Patient Evaluation and Risk Assessment Flashcards
1
Q
Dentistry and medicine today are different
(3)
A
➢ People live longer = more elderly patients
➢ People receive medical treatments for disorders that would be fatal a just a few
years ago
➢ Pharmaceuticals continue to advance
2
Q
Dentistry and medicine today are different
➢ The greater the number and the more complex the conditions and the more medications that are used to manage these conditions are all proportional the
A
combinations and permutations of dental treatments for our patients
3
Q
increased number of conditions
increased complexity of conditions
increased number of medications
=
A
increased combinations and
permutations of dental
treatments
4
Q
The dentist must now be more knowledgeable about a wider range of
medical conditions as patients receive dental treatment
➢ Many chronic disorders or their
treatments necessitate
A
modification
of dental treatment
➢ Hepatitis –1982 -gloves
➢ AIDS –1990 - PPE
➢ COVID-19 –2019 –PPE and vaccines
5
Q
Clincians must practice so that the benefit of dental treatment will
A
outweigh the risk(s) of a medical complication occurring either
during treatment or as a result of treatment.
6
Q
Organized Risk Assessment
(Dental Care) (4)
A
Bleeding
Infection
Drug Effects
Ability to Tolerate Care(CV –Resp –Psych)
7
Q
Organized Risk Assessment
Acquired Data can be applied to assess risk prior to any oral health care
delivery!
Use an — format.
A
A, B, C…..
8
Q
SKIPPED
Adjunctive Tests
& Procedures
A
- Refer
- Imaging
- Histopathology
- Microbiology
- Labs
- Anesthesia
- Molecular biology
- Sequencing
9
Q
P- patient evaluation
(7)
A
Medical History
Medications
Social and Family History
Review of Systems
Objective Findings
History of Present Illness
Chief Complaint
- Chief Complaint
- History of Present Illness
- Medical History
- Social and Family History
10
Q
P- patient evaluation
* Identify ALL (2), taken or supposed to be taken
* Review —, discuss relevant issues with patient
* Examine patient for —
* Review or gather recent — or images
* Obtain a —
A
medications & drugs
medical history
signs and symptoms of disease
laboratory tests
medical consult
11
Q
Obtain a medical consult
(2)
A
- If patient has a poorly controlled or undiagnosed problem
- If you’re uncertain about the patient’s health
12
Q
A (5)
A
Antibiotics
Analgesics
Anesthesia
Allergies
Anxiety
AL(llergies) was ANXIOUS to get ANTIBIOTICS,
ANALGESICS & ANESTHESIA
13
Q
- Allergies
A
- Is the patient allergic to drugs or substances that may be used or
prescribed?
14
Q
- Anxiety
A
- Will the patient need or benefit from a sedative or anxiolytic?
15
Q
- Antibiotics
A
- Will the patient need antibiotics?
- Is the patient taking an antibiotic?
16
Q
- Analgesics
A
- Is the patient taking aspirin or NSAIDs that can increase bleeding?
- Will analgesics be needed post-treatment?
17
Q
- Anesthesia
A
- Are there concerns using a local with or without epinephrine?
18
Q
B
(3)
A
Breathing
Bleeding
BP
19
Q
- Bleeding
A
- Is abnormal hemostasis possible?
20
Q
- Breathing
A
- Does the patient have difficulty breathing or is the patient’s
breathing fast or slow?
21
Q
- Blood pressure
A
- Is the patient’s BP well controlled or is it possible it may
increase/decrease during dental treatment
22
Q
C
(1)
A
- Chair position
23
Q
- Chair position
A
- Can the patient tolerate a supine or (horizontal) position?
- Is the patient going to have a problem being raised quickly, after
treatment?
24
Q
D
(2)
A
Drugs
Devices
25
* Drugs
* Any drug interactions, adverse effects, or allergies associated with
drugs being currently being taken or drugs that the dentist may
prescribe or use?
26
* Devices
* Does the patient have prosthetic or therapeutic device that may
require tailored management?
* e.g., prosthetic heart valve, prosthetic joint, stent, pacemaker,
defibrillator
27
E
(2)
Equipment
Emergencies
28
* Equipment
* Any potential issues with the use of dental equipment?
* e.g.: X-ray machine, electrocautery, oxygen supply, ultrasonic cleaner,
apex locator.
