1. Medical Risk Assessment for Dental Patients Donald A. Falace, D.M.D. Oral Diagnosis and Oral Medicine UK College of Dentistry

2. Can we provide routine dental treatment to this patient without endangering their (or our) health and well being? Is the benefit of having dental treatment worth the risk to the patient?

3. What do we do in the course of providing dental care that can affect the health and well being of a patient? Instill fear Inflict pain Inject local anesthetic solutions Inject potent vasoconstrictors Cause bleeding Control body position Expose to radiation Expose to dental materials Prescribe medications Alter oral function Alter appearance

4. Potential for the Occurrence of Adverse Events Dependent upon: –The medical condition of the patient (diagnosis, severity, stability, control) –The cardiopulmonary reserve which the patient has to be able to respond to physical/emotional challenges (METs; oxygen utilization) –The emotional stability of the patient (fear, anxiety) –The type of dental procedure (invasiveness, length of procedure, blood loss, type of anesthesia, use of vasoconstrictor)

5. Assessing the risk for the occurrence of Immediate adverse events –e.g. heart attack, stroke, hypoglycemia, allergic reaction, drug reaction, seizure Delayed adverse events –e.g. bleeding, infection, adrenal crisis

6. Risk Assessment? Can we provide routine dental treatment to this patient without endangering their (or our) health and well being? Yes. No problems are anticipated, and treatment can be delivered in the usual manner. (Benefit > Risk) Yes, but potential problems may be anticipated, and modifications in the delivery of treatment are necessary. (Benefit > Risk) No. Potential problems exist that are serious enough to make it inadvisable to provide elective dental treatment. (Risk > Benefit)

7. Risk? Medical Condition? Severity Stability Control Functional Capacity? METs Emotional Status? Fear Anxiety Dental Procedure? Invasiveness Length of procedure Blood Loss Vasoconstrictor use Risk Assessment Decreased Risk Increased Risk

8. Risk Assessment You may not be able to completely eliminate the risk of an adverse event occurring during dental treatment or as a result of dental treatment, however, our goal is to reduce that risk as much as possible The issue then becomes whether the remaining risk is acceptable and that having the dental treatment is of more benefit than not having it Risk vs Benefit?

9. Leading Causes of Death, USA 2003 (CDC) Heart Disease Cancer Stroke Emphysema/Chronic Bronchitis Accidents Diabetes Mellitus Influenza Alzheimer’s Disease Kidney Disease Septicemia Suicide Chronic Liver Disease and Cirrhosis Essential Hypertension and Hypertensive Nephropathy Parkinson’s disease Pneumonitis

10. Most Common Medical Emergencies in Dental Practice (4000 dentists over 10 years) Syncope 15,407 Mild Allergic Reaction 2,583 Angina Pectoris 2,552 Postural Hypotension 2,475 Seizures 2,195 Asthmatic Attack 1,392 Hyperventilation 1,326 “Epinephrine Reaction” 913 Insulin Shock 890 Cardiac Arrest 331 Anaphylaxis 304 Myocardial Infarction 289 Many of these events are preventable, or at least the chances of them occurring can be reduced

11. Medical Risk Assessment Begins with Identification of Medical Problems Medical history (questionnaire/interview) Physical examination (general survey, face, eyes, skin, etc) Laboratory tests (screening, confirmation) Medical consultation (physician, dentist, pharmacist)

12. Why take a medical history? Many medical problems and/or drugs can affect or influence the provision of dental care Examples: –Heart disease (infection, bleeding, drug interactions, cause an MI or angina, oral lesions) –Allergies (reactions to local anesthetics, antibiotics, analgesics, latex) –Diabetes (infection, hypoglycemia, periodontal disease) –Bleeding disorders; drug induced or genetic (abnormal hemostasis)

13. Medical History Printed questionnaire (patient must be literate, competent, of legal age) Follow-up with dialogue/research; make notes on questionnaire Use ink - not pencil Patient,student, and faculty signature, date Update regularly –Inquire at each appointment about any changes in health or medications since previous appointment; a brief comment is then included in the progress note (SHAPED) –New questionnaire should be completed every 2 years

15. The patient has completed filling out the medical history form….., now what?? +=

16. Gathering Information and Decision Making Review the Medical History form (3A) and note positive responses Question the patient to gain more information about those positive responses Innocuous or insignificant problems can be disregarded Potentially significant disorders OR unfamiliar disorders require further thought and/or investigation Resources to help in the evaluation of the medical history?

