Little and Falace's Dental Management of the Medically Compromised Patient, 8e

715 Pages·2012·87.73 MB·English

by  James W. Little DMD MS

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Dental Management of the Medically Compromised Patient ISBN: 978-0-323-08028-6
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Library of Congress Cataloging-in-Publication Data
Dental management of the medically compromised patient / James W. Little … [et al.]. – 8th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-323-08028-6 (pbk. : alk. paper)
I. Little, James W., 1934-
[DNLM: 1. Dental Care. 2. Dental Care for Chronically Ill. 3. Oral Manifestations. WU 29]
617.6–dc23
2011052299
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James W. Little, DMD, MS Craig S. Miller, DMD, MS
Professor Emeritus Professor of Oral Diagnosis and Oral Medicine
University of Minnesota Provost Distinguished Service Professor
School of Dentistry Department of Oral Health Practice
Minneapolis, Minnesota; Naples, Florida Department of Microbiology, Immunology
and Genetics
Donald A. Falace, DMD, FDS RCSEd The University of Kentucky College of Dentistry
and College of Medicine
Professor Emeritus
Lexington, Kentucky
Oral Diagnosis and Oral Medicine
University of Kentucky College of Dentistry
Lexington, Kentucky Nelson L. Rhodus, DMD, MPH
Morse Distinguished Professor and Director
Division of Oral Medicine, Oral Diagnosis and
Oral Radiology
University of Minnesota
School of Dentistry and College of Medicine
Minneapolis, Minnesota
iii
F O R E W O R D
It is now 4 years since the seventh edition of Dental activity, and aging. Projections estimate a possible dou-
Management of the Medically Compromised Patient was bling, or even tripling, in the coming decades if current
published. The number of patients in this critically trends continue. The list of medical diseases goes on, and
complex area of healthcare delivery continues to expand underscores the need for current, reliable, and practical
along with the scientific advances in etiology, patho- information to minimize or prevent potential problems
physiology, diagnosis, and treatment. The number of related to general health, and ongoing oral-dental care.
Americans over age 65, which now exceeds 15% of the Knowledge of the pathophysiology of common medical
population, is expected to increase by more than 20% diseases and conditions, along with the potential risks
within the next few decades. Thus the pool for such associated with some dental procedures and services,
patients seeking and needing dental care grows. Further- is essential.
more, as longevity increases, so do the number of dis- Interrelationships between oral and general health
eases and conditions that disable individuals, converting involve most organ systems. Some examples of medical-
them to compromised patients. dental interaction relate to hematologic, autoimmune,
With increasing longevity, and other factors such as and infectious diseases that strike both the young and
obesity, poor diets, suboptimal exercise, new infections, the elderly. These conditions include blood dyscrasias,
as well as widespread use and abuse of drugs, the rising vesiculobullous inflammatory diseases, and many bacte-
number of medically compromised patients will continue rial, viral, and fungal infections. Thus a very common
to grow. As a consequence, an ever increasing number issue is the proper recognition and management of oral
of individuals with oral health problems will create manifestations, control of blood-borne pathogens, and
demands and responsibilities on dental professionals avoidance of complications when providing dental treat-
with regards to services and standards of care. Education ment. Again, to appropriately meet this challenge,
and readily available resource materials are essential to updated information in a concise and understandable
providing these services in an optimal and safe manner, format is essential.
and the thoroughly revised and updated eighth edition Because the majority of medically compromised
fills this role perfectly. patients need and/or seek oral healthcare, a working
A multitude of diseases have an impact on oral health- knowledge of the multitude of medically complex condi-
care services. Some examples follow. Cancer is an age- tions is critical for dental professionals. This information
related disease that afflicts more than 1.5 million new will support and enable high standards for dental-oral
patients each year in the United States. This in turn healthcare delivery. This knowledge includes an under-
accounts for almost 25% of all deaths, and overall, is standing of medical conditions and compromised states
the second leading cause of death; in those under 85 and is necessary to help prevent, minimize, and alert
years of age, cancer is the leading cause of death. Because clinicians to possible adverse side effects potentially
of the number of new malignancies and the complica- associated with procedures and drugs used in dentistry.