29
* Emergencies
* Are there medical emergencies that can be anticipated or prevented
by modifying care?
* e.g: MI, stroke, asthma, uncontrollable bleeding
30
F
(1)
Follow up
31
* Follow up
* Is any follow up care indicated?
* e.g.: post-op analgesics, antibiotics, anxiety
* Post-op instructions for home care ALWAYS and prescriptions when
necessary
* Should the patient be contacted at home to assess post-treatment
response
32
Simple Rule: If a local anesthetic(s) are used on a patient and
there was bleeding during the appointment, the patient should
be contacted that evening or the following day
33
Medical History
* Must be taken for
every patient who is to receive dental treatment
34
Two basic techniques used to obtain a medical history
(2)
➢ Interview the patient
- Ask patient questions, record the patient’s verbal responses (axiUM at UMKC)
➢ A printed questionnaire the patient fills out
35
SKIPPED
Questions are designed to identify or hint to medical issues that may affect dental teatment:
* Anxiety
* Cardiovascular diseases
* Neurologic disorders
* Gastrointestinal diseases
* Respiratory tract diseases
* Musculoskeletal diseases
* Endocrine diseases
* STD’s
* Cancer & radiation treatment
36
Medical History is different from
Review of Systems (ROS)
37
MED history =
patient has already been diagnosed or,
patient presents with information needing a diagnosis
38
The point of a ROS is to
screen for potential new diseases
39
The point of a ROS is to screen for potential new diseases
(2)
* Screening through signs and symptoms with a systems-based approach
* Findings may be consistent with a particular systemic disease, but you will not diagnose
40
Findings may be consistent with a particular systemic disease, but you will not diagnose
(2)
* Physician’s role →further examine, request labs, diagnose
* Referral consultation letter →express findings, concerns and a basis for ROS
41
Functional Capacity
It is important to ask some screening questions.
Does the pt have the
ability to engage in normal day-to-day physical activity?
42
It is important to ask some screening questions. Does the pt have the
ability to engage in normal day-to-day physical activity?
➢ Ability to perform common daily tasks can be expressed in
➢ Higher MET =
metabolic
equivalent levels (METs)
better physical condition
43
A MET is a unit of
oxygen consumption
➢ 1 MET equals 3.5 mL of oxygen per kg of body weight per minute at
rest
44
Asking a patient, “Can you walk up two flights of stairs without
having to catch your breath” can indicate general cardiovascular
and/or pulmonary health.
T
45
SKIPPED
Caution
Heart disease
Diabetes
Tuberculosis
Anaphylactic allergies
Asthma, COPD, emphysema
Bleeding risk (disease-related and/or medication-related)
Infective endocarditis
Cancer and cancer treatment (past/present)
Antiresorptive or antiangiogenic medications (past/present)
Altered immune status (disease and/or medication-related)
History of infectious disease (HIV, Hepatitis B,C, STDs etc.)
Dialysis
Pregnancy
46
Not all ”allergies” are (true) allergies
➢ If a patient responds “yes” when asked if allergic to a particular substance the
mandatory follow-up question is
“ what happens?”
47
True allergy
(9)
➢ Anaphylaxis
➢ Itching
➢ Urticaria (hives)
➢ Rash
➢ Swelling
➢ Wheezing
➢ Angioedema
➢ Rhinorrhea
➢ Tearing eyes
48
Intolerance or an adverse side effect
(5)
oNausea
oVomiting
oDiarrhea
oHeart palpitations
oFainting
49
Sexually Transmitted Diseases
(3) can have manifestations in the oral
cavity
Syphilis, gonorrhea, HIV infection
50
Syphilis, gonorrhea, HIV infection can have manifestations in the oral
cavity
➢ --- may be the first to identify these conditions
➢ Some STD’s including (4), can
be transmitted to the dentist through direct contact with oral lesions
or infected blood
➢ --- is the single
most common STD in the US.
Dentist
HIV infection, hepatitis B and C, and syphllis
Chlamydial genitalia infection (Chlamydia trachomatis)
51
Steroids
(2) are examples of steroids that are used to treat
many diseases
Cortisone and prednisone
52
Cortisone and prednisone are examples of steroids that are used to treat
many diseases
➢ They are important because their use can result in
adrenal
insufficiency and the patient is unable to mount a normal response to
the stress of an infection or invasive dental procedure, e.g., extractions
or periodontal surgery.
