2.1
Patient History and Examination

Subir Banerji and Shamir B. Mehta

Principles

The foundation for successful treatment planning is largely reliant on the ability of the clinician to attain an accurate and contemporaneous patient history and to carry out a meticulous clinical examination. All findings should be appropriately recorded. Treatment planning should aim to fulfil the patient's realistic expectations, provide an outcome that boasts functional and aesthetic success (spanning beyond the short term) and, where possible, utilise techniques that involve minimal intervention.

The initial assessment should take place in a relaxed setting, perhaps distinct from the operatory, and permit the patient to voice their views. Emphasis should be placed on actively listening to the patient's concerns and attitudes.

Procedures

Begin by verifying the essential patient data, such as the patient's name, gender, date of birth, address and contact details. This may be attained by requesting completion of a pre-treatment evaluation document. The details can be checked by other members of your dental staff team, together with information concerning any relevant special needs.

Establish your patient's reasons for attendance, hence the nature of their complaint and associated history. There are three categories of 'dental aesthetic imperfections' that drive patients to seek aesthetic intervention, which may be broadly classified as matters relating to tooth colour, shape and/or position.1

A detailed medical history is mandatory. A template medical history form may prove helpful. It is beyond the scope of this text to discuss the relevance of the medical history and its impact on the provision of dental care. However, in brief, the patient's medical history (and status) may preclude them from attending necessary lengthy or frequent treatment sessions, require modification of the treatment protocol or may sometimes contraindicate certain types of treatment, as when there is an allergy to a material or product. Indeed, the underlying medical condition may also prove to be contributory to the aesthetic impairment, such as taking prescription medication that may induce gingival hyperplasia; or an eating disorder, hiatus hernia or gastric reflux, which may result in erosive tooth wear.

The condition of body dysmorphic disorder (BDD) is one to be particularly aware of. This may be considered a psychiatric illness characterised by a preoccupation with an imagined defect in appearance and may cause clinically significant distress or impairment in social, occupation or other important areas of functioning, with the preoccupation not being related to any other form of mental illnesses.2, 3 It would appear to be more common among patients seeking cosmetic and aesthetic treatments.

The patient's dental history, their attitude to dentistry and their oral health should be noted. Oral hygiene habits, past attendance habits and previous experience of dental care should also be detailed. Dental-phobic patients and those who lack the motivation to maintain a high standard of oral hygiene may be more suited to relatively simple, low-maintenance, minimally invasive forms of treatment. Patients with unrealistic expectations may require further counselling, especially prior to embarking on complex, irreversible forms of dental treatment.

The patient's social habits such as smoking and their level of alcohol consumption should be ascertained. Smoking and excessive alcohol consumption not only contribute to the initiation and progression of various forms of oral disease, they also may contraindicate certain forms of treatment, such as tooth whitening and implant therapy. A diet history should also be obtained, taking particular note of the frequency and quantity of refined carbohydrate intake, together with the consumption of acidic foods and drinks. Copious and frequent consumption of foods and beverages that may cause staining, including tea, coffee, red wine and turmeric, is a further factor to be considered when contemplating colour-enhancing treatments such as tooth whitening. The patient's occupation should also be noted, as it may affect their ability to attend on a frequent basis, or indeed have an aetiological role in the causation of their aesthetic concerns.

Now proceed to the initial examination phase. To be assured of completeness, you may wish to use an assessment template. Start with examination of the extra-oral features. This should include an assessment of the following:

• Temporomandibular joints and associated musculature
• Cervical lymph nodes and salivary glands
• Facial (and dento-facial) features such as facial proportions, symmetry, facial shape, profile and width, lip morphology and mobility
• Facial skin.

For details of how to carry out an evaluation of the temporomandibular joint and musculature, refer to Chapter 3.1.

A thorough intra-oral examination should be conducted in a systematic manner. It is common first to examine the soft tissues of the lips, cheeks, tongue, vestibule, soft palate, hard palate and floor of the mouth for the presence of any anomalies. The use of dental loupes with appropriate illumination is highly recommended.

Record the overall standard of oral hygiene; the use of plaque-disclosing tablets and the subsequent derivation of plaque scores may prove useful. The presence of any local factors that may encourage plaque and calculus accumulation and stagnation should also be identified, including overhangs and other defects in restorations. The presence and extent of extrinsic tooth stains should be noted also.

The gingival tissues should be examined for the presence of any inflammatory changes, including erythema, swelling, loss of stippling, blunting of the gingival papillae, bleeding on probing and the presence of any exudates. A Basic Periodontal Examination (BPE)4 should be conducted on a routine basis. A full-depth, six-point periodontal chart may sometimes be indicated. It may also be important to document the levels of attachment to determine the amount of periodontal destruction and recession that has occurred. Other periodontal features to note include the presence of any tooth mobility, furcation involvement and any bleeding on probing.

Accurate charting of the dental hard tissues should record the presence and absence of teeth, dental caries, sound and defective restorations, tooth fractures, cracks, wear of abrasive, erosive, abfractive and attritional varieties and any tooth malformations. The extent and location of any caries should be noted, as should the type and extent of all dental restorations present. Dental restorations should be further assessed for their marginal integrity and adaptation, structural integrity, form, function and aesthetic appearance. The presence of any secondary caries, open contacts and other food traps and wear facets, present on either the remaining dental tissues or the functional surfaces, should be documented. The use of a sharp probe is helpful. Dry the hard tissues using air from the three-in-one syringe. It is helpful if the teeth are stain and plaque free.

It is important to carry out a detailed occlusal assessment to establish the ways in which the patient's occlusal scheme differs from what may considered to be the ideal and to determine the constraints the occlusal scheme may place on fulfilling the patient's aesthetic expectations. Details on the means of performing a detailed occlusal assessment may be found in Chapter 3.1.

The occlusal assessment should be followed by a detailed evaluation of the aesthetic zone. Further details may be found in Chapter 2.3.

For patients presenting with tooth wear, the pattern of wear should be accurately recorded. A number of indices have been described that may be used for the purposes of monitoring or indeed treatment provision. For more details refer to Part 9.

Finally, for patients who are edentulous or partially dentate, a record should be made of their potential denture-bearing areas, such as the size, shape, texture and mobility of the ridges and overlying mucosa. This may include the use of a classification system to categorise the space. For patients who have been provided with removable appliances previously, a detailed history and inspection of their appliances should be undertaken.

The role of special tests must not be overlooked. However, they should serve as adjuncts to the clinical examination. Commonly used special tests include the following:

• Dental radiographs/imaging techniques
• Vitality testing
• Diagnostic (and mounted, articulated or surveyed) study casts
• Diet analysis
• Dental photographs.

Following the methodical and detailed examination and collaborative evidence from any special tests and investigations, a diagnosis should be established to enable an appropriate treatment plan to be developed.

Tips

• First impressions count. Remember that your patient will be forming an impression of you during this visit.
• Sometimes it is useful to have the initial appointment with a new patient over two visits. This enables the investigations, observations and data collected at the first appointment to be evaluated for discussion at the...