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Medical History


A patient’s health history is a legal document, and it’s essential to be thorough when obtaining information that could affect a patient’s dental outcome. With limited time in a dental hygiene appointment, it can be difficult to obtain the necessary information to best treat patients. However, it is your ethical duty as a licensed professional to properly assess and document all information, even if you don’t think it’s pertinent at the time. For optimal patient care and a better outcome, the clinician and

the patient need to become partners in the assessment process.

Published July 27, 2022


Reviewing the patient’s medical history at every appointment is not the only assessment we should be addressing. I know when you land your first clinical position as a dental hygienist, some things may fall off your radar because all you can think about is staying on time. However, it’s critical not to focus just on staying on time. Patients come to you, a healthcare professional, and it’s best to do your due diligence and obtain all necessary information that could affect your patient’s oral and systemic health and your license.

Here are just a few assessment categories to include in your armamentarium.


Mild cognitive impairment

Do you assess for mild cognitive impairment? MCI is the stage between the expected cognitive decline with aging and the more serious decline of dementia. There is no specific test to confirm a diagnosis of MCI except by asking people about their memory decline over time, their overall daily function, and whether they can follow instructions. Imagine an elder patient coming in perfectly attuned to his or her surroundings at one appointment. The next time they visit, they may see another provider who thinks their confusing behavior is normal. This would be because you didn’t take a comprehensive approach and notate in their chart that they were fine.


Diabetes

Another vital assessment is making sure diabetes is under control. Diabetics should be scheduled in the morning because their endogenous cortisol levels are generally higher at this time. Additionally, cortisol increases blood sugar levels. If the patient is unable to come in first thing in the morning, schedule them after they’ve eaten and remind them to eat before their visit. Furthermore, it’s important for you to document their A1C levels, what medication they take, why they take that medication, and when they last took it. It’s in the patient’s and your best interest to avoid a medical emergency such as hypoglycemia.


Airway

When a parent brings in their child for a dental appointment, checking signs for airway issues provides the parents and child with a better quality of life. For instance, a mother who came in for her routine visit brought her newborn daughter and was concerned that she was choking on milk. After getting permission to assess the baby, I quickly realized its tonsils were so enlarged that they were blocking her airway. I recommended she visit her physician or ENT to be evaluated, and I made a note to follow up.


I recommend learning how to use the Mallampati or Brodsky scale. Understanding how to use these will not only benefit you as a clinician but will also benefit your patients.

Studies have shown that if airway issues are not addressed early, this can have a significant impact on a person’s quality of life and IQ, especially in males. If a patient is unable to breathe properly through their nose, it can affect their arch development, lead to fatigue, and cause sleep disturbances such as sleep apnea. Nasal breathing filters allergens from entering the lungs and assists in reducing fatigue and stress by providing more oxygen to the cells.


Tongue posture can also affect airway and arch development. In addition to oral cancer, an assessment I perform regarding a patient’s tongue is to have them swallow while I hold their lips back to see if they’re a tongue thruster. Tongue thrusting can lead to an abnormal orthodontic condition called an open bite.


Nutrition

As oral health specialists, it is in our scope of practice to discuss nutrition with patients because some foods can affect oral health. In the search for an ideal meal plan, many people stress over a particular food group: carbohydrates. Carbohydrates provide energy to the cells, but some types of carbohydrates have been linked to chronic inflammation, such as gingivitis and periodontal disease.


However, not all carbohydrates are harmful or contribute to inflammation to the same degree because they’re not all digested at the same rate. Those foods are measured on the Glycemic Index scale. High glycemic foods such as bread, pasta, and baked goods digest quickly, which in turn results in a glucose spike and causes a surge of insulin. According to nutritional studies, eating complex carbs such as fruits and vegetables has been shown to decrease inflammation.


Nutritional deficiencies can be linked to oral manifestations, and patients with eating disorders are at an increased risk of poor oral and systemic health. Patients with eating disorders tend to have particular intraoral features, such as xerostomia, caries, erosion, hypersensitivity, and mucosal changes, to name a few. Implementing screening tools and an interprofessional approach is critical to addressing this disorder.

In conclusion, we are a community of healthcare professionals devoted to preventing and alleviating disease and promoting optimal oral and systemic health. The services we provide contribute to the health and well-being of our patients, and it is important be comprehensive with them. It is our responsibility to document effectively to ensure that we’re following our ethical duty to uphold our core values and our obligation to the healthcare profession.


Be thorough at each appointment with every patient and document, but also remember that patients may not disclose everything. Your work is important because you can help save lives, and you have the power to assist in the success of patients’ overall health and quality of life. Remember to listen, empathize, and assure patients because they could be giving you clues into other health-related concerns. Lastly, breathe, and know you’ve got this!

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