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
How do you identify BRONJ?
- rule out malignancy - HX of head and neck radiography
- painful can also involve a draining sinus
- Confirm that it isn’t a soft tissue infection which might be extensive - commonly associated with BRONJ
- Usually follows after a tooth extraction but can also be associated to a poorly fitting denture
The risk of BRONJ increases with?
Invasiveness of treatment and type of medication
i.e.
low risk: Oral bisphosphonate use < 3years
mild risk: Oral bisphosphonate use < 3 years + steroids + immunosuppressant’s
high risk: IV bisphosphonates for cancer
You have a patient present advising that they will be commencing long term oral or IV bisphosphonate therapy - how do you proceed in this appointment.
Full comprehensive examination, ensure all dentures are fitting appropriately, and that oral health is good with no concern. Liaison with GP if any cause for concern - referral to dentist if any extensive work i.e. extractions need to occur.
Important to be all clear prior to beginning therapy as once the patient begins bisphosphonates therapy should not be ceased.
What are the modifiable risk factors of a stroke?
- High BP
- Smoking
- Diabetes
- Cardiovascular disease
- Hypercholesterolaemia
What would your management be regarding a stroke patient?
May be modified depending on severity.
i.e. large handle or powered toothbrush may be required to aid with dexterity to increase OH effectiveness. Patients with dentures may find difficulty in cleaning them.
What are oral implications of stroke?
- Slurred speech
- Weak palate
- Difficulty swallowing
- May be unilateral paralysis of orofacial muscles
- Tongue may be flaccid
- R sided brain damage: may neglect left side leading to food accumulation, lack of OH etc
Medications relating to stroke patients?
Anticoagulants.
- Increases bleeding times
- Do no cease medication ever
What is eplilepsy?
A group of chronic neurological conditions characterised by recurrent unprovoked epileptic seizures.
When you are treating a patient with epilepsy what should you be doing?
Getting a good history!
i.e. types of seizures, age on onset, medications, degree of control, frequency, date of last seizure, precipitating factors, history of seizure related injuries
When you are managing a patient with epilepsy in the clinic what are some steps you would take?
Short appointments, use of mouth prop (in case of seizure - prevents injury)
Patients usually take anticonvulsants - common side effect is gingival hyperplasia - requires that the OHT regularly reviews OHI and gingival health
What LA should be avoided with MAIOs? (monoamine oxidase inhibitors)
LA w/ adrenaline
for other LAs dose reduction regarding antidepressant medications
What is multiple sclerosis?
A disease that affects central nervous system. The immune system attacks the myelin, the protective layer around nerve fibers and causes Inflammation and lesions. This makes it difficult for the brain to send signals to rest of the body.
What are clinical signs of MS?
- muscle atrophy
- visual disturbances
- bladder problems
- muscle hypertonicity
- fatigue
- loss of sensations
Medications relating to MS - oral manifestations?
- Burning mouth syndrome
- Bleeding problems
- Increased risk of infections
How does dental management vary for a pt with MS?
Mild - routine dental care can be achieved easily
More severe - may be difficulty to get the patient in and out of the chair - OHI very important, short appointments.
Head and neck cancer regarding the dental professional?
Mostly palliative/supportive.
Patient probably undergoing surgical, radiotherapy and or chemotherapies.
There is a high morbidity and mortality
What is the oral consideration regarding radiotherapy?
- reduced or absent saliva flow = dry mouth
- saliva substitutes, fluoride/toothpaste
- mandibular extractions prone to osteoradionecrosis - refer to specialist
- mucositis = impact on diet
Oral considerations regarding chemotherapy?
- Modify treatment to suit patients needs and circumstances
- Treat between chemo treatments
Oral complications of radiotherapy?
- Mucositis/Ulceration
- Radiation caries/dental hypersensitivity/ periodontal disease
- Xerostomia/loss of taste
- Dysphagia
- Candidosis
- Osteoradionecrosis
- Trismus
- Craniofacial defects (children)
What are the oral complications of chemotherapy?
- Mucositis/ulceration/lip cracking
- Infections
- Bleeding
- Orofacial pain
What are the primary tumours in orofacial tissues?
Oral squamous cell carcinoma
Salivary adenocarcinoma
Metastases in jaws or oral soft tissues usually occurs from which primaries?
breast, lung, prostate
Effects of tumour metabolites?
- Facial flushing
- Pigmentations
- Amyloidosis
- Oral erosions
What do we need to do before radiotherapy?
OHI/ preventative and restorative dentistry
Evaluation of risk/benefits with keeping teeth
Dental extrations
What do we do for our patient during radiotherapy?
- Discourage smoking and alcohol
- Eliminate infections ABs/antifungals/antivirals
- Relieve mucositis
- Saliva substitutes
- TMJ physiotherapy for trismus
What do we do for our patient after radiotherapy?
