By Mitchell Gardiner, DMD
Think back to the first time you walked into the patient clinic as a dental student. Perhaps you were looking around, feeling overwhelmed and intently reviewing mental checklists of all that was expected of you. Have you ever been more prepared or thorough than you were the first time you cared for a live patient?
Recall how much time you devoted to evaluating every current and past medical condition shared by your patient — assessing and documenting vital signs such as blood pressure, pulse and temperature, and dutifully reviewing the actions and interactions of their list of medications and conditions. As a student, you made sure that you knew all this information for every patient you saw and documented it in their record. Only then did you approach your clinical instructor to breathlessly regurgitate all that you had discovered, hoping that the patient would be medically cleared to allow treatment to begin.
This prelude to performing an actual dental procedure took 15 minutes or more of your precious clinical time. As a dental student, you chalked this up to the necessity of learning how to take an accurate and complete medical and dental history, understanding that this was an essential part of care management. Hopefully, it is an exercise that continues with you to this day for every patient in your care.
In the years that have followed, your clinical skills have become more proficient and polished. Can the same be said for the quality of the medical history that you take? Are you devoting the same time and effort to your current patients that you did as a dental student, or do you rush through a hastily filled out, partially completed medical and dental history form, sign it, and move on to determine the patient’s needs? Are you giving any thought to what your patient has told you in these forms? As a busy dental clinician, do you rely on a team member to obtain the medical history at the patient’s visit? Are you conducting a private interview with the patient specifically to review their history before moving on to discuss dental treatment?
Depending upon how you’ve answered these questions, it may be time to reevaluate how you obtain your patients’ medical histories. It is critical to assure that your systems address the importance of this information to your patient safety and well-being and to mitigate the risks you bear. The dental clinician’s legal and ethical responsibility is to obtain a complete and thorough medical and dental history. Failure to get a complete and honest medical history may result in the delivery of negligent care that does not meet accepted standards.
Health history information should be first and foremost in the patient file. Before any diagnosis or treatment takes place, this information must be thoroughly assessed. Dental boards in every state have made it a legal requirement to obtain an accurate medical and dental health history as part of the patient record. Without this information in the patient record, a court of law may find that you have practiced below accepted dental care standards. Following graduation and obtaining a license to practice the many aspects of dentistry, the expectation is that the clinician will provide patient care with the highest levels of safety and prudence. It is the ethical promise that we make to our patients. It cannot be accomplished without the dental clinician having a complete and thorough medical and dental history as the foundation for information to help provide that safe and prudent care.
Taking a complete and thorough medical history can be challenging to obtain accurately. Patients often misrepresent the truth about sensitive medical information, including the use of medications prescribed by a physician for medical reasons such as mental health, or for drugs that patients use for non-medical reasons. Examples are opioid medications, cocaine, methamphetamines, alcohol and marijuana. When patients do not trust their dentist to maintain confidentiality or question that the motive for asking is something other than to provide them with the best and safest medical care, they are unlikely to be truthful in revealing sensitive information.
The Centers for Disease Control and Prevention (CDC) has related that almost 40% of high school students report trying marijuana, and 48.2 million adults commonly use marijuana. Yet you may not see patients answering truthfully on your forms about marijuana use. Alcohol Use Disorder, most widely known to Americans as alcoholism, is a disease that affects more than 20 million people in our country. According to the CDC, excessive alcohol use leads to approximately 95,000 deaths per year and the increased risk of many harmful health conditions for both short and long-term health. As dental clinicians, we should be well-aware of the complications that excessive use of alcohol can cause during dental treatment. These complications can include bleeding difficulties and central nervous system depression that can create many complications during dental treatment. How often in your dental and medical histories do you see patients answer affirmatively for excessive use of alcohol? Do you even ask about alcohol consumption?
Often patients are reticent to discuss mental health issues with health care providers. In your medical histories, when patients are asked to list the medications taken daily, many patients will omit the use of anti- anxiety and antidepressant drugs because they are embarrassed to list a psychiatrist as a treating physician who prescribed these medications. According to the CDC, from 2015 to 2018, 13% of adults over 18 used antidepressant medications, and the number was twice as high with women as with men. Antidepressant usage was the highest among women aged 60 and over, at 25%. Antidepressants are one of the primary treatments for depression and are among the most frequently used therapeutic medications in the United States.
Carefully review some of your recent medical histories and you will note that many patients do not list these types of medications. Familiarity with these medications and the risks and complications they can cause during dental treatments is of the utmost importance for safe and prudent patient care. Not knowing that your patients take these medications makes providing safe dental care more difficult.
How you interview, follow up on these questions, and listen to responses is critical. Fine-tuning communication skills will build trust and reduce the patient’s discomfort for disclosing sensitive information. Clinicians must be prepared to explain the effects of these substances on a patient’s central nervous system and their impact on oral and overall health. Patients must come to understand how important these disclosures may be in allowing you to make the safest medical decision for treatment. When we do not know the medications and substances that patients use, we cannot anticipate possible complications that these drugs can present during our prescribed treatment. It is up to the clinician to ensure that the patient grasps the importance of these questions and that their candidness matters.
