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08/12/2011

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Dewi Agustina
Oral Medicine FKG UGM
MANAGEMENT OF MEDICALLY
COMPROMISED PATIENTS
refers to those patients who have medical
conditions which affect the dental treatment or
manifest as a specific oral and dental problem
Perlu modifikasi perawatan dental
Rujuk : asesmen medik definitif
The term of medically compromised
patients :
Daftar masalah pasien:
Chief complaint
Potential medical complication
Oral diseases and conditions
Masalah --- Chief complaint
Pain
Acut infection
Bleeding
Traumatic injury
Immediate
attention
&
urgent care
Potential medical complication
Kondisi medik pasien
yang dapat mengalami
komplikasi selama
perawatan dental
perlu modifikasi
perawatan
dental
Potential medical complication
Diagnosed medical
conditions
Current medications
Hypersensitivity
Undiagnosed medical
conditions
perlu
modifikasi
perawatan
dental
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Diagnosed medical conditions
Asthma
Epilepsy
Bleeding disorders
Pregnancy
Diabetes
Risk of serious
complication?
perlu modifikasi
perawatan
dental
perlu dicermati:riwayat
pengobatan dan status
fisiknya bila tidak jelas
-- rujuk/konsultasi
Current medications
Pengobatan yang sedang
dialami pasien
Perlu dipahami aksi,
interaksi dan efek
samping obat
Hypersensitivity
Alergi, idiosinkrasi
Hindari
obat yang sama
Undiagnosed medical conditions
Kondisi medik
yang belum
terdiagnosa atau
perlu
diwaspadai
Tidak mempunyai implikasi
langsung dengan perawatan
dental saran - konsultasi
Mempunyai implikasi langsung
dengan 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 stairs
w/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 flights
of stairs w/o short of breath/any discomfort; healthy
individual with extreme fear of dental tx)
Level 3 : A patient with severe systemic disease
(able to walk at a regular pace with limited physical
activity)
Level 4 : A patient with incapacitating or life-threatening
disease
(unable to do light activity for even a short period of time
and 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 moderate
systemic disease
Does not interfere with daily
activities
No treatment modifications are necessary

Minimal treatment modification may


needed

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 systemic
disease
Limits daily activity, but is not
incapacitating
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 systemic
disease
Limits daily activity, and is a
constant threat to life
Physician consultation mandatory
Treatment modification mandatory
Unstable angina
Liver failure
End-stage renal disease
AdvancedAIDs
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 DENTAL
PROCEDURES
(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 DENTAL
PROCEDURES (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
Lowrisk of adverse
patient reaction
Diagnostic and
Preventive procedure
ORA II
Minimal risk of adverse
patient reaction
Elective phase I care
Disease elimination
Routine dental care that
cause minimal bleeding
urgent dental care
ORA III
Moderate risk of
adverse patient or
dental 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 of
adverse patient
reaction
Hemorrhagic procedures
Multiple extractions
Orofacial infections
Intravenous anxiolytic
therapy
Emergency care (infections,
bleeding, trauma)
ORA V
High risk of adverse
patient reaction
Severe orofacial infections
Complex surgical procedure
Deep sedation
General anesthesia
Correlation between ORA and ASA as
RISK ASSESSMENT FOR DENTAL TREATMENT
ORA I ORA II ORA III ORA IV ORA V
ASA I
Routine
precaution
Routine
precaution
Routine
precaution
Routine precaution Routine
precaution
ASA II
Routine
precaution
Modification Modification Strict precaution and
medical consultation
Strict
precaution and
medical
consultation
ASA III
Routine
precaution
Modification
and medical
consultation
Modification
and medical
consultation
Strict precaution and
medical consultation
Hospitalization
protocol and
medical
consultation
ASA IV
Modification
and medical
consultation
Strict
precaution,
Hospitalization
protocol and
medical
consultation
Contra-
indicated
Defer until condition
improves, palliation in
hospital environment
and medical
consultation
Contra-
indicated
PRE-TREATMENT EVALUATION
The goal of the pre-treatment evaluation of the medically
complex patient is to determine the patients ability to
tolerate the planned dental procedure(s)
Evaluation of The Medically Compromised
Dental Patient
Dentist determine the answers to the following
questions :
Does the patient have a diagnosed or undiagnosed
medical condition that might complicate dental care ?
Can we proceed with dental treatment in a relatively safe
manner ?
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 compromised
patient
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Relatively recent history & physical examination
Laboratory data
Physician consult
Patient anxiety evaluation
The preoperative evaluation of the
patient may require the following:
Review your findings and treatment plan with the
physician
Ask for the physicians evaluation of the patients
health
Ask for the physicians evaluation of the patients
ability to tolerate your planned procedure
Ask for additional recommendations for the patients
care
Physician Consultation
As with many dental patients in general, medically
complex patients may have considerable anxiety
about dental treatment and would benefit from an
anxiety 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 both
orally 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 : Anemia
B : Bleeding tendency
C : Cardiorespiratory disorders
D : Drug treatment and allergies
E : Endocrine disease
F : Fits and faints
G : Gastrointestinal disorders
H : Hospital admissions and attendances
I : Infections
J : Jaundice and liver disease
K : Kidney disease
L : 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 over
last 6 8 weeks) ; (>7% = problem) ; can measure long
term 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 dietician
Note :
Glucometer and glucose tablet/orange juice should be
available 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 require
two 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 dental
procedures : ok. For surgical procedures : give
sedative agent prior to the procedures
- 170-190/115-125 mmHg or above : avoid dental tx
and 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, or
burning 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 of
Myocardial 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 history
of 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 Borne
Acute 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 medication
metabolized by the liver
When in doubt, use clinical lab tests to screen for the
presence 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 PTS
Stress :
Pregnancy
Fear of dental pain
need to prevent dental disease by increasing oral
hygiene
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 to
mercury
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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