Preoperative Health Status Evaluation

MEDICAL HISTORYAn accurate medical history is the most useful information a clinician can have

when deciding whether a patient can safely undergo planned dental therapy.The dentist must also be prepared to anticipate how a medical problem might

alter a a ie response to planned anesthetic agents and surgery.If obtaining the history is done well, the physical examination and laboratory

evaluation of a patient usually play minor roles in the presurgical evaluation.The medical history interview and the physical examination should be tailored

to each patient, taking into consideration the a ie medical problems, age,intelligence, and social circumstances; the complexity of the planned procedure;and the anticipated anesthetic methods.

A practitioner typically asks questions to obtain the following information about the patient:

Identification and demographics: name, age, height, weight.The "chief complaint (CC)" - the major health problem or concern, and its time course (e.g. chest pain for past 4 hours).History of the present illness (HPI) - details about the complaints.Past medical history (PMH) (including major illnesses, any previous surgery/operations.Review of systems (ROS) - Systematic questioning about different organ systemsFamily diseases - especially those relevant to the patient's chief complaint.Childhood diseases - this is very important in pediatrics.Social history - including living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets.Regular and acute medications (including those prescribed by doctors, and others obtained over-the-counter or alternative medicine)Allergies - to medications, food, latex, and other environmental factors

Standard Format for Recording Resultsof History and Physical Examinations

1. Biographic data2. Chief complaint and its history3. Medical history4. Social and family medical histories5. Review of systems6. Physical examination7. Laboratory and imaging results

Biographic DataThe first information to obtain from a patient is biographic data. These data include thea ie full name, home address, age, gender, and occupation, as well as the name of thea ie primary care physician.The clinician uses this information, along with an impression of the a ie

intelligence and personality, to assess the a ie reliability.This is important because the validity of the medical history provided by the patient

depends primarily on the reliability of the patient as a historian. If the identification dataand patient interview give the clinician reason to suspect that the medical history may beunreliable, alternative methods of obtaining the necessary information should be tried.

A reliability assessment should continue throughout the entire history interview andphysical examination, with the interviewer looking for illogical, improbable, orinconsistent patient responses that might suggest the need for corroboration ofinformation.

Chief ComplaintEvery patient should be asked to state the chief complaint.This can be accomplished on a form the patient completes, or the a ie

answers should be transcribed (preferably verbatim) into the dental record duringthe initial interview by a staff member or the dentist.

This statement helps the clinician establish priorities during history taking andtreatment planning. In addition, having patients formulate a chief complaintencourages them to clarify for themselves and the clinician why they desiretreatment.

Occasionally, a hidden agenda may exist for the patient, consciously orsubconsciously. In such circumstances, subsequent information elicited from thepatient interview may reveal the true reason the patient is seeking care.

History of Chief ComplaintThe patient should be asked to describe the history of the present complaint or illness,

particularly its first appearance, any changes since its first appearance, and its influenceon or by other factors.

For example, descriptions of pain should include date of onset, intensity, duration,location, and radiation, as well as factors that worsen and mitigate the pain. In addition,an inquiry should be made about constitutional symptoms such as fever, chills, lethargy,anorexia, malaise, and any weakness associated with the chief complaint.

This portion of the health history may be straightforward, such as a 2-day history of painand swelling around an erupting third molar.

However, the chief complaint may be relatively involved, such as a lengthy history of apainful, non healing extraction site in a patient who received therapeutic irradiation. Inthis more complex case, a more detailed history of the chief complaint is necessary.

Medical HistoryMost dental practitioners find health history forms (questionnaires) to bean efficient means of initially collecting the medical history, whetherobtained in writing or in an electronic format. When a credible patientcompletes a health history form, the dentist can use pertinent answers todirect the interview. Properly trained dental assistants can ed flagimportant patient responses on the form (e.g., circling allergies tomedications in red or electronically flagging them) to bring positiveanswers to the de i attention.

Health questionnaires should be written clearly, in nontechnical language, andin a concise manner.

The form should also include a way, for example, a signature line or pad, for thepatient to verify that he or she has understood the questions and the accuracy ofthe answers.

Numerous health questionnaires designed for dental patients are available fromdental textbooks.

The dentist should choose a prepared form or formulate an individualized one.

Medical HistoryThe items listed (collected on a form, via touch screen, or verbally) help establish asuitable health history database for patients; if the data are collected verbally,subsequent written documentation of the results is important.In addition to this basic information, it is helpful to inquire specifically about commonmedical problems that are likely to alter the dental management of the patient.These problems include angina, myocardial infarction (MI), heart murmurs, rheumaticheart disease, bleeding disorders (including anticoagulant use), asthma, chronic lungdisease, hepatitis, sexually transmitted infections (STIs), diabetes, corticosteroid use,seizure disorder, stroke, and any implanted prosthetic device such as artificial joint orheart valve.Patients should be asked specifically about allergies to local anesthetics, aspirin, andpenicillin. Female patients, in the appropriate age group, must also be asked at each visitwhether they could be pregnant.

Baseline Health History Database

1. Past hospitalizations, operations, traumatic injuries, and serious illnesses2. Recent minor illnesses or symptoms3. Medications currently or recently in use and allergies (particularly drug

allergies)4. Description of health-related habits or addictions such as the useof ethanol, tobacco, and illicit drugs; and the amount and type of daily exercise5. Date and result of last medical checkup or physician visit

Family historyA brief family history can be useful and should focus on relevant inheriteddiseases such as hemophilia. The medical history should be regularly updated.Many dentists have their assistants specifically ask each patient at checkupappointments whether there has been any change in health since the last dentalvisit.The dentist is alerted if a change has occurred and the changes documented inthe record.

Common Health Conditions to Inquire about verbally or on a Health Questionnaire

Alle gie a ibi ic l cal anesthetics

A gi a A ic ag la e A hma Bleedi g di de B ea feedi g C ic e id e Diabe e Hea m m He a i i

H e e i Im la ed he ic de ice L g di ea e M ca dial i fa c i i e hea

attack) O e i P eg a c Re al di ea e Rhe ma ic hea di ea e Sei e di de Se all a mi ed di ea e T be c l i

Review of SystemsThe medical review of systems is a sequential, comprehensive method ofeliciting patient symptoms on an organ-by-organ basis. This review can beextensive when performed by a physician for a patient with complicatedmedical problems.For example, the review of the cardiovascular system in a patient with ahistory of ischemic heart disease includes questions concerning chestdiscomfort (during exertion, eating, or at rest), palpitations, fainting, andankle swelling. Such questions help the dentist decide whether to performsurgery at all or to alter the surgical or anesthetic methods.If anxiety controlling adjuncts such as intravenous (IV) and inhalationsedation are planned, the cardiovascular, respiratory, and nervous systemsshould always be reviewed; this can disclose previously undiagnosedproblems that may jeopardize successful sedation.

Routine Review of Head, Neck, and Maxillofacial Regions

Constitutional: Fever, chills, sweats, weight loss, fatigue, malaise, loss ofappetiteHead: Headache, dizziness, fainting, insomniaEars: Decreased hearing, tinnitus (ringing), painEyes: Blurring, double vision, excessive tearing, dryness, painNose and sinuses: Rhinorrhea, epistaxis, problems breathing through nose,pain, change in sense of smellTemporomandibular joint area: Pain, noise, limited jaw motion, lockingOral: Dental pain or sensitivity, lip or mucosal sores, problems chewing,problems speaking, bad breath, loose restorations, sore throat, loud snoringNeck: Difficulty swallowing, change in voice, pain, stiffness

The need to review organ systems in addition to those in themaxillofacial region depends on clinical circumstances. The cardiovascular and

respiratory systems commonly require evaluation before oral surgery or sedation. Cardiovascular Review Respiratory Review

Chest discomfort on exertion, when eating, or at rest; palpitations;fainting; ankle edema; shortness of breath (dyspnea) on exertion;dyspnea on assuming supine position (orthopnea or paroxysmal nocturnal dyspnea); postural hypotension; fatigue; leg muscle cramping

Dyspnea with exertion, wheezing, coughing, excessive sputum production, coughing up blood (hemoptysis)

PHYSICAL EXAMINATION

The physical examination of the dental patient focuses on the oral cavity and, toa lesser degree, on the entire maxillofacial region. Recording the results of thephysical examination should be an exercise in accurate description rather than alisting of suspected medical diagnoses.For example, the clinician may find a mucosal lesion inside the lower lip that is 5mm in diameter, raised and firm, and not painful to palpation. These physicalfindings should be recorded in a similarly descriptive manner; the dentistshould not jump to a diagnosis and record only fibroma on lower lip. Anyphysical examination should begin with the measurement of vital signs.This serves as a screening device for unsuspected medical problems and as abaseline for future measurements.The techniques of measuring blood pressure and pulse rates are illustratedbelow.

