History Taking

Patient’s Full Name:

Age:
Gender:
Occupation:
Marital status:

1. Chief Concern
______________________________________________________________________________

2. HOPI
______________________________________________________________________________

3. Medical History
Last medical check-up:

Reason:
Illnesses:
Medication
Allergies:
Hospitalisation

4. Family History
- 3 generation

5. Social History
- Smoking:
(If yes) How many packet / sticks per day?
(If yes) Since when started?
(If yes) Thought of quitting?

- Alcohol:
(If yes) How much?
(If yes) How often?

- Coffee / Tea:
(If yes) How often?
(If yes) Rinse after drinking?
Is it sweetened
6. Dental History
Last visit to dentist:
Reason for the visit:
Tooth brushing:
Times a day; (state when he/she brushes)

Use of Fluoridated toothpaste/ brand

Toothbrush bristle: Soft / Medium / Hard
Flossing
Use of Mouth rinse
Appliances:
Snacking habit:
-frequency
-types of snack
 Extraoral Examination
1. Any surgeries around face area

2. Facial symmetry

3. Lip competence

4. TMJ (clicking, deviation)

5. Muscles of mastication

6. Lymph nodes examination (swelling, sore, tender)

Intraoral Examination
1. Soft Tissues:
2. Occlusion:
Molar:
Anterior teeth:
Overjet:
Overbite:
Others:

3. BPE:
BPE Score Grid:
R L

*Code 3 -> detailed periodontal charting (6 points pocket chart) for the particular sextant.
*Code 4 -> full mouth pocket chart for the entire dentition.
*check gum recession; NCCL
*check presence of calculus/ plaque
 S- sound FS- fissure sealant
Ex- extracted R1- composite
m- missing/unerupted R2- amalgam
Cx- ICDAS code

Tooth Charting:
11 21

12 22

13 23

14 24

15 25

16 26

17 27

18 28

31 41

32 42

33 43

34 44

35 45

36 46

37 47

38 48

Other findings:
Radiograph findings:

Pain History
Questions to ask
1. Is there a tooth that's bothering you?
2. Are you experiencing pain
3. How would you rate the pain from 1 - 10 - 7/10
4.How long has this pain been present?
5. When did you first experience pain
6. Is the pain now you're having different from the pain you had before the previous treatment?
7. When do you feel this pain?
8. is it a constant psin , if not describe when or how it occurs and how long it might last
9. has the pain occured more frequently or lasted longer in the past few days or weeks
10.is the pain stimulated by something hot or cold
11. is the a time of the day when the pain seems to be worse
12. does the pain awaken you at night - NO
13. how would you describe the pain, dull shap or electric like - DULL
14. have you noted any swelling, do you feel swollen at any area
15. is there an area of your face that is tender to touch
16. are there any teeth that hurt or are uncomfortable when you chew or after you have eaten?
17. do any of your teeth feel lose, or are you biting on any tooth sooner than other teeth

Examination to do :
Heat, cold, ept, air blow
Tender to percussion - vertical and horizontal
palpation
pocket depth
mobility
ELEMENT 1 : PATIENT LEVEL CARIES RISK FACTORS At RISK ( Tick Information
√ if yes )
Head and neck radiation
Dry mouth (conditions, medications/recreational
drugs/self-report)
Inadequate oral hygiene practices
Deficient exposure to topical fluoride
High frequency/ amount of sugary drinks/ snacks
Symptomatic-driven dental attendance
Social-economic status/Health access barriers
Note : Risk factors in red denote a factor which will always classify an individual as high caries risk
PATIENT’S RISK STATUS
Low risk status Lack of any high caries risk factor (Element 1: red text) and other risk factors are within “safe”
ranges (e.g. sugary snacks, oral hygiene practice, fluoride exposure).
Moderate risk A stage where the individual is not deemed to be definitely at Low risk or definitely at High
status risk of developing new caries lesions or of lesion progression.
High risk status Presence of any of the high risk factors in Element 1, where the level of several of the lower
risk factors in Box 1 suggests a combination likely to lead to a high risk status – the number
and levels of these factors will vary according to geographical location and the prevailing
socio-economic conditions.

ELEMENT 2: INTRAORAL LEVEL RISK FACTORS At RISK ( Tick √ Information

if yes )
Hypo-salivation/Gross indicators of dry mouth
PUFA (Exposed pulp, Ulceration, Fistula, Absess) –
Dental sepsis
Caries experience
Thick plaque: Evidence of sticky biofilm in plaque
stagnation areas
Appliances, restorations and other causes of increased
biofilm retention
Exposed root surfaces
Note : Risk factors in red denote a factor which will always classify an individual as high caries risk

ElemeNT 3 : Decision Making : Synthesis and DIAGNOSIS

Based on the risk and caries activity the likelihood of developing future lesions is determined
Caries risk analysis to assess likelihood of new lesions or caries progression :-

Current Caries Activity Status at the Patient Level

No Active caries lesions Initial stage active caries Moderate- or extensive-

lesions stage active caries lesions
RI Low risk Low likelihood Moderate likelihood Moderate likelihood
SK Moderate risk Low likelihood Moderate likelihood High likelihood
ST High risk Moderate likelihood High likelihood High likelihood
AT
US

Treatment Plan:
Systemic:
Supervised by:
Urgency:
Preparatory (X-ray, S&P): Format: (After treatment is done)
Restorative (prostho etc): Patient name, patient ID, treatment name, treatment code, operator name, then
Elective/definitive (Ortho, extraction, prostho, endo , perio ): click Pt. Completed, waiting to be discharged. *remember to charge for
Maintanence (Recall, OHI): radiographs