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 and as revised in 1961 by adding the sixth category. The purpose of the grading system was simply to assess the degree of a patient’s “sickness” or “physical state” prior to providing any treatment (Table 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 Despite its widespread acceptance, significant misunderstandings and discrepancies have always arised when calibration methods were tried with various medical practitioners. There has always been an intent to look and eventually propose an alternative classification system for medical risk assessment that is based on medical complexities, anticipated complications and more over dental modifications.53
|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 (B.P.), heart rate (H.R.), pulse, and respiratory rate (R.R.), 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:
Previously, dental practitioners used to generally postpone dental treatment until 6-12 months after a stroke, based on the presumed risk of recurrent stroke. However, current literature suggests that stroke patients including patients with higher risks of bacteremia who undergo dental procedures within one month to six months after ischemic vascular event, were not at an increased risk of experiencing a second event.46