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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