HEDC RESTORATIVE DENTISTRY PERSPECTIVE

what should you do when meeting a patient

• introduce yourself by name and role

• confirm patient identity: name, DOB, first line of address

• ensure patient notes match the patient

• confirm reason for attendance

outline the medical history

• should be taken at least every 12 months to ensure patient’s medical status allows safe dental treatment

• determine whether proposed treatment needs any special precautions

• determine impacts of current medication on dental treatment

• patient allergies to medication or materials used during treatment

• potential drug interactions to medication used during treatment

• indicator of capacity to give consent

what medication has interactions with warfarin

metronidazole

CCDH restorative dentistry assessment sheet

outline dental history

• patient’s attitudes

  • perceived dental treatment needed

• patient’s expectations of treatment

  • determine whether realistic and achievable

  • manage expectations to ensure adequate consent achieved

• past dental experience e.g. type of work carried out, MDAS scale

• problems encountered e.g. retching issues

MDAS scale

when would the MDAS scale be important

• when referring patients for sedation, they must hit a certain threshold on this scale

outline social history

• understanding of patient’s life e.g. how do they travel to surgery, arranging appointments around work/ school/ bus pass timings

• occupation incl. caring for family

• personal circumstances i.e. living arrangements - important for elderly and children

• smoking, alcohol, recreational drugs

• opinions on use of animal products (bovine/ porcine)

why is social history important

• able to plan extent of treatment

• able to plan timing of treatment

• may improve likelihood of successful treatment outcomes

outline smoking in social history

• major risk factor for periodontitis and oral cancer

  • synergistic effect if alcohol user

• weakens immune system

  • reduces blood flow to gingivae - this masks disease

    • often whilst they’re smoking, there is little to no bleeding, when they stop they bleed profusely

  • increases progression of gingivitis to periodontitis

• delayed healing after extractions and surgery

• stained teeth/ halitosis

• altered smell/ taste

what risk is increased in smokers post-extraction

increased risk of dry socket post-extraction

how should smoking be recorded in the social history

• record whether current or previous smoker

• record number smoked per day to calculate ‘pack years’

  • 20 cigarettes per day = 1 pack year

  • 10 cigarettes per day = ½ pack year

• record in notes with orange sticker if smoking cessation offered

• action referral if patient shows interest

outline VBA

very brief advice

• 3 step process:

  • ASK about a patient’s smoking status

  • ADVISE them on the best way to quit

  • ACT to offer support, such as referring to specialist service or prescribing medication

what is the aim of VBA

to trigger a quit attempt by identifying smokers and connecting them with evidence-based support

outline alcohol in social history

• erosion of teeth

  • acidity of alcoholic drinks directly affects teeth

  • vomiting if excess alcohol also contributes

• increased caries risk

  • diuretic effect reduces saliva

  • alcohol metabolises to sugar and some drinks are high in sugar

• increased risk of oral, laryngeal and oesophageal cancer

  • synergistic effect if also a smoker

• increased risk of trauma and assault

outline the Audit C tool

Alcohol Use Disorders Identification Test for Consumption

• screening tool was originally developed by the WHO as a simple method of screening for excessive drinking

• consists of 3 questions which the patient scores 0-4 with their answer

• total score identifies harmful or hazardous drinkers

clinicians need to be aware of units of alcohol

image of Audit-C tool

outline recreational drugs in social history

• effects from chemical properties

  • xerostomia increases caries risk

  • tooth erosion as many are highly acidic

  • gingival damage if rubbed into gums

• effects from behavioural change

  • clenching/ grinding » tooth wear/ breakage/ TMJ

  • neglect with poor OH increases caries and periodontitis risk

  • desire to eat sweet foods increases caries rate e.g. Methadone users (heroine addiction)

what does this clinical image show

meth mouth

what can be an alternative to sugars in drinks

sweeteners

how should current oral hygiene measures and diet be recorded

• consider brief OHE if obvious OH concerns

• consider diet diary if obvious dietary concerns

what are the aims of clinical examination

• determine the patient’s dental health now

• to assess disease progression over time

• medico-legal requirement

• to fully record the patient for identification purposes post-mortem

outline extra-oral clinical examination

• examine TMJ for clicks, deviation on opening/ closing, pain

• palpate lymph nodes

• examine muscles of mastication

• examine gland/ tonsillar tissues

• examine all soft tissues systematically

• note any lesions and measure them if appropriate

normally, how many fingers can you fit between incisors when patients open their mouth

