MEDICAL EMERGENCIES IN THE DENTAL OFFICE

CHAPTER 2

1
 INTRODUCTION

▪ This chapter provides a detailed discussion of the most important

components of physical evaluation.

▪ Which, when used properly, can lead to a significant reduction in the

occurrence of acute medical emergencies. (This chapter will be referred to
frequently throughout the rest of the text.)

2
 THE GOALS EACH DOCTOR SHOULD PURSUE

▪ 1. Determine the patient’s ability to physically tolerate the stress involved in

the planned treatment.

▪ 2. Determine the patient’s ability to psychologically tolerate the stress

involved in the planned treatment.

▪ 3. Determine whether treatment modifications are required to enable the

patient to better tolerate the stress involved in the planned treatment.

3
 THE GOALS EACH DOCTOR SHOULD PURSUE

▪ 4. Determine whether the use of sedation is warranted:

• Determine which sedation technique is most appropriate.

• Determine whether contraindications exist to any drugs to be used in the

planned treatment.

4
 THE GOALS EACH DOCTOR SHOULD PURSUE

▪ Although most patients are able to tolerate dental treatment, you should
determine before commencing treatment

• the potential problem

• the level of severity of the problem

• the potential effect of that problem on the planned dental treatment

5
 BACKGROUND

▪ Excessive stress may also be detrimental to a person who is not medically

compromised.

▪ Fear, anxiety, and pain - especially sudden, unexpected pain - lead to acute
changes in the body’s homeostasis.

▪ Many dental patients experience fear-related (psychogenic) emergencies,

including hyperventilation and vasodepressor syncope (fainting).

6
 PHYSICAL EVALUATION

▪ Physical evaluation in dentistry consists–minimally–of the medical history

questionnaire, physical examination, and dialogue history.

▪ Armed with this information, the doctor can better -

• determine the physical and psychological status of the patient, allowing

the doctor to

o (assign a risk factor classification to that patient;

o seek medical consultation; and

o institute appropriate treatment modifications.

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 MEDICAL HISTORY QUESTIONNAIRE

▪ The use of a written, patient-completed medical history questionnaire is a

moral and legal necessity in the health care professions.

▪ the medical history questionnaire provides valuable information concerning

the physical and psychological condition of the patient

▪ Many versions of medical history questionnaires are available.

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 MEDICAL HISTORY QUESTIONNAIRE

▪ There are two basic types:

• the short-form medical history: provides basic information about a

patient’s medical history and ideally is suited for a doctor who has
considerable clinical experience in physical evaluation

• the long-form medical history: two or more pages, provides a more

detailed summary of the patient’s past and present physical condition.

• It is used most often in teaching situations, for which it is ideal.

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10
 MEDICAL HISTORY QUESTIONNAIRE
▪ (1) Is your general health good?

• Comment: A survey question seeking patients’ general impression of their

own health.

• Studies have demonstrated that a “yes” response to this question does

not necessarily correlate with the patient’s actual state of health.

▪ (2) Has there been a change in your health within the last year?

▪ (3) Have you been hospitalized or had a serious illness in the last three
years? If YES, why?

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 MEDICAL HISTORY QUESTIONNAIRE

▪ (4) Are you being treated by a physician now? For what? Date of last
medical exam? Date of last dental exam?

▪ Comment: Questions 2, 3, and 4 seek information regarding recent changes

in the patient’s physical condition.

▪ In all instances of a positive response, an in-depth dialogue history must

ensue to determine the precise nature of the change in health status, type of
surgical procedure or illness, and the names of any medications or drugs the
patient may now be taking to help manage the problem(s).

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 MEDICAL HISTORY QUESTIONNAIRE
5. Have you had problems with prior dental treatment?

Comment: I have found that many adults are reluctant to verbally admit to the doctor,
hygienist, or assistant their fears about treatment for fear of being labeled a “baby.”

▪ This is especially true of young men in their late teens or early 20s; they attempt to
“take it like a man” or “grin and bear it” rather than admit their fears.

▪ All too often, such macho behavior results in an episode of vasodepressor syncope.

▪ Whereas many such patients do not offer verbal admissions of fear, I have found that
these same patients may volunteer the information in writing.

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 MEDICAL HISTORY QUESTIONNAIRE

▪ (6) Are you in pain now?

Comment: The primary thrust of this question is related to dentistry.

▪ Its purpose is to determine what prompted the patient to seek dental care.

