Oral and Dental Medicine

Oral Diagnosis I
Lab : patient’s record form orientation

Dr : (Fatma El-Sayed)
patient’s record
form orientation
Communication skills in
dental healthcare
Verbal Communication (Spoken Words)

Para-Verbal Communication

Non Verbal Communication

Ability to tailor your WORDS to a given audience
Non Verbal Communication
 Non Verbal Communication

(Active Listening)

The underlying message of active listening is “I am here for you.”

 Explain
diagnosis,
investigation

Decision-
Motivation
making

Instructions With relatives

Uses of
communication
skills in a
healthcare

With difficult With other

patients or health
relatives professionals

Informed Break bad

consent news
 3-Discussing
1- Initial 3-Discussing
5-Concluding
4- Discussing
2- 2- 4- Discussing 5-Concluding
treatment
contact & treatment
Examination
thefees
visit Examination fees the visit
History
options
taking options

•For
•Thorough
Dentist
•Introduce
•Be
•IMPORTANT honestexplanation
= Routine
yourself…Be
asand ofthe
initial treatment
open
of totooptions.
firstvisit.
the greetavoid
your
•For
•Patient
patientPatient
inclearly
the=operatory
misunderstanding. Main understand
Concern advantages and
•Explain
disadvantages
•Don’t the
what
Concludeprocess
ofwill
each
whilesystematically
option.
happen
walking during and
to thetheirclearly
door visit
.
•Explain
•Arrange thepatient
and introduce
•Take options
lead torole
themavoid from
toinstaff
the process
most simple
embarrassing
members and
patients.
•Maintain
inexpensive
•Call patients
•Confirm personal
toby
treatment costlyspace.
name. andand
plan difficult.
follow up.
•Start
•Demonstrate
•Sit at with
•Discuss areayour
eyealternative
level of
& complaint.
clinical
keep eyeexpertise.
payment contact.
options.
•Observe
••Encourage
•Listen
“Do You attentively
patient
attentively
have toany patient
to ask
their reactions.
questions
concerns.
other questionsto feel or
•Don’t use
involved.
•Patient
concern?” technical
should terms
be setting
jargon upright
or terms in chair.
•Don’t
•Motivate
•Take the
•“Call mepass
your instruments
leadership
if you patient.role and
remember inany front
guide ofto patient
thingthe ask?”
eyes.
••Don’t
Keep judge
through eye patient’s choices.
thecontact.
appointment.
•Summarize
•Clarifyhiminstructions
•Ask permission
•Walk toyour
the to findings.
and the
examine
door. timing for each
patient.
option.
 Keys For Effective
Communications with your
Patient
Listen Empathy
Friendliness
Understand not
Warm and caring
Respond to needs sympathy

Control but let

Respect the patient feel Clear information
control

Give options and Establish a plan and

Avoid arguing
alternatives follow it
 Patient’s
record form
for
Comprehensive Diagnosis & Treatment Planning
Diagnostic Steps (Method)
Prognosis
Treatment Plan
&
Collection of Establishment
Medical
Data of Diagnosis
Risk
Symptoms (Subjective) Assessment
/Signs (Objective)
A B Comprehensive plan

Definitive
Patient Clinical OR
History Examination
Treatment Referral
Direct Interview Extra-oral

Questionnaire Intra-oral Re-assessment

+/– Adjunctive
Diagnostic Aids
Laboratory Investigations?? Medically compromised Patients ??
Methods for obtaining patient's record?!!
From ?!! Patient . Parents- Caregivers – physician – Previous records
-1- Printed Health Questionnaire
(Standard Approach+ Consistent)
(No Skills + Save Time)

-2-Direct Interview
(Communicate)
(Flexible for all patients)
(Depth + Update)

