3. risk assessment and medical history

1. Dr. Suhail S. Kishawi
Consultant in Endocrinology and Diabetes
Consultant in Internal Medicine
Medical Risk Assessment
for Dental Patients

2. “The mouth is the mirror of
overall health”
Whatever affects our mouth
should affect our body and
vice versa

3. What is the Oral-Systemic Connection
and why is it important?
• Oral health and overall health are closely related
• General health risk factors also affect oral and
craniofacial health (ex. tobacco use, poor diet)
• Poor oral health has effects on quality of life and
general well-being
• The mouth and face can serve as a mirror of
health and disease (ex. HIV infection)

4. What is the Oral-Systemic Connection
and why is it important?
• The mouth can serve as a portal for infection (ex.
endocarditis)
– Several studies have shown that oral flora/infections are
associated with higher morbidity and mortality,
especially in certain patient populations
(immunocomprised) (ex. neutropenic, chemotherapy
pts, transplant patients)
– Oral bacteria have potential for causing respiratory
infections (ex. COPD pts, bacterial pneumonia)

5. What is the Oral-Systemic Connection
and why is it important?
• Periodontal disease—Diabetes connection
– Having diabetes increases incidence and progression of
periodontal disease
– Periodontal disease can affect glucose control in
diabetic patients
• Oral infection—Cardiovascular disease (heart
disease/stroke) connection
• Periodontal disease—Adverse pregnancy outcomes
connection (ex. preterm labor, preterm rupture of
membranes)

6. Oral-Systemic Connection
• Medical problems frequently start showing signs and
symptoms in a person’s mouth before they show any
symptoms affecting their general health.
• Often such problems are first detected by a dental surgeon,
who then refers patients to a general physician for a
thorough examination.
• Frequently, people who have come to a dentist’s office will
skip giving their medical records, even when asked
because they do not understand the correlation between
the two.

7. Occupational Health Problems in
Modern Dentistry
• Despite numerous technical advances in recent
years, many occupational health problems still
persist in modern dentistry.
• These include :
• Percutaneous Exposure Incidents (PEI)
• Exposure to infectious diseases (including bioaerosols)
• Radiation
• Dental materials, and noise
• Musculoskeletal disorders
• Dermatitis and respiratory disorders
• Eye injuries
• Psychological problems

8. Occupational Health Problems in
Modern Dentistry
• PEI remain a particular concern, as there is an almost
constant risk of exposure to serious infectious agents.
• Strategies to minimise PEI and their consequences should
continue to be employed, including sound infection control
practices, continuing education and hepatitis B
immunization.
• As part of any infection control protocols, dentists should
continue to utilize personal protective measures and
appropriate sterilization or other high-level disinfection
techniques.

9. Occupational Health Problems in
Modern Dentistry
 Aside from biological hazards, dentists continue to suffer a
high prevalence of musculoskeletal disorders (MSD),
especially of the back, neck and shoulders.
 Continuing education and investigation of appropriate
interventions to help reduce the prevalence of MSD and
contact dermatitis are also needed.
 For these reasons, it is therefore important that dentists
remain constantly informed regarding up-to-date measures
on how to deal with newer technologies and dental
materials.

10. Occupational Health Problems in
Modern Dentistry
IMPORTANT QUESTIONS
Can we provide routine dental treatment to
patients without endangering their (or our)
health and well being?
Is the benefit of having dental treatment worth
the risk to the patient ?

11. What do we do in the course of providing
dental care that can affect the health and
well being of a patient?
• Instill fear
• Inflict pain
• Inject local anesthetic
solutions
• Inject potent
vasoconstrictors
• Cause bleeding
• Control body position
• Expose to radiation
• Expose to dental
materials
• Prescribe medications
• Alter oral function
• Alter appearance

12. Potential for the Occurrence of
Adverse Events
Dependent upon:
 The medical condition of the patient (diagnosis,
severity, stability, control)
 The cardiopulmonary reserve which the patient has to
be able to respond to physical/emotional challenges
 The emotional stability of the patient (fear, anxiety)
 The type of dental procedure (invasiveness, length of
procedure, blood loss, type of anesthesia, use of
vasoconstrictor)

13. Assessing the risk for the
occurrence of Adverse Events
• Immediate adverse events
– e.g. heart attack, stroke, hypoglycemia, allergic
reaction, drug reaction, seizure
• Delayed adverse events
– e.g. bleeding, infection, adrenal crisis

14. Risk Assessment?
Can we provide routine dental treatment to this
patient without endangering their (or our) health
and well being?
Yes. No problems are anticipated, and treatment can be
delivered in the usual manner. (Benefit > Risk)
Yes, but potential problems may be anticipated, and
modifications in the delivery of treatment are necessary.
(Benefit > Risk)
No. Potential problems exist that are serious enough to make
it inadvisable to provide elective dental treatment. (Risk >
Benefit)