17. Reference Sources for Medical Information Little,J, Falace,D, Miller,C, Rhodus,N: Dental Management of the Medically Compromised Patient, 7th ed, Mosby, 2007 (~$65) Harrison ’ s Principles of Internal Medicine (~$125) Cecil ’ s Textbook of Internal Medicine (~$139) The Merck Manual (~$35) New edition in August ‘07

18. Reference Sources: Drug Information Drug Information Handbook for Dentistry (Lexicomp) Physician ’ s Desk Reference ( “ PDR ” ) –OTC drugs/dietary supplements –Herbal medications Facts and Comparisons Drug Information for the Health Care Provider (USPDI) Websites (online or downloaded to PDA)

19. Medical Problem Worksheet ID of medical problem ID of drugs taken for the problem Recognition of signs, symptoms or abnormal lab value related to problem Assessment of control or stability of the problem Recognition of possible issues or concerns related to dental care Treatment alterations

20. Drug Information Worksheet Brand or trade name Generic name Drug type or action Why prescribed Interactions –Epinephrine –Antibiotics –Analgesics –Sedative/hypnotics Oral manifestations Side effects

21. Clinical Examination General appearance Behavior Vital signs Head and neck Oral tissues Radiographs Laboratory tests

22. Medical Consultation Make sure you understand why you are seeking a consultation, and exactly what it is that you want to know Ask specific questions Be brief and to the point

23. Medical Consult: Example Problem: Pt reports a history of heart failure and an inability to be able to climb a flight of stairs without getting short of breath or having chest pain Reason for Consult: Can this patient tolerate routine dental treatment including fillings, and gingival surgery using local anesthetic with 1:100,000 epinephrine?

24. Then, answer these questions…. Are there any potential problems related to the provision of dental care? –If not, proceed with treatment in the usual manner –If yes, then…

25. Answer these questions…. Are there any potential problems related to the provision of dental care? If not, proceed with treatment in the usual manner –If yes, then… What do I need to do to avoid those problems?

26. Medical Problem Worksheet and the 3A

27. Examples of treatment modifications Limit treatment to specific times (e.g. hemodialysis; pregnancy) Preoperative anticoagulation level; blood pressure Preoperative antibiotics (e.g. prosthetic heart valve) Provide pre-operative or intra-operative sedation (e.g. unstable cardiac patient; fearful patient) Minimize the intraoperative use of epinephrine in local anesthesia, (e.g. unstable cardiac patient) Avoid the administration or prescription of certain drugs (e.g. erythromycin for patients taking certain lipid-lowering drugs) Make position changes slowly (e.g. BP medications) Ensure a comfortable chair position (e.g. heart failure, emphysema, pregnancy, arthritis) Provide postoperative antibiotics (poorly controlled diabetic with dental abscess)

28. Medical Risk Assessment and the OD Process….. Screening Data 1 Data 2,3.. Treatment planning appointment Medical History 3A is completed by the patient. Patient is assigned to student The medical history is reviewed and evaluated; Vital signs are obtained; The patient is examined; Problems are identified requiring medical problem, drug worksheets; Medical consults initiated Worksheets are discussed and a management plan is established; the back of the 3A is completed

29. Answer these questions…. Are there any potential problems related to the provision of dental care? –If not, proceed with treatment in the usual manner –If yes, then… What do I need to do to avoid those problems? Are there any oral manifestations related to the disease or it’s treatment?

30. Oral Manifestations Dry mouth (xerostomia) Oral ulcerations/lesions Burning mouth/tongue Gingival changes Fungal infections Orofacial pain