by : Stephen T. Sonis, D.M.D., D.M.Sc.
What are the objectives of pretreatment evaluation of a patient?
1. Establishment of a diagnosis
2. Determination of underlying medical conditions that may modify the oral
condition or the patient’s ability to tolerate treatment
3. Discovery of concomitant illnesses
4. Prevention of medical emergencies associated with dental treatment
5. Establishment of rapport with the patient
1. Establishment of a diagnosis
2. Determination of underlying medical conditions that may modify the oral
condition or the patient’s ability to tolerate treatment
3. Discovery of concomitant illnesses
4. Prevention of medical emergencies associated with dental treatment
5. Establishment of rapport with the patient
What are the essential elements of a patient history?1. Chief complaint
2. History of the present illness (HPI)
3. Past medical history
4. Social history
5. Family history
6. Review of systems
7. Dental history
2. History of the present illness (HPI)
3. Past medical history
4. Social history
5. Family history
6. Review of systems
7. Dental history
Define the chief complaint.
The chief complaint is the reason that the patient seeks care, as described
in the patient’s own words
The chief complaint is the reason that the patient seeks care, as described
in the patient’s own words
What is the history of the present illness?
The HPI is a chronologic description of the patient’s symptoms and should
include information about duration, location, character, and previous treatment.
The HPI is a chronologic description of the patient’s symptoms and should
include information about duration, location, character, and previous treatment.
What elements need to be included in the medical history?
• Current status of the patient’s general health
• Hospitalizations
• Medications
• Allergies
• Current status of the patient’s general health
• Hospitalizations
• Medications
• Allergies
What areas are routinely investigated in the social history?
• Present and past occupations
• Occupational hazards
• Smoking, alcohol or drug use
• Marital status
• Present and past occupations
• Occupational hazards
• Smoking, alcohol or drug use
• Marital status
Why is the family history of interest to the dentist?
The family history often provides information about diseases of genetic
origin or diseases that have a familial tendency. Examples include clotting
disorders, atherosclerotic heart disease, psychiatric diseases, and diabetes
mellitus.
The family history often provides information about diseases of genetic
origin or diseases that have a familial tendency. Examples include clotting
disorders, atherosclerotic heart disease, psychiatric diseases, and diabetes
mellitus.
How is the medical history most often obtained?
The medical history is obtained with a written questionnaire supplemented
by a verbal history. The verbal history is imperative, because patients may leave
out or misinterpret questions on the written form. For example,
some patientsThe medical history is obtained with a written questionnaire supplemented
by a verbal history. The verbal history is imperative, because patients may leave
out or misinterpret questions on the written form. For example,
may take daily aspirin and yet not consider it a “true” medication. The verbal
history also allows the clinician to pursue positive answers on the written form
and, in doing so, to establish rapport with the patient.
What techniques are used for physical examination of the patient?
How are they used in dentistry?
Inspection, the most commonly used technique, is based on visual
evaluation of the patient. Palpation, which involves touching and feeling the
patient, is used to determine the consistency and shape of masses in the mouth or
neck. Percussion, which involves differences in sound transmission of structures,
has little application to the head and neck. Auscultation, the technique of listening
to differences in the transmission of sound, is usually accomplished with a
stethoscope. In dentistry it is most typically used to listen to changes in sounds
emanating from the temporomandibular joint and in taking a patient’s blood
pressure.
What are the patient’s vital signs?
• Blood pressure
• Pulse
• Respiratory rate
• Temperature
• Blood pressure
• Pulse
• Respiratory rate
• Temperature
What are the normal values for the vital signs?
• Blood pressure:120mmHg/8OmmHg
• Pulse: 72 beats per minute
• Respiratory rate: 16—20 respirations per minute
• Temperature: 98.6°F or 37°C
• Blood pressure:120mmHg/8OmmHg
• Pulse: 72 beats per minute
• Respiratory rate: 16—20 respirations per minute
• Temperature: 98.6°F or 37°C
What is a complete blood count (CBC)?
A CBC consists of a determination of the patient’s hemoglobin, hematocrit,
white blood cell count, and differential white blood cell count.
