Michelle Dawn Mooney: Hello and welcome to the Healthfirst Talks podcast. I’m your host, Michelle Dawn Mooney, and today we’re talking about a critical but often overlooked part of dental care: evaluating patient medical histories and how they directly impact safety, treatment decisions, and outcomes. Dr. Don Cohen, Chief Clinical Officer at Healthfirst, is joining us, as well as Dr. David Reznik, Director of the Oral Health Center of Grady Health System’s Infectious Disease Program. Thank you both for joining me today.
Dr. Don Cohen: Pleasure.
Dr. David Reznik: Thank you. Looking forward to getting into what we need to talk about here, specifically the medical histories.
Michelle Dawn Mooney: But could you give us a brief bio, if you wouldn’t mind, just to let people know a little bit about who you are before we jump into the conversation?
Dr. Don Cohen: So as Chief Clinical Officer, obviously I handle all of those kind of health and medical questions that come up at our company. My background is as a dentist for many, many moons in New York State, and I’ve been blessed in working with some great people, such as Dr. Reznik.
Dr. David Reznik: Well, thank you, Dr. Cohen. I went to Emory undergraduate and Emory School of Dentistry. I started off in the private sector. There was an unmet need for people who were living with HIV. No one would touch that patient population, so I took it upon myself to address that. I went on a five-year campaign and opened up the Oral Health Center in 1993 at Grady, started the dental service in 2000. It’s been a remarkable experience working at the hospital and helping to manage — at this point, we have 9,000 patients in our program.
Michelle Dawn Mooney: So let’s start off here, because we’re talking about medical histories and how important they are with dental care. Why is reviewing the patient medical histories such a critical step when it comes to dental health and the care that dentists provide?
Dr. David Reznik: Well, the mouth is attached to the rest of the body, and we are doing procedures, and we want to make sure that we have healthy outcomes. If we don’t review the medical history, we could miss things such as hypertension, cardiovascular disease, uncontrolled diabetes — things that would actually impact how our outcomes are, or how patients respond. So reviewing the medical history is always an important task.
Michelle Dawn Mooney: My concern is how accurate are the medical histories. And what risks can arise when the histories may be incomplete or outdated? A lot of times people don’t keep up on the medical history. So what can happen there?
Dr. Don Cohen: Many of our patients are getting older, especially, and when we think of these patients, they’re on multiple meds — and the multiple meds are, as you heard Dr. Reznik say, cardiac conditions, diabetes, so many other issues of the body. If we don’t know, on the day of that dental visit, exactly what’s happening and what has changed, we can put you at really grave risk. And we can avoid many of those risks by having that current knowledge.
Dr. David Reznik: I completely agree. We’re not working on mannequins. We’re working on complex people. There are also social determinants of health that might come into the factors — things that we need to know about diet and allergies. But one of my big concerns is that I believe in medical-dental integration. That’s what I have here. I work with primary care and support services. You really need to know the patient. You need to know what your risks are. You need to know how to stratify your risk. And you also need to learn how to communicate with our primary care colleagues. I think that is really where we’re going to find the information that we need, because people are not great when it comes to reporting a medical history.
Dr. Don Cohen: Typically, many dentists don’t know how to address their medical colleagues, and many of our medical colleagues tend to look down at you because you are “only a dentist.” So there’s a whole bunch of communication involved, and I totally concur with Dr. Reznik. We need to recognize the oral health-systemic health connection and work with our medical compatriots to make sure that is totally understood.
Michelle Dawn Mooney: And there are a lot of medical factors here in play. So what medical conditions or medications most commonly impact dental treatment decisions?
Dr. David Reznik: Well, you have the bisphosphonates, because of people with osteoporosis or osteopenia — that can cause issues. A lot of people are on blood thinners these days for arrhythmias, and that can cause some issues when it comes to bleeding. If a patient is on diabetic medications, you need to know: did they eat in the morning? Don and I will always have this discussion of what’s more important, the hemoglobin A1C or a glucose. I’m in the hemoglobin A1C camp, but that’s something for us to talk about later. But literally, there are so many things in your medical history that can impact your outcomes. Our goal is to give you that beautiful smile, to eliminate infection, to restore function, to reduce inflammation, to reduce some of those oral-systemic connections that we know exist today.
