1. health and fitness

Designing A Comprehensive Health History
Mary Govoni, CDA, RDA, RDH, MBA; Wilhemina Leeuw, MS, CDA
Continuing Education Units: 2 hours
Online Course: www.dentalcare.com/en-US/dental-education/continuing-education/ce76/ce76.aspx
Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or
procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.
Over the years, the practice of dentistry has evolved from one of a relatively narrow scope, defined by the
boundaries of the oral cavity, to one of comprehensive proportions. We now know that a patient’s oral health
can greatly affect their overall health status and vice versa. The information contained in this course should
allow the dental professional to design a health history questionnaire or revise an existing questionnaire
to be more comprehensive. This course also provides basic information for the professional to remember
when interviewing patients and in minimizing the risks associated with treating patients, especially those with
medical conditions; and assist in providing safe treatment to all patients in a dental practice.
Conflicts of Interest Disclosure Statement
• The authors report no conflicts of interest associated with this work.
ADAA
This course is part of the home-study library of the American Dental Assistants
Association. To learn more about the ADAA and to receive a FREE e-membership
visit: www.dentalassistant.org
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The Procter & Gamble Company is an ADA CERP Recognized Provider.
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying
quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses
or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
Concerns or complaints about a CE provider may be directed to the
provider or to ADA CERP at: http://www.ada.org/cerp
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Approved PACE Program Provider
The Procter & Gamble Company is designated as an Approved PACE Program Provider
by the Academy of General Dentistry. The formal continuing education programs of this
program provider are accepted by AGD for Fellowship, Mastership, and Membership
Maintenance Credit. Approval does not imply acceptance by a state or provincial board
of dentistry or AGD endorsement. The current term of approval extends from 8/1/2013 to
7/31/2017. Provider ID# 211886
Overview
Over the years, the practice of dentistry has evolved from one of a relatively narrow scope, defined by
the boundaries of the oral cavity, to one of comprehensive proportions. We now know that a patient’s
oral health can greatly affect their overall health status and vice versa. We also know that many medical
conditions have oral manifestations that are often the first indicators of systemic disease. In addition, many
existing medical conditions have effects on the success or failure of dental treatment.
With these facts in mind, it is apparent that a patient’s health history is one of the most important
documents in a dental practice. This document is utilized to assess a patient’s current status, evaluate
past history and identify current conditions that may alter treatment plans or delay treatment. The health
history also aids the dental team in identifying patients with infectious diseases, such as tuberculosis, that
can pose serious hazards to the dental team and other patients in a dental practice.
It is the legal responsibility of a dentist to obtain a health history from every patient that s/he treats, in
order to make informed treatment decisions. Dental assistants are often assigned the task of obtaining
this information from patients, are often the first member of the dental team to have contact with patients
and many times assist patients in completing their health history forms. Therefore, it is vitally important for
assistants to understand the many facets of a comprehensive health history.
Learning Objectives
Upon completion of this course, the dental professional should be able to:
• Explain the importance of the health history and its relationship to patient treatment.
• Describe ways in which the patient, dentist and physician can communicate and share important
information that may affect treatment of the patient.
• Apply legal requirements for obtaining consent for treatment.
• Identify certain risk management issues, including record keeping and confidentiality, and compliance
with the Health Insurance Portability and Accountability Act (HIPAA).
• Describe techniques used for obtaining a health history.
• Identify the components of a comprehensive health history, including personal information, medical/
dental past history, family history, current medical/dental status and medications.
• List sources of information that may be used as references when reviewing a health history.
• Explain which medical conditions may affect treatment planning.
• Describe the changes that should be made in treating patients with certain medical conditions.
• Summarize the most current guidelines for antibiotic prophylaxis for identifying patients at risk for
bacterial endocarditis, and currently recommended medications/dosages.
• Explain how the CDC Guidelines for Preventing the Transmission of Tuberculosis in Health Care
Facilities will affect treatment of patients who have or are suspected of having infectious tuberculosis.
• Discuss how the Americans with Disabilities Act affects the treatment of patients with HIV or AIDS.
• Describe different methods for updating health history and the frequency at which it should be done.
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Course Contents
bacterial/infective endocarditis – Sometimes
referred to as subacute bacterial endocarditis (SBE),
a microbial infection of the inner lining of the heart.
•Glossary
• Purpose of the Health History
• Legal Requirements for Treatment
• Techniques for Obtaining a Health History
• Components of a Comprehensive Health
History
• Classification of Patient's Current Status
• Medical Conditions that Affect Dental
Treatment
• Reference Guides
• Updating the Health History
•Summary
• Appendix A
• Appendix B
• Appendix C
• Course Test Preview
• References
• About the Authors
cardiovascular disease – Collection of diseases
that involve the heart and circulatory system.
cerebrovascular accident (CVA) – Commonly
referred to as a stroke; a disruption of blood flow in
the brain or a hemorrhage in the brain.
chemotherapeutic agents – Drugs or chemicals
used to treat specific diseases, often cancers.
chlorhexidine gluconate – Antimicrobial or antiseptic
agent used in hand scrubs and mouth rinses.
chronic obstructive pulmonary disease (COPD) –
Term used to describe diseases of the small airways
or bronchioles in the lungs, resulting in obstruction,
narrowing or collapse.
Glossary
age of consent – In most states, 18 years of
age, the age at which a person is considered an
adult and can enter into contracts and agree to
medical treatment.
congenital heart defects – Anomalies that are
present in the heart at birth, may involve heart
valves, chambers or the walls of the heart (e.g., a
hole in the heart).
AIDS – Acquired immune deficiency syndrome;
advanced stage of HIV.
coronary artery disease (CAD) – Disease that
disrupts the flow of blood in the vessels surrounding
the heart, typically with a blockage of the artery.
anaphylaxis – Acute, systemic allergic reaction
that occurs when a sensitized person is again
exposed to the sensitizing agent.
dialysis – Treatment for patients with kidney
failure, in which the blood is circulated through a
machine that filters out the toxins normally removed
by the kidney.
angioedema – Manifestation of anaphylaxis,
characterized by hive-like skin eruptions that are
large and swollen both in the dermis or top layer
of the skin and the subcutaneous structures.
diastolic pressure – The bottom number of blood
pressure ration (i.e., 120/80), which measures the
pressure in the blood vessel during ventricular
relaxation, when the heart is at rest.
antibiotic prophylaxis – Regimen of antibiotics
that is given prior to certain procedures including
some dental procedures, to patients who are at
risk for bacterial endocarditis.
digital examination – Examination performed with
the fingers, by feeling or palpating.
atherosclerosis – Condition in which the walls of
the artery become thickened, obstructed and/or
lose their elasticity.
disclaimer – On a patient’s health history means
that the patient should sign a statement that he
has completed the information to the best of his
ability and will hold the dentist harmless if he (the
patient) was not truthful and/or accurate on the
questionnaire.
bacteremia – Sometimes called septicemia, the
invasion of the circulation (blood) by bacteria.
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disclosure – With regard to dental treatment
means that a dentist must inform patients of
all aspects of treatment, benefits, risks and
alternatives (as in informed consent).
HIV – Human immunodeficiency virus; a retrovirus
causing failure of the immune system.
hyperglycemia – Increase in the concentration of
sugar/glucose in the blood, a feature of diabetes.
discrimination – Denying a person access to
services based on race, color, sex, national origin,
age, size or any other characteristic, including
HIV/AIDS status.
hypertension – Abnormal elevation of the systolic
or diastolic arterial pressure.
hypoglycemia – Very low concentration of sugar/
glucose in the blood, usually less than 40mg/100ml
of blood; symptoms include nervousness, hunger,
weakness, dizziness and fainting.
emphysema – Destruction of the alveolar walls of
the lungs, resulting from chronic irritation, such as
cigarette smoking.
epinephrine – Also known as adrenaline, a
hormone secreted by the adrenal gland which
causes vasodilation of the blood vessels of skeletal
muscles, but also vasoconstriction of the arterioles
of the skin and mucous membranes, relaxation
of the bronchiolar smooth muscles and increased
heart rate; used as a vasoconstrictor in local
anesthetics to prolong their effect; used to treat
allergic reaction to help in relaxing the bronchioles
to allow the patient to continue breathing.
idiopathic – No known cause.
epistaxis – Bleeding from the nose.
intravenous – Injecting medication directly into a
vein, providing much faster action of the medication.
informed consent – Written or implied acceptance
of proposed treatment by a physician; includes
informing patients about the treatment’s associated
risks, alternative treatments and consequences of
not having a specific treatment.
intramuscular – Giving an injection into the
skeletal muscle, (e.g., upper arm or buttock).
hemorrhagic disorders – Diseases of the blood in
which spontaneous or excessive bleeding occurs.
latex/natural rubber latex (NRL) – Milky white
fluid that is produced by some seed plants that is
the basis for rubber, and is the major component
of latex gloves.
heart failure (HF) – Once more commonly known
as “congestive heart failure;” HF is a cardio-vascular
disease characterized by cardiac output that is
insufficient to meet the body’s needs, even at rest.
myocardial infarction (MI) – Necrosis or death
of myocardial tissue, due to disruption of blood/
oxygen flow to the tissues of the heart.
hepatitis – Inflammation of the liver; viral
hepatitis comes in several forms (A, B, C, D,
etc); healthcare workers are encouraged to be
vaccinated against HBV.
