The Medically and Physically Compromised Patient



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The Medically and Physically Compromised Patient

  • Chapter 29
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 29 Lesson 29.1

  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives

  • Pronounce, define, and spell the Key Terms.
  • Describe the type of dental management a medically compromised patient would receive.
  • Describe the stages of aging in the older population.
  • Describe orally related conditions affecting the older patient.
  • (Cont’d)
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives

  • (Cont’d)
  • Describe the importance of the medical history in the medically compromised patient.
  • Describe the major medical disorders that can affect a patient’s oral health.
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Rights of a Patient

  • Americans with Disabilities Act
    • Provides a clear, strong, enforceable standard addressing discrimination against people with disabilities
  • American Dental Association
    • Supports:
      • Title I: employment discrimination
      • Title II: access for the disabled
      • Title III: public accommodations
      • Title IV: telecommunications services
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Role of the Dental Assistant

  • Aid the dentist in providing treatment.
  • Act as a source of information to the patient and family.
  • Provide comfort to the patient.
  • Help reduce anxiety.
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Aging Population

  • Aging is the irreversible and inevitable changes that occur with time.
  • Stages of the older population:
    • Young/old: People 65 to 74 years old, better educated and more demanding of health services, retain more of their natural teeth.
    • Old: People 75 to 84 years old, beginning to have multiple health problems, have more fixed and removable prostheses.
    • Old/old: People 85 years old or older have fewer natural teeth, believe that tooth loss is inevitable, and have medical conditions reflected in their oral health.
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Dentally Related Aging Changes

  • Xerostomia is a condition, resulting from certain disorders and medications, that involves decreased flow of saliva.
  • Periodontal disease is an increasing problem in the older population. The tissues of older patients may be slower to heal.
  • Dental decay increases in the form of coronal and root caries and recurrent decay around defective restorations.
  • Dark and brittle teeth result from deposition of secondary dentin that have gradually reduced the size of the pulp chamber.
  • Bone resorption results in loss of the alveolar ridge.
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 29-3 Periodontal conditions of an older patient.

  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 29-4 Root caries of in an older patient.

  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 29-5 Darkened teeth associated with secondary dentin and aging.

  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig. 29-6 Bone resorption with loss of teeth and alveolar ridge.

  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Medically Compromised Patient

  • Patient Assessment
    • Category I: Healthy patient
    • Category II: Medical conditions requiring schedule changes
    • Category III: Medical conditions requiring significant modifications in dental treatment
    • Category IV: Medical conditions requiring major modifications in dental treatment
    • Category V: Serious medical conditions
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Neurologic Disorders

  • Alzheimer disease is a brain disorder that is marked by deterioration of mental capacity.
    • The disease progresses in three stages:
      • Early disease, or forgetfulness phase
      • Intermediate disease, or confused phase
      • Late disease, or dementia phase
  • Treatment-plan modifications
    • Thorough dental examination in early stages
    • Special attention to daily care of the mouth
    • Alertness to signs of xerostomia
  • (Cont’d)
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Neurologic Disorders

  • (Cont’d)
  • Seizures are an abrupt suspension of motor, sensory, and/or body function.
  • Epilepsy
    • Petit mal seizures usually last 5 to 10 seconds.
    • Grand mal seizures have many causes and arise in people in all age groups.
  • Treatment-plan modifications
    • Maintenance of oral hygiene
    • Surgical reduction of gingival hyperplasia
    • Questioning before any procedure with regard to eating, stress, pain, and alcohol consumption.
  • (Cont’d)
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Neurologic Disorders

  • Multiple sclerosis is a debilitating and degenerative disorder of the central nervous system that involves progressive weakening of the lower extremities, causing muscle weakness, unsteady gait, and paralysis.
  • Treatment-plan modifications
  • (Cont’d)
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Neurologic Disorders

  • (Cont’d)
  • Stroke, or cerebrovascular accident, is a minor to severe loss of central nervous system function caused by a sudden vascular lesion of the brain, such as hemorrhage, embolism, thrombosis, or ruptured aneurysm.
  • Treatment-plan modifications
  • Midmorning scheduling with additional time set aside
  • Modification of oral-hygiene aids
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders

  • Heart disease: leading cause of death in the United States
    • Angina: severe pain in the chest associated with an insufficient supply of blood to the heart
    • Myocardial infarction: heart attack
    • Treatment-plan modifications
      • Vital-sign checks throughout the procedure
      • Use of supplemental oxygen
      • Use of prophylactic sublingual nitroglycerin
      • Avoidance of epinephrine
  • (Cont’d)
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders

  • (Cont’d)
  • Hypertension: Referred to as high blood pressure, it results when the heart must work harder as it pumps against resistance (e.g., a blocked artery).
  • Major factors associated with hypertension:
    • Stress
    • Age
    • Heredity
    • Smoking
    • Obesity
  • (Cont’d)
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders

