Medical Considerations 

 

Medical History Considerations

The completed Medical History Questionnaire forms the basis of the medical history. At the assessment visit, the examining dentist checks the self-completed medical history questionnaire. If there is any doubt as to a patients' suitability for treatment in the clinic, we arrange for a separate medical assessment with one of our consultant anaesthetists. Where possible, we advise patients to accept sedation rather than general anaesthesia when discussing treatment in this medical context.

Only patients assessed as fit and healthy or with controlled systemic disease (ASA I or II) are appropriate for conscious sedation at this clinic.

If the patient is clearly unsuitable for treatment at this clinic on medical grounds, we will arrange to refer them to secondary care services in hospital by the Community Dental Services.

The following are mentioned as a guide to how patients' medical suitability for treatment at this clinic is assessed. Final decisions about suitability are up to the medical anaesthetist.


CARDIAC DISEASE

E.g. Angina, previous myocardial infarction, congestive heart failure, peripheral vascular disease, hypertension, valvular heart disease, medication associated with the above.

Evidence of cardiac disease is followed up by:

  • Contacting the patients General Medical Practitioner (GMP) to determine the exact extent and nature of the condition.
  • Arranging for a separate medical assessment by the anaesthetist

Low risk

Conditions suitable for day case sedation are:

  • Stable angina (infrequent attacks) where patients have brought their usual medication
  • Diagnosed asymptomatic arrhythmia
  • Patients with good exercise tolerance

High Risk

The following cases are not considered suitable for day stay sedation:

  • Recent MI (within last 6 months)
  • Unstable angina (frequent attacks)
  • Uncompensated congestive heart failure
  • Investigated symptomatic arrhythmia
  • Significant symptomatic valvular disease

HYPERTENSION

Advice from the GMP is sought if patients give an unclear history of their condition or the medication they are taking. If uncontrolled the sedation. session will be postponed until this has been investigated and treated by the GMP.

RESPIRATORY DISORDERS

E.g. Common cold / rhinitis, asthma, chronic obstructive airways disease (bronchitis / emphysema), heart related pulmonary disorders.

Rhinitis

If clear rhinitis with dry cough, clinically well and no fever- treatment may proceed. If purulent rhinitis with fever, worsening symptoms and Unwell - treatment will be postponed until signs and symptoms improve.

Common Cold

Treatment will be carried out unless there is significant nasal obstruction in which case 1-2 weeks after the last bouts of infection.

Asthma

If well controlled, treatment can be carried out. Patient are asked to bring their usual medication with them. However patients with the following conditions have their session postponed until they recover and will require a medical assessment by the anaesthetist prior to acceptance for treatment.

  • Acute exacerbation of asthma
  • Superimposed chest infection
  • Poorly controlled asthmatic(ASA III)

Chronic Obstructive Airways Disease

The anaesthetist prior to acceptance for treatment must undertake assessment

Medication

It is important that the patient takes their medication as normal on the day of the appointment, for both asthma and Chronic obstructive airways disease.

Action

  • Referring dentists should ensure that patients are aware pre-existing medical conditions may mean that they are found to be unsuitable for care in our practice and that alternative arrangements will be made where necessary
  • Referring dentists should ensure patients bring all medications with them to the assessment appointment

CONDITIONS REQUIRING ENDOCARDITIS PROPHYLAXIS

The antibiotic regimes outlined within the British National Formulary will be provided for patients with a history of Rheumatic fever or Endocarditis.

Not suitable for Day Stay Sedation:

  • Congenital heart defects
  • Hypertrophic cardiomyopathy

Possibly suitable for Day Stay sedation:

  • Past history of rheumatic fever
  • Past history of endocarditis
  • Prosthetic heart valves

Action - Referring colleagues are requested not to prescribe a course of penicillin for acute infective conditions if the referred patient Requires antibiotic cover. This is to avoid firstly, the complex alternative antibiotic regimes recommended for treatment under G.A or secondly delayed treatment before penicillin can be used again.

OBESITY

Obesity needs to be assessed by the anaesthetist . In general patients over 100 kg with no other medical history will be accepted for I.V sedation or relative analgesia. Patients with a body mass index (BMI) over 30 due to obesity are excluded from day-case surgery under general anaesthesia and are only offered sedation.

BMI is calculated as weight in Kilograms (kg) divided by height in metres squared. E.g. a patient 1.72m and weighing 60Kg would have a BMI of 60 / (1.72x 1.72) = 20.3-acceptable. A patient of 1.72 and 110 kg would have a BMI of 110/ (1.72x 1.72) = 37.2- unacceptable for this clinic

DIABETES

All diabetic patients will be identified and their care discussed with the anaesthetist prior to treatment.

Insulin dependant diabetes mellitus

These patients are not suitable patients to be treated using general anaesthesia in an outpatient environment. They may be suitable for IV Sedation according to their diabetic control. Their blood sugar must be monitored carefully and patients are requested to bring their 'BM Stix'.

Non insulin dependant diabetes mellitus

These patients are usually controlled by diet alone or in conjunction with oral hypoglycaemics. They will be assessed and given appropriate advice (e.g. omit hypoglycaemics, starve and make treatment appointments early-mid morning). All diabetics will have their blood sugar checked before discharge from recovery. After care by the escort is very important in these patients and if the suitability of the escort is in question the treatment is postponed.

Action - Referring dentists should ask patients to bring all medication and BM stix to the assessment visit.

HAEMATOLOGICAL DISORDERS

Patients with non-acute haematological conditions may be referred to the clinic for assessment.

Sickle cell anaemia

The sickle-rex status for all Afro Caribbeans MUST be know prior to their treatment.

Action - Referring practitioners should ensure sickle dex status is known prior to referral for assessment.

MUSCULAR DISORDERS

Unsuitable for Day Stay sedation:

  • Muscular dystrophy (e.g. Duchenes disease)
  • Myotonic dystrophy
  • Myasthenia Gravis (suitable for RA only)
  • Myasthenia Syndrome

INHERITED DISORDERS

Only suitable for conscious sedation:

  • Porphyria
  • Down's Syndrome

NEUROLOGICAL DISORDER

Multiple Sclerosis

Patients with a diagnosis of MS will require a comprehensive anaesthetic assessment.

Epilepsy

  • Well controlled: Can be undertaken in the day stay unit. Medication must be taken as normal.
  • Poorly controlled: (frequent lapses). Not suitable for treatment in the day stay unit.

PREGNANCY

In all cases, treatment using IV sedation or general anaesthesia will be avoided.

Female patients are questioned about the possibility of being pregnant both at the assessment and by the anaesthetist prior to treatment.

The safest and most recommended anxiety management technique is inhalation sedation with nitrous oxide and oxygen. This will be provided in the second trimester if treatment cannot be deferred.

OTHER

Any allergic reactions the patient may have encountered should also be noted on the referral form.