NIOSH N95 Mask – Sometimes referred to as a
particulate respirator, a mask that is able to filter out
very minute particles from the air; it is a special mask
designed for use when working with patients with
airborne infectious diseases, such as tuberculosis.
HEPA mask – High efficiency particulate air; a
mask able to filter out very minute particles from
the air; it is a special mask designed for use when
working with patients with airborne infectious
diseases, such as tuberculosis.
orthostatic hypotension – Aka: postural
hypotension; a sudden drop in blood pressure
caused by a change in body position; for instance,
standing too quickly after laying prone for dental
treatment.
HIPAA – Health Insurance Portability and
Accountability Act of 1996; a federal law that
allows for greater access to health care insurance
coverage and mandates that certain procedures
be followed by health care providers to protect the
privacy of patients’ health information.
palpitation – Perception of the heart action by the
patient, a heightened sense of awareness.
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Purpose of the Health History
paralysis – Loss of movement and/or sensation
due to injury or disruption of the central nervous
system.
The primary purpose of a patient’s health history is
to attempt to find out as much about each patient
as possible, so that the dental practice can treat the
patient safely and knowledgeably. Members of the
dental team need to know any and all information
about a patient’s current health status, as well as
any information about past medical and dental
treatment; since all these factors will affect treatment
and possibly predict a medical emergency.
Protected Health Information (PHI) – Information
about patient’s health that may not be released
without the patient’s specific written consent
for any use other than treatment, payment or
operation of the dental practice.
rheumatic heart disease – Results from
rheumatic fever and causes rigidity or deformity of
the heart valves.
New patients must complete forms that inform
the dental practice of their contact, billing, and
personal information including dental and medical
history information. In addition, returning patients
should be asked to update this information at each
visit. The registration and health history are legal
documents, as part of the treatment record for each
patient. These documents can be subpoenaed
in court cases, such as a malpractice suit, or
when disciplinary action is taken against a dental
professional by a regulatory board. Because these
documents can be used as legal evidence, they
must be thorough, accurate, and legible.
risk management – Procedures and protocols
designed to prevent errors in the treatment of
patients, including recordkeeping and documentation.
seizure – A disorder of brain or cerebral function
which causes altered consciousness, convulsions
and/or loss of motor control.
standard precautions – Protocol for infection
control procedures for health care workers in which
the health care workers must assume that every
patient is a potential carrier of infectious disease
and therefore must wear personal protective
equipment and sterilize or disinfect items used in
the treatment of that patient, regardless of his or
her medical history.
Under the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), these records
are also considered protected health information
(PHI) and dental practices must take federally
mandated steps to protect the privacy of this
information. The information may be used in
conjunction with treatment of the patient, payment
from insurance plans, and the general operation
of the dental practice, such as administrative
recordkeeping, which is defined by HIPAA as TPO,
with a general consent from the patient. If the
PHI is to be used for something other than TPO,
such as a list of patients that is sold to a marketing
company, a patient’s specific written consent must
be given for the release of this information.
systolic pressure – The top number of blood
pressure ration (i.e., 120/80), which measures
the pressure in the blood vessel at the point of
ventricular contraction of the heart.
TPO – Treatment, payment and operations
– defined by HIPAA as an appropriate use of
protected health information (PHI) with a general
consent from a patient.
urticaria – Hives, local wheals (round, raised
areas) and redness of the skin, typically seen in an
allergic reaction.
An excellent resource for information regarding
HIPAA and compliance requirement for dental
practices is the ADA HIPAA Compliance Manual,
available from the American Dental Association.
The American Dental Assistants Association
(ADAA) refers to HIPAA laws and compliance in
many continuing education courses as it relates
to the topic. These courses are available via
the ADAA website at: http://www.dentalassistant.
org/?page=CECatalog.
vital signs – Results of checking blood pressure,
body temperature, respirations, and pulse.
xerostomia – Absence of or marked decrease in
the production and flow of saliva, which may be the
result of medication, stress or radiation therapy to
the head and neck.
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Aside from the legal and recordkeeping aspects
of the health history, this document serves as a
bridge of communication between the patient’s
medical health care provider and the dentist. When
a patient completes a health history form, either
as a new patient or returning patient, emphasis is
placed on identifying any conditions that may affect
that patient’s current dental health, overall health,
and ability to receive dental care at the time. If
the patient indicates certain medical problems,
such as a heart condition, the dental team will
ask more probing questions of the patient and the
treating physician to assess the appropriateness of
proceeding with treatment and to determine if any
special precautions must be taken.
explain to patients that taking certain medications
will have effects on the oral cavity, such as
decreased saliva or xerostomia (dry mouth.) When
patients understand why the information is so
important, they may be less resistant to disclosing
it to the dental team.
Legal Requirements for Treatment
This information assists the dental team in
preventing medical emergencies during treatment.
In addition, undiagnosed conditions may be detected
as a result of completing and reviewing the health
history. For example, a patient who feels healthy
may have high blood pressure and not be aware
of it. Completing or updating a comprehensive
health history on each patient, including checking
vital signs, may identify patients who need medical
intervention to treat their condition.
Legal Consent
When patients complete a new health history or
update an existing history form, it is important to
make certain that the patient is of legal age and
competency to complete and sign the form. In
most states, children under the age of 18 are
considered minors. Minor patients, and patients
who are mentally incompetent, must have a parent
or legal guardian complete and sign their form on
their behalf. Since minor patients are sometimes
“'dropped off” at the dental office and the parent/
guardian does not stay for the appointment, the
dental assistant or team member who schedules
the appointment or greets the patient must
emphasize to the parent/guardian that the health
history form must be completed or updated before
any treatment can begin.
Because many patients do not realize that their
oral health and general health are interrelated,
emphasis is placed on compiling this information.
A critical task for all dental professionals is to
educate their patients on the importance of
completing their health history form and providing
the dental team with accurate and up-to-date
information. This can be accomplished by
explaining to patients about the oral manifestations
of many diseases, such as diabetes or
malnutrition. The dental professional should also
Disclosure/Disclaimer
At the end of the health history questionnaire the
patient should be required to sign a statement
that serves as a disclosure that the information is
complete and accurate and also a disclaimer that
the patient does not hold the dentist or other team
members responsible for any errors or omission
of information that the patient may have made
in completing the form. A sample paper form is
illustrated in Figure 1. Additionally, electronicallybased offices will have the patient complete the
Figure 1. Health History Disclaimer.
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computerized form that can be time and date
stamped to meet this obligation.
members who manage that information. First, all
paper records must be completed in ink, to avoid
the chance of erasure. A pen with permanent
ink is preferred, since many ink pens have water
soluble ink, which can wash off the record if liquid
is spilled or sprayed on it. If a mistake is made on
the form, have the patient cross out the incorrect
information with a single line and initial it. The
correct information can be entered just above or
below where the incorrect information was written.
Correction fluid or tape should never be used on any
patient records. If information is transferred from
a form completed by the patient to a computerized
patient record, always retain the paper copy
completed and signed by the patient or guardian. A
better option for a computerized record is to scan
and save the original form after each update.
Informed Consent
Before a dental professional performs any dental
procedure on a patient, that patient must give
their consent. Informed consent, as it is called,
involves gaining the patient’s permission before
treatment after all the facts, risks involved, and
any alternatives to the proposed procedure have
been explained. Informed consent also includes
informing the patient of the risks of not having a
procedure performed. For example, a patient who
refuses a periodontist referral for treatment of their
periodontal disease must be informed of the risk of
losing their teeth due to disease progression.
In many cases, informed consent is implied. In
other words, the fact that a patient makes an
appointment and allows a dentist, assistant,
or hygienist to treat him/her, implies that they
gave consent for treatment. Attorneys and risk
management specialists, however, recommend
that informed consent be in written form (Figure
2). This consent form can be attached to or
incorporated into the health history form. Many
times, dental specialists utilize customized consent
forms that detail the possible risks of the specific
procedures that they perform. The only instance
where a patient or guardian is not legally required
to give informed consent, is when the patient is
unconscious and in need of emergency treatment.
For example, if a patient is having an allergic
reaction to latex, you do not need to have them sign
a consent form to administer epinephrine to help
save him/her from anaphylaxis and possible death.
Some dental practices prefer to send out health
history and patient information forms to new
patients prior to their appointments, to save
time on the day of the appointment. This is an
excellent means of managing the appointment
time, except if the patients lose or forget to bring
the forms with them to their appointment. The
form can be made available via the office website
or the office can e-mail the form directly to the
patient’s e-mail address. For those patients
with no access to internet technology, sending a
stamped, self-addressed envelope along with the
forms and asking the patient to mail them back to
the office could alleviate that problem, provided
there is enough time for the forms to reach the
patient and be returned to the office prior to the
patient’s appointment.
It is common for new patients to be scheduled
for preventive or cleaning appointments at their
first visit to a dental practice. If new patients are
scheduled for treatment appointments at their
Risk Management
Because a health history is a legal document,
certain criteria must be met by the dental team
Figure 2. Consent Form.