Measurement of systemic blood pressure

Measurement of systemic blood pressureA cuff of proper size placed securely around the upper arm so that the lower edge of cufflies 2 to 4 cm above the antecubital fossa. The brachial artery is palpated in the fossa,and the stethoscope diaphragm is placed over the artery and held in place with thefingers of the left hand. The squeeze-bulb is held in the palm of the right hand, and thevalve is screwed closed with the thumb and the index finger of that hand. The bulb isthen repeatedly squeezed until the pressure gauge reads approximately 220 mm Hg.Air is allowed to escape slowly from the cuff by partially opening the valve while thedentist listens through the stethoscope.Gauge reading at the point when a faint blowing sound is first heard is systolic bloodpressure. Gauge reading when the sound from the artery disappears is diastolicpressure.Once the diastolic pressure reading is obtained, the valve is opened to deflate the cuffcompletely.

Blood pressure cuffsBlood pressure cuffs of varyingsizes for patients with arms ofdifferent diameters (rangingfrom infants through obese adultpatients). Use of an impropercuff size can jeopardize theaccuracy of blood pressureresults. Too small a cuff causesreadings to be falsely high, andtoo large a cuff causes artificiallylow readings.

Blood pressure cuffs typicallyare labeled as to the type and sizeof patient for whom they aredesigned.

Pulse rate and rhythmPulse rate and rhythm most commonly are evaluated by using the tips of themiddle and index fingers of the right hand to palpate the radial artery at thewrist.Once the rhythm has been determined to be regular, the number of pulsationsto occur during 30 seconds is multiplied by 2 to get the number of pulses perminute.If a weak pulse or irregular rhythm is discovered while palpating the radialpulse, the heart should be auscultated directly to determine heart rate andrhythm.

Lip mucosa examined by everting upper and lower lips The physical evaluation of various parts of the body

usually involves one or more of the following fourprimary means of evaluation:(1) inspection, (2) palpation, (3) percussion, and (4)auscultation.In the oral and maxillofacial regions, inspectionshould always be performed.The clinician should note hair distribution andtexture, facial symmetry and proportion, eyemovements and conjunctival color, nasal patency oneach side, the presence or absence of skin lesions ordiscoloration, and neck or facial masses.A thorough inspection of the oral cavity is necessary,including the oropharynx, tongue, floor of themouth, and oral mucosa.

Tongue examined by having the patient protrude it. The examiner then grasps the tongue with cotton sponge and gently manipulates it to examine the lateral borders. The patient also is asked to lift the

tongue to allow visualization of the ventral surface and the floor of mouth.Submandibular gland examined by bimanually feeling gland through floor of mouth and skin under

floor of mouth.

PalpationPalpation is important when examining temporomandibular joint (TMJ)function, salivary gland size and function, thyroid gland size, presence orabsence of enlarged or tender lymph nodes, and induration of oral soft tissues,as well as for determining pain or the presence of fluctuance in areas of swelling.Physicians commonly use percussion during thoracic and abdominalexaminations, and the dentist can use it to test teeth and paranasal sinuses.The dentist uses auscultation primarily for TMJ evaluation, but it is also used forcardiac, pulmonary, and gastrointestinal systems evaluations.

Physical Examination before Oral and Maxillofacial Surgery

Inspection Head a d face Ge e al ha e mme hai

distribution Ea N mal eac i d otoscopic

examination if indicated) E e S mme i e eac i i f il c l

of sclera and conjunctiva, movement, test of vision

N e Se m m c a a e c M h Tee h m c a ha li il Neck Si e f h id gla d j g la e

distention

Palpation Temporomandibular joint: Crepitus,

tenderness Paranasal: Pain over sinuses M h Sali a gla d fl f m h li

muscles of mastication Neck Th id gla d i e l m h de

Percussion Paranasal: Resonance over sinuses (difficult to

assess) M h Tee h

Auscultation Temporomandibular joint: Clicks, crepitus Neck Ca id b i

Brief Maxillofacial ExaminationRoutine ExaminationTemporomandibular Joint Region Pal a e a d auscultate joints. Mea e a ge f m i f ja a d e i g

pattern.Nose and Paranasal Region Occl de nares individually to check for patency. I ec a e i a al m c a

Mouth Take all em able he e I ec al ca i f de al al a d

pharyngeal mucosal lesions. Look at tonsils and uvula. H ld g e f m h i h d ga e hile

inspecting lateral borders. Pal a e g e li f l f m h a d ali a

glands (check for saliva). Pal a e eck f l m h de a d h id gla d

size. Inspect jugular veins.

While interviewing the patient, the dentistshould visually examine the patient for generalshape and symmetry of head and facial skeleton,eye movement, color of conjunctiva and sclera,and ability to hear.The clinician should listen for speech problems,temporomandibular joint sounds, and breathingability.

History A full and accurate history is of paramount importance in assessment of apatient. In some cases, the history may provide the diagnosis while in theremainder it will give essential clues to the nature of the problem.The approach to history taking needs to be tailored to the type ofcomplaint being investigated. It is important to have a systematicapproach to taking a history.A consistent series of questions will avoid inadvertently missing animportant clue. Use e rather than 'closed' (those usually eliciting ayes/no response) questions wherever possible to avoid leading the patient.Record the patient's own responses rather than paraphrasing.

The history will cover:

the complaintthe history of the complaintpast dental historysocial and family historymedical history.

The complaint'What is the problem?' Record the patient's symptoms.If there are severalsymptoms make a list, but with the principal problem first.

History of the complaint'When did the problem(s) start?' Identify the duration of the problem. Alsoremember to ask whether this is thefirst incidence of the problem or the latest of a series of recurrences.Past dental history

'Do you see your dentist regularly?' Establish whether the patient is a regularor irregular attender. Obtain a general picture of their treatment experience(fillings,dentures, local and general anaesthetic experience).

Social and family history

'Just a few questions about yourself.'The importance of recording such basic details as the age of the patient isself-evident. Other factors such as marital status and job help to gain apicture of the patient as a person rather than a mere collection ofsymptoms.Occupation can have direct relevance to some clinical conditions but mayalso reveal aggravating factors such as physical or psychological stress.Record alcohol consumption (units per week) and smoking. Familyhistory may be relevant in some instances, for example in some geneticdisorders such as amelogenesis imperfecta.

Medical history

'Now some questions about your general health/ This is obviously important. Some medical conditions may have oralmanifestations while others will affect the manner in which dental treatment is delivered. Even if the patient volunteers thatthey are 'fit and heal h when you say you are going to ask them a few medical questions, you must persist and enquirespecifically about key systems of the body:

cardiovascular (heart or chest problems)respiratory (chest trouble)central nervous system (fits, faints or epilepsy)allergiescurrent medical treatment: a negative response should be further confirmed by asking whether the patient has visitedtheir general practitioner recentlycurrent and recent drug therapypast medical history: previous occurrences of hospitalisation or medical carebleeding disordershistory of rheumatic feverhistory of jaundice or hepatitisany other current health problems: a negative response can be confirmed, with a final 'so you are fit and well?'.

