If you prefer videos, watch the youtube video we made on this topic!
In this blog, we’re going to discuss how you can take a better dental history and we’ll also provide you with a cheat sheet for you to use on clinics, to make sure you don’t miss anything out.
We’re going to focus on a lot of the stuff they don’t teach you at dental school like how to phrase your questions and give you a better understanding as to why you’re asking particular questions.
What’s the point?
The whole point of a history and examination is to gather all the information to be able to form a treatment plan and to do it in a way that flows well so you and the patient are comfortable.
Your university might already have these sheets that they force you to use but what we’re going to show you is what we think is the best order to ask the questions so that it flows well. This is a flow that you’ll develop yourself as you see more patients, and you might change it to suit yourself and your style of questioning.
It’s important to remember that there’s actually a logic behind asking particular questions and that they usually bring you closer to a diagnosis or result in a different way of treating your patients. For example, if the patient tells me they get pain when they bite down when eating, I usually think that I might be heading towards diagnosing them with periapical periodontitis or cracked tooth syndrome whereas if they say they have a sensitivity to hot or cold things, I instantly start to think it could be some level of pulpitis or dentinal sensitivity. For you to get a better understanding of why these diseases come to mind, make sure to read our last blog on diagnosing.
Order of histories
So the structure is to ask them what their complaining of (CO), to take a history of presenting complaints (HPC), take a medical history (MH), then a social history (SH), then a past dental history (PDH) and then examine them and determine if you need to do some further investigations to establish a diagnosis and treatment plan.
So after you get the patient in the chair and get all the small talk out of the way, you want to ask them about their presenting complaint. If this is an emergency appointment and you know they are there because of a problem, the phrasing I like to use is “How can I help you today?” or “So what brings you in today?”. If the appointment is for a check-up, or a review or something else, you can say “Have you had any problems since I last saw you?”. You want to write the answer to this question in the patient’s own words and If there are multiple complaints, make sure to number them, so you can take a history of each presenting complaint separately as well. The most structured way of taking a history of a complaint is with Socrates. When I started using it, I found it useful to just jot it down in the corner of my notes so I don’t miss any of it out.
HPC – SOCRATES
The first part of Socrates is Site – The phrasing I like to use is “Where is the pain?” and “Can you point to it with one finger?”
This is a simple tool to guide you where to look for the pain in your examination.
If they describe it to be poorly localised, I’m thinking it might be irreversible pulpitis. If they can tell you exactly where the pain is coming from, it can be reversible pulpitis, dentine hypersensitivity, acute apical periodontitis, or even a lateral periodontal abscess.
And remember, where not diagnosing the patient with just a couple of questions, asking all of the questions in your history paints a picture in your head of the possibilities and will aid you in forming your final diagnosis after your examination.
The next part is Onset and I would phrase this as When did it start and what were you doing?
When it started can tell you a lot about how much a particular disease might have progressed. For example, caries may lead to reversible pulpitis, then irreversible pulpitis as the bacteria progresses, then apical periodontitis, and then finally an apical abscess.
The significance of asking what they were doing when the pain started are things like, if they say I was eating some gummy bears or I had some cold water, you’re thinking dentine hypersensitivity or some form of pulpitis, and if they say they heard a crack and then it started hurting, you’re thinking they fractured a restoration or a cusp.
Next on the list is Character – I usually ask “How would you describe the pain? ” and depending on their answer, I might prompt them with “Is it sharp, dull or throbbing?“.
The technique to use to start with an open question and if they’re not answering in as much depth as you like, then you can ask them more a closed question. If they describe the pain as sharp it makes me think reversible pulpitis, dentine hypersensitivity, or cracked tooth syndrome, while if it was dull and throbbing, it would make me think along the lines of irreversible pulpitis or even acute apical periodontitis.
Then comes Radiation – I simply ask them, Is the pain spreading?
Certain diseases such as inflammatory and infectious diseases radiate and this can give us an indication of the severity of the disease. Other types of pain such as trigeminal neuralgia, TMJ and sinus pain can also radiate to affect dental structures. A patient may complain of a toothache that radiates to their TMJ. Your first call of action would be to find the tooth that might be causing the problem and if you don’t find anything, you might consider that the origin of the pain is from the TMJ and is radiating to the tooth rather than the tooth causing pain and radiates to the TMJ. As dentists, we like to constantly look for problems in the mouth but we always need to consider non-odontogenic causes of pain and a radiating pain is one feature that might point towards that.
