Chapter 3

Patient History

OBJECTIVES
Building Rapport
Establishing an Information Pool
As an Aid to Diagnosis
As an Aid to Management of the Patient
METHODS OF OBTAINING THE PATIENT'S
HISTORY
Interview
Health Questionnaire
Combined Method
COMPONENTS
Biographic Data

Chief Complaint and Its History

Social History
Emotional and Behavioral History
Family History
Medical History and Systems Review
Pertinent Dental History
Health Questionnaire
ANALYSIS OF RESPQNSES TQ THE HEALTH
QUESTIONNAIRE
For All Patients
For Women Only

OBJECTIVES

Building Rapport

Good dental care depends on accurate

diagnosis, and accurate diagnosis is based
on information. A great deal of this information must be obtained from the patient,
because he or she is the only person who
has witnessed all the events of his or her
life. A well-organized and pleasant interview
is an excellent way to get the needed
information as well as an opportunity to
begin to build a sound professional relationship.
The objectives of obtaining a history are:

The interview usually provides the dentist

the first opportunity to meet a new patient.
It allows the dentist to observe the patient,
to evaluate the patient's responses, and begin to develop rapport. Rapport is the foundation of the professional relationship, and
the principles for building it during the interview are discussed in Chapter 2.

1. To establish a positive professional relationship

2. To provide the dentist with information concerning the patient's past and
present medical, dental, and personal
history
3. To provide the dentist with information that may be necessary for making
a diagnosis
4. To provide information that aids the
dentist in making decisions concerning
treatment
32

Establishing an Information Pool

The prime objective of taking a history is

to obtain information concerning the patient's medical, social, family, and dental experiences. The medical history aids in understanding the physical and mental health of
the individual. Current medical problems
and their treatment should be identified.
.Chronic problems should be evaluated for
physical and emotional effects. Past medical
problems can be identified and evaluated for
possible residual effects. The history helps to
prevent medical emergencies in the office
and aids the dentist to be prepared to manage them if they occur.

PATIENT HISTORY

The dental history is evaluated much the

same as the medical history. Current dental
problems may be understood better when
results of previous therapy are known.
As an Aid to Diagnosis

Many systemic diseases affect the oral cavity. Any component of the patient's case
history may supply information critical to
making the diagnosis. The patient may report unexplained symptoms that require further exploration. This information may lead
to the diagnosis of other systemic disease
through appropriate medical referral.

33

tient is requested to answer at the first

appointment. The completed form is then
reviewed and notes made concerning the
responses.
Advantages of this method are that it takes
little of the dentist's time and it offers a standardized approach for each patient. The disadvantages are as follows: (1) there is little
opportunity to build rapport; (2) the questions or their format may be interpreted inaccurately by some patients; (3) questionnaires must be lengthy to be comprehensive;
(4) few questionnaires are designed to give
supplemental information peculiar to an individual case.

As an Aid to Management of the Patient

Systemic health influences management

and therapy in many ways. The choice of
treatment may depend on the nature of a systemic disease or its management. For example, a patient who has had a recent heart attack should have only palliative treatment
while certain precautions are observed, or a
patient with arthritic hands may require
modification of home care techniques.
METHODS OF OBTAINING
THE PATIENT'S HISTORY

The three methods for obtaining the patient's history are (L) interview, (2) health
questionnaire, and (3) a combination of
these.
Interview

In the interview, the patient is asked about

his or her health in an organized fashion. The
patient should be allowed to discuss any
problems fully. Initially, the interviewer may
wish to use a checklist of topics for discussion. The advantages of this method have
been discussed. Some disadvantages include
the following: (1) the information acquired
may be disorganized, making it difficult to review the history later; (2) this method depends on the dentist's skills as an interviewer; (3) the interviewer may omit important topics; (4) the interview requires time
to be done well.
Health Questionnaire

The health questionnaire is a printed

list of health-related questions that the pa-

Combined Method

This approach uses the advantages of both

techniques and reduces their disadvantages.
After reviewing a completed health questionnaire, the dentist discusses the responses
with the patient.
It is important to reaffirm specific negative
responses as well as positive responses.
Whatever the responses, the following topics should be reviewed,
1. Do you have any known allergies?
2. Have you had rheumatic fever?
3. Have you ever had any heart or lung
problem, such as a heart attack or tuberculosis?
4. Do you have any bleeding tendencies?
5. Have you had hepatitis or any other infectious disease?
6. Have you had cancer?
7. Do you have diabetes?
8. Are you currently taking any medications?
9. Have you recently been exposed to any
form of radiation for cancer therapy or
radiographs?
Any positive history should be entered in
the patient's record. In addition, certain negative topics should be recorded. For example, "The patient denies a history of known
allergies to medications, rheumatic fever,
heart and lung problems," and so on. The
combined method is considered by the authors to be the most appropriate technique
for history taking in the routine practice of
dentistry.

34

ORAL DIAGNOSIS, ORAL MEDICINE, AND TREATMENT PLANNING

COMPONENTS

Whatever method of obtaining a patient's

history is used, the approach should be consistent and systematic. The components of
the history are:
1.
2.
3.
4.
5.
6.

