Do you easily bruise or bleed? When was the condition diagnosed?
Are you receiving medical therapy for the condition?
What do you do to stop bleeding?
Have you required a blood transfusion? If yes, when?
Purpose and Implications for Professional Care:
Monitor for increased bleeding and reduced healing.
Determine the cause of the condition and manage as needed.
Identify risk for increased bleeding or hemorrhage.
28. Mental Health Problems
Relevant Questions:
Have you sought help from a mental health professional in the past? Are you currently being treated for any condition?
What medications are you taking?
Purpose and Implications for Professional Care:
Show concern and try to encourage self-interest in a healthy oral cavity.
Identify the need to initiate stress-reduction protocols.
Investigate medication side effects; xerostomia is common.
Identify emotional issues that may complicate oral care and patient self-care.
29. Cancer, Tumors, Growths, or Persistent Swollen Glands
Relevant Questions:
Have you ever been diagnosed with cancer? What type of cancer?
What treatments have you been receiving?
What is your current white blood cell count?
Purpose and Implications for Professional Care:
Chemotherapy often reduces the number of white blood cells; medical consultation is needed to establish the time when the patient can receive oral care while undergoing chemotherapy.
For oral malignancy, monitor tissues during every maintenance appointment for a new lesion or recurrence.
Investigate drug therapy for relevant side effects (e.g., mucositis, ulceration, xerostomia).
Identify any malignant disease and the need for an examination for recurrence at maintenance appointments.
30. Tumor or Growth
Relevant Questions:
What type of tumor did you have?
What treatment did you receive (e.g., surgery, radiation, chemotherapy)?
What was the outcome? Did you develop oral complications? Describe them.
Purpose and Implications for Professional Care:
Determine the cause and treatment success and manage as needed.
For radiation-induced xerostomia, consider salivary substitutes or oral lubricating products.
Monitor for oral effects, depending on the therapy received.
Identify the patient with a history of malignancy or neoplastic disease.
31. Liver Disease
Relevant Questions:
Do you know of any problems with your liver?
If hepatitis B virus (HBV): Are you being treated with antiviral agents? Are you contagious?
Do you bleed for a long time after a cut?
Purpose and Implications for Professional Care:
Determine etiology.
Liver disease may increase bleeding risk.
All practitioners should have immunity to HBV from a vaccine that is verified by a blood test.
Take care to avoid an injury that may compromise the standard precaution of gloves.
If a puncture occurs, immediately seek medical evaluation for recommended therapy.
Determine whether blood-borne transmission of a viral condition exists.
32. Allergic Reactions
Relevant Questions:
What type of reaction did you have? Describe it.
What antibiotic can you take?
Purpose and Implications for Professional Care:
Determine whether increased bleeding is probable.
New legislation gives some prescribing abilities to dental hygienists. Medications or over-the-counter products to which an allergy has occurred should not be recommended or provided to the patient.
Determine whether a reaction was a hypersensitivity reaction or a side effect.
Identify the allergies relevant to products used in dentistry.
Indicate the medications that should not be prescribed or products that should not be used in oral care.
Latex: Select nonlatex gloves, prophy cup, or other product; cover the arm with a barrier before placing the blood pressure cuff.
33. Serious Event Associated with a Previous Dental Treatment
Relevant Questions:
Have you had a serious event associated with a previous dental treatment?
What happened?
How can it be prevented today?
Purpose and Implications for Professional Care:
Investigate the event and institute procedures to prevent it.
For anxious patients, talking about their interests to keep the current treatment "off their mind" may reduce anxiety.
Identify the patient who may be at increased risk for syncope or other emergencies.
34. Disease, Condition, or Problem Not Previously Listed
Relevant Questions:
Do you have a disease, condition, or problem not previously listed that is important?
What is the condition?
Have you received medical treatment? What was the outcome?
Purpose and Implications for Professional Care:
Determine the cause of the condition and manage as needed.
Identify any condition not included on the history form.
35. Contact Lenses
Relevant Questions:
Are you wearing contact lenses?
Do you want to take your contact lenses out before treatment?
Purpose and Implications for Professional Care:
Consider the possibility of introducing an aerosol irritant to the eyes. Wearing protective eyewear is the standard of care, but prophylaxis paste spatter may cause irritation in some cases.
Identify special considerations, remove lenses, and provide protective eyewear.
