Management of Medically Compromised Patients in Dentistry

Management of Medically Compromised Patients in Dental Clinics

• The presentation is about managing medically compromised patients in dental clinics.
• It emphasizes treating the patient, not just the tooth/problem.

General Concept

• The presentation discusses the difference between treating a patient and treating a tooth, emphasizing that patients' underlying health conditions influence dental procedures.

Medically Compromised Patients

• Medically compromised patients often have underlying medical problems.
• These problems limit their ability to handle stress normally, increasing their risk of an acute exacerbation of their underlying diseases.

Pre-surgical Evaluation

• General physical condition assessment is crucial.
• Medical consultation is important to understand the patient's medical history.
• Drug sensitivities and interactions must be considered.
• Premedication is essential for managing anxiety.
• The choice of anesthesia is crucial and depends on multiple factors
• The need and quantity of vasoconstrictors in anesthesia should be carefully determined; techniques used should be carefully selected.
• Operative time considerations are crucial.
• Postoperative care plans should also be considered.
• Normal adult vital signs include: core temperature (98.6°F/37°C), heart rate (60-100 beats per minute), respiratory rate (12-18 breaths per minute), blood oxygen (95-100%), and blood pressure (120/80 mmHg).

American Society of Anesthesiologists (ASA) Classification

• ASA classification is a grading system used to determine the health status of patients before a surgical procedure requiring anaesthesia.

• It assesses the health risk associated with the procedure.

• ASA I: Normal, healthy patient

• ASA II: Patient with mild systemic disease or significant health risk factors.

• ASA III: Patient with severe systemic disease that is not incapacitating.

• ASA IV: Patient with severe systemic disease that is a constant threat to life.

• ASA V: Moribund patient not expected to survive without the operation.

• ASA VI: Declared brain-dead patient whose organs are being harvested for donation.

Threats Faced by Medically Compromised Patients

• Fear and stress
• Local anesthetic agents/vasoconstrictors
• Bacteremia
• Bleeding time

Stress

• Stress is a significant trigger affecting patients' health.
• It is a physical, chemical, or emotional pressure cause.
• It impacts bodily and mental tension and can cause disease.
• Stress is a potential trigger for a medical emergency in dental patients.
• The release of adrenaline is 40 times higher during stress (from 7 to 280/mm).

Anxiety

• Anxiety triggers the release of epinephrine and norepinephrine.
• This leads to an increase in heart rate, blood flow, and respiration.
• Vasodilation can occur in the periphery (arms and legs).
• Serum glucose levels can also change due to anxiety.

Signs of Acute Anxiety

• Cold, sweaty palms or forehead
• Flushing of face
• Altered facial expression (e.g., bulging eyebrows)
• Unnaturally stiff posture
• Dry mouth
• Bruxism (teeth clenching)
• Increased need to urinate

First Consultation

• Getting to know the patient is crucial for building a rapport.
• A thorough medical history is needed.
• Patient likes and dislikes should be noted.
• Acknowledging and validating patient feelings is vital.
• Empathetic understanding of the patient's situation is essential and long term.

Communication

• Active listening is necessary.
• Show interest in the patient's conversation to ease their anxiety
• Maintain eye contact at an appropriate level between the patient and staff.
• Positioning away from the equipment.

Stress Reduction in Dentistry (Before Appointment)

• Using hypnotic agents before surgery to improve sleep.
• Using sedative agents to decrease anxiety before the procedure is also an option.
• Scheduling morning appointments to minimize reception time.

Stress Reduction (During Appointment)

• Frequent verbal reassurances
• Distracting conversations
• Avoiding surprises.
• Ensuring the patient is comfortable.
• Using relaxing music
• Keeping surgical instruments out of patient's sight

Stress Reduction (After Appointment)

• Provide detailed instructions for postoperative care
• Providing information regarding possible complications
• Providing further reassurance.

Diabetes Mellitus

• Diabetes is a chronic metabolic disorder characterized by consistently high blood glucose levels.
• Insulin is vital for transporting glucose from the bloodstream into cells.

Types of Diabetes

• Type 1: Autoimmune condition where the immune system attacks and destroys insulin-producing cells. A daily insulin dose is needed to manage blood sugar levels.
• Type 2: The body doesn't use insulin properly, or doesn't produce enough insulin to manage blood glucose levels. Monitoring of blood glucose levels is crucial and managing it by lifestyle change is possible.
• Gestational: Type of diabetes that develops during pregnancy.

General Manifestations of Diabetes Mellitus

• Excessive thirst(Polydipsia)
• Extreme hunger (Polyphagia)
• Frequent urination(Polyuria)
• Unexplained Weight loss
• Sudden vision changes
• Tingling or Numbness in the hands and feet
• Feeling very tired much of the time
• Very dry skin
• Sores that are slow to heal.
• More infections than usual

Oral Manifestations in Diabetes Mellitus

• Dry mouth (xerostomia)
• Tooth decay (including root caries)
• Gingivitis, periodontal disease, oral candidiasis, burning mouth.
• Altered taste
• Geographic tongue, coated and fissured tongue.
• Oral lichen planus (OLP), recurrent aphthous stomatitis.
• Increased tendency to infection & defective wound healing & periapical lesions.

