Dental management of the medically complex patient 1+2

Aim and objectives

common/important conditions for dentistry:

cardiac (3)

respiratory (3)

Renal (4)

Hepatic (4)

Haematological (4)

Endocrine (3)

Neurological (4)

Psychiatric (5)

Immune system (4)

Genetic (2)

Oncology (4)

4 conditions accounting for 86% of deaths

• heart disease

• cancer

• respiratory disease

• diabetes

• smoking/diet

What should you do when you first see your patient when they walk in through the door? (4 main things)

Look at their:

• Skin

• Height/weight/frailty

• Gait/wheelchair/walking frame

• IV or central access, tracheostomy, PEG tubes, indwelling catheter, stoma bag (additional medical devices)

What is the first history you should go through?

MH

Sometimes if its really complex they don’t know everything - might need to work with GP/consultant - to get all necessary information to provide safe dental care

MC, medications, allergies, under consultant or gp care?, how frequently they visit hospital, care support?

Along with MH what factors as you also assessing for?

Patient factors

Well controlled Diabetes or uncontrolled?

what might you do to make sure you got all the details regarding medical history?

liaise with the medical specialists

e.g if on dialysis ask the nephrologist - which date is best for extraction due to AC and dialysis days

Now that you have all the information, what do you do with it?

Address/minimise risks e.g Arrange cover (AB for IE)if necessary, optimise condition before treatment (talk to diabetic consultant or consultant to help get diabetes under control if currently not controlled)

Take precautions (medical emergencies) e.g if the pt is epileptic make sure they have taken their medications before hand, asthmatic - have inhaler, angina - have GTN spray on the go and with the patient

Good infection control - infectious diseases e.g HIV,HBV/HCV

Minimise intra-operative and post-operative complications e.g haemophilia - give cover - local haemostatic measures to reduce risk of post operative bleeding

Review the patient - check on them a few days after in case of complications so if you need to treat again - helps us learnt what to avoid next time

Overall

For each condition what are the medical (5) and dental (4) considerations ?

• Diagnosis

• Characteristics

• Medical management

• Prognosis

• likely for there to be a ME?

• oral manifestation of condition

• oral affects of management

• direct dental treatment implications

• indirect dental treatment implications

Drugs for each medical emergency

Acute coronary syndrome

What is the ASA classification?

Classify how generally healthy/medically complex a patient is

healthy. mild, severe, constant threat to life, needs operation, brain-dead - donor

1-3 relevant to dentistry, referral criteria ASA 1-2 are safe in general practice, 3+ need to be seen in hospital

controlled diabetes - ASA class 2

uncontrolled - having severe impact on life - ASA class 3

set up for drawing blood

What is the first thing you do when collecting blood and then what is the order of colours?

[mnemonic]

culture, blue, red, yellow, purple, green

Specific colours and order of taking blood

5 main types of blood tests?

• FBC - platelet, neutrophil, Hb, WBC

• Coagulation screening times - Pt, INR, APTT

• urea and electrolyte - eGFR

• Liver function test -

• others: HIV/Diabetes

What are the normal ranges for each?

Significance of polypharmacy? (5)

• Dry mouth

• Caries risk - some drugs directly increase risk through sugar in the formulation/dry mouth

• Drug interactions - analgesics/AB prescribed don’t interact

• Signs of increased medical complexity - comorbidities - they have risks for dentistry

• Direct oral affects of medications - OAC - bleeding in mouth, gingival hypertrophy - Epilepsy medications

3 main cardiac conditoins?

• Ischaemic heart disease: Angina, MI

• Hypertension

• IE and associated conditions

What is angina (types) and what is MI? (simple)

• controlled - when sitting on a dental chair, ASA 2

• Uncontrolled - become anxious or climbed up a flight of stairs - ADA 3

• MI - irreversible

symptoms of Ischaemic heart disease? (4

• neck pain

• nausea

• chest pain

• abdominal pain

What are some medical managements for Angina/MI?

• Manage risk factors: smoking, HTN, stress

• GTN spray or other meds - AC, BB, diuretics

• Surgery - stents, bypass graft

Prognosis of ischaemic heart diseas?

uncontrolled - worse

Heart failure or repeated or recent MI = worse

Medical emergencies with ischaemic heart disease?

