Lecture 5 - ODM 814

• Risk assessment is important in dentistry to gauge potential good or bad outcomes.
• Risks include disease progression, infection, hospitalization, and even death.
• Risk is related to the patient's overall health and the specific dental procedure planned.
• Consistent and organized data collection is vital for risk assessment.
• Risk assessment should be part of the diagnostic sequence.
• Patient medical risk should be assessed before examining the mouth.
• Medical history documentation is important.
• 125 million Americans suffer from a chronic disease.

Diagnostic Sequence

• Includes demographics, chief complaint, medical and dental history and social history.
• Review of Systems (ROS) as well as vital signs and clinical examination are also part of the diagnostic sequence.
• Radiographic findings, laboratory tests, and a provisional diagnosis are obtained.
• Key step: Summarize problems/issues using PATSUM, and assess risk of treatment
• Finally consider risk, treatment and prognosis when making a treatment plan.

Medical Status

• The 3 S's help determine medical status: Stability, Severity, Significance.

American Society of Anesthesiologists (ASA) Physical Status (PS)

• The ASA-PS classification system is used to categorize a patient's overall health.

ASA Classifications

• ASA (PS) 1: A normal healthy patient.
• ASA (PS) 2: A patient with mild systemic disease.
• ASA (PS) 3: A patient with severe systemic disease.
• ASA (PS) 4: A patient with severe systemic disease that is a constant threat to life.
• ASA (PS) 5: A moribund patient who is not expected to survive without the operation.
• ASA (PS) 6: A declared brain dead patient whose organs are being removed for donor purpose.
• Examples for ASA PS I include healthy, nonsmoking, no or minimal alcohol use.
• Examples for ASA PS II include current smoker, social alcohol drinker, pregnancy, obesity (30 ASA PS III is one or more moderate to severe diseases.
• ASA PS III patients may be poorly controlled for DM or HTN, COPD, morbid obesity (BMI ≥40), and or have active hepatitis, alcohol dependence or abuse, as well as pacemaker.
• ASA PS IV can include recent MI, CVA, TIA, or CAD/stents and or ongoing cardiac ischemia or severe valve dysfunction, as well as severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis.
• Examples for ASA PS V include ruptured abdominal/thoracic aneurysm and or massive trauma, intracranial bleed with mass effect, ischemic bowel with significant cardiac pathology or multiple organ/system dysfunction.
• ASA is a spectrum based on the current status.
• ASA does not take into account the risk or type of dental procedure planned.
• ASA III patients may have limited daily activity, and be ok for dental care, but may need some modification in care.
• ASA IV has serious limitation of daily activity and may not be a good candidate for dental care, indicating likely major impact on anesthesia and surgery.

Determining ASA Requires

• Review of Medical History & Systems and asking questions.
• Knowing significant medical disorders, severity of condition, and condition stability.
• Ordering and reviewing blood laboratory findings and/or consulting.
• The dental professional needs to factor in the impact of the planned dental procedure.

Procedure Factors

• Factors include drugs administered, level of consciousness, drug interactions/ADEs, invasiveness/bleeding, duration of procedure, pain level, and skill/experience of the operator.

Clinical Pearls

• Medical risk assessment is a key component of the diagnostic process.
• ASA status and factors related to the patient and the procedure are components of the assessment process.
• The ASA-PS classification system is designed for patients undergoing anesthesia.
• Risk assessment is an additive process where more than 1 factor is assessed for proper evaluation.
• The condition's stability influences the risk category.
• Risk assessment may require obtaining a laboratory test result or consulting with a physician / nurse practitioner.
• Risk assessment requires knowing thresholds used to make a diagnosis and determine a severity scale.
• Always consider of the patient's condition and the procedure.

Infective Endocarditis (IE)

• IE is an infection of either the heart's inner lining (endocardium) or the heart valves.
• IE is serious and sometimes fatal.
• Risk factors for developing IE: heart valve disease, previous heart valve surgery, congenital heart disease, intravenous drug use, previous history of IE
• IE can affect men, women and children of all racial and ethnic groups.
• In the United States, there are more than 47,000 new cases each year.
• IE can occur due to an infected needle.
• IE can occur due to open wounds, dental procedures, cardiac devices, surgery and or intravascular catheters.
• Abnormal substrates that can cause IE are prosthetic valve, Rheumatic heart disease, Mitral valve prolapse, Aortic valve disease and Congenital Heart Disease.
• Outcomes of IE include: in-hospital mortality greater than 30%.
• Worse outcomes are associated with shock.
• Heart failure and acute kidney injury can be outcomes of IE.
• Recurrent infection common (>10%)
• The 2021 American Heart Association released a statement on prevention of infective endocarditis
• Cardiac conditions with high risk of Infective Endocarditis include: Prosthetic cardiac valve or material , Transcatheter implantation of prosthetic valves Cardiac valve repair with devices, including annuloplasty, rings, or clips, Left ventricular assist devices (LVAD) or implantable heart.
• Cardiac conditions with high risk of Infective Endocarditis Previous, relapse, or recurrent infective endocarditis
• Heart disease (CHD) as well as Cardiac transplant recipients who develop cardiac valvulopathy are also cardiac conditions considered high risk.
• All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa require antibiotic prophylaxis.
• The following are exemptions that do not require All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth Routine anesthetic injections through noninfected tissue, Taking of dental radiographs, Placement of removable prosthodontic or orthodontic appliances and Shedding of deciduous teeth and bleeding from.

Antibiotic Prophylactic Regimens

• Amoxicillin 2 g is used for adults if oral. 50 mg/kg is used for children if oral.
• Ampicillin OR 2 g IM or IV is used for inability to take oral medication for adults. 50 mg/kg IM or IV is used for inability to take oral medication for children.
• Cefazolin or ceftriaxone 1 g IM or IV for allergic to oral regimen.
• Cephalexin* 2 g for adults allergic to oral regimen. 50 mg/kg for children allergic to oral regimen.
• Azithromycin or clarithromycin 500 mg adults allergic to oral regimen. 15 mg/kg in children allergic to oral regimen.
• Doxycycline 100 mg for adults allergic to oral regimen and <45 kg, 2.2 mg/kg >45 kg, 100 mg in children for Doxycycline.
• Cefazolin or ceftriaxonet 1 g IM or IV if allergic to penicillin or ampicillin and unable to take oral medication.
• 50 mg/kg IM or IV is antibiotic prophylaxis for children unable to take oral medication and allergic to penicillin or ampicillin.
• Clindamycin is longer for antibiotic prophylaxis for a dental procedure.