Dental History

Dental History

Reviewed By:
Andrew M. Sicklick, D.D.S.

Summary

A dental history is a summary of a patient’s past and present dental symptoms, conditions and treatments. Patients who visit a new dentist for the first time are typically asked to fill out a form that includes this information. The dentist is then likely to use this information to ask additional questions that can aid in the diagnosis and treatment of the patient.

A dental history is often divided into three components:

  • Personal dental history. This includes facts about the patient’s present and past dental concerns.
  • Social history. This includes information about the patient’s habits and lifestyle that may affect oral health (e.g., diet, dental hygiene habits, tendency to eat sweets, tobacco use).
  • Family history. A family dental history includes information about any health conditions that tend to run in the patient’s family.

A dentist sifts through all of the information from the dental history to determine the patient’s health status, diagnose problems and determine the best course of treatment. Knowledge gained from the dental history can also help a dentist to look for hidden or developing dental problems that may be more likely given the patient’s dental history.

The reliability of the patient’s dental history is crucial because medical decisions are made based on this information. At times, however, dental history information may not be entirely accurate. Ambiguities and even omissions are common mistakes that patients make in maintaining accurate dental histories. However, omitting information can negatively affect dental care.

There are several steps that patients can take to help compile a more thorough dental history. These include writing down information about symptoms and previous dental history before a dental appointment and asking that medical forms be provided before an office visit to allow more time for accurate answers.Once a patient’s dental history has been compiled, it should be reviewed and updated regularly, incorporating any new information that becomes available over time.

About dental history

A dental history provides a comprehensive record of a patient’s previous dental experiences, including conditions (e.g., periodontal disease, abscesses), procedures (e.g., fillings, root canals), allergies to medications and more. It includes:

  • Personal dental history. This includes facts about the patient’s present and past dental concerns. Information focuses on any serious dental abnormalities, chronic conditions, and history of dental procedures and surgeries. In addition, a patient’s general personal medical history can provide important information that may help the dentist in diagnosing and treating oral health conditions.
  • Social history. This includes information about the patient’s habits and lifestyle that may affect oral health (e.g., diet, brushing and flossing habits, tendency to eat sweets, tobacco use). It can also help pinpoint circumstances that may be at the root of a patient’s dental health problem.
  • Family history. A family dental history includes information about any health conditions that tend to run in the patient’s family. For example, periodontal (gum) disease sometimes runs in families. The dentist may ask about the oral health of relatives – both living and deceased. The dentist may also be interested in family history of conditions such as high blood pressure, diabetes or cancer. Any other serious illnesses or surgeries will also need to be documented for relatives, usually going back three or four generations, if that information is available.

Typically, patients who visit a dentist for the first time are instructed to fill out a form detailing specific information relevant to compiling a thorough dental history. Once the form is completed, a dentist will likely use the information as a starting point for asking additional questions that further expand upon the patient’s dental history.

A dentist may ask several questions related to a patient’s dental history, including the following:

  • When was the patient’s last dental visit? What care was given at that time?
  • Is the patient experiencing symptoms related to oral health?
  • How often has the patient typically received dental care?
  • Is the patient now or has the patient ever been under the care of an orthodontist, periodontist or other dental specialist? Does the patient have a regular physician?
  • When did the patient last have dental x-rays? Has the patient ever had a complete set of dental x-rays?
  • Has the patient ever had head and neck radiation therapy?
  • Has the patient experienced symptoms in the past year related to the teeth, gums or jaw?

A dentist sifts through all of the information from the dental history to determine the patient’s health status, diagnose problems and determine the best course of treatment. Knowledge gained from the dental history can also help a dentist to look for hidden or developing dental problems that may be more likely given the patient’s dental history.

The dental history is often a key factor in making both a proper diagnosis and treatment plan. The reliability of the patient’s dental history is crucial because medical decisions are made based on this information.

At times, however, dental history information may not be entirely accurate. Ambiguities and even omissions are common mistakes that patients make in maintaining accurate dental histories. Omitting information can adversely affect care. For example, a patient may fail to mention a drug allergy to an antibiotic that the dentist prescribes to treat periodontal disease, which can then lead to an adverse reaction.  