Extra-oral examinationYou should: k h al a e l m h de be able ide if a d a e elli g sensory disturbance and motor

disturbances de a d ha l k f ba ed he hi

Like history taking, examination necessitates a systematic approach. As ageneral rule, use your eyes first, then your hands to examine a patient.Start with the extraoral examination before proceeding to examine theoral cavity.Take time to look at the patient. This may seem obvious but will identifyswellings, skin lesions and facial palsies.Facial pallor may indicate anaemia, or that the patient may be about tofaint.This process of observation will start while you are taking the history.

Visual areas would cover:

general patient condition mme elli g li e i al i e

Palpation would cover: l m h de temporomandibular joint (TMJ) ali a gla d blem-specific examination.

Lymph node examinationThe major lymph nodes of the maxillofacial region and neck are thesubmental, submandibular and the internal jugular nodes (jugulo-digastric and jugulo-omohyoid node being the largest) are of particularimportance because these receive lymph drainage from the oral cavity.Examination of the nodes should be systematic, although the order ofexamination is not critically important.To palpate the nodes, the examiner should stand behind the patient whilehe/she is seated in an upright position.

Use both hands (left hand for the left side of the patient etc.).A common sequence would be to start in the submental region, workingback to the submandibular nodes then further back to the jugulodigastricnode.Then continue by palpation of the parotid region downwards to theretromandibular area and down the cervical chain of nodes.When a node is perceived as enlarged, record the texture: a hard node of ametastasising malignancy contrasts well with a tender, softer node in aninflammatory process.

Temporomandibular jointA detailed examination of the TMJ is probably only needed when aspecific problem is suspected from the history.

Salivary glandsAs with the TMJ, examination of the salivary glands is only required whenthe history suggests this is relevant.

Problem-specific examinationThe examination will be made in the light of the symptoms reported bythe patient but the examiner may detect swelling, sensory or motordisturbance that the patient has not noticed.

Swelling/lumpThe procedure for examination of a swelling or a lump must encompass a range ofobservations:

anatomical siteshape and sizecoloursingle or multiplesurface texture/warmthtendernessfluctuationsensation/pulsation.

Consistency can be informative, ranging from the soft swelling of a lipoma,through 'cartilage hard' pleomorphic adenomas and 'rubbery hard' nodes inHodgkin's disease to the 'rock hard' nodes of metastatic malignancy.Tenderness and warmth on palpation usually indicates an inflammatoryprocess, while neoplasms are commonly painless unless secondarily infected.Fluctuation indicates the presence of fluid. To assess fluctuation, place twofingers on the swelling and press down with one finger.If fluid is present the other finger will record an upward pressure.Pulsation in a swelling will indicate direct (i.e. it is a vascular lesion) or indirectinvolvement (i.e. in immediate contact) of an artery.

Paraesthesia/anaesthesia

The presence of sensory disturbance is usually identified initially by thepatient in the history. It is important to identify the extent of the affectedarea and the degree of alteration in sensation.It is best to use a fairly fine, but blunt-ended, instrument for this at first,for example the handle of a dental mirror.First, run the instrument gently over what is assumed to be a normal areaof skin so that the patient knows what to expect.Then repeat this over the symptomatic area, asking the patient to saywhether they can feel anything.Record the area of altered sensation in the notes using a drawing.

The extent of the area of paraesthesia or anaesthesia will tell you the particularnerve, or branch of a nerve,involved. This will, in turn, inform you about thepossible location of the underlying lesion.For example, a patient with disturbed sensation of the upper lip has a lesionaffecting the maxillary division of the trigeminal nerve.If this is the sole site of sensory deficit, it suggests a lesion closer to the terminalbranches of this cranial nerve (e.g. in the maxillary sinus).In contrast, if sensory deficiencies are simultaneously present in other branchesof the nerve, it suggests that the lesion is more centrally located.

Paralysis/motor disturbance

While paralysis or motor disturbance may be reported as a symptom by thepatient, it may initially be identified during an examination. In the maxillofacialregion,the motor nerves that are likely to be under consideration are the facialnerve, the hypoglossal nerve and the nerves controlling the muscles that movethe eyes.Disturbance in function of the facial nerve will result in effects on the muscles offacial expression. Paralysis of the lower face indicates an upper motor neuronelesion (stroke, cerebral tumour or trauma).Paralysis of all the facial muscles (on the affected side) indicates a lower motorneurone lesion. The latter is seen in a large number of conditions but, for thedentist, important causes include Bell's palsy, parotid tumours, a misplacedinferior dental local anaesthetic and trauma.

Intra-oral examinationYou should: be able diffe e ia e de al a d -dental sources of symptoms de a d he ig ifica ce f fea e f lce ch as form, site and

pain be able e ami e f m a d e nerve dysfunction k h e ami e a h

Again, a systematic approach is essential to avoid being distracted by the firstunusual finding you encounter.The examination must include lips, cheeks, parotid gland orifices, buccalgingivae, lingual gingivae and alveolar ridges in edentulous areas, hard palate,soft palate, dorsal surface of the tongue, ventral surface of the tongue, floor ofmouth, submandibular gland orifices and, finally, the teeth.Different clinicians will have their own sequence of examination, but it is thethoroughness of the examination that is important,not the order in which theregions of the mouth are examined.Once the general intra-oral examination is complete,a problem-specificexamination can proceed. This is tailored to the clinical problem.

Swelling/lump

The examination of an intra-oral swelling or lump is essentially the sameas that described above as part of the extra-oral examination.Most oral swellings are inflammatory,caused by periapical or periodontalinfections.However, the minority of oral swellings and lumps that are non-dentalencompasses a wide range of conditions.

Ulcer

Examination of an ulcer should include assessment of eight importantcharacteristics:

sitesingle /multiplesizeshapebase of the ulceredgepaintime period.

Visual inspection is essential but palpation is also an important part of theexamination of an ulcer. Gloves must be worn for palpation and the texture ofthe ulcer base, margin and surrounding tissues should be ascertained by gentlepressure.Malignant neoplasms tend to ulcerate, and these often feel firm, hard or evenfixed to deeper tissues. A raised margin is a suspicious finding, as is the presenceof necrotic, friable tissue in the ulcer base and bleeding on lightly pressing.Healing traumatic ulcers tend to be painful on palpation and they feel soft andgelatinous. The finding of an ulcer on examination may necessitate takingadditional history, for example, if a traumatic ulcer is suspected, directquestioning may prompt the patient to recall the injury .If multiple ulcers are detected, this may lead to further enquiries about anyprevious history of recurrent oral ulceration or specific gastrointestinal diseases.

It is surprising how often ulceration is discovered that the patient is not aware of.When an ulcer is found, it is vital that a detailed record of the history and examinationfindings is made. Any oral mucosal ulcer that does not heal within 3 weeks should beconsidered as possibly malignant and urgent referral must be arranged.Certain ulcers have a tendency to occur in particular oral sites, for example squamouscell carcinomas are most common on the lower lip, in the floor of mouth and the lateralborder of the tongue. On the other hand traumatic ulcers are most common on thelateral border of the tongue and buccal mucosa in the occlusal plane.Ulceration on the lower lip is also a common site for traumatic ulceration, particularlyfollowing administration of an inferior dental block or after a sports injury.Site is also important in diagnosis, for example, minor aphthae are restricted to liningmucosa and can be ruled out if ulceration is occurring on the hard palate or gingivae.

Size and shape can also be helpful, for example linear fissure-type ulcers may beseen in Crohn's disease, though aphthae are more usual.The shape of a traumatic ulcer may reveal the cause, for example semicircularulcers are sometimes caused by the patient's fingernail. Bizarre persistentulceration is sometimes a result of deliberate self-harm, unusual habits or takingrecreational drugs; in such cases, diagnosis can be difficult as the patient maydeny knowledge of the causation.Minor aphthae have characteristic size and site features, which can distinguishthem from major and herpetiform aphthae.Pain is a feature of inflammatory and traumatic ulcers, while in the early stages amalignant ulcer is often painless.Advanced malignant ulcers eventually tend to become painful as a result ofinfection and involvement of adjacent nerves.

