MEDICAL HISTORY QUESTION

Are you in good health?

Are you currently under the
care of a physician?
Has there been any change in your general
health within the past year?
Have you had any serious illness, operation,
or been hospitalized in the past 5 years?
Have you had any problems with or during
dental treatment?

Are you allergic or had any reaction to any

medications (including local anesthetics)?

Any other allergies, such as metals,

latex, food, or pollen?
Artificial heart valves or shunts

Cardiovascular disease, such as heart

trouble, heart attack, angina, high blood
pressure, hardening of the arteries, or
stroke?

MEDICAL HISTORY QUESTIONS EXPLAINED

LOCAL ANESTHETIC IMPLICATIONS
Treatment modifications may be considered for patients who reveal a significant disability, medical or psychological condition.
Significant medical conditions may contraindicate or limit the use of a local anesthetic or vasoconstrictor.
Patients with special needs should not receive bupivacaine due to the possibility of self-mutilation.
Dental hygiene care modifications should be considered for a patient with a medically compromising condition.
Significant medical conditions may contraindicate or limit the use of a local anesthetic or vasoconstrictor.
Medical consultation with patients general physician or specialist may be indicated before anesthetic selection and treatment.
A recent change may indicate needed treatment modifications that may influence anesthetic selection.
Identify local anesthesia precautions that may be needed if there is a prior history of serious illness.
Existing or chronic medical conditions may indicate the need for m difications in care.
Stress reduction protocols implemented for patients with medical conditions that could be exacerbated by stress/anxiety from the
administration of local anesthetics and dental hygiene care.
Complications often are a source of patient dissatisfaction and fear; if possible avoid repeating the complication.
Stress reduction for the anxious patient.
Selection of local anesthetic of adequate duration for effective postoperative pain control.
Allergic reactions to local anesthetics are rare and essentially non-existent.
Evaluate further to determine if a true allergy exists.
Patient should be referred to an allergist if there is still concern regarding a local anesthetic allergy if after questioning the patient, the dental
hygienist is unsure if the patient has a true allergy to local anesthetics.
If the patient has a true allergy to sulfites, vasoconstrictors should be avoided.
Increase risk for a latex allergy from the rubber stopper and diaphragm of the glass cartridge.
However, no documented allergies to latex from the anesthetic cartridge have been reported.
Patients who have many allergies to foods, metals, or pollen may be more susceptible to allergic reactions to sulfites or ester topical
anesthetics.
The administration of local anesthetics does not require antibiotic prophylaxis, except for the periodontal ligament injection (PDL).
However, nonsurgical periodontal treatment performed by the dental hygienist requires antibiotic prophylaxis.
Nature of dental treatment will dictate the need for antibiotic prophylaxis.
Heart attack: delay treatment for 6 months, after 6 months: decrease the amount of cpinephrine to 0.04 mg per appointment, and
levonordefrin to 0.2 mg per appointment.
Unstable angina: ASA IVincreased risk of severe angina attack. Dental hygiene treatment should be postponed until condition is under
control. Absolute contraindication to vasoconstrictors until condition is under control.
Stable angina: ASA IIIadequate pain control will decrease the risk of angina attack due to apprehension and nervousness. Vasoconstrictors
can be administered, but at a decreased dose of 0.04 mg per appointment for epinephrine, and 0.2 mg for levonordefrin.
Uncontrolled high blood pressure: dental hygiene treatment should be postponed until blood pressure is under control, absolute
contraindication to vasoconstrictors until blood pressure is under control.
Controlled blood pressure with beta blockers: relative contraindication to vasoconstrictors and amide local anesthetics.
Monitor blood pressure after initial local anesthetic injection and post treatment for signs of increased blood pressure.
Stroke: delay treatment for 6 months, after 6 months: decrease the amount of vasoconstrictors to 0.04 mg per appointment for epinephrine
and 0.2 mg for levonordephrin.
Avoid intravascular injections of vasoconstrictors.

