Dental Assistants and Hygienists PDF

29 The Special Needs and Medically Compromised Patient L E A R N I N G A N D P E R F O R M A N C E O U TCO M E S Learning Outcomes On completion of this chapter, the student will be able to achieve the following objectives: 1. Pronounce, define, and spell the key terms....

29 The Special Needs and Medically Compromised Patient L E A R N I N G A N D P E R F O R M A N C E O U TCO M E S Learning Outcomes On completion of this chapter, the student will be able to achieve the following objectives: 1. Pronounce, define, and spell the key terms. 4. Discuss the importance of the medical history for the special 2. Discuss the role of the dental assistant when caring for the needs/medically compromised patient. special care patient. 5. Give the major medical disorders that can affect a patient’s oral 3. Describe the stages of aging in the older population and the health, and include the type of dental management a orally related conditions that affect this population. medically compromised patient would receive. Performance Outcome On completion of this chapter, the student will be able to meet competency standards in the following skill: 1. Demonstrate the correct transfer of a wheelchair-bound patient. KEY TERMS Alzheimer’s (AHLTS-hie-merz) disease a form of progressive hyperglycemia (hye-pur-glye-SEE-mee-uh) condition when the mental deterioration that occurs in middle to older age blood glucose level is too high and the body is not properly anemia (uh-NEE-mee-uh) a deficiency of red blood cells or using or making insulin hemoglobin in the blood, resulting in paleness and weakness hyperthyroidism (hye-pur-THYE-roid-iz-em, angina (an-JYE-nah) severe chest pain associated with an hye-pur-THYE-roi-di-zem) condition that results from insufficient supply of blood to the heart excessive activity of the thyroid gland arthritis (ahr-THRYE-tis) inflammation of a joint or many joints, hypoglycemia (hye-poe-glye-SEE-mee-uh) condition caused by a resulting in pain and swelling very low level of blood glucose, which is the body’s main asthma (AZ-muh) respiratory disease often associated with energy source allergies, characterized by sudden recurring attacks of labored hypothyroidism (hye-poe-THYE-roid-iz-em, breathing, chest constriction, and coughing hi-poe-THYE-roi-di-zem) condition that results from a thyroid atrophy (AT-ruh-fee) a wasting away or deterioration hormone insufficiency bacteremia (bak-tur-EE-mee-uh) presence of bacteria in the blood leukemia (loo-KEE-mee-uh) a type of cancer of the blood and bronchitis (bron-KYE-tis) inflammation of the mucous bone marrow that produces an increased number of immature membranes of the bronchial tubes or abnormal white cells dementia (duh-MEN-shuh) a mental disorder characterized by myocardial infarction (mye-oe-KAHR-dee-ul in-FAHRK- loss of memory, concentration, and judgment shun) condition in which damage occurs to the muscular diabetes mellitus (dye-uh-BEE-teez MEL-e-tus, me-LYE-tus) tissue of the heart, commonly caused by obstructed circulation; (DM) metabolic disorder characterized by high blood glucose also referred to as a heart attack and insufficient insulin produced by the body rheumatoid arthritis (RA) a disease that causes pain, stiffness, emphysema (em-fi-ZEE-muh) abnormal increase in the size of swelling, and loss of function in the joints the air spaces in the lungs, resulting in labored breathing and seizure an uncontrolled electrical disturbance in the brain, an increased susceptibility to infection causing a spasm or convulsion, that occurs in specific disorders endocarditis (en-doe-kahr-DYE-tus) inflammation of the stroke a sudden loss of brain function caused by blockage or endocardium lining of the heart rupture of a blood vessel to the brain; also called epilepsy (EH-pi-lep-see) neurologic disorder with sudden cerebrovascular accident recurring seizures of motor, sensory, or psychic malfunction xerostomia (zeer-oe-STOE-mee-uh) Loss of saliva production hemophilia (hee-moe-FIL-ee-uh) blood coagulation disorder in causing a dry mouth which the blood fails to clot normally 409 410 PART 6 Patient Information and Assessment T oday, every single dental practice will care for patients with a special need. Because of the major advances in medicine, people are living longer and surviving medical disorders that in the past would have resulted in disability or premature death. According to the U.S. Department of Commerce, statistics show that nearly 1 of every 2 people (133 million) have a chronic condition. This could be an illness such as heart disease, diabetes, arthritis, migraines, or back pain caused from a car accident. It is estimated that 2% have some type of disabling disorder, such as developmental disabilities, neuromuscular disorders, immunocom- promising conditions, cognitive impairment, mental disorders, and trauma. It is the responsibility of the dentist and the dental team to recognize these chronic diseases and identify the challenges that face these patients when receiving dental care. Patients who enter your dental practice may be ill, in pain, or physically challenged. Fig. 29.1 The aging population. (Copyright iStock.com/Goodboy Picture Your job is to use good judgment when working with these patients, Company.) which may mean bypassing some of the usual procedures that take place during an appointment. It is imperative that the dental team and the patient’s medical team work together to modify dental attitudes, characteristics, and needs, older adults can be divided treatment according to the patient’s needs. into three categories: Functionally independent older adults are better educated and Role of the Dental Assistant are more demanding of health services than in the past. This group has retained most of their natural teeth and expects to The dental assistant’s role in caring for the special care patient can maintain them throughout their lives. be divided into the following three major areas: Frail older adults are beginning to have multiple health problems. 