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

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.

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

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)

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

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

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

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

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)

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)

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!!

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

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

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

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)

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

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

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?

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?

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

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?

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

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)

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

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