Week Ten: Medically Compromised Patients Flashcards
When dealing with a medically compromised patient what should you consider in the clinical examination?
- Medical History - up to date; recent changes; chronic illness; operations; other
- Medications - current medications both prescribed, over the counter
and complementary
• medication list in writing from medical practitioner or pharmacist
• cross check medications with medical conditions
• Any medications that will require modification of dental management, or that have oral manifestations - Evaluate the ability of patient to tolerate type and length of procedure
• adjust length of appointment to suit condition
• consider time of day; fasting and eating; extractions
• life expectancy - modify treatment plan
What are important questions to ask yourself when dealing with a medically compromised patient?
• Is it safe to manage this patient?
• Does this patient need any precautionary measures
and if yes, which measures and steps?
• Do I need to contact patient’s GP, cardiologist,
surgeon, hemathologist, oncologist, radiologist, etc.
• Do I have the facilities and equipment to perform the
planned procedure(s)?
• Do I need to refer this patient?
What is diabetes mellitus?
The term is used to identify a group of disorders characterized by elevated levels of glucose in the blood.
How is diabetes mellitus caused?
By the body’s failure either to produce the hormone insulin or to effectively use its production of insulin
What types of diabetes are there?
Type 1, Type 2 & Gestational - there are also others…
Define Type 1 diabetes and its treatments
A chronic condition in which the pancreas produces little or no insulin.
Treated with monitoring blood sugar levels, insulin therapy, diet and exercise.
Define Type 2 diabetes and how it is treated?
A chronic condition that affects the way the body processes blood sugar (glucose)
The body doesn’t produce enough insulin or it resists insulin.
Treatments: diet, exercise, medication and insulin therapy
Define gestational diabetes and its treatment.
Elevated levels of blood glucose during pregnancy. Typically resolves after birth - these mothers are more likely to have type 2 diabetes later in life.
What is the normal level for random blood glucose?
3.5mmol/L to 8.0mol/L
*reasonable to control with dental treatment
What is a fair random control of blood glucose?
8.1% to 11.9%
What is a poor random control of blood glucose?
> 12.0%
- May wish to defer treatment here
- Liase with the GP as medications may need to be altered/pt needs to be further managed
What do you do if your patient has less than 3.5mmol/L glucose levels?
Treat as patient is hypoglycaemic - administer glucose and treat the patient as a medical emergency
Patient presents with oral infection and is confused. The patient is also noted to be taking insulin - what is the presumptive diagnosis?
Diabetic Ketoacidosis
Is there a relationship between diabetes and periodontal disease?
Yes
- Diabetes modifies the host response to plaque
- Periodontal disease modifies the ability to control blood sugar levels
*not an issue if diabetes is controlled
Is dental caries associated with diabetes?
There is little evidence suggesting this - though you should consider diet and and saliva quantity for the individual.
What are some oral manifestations of diabetes?
- Increased susceptibility to oral infections if poorly controlled
- Oral candida infections (increased association)
- Salivary dysfunction/dry mouth
- Taste disturbances/ neurosensory
How would you manage a well controlled diabetic patient?
- Similar to a non diabetic patient
- Are the type 1/2? NIDD (non insulin dependant diabetes - type 2) IDD (insulin dependant diabetes - type 1)
- Are they managing their glucose well?
- Appointments: short, stress free, early, post breakfast/lunch to avoid hypoglycaemic episode
What type of LA can you use with a diabetic patient?
- You can use a vasoconstrictor for profound anaesthesia
- Avoid excessive amounts of adrenaline to prevent elevation of blood glucose levels
An emergency TA appointment presents and the patient has diabetes, what steps are you going to take to ensure this will be a safe appointment and that they are not impacted post appointment?
- Thorough MHX, recent blood sugar reading
- Has the patient eaten recently
- If not, pain manage however request the patient eat something prior to treatment. Especially if the patient will be numb and will not be able to safely eat post treatment.
