Patient Evaluation, Risk Assessment, Diagnostic Process

Intro

▪ Practice of dentistry today is far different from that of only a decade or two ago-advances in medical science=people living longer

▪ The dentist must remain knowledgeable about a wide range of medical conditions

▪ 6 in 10 adults have a chronic disease, 4 in 10 have 2 or more

▪ Failure to make appropriate treatment modifications may have serious clinical consequences

▪ Key to successful dental management of a medically compromised patient is a thorough evaluation followed by assessment of risk to determine if a planned procedure can be safely tolerated

▪ Does the benefit of dental treatment outweigh the risk of a medical complication occurring during or as a result of treatment?

▪ If uncontrolled condition, do not treat!

Checklist for Evaluation, Risk Assessment, Dental Management Modification considerations

PREOPERATIVE RISK ASSESSMENT

R: Recognize risks

• Be aware of adverse events that may occur

P: Patient evaluation

• Review medical history and discuss with patient

• Identify all meds and drugs taken (or supposed to be taken)

• Examine for signs and symptoms of disease, obtain vitals

• Review or obtain recent lab tests/imaging as applicable

  • Ex) Diabetics, Peeps who take blood thinners, other diseases

• Obtain a medical consultation if poorly controlled or undiagnosed or if health status is uncertain

Medical History

▪ Must be taken for every patient who is to receive dental treatment

▪ Use of a questionnaire that the patient fills out is the most common approach in dental offices

▪ MUST be reviewed by dialogue with the patient!

▪ Clarify and determine the significance of any finding that might impact dental treatment

Heart Failure

▪A clinical syndrome complex that results from an underlying cardiovascular problem

▪Increased risk and generally are not candidates for elective dental treatment

▪Chair position may influence ability to breathe

• Can’t lay patients back

▪Vasoconstrictors should be avoided

Heart Attack (MI)

Within the recent past (30 days) may preclude elective dental care

Patients are at increased risk for reinfarctions, arrhythmias, and heart failure

Medications being taken may alter the dental management of patients

Potential interactions with vasoconstrictors in LA

Angina Pectoris

Brief substernal pain resulting from myocardial ischemia--a common, significant symptom of coronary heart disease

• ▪ Commonly provoked by physical activity or emotional stress

• ▪ Increased risk for arrhythmias, MI, and sudden death

• ▪ Not a candidate for elective dental care if unstable or progressive

High blood pressure

Should be identified by history and the diagnosis confirmed by measurement

▪ Some antihypertensive medications may require caution in the use of vasoconstrictors

▪ Co-administration of calcium channel blockers with macrolide antibiotics can result in excessive hypotension

▪ Stress and anxiety reduction measures may be appropriate

▪ Elective dental care should be deferred for patients with severe hypertension (BP ≥180/110mm Hg) until controlled

Heart murmur

▪ Caused by turbulence of blood flow that produces vibratory sounds during the beating of the heart

▪ May be an indication of underlying heart disease

▪ antibiotic prophylaxis not needed

Mitral valve prolapse

the leaflets of the mitral valve “prolapse” or balloon back into the left atrium during systole

▪ Can cause backflow of blood (regurgitation) into the atrium

▪ Antibiotic prophylaxis not needed for invasive dental procedures to prevent infective endocarditis

Rheumatic fever

An autoimmune condition that can follow upper respiratory hemolytic streptococcal infection and may lead to damage of the heart valves (rheumatic heart disease)

Congenital heart disease

▪ Patients with some forms of severe congenital heart disease are at increased risk for infective endocarditis (potentially fatal inflammation of heart valves’ lining and sometimes heart chambers’ lining)

• Some might need prophylaxis premeds

Artificial heart valve

▪ Associated with high risk for development of infective endocarditis, with significant morbidity and mortality

▪ *AHA recommends prophylactic antibiotics before most dental procedures

May be on anticoagulants to prevent blood clots associated with the valve

Excessive bleeding may be encountered with surgical procedures

• level of anticoagulation must be determined before any invasive procedure

Arrhythmias

▪ Frequently related to heart failure or ischemic heart disease

▪ Stress, anxiety, physical activity, drugs, and hypoxia may precipitate

▪ Vasoconstrictors in local anesthetics should be used cautiously

▪ Stress reduction measures may be appropriate

▪ Antiarrhythmic drugs may cause oral changes or other side effects

▪ Patients with atrial fibrillation also may be on anticoagulant or antiplatelet medication

