Essentials of Medical History-Taking in Dental Patients
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DentalPractice
Mark Greenwood
Essentials of Medical History-
Taking in Dental Patients
Abstract: The starting point in the assessment and management of any patient is dependent on good history-taking. The main parts of the
history-taking process well known to practitioners are the presenting complaint, the history of the presenting complaint and the current
and past medical history. This paper concentrates on those aspects of the process that are particularly important to dental practitioners.
Clinical Relevance: The cornerstone of safe and effective patient management lies with the history. This paper describes various aspects of
history-taking and highlights important areas.
Dent Update 2015; 42: 308–315
The main parts of a patient history are well presenting complaint should include the preceding event, including previous similar
established. It is important that practitioners following: episodes?;
follow a recognized systematic scheme When the condition/problem first started; Any associated symptoms, for example bad
of enquiry to minimize the risk of missing The overall duration and progression of the taste?
important information. condition, including whether it is episodic or
All dental practitioners are familiar constant; Past medical history
with the main components of the history- The nature and timing of any symptoms (see Generic questioning regarding
taking process. The purpose of this paper is below); major systems such as the cardiovascular
to revise those areas and add some context Details of any systemic signs or symptoms or respiratory systems is often the way
to some of the more important aspects and (such as fever); practitioners start obtaining a medical history.
provide updates where appropriate. The success or otherwise of previous Questioning should then focus on specific
treatments; disorders,1 such as asthma or other respiratory
Previous practitioners who have been disorders, diabetes mellitus, epilepsy,
The main components of a consulted regarding the same or related hypertension or other cardiovascular problems
patient history condition(s). (stroke, myocardial infarction, angina),
Presenting complaint In dental practice, the presenting hepatitis or jaundice. Positive responses
The presenting complaint may complaint is often pain. A generic scheme of should be followed-up by an assessment of
best be expressed in the patient’s own words. questions to assess the nature and severity of a the severity of the disorder, treatments used
The information presented can then be patient’s pain is shown as follows: and their efficacy. Previous problems with
summarized by the clinician. Site of pain − it is useful to ask the patient the arrest of haemorrhage are worth specific
to point with one finger to where the pain is enquiry. Table 1 highlights situations where
worst; the arrest of haemorrhage may be affected
History of presenting complaint Character, eg sharp, ache, throbbing; and implications for management.
A chronological approach should Ask about severity − on a scale of 1−10, 10 The past medical history is an
be used. As a minimum, the history of a being the most severe − how bad is it?; essential component of risk assessment for
Does the pain radiate anywhere else?; the likelihood of a patient experiencing a
Timing − was the onset sudden or gradual? medical emergency. The Resuscitation Council
Mark Greenwood, PhD, MDS, FRCS − how long has the pain been present? − is (UK) provide authoritative and up-to-date
FDS, FHEA, Consultant/Honorary Clinical it continuous or intermittent? − worse at any advice regarding the management of medical
Professor, School of Dental Sciences, particular time of day?; emergencies in dentistry.2
Newcastle University, Framlington Place, What makes the pain better or worse It is essential to ask about any
Newcastle upon Tyne, NE2 4BW, UK. (including the use and type of medication); known allergies and, if a positive response is
Is the patient aware of any relevant obtained, to enquire about the nature of such
308 DentalUpdate May 2015DentalPractice
an allergy. considerations in their management. Some of be less than 30 minutes, use 50% oxygen and
At the end of this process, patients the more important ones are summarized as: avoid repeated exposure.
should be allocated an American Society of The second trimester is the optimum time
Anesthesiologists (ASA) classification: for treatment; Sickle cell anaemia
ASA I Healthy Best where possible to avoid prescribing Sickle cell anaemia is an inherited
ASA II Mild systemic disease – No drugs; haemoglobinopathy found in individuals
functional limitation If prescriptions are necessary, check in the of African, Asian and Mediterranean origin.
ASA III Severe systemic disease – Definite British National Formulary (BNF); In situations of lowered oxygen tension
functional limitation Drugs taken by mother while breast-feeding the abnormal haemoglobin results in red
ASA IV Severe disease – Constant threat to can be transferred in some cases to breast milk blood cells becoming sickle-shaped, leading
life − check in the BNF; to increased blood viscosity and capillary
ASA V Moribund Local anaesthetic containing adrenaline is thrombosis. It can present either as a sickle cell
ASA VI Brain dead patient whose organs are acceptable; trait (heterozygous) or sickle cell anaemia itself
to be removed for donor purposes. Patients who faint or feel faint should be (homozygous).
