chapter 4 Physical and Psychological Evaluation
Before a new patient is treated, it is important that the dentist and staff become acquainted with the patient’s medical history. This is true in all situations, regardless of whether or not the patient is to receive drugs for pain or anxiety control. Because dental care can have a profound effect on both the physical and psychological well-being of the patient, it is extremely important for the person treating the patient to know beforehand the most likely problems to be encountered. It has been stated that “when you prepare for an emergency, the emergency ceases to exist.”1 Prior knowledge of a patient’s physical status enables the dentist to modify the proposed treatment plan to better meet the patient’s limit of tolerance. This is of special importance whenever the administration of a drug for the management of pain (e.g., local anesthetic) or anxiety (e.g., CNS depressant) is planned. The administration of certain drugs used in dentistry is specifically (relatively or absolutely) contraindicated in patients with some disease states. Knowledge of these contraindications is critical if potentially serious complications are to be prevented.
In the following discussion, a comprehensive but easy-to-use program of physical evaluation is described.2,3 Used as recommended, it allows the dentist to accurately determine any potential risk presented by the patient before the start of treatment. The following are the goals that are sought in the use of this system:
The first two goals involve the patient’s ability to tolerate the stress involved in the planned dental care. Stress may be of either a physiologic or psychological nature. Patients with underlying medical problems may be less able to tolerate the usual levels of stress associated with various types of dental care. These patients are more likely to experience an acute exacerbation of their underlying medical problem(s) during periods of increased stress. Such disease processes include angina pectoris, seizure disorders, asthma, and sickle cell disease. Although most of these patients will be able to tolerate the planned dental care in relative safety, it is the obligation of the dentist and staff to determine whether this problem does exist and the severity of the problem and how it might impact the proposed dental treatment plan.
Excessive stress can also prove detrimental to the nonmedically compromised (e.g., “healthy”) patient. Fear, anxiety, and acute pain produce abrupt changes in the homeostasis of the body that may prove detrimental. Many “healthy” patients suffer from fear-related emergencies, including hyperventilation and vasodepressor syncope (vasovagal syncope, “fainting”).
The third goal is to determine whether or not to modify the usual treatment regimen for a patient to enable the patient to better tolerate the stress of treatment. In some cases, a healthy patient will be psychologically unable to tolerate the planned treatment. Treatment may be modified to minimize the stress faced by this patient. The medically compromised patient will also benefit from treatment modification aimed at minimizing stress. The stress-reduction protocols discussed in this chapter are designed to aid the dentist in minimizing treatment-related stress in both the healthy and medically compromised patient.
When it is believed that the patient will require some assistance in coping with his or her dental treatment, the use of psychosedation should be considered. The last three goals involve the determination of the need for use of psychosedation, selection of the most appropriate technique, and selection of the most appropriate drug(s) for patient management.
With the information (database) collected from these three steps, the dentist will be better able to (1) determine the physical and psychological status of the patient (establish a risk factor classification for the patient); (2) seek medical consultation, if indicated; and (3) appropriately modify the planned dental treatment, if indicated. Each of the three steps in the evaluation process is discussed in general terms, with specific emphasis placed on its importance in the evaluation of the patient for whom pharmacosedation is considered.
The use of a written, patient-completed medical history questionnaire is a moral and legal necessity in the practice of both medicine and dentistry. These questionnaires provide the dentist with valuable information about the physical, and in some cases the psychological, condition of the prospective patient.
Many types of medical history questionnaires are available; however, most are simply modifications of two basic types: the “short” form and the “long” form. The short form medical history questionnaire provides basic information concerning a patient’s medical history and is best suited for use by a dentist with considerable clinical experience in physical evaluation. When using the short-form history, the dentist must have a firm grasp of the appropriate dialogue history required to aid in a determination of the relative risk presented by the patient. The dentist should also be experienced in the use of the techniques of physical evaluation and their interpretation. Unfortunately, most dentists use the short form or a modification of it in their office primarily as a convenience to their patient and themselves. The long form, on the other hand, provides a more detailed database concerning the physical condition of the prospective patient. It is used most often in teaching situations and represents a more ideal instrument for teaching physical evaluation.