Peeps with this may require a pacemaker or a d-fib to regulate or pace heart rhythm

• Caution advised with the use of certain types of electric equipment in patients with these

Coronary artery bypass graft/angioplasty/stent

▪ Performed in patients with coronary heart disease to restore patency to blocked coronary arteries

▪ The grafted artery bypasses the occluded portion of the artery

▪ The balloon catheter is inserted into the partially blocked artery; the balloon is then inflated, which compresses the atheromatous plaque against the vessel wall

Hemophilia or inherited bleeding disorder

▪ Patients are at risk for severe bleeding after any type of dental treatment that causes bleeding, including scaling and root planing

▪ These patients must be identified and managed in cooperation with their physician or hematologist

▪ Patients with severe factor deficiency may require factor replacement before invasive treatment, as well as aggressive postoperative measures to maintain hemostasis

Blood transfusion

 The underlying problem that necessitated this must be identified, and alterations in the delivery of dental treatment may have to be made

 These patients also may be carriers of hepatitis B or C or may have become infected with the human immunodeficiency virus (HIV) and must be identified

 Laboratory screening or medical consultation may be appropriate to determine the status of liver function

Anemia

▪ May result from an underlying pathologic process such as chronic blood loss, decreased production of red blood cells, or hemolysis

▪ Oral lesions, infections, delayed wound healing, and adverse responses to hypoxia all are potential matters of concern

Leukemia/lymphoma

Depending on the type of leukemia or lymphoma, status of the disease, and type of treatment, some patients may have oral manifestations (gingival enlargement), bleeding problems or delayed healing, or may be prone to infection

Blood thinner use

tendency to bleed longer than normal

 Information about an episode of unexplained bleeding should be obtained and evaluated

 Many reports of unexplained bleeding are more apparent than real

 Patients taking anticoagulant or antiplatelet medication will need to be evaluated to determine the risk for postoperative bleedin

Stroke

▪ Disorders that predispose this, like hypertension and diabetes, must be identified to allow for appropriate management alterations

▪ Avoid elective treatment in the immediate poststroke period (increased risk for subsequent)

▪ Caution using vasoconstrictors

▪ Possible paralysis, speech impairment, or other physical impairments that require special care

Calcifications may be seen in carotid arteries on Pano

• May be risk factor for this

• Refer to physician

Epilepsy, seizures, and convulsions

▪ A history of epilepsy or grand mal seizures should be identified, and the degree of seizure control should be determined

▪ Patients may discontinue the use of anticonvulsant medication without their doctor’s knowledge and thus may be susceptible to seizures during dental treatment

• Important to ask about regularity of taking meds!

Behavioral disorders and psychiatric treatment

▪ Patients with a history of a behavioral disorder or psychiatric illness, as well as the nature of that disorder or illness need to be identified

▪ May help explain unusual or unexpected behavior

▪ May require stress reduction measures

▪ Some psychiatric drugs could interact adversely with vasoconstrictors in LA or produce adverse oral effects

• Xerostomia, increased caries risk

Stomach or intestinal ulcers, gastritis, and colitis

Should not be given drugs that are directly irritating to the gastrointestinal tract

• Aspirin and NSAIDs

Patients with colitis or a history of colitis may not be able to take certain antibiotics

Some drugs used to treat gastric or duodenal ulcers may cause dry mouth

Hepatitis, liver disease, jaundice, and cirrhosis

▪ Patients who have a history of viral hepatitis may be asymptomatic carriers of the disease and can transmit it unknowingly to dental personnel or other patients

▪ Patients also may have chronic hepatitis (B or C) or cirrhosis, with associated impairment of liver function

▪ Can result in prolonged bleeding

Can result in less efficient metabolism of drugs like LA and analgesics

Allergies or hives

From antibiotics, analgesics

▪ Latex allergy also is common, and in patients so affected, alternative materials, such as vinyl or powderless gloves, and latex-free rubber dams, can be used to prevent an adverse reaction

