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

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Presentation on theme: "Medical Risk Assessment for Dental Patients Does the benefit of having dental treatment outweigh any increased medical risk to the patient?"— Presentation transcript:

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 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 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. 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? Instill fear Instill fear Inflict pain Inflict pain Inject local anesthetic solutions Inject local anesthetic solutions Inject potent vasoconstrictors Inject potent vasoconstrictors Cause bleeding Cause bleeding Control body position Expose to radiation Expose to dental materials Prescribe medications Alter oral function Alter appearance

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

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

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

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

8 Most Common Medical Emergencies in Dental Practice Syncope Syncope Mild Allergic Reaction Mild Allergic Reaction Angina Pectoris Angina Pectoris Postural Hypotension Postural Hypotension Seizures Seizures Asthmatic Attack 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 Medical History Physical Examination (vital signs, general survey, face, eyes, skin) Physical Examination (vital signs, general survey, face, eyes, skin) Laboratory tests Laboratory tests Medical consultation (physician, previous dentist, pharmacist) Medical consultation (physician, previous dentist, pharmacist)

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

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

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

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

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

16 Medical Consultation Purpose: Purpose: Verify or clarify information Verify or clarify information Determine risk for doing dental treatment on the patient Determine risk for doing dental treatment on the patient Determine if any changes are required in the delivery of dental treatment Determine if any changes are required in the delivery of dental treatment Be brief and to the point Be brief and to the point Response should attached to or recorded in the patient’s chart Response should attached to or recorded in the patient’s chart Fax, mail, or give to patient 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 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 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 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 Direct, written confirmation of this consult is advisable for medico-legal reasons Suggestion: Write a brief summary of the conversation 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 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? 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 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? 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? Are there any potential problems related to the provision of dental care? If not, proceed with treatment in the usual manner If not, proceed with treatment in the usual manner If yes, then… If yes, then… Are there any potential problems related to the provision of dental care? 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? How do I need to modify treatment to avoid those problems?

22 Examples of Treatment Modifications Pre-op: Pre-op: prophylactic antibiotics prophylactic antibiotics sedative sedative food intake food intake Intra-op: Intra-op: upright chair position upright chair position minimize or avoid epinephrine minimize or avoid epinephrine nitrous oxide nitrous oxide hemostasis measures hemostasis measures Post-op: Post-op: analgesics analgesics anti-fibrinolytic agent anti-fibrinolytic agent antibiotics 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? 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 Dry mouth (xerostomia) or burning mouth or tongue Oral ulcerations/lesions Oral ulcerations/lesions Bleeding Bleeding Gingival hyperplasia Gingival hyperplasia Fungal/bacterial infections Fungal/bacterial infections


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