IMPORTANCE OF HISTORY TAKING IN DENTISTRY.
This article was originally published by Indira Gandhi Institute of Medical Science and was migrated to Scientific Scholar after the change of Publisher.
Medical or dental professionals deal with humans who can communicate and discuss their problems; even people with special needs learn to communicate with sign languages. But alas in the fast paced life many of the professionals want to finish treating the person in their own ways, as they deem fit; rather than listening to what the patient is going through and what his/her expectations from the treatment are. Discussions take a back-seat; even though treatment following diagnosis and based on presenting complains should be the driving force. Communication with the adult patient or with the paedriatic patient and their guardians sets the environment where important information regarding the patients behaviour, their concerns and apprehensions can be ascertained culminating in wholesome treatment outcomes. Not only does this instil confidence in the patients and guardians but also makes treatment goals easily achievable for the professional.
A patient entering a dental set-up has some oral and/or dental issues which need to be resolved. Since this is the age of social media where information is available on the click of a button; many of them come with plethora of information regarding their problems.1
Lot many patients still may not have such information, especially the not-so-young generation or those with rural background.2 However what is common to both the groups is their concern regarding the existant condition and the treatment modalities available which they need to thoroughly discuss and only go ahead with the treatment if they feel satisfied.3 It is very important for the dental practioner to know about the patient's expectations from the treatment and let them know much before starting the procedure whether these expectations can be met totally/ partially/ or not at all. This can be achieved only and only if the practioner is a good listener and is able to communicate his decisions in an effective way. Having skilled pair of hands and delivering satisfactory results is what comes next in the pipeline. It is imperative that consent forms be filled by the adult patient or the guardian of paedriatic patient clearly stating the risk factors involved; so that the patient is in the know-how of pros and cons of the treatment and the clinician can produce the same in medico-legal issues.4
HISTORY OF PRESENTING COMPLAINT:
The great physician of 19th century, William Osler supposedly said to his pupil, "Listen to your patient; he is telling you the diagnosis.5 " R Macbeth Pitkin added to this "And she just might be telling you the best management too.5 " This underlines the importance of knowing straight from the patients mouth his/her complains his/her way. As regards the clinician, he should lead the patient to ascertain the history of his problem and should include
Patients or guardians initial observations of problem;
Whether the condition is acute or a chronic one;
Whether treatment regarding the same was attempted early or not;
Causes of recurrence (if treatment done earlier);
Practitioners previously consulted for the present complain, if any. Reason for discontinuation of treatment under him/her.
Any other local or systemic conditions under treatment
A thorough medical history forms the backbone for treating patients with dental issues. By simply ignoring the systemic conditions and focussing only on the dental issues the dentist runs the risk of encountering medical emergency during the procedures as well as encountering failures of his treatment since many systemic conditions affect dental outcomes.6 A dental practisioner can help diagnose many systemic diseases by just paying attention to their oral manifestations.6 According to Mahlon, the first step towards patients care is to involve them in understanding their problem, to communicate and attend to their concerns.7 It is only when the patient feels confident enough with the attending practioner will he/she share valuable details with regards to his/her conditions; that ultimately are gold standards to determine the diagnosis. Hence patient-approach of the practitioner is a must for proper history taking which is the first step to successful treatment outcomes.8 There are studies to support that 90% of untoward situations occurring during dental procedures can be avoided if the practioner is aware of the patients systemic background.9 It is not however always easy to get thorough and proper history from the patient and proper history taking is no less than an art.10 Since the source of the information is the patient, so it is only by building a rapport with the patient can we expect him/her to divulge details regarding oneself.11-13
Studies have shown that having the patients involvement right from history taking to decisionmaking with regards to treatment outcomes has reduced medical expenses by about 15 to 30 %.14 Both the dentist as well as the patient are in the know-how of risks.15,16
Risks that the patient may encounter during procedures
Risks that the dentist may encounter while performing the procedures
Hence, before the start of any procedure communicating with patient and listening to them not only yields better results but has economic gains too.14
There are several medical condition which need thorough evaluation before the start of dental procedures. If the patient is suffering from an acute or chronic systemic or local conditions, details have to be sought regarding the same. This may even require referral to the concerned specialist to rule out any uncontrolled condition which may require delaying the dental procedure. It is only when the condition returns to near normal can the dental procedure be initiated.
