Fundamentals of Oral Medicine and Radiology Durgesh N Bailoor, KS Nagesh
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The Diagnostic Sequence1

Bailoor DN,
Nagesh KS,
Chatra LK,
Pai Keerthilatha
“Learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone you can become an expert.”
—Sir William Osler
 
DEFINITION
 
History
History is defined as planned professional conversation followed by accurate recording of facts. Symptoms are primarily subjective complaints told or expressed by the patient who, may or may not, have externally observable element, e.g. Angina pectoris, neuralgic pain etc. Signs are those clinical entities, which the doctor can observe and record as objective findings, e.g. Pallor, Bulla, etc.
History is classified as two types – structured and unstructured.
  • Structured history consists of pre-decided format or a printed form in which questions can be asked in logical manner. In recent time computers have been programmed for structured history taking. Bertoft G6 (1996) in his retrospective study mentions how structured medical and dental history helps in diagnosis of oro-facial pain, TMD symptoms and evaluation of various psychological factors and is a strong proponent of this type of history.
  • Unstructured history taking. Clinicians with experience or senior consultants frequently appear to ask unrelated question and come to a fairly accurate diagnosis; they change the pattern of questions as per the patient's narration. They are casual but penetrating and in perceptive way they may arrive at a diagnosis. This may seem magical to an uninitiated young doctor. It is actually years of discipline, reading and knowledge that go into this magic.
It is also now possible to look at Manual and Computerized type of record keeping. Most clinics and hospitals today have electronic record keeping of differing sophistication.
 
Diagnostic Sequence
This is series of steps that clinicians take to arrive at a diagnosis. Diagnosis is defined as the recognition of the disease, naming the disease as per agreed criteria. In other words, diagnosis would mean recognizing the disease and naming it.
ICD-DA or International classification of diseases to Dentistry and Stomatology7 (1995) is a manual which gives a working clinician some kind of a codification which can help in noting the diagnosis as a number or using diagnostic words which are globally accepted. In research the use of ICD-DA numbers has proved invaluable for international communication and research (Fig. 1.2).2
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FIGURE 1.1: Listening carefully, recording meticulously and storing data systematically forms the cornerstone of good dental record making(Bailoor DN, Chatra LK 2004)
 
The Sequence
  • Discovery either by patient or doctor of something abnormal * History taking * Clinical Examination * General * Extra Oral * Intra Oral * Clinical Diagnosis * Provisional Diagnosis * Investigations e.g. Hematology, Urine Analysis * Differential Diagnosis * Further Investigations (special tests) * Final Diagnosis * Treatment (Fig. 1.1).
When a set of closely appearing lesions are diagnosed then their enumeration and subsequent distinction from each other constitutes the differential diagnosis.
 
HISTORY AND COMPONENTS OF HISTORY13
History starts with recording the name, age, sex, marital status, occupation and address, which are collectively, called as identifying data. Next is the presenting complaint, or the chief complaint, the primary reason why the patient seeks the dentist's opinion. This complaint is recorded in patient's own words and further details are asked in the format of origin, duration, progress, and radiation. The aggravating and relieving factors are recorded. The impact of these symptoms on home and occupational life is also assessed.
Origin: Records how the problems started.
Duration: The temporal quantification, meaning how many days, weeks, or months, the problem has existed.
Progress: Denotes whether the problem is static, getting worse or getting better.3
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FIGURE 1.2: Diagnostic sequence chart. Recognition and naming the disease is termed as Diagnosis—International Classification of diseases termed as ICD-10 is used for global standardization(Beena K, Nillofer S, Omal P, Bailoor DN 2004. Yenepoya Dental College and Hospital, Mangalore, India)
Radiation: Indicates whether the problem is changing from one anatomic location to another, and also if it is changing in quality.
 
