07/07/2023
New Patient Assessment, Consent, Note Keeping
New Patient Assessment
-Information gathering – everything you need to know about the patient before touching the patient
(interviewing & interrogating)
Medical, dental, social & family, history of presenting complaint
What do they want from the visit – setting an agenda
oImportant for treatment planning as you should centre treatment around the presenting
complaint
-Reasons for attendance include pain, decay, swelling/ulcer/patch, aesthetics, bleeding gums/loose tooth,
bad breath
May have incidental findings
Pain: SOCRATES
Decay: duration, associating features (diet etc), number, appearance, function, can they identify
where it is and have they had any work before (particularly on that side)
Swelling, ulcers, patch: similar to SOCRATES, size, any associated medical conditions
Aesthetics: shape, size, colour, length, gaps, placement etc
Bleeding gums/loose tooth: site, when did you notice, does anything make it worse, when did it
start, dark red/light red, bleeding could be due to systemic disease
Bad breath:
Medical History
-Work through systems: all systems have an
impact on the patient
-ASA (American Society Anaesthesiology): risk
assessment
Does not take into account disabilities
Unlikely to treat patients over grade 3 as
these would be referred to special care
dentistry
Grade 3: multiple medications, have to
rest whilst climbing the stairs
Variables you need to consider
Does not replace medical history
-Mobility/dexterity issues
Not considered by ASA
-Surgical sieve – can be anatomical (consider from every anatomical/histological structure) or surgical sieve
(all things that may be causing) – can use mnemonic VITAMIN CDEF
Vascular
Infective/inflammatory
Trauma
Autoimmune
Metabolic
Iatrogenic
Neoplastic
Congenital
Degenerative
Endocrine/Environment
Functional
-Surgical sieve helps identify common prevalent diseases – what oral manifestations may you see in the
head and neck
