The Medically and Physically Compromised Patient Chapter 29 Copyright © 2009, 2006 by Saunders, an...

The Medically The Medically and Physically and Physically

Compromised PatientCompromised Patient

Chapter 29Chapter 29

Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.


Lesson 29.1Lesson 29.1


Learning ObjectivesLearning Objectives

Pronounce, define, and spell the Key Terms.Pronounce, define, and spell the Key Terms. Describe the type of dental management a Describe the type of dental management a

medically compromised patient would medically compromised patient would receive.receive.

Describe the stages of aging in the older Describe the stages of aging in the older population.population.

Describe orally related conditions affecting Describe orally related conditions affecting the older patient.the older patient.(Cont’d)(Cont’d)


Learning Objectives Learning Objectives

(Cont’d)(Cont’d)

Describe the importance of the medical Describe the importance of the medical history in the medically compromised patient.history in the medically compromised patient.

Describe the major medical disorders that can Describe the major medical disorders that can affect a patient’s oral health.affect a patient’s oral health.


The Rights of a PatientThe Rights of a Patient

Americans with Disabilities Act Americans with Disabilities Act Provides a clear, strong, enforceable standard Provides a clear, strong, enforceable standard

addressing discrimination against people with addressing discrimination against people with disabilitiesdisabilities

American Dental Association American Dental Association Supports:Supports:

• Title I: employment discriminationTitle I: employment discrimination

• Title II: access for the disabledTitle II: access for the disabled

• Title III: public accommodationsTitle III: public accommodations

• Title IV: telecommunications services Title IV: telecommunications services


Role of the Dental AssistantRole of the Dental Assistant

Aid the dentist in providing treatment.Aid the dentist in providing treatment. Act as a source of information to the patient Act as a source of information to the patient

and family.and family. Provide comfort to the patient.Provide comfort to the patient. Help reduce anxiety.Help reduce anxiety.


The Aging PopulationThe Aging Population

Aging is the irreversible and inevitable Aging is the irreversible and inevitable changes that occur with time.changes that occur with time.

Stages of the older population:Stages of the older population: Young/old: People 65 to 74 years old, better educated and Young/old: People 65 to 74 years old, better educated and

more demanding of health services, retain more of their more demanding of health services, retain more of their natural teeth.natural teeth.

Old: People 75 to 84 years old, beginning to have multiple Old: People 75 to 84 years old, beginning to have multiple health problems, have more fixed and removable health problems, have more fixed and removable prostheses.prostheses.

Old/old: People 85 years old or older have fewer natural Old/old: People 85 years old or older have fewer natural teeth, believe that tooth loss is inevitable, and have medical teeth, believe that tooth loss is inevitable, and have medical

conditions reflected in their oral health.conditions reflected in their oral health.


Dentally Related Aging ChangesDentally Related Aging Changes

Xerostomia is a condition, resulting from certain disorders Xerostomia is a condition, resulting from certain disorders and medications, that involves decreased flow of saliva. and medications, that involves decreased flow of saliva.

Periodontal disease is an increasing problem in the older Periodontal disease is an increasing problem in the older population. The tissues of older patients may be slower to population. The tissues of older patients may be slower to heal. heal.

Dental decay increases in the form of coronal and root Dental decay increases in the form of coronal and root caries and recurrent decay around defective restorations. caries and recurrent decay around defective restorations.

Dark and brittle teeth result from deposition of secondary Dark and brittle teeth result from deposition of secondary dentin that have gradually reduced the size of the pulp dentin that have gradually reduced the size of the pulp chamber. chamber.

Bone resorption results in loss of the alveolar ridge. Bone resorption results in loss of the alveolar ridge.


Fig. 29-3 Periodontal conditions of an older patient.Fig. 29-3 Periodontal conditions of an older patient.


Fig. 29-4 Root caries of in an older patient.Fig. 29-4 Root caries of in an older patient.


Fig. 29-5 Darkened teeth associated with Fig. 29-5 Darkened teeth associated with secondary dentin and aging.secondary dentin and aging.


Fig. 29-6 Bone resorption with loss of teeth and Fig. 29-6 Bone resorption with loss of teeth and alveolar ridge.alveolar ridge.


