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PATIENT EXAMINATION BDS2 REFRESH > 14.Management of the medically compromised patient > Flashcards

14.Management of the medically compromised patient Flashcards

1
Q

LOs

A

· Identify the medically compromised patient by taking a thorough medical history

· Recognise the salient clinical features of common medical disorders presenting in the dental setting

· Explain which features determine the suitability of a medically compromised patient to be managed in the primary care setting and which patients to refer to secondary care

· Assess whether a patient is medically fit for dental treatment

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2
Q

DELETE CARD???

why we need to know about medical conditions?

A
  • People are living longer and as medical interventions are becoming more advanced,
  • Dentist will need to be aware of systemic conditions and treatments that may impact on the delivery of safe dental care.
  • 2014 -26% UK population >65yr
  • Dentist will see more patients with more medical conditions in general practice
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3
Q

what is a medically compromised patients?

A
  • 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

EXTRA INFO
- medical history forms should help you find out whether a patient has a condition
- make sure to update medical history on each visit

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4
Q

what key things should you look at when assessing a medically compromised patient?

A
  • individual condition?
  • how common the condition is?
  • how you identify the condition?
  • medical history
  • medical condition knowledge
  • treatment
  • drug interactions (anti-coag, antidepressant, antibiotic)
  • oral manifestations (EG. ulceration, gingival hyperplasia)
  • severity of condition
  • how it affects dental care
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5
Q

why is it important to look at the medical history of a patient and all of these key factors from card 4 (medical condition, treatment, drugs,etc)?

A

~ all of these factors are important to look at as they provide us with info about how likely they will impact on our dental care

~ medication is important to know about so that we don’t prescribe a drug that could negatively interact

~ some conditions and or medications can cause oral manifestations or presentations

~ help us decide what cases can be treated in general practice + what needs to be treated in hospital

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6
Q

what should you look at when taking a medical history?

A
  • PMH (go through review of systems)
    ~ CVS/ RS/ GIT/ GU/ CNS/ Haematological/
    ~ Dermal, musculoskelatal, Endocrine
    ~ Operations
    ~ Recent admissions
    ~ DH
    ~ Allergies
    ~ FH
    ~ SH
    ~ Habits Smoking/ alcohol
  • Dental Hxoral conditions , ulceration, periodontal disease
  • Past dental Tx, potential complications from previous treatment
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7
Q

what to examine?

A

EXTRA ORAL
- Examination of the patient with assoc. medical
problem needs to be thorough
- General appearance ( gait,weight,posture,skin)
- Vital signs Pulse, Bp, Temp, RR
- Head and Neck examination (Nodes, CN)

INTRAORAL

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8
Q

EG’s of being prepared for medical conditions

A
  • Check when patient last had food and if they have had their does of insulin/ oral hypoglycaemic meds
  • Have any symptomatic treatment readily available e.g. GTN tablets, salbutamol and consider prophylactic use of medications
  • Can get 1st presentation of problem (Angina)

ETC

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9
Q

CVD

Difficulties patients with cardiovascular system diseases may face?

A
  1. Patients may :
    a. become breathless when laid flat (eg Heart failure patients)
    b. have a bleeding tendency because of anticoagulants (eg patients with arrythmias (eg atrifibrolasium) (hence higher risk of bleeding)
    c. acute ischaemic event (Angina/ MI)
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10
Q

CVD

how do you treat a patient that has previously had an ischaemic event/ MI?

A
  • find out how long ago that happened
  • general rule is to not carry out any active dental treatment or surgical treatment within the first 3 months of having a myocardial infarc

(should be able to recognise signs + symptoms og patient in dental chair having an MI

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11
Q

CVD

can patients with CVD have LA with adrenaline

A

Currently, no evidence that adrenaline in LA is a hazard but if concerned use “citanest” as it contains prilocaine insead of adrenaline

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12
Q

CVD

can patients with CVD have GA?

A
  • yes they can BUT
  • there is a risk to patient
  • so consult anaesthetist + physician on case by case basis to reduce risk
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13
Q

how can you treat a patient on anticoagulants?

A
  • if need to carry out dental extraction, periodontal surgery, etc patient at higher risk of bleeding
  • plan treatment and adjust anticoagulation drugs in certain situ
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14
Q

1
what is ASA classification?

2
why is it useful?

3
what are the rankings?

A

1
- American Society of Anaesthesiologists physical status classification system

2
- clinicians can simply categorise patients physiological status
- can be helpful in predicting their operative risk
- useful to discuss with clinicians and physicians a patients underlying physiological state

3

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15
Q

INFECTIVE ENDOCARDITIS

1
what is infective endocarditis?

2
cause?

3
common? what may increase the risk?

A

1
infection of the lining of the heart, particularly affecting the heart valves,

2
caused mainly by bacteria but occasionally by other infectious agents.