This categorization is referred to in some treated in the left lateral position to avoid
protocols and also facilitates communication pressure on the inferior vena cava and
between clinicians. minimize risk of supine hypotension syndrome; Thalassaemias
Intravenous sedation must be avoided in the Thalassaemias are inherited
Specific situations and management first trimester and the last month of the third as autosomal recessive disorders in which
considerations trimester and ideally best avoided completely; there is decreased synthesis of either
Nitrous oxide can interfere with vitamin B12 alpha or beta globin chains. This allows
Pregnancy and folate metabolism − should not be used less normal haemoglobin to be produced.
Pregnant patients require special in first trimester − if used, exposure should Seen in Mediterranean races, patients with
Disorder Relevance to Patient Management
Disorders of haemostasis: Liaise with haematologist. Full blood count needed.
Thrombocytopaenia Platelet levels >50 x 109/L − advisable to treat in hospital setting.
DentalPractice
thalassaemia suffer from haemolytic anaemia. of dental treatment and the use of other drug also interacts with preparations that
Local anaesthesia is safe, general anaesthesia medications. Well known examples of drugs dentists may prescribe.8 The absorption of
or intravenous sedation should only be that are highly relevant in the context of dental paracetamol and orally administered diazepam
carried out after assessment by a specialist treatment include anticoagulants, such as is delayed and reduced due to delayed gastric
anaesthetist. warfarin and dabigatran and bisphosphonates. emptying. Carbamazepine reduces serum
Osteonecrosis is a recognized methadone levels and methadone increases
Leukaemias complication of bisphosphonate treatment.5 the effects of tricyclic antidepressants.
Liaison with a haematologist The condition is defined as the presence of Amphetamines and ecstasy may
is important due to the potential difficulty exposed bone for longer than 8 weeks in the produce thrombocytopaenia. Concomitant use
in controlling post-operative bleeding and absence of radiotherapy treatment but in with monoaminoxidase inhibitors and tricyclic
increased risk of infection. a patient who is using bisphosphonates. It antidepressants can precipitate a hypertensive
is diagnosed clinically but local malignancy crisis.
must be excluded.6 The bisphosphonates are Patients who abuse cocaine are
Steroid treatment
a group of drugs which include alendronic subject to increased risk of the effects of
Patients taking long-term
acid and risedronate sodium. These drugs ischaemia leading to loss of tissue. Testing
corticosteroid therapy will normally carry a
become adsorbed onto hydroxyapatite crystals the ‘quality’ of the drug by rubbing on the
steroid treatment card giving details of the
thereby slowing their rate of dissolution oral mucosa to test depth of anaesthesia
drug being used, its dosage and duration
and growth. Such drugs have been used in may lead to loss of gingivae and alveolar
of treatment. If steroid supplementation is
the management of osteoporosis in post- bone. An increased incidence of dental
required prior to treatment, acute adrenal
menopausal women, patients with bony caries may be seen if cocaine is bulked
insufficiency can be prevented. An increased
metastases and the hypercalcaemia of out with carbohydrates. As with heroin,
dose of corticosteroid should be administered
malignancy. thrombocytopaenia may be seen and, like
prior to treatment in such cases. Simple dental
Clearly, it is preferable to avoid cannabis, cocaine has a sympathomimetic
extractions and restorative dental procedures
dental extractions if possible in patients action.
are not usually a cause for concern,3 but
taking bisphosphonates. Local guidelines LSD (lysergic acid diethylamide) is
surgical extractions, the placement of
should be consulted when extractions are an hallucinogenic drug. Such drugs increase
dental implants or treatment under general
unavoidable in these patients. Established the incidence of bruxism and patients taking
anaesthesia are a potential risk.
cases of osteonecrosis require analgesia, and it may present with TMJ dysfunction. Dentists
long-term antiobiotic therapy and topical should be aware that stressful situations may
Angioedema antiseptic therapy if infected. Occasionally, cause flashbacks and panic attacks in these
In angioedema, widespread careful local debridement may be indicated to patients.
oedema may occur in response to quite remove limited bony sequestra.7 Risk factors A reduction in the dose of
trivial trauma as a result of increased vascular that increase the possibility of osteonecrosis adrenaline containing local anaesthetics
permeability. Two forms exist, one is hereditary developing include local infection, steroid is recommended in those who chronically
and is due to a lack of C1 esterase inhibitor use, trauma, chemotherapy and periodontal abuse solvents as such agents can sensitize
with resultant initiation of the complement disease. the myocardium to the actions of the
cascade. Administration of pre-operative As well as effects on bone, it catecholamine. Solvent abuse also increases
fresh frozen plasma (FFP) provides sufficient is thought that bisphosphonates might the risk of convulsions and status epilepticus
inhibitor to prevent the problem occurring. have toxic effects on soft tissues around an may occur.