▪ If pain or discomfort is present, the doctor may need to treat the patient
immediately on an emergency basis, whereas in the more typical situation
dental treatment can be deferred until future visits

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 HAVE YOU EXPERIENCED:

▪ (7) Chest pain (angina)

▪ Comment: A history of angina (defined, in part, as chest pain brought on by

exertion and alleviated by rest) usually indicates the presence of a significant
degree of coronary artery disease with attendant ischemia of the myocardium.

▪ (8) Swollen ankles?

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 HAVE YOU EXPERIENCED:

▪ Comment: Swollen ankles (pitting edema or dependent edema) indicate

possible heart failure (HF).

▪ However, varicose veins, pregnancy, and renal dysfunction are other possible
causes of ankle edema.

▪ Healthy persons who stand on their feet for long periods (e.g., police officers
and dental staff members) also may develop ankle edema.

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 HAVE YOU EXPERIENCED:

▪ (9) Shortness of breath?

▪ Comment: Although the patient may respond negatively to specific questions

(questions 29 to 35) in section III (below) regarding the presence of various
heart and lung disorders (e.g., angina, HF, pulmonary emphysema), clinical
signs and symptoms of heart or lung disease may be evident.

▪ A positive response to this question does not always indicate that the patient
has such a disease.

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 ▪ To more accurately determine the patient’s status before the start of dental
care, further evaluation is suggested.

▪ (10) Recent weight loss, fever, night sweats?

▪ Comment: The question refers primarily to an unexpected gain or loss of

weight, not intentional dieting.

▪ Unexpected weight changes may indicate HF, hypothyroidism (increased

weight), hyperthyroidism, widespread carcinoma, uncontrolled diabetes
mellitus (weight loss), or many other disorders.

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 ▪ The presence of fever or night sweats should be pursued to determine
whether these symptoms are innocent or perhaps clues to the presence of a
more significant problem, such as tuberculosis.

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 HAVE YOU EXPERIENCED:

▪ (11) Persistent cough, coughing up blood?

▪ Comment: A positive response mandates in-depth dialogue history to

determine the cause of the persistent cough or hemoptysis (blood-tinged
sputum).

▪ Common causes of hemoptysis are bronchitis/bronchiectasis, neoplasms, and

tuberculosis.

▪ A chronic cough can indicate active tuberculosis or other chronic respiratory

disorders, such as chronic bronchitis.

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 HAVE YOU EXPERIENCED:

▪ (12) Bleeding problems, bruising easily?

▪ Comment: Bleeding disorders such as hemophilia are associated with

prolonged bleeding or frequent bruising.

▪ They can lead to modification of certain forms of dental therapy (e.g., surgery
and local anesthetic administration) and must therefore be made known to the
doctor before treatment begins.

▪ Modifications in the dental treatment plan may be necessary when excessive

bleeding is likely to be present.

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 ▪ (13) Sinus problems?

▪ Comment: Sinus problems can indicate the presence of an allergy (ASA 2),
which should be pursued in the dialogue history; or upper respiratory tract
infection (ASA 2), such as a common cold.

▪ The patient may experience some respiratory distress when placed in a

supine position; distress may also be present if a rubber dam is used.

▪ Specific treatment modifications - postponing treatment until the patient

can breathe more comfortably, limiting the degree of recline in the dental
chair, and forgoing use of a rubber dam - are advisable.

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 HAVE YOU EXPERIENCED:
▪ (14) Difficulty swallowing?

▪ Comment: Dysphagia, or the inability to swallow, can have many causes.

▪ Before the start of any dental treatment, the dentist should seek to determine the
etiology and the severity of the patient’s symptoms.

▪ (15) Diarrhea, constipation, blood in stools?

▪ Comment: Evaluation is necessary to determine whether gastrointestinal problems

are present, many of which require patients to be medicated.

▪ Causes of blood in feces can range from benign, self-limiting events to serious, life-
threatening disease..

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 HAVE YOU EXPERIENCED:

▪ 16. Frequent vomiting, nausea?

▪ Comment: A multitude of causes can lead to nausea and vomiting.

Medications, however, are among the most common causes of nausea and
vomiting. Opiates, digitalis, levodopa, and many antineoplastic drugs to
induce vomiting. Drugs that frequently induce nausea include nonsteroidal
anti-inflammatory drugs, erythromycin, cardiac antidysrhythmic,
antihypertensive drugs, diuretics, oral antidiabetic agents, oral contraceptives,
and many gastrointestinal drugs, such as sulfasalazine.

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 HAVE YOU EXPERIENCED:

▪ Gastrointestinal and systemic infections, viral and bacterial, are the second
most common cause of nausea and vomiting.

▪ 17. Difficulty urinating, blood in urine?

