Quartz 4

T2 Treatment Planning

13 min read

History Taking and Communication Skills12

Lecture 2: Reviewing the information regarding History Taking and Communication skills.

Contact: poh.hun.loh@uwa.edu.au

But first…

Effective history taking and communication are fundamental clinical skills required to establish a diagnosis and build a therapeutic relationship with the patient.

Core Objectives of the Clinical Interview3

  • Information Gathering: Systematically collecting details regarding the patient’s symptoms, medical history, and social context.
  • Establishing Rapport: Building trust and empathy to facilitate open communication.
  • Clinical Reasoning: Using the history to generate and refine differential diagnoses.
  • Patient-Centered Care: Understanding the patient’s perspective, including their ideas, concerns, and expectations (ICE).
  • Developing Shared Beliefs: It is important to interact well to develop and achieve shared beliefs between the clinician and the patient.
  • Developing Processes: Clinicians must work on identifying goals and developing processes from the very first interaction with the patient.

Essential Communication Techniques

  • Active Listening: Giving the patient undivided attention and acknowledging their narrative through verbal and non-verbal cues.
  • Questioning Styles:
    • Start with open-ended questions to allow the patient to tell their story in their own words.
    • Use closed-ended questions later to clarify specific details or confirm facts.
  • Non-Verbal Communication: Maintaining appropriate eye contact, posture, and facial expressions to convey engagement.
  • Sincerity and Empathy: The clinician must be sincere and, most importantly, empathetic during interactions.
  • Individualized Interaction: Be aware of how you interact with patients; every person is different, and you should not interact with everyone in the same way.
  • Signposting: Transitioning clearly between different sections of the history (e.g., “Now I would like to ask some questions about your past medical history”).

Structuring the History

  1. Patient Profile: Confirming identity and basic demographic details.

  2. Chief Complaint: Identifying the primary reason the patient is seeking medical attention.

  3. History of Presenting Illness (HPI): A chronological account of the current problem, including onset, duration, and severity.

  4. Past Medical History (PMH): Previous illnesses, surgeries, and chronic conditions.

  5. Medications and Allergies: Current prescriptions, over-the-counter drugs, and known adverse reactions.

  6. Family History: Relevant hereditary conditions or familial patterns of disease.

  7. Social History: Lifestyle factors including occupation, smoking, alcohol consumption, and home environment.

  8. Review of Systems (ROS): A systematic screening for symptoms in other body systems not yet covered.

    • This is a discrete stage where the majority of treatment and procedures occur.
    • Involves screening out "difficult persons" or complex management issues.
    • In cases where no disease is present, this phase may involve repairing restorations.

Phased Care and Treatment Planning

Rationale for Phased Care4

Phased care is essential for structured clinical practice and patient-centered outcomes for several reasons:

  • Patient Preferences: Not everyone wants or requires complex care.
  • Prioritization: Needs are addressed in a logical sequence or order of priority.
  • Flexibility: Patients can defer treatment or proceed with further stages as needed or desired.
  • Resource Management: Allows for better management of time and costs.
  • Clinical Structure: Provides a necessary framework for early-career clinicians to develop structured treatment plans.
  • Future Planning: Enables the patient to plan for future dental needs.

Phases of Dental Treatment5

Dental treatment is organized into the following sequential phases:

  1. Assessment and diagnostic phase
  2. Emergency/Urgent/Acute Phase
  3. Control/Holding/Stabilisation phase
  4. Reconstructive/Rehabilitation/Reorganisation phase
  5. Maintenance phase

Assessment and Diagnostic Phase6

The initial phase of care involves a comprehensive evaluation to establish a clinical baseline:

  • This phase involves the initial assessment and "ballistic" fires (initial evaluation) of the patient's condition.

  • History

  • Patient Examination

  • Diagnostic tests and Opinions

  • Diagnosis

Emergency and Acute Phase7

The primary objectives of this phase are to address immediate clinical concerns:

  • Manage life-threatening conditions
  • Control pain
  • Control infection
  • Provide a measure of comfort, function, and temporary aesthetic rehabilitation
  • Address mental emergencies to preserve health and prevent future infections.

Control and Stabilization Phase8

This phase focuses on halting disease progression and protecting existing structures:

  • Eliminate:
    • Pain
    • Infection
    • Inflammation
  • Preserve:
    • Residual dentition

Reconstructive and Rehabilitation Phase9

This phase involves definitive restorative work and functional improvements:

  • Definitively replace lost tissue
  • Re-organise, re-develop, or define occlusion
  • Perform elective procedures for aesthetic improvement
  • Focuses on long-term, permanent, definitive replacements.
  • Analogous to "reorganizing the frozen" or "redeveloping the kitchen" to achieve a "win-win" outcome.

