1. Medical Risk Assessment for Dental Patients
Does the benefit of having dental treatment outweigh any increased medical risk to the patient?

2. Objectives
Help you identify patients with various types of medical problems who might be at risk for having problems as a result of dental treatment
Help you to plan and deliver dental treatment in such a way as to decrease the risk of an adverse event or outcome occurring, thus protecting your patients from injury, disease or adversity.
Help you to avoid litigation, anxiety, and sleepless nights.

3. What do we do in the course of providing dental care that can affect the health and well being of a patient?
Control body position
Expose to radiation
Expose to dental materials
Prescribe medications
Alter oral function
Alter appearance
Instill fear
Inflict pain
Inject local anesthetic solutions
Inject potent vasoconstrictors
Cause bleeding

4. Determining the Risk for the Occurrence of an Adverse Event
Must take into consideration 4 factors:
The medical condition of the patient (diagnosis, severity, stability, control)
The functional (cardiopulmonary) reserve of the patient that enables them to perform physical tasks
The emotional stability of the patient (fear, anxiety)
The nature of the dental procedure (invasiveness, length of procedure, blood loss, type of anesthesia, use of vasoconstrictor)

5. Risk Assessment Physical/Emotional Dental Procedure -stability
-control
-tolerance
-reserve
Dental Procedure
-invasiveness
-trauma
-blood loss
-duration

6. Risk Assessment Increased Risk Risk? Decreased Risk Medical Condition?
Severity
Stability
Control
Functional Capacity?
Emotional Status?
Fear
Anxiety
Dental Procedure?
Invasiveness
Length of procedure
Blood Loss
Vasoconstrictor use
Increased Risk
Risk?
Decreased Risk

7. Adverse Outcomes Immediate Delayed
Heart attack, Stroke, Hypoglycemia, Immediate allergic reaction, Seizure
Delayed
Bleeding, Infective Endocarditis, Drug Reaction, Delayed Allergic Reaction

8. Most Common Medical Emergencies in Dental Practice
Syncope
Mild Allergic Reaction
Angina Pectoris
Postural Hypotension
Seizures
Asthmatic Attack
Hyperventilation
Epinephrine Reaction
Insulin Shock
Cardiac Arrest
Anaphylaxis
Myocardial Infarction
Many of these events are preventable, or at least the chances of them occurring can be lessened

9. Risk Assessment
Can we provide routine dental treatment to this patient without endangering their (or our) health and well being?
Yes. Most patients. No problems are anticipated, and treatment can be delivered in the usual manner. Risk is very low. (Benefit > Risk)
Yes, BUT potential problems may be anticipated, and modifications in the delivery of treatment are necessary. Risk is moderately increased (Benefit > Risk)
No. Potential problems exist that are serious enough to make it inadvisable to provide elective dental treatment. Risk is significantly increased (Risk > Benefit)

10. Medical Risk Assessment Begins with the Identification of Medical Problems
Medical History
Physical Examination (vital signs, general survey, face, eyes, skin)
Laboratory tests
Medical consultation (physician, previous dentist, pharmacist)

11. The Medical History – Now What??
Review the Medical History and note positive responses
Interview the patient to gain more information about those positive responses
Innocuous or insignificant problems can be disregarded
Potentially significant disorders OR unfamiliar disorders require further thought and/or investigation
YOUR RESONSIBILITY!!

12. Drug Information Drug Name (brand and generic) Drug type or action
Why prescribed
Interactions
Epinephrine
Antibiotics
Analgesics
Sedative/hypnotics
Oral manifestations
Side effects

13. Medical Problem Worksheet
ID of medical problem
ID of drugs taken for the problem
Recognition of signs, symptoms or abnormal lab value related to problem
Assessment of control or stability of the problem
Recognition of possible issues or concerns related to dental care
Treatment alterations

14. Clinical Examination General appearance Behavior Vital signs
Head and neck
Oral tissues
Radiographs
Laboratory tests

15. Laboratory Tests Determine coagulation/hemostasis status
Screening for blood glucose (severe periodontal disease, burning mouth)
Screen for rheumatologic disease (Sjögren’s syndrome, SLE, rheumatoid arthritis)
Screening for liver function (hepatitis C, cirrhosis)
Screening for kidney function (renal failure)
Complete blood count with differential (burning mouth, unexplained oral lesions)

16. Medical Consultation Purpose: Verify or clarify information
Determine risk for doing dental treatment on the patient
Determine if any changes are required in the delivery of dental treatment
Be brief and to the point
Response should attached to or recorded in the patient’s chart
Fax, mail, or give to patient

17. Phone Consultation
A phone call is not the best way to obtain information but does provide information quickly
Often the physician will not be available to talk to you directly
It is mandatory to document this conversation, to include to whom you spoke and what was said
Direct, written confirmation of this consult is advisable for medico-legal reasons
Suggestion: Write a brief summary of the conversation

18. Medical Consult: Example
Pt History: 24 year old female with a past history of heart murmur but is unsure of current status
Reason for consult: Determine if the patient has a heart murmur and if so, determine if the patient requires antibiotic prophylaxis for invasive dental treatment?

19. Medical Consult: Example
Pt History: 62 year old male with history of symptomatic heart failure; an inability to climb a flight of stairs without getting short of breath or having chest pain
Reason for Consult: Can this patient tolerate routine dental treatment including fillings, and gingival surgery using local anesthetic with 1:100,000 epinephrine?

20. ABC’s of Problem Identification
Antibiotics
Anesthesia
Anxiety
Allergy
Bleeding
Chair position
Drugs
Devices
Equipment
Emergencies

21. You have obtained the history, performed a clinical exam, obtained appropriate lab results and consulted with the physician if necessary. Now, answer this question….
Are there any potential problems related to the provision of dental care?
If not, proceed with treatment in the usual manner
If yes, then…
Are there any potential problems related to the provision of dental care? If yes, then…
How do I need to modify treatment to avoid those problems?

22. Examples of Treatment Modifications
Pre-op:
prophylactic antibiotics
sedative
food intake
Intra-op:
upright chair position
minimize or avoid epinephrine
nitrous oxide
hemostasis measures
Post-op:
analgesics
anti-fibrinolytic agent
antibiotics

23. Examples of Treatment Modifications
Limit treatment to specific times (e.g. hemodialysis; pregnancy)
Preoperative anticoagulation level; blood pressure
Preoperative antibiotics (e.g. prosthetic heart valve)
Provide pre-operative or intra-operative sedation (e.g. unstable cardiac patient; fearful patient)
Minimize the intraoperative use of epinephrine in local anesthesia, (e.g. unstable cardiac patient)
Avoid the administration or prescription of certain drugs (e.g. erythromycin for patients taking certain lipid-lowering drugs)
Make position changes slowly (e.g. BP medications)
Ensure a comfortable chair position (e.g. heart failure, emphysema, pregnancy, arthritis)
Provide postoperative antibiotics (poorly controlled diabetic with dental abscess)

24. Finally, answer this question….
Are there any oral manifestations or abnormalities present that may be related to the disease or it’s treatment?

25. Oral Manifestations Dry mouth (xerostomia) or burning mouth or tongue
Oral ulcerations/lesions
Bleeding
Gingival hyperplasia
Fungal/bacterial infections