3. Define the chief complaint.
The chief complaint is the reason that the patient seeks care, as described in the patient’s own words.
4. What is the history of the present illness?
The HPI is a chronologic description of the patient’s symptoms and should include information about duration, location, character, and previous treatment.
5. What elements need to be included in the medical history?
6. What areas are routinely investigated in the social history?
7. Why is the family history of interest to the dentist?
The family history often provides information about diseases of genetic origin or diseases that have a familial tendency. Examples include clotting disorders, atherosclerotic heart disease, psychiatric diseases, and diabetes mellitus.
8. How is the medical history usually obtained?
The medical history is obtained with a written questionnaire supplemented by a verbal history. The verbal history is imperative because patients may leave out or misinterpret questions on the written form. For example, some patients may take daily aspirin and yet not consider it a “true” medication. Surprisingly, patients who are treated with an annual infusion of bisphosphonates for osteoporosis may not consider this a medication. The verbal history also allows the clinician to pursue positive answers on the written form and, in doing so, establish rapport with the patient.
9. What techniques are used for physical examination of the patient? How are they used in dentistry?
Inspection, the most commonly used technique, is based on visual evaluation of the patient. Palpation, which involves touching and feeling the patient, is used to determine the consistency and shape of masses in the mouth or neck. Percussion, which involves differences in sound transmission of structures, has little application to the head and neck. Auscultation, the technique of listening to differences in the transmission of sound, is usually accomplished with a stethoscope. In dentistry, it is generally used to listen to changes in sounds emanating from the temporomandibular joint and to take a patient’s blood pressure.
10. What are the patient’s vital signs?
11. What are the normal values for the vital signs?
12. What is a complete blood count (CBC)?
A CBC consists of a determination of the patient’s hemoglobin, hematocrit, white blood cell count, differential white blood cell count, and platelet count.
13. What are the normal ranges of a CBC?
| Hemoglobin: | Men, 14-18 g/dL | Differential white blood count: |
| Women, 12-16 g/dL | Neutrophils, 50%-70% | |
| Hematocrit: | Men, 40%-54% | Lymphocytes, 30%-40% |
| Women, 37%-47% | Monocytes, 3%-7% | |
| White blood count: | 4,000-10,000 cells/mm3 | Eosinophils, 0%-5% |
| Platelet count: | 150,000-400,000 cells/ mm3 | Basophils, 0%-1% |
14. What is the most effective blood test to screen for diabetes mellitus?
The most effective screen for diabetes mellitus is fasting blood glucose. The glycosylated hemoglobin test (HGbA1c, usually just called A1c) can be ordered without fasting and effectively assesses glucose levels over a 90 day period. A1c is typically used to monitor patients, rather than for diagnostic screening.
Oral Diagnosis
15. What is the technique of choice for the diagnosis of a soft tissue lesion in the mouth?
With a few exceptions, a biopsy is the diagnostic technique of choice for almost all soft tissue lesions of the mouth.
16. Is there any alternative diagnostic technique to biopsy for the evaluation of suspected malignancies of the mouth?
Exfoliative cytology has been used in the past for the diagnosis of oral lesions. Because of its high false-negative rate, it has never been particularly effective. Recently, the technique has been modified to include the use of a brush to obtain a cell sample and then a specific processing and evaluation procedure that increases the sensitivity of the assay. Biopsy remains the most reliable way to make a diagnosis.
17. When is immunofluorescence of value in oral diagnosis?
Immunofluorescent techniques are of value in the diagnosis of autoimmune vesiculobullous diseases that affect the mouth, including pemphigus vulgaris and mucous membrane pemphigoid. Immunofluorescence can also be used in the diagnosis and typing of herpes simplex virus (HSV) infection.