Past Dental History
This tells us whether the patient has been to a dentist before, what sort of treatment was done, what were the complications encountered. This part highlights the patient's attitude towards the dental treatment. Allergy to dental ointments, pastes mouth washes may also be recorded here.
1. Are you seeing a dentist regularly?
Yes
No
2. Do you bleed excessively after extraction?
Yes
No
3. Did you ever put braces?
Yes
No
4. Are you allergic to any injection, medicine or ointment applied to mouth?
Yes
No
5. Any other treatment.
Yes
No
 
Past Medical History
This can be recorded briefly by asking the following questions.
1. Are you seeing a family doctor for any illness now?
Yes/No
2. Are you taking medications for any health problems?
Yes/No
3. Are you allergic to any drugs, medicines, and food?
Yes/No
4. Were you hospitalized during the last five years for any major illness, operation, etc?
Yes/No
If any of the questions is answered ‘Yes’, then a detailed questionnaire should be assessed. Such type of questionnaire has been termed by deJong KJ5 (1997) as Medical risk-related history (MRRH). In his opinion the MRRH and personal interview follow up by the dentist, 4would lead to accuracy in detection of medical problems of the dental patients.
 
Cardiovascular System
1. Do you have breathlessness on exertion like climbing stairs, walking fast, etc.
Yes
No
2. Do you have pain on the left side of the chest on exertion or emotional outburst?
Yes
No
3. Did you have any operation of the Chest, heart-valves etc in childhood?
Yes
No
4. Do you get spontaneous dizziness, palpitation with profuse sweating?
Yes
No
5. Did you ever get a stroke
Yes
No
6. Did you get sore throat, fever and fleeting joint pains in recent past?
Yes
No
7. Any other complaints.
Yes
No
 
Respiratory System
8. Do you have problems of wheezing?
Yes
No
9. Did you suffer from tuberculosis?
Yes
No
10. Did you have any sort of breathing problem in recent times?
Yes
No
11. Did you get swelling of ankles of legs?
Yes
No
12. Any other (Specify)
Yes
No
 
Gastrointestinal and Hepatic
13. Do you have heart burn/acidity?
Yes
No
14. Have you suffered from jaundice?
Yes
No
15. Bouts of nausea, lack of appetite?
Yes
No
16. Piles?
Yes
No
17. Persistent loose motions.
Yes
No
 
Endocrinal System
18. Do you have excessive thirst, hunger?
Yes
No
19. Do you have to urinate at night disturbing your sleep?
Yes
No
20. Do you feel that you have developed black patches on the skin, in mouth?
Yes
No
21. Have you gained or lost weight excessively in last three months?
Yes
No
22. Do you feel lethargic and drowsy recently?
Yes
No
 
Genitourinary
23. Do you get puffiness of the face?
Yes
No
24. Did you suffer from burning micturation?
Yes
No
25. Bouts of severe pain in lower back?
Yes
No
26. Any other.
Yes
No
 
Neurological
27. Do you get persistent headaches?
Yes
No
28. Do you have weakness of any one side?
Yes
No
29. Do you get blackout, loss of memory?
Yes
No
30. Have you had numbness, or tingling of fingers of hand and legs?
Yes
No
31. Any other.
Yes
No
 
Trauma
32. Did you meet with any major accident in recent times?
Yes
No
33. Any sports injury to facial region.
Yes
No
34. Any other.
Yes
No
 
Bleeding Disorders
35. Do you bleed easily on cutting yourself?
Yes
No
36. Are you taking any medication, which any make you bleed more (Anticoagulants?)
Yes
No
37. Do you bruise easily, get pin-point bleeding spots on skin or mouth?
Yes
No
38. Any other.
Yes
No
38. For women only:
a. Are your menses regular?
Yes
No
b. Are you pregnant?
Yes
No
c. Any operations such as uterus removal, family planning, etc.
Yes
No
d. Any other.
Yes
No
 
For both Men and Women
40. Were you treated for venereal disease?
Yes
No
41. Have you had any contact with a prostitute or sex worker?
Yes
No
42. Did you have more than one sex partner in last two years?
Yes
No
43. History of homosexuality?
Yes
No
44. Which countries did you travel recently, mention
Yes
No
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45. Did you have blood transfusion recently?
Yes
No
46. Any other
Yes
No
 
