Patient Evaluation & Medical Risk Management MCQ

Oral surgery begins not with an instrument but with a decision: can this patient be operated on safely, and what has to be managed first? A thorough medical history and a structured risk assessment (the ASA classification) identify the patients whose anticoagulation, antiresorptive therapy, bleeding disorder, cardiac condition, or systemic disease must be addressed before a tooth is touched. The recurring lessons are practical: most patients do not stop their blood thinners for routine extractions, antibiotic prophylaxis is reserved for specific cardiac lesions (and is no longer routine for prosthetic joints), and the time to prevent osteonecrosis of the jaw is before antiresorptive therapy starts. Recognition of risk comes before the first incision.

Medical History and ASA Classification

• A thorough medical history is the first and most important step in surgical evaluation; it identifies the conditions and medications that change the plan.
• The ASA physical status classification stratifies risk: ASA I is a healthy patient, ASA II has mild controlled systemic disease, ASA III has severe systemic disease that limits activity but is not incapacitating, ASA IV has severe disease that is a constant threat to life, and higher classes describe moribund or brain-dead patients.
• Vital signs (especially blood pressure) are checked before surgery, because uncontrolled hypertension or other unstable findings may mean deferring elective surgery.
• Risk assessment determines whether to proceed, modify the plan, control a condition first, or refer.

Anticoagulants and Bleeding Disorders

• For routine extractions, anticoagulants and antiplatelets are usually continued, because the risk of a thromboembolic event from stopping them outweighs the bleeding risk, which can be controlled locally.
• For a patient on warfarin, the INR is checked, and simple extractions are generally safe when it is within the therapeutic range (commonly cited up to about 3.0 to 3.5); the direct oral anticoagulants (apixaban, rivaroxaban) and antiplatelets (aspirin, clopidogrel) are likewise generally continued for simple procedures.
• Local hemostatic measures (firm pressure, sutures, oxidized cellulose or a gelatin sponge, and a tranexamic acid mouthrinse) control the bleeding that does occur.
• Inherited bleeding disorders (hemophilia, von Willebrand disease) are different: they require coordination with the hematologist and pre-surgical factor replacement or desmopressin, not just local measures.

Bisphosphonates and MRONJ

• Antiresorptive drugs (bisphosphonates and denosumab) and some antiangiogenic agents carry a risk of medication-related osteonecrosis of the jaw (MRONJ).
• MRONJ is defined as exposed necrotic bone (or bone probed through a fistula) persisting more than 8 weeks in a patient taking an antiresorptive or antiangiogenic drug, with no history of head and neck radiation.
• Risk is much higher with intravenous, high-dose (oncologic) bisphosphonates than with the lower oral doses used for osteoporosis, and it rises with invasive procedures like extractions.
• The most effective strategy is prevention: complete needed extractions and dental work before antiresorptive therapy begins, and once a patient is on therapy, favor conservative, nonsurgical options and minimize bony surgery.

Antibiotic Prophylaxis

• Antibiotic prophylaxis to prevent infective endocarditis is reserved for specific high-risk cardiac conditions: a prosthetic heart valve (or prosthetic material used for valve repair), a history of infective endocarditis, certain congenital heart disease, and a cardiac transplant that develops valvulopathy.
• It is indicated only for procedures that manipulate the gingival tissue or periapical region of teeth or perforate the oral mucosa, which includes extractions.
• The standard regimen is amoxicillin 2 g by mouth, 30 to 60 minutes before the procedure (with alternatives for penicillin allergy).
• Routine antibiotic prophylaxis is no longer recommended for most patients with prosthetic joints; that decision is made with the orthopedic surgeon when there is a specific concern.

Other Systemic Conditions, Consent, and Workup

• Poorly controlled diabetes raises the risk of infection and delayed healing, so glucose is controlled, appointments are scheduled to avoid hypoglycemia (patient eats and takes medication as usual), and morning visits are common.
• Elective surgery is generally deferred in pregnancy; when treatment is needed, the second trimester is considered safest and certain drugs (such as tetracyclines) are avoided.
• Patients on chronic corticosteroids may have adrenal suppression, so the stress of major surgery raises the (uncommon) concern of adrenal crisis.
• Informed consent (risks, benefits, alternatives, and the patient's capacity to decide) and appropriate imaging (to assess proximity to the inferior alveolar nerve or maxillary sinus) complete the workup before surgery proceeds.