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Dementia & Other Medically Compromised Patients

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Introduction
There is no question that the practice of dentistry today has changed dramatically in the past 50 years. Not only has advanced technology made available a new era in cosmetic, implantology, and restorative dentistry, but also through medical science and public health measures, people are living longer and receiving medical care for conditions that only a few years ago were fatal. For example, kidneys that have failed or are failing are now transplanted, coronary arteries that are occluded are surgically bypassed or opened with stents, and patients with many types of cancers and malignancies are being managed or controlled. The improvement in technology, medical science and public health has also significantly increased life expectancy. In dental practice, this translates into an increase in both the number and complexity of older adults with medical compromising conditions who are seeking routine dental care. Many of these medical conditions, (or the medical management of these conditions), require modification or alteration of routine dental treatment to prevent adverse events or consequences. The purpose of this summary (and subsequent session) is to highlight the importance of evaluation of patients with medical compromising patients in dental practice, to provide references or resources that review guidelines or provide information for clinical patient management, and to suggest a practical approach for dealing with common medical emergencies.

Evaluation
The key to successful dental management of patients who have compromising medical conditions is a thorough evaluation and assessment of the level of risk the patient will be at if he or she would undergo the proposed dental treatment. In many cases, patients may need to be referred to health care providers from other disciplines, (physicians, pharmacists, laboratory technicians), in order to provide information to the dentist so they may be safely treated. Consultations between professionals for patients with compromising medical conditions should be routine and commonplace in today's dental practice. For example, prior to invasive surgery a consult to a laboratory technician to obtain an INR (International Normalized Ratio of the Prothrombin Time) should be ordered to assess the risk of a patient's bleeding intraoperatively. Another example is to refer an anxious patient with a cardiomyopathy to a cardiologist for stress testing and evaluation prior to undergoing invasive surgery. According to Little, Falace, Miller, and Rhodus (1), risk assessment involves the determination of at least three factors:

  1. the nature, severity, and stability of the patient's medical condition
  2. the emotional state of the patient
  3. the type and magnitude of the planned procedure (invasive or noninvasive)

These factors must be carefully considered for every patient treated, but especially the older patient with a previous history of a medical problem, or those who are at risk for medical problems, but previously undiagnosed.

Equally important in the evaluation of risk of the procedure to the patient, is the determination of the benefit of the dental treatment for the patient. For example, will the extraction of all the teeth in an asymptomatic Alzheimer's disease patient in order to prevent future dental problems, be the most appropriate or beneficial treatment plan? Risk assessment must always include an evaluation of all known risk factors (#1,2,3, mentioned above), a determination of benefit of the treatment, and a knowledgeable dentist and dental team, who is willing and able to manage patients with compromising conditions.

Patient Management
For patients with medical conditions, the dental management is the ultimate responsibility of the treating dentist. Not only should a medical history be taken on every patient who is to receive dental care but also the dentist should review the medical history in an interview format. In addition, it is critical that baseline vital signs are taken at the initial exam and prior to any invasive treatment to allow the dentist to determine physiologic or psychologic factors that may be significant. Proper referral or stress management procedures can then be implemented prior to dental care. The American Dental Association (2) publishes a good medical history form that is available to all members for a nominal cost. At the end of every medical history form, a section should be devoted to summarize the patient's health status and to rate a patients severity of disease. The American Society of Anesthesiologists (ASA) classification is a subjective system to categorize patients according to the severity of their disease or condition. Although, patients can change categories as their disease or medical condition is controlled or becomes more severe, the classification is helpful to determine a patient's stability and likelihood of needing dental treatment modification at a given time. The ASA categorizes patients into one of 4 groups:

  • ASA I - Normal healthy patient. No dental modifications needed.
  • ASA II - A patient with mild systemic disease that does not interfere with daily activity. These patients include those who have a significant health risk factor such as smoking or obesity, and others with controlled or stable chronic diseases such as high blood pressure, diabetes, chronic obstructive pulmonary disease, or angina.
  • ASA III - A patient with moderate to severe systemic disease that is not incapacitating but may alter daily activity. These patients include those with unstable angina pectoris, recent myocardial infarction or stroke, or hemophilia.
  • ASA IV - A patient with severe systemic disease that is a constant threat to life and definitely requires modifications of dental treatment. Patients in this category would include those with kidney or liver failure and advanced AIDS.

A brief, focused, physical examination by the dentist to assess the general appearance, exposed skin and extremities, and an examination of the head and neck should also routinely be done. For example, the outward appearance of a patient can give a very good indication of his or her physical health and mental state. A person with staggering or halting gait could represent a neurologic, pulmonary or cardiovascular problem; petechiae and ecchymosis on patients' arms could signal an underlying bleeding disorder; and unilateral facial paralysis could represent someone with Bell's palsy or who has had a stroke. Careful inspection of the head and neck could reveal undiagnosed skin cancers, benign or malignant cysts, and signs or symptoms of systemic disease (i.e., yellowing of the sclera indicating hepatitis).