53
Operations & Hospitalizations
History of hospitalizations can provide clues to past illnesses that
may have current significance
➢ An --- aspect of your evaluation but an effective way to
identify a current condition
INDIRECT
54
History of hospitalizations include (3)
➢ Operations; ---; any
emergencies; post-op bleeding; infection; drug allergy should
be ascertained
diagnosis, tx, and complications
reason for procedures must always be asked
55
Women who are or might be pregnant may need special consideration in
dental management
➢ Caution is warranted with:
(3)
*radiography
*drug administration
*timing of dental treatment
56
Good --- is important during pregnancy
--- trimester is the safest to provide dental treatment
--- for urgent care only
oral hygiene
2nd
Radiography
57
Pt’s with a hx of IV drug use increased risk for infectious diseases like:
(4)
Hepatitis B, C, HIV/AIDS, and infective endocarditis
58
--- and sedative meds should be Rx’dwith great caution or not at all
➢ Risk of triggering a relapse
Narcotic
59
Vasoconstrictors should be avoided for cocaine and methamphetamine
users
➢ These agents may precipitate
arrhythmias, severe hypertension, MI,
and Stroke
60
Substance Use, Misuse and Abuse
This portion of the patient interview →
PROFESSIONAL TRUST
61
Substance Use, Misuse and Abuse
Alcohol consumption
* Risk factor for many cancers and other diseases
* May lead to ---, many complications
* Ask how many standard drinks /week
liver cirrhosis
62
Substance Use, Misuse and Abuse
Tobacco
* Risk factor for many cancers and other diseases (especially oral cancer)
* Ask type of tobacco and frequency and establish cumulative risk,
current and past (for how many years)
➢ Cigarettes:
➢ Smokeless tobacco:
➢ Hookah:
➢ E-cigarettes:
packs/day ( 1 pack = 20 cigarettes)
cans/week
hours/week
cartridges/week
63
Social Parameters
(3)
* Occupation –looking for environmental/occupation risk
* Marital status - social support
* Children
64
Family History
Gives insight to potential diseases with heritability
Watch out for signs and symptoms
(5)
* Hypertension
* Diabetes
* Autoimmune disease
* Cancer
* Other hereditary diseases and syndromes
65
Family History
Questions?
(3)
* Do any diseases run in your family?
* Are your parents and siblings alive and well?
* What did your (mother/father/sibling pass of?)
66
Checking --- first is a good way to initiate a the medical history
medications
67
➢ Compare with their reported past medical history
➢ Speeds up the intake process, more focused on what to look for as well as on ROS
(3)
* Should match up with medical history
* Signs and symptoms of disease progression
* Signs and symptoms of drug-related adverse effects (bleeding, immunosuppression, BP,
MRONJ, etc.)
68
All drugs, medicines, or ‘pills’ that a patient is taking or is supposed to be
taking should be identified and investigated for actions, adverse side
effects, and potential drug interactions.
(2)
➢ Patients usually do not list OTC drugs or herbal medicines
➢ Complete list of medications may need to be sought from the patient’s
physician
69
Physical Examination –Objective Findings
(5)
Vital signs
General appearance
Skin
Fingers
Nails
70
Head and neck examination
(6)
Skin
Eyes & Nose
Ears
Cranial nerves
Neck examination
Intra-oral examination
71
Vital Signs
(6)
Blood pressure, pulse, respiratory rate, temperature, height,
weight
72
➢ In the dental setting, typically only (2) are measured
directly
BP and pulse
73
➢ Respiratory rate is by observation (--- r/m)
12-16
74
➢ Temperature is measured when
infection or systemic
involvement is suspected
- due to COVID pandemic, currently a part of every patient
encounter
75
Height and weight determined by
asking the patient
76
Establishing baseline
(2)
➢ Can compare if medical emergency occurs during treatment
➢ Screening for problems: poor control, progression,
undiagnosed
77
Purpose is for detection of abnormality and not diagnosis
(2)
➢ Diagnosis is responsibility of the physician
➢ Refer if finding is significantly abnormal
78
Blood Pressure
Why is it important to check?
Screening:
Monitoring –
Risk assessment –
Treatment modifications
Blood pressure (BP) is variable so --- readings are
really the most appropriate
you may be the first to detect
compliance/control/progression
potential serious complications
multiple
79
Blood Pressure
Determined by
➢ Cuff should encompass ---% of the circumference of the arm.
