ODM 814 - Lecture 2

• It is important to perform an evaluation of the dental patient when history taking
• The general dental assessment includes questionnaires, patient interviews, clinical examinations, and diagnostic tests.
• The general dental assessment process is: assessment, diagnosis, treatment planning, implementation, and evaluation.
• Detailed history taking includes chief complaints, history of present illness, previous treatments, medical history and medication intake, review of systems, surgical history, dental history and social history.

Chief Complaint

• Is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient's encounter
• Best obtained by asking open-ended questions
• Is usually stated in the patient's own words and in quotation
• If there is more than one complaint investigate each one separately and prioritize based on severity.
• Examples of chief complaints include "My tooth hurts", "I want a pretty smile", "My front tooth broke", "I don't know why I'm here, my mom brought me ask her", "My mouth is a mess", and "I want a second opinion".

History of the Present Illness

• The HPI is a chronological description of the development of the patient's chief complaint from the first sign/symptom or from the pervious encounter to the present
• The HPI contains at least 9 elements.
• Liqord AAA is used to collect this information
• Location describes where the patient is feeling the pain assessed by having the patient draw their pain on a face/whole body diagram and asking the patient to point with one finger to the area of pain.
• Consider if the pain is located in a single tooth, multiple teeth, quadrant, soft tissue, or Non-odontogenic (neuropathic, muscular, other)
• Intensity is a patients rating of their pain as subjective, variable, and can be influenced by psychosocial status.
• Quality of pain descriptors can direct the provider to diagnostic categories of pain
• Descriptors identify how the patient describes their pain such as throbbing shooting, stabbling, sharp, cramping, gnawing, hot/burning, aching, heavy, and/or tender
• Onset refers to when the pain began (weeks, months, years) and assess for circumstances that could be related to the pain onset such as trauma, a dental procedure, another procedure, or a stressful situation.
• Referral indicates if the pain extends beyond the are of interest, and whether it is localized or generalized.
• Modulating factors include precipitating factors (what causes the pain to begin), aggravating factors (what causes the pain to increase), and alleviating factors, (What causes the pain to reduce).
• Frequency describes how often the pain is present, pain that comes and goes is intermittent and constant pain remains.
• Duration, when in pain describes how long does it lasts such as seconds, minutes, hours, days, weeks, and months.
• Associated symptoms such as nausea and vomiting, headaches, limitation in opening, bite changes, Parafunctional habits, and/or swelling can assist the provider with diagnosis.
• Warning signs and symptoms (red flags) are: large facial swelling, tingling or numbness, difficulty or pain upon swallowing, bilateral submandibular swelling, difficulty breathing, and chest pain.

Previous Treatments

• Describes previous interventions (dental or medical) received for the chief complaints and the patients perceived outcome (positive, negative, no change).

