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From: Dr. Getter
Date: 30 May 2001
Time: 09:14 AM
HISTORY TAKING AND PREVENTION OF MEDICAL EMERGENCIES IN DENTISTRY
INTRODUCTION -
The old axiom of "never treat a stranger" is most appli-cable in the prevention and management of medical emergencies in the dental environment. The key elements in the prevention of the untoward occurrence are:
1. Know your patient
2. Know his physiologic state
3. Know his state of mind
To achieve this control of the situation, the dentist must be able to elicit from the patient all the vital medical and psycho logic data that pertains to the proposed treatment and management of that individual. The dentist must approach each patient as a potential medical emergency and take an appropriate history and do a good screening physical evaluation to prevent or minimize this risk.
Physical evaluation starts with the dentists general appre-ciation of the patient. The dentist must consider the patient's age, appearance (healthy or sickly) the gait, steady or unsteady, color of skin, skin tone, presence of ankle edema, facial puffi-ness, alertness, agility, skin temperature, sweating, hand strength, comprehension and orientation.
The general appearance of the patient can quickly alert the dentist to the possibility of future problems. patients whose appearance markedly deviates from the recognized norm should sensitize the practitioner to the probability of future problems.
The patient who varies only slightly from an easily recog-nized norm or who makes an apparently healthy presentation is the most difficult to assess for future problems.
After making an evaluation of the patient, the dentist can now obtain a more detailed medical history through the use of a written questionnaire. In addition to the written questionnaire, certain core questions must also be asked by the dentist. History Taking and Prevention of Medical Emergencies in Dentistry Page Two
These core questions are:
1. Are you now or have you been under care of a physician in the past 5 years? 2. Do you take medicine regularly?
3. Are you subject to fainting, dizziness, nervous disorders, convulsions or epilepsy?
4. Have you ever had breathing difficulty such as asthma, emphysema, chronic cough, pneumonia, tuberculosis or any lung disorder?
5. Have you every had any of the following illnesses? Heart trouble Stroke Rheumatic fever Hepatitis or liver trouble Kidney disease High or low blood pressure Diabetes Anemia? 6. Do you bleed excessively when injured or cut?
7. Are you allergic to any drug such as; penicillin aspirin novocaine?
8. Do you now have a cough, cold or sinus trouble?
9. Do you wear contact lenses?
10. Are you pregnant or could you be pregnant?
* Many patients refer to any local anesthetic as Novocaine. A positive answer must be further investigated.
The asking of these questions in addition to the written questionnaire should elicit enough information for the dentist to evaluate the current status of the patient.
Positive responses by the patient to any question should cause the dentist to make further inquiry into that response. When a more extensive evaluation is indicated a medical con-sultation is necessary. The request for the medical consulta-tion should include the following:
1. patient's name, age, sex
2. problem(s) you wish evaluated
3. the reason for the evaluation
History Taking and Prevention of Medical Emergencies in Dentistry Page Three 4. The proposed dental treatment to include: a. drugs to be used, dosage and mode of administration
b. type of treatment (example, surgical)
c. duration of each visit (approximate)
d. complications of treatment (if foreseen)
e. effect of treatment on patient's nutrition
(important in elderly and diabetics, etc.)
f. duration of incapacitation (if indicated)
g. patient's present medications (if known)
h. dentist's name and means of contact
Elective procedures should be deferred until the consulta-tion is returned and evaluated. If the returned consultation does not address the questions satisfactorily, the consultation should be returned and/or telephone contact with the physician should be initiated.
The patient's vital signs (to include the pulse, blood pressure and temperature) should be taken and recorded with the written questionnaire. It may be included with the consul-tation request if it is pertinent
The final assessment to be made by the dentist prior to the initiation of dental treatment is the patient's state of mind. The reduction of stress is a key feature in the pre-vention of medical emergencies in the dental environment. Many patients view dental care as an anxiety provoking expe-rience. Stress may be, by a multitude of factors, including:
1. previous dental experience
2. previous medical experience
3. childhood fears
4. current personal, adverse situations (loss
of a loved one, marital distress, job or
school pressures, etc.)
History Taking and Prevention of Medical Emergencies in Dentistry Page 4
5. fear of pain
6. irrational worries 7. phobias
8. medical conditions (ex. Angina, Psychoneurosis, etc .)
The patient may externalize or internalize anxiety. Ex-ternal signs include sweating, nervous speech patterns, clenching of the hands, etc. Anxiety induced signs and symptoms must be recognized and reduced. If techniques are to be utilized to reduce anxiety, these should also be included in any medical con-sultations obtained. The information provided in the consultation related to the sedation techniques to be utilized should include:
1. drugs to be used, dosage and mode of admin-istration
2. conscious sedation technique (if selected)
3. general anesthesia technique (if selected)
4. expected or usual sequela
5. drug interactions (if known)
The patient's physical, emotional and anxiety status have been thoroughly evaluated, the major steps in preventing and/or minimizing the unexpected problems have been taken.