➢ Center of cuff over --- artery
➢ Cuff too small →
➢ Cuff too large →
indirect measurement in the upper extremities with a BP
cuff and stethoscope
80
brachial
falsely elevated values*
falsely low values*
80
White Coat HTN’ elevate BP by --- mm Hg*
30
81
Pregnant pts w/ ≥ 10 mm Hg increase in systolic BP from baseline
➢ Risk of
eclampsia →immediate referral
82
lood Pressure
Arm position matters
➢ Horizontal at heart level (mid-sternum)
83
Arm below heart level
Over-Estimates systolic and diastolic pressures
Similar to Cuff too small →falsely elevated values*
84
Arm above heart level
under-estimates systolic and diastolic pressures
Similar to Cuff too large →falsely low values
85
Auscultation method of BP measurement is universally accepted
➢ BP cuff should be inflated until radial pulse disappears; then add
additional
➢ Release valve slowly turned. Fall rate of needle ~--- mm Hg per second
➢ First audible ‘Beating sound’ (Korotkoff sounds)
*This pressure point =
20-30 mm Hg
2-3
Systolic pressure
86
As needle continues to fall, beat will become louder and then diminish
until marked diminution in intensity occurs
(2)
➢ Weakened beats heard for a few moments
➢ Reliable index of diastolic pressure = point when sound disappears,
completely
87
Blood Pressure & Dentistry
Focus on accurate measurements:
Pt avoid (3)
Pt empty --- prior to BP
Sit quietly for at least -- minutes
Support --- to measure BP
Don’t take BP over ---
Take -- readings (on -- occasions)
caffeine, exercise, (nicotine*)
bladder
5
limb
clothes
2-3 , 2-3
88
cuff too small →
arm too low →
falsely elevated values*
falsely elevated values*
89
cuff too large →
arm too high →
falsely low values
falsely low values
90
Classification Range
Normal
Elevated
Stage 1
Stage 2
Hypertensive Crisis
< 120/80 mm Hg
120 - 129/< 80 mm Hg
130-139 or 80-89 mm Hg
≥ 140 or 90mm Hg
≥ 180 and/or >120
91
--- Readings on --- Separate Visits
≥ 2
≥ 2
92
NO dental care at UMKSC SOD if BP
≥ 180/110 mmHg
93
NO dental care at UMKSC SOD if BP ≥ 180/110 mmHg
➢ --- is classified as a Hypertensive Urgency by the AHA based on
2017 guidelines
➢ Urgent referral →
➢ If patient is symptomatic →
180/120
see doctor ASAP
Emergency Room
94
Pulse
Standard for
assessing pulse rate
(2)
➢ Palpate carotid
artery at side of
trachea →MORE
RELIABLE
OR
➢ Palpate radial artery
on the thumb side
of wrist
95
Do not use the --- for
pulse detection
thumb
thumb has a pulse
96
Classification Range
Normal
Tachycardia (too fast)
Bradycardia (too slow
60-100 bpm
>100 bpm
<60 bpm
97
Abnormal pulse rate may be a sign of --- disorder
CV
98
Pulse may be influenced by
(5)
➢ Exercise/conditioning
➢ Anemia
➢ Anxiety
➢ Drugs
➢ Fever
99
Rhythm The normal pulse is a series of rhythmic beats at regular intervals
➢ Irregular beats are described as:
➢ Palpate the pulse for a full (---) min for accuracy if an arrhythmia is
suspected
irregular, dysrhythmic or arrhythmic
1
100
Respiration
Rate and depth of breathing noted by careful observation of movement of
the chest and abdomen in the quietly breathing patient
➢ Normal respiratory rate adults:
➢ Note: Respiratory rate in small children is --- than adults
12-16 breaths/min
higher
101
Respiration
Abnormal Breathing Patterns
(4)
Labored breathing
Rapid breathing
Irregular breathing patterns
May be signs of systemic problems, especially cardiopulmonary disease
102
A common finding in apprehensive patients is hyperventilation (rapid,
prolonged, deep breathing or sighing), which may result in
lowered carbon
dioxide levels and cause disturbing symptoms and signs
103
Pre-COVID-19 pandemic - --- is not usually recorded during
routine dental examinations
Temperature
104
Pre-COVID-19 pandemic - Temperature is not usually recorded during
routine dental examinations
➢ Determined when a patient has febrile signs or symptoms that may be
due to
an abscessed tooth or a mucosal or gingival lesion
105
A Normal oral temp. is ---°F (37°C) but may vary by as much as plus or
minus 1°F over 24 hours
98.6
106
Weight
Patient’s should be questioned about recent unintentional loss or gain of
weight
➢ Rapid weight loss may be a sign of:
*malignancy, diabetes, tuberculosis, neoplasm or other wasting
disease
107
➢ Rapid weight gain can be a sign of:
*heart failure, edema, hypothyroidism, or neoplasm
108
SKIPPED
General Appearance
A lot can be learned about a patient’s health from a purposeful but tactful
visual inspection
➢ Lead to awareness of abnormal/unusual features or medical conditions
that may exist and could influence your dental care
This survey is an assessment of the general appearance and inspection of
exposed body areas
➢ Each visually accessible area may demonstrate peculiarities that can
signal underlying disease
109
Changes in the skin and nails can be associated with systemic disease.
