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

2. Interrelationships Of Medicine And Dentistry Physical Evaluation & Risk Assessment  Practice 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

3. Value Of The Health History Questionnaire & Medical History  It Is The Cornerstone Of Patient Evaluation & Risk Assessment  Identifies Systemic Disease  Identifies Medications  Establishes Rapport  Medicolegal Protection For The Practitioner

4. Risk Assessment Involves Identification Of: vNature, Severity, & Stability Of The Patient’s Medical Condition vFunctional Capacity Of The Patient vEmotional State Of The Patient vType & Magnitude Of The Dental Procedure

5. American Society Of Anesthesiologists Classification Of Patients Based On Medical Assessment Of Patient

6. ASA Classification Groups  ASA I  Normal, Healthy Patient  ASA II  Mild Disease  Does Not Interfere With Daily Activities  May Need Some Alteration Of Dental Treatment  Examples: Mild HTN Or COPD,Type II Diabetes, Allergy, Well-Controlled Epilepsy Or Asthma

7. ASA Classification Groups  ASA III  Moderate To Severe Systemic Disease  May Alter Daily Activities  Generally Requires Alteration Of Dental Treatment  Medications  Type I Diabetes, Moderate To Severe HTN, Angina, CHF, AIDS, COPD, Hemophilia, MI In Last 6 Months

8. ASA Classification Groups  ASA IV  Severe Systemic Disease  Life-Threatening Conditions  Requires Alteration Of Dental Management  ESRD, Liver Failure, Advanced AIDS

9. ASA Physical Status  P1A normal healthy patient  P2A patient with mild systemic disease  P3A patient with severe systemic disease  P4A patient with severe systemic disease that is a constant threat to life  P5A moribund patient who is not expected to survive without the operation  P6A declared brain-dead patient whose organs are being removed for donor purposes

10. Patients Requiring Further Evaluation By The Anesthesiologist For General Surgery  Morbid Obesity (BMI>38)  MI Within 6 Months  Angioplasty Within 3 Months  History Of Heart Transplant  History Of Unstable Angina

11. 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

12. Patients Requiring Further Evaluation By The Anesthesiologist For General Surgery  History Of Allergy To Local Anesthetics  History Of Dialysis Or Renal Transplant  History Of CVA/TIA Within 6 Months  (Cerebrovascular Accident/Transient Ischemic Attack)  Systolic BP>200 And/Or Diastolic BP>100  History Of Cirrhosis (Need Recent CBC, INR, LFT)

13. 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

14. Risk Assessment  A:  Antibiotics  Anesthesia  Anxiety  Allergy  B:  Bleeding  C:  Chair Position  D:  Drugs  Devices  E:  Equipment  Emergencies

15. Medical History Overview  Cardiovascular Diseases  Heart Failure (CHF)  A Clinical Syndrome Complex  No Routine Treatment If Not Controlled  Consider Chair Position  Cardiac Glycosides (Digoxin, Lanoxin) + Vasoconstrictors  Arrhythmias (Avoid Vasoconstrictors If Possible)

16. Medical History Overview  Cardiovascular Diseases (Cont.)  Myocardial Infarction  No Routine Treatment If In Last 1-6 Months (Refer To Your Text!)  Increased Risk Of Reinfarction, CHF & Arrhythmias

17. Medical History Overview  Angina Pectoris  Stable  Unstable: Chest Pain At Rest  Increased Incidence Of Arrhythmias, MI’s, Sudden Death  Elective Treatment Contraindicated  Cardiovascular Diseases (Cont.)

18. Medical History Overview  Hypertension  Non-Selective Beta-Blockers (Propranolol, Inderal) +Vasoconstrictors  Possible Hypertensive Crisis  Cardiovascular Diseases (Cont.)

19. Medical History Overview  Murmur  Functional  Organic  Regurgitation Associated With MVP  Diagnosed By Echocardiogram  No Recommendation For Endocarditis Prophylaxis From AHA  Cardiovascular Diseases (Cont.)

20. Medical History Overview  Rheumatic Heart Disease From Rheumatic Fever Following A Beta-Hemolytic Streptococcal Infection  Valve Damage?  No Recommendation For Endocarditis Prophylaxis  Cardiovascular Diseases (Cont.)

