Dental History Taking

Dr. Afroza Hoque BDS, MMEd.

Asst. Prof of Children Dentistry

Objectives

 Define case history

 Enumerate the guideline for taking a case history

 Describe the steps of history taking

Case history

It is a classic form of documentation ranges from clinical sketches to highly detailed and
extended accounts that help in arriving at a diagnosis and formulation of treatment plan
of a person before treatment

Steps in case history taking

Step 1: assemble all the available facts gathered from chief complaint, medical history,
dental history, diagnostic tests and investigations
Step 2: analyse and interpret the assembled clues to reach the provisional diagnosis
Step 3: make a differential diagnosis of all possible complications
Step 4: select a closest possible choice-final diagnosis

Guidelines for taking case history

- Questions should be open ended (encourage a detailed explanation). No ‘yes’ or ‘no’

questions
- Avoid leading questions

- Infants under 5yrs parent is interviewed

- The questions should be clear and should touch various aspects of the disease

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 - Symptoms are described by patient should record in his own words

- Doctor should be an empathetic listener

NB: Behavior shaping of child patient should be started from case history taking or even
before.
Consent
Especially in pediatric patients a written consent is a must to get adequate information about
the case and to escape from medico legal complications
Steps in case history taking
1. Vital statistics
a. Date

b. Time of admission- reference during follow up visits

c. Outpatient number- maintaining a record, billing , medico legal considerations

d. Name- to communicate with the patient -to establish a rapport (sympathetic relation)with
the patient

e. Age-

- chronological age (date of birth) should be noted to know whether growth and
development is normal or not

- occurrence of certain diseases correlated with age eg; primary herpetic

gingivostomatitis(6months to 6years) nursing caries-preschool going child

f. Behavior management techniques also vary according to age

g. Sex- girls mature earlier than boys-require treatment earlier -some diseases shows sex
predilection eg: anorexia-females hemophilia –males

h. Race/ethnic origin- certain religious cultures depend the etiology of certain diseases.

i. School/class:-to communicate with teacher -to know the iq level

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 j. Address- communication

- To chart out appointments for patients from distant places

- To know endemic status of disease in the locality
b. Socio economic status-to know about the nourishment, hygiene, payment capacity of the
patient

2. Chief complaint:

 Always record in patient’s own words

 Mention only the chief problem of the present day in the order of Severity

 Follows the chronological order

a. History of the present illness: it should indicate the severity and urgency of the problem

b. Detailed history of the chief complaint-

eg; Dental pain

 Quality-dull, sharp; throbbing, constant

 Quantity, severity, and frequency

 Location-localized, diffuse, referred, radiating.

 Duration of complaint -onset; spontaneous, on stimulation, intermittent (coming and

going at intervals)

 Aggravated by cold, heat, palpation, percussion

 Relieved by cold, heat, any medication ,sleep

3. Medical history – by Check list

a. Anemia

b. Bleeding disorders

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 c. Cardio respiratory disorders

d. Drug treatment and allergies

e. Endocrine disorders

f. Fits and faints

g. Gastrointestinal disorders

h. Hospital admissions and surgeries

i. Infections

j. Jaundice

k. Kidney disease

NB: Antibiotic prophylaxis needed in case of bacterial endocarditis .

4. Past dental history

a. History of dental treatment undergone by the patient ,along with patients experience
before, during and after the dental treatment

b. History of complications experienced by the patient

c. Family history

a. To know about parental attitude towards the child and towards the dental
treatment

b. Presence of genetic / inherited abnormalities

d. Personal history

e. Prenatal history: maternal history of nourishment, usage of drugs etc eg; tetracycline
staining of teeth, phenytoin sodium –cleft lips in child

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 f. Natal history: birth injuries –forceps delivery, premature baby, low birth weight baby
neonatal jaundice(due to rapid destruction of immature RBCs in liver Rh incompatibility
–rh+ father and Rh –ive mother)

g. Post natal history:

- Type of feeding-bottle or breast feeding

- Vaccination
- Presence of any habit along with its onset, duration, frequency and intensity
should be noted eg- mouth breathing, thumb sucking, tongue thrusting, Nail
biting
h. Behavioral status-co-operative or not

i. Diet chart -physical and emotional development of the child.

