"Are you experiencing any oral problems or concerns?"
Implications for Professional Care:
Identify the purpose of the appointment.
Address the chief complaint.
Create patient autonomy.
Build patient rapport.
Prior Dental Care:
Relevant Questions:
"When was your last dental visit?"
"What treatment was provided?"
"Were there any problems with your prior dental care?"
"Have you ever had any type of specialized dental care?"
"Do you feel anxious during dental appointments?"
Implications for Professional Care:
Establish prior dental care.
Identify specific needs.
Determine the patient's anxiety or fear, which may require the use of stress-reduction protocols.
Radiation History:
Relevant Questions:
"When was the last time you received dental x-rays? How many images were taken?"
"Have you had recent medical radiographs taken? If so, what type?"
Implications for Professional Care:
Request prior oral radiographs from the former dentist.
Limit radiographic exposure to only necessary images.
Determine medical radiation exposure.
Dental Complications:
Relevant Questions:
"Have you experienced any dental-related complications?"
"Do you have allergies to any medicines or other substances? If so, what type of reaction occurs?"
Implications for Professional Care:
Avoid dental complications, such as allergic reactions and adverse events from local anesthetics or dental products.
Patient Anxiety:
Relevant Questions:
"What causes you to fear dental treatment?"
"Have you ever taken medication to reduce your anxiety?"
"How can I help make this a more pleasant experience for you?"
Implications for Professional Care:
Evaluate patient anxiety.
Determine need for stress-reduction protocols.
Prepare for medical emergencies (e.g., syncope, hyperventilation).
Be empathetic and establish confidence and trust.
Patient Perception:
Relevant Questions:
"What do you know about oral health and entire body health?"
"Do you know it is possible to keep your teeth for the rest of your life?"
Implications for Professional Care:
Evaluate medical conditions affecting oral health, such as diabetes, infective endocarditis, and autoimmune diseases, as well as the patient's overall health status.
Adverse Events:
Relevant Questions:
"Are you experiencing pain? When did it occur and where?"
"What aggravates the pain? What improves the pain?"
Implications for Professional Care:
Conduct an oral examination with a focus on complications.
Provide recommendations for self-care and oral products to relieve discomfort.
Chewing Ability:
Relevant Questions:
"Do you have difficulty chewing or swallowing? Can you describe the experience?"
"Is it painful? Do you wear dentures? How do they fit?"
Implications for Professional Care:
Identify any difficulty chewing or swallowing that is related to ill-fitting dentures, oral appliances, missing teeth, or extensive decay.
Consider nutritional counseling and refer the patient to the dentist.
Periodontal Health:
Relevant Questions:
"Can you describe your oral hygiene habits?"
"Do your gums bleed when you brush or floss?"
"Do you have loose teeth, bad breath, or receding gums? How long have you experienced these conditions?"
"Do you understand why these situations are occurring?"
Implications for Professional Care:
Assess periodontium for systemic-related health concerns.
Assess the patient's oral health literacy and determine an education plan.
Complete a periodontal assessment for biofilm control and gingival architecture to establish oral hygiene instruction.
Determine an appropriate treatment schedule.
Oral Lesions:
Relevant Questions:
"Where are the sores located? How long have they been present?"
"Do you have any idea of their cause?"
Implications for Professional Care:
Determine the differential diagnosis or implement precautions for infectious lesions by identifying the cause (e.g., trauma, herpes virus, aphthae, leukemia, blood dyscrasia, syphilis, malignancy, medical disorders).
Determine appropriate referrals.
Assess the patient's oral health literacy and determine an education plan.
Oral Habits:
Relevant Questions:
"Do you clench or grind your teeth?"
"Does your child use a pacifier or suck his or her thumb?"
"Do you know what is causing this problem?"
Implications for Professional Care:
Determine the impact and appropriate counseling of oral habits.
Assess the patient's oral health literacy and determine an education plan.
Patient Satisfaction:
Relevant Questions:
"What causes dissatisfaction?"
"Have you considered treatment to improve the situation?"
Implications for Professional Care:
Identify conditions relating to dissatisfaction (e.g., periodontal disease, lack of regular dental care, medical problems, and developmental issues).
Determine alternative treatment options and schedules.
Facial or Oral Injuries:
Relevant Questions:
"Have you experienced any injury to your mouth or face?"
"Do you have jaw trouble or pain when opening your mouth?"
Implications for Professional Care:
Identify temporomandibular joint (TMJ) dysfunction or previous injuries.
