Lesson title: The dental chart (Diagnosis and Treatment planning part 1)

Lesson Objectives:
1. Learn how to fill up the dental chart
2. Learn the proper way of gathering information for dental recording.
3. Learn how to utilize the necessary information for proper diagnosis

Productivity Tip:
Don’t be afraid to “ASK QUESTIONS”. The only stupid question is the one you don’t ask. Engage,
participate or interact. It makes learning fun and enjoyable.

MAIN LESSON Activity 2: Content Notes (13 mins)

CONTINUATION FROM MODULE # 7

THE MEDICAL HISTORY
A medical history is a record of information about a person’s health. A personal medical history
may include information about allergies, illnesses, surgeries, immunizations, and results of physical
exams and tests. It may also include information about medicines taken and health habits, such as diet
and exercise. A family medical history includes health information about a person’s close family
members (parents, grandparents, children, brothers, and sisters). This includes their current and past
illnesses. A family medical history may show a pattern of certain diseases in a family. Also called health
history.
An accurate and current general medical history should include any medications the patient is
taking and all relevant medical conditions. If necessary, the patient’s physician or physicians can be
contacted for clarification. It may also be necessary to seek medical certification or clearance before any
dental procedure is done.
The following classification may be helpful:
1. Conditions affecting the treatment methods (e.g., any disorders that necessitate the use of
antibiotic premedication, any use of steroids or anticoagulants, and any previous allergic responses to
medication or dental materials). Once such conditions are identified, treatment usually can be modified
as part of the comprehensive treatment plan, although some conditions may severely limit available
options.

2. Conditions affecting the treatment plan (e.g., previous radiation therapy, hemorrhagic
disorders, extremes of age, and terminal illness). These can be expected to affect the patient’s response
to dental treatment and may influence the prognosis. For instance, patients who have previously
received radiation treatment in the area of a planned extraction require special measures (hyperbaric
oxygen) to prevent serious complications.
3. Systemic conditions with oral manifestations. For example, periodontitis may be
exacerbated by diabetes, menopause, pregnancy, or the use of anticonvulsant drugs (Fig. 1-4); in cases
of gastroesophageal reflux disease, bulimia, or anorexia nervosa, teeth may be eroded by regurgitated
stomach acid; certain drugs may generate side effects that mimic temporomandibular disorders or
reduce salivary flow.

Periodontitis in diabetic patients

*Note the gingival resorption on the

central incisor with a full crown

Fig. 1-4 Severe gingival

hyperplasia associated with
anticonvulsant drug use.

A A, Extensive damage caused by self-induced acid

regurgitation. Note that the lingual surfaces are
bare of enamel except for a narrow band at the
gingival margin. B, Teeth prepared for partial-
coverage restorations

4. Possible risks to the dentist and auxiliary personnel (e.g., patients who are suspected or
confirmed carriers of hepatitis B, acquired immunodeficiency syndrome, or syphilis).
 Hepa B Oral Syphillis

HIV

Dental offices practice “universal precautions” to ensure appropriate infection control. Universal
precautions refer to the practice, in medicine, of avoiding contact with patients' bodily fluids, by means
of the wearing of nonporous articles such as medical gloves, goggles, and face shields. The infection
control techniques were essentially good hygiene habits, such as hand washing and the use of gloves
and other barriers, the correct handling of hypodermic needles, scalpels, and aseptic techniques. This
means that full infection control is practiced for every patient; no additional measures are needed when
dentists treat known disease carriers. “Every patient must be treated as if infected and contagious
therefore precautions must be taken to eliminate or at least minimize risk.”
Patients frequently lie about their current health status for a variety of reasons. When the dentist
suspects the patient may be holding information, a form of “indirect questioning” may be ask by the
dentist. An example of this is when the dentist is suspecting the patient has a sexually transmitted
disease but the patient is denying or withholding it. Instead of the dentist asking the question like “Do
you have syphilis” which the patient would most like deny, the dentist will not be able to identify or
confirm oral syphilitic lesions and thus will have difficulty in establishing a diagnosis and treatment or
referral to the specialist.
A form of indirect questioning like “are you taking any antibiotics now” or “can you tell me the
name of the antibiotics you are taking now” and other follow up questioning would mostly reveal what
the patient is hiding. The dentist can also give an assurance that he is bound by “medical confidentiality”
(a.k.a. doctor-patient privilege). Legal protections prevent physicians from revealing certain discussions
with patients, even under oath in court. This physician-patient privilege only applies to secrets shared
between physician and patient during the course of the dental care for the purpose of providing accurate
diagnosis and accurate medical/dental care.
SAMPLE history is a mnemonic acronym to remember key questions for a person's medical assessment.
The SAMPLE history is sometimes used in conjunction with vital signs and OPQRST. The questions are
most commonly used in the field of emergency medicine by first responders during the secondary
assessment. It is used for alert people, but often much of this information can also be obtained from the
family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment
is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a
person's medical history.

