CHAPTER 2: DEFINITION OF TERMS / PATIENT INTERVIEW

patient interview

the first and often the most important step in effective di- agnosis and treatment planning.

demographic informa- tion should be obtained and recorded

Patient’s full name, and how he or she pre- fers to be addressed, for example, Mrs, Ms, first name, etc. If the name is unusual, a phonetic spelling to assist in correct pro- nunciation at the initial interview can be very helpful.

Address and telephone number(s).

Age, sex, and race. Although this informa- tion is routinely included in patient ques- tionnaires, it may be more prudent to house it in the medical history instead of the de- mographic form, emphasizing its need for legitimate patient care purposes.

Occupation.

Marital status.

Party to contact in case of emergency.

Third party involvement, if any, such as private insurance, Government benefit programs, and the like.

Responsible party: when dealing with a minor child, or legally disabled adult, it is critical to ascertain who can give consent for treatment, and who will be responsible for payment of fees. Divorce, remarriage, and all the complications of modern fam- ily life can make this question at once both difficult and absolutely essential to answer before proceeding very far

Corah Dental Anxiety Scale

A standardized instrument used during the course of the initial interview

one tool to measure and confront patient’s fears.

Using the scale: the questionnaire is scored by adding the total score for the four items, responses ‘a’ to ‘e’ valued 1 to 5 respectively.

A score of 20 indicates very high anxiety, whereas a score of 4 would indicate no anxiety.

If the patient scores 12 or less and doesn’t mark ‘e’ on any item, no follow- up is recommended; however, any ‘e’ response even if the total is 12 or less should be noted and followed up verbally, to identify and deal with that concern.

If the patient scores 13 or 14, suggesting an anxious patient, they should be asked about their dental experiences with an emphasis on what you can do to make them most comfortable.

Again, any ‘e’ response should be noted and followed up verbally, to identify and deal with that concern.

A score of 15 or higher suggests a highly anxious patient.

A digression from the interview is indicated to explore the source of the anxiety, encouraging the patient to recount and confront old experiences, to admit fears, and to suggest ways to relieve anxiety about future care.

medical issues that must be addressed in the dental environ- ment

PATIENTíS GENERAL HEALTH

ALLERGIES AND SENSITIVITIES

SYSTEMIC DISEASES

ISSUE OF PAST DISEASES, CONDITIONS, AND TREATMENT

issues may have significant den- tal implications

• Malignant and/or non-malignant tumors.

• Radiation therapy.

• Artificial or prosthetic joints.

• Use/abuse of tobacco, alcohol, narcotics,

  or other illicit drugs.

• Other past medical conditions, especially

  those requiring hospitalization and/or sur-

  gery.

• Pregnancy issues

conditions under endocrine systemic disease

arthritis, diabetes, thyroid problems

conditions under Respiratory systemic disease

asthma, tuberculosis, shortness of breat

conditions under Cardiac systemic disease

heart disease, rheumatic fever, heart murmur, heart valve problems, pacemaker, high blood pressure, chest pains, swollen ankles

conditions under Blood: systemic disease

abnormal bleeding, anemia, transfusions, fatiguability

conditions under Gastrointestinal/genitourinary: systemic disease

jaundice, hepatitis, liver disease, contact with HIV or AIDS virus, sexually transmitted disease, kidney dis- ease

conditions under Central nervous system: systemic disease

epilepsy, fainting spells, nervous disorder/psychiatric care

ROUTINE SYSTEMIC APPROACH

Doing examination and diagnosis the same way every time (routine) and in a logical order (systematic) saves a great deal of time while avoiding serious omissions and mistakes in the process

DATA GATHERING

Refers to the comprehensive collection of bits of information about the patient through interview, history, examination, and other aids.

PATIENT HISTORY

Consists of all information given to us by the patient

EXAMINATION

includes all additional methods used by the dentist beyond the interview and history, such as radiographs, clinical examination, and other diagnostic aids and modalities

TYPES OF EXAMINATION

EMERGENCY EXAMINATION

SCREENING EXAMINATION

COMPREHENSIVE EXAM

TRIAGE

EMERGENCY EXAMINATION

include basic patient information, a good health history, and only the dental history necessary to assess the chief complaint being addressed as an emergency

ex: those that have wound near the head/brain

SCREENING EXAMINATION

When large numbers of people are to be treated in, for example, an institutional setting, screening examinations are often employed as a means of triage to allocate time and resources efficiently

ex: during dental/medical missions

COMPREHENSIVE EXAMINATION

Given the appropriate setting and adequate time, the comprehensive examination is employed to gather ALL the relevant data about a dental patient.

