Dental practice: taking a history

When a patient attends a dental practice, establish the reason for their visit.

Take a dental history, which includes an overview of the patient’s previous dental problems and treatment, and a detailed history of the presenting condition. This assists with forming a provisional diagnosis—several potential diagnoses (ie differential diagnoses) may be likely. Ask specific questions to narrow the field—open-ended questions are more effective than leading questions (eg ask the patient what particular things cause dental pain, rather than asking if hot or cold drinks cause pain).

Take a medical history, which includes:

  • age and weight, particularly for children
  • medical conditions
  • pregnancy and breastfeeding status
  • a comprehensive medication history, including:
    • prescription medicines
    • over-the-counter and nonprescription medicines
    • complementary medicines (eg vitamins, supplements, herbal medicines)
    • smoking status (past or current)
    • alcohol intake
    • use of illicit drugs
    • history of allergies and adverse reactions to drugs
  • capacity assessment—assess the patient’s overall capacity to provide an accurate history, understand and consent to treatment, and understand and adhere to post-treatment care requirements.

Consult the patient’s carer, medical practitioner or other healthcare practitioner, if needed to complete the history. If the patient is unsure of the medicines they are taking, ask them to obtain a current list from their medical practitioner, pharmacist or electronic health record, to bring to the next appointment. Crosscheck the medicine list with the medical history—there may be conditions the patient has forgotten to mention or has not disclosed. See also History taking to assess the risk of medication-related osteonecrosis of the jaw for history taking in relation to use of drugs associated with osteonecrosis of the jaw.

A complete history also includes the patient’s social history (eg family, occupation, recreation).

At each appointment, check the patient’s history for any changes.