Medically Compromised Patient Dentistry PDF

Medically compromised patient in dentistry ❑ Cardiovascular diseases Dr. Lamia Mohammed ✓ Ischemic heart disease Hail ✓ Infected Endocardititis BDs, MDs in oral surgery and implantology ✓ Hypertension &hypotension ...

Medically compromised patient in dentistry ❑ Cardiovascular diseases Dr. Lamia Mohammed ✓ Ischemic heart disease Hail ✓ Infected Endocardititis BDs, MDs in oral surgery and implantology ✓ Hypertension &hypotension  Importance 1. Recognition of existing medical condition. 2. Adequate preparation. premedication prophylaxis adjustments prepare for any adverse effects 3. Postoperative consideration to control. bleeding infection  Urgency vs Emergency ❑ Urgency ❑ Emergency ❖ A Problem that requires ❖ A problem that is immediately life prompt response; it is not immediately life threatening threatening and requires immediate but could become so if it not action resolves promptly Cardiac arrest Syncope Hypoglacemia Anaphylaxis Seizure Obstructed airway Asthmatic attack Angina Mild allergic reaction Preparation for emergencies  Obtain a medical history on every patient and update it at each visit.  When confirming appointments, remind patients to take their normal medications on the day of their appointment.  All staff members should be trained in basic first aid procedures and basic life support (CPR)  The office should have a written emergency plan, emergency telephone numbers should be posted at each phone.  Basic life support (BLS)  “Single important step in preparation for medical emergencies”  In all emergency situations, initial management will always entail the application of needed steps of basic life support.  Drug therapy is always related to a secondary role  The ABCs of cardiopulmonary resuscitation (CPR) are assessment and treatment, if needed of, in that order(acc.to AHA 2010 guidelines): A. Airway (maintain patency) B. Breathing(respiratory movement) C. Circulation heart beat and blood pressure)  Use of any emergency drugs is considered only after attending to these ABCs The steps of basic life support by CPR Steps of basic life support  Step 1 – assessment of consciousness  Step 2 – call for help  Step 3 – position the patient Trendelenburg position The recovery position  Step 4 – Assess and open airway  Step 5 – Assess airway patency and breathing  Step 6 – Artificial ventilation if needed  Step 7 - Assess circulation  Step 8 - patient airway +adequate circulation-definite management  Step 9 – External chest compression  Health assessment  One key to reducing risk is to take a health history and vital signs to identify the “at risk” patient.  In some cases, extensive procedures on “at risk” patients might are best performed in a hospital setting.  ABC of any emergency  Supine position  100%oxygen  Evaluate airway, breathing, circulation.  Vitals signs ✓ Temperature ✓ Blood pressure ✓ Pulse ✓ Respiratory rate  Estimation  It has been estimated that one or two life threating emergencies will occur in the lifetime practice of a general dentist. What Types Of Emergencies Can Be Expected In The Dental Clinic? Type of emergency Percentage Syncope 50.3% Mild allergic reaction 8.4% Angina pectoris 8.3% Hypotension 8.0% Seizures 55.2% Asthma attack 4.5% Patients classification according to their physical condition According To The American Society Of Anesthesiologists (ASA)  Type I : Normal patient  Type II : Mild to moderate systemic disease  Type III : Sever systemic disease limiting patient activity  Type IV : Sever systemic disease threatening life  Type V : Morbid patient  Treatment options 1. Office treatment  ASA type I  ASA type II 2. Hospitalization  ASA type III 3. Hospitalization and emergency treatment only  ASA type IV 4. Hospitalization and palliative treatment  ASA type V Potential problem related to dental care:  Stress and anxiety related to dental visit must be reduction by (stress reduction protocol): Premedication. Short and morning appointment. Avoid excessive amounts of epinephrine. Nitrous oxide-oxygen.  Stress reduction protocol  Before appointment 1. Night before surgery sleeping bills ((Valium 5-10 mg) optional 2. Day of surgery short acting barbiturates (secobarbital 50- 100mg) optional 3. Early appointment 4. Short appointment Stress Reduction Protocol Cant.  During appointment 1. Relaxing background music. 2. Reassurance 3. No surprises 4. No unnecessary noise 5. Surgical instruments out of patient sight 6. Profound local anesthesia 7. IV sedation optional 8. Nitrous oxide sedation optional Stress Reduction Protocol Cant.  After surgery 1. Further reassurance 2. Detailed information about expected postoperative sequelae 3. Effective analgesics 4. Telephone call for the patient at home Who are Medically Compromised Patients?  Medically compromised patient : A patient suffers from significant medical conditions, which change the course of treatment by a dentist.  Medically compromised is a relative term. A patient exhibiting symptoms relative for a specialist when he is already a patient of another specialist and exhibits symptoms relative for him too.  Medically compromised patients are those patients for dental treatment at risk on dental chair  Why the dentist assest the condition of patient ? GOAL: To evaluate any source of infection that may compromise successful medical or surgical therapy and restore optimal oral health and function.  