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The medical history mistake every dental provider makes
It was a typical weekday in my private office. I was about one year out of hygiene school and had proudly mastered my time management in the operatory. In this office, I was hired to not only see a column of hygiene patients on the hour but also to anesthetize the doctor’s restorative and surgical patients. I still moonlight at this office from time to time, and I still receive comments from my colleagues asking, “How do you do it?” or “I would never agree to that.” Despite the busy days, I grew in my anesthesia, anatomy and pain management skills immensely, and for what it’s worth, I saw this hectic schedule as an opportunity to grow.
As per usual, I received a note from an assistant asking me to deliver anesthetic to a patient for fillings. I excused myself from my hygiene patient, hopped over to the next operatory and introduced myself to the doctor’s restorative patient. While slathering on hand sanitizer and gloving up, I performed a quick skim of the health history and muttered, “Any changes to the health history?” in between asking my patient about her weekend plans. After a verbal “nope!” from the patient, I delivered the most gorgeous Gow-Gates Mandibular Block injection (I know what you’re thinking: I have never and will never use an Inferior Alveolar nerve block for mandibular anesthesia). Upon recapping my needle and internally celebrating how awesome I am for nailing the anatomy of my injection, my patient began to experience some adverse effects.
First, she asked me to sit her up, as she was beginning to feel nauseous. She was a petite 19-year-old with a clean health history, and my one-year of clinical practice ego had been jolted. “Have you eaten this morning?” “Do you think you might have caught a flu bug?” “Have you reacted to anesthesia before?” The questions were racing, not in my mind, but out loud in a series of frantic verbal slurs to my patient. Immediately I began to mentally check the boxes: Did I overdose her? No. Did I deliver the injection intravenously? No. Did I deliver the anesthetic too quickly? No. I was lost and concerned for my patient, particularly when she awkwardly maneuvered among the cords and large equipment in my operatory to find the sink while muttering, “I think I’m going to throw up.” I asked my patient if I could do anything to make her feel more comfortable. Her response, “No, it’s probably just my morning sickness," to which I promptly felt like I was going to throw up.
After a few deep breaths and a giant swallow of my pride, I calmed myself in order to better evaluate the situation. Luckily, I had delivered my block with 2% lidocaine 1:100,000 epinephrine, a pregnancy category class B drug that’s considered suitable for pregnant patients (although several OBGYN physicians aren’t permitting the use of vasoconstrictor for concerns of elevated fetal heart rates, but maybe that’s for another article…). The use of 20% benzocaine topical was a slight concern, as it’s considered a category class C drug; however, such a small dose is systemically absorbed from the mucosal tissue and typically doesn’t dramatically affect fetal wellness. The patient was clearly still in her first trimester, as she was experiencing morning sickness and didn’t even have the small “Chipotle baby bump” showing on her tiny frame.
I immediately informed her of the concern I had with regards to delivering anesthetic for elective care during her first trimester, which was minor when compared to the concern I had that PREGNANCY didn’t ring a bell for her when I asked if there were any changes in her medical history.
It was then that I realized my mistake: I had assumed, which my Midwestern dad taught me years ago makes a you-know-what out of you and a you-know-what out of me. While I couldn’t fathom how she lacked understanding about how her pregnancy qualified as a medical history update, I also recognized that I was not being very comprehensive in my medical history review. In fact, what kind of training had I received, via dental hygiene school some blah-blah-blah years ago or continuing education, that qualified “any changes?” as an appropriate medical history review?
As professionals, I think most of us can agree that private practice not only allows but also requires us to abbreviate many of the habits we were taught to be right as young dental hygiene students. Over the years, I’ve certainly developed various efficiencies that have helped me stay on task and on schedule. However, at what point have we gone too far? At what point are we no longer serving our patients but rather serving the timeliness of the schedule?
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This occurrence happened many years ago. I’m relieved to share that since this experience, my patient delivered and has raised a happy and healthy young boy who got his biannual happy visits with our office and is now old enough to seek the precious care of our orthodontist. Not only am I grateful that I upheld my oath to “do no harm,” I’m also grateful for the ways in which I grew from this experience.
To this day, I have several health history review protocols that I have implemented into my personal practice protocol (say that five times fast!) and continually stand by:
1. Update the health history at appropriate intervals. While there are no strict ADA guidelines for the frequency of completed medical histories, it’s important for each dental office to establish and maintain guidelines for how frequently patients are being required to complete a medical history. Most published authors recommend having the patient complete a full medical history form every three years. However, many patients who have complicated medical histories are consistently adding/discontinuing medications or experience dramatic changes in their health status may need to complete a full medical history form sooner than every three years. But the burden of attaining appropriate medical history updates falls on the dental provider, and it’s recommended that at least annually, the patient is required to complete an abridged medical history update form. A verbal medical history review must be done at every patient visit, and this verbal medical history must be documented in the clinical notes.
