Dental management of medically compromised patients
u u u u u
The key to successful dental management of a medically compromised patient requires a thor
u u u u u u u u u u u u u
ough evaluation & assessment of risk to determine whether a patient can safely tolerate a plann
u u u u u u u u u u u u u u u
ed procedure.
u
Risk assessment involves the determination of the:
u u u u u u
(1) Nature, severity, & stability of the patient's medical condition.
u u u u u u u u
(2) Emotional state of the patient u u u u
(3) Type & magnitude of the planned procedure (i.e invasive or noninvasive)
u u u u u u u u u u
Patient evaluation & risk assessment is done by:
u u u u u u u
(A) Medical History: u
- A medical history must be taken on every patient who is to receive dental treat
u u u u u u u u u u u u u u
ment.
- Many techniques maybe used to obtain a medical history, ranging from an inte
u u u u u u u u u u u u
rview in which the questioner records the patient's responses on a sheet, to the u
u u u u u u u u u u u u u u
se of a printed questionnaire that the patient fills out independently.
u u u u u u u u u u
- Information about the patient's current physician (name/address/phone numb u u u u u u u
er) should be recorded for future referrals.
u u u u u u
- Medications being taken for an illness may be the only clue to the patient's dis u u u u u u u u u u u u u u
order, as some patients do not mention all their medical problems believing the
u u u u u u u u u u u u
y are not so important.
u u u u
- Drugs may also cause untoward reactions during dental treatment, thus dentis
u u u u u u u u u u
ts should identify the various drugs that patients maybe taking & become famil
u u u u u u u u u u u u
iar with their actions, side effects, & interactions.
u u u u u u u
(B) Dental History: u
- A dental history must include:
u u u u
i) Procedures that have been performed & their outcome u u u u u u u
ii) Any complications with the previous treatments u u u u u
(C) Physical examination: u
i. Assessment of the patient general appearance (wasted, cachectic, dirty cl u u u u u u u u u
othing, body odors, gait, posture, & difficulty of breathing)
u u u u u u u u
can signa u
l an underlying systemic disease.
u u u u
ii. Benefits of vital sign measurements (Pulse / blood pressure / temperature u u u u u u u u u u
/ respiration): u
- Establishment of baseline normal values to be a standard of comparison if an e u u u u u u u u u u u u u
mergency occurs during treatment. u u u
- Screening to identify diagnosed or undiagnosed abnormalities. u u u u u u
(D) Laboratory tests: u
- The dentist should know: u u u
i) The indications for ordering clinical laboratory tests.
u u u u u u
ii) The procedure for ordering them from a clinical laboratory.
u u u u u u u u
iii) How to interpret the results. u u u u
1
, Dental management of medically compromised patients
u u u u u
iv) The normal ranges for test results. u u u u u
v) The significance of abnormal values. u u u u
vi) The costs of these tests. u u u u
- Clinical laboratory tests & their normal values:
u u u u u u
(1) Complete blood count: u u
- WBC → 4,500-11,000 / mm3 u u u u u
- RBC → 4.5-6 million /mm3 u u u u
- Platelets → 150,000-450,000 /mm3 u u u u
- Hematocrit → 41-50% (♂) & 36-45% (♀) u u u u u u u
- Hemoglobin → 14-17 g/dl (♂) & 12-16 g/dl (♀) u u u u u u u u u
- Mean corpuscular volume → 80-96 µm3 u u u u u
- Mean corpuscular hemoglobin → 27-33 pg u u u u u
- Mean corpuscular hemoglobin concentrate → 33.5-35.5% u u u u u
(2) Differential WBC count: u u
- Neutrophils → 35% to 73% u u u u
- Lymphocytes → 23% to 33% u u u u
- Monocytes → 2% to 6% u u u u
- Eosinophils → 1% to 3% u u u u
- Basophils → 0% to 1% u u u u
(3) Hemostasis:
- Bleeding time → 2-8 minutes u u u u
- Prothrombin time → 10-15 seconds u u u u
- Partial Thromboplastin time → 25-35 seconds u u u u u
(4) Serum chemistry: u
- Glucose (fasting) → 70-110 mg/dl u u u u
- Calcium → 9-11 mg/dl u u u
(5) Serum enzymes: u
- Alkaline Phosphatase → 3-13 King Armstrong Unit u u u u u u
(E) Referral & Consultation: u u
- The usual methods are by: u u u u
i) Personal contact: Disadv.→ Lack of documented record of the consult. u u u u u u u u u
ii) Phone: Adv.→ Immediate information & chance to gain additional infor
u u u u u u u u u
mation to questions that may not have been included in a letter. u u u u u u u u u u u
iii) Letter: Should be concise, to the point, & polite. u u u u u u u u
Adv. → Documented record of the consult (Medicolegal issues)
