Patient Assessment and Medical History

Patient Assessment

Proper patient assessment is the absolute foundation of safe, effective, and ethically sound dental care. It is a mandatory requirement before initiating any clinical treatment and encompasses a multitude of diagnostic avenues. Patient assessment is not merely about inspecting the teeth; it requires an evaluation of the patient's holistic health, social background, and past dental experiences.

The Comprehensive Health History

The health history includes three main components: medical, dental, and social history.

Medical History

Obtaining a thorough medical history is a legal and ethical imperative. It must be completed, checked, and signed by the patient (or their legal parent/guardian) at their first visit. Crucially, it must be updated at every subsequent recall or before a new course of treatment begins. A comprehensive medical history form alerts the dental team to conditions that may directly affect the safety of treatment, dictate modifications, or present an emergency risk in the chair.

Key conditions to monitor include:

• Cardiovascular disease: A history of heart attacks, angina, or hypertension may dictate the type and volume of local anaesthetic used. High doses of adrenaline (a vasoconstrictor) are often contraindicated in severe cardiovascular patients due to the risk of cardiac arrhythmias or hypertensive crises.
• Bleeding disorders or anticoagulant medication: Conditions like haemophilia or medications such as Warfarin, Clopidogrel, or Direct Oral Anticoagulants (DOACs) exponentially increase the risk of uncontrolled, prolonged bleeding after extractions or minor oral surgery.
• Allergies: Determining allergies, particularly to latex, penicillin, or specific components of local anaesthetics, is an absolute necessity to prevent a life-threatening anaphylactic reaction.
• Asthma: The dental team must ensure the patient's reliever inhaler is readily available and placed on the bracket table during treatment.
• Diabetes: Diabetes significantly impacts wound healing and heavily increases susceptibility to periodontal disease. Furthermore, appointments should be strategically timed around the patient's meals and insulin regime to prevent hypoglycaemic emergencies.
• Medications: Many prescription drugs present with distinct oral side effects. For instance, calcium channel blockers or phenytoin can cause severe gingival hyperplasia (overgrowth), while antidepressants and antihistamines commonly induce xerostomia (dry mouth), which significantly increases caries risk.

Dental and Social History

The dental history uncovers past treatment experiences, anxiety levels, and daily oral hygiene routines (e.g., brushing frequency, fluoride exposure, and interdental cleaning). A detailed social history is equally important, focusing heavily on lifestyle factors like tobacco smoking and alcohol consumption. Smoking is the most significant risk factor for periodontal disease and oral cancer, while heavy alcohol consumption combined with smoking exponentially increases oral cancer risk. The dental team uses this information to deliver tailored smoking cessation advice and formulate preventive treatment plans.

The Clinical Examination

A full examination involves both extra-oral and intra-oral assessments.

• Extra-oral Examination: The dentist palpates the lymph nodes in the neck and submandibular region, checks the temporomandibular joint (TMJ) for clicking, crepitus, or restriction, and observes facial symmetry and skin lesions.
• Intra-oral Soft Tissue Examination: Before inspecting the teeth, the clinician examines the lips, buccal mucosa, tongue, floor of the mouth, hard and soft palate, and oropharynx. This is a critical screening process for oral cancer and mucosal diseases.
• Intra-oral Hard Tissue Examination: This involves charting the teeth, assessing for carious lesions, defective restorations, tooth wear (attrition, abrasion, erosion), and evaluating periodontal status.

Dental Charting Systems

Accurate charting provides a standardized graphical representation of the patient's mouth. Dental nurses are strictly responsible for recording the dentist's verbal findings onto physical or digital charts without error. Two primary charting systems are used in the UK.

Palmer Notation

The Palmer system is traditionally the most common paper-based system in the UK. It utilizes a cross grid to divide the mouth into four distinct quadrants: Upper Right (UR), Upper Left (UL), Lower Left (LL), and Lower Right (LR).

• Permanent Dentition: Teeth are numbered 1 to 8 in each quadrant, starting from the central incisor (1) and working backwards to the third molar (8). For example, the upper right canine is recorded as UR3.
• Deciduous (Primary) Dentition: Teeth are lettered A to E, starting from the central incisor (A) back to the second primary molar (E). For example, the lower left first primary molar is LLD.

FDI System (Fédération Dentaire Internationale)

The FDI system is a two-digit international standard heavily favored by modern computerized software because it does not require symbols.

• The first digit strictly indicates the quadrant and dentition type:
  • 1 = Upper Right Permanent
  • 2 = Upper Left Permanent
  • 3 = Lower Left Permanent
  • 4 = Lower Right Permanent
  • 5 = Upper Right Deciduous
  • 6 = Upper Left Deciduous
  • 7 = Lower Left Deciduous
  • 8 = Lower Right Deciduous
• The second digit indicates the tooth position from the midline (1 to 8 for permanent, 1 to 5 for deciduous).
• For example, the permanent upper right canine is 13 (pronounced 'one-three'). The deciduous lower left first molar is 74.

Standard Charting Abbreviations

• Surfaces: Mesial (M), Distal (D), Buccal (B), Lingual (L), Palatal (P), Occlusal (O), Incisal (I).
• Restorations/Conditions: Amalgam (often shaded), Composite (often outlined), Missing/Extracted (a cross or line through the tooth), MOD (Mesio-occluso-distal).

Periodontal Assessment (BPE)

The Basic Periodontal Examination (BPE) is a rapid, systematic screening tool used to assess a patient's overall periodontal health and determine if further detailed pocket charting is required. The dentition is divided into six sextants (upper right, upper anterior, upper left, lower left, lower anterior, and lower right).

A specialized WHO BPE probe is used. It features a 0.5mm spherical ball at the tip (to detect calculus and prevent tissue trauma) and a black band extending from 3.5mm to 5.5mm. The highest score in each sextant dictates the treatment need:

• Code 0: Healthy gingival tissues, no bleeding, no calculus, black band completely visible (pockets <3.5mm).
• Code 1: Bleeding observed on probing, no calculus, black band completely visible. (Treatment: Oral hygiene instruction).
• Code 2: Plaque retention factor present (e.g., supra/subgingival calculus or overhanging restoration margins), black band completely visible. (Treatment: Scaling and OHI).
• Code 3: Probing depth is between 3.5mm and 5.5mm (the black band is partially obscured). (Treatment: Initial root surface debridement and strict OHI).
• Code 4: Probing depth >5.5mm (the black band completely disappears into the deep periodontal pocket). This indicates severe periodontal disease requiring a full 6-point pocket chart.
• *Code : Furcation involvement is present (bone loss between the roots of multi-rooted teeth).