J Dent Educ. 71(5): 682-686 2007
© 2007 American Dental Education Association
Milieu in Dental School and Practice |
Medical Profile of a Dental School Patient Population
Lida Radfar, D.D.S., M.S.;
Lakshmanan Suresh, B.D.S., M.S.
Key words: medical profile, dental school, curriculum
Submitted for publication 10/24/06;
accepted 01/10/07
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Abstract
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Advances in health care and pharmacotherapeutics have led to a growing aging population living with complex medical conditions. These changes are apparent in patients presenting for treatment at dental schools. This study assessed the medical profile of patients seeking treatment at the School of Dental Medicine, State University of New York at Buffalo. Medical records of 1,041 consecutive patients who presented for comprehensive dental care at the school were retrospectively reviewed. The demographic data, medical status, and use of medications from the charts were analyzed. The mean age of the patients was 52 (SD±18), and the female to male ratio was 1.2:1. More than half of the patients had one or more systemic illnesses or were taking medication. The results of this study reflect the medical complexity of the growing aging population. The dental school curriculum should address the needs for management of the growing number of medically complex patients.
Due to vast improvements in medical science, people are living longer and better than ever before. The growth of the population age sixty-five and older is increasing at the highest rate in history. In the United States, the number of people age sixty-five or older has increased more than tenfold from 3 million (4 percent of the population) in 1900 to 35 million (13 percent of the population) in 2000. The size of the older population is estimated to double over the next thirty years, growing to 70 million by 2030.1 As the sixty-five and older age group increases in size, their health demands will increase as well. This age group tends to develop more systemic diseases and require more medical attention.1 The National Center for Health Statistics reported that 15 percent of the adult population age sixty-five and over have chronic medical conditions.2,3 The most prevalent reported diseases are cardiovascular ailments, diabetes, hypertension, chronic bronchitis, and arthritis.2,3
To provide optimal dental care for this medically complex population, it is important to obtain a good medical history prior to any dental treatment. Moreover, modifications of dental management due to compromising medical conditions are necessary to provide better and safer oral care for patients. The objectives of our study were:
- to evaluate the prevalence of systemic diseases with medication usage in a dental school patient population, and
- to assess if the medical status of the dental school patient population reflects the general population.
The overall goals of the study were to evaluate the need for modifications in the predoctoral curriculum in the management of medically complex patients, based on the population presenting to our dental school. In addition, we assessed the need for emphasis on clinical pharmacology education, with a focus on adverse effects and interactions of drugs, based on complex medication usage among the dental school patient population.
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Method and Subjects
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The charts of consecutive patients who presented to the School of Dental Medicine at the University at Buffalo from January 2000 to June 2000 were used for the study. Patients eighteen years old and older who had completed the school’s standardized medical questionnaire were included in the study. These questionnaires were reviewed with patients by dental students and clinical faculty. The patients’ charts were reviewed for demographic data, systemic diseases, and lists of medications. The patients were categorized into four age groups: eighteen to thirty-nine years, forty to fifty-nine years, sixty to seventy-nine years, and eighty years and over. Medical conditions were categorized systemically, and medications were categorized based on their therapeutic classifications. The study was approved by the Institutional Review Board at State University of New York at Buffalo.
The SAS statistical program was used to analyze the data, which included demographic data, frequency of each condition, and medications. A group comparison was performed using the ANOVA test, and logistic regression was used to determine the odds ratio in developing medical problems and taking medications in different age groups. The effects of gender and age on developing medical problems and subsequent medication usage were also evaluated (chi square statistics).
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Results
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Data were obtained from 1,041 patient charts. The mean age of the patients was fifty-two (SD ±18), with a range of eighteen to ninety-one years. When the study population was categorized into four age groups, 27 percent were under age forty, 36 percent were forty to sixty years old, 31 percent were sixty to seventy-nine years old, and 6 percent were eighty years old and older (Table 1
). The female to male ratio was 1.2:1 (553/488). More than half of the patients (564) included in this study had one or more medical conditions (54 percent), and 549 patients were taking at least one medication (53 percent). The effects of gender and age on having medical problems or taking medications were evaluated (chi square statistics). The gender effect on different medical conditions was not statistically significant. Frequency of systemic diseases was 45 percent in ages less than forty, 51 percent in ages forty to fifty-nine, 64 percent in ages sixty to seventy-nine, and 63 percent in those eighty years or older. The logistic regression test indicated statistical differences between age and developing medical conditions and in taking medications (for both medical conditions and taking medications: OR=1.7, p<0.0001). Further comparison among the four age groups found a statistically significant difference in developing systemic medical problems for the sixty to seventy-nine age group from the other three groups (Cochran-Mantel-Haenszel) Statistics, p=<0.0001, OR=1.8, and 95% CI=1.4–2.4). The same age group showed a statistically significant difference in taking medications (Cochran-Mantel-Haenszel Statistics: p=<0.0001, OR=1.7, and 95% CI=1.3–2.3). When the age category was changed into two categories of less than sixty and greater than sixty years old, there was no statistically significant difference between age and developing medical conditions or taking medications.
