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Oral and
Maxillofacial Surgery
for the Medically
Compromised Patient

A Guide to Management and

High-Quality Care
Daniel J. Meara
Rajesh Gutta
Editors

123
Oral and Maxillofacial Surgery for the
Medically Compromised Patient
Daniel J. Meara • Rajesh Gutta
Editors

Oral and Maxillofacial

Surgery for the
Medically Compromised
Patient
A Guide to Management
and High-­Quality Care
Editors
Daniel J. Meara Rajesh Gutta
Department of Oral Consultant Oral and Maxillofacial
and Maxillofacial Surgery Surgeon
Christiana Care Health System Private Practice
Wilmington, DE Midland, TX
USA USA

ISBN 978-3-030-82597-3    ISBN 978-3-030-82598-0 (eBook)

https://doi.org/10.1007/978-3-030-82598-0

© Springer Nature Switzerland AG 2022

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword

As an educator in Oral and Maxillofacial Surgery for the past 30 years, I have
had the opportunity to treat many patients and help train the next generation.
The academic environment gives you a unique perspective on so many aspects
of our field. The medically compromised population of patients is certainly
unique and presents many challenges for the oral and maxillofacial surgeon
but also provides so many teachable moments in a residency training program
and the community of interest. These opportunities allow the clinicians to
broaden their education by thoroughly preparing to manage these patients in
an office-based setting.
During residency and in their professional careers, I’ve gotten to know the
authors of this text. It is not surprising and certainly within their character that
they have chosen to compose a textbook on this topic. Their qualifications
make them distinctively qualified to write this text. Dr. Meara completed a
residency in internal medicine before deciding to pursue a career in oral and
maxillofacial surgery. Dr. Gutta completed a Master of Science degree while
in residency. I had the opportunity to work with them during their residency.
Both of them are extremely compassionate and caring individuals. They are
well-read and have spent many years preparing and presenting together on
this topic at local and national scientific meetings. Together, they bring a
unique perspective to the importance of preparedness in managing the medi-
cally compromised patient in the office setting.
Through advancements in medicine and pharmacology, patients are living
longer with chronic illnesses. Oral and Maxillofacial Surgeons, through their
deliberate and dedicated training, are entrusted with the assessment and man-
agement of these patients. A critical component in the management of any
patient and especially in the medically compromised patient is risk assess-
ment. The focus of this book is the identification and appropriate manage-
ment of patients who are at high risk during office-based procedures. The
authors have assembled a body of knowledge, through review of the literature
and their experience in patient care and education, to provide evidence-based
guidelines for the management of most common medical condition during
office-based surgery. It is designed in such a way to give the reader in-depth
knowledge and quick access to common questions in the management of
these patients.
Due to the focus of this text, this book will most likely become required
reading for all residents during their training. It will also serve as a reference

v
vi Foreword

for many clinicians performing office-based procedures. Due to its subject

matter, I know you will find this text as informative as the authors have
intended and one that you will keep going back to as you prepare to manage
these patients that our profession has been entrusted with.

Patrick
Birmingham, AL, USA J. Louis
Acknowledgements

Oral and Maxillofacial Surgery is an awesome profession and it is truly an

honor to care for patients and educate residents as an academic oral and max-
illofacial surgeon. Extreme thanks to my mentors: Drs. Patrick Louis, Peter
Waite, Bruce Horswell, and Eddie Granite. Special thanks to my Dad, Dr.
John W. Meara, Jr., an OMF surgeon, for being the ultimate role-model, and
Dr. BJ Costello for encouraging my pursuit of OMF surgery while I was an
internal medicine resident at UPMC. Thanks to my colleague, friend and aca-
demic partner, Dr. Raj Gutta, for his teamwork, patience, and enthusiasm.
Lastly, thanks to my family, especially my wife Dr. Regina Meara for her
sacrifice, support, and encouragement throughout this journey.
—Daniel J. Meara

