The Management of the Medically Compromised Patient

Question 1

What is a medically compromised patient?

Answer 1

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

Question 2

Why is it important to have knowledge about any medical conditions that the patients have?

Answer 2

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

Question 3

When taking patient’s history, what is important to do and ask about?

Answer 3

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

Question 4

How should you examine a medically compromised patient?

Answer 4

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

Question 5

What does being prepared for your patient involve?

Answer 5

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

Question 5

What kinds of complications/things are there to be aware of for patients with cardiovascular system problems?

Answer 5

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

Question 6

What is citanest?

Answer 6

Local anaesthetic that contains prilocaine

Question 6

What is the ASA (American Society of Anesthesiologists) classification?

Answer 6

Physical status assessment tool; helps determine RELATIVE risk for anaesthesia

Strongly associated with perioperative risk & outcomes

Question 7

What is infective endocarditis?

Answer 7

Infection of the lining of the heart, particularly affecting the heart valves

It’s caused mainly by bacteria but occasionally by other infectious agents

Question 8

Who is at risk of getting infective endocarditis?

Answer 8

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

Question 9

What is important to tell the patient about the current advice for people at risk of infective endocarditis?

Answer 9

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

Question 9

What is the current advice for people at risk of infective endocarditis?

Answer 9

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

Question 10

What determines the subgroup of people at risk of infective endocarditis for whom it might be prudent to specially consider routine antibiotic prophylaxis?

Answer 10

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Question 11

What are some oral antihypertensive drug side effects for patients who are hypertensive?

Answer 11

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

Question 12

What is important to be aware of for patients with hypertension in the dental clinic?

Answer 12

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

Question 12

What things are important to keep in mind with a patient who has respiratory issues?

Answer 12

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

Question 12

What do you have to be aware of when booking appointments for patients with diabetes mellitus?

Answer 12

Timing of the appointment to avoid patients having hypoglycaemia e.g. in the morning or just after lunch would be best

Question 12

What are diabetic patients more prone to getting and how does this affect them?

Answer 12

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

Question 12

What might be necessary to do if a diabetic patient requires GA?

Answer 12

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

Question 12

Ideally, when should dental treatment be carried out in epileptic patients?

Answer 12

When there is good seizure control

Question 13

What are some problems you have to be mindful of when it comes to patients with epilepsy?

Answer 13

Convulsions (self terminating/ buccal midazolam)

Drug reactions (enzyme inducers)

Bleeding tendency (sodium valproate CBZ)

Gingival hyperplasia with phenytoin

Question 14

What are some problems relating to liver disease that can impact dental care?

Answer 14

• 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

Question 14

How are patients with alcohol dependance medically compromised?

Answer 14

Can lead to wide range of problems like liver disease which then leads to problems with drug metabolism and bleeding

Question 15

What is the dental relevance of chronic renal disease?

Answer 15

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

Question 16

How are patients on corticosteriods medically compromised?

Answer 16

Exogenous corticosteroids can lead to adrenocortical suppression - inadequate response to stress, trauma, operation or infection

Avoid NSAIDS = peptic ulcer

Question 16

How do you assess the bleeding risk of a patient and what should you avoid if they do?

Answer 16

History, previous episode, previous surgery, family history, drug history

Avoid trauma, LA, intramuscular injections, aspirin or drugs that cause gastric bleeding

Question 17

What is the INR?

Answer 17

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

Question 18

What is the acceptable INR?

Answer 18

Less than 4

If more than 4, delay treatment until reduced
Check the value no more than 24 hours before procedure

Question 19

What are some examples of different ideal INRs depending on the patient’s condition?

Answer 19

Prosthetic heart valve 3.5-4.5

DVT or PE 2.0-2.5

Question 19

What if the patient’s INR doesn’t match the ideal INR of the procedure?

Answer 19

Adjust in collaboration with anti-coagulant/ GP

Question 20

What is the recommendation for patients on DOAC (direct oral anticoagulant) requiring dental treatment?

Answer 20

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

Question 20

What is important to note about being on antibiotics as well as warfarin?

Answer 20

The action of warfarin can be potentiated by some antibiotics e.g. erythromycin

Question 21

What is the dental relevance of anaemic patients?

Answer 21

Reduction oxygen carrying capacity of blood.

May present with angular cheilitis, glossitis or BMS (burning mouth syndrome)

Question 22

what are the 3 types of anaemia

Answer 22

Microcytic - Iron deficiency
Macrocytic - B12, Folate
Normocytic - Chronic disease

Question 23

How might patients with a sickle cell crisis present and what do they require

Answer 23

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

Question 24

What are the risks and things to be aware of with patients who have had transplants?

Answer 24

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

Question 24

How can patients with prostheses (device replacing body part) affect dental treatment?

Answer 24

Possible bleeding tendency due to warfarin and risk of Infective endocarditis

Question 25

What is Thalassaemia?

Answer 25

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

Question 26

What should be avoided and what is best in each trimester for pregnant patients?

Answer 26

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

Question 27

What LA should be used and avoided for pregnant women?

Answer 27

Lidocaine is safe but citanest should be avoided as it can cause contractions

Question 28

What is important to carry out and be aware of before, during, and after cytotoxic chemotherapy?

Answer 28

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

Question 29

What is important to carry out and be aware of before, during, and after radiotherapy?

Answer 29

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

Question 30

What are the key points for assessment of a medically comprised patient?

Answer 30

• 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