Treatment Planning: Taking a history

Hello. Welcome back, so last talk on treatment planning. So remember the first talk, we talked about general principles of when we’re planning treatment for children, what do we need to consider? But if you remember, I said, really, we need a detailed assessment to be able to help us, guide us towards that. So this talk is going to be thinking about that assessment. So why is that detailed assessment important? Well, it’s because it can help aid us making correct diagnosis and developing the appropriate treatment plan. And it’s going to help inform us, really, of the urgency for treatment, complexity of treatment required, what’s of patient cooperation like, what is the patient and parent compliance towards dentistry.

We can come up with a caries treatment plan, but if the parents aren’t going to come because they can’t when they’re working, then we’ve got to think about how we modify that. And then thinking about communication, so we’re going to go through all of these now. So I think the history of a presenting complaint is so important. It gives me so much information about what’s going on. So a lot of times, my students say to me, oh, the patient’s got pain. Well, pain, what sort of pain? How much information can I get from that? Because actually, I can get a lot.

So I’m thinking, in particular, about how long the pain has been going for and what type of pain is going to give you an indication of whether it’s a reversible or irreversible pulpitis. Now for a small child, you can’t really get them to explain that they’ve got exacerbating pain on the lower six and it comes and goes. They just can’t give you that information. So if you think about it, for a young child, you need to ask different questions of the parents. Want to know, is it affecting their eating? Is it affecting their sleeping? Are they having to have analgesics because it’s hurting? And have they had to have any antibiotics?

So all of those can give you good signs of whether that pulpitis is irreversible and whether you’re going to need to think about extraction or pop treatment. Thinking about what the patient/parent concerns are, so it’s really important to address those, to think, what is it that they’re worried about? And if you’re not able to address it straight away, for example, something aesthetic is going to need braces and so on, then you’ve got to be able to explain that you’ve heard their concerns. And we can make a plan for that, but it may not be something you can do straightaway. You want to think about how long the symptoms have been going on for.

If you’ve got a child ranting caries and it’s been going on for a couple of years and you haven’t really thought about seeing a dentist or having any care, you’ve got to be thinking, well, what else is going on that in that family? Is there a potential issue of neglect, and what questions do I need to ask? And likewise with trauma, remember, we’ve always got those key questions, when, where, how. And then when we think about medical, so asking medical history, we sort of do the tick boxes and we shouldn’t do that. But we’re really thinking about, well, what medical conditions could this child have that where if they’ve got dental disease, it really may compromise their health?

So an example of that would be people with an immunocompromised child. Well actually, if they’ve got a dental infection abscess, that could be really serious and life-threatening. So that’s so important you’re aware of all those issues, you’re liaising with the appropriate colleagues about that. But a child may have a medical condition that’s also influencing what dental treatment you provide. So a good example of that would be a child with a bleeding disorder, something like a haemophilia, when you really want to try and avoid construction if possible. Or if you are going to, it’s going to need to be in specialty settings and so on. So those sort of things are really key to how they influence your treatment planning.

Thinking about medications, I was asked what medications children take, and also in what form. Is it in a syrup? Is it syringe? Is it a tablet? Because I’ve seen quite a lot of really unwell children at Great Ormond Street, and some of them will be on lots of different medicines. Most of them taste pretty disgusting, so they will have to be in a syrup or have with a juice or so on to disguise it. And so if they’re having lots of those, you’ve got to be thinking about all those different sugar attacks every day. Allergies, obviously, really important, particularly if you’re worried if they’ve got some latex allergy, antibiotic allergy.

And I always find finding out if they’ve had any previous hospital treatment and how it went, really helpful, and it’s a good indication of behaviour management. If they’ve had lots of possible interventions and they know the minute they walk into a hospital something pretty unpleasant is going to happen to them, you can have quite a challenge for behaviour management, to start with. Thinking about vaccination and redbooks, and thinking about details of pregnancy and labour, particularly in first two to three years of life, because remember, that’s where a lot of the interior osteopermanent teeth are developing. So if there’s been any major issues in medical there, you may have some effects on anterior and posterior permanent teeth developing..

And I always think, sometimes parents aren’t always able to give you lots and lots of information, but I always think a really key question is, who is looking after that child’s medical care? Because if they’re under the care of their local GP and just see them whenever they need to, well, then that’s probably not so serious. Whereas if they’re going to see specialists in hospital and they’re seeing them every month, every three months, well, that’s giving me an indication that probably, there’s a more serious acute condition, and I’m going to need to investigate further. So I think finding out who’s looking after the patient’s medical care is a really helpful way of finding out what’s happening with the medical history.