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first visit, the business assistant or scheduling
coordinator must ask some preliminary health
history questions prior to receiving the form
completed by the patient. In particular, the
practice needs to know whether or not that
patient needs antibiotic prophylaxis. The current
guidelines from the American Heart Association
for prevention of infective (bacterial) endocarditis
should be followed. (Appendix A) It is common
practice for a patient to carry information about
their condition on a wallet card provided to them
from their cardiologist. The office should scan a
copy of this for the patient record. (Appendix B)
public health department; or reporting abuse/
neglect to authorities, as dental professionals are
considered mandated reporters.
Patients can be reluctant to disclose information
about themselves, out of fear of their
confidentiality being violated. These patients
require the sincere reassurances of all members
of the dental team that their privacy will not be
invaded and information about them will not be
disclosed inappropriately.
Title II of HIPAA sets forth specific requirements
for protecting the privacy of the patient’s
information disclosed on the health history. A
dental practice that is a covered entity must have
a written privacy policy, which must be given to
patients, and explains that the dental practice will
not disclose the PHI for any uses other that TPO
without the patient’s written consent.
Confidentiality and Privacy
Doctor-patient privilege requires a dentist to hold
in strictest confidence any information disclosed
by a patient for purposes of treatment. Therefore,
all information contained in the patient’s record,
including the health history, is confidential
information to be used only in relationship to the
patient’s treatment. Patient records must be
stored in a secure area that is accessible only
to members of the dental team. No information
about the patient’s medical or dental conditions
should be indicated on the outside of the patient’s
record (file folder). Although it is a common
practice to indicate allergies or the need for
antibiotic prophylaxis on a patient’s file folder, this
practice is a violation of patient confidentiality. To
alert staff members of certain medical conditions,
a “medic alert” sticker could be prominently
placed on an inside page of the record or a “flag”
placed in a computerized record. But, again,
nothing specific, such as “allergic to penicillin”
should be indicated on the outside of the folder.
This is especially important with regard to
transmissible diseases due to the high degree of
sensitivity of the information.
Legal Ownership of Patient Records
A patient’s records, including the health history
and radiographic images, are the legal property
of the treating dental office. Many patients,
however, believe that the records belong to
them. Most state statutes in the U.S. stipulate
the patient’s right to review and to photocopy
their records upon request. Patients also have
the right to request that copies of their records
(including radiographic images) be sent to a
new dentist or to a specialist for treatment or a
second opinion. The state attorney general’s
office in each state should be contacted to
become familiar with that state’s laws concerning
access to medical records. Original copies of
patient records, especially health histories and
radiographic images should not leave the dental
practice. If radiographic images are required for
submission of insurance claims, make copies
using duplicating film, or use double-film packets
when exposing images on patients. In some
cases, digital images may be submitted.
If a dental practice is contacted by another
health care provider for information related to
confidential patient information, it is best to have
that request confirmed in writing and have the
patient sign a “release of information” statement,
authorizing the dentist to disclose the information.
The exceptions to the doctor-patient privilege
law are cases in which the public welfare is in
jeopardy. Such cases would include reporting
an infectious disease (i.e., tuberculosis) to the
Under HIPAA, patients have additional rights to
review their records and request corrections or
clarifications of the information in those records.
Again, additional information regarding HIPAA
requirements may be obtained from the ADA
HIPAA Compliance Manual.
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Techniques for Obtaining a Health
History
Oral Interview
Once the health history form is completed, it should
be reviewed orally with the patient by the dental
professional to clarify the information and verify
its accuracy. Several very important questions
should always be asked of patients, who may not
remember or not consider the information important
enough to list on their health history form:
1. What medications/drugs are you currently
taking? (Both prescription and over-the-counter,
as well as recreational drugs and nutritional
supplements)
2. Have you been hospitalized for any reason
within the last 6 months?
3. Are you currently under a physician’s care? If
yes, then for what reason?
Written Questionnaire
Since the health history is a legal document,
it is important that it be complete, legible, and
in ink. This will ensure for clear reading of
the information. It is preferable to print these
instructions at the top of the health history form,
saving time in writing or verbally stating these
instructions each time a form is to be completed.
When designing or updating a questionnaire,
it is advisable to use at least a 12 point type
font, which is easier for most patients to read.
Selecting a serif font, such as Times New Roman
or Arial, will also make the information easier to
read. Some dental practices attempt to keep
the health history on one side of one 8 ½" X
11" sheet of paper, by using a small font and
eliminating some important information. It is
advisable to be as comprehensive as possible,
using as many pages as necessary. If patients
hesitate, because of the length of the form,
the dental team member should explain the
importance of the information and inform the
patients of the need to have a complete picture
or summary of their health status. Offering to
help patients record the information sometimes
alleviates their reluctance. If the office is
computerized and the patient can be questioned
in a private consultation or treatment area,
information about the health history can be asked
and entered directly into the computer database.
It is important to obtain a hard copy or electronic
signature after completion.
This information should be highlighted on the
health history form for possible consultation with
a physician prior to the patient receiving any
dental treatment. The section on “Classification of
Patient’s Current Status” gives specific information
about conditions for which a physician should
be consulted prior to treatment. Keep in mind,
however, that some patients may not disclose all
the necessary information on their health history
form. Some information is very sensitive, for
example, disclosing one’s HIV+ status or current
treatment for a sexually transmitted disease (STD),
like syphilis or gonorrhea. Therefore, some patients
may not want a dentist to know this information,
for fear of this information being disclosed to
persons outside of the dental practice. For this
reason, a health history cannot be relied on as an
indicator of the level of precautions that should
be taken for infection control procedures. The
theory of Standard Precautions states that all
persons should be treated as if they are potentially
infectious for bloodborne transmitted diseases,
regardless of their medical history.
If a new health history form is not sent to the
patient ahead of time, the patient should be
instructed to arrive approximately 10 minutes
before their appointment time in order to complete
the necessary forms. For patients not fluent
in English, it is important to make certain that
someone is available to translate for the patient.
This could be a family member or friend of the
patient, or a dental team member who may be
fluent in the patient’s native language. If the
patient is unable to read or write, a dental team
member or family member should be available to
complete the written questionnaire for the patient.
Visual Assessment
In addition to verbally reviewing the patient’s
written information, dental team members should
also be performing a visual assessment of each
patient. Questions to be answered include:
• Does the patient appear healthy?
• Does the patient exhibit signs of exertion when
walking from the reception room to an operatory?
• Is the patient short of breath/breathing hard/
coughing excessively?
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• Does the patient have any asymmetries of the
head/neck or the rest of the body?
• Can you see the patient’s fingernails and nail
beds? Do they appear pink, or have a bluish tint?
• Are the whites of the patient’s eyes yellow
instead of white?
• Does the patient have trouble hearing or
speaking?
• Does the patient have problems with manual
dexterity?
• Does the patient have trouble concentrating?
should be checked and recorded on his/her health
history form. Adult patients should be checked at
each return visit.
Many styles of blood pressure devices are
available for purchase. Along with the traditional
manual set up, the office can also purchase
automatically-inflating arm and wrist BP units that
provide a digital read out of the systolic/diastolic
ratio and the pulse rate to make this task simple
and fast for the dental team. Figure 3 illustrates
the normal, pre-hypertensive, and hypertensive
BP categories established by the American Heart
Association. Be aware, however, that some older
blood pressure cuffs contain natural rubber latex
(NRL) which could cause a sensitivity reaction
for latex allergic patients. NRL cuffs should be
replaced with a newer, latex-free cuff that will not
pose a risk of allergic reactions.
As one might guess, all these physical signs have
some relationship to systemic conditions, which
can affect the patient’s ability to be treated safely.
These conditions may also be related to the
patient’s current oral health status. For example,
a patient with limited manual dexterity will no
doubt have trouble with brushing and flossing.
Patients who become short of breath walking short
distances may have some type of uncontrolled
cardiovascular or lung disease, such as chronic
obstructive pulmonary disease (COPD).
Additionally, several thermometers are on the
market for fast temperature readings. Digital
types offer a fast reading and can be barriered
with a small plastic sleeve. Tympanic (ear) types
also have a thin plastic disposable barrier that still
offers a one-touch, fast, and accurate reading.
Always remember there are three components
to obtaining a patient’s health history – written
questionnaire; oral interview; visual assessment.
Communication Skills
Healthcare literacy has become an issue when
obtaining record information. Quite often, a
patient may not understand the medical or dental
conditions you are speaking of and may need
extra time and help to understand the concepts
Recording Vital Signs
Obtaining and recording the patient’s vital
signs should always be a part of the patient
appointment. As a rule, each new patient’s blood
pressure, pulse, temperature, and respiration rate
Figure 3. Blood Pressure Categories.
This chart reflects blood pressure categories defined by the American Heart Association.
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Components of a Comprehensive Health
History
and terminology. Patients may not even be
aware that their condition could be considered a
disease that needs special consideration while
receiving dental treatment. It is the dental team
member’s responsibility to make sure that patients
understand the treatment prescribed before
obtaining consent for themselves or children.