▪ Comment: Hematuria, the presence of blood in urine, requires evaluation to

determine the cause, potentially indicative of urinary tract infection or
obstruction.

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 HAVE YOU EXPERIENCED:

▪ 18. Dizziness?

▪ Comment: A positive response may indicate a patient’s chronic postural

(orthostatic) hypotension, symptomatic hypotension, anemia, or transient
ischemic attack (TIA), a form of prestroke.

▪ In addition, patients with certain types of seizure disorders, such as the “drop
attack,” may report fainting or dizzy spells. The doctor may be advised to
perform further evaluation, including consulting with the patient’s primary care
physician.

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 HAVE YOU EXPERIENCED:

▪ 19. Ringing in ears?

▪ Comment: Tinnitus (an auditory sensation in the absence of sound, heard in one or both ears,
such as ringing, buzzing, hissing, or clicking) is a common side effect of certain drugs,
including salicylates, indomethacin, propranolol, levodopa, aminophylline, and
caffeine.

▪ It may also be seen with multiple sclerosis, tumor, and ischemic infarction.

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 HAVE YOU EXPERIENCED:

20. Headaches?

Comment: Presence of headache should be evaluated to determine its cause.

Common causes include chronic daily headaches, cluster headaches, migraine
headaches, and tension-type headaches. If necessary, consult with the patient’s primary
care physician. The drug or drugs that the patient uses to manage symptoms should be
determined because many of these agents can influence clotting.

21. Fainting spells?

Comment: See comment for question 18.

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 HAVE YOU EXPERIENCED:

▪ 22. Blurred vision?

▪ Comment: Blurred vision is a common finding as the patient ages.

▪ Leading causes of blurred vision and blindness include glaucoma, diabetic

retinopathy, and macular degeneration.

▪ Double vision, or diplopia, usually results from extraocular muscle imbalance,

the cause of which must be sought.

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 HAVE YOU EXPERIENCED:

▪ 23. Seizures?

▪ Comment: Seizures are common dental emergencies. The most likely

candidate to experience a seizure in the dental environment is the epileptic
patient. Even epileptic patients whose seizures are well controlled with
antiepileptic drugs may experience a seizure in stressful situations, such as
might exist in the dental office. The doctor must determine the type of seizure,
frequency of occurrence, and drug or drugs used to prevent the seizure, prior
to the start of dental treatment.

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 HAVE YOU EXPERIENCED:

24. Excessive thirst?

Comment: Polydipsia, or excessive thirst, is often seen in diabetes mellitus,

diabetes insipidus, and hyperparathyroidism.

25. Frequent urination?

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 HAVE YOU EXPERIENCED:

Comment: Polyuria, or frequent urination, may be benign (too much fluid intake)
or a symptom of diabetes mellitus, diabetes insipidus, Cushing’s syndrome, or
hyperparathyroidism.

26. Dry mouth?

Comment: Fear is a common cause of a dry mouth, especially in the dental

environment. Many other causes of xerostomia exist, including Sjögren’s
syndrome and radiation therapy to the oral cavity.

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 HAVE YOU EXPERIENCED:

27. Jaundice?

Comment: Jaundice (yellowness of skin, whites of the eyes, and mucous membranes) is
due to a deposition of bile pigment resulting from an excess of bilirubin in the
blood (hyperbilirubinemia).

It is frequently caused by obstruction of bile ducts, excessive destruction of red

blood cells (hemolysis), or disturbances in the functioning of liver cells.

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 HAVE YOU EXPERIENCED:

▪ 28. Joint pain, stiffness?

▪ Comment: A history of joint pain and stiffness (arthritis) may be associated

with long-term use of salicylates (aspirin) or other nonsteroidal anti-
inflammatory drugs (NSAIDs), some of which may alter blood clotting.

▪ Arthritic patients who are receiving long-term corticosteroid therapy may have
an increased risk of acute adrenal insufficiency, especially those who have
recently stopped taking the steroid.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 29. Heart disease?

▪ Comment: This survey question seeks to detect the presence of any and all
types of heart disease.

▪ In the presence of a “yes” answer the doctor must seek more specific
detailed information on the nature and severity of the problem as well as a list
of any medications the patient is taking to manage the condition.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 30. Heart attack, heart defects?

▪ Comment: Heart attack is the lay term for a myocardial infarction (MI). The
doctor must determine the time that has elapsed since the patient sustained
the MI, the severity of the MI, and the degree of residual myocardial damage
to decide whether, and which, treatment modifications are indicated.

▪ In most instances elective dental care will be postponed for a period of 6

months after an MI.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 31. Heart murmurs?

