DTME0510

B efore providing any treat- ment, it is a clinician’s re- sponsibility to ask the right questions, in the right way, and to listen carefully to the patient’s re- sponses. If an important aspect of a patient’s history does not come to light in the consultation process, and problems arise as a result of this, attention tends to focus upon the clinical records and what they do (and do not) contain. In the ab- sence of any evidence that certain key questions were ever asked, it is extremely difficult to demonstrate at a later date that they were. If, on the other hand, there is a clear answer – perhaps in a medical history questionnaire which has been completed (and preferably, signed and dated) by the patient on a particular day, then there can be no doubt that the clinician asked the relevant question and was entitled to ing may be one such occasion. Such questions are sometimes called ‘closed’ questions bec- ause there is little or no oppor- tunity to obtain a more detailed reply from the patient. A direct ‘yes’ or ‘no’ is exactly what you are looking for. Closed questions can also be useful when deal- ing with patients whose answers tend to stray from the purpose of the question. Open questions These questions tend to be- gin with… What? Why? When? How? etc and because of this, they require the patient to pro- vide more information for you in their reply. This is often help- ful when dealing with less com- municative patients, or when you are hoping to gather infor- mation of a better quality, and in greater detail. ‘Why’ questions These questions, which are a specific kind of open question, can be extremely useful. They ‘Shopping list’ questions This approach is a little like a multiple-choice test, where you give the patient several possi- ble answers to choose from. For example ‘What makes the pain work from the assumption that the answer(s) given were correct. Four specific areas of the pa- tient’s history are worthy of par- ticular consideration in this brief overview: - • Medical history • Dental history • Personal/social history • History of the presenting com- plaint (if any) General observations Creating any history about a pa- tient is essentially an information gathering exercise. Specific tech- niques can usefully be employed to maximise the effectiveness of the process. The experienced cli- nician will choose between the available techniques according to the communication abilities of the individual patient that they are dealing with. Closed questions There are times when you need a definite ‘yes’ or ‘no’ answer to a specific question. The first stage of medical history screen- worse?... is it hot things?... or cold things?... or biting on the tooth?’... and so on. They can be use- ful when dealing with patients who seem not to understand the meaning of open questions and can thereby speed up the infor- mation gathering process. Leading questions These questions tend to be worded in such a way as either to suggest the answer or to invite a specific reply. For example ‘You have been wearing your appliance, haven’t you?’ They can be useful when trying to establish confidence and communication with a nervous, quiet, or uncommunicative pa- tient but are of limited value when seeking specific accurate informa- tion, or a more detailed reply. Medical history One of the first principles one learns at dental school is that of the importance of taking a detailed medical history before treating any patient. Most dental schools have their own design of medical history questionnaire, and this shapes the format, style and extent of any further questioning of the patient on particular points aris- ing from the medical history. Many practices, in similar fashion, take commendable care in designing and using their own medical history questionnaires which patients are asked to com- plete when attending the practice for the first time. In most cases the design provides for the patient to answer ‘yes’ or ‘no’, to a set of specific predetermined questions, and then to sign and date the com- pleted questionnaire. The dental surgeon then ensures that the patient has properly understood all of the questions (for example, where patients leave one or more answers blank), and where ‘yes’ answers have been given, further questioning of the patient will allow the details of any response to be clarified and expanded upon. Sometimes this highlights areas where further information needs to be gathered – perhaps by contacting the patient’s medical practitioner, perhaps by asking the patient to bring any medica- tion they are taking along to the next visit, so that the precise drugs and dosages can be identi- fied with certainty. In several recent cases, the patient’s medical history has been at the heart of negligence claims brought against dentists and other dental team members. It is crucially important, for ex- ample, to investigate the nature of heart murmurs, or other func- tional heart disease, in order to decide whether prophylactic an- tibiotics are indicated to prevent the risk of infective endocarditis. Infective endocarditis is a seri- ous and life-threatening disease, and most patients are left with permanent damage which has the potential to shorten their life and/or restrict its quality. Dam- ages in such cases are therefore very high indeed, often including a lifetime’s loss of earnings. Other recent cases have in- patient’s medical history. This can be a considerable