1st lecture ( history and physical examination ) د ضياء عبدالقادر الحمداني 28/10/2013
At present time there is great difference in practice of dentistry including technique and procedure ,in addition to that type of patient even changed, As a result of advances in medical science, improvement in life style and medical services people are living longer and are receiving medical treatment for disorders that were fatal only a few years ago.the dentist will face patients with chronic illnesses which could be cardiac problem (artificial valve, CABG,hypertension,angina and HF) and non cardiac problem chronic renal failure(CRF), diabetes mellitus(DM) and malignancy. the dentist must remain knowledgeable about patients medical conditions. Many chronic disorders or their treatments necessitate alterations in the provision of dental treatment. Failure to make appropriate treatment modifications may result in serious consequences.for example patient with Heart Failure the underlying cause of heart failure should be identified And wither the patient symptoms controlled or not ,because Patients with symptomatic heart failure generally are not candidates for elective dental treatment since they are at increased risk for arrhythmias, acute pulmonary edema, or sudden death and patient with HF may required:
Chair position modification because some patients unable to tolerate a supine position.
Vasoconstrictors should be avoided, if possible, in patients taking digitalis glycosides (digoxin) because the combination can precipitate arrhythmias .
Stress reduction measures also may be advisable.
The key to successful dental management of a medically compromised patient is a thorough evaluation and assessment of risk to determine whether a patient can safely tolerate a planned procedure. The purpose of Risk assessment include the evaluation of :
(1) the nature, severity. and stability of the patient's medical condition;
(2) the functional capacity of the patient;
(3) the emotional status of the patient;
(4) the type and magnitude of the planned procedure (invasive or noninvasive).
The aim of Risk assessment is to determine whether the benefits of having dental treatment outweigh the potential risks to the patient. The cornerstone of patient evaluation and risk assessment is
the medical history.
physical examination.
laboratory tests.
medical consultation.
MEDICAL HISTORY A medical history must be taken on every patient who is to receive dental treatment. There two basic techniques used to obtain a medical history
1)the interview in which the interviewer questions the patient and then records the patient's verbal responses on a blank sheet.
2) printed questionnaire that the patient fills out.
History inclued introductory information like
Name : age married : occupation: residency: religion:
Complain duration: the problem that make the patient take medical advice.detailed history of the present illness.then
systemic Review :
Cardiovascular system: heart failure,angina.(acute myocardial infarction (AMI),rheumatic fever,valvular heart disease,hypertension,congenital heart disease (CHD),arrhythmia,bypass operation,artificial valve .:chest pain,SOB, palpitation: leg edema:
Respiratory system : symptoms: cough,heamoptysis,SOB,wheezes,Allergies . Patients may be allergic to some drugs or materials used in dentistry. Common drug allergens include antibiotics and analgesics. Latex allergy also is common. For these patients, alternative materials such as vinyl or powder less gloves can be used to prevent an adverse reaction. Asthma avoid drug that precipitate the attack. Emphysema/Chronic Bronchitis. Patients with chronic pulmonary diseases such as emphysema and chronic bronchitis must be identified. The use of medications or procedures that might further depress respiratory function or dry or irritate the airway should be avoided. Chair position may be a factor; some patients may not be able to tolerate a supine position. Use of a rubber dam may not be tolerated because of a choking or smothering feeling.
Tuberculosis.is it active or in active disease,treated or untreated cured or not.
The use of high-flow oxygen may be contraindicated in patients with severe disease because it can decrease the respiratory drive.
Hematologic Disorders :Hemophilia or Inherited Bleeding Disorder. hemophilia A or B, or von Willebrand's disease, are at risk for severe bleeding following any type of dental treatment that causes bleeding, including scaling and root planing.
Blood Transfusion. Patients with a history of blood transfusions are of concern from at least two aspects. The underlying problem that necessitated a blood transfusion, such as an inherited or acquired bleeding disorder, must be identified.second point is that Patients may also be at risk to be carriers of hepatitis B or C or may become infected with the human immunodeficiency virus (HIV) and must be identified.