Personal Information
There are two classifications of information
contained on a health history: personal and
medical information. The personal information
includes the following: patient name, address,
home and cell phone numbers, date of birth,
current age, and gender. For adults, the personal
information also includes place of employment,
business address and phone number, spouse/
partner name, birth date, insurance information
(carrier, group number, policy number), and the
name of an emergency contact. For minors,
the information should also include the name of
the patient’s parent or legal guardian, billing and
insurance information, and a telephone number
at which they can be reached in an emergency.
The name of the patient’s primary care physician
should also be listed. In the case of patients
with specific medical conditions, the name of the
specialist(s) treating them should be listed. If
applicable, the name of the patient’s previous
dentist should be listed, in order for copies of
the patient’s previous treatment records and/or
radiographic images to be requested.
Obtaining personal information from patients,
especially for a health history, requires excellent
communication skills. Patients should feel
comfortable that the dental team member
interviewing them is objective, non-judgmental,
and sensitive to their needs. The dental team
member should make eye contact with the patient
when speaking and especially when asking
questions of the patient. If patients disclose
sensitive information, reassure the patient that this
information will be held in the strictest confidence
and utilized only in relationship to their dental
treatment. When discussing any patient PHI, the
dental team must be aware of the setting. PHI
must never be discussed with the patient/guardian,
among the dental team members, or with other
entities within earshot of other any other people.
Not only is this breaking the confidentiality of the
patient, it is not reassuring to patients that the
team protects their health information.
Medical Information
The medical information necessary on a health
history form will be the lengthiest and most timeconsuming for the patient and dental team to
complete. It should include the patient’s past
history including, for example, whether they
have had a previous heart attack; family history
(does anyone in the family have cardiovascular
disease?); and a list of all medications the patient
is currently taking, including over-the-counter
(OTC) medications, like antihistamines, antacids,
or nutritional supplements. Recent surgeries and
treatments such as chemotherapy or radiation
should be noted as the patient may be immunocompromised and unable to receive treatment.
The last component of the medical history is a
review of all the body systems, to determine if
there are any conditions that may affect, modify
or delay treatment. Table 1 is an example of a
review of the body systems. See Appendix C for
an example of a Medical Questionnaire.
It is important to obtain information on all medicines
or drugs the patient may be taking at the time of
the appointment. Patients must know that any
drug, whether taken legally or illegally can affect the
dental treatment and recovery times. Drug toxicity
or overdose can occur if the patient is not truthful in
disclosing all medications to the dental team.
The dental team member must also be cognizant
of their non-verbal communication with patients.
Even though the dental team member may
not verbally indicate a negative response at
some information that is disclosed, it may be
obvious, or misconstrued by the patient, in their
facial expressions. It is imperative to remain
professional, to become proficient at staying
expressionless and non-judgmental in respect of
the patients. These efforts can greatly enhance
a patient’s willingness to disclose all information
about his/her health status.
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Table 1. Review of the body systems.
Table 2. Suggested questions to ask patients about their past dental history.
Dental Information
dentist was, this information may be verified by
contacting that dentist.
Past History
The health history should also contain questions
regarding the patient’s past dental experiences.
Table 2 lists some suggested questions to ask
patients about their past dental history. If the
patient has indicated who his/her previous
Chief Complaint
In order to assess the patient’s understanding
of his/her oral health, and also to determine
the patient’s expectations, it is important to
ask the patient what is his/her chief complaint.
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In other words, why have they come to the
dental office? It is significant to ask if they are
experiencing pain, swelling, bleeding, sensitivity
to hot, cold or sweets, or difficulty biting/chewing.
Another central question to ask is if the patient
is concerned with his/her appearance. If the
patient is in pain, it is important for the dentist to
diagnose the source of the pain and to attempt to
resolve the problem, or the patient will feel that
his/her needs are not being met and may not
remain as a patient in the practice.
identifying a patient’s health status is illustrated
in Table 3. This classification system is based
on the patient’s medical history, drug history
(medications), physical and clinical examination
(vital signs), emotional evaluation, medical
consultation, and personal experiences. Patients
in ASA Class I are healthy and can be treated
without question. Patients in Class II and III
have mild and moderate health issues. The
dental team should consult with the patient’s
physician prior to treating patients in ASA Class
II depending on the medical condition. The
treating physician(s) of Class III patients must be
consulted in preparation of treatment. Nothing
may need to be altered, but it is best to verify
with the physician. Patients in ASA Class IV
should not receive dental treatment until stabilized
and away from life-threatening danger. Due to
extreme health issues, dental offices will not be
treating patients in Classes V or VI (see Figure 4).
After thorough review of the health history, each
patient should be assigned a classification that is
recorded in the treatment record and revised as
the patient’s status changes. All members of the
dental team should be aware of this classification.
Specific information about systemic diseases and
conditions is listed in the following sections.
Current Conditions
Identification of the patient’s chief complaint,
along with a clinical oral examination will
identify the patient’s current conditions. The
oral examination should consist of a visual
and manual examination of the mouth, head
and neck, a radiographic survey, and complete
charting of teeth and supporting structures,
including a periodontal charting. Current
conditions should be recorded on the treatment
record, as well as entering a summary description
on the health history, including classification of
existing restorations and teeth (e.g., rampant
caries or marginal breakdown on existing
restorations) and the periodontium (e.g.,
moderate gingival inflammation, bleeding on
probing). It is always imperative to remember
that HIPAA laws consider the above information
to be protected health information (PHI).
Medical Conditions that Affect Dental
Treatment
Medical Conditions that Affect Dental Treatment
Once all the information has been obtained from
the patient’s health history, both oral and written
questionnaires, the dental team must evaluate
Classification of Patient's Current Status
A simple classification system created by the
American Society of Anesthesiologists for
Table 3. ASA Physical Status (PS) Classification System.
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Figure 4. Dental Treatment Protocols According to the ASA Classifications.
the data and determine if any conditions exist
that will affect, alter, or delay any necessary
dental treatment. The ASA Classifications chart
becomes a useful tool at this time. The following
are conditions that will have some affect on dental
treatment:
regulated, 90-95% of cases; Gestational diabetes
occurs during pregnancy and is reversed after
delivery. If the patient indicates that they have
diabetes, the type must be noted in the history.
Patients with uncontrolled diabetes have
low resistance to infection and are prone to
periodontal disease. They have poor healing
response, including excessive bleeding, and may
experience hypoglycemia or hyperglycemia during
dental treatment. Patients who are undiagnosed
diabetics may report the following symptoms:
excessive thirst and hunger, increased urination,
and higher birth weights in babies.
Need for Antibiotic Prophylaxis
The current American Heart Association (AHA)
guidelines are used to determine the need for and
the protocol for antibiotic prophylaxis. The AHA, in
conjunction with the American Medical Association
and the American Dental Association, have
consistently reviewed and revised the type of patients
that need to be pre-medicated for dental treatment.
Each office should consult with the patient’s
physician if unsure of the patient’s status and
recommended antibiotic prophylaxis prescriptions.
When reviewing a health history, the following
questions should be asked of diabetic patients:
• Is your diabetes well controlled?
• When is the last time your blood glucose was
checked?
• Are you currently taking oral anti-diabetic
medications or insulin injections?
• When was the last time you ate?
• Did you take your medication on time today?
Syncope
Syncope, or fainting, is the most common emergency
in the dental office. Patients should be asked if they
have ever experienced a fainting episode in a dental
office, or at any time in their life. It is most commonly
associated with heavy coughing, orthostatic
hypotension, and medication. Syncope can happen
to any person at any age but are more common with
pregnant and geriatric patients.
It is advisable to keep sources of sugar on hand
for hyper or hypoglycemic episodes. Glucose gel
from a pharmacy, granulated sugar packets, honey
packets, or tubes of cake icing can be easily stored
and used in the case of an emergency.
Diabetes
There are three types of diabetes: Type I is
considered insulin dependent, 5-10% of cases;
Type II is when the body does not produce enough
insulin and, therefore diet and medication may be
When questioning diabetic patients before
treatment and you find out they have not eaten
or taken their insulin, their appointment should
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be rescheduled. Make sure they understand the
importance of these steps to maintain a normal
blood sugar level during dental treatment. After
approximately 8 hours of fasting, an average
range is between 70 – 99 mg/dL. If they have
eaten an average level should be less that
140 mg/dL. A strategy for making a dental
appointment for a diabetic patient is to keep it
short and in the early to mid-morning hours when
sugar levels are more stable.
several medications, particularly vasodilators
like nitroglycerin; or beta-blockers, such as
propanolol. The stress of a dental visit may
cause an angina attack, therefore it is important to
minimize patient stress, maximize patient comfort
and make certain that the patient has his/her
medications available, particularly nitroglycerin. In
addition, it is recommended that local anesthetic
without epinephrine or other vasoconstrictors
be used for these patients, to avoid further
constriction of the blood vessels. Patients with
unstable or uncontrolled angina should wait for
at least 30 days after their angina is stabilized to
receive dental treatment.
Cardiovascular Disease
Patients who state that they have experienced
chest pain, shortness of breath, pain that radiates
down their neck or arm, have swollen ankles,
and/or have high blood pressure are at risk for
cardiovascular disease. They may or may not
have been diagnosed by a physician. If this
patient also indicates that they are a smoker
and/or are overweight, the risk is increased. It
is recommended that a medical consultation or
evaluation be obtained for all patients who indicate
some type of cardiovascular disease on their
health histories. Additionally, medical consultations
should also be obtained for patients who are
reporting or exhibiting symptoms of cardiovascular
disease, but have not had a definitive diagnosis.