36. Tobacco Use
Relevant Questions:
Do you use or have you ever used tobacco? If so, what type? For how many years?
How much tobacco did you use each day? If you stopped, how long ago did you stop?
How do you feel about stopping smoking?
If you are contemplating or are ready to quit, would you like information on local tobacco cessation programs?
Purpose and Implications for Professional Care:
Offer information on local counseling programs for tobacco cessation.
Counsel that nicotine replacement drugs may be available from physicians or from dentists in some practices.
Regardless of the interest in quitting, encourage tobacco cessation to avoid lung, cardiovascular, and oral cancer conditions.
Identify the issues for tobacco cessation programs.
37. Alcohol and Substance Use and Abuse
Relevant Questions:
How often do you drink alcohol? How much do you drink? Has your drinking ever been a problem?
Do you have any problems with your liver?
When was your last drink?
Do you use recreational drugs? Do you use cocaine? How do you use it and when was your last use?
Purpose and Implications for Professional Care:
Do not recommend mouthrinse with alcohol to a patient who is a recovering alcoholic.
Withdrawal of alcohol in an alcohol-dependent patient can precipitate a seizure.
Vasoconstrictors (epinephrine) are contraindicated when cocaine has been used within the past 24 hours.
Cocaine use increases the risk for stroke and cardiac arrhythmias.
Identify the alcohol or substance abusing patient.
Identify cocaine interaction with a vasoconstrictor.
38. X-Rays or Ionizing Radiation
Relevant Questions:
Are you employed in a facility that regularly exposes you to x-rays or ionizing radiation? Do you have regular assessments to determine your level of ionizing radiation exposure?
Can we take dental x-rays if they are necessary?
Purpose and Implications for Professional Care:
Consider whether there is a need to avoid or limit dental x-ray exposure. Identify the need for reducing patient exposure to ionizing radiation.
39. Pregnancy
Relevant Questions:
Are you pregnant? If yes, when is your due date?
Purpose and Implications for Professional Care:
Radiographs can be taken during pregnancy using standard precautions.
The second trimester is the preferred time for elective oral care.
During the third trimester, to avoid supine hypotension, place a pillow under the right hip and rotate the abdomen to the left to avoid compression of the vena cava. Identify the time for an appointment plan.
40. Menstruation
Relevant Questions:
Do you have problems with menstrual periods? If yes, what are the problems? What do you do about them?
Purpose and Implications for Professional Care:
Determine the cause and manage as needed. Identify hormone imbalance.
41. Nursing
Relevant Questions:
Are you nursing? Can we schedule your appointment after your nursing time?
Purpose and Implications for Professional Care:
Schedule an appointment as directed by the patient. Identify an appointment planning schedule.
42. Birth Control
Relevant Questions:
Are you taking birth control pills? Do your gums bleed more since you started taking them?
Purpose and Implications for Professional Care:
Monitor patient blood pressure: there is a risk for increased values when hormones are taken.
Avoid antibiotics or use an additional birth control method when taking antibiotics.
Strict biofilm control is useful. Identify potential side effects relevant to oral care.
43. Hormone Replacement Therapy
Relevant Questions:
Are you experiencing any side effects?
Do you have hot flashes or signs of menopause?
Are you taking hormone replacement therapy?
Purpose and Implications for Professional Care:
Monitor the patient's vital signs and identify the increased risk for cardiovascular complications. Identify issues involving hormone replacement therapy.
44. Risk for Osteonecrosis
Relevant Questions:
Have you had a bone density test? If so, what was the result?
Have you been diagnosed with osteopenia or osteoporosis?
How long have you taken antiresorptive agents?
Which agent were or are you taking? Have you ever taken bisphosphonates or denosumab? Was it taken orally or intravenously?
Purpose and Implications for Professional Care:
Provide patient information on the small risk of osteonecrosis of the jaw when oral agents are taken for 3 or more years or with intravenous bisphosphonates taken for 10 months or longer.
Examine oral cavity for signs of osteonecrosis affecting the bone of the jaws.
Identify the patient at risk for osteonecrosis of the jaw.
CHAPTER 13: Legal and Ethical Issues Related to the Health History
ADHA and CDHA publish codes of ethics governed by public health statutes.
Public health statutes may identify responsibilities such as mandatory reporting of abuse and neglect, domestic violence, and infectious diseases.
Confidentiality relating to the patient's health history is protected by HIPAA.