1.
Chest Pain
CHAPTER 10
PHYSICAL AND PSYCHOLOGICAL EVALUATION
Medical History
*Ask additional question:
 Have you ever received a local
anesthetic for medical or dental care?
 Have you ever had a negative reaction
to a LA?
 If so, what was the reaction?
 How was it dealt with?
Goals
1. Determine the patient’s ability to
tolerate physically and psychologically
stresses involved in the planned dental
treatment
2. Determine whether treatment
modification is indicated to better
tolerate the treatment
3. Is psychosedation indicated?
4. Determine which technique of sedation
is most appropriate for the patient
5. Determine whether contraindications
exist to the planned treatment or any of
the drugs to be used
Physical Evaluation
 used to describe steps that involve in
fulfilling the aforementioned goals
Three components:
1. medical history questionnaire
2. physical examination
3. dialogue history
With information (data base) collected from
these steps, dentist and hygienist will be better
able to:
 determine the physical and
psychological status of the patient
(establish a risk factor classification for
the patient)
 seek medical consultation, if indicated
 appropriately modify the planned
dental treatment
HAVE YOU EXPERIENCED?
 History of angina (chest pain
brought on by exertion and
alleviated by rest)
 Indicates the presence of coronary
artery disease with attendant
ischemia of the myocardium
 Stable angina – ASA 3
 Present of dental fears – inhalation
sedation with nitrous oxide
 Pain control – LA with
vasoconstrictor
 Unstable or recent-onset angina –
ASA 4 risks
2. Swollen Ankles
 Pitting edema or dependent edema
indicates possible heart failure (HF)
 Other cause of ankle edema:
varicose veins, pregnancy, and renal
dysfuntion
3. Shortness of Breath
 Clinical signs and symptoms of
heart or lung disease may be
evident
 Positive response to this question
does not always indicate that the
patient suffer such a disease
4. Recent weight loss, fever, night sweats
 Not intentional weight loss (e.g.,
dieting)
 Unexpected weight change may
indicate HF, hypothyroidism
(increased weight),
hyperthyroidism, wide spread
carcinoma, uncontrolled diabetes
mellitus (weight loss)
 Night sweats – such as tuberculosis
5. Persistent cough, coughing up blood?
 Persistent cough or hemoptysis
(blood-tinged sputum)
 Most common cause of hemoptysis
are bronchitis and bronchiectasis,
neoplasm and tuberculosis
  Cough ssociated with an upper presence of intestinal polyps and
respiratory infection – ASA 2 thrombocytopenia
 Chronic bronchitis (smoked more
than one pack of cigarettes daily for PREGNANT
many years – ASA 3 risk  Administration of LA with or without
epinephrine is acceptable during
6. Bleeding Problem, bruising easily? pregnancy
 Hemophilia – prolonged bleeding or FDA Pregnancy Categories
frequent bruising A. Studies have failed to demonstrate of a
 Incidence of coagulopathies or risk to the fetus in any trimester
other bleeding disorders, injection B. Animal reproduction studies fail to
technique with greater incidence of demonstrate a risk to the fetus; no
positive aspiration should be human studies available
avoided C. Only given after risks to the fetus are
 Supraperiosteal, PDL, intraosseous considered; animal reproduction
(IO) – less likely to produce bleeding studies have shown adverse effects on
 Technique might be avoided: fetus; no human studies available
maxillary (V2) nerve block (high D. Definite human fetal risks; may be given
tuberosity approach, PSANB, IANB, in spite of risks if needed in life-
Gow-Gates and Akinosi Vazirani threatening conditions
mandibular blocks E. Absolute fetal abnormalities; not to be
used at time during pregnancy because
7. Sinus problem risk outweigh benefits
 Allergy ASA 2
 Respiratory distress when placed in Known Fetal Effects on Drugs
supine position Drug Effect
 Distress is present if a rubber dam Anesthetics, local No adverse effects in
is used dentistry
 Postponing treatment until the Articaine No adverse effects
patient is able to breathe more reported in dentistry
comfortably, limiting the degree of Bupivacaine Does not cross
recline in the dental chair and placenta readily; no
foregoing used of a rubber dam are adverse effect in
advisable dentistry
Epinephrine No adverse effects
8. Difficulty Swallowing reported for dental
 Dysphagia – inability to swallow use
 Determine the cause and severity of Lidocaine No adverse effects
