Ep. #317: The Top Thing Dentists Miss or Don't Ask with Patients, with Dr. Tom Viola, R.Ph., C.C.P

To make the best treatment planning decisions for patients, you need to know their medical history. And to do that, you need to ask the right questions. Today, Kirk Behrendt brings in Dr. Tom Viola to teach you the three key questions to ask patients to get their medical history. What you don't know about your patients could impact their care! To learn what you weren’t taught in dental school, listen to Episode 317 of The Best Practices Show!

Main Takeaways:

• Know your patients’ medical history to make well-informed treatment planning decisions.
• All you need is the patient’s medication list and an understanding of pharmacology.
• Build a good team around you and teach them how to take a good medical history.
• Ask patients good, open-ended questions to get the information you need.  
• The first question to ask patients is, “What do you take?”
• The second question to ask patients is, “Why do you take it?”
• The third question to ask patients is, “Did you take your medication today?”
• Asking those three questions will help you understand what you're getting into with patients.  
• Substance abuse/use has an effect on dental therapy. Ask patients about it!

Quotes:

• “We really sometimes miss [important] things when we take medical histories, when we inquire about patients’ medications. There are some things we miss because even we don't think it pertains to dentistry when, in fact, it does.” (08:00—08:12)
• “It goes well beyond medications and xerostomia and even system-induced xerostomia. It has to do with, do you know enough about the patient’s medical history to make well-informed, good clinical decisions in your treatment planning? And the only way you're going to really know that is if you know the patient well enough. And the only way that's going to happen is if you know their history. So, medical histories [are just as] important [as] almost anything else you do in your practice, because without knowing your patient intimately and sufficiently, you're not going to be able to make those decisions.” (08:23—08:57)
• “The greatest blessing ever bestowed upon dentistry was the fact that you could take the patient’s medical history directly from the patient themselves. They're right there. Right? What more convenience can there be? And the greatest curse ever inflicted upon dentistry was that you could take the patient’s medical history directly from the patient themselves. As in, if they don't know, you're not going to know. And if they don't want you to know, you're not going to know. But you can overcome that obstacle when you realize that all you really need is a list of their medications and a good working foundational knowledge in pharmacology.” (09:37—10:12)
• “I will tell you the thing I hear the most. In the beginning of the medical history, this is the question that gets asked, ‘Any changes to your medications?’ And immediately, the answer is, ‘No.’ Why? Because it’s easier to say no than it is to give me, the dental clinician, the information I need to be able to fill in the medical history. So, conditionally, I say, ‘No.’ And everybody’s like, ‘Okay. No.’ And we move on. But we missed so much of what we could've grabbed from that interaction.” (11:01—11:32)
• “Build a good team around you. You've got to invest the time and the money, if necessary, in your team to be able to teach them how to take a good medical history, what questions to ask, and how to ask leading questions and open-ended questions to get the patient to give up the information that maybe they don't want to give up, or maybe they don't know to give up.” (11:41—12:01)
• “Ask the right questions. So, you've had your teammate ask the questions. Now, you ask the question too, but in a different way. So, your team member could say, ‘Any change to your medications? What's new with your medications?’ Or something like that. But I have often said there’s got to be three questions from the clinician who’s actually intimately involved in that patient’s care. The first question is, not the D-word, drugs; not the M-word, medications. The first question is, ‘What do you take?’” (12:23—12:51)
• “I often say it like this, ‘What do you take?’ Say it with a little attitude. And that way, ‘What do you mean?’ ‘Do you take stuff?’ ‘Well, yes.’ ‘Well, what is it?’ So, that way, you get them a little bit like, ‘Whoa, should I be telling you all this?’ ‘Yes! I need to know what you're taking.’ But I don't want to say the word “drug” because that means, what? You're going to think little bottles. Or “M”, medication. Again, you're going to think little bottles. I want to know everything. I want to know prescription drugs you take, the nonprescription drugs you take. I want to know about the over-the-counter supplements you take. I want to know about the stuff you do on the weekends. I want to know everything. Give me all of it. And that way, I think I can get the best information I can from you. So, that's question number one.” (12:57—13:37)
• “Opportunity number two is, ‘Why do you take it?’ Because I know there are medications that people could take that are used for different things. A good example would be a drug like Norvasc, a calcium channel antagonist. I know that Norvasc is probably predominantly used for hypertension. But it can also be used to treat angina. It could also be used to treat arrhythmia. So, wait a second. How do I know what that patient’s taking that medication for? Because all I know is they said they take Norvasc. So, now, I have to ask, ‘Why do you take it?’ The first reason is so that I know what I'm treating can be influenced.” (17:22—18:00)
• “I want to know, number one, do [patients] understand their medical history enough to know why they take their medication, what their conditions are, and is there buy-in. Because I will get a sense of compliance if a patient tells me, ‘Oh, I take that medication for my blood pressure. That's very important.’ Or, ‘I don't know. The doc says I gotta take that pill every day.’ That means a lot to me so that I know if they're taking Norvasc and their blood pressure is high when I'm taking it right there in the office, I've got to wonder, ‘Did they take their medication?’ Because I know a lot of people who take blood pressure medications that don't take blood pressure medications. And so, that's the lead-in to opportunity number three, which is, ‘Did you take it today?’ I want to know if you bought into your drug therapy and if you are compliant. If not, that's going to mess up my understanding of your vitals, and that's going to affect the treatment planning in so many different ways.” (18:54—19:46)
• “Back then, if you had cardiovascular disease, you maybe took one or two drugs. If you had diabetes, you took maybe one drug like Diabinese, if you can remember that one. So, it was very rare to have people taking a lot of meds. Now, cardiovascular disease alone, you could be taking five, six, maybe even seven medications. Diabetes, you can be taking five or six medications. People say, ‘Why do you always pick on cardiovascular disease and diabetes? Well, you and I both know, and I'm sure everyone listening knows, that cardiovascular disease and diabetes and the inevitable triad that forms with periodontal disease and systemic inflammation. So, I pick on those two because those are the things, to me, that matter most in dentistry.” (23:25—24:08)
• “Choose cardiovascular disease and diabetes, and realize you've got at least 12 to 13 meds right there. Now, add in some issues with your GI, like reflux, heartburn, respiratory disease, especially if you're a smoker, central nervous system issues like if you have anxiety, or maybe you have difficulty sleeping. All of a sudden, I can easily get up to 20 medications without even blinking. And that's the medically complex patient, because now all those medications interact with all those other medications, and every one of them, either individually or together, can have an impact on dental therapy.” (24:23—25:01)
• “If my patient has cardiovascular disease, one of the first questions I'm going to ask them is, ‘When is the last time you had your cholesterol checked?’ I say this, and people say to me, ‘What the heck does that have to do with anything? Who cares about their cholesterol?’ But cholesterol is everything.” (25:49—26:04)
• “If you want to differentiate yourself, it’s not about marketing. It’s not about promoting yourself. It’s about giving such good care that that patient has no alternative in their mind but to see you again and again.” (32:33—32:45)
• “It’s an awkward and uneasy conversation to have, but you've got to ask your patients straight out, ‘Do you have, now, or have you had a history of substance use?’ If you don't want to use the word “abuse”, you don't want to use “addict”, don't. Just say “substance use” and just let them give you a positive yes or no, an affirmative or negative. Because that way, once that happens, then all the walls come down. And then, you can have the conversation like, ‘I'm not the police. I'm not here to report you to anybody. I'm not here to write anything down. I just want to know, because knowing is going to make me more informed in designing your treatment planning and knowing what's going to be safe for you and not safe for you. But if I don't know, it could be harmful.” (34:01—34:48)
• “With the advent of vaping, and dabbing, and all the cannabis extracts, your patient could be using cannabis, and you wouldn't even know it. ‘Okay. Well, why do I care? I don't need to know about cannabis.’ But you do, because cannabis has effects on dentistry that a lot of people aren't aware of. For example, cannabis can cause hypertension. Cannabis can cause tachycardia. Cannabis can cause immunosuppression. Well, okay, I couldn't think of three bigger things to worry about in dentistry than that.” (35:17—35:43)
• “Let's say I take Tagamet, or I take Prilosec. Both of those medications interfere with stomach acid production. So? So, that means you can't absorb as much calcium. So? That means you don't have normal bone homeostasis. So? That can lead to early implant failure. And I just had a conversation over the weekend with a doc at the Study Club. He’s like, ‘You know what, Viola? I never knew that. I've got all these cases where I don't know why their implant failed within the first four to six weeks, and you just told me that a drug for heartburn can have an impact.’ That's the kind of stuff that matters. Pharmacology is really more important than you thought it was in school.” (43:09—43:49)

