Background

Medically compromised patients refer to patients with health problems that compromise the treatment or response to it. These conditions may include ongoing medical conditions like diabetes and heart-related diseases or episodic conditions like severe infections or autoimmune diseases. 

• Importance of Assessment: General management of such patients begins with proper medical history and examination of Dental status. The data obtained varies from a patient’s past and present medical history, current clinical status, treatment regimens, and recent changes. Such information helps to plan the appropriate dental care and minimize the risk of the occurrence of the disease. 
• Interdisciplinary Approach: This can include coordination with your health care providers regarding your dental care. This interdisciplinary approach to your care helps attenuation of risks as well as treatment plans. 

Cardiac Patients 

• Medical History: Many underlying conditions can prevail in patients with cardiac disorders; therefore, it is always important to take a detailed medical history. The relevant conditions for cardiac patients are coronary artery disease, hypertension, or arrhythmia. 
• Antibiotic Prophylaxis: Certain cardiac patients such as those with prosthetic valve or history of infective endocarditis may be required to be placed on antibiotics prophylaxis before dental procedures to prevent endocarditis. 
• Stress Management: Stressful procedures must be eliminated, and if not possible, then the use of sedatives should be engaged. It should also be noted that the patient’s blood pressure and pulse must be checked. 
• Medications: Know the current drugs the patient uses, including anticoagulants that may affect bleeding during dental surgery. 
• Diabetic Patient 
• Regulation of Blood Sugar: If the diabetes is out of control, the likelihood of a heightened level of susceptibility to infections and poor wound healing will be the case, more so, if the patient is set for any dental treatment, there is a need to ascertain from the physician if indeed the diabetes is controlled. 
• Schedule: Dental appointments are best scheduled early in the morning, as blood sugar levels are usually low in the morning; Dentists recommend this timing for people with diabetes. 
• Medications: Consider how medications can affect the mouth, for example, by causing dry mouth or altering taste. 
• Risk of infection: Infection control should be given particular attention, since patients with diabetes are prone to infections, including oral infections. 

Infectious Disease Patients 

• Infection Control: Practice proper hand-washing procedures to avoid contracting or spreading infectious diseases. This entails the wearing of PPEs and ensuring instruments used in surgeries are cleaned to the maximum. 
• Consultation: Discuss with the physician of the patient to know the type of infection and the stage and if there is any kind of restrictions or medications required. 
• Avoid Aerosol-Generating Procedures: In some cases, depending on the mode of transmission of the disease especially where the disease-causing pathogen occurs in aerosols, it may be advisable to reduce operations which create aerosols. 
• Patient Isolation: Sometimes it may be thus important to seclude the patient to avoid any transfer of infectious diseases. 

Epidemiology

Anatomy

Pathophysiology

Etiology

Genetics

Prognostic Factors

Clinical History

Physical Examination

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Patient Treatment Plan: 

Alter the standard procedures if required. 

Formulate a treatment plan keeping in mind the specific requirements and medical history of the patient. 

Prioritize the treatment according to the patient’s general health and the urgency of the dental problems. 

Standard Operating Procedures having variation in specific cases. 

Consultation with Other Health Practitioners: 

Conduct medical consultation or acquire consent from the relevant medical doctors before the treatment. 

Infection Control and Safety: 

Strict standards should be followed as a means of not aggravating the problem further. 

There should be added preventive measures taken in case of patients who have weak immune systems or are at risk in another way. 

Emergency Preparedness: 

Be prepared for emergencies that might happen while treating the oral health complications of patients. 

Patient and Caregiver Education: 

List and discuss the aspects of oral hygiene and medications with the patient and their caregivers. 

Follow-Up and Monitoring: 

Follow-up visits should be arranged periodically to assess the patient’s reaction to the specific therapy and general condition. 

Adjust the treatment plan according to the patient’s status and changes in their clinical condition. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Dental management for diabetic patients

Management Objectives 

Blood Glucose Control: 

• Routine Procedures: This should be followed by treatments after breakfast to correspond with the patient’s antidiabetic medicine. 
• Surgical Procedures: The levels of blood glucose must be kept between 120-180mg/dL. Regular monitoring is very important. 

