It is difficult to overstress the importance of a good history and thorough clinical examination for every patient. It is on this that the diagnosis is made and the treatment plan based. A full, clearly written record of the original consultation is essential to assess progress following treatment. This is par­ticularly true if a colleague should be called to see the patient in the practitioner’s absence. The medico-legal importance of accurate records cannot be overemphasised.

In hospital and specialist practice this procedure can seldom be relaxed, but the student and the busy practitioner may find it irksome to maintain a high standard when faced with a series of apparently straightforward dental conditions. Nevertheless, sufficient time must be allowed for an unhurried consultation at the first visit. This will help to avoid errors of omission, and may contribute much to the success of treatment and to the interest of the practitioner. With experience, only important facts need be noted, the dental surgeon considering and setting aside the irrelevant points. This technique can be used with safety only after a long apprenticeship during which many histories and examinations have been methodically completed and all the information recorded. In this chapter a system for interviewing and examining patients, and recording findings, is briefly suggested.

History

At the first meeting it is important for the clinician to establish a rapport with the patient and to assess attitudes to the clinical situation. Behavioural issues must be addressed, attempting to put the patient at ease in what is for many a confrontational situation. The interview must be planned to facilitate the process, seating the patient comfortably, adjusting the chair as required to show care, as well as addressing them by the correct name and title. Even at this stage it should be possible to determine whether the patient is anxious or relaxed. The general details of age, sex, marital status, occupation and contact details, together with the names of their general medical and dental practitioner, should be available in the notes but can be checked. The history is then recorded under the headings shown in italics.

The patient will seldom tell their story well. Some will be verbose, others reticent, while the sequence is usually in inverse chronological order with the most recent events first. The art of the good history lies in avoiding leading questions, in eliciting all the essentials, in censoring verbosity and in arranging the facts in their true order, so that the written record is short and logical. Allowing the patient initially to give the history and subsequently writing notes in chronological order while rechecking and summarising the facts verbally, helps the clinician obtain a concise and accurate account of the patient’s symptoms.

Patient Referred By

The name and professional status of the person referring is noted. This facilitates a reply to the referral in the form of a letter.

Complains of (CO)

The patient’s chief complaint told in their own words. Opinions, professional and otherwise, repeated in an effort to help must be gently set aside and the patient encouraged to describe the symptoms they want cured, and not their views on the diagnosis.

History of Present Complaint (HPC)

This is an account in chronological order of the presenting complaint. When and how it first started, the suspected cause, any exacerbating factors and the character of the local lesion, such as pain, swelling and discharge. This includes remissions and the effects of any treatment received. General symptoms such as fever, malaise and nausea are also noted.

Previous Dental History (PDH)

This records how regularly the patient attends for dental care and the importance they attach to their teeth. Any past experience of oral surgery is included, especially where difficulty occurred in the administration of anaesthetics, the extraction of teeth and the control of bleeding.

Medical History (MH)

A summary in chronological order of the patient’s past illnesses. Details of prolonged illness or those requiring hospital admission are recorded. Current medication, which can give insight into the severity of any underlying conditions, and allergies of any kind, particularly drugs that might be prescribed and latex, must be noted. The more important medical conditions are discussed in Chapter 3.

The Family History (FH)

Occasionally this is of importance in oral surgery. Hereditary diseases such as the haemophilias and hypodontia together with autoimmune disease may be relevant in management of the patient.

The Social History (SH)

This includes a brief comment on the patient’s occupation and social habits, such as exercise, smoking and drinking. The home circumstances are important when surgery is to be performed – that is, whether the patient has far to travel, lives alone or has someone to look after them. These factors may influence the decision to treat as an in- or outpatient.

Principles of Examination

The basic principles of examination are the same in all fields of healthcare. It should be made according to a definite system, which in time becomes a ritual. In this way errors of omission are avoided.

From the moment the patient enters the surgery they should be carefully observed for signs of physical or of psychological disease which may show in the gait, the carriage, the general manner, or the relationship between parent and child. Too little time is often spent on visual inspection, both intra- and extraorally. Eyes first, then hands, should be the rule, not both together.

In palpation, all movements are purposeful and logical, and the touch firm but gentle. The tips of the fingers are used first to locate anatomical landmarks and then to determine the characteristics of the pathological condition. The patient’s co-operation is sought so that areas of tenderness may be recognised and the minimum discomfort caused. Wherever possible the normal side is examined simultaneously. Only by such comparison can minor degrees of asymmetry be detected. Swellings situated in the floor of the mouth or in the cheek are felt bimanually with one hand placed inside, and one outside, the mouth. Both positive and negative findings are written down as later one may wish to check that at the first visit no abnormality was found in certain structures.

Systematic Procedure for Examination of the Oro-Facial Tissues

Extraoral Examination

This commences with/>