11/13/24, 8\:09 PM Guide | Dental history

Dental history

Table of contents

Introduction

Taking a thorough dental history is an opportunity to build rapport with a patient, whilst informing your diagnosis and
management of dental issues. By adopting a systematic approach you can cover all critical points whilst allowing the patient
time to talk and voice their ideas in a way that helps reassure them.

Before the patient enters

Wash your hands and don PPE if appropriate.

As the patient enters

Observing the patient as they enter the room can provide several clues prior to taking the dental history. The patient's gait,
appearance, apparent age vs. chronological age, smell (e.g. of cigarette smoke), tone of voice and degree of eye contact can all
provide insights into their health and wellbeing. Be careful not to over-interpret these characteristics; we cannot read minds
and patients may behave di
stage - face the patient openly and smile as they enter the room.

Opening the consultation

Greet the patient as they enter the room.
Introduce yourself and the dental nurse including your names and roles.
Con
Ask the patient to take a seat and ensure they are comfortable.
Brie
u n d e r s t a n d w h y y o u' r e h e r e t o d a y a n d w h a t y o u' r e h o p i n g t o a c h i e v e f r o m t h e a p p o i n t m e n t .
"
Gain consent to proceed with taking the dental history\:
" A r e y o u h a p p y t o c o n t i n u e ?"

Presenting complaint

Use open questioning to explore the patient's presenting complaint\:
“ W h a t’ s b r o u g h t y o u i n t o s e e m e t o d a y ?”
" T e l l m e a b o u t t h e i s s u e s y o u' v e b e e n e x p e r i e n c i n g."
Allow the patient time to answer, trying not to interrupt or direct the conversation.
Facilitate the patient to expand on their presenting complaint if required\:
“ O k , s o t e l l m e m o r e a b o u t t h a t ?”
“ C a n y o u e x p l a i n w h a t t h a t p a i n w a s l i k e ?”
Once the patient has spoken, it is helpful to check if there are any other separate issues. If a patient is just attending for a
routine check-up, you can progress to an assessment of their medical history.
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If the patient has multiple presenting complaints, work with the patient to establish a shared agenda for the rest of the
consultation\:
" O k , s o y o u' v e m e n t i o n e d t h a t y o u h a v e t h r e e p r o b l e m s t o d a y t h a t y o u' d l i k e a d d r e s s i n g. A s t h e r e m a y n o t b e t i m e t o
a d d r e s s t h e m a l l t h o r o u g h l y i n t h i s c o n s u l t a t i o n , i t w o u l d b e h e l p f u l t o k n o w w h i c h o f t h e i s s u e s y o u f e e l i s m o s t i m p o r t a n t t o
d e a l w i t h t o d a y . I' l l t h e n l e t y o u k n o w w h i c h o f t h e s e i s s u e s I f e e l i s t h e p r i o r i t y a n d w e c a n a g r e e o n w h a t t h e f o c u s o f t o d a y' s
c o n s u l t a t i o n s h o u l d b e . D o e s t h a t s o u n d o k ?"
Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di

History of presenting complaint

“ L i s t e n t o y o u r p a t i e n t ; h e i s t e l l i n g y o u t h e d i a gn o s i s .
”
1
In dental practice, patients often present with either pain or a functional problem such as a lost crown or broken tooth. If a
speci
is useful for investigating pain in more depth - in reality, the patient may cover many of these points themselves as they tell you
about the problem. Be sure to
issue, and what are their expectations about what should be done.
2
Allow them time to speak and prompt them to