Biographic data
Chief complaint and its history
Social history
Emotional and behavioral history
Family history
Medical history and systems review
a. past illnesses
b. present illnesses
7. Pertinent dental history

Biographic Data

The biographic data include the full name

of the patient, age, sex, race, permanent address, and telephone number. Certain other
information may be necessary, particularly if
filing of insurance forms is required, usually
including social security and insurance policy numbers. Other information includes the
name and telephone number of the physician and of a relative who may be contacted
in case of emergencies. This information may
contribute to the diagnosis because some
medical problems have a tendency to occur
in a particular age group, sex, or race.
Chief Complaint and Its History

The chief complaint is usually the reason

for the patient's visit. It is important to establish this early because it determines the
format of the interview and the type of evaluation to be used. The chief complaint is best
stated in the patient's own words or in a brief
summary of the problem.
Social History

Social history includes marital status,

number of children, habits, education, and
job-related information such as occupation,
travel requirements, and date of expected
transfers. Job-related issues may have a direct bearing on the appointment schedule
or on the completion of treatment. The
patient's occupation may be associated with
a particular disease or may influence the
type of therapy. For example, a hockey
player may require a removable appliance
instead of a fixed appliance when contem-

plating restoration of anterior teeth. A single woman with children may have emotional and financial demands different from
those of a married woman with children.
Although the dental condition of both may
be similar, availability for appointments and
time required to pay expenses may differ.
This information should be taken into consideration when developing the treatment
plan.
The patient's education and intelligence
may have a direct bearing on an understanding of health matters. We recommend that
the patient be given an explanation of how
the situation developed and how it can be
treated. A thorough understanding by the patient will be important in motivating him or
her to make any needed changes in home
care habits. All pertinent habits should be
identified. The chronic excessive use of alcohol may lead to cirrhosis of the liver and
may present difficulties in hemostasis. Additionally, the alcoholic patient may have emotional problems. The use of tobacco in any
form may be the cause of certain oral
changes. Oral habits of cheek biting, nail biting, or tongue thrusting may have a direct
bearing on diagnosis and therapy.
Emotional and Behavioral History

Some dentists may feel uncomfortable

when trying to evaluate a patient's emotional
status, partly because of the implication that
a stigma may be associated with emotional
problems. This information may not be easily obtained during the initial visit, but as the
patient is observed and gently questioned, it
may become more apparent. Individuals
have certain personality traits. They may be
extroverted, introverted, passive, aggressive,
moody, depressed, apathetic, or receptive.
The extroverted person may respond easily
and excessively to questions. An introverted
one may be reserved, and it may be more difficult to develop good rapport or obtain information during the interview. The patient
should be questioned concerning satisfaction with his or her job and family life. Conditions such as bruxism, clenching habits, or
myofascial pain dysfunction syndrome are
often associated with unhappy situations. In
planning a multidisciplinary approach to
these problems, the emotional component
must be assessed.

35

PATIENT HISTORY

Family History

The family history is concerned with the

health of the patient's parents and siblings.
The cause of death of relatives may be an important clue to the presence of an inherited
disorder. Diabetes mellitus, hemophilia, hypertension, allergies, and some forms of cancer are but a few of the diseases with familial tendencies.
In addition to genetically related disorders, the patient may be living in an environment conducive to the spread of communicable diseases. Hepatitis or tuberculosis in
another family member increases the patient's risk of contracting these diseases.
Medical History and Systems Review

The patient's medical history includes review of past and present illnesses. This information may aid in the diagnosis of various
conditions occurring in the oral cavity that
are related to specific systemic diseases and
may influence the manner in which therapy
is provided. Through the review of systems
in the medical history and the clinical examination, the dentist should be able to classify
the patient's health status. Table 3-1 is
based on a 1984 Report of the Joint National
Committee on Detection, Evaluation, and
Treatment of High Blood Pressure. Table
3-2 relates the health status to the ability
to provide dental care. The past medical history includes previous serious illnesses,
childhood diseases, hospitalizations or operations, injuries to the head and neck, allergy
to medications, allergic reactions in general,
and a listing of medications taken in the last
6 months.
Some examples of serious illness include
heart attack, stroke, hypertension, congestive heart failure, bleeding disorders, and diabetes. Childhood diseases include mumps,
measles, chicken pox, scarlet fever, and
rheumatic fever. Any childhood disease that
produces fever may cause enamel defects if
it occurs during enamel formation. Tetracycline antibiotics prescribed to children may
produce a staining of the dentin. Rheumatic
fever may damage the heart valves, making
the prevention of bacterial endocarditis an
important consideration when planning
treatment. Hospitalizations may indicate past
disease and how it was treated. The type of
a neoplasm and its treatment is important.

Table 3 - 1 .
System

Health Status Classification

Level 1: A patient with no systemic disease.

A level 1 patient should be able to run for 2
minutes or longer or be able to climb two flights
of stairs without becoming short of breath or
experiencing any discomfort.
Level 2: A patient with mild systemic disease.
A level 2 patient should be able to walk two city
blocks at a fast pace or climb two flights of stairs
without becoming short of breath or experiencing
any discomfort.
Any healthy individual who experiences extreme
fear of dental treatment is classified as level 2.
Examples of mild systemic disease:
Well-controlled, non-insulin dependent diabetes
Well-controlled epilepsy, no seizures within a
1 -year period
Well-controlled hypertension
A diastolic pressure of 90 to 104 mm Hg*
Well-controlled asthma
Level 3: A patient with severe systemic disease.
A level 3 patient should be able to walk at a regular
pace; however, physical activity will be limited.
A level 3 patient will not be able to climb two
flights of stairs without becoming short of breath
or experiencing some discomfort.
Examples of severe systemic disease:
Insulin-dependent diabetes
Emphysema or chronic bronchitis
History of angina pectoris
Anticoagulant therapy
Prolonged steroid therapy
A diastolic pressure of 105 to 114 mm Hg*
Level 4: A patient with incapacitating or
life-threatening disease.
A level 4 patient will be unable to do light activity
for even a short period of time and may
experience discomfort while at rest.
Examples of incapacitating systemic disease:
Severe hypertension
A diastolic pressure >115 mm Hg*
Uncontrolled diabetes
Unstable angina pectoris
Acute myocardial infarction or a cerebrovascular
accident within the last 6 months
Renal dialysis
Hemophilia
*Classification of diastolic pressure based on the 1984
Report of the Joint National Committee on Detection,
Evaluation, and Treatment of High Blood Pressure,
United States Department of Health and Human Services, Public Health Service, National Institutes of
Health, National Heart, Lung and Blood Institute, National High Blood Pressure Education Program,
Bethesda, MD.

