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In-Hospital Care of the Dental Patient
Dental Admissions
Introduction
Both the medical health and the dental needs of patients must be considered when deciding on hospital admission. Hospital admission should be considered whenever the required treatment could threaten the patient’s well-being, or indeed life, or when the patient’s medical problems may seriously compromise the treatment.
Reasons for Admission
The reasons for admission to the hospital can be categorized into two groups: emergent hospitalizations, usually from the emergency department, or elective/scheduled hospitalizations for specific oral surgical or dental procedures.
Fractures of the Mandible/Maxillofacial Structures
Admission to the hospital is necessary for the management of multisystem injuries or injuries concomitant to mandible/maxillofacial fractures. It may be required for medically complex or special needs patients.
Infection
Admission is necessary if the patient has an infection that:
- Compromises nutrition or hydration (especially fluid intake, e.g., severe herpetic stomatitis in very young children, which might require hospitalization because of dehydration)
- Compromises the airway (e.g., Ludwig’s angina)
- Involves secondary soft tissue planes that drain or traverse potential areas of particular hazard and so are a danger to the patient (e.g., retropharyngeal or infratemporal abscesses)
Compromised Patients
Medically, mentally, or physically compromised patients who are insufficiently cooperative to be treated in an outpatient setting may be admitted to hospital for their procedure. This category includes patients who might require general anesthesia or deep sedation and/or appropriate cardiorespiratory monitoring during treatment (e.g., anxiety disorders).
Children
Young children who require treatment under deep sedation or general anesthesia because of the combination of poor cooperation and the need for a large number of dental procedures as a result of extensive caries and/or consequent infection may be admitted to the hospital.
Medical Consultations
Objectives
The objectives of medical consultations are to:
- Determine and reduce peri- and postoperative medical risk to the patient from the planned oral surgical/dental procedures
- Determine, and thus lessen or indeed prevent, the effects of the proposed surgery/procedures on any medical illness and limit possible post-procedure complications by managing and treating the patient’s underlying medical conditions
The Patient’s Medical History
The Admission Note
Introduction
There is an art to eliciting the correct, pertinent, and relevant information regarding a patient’s current medical and physical status. Taking an accurate, relevant, and concise medical history requires repeated practice and experience. The goal is to obtain sufficient information from the patient to facilitate the physical examination and, in conjunction with the examination, to arrive at a working diagnosis or diagnoses of the problem.
Old hospital records, if they exist, can be immeasurably helpful in providing information about past hospitalizations, operations (including complications), and medications, particularly if the reliability of the patient or guardian as an informant is in question.
- Record the patient’s positive and negative responses.
- Remember that the patient might not understand the need for, and value of, an accurate medical history in the dental setting.
- Be persistent and patient.
- Confirm the veracity of the information by reframing the questions (e.g., ask patients to list their current medical problems; a bit later ask for a list of their current medications; follow this up by asking the patient to detail what each specific drug/medication is used for).
- If you need to use an interpreter, try as much as possible to use a professional healthcare interpreter and not members of the patient’s family.
- If you need to gain consent for minors and intellectually impaired adults or elders, make sure that the person whose consent you gain (patient’s parent/guardian/caregiver) has the legal authority to provide consent.
Elements of the History
The following discussion of the components of the medical history is directed at providing a full and complete history. Often, a shorter form of the medical history is sufficient for a healthy patient admitted for routine care (e.g., extraction of teeth).
Informant and Reliability
Note the name of the person or material used to obtain the pertinent information (e.g., patient, parent, relative, medical/nursing record). Also note whether the informant was reliable—were your questions understood, was the informant coherent and knowledgeable, and how well does he or she know the patient?
Chief Complaint (CC)
Record what patients perceive to be the problem that brought them to the hospital. The patient’s own words should be used if possible.
