Evaluation of the
Orrett E. Ogle, dds
Prevention is the most important aspect of preparation for medical emergencies.
e 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. is 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.
A thorough initial medical evaluation to identify correctable medical abnormali-
ties and determine the residual risk is mandatory for all patients undergoing dental
treatment. e preoperative evaluation is the foundation for minimizing undesir-
able 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.
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11Pretreatment Evaluation of the Dental PatientOrrett E. Ogle, ddsPrevention is the most important aspect of preparation for medical emergencies. e 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. is 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 AssessmentA thorough initial medical evaluation to identify correctable medical abnormali-ties and determine the residual risk is mandatory for all patients undergoing dental treatment. e preoperative evaluation is the foundation for minimizing undesir-able 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.1 2PRETREATMENT EVALUATION OF THE DENTAL PATIENT1 Medical questionnairee most eﬃcient method of obtaining the medical history is to use a medical questionnaire. e form should be detailed and comprehensive (Fig 1-1). All health questions must be answered. Pertinent posi-tive answers must be addressed, and certain negative answers, such as allergies or bleeding history, must be conﬁrmed. e patient should be verbally ques-tioned about the severity and control of the disease. All medications must be noted.Any medical condition that could aﬀect dental treatment or that could be aﬀected by dental treat-ment should be noted on the record treatment page under a section for past medical history. If the condi-tion 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 promi-nently posted on the health questionnaire. For indi-viduals 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. e 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 pharmaceuti-cal) and allow the dental surgeon to formulate a treat-ment plan in light of the medical status. A patient may present with one or multiple established medical diag-noses, which may alter how dental care is delivered. e role of the dentist is to determine how these med-ical problems will inﬂuence care or how dental care may aﬀect medical treatment. Medical illness may pre-dispose the patient to acute physiologic decompensa-tion under stress or failure to do well posttreatment, or it may lead to drug interactions. e 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 condi-tions that may aﬀect the posttreatment phase (eg, dia-betes [infection and delayed wound healing] or aspirin use [impaired hemostasis]).1Medicationse patient’s medical record must list all drugs that the patient is currently taking. e 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 lap-top or tablet computers. Some available apps are Epocrates (Athenahealth), Davis Drug Guide (Un-bound Medicine), Pocket PC drug guide (Softonic), and Drugs.com medication guide (Drugs.com).e dentist should pay special attention to side eﬀects associated with the patient’s medications, be-cause some side eﬀects may aﬀect dental treatment. For example, heart medications, blood pressure drugs, sedatives, muscle relaxants, and other medi-cations 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 im-pacts 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 com-fort of removable prostheses, cause angular cheilitis, and promote candidal infections.Medical consultationMedical consultations are necessary when diagnostic medical questions are present or when the patient has medical problems that are beyond the dentist’s knowledge base. e dentist should ask the consul-tant 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? 3Medical AssessmentFig 1-1 Sample of long medical history form. NSAIDs, nonsteroidal anti-inammatory drugs.MEDICAL/DENTAL HISTORY QUESTIONNAIREName _________________________________________________ Date _______________________Address ____________________________________________________________________________Home phone _____________________________ Cell phone _______________________________Work phone ______________________________ Email ____________________________________Date of birth ______________________________ Sex M □ F □Marital status _____________________________ Occupation ______________________________Emergency contact _______________________________ Phone ____________________________If someone other than the patient is completing this form, indicate name and relationship to the patient ____________________________________________________________________________________ 