particularly if the growth was in the head and

neck. A patient who has had radiation therapy to the head and neck may develop osteoradionecrosis if not properly managed,
even many years after treatment. Addition-

36

ORAL DIAGNOSIS, ORAL MEDICINE, AND TREATMENT PLANNING

Table 3 - 2 . Implications for Dental

Treatment Relating to Health Status
Level 1: Patient can receive routine dental treatment,
no modification necessary.
Level 2: Routine dental treatment may require
modification such as medical consultation,
shortened appointment length, use of sedatives, or
antibiotic premedication.
Level 3: Routine dental treatment is indicated, but
treatment modifications are almost certainly
indicated and may be more complex.
Level 4: Only emergency dental treatment is
indicated. Whenever possible, dental treatment
should be postponed until the patient's medical
condition has improved to at least a level 3
classification. Emergency treatment should be
performed in a hospital dentistry setting.

ally, some malignant tumors may metastasize

to the head and neck or the jaws. A history
of facial injury is important to the dentist because it may be the cause of devitalized or
fractured teeth. Injury may account for temporomandibular joint pain orfracturesof the
jaws. Moreover, injuries may be the cause of
the loss of teeth rather than caries or periodontal disease, an important distinction to
be made in the determination of the prognosis.
A history of multiple allergies is associated
with a greater risk of developing an allergic
response to a dental material or prescribed
medication. These patients should be made
aware of the signs and symptoms of an allergic reaction, and for those in whom potential allergy is suspected, allergic testing
should be ordered.
The patient should be questioned concerning any medications taken in the last 6
months. These could be related to past or
present illnesses. It is important to note
whether the medication is still being taken
along with the reason for its prescription. If
the patient is unsure of the type of medication, the physician or dentist who prescribed
it should be called. Sometimes the tablet or
capsule can be identified from the chart in
ihe Physicians' Desk Reference. Using this or
a similar publication, the mode of action, indications and contraindications, drug interactions, side effects, and other appropriate
information may be reviewed.
The review of systems is that part of the
patient's medical history covering each major system of the body. By reviewing each

body system separately, the interviewer may

concentrate on the signs and systems of disorders particular to the system. The review
of systems includes (1) cardiovascular, (2)
respiratory, (3) central nervous, (4) gastrointestinal, (5) genitourinary, (6) musculoskeletal, (7) endocrine, (8) integument, (9)
ears and eyes.
Cardiovascular System

The cardiovascular and respiratory systems are closely related, and certain signs
and symptoms of one may indicate problems
in the other. Some signs and symptoms of
cardiovascular diseases include prolonged
elevated high blood pressure, chest pain after mild exertion, ankle edema, heart murmur, and shortness of breath. These findings
could be suggestive of angina pectoris, myocardial infarction, coronary artery insufficiency, or congestive heart failure. Additionally, the patient should be questioned concerning a past history of rheumatic fever or
stroke.
Respiratory System

Symptoms associated with respiratory disease are shortness of breath (dyspnea),

hoarseness, and cough. Whereas shortness of
breath may be an indication of cardiovascular problems, it is seen also with asthma, emphysema, or a lung tumor. To interpret dyspnea, more information should be sought as
to the circumstances under which it occurs
and whether it is progressive. When evaluating a cough, consider frequency and
whether or not it is productive. If it is productive, the character of the sputum should
be determined. This information can give
clues to whether the patient has an infectious process such as tuberculosis or pneumonia, whereas a nonproductive cough may
be associated with a physical irritation or
with cardiovascular problems.
Central Nervous System

Patients with a history of convulsions,

pain, paresthesia, paralysis, or syncope may
have a nervous system disorder. The location, character, onset, and other symptoms
associated with the complaint should be determined. These complaints may be associated with toothache, neuralgia, or epilepsy.

PATIENT HISTORY

37

Syncope may be an indication of a cardiovascular or an emotional condition. Allergy to

local anesthetics is relatively rare, and many
patients who claim to be allergic have in the
past simply fainted as a manifestation of
acute anxiety.

redness of the joint are present. Multiple

fractures of the long bones or jaws could indicate a hormonal problem such as hyperparathyroidism or other problems such as
Paget's disease, osteogenesis imperfecta, or
multiple myeloma.

Gastrointestinal System

Endocrine System

Gastrointestinal complaints are common,

and their significance must be evaluated to
determine whether further investigation is
necessary. The gastrointestinal system is associated with several organs that may produce similar complaints. Therefore, it becomes difficult to make an evaluation based
on a few nonspecific complaints. Some gastrointestinal complaints include nausea,
vomiting, diarrhea, constipation, indigestion,
loss of appetite, and abdominal pain. These
may be indicative of a peptic or duodenal ulcer, biliary obstruction, hiatal hernia, or diverticulitis. They may also be associated with
improper mastication. Gastrointestinal complaints in association with perioral pigmentation may be an indication of Peutz-Jeghers
syndrome, whereas similar complaints along
with supernumerary teeth and osteomas may
be a sign of Gardner's syndrome.

