This lesson outlines the importance of history taking. It is an introduction to prompt your revision, highlighting the fundamentals to expand upon with the third party reading.
It is important to find out if a patient is a regular attender and gain a perspective on their previous experiences at the dentist. The patient may mention problems with past treatment such as an allergy to a particular agent, and may state they have an element of dental anxiety. Patient anxiety and any previous history of treatment under sedation/GA can be helpful in identifying adjunctive treatment needs in any future oral surgical procedures. The patient’s oral hygiene regime should also be taken, as well a diet history (note: frequency).
Although the social history is often overlooked, it is part of a comprehensive assessment and can directly influence treatment planning. A minimum is to enquire about the patient’s smoking status and alcohol consumption; at this point the patient may also disclose any use of recreational drug or complementary therapies. If the patient shows interest in quitting smoking, the 3A’s of smoking cessation can be applied. It is also worth mentioning that, delivering better oral health, suggests to drink less than 14 units of alcohol a week. Moreover, it is important to provide smoking cessation after extractions to reduce the risk of alveolar osteitis (dry socket). In addition, a patient may not realise alcohol can have implications on their medication e.g. warfarin, and therefore, pose as an even greater bleeding risk if extractions were needed [2].
Taking a medical history is paramount to provide a holistic approach to dental treatment. It is also important to note, that the dental care practitioner may be the only healthcare professional the patient is seeing; therefore, we may be in a position to pick up underlying medical conditions and refer when needed.
Patient’s medical histories can be complex with marked implications on oral health, FGDP and NICE guidelines highlight that underlying conditions can increase a patient’s caries risk.
(The medically compromised patient will be discussed in more depth in a future lesson and in the systemic diseases related to dentistry topic area).
Clinicians can start off with generic questioning about systems in the body for example; cardiovascular, respiratory or gastro intestinal concerns. This can then be further expanded upon such as the medications used for management. The history of any past medical emergencies, and there severity, will help the clinician ascertain the patient’s clinical risk and allow them to act appropriately if an event was to occur. The stability of any disease will also have implications on treatment planning. Medical history forms and records should be updated and checked at the patient’s appointment to ensure no changes have occurred. It is important not to forget over the counter medications. It can also be useful if the patient brings in their most up to date prescription form, especially if they are on multiple medications.
An accurate pain diagnosis is crucial to avoid unnecessary treatment/ extractions. Some examples of conditions that can mimic odontogenic pain include: Trigeminal neuralgia, post traumatic neuralgia and headache conditions.
A useful mnemonic to remember is SOCRATES:
Site – where is the pain coming from? (can the pain be accurately placed?)
Onset – When does the pain start? was it sudden or gradual?
Character – Is it a sharp pain or a dull ache?
Radiation – Does the pain travel to somewhere else?
Associations – Are there any other symptoms with the pain?
E.g. Swelling or pus exudate.
Time course – Does the pain follow a pattern? Does it linger?
Exacerbating/Relieving factors – Does anything change your pain? E.g. exacerbating factors can be cold or hot foods/drinks, relieving factors can be Paracetamol, ibuprofen or a warm compress.
Severity – How bad is the pain? Pain is subjective, but if it keeps someone up at night, it can be useful between differentiating conditions e.g. acute apical periodontitis is characterised by intense throbbing pain, and severe tenderness to percussion [3].
Overall the information gathered can help lead to an idea of the endodontic and peri-radicular diagnosis, which can then be supplemented with the required special investigations to help confirm.
The above lesson is not an extensive list, but a framework to prompt your mind, and direct your reading. When taking histories, it is important to be thinking; how does this impact the care we are going to provide? Do other members of the health care team need to be included? All of which, puts the patient’s best interests first, keeping them safe.
1. Greenwood M. Essentials of medical history-taking in dental patients. Dental update. 2015 May 2;42(4):308-15.
2. Roth JA, Bradley K, Thummel KE, Veenstra DL, Boudreau D. Alcohol misuse, genetics, and major bleeding among warfarin therapy patients in a community setting. Pharmacoepidemiology and drug safety. 2015 Jun;24(6):619-27.
3. Endodontics AR. Endodontics Colleagues for Excellence. Chicago, Illinois: American Association of Endodontists. 2013:1-8.
General References:
Mitchell D, Mitchell L. Oxford handbook of clinical dentistry. Oxford University Press, USA; 2014.
Wilkinson I, Raine T, Hall C, Wiles K, Goodhart A, O'Neill H. Oxford handbook of clinical medicine. Oxford University Press; 2017.
Scully C. Churchill's Pocketbooks Clinical Dentistry E-Book. Elsevier Health Sciences; 2017 Jun 20.
Clinical examination and record keeping - FGDP
Caries risk assessment guide - FGDP
NICE - Histories and recall interval - Appendix F and G
Delivering better Oral health - DBOH
Pain diagnosis - Example chart of the pain differentials
GDC Principles - Standards
National Centre for Smoking Cessation and Training - NCSCT
Books/ Text:
Scully C. Medical Problems in Dentistry E-Book. Elsevier Health Sciences; 2010 Feb 8.
Renton T, Woolcombe S, Taylor T, Hill CM. Oral surgery I. British dental journal. 2013 Sep;215(5):213-23.
Hill CM, Renton T. Oral surgery II. British Dental Journal. 2017 Oct;223(8):573-84.