Presentation with a painful traumatic ulcer is common in dentistry. Thecause should be eliminated if possible (e.g. smoothing or replacement of anadjacent fractured restoration), symptomatic treatment such as analgesicmouthwash prescribed and most importantly, review arranged to ensurethat healing has occurred.Paraesthesia/'anaesthesiaThe principles of examination are those described above for extra-oralexamination. Once again, you need good anatomical knowledge of thenerves supplying different parts of the oral cavity to interpret the possiblesite of the underlying pathological process.

Paralysis/motor disturbance

Within the oral cavity, motor disturbance is seen in the tongue (owing todamage to the function of the hypoglossal nerve) and the soft palate(owing to lesions affecting the vagus nerve).With hypoglossal nerve lesions, there is deviation of the tongue towardsthe affected side when attempting protrusion.There is also a problem with speech, with 'lingual' sounds such as T, 't' and'd' affected.

Tooth problems

Tooth problems are the commonest problems facing the dentist. The context is usuallypain or swelling.A standard method of examination helps in reaching a diagnosis. You should not simplyhammer the suspect tooth with the mirror handle and take a radiograph as your methodof assessment! Indeed, careful examination may establish a diagnosis and thus avoid anyneed for radiography or other special tests.Examination will involve:

visualprobe restorationsassess mobilityperiodontal probingthermal testspressure tests.

Visual examination will reveal gross caries, the presence of restorations,signs of tooth wear and gingivitis.A probe will allow tactile assessment of restoration margins. Mobilityshould be assessed manually.Periodontal probing should be carried out to assess pocketing, thepresence of calculus/overhangs and, ultimately, bone loss.A basic test of vitality should always be performed, using a cotton woolpledget soaked with ethyl chloride(cold stimulus) and sometimes heatedgutta-percha(hot stimulus).While these are usually sufficient to reveal a hypersensitive tooth withpulpitis, an electrical pulp test can be used to assess vitality in some cases.

Pressure sensitivity should be assessed using direct finger pressure and,when this does not evoke a response, can be supplemented by percussionusing a dental mirror handle. This will assess whether periodontitis ispresent or not. However, if a single cusp is tender to percussion, this may beindicative of cracked cusp syndrome.

Special investigationsYou should:

understand what samples can be taken for tests, how to take and treatthese materials and what tests are available

know how to interpret the results that are returnedknow when imaging techniques would be informative and which type of

imaging to choose.

Chairside laboratory investigationsEvidence-based laboratory medicineWhenever special tests are undertaken, it is important to consider medicolegalissues, informed consent, appropriateness of the test and the evidence base for theuse of any particular laboratory investigation. It is always necessary to have adifferential clinical diagnosis in mind when requesting an investigation. Certaintests, such as those for human immunodeficiency virus (HIV) infection,requirepre-test counselling and informed consent;such tests should be undertaken onlyby specialists in the field. When requesting a test, it is vital to possess theknowledge and skills so that the result can be acted upon appropriately. In somesituations, for example suspected oral cancer, it may be wise to refer the patientdirectly to a specialist for a biopsy. Other important considerations whenconsidering laboratory testing are:

obtaining a representative/appropriate samplecollecting in the right specimen container and fluid if appropriatecompleting the information required by the laboratory correctlyhaving systems that avoid mixing up specimens; labelling the specimen

container with patient detailsorganising the correct packaging and transport to the laboratoryreading reports and acting on them; filling in patient recordsinterpretation: sensitivity and specificity.

MicrobiologyDiagnosis of infection and determination of sensitivity of the infectious agent topharmacotherapeutic agents are the principal requirements for microbiology testsin dentistry.Viruses. Most often a clinical diagnosis is adequate for acute or recurrent viral oralinfections such as herpes simplex. A viral swab can be used to collect virus fromfresh vesicles and must be forwarded in special transport medium to the virologylaboratory. Other virus infections such as glandular fever can be detected bylooking for a rising titre of antibodies in the patient's serum.Bacteria. Bacterial infections in the oral cavity, jaws and salivary glands may beidentified by forwarding a swab or specimen of pus to the laboratory, with arequest for culture and antibiotic sensitivity.

FungiCandida is the most common organism to cause oral fungal infection.Often clinical diagnosis is adequate; for example in denture-relatedstomatitis, the clinical history and appearance of the mucosa may besufficient.Direct smears from the infected mucosa and the denture-fitting surfacecan be stained by the periodic acid-Schiff or Gram's method.The presence of typical pseudohyphae indicates candidal proliferationconsistent with infection. Swabs or oral rinses can be used to discriminatethe various Candida species and heavy growth suggests infection ratherthan carriage.

Aspiration biopsy

Fluid from suspected cysts can be collected with a standard gauge needleand syringe: radicular cysts contain brown shimmering fluid because of thepresence of the cholesterol crystals, whereas odontogenic keratocystscontain pale greasy fluid, which may include keratotic squames. Infectionafter aspiration biopsy can be a problem and indeed the technique tends tobe restricted to atypical cystic lesions where neoplasia is suspected.Fineneedle aspiration biopsy (FNAB) can be used to obtain a sample of cellsfrom a solid tumour and is a hospital procedure.

Incisional/excisional biopsy

Mucosal biopsy is one of the more common investigations used bydentists in primary and secondary care.Tissue is removed under local or general anaesthesia using sharpdissection to avoid crushing the specimen.It is fixed in at least 10 times its volume of 10% neutral buffered formalinor similar fixative. It is then forwarded to the histopathology or specialistoral and maxillofacial pathology laboratory.Excisional biopsy. The entire lesion is removed and submitted fordiagnosis. It is suitable for benign polyps, papillomas, mucocoeles,epulides and other small reactive lesions.

Incisional biopsyA representative sample of a larger lesion is taken for diagnosis prior to treatment.This is a specialist procedure requiring some expertise and experience. It is usedfor generalised mucosal disorders such as lichen planus or for the diagnosis ofother red and white patches. An important consideration is obtaining a samplefrom an appropriate area. Non-healing ulcers are often investigated by incisionalbiopsy; here it is important to include the margin of the ulcer with some normaltissue and to obtain a sufficiently large sample (normally 10 mm x 10 mm) toidentify or exclude cancer.Sometimes fresh tissue is required for diagnosis, for instance in the vesiculo-bullous diseases where immunofluorescence is needed. Special arrangementsmust be made with the laboratory when such tests are planned.

Haematology

Patients presenting with oral manifestations of haematological disease arenormally referred for specialist opinion. Full blood count and assay ofhaematinics is an important investigation for patients presenting withlingual papillary atrophy or recurrent oral ulceration, for example.Coagulation studies and platelet counts may be required when excessivebleeding is encountered.Patients on anticoagulant therapy should have their INR (internationalnormalised ratio) checked before any surgical procedure is undertaken.The Sickledex test may be used to screen for sickle cell anaemia prior togiving general anaesthesia in situations of urgency. The blood sampleshould be subjected to haemoglobin electrophoresis.

Biochemistry

Biochemical investigations are used principally in specialist clinics toinvestigate patients presenting with oral manifestations of systemic disease,for example estimation of alkaline phosphatase in Paget's disease of bone,and serum calcium to exclude hyperparathyroidism when a giant cellgranuloma is diagnosed. Biochemical estimation of cyst fluid for proteincontent is sometimes undertaken as part of diagnosis of odontogenickeratocyst.

Immunology

Advances in knowledge and methods in immunology have resulted in alarge number of laboratory immunological investigations, available inspecialist laboratories. Sometimes diagnostic arrays of tests are offered bythe laboratory. Examples of tests in dentistry include detection ofantibodies against extractable nuclear antigens, including SS-A and SS-B,for the diagnosis of Sjogren's syndrome and autoantibodies invesiculobullous diseases.HIV testing should only be undertaken by specialists and does not falldirectly into the remit of dentistry. It requires informed patient consentand counselling. Dentists must be able to recognise the oralmanifestations of immunodeficiency states and arrange proper referral.

