Consultation Note

The consultation note is for a patient under the care of another provider who requests a dental opinion regarding a specific problem. Primary care responsibilities remain with the requesting provider and all orders should be confirmed with that provider prior to institution, unless responsibility has been transferred to the dentist. A consult note should be thorough yet concise and include the following information:

• Purpose: The purpose of the consultation should be outlined prior to the definitive assessment.
• History of present illness (HPI): A detailed history of the current dental problem relating to the consult request. If other conditions exist that brought the patient to the ED and are being treated by the primary provider (e.g., long bone injuries accompanying a mandible fracture from a motor vehicle accident), these too should be briefly described.
• Past medical history (PMH): A listing of the pertinent positive and negative findings from the patient’s past and current medical history. Any positive review of systems findings are generally included in this section for consultation notes. All positive findings should include a brief discussion describing the current status of the medical condition.
• Current medications (MED): A list of the patient’s medications with the route of administration, dose, and interval schedule. If unclear, a family member, the pharmacist, or the doctor who wrote the prescription(s) should be contacted.
• Allergies (ALL): A list of the patient’s known drug allergies and the particular response seen from previous administration (e.g., hives, itching, gastrointestinal upset).
• Physical examination (PE): This section should include an appropriate head and neck examination and a thorough oral examination. In addition, any other examination pertinent to the consultation request should also be performed (e.g., a neurologic examination for a patient with facial injuries). Examination results should be detailed, especially in the specific area mentioned for examination in the consult request.
• Radiographic and laboratory examination: Necessary radiographs and/or laboratory tests should be obtained and interpreted. Many radiographs (e.g., periapicals, panoramic) are interpreted by the dental consultant, not by a radiologist or the primary provider, and should, therefore, be read comprehensively, not just for the specific complaint. All pertinent laboratory data (e.g., CBC, platelet count, PT/INR, PTT) should be listed and interpreted as well.
• Assessment: This is a line-by-line listing of all the positive findings, followed by a brief discussion of the current status and its effect on the patient’s care.
• Recommendations and treatment: These are recommendations regarding diagnosis and appropriate treatment based on the assessment. Recommendations should be thorough and specific, indicating particular therapies, drugs, and dosages. No treatment should be performed without the consent of the primary provider. If any treatment is performed, it should be clearly noted in this section, along with any anesthesia used.
• Disposition or discharge information: This is a listing of instructions given to the patient, medications prescribed (with primary provider’s permission), follow-up appointments, or other plans.

Primary Care Notes

In some circumstances, the dentist might be the only clinician to see the patient. In these cases, it is even more imperative to consider the patient’s overall medical condition and not just the head and neck region. For example, patients with facial injuries might have concomitant cervical or intracranial injuries that often cannot be appreciated by the triage staff. Another example is oral bleeding. Although there are many local reasons for oral bleeding, the dentist is obliged to consider systemic sources or coagulopathies and order the appropriate tests to make the correct diagnosis, and then obtain appropriate medical consultation. It is important to write complete notes that more closely approximate an admission note. Orofacial trauma might be a result of syncope in the elderly (a common but significant and diagnostically complex syndrome with potential cardiovascular, neurologic, endocrinologic, visual, vestibular, and neuromotor implications), or abuse in a child or a dependent older individual. These situations dictate a medical and/or social services consult if abuse is suspected.

