SENIOR ORAL MEDICINE
Chapter 1: Physical Evaluation
& Risk Assessment
Susan Settle, D.D.S.
August 26, 2010
Interrelationships Of
Medicine And Dentistry
Physical Evaluation & Risk Assessment
Practice Goals
Deliver The Best Care Possible For
The Patient
Be Aware What Impact The Systemic
Status And Medications May Have On
Delivery Of Treatment
To Feel Comfortable Treating A
Variety Of Patients
Value Of The Health History Questionnaire &
Medical History
It Is The Cornerstone Of Patient
Evaluation & Risk Assessment
Identifies Systemic Disease
Identifies Medications
Establishes Rapport
Medicolegal Protection For The
Practitioner
Risk Assessment Involves
Identification Of:
Nature, Severity, & Stability Of The
Patient’s Medical Condition
Functional Capacity Of The Patient
Emotional State Of The Patient
Type & Magnitude Of The Dental
Procedure
American Society Of
Anesthesiologists
Classification Of Patients
Based On Medical
Assessment Of Patient
ASA Classification Groups
ASA I
Normal, Healthy Patient
ASA II
Mild Disease
Does Not Interfere With Daily Activities
May Need Some Alteration Of Dental
Treatment
Examples: Mild HTN Or COPD,Type II
Diabetes, Allergy, Well-Controlled
Epilepsy Or Asthma
ASA Classification Groups
ASA III
Moderate To Severe Systemic Disease
May Alter Daily Activities
Generally Requires Alteration Of Dental
Treatment
Medications
Type I Diabetes, Moderate To Severe HTN,
Angina, CHF, AIDS, COPD, Hemophilia, MI In
Last 6 Months
ASA Classification Groups
ASA IV
Severe Systemic Disease
Life-Threatening Conditions
Requires Alteration Of Dental
Management
ESRD, Liver Failure, Advanced
AIDS
ASA Physical Status
 P1 A normal healthy patient
 P2 A patient with mild systemic disease
 P3 A patient with severe systemic disease
 P4 A patient with severe systemic disease that
is a constant threat to life
 P5 A moribund patient who is not expected to
survive without the operation
 P6 A declared brain-dead patient whose organs
are being removed for donor purposes
Patients Requiring Further Evaluation By
The Anesthesiologist For General Surgery
Morbid Obesity (BMI>38)
MI Within 6 Months
Angioplasty Within 3 Months
History Of Heart Transplant
History Of Unstable Angina
Patients Requiring Further Evaluation By
The Anesthesiologist For General Surgery
History Of Carotid Surgery Within 6
Months
History Of Steroid-Dependent
Asthma Or COPD Particularly With
URI In Last 4 Weeks
 (Upper Respiratory Infection)
Seizure Within 3 Months While
Taking Anticonvulsants
Patients Requiring Further Evaluation By
The Anesthesiologist For General Surgery
History Of Allergy To Local Anesthetics
History Of Dialysis Or Renal Transplant
History Of CVA/TIA Within 6 Months
 (Cerebrovascular Accident/Transient Ischemic Attack)
Systolic BP>200 And/Or Diastolic BP>100
History Of Cirrhosis (Need Recent CBC, INR,
LFT)
Risk Assessment
ABCs Of Risk Assessment Are More
Helpful Than The ASA Physical
Classification System
ASA System Does Not Provide
Information About Modification Of
Treatment
Risk Assessment
A:
Antibiotics
Anesthesia
Anxiety
Allergy
B:
Bleeding
C:
Chair Position
D:
Drugs
Devices
E:
Equipment
Emergencies
Medical History Overview
Cardiovascular Diseases
Heart Failure (CHF)
A Clinical Syndrome Complex
No Routine Treatment If Not Controlled
Consider Chair Position
Cardiac Glycosides (Digoxin, Lanoxin)
+ Vasoconstrictors  Arrhythmias
(Avoid Vasoconstrictors If Possible)
Medical History Overview
Cardiovascular Diseases (Cont.)
Myocardial Infarction
No
Routine Treatment If
In Last 1-6 Months (Refer To Your Text!)
Increased Risk Of Reinfarction, CHF
Arrhythmias
&
Medical History Overview
Cardiovascular
Diseases (Cont.)
Angina Pectoris
Stable
Unstable: Chest Pain At Rest
 Increased Incidence Of
Arrhythmias, MI’s, Sudden
Death
Elective Treatment
Contraindicated
Medical History Overview
Cardiovascular Diseases (Cont.)
Hypertension
Non-Selective Beta-Blockers
(Propranolol, Inderal)
+Vasoconstrictors
Possible Hypertensive Crisis
Medical History Overview
Cardiovascular Diseases (Cont.)
