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2: Patient Assessment

Chapter 2
Patient Assessment

Aim
This chapter describes the process of assessing patients who require
minor oral surgery, reaching a diagnosis and treatment planning.

Outcome
After reading this chapter you will understand the importance of patient
assessment in the practice of minor oral surgery.

Introduction
Comprehensive patient assessment is a prerequisite for successful
surgical practice. It is based upon a candid and trusting relationship
between patient and clinician.

Competence in the skills of history taking and physical examination is

fundamental to this practice. The accurate interpretation of patients’
symptoms and the correct eliciting of relevant physical signs provide the
basis for diagnosis and treatment planning.

History Taking
Successful history taking involves fascinating detective work. Experienced
clinicians can accurately diagnose a patient’s problems within the opening
minute of a consultation. Only by continued practice and exposure,
however, can the less experienced aspire to such intuitive diagnoses. The
important principles that facilitate this process comprise:

introduction

recording patient details

the patient’s complaint

history of complaint

previous medical history

drug history and allergies

social history

case summary.

Introduction
Consultations begin with appropriate social introductions between clinician
and patient. A handshake provides not only a polite greeting but also
useful information about general health (see later). It must be
remembered, however, that a handshake may be inappropriate when
dealing with some ethnic groups.

Recording Patient Details

Information regarding the patient’s age, sex, racial origin and occupation
are extremely important for diagnostic and treatment planning purposes.

The Patient’s Complaint

The patient must describe their presenting problem in their own words.
The patient’s reports of previous clinicians’ diagnoses must be regarded
with caution. Failure to listen carefully to a patient’s history can lead to
inaccurate diagnosis and inappropriate treatment.

History of Complaint
The mode of onset of symptoms (sudden or gradual), their time course
(constant or intermittent), whether they are worsening, improving or
staying the same, and their response to any previous treatment provide
invaluable information. The application of this process to the common
clinical problem of oro-facial pain is summarised in 2-1.

Table 2-1
Oro-facial pain history

1. SITE – Point of maximum intensity?

2. CHARACTER – Sharp, dull, throbbing, burning?

3. TIMING – Date of onset, continuous, intermittent, time of day?

4. SEVERITY – How severe, increasing, decreasing, staying the same?

5. SPREAD – Where does the pain spread?

6. RADIATION – Any other sites affected?

7. AGGRAVATING FACTORS – Touch, temperature, pressure?

8. RELIEVING FACTORS – Analgesics, heat?

9. ASSOCIATED SYMPTOMS – Swelling, discharge, bad taste,

dysphagia?

Previous Medical History

It is often helpful to enquire generally whether the patient has ever been in
hospital for any illness or operation, or is currently seeing a doctor for
anything. This should take place before asking specifically about a history
of heart disease, hypertension, rheumatic fever, breathing problems,
diabetes, jaundice, TB, etc. Some important conditions relevant to the
practice of minor oral surgery are summarised in Table 2-2 – the medical
‘CHALLENGE’.

Table 2-2
The medical ‘CHALLENGE’

CARDIOVASCULAR DISEASE – Heart failure

Hypertension

Ischaemic heart disease

Infective endocarditis

HAEMORRHAGIC DISORDERS – Coagulation defects

Platelet disorders

ANAEMIAS

LIVER DISEASE – Hepatitis

Cirrhosis

LIFE-THREATENING – Malignant disease

CONDITIONS
Immunodeficiencies

ENDOCRINE DISEASE – Diabetes mellitus

Thyroid disorders

Systemic steroid therapy

NEUROLOGICAL CONDITIONS – Epilepsy

Multiple sclerosis (MS)

GASTRO-INTESTINAL
DISORDERS

RESPIRATORY DISEASE – Infections

Asthma

Chronic obstructive pulmonary

disease (COPD)

Drug History and Allergies

It is surprising how often patients fail to appreciate the relevance of
medication to surgical practice, prescribed or otherwise. It is therefore
best to specifically ask if tablets, pills, medicines, creams, ointments or
inhalers of any kind are being used.