Preventing medical crises during dental treatment
is the best method of protecting patients who are
medically compromised.
Myocardial Infarction (MI) is more commonly
known as a heart attack. Patients who have
experienced a recent myocardial infarction should
not receive any dental treatment for a minimum
of 6 months after the heart attack. Most fatalities
from MI occur within 3-4 months after the attack.
Stressful situations, like dental treatment can
cause a rupture in the area of infarct, leading to
further health problems and possible death.
Hypertension is a common condition
characterized by high blood pressure. Patients
with uncontrolled hypertension are at risk for
a stroke (also known as a cerebrovascular
accident, or CVA), kidney failure, or heart attack.
Since stress will increase blood pressure, dental
treatment is contraindicated in patients with severe
hypertension. Patients presenting with a systolic
pressure between 120 to 139 should be advised
to monitor their readings for improvement and see
their physician for assessment. As a rule, patients
with a systolic pressure greater than 160 and/
or a diastolic pressure greater than 95 should be
referred for medical consultation and treatment and
dental treatment should be delayed.
Rheumatic Heart Disease is a result of rheumatic
fever and can cause deformities in the heart
valves. Some patients will report taking antibiotics
on a regular basis, although this is not a required
practice. If the patient reports a history of
rheumatic fever, the dental practice must consult
with the patient’s physician to determine the extent
of the heart involvement. This assessment will
determine the need for antibiotic prophylaxis.
Congenital Heart Defects place the patient
at high risk for bacterial endocarditis. Again,
a statement from a physician is advisable to
determine the type of defect and to verify the
need for prophylactic antibiotics.
It is relatively common for patients to have
undiagnosed hypertension, making it very
important for the dental team to monitor patients’
vital signs during their dental visits. A patient who
reports having frequent dizziness, nosebleeds,
or headaches may have high blood pressure
and may be in need of medical intervention with
antihypertensive drugs and/or diuretics.
Coronary Artery Disease (CAD) results from
atherosclerosis. Patients may report having
been diagnosed with angina pectoris, or having
chest pain after some type of physical activity
or stress. These patients may be taking
Heart Failure (HF) was more commonly known
as “congestive heart failure” but the American
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Heart Association has recently renamed and
shortened the title to characterize a broader
spectrum of the disease. Depending on the type
of HF, patients will typically have swollen ankles
and shortness of breath, due to poor circulation
and fluids backing up in the lungs. These patients
may indicate that they must sleep upright or with
several pillows. In these cases, placing them in
a supine position for dental treatment may cause
them acute distress. HF patients are usually
taking one or more diuretic medications to remove
fluid. Supplemental oxygen may be needed for
these patients and use of nitrous oxide analgesia
is contraindicated.
Patients who are taking oral anticonvulsant
medications, such as Dilantin®, Zarontin®, or
Depacon®, may experience gingival hyperplasia.
Emphasis must be placed on meticulous home
care to prevent serious periodontal problems and
the increased need for regular dental visits.
Asthma
Asthma is a chronic respiratory disorder that
results in a narrowing of airways. An asthma
attack can be triggered in several ways including
environmental allergens, medications, or exercise.
Patients with asthma may be prone to an attack
or episode brought on by the stress of dental
treatment, or exposure to an allergen like latex.
The patient must always be instructed to bring his/
her medication/inhaler to each appointment. When
the health history is reviewed at the beginning of
treatment, the patient should be able to produce
the medication or inhaler just in case it is needed.
Kidney Disease
Patients with kidney disease have impaired renal
function, which results in accumulation of fluid and
waste products normally excreted by the kidney.
Renal problems often result from uncontrolled
or undiagnosed diabetes. These patients may
experience poor healing, incontinence, cystitis,
and excessive bleeding. They may be receiving
dialysis treatments or may have had/need a kidney
transplant. In either case, the patients may be
taking medications, such as anticoagulants or
immunosuppressive drugs. Consult with the PDR
regarding side effects of the medications and with
the patient’s physician if there is a need to prescribe
drugs for patients whose primary method of
excretion or metabolism is the kidney. The impaired
function of the kidney may cause toxic levels of the
drug to accumulate in the patient’s tissues.
Chronic Obstructive Pulmonary Disease (COPD)
The two most common forms of COPD are
emphysema and chronic bronchitis. Emphysema
is the irreversible enlargement of the air sacs in
the lungs making it hard to expel all oxygen during
breathing. Chronic bronchitis is characterized as
the irreversible condition of narrowed airways. Like
patients with HF, those with either of these types
of COPD may not be able to breathe easily in a
supine position or after walking certain distances.
Due to prolonged steroid use to treat their COPD,
these patients may have candida infections
(thrush) (see Figure 5).
Seizure Disorder
Seizure disorder is caused by an electrical
disturbance in the brain. Any person can experience
a seizure in a stressful situation and approximately
half of all seizures are considered idiopathic.
Epilepsy is a condition commonly associated with a
syndrome of associated seizure types.
Patients with COPD may need supplemental
oxygen and often carry their own supply with
When a known epileptic patient is scheduled for
treatment, the dental team should determine if the
patient has taken his/her anti-seizure medication.
These patients should be scheduled for short
appointments, when they are well rested. Patients
often report an aura before experiencing a seizure.
This aura can be a sound, feeling, or smell. Shining
a bright light in the patient’s eyes should be avoided,
since this has been known to trigger a seizure.
Figure 5. Candida Infection.
Courtesy of dentalcare.com
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them. However, these patients should not be
given high levels of oxygen, since this disease
prevents them from metabolizing it. It is important
that the COPD patient not receive nitrous oxide
and oxygen therapy during dental treatment due
to their impaired ability to exhale all gases.
suspected of having an active, infectious TB case.
If these patients can be referred for treatment in
a facility that is specifically designed to treat TB
patients (e.g., a hospital setting), it is acceptable
for the dental practice to make this referral
and not be liable for discriminatory practices.
(http://www.cdc.gov/oralhealth/infectioncontrol/
guidelines/slides/101.htm)
Infectious Diseases
Hepatitis is characterized as an inflammation
of the liver. It is a viral disease that appears in
several forms. It is referred to as hepatitis A, B,
C, D and E. A newer type of virus, non A-E, has
been discovered, but not much is known about
it at this time. Hepatitis B and C are transmitted
through blood or other body fluids, while hepatitis
A and E are usually transmitted indirectly through
contaminated food and water. Hepatitis D is a
piggyback virus that is linked to hepatitis B. Dental
health care workers should be vaccinated against
hepatitis B, to reduce their risk of infection when
treating patients. The dental practice is required
by law to pay for this vaccination. There is no
vaccine for hepatitis C at this time. There is no
way to visually identify every patient who has a
potentially infectious disease. And because many
patients are not aware if they have hepatitis, or
are carriers, it is important to remember to practice
standard precautions on every patient.
In addition to asking patients on their health
history if they have had TB, the patients should
also be asked if they have experienced any of the
following symptoms: night sweats, unexplained
fever, weight loss, or a prolonged or bloody
cough. If a patient has experienced any of
these symptoms, refer them to a physician for
evaluation before proceeding with anything but
emergency palliative treatment.
If emergency treatment must be performed on
a patient suspected of having infectious TB, the
following precautions should be taken:
• Schedule the patient at the end of the day, as
the last patient treated.
• All team members present in the treatment
room must wear a HEPA or NIOSH N 95 mask.
• High volume evacuation and dental dam
isolation must be used to reduce aerosols.
HIV+ and AIDS is a viral infection that impairs
a patient’s immune system, making the patient
highly susceptible to other infectious diseases.
It is transmitted through blood and other body
fluids, which puts dental health care workers
at some risk of infection from treating patients.
Again, the practice of standard precautions
must be followed, since many patients will not
disclose their HIV+ status for fear of humiliation
or rejection. Remember that information about a
patient’s HIV+ status is highly sensitive and must
be protected according to HIPAA. The dental
team must take every precaution to protect the
confidentiality of that patient’s health history.
If a patient presents for treatment and reports a
combination of fatigue, nausea, fever, dark urine
and/or jaundice, they should be referred for medical
treatment. When a patient reports a history of
hepatitis, consult the PDR and their physician
before drugs are prescribed to note if metabolized
by the liver, since liver function may be impaired.
Tuberculosis (TB) is a bacterial infection that
occurs primarily in the lungs, but can occur in other
organ systems in the body. It is spread through
airborne particles, when an infectious patient
coughs, sneezes, talks, or sings. TB is most easily
spread in small confined spaces where infectious
people share the same airspace with others.
Because TB is highly infectious and its airborne
transmission is difficult to control, the CDC has
issued specific guidelines to help protect health
care workers when treating patients.
The Americans with Disabilities Act of 1990
protects people with HIV/AIDS infections and
other diseases from discrimination in employment
and delivery of all types of services, including
health care. Although some dental health care
workers are fearful of treating AIDS patients, it is
illegal not to accept them into a dental practice
or to refer them to another practice, unless the
In the case of TB, these guidelines state that
elective, (non-emergency) dental treatment
should be postponed for patients who have or are
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type of treatment is not performed in that practice.
