1. University of Aden
Faculty of dentistry
Oral surgery dep
Compromised patient
(1)
Prepared by:
Dr.mohamed sheikh
Demonstrator in oral surgery dep.
Telephone no: 733258537
E-mail: dr.sheikhalkalady@yahoo.com
2. Objectives:
At the end of this presentation the student
will be able to:
Determine whether a patient can safely
tolerate a planned procedure
Recognize the components of risk
assessment
Apply the protocol of stress reduction in
dental management of medically
compromised patient
Deal with each specific medically
compromised patient in our field
3. This is a hand of one pt came to
Dr.S.Bagondwan, need to do
dental extraction. What is your
opinion?
4. Risk assessment
The 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:
5. Risk assessment
The 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)
6.
7. 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
8. General Stress Reduction
Protocol
Open communication about fears/concerns
Short appointments
Morning appointments
Preoperative sedation
Short-acting benzodiazepine (e.g., triazolam 0.125-
0.25 mg)
Night before appointment and/or
1 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
9. 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.
10. Angina pectoris
Consult patient's physician
Use general SRP
Have nitroglycerin tablets or spray
readily available
Ensure profound local anesthesia before
starting surgery
Consider use of nitrous oxide sedation
Monitor vital signs closely
Possible limitation of epinephrine used
(0.04mg maximum)
Maintain verbal contact with patient
11. CHF
Defer treatment until heart function
improved and after consultation
Use SRP
Possible administration supplemental
oxygen
Avoid supine position
Consider referral to oral and
maxillofacial surgeon
12. Asthma
Defer dental treatment until asthma is
well controlled
Use SRP but avoid use of respiratory
depressants
Keep a bronchodilator-containing
inhaler easily accessible
Avoid NSAIDs in susceptible patients
Local anesthetic considerations
13. Renal dialysis
Avoid some drugs and modify doses
of others
Defer dental care until the day after
dialysis
Consult physician concerning use of
prophylactic antibiotics
Take hepatitis precautions if unable to
screen for hepatitis
Look for signs of other diseases?
14. Hypertension
Mild-to-moderate
hypertension(systolic more than 140
,diastolic more than 90)
Be sure that the patient is under
medical therapy of hypertension
Use SRP
Monitor vital signs(BP test)
Epinephrine-containing LA should be
used cautiously(not more than0.04mg)
15. Hypertension
severe 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
16. Diabetic patient
Defer surgery until diabetes is well
controlled(consult physician)
Early morning appointment and use SRP
Monitor vital signs before,during, and
after surgery
Maintain verbal contact
Have 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
17. Diabetic patient
Advise pts not to resume normal
insulin doses until return to usual
caloric intake and activity level
Watch for signs of hypoglycemia
Treat infection aggressively
19. Hyperthyroidism
Defer surgery until thyroid dysfunction
is well controlled
Monitor vital signs before, during, and
after surgery
Limit amount of epinephrine used
20. Sickle cell anemia
Stress reduction protocol(SRP)
minimize vasoconstrictor use.
Use prophylactic antibiotics for major
surgical procedures.
21. Therapeutically anticoagulated
PT
Pts receiving aspirin or other platelet-
inhibiting drugs
Physician consultation for stopping the
drug
Defer surgery until the drug have
stoped for 5 days
Restart drug therapy on the day after
surgery if no bleeding is present
22. Therapeutically anticoagulated
PT
Pts receiving warfarin (coumadin)
Physician consultation for allowing the
PT to fall to 1.5 INR for a few days
Obtain the baseline PT
a- if the PT is 1-1.5 INR proceed with
surgery
b- if the PT is more than 1.5 INR , stop
the warfarin 2 days before surgery
Restart warfarin on the day of surgery
23. Therapeutically anticoagulated
PT
Pts receiving heparin
Physician consultation for stopping the
drug
Defer 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
24. Seizure pt
Defer surgery until seizure is well
controlled
Use SRP
Avoid hypoglycemia and fatigue
25. Pregnant pt
Defer surgery until after delivery
if possible
Consult the pt obstetrician if surgery
cannot be delayed
Avoid dental radiographs unless
necessary
Avoid use of teratogenic drugs
Avoid keeping the pt in the supine
position for long periods
Use SRP(sedative drugs are best
avoided)
26. 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