Imaging Imaging is an important special test in dentistry and oral and maxillofacialsurgery. Because X-ray exposure carries a quantifiable risk, X-rayexaminations should be selected according to specific selection (referral)criteria. Other imaging investigations not using ionising radiations(ultrasound and magnetic resonance imaging) have their place and shouldbe used in preference to X-ray techniques (radiography and computedtomography) when they can provide the same or better diagnosticinformation. Selection criteria should be based upon the diagnostic efficacyof the technique for the disease process being examined. For example,approximal caries diagnosis is best aided by bitewing rather than otherradiographs.

Conventional radiographyThis is familiar to every dentist and student in the forms of bitewing, periapical,occlusal and panoramic radiography. Other maxillofacial radiographs should beused in addition to the traditional 'dental' techniques when appropriate. Whiledetailed prescription of radiographs depends on the particular needs of eachpatient.Contrast investigationsSome radiological techniques use radio-opaque contrast media injected into partsof the body. In the maxillofacial region, they can be used to demonstrate fistulaeand sinuses and in vascular studies (angiograms). However, they are mostcommonly used for sialography and arthrography of the TMJ.

Computed tomography

Computed tomography (CT) is also known as CAT scanning. It providesprimarily axial crosssectional images and uses X-rays. The computercalculates the X-ray absorption (and thus indirectly the density) of eachunit volume (voxel) of tissue and then assembles the information into animage made up of many pixels (picture elements). Each pixel is given a grey-scale value according to its density (Hounsfield scale). Dense bone is white,most soft tissues are mid-grey, fat is dark grey and air is black. Metals arebeyond the comprehension of the computer software, so dental fillingscause artefacts.

Clinical maxillofacial applications include:

• large maxillary cysts/benign tumoursmalignancy arising in the antrumsoft tissue massesoral carcinoma.

Images can be reconstructed in two or three dimensions.In maxillofacialwork, reconstructions are invaluable for implantology and useful in majorfacial trauma and orthognathic surgical treatment planning.CT is associated with a relatively high dose of radiation. Generally, thethinner the sections (and the better the fine detail), the higher the dose.

Diagnostic ultrasound

Ultrasound uses the principle that high frequency (3.5-10 MHz) soundwaves can pass through soft tissue but will be reflected back from tissueinterfaces. The echoes can be detected to produce an image. The sound istransmitted and detected by the same hand-held transducer. Imaging is'real-time'.Clinical maxillofacial applications include: soft tissue lumps in the neck andthe salivary glands.

Radioisotope imagingRadioisotope imaging is also known as nuclear medicine. The technique usesradioisotopes (usually gamma ray emitters) tagged on to pharmaceuticals, whichare usually injected into the bloodstream. By choosing the radiopharmaceuticalappropriately, particular organs or types of tissues will become radioactive. Thepatient is placed in front of a gamma camera, which detects the emitted radiationto give an image of physiological activity. It is not an anatomical imaging modality.Clinical maxillofacial applications include:• salivary scanning (particularly in Sjogren's syndrome): uses sodiumpertechnetate-99m

bone scanning (for bone tumours, metastatic disease,Paget's disease, arthritisand condylar hyperplasia): uses technetium-99m-labelled methylenebisphosphonate.

Magnetic resonance imaging

Magnetic resonance imaging is also known as MR, MRI or NMR. In thistechnique, patients are placed into an intense magnetic field, forcing theirhydrogen nuclei (principally in water molecules) to align in the field.Radiofrequency waves are pulsed into the patient, the hydrogen nuclei'wobble', producing an alteration in the magnetic field. This induces anelectric current in coils placed around the patient. The computer is capableof reading this and, because different tissues contain different amounts ofhydrogen (in water), of producing an image that, superficially, is like a CTscan. However, imaging can be in any plane (axial, sagittal or coronal).

Writing a referral letterYou should: k he efe a a ie be able i e a c m e e efe al le e k kee g d ec d f he efe al

However good your diagnostic abilities are and however skilled you are as aclinician, there will come a time when you need to refer a patient on to acolleague. The letter should be thorough, providing the second clinicianwith a detailed history and the results of your examination. It isreprehensible to write a 'Dear Sir, please see and treat, yours sincerely' letter.

The referral must include:

name, address, date of birth of the patientdescription of the patient's problem/symptomsa history of the problemthe results of your examinationthe results of any special tests you have performedyour provisional diagnosis, if anythe medical historyany special factors, such as difficulty in attendingall relevant radiographs or investigations.

Medical aspects of patient careMedical assessmentDental relevance of the medical conditionMedical emergenciesDrug delivery

Medical assessmentYou should: k h b ai i f ma i ele a medical blem be able a e a a ie fi e f ea me k he a a ie h ld be efe ed f ea me i a hospital setting.

Today, many patients with life-threatening disease survive as a result ofadvances in medical and surgical treatment and may present for dentaltreatment looking deceptively fit and well. The medical assessment:

is important to establish the suitability of the patient to undergo dentaltreatment and may significantly affect the dental management

may prompt examination for particular oral manifestationsmay be particularly relevant when a sedation technique or general

anaesthesia (GA) is being consideredmay give prior warning of a possible medical emergency.

Medical historyAs a full medical examination of the patient is generally not feasible orappropriate, the medical history should be comprehensive. This will includequestions about previous serious illness and operations, present drughistory and known allergies, and the possibility of pregnancy. Informationmay then be obtained concerning the individual systems by relevantquestions depending on the age of the patient, the dental treatmentnecessary and the anticipated type of anaesthesia.Questions should refer to known medical problems, past history andpresent general fitness.

Cardiovascular system

Questions should refer to known medical problems,past history and presentgeneral fitness.

Is there a history of heart valve surgery, rheumatic fever or murmurs,which might necessitate prophylactic antibiotic cover

Is the patient aware of any heart disease or hypertension?Does the patient suffer from palpitations, swelling of the ankles and

dizziness?Can the patient lie flat without breathlessness?What is the patient's general fitness? For example, can the patient climb

stairs without breathlessness or chest pain?

Respiratory system

Does the patient have a cough or cold? If there is a cough, is thiscontinuous or intermittent and is it productive?

Does the patient suffer from bronchitis, emphysema or asthma?Is there shortness of breath or symptoms of wheeze or chest pain?If the patient is a smoker, how many cigarettes are smoked on average each

day?

Gastrointestinal systemQuestions concerning the gastrointestinal system may include:

Does the patient have a good appetite and weight constancy?Is there history of jaundice, liver and kidney diseaseHow many units of alcohol does the patient consume on average each week?

The neurological systemDoes the patient suffer from fits or faints?Is there any sensory loss or motor weakness at any site?The examiner should note the patient's balance, gait and the degree of general

mobility.

Medical examinationSufficient information can usually be obtained by obtaining a thoroughhistory such that a physical examination is unnecessary outside the hospitalsetting. However, if a sedation technique is being considered,then it may beappropriate to undertake a limited examination as follows.Observe the patient in general. Is the patient clinically well or are there anyobvious generalised clinical signs such as cyanosis, pallor or jaundice? Is thepatient unusually anxious? Are they talking continuously? Do they appearcalm but have sweaty palms? Weigh the patient and also take note of anyexcessive fat under the chin, particularly in a retrognathic mandible as thismay indicate a less than ideal airway.

Check the cardiovascular system. The radial pulse should be checked forrate, rhythm, volume and character. The arterial blood pressure may bemeasured using a sphygmomanometer on the upper arm of the patientwhile they are sitting. This limited examination is the minimum that shouldbe carried out for adult patients for whom intravenous sedation is proposed.Social history. Social factors also affect the patient's ability to cope withtreatment. The patient's age, the distance they have to travel for treatment,and the availability of an escort if considering sedation or generalanaesthesia should be determined.

Hospital setting

A full physical examination may be required in a hospital setting if patientsmay require GA or surgical or extensive dental treatment. Theappropriateness and extent will depend on the history. The aim is toestablish the baseline condition of the patient and to identify any problemsthat may have an effect on the treatment or anaesthesia.

