Journal of dentistry · 2026
Are patient-reported medical histories enough for safe dental care? A comparison with electronic medical records in dental practice.
СтатьяСравнительное исследованиеНазвание и аннотация: Перевод в очереди
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Zadik Yehuda, Sultan Shany Gonen, Becker Talia
Аннотация
OBJECTIVES: Accurate medical information is essential for safe dental treatment planning and for tailoring dental care to the patient's systemic condition. The patient-reported medical history questionnaire is a well-established and recommended practice in dental clinics, guiding the dentist in deciding whether to obtain additional information from the patient's treating physician. We aimed to evaluate the reliability of this approach through comparison with corresponding medical records.
METHODS: We retrospectively compared 276 self-reported medical questionnaires with corresponding electronic medical records obtained from the same healthcare organization. Participants were categorized into two age groups: 18-35 years (n = 91) and >35 years (n = 185). Two analytical models were used, encompassing a discrepancy in general diagnoses model assessing discordance between medical and dental records, and a cumulative number of diagnoses model comparing the number of concordant diagnoses per patient.
RESULTS: Overall, concordance between patient-reported medical history and the electronic medical record was limited, indicating frequent discrepancies between self-report and documented medical information. In exploratory age-stratified analyses, participants aged >35 years had lower concordance than those aged ≤35 years for selected outcomes. Age-associated conditions with particularly low agreement included hypertension (p = 0.034), diabetes mellitus (p = 0.018), and regular medication use (p = 0.029).
CONCLUSIONS: Self-reported medical history questionnaires cannot be relied upon as the sole source of medical information for safe dental care and should be routinely supplemented with objective, comprehensive data from the patient's electronic medical record.
CLINICAL SIGNIFICANCE: •Patient-reported medical questionnaires should not be used in isolation in dental practice, as they remain vulnerable to incomplete disclosure. •Patient-reported information should be supplemented with objective data from the electronic medical record, particularly diagnoses, medications, and allergies.
CLINICAL TRIAL REGISTRATION: Not applicable. This retrospective observational study was not registered as a clinical trial. The study protocol was approved by the Institutional Review Board of the Israel Defense Forces Medical Corps (reference no 2380/2023), which waived the requirement for written informed consent because the study was based on anonymized existing records.
METHODS: We retrospectively compared 276 self-reported medical questionnaires with corresponding electronic medical records obtained from the same healthcare organization. Participants were categorized into two age groups: 18-35 years (n = 91) and >35 years (n = 185). Two analytical models were used, encompassing a discrepancy in general diagnoses model assessing discordance between medical and dental records, and a cumulative number of diagnoses model comparing the number of concordant diagnoses per patient.
RESULTS: Overall, concordance between patient-reported medical history and the electronic medical record was limited, indicating frequent discrepancies between self-report and documented medical information. In exploratory age-stratified analyses, participants aged >35 years had lower concordance than those aged ≤35 years for selected outcomes. Age-associated conditions with particularly low agreement included hypertension (p = 0.034), diabetes mellitus (p = 0.018), and regular medication use (p = 0.029).
CONCLUSIONS: Self-reported medical history questionnaires cannot be relied upon as the sole source of medical information for safe dental care and should be routinely supplemented with objective, comprehensive data from the patient's electronic medical record.
CLINICAL SIGNIFICANCE: •Patient-reported medical questionnaires should not be used in isolation in dental practice, as they remain vulnerable to incomplete disclosure. •Patient-reported information should be supplemented with objective data from the electronic medical record, particularly diagnoses, medications, and allergies.
CLINICAL TRIAL REGISTRATION: Not applicable. This retrospective observational study was not registered as a clinical trial. The study protocol was approved by the Institutional Review Board of the Israel Defense Forces Medical Corps (reference no 2380/2023), which waived the requirement for written informed consent because the study was based on anonymized existing records.