9. Management Of A Medically Compromised Patient Flashcards
LOs
Recommended reading - would recommend at least 1st book - medical problems in dentistry
- others are guidelines to be familiar with
Medical Problems in Dentistry, 6th edition, Crispian
Scully British national formulary (recent)- available online
SDCEP Guidance (http://www.sdcep.org.uk/published-guidance/ )
FGDP Antimicrobial prescribing in Dentistry Good Practice Guidelines https://www.fgdp.org.uk/guidance-standards/antimicrobial-prescribing-in-Dentistry (3rd Edition- Recent update)
1st chapter of A Clinical guide to oral surgery available online: Renton T, Woolcombe S, Taylor T, Hill CM. Oral surgery: part 1. Introduction and the management of the medically compromised patient. Br Dent J. 2013 Sep 13;215(5):213-23.
- need to have enough knowledge to be able to determine where our limitations are as primary care practitioners and know which type of patients we can treat safely
- if there are doubts, can liaise with patients physicians, to ask for advice
How can I identify medically compromised patient?
- good indicator to know if patient is medically compromised or has a condition is to ask if they ‘attend hospital regularly for any appointments or specialist care settings?’
- will also give you an indication of the severity of the disease
What is ASA classification
- American Society of Anesthesiologists
- It’s a good indicator of how well patients are for treatment
- grading system that can accurately predict morbidity and mortality (how risky is it to treat patient in clinical setting)
- not just for primary care settings
What are the ASA classifications?
ASA grade 1-5
- what grade patients can be treated in practice and which need to be treated in hospital?
Medical history
Other considerations?
- look at how they will potentially impact treatment?
- article is quite a nice summary about how to manage medically compromised patients
(Are some things that need updating (eg use of DOACs) - Scully book is also a really good - highly recommend
CVS - history of angina
1
What are patients with angina at risk of?
2
What should you have on hand before treating them?
3
What to do if patient experiences chest pain while you are treating them?
4
What to do if the pain doesn’t subside?
1
- angina attack
- MI
2
- patient should have their GTN spray
- should have GTN spray + oxygen available on clinic
3
- stop treatment
- patient should take their GTN spray sublingually until pain subsides
4
- May be progressing towards MI
- follow emergency protocol for MI patients
CVS - recent MI
What precautions should we take?
1a
up to 3 months post MI
1b
Up to 6 months post MI
2a
What to do if the patient has dental pain post MI?
2b
What precautions should we take when treating?
2c
Pain medication can be prescribed?
1a
- consider deferring elective treatment
- as at significantly higher risk of having further MI
- avoid anything that may increase risk (EG invasive surgery)
1b
- no GA as 50% increase risk of repeat MI
2a
- Pain can act as a stressor
- so want to try + address as can increase MI risk
2b
- treatment in late morning/ early afternoon
- ideally non-invasive (eg extirpation instead of extraction)
- Good local anaesthesia, analgesia & anxiety management (ideally want to avoid IVS unless if dental phobic patient (if needs IVS - speak to their physician))
- Avoid high does NSAIDs
- ideally recommended refer to secondary care treatment if at high risk
2c
- Paracetamol can be prescribed
- +/- short term low dose ibuprofen if needed (200-400mg TDS) (BUT SHOULD BE AVOIDED - TALK TO THEIR PHYSICIAN)
CVS - recent MI but need to treat patient
1
Why should we treat patient in late morning/ early afternoon?
2
Why should we avoid high doses of NSAIDs
1
- higher adrenaline cortisol in blood stream in morning
2
as associated with a small increased risk of thrombotic events (e.g. myocardial infarction and stroke)
- paracetamol is an alternative + considered safe
CVS - Cardiac arrythmias, Cardiovascular disease/ failure
- Precautions to take/ consider
CVS - Cardiac defects/valve replacements/ previous IE
Precautions needed?
- B - as don’t want it to turn into a surgical procedure
EXTRA
When we make the decision need to think about:
- patient is 6 weeks post MI hence higher risk of developing MI
- HENCE want to delay any form of elective treatment
- patient being in severe pain from UL5 = stressor = also increases risk of MI
- HENCE good to take patient out of pain
- least invasive way = extirpate tooth
- will hopefully ease symptoms
- review patient at later date for definitive treatment
- which may be extraction of the UL5 or RCT + restoration
- LR8 doesn’t need immediate treatment as not in pain - call back in later to treat
HYPERTENSIVE PATIENTS
- uncontrolled HTN at increased risk of?
- bleeding
(Prolonged post op bleeding)
THROMBOTIC EVENTS
- stroke
- MI
HYPERTENSIONS
- what to ask patients before extractions + what to check?
