Ch11/12 Medical and Dental History – Key Vocabulary

Learning Objectives

• Understand the purpose of obtaining a comprehensive medical history before dental treatment

  • Prevent medical emergencies

  • Identify conditions requiring modifications (e.g.
    • antibiotic prophylaxis
    • stress‐reduction protocols)

• Recognize barriers to accurate history collection
  • language, literacy, embarrassment, misunderstanding, irrelevance, time

• Differentiate two main data‐collection methods
  • Questionnaire (written)
  • Interview (verbal)
  – Know characteristics, advantages, disadvantages, and why a mixed approach is often best

• Value of the chief complaint (CC)
  • First item addressed; records patient’s primary concern in their own words

• Apply ASA (American Society of Anesthesiologists) physical‐status classification to stratify systemic risk

• List essential components of a comprehensive history
  • Personal, medical, dental, psychosocial, medication, allergies, vitals

• Determine need for antibiotic prophylaxis (premed) based on health status & invasive procedure list

• Define & relate bacteremia and infective endocarditis (IE) to dentistry

• Memorize current adult premedication regimens
  • Standard: $2\,\text{g}$ amoxicillin $30{-}60\,\text{min}$ before procedure

• Distinguish sign, symptom, subjective vs. objective findings

• Complete and document history per UTHSCSA protocol (EPIC + SOAP)

Pre-Appointment Protocol

• Wash hands → Don all PPE → Disinfect operatory → Apply barriers → Run water lines $2$ min → Set up SOAP note

• Review prior notes, medical history, radiographs, exams

• Remove PPE → Team huddle

Seating the Patient

• Check-in at front desk (Liz)

• Observe physical characteristics on entry

• Patient hand hygiene (≥$20$ s) & preoperative rinse ($60$ s antimicrobial)

• Open EPIC chart; begin “Rooming” workflow

Dental Hygiene Process of Care (DHPOC)

• Assess → Diagnose → Plan → Implement → Evaluate → Document

• In room:
  • Don PPE
  • Obtain vitals (BP, HR, RR, Temp)
  • Conduct full medical-history interview & medication reconciliation
  • Enter data into EPIC Rooming tabs
  • Faculty must approve history before ANY intra-oral procedure

Purpose & Significance of History Taking

• Correlates systemic conditions with oral findings; informs differential diagnosis & treatment plan

• Offers insight into psychosocial factors (anxiety, compliance, lifestyle)

• Identifies unrecognized, untreated, or emerging medical problems

• Documents baseline for future comparison; provides medico-legal evidence

Frequency of Updates

• Full health history at first visit & every 12 months thereafter

• Interim update at every appointment—even if the last visit was “yesterday”

History-Collection Methods

Questionnaire (Self-History)

• Broad scope, time-efficient, standardized, legal value

• Limitations: impersonal, inflexible, literacy/language issues, misunderstandings

Interview

• Primary method in UTHSA clinic (guided by EPIC prompts)

• Setting: private, quiet, patient upright, eye level, culturally sensitive

• Advantages: rapport, clarification, flexibility, ability to observe non-verbal cues

• Drawbacks: time, potential omissions, patient embarrassment

Privacy & HIPAA Reminder

• All information is confidential; share only with supervising faculty

• Access only charts for patients you are directly treating

Common Barriers / Limitations

• Misinterpretation of questions

• Language differences or low literacy

• Perceived irrelevance by patient

• Embarrassment about sensitive topics

Preventing Medical Emergencies

• Primary reason to collect history

• Determine:
  • ability to tolerate stress
  • need for premed
  • need for medical consult
  • modifications in chair position, anesthesia, appointment length

History Components

Dental History

• Chief complaint (record verbatim)

• Previous treatments: periodontal therapy, surgeries, extractions, implants, orthodontics, trauma, prostheses

• Caries Risk Assessment (CRA)

Medical History

• Personal data (age, contact, PCP/specialists)

• Systemic diseases & conditions, hospitalizations, surgeries

• Current medications (drug, dose, purpose, oral effects, LA/vasoconstrictor precautions)

• Allergies & adverse reactions (drug, latex, foods)

• Requirement for antibiotic prophylaxis

• Psychosocial factors (tobacco, alcohol, recreational drugs, diet)

• Vital signs & baseline readings

Dental Management Considerations (Examples)

• Back/neck pain → modify chair position

• Multiple xerogenic meds → salivary substitutes, fluoride, short appts

• \text{BP}>160/100 mmHg → stress reduction, gradual chair changes

• Diabetes → early morning appts, ensure food intake, monitor glucose

• Diuretics → schedule bathroom breaks

• Tobacco/alcohol → heightened oral-cancer screening

“Items for the Medical History” Table Highlights (Wilkins Table 11-2)

• Bleeding disorders / anticoagulants → lab tests, hemostatic measures

• Cancer/radiation/chemotherapy → xerostomia, osteonecrosis risk, fluoride

• Cardiovascular diseases (angina, HTN, pacemaker) → limit epi, stress control, semi-supine positioning

• Congenital heart disease / history of IE → potential antibiotic prophylaxis

Diabetes-Specific Questions (Every Visit)

• Last meal? What?

• Last dose of medication? Time?

• Blood glucose today? Value? Time?

• History of hypoglycemic episodes?

• Latest $\text{HbA1c}$?