▪ True allergy to amide local anesthetics is uncommon

▪ Dentists should procure a history regarding allergy by specifically asking patients how they react to a particular substance

▪ Symptoms and signs include

• itching, urticaria (hives), rash, swelling, wheezing, angioedema, runny nose, and tearing eyes

▪ Isolated signs and symptoms

• nausea, vomiting, heart palpitations, and fainting

• generally are not of an allergic origin but rather are manifestations of drug intolerance, adverse side effects, or psychogenic reactions

Asthma

▪ The type should be identified, as should the drugs taken and any precipitating factors or triggers

▪ Patient who uses an albuterol inhaler for treatment of acute attacks should bring it to their appointment

Emphysema/chronic bronchitis

▪ Chair position-some patients may not be able to tolerate a supine position

▪ Most commonly caused by cigarette smoking

▪ Smoking cessation counseling may be indicated

Contagious respiratory infections

▪ Examples: influenza, COVID-19, TB

▪ Patients must be identified and information about the infectivity status, testing, and treatment must be sought

▪ Dental treatment must be delayed until active disease is effectively treated

▪ Providers should be familiar with stages and symptoms of these infections

Sleep apnea/snoring

increased risk for hypertension, MI, stroke, diabetes, and car crashes, and should receive treatment for the disorder

▪ Signs and symptoms: loud snoring, excessive daytime sleepiness, and witnessed breathing cessation during sleep

▪ Refer to a sleep physician specialist for evaluation

Arthritis

▪ Most common types are osteoarthritis and rheumatoid arthritis

▪ Patients with Sjӧgrensyndrome, which may occur with rheumatoid arthritis or independently of that, have a dry mouth that can be very problematic

▪ May have problems with manual dexterity that impact oral hygiene

▪ Could involve the temporomandibular joints

Prosthetic joints

▪ Some patients thought to be at increased risk for infection of the prosthesis subsequent to dental treatment

▪ Current guidelines do not recommend that prophylactic antibiotics be provided before any treatment likely to produce bacteremia

Diabetes

▪ Patients must be identified to determine the type, how it is being treated, and how well controlled it is

▪ Type 1 are of greater concern regarding management

▪ Symptoms and signs suggestive include

• dry mouth, excessive thirst and hunger, frequent urination, weight loss, poor wound healing, and frequent infections

• Odontogenic infections, oral candidiasis, periodontal disease

▪ Patients who take insulin are at risk for episodes of hypoglycemia in the dental office if meals are skipped or if stress or infection is present

Thyroid disease

▪ Patients with uncontrolled hyperthyroidism are potentially hypersensitive to stress and α1 -adrenergic effects of sympathomimetics, so the use of vasoconstrictors generally is contraindicated

▪ These patients also may be easily upset emotionally and intolerant of heat, and they may exhibit tremors

▪ Palpation of thyroid gland is important!

▪ Exophthalmos may be present

Kidney failure

▪ Patients with chronic kidney disease or a kidney transplant must be identified

▪ Potential for abnormal drug metabolism, immunosuppressive drug therapy, bleeding problems, hepatitis, infection, high BP, concurrent diabetes, and heart failure

Sexually transmitted diseases

▪ A variety of sexually transmitted diseases (STDs), such as syphilis, gonorrhea, and human immunodeficiency virus (HIV) infection, can have manifestations in the oral cavity because of oral-genital contact or secondary to hematogenous dissemination in the blood or immune suppression

▪ Dental professional may be the first to identify these conditions

▪ Risk of oropharynx cancer

Tobacco and alcohol use

▪ The use of tobacco products is a risk factor that is associated with cancer, cardiovascular disease, pulmonary disease, and periodontal disease

▪ Excessive use of alcohol is a risk factor for periodontal disease, malignancy, and heart disease, and may lead to liver disease

▪ Ask about quantity, duration, and whether they would like to quit/encourage them to do so

Drug addiction and substance use disorder

▪ Patients who have a history of intravenous drug use are at increased risk for infectious diseases such as hepatitis B or C, AIDS, and infective endocarditis