Cranial Nerve Function
Note: If any of the questions is answered Yes the clinician must do a detailed clinical examination of the various functions of that cranial nerve. If serious deficit is detected or suspected, Neurologist's opinion is mandatory for a complete assessment.
47. Can you smell normally? CNI
Yes
No
48. Did you have any vision problems? CN2
Yes
No
49. Are you able to move your eyeballs comfortably? CN3,4,6
Yes
No
50. Are you able chew food normally, and feel the forehead? CN5
Yes
No
51. Are you able to blow air into a balloon without difficulty? CN7
Yes
No
52. Is your taste diminished or changed? CN9,CN10
Yes
No
53. Do you feel that swallowing is a problem recently?CN9,CN10
Yes
No
54. Do you feel increasing dryness of eyes? CN7
Yes
No
55. Does your mouth run dry, recently? CN7,CN9
Yes
No
56. Are you able to hear properly and maintain balance? CN8
Yes
No
57. Has your ability to talk changed recently? CN 10
Yes
No
58. Can you turn your head, and lift your shoulders? CN11
Yes
No
59. Are you able to move your tongue just like before? CN12
Yes
No
 
Personal and Family History
 
Concept of Habit Index
The important aspects to be asked here are the habit patterns of the person, specially the abuse of tobacco, alcohol and any other drugs. It is important to note the frequency per day and length of the time that patient had the habit in years.
 
Habit Index
It is used in our department to quantity the effect of the habit.
For example if a person smokes 10 cigarettes for the last 15 years then the smoking index will be 10×15 = 150 (see Fig. 1.3).
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FIGURE 1.3: Tobacco abuse is the risk factor for many oral and systemic diseases. It needs to be recorded accurately(Bailoor DN, Keerthilatha Pai 2004)
Alcohol consumption usually is measured in peg per week × no of years, for example if a person consumes 2 pegs of whisky a day for ten years then his alcohol index will be calculated 14×10=140.
We divide the alcohol again into three categories.
  • Risk one is Wine and Beer
  • Risk two is Rum, Whisky, Gin etc.
  • Risk three is Country alcohol, Arrack etc. (see Fig. 1.4).
The above example now becomes 140 risk two.
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FIGURE 1.4: Distinction needs to be made between social drinking and alcohol abuse(Bailoor DN, Nagesh KS 2004)
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Betel chewing, betel leaf chewing with slaked lime and catechu could also be quantified in similar fashion by a product of the frequency per day × no of years, at the frequency of 8 a day for twelve years of betel chew index would be =12 × 8=96
Record the frequency of tooth cleaning, method of tooth cleaning, whether indigenous or modern, uses of dental floss, mouthwash or any other modalities.
Details of the diet are asked specially if patient has any food fads, is a pure vegetarian, etc.
A family tree is drawn up, usually with father mother and diagram of siblings if any inherited disease is suspected, and the details of the members affected is duly recorded.
For example – Diabetes, hemophilia, hypertension, cleft lip, etc.
Fear of the dentist and his drill is almost proverbial. Dentistry today is painless and comforting. See that your patient feels comfortable and alleviate his fear to get good treatment compliance from him. All are afraid of dentists—remember that so your approach can be more sympathetic (see Fig. 1.5).
 