A CBC consists of a determination of the patient’s hemoglobin, hematocrit,
white blood cell count, and differential white blood cell count.
What are the normal ranges of a CBC?
Hemoglobin: men, 14—18 g/dl
women, 12—16 g/dl
Hematocrit: men, 40—54%
women, 37—47%
White blood count: 4,000—10,000 cells/mm3
Differential white blood count
Neutrophils, 50—70%
Lymphocytes, 30—40%
Monocytes, 3—7%
Eosinophils, 0—5%
Basophils, 0—1%
Hemoglobin: men, 14—18 g/dl
women, 12—16 g/dl
Hematocrit: men, 40—54%
women, 37—47%
White blood count: 4,000—10,000 cells/mm3
Differential white blood count
Neutrophils, 50—70%
Lymphocytes, 30—40%
Monocytes, 3—7%
Eosinophils, 0—5%
Basophils, 0—1%
What is the most effective blood test to screen for diabetes mellitus?
The most effective screen for diabetes mellitus is fasting blood sugar.
The most effective screen for diabetes mellitus is fasting blood sugar.
What is the technique of choice for diagnosis of a soft-tissue lesion in the mouth?
With few exceptions, biopsy is the diagnostic technique of choice for
virtually all soft-tissue lesions of the mouth.
With few exceptions, biopsy is the diagnostic technique of choice for
virtually all soft-tissue lesions of the mouth.
Is there any alternative diagnostic technique to biopsy for the
evaluation of suspected malignancies of the mouth?
Exfoliative cytology may be used as a screening technique for oral lesions.
This technique is analogous to the Papanicolaou smear used to screen for cervical
cancer. Unfortunately, a high rate of false negatives makes exfoliative cytology a
dangerous practice in the screening of suspected oral cancers. It has value mainly
in the diagnosis of certain viral, fungal, and vesiculobullous diseases.
evaluation of suspected malignancies of the mouth?
Exfoliative cytology may be used as a screening technique for oral lesions.
This technique is analogous to the Papanicolaou smear used to screen for cervical
cancer. Unfortunately, a high rate of false negatives makes exfoliative cytology a
dangerous practice in the screening of suspected oral cancers. It has value mainly
in the diagnosis of certain viral, fungal, and vesiculobullous diseases.
When is immunofluorescence of value in oral diagnosis?
Immunofluorescent techniques are of value in the diagnosis of a number of
autoimmune diseases that affect the mouth, including pemphigus vulgaris and
mucous membrane pemphigoid.
What elements should be included in the dental history?
1. Past dental visits, including frequency, reasons, previous treatment, and
complications
2. Oral hygiene practices
3. Oral symptoms other than those associated with the chief complaint,
including tooth pain or sensitivity, gingival bleeding or pain, tooth mobility,
halitosis, and abscess formation
4. Past dental or maxillofacial trauma
5. Habits related to oral disease, such as bruxing, clenching, and nail biting
6. Dietary history
Immunofluorescent techniques are of value in the diagnosis of a number of
autoimmune diseases that affect the mouth, including pemphigus vulgaris and
mucous membrane pemphigoid.
What elements should be included in the dental history?
1. Past dental visits, including frequency, reasons, previous treatment, and
complications
2. Oral hygiene practices
3. Oral symptoms other than those associated with the chief complaint,
including tooth pain or sensitivity, gingival bleeding or pain, tooth mobility,
halitosis, and abscess formation
4. Past dental or maxillofacial trauma
5. Habits related to oral disease, such as bruxing, clenching, and nail biting
6. Dietary history
When is it appropriate to use microbiologic culturing in oral diagnosis?
1. Bacterial infection.
Because the overwhelming majority of oral infections are sensitive to treatment with penicillin, routine bacteriologic culture of primary dental infections is not generally indicated. However, cultures are
indicated in patients who are immunocompromised or myelosuppressed for two reasons: (1) they are at significant risk for sepsis, and (2) the oral flora often change in such patients. Cultures should be obtained for infections that are refractory to the initial course of antibiotics before changing antibiotics.