I am deeply indebted to Drs. Patrick J. Louis and Peter D. Waite for training
me as an oral and maxillofacial surgeon and their continued mentorship.
Special thanks to the OMS residents, colleagues, and patients for providing
the impetus towards this publication. My sincere gratitude to Dr. Dan Meara
for all the years of academic partnership. My heartfelt appreciation to Dr.
Asvin Vasanthan for his friendship and support.
—Rajesh Gutta

vii
Contents

1 Introduction��������������������������������������������������������������������������������������   1
Daniel J. Meara and Rajesh Gutta
2 Management of the Cardiac Patient����������������������������������������������   5
Rajesh Gutta
3 Patients with Respiratory Disease: High Yield Concepts
for Optimal Clinical Care���������������������������������������������������������������� 17
Habib Asmaro and Daniel J. Meara
4 Liver Diseases ���������������������������������������������������������������������������������� 23
Shachika Khanna
5 Oral and Maxillofacial Surgical Management
for the Renal Compromised Patient���������������������������������������������� 33
Blair H. Racker and Srinivasa Rama Chandra
6 The Immunocompromised Patient ������������������������������������������������ 49
Cory M. Resnick
7 Metabolic Disorders in the Oral and Maxillofacial
Surgical Patient�������������������������������������������������������������������������������� 55
Barry C. Boyd
8 Psychiatric and Behavioral Disorders�������������������������������������������� 71
Ahmad Eltejaye and Etern S. Park
9 Practice Considerations for Patients with Substance
Use Disorder ������������������������������������������������������������������������������������ 87
Soroush Samimi and Deepak G. Krishnan
10 Oral and Maxillofacial Surgery and Hematologic Diseases�������� 99
Karen Zemplenyi and Jasjit K. Dillon
11 Preoperative Evaluation of Patients with Neurological
Disorders������������������������������������������������������������������������������������������ 109
Chad W. Dammling and Kathlyn K. Powell
12 Management Dilemmas ������������������������������������������������������������������ 119
Rajesh Gutta and Daniel J. Meara

ix
 Introduction
1
Daniel J. Meara and Rajesh Gutta

1.1 Patient Safety and Safe Care medical history undergoes general anesthesia or
procedural sedation, the anesthesia provider is
The World Health Organization (WHO) defines responsible for preoperative medical assessment
patient safety as “the absence of preventable and coordinating care to optimize the patient
harm to a patient during the process of health before surgery [4]. For the vast majority of these
care and reduction of risk of unnecessary harm patients, perioperative risk is attributed to cardiac
associated with health care to an acceptable mini- morbidity and mortality.
mum” [1]. Generally, the complexity of health In an attempt to provide optimal surgical care,
care systems makes humans more prone towards the concept of medical clearance came into exis-
mistakes which lead to patient harm. According tence. It is not uncommon to see the patient’s
to the Agency for Healthcare Research and physician stating, “patient is cleared for dental
Quality (AHRQ), patient safety refers to the free- extraction under mild sedation or general anes-
dom from accidental or preventable injuries pro- thesia.” What does that mean? Is the risk shared
duced by medical care [2]. The agency further by the physician? Or is the surgeon immune from
emphasizes that practices or interventions must a complication? There is no universally accepted
be implemented to reduce preventable adverse definition. But the term “medical clearance” is
events, and this improves patient safety. loosely used in clinical practice and has led to a
Cardiac complications are the leading cause significant use of perioperative testing (Table 1.1).
of death among patients undergoing elective non- There is a great degree of assumption that a series
cardiac surgery [3]. As the baby boomers age, the of laboratory tests prior to any operative proce-
number of noncardiac surgical procedures is dure would enhance safety for surgical patients
expected to increase. If the patient with complex and reduce liability for adverse events. In fact,
recent studies have indicated adverse outcomes
D. J. Meara (*)
in patients who underwent medical consultation
Department of Oral and Maxillofacial Surgery, prior to major noncardiac surgeries [5].
Christiana Care Health System, Wilmington,
DE, USA
Department of Physical Therapy, University of 1.2 Goal of Medical Clearance
Delaware, Newark, DE, USA
e-mail: [email protected]
The aim of preoperative medical clearance should
R. Gutta be obtained to identify patients with potentially
Consultant Oral and Maxillofacial Surgeon,
Private Practice, Midland, TX, USA
life-threatening cardiac disease that requires preop-