Modification of Dental Treatment for Specific Medical Conditions
A number of excellent texts and web-based resources are available which review guidelines for medical and dental management of patients with medical compromising conditions. Several of these, which I have found useful, are included in the appendix of this summary. In general, there are three areas of concern regarding dental treatment in patients with medical compromising conditions(3):

  1. The effect of the patient's medical problem and drug therapy on the delivery of treatment.
  2. Specific oral and dental problems that can arise from either the underlying medical condition or the patient's medication.
  3. Possible interaction between the patient's oral health and their general health.

For each of these categories, it is possible to identify specific examples that occur quite often in the typical geriatric dental practice.

Dental Care in Different Settings
For most older patients (functionally independent elders), delivery of dental care will take place in a conventional dental operatory/dental clinic setting. These patients are responsible for their own transportation to and from the dental office/clinic, financial obligations for the care provided, and homecare (i.e., brushing, flossing, etc), to be done. In about 25% of the older population (functionally dependent or frail elders), patients themselves are not able to do one or more or the above, and rely on their family or caregivers (staff) at home or in a long-term care facility. Many large nursing facilities contain dental clinics with in-house dentists who serve as dental directors of that facility. Similarly, teaching and tertiary trauma hospitals, particularly those in urban areas also contain dental clinics with staff dentists trained to evaluate and treat patients with complex medical conditions and dental needs. Some dentists can provide dental care in the nursing home or homebound setting by using mobile dental equipment. Every patient, whether functionally dependent or frail, can ultimately be treated by a trained and willing dentist. However, the most appropriate setting for the delivery of care will depend upon the risk assessment and evaluation of benefit of treatment, the training of the dentist, and the availability of dental facility for the treatment to be provided.

Practical Approaches to Common Medical Emergencies
Unfortunately, despite the best pre-treatment evaluation, preparation, and modification of dental procedure, life-threatening medical emergencies can and do happen during the practice of dentistry. Although the occurrence of emergencies are infrequent in a dental setting as a rule, Malamed (4) has noted that older patients are at a greater risk for adverse events due to an older person's decreased physiologic reserve, especially the cardiovascular system. As noted by Malamed, when subjected to stress (pain, fear, anxiety), the cardiovascular system may not be able to meet the body's demands for increased oxygen and nutrients, a lack of which can lead to the development of acute cardiovascular complications such as life-threatening dysrhythmias and anginal pain. Because medical emergencies can happen to anyone; the patient, dentist, member of the office staff or even the person accompanying the patient, the entire office staff must be prepared to act as a team.

Medical emergencies in the dental office setting are most often caused by the patient's inability to withstand either the physical or emotional stress or the patient's reaction to drugs given by the dentist. Emergencies can also be caused by a complication of a systemic disease or a lack of evaluation of a person's risk factors or poor preparation by the dentist, or dental team. A simple, practical approach to deal with common medical emergencies can be remembered by the acronym P.R.N. standing for Preparation, Recognition and Needed management. The primary goal of any dental professional should be to prevent a medical emergency from occurring. Preparing (P) yourself and the office team to respond to emergencies, and to have the proper equipment and drugs on hand to respond immediately, are the most important first steps a dentist should take. If a medical emergency should occur, quick recognition (R) or diagnosis must be done in order to be able to render what could be life-saving needed management (N) or treatment.

The top ten most common types of medical emergencies reported by Fast (5) and Malamed (6) are: syncope, mild allergic reaction, angina pectoris, postural hypotension, seizures, asthmatic attack (broncospasm), hyperventilation, "epinephrine reaction", insulin shock (hypoglycemia), and cardiac arrest. However, from a treatment approach, a simpler approach recognizes what clinical symptoms a patient presents with and determines the underlying cause.

This system includes the following categorization for managing emergencies and gives a differential diagnosis for each:

  • Unconsciousness: syncope, CVA, alcohol overdose, acute adrenal insufficiency, insulin shock (diabetic coma)
  • Respiratory difficulty: allergic reaction, hyperventilation, bronchial asthma, heart failure
  • Chest Pain: Hyperventilation, GERD, myocardial infarction, angina pectoris
  • Other reactions: mild allergy, overdose, intra-artery injection of epinephrine, other

After making the diagnosis, the dentist along with the dental team, should be trained to initiate basic life support (CPR), give drugs to support vital signs or counteract the patient's symptoms, and/or call for help.

References (emergencies)

  1. Little JW, Falace DA, Miller CS, Rhodus NL. Dental management of the medically compromised patient, sixth edition. Mosby, St. Louis, Missouri, 2002.
  2. Seymour RA. Dentistry and the medically compromised patient. J R Coll Surg Edinb Irel. 1:4; 207-214, 2003.
  3. American Dental Association. Web-site: www.adacatalog.org. Price: $6.50 per 100.
  4. Malamed SF, Robbins KS. Medical emergencies in the dental office, fifth edition. Mosby, St Louis, Missouri, 2000.
  5. Fast TB, Martin MD, Ellis TM. Emergency preparedness: a survey of dental practitioners. J Am Dent Assoc. 112:499-501, 1986.
  6. Malamed SF. Managing medical emergencies. J Am Dent Assoc 124:4-53, 1993.

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