Download Note that some risks are not due to the disease itself, but are due to

Summary of Medical History Information for Final Exam
Functional Capacity
A.
B.
C.
D.
Method for determining cardiac risk
Based on the patient’s ability to perform basic daily activities
Adequate functional capacity = able to perform activities that meet a 4 metabolic level of
endurance or 4 METs WITHOUT the following:
1.
Shortness of breath
2.
Fatigue
3.
Chest tightness or pain
MET = unit of oxygen consumption needed for physical activity
Energy Requirements
in Metabolic
Equivalents
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Activities
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Eating, getting dressed, working at desk
Taking a shower, walking DOWN 8 steps
1-2 blocks slow walking, moderate housework
Light yard work (power), painting, light carpentry
Walking briskly (4 mi/hr), dancing, washing the car
9 holes of golf, carry clubs, manual yard work
Heavy outdoor work, digging, tennis, carry 60 lbs
Moving heavy furniture, jogging, going up stairs quickly
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with 20 lbs
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 Bicycling at a moderate pace, sawing wood
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 Swimming briskly, bicycle up hill, jog 6 mi/hr
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 Full court basketball, cross-country skiing
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 Running – 8 minute mile
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 Competitive sports
VA Activity Questionnaire
F.
METS and Risk for Perioperative Myocardial Infarction
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METS < 4
METS 4-6
METS > 7
Major risk of ischemia
Intermediate risk of ischemia
Low risk
Situations that require a Medical Consultation
A.
B.
C.
D.
When additional information is required from another health care provider
When the patient is a poor historian
Signs or symptoms are present which indicate undiagnosed disease
The patient appears to have an unusual disease and you cannot find information
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ASA (Physical Status) Classification
Used to determine and quickly communicate the patient’s risk when undergoing dental treatment
and to help you determine how the treatment should be modified.
ASA I
Healthy patient without systemic disease
ASA II
Patient with mild systemic disease that does not interfere with daily activity; or a
healthy client with significant risk factors (obesity, smoking, substance abuse,
very fearful/anxious about dental treatment
ASA III
Patient with moderate to severe systemic disease that limits activity but is not
incapacitating
ASA IV
Patient with an incapacitating systemic disease that is a constant threat to life
ASA V
Patient not expected to survive 24 hours with or without an operation
ASA VI
Brain dead patient whose organs are to be removed for donor purposes
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Summary of Risks Associated with Dental Treatment - must be memorized!
Risk with Dental Treatment:
Bleeding problems with invasive procedures
Negative reaction (including allergy) to
medications used and/or prescribed by the
dentist
Infection which could be passed on to the
health care worker
Items from the Health History Questionnaire form,
which if checked, may indicate the presence of the risk
 Stroke – taking anticoagulants
 Heart attack - taking anticoagulants
 Blood clots or thrombosis – taking anticoagulants
 Hemophilia
 Blood transfusion – may have a bleeding disorder
 Bruise easily for no apparent reason – may have bleeding
disorder
 Headaches or chronic back pain – taking
aspirin/NSAIDS
 Frequent or severe nosebleeds
 Arthritis – taking aspirin/NSAIDS
 Hepatitis – Decreased clotting factors
 Jaundice – Hepatitis
 Cirrhosis of the liver/liver disease – Impaired clotting
factors
 Renal dialysis – anticoagulants
 Heavy drinker - alcoholic beverages – Liver disease
 Taking aspirin, non-steroidal anti-inflammatory drugs or
anticoagulants
 Stroke – Vasoconstrictor
 Heart surgery – Vasoconstrictor
 Pacemaker – Vasoconstrictor
 Irregular heart beat – Vasoconstrictor
 Epilepsy/seizure disorder – Stress
 Glaucoma – Increased ocular pressure
 Kidney disease – Decreased metabolism of drug
 Cirrhosis of the liver/liver disease – Decreased
metabolism of drug
 Ulcers – May worsen condition
 Medication allergies - Anaphylaxis
 Methamphetamine or cocaine/crack – Local anesthetic
and vasoconstrictor
 Recovering alcoholic or drug addict – Relapse
 Breastfeeding – drug may pass through placenta
 Tuberculosis
 Cough up bloody sputum – Tuberculosis
 Venereal disease/sexually transmitted diseases
 Hepatitis
 Jaundice – Hepatitis
 Persistent fever - HIV
 Blood transfusion – HIV, hepatitis
 HIV or AIDS
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Delayed healing and infection
Inability to handle stress from dental
procedures
Infective endocarditis
Infection of existing artificial joint
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Sickle cell disease
Diabetes
Cushing’s syndrome
Renal dialysis
Suppressed immune system
Tested positive for HIV or been diagnosed with AIDS
Taken steroid/prednisone
Organ transplant – due to immune suppression
High blood pressure
Heart attack
Stroke or transient ischemic attack
Pacemaker
Angina – Anginal attack or heart attack
Irregular heart beat – Heart attack
Sickle cell disease – Sickle cell crisis
Asthma – Asthmatic attack
Taken steroid/prednisone – Adrenal insufficiency
Hypothyroid
Hyperthyroid
Diabetes – Severe hypoglycemia
Epilepsy/seizure disorder – Seizure
Previous history of endocarditis
Cardiac transplant patients who develop cardiac
valvulopathy
 Congenital heart disease (non-repaired)
 Artificial heart valve
 Patients with an existing artificial joint AND
o The joint was placed < 2 years previously
o Insulin dependent diabetic
o Previous prosthetic joint infection
o Malnourishment
o Hemophilia
o Rheumatoid arthritis or systemic lupus
o Immune compromised/suppressed patient (disease,
drug or radiation induced)
Note that some risks are not due to the disease itself, but are due to medication or other treatment of the
disease.