1. Are you in good health? □ YES □ NO 2. Has there been any change in your general health within the past year? □ YES □ NO 3. Months since your last physical examination: ___________ 4. Are you under the care of a physician(s)? □ YES □ NOIf yes, provide name and phone number of physician(s): ____________________________________________________________________________________ ____________________________________________________________________________________ 5. Have you ever had any serious illness, operation, or been hospitalized in the past? If so, when and what was the illness or problem? ____________________________________________________________________________________ ____________________________________________________________________________________ 6. List all medications, including the doses that you are currently taking (include over-the-counter medications and herbal remedies): ____________________________________________________________________________________ ____________________________________________________________________________________ 7. Check the appropriate box(es) if you are allergic to or had a reaction to the following:□ Local anesthetics□ Aspirin□ Pain medications (codeine, NSAIDs, narcotics)□ Penicillin or other antibiotics□ Iodine□ Latex 8. Check the appropriate box(es) if you have, or ever had, the following conditions:□ Heart disease□ Chest pain□ Heart murmur□ Rheumatic fever/rheumatic heart disease□ Endocarditis□ Swollen ankles/feet□ Shortness of breath□ Fainting or dizziness□ Stent placement (coronary, kidney, etc)□ Heart pacemaker□ Automatic implantable cardiac debrillator (AICD)□ Organ transplantation (heart, kidney, lung, bone, etc)□ Stroke□ Diabetes□ Kidney disease□ High blood pressure□ Low blood pressure□ Asthma□ Chronic obstructive pulmonary disease (COPD)/emphysema□ Use of an inhaler□ Persistent cough or cough that produces blood□ Tuberculosis□ Liver disease□ Hepatitis, type A, B, or C□ Epilepsy/seizure disorder□ Stomach ulcer 4PRETREATMENT EVALUATION OF THE DENTAL PATIENT1 □ Inammatory bowel disease (Crohn disease, ulcerative colitis)□ Blood disease/disorder (hemophilia, anemia, sickle cell disease)□ Prolonged bleeding/abnormal bleeding□ Thyroid disease□ HIV positive/AIDS□ Sexually transmitted disease□ Sinus problem□ Tumor/growth/cancer□ Nervousness□ Depression□ Eating disorder□ Alzheimer disease 9. Have you ever had radiation treatment? □ YES □ NOIf yes, to what part of your body and when? __________________________________________10. Have you ever been treated with bisphosphonates, such as Zometa, Aredia, Actonel, Fosamax, or Boniva? □ YES □ NO11. Are you taking or have you ever taken any steroid medications? □ YES □ NOIf yes, what medication and when? _________________________________________________12. Is there any other disease, condition, or problem with your health that we should know about? ____________________________________________________________________13. Do you drink alcohol? □ YES □ NO If yes, how many drinks per week? ___________14. Have you ever smoked cigarettes? □ YES □ NO If yes, how many packs per day and for how many years? ______________________________ Year stopped smoking: ______________________________________________________________15. Do you chew tobacco? □ YES □ NO16. Do you use recreational drugs? □ YES □ NO Type/frequency: _________________________________________________________________Women only: 17. Are you pregnant? □ YES □ NO 18. Are you nursing? □ YES □ NOI have read and understood the above questions. Questions I may have had about this form have been answered by the staff to my satisfaction. I will not hold my dentist or any member of the staff responsible for errors or omissions that I may have made in the completion of this form.Signature of patient or guardian ____________________________________ Date ______________FOR COMPLETION BY THE DENTISTSignicant ndings/alerts concerning the medical history: ________________________________________________________________________________________________________________________________________________________________________________________________________Dental/medical management considerations: ____________________________________________________________________________________________________________________________________________________________________________________________________________________Physician consults: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Dentist’s signature ______________________________________ Date ________________________(Fig 1-1 cont) 5Risk AnalysisCLASS II CLASS III CLASS IVAngina only during strenuous or prolonged physical activitySlight limitation, with angina only during vigorous physical activitySymptoms with everyday living activities, ie, moderate