medical dental-history-160217193637
TRANSCRIPT
![Page 1: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/1.jpg)
Medical and Dental Histories
![Page 2: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/2.jpg)
HIPAA
• The Health Insurance Portability & Accountability Act
• Standards for protecting sensitive patient data.
• Medical records must be kept under lock and key and are available only on a need-to-know basis.
![Page 3: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/3.jpg)
The Patient History
Significance:• Oral conditions reflect the general health of the
patient• Dental procedures may complicate an existing
condition• Health factors influence response to treatment such
as tissue healing
![Page 4: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/4.jpg)
Interviewing Skills; B1, B2
• Use terms patient understand• Use probing questions• Ask open ended questions• Use verbal/nonverbal signals• Maintain eye contact• Use proper grammar• Use appropriate terms
![Page 5: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/5.jpg)
Recording Information B1, B2
• Blue/black and red pen• Patient chart• All questions require a response; no blanks• All yes response require date and details in red pen• Write legibly, no erasure marks• Corrections: a single line through error, date and initial• Patient signs at each recall• Under 18 is considered a minor, need parent signature
![Page 6: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/6.jpg)
Medications B4
List all prescription and non-prescription medications• Look up the medication in Lexicomp
• Record; adverse reactions associated with bleeding and dental care
• Sign on instructor list for health history check (HH)
![Page 7: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/7.jpg)
Vital Signs B4
• Record patient’s blood pressure (18 and older)
• Systolic over diastolic• How it was taken: RAS: LAS:• Factors affecting vital signs: Fear, oral temp. exercise
![Page 8: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/8.jpg)
Blood Pressure Screening Protocol
• Normal: below 120/80 mmHg• Pre-hypertension: 120/80- 139/89mmHg• Stage 1 hypertension: 140/90-159/99mmHg• Stage 2 hypertension: above 160/100mmHg
• Inform supervising dentist• Consult medical history for other risk factors• Consult medications• May require medical referral prior to treatment• May require shorter appointment to reduce fatigue• Retake blood pressure at subsequent appointments• Review Blood Pressure Procedures in Clinic Manual B23-25
![Page 9: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/9.jpg)
Medical History Considerations
Gender, ethic/racial Influences:
• American Indians and African Americans=diabetes
Allergic reactions:• Latex
Hormones:• Pregnancy, puberty,
menopause, BCP
Diseases with oral manifestations:
• Hematologic disorders• Phenytoin-induced
gingival overgrowth;• Herpes virus
Communicable diseases:• TB, hepatitis, herpes,
syphilis
![Page 10: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/10.jpg)
Heart Conditions B5
Treatment Contraindicated:• Heart attack within last 6 months
Premedication:• Shunts• Artificial/damaged valves• Congenital heart defects• Previous endocarditis• TransplantsPacemakers:• Shielded: may use ultrasonic
scaler• Unshielded: do not use ultrasonic
scaler
No Premedication:• Heart Murmur• Mitral valve prolapse • Stents
Requires medical clearance:• Heart surgery (bypass, open
heart) • Coronary heart disease• Congestive heart failure• Blood pressure over 140/90 ages
18-59 or 160/90 ages 60 and over
![Page 11: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/11.jpg)
Blood Disorders B6
Leukemia: • Need medical clearance from physician stating their health
will not be compromised by having an oral prophylaxisHemophilia• Patient taking blood thinner will need a medical consult before
instrumentation may occurAnemia• No special treatment indicated
Signs to watch for: spontaneous bleeds, petechiae, pallor tissues, chronic oral infections, atrophy of papillae (tongue), ulcerations, tissue sloughing, lymph node enlargements
![Page 12: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/12.jpg)
HIV Infection/Immune Disorders B6
HIV • Date of diagnoses• Date of last visit with
physician• Ask if immune system
(T-count) can handle prophylaxis