In recent years, computer-generated medical history questionnaires have been developed.4,5 These questionnaires permit patients to enter their responses to questions electronically on a computer. Whenever a positive response is given, the computer asks additional questions related to the positive response. In effect the computer asks the questions called for in the dialogue history.
Any medical history questionnaire can prove to be extremely valuable or entirely worthless. The ultimate value of the questionnaire resides in the ability of the dentist to interpret the significance of the answers and to elicit additional information through physical examination and dialogue history.
In this fifth edition of Sedation, I have included as the prototypical adult health history questionnaire one that has been developed by the University of the Pacific (UOP) School of Dentistry in conjunction with MetLife (Figure 4-1). Figure 4-2 is an example of a pediatric medical history questionnaire.
Figure 4-1 Adult health history questionnaire.
(Reprinted with permission from University of the Pacific Arthur A. Dugoni School of Dentistry in San Francisco, CA.)
Figure 4-2 Pediatric medical history questionnaire.
(From Malamed SF: Medical emergencies in the dental office, ed 6, St Louis, 2007, Mosby.)
This health history has been translated into 36 different languages, comprising the languages spoken by 95% of the persons on this planet. The cost of the translation was supported by several organizations including the California Dental Association, but most extensively by MetLife Dental. The health history (see Figure 4-1), translations of the health history (Figure 4-3), the interview sheet (Figure 4-4), medical consultation form (Figure 4-5), and protocols for the dental management of medically complex patients may be found on the University of the Pacific’s website at www.dental.pacific.edu under Dental Professionals and then under Health History Forms. Protocols for management of medically complex patients can be found at the same website under Pacific Dental Management Protocols. Translations of the medical history form can also be found at www.metdental.com under Multi-Language Medical Health History Forms Available.
Figure 4-3 Spanish health history questionnaire.
(Reprinted with permission from University of the Pacific Arthur A. Dugoni School of Dentistry in San Francisco, CA.)
Figure 4-4 Health history interview sheet.
(Reprinted with permission from University of the Pacific Arthur A. Dugoni School of Dentistry in San Francisco, CA.)
Figure 4-5 Medical consultation form.
The health history was translated, keeping the same question numbering sequence. Thereby a dentist who speaks English and is caring for a patient who does not, can ask the patient to complete the health history in his or her own language. The dentist then compares the English health history with the patient’s translated health history, scanning the translated version for “yes” responses. When a “yes” is found, the dentist is able to look at the question number and match it to the question number on the English version. For example, the dentist would know that a “yes” response to question 34 on the non-English version is the same as question 34 on the English version and relates to high blood pressure (HBP). For that matter, a Chinese-speaking dentist could also use the multilanguage health history with an English-speaking patient and have the same cross-referenced information. A dentist who speaks Spanish could use the multilanguage health history with a patient who speaks French. With the uniform health history question sequence, these health history translations can serve patients and dentists all around the world.
The health history is divided into sections related to signs and symptoms (“Have you experienced?”), diagnosed diseases (“Do you have or have you had?”), medical treatments (including drugs and other physiologically active compounds), and several other questions.
Although both long- and short-form medical history questionnaires are valuable in determining a patient’s physical condition, a criticism of most available health history questionnaires is the absence of questions relating to the patient’s attitudes toward dentistry. It is recommended therefore that one or more questions be included that relate to this all-important subject:
COMMENT: A general survey question seeking the patient’s general impression of their health. Studies have demonstrated that a YES response to this question does not necessarily correlate with the patient’s actual state of health.5
COMMENT: Questions 2, 3, and 4 seek information regarding recent changes in the patient’s physical condition. In all instances of a positive response, an in-depth dialogue history must ensue to determine the precise nature of the change in health status, type of surgical procedure or illness, and the names of any medications the patient may now be taking to help manage the problem.
COMMENT: I have found that many adults are reluctant to verbally admit to the dentist, hygienist, or assistant their fears about treatment for fear of being labeled a “baby.” This is especially true of young men in their late teens or early twenties; they attempt to “take it like a man” or “grin and bear it” rather than admit their fears. All too often, such macho behavior results in an episode of vasodepressor syncope. Whereas many such patients do not offer verbal admissions of fear, I have found that these same patients may volunteer the information in writing. (Additional ways a dentist can determine a patient’s anxiety are discussed later in this chapter.)
