Dental Care & Medicine (2)

8/3/2019 Dental Care & Medicine (2)

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Dental care &Dental care &

MedicineMedicine


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ASA PHYSICAL STATUSASA PHYSICAL STATUS

CLASSIFICATION SYSTEM*CLASSIFICATION SYSTEM* ASAIASA I

ASAIIASA II

ASAIIIASA III ASAIVASA IV

ASAVASAV

ASAVIASAVI

ASAASA--EE


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ASA IASA I

Patients are considered to be normal andPatients are considered to be normal and

healthy.healthy. Patients are able to walk up one flightPatients are able to walk up one flight

of stairs or two level city blocks withoutof stairs or two level city blocks withoutdistress.distress. Little or no anxiety.Little or no anxiety. Little or noLittle or norisk.risk. This classification represents a This classification represents a "" green flag green flag""

for treatment.for treatment.


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ASA IIASA II

Patients have mild to moderate systemic diseasePatients have mild to moderate systemic disease

or are healthy ASA I patients who demonstrate aor are healthy ASA I patients who demonstrate a

more extreme anxiety and fear towardmore extreme anxiety and fear towarddentistry.dentistry. Patients are able to walk up one flightPatients are able to walk up one flightof stairs or two level city blocks, but will have toof stairs or two level city blocks, but will have to

stop after completion of the exercise because ofstop after completion of the exercise because of

distress.distress. Minimal risk during treatment.Minimal risk during treatment. ThisThisclassification represents aclassification represents a "" yellow flag yellow flag"" forfor

treatment.treatment.


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ExamplesExamples: History of well: History of well--controlled disease statescontrolled disease statesincluding nonincluding non--insulin dependent diabetes,insulin dependent diabetes,prehypertension, epilepsy, asthma, or thyroidprehypertension, epilepsy, asthma, or thyroid

conditions; ASA I with a respiratory condition,conditions; ASA I with a respiratory condition,pregnancy, and/or active allergies. May need medicalpregnancy, and/or active allergies. May need medicalconsultation.consultation.

Note:Note: Patients who demonstrate a more extremePatients who demonstrate a more extremeanxiety and fear toward dentistry have a baseline ofanxiety and fear toward dentistry have a baseline ofASA II even before their medical history is considered;ASA II even before their medical history is considered;that situation raises the classification system.that situation raises the classification system.


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ASA IIIASA III

Patients have severe systemic disease that limitsPatients have severe systemic disease that limits

activity, but is not incapacitating.activity, but is not incapacitating. Patients arePatients are

able to walk up one flight of stairs or two levelable to walk up one flight of stairs or two levelcity blocks, but will have to stop enroutecity blocks, but will have to stop enroutebecause of distress.because of distress. If dental care is indicated,If dental care is indicated,

stress reduction protocol and other treatmentstress reduction protocol and other treatment

modifications are indicated.modifications are indicated. This classification This classificationrepresents arepresents a ""yellow flagyellow flag""for treatment.for treatment.


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Examples:Examples: History of angina pectoris,History of angina pectoris,

myocardial infarction, or cerebrovascularmyocardial infarction, or cerebrovascular

accident, congestive heart failure over sixaccident, congestive heart failure over sixmonths ago, slight chronic obstructivemonths ago, slight chronic obstructivepulmonary disease, and controlled insulinpulmonary disease, and controlled insulin

dependent diabetes or hypertension. Will needdependent diabetes or hypertension. Will need

medical consultation.medical consultation.


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ASA IVASA IV

Patients have severe systemic disease that limits activityPatients have severe systemic disease that limits activityand is a constant threat to life.and is a constant threat to life. Patients are unable toPatients are unable to walk up one flight of stairs or two level city walk up one flight of stairs or two level city

blocks.blocks. Distress is present even at rest. Patients poseDistress is present even at rest. Patients posesignificant risk since patients in this category have asignificant risk since patients in this category have asevere medical problem of greater importance to thesevere medical problem of greater importance to thepatient than the planned dental treatment.patient than the planned dental treatment. WheneverWheneverpossible, elective dental care should be postponed untilpossible, elective dental care should be postponed untilsuch time as the patient's medical condition hassuch time as the patient's medical condition hasimproved to at least an ASA III classification.improved to at least an ASA III classification. ThisThisclassification represents aclassification represents a ""red flagred flag"" -- a warning flaga warning flagindicating that the risk involved in treating the patient isindicating that the risk involved in treating the patient is

too great to allow elective care to proceed.too great to allow elective care to proceed.


