The Medically and Physically Compromised Patient

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The Medically and Physically Compromised Patient

Chapter 29

Chapter 29 Lesson 29.1

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)

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.

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

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.

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.

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.

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

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

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

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

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

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)

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)

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

Adrenal suppressants to relax muscles.
Extra time for procedures, if the patient is wheelchair-bound

(Cont’d)

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

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)

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)

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)

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.

Chapter 29 Lesson 29.2

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.

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)

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)

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

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.

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.

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)

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

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

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.

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