DNS2106 - Introduction to the Clinical Management of the Dental Patient

Introduction and History-taking

Oral Diagnosis and Consultation

Overview
• The consultation is the cornerstone of dental practice:
o Diagnosis
o Treatment planning
• Represents the main social encounter between dentist and patient.
• Patients sometimes don’t go to the dentist out of fear, thus this interaction is crucial.
• Categorisation of consultation and examination by patient needs:
o New patient
o Review patient
o Recall patient
o Unscheduled patient (what we call emergency but not a life-threatening
emergency)
o Patient needing referral

New patient
There’s an escalation. You start with the least invasive thing you can do. Things which are
invasive need to be justified.
• History
• Clinical examination
• Diagnosis
• Consultation
• Treatment planning
• Informed consent
• Treatment
• Maintenance and recall
• Record-keeping
o You have to record questions and answers. Important to record both for proof
that you asked the question. If e.g. you ask a patient about allergies and he
says no, and then later the patient has a severe allergic reaction to a drug,
you are not at fault. It is important to record everything even to take care of
the patient well with all the information. You have to write even negative
answers. This is also good to train yourself to ask all the necessary questions.
In law, good records = good defence, bad records = bad defence. If you go to
court, the only thing between you and prison are your records.
• Confidentiality
o It is very important to respect patients’ privacy. It is also a legal requirement. It is easy to
make an unknown mistake. The data owner has control over the data collected. It is
important to not leave patient records lying around.
• Data Protection Act

1
DNS2106 - Introduction to the Clinical Management of the Dental Patient

History-taking

• Introductions
o Firstly introduce yourself to the patient and then the patient introduces
themselves

• Personal (administrative) information

o Patient’s name (and preferred name) imp. to take note of both as some
people have nicknames they’re so used to, that they may not use their legal
name on a daily basis.
o Patient’s unique identifier (e.g. ID no.) imp to ask for this to ensure correct
patient and correct spelling of name. It is also important to have unique
patient identifier.
o Patient’s address
o Details of patient’s parents, guardians and/or carers (if applicable)
o Patient’s contact numbers, e-mail, etc.
o Patient’s GMP (and specialist practitioner/s)
o Family details and emergency contacts
o Preferred contact method and consent to contact

• Sociobehavioural history
o Occupation and work history (more relevant for elderly patient)
o Family
o Dietary/nutritional practices (imp as greatly affects oral health)
o Smoking and tobacco use (very harmful, carcinogenic, causes gum disease,
etc.)
o Alcohol consumption (acidic)
o Other habits
o Contact and outdoor sports and hobbies
o Personal circumstances and lifestyle
o Religious practices (e.g. Jehovah Witnesses do not accept blood transfusion.
In implants we do bone grafts which come from cows, pigs or horses.
Membrane of tissues comes from pig pericardium. In some religion, coming
into contact with is absolutely not allowed. This isn’t something to take
lightly).
o Availability to attend appointments
o Motivation and general attitude to healthcare

• Medical and Drug History

o Cardiovascular: Rheumatic fever, heart, blood pressure, congenital anaemia,
bruising, bleeding, healing, swollen ankles, chest pain, shortness of breath
▪ Infective endocarditis is a severe infection in the heart which an be
fatal. Even though nobody is immune to it, there are some conditions
which make patients more prone to having it.
▪ Atrial fibrillation: Heart beats fast and increases flow and increases
the risk of thrombus. These patients have to take medication for the
atrial fibrillation but also for the risk of thrombus, which are blood

2
DNS2106 - Introduction to the Clinical Management of the Dental Patient

thinners. This is very important. Ask about conditions and medications

and specifically for blood thinners as there is a risk of severe bleeding.
▪ Chest pain (angina): patients are at a higher risk of getting a heart
attack. These patients you have to treat with more care considering
anaesthesia. There are dental implications which may affect this
condition.

o Respiratory: Asthma, sinusitis, coughs/colds, influenza, tuberculosis

▪ Asthma: patients who have asthma may have an acute asthmatic
attack. They are also more resistant to pain killers. You have to ask
about what analgesics that they have taken. You have to ask them
what NSAIDs they have taken to see what they are allergic to. It is
important to take note of these.