▪ Vasoconstrictors should be avoided in patients who are cocaine or methamphetamine users because these agents may precipitate arrhythmias, MI, or severe hypertension

Tumors and cancer

▪ Patients who have had cancer are at risk for recurrence, so they should be closely monitored

▪ Cancer treatment regimens including chemotherapy, targeted biologic agents, immunotherapy, or radiation therapy may result in infection, gingival bleeding, oral ulcerations, dry mouth, mucositis, and impaired healing after invasive dental treatment, all of which represent significant management considerations

Therapy for head and neck cancers

Patients who had previous surgery may have severe oral function deficits

Patients with previous radiation treatment to the head, neck, or jaw must be carefully evaluated

• Destroys blood supply to the jaws, mucositis and irreversible damage to salivary glands, fibrosis of masticatory muscles

Chemotherapy can produce many undesirable adverse effects, most commonly a severe mucositis

• Resolve after therapy is complete

Steroids

▪ Used in treatment of inflammatory and autoimmune diseases

▪ Cortisone and prednisone are examples of steroids that are used in treatment of many diseases

Operations or hospitalizations

▪ A history of hospitalization can provide a record of past serious illnesses that may have current significance

▪ Information about hospitalizations should include diagnosis, treatment, and complications

Pregnancy

▪ Women who are or may be pregnant may need special consideration in dental management

▪ Caution in administration of drugs, timing of dental treatment, and chair position

▪ Stress the importance of maintaining good oral hygiene during pregnancy!

Current physician

▪ Information should be sought regarding the identity of the patient’s physician, why the patient is under medical care, diagnoses, and treatment received

▪ A patient who does not have a physician may require a more cautious approach than a patient who sees a doctor regularly

Drugs, medicines, or pills

▪ All drugs, medicines, supplements, or pills that a person is taking, or is supposed to be taking, should be identified and investigated for actions, adverse side effects, and potential drug interactions

▪ The dentist should have a reliable, up-to-date, comprehensive source for drug information, in print format or through an online database

▪ The patient's list of medications (“drug history”) may provide the only clues to presence of an unreported medical disorder

Functional capacity

▪ It is important to ask some screening questions regarding the ability of the patient to engage in normal physical activity (functional capacity)

▪ A patient who reports an inability to walk up a flight of stairs without shortness of breath, fatigue, or chest pain may be at increased risk for medical complications during dental treatment, especially when such limitation is combined with other risk factors and the patient is under stress

Physical exam

▪ Skin and nails

▪ Face

▪ Eyes

▪ Ears

▪ Neck

▪ Pulse

▪ Rate

▪ Rhythm

▪ Blood pressure

▪ Respiration

▪ Oxygen saturation

▪ Temperature

▪ Height

▪ Weight

General appearance

 Careful observation can lead to awareness and recognition of abnormal or unusual features or medical conditions that may exist and may influence the provision of dental care

 Consists of an assessment of the general appearance of the patient and inspection of exposed body areas

 The patient's outward appearance and movement can give an indication of her or his general state of health and well-being

Skin and nails

▪ Changes associated with systemic disease

▪ Alterations in the fingernails, such as clubbing, white discoloration, yellowing, and splinter hemorrhages, usually are caused by chronic disorders

▪ Dorsal surfaces of the hands are common sites for actinic keratosis and basal cell carcinomas

▪ A raised, darkly pigmented lesion with irregular borders may be a melanoma

Face

▪ The shape and symmetry of the face are abnormal in a variety of syndromes and conditions

▪ Acromegaly, Cushing (hyperthyroidism), Bell palsy

Eyes

▪ Sensitive indicators of systemic disease and should be closely inspected

Ears

▪ The ears should be inspected for gouty tophi in the helix or antihelix

Neck

▪ The neck should be inspected for enlargement and asymmetry

▪ Lymph nodes evaluated for size, location, tenderness, and whether movable or fixed

▪ Bilateral palpation of the thyroid gland should be performed

Vital signs

Consist of blood pressure, pulse, respiratory rate, temperature, height, and weight

▪ Not always done in private practice.. educate!