The most common systemic diseases were hypertension (22 percent), diabetes (14 percent), arthritis (primarily osteoarthritis) (13 percent), dyslipidemia (10 percent), cardiac diseases (9 percent), and mental disorders (9 percent). Allergy to medication was reported as 17 percent (Table 2). Twenty-five percent (205 patients) were smokers. Of those who smoked, 195 patients were smoking one pack or less per day, and ten patients (0.3 percent) were smoking one and a half to two packs of cigarettes per day. Fifty-five patients had quit smoking sometime in the past. Data regarding the length of smoking in our patients were not available in the charts. Alcohol use was reported as a social event by 27 percent of our patients.
Eighteen percent of our patients were taking at least one medication, and 14 percent were taking two medications per day. About 1.3 percent of patients were taking seven to thirteen different medications. The most common medication category was antihypertensive medications (35 percent), followed by non-narcotic pain medications (19 percent), antidepressants (17 percent), antidyslipidemic agents (10 percent), antiplatelet agents (9 percent), thyroid hormone (8 percent), antacids (6 percent), bronchodilators (7 percent), and hypoglycemic agents (5 percent). Multivitamins were used by 5 percent of the patients (Table 3).
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Discussion
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Among the four age groups, those ages sixty to seventy-nine had the highest level of medical issues (64 percent) and a higher risk of developing those conditions (OR=1.7) compared with the other age groups (Table 1
). The younger population (under forty years old) had a high rate of medical problems (45 percent) for that age group. This rate was higher than the national vital statistics data for year 2000 in that age category.4 On the other hand, the older population (eighty or more years) did not show statistical differences in developing systemic diseases or in taking medications when compared with the younger group. We believe that younger populations who have systemic medical conditions have a tendency to come to the dental school for their dental care. In addition, the older population tends to have more complex medical conditions that limit them from coming to the dental school for treatment. Only those with better physical ability and/or transportation are able to attend the dental school for treatment. As aging is associated with progressive loss of memory, there is also a possibility that older patients did not report all of their medical conditions while at the dental clinic.5
In our study we found that hypertension (22 percent) and diabetes (14 percent) were the most common medical problems reported. In 2000, the National Health Interview Survey reported that 20 percent of the population had hypertension.4 In 2003, the hypertension rate in the state of New York alone had risen to 25.3 percent and in the nation was reported as 24.8 percent. Our dental school patient population had hypertension comparable to state and national averages. The prevalence of diabetes in the state of New York had risen from 4.2 percent in 1995 to 7.5 percent in 2004. The national prevalence of diabetes in 2004 was 7 percent.8 We found the rate of diabetes to be much higher than reported averages on both state and national levels. (The most common reported diseases are summarized in Table 2.)
The increasing incidence and prevalence of systemic diseases, especially chronic diseases, among older adults have also led to a growing demand for medications. In a study by Heft and Mariotti, on average, 40 percent of the seniors were taking at least three medications per day.6 This was reflected in our study population, as more than half of the patients were taking one or more drugs (51 percent). The average medication taken by patients in our study was 1.2 per day. This result is similar to a study by Jainkittivong et al. on 510 elderly Thai dental patients aged sixty years and older. The average number of drugs used in that study was reported as 1.5 per person.7 In our study, 386 patients (37 percent) were sixty years of age or older, and the average medication used in that age group was 1.5.
Table 3 shows the common medications reported by our patients in this study. The highest category was antihypertensive medication (35 percent), which corresponds with hypertension as the most common medical problem. Pain medications, antidepressants, and antidyslipidemic agents were the next most used medications reported by our patients. The results of our study indicate that many patients were taking a variety of medications. Concomitant use of variety of medications requires health care providers to be conversant with the drugs and their interactions.
Changing oral care needs were investigated from multiple national databases by Miller et al. in 2001.9 The results indicated a growing demand for diagnosis and management of patients with oral conditions and oral manifestations of systemic diseases. These researchers emphasized that these increasing demands should be reflected in dental education for dental students and continuing education for practitioners.9 There is increasing evidence that neglecting oral health can negatively impact systemic health such as cardiovascular disease, atherosclerotic vascular disease, ischemic stroke, and peripheral vascular disease.10 Furthermore, there is evidence that neglecting oral health can negatively impact nutrition, particularly in older adults, which subsequently increases the likelihood of systemic complications such as diabetes.11 The incidence of overlapping oral health care and systemic conditions increases with age, particularly for those patients living at low-income or poverty levels and having a comorbid psychological diagnosis.12–14 Oral health has also been correlated to the quality of life, psychological well-being, and life satisfaction.15–17
The practice of medicine and dentistry has been changing and will continue to change in the future. Since people are living longer with better oral hygiene, they keep more teeth for a longer period of time. Dentists are increasingly treating more medically complex patients who require complex services with more challenging dental treatment planning.7 Today’s dental students will be challenged by the growing older population, which will likely continue to the peak of their professional lives. There has been a significant increase in the percentage of patients with medical conditions coming to U.S. dental schools for treatment during the past three decades. Rhodus et al.18 compared the dental school patient population with medical conditions in 1976 and 1986. The patient population with medical problems increased from 7.3 percent in 1976 to 24.6 percent in 1986.18 Our study showed similar results and reflects the increasing medical complexity of dental schools’ patient population.
