General patient history
- Review general health status of patient, medication and previous surgeries/treatments.
- Evaluate potential interferences with planned or likely treatment.
- In case of doubt seek general medical / internist’s advise.
Initial assessment - Patient interview
It is helpful if a clinician is situated so that his/her eyes are at the level of the patient's eyes. For example, if the patient is seated, the clinician should also be seated. It is beneficial if the interview between clinician and patient does not occur in a dental chair as this will not facilitate confidence. In this way, key aspects of the patient's personality, expectations, and medical conditions are more likely to be shared. It is vital that the patient's chief complaint be identified to be later matched with his treatment expectations. All patient interview procedures should ensure patient privacy.
General health assessment
A general health assessment should review the following biological systems:
- Metabolic diseases
- Previous surgeries and hospital visits
- Allergies, skin (especially allergies to substances found in dental (restoration) materials)
- Infections, specific infections (Hepatitis, HIV)
- Head and neck conditions including angiomata, nasal or sinus surgery and laryngeal or oro-pharyngeal complaints
In addition, one should inquire about a history of travel to tropical countries (latency of certain diseases). It may be necessary to procure medical reports if available. In case of doubt consider referring patient to the house doctor or internist for further evaluation or recommendations.
Absolute contraindications to treatment due to health problems are rare, if any, but acute stages of local/general diseases and certain medications may call for temporary attention and postponed treatment.
Also, consider inquiring/assessing about use of nicotine, alcohol, drugs (Refer also to chapter ‘risk assessment’).
Reviewing the medications that the patient is currently taking, or has taken in the past, may identify risks to surgical and prosthetic treatment. Furthermore, a patient may not always know the conditions for which they are being treated and their medication list may signal additional conditions of concern to be investigated by the clinician. For example, elderly patients consider medication a routine and might forget to mention them, if asked in a generic way. In case of doubt ask patients if they take any medication for the bone, for the heart and so on.