COMMENT: The primary aim of this question is related to dentistry. Its purpose is to determine what prompted the patient to seek dental care. If pain is present, the dentist may need to treat the patient immediately on an emergency basis, whereas in the more normal situation treatment can be delayed until future visits. This may impact the use of sedation because many sedation techniques require the patient to fast (NPO status) before administration of the drugs.
COMMENT: A history of angina (defined, in part, as chest pain brought on by exertion and alleviated by rest) usually indicates the presence of a significant degree of coronary artery disease with attendant ischemia of the myocardium. The risk factor for the typical patient with stable angina is ASA 3.* Stress reduction is strongly recommended in these patients. In the presence of dental fears, sedation is absolutely indicated in the anginal patient. Inhalation sedation with N2O-O2 is preferred. Patients with unstable or recent-onset angina represent ASA 4 risks.
COMMENT: Swollen ankles (pitting edema or dependent edema) indicate possible heart failure (HF). However, varicose veins, pregnancy, and renal dysfunction are other causes of ankle edema. Healthy persons who stand on their feet for long periods (e.g., mail carriers and dental staff members) also may develop ankle edema that is not life threatening, merely esthetically unpleasing.
COMMENT: Although the patient may respond negatively to the specific questions (questions No. 29 to No. 35) in section III regarding the presence of various heart and lung disorders (e.g., angina, HF, pulmonary emphysema), clinical signs and symptoms of heart or lung disease may be evident. A positive response to this question does not always indicate that the patient suffers such a disease. To more accurately determine the patient’s status before the start of dental care, further evaluation is suggested. Because many CNS-depressant drugs are also potential respiratory depressants (to varying degrees), respiratory function of the prospective sedation patient must be fully evaluated.
COMMENT: The question refers primarily to an unexpected gain or loss of weight, not intentional dieting. Unexpected weight change may indicate HF, hypothyroidism (increased weight), hyperthyroidism, widespread carcinoma, uncontrolled diabetes mellitus (weight loss), or a number of other disorders. The presence of fever and/or night sweats should be pursued to determine whether they are innocent or perhaps clues to the presence of a more significant problem, such as tuberculosis.
COMMENT: A positive response mandates in-depth dialogue history to determine the cause of the persistent cough or hemoptysis (blood-tinged sputum). The most common causes of hemoptysis are bronchitis and bronchiectasis, neoplasms, and tuberculosis.
A chronic cough can indicate active tuberculosis or other chronic respiratory disorders, such as chronic bronchitis. Cough associated with an upper respiratory infection confers an ASA 2 classification on the patient, whereas chronic bronchitis in a patient who has smoked more than one pack of cigarettes daily for many years may indicate chronic lung disease and confer on the patient an ASA 3 risk. The dentist must weigh carefully the risks before administering central nervous system (CNS) depressants—especially those, such as opioids and barbiturates, which depress the respiratory system more than others—to patients who exhibit signs of diminished respiratory reserve (ASA 3 and 4).
COMMENT: Bleeding disorders, such as hemophilia, are associated with prolonged bleeding or frequent bruising and can lead to modification of certain forms of dental therapy (e.g., surgery, technique of local anesthetic administration, and venipuncture) and must therefore be made known to the dentist before treatment is begun. Modifications in the planned dental treatment plan may be necessary when excessive bleeding is likely to be present.
COMMENT: Sinus problems can indicate the presence of an allergy (ASA 2), which should be pursued in the dialogue history, or upper respiratory tract infection (URI) (ASA 2), such as a common cold. The patient may experience some respiratory distress when placed in a supine position; distress may also be present if a rubber dam is used. Specific treatment modifications—postponing treatment until the patient is able to breathe more comfortably, limiting the degree of recline in the dental chair, and foregoing use of a rubber dam—are advisable.
COMMENT: Dysphagia, or the inability to swallow, can have many causes. Before the start of any dental treatment, the dentist should seek to determine the cause and severity of the patient’s complaint.
