19.1 History Taking and Clinical Examination

The First Blueprint Topic of Paper B

The Paper B blueprint lists "diagnosis and management of disease relevant to dentistry" before any individual clinical discipline. It is the connective tissue of the paper: most Paper B stems open with a history and an examination finding and ask what should happen next.

Structure of the Dental History

Two points are examined repeatedly. First, the medical history must be updated and signed at every course of treatment, not taken once at registration. Second, pain history discriminates: pain lingering for more than a few seconds after a cold stimulus points to irreversible pulpitis, whereas pain relieved immediately points to reversible pulpitis or dentine hypersensitivity.

Extra-Oral Examination

• General observation — gait, pallor, breathlessness, distress, clubbing, signs of self-neglect
• Facial symmetry, swelling and skin lesions, including sun-exposed lip vermilion
• Temporomandibular joints — range of movement, deviation, clicking, crepitus, muscle tenderness
• Cervical lymph nodes — a systematic sequence covering submental, submandibular, pre- and post-auricular, occipital, and the deep and superficial cervical chains. Record site, size, consistency, tenderness and mobility. A hard, non-tender, fixed node is sinister; a soft, tender, mobile node suggests reactive lymphadenopathy.
• Cranial nerve examination where there is sensory or motor disturbance

Intra-Oral Examination

A systematic sequence prevents omission and is what examiners expect:

1. Soft tissues in a fixed order — lips, labial and buccal mucosa, buccal sulci, hard and soft palate, oropharynx and tonsillar fauces, dorsum of tongue, lateral and ventral tongue, floor of mouth. The lateral and ventral tongue and the floor of mouth are the highest-risk sites for oral cancer and are the areas most often skipped.
2. Periodontal screening — BPE for adults, simplified BPE for children aged 7 to 17.
3. Hard tissues — charting of teeth present, restorations, caries, tooth surface loss, cracks and fractures.
4. Occlusion — incisor relationship, molar and canine relationship, overjet, overbite, crossbites, displacements, wear facets.
5. Dentures and appliances, examined in and out of the mouth.

Record Keeping

Records are a clinical tool, a medico-legal document and a GDC Standards requirement under Principle 4. They must be contemporaneous, accurate, comprehensive and legible, and they must record:

• The history taken and the medical history update
• Examination findings, including negative findings that were actively checked
• The diagnosis, the options discussed including no treatment, and the risks and benefits explained
• The consent conversation, not merely a signature
• Radiographs taken with their justification, grading and report
• Treatment provided, materials used, local anaesthetic type, dose and batch where relevant
• Postoperative instructions and the review arrangement

Medico-legal rule. If it is not in the notes it did not happen. In a GDC or civil claim the burden falls on the clinician to show what was discussed, and the contemporaneous record is usually the only evidence available.

Taking a Medical History That Actually Protects the Patient

A medical history is only useful if it is structured, updated and acted upon. UK practice is to record a written history, signed and dated by the patient, at the first visit and to check and re-sign it at each course of treatment, because medication changes are frequent and patients rarely volunteer them. The examinable content is systematic: cardiovascular, respiratory, endocrine, haematological, hepatic and renal disease; neurological and psychiatric history; infectious disease; previous hospital admissions, operations and anaesthetics; current medication including over-the-counter drugs, herbal preparations and recreational drug use; allergies with a description of the reaction; pregnancy and breastfeeding; and smoking and alcohol quantified.

Two recording habits are directly examinable. First, an allergy must be described, not merely listed — a patient who says they are "allergic to penicillin" because it gave them diarrhoea is in a very different risk category from one who developed urticaria and wheeze, and the distinction changes prescribing. Second, when a history discloses something that alters treatment, the alteration must be recorded alongside it, so the notes show the reasoning and not just the fact.

The Soft Tissue Examination as a Routine

A complete intra-oral examination includes a systematic soft tissue and oral cancer examination performed in the same order every time so that nothing is missed: lips, labial and buccal mucosa, the buccal sulci, the dorsum, lateral borders and ventral surface of the tongue, the floor of mouth, the hard and soft palate, the oropharynx and the gingivae, followed by bimanual palpation of the floor of mouth and palpation of the cervical lymph node chains. The lateral border and ventral surface of the tongue and the floor of mouth are the highest-risk sites and require the tongue to be held in gauze and drawn forward. The examinable rule is that any mucosal abnormality persisting beyond three weeks without an obvious cause requires urgent referral on the suspected cancer pathway, and that "keep an eye on it" is the wrong answer in an SBA.