SENIOR ORAL MEDICINESENIOR ORAL MEDICINE

Chapter 1: Physical Evaluation Chapter 1: Physical Evaluation & Risk Assessment& Risk AssessmentSusan Settle, D.D.S.Susan Settle, D.D.S.August 26, 2010August 26, 2010

Interrelationships Of Medicine And Dentistry

Physical Evaluation & Risk AssessmentPractice Goals

Deliver The Best Care Possible For The Patient

Be Aware What Impact The Systemic Status And Medications May Have On Delivery Of Treatment

To Feel Comfortable Treating A Variety Of Patients

Value Of The Health History Questionnaire & Medical History

It Is The Cornerstone Of Patient Evaluation & Risk Assessment

Identifies Systemic DiseaseIdentifies MedicationsEstablishes RapportMedicolegal Protection For The

Practitioner

Risk Assessment Involves Identification Of:

Nature, Severity, & Stability Of The Patient’s Medical Condition

Functional Capacity Of The Patient Emotional State Of The Patient Type & Magnitude Of The Dental

Procedure

American Society Of Anesthesiologists

Classification Of Patients

Based On Medical Assessment Of Patient

ASA Classification GroupsASA I

Normal, Healthy Patient

ASA IIMild DiseaseDoes Not Interfere With Daily ActivitiesMay Need Some Alteration Of Dental

TreatmentExamples: Mild HTN Or COPD,Type II

Diabetes, Allergy, Well-Controlled Epilepsy Or Asthma

ASA Classification Groups

ASA IIIModerate To Severe Systemic DiseaseMay Alter Daily ActivitiesGenerally Requires Alteration Of Dental

TreatmentMedicationsType I Diabetes, Moderate To Severe HTN,

Angina, CHF, AIDS, COPD, Hemophilia, MI In Last 6 Months

ASA Classification GroupsASA IV

Severe Systemic DiseaseLife-Threatening ConditionsRequires Alteration Of Dental

ManagementESRD, Liver Failure, Advanced

AIDS

ASA Physical Status P1 A normal healthy patient P2 A patient with mild systemic disease P3 A patient with severe systemic disease P4 A patient with severe systemic disease that is

a constant threat to life   P5 A moribund patient who is not expected to

survive without the operation   P6 A declared brain-dead patient whose organs

are being removed for donor purposes

Patients Requiring Further Evaluation By The Anesthesiologist For General Surgery

Morbid Obesity (BMI>38)MI Within 6 MonthsAngioplasty Within 3 MonthsHistory Of Heart TransplantHistory Of Unstable Angina

Patients Requiring Further Evaluation By The Anesthesiologist For General Surgery

History Of Carotid Surgery Within 6 Months

History Of Steroid-Dependent Asthma Or COPD Particularly With URI In Last 4 Weeks (Upper Respiratory Infection)

Seizure Within 3 Months While Taking Anticonvulsants

Patients Requiring Further Evaluation By The Anesthesiologist For General Surgery

History Of Allergy To Local AnestheticsHistory Of Dialysis Or Renal TransplantHistory Of CVA/TIA Within 6 Months

(Cerebrovascular Accident/Transient Ischemic Attack)

Systolic BP>200 And/Or Diastolic BP>100History Of Cirrhosis (Need Recent CBC, INR,

LFT)

Risk Assessment

ABCs Of Risk Assessment Are More Helpful Than The ASA Physical Classification System

ASA System Does Not Provide Information About Modification Of Treatment

Risk AssessmentA:

AntibioticsAnesthesiaAnxietyAllergy

B:Bleeding

C:Chair Position

D:DrugsDevices

E:EquipmentEmergencies

Medical History Overview

Cardiovascular DiseasesHeart Failure (CHF)

A Clinical Syndrome ComplexNo Routine Treatment If Not ControlledConsider Chair PositionCardiac Glycosides (Digoxin, Lanoxin)

+ Vasoconstrictors Arrhythmias (Avoid Vasoconstrictors If Possible)

Medical History Overview

Cardiovascular Diseases (Cont.)

Myocardial InfarctionNo Routine Treatment If In Last 1-6 Months (Refer To Your Text!)Increased Risk Of Reinfarction, CHF & Arrhythmias

Medical History Overview

Angina PectorisStableUnstable: Chest Pain At Rest

Increased Incidence Of Arrhythmias, MI’s, Sudden Death

Elective Treatment Contraindicated

Cardiovascular Diseases (Cont.)

Medical History Overview

HypertensionNon-Selective Beta-Blockers

(Propranolol, Inderal) +Vasoconstrictors

Possible Hypertensive Crisis

Cardiovascular Diseases (Cont.)