Determine appropriate care scheduling and use of mouth props for patient comfort.
Oral Biofilm Control:
Relevant Questions:
"What type of toothpaste, toothbrush, and floss do you use? What type of oral rinses do you use?"
"Can you tell me about your oral hygiene habits?"
Implications for Professional Care:
Determine the patient's oral health habits and need for product recommendations.
Assess the patient's oral health literacy and determine an education plan.
Fluorides and Sealants:
Relevant Questions:
"Do you use fluoride products or have fluoridated water?"
"Do you want a topical fluoride treatment today?"
"Have you had sealants placed on teeth?"
Implications for Professional Care:
Assess the patient's need for caries prevention products and treatment.
Carcinogenic Diet:
Relevant Questions:
"How often do you drink sugar-sweetened beverages, coffee, or tea? How about sugar-free drinks and bottled water?"
"How often do you snack between meals or eat sweets?"
Implications for Professional Care:
Assess the patient's carcinogenic diet and determine the need for nutritional counseling.
Beliefs and Values Regarding Oral Health:
Relevant Questions:
"How important is your oral health?"
"Did you know it is possible to keep your teeth for your entire life?"
Implications for Professional Care:
Assess motivational strategies and an education plan to improve the patient's oral health beliefs and values.
Patient Health History
General Health
Determination of General Health:
Relevant Question: "How is your health?"
Purpose and Implications:
Determine whether conflicting data exists in the health history.
Investigate misunderstandings for accurate documentation and treatment planning.
Change in General Health:
Relevant Question: "Has there been any recent change in your health? What has happened?"
Purpose and Implications:
Determine whether medical consultation is warranted.
Last Physical Examination:
Relevant Questions:
"When was your last physical examination?"
"What were the results? Who performed the examination?"
Purpose and Implications:
Determine the patient's previous health history and compliance with regular medical care.
Currently Under Medical Care:
Relevant Questions:
"Do you see a physician for any ongoing illness?"
"What type of treatment are you undergoing? Are you experiencing any complications?"
Purpose and Implications:
Determine the patient's current health status, chronic health problems, risk for medical emergencies, and the need for medical consultation before initiating oral care, as well as the need for modifications to treatment planning.
Serious Illness or Hospitalization (past 5 years):
Relevant Questions:
"Have you experienced any hospitalizations or surgeries in the last 5 years? Did you experience any complications?"
"Do you take any medications because of the illness or hospitalization?"
Purpose and Implications:
Identify recent surgeries or hospitalizations and potential for antibiotic prophylaxis (e.g., cardiac valve replacement).
Determine risk of pharmacologic effect, interactions with local anesthetics, or prescribed medications.
Medical Radiation or X-ray Examination (past 5 years):
Relevant Questions:
"Have you undergone any x-ray examinations in the last 5 years? Was it diagnostic or treatment radiation?"
"Did you experience any complications from radiation therapy? If so, please describe them."
Purpose and Implications:
Determine the patient's current health status, based on the reason for radiation therapy.
Determine the need for oral care product recommendations, based on oral needs.
Limit oral radiographic exposure only to necessary images.
Identify cancer therapy or any other medical problem, such as hyperthyroidism.
Alert: Limit oral radiographic exposure.
Medications (including nonprescription agents and herbs):
Relevant Questions:
"Are you taking any medications, including nonprescription drugs or herbs?"
"Why are you taking each drug or herb, and what is the dose and frequency for each?"
"Have you noticed any side effects from each drug or herb?"
Purpose and Implications:
Identify prescriptions to investigate in a drug reference.
Identify drug effects or side effects that may influence patient management (e.g., xerostomia, bleeding, drug-influenced gingival enlargement, vital sign changes).
Consider medical conditions being pharmacologically managed and their effect on oral care (e.g., interaction with local anesthesia).
Identify current drug or herbal effects relevant to oral care.
Consider effects of each drug or herb and potential side effects relevant to oral care.
Allergies and Reactions:
Relevant Questions:
"Did you experience hives, rash, or itching or become short of breath?"
"Did you report all reactions to your physician?"
Purpose and Implications:
True allergic reactions usually involve rash, itching, or anaphylaxis (e.g., facial swelling, bronchial constriction, hypotension, shock).
Use the appropriate antibiotic from a different class if the patient is allergic to penicillin (e.g., azithromycin or cephalexin).
Avoid the offending drug and drug class when an allergy exists.
Identify any allergy to drugs and substances used in dental hygiene care.