Social History
Details of tobacco, alcohol or other recreational drug use must be
recorded. In addition, it is important to determine who will care for the
patient following surgery. This is especially important if conscious sedation
is being considered.

Case Summary
At the end of history taking, the clinician should:

recognise all relevant signs and symptoms

understand the impact of the clinical problem on the patient.

construct a list of possible diagnoses to aid the clinical examination,

which follows.

Patient Examination
Valuable information about patients’ general wellbeing can be obtained by
careful observation as they first enter the surgery. Their mental state
(lucid, cooperative, anxious, depressed), nutritional condition
(underweight, overweight or obese), general cardio-respiratory status
(pallor, cyanosis, breathlessness, wheeze), the presence of jaundice or
skin disease can all be ascertained during these initial moments of
consultation. Shaking hands, as introductions occur, can yield additional
medical information, such as the metabolic flap of liver disease, finger
clubbing, koilonychia, bruising and purpura (Fig 2-1). Detailed and
systematic oro-facial examination should be carried out with the patient
seated. Appropriate lighting and examination equipment must be available
(Table 2-3).

Fig 2-1 Bruising on the hand is suggestive of a bleeding disorder,

which should be investigated prior to performing surgery.

Table 2-3
Systematic oro-facial examination

THE FACE – Skin colour and complexion

Symmetry

Bony skeleton

Facial nerve function

Sensory deficits

Eyes

TEMPOROMANDIBULAR JOINTS – Tenderness

Clicks

Mandibular movements

MAJOR SALIVARY GLANDS – Swelling and tenderness

Nodular enlargement

LYMPH NODES – Facial

Cervical

LIPS – Colour

Lesions

INTRA-ORAL – General inspection and salivary

flow

Buccal mucosa and parotid ducts

Tongue dorsum

Ventral and lateral tongue

Floor of mouth, submandibular

ducts and sublingual glands

Fauces, tonsils and pharynx

Retromolar regions

Teeth and periodontal tissues

Edentulous ridges

Occlusion

An example of the information necessary for assessment of an oro-facial

swelling is listed in Table 2-4.

Table 2-4
Assessment of an oro-facial swelling

1. ANATOMICAL SITE?

2. SUPERFICIAL or DEEP in origin?

3. SINGLE or MULTIPLE?

4. SHAPE?

5. SIZE?

6. COLOUR?

7. SURFACE – smooth, lobulated, irregular?

8. EDGE – defined, diffuse?

9. CONSISTENCY – fluctuant, soft, firm, rubbery, hard?

10. TENDERNESS or WARMTH on palpation?

11. ASSOCIATED LYMPHADENOPATHY?

Upon completion of the examination, it is helpful to summarise the salient

findings under the term ‘special pathology’.

Diagnosis
The diagnostic process requires consideration of the principal
mechanisms of surgical disease, as applied to the relevant tissue or organ
involved (Table 2-5). This exercise is traditionally referred to as the
‘surgical sieve’.

Table 2-5
Principal mechanisms of surgical disease

ANATOMICAL ABNORMALITIES – Congenital

Acquired

TRAUMA

INFLAMMATION – Acute

Chronic

NEOPLASIA – Benign

Malignant

TISSUE – Hyperplasia
GROWTHABNORMALITIES
Hypertrophy

Cyst formation

ISCHAEMIA ANDINFARCTION

METABOLIC ANDENDOCRINE
DISORDERS
Many diagnoses are apparent after an accurate history and examination
have been carried out, although it is sometimes necessary to consider a
list of differential diagnoses. Further specialised investigations may be
required to confirm the definitive diagnosis and to aid overall patient
management (Table 2-6). Some of these investigations require
consultation with other healthcare professionals, such as the patient’s
general medical practitioner or hospital consultant. It is essential that the
clinician determines and records the final, definitive diagnosis before
proceeding with treatment planning.

