pt evaluation and risk assessment Flashcards
longer life expectancy and its effect on practice
Dentistry and medicine today are different
➢ 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
effect of increased conditions, tx’s, and the complexity of them
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 combinations and permutations of dental treatments for our patients
what must dentists be knowledgeable of regarding new medical conditions?
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 what?
historic examples?
➢ Many chronic disorders or their treatments necessitate modification
of dental treatment
➢ Hepatitis –1982 -gloves
➢ AIDS –1990 - PPE
➢ COVID-19 –2019 –PPE and vaccines
how must clinicians practice relative to med complications?
Clincians must practice so that the benefit of dental treatment will outweigh the risk(s) of a medical complication occurring either during treatment or as a result of treatment.
(Pre-operative, Intra-operative, and Post-operative Considerations)
medical consults
we propose the dental tx to the MD to see if it is deemed the pt cna tolerate it
Paul Dudley White MD
ushered in the era of modern cardiology and pt evaluation
Organized Risk Assessment factors
(Dental Care)
- Bleeding
- Infection
- Drug Effects (adverse effects, timing, etc.)
- Ability to Tolerate Care (CV –Resp –Psych)
general pnemonic for risk assessment
start with P then go ABC’s to F
patient evaluation components
through assessment, inform pt of findings
Adjunctive Tests
& Procedures with pt evaluation
- Refer
- Imaging
- Histopathology
- Microbiology
- Labs
- Anesthesia
- Molecular biology
- Sequencing
patient evaluation
* Identify ALL?
* Review?
* Examine patient for?
* Review or gather?
* Obtain a? when to do this?
P- patient evaluation
* Identify ALL medications & drugs, taken or supposed to be taken
* Review medical history, discuss relevant issues with patient
* Examine patient for signs and symptoms of disease
* Review or gather recent laboratory tests or images
* Obtain a medical consult:
If patient has a poorly controlled or undiagnosed problem or If you’re uncertain about the patient’s health
A of pt evaluation
determine use of this or contraindications
- Allergies
- Is the patient allergic to drugs or substances that may be used or prescribed?
Anxiety
- Will the patient need or benefit from a sedative or anxiolytic?
- Antibiotics
- Will the patient need antibiotics?
- Is the patient taking an antibiotic?
- Analgesics
- Is the patient taking aspirin or NSAIDs that can increase bleeding?
- Will analgesics be needed post-treatment?
- Anesthesia
- Are there concerns using a local with or without epinephrine?
B of pt evaluation
breathing, bleeding, BP
- Bleeding
- Is abnormal hemostasis possible?
- Breathing
- Does the patient have difficulty breathing or is the patient’s breathing fast or slow?
- Blood pressure
- Is the patient’s BP well controlled or is it possible it may increase/decrease during dental treatment
C of pt evaluation
- Chair position
- Can the patient tolerate a supine or (horizontal) position?
- Is the patient going to have a problem being raised quickly, after treatment?
D of pt evaluation
Drugs
* Any drug interactions, adverse effects, or allergies associated with drugs being currently being taken or drugs that the dentist may prescribe or use?
Devices
* Does the patient have prosthetic or therapeutic device that may require tailored management?
* e.g., prosthetic heart valve, prosthetic joint, stent, pacemaker, defibrillator
E of pt evaluation
Equipment:
* Any potential issues with the use of dental equipment?
* e.g.: X-ray machine, electrocautery, oxygen supply, ultrasonic cleaner, apex locator.
Emergencies:
* Are there medical emergencies that can be anticipated or prevented by modifying care?
* e.g: MI, stroke, asthma, uncontrollable bleeding
F of pt evaluation
post-op instructions>?
contact pt?
