The Historical Profile
“Never treat a stranger.” Sir William Osler’s statement is especially applicable to the practice of dentistry, in which the physical and emotional ability of the patient to undergo and respond to dental care is determined primarily by reviewing the medical/dental history. An initial historical profile (Table 1.5) should identify the patient; establish the chief complaint; reflect the dental history; document drug allergies or other adverse drug effects; identify medications, vitamins, dietary supplements, or special diets; and provide a record of past and present illness, major hospitalizations, and a review of major organ systems. The historical profile shall be reviewed with the patient at each subsequent appointment and any new information obtained should be documented in the progress notes (Table 1.7).
The current trend among dental practitioners is to use a combined printed and oral approach to establish the historical profile of a patient. A written questionnaire will elicit information that may be omitted by oral inquiry. Oral communication will provide important insight into a patient’s feelings about past, present, and future illnesses and courses of treatment. This process is critical to the patient-doctor relationship and establishment of the rapport that precedes successful treatment.
Clinicians must be aware of the patient’s overt and hidden concerns and develop a sense of the patient’s reliability as an interpreter and reporter of events. Patients may suppress some information purposely or unknowingly. They may under-report other experiences or present them in a context that is less disconcerting than might be appropriate. Circumstances that may be of concern to clinicians might not be seen as unusual to patients. Practitioners must be compulsive in compiling data, directing careful attention to the obvious and maintaining sensitivity to the less obvious “soft” clues that may be revealed in the history. An appreciation of the patient’s perspective and an attitude of friendliness and respect will go a long way in assuring the patient’s cooperation in gathering information.
Failure to obtain an initial historical profile, or to update it regularly, is not an excuse for being unaware of a patient’s physical and emotional problems. Responses should be explored to determine whether the patient understands the question, is certain of the answer, and appreciates the importance of the question and the answer in the context of the care to be provided. If the patient is confused, the dentist has an obligation to educate the patient to respond to questions, or the dentist may need to seek the necessary information from an additional informant. In all cases, the dentist should reduce those responses to writing. Failure to document and correctly interpret the historical profile of a patient may have devastating effects for the patient and the clinician.
The basic biographical data should include the patient’s name, age, sex, ethnic extraction, marital status, occupation, and place of residence. The date of the evaluation also must be recorded. Not only are these items essential for patient identification but also they may provide invaluable background information for the differential diagnosis of certain conditions, or identify patients in a high-risk category for a variety of diseases. For example, healthcare workers, military personnel, immigrants from developing countries, and people who work or live in institutions should be considered at higher risk for harboring certain infectious or communicable diseases.
The dentist must record the patient’s description of signs and symptoms associated with the current oral condition in a logical sequence. A clinician should begin with the chief complaint, stated in the patient’s own words. An attempt should be made to determine why the patient is consulting the dentist today and not yesterday or tomorrow. The answer may reveal an important clue to the severity of pain, underlying emotional problems, or other matters that are important in the overall understanding of the patient’s illness. Did acute symptoms prompt the visit, or was it the desire for a checkup because a neighbor, friend, or another family member was told they have oral cancer or have been diagnosed with HIV infection? The dentist should remember that a patient’s expressed reason for seeking advice might mask underlying concerns. After an understandable statement of the chief complaint has been elicited, the chronology of the illness should be delineated.
The most common complaint causing a person to seek the services of a healthcare provider is pain. Determine its character. Is it sharp or dull? Is it pain or is it merely discomfort? Does it appear suddenly and disappear quickly, or does it gradually increase in intensity and subside slowly? A lesion should be inspected. Is it white, red, pigmented, ulcerative, vesicular, bullous, exophytic, or a combination of these various characteristics? Admittedly, this observation is part of the examination, not the history, but there are at least two good reasons for doing it at this point in time. First, it establishes the dentist’s concern for the patient’s problems, and second, it may suggest additional questions to be asked during the history-taking process.
A number of questions should be considered. How long has the condition associated with the patient’s chief complaint been present? Has the problem developed slowly or rapidly? Some conditions have a sudden onset, but others begin slowly and insidiously. Have the symptoms become worse or better? Are they better at times and worse at other times?
One must determine whether the pain or discomfort remains localized or radiates to other anatomic locations. When dealing with a lesion, the dentist should determine if it is found on the lips, tongue, buccal mucosa, hard or soft palate, floor of the mouth, or other areas of the head and neck, because the location of a disease may assist in its diagnosis.
One should evaluate the effects of normal activities on the symptoms. What is the effect of the problem on mastication? Are the symptoms worse when the patient is chewing? In some instances, mastication relieves symptoms; in others, it aggravates them. Similar insights into the effects of swallowing, drinking, and speaking on the symptoms should be obtained.