COMMENT: This is an evaluation to determine whether gastrointestinal (GI) problems are present, many of which require patients to be medicated. Causes of blood in feces can range from benign, self-limiting events to serious life-threatening disease. Some common causes include: anal fissures, aspirin-containing drugs, bleeding disorders, esophageal varices, foreign body trauma, hemorrhoids, neoplasms, use of orally administered steroids, the presence of intestinal polyps, and thrombocytopenia.
COMMENT: A multitude of causes can lead to nausea and vomiting. Medications, however, are among the most common causes of nausea and vomiting.7–9 Opiates, digitalis, levodopa, and many cancer drugs act on the chemoreceptor trigger zone in the area postrema to induce vomiting. Drugs that frequently induce nausea include nonsteroidal antiinflammatory drugs (NSAIDs), erythromycin, cardiac antidysrhythmics, antihypertensive drugs, diuretics, oral antidiabetic agents, oral contraceptives, and many GI drugs, such as sulfasalazine.7–9
COMMENT: A positive response may indicate a patient’s chronic postural (orthostatic) hypotension, symptomatic hypotension or anemia, or transient ischemic attack (TIA), a form of prestroke. In addition, patients with certain types of seizure disorders, such as the “drop attack,” may report fainting or dizzy spells. The dentist may be advised to perform further evaluation, including a consultation with the patient’s primary care physician. A transient ischemic attack represents an ASA 3 risk, whereas chronic postural hypotension is normally an ASA 2 or 3 risk.
COMMENT: Tinnitus (an auditory sensation in the absence of sound heard in one or both ears, such as ringing, buzzing, hissing, or clicking) is a common side effect of certain drugs including salicylates, indomethacin, propranolol, levodopa, aminophylline, and caffeine. It may also be seen with multiple sclerosis, tumor, and ischemic infarction.
COMMENT: The presence of headache should be evaluated to determine the cause. Common causes include: chronic daily headaches, cluster headaches, migraine headaches, and tension type of headaches. If necessary, consultation with the patient’s primary care physician is warranted. Determine the drug(s) used by the patient to manage his or her symptoms because many of these agents can have an influence on clotting.
COMMENT: Blurred vision is a common finding as the patient ages. Leading causes of blurred vision and blindness include glaucoma, diabetic retinopathy, and macular degeneration. Double vision, or diplopia, usually results from extraocular muscle imbalance, the cause of which must be sought. Common causes include damage to third, fourth, or sixth cranial nerves secondary to myasthenia gravis, vascular disturbances, and intracranial tumors.
COMMENT: Seizures are common dental emergencies. The most likely candidate to have a seizure is the epileptic patient. Even epileptics who are well controlled with antiepileptic drugs may suffer seizures in stressful situations, such as might occur in the dental office. The dentist must determine the type, frequency of occurrence, and drug(s) used to prevent the seizure before the start of dental treatment. Treatment modification using the stress-reduction protocols (discussed later in this chapter) is desirable for patients with known seizure disorders. Sedation is highly recommended in the fearful epileptic dental patient as a means of preventing a seizure from developing during treatment. Epileptics whose seizures are under control (infrequent) are ASA 2 risks; those with more frequent occurrence of seizures represent ASA 3 or 4 risks.
COMMENT: Jaundice, or a yellowness of skin, whites of the eyes, and mucous membranes, is due to a deposition of bile pigment resulting from an excess of bilirubin in the blood (hyperbilirubinemia). It is frequently caused by obstruction of bile ducts, excessive destruction of red blood cells (hemolysis), or disturbances in the functioning of liver cells. Jaundice is a sign that might be indicative of a benign problem, such as a gallstone obstructing the common bile duct, or it might be due to pancreatic carcinoma involving the opening of the common bile duct into the duodenum. Because most drugs used in sedation undergo primary transformation in the liver, the presence of significant hepatic dysfunction will represent either a relative or absolute contraindication to the drug’s administration.
COMMENT: A history of joint pain and stiffness (arthritis) may be associated with chronic use of salicylates (aspirin) or other NSAIDs, some of which may alter blood clotting. Arthritic patients who are receiving long-term corticosteroid therapy may suffer an increased risk of acute adrenal insufficiency, especially for the patient who has recently stopped taking the steroid. Such patients may require reinstitution of steroid therapy or a modification (increase) in corticosteroid doses during dental treatment so that their body will be better able to respond to any additional stress that might be associated with the treatment.
