Evaluation of the Medically Compromised Patient PDF

Evaluation of the Medically Compromised Patient Ruben Figueroa DMD, MS Clinical Associate Professor Department Oral and Maxillofacial Surgery Medical Director Goals of Physical and Psychological Evaluation • To determine patient’s ability to: • tolerate physical and psychological stress • treatmen...

Evaluation of the Medically Compromised Patient Ruben Figueroa DMD, MS Clinical Associate Professor Department Oral and Maxillofacial Surgery Medical Director Goals of Physical and Psychological Evaluation • To determine patient’s ability to: • tolerate physical and psychological stress • treatment modification • which sedation technique is most appropriate • possible contraindications • 6 in 10 adults have a chronic disease • Does the benefit of dental treatment outweigh the risk of medical complications Patient Evaluation: Never Treat a Stranger • Medical History • Overall Assessment • vital signs (BP,P,RR,T) • examination Medical History • It is the most useful information a clinician can have when deciding whether a patient can safely undergo planned dental therapy • If well done, the physical and laboratory examinations of a patient usually play relatively minor roles in the presurgical evaluation • It should be tailored to each patient Medical History • Biographic Data • Chief complaint • History of present illness (History of Chief Complaint) • Past medical history/Past Surgical Hx • Review of systems • Social history • Family history Biographic Data • Patient’s full name, address, age, gender, occupation, marital status, and PCP • Assess the patient’s reliability • Our Patient • • • • • Jose Rivera, Boston 53 y/o, male Disable married Chief Complaint • Why is the patient here? • Carious/bleeding tooth lower rt • Listen to the patient’s concerns • Clarifies why they desire treatment • In patient’s own words • Helps establish priorities History of Present Illness • When/how did the problem arise? • Previous treatment • Pain: location, onset, intensity, duration, what makes it worsen/stop? • Constitutional symptoms: fever, chills, lethargy, anorexia, malaise, and weakness associated with the chief complaint. • Acute vs Chronic Past Medical History • General state of health • Medical and psychiatric illnesses • Allergies • Current medications • Previous surgery/anesthesia Review of Systems • Sequential and comprehensive • Organ system basis • It may reveal undiagnosed medical conditions unknown to the patient. • Questions are guided by medical hx • If IV sedation or GA planned, the CV, respiratory, and nervous systems should be reviewed • Head & neck: Dentist is expected to perform a quick review of the head, ears, eyes, nose, mouth, and throat on every patient Review of Systems • Constitutional Symptoms • Eyes • Ear, Nose and Throat • Cardiovascular • Respiratory • Gastrointestinal Social History • Tobacco • Alcohol • Drugs Family History • Diabetes • Heart disease • Cancer • Anesthetic problems Physical Examination • Start with vital signs. • Focuses on the oral cavity and to a lesser degree on the entire maxillofacial region. • Accurate description – not a diagnosis. • Physical evaluation involves: Inspection, Palpation, Percussion and Auscultation. Vital Signs • Before every appointment • Heart rate • BP Pulse • Rate • Rhythm • Character: Form of the individual pulse wave. May have diagnostic value in valvular disease • Volume: Full vs. Weak (“thready”) • Condition of Vessel Wall Head and Neck Exam • Extraoral • asymmetry • lymph nodes • trachea/thyroid • eyes • TMJ Head and Neck Exam • Observation • Palpation • Percussion • Auscultation Head and Neck Exam • Intraoral • • • • • • tongue palate pharynx floor of mouth gingiva teeth Pertinent x-rays 2/3/08 18 Trustees Presentation Assessment 1. An appraisal or evaluation of a patient's condition by a physician, nurse, or other health care provider, based on clinical and laboratory data, medical history, and the patient's account of symptoms. 2. The process by which a patient's condition is appraised or evaluated. 2/3/08 19 Trustees Presentation Diagnosis • Generalized periodontal disease • RR #31 with periapical lesion Differential Diagnosis • list of possible conditions that share the same symptoms • This list is not your final diagnosis, but a theory as to what is potentially causing your symptoms Differential Diagnosis • • • • • Hematoma Acute infection Vascular lesion Tumor Coagulopathy 2/3/08 21 Trustees Presentation Consultation • To discuss management • To evaluate a new symptom • To control an uncontrolled problem Laboratory Tests • When indicated • Based on: • medical history • procedure planned ASA I • Normal healthy patient ASA II • Mild systemic disease that does not interfere with daily activity • May or may not need dental management alterations • Examples: mild hypertension, well-controlled asthma, well-controlled epilepsy, HIV +, smoking, obesity ASA III • Moderate to severe systemic disease that is not incapacitating but which may alter daily activity • Generally require dental management alterations • Examples: IDDM, stable angina, AIDS, hemophilia, ASA IV • Severe systemic disease that is a constant threat to life • Definitely require dental management alterations • Example: severe cardiac disease, end-stage renal or liver failure, advanced AIDS, unstable angina Stress • Cardiac disease • Asthma • Epilepsy Stress Reduction Protocol • Recognition of Stress • Premedication night before and day of treatment • Morning appointment • Minimize waiting period Coronary Artery Disease • Narrowing or spasm of coronary vessels • Myocardial oxygen demand > supply • Myocardial infarction (MI) - cellular death due to ischemia • Angina - chest pain or pressure • symptom of myocardial ischemia Management of Patient with Coronary Artery Disease • Consult patient’s physician • Stress-reduction protocol • Have nitroglycerin available (?premed) • Consider N20 sedation • Profound local anesthesia (limit epi.) • Monitor vital signs • maintain verbal contact with patient • Defer treatment until 6 months after MI • Check if patient is using anticoagulants Asthma • Hyperactivity of tracheobronchial tree • Pathophysiology • increased bronchial smooth muscle spasm • increased mucous secretions • increased bronchial wall edema Asthma Triggers • Intrinsic vs extrinsic • Stress • Allergy • Bronchial infections • Histamine releasing drugs (meperidine, barbiturates) Management of the Asthmatic Patient • Defer tx until asthma is well-controlled • Listen to chest with stethoscope for wheezing • Stress-reduction protocol • If patient is using steroids chronically, tx as if adrenal insufficiency • Keep bronchodilator inhaler nearby (?pre-med) • ? patient regarding ASA or NSAID sensitivity Management of Renal Insufficiency and Dialysis • Consult patient’s physician • Avoid or modify drugs which depend on renal metabolism/excretion • Avoid nephrotoxic drugs (NSAID’s) • Tx the day after dialysis Management of Renal Insufficiency and Dialysis • Prophylactic antibiotics for arteriovenous (A-V) shunt • Monitor BP and HR • Look for signs of secondary hyperparathyroidism • Hepatitis screening/precautions Management of Patients with Liver Failure • Consult patient’s physician • Hepatitis screening/precautions • Avoid/modify drugs which require hepatic metabolism/excretion (Tylenol) • Screen for bleeding disorders Management of Patients with Epilepsy • Question patient about the frequency, type, duration of seizures • Consider checking drug levels • Stress-reduction protocol Management of the Pregnant Patient • Defer tx until after delivery if possible • Consult patient’s obstetrician • Avoid x-rays if possible; especially in 1st trimester; proper shielding • Monitor vital signs • Avoid teratogenic medications ADA and Pregnancy • Regular and emergency dental care, including the use of local anesthetics and radiographs, is safe at any stage during pregnancy • The American Dental Association and the American College of Obstetricians and Gynecologists (ACOG) agree that emergency treatments, such as extractions, root canals or restorations can be safely performed during pregnancy and that delaying treatment may result in more complex problems.1 Last Updated: June 22, 2023 Prepared by: Department of Scientific Information, Evidence Synthesis & Translation Research, ADA Science & Research Institute, LLC 2/3/08 35 Trustees Presentation Medications Considered Safe” During Pregnancy • Lidocaine (with epinephrine) • Bupivicaine (Marcaine) • Mepivicaine (Carbocaine) • Acetaminophen (Tylenol) • Codeine • Penicillin Management of Pregnant Patients • Avoid supine position for long periods of time (vena cava compression) • Allow frequent “bathroom breaks” Epinephrine Effects • Increased: •heart rate & cardiac output •arrhythmias •blood pressure •stroke volume •bronchodilation Epinephrine Absolute Contraindications •Uncontrolled hyperthyroidism •sulfite sensitivity; steroid-dependent asthma •pheochromocytoma •recent cocaine abuse Epinephrine Absolute Contraindications • Cardiovascular disease •unstable angina •recent M.I. •recent coronary artery bypass graft •refractory arrhythmias* •uncontrolled hypertension •uncontrolled congestive heart failure Epinephrine Relative Contraindications • tricyclic antidepressants • phenothiazine compounds • MAO inhibitors • nonselective B-blockers Local Anesthetics Relative Contraindications • atypical plasma cholinesterase • methemoglobinemia Corticosteroids • patients taking exogenous steroids may develop adrenal suppression • adrenal glands are capable of producing up to 300 mg of hydrocortisone during stressful situations • role of dental “stress” is felt to be minimal Corticosteroids • Stress response regained within 2 weeks • Good pain control is essential • Signs of adrenal crisis: hypotension, nausea, vomiting, weakness, headache Corticosteroids: Dental Management • Routine dentistry/local anesthesia - currently taking steroids normal dose • Extensive dentistry/anxious patient - currently taking steroids double normal daily dose • General anesthesia/hospital - hydrocortisone 100mg IV pre-op, intra-op, post-op Type I Diabetes • Insulin dependent (IDDM) • early AM, short appointments • take usual insulin/ eat regular meal • IV anesthesia - take 1/2 insulin, give dextrose IV • Keep “on the sweet side” (100-200) Type II Diabetes • Non-insulin dependent (NIDDM) • Early AM, short appointments • Much less prone to hypo- or hyperglycemia • Take usual insulin med, regular meal • IV anesthesia - skip medication Diabetes - Chronic Effects • Primary damage is to small blood vessels • Increased atherosclerosis • Progressive renal failure • Coronary artery disease • Retinopathy • Peripheral vascular disease • Peripheral neuropathy • Increased risk of infection Coumadin (Warfarin) • Anticoagulant • Decrease formation of factors II,VII,IX,X • Affects the extrinsic pathway • Measure prothrombin time (PT) and INR • Blood levels reached in 48-72 hrs • Reverse with vitamin K Dental Management of the Coumadin Patient • Why is patient on coumadin? • What is the therapeutic range for the PT? • INR < 3 - normal tx • INR > 3 - discuss tx • Coumadin could be : • Discontinue or adjusted dosage and do INR 24 hr. prior procedure • No change • If patient MUST be anticoagulated, consider bridging technique Questions?