• Acute coronary syndrome - severe unremitting chest pain - could be uncontrolled angina (reversible) or MI (if irreversible)

Chronic MI may cause what in the patient? (4)

• Heart Failure

• Shortness of breath

• Swollen ankles

• Risk of further MI

Oral affects of management? (2)

• Can have dry mouth and caries risk - due to polypharmacy

• Anti-coagulated

Direct dental treatment implications? (1)

• Bleeding from anticoagulation (mainly during extractions)

Indirect dental implications?

• stress/anxiety (worsens) and pain management crucial (inadequate pain control - release of adrenaline - increases load on the heart)

• Higher risk of IV sedation

• IHS with NO2 very useful (can dilate arteries to the heart so not only reduces anxiety but also helps with angina pain)

• hospital setting for sedation if previous MI

• Higher risk of another MI within 6 months (careful when supplying any kind of dentistry within this time frame, delay all elective treatment, precaution with emergency tx)

• sedation/GA risk, access, timing of appointment etc

• LA with adrenaline, generally if it is controlled you can still use them, if uncontrolled you might need to use plain solutions or restrict the use of LA as the adrenaline increases the load on the heart

What medications are used a lot with ischaemic heart diseases?

Anti-coagulants

What are 4 main types of anti-coagulants?

1. Warfarin

2. Low molecular weight heparin

3. Direct oral anti-coagulants DOACs

4. Anti-platelet drugs

What must you check with Warfarin? what is the implication?

INR, it is less than 4 then you can proceed with local measures (local haemostatic measures such as surgicel and sutures)

LMWH, when are they used? give 3 examples and what do they always end in? what is this implication?

• -parin

• Enoxiparin, dalteparin, tinzaparin

• often used short-term (rarely used long-term, used while patient is in a hospital - might delay treatment until their condition is stabilised)

• If you cannot delay tx and bleeding risk - consult physician

DOACs, give some examples (4)? implicaiton?

• Dabigatran, Rivaroxaban, Edoxaban Apixaban

• If bleeding risk, delay/skip the the dose

Anti-platelet drugs, name some (3) implications (2)?

• Aspirin, clopidogrel, ticagrelor

• Proceed as usual if just one but local measures

• cautious if dual and invasive treatment

Name dental procedures that are unlikely to cause bleeding according to SDCEP

Dental procedures likely to cause bleeding: low and high risk of post op bleeding

• LA, BPE, supraPMPR, supra restos, endo, impressions, fitting/adjustment of ortho appliances

• low risk: Simple extraction (1-3 teeth - if next to each other - then a bigger wound so is it restricted?), 6PPC, RSD, sub restos

• high risk: complex extraction, flap raising procedures

What are the usual schedule, morning does (pre-treatment) or not applicable, and post-treatment changes to the DOACS: Apixaban, Dabigatran, Rivaroxaban and Edoxaban

What are some medical conditions that are associated with an increased bleeding risk?

• Chronic renal failure (platelet)

• Liver disease (coagulation factors)

• haematological malignancy

• coagulation disorder

• CT disorders

Hypertension:

what is it and symtpoms?

• High blood pressure

• Generally no symptoms, blurred vision, tingling extremities headache

Medical management of hypertension? (2 main) (3 drugs)

• risk factors: weight, exercise, diet, smoking

• Diuretics, BB , statins

ADA grades 1- 4 for blood pressure?

high - increased risk of a heart attack

might write to GP - to try and bring it under control

conscious sed - lowers BP, but slightly more risk as well for having conscious sedation

NO2 - reduce anxiety and help reduce bp

sometimes gives time to rest before taking BP

What is infective endocarditis?

• A rare but potentially life threatening infection of the endocardium

• Predominantly heart valves - especially damaged or prosthetic

• Bacteraemia leading to endocardium infection (gingivitis/extraction/surgery bacteria enter mouth and attach to valves and form biofilm)

Symptoms/signs of IE? (7)

• night sweats

• fever

• Weight loss

• head aches

• heart murmur

• Osler’s nodes

• Janeway lesions (spots on hand)

Medical management?

• Prevention

• cute management - admission, IV AB, potentially surgery

Prognosis?

30% fatal

Infective endocarditis linked to dentistry how? (3)

• Any oral bleeding likely to cause transient bacteraemia, including tooth brushing with gingivitis

• Reports of IE after invasive dental tx

• Oral bacteria frequently cultured from IE patients endocardium

Again what was the main management of IE?

prevention

What is included in prevention? (3)

• ID patients at risk

• oral hygiene (Need to give good OHI, take out tooth risk of bacteraemia is 2 weeks, brushing everyday - with gingivitis - longer risk- PD disease is more important in preventing IE so we need to focus more on OH than AB prophylaxis)

• follow national guidance

What does the NICE, EU and American guidelines say about cover and if there is cover what type of cover is it?