The parts of the mnemonic are:

• S – Signs/Symptoms (Symptoms are important but they are subjective.)
• A – Allergies
• M – Medications
• P – Past Pertinent medical history
• L – Last Oral Intake (Sometimes also Last Menstrual Cycle.)
• E – Events Leading Up to Present Illness / Injury

Vital signs (also known as vitals) are a group of the four to six most important medical signs that indicate
the status of the body’s vital (life-sustaining) functions. These measurements are taken to help assess
the general physical health of a person, give clues to possible diseases, and show progress toward
recovery. The normal ranges for a person’s vital signs vary with age, weight, gender, and overall health.
There are four primary vital signs: body temperature, blood pressure, pulse (heart rate), and
breathing rate (respiratory rate), often notated as BT, BP, HR, and RR. However, depending on the clinical
setting, the vital signs may include other measurements called the "fifth vital sign" or "sixth vital sign".
The "fifth vital sign" may refer to a few different parameters. Pain is considered a standard fifth
vital sign in some organizations. Pain is measured on a 0–⁠10 pain scale based on subjective patient
reporting and may be unreliable.
• Pain
• Menstrual cycle
• Oxygen saturation (as measured by pulse oximetry)
• Blood Glucose level
Sixth vital signs
There is no standard "sixth vital sign"; its use is more informal and discipline-dependent.
• End-tidal CO2
• Functional status
• Shortness of breath
• Gait speed
• Delirium
----------------------------------------------------------------------------------------------------------------------------------------
THE DENTAL HISTORY
Clinicians should complete a thorough examination before establishing a diagnosis. With
adequate experience, a clinician can often assess preliminary treatment needs during the initial
appointment, but review and analysis of additional diagnostic information are frequently necessary.
Also, assessing the quality of a previously rendered treatment fairly can be difficult because the
circumstances under which the treatment was rendered are seldom known. When such an assessment
is requested for legal proceedings, the patient should be referred to a specialist familiar with the “usual
and customary” standard of care.
The dental history should include initially the name of the previous dentist, the last dental visit
and the different procedures done based on the patient’s memory. A simple question like “Why won’t you
go back to your previous dentist” may reveal previous dental experience or the patient’s character that can
make the planned treatment difficult.
Periodontal History. (Past periodontal treatment) The patient’s oral hygiene is assessed, and current
plaque-control measures are discussed, as are previously received oral hygiene instructions. The
frequency of any previous debridement should be recorded, and the dates and nature of any previous
periodontal surgery should be noted. The patient’s ability to clean the oral cavity should be
supplemented if it is inadequate as any prosthodontic procedure done will most likely fail in the long run
if the patient doesn’t know how to maintain proper hygiene.
Restorative History. (Past restorative treatment) The patient’s restorative history may include only
simple composite resin or dental amalgam fillings, or it may involve crowns and extensive fixed dental
prostheses. The age of existing restorations can help establish the prognosis and probable longevity of
any future fixed prostheses. When the restorations are properly recorded the dentist can predict failure
and may need to alter the existing restoration before more damage is done.
Endodontic History. (Past endodontic treatment) Patients often forget which teeth have been
endodontically treated. These can be readily identified with radiographs. The findings should be
reviewed periodically so that periapical health can be monitored and any recurring lesions promptly
detected. Aside from radiographs, the tooth can be readily identified visually by discoloration of the tooth
if it is not yet restored with a crown and may need to be included in the planned prosthodontic
restoration.
Orthodontic History. (Past orthodontic treatment) Occlusal analysis should be an integral part of the
assessment of dentition after orthodontic treatment. If restorative treatment needs are anticipated, the
restorative dentist should perform the occlusal evaluation. Occlusal adjustment (reshaping of the
occlusal surfaces of the teeth) may be needed to promote long-term positional stability of the teeth and
to reduce or eliminate parafunctional activity. On occasion, root resorption (detected on radiographs)
may be attributable to previous orthodontic treatment. Because this may affect the crown-to-root ratio,
future prosthodontic treatment and its prognosis may also be affected. Restorative treatment can often
be simplified by minor tooth movement. In orthodontic treatment, considerable time can be saved if
minor tooth movement (for restorative reasons) is incorporated from the start. Thus, good
communication between the restorative dentist and the orthodontist may prove very helpful. Certain
procedure necessitates orthodontic movement done first before any prosthodontic procedures are
made. This will sometimes create misunderstanding between the patient and the dentist if it is not
carefully discussed as most patients would most likely opt for the prosthodontic treatment immediate.
So, it is necessary to have the patient understand the whole treatment plan before the actual treatment
is started.
Removable Prosthodontic History. The patient’s experiences with removable prostheses must be
carefully evaluated. For example, a partial removable dental prosthesis may not have been worn for a
variety of reasons, and the patient may not even mention its existence. Careful questioning and
examination usually elicit discussion concerning any such devices. Listening to the patient’s comments
about previously unsuccessful removable prostheses can be very helpful in assessing whether future
treatment will be more successful. The patient should be informed to bring any old prosthesis if possible.
Oral Surgical History. The clinician must obtain information about missing teeth and any complications
that may have occurred during tooth removal. Special evaluation and data collection procedures are
necessary for patients who require prosthodontic care after orthognathic surgery. Before any treatment
is undertaken, the prosthodontic component of the proposed treatment must be fully coordinated with
the surgical component.
Radiographic History. Previously made radiographs may prove helpful in judging the progress of dental
disease. They should be obtained if possible. Dental practices usually forward radiographs or acceptable
duplicates promptly on request. In most instances, however, a current (new) diagnostic radiographic
series is still essential and should be obtained as part of the examination.
Myofascial Pain and Temporomandibular Joint Dysfunction History. Myofascial pain, clicking in the
temporomandibular joints (TMJs), or neuromuscular symptoms, such as abnormal muscle tone or
tenderness to palpation, should be treated and resolved before fixed prosthodontic treatment begins. A
screening questionnaire efficiently identifies patients with these symptoms who may be at higher risk
for complications. Such patients should be questioned regarding any previous treatment for joint
dysfunction (e.g., occlusal devices, medications, biofeedback, or physical therapy exercises).
-----------------------------------------------------------------------------------------------------------------------------------------
INFORMED CONSENT
Informed consent is a process for getting permission before conducting a healthcare intervention
on a person, or for disclosing a person's information. A health care provider may ask a patient
to consent to receive therapy before providing it, Informed consent is collected according to guidelines
from the fields of medical ethics and research ethics.
 An informed consent can be said to have been given based upon a clear appreciation and
understanding of the facts, implications, and consequences of an action. To give informed consent, the
individual concerned must have adequate reasoning faculties and be in possession of all relevant facts.
Impairments to reasoning and judgment that may prevent informed consent include basic intellectual
or emotional immaturity, high levels of stress such as posttraumatic stress disorder (PTSD) or a severe
intellectual disability, severe mental disorder, intoxication, severe sleep deprivation, Alzheimer's disease,
or being in a coma.
If an individual is considered unable to give informed consent, another person is generally
authorized to give consent on his behalf, e.g., parents or legal guardians of a child (though in this
circumstance the child may be required to provide informed assent) and conservators for the mentally
disordered, or consent can be assumed through the doctrine of implied consent, e.g., when an
unconscious person will die without immediate medical treatment.
An example of informed consent (above) should be included in the charting procedure and should
be signed by both dentist and patient.