SOCRATES

The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most
commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may
not be relevant to all symptoms.
Site
" W h e r e i s t h e p a i n ?"
" C a n y o u p o i n t t o t h e t o o t h o r a r e a i n q u e s t i o n ?" (n.b. pulpitis can be poorly localised)
Onset
" W h e n d i d t h e p a i n s t a r t ?"
" D i d i t c o m e o n s u d d e n l y o r g r a d u a l l y ?"
Character
" H o w w o u l d y o u d e s c r i b e t h e p a i n ?" (e.g. achey, sore, throbbing, sharp)
" I s t h e p a i n c o n s t a n t o r d o e s i t c o m e a n d go ?"
Radiation
" D o e s t h e p a i n s p r e a d e l s e w h e r e ?"
Associations
" A r e t h e r e a n y o t h e r s y m p t o m s t h a t s e e m a s s o c i a t e d w i t h t h e p a i n ?" (e.g. bad taste, fever)
Time course
" H o w h a s t h e p a i n c h a n g e d o v e r t i m e ?"
Exacerbating or relieving factors
" D o e s a n y t h i n g m a k e t h e p a i n b e t t e r ?" (e.g. analgesics)
" D o e s a n y t h i n g m a k e i t w o r s e o r t r i g g e r i t ?" (e.g. cold, touch, lying down)
Severity
" O n a s c a l e o f 0-1 0 , h o w s e v e r e i s t h e p a i n , i f 0 i s n o p a i n a n d 1 0 i s t h e w o r s t p a i n y o u’ v e e v e r e x p e r i e n c e d ?"
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Ideas, concerns and expectations

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE).
Asking about a patient’s ideas, concerns and expectations can allow you to gain insight into how a patient currently perceives
their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can sometimes be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have
provided several examples for each of the three areas below.
Ideas
" W h a t d o y o u t h i n k t h e p r o b l e m i s ?"
" W h a t a r e y o u r t h o u g h t s a b o u t w h a t i s h a p p e n i n g?"
“ I t’ s c l e a r t h a t y o u’ v e g i v e n t h i s a l o t o f t h o u gh t a n d i t w o u l d b e h e l p f u l t o h e a r w h a t y o u t h i n k m i gh t b e go i n g o n .
”
Concerns
" I s t h e r e a n y t h i n g , i n p a r t i c u l a r , t h a t' s w o r r y i n g y o u ?"
“ W h a t’ s y o u r n u m b e r o n e c o n c e r n r e g a r d i n g t h i s p r o b l e m a t t h e m o m e n t ?”
“ W h a t’ s t h e w o r s t t h i n g y o u w e r e t h i n k i n g i t m i g h t b e ?”
Expectations
“ W h a t w e r e y o u h o p i n g I’ d b e a b l e t o d o f o r y o u t o d a y ?”
“ W h a t w o u l d i d e a l l y n e e d t o h a p p e n f o r y o u t o f e e l t o d a y’ s c o n s u l t a t i o n w a s a s u c c e s s ?”
“ W h a t d o y o u t h i n k m i g h t b e t h e b e s t p l a n o f a c t i o n ?”

Summarise

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding
regarding everything the patient has told you. It also provides an opportunity for the patient to correct any inaccurate
information and expand further.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. This can be a useful tool when transitioning between di
the patient to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s a n d y o u r c o n c e r n s r e g a r d i n g t h e m .
”
What you plan to cover next\:
“ N o w I’ d l i k e t o d i s c u s s y o u r p a s t m e d i c a l h i s t o r y a n d t h e m e d i c a t i o n s y o u t a k e .
”

Medical history

A thorough medical history is essential for all patients - it helps identify conditions that may a
the risk of a patient experiencing a medical emergency, and aids in the diagnosis of oral manifestations of systemic disease.
3
At each recall examination, the medical history should be con
4
Most practices will have a medical history questionnaire for patients to complete prior to the appointment - this helps save
time, guide further questioning and acts as a clinical record. It tends to cover the main body systems and other key conditions
as outlined below. A blank box on the questionnaire allows patients to add anything else of relevance.
Any signi
If you are in doubt about the patient’s reported medical history, for instance, if they can’t remember the names of certain
medications, it can be useful to speak to their GP or pharmacist - they will usually be very helpful on the phone. You can also
ask the patient to bring in their repeat prescription to the next appointment.
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As some medical conditions can have a signi
knowledge up to date. If in doubt, seek advice from the relevant specialists.