Medical History and Medication Intake

• Medical history gathers information about past and present medical conditions that are related to the patient’s chief complaint.
• It must be obtained from each patient and updated periodically, recommended annually.
• It is obtained through a medical history questionnaire followed by a patient interview.
• It contributes to risk assessment and identification of cases that may require a referral.
• Some medical history examples are Hypertension, Angina, Mitral valve prolapse, Rheumatic fever, Endocarditis, Arrhythmia, Aneurysm, Clotting disorder, Rheumatic heart disease, Anemia, Sickle cell anemia, Glaucoma, Hearing loss, Epilepsy, Panic attacks, Dizziness, Seizures, Depression, Anxiety, Ulcers (GI), Ulcerative colitis, Hepatitis, Hepatitis B, Hepatitis C, Liver disease, Jaundice, Cirrhosis, Eating disorder, Sinus disease, Bulimia nervosa, Asthma, COPD, Chronic bronchitis, Congenital heart disease and Stroke.
• It is important to care about medical history because it has the possibility of something going wrong, it's worth outcome, prevent/manage emergencies, dental treatment complications/contraindications, detection and manifestation of systemic disease, we see patients more often than their doctors, and to detect uncontrolled and undiagnosed diseases.
• Medication intake assesses and documents all the medications(over the counter and prescribed) and supplements, (herbal, vitamins), the patients is currently taking and the for taking them.
• It's ideal if obtained from physician, pharmacist or patient's printed list.
• Allergen is the substance the caused the allergic reaction.
• Allergy occurs when the body's immune system sees a substance as harmful and overreacts to it..
• Routes of exposure to allergens are: inhalations, ingestions, injection, and topical.
• Allergic reactions vary from patient to patient, keep in mind that any medication can cause an adverse reactions.
• Adverse reactions = unwanted, uncomfortable or dangerous effects that drugs may have.
• Adverse reactions also equal allergic reactions + side effects
• Adverse Reaction severity ranges from mildly to life threatening.
• Examples of an allergic reaction are itchy, watery eye, itchy nose, sneezing, runny nose rashes hives, stomach cramp, vomiting, diarrhea, bloating, swelling, redness, pain, tongue swelling cough, throat closing, wheezing, chest tightness losing breath and/or feeling faint.
• Anaphylaxis is the most serious allergic reaction or rapid onset that can cause death.
• Symptoms usually involve the dysfunction of more than one body system.
• All medications have the potential to cause side effects.
• Only about 5 to 10% of averse reactions to drugs are allergic.
• To document the specific medications and reactions such as Aspirin - rash, Penicillin - anaphylactic shock, and Ibuprofen - severe stomach pain, or there are no known allergies (NKDA).
• Assessing compliance, Compliance doesn’t necessarily mean the disease is stable or controlled.
• Assess medical status based on : stability, Severity, and Significance Compliance doesn't mean stability by to be stable one must be compliant
• Positive findings are considered a significance finding.
• Severity refers to the complexity of a medical condition which dental management can vary.
• Important to to obtain patient's medication list to Assess Compliance, Assess Medical, Correlate to the positive findings in the PMH, and to Avoid drug interactions.

Review of Systems

• Is a screening tool that should be obtained from every patient by asking closed ended questions pertaining to the body systems.
• The main goal is to identify signs and/or symptoms of diagnosed and undiagnosed medical illnesses.
• Includes:
  • Constitutional: fever, chills or weight loss.
  • Eyes: Vision loss, blurred or double vision.
  • Ears, nose, mouth, throat: Hearing loss, epistaxis, ulcers, dysphagia, ear pain, or odynophagia.
  • Cardiovascular: Heart palpitations, irregular heartbeat or chest pain.
  • Respiratory: Snoring, gasping for air, cough, difficulty breathing, wheezing or SOB.
  • Gastrointestinal: Abdominal pain or heartburns.
  • Musculoskeletal: Muscle or joint pain, restricted ROM.
  • Skin: Skin lesions, rashes, blisters, ulcers, growth.
  • Neurological: Headaches, tingling or numbness, memory problems.
  • Endocrine: Polydipsia, polyphagia or polyuria. Heat or cold intolerance.
  • Hematologic/lymphatic: Easy bruising or abnormal bleeding.
  • Psychiatric: mood alterations, sadness, feelings of anxiety.
  • Genitourinary: nocturia, pain during urination.
• MH assesses for medical conditions versus ROS which assess for signs/symptoms of undiagnosed medical conditions.

Past Surgical History

• Assess previous illness and the severity and Stability of the condition
• Assess the patient for reaction to anesthesia and potential dental treatment complications such as radiation or heart surgeries.
• Document type of surgery, date, and outcome.

Dental History

• Investigates prior dental conditions, regularity of care, and treatments that might related to the current chief complaint.
• Dental history includes: Orthodontic treatment, Surgical intervention, Occlusal adjustments, Full mouth rehabilitations, Bite guards, and assessments of oral hygiene habits, diet, and previous radiographic images.

Social History

• Should include current and past history of:
  • Substance use:
    • Smoking
    • Alcohol
    • Recreational (illicit drug use)
  • Marital status
  • Occupation
  • Physical activity
• Also includes e-cigs, vaping substances, such as nicotine, TCH, CBD, Flavoring and vaping devices which are disposable, pre-filled, and refillable tanks.
• Common medications use in social history are Vivitrol® (naltrexone) for alcohol dependence, Suboxone ® (buprenorphine/naloxone) for opioid dependence, Dolophine® (Methadone) also for opioid disorder and Antabuse® (disulfiram) alcohol dependence.