Differentiate between a true allergic reaction and a side effect.
Medical Conditions
Cardiovascular Disease:
Relevant Questions:
"Do you have any medical problems with your heart? Tell me about the cardiac condition and when it developed."
"Has your physician told you to take antibiotics before dental treatment?"
"Did you take your antibiotic? What did you take? What dose, and how long ago did you take it?"
Purpose and Implications:
Investigate the patient's cardiac condition and current outcome (may need medical consultation).
If applicable, record the antibiotic agent, dose, and time it was administered in the patient record.
Suggests taking an appropriate antibiotic 1 hour before; if forgotten, it can be administered at the appointment or within 2 hours of the appointment.
Advise the patient to notify the dentist if fever develops within 2 weeks, as this is a sign of endocarditis.
Antibiotic prophylaxis may be indicated before any dental hygiene procedure for these cardiac conditions.
Alert: Medical consultation may be necessary.
Vascular Disease:
Relevant Questions:
"Have you experienced any medical problems with your heart or blood vessels? When? What was the outcome? Is the condition controlled? Do you take any medications for it?"
"Did you have complications from the condition or the medical therapy? Has your physician warned you about receiving dental care?"
Purpose and Implications:
Monitor patient vital signs and functional capacity to assess cardiovascular recovery.
Determine the time since the cardiovascular event and the physician's recommendations regarding dental care.
A recent event may require physician consultation.
A prior myocardial infarction (MI) requires 1 month for convalescence, and a prior stroke requires 6 months' convalescence before dental hygiene care.
Identify specific cardiac diseases.
Chest Pain (Angina):
Relevant Questions:
"Tell me more about your chest pain. When does it occur? What do you do for it? What makes the pain lessen? What makes it increase?"
"Do you have a recent prescription for nitroglycerin? When was your last attack of chest pain? What were you doing? Has it occurred at a dental appointment?"
Purpose and Implications:
Determine functional capacity and extent of damage to cardiac muscle.
Determine the risk for an anginal attack during the appointment.
Identify nitroglycerin therapy.
Ensure that nitroglycerin is available and current.
Administer sublingual nitroglycerin every 5 minutes with a maximum of 3 doses if angina occurs.
Monitor blood pressure every 5 minutes during angina management.
Record management procedure.
Identify coronary arteriosclerosis and reduced blood flow to cardiac muscle.
Alert: Increased risk for unstable angina or heart attack.
Shortness of Breath:
Relevant Questions:
"Are you ever short of breath after mild exercise or when lying down? Can you walk up a flight of stairs without stopping to rest?"
"What does your physician say about your shortness of breath or your problem walking up a flight of stairs?"
"Let me know if you begin to feel any problem as I provide treatment."
Purpose and Implications:
Adequate functional capacity to receive dental procedures includes the ability to walk a block or climb a flight of stairs without stopping.
A contraindication exists if an MI occurred less than 1 month earlier.
Pillow Use:
Relevant Questions:
"How many pillows do you need to sleep? Have you always used that number of pillows to sleep? Why do you need to be upright to sleep?"
"Have you been evaluated for heart failure?"
Purpose and Implications:
The inability to sleep in a supine position may be a sign of congestive heart failure.
Investigate whether a medical evaluation has been completed.
Stress can exacerbate heart failure; consider medical consultation and stress-reduction protocol.
"How do you control signs and symptoms of your breathing disease? What makes your respiratory disease worse? What makes it better? Do you carry a rescue inhaler?"
"When were you diagnosed? What are your asthma triggers? Can you tolerate being placed in a supine position?"
Purpose and Implications:
Determine the need for semisupine positioning.
Continuous oxygen ventilation by nasal cannula may be needed.
Avoid aerosol production.
Avoid nitrous oxide for analgesia.
A bronchodilator must be present at every appointment.
Alert: Stress may cause an acute attack.
Alert: Identify risk for a constricted airway.
Alert: Nitrous oxide-oxygen analgesia may be contraindicated in the patient with COPD.
Fainting Spells:
Relevant Questions:
"What causes you to faint? When was the last time it occurred? Have you fainted during a dental appointment?"
Purpose and Implications:
Determine the cause of the fainting and prevent its reoccurrence.
Identify risk for an emergency involving loss of consciousness.
Epilepsy or Other Neurologic Disorders:
Relevant Questions:
"Do you have a history of a seizure disorder or any problems with your nervous system? Are you taking antiseizure medication? Did you take it today?"