1. Aiding the dentist in providing treatment. The chairside assistant Some have maintained their natural teeth, but more of them must be familiar with specialized techniques and equipment have fixed and removable prostheses. used in treating the medically and physically compromised Dependent older adults have fewer natural teeth and often think patient. The efficiency of all dental team members is important tooth loss is an inevitable part of aging. This segment of the to the speed and ease of treatment. population tends to have medical conditions that are reflected 2. Serving as a source of information for the patient and the family. in their oral health. Preventive dentistry is particularly important and may prove difficult for the physically and medically challenged patient. The assistant may be asked to work with the patient and family RECALL to develop and implement a preventive program that is tailored 1. What role does the dental assistant have with medically and physically to the needs of the patient. compromised patients? 3. Making the patient more comfortable and reducing anxiety. The 2. What is the fastest growing segment of the population? patient may be particularly apprehensive because of extensive past painful experiences with medical treatment. It is the job of the dental team to help alleviate anxiety and provide a Oral Health of the Aging comfortable environment. The aging population is faced with special oral health issues, The Aging Population and the goal of the dental team for these patients is to factor this into the treatment planning phase. The condition of a patient’s With a declining birth rate and increased longevity, the aging mouth can a%ect self-esteem, esthetics, nutrition, social interaction, population is the fastest growing segment of the U.S. population. and personal comfort. A person’s general health can deteriorate People age 65 and older make up 13.7 of the population and because of poor oral health. represent about one in every eight persons in the United States. Along with the medical history, it is essential that a medication It is estimated that by 2050, people age 65 and older will make profile be completed for each patient. One of the hallmarks of up 21% of the U.S. population (Fig. 29.1). disease is the list of prescriptions a patient is taking. These drugs not only indicate the patient’s disease state, but they also have potential adverse e%ects that, along with drug interactions, must Stages of Aging be taken into consideration during treatment planning. A medication Aging refers to the irreversible and inevitable changes that occur profile can indicate the severity of a patient’s medical condition with time. Most oral conditions that develop in older adults were (Fig. 29.2). once thought to be the result of aging, not of disease. Current science is showing that this is not the case. In diagnosis and treat- Oral Health Conditions ment planning, it is helpful to di%erentiate signs and symptoms caused by aging from those caused by disease. The most commonly reported oral health–related conditions that Older adults, or persons older than age 65, vary in their psy- a%ect the aging population are xerostomia, periodontal disease, chological and physiologic stages. In agreement with their varying tooth decay, dark and brittle teeth, and bone resorption.  CHAPTER 29 The Special Needs and Medically Compromised Patient 411 Be an Active Member of Your Health Care Team DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration My Medicine Record Name (Last, First, Middle Initial): Birth Date (mm/dd/yyyy): What I’m Using Rx – Brand & generic What It Looks Like Start / How to Use / Why I’m Using / Who Told Me to Use / name; Color, shape, size, How Much Stop When to Use Notes How to Contact OTC – Name & active markings, etc. Dates ingredients — Enter ALL prescription (Rx) medicine (include samples), over-the-counter (OTC) medicine, and dietary supplements — 40 mg; Take orally, 2 times a Lowers blood pressure; 20 mg pill; Dr. X Ex: XXXX/xxxxxxxxxx use two 20 mg day, at 8:00 am & 1-15-11 check blood pressure once a small, white, round (800) 555-1212 pills 8:00 pm week; blood test on 4-15-11 1 2 3 4 Fig. 29.2Example of a medication profile for a patient. (Courtesy Department of Health and Human Services, Food and Drug Administration.) Fig. 29.3 Periodontal conditions of an older patient. Fig. 29.4 Root caries of a tooth in an older patient. Xerostomia (Fig. 29.3). Periodontal disease can be prevented by better oral Also known as dry mouth, xerostomia is the result of medical hygiene and more frequent visits to the hygienist. disorders and medications that cause a decreased flow of saliva. Hundreds of medications, including many over-the-counter drugs, Tooth Decay produce dry mouth as a side effect. In addition to drug adverse Studies have shown that older patients have a higher risk for root effects, xerostomia is frequently associated with alcoholism, caries and recurrent decay around old or worn restorations. With autoimmune disorders, Parkinson’s disease, psychological disorders, aging, often the gums recede, exposing the roots of the teeth. In dehydration, radiation to the salivary glands, diabetes, Sjögren’s contrast to the crowns, the roots of the teeth are not protected by syndrome, and oral breathing. enamel, so decay can quickly develop on root surfaces (Fig. 29.4). Root caries can sometimes be prevented by dietary adjustments Periodontal Disease and changes in oral hygiene care. Periodontal conditions are an increasing problem in the aging population. More than 50% of older people may be affected by Dark and Brittle Teeth periodontal disease, and most are unaware of it. As a larger number As we age, teeth may darken and become more brittle. This is a of older people retain their teeth, periodontal disease will increase result of deposits of secondary dentin that have gradually reduced 412 PART 6 Patient Information and Assessment Category IV: Patients with medical conditions who require more significant modifications in dental treatment planning, including treatment to meet dental needs within the operating room Category V: Patients with serious medical conditions who require only limited care to eliminate serious acute oral disease; includes patients who must be kept free of pain and discomfort Assistance From Organizations Many organizations can provide information to assist you in updating and educating the dental staff. To better prepare you, the patient, and the family, seek guided assistance from these groups. The American Speech-Language-Hearing Association, for example, offers information on hearing loss and communication problems in older people and provides a list of certified audiologists and speech pathologists. Fig. 29.5 Darkened teeth associated with secondary dentin and aging. RECALL 3. In what category would you assess a patient who has experienced a stroke and is wheelchair bound? 4. What is xerostomia? 