Download The Medical History and Risk Assessment

Medical Risk Assessment
for Dental Patients
Donald A. Falace, D.M.D.
Oral Diagnosis and Oral Medicine
UK College of Dentistry
Can we provide dental treatment to
the patient without endangering their (or
our) health and well being?
Is the benefit of having dental treatment
worth the risk to the patient?
What do we do in the course of providing
dental care that can affect the health and
well being of a patient?
• Instill fear
• Inflict pain
• Inject local
anesthetic
solutions
• Inject potent
vasoconstrictors
• Cause bleeding
• Control body
position
• Expose to
radiation
• Expose to dental
materials
• Prescribe
medications
• Alter oral function
• Alter appearance
Assessing the risk for the
occurrence of
• Immediate adverse events
– e.g. heart attack, stroke,
hypoglycemia, allergic reaction,
seizure
• Delayed adverse events
– e.g. bleeding, infection, adrenal crisis
Most Common Medical
Emergencies in Dental
Practice (4000 dentists over 10 years)
•
•
•
•
•
•
Syncope 15,407
Mild Allergic Reaction 2,583
Angina Pectoris 2,552
Postural Hypotension 2,475
Seizures 2,195
Asthmatic Attack 1,392
•
•
•
•
•
•
Hyperventilation 1,326
“Epinephrine Reaction” 913
Insulin Shock 890
Cardiac Arrest 331
Anaphylaxis 304
Myocardial Infarction 289
Many of these events are preventable, or at least the chances
of them occurring can be reduced
Risk Factors for the Occurrence
of Adverse Events
• Dependent upon 4 factors:
– The medical condition of the patient (diagnosis,
severity, stability, control)
– The nature of the dental procedure (invasiveness,
length of procedure, blood loss, type of anesthesia,
use of vasoconstrictor)
– The cardiopulmonary reserve which is the ability to
respond to physical/emotional challenges (METs;
oxygen utilization); can the patient climb a flight of
stairs without chest pain or shortness of breath = 4
METs
– The emotional stability of the patient (fear, anxiety)
Risk Assessment
Increased Risk
Medical Condition?
Severity
Stability
Control
Functional Capacity?
METs
Emotional Status?
Fear
Anxiety
Decreased Risk
Dental Procedure?
Invasiveness
Length of procedure
Blood Loss
Vasoconstrictor use
Risk Assessment
Increased Risk
Medical Condition?
Angina
Dental Procedure?
Full mouth extraction
Functional Capacity?
Climbing a flight of
stairs causes
shortness of breath
Emotional Status?
Afraid of the dentist
Risk Assessment
Medical Condition?
Angina
Dental Procedure?
Exam and x-rays
Functional Capacity?
Climbing a flight of
stairs causes chest
pain
Emotional Status?
Doesn’t like dentists
Decreased Risk
Risk Assessment?
Can we provide routine dental treatment to this
patient without endangering their (or our) health and
well being?
Yes. No problems are anticipated, and treatment
can be delivered in the usual manner.
(Benefit >> Risk)
Yes, but potential problems may be anticipated,
and modifications in the delivery of treatment are
necessary. (Benefit > Risk)
No. Potential problems exist that are serious
enough to make it inadvisable to provide elective
dental treatment. (Risk > Benefit)
Risk vs Benefit
• You may not be able to completely eliminate
the risk of an adverse event occurring during
dental treatment or as a result of dental
treatment, however, our goal is to reduce that
risk as much as possible
• The issue then becomes whether the
remaining risk is acceptable and that having
the dental treatment is of more benefit than
not having it
Medical Risk Assessment
Begins with Identification of
Medical Problems
• Medical history (questionnaire/interview)
• Physical examination (general survey, face,
eyes, skin, etc)
• Laboratory tests (screening, confirmation)
• Medical consultation (physician, dentist,
pharmacist)
Why take a medical history?