- 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
simple rule with LA (Dr.A doesnt follow this)
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
what Must be taken for every patient who is to receive dental treatment?
medical Hx
Two basic techniques used to obtain a medical history
➢ Interview the patient
➢ Ask patient questions, record the patient’s verbal responses (axiUM at UMKC)
➢ A printed questionnaire the patient fills out
how are medical hx questions designed
Questions are designed to identify or hint to medical issues that may affect dental teatment
med hx vs ROS
- Medical History is different from Review of Systems (ROS)
- MED history = patient has already been diagnosed or,
patient presents with information needing a diagnosis - The point of a ROS is to screen for potential new diseases
- Screening through signs and symptoms with a systems-based approach
- Findings may be consistent with a particular systemic disease, but you will not diagnose
- Physician’s role →further examine, request labs, diagnose
- Referral consultation letter →express findings, concerns and a basis for ROS
ROS; 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?
➢ Ability to perform common daily tasks can be expressed in metabolic equivalent levels (METs)
➢ Higher MET = better physical condition
MET
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
MET scale
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/F?
true
determining if allergies mentioned are really allergies?
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?”
True allergy rxns
➢ Anaphylaxis
➢ Itching
➢ Urticaria (hives)
➢ Rash
➢ Swelling
➢ Wheezing
➢ Angioedema
➢ Rhinorrhea
➢ Tearing eye
Intolerance or an adverse side effect (not allergies), still serious?
oNausea
oVomiting
oDiarrhea
oHeart palpitations
oFainting
STILL SERIOUS
Sexually Transmitted Diseases
Syphilis, gonorrhea, HIV infection can have manifestations in the oral
cavity
➢ Dentist may be the first to identify these conditions
➢ Some STD’s including HIV infection, hepatitis B and C, and syphllis, can be transmitted to the dentist through direct contact with oral lesions or infected blood
➢ Chlamydial genitalia infection (Chlamydia trachomatis) is the single most common STD in the US.
Exogenous Steroids use and implication
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.
Previous Operations & Hospitalizations
why is this good to know?
History of hospitalizations can provide clues to past illnesses that may have current significance
➢ An INDIRECT aspect of your evaluation but an effective way to identify a current condition
History of hospitalizations include diagnosis, tx, and
complications
➢ Operations; reason for procedures must always be asked; any emergencies; post-op bleeding; infection; drug allergy should be ascertained
Pregnancy
➢ Caution is warranted with:
Good oral hygiene?
the safest time to provide dental treatment?
Radiography?
Women who are or might be pregnant may need special consideration in dental management
➢ Caution is warranted with:
*radiography
*drug administration
*timing of dental treatment
Good oral hygiene is important during pregnancy
2nd trimester is the safest to provide dental treatment
Radiography for urgent care only
Substance Use, Misuse and Abuse
Pt’s with a hx of IV drug use increased risk for?
Rx’s?
contraindicated with meth/coke?
trust?
Pt’s with a hx of IV drug use increased risk for infectious diseases like: Hepatitis B, C, HIV/AIDS, and infective endocarditis
Narcotic and sedative meds should be Rx’d with great caution or not at all
➢ Risk of triggering a relapse
Vasoconstrictors should be avoided for cocaine and methamphetamine users
➢ These agents may precipitate arrhythmias, severe hypertension, MI, and Stroke
This portion of the patient interview →PROFESSIONAL TRUST
Alcohol consumption
risk for?
may lead to?
ask what?
- Risk factor for many cancers and other diseases (CV, bleeding, hepatic)
- May lead to liver cirrhosis, many complications
- Ask how many standard drinks week
standard measurements of alc drinks
pt may have different idea
Tobacco
risk of?
ask what?
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)
figures to determine
➢ Cigarettes:
➢ Smokeless tobacco:
➢ Hookah:
➢ E-cigarettes:
➢ Cigarettes: packs/day ( 1 pack = 20 cigarettes)
➢ Smokeless tobacco: cans/week
➢ Hookah: hours/week
➢ E-cigarettes: cartridges/week
Social Parameters in pt eval
- Occupation –looking for environmental/occupation risk
- Marital status - social support
- Children
Family History
Gives insight to potential diseases with heritability Watch out for signs and symptoms
* Hypertension
* Diabetes
* Autoimmune disease
* Cancer
* Other hereditary diseases and syndromes
family hx questions?
