Medical History Review and Assessment

Core Review

Components of a Comprehensive Medical History

A thorough medical history includes the following elements, each with specific clinical significance:

Identification and Demographics — Name, date of birth, emergency contact. Establishes patient identity and provides contact for emergencies.

Chief Complaint and History of Present Illness — The primary reason for the visit, documented in the patient's own words. Duration, location, severity, and character of symptoms.

Past Medical History — A systematic review of current and past conditions organized by body system:

Cardiovascular — Hypertension, coronary artery disease, myocardial infarction, angina, congestive heart failure, arrhythmias, stroke/TIA, valvular disorders, congenital heart defects. Known which conditions require antibiotic prophylaxis (per current AHA guidelines: prosthetic cardiac valves, history of infective endocarditis, specific congenital heart conditions, cardiac transplant with valvulopathy).

Respiratory — Asthma, COPD, emphysema, tuberculosis, sleep apnea. Asthma severity and triggers must be documented; patients with active respiratory infections may need treatment deferral.

Endocrine — Diabetes mellitus (type 1 and type 2), thyroid disorders, adrenal insufficiency. For diabetic patients, document HbA1c, recent blood glucose, timing of meals and medications relative to the appointment.

Hematologic — Anemia, bleeding disorders (hemophilia, von Willebrand disease), clotting disorders, anticoagulant therapy. INR values should be within therapeutic range before invasive procedures.

Hepatic — Hepatitis (A, B, C), cirrhosis, jaundice. Patients with liver disease may have impaired drug metabolism and increased bleeding risk.

Renal — Chronic kidney disease, dialysis, renal transplant. Patients on dialysis should be scheduled on non-dialysis days.

Neurologic — Seizure disorders, multiple sclerosis, Parkinson disease, dementia. Know seizure first aid and recognize that anti-seizure medications (phenytoin) can cause gingival hyperplasia.

Musculoskeletal — Arthritis, osteoporosis, joint replacement. Patients with recent joint replacement may require antibiotic prophylaxis per orthopedic surgeon consultation. Limited mobility may require positioning modifications.

Infectious Disease — HIV/AIDS, tuberculosis, hepatitis. Standard precautions apply universally; transmission-based precautions for active TB.

Autoimmune — Rheumatoid arthritis, lupus, Sjögren syndrome. Sjögren syndrome is strongly associated with xerostomia and increased caries risk.

Psychiatric — Depression, anxiety, bipolar disorder, schizophrenia. SSRIs can cause xerostomia; lithium can increase gag reflex.

Cancer History — Type, treatment (chemotherapy, radiation, bisphosphonate therapy). Head and neck radiation increases risk of xerostomia, caries, and osteoradionecrosis. Bisphosphonate therapy is a risk factor for medication-related osteonecrosis of the jaw (MRONJ).

Allergies — Document specific allergens and reaction type (rash, anaphylaxis, nausea). Distinguish true allergy from adverse effects or intolerance. Latex allergy requires latex-free environment. Local anesthetic allergies must be identified before administration.

Medications — Record all current medications including:

• Prescription medications (name, dose, frequency)
• Over-the-counter medications
• Herbal and dietary supplements
• Recreational substances

Medication review is essential because:

• Anticoagulants/antiplatelets increase bleeding risk
• Antihypertensives (particularly beta-blockers) can cause orthostatic hypotension
• Bisphosphonates increase MRONJ risk
• Calcium channel blockers, phenytoin, and cyclosporine can cause gingival overgrowth
• Anticholinergics, antidepressants, and antihistamines cause xerostomia
• Corticosteroids may require supplementation for adrenal insufficiency
• Diabetes medications interact with appointment timing

Surgeries and Hospitalizations — Document dates, procedures, and complications. Recent surgeries may require medical clearance. Cardiac surgeries are particularly relevant for endocarditis risk assessment.

Pregnancy — Document trimester, due date, and any complications. Dental hygiene care is safe during pregnancy, particularly the second trimester. Elective treatment is typically deferred during the first trimester (organogenesis) and late third trimester (supine hypotensive syndrome risk). Supine positioning should be modified with a right hip wedge to displace the uterus from the vena cava. Local anesthetics with epinephrine are generally considered safe during pregnancy. Radiographs may be taken with appropriate shielding when clinically necessary.

