Medical Risk Assessment Medical Risk Assessment for Dental Patientsfor Dental Patients

Does the benefit of having Does the benefit of having dental treatment outweigh dental treatment outweigh any increased medical risk any increased medical risk

to the patient?to the patient?

ObjectivesObjectives

Help you identify patients with various types Help you identify patients with various types of medical problems who might be at risk for of medical problems who might be at risk for having problems as a result of dental having problems as a result of dental treatmenttreatment

Help you to plan and deliver dental treatment Help you to plan and deliver dental treatment in such a way as to decrease the risk of an in such a way as to decrease the risk of an adverse event or outcome occurring, thus adverse event or outcome occurring, thus protecting your patients from injury, disease protecting your patients from injury, disease or adversity.or adversity.

Help you to avoid litigation, anxiety, and Help you to avoid litigation, anxiety, and sleepless nights. sleepless nights.

What do we do in the course of providing What do we do in the course of providing dental care that can affect the health and dental care that can affect the health and

well being of a patient?well being of a patient?

Instill fearInstill fear Inflict painInflict pain Inject local Inject local

anesthetic anesthetic solutionssolutions

Inject potent Inject potent vasoconstrictorsvasoconstrictors

Cause bleedingCause bleeding

Control body positionControl body position Expose to radiationExpose to radiation Expose to dental Expose to dental

materialsmaterials Prescribe Prescribe

medicationsmedications Alter oral functionAlter oral function Alter appearanceAlter appearance

Determining the Risk for the Determining the Risk for the Occurrence of an Adverse EventOccurrence of an Adverse Event

Must take into consideration 4 factors:Must take into consideration 4 factors:

I.I. The medical condition of the patient The medical condition of the patient (diagnosis, severity, stability, control) (diagnosis, severity, stability, control)

II.II. The functional (cardiopulmonary) reserve of The functional (cardiopulmonary) reserve of the patient that enables them to perform the patient that enables them to perform physical tasks physical tasks

III.III. The emotional stability of the patient (fear, The emotional stability of the patient (fear, anxiety)anxiety)

IV.IV. The nature of the dental procedure The nature of the dental procedure (invasiveness, length of procedure, blood (invasiveness, length of procedure, blood loss, type of anesthesia, use of loss, type of anesthesia, use of vasoconstrictor)vasoconstrictor)

Physical/Emotional-stability-control-tolerance-reserve

Dental Procedure-invasiveness-trauma-blood loss-duration

Risk AssessmentRisk Assessment

Risk?

Medical Condition? Severity Stability Control

Functional Capacity? Emotional Status? Fear Anxiety

Dental Procedure? Invasiveness Length of procedure Blood Loss Vasoconstrictor use

Risk AssessmentRisk Assessment

Decreased Risk

Increased Risk

Adverse OutcomesAdverse Outcomes

ImmediateImmediate Heart attack, Stroke, Hypoglycemia, Heart attack, Stroke, Hypoglycemia,

Immediate allergic reaction, SeizureImmediate allergic reaction, Seizure DelayedDelayed

Bleeding, Infective Endocarditis, Bleeding, Infective Endocarditis, Drug Reaction, Delayed Allergic Drug Reaction, Delayed Allergic ReactionReaction

Most Common Medical Most Common Medical Emergencies in Dental Emergencies in Dental

PracticePractice

Syncope Syncope Mild Allergic ReactionMild Allergic Reaction Angina Pectoris Angina Pectoris Postural HypotensionPostural Hypotension SeizuresSeizures Asthmatic AttackAsthmatic Attack

HyperventilationHyperventilation Epinephrine Epinephrine

ReactionReaction Insulin ShockInsulin Shock Cardiac ArrestCardiac Arrest AnaphylaxisAnaphylaxis Myocardial Myocardial

InfarctionInfarctionMany of these events are preventable, or at least the chances of them occurring can be lessened

Risk AssessmentRisk AssessmentCan we provide routine dental treatment to this Can we provide routine dental treatment to this patient without endangering their (or our) health patient without endangering their (or our) health and well being?and well being?

