2. This is the most important part of any medical consultation request
It establishes, for the physician or other HCW, that you have been careful
Taking a thorough patient history
Assessing the patient’s simple or complex medical status, AND MOST IMPORTANTLY
3. That you have appropriately analyzed the significant medical factors in the patient’s history and FORMULATED A SPECFIC SET OF RELEVANT QUESTIONS.
4. All medical consultations should be narrowly tailored to ask specific medical management questions that call for specific objective answers.
5. Only if the objective data is particularly open to a fairly wide range of clinical judgment, should an opinion on that objective data be expressly requested by the dentist and given by the consulting physician or other HCW.
6. Better medical consultations identify the dental management problem for the physician to consider, in the first line of this section, and then suggest a specific management approach to be used to ameliorate the problem.
7. Example: 72 y.o. AA female è h/o MI x 3, CABG, and A-fib, on Coumadin.
a. Must have patient’s
INR 2.0-2.5 to proceed. If pt.’s INR is higher, we would normally D/C Coumadin 2 days prior to tx, do stat PT/INR the AM of tx, and resume Coumadin at the next scheduled dose. OK?
Please report the pt.’s most recent INR and advise.
8. It is extremely important that a medical consultation reflects the patient’s comprehensive needs so that repeated consults are not required because the dental practitioner failed to think through potential medical complications which may arise with different modalities of treatment.
9. Telephone consults are strongly discouraged!
They should be limited to clarification of the physician’s recommendation, if it is illegible or contrary to regular regimens employed throughout Dentistry or Medicine.
For example, chronic renal failure patients on hemodialysis may require a different antibiotic for SBE prophylaxis, and/or a different dosing regimen than other patients.
A contemporaneous note in the chart should summarize this clarification of the initial consult.
D. The following patients may be unable to reliably relate their medical histories:
2. Those suffering dementia or Parkinson’s disease
3. Developmentally Challenged; Special Needs Patients
4. Mentally Disable (psychosis patients)
5. In these cases, the only reliable method for determining relative safety to treat is the Complete Physical Examination findings.
6. The Complete Physical Examination
7. Interpreting the Findings for Relative Safety to Treat the Dental Patient
8. Who Cannot Reliably Relate a Medical History.
OUTLINE OF PHYSICAL EXAMINATION (H&PE) 1. Vital signs: Temperature, pulse, blood pressure (both arms), respiratory rate. These observations need not be repeated under their respective subheadings.
2. General appearance: state of orientation; development, state of nutrition, degree of discomfort, cooperativeness, other conspicuous general characteristics of appearance (including dress, neatness, behavior, gait and posture).
9. Neck; stiffness, masses, venous distention, abnormal pulsations, thyroid, position of trachea; carotid bruits.
10. Lymph nodes: size, consistency, tenderness, and mobility of cervical, supraclavicular, axillary, inguinal. (All nodes may be described here, or the regional nodes may be described with appropriate areas as examined.)
11. Thorax: configuration, AP diameter, symmetry, and amplitude of motion.
Breasts: masses, tenderness, discharge from nipples, areolae.
Joints: swelling, effusion, deformities, tenderness, increased warmth, mobility. Clubbing, cyanosis, edema. Calf tenderness, Homan's sign. Character and equality of radial, femoral, posterior tibial and dorsalis pedis pulses; sclerosis of arterial walls; abnormal venous structures (varicosities, telangiectases).
17. Neurological: A limited or screening neurological examination is part of every routine physical examination. When positive findings make a more complete study necessary, the complete examination is done. Mental status; gait and station, abnormal movement; cerebellar signs; cranial nerves; muscle strength, atrophy, fasciculations; sensation: touch, pain, vibration, position sense; reflexes: (biceps, triceps, Hoffman, abdominals, cremasterics, knee jerks, ankle jerks, plantar); meningeal irritation (nuchal rigidity, Kernig's sign).
b. Female: speculum examination of vagina and cervix, palpation of uterus and adnexa. papa smears, culture when indicated.
19. Rectal: External hemorrhoids, fissures.
Digital: Sphincter, hemorrhoids, prostate, seminal vesicles (or uterus and cervix), Feces (description of gross appearance) and test for occult blood.
Concise summary of relevant points in history and physical examination.
This is intended to alert the reader to the basis on which the diagnoses were made and the direction in which the work-up will process.
It is a statement of what the leading diagnoses are, which diagnoses you favor and why, how you will differentiate between the likely diagnoses and a general approach to therapy, if there is a presumptive diagnosis.
Diagnosis: Plans for further investigation and management:
INTRODUCTION TO TREATMENT PLANNING
FORMAT FOR COMPREHENSIVE TREATMENT PLAN WORK UP I. History (S)
A. Chief Complaint (CC)
1. It should be a symptom - record the patient’s impression of disease/problem in his/her own words.
B. History of Present Illness (HPI)
1. Record details of chief complaint and related complaints - history of chief complaint.
C. Past Medical History (PMH)
1. Record health history of systemic conditions, injuries, and hospitalizations in detail - medical consultation is present, if indicated.
a. Childhood diseases
b. Serious illnesses/transfusions
c. Family health history which may bear on patient’s present or future health status
2. Allergies and sensitivities
3. Current medications
4. Review of systems (ROS)
D. Environmental/social history
1. Describe in detail any environmental factors that could impact on diagnosis and treatment planning, i.e., alcohol intake, tobacco usage, vocation, finances, etc.
