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Dewi AgustinaOral Medicine FKG UGM

MANAGEMENT OF MEDICALLYCOMPROMISED PATIENTS refers to those patients who have medical

conditions which affect the dental treatment ormanifest as a specific oral and dental problem

Perlu modifikasi perawatan dental Rujuk : asesmen medik definitif

The term of medically compromisedpatients :

Daftar masalah pasien:

Chief complaint Potential medical complication Oral diseases and conditions

Masalah --- Chief complaint

Pain Acut infection Bleeding Traumatic injury

Immediateattention

&urgent care

Potential medical complication

Kondisi medik pasienyang dapat mengalamikomplikasi selamaperawatan dental

perlu modifikasiperawatan

dental

Potential medical complication

Diagnosed medicalconditions

Current medications Hypersensitivity Undiagnosed medical

conditions

perlumodifikasiperawatandental

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Diagnosed medical conditions

Asthma Epilepsy Bleeding disorders Pregnancy Diabetes

Risk of seriouscomplication?

perlu modifikasiperawatan

dental

perlu dicermati:riwayatpengobatan dan statusfisiknya bila tidak jelas-- rujuk/konsultasi

Current medicationsPengobatan yang sedangdialami pasien

Perlu dipahami aksi,interaksi dan efek

samping obat

Hypersensitivity

Alergi, idiosinkrasiHindari

obat yang sama

Undiagnosed medical conditions

Kondisi medikyang belumterdiagnosa atauperludiwaspadai

Tidak mempunyai implikasilangsung dengan perawatandental saran - konsultasi

Mempunyai implikasi langsungdengan perawatan dental rujuk- konsultasi medik

Evaluation of MCP :

Risk of dental procedures Patientss medical risk Physician consultation Dental specialist consultation Laboratory test Evaluation of medications

Health status classification system Level 1 : A patient with no systemic disease

(able to run for 2 min/longer ; to climb 2 flights of stairsw/o short of breath/any discomfort)

Level 2 : A patient with mild systemic disease(able to walk 2 city blocks at a fast pace; to climb 2 flightsof stairs w/o short of breath/any discomfort; healthyindividual with extreme fear of dental tx)

Level 3 : A patient with severe systemic disease(able to walk at a regular pace with limited physicalactivity)

Level 4 : A patient with incapacitating or life-threateningdisease(unable to do light activity for even a short period of timeand may experience discomfort while a rest)

ASA (MED Type) Risk Classification of Dental Patients(After Crawford, 2002)

ASA I (MEDType I)

A normal healthy patient

ASA lI (MEDType lI)

A patient with mild to moderatesystemic disease

Does not interfere with dailyactivities

No treatment modifications are necessary

Minimal treatment modification mayneeded

Well controlled diabetes; Controlled hypertension, History of asthma, Mild obesity, Pregnancy, smoker

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ASA (MED Type) Risk Classification of Dental Patients (cont)

Physician consultation recommended Treatment modification mandatory

ASA IlI (MEDType IlI)

A patient with severe systemicdisease

Limits daily activity, but is notincapacitating

Stable angina Post-myocardial infarction Poorly controlled hypertension Symptomatic respiratory disease Massive obesity

ASA (MED Type) Risk Classification of Dental Patients (cont)

ASAV (MEDTypeV)

A patient with severe systemicdisease

Limits daily activity, and is aconstant threat to life

Physician consultation mandatory Treatment modification mandatory

Unstable angina Liver failure End-stage renal disease Advanced AIDs

ASA IV (MEDType IV)

A moribund patient Not expected to survive 24

hours without surgery Dental care contraindicated

Risk classification of Dental Procedures[After Sonis]

Type INonsurgical, Noninvasive,NoWounds, No Stress

Examinations (soft tissue, vital signs, caries detection) Study cast impressions Oral hygiene instructions