- Do any diseases run in your family?
- Are your parents and siblings alive and well?
- What did your (mother/father/sibling pass of?)
medications
Checking medications first is a good way to initiate a the medical history
➢ Compare with their reported past medical history
➢ Speeds up the intake process, more focused on what to look for as well as on ROS
* 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.)
what should be listed with medications, what to do with this info?
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.
what do pts typically fail to list with medications?
how to obtain this?
➢ Patients usually do not list OTC drugs or herbal medicines
➢ Complete list of medications may need to be sought from the patient’s physician
components of the physical exam
Head and neck examination:
Skin, Eyes & Nose, Ears, Cranial nerves, Neck examination
Intra-oral examination
Vital signs
General appearance
Skin
Fingers
Nails
vital signs
➢ In the dental setting, typically only what are measured?
➢ by observation?
➢ Temperature?
➢ Height and weight determined by?
Blood pressure, pulse, respiratory rate, temperature, height, weight
➢ In the dental setting, typically only BP and pulse are measured directly
➢ Respiratory rate is by observation (12-16 r/m)
➢ Temperature is measured when infection or systemic
involvement is suspected
- due to COVID pandemic, currently a part of every patient
encounter
➢ Height and weight determined by asking the patient
Establishing baseline with vital signs
➢ Can compare if medical emergency occurs during treatment
➢ Screening for problems: poor control, progression,
undiagnosed
vital signs abnormality detection
Purpose is for detection of abnormality and not diagnosis
➢ Diagnosis is responsibility of the physician
➢ Refer if finding is significantly abnormal
Blood Pressure: Why is it important to check?
Screening: you may be the first to detect
Monitoring-compliance/control/progression
Risk assessment –potential serious complications
Treatment modifications
Blood pressure (BP) is variable so multiple readings are really the most appropriate
Blood Pressure determined by?
➢ Cuff should encompass how much?
➢ Center of cuff over?
Determined by indirect measurement in the upper extremities with a BP
cuff and stethoscope
➢ Cuff should encompass 80% of the circumference of the arm.
➢ Center of cuff over brachial artery
➢ Cuff too small?
➢ Cuff too small →falsely elevated values*
➢ Cuff too large?
➢ Cuff too large →falsely low values*
‘White Coat HTN’
elevate BP by 30 mm Hg*
Pregnant pts w/ ≥ 10 mm Hg increase in systolic BP from baseline?
➢ Risk of eclampsia →immediate referral
BP arm positions
Arm position matters
➢ Horizontal at heart level (mid-sternum)
Arm below heart level Over-Estimates systolic and diastolic pressures
Similar to Cuff too small →falsely elevated values*
Arm above heart level under-estimates systolic and diastolic pressures
Similar to Cuff too large →falsely low values
Auscultation method of BP
Auscultation method of BP measurement is universally accepted
➢ BP cuff should be inflated until radial pulse disappears; then add additional 20-30 mm Hg
➢ Release valve slowly turned. Fall rate of needle ~2-3 mm Hg per second
➢ First audible ‘Beating sound’ (Korotkoff sounds)
*This pressure point = Systolic pressure
As needle continues to fall, beat will become louder and then diminish
until marked diminution in intensity occurs
➢ Weakened beats heard for a few moments
➢ Reliable index of diastolic pressure = point when sound disappears, completely
how to ensure accurate bp measurements
caffeine, exercise?
bladder?
Sit quietly for at least?
Support?
clothes?
