Chapter 4

Medical Evaluation and Patient Management

Introduction

It is not the remit of this book to cover the vast field of medical assessment but merely to provide a phil­osophy for the safe management of patients before, during and after treatment. The clinician should be sufficiently trained in the assessment of patients and must refer to texts and training programmes designed to impart such information. There is a paucity of established data on the impact of medical condition on the well-being of implants. Clinical judgement and experience are valuable, and consultation with specialist physicians and surgeons is strongly advised during the assessment. There are numerous publications that arbitrarily list absolute and relative contraindications. These must be viewed in light of risks and bene­fits as well as the facilities that are available to safely manage the patient.

The life expectancy of patients has greatly increased and many patients attending treatment have disorders that are being medically treated. The disorder being treated might well have comorbidities, and the drugs that are used to contain the disorder will invariably have an impact on the patient’s physiology. Consequently, a thorough working knowledge of med­ical conditions and currently used drugs is necessary. Numerous conditions require surgical intervention, which may require precautions and are indicative of an underlying susceptibility.

Medical Evaluation

Implant dentistry is an elective procedure that is carried out to enhance the patient’s well-being. It is not a life-saving procedure, and the patient should, therefore, not be put at unnecessary risk. A medical history form should be completed by the patient and discussed in detail with the clinician to ensure that all aspects of the patient’s health have been covered. This provides an opportunity to address conditions not covered directly within the medical history form. The format of the medical history form should be such that it is easy for the patient to complete and for the clinician to assess. A broad range of medical history forms is available. The main topics that should be addressed are:

• • medical care, present or past (including current medication)
• • current or past illnesses (e.g. cardiovascular, respiratory, neurological, gastrointestinal, endocrine, renal, hepatic or haematopoietic problems)
• • psychological profile
• • infectious diseases
• • allergies
• • social profile (for example, smoking, drinking).

Aim

Assessment of the medical condition of the patient should consider the factors affecting the short-, medium- and long-term well-being of the patient. The treatment process and outcome should be considered along these timescales, which are arbitrary and overlapping. A process of risk assessment and risk containment should be taken with the seriousness it deserves.

Short-term Issues

This period refers to the perioperative time and the key concern is that the patient should first survive and, second, not suffer any complications that require emergency resuscitation or remedial action.

A number of conditions that are potentially harmful need to be identified. Typically these would affect those systems fundamental to life support. Therefore, assessment of medical conditions that would typically result in life-threatening incidents should be considered, for example:

• • cardiovascular system – acute myocardial infarction or a stroke
• • respiratory system – respiratory distress as may be caused by asthma, emphysema, or obstruction
• • endocrine system – diabetic crisis (normally caused by hypoglycaemia)
• • haematopoietic system – bleeding disorders (factor VIII, haemophilia)
• • nervous system – epilepsy.

Medium-term Issues

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