"What type of seizure disorder do you have? Do you know when a seizure is about to happen? When was your last seizure? Have you ever had to go to the hospital because of a prolonged seizure?"
Purpose and Implications:
Determine risk for a seizure during the oral care appointment.
Avoid flashing overhead light.
Plan for seizure management if one occurs.
Investigate side effects of seizure pharmacotherapy (e.g., drug-influenced gingival enlargement, bleeding).
Alert: Stress may cause an acute attack.
Alert: Failure to take antiseizure medication is a risk factor for recurrent seizures.
Low Blood Pressure:
Relevant Questions:
"Have you ever lost consciousness after lying down or rising from a chair? Have you consulted a physician about it?"
Purpose and Implications:
Low blood pressure may be normal for physically fit individuals.
Consider collecting supine, sitting, and standing blood pressures.
Determine risk for postural hypotension and follow the protocol to prevent it.
Alert: Risk for postural (orthostatic) hypotension and syncope is increased.
Bowel and Bladder Problems:
Relevant Questions:
"Do you have any problems with your bowel or bladder function? Which condition? How do you manage the condition?"
"Do you need to go to the restroom before we begin? Let me know if we need to stop during the appointment."
Purpose and Implications:
Determine the cause of the problem and appropriately manage care.
Assess the need for a bathroom break during the appointment.
Symptoms can be associated with various disorders (e.g., urinary tract infection, neurologic disease, AIDS, malignancy, bowel disorders, febrile illness).
Diabetes Mellitus (DM):
Relevant Questions:
"Have you been diagnosed with diabetes or prediabetes? When were you diagnosed? When was your last medical evaluation for diabetes? What was your last hemoglobin A1c value?"
"How do you manage your diabetes—by diet, exercise, and/or medication? Do you have low blood sugar (hypoglycemic) episodes? Do you use a glucose meter? What was your reading this morning? Did you eat before coming in today?"
"Have you ever been checked for diabetes? Does anyone in your family have diabetes?"
Purpose and Implications:
Controlled DM is characterized by a recent hemoglobin A1c test result of <7%.
Morning blood sugar goal: 70-130 mg/dL.
Levels >200 mg/dL should be referred for medical evaluation.
Determine risk for hypoglycemia (glucose <70 mg/dL) and keep sugar available.
Schedule appointments in the morning after a meal.
Patients with controlled diabetes are treated the same as normal healthy patients.
Uncontrolled DM may cause reduced healing and greater periodontal destruction.
Prophylactic antibiotics are not indicated.
Examine oral tissues for signs of uncontrolled DM (e.g., periodontal abscess, extensive attachment loss, fruity breath odor, candidiasis).
Monitor vital signs.
Cardiovascular disease may be present.
In case of emergency, call 911.
Alert: Risk for a hyperglycemic event is increased.
Frequent Urination or Thirst, Recent Weight Change, Slow Healing:
Relevant Questions:
"Do you have to urinate (pass water) more than six times a day? More than three times during the night? Are you thirsty much of the time? Have you had a recent weight change of more than 10 pounds? Are you slow to heal or do you get frequent infections?"
Purpose and Implications:
If the cause cannot be determined, refer for medical evaluation.
The patient may need a medical evaluation before treatment.
Alert: These are signs and symptoms of undiagnosed or uncontrolled DM.
Thyroid Problems:
Relevant Questions:
"Are you aware of any problems with your thyroid gland? Have you been diagnosed with hypothyroidism or hyperthyroidism? Are you currently being treated for a thyroid disorder? Are there any drugs that you cannot tolerate?"
Purpose and Implications:
Uncontrolled hyperthyroidism is characterized by an increased pulse rate and increased body temperature.
Uncontrolled hypothyroidism is characterized by edema, enlarged tongue, bradycardia, and hypotension.
Alert: Uncontrolled thyroid disease poses increased risk for a medical emergency.
Alert: A thyroid storm is associated with uncontrolled hyperthyroidism; monitor the patient's pulse rate and body temperature.
Arthritis, Rheumatism, or Painful Swollen Joints:
Relevant Questions:
"Do you have any problems with your joints? How does this affect your ability to perform oral self-care such as brushing and flossing? What medications do you take? What did you take today? Are you able to lie down without discomfort? When is the best time for your appointment—midmorning or afternoon? Is your jaw [temporomandibular joint (TMJ)] affected?"
Purpose and Implications:
Evaluate effects of each drug taken before the appointment.
Monitor for clotting during care; use digital pressure to achieve hemostasis during oral procedures.