Ch11/12 Medical and Dental History – Key Vocabulary

A set of vocabulary flashcards covering essential terms, concepts, and protocols related to taking and using medical and dental histories in clinical practice.

Medical History (Dental)

A comprehensive record of a patient’s past and current systemic conditions, medications, allergies, and psychosocial factors used to guide safe dental treatment.

Chief Complaint

The primary reason the patient seeks care, recorded in the patient’s own words and addressed first during treatment planning.

ASA Classification

American Society of Anesthesiologists system that categorizes patients’ physical status (I–VI) to estimate medical risk during dental care.

ASA I

A normal, healthy patient with no systemic disease; tolerates routine dental stress without limitations.

ASA II

A patient with mild systemic disease or significant anxiety (e.g., well-controlled hypertension, pregnancy); minimal treatment modifications needed.

ASA III

A patient with severe systemic disease that limits activity but is not incapacitating (e.g., stable angina, post-MI > 6 months).

ASA IV

A patient with severe systemic disease that is a constant threat to life (e.g., MI within 6 months, unstable angina).

Bacteremia

The presence of bacteria in the bloodstream, often occurring after invasive dental procedures.

Infective Endocarditis (IE)

Life-threatening infection of the endocardium that can develop from bacteremia; prevention is a focus of antibiotic prophylaxis.

Antibiotic Prophylaxis (Premedication)

Single-dose antibiotic regimen taken 30-60 minutes before certain dental procedures to reduce bacteremia in high-risk patients.

Standard Adult Premedication Dose

2 g of amoxicillin taken orally 30–60 minutes before the dental procedure (2021 AHA guideline).

Questionnaire (Health History)

Written form completed by the patient to collect health information; broad, consistent, time-saving but impersonal and inflexible.

Interview (Health History)

Face-to-face verbal method of gathering health data that builds rapport and allows clarification; time-consuming and may omit items.

Bacteremia-Prone Dental Procedures

Treatments manipulating gingival tissue, tooth apices, or perforating oral mucosa, such as scaling or root canals.

Non-Premed Procedures

Dental actions not requiring antibiotic prophylaxis, e.g., radiographs, local anesthesia in healthy tissue, orthodontic bracket placement.

Sign

Objective clinical finding observed by the clinician, such as swelling or elevated blood pressure.

Symptom

Subjective sensation reported by the patient, such as pain, dizziness, or sensitivity.

Subjective Data

Information obtained from the patient’s perspective, including symptoms and chief complaint.

Objective Data

Measurable clinical observations like vital signs and physical exam findings.

SOAP Note

Structured clinical documentation with Subjective, Objective, Assessment, and Plan sections.

Pre-Appointment Protocol

Steps before seating the patient: hand hygiene, PPE, room disinfection, water-line flush, record review, and huddle.

Vital Signs

Blood pressure, pulse, respiratory rate, and temperature collected to assess current physiologic status.

Medical Consult

Formal communication with a physician to obtain clearance or additional information before dental treatment.

Risk Assessment Forms (CRA)

Caries-risk assessment tools evaluating factors contributing to dental decay.

Psychosocial History

Lifestyle information—smoking, alcohol, drug use, diet, cultural beliefs—impacting oral health.

Xerostomia

Dry mouth, often medication-induced, increasing caries risk and affecting oral comfort.

Orthostatic Hypotension

Drop in blood pressure upon standing; chair should be raised slowly for patients on antihypertensives.

Diabetic Management Questions

Standard visit inquiries: last meal, medication timing, glucose reading, hypoglycemia history, recent HbA1c.

Health History Update

Reviewing and documenting changes at every visit and completing a full medical history annually.

Privacy / Confidentiality (HIPAA)

Legal obligation to protect patient health information and limit access to authorized personnel.

Bacteremia Risk Cardiac Conditions

Prosthetic valves, previous IE, select congenital heart defects, and transplant recipients—patients requiring prophylaxis.

Prosthetic Joint Premedication Policy

ADA: antibiotics generally unnecessary; consider only after surgeon consultation in patients with joint-surgery complications.

ADPIE Process

Dental hygiene care model: Assess, Diagnose, Plan, Implement, Evaluate (plus documentation).

Dental Management Considerations

Treatment modifications based on medical history, such as chair positioning for back pain or early appointments for diabetics.

Bactericidal vs. Bacteriostatic Antibiotics

Categories indicating whether a drug kills bacteria (bactericidal) or inhibits growth (bacteriostatic); guides alternative prophylaxis selection.

Clindamycin Alternative Dose

600 mg orally 30–60 minutes before procedure for penicillin-allergic adults able to take oral medication.

Health History Limitations

Barriers including language, illiteracy, misunderstanding, or embarrassment that can hinder accurate data collection.

Faculty Medical Check-In

Mandatory approval by supervising instructor before any intraoral procedure is initiated on the patient.

Electronic Health Record (Epic)

Digital system used in clinic to document medical histories, enter SOAP notes, and manage patient data.