tions caused by aggressive therapy to increase survival An understanding will assist in formulating treatment
rates, dental services and information—for example, oral plans that are safe and compatible with a patient’s
complications of cancer treatments and rehabilitation— medical status.
take on significant importance. Furthermore, this is a Care of the medically compromised patient often is
global problem with new cases of cancer exceeding 12 complicated, and requires specialists. However, occur-
million each year. rence of compromised patients is so common that prac-
Other examples of conditions that commonly affect titioners and students must know how to recognize and
dental-oral care are cardiovascular diseases, the number prevent problems associated with dental management,
one killer of Americans, and diabetes. In Part 2, six and to use consultations and referrals appropriately. This
chapters thoroughly cover all aspects of cardiovascular updated, revised, and expanded text recognizes and
disease of interest for dental professionals. Diabetes (see supplies this type of information with practical and
Part 6, Chapter 14) is an exploding global problem with organized overviews of diagnosis and management.
a profound effect on Americans, affecting more than 25 This is accomplished in 30 well-organized and revised
million with diagnosed diabetes, and an additional 12 chapters by comprehensively covering diseases and con-
million with undiagnosed diabetes. Diabetes has a large ditions that lead to compromised states that affect a
impact on dental health and care. It is the leading cause person’s well-being. The 30 chapters, are presented in 9
of end-stage renal disease and blindness among adults, logical parts that enhance user-friendly utility. The mate-
and a major cause of heart disease and stroke. Diabetes rial is supported by summary tables for easy access to
is associated with obesity, poor diet, suboptimal physical information, figures, and graphs to supplement text, and
vii
viii FOREWORD
appendices that allow the reader to recognize disease tobacco control. In its present format, this text serves as
states, be aware of potential complications, and select an both a quick reference, and a somewhat in-depth resource
approach to drug management. New Chapter 30 for this critical interface of medicine and dentistry. It will
addresses the increasing problem of drug and alcohol help ensure high standards of care, and help reduce the
abuse. An appendix on alternative and complementary occurrence of adverse reactions by improving knowledge
medicine is helpful for background information regard- and encouraging judgment in the management of at-risk
ing some of the more common agents. patients.
Although the main focus is on the dental management In summary, treating the medically compromised
of medically compromised patients, the text effectively patient is a complex part of dentistry, requiring compe-
includes a medical overview of each disease entity, tent practitioners with many attributes: sound technical
including etiology, signs and symptoms, pathophysiol- skills, insight into medicine, familiarity with pharmaco-
ogy, diagnoses, treatment, and prognosis. Therefore, it therapeutics, and the capability of analyzing findings
also serves as a mini-text on common medical diseases from patient histories and signs and symptoms. There-
and conditions. Because tobacco use is the most common fore, the usefulness of this excellently updated, compre-
cause of preventable deaths in the United States (more hensive text as a reference for students and practitioners
than 440,000 each year), Chapter 8 describes approaches is evident.
that enable dental professionals to assess tobacco habits Sol Silverman, Jr., MA, DDS
of patients and resources for cessation. Dental profes- Emeritus Professor of Oral Medicine
sionals have the opportunity to play a significant role in University of California, San Francisco
We would like to dedicate this eighth edition to The American
Academy of Oral Medicine that was founded by Dr. Samuel Charles
Miller. The Academy’s membership has dedicated their time and
expertise to students, dentists, and patients in need. Working along-
side dedicated professionals in our Academy to excel and improve the
quality of life of our patients has motivated us with each new edition
of our textbook. It has been our pleasure and privilege to observe and
contribute to The American Academy of Oral Medicine’s growth.
