Module 4: Medical History
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Topic Overview: Medical History
• How does the medical history protect the patient’s
health?
• How can we obtain a medical history from a non-Englishspeaking 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?
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Medical History Assessment
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There is a strong two-way relationship
between systemic health and oral conditions.
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Relationship 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
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Health History Forms
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Medical History Forms
• Used to gather subjective data about the patient’s:
– Past health problems
– Present health problems
– Medications
• Many different formats and lengths
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Multicultural 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
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Multilanguage 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
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Informed Consent and the Medical History
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Informed 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
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Capacity for Consent
• Ability of a patient to fully understand the proposed
treatment, possible risks, and alternative treatments
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Informed 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
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Patient 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
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Information-Gathering Phase
of the Medical History Assessment
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Information-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.
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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.
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Medical Alert Box
The Medical Alert Box on the patient record brings
attention to something that would require modifications to
dental treatment.
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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
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Determination of the Medical Risks
of Dental Treatment
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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.
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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.
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ASA 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
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ASA 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.
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ASA 1 Modifications for Safe Care
• ASA 1 is a green flag for dental treatment
• No treatment modifications are necessary
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ASA Level 2 Health Status
• A patient with mild systemic disease
• Or a patient who is healthy but who is anxious or fearful
of dental treatment
• Examples: well-controlled diabetes, epilepsy, or
asthma
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ASA 2 Modifications for Safe Care
• Yellow flag for dental treatment
• Employ stress-reduction strategies
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ASA Level 3 Health Status
• A patient with severe systemic disease that limits
activity
• Examples: angina, stroke, heart attack, congestive heart
failure
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ASA 3 Modifications for Safe Care
• Yellow flag for dental treatment
• Employ stress-reduction strategies
• Treatment modifications are needed, such as
antibiotic premedication
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ASA Level 4 Health Status
• A patient with severe systemic disease that is a
constant threat to life
• Examples: heart attack or stroke within the past 6
months
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ASA 4 Modifications for Safe Care
• Red flag for dental treatment at the current time
• Elective dental care should be postponed until the
patient’s medical condition has improved to at least an
ASA 3 classification.
• Emergency dental care in a hospital dentistry setting
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Consultation with a Physician
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Medical Consultation
• A consultation is simply a request for additional
information and/or advice about the medical implications
of dental treatment.
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Physician’s Consult
• If there is any question or doubt, consult the patient’s
physician
• Request additional information
• Request advice about procedures
• Written request and reply is ideal
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Written 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
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Caution
• Remember, a physician is a medical expert who may
have little knowledge about dental procedures.
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Explain 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
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Patient’s Signature
• The patient must grant written consent for the physician
to release information about the patient’s medical
conditions.
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Written Request
• The consult should be in triplicate:
– Clinic copy for patient’s chart
– Patient’s copy
– Copy faxed to physician
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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.
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Stress Reduction Protocol
for Anxious Patients
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An upcoming dental appointment causes
considerable anxiety and stress for some
patients.
For anxious patients, stress-reduction
strategies are recommended.
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Overview: Strategies for Stress Reduction
1. Good communication
2. Reduce anxiety
3. Scheduling
4. Suggestions for patient
5. Length of treatment
6. Pain control
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Strategy 1: Good Communication
• Use empathy and effective communication to establish
trust and determine the cause(s) of the patient’s anxiety.
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Strategy 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
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Strategy 3: Scheduling
• Schedule appointments early in the day (so that patient
will not have all day to worry about the upcoming
treatment).
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Strategy 4: Suggestions for Patient
• Suggest patient eat a normal meal before appointment,
and allow ample time to get to dental office
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Strategy 5: Length of Treatment
• Keep appointments short to avoid stressing the patient.
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Strategy 6: Pain Control
• Ensure good pain control before, during, and after the
appointment.
• Good pain management includes, as appropriate, the use
of pain medications, local anesthesia, and/or nitrous
oxide sedation.
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Recap: 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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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.
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
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