For example, if a general dental practice does not
perform periodontal surgeries, it is legal to refer
HIV+ or AIDS patients to a periodontist, since
non-HIV or non-AIDS patients are referred as
well. However, if only the HIV+ or AIDS patients
are referred for periodontal surgery, this would be
considered discriminatory.
disease. A patient with one of these disorders will
bruise very easily, may experience spontaneous,
excessive bleeding, including unprovoked
epistaxis (bleeding from the nose).
Dental treatment, such as extractions, that may
cause bleeding can be risky for these patients.
Close monitoring by the physician is necessary.
Treatment should be confined to specific areas
(e.g., one tooth or quadrant at a time) and
transfusion with clotting factors may be necessary
prior to treatment. Aspirin must never be
prescribed for pain control for these patients, since
it is a natural blood thinner and increases bleeding.
When treating patients with full blown AIDS, who
are typically immunosuppressed, the dental team
should take extra precautions to protect the patient
from opportunistic infections. These may include
wearing sterile surgical gloves rather than nonsterile exam gloves, having the patient use a pretreatment rinse of chlorhexidine gluconate or other
mouthwash to prevent bacteremia, and using only
sterile water for irrigation rather than from the air/
water syringe, which may contain some bacterial
contamination.
Allergies
Allergies are specific body responses to foreign
substances. An allergic reaction may be localized
or limited to a skin rash or hives, or may be
systemic and life-threatening, as in anaphylaxis.
Many patients will indicate on their health history
that they are allergic to environmental agents,
such as pollen and dust. Many are also allergic
to medications, such as codeine or penicillin.
When prescribing medications, it is important
to review the health history and orally question
patients about known drug allergies.
Blood Dyscrasias (Diseases)
Anemia is a deficiency of red blood cells, caused by
vitamin or iron deficiency or bone marrow problems.
An anemic patient may have problems with slow
wound healing and excessive bleeding. They may
report feeling weak and fatigued, and may appear
very pale. If a patient exhibits these symptoms a
medical evaluation should be recommended.
Latex allergies are becoming more common
in dental and medical treatment. Repeated
exposure to latex or natural rubber latex (NRL)
during dental or medical treatment can cause a
patient to become allergic. Again, the reaction
may be localized, in which the patient’s lips
become itchy or swollen from contact with
latex gloves or dental dam material. Some
patients, however, can experience a very serious
anaphylactic reaction where their entire body
responds when exposed to the allergen. The
most serious symptom of anaphylaxis is swelling
of the tongue, which closes off the patient’s
airway. Without medical intervention, particularly
without administration of epinephrine, patients can
die from anaphylaxis.
Leukemia is a type of blood cancer, where there
is an overgrowth of white blood cells. These white
blood cells may displace red blood cells, used to
transport oxygen in the blood. These patients may
exhibit oral signs, often before other symptoms
of their disease. These signs typically include
excessive gingival irritation in the absence of other
causative agents, like heavy plaque or calculus.
Patients with leukemia are very prone to infections,
including periodontal infections. In addition, the
chemotherapeutic agents used to treat the disease
have many side effects, most notably xerostomia
(dry mouth). Consult the treating physician before
proceeding with treatment. Also consult the PDR
for side effects from medications.
A health history should ask questions about any
allergies the patient may have, including latex,
although some patients may not know that they
are latex sensitive. Additional questions on the
written questionnaire or oral interview may help
to determine if this is the case. Patients noting
spina bifida or urogenital anomalies are also
Hemorrhagic disorders are ailments in which
patients experience excessive bleeding, due
to a deficiency of clotting factors in their blood.
Common bleeding disorders are hemophilia A &
B, factor II, V, VII, X, XII, and von Willebrand’s
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associated with latex allergies. Patients should
be asked if they have ever experienced stomach
cramps, nausea or vomiting after eating bananas,
kiwis, water chestnuts, or avocados. These foods
contain chemicals similar to those in NRL. Also,
ask patients if they have ever experienced any
itching after handling balloons or after previous
visits to the dentist or physician, where the health
care providers wore latex gloves.
problems and antihistamines use to treat allergies.
Patients taking these medications must be advised
about the adverse effects that dry mouth can have
on their teeth and oral mucosa and be given tips to
counteract these symptoms, especially if their oral
hygiene is lacking. In addition, saliva replacements
may need to be prescribed. Patients with systemic
diseases, such as liver or kidney disease should not
be prescribed medications that are metabolized by
the liver or excreted by the kidneys.
To safely treat latex allergic patients, all members
of the dental team who come in direct contact with
the patient must wear non-latex (vinyl or other
synthetic material) gloves, and non-latex dental
dam must be available when used. In addition,
the dental team must check all products, such
as prophylaxis cups, oxygen masks, and other
items to determine whether those products contain
latex. Latex-free substitutes are available for most
products that currently contain latex, and many
products are now labeled as “latex free.” Patients
with latex sensitivity or allergy must be scheduled
first in the morning before latex powders from
other treatment areas are in the air. As latex is
used, the powder/dust particles become airborne
in the office from gloves being put on and taken
off. Performing proper hand hygiene protocols is
also important to remove residual latex powder.
Epinephrine auto-injectors, or “epi-pens,” should
be located in each treatment room, ready to
administer immediately to a patient who begins to
exhibit signs of an allergic reaction.
Reference Guides
Merck Manual
The Merck Manual is a reference book that lists
detailed data (signs and symptoms) of systemic
diseases. It can assist the dental team members
in understanding the process of a disease,
precautions that should be taken and possible
medications that the patient may be taking. The
Merck Manual is also available online at http://
www.merckmanuals.com/professional/.
Physicians’ Desk Reference
The Physicians’ Desk Reference or PDR is a
reference that gives information on prescription
and some non-prescription drugs. The PDR
can be used to identify side effects, precautions
and drug interactions. It can also be utilized to
identify medication by their size, shape and color;
in cases where patients do not know the name of
a prescription drug they are taking. The PDR is
updated yearly and includes mid-year supplements
for the newest prescription drugs. It is available
in a hardbound book, on CD-ROM, via electronic
tablet, or online at http://www.pdr.net/.
Patient Medications can cause a reaction
at any time. Some of the most important
information gained from a health history is an
accurate list of medications that a patient is
currently taking, both prescription and over-thecounter. However, some patients may not know
the names of the medications or not think that
it is important to list certain ones. For some
elderly patients, it may be advisable to ask the
patient to bring all their meds with them, so that
an accurate list may be documented. Consult
the PDR to identify medications, side effects,
precautions, and particularly drug interactions and
contraindications.
Release of Medical Information from Physician/
HIPAA Privacy Rules
Due to the confidentiality of medical information
and the physician-patient relationship, all
requests for medical consultation information
on patients should be made in writing, with the
patient’s signature authorizing the release of the
information. Figure 6 is a sample release form. In
some cases, the release form may be sent to the
physician with the patient or through the mail. In
other cases, to save time, the form may be sent
by fax and returned in this manner. This electronic
transmission of protected health information
is covered by HIPAA and the dental practice
must have a signed consent form signed by the
Most medications have some side effects, many
of which appear in or affect the oral cavity.
Xerostomia is a very common side effect of many
prescription medications including those for heart
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Figure 6. Sample Release Form.
Figure 7. Updating a Health History.
patient for the transmission of this information,
in addition to the release that must be signed for
the physician to release the information to the
dental practice. If worded so, the document can
be signed one time and kept on file to cover both
entities until the patient revokes the authorization.
validate the updated information. The dental
team member who updates the information should
also initial the updates. A common method for
facilitating this update is to create a section on the
health history form with blank lines for initials and
dates (Figure 7).
Updating the Health History
If it has been 2-3 years since a patient has been
treated in the office, it is recommended that the
patient complete a new health history form, since
there may be many changes, not only to medical
information, but to personal information as well.
When the patient completes a new questionnaire,
it should be attached to the old form. The
outdated or “old” form should never be thrown
away or destroyed.
Each time a patient visits the dental office for
treatment, the health history should be updated.
If it has been a relatively short time since the
patient was seen in the office (weeks or months)
the health history can be updated verbally, by
asking if there have been any changes and if the
patient is taking any new or different medications.
Once this information is obtained, the patient
must initial and date the health history form, to
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Summary
questionnaire or revise an existing questionnaire
to be more comprehensive. This course also
provides basic information for the professional
to remember when interviewing patients and
in minimizing the risks associated with treating
patients, especially those with medical conditions;
and assist in providing safe treatment to all
patients in a dental practice.
The health history is a very important component
of the patient record. By using a comprehensive
form, the office can properly treat patients and
also prevent possible medical emergencies from
occurring in the dental office. The information
contained in this course should allow the
dental professional to design a health history
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Appendix A
Appendix A. AHA Guidelines for Infective Endocarditis Prophylaxis.
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Appendix B
Appendix B. Wallet Card.
All dental procedures that involve manipulation of gingival tissue or the
periapical region of teeth, or perforation of the oral mucosa*
PREVENTION OF INFECTIVE (BACTERIAL) ENDOCARDITIS
Wallet Card
This wallet card is to be given to patients (or parents) by their physician. Healthcare professionals: Please see back of card for reference
to the complete statement.
