Professional
The importance of adequate
history taking in dentistry
This article will describe the role of the dental nurse in taking personal, medical and dental histories. It will
also emphasise the need for confidentiality and good records of this process, as well as the importance of the
patient’s first impression of the dental practice, or treatment clinic, being a positive and supportive one
M
any patients, and some members
of the dental team, may regard
treatment as ‘doing’ rather than
discussing. However, some of the
most important aspects of dental care relate to
talking and listening to patients, as well as working
in their mouths. Communicating effectively
together, particularly at the first contact or visit,
provides vital information needed for safe and
effective treatment. While the treating clinician still
has the ultimate responsibility for all of the patient’s
dental treatment, this contact is a role that can be
delegated to the dental nurse.
But why is this information so important?
Confidentiality and records
Good information, and good records, are essential
for clinical and ethical risk management. Keeping
out of trouble is all about providing good treatment
for patients but also about communicating well and
finally recording what was said and done.
Moreover, General Dental Council (GDC, 2013)
guidance is clear on the need for good initial and
Andrew Collier is a senior dento-legal
consultant with Dental Protection, with
responsibility for dental nurses. He was
previously a general dental practitioner
and dental undergraduate teacher. He was a
member of the Council and Executive of the
National Examining Board for Dental Nurses
and is now an emeritus dental nurse examiner.
Email: andrew.collier@mps.org.uk
288

ongoing records (particularly of the patient history)
where it states:
‘You must make and keep complete and accurate
patient records, including an up-to-date medical
history, each time that you treat patients.’
Any information obtained must also be kept
confidential as confidentiality is an absolute
relationship of trust between patients and the dental
team. If a patient thinks that their information will
not be kept confidential then they will be reluctant
to ever give true facts about themselves and their
oral health. GDC (2013) guidance is again clear,
saying:
‘Confidentiality is central to the relationship and
trust between you and your patients. You must keep
patient information confidential.
This applies to all the information about patients
that you have learnt in your professional role
including personal details, medical history,
what treatment they are having and how much
it costs.’
The information obtained, and recorded, from
patients at all appointments is therefore important,
but especially so at the first visit.
The patient’s first visit
Nobody gets a second chance to make a first
impression and patients gain confidence when they
© 2014 MA Healthcare Ltd
have a positive view of all members of the dental
team. Quite often patients, particularly if it is
their first visit, will be nervous about the prospect
of treatment so friendly reassurance, while still
obtaining the information needed, can be an ideal
Dental Nursing May 2014 Vol 10 No 5