Have you taken cortisone in the

last 2 years?
Were you born with any
heart problems?
Sinus trouble, asthma,
hayfever, or skin rashes?
Fainting spells, seizures,
epilepsy or convulsions?

Diabetes?

Hepatitis, yellow jaundice,

cirrhosis, or liver disease?
AIDS or HIV infection?

Thyroid problems (goiter)?

Respiratory problems, emphysema,

bronchitis?
Have you ever had a joint
replacement?
Kidney trouble or dialysis
treatment
Anemia or blood disorders?
Have you been diagnosed
with alcoholism?
Do you use recreational drugs?

Identify patients at risk for adrenal insufficiency.

Stress reduction protocol, and consider nitrous oxide or IV sedation to further reduce stress.
Usually can safely receive dental care with the use of local anesthetics and vasoconstrictors.
Medical consultation as needed.
Asthma: adequate pain control to not precipitate attack.
Stress reduction protocol.
Sodium bisulfite preservative for vasoconstrictors may cause respiratory reactions in asthmatics (predominantly steriod dependent
asthmatics).
Anxiety during injection.
Adequate pain control to not precipitate seizure.
Stress reduction protocol.
Epinephrine is associated with the inhibition of peripheral glucose uptake by the tissues and opposes the action of insulin. Concentrations of
epinephrine used in dentistry do not raise the glucose blood levels significantly.
Uncontrolled brittle diabetes: dental hygiene treatment should be postponed until condition is under control. Use epinephrine with
caution.
Controlled diabetes: blood glucose levels should be evaluated prior to dental hygiene treatment.
Morning appointments after a meal. Vasoconstrictors can be administered.
Decreased liver function increases the half-life of the amides metabolized in the liver, increasing risk of overdose.
Limit the dose of amides metabolized in the liver.
Articaine may be a safer choice because it is predominantly metabolized in the blood.
Careful disposal of contaminated needles.
Hyperthyroid patients have an increased sensitivity to epinephrine.
Uncontrolled hyperthyroidism: postpone dental hygiene treatment until condition is under control, absolute contraindication to
vasoconstrictors.
Controlled hyperthyroidism: vasoconstrictors can be administered, but use minimal effective dose.
Pheochromocytoma (catecholamine producing tumor): postpone dental hygiene treatment until condition is under control. Absolute
contraindication to vasoconstrictors.
Liver function may be reduced: limit the dose of amides.
Stress reduction protocol.
The administration of local anesthetics does not require antibiotic prophylaxis, except for the PDL injection.
However, nonsurgical periodontal treatment performed by the dental hygienist requires antibiotic prophylaxis.
Nature of dental treatment will dictate the need for antibiotic prophylaxis.
Usual doses do not pose an increased risk.
Significant renal disease: medical consultation needed.
Limiting the amount of anesthetic is recommended depending upon severity.
Methemoglobinemia: substitute other amides for prilocaine, and topical lidocaine for topical benzocaine.
Atypical plasma cholinesterase: substitute ester topical anesthetics with lidocaine and substitute articaine with other amides.
Avoid block injections for clotting disorders.
Decreased liver function increases the half-life of the amides metabolized in the liver, increasing risk of overdose.
Limit the dose of amides.
Articaine may be a safer choice because it is predominantly metabolized in the blood.
Vasoconstrictors administered the same day that a patient has used cocaine or methamphetamine can be life-threatening.

Are you pregnant or nursing a baby?

Are you taking any medications, including

any nonprescription medications or natural
supplements, such as birth control, calcium,
ginseng, or garlic?

