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Lecture 1:

Steps:
1. Greet patient.- 1. ID: name, address, DOB, age, 2. Introduce self/role 3. Pleasantries-comfort 4.
Observations of ptnt. Why greet? 1. Polite 2. ID 3. Wrong person?
2. RFA- CC- presenting symptoms
a. Q- What can I do for you?, What brings you here? What is the problem?
b. Have you noticed anything different in your mouth e.g. food trapping? Bad breathe? Bad or strange
taste? Sensitivity to temperature changes? Swollen gums? Teeth moving? Changed bite? Crowding?
c. Pain? How often do you get the pain? Constantly, several times a day, just in the morning, after eating
sweet foods, occasionally.?
d. How often do you drink alcohol
e. Layman, patients words
f. None?- record as C/O- Nil
3. HPC- Ws
a. What, When, Where, How(freq): see below
b. What do you have & where do you have it?
c. When did you become aware?
d. Continuous or intermittent(how freq?)
e. Worsening/better/same?
f. Previous episodes?
g. Previous treatment? If yes outcome?
h. IF PAIN:
i. OLDCAARTS
ii. Angalgesic/ Up @ night?
i. More than 1 complaint? Address CC first!
i. Record ALL.
1. In pts words
2. Remain focussed by paraphrasing
3. Summarize interview up to that point
ii. Prioritise concerns:
1. Patients 2. Clinicians
4. Other complaints
5. Past History
a. Medical Hx
b. Dental Hx
6. Family & Social Hx.
7. IO/EX Examination
8. Special Diagnostic tests/ Explanation of tests. DD, PD, Dx.
9. Rx
History taking:
o Build raport- else unrewarding info gained. 1st impressions. Each session aim: patient leaves feeling
better.
o Signs: objective morbid changes detectable by the clinician
o Symptoms: subjective complaints, which the clinician learns from the patients account of his or her
feelings.
o Why? $cheapest way come to a dx. With experience: Hx alone can come to a Dx
Why Take a Medical History?
o Obtain info necessary to provide appropriate, individualised care.
o 1. Helps ID conditions relevant to patients dental health or which could have an impact on how treatment
is performed. (Ie LA, antibiotics etc)
o 2. Info on med conditions (diabetes, epilepsy, allergies, heart disease) could be vital if a medical
emergency occurs in the practice.
o 3. Recording a medical history is an important adjunt to the opportunisitc monitoring of the oral soft
tissues, enable the dentist to ID and address risk factors for oral cancer.
o 4. Medical histories reveal critical information required to address infection control issues. Standard
precautions. @ risk groups.
o 5. Prevent mediacal compications and thus minimise detrimental effects to the patient and the possiblity
of medicao-legal complications
o 6. Come to a diagnosis
o 7.to make sure patient is suitable for outpatient dental care ie
patient safety.
o 8. To work out if YOU ARE the right practitioner to see the patient.
o 9. In everyones best interest for safety of staff and patient
Medical History: recall our dental software and what we ask.
o Must do
o Signed/dated
o Every question answered
o All medications, name and dosage
o Constantly updated! Every time you see them- even 24hrs later.
Anything changed since last visit? New meds? New illnesses? New
things didnt tell me?
Detailed medical history MUST be done if havent seen in
MONTHS or years.
o If they have one: 1. Severity, 2. Controlled/uncontrolled? GP satisfied with you? Has patient taken
meds/eaten/monitored today? Preop testing needed? Do I have all info needed or should I contact GP?
o Taking meds? Why? For what? Is it controlled? What class of drug?Dont know- ask them to bring it? Look
up MIMS if reqd
Dental history: update to your needs for things. Also, use alongside medical history, to find connections.

Past Dental History:


o 1. Regular/irregular attendance- freq of visits.
o 2. Past dental treatment
o 3. Ongoing dental problems
o 4. Level of anxiety- dental phobic/needle phobic
o 5. Previous bad experience
o 6. Difficult exos
o 7. Excessive bleed after exo
o 8. Post op comp: dry socket etc.

Family History:
o Family dental problems (genetic, env)
Perio dz
Caries
Missing teeth etc, amelogenesis imperfecta
o Medical e.g. diabetes.
Social History:
o SES
o Education
o Occupation
o Lifestyle
o Habits
o Health values
o Self responsibility
o Oral Hygiene
o Diet and nutrition
Sugar intake
Acid intake
o Smoking (amount/yrs)also in MH
o Alcohol intake- also in MH
o WHY WHY WHY WHY WHY..
Oral
Hygiene Habits: also part of the examination
o Toothbrushing
Frequency
Type of toothbrush (electric, hard)
Toothpaste (F, sensitive, whitening)
o Interdental Cleaning: type and frequency
o Mouthrinse: type and frequency
o Denture care: is denture removed at night? Cleaning routine is what??

Dental risk assessment


o Caries, periodontal disease
o E.g. saliva testing: 1. Quality, 2. Flow (resting& stimulated) 3. pH-resting and 4. Buffering capacity-
stimulated.
o Risk assessment is the corner stone of practice- not an afterthought.