2.2: Common medical red flags: Identification, significance and management
Jessica Zachar and Sowmya Shetty
Learning outcomes
- Understand rationale for recording specific medical conditions in the clinical record.
- Know the common medical red flags of importance in general dental practice, using the American Society of Anaesthesiologists physical classification.
- Briefly explain the effect of planned surgery on specific medical conditions.
- Understand the effect of specific medical conditions on planned dental surgeries.
- Provide some examples of the effect of medications on dental invasive treatments.
With increased ageing populations, there has been a rise in frail, multiple comorbidities, being on several medications, a gradual decrease in organ function and healing ability. This has increased the risk of postoperative complications. Additionally, even minor surgical procedures can trigger significant worsening of pre-existing medical conditions due to physiological effects, potentially resulting in severe and unforeseen morbidity.
Delpachitra et al. (2021) suggested that prior to any invasive dental procedures (e.g. extractions) we should ask ourselves three key questions first:
- What is the effect of planned surgery on medical condition?
- What is the effect of medical condition on planned surgery?
- How will associated medications of a medical condition affect surgery?
A useful classification system to decide if your patient is medically fit to undergo an invasive procedure is the Physical classification system by American Society of Anaesthesiologists (ASA):
| ASA Class | Class Definition | Example | Dental Implication |
|---|---|---|---|
| ASA I | A normal healthy patient. | Fit, nonobese (BMI under 30), a nonsmoking patient with good exercise tolerance. | Treatment can usually be performed. |
| ASA II | A patient with mild systemic disease. | Patient with no functional limitations and a well-controlled disease (e.g., treated hypertension, obesity with BMI under 35, frequent social drinker, or cigarette smoker). | Minimal risk during treatment. |
| ASA III | A patient with a severe systemic disease that is not life-threatening. | Patient with some functional limitation due to disease (e.g., poorly treated hypertension or diabetes, morbid obesity, chronic renal failure, a bronchospastic disease with intermittent exacerbation, stable angina, implanted pacemaker). | If dental care is required, treatment modifications indicated and medical consult needed. |
| ASA IV | A patient with a severe systemic disease that is a constant threat to life. | Patient with functional limitation from severe, life-threatening disease (e.g., unstable angina, poorly controlled COPD, symptomatic CHF, recent (less than three months ago) myocardial infarction or stroke. | If emergency treatment is needed, medical consult indicated; performed in hospital setting. |
| ASA VI | brain-dead patient whose organs are being removed with the intention of transplanting them into another patient. | Only palliative dental care if required. |
Note: Adapted from “American Society of Anesthesiologists classification” by D. J. Doyle, J. M., Hendrix, J. M., & E. H. Garmon, StatPearls, 2023, StatPearls Publishing. Copyright 2024 by StatPearls Publishing. (https://www.ncbi.nlm.nih.gov/books/NBK441940/). CC BY-NC-ND 4.0.
Common Red Flags
- High Blood Pressure (Hypertension)
- Diabetes
- Risk of Infective Endocarditis
- Pregnancy & Lactation
- Medication Related OsteoNecrosis of the Jaws (MRONJ) Risk
- Previous Radiation or Chemotherapy
- Renal or Hepatic impairment
- Adrenal Suppression
- Bleeding risk.
Medical red flags: Key points for dental treatment
References
American Association of Oral and Maxillofacial Surgeons. (2022). Position paper. https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/mronj_position_paper.pdf
Cahill, T. J., Dayer, M., Prendergast, B., & Thornhill, M. (2017). Do patients at risk of infective endocarditis need antibiotics before dental procedures? BMJ, 358(8120), j3942. https://doi.org/10.1136/bmj.j3942
Delpachitra, S., Sklavos, A., & Kumar, R. (2021). Principles of dentoalveolar extractions. Wiley. https://doi.org/10.1002/9781119596455
Dentists should give antibiotics to high-risk patients to help prevent life-threatening heart infection. British Dental Journal, 233(375), 375. https://doi.org/10.1038/s41415-022-4999-7
Doyle, D. J., Hendrix, J. M., & Garmon, E. H. (2023, August 17). American Society of Anesthesiologists classification. In: StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441940/
Thornhill, M. H., Dayer, M. J., Forde, J. M., Corey, G. R., Hock, G., Chu, V. H., Couper, D. J., & Lockhart, P. B., (2011). Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: Before and after study. BMJ, 342I(7807), d2392. https://doi.org/10.1136/bmj.d2392
