Compromised patient

1. University of Aden
Faculty of dentistry
Oral surgery dep
Compromised patient
(1)
Prepared by:
Dr.mohamed sheikh
Demonstrator in oral surgery dep.
Telephone no: 733258537
E-mail: dr.sheikhalkalady@yahoo.com

2. 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

3. This is a hand of one pt came to
Dr.S.Bagondwan, need to do
dental extraction. What is your
opinion?

4. 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:

5. Risk assessment
 The nature, severity, and stability of
the patient's 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)

7. 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

8. General Stress Reduction
Protocol
 Open communication about fears/concerns
 Short appointments
 Morning appointments
 Preoperative sedation
Short-acting benzodiazepine (e.g., triazolam 0.125-
0.25 mg)
Night before appointment and/or
1 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

9. General Stress Reduction
Protocol
 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.

10. Angina pectoris
 Consult patient's 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

11. 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

12. 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

13. 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?

14. 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)

15. 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

16. 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

17. 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

18. Diabetic patient

19. Hyperthyroidism
 Defer surgery until thyroid dysfunction
is well controlled
 Monitor vital signs before, during, and
after surgery
 Limit amount of epinephrine used

20. Sickle cell anemia
 Stress reduction protocol(SRP)
 minimize vasoconstrictor use.
 Use prophylactic antibiotics for major
surgical procedures.

21. Therapeutically anticoagulated
PT
 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

22. Therapeutically anticoagulated
PT
 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

23. Therapeutically anticoagulated
PT
 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

24. Seizure pt
 Defer surgery until seizure is well
controlled
 Use SRP
 Avoid hypoglycemia and fatigue

25. 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)

26. 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

27. References:
 http://www.mdconsult.com.proxy.library.vcu.
edu/das/book/body/107978522-4/0/152...
10/21/2008
 Larry J. Peterson , Contemporary oral and
maxillofaciall surgery , fourth
edition,2003,USA
 Little: Dental Management of the Medically
Compromised Patient, 7th ed.Copyright ©
2007 Mosby, An Imprint of Elsevier

28. T H A N K S