5. What are the most common oral health conditions that affect the aging population? Specific Disorders of the Medically Compromised Patient A basic understanding of how a disorder can affect a person’s oral Fig. 29.6 Bone resorption with loss of teeth and alveolar ridge. health is important to prevent tooth loss or other complications. Symptoms of more than 100 diseases can indirectly affect a patient by causing a person to be less capable of caring for his or her the size of the pulp chamber. These teeth can then become more mouth. susceptible to fracture (Fig. 29.5). Medical and physical disorders are categorized to help you learn and understand each disease and how to care for that patient in Bone Resorption your practice. When teeth are missing, the patient is partially to fully edentulous. Portions of the alveolar ridge will become compromised and lost Developmental Disorders (Fig. 29.6). Bone resorption can affect whether the patient will wear a removable prosthesis, as well as the patient’s speech and Developmental disorders are the result of an impairment that diet (see Chapter 52). occurred during a person’s developmental phase (prenatal through age 18). This impairment can occur prenatally, during birth, or The Special Needs Patient postnatally. Disorders causing a developmental disability can be chromosomal abnormalities such as intellectual disability and Down Providing dental care to patients with a physical or medical disorder syndrome, autism, cerebral palsy, fetal alcohol syndrome, postnatal will require increased awareness and attention and possibly modifica- infection, or birth anoxia. Many patients with developmental tion of clinical care by the dentist and dental staff. Once the health disorders are routinely seen in a pediatric dental office. The pediatric and medication histories have been obtained from the patient, dentist receives extensive education and training on seeing and this information is reviewed at each appointment. Each patient treating these types of special patients. For more information on should be assessed before treatment is provided. oral conditions and clinical management, refer to Chapter 57. An easy technique to use with your patients is to categorize each patient according to how treatment is anticipated to proceed Intellectual Disability and what changes are to be made by the dental team: Intellectual disability is the impairment in intellectual and adaptive Category I: Healthy patients who require no special functioning. The cause is not always known, and multiple causes modifications are commonly identified. Some of the known reasons are chro- Category II: Patients with medical conditions who require mosomal abnormalities, prenatal conditions (rubella, alcohol use, scheduling changes or shorter appointments and drug use), perinatal events (anoxia), and postnatal conditions Category III: Patients with medical conditions who have lifelong (meningitis, encephalitis, trauma, cultural deprivation, severe implications; these patients require modifications in dental malnutrition). treatment planning, including alterations in anesthetic, types Intellectual disability occurs at many levels, and it is important of dental materials, and patient positioning to understand a patient’s level of communication.  CHAPTER 29 The Special Needs and Medically Compromised Patient 413 alkways, sidewalks, and parking facilities Down Syndrome Entrance ramps, handrails, hallways, and elevators Down syndrome, also termed trisomy 21, is one of the most well- Door width and door pressure or ease of opening known developmental disorders. It is associated with an extra Adequate space around door to maneuver a wheelchair and chromosome of the twenty-first group. These individuals have 47 elevator accessibility chromosomes rather than the standard complement of 46. The Floor surface, carpets, and rugs incidence of Down syndrome is 1 in 700 live births. However, Restroom facilities incidence increases with the age of the mother; at age 54, the Reception room design, furniture style, and lighting incidence is 1 in 54. Operatory design to allow for wheelchair transfer or in-wheelchair Physical appearance includes slanted eyes; a broad, flat nose; treatment and a shorter stature. This disorder brings about multiple medical A wheelchair provides mobility to an individual who is paralyzed, conditions that are to be considered when treating the patient, has an amputation, or has a debilitating disease that produces including intellectual disability, congenital cardiac anomalies, seizure weakness in the lower half of the body. Many dental units now disorders, upper respiratory tract disease, leukemia, and are designed to accommodate a wheelchair, so the patient may hepatitis. remain seated in the chair rather than having to be moved. If the circumstance arises for the patient to be transferred to the Autism dental chair, you must follow a routine procedure for transferring a Autism affects how information is processed in the brain by altering patient. how nerve cells and their synapses connect and organize. Individuals See Procedure 29.1: Transferring a Patient From a Wheelchair. with autism disorders demonstrate di%culties in three main areas: social interaction, communication, and repetitive behaviors or Vision Impairment restricted interests. Visual impairments vary from total blindness to limitations in The aspects of social interaction in individuals with autism color perception, distance perception, recognition of shapes, may alter how a patient will interact at the dental o%ce. They and size of visual field (Fig. 29.8). The vision-impaired person may have difficulties with eye contact, an inability to read has learned to rely on the sense of touch and on verbal com- facial expressions, and difficulties with social exchange and munication with others. For patients who cannot see their interactions. surroundings, all procedures should be thoroughly explained first. The trip to the treatment area, positioning, and even smells from the dental materials must be discussed before Physical Disorders treatment. The patient who is physically challenged must adapt to a very fast-paced and mobile world. A wheelchair-bound, vision-impaired, or hearing-impaired patient who is entering the dental o%ce can CLINICAL CONSIDERATIONS FOR VISUALLY alter the daily routine if the o%ce is not prepared (Fig. 29.7). This IMPAIRED PATIENTS patient may need more time for the appointment, and the dental unit may have to be arranged differently. However, the best way When guiding the visually impaired patient, offer your arm and let the to prepare is through teamwork and communication. patient hold your