4: Physical and Psychological Evaluation

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.


The term physical evaluation is used to discuss the steps involved in fulfilling the aforementioned goals. Physical evaluation in dentistry consists of the following three components:

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.

Medical History Questionnaire

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.

(Reprinted with permission from University of the Pacific Arthur A. Dugoni School of Dentistry in San Francisco, CA.)

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:

(1) Do you feel very nervous about having dentistry treatment? (2) Have you ever had a bad experience in the dental office?

Following is the UOP medical history questionnaire with a discussion of the significance of each:

Medical History Questionnaire (see Figure 4-1)

I. CIRCLE APPROPRIATE ANSWER (leave blank if you do not understand question):


7. Chest pain (angina)

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.

16. Frequent vomiting, nausea?

COMMENT: A multitude of causes can lead to nausea and vomiting. Medications, however, are among the most common causes of nausea and vomiting.79 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.79

GI and systemic infections, viral and bacterial, are the second most common cause of nausea and vomiting.


30. Heart attack, heart defects?

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.

31. Heart murmurs?

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

32. Rheumatic fever?

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.

35. Asthma, TB, emphysema, other lung disease?

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.

49. Thyroid, adrenal disease?

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.

Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 4: Physical and Psychological Evaluation
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