Dental History Taking - PDF

History taking - Dental Benjamin Tighe FCSP GDC Learning Outcomes 1.1.3 Explain general and systemic disease and their relevance to oral health 1.1.8 Describe the properties of relevant medicines and therapeutic agents and discuss their application to patient management 1.2.2 Recognise the impo...

History taking - Dental Benjamin Tighe FCSP GDC Learning Outcomes 1.1.3 Explain general and systemic disease and their relevance to oral health 1.1.8 Describe the properties of relevant medicines and therapeutic agents and discuss their application to patient management 1.2.2 Recognise the importance of and record a comprehensive and contemporaneous patient history Intended learning outcomes Recognise when to ask open and closed ques4ons Be able to explore points raised by the pa4ent and inves4gate further Iden4fy opportuni4es for interven4on What is a dental history? Reasons behind Past dental Financial factors experiences ABendance past treatment Familial dental Success / Failure experiences of past treatment Family dental Dental History Idea’s pa4ent has Presen4ng on their history complaint treatment Changes in dental Current prac4ce Past / current Oral hygiene rou4ne percep4ons of Value they place their oral health on their health Past / current diet Friends dental experiences Current Pain History percep4ons of the dental team Why do we take a Dental history? Gain insight Builds rapport Provides reassurance Guides our decision making process Medico legal - part of the notes process  TEMPLATE Dental History: o What treatment has been provided in the last 5 years? o How many restorations does this patient have? o Missing teeth? o Is this a heavily restored dentition? o Is there a history of fractured teeth/fillings? o If so, what causes any such sensitivity? o Are the teeth worn? o Do the patient's gums bleed on tooth brushing or spontaneously? o Has the patient experienced any particular problems in the past associated with treatment provided for them in the past? If so, what? o Are any teeth painful or sensitive? SOCRATES SOCRATES Site “Where is the pain?” “Can you point to the tooth or area in question?” SOCRATES Onset “When did the pain start?” “Did it come on suddenly or gradually?” SOCRATES Character “How would you describe the pain?” (e.g. achey, sore, throbbing, sharp) “Is the pain constant or does it come and go?” SOCRATES Radiation “Does the pain spread elsewhere?” SOCRATES Associations “Are there any other symptoms that seem associated with the pain?” (e.g. bad taste, fever) SOCRATES Time course “How has the pain changed over 3me?” SOCRATES ExacerbaIng or relieving factors “Does anything make the pain be;er?” (e.g. analgesics) “Does anything make it worse or trigger it?” (e.g. cold, touch, lying down) SOCRATES Severity “On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”  TEMPLATE Dental aLendee: Does the pa4ent have their own GDP? When was the last 4me they visited their GDP? And the 4me before that? Does the den4st tell them when they need to go back or do they decide? Do they only visit when they have pain? How oSen does the pa4ent usually visit their hygienist?  TEMPLATE Mouthguard: Does the pa4ent where a mouth guard? What is it for? Was it made by a den4st? How long have they worn it for?  TEMPLATE OrthodonIc treatment: Have they ever had braces? Which type? How long were they on for? When were they removed? What were the teeth like before? Considering braces?  TEMPLATE Dentures: Do they have full dentures or par4als? How long have they been wearing them? Why were the teeth removed? How do they care for their dentures? Are they happy for the dentures to be removed today?  TEMPLATE Previous Periodontal Rx: To your knowledge, do you suUer from gum disease? How would you rate your overall gum health? Do your gums currently bleed? How long do they bleed for? When do they bleed? Have your gums ever bled? How long has the bleeding gone on for? Any family history of gum problems?  TEMPLATE Scaling with: o Hand instruments? o Power driven scalers? Last scaling visit: o Weeks / months / years o Who was it with? Hygienist? Den4st? How long was the visit: o SpeciVc scaling appt? o 20 / 30 / 60 minute appointments? o Number of appointments?  TEMPLATE Was LA used? Pa4ent anxiety? Sensi4vity? Deep pockets Lots of in]amma4on?  TEMPLATE Any other issues: Is the pa4ent apprehensive about receiving dental care? If so, do these concerns relate to any par4cular dental procedure(s) or to the experience in general? Previous issues they have had? Any concerns? Has the pa4ent experienced any par4cular problems in the past associated with treatment provided for them in the past? If so, what? Parafunc4onal habits Oral hygiene history Tooth brushing How oSen do you brush your teeth? With what? How long for? How oSen do you change your toothbrush [heads]? Do you keep it charged, or let the charge run out? Toothpaste What toothpaste do you use? Do you know how much ]uoride it has in it? Why do you use that toothpaste? Could you tell me how much you use? Spit or rinse? Interdental cleaning Do you use anything to clean between your teeth? How oSen do you clean between your teeth? How oSen do you change them? Tongue Cleaning Do you clean your tongue? With what? Moving on Discussing the next steps At the end of the history-taking, thank the pa4ent and explain what will happen next Your turn Work in groups – 1 actor Then swap around. Did you miss anything? Share your experiences Further reading Greenwood M. Essentials of Medical History–Taking in Dental Patients. Dental Update 2015;42:308-315. Rushworth B, Kanatas A (eds). Oxford Handbook of Clinical Dentistry (7th ed). The Medical History. Available at: https://oxfordmedicine.com/view/10.1093/med/9780198832171. 001.0001/med-9780198832171-chapter-1#med-978019883217 1-chapter-1-div1-6 [Accessed 15.2.21] FGDP(UK). Clinical Examination and Record Keeping. 3.3 Medical History. Available at: https://www.fgdp.org.uk/clinical-examination-record-keeping-sta ndards/33-medical-history [Accessed 15.2.21] 32