Primary care notes differ from consult notes as follows:

• Chief complaint (CC): The chief complaint should be brief (one sentence or less) and recorded in the patient’s words.
• HPI: The history must be comprehensive and include all information relating to the present condition, not just that affecting the head and neck. Traumatic dental or facial injuries, for example, should be detailed as to the time, mechanism, and severity of the injury as well as previous traumatic episodes. Specific questions should be directed at ascertaining the likelihood of other systemic injuries (e.g., chest, abdominal, cervical, or intracranial).
• Social history (SH): A social history containing information germane to the problem should be included. For instance, a history of substance use may be important for the evaluation of a potentially cancerous lesion.
• Family history (FH): A family history may be helpful to rule out potentially inherited problems.
• The physical examination, while certainly emphasizing the head and neck findings, should nevertheless include a basic examination of any other bodily system that is pertinent to the HPI. Positive findings should indicate the need for appropriate medical consultation.
• Radiology/labs: Appropriate films (e.g., C-spine) and lab data should be obtained (when indicated by the history or PE) to rule out concomitant injuries and/or possible systemic factors, as well as to diagnose the acute dental or facial injuries.
• Assessment/plan (A/P): This should reflect the patient’s overall condition including the oral findings and any others. When nondental items are listed, specific medical consultation should be ordered and noted in the medical record.
• Admission notes: These should consist of the primary care note and the following:
  • Indication for admission
  • Name of the attending dentist
  • Principal diagnosis
  • Place to be admitted
  • Condition of the patient
  • Immediate treatment plan

Consultation Request Notes

Written consultation requests to another service or doctor should be instituted whenever the dentist feels that it is necessary for the comprehensive and appropriate care of the patient. The best practitioners are the ones who know when to ask for assistance in the best interest of the patient. When in doubt, obtain a consult. A consult request should include the following:

• A brief summary of the HPI and treatment to date
• Any pertinent medical history, physical findings, and radiographic or laboratory data
• A detailed and specific explanation of why the consult is being ordered and what information is desired from the consultant. If any necessary treatment by the consultant is desired, this should also be indicated in the note
• Direct verbal communication between dentist and consulted physician is encouraged whenever possible.

Follow-Up Notes

Follow-up notes can be written in the “SOAP” format as follows:

• Subjective: This includes the patient’s chief complaint if there is one, or any comments the patient has regarding the condition, past treatment, and so on.
• Objective: This includes the physical examination and the radiographic and laboratory data, if ordered.
• Assessment: This is a summary of the patient’s condition.
• Plan: The plan is the consideration for the future management of the patient and any appointments scheduled.

General Principles

Pain of odontogenic origin is the most common dental emergency seen in the ED. Although the etiology and management are usually straightforward, other more serious conditions can present with a similar clinical presentation. Misdiagnosis can have serious ramifications and it is incumbent upon the practitioner to perform a complete diagnostic work-up that includes the following:

• History: The history of pain should include duration, location, description (character and intensity on a scale of 1 to 10) and what exacerbates and relieves the pain. Note the medications taken, dose and duration, and how effective or ineffective they have proved to be. Any previous treatment or similar history should be noted.
• Physical examination: The patient should be examined for any tooth that is sensitive to percussion, pressure on biting/mastication, and palpation, as well as for mobility, periodontal pocketing, adjacent soft tissue swelling, caries, fractures, integrity of existing restorations, and pulp vitality.
• Radiographic and laboratory examination: Intra-oral and/or panoramic radiographs should be obtained and examined for caries, periodontal disease and periapical changes, fractures, or other pathology. Occlusal views (for the anterior segment of the maxilla or mandible) may be useful for children. A Water’s view or computerized tomographic scan (CT scan) might be necessary to examine for sinus disease. Reviewing laboratory values such as the white blood cell count (WBC) or a complete blood count (CBC) and obtaining a Grams stain along with anaerobic and aerobic cultures are often useful when an infection exists or is suspected.