3
- rare condition
- people with certain structural cardiac conditions are at risk
~ congenital heart disease
~ Rheumatic heart disease
~ aortic valve disease
~ prosthetic valves
~ previous endocarditis
~ hypertrophic cardiomyopathy
~ IVDU

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16
Q

INFECTIVE ENDOCARDITIS

infective endocarditis concern/ relevance in dentistry?

A

dentistry may cause a bacteraemia which may lead to this problem

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17
Q

management of patients with infective endocarditis in regards to dentistry?

A
  • Offer people at risk of infective endocarditis clear and consistent information about prevention
  • 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. [2015]
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18
Q

Make Q SLIDE 17

Prophylaxis against infective endocarditis

A

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

• Chlorhexidine mouthwash should not be offered as prophylaxis against infective endocarditis to people at risk of infective endocarditis undergoing dental procedures. [2015]

• The vast majority of patients at increased risk of infective endocarditis will not be prescribed prophylaxis. However, for a very small number of patients, it may be prudent to consider antibiotic prophylaxis (non-routine management), in consultation with the patient and their cardiologist or cardiac surgeon
(SDCEP 2018)

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19
Q

ADD IN Q SLIDE 18

A

The identification and assessment of these ‘sub group increased risk ‘ patients will require liaison with their cardiology consultant, cardiac surgeon or the local cardiology centre

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20
Q

ADD IN Q SLIDE 19

A
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21
Q

EXTRA FC SPACE

A
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22
Q

EXTRA FC SPACE

A
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23
Q

EXTRA FC SPACE

A
24
Q

EXTRA FC SPACE

A
25
Q

HYPERTENSION

1
common/ uncommon?

2
can you treat a patient with hypertension?

3
antihypertensive drugs and side- effects

A

1
common

2
- important to be aware of how well controlled the patient is
- can treat patient who has controlled hypertensions
HOWEVER
- don’t want to carry out dental treatment on patient with uncontrolled hypertension due to risk cerebrovascular accident (CVA) (stroke)

3
- hypertensive patients sometimes on antihypertensive drugs
- can have side effects that impact oral health and dentistry

  • DIURETICS = xerostomia
  • ACE inhibitors = Lichenoid reactions in mouth
  • Ca CHANNEL BLOCKERS = gingival hyperplasia (overgrowth)
26
Q

HYPERTENSION

1
what may cause postural hypotension?

2
how to avoid postural hypotension?

A

1
- hypotensive patients may develop if stand up suddenly

2
- slowly sit up patient and then stand up, especially after long supine position

27
Q

RESPIRATORY DISEASE

  1. can you give GA
  2. what may patients need to be given to be able to cope with stress during treatment
  3. what should patients do after taking an inhaler puff to help their oral health, why?
A
  • useful to have symptomatic therapy to hand (eg salbutamol) in case develop symptoms during dental treatment
  • anxiety can cause exacerbation

1
yes but better to give LA and avoid sedation

  1. patients with severe respiratory disorders may be on long term corticosteroids therapy so may have adrenocorticotical suppression
    - so need steroid cover to manage the stress of managing dental treatment

3
- rinse mouth out following any inhaled steroid therapy
- inhaler contain steroids - can cause candida in mouth

28
Q

RESPIRATORY DISEASE

  1. what drugs may patients with asthma be sensitive to?
  2. what should a dentist ask before prescribing this medication?
A

1
- NSAIDS
- non steroidal anti inflammatory agents
- eg. ibuprofen, diclofenac

2
- these are some of most common medicine prescribed as dentists
- hence ask patients if they have have sensitivity to anti-inflamm agents, if so avoid

29
Q

DIABETES MELLITUS

  1. types of diabetes?
  2. treatment?
A

1
- type I
- type II
- gestational

2
may be:
- diet
- oral hypoglycaemics (type II)
- insulin (type I + II)

30
Q

DIABETES MELLITUS

Key factors to take into account when treating patients with diabetes

A
  • Timing of appointments to avoid hypoglycaemia
  • Orofacial infections more likely
  • surgery cause stress response therefore raising glucose
  • Periodontal disease = more likely
  • Xerostomia may occur= more likely
  • GA may necessitate IV insulin based on a Variable Rate Intravenous Insulin Infusion (old name : sliding scale)
  • Risk of ischaemic heart disease and may develop silent MI while on the chair

https://journals.sagepub.com/doi/abs/10.1177/2050168420923864 (interesting article)

31
Q

EPILEPSY

  1. when is treatment carried out?
  2. problems that could occur
A

1
- Dental treatment carried out when good seizure control
- ask patent:
~ when last had seizure
~ due you get signs before a seizure

2
Problems :
- convulsions
~ usu self limiting/ terminating
~ worry that it may be epileptic seizure if go on
for several minutes
~ important to know how to manage with eg
buccal midazolam