limitationSevere limitation of physical activity; inability to perform any activity without angina or angina at restCLASS I CLASS II CLASS III CLASS IVFig 1-3 Canadian Cardiovascular Societyclassication of angina pectoris. (Modied from the Canadian Cardiovascular Society4 with permission.)ASA 1Normal healthy patientPatient with mild systemic diseasePatient with severe systemic diseasePatient with severe systemic disease that is a constant threat to lifeMoribund patient who is not expected to survive without the operationDeclared brain-dead patient whose organs are being removed for donor purposeAdded to ASA classication to denote an emergency case (eg, ASA 4E)ASA 2ASA 3ASA 4ASA 5ASA 6Fig 1-2 ASA classication of physical status. (Reprinted from the ASA3 with permission.)ESimply 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 physi-cian 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 AnalysisA useful step in patient assessment is to assign an American Society of Anesthesiologists (ASA) physical status classiﬁcation (Fig 1-2).1 is will inform the dental team of the degree of risk the patient’s physical ailments constitute. Figure 1-3 and Table 1-1 pro-vide 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 preg-nancy that is close to the estimated date of delivery.1 6PRETREATMENT EVALUATION OF THE DENTAL PATIENT1 TABLE 1-2 Approaches to patient evaluation based on medical history*Suggested preoperative evaluationAllergies Determine if the patient has allergies to drugs or latex.Asthma Emotional factors may trigger an attack. Evaluate wheezing and do not initiate dental treatment if the patient is wheezing. Have a rescue inhaler available. Do not prescribe NSAIDs or aspirin for pain.Cerebrovascular diseaseEvaluate the patient’s blood pressure. Do not undertake elective oral surgery within 9 months of the cerebrovascular accident. Stroke patients usually take anticoagulation therapy. Review the method of anticoagulation and obtain the most recent INR from the patient’s physician.Chronic obstructive pulmonary diseaseOnly the most severe respiratory compromise is a contraindication to routine outpatient dental or oral and maxillofacial surgical care with local anesthesia. Determine the patient’s functional capacity (should be able to walk one or two blocks on level ground at 2 to 3 mph and climb a ight of stairs). Do not perform long or extensive surgical procedures and do not administer 100% oxygen.Coagulopathy Consult a hematologist for individuals with denitively diagnosed coagulopathies. In the absence of a history of bleeding diathesis, abnormal bleeding following exodontia is rare, and obtaining prothrombin time or partial thromboplastin time is not indicated. Coronary artery diseaseStratify the patient’s condition based on symptoms and the exercise capacity by the history. Determine the patient’s functional capacity (should be able to walk one or two blocks on level ground at 2 to 3 mph; climb a ight of stairs; and do light housework). Patients that can perform these functions are at low risk for cardiac decompensation during oral surgery (see Table 1-1).Diabetes mellitusDiabetes is only associated with higher perioperative risks in vascular surgery and coronary artery bypass grafting. Dental treatment poses no problem for patients with well-controlled diabetes. Review symptoms such as excessive thirst, nocturia, malaise, and hunger to assess the level of control.Epilepsy Patients with well-controlled epilepsy are no different from the average patient. Review the patient’s compliance with therapy.TABLE 1-1 Cardiac stratication*Heart disease to be treated in a hospital settingHeart disease that may be treated in an ofce settingMyocardial infarctionWithin past 6 months More than 6 months previouslyAngina 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 Signicant arrhythmias Low functional capacity(eg, inability to walk three city blocks)Dental Treatment StrategyDelay surgery if possible; consult with cardiologist Determine the patient’s functional capacity*Modied from Petranker et al1 with permission.†See Fig 1-2. 