The Medically Compromised PatientThe Medically Compromised Patient

Patient AssessmentPatient Assessment Category I: Healthy patientCategory I: Healthy patient Category II: Medical conditions requiring schedule Category II: Medical conditions requiring schedule

changeschanges Category III: Medical conditions requiring Category III: Medical conditions requiring

significant modifications in dental treatmentsignificant modifications in dental treatment Category IV: Medical conditions requiring major Category IV: Medical conditions requiring major

modifications in dental treatmentmodifications in dental treatment Category V: Serious medical conditionsCategory V: Serious medical conditions


Neurologic DisordersNeurologic Disorders

Alzheimer disease is a brain disorder that is Alzheimer disease is a brain disorder that is marked by deterioration of mental capacity.marked by deterioration of mental capacity. The disease progresses in three stages:The disease progresses in three stages:

• Early disease, or forgetfulness phaseEarly disease, or forgetfulness phase

• Intermediate disease, or confused phaseIntermediate disease, or confused phase

• Late disease, or dementia phaseLate disease, or dementia phase

Treatment-plan modificationsTreatment-plan modifications Thorough dental examination in early stagesThorough dental examination in early stages Special attention to daily care of the mouthSpecial attention to daily care of the mouth Alertness to signs of xerostomia Alertness to signs of xerostomia



Neurologic DisordersNeurologic Disorders(Cont’d)(Cont’d)

Seizures are an abrupt suspension of motor, sensory, Seizures are an abrupt suspension of motor, sensory, and/or body function. and/or body function.

Epilepsy Epilepsy Petit mal seizures usually last 5 to 10 seconds. Petit mal seizures usually last 5 to 10 seconds. Grand mal seizures have many causes and arise in people in all age Grand mal seizures have many causes and arise in people in all age

groups.groups. Treatment-plan modificationsTreatment-plan modifications

Maintenance of oral hygieneMaintenance of oral hygiene Surgical reduction of gingival hyperplasiaSurgical reduction of gingival hyperplasia Questioning before any procedure with regard to eating, stress, pain, and Questioning before any procedure with regard to eating, stress, pain, and

alcohol consumption.alcohol consumption.




Multiple sclerosis is a debilitating and Multiple sclerosis is a debilitating and degenerative disorder of the central nervous degenerative disorder of the central nervous system that involves progressive weakening system that involves progressive weakening of the lower extremities, causing muscle of the lower extremities, causing muscle weakness, unsteady gait, and paralysis.weakness, unsteady gait, and paralysis.

Treatment-plan modificationsTreatment-plan modifications Adrenal suppressants to relax muscles.Adrenal suppressants to relax muscles. Extra time for procedures, if the patient is Extra time for procedures, if the patient is

wheelchair-boundwheelchair-bound





Stroke, or cerebrovascular accident, is a minor Stroke, or cerebrovascular accident, is a minor to severe loss of central nervous system to severe loss of central nervous system function caused by a sudden vascular lesion of function caused by a sudden vascular lesion of the brain, such as hemorrhage, embolism, the brain, such as hemorrhage, embolism, thrombosis, or ruptured aneurysm. thrombosis, or ruptured aneurysm.

Treatment-plan modifications Treatment-plan modifications Midmorning scheduling with additional time set Midmorning scheduling with additional time set

asideaside Modification of oral-hygiene aidsModification of oral-hygiene aids


Cardiovascular DisordersCardiovascular Disorders

Heart disease: leading cause of death in the Heart disease: leading cause of death in the United States United States Angina: severe pain in the chest associated with Angina: severe pain in the chest associated with

an insufficient supply of blood to the heartan insufficient supply of blood to the heart Myocardial infarction: heart attackMyocardial infarction: heart attack Treatment-plan modificationsTreatment-plan modifications

• Vital-sign checks throughout the procedureVital-sign checks throughout the procedure

• Use of supplemental oxygenUse of supplemental oxygen

• Use of prophylactic sublingual nitroglycerinUse of prophylactic sublingual nitroglycerin

• Avoidance of epinephrineAvoidance of epinephrine





Hypertension: Referred to as high blood pressure, Hypertension: Referred to as high blood pressure, it results when the heart must work harder as it it results when the heart must work harder as it pumps against resistance (e.g., a blocked artery). pumps against resistance (e.g., a blocked artery).