James W. Little
Donald A. Falace
Craig S. Miller
Nelson L. Rhodus
A P P E N D I X
A
Guide to Management of Common Medical
Emergencies in the Dental Office*
(1) being well prepared, (2) having confidence in selected
GENERAL CONSIDERATIONS
interventions, and (3) remaining calm in difficult circum-
The best management of a dental office medical emer- stances. The health professional is responsible for
gency is prevention. Dental practitioners must be pre- knowing and using techniques that are recognized to be
pared to treat the seemingly well but chronically ill up to date, safe, and efficient. An unfamiliar or unreli-
patient whose condition is managed by a variety of able maneuver should never be attempted. The dentist
drugs. Prevention begins with the dental professional’s must be trained in providing basic cardiac life support
awareness of the patient’s medical condition at the outset (BCLS) and in managing emergencies in the dental office.
of the dental visit. Knowledge of the type of condition, Advanced cardiac life support (ACLS) training to include
its severity, and level of control provides a strong indica- intravenous (IV) drug administration may be useful in
tor of the patient’s risk for experiencing a medical emer- dental practices that more often encounter medically
gency. Proper assessment that includes review of the complex cases. The dental practitioner also should be
medical history, physical evaluation, and medical consul- aware of the changes in basic cardiopulmonary resuscita-
tation gives the practitioner the opportunity to take mea- tion (CPR) guidelines introduced in 2010.
sures that could prevent such emergencies. If an Although dentists should be prepared to provide
emergency does occur, an informed dentist will have a resuscitation procedures in the dental setting, even more
better idea of the type of medical problem the patient is consideration should be directed at preventing such situ-
experiencing. The dentist must also understand the ations. Prevention begins with obtaining an adequate
pathophysiologic factors regulating disease processes medical history of the patient, making an appropriate
and the pharmacodynamics of drug action and physical evaluation, and ensuring that both patient and
interaction. environment are properly prepared before treatment
Patients frequently experience physical reactions begins. Sometimes a potentially catastrophic event may
during treatment. Accordingly, considerable responsibil- be prevented through recognition of physical conditions
ity rests on the dentist first to recognize the signs and or limitations before treatment begins.
symptoms of the problem and then to respond to any Management of emergencies must begin long before
emergency quickly, efficiently, and competently with the point of occurrence. Preparation should include a
adequate resuscitative procedures. Obviously, important designated plan of action and an adequate armamen-
precepts of good medical emergency management include tarium to meet emergencies. To minimize largely unhelp-
ful emotional responses, the actions of the dental team
must be based on a thorough background in relevant
subject matter, continued study, and carefully prepared
*Much of the material contained herein is modified from Malamed
and rehearsed emergency procedures in which each
SF: Medical emergencies in the dental office, ed 6, St Louis, 2007,
person has specific duties and responsibilities. This
Mosby; Malamed SF: Emergency medicine in the dental office
(DVD), Edmonds, WA, HealthFirst Corporation, 2008, Joseph approach will require the availability of appropriate
Massad Productions; 2005 American Heart Association guidelines resuscitative equipment and drugs to permit the team to
for cardiopulmonary resuscitation and emergency cardiovascular work together calmly and precisely. This teamwork must
care, Circulation 112(Suppl 24):IV1-203, 2005; and Part 1: execu-
be based on knowledge, practice, sound judgment, and
tive summary: 2010 American Heart Association guidelines for
confidence. To this end, all members of the dental office
cardiopulmonary resuscitation and emergency cardiovascular care,
Circulation 122(Suppl 3):S640-S656, 2010. (dentist, hygienist, assistant, receptionist) should be
576
APPENDIX A  Guide to Management of Common Medical Emergencies in the Dental Office  577
trained in and be able to perform BCLS procedures prop- TYPES OF EMERGENCIES AND
erly when needed. Also, every dental office should have THEIR TREATMENT
a written plan that spells out specific duties for each
member of the office staff, covering areas such as who Unconsciousness
will activate the emergency medical services (EMS)
system (i.e., call 911), start CPR, place an intravenous Syncope and Psychogenic Shock
line, and administer drugs. A staff member should be
designated to assist in necessary tasks during the emer- Signs and Symptoms. Pallor, sweating, nausea, anxiety,
gency situation, such as getting and preparing drugs and pupillary dilation, yawning, decreased blood pressure,
recording every event and the time of each action. bradycardia (slow pulse), convulsive movements,
Dental offices should have up-to-date emergency unconsciousness.