Type IINonsurgical, Noninvasive, NoWounds, Low Stres

Type IIINonsurgical, Invasive, Few SuperficialWounds, Mild Stress

Simple operative dentistry Supragingival prophylaxis Orthodontic therapy

Advanced operative dentistry Subgingival probing, scaling, root planing Nonsurgical endodontic therapy

TypeVClosed Surgical, Invasive,Several DeepWounds, Moderate Stress

Type IVClosed Surgical, Invasive,Single DeepWound, Mild Stress

Simple extractions Periodontal curettage, gingivoplasty

TypeVIOpen Surgical, Invasive,Many DeepWounds, High Stress

Flap surgery Multiple extractions Single bony extraction of impacted tooth Endodontic apioectomy

Full arch/mouth extractions Extraction of multiple impacted teeth Orthognathic surgery

Risk classification of Dental Procedures[After Sonis] (cont)

RISK CATEGORIES FOR SELECTED DENTALPROCEDURES(after Stefanac & Nesbit, 2002)

Dental procedures Risk level

Oral examination Radiographs Study model

little to none

Local anesthesia Simple restorative treatment Prophylaxis Asymptomatic endodontic therapy Simple extractions Orthodontic treatment

low

RISK CATEGORIES FOR SELECTED DENTALPROCEDURES (cont)

Dental procedures Risk level

Symptomatic endodontic therapy Multiple extractions Single implant placement Deep scaling and root planing

medium

Extensive surgical procedures Multiple implant placement General anesthesia

high

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ORAL RISK ASSESSMENT (ORA)

Procedure Risk assessment Examples

ORA I Low risk of adversepatient reaction

Diagnostic and Preventive procedure

ORA II Minimal risk of adversepatient reaction

Elective phase I care Disease elimination Routine dental care that

cause minimal bleeding urgent dental care

ORA III Moderate risk ofadverse patient ordental outcome

Phase II care Complex reconstructive

dentistry Drug therapy Lengthy appointment Invasive

(Bricker, 1994)ORAL RISK ASSESSMENT (ORA)

Procedure Risk assessment Examples

ORA IV Significant risk ofadverse patientreaction

Hemorrhagic procedures Multiple extractions Orofacial infections Intravenous anxiolytic

therapy Emergency care (infections,

bleeding, trauma)

ORA V High risk of adversepatient reaction

Severe orofacial infectionsComplex surgical procedureDeep sedationGeneral anesthesia

Correlation between ORA and ASA asRISK ASSESSMENT FOR DENTAL TREATMENT

ORA I ORA II ORA III ORA IV ORA V

ASA I RoutineprecautionRoutineprecaution

Routineprecaution

Routine precaution Routineprecaution

ASA IIRoutineprecaution

Modification Modification Strict precaution andmedical consultation

Strictprecaution andmedicalconsultation

ASA IIIRoutineprecaution

Modificationand medicalconsultation

Modificationand medicalconsultation

Strict precaution andmedical consultation

Hospitalizationprotocol andmedicalconsultation

ASA IVModificationand medicalconsultation

Strictprecaution,Hospitalizationprotocol andmedicalconsultation

Contra-indicated

Defer until conditionimproves, palliation inhospital environmentand medicalconsultation

Contra-indicated

PRE-TREATMENT EVALUATION

The goal of the pre-treatment evaluation of the medicallycomplex patient is to determine the patients ability totolerate the planned dental procedure(s)

Evaluation of The Medically CompromisedDental Patient

Dentist determine the answers to the followingquestions :

Does the patient have a diagnosed or undiagnosedmedical condition that might complicate dental care ?

Can we proceed with dental treatment in a relatively safemanner ?

Is a pre-treatment medical consultation indicated ?