▪ Comment: Heart murmurs are common, but not all murmurs are clinically
significant.

▪ A major clinical symptom of a significant (organic) murmur is undue fatigue.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 32. Rheumatic fever?

▪ Comment: A history of rheumatic fever should prompt the doctor to perform

an in-depth dialogue history for the presence of rheumatic heart disease (a
condition in which the heart valves have been permanently damaged by rheumatic fever) .

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 33. Stroke, hardening of arteries?

▪ Comment: The doctor must pay close attention to stroke (cerebrovascular

accident [CVA], or “brain attack” [the term being increasingly used to confer on the
lay public as well as health care professionals the urgency needed in prompt management of

the victim of a CVA]).

▪ A patient who has had a CVA (status post-CVA) is at greater risk of suffering a
recurrent CVA or a seizure should they become hypoxic.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 34. High blood pressure?

▪ Comment: Elevated blood pressure measurements are frequently

encountered in the dental environment, primarily as a result of catecholamine
release related to the added stress many patients experience with the visit to
the dentist (“White coat syndrome”).

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 DO YOU HAVE OR HAVE YOU HAD:
▪ 35. Asthma, tuberculosis, emphysema, other lung disease?

▪ Comment: Determining the nature and severity of respiratory problems is an

essential part of patient evaluation. Many acute problems developing in the
dental environment are stress related, increasing the workload of the
cardiovascular system and the oxygen requirements of many tissues and
organs in the body. The presence of severe respiratory disease can greatly
influence the planned dental treatment.

▪ Asthma (bronchospasm; hyperactive airway disease) is marked by a partial

obstruction of the lower airway.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ With a history of tuberculosis, the doctor must first determine whether the
disease is active or arrested.

▪ Emphysema is a form of chronic obstructive pulmonary disease (COPD), also

called chronic obstructive lung disease (COLD). The patient with emphysema
has a decreased respiratory reserve to draw from if the body’s cells require
additional O2, which they do during stress

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 36. Hepatitis, other liver disease?

▪ Comment: These diseases or problems are transmissible (hepatitis A and B)

or indicate the presence of hepatic dysfunction. A history of blood transfusion
or of past or present drug addiction should alert the doctor to a probable
increase in the risk of hepatic dysfunction.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 37. Stomach problems, ulcers?

▪ Comment: The presence of stomach or intestinal ulcers may indicate acute

or chronic anxiety and the possible use of medications such as tranquilizers,
H1-inhibitors, and antacids.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 38. Allergies to: drugs, foods, medications, latex?

▪ Comment: The doctor must evaluate a patient’s allergies thoroughly before

administering dental treatment or drugs. The importance of this question and
its full evaluation cannot be overstated. A complete and vigorous dialogue
history must be undertaken before the start of any dental treatment,
especially when a presumed or documented history of drug allergy is present.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 39. Family history of diabetes, heart problems, tumors?

▪ Comment: Knowledge of family history can help determine the presence of

many disorders that have a hereditary component.

▪ 40. AIDS?

▪ Comment: Patients who have tested positive for human immunodeficiency

virus (HIV) come from every area of the population. The usual barrier
techniques should be employed to minimize risk of cross-infection to both the
patient and staff members.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 41. Tumors, cancer?

▪ Comment: The presence or previous existence of cancer of the head or neck

may require specific modification of dental therapy. Irradiated tissues have
decreased resistance to infection, diminished vascularity, and reduced healing
capacity. However, no specific contraindication exists to the administration of
drugs for the management of pain or anxiety in these patients.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ Many persons with cancer may also be receiving long-term therapy with CNS
depressants, such as antianxiety drugs, hypnotics, and opioids. Consultation
with the patient’s oncologist is recommended before dental treatment.

▪ 42. Arthritis, rheumatism?

▪ Comment: See Comment for question 28.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 44. Skin diseases?

▪ Comment: Skin represents an elastic, rugged, self-regenerating, protective

covering for the body. The skin also represents our primary physical
presentation to the world and as such presents with a myriad of clinical signs
of disease processes, including allergic, cardiac, respiratory, hepatic, and
endocrine disorders

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 45. Anemia?

▪ Comment: Anemia is a relatively common adult ailment, especially among

young adult women (iron deficiency anemia). The ability of the blood to carry
O2 or to give up O2 to other cells is decreased in anemic patients. This
decrease can become significant during procedures in which hypoxia is likely
to develop.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 46. Venereal disease (syphilis or gonorrhea)?

▪ 47. Herpes?