Blood dyscrasias: Patients with various blood dyscrasias like leukemia, anaemia, thrombocytopenia etc are at a risk of bleeding profusely and have compromised immunity. Patients with sickle cell anaemia carry general anaesthetic risk.
Cardiac patients: Patients with unstable angina or with history of cardiac surgeries are at a risk of bleeding profusely if anticoagulant thereby is not stopped 2 to 5 days before dental surgeries in consultation with the patient's cardiologist. Care has to be taken while administering local anaesthic without vasoconstrictor. Valvular heart diseases will require prophylactic antibiotic coverage to avoid the risk of development of Subacute bacterial endocarditis.
Respiratory patients: Care has to be taken that patients with Chronic obstructive pulmonary diseases and Asthma are not given Non-steroidal anti-inflammatory drugs and carry their inhalers as they may pose dental emergencies during procedures .
Gastro-intestinal ailments: The acidic reflux problems in patients with Gastro-oesophageal reflux disease leads to erosion of dental tissues making them prone to sensitivity.
Hepatic ailments: Alcohol or bacterial / viral inflammatory changes in liver lead to altered metabolic functions, thereby making the person more prone to infections and bleeding disorders.
Neurological disorders: Patients with Parkinson's disease or Epilepsy will require special attention and consultation with attending consultant.
Temporomandibular joint dysfunctions: Such patients may not be able to adequately maintain mouth opening during dental procedures.
Pregnancy: It is better to avoid dental procedures till the birth of child . If absolutely necessary second trimester is preferred but consultations with referring Gynaecologist is a must.
Drug history and allergy: If a patient is allergic to any substance that has to be avoided. Anticoagulant therapy has to be stopped; Gingival overgrowth due to phenytoin and Steroid therapy leading to decreased immunity has to be assessed before any surgical procedures.
Occupational history: It gives an idea with regards to any occupational exposure to agents having detrimental effect on health. Moreover the patients availability can be assessed and appointments scheduled accordingly.
Dietary habits: Diet play an important role in the development or progression of dental ailments. Excessive consumption of sugary, processed and carbonated products predisposes to caries as well as periodontal involvement of persons
Smoking and alcohol addictions: Smoking and/ or alcohol consumption with its ill-effects on lungs and liver respectively decrease the immune power of a person.
It is of utmost importance to know about the patients anxiety levels while visiting the dental clinic. If the patient is visiting a dentist first time or previously has visited any such place and his/her previous experiences. This helps to assess the co-operation that the patient will have during the procedures.
Assessing the patients oral hygiene maintenance regimen also gives a fair idea of how the patient will follow the post-procedural advise and thereby contributing towards successful maintenance of the treatment.
Toothbrushing: whether the patient brushes once or twice or more frequently, the type of tooth brush and toothpaste used.
Interdental cleaning: whether the patient uses interdental cleaning devices like floss, interdental brushes, single-tufted brushes etc. Does the patient have a habit of using toothpicks.
Mouth rinse: whether the patient rinses after meals with plain water or medicated rinses.
Gum massage: whether the patient follows massaging gums with finger tips, with gum astringents or never does so.
All this provides a valuable information to the dentist regarding the level of oral hygiene awareness of the patient and hence compliance expected from them during treatment.
Appropriate diagnosis needs a thorough and comprehensive patient history. Many a times, clinicians "rush to judgement” during initial examination. A natural bias of a specialist is to characterize problems in term of his or her interest. This bias must be recognised and consciously rejected. Diagnosis must be comprehensive with interview of patient and parent forming an essential part alongwith clinical examination and evaluation of diagnostic records.
- Major's Physical diagnosis :an introduction to the clinical process. (9th). Philadelphia: Saunders; 1981. p. :15-20.
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- Medical emergencies in the dental office. (1). Islamieh publication; 1993. p. :14-6. 105-40
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- Medical History Taking in Dentistry. Dundee Dental Hospital co; 1997. p. :10-60.