When asked about medications, it is common for patients to tell the interviewer that they “forgot” the names of medications that they are taking. They might say something to the effect that they are taking a blood pressure medication, another medication for nerves and another medication for their diabetes or cholesterol. Treating a patient without knowing what medications they’re taking is a risky proposition. It is challenging to provide safe and prudent care under these circumstances. Accepted standards of medical and dental care require practitioners to have a complete understanding of medications that their patients are taking before treatment commences. Clinicians can be liable if there are complications and bad treatment outcomes due to incomplete or ignored medical histories. Consultation with the patient’s primary medical provider can fill in the gaps.
In authoring this article, I am drawing on my professional training, along with more than 30 years of experience as an expert witness testifying in legal proceedings on behalf of both dentists and patients in the area of dental malpractice. The difficulties in defending dentists who are sued for negligent treatment that involves incomplete or ignored medical histories can be insurmountable. These cases are heartbreaking for both patients and dental clinicians, as shown by the following case experience.
Case Report
Recently I testified in a dental malpractice lawsuit on behalf of a general dentist who received her DMD five years ago. The plaintiff was a 42-year-old man when he became a patient with the dental practice’s previous owner in 1998. At that time, he filled out and signed a two-page medical history that listed no medical issues of concern. No physicians were listed as treating the patient, nor were there any noted issues concerning the patient’s health over the next 14 years while receiving routine dental care at this office without complication.
In 2012, the patient began to experience health concerns related to his heart, including shortness of breath, weakness and fatigue, causing him to seek care from a cardiologist. A cardiac surgeon performed a bicuspid aortic valve surgical procedure later that same year. The patient recovered well from his valve replacement surgery, and he had no medical issues of note.
I learned this medical information by reviewing the patient’s medical records obtained from his cardiologist and cardiac surgeon. No documented history appears in his dental record about these experiences. The original dental-medical health history form from 1998 was the only completed and signed health form found in his dental chart. No updated medical history form appeared in the patient’s dental records.
The initial treating dentist died in 2014, and the practice was sold to a friend. The patient stayed with the practice and continued to receive routine cleanings and restorative dentistry. The new dentist made no additions to the original 1998 medical history form. There were no notations in the dental records concerning the need to use prophylactic antibiotics to cover the patient due to cardiac valve surgery. However, several notations made in the dental records by the second owner of the practice documented that each visit by the patient had a review of medical history, with no change noted.
The dental practice was again sold in 2017 to the defendant, a recent dental school graduate. She finished restorative care for the patient, and while treating him, she documented in the records that she reviewed his medical history and found no changes. According to this new dental practice owner, the patient told her that he had open-heart surgery in 2012 and recovered with no issues. She asked him if he had stents placed and if he was on any medication for his heart, to which the patient answered “no.” The dentist never asked her patient if a cardiac specialist was treating him, and he never volunteered that information. The treating dentist claimed that there was no documentation of prophylactic antibiotics ever being given or prescribed to the patient for any invasive procedures or for any periodontal cleaning appointments in the records that predate her joining the practice. A review of the records from 1998-2017 showed no antibiotics ever given or prescribed for this patient following his visits. In 2019, the defendant dentist performed root canal treatment for the patient under a previously placed crown. This endodontic procedure was successfully completed over one week.
The patient began to feel sick within three weeks and was admitted to the hospital. Bloodwork confirmed he had an infection with Streptococcus salivarius. The patient’s cardiologist and an infectious disease specialist diagnosed subacute infective endocarditis. The patient spent several weeks in the hospital and, after intensive antibiotic therapy, was released for continuing care at home. Healing was uneventful and it appeared that the patient did not suffer any permanent damage to his surgically replaced aortic valve.
Within six months, the patient filed paperwork to sue the owner dentist for negligence in treating him. This malpractice lawsuit became the focal point of this young dentist’s life over the next three years. The hours she spent preparing to defend her reputation are incalculable, and the anxiety and worry accompanying this lawsuit remained with her every day, every week and every month. Although I have condensed the facts of the case for this article, what should stand out to you is that this case focuses on the medical history documented in the dental records over 20 years and the medical history obtained by the dentists from the patient.
Several issues are quite clear after investigation:
• The patient over this time was never asked to complete a new medical history form, and only one from 1998 was documented in the records.
• None of the treating dentists for this patient ever sat down with him to ask the appropriate questions necessary to obtain a complete and thorough medical history.
• It became apparent from the facts of this case that the medical history for the patient had changed dramatically during his years with the practice.
In 2007, in conjunction with the American Dental Association’s Council on Scientific Affairs, the American Heart Association published guidelines for dentists to use when considering prophylactic antibiotic coverage for their patients.These evidence-based guidelines are well known and are regarded as the accepted standard of care in dentistry. These standards call for antibiotic prophylaxis for all invasive dental procedures for patients with a high risk of infective endocarditis. Patients who have had cardiac valve replacement surgery are considered in this group.