drugs, oxygen, a pulse oximeter, and an automated Cause. Cerebral hypoxia (reduced blood flow to brain),
external defibrillator (AED). Electrocardiography is an sitting or standing stiff, anxiety.
additional important adjunct modality for monitoring
the patient’s vital signs. Treatment
P: Positioning: Place patient in supine position; lower
head slightly and elevate legs (for pregnant women,
GENERAL PRINCIPLES OF
roll on left side)—assess consciousness.
EMERGENCY CARE
A: Airway: Ensure open airway.
Most life-threatening office emergencies are caused by B: Breathing: Check breathing—should be adequate.
the patient’s inability to withstand physical or emotional C: Circulation: Check carotid pulse—should be
stress or the patient’s reaction to drugs. Emergencies adequate.
also can originate with a complication of a preexisting D: Dispense/administer:
systemic disease. Cardiopulmonary systems can be • Oxygen at flow rate of 5-6 L/minute
involved, thereby necessitating some emergency support- • Aromatic ammonia (e.g., Vaporole)—“smelling
ive therapy. salts” (optional)
Algorithms (i.e., standardized step-by-step proce- • Cold compresses applied to forehead
dures) are recommended to be performed during emer- E: Ensure that vital signs, drug administration, and
gencies after the signs and symptoms of the condition patient responses are properly monitored and
are recognized. Most often, the algorithm for medical recorded.
emergencies follows the sequence P-A-B-C-D, where P is F: Facilitate next steps in medical/dental care and reas-
for positioning, A is for airway, B is for breathing, C is sure patient.
for circulation, and D is for definitive care (e.g., diagno-
sis, drugs and defibrillator and other equipment). Of
note, however, in 2010, the American Heart Association
Low Blood Pressure/Slow Pulse
recommended use of a slightly different algorithm for
cardiac arrest, that is, P-C-A-B-D. Our own contribution For low blood pressure or pulse (systolic is less than
has been to add an E, for ensure proper patient response, previous diastolic), the following protocol is indicated:
and an F, for facilitate next steps in medical/dental care,
for a more specific approach to this aspect of dental Treatment: Low Blood Pressure
management. P: Positioning: Place patient in supine position; lower
This appendix presents recommended management head and raise legs.
protocols, following the algorithms just described, for A: Airway: Ensure open airway.
various medical emergencies likely to be encountered in B: Breathing: Check breathing—should be adequate.
the dental office. C: Circulation: Check pulse and ensure adequate circu-
lation, which may be weak.
D: Dispense/administer:
Key Points
• Intravenous drip of 5% dextrose in lactated Ring-
The following elements are essential to the successful er’s solution
treatment of medical emergencies: • In unresponsive patient: a vasopressor drug such
1. Quick recognition of signs and symptoms and early as phenylephrine 10 mg/mL (1 ampule), or epi-
diagnosis of the underlying problem nephrine 0.3-0.5 mg given subcutaneously (SC) or
2. Fast response time (4 to 6 minutes without oxygen intramuscularly (IM), or intravenously (IV) with
leads to irreversible brain damage) ACLS training
3. Systematic monitoring of the patient’s well-being E: Ensure that vital signs, drug administration, and
using an algorithm such as P-A-B-C-D-E-F or, for patient responses are properly monitored and
cardiac arrest, P-C-A-B-D-E-F recorded.
