medical dental history
Post on 15-Jul-2015
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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.
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
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
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
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)
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
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
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
Heart Conditions B5
Treatment Contraindicated:• Heart attack within last 6 months
Premedication:• Shunts• Artificial/damaged valves• Congenital heart defects• Previous endocarditis• Transplants
Pacemakers:• 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
Blood Disorders B6
Leukemia: • Need medical clearance from physician stating their health
will not be compromised by having an oral prophylaxis
Hemophilia
• Patient taking blood thinner will need a medical consult before instrumentation may occur
Anemia• 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
HIV Infection/Immune Disorders B6
HIV • Date of diagnoses
• Date of last visit with physician
• Ask if immune system (T-count) can handle prophylaxis
Immune Disorders• Can patient fight off
infection?• Consult with
physician
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
Kidney Disease/ Spleen Removed B7
Kidney Disease• Determine how often
and what kind of problem
• Type of treatment
Premedication needed if:
• Hemodialysis• Renal transplant• Glomerulonephritis• Inflammation
Spleen Removed
• Dates
• Patient may need medication; consult with physician
Respiratory Disease B8
Emphysema/Bronchitis• Determine triggers
• How is it controlled?
• Keep appointment short
• Seat patient upright
• May need oxygen in emergency
Asthma• Determine triggers
• Ultrasonic use OK
• How is it controlled? Inhaler?
• Keep appointment short
Sinus Problems• Determine if patient on
medications
• Ask about symptoms and frequency
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
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
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 • No Premedication
• 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
Sexually Transmitted Disease/Mental Health Problems B10
Syphilis, Gonorrhea, Chlamydia• Type of disease
• Dates
• Treatment/Medication
• Reappoint if treatment is not complete
Eating 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
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?
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
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
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
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
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
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.
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
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
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
– 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.
Review
A person’s health is not static; therefore, a health history must be updated when or how often?
A) Annually
B) At every recall appointment
C) At each and every appointment
D) At the initial appointment
Answer
C) At each and every appointment
Updating 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.
Review
Which of the following is true for the information in the patient’s health history?
A) It is confidential and must be updated annually
B) It is a legal document and must be written in pencil to allow for changes
C) It is to be written in pencil so that changes may be made and provide a specific line for the signature of the patient
D) It is a confidential and legal document to be handwritten in permanent ink
E) A minor must sign the informed consent form also
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.
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