Medical and Dental Histories

HIPAA

• The Health Insurance Portability & Accountability Act

• Standards for protecting sensitive patient data.

• Medical records must be kept under lock and key and are available only on a need-to-know basis.

The Patient History

Significance:• Oral conditions reflect the general health of the

patient• Dental procedures may complicate an existing

condition• Health factors influence response to treatment such

as tissue healing

Interviewing Skills; B1, B2

• Use terms patient understand

• Use probing questions

• Ask open ended questions

• Use verbal/nonverbal signals

• Maintain eye contact

• Use proper grammar

• Use appropriate terms

Recording Information B1, B2

• Blue/black and red pen• Patient chart• All questions require a response; no blanks• All yes response require date and details in red pen• Write legibly, no erasure marks• Corrections: a single line through error, date and

initial• Patient signs at each recall• Under 18 is considered a minor, need parent

signature

Medications B4

List all prescription and non-prescription medications• Look up the medication in Lexicomp

• Record; adverse reactions associated with bleeding and dental care

• Sign on instructor list for health history check (HH)

Vital Signs B4

• Record patient’s blood pressure (18 and older)

• Systolic over diastolic

• How it was taken: RAS:

LAS:

• Factors affecting vital signs:

Fear, oral temp. exercise

Blood Pressure Screening Protocol

• Normal: below 120/80 mmHg

• Pre-hypertension: 120/80- 139/89mmHg

• Stage 1 hypertension: 140/90-159/99mmHg

• Stage 2 hypertension: above 160/100mmHg

• Inform supervising dentist

• Consult medical history for other risk factors

• Consult medications

• May require medical referral prior to treatment

• May require shorter appointment to reduce fatigue

• Retake blood pressure at subsequent appointments

• Review Blood Pressure Procedures in Clinic Manual B23-25

Medical History Considerations

Gender, ethic/racial Influences:

• American Indians and African Americans=diabetes

Allergic reactions:• Latex

Hormones:• Pregnancy, puberty,

menopause, BCP

Diseases with oral manifestations:

• Hematologic disorders• Phenytoin-induced

gingival overgrowth;• Herpes virus

Communicable diseases:• TB, hepatitis, herpes,

syphilis

Heart Conditions B5

Treatment Contraindicated:• Heart attack within last 6 months

Premedication:• Shunts• Artificial/damaged valves• Congenital heart defects• Previous endocarditis• Transplants

Pacemakers:• Shielded: may use ultrasonic

scaler• Unshielded: do not use ultrasonic

scaler

No Premedication:• Heart Murmur• Mitral valve prolapse • Stents

Requires medical clearance:• Heart surgery (bypass, open

heart) • Coronary heart disease• Congestive heart failure• Blood pressure over 140/90 ages

18-59 or 160/90 ages 60 and over

Blood Disorders B6

Leukemia: • Need medical clearance from physician stating their health

will not be compromised by having an oral prophylaxis

Hemophilia

• Patient taking blood thinner will need a medical consult before instrumentation may occur

Anemia• No special treatment indicated

Signs to watch for: spontaneous bleeds, petechiae, pallor tissues, chronic oral infections, atrophy of papillae (tongue), ulcerations, tissue sloughing, lymph node enlargements

HIV Infection/Immune Disorders B6

HIV • Date of diagnoses

• Date of last visit with physician

• Ask if immune system (T-count) can handle prophylaxis

Immune Disorders• Can patient fight off

infection?• Consult with

physician

Mononucleosis/Oral Herpes B7

Mononucleosis• Date of disease

• Treatment completed

Oral Herpes• How often does the

patient get them?• Reappoint if sore is

less than 4 days old• Keep lubricated • Avoid pressure on the

area

Kidney Disease/ Spleen Removed B7

Kidney Disease• Determine how often

and what kind of problem

• Type of treatment

Premedication needed if:

• Hemodialysis• Renal transplant• Glomerulonephritis• Inflammation

Spleen Removed

• Dates

• Patient may need medication; consult with physician

Respiratory Disease B8

Emphysema/Bronchitis• Determine triggers

• How is it controlled?

• Keep appointment short

• Seat patient upright

• May need oxygen in emergency

Asthma• Determine triggers

• Ultrasonic use OK

• How is it controlled? Inhaler?

• Keep appointment short

Sinus Problems• Determine if patient on

medications

• Ask about symptoms and frequency

Allergies/Thyroid Disease B9

Allergies• Determine if patient

on medications • Specific type of

allergy and reactions• Be aware of local

anesthetic agents

Thyroid Disease• Type of disease

• Does the patient take medication

Tuberculosis/ Persistent cough B9

• Determine if there was a positive chest x-ray or TB test

• Do not treat in clinic if active TB unless you receive medical clearance from physician

• If patient is undergoing treatment and is negative for TB, use standard precautions

• What medications are being used?

• Persistent cough may indicate TB or other respiratory disease

Swollen gland/Arthritis/Joint Replacement B10

Swollen Glands• How long have the gland

been swollen?

• What treatment has been given?

• Has patient see a doctor?

Joint Replacement • No Premedication

• Determine which joint?

Arthritis• Determine the type of

arthritis?

• What medications the patient is taking?