Dental relevance of the medicalconditionYou should:

know when to use antibiotic cover and suitable regimensknow the prerequirements for dental treatment in medical conditions interms of control and stabilisation of the conditionknow how to monitor such patients during treatmentunderstand how to deal with medical problems arisingduring treatment.

Patients with medical conditions sometimes require modifications oftheir perioperative care when oral surgery is planned.

Cardiovascular ProblemsIschemic heart disease

Angina pectoris.Narrowing of myocardial arteries is one of the most common health problems thatdentists encounter. This condition occurs primarily in men over age 40 years and is alsoprevalent in postmenopausal women.The basic disease process is a progressive narrowing or spasm (or both) of one or moreof the coronary arteries. Angina is a symptom of ischemic heart disease produced whenmyocardial blood supply cannot be sufficiently increased to meet the increased oxygenrequirements that result from coronary artery disease.The myocardium becomes ischemic, producing a heavy pressure or squeezing sensationin the a ie substernal region that can radiate into the left shoulder and arm andeven into the mandibular region. The patient may complain of an intense sense of beingunable to breathe adequately. Stimulation of vagal activity commonly occurs withresulting nausea, sweating, and bradycardia.The discomfort typically disappears once the myocardial work requirements are loweredor the oxygen supply to the heart muscle is increased.

The ac i i e responsibility to a patient with an angina history is to use allavailable preventive measures, thereby reducing the possibility that the surgicalprocedure will precipitate an anginal episode. Preventive measures begin withtaking a careful history of the a ie angina. The patient should bequestioned about the events that tend to precipitate the angina; the frequency,duration, and severity of angina; and the response to medications or diminishedactivity. The a ie physician can be consulted about the a ie cardiacstatus.If the a ie angina arises only during moderately vigorous exertion andresponds readily to rest and oral nitroglycerin administration and if no recentincrease in severity has occurred, ambulatory oral surgery procedures are usuallysafe when performed with proper precautions.

However, if anginal episodes occur with only minimal exertion, if several dosesof nitroglycerin are needed to relieve chest discomfort, or if the patient hasunstable angina (i.e., angina present at rest or worsening in frequency, severity,ease of precipitation, duration of attack, or predictability of response tomedication), elective surgery should be postponed until a medical consultationis obtained.Alternatively, the patient can be referred to an oral-maxillofacial surgeon ifemergency surgery is necessary.

Once the decision is made that ambulatory elective oral surgery can safelyproceed, the patient with a history of angina should be prepared for surgery andthe a ie myocardial oxygen demand should be lowered or prevented fromrising. The increased oxygen demand during ambulatory oral surgery is theresult primarily of patient anxiety. An anxiety-reduction protocol shouldtherefore be used.Profound local anesthesia is the best means of limiting patient anxiety.Although some controversy exists over the use of local anesthetics containingepinephrine in patients with angina, the benefits (i.e., prolonged andaccentuated anesthesia) outweigh the risks.However, care should be taken to avoid excessive epinephrine administration byusing proper injection techniques. Some clinicians also advise giving no morethan 4 mL of a local anesthetic solution with a 1 : 100,000 concentration ofepinephrine for a total adult dose of 0.04 mg in any 30-minute period.

General Anxiety-Reduction Protocol

Before Appointment H ic agent to promote sleep on night before surgery

(optional) Seda i e age dec ea e a ie m i g f ge

(optional) M i g a i me a d ched le ha ece i m

timeis minimizedDuring AppointmentNonpharmacologic Means of Anxiety Control F e e e bal ea a ce Di ac i g c e a i N i e cli icia a a ie bef e d i g a hi g ha

could cause anxiety) N ece a i e S gical i me f a ie igh Rela i g backg d m ic

Pharmacologic Means of Anxiety Control L cal a e he ic f fficie i e i a d d a i Ni ide I a e anxiolytics

After Surgery S cci c i c i f e a i e ca e Pa ie i f ma i e ec ed gical

sequelae (e.g., swelling or minor oozing of blood)

F he ea a ce Effec i e a alge ic Pa ie i f ma i h ca be c ac ed if

any problems arise Tele h e call a ie a h me d i g e e i g

after surgery to check whether any problems exist

Before and during surgery, vital signs should be monitored periodically

In addition, regular verbal contact with thepatient should be maintained.The use of nitrous oxide or other conscioussedation methods for anxiety control inpatients with ischemic heart disease shouldbe considered. Fresh nitroglycerin should benearby for use when necessary.The introduction of balloon-tipped cathetersinto narrowed coronary arteries for thepurpose of re-establishing adequate bloodflow and stenting arteries open is becomingcommonplace.If the angioplasty has been successful (basedon cardiac stress testing), oral surgery canproceed soon thereafter, with the sameprecautions as those used for patients withangina.

Management of Patient with History of Angina Pectoris

C l he a ie h icia2. Use an anxiety-reduction protocol.3. Have nitroglycerin tablets or spray readily

available. Use nitroglycerin premedication, if indicated.

4. Ensure profound local anesthesia before starting surgery.

5. Consider the use of nitrous oxide sedation.6. Monitor vital signs closely.7. Consider possible limitation of amount of

epinephrine used (0.04 mg maximum).8. Maintain verbal contact with patient

throughout the procedure to monitor status.

Myocardial infarction MI occurs when ischemia (resulting from an oxygendemand supply mismatch) causes myocardial cellulardysfunction and death. MI usually occurs when an areaof coronary artery narrowing has a clot form that blocksall or most blood flow. The infarcted area of myocardiumbecomes nonfunctional and eventually necrotic and issurrounded by an area of usually reversibly ischemicmyocardium that is prone to serve as a nidus fordysrhythmias. During the early hours and weeks after anMI, if thrombolytic treatment was tried and wasunsuccessful, treatment consists of limiting myocardialwork requirements, increasing myocardial oxygen supply,and suppressing the production of dysrhythmias byirritable foci in ischemic tissue. In addition, if any of theprimary conduction pathways were involved in theinfarcted area, pacemaker insertion may be necessary. Ifthe patient survives the early weeks after an MI, thevariably sized necrotic area is gradually replaced withscar tissue, which is unable to contract or properlyconduct electrical signals.

Management of Patient with a History of Myocardial Infarction

C l he a ie ima ca e h icia2. Check with the physician if invasive dental care is

needed before 6 months since the myocardial infarction (MI).

3. Check whether the patient is using anticoagulants (including aspirin).

4. Use an anxiety-reduction protocol.5. Have nitroglycerin available; use it prophylactically if

the physician advises.6. Administer supplemental oxygen (optional).7. Provide profound local anesthesia.8. Consider nitrous oxide administration.9. Monitor vital signs, and maintain verbal contact with

the patient.10. Consider possible limitation of epinephrine use to

0.04 mg.11. Consider referral to an oral-maxillofacial surgeon.

The management of an oral surgical problem in a patient who has had an MIbegins with a consultation with the a ie physician. Generally, it isrecommended that elective major surgical procedures be deferred until atleast 6 months after an infarction.This delay is based on statistical evidence that the risk of reinfarction afteran MI drops to as low as it will ever be by about 6 months, particularly if thepatient is properly supervised medically.The advent of thrombolytic-based treatment strategies and improved MIcare make an automatic 6-month wait to do dental work unnecessary.Straightforward oral surgical procedures typically performed in the dentaloffice may be performed less than 6 months after an MI if the procedure isunlikely to provoke significant anxiety and the patient had an uneventfulrecovery from the MI.In addition, other dental procedures may proceed if cleared by the a iephysician via a medical consult.

Patients with a history of MI should be carefully questioned concerning their cardiovascular health

Patients who have had an MI take aspirin and other anticoagulants to decrease coronarythrombogenesis; details of this should be sought because it can affect surgical decisionmaking.If more than 6 months have elapsed or physician clearance is obtained, themanagement of the patient who has had an MI is similar to care of the patient withangina.An anxiety-reduction program should be used. Supplemental oxygen can be consideredbut is usually unnecessary.Prophylactic nitroglycerin administration should be done only if directed by the

a ie primary care physician, but nitroglycerin should be readily available. Localanesthetics containing epinephrine are safe to use if given in proper amounts using anaspiration technique.Vital signs should be monitored throughout the perioperative period.