Elective dental hygiene care with anesthesia can be safely administered in any trimester, in consultation with the patients physician.
Conservative approach: avoid elective treatment with anesthesia until the second trimester.
Choose local anesthetic that falls in category B.
Choose safe anesthetic for lactation.
Decrease amount of amide local anesthetic for patients taking cimetidine, beta blockers, CNS depressants.
Decrease amount of esters and articaine for patients taking sulfonamides and cholinesterase inhibitors.
Decrease the amount of epinephrine per appointment for patient taking tricyclic antidepressants, beta blockers, phenothiazides, and digitalis
glycosides.
Avoid levonordefrin for patients taking tricyclic antidepressants.

SIGNIFICANCE OF SCREENING QUESTIONS

Disease
Atherosclerosis, coronary artery disease (CAD)
Hypertension
Prior myocardial infarction (MI)
Heart failure (HF)
Arrhythmias
Valvulopathy
Hyperlipidemia
Prior cardiac intervention stents, bypass, CIED
Angina
Shortness of breath
Level of exercise tolerance
Palpitations; unprovoked episodic tachycardia
Irregular heart beat
Cough
Dizziness
Orthostatic hypotension
Syncope
Smoking
Sedentary life style
Family history of sudden cardiac death

Select cardiovascular concerns

Inability to tolerate increased cardiac work (increased rate or force of contraction)
Increased cardiac workload, known risk factor for CAD, MI, HF; perianesthetic hypotension
Post infarct irritability, arrhythmia, re-infarction with recent MI (<30 days)
Level of compensation, exercise tolerance
Level of control, side effects of anti-arrhythmic medication, symptoms, possibility of recurrence during anesthesia
Increased cardiac workload, aortic stenosis limits cardiac output
Atherosclerosis, CAD
Stent re-thrombosis, compliance with anti-platelet therapy, device efficacy, battery life
Never normal, could indicate coronary artery disease
Never normal, non-specific symptom, cardiac and/or pulmonary origin
Should be able to take care of self, ascend one flight of stairs (4 METS)
Atrial fibrillation, PVCs, supraventricular tachycardia
Atrial fibrillation, PVCs
Non-specific symptom, decompensated heart failure, COPD
Arrhythmia, pre-syncope, hypotension
Side effect of anti-hypertensive medications
Vasovagal syncope, carotid sinus hypersensitivity
Atherosclerosis, COPD, increased airway irritability, sympathomimetic, falsely elevated SpO2
Atherosclerosis, obesity
Hereditary long QT syndrome

COMPLETE BLOOD COUNT

Components

Reference range

White blood cells (WBC)

4,50011,000/mm3

Hemoglobin
Hematocrit
Trombocite

Possible indications
Infection
Anemia
Immunodeficiency hemorrhage

Male: 13.517.5 g/dL

Female: 1216 g/dL
Male: 4153%
Female: 3646%
150,000400,000/mm3

COMPLETE BLOOD COUNT

Components

Reference range

White blood cells (WBC)

4,50011,000/mm3

Hemoglobin
Hematocrit
Trombocite

Possible indications
Infection
Anemia
Immunodeficiency hemorrhage

Male: 13.517.5 g/dL

Female: 1216 g/dL
Male: 4153%
Female: 3646%
150,000400,000/mm3

STRESS REDUCTION PROTOCOL

Recognize the patients level of anxiety (be a good observer)
Complete medical consultation before care, as needed
Premedicate the evening before the dental appointment, as needed
Premedicate immediately before the dental appointment, as needed
Schedule the appointment in the morning
Minimize the patients waiting time
Monitor and record preoperative vital signs and postoperative vital signs
Consider psychosedation during therapy
Consider appointment length for highly anxious and medically compromised patient; do not exceed the patients limits of tolerance
Select an anesthetic agent with appropriate posttreatment pain control
Administer adequate pain control during therapy
Follow up with postoperative pain and anxiety control
Telephone the highly anxious or fearful patient later the same day that treatment was delivered

ADULT BLOOD PRESSURE GUIDELINES USED IN THE DENTAL PROCESS OF CARE

BLOOD PRESSURE (MM HG)

ASA PHYSICAL STATUS

CLASSIFICATION

<140 systolic and

<90 diastolic

DENTAL AND DENTAL THERAPY CONSIDERATION AND INTERVENTIONS RECOMMENDED

No unusual precautions related to patient management based on blood pressure readings.
Recheck in 6 months.
No unusual precautions related to patient management based on blood pressure readings needed unless

140159 systolic and/or

9094 diastolic

II

160199 systolic and/or

95114

III

>200 systolic and/or

>115 diastolic

IV

blood pressure remains above normal after three consecutive appointments.

