Risk Assessment in Dentistry: Utilizing the American Society of Anesthesiologists Physical Status Classification

Advancements in healthcare have led to an increase in life expectancy, and as a result, dental patients now often have more complex medical histories, with multiple co-morbidities and polypharmacy. More patients, especially as they age, are coming in with a complex list of medications and health conditions that dental and medical professionals must assess before administering sedation medication.

To ensure patient safety, dental professionals must assess these patients’ risk. Risk prediction tools are commonly used in medicine to aid clinical decision-making, focusing on the patient’s overall physical status. One widely accepted assessment tool in both medicine and dentistry is the American Society of Anesthesiologist’s Physical Status (ASA PS) Classification.

Initially developed for data collection in anesthesia, it aimed to establish a link between operative risk and prognostic outcomes. Despite criticisms regarding its accuracy and usefulness, ASA PS is extensively used in medicine, including performance evaluation, clinical research, and policy making.

In dentistry, ASA PS is commonly used to summarize patients’ general health, particularly in those receiving dental treatment under conscious sedation. Dental professionals trained in conscious sedation techniques are expected to understand the patient’s ASA status and document it accordingly. While ASA III or higher patients are generally considered unsuitable for conscious sedation in primary care, exceptions may be made for patients with additional needs.

Effectiveness of ASA PS in Dental Treatment

Recent research has sought to examine the effectiveness of ASA PS in evaluating medical risk in dentistry. For example, a 2016 study used an online cross-sectional questionnaire to gather information from anesthetists and dentists in London, including general dental practitioners, hospital dental practitioners, and community dental practitioners.

In this questionnaire, dentists and anesthetists were asked about their experience in conscious sedation and the classifications of patients they believed should be treated in primary or secondary care settings. Anesthetists were also asked about their experience working with dental teams and their perception of dentists using ASA PS scores. Further, the questionnaire included hypothetical patient scenarios where both dentists and anesthetists would asses risk using the ASA PS Classification.

Out of 101 initial responses received, 82 were considered complete. The results of the questionnaire found that anesthetists reported the highest frequency of using the ASA PS Classification, while most general dental practitioners (GDPs) reported never using it and finding it unhelpful. A significant proportion of hospital dental practitioners (HDPs) and community dental practitioners (CDPs) were involved in dental treatment under conscious sedation and found ASA PS somewhat helpful, but compliance with recording scores in patient records was low.

The responses also showed that dental practitioners were less aware of other physical assessment scales than anesthetists. GDPs believed ASA PS I and II patients were suitable for referral to community dental services (CDS), while some considered ASA PS III and IV patients appropriate as well. Further, it found that anesthetists regularly worked with dental teams and generally believed dentists could assign ASA PS scores correctly. However, the results found considerable variation among professional groups when assigning ASA grades to hypothetical patients. According to the questionnaire responses, there was a low level of awareness regarding alternative physical assessment tools, which are important for medical risk prediction and inter-professional communication.

This study identified subjectivity, poor reproducibility, and limitations of the ASA PS Classification, highlighting the need for education on its use among all professional groups. The results also highlighted the need for more dental-specific physical assessment tools that consider factors such as anxiety and underlying medical co-morbidity.

Improving Medical Risk Evaluation in Dentistry

There is clearly room for improvement in the understanding and consistent use of the ASA PS Classification among dental practitioners. Although they may seem discouraging, it presents an opportunity for growth rather than a cause for concern.

Dental professionals need to be educated in the use of the ASA PS Classification, especially when assessing medical risk for patients undergoing conscious sedation. Additionally, increasing awareness of alternative assessment scales and considering factors like dental anxiety could enhance patient care and facilitate better communication among healthcare teams. By acknowledging the limitations of the ASA PS Classification and promoting education, we can promote safer and more effective medical risk assessment in dentistry, ultimately benefiting both patients and practitioners.