Tobacco Use — Document type (cigarettes, cigars, pipes, smokeless, electronic), frequency, duration, and pack-year history. Tobacco use is a major risk factor for periodontitis, oral cancer, implant failure, and delayed wound healing. All patients who use tobacco should receive tobacco cessation counseling as part of the dental hygiene process of care.

Alcohol and Substance Use — Document type, frequency, and quantity. Chronic alcohol use increases bleeding risk (liver damage), complicates anesthesia, and is associated with oral cancer (synergistic with tobacco). Substance use has implications for pain management, sedation, and potential drug interactions.

Review of Systems — A head-to-toe review of each body system to capture conditions or symptoms the patient may not have mentioned. Include questions about headache, vision changes, hearing loss, dysphagia, shortness of breath, chest pain, palpitations, nausea, abdominal pain, diarrhea, constipation, urinary frequency, joint pain, weakness, numbness, skin changes, and mood changes.

Medication History: Clinical Significance

The medication history is arguably the most clinically actionable component of the medical history. Key considerations:

Bleeding Risk Medications:

• Warfarin (Coumadin): Check INR; therapeutic range typically 2.0-3.5 for most indications. Routine scaling and root debridement is generally safe if INR is within therapeutic range.
• Direct oral anticoagulants (apixaban, rivaroxaban, dabigatran): No routine lab monitoring; consult prescribing physician for management.
• Antiplatelets (aspirin, clopidogrel): Routine dental hygiene procedures can be performed without discontinuation.

Medications Causing Xerostomia:

• Over 400 medications list xerostomia as a side effect
• Most common: anticholinergics, antidepressants (SSRIs, TCAs), antihistamines, decongestants, diuretics, antihypertensives, opioids
• Xerostomia significantly increases caries risk; fluoride therapy and salivary substitutes should be recommended

Medications Associated with Gingival Overgrowth:

• Calcium channel blockers (nifedipine, amlodipine)
• Phenytoin (Dilantin)
• Cyclosporine
• Onset typically within 3 months of starting medication; improved oral hygiene reduces severity

Bisphosphonates and MRONJ:

• Oral bisphosphonates (alendronate, risedronate) for osteoporosis: risk increases after 3+ years
• IV bisphosphonates (zoledronic acid) for cancer: significantly higher risk
• Non-surgical periodontal therapy is generally safe; surgical procedures require consultation

Updating the Medical History

The medical history is not a one-time event. It must be:

• Updated at every appointment — Ask: "Has anything changed in your health or medications since your last visit?"
• Reviewed before treatment — Never proceed without a current medical history
• Documented — Include date of review and clinician initials

Clinical Application

A 72-year-old patient presents for continuing care. Medical history update reveals: new diagnosis of atrial fibrillation started on warfarin (INR 2.5), continued use of amlodipine for hypertension (noted mild gingival overgrowth on the facial of teeth #24-25), and a new prescription for alendronate for osteoporosis (started 2 years ago). The patient also reports dry mouth, which correlates with the new addition of cetirizine (antihistamine) for seasonal allergies.

Clinical decisions: (1) INR 2.5 is within therapeutic range — proceed with routine scaling and root debridement; (2) reinforce oral hygiene instruction to minimize amlodipine-related overgrowth; (3) alendronate 2 years — non-surgical periodontal therapy is appropriate, document and monitor; (4) recommend fluoride varnish and xylitol products for xerostomia management; (5) discuss antihistamine alternatives with the patient's physician if dry mouth becomes problematic.

Common Traps

• TRAP: Assuming the medical history from last visit is still accurate. Always update and document.
• TRAP: Confusing true allergy with adverse effect. Anaphylaxis = allergy; nausea from opioids = adverse effect.
• TRAP: Forgetting herbal supplements. Ginkgo biloba, garlic, ginseng, and fish oil all have antiplatelet effects.
• TRAP: Failing to defer treatment for uncontrolled conditions. BP >180/110 mmHg = elective treatment deferred.
• TRAP: Not recognizing that the medical history drives the entire treatment plan — it is not just paperwork.