Information Gathering

Question 1

Basic case approach — how to review a case (order)

Answer 1

1) Medical history
2) Dental history
3) Social history
4) Chief complaint
5) Extraoral exam
6) Intraoral exam
7) Radiographic exam - based on exam findings, age, caries risk, and chief complaint
8) Treatment recommendations (be sure to address CC specifically)

Question 2

How to start each case

Answer 2

• First step: Always state that you would review thorough medical, dental, and social histories, as well as the patient’s chief complaint.
• For the first case, describe the steps of taking an extremely thorough medical, dental, and social histories.
• After the first case, you will probably not be asked to repeat all of the detailed questions for the histories. Nonetheless, still say in subsequent cases, “I would review a thorough medical, dental, and social history for the patient as well as their chief complaint. I can go into detail as I did previously if you would like.”

Question 3

Medical History

Answer 3

Med Hx = Take the HI ROAD

• H = hospitalizations
• I = Illnesses (past and present)
• R = Review of Systems: HEENT (Head, Ears, Eyes, Nose, Throat), Cardiac, Respiratory, Neurologic, Gastrointestinal, Genitourinary, Hepatic, Musculoskeletal, Skin, Hematologic, Psychologic
• O = Operations (history of surgeries)
• A = Allergies to medications, foods or other substances
• D = Drugs (medications) that the patient is taking

Question 4

Dental History

Answer 4

• Does the patient have a dental home?
  
  • Have they ever been to the dentist before?
  • Ever had a bad experience at the dentist?
• Does the patient brush and floss? Fluoride toothpaste? Alone or with parental assistance?
• Does the patient live in an area with fluoridated water?
• Does the patient have frequent snacking between meals or a high frequency sugar diet?
• Does the patient go to bed with a bottle or carry a sippy cup of anything but water during the day?
• Previous dental trauma?
• Complete a caries risk assessment using the AAPD CRA form.

Question 5

Social History

Answer 5

• Who is the primary caregiver?
• Who else lives with them (parents, grandparents, siblings)?
• Parent marital status?
• How stable is their home life (do they move frequently)?
• What is their socioeconomic status?
• Has there been any history of abuse or neglect?

Question 6

Other important points

Answer 6

• For every case, verify that the patient was brought in by the legal guardian
  
  • Step-mom, grandparent, friend of family, uncle, minor sibling- must have written 3rd party consent from pt’s legal guardian if another person brings them (for the purpose of this exam)
• Informed consent was obtained for treatment. Get informed consent before every treatment.
  
  • Adequate informed consent includes an explantation of:
    1) Benefits and risks of treatment
    2) Alternative treatment options (including no treatment, this is ALWAYS an option)
    3) Consequences of no treatment
    4) Signed by parent/guardian, doctor, and third party witness

Question 7

Treatment planning

Answer 7

• Diagnosis
• A complete treatment plan for this exam includes:
  - Preventive plan (oral hygiene, fluoride, diet), anticipatory guidance per age
  - Periodontal concerns
  - Restorative needs by quadrants
  - Behavior modification needs
  - Then recall

Question 8

Informed Consent

Answer 8

1) Risks
2) Benefits
3) Alternative treatments

• Signed and witnessed
• Basic terminology
• In native language of parent
• All questions answered