The Management of the Medically Compromised Patient Flashcards
What is a medically compromised patient?
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
Why is it important to have knowledge about any medical conditions that the patients have?
Because we will then know if we are causing any drug interactions or also whether something we see is just an oral manifestation of that disease
When taking patient’s history, what is important to do and ask about?
Ask questions relating to each one of the systems e.g. CV system, respiratory system, CNS etc.
Also ask about social history, family history, dental history, prior treatment etc.
Check medications and allergies
How should you examine a medically compromised patient?
Examination needs to be thorough
Observe general appearance as soon as they walk through the door (gait, posture, weight, skin etc.)
Check vital signs (pulse, bp, temp, rr)
Head & neck examination (nodes, CN)
Intra oral examination
What does being prepared for your patient involve?
Check when they’ve last had food & if they have their dose of insulin/oral hypoglycaemic meds e.g. if diabetic
Have any symptomatic treatment readily available e.g. GTN tablets, salbutamol & consider prophylactic use of medications
What kinds of complications/things are there to be aware of for patients with cardiovascular system problems?
Patients may:
-Become breathless when laid flat (heart failure)
-Have a bleeding tendency because of anticoagulants (atrial fibrillation)
-Acute ischaemic event (angina/MI)
-There is no evidence that adrenaline in LA is a hazard, but if concerned use “citanest”
GA does constitute a risk so consult the anaesthesist/physician
What is citanest?
Local anaesthetic that contains prilocaine
What is the ASA (American Society of Anesthesiologists) classification?
Physical status assessment tool; helps determine RELATIVE risk for anaesthesia
Strongly associated with perioperative risk & outcomes
What is infective endocarditis?
Infection of the lining of the heart, particularly affecting the heart valves
It’s caused mainly by bacteria but occasionally by other infectious agents
Who is at risk of getting infective endocarditis?
It’s a rare condition but people with certain structural cardiac conditions are at risk
e.g. congenital heart disease, Rh heart disease, aortic valve disease, prosthetic valves, previous endocarditis, hypertrophic cardiomyopathy, IVDU
What is important to tell the patient about the current advice for people at risk of infective endocarditis?
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
What is the current advice for people at risk of 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
What determines the subgroup of people at risk of infective endocarditis for whom it might be prudent to specially consider routine antibiotic prophylaxis?
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What are some oral antihypertensive drug side effects for patients who are hypertensive?
Xerostomia (diuretics)
Lichenoid reactions (ACE inhibitors)
Gingival hyperplasia (Ca channel blockers)
POSTURAL HYPERTENSION MAY OCCUR SO SIT PATIENT UP SLOWLY, ESPECIALLY AFTER LONG SUPINE PERIODS
What is important to be aware of for patients with hypertension in the dental clinic?
1- make sure it’s controlled as you don’t want to be treating someone with uncontrolled hypertension
2- they can get postural hypotension so sit the patients up slowly, especially after long supine periods
What things are important to keep in mind with a patient who has respiratory issues?
Make sure you have the symptomatic therapy to hand
Use LA if possible/be cautious with sedation
Some patients may require a steroid cover if they required long-term corticosteroid therapy and now have a degree of adrenocortical suppression
Their inhalers can contain steroids and there’s risk of oral candida so it’s important to rinse their mouth out after steroid therapy
They may be sensitive to NSAIDs
Anxiety may cause exacerbation
What do you have to be aware of when booking appointments for patients with diabetes mellitus?
Timing of the appointment to avoid patients having hypoglycaemia e.g. in the morning or just after lunch would be best
What are diabetic patients more prone to getting and how does this affect them?
Ischaemic heart disease, xerostomia, periodontal disease, infection; particularly orofacial infection.
Orofacial infection and things like surgery cause a stress response which could therefore raise their glucose levels
What might be necessary to do if a diabetic patient requires GA?
GA may necessitate IV insulin based on a variable rate intravenous insulin infusion (the old name for this is a sliding scale)
I.E checking insulin levels are ok
Ideally, when should dental treatment be carried out in epileptic patients?
When there is good seizure control
What are some problems you have to be mindful of when it comes to patients with epilepsy?
Convulsions (self terminating/ buccal midazolam)
Drug reactions (enzyme inducers)
Bleeding tendency (sodium valproate CBZ)
Gingival hyperplasia with phenytoin
What are some problems relating to liver disease that can impact dental care?
- Bleeding tendency
- Altered drug metabolism
- Delayed Healing
-Protein & Ig deficiency
- LA is safe but avoid IV sedation and GA
- Could get viral hepatitis
- Could be liver transplant patients
How are patients with alcohol dependance medically compromised?
