Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Module 4: Medical History

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Module 4: Medical HistoryModule 4: Medical History


Topic Overview: Medical History Topic Overview: Medical History

• How does the medical history protect the patient’s health?

• How can we obtain a medical history from a non-English-speaking patient?

• What does the information-gathering phase involve?

• How do we determine the medical risks of dental care?

• When do we consult with a physician?

• How can we reduce anxiety for an anxious patient?


Medical History AssessmentMedical History Assessment


There is a strong two-way relationship between

systemic health and oral conditions.

There is a strong two-way relationship between

systemic health and oral conditions.


Relationship Between Systemic and Oral HealthRelationship Between Systemic and Oral Health

• Systemic disease may have oral implications.

• Medications produce changes in oral health.

• Systemic conditions may require certain precautions prior to dental treatment.

• Oral manifestations may need to be checked by the primary care physician.

• Substances or drugs used in treatment may produce an adverse reaction


Health History FormsHealth History Forms


Medical History FormsMedical History Forms

• Used to gather subjective data about the patient’s:

– Past health problems

– Present health problems

– Medications

• Many different formats and lengths


Multicultural ConsiderationsMulticultural Considerations

• Need to find a way to assess the health history of a patient who speaks another language

• Trained dental interpreter is ideal, but not practical

• Some medical history forms have identical “other language” forms


Multilanguage Health History ProjectMultilanguage Health History Project

• University of the Pacific Dental School

• California Dental Association

• MetLife Inc.

The UOP health history form has been translated into more than 25 languages.

Available online at http://dental.pacific.edu


Informed Consent and the Medical HistoryInformed Consent and the Medical History


Informed Consent – Ethical ConsiderationsInformed Consent – Ethical Considerations

• Responsibility of clinician to provide complete and comprehensive information about assessment and treatment procedures

• Inform patient about expected successful outcomes and possible risks, unanticipated outcomes, and alternative treatments


Capacity for ConsentCapacity for Consent

• Ability of a patient to fully understand the proposed treatment, possible risks, and alternative treatments


Informed RefusalInformed Refusal

• Patient may decide to refuse one or more of the recommended assessment procedures

• Refusal may not be considered optimal choice by clinician, but patient has right to make any decision about treatment


Patient ResponsibilitiesPatient Responsibilities

• Provide accurate responses on medical history

• Clinician can attempt to put patient at ease when filling out medical history

• Patient may need to reveal private or potentially embarassing medical details


Information-Gathering Phase of the Medical History Assessment

Information-Gathering Phase of the Medical History Assessment


Information-Gathering PhaseInformation-Gathering Phase

• A methodical plan for information gathering and review

• The goal is to obtain complete information about the patient’s past and present medical conditions/diseases and medications.

• A verbal interview provides an opportunity to clarify information and ask follow-up questions about information on the written questionnaire.


Information-Gathering Phase (cont.)Information-Gathering Phase (cont.)

• Thoroughly read the form completed by the patient.

• Prioritize. Pain takes priority.

• Research the patient’s medical conditions and diseases.

• Research the patient’s prescription and OTC drugs.

• Formulate questions to ask patient for additional info.

• Interview patient and ask questions to clarify info.

• Consult with patient’s physician, if appropriate.


Medical Alert BoxMedical Alert Box

The Medical Alert Box on the patient record brings attention to something that would require modifications to dental treatment.


What Goes in the Box?What Goes in the Box?

Any medical condition or disease that:

• Alters dental treatment

• Alters drugs used during the course of dental treatment

• Places the patient at risk for a medical emergency

• Could result in postoperative complications


Determination of the Medical Risks of Dental Treatment

Determination of the Medical Risks of Dental Treatment


The information gathered from the patient

and the clinician’s research on the patient’s medical conditions and medications

are used to determine the need for precautionary measures before or during dental treatment.

The information gathered from the patient

and the clinician’s research on the patient’s medical conditions and medications

are used to determine the need for precautionary measures before or during dental treatment.


American Society of Anesthesiologists American Society of Anesthesiologists

• The American Society of Anesthesiologists (ASA) is one of the pioneers in the field of patient safety in medicine.

• The ASA status of the patient is used to determine the patient’s level of medical risk during dental treatment.


ASA Classification LevelsASA Classification Levels

• ASA 1—Normal

• ASA 2—Mild disease, anxious

• ASA 3—Severe systemic disease

• ASA 4—Severe systemic disease that is a constant threat to life


ASA Level 1 Health StatusASA Level 1 Health Status

• A normal healthy patient

• In addition to being healthy, an ASA 1 patient must have little or no anxiety about dental treatment.


