Pre operative assessment of patient schedule for oral surgery

1. Pre-operative assessment of patient schedule
for oral surgery procedure
BY:- Nuha fadhil

2. Physicalevaluationandriskassesssment
Dentistry today is far different from what was practiced
only a decade or two ago, not only in techniques and
procedures but also in the types of patients seen. As a
result of advances in medical science, people are living
longer and are receiving medical treatment for
disorders that were fatal only a few years ago.
For example:- damaged heart valves are
surgically replaced, occluded coronary
arteries are surgically bypassed or opened
by balloons, organs are transplanted, severe
hypertension is medically controlled, and
many types of malignancies and immune
deficiencies are managed or controlled.

3. 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.
*Risk assessment involves the evaluation of at least four
components:-
(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). All factors must be
carefully weighed for each patient.

4. Risk assessment :-

5. *General Stress Reduction Protocol
1. Open communication about fears/concerns
2. Short appointments
3. Morning appointments
4. Preoperative sedation Short-acting
benzodiazepine (e.g., triazolam 0.125-0.25
mg) Night before appointment and/or 1 hr
before appointment
5. Intraoperative sedation (N2O/O2) analgesia
6. Profound local anesthesia; topical, use prior
to injection
7. Adequate postoperative pain control
8. Patient contacted on evening of the
procedure

6. *The cornerstone of patient
evaluation and risk assessment is
the medical history,
supplemented by physical
examination, laboratory tests,

7. Medical history
It is recording all
of medical
problems and the
treatment that the
person has had

8. A- Cardiovascular diseases:-
Patients with untreated or symptomatic heart failure are
at increased risk for myocardial infarction (MI),
arrhythmias, acute heart failure, or sudden death and
generally are not candidates for elective dental
treatment. Chair position may influence a patient's ability
to breathe, with 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
A history of a heart attack (MI) within the very recent past
may preclude elective dental care because during the
immediate postinfarction period, patients have increased
risk for reinfarctions, arrhythmias, and heart failure.
Patients may be taking medications such as antianginals,
anticoagulants, adrenergic blocking agents, calcium
channel blockers, antiarrhythmic agents, and digitalis.
Some of these drugs may alter the dental management
of patients because of potential interactions with
vasoconstrictors in the local anesthetic.

9. Patients with hypertension (blood pressure greater than 140/90 mm
Hg) should be identified by history and confirmed by blood pressure
measurement. Patients with a history of hypertension should be
asked if they are taking or are supposed to be taking
antihypertensive medication. Failure to take medication is often the
cause of elevated blood pressure in a patient who reports being
under treatment for high blood pressure. Current blood pressure
readings and any symptoms that may be associated with
hypertension, such as visual changes, dizziness, and headaches,
should be noted. Some antihypertensive medications,such as the
nonselective beta-blocking agents, may require cautious use of
vasoconstrictors
Patients with angina, especially unstable angina, are at
increased risk for arrhythmias, MI, and sudden death. A variety
of vasoactive medications, such as nitroglycerin, beta-blocking
agents, and calcium channel blockers, are used to treat angina.
Vasoconstrictors should be used cautiously. Patients with
unstable or progressive angina are not candidates for elective
dental care

10. Patients with some forms of severe congenital heart disease are at risk
for bacterial endocarditis. The American Heart Association recommends
that patients with certain conditions be given prophylactic antibiotics for
most dental procedures. These are primarily patients with complex
cyanotic heart disease (e.g., tetralogy of Fallot), and those who have had
surgical repair of a congenital defect with residual leak. These patients
have a high risk for bacterial endocarditis and require antibiotic
prophylaxis for certain dental procedures. Patients with most other types
of congenital heart disease are not considered at risk for bacterial
endocarditis from invasive dental procedures,
Vasoconstrictors in local anesthetics should be used cautiously in
patients prone to arrhythmias because they can be precipitated by
excessive quantities or inadvertent intravascular injections. Some of
these patients take antiarrhythmic drugs; certain agents may cause
oral manifestations or other effects Patients with arrhythmias may
require a pacemaker or a defibrillator to artificially regulate or pace
heart rhythm. These patients do not require antibiotic prophylaxis

