Clinical examination & record-keeping: good practice guidelines, 2nd edition

FGDP(UK) £27; £22 for FGDP(UK) members

Very enlightening scenarios

FGDP publications are often seen as the evidential basis for the majority of dental treatment and investigation performed within the UK, and an authority that both the General Dental Council and the Department of Health look to. This is a new edition of one of their core publications, and is thoroughly contemporary in its outlook. Its recommendations are laid out with a nod to current practice including priorities cited by the NHS. The book is in a sturdy spiral bound format which lends itself to a ‘quick reference’ feel, and leads from a preface including scope of the document (similar to a clinical paper). The mantras of the taking of a medical history and record keeping are covered by the first two chapters. Another nice element of the layout is that core points are bullet-pointed in ‘key facts’ style boxes, while the background to the selections and recommendations made form the main text.

Chapter 4 ‘Full/Comprehensive Examination’ goes on to detail specific investigations and outcomes that should be achieved within the scope of a patient exam – including periodontal, orthodontic, endodontic considerations, justification for radiographs and study models. Chapters 5, 6 and 7 continue to detail recommended practice for recall visits, emergency visits, and research-focused visits. Following the main chapters there are a selection of very enlightening scenarios detailing some potentially tricky situations, and how an appropriate examination and assessment can support the case of a clinician. I found these scenarios to be most interesting, and could relate them to experiences which I have observed within a practice setting. They cover such situations as prior periodontal neglect and a consent issue, with three others. A final appendices section contains such things as sample forms, and models upon which to chart and record elements of examinations. These include some short discussions regarding the formation of a medical history form, a consent form, etc.

In all, I find this book to be one of those publications which you sometimes come across which has a sense of having a real impact on how dentistry is performed. It may be a case of evolution rather than revolution, but it offers a lot of contemporary clarity regarding how records should be held – with particular regard to computerisation, and the gold standard in the variety of outcomes which should be achieved in performing an examination. Even from a student perspective, I have a new-found understanding in the importance of evaluative procedures, and a desire to do the best that I can for the welfare of patients.