Subject: Medical History

More than 200,000,000 persons seek dental care annually in the United States.¹ There is an expectation that dental care is provided to these patients in a safe and effective manner. When a patient makes regular, non-emergent visits to the same dentist for treatment (i.e., has a dental home), the dentist may be quite familiar with the patient and the patient’s family. However, not all dental care is regularly scheduled, and many patients receive care in an episodic manner. Whether the care is routine or episodic, the dentist is responsible for the proper evaluation of the patient. An important initial step in the evaluation process is taking a thorough medical history. 

The medical history should accurately reflect the past and current health status of the patient. The history is derived from information provided by the patient and can be obtained from written information on a standardized form or electronically.² Health history information may also be obtained from prior medical or dental records or from family or caregivers. Regardless of the mode, the medical history should be a thorough and accurate assessment of the patient’s systemic conditions and diseases and include evaluation of organ dysfunction and inflammatory, infectious, metabolic, degenerative, and neoplastic diseases, as well as past and present medical therapies.^2,3 The dentist should be aware that medical history questionnaires and information supplied by patients regarding their medical history do not always provide accurate information^4,5 and that referral letters are often incomplete.⁶ Thus, the method of dialogue with the patient should be utilized to review the historical information and confirm its accuracy.⁷ Methods should be employed such that the patient is notified in advance of the appointment to bring information regarding current and past medical conditions; primary care physician’s name, address, and phone number; and a list of current and past medications, including alternative or homeopathic formulations. A complete medical history is helpful in identifying not only existing disease conditions but also disease severity and stability.⁸ This information, in turn, is important for understanding the potential relationships among, and the impact of, systemic health, medications, and past and current therapeutic interventions on the patient’s orofacial health and the ability of the patient to tolerate dental treatment.

1. The AAOM recognizes that
1. The medical history is a key component of dental care
2. Careful review of the medical history promotes awareness of diseases, conditions and therapies that can impact or interfere with a patient’s dental treatment
3. The medical history should be obtained prior to the performance of the physical examination.

4. The medical history is integral to assessing the patient and establishing rapport.

2. The AAOM thus encourages dental care providers to obtain an accurate and thorough medical history on all patients.
   
   
3. The AAOM recognizes that the medical history should provide information regarding
1. Patient identifying and contact information
2. Date of the medical history
3. Current and/or prior dental practices in which dental care has been delivered
4. Significant medical diseases, as well as disorders of body systems and their symptoms
5. Present and clinically relevant prior medication use (prescription and over-the-counter) including dose when appropriate (e.g. warfarin, prednisone, etc.)
6. Past medical care, including hospitalizations
7. Bleeding and bleeding disorders
8. Allergies
9. Functional status, cardiac reserve, and mobility/ambulatory ability
10. Anxiety regarding dental care
11. Primary care physician information
12. Patient’s signature and date
13. Dentist’s signature and date
    
    
4. The AAOM recognizes that at each appointment the dental care provider should inquire as to and record
1. Changes in patient medical health since last appointment
2. Change in medications since last appointment
3. Visit(s) to a health care provider(s) since last appointment and the reason and outcome of that visit
   
   
5. The AAOM recognizes that
   1. The medical history should be updated at each dental visit based upon the planned dental treatment for that visit
   2. The medical history should typically be comprehensively updated on an annual basis, or more frequently depending upon the medical complexity of the patient
      
      
6. The AAOM recognizes that
1. A medical consultation should be obtained when the patient's medical history is incomplete or unclear.
2. An incomplete medical history can be a reason for deferral of care

1. Centers for Disease Control and Prevention. Surveillance for certain health behaviors among states and selected local areas d United States, 2010. MMWR. 2013;62:37.
2. Little JW, Falace DA, Miller CS, Rhodus NL, eds. Little and Falace’s Dental Management of the Medically Compromised Patient. 8th ed. St. Louis, MO: Elsevier Mosby; 2013:2-18.
3. Lockhart PB, ed. Oral Medicine and Medically Complex Patients. 6th ed. Ames, IA: Wiley-Blackwell; 2013:1-9.
4. Harrington KF, DiClemente RJ, Wingood GM, et al. Validity of self-reported sexually transmitted diseases among African American female adolescents participating in an HIV/STD prevention intervention trial. Sex Transm Dis. 2001;28: 468-471.
5. Pistorius A, Kunz M, Jakobs W, Willershausen B. Validity of patient-supplied medical history data comparing two medical questionnaires. Eur J Med Res. 2002;7:35-43.
6. DeAngelis AF, Chambers IG, Hall GM. The accuracy of medical history information in referral letters. Aust Dent J. 2010;55: 188-192.
7. De Jong KJ, Abraham-Inpijn L, Oomen HA, Oosting J. Clinical relevance of a medical history in dental practice: comparison between a questionnaire and a dialogue. Community Dent Oral Epidemiol. 1991;19:310-311.
8. LaRocca CD, Jahnigen DW. Medical  history and risk assessment. Dent Clin North Am. 1997;41:669-679.