when a patient comes into our office and presents needing an extraction or some
type of dental procedure there is a classification system that you should be
aware of, which will allow you to determine a general level of safety for
working on that patient and that is the ASA classification. The American
Society of Anesthesiologists basically classifies people from ASA I
all the way to ASA VI and these different classes have different
characteristics associated with them in terms of the patient's health. An ASA I
patient is the ideal patient for your office. These are patients who
are very unlikely to have any adverse reactions to treatment. These
patients are patients who will have normal vital signs so you'll take their
blood pressure and heart rate...[it] falls within normal limits their organ systems
are all functioning normally they have no medical histories that are
significant, they're not taking medications, they're not smoking, they're
not using alcohol, or they're using just a very minimal amount, and they're
someone who can walk say a whole flight of stairs or a couple blocks in the city
and they don't have any cardiovascular distress. The other thing that's
important with the classification system is it also takes into account the
anxiety of the patients so this ASA I classification means that patients are
very calm in your chair; they have minimal to no anxiety. The ASA II
patient is a terrific patient to be working on in your office. You just
have to keep in mind that they're maybe not as healthy as the ASA I patient
and they may have a little bit more of a medical history than with the ASA I
category. What constitutes an ASA II patient? Well, first off you could have
someone who's ASA I, but they're extremely fearful of the dentist. Now if
that's the case they're actually considered ASA II, the reason being
that stress is a huge precipitator of adverse events in the dental office.
That is one condition, the next thing would be someone who maybe has a mild
systemic disease so let's say that they've got well-controlled diabetes
so they've been taking medications for many years everything has been really
good with their blood sugars and they really have very few complications with
this condition. That is an ASA II patient. Now they could have another condition
say asthma or thyroid problems or epilepsy those would all push them into
the ASA II category. Ladies I'm sorry but pregnancy also would include you into
the ASA II category, not a medical condition but just overall maybe more
considerations when you're treating that class of patient. The other thing with
ASA II people is if they climb a flight of stairs or walk a couple city blocks,
maybe they need to kind of catch their breath a little bit. They're maybe not
as cardiovascularly fit as the ASA I patient and I'm starting to wonder if
I'm slipping into this category - I hope not, but I think I'm headed there over
time eventually I'll get there... I think we all do! Now BMI is another one so if
you have a 30 to 40 BMI, the body mass index then that could constitute you as
an ASA II patient. Smoking is the final thing so if you are a smoker, someone
who's doing that habit, that is not a good thing and that will push you into
the ASA II category. When you encounter an ASA III patient in your office you might
want to take a step back for a minute, just to reassess whether or not you're
equipped to be dealing with the conditions that they're presenting to
you with and any of the complications that may be associated with those
conditions. So what I'm talking about would be someone who maybe can't climb a
flight of stairs without stopping to take a break; someone who can't walk two
level city blocks without again, leaning on something just to catch their breath
before they continue. This is someone who cardiovascularly typically isn't
very healthy. They usually will have one or more moderate to severe systemic
conditions that severely limit them so one of those could be say angina, they
could have a history of myocardial infarction, they could have mild COPD,
they might be someone who has coronary artery disease with stents in their
heart; these are all signs that you're dealing with someone who maybe isn't as
fit or as healthy is that ASA II classification. Something else that would
put you into the ASA III category would be if you had
a BMI say over 40. Really obese people tend to have other associated health
conditions and that is something that we need to be aware of. We talked about
diabetics being ASA II patients and that is largely true as long as they are
well-controlled diabetics. Now if you have a poorly-controlled diabetic or say
someone with hypertension who isn't being treated effectively or maybe
they've just been diagnosed and they haven't yet got their medications sorted
out so that they have good blood sugars, or a reasonable blood pressure; these are
patients that we need to be very cautious about when we're choosing to
treat them in our office. The ASA IV patient is experiencing conditions that
are a constant threat to their life. Now if that sentence there doesn't tell you
that you shouldn't be treating these patients you might want to rewind and
listen to game because this is a very concerning group of people to have in
your chair. So what they should be doing in your chair is they should be waiting
for you to write out a referral to the oral surgeon where they can then move on
to someone who's a little bit more trained to handle any complications that
could arise when these patients are getting their treatment. Now they may
even consider treating these patients in a hospital setting because their medical
problems typically outweigh the dental problems that they're experiencing.
What is this group of patients? How do we identify them? Well if you ask them , "can
you climb a flight of stairs?" they will tell you no I cannot. They cannot get
up a flight of stairs. They cannot walk two level city blocks
they just can't physically do is not they have to take a break they just
can't make it that far. Very, very unhealthy people. The
conditions they may be experiencing would be say a congestive heart failure
that is fairly advanced. They may have a history of a heart attack within three
months of the time that they presented to you. They could have severe or
moderate COPD. They could also have end-stage renal
disease. Any of these things places them in that ASA IV category and what
you'll notice is that they're in distress even at rest so let's say
they've been waiting for ten minutes in your chair to see you, you come in the
room and you hear... [Breathing Noises] you can hear them breathing
they're
struggling to breathe, they're tired and they haven't even done anything. There's
no exertion, they've had a chance to rest in your chair, they might even have
oxygen on. These are signs that you don't want to be treating these patients and
you need to pass them along to someone who's more experienced like
an oral and maxillofacial surgeon. For the sake of completeness we're going to
talk about ASA V and ASA VI patients. Now you will never see these patients in
your office reason being that an ASA V patient is someone who is terminally ill.
They have something wrong with their health that is a very, very severe that
would expect them to only live for maybe 24 hours. An example of this could be
an intracranial bleed maybe massive trauma or some form of a ruptured
aneurysm. Something that's going on that is going to cause them to die within the
day. Now these patients never receive elective care, they might receive some
palliative care if necessary to get them through to the end of their life.
An ASA VI patient is someone who is essentially being kept alive for the
sole purpose of harvesting their organs. So again this is not a patient who's
really even alive anymore; basically that is the end of the spectrum of the ASA
classification. What we've talked about would be the ASA I to [ASA] II
patients; those are the ideal ones that you want to be treating in your office.
ASA III is where you should kind of put the brakes on a little bit and make sure
you're very confident in your medical knowledge and your ability to handle
emergencies and you should also have a good knowledge of the prior history of
these patients to have a full understanding of the conditions they are
afflicted with. ASA IV should be an immediate referral for you no matter
what, because they need the the care of a more experienced provider and even a
more experienced provider setting like a hospital. Then of course ASA V
and [ASA] VI are patients that we won't even be seeing or won't be needing to treat