Informed Refusal
Another form called “Informed refusal” maybe included as dentist tend to have several treatment
options. Informed refusal (sample below) is where a person has refused a recommended dental
treatment based upon an understanding of the facts and implications of not following the treatment.
Informed refusal is linked to the informed consent process, as a patient has a right to consent, but also
may choose to refuse. As applied in the medical field, a dentist has made an assessment of a patient and
finds a specific test, intervention, or treatment is necessary. The patient refuses to consent to this
recommendation. The dentist then needs to explain the risks of not following through with the
recommendations to allow the patient to make an informed decision against the recommendation. While
in the past documentation of refusal of treatment has not been important, the widespread use of
managed care, cost containment processes, as well as increased patient autonomy have created a
situation where documented "informed refusal" is viewed as becoming more important. When refusal
of treatment may result in significant damage or death, the interaction needs to be documented to
protect the care giver in a potential later litigation against the allegation that the recommendation was
either not made or not understood. On occasion, a patient will also refuse to sign the "informed refusal"
document, in which case a witness would have to sign that the informed process and the refusal took
place.
Activity 3: Skill-building Activities (18 mins + 2 mins checking)
Instruction: Make/design your own set of medical history questions/questionnaire using the
blank table below (No copy and paste please). Use the example Medical History Questionnaire on
page 6 of this module as a guide. You can more questions that you think is relevant to medical
history taking.
 Example Medical History
Instruction to patient: right Y = Yes or N=No
Are you under a physician’s care? Physician’s Name: ___________________________________
Are you in good health?
Are you taking any medications right now?
Do you have any serious illness or surgical operation before?
Have you ever been hospitalized?
You continue or make your own ……

Activity 5: Check for Understanding (5 mins)

Instruction: Using the different disease/condition on the “Medical History Questionnaire” (page 6
of this module), pick out the disease and place them in the different categories provided. A
disease can be placed in more than one category if applicable
Examples of disease/Conditions affecting the treatment methods
1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
4. Click or tap here to enter text.
5. Click or tap here to enter text.

Examples of disease/Conditions affecting the treatment plan

1. Click or tap here to enter text.
 2. Click or tap here to enter text.
3. Click or tap here to enter text.
4. Click or tap here to enter text.
5. Click or tap here to enter text.

Examples of disease/Systemic conditions with oral manifestations

1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
4. Click or tap here to enter text.
5. Click or tap here to enter text.

Examples of disease/conditions that poses Possible health risks to the dentist and dental
staff (you can add more if you want).
1. Click or tap here to enter text.
2. Click or tap here to enter text.
3. Click or tap here to enter text.
4. Click or tap here to enter text.
5. Click or tap here to enter text.

Contact Information
Dr. Allan Rotello Sia Ebua
• Mobile: +63-929-886-1569
• Facebook/Messenger: https://www.facebook.com/alexstrasz/
https://www.facebook.com/dr.allan.ebua