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Medical dental-history-160217193637
- 1. Medical and Dental Histories
- 2. 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.
- 3. 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
- 4. 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
- 5. 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
- 6. 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)
- 7. 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
- 8. 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
- 9. 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
- 10. 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
- 11. 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
- 12. HIV Infection/Immune Disorders B6 HIV • Date of diagnoses • Date of last visit with physician • Ask if immune system (T-count) can handle prophylaxis • No ultrasonic use Immune Disorders • Can patient fight off infection? • Consult with physician
- 13. 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
- 14. 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 Spleen Removed • Dates • Patient may need medication; consult with physician
- 15. Respiratory Disease B8 Emphysema/Bronchitis • Determine triggers • How is it controlled? • Keep appointment short • Seat patient upright • May need oxygen in emergency COPD (Chronic Obstructive Pulmonary Disease • No ultrasonic use Asthma • Determine triggers • Ultrasonic use OK if controlled • How is it controlled? Inhaler? • Keep appointment short Sinus Problems • Determine if patient on medications • Ask about symptoms and frequency
- 16. 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
- 17. 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
- 18. 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 • Consult MD for premedication requirement • 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
- 19. 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
- 20. 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?
- 21. 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
- 22. 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
- 23. 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
- 24. 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
- 25. 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
- 26. 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.
- 27. 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
- 28. 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
- 29. 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, diagnosed mental health. – 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.
- 30. 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
- 31. 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.
- 32. 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
- 33. 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.
Editor's Notes
- For safe, scientific dental and dental hygiene care, a meaningful, complete patient history is an essential part of the complete assessment. The history is needed before oral examination procedures with periodontal probe and explorer are carried out. The use of instruments that would manipulate the soft tissue around the teeth is contraindicated until after it has been determined whether antibiotic premedication is required. When a question exists about the medical history as described by the patient, consultation with the patient’s physician or referral for examination of the patient who does not have a physician is mandatory.
- The significance of taking a complete and accurate patient history cannot be overestimated because oral conditions reflect the general health of the patient; dental procedures may complicate or be complicated by existing pathologic or physiologic conditions elsewhere in the body. General health factors influence response to treatment, such as tissue healing, and thereby influence the outcomes that may be expected from oral care. 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. Purposes of the history: carefully prepared personal, medical, and dental histories are used in comprehensive patient care to provide information pertinent to the etiology and diagnosis of oral conditions and the total patient care plan; reveal conditions that necessitate precautions, modifications, or adaptations during appointments to ensure that dental and dental hygiene procedures will not harm the patient and that emergency situations will be prevented; aid in the identification of possible unrecognized conditions for which the patient will be referred for further diagnosis and treatment; permit appraisal of the general health and nutritional status, which, in turn, contributes to the prognosis of success in patient care and instruction; give insight into emotional and psychological factors, attitudes, and prejudices that may affect present appointments as well as continuing care; document records for reference and comparison over a series of appointments for periodic follow-up; furnish evidence in legal matters if questions arise; identify cultural beliefs and practices that affect risk for oral disease; and determine ethnic/racial influences on risk factors for oral disease.
- Educate the patient about why the information requested in the history is essential before treatment Convey the idea that oral health and general health are interrelated To build rapport, allow children to participate in their history preparation, but most of the information will need to be supplied by a parent or legal guardian. The signature of the responsible adult is required on the record.
- Broad in scope; useful during the interview to identify positive areas that need additional clarification. Time saving. Consistent; all selected questions are included, and none is omitted because of time or other factors. Patient has time to think over the answers; not under pressure, nor under the eyes of the interviewer. Patient may write information that might not be expressed directly in an interview. Legal aspects of a written record with patient’s signature.
- Gender or ethnic/racial influences that increase risk for systemic and oral disease. Example: American Indians and African Americans have increased risk for diabetes and a related increased risk for periodontal disease. Allergic or untoward reactions. Examples: latex hypersensitivity; medication or material for which there was a previous adverse reaction. Diseases and drugs with manifestations in the mouth. Examples: hematologic disorders; phenytoin-induced gingival overgrowth; infectious diseases such as herpesvirus. Communicable diseases that endanger the dental personnel. Examples: active tuberculosis; viral hepatitis; herpes; syphilis. Physiologic state of the patient. Examples: pregnancy; puberty; menopause; birth control pills.
- When a patient is receiving radiation therapy or has had recent radiation for other purposes, a conference with the physician or oncologist involved is recommended to discuss the quantity of radiation to be received from any necessary dental radiographs. No apparent rationale exists for precluding a properly justified dental radiographic examination because of a history of radiation therapy.
- tissue manipulation that could create a bacteremia. All tissue manipulation, particularly the use of instruments subgingivally, At-risk patients already taking an antibiotic for other health conditions may require additional antibiotic prophylaxis prior to dental and dental hygiene instrumentation. The recommendation is to administer a different class of antibiotic rather than to increase the dose of the current antibiotic.
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- ASA I: a patient without apparent systemic disease: a normal healthy patient. ASA II: a patient with mild systemic disease. ASA III: a patient with severe systemic disease that limits activity but is not incapacitating. ASA IV: a patient with an incapacitating systemic disease that is a constant threat to life. ASA V: a moribund patient not expected to survive 24 hours with or without care. ASA E: emergency of any variety: precede the ASA number with E to indicate the patient’s physical status (for example, ASA E-III).