arm; do not push the patient. Describe obstacles as you guide the patient. The Patient in a Wheelchair If a guide dog is being used, do not pet or interfere with the dog first ask the patient how to handle the dog. Accessibility to the dental o%ce is necessary if you are going to provide dental care to individuals with physical disabilities. Failure to provide access such as wheelchair ramps could be considered discrimination. Specific considerations should be included when an o%ce is being designed for all patients: Hearing Impairment The patient who is hearing impaired should be treated with extra care and courtesy. Hearing-impaired patients may show no visible evidence of hearing loss and may not respond to questions and instructions or may respond inappropriately. CLINICAL CONSIDERATIONS FOR HEARING- IMPAIRED PATIENTS Remove unnecessary noise such as suction and music when communicating. Remove your mask when speaking to expose your lips. Use mirrors, models, drawings, and written information to supplement communication. Keep directions simple and provide written copies for the patient to take home. A sign language interpreter can be valuable. Fig. 29.7 Handicapped sticker. (Copyright 2009 Mila Dragonfly, United Kingdom. Image from BigstockPhoto.com.) 414 PART 6 Patient Information and Assessment Neurologic Disorders A neurologic disorder involves the nervous system, which begins in the brain. Specifically, it covers all categories of diseases involving the central, peripheral, and autonomic nervous systems, which include the coverings, blood vessels, and tissues such as muscle. Alzheimer’s Disease Alzheimer’s disease is a disorder that can begin at middle age and is marked by deterioration of mental capacity (dementia). This disease is the fourth-leading cause of death in adults older than age 65 in the United States. The patient starts by showing loss of memory and impairment of judgment, comprehension, and intellect. Anxiety, depression, and emotional disturbances can occur as well. Over time, the person becomes dependent and unable to perform activities of daily living without assistance. CLINICAL CONSIDERATIONS FOR ALZHEIMER’S DISEASE Complete a thorough dental examination in the early stages of the disease. Dental treatment can be tolerated easily in the early stages. Pay special attention to prevention. Regular oral hygiene and the use of fluoride supplements and salivary substitutes are important in preserving dental health. In advanced stages of the disease, many patients are not able to tolerate dentures. Patients may experience xerostomia, caused by prescribed psychoactive drugs. Fig. 29.8 Escorting a vision-impaired patient. Dental visits should be scheduled with an awareness of the patient’s best time of day. Nonepileptic seizures are not related to epilepsy but are caused The presence of a familiar caregiver, such as a family member, in the by other things, such as diabetes, a high fever, or some other treatment room often eases the patient’s fear. cause. Status epilepticus is a continuing seizure and one of the few reasons emergency personnel should be contacted. Seizures TYPES OF GENERALIZED SEIZURES Seizure disorders are caused by abnormal electrical brain activity, which can manifest in several ways. A patient with a history of Absence seizures may cause the person to appear to be staring into space with or without slight twitching of the muscles. seizures can have an abrupt suspension of motor, sensory, behavioral, Tonic seizures cause stiffening of muscles, generally those in the back, or bodily function at any time. Patients who have a seizure disorder legs, and arms. may be receiving antiepileptic medication such as phenytoin Clonic seizures cause repeated jerking movements of muscles on both (Dilantin), which may cause increased bleeding tendencies, drowsi- sides of the body. ness, lack of coordination, drug-induced gingival overgrowth, and Myoclonic seizures cause erks or twitches of the upper body, arms, or xerostomia. legs. Epilepsy is a neurologic disorder characterized by clusters of Atonic seizures cause a loss of normal muscle tone, which often leads nerve cells, or neurons, in the brain that signal abnormally and the affected person to fall or drop the head involuntarily. cause recurrent episodes of seizures. In most patients, epileptic Tonic-clonic seizures cause a combination of symptoms, including seizures are controlled with medication; however, under stressful stiffening of the body and repeated erks of the arms and or legs, as well as loss of consciousness. conditions, a seizure may still occur. There are many different types of seizures. Generally, seizures are categorized based on which part of the brain is involved in a seizure. People might experience one type or more than one CLINICAL CONSIDERATIONS FOR SEIZURES type of seizure. There are four main categories of seizures, as Be aware of trigger factors such as anxiety or tiredness. follows: Be aware of the presence of an aura. Generalized seizures, having been referred to as grand mal seizures, Sedation may help prevent a sei ure during a stressful dental visit. affect the entire brain. Staff should be prepared to handle an emergency. Partial seizures, having been referred to as petit mal seizures, Severe cases may require dental treatment to be completed under affect a part of the brain. A person experiencing a partial general anesthesia. seizure will often stay awake and aware throughout the seizure; Maintain oral hygiene. however, although the person knows what is happening, he Before treatment, question patients about (1) skipping medications or or she may be unable to speak and/or move until the seizure meals, (2) stress and fatigue, ( ) pain, and (4) alcohol consumption. is over.  