• No ultrasonic use
Immune Disorders• Can patient fight off
infection?• Consult with
physician
![Page 13: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/13.jpg)
Mononucleosis/Oral Herpes B7
Mononucleosis• Date of disease• Treatment completed
Oral Herpes• How often does the
patient get them?• Reappoint if sore is
less than 4 days old• Keep lubricated • Avoid pressure on the
area
![Page 14: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/14.jpg)
Kidney Disease/ Spleen Removed B7
Kidney Disease• Determine how often and
what kind of problem• Type of treatmentPremedication needed if:• Hemodialysis• Renal transplant• Glomerulonephritis• Inflammation
Spleen Removed• Dates• Patient may need
medication; consult with physician
![Page 15: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/15.jpg)
Respiratory Disease B8
Emphysema/Bronchitis• Determine triggers• How is it controlled?• Keep appointment short• Seat patient upright• May need oxygen in
emergencyCOPD (Chronic Obstructive
Pulmonary Disease• No ultrasonic use
Asthma• Determine triggers• Ultrasonic use OK if controlled• How is it controlled? Inhaler?• Keep appointment short
Sinus Problems• Determine if patient on
medications• Ask about symptoms and
frequency
![Page 16: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/16.jpg)
Allergies/Thyroid Disease B9
Allergies• Determine if patient
on medications • Specific type of
allergy and reactions• Be aware of local
anesthetic agents
Thyroid Disease• Type of disease• Does the patient take
medication
![Page 17: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/17.jpg)
Tuberculosis/ Persistent cough B9
• Determine if there was a positive chest x-ray or TB test
• Do not treat in clinic if active TB unless you receive medical clearance from physician
• If patient is undergoing treatment and is negative for TB, use standard precautions
• What medications are being used?• Persistent cough may indicate TB or other
respiratory disease
![Page 18: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/18.jpg)
Swollen gland/Arthritis/Joint Replacement B10
Swollen Glands• How long have the gland
been swollen?• What treatment has been
given?• Has patient see a doctor?
Joint Replacement • Consult MD for
premedication requirement• Determine which joint?
Arthritis• Determine the type of
arthritis?• What medications the
patient is taking?• May require special oral
hygiene aids
Pins, screws, and plates
• No premedication
![Page 19: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/19.jpg)
Sexually Transmitted Disease/Mental Health Problems B10
Syphilis, Gonorrhea, Chlamydia• Type of disease• Dates• Treatment/Medication• Reappoint if treatment is not
completeEating Disorder• Type of disorder• Dates• Treatment
Mental Health Problems• Type of disease• Treatment/Medication
Alcohol Drug Dependency• Determine the type• Treatment received• May need to alter
mouthwashes and anesthesia
![Page 20: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/20.jpg)
Epilepsy/Neurological Disorder B10
Epilepsy• Type of seizers• Medication• Last seizure• Avoid sudden lights/noise• Minimize stress• Short appointment• Prepare for potential
emergency
Cerebral Palsy• Adjust patient education
and oral aids
Seizures and Fainting Spells
• Determine triggers• Avoid sudden changes in
charge position• Has the patient seen a
physician?
![Page 21: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/21.jpg)
Cancer/Radiation/Chemotherapy B11
• Type of disease?• Dates• Treatment• Stage• Physician consultation
for radiographs
• What is the treatment for?
• Which type of treatment?
• May need pre-medication?
• Physician consult
![Page 22: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/22.jpg)
Hepatitis, Jaundice, Liver Disease B12
• Determine the type of Hepatitis: A, B,C,D,E• Is the patient a carrier?• Use standard precautions• Hepatitis A and E are not carrier states;
ultrasonic can be used• Hepatitis B,C, and D have carrier states; do
not use ultrasonic scaler• Minimal amounts of anesthesia are
recommended for patients with liver disease
![Page 23: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/23.jpg)
Stents and Shunts/Organ Transplants B13
Stents• How long ago was the
stent placed?• Where is the stent?• No premedication needed
Shunts• Where is the shunt?