Periodontal Abscess

• Etiology: Acute exacerbation of chronic periodontitis; unable to drain through gingival crevice. Localized plaque and/or calculus deep in gingival crevice. Foreign body in the gingival crevice. Endodontic abscess. Root fracture
• Diagnosis: Progressive, localized pain and deep isolated pocket formation. Gingival tissues become red, swollen, and painful with possible purulence from gingival crevice. Tooth mobility. Foreign body may be found in crevice. Non-vital pulp possible. Dentification of root fracture with deep pocket
• Treatment: Local anesthesia; irrigation with saline or chlorhexadine if indicated. Ultrasonic debridement, scaling, and root planing. Incision and drainage if fluctuant, with or without a Penrose drain, to obtain drainage through gingival crevice. Enteral antibiotic coverage in presence of systemic signs or symptoms (penicillin, amoxicillin, or for penicillin-allergic patients, clindamycin) (Appendix 12, Table A12-4). Close periodontal follow-up

Necrotizing Ulcerative Gingivitis or Periodontitis

• Etiology: Necrotizing ulcerative gingivitis (NUG) and necrotizing ulcerative periodontitis (NUP) are painful, noncontagious bacterial infections of the papillary and marginal gingiva and alveolar bone, respectively. They are usually opportunistic infections of mixed anaerobic flora, but anaerobic spirochetes and fusiforms commonly predominate. Commonly associated with mild local or systemic immunosuppression that accompanies periods of emotional stress, fatigue, malnutrition, poor hygiene, pre-existing gingivitis, and smoking. The periodontitis form has been associated with the systemic immunosuppression resulting from HIV infection
• Diagnosis: Bleeding, necrosis, and blunting of the interdental papillary gingiva with pseudomembrane formation. Gingival pain, usually severe, and halitosis. Fever, malaise, cervical lymphadenopathy. Periodontitis form also is associated with periodontal ligament attachment loss and alveolar bone destruction
• Treatment: Saline, or chlorhexadine if desired, irrigation using a large syringe and plastic IV catheter. Gross mechanical debridement (ultrasonic or, if possible, scaling and curettage) using local anesthesia. Oral hygiene, dietary and stress counseling. Enteral antibiotic therapy when systemic signs are present (clindamycin or metronidazole) (Appendix 12, Table A12-4). Prompt follow-up appo­intment for oral hygiene. Analgesic medication as needed. Consider HIV testing when periodontitis form is present or if index of suspicion is high (Appendix 18)

Herpes Simplex Infection

• Etiology: Infection caused by the herpes simplex type 1 (HSV-1) or herpes virus type 1 (HHV-1) virus or, less commonly, by the herpes simplex type 2 (HSV-2) or HHV-2 virus, which more commonly causes genital lesions. Approximately 80% of the adult population have antibodies following primary infection. The latent virus persists in the trigeminal nerve ganglion innervating the affected area, where it may be reactivated to reappear later, under a variety of conditions, as a recurrent herpes infection

Aphthous Ulcers

• Etiology: The etiology of aphthous ulcers is not clearly understood but they appear to be autoimmune with many possible contributory mechanisms, including psychic, allergic, microbial, traumatic, endocrine, and heredity. Despite some clinical similarities, aphthae are separate and distinct entities from recurrent herpetic lesions
• Diagnosis: Can occur at any age. Originates as an erythematous macule or papule that undergoes central blanching, necrosis, and eventual ulceration. Shallow ulcers range in size from 0.5 (minor aphthae) to 3 cm (major aphthae). Demonstrates gray or yellow necrotic center and an erythematous halo. Although usually singular, they can occur in small groups (herpetiform type) that later become a single or a few confluent ulcers. Almost always occur on non-keratinized, unattached tissue (e.g., vestibule, ventral tongue, labial mucosa, floor of mouth). Pain is moderate to severe
• Treatment: Generally supportive in nature, as the lesions usually disappear in seven to 14 days. Particularly severe aphthae and major aphthae might require additional measures. This should include adequate hydration and nutrition. Although there is no proven treatment for aphthae, a number of clinical therapies have been advocated for minimizing pain or shortening the life of the ulcer, including:
  • Topical agents such as tetracycline or chlorhexidine mouthwashes; protective topical dressings such as hydroxypropyl cellulose or Orabase® used PRN
  • Topical steroids such as tramcinolone (e.g., Kenalog® in Orabase®) or fluocinonide (e.g., Lidex®) ointment twice a day
  • Analgesics such as benzocaine in Orabase® applied PRN or benzydamine rinse, if available. (Appendix 12, Table A12-4)