CHAPTER 29 The Special Needs and Medically Compromised Patient 415 Multiple Sclerosis Cerebrovascular Accident Multiple sclerosis (MS) is one of the most common neurologic A patient who has had a cerebrovascular accident (CVA), or stroke, disorders affecting adults between the ages of 30 and 50. As has experienced minor to severe loss of central nervous system the disorder advances, the patient experiences progressive (CNS) function caused by a sudden vascular lesion in the brain. weakening of the lower extremities, causing muscle weakness, This can be attributed to hemorrhage, embolism, thrombosis, or unsteady gait, and paralysis. In the treatment of patients with a ruptured aneurysm (Fig. 29.9). The clinical presentation of a MS, adrenal suppressants such as prednisone and muscle relax- patient can vary, depending on the area and extent of injury to ants such as diazepam may be prescribed to control muscle the brain. The patient may have unilateral weakness or paralysis spasms. of the eyes and facial muscles, as well as slurring or loss of speech. Numbness, vertigo, visual disturbances, sweating, headache, and nausea often can be present. CLINICAL CONSIDERATIONS FOR A PATIENT CLINICAL CONSIDERATIONS FOR MULTIPLE WITH HISTORY OF STROKE SCLEROSIS Schedule for the midmorning, with an average of 1 minutes added to Schedule shorter appointments. the appointment for additional communication and explanation of Patient may be wheelchair bound. instructions. Patient may have difficulty in locali ing intraoral pain and Modified oral hygiene aids may have to be introduced. discomfort. Some patients develop trigeminal neuralgia, which is a chronic pain affecting the trigeminal nerve. Respiratory problems may be caused by the effect of the disease on the muscles that control breathing. A rubber dam may be useful only if RECALL the patient is able to breathe through the nose. Do not position the patient in a supine position (to protect airway) 45 6. What is dementia? degrees is better. 7. What adverse effects can occur as the result of taking Dilantin Sedation may be required. 8. What is another term for cerebrovascular accident? 9. What are two examples of neurologic disorders? Fig. 29.9 Effects of a cerebrovascular accident (stroke). (Copyright iStock.com/alex-mit.) 416 PART 6 Patient Information and Assessment Arthritis Neuromuscular Disorders There are several types of arthritis, but the two most commonly Neuromuscular disorders affect the nerves that control your vol- seen are rheumatoid arthritis (RA) and osteoarthritis. untary muscles. Voluntary muscles are the ones you can control, such as those in your arms and legs. Your nerve cells, also called Rheumatoid Arthritis neurons, send messages that control these muscles. When neurons RA is a chronic disease that causes pain, stiffness, swelling, and become unhealthy or die, communication between your nervous loss of function in the joints. It occurs when the immune system, system and muscles breaks down. As a result, your muscles weaken the system that protects the body from outside harm, mistakenly and waste away. Weakness can lead to twitching, cramps, aches starts attacking healthy tissue. This causes inflammation that leads and pains, and joint and movement problems. Sometimes it also to swelling in the joints, making them progressively less mobile affects heart function and your ability to breathe. The neuromuscular (Fig. 29.10). If not managed properly, over time RA can cause disorders listed involve the same type of clinical considerations joint damage and can even result in permanent joint destruction. needed when treating this type of patient. Osteoarthritis Older patients are likely to have chronic progressive arthritis with CLINICAL CONSIDERATIONS FOR stiffening of joints called osteoarthritis. This disorder causes the NEUROMUSCULAR DISORDERS joints to become inflamed and painful. Physicians prescribe aspirin Patients require short appointments. and corticosteroids to reduce the symptoms of arthritis. A patient may have to be transferred from wheelchair to dental chair. A dental dam may be useful if the patient is able to breathe through CLINICAL CONSIDERATIONS FOR ARTHRITIS the nose. Do not place patient in a supine position (to protect airway), but the Schedule patients with arthritis in the morning and keep appointments patient can be placed at 45 degrees. short. Nitrous oxide, sedation, and general anesthesia should be avoided The disease can limit the patient’s ability to hold and use a toothbrush. because of impaired pulmonary (breathing) function. Modified oral hygiene aids may have to be introduced. Arthritis of the aw oints limits the patient’s ability to open the mouth or chew comfortably. Muscular Dystrophy Muscular dystrophy is a disease characterized by progressive atrophy Cardiovascular Disorders and weakness of the skeletal muscles with increasing disability and deformity. The muscle fibers degenerate and are replaced by fatty It is estimated that 20 million Americans today have some form and fibrous tissue. This disease is eventually fatal because of the of cardiovascular disease. Heart disease continues to be one of the onset of infectious and respiratory diseases, as well as pulmonary most serious threats to the health of an individual; it is the leading dysfunction. Atrophy of the muscles involved in respiration reduces cause of death among men over age 40 and among women over the vital capacity of the lungs and interferes with the ability to age 65. Heart disease can manifest in many ways, such as hyperten- cough. sion, stable or unstable angina, congestive heart failure, and myocardial infarction. The dentist should initiate communication Parkinson’s Disease with the patient’s cardiologist and acquire a background on how Parkinson’s disease (PD) is a motor system disorder that is the the patient’s heart disease is being managed and what medications result of loss of dopamine-producing brain cells. The four primary the patient is taking. symptoms of PD are tremor, or trembling in hands, arms, legs, The cardiovascular disorders listed involve the similar types of jaw, and face; rigidity, or stiffness of the limbs and trunk; slowness clinical considerations needed when treating this type of patient. of movement; and impaired balance and coordination. As these symptoms become more pronounced, patients may have di%culty walking, talking, or completing other simple tasks. PD usually affects people older than age 50. Cerebral Palsy Cerebral palsy is a group of nonprogressive neuromuscular disorders caused by brain damage (usually resulting from anoxia) sustained during the prenatal or perinatal period or during infancy. This condition affects 1 to 4 individuals in 1000 live births. Amyotrophic Lateral Sclerosis Commonly referred to as Lou Gehrig’s disease, amyotrophic lateral sclerosis (ALS) is a degenerative nervous system disease that causes loss of motor neurons in the cerebral cortex, brain stem, and spinal cord, resulting in muscular atrophy, weakness, and spasticity. The disease is progressive, with patient survival of 3 to 5 years or less. The origin is unknown, and no cure is Fig. 29.10 Effects of rheumatoid arthritis on the body. (Copyright iStock. known. com/DouglasOlivares.)  