Assessment & planning
From a patient story to a defensible shared treatment plan.
Topics
9 notes
History taking
Record the presenting complaint in the patient's words, its chronology, relevant medical and dental history, medicines, allergies, social factors and expectations.
Read detailed note ↗Extraoral examination
Inspect and palpate facial symmetry, skin, lymph nodes, salivary glands, muscles and temporomandibular joints as indicated. Record positives and relevant negatives.
Read detailed note ↗Intraoral examination
Use a systematic soft tissue, periodontal, dental and occlusal examination. Describe lesions by site, size, morphology and change over time.
Read detailed note ↗Pulp and periapical tests
Cold, electric, percussion, palpation and imaging contribute different information. A sensibility response does not directly prove pulpal blood supply.
Read detailed note ↗Risk assessment
Caries, periodontal, erosion and oral cancer risks are dynamic. Combine disease activity, behaviours, clinical findings and protective factors.
Read detailed note ↗Differential diagnosis
Use the pattern of symptoms, examination and investigations to keep serious alternatives in view. Revisit the differential when findings conflict.
Read detailed note ↗Treatment planning
Stabilise disease and pain, discuss reasonable options, sequence care and plan review. Document patient priorities and the reason for each choice.
Read detailed note ↗Referral and handover
A useful referral states the question, urgency, site, history, findings, imaging and relevant risks. Safety-net when results or appointments are pending.
Read detailed note ↗Complex case synthesis
For multiple interacting problems, prioritise safety, prognosis and patient goals; identify the decisions requiring multidisciplinary input.
Read detailed note ↗