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A good dentist or doctor has the basic characteristic of maintaining the records for each and every patient. This is not just limited to the number of visits but also includes x-rays, problems you have faced, prescriptions they gave you and so on. This helps you to maintain a record of your health and transfer the data when you need to switch your doctor for any reason. That is why Back Bay Family Dentistry is famous amongst its patients. Following you will find reasons as to why your new dentist needs your previous treatment records- Your individual dental historyWhen you change your dentist it becomes important to have your dental history records so that the new dentist doesn’t need to start back from the scratch too. The dentist can treat you in a better way than you think of. Following you will find reasons for the same
Time and moneyThis is a very important factor for you too. You need to share your past records because you have already spend a lot of time as well as money on previous treatments. It would be a waste of resources if you undergo the same procedures again for the new dentist to know your situation. Dentists need to know your past records and if you don’t have those reports then you will have to spend money again on getting the same reports. Information mention in the previous records could be:
Coordinating dental care with your general healthTeeth are also part of the body and it is where we intake the food from and thus, start the digestion process. Some oral problems can affect your overall health too. Previous data helps you in the following the ways
It is very important for the doctor, as well as for the patient, to have the complete data about the issues because it helps in avoiding many problems. Choose your clinic properly like Back Bay Family Dentistry so that you do not face any other problems in the future.
Taking a thorough dental history is an opportunity to build rapport with a patient, whilst informing your diagnosis and management of dental issues. By adopting a systematic approach you can cover all critical points whilst allowing the patient time to talk and voice their ideas in a way that helps reassure them. This guide provides a systematic approach to taking a dental history which you can then adjust to your patient’s specific needs. Before the patient entersWash your hands and don PPE if appropriate. As the patient entersObserving the patient as they enter the room can provide several clues prior to taking the dental history. The patient’s gait, appearance, apparent age vs. chronological age, smell (e.g. of cigarette smoke), tone of voice and degree of eye contact can all provide insights into their health and wellbeing. Be careful not to over-interpret these characteristics; we cannot read minds and patients may behave differently in unfamiliar or clinical settings. Be aware of your own non-verbal communication at this stage – face the patient openly and smile as they enter the room. You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation. Opening the consultationGreet the patient as they enter the room. Introduce yourself and the dental nurse including your names and roles. Confirm the patient’s name and date of birth. Ask the patient to take a seat and ensure they are comfortable. Briefly explain what the dental assessment will involve using patient-friendly language: “I’ll begin by asking some questions to understand why you’re here today and what you’re hoping to achieve from the appointment.” Gain consent to proceed with taking the dental history: “Are you happy to continue?” Presenting complaintUse open questioning to explore the patient’s presenting complaint:
Allow the patient time to answer, trying not to interrupt or direct the conversation. Facilitate the patient to expand on their presenting complaint if required:
Once the patient has spoken, it is helpful to check if there are any other separate issues. If a patient is just attending for a routine check-up, you can progress to an assessment of their medical history. If the patient has multiple presenting complaints, work with the patient to establish a shared agenda for the rest of the consultation:
History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis. History of presenting complaint“Listen to your patient; he is telling you the diagnosis.” 1 In dental practice, patients often present with either pain or a functional problem such as a lost crown or broken tooth. If a specific tooth or restoration is damaged, ask about any previous dental treatment in the affected area. The SOCRATES acronym is useful for investigating pain in more depth – in reality, the patient may cover many of these points themselves as they tell you about the problem. Be sure to find out about the problem from their perspective – what are their ideas and concerns about the issue, and what are their expectations about what should be done.2 Allow them time to speak and prompt them to fill in the gaps as necessary, moving from open to closed questions as required. SOCRATESThe SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms. Site
Onset
Character
Radiation
Associations
Time course
Exacerbating or relieving factors
Severity
Ideas, concerns and expectationsA key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE). Asking about a patient’s ideas, concerns and expectations can allow you to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation. The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred and not overly formulaic. It can sometimes be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below. Ideas
Concerns
Expectations