Burns

• Etiology:
  • Chemical: most commonly seen with topically used salicylates (e.g., aspirin), which cause coagulation necrosis. Iatrogenic chemical burns can result from common materials such as eugenol. Occasionally seen with accidental or intentional ingestion of caustic materials (e.g., lye or gasoline). For that reason, the trajectory of the chemical pathway must be assessed to rule out or confirm concomitant phayngeal and/or esophageal burns
  • Physical: Can occur in a child biting an electrical cord or a burn from a dental handpiece. Also common from hot food (e.g., “pizza palate”). Electrical burns are arch burns and as such result in tissue damage well beyond what is initially recognized during the hours immediately after the injury
    For extensive chemical, thermal, or electrical burns, referral to the appropriate specialist should be considered.
• Diagnosis: Mild burns (first degree) manifest as erythema. More severe burns are mixed red–white areas, or just white areas, indicating tissue necrosis. Electrical wire burns usually occur at the commissures of the mouth. Can cause severe scarring and contraction if left to heal without treatment. Can be complicated by delayed hemorrhage from the facial/labial arteries
• Treatment: Most mild burns require no treatment and heal spontaneously, although adequate hydration and nutrition must be assured. More severe burns may require debridement of necrotic tissue, which can be accomplished with or without local anesthesia as warranted. Also saline rinses and good oral hygiene. Topical (e.g., viscous lidocaine) or systemic analgesics often necessary. For electrical burns, the patient should be referred immediately to a pediatric dentist for splint construction to prevent contracture of the commissures subsequent to healing and fibrous scarring. In the case of swallowed caustics refer for endoscopy

Human Bites

• Human bites are considered to be “crush” injuries that are contaminated with numerous microorganisms. The usual organisms are Staphylococcus aureus, Streptococcus species, and Eikenella corrodens. Anaerobic bacteria such as Bacteroides, Prevotella, Fusobacteria species, and others are common. Gram-negative species are less common. E. corrodens is especially important because of its unusual antibiotic sensitivity—it is sensitive to penicillin and ampicillin but resistant to semisynthetic penicillins and first-generation cephalosporins.
• Management: Because they are contaminated, crush injuries, all bites should receive appropriate tetanus prophylaxis. Treatment then involves thorough cleansing, copious irrigation, debridement, and the appropriate use of prophylactic antibiotics. Bites often occur in daycare settings. Child abuse should be suspected in bites with a questionable history. Human bites to the face seen within 24 hours can be primarily sutured after appropriate cleansing and debridement. Prophylactic antibiotics should be given. Hand bites require special treatment because of the possibility of unrecognized penetrating injury to a joint. Human bite injuries to the hand must be irrigated thoroughly and an appropriate wound dressing placed. Close follow-up is essential. There is a high incidence of infection of the soft tissue and joint space (metacarpophalangeal) and referral to the appropriate specialist should be considered. Treatment recommendations for bites other than the hand and face are individualized but always include thorough debridement and irrigation and generally prophylactic antibiotics. Broad-spectrum, second-generation cephalosporins have been recommended for human bites, but amoxicillin plus clavulanic acid is an excellent choice (Appendix 12, Table A12-4). For bite injuries that result in avulsion, referral to the appropriate specialist should be considered.