11. Patients with prosthetic heart valves are
considered to be at high risk for bacterial
endocarditis with significant morbidity and
mortality. As a result, the American Heart
Association recommends that all patients
with a prosthetic heart valve be given
prophylactic antibiotics for most dental
procedures
Previously, the American Heart Association
recommended that patients with rheumatic
heart disease receive antibiotic prophylaxis
for invasive dental procedures to prevent
bacterial endocarditis. However, on the
basis of accumulated scientific evidence,
recently revised guidelines have omitted this
recommendation

12. the American Heart Association recommended that patients with MVP
with regurgitation receive antibiotic prophylaxis for invasive dental
procedures to prevent bacterial endocarditis. However, on the basis of
accumulated scientific evidence, recently revised guidelines have omitted
this recommendation
Previously, the American Heart Association recommended antibiotic
prophylaxis for many patients with heart murmurs caused by valvular disease
(e.g., mitral valve prolapse, rheumatic heart disease); however, on the basis
of accumulated scientific evidence, recently revised guidelines have omitted
this recommendation. If a murmur is due to a specific cardiac condition (e.g.,
previous endocarditis, prosthetic heart valve, complex congenital cyanotic
heart disease), the American Heart Association recommends antibiotic
prophylaxis for most dental procedures
The grafted artery bypasses the occluded portion of the artery. These
patients do not require antibiotic prophylaxis Patients who have had
balloon angioplasty with or without placement of a stent do not require
prophylaxis

13. B- Hematologic Disorders:-
Patients with an inherited bleeding disorder such as 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. These patients
must be identified and managed in cooperation with their
physician or hematologist. Patients with severe factor deficiency
may require factor replacement prior to invasive treatment, as
well as aggressive postoperative measures to maintain
hemostasis
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, and alterations in the delivery of
dental treatment may have to be made. 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. Laboratory screening or medical consultation may be
appropriate to determine the status of liver function, and, as
always, standard infection control procedures are mandatory

14. Some anemias, such as glucose-6-phosphate
dehydrogenase deficiency and sickle cell
disease, require dental management
modifications. Oral lesions, infections, delayed
wound healing, and adverse responses to
hypoxia are all potential matters of concern
Depending on the type of leukemia, status of
the disease, and type of treatment, some
patients may have bleeding problems or
delayed healing, or may be prone to infection.
Gingival enlargement can be a sign of
leukemia. Some adverse effects can result
from the use of chemotherapeutic agents and
may require dental management modifications

15. E- Respiratory Tract
Disease
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. The use of high-flow oxygen may be contraindicated
in patients with severe disease because it can decrease the
respiratory drive
The type of asthma should be identified, as should the drugs
taken and any precipitating factors or triggers. Stress may be
a precipitating factor and should be minimized when possible
. It is often helpful to ask whether the patient has had to go to
an emergency room for acute treatment of asthma, as this
would indicate more significant disease. If patients use an
inhaler for acute attacks, they should bring it to dental
appointment with them

16. 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
powderless gloves can be used to prevent an adverse
reaction. True allergy to amide local anesthetics is
uncommon. Dentists should procure an allergic history
by specifically asking patients how they react to a
particular substance. This will help to establish a
diagnosis of allergy rather than an intolerance or adverse
effect that has been incorrectly identified as an allergy.
Symptoms consistent with allergy include itching,
urticaria (hives), rash, swelling, wheezing, angioedema,
runny nose, and tearing eyes. Isolated symptoms such
as nausea, vomiting, palpitations, and fainting are
generally not of an allergic origin but rather are
manifestations of drug intolerance, adverse effects, or
psychogenic reactions

