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.

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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 supplementation is the management of osteoporosis in post- bone. An increased incidence of dental required prior to treatment, acute adrenal menopausal women, patients with bony caries may be seen if cocaine is bulked insufficiency can be prevented. An increased metastases and the hypercalcaemia of out with carbohydrates. As with heroin, dose of corticosteroid should be administered malignancy. thrombocytopaenia may be seen and, like prior to treatment in such cases. Simple dental Clearly, it is preferable to avoid cannabis, cocaine has a sympathomimetic extractions and restorative dental procedures dental extractions if possible in patients action. are not usually a cause for concern,3 but taking bisphosphonates. Local guidelines LSD (lysergic acid diethylamide) is surgical extractions, the placement of should be consulted when extractions are an hallucinogenic drug. Such drugs increase dental implants or treatment under general unavoidable in these patients. Established the incidence of bruxism and patients taking anaesthesia are a potential risk. cases of osteonecrosis require analgesia, and it may present with TMJ dysfunction. Dentists long-term antiobiotic therapy and topical should be aware that stressful situations may Angioedema antiseptic therapy if infected. Occasionally, cause flashbacks and panic attacks in these In angioedema, widespread careful local debridement may be indicated to patients. oedema may occur in response to quite remove limited bony sequestra.7 Risk factors A reduction in the dose of trivial trauma as a result of increased vascular that increase the possibility of osteonecrosis adrenaline containing local anaesthetics permeability. Two forms exist, one is hereditary developing include local infection, steroid is recommended in those who chronically and is due to a lack of C1 esterase inhibitor use, trauma, chemotherapy and periodontal abuse solvents as such agents can sensitize with resultant initiation of the complement disease. the myocardium to the actions of the cascade. Administration of pre-operative As well as effects on bone, it catecholamine. Solvent abuse also increases fresh frozen plasma (FFP) provides sufficient is thought that bisphosphonates might the risk of convulsions and status epilepticus inhibitor to prevent the problem occurring. have toxic effects on soft tissues around an may occur. The non-hereditary type is similar to urticaria extraction site, impairing the function of Some patients may abuse anabolic in which certain food and drugs produce an vascular and epithelial cells. steroids and performance enhancers, which allergic response. Trauma tends not to produce may precipitate increased carbohydrate serious complications in this type. Clearly, consumption with its inevitable effects on the ’Recreational’ drugs liaison with an immunologist is important in dentition. The systemic effects of adrenaline in The use of drugs of abuse is managing these patients. dental local anaesthetics can be exacerbated common and dentists should have a working by the sympathomimetic effects of certain knowledge of the implications for patients anabolic steroid drugs. As with many other Medications and drugs who say that they are using these. Cannabis illicit drugs, anabolic steroids may interfere All medications or drugs that the has a sympathomimetic action and in theory with blood clotting. patient may be taking should be included.4 could exacerbate the systemic effects of This should include ‘recreational’ drugs and adrenaline in dental local anaesthetics. Heroin homeopathic or other over-the–counter and methadone are opioid drugs, the latter Complementary therapies preparations. In addition, it is pertinent to ask being used in rehabilitation programmes. Oral Complementary therapies about inhaled or topical medicines as many methadone has a high sugar content that are often used by patients. It is important patients do not consider these as ‘drugs’. can cause rampant caries. Heroin can cause to remember possible interactions with Concurrent drug therapy can impact upon oro- thrombocytopaenia. Some of those addicted prescription drugs, some of which may be facial signs and symptoms, the safe provision to heroin have a low threshold for pain. The prescribed by dental practitioners. Some of

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the more common interactions are shown in drugs or complementary therapies. The system whether e-cigarettes are an effective smoking Table 2. of units for measuring alcohol consumption is cessation method.9 summarized as follows: Finally, information concerning the patient’s home circumstances is significant. It Past dental history  A pint of ordinary strength lager − 2 units is particularly important to find out whether The past dental history assumes  A pint of strong lager − 3 units a patient lives with another ‘competent’ adult different forms, depending on the patient’s  A pint of ordinary bitter − 2 units as, in cases of intravenous sedation or day case previous exposure to dental treatment. It is  A pint of best bitter − 3 units general anaesthesia, the patient should not be clearly relevant to find out whether a patient  A pint of ordinary strength cider − 2 units left alone for 24 hours following the procedure. is a regular attender and of their previous  A pint of strong cider − 3 units Disorders with a genetic origin experience of dental treatment and its nature.  A 175 ml glass of red or white wine around should be recorded. The previous use of local anaesthetic agents 2 units and any associated problems can be checked.  A pub measure of spirits − 1 unit If not covered by the previous history, adverse  An ‘alcopop’ around 1.5 units Psychiatric history events, such as post-extraction haemorrhage, The patient’s occupation (or previous The psychiatric history is not may be highlighted at this point. occupation if retired) is also important. included as routine but may be relevant in Clinicians identifying patients some cases.10 who smoke should inform the patient of the Social history/family history availability of smoking cessation services after Systems review The social history is often it has been ascertained whether the patient In hospital practice, a body neglected but clearly it is an important part of wishes to try and quit. Some patients will be systems review is undertaken after the the comprehensive assessment of a patient. using e-cigarettes. It is worth being aware that preliminary history. Whilst this would rarely It may directly influence treatment or the way the long-term safety of the e-cigarette is not be used in mainstream dental practice, it is it is delivered. As a minimum, enquiry should yet established but it is thought that they are discussed here to highlight its effectiveness on be made of the patient’s smoking status and likely to be less harmful than conventional medically assessing various systems. alcohol consumption, and if positive these cigarettes. Patients should be advised to seek should be quantified. It is at this point that smoking cessation services if they are willing General enquiry patients may disclose the use of ‘recreational’ to try and quit. It is not fully established It is worth starting with a series

