Triaging Consultations

Consultations (consults) should be prioritized, or “triaged,” on their degree of urgency. For example, trauma, hemorrhage, and infection, particularly in immunosuppressed patients, should be considered urgent requests for dental services and should be addressed as soon as possible. For non-acute consultation requests, an answer within 24 hours is acceptable, and a response on the same day is ideal. This might be specified in the hospital or departmental staff by-laws or policy manual.

The Different Types of Consultations

Whether seeking or responding to a consultation request, there are different types of consultations:

• Opinion only; for example:
  • A cardiology consult may be requested for management assistance in a patient with extensive valvular disease at risk for infective endocarditis after an invasive dental procedure.
  • A dental consult may be requested concerning the immediate need or timing for a dental treatment for a hospitalized patient.
• Opinion and treatment of a specific problem: This request is problem-specific and does not require comprehensive care for the patient.

Examples of Medical or Surgical Services

• Neurology/geriatrics for further assessment in the event of suspected dementia
• Internal medicine to assist in medical management of patients
• Anesthesiology for pre-general anesthesia assessment
• Specialist surgical services, especially for patients requiring general anesthesia to provide their dental care, but who also need other semi-elective surgical procedures under general anesthesia
• Psychiatry or psychology to assist in behavioral management issues, to address concerns regarding potential interactions with ongoing psychoactive medication regimens, and to assess suspected depressive illness
• Diabetic services to assist with diet issues and establishing appropriate glycemic control with appropriate diet control

Other Clinical Services Consulted as Dictated by the Patients’ Needs

• Physical therapy for advice regarding such issues as assistance in transferring a patient between bed, gurney, wheelchair, and dental operatory, and addressing physical rehabilitation related to temperomandibular joint dysfunction management and/or post intermaxillary fixation
• Occupational therapy to assist in the selection and fabrication of adjunctive oral health devices for patients with impairment of hands and arms
• Speech therapy for appraisal of suspected swallowing dysfunction or other oral motor function (e.g., speech, mastication). Also to assist in improving communication with an aphasic patient
• Pharmacy for advice regarding medication dose adjustments (e.g., patients with renal insufficiency/failure or liver dysfunction) and drug interactions
• Social work to assist in communicating with a patient’s family and other healthcare institutions, social services, and health financial services
• Nutrition/dietary to assist in nutritional assessment and planning and supplementation (e.g., soft diet) for newly edentulous patients

Where Are You Going to Undertake Your Assessment of the Patient?

Does this examination need to take place bedside or can the patient be transferred to your department, with all the advantages of a dental chair, equipment (lights and mirrors), and access to radiographic equipment? Some patients clearly are not fit to be easily, or safely, transferred and are best seen bedside. For example:

• Patients on respiratory or neutropenic precautions
• Intubated patients, or those requiring intensive cardiopulmonary monitoring
• High-risk pregnant patients on strict bed rest
• Patients with significant physical impairment

When in doubt, examination should be conducted at the patient’s bedside. Patients should almost never be brought to the dental clinic before reviewing the medical chart and seeing them bedside to ensure that there is no risk to the patient or dental clinic staff.

Bedside Oral Examination

Ensure that you have all the necessary equipment when conducting a bedside oral examination. Most medical/surgical wards stock gloves and tongue blades, but not a good source of light (headlight or flashlight) or dental mirrors. For minors and intellectually impaired people, consider having a member of the clinical staff of the hospital as a chaperone present for your interview and examination.

Patient Transport and Escorts

For patients sufficiently healthy and mobile to be seen in your office, ensure that they are transported in a wheelchair, if appropriate, with their medical chart. Patients in wheelchairs are easier to examine and radiograph than if they are on a stretcher. Prior to their transfer, check if they have any intravenous fluids running or if they require continuous oxygen. Patients receiving medication intravenously, such as chemotherapy or antibiotics, or who are in constant need of oxygen, might require hospital transportation or a nurse escort both for transportation and for the duration of their visit to the dental clinic. This may be mandatory for patients with airways compromise, such as intermaxillary wiring or fixation.

Priority: The Patient’s Point of View

A request or problem that might seem mundane to the dentist (e.g., an ill-fitting denture, chipped front tooth) can be a major concern and source of distress to the patient, the family, or the referring physician. Such requests also provide an opportunity to perform an oral examination on a patient who might not otherwise be seen by a dentist on a regular basis.

Reviewing the Patient’s Records

The patient’s records should be reviewed thoroughly. Note significant points in the medical history and hospital course. A concise but thorough note should be written, and significant findings and recommendations might need to be discussed with the physician verbally in addition to their inclusion in the written response. Effort should be made to minimize or eliminate dental jargon or terminology to ensure that the reader fully comprehends the response (e.g., “quadrant,” “ortho,” “endo,” and “apex” mean very different things to physicians and dentists).

Avoid making recommendations that create work for the consulting physician (e.g., ordering/acquiring radiographs, oral debridement of blood clots, arranging appointments with the dental office).

Findings and treatment should be discussed with relevant members of the patient’s family, if appropriate, and with the family dentist whenever possible.

Clarify who will perform any dental treatment that proves necessary, and who will be responsible for follow-up care.

Urgent/Acute Consultation Requests

Dental Consult 1: Dental Trauma Following Motor Vehicle Collision (MVC), Risk of Aspiration

Comments

• Note that the description of the intraoral findings uses as little dental jargon as possible for the benefit of the physicians and nurses caring for this patient, but that there is a thorough baseline documentation of significant positive and negative findings.
• Significant negative findings (e.g., lack of jaw deviation, tenderness, occlusal disharmonies, mobile segments) are especially important in the evaluation of the maxillofacial trauma patient.
• The consult addresses the specific reason for the request (i.e., the safety of deflation of the ETT cuff). However, as no other clinical service has addressed the odontogenic trauma, a thorough appraisal of this region is desirable.
• Note that it was made clear that the exam was limited by the patient’s consciousness/ability to follow commands, immobilization, and body habitus, and that subsequent clinical evaluations, with radiographs, may reveal additional problems.
• Note that it was made clear in the consult that the problems were not urgent and could be addressed when the medical condition stabilizes.
• While laboratory values are used consistently in consultations, electrolytes are most important for patients who are dehydrated, especially from vomiting and diarrhea, and the BUN and creatinine are important for patients with renal disease.