THE MEDICALLY COMPROMISED PATIENT & COMMONLY USED PRESCRIPTION DRUGS
Entire textbooks have been written describing the topic of this short discussion. Obviously, the
entire area can hardly be covered in such a short time. What we would like to do, however, is
to touch upon a few important issues and to place the entire area into a more easily understood
context.
Strategic Reserve: Normal, healthy people have built in levels of strategic physiologic reserve
as it relates to the functioning of the various organ systems. This fact is taken advantage of in
organ transplantation in that a close relative of a kidney patient may be an organ donor, giving
up a kidney and yet function essentially normally for the rest of his or her life. The amount of
reserve varies, but in general, nature has built a surplus into each system. As a rule, nature
generally does not do things wastefully and this strategic reserve handles the "overload" or
increase in need as the individual is challenged by various stresses. These stresses may take
many forms, such as physical privation during periods of starvation, injury following a motor
vehicle accident, or the flight or fright response when faced with anxiety provoking situations
such as dental treatment. In the last example, both pulse and blood pressure are raised, the
pupils dilated, the skin cool and clammy and the patient is ready to bolt at the slightest
provocation. Nature has built into the autonomic nervous system and the cardiovascular
system, the ability to "rise to the occasion" of impending threat with a temporary tapping of that
latent reserve in order to meet this threat.
Systemic Illness and Loss of Strategic Reserve: When viewed in this context, each system has
such a reserve, but this reserve is finite. The system can only tap its reserves so much in the
face of threat and when this reserve is exhausted, failure of the system in imminent. In the
medically compromised patient, this reserve is diminished as a function of chronic disease such
that the patient’s ability to "rise to the occasion" is diminished. The patient is less capable of
dealing with stress and prone to medical crisis. In the office setting this is not a practice builder.
For clarity, we have elected to discuss loss of strategic reserve, or illness, on a scale of 1 to 4.
For example, angina may be classified as follows:
Class 1:
Class 2:
Class 3:
Class 4:
angina on extreme exertion (climbing 10 flights of stairs)
angina on moderate exertion (climbing 2 flight of stairs)
angina with normal activity (walking down the street)
angina at rest (sitting watching TV)
As this example illustrated, the patient's strategic reserve diminishes as disease progresses
and the stress needed to induce angina decreases. This simple classification system can be
used for a number of other diseases as well. We have selected the following as some of the
more common.
Table I:
Disease Classification by Symptoms or Description
Disease
Class 1
Class 2
Class 3
Class 4
Myocardial
Ischemic
Disease
angina with
extreme
exertion
or
MI > 2 yrs
angina with
moderate
exertion
or
MI < 2 yrs
angina with
minimal
exertion
or
MI < 1 yr
angina at
rest
Congestive
Heart
Failure
SOB with
extreme
exertion
SOB with
moderate
exertion
SOB with
minimal
exertion
SOB at rest
Hypertension
diastolic
>90
<95
or
no symptoms
diastolic
>95
<100
or
minimal
symptoms
(headache)
diastolic
>100
<110
or
moderate
symptoms
(CHF)
diastolic
>110
Asthma
cannot find
puffer
uses puffer
monthly
uses puffer
weekly
uses puffer
daily
COPD
SOB with
extreme
exertion
SOB
moderate
exertion
SOB
minimal
exertion
SOB
at rest
Diabetes
diet
controlled
or
no symptoms
oral hypoglycemics
or
minimal
symptoms
(neuropathy)
controlled
with insulin
or
moderate
symptoms
(blurry vision)
brittle
diabetic
or
severe
symptoms
(amputations
or MI or blind)
Bleeding
on ASA
on Coumadin
with good control
on Coumadin
with poor control
or
no symptoms
or
minor bruising
or
moderate
bruising or
bleeding
hemophiliac
poorly
controlled
or
severe
bleeding or
haemarthrosis
or
MI<6mths
or
severe
symptoms
(stroke)
A very useful way to assess a patient's disease state is to determine what medication they are
