Advanced Education In General Dentistry

Module 01: Advanced Pain Control and Sedation

Clinical Assessment and Guidelines

Patient Assessment

It is important to perform a history and do a focused physical exam to be sure that there aren't any medical risks that would predispose the patient to a medical emergency during the actual procedure. It is also important to talk to the patient to get a feel for the patient's psychological state. Be sure to assess the following:

Risk Assessment

In order to answer these questions, a risk assessment is performed, which requires taking a medical history and performing a physical examination.

Most of the information obtained in the medical history will be the basis for the risk assessment and it is important for the clinician to spend time talking with the patient. Information gathered in the patient history includes:

During the physical examination a review of systems is conducted, in order to obtain information about specific organ systems. The focused physical exam should include the following components:

Physical Examination

A good history is merely confirmed by the physical examination. Begin with the basic vital signs including blood pressure, heart rate, respiratory rate, and record the height and weight of the patient.

A complete pre-operative physical exam should also include a head and neck exam, cardiovascular exam and pulmonary exam. In addition, it is also important to perform an airway exam, and that involves looking at the tongue, at the neck. During the airway exam, use the following questions to help you determine if the patient is at risk for airway obstruction during sedation:

During the history and physical examination, it is also important to ascertain the patient's anxiety level. Some symptoms of anxiety include sweating, dilated pupils; the patient may also be very talkative, and/or may have an increased blood pressure and heart rate.

ASA Classification System

The ASA Classification system is used by anesthesiologists to classify patients according to their medical history. It is a graded scale from one through five, with an E is added to indicate an emergency procedure.

P1 A normal healthy patient
P2 A patient with mild systemic disease
P3 A patient with severe systemic disease
P4 A patient with severe systemic disease that is a constant threat to life
P5 A moribund patient who is not expected to survive without the operation
P6 A declared brain-dead patient whose organs are being removed for donor purposes

For example, a healthy normal 18-year-old patient would be an ASA P1. If that patient was undergoing an emergency appendectomy, then the classification would be 1E

Examples of an ASA 2 would be:

Examples of ASA 3 patients include:

Examples of ASA 4 patients include:

Patients classified as ASA 1 or 2 do not require any modifications to the sedative technique. An ASA 3 patient requires more caution; modifications might be needed, such as lighter sedation or treatment in a hospital setting. An ASA 4 patient should only be treated in a hospital dental facility, and should generally undergo emergency and palliative care only.

Further Reading

Silverman, SJ, Bruno, JR and Foote, JW. Preoperative Evaluation. In: Fonseca, R, Walker, R and Betts, N, editors. Oral & Maxillofacial Surgery, Volume 1. Saunders: 2000. p. 13-40.