HERB CONVENTIONAL DRUG POTENTIAL PROBLEM

St John’s wort Monoamine oxidase inhibitor and Serotonin Mechanism of herbal effect uncertain. reuptake inhibitor Insufficient evidence of safety with Antidepressants concomitant use − therefore not advised Iron May limit iron absorption

Karela, ginseng Insulin, sulphonylureas, biguanides Altered glucose concentrations

Feverfew, garlic, ginseng, ginger Warfarin Altered prothrombin time/INR

Echinacea used for >8 weeks Anabolic steroids, methotrexate, Amiodarone, Hepatotoxicity ketoconazole

Feverfew Non-steroidal anti-inflammatory drugs Inhibition of herbal effect

Ginseng Oestrogens, corticosteroids Additive effects

Evening primrose oil Anticonvulsants Lowered seizure threshold

Kava Benzodiazepines Additive sedative effects, coma

Echinacea, zinc (immunostimulants) Immunosuppressants (such as Antagonistic effects corticosteroids, ciclosporin)

Table 2. Complementary medicines and their interactions with conventional medicines with potential consequences.

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of general questions that may highlight Medical Problem Implications for Management relevant conditions that otherwise may be missed from the more specific systems Valve replacement, structural cardiac No antibiotic cover required. Consideration review.11 Such findings include: defect should be given of a recent publication  Appetite, weight loss; suggesting a possible re-think on this in the  Lethargy or fatigue; future.12 Currently, no change in guidelines.  Fevers;  The presence of any lumps, bumps or Myocardial infarction No elective dental treatment for 3 months swellings; after an MI. Ideally no general anaesthetic  The presence of skin rashes (especially if for the first 6 months. associated with oral mucosal lesions).

Angina Ensure availability of emergency drugs and oxygen. Enquire about frequency of attacks, Cardiovascular system their precipitation and effectiveness of GTN.  A differential diagnosis of chest pain (bearing in mind other potential causes) includes: – Angina; Hypertension In oral surgical cases if more than 160/100 mmHg, consider postponing until – Myocardial infarction; better control. In acute situations IV sedation –Oesophageal reflux; may be helpful. –Musculoskeletal; –Pleuritic (for example pulmonary Table 3. Cardiovascular disorders and potential management implications. embolism); –Hyperventilation; Medical Problem Implications for Management –Referred pain from the abdomen. Liver Disease Potential for bleeding problems, care with drug prescriptions, Does the chest pain occur at rest or after infection risk from various types of hepatitis virus. For exertion − how much exertion?; treatment under LA a minimum of a coagulation screen  Dyspnoea (remember potential and full blood count should be carried out. If liver function respiratory causes either co-existing or in (assessed via liver function tests) is impaired, LA and isolation); particularly sedation should be carried out with caution. The  Does breathlessness occur at rest/on BNF has an Appendix (2) which highlights drugs to be used exertion?; with caution (or not at all) in patients with liver disease.  Paroxysmal nocturnal dyspnoea (waking from sleep feeling breathless) or Table 4. Liver disease and management implications. orthopnoea (breathlessness on lying flat);  Palpitations; Medical Problem Implications for Management  Prosthetic/replacement heart valves;  History of rheumatic fever and/or Epilepsy Enquire about the nature of seizures and the degree of control infective endocarditis; – timing and precipitation (if known) of last 3 seizures. Ask  Claudication pains and what is required about recent changes in medication and why this was thought to precipitate them. necessary. Ensure that buccal midazolam is available.