  • drug reactions (enzyme inducers) so need to be careful when prescribing antibiotics
  • bleeding tendency (sodium valproate CBZ)
  • phenytoin = may cause gingival hyperplasia
32
Q

LIVER DISEASE

  1. function of liver?
  2. how may liver disease impact dental care?
  3. dental treatment relevance
A

1
- immunity against infection
- regulates blood clotting
- clears blood of drugs, chemicals, alcohol
- factory for proteins + cholesterol

2
- bleed tendency
- less likely to fight infection
- altered drug metabolism
- delayed healing
~ protein & Ig deficiency
- viral hepatitis risk
- Liver transplant patients

3
- be careful with:
~ dental extractions
~ prescribing medication
- may need to talk to hepatologist before prescribing any med
- LA is safe but avoid IV sedation and GA

33
Q

ALCOHOL DEPENDENCE

what problems can this lead to

A
  • Liver disease eg. cirrhosis
    ~ higher bleeding
    ~ altered drug metab
  • GIT eg. Gastritis and oesophagitis
    ~ avoid NSAIDs
  • CVS eg. HTN, cardiomyopathy
  • CNS eg. perip neuropathy, Wernicke encephalopathy, Korsakoff pyschosis
  • Endocrine: eg. increased Oestrogen decreased Testosterone
    ~ impotence testicular atrophy
    ~ gynacomastia
  • Avoid metronidazole as will react badly with patients who drink alcohol - use alternative antibiotic
34
Q

possible HHD Q

A
  • Discuss chronic renal failure.
  • What are the most common causes and the clinical features of chronic renal failure?
  • How may this condition be managed?
  • Discuss the dental relevance of this condition.
35
Q

RENAL DISEASE

  1. normal func
  2. unhealthy kidney problems
A

1
- Na and water removal
- waste removal
- hormone production

2
- fluid overload
- elevated waste
~ urea
~ creatine
~ potassium
- changes in hormone levels controlling:
~ blood pressure
~ RBC produc
~ Ca uptake

36
Q

RENAL DISEASE

dental relevance

A
  • Prevention of dental disease
  • Drug metabolism may be altered
    ~ hence don’t want to prescribe drugs
    metabolised by kidneys EG NSAIDs
  • more prone to Infections
  • may be immunosupressed (especially if had transplant)
  • Hypertension (due to water salt balance)
  • Lytic lesions jaw
  • Dialysis CAPD - need to check cotting
  • Haemofiltration = given anticoagulants hence do not carry out procedures that could result in bleeding
37
Q

corticosteroid use
(add Q’s)

A
  • Exogenous corticosteroids can lead to adrenocortical suppression so that inadequate response to:
    ~ stress of trauma, operation or infection

Common drugs used are prednisolone and hydrocortisone

Liable to infections e.g. candidiasis.

Avoid NSAIDs as increase risk of peptic ulceration

May require steroid cover as may not be able to mount a response to stress

38
Q

steroid cover guidelines

A
39
Q

BLEEDING RISK

  1. how to assess bleeding risk
  2. what to avoid?
A
  • very important to assess as many treatments can lead to bleeding

1
TAKE GOOD HISTORY
- Previous episode
- Past surgery
- Previous treatment e.g. local measures
- Family history
- Relevant Medical History liver or renal disease, bone marrow disorder
- Drug History , anti-coagulant warfarin / DOAC (NOAC direct oral anti-coag rivaroxaban )Anti-platelet druGs
- Screening : FBC, Platelet, PT, APTT, TT, BT (Extrinsic / Intrinsic )

2
AVOID
a. trauma
b. regional local anaesthesia
c. intramuscular injections
d. drugs causing gastric bleeding or increased bleeding tendency (aspirin)
b. avoid aspirin

https://journals.sagepub.com/doi/abs/10.1177/2050168420923866 (interesting article)

40
Q

ORAL ANRICOAGULANTS

  1. most common anticoagulant?
  2. what to look at before treatment
A

1
warfrin

2
2. Monitored by means of International normalised ratio (INR)
3. Desired INR varies with condition
a. prosthetic heart valve 3.5-4.5
b. DVT or PE 2.0-2.5
4. Ideal INR depends of procedure
5. Adjust in collaboration with anti-coagulant/ GP
6. Potentiated by antibiotics e.g. erythromycin

41
Q

how to treat a patient with warfarin?

A
42
Q

treating a patients taking anti-platelet drugs

A
43
Q

recommendation for patients taking DOAC (direct oral anti-coagulant

A
44
Q

medical conditions associated with bleeding?