17. C- Neurologic Disorders
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 of diphenylhydantoin.
Patients may discontinue use of antiseizure medication without their
doctors’ knowledge and thus may be susceptible to seizures during dental
treatment. Therefore, verification of patients’ adherence to their
medication schedule is important
Elective dental care should be avoided in the immediate poststroke
period because of increased risk for subsequent strokes.
Vasoconstrictors should be used cautiously. Anticoagulant medications
and antiplatelet medications can result in prolonged bleeding. Stress and
anxiety reduction measures may be necessary

18. D- Gastrointestinal Diseases
Patients who have a history of viral hepatitis are of concern in
dentistry because they may be asymptomatic carriers of the
disease and can transmit it unknowingly to dental personnel or
other patients. Of the several types of viral hepatitis, only B, C, and
D have carrier stages. Fortunately, laboratory tests are available to
identify these patients. Patients also may have chronic hepatitis (B
or C) or cirrhosis and, as a result, have impaired liver function. This
may result in prolonged bleeding and an impaired ability to
efficiently metabolize certain drugs, including local anesthetics and
analgesics
Patients with gastric or intestinal disease should not be given
drugs that are directly irritating to the gastrointestinal tract, such as
aspirin or nonsteroidal antiinflammatory drugs. Patients with colitis
or a history of colitis may not be able to take certain antibiotics.
Many antibiotics can cause a particularly severe form of colitis (i.e.,
pseudomembranous colitis). Some drugs used to treat ulcers may
cause dry mouth

19. F- Musculoskeletal Disease
Many types of arthritis have been identified; the most common of
these are osteoarthritis and rheumatoid arthritis. Patients with
arthritis may be taking a variety of medications that could influence
dental care. Nonsteroidal antiinflammatory drugs, aspirin,
corticosteroids, and cytotoxic and immunosuppressive drugs are
examples. Tendencies for bleeding and infection should be
considered. Chair position may be a factor in physical comfort.
Patients may have problems with manual dexterity and oral
hygiene. In addition, patients with arthritis may have involvement of
the temporomandibular joints
Some patients with artificial joints are at increased risk for infection of
the prosthesis and may need to be provided with prophylactic
antibiotics prior to any dental treatment that is likely to produce
bacteremia. Patients included in this category are those with
rheumatoid arthritis, type 1 diabetes, recent joint placement, and
hemophilia, as well as those who are immunosuppressed. Patients
with joint prostheses who do not fall into these risk categories do not
require antibiotic prophylaxis

20. G-Endocrine Disease
Patients with diabetes mellitus must be identified in terms of type of
diabetes diagnosed and control measures taken. Patients with type 1
diabetes require insulin, whereas type 2 diabetes is usually controlled
through diet and/or oral hypoglycemic agents. Some patients with type 2
diabetes may also require insulin. Those with type 1 diabetes have a
greater number of complications and are of greater concern regarding
management than are those with type 2 diabetes.. Patients with diabetes
typically 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
Patients with uncontrolled hyperthyroidism are potentially
hypersensitive to stress and sympathomimetics; the use of
vasoconstrictors is generally contraindicated. In rare cases,
infection or surgery can initiate a thyroid crisis—a serious
medical emergency. Patients with uncontrolled
hyperthyroidism may be easily upset emotionally and
intolerant of heat, and they may exhibit tremors

21. H- Genitourinary Tract
Disease
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.
A variety of sexually transmitted diseases such as
syphilis, gonorrhea, human immunodeficiency virus (HIV)
infection, and AIDS can have manifestations in the oral
cavity because of oral/genital contact or hematogenous
dissemination in the blood. The dentist may be the first to
identify these conditions. In addition, some sexually
transmitted diseases, including HIV, hepatitis B and C,
and syphilis, can be transmitted to the dentist via direct
contact with oral lesions or infectious blood

