Preoperative Health Status Evaluation

Biographic Data

The first information to obtain from a patient is biographic data. These data include the patient's full name, home address, age, gender, and occupation, as well as the name of the patient's primary care physician. The clinician uses this information, along with an impression of the patient's intelligence and personality, to assess the patient's reliability. This is important because the validity of the medical history provided by the patient depends primarily on the reliability of the patient as a historian. If the identification data and patient interview give the clinician reason to suspect that the medical history may be unreliable, alternative methods of obtaining the necessary information should be tried. A reliability assessment should continue throughout the entire history interview and physical examination, with the interviewer looking for illogical, improbable, or inconsistent patient responses that might suggest the need for corroboration of information.

Chief Complaint

Every patient should be asked to state their chief complaint. This can be accomplished on a form the patient completes, or the patient's answers should be transcribed (preferably verbatim) into the dental record during the initial interview by a staff member or the dentist. This statement helps the clinician establish priorities during history taking and treatment planning. In addition, having patients formulate a chief complaint encourages them to clarify for themselves and the clinician why they desire treatment. Occasionally, a hidden agenda may exist for the patient, consciously or subconsciously. In such circumstances, subsequent information elicited from the patient interview may reveal the true reason the patient seeks care.

History of Chief Complaint

The patient should be asked to describe the history of the present complaint or illness, particularly its first appearance, any changes since its first appearance, and its influence on or by other factors. For example, descriptions of pain should include date of onset, intensity, duration, location, and radiation, as well as factors that worsen and mitigate the pain. In addition, an inquiry should be made about constitutional symptoms such as fever, chills, lethargy, anorexia, malaise, and any weakness associated with the chief complaint.

This portion of the health history may be straightforward, such as a 2-day history of pain and swelling around an erupting third molar. However, the chief complaint may be relatively involved, such as a lengthy history of a painful, nonhealing extraction site in a patient who received therapeutic irradiation. In this more complex case, a more detailed history of the chief complaint is important to obtain.

Medical History

Most dental practitioners find health history forms (questionnaires) to be an efficient means of initially collecting the medical history, whether obtained in writing or in an electronic format. When a credible patient completes a health history form, the dentist can use pertinent answers to direct the interview. Properly trained dental assistants can “red flag” important patient responses on the form (e.g., circling allergies to medications in red or electronically flagging them) to bring positive answers to the dentist's attention.

Health questionnaires should be written clearly, in nontechnical language, and in a concise manner. To lessen the chance of patients giving incomplete or inaccurate responses, and to comply with Health Insurance Portability and Accountability Act regulations, the form should include a statement that assures the patient of the confidentiality of the information and a consent line identifying those individuals the patient approves of having access to the dental record, such as the primary care physician and other clinicians in the practice. The form should also include a way (e.g., a signature line or pad) for the patient to verify that he or she has understood the questions and the accuracy of the answers. Numerous health questionnaires designed for dental patients are available from sources such as the American Dental Association and dental textbooks ( Fig. 1.1 ).

Answers to the items listed in Box 1.2 (collected on a form via touch screen or verbally) help establish a suitable health history database for patients; if the data are collected verbally, subsequent written documentation of the results is important.

In addition to this basic information, it is helpful to inquire specifically about common medical problems that are likely to alter the dental management of the patient. These problems include angina, myocardial infarction (MI), heart murmurs, rheumatic heart disease, bleeding disorders (including anticoagulant use), asthma, chronic lung disease, hepatitis, sexually transmitted infections, diabetes, corticosteroid use, seizure disorder, stroke, and any implanted prosthetic device such as artificial joint or heart valve. Patients should be asked specifically about allergies to local anesthetics, aspirin, and penicillin. Female patients in the appropriate age group must be asked at each visit whether they are or may be pregnant.

A brief family history can be useful and should focus on relevant inherited diseases such as hemophilia ( Box 1.3 ). The medical history should be regularly updated. Many dentists have their assistants specifically ask each patient at checkup appointments whether there has been any change in health since the last dental visit. The dentist is alerted if a change has occurred, and the changes are documented in the record.

Review of Systems

The medical review of systems is a sequential, comprehensive method of eliciting patient symptoms on an organ-by-organ basis. The review of systems may reveal undiagnosed medical conditions. This review can be extensive when performed by a physician for a patient with complicated medical problems. However, the review of systems conducted by the dentist before oral surgery should be guided by pertinent answers obtained from the history. For example, the review of the cardiovascular system in a patient with a history of ischemic heart disease includes questions concerning chest discomfort (during exertion, eating, or at rest), palpitations, fainting, and ankle swelling. Such questions help the dentist decide whether to perform surgery at all or to alter the surgical or anesthetic methods. If anxiety-controlling adjuncts such as intravenous (IV) and inhalation sedation are planned, the cardiovascular, respiratory, and nervous systems should always be reviewed; this can disclose previously undiagnosed problems that may jeopardize successful sedation. In the role of the oral health specialist, the dentist is expected to perform a quick review of the head, ears, eyes, nose, mouth, and throat on every patient, regardless of whether other systems are reviewed. Items to be reviewed are outlined in Box 1.4 .

The need to review organ systems in addition to those in the maxillofacial region depends on clinical circumstances. The cardiovascular and respiratory systems commonly require evaluation before oral surgery or sedation ( Box 1.5 ).

Cardiovascular Problems