The subject of medical record keeping is no less important in dentistry than it is in medicine. It is critical that dentists keep a permanent record of all data collected for a patient, and that the information collected includes their previous medical history and current medical conditions. For an article on the importance of record keeping in dentistry, you may want to follow this link.
Organization of this Chapter
You May Skip to Whatever Subject Interests You Now
Basics
Health History
What the Dentist Measures in the Office
Unrecognized High Blood Pressure
Temperature
What the Dentist Checks in the Office
The Lymph Nodes
Jaw Movements
The TMJ
Existing Conditions Record
Bottom Line
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Basics – the Patient Chart
The dentist will keep a chart, either in paper folders, or on a computer data base (with appropriately high security). In this chart will be the Health History form, the results of the soft tissue examination, the X-rays taken and their dates, the periodontal chart, possibly an esthetic evaluation, including pictures from various angles, a Record of Existing Conditions, the Problem List (including the Chief Complaint), the Sequenced Treatment Plan with options (visit Chapters VI.1 and VI.2 for more on treatment plans), and the Progress Notes.
We’ve discussed, elsewhere in this Section, things that are evaluated directly in the patient’s mouth – but very valuable information relies on the patient having accurately filled out the Health History Form – which is a key part of any patient chart. This has to do with SYSTEMIC health as opposed to ORAL health.
Another critical part of the Patient Chart is the Progress Notes. Here the dentist will write down what he has observed, measured, that does not have its own form, said to you, heard from you and DONE.
We’ve discussed most of these records previously in this section, but the Health History and recordings made in the Progress Notes are particularly vital.
Health History
You’ve all seen these forms in doctor’s and dentist’s offices before. Some are more complete than others in both fields.
The reason why the dentist needs to know everything about your health is that he may be planning to do things that would interact adversely with your health issues, and be prescribing things that would interfere with what you are already taking.
It is important that the dentist knows what medical and health problems you have, and what you are doing about each one. If you have diabetes and are taking insulin, he needs to know how often you are taking insulin and what is your record of blood sugar control – are you well controlled or haphazard? If he needs to do a procedure that might require anesthesia and may elicit anxiety for you, the blood sugar level needs to be reasonable, and not reactive to stress.
Perhaps you have had a cardiovascular accident within the last six months – a heart attack. What was done about it? If there is a potentially traumatic dental procedure to be done, does the cardiologist think there are special precautions that need to be taken?
If you are taking blood thinners for fear of making clots in the vessels that could lead to a stroke – the dentist may well have to make adjustments in this medication so that bleeding after an extraction is not excessive. This is done in collaboration and with the suggestions of the physician that is involved.
Maybe your blood pressure is high and you are not taking any medication at all. You may not even know you have a blood pressure problem, but if you do it must be mentioned on the health history form, and discussed.
Of course, an important part of this form is the list of medications taken, including over-the-counter supplements. While dentists don’t tend to prescribe many pharmaceuticals – pain killers, anti anxiety drugs, and antibiotics are three large areas where they do.
The dentist cannot DO work on a patient, or prescribe medications unless he has all of the information about the patient that is relevant, and it is ALL relevant.
What the Dentist Measures in the Office
Blood pressure is one of the most important things that the dentist will measure. After the dentist knows the patient for some time, the BP may not be taken for routine procedures, but if there is something potentially more traumatic it should be measured.
Unrecognized High Blood Pressure
One year I had a father and son come into my dental practice. They came as new patients for getting check-ups. I went through the initial screening, having them fill out forms, etc – but when it came time to check their blood pressures I was SHOCKED! Most people know that normal blood pressure is 120/80. High blood pressure starts at 140 or 90. Very high blood pressure is considered 160 or 95. Well – BOTH the father and son had blood pressures of 200/110! And – they had no idea that either had any blood pressure problems.
Well, this father and son were disasters waiting to happen. There is something we call Familial Hypertension – and they had it in spades.
What did I do? First I told them, calmly, about the problem and the potential effects. Then I said that we would forego any evaluations of their dental condition in view of the fact that their blood pressures needed to be looked at, IMMEDIATELY. I knew where the closest hospital was, and so did they, and I encouraged them to simply drive over there to the ER and get checked out, as they had no family doctor.
It might have been wise for me to insist on driving them to the ER, simply to KNOW that they went – but they seemed to understand the need to go and were preparing to go directly there. I know they never came back to my practice after that and I never found out the results of their medical evaluation – but the best I could do was to see that they were aware they needed help, and I sincerely hope they got it.
Many dentists would not have known that these two men had high blood pressure, and would proceed to do procedures without realization that they were putting their patient’s lives at risk!
Some dentists will also check the level of oxygenation in the patient’s blood. This is really easy to do these days – simply clip that little device to the patient’s finger tip and it will read pulse rate and percent oxygenation. If the pulse is pretty normal and the oxygenation is 95% or better, then there is no concern. But, patients that have breathing problems associated with lung disease may well have low oxygenation, and the dentist needs to know that. Again, it may be that the patient doesn’t even know.
Sometimes the dentist will take the patient’s temperature. It must be known that they might be fighting an infection and that infection may be more systemic than localized to the mouth, or perhaps spread out FROM the mouth to the body more generally. To see if the body is reacting to any infection is important.