The non-hereditary type is similar to urticaria extraction site, impairing the function of Some patients may abuse anabolic
in which certain food and drugs produce an vascular and epithelial cells. steroids and performance enhancers, which
allergic response. Trauma tends not to produce may precipitate increased carbohydrate
serious complications in this type. Clearly, consumption with its inevitable effects on the
’Recreational’ drugs
liaison with an immunologist is important in dentition. The systemic effects of adrenaline in
The use of drugs of abuse is
managing these patients. dental local anaesthetics can be exacerbated
common and dentists should have a working
by the sympathomimetic effects of certain
knowledge of the implications for patients
anabolic steroid drugs. As with many other
Medications and drugs who say that they are using these. Cannabis
illicit drugs, anabolic steroids may interfere
All medications or drugs that the has a sympathomimetic action and in theory
with blood clotting.
patient may be taking should be included.4 could exacerbate the systemic effects of
This should include ‘recreational’ drugs and adrenaline in dental local anaesthetics. Heroin
homeopathic or other over-the–counter and methadone are opioid drugs, the latter Complementary therapies
preparations. In addition, it is pertinent to ask being used in rehabilitation programmes. Oral Complementary therapies
about inhaled or topical medicines as many methadone has a high sugar content that are often used by patients. It is important
patients do not consider these as ‘drugs’. can cause rampant caries. Heroin can cause to remember possible interactions with
Concurrent drug therapy can impact upon oro- thrombocytopaenia. Some of those addicted prescription drugs, some of which may be
facial signs and symptoms, the safe provision to heroin have a low threshold for pain. The prescribed by dental practitioners. Some of
310 DentalUpdate May 2015DentalPractice
the more common interactions are shown in drugs or complementary therapies. The system whether e-cigarettes are an effective smoking
Table 2. of units for measuring alcohol consumption is cessation method.9
summarized as follows: Finally, information concerning the
A pint of ordinary strength lager − 2 units patient’s home circumstances is significant. It
Past dental history
A pint of strong lager − 3 units is particularly important to find out whether
The past dental history assumes
A pint of ordinary bitter − 2 units a patient lives with another ‘competent’ adult
different forms, depending on the patient’s
A pint of best bitter − 3 units as, in cases of intravenous sedation or day case
previous exposure to dental treatment. It is
A pint of ordinary strength cider − 2 units general anaesthesia, the patient should not be
clearly relevant to find out whether a patient
A pint of strong cider − 3 units left alone for 24 hours following the procedure.
is a regular attender and of their previous
A 175 ml glass of red or white wine around Disorders with a genetic origin
experience of dental treatment and its nature.
2 units should be recorded.
The previous use of local anaesthetic agents
and any associated problems can be checked. A pub measure of spirits − 1 unit
If not covered by the previous history, adverse An ‘alcopop’ around 1.5 units Psychiatric history
events, such as post-extraction haemorrhage, The patient’s occupation (or previous The psychiatric history is not
may be highlighted at this point. occupation if retired) is also important. included as routine but may be relevant in
Clinicians identifying patients some cases.10
who smoke should inform the patient of the
Social history/family history availability of smoking cessation services after
Systems review
The social history is often it has been ascertained whether the patient
In hospital practice, a body
neglected but clearly it is an important part of wishes to try and quit. Some patients will be
systems review is undertaken after the
the comprehensive assessment of a patient. using e-cigarettes. It is worth being aware that
preliminary history. Whilst this would rarely
It may directly influence treatment or the way the long-term safety of the e-cigarette is not
be used in mainstream dental practice, it is
it is delivered. As a minimum, enquiry should yet established but it is thought that they are
discussed here to highlight its effectiveness on
be made of the patient’s smoking status and likely to be less harmful than conventional
medically assessing various systems.
alcohol consumption, and if positive these cigarettes. Patients should be advised to seek
should be quantified. It is at this point that smoking cessation services if they are willing General enquiry
patients may disclose the use of ‘recreational’ to try and quit. It is not fully established It is worth starting with a series
HERB CONVENTIONAL DRUG POTENTIAL PROBLEM
St John’s wort Monoamine oxidase inhibitor and Serotonin Mechanism of herbal effect uncertain.
