Medical Risk Assessment for Dental Patients

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Medical Risk Assessment for Dental Patients

• Donald A. Falace, D.M.D.
• Oral Diagnosis and Oral Medicine
• UK College of Dentistry

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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?
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What do we do in the course of providing dental
care that can affect the health and well being of
a patient?

• 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
• Control body position

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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

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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
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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)

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Risk Assessment
Medical Condition? Severity Stability
Control Functional Capacity? METs Emotional
Status? Fear Anxiety Dental Procedure?
Invasiveness Length of procedure Blood Loss
Vasoconstrictor use
Increased Risk
Decreased Risk
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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
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Risk Assessment
Medical Condition? Angina Dental Procedure?
Exam and x-rays Functional Capacity? Climbing
a flight of stairs causes chest
pain Emotional Status? Doesnt like
dentists
Decreased Risk
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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 gtgt Risk)
• Yes, but potential problems may be anticipated,
  and modifications in the delivery of treatment
  are necessary. (Benefit gt Risk)
• No. Potential problems exist that are serious
  enough to make it inadvisable to provide elective
  dental treatment. (Risk gt Benefit)

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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

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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)

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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)

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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

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The patient has completed filling out the
medical history.., now what??


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• 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?

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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

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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

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Reference Sources Drug Information

• Drug Information Handbook for Dentistry
  (Lexicomp)
• Physicians 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)

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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

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Clinical Examination

• General appearance
• Behavior
• Vital signs
• Head and neck
• Oral tissues
• Radiographs

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Laboratory Tests

• Determine coagulation/hemostasis status
  (coumadin, hepatitis C)
• Screening for blood glucose (severe periodontal
  disease, burning mouth)
• Screen for rheumatologic disease (dry mouth,
  Sjögrens syndrome)
• Screening for liver function (hepatitis C,
  cirrhosis)
• Screening for kidney function (renal failure)
• Complete blood count with differential (burning
  mouth, unexplained oral lesions)

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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
  patients chart
• Fax, mail, or give to patient
• Take to Adrena to for faxing

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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
  1100,000 epinephrine?

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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

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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

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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?

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Medical Problem Worksheet and the 3A
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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)

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Medical Risk Assessment and the OD Process..
Treatment planning appointment
Data 1
Screening
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
Worksheets are discussed and a management plan
is established the back of the 3A is completed
Medical History 3A is completed by the
patient. Patient is assigned to student
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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

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