The chronology of events that leads to a dental problem or tooth ache is called as dental history. The information received from the patient helps the dentist to arrive at a diagnosis and plan the treatment. The history should include past and present symptoms, as well as any procedures or trauma that might have evoked the chief complaint. Proper documentation is important to be safe from medicolegal issues. Often an S.O.A.P. format is used, designating the Subjective Objective Appraisal Plan for the diagnostic workup.

History of Present Dental Problem 

Involves dialogue between the patient and the doctor. The conversation helps to gather a lot of data from the patient regarding the purpose of visit to the doctor. The events should be recorded in a chronological event i.e. what occurred first and followed by other sequence of events that lead to dental problem. This helps the doctor in diagnosing the problem. The chief complaint of the patient should be recorded in patient’s own words 

Dental History Interview 

The dental history is divided into five basic directions of questioning: localization, commencement, intensity, provocation, and duration.

Localization – The doctor asks the patient to point out the offending tooth. Often the patient can point to or “tap” the offending tooth. This is beneficial to the doctor as it makes his work simpler. In addition, localization allows subsequent diagnostic tests to focus more on that particular tooth. It is important to observe the offending tooth as well as the surrounding tissues near the tooth of interest.

Commencement – The doctor asks when did the symptoms first occur. Initiating events can also be elicited from the patient. It may be spontaneous in nature, it may have begun after a dental visit for a restoration, trauma may be the etiology, or biting on a hard object may have initially produced the symptoms etc. Onset, intensity, nature, duration and the aggravating and relieving factors should be asked. Any other radiating nature of pain or associated symptoms should be asked by the doctor to the patient.

Provocation and Relief of Pain - What produces or reduces the symptoms is of main interest here. The patient may relate that drinking something cold or hot causes the pain or possibly that chewing or biting is the only stimulus that “makes it hurt”. The patient can also tell that medication is the relieving factor of pain.

Duration - Do the symptoms subside shortly, or do they linger after they are provoked is the main focus here. The duration of symptoms after a stimulating event should be recorded as to how long the sensation is felt by the patient, and documented in terms of seconds or minutes.

This gives an idea to the doctor regarding the dental problem. Dental history helps in gathering subjective as well as objective symptoms of pain by conversing with the patient and performing the necessary tests.

Article by Dr. Siri P.B.