Chapter 29
Patient's Health
About 50% of U.S. adults have chronic diseases, necessitating specialized dental care approaches. Dental teams must identify patients' challenges and adapt treatment accordingly.
Role of the Dental Assistant
Dental assistants are crucial in:
Aiding Treatment: Essential knowledge of specialized techniques and equipment for treating medically compromised patients.
Providing Information: Collaborating with patients and families to create personalized preventive programs.
Enhancing Comfort: Reducing patient anxiety, especially for those with past medical traumas.
Aging Population
As individuals aged 65+ make up 16% of the U.S. population (projected to reach 21% by 2050), aging can lead to:
Functionally independent seniors: Retaining natural teeth and needing health services.
Frail older adults: Experiencing complex dental needs.
Dependent older adults: Believing tooth loss is normal, requiring more assistance with oral care.
Oral Health conditions
Aging presents oral health challenges, including xerostomia, periodontal disease, tooth decay, darkened teeth, and bone resorption (loss).
Xerostomia is result of medication that cause decrease flow of saliva. Also associated with alcoholism autoimmune disorders, Parkinson disease (PS) etc.
50% old ppl have Periodontal desease. Improved oral hygiene and frequent visits to hygienist can fix periodontal disease risks. While aging commonly results in darker, brittle teeth prone to fractures.
Tooth decay high risk for root caries and decay around old or worn restorations. With aging, gums recede, exposing roots of teeth. Roots are not covered by enamel, so decay develop on root. Rot caries can be fixed by dietary changes and changes in oral hygiene.
Dark and brittle teeth is result of deposits of secondary dentin that made pulp chamber smaller. These teeth are may be fractured.
Bone resorption, when teeth are missing, parts of alveolar ridge will be lost. This effect patient will wear removable prosthesis + patient’s speech and diet.
Special Needs Patient Care
Dental care for special needs patients should accommodate unique conditions, classified by complexity:
Category I: Healthy patients needing no modifications.
Category II: Patients requiring scheduling flexibility.
Category III: Patients needing significant treatment planning adjustments.
Category IV and V: Patients needing substantial modifications, possibly requiring operating room treatment.
Specific Disorders of Medically Compromised Patients
Understanding disorders impacting oral health is vital, including:
Developmental Disorders: result of an impairment that occur during development stage (prenatal - 18). Paediatric dentist are trained in treating special patients.
Neurologic Disorders: Conditions like Alzheimer's and stroke needing tailored dental approaches.
Respiratory Disorders: Such as asthma and COPD requiring careful scheduling and monitoring.
Cardiovascular Disorders: Patients needing careful monitoring during dental procedures.
Overview of Disorders and Clinical Considerations
1. Alzheimer Disease
Alzheimer Disease: A progressive neurodegenerative disorder primarily affecting memory and cognitive function in older adults, leading to significant impairment in daily activities.
Clinical Considerations: Requires careful handling and communication. Dental staff should be trained to recognize signs of anxiety and confusion. Ensuring a comfortable and familiar environment can help reduce stress during visits.
2. Anemia
Anemia: A condition characterized by reduced levels of red blood cells or hemoglobin, resulting in fatigue and pallor. Common forms include iron-deficiency anemia and aplastic anemia.
Clinical Considerations: Monitor patients for signs of fatigue and pallor. Adjust treatment plans to accommodate energy levels and may require modifications in the amount of time a patient can spend in the dental chair.
3. Angina
Angina: Chest pain due to reduced blood flow to the heart muscle, usually indicating underlying coronary artery disease. Unstable angina is critical and requires immediate medical attention.
Clinical Considerations: Recognize the signs of angina attacks and have protocols in place for emergencies. Dental work should avoid triggering episodes; stress management and short appointments are crucial.
4. Arthritis
Arthritis: Involves joint inflammation causing pain and swelling. Major types include osteoarthritis (degenerative) and rheumatoid arthritis (autoimmune).
Clinical Considerations: Patients may have difficulty with mobility; provide assistance or special adaptations for comfort during procedures. Pain management strategies may be necessary.