The endocrine system involves several

glands. Each may be overactive or have decreased function, and each has different findings. The interviewer should be aware of the
signs and symptoms of the more common
endocrine diseases such as diabetes mellitus,
hyper- and hypothyroidism, Addison's and
Cushing's diseases, and hyper- and hypoparathyroidism.

Genitourinary System

Symptoms associated with this system relate to menstruation, frequency of urination,

pain on urination, and blood or pus in the
urine. These symptoms alone or in combination may indicate any number of disorders
such as prostate disease, kidney stones, bladder infections, neoplasms, and diabetes mejlitus. Some oral conditions associated with
these symptoms include Stevens-Johnson,
Beh(;et's, and Reiter's syndromes.
Musculoskeletal System

Symptoms associated with this system include muscle or bone pain, loss of joint function, muscle weakness, and occasionally,
multiple bony fractures. These may be associated with normal muscular fatigue from exertion or may be indicative of a more serious problem. Muscle pain or tenderness may
be associated with emotional problems. Impaired function of joints is indicative of arthritis of varying types, particularly when
other symptoms of swelling, tenderness, and

Integument

This system involves disorders of the skin,

hair, and nails. Many of the changes associated with the integument are readily visible.
When these are noted, further details should
be sought. Some signs and symptoms associated with the skin are itching, rash, dryness,
sweating, and increased pigmentation. The
hair may be sparse, thin, or coarse, and baldness may occur in patches or patterns. Nail
changes such as clubbing, spoon shape, or
nail biting may give clues as to systemic or
emotional problems.
Ears and Eyes

These two sensory organs are important to

communication. The interview helps one to
evaluate the patient's ability to hear and see.
Impairment may account for poor communication. Itching of the eyes may be associated with allergy. Vertigo, tinnitus, or ear
pain may be due to diseases of the ears or
may be referred from pulpitis, diseases of the
temporomandibular joint, or an elongated
styloid process.
Vital Signs

This information is an important part of a

comprehensive medical history because it
gives baseline information that is not subjective. Vital signs include the patient's blood
pressure, pulse, respiration rate, temperature, height, and weight. This information
becomes more valuable with successive
readings. For example, a moderately ele-

38

ORAL DIAGNOSIS, ORAL MEDICINE, AND TREATMENT PLANNING

vated blood pressure taken only one time

does not necessarily indicate that the patient
has hypertension. Marked elevation can be
alarming, but an additional reading should be
taken alter the patient has been observed at
rest for 30 minutes. Some patients may have
elevated blood pressure simply because of
anxiety related to the dental visit or because
of exertion expended in getting to the office.
The techniques of obtaining vital signs are
discussed in detail in Chapter 5.
Pertinent Dental History

The dental history may provide insight

into the patient's dental IQ, priority given to
dental care, and fears associated with dentistry. The pertinent dental history includes:
1. The frequency of previous visits
2. The purpose of past visits: Were they
for emergency only? What was done?
3. Any difficulties with dental care
4. The type of care provided: When was
it done? Is the patient satisfied? Inquire
into previous:
a. Orthodontics
b. Periodontics
c. Endodontics
d. Prosthodontics
e. Oral surgery
5. Recent dental radiographs
A patient with a history of periodontal surgery now needing additional surgery is different from one who has no history of periodontal therapy. A history of neglect affects
the prognosis if complete reconstruction pf
the dentition is considered.
The patient's dental history should include
a determination of the availability of past
dental radiographs. This information may
help reduce the amount of radiation given to
the patient.
Health Questionnaire

One must make every effort to obtain a

complete medical history and to give it
proper consideration. Other segments of this
book deal with the specific signs and symptoms of diseases and special management
procedures. Therefore, they are not addressed here.

ANALYSIS OF RESPONSES TO THE

HEALTH QUESTIONNAIRE
For All Patients

The following discussion briefly describes

the significance of each question of the questionnaire (Fig. 3-1). The description is not
intended to be exhaustive, but rather to
serve as a guide for understanding the purpose of each response.
1. Are you currently under the care of a
physician?
This question can establish any chronic or
acute disease. The patient's disease may infiuence the dentist's diagnosis, therapy, and
the drugs prescribed. Each condition, who is
providing the care, and what kind of treatment is given should be identified.
2. Are you allergic to penicillin or other
antibiotics, iodine, or any other medicine?
The medication to which the patient is allergic should be identified and questions
should be asked concerning the symptoms
experienced. Mere syncope is not considered an allergic reaction, but is often identified as such by patients. Penicillin can be a
potent allergen. If a patient responds that he
or she had a reaction, the drug should be
avoided or the patient referred for testing.
Iodine is commonly used in dental practice
as an antiseptic and a radiopaque dye. Patients who are allergic usually know that
they cannot use iodized salt, the main source
of iodine in our diets.
3. Have you ever had rheumatic fever or a
heart murmur?
Rheumatic fever is a condition that most
commonly affects individuals under the age
of 20 years. The disease may affect the heart,
particularly the valves, resulting in a murmur. Rheumatic heart disease is not the only
cause of heart murmur; therefore, specific
questioning should be done to determine
the cause of any murmurs. In dentistry, the
significance of identifying the patient with
rheumatic heart disease or heart murmur is
that one is thereby alerted to the need to
prevent bacterial endocarditis, an often fatal
disease. The recommended precautions of
the American Heart Association are outlined
in Chapter 10.
4. Have you had a tumor or cancer?
If the patient answers "yes" to this question, the following questions should be

PATIENT HISTORY

39
YM

No

Ara you allergic to penicillin, antibiotics, lOdme, or any other medicines?