Anemia. Which could be due to acute or chronic blood loss, decreased production of red blood cells, or hemolysis .Leukemia.
Taking a Blood Thinner/Tendency to Bleed Longer Than Normal. an anticoagulant or an antiplatelet drug .
Neurologic Disorders: ask for 1)Stroke. It may be associated with hypertension and diabetes which must be identified and appropriate management can be made. Elective dental care should be avoided in the immediate post stroke period because of increased risk for subsequent strokes. Vasoconstrictors should be used cautiously. Anticoagulant medications and antiplatelet medications can result in prolonged bleeding should be search for .2) Epilepsy, Seizures, and Convulsions. A history of epilepsy or grand mal seizures should be identified, and the degree of seizure control that is needed should be determined. Specific triggers of seizures (e.g., odors, bright lights) should be identified and avoided. Some medications used to control seizures may affect dental treatment because of drug actions or adverse effects. For example, gingival hyperplasia is a well-known adverse effect phenytoin. Patients may discontinue use of antiseizure medication without their doctors knowledge and thus may be susceptible to seizures during dental treatment.
Gastrointestinal Diseases ask for (Stomach or Intestinal Ulcers, Gastritis, and Colitis. ).
I should avoid drug that effect the stomach and avoid antibiotics that affect colon. Hepatitis, Liver Disease, Jaundice, and Cirrhosis.the condition may be infectious or associated with bleeding tendency.
Musculoskeletal Disease Arthritis, Prosthetic Joints.
Endocrine Disease :Diabetes:Symptoms suggestive of diabetes include excessive thirst and hunger, frequent urination, weight loss, and frequent infections. diabetic patients have many Complications include blindness, hypertension, and kidney failure, which may affect dental management. They do not handle infection very well and may have exaggerated periodontal disease. Patients who take insulin are potentially prone to episodes of hypoglycemia in the dental office if meals are skipped.
Genitourinary Tract Disease Kidney Failure. Patients with end-stage kidney failure or a kidney transplant must be identified. The potential for abnormal drug metabolism, immunosuppressive drug therapy, bleeding problems, hepatitis, infection,high blood pressure, and heart failure must be considered in management. Patients on hemodialysis do not require antibiotic prophylaxis.
Operations or Hospitalizations.
A history of hospitalizations can provide a record of past serious illnesses that may have current significance Information about hospitalizations should include diagnosis,
treatment, and complications. If a patient has undergone any operation, the reason for the procedure and any untoward events associated with it such as anesthetic emergencies, unusual postoperative bleeding, infection, and drug allergy should be addressed.
Drug history like: Corticosteroid usage is important because it can result in adrenal insufficiency and may render a patient unable to adequately respond to the stress of a dental procedure such as an extraction or periodontal surgery. Cortisone and prednisone are examples of steroids that are used in the treatment of many diseases. Generally, however, most routine dental procedures, other than extraction or other surgery, do not require supplemental steroids.Antiplatletesanticoagulant,antihypertensive drug.
Pregnancy.the hazardous of radiation. Women who are or may be pregnant may need special consideration in the taking of radiographs, administration of drugs, or timing of dental treatment.
Current Physician: why the patient is under medical care, diagnoses, and treatment received. The patient who does not have a physician may need a more cautious approach than the patient who sees one regularly.
PHYSICAL EXAMINATION
The purpose of physical examination is for detection of an abnormality rather than the diagnosis. The later is the responsibility of the physician. If an abnormal finding is seems to be significant, the patient should be referred to a physician for further evaluation.
The dentist should performs a simple, abbreviated physical examination.this examination include:
assessment of general appearance.
measurement of vital signs.
examination of the head and neck.