embar- rassment when the patient has attended the same practice over a large number of years, and the practitioner is apparently still re- lying upon the patient’s original medical history details. It is self-evident that a pa- tient’s medical status is not static, and indeed, a patient’s medica- tion prescribed by others may change from visit to visit – it is prudent, therefore, to ensure not only that changes in medical his- tory (including medication) are regularly checked and updated, but also that this fact is clearly recorded as a dated entry in the patient’s clinical notes. volved, for example, a failure to take into account certain aller- gies to drugs (especially peni- cillin and other antibiotics), or to recognise the significance of long-term aspirin medication predisposing to postoperative bleedings, or to recognise the po- tential for drug interactions. Cases such as these often re- veal the fact that although a prac- titioner might have taken a com- prehensive medical history when the patient first attended as a new patient, this process has either not been repeated, or has been much more superficial, when the patient has returned for suc- cessive courses of treatment. In the majority of cases, no further written medical history question- naire is ever undertaken, and indeed there is rarely any note on the record card to confirm what (if any) further question- ing has taken place to update the Many practices take medical histories verbally and if no posi- tive or significant responses are elicited, an entry such as ‘MH – nil’ is made in the records. While better than nothing at all, this approach carries the disad- vantage that it can be difficult or impossible to establish precisely what questions were asked of the patient, in what terms, and what answers were given. Clearly, a well structured medical history questionnaire form, which is completed, signed and dated by the patient, and subsequently up- dated on a regular basis (ideally, during each successive course of treatment), is not only in the patient’s best interest, but is also the best platform for the success- ful defence of cases where failure to elicit or act upon a relevant as- pect of medical history leads to avoidable harm to the patient. In all cases, the taking and confirmation of a medical his- tory is the role of the dental sur- geon and is certainly a key part of a dentist’s duty of care. If in doubt, it may be sensible to defer treatment pending clarification of any areas of uncertainty in a patient’s medical history. Dental history However thoroughly it is carried out, any clinical examination is still only a snapshot of a pa- tient’s dental and oral tissues at a moment in time. While it will provide a lot of useful basic in- formation, the clinician’s under- standing of the patient’s present- ing condition is greatly improved by knowing how the patient reached the present position. • Is the patient a regular or irregular attender? • Is there a history of fractured teeth/fillings? • Are any teeth painful or sensitive? • If so, what causes any such sensitivity? • Do the patient’s gums bleed on tooth brushing or spontaneously? • Is the patient apprehensive about receiving dental care? • If so, do these concerns relate to any particular dental procedure(s) or to the experience in general? • Has the patient experienced any particular problems associated with treatment provided for them in the past? If so, what? ‘Any clinical exami- nation is still only a snapshot of a patient’s dental and oral tissues at a mo- ment in time’ • What treatment has been provided in the last five years? Not only will questions like those above help to inform the clinician regarding areas which may or may not need treatment, or which should be kept under review, they will also guide the clinician regarding the success (or failure) of treatment ap- proaches that have been tried in the past. If this knowledge helps the clinician to avoid repeating the previous mistakes of other clinicians, it can also help to avoid claims and complaints that might otherwise have resulted. Social history The social history should include details of employment (and in- terests, hobbies, etc) as well as other social and family related information. The patient’s occu- pation should be included in the consideration of relevant factors affecting diagnosis, treatment planning, consent and treatment, bearing in mind the fact that this is an aspect of a patient’s history that may change as time passes. It is worth establishing a routine of checking the patient’s contact details and employment, when carrying out a periodic update of the patient’s medical history. The ability to attend for ap- pointments could affect the success of complex or exten- sive treatment, eg crown and bridgework, implants, long term periodontal treatment and ortho- dontics. Certain occupations can place severe constraints on a pa- tient’s ability to attend regularly for appointments. Issues relating to a patients employment or recreational in- terests have also been known to have an impact on treatment: For example: • Bruxism in air traffic control- lers, marathon runners and certain other sports players Getting to know you A detailed history is an essential element in understanding the background to a patient’s oral health and planning effectively for their present and future treatment - Dental Protection Media CME DENTALTRIBUNE Middle East & Africa Edition6 2 Hours