Many medical problems can affect or
influence the provision of dental care
Examples:
– Heart disease (infection, bleeding, drug
interactions, cause an MI or angina)
– Allergies (reactions to local anesthetics,
antibiotics, analgesics, latex)
– Diabetes (infection, hypoglycemia, periodontal
disease)
– Bleeding disorders; drug induced or genetic
(abnormal hemostasis)
Medical History
• Printed questionnaire (patient must be
literate, competent, of legal age)
• Follow-up with dialogue/research; make
notes on questionnaire
• Use ink - not pencil
• Patient,student, and faculty signature, date
• Update regularly
– Inquire at each appointment about any changes in
health or medications since previous appointment;
a brief comment is then included in the progress
note (SHAPED)
– New questionnaire should be completed every 2
years
The patient has completed filling out
the medical history….., now what??
+
=
• Review the Medical History form (3A) and note
positive responses
• Question the patient to gain more information
about those positive responses (write comments in
the margins)
• Innocuous or insignificant problems can be
disregarded
• Potentially significant disorders OR unfamiliar
disorders require further thought and/or
investigation
• Resources to help in the evaluation of the medical
history?
Reference Sources for Medical
Information
• Little,J, Falace,D,
Miller,C,
Rhodus,N:
Dental
Management of
the Medically
Compromised
Patient, 7th ed,
Mosby, 2008
• The Merck
Manual
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
Reference Sources: Drug
Information
• Drug Information
Handbook for Dentistry
(Lexicomp)
• Physician’s Desk
Reference (“PDR”)
– OTC drugs/dietary
supplements
– Herbal medications
• Facts and Comparisons
• Drug Information for the
Health Care Provider
(USPDI)
• Websites (online or
downloaded to PDA)
Drug Information Worksheet
•
•
•
•
•
Brand or trade name
Generic name
Drug type or action
Why prescribed
Interactions
–
–
–
–
Epinephrine
Antibiotics
Analgesics
Sedative/hypnotics
• Oral manifestations
• Side effects
Clinical Examination
• General
appearance
• Behavior
• Vital signs
• Head and neck
• Oral tissues
• Radiographs
Laboratory Tests
• Determine coagulation/hemostasis status
(coumadin, hepatitis C)
• Screening for blood glucose (severe
periodontal disease, burning mouth)
• Screen for rheumatologic disease (dry mouth,
Sjögren’s syndrome)
• 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
• Take to Adrena to for faxing
Medical Consult: Example
• Problem: Pt reports a history of heart
failure and an inability to be able 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?
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
• You may instead talk with a nurse or receptionist who will
convey what the physician has said or who will tell you what
is in the chart
• 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 and
FAX it to the physician; include a statement to the effect
that if they disagree with the summary, they should FAX
their correction to you within 24 hours; your FAX should be
attached to the chart
Then, 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…
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…
• What do I need to do to avoid
those problems?
Medical Problem Worksheet
and the 3A
Examples of treatment
modifications
• Limit treatment to specific times (e.g. hemodialysis; pregnancy)
• Obtain preoperative anticoagulation level (e.g. taking
coumadin)
• Prescribe 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 “statins”)
• Make chair 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)
Medical Risk Assessment and
the OD Process…..
Screening
Medical History
3A is completed
by the patient.
Patient is assigned
to student
Data 1
Data 2..
The medical history
is reviewed and evaluated;
Vital signs are obtained;
The patient is examined;
Problems are identified
requiring medical
problem, drug worksheets;
Medical consults initiated
Treatment
planning
appointment
Worksheets are
discussed and a
management plan
is established; the
back of the 3A is
completed
ASA Classification
(The risk increases as the
classification level increases)
• ASA 1: Normal, healthy patient
• ASA 2: Patient with mild systemic disease or
patient with a significant risk factor
• ASA 3: Patient with moderate to severe
systemic disease that is not incapacitating but
that may alter daily activity
• ASA 4: Patient with severe systemic disease
that is incapacitating and is a constant threat
to life