Dental History

After completing the medical history the clinician should develop the dental history. The purpose of a dental history is to create a record of the chief complaint, the signs and symptoms the patient reports, when the problem began, and what the patient can discern that improves or worsens the condition. The most efficacious way for the clinician to gather this important information is to ask the patient pertinent questions re

garding the chief complaint, and to listen carefully and sensitively to the patient's responses. For example, the doctor might begin by simply asking the patient. "Could you tell me about your problem?" To determine the chief complaint, this question should be followed by a series of other questions, such as "When did you first notice this?" (inception). Affecting factors that improve or worsen the condition should also be determined. "Docs heat, cold, biting, or chewing cause pain?" (provoking factors). "Does anything hot or cold relieve the pain?" (attenuatingfactors). "How often does this pain occur?" (frequency). "When you have pain, is it mild, moderate, or severe?" (intensity). The answers to these questions provide the information the dentist needs to develop a brief narrative description of the problem.

The majority of patients present with evident problems of pain or swelling, so most questions should focus on these areas. For example, "Could you point to the tooth that hurts or the area that you think is swelling?" (location). "When cold {or heat) causes pain, docs it last for a moment or for several seconds or longer?" (duration). "Do you have any pain when you lie down or bend over?" (postural). "Does the pain ever occur without provocation?" (stimulated or spontaneous). "What kind of pain do you get? Sharp? Dull? Stabbing? Throbbing?" (quality). Questions like these help the clinician establish the location, nature, quality, and urgency of the problem and encourage the patient to volunteer additional information that completes the verbal picture of the problem. The clinician may be able to formulate a tentative diagnosis while taking a dental history. The examination and testing that follow often corroborate the tentative diagnosis. It is then merely a matter of identifying the problem tooth/1'7

In the gathering of a dental history, common sense must prevail. The questions outlined here, along with other questions described in Chapter 2, should be asked if the diagnosis is elusive. If the clinician can see a grossly decayed tooth while sitting and talking with the patient and if the patient points to that tooth, the dental history should be brief because of the obvious nature of the problem. Furthermore, if the patient is suffering from severe distress, with acute symptoms (Chapter 2), the dental history should be brief so the clinician can relieve the pain as soon as possible.

Pain

Because dental pain frequently is the result of a diseased pulp, it is one of the most common symptoms a dentist is required to diagnose.14" The source of the pain is usually made evident by dental history, inspection, examination, and testing. However, because pain has psychobiologic components—

physical, emotional, and tolerance—identifying the source is at times quite difficult. Furthermore, because of psychological conditioning, including fear, the intensity of pain perception may not be proportional to the stimulus. When patients present with a complaint of pain that is subsequently determined to be of odontogenic origin, the vast majority of these cases reflect conditions of irreversible pulpitis, with or without partial necrosis.19'23

Patients may report the pain as sharp, dull, continuous, intermittent, mild, severe, etc. Because the neural portion of the pulp contains only pain fibers, if the inflammatory state is limited to the pulp tissue it may be difficult for the patient to localize the pain. However, once the inflammatory process extends beyond the apical foramen and begins to involve the peri-odontal ligament, which contains proprioceptive fibers, the patient should be able to localize the source of the pain. A percussion test at this time to corroborate the patient's perception of the source will be quite helpful.

At times pain is referred to other areas within, and even beyond, the mouth. Most commonly it is manifested in other teeth in the same or the opposing quadrant. It almost never crosses the midline of the head. However, referred pain is not necessarily limited to other teeth. It may, for example, be ipsi-laterally referred to the preauricular area, or down the neck, or up to the temporal area. In these instances the source of cxtraorally referred pain almost invariably is a posterior tooth. Ostensible toothache of nonodontogenic origin (i.e., resulting from neurologic, cardiac, vascular, malignant, or sinus diseases) is described in Chapter 3.

Patients may report that their dental pain is exacerbated by lying down or bending over. This occurs because of the increase in blood pressure to the head, which increases the pressure on the confined pulp.

The dentist should be alert for patients who manifest emotional disorders as dental pain. If no organic cause can be discovered for what appears as dental pain, the patient should be referred for medical consultation. Patients with atypical facial pain of functional rather than organic cause may begin their long journey through the many specialties of the health sciences in the dentist's office.

If the dentist can determine the onset, duration, frequency, and quality of the pain and the factors that alter its perception, and if the dentist can reproduce or relieve the pain by clinical testing, then surely the pain is of odontogenic origin. The patient will usually gain immeasurable psychological benefit if the clinician provides caring and sincere reassurance that, once the source is discovered, appropriate treatment will be provided immediately to stop the pain.

+1 0

Responses

  • Gimja
    What do patients with grossly decayed tooth notice?
    11 months ago

Post a comment