u u u u u u u u
- ASA (American Society of Anesthesiologists) classification:
u u u u u u
It is a classification of patients according to their pre-
u u u u u u u u u
operative physical status: ASA 1 → Normal healthy patient (P1)
u u u u u u u u u
ASA 2 → Patient with mild systemic disease (P2) ASA
u u u u u u u u u u
3 → Patient with severe systemic disease (P3)
u u u u u u u
ASA 4 → Patient with severe systemic disease that is a constant threat to life (P4)
u u u u u u u u u u u u u u u
→ Emergency patient (PE)
u u u
2
, Dental management of medically compromised patients
u u u u u
- Stress reduction protocol:
u u
i) Open communication with the patient about fears & concerns
u u u u u u u u
ii) Short appointments u
iii) Morning appointments u
iv) Preoperative sedation (short acting benzodiazepine 0.125- u u u u u
0.25 mg night before appointment & 1 hr before appointment)
u u u u u u u u u
v) Intraoperative sedation (N2O/O2) u u
vi) Profound local anaesthesia; topical used prior injection u u u u u u
vii) Adequate postoperative pain control u u u
viii) Patient contacted evening of the procedure u u u u u
(1) Pregnancy u
# Physiology:
u
- Although pregnant woman can not be considered systemically diseased, yet they present a set
u u u u u u u u u u u u u u
of unique management problems to the dentist.
u u u u u u
- It is important for the dentist to be familiar with the normal stages of pregnancy & fetal de
u u u u u u u u u u u u u u u u u
velopment. (Normal pregnancy lasts for about 40 weeks)
u u u u u u u
1st trimester → Formation of the systems & organs of the fetus. 2nd
u u u u u u u u u u u u u
& 3rd trimesters → Growth & maturation of the fetus.
u u u u u u u u u
- Pregnant women are subjected to changes in their body physiology. These changes are:
u u u u u u u u u u u u
i) Endocrinal changes: u
- Increase in production of maternal & placental hormones u u u u u u u
ii) Cardiovascular changes: u
- Increase in blood volume u u u
- Increase in cardiac output u u u
- Slight increase in RBC volume u u u u
- Slight decrease in blood pressure (usually 100/70 mmHg or lower)
u u u u u u u u u
- Tachycardia
- Benign systolic murmur develops in 90% of pregnant woman but disappears sho
u u u u u u u u u u u
rtly after delivery u u
- During late pregnancy, a phenomenon known as "Supine Hypotensive Syndr
u u u u u u u u u
ome" (also called Inferior Vena Cava Syndrome) may occur that is manifested by
u u u u u u u u u u u u u
a sudden drop in blood pressure & loss of consciousness of the pregnant woman w
u u u u u u u u u u u u u u
hen she's in a supine position, due to:
u u u u u u u
Gravid uterus → Compression on the inferior vena cava → ↓ Venous return to the
u u u u u u u u u u u u u u u
heart → ↓ Blood pressure → ↓ Cardiac output → Loss of consciousness.
u u u u u u u u u u u u
iii) Hematological changes: u
- Anemia usually iron deficiency anemia (because blood volume increase more th
u u u u u u u u u u
an RBC mass does, which will result in a fall in hemoglobin & a marked need for a
u u u u u u u u u u u u u u u u u
dditional folate & iron) u u u
- ↓ Hematocrit value u u
3
, Dental management of medically compromised patients
u u u u u
- ↑ Neutrophils (May complicate interpretation of CBC during infection)
u u u u u u u u
- ↑ several blood clotting factors (Increased risk of thrombosis)
u u u u u u u u
iv) Neurological changes: u
- Fatigue
- ↑ gag response makes women vulnerable to nausea & vomiting (hyperemesis or
u u u u u u u u u u u u
morning sickness) u
# Oral manifestations:
u u
- Pregnancy gingivitis; which is an exaggerated inflammatory response of gingival tissue to loc
u u u u u u u u u u u u
al irritants as a result of hormonal influence which begins in the 2nd month of pregnancy.
u u u u u u u u u u u u u u u
- Pregnancy tumor or Pyogenic granuloma; which is an exaggerated local inflammatory hyper
u u u u u u u u u u u
plasia of the gingival tissue to irritant, the lesion is generally asymptomatic, easily bleeds & bec
u u u u u u u u u u u u u u u
omes apparent around the 2nd month of pregnancy & continues until after delivery, at which tim
u u u u u u u u u u u u u u u
e the gingival tissues usually regress & return to normal provided proper oral hygiene measures
u u u u u u u u u u u u u u u
are implemented & any calculus present is removed.
u u u u u u u
N.B: Pregnancy does not cause periodontal disease but can modify & worsen what is already pr
u u u u u u u u u u u u u u u
esent.