History of Present Illness (HPI)
Make a chronologic description of the development of the chief complaint. Record the following:
- When the symptoms started
- The course since onset—the duration and progression
- Whether the symptoms are constant or episodic (if episodic, note the nature and duration of any periods of remission and exacerbation)
- The character of the symptoms (e.g., sharp, dull, burning, aching) and severity (e.g., impact on daily living)
- Any systemic signs and/or symptoms (e.g., weight gain or loss, chills, fever)
- Previous diagnoses and the results of previous trials (success, partial resolution, or unsuccessful) with treatment and/or medication related to the chief complaint
Past Dental History
You now need to gather as full a past dental history as possible. Ask the patient about:
- Previous oral surgery, orthodontics (age, duration), periodontics, endodontics (tooth, date, reason), prosthetics, other appliances, oral mucosal problems (e.g., secondary herpes, aphthae), dental trauma
- Frequency of dental visits (regular or emergency only)
- Frequency of dental cleanings (when were the patient’s teeth last cleaned?)
- Experience with local anesthesia/sedation (if possible, find out what type was used) and general anesthesia (e.g., allergy, syncope) (Appendix 12, Table A12-7)
- Experience with extractions—was there postoperative bleeding or infection? How well did they heal?
- History of pain, swelling, bleeding, abscess, toothaches
- Temporomandibular joint—history of pain, clicking, subluxation, trismus, crepitus
- Habits including nail-biting, thumb-sucking, clenching, bruxing, mouth-breathing
- Fluoride exposure—was this systemic or topical?
- Home care—brushing method and frequency, instruction, floss or other aids; caregiver assistance required?
- Food habits/diet—ask about form and frequency of sucrose exposure (including liquid oral medicines). For children, the history and frequency of bottle and breastfeeding as well as between-meal snacking should be included. Find out about nutritional supplements (form and consistency), liquid diets, tube feedings
- Problems with saliva (hyper-/hypo-salivation) chewing, speech
- Negative dental experiences
Past Medical History (PMH)
Direct questioning is probably the best way to elicit the patient’s past medical history.
Ask the patient “Are you being treated for anything by your doctor at the moment?” If the answer is “Yes,” ascertain how severe the condition is (the extent to which it interferes in daily living activities) and how stable it is. A severe condition (e.g., angina) might prove not to be a significant hindrance to planned dental treatment as long as it is well managed and stable. However, a patient with unstable angina should not be treated until the angina is stabilized, or if this is not practical, treatment should be planned while the patient is monitored, and possibly lightly sedated, to minimize stress and anxiety.
Ask the patient “Have you been treated in the past, or are you currently being treated for any of the following”:
- Rheumatic fever, heart murmurs, infective endocarditis, angina, heart attack, or an irregular heart beat
- Asthma, emphysema, hay fever, or allergic rhinitis or sinusitis
- Epilepsy, stroke, or nervous or psychiatric conditions?
- Diabetes or thyroid conditions
- Peptic or gastric ulcer disease or liver disease (e.g., hepatitis or cirrhosis)
- Kidney problems: Obstruction, stones, or infection
- Urinary problems: Obstruction or infection
- Gynecologic or “women’s” problems. Ask, “Are you pregnant?”
- Rheumatoid or osteoarthritis, osteoporosis, back or spinal problems
- Skin cancer or rashes
- HIV
- Infection requiring antibiotics
- Ask “Do you have a prosthetic valve or joint?”
If the patient is currently receiving treatment for cancer, find out the mode and schedule of treatment (surgery, chemotherapy, or radiotherapy). Finally, ask if the patient has ever required a blood transfusion or other blood products (platelets, plasma, or clotting factors).
Review of Systems
As part of the past medical history, you need to question the patient systematically about all of the body systems. It is often possible to obtain significant additional symptoms or information not elicited in the discussion of the patient’s past and present illness. A positive (“yes”) response should be probed in depth and significant negatives (“no”) must also be noted.
General
This includes weight loss or gain, anorexia, general health throughout life, strength and energy, fever, chills, and night sweats.
Cardiovascular
This includes palpitations, chest pain or pressure with or without radiation, orthopnea (number of pillows), cyanosis, edema, varicosities, phlebitis, and exercise tolerance.
Respiratory
Ask about cough, sputum production (taste, color, consistency, odor, amount/24 hours) hemoptysis, dyspnea, wheezing, cyanosis, fainting, and pain with deep inspiration.
Neurologic
Questions about this system should include loss of smell, taste, or vision; muscle weakness or wasting; muscle stiffness; paresthesia; anesthesias; lack of coordination; tremors; syncope; fatigue; aphasias; memory changes; and paralysis.