reuptake inhibitor
Insufficient evidence of safety with
Antidepressants concomitant use − therefore not advised
Iron May limit iron absorption
Karela, ginseng Insulin, sulphonylureas, biguanides Altered glucose concentrations
Feverfew, garlic, ginseng, ginger Warfarin Altered prothrombin time/INR
Echinacea used for >8 weeks Anabolic steroids, methotrexate, Amiodarone, Hepatotoxicity
ketoconazole
Feverfew Non-steroidal anti-inflammatory drugs Inhibition of herbal effect
Ginseng Oestrogens, corticosteroids Additive effects
Evening primrose oil Anticonvulsants Lowered seizure threshold
Kava Benzodiazepines Additive sedative effects, coma
Echinacea, zinc (immunostimulants) Immunosuppressants (such as Antagonistic effects
corticosteroids, ciclosporin)
Table 2. Complementary medicines and their interactions with conventional medicines with potential consequences.
May 2015 DentalUpdate 313DentalPractice
of general questions that may highlight
Medical Problem Implications for Management relevant conditions that otherwise may
be missed from the more specific systems
Valve replacement, structural cardiac No antibiotic cover required. Consideration review.11 Such findings include:
defect should be given of a recent publication Appetite, weight loss;
suggesting a possible re-think on this in the Lethargy or fatigue;
future.12 Currently, no change in guidelines.
Fevers;
The presence of any lumps, bumps or
Myocardial infarction No elective dental treatment for 3 months swellings;
after an MI. Ideally no general anaesthetic The presence of skin rashes (especially if
for the first 6 months. associated with oral mucosal lesions).
Angina Ensure availability of emergency drugs and
oxygen. Enquire about frequency of attacks, Cardiovascular system
their precipitation and effectiveness of GTN. A differential diagnosis of chest pain
(bearing in mind other potential causes)
In oral surgical cases if more than includes: – Angina;
Hypertension
160/100 mmHg, consider postponing until – Myocardial infarction;
better control. In acute situations IV sedation –Oesophageal reflux;
may be helpful. –Musculoskeletal;
–Pleuritic (for example pulmonary
Table 3. Cardiovascular disorders and potential management implications. embolism);
–Hyperventilation;
Medical Problem Implications for Management –Referred pain from the
abdomen.
Liver Disease Potential for bleeding problems, care with drug prescriptions, Does the chest pain occur at rest or after
infection risk from various types of hepatitis virus. For exertion − how much exertion?;
treatment under LA a minimum of a coagulation screen Dyspnoea (remember potential
and full blood count should be carried out. If liver function respiratory causes either co-existing or in
(assessed via liver function tests) is impaired, LA and isolation);
particularly sedation should be carried out with caution. The Does breathlessness occur at rest/on
BNF has an Appendix (2) which highlights drugs to be used exertion?;
with caution (or not at all) in patients with liver disease. Paroxysmal nocturnal dyspnoea (waking
from sleep feeling breathless) or
Table 4. Liver disease and management implications.
orthopnoea (breathlessness on lying flat);
Palpitations;
Medical Problem Implications for Management Prosthetic/replacement heart valves;
History of rheumatic fever and/or
Epilepsy Enquire about the nature of seizures and the degree of control infective endocarditis;
– timing and precipitation (if known) of last 3 seizures. Ask Claudication pains and what is required
about recent changes in medication and why this was thought to precipitate them.
necessary. Ensure that buccal midazolam is available.
Table 5. Epilepsy and management implications. Cardiovascular disorders and potential
management implications
Medical Problem Implications for Management Cardiovascular disorders and
potential management implications are
Kidney Disease Renal dialysis patients are best treated the day after dialysis as summarized in Table 3.
renal function optimal and heparin effect has worn off. Renal
transplant patients may be immune-suppressed and heightened
Respiratory system
vigilance for oral infection and cutaneous malignancy should
Breathlessness/wheeziness;
be remembered. Do not assume normal renal function after
The presence or otherwise of a cough, its
a kidney transplant – a urea and electrolyte blood test/liaison
duration and whether productive or not;
with the renal physician should be undertaken. The BNF has an
Haemoptysis (coughing up blood);
appendix which details the drugs contraindicated/to be used
History of known respiratory disorders
with caution in patients with renal disease.
and exacerbations − note the degree of
Table 6. Kidney disease and implications for patient management. success of treatment (judged by control/
relief of symptoms).
314 DentalUpdate May 2015DentalPractice
Gastrointestinal system References
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Odynophagia (pain on swallowing); 7th edn. Chapter 2: Medical history
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