- ↑ Caries activity; due to poor oral hygiene as a result of the presence of gingival Inflamm.
u u u u u u u u u u u u u u u u
- Teeth mobility of the 1st degree due to the gingival & periodontal changes, which is reversed
u u u u u u u u u u u u u u u u
after delivery.
u
# Potential problems or complications related to dental care:
u u u u u u u u
I) During 1st trimester: u u
1) Spontaneous abortion (miscarriage); occurs in more than 15% of all pregnancies, the u u u u u u u u u u u u
majority of which are caused by intrinsic fetal abnormalities. Therefore it is most unlikel
u u u u u u u u u u u u u
y that any dental procedure would result in spontaneous abortion.
u u u u u u u u u
However febrile illnesses & sepsis can result in a miscarriage, therefore immediate treat
u u u u u u u u u u u u
ment of an odontogenic infection & periodontitis is advised.
u u u u u u u u
Always ask the patient about previous miscarriages u u u u u u
2) Fetal malformations by the teratogenic effects of drugs, radiation & infection;
u u u u u u u u u u
i) Drugs: - u u
Ideally no drug should be administered during pregnancy, howev u u u u u u u u u
er adhering to this rule is sometimes impossible. u u u u u u u
a) Local Anaesth.: - Lidocaine & Prilocaine → Safe to use in pregnancy u u u u u u u u u u u
- Mepivacaine → May cause fetal bradycardia u u u u u
b) Analgesics: - u u
Acetaminophen (Tylenol) & Paracetamol → Safe to us u u u u u u u u
e in pregnancy u u
- Aspirin → Avoid in 3rd trimester as it may cause postp u u u u u u u u u u
artum hemorrhage u
- Ibuprofen → Avoid in 2nd half of pregnancy as it may u u u u u u u u u u u
4
u u u u u
The key to successful dental management of a medically compromised patient requires a thor
u u u u u u u u u u u u u
ough evaluation & assessment of risk to determine whether a patient can safely tolerate a plann
u u u u u u u u u u u u u u u
ed procedure.
u
Risk assessment involves the determination of the:
u u u u u u
(1) Nature, severity, & stability of the patient's medical condition.
u u u u u u u u
(2) Emotional state of the patient u u u u
(3) Type & magnitude of the planned procedure (i.e invasive or noninvasive)
u u u u u u u u u u
Patient evaluation & risk assessment is done by:
u u u u u u u
(A) Medical History: u
- A medical history must be taken on every patient who is to receive dental treat
u u u u u u u u u u u u u u
ment.
- Many techniques maybe used to obtain a medical history, ranging from an inte
u u u u u u u u u u u u
rview in which the questioner records the patient's responses on a sheet, to the u
u u u u u u u u u u u u u u
se of a printed questionnaire that the patient fills out independently.
u u u u u u u u u u
- Information about the patient's current physician (name/address/phone numb u u u u u u u
er) should be recorded for future referrals.
u u u u u u
- Medications being taken for an illness may be the only clue to the patient's dis u u u u u u u u u u u u u u
order, as some patients do not mention all their medical problems believing the
u u u u u u u u u u u u
y are not so important.
u u u u
- Drugs may also cause untoward reactions during dental treatment, thus dentis
u u u u u u u u u u
ts should identify the various drugs that patients maybe taking & become famil
u u u u u u u u u u u u
iar with their actions, side effects, & interactions.
u u u u u u u
(B) Dental History: u
- A dental history must include:
u u u u
i) Procedures that have been performed & their outcome u u u u u u u
ii) Any complications with the previous treatments u u u u u
(C) Physical examination: u
i. Assessment of the patient general appearance (wasted, cachectic, dirty cl u u u u u u u u u
othing, body odors, gait, posture, & difficulty of breathing)
u u u u u u u u
can signa u
l an underlying systemic disease.
