Module 1_Management of Medically Compromised Patients

Question 1

What 3 factors should be considered in the management of a medically compromised patient?

Answer 1

• Medical status of the patient
• Interactions between potential treatment and the patient’s status
• Overall management of the patient

Question 2

What types of interactions can occur between a patient’s medical health and their dental treatment? (i.e. what sort of impacts can their medical condition have on their health and vice versa?)

Answer 2

Stability

• Potential for treatment to destabilise patient’s condition
• Determined by stability of patient’s medical condition
• Is patient’s medical condition easily made worse?
• Does the patient’s medication frequently change?
• Common examples of low stability diseases: coronary disease, asthma

Co-operation

• Condition can impact on patient’s ability to co-operate with operator
• Can be due to behaviour or physical factors

Bleeding

• Procedures done on patients can cause them to bleed to varying degrees
• Can be an issue with patients on anticoagulants and patients with liver disease that lack normal coagulating factors

Healing
-Patient’s medical condition can retard healing (e.g. patients on steroids or patients with diabetes)

Bacteremia
-Dental procedures can introduce bacteria into the blood, resulting in presence of viable organisms in the blood stream

Drug interation

Question 3

What is angina? Is it reversible or irreversible?

Answer 3

• Temporary interference of blood supply to cardiac muscles

- Reversible

Question 4

What is myocardial infarction?

Answer 4

• More extensive interference with blood supply to cardiac muscles
• Causes wall of heart to undergo ischemia and irreversibly die within a number of hours

Question 5

What measures can be taken to reduce chance of triggering cardiac problems in pt with cardiac disease?

Answer 5

• Minimise stress with short appointments
• Minimising pain
• If major then refer pt to be treated in hospital setting (under GA by skilled anaesthetist maximises pt’s oxygenation to heart)
• Be prepared to do CPR in case of collapse

Question 6

What is the pathophysiology of asthma?

Answer 6

• Constriction of muscles in middle layer of bronchioles (decrease dimension of bronchioles)
• Secretion of mucous by inner layer of cells
• Thus resulting in blockage of airway and inability for oxygen to reach alveoli where gaseous exchange occurs

Question 7

What is status asthmaticus?

Answer 7

-Continuous asthma attacks

Question 8

What factors should be taken into account in the management of asthma?

Answer 8

• Be aware of triggers for asthma
• Have to know management of asthma and be prepared for management of acute asthma attacks
• Consider the need to hospitalise patient for use of GA

Question 9

What factors can interfere with a patient’s physical ability to co-operate?

Answer 9

Epilepsy

Pregnancy

Question 10

How should you manage an epileptic patient?

Answer 10

Info gathering:

• Be aware if pt epileptic
• Be aware of epileptic history (one seizure several years ago and no repeat, or multiple on daily basis?)
• Type of epilepsy (whole body/grand mal or local reaction?)
• Be aware of warning signs of upcoming fit–>allows you to stabilise treatment before fit occurs
• Use of rubber stopper to allow time to remove fingers and instruments in case of epileptic fit
• Once instruments and fingers removed, allow patient to fit
• Support patient on the chair or on the floor so that they don’t damage themselves
• Fit usually lasts for about a minute
• After fit, put patient in recovery position and be ready to clear out airways in case patient vomits
• Be aware that after apparent recovery pt is still affected and thus may try to flee from surgery
• Do not allow the patient to go or drive home by themselves
• Keep patient until they are fully recovered or get friend/relative to escort them home

Question 11

What is one shortcoming of epileptic drugs other than side effects of gingival hyperplasia that can cause problems?

Answer 11

• Short half life
• If pt rushing to get to clinic and forget to take medications then situation is very different than when they readily take their medication

Question 12

What is one issue with grand mal seizure?

Answer 12

• Whole body reaction
• Therefore includes jaws coming together
• Makes it difficult to pry them open
• Therefore can manage by using rubber mouth prop between teeth–> allows time for dentist to remove equipment and fingers in case of fit

Question 13

What info should you gather for a pregnant patient?

Answer 13

-Pregnancy stability (if 10 pregnancies, different case if they have had 9 healthy babies vs 1)

Question 14

How should you manage a pregnant patient?