In some cases, embarrassment or fear of judgment may prevent patients from being forthcoming about their dental history. For example, patients may be reluctant to acknowledge a long period of time between routine dental examinations. However, omitting such information from the dental history can result in a reduced level of dental care.

Many patients believe that it is sufficient for dentists to maintain dental records. However, maintaining copies of dental records is an important step all patients can take to improve their own dental care. Having access to earlier dental care records is particularly important for people who change dentists, such as people moving to a new city. With proper record-keeping habits, patients can be more thorough when completing dental questionnaires.

Without this information, dental histories may be less accurate. Once a patient’s dental history has been compiled, it should be reviewed and updated regularly, incorporating any new information that becomes available over time. Patients who schedule a routine dental examination will typically be asked about any new developments since their last dental visit, including new symptoms, new medications, recent lllnesses or hospitalizations, and life changes (e.g., pregnancy).

Personal dental history

A personal dental history includes a chronology of the onset of symptoms associated with a patient’s mouth, teeth, and jaws. A detailed description of the symptoms, how often they occur and how long they last is also necessary. Symptoms that may be of interest to a dentist include:

  • Bad breath (halitosis)
  • Bleeding or sore gums
  • Burning sensation in the mouth
  • Calculus buildup
  • Chewing difficulty
  • Cold sores
  • Dry mouth (xerostomia)
  • Fractured or broken fillings
  • Grinding of teeth (bruxism)
  • Jaw problems, such as soreness, clicks or pops
  • Loose teeth
  • Mouth sores
  • Recession of gums
  • Sensitivity of teeth
  • Sinus problems
  • Swallowing difficulty
  • Yellowing or discoloration of teeth
  • Sensitive gag reflex

The dental history also includes a recounting of any past dental work (e.g., fillings, root canals, orthodontic work) or conditions (e.g., periodontal disease, prolonged bleeding after tooth cleaning, conditions that require preventative antibiotics). It is important to include this information even if a procedure was not successful, such as a failed dental implant.

A dentist is also likely to request information about the patient’s general medical history. This will include information about the patient’s health in areas not specifically related to oral health. For example, the dentist will likely ask about any previous illnesses or surgeries the patient has experienced. Some conditions (e.g., certain heart conditions, presence of artificial joints) may require additional antibiotic care before some dental procedures. The dentist will also want to know about any longstanding or chronic conditions, such as the following:

  • Bone/joint conditions (e.g., arthritis, osteoporosis, presence of artificial joints)

  • Blood conditions (e.g., stroke, hemophilia, leukemia, immunodeficiency problems)

  • Cardiovascular conditions (e.g., mitral valve prolapse; heart disease, heart failure and heart attack; heart murmur or arrhythmia; presence of pacemaker or artificial heart valves; high or low blood pressure)

  • Endocrine system conditions (e.g., diabetes, thyroid disease, frequent urination)

  • Gastrointestinal/digestive system conditions (e.g., diarrhea, stomach ulcers, jaundice)

  • Genitourinary system conditions (e.g., kidney disease, sexually transmitted diseases)

  • Neurological/psychological conditions (e.g., seizures, frequent headaches, epilepsy, paralysis, Spina Bifida, Alzheimer’s disease, multiple sclerosis, clinical depression)

  • Respiratory system conditions (e.g., lung disease, asthma, bronchitis, shortness of breath)

  • Sensory/physical disabilities (e.g., eye disease, hearing disorders, substance abuse problems)

Finally, the dentist will ask about any medications the patient is currently taking (including oral contraceptives, hormone replacement, herbal supplements) and about any known allergies to various substances (e.g., foods, latex, metals) or drugs, especially:

  • Anesthesia (including local and topical formulations)
  • Antibiotics
  • Aspirin
  • Sedatives
  • Codeine
  • Steroids
  • Sulpha drugs
  • Tranquilizers

Social dental history

Patients are also asked about their social history, which includes information about lifestyle and habits related to overall dental hygiene, diet and other factors. A patient’s social history can have a significant impact on dental health.