The failure to provide antibiotic prophylaxis by the treating dentist for the patient in question was noted to be a deviation from accepted standards of dental care. It was claimed to be the proximate cause of the patient’s infective endocarditis. The liability insurance carrier was concerned about the patient’s lack of up-to-date medical histories and the failure by the treating dentist to document that cardiac valve surgery was discussed between the dentist and patient. A confidential settlement conference was elected as the best option for the dentist to settle this case.
It would have been very easy and straightforward to have prevented this patient encounter from becoming the frightening clinical situation experienced by the patient and the damaging lawsuit that followed for the dentist. This story underscores the importance of obtaining a complete and thorough medical history and documenting any changes at every patient visit.
There is an art and a science to gathering the information necessary to give the clinician a complete, thorough and honest medical and dental history. The medical/dental history form provides the initial information from the patient for review by the clinician, and it is only the beginning of the process. Dentists should view this task as a labyrinth, where your patient will lead you through many doors that need to be opened along the way. Your eyes, and especially your ears, are your best tools for obtaining a complete, thorough and honest medical history. The biggest problem with communication is the misconception that it has taken place.
As clinicians, we must establish a level of trust with our patients so they believe we are there to take care of their dental needs safely. Sometimes this bridge of trust will take time to build. Listening to what your patients say to you is of the utmost importance in building that trust and allowing your patients to give you the information you need. Watching how your patients respond to your questions and careful eye contact and body language are excellent tools in helping you to best understand your patient.
All of this takes time and the proper environment. Many clinicians complain that they do not have the appropriate time to do this. However, my experience has proven that this is the best and most crucial time you can ever spend with a patient. I can guarantee you that if you ignore this advice about communicating with your patients concerning their medical health, it will come back to haunt you in ways that are difficult to imagine during your professional career. As discussed, I have seen this too often in court. What many dental clinicians forget is that comfort and trust are the tools that will allow you to gain a full and accurate history. The only way to gain comfort and trust is by spending time with your patients and speaking with them, not time operating on them. If you view this as wasted time, then you are sorely mistaken.
When I teach dental professionals about taking medical histories, I am always asked: “Do patients have to volunteer information about their medical history?” My response is that patients do not need to volunteer information that is not asked of them on a form or through a conversation. Understand that many times if you do not ask them questions concerning their medical and dental history, they will not voluntarily disclose some of those details. Many dentists and hygienists who attend my courses comment that they are reluctant to ask personal questions about recreational drug use and alcohol consumption. They feel that maybe it is not their business to know this information. Yet it is a well-established fact that many of these recreational drugs and the over-consumption of alcohol directly affect dental care and dental procedures. As clinicians, we must know all of the drugs and medications that patients are consuming so that we can treat them safely and prudently. It is our legal and ethical responsibility to have as much of this information as possible.
However, this information does not come easily. It requires trust from the patient and the communication established by you, the clinician, to bridge this gap and let your patient understand that you are there to treat them safely and confidentially. This only comes with the proper amount of time, experience and desire to reach that goal of fully understanding your patient’s medical condition.
Patients are expected to answer questions and provide truthful information about their medical histories. When patients are untruthful or give incomplete information that result in harm to them from these omissions, courts of law typically find that patients are liable, and not clinicians.
Medical histories need to be reviewed thoroughly at each dental appointment. Three specific questions should be posed to the patient when updating past medical histories:
- Have you been to the hospital for any treatment since your last dental visit?
- Have you been to a doctor of any kind for any health care since your last dental visit?
- Are you taking any new medications or drugs since your last dental visit?
The standard of care in your practice should be that your patients regularly complete a new medical and dental history and review it before each visit. It is my experience that many patients fight this inquiry and complain to staff members and dentists that this is cumbersome and unnecessary. This is where communication with your patient is so important. Be prepared by rehearsing talking points with your team on how the practice needs to be as safe and as careful as possible in caring for patients. Build a bridge of trust so patients understand how vital their overall health is to you and your team.
Once you incorporate this protocol into your practice, you will be shocked by what you learn and how much answers on medical histories have changed when contrasted with older forms buried in the records. Your patient care will reach new levels of safety, and you will feel better ethically and legally knowing that you are doing everything you can to treat your patients in the manner they deserve.
References Available Upon Request
Mitchell Gardiner, DMD, graduated from Rutgers College in 1974 with a degree in zoology. He is a 1977 graduate of the University of Medicine and Dentistry of New Jersey. He is a full-time general dentist in a multi-specialty practice in New Jersey. For more than 30 years Gardine has reviewed dental malpractice lawsuits as an expert witness. He lectures throughout the United States and Canada on various dental malpractice issues and standards of care. He is an assistant clinical professor on the faculty of the Rutgers School of Dental Medicine and teaches clinical fixed prosthodontics. He is a fellow of the Academy of General Dentistry, the American College of Dentists and the International College of Dentists.
Reprinted, with permission, from the Journal of the Michigan Dental Association, April 2022 issue (Vol. 104, No. 4).
Beyond the Bite 