University of Aden Faculty of dentistry Oral surgery dep Compromised patient (1)Prepared by:Dr.mohamed sheikhDemonstrator in oral surgery dep.Telephone no: 733258537E-mail: email@example.com
Objectives:At the end of this presentation the student will be able to: Determine whether a patient can safely tolerate a planned procedure Recognize the components of risk assessment Apply the protocol of stress reduction in dental management of medically compromised patient Deal with each specific medically compromised patient in our field
This is a hand of one pt came toDr.S.Bagondwan, need to dodental extraction. What is youropinion?
Risk assessment The key to successful dental management of a medically compromised patient is: A thorough evaluation and assessment of risk to determine whether a patient can safely tolerate a planned procedure Risk assessment involves the evaluation of at least four components:
Risk assessment The nature, severity, and stability of the patients medical condition; The functional capacity of the patient; The emotional status of the patient; and The type and magnitude of the planned procedure (invasive or noninvasive)
Note: In 1964, the American Heart Association and the American Dental Association concluded a joint conference by stating that “the typical concentrations of vasoconstrictors contained in local anesthetics are not contraindicated with cardiovascular disease so long as preliminary aspiration is practiced, the agent is injected slowly, and the smallest effective dose is administered
General Stress ReductionProtocol Open communication about fears/concerns Short appointments Morning appointments Preoperative sedationShort-acting benzodiazepine (e.g., triazolam 0.125- 0.25 mg)Night before appointment and/or1 hr before appointment Intraoperative sedation (N2O/O2) Profound local anesthesia; topical, use prior to injection Adequate postoperative pain control Patient contacted on evening of the procedure
General Stress ReductionProtocol Morning appointments are usually best. „ Keep appointments as short as possible. „ Freely discuss any questions, concerns, or fears that the patient has. „ Establish an honest, supportive relationship with the patient. „ Maintain a calm, quiet, professional environment. „ Provide clear explanations of what the patient should expect and feel. „ Premedicate with benzodiazepines if needed. „ Ensure good pain control through judicious selection of local anesthetic agents appropriate for maintenance of patient comfort throughout the procedure. „ Use nitrous oxide as needed (avoid hypoxia). „ Use gradual position changes to avoid postural hypotension. „ End the appointment if the patient appears overstressed.
Angina pectoris Consult patients physician Use general SRP Have nitroglycerin tablets or spray readily available Ensure profound local anesthesia before starting surgery Consider use of nitrous oxide sedation Monitor vital signs closely Possible limitation of epinephrine used (0.04mg maximum) Maintain verbal contact with patient
CHF Defer treatment until heart function improved and after consultation Use SRP Possible administration supplemental oxygen Avoid supine position Consider referral to oral and maxillofacial surgeon
Asthma Defer dental treatment until asthma is well controlled Use SRP but avoid use of respiratory depressants Keep a bronchodilator-containing inhaler easily accessible Avoid NSAIDs in susceptible patients Local anesthetic considerations
Renal dialysis Avoid some drugs and modify doses of others Defer dental care until the day after dialysis Consult physician concerning use of prophylactic antibiotics Take hepatitis precautions if unable to screen for hepatitis Look for signs of other diseases?
Hypertension Mild-to-moderate hypertension(systolic more than 140 ,diastolic more than 90) Be sure that the patient is under medical therapy of hypertension Use SRP Monitor vital signs(BP test) Epinephrine-containing LA should be used cautiously(not more than0.04mg)
Hypertension severe hypertension(systolic more than 200,diastolic more than 110) Defer elective dental treatment until hypertension is better controlled Consider referral to oral and maxillofacial surgeon for emergency problems
Diabetic patient Defer surgery until diabetes is well controlled(consult physician) Early morning appointment and use SRP Monitor vital signs before,during, and after surgery Maintain verbal contact Have the pt eat a normal breakfast before surgery and take the usual dose of regular insulin or hypoglycemics but only ½ dose of NPH insulin
Diabetic patient Advise pts not to resume normal insulin doses until return to usual caloric intake and activity level Watch for signs of hypoglycemia Treat infection aggressively
Hyperthyroidism Defer surgery until thyroid dysfunction is well controlled Monitor vital signs before, during, and after surgery Limit amount of epinephrine used
Sickle cell anemia Stress reduction protocol(SRP) minimize vasoconstrictor use. Use prophylactic antibiotics for major surgical procedures.
Therapeutically anticoagulatedPT Pts receiving aspirin or other platelet- inhibiting drugs Physician consultation for stopping the drug Defer surgery until the drug have stoped for 5 days Restart drug therapy on the day after surgery if no bleeding is present
Therapeutically anticoagulatedPT Pts receiving warfarin (coumadin) Physician consultation for allowing the PT to fall to 1.5 INR for a few days Obtain the baseline PT a- if the PT is 1-1.5 INR proceed with surgery b- if the PT is more than 1.5 INR , stop the warfarin 2 days before surgery Restart warfarin on the day of surgery
Therapeutically anticoagulatedPT Pts receiving heparin Physician consultation for stopping the drug Defer surgery until the drug have stopped for (6 hours if iv or24h if sc) or reverse heparin with protamine Restart heparin once a good clot has formed
Seizure pt Defer surgery until seizure is well controlled Use SRP Avoid hypoglycemia and fatigue
Pregnant pt Defer surgery until after delivery if possible Consult the pt obstetrician if surgery cannot be delayed Avoid dental radiographs unless necessary Avoid use of teratogenic drugs Avoid keeping the pt in the supine position for long periods Use SRP(sedative drugs are best avoided)
Remember: MRD of epinephrine in LA for dental management of medically compromised pt is not more than 0.04mg Aspiration during LA of this pt is very important determine whether the benefits of having dental treatment outweigh the potential risks to the patient Each situation requires thoughtful consideration