An analysis of patient-completed written versus clinician-mediated verbal anamnesis in dental practice: a retrospective cross-sectional study

Abstract

Abstract Background Accurate medical history is vital for safe dental practice and perioperative risk management; however, the optimal method for acquiring this information remains unclear. The aim of this study is to analyze the reporting completeness of patient self-reported written anamnesis (PSWA) versus clinician-mediated verbal anamnesis (CMVA) in assessing systemic diseases and related comorbidity patterns. Methods This retrospective, cross-sectional analysis included the data of 2,800 patients retrieved from the archives of Kocaeli University, Faculty of Dentistry. The investigated data consisted of the CMVA records registered in the hospital information management system (HIMS) in 2024 and the data gathered from previously used PSWA forms collected in 2018. Age- and sex-matched cohorts ( n = 1,400) were formed, one from each database. In addition to descriptive statistics, a multivariate binary logistic regression model was utilized to identify independent predictors of systemic disease disclosure. Results Overall disease prevalence was found to be higher in the PSWA cohort (44.9%) compared with the CMVA cohort (34.1%). While major systemic conditions (e.g., hypertension, diabetes) presented similar rates across both groups, secondary conditions such as anemia (16.2% vs. 3.0%, p < 0.001) and gastrointestinal diseases (11.4% vs. 3.3%, p < 0.001) presented significantly lower rates in the CMVA group. The multivariate model indicated that the PSWA method increased the likelihood of disease disclosure (aOR: 1.66, 95% CI: 1.41–1.96, p < 0.001), independent of the demographic variables. Furthermore, investigation of PSWA forms revealed higher rates of overall multimorbidity and clinically relevant specific comorbidity patterns. The difference between the two methods was most pronounced in patients under 40 years of age. Conclusions Relying solely on CMVA may contribute to an underreporting of secondary chronic conditions and related pharmacological risks. PSWA forms still seem to be a valuable tool in supplementing the widely used CMVA approach to avoid underreporting medical conditions. Adopting a standardized PSWA or a hybrid protocol incorporating both methods could provide a more reliable approach to assessing the reported burden of systemic disease and subsequently enhancing patient safety.