Take how many readings
Pt avoid caffeine, exercise, (nicotine*)
Pt empty bladder prior to BP
Sit quietly for at least 5 minutes
Support limb to measure BP
Don’t take BP over clothes
Take 2-3 readings (on 2-3 occasions)
BP scale
WNL
elevated
stage 1
stage 2
htn crisis
cutoff bp at school
180/110mmHg
hypertensive urgency
➢ 180/120 is classified as a Hypertensive Urgency by the AHA based on 2017 guidelines
➢ Urgent referral →see doctor ASAP
➢ If patient is symptomatic →Emergency Room
how to take a Pulse
Standard for assessing pulse rate
➢ Palpate carotid artery at side of trachea →MORE RELIABLE
OR
➢ Palpate radial artery on the thumb side of wrist
Do not use the thumb for
pulse detection
pulse ranges
Norma:l 60-100 bpm
Tachycardia: >100 bpm
Bradycardia: <60 bpm
Abnormal pulse rate may be a sign of?
Abnormal pulse rate may be a sign of CV disorder
Pulse may be influenced by
➢ Exercise/conditioning
➢ Anemia
➢ Anxiety
➢ Drugs
➢ Fever
Rhythm of the pulse
The normal pulse is a series of rhythmic beats at regular intervals
➢ Irregular beats are described as: irregular, dysrhythmic or arrhythmic
➢ Palpate the pulse for a full (1) min for accuracy if an arrhythmia is
suspected
Respiration rate
normal value?
kids?
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: 12-16 breaths/min
➢ Note: Respiratory rate in small children is higher than adults
Abnormal Breathing Patterns
Labored breathing
Rapid breathing
Irregular breathing patterns
May be signs of systemic problems, especially cardiopulmonary disease
A common respiratory finding in apprehensive patients is:
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
Temperature
when taken?
WNL?
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
A Normal oral temp. is 98.6°F (37°C) but may vary by as much as plus or minus 1°F over 24 hours
Weight
why ask?
➢ Rapid weight loss may be a sign of:
➢ Rapid weight gain can be a sign of:
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
➢ Rapid weight gain can be a sign of:
*heart failure, edema, hypothyroidism, or neoplasm
Physical Examination: 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
Skin and Nails
Changes in the skin and nails can be associated with?
Examples:
➢ Cyanosis can indicate?
➢ Yellowing or jaundice?
➢ Pigmentation may be due to?
➢ Petechiae or ecchymoses can be sign of?
Changes in the skin and nails can be associated with systemic disease.
Examples:
➢ Cyanosis can indicate cardiac or pulmonary insufficiency
➢ Yellowing or jaundice may be due to liver disease
➢ Pigmentation may be due to hormonal abnormalities
➢ Petechiae or ecchymoses can be sign of blood dyscrasia or bleeding
disorder
alterations of fingernails
➢ Clubbing?
➢ White discoloration?
➢ Yellowing?
➢ Splinter hemorrhages?
Alterations in fingernails usually seen in chronic disorder
➢ Clubbing (cardiopulmonary insufficiency)
➢ White discoloration (cirrhosis)
➢ Yellowing (malignancy)
➢ Splinter hemorrhages (infective endocarditis)
Dorsal hand surfaces are common for:
Dorsal hand surfaces are common for actinic keratosis & basal cell carcinomas
Face
Shape and symmetry of face
Well-regarded examples:
Shape and symmetry of face are abnormal in many syndromes and
conditions
Well-regarded examples:
➢ Coarse and enlarged features of acromegaly
➢ Moon face in Cushing’s syndrome
➢ Unilateral paralysis of Bell’s palsy
Eyes
Eyes can be indicators of systemic disease and should be
inspected closely
Patients wearing glasses should be asked to remove them during examination of head and neck
Examples of indicators of systemic disease seen at eyes
➢ Hyperthyroidism
➢ Hypercholesterolemia
➢ Liver Disease
➢ Allergy or Sicca syndrome
➢ Hyperthyroidism
* exopthalamy
➢ Hypercholesterolemia
* Xanthomas of the eyelids
➢ Liver Disease (**Problem metabolizing drugs)
* Yellowing of sclera
* Hepatitis, Alcoholics
➢ Allergy or Sicca syndrome
* Conjunctiva reddening
Ears
An earlobe crease ‘may’ be an indicator of?
