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Medical History, Physical Evaluation, and Risk Assessment

Lauren L. Patton, DDS

Abbreviations used in this chapter

I. Background

The US and global population demographics are constantly changing, chronic diseases are becoming more prevalent, new medications are being developed and brought to the market, and new and reemerging infectious diseases are being identified. The average life expectancy in the USA increased from 70.0 years to 76.2 years for males and from 77.4 years to 81.0 years for females in the 30 years between 1980 and 2010.1 With this increased life expectancy comes an increase in chronic medical conditions. Americans' use of prescription drugs has grown over the past half-century due to many factors, with almost one-half of the US population taking at least one prescription drug in the preceding month and 1 in 10 taking five or more drugs.1

More patients seeking oral health care have underlying medical conditions that may alter oral health status, treatment approaches, and outcomes. The challenges of medical history information gathering and risk assessment required for safe dental treatment planning and care delivery will be discussed and presented in a practical manner applicable to day-to-day needs of the general practice dentist. There are four key considerations that serve as a framework for assessing and managing the risks of dental care used in this book, although additional considerations may be relevant for certain medical conditions. The key considerations are impaired hemostasis, susceptibility to infections, drug actions/interactions, and ability to tolerate the stress of dental care. The potential for the dental practice to encounter different types of medical emergencies is related to the patient's medical health, adequacy of management, and stress tolerance.

Four key risks of dental care

• Impaired hemostasis
• Susceptibility to infections
• Drug actions/interactions
• Patient's ability to tolerate dental care

II. Medical History

A medical history can be recorded by the patient in advance of the dental appointment and reviewed by providers seeking clarification of patient responses. In the national shift to electronic health records, medical history, medications, and allergies may be recorded in a number of data collection formats and in a variety of settings, including use of web-based applications. Personal information should be kept private and shared only in compliance with privacy rules.

An example is the American Dental Association (ADA) Health History Form (see Fig. 1.1; available at http://www.ada.org), which is comprised of the following:

• demographic information;
• screening questions for active tuberculosis;
• dental information;
• medical information, including physician contact information;
• hospitalizations, illnesses, and surgeries;
• modified review of systems and diseases survey;
• medications (prescribed, over-the-counter, and natural remedies, including oral and intravenous bisphosphonates);
• substance use history, including tobacco, alcohol, and controlled substances;
• allergies;
• a query about prosthetic joint replacements and any prior antibiotic recommendations by a physician or dentist and name and contact phone number of recommending provider;
• a query about the four cardiac disease conditions recommended for antibiotic coverage for prevention of infective endocarditis;
• a query of women about current pregnancy, nursing status, or birth control pills or hormonal therapy.

Figure 1.1 ADA Health History Form: (a) adult form S500 page 1, copyright 2007; (b) adult form S500 page 2, copyright 2007. American Dental Association. Reproduced with permission of the American Dental Association.

There is a Child Health/Dental History Form (see Fig. 1.2) also available from the ADA that focuses on inherited, developmental, infectious, and acquired diseases of importance to dental health-care delivery for children.

Figure 1.2 ADA Child Health/Dental History Form S707, copyright 2006. American Dental Association. Reproduced with permission of the American Dental Association.

Family history can facilitate awareness of need to screen for and engage in prevention efforts for common diseases (such as heart disease, cancer, diabetes) and rarer diseases (including hemophilia, sickle cell anemia, and cystic fibrosis). The Surgeon General has created a family health history initiative to facilitate family discussion of inherited diseases. This free tool, found at https://familyhistory.hhs.gov, will allow patients and providers to download the form to gather relevant health information for patients to share with providers. Whether disease etiology derives from genetics, environment, learned behaviors, or a combination of factors, many health conditions, such as propensity to hypertension, may run in families.

III. Physical Evaluation and Medical Risk Assessment

The initial and ongoing assessment of patient medical risk in dental practice has several purposes:

• To minimize risk of adverse events in the dental office resulting from dental treatment.
• To identify patients who need further medical assessment and management.
• To identify patients for whom specific perioperative therapies or treatment modifications will minimize risk, including postponing elective treatment.
• To identify appropriate anesthetic technique, intraprocedure monitoring, and postprocedure management.
• To discuss treatment procedures with patients, outlining risks and benefits, in order to obtain informed consent and determine need for additional anxiolysis.

One of the most common medical risk assessment frameworks is the American Society of Anesthesiologists (ASA) Physical Status Score2 used to classify patients for anesthesia risk (Table 1.1 A medical risk-related health history is important to detect medical problems in patients. While across all ages most (78%) dental patients are healthy ASA 1 patients, the percentage that is of higher ASA physical status (ASA 2-ASA 6) increases with increasing age.3 By age 65, only 55% of adults remain healthy ASA 1. Medical conditions such as cardiovascular disease and hypertension account for a high proportion of ASA 3 and ASA 4 patients.

Table 1.1 ASA Physical Status (PS) Classification,2 Activity Characteristics/Treatment Risk, and Medical Examples

• Patient is able to walk up one flight of stairs or two level city blocks without distress.
• Little of no anxiety.
• Little or no risk during treatment.

• Healthy 20-year-old.

• Patient has mild to moderate systemic disease or is a healthy ADA PS1 patient who demonstrated a more extreme anxiety and fear towards dentistry.
• Patient is able to walk up one flight of stairs or two level city blocks, but will have to stop after completion of the exercise because of distress.
• Minimal risk during treatment.

• ASA 1 with respiratory condition, active allergies, dental phobia, or pregnancy.
• Well diet or oral hypoglycemic agent-controlled diabetic.
• Well-controlled asthmatic.
• Well-controlled epileptic.
• Well-controlled hypertensive not on medication.

• Patient has severe systemic disease that limits activity, but is not incapacitating.
• Patient is able to walk up one flight of stairs or two level city blocks, but will have to stop on the way because of distress.
• If dental care is indicated, stress reduction protocol and other treatment modifications are indicated.

• Well-controlled hypertensive on medication.
• Well-controlled diabetic on insulin.
• Slight chronic obstructive pulmonary disease.
• Thirty days or more ago history of myocardial infarction or cerebrovascular accident or congestive heart failure.

• Patient has severe systemic disease that limits activity and is a constant threat to life.
• Patient is unable to walk up one flight of stairs or two level city blocks. Distress is present even at rest.
• Patient poses significant risk during treatment.
• Elective dental care should be postponed until such time as the patient's medical condition has improved to at least an ASA P3...