Murmur
Functional
Organic
Regurgitation Associated With MVP
Diagnosed By Echocardiogram
No Recommendation For
Endocarditis Prophylaxis From
AHA
Medical History Overview
Cardiovascular Diseases (Cont.)
Rheumatic Heart Disease
From Rheumatic Fever Following A
Beta-Hemolytic Streptococcal Infection
Valve Damage?
No Recommendation For
Endocarditis Prophylaxis
Medical History Overview
Cardiovascular Diseases (Cont.)
Congenital Heart Disease
Prosthetic Heart Valves
Arrhythmias: Frequently Related To
Heart Failure Or Ischemic
Disease
Medical History Overview
Cardiovascular Diseases (Cont.)
Cardiac Surgery
CABG (Coronary Artery
Bypass Graft)
Transplant:
Immunosuppression
Considerations
Medical History Overview
Cardiovascular Diseases (Cont.)
Stroke Or CVA: Anticoagulation
Possibilities
Aneurysm: If Repaired, No
Prophylaxis Required After
6 Months
Medical History Overview
Hematologic Disorders
Transfusion: Why Was It Done? Risks
Anemia
Leukemia
“Bleeds Longer Than Normal”
Genetic (Hemophilias)
Acquired (Pharmacotherapy)
Medical History Overview
Neural/Sensory Disorders
Headache, Dizziness, Syncope
Glaucoma: Avoid Anticholinergic Drugs
If Patient Has Closed-Angle Glaucoma
(Banthine, Pro-Banthine)
Given To “Dry Up” Saliva
Epilepsy, Seizures, Convulsions
Psychiatric Treatment
Medical History Overview
GI Diseases
Peptic Ulcer Disease
(PUD)
Inflammatory Bowel
Disease (Crohn’s,
Ulcerative Colitis - IBD)
Irritable Bowel Syndrome
(IBS)
Hepatitis, Cirrhosis
Medical History Overview
Respiratory Diseases
Allergic History
COPD-Chronic Obstructive Pulmonary
Disease (Emphysema, Chronic
Bronchitis)
Asthma
Tuberculosis
Sleep Apnea/Snoring
Medical History Overview
Musculoskeletal, Mucocutaneous, Dermal
Prosthetic Joints
Arthritis (Osteo & Rheumatoid)
Medical History Overview
Autoimmune Disorders
Rheumatoid Arthritis
SLE (Systemic Lupus
Erythematosus)
Sjögren’s Syndrome
Medical History Overview
Autoimmune
Disorders
Scleroderma
RAS (Recurrent Aphthous
Stomatitis) Or “Major”
Aphthous
Medical History Overview
Endocrine Diseases
Diabetes
Thyroid (Hypo, Hyper)
Urinary Tract
Kidney Disease
Bladder Disease
Medical History Overview
Sexually-Transmitted Diseases
Gonorrhea
Syphilis
HIV Positive
AIDS
Medical History Overview
Social History
Tobacco
Alcohol
Recreational Drugs
Medical History Overview
Cancer History Or
Treatment
Chemotherapy
Radiation Therapy
Surgery
Medical History Overview
Operations/Hospitalizations & Sequelae
Anesthesia Complications
Medical History Overview
Medications
Use Appropriate References When
Looking Up Something
Steroids, Anticoagulants,
Immunosuppressives
Allergies, Adverse Reactions
Stress Importance Of OTC (Over The
Counter) Drugs
Medical History Overview
Dental History
Vital Signs: Initial Exam, Recalls,
Whenever Indicated
Pulse
Rate & Rhythm (60-100
bpm)
BP: S <120; D <80
Respiration (12-16 bpm)
Medical History Overview
General Physical Assessment
Gait, Speech, Skin, Nails,
Eyes, Nose, Ears, Neck
Medical History Overview
Laboratory Tests
(Indicated?)
Hematocrit, Hemoglobin
Platelet Count, PT (INR)
Fasting Blood Glucose
Biopsy
Culture & Sensitivity
Who Orders The Tests?
Communication With Physician
HIPAA Forms Must Be Filled
Out By Patient At Physician’s
Office
HIPAA Forms Must Be Filled
Out By Patient At Dentist’s
Office
Communication With Physician
Phone & “Sidewalk”
Consults Should Be
Documented In Progress
Notes
Formal Documentation
Preferred
And Now For Some Relatively New
Stuff:
2007 AHA Guidelines for Endocarditis
Prophylaxis
History Of Bisphosphonate Use
2009 American Association of Orthopaedic
Surgeons Information Statement
Regarding Prosthetic Joint Prophylaxis
Risk Is Always Increased When
You Treat A Medically
Compromised Patient
Your Goal Is To Reduce The Risk
As Much As Possible