Documenting Dental History
Obtaining and documenting a thorough dental history is essential to maintaining proper patient records. A patient’s dental history helps support the practitioner’s clinical assessment, aids in determining an accurate diagnosis, and helps develop a comprehensive preventive and therapeutic treatment plan for each patient.
In order to record the patient’s dental history, the dentist and/or staff member(s) should obtain a complete and thorough dental history from the patient. Note any information offered by the patient about current fears and concerns, as well as any details shared about past dental experiences. The patient’s oral health conditions, as observed on the day of the evaluation, should also be recorded. The clinical observations that should be recorded in the patient’s dental history include, but are not limited to: previous restorations, periodontal treatment, extractions, orthodontic treatment, oral habits, and patient reactions to treatment, including anesthesia experiences and the efficacy of the anesthesia methods. Additionally, intraoral photographs should be taken for a baseline comparison.
It is important that the names of previous dentists are obtained and the appropriate record releases are signed by the patient or custodial individual prior to the patient’s evaluation visit. This allows any past patient documentation or records to be requested and obtained from prior treating providers, as deemed necessary by the current treating dentist, prior to the patient’s evaluation. Having the necessary documentation from the previous dentist(s) in hand at the initial evaluation visit can greatly enhance the dentist’s ability to complete the initial evaluation process without having to wait for the supportive historical information.
Note: The majority of this article focuses on documenting dental history for a pediatric patient. However, these concepts can also apply to adult patients.
What Does a Dental History Include?
There are some basic information items that are essential to include in the patient’s dental history. In addition, it is also helpful to determine the patient’s overall caries risk.
According to the American Academy of Pediatric Dentistry (AAPD), a dental history should address the following:
»» Chief complaint.
»» Previous dental experience.
»» Date of last dental visit.
»» Date of last radiographs.
»» Oral hygiene habits and practices.
»» Fluoride use/exposure history.
»» Dietary habits (including bottle/ no-spill training cup use in young children).
»» Sports activities.
»» Previous orofacial trauma.
»» Temporomandibular joint (TMJ) history.
»» Family history of caries.
»» Social development.
Some factors to note in addition to those items listed above that can affect caries risk, according to the AAPD, are:
Risk Factors to Note for Children 0-5 Years Old
»» Biological:
-- Does the parent or primary caregiver have active caries?
-- What is the parent or primary caregiver’s socioeconomic status?
-- How many between meal, sugar containing snacks or beverages does the child consume per day? (More or less than three?)
-- Is the child put to bed with a bottle containing natural or added sugar?
-- Does the child have special health care needs?
-- Is the child a recent immigrant?
»» Protective:
-- Does the child receive optimally fluoridated drinking water or fluoride supplements?
-- Does the child brush his teeth daily with fluoridated toothpaste?
-- Does the child receive topical fluoride from a health professional?
-- Does the child have a “dental home” or receive regular dental care?
»» Clinical Findings:
-- How many decayed/missing/filled surfaces does the child have?
-- Does the child have active white spot lesions or enamel defects?
-- Does the child have elevated mutans streptococci levels?
-- Does the child have plaque on his teeth?
Risk Factors to Note for Children 6 and Older
»» Biological:
-- Is the patient of low socioeconomic status?
-- How many between meal, sugar containing snacks or beverages does the patient consume per day? (More or less than three?)
-- Does the patient have special health care needs?
-- Is the patient a recent immigrant?
»» Protective:
-- Does the patient receive optimally fluoridated drinking water?
-- Does the patient brush her teeth daily with fluoridated toothpaste?
-- Has the patient received topical fluoride from a health professional?
-- Does the patient use additional home measures (e.g., xylitol, MI paste, antimicrobial)?
-- Does the patient have a “dental home” or receive regular dental care?
»» Clinical Findings:
-- How many interproximal lesions does the patient have?
-- Does the patient have active white spot lesions or enamel defects?
-- Does the patient have low salivary flow?
-- Does the patient have defective restorations?
-- Is the patient wearing an intraoral appliance?
Once the caries risk factors are determined and an assessment is made (using recognized assessment tools), the overall caries risk for the patient can be determined and recorded. Recognized assessment tools are available from the ADA, California Dental Association, and AAPD.
Reporting Caries Risk Assessment
The following CDT codes may be used to describe the assessment and documentation of the patient’s caries risk:
D0601 Caries risk assessment and documentation, with a finding of low risk
Using recognized assessment tools.
D0602 Caries risk assessment and documentation, with a finding of moderate risk
Using recognized assessment tools.
D0603 Caries risk assessment and documentation, with a finding of high risk
Using recognized assessment tools.
Recording Existing Conditions
In addition to recording the patient’s past experiences, noting the caries risk factors, and determining the caries risk level, the condition of the patient’s oral cavity should also be documented at the first appointment.
Today, many dental practices utilize technology to streamline this documentation process. Technology used by dental teams may include an intraoral camera, CariVuTM, radiographic images, cone beam computed tomography (CBCT), and/or voice recordings. By utilizing some or all of these technologies and techniques, the process of recording the present dental conditions is augmented and the time, energy, and efforts needed are reduced.
The images captured by an intraoral camera are an exact representation of the existing condition of the patient’s mouth. On the other hand, a “drawing” or computer generated “free hand” tooth chart of existing restorations and conditions is not as accurate nor as graphic as photographic and radiographic images. With proper training, the images captured by an intraoral camera improve accuracy and reduce the time needed to record the existing conditions found in the mouth when the patient presents for an evaluation. Whether or not the practice utilizes these technologies or chooses to create manual documentation, charting of the existing conditions, restorations, and anatomy should be included in the clinical record.
To help expedite reimbursement, it is important to note the delivery dates for existing major services, such as crowns, bridges, partials, dentures, implants, periodontal surgery, scaling and root planing procedures, etc. If clinical records are available from previous dentists, those dates can easily be obtained from the existing clinical records. If these records are not available, try to obtain a date of service from the patient. Be aware that the patient may not be able to provide accurate dates of service and that the lack of this documentation may reduce or limit future reimbursement for repeated treatments and prosthetic replacements. (Example: If there is a five year limitation for a new crown, then performing a new crown procedure one day early will result in no reimbursement.)
Once a baseline dental history is obtained from the patient, the information should be recorded either electronically or using a predeveloped comprehensive dental history form. The patient or caregiver should sign the dental history form, confirming that the information shared verbally with the dentist or qualified dental staff member is complete and accurate. This form should never be altered and should be kept in the clinical notes as a reference to previous treatments and the patient’s recollection of those treatments, as well as any other contributing factors. Manual forms should be scanned into the patient’s clinical record or included in a paper record.
It is vital to obtain a complete dental history and to properly record it in the patient’s clinical record. This dental history can be used to help support the practitioner’s clinical assessment. It can also help determine an accurate diagnosis and help develop a comprehensive preventive and therapeutic treatment plan tailored for each patient. Failing to obtain and record the dental history for each patient may hinder the dentist’s ability to provide quality care for patients.