Patient History and Examination

Patient History and Examination

Subir Banerji and Shamir B. Mehta


The foundation for successful treatment planning is largely reliant on the ability of the clinician to attain an accurate and contemporaneous patient history and to carry out a meticulous clinical examination. All findings should be appropriately recorded. Treatment planning should aim to fulfil the patient’s realistic expectations, provide an outcome that boasts functional and aesthetic success (spanning beyond the short term) and, where possible, utilise techniques that involve minimal intervention.

The initial assessment should take place in a relaxed setting, perhaps distinct from the operatory, and permit the patient to voice their views. Emphasis should be placed on actively listening to the patient’s concerns and attitudes.


Begin by verifying the essential patient data, such as the patient’s name, gender, date of birth, address and contact details. This may be attained by requesting completion of a pre-treatment evaluation document. The details can be checked by other members of your dental staff team, together with information concerning any relevant special needs.

Establish your patient’s reasons for attendance, hence the nature of their complaint and associated history. There are three categories of ‘dental aesthetic imperfections’ that drive patients to seek aesthetic intervention, which may be broadly classified as matters relating to tooth colour, shape and/or position.1

A detailed medical history is mandatory. A template medical history form may prove helpful. It is beyond the scope of this text to discuss the relevance of the medical history and its impact on the provision of dental care. However, in brief, the patient’s medical history (and status) may preclude them from attending necessary lengthy or frequent treatment sessions, require modification of the treatment protocol or may sometimes contraindicate certain types of treatment, as when there is an allergy to a material or product. Indeed, the underlying medical condition may also prove to be contributory to the aesthetic impairment, such as taking prescription medication that may induce gingival hyperplasia; or an eating disorder, hiatus hernia or gastric reflux, which may result in erosive tooth wear.

The condition of body dysmorphic disorder (BDD) is one to be particularly aware of. This may be considered a psychiatric illness characterised by a preoccupation with an imagined defect in appearance and may cause clinically significant distress or impairment in social, occupation or other important areas of functioning, with the preoccupation not being related to any other form of mental illnesses.2, 3 It would appear to be more common among patients seeking cosmetic and aesthetic treatments.

The patient’s dental history

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Feb 16, 2017 | Posted by in Esthetic Dentristry | Comments Off on Patient History and Examination
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