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

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

2. Interrelationships Of Medicine And DentistryPhysical 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: • 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

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 • 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

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

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

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

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

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

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

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

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 • Autoimmune Disorders • Scleroderma • RAS (Recurrent Aphthous Stomatitis) Or “Major” Aphthous

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