Social and Occupational History
The fact that psychosocial factors affect the general health of the patient and his oral health is well established. So recording whether the patient stays alone (Loneliness) or in joint family (Intra-family tensions) becomes important. A woman may have mother in-law problem in her MPDS diagnosis!
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FIGURE 1.5: Fear of dentists or dental treatment is termed as odontophobia. Patients fear the dentist's injection and drill(Bailoor DN 2004)
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FIGURE 1.6: Showing mechanical abrasion on the crown of central incisors due to hold of bolts and nuts by car mechanic who reported with severe pain in the upper anterior region(Ajay Nayak, Prasanna Kumar, Bailoor DN 2004, Yenepoya Dental College and Hospital, Mangalore)
Occupational stress can play a major role in lifestyle diseases of today characterized by Worry, Curry and Hurry (see Figs 1.6 and 1.7).
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FIGURE 1.7: Stress is a major cause in grinding of teeth (bruxism), TM joint problems, Ulcers in the mouth and many other diseases(Bailoor DN, Nagesh KS 2004)
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Cardiovascular diseases, headaches, hypertension, ulcers in the mouth and stomach, Sleeplessness and fatigue can all be a serious risk factor for the dental patient.
Bailoor DN and Nagesh KS 2004 have suggested a more holistic model for disease which takes into account the biological, psychological, spiritual and sociological factors. This model may be termed as the Bio-psycho-socio-spiritual model of illness. The findings to support this model were presented at the XIV national conference of the IAOMR at Hyderabad in December 2003 (Fig. 1.8).
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FIGURE 1.8: Diseases are caused by interaction of biological, psychological, social and spiritual factors. Holistic model of illness(Bailoor DN, Nagesh KS 2004)
Where the patient works, and what are his work tensions, affect of the important facets on his health. Now there are newer specialization like sports medicine and occupational medicine, which gives us good insight into this aspect of diagnosis.
Liss GM et al8 (1997) have clearly indicated the importance of the occupational history in looking at newer diseases emerging in the clinics today. They also mentioned that hospital records that are properly codified and indexed are a good source of occupational risk information.
Jackson JL et al9 (1998) have found four clinical clues that predicted patients likely to have depressive and anxiety disorders. They were Stress (recent); Somatic Symptoms; Status of health (generally poor or perceived by patient as poor); Symptom severity. They term it the 4-S way of testing.
The health psychology and its study today indicate that all the diseases today including oral diseases have what is termed as the bio-psycho-social etiological frames of reference. Lennart L13 (1997) has clearly supported the biopsychosocial approach to etiology and pathogenesis when he indicates that emotions, behavior, stress, coping and social and family support play a great role in prognosis of a disease.
It is important to record the finding in a card or file and at the end of his statement, take his signature in presence of a witness. This helps us.
  1. To enter changes that the patient may tell at a later date.
  2. To protect ourselves in event of a medico-legal problem
 
EXAMINATION OF THE PATIENTS
Now we start examining the patient in this order, the general examination, the extraoral examination and the intraoral examination.
 
General Examination
Here the build, nourishment, consciousness and the cooperativeness of the patient are noted.
  • Build—Well-built, moderately built or poorly built indicates the bone structure of the patient.
  • Nourishment—Well, moderate and poor indicates the soft tissue profile of the patient.
  • Conscious or unconscious—In dental OPD most of the patients will come conscious. Only in trauma or emergency care center will the patients be brought in stretcher.
  • Note whether the patient is cooperative or not.
The weight, height, temperature, respiratory rate and gait of the person are recorded.
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FIGURE 1.9: Using the BP Instrument is a must in any dental clinic. All obese patients and all patients above 40 years of age must be examined using a sphygmomanometer(Kiran K, Beena K, Bailoor DN 2004, Yenepoya Dental College and Hospital Mangalore)
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Weight of the patient is recorded in Kg. Height is recorded in Meters and BMI is recorded by the formula,
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BMI is a clinically usable nutritional parameter by dentists. Either a manual or electronic sphygmomanometer records blood pressure, routinely, pulse and temperature is noted. Cyanosis, clubbing, pallor, any apparent lesions on the skin of the forearm, legs, etc. should be observed. A general dental practitioner need not routinely do cranial nerve examination but if he suspects any neurological deficit he must be able to express suspicion as to which cranial nerve is involved. Reference to a neurologist is usually a good idea in such cases (Fig. 1.9).
 
Extraoral Examination
  • Eye—Spectacles, contacts, change in vision, inflammation lacrimation, color (Pallor, Jaundice, etc)
  • Otolaryngological points—Pain in the ears, hearing changes, tinitus, sinus disease, mucous discharge, blood discharge, nasal obstruction, voice changes, sore throat and tonsillitis. The symmetry of the face. Overlying skin, bruising, itching and rashes. Observe for tremors, convulsions, anesthesia, paresthesia and paralysis (Figs 1.11 and 1.12).
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FIGURE 1.10: Figure showing some important groups of lymph nodes that a dentist must routinely palpate and then write a report on the number, consistency, tenderness, etc. of the lymph nodes(Prasanna Kumar, Bailoor DN, YDC Mangalore 2004)
 