Assessment of General Appearance : Include:
degree of illness (how does the patients looks? is he or she looks( mildly ill ,severely ill or well)? .
state of nutrition (thin overweight,obese ,emaciated).
dressing-clean or dirty clothing.
breathing is there any difficulty in breathing is the patient in respiratory distress or not.
any characteristics facial appearance. the face are abnormal in a variety of syndromes and conditions, examples include the coarse features of acromegaly , the pale, edematous features of nephrotic syndrome; moon facies in Cushing's syndrome; the dull, puffy facies of myxedema; and the unilateral paralysis of Bell's palsy
examine eye, nose ,ear, Hyperthyroidism may produce a characteristic lid retraction, resulting in a wide-eyed stare , Xanthomas of the eyelids are frequently associated with hypercholesterolemia as is arcus senilis in an older individual. Scleral yellowing may be caused by hepatitis. Reddened conjunctiva can result from the sicca syndrome, allergy, or iritis.). The ears should be inspected for gouty tophi in the helix or antihelix.
Colour of the patient: anemic, jaundice or cyanosis.
body odors;The dentist should remain sensitive to breath odors such as acetone and alcohol, possibly associated with alcohol abuse or subsequent liver disease associated with diabetes, ammonia associated with renal failure, putrefaction of pulmonary infections.
Then hand examination for NaiL:for
Clubbing (biliary cirrhosis, IBD, coeliac disease,cardiopulmonary disease).
Leukonychia (hypoalbuminemia esp. in Chronic liver disease(CLD).
Koilonychia (iron deficiency anaemia).spoon shape appearance of the nail.
peripheral cyanosis which is seen in peripheral vascular disease or during cold exposure .
Blue lanulae (Wilsons disease). Which is metabolic disorder of cupper . Hand examination also include :PALM:Warmth & moisture (thyrotoxicosis).
Pallor (anaemia).
Palmar erythema (Chronic liver disease(CLD), thyrotoxicosis).
Dupuytrens contracture (in alcoholism, pancreatitis).
TREMOR:
Fine tremor (Wilsons disease, alcoholism).
Flapping tremor flappinf of hepatic encephalopathy- (liver failure, alcoholism, Wilsons disease).
The skin for bruzing and Petechiae( features of blood or liver disease) .
The neck should be inspected for enlargement and asymmetry. Bilateral palpation of enlarged thyroid gland enlargement ( goiter) , cysts , enlarged lymph nodes whichmay refelect local or systemic disorder(leukemia,lymphoma).
Vital Signs .radial pluse,blood pressurz,temperature,respiratory rate .
. The benefits of vital sign measurement during an initial examination include : First, the establishment of baseline normal values which are essential for comparison in emergency event during treatment.. A second benefit of vital sign measurement during an examination involves screening to identify abnormalities, either diagnosed or undiagnosed. For example, if a person with severe, uncontrolled hypertension was not identified and was treated with no management alteration, the consequences could be serious. In the dental setting, usually only blood pressure and pulse are measured directly. Respiratory rate is determined by observation. Temperature is usually measured only when indicated, such as with infection .
Pulse examination :for rate and rhythm using either the radial or the carotid artery the later is preferable because it is easily palpable and will be helpful in emergency condition with circulatory collapse.count the pulse for 1 minute. The average pulse rate in normal adults is 60 to 100 beats per minute. A pulse rate greater than 100 beats per minute is called tachycardia as in exercise, anxiety, anterior myocardial infarction,drugs, or fever and heart failure. whereas a slow pulse rate of less than 60 beats per minute is called bradycardia.as in athletics, increase intracranial pressure, hypothyroidism , inferior myocardial infarction,jaundice heart block ,vasovagal attack and drug. An abnormal pulse rate may be a sign of a cardiovascular disorder. Check the rhythm.
The normal pulse is a series of rhythmic beats that occur at regular intervals. When the beats occur at irregular intervals, the pulse is called irregular which could be due to different rhythm abnormalities like ectopic,atrial fibrillation,sinoartial block.
Blood Pressure. Blood pressure is determined by blood pressure cuff and stethoscope .
Respiration. The rate and depth of respiration should be noted through careful observation of the movement of the chest and abdomen in the quietly breathing patient. The respiratory rate in a normal resting adult is approximately 12 to 18 breaths per minute. The respiratory rate in small children is higher than that of an adult. Notice should be made of patients with difficult breathing, rapid breathing, or irregular breathing patterns because all may be signs of systemic problems, especially cardiopulmonary disease.
