Medical Risk Assessment for Dental Patients

1. Medical Risk Assessment for Dental Patients Donald A. Falace, D.M.D. Oral Diagnosis and Oral Medicine UK College of Dentistry

2. 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?

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

4. 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

5. 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 Most Common Medical Emergencies in Dental Practice (4000 dentists over 10 years) Many of these events are preventable, or at least the chances of them occurring can be reduced

6. 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)

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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)

13. 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)

14. 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

16. The patient has completed filling out the medical history….., now what?? + =

17. 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?

18. 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

19. 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 concernsrelated to dental care • Treatment alterations

20. 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 ordownloaded to PDA)

21. 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

22. Clinical Examination • General appearance • Behavior • Vital signs • Head and neck • Oral tissues • Radiographs

23. 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)

24. 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

25. 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?

26. 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

27. 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…

28. 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?

29. Medical Problem Worksheet and the 3A

30. 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)

31. 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

32. 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