Examples:
➢ Cyanosis can indicate
➢ Yellowing or jaundice may be due to
➢ Pigmentation may be due to
➢ Petechiae or ecchymoses can be sign of
cardiac or pulmonary insufficiency
liver disease
hormonal abnormalities
blood dyscrasia or bleeding disorder
110
Alterations in fingernails usually seen in chronic disorder
➢ Clubbing
➢ White discoloration
➢ Yellowing
➢ Splinter hemorrhages
(cardiopulmonary insufficiency)
(cirrhosis)
(malignancy)
(infective endocarditis)
111
Dorsal hand surfaces are common for
actinic keratosis & basal cell carcinomas
112
A raised, darkly pigmented lesion w/ irregular borders could be a ---
melanoma
113
Shape and symmetry of face are abnormal in many syndromes and
conditions
Well-regarded examples:
➢ acromegaly
➢ Cushing’s syndrome
➢ Bell’s palsy
Coarse and enlarged features
Moon face
Unilateral paralysis
114
bells palsy
May be indicative of a
permanent or temporary paralysis
May limit intraoral access
115
Eyes can be indicators of --- and should be
inspected closely
Patients wearing glasses should be asked to remove them during
examination of head and neck
systemic disease
116
➢ Hyperthyroidism
* Lid retraction
117
➢ Hypercholesterolemia
* Xanthomas of the eyelids
118
➢ Liver Disease (**Problem metabolizing drugs)
* Yellowing of sclera
* Hepatitis, Alcoholics
119
➢ Allergy or Sicca syndrome
* Conjunctiva reddening
120
Ears
An earlobe crease ‘may’ be an indicator of
Malignant or premalignant lesions may be found in or around the ears
coronary artery disease
121
earlobe crease –non-specific for
heart disease
122
Head & Neck Examination
Examination of the head and neck may vary in its comprehensiveness but
should include
inspection and palpation of the soft tissues of the oral
cavity, maxillofacial region, and neck, as well as evaluation of cranial nerve
function
123
Neck Inspected for enlargement or asymmetry
➢ Normal, enlarged
(3)
*Soft, hard
*Mobile, fixed
*Non-tender, tender
124
inspected for enlargement or asymmetry
(5)
Infections, goiter, cysts,
Masses, vascular deformities
125
intraoral Examination
Should be performed in an organized way:
➢ Don’t go straight for the patient’s ---
➢ Following a logical identical sequence every time
(remember protocol on reading an FMS)
➢ Only evaluate --- structure at a time; if you multitask you are likely to --
➢ -- is extremely important
chief complaint
one, miss details
Palpation
126
Intraoral Examination
Requires
(5)
➢ Good lighting, constantly moving
➢ Dental mirror
➢ Gauze
➢ Periodontal probe
➢ Other circumstances: Endo Ice, explorer
127
Physical Examination
Must be routine
(2)
➢ do it the same way every time
➢ aka - like reviewing an FMS
128
Physical Examination
A recommended sequence (courtesy of Dr. Tiffany Tavares)
➢ Lower lip, upper lip
➢ R buccal mucosa and vestibule –“milk” parotid gland (extraoral)
➢ R retromolar trigone
➢ R mandibular arch (buccal and lingual –push the tongue away)
➢ L mandibular arch (buccal and lingual –push the tongue away)
➢ L retromolar trigone
➢ L buccal mucosa and vestibule - “milk” parotid gland (extraoral)
➢ L maxillary arch, vestibule, and tuberosity
➢ L hard palatal mucosa
➢ R hard palatal mucosa
➢ R maxillary arch, vestibule, and tuberosity
➢ Tongue dorsum –stick out, wipe off, lasso with a gauze
➢ R ventral tongue –pull to left with gauze and ALWAYS palpate; should be
able to see lingual tonsils
➢ R floor of mouth
➢ L ventral tongue - pull to right with gauze and ALWAYS palpate; should
be able to see lingual tonsils
➢ Remove gauze and look at anterior ventral tongue and caruncle
➢ Bimanual palpation of salivary glands and ”milk” sublingual glands