© Springer Nature Switzerland AG 2022 1

D. J. Meara, R. Gutta (eds.), Oral and Maxillofacial Surgery for the Medically Compromised Patient,
https://doi.org/10.1007/978-3-030-82598-0_1
2 D. J. Meara and R. Gutta

Table 1.1 Commonly ordered preoperative tests Noncardiac Surgery. At the time of publica-
Renal function tests tion, the guidelines recommended that testing
Electrolytes should be reserved for those patients in whom
Liver function tests the results would impact care. Testing a low-
12-lead EKG risk population not only increases costs unnec-
Chest radiography essarily but may increase morbidity and causes
Urine analysis harm by delaying a noncardiac operation. In
Pregnancy tests
fact, 77% of US physicians say the frequency
Bleeding and coagulation tests
Blood glucose tests
with which doctors order unnecessary medical
Blood counts tests and procedures is a serious problem [8].
Echocardiography The burden to the healthcare system due to
Cardiac stress testing such unnecessary testing is approximately
Pulmonary function tests $200 billion annually [9]. Other than to dis-
Computed tomography or magnetic resonance cover the previously unknown condition,
imaging results of preoperative testing will rarely trig-
Radionucleotide testing
ger a change in medical therapies to reduce
Coronary angiography
risk [10, 11]. However, if the risk is deemed
less than 1% and even if the patient is shown
erative assessment and treatment by a c­ ardiologist, to be at elevated risk with poor exercise toler-
to identify the most appropriate testing and avoid ance, it is rare that preoperative tests will
unnecessary testing, and to implement medical and change management. In addition, current ther-
interventional cardiovascular treatment strategies apeutic approaches to mitigate the risk of non-
as indicated [6]. As an alternative to routine preop- cardiac surgery are limited. In fact, abnormal
erative testing, a wise practitioner would be able to lab tests that resulted in a change in manage-
judiciously interview the patient and do a risk ment have only ranged from 0.1 to 2.6% of
assessment based on the patient’s functional capac- time [12]. Despite evidence demonstrating
ity than mere lab values indicating the presence or that routine preoperative testing before elec-
absence of a disease state. tive, low-risk ambulatory surgery is not indi-
According to the American College of cated, more than 60% of all patients underwent
Cardiology (ACC) and the American Heart at least one laboratory test during their preop-
Association (AHA) task force, “the purpose of erative evaluation [13]. Clinicians should thus
preoperative evaluation is not to give medical use the existing guidelines to identify those
clearance, but rather to; perform an evaluation of patients who require additional testing due to
the patient’s current medical status, make recom- poor or unknown exercise tolerance and thus
mendations concerning the evaluation, manage- reduce the probability of a major cardiovascu-
ment, and risk of cardiac problems over the entire lar event. Such a strategy will result in many
perioperative period and to provide a clinical risk fewer tests ordered and more cost-effective
profile that the patient, primary physician, anes- tests [14].
thesiologist, and surgeon can use in making treat-
ment decisions” [7].

1.4 Seeking Medical Clearance

1.3 Preoperative Testing and Its
Usefulness Rather than anecdotal evidence, Perioperative
management of the patient should be based on
It now has been approximately 25 years since the best available scientific evidence, individual
the ACC/AHA first published multispecialty patient’s risk stratification, and cost-­effectiveness.
Guidelines on Preoperative Evaluation for Improvements in preoperative risk assessment,
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