Dental case history is a classic form of documentation in dentistry. It includes several parts: general information about the patient, information about the patient’s general condition and health, the patient’s reason for attendance, past dental history, family and social background and in some countries it includes also part with insurance type information. The first part of the dental case history contains information about patient’s name and surname, address, age, sex, occupation and so on.
This information is essential and it should always be checked for accuracy. It is quite possible to have two people with the same name in the wailing room or the practice, and only careful and routine checking will prevent serious mistakes being made. Age will have considerable bearing on the state of dental development in younger patients and is important for a variety of reasons at other ages. The patient’s sex usually has no bearing on the treatment advised, although it’s usually recorded to avoid confusion.
It should not be assumed that female patients are more concerned with their appearance than male patients. The patient’s occupation may affect availability for treatment. Some patients have an urgent problem such as pain or trauma, while other attend for a routine examination without particular symptoms. When symptoms are present the patient should be encouraged to describe these as clearly and in as much detail as possible. However, attitudes may become apparent during conversation, particularly when past dental treatment and experience are discussed.
Information about the patient’s general condition and health can help us to avoid usage of dangerous and unsuitable for the patient medicines and methods. This part should include history of heart or chest disease, current or recent medication, allergies, any difficulty in the arrest of hemorrhage after extraction or injury, previous hospital admissions, other diseases, pregnancy, contact with HIV or AIDS and so on. When these questions are answered positively it may be necessary to refer to the patient’s general medical practitioner or to arrange further investigations before proceeding with treatment.
A patient’s past dental history can be of considerable assistance. Previous treatment indicates susceptibility to disease as well as attitudes towards dental care. It is possible to build up a picture of past dental history which may include caries experience, restorative treatment received, susceptibility to periodontal disease, periodontal treatment received, extractions and the reason for the loss of the teeth, and information about prosthetic replacements.
Where an inherited condition is suspected, clearly the distribution within the family is important. In other cases attitudes to dental health, positive or negative, engendered within the family may have an important bearing on the condition with which the patient presents or upon acceptance of treatment. The same is true of the patient’s social background. Other aspects of the social history — for example availability for long appointments — will also determine the type of treatment.