Communication in the dental office. Anamnesis, status assessment and documentation of data.Referral and consultation with other medical professions.

Oral Diagnostic

Dr Bródy AndreaSemmelweis EgyetemOral Diagnostic Department

Further procedure

• Main complain• General health status assessment (family

and social anamnesis)• Mouth hygiene habits• Clinical examination

extraoral Intraoral

teeth

oral cavity and mucosa

Main complain

• The reason, why patient came to us

complain, control, need• Must clarify

Good anamnesis

• Important in the three main steps of the patient treatment: diagnose, treatment, prognosis

• Main key of the anamnesis – good communication skill

Good anamnesis

• Important in the three main steps of the patient treatment: diagnose, treatment, prognosis

• Main key of the anamnesis – good communication skill

The model of mutuality• Both the doctor and patient are in control of the situation

• The doctor places the expectations of the patient into the scope of his expertise

• The patient receives full and understandable information

• The patient is an active participant in the treatment

This model ensures the right diagnosis and successful treatment.

Diagnose Gathering information

• Verbal questioning and filling out a questionnaire, preferably without errors and misses

• Sort the information – only the relevant information help the diagnostic process

• Have to percieve the answer!

analyzing

more questions

summarize

Obstructing factors (noise)• Due to a previous bad experience the patient

is not sincere• The patient does not know the significance of

earlier diseases, treatment or taken medicine• The patient is ashamed – e.g. alcohol abuse,

or is afraid of the consequences – e.g. Drugs• The patient is not able to give the necessary

information• Sometimes there is no explanation

Factors of efficacy (decrease the noise)

Important communication skills in doctoral work•General speech skill•Good question’s skill•The ability to listen to others – effective listening•Tactfulness, using the right expressions• Decoding of non-verbal signs

Verbal communication

•Open question: the patient tells us the information with her own words•Closed question: previously given options for answers•Leading question – the information received may be misleading•Applying open and closed questionning techniques: we aim from open to closed questionning•Pay attention to the language use!•we should use medical terminology as little as possible•pay attention to the expressions used

Non-verbal communication

• Non-verbal channels – body positure, movements, mymes

• Non-verbal communication often gives more precise information

• It suggests that the partner is not sincere or satisfied if the words and gestures or mymes refer to a different meaning.

Problems in communication

Too little information provided to the patient Impatience, trepidityo Doctors often interrupt the patients right after the first sentence – in

average, after 18 seconds!o The patients could not finish 98% of the interrupted sentences later eithero In 94% of the cases interruption ended up in the doctor controlling the

conversation.o Patients don’t manage to tell 54% of their symptoms at all

Information loss

Results of bad communication

• Patient don’t understand their status• They are not cooperate• Change for an other dentist• Cancel the therapy• Has the law on

Lost of trust

General health status assessment

First step: thoroughly survey the whole body of the patient

Anamnezis

Is the information received always realistic?

No! Because:• The patient had a bad experience earlier and

doesn’t tell us the truth • Extenuate the earlier treatments or earlier used

medicines• Is ashamed of the problem – e.g. alcohol abuse,

or afraid of the consequences – e.g. drugs• Is unable to give us the right information• No explanation

(Noise)

Risks related to general health condition

The general health condition of the patient may be of risk:• to himself (e.g. prosthetic valve, hemophilia)• to the surroundings including healthcare staff (e.g.

infectious diseases)• both (e.g. Hemophilic HIV positive patients)

Contraindications relating with general health status

Treatment is contraindicated in case of

• Acute infective diseases• Patient in need of

hospitalization• Mental disorders in need of

sedatives• Antikoagulant therapy• Severe allergic reaction to

earlier dental treament with unknown origin

Must find the solution!

Important diseases related to dental treatment

• Infectious diseases• Autoimmun diseases• Cardiovascular diseases• Diabetes mellitus• Haematological diseases• Malignant diseases• Rheumatological diseases• Eating disorders• Psychiatrical disorders• Additional risks: abuses, pregnancy

We never know which case will bring

unexpected complications

Focal infection researching

• Preferably based on the written request of the doctor

• Reviewal of significant evidence • Recommendation is subject of the original

disease and intended treatment

Status assessment

Physical examination

• The dentist examines the patient using his/her senses

Inspection, palpation, percussion,

bimanual, bilateral, etc.