4 Have you had it tumor or cancer?

5. Have you received chemotherapy. -ray, radium or cobalt treatment?
6 Have you had any K-rays for any purpose (chest, dental, etc.l within the patt 24 montht?

Marital Ktatiii
Race

SeH

who can we contaci ?

6. Have you had any teeth extracted or your tonsils removed?
9, Have you ever had a local anesthetic (novocaine) or a general anesthetic lethar)?
10. Have you ever had a reaction to any anesthetic?

PhySiCi

12.
13.
14.
15
16.
17.
tS.
19.
20.
21

For Wh at Puroose?

Have you ever had an injury to your (ace or jaws?

Oo you have any problems with your eyet (cataracts or glaucoma)?
Oo you have earaches, ringing m your eart or loss 0< hearing?
Oo you have sinus trouble, asthma, hayfever, or severe headaches?
Do you have frequent sore throats or neck pain?
Do you have high or low blood pressure?
Have you had a heart attack ot pains in your chest?
Do you have a pacemaker?
Does mild exercise leave you short of breath?
Have you had tuberculosis or any other luna problem?

Physici
Last Ti Tie at Phvsician:

In Cate of Emergency Please

1.

Tel. No.

7.

Tel. No.

Height

Weight:

Blood Frawura:
23. Have you ever had a liver condition (such as hepatitis, jaundica or cirrhotiti?
24. Have you had any kidney or bladder trouble?

PUIM:

RESP:

Tampa
26. Oo you urinate (patt water) frequently?
27. Oo you have diabetet?
tf yet. am you controlled by:
Insulin __Pills
Oiet
Nothing
28. Ooet anyone in your family have diabetet?
30. Oo you consider yourself to be a nervous or tense parson?

Data
Sig:

32. Oo you have sore musclei or stiff joints?

33, Do you have a tendency to bleed longer than normal from small cuts?
34. Do you bruise easily?

Dat*
Sig:

36.

Have you ever had a blood transfusion?

Sig:
Oatt
Sig:

b. Anticoagulants or blood thinners?

39. Do you have allergies?

40, Do you ever have skin rashes or severe itching?
41. Do you have any disease, condition or problem not listed abova?
WOMEN ONLV

Oat*
Sig:

42. Are you pregnant?

Oat*
Sig:

43, Are you taking birth control pilll or hormones?

COMMENTS ANO SUMMARY

Fig. 3 - 1 . Health questionnaire.

asked. Where was the tumor located? Was

the tumor benign or malignant? How was the
tumor treated? If the tumor is currently being treated by radiation to the head and neck,
the dentist may observe intraoral changes.
Radiation therapy may be associated with a
decrease in taste, xerostomia, increased caries activity, and the possibility of developing
osteoradionecrosis. A malignant neoplasm at

one site may metastasize to another. Because

certain neoplasms are more likely to metastasize to the jaws, the interviewer must determine the type.
5. Have you received chemotherapy,
x-ray, radium, or cobalt treatment?
This question is used to check the previous question. Usually, chemotherapy suppresses granulocyte production. Patients

40

ORAL DIAGNOSIS, ORAL MEDICINE, AND TREATMENT PLANNING

who are receiving chemotherapy have an increased susceptibility to infections, may

have difficulty with healing, or may have
multiple oral ulcers, nausea, and vomiting.
6. Have you had x-rays for any purpose
(chest, dental, etc.) within the past 24
months?
Today the medical and dental professions
are concerned over the use of ionizing radiation. It is now recommended that each exposure should be recorded in the patient's
chart. The dentist's responsibility is to use radiation prudently; therefore, radiographic
films should be made only when the clinical
examination indicates that they are necessary. Because radiographs provide much information that cannot be obtained otherwise, their use is often necessary.
7. Are there any recent dental x-ray pictures of your teeth that we might borrow?
This question may lead to a reduction of
the amount of radiation administered to a patient, if a recent series of good radiographs
can be borrowed. If these radiographs are
poor in quality, do not cover the desired
area, or are too old in a specific case, further
radiographs will be necessary for the diagnosis. Even extremely old radiographs may be
helpfiil in arriving at a diagnosis. The
progress of disease such as caries or periodontitis may be followed and a more accurate assessment of the current findings
made.
Borrowed radiographs should be duplicated and the original ones returned to the
lender. Many dentists are reluctant to relinquish their radiographs because they are an
important part of the patient's record, particularly for medicolegal reasons.
8. Have you had any teeth extracted or
tonsils removed?
This question is used primarily to identify
the patient's past experiences with any surgical procedures. The reason for the extractions should be determined. Whether the
teeth were removed as a result of trauma or
for carious or periodontal reasons is important when developing the treatment plan.
9. Have you ever had a local anesthetic
(Novocain) or a general anesthetic?
This question checks the accuracy of the
previous question. It is also designed to determine the patient's past experience with
anesthetics. A positive response necessitates
a determination of which anesthetic was

used and why and when it was administered.