5. Asthma
Asthma: A chronic respiratory condition characterized by airway inflammation, causing difficulty in breathing, wheezing, and coughing, often triggered by allergens.
Clinical Considerations: Ensure that the dental environment is free of allergens. Be prepared for asthma attacks, and allow time for breathing treatments before and after procedures if necessary.
6. Atrophy
Atrophy: The wasting away or decrease in size of muscle or tissue due to disuse, disease, or aging, affecting overall physical function.
Clinical Considerations: Assess muscular strength and stability, especially in older adults. Adjust seating and equipment to accommodate reduced physical abilities.
7. Bacteremia
Bacteremia: Presence of bacteria in the bloodstream, often leading to severe infections or sepsis if not treated promptly.
Clinical Considerations: Prophylactic antibiotics may be required for patients with certain medical conditions to prevent infections. Monitor for signs of infection after procedures.
8. Bronchitis
Bronchitis: Inflammation of the bronchial tubes, causing persistent cough and mucus production; can be acute (short-term) or chronic (long-term).
Clinical Considerations: Evaluate for persistent coughing during appointments. Ensure that the dental setting minimizes irritation to the airways.
9. Dementia
Dementia: A decline in cognitive function affecting memory and social abilities, significantly impacting daily life; can include various types like Alzheimer's and vascular dementia.
Clinical Considerations: Appointments should be brief and straightforward. Use clear, simple communication and be patient with the patient’s responses and actions.
10. Diabetes Mellitus
Diabetes Mellitus: A metabolic disorder that results in high blood sugar levels due to insulin production issues, categorized primarily into type 1 (autoimmune) and type 2 (lifestyle-related).
Clinical Considerations: Monitor blood sugar levels before and after dental procedures. Be mindful of the timing of appointments relative to meals and insulin administration.
11. Emphysema
Emphysema: A chronic lung condition, part of COPD, that damages the air sacs in the lungs, making it increasingly difficult to breathe.
Clinical Considerations: Minimize stress during procedures and have emergency oxygen available. Positioning patients comfortably to facilitate easier breathing is critical.
12. Endocarditis
Endocarditis: Inflammation of the inner lining of the heart, often resulting from infection; can lead to severe complications such as heart failure if untreated.
Clinical Considerations: High-risk patients may require antibiotic prophylaxis before procedures to prevent heart infections. Monitor for any signs of complications post-treatment.
13. Epilepsy
Epilepsy: A neurological disorder marked by recurrent seizures caused by abnormal electrical activity in the brain.
Clinical Considerations: Make accommodations for patients who may experience seizures in the dental chair. Have emergency protocols ready and inform staff about patient history.
14. Hemophilia
Hemophilia: A genetic bleeding disorder where blood does not clot properly due to the absence of certain clotting factors, leading to excessive bleeding.
Clinical Considerations: Consult with hematologists for management plans. Ensure patients have pre-procedure assessments for bleeding risk and consider using local anesthetics that minimize trauma.
15. Hyperglycemia
Hyperglycemia: Elevated blood glucose levels, often requiring management in diabetic patients to prevent long-term complications.
Clinical Considerations: Monitor for symptoms of high blood sugar before the appointment. Patients with diabetes may require adjustments in dental treatment timing and care.
16. Hyperthyroidism
Hyperthyroidism: An overactive thyroid condition resulting in accelerated metabolism, weight loss, and rapid heart rate, frequently due to conditions like Graves' disease.
Clinical Considerations: Monitor patients’ cardiac status due to increased heart rates. Avoid stimulants and consider the timing and medications that may interact with dental treatments.
17. Hypoglycemia
Hypoglycemia: Abnormally low blood sugar levels, which can occur in diabetics due to excessive insulin or insufficient food intake, leading to symptoms of confusion and weakness.
Clinical Considerations: Be aware of symptoms such as confusion or irritability, and ensure that patients have a quick source of sugar available during appointments.