Dr. Don Cohen: And if we don’t have a proper medical history that lists what medications you’re on — I mean, people forget. I’m getting a little older, but I carry my medications in my wallet. I’ve had a few back surgeries. They ask me the dates — I don’t remember. I say, “Check the file.” But there are certain things that really do impact our outcomes. If you have an uncontrolled diabetic, do you want to put an implant in their mouth and risk failure? There are so many different considerations — do you want someone to have an MI in your dental clinic when they see the bill? The whole nine yards of how we manage someone comes back to doing it as safely and effectively as possible. It starts with the medical history.
Michelle Dawn Mooney: And we don’t want to scare people here, but at the same time, this is a cautionary tale. We want people to be aware of the seriousness that can happen here. So what are some examples of those serious complications that can occur if key history details are missed?
Dr. David Reznik: Patients very often will be referred to their endodontist for treatment of a root canal. There they are, and they’re prescribed amoxicillin 500 — but at the same time, nobody has talked to the person treating their allergies, who has them on a totally different medication regimen, or even their periodontist who has them on doxycycline. When you go through some of the different meds, there can be all kinds of conflicts in there. You would look at it and say, “Well, the pharmacist should have caught that.” That could be very true, but meanwhile, we’re the ones treating that patient today. That’s why you always check the medical history.
I know that both of us are very passionate about checking for hypertension, too. I would say that most of the time, I’m a well-controlled hypertensive. There are days where I might not be so well-controlled, and I definitely don’t want to be in the dental office — although my nephew is a fabulous dentist.
Michelle Dawn Mooney: So a lot of patients may have one issue, but then you have some that have more than one. How should dental teams approach medically complex patients?
Dr. David Reznik: That’s what I do. This is a Ryan White-funded program to treat people with HIV, but we also have people who have hepatitis C, people who might have diabetes. We’re noticing it’s easier to get HIV under control right now than it is diabetes. Diabetes seems to be harder for us to get under control.
So when you’re dealing with this, I think the key is to know what questions you want to ask the primary care provider. Are there specific labs that you want to know? A colleague of mine focuses on risk stratification — what is the operative risk? People are trying to get clearance from a medical provider who has no clue what we’re doing in the dental field, and they are not legally protected by that clearance — neither the dentist nor the medical side. So you need to know the specific questions. Diabetic: Don’s going to say, “What is your average glucose?” A lot of people are wearing devices. I had someone in my office today who kept beeping because she stopped at Krispy Kreme. Seriously — her blood sugar was high. That’s not the normal right now. And so you really want to know what your risk is for the patient, because we want to do the right thing. If we have to take teeth out, we want to know upfront whether there are bleeding issues to be aware of.
What do you do with someone who’s on one of the blood thinners? Luckily, we’re no longer using Coumadin or warfarin, which meant you had to get a stat INR before you treated. So there are rules out there. You need to stay up with your continuing education. Go to some of the wonderful courses that are offered. Look at medical emergencies in the dental setting, because that is so important. You want to be prepared, but it all starts with that piece of paper — and that piece of paper is accurate about half the time. It’s not that people want to lie. There might be some things they don’t want to admit. I work in HIV. It’s a very stigmatized disease. People might not want to put that on their medical history. But right now, 90% of the folks that I follow have undetectable viral load and cannot transmit.
So if you stay up with the information and you know what specific questions to ask, if you know your limitations on blood pressure — and the American Dental Association and the American Heart Association have guidelines, Dr. Cohen’s much more familiar with this than I am — follow the guidelines. How do you handle a blood pressure that’s too high? What can you do to make it drop? Have the patient uncross their legs. Have the patient void before taking the blood pressure. Make sure that the arm is elevated above the heart. Just how you take a blood pressure matters. I want every patient to have a blood pressure taken. We do that here, but I want it done right. Flopping around and getting numbers and hearing bells go off — that’s not the answer.
