THE ODTP PROCESS

1. THE ODTP PROCESS A Case-Based Overview Orientation to the Clinical Practice of General Dentistry, Fall Quarter Alan W. Budenz, MS, DDS, MBA

2. Heather – a new patient • Screened by faculty September 26, 2005 • Designated as a 2nd Year teaching case

3. Chief Concern (CC): I would like a bridge for my lower front teeth

4. The ODTP Process: Step 1Preparation • Pre-appointment preparation • Review chart • Read screening and/or treatment notes • Review health history • Review radiographs • Make notes • Plan out the first appointment

5. The Pacific Health History Questionnaire Form- Comprehensive-Standardized - Translations

6. The Pacific Health History Questionnaire Form • Section 1: General Questions • Designed to elicit general information about the patient’s health, and whether they have seen a physician recently, are currently in pain, or have had any problems with prior dental treatment.

7. The Pacific Health History Questionnaire Form • Section 2: Signs and Symptoms • Focuses on various signs and symptoms that are indicative of medical problems. • Signs = indications of disease that can be observed by the practitioner. • Symptoms = problems associated with a disease that are experienced by the patient, but cannot be seen by the practitioner.

8. The Pacific Health History Questionnaire Form • Section 2: Signs and Symptoms • Note: No time frame is specified for any of these signs or symptoms. • Determining the relevance of the time frame is the responsibility of the practitioner.

9. The Pacific Health History Questionnaire Form • Section 3: Specific Diseases • Concentrates on specific diseases which have been previously diagnosed by a physician. • All of these diseases have a systemic effect. • Therefore, all of these diseases have potential ramifications on dental care delivery.

10. The Pacific Health History Questionnaire Form • Section 3: Specific Diseases • The patient’s physiology is compromised by their medical problems, and many dental procedures have a significant physiologic impact. • Therefore, the dental procedure may need to be modified to insure patient safety.

11. The Pacific Health History Questionnaire Form • Section 4: Treatments • Discusses medical treatments and prosthetic devices which may have a bearing on dental management of the patient. • Decisions regarding dental management depend on the patient’s specific situation and the extent of the treatment and/or resultant outcome.

12. The Pacific Health History Questionnaire Form • Section 5: Medications and Drugs • Elicits important information on prescription drugs, over-the-counter medications, natural remedies, and any other drugs the patient might be taking. • Documents the extent of any problems noted on other parts of the health history, or possibly problems not identified by the patient.

13. The Pacific Health History Questionnaire Form • Section 6: Women Only • Elicits specific information relative to women uniquely. • Pregnancy and the use of birth control pills are especially pertinent to dental care delivery.

14. The Pacific Health History Questionnaire Form • Section 7: All Patients • Consists of a catch-all question designed to elicit information the patient feels is appropriate to provide, but which has not been otherwise directly queried.

15. The Pacific Health History Questionnaire Form • Patients should sign and date the health history after initially completing it. • The patient should review, update, and re-sign the form at each recall visit. • At start of each appointment, ask “Have there been any changes in your health?” Note response in the treatment record.

16. The Health History Form • In our clinic, the patient fills out a medical questionnaire when they first register. • This must be followed up with a verbal interview by the student doctor • To insure that the patient properly understood the questions • To ask about and obtain a history about any positive responses • To insure that a negative response was what the patient intended for certain questions.

17. The Pacific Health History Interview Sheet

18. The Health History Interview Form • The separate interview sheet provides a location for notation of any significant findings and a description of any dental management considerations. • It is best not to alter or make notations on the patient’s Health Questionnaire form. • The interview sheet is used to ensure that any positive questionnaire responses are followed up and appropriately documented.

19. The Pacific Health History Interview Form • Includes 6 questions that need to be verbally asked of every patient: Do you have any… • Cardiovascular problems? • Infectious diseases? • Allergies to medicines (or latex)? • Bleeding problems? • Take any medications? • Other medical problems not asked about?

20. Cardiovascular problems? Infectious diseases? Allergies to medicines (or latex)? Bleeding problems? Take any medications? Other medical problems not asked about? The six areas covered by these questions are extremely important to the dentist and it is appropriate to ask them again to insure that the patient properly understands and correctly answers the questions. The Pacific Health History Interview Form

21. The Pacific Health History Interview Form • Cardiovascular problems? • Comprise the bulk of medical problems that require dental management considerations. • 51% of patients with medical complexities have CV problems with the incidence rapidly increasing with age. (Smeets et al, Preventative Medicine 1998) • Heart disease is the leading cause of adult deaths in the U.S. • Stroke is the third leading cause of death in adults in the U.S.

22. Most specifically, patients should be asked if they have any history of “heart problems or heart murmurs”. • If “yes”, questions to ask: • When was the problem first diagnosed? • Did your doctor ever say you should take antibiotics before dental treatment? • Did your doctor ever say you don’t need to take antibiotics before dental treatment? • For heart murmurs specifically: Was it termed functional or organic? Is there regurgitation?

23. The Pacific Health History Interview Form • Infectious diseases? • Hepatitis is the most common infectious disease with implications for dental complications. • HIV+ and AIDS often produce significant oral and systemic changes. • Note: All patients should be treated as though they are infectious, i.e. universal precautions are the standard infection control protocol for all patients, with one exception...

24. The Pacific Health History Interview Form • Infectious diseases? • The one exception... Active tuberculosis requires additional precautions, and these patients should generally be treated only in a hospital isolation facility.