*Antibiotic prophylaxis is NOT recommended for the following dental
procedures or events: routine anesthetic injections through noninfected
tissue; taking dental radiographs; placement of removable prosthodontic or
orthodontic appliances; adjustment of orthodontic appliances; placement
of orthodontic brackets; and shedding of deciduous teeth and bleeding
from trauma to the lips or oral mucosa.
Name: _________________________________________
needs protection from
INFECTIVE (BACTERIAL) ENDOCARDITIS
because of an existing heart condition.
Antibiotic Prophylactic Regimens
for Dental Procedures
Diagnosis: ______________________________________
Prescribed by: __________________________________
Date: __________________________________________
Situation
You received this wallet card because you are at increased risk for
developing adverse outcomes from infective endocarditis (IE), also
known as bacterial endocarditis (BE). The guidelines for prevention
of IE shown in this card are substantially different from previously published guidelines. This card replaces the previous card that was based
on guidelines published in 1997.
The American Heart Association’s Endocarditis Committee together with
national and international experts on IE extensively reviewed
published studies in order to determine whether dental, gastrointestinal
(GI), or genitourinary (GU) tract procedures are possible causes of IE.
These experts determined that there is no conclusive evidence that
links dental, GI, or GU tract procedures with the development of IE.
Regimen—Single Dose
30-60 minutes
before procedure
Adults
Children
Oral
Amoxicillin
2g
50 mg/kg
Unable to
take oral
medication
Ampicillin OR
2 g IM or IV*
50 mg/kg IM
or IV
Cefazolin or
ceftriaxone
1 g IM or IV
50 mg/kg IM
or IV
Cephalexin**†
2g
50 mg/kg
600 mg
20 mg/kg
Azithromycin or
clarithromycin
500 mg
15 mg/kg
Cefazolin or
ceftriaxone†
1 g IM or IV
50 mg/kg IM
or IV
OR
Clindamycin
600 mg IM
or IV
20 mg/kg IM
or IV
Allergic to
penicillins or
ampicillin—
Oral regimen
The current practice of giving patients antibiotics prior to a dental
procedure is no longer recommended EXCEPT for patients with the
highest risk of adverse outcomes resulting from IE (see below on this
card). The Committee cannot exclude the possibility that an exceedingly
small number of cases, if any, of IE may be prevented by antibiotic
prophylaxis prior to a dental procedure. If such benefit from prophylaxis
exists, it should be reserved ONLY for those patients listed below. The
Committee recognizes the importance of good oral and dental health
and regular visits to the dentist for patients at risk of IE.
Agent
Allergic to
penicillins or
ampicillin and
unable to take
oral medication
OR
Clindamycin
OR
*IM—intramuscular; IV—intravenous
**Or other first or second generation oral cephalosporin in equivalent
adult or pediatric dosage.
†Cephalosporins should not be used in an individual with a history of
anaphylaxis, angioedema or urticaria with penicillins or ampicillin.
The Committee no longer recommends administering antibiotics solely
to prevent IE in patients who undergo a GI or GU tract procedure.
Changes in these guidelines do not change the fact that your cardiac
condition puts you at increased risk for developing endocarditis. If you
develop signs or symptoms of endocarditis—such as unexplained fever
—see your doctor right away. If blood cultures are necessary (to determine if endocarditis is present), it is important for your doctor to obtain
these cultures and other relevant tests BEFORE antibiotics are started.
Gastrointestinal/Genitourinary Procedures: Antibiotic prophylaxis
solely to prevent IE is no longer recommended for patients who undergo
a GI or GU tract procedure, including patients with the highest risk of
adverse outcomes due to IE.
Other Procedures: Procedures involving the respiratory tract or
infected skin, tissues just under the skin, or musculoskeletal tissue for
which prophylaxis is reasonable are discussed in the updated document
(reference below).
Antibiotic prophylaxis with dental procedures is reasonable only
for patients with cardiac conditions associated with the
highest risk of adverse outcomes from endocarditis, including:
Adapted from Prevention of Infective Endocarditis: Guidelines From the American
Heart Association, by the Committee on Rheumatic Fever, Endocarditis, and
Kawasaki Disease. Circulation, 2007; 116: 1736-1754. Accessible at http://circ.
ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095.
• Prosthetic cardiac valve or prosthetic material used in valve repair
• Previous endocarditis
• Congenital heart disease only in the following categories:
Healthcare Professionals—Please refer to these recommendations for
more complete information as to which patients and which procedures
need prophylaxis.
–Unrepaired cyanotic congenital heart disease, including those
with palliative shunts and conduits
–Completely repaired congenital heart disease with prosthetic
material or device, whether placed by surgery or catheter
intervention, during the first six months after the procedure*
–Repaired congenital heart disease with residual defects at the
site or adjacent to the site of a prosthetic patch or prosthetic
device (which inhibit endothelialization)
The Council on Scientific Affairs of the
American Dental Association has approved
this statement as it relates to dentistry.
• Cardiac transplantation recipients with cardiac valvular disease
*Prophylaxis is reasonable because endothelialization of prosthetic material occurs
within six months after the procedure.
National Center
7272 Greenville Avenue
Dallas, Texas 75231-4596
americanheart.org
Dental procedures for which prophylaxis is reasonable in
patients with cardiac conditions listed above.
© 2008, American Heart Association.
All Rights Reserved. Lithographed in Canada.
50-1605 0805
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Appendix C
Appendix C. Medical Questionnaire.
MEDICAL QUESTIONNAIRE
Patient Name
Date Today
Please check if you have any of the following problems:
□ AIDS / HIV Positive
□ Alcoholism
□ Allergies
Describe
□
□
□
□
□
□
□
□
□
□
□
□
□
Anemia
Arthritis
Artificial heart valves
Artificial joints
Asthma
Back problems
Blood disease
Cancer
Chemotherapy
Circulation problems
Cortisone treatments
Cough, persistent
Cough, up blood
Known Allergies:
□
□
□
□
□
□
□
□
Local anesthetic
Aspirin
Penicillin
Codeine
Sulfa
Iodine
Latex
Other:
□ Diabetes
□ Epilepsy
□ Fainting
□ Food allergies
□ Glaucoma
□ Headaches, frequent
□ Headaches, migraines
□ Heart murmur
□ Heart, any problems
Describe
□
□
□
□
□
□
□
Hemophilia
Herpes
Hepatitis A B C
High blood pressure
Jaw pain
Kidney disease
Liver disease
Mitral valve prolapse
Nervous problems
Pacemaker
Psychiatric care
Radiation treatment
Respiratory disease
Rheumatic fever
Seizure disorders
Shingles
Shortness of breath
Skin rash
Stroke
Surgical implants
Swelling, feet or ankles
Thyroid problems
Tobacco use
Tuberculosis
Ulcers/colitis
List any medications you are currently taking:
Pre-medication required
Consulting Physician
Pharmacy
Check if you have had any problems with the following:
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Bad breath
Bleeding, sensitive gums
Clicking or popping jaw: right or left
Food trapped between teeth
Grinding or clenching teeth
Loose teeth
Broken fillings
□
□
□
□
□
□
□
Periodontal treatment
Sensitivity to cold
Sensitivity to hot
Sensitivity to sweets
Sensitivity to biting
Sores in mouth
Staining
Authorization:
I have reviewed the information and answered all questions to the best of my knowledge. I understand this
information will be used to determine the dental treatment I receive at this office and may be shared with other
medical offices only as necessary. I will notify the office should any information change in the future.
Signature of patient, or parent if a minor:
Reviewed by:
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised January 20, 2015
Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please go to:
www.dentalcare.com/en-US/dental-education/continuing-education/ce76/ce76-test.aspx
1.
Patients experiencing heart failure will often be taking a diuretic. Antibiotic prophylaxis prior
to a dental procedure is still advised for patients with a history of infective endocarditis.
a.
b.
c.
d.
Both statements are true.
The first statement is true. The second statement is false.
The first statement is false. The second statement is true.
Both statements are false.
2.
_______________, is a true statement regarding a health history.
3.
The proper protocol for treating a patient who indicates that she/he has had a heart attack
within the last 60 days is to _______________.
a.
b.
c.
d.
e.
a.
b.
c.
d.
The health history is a legal document
Minor patients should not complete or sign their health history form
Patients may not be truthful on a health history form
A health history determines what infection control measures are used
A, B, and C
consult with the physician prior to treatment
premedicate the patient with antibiotics prior to treatment
consult with the physician and delay treatment until 6 months after the heart attack
treat as normal, no precautions are necessary
4.
When completing a health history on a patient _______________.
5.
It is legally acceptable for a patient or guardian not to give informed consent if
_______________.
a.
b.
c.
d.
a.
b.
c.
d.
6.
the
the
the
the
patient
patient
patient
patient
is a minor and the parent is not present
is mentally incapacitated
is unconscious and needs emergency treatment
refuses to sign the informed consent
The law that prevents a dentist or his/her employees from disclosing protected health
information for reasons other than treatment, payment or health care operations without the
patient’s written permission is _______________.
a.
b.
c.
d.