10. Have you ever had a reaction to any
anesthetic?
A reaction to an anesthetic may be an
allergic reaction. The dentist must now determine what the patient considers to be a
reaction. Most commonly the patient will report "passing out" after or during the administration of the local anesthetic. If this is the
case, syncope should be suspected. If, however, the patient has a history of a rash, itching, difficult breathing, or extreme tiredness
following the visit, allergy or an idiosyncratic
reaction should be suspected and the drug
avoided.
11. Have you had difficulty with dental
treatment?
This is an excellent question for whatever
the patient reports. Even a trivial-sounding
positive response means that the patient
considers it important and it should not be
taken lightly. Responses to this question may
range from difficulties w^ith endodontics and
pain following an extraction to concerns
about aesthetics. Whatever the case, the dentist should take this opportunity to show
concern for the patient and to ensure the patient that everything will be done to study
this problem. One word of caution, however:
remember that the principle of avoiding
hasty reassurance applies here and an opinion should not be given until a complete assessment can be made.
12. Have you ever had an injury to your
face or jaws?
A positive response to this question may
help explain observed scars or paralysis as
well as other findings in the oral cavity. The
past history of injury can explain why teeth
are nonvital when no other cause can be
identified. Fragments of glass may be seen in
patients who have had automobile accidents.
13. Do you have problems with your eyes
(cataracts, glaucoma)?
The most common complaint regarding a
patient's eyes is the need to wear eyeglasses.
This is usually of limited significance. More
important is a patient who has reported the
need for several new eyeglass prescriptions
over the past few years. This may be a clue
to untreated hypertension or diabetes mellitus. Symptoms of poor vision often precede
these two conditions for an extended period.
The use of antisialagogues is contraindicated
in patients with glaucoma because they may

PATIENT HISTORY

cause an increase in intraocular pressure,

thus aggravating the glaucoma.
14. Do you have earaches, ringing in your
ears, or loss of hearing?
A patient who complains of earaches may
be experiencing temporomandibular joint
pain, because of the close approximation of
these two structures. The symptom of otalgia should be investigated to determine
whether it arises from the temporomandibular joint or any other oral structures. Patients who are hard of hearing may present
a communication problem, and efforts
should be made to speak so the patient can
hear. Ringing is a symptom seen in hypertension, Meniere's disease, diseases of the inner
ear, and myofascial pain dysfunction syndrome.
15. Do you have sinus trouble, asthma, ha^
fever, or severe headaches?
The maxillary posterior teeth are in close
proximity to the maxillary sinus. A patient
with acute sinusitis may develop toothaches
on the affected side. Therefore, the dentist
must be able to correlate the finding of generalized toothaches in an entire maxillary
quadrant to a history of sinusitis. Any patient
who has hay fever or a history of allergies to
pollens or dust is more likely to develop
other types of allergies. The asthmatic patient can present a management problem for
the dentist and appropriate precautions
should be taken. Because almost everyone
experiences headaches, occasional headaches once or twice a month are not significant. A patient with frequent severe headaches should be further questioned to determine the nature of the headaches. Headaches
may be due to tehiporomandibular joint dysfunction. The location of the headache is important. Tension headaches are usually located in either the frontal or the occipital areas.
Hypertension can produce headaches located in the occipital area, accompanied by
visual disturbances and by muscle aches in
the lower extremities. Unlike with tension
headaches, a night's rest often provides little
or no relief from a headache caused by hypertension.
16. Do you have frequent sore throats or
neck pain?
A sore throat can indicate an infection.
Frequent sore throats may be associated
with decreased resistance to infection. It

41

may be a clue to habits such as mouth

breathing or the use of tobacco. Other
causes include nonspecific pharyngitis, recurrent aphthous ulcers, and lymphonodular
pharyngitis. Neck pain may indicate the presence of a recent injury to the head and neck
but more often is associated with tension.
The location of the pain, its onset, and the
severity of the pain should be investigated.
Neck pain may be caused by tender inflammatory nodes, carotodynia, and arthritis of
the cervical vertebrae.
17. Do you have high or low blood pressure?
Patients with high blood pressure (hypertension) are usually of more concern than
those with low blood pressure (hypotension). Several factors must be taken into consideration when determining whether a patient is hypertensive. The patient's age, sex,
race, and weight must be related to the evaluation of blood pressure.
Hypertension can be caused by several
conditions. Renal disease and atherosclerosis
are the most common. A positive diagnosis
of hypertension occurs when systolic pressure is above 150 mm Hg and the diastolic
pressure is above 90 mm Hg. The determination of elevated blood pressure must be
made on several readings.
Hypotension can be caused by massive
hemorrhage, stroke, or Addison's disease. A
patient may become hypotensive owing to
the position in the dental chair and secondary to the use of hypotensive drugs. Many
young women are naturally hypotensive,
with blood pressure readings of 105 or 110
over 65 or 70 mm Hg.
18. Have you had a heart attack or pains
in your chest?
This direct question is used to determine
whether the patient has angina pectoris or
has had a myocardial infarction. The interviewer should ascertain when the heart attack occurred, its severity, what medications
are taken, and how well the patient recovered. In management of the heart attack
patient, it is best to delay routine dental procedures until 6 months after the episode. Patients who take nitroglycerin tablets to control angina pain should have it available at
each dental appointment. All appointments
should be conducted in a relaxed atmosphere with close attention to the patient's
tolerance for the length of time for a proce-