▪ Establishment of baseline normal values ensures a standard of comparison in the event of a medical emergency during treatment

▪ The purpose of this examination is merely detection of abnormality--not diagnosis

▪ Discuss abnormalities with pt and refer to physician for further evaluation

Pulse

▪ Can be determined by palpating carotid artery at the side of the trachea or the radial artery on the thumb side of the wrist

▪ Pulse should be palpated for 1 minute

Rate

▪ The average pulse rate in normal adults is 60 to 100 beats/minute

▪ Abnormal pulse rate may be a sign of cardiovascular disorder, but the pulse also may be influenced by anemia, exercise, conditioning, anxiety, drugs, or fever

Rhythm

▪ The normal pulse is a series of rhythmic beats that occur at regular intervals

Blood pressure

▪Determined by indirect measurement in the upper extremities with a blood pressure cuff and stethoscope

▪A cuff that is too small yields falsely elevated values, whereas a cuff that is too large yields falsely low values

• Normal systolic pressure ranges between 90 and 120mm; normal

• diastolic pressure ranges between 60 and 80 mm

Respiration

▪ The rate and depth of respiration should be noted through careful observation of movement of the chest and abdomen in the quietly breathing patient

▪ Make note of patients with labored breathing, rapid breathing, or irregular breathing patterns

▪ 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

Oxygen saturation

▪ Determined with a pulse oximeter placed on pad of index finger

▪ Levels should be 98% or higher

▪ Levels below 92% suggest supplemental oxygenation and evaluation

Temp

not usually recorded during a routine dental examination but rather is determined when a patient has febrile signs or symptoms such as might be found with an abscessed tooth, a mucosal or gingival lesion, or a fascial space infection

▪ Normal oral temperature is 98.6°F (37°C) but may vary by as much as ±1°F over 24h and usually is highest in the afternoon

Height

should be determined so insight into growth and development as well as conditions such as osteoporosis can be assessed

Weight

▪ Patients should be questioned about any recent unintentional gain or loss of weight

▪ Rapid loss could indicate malignancy, diabetes, TB, or other wasting disease

▪ Rapid gain could indicate heart failure, edema, hypothyroidism, or neoplasm

▪ Obesity (BMI of 30 or higher) is a risk factor for many health problems including heart disease and diabetes

Head and neck exam

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

Diagnostic tests

▪ An important part of the evaluation of a patient’s health status

▪ Indications for clinical laboratory testing in dentistry

▪ Aiding in detection of suspected disease (diabetes, infection, bleeding disorders, malignancy)

▪ Screening at-risk patients for diabetes, HIV, chronic kidney disease, hepatitis B or C

▪ Establishing normal baseline values before treatment (anticoagulant status, WBCs, platelets)

▪ Assessing risk for bleeding

Physician referral and consultation

▪ Contacting the physician for consultation or referral purposes may be warranted if any concerns on patient’s general health

▪ Conversation and all communications must be recorded in the progress notes

Problem list and diagnoses

▪ Once all information is collected, a problem list with diagnoses should be constructed. The list should be comprehensive and include final conclusions regarding abnormalities detected after assessment of the chief complaint

Risk assessment

▪ Recommended prior to dental treatment

▪ “ABC” checklist offers an assessment as to whether a patient can safely undergo planned dental treatment.

▪ American Society of Anesthesiologists (ASA) Physical Classification System- method of assessing medical risk

▪ As classification level increases, so does the risk

▪ Each situation requires consideration to determine whether the benefits of having dental treatment outweigh the potential risks to the patient

Age

▪ Young patients may have behavioral and cognitive issues that make it difficult to sit still or take instruction

▪ Elderly patients may suffer from multiple comorbid conditions of variable degree

▪ Tend to have more medical problems and take more medications

▪ ½ of older adults report having 2 or more chronic illnesses, 1/3 of all prescription meds are taken by older adults

Treatment modifications

▪ The goal is to provide methods to evaluate and reduce risk as much as possible, including the possibility of urgencies or emergencies that can arise in the dental office

▪ Simple modifications in the delivery of dental treatment can be made in an effort to reduce risk to the patient

• ▪ Antibiotic prophylaxis or anxiolytic drug

• ▪ Adjustment of chair position

• ▪ Monitoring of vitals

Stress and anxiety reduction

important to control to help reduce risk

establish good rapport and trust