Another important factor to consider is referred pain. A patient might come in complaining of pain from their ULQ but after you investigate further, you find that the only tooth with a problem is in the LLQ. How could that be the case? This is explained with the concept of converging nerves. As you might remember from your neuroanatomy of the head and neck, there’s a lot of sensory convergence to relatively small areas of the brain and in this particular example, the sensory nerves of the maxillary branch of the trigeminal, V2, and the Mandibular branch of the trigeminal, V3, come together and converge onto a single second-order neuron. The brain is then unable to determine whether the pain is originating from V2 or V3, and pain is perceived in the incorrect location.
After radiation is Associated factors – For this, I like to ask “have you noticed anything else associated with the pain?” and if needed, I prompt with “Anything like bleeding, bad taste, or a swelling?”.
If there’s a foul smell I think dry socket, pericoronitis, or an abscess. Again, if you want to learn more about these diseases, check out our blog on the diagnoses of dental diseases. If there was bleeding I would think it could because of poor oral hygiene and periodontitis and if there was a swelling I would think abscess or trauma.
Next on the list is Timing and I would ask them, How long does it last for? If they give me an answer that I wasn’t really looking for, then I would prompt them with: Does it last Seconds, minutes, hours or is it constant? I would also ask them: Does it keep you up at night?
Dentine hypersensitivity or reversible pulpitis results in a short sharp pain because of the A-delta fibres. Pain that stays on for longer and is waking them up is more likely to be irreversible pulpitis because of the C fibers.
Second to last on the list is Exacerbations – Two simple phrases to use here are Does anything make it worse? and Does anything that makes it better?
If it’s made worse by hot, cold, or sweet things, you think dentinal hypersensitivity or pulpitis and if it’s made worse when they bite, you should be thinking there is some sort of peri-apical infection or cracked tooth syndrome. It’s also important to ask them if they have been using any painkillers and if it’s been helping? If they say yes, ask which medication have you been taking and how much?. If painkillers have not helped it points towards irreversible pulpitis. It’s also important to check for overdose and send them to A&E straight away and the recommended amount of paracetamol is 4g/day and ingestion over 75mg/Kg is considered an overdose.
You want to know how much they have taken to check for an overdose. The recommended amount of paracetamol is 4g/day and an ingestion over 75mg/Kg is considered an overdose. If you think they might have, you need to speak to your supervisor and consider sending the patient to A&E or calling the poison unit of your hospital.
The last thing you want to establish in the HPC is the Severity – I think a common way to phrase this is on a scale of 1-10, 1 being it doesn’t hurt that much and 10 being you’re in agony – what are you experiencing?
This is quite a subjective one but I kind of use it to gauge the urgency of treatment and how much it affects their daily activities.
So that was for pain, but keep in mind you can use aspects of Socrates for other complaints. For example, if they come in saying my tooth is wobbling, I would start by asking which tooth, and if it hurts? If it doesn’t then certain aspects of SOCRATES don’t apply, like the character of the pain, the radiation, and the timing. Instead, I would ask the questions that do apply from Socrates like when did you notice it? Is that the only tooth that you’ve noticed? Does it bleed when you brush (so that would be an associated factor)? Does it prevent you from eating (that would be severity in terms of if it affects their daily functioning)?
There are so many other complaints that you could get but you just need to use some common sense and ask the questions that apply.
Okay, now that you’ve finished taking the HPC, it’s important to summarise what they’ve told you so that they know you care and that you’ve listened, and obviously it helps to check your understanding of what they’ve tried to articulate.
After you’ve taken your history of presenting you want to take a full medical history. A medical history is important because it might alter the way you treat the patient. Your uni will most likely give you a sheet with a set order to follow but the important thing here is to learn how to use the order in a way that you feel comfortable with. We think it’s best if you take your medical history sheet home with you and come up with questions you feel comfortable asking. One of the orders we quite like is working through the body working from top to bottom and then out. Instead of boring you by going through each and every organ in the body, we’ve included this order in the document below with examples of phrases to use. There are some questions we wanted to highlight that we felt are often missed. For example, when a patient tells you they have asthma or they get seizures, it’s important to ask follow up questions and not just jot down asthma.