Key Indicators for Diabetes

• Fasting Blood Glucose (for 8 hours):

  • Normal: 70-100 mg/dL
  • At Risk: 100-125 mg/dL
  • Diabetic : 126 mg/dL or higher on two separate tests

• Hemoglobin A1C (HbA1c) test:

  • Normal: Below 5.7%
  • Prediabetes: 5.7% to 6.4%
  • Diabetic: 6.5% or above

Random Blood Sugar Test

• This measures blood sugar level at the time of the test.
• Blood sugar level of 200 mg/dL or higher indicates diabetes.
• No need to fast first.

Management of Diabetes

• Elective surgery should be deferred until diabetes is well-controlled.
• Consult the patient's physician about the current state of their health.
• Monitor pulse, respiration, and blood pressure before, during, and after surgery.
• Early short appointments
• Patients take his/her medication before conducting the surgery to avoid hyperglycemic coma.
• Patients take his/her breakfast before conducting the surgery to avoid hypoglycemic coma.
• Maintain verbal contact with the patient throughout the procedure.
• Alter medication dosage and administer antibiotic if needed.

Anxiety And Fear Management

• General physical condition
• Medical consultation
• Drug sensitivities
• Premedication or use of sedatives

Chronic Stress Management

• Stress reduction protocol

Management of other clinical conditions

• Adrenal insufficiency
  • Patients on long term corticosteroids should have a double dose on surgical days.
• Thyroid Diseases
  • Defer treatment.
  • Monitor pulse and blood pressure.
  • Avoid use of LA with vasoconstrictors.
• Hypertension
  • Mild‐moderate: seek guidance for medical therapy; monitor blood pressure, use LA with vasoconstrictor up to 4 carpules of L.A
  • Severe: emergency treatment, medical consultation required, no antibiotics, 0.04 epinephrine only.
  • Use anxiety-reduction protocol, avoid rapid posture changes, avoid administration of sodium-containing IV solutions.
• Cardiac Disorders (Ischemic Heart Disease)
  • Precipitating factors: physical exertion, stress, heavy meals, cold exposure, smoking, emotional disturbances.
  • Angina Pectoris: chest pain relieved by rest/nitrates; typically caused by mild coronary ischemia.
  • Myocardial infraction: severe angina pectoris over a long-term causes necrosis in the heart muscle; surgery should be deferred at least 6 months after the last attack.
• Heart Failure
  • Elective surgery under GA is contraindicated until CHF is under control.
  • For controlled patients, treatment under LA is possible providing the underlying cause is considered. Avoid placing the patient in a supine position if they cannot tolerate it.
• Rheumatic Fever
  • Aggressive preventive regimen is necessary during periods of active disease. Treatment planning may vary.
• Bleeding Disorders
  • Treatment is deferred until a specialist consults. Coagulation tests are necessary; Schedule the surgery after measures have been taken for correction
• Anemia and Thrombocytopenia
  • Laboratory investigations (CBC) are important. Ensure hemoglobin is above 11 g/dL and the patient is symptom-free.
• Leukemia
  • Medical consultation is essential. Avoid procedures for patients with low platelet counts. Use preventative antibiotics. Local hemostatic measures should be used.
• Hepatic Disorders
  • Evaluate and monitor for viral components (B, C).
  • Avoid drug with hepatic metabolism/excretion & use amide type L.A
• Asthma
  • Defer dental treatment until asthma is controlled and no sign of infection is present.
• Chronic Obstructive Pulmonary Disease (COPD)
  • Defer treatment until pulmonary function has improved. Listen to breath sounds.. Use anxiety-reduction protocol, but avoid respiratory depressants and supine positioning. Provide supplemental oxygen only with physician consultation and following prescribed flow rate
• Organ Transplants -Defer treatment until the patient's primary care physician or transplant surgeon clears the patient for dental care. Avoid nephrotoxic drugs. Monitor blood pressure. Consider the use of supplemental corticosteroids. Consider screening before dental care
• HIV & AIDS
  • Last appointment and infection control measures . Use disposable instruments. If not disposable, wash and immerse in 2% glutaraldehyde for 24 hours before autoclaving. Avoid alginate(syneresis & imbibition). Use silicone or rubber base
• Chemotherapy and Radiotherapy
  • Remove septic foci before administration. Avoid extractions (potential osteoradionecrosis). If extraction, allow at least 6 months after last dose for blood supply regeneration. Consult for exact drugs to potentially modify or avoid.

This presentation focuses on the management of medically compromised patients within dental clinics. It highlights the importance of evaluating patients' overall health conditions and their impact on dental treatments. Understanding patient history, pre-surgical assessments, and appropriate medication are key to successful dental care for these individuals.