taking. With most diseases, physicians use a staged or stair-stepped approach to
pharmacological management. As the disease state worsens, The strength and number of
drugs used tends to increase. Careful analysis of the patient's list of drugs usually indicates
their medical diagnosis and further analysis will indicate how advanced this disease is. This is
indicated for the above diseases with the following table:
Table II:
Disease Classification by Pharmacology
1. Myocardial Ischemic Disease
Class 1
vasodilator
PRN
vasodilator
PRN
vasodilator
PRN
Class 2
Class 3
Class 4
vasodilator
PRN
examples
nitroglycerine
+
+
+
vasodilator
prophylactically
vasodilator +
prophylactically
vasodilator +
prophylactically
Isordil
nitropaste
B blocker
B blocker
+
Timolol
Labetolol
Propranolol
calcium
channel
blocker
Nifedipine
Diltiazem
Verpamil
2. Congestive Heart Failure (CHF)
Class 1
Class 2
diuretic
diuretic
+
Class 3
diuretic
+
Class 4
diuretic
+
examples
Diazide
second
diuretic
second
diuretic
second
diuretic
+
inotrope
+
inotrope
Lasix
+
Digoxin
home
oxygen
oxygen
3. Hypertension
Class 1
Class 2
Class 3
Class 4
examples
B blocker
B blocker
B blocker
diuretic
Timolol
Labetolol
Propranolol
+
+
+
diuretic
diuretic
diuretic
Diazide
Lasix
+
+
ACE inhibitor
ACE inhibitor
Captopril
Enalapril
+Ca channel
blocker
Nifedipine
Diltiazem
Verapamil
4. Asthma
Class 1
Class 2
Class 3
Class 4
bronco- dilator
bronco- dilator + proph steroids
bronco- dilator + proph steroids + proph bronco-dilator
bronco- dilator + proph steroids + proph bronco-dilator + histamine vesicle
stabilizer
examples
Ventolin
Beclovent
Theophylline
Chromolyn
5. Chronic Obstructive Pulmonary Disease (COPD)
Class 1
broncodilator PRN
Class 2
bronco+ proph steroids
dilator PRN
Class 3
bronco+ proph steroids + proph broncodilator PRN
dilator
Class 4
bronco+ proph steroids + proph broncodilator PRN
dilator
examples
Ventolin
Beclovent
+
Theophylline
(Theodur)
antibiotics
& home oxygen
Ceclor
Oxygen
6. Diabetes
Class 1
diet
Class 2
diet
+
oral hypoglycemic
Class 3
diet
+
oral hypoglycemic
+
insulin
(minimal
dose change)
Class 4
diet
+
oral hypoglycemic
+
insulin
(minimal
hospital)
examples
CHO
restriction
Glyburide
Diabinase
Humulin
NPH / Lente
+
insulin
(multiple
hospital)
Humulin
NPH / Lente
7. Bleeding problems (Bleeding diatheses / coagulopathies)
Class 1
ASA
Class 2
Coumadin
INR < 1.5
Class 3
Coumadin
INR > 1.5
Class 4
examples
Haemophilia
post MI
Proph
for atrial
fibrillation
previous
DVT or
prosthetic valve
(multiple
hospitalizations)
Procedural Stress:
From a systemic point of view, each procedure we do carries with it a certain level of stress to
the patient. Simple procedures such as denture adjustments, examinations or radiographs
carry minimal stress. More complex procedures such as scaling or root planing, simple
restorations or impressions carry increased levels of demand on the system. Still more
complex procedures such as lengthy crown and bridge appointments or extractions are
increasingly stressful. Finally, complicated surgery such as difficult impactions or orthognathic
surgery carry even greater levels of threat to the patient. The threat any given procedure
presents to a patient may be magnified as a function of patient anxiety and this factor must also
be taken into the equation. In general, a simple categorization of stress levels may be applied to
given procedures:
Level 1:
denture adjustments, examinations or radiographs
Level 2:
scaling or root planing, simple restorations or impressions
Level 3:
lengthy crown and bridge appointments or extractions
Level 4:
difficult impaction or orthognathic surgery
Our job as clinicians is to assess this reserve, to assess the threat to the system that our
procedure represents and to make sure that we stay within the limits of the systems's ability to
handle the threat. When procedural "threat", "stress" or "complexity" exceeds the patient's
ability to handle the situation, we are faced with the potential for medical crisis. Careful
assessment of risk allows us to avoid precipitating medical emergencies.
For each system…fill in the blanks as you progress through the course:
System
Anatomy
Physiology
Disease
Pathophysiology
Symptoms
Signs
Therapy
Pharmacology
Failure