2. Evaluate the questions on your form. Just as research continues to evolve, so should our documentation. It’s important for dental offices to periodically review their complete medical history forms as well as their update forms for prompts that need to be removed or must be added. For example, research is linking increased levels of P. gingivalis to infertility, Fusobacterium nucleatum to colorectal cancer and identifying Human Papillomavirus within the oropharynx. Would your office consider integrating screening questions about recent fertility issues, cancer screenings or new diagnosis of HPV? New guidelines for stages of hypertension and identification of prediabetic patients are improving opportunities for providers to have robust conversations with patients about their chronic disease risk factors. New medications, increasing dosages, or altering medications can provide significant information about changes in the oral microflora. I encourage you to take the time - perhaps once per year - to evaluate your medical history forms, ensure they’re serving your patient population to the best of their ability and make changes where necessary.
3. Review the medical history yourself. I worked in an office where the front desk staff would have the patient fill out an updated medical history, but the staff members were too backed up to input the medical history alerts into our software in that moment. So, the completed medical history update form would loiter at the front desk while I seated my patient, asked a brief set of medical history questions and began the hygiene appointment. I learned immediately that was a bad idea when my 20-something 6-month recare patient presented with symptomatic linear gingival erythema. Imagine how ridiculous I looked when I began a delicate and sensitive conversation with my patient about if he had a recent CD4 or white blood cell count only to find out that he had already shared his new diagnosis with HIV on his update form. I would have likely been more prepared to have an informed conversation with my patient if I would have had an opportunity to read the form that was being held hostage by the friendly check-in desk. Bottom line: It shouldn’t be asking too much to have the individual with the letters after their name and the licenses hanging on the wall review the medical history in its entirety prior to treating the patient.
4. Do not take anyone else’s word for it. I temp in an office where I work a double-column, assisted hygiene schedule. One of the benefits and concerns regarding double-column hygiene is the amount of trust instilled to the assistant. While I certainly trust my assistant, the reality is this: If I make a critical mistake in my patient care, I’m the one defending my license at the state board, not my assistant. While I entrust that my assistant does a beautiful job with the medical history review, I ALWAYS check the health history myself to ensure I’m knowledgeable about systemic diseases, potential need for treatment modifications, or possible premedication or cardiac dose of vasoconstrictor considerations.
5. Change your verbiage. It was clear that my biggest mistake was asking, “Any changes to your medical history?” Many patients still don’t understand the relevance of their medical conditions to their dental care. It’s our job to connect those dots through comprehensive education to our patients. For some patients, a new heart surgery, joint replacement or, dare I say, pregnancy may not seem significant enough to bring up to their dental provider. It’ imperative that we take the time necessary to be verbose in our comprehension of our patients’ histories. My scripted “Any changes to your medical history?” evolved into asking about any new surgeries or hospitalizations; I inquire about any new diagnoses of conditions by their doctor; I ask them about the last visit they had with their primary care physician; I read aloud the list of medications I have on file while confirming why the patient is taking each medication; I ensure I have all drug allergies updated on my forms; and finally, I ask them if there is anything else I need to know about their medical conditions before I treat them today. Is that a bit much? Maybe, but for the majority of my patients, this review takes less than two minutes and is typically done while I’m washing my hands and gloving up for patient care. Surprisingly, patients appreciate the attentiveness to their unique medical and dental concerns while still getting the chance to complain about how annoying X-rays are or having to experience an awkwardly long makeout session with my slow-speed suction.
As dental hygienists, inflammatory specialists, oral health providers and preventive care personnel, we experience the incredible manifestations of the oral-systemic link on an hourly basis. While it’s easy to get swept up in the hustle and bustle of our busy schedules, it’s important for us to remember the imperative ways in which we’re tasked with the incredible responsibilities of ensuring overall health and wellness of our patients and their quality of life.
Our dental hygiene oath reminds us of the role we play in committing to the improvement of oral health for the public, to the advancement of the art and science of dental hygiene and to promote the highest standards of quality patient care. I encourage you to consider the beautiful professional responsibilities you’ve been gifted with as a dental professional and, in doing so, consider a new approach to the most awkwardly close-ended but strangely open-ended question we all ask our patients: “Any changes?”