➢ Soft palate
➢ Oropharynx –depress tongue dorsum with mirror or tongue depressor
* Ask patient to take a deep breath through their mouth and say ”ah”
129
Stress & Anxiety Reduction
Open communication about ---
--- appointments (usually in the ---)
Pre-dental treatment sedation—
During dental treatment sedation (i.e., ---)
Profound ---
Good post-dental treatment --- control
Patient contacted the --- of the procedure
fears/concerns (rapport*)
Short, morning
1hr prior appt.*, Benzodiazepines (e.g., triazolam .25mg)
Nitrous Oxide
local anesthesia
pain
evening
130
Risk Assessment
Completion of patient evaluation
(3)
➢ Medical history
➢ Meds/drugs
➢ Clinical examination
131
SKIPPED
Do I have all the information I need?
(4)
➢ Do I need adjunctive tests and procedures?
➢ Is a medical consultation/referral warranted?
➢ Can the patient safely undergo the planned treatment?
➢ Are treatment modifications necessary?
132
Clinical Laboratory Tests
An important part of the evaluation of a patient’s ---
When laboratory test results are reported, they are accompanied by ----
If you’re ordering labs or reviewing labs with a patient, than more than
likely the patient has ---
health status
normal values for that particular laboratory
medical complexities
133
Clinical Laboratory Tests
Indications for laboratory testing in dentistry:
(4)
➢ Aid in detecting suspected disease (e.g., diabetes, infection, bleeding
disorders, malignancy)
➢ Screen high-risk patients for undetected disease (e.g., diabetes, AIDS,
chronic kidney disease)
➢ Establish normal baseline values before treatment (e.g., anticoagulant
status, white blood cells, platelets)
➢ Address medical-legal considerations (e.g., possible bleeding disorders,
hepatitis B infection)
134
Clinical Laboratory Tests Common laboratory testing in dentistry:
➢ CBC: Complete blood count with platelets & WBC differential
* RBC:
* WBC:
* Platelet Count:
4.2-5.9 million/mm3
4,000-10,000/mm3 h
150,000-400,000/mm3
135
Common laboratory testing in dentistry:
➢ Prothrombin time –International Normalized Ratio (PT-INR):
* Helps determine
* Measures (2)
* Normal =
* Higher INR means
bleeding risk
extrinsic and normal coagulation cascade pathways
1 (*INR= 2-3 if on Coumadin)*
higher bleeding risk
136
Common laboratory testing in dentistry:
➢ P.T.T.: Partial Thromboplastin Time (I.V. Heparin)
* --- Pathway
* Normal range is
* aPTT is used for
**Balance the risk of bleeding vs risk of ---
Intrinsic
25-38 seconds
Pradaxa (activatedPTT)
thrombosis
137
Current Physician(s)
Identify the patient’s physician
Why is the patient receiving medical care, diagnoses, and treatment
received
➢ Even for routine physical examinations, the patient should be asked
➢ The name, address, and phone number of the physician should be
recorded
whether any problems were discovered and the last date of the exam
138
Current Physician(s)
Patient without a physician, no recent routine check-up history? CAUTION
The response may provide insight into the priorities that a patient assigns
to health care
➢ The patient may be unaware of an underlying condition
➢ --- is very important in these patients
➢ Refer patient to have a check-up and general labs drawn prior to any
invasive dental treatment
ROS
139
Medical Consultation/Referral
On the basis of medical history, physical examination, and laboratory
screening, contact with the patient’s physician for consultation or referral
purposes may be warranted
Requests for information should be made in writing by letter or fax, if
possible; however, a phone call may be more expedient
Document --- in the patient’s chart!