Because of possible difficulties in positioning the patient comfortably, modifications may be necessary to accommodate the patient’s physical disability. Most patients receiving corticosteroids are categorized as ASA 2 or 3 risks depending on the reason for the medication and the degree of disability present. Patients with significantly disabling arthritis are ASA 3 risks. Positioning problems secondary to arthritis may negatively affect the use of sedation techniques.
COMMENT: This represents a survey question seeking to detect the presence of any and all types of heart disease. In the presence of a YES answer, the dentist must seek more specific detailed information as to the nature and severity of the problem and a list of any medications taken by the patient to manage the condition. Because many forms of heart disease are exacerbated in the presence of stress, consideration of the stress-reduction protocol (SRP) becomes increasingly important.
COMMENT: Heart attack is the lay term for myocardial infarction (MI). The dentist must determine the time that has elapsed since the patient suffered the MI, the severity of the MI, and the degree of residual myocardial damage to decide whether or not treatment modifications are indicated. Elective dental care should be postponed 6 months after an MI.10 Most post-MI patients are considered to be ASA 3 risks; however, a patient who has experienced an MI fewer than 6 months before the planned dental treatment should be considered an ASA 4 risk. Where little or no residual damage to the myocardium is present, the patient may be considered an ASA 2 risk after 6 months.
Heart failure: The degree of heart failure (weakness of the “pump”) present must be assessed through the dialogue history. When a patient has a more serious condition, such as congestive heart failure (CHF) or dyspnea (labored breathing) at rest, specific treatment modifications are warranted. In this situation, the dentist must consider whether the patient requires supplemental O2 during treatment. Whereas most HF patients are classified according to the American Society of Anesthesiologists’ (ASA) physical status classification system as ASA 2 (mild HF without disability) or ASA 3 (disability developing with exertion or stress) risks, the presence of dyspnea at rest is an ASA 4 risk. Sedation is indicated in the ASA 2 and 3 HF patient, but care must be taken in selecting the appropriate drugs and technique to prevent additional respiratory depression.
Congenital heart lesions: An in-depth dialogue history is required to determine the nature of the lesion and the degree of disability present. Patients can represent ASA 2, 3, or 4 risks. The dentist may recommend medical consultation, especially for the pediatric patient, to judge the lesion’s severity. Some dental treatments will require prophylactic antibiotics.
COMMENT: Heart murmurs are common, and not all murmurs are clinically significant. The dentist should determine whether a murmur is functional (nonpathologic, or ASA 2) or whether clinical signs and symptoms of either valvular stenosis or regurgitation are present (ASA 3 or 4) and whether antibiotic prophylaxis is warranted. A major clinical symptom of a significant (organic) murmur is undue fatigue. Table 4-1 provides guidelines for antibiotic prophylaxis. These were most recently revised in 2007.11 Box 4-1 categorizes cardiac problems as to their requirements for antibiotic prophylaxis, and Box 4-2 addresses prophylaxis and dental procedures specifically. Guidelines for antibiotic prophylaxis in orthopedic patients with joint replacements were last published in 1997.12
Cardiac Conditions Associated With the Highest Risk of Adverse Outcome from Endocarditis for Which Prophylaxis With Dental Procedures Is Recommended
Dental Procedures for Which Endocarditis Prophylaxis Is Recommended for Patients
* The following procedures and events do not need prophylaxis: routine anesthetic injections through noninfected tissue, taking dental radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of deciduous teeth, and bleeding from trauma to the lips or oral mucosa.
COMMENT: A history of rheumatic fever should prompt the dentist to perform an in-depth dialogue history for the presence of rheumatic heart disease (RHD). In the presence of RHD, antibiotic prophylaxis may be indicated as a means of minimizing the risk of developing subacute bacterial endocarditis (SBE). Depending on the severity of the disease and the presence of a disability, RHD patients can be an ASA 2, 3, or 4 risk. Additional treatment modifications may be advisable.