Important elements of a past dental history include frequency of visits to the dentist, history of radiographic examinations, type of care received in the past, history of orofacial injuries, and difficulties with past treatment. A history of adverse reactions to local anesthetic agents, latex products (gloves, rubber dam), or other dental materials should also be investigated. Note the attitude of the patient toward previous dentists and therapeutic interventions. Is this a patient who will never be satisfied no matter the skill of the clinician, or does the patient have significant undiagnosed problems that form the basis of the chief complaint? What is the patient’s dental IQ and what priority is the patient likely to place on home care following periodontal surgery or extensive restorative care?
The oral healthcare provider should document a history of allergic drug reactions and other adverse drug effects and investigate whether drugs or medications are being taken. Many patients habitually take drugs for minor complaints, a practice that should be documented carefully. Patients often do not recognize nonprescription medications as drugs and, therefore, do not mention the habitual use of aspirin, decongestants, antihistamines, vitamins, and many other over-the-counter medications. Inquire about dietary supplements or special diets the patient may be on. Immunosuppressant therapy may place a patient in the high-risk category for many viral, fungal, and bacterial infections and de novo malignancies.
The dentist should inquire about the patient’s general health, as perceived by the patient, and summarize past and present medical conditions. A clinician must record any hereditary or developmental abnormalities. Patients with hemophilia or other coagulopathies are at a higher risk for hepatitis and HIV infection because of the potential for undergoing multiple blood transfusions. Previous operations, injuries, accidents, and hospitalizations should be recorded, as well as comments about anesthesia, drug reactions, blood transfusions, or transmissible diseases. A history of repeated hospitalizations for the same condition, failure of an infection to resolve following therapy, recurrent infections with the same pathogen, and infection with unusual organisms, especially in the absence of “hard” signs of infection, may be suggestive of hereditary or acquired immunodeficiency, or therapeutic immunosuppression.
Diabetes mellitus, hypertension, dyslipidemia, and allergic reactions have a significant tendency to appear in certain families, and certain types of cancer stalk through generations of the same family. The family history is particularly important in assessing diseases of the nervous system. Some conditions such as hemophilia, passed on by an affected mother to her sons, are always hereditary. In addition to hereditary conditions, acquired infectious diseases may be transmitted from one family member to another, some requiring only casual contact, while others are transmitted only through repeated, intimate encounters (sometimes associated with child abuse).
Because of the frequency of facial and intraoral injuries and/or the presence of suspected sexually transmitted diseases associated with family violence (child abuse, spouse abuse), the oral healthcare provider is likely to be the first professional to observe the victim. While obtaining the history of the problem, careful attention must be paid to the explanation provided by the patient or other family members relative to the suspected problem. Look for any inconsistencies or behaviors suggestive of reluctance to provide information. Note nonverbal behaviors, which may not match verbal statements. The dentist does not have to determine abuse. However, reasonable suspicions should be reported to the appropriate local or state agency for follow-up.
The personal habits of patients may reveal important clues to diagnosis. Excessive use of tobacco and alcohol may produce symptoms whose significance is lost without knowledge of a patient’s smoking and drinking habits. The daily use of tobacco products should be recorded in numbers of cigars, cigarettes (packs), or pipefuls smoked. Alcohol use is unequivocally associated with child abuse, fatal traffic accidents, homicides, rapes, and suicides. Alcohol consumption should be recorded in terms of quantity and type over a specific period of time. Since patients with alcoholism are especially prone to certain diseases, it is important not to overlook this particular finding. The simple question “when was the last time you had more than X drinks in 1 day?” where X equals five for men and four for women should be asked as part of the interview. A response of “within the past 3 months” usually indicates the patient has a drinking problem and should undergo further assessment.
The patient’s social history may also alert the clinician to the presence of environmental and cultural factors that may significantly influence the patient’s general health and provide insight into the patient’s personality and emotional state. A history of recreational drug use, frequent moves, sexual promiscuity (whether homosexual, bisexual, or heterosexual), frequent travels to developing countries, or recent immigration into the United States should alert clinicians to patients at high risk for infectious diseases. Information about educational, social, religious, and economic background and feelings of achievement or frustration can provide important insight into understanding the patient as a person. From this information, one can assess which factors might have a bearing on the current problem and whether they might be supportive or stressful influences.
The chief complaint and the medical, family, and social histories of the patient should guide the clinician to investigate areas of special concern. All signs and symptoms related to specific organ systems should be recorded. The status of organ systems may suggest the presence of concomitant systemic conditions, contribute to the diagnostic process, and influence projected treatment protocols and prognosis.