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ExamplesExamples: History of unstable angina pectoris,: History of unstable angina pectoris,

myocardial infarction or cerebrovascularmyocardial infarction or cerebrovascularaccident within the last six months, severeaccident within the last six months, severe

congestive heart failure, moderate to severecongestive heart failure, moderate to severechronic obstructive pulmonary disease, andchronic obstructive pulmonary disease, and

uncontrolled diabetes, hypertension, epilepsy, oruncontrolled diabetes, hypertension, epilepsy, or

thyroid condition. If emergency treatment isthyroid condition. If emergency treatment isneeded, medical consultation is indicated.needed, medical consultation is indicated.


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ASA VASA V

Patients are moribund and are not expected toPatients are moribund and are not expected to

survive more than 24 hours with or without ansurvive more than 24 hours with or without anoperation.operation. These patients are almost always These patients are almost always

hospitalized, terminally ill patients.hospitalized, terminally ill patients. ElectiveElectivedental treatment is definitely contraindicated;dental treatment is definitely contraindicated;

however, emergency care, in the realm ofhowever, emergency care, in the realm of

palliative treatment may be necessary.palliative treatment may be necessary. ThisThisclassification represents aclassification represents a red flagred flag"" for dentalfor dental

care and any care is done in a hospital situation.care and any care is done in a hospital situation.


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ASAASA--EE

Emergency operation of any variety (used toEmergency operation of any variety (used to

modify one of the above classifications, i.e.,modify one of the above classifications, i.e.,ASA IIIASA III--E).E).


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Types of dental care is divided into either:Types of dental care is divided into either:

1.1. Primary carePrimary care

2.2. Secondary careSecondary care Or either into:Or either into:

1.1. RoutineRoutine

2.2. ElectiveElective3.3. emergencyemergency


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ORAL MEDICINE IN THEORAL MEDICINE IN THE

HOSP

ITAL

HOSP

ITAL

The hospital is frequently the setting for the The hospital is frequently the setting for the

most complex cases in oral medicine.most complex cases in oral medicine.Hospitalized patients are most likely to have oralHospitalized patients are most likely to have oral

or dental complications of bone marrowor dental complications of bone marrowtransplantation, hematologic malignancies,transplantation, hematologic malignancies,

poorly controlled diabetes, major bleedingpoorly controlled diabetes, major bleeding

disorders, and advanced heart disease.disorders, and advanced heart disease.


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The hospital that wishes to provide the highestThe hospital that wishes to provide the highest

level of care for its patients must have a dentallevel of care for its patients must have a dentaldepartment.department.

The hospital dental department should serve as aThe hospital dental department should serve as acommunity referral center by providing thecommunity referral center by providing the

highest level of dental treatment for patientshighest level of dental treatment for patients

with severe systemic disease and management ofwith severe systemic disease and management ofthe most medically complex patientsthe most medically complex patients


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Because of the availability of sophisticatedBecause of the availability of sophisticated

diagnostic and lifediagnostic and life--sustaining equipment and thesustaining equipment and theproximity of expert consultants in all areas ofproximity of expert consultants in all areas of

health care.health care.


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Hospital patient in dentistryHospital patient in dentistry

The patient may be admitted as an inpatient toThe patient may be admitted as an inpatient to

the dental service.the dental service.

The patient may be seen as a hospital The patient may be seen as a hospitaloutpatient.outpatient.

The patient may be seen by consultation at theThe patient may be seen by consultation at the

request of another department of the hospital.request of another department of the hospital.