COMMENT: The dentist must pay close attention to stroke, cerebrovascular accident (CVA), or “brain attack” (the term increasingly used to confer on the lay public and health care professionals the urgency needed in prompt management of the victim of a CVA). A patient who has suffered a CVA is at greater risk of suffering another CVA or a seizure should they become hypoxic. If the dentist uses sedation in patient management, only minimal to moderate levels, such as those provided through inhalation sedation or intravenous (IV) sedation, are recommended. The dentist should be especially sensitive to the presence of transient cerebral ischemia (TCI), a precursor to CVA; TCI represents an ASA 3 risk. The post-CVA patient is an ASA 4 risk within 6 months of the CVA, becoming an ASA 3 risk 6 or more months after the incident (if the recovery is uneventful). In rare cases, the post-CVA patient can be an ASA 2 risk.
COMMENT: Elevated blood pressure (BP) measurements are frequently encountered in the dental environment secondary to the added stress many patients associate with a visit to the dental office. With a history of HBP, the dentist must determine the drugs the patient is taking, the potential side effects of those medications, and any possible interactions with other drugs that might be used during dental treatment. Guidelines for clinical evaluation of risk (ASA categories) based on adult BP values are presented later in this chapter. The SRP is a significant factor in minimizing further elevations in BP during treatment.
COMMENT: Determining the nature and severity of respiratory problems is an essential part of patient evaluation. Many acute problems developing in the dental environment are stress related, increasing the workload of the cardiovascular system and the O2 requirements of many tissues and organs in the body. The presence of severe respiratory disease can greatly influence the planned dental treatment and the choice of drugs and technique for sedation.
Asthma (bronchospasm) is marked by a partial obstruction of the lower airway. The dentist must determine the nature of the asthma (intrinsic [allergic] versus extrinsic [nonallergic]), frequency of acute episodes, causal factors, method of management of acute episodes, and drugs the patient may be taking to minimize the occurrence of acute episodes. Stress is a common precipitating factor in acute asthmatic episodes. The well-controlled asthmatic patient represents an ASA 2 risk, whereas the well-controlled but stress-induced asthmatic patient is an ASA 3 risk. Patients whose acute episodes are frequent and/or difficult to terminate (requiring hospitalization) are ASA 3 or 4 risks.
With a history of tuberculosis, the dentist must first determine whether the disease is active or arrested. (Arrested tuberculosis represents an ASA 2 risk.) Medical consultation and dental treatment modification are recommended when such information is not easily determined. Inhalation sedation with nitrous oxide (N2O) and O2 is not recommended for patients with active tuberculosis (ASA 3 or 4) because of the likelihood that the rubber goods (reservoir bag and conducting tubing) may become contaminated and the difficulty in their sterilization. However, for dentists who treat many patients with tuberculosis and other infectious diseases, disposable rubber goods for inhalation sedation units are recommended.
Emphysema is a form of chronic obstructive pulmonary disease (COPD), also called chronic obstructive lung disease (COLD). The emphysematous patient has a decreased respiratory reserve from which to draw if the body’s cells require additional O2, which they do during stress. Supplemental O2 therapy during dental treatment is recommended in severe cases of emphysema; however, the severely emphysematous (ASA 3, 4) patient should not receive more than 3 L of O2 per minute.13 This flow restriction helps to ensure that the dentist does not eliminate the patient’s hypoxic drive, which is the emphysematous patient’s primary stimulus for breathing. The emphysematous patient is an ASA 2, 3, or 4 risk depending on the degree of disability.
COMMENT: These diseases or problems either are transmissible (hepatitis A and B) or indicate the presence of hepatic dysfunction. A history of blood transfusion or of past or present drug addiction should alert the dentist to a probable increase in the risk of hepatic dysfunction. (Hepatic dysfunction is a common finding in the parenteral drug abuse patient.) Hepatitis C is responsible for more than 90% of cases of posttransfusion hepatitis, but only 4% of cases are attributable to blood transfusions; up to 50% of cases are related to IV drug use. Incubation of hepatitis C averages 6 to 7 weeks. The clinical illness is mild, usually asymptomatic, and characterized by a high rate (>50%) of chronic hepatitis.14 Because most drugs are biotransformed in the liver, care must be taken when selecting specific drugs and techniques of administration in the patient with significant hepatic dysfunction. Inhalation sedation with N2O-O2 is not contraindicated in these patients.