  • (Cont’d)
  • Congestive heart failure is a condition where the heart cannot pump enough blood to the body’s other organs.
  • This lack of circulation throughout the body can result from:
    • Narrowed arteries
    • Interference with the heart muscle by scar tissue from a past heart attack
    • High blood pressure
    • Heart-valve disease
    • Heart defect
    • Infection of the heart valve or muscle (endocarditis or myocarditis)
  • (Cont’d)
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Cardiovascular Disorders

  • (Cont’d)
  • A patient with cardiac disease or a prosthetic replacement carries an increased risk of infection with bacteria carried in the blood.
  • Endocarditis is a severe infection of the cardiac valves and supporting structures caused by bloodborne pathogens that gain entry to the bloodstream from such places as the mouth and gastrointestinal tract.
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Chapter 29 Lesson 29.2

  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Learning Objectives

  • Describe the major medical disorders that can affect a patient’s oral health.
  • Describe the type of dental management a medically compromised patient would receive.
  • Demonstrate the correct transfer of a wheelchair-bound patient.
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pulmonary Disorders

  • Disorders that affect the lungs and are characterized by airway obstruction.
    • Bronchial asthma: Often arising from allergies characterized by an increased hypersensitivity to various stimuli, which results in bronchial edema and widespread narrowing of the bronchial airways.
    • Treatment-plan modifications
      • Minimizing stress
      • Shortening appointments
      • Minimizing the use of epinephrine and aspirin
  • (Cont’d)
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pulmonary Disorders

  • (Cont’d)
  • “Chronic obstructive pulmonary disease” is the general term for pulmonary diseases characterized by airflow blockage during respiration.
  • Bronchitis is a narrowing of the bronchial airways resulting from chronic inflammation.
  • Emphysema is an irreversible enlargement of the size of the air spaces, resulting in labored breathing and increased susceptibility to infection.
  • (Cont’d)
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Pulmonary Disorders

  • (Cont’d)
  • Treatment-plan modifications
    • Minimizing stress
    • Shortening appointments
    • Setting morning appointments
    • Considering the use of sedation techniques
    • Consider the use of humidified oxygen
    • Refraining from fully reclining the patient
    • Avoidance of anticholinergic drugs
    • Avoidance of appointments in hot and humid weather
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Blood Disorders

  • Disorders that involve the cellular elements of the body
    • Leukemia is an excessive increase in the number of white blood cells.
    • Hemophilia is a disease marked by excessive bleeding, caused by a congenital lack of a protein substance necessary for blood clotting.
    • Treatment-plan modifications
    • Make modifications for any surgical procedures.
    • Antibiotic prophylaxis may need to be prescribed for high-risk procedures.
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Muscular Disorders

  • The musculoskeletal system includes the bones, muscles, and joints.
    • Older patients are more likely to have chronic progressive arthritis with stiffening of joints.
    • Muscular dystrophy involves the striated muscles in the body, resulting in progressive atrophy and weakness.
    • Treatment-plan ,odifications
    • See arthritic patients in the morning.
    • Avoid sedation in patients whose breathing is impaired.
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Endocrine Disorders

  • Glands throughout the body release hormones into the bloodstream to help regulate the metabolism.
    • Hyperthyroid is an overactive thyroid gland.
    • Hypothyroid is an underactive thyroid gland that produces fewer hormones.
    • Treatment-plan modifications
    • Medical consultation is essential.
    • Such patients are highly sensitive to epinephrine and other “amine” anesthetics.
  • (Cont’d)
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Endocrine Disorders

  • (Cont’d)
  • Diabetes mellitus is a disease characterized by a sustained high blood glucose level resulting from an absolute or a relative lack of insulin.
      • Type 1 disease renders the patient insulin- dependent.
      • Type 2 disease is controlled with the use of diet and oral medications.
    • Treatment-plan modifications
      • Minimizing stress
      • Schedule appointments for midmorning
      • Use of sedation techniques
      • Normal dietary intake before treatment
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Behavioral and Psychiatric Disorders

  • Anxiety is a feeling of impending disaster.
  • Depression is a condition of general emotional rejection and withdrawal.
  • Schizophrenia is a disturbance in thinking and perception with delusions, hallucinations, and impaired reality testing.
    • Treatment-plan modifications
    • Addition of a fluoride supplement and salivary substitutes because of xerostomia
    • Importance of regular hygiene
    • Understanding that gaining informed consent may be difficult
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Physically Compromised Patient

  • Wheelchair-bound patient
    • Transferring the patient is a concern.
  • Vision-impaired patient
    • This patient relies on his or her sense of touch and oral communication.
  • Hearing-impaired patient
    • Face your patient.
    • Speak slowly.
    • Keep directions simple.
    • Give written instructions.
  • Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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