▪ Comment: When treating patients with sexually transmitted diseases, dentists

and staff members are at risk of infection. In the presence of oral lesions,
elective dental care should be postponed. Standard barrier techniques,
protective gloves, eyeglasses, and masks provide operators with a degree of
(but not total) protection. Such patients usually represent ASA 2 and 3 risks
but may be 4 or 5 risks in extreme situations.

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52
 DO YOU HAVE OR HAVE YOU HAD:

▪ 49. Thyroid, adrenal disease?

▪ Comment: The clinical presence of thyroid or adrenal gland dysfunction -

either hyper- or hypo-function - should prompt the doctor to use caution in
the administration of certain drug groups (e.g., epinephrine to clinically
hyperthyroid patients, CNS depressants to clinically hypothyroid patients). In
most instances, however, patients have already seen a physician and
undergone treatment for their thyroid disorder by the time they seek dental
treatment.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 50. Diabetes?

▪ Comment: A positive response to this question requires further inquiry to

determine the type, severity, and degree of control of the diabetic condition.

▪ A significant concern relates to the possible effects of dental care on

subsequent eating and the development of hypoglycemia (low blood sugar)

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 51. Psychiatric care?

▪ Comment: The doctor should be aware of any nervousness (in general or

specifically related to dentistry) or history of psychiatric care before treating the
patient. Such patients may be receiving drugs to manage their disorders that might
interact with the drugs used in dentistry to control pain and anxiety (see Table 2-2).
Medical consultation should be considered in such cases.

▪ 52. Radiation treatments?

▪ 53. Chemotherapy?

▪ Comment: Therapies for cancer. See Comment for question 41.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 54. Prosthetic heart valve?

▪ Comment: Patients with prosthetic (artificial) heart valves are no longer

uncommon. The doctor’s primary concern is to determine the appropriate
antibiotic regimen. Antibiotic prophylactic protocols list these requirements.
The doctor should be advised to consult with the patient’s physician (e.g.,
the cardiologist or cardiothoracic surgeon) before commencing treatment.
Patients with prosthetic heart valves usually represent ASA 2 or 3 risks.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 56. Hospitalization?

▪ 57. Blood transfusions?

▪ 58. Surgeries?

▪ Comment: Determine the cause of the hospitalization, the duration of stay in the hospital, and
any medications prescribed that the patient may still be taking.

▪ Determine the reason for the blood transfusion (e.g., prolonged bleeding, accident, type of
surgery).

▪ Determine the nature (elective, emergency) and type of surgery (e.g., cosmetic,
gastrointestinal, cardiac) and the patient’s physical status at the time of the dental visit.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 59. Pacemaker?

▪ Comment: Cardiac pacemakers are implanted beneath the skin of the upper
chest or the abdomen with pacing wires extending into the myocardium
(Figure 2-7). The most frequent indication for the use of a pacemaker is the
presence of a clinically significant dysrhythmia.

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59
 DO YOU HAVE OR HAVE YOU HAD:

▪ 62. Drugs, medications, over-the-counter medicines (including aspirin),

natural remedies?

▪ Comment: Because many patients distinguish between the terms “drug” and
“medication,” questionnaires should use both terms to determine what drugs
(pharmaceutically active substances) a patient has taken. Unfortunately, to
some people the term “drug” often is associated with the use of illicit
substances (e.g., heroin, cocaine). In the minds of many patients, people “do”
drugs but “take” medications to manage medical conditions

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 ▪ The doctor must be aware of all medications and drugs patients take to control and
to treat medical disorders. Frequently, patients take medications without knowing the
condition the medications are designed to treat; many patients do not even know the
names of drugs they take. It becomes important, therefore, for doctors to have
available one or more means of identifying these medications and of determining
their indications, side effects, and potential for drug–drug interactions.

▪ Many excellent sources are available, including online services such as Clinical Key
(www.clinicalkey.com) and Epocrates (www.epocrates.com). The Physicians’ Desk
Reference (PDR),21 both in hard copy and online, offers a picture section that helps
identify commonly prescribed drug

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 DO YOU HAVE OR HAVE YOU HAD:

▪ 63. Tobacco in any form?

▪ 64. Alcohol?

▪ Comment: Long-term use of tobacco or alcohol can lead to potentially life-

threatening problems, including neoplasms, hepatic dysfunction, and, in
females, complications during pregnancy..

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 DO YOU HAVE OR HAVE YOU HAD:

▪ Women Only:

▪ 65. Are you or could you be pregnant or nursing?

▪ 66. Taking birth control pills?

▪ Comment: Pregnancy represents a relative contraindication to extensive

elective dental care, particularly during the first trimester. Consultation with
the patient’s obstetrician/gynecologist is recommended before the start of any
dental treatment.