18. What elements should be included in the dental history?
1. Past dental visits, including frequency, reasons, previous treatment, and complications
2. Oral hygiene practices
4. Past dental or maxillofacial trauma
5. Habits related to oral disease, such as bruxing, clenching, and nail biting
6. Dietary history
19. When is it appropriate to use microbiologic culturing in oral diagnosis?
1. Bacterial infection. Because the overwhelming majority of oral infections are sensitive to treatment with penicillin, routine bacteriologic culture of primary dental infections is not generally indicated. However, cultures are indicated for patients who are immunocompromised or myelosuppressed for two reasons: (1) they are at significant risk for sepsis; and (2) the oral flora often change in these patients. Cultures should be obtained for infections that are refractory to the initial course of antibiotics before changing antibiotics.
2. Viral infection. Immunocompromised patients who present with mucosal ulcerations may be manifesting signs of a herpes simplex infection. A viral culture is warranted. Routine culturing for typical secondary herpes infections (herpes labialis) is not warranted for healthy patients. Once a specimen is obtained, it should be kept on ice and transported to the laboratory as quickly as possible because viral cultures are temperature-sensitive.
3. Fungal infection. Candidiasis is the most common fungal infection affecting the oral mucosa. Because its appearance is often varied, especially in immunocompromised patients, fungal cultures may be of value. In addition, because a candidal infection is a frequent cause of a burning mouth, culture is often indicated for immunocompromised patients, even in the absence of visible lesions. Of note, however, a positive culture does not confirm infection, but only the presence of candida organisms.
20. How do you obtain access to a clinical laboratory?
It is easy to obtain laboratory tests for your patients, even if you do not practice in a hospital. Community hospitals provide almost all laboratory services that your patients may require. Usually, the laboratory provides order slips and culture tubes. Simply indicate the test needed, and send the patient to the laboratory. Patients who need a test at night or on a weekend can generally be accommodated through the hospital’s emergency department. Commercial laboratories also may be used, and they also supply order forms. If you practice in a medical building with other physicians, find out which laboratory they use. If they use a commercial laboratory, a pick-up service for specimens may be provided. The most important issue is to ensure the quality of the laboratory. Adherence to the standards of the American College of Clinical Pathologists is a good indicator of laboratory quality.
21. What is the approximate cost of a complete blood count (CBC)?
The Medicare allowable rate is $10.95.
22. Which laboratory tests should be used to assess a patient who may be at risk for a deficiency in hemostasis?
The basic laboratory tests for a possible coagulopathy should include assessments of platelet number and clotting factors of the internal and external pathways. The three essential tests are a CBC, which includes platelet number, prothrombin time (typically expressed as the international normalized ratio, or INR), and partial thromboplastin time.
23. What positive responses in the medical history should suggest to you that a patient may have a problem with hemostasis?
• Family history of a bleeding problem, such as hemophilia
• Taking medications that can cause thrombocytopenia, such as cancer chemotherapy
• History of a disease that may cause thrombocytopenia
• Taking medications known to cause prolonged bleeding, such as aspirin, warfarin, or vitamin E
• History of liver disease
24. What are the causes of halitosis?
Halitosis may be caused by local factors in the mouth and by extraoral or systemic factors. Local factors include food retention, periodontal infection, caries, acute necrotizing gingivitis, and mucosal infection. Extraoral and systemic causes of halitosis include smoking, alcohol ingestion, pulmonary or bronchial disease, metabolic defects, diabetes mellitus, sinusitis, and tonsillitis.
25. Which bacteria are associated with halitosis?
Gram-negative anaerobes are associated with halitosis.
26. Which gases are associated with halitosis?
Volatile sulfur compounds—in particular, hydrogen sulfide, methyl mercaptan, and dimethyl sulfide—are associated with halitosis.
27. What are the most commonly abused drugs in the United States?
• Alcohol
• Marijuana
• Cocaine
• Phencyclidine (PCP)
• Heroin
• Methamphetamines
• Prescription medications
• Narcotic analgesics
• Tricyclic antidepressants
• Sedative-hypnotics
• Stimulants
• Anxiolytic agents
• Diet aids
28. What are the common causes of lymphadenopathy?
1. Infectious and inflammatory diseases of all types—oral conditions that can cause lymphadenopathy include herpes infections, dental infection, pericoronitis, aphthous or traumatic ulceration, and acute necrotizing ulcerative gingivitis
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