A --- record is a legal record!
communications
written
140
Good practices
* Provide clinical context
* Patient-reported medical history
* Patient-reported medications
* Positive findings on review of systems where applicable
* Vital readings
* Dental treatment to be performed (stress, bleeding, drugs to be used pre, peri, and/or
post-operatively )
* Any other relevant intraoral or extraoral findings
* Avoid dental jargon
* Concisely express your concerns, but be specific about the input you need
* You MUST KNOW WHY you are asking that question
* Take ownership (even if partial) of the risk assessment
Remember that you are asking for a favor
When there is complex medical history or if patient seems to be a poor
historian
* Ask for last clinical note (helps provide more context on the patient’s
health status)
141
Take ownership (even if partial) of the risk assessment
* Sample questions:
(2)
➢What is the patient’s BP goal (range)?
➢ Do you have any concerns regarding the proposed dental treatment based on his current
cardiac status?
142
When there is complex medical history or if patient seems to be a poor
historian
* Ask for last clinical note (helps provide more context on the patient’s
health status)
➢ Please provide us with
a copy of the patient’s most recent clinical note
143
* Check for missing medical information and updated medication list
(2)
➢ Are there any other medical problems not listed here that we should be aware of?
➢ Please provide an updated medication list. OR Is the patient taking any other
medications not listed here?
144
Treatment Modifications
(2)
Systematic assessment of risk and identifying potential problems
Simple modifications in dental tx delivery can reduce risk to the patient
145
Simple modifications in dental tx delivery can reduce risk to the patient
➢ Risk is always increased when treating a
➢ Try to anticipate
medically complex patient
possible urgencies or emergencies and be prepared to
manage
146
Don’t start something you cannot finish
Don’t start a procedure if you cannot deal with the potential complications
(3)
➢ Know potential complications
➢ Apply to patient’s clinical context
➢ Plan around likelihood of most severe complication
147
ASA PS 1
(5)
▪ Healthy 20
year old
▪ Pt is able to walk up
one flight of stairs or 2
level city blocks without
distress
▪ Little or no anxiety
▪ Little or no risk during
treatment
A normal healthy
patient
148
ASA PS 2
▪ --- systemic disease
▪ Blocks/fight of stairs
▪ --- risk during treatment
▪ Who? (6)
Mild
▪ Pt has mild systemic disease
Pt walk one flight of stairs
or 2 level city blocks, but
has to stop after exercise
because of distress
Minimal
▪ ASA PS1 with extreme anxiety/fear
▪ ASA 1 w/ respiratory condition, allergies, phobic, pregnant
▪ Diet or hypoglycemic agent-controlled diabetic
▪ Well-controlled asthmatic
▪ Well-controlled epileptic
▪ Well-controlled hypertensive, not on medication
149
ASA PS 3
▪ --- Systemic disease
▪ Blocks/flight of stairs
▪ If dental care is needed,
▪ Who? (3)
▪ 30 days or more ago hx of:
(3)
Severe
▪ Severe systemic dz, limits activity but not incapacitated
Can walk up 1 flight of stairs or 2 level city blocks but has to stop on the way b/c of distress
stress reduction protocol and other tx modifications are indicated
▪ Well-controlled hypertensive on medication
▪ Well-controlled diabetic on insulin
▪ Slight COPD
➢ Myocardial infarction
➢ Cerebrovascular accident
➢ Congestive heart failure
150
asa 3
Patient’s disease has significant impact on
daily activity
151
ASA PS 4
▪ --- Systemic disease that is a ---
▪ Block/flight of stairs?
▪ Pt poses
▪ Elective dental care postponed until
▪ Emergency dental care may be
best in
Who? (6)
Severe, constant threat to life
▪ Severe systemic dz, limits activity and constant threat to life
Unable to walk up 1 flight of stairs
or 2 level city blocks. Distress is
present at rest
significant risk during treatment
ASA 3 class
a hospital with a consultation with the Pt’s physician team
▪ Hx unstable angina, MI, CVA in last 30-days
▪ Severe congestive heart failure
▪ Mod to severe COPD
▪ Uncontrolled hypertension
▪ Uncontrolled diabetes
▪ Uncontrolled epilepsy or seizure disorder
