ODM 814 - Lecture 1

• The presentation introduces patient evaluation and assessment in the context of dentistry.
• Marcia Rojas is an Assistant Professor in the Division of Oral Diagnosis, Oral Medicine, and Oral Radiology at the University of Kentucky, and teaches ODM 814.

Types of Dental Examinations

• Comprehensive Examination: An in-depth assessment and recording of an individual’s chief complaint, dental history, extraoral, intraoral, and soft tissue findings (D0150).
  • Recommended for first visits, patients with significant health changes, and every 3 years thereafter, as it is lengthy and detailed.
  • Includes medical and dental history, periodontal and dental examinations, soft tissue and occlusal examinations, head and neck assessment, TMJ and masticatory muscle assessment, X-rays or other diagnostic procedures, and esthetic examination.
• Periodic Examination: Performed on established patients to check for any changes to their dental or health status since their last evaluation (D0120).
  • Recommended every 6 months.
  • Includes updates in the dental history, medical history, medication intake, and dental/periodontal/soft tissue/other findings.
• Problem-Focused Exam/Limited Oral Exam: Addresses a specific dental complaint or acute need/problem (D0140).
  • Gathers information about the health status but limits the dental examination.
  • Potential situations include: oral lesion or wisdom teeth eruption, dental emergency/urgency, traumatic injury and acute infection.

Dentistry Patients

• Out-patients: Receive regular dental care without being admitted to a hospital.
• In-patients: Hospitalized patients.

The Diagnostic Process During Dental Exam

• The process involves Chief Complaint and HPI, Medical, Dental and Social Histories, Clinical Examination, Diagnosis, and Treatment Plan in a cycle.

Methods of Obtaining Patient History

• Patient history can be obtained through questionnaires & forms, patient interviews, or by requesting information from another health care provider.
• Questionnaires and forms:
  • Advantages include saving clinic time, a standardized method for data collection, no special skills required, and can be generic or custom made.
  • Disadvantages include information limited to questions asked, incorrect answers, misinterpretation, and not as comprehensive.
  • EHR can overcome some of the paper questionnaire disadvantages and “Pop-up” menu for positive responses enables more data collection.
• Patient Interview:
  • Questions can be tailored to each patient.
  • The patient health, oral care needs, requests, and concerns are the center of the interview.
  • The interview process has a level of formality and develops quite differently from a personal conversation.
• Open Ended Questions:
  • Examples include: "How may I help you?", "Can you describe your pain?", "Can you tell me about your past dental care?", "Can you tell me more about your kidney problem?"
• Closed Ended Questions:
  • Examples include: "Do any of your teeth hurt?", "Which tooth is sensitive to cold?", "Do you brush your teeth?", "Do you have shortness of breath?", "Do you take any medications?"

Interview Process

• Start by introducing yourself and stating your role.
• Ask what brings them to the clinic and their expectations.
• Face your patient when you talk to them.
• Eye contact is important but avoid staring.
• Be professional.
• Communication skills are important and you should be able to communicate with patients from different cultures, gender, and socioeconomic backgrounds.
• Using simple/plain language is required.
• An interpreter (interpretation services) should be provided if the patient speaks a different language (not fluent in English), the patient requests an interpreter, or the provider deems it necessary.
• Listening more than talking is the golden role of an interview.
• Information flow should not be interrupted unless no pertinent information is received (do it politely).
• Avoid influencing the patient response and be unbiased.
• Establish a differential diagnosis from the history.
• Be attentive, compassionate, and aware of patient emotional responses and concerns.
• Be aware of non-verbal communication (crossing arms and legs, facial expressions or avoiding eye contact).

Interview Errors

• Include lack of clear introduction, ignoring patient's emotions, failure to establish an atmosphere of trust, failure to establish professionalism.
• Relying heavily on closed questions or leading questions and lack of knowledge, as well as influencing patient's responses and early conclusions.
• Interrupting the flow of the interview, distractions, providing premature treatment options and inadequate time management.

Patient History

• It's important to know patients and "Never treat a stranger" quoting Canadian physician Sir William Osler.
• Obtaining a complete and accurate patient history, and focusing on pertinent information should be the goal.
• The complexity of data collection varies among patients.

Signs vs Symptoms

• Symptoms are subjective and are physical or mental problems experienced and reported by the patient.
• Examples of symptoms: pain (toothache), tooth sensitivity (cold, sweets), bad breath, sensation of oral dryness and agitation.
• Signs are objective findings are observed or measured by the provider during examination.
• Examples of signs are a decayed tooth, swollen face and ankles, difficulty breathing, bruises (ecchymosis) or bleeding, and fever.

Patient History Confidentiality

• The Health Insurance Portability and Accountability Act HIPAA-1996 aims to:
  • Protect the Confidentiality and Security of Health Care Information
  • 18 HIPAA identifiers, including: Patients name, geographical elements (address, city, county, zip code), dates related to health, telephone numbers, fax numbers and email addresses.
  • Also includes, social security numbers, medical record numbers, health insurance information, account numbers and full face photographs