Can lead to wide range of problems like liver disease which then leads to problems with drug metabolism and bleeding
What is the dental relevance of chronic renal disease?
Prevention of dental disease is v important
Drug metabolism can be impacted (wouldn’t want to prescribe drugs that get excreted by kidneys i.e. NSAIDs)
Renal patients can be more prone to infections, can be immunosuppressed, could have had a transplant
Could have hypertension
Could present with lytic lesions in the jaw
Could be on dialysis CAPD/haemofiltration so anticoagulants would be given to them so you wouldn’t want to carry out procedures that will result in bleeding,
Check clotting
How are patients on corticosteriods medically compromised?
Exogenous corticosteroids can lead to adrenocortical suppression - inadequate response to stress, trauma, operation or infection
Avoid NSAIDS = peptic ulcer
How do you assess the bleeding risk of a patient and what should you avoid if they do?
History, previous episode, previous surgery, family history, drug history
Avoid trauma, LA, intramuscular injections, aspirin or drugs that cause gastric bleeding
What is the INR?
International normalised ratio = a ratio of patient’s PT to normal mean PT (prothrombin time)
PT measures the extrinsic pathway
Normal INR is 1 but the desired INR varies with condition
What is the acceptable INR?
Less than 4
If more than 4, delay treatment until reduced
Check the value no more than 24 hours before procedure
What are some examples of different ideal INRs depending on the patient’s condition?
Prosthetic heart valve 3.5-4.5
DVT or PE 2.0-2.5
What if the patient’s INR doesn’t match the ideal INR of the procedure?
Adjust in collaboration with anti-coagulant/ GP
What is the recommendation for patients on DOAC (direct oral anticoagulant) requiring dental treatment?
If dental treatment has low bleeding complications risk, there is no need to interrupt the anticoagulant medication.
If dental treatment has high bleeding complications risk, advise them to miss their morning dose on the day of their dental treatment
What is important to note about being on antibiotics as well as warfarin?
The action of warfarin can be potentiated by some antibiotics e.g. erythromycin
What is the dental relevance of anaemic patients?
Reduction oxygen carrying capacity of blood.
May present with angular cheilitis, glossitis or BMS (burning mouth syndrome)
what are the 3 types of anaemia
Microcytic - Iron deficiency
Macrocytic - B12, Folate
Normocytic - Chronic disease
How might patients with a sickle cell crisis present and what do they require
May present with oral pain (may be due to infarction or osteomyelitis)
Often require aggressive treatment of infections as it may precipitate a crisis
They might need surgery which requires antimicrobial prophylaxis
Avoid GA if possible, liaise with GP/haematologist
What are the risks and things to be aware of with patients who have had transplants?
May have gingival hyperplasia if taking cyclosporin
May require:
- Antimicrobial prophylaxis
- Steroid cover
-May have a bleeding tendency if anticoagulated
-Liable to infections secondary to immunosuppression
-Discuss the case with the physician
-Risk of cancers
How can patients with prostheses (device replacing body part) affect dental treatment?
Possible bleeding tendency due to warfarin and risk of Infective endocarditis
What is Thalassaemia?
Asian, Middle Eastern, mediterranean
Iron overload, prone to infection
Severe anaemia
Thalassaemia major = regular transfusions whereas Thalassaemia minor doesn’t and people with the minor version live relatively normal lives
What should be avoided and what is best in each trimester for pregnant patients?
Drugs and radiation should be avoided especially in first trimester
Dental treatment best during second trimester
Antimicrobial drugs usually prescribed : penicillin and erythromycin
Analgesic’s prescribed: paracetamol
What LA should be used and avoided for pregnant women?
Lidocaine is safe but citanest should be avoided as it can cause contractions
What is important to carry out and be aware of before, during, and after cytotoxic chemotherapy?
Ensure patient is dentally fit before chemotherapy
Oral candidiasis is often a problem and may be treated with anti-fungal
Treatment should be carried out during the rest phase
What is important to carry out and be aware of before, during, and after radiotherapy?
Treatment should be carried out prior to radiotherapy
During radiotherapy, need supportive oral care due to mucositis (painful) and dry mouth (synthetic saliva)
After, maintain good oral hygiene
What are the key points for assessment of a medically comprised patient?
- Take a thorough medical history
- Identify the condition
- Understand the significance of the disease and how treatment will affect dental care
- Identify which cases can be treated safely in practice and which need hospital setting