21. Medical History Overview  Congenital Heart Disease  Prosthetic Heart Valves  Arrhythmias: Frequently Related To Heart Failure Or Ischemic Disease  Cardiovascular Diseases (Cont.)

22. Medical History Overview  Cardiac Surgery  CABG (Coronary Artery Bypass Graft)  Transplant: Immunosuppression Considerations  Cardiovascular Diseases (Cont.)

23. Medical History Overview  Stroke Or CVA: Anticoagulation Possibilities  Aneurysm: If Repaired, No Prophylaxis Required After 6 Months  Cardiovascular Diseases (Cont.)

24. Medical History Overview  Hematologic Disorders  Transfusion: Why Was It Done? Risks  Anemia  Leukemia  “Bleeds Longer Than Normal”  Genetic (Hemophilias)  Acquired (Pharmacotherapy)

25. Medical History Overview  Neural/Sensory Disorders  Headache, Dizziness, Syncope  Glaucoma: Avoid Anticholinergic Drugs If Patient Has Closed-Angle Glaucoma (Banthine, Pro-Banthine) Given To “Dry Up” Saliva  Epilepsy, Seizures, Convulsions  Psychiatric Treatment

26. Medical History Overview  GI Diseases  Peptic Ulcer Disease (PUD)  Inflammatory Bowel Disease (Crohn’s, Ulcerative Colitis - IBD)  Irritable Bowel Syndrome (IBS)  Hepatitis, Cirrhosis

27. Medical History Overview  Respiratory Diseases  Allergic History  COPD-Chronic Obstructive Pulmonary Disease (Emphysema, Chronic Bronchitis)  Asthma  Tuberculosis  Sleep Apnea/Snoring

28. Medical History Overview  Musculoskeletal, Mucocutaneous, Dermal  Prosthetic Joints  Arthritis (Osteo & Rheumatoid)

29. Medical History Overview  Autoimmune Disorders  Rheumatoid Arthritis  SLE (Systemic Lupus Erythematosus)  Sjögren’s Syndrome

30. Medical History Overview  Scleroderma  RAS (Recurrent Aphthous Stomatitis) Or “Major” Aphthous  Autoimmune Disorders

31. Medical History Overview  Endocrine Diseases  Diabetes  Thyroid (Hypo, Hyper)  Urinary Tract  Kidney Disease  Bladder Disease

32. Medical History Overview  Sexually-Transmitted Diseases  Gonorrhea  Syphilis  HIV Positive  AIDS

33. Medical History Overview  Social History  Tobacco  Alcohol  Recreational Drugs

34. Medical History Overview  Cancer History Or Treatment  Chemotherapy  Radiation Therapy  Surgery

35. Medical History Overview  Operations/Hospitalizations & Sequelae  Anesthesia Complications

36. Medical History Overview  Medications  Use Appropriate References When Looking Up Something  Steroids, Anticoagulants, Immunosuppressives  Allergies, Adverse Reactions  Stress Importance Of OTC (Over The Counter) Drugs

38. Medical History Overview  Dental History  Vital Signs: Initial Exam, Recalls, Whenever Indicated  Pulse  Rate & Rhythm (60-100 bpm)  BP: S <120; D <80  Respiration (12-16 bpm)

39. Medical History Overview  General Physical Assessment  Gait, Speech, Skin, Nails, Eyes, Nose, Ears, Neck

40. Medical History Overview  Laboratory Tests (Indicated?)  Hematocrit, Hemoglobin  Platelet Count, PT (INR)  Fasting Blood Glucose  Biopsy  Culture & Sensitivity  Who Orders The Tests?

41. Communication With Physician  HIPAA Forms Must Be Filled Out By Patient At Physician’s Office  HIPAA Forms Must Be Filled Out By Patient At Dentist’s Office

42. Communication With Physician  Phone & “Sidewalk” Consults Should Be Documented In Progress Notes  Formal Documentation Preferred

43. And Now For Some Relatively New Stuff:  2007 AHA Guidelines for Endocarditis Prophylaxis  History Of Bisphosphonate Use  2009 American Association of Orthopaedic Surgeons Information Statement Regarding Prosthetic Joint Prophylaxis

44. Risk Is Always Increased When You Treat A Medically Compromised Patient Your Goal Is To Reduce The Risk As Much As Possible