• May require special oral hygiene aids

Pins, screws, and plates

• No premedication

Sexually Transmitted Disease/Mental Health Problems B10

Syphilis, Gonorrhea, Chlamydia• Type of disease

• Dates

• Treatment/Medication

• Reappoint if treatment is not complete

Eating Disorder• Type of disorder

• Dates

• Treatment

Mental Health Problems• Type of disease

• Treatment/Medication

Alcohol Drug Dependency• Determine the type

• Treatment received

• May need to alter mouthwashes and anesthesia

Epilepsy/Neurological Disorder B10

Epilepsy

• Type of seizers• Medication• Last seizure

• Avoid sudden lights/noise• Minimize stress• Short appointment• Prepare for potential

emergency

Cerebral Palsy

• Adjust patient education and oral aids

Seizures and Fainting Spells

• Determine triggers• Avoid sudden changes in

charge position• Has the patient seen a

physician?

Cancer/Radiation/Chemotherapy B11

• Type of disease?• Dates• Treatment• Stage• Physician consultation

for radiographs

• What is the treatment for?

• Which type of treatment?

• May need pre-medication?

• Physician consult

Hepatitis, Jaundice, Liver Disease B12

• Determine the type of Hepatitis: A, B,C,D,E

• Is the patient a carrier?

• Use standard precautions

• Hepatitis A and E are not carrier states; ultrasonic can be used

• Hepatitis B,C, and D have carrier states; do not use ultrasonic scaler

• Minimal amounts of anesthesia are recommended for patients with liver disease

Stents and Shunts/Organ Transplants B13

Stents• How long ago was the

stent placed?• Where is the stent?

• No premedication needed

Shunts• Where is the shunt?

Heart/Brain?• How long ago was the

shunt placed?

• Premedication needed

• Need medical clearance

Organ Transplants• Date of transplant

• Type

• Premedication needed

Medication Considerations B13

Cortisone, prednisone, steroids

• Patients immune response will be compromised

• Patient may need premedication

Cocaine• Contraindicated with local

anesthetic

Dexfenfluramine (Phen-Fen)

• Dates• Consult with physician

Diabetes and Pregnancy B14

Diabetes• If controlled, determine the

method; Medication? Diet?

• Has the patient eaten before appointment?

• Morning appointments better for insulin stability

• Cannot treat uncontrolled diabetes in clinic

• Be familiar with treatment of hypo/hyperglycemia

Pregnancy• Due Date

• No x-rays

• Ultrasonic use; do not drape cord over patients abdomen

Prophylactic Premedication

• Risk for infectious endocarditis:the extent of creating bacteremia is directly related to the degree of inflammation

• Risk factors with invasive procedures: any procedures which may cause bleeding

• Timing of ingestion of oral antibiotics: 1 hour prior to patient care) ensures adequate concentrations in the blood during, and immediately following, the actual instrumentation.

• Recommendation for class of antibiotics: administer a different class of antibiotic rather than to increase the dose of the current antibiotic.

Dental Procedures for Which Premedication Is Recommended

• Dental extractions• Periodontal

procedures

• Dental implant placement

• Orthodontic band placement

• Intraligamentary local anesthesia

• Endodontic instrumentation

• Dental hygiene care when bleeding anticipated

Procedures Deemed Not Necessary for Antibiotic Coverage

• Restorative dentistry

• Local anesthesia

• Postsurgical suture removal

• Placement of rubber dam

• Impression taking

• Fluoride treatment

• Exposing intraoral radiographs

• Orthodontic band adjustment

• Shedding of primary teeth

Dental Procedures for Which Premedication Is

Not Recommended

ASA Determination

• ASA Physical Status Classification System: Medical Risk Categories I to VI– I: a normal healthy patient. IE: no smoking, no or very minimal drinking.

– II: a patient with mild systemic disease. IE: Smoker; more than minimal drinking; pregnancy; obesity; well controlled diabetes, well controlled hypertension; mild lung disease.

– III: a patient with severe systemic disease not incapacitating. IE: Diabetes, poorly controlled hypertension; distant history of MI, CVA, TIA, cardiac stent; COPD, ESRD; dialysis; active hepatitis; implanted pacemaker; ejection fraction below 40%; congenital metabolic abnormalities

– IV: a patient with an severe systemic disease that is a constant threat to life. IE: Recent history of MI, CVA, TIA, cardiac stent; Ongoing cardiac ischemia or severe valve dysfunction; implanted ICD; ejection fraction below 25%.

– V: A moribund patient not expected to survive. IE: Ruptured abdominal or thoracic aneurism; intracranial bleed with mass effect; ischemic bowel in the face of significant cardiac pathology..

– VI: A patient who has already been declared brain-dead and whose organs are being removed for transplant.

Review

A person’s health is not static; therefore, a health history must be updated when or how often?

A) Annually

B) At every recall appointment

C) At each and every appointment

D) At the initial appointment

Answer

C) At each and every appointment

Updating the patient’s health history at each appointment is essential for current information concerning the patient. The state of the patient’s health is constantly changing. Therefore, the history represents only the period in the patient’s life during which the history was made.

Review

Which of the following is true for the information in the patient’s health history?

A) It is confidential and must be updated annually

B) It is a legal document and must be written in pencil to allow for changes

C) It is to be written in pencil so that changes may be made and provide a specific line for the signature of the patient

D) It is a confidential and legal document to be handwritten in permanent ink

E) A minor must sign the informed consent form also

Answer

D) It is a confidential and legal document to be handwritten in permanent ink

The patient record is to be dated at every entry; if handwritten, use permanent ink; and provide a specific line on a health history form for the signature of the patient. The completed history for a minor must be signed by a parent or guardian. A signature is also needed on the informed consent form. All information obtained for a patient history must be maintained in strictest privacy.