Complete health history Date last physical examination List of medical condition being treated List of medication Allergies & medical emergencies experienced Hospitalization Name, address physicians or specialist

Assessment of the medically compromisedpatient

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Relatively recent history & physical examination Laboratory data Physician consult Patient anxiety evaluation

The preoperative evaluation of thepatient may require the following:

Review your findings and treatment plan with thephysician

Ask for the physicians evaluation of the patientshealth

Ask for the physicians evaluation of the patientsability to tolerate your planned procedure

Ask for additional recommendations for the patientscare

Physician Consultation

As with many dental patients in general, medicallycomplex patients may have considerable anxietyabout dental treatment and would benefit from ananxiety reduction protocol prior to treatment

Anxiety Evaluation

Before appointment : Hypnotic agent to promote sleep the night before dental

treatment Sedative agent to decrease anxiety on morning of dental

treatment Morning appointments Minimize waiting room time

Anxiety Reduction Protocol

During appointment :

Non-pharmacologic: Frequent verbal reassurances Distracting conversation No surprises, advise patient of all treatment No unnecessary noises Have instruments out of sight Relaxing background music

Pharmacologic Local anesthesia Nitrous Oxide Oral anxiolytics

Anxiety Reduction Protocol

After appointment :

Succinct instructions of postoperative care, given bothorally and in writing

Describe expected post operative sequelae Effective analgesics Further reassurance Clinic/dentist contact information if problems occur

Anxiety Reduction Protocol

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Medical problems list :

Medical problems : Drugs taken for this problem : . Present diseases related :

Symptoms, Signs, Laboratoris Degree of Control/ Stability:

Excellent, Good, Fair, Poor, Not able to determine

Medical problem list :A : AnemiaB : Bleeding tendencyC : Cardiorespiratory disordersD : Drug treatment and allergiesE : Endocrine diseaseF : Fits and faintsG : Gastrointestinal disordersH : Hospital admissions and attendancesI : InfectionsJ : Jaundice and liver diseaseK : Kidney diseaseL : Likelihood of pregnancy, or pregnancy itself..........................

Types of DM Insulin Dependent DM Type 1 Non-Insulin Dependent DM, Type 2 Gestational DM Drugs induced DM

Diabetes Mellitus

Fasting blood sugar (reflects current control, that day) ;(> 126 mg/dl)

Random plasma glucose > 200mg/dl with symptoms(polyuria, polydipsia, unexplained weight loss)

Glycosylated hemoglobin (reflects average control overlast 6 8 weeks) ; (>7% = problem) ; can measure longterm hyperglycemia

Diagnostic Tests

Management Recommended for morning appt. and in short time

Medications : Controlled : as usual Uncontrolled : require physician guided alteration

Diet : Controlled : take the normal diet prior to dental care Uncontrolled : require counseling due to nutritional

intake before and after dental tx

Stress reduction : All diabetics : must be reduced If necessary premedication and/or analgesics are

considered Use bathroom and small snacks

Hygiene and Recall Visit : Need to be recalled for complete dental examinations

as frequently as non-diabetic pts In selective cases more frequent recall may be

necessary Home oral care should be reviewed at each appt.

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Antibiotics : All diabetics : no Ab cover prior to dental care Uncontrolled : need Ab before invasive oral care and

continue for several days after procedures :- Amoxicillin 2 g 1 h pre, followed by 500 mg/3x1/4 d- Clindamycin 600 mg 1 h pre, followed by

150 mg/4x1/4 d (if allergic to penicillin)

Post-tx Diet Control : consultation to dieticianNote :

Glucometer and glucose tablet/orange juice should beavailable in the clinic all the times

SBP > 140mm Hg, DBP > 90 mm Hg It can cause: Enlargement of the heart Aneurysms to form in blood vessels Narrowing of the blood vessels in the kidneys

leading to kidney failure Acceleration in hardening to the arteries

especially in the heart brain, kidneys, and legs Rupture of blood vessels

Hypertension

Treatment

1.Pharmacologic therapy (most patients will requiretwo or more antihypertensive agents)

2.Lifestyle changes weight reduction decreased alcohol reduction dynamic exercise dietary modifications decrease in sodium and fat