Inspection
Of the face involves the observation of the symmetry of the face, swelling, how patients opens and closes, and if he is suffering from any tics, facial weakness, birth mark, etc.
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FIGURE 1.11: Showing the deviation of the TMJ due to Fibrous ankylosis on the right side. The right TMJ will be affected in this case.(Prasanna K, Beena K, Bailoor DN 2004, Yenepoya Dental College and Hospital, Mangalore)
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FIGURE 1.12: Figure showing the lack of tonicity of muscles in the right side of the face with drooping of the angle of the mouth on smiling in patient of Bell's Palsy.(Prasanna K, Beena K, Bailoor DN 2004, Yenepoya Dental College and Hospital, Mangalore)
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FIGURES 1.13A and B: Figure on the left showing the TMJ being palpated by the two finger method—doctor positioned posteriorly. On the right it shows the doctor positioning from the anterior aspect. Here the clinician can observe even slight deviation(Nayak A, Bailoor DN 2003. Yenepoya Dental College and Hospital, Mangalore)
 
Palpation
A regular palpation of TMJ and the lymph nodes in the cervical and the peri-oral regions is mandatory. If any swelling, asymmetry or obvious deformity is evident, clinically palpating and recording the size, shape, consistency, fixity to underlying regions, and other properties must be recorded (Fig. 1.10).
The temporomandibular joint (TMJ) is palpated using either the one-finger method or the two-finger method. The dentist may position himself either in front of the patient or behind the patient. We advocate the TMJ palpation with a two-finger method in our department. The forefinger is inserted in the external auditory meatus gently and ball of the thumb is placed on the preauricular region to feel for the clicks, popping, crepitus, and tenderness. The patient is asked to open and close the jaw gently; the degree of opening and deviation if any is noted. The patient is 2approached from the front with his chair position being upright.
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FIGURES 1.14A and B: (A) Wrong way to palpate the lymph nodes. Never attempt to palpate both the sides at the same time. The patients neck is stretched and this will preclude the early detection of any changes in the consistency of the lymph nodes. (B) Right way to palpate the left submandibular lymph nodes by tilting the patients head on the same side(Prasanna K, Bailoor DN 2003, Yenepoya Dental College and Hospital, Mangalore)
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A stethoscope could be used to amplify the TMJ sounds if there are any positive findings (Fig. 1.13).
Lymph nodes of the submental, submandibular, pre-auricular, post-auricular, superficial and deep cervical group are palpated and recorded as palpable/non-palpable, tender/non-tender and the quality like matted, hard rock like, rubbery, etc. are recorded so that their clinical significance could be integrated with the final diagnosis (Fig. 1.14).
Bi-digital palpation of the floor of the mouth region is an important component of any lesion in this area and for early detection of sialoliths in submandibular gland ducts.
Facial skin and facial symmetry should be noted for any abnormality, angle of the lips for any lesions like angular cheilitis, ulcers like primary herpetic stomatitis.
Nasolabial fold should be consciously observed and its obliteration may be seen in Bell's palsy, or sometimes swelling in the canine region of the face.
  • Intraoral examination again is divided into soft tissue analysis and hard tissue analysis.
  • Soft tissue should be examined thoroughly especially, at the ventral portion of the tongue, the floor of the mouth, the tonsillar fauces examined in addition to the buccal mucosa, plate, labial mucosa, etc.
  • The lesions like white lesion, vesiculo-bullous lesion, pigmentations, ulcerative lesion, etc. should be noted.
  • Hard tissue analysis—Usually a notation of decayed; missing and filled teeth is made on each tooth examined. The caries is further classified as occlusal, proximal, or smooth surface and root according to location. It is important to note whether the caries is primary, secondary, or rampant according to distribution. The qualifying words are used wherever relevant. The regress ional changes such as attrition, abrasion and erosion also are duly recorded.
We use a visually appealing dental record for initial noting of the conditions as shown in Figure 1.15.
KEY
Decayed
D
Missing
M
Attrition
AT
Filled
F
Abrasion
AB
Root stumps
RS
Erosion
ER
Crown
C
Mobility
MO
Bridge
B
Furcation involvement
FI
RPD
RPD
Fracture
#
Pulp Exposure
PE
Discoloration
DI
Pain on Percussion
POP+/−
Tentative: Diagnosis is now recorded by describing the positive finding in the above examination. It states the sex, medical status, soft tissue diagnosis and hard tissue diagnosis. For example a typical tentative diagnosis would read; A 45 -year-old male diabetic (6 years) on treatment, with generalized suppurative periodontitis and caries in relation to 36 and 46.