Major factors associated with hypertension:Major factors associated with hypertension: StressStress AgeAge HeredityHeredity SmokingSmoking ObesityObesity





Congestive heart failure is a condition where the heart Congestive heart failure is a condition where the heart cannot pump enough blood to the body’s other organs.cannot pump enough blood to the body’s other organs.

This lack of circulation throughout the body can result This lack of circulation throughout the body can result from:from: Narrowed arteriesNarrowed arteries Interference with the heart muscle by scar tissue from a past heart attack Interference with the heart muscle by scar tissue from a past heart attack High blood pressureHigh blood pressure Heart-valve diseaseHeart-valve disease Heart defectHeart defect Infection of the heart valve or muscle Infection of the heart valve or muscle

(endocarditis or myocarditis)(endocarditis or myocarditis) (Cont’d)(Cont’d)




A patient with cardiac disease or a prosthetic A patient with cardiac disease or a prosthetic replacement carries an increased risk of replacement carries an increased risk of infection with bacteria carried in the blood.infection with bacteria carried in the blood.

Endocarditis is a severe infection of the Endocarditis is a severe infection of the cardiac valves and supporting structures cardiac valves and supporting structures caused by bloodborne pathogens that gain caused by bloodborne pathogens that gain entry to the bloodstream from such places as entry to the bloodstream from such places as the mouth and gastrointestinal tract.the mouth and gastrointestinal tract.



Lesson 29.2Lesson 29.2


Learning Objectives Learning Objectives

Describe the major medical disorders that can Describe the major medical disorders that can affect a patient’s oral health.affect a patient’s oral health.

Describe the type of dental management a Describe the type of dental management a medically compromised patient would medically compromised patient would receive.receive.

Demonstrate the correct transfer of a Demonstrate the correct transfer of a wheelchair-bound patient.wheelchair-bound patient.


Pulmonary DisordersPulmonary Disorders

Disorders that affect the lungs and are Disorders that affect the lungs and are characterized by airway obstruction.characterized by airway obstruction. Bronchial asthma: Often arising from allergies Bronchial asthma: Often arising from allergies

characterized by an increased hypersensitivity to characterized by an increased hypersensitivity to various stimuli, which results in bronchial edema various stimuli, which results in bronchial edema and widespread narrowing of the bronchial airways.and widespread narrowing of the bronchial airways.

Treatment-plan modificationsTreatment-plan modifications• Minimizing stressMinimizing stress

• Shortening appointmentsShortening appointments

• Minimizing the use of epinephrine and aspirin Minimizing the use of epinephrine and aspirin (Cont’d)(Cont’d)




““Chronic obstructive pulmonary disease” is the Chronic obstructive pulmonary disease” is the general term for pulmonary diseases general term for pulmonary diseases characterized by airflow blockage during characterized by airflow blockage during respiration. respiration.

Bronchitis is a narrowing of the bronchial airways Bronchitis is a narrowing of the bronchial airways resulting from chronic inflammation. resulting from chronic inflammation.

Emphysema is an irreversible enlargement of the Emphysema is an irreversible enlargement of the size of the air spaces, resulting in labored size of the air spaces, resulting in labored breathing and increased susceptibility to infection. breathing and increased susceptibility to infection. (Cont’d)(Cont’d)




Treatment-plan modificationsTreatment-plan modifications Minimizing stressMinimizing stress Shortening appointmentsShortening appointments Setting morning appointmentsSetting morning appointments Considering the use of sedation techniquesConsidering the use of sedation techniques Consider the use of humidified oxygenConsider the use of humidified oxygen Refraining from fully reclining the patientRefraining from fully reclining the patient Avoidance of anticholinergic drugsAvoidance of anticholinergic drugs Avoidance of appointments in hot and humid Avoidance of appointments in hot and humid

weatherweather


Blood DisordersBlood Disorders

Disorders that involve the cellular elements of Disorders that involve the cellular elements of the body the body Leukemia is an excessive increase in the number Leukemia is an excessive increase in the number

of white blood cells.of white blood cells. Hemophilia is a disease marked by excessive Hemophilia is a disease marked by excessive

bleeding, caused by a congenital lack of a protein bleeding, caused by a congenital lack of a protein substance necessary for blood clotting. substance necessary for blood clotting.