Malignant or premalignant lesions?
An earlobe crease ‘may’ be an indicator of coronary artery disease
Malignant or premalignant lesions may be found in or around the ears
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
Neck
Inspected for?
Inspected for enlargement or asymmetry
➢ Normal, enlarged
*Soft, hard
*Mobile, fixed
*Non-tender, tender
Infections, goiter, cysts, Masses, vascular deformities
LN’s of the neck
Intraoral Examination
Should be performed in an?
➢ Don’t go straight for?
➢ sequence?
➢ Only evaluate what at a time?
➢ Palpation importance?
Should be performed in an organized way:
➢ Don’t go straight for the patient’s chief complaint
➢ Following a logical identical sequence every time
(remember protocol on reading an FMS)
➢ Only evaluate one structure at a time; if you multitask you are likely to miss details
➢ Palpation is extremely important
instruments for intraoral exam
➢ Good lighting, constantly moving
➢ Dental mirror
➢ Gauze
➢ Periodontal probe
➢ Other circumstances: Endo Ice, explorer
The Anxious Dental Patient cycle
Stress & Anxiety Reduction
Open communication about?
appt length/time of day?
Pre-dental treatment sedation?
During dental treatment sedation?
local anesthesia?
post-dental treatment pain control?
Patient contacted when?
Open communication about fears/concerns (rapport)
Short appointments (usually in the morning)
Pre-dental treatment sedation—1hr prior appt.
➢ Benzodiazepines (e.g., triazolam .25mg)
During dental treatment sedation (i.e., Nitrous Oxide)
Profound local anesthesia
Good post-dental treatment pain control
Patient contacted the evening of the procedure
Risk Assessment:
completion of?
what other info could I need?
Completion of patient evaluation
➢ Medical history
➢ Meds/drugs
➢ Clinical examination
Do I have all the information I need?
➢ 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?
Clinical Laboratory Tests
An important part of the evaluation of a patient’s health status
When laboratory test results are reported, they are accompanied by normal values for that particular laboratory
If you’re ordering labs or reviewing labs with a patient, than more than likely the patient has medical complexities
Indications for laboratory testing in dentistry:
➢ Aid in detecting?
➢ Screen?
➢ Establish?
➢ Address what considerations?
➢ 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)
Common laboratory testing in dentistry:
CBC
PT/PTT
➢ CBC
➢ CBC: Complete blood count with platelets & WBC differential
* RBC: 4.2-5.9 million/mm3
* WBC: 4,000-10,000/mm3 h
* Platelet Count: 150,000-400,000/mm3
➢ Prothrombin time –International Normalized Ratio (PT-INR):
* Helps determine?
* Measures?
* Normal value? (if on Coumadin?)*
* Higher INR means?
➢ Prothrombin time –International Normalized Ratio (PT-INR):
* Helps determine bleeding risk
* Measures extrinsic and normal coagulation cascade pathways
* Normal = 1 (INR= 2-3 if on Coumadin)
* Higher INR means higher bleeding risk
➢ P.T.T.: Partial Thromboplastin Time (I.V. Heparin)
*measures?
* Normal range?
* aPTT is used for?
**Balance the risk of?
➢ P.T.T.: Partial Thromboplastin Time (I.V. Heparin)
* Intrinsic Pathway
* Normal range is 25-38 seconds
* aPTT is used for Pradaxa (activatedPTT)
**Balance the risk of bleeding vs risk of thrombosis
initial steps for med consult
Identify the patient’s?
info to obtain?
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?
➢ Even for routine physical examinations, the patient should be asked whether any problems were discovered and the last date of the exam
➢ what should be recorded regarding the physician
➢ The name, address, and phone number of the physician should be
recorded
Patient without a physician, no recent routine check-up history?