Medically complex patients need more in-depth evaluation, which indeed requires more knowledge of medicine. Patients’ medical conditions demand a more detailed assessment and modification of dental management. This is an important issue that leads to reassessing whether medicine should be taught more in-depth in dental schools. Dental schools may have to expand subjects such as management of the medically complex patients, pharmacology, and medical emergencies. Continuing education courses should emphasize these subjects as well. In dentistry, the curriculum may require modification toward a more medically oriented dental education. Dental educators should reassess their material and method of education to make sure that dental practitioners are equipped for the population’s requirements for dental care as medical needs change. Knowing about systemic diseases and medications will help dental practitioners to be aware of life-threatening situations that may occur during dental treatment.
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Footnotes
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Dr. Radfar was Assistant Professor, Oral Medicine, Department of Oral Diagnostic Sciences, School of Dental Medicine, State University of New York at Buffalo, at the time of this research; Dr. Suresh is Assistant Director of Oral and Immunopathology, IMMCO Diagnostics, Inc., Buffalo, NY. Direct correspondence and requests for reprints to Dr. Lida Radfar, Oral Diagnosis and Radiology Department, College of Dentistry, University of Oklahoma, Oklahoma City, OK 73117; 405-271-5988 phone; 405-271-3158 fax; lida-radfar{at}ouhsc.edu.
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REFERENCES
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- Older American update 2006: key indicators of well-being. Federal interagency forum on aging-related statistics. Washington, DC: U.S. Government Printing Office, May 2006. At: www.agingstats.gov/agingstatsdotnet/Main_Site/Data/Data_2006.aspx. Accessed: October 2006.
- Pamuk ER, Wagener DK, Molla MT. Achieving national health objectives: the impact on life expectancy and on healthy life expectancy. Am J Public Health 2004; 94: 378–83.[Abstract/Free Full Text]
- Trust for American Health. Preventive epidemic: protecting people. The state of your health, New York. Your state’s health, 2006. At: http://healthyamericans.org/state/index.php. Accessed: October 2006.
- Pleis JR, Schiller JS, Benson V. Summary health statistics for U.S. adults: National Health Interview Survey, 2000. Vital Health Stat 2003; 215:1–132.
- Mahncke HW, Bronstone A, Merzenich MM. Brain plasticity and functional losses in the aged: scientific bases for a novel intervention. Prog Brain Res 2006; 157:81–109.[Medline]
- Heft MW, Mariotti AJ. Geriatric pharmacology. Dent Clin North Am 2002; 46(4):869–85.[Medline]
- Jainkittivong A, Aneksuk V, Langlais RP. Medical health and medication use in elderly dental patients. J Contemp Dent Pract 2004; 5(1):31–41.[Medline]
- Trust for American Health. Preventive epidemic: protecting people. The state of your health, adult health indicators. At: http://healthyamericans.org/state/index.php. Accessed: October 2006.
- Miller CS, Epstein JB, Hall EH, Sirois D. Changing oral care needs in the United States: the continuing need for oral medicine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 91(1):34–44.[Medline]
- Ciancio S. Taking oral health to heart: an overview. J Am Dent Assoc 2002; 133(Suppl):4S–6S.[Abstract/Free Full Text]
- Marshall TA, Warren JJ, Hand JS, Xie XJ, Stumbo PJ. Oral health, nutrient intake, and dietary quality in the very old. J Am Dent Assoc 2002; 133(10):1369–79.[Abstract/Free Full Text]
- Budtz-Jorgensen E, Chung JP, Rapin CH. Nutrition and oral health. Best Pract Res Clin Gastroenterol 2001; 15(6):885–96.[Medline]
- Chavers LS, Gilbert GH, Shelton BJ. Racial and socioeconomic disparities in oral disadvantage, a measure of oral health-related quality of life: 24-month incidence. J Public Health Dent 2002; 62(3):140–7.[Medline]
- Stetson BA. Influence of behavioral science research on oral health promotion. Compend Contin Educ Dent Suppl 2000; 30:24–30.[Medline]
- Stiefel DJ, Truelove EL, Menard TW, Anderson VK, Doyle PE, Mandel LS. A comparison of the oral health of persons with and without chronic mental illness in community settings. Spec Care Dentist 1990; 10(1):6–12.[Medline]
- Kiyak HA. Successful aging: implications for oral health. J Public Health Dent 2000; 60(4):276–81.[Medline]
- Locker D, Clarke M, Payne B. Self-perceived oral health status, psychological well-being, and life satisfaction in an older adult population. J Dent Res 2000; 79(4):970–5.[Abstract/Free Full Text]
- Rhodus NL, Bakdash MB, Little JW, Haider ML. Implications of the changing medical profile of a dental school population. J Am Dent Assoc 1989; 119(3):414–16.[Abstract]
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Abstract
Method and Subjects