42

ORAL DIAGNOSIS, ORAL MEDICINE, AND TREATMENT PLANNING

dure. If a patient has had chest pains and is

not under the care of a physician, a medical
consultation should be initiated.
19. Do you have a pacemaker?
A positive response to this question indicates that the patient has heart problems.
Care must be exercised in the management
of these patients. Ultrasonic and electrocautery devices should be avoided as well as
electric pulp testers. The patient should be
questioned as to whether the pacemaker is
in contact with the circulation. If so, prophylactic antibiotic premedication should be
used in the same manner as for rheumatic
heart patients.
20. Does mild exercise leave you short of
breath?
This is a check question to disclose undiagnosed heart problems; however, a positive
response to this question must be evaluated
in light of the patient's physical status. Many
people become short of breath on exertion
as a result of the lack of routine exercise. A
patient who becomes short of breath extremely easily may have cardiac insufficiency. If the interviewer believes that the
shortness of breath is not physiologic, a medical consultation should be sought.
21. Have you had tuberculosis or any
other lung problem?
A patient with a history of tuberculosis
should be questioned to determine whether
it has been completely treated. If the disease
is active, the dentist and personnel should
take precautions to prevent contracting the
disease. In some areas of lower socioeconomic conditions, tuberculosis is endemic
and the dentist and assistant should wear
rubber gloves and a mask routinely. Moreover, questioning for tuberculosis may reveal other lung conditions.
22. Do you have any trouble with your
stomach or intestinal tract (such as ulcers,
gastritis, or colitis)?
A patient with a history of gastrointestinal
disorders may have many different symptoms. Some patients who complain of "stomach trouble" may have faulty mastication,
and in particular, need of the dentist's care.
A patient with an ulcer may have emotional
problems and thus may have emotional disorders such as myofascial pain dysfunction
syndrome. In addition, he or she may be taking medications that can interfere with the
absorption of any medication the dentist

may prescribe. The patient who has an ulcer

should not be given aspirin or other medications that irritate the gastrointestinal tract.
23. Have you ever had a liver condition
(such as hepatitis, jaundice, or cirrhosis)?
Hepatitis is a general term for inflammation of the liver. Patients who say they have
had hepatitis usually mean viral hepatitis.
This information is of more concern to the
dentist, dental personnel, and other patients
than to the patient with the positive history.
Because hepatitis can be transmitted by the
dentist, he or she must take appropriate precautions. Jaundice is a sign of liver disorders
that can be caused by viral hepatitis or other
conditions, including cirrhosis. A patient
with liver disorders may have an increased
tendency to develop bleeding problems, because most clotting factors are synthesized
in the liver.
24. Have you had kidney or bladder trouble?
A positive response to this question may
reveal kidney stones, kidney transplants, or
a patient on dialysis. Kidney stones may indicate problems with calcium metabolism
and may account for certain radiographic
findings. Renal transplant and dialysis patients need modification in the method of
providing care. Patients with bladder trouble
may have an increased frequency of urination or painful urination. Polyuria is a sign of
diabetes.
25. Have you had syphilis, gonorrhea, or
any other venereal disease?
A patient with venereal disease may develop lesions in the mouth. The dentist
should learn when the disease was contracted and whether the disease is controlled. Syphilitic chancres are teeming with
Treponema pallidum organisms and may infect the dentist or dental assistant on contact.
26. Do you urinate (pass water) frequently?
This question can be a check question for
evaluating the accuracy of questions concerning renal disease, bladder disease, prostatitis, or diabetes. The patient and the dentist must agree on the definition of "frequent."
27. Do you have diabetes? If so, how is it
controlled?
The diabetic patient needs special care because manifestations of the disease may oc-

PATIENT HISTORY

cur in the oral cavity. The interviewer must

determine when the disease began, how it is
being managed, and the degree of control. In
general, diabetics are more susceptible than
normal to bacterial and fungal infections.
The presence of infection alters the insulin
requirement. Additionally, the diabetic may
not heal well following injury or surgery and
may develop xerostomia. A diabetic patient's
appointment should be scheduled for shortly
after regular medication and a meal. This
usually means morning appointments. Patients should be urged to continue routine
medication and food prior to dental appointments unless general anesthesia is planned.
28. Does anyone in your family have diabetes?
Diabetes may be hereditary, making this
an important question. A patient who is not
responding to treatment, particularly periodontal therapy, and who has a family history of diabetes should be suspected of having the disease. Diabetes is usually diagnosed
by evaluating blood sugar levels using several determinations, as in the glucose tolerance test.
29- Have you ever had seizures or convulsive disorders?
Complete dental care can be provided if
the dentist knows the frequency of seizures,
medications used, and severity. Consultations may be indicated in severe cases. The
dentist should be prepared to manage a seizure. Fortunately, the patient has warning
signs prior to most seizures and can alert the
dentist.
30. Do you consider yourself to be a nervous or tense person?
Tension or nervousness are perceived differently by different people. The interviewer
should try to determine the cause of the
tension. Nervousness may be caused by the
dental appointment or may be related to life
situations. The dentist should try to allay apprehension. Tension may be expressed by
bruxism, temporomandibular joint dysfunction, or pain.
31. Have you even taken any medication
for nervousness or depression?
Many people respond positively to this
question, owing to the large amounts of tranquilizers in use. Some idea of the severity of
the problem can be obtained by evaluating
prescribed medications. Most tranquilizers
and antidepressants have the side effect of

43

xerostomia. Patients with xerostomia may

complain of burning tongue, difficulty in eating, and difficulty in wearing dentures, and
they may have a characteristic caries pattern.
32. Do you have sore muscles or stiff
joints?
Complaints of occasional sore muscles
may indicate tension. Soreness in the muscles of mastication can be evaluated during
the clinical examination. The complaint of
stiff joints may be a sign of arthritis. Arthritis
may follow trauma, may be a crippling disease, or may simply be a part of the aging
process. The temporomandibular joint may
be affected. Patients with arthritis of the
hands may have difficulty in maintaining
home care.
33. Do you have a tendency to bleed
longer than normal for small cuts?
This question is used to identify a patient
who may have a bleeding diathesis. The interviewer must try to determine what the patient means by "bleeding longer than normal." If the dentist determines the patient
may have a bleeding diathesis, laboratory
tests should be ordered, such as the platelet
count, prothrombin time, and partial thromboplastin time studies. The dentist should be
prepared at all times to control a bleeding
problem.
34. Do you bruise easily?
This question is used to check the previous question. Bruising may indicate capillary
fragility, platelet disorders, or coagulation
failure. The interviewer must evaluate what
is meant by "easy bruising." Many patients respond positively to this question but have no
difficulties with hemostasis.
35. Do you have any blood disorder such
as anemia or leukemia?
Patients with anemia or leukemia may
demonstrate oral manifestations of the disease including a pale tongue, a fiery-red
burning tip of the tongue, and gingivitis. Patients with leukemia may be taking medications such as methotrexate, which may cause
increased susceptibility to infections and
oral ulcerations. Additionally, there may be
difficulty with hemostasis.
36. Have you ever had a blood transfusion?
A patient may have had a blood transfusion
for major surgery. If so, the dentist should
determine the reason for the surgery. Patients who receive regular transfusions may
have a blood dyscrasia or chronic leukemia.