Maintenance and Preventive Phase10

The final phase ensures long-term success and health through ongoing care:

  • Maintain reconstructions
  • Monitor oral hygiene
  • Implement preventive regimes to avoid the return of pathology
  • Focus on harm/risk reduction and minimisation
  • Relies heavily on the patient's level of commitment, such as returning for regular check-ups every six months.

Clinical Decision Making and Flexibility111213

Determining which procedure fits into a specific phase can be confusing, as the boundaries between phases are flexible.

Certain procedures may be categorized differently depending on the clinical context:

  • Dentures: May be used for temporary aesthetics (Acute/Stabilization) versus definitive replacement (Reconstructive).
  • Extracting Teeth: May be performed to alleviate pain (Acute) versus improving function (Reconstructive).
  • Temporary Crowns: Utilized in the stabilization phase to establish an occlusal scheme.
  • Endodontic Treatment: May involve pulp extirpation for an acute condition versus elective treatment to gain retention for a restoration.

Despite clinical flexibility, two priorities must be established early in the planning process:

  1. Control Disease and Pathology
  2. **Patient Goals and Expectations

Longevity and Trends

  • The history of a patient's dental work provides a window into the longevity of future treatments (e.g., being problem-free for 10-20 years).
  • Generally, plastic restorations may have a similar outlook regarding the patient's clinical standing.**

Systematic Treatment Sequencing

I. Systemic Treatment14

  1. Consultation with patient’s physician
  2. Premedication
  3. Stress/fear management
  4. Necessary treatment considerations for systemic disease

II. Acute Treatment

  1. Emergency treatment for pain or infection
  2. Treatment of the urgent chief complaint when possible

III. Disease Control

  1. Caries removal to determine restorability of questionable teeth
  2. Extraction of hopeless or problematic teeth
    • Possible provisional replacement of teeth
  3. Periodontal disease control
    • Oral hygiene instruction
    • Initial therapy (scaling and root planing, prophylaxis)
    • Controlling other contributing factors (replacing defective restorations, removing caries, reducing parafunctional habits/smoking)
  4. Caries control
    • Caries risk assessment
    • Provisional (temporary) restorations
    • Definitive restorations (e.g., amalgam, composite, glass ionomers)
  5. Replace defective restorations
  6. Endodontic therapy for pathologic pulpal or periapical conditions
  7. Stabilization of teeth with provisional or foundation restorations
  8. Posttreatment assessment

IV. Definitive Treatment

  1. Advanced periodontal therapy
  2. Stabilize occlusion (vertical dimension, anterior guidance, and plane of occlusion)
  3. Orthodontic and orthognathic surgical treatment
  4. Occlusal adjustment
  5. Definitive restoration of individual teeth (endodontically treated teeth, key teeth, and others)
  6. Esthetic dentistry (esthetic restorations, bleaching)
  7. Elective extraction of asymptomatic teeth
  8. Prosthodontic replacement of missing teeth (fixed partial dentures, implants, removable partial dentures, or complete dentures)
  9. Posttreatment Assessment

V. Maintenance Therapy

  1. Periodic visits

Principles of History Taking

History taking can be summarized by the question: “What do you want?”

Components of History Taking15

  • Presenting complaint
  • History of presenting complaint
  • Dental history
  • Medical history

Factors Influencing Treatment Plans16

The development of a treatment plan depends on several critical factors:

  • History
  • Thorough assessment, evaluation, and clinical findings
  • Diagnosis
  • Problem list
  • Treatment options
  • Indications and contraindications
  • Prognosis
    • Short term
    • Medium term
    • Long term

Patient-Centered Factors17

  • Relationship with clinician
  • Expectation
  • Attitudes and motivation
  • Age
  • Gender
  • Cost and finances
  • Attendance
  • Maintenance

Building Rapport and Communication

Core Skills18

  • Asking the right questions.
  • Listening.
  • Patients seek help and advice, which requires establishing a background.
  • Patients are simultaneously deciding whether to place their confidence in the clinician.
  • History taking is a clinical skill that requires time to develop.

Establishing Connection19

  • Make small talk and build rapport to relieve anxiety.
  • Identify social and family issues.
  • Information gathered helps both the clinician and patient make decisions later.
  • Facilitates effective patient management.

Clinical Observation During Interaction20

  • Use humor (“Make ‘em laugh”) to observe the patient naturally.
  • Evaluate the smile line.
  • Observe tooth length and worn teeth.
  • Assess the incisal and occlusal plane.
  • Note if patients try to hide or camouflage their teeth.
  • Assess speech patterns.
  • Clinicians should observe how patients interact and be mindful of their specific management needs.

Managing Upset or Anxious Patients21

What about the challenging patient?