USE CAUTION
Patient without a physician, no recent routine check-up history:
The response may provide insight into?
➢ The patient may be unaware of?
➢ ROS importance?
➢ Refer patient to have?
The response may provide insight into the priorities that a patient assigns to health care
➢ The patient may be unaware of an underlying condition
➢ ROS is very important in these patients
➢ Refer patient to have a check-up and general labs drawn prior to any invasive dental treatment
consulting physician for pt info
how should this be done?
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 communications in the patient’s chart!
A written record is a legal record!
med consult: providing clinical context
* medical history?
*medications?
*review of systems?
* Vitals?
* Dental treatment?
* Any other?
- 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
dental jargon in consults
no
expressing concerns in consults
- Concisely express your concerns, but be specific about the input you need
- You MUST KNOW WHY you are asking that question
taking ownership of risk assessment in consult
Take ownership (even if partial) of the risk assessment
* Sample questions:
➢What is the patient’s BP goal (range)?
➢ Do you have any concerns regarding the proposed dental treatment based on his current
cardiac status?
* Remember that you are asking for a favor
what to do when there is complex medical history or if patient seems to be a poor
historian
ask for clinical note
Checking for missing medical information and updated medication list with med consults
compare and contrast with what pt told you
➢ 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?
model med consult
Treatment Modifications
Systematic assessment of risk and identifying potential problems
Simple modifications in dental tx delivery can reduce risk to the patient
➢ Risk is always increased when treating a medically complex patient
➢ Try to anticipate possible urgencies or emergencies and be prepared to manage
Treatment Modifications
Systematic assessment of risk and identifying potential problems
Simple modifications in dental tx delivery can reduce risk to the patient
➢ Risk is always increased when treating a medically complex patient
➢ Try to anticipate possible urgencies or emergencies and be prepared to manage
Prudent Rules for Clinical Practice
Don’t start something you?
Don’t start a procedure if you cannot deal with?
Don’t start something you cannot finish
Don’t start a procedure if you cannot deal with the potential complications
➢ Know potential complications
➢ Apply to patient’s clinical context
➢ Plan around likelihood of most severe complication
ASA PS 1
▪ 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
ASA PS 2
▪ Pt has?
▪ ASA PS1 with?
▪ Pt walk one flight of stairs
or 2 level city blocks?
▪ risk during treatment?
▪ ASA 1 w/?
▪ diabetic?
▪ asthmatic?
▪ epileptic?
▪ hypertensive?
▪ Pt has mild systemic
disease
▪ ASA PS1 with extreme anxiety/fear
▪ Pt walk one flight of stairs
or 2 level city blocks, but has to stop after exercise because of distress
▪ Minimal risk during
treatment
▪ 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
ASA PS 3
▪ systemic dx?
▪ Can walk up 1 flight of stairs or 2 level city blocks?
▪ If dental care is needed, what is indicated?
▪ hypertensive?
▪ diabetic?
▪ COPD?
▪ 30 days or more ago hxof?
▪ 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
▪ If dental care is needed, stress reduction protocol and other tx modifications are indicated
▪ Well-controlled hypertensive on medication
▪ Well-controlled diabetic on insulin
▪ Slight COPD
▪ 30 days or more ago hxof:
➢ Myocardial infarction
➢ Cerebrovascular accident
➢ Congestive heart failure
ASA PS 4
▪ systemic dx?
walk up 1 flight of stairs or 2 level city blocks?
▪ risk during treatment?
▪ Elective dental care postponed?
▪ Emergency dental care?
▪ Hx of?
▪ congestive heart failure?
▪ COPD?
▪hypertension?
▪ diabetes?
▪epilepsy or seizure disorder?
▪ 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
▪ Pt poses significant risk during treatment
▪ Elective dental carepostponed until ASA 3 class
▪ Emergency dental care may be best in 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