start in their relationship with the practice or clinic.
Unfortunately, a bad first impression can also stay
with them just as effectively as a good one.
As already mentioned, although the ultimate
responsibility for all of the patient’s clinical treatment,
as well as the information obtained, lies with the
treating clinician who is usually the dentist, dental
nurses can have a pivotal role in gaining patient
confidence and obtaining that information.
So what information is needed and how is it best
obtained?
‘Open’ and ‘closed’ questions
Good communication is essential for successful
dentistry. Patients must feel at ease and if they do,
then obtaining an accurate history is so much easier.
How are the best results obtained?
Questions can be ‘closed’ or ‘open’. ‘Closed’ questions
are used when a clear and definite answer is needed. An
initial, or updated, medical history is a good example.
Do you take medication? Do you have any heart or
chest problems? The (initial) answer is yes or no.
‘Open’ questions usually begin with one of the
5 ‘Ws’ or the ‘H’; Who? What? When? Which? Where?
and How? ‘Open’ questions are used when we want
greater detail or to understand how a patient feels. For
example, ‘what are your main dental concerns?’
The right questions, using the right manner, will
get the relationship with the patient off to the best
start and the appropriate information will be obtained
before commencing the clinical examination.
Personal history
Checking the patient’s name, date of birth and address/
contact details is very much a ‘baseline’ requirement.
However, other information is often very important.
For example, although details of the patient’s job may
not seem relevant, they frequently are. The pastry chef
breathing in sugar dust all day may develop caries
much quicker than average. Other factors such as a
stressful job may lead to bruxism or clenching, which
Case study: taking a patient’s medical history
A new patient attended complaining of pain in her
© 2014 MA Healthcare Ltd
facial muscles. A full medical and dental history
was taken by the dental nurse on the dentist’s behalf,
which revealed nothing abnormal. On examination
the dentist was of the opinion that the problem
Dental Nursing May 2014 Vol 10 No 5
Professional
can cause pain in itself or affect the outlook of any
restorative treatment.
Some jobs may also affect both our and the patient’s
views on future treatment. For example, the career of
a singer or wind instrument musician would be much
more disadvantaged by any nerve injury following a
difficult or surgical extraction.
Medical history
A thorough medical history is essential. If problems
occur that could have been prevented had the
necessary information been obtained, then it
is a serious omission as well as being clinically
dangerous. Formats vary; some clinicians go through
the questions on each and every occasion. Others
use a standard form that the patient fills in. The
latter is efficient but it should never be forgotten that
the patient must understand the questions and be
happy with their reply. A patient signature of a form
is no protection if he or she did not understand the
questions. If there is any doubt, the understanding
must be verified. Medical histories must also be
regularly updated.
Dental history
It is often tempting to think that all of a patient’s
dental history will be revealed by examining the teeth
and soft tissues. However, a lot of information can be
obtained from a history of previous dental treatment.
Even though the patient is a lay-person they will
usually have much to tell; for example:
n Are you a regular attender?
n What treatment have you received in the last
5 years?
n Are any teeth painful/sensitive?
n Do your gums ever bleed on brushing or
spontaneously?
n Are you worried about any area of dental treatment?
n Have you had any particular problems with dental
treatment previously?
The following case study shows the importance of
good history taking and the dental nurse’s role.
was caused by a high spot on one of the patient’s
crowns and that there were no other factors.
Unfortunately, despite careful occlusal adjustment the
patient returned complaining of continued muscular
discomfort for which no apparent cause could be
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 Professional

Case study: taking a patient’s medical history (continued)

found. However, when the dentist briefly left the
room the patient told the dental nurse that she had
just started a new job. The job was not only stressful
in itself but also included a lot of driving, which she
found difficult, and that she felt she was clenching
her teeth. The patient further stated that she had not
felt this was relevant to her dental treatment and had
therefore not mentioned it when she first saw the
nurse nor when she subsequently saw the dentist.
The dentist was duly informed and a soft splint was
constructed, which the patient wore while driving and
at nights. The symptoms resolved as the cause of the
pain, clenching due to stress, was now known.
Following this incident, it was agreed that a
thorough personal history would also be taken with
the medical and dental histories for new patients,
as well as a personal history update for existing
practice patients.

The lesson from this case is that all aspects of the

patient’s history need to be explored but also that
Key points patients may tell other members of the team things
that they would not necessarily inform the dentist of.
A patient’s medical, dental and personal
n The history taking is therefore vital and can be the
histories provide vital information role of the dental nurse.
before a clinical exam takes place.
Taking a thorough medical history is a
n Conclusion
clear requirement of the GDC. It is very tempting to look before asking and
listening. A thorough history, and review of the
The history taken is a vital part of the
n
patient’s clinical record. patient answers, is a vital part of the treatment
process, as well as being a clear ethical requirement
Taking the history can be a role
n of the GDC. Failure to ask the right questions,
delegated to the dental nurse, although and act on the answers, can lead to failure of the
the treating clinician remains ultimately
treatment later on. DN
responsible for all aspects of the
patient’s treatment.
General Dental Council (2013) Standard for the Dental Team. GDC,
London

© 2014 MA Healthcare Ltd

290 Dental Nursing May 2014 Vol 10 No 5


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