You ask a patient to open his mouth and he does not respond. What should you do?

Correct answer: C. Review the medical history and assess for hearing loss, cognitive impairment, a language barrier or medication effects

• A. Speaking louder helps only if the problem is hearing, and it is patronising and ineffective for every other cause on the list.
• B. Dismissing a patient who may be having a medical event, or who has a disability requiring accommodation, is a failure of care and potentially a discrimination issue.
• C. CORRECT. Non-response is a SYMPTOM, not defiance. The differential is wide and clinically important: hearing impairment, dementia or cognitive impairment, a language barrier, aphasia following a stroke, sedative or psychotropic medication effects, autism spectrum communication differences, an acute medical event, or trismus that makes opening physically impossible. The medical history and a careful assessment tell you which — and each of these requires a different response.
• D. Forcing the mouth open without understanding why it is closed risks injury and is done without meaningful consent.

Note: If the patient cannot open because of trismus, that is itself a finding requiring investigation — infection, TMD, post-injection myospasm, radiation fibrosis, or a submucous fibrosis.