EBTISAM EL HAMALAWY
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History taking
Introduction:
My name is DR ………, I am one of the dentists here and will be seeing you.
Personal history:-
No dependents
CHIEF COMPLAIN:
Section: 1. Pain
2. Periodontics
3. Oral medicine
4. Denture
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Notes:
Dental history:
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6. Have you noticed any clicking from your jaw joints?
Clicking/ no clicking
TMPDS
Tempromandibular pain dysfunction syndrome
Social history
SADS
1. Smoking:
I. Do you smoke?
YES
2. Alcohol:
(White/ red wine are highly acidic PH they cause tooth surface loss)
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3. Diet:
4. Stress:
Medical history
Always take a consent prior to embarking on the MEDICAL history
questioners
Can I ask you a few questions about your health just to make sure everything
is okay?
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11.Have you ever been refused blood donation in UK before?
LADY:
1. Are you pregnant?
2. Are you on any contraceptive pills?
3. How about your periods are they regular?
12.Systems:
a. Do you have any skin, joint, eye trouble?
(Systemic lupus erythromatous, Sjogren syndrome, rheumatoid
artheritis, Behcet syndrome, Lichen planus).
b. Do you have any heart, liver, kidney trouble?
c. Do you have any breathing or lung troubles?
d. Do you have any tummy trouble?
e. Have you had any faints, fits, Blackouts before?
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How can I help you today?
Pain cases
Differential diagnosis
Hierarchy of events
1. Dentine hypersensitivity:
Sensitivity/ hot and cold/ air/ last for a few seconds / recent/ restoration/
dental caries
2. Reversible pulpitis:
Non –localized / Pain on hot and cold/ last for less than one minute/ sharp/
intermitted/ doesn’t disturb sleep/ no radiation/ relieved by medication
3. Irreversible pulpitis:
Non -localized/ Pain on hot and cold or (pain on hot and relieved on cold) /
last for more than 1 min/ radiates/ disturb sleep/ not relieved on medication/
no pain on biting/ sever
4. Apical periodontitis:
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5. Acute periapical abscess:
Sever/ swelling/ foul taste/ halitosis/ fever/ localized /throbbing pain/ radiated
to the side of the face/ pervious history of infection / previous history of dental
treatment/ pain on biting/ trismus
Localized/ dull ach/ foul taste/ parulis/ previous history of treatment/ previous
history of swelling and antibiotics
Localized/ dull pain/ foul taste/ parulis/ previous history of swelling and
antibiotics/ Mobile tooth/ gingival bleeding localized
Non-localized/ pain on the side of the face/ in the morning/ improves through
the day/ bruxism/ clicking from TmJ/ stress? Previous night guard treatment
Non localized/ dull pain/ pain crosses the anatomical boundaries/ failure of
previous treatment/ stress/ depression and antidepressant medication/ pain
worsen on evening
11.Pericoronitis:
QUESTIONS
Rest assured we will definitely do something for it today, but can I ask you a
couple of questions first
Pain
1. Can u point to the site of pain, is it from a specific tooth (localized/ non-
localized)?
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8. Do you have any Swelling?
10.Do you have any boil on your gums next to that tooth?
16.When?
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Radiograph
OR
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Special Investigation
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X-ray report
Please report on……. shown in the box below. You will have the
radiograph in your folder of artifacts
Radiograph
Teeth: 7654
7654
Film Quality 1
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Last page of the treatment planning
1. Medical link:
1. Ensure that the patient take medication and meal prior to appointment.
2. Stress reduction protocols (short and early morning appointments).
3. Diabetes a risk factor for periodontitis and candida infection.
4. Oral hypoglycemic associated dry mouth/ Lichinoid reaction.
5. Prepadness to deal with a hypoglycemic attack (Oxygen/ Gluo gel/
Glucagon).
Treatment option:
Presentation points:
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Sheet 7 Green Treatment Plan Form Continued
Considering this patient, briefly describe what has led you into choosing this
overall care plan and the benefits (likely success, cost, time, etc) to the patient.
Describe
Reasons Benefits
Disadvantage:
1. Multiple visits
2. Expensive
3. Surgical complications ( bleeding/ swelling/ damage to roof of the mouth)
4. Long treatment
5.
Would you provide all or part of the treatment for this patient yourself? If so
which part or parts? (Give your reasons.)
Would you refer the patient for all or part of the treatment? If so which part
or parts and to which Specialist/s? (Give your reasons.)
Periodontitis:
Reasons:
1. Complexity 3 index on the BPS score
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Chronic generalized periodontitis
1. Surgical debridement
2. Regenerative periodontal surgery: ( Guided tissue regeneration/ Bone
graft)
SHEET 7
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Preferred Definitive Treatment
Explanation
Myofacial pain dysfunction syndrome
Dentist:
Mr…………. as for the discomfort on the side of your face that’s because you
have been grinding on your teeth so you ut too much pressure on the muscles on
the side of your face .
Is it clear so far?
So for the discomfort to go away you will have to stop the grinding, it will take
you some time to improve you need to be patient and give the treatment some time
to work.
For now
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6. Apply warm towels on the side of your face to reduce the discomfort, it will
help massage the area
7. I will give you a leaflet of some jaw relaxation to use to help with ypur
muscle ach
I will be seeing you regularly if the muscle ach still persists we will give you
a plastic plate that goes between the teeth to keep them apart and decrease
the pressure from your muscles.
IRREVERSABLE PULPITIS
Thank you for waiting Mr. ………….. I have the results of your
investigations we will go through it together and I will be explaining to you
the treatment plan available and what options we have for it.
How does that sound??
Patient: sounds okay
Dentist: Because your diabetic don’t forget to take a proper meal and your
medication before you come to see me and if there is anything about the
treatment that makes you stressed or uncomfortable let me know about it.
Is that’s alright?
Dentist: for the pain you’re having it’s from your big back tooth.
Unfortunately you have tooth decay that has reached the tooth nerve and
now the nerve is irritated beyond repair.
Is it clear Mr.…………….?
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Patient: yes
Dentist: What I am going to do today is to numb that tooth and have the
nerve taken out, I will give you some pain killers to use.
That will relieve your pain.
How does that sound?
Patient: Thanks
Dentist: In the future you have one of two options to think about regarding
that tooth. You can either save it or take it out.
If you are to save the tooth we will need to do a nerve treatment, have you
heard about it before?
Patient: Not really
Dentist: It entails cleaning the inside of the tooth and putting a filling in
place. The advantages are: you will end up saving the tooth but on the down
side: it requires multiple appointments and when we are done I have to give
you a cap that goes on top of that tooth to protect it. That will cost more
money.
Dentist: the second option is having the tooth taken out, have you had any
tooth taken out before?
Patient: yes
Dentist:
It’s the same procedure the advantages are: it’s a simple one appointment
procedure on the downside: you will end up losing a big back tooth and have
a gap instead if its not restored with an artificial tooth teeth nxt to the space
will drift in and you will end up with more gaps between your that will cause
more problem in the future.
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