1. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Module 4: Medical History

2. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Topic Overview: Medical History How does the medical history protect the patient’s health? How can we obtain a medical history from a non-English- speaking patient? What does the information-gathering phase involve? How do we determine the medical risks of dental care? When do we consult with a physician? How can we reduce anxiety for an anxious patient?

3. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical History Assessment

4. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins There is a strong two-way relationship between systemic health and oral conditions.

5. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Relationship Between Systemic and Oral Health Systemic disease may have oral implications. Medications produce changes in oral health. Systemic conditions may require certain precautions prior to dental treatment. Oral manifestations may need to be checked by the primary care physician. Substances or drugs used in treatment may produce an adverse reaction

6. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Health History Forms

7. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical History Forms Used to gather subjective data about the patient’s: –Past health problems –Present health problems –Medications Many different formats and lengths

8. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Multicultural Considerations Need to find a way to assess the health history of a patient who speaks another language Trained dental interpreter is ideal, but not practical Some medical history forms have identical “other language” forms

9. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Multilanguage Health History Project University of the Pacific Dental School California Dental Association MetLife Inc. The UOP health history form has been translated into more than 25 languages. Available online at http://dental.pacific.edu

10. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Informed Consent and the Medical History

11. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Informed Consent – Ethical Considerations Responsibility of clinician to provide complete and comprehensive information about assessment and treatment procedures Inform patient about expected successful outcomes and possible risks, unanticipated outcomes, and alternative treatments

12. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Capacity for Consent Ability of a patient to fully understand the proposed treatment, possible risks, and alternative treatments

13. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Informed Refusal Patient may decide to refuse one or more of the recommended assessment procedures Refusal may not be considered optimal choice by clinician, but patient has right to make any decision about treatment

14. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Responsibilities Provide accurate responses on medical history Clinician can attempt to put patient at ease when filling out medical history Patient may need to reveal private or potentially embarassing medical details

15. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Information-Gathering Phase of the Medical History Assessment

16. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Information-Gathering Phase A methodical plan for information gathering and review The goal is to obtain complete information about the patient’s past and present medical conditions/diseases and medications. A verbal interview provides an opportunity to clarify information and ask follow-up questions about information on the written questionnaire.

17. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Information-Gathering Phase (cont.) Thoroughly read the form completed by the patient. Prioritize. Pain takes priority. Research the patient’s medical conditions and diseases. Research the patient’s prescription and OTC drugs. Formulate questions to ask patient for additional info. Interview patient and ask questions to clarify info. Consult with patient’s physician, if appropriate.

18. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Alert Box The Medical Alert Box on the patient record brings attention to something that would require modifications to dental treatment.

19. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins What Goes in the Box? Any medical condition or disease that: Alters dental treatment Alters drugs used during the course of dental treatment Places the patient at risk for a medical emergency Could result in postoperative complications

20. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Determination of the Medical Risks of Dental Treatment

21. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins The information gathered from the patient and the clinician’s research on the patient’s medical conditions and medications are used to determine the need for precautionary measures before or during dental treatment.

22. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins American Society of Anesthesiologists The American Society of Anesthesiologists (ASA) is one of the pioneers in the field of patient safety in medicine. The ASA status of the patient is used to determine the patient’s level of medical risk during dental treatment.

23. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ASA Classification Levels ASA 1—Normal ASA 2—Mild disease, anxious ASA 3—Severe systemic disease ASA 4—Severe systemic disease that is a constant threat to life

24. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ASA Level 1 Health Status A normal healthy patient In addition to being healthy, an ASA 1 patient must have little or no anxiety about dental treatment.

25. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ASA 1 Modifications for Safe Care green flagASA 1 is a green flag for dental treatment No treatment modifications are necessary

26. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ASA Level 2 Health Status mildA patient with mild systemic disease Or a patient who is healthy but who is anxious or fearful of dental treatment well-controlledExamples: well-controlled diabetes, epilepsy, or asthma

27. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ASA 2 Modifications for Safe Care Yellow flagYellow flag for dental treatment Employ stress-reduction strategies

28. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ASA Level 3 Health Status severeA patient with severe systemic disease that limits activity Examples: angina, stroke, heart attack, congestive heart failure

29. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ASA 3 Modifications for Safe Care Yellow flagYellow flag for dental treatment Employ stress-reduction strategies Treatment modifications are neededTreatment modifications are needed, such as antibiotic premedication

30. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ASA Level 4 Health Status severe constant threat to lifeA patient with severe systemic disease that is a constant threat to life Examples: heart attack or stroke within the past 6 months

31. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins ASA 4 Modifications for Safe Care Red flagRed flag for dental treatment at the current time ElectiveElective dental care should be postponed until the patient’s medical condition has improved to at least an ASA 3 classification. EmergencyEmergency dental care in a hospital dentistry setting

32. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Consultation with a Physician

33. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Medical Consultation A consultation is simply a request for additional information and/or advice about the medical implications of dental treatment.

34. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Physician’s Consult If there is any question or doubt, consult the patient’s physician Request additional information Request advice about procedures Written requestWritten request and reply is ideal

35. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Written Request State medical condition Explain planned dental treatment Request additional information Include patient-signed release-of-information form Include dentist’s signature, address, phone and fax numbers

36. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Caution medical expertRemember, a physician is a medical expert who may have little knowledge about dental procedures.

37. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Explain Planned Treatment Explain to physician: –Procedures planned –Length of time for appointment –Specify surgical procedures (including periodontal débridement) –Amount of anticipated blood loss –Possible complications –Medications or anesthetics that will be used

38. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient’s Signature The patient must grant written consent for the physician to release information about the patient’s medical conditions.

39. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Written Request The consult should be in triplicate: –Clinic copy for patient’s chart –Patient’s copy –Copy faxed to physician

40. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins In Writing or Over the Phone? Telephone conversations do not hold up in court. If the initial request or discussion occurs over the phone, always follow up in writing.

41. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Stress Reduction Protocol for Anxious Patients

42. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins An upcoming dental appointment causes considerable anxiety and stress for some patients. For anxious patients, stress-reduction strategies are recommended.

43. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Overview: Strategies for Stress Reduction 1.Good communication 2.Reduce anxiety 3.Scheduling 4.Suggestions for patient 5.Length of treatment 6.Pain control

44. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strategy 1: Good Communication Use empathy and effective communication to establish trust and determine the cause(s) of the patient’s anxiety.

45. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strategy 2: Reduce Anxiety Premedicate as needed with an anti-anxiety medication use: –The night before appointment to help patient get a good night’s sleep –The day of the appointment to keep patient calm

46. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strategy 3: Scheduling Schedule appointments early in the day (so that patient will not have all day to worry about the upcoming treatment).

47. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strategy 4: Suggestions for Patient Suggest patient eat a normal meal before appointment, and allow ample time to get to dental office

48. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strategy 5: Length of Treatment Keep appointments short to avoid stressing the patient.

49. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Strategy 6: Pain Control beforeduringafterEnsure good pain control before, during, and after the appointment. Good pain management includes, as appropriate, the use of pain medications, local anesthesia, and/or nitrous oxide sedation.

50. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Recap: Medical History Systemic disease may have oral implications. Systemic conditions may require certain precautions prior to dental treatment. Multilanguage health history forms are helpful in obtaining accurate information from a patient who does not speak or read English. A verbal interview provides an opportunity to clarify information and ask follow-up questions about information on the written questionnaire.

51. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Recap: Medical History (cont.) The patient’s ASA status is used to determine the patient’s level of medical risk during dental treatment. A medical consultation is a request for additional information and/or advice about the medical implications of dental treatment. Stress-reduction strategies are recommended for anxious patients.