1. The Medically and Physically Compromised Patient Chapter 29 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

2. Chapter 29 Lesson 29.1 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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

4. Learning Objectives 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.

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 I: employment discrimination Title II: access for the disabled Title II: access for the disabled Title III: public accommodations Title III: public accommodations Title IV: telecommunications services Title IV: telecommunications services Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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

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

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

9. Fig. 29-3 Periodontal conditions of an older patient. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

10. Fig. 29-4 Root caries of in an older patient. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

11. Fig. 29-5 Darkened teeth associated with secondary dentin and aging. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

12. 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.

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

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 Early disease, or forgetfulness phase Intermediate disease, or confused phase Intermediate disease, or confused phase Late disease, or dementia 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.

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. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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

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

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 Vital-sign checks throughout the procedure Use of supplemental oxygen Use of supplemental oxygen Use of prophylactic sublingual nitroglycerin Use of prophylactic sublingual nitroglycerin Avoidance of epinephrine Avoidance of epinephrine(Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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 (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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) (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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

22. Chapter 29 Lesson 29.2 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

23. Learning Objectives 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.

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 Minimizing stress Shortening appointments Shortening appointments Minimizing the use of epinephrine and aspirin Minimizing the use of epinephrine and aspirin(Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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. (Cont’d) Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

26. 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.

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

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

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

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 1 disease renders the patient insulin- dependent. Type 2 disease is controlled with the use of diet and oral medications. Type 2 disease is controlled with the use of diet and oral medications.  Treatment-plan modifications Minimizing stress Minimizing stress Schedule appointments for midmorning Schedule appointments for midmorning Use of sedation techniques Use of sedation techniques Normal dietary intake before treatment Normal dietary intake before treatment Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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

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