22. I- Other conditions
The use of tobacco products is a risk factor that is
associated with cancer, cardi-ovascular disease,
pulmonary disease, and periodontal disease. Patients
who use tobacco products should be asked whether
they would like to quit and should be encouraged to do
Patients who have a history of intravenous drug use are at risk for
infectious diseases such as hepatitis B or C, AIDS, and infective
endocarditis. Narcotic and sedative medications should be prescribed
cautiously, if at all, for these patients, because of the risk of triggering
a relapse. Vasoconstrictors should be avoided in active cocaine or
methamphetamine users because they may precipitate arrhythmias or
severe hypertension
Women who are or may be pregnant may need
special consideration in the taking of radiographs,
administration of drugs, or timing of dental
treatment

23. Patients with previous radiation treatment of the head,
neck, or jaw must be carefully evaluated because radiation
can permanently destroy the blood supply to the jaws,
leading to osteoradionecrosis after extraction or trauma.
Chemotherapy can produce many undesirable adverse
effects, most commonly a severe mucositis
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
A history of hospitalizations can provide a record of past serious
illnesses that may have current significance. For example, a patient
may have been hospitalized for cardiac catheterization for ischemic
heart disease. patients may not have received medical follow-up
care for these problems, and the response to this question is the
only indication of these past problems. 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.

24. Drug history
.
All of the drugs, medicines, or pills that a
patient is taking, or is supposed to be taking,
should be identified and investigated for
actions, adverse effects, and potential drug
interactions.
However, the patient may report taking
medication typically prescribed for a disease.
An example might be a patient with
hypertension who fails to report a history of
that problem but lists medications used to
treat hypertension such as an angiotensin-
converting enzyme (ACE) inhibitor

25. PHYSICAL EXAMINATION
General Appearance
This survey consists of an assessment of
the general appearance of the patient and
inspection of exposed body areas, including
skin, nails, face, eyes, nose, ears, and
neck. Each visually accessible area may
demonstrate peculiarities that can signal
underlying systemic disease or
abnormalities. The outward appearance of
a patient can give an indication of the
patient's general state of health and well-
being.

26. Skin and Nails. The skin is the largest organ of the body; usually, large
areas are exposed and accessible for inspection. Changes in the skin
and nails frequently are associated with systemic disease. For
example, cyanosis can indicate cardiac or pulmonary insufficiency,
yellowing may be caused by liver disease, pigmentation may be
associated with hormonal abnormalities, . Alterations in the fingernails,
such as clubbing (seen in cardiopulmonary insufficiency) white nails
(seen in cirrhosis), yellowing of nails (from malignancy), and splinter
hemorrhages (from bacterial endocarditis), are usually caused by
chronic disorders. The dorsal surfaces of the hands are common sites
for actinic keratosis and basal cell carcinomas, as are the bridge of the
nose, infraorbital regions, and the ears
Face. The shape and symmetry of the face are abnormal in a
variety of syndromes and conditions. Well-known 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

27. The eyes can be sensitive indicators of systemic disease and therefore should
be closely inspected. Patients who wear glasses should be requested to
remove them during examination of the head and neck. 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.
Ears. The ears should be inspected for gouty tophi in the helix or antihelix. An
earlobe crease occurs more frequently in patients with coronary artery disease
than in those without this condition.Malignant or premalignant lesions (i.e., skin
cancer) may be found on and around the ears
Neck. The neck should be inspected for enlargement and asymmetry. Bilateral
palpation of the thyroid gland should be performed Depending on location and
consistency, enlargement may be caused by goiter, infection, cysts, enlarged
lymph nodes, or vascular deformities.

28. Vital signs

29. 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)
4. Addressing medicolegal considerations (e.g.,
possible bleeding disorders, hepatitis B infection)

30. 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:

31. 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

32. TREATMENT MODIFICATIONS
Pre-operative
1. Prophylactic antibiotics given prior to
certain dental procedures in a patient at risk
for bacterial endocarditis
2. Determination of the international
normalized ratio (INR) prior to surgery in a
patient taking Coumadin
3. Ensuring food intake prior to dental
treatment in a diabetic patient on insulin
4. Prescribing an anxiolytic drug for an
anxious patient with stable angina