Infection control

Dental office is high risk for infection• Protective equipment should be worn –

mask, glasses, gloves, rubber dam isolation

• Protect patient against nosocomial infection – desinfection of contaminated surfaces

Viewing •: We have to position the patient, ourselves and lights

correctly

Removing objects that obscure vision. saliva debris dentures• Aids: - dental mirror, lupe

Viewing

•Inspection

- passive, the patient is in a relaxed situation•Visualization

- Active e.g. Opening the mouth, spreading the tongue•Transillumination

- cross illuminating the oral tissues with light

- approximal carious laesions

Palpation

•It is based on the sense of feeling•It observes the deeper tissues under the surfaceThe dentist examines the following:• compressibility• sensitivity - inflammation• shape, size, anatomical location• mobility compared to the surrounding tissue (mobile

bound)• hardness• the boundaries of the laesio: solid or diffuse• the non seeable anatomical connections• whitening - diascopia

Smells

• alcohol• acetone – diabetes mellitus• bacterial infections – putrid smell• bacterial metabolic produce

containing sulphur (halitosis)

Auscultation

Definition: listening to the sounds different organs make

By increasing the sound or without doing soe.g. the operation of the TMI; vascular thrill (glide)

Aspiration

Probing with a sharp-edged tool (needle), removing the content with negative pressure

– The examination of the aspiratum e.g. puss, blood

The examination of the dimensions of a thin route or cave with a narrow tool

– fistula

– the outlet tubes of the large salivary glands

– carious laesion (rather puster, laser)

– periodontium

Probing

DIAGNOdent

• Red laser beam – the fluorescece of the carious tissue is stronger False result is frequent – dental plaque, fillings, food

remains (especially green), reminarilized enamel,

– may only be used on thoroughly washed teeth May be used in approximately 2 mm depth Only for fissura caries examination

DIAGNOcam• Works on similar principles as the

DIAGNOdent, but the signal is received by a camera so the aproximal carious lesions are also visible (caries affected areas are darker)

Extraoral examination (examination of head and neck region)

• Facial shape• Temporamandibular joint – opening the mouth, deviation, crepitation• Limph nods

Intraoral examination

Examination of soft areas, teeth, periodontium• First we examine the mucosa• Teeth – first the whole dentition, then the teeth one-by-one

cariologic examination

abrasio, attritio

occlusio

Vitality• Mouth hygiene, periodontium

Dental examination

• Looking for carious lesion• Abrasion, attrition, abfraction, erosion• Oral hygine• Parodontium

Assessment of the function

• sensitivity trial – indicates the reaction of the pulpa (the response of the sensor nerves to external stimulus)

• occlusion• atypical occlusional connection

• salivary gland function

Supplementary diagnostic examinations

• Radiology• Clinical laboratory• Microbiological

Documenting the data

Documentation• „The medical documentation contains the

data concerning the examination and treatment of the patient. The documentation tasks should be carried out in a manner that ensures the data properly reflect the course of the treatment.”

• Records the relevant data• Protects the patients from repeated examinations• Official source of data – legal problems

• Should not be possible to alter or change information without detection – photo, video

• Dates is important• Both the doctor and patient

should authenticate• To be preserved for the

obligatory period (5-10 years)

• Has to be stored separately, safely

Registration obligation• Personal data, anamnesis, status, diagnosis,

risk factors, treatments and their results• Date, signature• Documents signed by the patientThey were informed of the treatment and have accepted it

• It is advised to enclose the findings and x-ray records too

• Ambulant diary• Financial regulations

• Treatment sheet – Contains the original status, the treatment plan, the specific data connected to the treatment, dates, call-backs – with the written consent of the patient

• Ad hoc/casual documentation – e.g. certification

• Consultation requesting form – additional examinations by expert institutes

Documentation related to teeth

• Clearly marking milk-teeth and normal teeth (milk-teeth with roman numerals)

• Signalling with „Zsigmondy cross” or FDI system

• FDI: two digits, the first standing for the quadrant, the second for the tooth

• Tooth surfaces must be marked too

Reporting obligation•To the body providing the finances•ÁNTSZ - regarding personnel changes, reporting obligations of infectious diseases

Obligation of providing data•The patient has the right to know all data created during the entire process and is entitled to freely decide about such data

Data management:•personal rights of the patients must be respected – data protection

Referring and consultation

Consultation

• Communication between two experts• The consultant is the expert advisor of

the doctor performing the treatment – does not actively take part in the treatment

• Gives his expert opinion in writing regarding the specific problem and the recommended treatment

Refers the patient back to his dentist

Process of the consultation• Relevant information (only such

information) and important evidences have to be summarized with technical terms – they must be provided

• It covers the Diagnosis Proposed measures Prognosis

• May be obligatory

Consultation requesting formContains the identification data of the patient•The opinion and evaluation of the doctor•Documentation•What we expects from the consultation – only opinion or active participation•Warning regarding certain risks•The identification of the dentist•Via telephone: fast and efficient in simple cases but may lead to legal problems•The patient may need to be accompanied if there is a dangerous complication•The number of diagnostic interventions must be minimized

Dear Endontotic Department! I ask the treatment of our patient because focal research and ocular bleeding.

Thank you for your attention

brody.andrea@gmail.com