Quality Resource Guide
l
Medical Health History in Dental Practice 6th Edition
3
www.metdental.com
Besides ensuring an accurate health history, using
a health history translated into a patient’s primary
language or seeking the services of an interpreter
documents a level of respect that is an important
first step in establishing appropriate patient rapport
and developing an optimal working relationship
with the patient. Importantly, while the patient may
have completed a health history questionnaire
written in his or her own language, the health
history Interview process, is also required. It is
incumbent upon the dentist to ensure that the
patient fully understood the medical meaning of
the questions in the health history questionnaire.
“Yes” responses should be fully explored and
“no” responses to crucial questions, such as
heart disease, should be verbally confirmed. The
clinician must carry on a verbal discussion with
the patient. If it appears that the patient cannot
adequately communicate to understand the health
history interview questions it is appropriate to
use an interpreter (In some states, it is legally
required that the practice provides an interpreter
if necessary).
The Pacific health history is used in this Guide
as a source to illustrate the components of a
thorough health history. Dentists should carefully
evaluate the health history form they currently
use to ensure that is up-to-date and contains the
appropriate questions/elements that will elicit signs
and symptoms of diseases and ask about specific
diseases, medical problems and medications that
are important relative to dental therapy.
Sections of the Health History
I.
General Questions
Section I is designed to elicit general information
about the patient’s health.
Specifically the last
visit with their physician, their physican’s name,
are they currently in pain, or have had any
problems with prior dental treatment.
This section
may also have an option for patients to indicate
their preferred pronoun of reference.
10
II.
Signs and Symptoms
Section II focuses on various signs and symptoms
that are indicative of medical problems. Signs are
indications of disease that can be observed by
to dental procedures. Some diseases of the heart
require antibiotic premedication to prevent the
development of bacterial endocarditis following
invasive dental procedures. Some patients with
uncontrolled hypertension or recent heart attack
may not be able to tolerate dental procedures
until their condition is controlled. Liver problems
can alter the ability of the patient to metabolize
drugs and may also predispose them to bleeding
problems. Patients in treatment for cancer may be
at risk for increased bleeding or risk of infection.
In such situations the clinician may appropriately
request laboratory tests to further evaluate risks
of treatment for the patient. The primary lab test
of interest to dentists would be a CBC (complete
blood count) with a differential. If the patient is
taking anti-coagulants or there is a concern about
bleeding for any reason then a PT, PTT, INR,
and bleeding time are appropriate.
11
Practitioners
could also request a medical consultation for
further evaluation and recommendations.
While many dental procedures have a physiological
impact they are not usually significant, unless
the patient’s physiology is also compromised
by medical conditions. Surgical procedures are
usually the most stressful and potentially risky
procedures, though for some patients prolonged
restorative procedures can also be physiologically
demanding. The dentist must be aware of potential
problems with any dental procedure and the
possible need to modify the procedure (
e.g.,
choice of anesthetic) or mitigate the physiological
impact to ensure patient safety. Depending on the
patient’s medical problem, the dentist may require
a medical consult to gain a better understanding
of the medical problems before proceeding with
dental therapy. All of the diseases, signs and
symptoms, and other questions on the health
history have, or could have, dental relevance
depending on the patient and the dental procedure
being done or medication being utilized.
IV.
Treatments
Section IV discusses medical treatments and
prosthetic devices, which can have a bearing
on dental management. A positive response to
“radiation therapy”, especially if it is in the head
the practitioner,
e.g.
swollen ankles. Symptoms
are problems associated with a disease that are
experienced by the patient, but cannot be seen
by the practitioner,
e.g
. the pain from a migraine
headache. All of the signs and symptoms listed
are associated with one or another disease. A
“yes” response to “frequent thirst” and “frequent
urination” would be a symptom and a sign,
respectively, associated with diabetes. A positive
response to “swollen ankles” can be a sign
associated with heart failure. Some of the other
signs and symptoms are less clearly associated
with a specific medical problem. For example,
“headaches” and “dizziness” could be signs
associated with several problems including
high blood pressure. Based on that, it would be
prudent for the clinician to take the patient’s blood
pressure. Also, if the headaches and dizziness
were persistent or marked, it would certainly be
appropriate for the clinician to encourage the
patient to see their physician.
No time frame is given for the patient’s problem/
complaint. Therefore, they may answer “yes” for
a sinus problem that had occurred many years
ago. This is intentional; determining the relevance
of the time frame is the responsibility of the
clinician.
Pertinent information may be missed
if the questions are restricted only to problems
that have occurred within the last year. A “yes”
response in the signs and symptoms section may
require a medical consultation in order to develop
a definitive diagnosis.
III.
Specific Diseases
Section III concentrates on specific diseases
that have been previously diagnosed.
These
problems have the greatest potential to be of
dental significance. If they have already made the
patient ill enough to send them to the physician,
and the physician has developed a diagnosis,
then these diseases are clearly having a systemic
effect.
All
of
the
diseases
listed
have
potential
ramifications
relative
to
oral
health
care.
Diseases of the heart and liver or diseases such
as diabetes and cancer may have a profound
impact on the management of the patient relative