1. The Medically and Physically Compromised Patient
Chapter 29
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2. Chapter 29 Lesson 29.1
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3. 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)
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4. 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.
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5. 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
Which law states that a dental practice, clinic, or school must provide appropriate access for disabled persons?
Which law extends telecommunication services to hearing-impaired and speech-impaired persons?
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6. 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.
What should a dental assistant expect in patients with special needs? (Patients who enter the dental practice may be very ill, in pain, or physically challenged. The dental assistant should use good judgment in helping these patients, which may mean bypassing some of the usual routines during an appointment.)
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7. 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.
What aging category would include a 76-year-old dental patient?
What are the oral health conditions that affect the aging population?
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8. 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.
What is xerostomia? How does it affect the oral cavity?
What are root caries?
Why does recurrent decay occur around defective restorations?
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9. Fig. 29-3 Periodontal conditions of an older patient.
What is the incidence of periodontal disease in older people?
Can periodontal disease be prevented?
In this photograph, what are the signs of periodontal disease?
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10. Fig. 29-4 Root caries of in an older patient.
What happens to a person’s oral cavity with aging?
Where are the root caries in this older person’s mouth?
Can root caries be restored? What type of restoration is first used in most cases of root caries?
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11. Fig. 29-5 Darkened teeth associated with secondary dentin and aging.
What happens to the color of teeth as people age?
In this picture, where are the dark teeth?
Which teeth have been restored since fracturing?
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12. Fig. 29-6 Bone resorption with loss of teeth and alveolar ridge.
How are tooth loss and changes in the jaw bone related to age?
Which teeth are missing in this photograph of an older person’s mouth?
What has happened to the alveolar bone that used to surround the missing teeth?
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13. 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
What does it mean to be medically compromised?
How does a medically compromised patient affect the dental office?
Patients in which categories may require a physician’s consultation before dental treatment?
What types of medical conditions may present an increased risk of emergency in the dental office?
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14. 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)
What is dementia? Why do some patients who have dementia experience xerostomia?
What challenges does a patient with dementia present for dental practitioners?
In the later stages of the disease, who takes care of the patient’s oral cavity?
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15. 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.
What common side effect is caused by phenytoin?
Why does a patient with a neurologic disorder need to be questioned before treatment about eating, stress, pain, and alcohol consumption?
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16. 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)
Why would extra time be needed during a dental appointment if the patient with multiple sclerosis is in a wheelchair?
Why is it important for dental office staff to encourage relaxed muscles in patients who have multiple sclerosis?
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17. 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
What is another term for cerebrovascular accident?
Why is a patient who has had a stroke scheduled for a dental visit in the morning?
Why do such patients need modified oral-hygiene aids?
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18. 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)
What does it mean when the patient has a history of angina?
How does treating a patient who has a history of angina affect dental-office practices?
What is another term for myocardial infarction?
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19. 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
What is another term for hypertension?
How is high blood pressure treated?
How can the dental office prepare for a patient who has hypertension?
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20. 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)
How does high blood pressure affect the circulation?
What is endocarditis?
What is the appearance of a patient who has congestive heart failure?
What precautions should the dental-office staff take with a patient who has congestive heart failure?
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21. 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.
How does the dental-office staff reduce the risk of infection to a cardiac patient or a patient with a joint prosthesis?
How does the dental-office staff prevent endocarditis in patients who are at high risk for this disorder?
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22. Chapter 29 Lesson 29.2
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23. 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.
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24. 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)
Why should stress be minimized during the dental appointment of a patient with a pulmonary disorder?
How is stress minimized in the dental office?
Which organs are affected by pulmonary disorders?
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25. 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.
What does the acronym “COPD” stand for?
What is the appearance of a patient with COPD?
What are the implications for dental treatment for patients with pulmonary disorders?
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26. Pulmonary Disorders Treatment-plan modifications Minimizing stress
(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
Why should a patient with a pulmonary disorder not be fully reclined?
How does hot, humid weather affect the patient with a pulmonary disorder?
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27. 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.
How are bacterial infections prevented in patients with blood disorders such as leukemia?
Why would a bleeding disorder be a problem when a tooth is extracted and afterward during healing?
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28. 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.
What dental procedures may be difficult in a patient with arthritis?
How does rheumatoid arthritis affect oral health and dental care?
Should nitrous oxide, sedation, and general anesthesia be used on a patient with muscular dystrophy? Why or why not?
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29. 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)
How does hyperthyroidism affect the body?
How does hyperthyroidism affect oral health and dental treatment?
How does hypothyroidism affect dental treatment?
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30. 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
How is a patient with type 2 diabetes classified with regard to the need for insulin?
What are the oral manifestations of diabetes?
What type of sedation technique would be used in a diabetic patient to reduce stress during a dental appointment?
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31. 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
Why do these patients have a high risk of caries?
Why is xerostomia a common occurrence in patients being treated for depression or schizophrenia?
Why is informed consent difficult to obtain from patients with behavioral and psychiatric disorders?
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32. 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.
How can the dental office accommodate wheelchair-bound patients?
How can the dental office accommodate patients with vision or hearing impairment?
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