Essentials of Medical History- Taking in Dental Patients

DentalPractice Mark Greenwood Essentials of Medical History- Taking in Dental Patients Abstract: The starting point in the assessment and management of any patient is dependent on good history-taking. The main parts of the history-taking process well known to practitioners are the presenting complaint, the history of the presenting complaint and the current and past medical history. This paper concentrates on those aspects of the process that are particularly important to dental practitioners. Clinical Relevance: The cornerstone of safe and effective patient management lies with the history. This paper describes various aspects of history-taking and highlights important areas. Dent Update 2015; 42: 308–315 The main parts of a patient history are well presenting complaint should include the preceding event, including previous similar established. It is important that practitioners following: episodes?; follow a recognized systematic scheme When the condition/problem first started; Any associated symptoms, for example bad of enquiry to minimize the risk of missing The overall duration and progression of the taste? important information. condition, including whether it is episodic or All dental practitioners are familiar constant; Past medical history with the main components of the history- The nature and timing of any symptoms (see Generic questioning regarding taking process. The purpose of this paper is below); major systems such as the cardiovascular to revise those areas and add some context Details of any systemic signs or symptoms or respiratory systems is often the way to some of the more important aspects and (such as fever); practitioners start obtaining a medical history. provide updates where appropriate. The success or otherwise of previous Questioning should then focus on specific treatments; disorders,1 such as asthma or other respiratory Previous practitioners who have been disorders, diabetes mellitus, epilepsy, The main components of a consulted regarding the same or related hypertension or other cardiovascular problems patient history condition(s). (stroke, myocardial infarction, angina), Presenting complaint In dental practice, the presenting hepatitis or jaundice. Positive responses The presenting complaint may complaint is often pain. A generic scheme of should be followed-up by an assessment of best be expressed in the patient’s own words. questions to assess the nature and severity of a the severity of the disorder, treatments used The information presented can then be patient’s pain is shown as follows: and their efficacy. Previous problems with summarized by the clinician. Site of pain − it is useful to ask the patient the arrest of haemorrhage are worth specific to point with one finger to where the pain is enquiry. Table 1 highlights situations where worst; the arrest of haemorrhage may be affected History of presenting complaint Character, eg sharp, ache, throbbing; and implications for management. A chronological approach should Ask about severity − on a scale of 1−10, 10 The past medical history is an be used. As a minimum, the history of a being the most severe − how bad is it?; essential component of risk assessment for Does the pain radiate anywhere else?; the likelihood of a patient experiencing a Timing − was the onset sudden or gradual? medical emergency. The Resuscitation Council Mark Greenwood, PhD, MDS, FRCS − how long has the pain been present? − is (UK) provide authoritative and up-to-date FDS, FHEA, Consultant/Honorary Clinical it continuous or intermittent? − worse at any advice regarding the management of medical 2 Professor, School of Dental Sciences, particular time of day?; emergencies in dentistry. Newcastle University, Framlington Place, What makes the pain better or worse It is essential to ask about any Newcastle upon Tyne, NE2 4BW, UK. (including the use and type of medication); known allergies and, if a positive response is Is the patient aware of any relevant obtained, to enquire about the nature of such 308 DentalUpdate May 2015 DentalPractice an allergy. considerations in their management. Some of be less than 30 minutes, use 50% oxygen and At the end of this process, patients the more important ones are summarized as: avoid repeated exposure. should be allocated an American Society of The second trimester is the optimum time Anesthesiologists (ASA) classification: for treatment; Sickle cell anaemia ASA I Healthy Best where possible to avoid prescribing Sickle cell anaemia is an inherited ASA II Mild systemic disease – No drugs; haemoglobinopathy found in individuals functional limitation If prescriptions are necessary, check in the of African, Asian and Mediterranean origin. ASA III Severe systemic disease – Definite British National