j. Oral hygiene status of the child-type, method and frequency of brushing

5. General examination

 Analyze while child entering the clinic built, height ,wt, and posture should be noted

 Nourishment of the child vital signs like temperature, blood pressure, pulse,
respiratory rate should be noted

 Body type-ectomorphic (lean), mesomorphic (normal), endomorphic (obese)

Extra oral examination

a. Shape of head- mesocephalic (oval), brachycephalic (short and broad), dolicocephalic

(long ,thin ,tapering)
b. Facial form –straight, convex (class II), Concave (class III)

c. Facial symmetry –bilaterally symmetrical/asymmetrical

d. Lip competency-competent/incompetent

e. Soft tissue-color ,contour, consistency, temperature ,size ,extend and shape

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f. TMJ-clicking ,deviation ,pain , crepitation should be noted while jaw movements

g. Lymphnodes : size, shape, consistency, number, tender on palpation, mobility should

be noted

h. Salivary glands- Submandibular gland-bimanual palpation

Intra oral examination

a. Soft tissue examination

I. Lips- sinus, fistula, ulcers, bite marks

II. Mucosa- (buccal, alveolar, labial); ulcerations, color, consistency, koplik’s spots in
measles, white lesions, trauma.

III. Hard and soft palate-developmental anomalies, lesions, systemic disorders,

growths.

IV. Gingiva- color, contour, consistency, size, shape, exudation.

V. Toungue- growth, developmental anomalies, ulcers and lesions, speech pattern

,trauma

VI. Floor of the mouth-ulcers and lesions, growth etc

VII. Tonsils and adenoids:-inflammatory enlargements

VIII. Salivary orifice-flow of saliva, inflammation, exudation

b. Hard tissue examination

I. Oral hygiene status

II. Restorations-fractures or failures, over extensions.

III. Dental caries

IV. Missing teeth

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 V. Discolorations

VI. Regressive alterations-attrition ,abrasions, erosions

VII. Periodontal status-bleeding from gums ,mobility (grade I-Slight, II- Moderate
mobility within a range of 1 mm, III-Extensive movement more than 1mm both
mesiodistal and vertical) recession, furcation involvement

VIII. Class of malocclusion

IX. Crowding, rotations, space loss

X. Pulpal diseases

XI. Eruption status and development of jaws and teeth

XII. Retained deciduous teeth

XIII. Faulty restorations

XIV. Periodontal diseases

XV. Occlusal Dental caries

XVI. Spacing discrepancies

6. Provisional diagnosis

A general diagnosis based on the clinical impression without any laboratory

Investigations Differential diagnosis the process of listing out of 2 or more diseases
having similar signs and symptoms of which only one could be attributed to the patient’s
suffering

7. Investigations - Radiographs, biopsy, other tests.

8. Final diagnosis - A confirmed diagnosis based on all available data.

9. Treatment plan

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 a. Systemic phase; stabilize the medical condition if any, antibiotic, prophylaxis, sedation,
consent

b. Preventive phase: caries risk assessment, personal oral hygiene, flouride application, pit
and fissure sealant, diet counseling

c. Preparatory phase: behavior management, oral prophylaxis, caries control, orthodontic

consultation, oral surgical procedure (extractions) ,endodontic therapy

d. Corrective phase: restorative dentistry-permanent fillings, stainless steel crowns

prosthetic rehabilitation-tooth replacements ,jacket crowns early orthodontic
intervention;-minor tooth movements, serial extraction, space management

10. Maintenance phase

a. 3-6 month recalls -review check up of oral health indices

b. Repeat caries activity tests

c. Reinforcement of home care measures

d. Motivation and re-counseling of the parent

e. Follow up of treatment procedures

Bibliography
 Text books of pedodontics- Shoba tandon -Damlae –Pinkham
 Text book of pediatric operative dentistry-Kennedy
 Text book of oral medicine-Burkette
 Carranza’s periodontology
 Text book of endodontics-Grossman -Nisha garg