u u u u
ii. Benefits of vital sign measurements (Pulse / blood pressure / temperature u u u u u u u u u u
/ respiration): u
- Establishment of baseline normal values to be a standard of comparison if an e u u u u u u u u u u u u u
mergency occurs during treatment. u u u
- Screening to identify diagnosed or undiagnosed abnormalities. u u u u u u
(D) Laboratory tests: u
- The dentist should know: u u u
i) The indications for ordering clinical laboratory tests.
u u u u u u
ii) The procedure for ordering them from a clinical laboratory.
u u u u u u u u
iii) How to interpret the results. u u u u
1
, Dental management of medically compromised patients
u u u u u
iv) The normal ranges for test results. u u u u u
v) The significance of abnormal values. u u u u
vi) The costs of these tests. u u u u
- Clinical laboratory tests & their normal values:
u u u u u u
(1) Complete blood count: u u
- WBC → 4,500-11,000 / mm3 u u u u u
- RBC → 4.5-6 million /mm3 u u u u
- Platelets → 150,000-450,000 /mm3 u u u u
- Hematocrit → 41-50% (♂) & 36-45% (♀) u u u u u u u
- Hemoglobin → 14-17 g/dl (♂) & 12-16 g/dl (♀) u u u u u u u u u
- Mean corpuscular volume → 80-96 µm3 u u u u u
- Mean corpuscular hemoglobin → 27-33 pg u u u u u
- Mean corpuscular hemoglobin concentrate → 33.5-35.5% u u u u u
(2) Differential WBC count: u u
- Neutrophils → 35% to 73% u u u u
- Lymphocytes → 23% to 33% u u u u
- Monocytes → 2% to 6% u u u u
- Eosinophils → 1% to 3% u u u u
- Basophils → 0% to 1% u u u u
(3) Hemostasis:
- Bleeding time → 2-8 minutes u u u u
- Prothrombin time → 10-15 seconds u u u u
- Partial Thromboplastin time → 25-35 seconds u u u u u
(4) Serum chemistry: u
- Glucose (fasting) → 70-110 mg/dl u u u u
- Calcium → 9-11 mg/dl u u u
(5) Serum enzymes: u
- Alkaline Phosphatase → 3-13 King Armstrong Unit u u u u u u
(E) Referral & Consultation: u u
- The usual methods are by: u u u u
i) Personal contact: Disadv.→ Lack of documented record of the consult. u u u u u u u u u
ii) Phone: Adv.→ Immediate information & chance to gain additional infor
u u u u u u u u u
mation to questions that may not have been included in a letter. u u u u u u u u u u u
iii) Letter: Should be concise, to the point, & polite. u u u u u u u u
Adv. → Documented record of the consult (Medicolegal issues)
u u u u u u u u
- ASA (American Society of Anesthesiologists) classification:
u u u u u u
It is a classification of patients according to their pre-
u u u u u u u u u
operative physical status: ASA 1 → Normal healthy patient (P1)
u u u u u u u u u
ASA 2 → Patient with mild systemic disease (P2) ASA
u u u u u u u u u u
3 → Patient with severe systemic disease (P3)
u u u u u u u
ASA 4 → Patient with severe systemic disease that is a constant threat to life (P4)
u u u u u u u u u u u u u u u
→ Emergency patient (PE)
u u u
2
, Dental management of medically compromised patients
u u u u u
- Stress reduction protocol:
u u
i) Open communication with the patient about fears & concerns
u u u u u u u u
ii) Short appointments u
iii) Morning appointments u
iv) Preoperative sedation (short acting benzodiazepine 0.125- u u u u u
0.25 mg night before appointment & 1 hr before appointment)
u u u u u u u u u
v) Intraoperative sedation (N2O/O2) u u
vi) Profound local anaesthesia; topical used prior injection u u u u u u
vii) Adequate postoperative pain control u u u
viii) Patient contacted evening of the procedure u u u u u
(1) Pregnancy u
# Physiology:
u
- Although pregnant woman can not be considered systemically diseased, yet they present a set
u u u u u u u u u u u u u u
of unique management problems to the dentist.
u u u u u u
- It is important for the dentist to be familiar with the normal stages of pregnancy & fetal de
u u u u u u u u u u u u u u u u u
velopment. (Normal pregnancy lasts for about 40 weeks)
u u u u u u u
1st trimester → Formation of the systems & organs of the fetus. 2nd
u u u u u u u u u u u u u
& 3rd trimesters → Growth & maturation of the fetus.
