Chapter 1

Patient Assessment and Presentation of Treatment Options

Aim

The aim of this chapter is to outline the process from initial patient contact to arrival at a treatment plan. An algorithm is suggested to assist methodical data collection and diagnosis.

Outcome

After reading this chapter, the clinician should be able to provide a framework within which to accumulate and interpret clinical findings in order to formulate a relevant treatment plan for individual patients.

Introduction

During the first consultation, both the patient’s presenting complaint and its history should be recorded in the patient’s own words and be as detailed as possible. The record should act as a focus during examination, and the final treatment option must fully address this complaint. A record must be made of any previous treatment for the same complaint to assist in the analysis of success or failure. A complete patient record consists of three phases:

• patient history

• dental examination

• special tests.

Patient History

A complete patient history should include:

• Dental history – a record of past attendance, treatments and associated complications following treatment. It should address any history of trauma and reasons for extraction of teeth. The former is significant as teeth may, as a consequence, be compromised, and the prognosis for treatment involving these teeth can be less favourable. Loss of teeth may be an indicator of caries or periodontal disease susceptibilities and suggest difficulties with replacement of missing teeth from ongoing caries or soft tissue recession and attachment loss.

• Medical history – this can be recorded using a variety of methods, but before treatment the following questions must be addressed:

  • Will any element of the patient’s medical history affect dental treatment?

  • Will any element of the patient’s dental treatment affect his or her medical status?

  • Is the patient taking any medic