So even something as simple as taking a blood pressure — which most dentists don’t do themselves, their assistant or dental hygienist will — we play a role in it. It’s our responsibility. We need to make sure that we have as good of information as we can get and do the best we can under the circumstances. And if you’re unsure, postpone until you are sure.
Dr. Don Cohen: Well said, David. And to that point, it might even be rules within your own organization. I taught at Columbia for many years, and one of our policies that we established was: if you’re going in for any kind of coronary procedure, one of the things you had to have was dental clearance. Meaning — you get a patient who has severe periodontal disease with first, second, third-degree mobility. Should you be putting a valve in that patient at this time, or should you be cleaning them up first and then going there? We’ve had numerous situations, and this is where dentists need to learn how to talk to physicians. I remember one of my residents getting yelled at at Columbia for holding up a scheduled surgery — because we didn’t want to see the patient harmed. Communication becomes incredibly important.
And as you heard Dr. Reznik say, that is a key skill. It’s a key skill, but the fact that the surgeon may say, “No, no, don’t sweat it, it’s fine,” doesn’t remove your responsibility to know what the right thing to do is. And it’s the same with oncology patients. For chemo or radiation, we have better outcomes if the disease in the mouth is taken care of. One of my colleague universities has set up an oral health head and neck dental clinic in Atlanta right now, which is a blessing that we have here.
To that point, David — having just dealt with one of the premier cancer institutions for my wife with breast cancer — one of the questions that was never asked was about oral health.
Michelle Dawn Mooney: I feel like there could be a variety of different reasons here, but why do patients sometimes leave out important medical information?
Dr. David Reznik: I sometimes think they don’t think it’s pertinent. “Oh, I’m taking a blood thinner. Does that matter?” We’re trained to see the consequences. We know that if someone is on chemotherapy, or on a blood thinner, or on A, B, C, or D, we know how it impacts. But patients might be thinking the oral-systemic connection really doesn’t exist — “I’m just going to the dentist. I’m just getting my teeth cleaned. Why do I need to tell them that I had such-and-such six months ago?” And so that’s why it’s always important to probe when they come back in.
It’s easy for me to say because I have access to the electronic medical record, and there are certain other questions that I end up asking. I also work with primary care, and we have a very unique, intertwined relationship. They need me, and I need them. We work together, and it’s very collegial. They don’t dismiss me as “just a dentist” because I come in prepared with the questions I need to ask, or because I’ve done something in the past that helped them with a patient.
It’s about establishing relationships. I learned about this working relationship through my best friend, who was a medical student and then became a physician. Because he was my best friend, we communicated. There wasn’t a whole lot out there. And you have to learn by asking. You have to be inquisitive — dentistry is lifelong learning. I don’t know that our patients actually realize that sometimes. You look at dental insurance — that’s an issue. You look at what’s covered — that’s an issue. You look at how it’s different from the primary care system, and how that friend I was talking about said physicians are “good from the nose up and the chin down — leave the mouth to the dentists.”
I’ve always asked, when I go for my every six-month visit — because I’m older now — they look in my mouth, and I ask, “What are you looking for?” And I really don’t get an answer. It’s like they’re so used to saying “open wide” and just going, “okey-dokey.” I know what I’m looking for when I do that. So I teach them what they’re looking for — but that’s because I’m in an environment where we’re all in one building.
Dr. Don Cohen: Earlier, we talked about things that a patient may leave out. Well, it just so happens your patient’s taking St. John’s Wort. Now, it’s nothing special — it’s an over-the-counter, you can get it at just about any place, no prescription. But the effects that it could have on some of the other medications that you’re taking can be crucial. So I think the key is not to doubt your patient, but if you know your patient has a complex history, one of the things that we did in our office was ask when we confirmed the appointment — making sure we could have this discussion — “Could you bring in an exact list of what medications and doses you’re taking?” It saved a ton of time on the front end, and on the other side, it protected the patient immensely.
