History and Examination



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  1. History and Examination


Date and Clinic

Patient referred by…. (Dentist Bloggs)….regarding…(removal of lower wisdom teeth)



Presenting complaint (PC)

Remember SOCRATES



Site

Onset

Character

Radiating

Alleviating

Timing

Exacerbating

Severity
History of presenting complaint (HPC)

Medical History

Heart/CVS; hypertension, previous MI, stroke, rheumatic fever or endocarditis, heart murmur, angina

Chest/Resp; Asthma, Bronchitis, COPD, Recurrent chest infections

Liver and Kidney function

Diabetes

Epilepsy


Musculoskeletal; Arthitis (Rheumatoid and Osteo), Osteoporosis

Bleeding Disorders; Congenital or medication related

Infectious diseases

Allergies

Medication;

Previous operations;

For all conditions identified, ascertain how well they are controlled. For example;

Angina…chest pain on during exertion (running/walking up stairs/standing up), never occurs at rest, eased when patient uses GTN spray. Patient only has to use the spray approximately once every six months.



Social History (SH)

Patient lives with;

Occupation

Smokes; how many a day for how many years?

Alcohol; units per week

Examination

Extra-oral

TMJ; click or crepitus on opening or closing

Cervical lymphadenopathy

Muscles of Mastication (Temporalis)

Mouth opening; trismus, deviation on opening?

Swelling/Lumps; site, size, overlying colour, texture (soft/firm/bony hard), fluctuance, associated structures and draw diagram

Cranial Nerves; particularly V and VII

Intraoral

Teeth present; caries, # restorations, generalised mobility, TTP, sinus or tenderness

Soft tissue examination; site, size, overlying colour, texture (soft/firm/bony hard), fluctuance, associated structures and draw diagram of lesions

Muscles of Mastication; masseter, lateral pterygoid



Differential Diagnosis

Further Investigations

Radiographs

Vitality Testing

Testing for cracked cusps (Cotton Wool)



Definitive Diagnosis

Management/ Treatment Plan

Does the patient need any further investigations prior to treatment?

For example;

Haematology patient-liaise with haematologist

History of high alcoholic intake; Bloods to include FBC, clotting screen and LFTs

2. Clerking a patient prior to surgery


Check the documentation from initial assessment

Has there been any change in the presenting complaint or medical history?

Is everything ready for surgery?

Images


Consent

Blood results

Lab work (splints, stents, models)

Marked patient (if applicable)

Complete the;

Correct Site Surgery form

VTE Prophylaxis form

Discharge form/TTOs


  1. Facial Trauma 


Suspected Fracture

Symptoms

Signs

Mandible

History of trauma

Altered sensation of lip

Teeth not meeting properly

Pain on opening mouth



Gingival or facial lacerations

Swelling and bruising

Sublingual haematoma

Step deformity (lower border of mandible)

Mobility of mandible

Malocclusion and step deformity teeth

Para/anaesthesia of lower lip

Damaged teeth

Bleeding from the ear


Zygomatic complex

History of trauma

Pain and swelling

‘Flat cheek’

Numbness of cheek or teeth




Flattened zygoma/Asymmetry

Swelling and bruising of cheek

Step deformity (orbital rims)

Peri-orbital ecchymosis

Subconjunctival haemorrhage

Para/anaesthesia of infra-orbital nerve

Trismus and restricted lateral excursion

Epistaxis




Isolated Orbit

History of trauma

Blurred vision

Double vision


Step deformity in orbital rim

Enopthalmus /Exopthalmus

Peri-orbital ecchymosis

Subconjunctival haemorrhage

Para/anaesthesia of infra-orbital nerve

Restricted eye movements

Diplopia

NB Retrobulbar haemorrhage


Midface fractures

Any of the above depending on level (Le Fort I, II or III)

As above but more specifically;

Mobility of maxilla

Mobile middle third of face

Deranged occlusion

Palpable crepitus in upper buccal sulcus

‘Cracked pot’ percussion note from upper teeth

Haematoma intra-orally (zygoma or palate)

Gagging on posterior teeth

Anterior open bite

Septal haematoma

CSF leak (nose and ear)


Radiographs

Radiographs in two planes

Mandible; OPG and PA mandible

Zygomatic complex (zygomatic butress, orbital rim) ; OM, OM15, or OM30

Le Fort Fractures, OM views

Communited or multiple fractures; consider CT scan


  1. Medical Emergencies


Asthma

Symptoms and Signs

Clinical features of acute severe asthma in adults include:



  • Inability to complete sentences in one breath.