Recheck blood pressure prior to dental or dental hygiene therapy for three consecutive appointments; if all
exceed these guidelines, seek medical consultation.
Stress-reduction protocol if indicated, such as administration of nitrous oxide-oxygen analgesia, should be
considered.
Recheck blood pressure in 5 minutes; if still elevated, seek medical consultation prior to dental or dental
hygiene therapy.
No unusual precautions related to patient management based on blood pressure readings after medical
approval is obtained.
Stress-reduction protocol if indicated, such as administration of nitrous oxide-oxygen analgesia.
Recheck blood pressure in 5 minutes; immediate medical consultation if still elevated.
Dental or dental hygiene therapy, routine, or emergency treatment may be performed if nitrous oxideoxygen analgesia lowers the blood pressure below >200 systolic or >115 diastolic.
If blood pressure is not reduced using nitrous oxide-oxygen analgesia, only (noninvasive) emergency therapy
with drugs (analgesics, antibiotics) is allowable to treat pain and infection.
Refer to hospital if immediate dental therapy is indicated.

AMERICAN SOCIETY OF ANESTHESIOLOGISTS (ASA) PHYSICAL CLASSIFICATION SYSTEM

ASA I
ASA II
ASA III
ASA IV
ASA V
ASA E

A normal, healthy patient

A patient with a mild systemic disease but this does not interfere with daily activity (e.g., a healthy patient with considerable anxiety; a healthy pregnant
patient; a patient who has well-controlled type 2 diabetes, controlled epileptic, and/or well-controlled asthma)
A patient with moderate to severe systemic disease that limits activity but is not incapacitating but may affect daily activity (e.g., stable angina,
exerciseinduced asthma, postmyocardial infarct or cerebrovascular accident more that 6 months before treatment, poorly controlled hypertension)
A patient with an incapacitating systemic disease that is a constant treat to life (e.g., myocardial infarction within past 6 months, or cerebrovascular accident
within 6 months, uncontrolled epilepsy or uncontrolled diabetes, blood pressure greater than 200/115)
A moribund patient not expected to survive 24 hours with or without an operation
Emergency operation. The E precedes the number to indicate the patients physical status, (e.g., ASAE-III)

AMERICAN HEART ASSOCIATION RECOMMENDATIONS FOR PROPHYLACTIC ANTIBIOTIC COVERAGE REGIMEN FOR
SELECT DENTAL PROCEDURES IN ADULTS AND CHILDREN WITH HIGH AND MODERATE RISK FOR INFECTIVE ENDOCARDITIS
SITUATION

AGENT

Standard prophylaxis for persons not allergic

to penicillin

Amoxicillin (oral)

Allergic to penicillin

Clindamycin (oral) or Azithromycin

(oral) or clarithromycin (oral)

Unable to take oral medications

Ampicillin (IM or IV)

Allergic to penicillin and unable to take oral

medications

Clindamycin (IV)

CHILD OR ADULT

Adult
Child
Adult
Child
Adult
Child
Adult
Child

REGIMEN

2 g orally 1 hour before the procedure

50 mg/kg orally 1 hour before the procedure
600 mg orally 1 hour before the procedure
20 mg/kg orally 1 hour before the procedure
2 g within 30 minutes before the procedure
50 mg/kg within 30 minutes before the procedure
600 mg within 30 minutes before the procedure
20 mg/kg within 30 minutes before the procedure