Medical conditions

Ask if the patient has any medical conditions\:
“ D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?”
“ A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e gu l a r l y ?”
If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and
what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition
including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. heart valve replacements)\:
“ H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?”
“ W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?”
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs
Pregnancy
It's important to know if a patient is pregnant and if so what gestation, as this may signi
dental issues (e.g. certain medications will be contraindicated and non-essential X-rays should be avoided).

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
“ A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?”
Medication examples
Anticoagulants or antiplatelets\: signi
Combined oral contraceptive pill\: pre-disposes to gingival disease.
Steroid inhalers\: can cause local immunosuppression resulting in oral candidiasis.
Anticonvulsants\: may cause drug-induced gingival overgrowth (e.g. phenytoin, topiramate, lamotrigine).
Calcium channel blockers\: cause drug-induced gingival overgrowth (e.g. amlodipine).
Immunosuppressants\: predispose to malignancy and infections (e.g. oral candidiasis, oral abscesses).

Systems review

Patients may forget to mention important medical conditions, so it's worth quickly performing a systems review to screen for
medical conditions which may be relevant.
General
Symptoms\:
Fevers
Reduced appetite
Weight loss
Fatigue
Skin rashes
New lumps/swellings
Bleeding/bruising
Condition examples\:
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Anaemia and blood dyscrasias\: oral manifestations of systemic disease (e.g. glossitis in B12 de
risk and signi
Leukaemia\: increased bleeding risk, susceptibility to oral infections and oral manifestations of systemic disease.
Cardiovascular system
Symptoms\:
Chest pain
Dyspnoea (shortness of breath)
Palpitations
Syncope (loss of consciousness)
Condition examples\:
Valvular heart disease\: increased risk of infective endocarditis which may require antibiotic prophylaxis.
Arrhythmias, angina\: bleeding risk if taking anticoagulants/antiplatelets, medical emergencies risk, certain local anaesthetics
may be contraindicated.
Respiratory system
Symptoms\:
Dyspnoea (shortness of breath)
Wheeze
Cough
Haemoptysis (coughing up blood)
Condition examples\:
Asthma and chronic obstructive pulmonary disease\: medical emergencies risk, oral side-e
steroid inhalers and challenges with dental chair positioning.
Gastrointestinal system
Symptoms\:
Indigestion
Nausea or vomiting
Dysphagia (di
Odynophagia (pain when swallowing)
Change in bowel habit
Condition examples\:
Gastro-oesophageal re
In
Alcoholism and hepatitis\: increased bleeding risk, altered drug metabolism and infection control issues.
Neurological system
Symptoms\:
Seizures
Headache
Motor or sensory disturbance (i.e. weakness, tremor, numbness)
Co-ordination problems
Confusion
Condition examples\:
Epilepsy\: medical emergencies risk
Parkinson’s disease\: reduced ability to perform oral hygiene measures
Musculoskeletal system
Symptoms\:
Joint pain/sti
Joint swelling
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Condition examples\:
TMJ dysfunction\: may struggle to open mouth adequately.

Social history

The social history allows you to put disease or dental problems in context and allows you to take a more holistic approach to
care. These topics can be sensitive, so ask about them in a non-judgemental way.
“ D o y o u m i n d i f w e s p e n d a c o u p l e o f m i n u t e s t a l k i n g a b o u t …?”
Smoking
Record the patient's current and past smoking history, including the type and amount of tobacco or substance used. If the
patient does smoke, overy brief advice’ 5
and signpost them appropriately.
Alcohol
Record the frequency, type and amount of alcohol consumed. It can be useful to include AUDIT-C 6
as part of the medical
history questionnaire to aid this. If the patient is drinking more than the recommended amount of alcohol, again o
advice’ and signpost them appropriately.
Diet
It is useful to record diet history in order to help assign caries and tooth wear risks, however, patients are often unreliable in
reporting this. Ask about snacking habits and what drinks they have between meals. Alternatively, by asking after a physical
examination, you can target the questions more accurately based on what you have seen in the mouth, and this may lead to
more useful discussions.
“ I’ v e s e e n s i g n s o f d e c a y i n a f e w o f y o u r t e e t h , d o y o u t e n d t o s n a c k o n s u g a r y f o o d s o r s o f t d r i n k s ?”
It may be useful to set time aside in a future appointment to discuss these issues in more depth, including exploring what the
patient knows about the impact of these factors on their dental health, and outlining what resources are available to help them.
Occupation
This is helpful to record as it can impact the patient’s availability for appointments and may highlight shift working patterns
which increase caries risk.
7

