E-Book, Englisch, 200 Seiten
ISBN: 978-0-86715-911-0
Verlag: Quintessence Publishing Co, Inc
Format: EPUB
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)
Orrett E. Ogle, DDS is a practicing Oral & Maxillofacial Surgeon in Floral Park, NY. Dr. Ogle graduated from Columbia University College of Physicians & Surgeons in 1974 and has been in practice for 43 years.
Autoren/Hrsg.
Weitere Infos & Material
1 Pretreatment Evaluation of the Dental Patient Orrett E. Ogle, DDS Prevention is the most important aspect of preparation for medical emergencies. The dental practitioner can prevent many emergencies by conducting a thorough medical history, making appropriate alterations to dental treatment as required, and optimally stabilizing the patient’s medical condition when possible. This chapter will discuss pretreatment assessments that are essential to ensuring that the dentist can provide dental treatment that is also medically appropriate for each patient. Medical Assessment A thorough initial medical evaluation to identify correctable medical abnormalities and determine the residual risk is mandatory for all patients undergoing dental treatment. The preoperative evaluation is the foundation for minimizing undesirable outcomes; the clinician can use the assessment to identify and mitigate risk factors and develop a plan that will best balance the risks, benefits, and alternatives that are available. Routine preoperative evaluation will vary among patients, depending on their age and general health. In evaluating a patient for any interventional procedure, the dental surgeon must consider two aspects: (1) the necessary work-up that must be performed prior to treatment and (2) whether the patient can safely undergo the planned dental or surgical procedure. Medical questionnaire The most efficient method of obtaining the medical history is to use a medical questionnaire. The form should be detailed and comprehensive (Fig 1-1). All health questions must be answered. Pertinent positive answers must be addressed, and certain negative answers, such as allergies or bleeding history, must be confirmed. The patient should be verbally questioned about the severity and control of the disease. All medications must be noted.
Fig 1-1 Sample of long medical history form. NSAIDs, nonsteroidal anti-inflammatory drugs. Any medical condition that could affect dental treatment or that could be affected by dental treatment should be noted on the record treatment page under a section for past medical history. If the condition is critical (eg, allergies or heart conditions), the external portion of the chart should be flagged with a sticker for medical alerts or annotated in red ink. Electronic records should also be flagged using the method available in the software system. Emergency telephone numbers should be prominently posted on the health questionnaire. For individuals with serious illness, the name and telephone number of the primary care physician should also be obtained. If there are serious health issues, the health history should be updated at every visit, and any changes in the condition should be noted in the record. The health history must be dated and signed by the patient or parent/guardian and the dentist. Failure to sign the form may imply that the dentist did not review it. A detailed medical history will identify potential management problems (physiologic and pharmaceutical) and allow the dental surgeon to formulate a treatment plan in light of the medical status. A patient may present with one or multiple established medical diagnoses, which may alter how dental care is delivered. The role of the dentist is to determine how these medical problems will influence care or how dental care may affect medical treatment. Medical illness may predispose the patient to acute physiologic decompensation under stress or failure to do well posttreatment, or it may lead to drug interactions. The dentist must be aware of potential results and what precautions must be taken to minimize risks. Clinicians must identify issues that should be addressed prior to treatment (eg, insulin, warfarin, or aspirin use), illnesses that may cause physiologic decompensation during treatment (eg, angina, seizure disorders, or asthma), and conditions that may affect the posttreatment phase (eg, diabetes [infection and delayed wound healing] or aspirin use [impaired hemostasis]).1 Medications The patient’s medical record must list all drugs that the patient is currently taking. The dentist should know what each drug is and why it is being used. Information on drugs can be obtained very quickly from programs downloaded to smartphones or laptop or tablet computers. Some available apps are Epocrates (Athenahealth), Davis Drug Guide (Unbound Medicine), Pocket PC drug guide (Softonic), and Drugs.com medication guide (Drugs.com). The dentist should pay special attention to side effects associated with the patient’s medications, because some side effects may affect dental treatment. For example, heart medications, blood pressure drugs, sedatives, muscle relaxants, and other medications may contribute to bladder control problems. Patients taking these drugs need to urinate frequently and will not be able to tolerate long appointments. Pregabalin (Lyrica, Pfizer), thiazides, all diuretics, and carbonic anhydrase inhibitors are other drugs that will cause frequent urination and urgency. Another common medication side effect that impacts dental care is xerostomia. More than 500 drugs can cause xerostomia. Medication use is the most frequent cause of xerostomia complaints, especially among the elderly.2 Xerostomia can affect the comfort of removable prostheses, cause angular cheilitis, and promote candidal infections. Medical consultation Medical consultations are necessary when diagnostic medical questions are present or when the patient has medical problems that are beyond the dentist’s knowledge base. The dentist should ask the consultant at least these basic questions: • Is the patient in optimal condition to undergo routine dental treatment in an office setting? • Does the patient have reversible disease? • Where is the patient in the continuum of disease? Simply sending a request asking a physician to “clear a patient” for a dental procedure is likely to yield an equally uninformative response of “patient cleared” and must be avoided.1 Even when a physician states that a patient is medically cleared, the final decision regarding treatment is the responsibility of the dental surgeon. A medical consultation is simply a tool for risk assessment and is not a “green light” to the dentist indicating that all will be well. Risk Analysis A useful step in patient assessment is to assign an American Society of Anesthesiologists (ASA) physical status classification (Fig 1-2).1 This will inform the dental team of the degree of risk the patient’s physical ailments constitute. Figure 1-3 and Table 1-1 provide further classification strategies1,4 for patients who have cardiac disease. Nondisease factors that are not listed in the ASA classification but that must be regarded as an additional risk are extreme age (more than 80 years), increased body mass index, and pregnancy that is close to the estimated date of delivery.1 Fig 1-2 ASA classification of physical status. (Reprinted from the ASA3 with permission.) Fig 1-3 Canadian Cardiovascular Society classification of angina pectoris. (Modified from the Canadian Cardiovascular Society4 with permission.) TABLE 1-1 Cardiac stratification* Heart disease to be treated in a hospital setting Heart disease that may be treated in an office setting Myocardial infarction Within past 6 months More than 6 months previously Angina pectoris Unstable or severe (Class III or IV)† Mild (Class I or II)† Heart failure Decompensated heart failure (Class III or IV; ejection fraction < 30%) Compensated or prior heart failure (Class I or II) Other Significant arrhythmias Low functional capacity (eg, inability to walk three city blocks) Dental Treatment Strategy Delay surgery if possible; consult with cardiologist Determine the patient’s functional capacity *Modified from Petranker et al1 with permission. †See Fig 1-2. The dental practitioner must emphasize risk reduction strategies and find a balance between the risks and benefits of performing an oral procedure. The risk-benefit ratio must always stay in the patient’s favor. The clinician should also consider alternative approaches and when it is appropriate not to perform any intervention. The first step in risk mitigation is to ensure that the patient is in as healthy a condition as possible. Table 1-2 outlines an approach for evaluating patients depending on the answers provided in the medical history.1 Disease that can be reversed, should be.1 Patients at risk for cardiovascular disease who are not currently under medical care should be evaluated by an internal medicine specialist for disease and managed medically before dental treatment is initiated. At-risk patients include elderly patients; patients with long-standing diabetes, hypertension, or dyslipidemia; and...
