Medical Risk & Dentistry PDF

Medical Risk and Dentistry Craig S. Miller, D.M.D., M.S. Professor of Oral Medicine Division of Oral Diagnosis, Oral Medicine, Oral Radiology Associate Dean for Faculty Affairs [email protected] Objectives opics to cover and understand: 1)...

Medical Risk and Dentistry Craig S. Miller, D.M.D., M.S. Professor of Oral Medicine Division of Oral Diagnosis, Oral Medicine, Oral Radiology Associate Dean for Faculty Affairs [email protected] Objectives opics to cover and understand: 1) Why risk assessment is important. 2) How to assess medical and physical status (PS) risk. 3) American Society of Anesthesiologists (ASA)-PS classification system. 4) Correctly categorize risk using ASA-PS classification system.  What is the Goal of Risk Assessment? Risk of What? Good or Bad outcome - Disease Progress - Infection - Hospitalization - Death What is Risk Related To? 1. Patient 2. Procedure How Do You Get Good at Risk Assessment? Follow The Diagnostic Sequence The first step in care. Important to: - obtain data - obtain a diagnosis - assess risk - in an organized manner. The Diagnostic Sequence Demographics (name, age, gender) Chief complaint Medical and dental history Social history (determinants of health) Review of Systems (ROS) Vital Signs Clinical Examination Radiographic findings Laboratory tests Provisional Diagnosis - PATSUM: summarize problems/issues Assess risk of treatment Treatment plan  Consider risk, treatment, prognosis You want to look in their mouth, but You should assess medical risk first! WHY? Where to Document Medical History: WHY? What do you see? How do you determine Medical Status? How do you determine ASA? American Society of Anesthesiologists (ASA) Physical Status (PS) Classification System How many PS Classes are there? ASA CLASSIFICATION DEFINITION 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 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  American Society of Anesthesiologists (ASA) Physical Status (PS) Classification System Assign the ASA Exercise A person who is pregnant is _________. A person who is overweight is ________. A person who is morbidly obese is ________. A person who has an implanted pacemaker is _____. A person who is on irregular dialysis schedule is ________. A person who has severe heart disease is _____.  May limit daily activity. Okay for dental care, but may need some modification in care. Serious limitation of daily activity. Not good candidates for dental care; likely major impact on anesthesia and surgery Determining ASA Requires: Review of Medical History & Systems - dialogue – Ask questions... You are responsible for knowing the patient’s – Significant medical disorder – Severity condition and – Stability condition This may require ordering and review of blood ar old female. 5’2” 189 lb. Her BMI is 34.6. She ic back pain and depression, takes Tylox and Cel t nervous and needs one tooth extracted. ooth aches but there is no swelling. esires some oral sedation with a benzodiazepine lam. t is her ASA? ASA II ASA is a spectrum based on current status It does NOT take into account the risk or type  Stable Unstable  r old male. 2’ 3” 49 lb. Takes no medicatio as a sore area on his chin. is his ASA? ASA II Case 35 year old pregnant female. 5’2” 189 lb. Her BMI is 34.6. She has asthma which is controlled with Fluticasone (Flovent). She is a bit nervous and needs one tooth extracted. Her tooth aches but there is no swelling. She desires some anti-anxiety therapy. What is her ASA? ASA II: Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease Case 65 year old female. 5’2” 189 lb. Her BMI is 34.6 and BP is 158/92 She drinks 4 glasses of wine each evening and is diabetic. She does not know her fasting blood glucose or HbA1C level. She is a bit nervous and needs one tooth extracted. Her tooth aches but there is no swelling. She desires some anti-anxiety therapy. You take her fasting blood What is her ASA? glucose and it is 280 mg% ASA III: poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (>3 months) of MI, CVA, TIA, or CAD/stents.  