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 DO YOU HAVE OR HAVE YOU HAD:

▪ All Patients:

▪ 67. Do you have, or have you had any other diseases or medical problems
NOT listed on this form?

▪ Comment: The patient is encouraged to comment on specific matters not

previously mentioned.

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 MEDICAL HISTORY QUESTIONNAIRE
▪ To the best of my knowledge, I have answered every question completely and
accurately. I will inform my dentist of any change in my health and/or
medication.

▪ Comment: This final statement is important from a medical legal perspective

because, although instances of purposeful lying on health histories are rare, they do
occur. This statement must be accompanied by the date on which the history was
completed and the signatures of the patient (or the parent or guardian if the patient is
a minor or is not legally competent) and of the doctor who reviews the history. This in
effect becomes a contract obliging the patient, parent, or guardian to report any
changes in the patient’s health or medications.

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 MEDICAL HISTORY QUESTIONNAIRE

▪ The medical history questionnaire must be updated on a regular basis,

approximately every 3 - 6 months or after any prolonged lapse in treatment.

▪ In most instances the entire medical history questionnaire need not be

redone.

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 MEDICAL HISTORY QUESTIONNAIRE

▪ The doctor need ask only the following questions:

• 1. Have you experienced any change in your general health since your last
dental visit?

• 2. Are you now under the care of a medical doctor? If so, what is the
condition being treated?

• 3. Are you currently taking any drugs, medications, or over-the-counter

products?

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 MEDICAL HISTORY QUESTIONNAIRE

▪ The medical history questionnaire should be completed in ink. Corrections or

deletions are made by drawing a single line through the original entry
(without obscuring it). The change is then added along with the date of the
change. The doctor initials the change.

▪ A written notation should be placed in the chart whenever a patient reveals

significant information during the dialogue history. As an example, when a
patient answers affirmatively to the question about a “heart attack,” the
doctor’s notation may read “June 2010” (the month and year the myocardial
infarction occurred).

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 ASA PHYSICAL STATUS CLASSIFICATION SYSTEM

▪ ASA 1: A normal, healthy patient without systemic disease

▪ ASA 2: A patient with mild systemic disease

▪ ASA 3: A patient with severe systemic disease

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 ASA PHYSICAL STATUS CLASSIFICATION SYSTEM

▪ ASA 4: A patient with an incapacitating systemic disease that is a constant

threat to life

▪ ASA 5: A moribund patient not expected to survive without the operation

▪ ASA 6: A declared brain-dead patient whose organs are being removed for
donor purposes

▪ ASA E: Emergency operation of any variety, with E preceding the number to

indicate the patient’s physical status

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 PHYSICAL EXAMINATION

▪ Physical examination in dentistry consists of the following steps:

▪ Monitoring of vital signs

▪ Visual inspection of the patient

▪ Function tests as indicated

▪ Auscultation, monitoring (via electrocardiogram), and laboratory tests of the

heart and lungs as indicated

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 VITAL SIGNS

▪ 1. Blood pressure

▪ 2. Heart rate (pulse) and rhythm

▪ 3. Respiratory rate

▪ 4. Temperature, more commonly is done in situations in which it is deemed

necessary (e.g., when infection is present or the patient appears febrile)

▪ 5. Height

▪ 6. Weight - when parenteral (IM or IN) or enteral (oral) sedation is to be used.

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 BLOOD PRESSURE

▪ A stethoscope and sphygmomanometer (blood pressure cuff) are the basic

equipment

▪ The aneroid manometer is calibrated to show results in millimeters of mercury

(mm Hg) and is also quite accurate if well maintained.

▪ The patient should be permitted to rest for at least 5 minutes before the blood
pressure is recorded. This permits the patient to relax so that the blood
pressure recorded is closer to the patient’s usual baseline reading.

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76
 BLOOD PRESSURE
Some relatively common errors associated with the recording of blood pressure include the
following

▪ Loose application of the blood pressure cuff provides false elevated readings, which are probably
the most common errors.

▪ Use of the wrong cuff size can result in erroneous readings.

▪ An auscultatory gap may occur. This gap represents a loss of sound between systolic and
diastolic pressures, with the sound reappearing at a lower level

▪ Use of the right or left arm produces differences in recorded blood pressure. A difference of 5 to
10 mm Hg exists between the arms, with the left arm commonly producing slightly higher
measurements.

▪ Anxiety

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78
 BLOOD PRESSURE
▪ When monitoring blood pressure, keep in mind these tips:

▪ Do not smoke or drink caffeine 30 minutes before you plan to take your blood pressure.