Neck examination for any swelling include thyroid and lymph node enlargement.
CLINICAL LABORATORY TESTS
Laboratory evaluation can be an important part of the evaluation of a patient's health status. Whether the dentist orders tests personally or refers the patient to a physician for testing, the dentist should be familiar with indications for clinical laboratory testing, what tests measure, and what abnormal results mean.
Some indications for clinical laboratory testing in dentistry include the following:
1. Aiding in the detection of suspected disease (e.g., diabetes, infection, bleeding disorders, malignancy)
2. Screening high-risk patients for undetected disease (e.g., diabetes, AIDS)
3. Establishing normal baseline values before treatment (e.g., anticoagulant status, white blood cells, platelets.PHYSICIAN REFERRAL AND CONSULTATION
On the basis of medical history, physical examination, and laboratory screening, contact with the patient's physician for consultation or referral purposes may be warranted. Requests for information should be made in writing by letter.
RISK ASSESSMENT
Once collection of the patient's health data (history, clinical examination, laboratory test results, consultations) is complete, the data must be assessed to determine whether the patient can safely undergo dental treatment and what, if any, modifications in the delivery of dental care are required. One widely used method of expressing medical risk is the American Society of Anesthesiologists (ASA) Physical Classification System. This system was originally developed to classify patients according to their risk for general anesthesia; however, it has been adapted for outpatient medical and dental use and for all types of surgical and nonsurgical procedures, regardless of the type of anesthesia used. Briefly, the system is as follows:
ASA I Normal healthy patient
ASA II Patient with mild systemic disease that does not interfere with daily activity, or patient with a significant health risk factor (e.g., smoking, alcohol abuse, gross obesity) .
ASA III Patient with moderate to severe systemic disease that is not incapacitating but that may alter daily activity.
ASA IV Patient with severe systemic disease that is incapacitating and is a constant threat to life .
Possible Issues or Concerns in Risk Assessment
A: Antibiotics (prophylactic or therapeutic)
Anesthesia (type, vasoconstrictor) Anxiety, Antibiotics. Will the patient need antibiotics, prophylactically or therapeutically? Anesthesia. Are any potential problems or concerns associated with the use of local anesthetics or with vasoconstrictors found in the local anesthetic?
Anxiety. Will the patient need a sedative/anxiolytic?
Allergy. Is the patient allergic to anything that the dentist may prescribe or with which he or she may come into contact in the dental office?
B: Bleeding. Is abnormal hemostasis a possibility?
C : chair position.
D : drug interaction,side effect. Devices(prosthetic vlave,pace maker ,prosthetic joint.
E : equipment (x ray,O2,electrosurgery).
Treatment modification: according to data of assessment treatment modification may be required to prevent or minimize the complication during dental procedure.
Examples include the following:
Preoperative:
Prophylactic antibiotics given prior to certain dental procedures in a patient at risk for bacterial endocarditis
Determination of the international normalized ratio (INR) prior to surgery in a patient taking Coumadin
Ensuring food intake prior to dental treatment in a diabetic patient on insulin
Prescribing an anxiolytic drug for an anxious patient with stable angina
Intraoperative:
Limiting the amount of vasoconstrictor in a patient who takes a nonselective beta blocker
Administering nitrous oxide/oxygen to an anxious patient with poorly controlled hypertension
Using an upright chair position for a patient with heart failure
Avoiding the use of electrosurgery in a patient with a pacemaker
Avoiding elective radiographs in a pregnant patient
Postoperative:
Use of extra local measures for hemostasis in a patient taking Coumadin
Prescribing antibiotics for a poorly controlled diabetic following surgery
Prescribing adequate post-operative analgesia for a patient on chronic steroids . It should be remembered that risk is always increased when a medically compromised patient is treated; the goal is to reduce the risk as much as possible by simple modifications in the delivery of dental treatment.
The end.