25. The Pacific Health History Interview Form • Allergies to medicines (or latex)? • Patients should be asked about allergies to any medications in general, and specifically about possible allergies to: • Antibiotics • Pain medications, including aspirin • Narcotics • Local anesthetics • Latex

26. The Pacific Health History Interview Form • Hematologic, bleeding problems? • Has the patient ever had any bleeding problems or do they bruise easily? • Positive responses may be indicative of undiagnosed hematologic disease. • Referral to or consultation with the patient’s physician may be indicated.

27. The Pacific Health History Interview Form • Take any medications? • Indicates that the patient’s medical problems are severe enough to require medical treatment. • Knowing any medications that the patient may be taking allows the dentist to be alert to possible side effects, toxicity, or drug interactions that may occur during dental care.

28. The Pacific Health History Interview Form • Take any medications? • The increasing use of over-the-counter, natural, and herbal medications and supplements may have a significant impact on the delivery of dental care. • Patients often fail to disclose these medications unless specifically asked about them.

29. The Pacific Health History Interview Form • Other medical problems not asked about? • This catch-all question asked in a one-on-one confidential setting may elicit significant information that a patient may be reluctant to write down on a form. • May also induce the patient to discuss anxieties and concerns they may have regarding dental treatment. • Allows dentists to establish a thoughtful and caring rapport with their patients.

30. The ODTP Process: Step 1Medical History Review “Yes” answer to #3: Hospitalized or serious illness (3yrs) Listed: Lung problem What questions do you want to ask?

31. The ODTP Process: Step 1Medical History Review “Yes” answers to #4: Being treated by physician Listed: Anemia, GERD What questions do you want to ask?

32. The ODTP Process: Step 1Medical History Review “Yes” answers to #37: Stomach problems, ulcer What questions do you want to ask?

33. The ODTP Process: Step 1Medical History Review “Yes” answers to #62: Taking medications Listed: Warfarin, Prevacid What questions do you want to ask?

34. The ODTP Process: Step 1Medical History Review “Yes” answers to #63: Tobacco What questions do you want to ask?

35. Health History Review • From your analysis of the medical history: Is the patient’s medical condition controlled and stabilized under the supervision of a physician? Do you need to make any care delivery accommodations because of the patient’s health status?

36. Dental Management of Medically Complex Patients • Good sources for information on this subject: • From the UOP web site: www.dental.pacific.edu • Protocols for the Dental Management of Medically Complex Patients • Protocols for the Dental Management of Patients with HIV Disease • Little, Falace, Miller & Rhodus, Dental Management of the Medically Compromised Patient, 6th Edition, Mosby-Year Book, Inc., 2002 (will get in 2nd Year Student kit)

37. The ODTP Process: Step 1Radiographic Interpretation Patient has brought in an FMX dated 4/20/99. Do we need a new FMX?

38. The ODTP Process: Step 1Radiographic Interpretation Complete a Radiographic Diagnosis Worksheet (available in Radiology)

39. The ODTP Process: Step 1Radiographic Interpretation Radiographic Findings: #2: possible mesial caries #3: gross distal caries w/ apical radiolucencies #13, 24, 25: severe vertical bone loss #14: gross mesial caries w/ apical radiolucencies #4, 17, 30, 32: missing

40. The ODTP Process: Step 1 All of this should be done BEFORE your first appointment with Heather. The better prepared you are, the smoother and faster the appointment will go, and the better the impression you will make upon the patient.

41. The First Appointment:D0150 Initial Oral Examination Greet Heather in the waiting room and introduce yourself. Ask her how she is today. Does she have any tooth pain? Give her a brief overview of what you are going to do during this appointment.

42. The First Appointment:D0150 Initial Oral Examination Give her a brief overview of what you are going to do this appointment: “Today I’m going to do a very thorough examination of all of your teeth and gums, and then I’ll be able to discuss with you what dental care you need and what treatment options you have. I particularly want to evaluate your lower front teeth.”

43. The ODTP Process: Step 2Medical History Interview/ Physical Exam/Vital Signs Review the health history with the patient (MH) Take vital signs (VS) Perform intra- and extraoral exams (EOE & IOE) Take diagnostic casts if needed

44. The ODTP Process: Step 2Medical History Interview/ Physical Exam/Vital Signs Health History: Ask your questions from your Step 1 review of the completed form and record Heather’s responses to your questions on the Health History Interview Sheet.

45. The ODTP Process: Step 2Medical History Interview/ Physical Exam/Vital Signs What is significant in Heather’s health history for safe delivery of dental treatment? Where do you record this information?

46. The ODTP Process: Step 2Medical History Interview/ Physical Exam/Vital Signs Do you still have questions about Heather’s health? If so, how do you get them answered?

47. The ODTP Process: Step 2Medical History Interview/ Physical Exam/Vital Signs Physical exam (PE) findings: VS: BP 105/70 – R, pulse 77 reg. EOE & IOE: all WNL

48. The ODTP Process: Step 2Medical History Interview/ Physical Exam/Vital Signs This is a good time to start gathering a dental and social history of Heather. What questions do you want to ask?

49. Dental History: HCC: currently asymptomatic. DH: Last dental appt. for delivery of a maxillary partial denture, June 2000. Has had sporadic dental care most of her life. Perio: “deep cleanings” occasionally Ortho and Endo : none OS: #1,3,13,14,16 ext. at UOP in 1999; #4,19,30,32 ext. prior, different times Restorative: moderate restorations: amalgams, crowns, bridge #29 – 31, maxillary removable partial denture (RPD).

50. Social History: Grew up in Ireland, lived in Berlin, moved to Arizona in 1985, moved to LA in 1989, moved to SF in 1998. Parents deceased; 2 sisters, 1 brother living in Ireland. Separated from husband who lives in Arizona with their 19 y.o. son. Lives with 3 roommates in SF. Enjoys reading and furniture restoration.