Dental history

Clarify the patient's recent dental history and assess their overall attendance frequency\:
“ W h e n w a s t h e l a s t t i m e y o u v i s i t e d a d e n t i s t ?”
“ D o y o u v i s i t a d e n t i s t r e g u l a r l y ?”
It can also be useful to ask the patient how they feel about visiting the dentist to get a sense of their level of dental anxiety. You
can do this by asking an open question or by including a short scale such as the Modi8
on the medical
history questionnaire.
Ask about the patient’s oral hygiene routine by starting with a general invitation\:
“ C a n y o u t e l l m e a b i t a b o u t h o w y o u l o o k a f t e r y o u r t e e t h a t t h e m o m e n t ?”
Then progress to closed questions in the following areas if required\:
Toothbrushing\: frequency, duration, time of day, type of brush used, type of toothpaste used and use of rinsing.
Interdental cleaning\: frequency, devices used (e.g.
Mouth rinse\: frequency and time of use (e.g. after brushing).
Although detailed oral hygiene instruction will usually be included as part of a treatment plan, it can be useful at this stage to
brie
brushing or to ‘spit don’t rinse’
.
Most patients give accurate accounts of their health-related behaviours, but a minority may not tell the truth about their health
or habits. A survey of U.S. patients suggested that 27% of patients admit lying to their dentist. 9
Avoid accusatory questioning and
try to build up trust, using subsequent examinations as an opportunity to open up a further discussion if required, for instance, if
the plaque and gingivitis levels do not correspond to their reported oral hygiene activities.
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Discussing the next steps

At the end of the history-taking, thank the patient and signpost them to what will happen next - most likely a dental exam.
Allow them to ask any further questions or voice their ideas and concerns at this stage if questioning has brought up any
issues.

References

1. Gandhi J S (2000) ‘William Osler\: A Life in Medicine’ B r i t i s h M e d i c a l J o u r n a l 321\: 1087
2. Kurtz, S M and Silverman J D (1996) ‘The Calgary-Cambridge Referenced Observation Guides\: an aid to de
and organizing the teaching in communication training programmes’ M e d i c a l E d u c a t i o n 30(2)\: 83-89.
3. Greenwood, M (2015) ‘Essentials of Medical History-Taking in Dental Patients’ D e n t a l U p d a t e 42(4)\: 308-315
4. Faculty of General Dental Practice (UK) (2016) Clinical Examination and Record-Keeping (3rd Edition) London\: Faculty of General
Dental Practice (UK)
5. National Centre for Smoking Cessation and Training (2018) ‘Very Brief Advice for Smoking Cessation for Dental Patients’
.
Available at [LINK].
6. Public Health England (2017) ‘Alcohol use disorders identiLINK]
7. Roestamadji R I, Nastiti, N I, Surboyo M D C and Irmawati A (2019) ‘The Risk of Night Shift Workers to the Glucose Blood Levels,
Saliva, and Dental Caries’ E u r o p e a n J o u r n a l o f D e n t i s t r y 13(3)\: 323-329.
8. Humphris G M, Morrison T, Lindsay S J (1995) ‘The Modi
Community Dental Health. 12(3)\: 143-150.
9. American Academy of Periodontology (2015) M o r e t h a n a q u a r t e r o f U .S . a d u l t s a r e d i s h o n e s t w i t h d e n t i s t s a b o u t h o w o f t e n
t h e y LINK]
Source\: geekymedics.com
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