Psychiatric/Emotional
Ask about general mood, problems with “nerves,” bruxism/ clenching, habits or tics, insomnia, hallucinations, delusions, and medications. Ask children about sleeping patterns and night terrors/nightmares.
Endocrine
This includes goiter, hot/cold intolerance, voice changes, changes in body contours, changes in hair patterns, polydypsia, polyuria, and polyphagia.
Gastrointestinal
Questions about this system should include appetite; food intolerance; belching; indigestion and relief; hiccups; abdominal pains; radiation of pain; nausea and vomiting; hematemesis; cramping; stool color and odor; flatulence; steatorrhea; diarrhea; constipation; mucus in stools; hemorrhoids; hepatitis; jaundice; alcohol abuse; ascites; and ulcers.
Genitourinary
This includes urinary frequency (day and night), changes in stream, difficulty starting or stopping stream, dysuria, hematuria, pyuria, urinary tract infections, impotence, libido alterations, venereal disease, genital sores, incontinence, and sterility.
Gynecologic
Ask about gravida/para (pregnancies/live births) and complications, abortions or miscarriages, menstrual history, premenstrual tension, painful or difficult menstruation (dysmenorrhea), bleeding between periods, clots of blood, excessive menses (menorrhagia), frequency, regularity, date of last period, menopause (date, symptoms, treatment), postmenopausal bleeding.
Breasts
This includes development, lumps, pain, discharge, and family history of breast cancer.
Musculoskeletal
Questions about this system should include trauma, fractures, lacerations, dislocations with decreased function, arthritis, inflamed joints, arthralgias, bursitis, myalgias, muscle weakness, limitation of motion, claudication, and gait.
Dermatologic
Inquire about hair or nail changes, scaling, dryness or sweating, pigmentation changes, jaundice, lesions, pruritus, biopsies, piercing, and tattoos.
Head, Eyes, Ears, Nose, Throat (HEENT)
Questions should include:
- Head: Headache, fainting, vertigo, dizziness, pains in head or face, and trauma
- Eyes: Vision, glasses, trauma, diplopia, scotomata, blind spots, tunnel vision, blurring, pain, swelling, redness, tearing, dryness, burning, and photophobia
- Ears: Decreased hearing or deafness, pain, bleeding or discharge, ruptured ear drum, clogging, and ringing
- Nose: Epistaxis, discharge (amount, color, consistency), congestion, colds, change in sense of smell or taste, and polyps
- Mouth and throat: Pain, sore throat, dental pain, dental hygiene history, bleeding or painful gums, sore tongue, lesions, bad taste in mouth, loose teeth, halitosis, dysphagia, temporomandibular joint dysfunction, trismus, hiccups, voice changes, neck stiffness, nodes or lumps, and trauma
Hematologic
This includes increased bruising, bleeding problems, nodes or lumps, and anemia.
Family History
Find out what illnesses the patient’s grandparents, parents, siblings, and children have/had. If any of these relatives are dead, at what age did they die and what was the cause? Ask about family history of tuberculosis, diabetes, heart disease, hypertension, allergies, bleeding problems, jaundice, gout, epilepsy, birth defects, breast cancer, and psychiatric problems.
Social History
Ask about the patient’s home life, education, occupational history (including military, if applicable), family closeness, domestic violence, normal daily activities, financial pressures, sexual relationship(s), recreational drugs use, and tobacco and alcohol history. A good question to ask is “What will you do when you get better?”
History for Pediatric Patients (Infants and Children)
Generally, history taking is similar for a pediatric patient as for an adult patient. However, unlike the adult history, much of the history for a child is taken from the parent or guardian. If the child is old enough, it is a good idea to interview the child as well. There are two basic rules when interviewing children: Do not ask too many questions too quickly, and use age-appropriate language. Special emphasis should be placed on the following areas.