YesYes.. Most patients. No problems are Most patients. No problems are anticipated, and treatment can be delivered in the anticipated, and treatment can be delivered in the usual manner. Risk is very low. usual manner. Risk is very low. (Benefit > Risk)(Benefit > Risk)

YesYes,, BUTBUT potential problems may be potential problems may be anticipated, and modifications in the delivery of anticipated, and modifications in the delivery of treatment are necessary. Risk is moderately treatment are necessary. Risk is moderately increased increased (Benefit > Risk)(Benefit > Risk)

NoNo.. Potential problems exist that are serious Potential problems exist that are serious enough to make it inadvisable to provide elective enough to make it inadvisable to provide elective dental treatment. Risk is significantly increased dental treatment. Risk is significantly increased (Risk > Benefit)(Risk > Benefit)

Medical Risk Assessment Medical Risk Assessment Begins with the Identification Begins with the Identification

of Medical Problemsof Medical Problems Medical HistoryMedical History

Physical ExaminationPhysical Examination (vital signs, general (vital signs, general survey, face, eyes, skin)survey, face, eyes, skin)

Laboratory testsLaboratory tests

Medical consultationMedical consultation (physician, previous (physician, previous dentist, pharmacist)dentist, pharmacist)

The Medical History – Now The Medical History – Now What??What??

Review the Medical History and note Review the Medical History and note positive responsespositive responses

Interview the patient to gain more Interview the patient to gain more information about those positive responses information about those positive responses

Innocuous or insignificant problems can be Innocuous or insignificant problems can be disregardeddisregarded

Potentially significant disorders OR Potentially significant disorders OR unfamiliar disorders require further thought unfamiliar disorders require further thought and/or investigationand/or investigation

YOUR RESONSIBILITY!!YOUR RESONSIBILITY!!

Drug InformationDrug Information

Drug Name (brand and generic)Drug Name (brand and generic) Drug type or actionDrug type or action Why prescribedWhy prescribed InteractionsInteractions

EpinephrineEpinephrine AntibioticsAntibiotics AnalgesicsAnalgesics Sedative/hypnoticsSedative/hypnotics

Oral manifestationsOral manifestations Side effectsSide effects

Medical Problem Medical Problem WorksheetWorksheet ID of medical problemID of medical problem

ID of drugs taken for the problemID of drugs taken for the problem Recognition of signs, symptoms or Recognition of signs, symptoms or

abnormal lab value related to problemabnormal lab value related to problem Assessment of control or stability of Assessment of control or stability of

the problemthe problem Recognition of possible issues or Recognition of possible issues or

concernsconcerns related to dental carerelated to dental care Treatment alterationsTreatment alterations

Clinical ExaminationClinical Examination

General General appearanceappearance

BehaviorBehavior Vital signsVital signs Head and neck Head and neck Oral tissuesOral tissues RadiographsRadiographs Laboratory testsLaboratory tests

Laboratory TestsLaboratory Tests Determine coagulation/hemostasis status Determine coagulation/hemostasis status Screening for blood glucose (severe Screening for blood glucose (severe

periodontal disease, burning mouth)periodontal disease, burning mouth) Screen for rheumatologic disease (SjScreen for rheumatologic disease (Sjögren’s ögren’s

syndrome, SLE, rheumatoid arthritis)syndrome, SLE, rheumatoid arthritis) Screening for liver function (hepatitis C, Screening for liver function (hepatitis C,

cirrhosis)cirrhosis) Screening for kidney function (renal failure)Screening for kidney function (renal failure) Complete blood count with differential Complete blood count with differential

(burning mouth, unexplained oral lesions)(burning mouth, unexplained oral lesions)

Medical ConsultationMedical Consultation

Purpose: Purpose: Verify or clarify informationVerify or clarify information Determine risk for doing dental treatment on the Determine risk for doing dental treatment on the

patientpatient Determine if any changes are required in the Determine if any changes are required in the

delivery of dental treatmentdelivery of dental treatment Be brief and to the pointBe brief and to the point Response should attached to or recorded in the Response should attached to or recorded in the

patient’s chartpatient’s chart Fax, mail, or give to patientFax, mail, or give to patient

Phone ConsultationPhone Consultation

A phone call is not the best way to obtain A phone call is not the best way to obtain information but does provide information information but does provide information quicklyquickly

Often the physician will not be available to talk Often the physician will not be available to talk to you directlyto you directly

It is mandatory to document this conversation, It is mandatory to document this conversation, to include to whom you spoke and what was to include to whom you spoke and what was saidsaid

Direct, written confirmation of this consult is Direct, written confirmation of this consult is advisable for medico-legal reasonsadvisable for medico-legal reasons

Suggestion: Write a brief summary of the Suggestion: Write a brief summary of the conversationconversation

Medical Consult: Medical Consult: ExampleExample

Pt History: 24 year old female with a Pt History: 24 year old female with a past history of heart murmur but is past history of heart murmur but is unsure of current statusunsure of current status

Reason for consult: Determine if the Reason for consult: Determine if the patient has a heart murmur and if patient has a heart murmur and if so, determine if the patient requires so, determine if the patient requires antibiotic prophylaxis for invasive antibiotic prophylaxis for invasive dental treatment?dental treatment?

