Treating elderly and medically compromised patients in a dental care setting have their own challenges that can potentially test any clinician to their limits, The physical symptoms present in elderly patients may include but not be limited to disability with motor function, balance, and other behavioral issues. For example, the greatest incidence of stroke is considered to be among adults sixty years and older, which further adds complexities to even simple dental procedures. Encountering more compromised elderly patients on a daily basis is never considered easy; however, with additional training the dental staff can improve their patient handling techniques and thus provide treatment to the best of their capacity, knowledge and clinical judgment.
The American Society of Anesthesiologists (ASA) Physical Status classification system was initially created in 1941 by the American Society of Anesthetists. The purpose of the grading system is simply to assess the degree of a patient’s “sickness” or “physical state” prior to providing any treatment (Figure 1). Describing patients’ preoperative physical status is used for record keeping, for communicating between colleagues, and to create a uniform system for statistical analysis.27
Figure 1. ASA Physical Status Classification System.27
|ASA 1||Healthy patients|
|ASA 2||Mild to moderate systemic disease caused by the surgical condition or by other pathological processes, and medically well controlled|
|ASA 3||Severe disease process which limits activity but is not incapacitating|
|ASA 4||Severe incapacitating disease process that is a constant threat to life|
|ASA 5||Moribund patient not expected to survive 24 hours with or without an operation|
|ASA 6||Declared brain-dead patient whose organs are being removed for donor purposes|
Taking a detailed medical history before starting any dental treatment is not only paramount but is a required ‘standard of care.’ Measuring the patient’s vital signs, including blood pressure, heart rate, pulse, and respiratory rate, should be a standard practice in all dental offices. The dental team should consider the physical characteristics of the patient before concentrating on their dental problems. A detailed medical history including medical diagnoses, an updated list of all medications along with past surgeries or hospitalizations give the clinician a fair chance to evaluate the given circumstances.17 This history may also identify the need for the administration of a prophylactic antibiotic due to patient’s orthopedic or cardiac status before proceeding intraorally.
Some common medical conditions that may potentially be identified include:
|High Blood Pressure/Hypertension|
|Stage 1 Hypertension||140-159||or||90-99|
|Stage 2 Hypertension||≥ 160||or||≥ 100|
Most important, the dental hygienist or even the dentist should not hesitate to contact the patient’s primary physician requesting copies of clinical test reports such as INR values, if the patient is on anticoagulants, along with the patient’s medical diagnoses, and current medications in order to update the patient’s medical records at every visit. This requires active communication, building trust and frequent engagement with other healthcare professionals such as physicians, nurses, aides, pharmacists and anyone involved in providing care for the elderly patient. Even a minor fluctuation in the dosage of a patient’s current medication can hamper the outcome of the dental procedure. In order to have a better understanding of a patient’s dental outcome, a direct conversation with the previous dentist can be beneficial in understanding the behavioral patterns and any modifications in the treatment approach. Of utmost importance is the maintenance of comprehensive and accurate medical and treatment records, as all practitioners are required by law to maintain these records in order to provide evidence of continuity of care as well these records may be subpoenaed in medico-legal or insurance fraud cases.43
For wheelchair bound patients, the wheelchair should be moved as close as possible to the dental chair44 for the dental staff to have full access to their dental equipment. In some cases where the patient cannot be transferred to the dental chair, special head and neck support systems (Figure 5) can be employed that will provide support for the patient’s neck and head to minimize patient discomfort.
The staff should also be trained in understanding the basic concepts of Safe Patient Handling (SPH) and be aware and accountable for providing appropriate assistance during the movement of patients.45,46 For patients having difficulty standing up or have reduced weight bearing capacities, they should be assisted when moving from their wheelchair to the dental chair and then back to their wheelchair using patient transfer devices or other mechanical,devices. The determination to have either a one-person or two-person transfer should be made considering the staff training and the disability of the patient. Transfer Boards, Pivot Discs, Transfer belts (Figure 6), EZ lift (Figure 7) or Hoyer lifts (Figure 8) can be used by the staff in transferring the patient to or from the wheelchair.