  • Respiratory rate > 25 per minute.

  • Tachycardia (heart rate > 110 per minute)



Clinical features of life threatening asthma in adults include:

  • Cyanosis or respiratory rate < 8 per minute.

  • Bradycardia (heart rate < 50 per minute).

  • Exhaustion, confusion, decreased conscious level


Management

Salbutamol (100 micrograms/activation) with large volume spacer. Up to 10 activations every 10 minutes


Oxygen (15 litres per minute) should be given.
If any patient becomes unresponsive always check for ‘signs of life’ (breathing and circulation) and start CPR if indicated

Anaphylaxis

Signs and symptoms may include:




  • Urticaria, erythema, rhinitis, conjunctivitis.

  • Abdominal pain, vomiting, diarrhoea and a sense of impending doom.

  • Flushing is common, but pallor may also occur.

  • Marked upper airway (laryngeal) oedema and bronchospasm may develop,

causing stridor, wheezing and/or a hoarse voice.

  • Vasodilation causes relative hypovolaemia leading to low blood pressure

and collapse. This can cause cardiac arrest.

Treatment
Use an ABCDE approach to recognise and treat any suspected anaphylactic reaction
Restoration of blood pressure (laying the patient flat, raising the feet) and the

Administration of oxygen (15 litres per minute).

Adrenaline intramuscularly (anterolateral aspect of the middle third of the thigh)

500 micrograms (0.5 Ml adrenaline injection of 1:1000)

Repeat if necessary at 5 minute intervals
Antihistamine drugs and steroids, whilst useful in the treatment of anaphylaxis, are not first line drugs and they will be administered by the ambulance personnel if necessary

Myocardial Infarction
Signs and symptoms


  • Progressive onset of severe, crushing pain in the centre and across the front of chest. The pain may radiate to the shoulders and down the arms (more commonly the left), into the neck and jaw or through to the back.

  • Skin becomes pale and clammy.

  • Nausea and vomiting are common.

  • Pulse may be weak and blood pressure may fall.

  • Shortness of breath


Management
Call 999
Allow the patient to rest in the position that feels most comfortable
Give sublingual GTN spray
Aspirin in a single dose of 300 mg orally, crushed or chewed
High flow oxygen may be administered (15 litres per minute) if the patient is cyanosed or conscious level deteriorates
If the patient becomes unresponsive always check for ‘signs of life’ (breathing and circulation) and start CPR

Epileptic seizure
Signs and symptoms


  • Brief warning or ‘aura’.

  • Sudden loss of consciousness, the patient becomes rigid, falls, may give a cry, and becomes cyanosed (tonic phase).

  • After a few seconds, there are jerking movements of the limbs; the tongue may be bitten (clonic phase).

  • There may be frothing from the mouth and urinary incontinence.

  • The seizure typically lasts a few minutes; the patient may then become floppy but remain unconscious.

  • After a variable time the patient regains consciousness but may remain confused.


Management
Reduce risks of harm to patient but do not restrain
Give high flow oxygen (15 litres per minute)
After convulsive movements have subsided place the patient in the recovery position and reassess
If the patient remains unresponsive always check for ‘signs of life’ (breathing and circulation) and start CPR if indicated
Check blood glucose level to exclude hypoglycaemia;

If blood glucose <3.0 mmol per litre or hypoglycaemia is clinically suspected, give oral/buccal glucose, or glucagon


It may not always be necessary to seek medical attention or transfer to hospital unless the convulsion was atypical, prolonged (or repeated), or if injury occurred. These signs include;

  • Status epilepticus.

  • High risk of recurrence.

  • First episode.

  • Difficulty monitoring the individual’s condition.