Table 5. Epilepsy and management implications. Cardiovascular disorders and potential management implications Medical Problem Implications for Management Cardiovascular disorders and potential management implications are Kidney Disease Renal dialysis patients are best treated the day after dialysis as summarized in Table 3. renal function optimal and heparin effect has worn off. Renal transplant patients may be immune-suppressed and heightened Respiratory system vigilance for oral infection and cutaneous malignancy should  Breathlessness/wheeziness; be remembered. Do not assume normal renal function after  The presence or otherwise of a cough, its a kidney transplant – a urea and electrolyte blood test/liaison duration and whether productive or not; with the renal physician should be undertaken. The BNF has an  Haemoptysis (coughing up blood); appendix which details the drugs contraindicated/to be used  History of known respiratory disorders with caution in patients with renal disease. and exacerbations − note the degree of Table 6. Kidney disease and implications for patient management. success of treatment (judged by control/ relief of symptoms). 314 DentalUpdate May 2015 DentalPractice

Gastrointestinal system References  Dysphagia (difficulty swallowing); 1. Scully C. Medical Problems in Dentistry  Odynophagia (pain on swallowing); 7th edn. Chapter 2: Medical history  Indigestion, nausea or vomiting; and risk assessment. Oxford: Elsevier,  Haematemesis (vomiting blood); 2014.  Change in bowel habit; 2. Resuscitation Council (UK). Quality  Spleen or liver problems. Standards for Cardiopulmonary NO COMPROMISE Resuscitation Practice and Training in Liver disease and management implications Primary Dental Care. November 2013. Liver disease and management https://www.resus.org.uk/pages/ Plaque implications are summarized in Table 4. QSCPR_Main.htm 3. Thomason JM, Girdler NM, Kendal- Taylor P, Wastell H, Weddell A, Seymour Neurological system RA. An Investigation into the need for  Any history of fits, faints or blackouts; Gum Problems supplementary steroids in organ  Headache or facial pain; transplant patients undergoing  Disturbance in motor function or gingival surgery. J Clin Periodont 1999; sensation; 26: 577−582.  Muscle wasting, weakness or fasciculation; 4. British National Formulary – online at Sensitivity  Disorders of co-ordination. http://bnf.org 5. Hellstein JW, Marek CL. Epilepsy and management implications Bisphosphonate osteochemocrosis Epilepsy and management (bis-phossy jaw): is this phossy jaw of Caries implications are summarized in Table 5. the 21st century? J Oral Maxillofac Surg 2005: 63 682−689. 6. Khan A. Osteonecrosis of the jaw and Musculoskeletal system bisphosphonates. Br Med J 2010; 340:  Pain/swelling/stiffness of joints; c246. Halitosis  Gait (bear in mind potential neurological 7. Migliorati CA, Casigalia J, Epstein J, problems); Jacobsen PL, Siegel MA, Woo SB.  Joint prostheses; Managing the care of patients with  Locomotor and manual impairment bisphosphonate-associated secondary to musculoskeletal disorders. Tartar osteonecrosis: an American Academy of Oral Medicine position paper. J Am Genito-urinary system Dent Assoc 2005; 136: 1658−1668. Usually the genito-urinary system 8. Meechan JG, Seymour RA. Drug is not enquired about in any detail. Patients Dictionary for Dentistry. Oxford: Oxford Staining with repeated urinary tract infections may University Press, 2002. be taking antibiotics, which could be of 9. Worsley DJ, Jones K, Marshman Z. relevance. Patients are asking about e-cigarettes. What do we tell them? Br Dent J 2014; 217: 91−95. Enamel Erosion Kidney disease and implications for patient 10. Brown S, Greenwood M, Meechan JG. management General medicine and surgery for Kidney disease and implications dental practitioners 5: Psychiatric for patient management are summarized in disorders. Br Dent J 2010; 209(1): Table 6. 11−16. 11. Longmore M, Wilkinson I, Davidson E, Foulkes A, Mafi A. Oxford Handbook of Conclusions Clinical Medicine 8th edn. Oxford: Much of the medical assessment Oxford University Press, 2010. of a patient is derived from the history. 12. Dayer MJ, Jones S, Prendergast ORAL-B PRO-EXPERT Some underlying conditions may be of B, Baddour LM, Lockhart PB, ALL-AROUND PROTECTION direct relevance to the safe management of Thornhill MH. Incidence of infective featuring breakthrough dental patients. It is important that dental endocarditis in England, 2000-13: a Stabilised Stannous Fluoride technology practitioners have a sound knowledge of secular trend, interrupted time-series CLINICALLY PROVEN TO such conditions and are able to put them analysis. Lancet 2014; Nov 18: pii: PROTECT ALL THE 8 into context when managing such patients. S0140-6736(14)62007-9. AREAS YOU CHECK MOST

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