Prenatal and Perinatal History
Was the child full term or premature? Were there any complications during pregnancy? What was the perinatal course:
- Hospitalizations: Reasons and dates
- Operations: Procedures and dates, including anesthetic used and any complications
- Allergies: Medications, foods, tapes, soaps, and latex. Include a note on the type of reaction. Be careful to differentiate between true hypersensitivity/allergy reactions and adverse side effects
- Medications past and present: Dose and frequency, prescription and over-the-counter (including topical agents)
- Potential exposure to dangerous or easily transmissible infections: Tuberculosis, venereal disease, hepatitis, flu, HIV, and prion disease (UK)
- Maternal immunizations: Tetanus, rubella, hepatitis
- Transfusions
- Trauma
- Diet while pregnant
- Maternal habits: Alcohol intake, tobacco, and recreational drugs
Postnatal History
It is also important to look into:
- Immunization status: Is the child up to date with immunizations?
- Infection: Has the child had recent exposure to childhood infections (e.g., cold, flu, chickenpox, rubella, or mumps) because this may be sufficient cause to postpone elective surgery. Also ask about acute otitis history.
- Nutrition: Was the child bottle- or breastfed? What was the frequency and duration of feedings? At what age was the child weaned? Does the child have any food allergies? Is there any history with fluoride?
- Personal or family history of complications from general anesthesia.
- Growth and development: attainment of developmental milestones (physical, cognitive, social and emotional, speech and language, and fine and gross motor skills).
- School status.
- Significant febrile episodes in early childhood.
- Social history: What is the home environment (e.g., smokers at home, pets, main caregiver)? What are the parental arrangements and custody, sequence of patient among siblings, siblings (number, ages, health status, social arrangements [e.g., living at home])?
Physical Examination
Introduction
Depending on training and dental practice laws, dentists might be responsible for completing a full physical examination when admitting a patient. The admitting dentist will certainly be responsible for the detailed examination of the oral cavity and must be able to interpret the results of the history, physical examination, and laboratory tests. Whenever possible, the physical examination should be completed in a systematic manner, so that nothing is omitted, although physical limitations of the patient might preclude this.
Elements of the Physical Examination
Start the physical examination by giving a statement of the setting in which the examination was performed and a gauge of the reliability of the examination (i.e., whether you were able to perform a full exam).
General Inspection
Note the patient’s apparent age, race, sex, build, posture, body movement, voice, speech disorders, nutritional/hydration status, and facial or skeletal deformities or asymmetries.
Vital Signs
- Pulse: If irregular, measure the apical pulse and note its beat as “regularly irregular” or “irregularly irregular.”
- Blood pressure: Take in both arms with the patient sitting, supine, and standing.
- Temperature: Note the site at which the temperature was recorded.
- Respiratory rate.
- Height, weight (for a child record the percentile height/weight).
- Global pain score on a scale of 1 to 10 (1 = no pain and 10 = worst possible pain).
Integument
Note the color/pigmentation, texture, state of hydration (turgor), temperature, vascular changes, lesions, scars, hair type and distribution, nail changes, tattoos, and piercing.
Head, Eyes, Ears, Nose, Throat
- Head: Note the size (normally noted as normocephalic) and palpate for swelling, tenderness, injuries, and symmetry. Take an actual measurement of the circumference in centimeters in children.
- Eyes:
- Visual acuity: If corrected, the degree should be estimated
- Periorbital tissues: Edema, discoloration, and ptosis
- Exophthalmos/enophthalmos
- Conjunctiva and sclera: Pigmentation, dryness, abnormal tearing, lesions, edema, hyperemia, and icterus
- Oculomotor: PERRLA (pupils equal, round, react to light and accommodation), EOMI (extraocular movements intact) or gaze restricted, nystagmus, and strabismus
- Fundoscopy: Optic disc (size, shape, color, depression, margins, vessels), macula, periphery, light reflexes, exudates, and edema
- Ears: Hearing (watch tick, hair manipulation, whisper, Rinne and Weber tests when indicated), external auditory canal, tympanic membranes, mastoids, wax, and discharge
- Nose: Septum (position, lesions), discharge, polyps, obstruction, turbinates, and sinus tenderness to palpation (if necessary, transilluminate)
- Mouth and throat:
- Lips: Color and lesions
- Teeth: Hygiene, decayed, missing or filled teeth, mobility, prostheses, and occlusion. Record the developmental status in children (primary, mixed) and whether this is appropriate for the chronological age (Appendix 22).