Medical History Overview

MurmurFunctionalOrganicRegurgitation Associated With MVP

Diagnosed By EchocardiogramNo Recommendation For

Endocarditis Prophylaxis From AHA

Cardiovascular Diseases (Cont.)

Medical History Overview

Rheumatic Heart Disease From Rheumatic Fever Following A Beta-Hemolytic Streptococcal InfectionValve Damage?No Recommendation For

Endocarditis Prophylaxis

Cardiovascular Diseases (Cont.)

Medical History Overview

Congenital Heart DiseaseProsthetic Heart ValvesArrhythmias: Frequently Related To

Heart Failure Or Ischemic Disease

Cardiovascular Diseases (Cont.)

Medical History Overview

Cardiac SurgeryCABG (Coronary Artery Bypass Graft)

Transplant: Immunosuppression Considerations

Cardiovascular Diseases (Cont.)

Medical History Overview

Stroke Or CVA: Anticoagulation Possibilities

Aneurysm: If Repaired, No Prophylaxis Required After 6 Months

Cardiovascular Diseases (Cont.)

Medical History Overview

Hematologic DisordersTransfusion: Why Was It Done? RisksAnemia Leukemia“Bleeds Longer Than Normal”

Genetic (Hemophilias)Acquired (Pharmacotherapy)

Medical History Overview

Neural/Sensory DisordersHeadache, Dizziness, SyncopeGlaucoma: Avoid Anticholinergic Drugs

If Patient Has Closed-Angle Glaucoma (Banthine, Pro-Banthine)

Given To “Dry Up” SalivaEpilepsy, Seizures, ConvulsionsPsychiatric Treatment

Medical History Overview

GI DiseasesPeptic Ulcer Disease

(PUD)Inflammatory Bowel

Disease (Crohn’s, Ulcerative Colitis - IBD)

Irritable Bowel Syndrome (IBS)

Hepatitis, Cirrhosis

Medical History Overview

Respiratory DiseasesAllergic HistoryCOPD-Chronic Obstructive Pulmonary

Disease (Emphysema, Chronic Bronchitis)

AsthmaTuberculosisSleep Apnea/Snoring

Medical History Overview

Musculoskeletal, Mucocutaneous, DermalProsthetic JointsArthritis (Osteo & Rheumatoid)

Medical History Overview

Autoimmune DisordersRheumatoid ArthritisSLE (Systemic Lupus

Erythematosus)Sjögren’s Syndrome

Medical History Overview

SclerodermaRAS (Recurrent Aphthous

Stomatitis) Or “Major” Aphthous

Autoimmune Disorders

Medical History OverviewEndocrine Diseases

DiabetesThyroid (Hypo, Hyper)

Urinary TractKidney DiseaseBladder Disease

Medical History Overview

Sexually-Transmitted DiseasesGonorrheaSyphilisHIV PositiveAIDS

Medical History Overview

Social HistoryTobaccoAlcoholRecreational Drugs

Medical History Overview

Cancer History Or TreatmentChemotherapyRadiation TherapySurgery

Medical History Overview

Operations/Hospitalizations & SequelaeAnesthesia Complications

Medical History Overview

MedicationsUse Appropriate References When

Looking Up SomethingSteroids, Anticoagulants,

ImmunosuppressivesAllergies, Adverse ReactionsStress Importance Of OTC (Over The

Counter) Drugs

Medical History Overview

Dental History Vital Signs: Initial Exam, Recalls,

Whenever IndicatedPulse

Rate & Rhythm (60-100 bpm)

BP: S <120; D <80Respiration (12-16 bpm)

Medical History Overview

General Physical AssessmentGait, Speech, Skin, Nails,

Eyes, Nose, Ears, Neck

Medical History Overview

Laboratory Tests (Indicated?)Hematocrit, HemoglobinPlatelet Count, PT (INR)Fasting Blood GlucoseBiopsyCulture & SensitivityWho Orders The Tests?

Communication With PhysicianHIPAA Forms Must Be Filled

Out By Patient At Physician’s Office

HIPAA Forms Must Be Filled Out By Patient At Dentist’s Office

Communication With PhysicianPhone & “Sidewalk”

Consults Should Be Documented In Progress Notes

Formal Documentation Preferred

And Now For Some Relatively New Stuff:

2007 AHA Guidelines for Endocarditis Prophylaxis

History Of Bisphosphonate Use2009 American Association of

Orthopaedic Surgeons Information Statement Regarding Prosthetic Joint Prophylaxis

Risk Is Always Increased When You Treat A Medically Compromised Patient

Your Goal Is To Reduce The Risk As Much As Possible