578 APPENDIX A  Guide to Management of Common Medical Emergencies in the Dental Office
F: Facilitate next steps in medical/dental care; reassure Two operators: 15 compressions per every 2 ventila-
patient. tions (without pause for compressions), for a rate
Treatment: Slow Pulse. (Less than 60 beats/minute) of 100 compressions/minute. Continue resuscita-
P: Positioning: Place patient in supine position; lower tion until spontaneous pulse returns.
head and raise arms and legs. NOTE: The importance of technique for chest com-
A: Airway: Ensure and maintain patent airway. pressions cannot be overemphasized; they must
B: Breathing: Check breathing—should be adequate. be hard, fast, and maximally effective, with
C: Circulation: Check—should be adequate in this minimal interruptions.
situation. D: Defibrillator: Attach and use automated external
D: Dispense/administer: defibrillator (AED) as soon as available (ideally
• Oxygen at flow rate of 5-6 L/minute (if patient is within 3 to 5 minutes of collapse).
hypoxemic) • Check rhythm and shock if indicated (repeated every
• Atropine 0.5 mg IV (to increase heart rate). 2 minutes).
Repeat dose up to 3 mg; then consider use of • Resume CPR beginning with compressions immedi-
additional vasopressors (dopamine or ately after each shock.
epinephrine). NOTE: With intravenous drugs: Start normal saline
E: Ensure that vital signs, drug administration, and solution (with ACLS-trained rescuer).
patient responses are properly monitored and • Epinephrine 1.0 mg 1 : 1000; repeat every 3 to 5
recorded. minutes as needed.
F: Facilitate next steps in medical/dental care; reassure • Vasopressin 40 units can replace first or second
patient. dose of epinephrine.
• Amiodarone—first dose: 300 mg bolus; second
dose: 150 mg
Other drugs used for treatment of cardiac arrest
Cardiac Arrest
(with ACLS-trained rescuer)
Signs and Symptoms. No pulse or blood pressure, • Lidocaine (antiarrhythmic agent)
sudden cessation of respiration (apnea), cyanosis, dilated • Calcium chloride (increases myocardial
pupils. contractility)
Cause. Abrupt interruption of blood supply and oxygen • Morphine sulfate (for pain relief)
to the coronary arteries and heart muscle due to ischemia • Thrombolytic agents
(clot). E: Ensure that vital signs, drug administration, and
patient responses are properly monitored and
Treatment recorded.
For unresponsive cardiac arrest victim (adult): F: Facilitate/ensure next steps in medical care (transport
P: Positioning: Place patient in supine position and to hospital); reassure patient.
establish unresponsiveness (tap and shout). Call for
help, activate EMS (call 911), and get defibrillator.
C: Circulation and compressions: Health care provider
Hypoglycemia (Insulin Shock)
should assess pulse (carotid) for no more than 10
seconds. If no pulse is detected, and victim is not Signs and Symptoms. Hunger, weakness, trembling,
breathing and is unresponsive, promptly initiate chest tachycardia, pallor, sweating, paresthesias, uncoo-
compressions. perative, mental confusion (headache), incoherent,
One operator: 30 compressions per every 2 ventila- uncooperative, belligerent, unconscious, tonic-clonic
tions for a rate of 100 compressions/minute movements, hypotension, hypothermia, rapid thready
(depth of 2 inches), until advanced airway is pulse, coma.
placed Cause. Lack of blood glucose to the brain; taking insulin
A: Airway: Establish airway by head tilt–chin lift, or by and not eating.
jaw thrust if neck injury is suspected. Suction mouth/
pharynx if vomitus is blocking the airway. Treatment
B: Breathing: Ventilate lungs with mask Ambubag– P: Position:
delivered positive-pressure oxygen (or mouth-to- In conscious patient: place in upright sitting
mask resuscitation); breathe every 6 to 8 seconds (8 position.
to 10 breaths/minute). In unconscious patient: place in supine position.
If rescuer is ACLS-trained, perform endotracheal A: Airway: Ensure open airway.
intubation and provide positive-pressure oxygen. B: Breathing: Ensure that patient is breathing.
NOTE: As of 2010: Ventilation technique uses slower C: Circulation: Check pulse and confirm adequate
breaths with inspiration time of 1.5 to 2 seconds. circulation; pulse could be weak.