ASA Physical-Status Classification (Adults)

• ASA I: normal healthy; tolerate $\ge1$ flight of stairs w/o distress

• ASA II: mild systemic disease or extreme dental anxiety; e.g.
  • controlled Type II DM, pregnancy, well-controlled asthma, healthy >60 y, BP $140{-}159/90{-}94$ mmHg

• ASA III: severe systemic disease limiting activity; can climb stairs but must stop
  • stable angina, uncontrolled Type I DM, post-MI >6 mo, COPD, BP $160{-}199/95{-}114$ mmHg

• ASA IV: disease that is constant threat to life; unable to climb stairs
  • unstable angina, MI within <6 mo, BP $\ge200/\ge115$ mmHg

• ASA V/VI seldom seen in outpatient dentistry

Bacteremia & Infective Endocarditis (IE)

• Bacteremia = presence of bacteria in bloodstream (transient after scaling, extraction)

• IE = bacterial infection of endocardium or heart valves; high morbidity/mortality

• Goal of prophylaxis: reduce magnitude of procedure-induced bacteremia in high-risk patients

Antibiotic Prophylaxis

Candidates (2021 AHA/SADA)

• Prosthetic heart valves or material

• Previous IE

• Specific congenital heart disease (unrepaired cyanotic, repaired <6 mo, repaired with residual defects)

• Cardiac transplant with valvulopathy

• Orthopedic prostheses: NOT routinely indicated; consider only if prior complications—consult surgeon.
  – UTHSA policy: premed for artificial joints during first $2$ yrs post-op unless surgeon states otherwise

Dental Procedures Requiring Premed (Box 11-2)

• Manipulation of gingival tissue (scaling, probing)

• Procedures at tooth apex (root canal)

• Oral-mucosal perforation (surgery, biopsy)
  NOT required for:
  • local anesthesia injections in healthy tissue
  • radiographs
  • ortho appliances, bracket placement
  • shedding primary teeth, trauma to lips/cheeks

Regimens (2021)

• Standard adult oral: $2\,\text{g}$ amoxicillin $30{-}60\,\text{min}$ prior

• Cannot take oral: $2\,\text{g}$ ampicillin IV/IM or $1\,\text{g}$ cefazolin/ceftriaxone IV/IM

• Pen-allergic oral:
  • $2\,\text{g}$ cephalexin OR $600\,\text{mg}$ clindamycin OR $500\,\text{mg}$ azithromycin/clarithromycin OR $100\,\text{mg}$ doxycycline

• Pen-allergic & NPO: $1\,\text{g}$ cefazolin/ceftriaxone or $600\,\text{mg}$ clindamycin IV/IM

• Single dose only; no second dose post-op

• Consider antibiotic resistance & anaphylaxis risk; very small percentage of IE is actually prevented

After Completing History

• Compose detailed SOAP note
  • S: Chief complaint (patient quote)
  • O: Vitals, clinical observations
  • A: Risk assessment, ASA, need for consult/premed
  • P: Planned interventions, patient education

• Instructor must review and sign history & SOAP; patient signs documentation

SOAP Note Examples (New vs. Return)

• Include student, faculty, dentist names, operatory #, CC, med hx summary, allergies, meds, dental hx, vitals, management recommendations, approval signature

• Return visit: document changes, new medications, updated vitals

Updating Returning Patients

• At every visit: direct questions re interim illnesses, physician visits, lab tests, med changes, soft-tissue changes

• Full medical history re-entered yearly

EPIC Workflow Highlights

• Desktop icons: “Epic UT-Prod”, “Epic Read-Only”

• Tabs: Rooming → Allergies → Medication Review → Dental Vitals → History

• Must complete “Rooming” tasks before faculty approval

• Soft Tissue & Tooth Chart sections for EO/IO findings

• Use SnapShot, MyChart, BestPractice advisories for alerts

• Chart color coding (green team vs. blue team) & chair assignments

• Functions: Add procedures, findings, allergies, medications; verify pharmacy benefits; print AVS; sign visit

Medical Consults & Referrals

• Obtain written clearance for conditions outside dental scope, e.g.
  • recent MI/CVA, unstable angina, bleeding disorders, chemotherapy

• Telephone screening prior to appointment: capture surgeon/PCP names, drug lists, clarify need for premed

Drug Information Sheet (Clinic Form)

• For each medication:
  • Indication
  • LA/vasoconstrictor precautions
  • Systemic side effects relevant to dentistry
  • Dental considerations (xerostomia, bleeding, taste changes)

Ethical & Legal Considerations

• Accurate documentation can become evidence in legal disputes

• Failure to review history or obtain required premed may constitute negligence

• Respect patient autonomy & cultural beliefs; employ interpreters when required

Review / Exam Pointers

• MAIN purpose of medical history: patient safety & emergency prevention

• Collection method in clinic: verbal interview using EPIC prompts, augmented by annual questionnaire

• Chief complaint guides immediate priorities, builds rapport, affects coding & treatment planning

• ASA classification helps predict stress tolerance & guides appointment modifications

• Antibiotic prophylaxis: memorize high‐risk cardiac conditions & $2\,\text{g}$ amoxicillin adult protocol

Reminders for Clinical Practice

• Pre-screen by phone; if premed indicated, obtain MD prescription or write one per guidelines

• No intra-oral procedure until faculty signs off med-history check

• Update vitals after clearance; proceed with DHPOC

• Continually evaluate effectiveness of care and update documentation