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FIGURE 1.15: Graphic diagram which depicts the permanent dentition and will help in recording the decayed, missing, filled teeth status for dental record(Bailoor DN, Chatra LK 2004)
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  • After tentative diagnosis usually the dental surgeon asks for some tests to be done. If the patient has some metabolic or systemic problem then routine hematology and urine testing usually gives an important clue to follow up. If some soft tissue lesion is there, then usually a biopsy, of incision type is performed, the bit of tissue fixed in 10% formalin, and then a histopathological testing is done. In case there is gross carious destruction or advanced periodontal disease or any other hard tissue involvement then the best test to be performed is the Intra oral peri-apical radiography or the IOPA‥ (See the diagnostic sequence chart) or screening-radiograph usually preferred is the Orthopantomograph (OPG) See chapter no 29. As the results from these tests come through a positive confirmation name of the Lesion emerges. This then would be termed as the final diagnosis.
  • Normally treatment plans are based on the final diagnosis. Treatment plans are charted in many ways, in our department we use the following chart. This chart is divided into dept. Sections merely to facilitate the divisions of work and to do time management. It also helps us to prioritize the treatment keeping in mind the chief complaint of the patient.
Medical Alert:
Allergy Profile
Appointment
Physicians Referral
Oral Medicine
Radiology
Periodontia
Appointment
Restorative
Oral Maxfac Surgery
Prosthodontics
Orthodontics
Two other columns could be added to this for noting time and date of the appointment given and also the charges that are charged on that particular day, this can be again cross-referenced with the financial accounting done at the clinic.
Kay and Nuttal12 (1995) make an important point about assessing the risks involved in all the treatment plans and determining the probabilities of success in various treatment options. Using the concept of Evidence Based Dentistry (EBD) clinician assesses the risks. The clinician does a thorough examination of peer reviewed literature. He then communicates clearly to the patient the risks and benefits of the procedure in order to involve him in the decision-making process of the treatment planning.
Today it is recommended that the entire record keeping should be done on microcomputer system together with a good quality printer, this will make the dental surgeons job much easier and more accurate.
Sicotte C et al11 (1998) state that reengineering of the workplace through Information Technology is an important strategic issue for today's hospitals. The Computer-based patient record (CPR) is one technology that has the potential to profoundly modify the work routines of the care unit. It also raises ethical and confidentiality related problems. Szekely DG et al4 (1996) have highlighted how human errors as well as software design errors can impinge on clinical data security.
Warren JR et al10 (1998) mention about the Patients Interview Support Application (PISA) which is a program intended for operation by a non-expert clerk to interview an ambulatory primary care patient. This program was downloaded on to the web. The resultant Web environment attracted thought-provoking and detailed feedback from users, indicating that significant attention can be obtained from the global community by mounting an interactive system on the Web. Specific enhancements to the PISA's artificial intelligence are suggested by user reaction. These authors envision a future global health informatics ‘marketplace’ with a multitude of Web-based system components available for composition of health information systems.
  • See the module on Computers in Dentistry chapter no 30 for further details.
  • Problem Oriented Recorded (POR) keeping have also become popular in some specialties where each problem of the patient is recorded and its detailed resolution planned therapeutically before going to the next.
 
SUMMARY
History taking, clinical examination and the investigative tests make a good diagnostic sequence.12
Correct selection of tests is important for proper treatment planning. Treatment planning takes into account the principal reason that the patient came to you, his attitude, his medical status and finally his financial status.
Indian income tax Act also mandates that a form 3C be maintained by all dental surgeons in which the patient's name, treatment rendered and fees charged be recorded on a daily basis.
Take help of a professional chartered accountant to help you in maintaining and filing the tax returns every year.
Accurate recording system helps to do good treatment, remember financial details and protects you from any consumer or legal action, which may arise due to some misunderstanding by patient of your treatment decisions.
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