Taking a Dental History – OSCE Guide

geekymedics.com/taking-a-dental-history-osce-guide

Dr Lucy Alderson August 8, 2020

dental history taking post pic

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.

Download the dental history taking PDF OSCE checklist, or use our interactive OSCE
checklist.

Before the patient enters

Wash your hands and don PPE if appropriate.

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You might also be interested in our premium collection of 1,000+ ready-made OSCE
Stations, including a range of communication skills and history taking stations

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As the patient enters
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

Greet the patient as they enter the room.

Introduce yourself and the dental nurse 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-friendly language: “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?”

Presenting complaint
Use open questioning to explore the patient’s presenting complaint:

“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 presenting complaint 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 separate issues. If
a patient is just attending for a routine check-up, you can progress to an assessment of
their medical history.

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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 closed questions. 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.

SOCRATES
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.

Site

“Where is the pain?”

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“Can you point to the tooth or area in question?” (n.b. pulpitis can be poorly localised)

Onset

“When did the pain start?”

“Did it come on suddenly or gradually?”

Character

“How would you describe the pain?” (e.g. achey, sore, throbbing, sharp)
“Is the pain constant or does it come and go?”

Radiation

“Does the pain spread elsewhere?”

Associations

“Are there any other symptoms that seem associated with the pain?” (e.g. bad taste,
fever)

Time course

“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)

Severity

“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.

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Ideas

“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.”

Concerns

“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?”

Expectations

“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
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

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.

Signposting examples

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.”

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Medical history
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.

Medical conditions
Ask if the patient has any medical conditions:

“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 how well controlled 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 hospital admissions.

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?”

Allergies

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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).

Pregnancy

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).

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-

counter remedies:

“Are you currently taking any prescribed medications or over-the-counter treatments?”

Medication examples
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).

Systems review

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.

General

Symptoms:

Fevers
Reduced appetite
Weight loss
Fatigue
Skin rashes
New lumps/swellings
Bleeding/bruising

Condition examples:

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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.

Cardiovascular system

Symptoms:

Chest pain
Dyspnoea (shortness of breath)
Palpitations
Syncope (loss of consciousness)

Condition examples:

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.

Respiratory system

Symptoms:

Dyspnoea (shortness of breath)

Wheeze
Cough
Haemoptysis (coughing up blood)

Condition examples:

Asthma and chronic obstructive pulmonary disease: medical emergencies risk, oral
side-effects of improperly administered steroid inhalers and challenges with dental
chair positioning.

Gastrointestinal system

Symptoms:

Indigestion
Nausea or vomiting
Dysphagia (difficulty swallowing)
Odynophagia (pain when swallowing)
Change in bowel habit

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Condition examples:

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.

Neurological system

Symptoms:

Seizures
Headache
Motor or sensory disturbance (i.e. weakness, tremor, numbness)
Co-ordination problems
Confusion

Condition examples:

Epilepsy: medical emergencies risk

Parkinson’s disease: reduced ability to perform oral hygiene measures

Musculoskeletal system

Symptoms:

Joint pain/stiffness (including temporomandibular joint)

Joint swelling

Condition examples:

TMJ dysfunction: may struggle to open mouth adequately.

Social history
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…?”

Smoking

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Record the patient’s current and past smoking history, including the type and amount of
tobacco or substance used. If the patient does smoke, offer ‘very brief advice’5 and signpost
them appropriately.

Alcohol

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.

Diet

It is useful to record diet history in order to help assign caries and tooth wear risks,
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.

Occupation

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

Dental history
Clarify the patient’s recent dental history and assess their overall attendance frequency:

“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 hygiene routine by starting with a general invitation:

“Can you tell me a bit about how you look after your teeth at the moment?”

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Then progress to closed questions 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 further questions or voice their
ideas and concerns at this stage if questioning has brought up any issues.

References
1. Gandhi J S (2000) ‘William Osler: A Life in Medicine’ British Medical Journal 321: 1087
2. 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.
3. Greenwood, M (2015) ‘Essentials of Medical History-Taking in Dental Patients’ Dental
Update 42(4): 308-315
4. Faculty of General Dental Practice (UK) (2016) Clinical Examination and Record-
Keeping (3rd Edition) London: Faculty of General Dental Practice (UK)
5. National Centre for Smoking Cessation and Training (2018) ‘Very Brief Advice for
Smoking Cessation for Dental Patients’. Available at [LINK].
6. Public Health England (2017) ‘Alcohol use disorders identification test for consumption
(AUDIT C)’ Available at [LINK]
7. 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.

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8. 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.
9. NPR (2015) Are You Flossing Or Just Lying About Flossing? The Dentist Knows.
Available at [LINK]

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