Table 2-6 Further investigation for minor oral surgery

Further investigation

ORO-FACIAL – Tooth vitality tests

Local anaesthetic injections

Oral microbiology swab

Fine needle aspiration biopsy

(FNAB)

Tissue biopsy

GENERAL – Temperature

Pulse

Blood pressure

Respiratory rate

Weight

Electrocardiogram (ECG)

HAEMATOLOGY and – Full blood count

BIOCHEMISTRY
Clotting studies

Urea and electrolytes

Blood glucose

Liver function tests

Serum calcium

RADIOLOGY – Dental panoramic tomograph

(DPT)

Periapical views

Occlusal views

Treatment Planning
A satisfactory treatment plan requires consideration of pre-operative,
operative and post-operative care, relevant to the individual patient and
their specific disease process. By way of example Table 2-7 summarises
the process as applied to the surgical removal of a lone-standing maxillary
molar tooth in an elderly diabetic patient on anticoagulant medication.

Table 2-7
Treatment planning example

CASE HISTORY – Elderly non-insulin dependent

diabetic patient on warfarin
(post-pulmonary embolus)
requiring extraction of a lone-
standing maxillary molar.

PRE-OPERATIVE – GENERAL PREPARATIONS

Ensure use of all regular

medications and normal diet

Out-patient local anaesthetic

appointment with
accompanying person

Up to date INR blood test

(consider warfarin adjustment in
consultation with patient’s
physician if INR >4.0)

Consider use of pre-emptive

analgesia and prophylactic
antibiotics (but beware
interactions between aspirin,
NSAIDs and metronidazole with
warfarin)

DENTO-ALVEOLAR – Radiographic assessment

Informed patient consent

Specific warnings re: tuberosity

fracture, oro-antral
communication (OAC)

OPERATIVE CONSIDERATIONS – Local anaesthetic administration

Transalveolar surgical approach

Identification and management of

any surgical complication.

POST-OPERATIVE CARE – Regular analgesic medication

Possible need for antibiotics or

ephedrine nasal drops if OAC
created.

Importance of maintaining normal

diet

Written post-operative
instructions and contact
telephone number for advice

Care at home upon discharge

As mentioned in Chapter 1, it is often appropriate for the practitioner to

refer the patient for treatment elsewhere. The reasons for referral include:

surgical competence

need for general anaesthesia

underlying medical condition.

Many patients who require surgical dentistry and who suffer from medical
conditions can be treated in a general dental practice. As a rough guide
the use of the American Society of Anesthesiologists (ASA) classification
of medical fitness is helpful (Table 2-8). This system provides a numerical
value to patient health. Patients who are classified as ASA III or above are
best treated in specialist centres.

Table 2-8
ASA fitness scale

ASA I Normal healthy patients

ASA II Patients with mild systemic

disease

ASA III Patients with severe systemic

disease that is limiting but not
incapacitating

ASA IV Patients with incapacitating

disease that is a constant threat
to life

ASA V Patients not expected to live

more than 24 hours

No matter where the patient is treated, part of the treatment planning

process includes consultation with other healthcare workers involved in
the management of medically compromised patients. It is better to receive
advice that might prevent potential problems in advance rather than seek
help to manage an acute complication or emergency (see Chapter 14).

Conclusions
Thorough assessment of the patient is essential for the safe practice of
minor oral surgery.

The taking of a good history is important in obtaining an accurate

diagnosis.

The patient’s medical status impacts on the practice of minor oral

surgery.

Further Reading
Moore UJ (ed). Principles of Oral and Maxillofacial Surgery. 5th edn.
Oxford: Blackwell Science, 2001.

Scully C, Cawson RA. Medical Problems in Dentistry. 5th edn. Oxford:

Wright, 2004.

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Jan 14, 2015 | Posted by mrzezo in Oral and Maxillofacial Surgery | Comments Off

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