A
  • for patients with these complicated conditions, would need to consult their physician to ensure they’re treated safely
45
Q

managing a patient taking anticoagulant or platelet drugs

A
46
Q

ANAEMIA

  1. what is anaemia
  2. types
  3. dental relevance
A

1
- Reduction oxygen carrying capacity of blood

2
- microcytic e.g. iron deficiency
- macrocytic e.g. B12, folate
- normocytic e.g. chronic disease

3
- Angular cheiltis
- Glossitis
- BMS (burning mouth syndrome)

47
Q

SICKLING DISORDERS

(make Q)

A

Sickle cell trait HbAS :
a. full oxygenation during GA
b. Extreme conditions may sickle

Sickle cell anaemia Hbss :
Sickle cell crisis
~ Hypoxia, hypothermia, dehydration, Infection
(including dental)
a. preventive care
b. oral pain may be due to infarction or osteomyelitis (due to loss of blood supply)
c. aggressive treatment of infections as may precipitate a crisis
d. surgery requires antimicrobial prophylaxis
e. avoid GA if possible, Liaise with Gp / Heamatologist

48
Q

THALASSAEMIAS

  1. what? what ethnicity is it most common?
  2. 2 types
  3. dental relvance
A

1
Inherited disorder of Hb
Asian, Middle East, Mediterranean

2
- Thalasseamia Major- transfusion dependent
- Thalasseamia Minor- usu symptom free

3
- Iron overload
- Prone to infection
- Severe anaemia

49
Q

PROSTHESES

Prostheses patients may have and how may this impact dental treatment

A
  1. Cardiac prostheses
    ~ possible bleeding tendency due to
    anticoagulant (warfarin)
    ~ risk of infective endocarditis
  2. Pacemakers
    ~ may be interfered with by equipment e.g.
    electrosurgery, scalers
  3. “Joints” and ventriculo-atrial shunts
    ~ little evidence but give antibiotic prophylaxis if
    surgeon wishes
50
Q

medical and dental impact of transplants

A
  1. Gingival hyperplasia if taking cyclosporin
  2. May require :
    a. antimicrobial prophylaxis
    b. steroid cover
  3. May have a bleeding tendency if anticoagulated.
  4. Liable to infections secondary to immunosuppression.
  5. Discuss the case with the physician

6 Risk cancers

51
Q

PREGNANCY

  1. what to avoid during pregnancy
A
  1. Drugs and radiation should be avoided especially in first trimester but if needed :
    a. antimicrobial : penicillin, erythromycin
    b. analgesic : paracetamol
  2. Dental treatment best carried out in second trimester
  3. In the third trimester, supine hypotension syndrome may occur if patient is laid flat.
  4. Lidocaine – safe, “Citanest” should be avoided
52
Q

CYTOTOXIC CHEMOTHERAPY

  1. before chemo advice
  2. during chemo advice and dental problems
  3. after chemo advice
A
  1. Before chemotherapy :
    a. detailed dental assessment , ideally ‘dentally fit’
    b. oral hygiene measures
  2. During chemotherapy :
    a. neutropenic low WCC
    b. any treatment should be carried out during the “rest phase” of the cycle after discussion oncologist regarding blood counts and appropriate antimicrobial prophylaxis
    c. oral candidiasis is often a problem and may be treated with antifungal
    d. xerostomia, mucositis and ulcers
    e. pain due to neurotoxicity
  3. After chemotherapy :
    a. maintain oral hygiene
    b. “low counts” may persist
53
Q

RADIOTHERAPY

  1. before radiotherapy advice
  2. during radiotherapy advice and dental problems
  3. after radiotherapy advice
A
  1. Before radiotherapy
    - Treatment to be completed prior to radiotherapy
    - Extraction of any suspect teeth in the field by minimum two weeks prior
  2. During radiotherapy
    Supportive oral care
    mucositis -painful
    Dry mouth- synthetic saliva
    antifungal drugs
  3. After radiotherapy :
    a. oral hygiene and prevention
    b. extractions may precipitate osteo radionecrosis
    Atraumatic extractions / Antibiotics prophylaxis,
    c. radiation caries and dental hypersensitivity controlled by daily fluoride mouthrinses
54
Q
  1. common drugs dentist use?
  2. why is it important to know what drugs patients are taking?
A

1
What dentist use:
~ LA
~ Sedatives
~ Analgesia
~ Antibiotics

2
- as drugs we prescribe may interact negatively with drugs they’re already on
- drugs they are on may impact treatment

55
Q

Medication-related Osteonecrosis of the Jaw (MRONJ)

A
56
Q

KEY POINTS

A
  • Thorough Medical history
    ~ questionnaire & verbal confirmation
  • Identify the condition
  • Understanding the significance of the disease / treatment -affects dental care
  • How the dental disease may affect the medical condition
  • Which cases can be safely treated in practice
  • Which cases need hospital setting

PATIENT EXAMINATION BDS2 REFRESH (7 decks)

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