- poor or well controlled blood pressure
- some patients may have HTN but are unaware
- If patient is anxious can cause BP to increase
- check BP if possible prior to extractions
EXTRA
- some patients have HTN but are unaware
- high BP at one appointment does not diagnose HTN
- high BP needs to be recorded 3x over a 3 months period
HYPERTENSION
What to do if BP readings above 160/100?
- inform GP if preciously unknown hypertensive so they can monitor
- useful to measure BP as a screening tool
- IVS is useful in patients with high BP
- good consideration for those whose BP may not be controlled
RESPIRATORY DISEASES - asthma
How to risk assess patients with asthma?
RESPIRATORY DISEASES - asthma + COPD
MANAGEMENT
When do we refer patients on?
DIABETES
What are the risks?
DIABETES
What to ask patients before treatment + what to consider?
DIABETES
Hyperglycaemic individuals
DIABETES
Give antibiotics?
DIABETES
- diabetic complications may include
HINT
KNIVES
BLEEDING DISORDERS (look at coagulopathy lecture + management)
What patients with bleeding disorders would you only treat in hospital settings?
- patients on dual anti platelet therapy (EG aspirin, clopidogrel)
BLEEDING DISORDERS
How to manage patients with bleeding disorders/ what to do before treating them?
BLEEDING DISORDERS - Anticoagulant therapy
What would you check before treatment patients on warfarin?
- check INR
- ## only time you would check INR exclusively is for patients who are warfrinised
BLEEDING DISORDERS - Anticoagulant therapy
1
If patients are on warfarin what medications should you avoid giving them + why?
2
If patients are on DOAC (apixaban + rivaroxaban) do they require routine monitoring? What should you avoid giving them?
EPILEPSY
1
Risks?
2
Q’s to ask before treatment?
3
How to mange when performing invasive procedures like tooth extraction?
1
• Seizures precipitated by stress of surgery/ pain
- be careful of overhead light - can cause seizures
2
- ask them when they’re last seizure was
- what meds they’re one
- generally well controlled?
- triggers?
INFECTIOUS DISEASES - TB
How to manage? Can you treat?
INFECTIOUS DISEASES - HIV
1
What does it infect? + what does this cause?
2
Risks/ what precautions to take before tooth extraction?
1
• Infects CD4 lymphocytes
- can become immunodeficient
- vita effective retroviral therapy, patients who suffer with HIV are not immunosuppressed + live normalise lives
2
CANCER
1
Risks they may have?
2
How to manage these risks?
3
Risks/ management of patients receiving chemo?
-
Cancer - RADIOTHERAPY
1
What to find out from patient before extraction?
2
Risks after having tooth taken out?
3
Post op + pre op protocols to prevent osteoradionecrosis of h jaw
1
• Find out area of radiotherapy, dose & duration
2
• Radiotherapy to head & neck- risk of osteoradionecrosis of jaw post operatively of having a tooth taken out
• Radiation-induced fibrosis- bone cell damage through acute inflammation, free radicals & chronic activation of fibroblasts by a series of growth factors
3
BISPHOSPHONATES (covered more in further lectures)
3
What are bisphosphonates
2
What risk factors are there?
1
What pre op precautions are there?
4
Why may patients take bisphosphonates? (EXTRA)
3
Anti resorptive medication (slow down bone loss)
4
- to help strengthen bones
- reduce risk of bones breaking
- to prevent or slow done bone thinning (osteoporosis)
- osetopenia
- cancer - if has metastatized to bone
BISPHOSPHONATES EG
Patient was on an IV bisphosphonate
- areas with necrotic bone
BISPHOSPHONATES
- prevention is better than management
- hard to manage these patients
How to prevent osteonecrosis
EXTRA
- patient is in pain + taking pain killers
- ideally probably shouldn’t take painkillers (they’re safe BUT long term pain killers is not ideal whilst pregnant)
- also not ideal for quality of life
- would be waiting another 3 months for 3rd trimester = v long
- before undertaking extraction would need to take x-ray - it’s safe to take PA when pregnant
- if tooth is deemed unrestorable, those would be your 2 options
- depended if patient feels comfortable having x-ray whilst pregnant or not
- reassure patient that x-ray is safe but if they don’t want to then you can expirate tooth until given birth or if willing to do extract tooth
EXTRA
- NICE guidelines state ABs are not routinely given (this is case dependent)
- in all cases with something like this, I would liaise with a patients physician/ cardiologist + ask their advices
- always remind patients at risk of IE the symptoms of IE, regardless of whether you give the AB prophylaxis
- patients with retroviral therapy are usu very aware of their CD4 count + viral load + will usu give you a reliable response
- if normal CD4 count + undetectable viral load, does not need amendment to manage to + does not need any investigations
- good practice to have whatever most recent blood investigations form their GP for the patients health records