CHAPTER 29 The Special Needs and Medically Compromised Patient 417 CLINICAL CONSIDERATIONS FOR RECALL CARDIOVASCULAR DISORDERS 1. What is the leading cause of death of men over 4 and women over 5 Avoid stressful, lengthy appointments. in the United States Assess vital signs before treatment consider monitoring throughout the 11. Is dental anesthetic with epinephrine recommended for use in patients procedure. with heart disease? The dentist may use psychotropic premedication and nitrous oxide to 12. Provide another term for hypertension. help relieve stress. Consider the use of supplemental oxygen throughout the procedure. The dentist may consult with the patient’s cardiologist about the use of prophylactic sublingual nitroglycerin immediately before treatment. Epinephrine and other vasoconstrictors can be administered within Pulmonary Disorders limits to patients with mild to moderate cardiovascular disease. Pulmonary disorders affect the lungs and are characterized by airway Seated patients are more comfortable in a semisupine rather than a obstruction. Patients can be diagnosed with a pulmonary disorder supine position. with symptoms from several disease categories. Allergies It is estimated that one in every four individuals is allergic to Congestive Heart Failure something. An allergy is a condition in which the body reacts to Congestive heart failure is a condition in which the heart cannot an antigen. Common antigens include dust mites, pollen, animal pump enough blood to the body’s other organs. People with this dander, food, and drugs. Most reactions can be managed by having disease cannot exert themselves because they become short of breath the patient take an over-the-counter medication or a prescribed and tired. This lack of circulation throughout the body can result medication that reduces the symptoms of the allergy. If the reaction from any of the following: narrowed arteries, scar tissue from a goes beyond this type of management, the allergy becomes a past heart attack that interferes with function of the heart muscle, life-threatening emergency (see Chapter 31). high blood pressure, heart valve disease, heart defect, or infection of the heart valve or muscle (endocarditis or myocarditis). CLINICAL CONSIDERATIONS FOR ALLERGIES Hypertension Also referred to as high blood pressure, hypertension is the result Complete a thorough medical history to determine specific allergens. of the heart’s having to work harder as it pumps against resistance Pay special attention to latex and dental material use. Have an EpiPen available for potential allergic reaction. such as that provided by a blocked artery (Fig. 29.11). According to the American Heart Association, about 80 million U.S. adults have been diagnosed with high blood pressure. Age, heredity, smoking, obesity, and stress are contributing factors in the disease. Bronchial Asthma Most patients with a diagnosis of hypertension are on a program Asthma is a chronic lung disease that inflames and narrows the of drug therapy to help relieve the high blood pressure. In addi- airways. Asthma causes recurring periods of wheezing, chest tight- tion, patients are instructed to limit salt intake, follow a particular ness, shortness of breath, and coughing. Coughing often occurs diet, increase their exercise regimen, and reduce stress in their at night or early in the morning. Bronchial asthma often arises lives. from allergies and is characterized by an increased hypersensitivity to various stimuli, resulting in bronchial edema and widespread Angina narrowing of the bronchial airways. Angina pectoris is a coronary disease in which a decrease in blood The disease affects people of all ages, but it most often starts supply to the heart muscle causes a sharp pain in the chest. Angina in childhood. In the United States more than 22 million people can be “stable,” in which case the pain is usually predictable, or are known to have asthma. Nearly 6 million of these people are “unstable,” in which case the pain is unpredictable. Patients children. diagnosed with angina has been given a diagnosis of coronary atherosclerotic heart disease. Angina is a sign that a patient is at risk for a heart attack. CLINICAL CONSIDERATIONS FOR BRONCHIAL Patients with a history of angina pectoris should be on a program ASTHMA of drug therapy, exercise, weight control, salt restriction, and smoking cessation. Every effort should be made to minimi e stress. It is best to schedule short appointments and use sedation techniques. Endocarditis The use of epinephrine and aspirin should be minimi ed. Epinephrine can enhance the adverse effects of bronchodilators, and aspirin may Cardiac disease and prosthetic replacements convey an increased cause a laryngospasm or attack. risk for bacteria to be carried in the blood system (bacteremia); this is called endocarditis. Infective endocarditis is a severe infection of the cardiac valves and supporting structures that is caused by blood-borne pathogens that gain entry to the bloodstream from such places as the mouth and the gastrointestinal tract. Refer to Chronic Obstructive Pulmonary Disease Chapter 30 for information on the use of antibiotic therapy if a Chronic obstructive pulmonary disease (COPD) is a general term patient requires premedication. for pulmonary diseases characterized by blocked airflow during 418 PART 6 Patient Information and Assessment Endothelial damage— cells and lipid accumulate Tunica Atheroma— intima mass of fibrofatty Tunica material, media cells, and lipid Adventitia A. Fatty streak B. Plaque Small lumen Total occlusion Artery of artery partially by thrombus obstructed Thrombus Atheromatous plaque C. Formation of thrombus D. Complications Necrosis or calcification weakens wall 3. Embolus blocks small artery 2. Embolus flows along artery 1. Thrombus breaks off of a plaque formation E. Embolus Fig. 29.11 Effects of increased blood pressure. (From Gould BA: Pathophysiology for the health profes- sions, ed 5, St Louis, 2015, Saunders.) respiration. Chronic bronchitis and emphysema are the two most susceptibility to infection. This interferes with expiration, and the common diseases classified as COPD. lungs become overinflated because of the trapping of air. Chronic bronchitis is a disorder that results in irreversible narrowing of the bronchial airways caused by chronic inflammation, increased production of mucus, edema of the bronchial mucosa, RECALL and reduced ciliary activity (Fig. 29.12). Emphysema is the irreversible enlargement of the size of the 13. What organs of the body do pulmonary disorders affect? air spaces that results in labored breathing and an increased 14. What does