Amox and clindamycin

What does SDCEP say?

Advise of risk no AB cover

Patients at risk and sub-groups requiring special considerations

bold - consult with cardiologist in the increased risk

most cardiologists - say yes

remember to educate on symptoms and OHI

3 conditions in Respiratory conditons

• Asthma

• COPD

• OSA - obstructive sleep apnoea

What is Asthma?

• reversible airway obstruction, inflammation, bronchial hypersensitivity

Signs/symptoms of Asthma? 3 severe symptoms?

• wheeze

• cough

• dyspnoea

• use of accessory muscles for respiration

• cyanotic

• unconscious

• apnoea (stop breathing?)

Medical management of Asthma?

• Beta agonist - salbutamol

• Steroids

• Other meds - Theophylline

• who treating - consultant - if under consultant - this means that their asthma isn’t well controlled so more likely to have asthma attack during tx

Prognosis?

Good but risks with severe asthma attack

some grow out of it

ME?

Acute asthma

Oral manifestation of condition?

• incorrect use of inhalers - trauma/ candida

Indirect dental implications? (3)

• careful if severe and conscious sedation

• prepared or ME, contact consultant if needed

• review status on the day

What is COPD?

primarily caused by what

Chronic, progressive, irreversible airway obstruction

smoking

What are some signs or symptoms? Advanced severe (3)

• wheeze, Chronic cough, dyspnoea and sputum

• Dependent on oxygen, respiratory failure, cor pulmonale (heart failure caused by respiratory failure)

Medical management of COPD? (drugs (3))

• Risk factor

• Bronchodilators, steroids, AB for chest infections

• Oxygen in severe cases

Prognosis of COPD? (3 categories )

• Low risk - Normal blood gases

• Moderate - on steroids and multi-pharmacy

• High - symptomatic or untreated - (affects their day to day life)

Indirect dental implications of COPD? (5)

• IV sedation high risk (avoid in severe COPD, hospital setting for mild/mod)

• High risk GA

• Transport, access and O2 practicalities

• In very severe cases avoid giving oxygen

• treat upright position

What is Chronic Kidney Disease CKD?

What can it be caused by? (4)

• Chronic irreversible renal damage and loss of function

• Diabetes, chronic infection, autoimmune, hypertension, infections others

What are signs/symptoms of CKD?

• weakness/fatigue (anaemia)

• Anorexia (loss of appetite)

• nausea/vomiting

• Bruising

• Bone pain

• Secondary disease in other major organs - liver and IHD

What are the managements of Chronic Kidney Disease CKD at the early, severe and end stage?

• Early - Risk factors and address symptoms

• Severe - haemodialysis or peritoneal dialysis

• End-stage - Renal transplant

Prognosis in terms of stages and GFR ?

1 - >90

2 - 60-89

3- 30-59

4 - 15-29

5 - < 15

What are oral manifestations of the condition? (4)

Bone issues, dry mouth, swollen salivary glands

Discolouration of soft tissues - Pale buccal mucosa

(remember kidney control water and electrolytes)

Direct dental treatment implications of CKD? (3)

• Bleeding risk (platelet function, anticoagulated during haemodialysis) - local haemostatic agents, consult nephrologist, DDAVP (desmopressin)

• Infection risk (WBC function) - aggressive tx of infections, antibiotics but take care of doses

• Anaemia (EPO)

oral affects of management are due to dialysis

Indirect dental implications (3)

• High risk IV sedation/GA

• Change prescription dose/drug

• Timings of appointment on day after haemodialysis and associated anticoagulant - consult nephrologist (drug may still be in their system and have effect the next day - usually use LMWH)

Medical management of renal transplant/transplant in general?

• life long immunosuppressed to avoid rejection

• often with steroids

Prognosis of organ transplant?

• 70% at 5 years

sign/symptoms of renal; transplant? (3)

• Immunosuppression

• Oral infections : candida, herpes simplex

• Symptoms associated with failure of transplant organ

• Steroid effects - coming up

Oral manifestations of condition/management of transplant? (2)

• immunosuppression and viral oral cancers

• oral infections

Direct dental treatment implications of organ transplants? (4)

• Bleeding risk if function of organ low and involved in clotting (live renal)

  • High infection risk (immunosuppression)

• anaemia

• if chronic steroid use might need steroid cover

Indirect dental implications?