the patients complaint reported in dentistry
Mepivacaine No adverse effects
9. Diarrhea, constipation, blood in stool reported in dentistry
 Causes of blood in feces – anal Prilocaine No adverse effects
fissures, aspirin-containing drugs, reported in dentistry
bleeding disorders, esophageal
varices, foreign body trauma, Physical Examination
hemorrhoids, neoplasm, use of Patient must be:
orally administered steroids,
  Aware of the presence of any medical
condition
 Willing to share this information with
the dentist
Vital Signs:
1. Blood pressure (BP)
2. Heart rate (pulse) and rhythm
3. Respiratory rate
4. Temperature
5. Height
6. Weight
Blood Pressure
Vasodilators
*All local anesthetics are vasodilators
 When injected they dilate the blood
vessels around the site. This increases
blood flow to the site and also carries
the anesthetic away from the site into
the circulatory system of the body
*The degree of dilation depends on:
 The particular anesthetic
 The injection site
 Individual patient response
Increase blood flow in the site of injection
(perfusion) in turn causes:
 An increased rate of anesthetic
absorption into the blood stream
increasing toxicity
 A decrease in the duration of the
anesthetics actions because it is taken
away from the site
 Increase bleeding in the area due to the
increase flow of blood in to the area
 Higher plasma levels
These disadvantages can be overcome to a
certain extent by adding vasoconstrictors
 Vasoconstrictors also called
vasopressor
 Helpful in Dentistry where longer
duration and more profound anesthesia
are required
 Vasoconstrictors are drugs that
constrict blood vessels and thereby
keep the anesthetic at the site needed
 They added to LA’s to oppose the
natural vasodilatory action of the LA’s
Vasoconstrictors added to LA:
 Epinephrine (mostly used)
 Levonordephrine (used 2% with
Mepivacaine)
Normal dose do not affect CNS or CVS
 Overdose does affect ANS & CVS –
anxiety, nausea, headache,
hyperventilation and increase BP
Medically compromised patient especially those
that have ‘heart’ issues are restricted to 2
cartridge per appointment
Conditions
Malignant Hyperthermia
 One of the most intense and life-
threatening complications associated
with administration of general
anesthesia
 Genetically transmitted by a dominant
gene
 Seen foremost in males increasing with
age
 Triggered by certain anesthetics during
general anesthesia
 Amide anesthetic were once considered
an absolute contraindication, but now
they are considered a relative
contraindication
 Based on limited clinical evidence, all
local anesthetic drugs appear to be safe
for MH susceptible individuals
 Usually will volunteer the information
 Recommended that the dentist contact
the patient’s primary care physician to
discuss treatment options
Atypical Plasma Cholinesterase
 Approx. 1 out of every 2820 person
possess an atypical form of plasma
cholinesterase
  Genetic. Patient volunteer this are given doses of Prilocaine within
information on the medical history recommended limits
sheet
 Not all cases produce clinically
significant signs and symptoms
 Should alert the dentist to increase risk
of prolonged apnea in patients
receiving succinylcholine (muscle
relaxant) during general anesthesia
 Of greater importance is the increased
risk of developing elevated blood
vessels of the ester local anesthetic
 Signs and symptoms for LA overdose
are more apt to be noted in these
patients even with normal dosages
Because they undergo biotransformation in the
liver, amide LA do not present an increased risk
overly high blood levels in most of these
patients
Ester anesthetic may be administered, if
deemed necessary by the doctor, but their
doses should be minimized

Methaglobinemia
 Genetic condition where a cyanosis like
state develops in the absence of cardiac
or respiratory abnormalities
 Patients volunteer this information on
the medical history form
 Severe condition show chocolate brown
blood, blue nail beds, ashen complexion
with respiratory depression and
syncope
 Benzocaine topical can also produce
symptoms but only when administered
in very large doses
 Other substances can also produce this:
crayons, ink, shoe polish,
dermatological, nitrates etc.
 Signs and symptoms usually appear
within 3-4 hours to healthy patients and
sooner with smaller doses in patients
with the congenital disorder
 Treatment: slow administration of
methylene blue
 Do not have to worry about this
development in healthy patients who