The Management of the Medically-Compromised Patient

• What is a medically compromised patient?

  Patients with a condition or treatment of the condition can impact on the delivery of safe and optimal dental care.

  
  

  Extra knowledge and care can prevent potential complications causing unnecessary morbidity and mortality
• Why is it important to have knowledge about any medical conditions that the patients have?

  Because we will then know if we are causing any drug interactions or also whether something we see is just an oral manifestation of that disease
• When taking patient's history, what is important to do and ask about?

  Ask questions relating to each one of the systems e.g. CV system, respiratory system, CNS etc.

  
  

  Also ask about social history, family history, dental history, prior treatment etc.

  
  

  Check medications and allergies
• How should you examine a medically compromised patient?

  Examination needs to be thorough

  
  

  Observe general appearance as soon as they walk through the door (gait, posture, weight, skin etc.)

  
  

  Check vital signs (pulse, bp, temp, rr)

  
  

  Head & neck examination (nodes, CN)

  
  

  Intra oral examination
• What does being prepared for your patient involve?

  Check when they've last had food & if they have their dose of insulin/oral hypoglycaemic meds e.g. if diabetic

  
  

  Have any symptomatic treatment readily available e.g. GTN tablets, salbutamol & consider prophylactic use of medications
• What kinds of complications/things are there to be aware of for patients withcardiovascular systemproblems?

  Patients may:

  -Become breathless when laid flat (heart failure)

  -Have a bleeding tendency because of anticoagulants (atrial fibrillation)

  -Acute ischaemic event (angina/MI)

  -There is no evidence that adrenaline in LA is a hazard, but if concerned use"citanest"

  GA does constitute a risk so consult the anaesthesist/physician
• What is citanest?


  Local anaesthetic that containsprilocaine
• What is the ASA (American Society of Anesthesiologists) classification?

  Physical status assessment tool; helps determine RELATIVE risk for anaesthesia

  
  

  Strongly associated with perioperative risk & outcomes

  
• What is infective endocarditis?

  Infection of the lining of the heart, particularly affecting the heart valves

  
  

  It's caused mainly by bacteria but occasionally by other infectious agents
• Who is at risk of getting infective endocarditis?

  It's a rare condition but people with certain structural cardiac conditions are at risk

  e.g.congenital heart disease, Rh heart disease, aortic valve disease, prosthetic valves, previous endocarditis, hypertrophic cardiomyopathy, IVDU
• What is important to tell the patient about the current advice for people at risk of infective endocarditis?

  The benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended

  
  

  The importance of maintaining good oral health

  
  

  Symptoms that may indicate infective endocarditis and when to seek expert advice

  
  

  The risks of undergoing invasive procedures, including non‑medical procedures such as body piercing or tattooing
• What is the current advice for people at risk of infective endocarditis?


  Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures

  Chlorhexidinemouthwash should not be offered as prophylaxis against infective endocarditis to people at risk of infective endocarditis undergoing dental procedures
• What determines the subgroup of people at risk of infective endocarditis for whom it might be prudent to specially consider routine antibiotic prophylaxis?

  
• What are some oral antihypertensive drug side effects for patients who are hypertensive?

  Xerostomia (diuretics)

  Lichenoid reactions (ACE inhibitors)

  Gingival hyperplasia (Ca channel blockers)

  
  

  POSTURAL HYPERTENSION MAY OCCUR SO SIT PATIENT UP SLOWLY, ESPECIALLY AFTER LONG SUPINE PERIODS
• What is important to be aware of for patients with hypertension in the dental clinic?

  1- make sure it's controlled as you don't want to be treating someone with uncontrolled hypertension

  
  

  2- they can get postural hypotension so sit the patients up slowly, especially after long supine periods
• What things are important to keep in mind with a patient who has respiratory issues?


  Make sure you have the symptomatic therapy to hand

  
  

  Use LA if possible/be cautious with sedation

  
  

  Some patients may require a steroid cover if they required long-term corticosteroid therapy and now have a degree of adrenocortical suppression

  
  

  Their inhalers can contain steroids and there's risk of oral candida so it's important to rinse their mouth out after steroid therapy

  
  

  They may be sensitive to NSAIDs

  
  

  Anxiety may cause exacerbation
• What do you have to be aware of when booking appointments for patients with diabetes mellitus?

  Timing of the appointment to avoid patients having hypoglycaemia e.g. in the morning or just after lunch would be best
• What are diabetic patients more prone to getting and how does this affect them?

  Ischaemic heart disease, xerostomia, periodontal disease, infection; particularly orofacial infection.

  
  

  Orofacial infection and things like surgery cause a stress response which could therefore raise their glucose levels
• What might be necessary to do if a diabetic patient requires GA?


  GA may necessitate IV insulin based on a variable rate intravenous insulin infusion (the old name for this is a sliding scale)

  
  

  I.E checking insulin levels are ok
• Ideally, when should dental treatment be carried out in epileptic patients?