For example, a history of consuming sugary foods and sodas may increase the risk of cavities. The habit of breathing through the mouth increases the likelihood of dry mouth. Habits such as nail biting or using the teeth to open food packages can increase wear on the teeth. A history of tobacco use also increases the risk of dental problems such as tooth decay and periodontal (gum) disease. Anxiety or fear of dental procedures may increase the chance of a patient neglecting regular professional care. Informing dentists of such anxiety may allow them to help anxious patients to relax and remain calm.

The dentist will also inquire about the patient’s brushing and flossing habits, as poor day-to-day maintenance is the most significant factor in many dental health problems. The information in a social dental history helps the dentist to make better decisions and offer more effective counseling regarding prevention and early treatment. By law, such information cannot be shared with anyone without the patient’s written permission.

Family dental history

A family medical history provides detailed information about the present and past health of the patient’s family members. The patient’s family medical history can increase (or decrease) the patient’s risk of developing certain oral health conditions. For example, periodontal (gum) disease sometimes runs in families, making some people more susceptible than others to developing this illness.

Patients who compile a thorough family dental history and share this information with a dentist can help provide insight into potential health threats. However, family dental histories are not helpful in situations where a patient is adopted unless the information pertains to the patient’s birth parents.

Family history is even more important in diagnosing and monitoring other conditions that may affect a patient’s overall health. For example, some diseases that can have an impact on a patient’s oral health (e.g., cancer, diabetes, heart conditions) often have a genetic component.  Many patients keep track of their general family medical history by creating a medical family tree. A complete family tree traces the medical history of an individual through at least several generations. For each relative, the tree includes such information as:

  • Any known congenital (existing at birth) or hereditary disorders
  • Major illnesses or conditions, dates when they were diagnosed and affected organs
  • Chronic ailments or risk factors (such as smoking or alcohol problems)
  • The cause of death and age at the time of death of deceased relatives
  • Childhood illnesses, immunizations, surgeries and treatments
  • Histories of infertility, miscarriages, stillbirths or sudden infant death syndrome

It may be helpful to bring this information along during an initial dental visit.

It is possible for patients who do not have enough information about deceased relatives to track down much of the information through public records. For instance, a great deal of information can be obtained through death certificates from state health departments. There are sometimes fees for these records, but they are usually under $10 and records will include an age and cause of death.

It is never advisable for patients to guess their family history. Although it is important to gather a complete picture with as much accurate information as possible, it is just as important not to speculate about any blanks that might be left.

Tips regarding dental history

There are several steps that patients can take to help compile a more thorough dental history. These include:

  • Write down information about any history of symptoms, conditions and dental work before a dental appointment. It is easy to forget important details during a visit to a dentist, especially on a first visit.
  • Ask that medical forms be provided before an office visit to allow more time for accurate answers.
  • Maintain an up-to-date list of all medications (past and present) including the drug name, purpose, dose and instructions, as well as the physician who prescribed it and the date it was prescribed. Include all herbal or vitamin supplements, alternative or over-the-counter medications, as well as alcohol and illegal drugs. List any allergies to medications.
  • List information needed in the event of an emergency separately so that it will be easy to locate quickly.
  • Maintain a list of the names, addresses and telephone numbers of all dentists seen over the past several years.
  • Request a copy of dental records from all providers past and present.
  • Keep copies of dental insurance information.

With advanced technology, there are several companies that store medical histories in accounts online. This option offers individuals the advantage of having all of their information in one safe place. In addition, it allows for easy access and the ability to update their records on a continual basis.

Questions for your doctor about dental history

Preparing questions in advance can help patients to have more meaningful discussions regarding their conditions. Patients may wish to ask their doctor the following questions related to dental history:

  1. What type of information should I include when gathering my dental history?
  2. Would it be helpful for you to have copies of dental records from dentists who have treated me in the past?
  3. Will I have to pay for copies of my records from dentists who have treated me in the past?
  4. What if I don’t remember specific dates related to events in my personal dental history?
  5. What should I do if I don’t know my family’s dental history?
  6. I’m adopted. How can I obtain family dental and medical history information?
  7. What information will you need from my social dental history?
  8. Should I have any specific screening tests or preventative procedures based on my personal or family dental history?
  9. Can you recommend any companies that gather and store medical histories?
  10. What information will you need from my general medical history?
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