the abbreviation C PD stand for  CHAPTER 29 The Special Needs and Medically Compromised Patient 419 cells and stimulates passage of calcium into the bones from the blood. Hyperthyroidism A patient with an overactive thyroid gland may be diagnosed with Graves’ disease, the most common form of hyperthyroidism. This disorder affects women 4 to 7 times more often than men. The average age of onset is before 40. Infection, physical or emotional stress, trauma, pain, or surgery may precipitate a hyperthyroid crisis, which can be fatal. CLINICAL CONSIDERATIONS FOR HYPERTHYROIDISM An accurate and current patient history and medical consultation are essential. Hyperthyroid patients who are not being treated are highly sensitive to epinephrine and other amine anesthetics. Fig. 29.12 The lung is inflamed, causing obstructed airflow. (Copyright iStock.com/wildpixel.) Hypothyroidism When the thyroid gland is underactive and produces fewer hormones CLINICAL CONSIDERATIONS FOR COPD than usual, the patient is diagnosed with hypothyroidism. These patients are not in any danger associated with receiving dental Minimi e stress by keeping appointments short and scheduling them in care. Patients with mild hypothyroidism can receive depressants, the morning. Consider using sedation techniques in low-risk to moderate-risk sedatives, or narcotic analgesics before treatment, but they may patients. show signs of an exaggerated response to these drugs. Patients who Consider using humidified oxygen given by nasal cannula. are not under a physician’s care may be sensitive to narcotic Avoid the use of nitrous oxide. analgesics, barbiturates, and tranquilizers because of the depressant Do not treat patients in a fully reclined chair. effects of these drugs on the CNS. Avoid anticholinergic drugs, which dry bronchial secretions. Do not schedule elective treatment during hot and humid weather. Diabetes Mellitus Diabetes mellitus is a disorder of the metabolism, the way the body uses digested food for energy. With the help of a hormone called insulin, cells throughout the body absorb glucose and use Blood Disorders it for energy. Diabetes develops when the body does not make enough insulin or is not able to use insulin effectively, in which Blood disorders involve cellular elements of the body. The bone blood glucose (a type of sugar in the blood) levels become too marrow can be susceptible to malignant cells, which can cause high. tumors of the bone marrow. Anemia is a condition that develops The disease is classified in the following two categories: when your blood lacks enough healthy red blood cells or hemo- Type 1 diabetes, previously known as juvenile diabetes, is diagnosed globin. An excessive increase in white blood cells may indicate in children and young adults. This chronic condition is when infection or leukemia. Excessive bleeding caused by congenital the pancreas produces little to no insulin, and the patient then lack of a protein substance necessary for blood clotting can occur becomes insulin dependent. in patients with hemophilia. Type 2 diabetes was previously known as adult-onset diabetes, because it was commonly diagnosed in adults. This chronic disease affects the way the body processes blood sugar or glucose. CLINICAL CONSIDERATIONS FOR BLOOD Because of an increase in obesity in children, type 2 diabetes DISORDERS is increasing in children and young adults. The patient is treated The important factor for patients with a blood disorder is their with lifestyle changes, oral medications (pills), and possibly susceptibility to bacterial infection. insulin. Treatment modifications must be made for any surgical procedure. When the balance shifts, with too much or too little food Antibiotic prophylaxis may need to be prescribed for high-risk ingested, insulin levels change, resulting in hyperglycemia (too procedures. much blood sugar) or hypoglycemia (too little blood sugar). Hyperglycemia is a condition in which there is an abnormal increase in the glucose (sugar) level in the blood. (Hyperglycemia Endocrine Disorders means blood sugar that is abnormally high.) If untreated, hyper- glycemia may progress to diabetic ketoacidosis and a life-threatening The endocrine system is composed of glands located in many diabetic coma. different regions of the body, all of which release hormones into Hypoglycemia, also known as insulin shock, is an abnormal the bloodstream. The thyroid gland regulates metabolism in body decrease in glucose level in the blood. (Hypoglycemia means blood 420 PART 6 Patient Information and Assessment sugar that is abnormally low.) Hypoglycemia can manifest rapidly. Substance abuse with alcoholism and drug dependence is a serious The most common causes of hypoglycemia are missing a meal, problem in the United States. Chemical dependency is a chronic taking an overdose of insulin without adequate food intake, and progressive disease that can affect all aspects of a person’s life. exercising excessively without appropriate adjustment of insulin Posttraumatic stress disorder is characterized by the “reexperienc- and food intake. ing” of a psychologically traumatic event. It is most commonly associated with veterans of war. It also can be seen in patients who experience trauma such as natural disasters, airplane crashes, and CLINICAL CONSIDERATIONS FOR DIABETES rape. The traumatic event is experienced as recurring disruptive, MELLITUS intrusive thoughts of past experiences and nightmares. Minimi e stress by keeping appointments short and scheduling them in Schizophrenia is a psychotic disorder characterized by varying the midmorning. degrees of personality disorganization. The individual’s thought Use sedation techniques such as administration of nitrous oxide or oral processes are disrupted by bizarre delusions and perceptual distur- dia epam. bances such as hallucinations. This decreases the individual’s ability Instruct patient to maintain normal dietary intake before dental to communicate and work with others. Therefore routine daily appointments; the most common cause of hypoglycemia is failure functions such as work, social relationships, and self-care are to eat. impaired. The therapy of choice involves antipsychotic agents and Minimi e the risk for infection. phenothiazines. CLINICAL CONSIDERATIONS FOR BEHAVIORAL RECALL AND PSYCHIATRIC DISORDERS 15. What disorder is associated with an overactive thyroid gland? Understand that xerostomia may result from the psychoactive drugs 16. What treatment is prescribed for a patient with type 2 diabetes? prescribed. Regular hygiene