Temperature
If you are running a temperature significantly above normal, then that is a sign that your body’s immune system is working to fight off some kind of infection. This could be a viral or bacterial infection.
The dentist will NOT prescribe antibiotics for you, since the regulations prohibit him/her from prescribing for anything other than oral infections. And, of course, antibiotics are not of use for viral infections anyway.
It is possible that the dentist will defer treatment, depending on what is being done, based on this elevated temperature.
For example, if root planing is scheduled, it is likely that bacteria from the mouth will enter the blood stream during the therapy. The additional load of bacteria to your blood stream is of little significance for typical people when they are NOT fighting some other infection. But, if they ARE fighting another infection, it can put more of a load on the immune system, which is not desired.
And, certainly, if your temperature is elevated, and you have a history of bacterial colonization of a heart valve or other related structure, the dentist will NOT do anything to potentially compromise your body dealing with what may be a serious condition.
What the Dentist Checks in the Office
There are other things we haven’t mentioned previously that the dentist MAY check, particularly for a new patient.
Lymph Nodes
Following up on the possibility of infection, which may be revealed by temperature, the dentist may also check the patients lymph nodes in the neck, particularly under the chin on the right and left sides. Also there is a chain of nodes running down the neck on the right and left sides. If there is noticeable swelling or pain to touch in these areas, it is an indication that there is an infection somewhere in the mouth area, and this will suggest the dentist looks carefully to find out where. The patient may not even be aware that they have an infection – perhaps they have a necrotic tooth which is infected into the bone but isn’t that sensitive to touch yet and has not produced a throbbing toothache. The dentist will look as well at every root apex on the X-rays to see if that might be the case.
I was taught in dental school to also check the lymph nodes just behind the collar bones, right and left. Few dentists do that these days, but if there are swollen nodes there it may be an indication of infection or immune reaction to something in or around the lungs. Fortunately I never had to report to a patient that they might have a problem there.
Jaw Movements
Also, the dentist should check the movement of the patient’s jaw – right-to-left and forward and back. This goes along with an evaluation of the state of wear to the teeth. As we’ve discussed, the mouth is designed so that the canine teeth will make the back teeth and front teeth separate as the jaw is shifted right-to-left and forward, respectively.
If the patient has ground down their canines and this causes what we call GROUP FUNCTION in the back of the mouth (all of the back teeth grind on each other in lateral movement), then this has potential ramifications for doing any restorations in the back of the mouth. Also, if the patient’s anterior teeth are grinding on each other during protrusive movements – in and out – it has implications for how things are managed if these front teeth need to be restored.
These observations should be noted on the patient’s chart in a way so that the dentist will notice these limitations when designing a treatment plan, or during any routine visits.
The TMJ
Also, the dentist will check the movement of the jaw as he/she feels the TMJ joint itself. You can do this for yourself as well. Place your index fingers just in front of your ears on both sides and slightly open and close your mouth. You can feel a hard bump in each area and you can feel that it is moving a little as the jaw opens and closes.
At this point, with slight opening and closing of the mouth, the condyle of the TMJ, which is what you are feeling, is simply rotating. As it is irregular in shape, you can feel this rotation as a little movement. But, NOW open the mouth farther and what happens? You can feel the condyle MOVE downward – this is as the condyle moves down the slope of the fossa in which it sits.
These tactile observations of the TMJ are normal. What is NOT normal is if there is a distinct clicking feeling or snapping sound as the jaw opens and closes. Also, if there is any difference between the way the two sides feel in slight and wider mouth opening, it indicates something amiss. Whether there is anything that needs to be done is largely up to the comfort level of the patient, but irregular movement and clicking indicates that if the patient is comfortable now, this may not last – and the joint should be monitored. It may even suggest an X-ray scan of the joint, or even an MRI to see if there is something organically wrong with the joint.
Typically, if the joint is in serious trouble, including arthritic degradation, the patient will be well aware of it due to pain in movement. But, when the dentist can detect early stages of structural or functional problems, it is an important observation and follow-up may reveal an underlaying issue that can best be addressed when recognized early.
Existing Conditions Record
The Existing Condition Record is another diagram that the dentist should have as part of the patient’s chart. On this page, whether it is on paper or in digital format, will be indicated what has previously been done to the teeth. There will be indications of missing teeth, the existence of bridges, where fillings are located and what the restorative material is, and also an indication of decay that exists and needs to be taken care of.
The Existing Condition Record is a way for the dentist to, at a glance, see precisely what restorative needs you have and what has been done already. It is very useful in the formulation of a treatment plan, as it provides a visual representation of your mouth, as far as your teeth are concerned.
Bottom Line for Health History and Additional Charting
For the range of situations in your mouth and general area that fall under the purview of the dentist, there is MUCH that must be known.
It is irresponsible to start treatment on any patient, for ANYTHING, when there is anything unknown about the patient’s health conditions, systemically, and locally.
For continuing treatment of any patient, the records that are kept must be kept well, reliably, and completely.
The Health History allows the dentist to know what overall conditions you have and what medications you are taking.
When the dentist measures your blood pressure and temperature, it is precisely to determine if there is a suggestion of something compromising your health at that time. Treatment plans may need to be delayed depending on the observations.
When the dentist checks lymph nodes, jaw movement and your joint, he/she is being thorough about knowing all possible conditions that may only be detected at the time you are in the dental office.