44

ORAL DIAGNOSIS, ORAL MEDICINE, AND TREATMENT PLANNING

and the therapy provided by the dentist will

need to be altered. Some patients with blood
dyscrasias need clotting factor replacement
therapy prior to dental procedures to prevent uncontrollable bleeding. A history of
multiple blood transfusions exposes a patient to a higher risk of contracting viral hepatitis.
37. Have you been hospitalized or received medical treatment within the past 5
years?
This question has two purposes. Usually,
the problems for which a patient may have
been hospitalized are worthy of note. The interviewer should list dates of previous hospitalizations, reasons for admission, and the
type and effectiveness of treatment. Second,
this question serves as a check question to
question 1. The dentist must determine the
reasons for any medical treatment, whether
by physicians, osteopaths, homeopaths, chiropractors, optometrists, or dentists.
38. Have you taken any of these medications in the last 6 months?
A patient's drug history should be detailed.
Medications may indicate a particular disease or its severity. Side effects of the medications may include xerostomia, susceptibility to infection, increased bleeding tendencies, and intolerance to stress. Moreover, any
medication a dentist prescribes may influence the drugs the patient is currently taking.
Cortisone or other steroids? Patients who
are receiving corticosteroids do not respond
well to stress. The action of corticosteroids
can diminish the signs and symptoms of infection, making diagnosis more difficult.
These complications are reversible and disappear on cessation of therapy.
Anticoagulants or blood thinners? Anticoagulants are prescribed for cardiovascular
diseases. A patient taking anticoagulants can
develop bleeding from minor injury. Prolonged antibiotic therapy may add to the tendency toward bleeding. Consultation with
the patient's physician is indicated.
Tranquilizers or antidepressants? The dentist should determine why the drug is prescribed. Tranquilizers and antidepressants
have several side effects and may be influenced by any other medication. Diazepam
may make the depressive patient more depressed.
Any other medications or drugs? This al-

lows the patient an opportunity to indicate

any other medications. These drugs should
be listed along with the purpose.
39. Do you have allergies?
Patients who are allergic to pollen and
other items have increased likelihood to becoming sensitized to some medications that
may be prescribed. In addition, it is a check
question to "any allergies to medications."
40. Do you ever have skin rashes or severe
itching?
An affirmative response to this question
can indicate an allergy. Additionally, this
question may disclose a dermatologic disorder. If so, the condition should be identified
and may later relate to conditions present on
the oral mucosa, including lichen planus and
pemphigus.
41. Do you have any disease, condition, or
problem not listed above?
This allows the patient an opportunity to
inform the dentist of other conditions not included in the questionnaire. We recommend
that an internal medicine text be kept on
hand for the myriad conditions that the patient may report.
For Women Only

42. Are you pregnant? Expected delivery

date?
The pregnant woman needs special attention. These patients must be managed so to
decrease the likelihood of developing pregnancy gingivitis. They should also have care
provided to prevent pain or discomfort that
might arise during the pregnancy. Precautions must be taken when using ionizing radiation and the administration of drugs. Most
pregnant patients can have routine dental
care during the second trimester and early
in the third. Only emergency care should be
provided in the first and late third trimesters.
43. Are you taking birth control pills or
hormones?
Usually, a history of taking birth control
pills or hormones is in itself of little significance to the dentist. This question is important, however, in that if the patient is preventing a pregnancy, then the dentist is not
as likely to face the dilemma of determining
whether a patient is pregnant. Most women
are not certain that they are pregnant until
well into the second or even third month following conception.

PATIENT HISTORY

Patients who are taking hormones may

have a history of a complete hysterectomy
or may be taking them for the relief of symptoms of menopause.
44. Do you have any problems associated
with your menstrual period?
A patient may respond affirmatively to this
question if she is menopausal, which may explainfindingsof "burning mouth" or other intraoral findings. Moreover, bleeding problems are easily correlated with the menstrual
history. Iron deficiency anemia may result
from excessive blood loss during menstruation.
In summary, the health questionnaire
should be used as a starting point for the interviewer. As the dentist reviews the questionnaire, many questions must be asked to

45

verily the accuracy of the patient's responses

and to expand on the patient's leads. Each response should stimulate ftirther questions to
analyze the answers.
The length of the questionnaire is not as
important as the skill of the interviewer in
obtaining a complete medical history.
SELECTED READINGS
Kerr, D. A., Ash, M. M., and Millard, H. D.: Oral
Diagnosis. 6th Ed. St. Louis, C. V..Mosby, 1983.
Lynch, M. A.; Burket's Oral Medicine. 8th Ed. Philadelphia, J.B. Lippincott, 1984.
Mitchell, D. F., Standish, S. M., and Fast, T. B.: Oral
Diagnosis/Oral Medicine. 3rd Ed. Philadelphia,
Lea & Febiger, 1978.
Prior, J. A., and Silberstein, J. S.: Physical Diagnosis. 6th Ed. St. Louis, C. V. Mosby, 1981.