The diagnostic procedures described above are also designed to help the dentist (1) recognize significant deviations from normal general health status that may affect dental treatment, (2) make informed judgments on the risk of dental procedures, and (3) identify the need for medical consultation to provide assistance in diagnosing or treating systemic disease that may be an etiologic factor in oral disease or that is likely to be worsened by the proposed dental treatment. The end point of the diagnostic process is thus twofold, and an evaluation of any special risks posed by a patient’s compromised medical status under the circumstances of the planned anesthetic, diagnostic, or medical or surgical treatment procedures must also be entered in the chart, usually as an addendum to the plan of treatment. This process of medical risk assessment is the responsibility of all clinicians prior to any anesthetic, diagnostic, or therapeutic procedure and applies to outpatient as well as inpatient situations.
A routine of initial history taking and physical examination is essential for all dental patients because even the apparently healthy patient may on evaluation be found to have history or examination findings of sufficient significance to cause the dentist to re-evaluate the plan of treatment, modify a medication, or even defer a particular treatment until additional diagnostic data are available. To respect the familiar medical axiom primum non nocere (first, do no harm), all procedures carried out on a patient and all prescriptions given to a patient should be preceded by the dentist’s conscious consideration of the risk of the particular procedure. Medical risk assessment, by establishing a formal summary in the chart of the specific risks that are likely to occur in treating a particular patient, ensures that continuous self-evaluation will be carried out by the clinician.
A decision for or against dental treatment for a medically complex patient is traditionally arrived at by the dentist’s requesting the patient’s physician to “clear the patient for dental care.” Unfortunately, in many cases, the physician is provided with little information about the nature of the proposed dental treatment and may have little (other than personal experience with dental care) on which to judge the stress likely to be associated with the proposed dental treatment. The response of a given patient to specific dental treatment situations may also be unpredictable, particularly when the patient has a number of disease processes and is maintained on a variety of medications. In addition, the practitioner identified by the patient as his or her physician may not have adequate or complete data from previous evaluations, data necessary to make an informed judgment on the patient’s likely response to dental care. All too frequently, the dentist receives the brief comment “OK for dental care,” which suggests that clearances are often given casually and subjectively rather than being based on objective physiologic data.
A decision for or against dental treatment for a medically complex patient is traditionally arrived at by the dentist’s requesting the patient’s physician to “clear the patient for dental care.” Unfortunately, in many cases, the physician is provided with little information about the nature of the proposed dental treatment and may have little (other than personal experience with dental care) on which to judge the stress likely to be associated with the proposed dental treatment. The response of a given patient to specific dental treatment situations may also be unpredictable, particularly when the patient has a number of disease processes and is maintained on a variety of medications. In addition, the practitioner identified by the patient as his or her physician may not have adequate or complete data from previous evaluations, data necessary to make an informed judgment on the patient’s likely response to dental care. All too frequently, the dentist receives the brief comment “OK for dental care,” which suggests that clearances are often given casually and subjectively rather than being based on objective physiologic data.
More important, the practice of having the patient “cleared” for dental care confuses the issue of responsibility for untoward events occurring during dental treatment. Although the dentist often must rely on the physician or a consultant for expert diagnostic information and for an opinion about the advisability of dental treatment or the need for special precautions, the dentist retains the primary responsibility for the procedures actually carried out and for the immediate management of any untoward complications .The dentist is most familiar with the procedures he or she is carrying out, as well as with their likely complications, but the dentist must also be able to assess patients for medical or other problems that are likely to set the stage for the development of complications. Thus, physicians can only advise on what type of modifications are necessary to treat a patient, but the treating dentist is ultimately responsible for the safety of the patient.
A number of guides have been developed to facilitate efficient and accurate preoperative assessment of medical risk.
The majority of these guides were developed for the assessment of risks associated with general anesthesia or major surgery and focus on mortality as the dependent variable; guides for the assessment of hazards associated with dental or oral surgical procedures performed under local or regional anesthesia usually take the same approach. Of these, the most commonly used are the American Society of Anesthesiologists (ASA) Physical Scoring System
(illustrated, in a form modified for dental use, in Table 2-8) and Goldman’s Cardiac Risk Index
(Table 2-9). Although scores such as these are commonly included in the preoperative evaluation of patients admitted to hospitals for dental surgery, they use relatively broad risk categories, and their applicability to both inpatient and outpatient dental procedures is limited. The validity of preanesthetic risk assessment has also been questioned by several authors in light of data suggesting that the “demonstrable competence” of the anesthetist can also be a significant factor in anesthetic outcome.
surgery residency programs. It is hoped that revisions in dental undergraduate curricula will recognize this need and provide greater emphasis on both the pathophysiology of systemic disease and the practical clinical evaluation and management of medically compromised patients in the dental student’s program.
A number of guides have been developed to facilitate efficient and accurate preoperative assessment of medical risk.
The majority of these guides were developed for the assessment of risks associated with general anesthesia or major surgery and focus on mortality as the dependent variable; guides for the assessment of hazards associated with dental or oral surgical procedures performed under local or regional anesthesia usually take the same approach. Of these, the most commonly used are the American Society of Anesthesiologists (ASA) Physical Scoring System
(illustrated, in a form modified for dental use, in Table 2-8) and Goldman’s Cardiac Risk Index
(Table 2-9). Although scores such as these are commonly included in the preoperative evaluation of patients admitted to hospitals for dental surgery, they use relatively broad risk categories, and their applicability to both inpatient and outpatient dental procedures is limited. The validity of preanesthetic risk assessment has also been questioned by several authors in light of data suggesting that the “demonstrable competence” of the anesthetist can also be a significant factor in anesthetic outcome.
surgery residency programs. It is hoped that revisions in dental undergraduate curricula will recognize this need and provide greater emphasis on both the pathophysiology of systemic disease and the practical clinical evaluation and management of medically compromised patients in the dental student’s program.