The Patient History, Physical Evaluation, and Risk Assessment
You will receive 4 credit(s) of continuing education credit upon successful completion of this course.

This course will include a discussion of the essential components of the history, physical evaluation, and risk assessment for dental patients.  Knowledge gained from this review will aid in formulating an accurate diagnosis and logical treatment plan that is safe for each patient.

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Gregory Naylor, DDS

Dr. Gregory D. Naylor is a native of western Massachusetts.  He graduated with honors from Springfield College in 1974 with a Bachelor of Science Degree in Biology.  He received a Doctorate in Dental Surgery from Georgetown University School of Dentistry in 1978 and was inducted into the Omicron Kappa Upsilon Honor Society.  After graduation from dental school, he received a commission in the United States Navy and served in the Navy for over 27 years.  His assignments in...

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Learning Objectives:

After completing this lesson, the reviewer will:


1.   Understand the importance of gathering a thorough patient history.

2.   Understand the importance to remain knowledgeable about complex medical conditions due to the aging of our population.

3.   Accurately assess the overall health of the patient by the physical evaluation and relate this information in order to formulate an accurate diagnosis.

4.   Understand that the benefit of the proposed dental treatment should outweigh the risk of a medical complication occurring during or after treatment.

5.   Use risk assessment to identify specific medically complex conditions and to appropriately adjust the proposed treatment plan for maximum patient safety.


An accurate diagnosis and treatment plan should be based on information obtained from a combination of a written health questionnaire and an interview.  The objectives of obtaining a patient history include: to establish a professional relationship; to provide information concerning the patient’s past and present medical, dental, and personal history; to provide information necessary for making a diagnosis; and finally to provide information needed to design an appropriate treatment plan.  Components of a patient history should include the: biographical data, chief complaint or present illness and its history, social history, emotional and behavioral history, family history, medical history and systems review, other significant medical history, physical evaluation, clinical laboratory tests, physician referral if necessary, risk assessment, and pertinent dental history.  Acquiring a thorough patient history is of paramount importance because it provides the necessary information to formulate an accurate diagnosis of a variety of oral conditions that may result from systemic diseases.  As the result of taking a patient history along with the physical evaluation and risk assessment for each patient, treatment plan modifications may be necessary due to the identification of medically complex conditions. 


