Management of medically compromised patients in dentistry ppt

SPECIAL PATIENT CARE
Chronic Obstructive Pulmonary Disease
Marge Buehner, RDA, RDH, MHSA

EXAMPLE PPT

Demographics

68 year old African American female
Lives at home with husband
Patient 25 pounds over weight
Pre-diabetic using diet to control
Blood pressure 145/95 ras
Medical History

History of Rheumatic fever at age 9
Heart murmur with valvular regurgitation, mitral valve prolapse
Mitral valve replaced with “pig” valve 3 years ago
History of high blood pressure for 35 years
Mild stroke 2 years ago
Allergic to penicillin and codeine
Medical History

History of smoking for 40 years; smoke free for the last ten. Her history of smoking caused Chronic Obstructive Pulmonary Disease (COPD)
Physician prescribed patient to use supplemental oxygen constantly, patient chooses to use only while at home.
Medical Concerns

Mitral valve replacement need premed
Patient allergic to amoxicillin- must use Clindamycin 600mg , 30-60 minutes prior to appointment
High blood pressure-need to monitor at every appointment
Use of oxygen during every appointment
Medical Concerns

Chronic obstructive pulmonary disease (COPD) is comprised primarily of two related diseases - chronic bronchitis and emphysema. In both diseases, there is chronic obstruction of the flow of air through the airways and out of the lungs, and the obstruction generally is permanent and progressive over time.
Medical Concerns

Hypertension: Is an abnormal elevation of arterial pressure that can be fatal if sustained and untreated.
Excess body fat can play a role in severity and progression.
Stress and anxiety may increase BP
Medications

Vasotec (enalapril)
Capoten (captopril)
Lasix (furosemide)
Slow K (potassium chloride)
Lopressor (metoprolol)
Proventil (Albuterol)
Nitrostat (nitroglycerin)
Coumadin (warfarin)
Medications

Vasotec (enalapril)-angiotensin-converting enzyme (ACE) inhibitor
Capoten (captopril) -ACE inhibitor
ACE inhibitors blocks vasoconstriction mainly on arterioles which help lower blood pressure. Must monitor BP; possible orthostatic hypotension, syncope or dizziness.

Medications

Lasix (furosemide)-loop diuretic; Acts on loop of Henle to decrease the reabsorption of chloride and sodium with resultant diuresis. Dry mouth, orthostatic hypotension.
Slow K -supplemental potassium to prevent electrolyte imbalance while on loop diuretics.
Medications

Lopressor (metoprolol)-slective beta blocker; xerostomia, diarrhea, be careful when prescribing NSAID’s longer than 3 weeks
Beta blockers, also known as beta-adrenergic blocking agents, are a class of drugs that works by blocking the neurotransmitters, norepinephrine and epinephrine, from binding to receptors.
Proventil (Albuterol) inhaler -Beta 2 Agonist; xerostomia, taste alterations, discolors teeth
Medications

Nitrostat (nitroglycerin)- Artery and venous dilator; reduces left ventricular pressure, systemic vascular resistance
The principal pharmacological action of nitroglycerin is relaxation of vascular smooth muscle.
Coumadin (warfarin)- anticoagulant; mouth ulcers, taste disturbance
Anticoagulants act by inhibiting the synthesis of Vitamin K dependent clotting factors
Local Anesthesia Considerations

Patients with mild to moderate elevations in systolic or diastolic pressure are acceptable risks for dental care including use of local anesthetics with vasopressors.
The administration of vasopressors in patients with beta blockers increases the likelihood of a serious elevation of the blood pressure.
Nitrous Oxide Considerations

Medical consults for cardiac and pulmonary conditions.
N20 should not be used in severe COPD
*

Dental History

Patient has a full upper denture and lower partial denture which she refuses to leave out at night.
Multiple lesions on hard and soft palate- denture stomatitis
Missing teeth: all maxillary teeth as well as #17, 29, 31 and 32
Lower anterior teeth are misaligned
Last perio maintenance was 4 years ago
Pictures

Radiographs

Periodontal Chart

Periodontal Charting

Heavy plaque
Heavy calculus and heavy bleeding upon probing
Moderate advanced periodontitis on remaining teeth
Remaining teeth have 4-5 mm pockets
Hygiene Care Plan

Root planing and scaling lower arch; re-eval in 4 weeks
Information and instructions on denture care
Modified Bass technique, flossing and use of end tuft brush for linguals of mandibular anteriors
Activity of Daily Living

Level 0-patient has the ability to perform ordinary daily tasks without assistance
OSCAR- Oral

Moderate supra and sub-g calculus
25-50% bone loss on radiographs
Lower arch RP/S with anesthesia, w/o epinephrine
Denture stomatitis
ASA Classification

ASA III-systemic disease which limits activity but is not incapacitating
OSCAR-Systemic

Medical Diagnosis
Mitral valve replacement
COPD
Hypertension
Medication allergies
Stroke-hx of
Pharmacologic Agents
Loop diuretic
Beta Blocker
Vasodialator
Beta 2 agonist
ACE inhibitor
Anticoagulant
Premed antibiotic
Electrolyte
OSCAR-Capability

Patient can function and contributes to self care
No problems with mobility
OSCAR-Autonomy

Patient cans make decisions for herself, is not dependent on a caregiver and can transport herself to the dental office
OSCAR-Reality

Patient is able to afford dental treatment and is medically stable, although brittle, for dental treatment.
Hygiene Care Delivery Considerations

Medical consult needed before treatment begins
Question MD about
Coumadin reduction
Antibiotic pre-med
Deliver care in semi-upright sitting position
Be sure oxygen tank is connected and patient is removed from personal equipment
References

GageTW, Pickett FA, (2003) “Dental Drug Reference”, Mosby, St. Louis, MO
Little JW, Falace DA, Miller CS, Rhodus NL, (2008), “Dental Management of the Medically Compromised Patient”, Mosby, St. Louis, MO
Wynn RL, Meiller TF, Crossley HL, (2007), “Drug Information Handbook for Dentistry, Lexi-Comp, Hudson, OH
References

Malamed SF,(2004), “Handbook of Local Anesthesia”, Elsevier Mosby, St. Louis, MO
www.rxlist.com
www.google.com American Heart Association: Mitral Valve Prolapse
http://hcd2.bupa.co.uk/fact_sheets/html/heart_valve_surgery.html
http://academic.evergreen.edu/h/huyvin17/chronic.html