Module 1_Management of Medically Compromised Patients Flashcards
What 3 factors should be considered in the management of a medically compromised patient?
- Medical status of the patient
- Interactions between potential treatment and the patient’s status
- Overall management of the patient
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?)
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
What is angina? Is it reversible or irreversible?
- Temporary interference of blood supply to cardiac muscles
- Reversible
What is myocardial infarction?
- More extensive interference with blood supply to cardiac muscles
- Causes wall of heart to undergo ischemia and irreversibly die within a number of hours
What measures can be taken to reduce chance of triggering cardiac problems in pt with cardiac disease?
- 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
What is the pathophysiology of asthma?
- 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
What is status asthmaticus?
-Continuous asthma attacks
What factors should be taken into account in the management of asthma?
- 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
What factors can interfere with a patient’s physical ability to co-operate?
Epilepsy
Pregnancy
How should you manage an epileptic patient?
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
What is one shortcoming of epileptic drugs other than side effects of gingival hyperplasia that can cause problems?
- 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
What is one issue with grand mal seizure?
- 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
What info should you gather for a pregnant patient?
-Pregnancy stability (if 10 pregnancies, different case if they have had 9 healthy babies vs 1)
How should you manage a pregnant patient?
- 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
T or F?
Hepatitis is a term that can be applied to both inflammation of the liver and viral infection of the liver?
T
T or F?
The liver and kidneys are the main detoxifying organs in the body
T
What considerations should be considered when treating a patient with liver disease?
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
What percentage of liver cells can you lose up to before you have problems?
80%
However, by 20% problems so severe that liver transplant may be the only option
How should you manage a patient that is on warfarin?
-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
How should an extracction patient with INR range 2-4 be managed?
- Local measures to control bleeding (surgical, suturing, transexamic acid)
- Covered in later modules
T or F?
Aspirin affects INR
F
Aspirin only increases bleeding time
No current tests to measure this as the results are not meaningful
Would you stop using aspirin prior to extractions?
No
However, for major surgeries such as face lifts, breast reduction, pre-prosthetic sulcaplasty cease use of aspirin 10 days before
What is clopidogrel? Should you cease it prior to treatment?
- 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)
T or F
Clopidogrel affects INR.
F as it is an antiplatelet drug