Answer 14

• Defer all dental treatment unless absolutely required (remember if problem happens after treatment pt may blame you even if it’s not the cause); e.g. emergency for pain is reasonable, crown placement is not
• If possible try to do any procedures during mid trimester as risk of teratology greatest in first; max discomfort in third
• Elevate the right hip to avoid fetus pressing on vena cava
• Raise patient and have them get up slowly to avoid ill effects of postural hypertension
• Be aware that pressure from developing fetus may press on bladder causing need to urinate

Question 15

T or F?

Hepatitis is a term that can be applied to both inflammation of the liver and viral infection of the liver?

Answer 15

T

Question 16

T or F?

The liver and kidneys are the main detoxifying organs in the body

Answer 16

T

Question 17

What considerations should be considered when treating a patient with liver disease?

Answer 17

Do not embark on elective treatment such as extensive crown and bridge work as periodontium will almost certainly fail

Be aware that as liver produces many coagulation factors patient may experience bleeding problems

Be aware of drug actions and if drugs you are prescribing will require the liver to break them down

Question 18

What percentage of liver cells can you lose up to before you have problems?

Answer 18

80%

However, by 20% problems so severe that liver transplant may be the only option

Question 19

How should you manage a patient that is on warfarin?

Answer 19

-Enquire why they are on warfarin (e.g. if because of prosthetic heart valve may also need to consider antibiotic prophylaxis)

• If require invasive procedure such as extraction then determine the extent of patient’s bleeding tendency
• Done by INR test that measures patient’s prothrombin levels
• INR 1 = normal/sub-therapeutic (if pt on warfarin has this value meds not working)
• INR 2-4 = Therapeutic local measures
• INR 4-5 or higher = At risk of internal bleeding

Question 20

How should an extracction patient with INR range 2-4 be managed?

Answer 20

• Local measures to control bleeding (surgical, suturing, transexamic acid)
• Covered in later modules

Question 21

T or F?

Aspirin affects INR

Answer 21

F
Aspirin only increases bleeding time
No current tests to measure this as the results are not meaningful

Question 22

Would you stop using aspirin prior to extractions?

Answer 22

No

However, for major surgeries such as face lifts, breast reduction, pre-prosthetic sulcaplasty cease use of aspirin 10 days before

Question 23

What is clopidogrel? Should you cease it prior to treatment?

Answer 23

• Potent anti-platelet drug
• Do not cease (if ceased in first 6 months after stent placement, 1/8 chance of patient dying from acute myocardial infarction due to stent obstruction)

Question 24

T or F

Clopidogrel affects INR.

Answer 24

F as it is an antiplatelet drug

Question 25

What measures should be taken to manage an extracction patient on Clopidogrel?

Answer 25

Local measures (same applies to any other anti platelet drug)

Question 26

How should a patient who is on steroids be managed?

Answer 26

• Determine the underlying reason for steroid use + stability of condition
• If doing any minor surgeries such as extractions, double the dose of steroids to allow patient to respond to stress (as long term users can experience suppression of steroid production from adrenal cortex)

Question 27

How should a diabetic patient be managed?

Answer 27

• Determine what type they are
• Assess stability with blood glucose test
• If need to take out a considerable number of teeth, have patient sent to be managed in hospital especially for type I case; as if you manage as outpatient and something happens you’re creating a real challenge for the medical practitioner

Question 28

What effects do resting, fasting and medication have on a diabetic patient’s blood glucose level?

Answer 28

Rest: increase
Fast: decrease
Medication: decrease

Question 29

What is infective endocarditis?

Answer 29

• Destruction of the heart valves when bacterial colonies develop on the heart valves
• Can be caused by dental procedures introducing bacteria to the bloodstream causing bacteraemia

Question 30

What are the dosages for antibiotic prophylaxis?

Answer 30

2gm Amoxycyillin orally 1 hour before procedure

or

600mg clindamycin orally 1 hour before procedure

Question 31

What other situations may an antibiotic prophylaxis be indicated

Answer 31

• Patients with new artificial joints placed within last 6 months
• Patients with failing joints