Management

Take a comprehensive history and current medications Record the blood pressure :

- 120/80 mmHg (N) : use the planned dental tx- 140/90 mmHg : use routine dental procedures- 140-160/90-105 mmHg : non-invasive dentalprocedures : ok. For surgical procedures : givesedative agent prior to the procedures- 170-190/115-125 mmHg or above : avoid dental txand refer to a physician

Minimize anxiety of dental tx

Record blood pressure at each visit Avoid LA with epinephrine for uncontrolled pts Avoid the use of topical vasopressors to control local

bleeding Sedative must be used with great caution in pts on

anti-hypertensive drugs Afternoon appt. Avoid long-term use of NSAIDs

Symptoms : Substernal pain spreading across the chest to the left

shoulder, arm and mandible; pressure, squeezing, orburning pain

Relieved by rest, last only a few minutes Relieved by nitroglycerin

Ischemic Heart Disease (Angina Pectoris) :

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Laboratory examination: CXR: enlarged heart indicates EKG: hypertrophy, old infarction, ST andT wave

changes

Management

Ischemic Heart Disease :

If chest pain develops :- stop dental procedures- give nitroglycerin tablet under the tongue- administer oxygen :

(i) relieve within 5 min(ii) not relieve within 5 min

Stable Angina Pectoris (with history ofMyocardial infarction 6 mths ) : Morning appt. VS pretx Semisupine chair position Nitroglycerin should be available Stress and anxiety reduction Premed with nitroglycerin, if angina precipitated Good pain control

Avoid use of epinephrine in retraction cord Avoid anticholinergic drugs Discontinue or reschedule if pt becomes

fatigued/change in pulse rate/rhythm Pts with daily aspirin therapy : may have

increased bleeding Pt with warfarin sodium, pretx PT : 2 x Normal INR

< 3.0

Unstable Angina Pectoris (with historyof Myocardial infarction < 6 mths ) Avoid elective dental care If necessary treat the pts in special pt care setting Consultation with physician Pretx at home Pretx in office Intraoperatively Pain control with LA (best to avoid

vasoconstrictors)

Cirrhosis from any cause Drugs & toxins Viral hepatitis Carcinomas primary or metastatic Will have elevated PT, PTT, & decreased

platelets depending on severity of disease

LIVER DISEASE

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Water/Food Borne Blood BorneAcute Type Chronic Type

- Hepatitis A - Hepatitis B- Hepatitis E - Hepatitis C

- Hepatitis D

VIRAL HEPATITIS

AST, ALT PT & PTT INR

Diagnostic test

Management : Take comprehensive history Identify potential or actual carriers of HBV, HCV, and HDV Avoid routine elective dental care for pts with active

hepatitis If urgent dental treatment is required, adhere to the UP of

infection control methods and avoid medicationmetabolized by the liver

When in doubt, use clinical lab tests to screen for thepresence HbsAb or anti-HCV

Identify persons at high risk of HBV infection Consult the physician fo HbsAg + pts/who has a history of

hepatitis Pts completely recovered : dental tx w/o any modifications

MANAGEMENT OF PREGNANT PTSStress : Pregnancy Fear of dental pain

need to prevent dental disease by increasing oralhygiene

Timing of dental tx : Dental pain and infection should be treated Routine OH procedure First trimester, avoid : elective procedures, teratogenic

medication, morning appt., dental radiograph, exposure tomercury

Avoid undue problems to the mother or the fetus Additional appt consider the increased

frequency of urination Short appt.

Medications : Local anaesthesia is ok Analgesics with caution Avoid Tetracyclin and Clindamycin Penicillin, Erythromycin, Cephalosporin : ok Avoid Barbiturate and Benzodiazepins

Position of patient : Second and third trimester : no supine position Left lateral decubitus position to prevent foetal distress Allowing pts to change positions frequently

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