How the dentist assest the condition of patient ? * The key to successful dental management of medically compromised patient is accomplished by detailed history including past health , drugs, and medications taken by the patients 1. Full mouth intra-oral radiographs plus panoramic radiograph. 2. Panoramic radiograph only if edentulous or not able to take intraoral films. 3. Thorough medical and dental history including medications , documented on the dental chart. 5. Initiate preventive therapy. 6. Arrange treatment. 7. Arrange follow-up. Physical Evaluation and Risk Assessment: The key to successful dental management of a MCP. is a thorough evaluation and assessment of risk to determine whether a patient can safely tolerate a planned procedure. Physical Evaluation and Risk Assessment Con't Risk assessment involves the evaluation of at least four components: ❑ The nature, severity, stability of the patient's medical condition. ❑ The functional capacity of the patient. ❑ The emotional status of the patient. ❑ The type and magnitude of the planned procedure (invasive or noninvasive). Physical Evaluation and Risk Assessment Con't All factors must be carefully weighed for each patient. Each situation requires thoughtful consideration to determine whether the benefits of having dental treatment outweigh the potential risks to the patient.  Physical Evaluation and Risk Assessment Con't For example, A patient may have symptomatic heart failure The risk is minimal to taking radiographs (noninvasive) and the patient is not anxious or fearful. Conversely, in the same patient, The risk may be significant to a full mouth extraction (invasive), and the patient is very anxious. Physical Evaluation and Risk Assessment Con't Therefore, the dentist must carefully weigh the physical and emotional state of the patient against a- The invasiveness. b- Trauma of the planned procedure The cornerstone of patient evaluation and risk assessment is The medical history physical examination Laboratory tests Medical consultation. Physical Evaluation and Risk Assessment Con't 1st- MEDICAL HISTORY (MH): The medical history must be taken for every patient The two basic techniques used to obtain a MH consist of: 1) The interview (medical model) in which the interviewer questions the patient and records the patient's verbal responses on a sheet. 2) A printed questionnaire that the patient fills out. Also it is important that follow-up questioning occur for gaining additional information about the responses of the treatment (ttt).  Systemic disorders that dentists should be aware of:  Cardiovascular problems as high blood pressure  Endocrine disease as diabetes  Hematological disorder as hemophilia  Gastrointestinal disease and liver.  Respiratory disease as asthma.  Genitourinary tract disease.  Neurological disorder as epilepsy.  Cardiovascular diseases: Any dental procedure that causes injury to the soft tissues or bone can produce a transient bacteremia and in susceptible patient can result in infective endocarditis even minor dental manipulations such as matrix band placement or cleaning the teeth. Main signs &symptoms of ( c v d ):  Chest pain.  Dyspnea.  Cyanosis.  Palpitation.  Syncope.  Edema of ankle.  Clubbing fingers.  Cold pale extremities.  Easy fatigue. PART I  Ischemic heart disease  It's usually caused by decreased coronary blood flow, increased myocardial oxygen demand or both. Main disorders including are : A) Angina pectoris. B) Myocardial infarction. C) Congestive heart failure.  A) Angina pectoris.  It is a myocardial ischemia resulting from imbalance between coronary blood flow &oxygen demand.  A temporary inability of the coronary arteries to supply the heart musculature by oxygenated blood.  Signs & symptoms:  Substernal pain radiates to the left shoulder.  Dull ,heavy ,pressure sensation of short duration140mmHg SBP and >90 mmHg DBP) It is a highly common in cardiovascular and renal disease.  Classification: Category Systolic Dystolic Normal 120 80 (mild) Prehypertension 140-159 >80-90 Grade 1(moderate) 160-179 90-100 hypertension Grade 2(sever) >180 >100 hypertension  Be alert for: High blood pressure: 1. Request patient inform you if they feel as though their blood pressure is increasing or if they are getting a headache. Some patients feel jittery, other feel as though there is increased pressure behind the eyes. 2. Profuse bleeding, beyond what would be expected Dental management considerations  Mild to moderate hypertension: 1. Medical consultation 2. Monitor the patient Bp when given local anesthesia with epinephrine. 3. Inject anesthesia slowly and avoid intravascular injection. 4. Use anxiety reduction protocol. 5. Avoid rapid posture changes that lead to hypotension and syncope. 6. Avoid administration of sodium containing intravenous solution. Dental management considerations Sever hypertension: 1. Delay the optional dental treatment until hypertension is controlled. 2. Consider referral to oral and maxillofacial surgeon for emergent problems. Dental management considerations  Antibiotics Avoid the use of erythromycin and clarithromycin (not azithromycin) with CCBs because the combination can enhance hypotension.  Analgesics Avoid long-term (>2 weeks) use of NSAIDs because these agents may interfere with effectiveness of some antihypertensive medications.  Avoid epinephrine –containing gingival retraction cord because this material contains highly concentrated epinephrine , resulting in tachycardia and elevated BP.  The end….