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It is important to try and build in some guidelines when you review the
medical history and try to have some ways of being able to raise a Red
Flag when things are likely to pose a problem in the dental management
of the patient.
Patients are getting older and are retaining their dentition longer. Their
medical condition is also getting progressively more complicated. One out
of three adults in this country has hypertension, one out of seven has
hyperlipidemia and one out of eight adults has diabetes. It is therefore
not unusual to have to carefully evaluate the medical needs of the patient
prior to planned sedation.
The age of the patient would be the first thing that can raise a Red Flag.
Patients greater than the age of 65 should raise a Red Flag. They are
more likely to have hypertension, hyperlipidemia, diabetes, heart disease
and vascular disease.
They metabolize and excrete drugs much more slowly and are more likely
to develop adverse drug reactions. This is particularly important in
sedation dentistry since the dose of benzodiazepines has to be reduced in
In patients above the age of 65, you need to reduce sedation medication
by one half.
It is important to pay attention to the last time a patient has had a medical
evaluation. A patient who has never seen a physician would have no
known medical problems at all!
Patients above the age of 50 should have had an evaluation within the
past year.
Any patient above the age of 60 and any patient with complex medical
issues who has not had a medical evaluation within the past 6 months
should raise a Red Flag.
Hypertension, heart disease and diabetes mellitus are the most common
conditions where patients may seek sedation. Some patients seeking
dentistry may have a coronary stent.
HYPERTENSION
The good news is that there is good evidence that hypertension can be
controlled, but it will take an intense and sustained effort.
Patients with Type 1 diabetes mellitus has diabetes as the result of insulin
deficiency.
Patients with Type 2 diabetes mellitus has insulin resistance and is treated
with.
Patients with Type 1 diabetes mellitus are treated with insulin. Patients
with Type 2 diabetes are started on life style modification, diet, exercise
with the goal to lose weight. In many instances, they would need oral
hypoglycemic agents to get blood sugar into reasonable range. In some
instances, control cannot be established without the addition of insulin.
Diabetics are particularly prone to oral infection. This can lead to poor
glucose control. In general, it is important to aggressively control oral
infection and this may result in more liberal use of antibiotics in the
diabetic patient.
Patients whose diabetes is not under adequate control should raise a Red
Flag since they are much more prone to having infection that is difficult to
control. We now monitor adequacy of control by the determination of
HbA1c, which provides an assessment of the average blood sugar level
over a 90-day period.
All diabetics should have an HbA1c value from within the last 3-6 months.
All patients with a HbA1c of greater than 8.5% should raise a Red Flag:
ANGINA
CORONARY STENTS
For every patient who identifies angina as a medical issue, you should ask
the following questions:
The 6-month time point can then be used to guide dental management,
including significant changes in treatment protocols. These guidelines
form the basis for recommendations in the Ultimate Cheat Sheets.
Although dental procedures may not the same as complex surgery, it is
still prudent to be aware of the concerns about doing ANY surgery within 6
months after a myocardial infarction.
The available screening tests are now accurate (99.7-100% sensitivity and
specificity), quick (<20 minutes) and can be done in-office.
With the practice of universal precautions, caring for the HIV patient does
not pose a special problem.
Protease inhibitors
Anti-fungal agents
These should raise Red Flags since they will have significant interactions
(category D drug-drug interactions) with many of the drugs that would be
used for sedation dentistry. (to be covered in Pharmacology II).
Patients with HIV are not obligated to tell you of their disease but they are
obligated to tell you all of the medications they are on.
PREGNANCY
The following table explains the assignment of the various drug categories
in the pregnant female:
After consideration of the medical issues a given patient has, it is then possible to
stratify the risk of a specific procedure for the patient. The most commonly used
scale for risk assessment is the ASA Physical Status Classification widely used by
anesthesiologists and surgeons in the risk stratification of patients about to
undergo a surgical procedure.
The original classification of Physical Status was developed by the ASA in 1941
and very little has changed in the intervening decades:
Controlled hypertension
Hyperlipidemia
Type II diabetes, under good control
Hypothyroidism, under good control
ASA III: patient with severe systemic disease that limits activity but is
non-incapacitating
Stable angina
Remote history of myocardial infarction (>6 mos)
Type 1 diabetes mellitus
In general, patients with ASA I and II classification are good candidates for
sedation dentistry.
Based upon the information we are able to derive from the medical history,
verified by the patient, we should be able to do a reasonable risk
assessment. We should be on the lookout for Red Flags in the Medical
History Form, examine the overall complexity of the patient, consider the
dental procedure planned and then make the decision with respect to
acceptability of the candidate for oral conscious sedation.