Medical Consult: Medical Consult: ExampleExample

Pt History: 62 year old male with history Pt History: 62 year old male with history of symptomatic heart failure; an inability of symptomatic heart failure; an inability to climb a flight of stairs without getting to climb a flight of stairs without getting short of breath or having chest painshort of breath or having chest pain

Reason for Consult: Can this patient Reason for Consult: Can this patient tolerate routine dental treatment tolerate routine dental treatment including fillings, and gingival surgery including fillings, and gingival surgery using local anesthetic with 1:100,000 using local anesthetic with 1:100,000 epinephrine?epinephrine?

ABC’s of Problem Identification

Antibiotics Anesthesia Anxiety Allergy Bleeding Chair position Drugs Devices Equipment Emergencies

You have obtained the history, performed a You have obtained the history, performed a clinical exam, obtained appropriate lab results clinical exam, obtained appropriate lab results and consulted with the physician if necessary. and consulted with the physician if necessary.

Now, answer this question….Now, answer this question…. Are there any potential problems related to the Are there any potential problems related to the

provision of dental care?provision of dental care?

If not, proceed with treatment in the usual If not, proceed with treatment in the usual

mannermanner

If yes, then…If yes, then… Are there any potential problems related to the Are there any potential problems related to the

provision of dental care? If yes, then…provision of dental care? If yes, then…

How do I need to modify treatment to avoid those How do I need to modify treatment to avoid those problems?problems?

Examples of Treatment Examples of Treatment ModificationsModifications Pre-op:Pre-op:

prophylactic antibiotics prophylactic antibiotics sedativesedative food intakefood intake

Intra-op: Intra-op: upright chair position upright chair position minimize or avoid epinephrineminimize or avoid epinephrine nitrous oxidenitrous oxide hemostasis measureshemostasis measures

Post-op:Post-op: analgesicsanalgesics anti-fibrinolytic agent anti-fibrinolytic agent antibiotics antibiotics

Examples of Treatment Examples of Treatment ModificationsModifications

Limit treatment to specific times (e.g. hemodialysis; Limit treatment to specific times (e.g. hemodialysis; pregnancy)pregnancy)

Preoperative anticoagulation level; blood pressurePreoperative anticoagulation level; blood pressure Preoperative antibiotics (e.g. prosthetic heart valve)Preoperative antibiotics (e.g. prosthetic heart valve) Provide pre-operative or intra-operative sedation (e.g. Provide pre-operative or intra-operative sedation (e.g.

unstable cardiac patient; fearful patient)unstable cardiac patient; fearful patient) Minimize the intraoperative use of epinephrine in local Minimize the intraoperative use of epinephrine in local

anesthesia, (e.g. unstable cardiac patient)anesthesia, (e.g. unstable cardiac patient) Avoid the administration or prescription of certain drugs Avoid the administration or prescription of certain drugs

(e.g. erythromycin for patients taking certain lipid-lowering (e.g. erythromycin for patients taking certain lipid-lowering drugs)drugs)

Make position changes slowly (e.g. BP medications)Make position changes slowly (e.g. BP medications) Ensure a comfortable chair position (e.g. heart failure, Ensure a comfortable chair position (e.g. heart failure,

emphysema, pregnancy, arthritis)emphysema, pregnancy, arthritis) Provide postoperative antibiotics (poorly controlled diabetic Provide postoperative antibiotics (poorly controlled diabetic

with dental abscess)with dental abscess)

Finally, answer this Finally, answer this question….question….

Are there any oral Are there any oral manifestations or manifestations or abnormalities present that abnormalities present that may be related to the may be related to the disease or it’s treatment?disease or it’s treatment?

Oral Oral ManifestatioManifestatio

nsns Dry mouth Dry mouth

(xerostomia) or (xerostomia) or burning mouth or burning mouth or tonguetongue

Oral Oral ulcerations/lesionsulcerations/lesions

BleedingBleeding Gingival Gingival

hyperplasiahyperplasia Fungal/bacterial Fungal/bacterial

infectionsinfections