compromised patient
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University of AdenFaculty of dentistry
Oral surgery dep
Compromised patient(1 )
Prepared by:Dr.mohamed sheikhDemonstrator in oral surgery dep.Telephone no: 733258537E-mail: dr.sheikhalkalady@yahoo.com
Objectives:At the end of this presentation the
student will be able to:Determine whether a patient can safely
tolerate a planned procedureRecognize the components of risk
assessmentApply 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 to Dr.S.Bagondwan, need to do dental extraction. What is your opinion?
Risk assessmentThe 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 assessmentThe 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)
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 Reduction Protocol
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 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.
Angina pectorisConsult patient's physicianUse general SRPHave nitroglycerin tablets or spray
readily availableEnsure profound local anesthesia before
starting surgeryConsider use of nitrous oxide sedationMonitor vital signs closelyPossible limitation of epinephrine used
(0.04mg maximum)Maintain verbal contact with patient
CHFDefer treatment until heart
function improved and after consultation
Use SRPPossible administration
supplemental oxygenAvoid supine positionConsider referral to oral and
maxillofacial surgeon
AsthmaDefer dental treatment until
asthma is well controlledUse SRP but avoid use of
respiratory depressantsKeep a bronchodilator-containing
inhaler easily accessibleAvoid NSAIDs in susceptible
patientsLocal anesthetic considerations
Renal dialysisAvoid some drugs and modify
doses of othersDefer dental care until the day
after dialysis Consult physician concerning use
of prophylactic antibioticsTake hepatitis precautions if
unable to screen for hepatitisLook for signs of other diseases?
HypertensionMild-to-moderate
hypertension(systolic more than 140 ,diastolic more than 90)
Be sure that the patient is under medical therapy of hypertension
Use SRPMonitor vital signs(BP test)Epinephrine-containing LA
should be used cautiously(not more than0.04mg)
Hypertensionsevere 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 patientDefer surgery until diabetes is well
controlled(consult physician)Early morning appointment and use
SRPMonitor vital signs before,during, and
after surgeryMaintain verbal contactHave 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 patientAdvise pts not to resume normal
insulin doses until return to usual caloric intake and activity level
Watch for signs of hypoglycemiaTreat infection aggressively
Diabetic patient
HyperthyroidismDefer surgery until thyroid
dysfunction is well controlledMonitor vital signs before, during,
and after surgeryLimit amount of epinephrine used
Sickle cell anemia Stress reduction protocol(SRP) minimize vasoconstrictor use.Use prophylactic antibiotics for
major surgical procedures.
Therapeutically anticoagulated PTPts receiving aspirin or other
platelet-inhibiting drugsPhysician consultation for
stopping the drugDefer surgery until the drug have
stoped for 5 daysRestart drug therapy on the day
after surgery if no bleeding is present
Therapeutically anticoagulated PTPts receiving warfarin (coumadin)Physician consultation for allowing the
PT to fall to 1.5 INR for a few daysObtain the baseline PTa- if the PT is 1-1.5 INR proceed with
surgeryb- if the PT is more than 1.5 INR , stop
the warfarin 2 days before surgeryRestart warfarin on the day of surgery
Therapeutically anticoagulated PTPts receiving heparinPhysician consultation for
stopping the drugDefer 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 ptDefer surgery until seizure is well
controlledUse SRPAvoid hypoglycemia and fatigue
Pregnant ptDefer surgery until after delivery if possibleConsult the pt obstetrician if surgery
cannot be delayedAvoid dental radiographs unless
necessaryAvoid use of teratogenic drugsAvoid 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
References:http://www.mdconsult.com.proxy.librar
y.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
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