OHI - preventative dentistry
Specialist OMFS for dental extractions/ oral surgery
- Topical fluorides
- Avoidance of mucosal trauma
- Saliva substitutes
What do we do with our patient prior to chemotherapy?
Oral/dental assessment
OHI
preventative dentistry
What do we do for our patient during chemotherapy?
- Folic acid to reduce ulceration
- Ice to cool oral mucosa
- Chlorhex mouthwashes
- Eliminate infections - ABs antifungals & antivirals
What do we do for our patient after chemotherapy?
OHI + preventative dentisitry
Monitor - risk of anaemia, bleeding, infection
What is hypertension?
High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). Symptoms varies from person to person and generally include unexplained fatigue and headache
If a patient has high blood pressure when are they able to have dental treatment?
They can have dental treatment if they are controlled with medication
What are the oral side effects of BP medications?
.
What medication should be used with caution and patients that have hypertension?
NSAIDs - can cause renal impairment
What is coronary artery disease?
A condition where the major blood vessels supplying the heart are narrowed. The reduces blood flow can cause chest pain and shortness of breath
Regarding Coronary Artery Disease - Angina, what does stable and unstable mean?
.
What medications do you take for coronary artery disease?
.
What is a myocardial infraction?
A heart attack
What are the oral effects of medications for CAD?
.
What is the difference between a anti coagulant and antiplatelet?
.
If your patient has a pacemaker is this a concern to you during general dental treatment?
They do not present a problem during general dental treatment.
If a patient w/ CAD has had elective treatment after myocardial infraction - had a stent placed or coronary bypass surgery how do you manage them?
- Liaison w/ GP and dentist
- Emergencies can be treated - refer to prophylaxis guidelines
- Post 6months confirm w/ GP if AB prophylaxis is required.
What medications do you need for heart failure?
Anti-hypertensives
Diuretics
Digoxin
What are the oral side effects of anti-hypertensives?
.
Oral side effects of diuretics?
.
Oral side effects of digoxin?
.
How do we manage a heart failure patient in the dental chair?
- Short appointment
- Slightly raised head position
- NSAID should be avoided
What conditions do we need to be aware of for endocarditis prevention?
Prosthetic Heart Valves or Prosthetic repairs
Congenital Heart disease
Cardiac Transplant
History of rheumatic heart disease - if an indigenous Australian
Summarise congenital heart defects
- Faults in the structure of the heart and great vessels that are present from birth
- Defects usually obstructs blood flow in the heart or nearby vessels, or causes blood to flow through the heart in an abnormal way
What is concerning about congenital heart defects dentally?
They are susceptible to bacterial endocarditis:
Thus may be requiring AB prophylaxis if unrepaired defects, if partially repaired or only 6months since surgery ABs required
*if repaired no need for ABs*
What are some anticoagulation and antiplatelet drugs?
Warfarin, Heparin, Aspirin, Clexane
Patients on these medication undergoing dentoalveolar surgery need to be assessed on the benefit of stopping medication VS continuing
INR?
International normalised ratio - i.e. monitoring levels of warfarin
What is the INR supposed to be prior to routine dental treatment
Less than 2.2
What dental considerations are there of leukaemia?
- Prolonged bleeding
- Infection
- Delayed healing
- Oral ulcerations
- Gingival Hyperplasia
How do you manage leukaemia during acute stage?
- Avoid dental treatment if possible
- AB + analgesics for infections
Dental management of leukaemia during remission
- Treat all active disease
- No complex treatment plan if poor prognosis - consider palliative care
What are some haematological conditions/bleeding disorders?
Thrombocytosis, haemophilia, von Willebrand’s disease
What are some dental considerations for bleeding disorders. haematological conditions?
- Prolonged bleeding
- Use atraumatic dental procedures - with suture and dressings for extractions
- Avoid mandibular block injections as they may be complicated by dissecting haematoma and airway obstruction
Where should you avoid injections for H.conditions and bleeding disorders?
Highly vascular areas
If your patient has H. Condition or bleeding disorders do you need a referral for periodontal deep scaling?
YES
What condition requires hospital admission upon multiple extractions?
Haematological Conditions and Bleeding Disorders
In your medical history relating to a patient with asthma what should you note?
- Triggers
- Last attack
- Severity
- Medications?
- Are the medications with them
Management of asthma - what should we consider?
Oral Candidosis - due to long term steroid use
Patient should frequently rinse mouth with water before and after inhaler
Medications we should avoid with asthma?
NSAIDs
Paracetamol as analgesic of first choice
What is COPD?
Chronic obstructive pulmonary disease
What is COPD a combination of ?
Emphysema - where the lung parenchyma are structurally damaged)
Airway damage - with wall thickening and narrowing of the airway
Cigarette smoking is the major causative factor