2. Viral infection.
indicated in patients who are immunocompromised or myelosuppressed for two reasons: (1) they are at significant risk for sepsis, and (2) the oral flora often change in such patients. Cultures should be obtained for infections that are refractory to the initial course of antibiotics before changing antibiotics.
2. Viral infection.
Immunocompromised patients who present with mucosal lesions may well be manifesting herpes simplex infection. A viral culture is warranted. Similarly, other viruses in the herpes family, such as cytomegalovirus,
may cause oral lesions in the immunocompromised patient and should be isolated, if possible. Routine culturing for primary or secondary herpes infections is not warranted in healthy patients.
3. Fungal infection.
Candidiasis is the most common fungal infection affecting the oral mucosa. Because its appearance is often varied, especially in immunocompromised patients, fungal cultures are often of value. In addition, because candidal infection is a frequent cause of burning mouth, culture is often indicated in immunocompromised patients, even in the absence of visible lesions.
How do you obtain access to a clinical laboratory?
It is easy to obtain laboratory tests for your patients, even if you do not practice in a hospital. Community hospitals provide virtually all laboratory services that your patients may require. Usually the laboratory provides order slips and culture tubes. Simply indicate the test needed, and send the patient to the laboratory. Patients who need a test at night or on a weekend can generally be accommodated through the hospital’s emergency department. Commercial laboratories also may be used. They, too, supply order forms. If you practice in a medical building with physicians, find out which laboratory they use. If they use a commercial laboratory, a pick-up service for specimens may well be provided. The most important issue is to ensure the quality of the laboratory. Adherence to the standards of the American College of Clinical Pathologists is a good indicator of laboratory quality.
What is the approximate cost of the following laboratory tests:
complete blood count, platelet count, PT, fasting glucose, bacterial culture, and fungal culture?
CBC $18
Platelet count $18
PT $29
Fasting glucose $13
Bacterial culture $32
Fungal culture $42
What are the causes of halitosis?
Halitosis may be caused by local factors in the mouth and by extraoral or
systemic factors. Among the local factors are food retention, periodontal infection,
caries, acute necrotizing gingivitis, and mucosal infection. Extraoral and systemic
causes of halitosis include smoking, alcohol ingestion, pulmonary or bronchial
disease, metabolic defects, diabetes mellitus, sinusitis, and tonsillitis.
may cause oral lesions in the immunocompromised patient and should be isolated, if possible. Routine culturing for primary or secondary herpes infections is not warranted in healthy patients.
3. Fungal infection.
Candidiasis is the most common fungal infection affecting the oral mucosa. Because its appearance is often varied, especially in immunocompromised patients, fungal cultures are often of value. In addition, because candidal infection is a frequent cause of burning mouth, culture is often indicated in immunocompromised patients, even in the absence of visible lesions.
How do you obtain access to a clinical laboratory?
It is easy to obtain laboratory tests for your patients, even if you do not practice in a hospital. Community hospitals provide virtually all laboratory services that your patients may require. Usually the laboratory provides order slips and culture tubes. Simply indicate the test needed, and send the patient to the laboratory. Patients who need a test at night or on a weekend can generally be accommodated through the hospital’s emergency department. Commercial laboratories also may be used. They, too, supply order forms. If you practice in a medical building with physicians, find out which laboratory they use. If they use a commercial laboratory, a pick-up service for specimens may well be provided. The most important issue is to ensure the quality of the laboratory. Adherence to the standards of the American College of Clinical Pathologists is a good indicator of laboratory quality.
What is the approximate cost of the following laboratory tests:
complete blood count, platelet count, PT, fasting glucose, bacterial culture, and fungal culture?
CBC $18
Platelet count $18
PT $29
Fasting glucose $13
Bacterial culture $32
Fungal culture $42
What are the causes of halitosis?
Halitosis may be caused by local factors in the mouth and by extraoral or
systemic factors. Among the local factors are food retention, periodontal infection,
caries, acute necrotizing gingivitis, and mucosal infection. Extraoral and systemic
causes of halitosis include smoking, alcohol ingestion, pulmonary or bronchial
disease, metabolic defects, diabetes mellitus, sinusitis, and tonsillitis.
