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Table of Contents
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.
This guide provides a systematic approach to taking a dental history which you can then adjust to your patient’s specific needs.
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 differently in unfamiliar or clinical settings. Be aware of your own non-verbal communication at this stage – face the patient openly and smile as they enter the room.
Opening the consultation
Greetthepatient as they enter the room.
Introduceyourself and the dentalnurse including your names and roles.
Confirm the patient’s name and date of birth.
Ask the patient to take a seat and ensure they are comfortable.
Briefly explain what the dental assessment will involve using patient-friendlylanguage: “I’ll begin by asking some questions to understand why you’re here today and what you’re hoping to achieve from the appointment.”
Gain consent to proceed with taking the dental history: “Are you happy to continue?”
Use open questioning to explore the patient’s presentingcomplaint:
“What’s brought you in to see me today?”
“Tell me about the issues you’ve been experiencing.”
Allow the patient time to answer, trying not to interrupt or direct the conversation.
Facilitate the patient to expand on their presentingcomplaint if required:
“Ok, so tell me more about that?”
“Can you explain what that pain was like?”
Once the patient has spoken, it is helpful to check if there are any other separateissues. If a patient is just attending for a routine check-up, you can progress to an assessment of their medical history.
If the patient has multiple presenting complaints, work with the patient to establish a shared agenda for the rest of the consultation:
“Ok, so you’ve mentioned that you have three problems today that you’d like addressing. As there may not be time to address them all thoroughly in this consultation, it would be helpful to know which of the issues you feel is most important to deal with today. I’ll then let you know which of these issues I feel is the priority and we can agree on what the focus of today’s consultation should be. Does that sound ok?”
Open vs closed questions
History taking typically involves a combination of open and closedquestions. Open questions are effective at the start of 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 differential diagnosis.
History of presenting complaint
“Listen to your patient; he is telling you the diagnosis.” 1
In dental practice, patients often present with either pain or a functional problem such as a lost crown or broken tooth. If a specific tooth or restoration is damaged, ask about any previous dental treatment in the affected area. The SOCRATES acronym 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 find out about the problem from their perspective – what are their ideas and concerns about the issue, and what are their expectations about what should be done.2
Allow them time to speak and prompt them to fill in the gaps as necessary, moving from open to closed questions as required.
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.
“Where is the pain?”
“Can you point to the tooth or area in question?” (n.b. pulpitis can be poorly localised)
“When did the pain start?”
“Did it come on suddenly or gradually?”
“How would you describe the pain?” (e.g. achey, sore, throbbing, sharp)
“Is the pain constant or does it come and go?”
“Does the pain spread elsewhere?”
“Are there any other symptoms that seem associated with the pain?” (e.g. bad taste, fever)
“How has the pain changed over time?”
Exacerbating or relieving factors
“Does anything make the pain better?” (e.g. analgesics)
“Does anything make it worse or trigger it?” (e.g. cold, touch, lying down)
“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?”
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 fluid throughout the consultation in response to patient cues. 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.
“What do you think the problem is?”
“What are your thoughts about what is happening?”
“It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”
“Is there anything, in particular, that’s worrying you?”
“What’s your number one concern regarding this problem at the moment?”
“What’s the worst thing you were thinking it might be?”
“What were you hoping I’d be able to do for you today?”
“What would ideally need to happen for you to feel today’s consultation was a success?”
“What do you think might be the best plan of action?”
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, 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 different parts of the history-taking process and it allows the patient to prepare for what is coming next.
Explain what you have covered so far:“Ok, so we’ve talked about your symptoms and your concerns regarding them.”
What you plan to cover next:“Now I’d like to discuss your past medical history and the medications you take.”
A thorough medical history is essential for all patients – it helps identify conditions that may affect dental treatment, highlights 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 confirmed, dated and signed by the patient and dentist.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 significant past medical history should be recorded in the patient’s notes as these may impact planned dental care.
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.
As some medical conditions can have a significant impact on dental care and patient safety, it is important to keep your knowledge up to date. If in doubt, seek advice from the relevant specialists.
Ask if the patient has any medicalconditions:
“Do you have any medical conditions?”
“Are you currently seeing a doctor or specialist regularly?”
If the patient does have a medical condition, you should gather more details to assess howwellcontrolled 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 hospitaladmissions.
Ask if the patient has previously undergone any surgery or procedures (e.g. heart valve replacements):
“Have you ever previously undergone any operations or procedures?”