COMMENT: The presence of stomach or intestinal ulcers may be indicative of acute or chronic anxiety and the possible use of medications such as tranquilizers, H1-inhibitors, and antacids. Knowledge of which drugs are taken is important before additional drugs are administered in the dental office. A number of H1-inhibitors are now over-the-counter drugs. Because many patients do not consider such drugs “real” medications, the dentist must specifically question the patient about them. The presence of ulcers does not itself represent an increased risk during treatment. In the absence of additional medical problems, the patient may represent an ASA 1 or 2 risk.
COMMENT: The dentist must evaluate a patient’s allergies thoroughly before administering dental treatment or drugs. The importance of this question and its full evaluation cannot be overstated. A complete and vigorous dialogue history must be undertaken before the start of any dental treatment, especially when a presumed or documented history of drug allergy is present. Adverse drug reactions are not uncommon. Many, if not most, are labeled as “allergy” by the patient and also on occasion by his or her physician. However, despite the great frequency with which allergy is reported, true documented and reproducible allergic drug reactions are relatively rare. All adverse drug reactions must be evaluated thoroughly, especially when the dentist plans to administer or prescribe closely related medications for the patient during dental treatment.
The presence of allergy alone represents an ASA 2 risk. No emergency situation is as frightening to health care professionals as the acute, systemic allergic reaction known as anaphylaxis. Prevention of this life-threatening situation is more gratifying than treatment of anaphylaxis once it develops.
COMMENT: Patients who have a positive test result for human immunodeficiency virus (HIV) are representative of every area of the population. The usual barrier techniques should be employed to minimize risk of cross infection to both the patient and staff members. Patients who are HIV-positive are considered ASA 2, 3, 4, or 5 risks depending on the progress of the infection.
COMMENT: The presence or prior existence of cancer of the head or neck may require specific modification of dental therapy. Irradiated tissues have decreased resistance to infection, diminished vascularity, and reduced healing capacity. However, no specific contraindication exists to the administration of drugs for the management of pain or anxiety in these patients. Many persons with cancer may also be receiving long-term therapy with CNS depressants, such as antianxiety drugs, hypnotics, and opioids. Consultation with the patient’s oncologist is recommended before dental treatment. A past or current history of cancer does not necessarily increase the ASA risk status. However, patients who are cachectic or hospitalized or are in poor physical condition may represent ASA 4 or 5 risks.
COMMENT: For patients with glaucoma, the need to administer a drug that diminishes salivary gland secretions will need to be addressed. Anticholinergics, such as atropine, scopolamine, and glycopyrrolate, are contraindicated in patients with acute narrow angle glaucoma since these drugs produce an increase in intraocular pressure. Patients with glaucoma are usually ASA 2 risks.
COMMENT: Skin represents an elastic, rugged, self-regenerating, protective covering for the body. The skin also represents our primary physical presentation to the world and as such displays a myriad of clinical signs of disease processes including allergy, cardiac, respiratory, hepatic, and endocrine disorders.15
COMMENT: Anemia is a relatively common adult ailment, especially among young adult women (iron deficiency anemia). The dentist must determine the type of anemia present. The ability of the blood to carry O2 or to give up O2 to other cells is decreased in anemic patients. This decrease can become significant during procedures in which hypoxia is likely to develop.
Though rare, hypoxia is more likely to occur with the use of deep sedation as can develop with intramuscular (IM), intranasal (IN), or IV drug administration in the absence of the concomitant administration of supplemental O2. Hypoxia can become even more of a problem if the patient is anemic. ASA risk factors vary from 2 to 4 depending on the severity of the O2 deficit.
Sickle cell anemia is seen exclusively in black patients. Periods of unusual stress or of O2 deficiency (hypoxia) may precipitate sickle cell crisis. The administration of supplemental O2 during treatment is strongly recommended for patients with sickle cell disease. Persons with sickle cell trait represent ASA 2 risks, whereas those with sickle cell disease are 2 or 3 risks.