Examples of questions:
• Examples:
Your patient has a history of multiple blood transfusions. What is the risk with dental treatment?
Bleeding
What are three conditions which might indicate the patient has an infection that could be contagious?
Jaundice, persistent fever, sexually transmitted disease
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Antibiotic Prophylaxis
A.
B.
C.
D.
Patients with certain conditions are at risk for serious infection because of the bacteremia
that results from manipulation of oral tissues (bleeding)
These patients must be identified and treated prophylactically with antibiotics PRIOR to
dental treatment to avoid infection
Medical Conditions Requiring Prophylaxis
1.
Cardiac
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Risk: Infective endocarditis
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Specific cardiac conditions requiring prophylaxis
a. Prosthetic mechanical or biologic heart valves
b. Previous infective endocarditis
c. Unrepaired cyanotic congenital heart disease
d. Completed repaired CHD within 6 months
e. Repaired CHD with residual defect
f. Cardiac transplant with valvulopathy
2.
Artificial joint
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Risk: Infection of the artificial joint
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Specific conditions requiring prophylaxis – artificial joint with one or more
of the following:
a. Within the first 2 years after placement
b. Previous infection of the joint
c. Patient has rheumatoid arthritis or systemic lupus
d. Patient has disease, drug or radiation induced immunosuppression
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No risk with:
a. Minor joints (finger, toe)
b. Breast, penile, corneal, dental implants
3.
Other conditions
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Risk: Serious oral infections
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Specific conditions requiring prophylaxis
a. Organ transplant patients on immunosuppressants
b. Cancer patients on chemotherapy
c. Uncontrolled diabetic
d. Advanced AIDS
Dental procedures requiring prophylaxis in susceptible patients
1.
Recommended: For all dental procedures that involve manipulation of gingival
tissue or the periapical region of the teeth or perforation of mucosa.
2.
Not Recommended:
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Routine anesthetic injections through non-infected tissue
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Taking of dental radiographs
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Placement of removable prosthodontic or orthodontic appliances
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Adjustment of orthodontic appliances
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Shedding of deciduous teeth and bleeding from trauma to the lips or oral
mucosa
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E.
Antibiotic protocol
1.
Oral only (patients unable to take oral antibiotics should not be treated in the predoctoral clinic)
2.
All doses should be taken 30-60 minutes before the procedure
Condition
Antibiotic
Adult Dose
Amoxicillin
OK if Penicillin or
Ampicillin Allergic?
Yes
Heart (1st choice)
Joint
Other
Heart
Joint
Other
Heart
Joint (1st choice)
Other
Heart
Other
Heart
Other
Heart
Other
Clindamycin
Yes (1st choice)
600 mg
Cephalexin
Not if immediate type allergic
reaction*
2 grams
Cephadroxil
2 grams
Azithromycin
Not if immediate type allergic
reaction*
Yes
Clarithromycin
Yes
500 mg
2 grams
500 mg
* History of anaphylaxis, angioedema, urticaria with penicillin
Medical Conditions that may worsen with local anesthetic with vasoconstrictor
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Unstable angina – vasoconstrictor is contraindicated
Uncontrolled (severe) hypertension – avoid vasoconstrictor
Arrhythmias – minimize the use of vasoconstrictor
Use or suspected use of cocaine or methamphetamine – no vasoconstrictor for 24 hours
after last use
Use of tricyclic antidepressants – minimize vasoconstrictor
Uncontrolled hyperthyroid – avoid vasoconstrictor
Previous myocardial infarction or stroke – minimize use
“Minimize use” = Cardiac dose = 2 cartridges of 2% lidocaine with 1:100,000 epinephrine
Stress reduction protocol
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Proper rest the night before – sleep medication if needed
Intraoperative sedation – nitrous oxide, IV
Morning appointment or when functional reserve is highest
Limit duration of treatment appointment
Avoid elective treatment during unusually hot or humid weather
Provide adequate post-op pain and anxiety control
Phone patient the evening after appointment
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