By Sharon Boyd, MA, RDH
Preventing medical emergencies in the dental practice begins with a thorough patient assessment and medical history review, particularly for sedation dentistry providers. Being able to spot major red flags in a patient's records prior to a planned sedation procedure allows for better overall care, treatment modifications, medical intervention, and referrals when needed.
Patient Health History Red Flags
1. Patients Over Age 65
As we age, our risk of heart disease, hypertension, diabetes, and vascular disease rises. Especially past the age of 65. These individuals tend to metabolize medications much more slowly and are more likely to suffer from adverse drug reactions. As a general rule, these patients typically need half of the normal dose of benzodiazepines as compared to younger patients.
2. When a Patient Had Their Last Checkup
Just because a patient hasn't been to the doctor lately doesn't mean they're healthy; they could have an unknown, underlying medical condition. Younger patients need to have had a checkup within the last two years and anyone over age 50 in the last 12 months. If the patient is 60 or older, a blood screen and recent electrocardiogram are necessary.
1 in 3 adults has some form of hypertension, making it extremely common among dental patients. The higher the stage of hypertension, the greater the relative risk is for cardiac mortality. If the patient has a systolic blood pressure over 160 or diastolic reading higher than 100, they should be considered unstable. As is any patient on four or more drugs for their condition.
About 1 in 12 Americans has diabetes. Diabetic patients whose condition is not currently under control are always red flag scenarios. Especially those with Type 1 diabetes because of the complexity of their medical management. Make a note of any patient whose A1C levels are greater than 8.5% (BS>200) or if they currently have diabetic triopathy (a combination of renal and eye disease and peripheral neuropathy).
Angina impacts oxygen supply to the heart, which typically results in chest pain. If a patient has experienced angina at rest, is unstable, or currently taking four or more medications to help manage their condition, it should immediately raise a red flag. Be sure to ask how frequently they experience angina, if angina patterns have changed recently, or if their medication regimen has recently changed.
6. Myocardial Infarction and Coronary Stents
Any patient who’s had a coronary stent placed or myocardial infarction in the past six months should immediately raise a red flag to dental providers, as they are more susceptible to recurrent infarctions, develop rhythm disturbances, and congestive heart failure.
If your patient has a coronary stent, is taking Plavix, and is in the first six months after this procedure, they'll need to be managed in a way that doesn't interrupt their Plavix therapy.
An HIV-positive patient is not obligated to tell you about their diagnosis. However, they are obligated to tell you which medications they're on, which can help you detect their potential red flag. If the patient's CD4 counts are low, they will be significantly more prone to oral infections and infectious complications. However, patients with HIV infection pose a special concern for sedation dentistry because many of them take protease inhibitors and anti-fungal agents which would pose a significant category D drug-drug interaction when mixed with sedatives.
Sedation drugs have evidence of human fetal risk, making any potential pregnancy an immediate red flag for sedation. However, there are instances where the use of certain drugs is still beneficial to the pregnant patient. For instance, if life-threatening situations are involved. In those scenarios, specific drugs must be selected to outweigh the potential risk to the fetus. Category X drugs such as Triazolam are classic examples of where the risk of the drug itself outweighs any potential benefit to the pregnant mother.
9. Respiratory Diseases
COPD, asthma, and obstructive lung diseases raise a person's chances of bacterial pneumonia and pulmonary embolism or airway obstruction. This can impact the specific sedation dentistry procedure that's planned due to potential triggers, reduced airflow, or inadequate pulmonary function. Asthmatic patients should be addressed on a case-by-case basis, as flare-ups and severity can significantly differ from one individual to the next. Any patient with severe respiratory disease is immediately categorized as an ASA IV patient and ineligible for sedation.
10. Sleep Apnea
Patients with obstructive Sleep Apnea (OSA) and Central Sleep Apnea (CSA) may require extended monitoring as they recover from a sedation procedure due to their irregular breathing patterns and oxygen intake. OSA patients require modifications to prevent hypoxemia and are at a statistically high risk for congestive heart failure. Whereas CSA patients may experience high carbon dioxide levels in their blood due to inadequate neurological feedback. Given the connection with cardiovascular events, thorough medical screening is essential. Patients with CSA may be more sensitive to lower doses of sedation medications.
11. Liver Disease
Besides respiratory health issues, liver disease poses the greatest risk to patients undergoing sedation. Particularly because it is the liver that’s responsible for drug metabolism and excretion. Both hepatitis and cirrhosis patients need to be checked for liver function. On a related note, there is also an increased risk of bloodborne pathogen exposure to dental professionals, due to the potentially infectious blood and saliva of infected patients. Hepatitis B can have an incubation period of up to four months, while Hep A, C, D, and E have a 1-2 month average. Due to the severity of Hepatitis B and its easy transmission, dental professionals should be vaccinated with regular boosters.
12. Polypharmacy and Drug Interactions
Any patient taking eight or more medications should immediately raise a red flag. Due to the number of prescriptions being taken and their interactions with one another, sedation medication could pose a risk for adverse reactions. However, a “Rule of 4,” where patients require four or more medications to manage or control any underlying medical condition warrant special attention. These patients, as well as any who is on eight or more drugs (“Rule of 8”) require extra scrutiny during the treatment planning process.
Performing a Risk Assessment
Being able to perform appropriate assessments and dictating when to conduct medical consultations can help dental providers to be better equipped for the selection of sedation candidates and offering those services to appropriate patient populations within their private practices.
Patients are classified in specific ASA categories depending on their health and risk factors. ASA I (healthy patients) and II (mild systemic disease) where health is controlled typically do not pose serious red flags. Whereas ASA III has more severe disease. But category IV patients are consistently at risk for a life-threatening emergency and category V patients are not expected to survive. Being able to properly categorize and manage each ASA type is an integral skill of the sedation dentistry provider.
DOCS advanced Sedation Solutions course reviews appropriate case management for elevated ASA patient types, depending on the red flags of each specific patient. Participants delve deep into the various red flag conditions to discuss the benefits and risks of sedation and how each respective patient group should be addressed.
Author: Sharon Boyd, MA, RDH — Sharon has over 20 years of experience in the dental industry and is founder of DentaSpeak, LLC. In addition to being a registered hygienist, she serves as a full-time patient education professional, with special interests in strategic dental communications. She often works as a liaison between practitioners and patients, bridging the gap between care needs and patient concerns. Sharon is an Ironman, band mom, and enjoys volunteering at her family’s church.