SummariseSummarise what the patient has told you about their presenting complaint. This allows you to check your understanding regarding everything the patient has told you. It also provides an opportunity for the patient to correct any inaccurate information and expand further. Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history. SignpostingSignposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. This can be a useful tool when transitioning between different parts of the history-taking process and it allows the patient to prepare for what is coming next. Signposting examplesExplain what you have covered so far: “Ok, so we’ve talked about your symptoms and your concerns regarding them.” What you plan to cover next: “Now I’d like to discuss your past medical history and the medications you take.” Medical historyA thorough medical history is essential for all patients – it helps identify conditions that may affect dental treatment, highlights the risk of a patient experiencing a medical emergency, and aids in the diagnosis of oral manifestations of systemic disease.3 At each recall examination, the medical history should be confirmed, dated and signed by the patient and dentist.4 Most practices will have a medical history questionnaire for patients to complete prior to the appointment – this helps save time, guide further questioning and acts as a clinical record. It tends to cover the main body systems and other key conditions as outlined below. A blank box on the questionnaire allows patients to add anything else of relevance. Any significant past medical history should be recorded in the patient’s notes as these may impact planned dental care. If you are in doubt about the patient’s reported medical history, for instance, if they can’t remember the names of certain medications, it can be useful to speak to their GP or pharmacist – they will usually be very helpful on the phone. You can also ask the patient to bring in their repeat prescription to the next appointment. As some medical conditions can have a significant impact on dental care and patient safety, it is important to keep your knowledge up to date. If in doubt, seek advice from the relevant specialists. Medical conditionsAsk if the patient has any medical conditions:
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions. Ask if the patient has previously undergone any surgery or procedures (e.g. heart valve replacements):
AllergiesAsk if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis). PregnancyIt’s important to know if a patient is pregnant and if so what gestation, as this may significantly impact the management of dental issues (e.g. certain medications will be contraindicated and non-essential X-rays should be avoided). Drug historyAsk if the patient is currently taking any prescribed medications or over-the-counter remedies:
Systems reviewPatients may forget to mention important medical conditions, so it’s worth quickly performing a systems review to screen for medical conditions which may be relevant. GeneralSymptoms:
Condition examples:
Cardiovascular systemSymptoms:
Condition examples:
Respiratory systemSymptoms:
Condition examples:
Gastrointestinal systemSymptoms:
Condition examples:
Neurological systemSymptoms:
Condition examples:
Musculoskeletal systemSymptoms:
Condition examples:
Social historyThe social history allows you to put disease or dental problems in context and allows you to take a more holistic approach to care. These topics can be sensitive, so ask about them in a non-judgemental way. “Do you mind if we spend a couple of minutes talking about…?” SmokingRecord the patient’s current and past smoking history, including the type and amount of tobacco or substance used. If the patient does smoke, offer ‘very brief advice’5 and signpost them appropriately. AlcoholRecord the frequency, type and amount of alcohol consumed. It can be useful to include AUDIT-C6 as part of the medical history questionnaire to aid this. If the patient is drinking more than the recommended amount of alcohol, again offer ‘very brief advice’ and signpost them appropriately. DietIt is useful to record diet history in order to help assign caries and tooth wear risks, however, patients are often unreliable in reporting this. Ask about snacking habits and what drinks they have between meals. Alternatively, by asking after a physical examination, you can target the questions more accurately based on what you have seen in the mouth, and this may lead to more useful discussions. “I’ve seen signs of decay in a few of your teeth, do you tend to snack on sugary foods or soft drinks?” It may be useful to set time aside in a future appointment to discuss these issues in more depth, including exploring what the patient knows about the impact of these factors on their dental health, and outlining what resources are available to help them. OccupationThis is helpful to record as it can impact the patient’s availability for appointments and may highlight shift working patterns which increase caries risk.7 Dental historyClarify the patient’s recent dental history and assess their overall attendance frequency:
It can also be useful to ask the patient how they feel about visiting the dentist to get a sense of their level of dental anxiety. You can do this by asking an open question or by including a short scale such as the Modified Dental Anxiety Scale8 on the medical history questionnaire. Ask about the patient’s oral hygiene routine by starting with a general invitation:
Then progress to closed questions in the following areas if required:
Although detailed oral hygiene instruction will usually be included as part of a treatment plan, it can be useful at this stage to briefly suggest some tweaks to their routine if required, such as advising them to not use mouth rinse immediately after brushing or to ‘spit don’t rinse’. Most patients give accurate accounts of their health-related behaviours, but a minority may not tell the truth about their health or habits. A survey of U.S. patients suggested that 27% of patients admit lying to their dentist.9 Avoid accusatory questioning and try to build up trust, using subsequent examinations as an opportunity to open up a further discussion if required, for instance, if the plaque and gingivitis levels do not correspond to their reported oral hygiene activities. Discussing the next stepsAt the end of the history-taking, thank the patient and signpost them to what will happen next – most likely a dental exam. Allow them to ask any further questions or voice their ideas and concerns at this stage if questioning has brought up any issues. References
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