An important cause of pruritus, especially associated with a bitter metallic taste and burning tongue, may be psychogenic (e.g., a reaction to stress and strain). A subtle and important cause of pruritus without a visible rash may be a reaction to drugs, such as aspirin, opiates and their derivatives, heroin, or amphetamine abuse. Generalized pruritus is frequently the first sign of biliary cirrhosis and may occur many months before the onset of jaundice. It may also be associated with carcinoma or a hematological disorder such as polycythemia vera, Hodgkin’s lymphoma, or T-cell lymphoma (Sezary syndrome). Patients with pruritus in association with obvious skin lesions, such as papules, vesicles, bullae, or ulcerations, should be referred to a dermatologist. Many of these disorders require specialized dermatological approaches to establish the diagnosis.
Vitiligo is an acquired depigmenting disorder characterized by localized or generalized hypomelanosis of the skin and hair. Its etiopathogenesis is poorly understood, but likely involves multiple overlapping pathogenic mechanisms. When localized, hypomelanosis of the skin and hair may be restricted to one region, such as the scalp. When generalized, the pattern of hypomelanosis is quite typical, with lesions particularly on the face and neck coupled with loss of pigment in the hair.
Neurofibromatosis (von Recklinghausen disease) is inherited as an autosomal dominant trait. It is characterized by the appearance of numerous cutaneous café-au-lait spots. The majority of these lesions occur on the trunk and vary in diameter from less than 1 cm to more than 15 cm. The presence of six or more café-au-lait spots, each with a diameter greater than 1.5 cm (> 0.5 cm in children), is highly suggestive of neurofibromatosis even without a familial history of the disease.
Peutz-Jeghers syndrome is an autosomal dominant trait associated with intestinal polyposis and mucocutaneous pigmentation. The polyposis is most frequent in the ileum and jejunum and the mucocutaneous hypermelanosis is most noticeable in periorificial sites and the oral mucosa. It is now recognized that patients with Peutz-Jeghers syndrome are at increased risk for developing both gastrointestinal and nongastrointestinal malignancies.
Diffuse brown hypermelanosis is a striking feature of primary adrenocortical insufficiency (Addison’s disease). Most cases are caused by an autoimmune process or infiltration of the gland by an infectious agent (HIV, MBT). There is significant accentuation of pigmentation in certain mucocutaneous areas, namely along pressure points and oral mucous membranes. These patients demonstrate hypotension and a decreased tolerance to stress associated with infection, surgery, or trauma. An identical type of diffuse hyperpigmentation also has been reported as a sequela of adrenalectomy in patients with Cushing’s disease (Nelson syndrome). A third example of the Addisonian type of hypermelanosis has been reported in patients with pancreatic and lung tumors. This phenomenon is known as a paraneoplastic syndrome.
In certain chronic nutritional deficiencies, splotches of dirty-brown hyperpigmentation may appear, especially on the trunk. Patients with protein deficiency may demonstrate a change in hair color, first to reddish brown and eventually to gray. In other selective deficiencies, such as sprue (faulty absorption of fats and carbohydrates), the hypermelanosis may be distributed over any area of the body, whereas in pellagra (niacin deficiency), it is limited to skin that is exposed to light or irritation. In vitamin B12 deficiency, the hair loses it original color and becomes gray and there is a diffuse cutaneous distribution of hypermelanosis.
Male-pattern baldness is inevitable in the presence of androgenic stimuli in patients with a genetic predisposition to baldness. The hypopituitary dwarf may completely lack hair, while patients with acquired hypopituitary states rapidly lose hair from the axillae, pubis, and, at times, the scalp. In congenital cretinism, lanugo hair may be retained, but the scalp hair is sparse and dry. In adults, hypothyroidism causes a decrease in secondary sexual or hormonal hair, in addition to the characteristic loss of the lateral third of the eyebrows. The loss of scalp hair in a male pattern along with an increase in body and facial hair may be due to increased production of adrenal androgens (Cushing’s syndrome) or exogenous adrenocorticotropic hormone administration.
In women, postpartum increase in hair loss is normal. The prolonged growth phase resulting from hormonal stimulation during pregnancy ends after delivery, and a synchronized onset of the resting phase occurs in the scalp hair follicles. Prolonged febrile illnesses, systemic lupus erythematosus, dermatomyositis, severe cachexia, and lymphomas also may be associated with hair loss. Permanent hair loss on the extensor surfaces of the fingers is an early sign of systemic scleroderma. Superficial/>