7ConclusionSuggested preoperative evaluationHypertension For stages 2 and 3, delay nonemergency treatment until blood pressure can be controlled. For these patients, only emergency procedures (eg, treatment of infection) should be performed.Stage 1 (140–159/80–99 mm Hg): Minimal risk of cardiac complications.Stage 2 (160–179/100–109 mm Hg): Moderate risk of cardiac complications.Stage 3 (>180/>110 mm Hg): High risk of cardiac complications.Liver disease Screen for hepatitis B and C. Treatment for hepatitis C with Harvoni (Gilead Sciences) does not produce any signicant side effects. Patients taking interferon for hepatitis C virus will be anemic and easily fatigued, and their platelet counts may be low. Chronic severe liver disease may increase the INR. Check the history of ethanol usage.Medication The medication history will indicate what conditions the patient is being treated for and the severity of those conditions. Avoid drug interactions.Outpatient treatment with warfarinCheck the current INR with the treating physician. INR values of less than 3.5 do not signicantly inuence the incidence of postoperative bleeding. Dental extractions can be performed without modication of oral anticoagulant treatment. An INR of up to 3.4 is acceptable for extraction of up to three teeth. Local hemostasis with a gelatin sponge and sutures appears to be sufcient to prevent postoperative bleeding.Renal insufciencyConsult with a nephrologist if the patient’s history is inadequate. Compensated renal disease is not a contraindication to in-ofce oral surgery, and simple tooth extraction under local anesthesia is generally not a problem. For patients undergoing dialysis, perform oral surgery on a nondialysis day to avoid problems with anticoagulation. In an emergency, treat the patient more than 4 hours after dialysis. Do not use penicillin with potassium (penicillin VK), because potassium is difcult to eliminate by dialysis and may cause changes in the patient’s electrocardiogram.* Modied from Petranker et al1 with permission. NSAID, nonsteroidal anti-inammatory drug; INR, international normalized ratio.e dental practitioner must emphasize risk reduc-tion strategies and ﬁnd a balance between the risks and beneﬁts of performing an oral procedure. e risk-beneﬁt ratio must always stay in the patient’s favor. e clinician should also consider alternative approaches and when it is appropriate not to perform any intervention.e ﬁrst step in risk mitigation is to ensure that the patient is in as healthy a condition as pos-sible. Table 1-2 outlines an approach for evaluat-ing 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 treat-ment is initiated. At-risk patients include elderly patients; patients with long-standing diabetes, hy-pertension, or dyslipidemia; and patients with a history of smoking, previous myocardial infarction, or angina. Figure 1-4 presents an algorithm for pre-treament evaluation and classiﬁcation of the dental patient to determine when to continue with routine dental care, modify treatment, or refer for medical consultation.Conclusione dentist can prevent many emergencies by com-pleting a thorough pretreatment assessment to iden-tify the risks associated with treatment for each pa-tient. e assessment begins with a medical history questionnaire, including an investigation of all medi-cations the patient is taking. When necessary, the patient’s physician or medical specialists should be consulted prior to treatment. Classifying the patient’s health enables the dentist to alter the treatment plan as required and optimally stabilize the patient’s medi-cal condition prior to dental treatment.(Table 1-2 cont) 8PRETREATMENT EVALUATION OF THE DENTAL PATIENT1 References1. Petranker S, Nikoyan L, Ogle OE. Preoperative evalu-ation of the surgical patient. Dent Clin North Am 2012;56:163–181.2. Porter SR, Scully C, Hegarty AM. An update of the eti-ology and management of xerostomia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;97:28–46.3. American Society of Anesthesiologists. ASA physical status classiﬁcation system. Last approved October 15, 2014. http://www.asahq.org/resources/clinical-information/asa-physical-status-classiﬁcation-system. Accessed March 3, 2015. 4. Canadian Cardiovascular Society. Grading of an-gina pectoris. http://www.ccs.ca/images/Guidelines/Guidelines_POS_Library/Ang_Gui_1976.pdf. Accessed March 13, 2015.Fig 1-4 Algorithm for pretreatment evaluation and classication of the dental patient. MI, myocardial infarction; UA, unstable angina; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease.*At-risk conditions• Uncontrolled hypertension• MI in last 9 months or UA• CHF with exercise tolerance of less than two ights of stairs• Cerebrovascual accident in last 6 months• COPD with exercise tolerance of less than two ights of stairs• Hepatic disease• Uncontrolled diabetes• Anticoagulation/coagulopathiesRequire medical consultation and treatmentComplete routine dental careModify dental careIf disease is poorly controlled or risk factors are signicant*If ASA 2, 3, 4Take blood pressure and pulse; perform full head and neck examNote• Medical illnesses• Medication allergies• Social history (tobacco and alcohol use)• Current medicationPretreatment evaluation1. Patient completes medical history form2. Dentist reviews medical historyIf ASA 1Assign patient an ASA class (see Fig 1-2)If disease is controlled and risk factors are minimalExpand medical history and evaluate for disease control and risk factors