APPENDIX A  Guide to Management of Common Medical Emergencies in the Dental Office  579
D: Dispense: • Also provide hydrocortisone 100 mg, or dexa-
In conscious patient: Give a drink with high sugar methasone 4 mg (IV).
content such as orange juice, or a glucose paste • Give a vasopressor drug (e.g., epinephrine
(cake icing) applied to the buccal mucosa. 1 : 1000, 0.5 mL).
In unconscious patient: Activate EMS by calling 911; E: Ensure that vital signs, drug administration, and
then administer: patient responses are properly monitored and
• Oxygen at flow rate of 5-6 L/minute recorded.
• 5% dextrose in Ringer’s lactate (D5LR) IV: Run F: Facilitate/ensure next steps in medical care (transport
the intravenous drip as fast as possible. to hospital); reassure patient.
• Alternatively, give glucagon 1 mg SC or IM (or
IV), or epinephrine (for transient relief).
E: Ensure that vital signs, drug administration, and
Cerebrovascular Accident (Stroke)
patient responses are properly monitored and
recorded. Signs and Symptoms. Dizziness (patient may fall),
F: Facilitate/ensure next steps in medical care (trans- vertigo and vision changes, nausea and vomiting, tran-
port to hospital, if some improvement is not fairly sient paresthesia, unilateral weakness or paralysis, head-
rapid). When patient regains consciousness, provide ache, nausea, vomiting, convulsions, coma.
reassurance and information about what happened, NOTE: Blood pressure and pulse generally are normal.
because person is likely to have little memory of the Raised blood pressure and body temperature and lowered
incident. pulse and respiration indicate increased intracranial
pressure.
Cause. Interruption of blood supply and oxygen to the
brain occurring as a result of ischemia or hemorrhage.
Acute Adrenal Insufficiency
Treatment
Signs and Symptoms. Altered consciousness, wet, P: Positioning: Place patient in reclined, semisitting
clammy, confusion, weakness, fatigue, headache, pain in position with the head elevated. Call for help and
abdomen or legs, nausea and vomiting, hypotension and activate EMS (call 911).
syncope, coma. A: Airway: Ensure that airway is open and maintained
Cause. Adrenal suppression (low adrenocorticotropic open.
hormone) by exogenous steroids. The patient may be B: Breathing: Ensure that breathing is adequate.
medicated with steroids for many medical problems, or C: Circulation: Check pulse and confirm adequate
the cause may be primary or secondary malfunction of circulation.
the adrenal cortex. D: Dispense/administer:
• Use pulse oximeter to determine oxygenation.
Treatment • Administer oxygen at flow rate of 5-6 L/minute if
P: Positioning: Place patient in semireclined position, needed.
and raise feet slightly; call for help. E: Ensure that vital signs, drug administration, and
A: Airway: Ensure open airway. patient responses are properly monitored and
B: Breathing: Should be adequate (i.e., predicted to be recorded.
adequate in this situation). • Keep patient quiet and still.
C: Circulation: Check pulse and confirm adequate F: Facilitate/ensure next steps in medical care (transport
circulation. to hospital); reassure patients. (Seizure)
D: Dispense:
In conscious patient:
• Provide oxygen at flow rate of 5-6 L/minute. Convulsions (Seizure)
• Give hydrocortisone 100 mg, or dexamethasone
4 mg (IV). Signs and Symptoms. Aura (flash of light or sound, a
In unconscious patient: unusual smell), mental confusion, excessive salivation,
• Place in supine position. rolling back of eyes, loss of consciousness, tonic phase
• Activate EMS by calling 911. (contractions—clenching of teeth) followed by clonic
• Administer oxygen at flow rate of 5-6 L/minute. phase (tremors, convulsive movements of extremities).
• Confirm diagnosis from review of medical history, Causes. There are several potential causes of convul-
signs, and symptoms. sions and seizures including syncope, drug reactions
• Then start intravenous administration of 5% (local anesthetic overdose), hypoglycemia, hyperventila-
dextrose in Ringer’s lactate (D5LR) and run the tion, cerebrovascular accident, and convulsive seizure
intravenous drip as fast as possible. disorder.