- Gingiva: Color, texture, size, bleeding, lesions, and recession
- Buccal mucosa: Color, lesions, and salivary flow from parotid glands, Stensen’s ducts
- Floor of mouth: Color, lesions, and salivary flow from submandibular/sublingual glands, Wharton’s ducts
- Tongue: Color, lesions, papillary distribution or changes, movement, and taste (if indicated)
- Hard and soft palate: Color, lesions, deformities, petechiae, and movement of soft palate
- Oropharynx: Tonsillar pillars, color, lesions, and gag reflex
- Temporomandibular joint (TMJ): Click, pop, crepitus, tenderness, and trismus from a variety of problems (e.g., infection, micrognathia, scleroderma, arthritis)
- Muscles of mastication: Tenderness and spasm
Neck
- Lymph nodes: Deep cervical, posterior cervical, occipital, supraclavicular, preauricular, posterior auricular, tonsillar, submaxillary, sublingual, and submental
- Trachea: Position and movement with swallowing
- Thyroid: Size, consistency, tenderness, mobility, masses, and bruits
- Throat/neck: Dysphagia, carotid bruits, jugular venous distention (JVD), and hoarseness
- Cervical spine: Mobility, posture, pain, and muscle spasm
Thorax
- Observation: Symmetry, size, scars, shape, anteroposterior dimension, and respiratory excursions
- Percussion: Resonance or dullness and where located, and tactile fremitus
- Auscultation: Breath sounds, stridor, wheezing, rales, rubs, rhonchi.
Breasts
See Box 1.1.
- Size
- Symmetry
- Lesions
- Stippling
- Discharge
- Masses
- Tenderness
- Tanner stage (in children and adolescents)
- Gynecomastia (in males)
Box 1.1. Sensible Precautions When Examining a Patient
The breast and genetourinary examinations are routinely deferred. Make sure that a chaperone is present during the examination.
Cardiovascular
- Point of maximal impulse (PMI): Inspect and palpate for PMI, noting location and character, thrills, and heaves.
- Auscultate: Note ate and rhythm (regular vs. irregular), murmurs, friction rubs, gallops, and other abnormal sounds. When indicated, changes in heart sounds with exercise or change of position should be noted.
- Edema: Note location, degree, extent, tenderness, and temperature.
- Arteries: The carotid, superficial temporal (facial), brachial, radial, femoral, ulnar, popliteal, posterior tibial, and dorsalis pedis pulses should be palpated for strength, character, and equality.
- Veins: Note pressure, varicosities, cyanosis, rubor, and tenderness.
Abdomen
- Appearance: Size, shape, symmetry, pigmentation, and scars
- Auscultation: Bowel sounds, peristaltic rushes, and bruits
- Percussion: Note borders of organs and fluid, areas of tympany, hyperresonance, dullness or flatness, shifting dullness, and tenderness
- Palpation: Size of the abdominal aorta and pulsations, liver, spleen, kidneys, masses, fluid wave, tenderness, guarding, rebound tenderness, hernia, and inguinal adenopathy
Genitalia (When Appropriate)
See Box 1.1.
Male
Note development, penile scars or lesions, urethral discharge, testes descended, hernia, tenderness, masses, and circumcision.
Female
- External examination: Hair, skin, labia, clitoris, Bartholin’s and Skene’s glands, urethral discharge, vaginal discharge, and lesions
- Internal examination: Cervix, uterus, ovaries (masses, tenderness, lesions), and indication of pregnancy
Anorectal
Record hemorrhoids, skin tags, fissures, rectal sphincter tone, masses, strictures, character of stool, and guaiac stool. In males, prostate size, consistency, nodularity, and tenderness should also be noted.
Extremities
Note proportions (to each other and to entire body), amputations, deformities, finger clubbing, cyanosis, koilonychia, edema, erythema, enlargement, tenderness, range of motion of joints, cords, muscle atrophy, strength, swelling, spasm, and tenderness.
Spine
Note alignment and curvature, range of motion, tenderness to palpation and percussion, and muscle tone.
Neurologic
- Appropriateness; alertness; orientation to person, place, time, and situation; recall for past and present. For adults aged 55 and older whose responses to questions seem inconsistent, the Mini Mental State Exam (MMSE) can be used to check the possibility of dementing illness or other insidious, progressive cognitiv/>
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