14.Management of the medically compromised patient Flashcards
LOs
· Identify the medically compromised patient by taking a thorough medical history
· Recognise the salient clinical features of common medical disorders presenting in the dental setting
· Explain which features determine the suitability of a medically compromised patient to be managed in the primary care setting and which patients to refer to secondary care
· Assess whether a patient is medically fit for dental treatment
DELETE CARD???
why we need to know about medical conditions?
- People are living longer and as medical interventions are becoming more advanced,
- Dentist will need to be aware of systemic conditions and treatments that may impact on the delivery of safe dental care.
- 2014 -26% UK population >65yr
- Dentist will see more patients with more medical conditions in general practice
what is a medically compromised patients?
- Patients with a condition or treatment of the condition can impact on the delivery of safe and optimal dental care.
- Extra knowledge and care can prevent potential complications causing unnecessary morbidity and mortality
EXTRA INFO
- medical history forms should help you find out whether a patient has a condition
- make sure to update medical history on each visit
what key things should you look at when assessing a medically compromised patient?
- individual condition?
- how common the condition is?
- how you identify the condition?
- medical history
- medical condition knowledge
- treatment
- drug interactions (anti-coag, antidepressant, antibiotic)
- oral manifestations (EG. ulceration, gingival hyperplasia)
- severity of condition
- how it affects dental care
why is it important to look at the medical history of a patient and all of these key factors from card 4 (medical condition, treatment, drugs,etc)?
~ all of these factors are important to look at as they provide us with info about how likely they will impact on our dental care
~ medication is important to know about so that we don’t prescribe a drug that could negatively interact
~ some conditions and or medications can cause oral manifestations or presentations
~ help us decide what cases can be treated in general practice + what needs to be treated in hospital
what should you look at when taking a medical history?
- PMH (go through review of systems)
~ CVS/ RS/ GIT/ GU/ CNS/ Haematological/
~ Dermal, musculoskelatal, Endocrine
~ Operations
~ Recent admissions
~ DH
~ Allergies
~ FH
~ SH
~ Habits Smoking/ alcohol - Dental Hxoral conditions , ulceration, periodontal disease
- Past dental Tx, potential complications from previous treatment
what to examine?
EXTRA ORAL
- Examination of the patient with assoc. medical
problem needs to be thorough
- General appearance ( gait,weight,posture,skin)
- Vital signs Pulse, Bp, Temp, RR
- Head and Neck examination (Nodes, CN)
INTRAORAL
EG’s of being prepared for medical conditions
- Check when patient last had food and if they have had their does of insulin/ oral hypoglycaemic meds
- Have any symptomatic treatment readily available e.g. GTN tablets, salbutamol and consider prophylactic use of medications
- Can get 1st presentation of problem (Angina)
ETC
CVD
Difficulties patients with cardiovascular system diseases may face?
- Patients may :
a. become breathless when laid flat (eg Heart failure patients)
b. have a bleeding tendency because of anticoagulants (eg patients with arrythmias (eg atrifibrolasium) (hence higher risk of bleeding)
c. acute ischaemic event (Angina/ MI)
CVD
how do you treat a patient that has previously had an ischaemic event/ MI?
- find out how long ago that happened
- general rule is to not carry out any active dental treatment or surgical treatment within the first 3 months of having a myocardial infarc
(should be able to recognise signs + symptoms og patient in dental chair having an MI
CVD
can patients with CVD have LA with adrenaline
Currently, no evidence that adrenaline in LA is a hazard but if concerned use “citanest” as it contains prilocaine insead of adrenaline
CVD
can patients with CVD have GA?
- yes they can BUT
- there is a risk to patient
- so consult anaesthetist + physician on case by case basis to reduce risk
how can you treat a patient on anticoagulants?
- if need to carry out dental extraction, periodontal surgery, etc patient at higher risk of bleeding
- plan treatment and adjust anticoagulation drugs in certain situ
1
what is ASA classification?
2
why is it useful?
3
what are the rankings?
1
- American Society of Anaesthesiologists physical status classification system
2
- clinicians can simply categorise patients physiological status
- can be helpful in predicting their operative risk
- useful to discuss with clinicians and physicians a patients underlying physiological state
3
INFECTIVE ENDOCARDITIS
1
what is infective endocarditis?
2
cause?
3
common? what may increase the risk?
1
infection of the lining of the heart, particularly affecting the heart valves,
2
caused mainly by bacteria but occasionally by other infectious agents.
3
- rare condition
- people with certain structural cardiac conditions are at risk
~ congenital heart disease
~ Rheumatic heart disease
~ aortic valve disease
~ prosthetic valves
~ previous endocarditis
~ hypertrophic cardiomyopathy
~ IVDU
INFECTIVE ENDOCARDITIS
infective endocarditis concern/ relevance in dentistry?
dentistry may cause a bacteraemia which may lead to this problem
management of patients with infective endocarditis in regards to dentistry?
- Offer people at risk of infective endocarditis clear and consistent information about prevention
- the benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended
- the importance of maintaining good oral health
- symptoms that may indicate infective endocarditis and when to seek expert advice
- the risks of undergoing invasive procedures, including non‑medical procedures such as body piercing or tattooing. [2015]
Make Q SLIDE 17
Prophylaxis against infective endocarditis
• Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures
• Chlorhexidine mouthwash should not be offered as prophylaxis against infective endocarditis to people at risk of infective endocarditis undergoing dental procedures. [2015]
• The vast majority of patients at increased risk of infective endocarditis will not be prescribed prophylaxis. However, for a very small number of patients, it may be prudent to consider antibiotic prophylaxis (non-routine management), in consultation with the patient and their cardiologist or cardiac surgeon
(SDCEP 2018)
ADD IN Q SLIDE 18
The identification and assessment of these ‘sub group increased risk ‘ patients will require liaison with their cardiology consultant, cardiac surgeon or the local cardiology centre
ADD IN Q SLIDE 19
EXTRA FC SPACE
EXTRA FC SPACE