15. Risk?
Medical Condition?
Severity
Stability
Control
Functional Capacity?
METs
Emotional Status?
Fear
Anxiety
Dental Procedure?
Invasiveness
Length of procedure
Blood Loss
Vasoconstrictor use
Risk Assessment
Decreased Risk
Increased Risk
The Metabolic Equivalent of Task (MET), or simply metabolic
equivalent, is a physiological measure expressing the energy cost of
physical activities and is defined as the ratio of metabolic rate (and
therefore the rate of energy consumption) during a specific physical
activity to a reference metabolic rate, set by convention to 3.5 ml
O2·kg−1
·min−1
or equivalently. MET values of activities range from 0.9
(sleeping) to 23 (running at 22.5 km/h

16. Risk Assessment
• You may not be able to completely eliminate the risk of an
adverse event occurring during dental treatment or as a
result of dental treatment, however, our goal is to reduce
that risk as much as possible
• The issue then becomes whether the remaining risk is
acceptable and that having the dental treatment is of more
benefit than not having it
Risk vs Benefit?

17. Medical Risk Assessment Begins with
Identification of Medical Problems
• Medical history (questionnaire/interview)
• Physical examination (general survey, face, eyes,
skin, etc)
• Laboratory tests (screening, confirmation)
• Medical consultation (physician, dentist,
pharmacist)

18. Why take a medical history?
Many medical problems and/or drugs can affect or influence
the provision of dental care
Examples:
– Heart disease (infection, bleeding, drug interactions, cause an
MI or angina, oral lesions)
– Allergies (reactions to local anesthetics, antibiotics, analgesics,
latex)
– Diabetes (infection, hypoglycemia, periodontal disease)
– Bleeding disorders; drug induced or genetic (abnormal
hemostasis)

19. Medical History
• Printed questionnaire (patient must be literate, competent,
of legal age)
• Follow-up with dialogue/research; make notes on
questionnaire
• Use ink - not pencil
• Patient, student, and faculty signature, date
• Update regularly
– Inquire at each appointment about any changes in health or
medications since previous appointment; a brief comment is
then included in the progress note
– New questionnaire should be completed every 2 years

21. The patient has completed filling out the medical
history form….., now what??
+ =

22. Gathering Information and Decision Making
• Review the Medical History form and note positive
responses
• Question the patient to gain more information about those
positive responses
• Insignificant problems can be disregarded
• Potentially significant disorders OR unfamiliar disorders
require further thought and/or investigation
• Resources to help in the evaluation of the medical history?

23. Reference Sources for Medical Information
• Little,J, Falace,D, Miller,C,
Rhodus,N: Dental
Management of the
Medically Compromised
Patient
• Harrison’s Principles of
Internal Medicine
• Cecil’s Textbook of Internal
Medicine
• The Merck Manual

24. Clinical Examination
• General appearance
• Behavior
• Vital signs
• Head and neck
• Oral tissues
• Radiographs
• Laboratory tests

25. Medical Consultation
• Make sure you
understand why you
are seeking a
consultation, and
exactly what it is that
you want to know
• Ask specific
questions
• Be brief and to the
point

26. Medical Consultation : Example
• Problem: Pt reports a history of heart failure and
an inability to be able to climb a flight of stairs
without getting short of breath or having chest
pain
• Reason for Consultation: Can this patient tolerate
routine dental treatment including fillings, and
gingival surgery using local anesthetic with
1:100,000 epinephrine?

27. Answer these questions….
• Are there any potential problems related to the
provision of dental care?
– If not, proceed with treatment in the usual manner
– If yes, then…
• What do I need to do to avoid those problems?
• Are there any oral manifestations
related to the disease or it’s
treatment?

28. Examples of treatment modifications
• Avoid the administration or prescription of certain
drugs (e.g. erythromycin for patients taking certain
lipid-lowering drugs)
• Make position changes slowly (e.g. BP medications)
• Ensure a comfortable chair position (e.g. heart failure,
emphysema, pregnancy, arthritis)
• Provide postoperative antibiotics (poorly controlled
diabetic with dental abscess)

29. Examples of treatment modifications
• Limit treatment to specific times (e.g. hemodialysis;
pregnancy)
• Preoperative anticoagulation level; blood pressure
• Preoperative antibiotics (e.g. prosthetic heart valve)
• Provide pre-operative or intra-operative sedation (e.g.
unstable cardiac patient; fearful patient)
• Minimize the intraoperative use of epinephrine in local
anesthesia, (e.g. unstable cardiac patient)

30. THANK YOUTHANK YOU