Clinical Approach22

  • Most patients are reasonable with reasonable requests.
  • Some patients present in pain, or are anxious and fearful of dentists.
  • Avoid being formulaic in your approach.
  • Sincerity is key.
  • Demonstrate empathy, care, and compassion.

Non-Verbal Communication23

  • Be mindful of body language.
  • Avoid looking at the clock.
  • Maintain eye contact; look at the patient’s eyes rather than just their teeth or mouth.
  • Sit at the same level as the patient.
  • Remove masks and gloves during the initial conversation.

Management Strategies24

Verbal Techniques25

  • Use supportive words:
    • “I’m really sorry to hear that”
    • “That sounds unbearable”
    • “How can I help you?”
  • Utilize open-ended questions.
  • Allow sufficient time for the patient to answer.
  • Avoid talking over or talking down to the patient.
  • When a patient has not followed a medical regimen (e.g., not taking medicine), the clinician should ask investigative questions such as, "First of all, tell me what was the problem with taking the medicine?"

Components of the Clinical History

Presenting Complaint26

The presenting, primary, or chief complaint may be described as an issue, worry, or problem.

Interviewing Techniques27

  • Tailor your performance to the specific patient.
  • Resist the temptation to fill in blanks or answer for the patient.
  • Read between the lines of what is being said.
  • Consider if there are languages involved other than English.

Categories of Complaints (Rosenstiel 2006)28

  1. Comfort
    • Pain, sensitivity, swelling
  2. Function
    • Difficulty eating or speaking
  3. Social
    • Bad taste or odour
  4. Appearance
    • Missing or fractured teeth

Investigative Questions29

  • What?
  • Why?
  • Where?
  • When?
  • How?

Conversational Reframing Tips

Instead of saying thisSay this
I’m retiredI have worked a lifetime to finally be free of servitude
Can you help me?If you care to help it might go faster. There’s much work to do
Thank you.Thank you for bringing peace to my valley
It runs in your blood.You are a Mandalorian! Your ancestors rode the great Mythosaur. Surely you can ride this young foal.
It’s my way or the highwayI have spoken

Dental History

Patient Background30

  • Relies on the patient’s memory.
  • Pattern of attendance.
  • Level of commitment.
  • Previous records.
  • Previous dentist(s):
    • Names
    • Attitude
    • Quality of previous dentistry - Patient Attitude: In certain settings, patients should be grateful for the care they are receiving. - Lifestyle Factors: Patients may present with busy, hectic lives that interfere with their treatment compliance.

Specific Dental History Items31

  • Orthodontics
  • Wisdom teeth
  • Dento-facial trauma
  • Longevity

Risk Factors and Medical History

Risk Factors for Oral Disease32

History taking provides a window into various risk factors:

  • Medical conditions and co-morbidities
  • Smoking
  • Alcohol
  • Drug use
  • Diet and nutrition
    • Non-medical Alternatives: Patients may express a desire to discuss non-medical alternatives rather than standard medicine.

Clinical Application and Forms

Patient Contact and Records

Patient Contact Details33

  1. Complete the following only if there are changes to the Titanium System contact details. Advise OHCWA Reception of any changes as soon as possible.
    • Street address
    • Suburb/Town
    • State
    • Postcode
    • Telephone numbers (1, 2, and 3)

Special Needs

  1. Outline any special needs (e.g., physical disability, hearing impairment, language translation, carer, etc.):

Medical Practitioner Information

  1. a. Are you under the care of a medical practitioner (family doctor) or specialist?

    • If yes, provide:
      • Name of medical practitioner
      • Reason for care
      • Contact details

  2. b. Approximate date of your last medical appointment:

Medical History Questionnaire

  1. Please indicate Yes or No for the following conditions and provide details in the box below:

  • Cardiovascular Health

    • Any heart (cardiac) complaint/treatment
    • Rheumatic fever or heart murmur
    • Chest pain/angina/previous heart attack
    • Palpitations or irregular heartbeat
    • High/low blood pressure
    • Heart pacemaker/artificial heart valves
    • Anti-coagulant or blood thinning (See Q5)

  • Respiratory and Sleep

    • Shortness of breath on exertion or troublesome shortness of breath
    • Regular snoring or sleep apnoea
    • Chest trouble/breathing difficulties/asthma
    • Tuberculosis
    • Smoker (provide details on substance, quantity, and frequency)

  • Hematology and Healing

    • Bleeding or bruising easily
    • Problems with extractions/wound healing
    • Blood disorders including anaemia/blood clotting problems
    • Hepatitis, jaundice, and/or liver problems