-3- Combination
(↑ Advantages of both)
Written records– Software
11:32
1- HISTORY
2- CLINICAL EXAMINATION
2- CLINICAL EXAMINATION
School of Dental Medicine (ZMK), University of Bern-Department of Periodontology
http://www.periodontalchart-online.com/us/
Treatment planning
Referral letter form
Steps for recording
Case History
A- Patient History 1
Personal
History
7 2
Social H. & Chief
personal complaint
habits
➢Name
➢Age
➢Gender
➢Address
➢Phone Number
6 ➢Race 3
Family ➢Marital Status H . of chief
History complaint
➢Occupation
➢Birth place

5
Medical 4
History & Dental
Review of History
systems
‫محمد علي حسن‬ ‫‪Gender:‬‬ ‫‪45‬‬ ‫القاهرة‬

‫‪3‬‬ ‫مدرس‬
‫مدينة نصر‬ ‫‪0117654839‬‬
 Age?!!!
Infants

Eruption cyst Hemangioma

 Children

Herpetic Gingivostomatitis Measles

 Middle age

Lichen planus Aphthous ulcer

 Old Age

Angular Chelitis
Extremes of Age

Oral Candidiasis
 Gender?!!

Lupus Erythermatosis Lip Carcinoma

 Race?!!

Physiologic pigmentation
Birth Place?!!

Dental flourosis
 Occupation?!!

Notched tooth Actinic chelitis

Other Examples ??
Marital Status
Address
2- Chief Complaint
"Can you tell me why you came to the clinic?" or "Please tell me about your problem."

 Symptoms or signs described by the patient in his words own

related to abnormal condition promoted him to seek treatment.
= Primary reason for dental
treatment if more!!
RANK THEM
Max 2CC/VISIT

Referred
Unspecified I(ifwant
patient Patients
come
to clean forteeth
my regular
/ check up)
I want to replace my missing teeth
Oral and Dental Chief Complaints

Pain Sores Burning

sensation
 Oral and Dental Chief Complaints

Bleeding Loose teeth Recent occlusal

problem
 Oral and Dental Chief Complaints

Delayed Tooth Eruption Dry Mouth Excessive

(Xerostomia) salivation
 Oral and Dental Chief Complaints

Swelling Bad Taste Bad odor

(A Lump) (Halitosis)
 Oral and Dental Chief Complaints

Anesthesia and Esthetic problem Masticatory

Paresthesia Problem
 Gradual Pain in Upper right posterior teeth
since 1week, symptoms last for 1 hour, increase at night

Severe and sharp

PainIntermittent
in a tooth with/followed by a swollen face/gum
Upper right posterior teeth
(*History of each should be taken separately)
Unilateral and radiate to the ear

Hot and cold drinks

Pain killers

---------……………?
Ibuprofen tablets 600mg 2times/day for 3 days
 Does the problem appear suddenly or gradually?

When the problem was first noticed?

And for how long the symptoms last? Any specific timing?
How would you describe your problem and its severity,
Is it like…?
Have the symptoms gotten better or worse over time?

Can you identify the location of the problem exactly?

Is it on both sides/ do you feel the symptoms in other areas?

What brings or makes the symptoms worse or better?

Have you noticed any other symptoms or signs with your problem like……………?

Have you taken any medication for your problem lately or in the last 3 months? If so
please tell me the name, duration, dose, formula and frequency if possible?

What is your main concern in treatment?

• For prosthetic construction:
• Why do you want to replace your missing teeth?
(Esthetic, phonetic, chewing problem)
• Take history of the cause of extraction.
• When the last tooth was extracted?
• Ask about previous prosthetic replacement.
Role Play Activity
Burning sensation
Look in the history for underlying causes

Burning sensation

Psychological Infectious Developmental Local Systemic

Bleeding
Look in the history for underlying causes

Oral Bleeding

Inflammatory Local Invasive Develompmental Bleeding and

vascular clotting disorders
Loose teeth
Look in the history for underlying causes
Loose teeth
(Other than Physiological
shedding)

Inflammatory
Periodontal Traumatic Tumors Genetic AIDS
Or periapical abnormalities
Dry Mouth (Xerostomia)
Look in the history for underlying causes

Dry Mouth

Salivary gland Local Drugs or Habits Systemic

diseases
causes therapy diseases