ASA 1 Modifications for Safe CareASA 1 Modifications for Safe Care

• ASA 1 is a green flaggreen flag for dental treatment

• No treatment modifications are necessary



• A patient with mildmild systemic disease

• Or a patient who is healthy but who is anxious or fearful of dental treatment

• Examples: well-controlledwell-controlled diabetes, epilepsy, or asthma



• Yellow flagYellow flag for dental treatment

• Employ stress-reduction strategies



• A patient with severesevere systemic disease that limits activity

• Examples: angina, stroke, heart attack, congestive heart failure



• Yellow flagYellow flag for dental treatment

• Employ stress-reduction strategies

• Treatment modifications are neededTreatment modifications are needed, such as antibiotic premedication



• A patient with severesevere systemic disease that is a constant threat to lifeconstant threat to life

• Examples: heart attack or stroke within the past 6 months



• Red flagRed flag for dental treatment at the current time

• ElectiveElective dental care should be postponed until the patient’s medical condition has improved to at least an ASA 3 classification.

• EmergencyEmergency dental care in a hospital dentistry setting


Consultation with a PhysicianConsultation with a Physician


Medical ConsultationMedical Consultation

• A consultation is simply a request for additional

information and/or advice about the medical implications

of dental treatment.


Physician’s ConsultPhysician’s Consult

• If there is any question or doubt, consult the patient’s physician

• Request additional information

• Request advice about procedures

• Written requestWritten request and reply is ideal


Written RequestWritten Request

• State medical condition

• Explain planned dental treatment

• Request additional information

• Include patient-signed release-of-information form

• Include dentist’s signature, address, phone and fax numbers


CautionCaution

• Remember, a physician is a medical expertmedical expert who may

have little knowledge about dental procedures.


Explain Planned TreatmentExplain Planned Treatment

• Explain to physician:

– Procedures planned

– Length of time for appointment

– Specify surgical procedures (including periodontal débridement)

– Amount of anticipated blood loss

– Possible complications

– Medications or anesthetics that will be used


Patient’s SignaturePatient’s Signature

• The patient must grant written consent for the physician

to release information about the patient’s medical

conditions.


Written RequestWritten Request

• The consult should be in triplicate:

– Clinic copy for patient’s chart

– Patient’s copy

– Copy faxed to physician


In Writing or Over the Phone?

• Telephone conversations do not hold up in court.

• If the initial request or discussion occurs over the phone, always follow up in writing.


Stress Reduction Protocol for Anxious Patients

Stress Reduction Protocol for Anxious Patients


An upcoming dental appointment causes considerable anxiety and stress for some patients.

For anxious patients, stress-reduction strategies are recommended.

An upcoming dental appointment causes considerable anxiety and stress for some patients.

For anxious patients, stress-reduction strategies are recommended.


Overview: Strategies for Stress ReductionOverview: Strategies for Stress Reduction

1. Good communication

2. Reduce anxiety

3. Scheduling

4. Suggestions for patient

5. Length of treatment

6. Pain control


Strategy 1: Good Communication Strategy 1: Good Communication

• Use empathy and effective communication to establish

trust and determine the cause(s) of the patient’s anxiety.


Strategy 2: Reduce AnxietyStrategy 2: Reduce Anxiety

• Premedicate as needed with an anti-anxiety medication use:

– The night before appointment to help patient get a good night’s sleep

– The day of the appointment to keep patient calm


Strategy 3: SchedulingStrategy 3: Scheduling

• Schedule appointments early in the day (so that patient

will not have all day to worry about the upcoming

treatment).


Strategy 4: Suggestions for PatientStrategy 4: Suggestions for Patient

• Suggest patient eat a normal meal before appointment,

and allow ample time to get to dental office


Strategy 5: Length of TreatmentStrategy 5: Length of Treatment

• Keep appointments short to avoid stressing the patient.


Strategy 6: Pain ControlStrategy 6: Pain Control

• Ensure good pain control beforebefore, duringduring, and afterafter the appointment.

• Good pain management includes, as appropriate, the use of pain medications, local anesthesia, and/or nitrous oxide sedation.


Recap: Medical HistoryRecap: Medical History

• Systemic disease may have oral implications.

• Systemic conditions may require certain precautions prior to dental treatment.

• Multilanguage health history forms are helpful in obtaining accurate information from a patient who does not speak or read English.

• A verbal interview provides an opportunity to clarify information and ask follow-up questions about information on the written questionnaire.


Recap: Medical History (cont.)Recap: Medical History (cont.)

• The patient’s ASA status is used to determine the patient’s level of medical risk during dental treatment.

• A medical consultation is a request for additional information and/or advice about the medical implications of dental treatment.

• Stress-reduction strategies are recommended for anxious patients.

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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Module 4: Medical History