• Usually high sedation risk (depending on organ)

• Contact medical team (if doing complex work/ga/sedation)

• Complete dental work before transplant

• Defer elective treatment until after 6 months post transplant

What are steroids?

general functions? (4)

what are the synthetic steroids used for?

Naturally occurring hormones secreted by adrenal glands. Glucocorticoids and mineralocorticoids. Generally referrers to glucocorticoids like cortisol

Multiple functions: immune system, metabolism, infection response, stress

mainly used for immunosuppression but also replace natural corticosteroids if low such as in Addison’s disease - autoimmune disease

Signs and symptoms of chronic steroid use? (8)

• weight gain in face and back

• HTN

• diabetes

• immunosuppressed

• muscle weakness

• mood changes

• hirsutism

• osteoporosis - put on bisphosphonates

Are all steroids equal, what are the approximate potencies of systemic corticosteroids relative to cortisol?

Prednisolone the most widely used

Those on steroids are at increased risk of? (2)

oral infections and viral cancers

Synthetic steroids do what to the hypothalamus-pituitary axis?

so the body cannot what?

Therefore at risk of?

what are some signs/symptoms of this? (4)

• Supress it

• HPA supressed by synthetic steroids

• So the body will not produce own steroids when stressed e.g during dentistry or wound healing

• At risk of acute adrenal insufficiency - serious lack of steroids causing hypotension, vomiting, collapse and death

How could you give steroid cover? (2)

• 100 mg IM hydrocortisone

• Double dose of steroid on day of procedure

HPA axis suppression will occur if taking what dose of prednisolone for how long?

• 5 mg Prednisolone for 3 months - (if taking other consider the comparative dose)

• Follow local guidance if available or consult specialist/medical team

• (5-20 mg then consider doubling the dose, anything more than 20mg doesn’t need cover)

What is the guidance for Addison’s disease?

Addison’s is more severe and not quite applicable for those with chronic steroid use

Chronic liver disease, could have C and later on this can become what?

• Cirrhosis - irreversible damage to liver structure with loss of function - liver failure

can be caused by? (3) (rarer (3))

Caused by alcohol, viral hep B/C

rarer- toxins, heart failure, biliary obstruction

Signs/symptoms of chronic liver disease?

• Bleeding/bruising

• Regurgitation

• Jaundice

• Finger clubbing

• Encephalopathy

• Oesophageal varices

• Hepato-renal syndrome (renal function is reduced with absence of kidney dx)

• Ascites

• Spider naevi

Medical management of chronic liver disease patients? (3)

• Address cause

• Risk factors

• Liver transplant

Prognosis of Chronic liver disease? (if severe)

if severe, life expectancy - 5-10 years

ME for chronic liver disease?

• bleeding/drug metabolism

Oral affects of management of chronic liver disease? (3)

Dry mouth, caries risk

immunosuppressed if transplant

Direct dental treatment implications? (4)

• High bleeding risk (clotting factors)

• Increased infection risk

• anaemia (sedation)

• Adjust dose/drug of choice of prescriptions (drug metabolism)

Indirect dental implications of chronic liver disease?

High risk sedation (Benzodiazepines m[higher toxicity risk] metabolism, anaemia)

Chronic alcohol abuse can cause?

• anxiety/depression

• Liver disease/cirrhosis

• Pancreatitis

• GI ulcers

• Wernicke/Korsakoff syndrome (cognitive impairment - build up of toxins in the brain (may impact capacity)

• Ischaemic heart disease

• Anaemia

• Immune system dysfunction

• gout

Haematological?

• Bleeding disorders (haemophilia/VWD)

• anticoagulated/deficiencies

• Sickle cell aneamia

What is haemophilia and VWD?

• haemophilia is a x-linked congenital deficiency of clotting factors A=8 B=9

• VWD - deficiency in VW factor which is involved in platelet function and stability

Signs/symptoms of H and VWD

• Bleeding:

• immediate = platelet dysfunction (VWD, thrombocytopenia)

• Delayed = clotting factor dysfunction (H/liver disease)

• Joint damage/deformity

• Bruising/petechiae

• heavy menstrual cycle

Medical management of these bleeding disorders? (4)

• Close relationship with haemophilia centres

• Replace missing factors/platelets

• Desmopressin DDAVP/tranexamic acid (stabilise the clot when it is alr there)

• Prevention (e.g OHI to prevent gingivitis which would cause even mroe bleeding)

Prognosis of these bleeding diorders?

managed quite well nowadays so good

ME?

Bleeding can be fatal