1.  Introduction

2.  Components of the Patient History

      A.   Biographical data

      B.   Chief complaint or present illness

      C.   Social history

      D.   Emotional and behavioral history

      E.   Family history

      F.   Medical history and systems review

      G.   Other significant medical history

      H.   Physical evaluation

      I.   Clinical laboratory tests

      J.   Physician referral

      K.   Risk assessment

      L.   Pertinent dental history

3.  Medical History and Systems Review

      A.   Cardiovascular Disease

            1.  Hypertension

            2.  Angina

            3.  Myocardial Infarction

            4.  Congestive Heart Failure

            5.  Rheumatic Fever

            6.  Rheumatic Heart Disease

            7.  Heart Murmur and Mitral Valve Prolapse

            8.  Congenital Heart Disease

            9.  Prosthetic Heart Valves

            10.  Open Heart Surgery and Coronary Artery Bypass Graft, Angioplasty or Stent

            11.  Dysrhythmias, Pacemakers and Defibrillators                        

     B.   Respiratory Disease

            1.  Allergies

            2.  Sinusitis      

            3.  Asthma

            4.  Emphysema and Chronic Bronchitis

            5.  Tuberculosis

            6.  Sleep Apnea

      C.   Hematologic Disease

            1.  Anemia

            2.  Sickle Cell Anemia

            3.  Glucose-6-phosphate Dehydrogenase Deficiency

            4.  Leukemia

            5.  Lymphoma                                                                                      

            6.  Hemophilia

            7.  Thrombocytopenia

            8.  Blood Transfusions

            9.  Anticoagulant Therapy

      D.   Neurologic Disease

            1.  Seizures Disorders

            2.  Cerebrovascular Accident  / Stroke

            3.  Fainting / Dizziness

            4.  Behavioral Disorders

      E.   Gastrointestinal Disease

            1.  Hepatitis A (HAV, infectious hepatitis) 

            2.  Hepatitis B (HBV, serum hepatitis)

            3.  Hepatitis C (HBC)

            4.  Hepatitis D (HDV, delta agent)

            5.  Hepatitis E (HEV)

            6.  Hepatitis non-A-E

            7.  Hepatitis Transmission from Dentists

            8.  Cirrhosis

            9.  Gastrointestinal Ulcers

            10.  Ulcerative Colitis

            11.  Crohn’s Disease

      F.   Genitourinary Disease

            1.  Acute and Chronic Renal Failure

            2.  Sexually Transmitted Diseases

      G.   Endocrine Disease

            1.  Pituitary Gland Disorders

            2.  Adrenal Gland Disorders

            3.  Thyroid Disorders

            4.  Parathyroid Disorders

            5.  Diabetes Mellitus

            6.  Pregnancy and Breast Feeding

      H.   Musculoskeletal Disease

            1.  Osteoarthritis (Degenerative Joint Disease)

            2.  Rheumatoid Arthritis

            3.  Total Joint Replacements        

4.  Other Significant Medical History     

      A.   Present Medications                 

      B.   History of Allergies or Idiosyncratic Reactions to Medications

      C.   Tobacco and Alcohol Use

      D.   Drug Addiction

      E.   Steroid Use

      F.   Previous Hospitalizations and Surgeries

      G.   Cancer Diagnosis and Treatment

      H.   Unexplained Weight Gain

      I.   Patients not Allowed to Donate Blood

      J.   Require Antibiotic Prophylaxis Before Dental Treatment

      K.   For Women Only

      L.   Any Other Medical Problems

 5.  Physical Examination

      A.   General Appearance

            1.  Face

            2.  Eyes and Nose

            3.  Ears

            4.  Skin and Nails

      B.   Vital Signs

            1.  Pulse

            2.  Blood Pressure

            3.  Respiration

            4.  Temperature

            5.  Weight

      C.   Head and Neck Examination

6.  Clinical Laboratory Tests

7.  Physician Referral

8.  Risk Assessment

9.  Pertinent Dental History

10.  Summary and Treatment Recommendations

11.  Examination


1.  Bricker SL, Langlais RP, and Miller CS.  Oral Diagnosis, Oral Medicine, and Treatment Planning.  Second ed.  Hamilton, Ontario, Canada:  B. C. Decker 2001. 

2.  Little JW, Falace DA, Miller CS, Rhodus NL. Dental Management of the Medically Compromised Patient. 7th ed. St Louis, MI: Mosby Elsevier; 2008

3.  James, PA, Oparil, S, Carter, BL et al. 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). JAMA Published Online: December 18, 2013, E1-E14.

4.  Wilson W, Taubert KA, Gewitz M, et al.  Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 116(15):e376-7, 2007.

5.  Findler M, Galili R, Meidan Z, Yakirevitch V, Garfunkel AA.  Dental treatment in very high risk patients with active ischemic heart disease.  Oral Surg Oral Med Oral Pathol 76:298-300, 1993.

6.  Niwa H, Sato Y, Matsura H.  Safety of dental treatment in patients with previously diagnosed acute myocardial infarction or unstable angina pectoris.  Oral Surg Oral Med Oral Pathol 89:35-41, 2000.

7.  Wahl MJ.  Myths of dental surgery in patients receiving anticoagulant therapy. J Am Dent Assoc 131:77-81, 2000.

8.  Hunt SA, Abraham WT, Chin MH.  ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult—Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): Developed in Collaboration With the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: Endorsed by the Heart Rhythm Society.  Circulation.112:1825-1852, 2005.

9.  Vichitvejpaisal H, Joshi GP, Liue J et al.  Effect of pulmonary disease on nitrous oxide washin and washout characteristics.  J Med Assoc Thai  80:378-383, 1997.

10.  Smith HB, McDonald DK, Miller RIRI.  Dental management of patients with sickle cell disorders. J AM Dental Assoc 114: 85-87, 1987.

11.  Guerrini R.  Epilepsy in children. Lancet 367:499-506, 2006.

12.  Centers for Disease Control and Prevention: Surveillance for acute viral hepatitis – United States 2006, MMWR Surveill Sum 57(SS-2): 289-299, 2008.

13.  Goodman RA, Solomon SL.  Transmission of infectious diseases in outpatient health care settings. JAMA 265:2377-2381, 1991.

14.  Stickel F, Seitx HK.  Alcoholic steatohepatitis, Best  Pract Res Clin Gastroenterol 24:683-693, 2010. 

15.  Leoci C, et al.  Incidence and risk factors of duodenal ulcer.  A retrospective cohort study. J Clin Gastroenterol 20:104-109, 1995.

16.  Lukas M.  Inflammatory bowel diseases as a risk factor for colorectal cancer.  Dig Dis 28:619-624, 2010.

17.  Gavalda C et al.  Renal hemodialysis patients: oral, salivary, dental and periodontal findings in 105 adult cases.  Oral Dis 5:299-302, 1999. 

18.  Corey L, Wald A, Patel R, et al.  Once daily valacyclovir to reduce the risk of transmission of genital herpes. N Engl J Med 350(1):11-20, 2004.

19.  Moscicki AB.  HPV vaccines: today and in the future. J Adolesc Health 43:S26-S40, 2008. 

20.  Greene MF, Solomon CG.  Gestational diabetes mellitus – time to treat. N Engl J Med 352:2544-2546, 2005.

21.  Turner M, Aziz MR.  Management of the pregnant oral and maxillofacial surgery patient.  J Oral Maxillofac Surg 60:1479-1488, 2002.

22.  ADA/AAOS. Antibiotic prophylaxis for dental patients with prosthetic joints. J Am Dent Assoc 134:895-897, 2003.

Release date: June 1, 2017
Review date: February 3, 2018
Expiration date: February 6, 2021
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