E. Dental History
1. Describe in detail the patient’s awareness of and involvement in previous dental treatment.
2. Family dental health history (parents, siblings, spouse, children)
3. Oral hygiene habits
II. Examination - Findings; list problems requiring attention, all of these must be addressed in TX sequence; charting must be complete - (O)
A. List general observations and systemic findings - age, vital signs, skin, limbs, development nutrition.
B. Record oral and extraoral findings: perform a thorough examination of the head, neck, face, and oral tissues.
1. Head, neck, eyes, ears, nose, skin and secretions
2. Lips, oral mucus, palate, pharynx, tongue and floor of mouth
3. Gingival - color, texture, consistency, contour, amount of keratinized tissue, bleeding; details of periodontal condition on appropriate form
4. Occlusion/musculature - a general statement of condition; details on appropriate form
5. Dentition - a general statement of condition; details on appropriate form
6. Oral hygiene - a general statement of condition; details on appropriate form
C. Radiographic Findings
1. Obtain indicated radiographs which may include the following:
a. periapical films (full mouth survey)
b. posterior bitewing films
c. panoramic film
d. any necessary supplemental films
D. Microscopic - if indicated, obtain a phase contrast evaluation of microflora
NOTE: The case is mounted on an articulator, all required radiographs,
laboratory and clinical tests are obtained.
III. Diagnosis - (A)
A. List disease processes and abnormalities that address all pertinent findings.
1. Systemic diagnosis
2. Dental diagnosis
IV. Treatment Objectives - (A)
A. Make a general statement of the desired goals of treatment taking into account the findings, the patient’s situation and the resources of the practitioner. List considerations:
1. Patient health
2. Patient desires
3. Patient age
4. Patient financial restraints
5. Prognosis (long and short term)
6. Provider skills
B. Devise ideal (long-term) treatment objectives and immediate objectives (if applicable) that will support the ideal; formulate a segmented (progressive) treatment plan. Discuss all treatment options with the patient.
C. All fees for all treatment must be listed when the treatment plan is presented to the patient.
V. Planned Treatment Sequence - (P)
(The Written Treatment Plan)
A. A planned, well organized sequence of treatment is listed according to treatment phases that addresses all diagnosis and pertinent findings; materials to be used and alternate treatment plans are listed; best treatment plan for that individual patient is presented.
B. Order of treatment (Enter Each Phase - e.g., If N/A Enter “Phase 1 - N/A”)
1. Systemic phase
Systemic health considerations. Consult with physician when in doubt. Determine need for premedication, diet, precautions to protect patient and dental team, etc.
2. Urgent phase
Treat problems of acute pain, bleeding, lost restorations, etc.
3. Hygienic phase (most import phase - steps necessary to control disease) for this specific patient generally in the order listed:
a. Patient education and instruction in plaque control; fluoride program
b. Biopsies if necessary
c. Preliminary gross scaling - if necessary
d. Caries control, and endodontic therapy
e. Extraction of hopeless teeth. Temporary CPD’s and RPD’s if
f. Root planning
g. Maintain plaque control
h. Preliminary occlusal adjustment if indicated
I. Minor tooth movement/orthodontic treatment
j. Occlusal splints if indicated
k. Definitive occlusal adjustment when necessary
l. Continuous evaluation of oral hygiene and tissue response, and reassessment of the entire treatment plan
b. Periodontal surgery, bone and soft tissue grafting
c. Treatment of hypersensitive teeth
e. Restorative dentistry (should wait at least two months following extensive surgery)
f. Recheck and refine occlusion
5. Maintenance phase:
a. Re-examine for effectiveness of plaque control, recurrence of periodontal disease, caries, and occlusal problems: reinforce oral hygiene instruction, perform prophylaxis including topical fluoride application. Recall based on the specific patient’s needs.
b. Complete periodic radiographic survey of the dentition if indicated. Compare with prior radiographs
c. Recheck prosthetic treatment
d. Treatment of any active periodontal disease
e. Treatment of recurrent carious lesions
f. Endodontic therapy if pulpal and/or periapical lesions have developed or not resolved
g. Replacement of restorations which no longer satisfy health, function or esthetic requirements
h. Make new occlusal splints when old ones are broken down, worn out or lost
1. State a prediction, based on an educated calculation, of the response of hard and soft tissue to the treatment planned, both long and short term.
VII. Signing the Treatment Plan
1. The patient must sign the treatment plan prior to any treatment being rendered. This is to establish that the patient accepts the treatment plan. The resident and
faculty member should also sign the treatment plan.