So you should be asking them: How long have you had it? When was the last episode? How badly does it affect you? E.g Do you get seizures with lights, or does your hypotension affect you when lying down in the dentist chair? Does having dental treatment make your asthma worse or cause you asthma attacks? Do you take any medication for it? Do you know the dose? Do you have your inhaler with you? And lastly, DON’T forget to ask about allergies!
Once you’ve taken their MH, you need to move on to take their Social History and there are 5 things you need to ask about:
The first is their Occupation – If they work in a battery factory, for example, the constant exposure to acid could cause TSL due to erosion; or if they only work night shifts, for example, you need to tailor your OHI to suit that. It also helps you to gauge their availability and readiness to commit to a different, healthier lifestyle if that’s something that they need. Another example is if the patient has a complex treatment plan, you need to make sure the patient has the availability to regularly be able to commit to their appointments.
Secondly, Smoking is a major risk factor for periodontitis and the DBOH advises that we give very brief advice “VBA” opportunistically in under 30 seconds. We use something called the 3 A’s, ask, advise, and act. So usually what I do is, ask if they smoke, what they smoke, and how often they smoke. I advise them that they’re 4x more likely to quit with support and finish off by asking: do you want me to refer you? If they say yes, then you refer, if not, then mention that this option is always available if you change your mind in the future.
The third thing you need to ask about is Drinking. The guidelines state a recommended value of no more than 14 units per week and if they have had more than 50 units a week then you should bear in mind that it could cause bleeding complications with extractions and they need to do a LFT pre-extraction.
The fourth one to ask about is Recreational drugs and this is important because it can lead to lots of diseases. Things like ecstasy, cocaine, amphetamine, and methamphetamine use can lead to tooth grinding and jaw clenching (which is AKA bruxism) and this can cause tooth wear. Tooth wear increases the chances of cracked teeth and cracked teeth can lead to nerve damage. Don’t be scared to ask them when they used it last because there could be consent issues if they’re under the influence during the appointment.
The fifth question I ask about in the SH is the patients living arrangements and if they have any dependents. If the patient walks in presenting with TSL due to a suspected parafunctional habit like grinding at night, it would be useful to know if they have a partner, so we can tell the patient to ask their partner if they notice anything at night like grinding or even symptoms of sleep apnoea. Asking about the dependants could also be useful to make sure there’s someone who’s able to look after the children while they’re at the appointment.
The last thing to ask is Past Dental History – If you’re seeing the patient at a hospital you want to ask “are you registered with a dentist?” and “how often do you visit the dentist”. This gives you an idea of how much they care for their oral health.
Asking “have you had any treatment in the past?” is one of the major questions because there may be work you could otherwise miss, especially to an untrained eye. It could also give you a hint at what might be causing the problem. For example, they might tell you that they have a crown on a tooth where they’re experiencing pain right now.
Finally asking “do you usually have any anxiety with being at the dentist?” is important so you know how careful you need to be in showing or hiding things like Local Anaesthetic.
In this section, you also want to ask them about their oral hygiene regime: I always ask “How often do you brush?”, “How long do you brush for?” “do you do any interdental cleaning like flossing?” “Do you use a manual or electric toothbrush” and finally “what toothpaste do you use?”. The answers to these questions will help you give thorough oral hygiene instructions down the line.
Lastly, you want to briefly ask about diet: I usually ask “what do you eat on a normal day?” and I usually have to prompt further with “do you have a sweet tooth?”, “do you drink tea or coffee?” “do you have fizzy drinks or juices”. You don’t have to go into too much depth with how much and how often. These questions are meant to highlight if there is a need for you to give them a diet diary.
What we’ll be covering next week
So that was everything you need to ask for your history. In the next blog we’ll be covering the examination and special investigations, so make sure you don’t miss it. Don’t forget to have a look at the document below for the cheat sheet and even more useful information. We hope you found this blog useful and if you did, we’d really appreciate it if you shared it with others.