Case 1
Examination and Documentation

CASE STORY

A 55‐year‐old Caucasian female presented with a chief complaint of: “My mouth is always dry, and I have difficulty swallowing.” She said, “I was recently diagnosed with scleroderma, and my doctor told me I should see a dentist.” The vital signs were blood pressure: 159/92 mmHg; respiration: 16 breaths/min; pulse: 72 beats/min, temperature: 98°F; and nonsmoker.

PROBLEM‐BASED LEARNING GOALS AND OBJECTIVES

• Discuss the role of the patient's medical, social, and dental histories (comprehensive health history) in the patient examination
• List and describe the five parts of a comprehensive clinical examination
• Differentiate between types of findings in a clinical examination including signs and symptoms, and significant and insignificant findings
• Discuss the definition, purpose, and methods of documentation
• Identify the components of care documented in the patient's permanent record

Medical History

The patient was diagnosed with scleroderma and gastroesophageal reflux disease (). She is taking antacids for GERD and immunosuppressant medications and a calcium channel blocker for scleroderma.

Dental History

The patient reported that her last dental visit was one year ago. She has a history of childhood caries but has been caries free since college. Also, she has symptoms of dry mouth and difficulty opening her mouth and swallowing.

Social History

The patient is a self‐described over‐achieving professional concerned about her health and the appearance of her teeth. She lives with her husband in a suburb of Manhattan, has three adult children, and enjoys reading.

Review of Systems (Physical Examination)

Gastrointestinal Examination

The patient has difficulty swallowing (dysphagia) and GERD.

Cardiovascular Examination

The patient has a history of Raynaud's phenomenon and hypertension (BP: 159/92).

Cutaneous Examination

The patient stated that her fingers are extremely sensitive to the cold. The skin of her hands appeared shiny and stretched with varying degrees of pigmentation. The patient struggled to hold the pen while signing consent forms.

Head and Neck Examination

Extraoral

The patient exhibited microstomia restricting her mouth opening (<20 mm), and the lips were thin and stretched.

Intraoral

Examination of the major and minor salivary gland duct openings showed loss of quality and quantity of saliva.

Periodontal charting showed areas of bleeding on probing without CAL (clinical attachment loss).

Generalized fibrotic changes in mucosal tissues were noted with mucogingival paresthesia. Oral mucosal tissues appeared pale and tight with hardening of the soft palate. The patient's GI score was 2. Several restorations and crowns were noted. No caries present. Generalized moderate biofilm accumulation was apparent. The debris index () and the calculus index () were both scored as 1 (debris and calculus covered less than 1/3 of the examined tooth surfaces).

Class I: right and left sides; teeth #7 and #10 are in torso version and overlap slightly with #8 and #9.

Radiographic Examination

No significant findings.

Dental Hygiene Diagnosis

Problems

Related to Risks and Etiology

Xerostomia

Loss of quality and quantity of saliva and scleroderma Goal: The patient will experience relief from xerostomia due to scleroderma immediately upon initiation of local and systemic measures to stimulate saliva flow

Increased periodontal disease risk

Insufficient daily biofilm management, limited hand strength and mouth opening as evidenced by gingival inflammation and a high GI score Goal: The patient will reduce the GI score from 2 to <1.0 by the next visit

Increased caries risk

Low salivary flow, inadequate biofilm management and fluoride intake, an acidic environment created by GERD, and a soft, high carbohydrate diet because of dysphagia Goal: The patient will suppress potential bacterial activity by increasing caries protective factors

Blood pressure elevated above treatment goal for patients <65 years old

Blood pressure readings of 159/92 Goal: Patient will report having blood pressure evaluated by a physician before rescheduled visit

Planned Interventions

Planned Interventions (to arrest or control disease and regenerate, restore, or maintain health)

Clinical

Education/Counseling

Oral Hygiene Instruction

BP was taken at every visit Initial exam, FMS radiographs, Adult prophylaxis In‐office 5% sodium fluoride varnish Three‐month continuing care interval because of scleroderma and associated medicine risks Referral to primary care physician for blood pressure evaluation Referral to occupational therapist to manage symptoms of scleroderma

Significance of management of xerostomia Determine patient’s motivation to reduce plaque accumulation and oral disease risks: “What are possible benefits of removing plaque?” “On a scale of 1–10, how confident are you that you can reduce your plaque score?” Increased risk of caries because of lack of fluoride and soft, high carbohydrate diet Provide information on alternative self‐care aids such as an enlarged or extended toothbrush handle, a powered toothbrush and flossing device Correlation of hypertension to general health

Use of prescribed cholinergic agonist agent Frequent use of water and saliva substitutes (Tolle 2012) Use of chlorhexidine for reduction of bacterial and gingival inflammation and prevention of Candida (Spolarich 2011) and a daily 1.1% sodium fluoride (prescription) mouthrinse for caries reduction (Featherstone 2000; Tolle 2012) Use of pump‐type toothpaste dispenser and a power toothbrush with child‐size brush inserts, interdental aids with elongated and enlarged handles or flosser with a toothbrush‐like handle (Yuen et al. 2011)

Progress Notes

The patient arrived on time for her appointment and was treated without delay. A complete medical, social, and dental history was taken. An initial exam, FMS and adult prophylaxis were performed followed by an application of 5% sodium fluoride varnish. The patient was advised to see her physician for a BP evaluation and an occupational therapist for effects of scleroderma on daily living.

Discussion: Examination and Documentation in Patient Assessment

Patient assessment represents the most important step in the dental hygiene process of care because it provides a baseline of information, opens a dialogue between the patient and provider, and establishes trust and confidence in their relationship (Figure 1.1.1). All information collected during the assessment process is inextricably bound to each other. Information from the patient history is used to distinguish significant from insignificant findings in a clinical examination, helps generate a list of dental hygiene diagnoses, and ultimately leads to the formation of an individualized care plan.

Figure 1.1.1: Assessment as detective work.

During an examination, the dental hygienist documents findings as signs of health or disease. On the other hand, findings revealed by the patient are referred to as symptoms of their problems. The chief complaint or concern is the primary reason that patients present for treatment and should be the first diagnostic statement in the care plan (Wilkins et al. 2017). Typically, the chief complaint is a symptom or a request and may need to be elicited by asking open‐ended questions such as, “What brought you to the dental office?” or “Is there anything you hope I can do for you?” Paying close attention to a patient's chief concern(s) serves many purposes: it alerts the provider to relevant diagnostic information; it offers insight into a patient's perception regarding his or her problems; and finally, it provides insight into the patient's health literacy including their level of knowledge about dentistry.

A comprehensive clinical exam is made up of five parts (Figure 1.1.2).

1. The Physical Exam or Review of Systems (ROS) is a list of questions, by organ system, intended to uncover disease or dysfunction. The list is often given to patients before treatment. Along with the medical history, the ROS assists in determining a patient's MCS or ASA (methods for physical status classification). When using the ROS, clinicians must be aware of associations between noncommunicable diseases and oral disease because they share common risk factors as well as underlying infection/inflammation pathways (Jin et al. 2016).
2. The Extraoral and Intraoral Soft Tissue...