  • Systemic and Other Conditions

    • Osteoporosis or low bone density/other bone diseases
    • Thyroid disease including goitre
    • Diabetes or family history of diabetes
    • Radiotherapy or chemotherapy (See Q5)
    • Stomach ulcers/other intestinal problems
    • Acid reflux or regular indigestion
    • Epilepsy/nerve/nervous system problems
    • Bladder or Kidney problems
    • Hip or knee joint replacement surgery
    • Past or current, long or serious illnesses
    • Hospitalised or undergone operations
    • Problems or complications with past operations, procedures, or anaesthetics

  • Allergies

    • Allergies or reactions to medications (e.g., penicillin, antibiotics, local/general anaesthetics, or injections)
    • Allergies or reactions to chemicals or substances (e.g., latex, resins, iodine, nickel)

  • Females

    • Pregnant or possibly pregnant

Details:

Medications

  1. List any medications you are taking or have recently stopped taking (including recreational, herbal, prescribed, over-the-counter, supplements, etc.):

Staff use only: Highlight or place medical or drug alert sticker where appropriate.

Patient Acknowledgment and Privacy

  1. In signing this form, I acknowledge that this represents an accurate medical history. I will advise my clinician of any changes to my medical history in the future. I understand that all medical details will be treated with complete professional confidentiality. I understand that the OHCWA privacy policy is available on request, at all reception desks, and on the OHCWA website.
  • Patient Signature (Parent/guardian if under 18)
  • Date
  • Clinician Signature and ID
  • Supervisor Signature and ID (if student clinician)

Medical History Re-evaluation and Health Record Review

Are there any changes to the Medical History (Question 4) or Medications (Question 5) previously recorded?

  • If yes, provide details below (if significant changes occur, complete a new Form 1).
  • If no, proceed to signature.

Details of changes:

  • Patient Signature (Parent/guardian if under 18)
  • Date
  • Clinician Signature and ID
  • Supervisor Signature and ID (if student clinician)

Clinical Protocols in the OHCWA Context

Pre-Appointment and Patient Reception34

  • Read previous notes before the appointment.
  • Briefly outline the ATS (Assessment, Treatment, Summary) to your tutor regarding your aim for the appointment.
  • Collect the patient from the waiting room and introduce yourself.

Patient Positioning

  • Seat the patient in the chair comfortably.
    • Adjust the headrest.
    • Provide a pillow or towel.

Footnotes

  1. Original PDF page 1: L2 TxPlan, p.1 ↩

  2. Original PDF page 2: L2 TxPlan, p.2 ↩

  3. Original PDF page 3: L2 TxPlan, p.3 ↩

  4. Original PDF page 4: L2 TxPlan, p.4 ↩

  5. Original PDF page 5: L2 TxPlan, p.5 ↩

  6. Original PDF page 6: L2 TxPlan, p.6 ↩

  7. Original PDF page 7: L2 TxPlan, p.7 ↩

  8. Original PDF page 8: L2 TxPlan, p.8 ↩

  9. Original PDF page 9: L2 TxPlan, p.9 ↩

  10. Original PDF page 10: L2 TxPlan, p.10 ↩

  11. Original PDF page 11: L2 TxPlan, p.11 ↩

  12. Original PDF page 12: L2 TxPlan, p.12 ↩

  13. Original PDF page 13: L2 TxPlan, p.13 ↩

  14. Original PDF page 14: L2 TxPlan, p.14 ↩

  15. Original PDF page 15: L2 TxPlan, p.15 ↩

  16. Original PDF page 16: L2 TxPlan, p.16 ↩

  17. Original PDF page 17: L2 TxPlan, p.17 ↩

  18. Original PDF page 18: L2 TxPlan, p.18 ↩

  19. Original PDF page 19: L2 TxPlan, p.19 ↩

  20. Original PDF page 20: L2 TxPlan, p.20 ↩

  21. Original PDF page 21: L2 TxPlan, p.21 ↩

  22. Original PDF page 22: L2 TxPlan, p.22 ↩

  23. Original PDF page 23: L2 TxPlan, p.23 ↩

  24. Original PDF page 24: L2 TxPlan, p.24 ↩

  25. Original PDF page 25: L2 TxPlan, p.25 ↩

  26. Original PDF page 26: L2 TxPlan, p.26 ↩

  27. Original PDF page 27: L2 TxPlan, p.27 ↩

  28. Original PDF page 28: L2 TxPlan, p.28 ↩

  29. Original PDF page 29: L2 TxPlan, p.29 ↩

  30. Original PDF page 30: L2 TxPlan, p.30 ↩

  31. Original PDF page 31: L2 TxPlan, p.31 ↩

  32. Original PDF page 32: L2 TxPlan, p.32 ↩

  33. Original PDF page 33: L2 TxPlan, p.33 ↩

  34. Original PDF page 34: L2 TxPlan, p.34 ↩

Graph View