- Planning is incredibly important with diabetic patients
Risk of hypoglycaemic episode is increased by?
- Lack of food before appointment
- Stress
- Exercise
- Excess alcohol
What risks can cause hyperglycaemic crisis?
- High blood sugar
- Lack of insulin
The thyroid gland produces?
Thyroxine
What are the two main disorders of the thyroid gland?
- Hyperthyroidism
- Hypothyroidism
What are the oral manifestations of hyperthyroidism?
- Accelerated dental eruption in children
- Maxillary/mandibular osteoporosis
- Enlargement of extra glandular thyroid tissue - prominent at the lateral posterior tongue
- Increased susceptibility to caries
- Periodontal disease
- Burning mouth syndrome
- Development of connective tissue disease i.e. Sjogren’s syndrome, systemic lupus erythematous
What are the oral manifestations of hypothyroidism?
- Delayed eruption
- Enamel hypoplasia in both dentitions - less so in permanent
- Anterior open bite
- Macroglossia
- Micrognathia
- Thick lips
- Mouth breathing
What is the function of the parathyroid hormone?
Secreted in the parathyroid, it is closely linked with homeostatic regulation of the calcium ion concentration
What are some oral manifestations of hyperparathyroidism?
Dental anomalies: 1. Widened pulp chambers 2. Development defects 3. Alterations in dental eruption 4. Weak teeth 5. Malocclusions
Other: Brown tumor, Loss of bone density, Soft tissue calcifications
What are some oral manifestations of hypoparathyroidism?
Mandibular Tori, Chronic Candidiasis, Paraesthesia of the tongue or lips
Specific dental anomalies: Enamel hypoplasia in horizontal lines, poorly calcified dentine, widened pulp chambers, dental pulp calcifications, shortened roots, hypodontia, delay or cessation of dental development
What considerations do we have to make when a patient presents with hyper/hypoparathyroidism?
- Must be managed by medication, diet and vitamin D supplement
- Patients who have hyperparathyroidism may also develop osteoporosis
*some medications of the above have dental implications
What are adrenal disorders commonly treated with?
Corticosteroids
What are corticosteroids often used for?
Supress inflammatory response, immunosuppression in patients with autoimmune disorders/transplant patients, corticosteroids can suppress the normal adrenocortical response to stress
What happens if a patient has been taking corticosteroids for already a period more than a week?
Adrenal supression
Why does administration of systemic corticosteroids cause suppression of adrenal function?
Corticosteroids reduce the stimulation required from the adrenal glands, there incurs a negative feedback and the bodies natural steroid production is reduced. This in time leads the adrenal cortex to atrophying. This means that the adrenals cannot produce increased levels of hormones when a patient is under stress - this leads to adrenal crisis
What is adrenal crisis?
Blood pressure immediately drops which can result in cerebral hypoxia if untreated
What must we consider when treating a patient taking corticosteriods?
Liase with the GP as the patient may need their dose increased prior to treatment. It is also important to check that they are not also taking bisphosphonates for steroid induced osteoporosis.
What does adrenal crisis look like?
It can present 6-12hrs after surgical stress, the patient may feel initially faint, become confused and may even collapse.
What considerations do we make for a patient that is taking corticosteroids?
- Increased risk of oral infections
- Delayed wound healing
- Risk of secondary infections
Simply explain osteoporosis.
Low bone mass and deterioration of bone - a bone and calcium disorder
What are some other bone disorders?
- Pagets disease
- Malignancy
- Hypocalcaemia
For Bone and Calcium disorders, beside corticosteroids what else is a drug of choice for management?
Bisphosphonates - they can be used in conjunction with corticosteroids
What is BRONJ?
Bisphosphonate related osteoradionecrosis of the jaw - this occurs after an area of bone is exposed for more than 8 weeks in a patient treated with bisphosphonates.
What is this image?
BRONJ
What is this XR showing?
BRONJ