2 fingers

outline criteria for intra-oral examination

• clean, dry teeth - also examine wet

• good lighting

• good vision - magnification

examining the dentition

• teeth present/ absent, supernumerary, retained roots

• presence of caries: site, extent (early/ cavitated), activity (active/ arrested), status (primary/ secondary )

• presence of tooth tissue loss not caused by caries

  • record tooth wear using Smith & Knight scale: Grade 0-3 (3 = pulpal involvement)

• record any tooth mobility: grade 0-3 (mm thresholds)

what are signs and symptoms of an unstable occlusion

• tooth wear

• fractured cusps

• fractured restorations

• localised periodontitis

• pulpitis

• failure of crowns and bridges

• cracked tooth syndrome

• TMJ symptoms

how should occlusion be examined

• use articulating paper to see contacts in ICP and in CR

• assess whether ICP is stable or unstable

• assess whether occlusal vertical dimension is normal or reduced

• determine whether ICP = RCP

  • if not, determine whether the slide between them is vertical/ horizontal

• assess in protrusive and lateral excursions

• can take impressions for study models to view occlusion on an articulator

what kind of tool is the BPE

BPE is for screening, it is not a diagnostic tool

outline examining the periodontium

• do BPE (excludes 8s)

  • required for all new patients

  • required every examination for code 0/1/2 patients

  • code 3 or 4 patients require a more detailed periodontal charting

• use indices to score patients at baseline and monitor progress

  • 6PPC, PI, BI, M, R (recession), F (furcation)

when would 8s be included in a BPE

if the 6s or 7s are absent

pathways for different BPE scores

when should the indices be taken for a code 3 pathway patient

for code 3 pathway, indices are taken 3 months following the initial therapy

when should the indices be taken for a code 4 pathway patient

for code 4 pathway, indices are taken initially and post-therapy

outline denture examination

examine dentures in situ and out of patient’s mouth and assess:

• appearance

• extension of denture bases and flanges

• occlusion

• speech

• vertical dimension

• design

what else should be recorded about dentures

• type: partial/ complete

• record material: acrylic, cobalt chrome, nylon

• assess retention and stability

• assess amount of wear, hygiene status and age

outline special investigations

• pulpal diagnosis: sensibility tests e.g. EndoFrost, EPT, ethyl chloride

• periapical diagnosis: percussion testing, palpation of sulci

• cracked tooth syndrome (CTS): tooth slooth

• transillumination

• radiographs

outline the types radiographs and when they would be taken

• bitewings: posterior proximal caries, bone levels

• periapicals: caries extent, periapical pathology, bone levels

• OPT: overall view, trauma, pathology, 3rd molars

• CBCT: implants, endodontics, pathology

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ALL RADIOGRAPHS SHOULD BE GRADE FOR QUALITY (A/ NA), DATED AND REPORTED ON

outline diagnosis, prognosis, risk factors

• make diagnoses for any conditions

• assign prognoses to all diagnoses with justification

• consider general prognosis for multiple conditions

example of diagnosis, prognosis and risk factor table

if in doubt of prognosis, go lower

staging treatment plans 1 - ALWAYS PREVENTION FIRST

staging treatment plans 2 - ALWAYS PREVENTION FIRST

stages of treatment plans flow chart

treatment planning involving patient

• plan the order of treatment required

• discuss with patient respecting their views

• gain patient consent for treatment

finalising the treatment plan

• gain informed patient consent for treatment

• provide written treatment plan

• discuss any costs involved

• plan maintenance following treatment