▪ Sinusitis: Maxillary sinuses are just above the maxillary posterior

teeth. The maxillary branch of the superior alveolar nerve supplies
this area. If a patient suffers from a sinus infection (cold, allergy, etc),
the nerve will be irritated throughout its path through the sinus which
may present as tooth pain. If a patient presents with pain in these
teeth, the cause may be sinusitis so it is important to take this into
consideration.

o Gastrointestinal: Jaundice, diabetes (endocrine), inflammatory bowel

disease, ulcers and acidity
▪ Jaundice: liver not functioning properly. It could also be caused by
hepatitis. There are many variants of hepatitis.
▪ Diabetes: Has a strong negative correlation with periodontal health
and also prone to having a diabetic emergency.
▪ IBS: may have signs in oral cavity so imp. To know signs even for
Crohn’s disease
▪ Ulcers: can be caused by gastric acid
▪ Some drugs may be contraindicated. E.g. some NSAIDs cause
asthmatic attacks.

o Skeletomuscular: Joints, cramps, arthritis

o Dermatological: Rashes, irritations, tattoos, piercings

▪ Skin conditions: may develop symptoms even in mouth
▪ Tattoos: some patients have tattoos in mouth. Important to tale note
so as not to mistake for melanoma.
▪ Piercings: Can be in mouth and need to inform patient on risks.

o Genitourinary: Pregnancy, sexually transmitted diseases, kidneys

▪ STDs: sometimes manifest themselves in the mouth
▪ Kidneys: impaired kidney function may affect dosage requirement

o Neurological:

3
DNS2106 - Introduction to the Clinical Management of the Dental Patient

▪ Epilepsy, faints, migraine, pains, numbness

o Oncology:
▪ History of cancer and treatment (surgery, chemotherapy,
radiotherapy)
▪ Cancer pts – some treatment may affect patients health.
▪ Treatment in a jaw which was irradiated even many years later could
lead to jaw necrosis so history taking needs to go all the way back.

o Hospital admissions and GMP visits:

▪ Blood and urine tests, biopsies, medical problems, surgery, and
general anaesthesia
▪ Imp open ended question to ask as patient will relate it a lot to their
medical history. It also helps to ask about any reactions to
anaesthesia.
▪ Important to ask about any previous surgeries. This helps give us
information about any previous reactions to general anaesthesia.
▪ It is important also to ask the patient about any previous
investigations such as blood tests, which you may need to look at. No
need to retest if tests were recent.

o Allergies:
▪ Hayfever, reactions, drugs, food, metals
▪ Imp to note especially of drugs and anaesthesia.
▪ When we prescribe, it’s important to ask about any allergies
(antibiotics, NSAIDs, etc). Refer to drugs by their generic name not
their brand name. You have to keep a book with formulae or a
computer, to look up drugs)

o Family history: This is helpful. A patient who has an allergy is more

prone/susceptible to other allergies.

o Medications: Prescribed, OTC, what, why, when, how, side-effects. When you
prescribe, write the brand name in brackets and generic name next to it. E.g.
(Augmentin) amoxiclav. It is important to get a good medication history as
drugs taken months prior may also have an impact.

• Use open-ended questions. Some questions may seem stupid but are necessary.
There were certain cases of conditions which were not known to have affect on
dental treatment.

• Dental History
o Previous treatment
▪ Endodontic, periodontal, surgical, orthodontic, fixed and/or
removable prostheses
▪ Where, when, how often, success/failure
o Previous dental disease experience
▪ Caries, periodontitis, trauma, malocclusion

4
DNS2106 - Introduction to the Clinical Management of the Dental Patient

o Pain and discomfort

▪ Where, when, amount, relieving/exacerbating factors
▪ Headaches, muscle pains, clicking/noises, movement
o Gums
▪ Bleeding, soreness, food traps, bad breath
o Teeth
▪ Chewing, grinding, clenching, soreness, fractures, sensitivity
o Periodontal disease is the most common cause of tooth loss
o Aesthetics
▪ Patient’s assessment
▪ Important to note patient’s perception on things especially aesthetics.
It’s important not to influence their decision. A patient may be happy
with their mouth even though it is not the perfect scientific shape.
o Oral hygiene habits
▪ Type and frequency of brush, floss, other aids
o Dental habits
▪ Thumb-sucking, pipe smoking, breaking thread with teeth, wind
instrument playing
o Diet
▪ Quality, frequency, quantity
o Understanding, motivation, commitment

A dentist must present and offer all options to the patient. E.g. a patient had a bridge done
20 years ago and after 20 years it failed. It already went way past its lifetime. The dentist had
offered the patient a denture, a bridge or to do nothing. But he forgot to offer her an
implant which he may have not offered because he knew it was out of her budget. When the
bridge failed, lawyers argued that the dentist is at fault for the bridge failing and the tooth
being destroyed because he didn’t offer all available options and he lost the case and had to
pay.

5
DNS2106 - Introduction to the Clinical Management of the Dental Patient

• You give patient a Confidental Medical History Form (BDA). Ask them to fill it.

6
DNS2106 - Introduction to the Clinical Management of the Dental Patient

Confidential medical history form (denplan)

• You also ask many questions about family history, medications, illnesses, conditions,
etc. You need to be thorough as sometimes they may not understand. E.g. you ask
about hypertension and they say they don’t suffer from it because they take the
medication.
• It is very important to take medical history and to refer to medical history when you
see the patient again as if there is something that may impact treatment plan, you
need to remember.

• Medical Alerts on patient system.

• Treat all patients at high risk. All patients may pose a risk. They may be HIV positive
but don’t know. You need to apply measures which are effective for all situations.