Only if seizure is prolonged (over 5 minutes); give midazolam given via the buccal route in a

single dose of 10mg for adults (child 1-5 years 5mg, child 5-10 years 7.5mg, above 10 years 10mg)

Hypoglycaemia
Signs and symptoms


  • Shaking and trembling.

  • Sweating.

  • Headache.

  • Difficulty in concentration / vagueness.

  • Slurring of speech.

  • Aggression and confusion.

  • Fitting / seizures.

  • Unconsciousness.


Management
Measure blood glucose
Conscious; Oral glucose (sugar (sucrose), milk with added sugar, glucose tablets or gel). If necessary this may be repeated in 10 -15 minutes
Unconscious; Glucagon should be given via the IM route (1mg in adults and children >8 years old or >25 kg, 0.5mg if <8 years old or <25 kg)
Re-check blood glucose after 10 minutes to ensure that it has risen to a level of 5.0 mmol per litre or more
If any patient becomes unconscious, always check for ‘signs of life’ (breathing and circulation) and start CPR if indicated
Once conscious, the patient should be given oral glucose, accompanied home if fully recovered and their GP informed
Syncope
Signs and symptoms


  • Patient feels faint / dizzy / light headed.

  • Slow pulse rate.

  • Low blood pressure.

  • Pallor and sweating.

  • Nausea and vomiting.

  • Loss of consciousness.


Management
Lay the patient flat
If any patient becomes unresponsive, always check for ‘signs of life’ (breathing, circulation) and start CPR if appropriate

Adrenal Insufficiency
Guidance on the management of those patients with known Addison’s disease is

available from the Addison’s Clinical Advisory Panel (http://www.addisons.org.uk/)


Download Resuscitation Council Guidelines (Revised December 2012)

http://www.resus.org.uk/pages/MEdental.pdf


  1. Management of the Anticoagulated patient


Pre-operatively
The risk of significant bleeding in patients on oral anticoagulants and with a stable INR in the therapeutic range 2-4, is low. The risk of thrombosis if anticoagulants are discontinued may be increased. Oral anticoagulants should not be discontinued in the majority of patients requiring out-patient dental treatment.
Individuals in whom the INR is unstable, should be discussed with their anticoagulant management team
In patients receiving long-term anticoagulant therapy and who are stably

anticoagulated on warfarin an INR check 72 hours prior to surgery is recommended.

This allows sufficient time for dose modification if necessary to ensure a safe INR (2-

4) on the day of dental surgery.


The INR should also be checked if performing an inferior alveolar nerve block (IANB)

as there is an anecdotal risk of haematoma and airway compromise. If needed, an

IANB should be given cautiously, using an aspirating syringe, with an INR <3.0.

Peri-operatively

The risk of bleeding may be minimised by the use of oxidised cellulose (Surgicel) or collagen sponges and sutures



Post-operatively

Patients taking warfarin should not be prescribed nonselective NSAIDs and COX-2 inhibitors as analgesics following dental surgery.


Drug interactions
Refer to BNF when prescribing the following to a warfarinised patient;

Amoxicillin, Clindamycin , Erythromycin (and other macrolides), Metronidazole , NSAIDs , Miconazole, Carbamazepine


Anti Platelet medications
Common anti-platelet drugs include asprin and clopidogrel. These do not need to be interrupted to perform minor oral surgery. When two anti-platelet drugs are being taken, local haemostatic measures may be prudent post extraction
Newer medications

Rivaroxaban and Dabigatran are relatively new oral anticoagulants that interfere with the clotting cascade. They can be prescribed in patients that have had pulmonary embolisms, deep vein thromboses and atrial fibrillation.

Care needs to be exercised when extracting teeth on these patients and it may be prudent to consult a haematologist for advice regarding their management. The overall outcome will be dependent on the patients overall risk to thrombo-embolic episodes.

Guidelines for the management of patients on oral anticoagulants requiring dental surgery

British Committee for Standards in Haematology, September 2011


http://www.bcshguidelines.com/documents/WarfarinandentalSurgery_bjh_264_2007.pdf


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