Anamnesis, clinical and complementary examinations in the dental office
All medical and dental history reported by the patient during the medical interview/questionnaire or combination of the two procedures.
The anamnesis contains: the reason for the patient’s presentation, history of the disease, hereditary-collateral history (general and oromaxillary history), general personal history (physiological and pathological), local personal history (main dental lesions, extractions, signs of periodontal disease, dental treatments, parafunctions, vicious habits).
The first session in the dental surgery is always dedicated to getting to know the patient and obtaining as much information as possible to facilitate the next steps of the therapy.
Anamnesis is the questionnaire through which the dentist becomes familiar with the patient’s conditions and the patient’s wishes regarding the treatment plan.
Although it may seem useless or boring to the patient, the amount of information acquired through this medical questionnaire facilitates further communication and reaching a common therapeutic point.
Information obtained through the history
General data about the patient: age, place of work and standard of living are information that can guide us towards certain pathologies.
Old age may be associated with periodontal disease or general conditions requiring a different approach to dental therapy and some jobs involving the use of powders or powders may have an abrasive effect on teeth.
Information on brushing frequency and type of toothbrush used provides clues about the patient’s dental hygiene status, which is then correlated with the results of the endooral examination.
Reason for presentation: often patients’ wishes may differ from those of the dentist.
Thus, the reasons for presentation may be pain, bleeding, difficulty in chewing, swallowing or aesthetic causes.
Other times the patient may be bothered by abnormal tooth mobility or just wants a routine check-up to prevent or detect oral pathologies at an early stage.
History of the disease: the patient will give information about the onset of the disease that referred him/her to the dentist and, if associated with pain, explain the conditions of its onset.
General and local conditions: any general pathology (cardiac, renal, hepatic, neurological) will be mentioned. Any hospitalizations and surgical operations will also be mentioned. Great importance is also attached to medication; any current treatment will be indicated by the patient.
In relation to local pathologies, interventions in the oral cavity (dental, surgical, prosthetic) should be mentioned.
After taking a history, the dentist will examine the patient closely.
By inspection and palpation, both extra oral and normal structures will be examined.
Asymmetries, interruptions of bone contour or areas of marked sensitivity may be detected extra orally.
In the oral cavity, carious lesions, prosthetic work, the materials from which they are made and the arching, as well as the appearance of the oral mucosa, the level of the gingiva and its color will be examined.
The complementary examination follows the clinical examination and provides additional information about the oral cavity as whole, details that cannot be seen by simple inspection or palpation.
It consists of performing:
Study models – important to explain the steps of treatment to the patient and to give the doctor time to think about the best therapeutic solutions.
X-rays – periapical, orthopantomograms or CBCT, for additional information about structures that are not directly visible and to establish relationships between different formations
Photographs – used to illustrate the differences between the dental status before and after treatment.
Although the whole process of obtaining information can be time consuming and the patient may be dissatisfied, in reality, following these steps makes the next steps easier.
Having a good baseline before starting treatment reduces the risk of complications and increases the rate of therapeutic success.