Michelle Dawn Mooney: Dr. Reznik, I want to ask you — you mentioned working with patients with HIV, which is clearly a sensitive area that anyone could understand. So how can dental teams effectively discuss these sensitive topics, such as medication use, substance use, or a medical diagnosis?
Dr. David Reznik: Treat people like they’re adults. Listen. Our best skill — I’m doing a lot of talking right now, that’s not actually my best skill. My best skill is in the few seconds I’m not talking: to listen. What is the patient telling me? Is there something that feels missing?
And in some cases in this environment, it could be a history of substance use. A program I’m working with now is having a real issue with crystal meth again. And sometimes you think that’s not in the news — it’s gone because everything is fentanyl. Well, crystal meth is still around, and it’s hard to get some of these people anesthetized. So you have to listen to what’s not being said. Look at the person. You see the face. You can tell if someone is comfortable. And trying to make someone comfortable — that’s my whole personality, my whole approach. I want my patients to be comfortable. That’s why I’m here.
So listening to them — there might be some that have different life choices than I’ve made. It’s not for me to judge. It’s for me to see: will that impact what I’m about to do? Do I need to look for a sexually transmitted infection in the mouth? Yes. I’m doing a study on human papillomavirus right now. The number of people enrolled — 280 so far — and it’s amazing what we are finding. I’ll say it again: it’s listening and not judging and not being “I’m the dentist and you’re the patient.” We’re both humans. I have a skill set that I’ve been blessed to be able to provide. You are here because you need my skill set. We are equal.
And it’s the same with physicians. I was very fortunately empowered when I first started at Grady in 1993 by the medical director, because I had a disagreement with an infectious disease physician. And he basically said, “David, you are right. This other person was wrong.” And just that little bit of empowerment helped to create whatever I became — because I’m not intimidated talking to a physician, or a physician assistant, or a nurse practitioner, or a nurse. All of these people are important parts of the primary care team. I don’t have to necessarily speak to the physician. I sometimes get better information from the PA or the advanced practice nurse practitioner.
I think there’s a holistic nature to what we do. A patient just comes in needing a filling done, or something of that nature. And there’s the patient limping into the chair. “How come you’re limping today? I don’t see anything in your history.” “Oh, that’s nothing.” “Well, just tell me — how long have you been limping?” “Yeah, it started in this knee, but last week it was this knee.” And by the time you get done with it, we came out with, “Maybe you need to see your physician because some of those things could even be Lyme disease” — as simple as that. I don’t think there’s ever a time that we shouldn’t feel comfortable questioning things.
Dr. Don Cohen: I remember dealing with a resident who was being, to put it nicely, recalcitrant. There’s a patient who’s 90-odd years old with a large basal cell on their nose, and the resident is saying, “Yeah, but I just want you to check how this partial fits — just sign off on it.” I said, “Yeah, but what about that?” And sure enough, at Columbia, we got the dermatology chief to come in. They looked at it and said, “Yeah, that’s a pretty good example of it.” The derm chief then talked to the patient’s 65-year-old daughter. “That really needs to be dealt with.” And the daughter said, “My mother is 90 years old.” And the chief replied, “Really? How old would you like your mother to get? You want another 10 years? She’s not going to have a nose if you don’t do something.” That’s a chief resident for you.
And I think that’s a real issue. When I first started in private practice in a very nice area of town, if a patient needed a crown on number 30, my eyes went to number 30. Then I started seeing medically complex patients. If I knew the patient was scheduled to have a crown on number 30, my first five to ten minutes were medical history — going over what’s going on, doing a head and neck exam, an intraoral and extraoral exam, looking at the back of the throat, looking at all the soft tissues. Then I’ll get started. And that’s what I teach. Because we are taking care of a whole person. Sometimes people think the mouth is just something you pull out like a dentoform and work on. It’s not that.
Michelle Dawn Mooney: Who should be responsible for collecting and verifying patient history information?
Dr. Don Cohen: The dentist. Period.
Dr. David Reznik: Moving on, right? Short and sweet. Well, but in reality, the assistants go over it. In reality, the hygienists go over it. My reality: if I’m in that operatory, I’m going over it. It’s my responsibility. It’s my license. It’s my patient. There are certain things that we have other people do for us — but when it comes to something as important as a medical history, that’s my responsibility.