7.
it should be short and concise so as not to offend the patient
it should be completed only on the patient's first visit to the office
all information used in conjunction with treatment is the property of the patient
all information used in conjunction with treatment is protected by HIPAA
Ethics and Jurisprudence Act
Americans with Disabilities Act
Health Insurance Portability and Accountability Act
Dental Practice Act
If a dental practice needs additional information about patients from their physician, they
should _______________.
a.
b.
c.
d.
have the patient sign a release information form that is sent to the physician
call the physician and have the dentist speak to him/her directly
have the patient call the physician and report back to the dentist
force the patient to tell as HIPAA laws will not allow a physician to release information to the dentist
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised January 20, 2015
8.
The health history is to be updated _______________.
9.
If a patient appears to be short of breath while being escorted from the reception area to the
treatment room, ____________ might be suspected.
a. verbally at each office visit
b.yearly
c.biannually
d. only as the patient reports changes
a. a latex allergy
b. a diabetic condition
c.COPD
d. a blood dyscrasia
10. After reviewing a patient’s health history, the dentist determines that the patient is an ASA
Class III patient. The next step is _______________.
a.
b.
c.
d.
to consult the patient’s physician prior to treatment
that no special precautions should be taken
for the dental team to practice their protocols for medical emergencies
the patient should receive prophylactic antibiotics
11. If a diabetic patient presents for treatment and indicates that they did not eat or take their
insulin prior to their appointment, the dental assistant should _______________.
a.
b.
c.
d.
inform the dentist and give orange juice to the patient
inform the dentist, who can give the patient an insulin injection
call the patient's physician to find out if the patient's disease is well controlled
reappoint the patient and remind them that it is very important that they eat and take their insulin
before their next appointment
12. ____________ is the first and most important drug to be administered to a patient having an
anaphylactic reaction to all allergens.
a.Corticosteroids
b.Benadryl
c.Epinephrine
d.Glucose
13. A patient presents for treatment and gives no indication on his health history that he
has any type of cardiovascular disease, but his ankles and feet are very swollen. When
questioned, the patient indicates that his feet “always look this way.” The patient should be
_______________.
a.
b.
c.
d.
prescribed a diuretic
referred for a medical evaluation before proceeding with treatment
reassured that it happens to lots of patients
assumed to have cardiovascular disease and treat normally
14. A special consideration when treating patients with diabetes and kidney disease is that they
may be prone to experience _______________.
a.
b.
c.
d.
severe xerostomia
high incidence of caries
excessive bleeding
lack of manual dexterity
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised January 20, 2015
15. If a patient indicates that he has had a fever and bloody cough for several weeks, the
dentist would _______________.
a.
b.
c.
d.
suspect that the patient has infectious tuberculosis and defer treatment
suspect that the patient has HIV/AIDS and treat normally
suspect that the patient has HIV/AIDS and treat with special precautions
treat as normal, a bloody cough has no bearing on dental treatment
16. _______________ is a true statement concerning a medical alert label on a patient record
folder.
a. Place the medical alert sticker on the outside of the patient record folder so the dental team
members take extra precautions with regard to infection control
b. No alert notice is ever necessary on any part of the patient record
c. Place the sticker on the outside of the partient record folder so all dental team members take extra
precautions when prescribing medications
d. Only place the alert sticker on the inside of the folder to protect the patient’s privacy
17. According to the CDC, elective dental treatment should be postponed on any patient who
has or is suspected of having ____________.
a.hemophilia
b.AIDS
c. active TB
d. All of the above.
18. If a patient isn’t sure what particular medication he is taking, the dental assistant could
show the patient pictures of drugs contained in _______________.
a.
b.
c.
d.
the Merck Manual
a pharmacology textbook
the Physicians' Desk Reference
The ADA Guide to Dental Therapeutics
19. If a patient indicates a latex allergy, the best time to schedule their dental appointment is
_______________ to prevent exposure to airborne latex.
a.
b.
c.
d.
whenever it is convenient for the patient
at the beginning of the day
at the end of the day
when they are rested
20. A patient may have a latex allergy if they indicate a food allergy to _______________.
a.oranges
b.apples
c.bananas
d.pears
21. _______________ is the law or agency that protects the rights of HIV+ and AIDS patients to
receive dental and medical treatment.
a.
b.
c.
d.
Centers for Disease Control and Prevention
American Dental Association
American Medical Association
Americans with Disabilities Act
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised January 20, 2015
22. _______________ is a term used to describe “dry mouth” or lack of saliva.
a.Halitosis
b.Hyperplasia
c.Xerostomia
d. Salivary stone
23. Patients with unstable or uncontrolled angina should wait for at least _____ days after their
angina is stabilized to receive dental treatment.
a.10
b.30
c.60
d.120
24. Medical information should include _______________.
a.
b.
c.
d.
family medical history
current medications
past medical history
All of the above.
25. As a rule, patients with a systolic pressure greater than _____ and/or a diastolic pressure
greater than _____ should be referred for medical consultation and treatment and dental
treatment should be delayed.
a.120/80
b.160/95
c.170/70
d.150/100
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised January 20, 2015
References
1. Advisory statement. Antibiotic prophylaxis for dental patients with total joint replacements. American
Dental Association; American Academy of Orthopaedic Surgeons. J Am Dent Assoc. 1997 Jul;
128(7):1004-8.
2. American Dental Association. HIPAA Compliance Manual. 2002.
3. American Dental Association. Prevention of Infective Endocarditis: Guidelines from the American
Heart Association. J Am Dent Assoc. 2007 Jun;138(6);739-45, 747-60.
4. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the
American Heart Association: a guideline from the American Heart Association Rheumatic Fever,
Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young,
and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the
Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc. 2007
Jun;138(6):739-45, 747-60.
5. American Heart Association. Understanding Blood Pressure Readings. Updated November 17,
2014. Accessed January 13, 2015.
6. Beers MH, Berkow R. The Merck Manual of Diagnosis and Therapy. 17th Ed. Merck & Company,
Inc. 1999.
7. Bird DL, Robinson DS. Modern Dental Assisting. 11th Ed. Elsevier Saunders, St. Louis, MO. 2015.
8. Centers for Disease Control and Prevention. Division of Oral Health. Slide 101: Preventing
Transmission of TB in Dental Settings. Guidelines for Infection Control in Dental Health-Care
Settings—2003. Slides 99-101. Accessed January 13, 2015.
9. Centers for Disease Control and Prevention. Division of Oral Health. Infection Control. Frequently
Asked Questions - Contact Dermatitis and Latex Allergy. Accessed January 13, 2015.
10. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by
the American Heart Association. JAMA. 1997 Jun;11;277(22):1794-801.
11. Grimes EB. Medical Emergencies. Essentials for the Dental Professionals. 2nd Ed. Pearson/
Prentice Hall. UpperSaddle River, NJ, 2012.
12. Kleinman DV, Horowitz AM. Oral Health Literacy. Woman Dentist Jour. 2007 Jul;24-28.
13. Little JW, Falace DA. Dental Management of the Medically Compromised Patient, 6th Ed. Mosby
Inc. 2002.
14. Malamed SF. Medical Emergencies in the Dental Office. 6th Ed. Mosby. St. Louis, MO. 2007.
15. PDRHealth. Physicians Desk Reference®. Accessed January 13, 2015.
16. Phinney DJ, Halstead JH. Dental Assisting: A Comprehensive Approach. Delmar Cengage
Learning, 4th Ed. Clifton Park, NY. 2013.
17. Tyler MT. Editor, Clinician’s Guide to Treatment of Medically Complex Dental Patients. American
Academy of Oral Medicine, 2001.
18. US Department of Health and Human Services. Health Insurance Portability and Accountability Act
of 1996. Accessed January 12, 2015.
19. Public Law 101-336 Americans with Disabilities Act of 1990. July 26, 1990. Accessed January 12,
2015.
20. Woodall IR. Comprehensive Dental Hygiene Care. 4th Ed.Mosby-Year Book, Inc. 1993.
21. American Heart Association. Infective Endocarditis. Updated October 14, 2014. Accessed January
14, 2015.
22. American Society of Anesthesiologists. ASA Physical Status Classification System. Accessed
January 15, 2015.
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised January 20, 2015
About the Authors
Mary Govoni, CDA, RDA, RDH, MBA
Mary Govoni, CDA, RDA, RDH, MBA, is an internationally recognized speaker,
author and consultant on clinical efficiency, ergonomics, OSHA & HIPAA compliance,
infection control and team communication. Mary is a past president and a life
member of the American Dental Assistants Association, a member of the American
Dental Hygienists Association, a consultant to the American Dental Association
Council on Dental Practice, a member of the Organization for Safety and Asepsis
Procedures, the National Speakers Association, and the Academy of Dental
Management Consultants and the Speaking and Consulting Network. She is also a featured speaker on
the ADA Continuing Education and lifelong learning seminar series.
Wilhemina Leeuw, MS, CDA
Wilhemina Leeuw, MS, CDA is a Clinical Assistant Professor of Dental Education at Indiana University
Purdue University, Fort Wayne. A DANB Certified Dental Assistant since 1985, she worked in private
practice over twelve years before beginning her teaching career in the Dental Assisting Program at
IPFW. She is very active in her local and Indiana state dental assisting organizations. Prof. Leeuw’s
educational background includes dental assisting – both clinical and office management, and she
received her Master’s degree in Organizational Leadership and Supervision.
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