Snippets:

• Dr. Viola’s background. (4:00—05:32)
• Why this topic is important to dentistry. (07:03—09:03)
• Challenges on the patient and clinician side. (09:31—12:21)
• The first question to ask patients. (12:22—14:35)
• Follow-up questions to unknown medications. (14:49—15:50)
• Why pharmacology is important. (16:00—17:07)
• The second question to ask patients. (17:15—20:05)
• How transparent are patients about their medications? (20:16—21:45)
• Advice for younger dentists. (22:50—25:01)
• Other trends or things that are missed that are important. (25:20—30:04)
• Dentists and hygienists diagnose more diverse illnesses than other clinicians. (30:42—32:45)
• Other important things to pay attention to with medical history. (33:30—38:45)
• There will always be a place for opioids in dentistry. (39:27—44:13)
• Last thoughts. (44:28—46:00)
• Dr. Viola’s contact information. (46:22—48:29)

Reach Out to Dr. Viola:

Dr. Viola’s website: https://www.tomviola.com/

Dr. Viola’s podcasts: https://www.tomviola.com/category/podcasts/

Dr. Viola’s Instagram: @pharmacologydeclassified https://www.instagram.com/pharmacologydeclassified/?hl=en

Dr. Viola’s Facebook: https://www.facebook.com/tomviolarph

Dr. Tom Viola Bio:

THOMAS A. VIOLA, R.Ph., C.C.P.

With over 30 years of experience as a pharmacist, educator, speaker, and author, Tom Viola, R.Ph., C.C.P., has earned his reputation as the go-to specialist for delivering quality continuing education content through his informative, engaging presentations. Tom’s sellout programs provide an overview of the most prevalent oral and systemic diseases and the most frequently prescribed drugs used in their treatment. Special emphasis is given to dental considerations and strategies for effective patient care planning.

As a clinical educator, Tom is a member of the faculty of 12 dental professional degree programs and has received several awards for Outstanding Teacher of the Year. Tom instructs dental hygiene students and practice dental hygienists in pharmacology and local anesthesia in preparation for national board exams. As a published writer, Tom is well-known internationally for his contributions to several professional journals in the areas of pharmacology, pain management, and local anesthesia. In addition, Tom has served as a contributor, chapter author, and peer reviewer for several pharmacology textbooks. As a professional speaker, Tom has presented continuing education courses to dental professionals internationally since 2001. Meeting planners agree that Tom is their choice to educate audiences within this specialty.