In general, with respect to major oral surgical care, patients who have hadcoronary artery bypass grafting (CABG) are treated in a manner similar topatients who have had an MI.Before major elective surgery is performed, 3 months are allowed to elapse.If major surgery is necessary earlier than 3 months after the CABG, the a iephysician should be consulted.Patients who have had CABG usually have a history of angina, MI, or both andtherefore should be managed as previously described.Routine office surgical procedures may be safely performed in patients less than6 months after CABG surgery if their recovery has been uncomplicated andanxiety is kept to a minimum.

Cerebrovascular accident (stroke)

Patients who have had a cerebrovascular accident (CVA) are always susceptibleto further neurovascular accidents.These patients are often prescribed anticoagulants and, if hypertensive, aretaking blood pressure lowering agents. If such a patient requires surgery,clearance by the a ie physician is desirable, as is a delay until significanthypertensive tendencies have been controlled. The a ie baseline neurologicstatus should be assessed and documented preoperatively.The patient should be treated by a nonpharmacologic anxiety-reductionprotocol and have vital signs carefully monitored during surgery. Ifpharmacologic sedation is necessary, low concentrations of nitrous oxide can beused.

Dysrhythmias

Patients who are prone to or who have cardiac dysrhythmias usually have ahistory of ischemic heart disease requiring dental management modifications.Many advocate limiting the total amount of epinephrine administration to 0.04mg.However, in addition, these patients may have been prescribed anticoagulants orhave a permanent cardiac pacemaker. Pacemakers pose no contraindications tooral surgery, and no evidence exists that shows the need for antibioticprophylaxis in patients with pacemakers.Electrical equipment such as electrocautery and microwaves should not be usednear the patient.

Pulmonary Problems. AsthmaWhen a patient has a history of asthma, the dentist should first determine,through further questioning, whether the patient truly has asthma or has arespiratory problem such as allergic rhinitis that carries less significance for dentalcare. True asthma involves the episodic narrowing of inflamed small airways,which produces wheezing and dyspnea as a result of chemical, infectious,immunologic, or emotional stimulation, or a combination of these. Patients withasthma should be questioned about precipitating factors, frequency and severityof attacks, medications used, and response to medications. The severity of attackscan often be gauged by the need for emergency room visits and hospitaladmissions. These patients should be questioned specifically about aspirin allergybecause of the relatively high frequency of generalized nonsteroidal anti-inflammatory drug (NSAID) allergy in those with asthma.

Oral surgical management

Oral surgical management of the patient with asthma involves recognition of therole of anxiety in bronchospasm initiation and of the potential adrenalsuppression in patients receiving corticosteroid therapy. Elective oral surgeryshould be deferred if a respiratory tract infection or wheezing is present. Whensurgery is performed, an anxiety-reduction protocol should be followed; if thepatient takes steroids, the a ie primary care physician can be consulted aboutthe possible need for corticosteroid augmentation during the perioperative periodif a major surgical procedure is planned. Nitrous oxide is safe to administer topersons with asthma and is especially indicated for patients whose asthma istriggered by anxiety. The a ie own inhaler should be available during surgery,and drugs such as injectable epinephrine and theophylline should be kept in anemergency kit. The use of NSAIDs should be avoided because they oftenprecipitate asthma attacks in susceptible individuals.

Management of the Patient with Asthma

1. Defer dental treatment until the asthma is well controlled and the patient has no signs of a respiratory tract infection.

2. Listen to the chest with the stethoscope to detect any wheezing before major oral surgical procedures or sedation.

3. Use an anxiety-reduction protocol, including nitrous oxide, but avoid the use of respiratory depressants. C l he a ie h icia ab ible e e a i e e f cromolynsodium.

5. If the patient is or has been chronically taking corticosteroids, provide prophylaxis for adrenal insufficiency.

6. Keep a bronchodilator-containing inhaler easily accessible.7. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in susceptible

patients.

Chronic obstructive pulmonary disease

Obstructive and restrictive pulmonary diseases are usually caused by long-termexposure to pulmonary irritants such as tobacco smoke that cause metaplasia ofpulmonary airway tissue.Airways are inflamed and disrupted, lose their elastic properties, and becomeobstructed because of mucosal edema, excessive secretions, and bronchospasm,producing the clinical manifestations of COPD.Patients with COPD frequently become dyspneic during mild to moderate exertion.They have a chronic cough that produces large amounts of thick secretions, frequentrespiratory tract infections, and barrelshaped chests, and they may purse their lips tobreathe and have audible wheezing during breathing.Bronchodilators such as theophylline are usually prescribed for patients with significantCOPD; in more severe cases, patients are given corticosteroids. Only in the most severechronic cases is supplemental portable oxygen used.

In the dental management of patients with COPD who are receiving corticosteroids, thedentist should consider the use of additional supplementation before major surgery.Sedatives, hypnotics, and narcotics that depress respiration should be avoided. Patientsmay need to be kept in an upright sitting position in the dental chair to enable them tobetter handle their commonly copious pulmonary secretions.Finally, supplemental oxygen during surgery should not be used in patients with severeCOPD unless the physician advises it. In contrast with healthy persons in whom anelevated arterial carbon dioxide (CO2) level is the major stimulation to breathing, thepatient with severe COPD becomes acclimated to elevated arterial CO2 levels andcomes to depend entirely on depressed arterial oxygen (O2) levels to stimulatebreathing.If the arterial O2 concentration is elevated by the administration of O2 in a highconcentration, the hypoxia-based respiratory stimulation is removed, and the a ierespiratory rate may become critically slowed.

Management of Patient with Chronic Obstructive Pulmonary Disease1. Defer treatment until lung function has improved and treatment is possible.2. Listen to the chest bilaterally with stethoscope to determine adequacy of breath sounds.3. Use an anxiety-reduction protocol, but avoid the use of respiratory depressants.4. If the patient requires chronic oxygen supplementation, continue at the prescribed flow rate. If

the patient does not require supplemental oxygen therapy, consult his or her physician before administering oxygen.

5. If the patient chronically receives corticosteroid therapy, manage the patient for adrenal insufficiency.

6. Avoid placing the patient in the supine position until you are confident that the patient can tolerate it.

7. Keep a bronchodilator-containing inhaler accessible.8. Closely monitor respiratory and heart rates.9. Schedule afternoon appointments to allow for clearance of secretions.

Renal ProblemsManagement of Patient with Renal Transplant

Defe ea me il he a ie ima ca e physician or transplant surgeon clears the patient for dental care.2. Avoid the use of nephrotoxic drugs.3. Consider the use of supplemental corticosteroids.4. Monitor blood pressure.5. Consider screening for hepatitis B virus before dental care. Take necessary precautions if unable to screen for hepatitis.6. Watch for presence of cyclosporine A induced gingival hyperplasia. Emphasize the importance of oral hygiene.7. Consider use of prophylactic antibiotics, particularly in patients taking immunosuppressive agents.

Renal failure. Elective oral surgery is bestundertaken the day after a dialysis treatment hasbeen performed. This allows the heparin usedduring dialysis to disappear and to be in the bestphysiologic status with respect to intravascularvolume and metabolic byproducts.Drugs that depend on renal metabolism orexcretion should be avoided or used in modifieddoses to prevent systemic toxicity. Relativelynephrotoxic drugs such as NSAIDs should also beavoided in patients with seriously compromisedkidneys.Because of the higher incidence of hepatitis inpatients undergoing renal dialysis, dentistsshould take the necessary precautions

Hypertension

Chronically elevated blood pressure for which the cause is unknown is called essentialhypertension. Mild or moderate hypertension (i.e., systolic pressure

Management of Patient with Hypertension Mild to Moderate Hypertension (Systolic >140 mm Hg; Diastolic >90 mm Hg)

Rec mme d ha he a ie eek he ima ca e h icia g ida ce f medical therapy of hypertension. It is not necessary to defer needed dental care. M i he a ie bl d e e a each i i a d he e e admi i a i of epinephrine-containing local anesthetic surpasses 0.04 mg during a single visit.