And then when we think about dental, it’s really good to know, have they had any previous experience with dental treatment, and how was it? Have they had a local? How did it go? Have they had an extraction? Have they needed treatment under general anaesthetic or sedation? These are really good clues about what’s happened previously and then what we’re going to be up against because remember, we said in previous talk of they’ve had a bad, negative experience, they’re going to be more anxious. So it’s going to give you an idea of what you need to think about. And also, what about their attendance?

Do they come along every three to six months as regular, or do they only come when they’re in pain? I always ask about social history as well. I want to know about schooling, just because it’s nice. We’re building rapport with a patient, but also, it’s quite a useful way if I think there may be something happening in the medical history that the parents aren’t exactly explaining anything, to ask about what sort of school they go to. And if I think there may be some sort of special needs element there, then I’m going to ask, is it a special needs school? Or if it’s a mainstream school, do they get any one-to-one support?

Because if they do, then that’s giving me an indication of what extra things I need to think about in terms of my behaviour management. But maybe they haven’t explained properly medical history, and they might be a bit reluctant to, so school’s a really good way of getting to that. And then you’ve also got to think about, well, who’s the person they come with, accompanied parent, person? If the parent, do they have parental responsibility? Particularly if you’re thinking about taking consent before sedation or extractions, under general anesthesia, you must be sure that person has parental responsibility. So what I always ask is, who have you brought with you today?

I don’t make the mistake of assuming that it’s grandma or grandpa when it’s mum or dad. That really doesn’t go down very well. But always make sure that you just ask, who have you come with today, so you can be sure that they’ve got parental responsibility. And I think if you’ve got siblings coming in as well, you’re seeing the whole family. And it can be quite helpful because if you know that the siblings before have had a high caries risk and have needed to have teeth taken out, you know you’re going to need to focus a bit more prevention on the younger ones coming through because otherwise, it’s going to be the same environment for them.

And also behaviour management, siblings can be really helpful as models if they’re good. So if you’re a young child, a little bit anxious, but older sister is happily sitting in a chair having an exam, that’s a really nice model for that child. Clearly, if the sibling is a complete nightmare, you don’t want to use them because that’s going to make things worse, but they can be quite helpful in that. And then going on thinking about history, now remember, we’re doing this all within sort of five, 10 minutes, so I think we sometimes don’t give ourselves enough credit for how much information we can get from our patients and parents in a very short amount of time.

But when we’re thinking about sort of diet, really, I think for young children, I’m thinking of breast or bottle feeding on demand. Am I looking at early childhood caries, and is this still going on? What sort of advice are you going to need to give? And I think particularly young children, it’s a lot of drinks. What drinks are they having? I’m amazed how many children seem to be allergic to water, any yet when you ask, what do you have at school, oh, they have water. Well, OK. I think all of us, if we’ve got a choice of something more exciting in the fridge, we’re going to go for that.

So it’s about really educating the whole family when it comes to dietary advice. But I think that really, the focus, if I’ve only got five minutes in my assessment appointment, I really want the focus to be on tooth brushing, the delivery of fluoride through the toothpaste. So I really need to know what type of toothpaste they’re on. I need to be sure that it’s the right strength of fluoride toothpaste for that child and their caries risk. I want to know if the tooth brushing supervised or unsupervised. When do they brush? So many children just brushing in the morning, forget at night time. You have to explain the importance of that.

Whether they’re rinsing with water after they’re brushing or just spitting. And obviously, if they are rinsing, you want to really encourage them just to spit so that you’ve still got a bit of toothpaste around the mouth that’s still having a beneficial effect afterwards. And I think sometimes parents can really struggle when they’ve got small children about how to brush their teeth and what position. And it’s about giving them guidance about, well, sometimes it can be facing the child front ways, or actually sometimes can be behind them and sort of having them standing there, their head near your tummy, and you can just brush the teeth easily that way.

So if they are struggling with that, it’s about giving them good advice. And I think if you’ve got a child who’s really willful, little toddler going through the terrible twos, and they absolutely won’t let the parent brush their teeth, well actually, it’s even better to just give them a little bit of toothpaste on the toothbrush, let me just suck it for a few seconds. Nothing else, at least they’re getting some fluoride through the toothpaste into their mouth.