Bleeding from an Extraction or Bony Surgery Site

• Etiology: Loss of organized blood clot from smoking, excessive spitting and rinsing, or using a straw within 24 hours of surgery; salivary plasminogens; reopening of a vessel that was tamponaded or vasoconstricted at the time of surgery; loss of one or more sutures; excessive highly vascular granulation tissue in the socket (as is often seen in severe periodontal disease); acquired coagulopathy, most commonly drug related (e.g., warfarin or substances containing aspirin or alcohol); less frequently, an inherited coagulopathy
• Identify the site of origin: Small bleeding vessel within the bony wall of the socket; brisk bleeding from the apical area indicating possible arterial damage, especially if pulsatile; bleeding emanating from the soft tissue around the socket; bleeding from granulation tissue left in the socket; generalized oozing from all areas
• Management:
  • Thorough history and physical examination. Particular emphasis should be placed on current medications and herbal supplements (patients are often unaware of medications and herbal supplements that may impair coagulation). Also inquire about compliance with postoperative instructions; take care phrasing these questions (e.g., “Have you had to spit much blood to keep from swallowing it?”)
  • Ensure the appropriate suction equipment (with a small-diameter stiff suction tip) and lighting (preferably a headlight) is available
  • Examine for obvious bleeding vessels in or around the site. If visualized, electrically coagulate or ligate with resorbable suture under local anesthesia
  • If the bleeding is noted to be brisk or arterial (pulsatile) in nature, inject local anesthesia with a vasoconstrictor, debride, irrigate the socket, and examine closely for specific areas of bleeding. Small bone bleeders may be crushed with a metal instrument or stopped with a small amount of bone wax. Apical or non-isolatable bleeds should be packed with Surgicel®, Avitene™, or Gelfoam®.
    Following this, or if bleeding is coming from the soft tissues, use interpapillary or figure-of-eight “hemorrhagic” sutures and reinstitute pressure
  • Blood “liver” clots may form, especially in the setting of thrombocytopenia. These gelatinous clots need to be removed prior to controlling bleeding because otherwise their movement will likely promote further oozing
  • If no obvious vessels are seen, initial management should always be with tamponade (direct pressure). This is accomplished by biting on gauze, under observation, for 20 minutes. If this fails, a gauze impregnated with liquid topical thrombin or 5% tranexamic acid can be tried for an additional 20 minutes
  • When local causes have been ruled out, appropriate laboratory tests should be ordered. This includes a complete (full) blood count (CBC), (FBC) with differential and platelet count, prothrombin time (PT), and international normalized ratio (INR), and partial thromboplastin time (APTT). If abnormalities are detected, medical consultation is indicated
  • Instructions: When the bleeding is controlled, the patient should be given careful verbal and written instructions to decrease risk of recurrence

Bleeding from the Gingiva

• Etiology: Severe gingival or periodontal infection, including acute necrotizing ulcerative gingivitis, linear gingival erythema, and primary herpes; trauma; intrinsic (e.g., hemophilia) or extrinsic (medications) coagulopathy; other systemic cause (e.g., acute leukemia)
• Diagnosis: History and physical examination should differentiate local from systemic sources. When indicated, obtain appropriate blood tests
• Management: Injection of local anesthesia with vasoconstrictor into the area; gauze pressure; removal of granulation tissue in periodontal conditions; repair of traumatic injuries; medical consultation for coagulopathies

Bleeding from Postoperative Soft-Tissue Incisions

• Etiology: Wound margin bleeder; dead-space hematoma; arterial or venous bleeding within the wound itself
• Diagnosis: Examine and palpate the surgical site. Gradual discoloration and swelling at the site usually indicates an underlying hematoma. Brisk, bright red blood usually indicates arterial bleeding. This may be immediate or delayed (from loss of a suture or vascular invasion)
• Management: Wound margin bleeders and slow, venous bleeders can usually be stopped with direct pressure or a pressure bandage, but might require additional sutures. Deep arterial bleeding mandates opening the wound; explore for vessel to be coagulated or ligated. Hematomas should be evacuated by opening a small area of the incision, probing with a hemostat until the hematoma is found, and expressing the blood. Direct pressure and a pressure bandage should be used to prevent secondary hematoma formation. If bleeding persists, the wound should be explored.