Treatment-plan modificationsTreatment-plan modifications Make modifications for any surgical procedures.Make modifications for any surgical procedures. Antibiotic prophylaxis may need to be prescribed Antibiotic prophylaxis may need to be prescribed

for high-risk procedures.for high-risk procedures.


Muscular DisordersMuscular Disorders

The musculoskeletal system includes the The musculoskeletal system includes the bones, muscles, and joints. bones, muscles, and joints. Older patients are more likely to have chronic Older patients are more likely to have chronic

progressive arthritis with stiffening of joints. progressive arthritis with stiffening of joints. Muscular dystrophy involves the striated muscles Muscular dystrophy involves the striated muscles

in the body, resulting in progressive atrophy and in the body, resulting in progressive atrophy and weakness. weakness.

Treatment-plan ,odificationsTreatment-plan ,odifications See arthritic patients in the morning.See arthritic patients in the morning. Avoid sedation in patients whose breathing is Avoid sedation in patients whose breathing is

impaired. impaired.


Endocrine DisordersEndocrine Disorders

Glands throughout the body release Glands throughout the body release hormones into the bloodstream to help hormones into the bloodstream to help regulate the metabolism.regulate the metabolism. Hyperthyroid is an overactive thyroid gland.Hyperthyroid is an overactive thyroid gland. Hypothyroid is an underactive thyroid gland that Hypothyroid is an underactive thyroid gland that

produces fewer hormones.produces fewer hormones. Treatment-plan modificationsTreatment-plan modifications Medical consultation is essential.Medical consultation is essential. Such patients are highly sensitive to epinephrine Such patients are highly sensitive to epinephrine

and other “amine” anesthetics.and other “amine” anesthetics.(Cont’d)(Cont’d)


Endocrine DisordersEndocrine Disorders


Diabetes mellitus is a disease characterized by Diabetes mellitus is a disease characterized by a sustained high blood glucose level resulting a sustained high blood glucose level resulting from an absolute or a relative lack of insulin. from an absolute or a relative lack of insulin.

• Type 1 disease renders the patient insulin- dependent.Type 1 disease renders the patient insulin- dependent.

• Type 2 disease is controlled with the use of diet and Type 2 disease is controlled with the use of diet and oral medications. oral medications.

Treatment-plan modificationsTreatment-plan modifications• Minimizing stressMinimizing stress

• Schedule appointments for midmorningSchedule appointments for midmorning

• Use of sedation techniquesUse of sedation techniques

• Normal dietary intake before treatmentNormal dietary intake before treatment


Behavioral and Psychiatric DisordersBehavioral and Psychiatric Disorders

Anxiety is a feeling of impending disaster. Anxiety is a feeling of impending disaster. Depression is a condition of general emotional Depression is a condition of general emotional

rejection and withdrawal. rejection and withdrawal. Schizophrenia is a disturbance in thinking and Schizophrenia is a disturbance in thinking and

perception with delusions, hallucinations, and perception with delusions, hallucinations, and impaired reality testing.impaired reality testing. Treatment-plan modificationsTreatment-plan modifications Addition of a fluoride supplement and salivary substitutes Addition of a fluoride supplement and salivary substitutes

because of xerostomiabecause of xerostomia Importance of regular hygieneImportance of regular hygiene Understanding that gaining informed consent may be difficultUnderstanding that gaining informed consent may be difficult


The Physically Compromised PatientThe Physically Compromised Patient

Wheelchair-bound patientWheelchair-bound patient Transferring the patient is a concern.Transferring the patient is a concern.

Vision-impaired patientVision-impaired patient This patient relies on his or her sense of touch and This patient relies on his or her sense of touch and

oral communication.oral communication. Hearing-impaired patientHearing-impaired patient

Face your patient.Face your patient. Speak slowly.Speak slowly. Keep directions simple.Keep directions simple. Give written instructions. Give written instructions.


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