▪ Rest quietly for 5 minutes before starting.

▪ Sit with your feet flat on the floor, with your back and arm supported. Keep your arm at heart
level.

▪ Apply the blood pressure cuff on a bare arm.

▪ Measure it twice in the morning and twice in the evening for 7 days before your doctor’s
appointment (or after a change in medication).

▪ Keep your readings in a log. Download a Blood Pressure Log (.pdf)

▪ Try not to speak while taking your measurement.

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 HEART RATE AND RHYTHM

▪ Heart rate (pulse) and rhythm can be measured through palpation of any
readily accessible artery.

▪ Most commonly employed for routine (nonemergency) measurement are the

brachial artery, located on the medial aspect of the antecubital fossa, and
the radial artery, located on the radial and volar aspects of the wrist.

▪ Other arteries, such as the carotid and femoral, can also be used

▪ In emergency situations the carotid artery should be palpated in lieu of others

because it delivers oxygenated blood to the brain

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81
 TEMPERATURE

▪ Guidelines for clinical evaluation:

▪ The normal oral temperature of 37° C (98.2° F) is merely an average.

▪ The true normal range is from 36.1° to 37.5° C (97° to 99.6° F).

▪ Body temperature varies slightly, from 0.25° to 1.1° C (0.5° to 2.0° F), throughout the
day; temperature is lowest in the early morning and highest in the late afternoon.

▪ Fever represents an increase in temperature beyond 37.5° C (99.6° F). Temperatures

above 38.3° C (101° F) usually indicate the presence of an active pathologic process.

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 RESPIRATORY RATE

▪ The respiratory rate must usually be assessed surreptitiously

▪ The normal adult respiratory rate is 16 to 18 breaths per minute.

▪ Bradypnea (slow rate of breathing) may be produced by opioid administration, while

tachypnea (rapid rate of breathing) is seen with fever and alkalosis.

▪ The most commonly noted change in breathing in dentistry is hyperventilation, an

abnormal increase in both the rate and depth of breathing that is usually a clinical
manifestation of anxiety.

▪ Hyperventilation also is seen in patients with diabetic acidosis. Extreme psychological

stress is the most common reason for hyperventilation in dental settings.

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 HEIGHT AND WEIGHT

▪ Gross obesity or extreme underweight may indicate the presence of an active

pathologic process. Patients with various endocrine disorders, such as
Cushing’s syndrome, may be obese; those with pulmonary tuberculosis,
malignancy, the latter stages of AIDS, and hyperthyroidism may be extremely
underweight.

▪ Excessively tall persons are referred to as giants, whereas persons who are
decidedly shorter than normal are called dwarfs. In both instances, endocrine
gland dysfunction may be present. Medical consultation relative to the
planned dental treatment is usually unnecessary.

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87
 STRESS-REDUCTION PROTOCOLS

NORMAL, HEALTHY, ANXIOUS PATIENT (ASA▪ Consider sedation during therapy.

1)
▪ Administer adequate pain control during
▪ Recognize the patient’s level of anxiety. therapy.

▪ Premedicate the evening before the dental ▪ Length of appointment variable.

appointment, as needed.
▪ Follow up with postoperative pain and anxiety
▪ Premedicate immediately before the dental control.
appointment, as needed.
▪ Telephone the highly anxious or fearful
▪ Schedule the appointment in the morning. patient later the same day that treatment was
delivered.
▪ Minimize the patient’s waiting time.

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 STRESS-REDUCTION PROTOCOLS
▪ MEDICAL RISK PATIENT (ASA 2, 3, 4) ▪ Follow up with postoperative pain and anxiety
control.
▪ Recognize the patient’s degree of medical risk.

▪ Complete medical consultation before dental therapy,

▪ Telephone the higher medical risk patient later on the
same day that treatment was delivered.
as needed.

▪ Schedule the patient’s appointment in the morning.

▪ Arrange the appointment for the highly anxious or
▪ Monitor and record preoperative and postoperative
vital signs.
▪ Consider sedation during therapy.
▪ Administer adequate pain control during therapy.
▪ Length of appointment variable; do not exceed the
patient’s limits of tolerance.
fearful, moderate-to-high–risk patient during the first
few days of the week (Monday through Wednesday in
most countries; Saturday or Sunday through Monday
in many Middle Eastern countries) when the office is
open for emergency care and the treating doctor is
available.

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 VISUAL INSPECTION
▪ Observation of a person’s posture, body movements, speech, and skin may help the doctor detect
disorders that may previously have gone unnoticed.

