1.2 History Taking, Communication & Clinical Examination

The Structured History

Outcomes B2.1 and B2.2 ask for the principles underpinning an appropriate assessment and a thorough patient history. A defensible history has a fixed order, so nothing is missed under time pressure:

The medical history must be updated at every course of treatment, not taken once and filed. A signed but stale medical history form is a common finding in negligence claims.

SOCRATES for orofacial pain

• Site — which tooth, which region, can the patient point to it?
• Onset — sudden or gradual; what were they doing?
• Character — sharp, dull, throbbing, electric-shock, burning
• Radiation — to the ear, temple, neck, opposite arch
• Associated features — swelling, bad taste, fever, trismus, altered sensation
• Time course — duration of each episode, periodicity, nocturnal waking
• Exacerbating and relieving factors — hot, cold, sweet, biting, lying flat, analgesics
• Severity — a 0–10 scale, and what it stops the patient doing

The discriminating features are largely temporal. Lingering pain after a thermal stimulus, or spontaneous pain that wakes the patient, indicates irreversible pulpitis. Pain on release of biting pressure suggests a cracked tooth. Electric-shock pain in a trigger zone suggests trigeminal neuralgia. Pain worse on lying flat and on walking downstairs, with tenderness of several upper posterior teeth, suggests maxillary sinusitis rather than a single tooth.

Communication: Outcomes A3.7–A3.9

Three communication outcomes are flagged for SBA assessment, so they appear as scenario stems rather than as skills stations:

• A3.7 — different communication modes and styles. Match the mode to the patient: written and easy-read information for a patient with a learning disability, an interpreter (not a family member) where language is a barrier, written summaries for patients with hearing loss, and text or telephone follow-up where attendance is difficult.
• A3.8 — active listening and clarification. Open questions first, then closed questions to fill gaps. Do not interrupt the opening statement. Pick up cues ("I've been worried about it since my father's diagnosis") and explore them.
• A3.9 — accurate summarising. Summarise the diagnosis, the active and potential problems and the plan back to the patient, and check understanding using teach-back ("just so I know I've explained it clearly, what will you tell your partner we agreed?"). Chunk information and check after each chunk.

Eliciting ideas, concerns and expectations (ICE) is what turns a monologue into shared decision-making, and it is the part of the discussion most worth recording in the notes.

Extra-Oral Examination

Work outside in, in the same order every time:

1. General appearance — distress, pallor, breathlessness, gait, weight loss.
2. Face and skin — symmetry, swelling, sinuses, scars, pigmented or ulcerated skin lesions.
3. Lymph nodes — submental, submandibular, jugulodigastric and the deep cervical chain, posterior triangle, supraclavicular. Record site, size, consistency, tenderness and fixation. A hard, fixed, non-tender node is the sinister combination.
4. Temporomandibular joints — maximum incisal opening (normal roughly 40 mm and above; trismus below about 30 mm), deviation on opening, clicking, crepitus, tenderness of the joint and of masseter and temporalis.
5. Cranial nerves where indicated — particularly sensory testing of V2 and V3 and motor testing of VII before and after any surgery near those nerves.

Intra-Oral Examination

1. Soft-tissue screen in a fixed sequence — lips, labial and buccal mucosa, buccal sulci, hard and soft palate, oropharynx, dorsum of tongue, lateral borders and ventral surface of tongue with the tongue held in gauze, floor of mouth (bimanual palpation), gingivae. The lateral border of the tongue and the floor of mouth are the highest-risk sites and the easiest to skip.
2. Periodontal assessment — BPE as the screening tool, escalating to six-point charting as the code dictates.
3. Charting — teeth present, restorations, caries, prostheses.
4. Occlusion — incisor and molar relationship, overjet, overbite, crossbites, wear facets, guidance.

Assessing the dentition (outcome B2.9)

• Mobility — grade 1 up to 1 mm horizontally, grade 2 more than 1 mm horizontally, grade 3 horizontal plus vertical depressibility.
• Tooth surface loss — the Basic Erosive Wear Examination (BEWE) records the most affected surface in each sextant: 0 no wear, 1 initial loss of surface texture, 2 distinct defect affecting less than 50% of the surface area, 3 defect affecting 50% or more. The six scores are summed to 0–18 and interpreted as none (2 or less), low (3–8), medium (9–13) or high (14 and above) risk.
• Restorability — remaining tooth structure, ferrule, subgingival extent, periodontal support.
• Retained roots, unerupted teeth and edentulous ridges, which the charting must record even though they carry no restoration.