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Who Needs a Medical History Anyway?

In spite of all of the technology available today, the medical history is still the mainstay of diagnosis. The impact of social, environmental, hereditary and behavioral factors on a patient’s well-being and illness must be realized in the patient’s history.

What is a medical history?

A person’s medical history is made up of many different pieces of information that tell the complete story about that individual’s current and past health. A complete medical history record should include information on the person’s: medical conditions, known allergies, current medications, emergency contact information, family medical history, insurance information.

Unfortunately, most patients do not realize how important these pieces of information are to their dental provider. They assume that because it’s a dental office all these details are not really needed so what ends up happening with frequency is that patients return incomplete medical history forms. The provider reviews it with the patient and to the provider, it seems that this patient is clear for treatment and so the treatment is begun. People often think: “what can possibly go wrong at a dentist office?” Let’s see some examples.

Scenario 1

Mr. Smith, a 35-year-old male patient, presented at an oral surgeon`s office with a history of hypertension that was controlled by the drug Inderal. Inderal is a beta blocker that should not be taken with epinephrine. The combination can cause a hypertensive crisis and/or bradycardia.

Mr. Smith was referred to the oral surgeon for the extraction of tooth #3. He had a 3 p.m. appointment, and he arrived five minutes before the appointment. The dental assistant seated Mr. Smith and reviewed his medical history. Patient neglected to include his condition and the medication he was taking in the medical history and did not mention it to the dental assistant or to the doctor.

The doctor administered a dental anesthetic which contained epinephrine. Immediately after the extraction, Mr. Smith started suffering from intense palpitations, he’s blood pressure elevated and had to be rushed immediately to the hospital.

Scenario 2

Mr. H presented to his dentist for periodontal treatment (Scaling and Root Planing). Mr. H neglected to mention in his medical history that he’d had a diseased heart valve replaced with a prosthetic one four months earlier. Eight months later, Mrs. H called to say her husband had passed away.   An autopsy confirmed that her husband had developed prosthetic valve endocarditis (PVE), reportedly caused by the dental treatment.

 

The accuracy and completeness of the information contained in a patient’s history is essential for optimal patient care. A complete and accurate history is the foundation for all patient care. It is also important to maintain medical history up to date. Any new or discontinued medications, new conditions, new allergies, or changes in socio- or demographic information should be mentioned to your dental provider. Drug-to-drug interactions are a significant cause of patient morbidity and mortality and that’s one of the main reasons to always provide a complete list of medications including any supplements. Whether its echinacea or aspirin, always tell your dentist about any medications and supplements you are taking.

Everything you ingest, even vitamins, causes a certain reaction. If your dentist doesn’t know what drugs or supplements you have taken, he or she will not know how to protect you from possible substance interactions. This is particularly important if you are undergoing any surgical treatment.

For example; Ginkgo biloba and vitamin E can be dangerous when taken with aspirin because they each can act as blood thinners. The combination may cause difficulties in blood clotting, which could be serious for patients undergoing surgery. Taking high dosages of vitamins before undergoing anesthesia can also cause concern. In particular, vitamin C, often taken in high dosages for cancer treatment, can weaken the efficiency of anesthesia, among other problems. Calming supplements, such as Kava Kava or St. John’s Wort, can strengthen the effects of anesthesia.

When medical history is documented properly it assures that the provider will be able to give the most appropriate and effective treatment and support for the individual so that they maintain the best possible health.

 

 

 

Works Cited

PSIC. “Why the Patient History Is So Important.” 2011. psicinsurance. 8 March 2017 <https://www.psicinsurance.com/webres/File/physicians/connection_publication/2011_Issue4.pdf >.

“Understanding the Importance of Medical History.” 6 October 2011. ddssafety. 8 March 2017 <http://www.ddssafety.net/sites/default/files/attachments/10-06-11/FAMedicalHistory_0.pdf>.

“Using herbal supplements? Why you should tell your dentist.” deltadentalins. 8 March 2017 <https://www.deltadentalins.com/oral_health/herbal_supplements.html>.

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Charlotte Dentistry®
Armstrong & Eshleman, PA

201 Providence Road
Charlotte, NC 28207
704-376-6470
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