3. Use an anxiety-reduction protocol.4. Avoid rapid posture changes in patients taking drugs that cause vasodilation.5. Avoid administration of sodium-containing intravenous solutions.Severe Hypertension (Systolic >200 mm Hg; Diastolic >110 mm Hg)1. Defer elective dental treatment until the hypertension is better controlled.2. Consider referral to an oral-maxillofacial surgeon for emergent problems.

Hepatic DisordersThe patient with severe liver damage resulting from infectious disease, ethanolabuse, or vascular or biliary congestion requires special consideration before oralsurgery is performed. An alteration of dose or avoidance of drugs that requirehepatic metabolism may be necessary.The production of vitamin K dependent coagulation factors (II, VII, IX, X) may bedepressed in severe liver disease; therefore, obtaining an international normalizedratio (INR; prothrombin time [PT]) or partial thromboplastin time (PTT) may beuseful before surgery in patients with more severe liver disease.Portal hypertension caused by liver disease may also cause hypersplenism, asequestering of platelets causing thrombocytopenia. Finding a prolonged bleedingtime or low platelet count reveals this problem. Patients with severe liverdysfunction may require hospitalization for dental surgery because their decreasedability to metabolize the nitrogen in swallowed blood may cause encephalopathy.Finally, unless documented otherwise, a patient with liver disease of unknownorigin should be presumed to carry hepatitis virus.

Endocrine Disorders. Diabetes mellitusDiabetes mellitus is caused by an underproduction of insulin, a resistance of insulinreceptors in end organs to the effects of insulin, or both. Diabetes is commonly dividedinto insulin-dependent (type I) and non insulin-dependent (type II) diabetes.Persons with type I diabetes must strike a balance with regard to caloric intake, exercise,and insulin dose. Any decrease in regular caloric intake or increase in activity, metabolicrate, or insulin dose can lead to hypoglycemia, and vice versa.Patients with type II diabetes usually produce insulin but in insufficient amountsbecause of decreased insulin activity, insulin receptor resistance, or both. This form ofdiabetes typically begins in adulthood, is exacerbated by obesity, and does not usuallyrequire insulin therapy. This form of diabetes is treated by weight control, dietaryrestrictions, and the use of oral hypoglycemics.Insulin is required only if the patient is unable to maintain acceptable serum glucoselevels using the usual therapeutic measures. Severe hyperglycemia in patients with typeII diabetes rarely produces ketoacidosis but leads to a hyperosmolar state with alteredlevels of consciousness.

Short-term, mild-to-moderate hyperglycemia is usually not a significant problem forpersons with diabetes. Therefore, when an oral surgical procedure is planned, it is bestto avoid an excessive insulin dose and to give a glucose source.Ambulatory oral surgery procedures should be performed early in the day, using ananxiety-reduction program. If intravenous (IV) sedation is not being used, the patientshould be asked to eat a normal meal and take the usual morning amount of regularinsulin and a half dose of neutral protamine Hagedorn (NPH) insulin.The a ie vital signs should be monitored; if signs of hypoglycemia hypotension,hunger, drowsiness, nausea, tachycardia, or a mood change occur, an oral or IV supplyof glucose should be administered.Ideally, offices have an electronic glucometer available with which the clinician orpatient can readily determine serum glucose with a drop of the a ie blood. Thisdevice may avoid the need to steer the patient toward mild hyperglycemia.

If a patient must miss a meal before a surgical procedure, the patient should be toldto omit any morning insulin and only resume insulin once a supply of calories canbe received. Regular insulin should then be used, with the dose based on serumglucose monitoring and as directed by the a ie physician. Once the patient hasresumed normal dietary patterns and physical activity, the usual insulin regimencan be restarted. Persons with well-controlled diabetes are no more susceptible toinfections than are persons without diabetes, but they have more difficultycontaining infections.Difficulty in containing infections is more significant in persons with poorlycontrolled diabetes. Therefore, elective oral surgery should be deferred in patientswith poorly controlled diabetes until control is accomplished.However, if an emergency situation or a serious oral infection exists in any personwith diabetes, consideration should be given to hospital admission to allow for acutecontrol of the hyperglycemia and aggressive management of the infection.Many clinicians also believe that prophylactic antibiotics should be given routinelyto patients with diabetes undergoing any surgical procedure.

Hematologic Problems. Hereditary coagulopathiesPatients with inherited bleeding disorders are usually aware of their problems, allowing theclinician to take the necessary precautions before any surgical procedure.However, in many patients, prolonged bleeding after the extraction of a tooth may be the firstevidence that a bleeding disorder existsTherefore, all patients should be questioned concerning prolonged bleeding after previousinjuries and surgery. The management of patients with coagulopathies who require oral surgerydepends on the nature of the bleeding disorder. Specific factor deficiencies such as hemophiliaA, B, or C; or von Willeb a d disease are usually managed by the perioperative administrationof coagulation factor concentrates and by the use of an antifibrinolytic agent such asaminocaproic acid (Amicar). The physician decides the form in which factor replacement isgiven, on the basis of the degree of factor deficiency and on the a ie history of factorreplacement. Patients who receive factor replacement sometimes contract hepatitis virus or HIV.Therefore, appropriate staff protection measures should be taken during surgery. Localanesthesia should be given by local infiltration rather than by field blocks to lessen thelikelihood of damaging larger blood vessels, which can lead to prolonged postinjection bleedingand hematoma formation. Consideration should be given to the use of topical coagulation-promoting substances in oral wounds, and the patient should be carefully instructed in ways toavoid dislodging blood clots once they have formed.

Therapeutic anticoagulation

Therapeutic anticoagulation is administered to patients with thrombogenicimplanted devices such as prosthetic heart valves; with thrombogenic cardiovascularproblems such as atrial fibrillation or after MI; or with a need for extracorporeal bloodflow such as for hemodialysis. Patients may also take drugs with anticoagulantproperties such as aspirin, for secondary effect.When elective oral surgery is necessary, the need for continuous anticoagulation mustbe weighed against the need for blood clotting after surgery. This decision should bemade in consultation with the a ie primary care physician.Drugs such as low-dose aspirin do not usually need to be withdrawn to allow routinesurgery. Patients taking heparin usually can have their surgery delayed until thecirculating heparin is inactive (6 hours if IV heparin is given, 24 hours if givensubcutaneously).Protamine sulfate, which reverses the effects of heparin, can also be used if emergencyoral surgery cannot be deferred until heparin is naturally inactivated.

MANAGEMENT OF PATIENTS DURING AND AFTER PREGNANCY

Although not a disease state, pregnancy is still a situation in which specialconsiderations are necessary when oral surgery is required, to surgicalprocedure properly without using radiography or medications; therefore,one option is to defer any elective oral surgery until after delivery to avoidfetal risk.Frequently, temporary measures can be used to delay surgery.

Management of Patient Who Is Pregnant

1. Defer elective surgery until after delivery, if possible. C l he a ie b e icia if ge ca be dela ed

3. Avoid dental radiographs unless information about tooth roots or bone is necessary for proper dental care. If radiographs must be taken, use proper lead shielding.

4. Avoid the use of drugs with teratogenic potential. Use local anesthetics when anesthesia is necessary.

5. Use at least 50% oxygen if nitrous oxide sedation is used.6. Avoid keeping the patient in the supine position for long periods, to prevent

vena caval compression.7. Allow the patient to take trips to the restroom as often as needed

Dental Medications to Avoid in Pregnant Patients

Aspirin and Other Nonsteroidal Anti-inflammatory DrugsCarbamazepineChloral hydrate (if chronically used)ChlordiazepoxideCorticosteroidsDiazepam and other benzodiazepinesDiphenhydramine hydrochloride (if chronically used)MorphineNitrous oxide (if exposure is greater than 9 hours per week or oxygen concentration is less than

50%)Pentazocine hydrochloridePhenobarbitalPromethazine hydrochlorideTetracyclines