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Dental considerationsDental considerations

PregnancyPregnancy

HypertensionHypertension

DiabetesDiabetesAdrenal insuffieciencyAdrenal insuffieciency

Ischemic heartIschemic heart

PregnancyPregnancy

Renal diseaseRenal disease

Bleeding tendancyBleeding tendancy


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PAIN CONTROL TECHNIQUESPAIN CONTROL TECHNIQUES

STRESS REDUCTION PROTOCOLSTRESS REDUCTION PROTOCOL

PREPRE--EMPTIVE ANALGESIAEMPTIVE ANALGESIA

LOCAL ANAESTHESIALOCAL ANAESTHESIA CONSCIOUS SEDATIONCONSCIOUS SEDATION

GENERAL ANAESTHESIAGENERAL ANAESTHESIA

PATIENT CONTROLLED ANALGESIAPATIENT CONTROLLED ANALGESIA


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OBJECTIVES OF PAINOBJECTIVES OF PAINCONTROLCONTROL

ReliveRelive patientpatient anxietyanxiety toto helphelpestablishingestablishing aa communicationcommunication..

AllowAllow betterbetter patientpatient assessmentassessmentAssociateAssociate patientpatient inin thethe treatmenttreatment planplan..

ImproveImprove qualityquality ofof lifelife postoperativelypostoperatively

(pain is related to sickness)(pain is related to sickness)


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StressStress--Reduction ProtocolReduction Protocol(Medically Compromised(Medically Compromised

Patients)Patients)1. Recognize medical risk/ anxiety1. Recognize medical risk/ anxiety2. Consult patients physician(s)2. Consult patients physician(s)

3. Pharmacological sedation, as indicated3. Pharmacological sedation, as indicated4. Short appointments4. Short appointments

5. Morning appointments5. Morning appointments

6. Minimize waiting room time6. Minimize waiting room time7. Excellent intraoperative pain control7. Excellent intraoperative pain control

8. Excellent post8. Excellent post--operative pain controloperative pain control


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PREPRE--EMPTIVE ANALGESIAEMPTIVE ANALGESIA

PreventionPrevention ofof painpain ratherrather thanthan treatingtreatingpainpain isis importantimportant andand couldcould reducereduce thetheanalgesicanalgesic requirementsrequirements afterafter surgerysurgery..

SystemicSystemic analgesicsanalgesics beforebefore thethe locallocalanaestheticanaesthetic (LA)(LA) hashas wornworn offoff oror anan LALAduringduring generalgeneral anaesthesiaanaesthesia (GA)(GA) toto

preventprevent painpain inin thethe earlyearly postoperativepostoperativephasephase


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PATIENT CONTROLLEDPATIENT CONTROLLEDANALGESIAANALGESIA

UsuallyUsually intravenousintravenous (i(i..vv..)) morphinemorphine isisusedused viavia anan infusioninfusion pump,pump, afterafter majormajorheadhead && neckneck surgery,surgery, withwith aa locklock toto limitlimitthethe dosedose forfor safetysafety..

PatientsPatients givengiven thisthis controlcontrol overover theirtheirownown painpain reliefrelief usuallyusually useuse smallersmaller

dosesdoses thanthan wouldwould havehave beenbeen prescribedprescribed..


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DrugDrug--induced,induced, alteredaltered statestate of ofconsciousnessconsciousness

MayMay bebe oral,oral, inhalational,inhalational, ororintravenousintravenous

LocalLocal anaesthesiaanaesthesia isis stillstill requiredrequired

RequiredRequired aa trainedtrained dentistdentist && nursenurse toto

performperform itit MorbidityMorbidity && mortalitymortality isis lessless thanthan GG..AA

NeedsNeeds patientpatient selectionselection


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It prevents anxiety during treatmentIt prevents anxiety during treatmentbecause of loss of consciousnessbecause of loss of consciousness

Risk of morbidity & mortality, requireRisk of morbidity & mortality, requirepatient selectionpatient selection

Anesthetist must administer theAnesthetist must administer theanaesthetic agent.anaesthetic agent.

Can be as an outCan be as an out--patient or inpatient or in--patientpatientservice.service.


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AnaesthesiaAnaesthesia isis thethe lossloss ofof consciousnessconsciousnessandand allall formform ofof sensationsensation..

LocalLocal AnaesthesiaAnaesthesia isis thethe locallocal lossloss of ofpain,pain, temperature,temperature, touch,touch, pressurepressure andandallall otherother sensationsensation..

InIn dentistry,dentistry, OnlyOnly lossloss ofof painpain sensationsensation

isis desirabledesirable.. LocalLocal AnalgesiaAnalgesia..


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Dental Care & Medicine (2)