“When was the operation/procedure and why was it performed?”
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 anaphylaxis).
It’s important to know if a patient is pregnant and if so what gestation, as this may significantly impact the management of dental issues (e.g. certain medications will be contraindicated and non-essential X-rays should be avoided).
Ask if the patient is currently taking any prescribedmedications or over-the-counterremedies:
“Are you currently taking any prescribed medications or over-the-counter treatments?”
Anticoagulants or antiplatelets: significantly increase a patient’s bleeding risk.
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).
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.
Anaemia and blood dyscrasias: oral manifestations of systemic disease (e.g. glossitis in B12 deficiency), increased bleeding risk and significant general anaesthetic risk in patients with sickle cell disease.
Leukaemia: increased bleeding risk, susceptibility to oral infections and oral manifestations of systemic disease.
Dyspnoea (shortness of breath)
Syncope (loss of consciousness)
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.
Dyspnoea (shortness of breath)
Haemoptysis (coughing up blood)
Asthma and chronic obstructive pulmonary disease: medical emergencies risk, oral side-effects of improperly administered steroid inhalers and challenges with dental chair positioning.
Nausea or vomiting
Dysphagia (difficulty swallowing)
Odynophagia (pain when swallowing)
Change in bowel habit
Gastro-oesophageal reflux disease: secondary dental erosion from acid reflux.
Inflammatory bowel disease: oral manifestations of systemic disease (e.g. ulcers in Crohn’s disease).
Alcoholism and hepatitis: increased bleeding risk, altered drug metabolism and infection control issues.
Motor or sensory disturbance (i.e. weakness, tremor, numbness)
Epilepsy: medical emergencies risk
Parkinson’s disease: reduced ability to perform oral hygiene measures
TMJ dysfunction: may struggle to open mouth adequately.
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.
“Do you mind if we spend a couple of minutes talking about…?”
Record the patient’s current and pastsmokinghistory, including the type and amount of tobacco or substance used. If the patient does smoke, offer ‘very brief advice’5 and signpost them appropriately.
Record the frequency, type and amount of alcohol consumed. It can be useful to include AUDIT-C6 as part of the medical history questionnaire to aid this. If the patient is drinking more than the recommended amount of alcohol, again offer ‘very brief advice’ and signpost them appropriately.
It is useful to record diethistory in order to help assign caries and toothwearrisks, 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’ve seen signs of decay in a few of your teeth, do you tend to snack on sugary foods or soft drinks?”
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.
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
Clarify the patient’s recent dental history and assess their overall attendancefrequency:
“When was the last time you visited a dentist?”
“Do you visit a dentist regularly?”
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 Modified Dental Anxiety Scale8 on the medical history questionnaire.
Ask about the patient’s oral hygieneroutine by starting with a general invitation:
“Can you tell me a bit about how you look after your teeth at the moment?”
Then progress to closedquestions 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. floss), interdental brushes, single-tufted brushes and toothpicks.
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 briefly suggest some tweaks to their routine if required, such as advising them to not use mouth rinse immediately after 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.
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 furtherquestions or voice their ideas and concerns at this stage if questioning has brought up any issues.
Gandhi J S (2000) ‘William Osler: A Life in Medicine’ British Medical Journal 321: 1087
Kurtz, S M and Silverman J D (1996) ‘The Calgary-Cambridge Referenced Observation Guides: an aid to defining the curriculum and organizing the teaching in communication training programmes’ Medical Education 30(2): 83-89.
Greenwood, M (2015) ‘Essentials of Medical History-Taking in Dental Patients’ Dental Update 42(4): 308-315
Faculty of General Dental Practice (UK) (2016) Clinical Examination and Record-Keeping (3rd Edition) London: Faculty of General Dental Practice (UK)
National Centre for Smoking Cessation and Training (2018) ‘Very Brief Advice for Smoking Cessation for Dental Patients’. Available at [LINK].
Public Health England (2017) ‘Alcohol use disorders identification test for consumption (AUDIT C)’ Available at [LINK]
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’ European Journal of Dentistry 13(3): 323-329.
Humphris G M, Morrison T, Lindsay S J (1995) ‘The Modified Dental Anxiety Scale: validation and United Kingdom norms’ Community Dental Health. 12(3): 143-150.
American Academy of Periodontology (2015) More than a quarter of U.S. adults are dishonest with dentists about how often they floss their teeth [Press release]. Available at [LINK]