u u u u u u u u u
- Pregnant women are subjected to changes in their body physiology. These changes are:
u u u u u u u u u u u u
i) Endocrinal changes: u
- Increase in production of maternal & placental hormones u u u u u u u
ii) Cardiovascular changes: u
- Increase in blood volume u u u
- Increase in cardiac output u u u
- Slight increase in RBC volume u u u u
- Slight decrease in blood pressure (usually 100/70 mmHg or lower)
u u u u u u u u u
- Tachycardia
- Benign systolic murmur develops in 90% of pregnant woman but disappears sho
u u u u u u u u u u u
rtly after delivery u u
- During late pregnancy, a phenomenon known as "Supine Hypotensive Syndr
u u u u u u u u u
ome" (also called Inferior Vena Cava Syndrome) may occur that is manifested by
u u u u u u u u u u u u u
a sudden drop in blood pressure & loss of consciousness of the pregnant woman w
u u u u u u u u u u u u u u
hen she's in a supine position, due to:
u u u u u u u
Gravid uterus → Compression on the inferior vena cava → ↓ Venous return to the
u u u u u u u u u u u u u u u
heart → ↓ Blood pressure → ↓ Cardiac output → Loss of consciousness.
u u u u u u u u u u u u
iii) Hematological changes: u
- Anemia usually iron deficiency anemia (because blood volume increase more th
u u u u u u u u u u
an RBC mass does, which will result in a fall in hemoglobin & a marked need for a
u u u u u u u u u u u u u u u u u
dditional folate & iron) u u u
- ↓ Hematocrit value u u
3
, Dental management of medically compromised patients
u u u u u
- ↑ Neutrophils (May complicate interpretation of CBC during infection)
u u u u u u u u
- ↑ several blood clotting factors (Increased risk of thrombosis)
u u u u u u u u
iv) Neurological changes: u
- Fatigue
- ↑ gag response makes women vulnerable to nausea & vomiting (hyperemesis or
u u u u u u u u u u u u
morning sickness) u
# Oral manifestations:
u u
- Pregnancy gingivitis; which is an exaggerated inflammatory response of gingival tissue to loc
u u u u u u u u u u u u
al irritants as a result of hormonal influence which begins in the 2nd month of pregnancy.
u u u u u u u u u u u u u u u
- Pregnancy tumor or Pyogenic granuloma; which is an exaggerated local inflammatory hyper
u u u u u u u u u u u
plasia of the gingival tissue to irritant, the lesion is generally asymptomatic, easily bleeds & bec
u u u u u u u u u u u u u u u
omes apparent around the 2nd month of pregnancy & continues until after delivery, at which tim
u u u u u u u u u u u u u u u
e the gingival tissues usually regress & return to normal provided proper oral hygiene measures
u u u u u u u u u u u u u u u
are implemented & any calculus present is removed.
u u u u u u u
N.B: Pregnancy does not cause periodontal disease but can modify & worsen what is already pr
u u u u u u u u u u u u u u u
esent.
- ↑ Caries activity; due to poor oral hygiene as a result of the presence of gingival Inflamm.
u u u u u u u u u u u u u u u u
- Teeth mobility of the 1st degree due to the gingival & periodontal changes, which is reversed
u u u u u u u u u u u u u u u u
after delivery.
u
# Potential problems or complications related to dental care:
u u u u u u u u
I) During 1st trimester: u u
1) Spontaneous abortion (miscarriage); occurs in more than 15% of all pregnancies, the u u u u u u u u u u u u
majority of which are caused by intrinsic fetal abnormalities. Therefore it is most unlikel
u u u u u u u u u u u u u
y that any dental procedure would result in spontaneous abortion.
u u u u u u u u u
However febrile illnesses & sepsis can result in a miscarriage, therefore immediate treat
u u u u u u u u u u u u
ment of an odontogenic infection & periodontitis is advised.
u u u u u u u u
Always ask the patient about previous miscarriages u u u u u u
2) Fetal malformations by the teratogenic effects of drugs, radiation & infection;
u u u u u u u u u u
i) Drugs: - u u
Ideally no drug should be administered during pregnancy, howev u u u u u u u u u
er adhering to this rule is sometimes impossible. u u u u u u u
a) Local Anaesth.: - Lidocaine & Prilocaine → Safe to use in pregnancy u u u u u u u u u u u
- Mepivacaine → May cause fetal bradycardia u u u u u
b) Analgesics: - u u
Acetaminophen (Tylenol) & Paracetamol → Safe to us u u u u u u u u
e in pregnancy u u
- Aspirin → Avoid in 3rd trimester as it may cause postp u u u u u u u u u u
artum hemorrhage u
- Ibuprofen → Avoid in 2nd half of pregnancy as it may u u u u u u u u u u u
4
