Dr Mike Rutherford, Senior Dentolegal Consultant at Dental Protection, looks at the consequences of not completing a full medical history

A common question we get asked by members is “how often do you have to take or update a medical history” – mainly because this is not stated prescriptively in Australian dental practice. While once a year may be adequate for most people, for some it would be potentially dangerously inadequate.

We have to go back to basics – why do we take a medical history? For one reason only – so that we may provide safe dental treatment, and so this philosophy must also extend to how often we update medical histories.

Deciding when to update a history

If we accept that a set interval may not suit all patients’ circumstances, how do we decide when to update medical histories? Broadly there could be considered to be three criteria on which you can base the decision to review:

• The passage of time – that is at set intervals
• Patient reporting – where a patient is telling you about a medical event or change in medication; this can be formally, as “my orthopaedic surgeon told me I should tell you that..” or informally, in conversation – “I’ve felt lousy ever since my bypass op and the infection in my new valve”
• Prior to a planned procedure – a mandibular surgical tooth extraction requiring bone removal is a good example because there are many potentially interacting health and medication scenarios

Once we have these updated medical histories we may then:

• Continue with treatment as planned because there are no contraindications
• Modify the timing of treatment – for example in the post-surgical phase of cardiac stent placement, we would most likely delay treatment for three months. A recent episode of uncontrolled diabetes, and a doctor’s efforts to get this under control, may also warrant delay of treatment. Or perhaps it would speed treatment up – impending chemo or radiation therapy, or pre bisphosphonate IV transfusion
• Modify a treatment plan – for example, due to a high risk of BRONJ – bisphosphonate related osteo necrosis of the jaw – a tooth with a hopeless restorative prognosis that was planned for removal may instead be endodontically treated and then left as a nonfunctional but inert root to negate the risk of removal. Similarly and increasingly frequently, a diagnosis of early onset dementia may negate the advantages of high maintenance treatments such as fixed bridgework
• Elect not to proceed with treatment – a patient who declares an inoperable tumour may no longer be concerned about their lack of posterior support

What is the view from AHPRA?

From Dental Protection’s experience the regulators are very concerned if there is no current medical history, and unfortunately we do see this from time to time.

Or similarly, no evidence of updating – in these instances AHPRA are concerned and this may lead to at best a recommendation from AHPRA that this be done. Or at worst a condition on their registration that a dental practitioner take further education into the requirements of clinical record keeping. This can occur regardless of what the initial complaint was to AHPRA – it may have been loose dentures, it may have been dissatisfaction with a bleaching outcome – it doesn’t matter, AHPRA reviews all aspects of a patient’s treatment.

Regulators do wish to see evidence of a thought process behind the medical history. The history should not be an administrative exercise where a patient signs it and it is filed away. Like all other clinical records, the medical history should be personalised for the individual concerned.

If there are relevant “yes” responses on a medical history, regulators want to see evidence of further questioning – for example, a yes response to a question such as heart problems should be followed by an explanation of what sort – “was it a heart attack?”, and further questioning by the dental practitioner along the lines  of “did you have surgery?”, “do you have a stent?”, “are you on any medications?”, “do you see a cardiologist?” – all these questions are relevant to a comprehensive history, and most dental practitioners ask these questions but we also need to evidence this as well – if it is not written down, it didn’t happen.

Another common area that was explored by Dr Geraldine Moses in her webinar for Dental Protection is stated allergies. When a patient says they are allergic to a particular antibiotic, what do they mean – a true allergy, or as is often the case with for example erythromycin – or stomach upsets and diarrhea. This is important – as Geraldine pointed out, sometimes dental practitioners will swap to a less effective antibiotic or even to an antibiotic with more severe potential side effects than the stated allergy.

Good records, good defence

When Dental Protection is assisting a member we like to see a comprehensive recent medical history – dated and signed by the patient, with some additional notes in the dental practitioner’s handwriting (or in the clinical notes) offering context and further information to what has been provided by the patient.

As dentolegal consultants we have experienced that moment when we review a member’s records and find they have limited or missing information. “But I always ask patients if they are allergic to penicillin before giving it to them” is a common response, but if it is not written down, it didn’t happen.

From a claimant lawyer’s perspective, not only did it not happen but in a legal claim, a claimant’s expert report might say not only that you didn’t ask, but the very not asking is evidence that you are practising below the expected standard. A step taken in an attempt to portray you as an incompetent and negligent practitioner.

Medical histories and serious claims at Dental Protection

The more serious and high value claims that we see that hinge on medical histories are claims based on failure to prescribe prophylactic antibiotics, or postoperative antibiotics – usually relating to infective endocarditis but not necessarily.  Sometimes the more serious claims can involve infections in other areas of the body remote from the dentition, as well as localised or systemic infections.

The claim is often based on an allegation that a failure of the dental practitioner to consider or know of, for example, a previous cardiac valve replacement, an immunosuppressive condition that would alter usual antibiotic protocols, or a particular susceptibility to infection based on racial, social or physical conditions led to the infection in question. Based on the Therapeutic Guideline protocols or other expert opinion, these claims can often be denied on a scientific basis; however, if the medical history demonstrates that the possibility wasn’t known about or explored sufficiently, it is difficult to argue that this was a sound clinical decision based on knowledge not to prescribe.

Similarly, BRONJ or osteonecrosis related to similar osteoporotic medications can lead to some devastating loss of oral bone and teeth for our patients. We are well aware that even following all the recommended protocols relating to tooth removal, our patients are still at risk of developing this condition – and this argument can be used if your protocols are consistent with good contemporary clinical practice. However, if the risk is not recognised in the medical history or explored in the clinical records as part of the consent process, this defence is negated.

Other claims can be allegations that appropriate steps have not been taken to manage warfarin or newer anticoagulant medications, or claims that postoperative infections were caused by a failure to prescribe antibiotics. These claims come from patients who have been distressed by their postoperative complications, often from seemingly simple dental procedures. If our medical history taking is robust, we can defend the clinical decision – if it is appropriate.

Learning points

• A up to date medical history is a must for patient safety
• It is prudent have a practice protocol for updated medical histories, to ensure nothing ‘falls through the gaps’
• Be familiar with the current guidance on medications