18. Hypothyroidism
Hypothyroidism: Condition where the thyroid gland does not produce enough thyroid hormones, leading to symptoms such as fatigue, weight gain, and sensitivity to cold.
Clinical Considerations: Pay attention to patients' comfort during procedures and anticipate fatigue or sensitivity to cold, which may require warming blankets in the dental setting.
19. Leukemia
Leukemia: A type of cancer that affects blood and bone marrow, characterized by the overproduction of abnormal white blood cells, impairing the immune system.
Clinical Considerations: Treatment should be coordinated with medical providers; be aware of infection risks and monitor for signs of bleeding or bruising.
20. Myocardial Infarction
Myocardial Infarction: Also known as a heart attack; occurs when blood flow to a part of the heart is blocked, causing damage to the heart muscle.
Clinical Considerations: Assess cardiac health and scheduling around potential recovery timelines. Monitor vital signs and be prepared for emergencies.
21. Seizure
Seizure: A sudden disturbance in brain function, often resulting in convulsions, loss of consciousness, or unusual behaviour.
Clinical Considerations: Develop emergency protocols for seizures during treatment, ensuring a clear area and immediate response measures.
22. Stroke
Stroke: A medical emergency caused by interrupted blood supply to the brain, classified as ischemic (clot) or hemorrhagic (bleeding).
Clinical Considerations: Understand the patient’s recovery stage and physical limitations. Treatment may need to be adapted for mobility or cognitive issues post-stroke.
23. Xerostomia
Xerostomia: Decreased saliva production leading to dry mouth, often caused by medications or systemic diseases, significantly impacting oral health.
Clinical Considerations: Adjust dental practices to manage dry mouth, including recommending salivary substitutes and ensuring hydration during appointments. Monitor oral health closely due to increased risks of decay and periodontal disease.
Developmental Disorders:
Intellectual disability is term used when person with limitations in cognitive function and skills.
Down syndrome (trisomy 21) 47 chromosomes rather than 46. 1 in 700. Risk increases with mothers age. short, upward slant eye, flat nose. Several other disabilities.
Autism Spectrum Disorder (ASD) appear at age of 2-3, combo of genetic and environmental factors that affect how info is processed in brain + how nerve cells and synapses connect and organize.
Physical Disorders
1. Wheelchair Bound Individuals
Individuals who are wheelchair-bound have limited mobility, requiring adaptations in healthcare settings.
Considerations: Ensure accessibility in facilities.
2. Vision Impairment
Vision impairment can range from mild difficulties to complete blindness, affecting communication and understanding of visual aids.
Considerations:
Offer arm, use clear, verbal instructions and tactile materials. If guide dog, ask how to handle it.
3. Hearing Impairment
Hearing impairment can range from mild to profound loss, impacting communication methods.
Considerations: remove suction and music sound; remove mask, expose lips, use mirrors/models; simple direction with take home papers, interpreter.
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Neurologic Disorders
1. Alzheimer's Disease (dementia)
Definition: A progressive neurodegenerative disorder primarily impacting memory, cognitive function, and daily activities.
Clinical Considerations: Requires tailored communication strategies and a familiar environment to minimize anxiety during visits.
2. Seizures
Definition: Sudden disturbances in brain function caused by abnormal electrical activity, often resulting in convulsions or loss of consciousness.
Dilantin is used
Epilepsy is disorder characterized by clusters of nerve, cells, or neurons in brain that signal abnormally and cause seizures.
Tonic describes the muscles in the body becoming stiff, Atonic describes the muscles in the body relaxing, Myoclonic describes short jerking in parts of the body, Clonic describes periods of the body shaking and jerking
Generalized seizures, which affect both sides of the brain.
• Absence seizures, sometimes called petit mal seizures, can cause rapid blinking or a few seconds of staring into space.
• Tonic-clonic seizures also called grand mal seizures, can make a person cry out, lose consciousness, fall, and have muscle jerks or spasms.
• Focal seizures affect one area of the brain, also referred to as partial seizures.
• Simple focal seizures affect the small part of the brain and can cause twitching or a change in sensation such as a strange taste or smell.