Threshold Lab value Controlled Poorly Controlled Uncontrolled “DLDK” Didn’t look, Don’t know  SAFETY Risk of dental procedure planned Patient factors Procedure Factors - Age, ASA (Medical - Drugs to be administered Status) - Level of consciousness - Airway, Breathing, Bleeding, Circulatory issues - Drug Interactions/ADEs - Drug(s) take daily - Invasiveness/bleeding - Emotional & Cognitive Capacity - Duration of procedure - Functional capacity - Pain level - Tolerance/ functional reserve - Skill, experience of operator - Got Orofacial Health issues? - Patient Risk Assessment Categories 0 1 2 Age and ASA ASA 1 ASA 2 ASA 3 or ASA 4 (Severity) Stable: no signs or No signs or symptoms. Poor control: presence of signs Stability of symptoms. One abnormal lab test and/or symptoms. Abnormal Medical Health No abnormal lab tests. that does not elevate vital signs or lab tests. Not taking drugs with risk. Taking several meds or drugs Drugs significant effects or Taking few meds; drug (steroids, anticoagulants, interactions with interactions unlikely. bisphosphonates, etc.) that can planned medications. Prophylactic medication have significant impact on care Prophylaxis not indicated. or drug interactions likely. indicated. Emotional Not anxious / nervous / Slightly anxious / Very anxious / nervous / can not (Cognitive) can sit still. nervous / can sit still for sit still even for short periods / State & Ability only short period. can not respond to verbal to Sit Still suggestions. Functional MET > 4 Capacity MET = 4 MET < 4 Tolerance / Reserve Minimal problems. Moderate or chronic No pain in orofacial inflammatory condition Signs of active oral region. (no swelling). disease/infection. Orofacial No or small dental No/low level pain (VAS Presence of acute swelling, Health caries. Gingivitis or early < 5). fever, difficulty breathing or periodontal disease. No/mild, nonpainful swallowing, pallor. Pain > 5 on lymphadenopathy. VAS. Fracture of bone, presence Procedural Risk Assessment Categories 0 1 2 Drug Local Anesthetic (LA) < Antibiotics Anxiolytics Conscious Sedation Administration 4 carp Nitrous Oxide Deep Sedation and LA + Epinephrine > 2 General Anesthesia LA + Epinephrine < 2 carpules carpules Significant drug Drug Possible mild drug interaction interaction/adverse effects Interactions/ or adverse effect with respect possible/probable None/unlikely Adverse Effects to medical condition/current medications Responds only to pain Level of Minimal anxiolysis: patient stimuli / Unconscious and Awake and alert Consciousness responds to verbal stimuli unresponsive Invasiveness, Non-invasive: Invasive procedure < 1 Invasive procedure > 1 Pain Level and Visual Analogue Scale hour hour Duration (VAS) 1-3 VAS 4-6 VAS 6-10 Periodontal SRP Implant Placement Dialogue History/Exam Biopsy, Gingival Surgery, Extractions > 5 Erupted Radiographs Painful root canal therapy, Teeth Orthodontics apicoectomy Surgical Extractions, Removable Nonsurgical Extractions < 4 Alveoplasty Prosthodontics Erupted Teeth Osseous Surgery / Sinus Lift Restorative Bone Biopsy Non-surgical Orthognathic Surgery Endodontics Cancer Surgery & Resections Risk depends on the Procedure: In this example, level of anesthesia Local anesthesia N2O N2O+Oral BZDP  Conscious IV Sedation  1 agent, 2 agents, 3 agents General Anesthesia Risk factors with anesthesia: Age, weight/BMI, emotional/ cognitive state, lung capacity (COPD), sleep apnea, Mallampati score Clinical Pearls Medical risk assessment is a key component of the diagnostic process ASA status is one component of the assessment process There are patient-related factors and procedure (skill and attention) related components The ASA-PS classification system is designed for patients undergoing anesthesia Risk assessment is an additive process; more than 1 factor should be assessed for proper evaluation Stability of the condition 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 Value the importance of risk assessment (the patient and the procedure) How Does Endocarditis Occur? Infective Endocarditis | SpringerLink OUTCOMES In hospital mortality > 30% Worse outcomes associated with Shock Heart failure Acute kidney injury Recurrent infection common (>10% Little and Falace’s Dental Management of the ally Compromised Patient J Am Dent Assoc. 2021 Nov;152(11):886-9 doi: 10.1016/j.adaj.2021.09.003. Cardiac Conditions with High Risk of Infective Endocarditis Which are Recommended for Antibiotic Prophylaxis1 1. Prosthetic cardiac valve or material Includes: Transcatheter implantation of prosthetic valves Cardiac valve repair with devices, including annuloplasty, rings, or clips Left ventricular assist devices (LVAD) or implantable heart 2. Previous, relapse , or recurrent infective endocarditis 3. Congenital heart disease (CHD) 4. 1 If Cardiac transplant dental procedure recipients warrants it. who develop All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa This includes all dental procedures except the following procedures and events: Routine anesthetic injections through noninfected tissue Taking of dental radiographs Placement of removable prosthodontic or orthodontic appliances Adjustment of orthodontic appliances Shedding of deciduous teeth and bleeding from