triage

This is a concept developed by the military for dealing with multiple casualties most effectively

used in ER to identify who needs immediate care and who can wait

triage categories: emergency

those with emergency signs require immediate emergency treatment

a life-threatening medical condition

expect to receive immediate attention

triage categories: priority / very urgent

those with priority signs should be given priority in queue for rapid assessment

a serious medical condition

expect attention after red patients have been stabilized

triage categories: urgent

expect attention after red and orange patients have been stabilized

triage categories: non-urgent / routine

those who have no emergency or priority signs are non-urgent cases and can wait their turn for assessment and treatment

can function without immediate care and will be attended to as soon as possible

category 1

resuscitation

ex: heart attack, major car accident

immediate (seconds)

category 2

emergency

ex: severe blood loss, overdose

within 10 mins

category 3

urgent

ex: head injury (conscious), breathing difficulties, infection

within 30 mins

category 4

semi-urgent

ex: sprained ankle with possible fracture, eye inflammation

within 1 hr

category 5

non-urgent

ex: cut not requiring stitches, common cold

within 2 hrs

techniques of examination

inspection

palpation

percussion — blunt end of mouth mirror, tap

auscultation —stethoscope; checks crepitus

olfaction — often overlooked; sense of smell

types of palpation

bi-manual palpation

bi-digital palpation

bilateral palpation

digital palpation

bi-manual palpation

Uses both hands on the same structure (one inside, one outside)

checks the floor of the mouth

Digital palpation

Uses index finger (detect presence of exostosis on the mandible)

bi-digital palpation

Uses finger and thumb of same hand

use of two fingers either of the same hand or 1 finger from each hand

(palpate the lips)

bilateral palpation

Use both hands at same time to examine structures on opposite sides (examine submental nodes)

palpates the left and right side of a patient’s body

checks clicking

FINDINGS

All bits of information obtained in the history and examination process

may be normal or abnormal, healthy, or pathologic

CHIEF COMPLAINT

It is the reason, usually a symptom or cluster of symptoms, why the patient seeks treatment.

It can be urgent, such as acute pain or gross swelling, or minor, such as a small chip on a tooth, which has been present for some time.

complain — the action

complaints — ang unod sa complain; gist

symptoms

subjective, elicited by history and interview, as described by the patient

ex: pain, sensitivity to hot/cold, altered taste, inability to chew or to speak clearly, esthetic complaints

signs

objective, often measurable, discovered by examination)

Obviously, some overlap is possible

ex: redness, swelling, measurable, fever, tenderness to palpation, crepitus, bad breath, molar crossbite

SOAP

subjective

objective

assessment

plan

NORMAL

• Refers to the most typical or ideal value/condition.

• Often a single expected value or description.

• Represents what is commonly observed in healthy individuals.

—what might be normal to one, might not be normal to the other one!!

RANGE OF NORMAL

• Refers to the acceptable limits around the normal value.

• Accounts for physiologic differences among individuals.

• Values within this range are still considered healthy.

variation of normal

usually structural, anatomical, developmental differences.

refers to individual differences that deviate from the ideal normal
but do not indicate disease or pathology.

ex: Peg-shaped lateral incisors, Diastema in mixed dentition

Pain or discomfort

the most common chief complaint and should always be given weight in the diagnosis.

different types of DIAGNOSIS

snap

TENTATIVE OR WORKING

DIFFERENTIAL

MULTIFACTORIAL

DEFINITIVE OR FINAL

SNAP diagnosis

Made quickly and on the spot, it can be a perfectly good diagnosis

ex: A patient returns 3 days after removal of a lower third molar complaining of pain and a bad taste and exhibiting inflammation and odorous discharge at the extraction site.

TENTATIVE OR WORKING diagnosis

A little more precise than the ‘snap’ diagnosis, this type of assessment assumes that the clinical picture ‘fits’ a given disease state, so that preliminary treatment may proceed, or other diagnostic tests may be selected.

ex: An ulceration under a partial denture flange of which the patient has been unaware may simply be an inflammatory response to irritation.

DIFFERENTIAL diagnosis

This refers to the process which, given a set of findings (signs and symptoms), the clinician categorizes that information into data relevant to making a diagnosis, and develops a list of the most likely diseases or disorders consistent with the findings

MULTIFACTORIAL diagnosis

Aka: Problem List

isuwat tanan problema

This is aimed at addressing the problems so as to provide maximum comfort, function, and esthetics, with the goal of long-term retention of the natural dentition.

DEFINITIVE OR FINAL diagnosis

Using the differential process just described, the definitive or final diagnosis is derived, and appropriate treatment rendered. If the disease fails to respond, it may be necessary to backtrack on the differential diagnosis and try again.

In the case of soft tissue diseases, microscopic examination of tissue samples at the cellular level often determines the final diagnosis. Blood dyscrasias or diseases provoking an immune response may be proved serologically. Not all problems can be solved so neatly, however, because the range of abnormal is as wide as that of normal.

different types of treatment plan

emergency

prevention-oriented

patient-oriented

comprehensive

emergency treatment plan

Immediate treatment plan

This addresses the definitive diagnosis directly, and must generally be instituted at once.

prevention-oriented treatment plan

If in our diagnosis we have successfully identified etiologic factors, then they can be addressed in the treatment plan.

no concept of the disease yet, just prevention: oral prophylaxis, pit/fissure sealtant

patient-oriented treatment plan

aka: humanistic or holistic approach

means working from our patients’ frame of reference and involving them in the entire process

comprehensive treatment plan

This derives from a problem list diagnosis, and may be safely postponed if necessary, or carried out in stages over time.

PROGNOSIS

forecast

prediction as to the future outcome of a disease made with or without therapy

REFERRAL

refers to sending a patient to another health professional for further consultation, treatment, or co-management