• Complex focal seizures can make a person confused or dazed and unable to respond.
• Secondary generalized seizures begin in one part of the brain and spread to both sides.
Clinical Considerations: Develop emergency protocols for seizure management in dental settings and ensure patient history is communicated to the dental team.
3. Multiple Sclerosis (MS)
Definition: A chronic autoimmune disease that affects the central nervous system, leading to neurological symptoms and varying degrees of disability.(30-50)
Clinical Considerations: Assess mobility and fatigue levels, allowing for flexible appointment scheduling and adaptations in treatment to accommodate physical limitations.
4. Cerebrovascular Accident (CVA) or Stroke
Definition: A medical emergency caused by interrupted blood supply to the brain, resulting in brain damage and impaired functions, classified as ischemic or hemorrhagic.
Clinical Considerations: Be aware of the patient's recovery stage, adapt treatment plans for mobility and communication challenges, and monitor vital signs closely during visits.
Neuromuscular Disorders
Neuromuscular Disorders: These conditions impact the peripheral nervous system, which connects the brain and spinal cord to the muscles, leading to muscle weakness and impaired function.
Key Conditions:
Arthritis: Involves joint inflammation, leading to pain and swelling, affecting mobility and overall wellness.
Rheumatoid Arthritis: An autoimmune disorder causing chronic inflammation of joints, resulting in pain and potential joint damage.
Osteoarthritis: A degenerative joint disease characterized by the breakdown of cartilage, commonly affecting older adults and leading to pain and stiffness.
Muscular Dystrophy: A genetic disorder characterized by progressive muscle degeneration and weakness, impacting mobility.
Parkinson’s Disease: A neurodegenerative disorder that affects movement, causing tremors, rigidity, and bradykinesia (slowness of movement).
Cerebral Palsy: A group of disorders affecting movement and posture caused by non-progressive brain injury or malformation during fetal development or infancy, leading to varying degrees of physical and intellectual disabilities.
Amyotrophic Lateral Sclerosis (ALS): A progressive neurodegenerative disease that affects motor neurons, leading to muscle weakness and paralysis as mobility deteriorates.
Clinical Considerations:
Morning and short apt. Modify oral hygiene aid bc cant hold toothbrush, jaw arthritis limit patients ability to open the mouth.
Cardiovascular Disorders
Cardiovascular disorders refer to a variety of conditions that affect the heart and blood vessels. These disorders can lead to serious health complications if not managed properly. Here are key conditions related to cardiovascular disorders:
1. Congestive Heart Failure (CHF)
Definition: A condition in which the heart cannot pump enough blood to meet the body's needs.
Symptoms: Shortness of breath, fatigue, fluid retention, and swelling in the legs.
Management: Lifestyle changes, medication, and in severe cases, surgery may be necessary.
2. Hypertension
Definition: Also known as high blood pressure, it is a chronic condition where the blood pressure in the arteries is persistently elevated.
Risk Factors: Obesity, lack of physical activity, high-salt diet, and genetic factors.
Management: Lifestyle changes, medication adherence, and regular monitoring of blood pressure.
3. Angina
Definition: Chest pain or discomfort resulting from reduced blood flow to the heart muscle, often a symptom of coronary artery disease.
Types: Stable (predictable and manageable), unstable (more severe and may require immediate medical attention).
Management: Medications, lifestyle modifications, and possibly surgical interventions such as angioplasty or bypass surgery.
4. Endocarditis
Definition: An infection of the inner lining of the heart chambers and valves, often from bacterial infection.
Symptoms: Fever, chills, heart murmur, and fatigue.
Management: Requires antibiotic treatment, and in some cases, surgery to repair or replace damaged heart valves.
Clinical Considerations:
Avoid stressful+lengthy apt, do vitals before + monitor during procedure, use of psychotropic remedication and nitrous oxide for stress.
Pulmonary Disorders
Effect lungs and airway obstruction.
1. Allergies
Definition: Allergies are hypersensitivity reactions to environmental substances (allergens) that can affect the respiratory system.