Avoiding Complications: 

• Hyperglycemia: These complications include delayed wound healing and other dysfunctions. 
• Hypoglycemia: IV glucose infusion must be used for management while soluble insulin must be modified if necessary. 
• Infections: Provide antibiotics of moderate to severe infections before and post dental treatment because of the reduced immunity of the patient. 

Drugs that should be avoided during treatment: 

• Aspirin: These will affect blood glucose levels and coagulation disorders. 
• Steroids: These will affect the blood sugar level. 

During Treatment 

• Nonsurgical: This must be carried out post mealtime. 
• Surgical: The glucose must be strictly controlled; otherwise, the patient can be given IV glucose. 

Post-Op: 

• Antibiotics: They are to be given according to the prescription thereby avoiding infections. 
• Monitor: Active assessment for infection and proper healing of wound must be done.
  Diabetic patients are immunocompromised; therefore, they should be prescribed antibiotics three to five days preoperatively with mild to severe dental infections before the extraction of the tooth and three to five days postoperatively after surgery. 

Dental management in cardiac patients

Scheduling: 

• Timing: Advise the patient to visit morning appointments. 
• Duration: It is advisable to schedule the dental visits for shorter sessions to reduce stress while handling the patient. 

Anxiolytic Medication: 

• For Anxious Patients: Give instructions to take 5 to 10 mg of diazepam the night before and for one to two hours before the dentist consultation. 

During Treatment: 

• Local Anesthesia: Ensure the use of a good local anesthetic technique and avoid giving the anesthesia in an intravascular mode.
  To a maximum of two cartridges (1.8 ml x 2) of the anesthetic with the vasoconstrictor only.
  In case of requirement of more dose of anesthesia, add it without vasoconstrictor as this will further increase blood pressure. 
• Sutures: Do not use absorbable sutures with adrenaline, as this is hazardous for the regulation of blood pressure. 
• In Case of Poor Blood Pressure Control:  Ask the patient to see their respective doctor for a better outcome of their hypertension status before going for non-emergency dental procedures. 

Emergency Visits: 

• Treatment Approach: Focus on conservative management, using analgesics and antibiotics as needed to address the immediate issues without exacerbating the patient’s condition. 

Dental management in infectious disease

Infection Control: 

• Personal Protective Equipment (PPE): Personal protective gears in form of gloves, masks, spectacles, and gowns should be worn to avoid contact transmission. 
• Sterilization and Disinfection: Establish clear guidelines for cleaning the instruments and sanitizing other equipment to minimize the incidences of transmitting diseases. 
• Hand Hygiene: Washing the hands, especially the palms and fingertips, is one of the proven ways of preventing pass on the viruses. 

Antibiotic Prophylaxis: 

• Risk Assessment: Counsel the patient on the need for antibiotic prophylaxis before undergoing any dental procedures, depending on underlying diseases that may make the patient more susceptible to infections. 
• Dosage and Timing: A prescription of antibiotics should be done in line with the operations to be carried out on the patient to avoid possible infections associated with dental procedures. 

Preventive measures: 

• Sterilization and Disinfection: Clean all reusable dental instruments through autoclaving and other suggested processes.
  Clean and disinfect surfaces, medical equipment, and other instruments used. 
• Safe Injection Practices: The needle and syringes must be disposable, and each patient should be injected with a different needle and syringe.
  Place needles and sharps into special puncture-resistant containers. 
• Cleaning and Disinfection Procedures: It is advisable to disinfect all the equipment in the dental operatory including chairs, counters and even the handles of the photographing light.
  There are specific guidelines provided on how to disinfect dental equipment and accessories, and these need to be followed. 

dental-management-in-asthma-patients

If an asthma attack occurs during a dental procedure, the following protocols should be followed. 

• Discontinue the Procedure: Stop the dental work immediately and help the patient sit or lie down in a comfortable position. 
• Open Airway and Medicate: Ensure the patient’s airway are clear. Give a bronchodilator such as a beta 2 agonist, by either an inhaler method or nebulizer method. 
• Provide Oxygen: Supplemental oxygen should be given through a face mask, nasal hood, or a simple cannula to improve breathing patterns. 
• Emergency Response: In case of no improvement and adverse changes in the patient’s condition, the patient is administered subcutaneous epinephrine. A 1:1000 solution with dosing of 0. 01 mg/kg. 

Medication

Future Trends

Media Gallary

References

(PDF) A brief review in the dental management of medically compromised patients (researchgate.net)