Formulary (BNF); In situations of lowered oxygen tension functional limitation Drugs taken by mother while breast-feeding the abnormal haemoglobin results in red ASA IV Severe disease – Constant threat to can be transferred in some cases to breast milk blood cells becoming sickle-shaped, leading life − check in the BNF; to increased blood viscosity and capillary ASA V Moribund Local anaesthetic containing adrenaline is thrombosis. It can present either as a sickle cell ASA VI Brain dead patient whose organs are acceptable; trait (heterozygous) or sickle cell anaemia itself to be removed for donor purposes. Patients who faint or feel faint should be (homozygous). This categorization is referred to in some treated in the left lateral position to avoid protocols and also facilitates communication pressure on the inferior vena cava and between clinicians. minimize risk of supine hypotension syndrome; Thalassaemias Intravenous sedation must be avoided in the Thalassaemias are inherited Specific situations and management first trimester and the last month of the third as autosomal recessive disorders in which considerations trimester and ideally best avoided completely; there is decreased synthesis of either Nitrous oxide can interfere with vitamin B12 alpha or beta globin chains. This allows Pregnancy and folate metabolism − should not be used less normal haemoglobin to be produced. Pregnant patients require special in first trimester − if used, exposure should Seen in Mediterranean races, patients with Disorder Relevance to Patient Management Disorders of haemostasis: Liaise with haematologist. Full blood count needed. Thrombocytopaenia Platelet levels >50 x 109/L − advisable to treat in hospital setting. <50 x 109/L will require platelet transfusion. Local haemostatic measures post-op: – DDAVP, tranexamic acid may be required. – No NSAIDs should be prescribed. Haemophilia A, B, von Willebrand’s Liaise with haematologist. Disease Factor VIII levels between 50−70% are required prior to treatment − may need factor VIII supplementation/DDAVP, tranexamic acid may be needed. Factor IX replacement may be required in haemophilia B. Tranexamic acid may be needed. Treat in hospital. May require in-patient management. Avoid inferior dental nerve blocks if possible. Anticoagulant therapy New oral anticoagulants such as dabigatran do not increase INR. Patients taking warfarin with INR ≤4 ok for treatment, if ≥4 refer back to haematology clinic for adjustment. Dual antiplatelet therapy treat in hospital − usually one stopped (after consultation). Local haemostatic measures post-procedure. Do not use NSAIDs. Table 1. Disorders of haemostasis and implications for patient management. May 2015 DentalUpdate 309 DentalPractice thalassaemia suffer from haemolytic anaemia. of dental treatment and the use of other drug also interacts with preparations that Local anaesthesia is safe, general anaesthesia medications. Well known examples of drugs dentists may prescribe.8 The absorption of or intravenous sedation should only be that are highly relevant in the context of dental paracetamol and orally administered diazepam carried out after assessment by a specialist treatment include anticoagulants, such as is delayed and reduced due to delayed gastric anaesthetist. warfarin and dabigatran and bisphosphonates. emptying. Carbamazepine reduces serum Osteonecrosis is a recognized methadone levels and methadone increases 5 Leukaemias complication of bisphosphonate treatment. the effects of tricyclic antidepressants. Liaison with a haematologist The condition is defined as the presence of Amphetamines and ecstasy may is important due to the potential difficulty exposed bone for longer than 8 weeks in the produce thrombocytopaenia. Concomitant use in controlling post-operative bleeding and absence of radiotherapy treatment but in with monoaminoxidase inhibitors and tricyclic increased risk of infection. a patient who is using bisphosphonates. It antidepressants can precipitate a hypertensive is diagnosed clinically but local malignancy crisis. must be excluded.6 The bisphosphonates are Patients who abuse cocaine are Steroid treatment a group of drugs which include alendronic subject to increased risk of the effects of Patients taking long-term acid and risedronate sodium. These drugs ischaemia leading to loss of tissue. Testing corticosteroid therapy will normally carry a become adsorbed onto hydroxyapatite crystals the ‘quality’ of the drug by rubbing on the steroid treatment card giving details of the thereby slowing their rate of dissolution oral mucosa to test depth of anaesthesia drug being used, its dosage and duration and growth. Such drugs have been used in may lead to loss of gingivae and alveolar of treatment. If steroid

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