▪ Persons with HF and chronic pulmonary disorders often must sit more upright in the dental chair
than other patients because of severe orthopnea (e.g., three- or four-pillow orthopnea).

▪ Arthritic patients with a rigid neck may need to rotate their entire trunk when turning toward the
doctor or when viewing an object from the side. Recognition of these factors better enables the
doctor to determine necessary treatment modifications.

▪ Epileptic patients receiving long-term antiepileptic drug therapy may demonstrate sluggish speech
patterns. Anxiety about the impending dental treatment also can be detected in speech.

▪ Rapid response to questions or nervous voice quivers can indicate increased anxiety and the
possible need for sedation during dental treatment

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 DIALOGUE HISTORY

▪ the doctor must next determine what significance, if any, these disorders
present to the planned dental treatment.

• (By “significance,” this text means the risk that a patient’s preexisting
medical problem would be acutely exacerbated during or immediately
following the dental appointment.)

▪ This discussion with the patient is the dialogue history, in which the doctor
must use all available knowledge of the pathologic process to assess the
degree to which the patient is at risk.

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 DIALOGUE HISTORY
▪ At what age did you develop diabetes?

▪ Comment: This question is designed to help determine whether the disease

manifested itself while the patient was a child or an adult. Diabetes developing when
the patient is a child (previously known as juvenile-onset diabetes) is known as type 1
or insulin-dependent diabetes mellitus, whereas an adult onset of diabetes more
likely represents type 2 or non-insulin-dependent diabetes mellitus.

▪ How do you control your blood sugar levels?

▪ Comment: The answer should provide enough information to determine whether the
diabetes is type 1 or type 2. Type 1 diabetics are more likely to develop acute
complications associated with diabetes, primarily hypoglycemia.

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 DIALOGUE HISTORY
▪ How often do you monitor your blood sugar, and what are the
recordings? (determining the degree of control the patient maintains over
their diabetes)

▪ Have you been hospitalized for your diabetes? Why?

▪ Comment: A history of hospitalization for low blood glucose (hypoglycemia)

may alert the doctor to seek outside assistance more immediately in the event
of a problem developing in this patient during treatment. Additionally,
hospitalization due to the chronic complications of diabetes should prompt the
doctor to seek signs and symptoms of cardiovascular disease.

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 RECOGNITION OF DENTAL FEAR AND ANXIETY

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95
 RECOGNITION OF DENTAL FEAR AND ANXIETY

▪ Patients with severe anxiety usually make no effort at hiding this fact from
their doctor or any member of the office staff. In fact, these patients frequently
do anything in their power to avoid dental treatment.

▪ It is estimated that between 6% and 14% (14 million to 34 million) of

Americans actively avoid dental treatment completely because of fear and that
another 20% to 30% dislike it enough to make only occasional visits

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 RECOGNITION OF DENTAL FEAR AND ANXIETY

▪ These patients constitute the severe anxiety group. When in the dental office,
they may be recognized by the following signs:

▪ Increased blood pressure and heart rate

▪ Trembling

▪ Excessive sweating

▪ Dilated pupils

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 DETERMINATION OF MEDICAL RISK
▪ After completing the physical examination, performing a thorough dental
examination, and deciding on a tentative treatment plan, the doctor must review all of
this information to answer the following questions:

▪ Is this patient capable, both physiologically and psychologically, of tolerating in

relative safety the stress involved in the proposed dental treatment plan?

▪ Is the patient at greater risk (of morbidity or mortality) than usual during the planned
dental care?

▪ If the patient does represent an increased risk, what treatment modifications, if any,
may be employed to minimize this risk during the planned dental treatment?

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 MEDICAL CONSULTATION

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 DURATION OF DENTAL TREATMENT

▪ The length of the treatment period is significant in both the medically compromised
and the apprehensive patient. Unless the patient’s physical condition mandates short
visits, the doctor should consider the patient’s wishes and decide on an appropriate
length

▪ In many instances fearful patients (ASA 1 or 2) may desire to have as few dental
appointments as possible, regardless of their length; such patients may prefer to
accomplish their dental treatments with 3-hour or longer appointments.

▪ However, attempting to satisfy the patient’s desire for a longer appointment is

inadvisable when the doctor believes that a shorter appointment is warranted.

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 POSTOPERATIVE CONTROL OF PAIN AND ANXIETY

Consider potential complications that might arise during the 24 hours

immediately after dental care, discuss these with the patient, and take steps to
help the patient prevent or manage them.

These steps may include any or all of the following:

▪ Be available by telephone 24 hours a day

▪ Monitor pain control

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 Question?

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