Medical

Compromised
Patients
Presented by
 01 Asthma

contents 02 Diabetes Mellitus

03 Hypertension
 Asthma
Asthma is a chronic inflammatory disease of the airways characterized by reversible
episodes of increased airway hyperresponsiveness, which results in recurrent episodes of
dyspnea, coughing, and wheezing. The bronchiolar lung tissue of patients with asthma is
particularly sensitive to a variety of stimuli . Overt attacks (flare-ups ) may be provoked
by allergens, URI, exercise, cold air, certain medications (salicylates, nonsteroidal a
antiinflammatory drugs (NSAIDs), cholinergic drugs, and β-adrenergic blocking drugs ),
chemicals, smoke, and highly emotional states such as anxiety and stress .
 clinical features of asthma
In well-controlled patients with asthma, clinical features may be absent.
During an asthmatic episode symptoms may include dyspnoea, cough and paroxysmal
expiratory wheeziness with laboured expiration.
Patients may become distressed, anxious, tachycardic, have reduced chest expansion and be
using accessory respiratory muscles to increase their ventilatory effort.
A prolonged asthmatic attack, which is refractory to treatment, may lead to life-threatening
status asthmaticus (persists for more than 24 h).
LABORATORY AND DIAGNOSTIC FINDINGS

Diagnostic testing by a physician is important in the differentiation of asthma from

other airway diseases. Commonly ordered tests include 6-minute

walk test, spirometry before and after administration of

a short-acting bronchodilator, chest radiographs (to detect

hyperinflation), skin testing (for specific allergens),

bronchial provocation histaminmine or methacholine

chloride challenge) testing, sputum smear examination

and cell counts (to detect neutrophilia or eosinophilia),

arterial blood gas determination, and antibody-based enzyme-linked

immunosorbent assay (ELISA) for measurement of environmental allergen

exposure.3
Dental aspects:
Asthmatic patients should bring their usual medication.
Elective dental care should be deferred in severe asthmatics.
Stress reduction protocol: Anxiety may precipitate acute asthmatic attacks so stress
reduction protocol is mandatory to lessen fear of dental treatment.
Semisupine or upright chair position better for treatment of these patients.
Local anaesthesia: is best used.
Occasional patients may react to the sulfites present as preservatives in
vasoconstrictor, so it is better, to avoid solutions containing vasoconstrictor.
Epinephrine may theoretically enhance the risk of arrhythmias with beta agonists and
is contraindicated in patients using theophylline as it may precipitate arrhythmias.
Allergy to penicillin may be more frequent in asthmatics.
Conscious sedation:
Nitrous oxide and oxygen is preferable to intravenous sedation and gives more
immediate control.
Sedatives in general are better avoided as, in an acute asthmatic attack; even
benzodiazepines can precipitate respiratory failure by depression of respiratory system.
Diabetes mellitus
Diabetes mellitus is a group of metabolic diseases characterized by
high blood glucose levels (hyperglycemia)
and the inability to produce and/or use insulin.
COMPLICATIONS

Patients with diabetes undergoing dental

treatment may not be diagnosed and may be at risk for complications
such as unconsciousness, infection, bleeding, drug
interactions, and side effects. These events could prove serious.
The dentist must be able to identify these patients, assess
risk based on history and clinical findings, and work closely
with the managing physician to develop a dental management
plan that will be effective and safe for the patient.
Diagnosis

Fasting plasma glucose FBG (no caloric intake for 8h) >
7.0mmol/L – ≥ 126 mg/dL on two occasions.

Random blood glucose RBG (taken any time of day) ≥

11.1mmol/L- ≥ 200 mg/dL with classic signs and
symptoms of DM.
Oral glucose tolerance test (Plasma glucose taken 2h
after a person has consumed a drink containing 75g of
glucose) 2 hour glucose ≥ 11.1mmol/L - ≥ 200 mg/dL.
Glycated hemoglobin: HbA1c ≥ 6.5%.
Dental management of diabetes
Any infection must be treated vigorously. Failure of too treat infection can promote occurrence of acute
or chronic osteomyelitis and worse diabetes control.
Management depends on:
The glycemic status: elective dental extraction FBG up to 180 mg/dL, less than 70mg/dL should defer or
give carbohydrates.
The type of operation and anaesthesia (G.A/L.A).
Minor operation under L.A:
Early morning, breakfast and medication.
Major operation under G.A:
Essential requirement in surgical procedures is to avoid hypoglycemia and hyperglycemia.
Admit the pt in the hospital 2-3 days preoperatively
Shift his medication to insulin after measurement of his blood glucose level
Do fasting blood sugar at the day of surgery by role of 10 as follows:
If the FBS is bellow 6 mmol /l:
Give 10% of dextrose.
5 units of soluble insulin.
10 mg of kcl.
If the FBS is above 6 mmol /l:
Give 5% of dextrose.
10 units of soluble insulin.
10 mg of kcl.
G.A for diabetic patient is a matter of specialist anaesthetist cause it may complicated by:

Hypoglycemia.

Chronic renal failure.

I.H.D.

Autonomic neuropathy, postural hypotension and severe cardiorespiratory arrest.

Oral manifestations of DM

Xerostomia.
Oral candidiasis.
Periodontal disease.
Delayed wound healing.
Alveolar bone resorption.
Sialosis.
Glossitis.
Burning sensation in tongue.
Oral lichenoid reactions secondary to oral hypoglycemic
drug.
Acetone smell in breath.
 Hypertension
Hypertension is an abnormal elevation in arterial pressure
that can be fatal if sustained and untreated. People with
hypertension may not display clinical signs or symptoms
for many years but eventually can experience symptomatic
damage to several target organs, including the kidneys,
heart, brain, and eyes. In adults, a sustained systolic blood
pressure (BP) of 140 mm Hg or greater or a sustained
diastolic blood pressure of 90 mm Hg or greater is defined
as hypertension.
LABORATORY AND DIAGNOSTIC FINDINGS

Current JNC 7 and 8 guidelines recommend that patients

who have sustained hypertension be screened through
routine laboratory tests, including 12-lead electrocardiography (ECG),
urinalysis, blood glucose, hematocrit,
electrolytes, creatinine, calcium, and lipid profile.1,18 Results
of these tests serve as baseline laboratory values that the
physician should obtain before initiating therapy. Additional tests that
assess thyroid function and serum
aldosterone should be considered if clinical and laboratory
findings suggest the presence of an underlying cause for
hypertension.
Dental aspects
Blood pressure should be controlled before elective dental treatment or the opinion of a
physician should be sought first.

Dental management can be complicated, since the Blood pressure rises even before a visit for
dental care; pre-operative reassurance is important and sedation using temazepam may be
helpful.
Blood pressure values between 140-160/90-95 mmHg may undergo dental surgery safely,
whereas patients with blood pressure values ranging 160–190/95–110 mmHg will have to be
given premedication half an hour to an hour before the surgical procedure, especially patients
under stress.

If the blood pressure values remain high even after premedication (e.g., over 180/110 mmHg)
the dental session is postponed and the patient is referred to his/her physician for further
treatment.

Patients with blood pressure values over 190/110 mmHg are not allowed regular dental
treatment. The patient’s treating physician is consulted immediately and if there is an acute
dental problem (emergency), the patient must be treated in a hospital.
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