COMMENT: When treating patients with sexually transmitted diseases (STDs), dentists and staff members are at risk of infection. In the presence of oral lesions, elective dental care should be postponed. Standard barrier techniques: protective gloves, eyeglasses, and masks provide operators with a degree of (but not total) protection. Such patients usually represent ASA 2 and 3 risks but may be 4 or 5 risks in extreme situations.
COMMENT: The dentist should evaluate the nature of the renal disorder. Treatment modifications including antibiotic prophylaxis may be appropriate for several chronic forms of renal disease. Functionally anephric patients are ASA 4 risks, whereas patients with most other forms of renal dysfunction are either ASA 2 or 3 risks. Box 4-3 shows a sample dental referral letter for a patient on long-term hemodialysis treatment because of chronic kidney disease.
The patient who bears this note is undergoing long-term chronic hemodialysis treatment because of chronic kidney disease. In providing dental care to this patient, please observe the following precautions:
We recommend 3 g of amoxicillin 1 hour before the procedure and 1.5 g 6 hours later. For patients with penicillin allergies, 1 g of erythromycin 1 hour before the procedure and 500 mg 6 hours later is recommended.
COMMENT: The clinical presence of thyroid or adrenal gland dysfunction—either hyperfunction or hypofunction—should prompt the dentist to use caution in the administration of certain drug groups (e.g., epinephrine to hyperthyroid patients and CNS depressants to hypothyroid patients). In most instances, however, the patient has previously seen a physician and undergone treatment for thyroid disorder by the time he or she seeks dental treatment. In this case the patient is likely to be in a euthyroid state (normal blood levels of thyroid hormone) because of surgical intervention, irradiation, or drug therapy. The euthyroid state represents an ASA 2 risk, whereas clinical signs and symptoms of hyperthyroidism or hypothyroidism represent ASA 3 or, in rare instances, ASA 4 risks.
Patients with hypofunctioning adrenal cortices have Addison disease and receive daily replacement doses of glucocorticosteroids. In stressful situations, their body may be unable to respond appropriately leading to loss of consciousness. Hypersecretion of cortisone, Cushing syndrome, rarely results in a life-threatening situation.
COMMENT: A patient who responds positively to this question requires further inquiry to determine the type, severity, and degree of control of the diabetic condition. A patient with type I (insulin-dependent diabetes mellitus, or IDDM) or type II (non–insulin-dependent diabetes mellitus, or NIDDM) diabetes mellitus is rarely at great risk from dental care or commonly administered dental drugs (e.g., local anesthetics, epinephrine, antibiotics, CNS depressants). The NIDDM patient is usually an ASA 2 risk; the well-controlled IDDM patient, an ASA 3 risk; and the poorly controlled IDDM patient, an ASA 3 or 4 risk.
The greatest concerns during dental treatment relate to the possible effects of the dental care on subsequent eating and development of hypoglycemia (low blood sugar). Patients leaving a dental office with residual soft tissue anesthesia, especially in the mandible, usually defer eating until sensation returns, a period potentially of 3 to 5 (lidocaine, mepivacaine, articaine, prilocaine with vasoconstrictor) or more (up to 12 hours) hours (bupivacaine with vasoconstrictor). Diabetic patients have to modify their insulin doses if they do not maintain normal eating habits. Administration of the recently released local anesthetic reversal agent, phentolamine mesylate, at the conclusion of dental treatment can minimize residual soft tissue anesthesia by up to 50%.17
COMMENT: The dentist should be aware of any nervousness (in general or specifically related to dentistry) or history of psychiatric care before treating the patient. Such patients may be receiving a number of drugs to manage their disorders that might interact with drugs the dentist uses to control pain and anxiety (Table 4-2). Medical consultation should be considered in such cases. Extremely fearful patients are ASA 2 risks, whereas patients receiving psychiatric care and drugs represent 2 or 3 risks.
COMMENT: Patients with prosthetic (artificial) heart valves are no longer uncommon. The dentist’s primary concern is to determine if antibiotic prophylaxis is required. Antibiotic prophylactic protocols were presented earlier in this chapter.11,12 The dentist should be advised to consult with the patient’s physician (e.g., the cardiologist or cardiothoracic surgeon) bef/>