likely to generate
a number of potential adverse interactions between
medical therapies and dental care. Controversies that
may (re)emerge include the need to premedicate
patients and whether or not modifications in
medication regimens may also interfere with patients’
medical and dental management protocols.
Our institution’s policy is to consult with patients’
physicians if there are significant comorbidities that
may require either a modification to our standard
treatment protocols or in patients’ medical management
regimens. Most often, these patients require extraction
of multiple teeth or other oral surgical procedures. This
would include patients who have to remain anti-
coagulated and at risk for perioperative or post-
operative bleeding (e.g., with an arrhythmia), patients
with significant cardiac disease or poorly controlled
hypertension, and patients with cognitive impairments
who require general anesthesia. Since our retrospective
record review did not include patients’ treatment plans,
we could not determine if medical consultations were
undertaken, but to our knowledge, none of the more
severely compromised patients included in this study
had an adverse outcome as a consequence of their
dental treatment.
MEDICAL MANAGEMENT AND PHARMACOLOGY UPDATE
Guggenheimer, Bilodeau and Barket 383
Although the majority of the medical conditions in the
current sample of clinic patients were similar to those that
are likely to be encountered in the U.S. population, they
were not within the same order of magnitude.9 This is
most likely attributable to the socioeconomic
characteristics of our study population, which
contained an overrepresentation of disadvantaged
(lower-income) individuals based on the proportion of
patients in the Medicaid and self-pay groups (>75%;
Table I). These patients are more likely to seek dental care
in federally subsidized community clinics and hospital-
based or academic-affiliated clinical facilities.15
Furthermore, this segment of the population is at
greater risk for a number of health disparities that
include mental health issues, abuse of alcohol or other
substances, hepatitis, HIV/AIDS, and diseases related
to their higher rates of smoking.16 Our findings
confirmed the association between SES and smoking,
mental health conditions, and use of recreational drugs
(Table IV). With the exception of these conditions, the
prevalence of the other self-reported medical conditions
by the patients in this study may be similar to those that
may be encountered in the private practice sector. These
data could, therefore, be useful to establish a baseline of
current disease prevalence, determine future directions
that reflect the changing demographic characteristics of
the U.S. population, and serve as guidelines for learning
objectives in undergraduate, graduate, and continuing
education courses.
CONCLUSIONS
As advances in the provision of health care continue to
be made, more patients will present with a greater di-
versity of complex health issues that will also require
modifications in how that care is provided. To more
effectively address these concerns, there is increasing
focus on the development of multidisciplinary health
care teams that will collaborate in providing integrated,
comprehensive patient care.17 Irrespective of the
configuration of innovative models that optimize the
provision of health care, the implementation of the
concepts and recommendations that began with the
Gies Report in 1926 must be continued.1
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Reprint requests:
James Guggenheimer, DDS
Department of Diagnostic Sciences
University of Pittsburgh, School of Dental Medicine
G-137 Salk 3501 Terrace Street
Pittsburgh, PA 15261
guggen@pitt.edu