Symptoms: Include sneezing, runny nose, and airway inflammation, which may exacerbate other pulmonary conditions.
Management: Avoidance of allergens, use epipen, latex and dental material use.
2. Bronchial Asthma
Definition: A chronic inflammatory lung disorder of the airways characterized by episodes of wheezing, shortness of breath, chest tightness, and coughing. Bronchial asthma arise from allergies. Often start from childhood.
Triggers: Can include allergens, respiratory infections, cold air, exercise, and stress.
Management: minimize stress, short apt + sedation techniques, minimize use of epinephrine and aspirin
3. Chronic Obstructive Pulmonary Disease (COPD)
Definition: A progressive lung disease that includes chronic bronchitis and emphysema, leading to breathing difficulties.
Symptoms: Chronic cough, sputum production, and dyspnea (difficulty breathing).
Management: Smoking cessation, bronchodilators, corticosteroids, and pulmonary rehabilitation programs.
4. Blood Disorders
Bone marrow can be susceptible to malignant cells, which cuse tumors of the bone marrow.
Anemia is when blood lacks enough healthy red blood cells/hemoglobin.
Leukaemia is increase in white blood cells.
Hemophilia is excessive bleeding caused by congenital lack of protein substance necessary for blood clotting.
CC (Clinical considerations)
Susceptibility to bacterial infection, modifications must be made for any surgical procedure, antibiotic prophylaxis may need to be prescribed for high risk procedures. Prevents endocarditus.
Endocrine Disorders
Endocrine sysm is made of glands in different area, they all release hormones into bloodstream.
Thyroid gland regulates metabolism in body + stimulates the passage of calcium in bones from blood.
1. Hyperthyroidism
Smone with overactive thyroid gland may be diagnosed with graves’s disease, most common form of hyperthyroidism. Effect women 4-7 times more than men. 40 years of age. Infection, stress, trauma, pain cause thyperthroid crisis, is fatal.
Cc : accurate patient history and medical consultation is vvi.
2. Hypothyroidism
Thyroid gland is under-active and makes few hormones is hypothyroidism. Not danger in receiving dental care. Patient with mild hypothyroidism can recieve depressants/narcotic analgesics before treatment. May show signs of exaggerated response to drugs. Patient not under physician care may be sensitive to drugs bc depresant effect of drugs on CNS.
3. Diabetes Mellitus
Is chronic disese of metabolism and the way body uses blood sugar(glucose). Glucose if vital bc provides energy for cells of the body. It circulates through body using insulin, comes from pancreas.
Diabetes develop when body dont make/use enough insulin causing blood glucose level to become too high.
Type 1 diabetes: insulin dependent or juenile-onset.
Type 2: non-insulin dependent or adult-onset diabetes.
Hyperglycaemia (too much blood sugar), if not treated may result in diabetic ketoacidosis + life-threatening diabetic coma.
hypoglycaemia (too little blood sugar) aka insulin shock. Missing meal, overdose of insulin, exercising without insulin/food intake.
Cc for diabetes mellitus
Short appt, to reduce stress, use sedation like nitrous oxide/oral diazepam. Make sure patient dietary intake before appt. Most common cause of hypoglycaemia is not eating.
Behavioural & psychiatric Disorders
Anxiety - “all is not well” feeling
Depression - is emotional rejection + withdrawal. Lack of personal hygiene
Eating disorders - anorexia nervosa = self-starvation + excessive weight loss.
Binge eating disorder - binge eating (eating too much in short period of time)
Bulimia nervosa - cycle of bineing andn self-induced vomiting, to undo binge eating.
Bipolar (manic-deoressive disorder) - extreme elation followed by depression.
Substance abuse - with alcoholism + drugs
Posttraumatic stress disorder - “reexperiencing” of traumatic event.
Schizophrenia - psychotic disorders, varying of personality disorders.
CC for behavioural and psychiatric disorders: xerostomia from meds, regular hygiene + use of fluoride + salivary substitutes are important, patient cooperation + consent may cause problem.