  When there is good seizure control
• What are some problems you have to be mindful of when it comes to patients with epilepsy?

  Convulsions (self terminating/ buccal midazolam)

  
  

  Drug reactions (enzyme inducers)

  
  

  Bleeding tendency (sodium valproate CBZ)

  
  

  Gingival hyperplasia with phenytoin
• What are some problems relating to liver disease that can impact dental care?

  - Bleeding tendency

  
  

  - Altered drug metabolism

  
  

  - Delayed Healing

  
  

  -Protein & Ig deficiency

  
  

  - LA is safe but avoid IV sedation and GA

  
  

  - Could get viral hepatitis

  
  

  - Could be liver transplant patients

  
• How are patients with alcohol dependance medically compromised?

  Can lead to wide range of problems like liver disease which then leads to problems with drug metabolism and bleeding

  
• What is the dental relevance of chronic renal disease?


  Prevention of dental disease is v important

  
  

  Drug metabolism can be impacted (wouldn't want to prescribe drugs that get excreted by kidneys i.e. NSAIDs)

  
  

  Renal patients can be more prone to infections, can be immunosuppressed, could have had a transplant

  
  

  Could have hypertension

  
  

  Could present with lytic lesions in the jaw

  
  

  Could be on dialysis CAPD/haemofiltration so anticoagulants would be given to them so you wouldn't want to carry out procedures that will result in bleeding,

  Check clotting
• How are patients on corticosteroids medically compromised?

  Exogenous corticosteroids can lead to adrenocortical suppression - inadequate response to stress, trauma, operation or infection

  
  

  Avoid NSAIDS = peptic ulcer

  
• How do you assess the bleeding risk of a patient and what should you avoid if they do?

  History, previous episode, previous surgery, family history, drug history

  
  

  Avoid trauma, LA, intramuscular injections, aspirin or drugs that cause gastric bleeding

  
• What is the INR?

  International normalised ratio = a ratio of patient's PT to normal mean PT (prothrombin time)

  
  

  PT measures the extrinsic pathway

  
  

  Normal INR is 1 but the desired INR varies with condition
• What is the acceptable INR?

  Less than 4

  
  

  If more than 4, delay treatment until reduced

  Check the value no more than 24 hours before procedure
• What if the patient's INR doesn't match the ideal INR of the procedure?

  Adjust in collaboration with anti-coagulant/ GP
• What are some examples of different ideal INRs depending on the patient's condition?

  Prosthetic heart valve 3.5-4.5

  
  

  DVT or PE 2.0-2.5
• What is important to note about being on antibiotics as well as warfarin?

  The action of warfarin can be potentiated by some antibiotics e.g. erythromycin
• What is the recommendation for patients on DOAC (direct oral anticoagulant) requiring dental treatment?

  If dental treatment has low bleeding complications risk, there is no need to interrupt the anticoagulant medication.

  
  

  If dental treatment has high bleeding complications risk, advise them to miss their morning dose on the day of their dental treatment

  
• What is the dental relevance of anaemic patients?

  Reduction oxygen carrying capacity of blood.

  
  

  May present with angular cheilitis, glossitis or BMS (burning mouth syndrome)
• 3 types of anaemia

  Microcytic - Iron deficiency

  Macrocytic - B12, Folat

  Normocytic - Chronic disease
• How might patients with a sickle cell crisis present and what do they require?

  May present with oral pain (may be due to infarction or osteomyelitis)

  
  

  Often require aggressive treatment of infections as it may precipitate a crisis

  
  

  They might need surgery which requires antimicrobial prophylaxis

  
  

  Avoid GA if possible, liaise with GP/haematologist
• What is Thalassaemia?


  Asian, Middle Eastern, mediterranean

  
  

  Iron overload, prone to infection

  
  

  Severe anaemia

  
  

  Thalassaemia major = regular transfusions whereas Thalassaemia minor doesn't and people with the minor version live relatively normal lives
• How can patients with prostheses (device replacing body part) affect dental treatment?

  Possible bleeding tendency due to warfarin and risk of Infective endocarditis

  
• What are the risks and things to be aware of with patients who have had transplants?

  May have gingival hyperplasia if takingcyclosporin

  May require:

  - Antimicrobial prophylaxis

  - Steroid cover

  -May have a bleeding tendency if anticoagulated

  -Liable to infections secondary to immunosuppression

  -Discuss the case with the physician

  -Risk of cancers
• What should be avoided and what is best in each trimester for pregnant patients?

  Drugs and radiation should be avoided especially in first trimester

  Dental treatment best duringsecondtrimester

  Antimicrobial drugs usually prescribed :penicillinanderythromycin

  Analgesic’s prescribed:paracetamol

  
• What LA should be used and avoided for pregnant women?

  Lidocaineis safe butcitanestshould be avoided as it can cause contractions