and the use of fluoride supplements and salivary substitutes are important for preserving dental health. Patient cooperation and informed consent may cause problems, Behavioral and Psychiatric Disorders particularly in the patient with anxiety. Biologic, genetic, psychological, and social components can contribute to many types of behavioral and mental disorders. Psychiatric disorders can affect the treatment of dental patients because of the drugs prescribed, which influence the function of Legal and Ethical Implications the brain. The disorders listed include the same types of clinical consideration when treating this type of patient. All patients, whether healthy or diagnosed with a compromising Anxiety is a feeling that “all is not well,” including a sense of medical or physical condition, have the right to know about impending disaster. Treatment may involve counseling, stress treatment plans and available alternative procedures. Patients have reduction therapy, and antianxiety medications. rights regarding privacy of personal and medical information and Depression is a condition of general emotional rejection and informed consent. The dentist is accountable for obtaining a physical withdrawal. The disorder may lead to a lack of interest in personal and medical background on every patient and then presenting the hygiene. Patients with depression are most often treated with method of treatment that would best suit a patient with a medical antidepressant agents. or compromising condition. Eating disorders are marked by extremes. These are present when a person experiences severe disturbance in eating behavior, such Eye to the Future as extreme reduction of food intake or extreme overeating or feelings of extreme distress or concern about body weight or shape. Chapters The use of adult stem cells in research and therapy is not as 16 and 17 provide additional information regarding nutritional controversial as the use of embryonic stem cells because the produc- and pathologic aspects of these disorders. tion of adult stem cells does not require the destruction of an Anorexia nervosa is potentially life-threatening eating disorder embryo. Official licensed clinics today throughout the world are characterized by self-starvation and excessive weight loss. treating patients with their own adult stem cells. They extract and Binge eating disorder is a type of eating disorder characterized select stem cell material for self-treatment. They are already focusing by recurrent binge eating without the regular use of compensatory on therapy for diabetes, stroke, spinal injury, multiple sclerosis, measures to counter the binge eating. Parkinson’s disease, and Alzheimer’s disease, as well as arthritis, Bulimia nervosa is a potentially life-threatening eating disorder heart disease, and eye disease. characterized by a cycle of bingeing and compensatory behaviors such as self-induced vomiting designed to undo or compensate Critical Thinking for the effects of binge eating. Bipolar disorder is also known as manic-depressive disorder. The 1. One of your patients, Ms. Smith, has submitted an updated patient suffers from alternating, prolonged episodes of extreme health history, and you notice that she has checked “Yes” for elation followed by depression. Periods of mania are characterized recently being diagnosed with a blood disorder. When you ask by hyperactivity involving excessive participation in multiple her about this, Ms. Smith tells you that tests showed she was activities; this is unrecognized by the patient. Speech is often positive for leukemia. What is one of your main considerations pressured, loud, rapid, theatrical, dramatic, and difficult to interpret, regarding how Ms. Smith will now be treated in the dental with abrupt changes in topics. office?  CHAPTER 29 The Special Needs and Medically Compromised Patient 421 2. Mr. Jones, a patient of the practice, has diabetes and is taking 5. Describe a personal experience you may have had with a medically metformin. How would Mr. Jones’ type of diabetes be classified? or physically compromised patient and what techniques you What dental considerations might apply to Mr. Jones? found to be helpful in daily care. 3. You are preparing Mrs. Rodriguez for a dental procedure when she mentions that pollen has been bothering her lately. You ELECTRONIC RESOURCES review her medical-dental history and notice that she has asthma. What type of drugs should be minimized for an asthmatic Additional information related to content in Chapter 29 can be patient such as Mrs. Rodriguez? found on the companion Evolve Web site. 4. Describe three ways to help treat a patient with coronary artery Practice Quiz disease in the dental office. PROCEDURE 29.1 Transferring a Patient From a Wheelchair Equipment 7. Stand facing the patient with your feet slightly apart and knees bent. ait belt. Place your fingers between the gait belt and the patient, using an underhand motion to grasp the gait belt. Ask the patient to stand as you Procedural Steps lift him or her with the belt and guide the patient to the transfer 1. Clear all items from the pathway of the wheelchair to the dental chair. location. 2. When entering the treatment room, determine whether it is best to go forward or to back the patient into the area. PURPOSE You want the patient to be positioned the same way he or she would be seated in the dental chair.. Move the wheelchair as close to the dental chair as possible so that it is at a 45-degree angle to the dental chair. PURPOSE Allows the patient to move closer to the chair without having to pivot as much. 4. Lock the wheelchair and raise the footrests. 5. Ask the patient to scoot forward in the wheelchair so a gait belt can be placed around the waist. Make sure the belt is positioned over the clothing and that the clip is in front. This will allow for easier belt ad ustments and removal. Bring the patient to the edge of the wheelchair if possible. (Photos courtesy Kathleen Muzzin and Bobi Robles, Dallas, TX..). Help the patient stand slowly. 1. Pivot the patient so that the patient’s backside is where the patient should be seated in the dental chair. 11. Help the patient to safely sit down. Ask the patient to slide back a bit so not in danger of falling from the seated location. nce the patient is safely seated on the transfer location, remove the gait belt.. Ask the patient to slide forward to the edge of the wheelchair seat, 12. Swing the patient’s legs over and onto the dental chair. making sure the patient’s feet are placed flat on the floor.