Michelle Dawn Mooney: Follow-up to that: how often should medical histories be reviewed and updated?
Dr. Don Cohen: My feeling is at every visit — but I’m not talking about going over every single system. The most common thing is: what changes have occurred in your medical history since we last saw you, including any prescription changes or any visits to your doctor or the hospital? Every single visit.
Michelle Dawn Mooney: With that, what would you say are the most important red flags that should trigger additional precautions or maybe a medical consultation?
Dr. David Reznik: I think Dr. Cohen hit it very early on. Our patient population is getting older. We have people who are on polypharmacy. We have people who are living longer but with multiple chronic diseases — they’re medically complex patients. We need to look out for that. I also think there are certain behavioral things we can watch out for. Like I said, I work in a one-stop shop. One of the things that sometimes comes up are concerns with well-being, mental health, or substance use — and sometimes these things are very obvious. You would never expect that a professional dentist who spent all that time and money to become a dentist might have a substance abuse issue or a mental health issue. So you don’t know with your patients. When I see them, I can’t judge. That’s where the listening and the looking come in.
It’s hot in Atlanta — we’re called Hotlanta. We’re only legally allowed to observe certain things, but if somebody’s coming in wearing a tank top and shorts, we’re going to look at the whole body. Some of the manifestations associated with certain diseases show up on the ankles or in different areas. Somebody has a DVT. Somebody has knee problems. “I see you’re limping, like Dr. Cohen mentioned — are you going to get a hip or knee replacement? Are there things that we need to get done before that?” I think there’s a lot that goes into it.
Michelle Dawn Mooney: What are some simple steps that practices can implement immediately to improve their history review process?
Dr. David Reznik: I think continuing education is key. I think understanding what some of the “yes” answers mean. If someone comes to your office and they’re being honest — “I have dry mouth all the time. I’m getting up in the middle of the night. I’ve got to go to the bathroom constantly. My urinary frequency has greatly increased” — what comes to my mind is undiagnosed diabetes. We have so many pre-diabetics in the United States, it is frightening. Honestly frightening. So because of that, you have to look through things carefully. And now we have point-of-care technologies where we can literally check what Dr. Cohen’s glucose is or what my hemoglobin A1C is. We can even give two different tests. We don’t diagnose diabetes, but we can certainly point you in the right direction. Use all of your senses — your eyes, your ears, and in some cases your brain — and you can help people in ways you never thought you could.
Dr. Don Cohen: There was a great article by Dr. Greenberg, and one of the things they did was exactly what you heard David describing. For this particular screening, they did blood pressure, they did A1C, and they checked cholesterol. It was that simple. And lo and behold, the percentage of patients who had one or more of those out of the normal range was phenomenal. And what’s the great thing we could do with that? We could get them into the system early — so things are treatable rather than, as I like to say, “oh my God-able.”
Michelle Dawn Mooney: What is one actionable takeaway that listeners can implement right now? What’s the big message you want to leave everybody with today?
Dr. Don Cohen: How about two? The medical history is remarkably important — and take blood pressure at every visit.
Dr. David Reznik: Absolutely.
Michelle Dawn Mooney: All right — short and sweet. Great conversation. I appreciate both of you taking the time, because I know how busy you are. Dr. Don Cohen, Chief Clinical Officer of Healthfirst, and Dr. David Reznik, Director of the Oral Health Center of Grady Health System’s Infectious Disease Program — this was important, and really life-saving information. I appreciate you taking the time to educate all of us about what we need to know and how important it is. Thank you for being here today.
Dr. Don Cohen: Thank you.
Dr. David Reznik: Thank you, Michelle.
Michelle Dawn Mooney: And I want to thank all of you for tuning in and listening to this episode of the Healthfirst Talks podcast, brought to you by Healthfirst. We hope you’ll subscribe to hear more engaging conversations like this one. I’m your host, Michelle Dawn Mooney. We hope to connect with you on another podcast soon.