Heart/Brain?• How long ago was the shunt
placed?• Premedication needed• Need medical clearance
Organ Transplants• Date of transplant• Type• Premedication needed
![Page 24: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/24.jpg)
Medication Considerations B13
Cortisone, prednisone, steroids• Patients immune response
will be compromised• Patient may need
premedication
Cocaine• Contraindicated with local
anesthetic
Dexfenfluramine (Phen-Fen)
• Dates• Consult with physician
![Page 25: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/25.jpg)
Diabetes and Pregnancy B14
Diabetes• If controlled, determine the
method; Medication? Diet?• Has the patient eaten
before appointment?• Morning appointments
better for insulin stability• Cannot treat uncontrolled
diabetes in clinic• Be familiar with treatment of
hypo/hyperglycemia
Pregnancy• Due Date• No x-rays• Ultrasonic use; do not drape
cord over patients abdomen
![Page 26: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/26.jpg)
Prophylactic Premedication
• Risk for infectious endocarditis:the extent of creating bacteremia is directly related to the degree of inflammation
• Risk factors with invasive procedures: any procedures which may cause bleeding
• Timing of ingestion of oral antibiotics: 1 hour prior to patient care) ensures adequate concentrations in the blood during, and immediately following, the actual instrumentation.
• Recommendation for class of antibiotics: administer a different class of antibiotic rather than to increase the dose of the current antibiotic.
![Page 27: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/27.jpg)
Dental Procedures for Which Premedication Is Recommended
• Dental extractions• Periodontal
procedures• Dental implant
placement• Orthodontic band
placement
• Intraligamentary local anesthesia
• Endodontic instrumentation
• Dental hygiene care when bleeding anticipated
![Page 28: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/28.jpg)
Procedures Deemed Not Necessary for Antibiotic Coverage
• Restorative dentistry• Local anesthesia • Postsurgical suture
removal• Placement of rubber
dam• Impression taking
• Fluoride treatment• Exposing intraoral
radiographs• Orthodontic band
adjustment• Shedding of primary
teeth
Dental Procedures for Which Premedication Is
Not Recommended
![Page 29: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/29.jpg)
ASA Determination
• ASA Physical Status Classification System: Medical Risk Categories I to VI– I: a normal healthy patient. IE: no smoking, no or very minimal drinking.
– II: a patient with mild systemic disease. IE: Smoker; more than minimal drinking; pregnancy; obesity; well controlled diabetes, well controlled hypertension; mild lung disease.
– III: a patient with severe systemic disease not incapacitating. IE: Diabetes, poorly controlled hypertension; distant history of MI, CVA, TIA, cardiac stent; COPD, ESRD; dialysis; active hepatitis; implanted pacemaker; ejection fraction below 40%; congenital metabolic abnormalities, diagnosed mental health.
– IV: a patient with an severe systemic disease that is a constant threat to life. IE: Recent history of MI, CVA, TIA, cardiac stent; Ongoing cardiac ischemia or severe valve dysfunction; implanted ICD; ejection fraction below 25%.
– V: A moribund patient not expected to survive. IE: Ruptured abdominal or thoracic aneurism; intracranial bleed with mass effect; ischemic bowel in the face of significant cardiac pathology..
– VI: A patient who has already been declared brain-dead and whose organs are being removed for transplant.
![Page 30: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/30.jpg)
Review
A person’s health is not static; therefore, a health history must be updated when or how often?
A) AnnuallyB) At every recall appointmentC) At each and every appointmentD) At the initial appointment
![Page 31: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/31.jpg)
Answer
C) At each and every appointmentUpdating the patient’s health history at each
appointment is essential for current information concerning the patient. The state of the patient’s health is constantly changing. Therefore, the history represents only the period in the patient’s life during which the history was made.
![Page 32: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/32.jpg)
Review
Which of the following is true for the information in the patient’s health history?
A) It is confidential and must be updated annuallyB) It is a legal document and must be written in pencil to allow
for changesC) It is to be written in pencil so that changes may be made
and provide a specific line for the signature of the patientD) It is a confidential and legal document to be handwritten in
permanent inkE) A minor must sign the informed consent form also
![Page 33: Medical dental-history-160217193637](https://reader031.vdocuments.mx/reader031/viewer/2022022200/58aae91b1a28abc73a8b4f31/html5/thumbnails/33.jpg)
Answer
D) It is a confidential and legal document to be handwritten in permanent ink
The patient record is to be dated at every entry; if handwritten, use permanent ink; and provide a specific line on a health history form for the signature of the patient. The completed history for a minor must be signed by a parent or guardian. A signature is also needed on the informed consent form. All information obtained for a patient history must be maintained in strictest privacy.