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Taking a history

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Taking a history

For all patients, a full medical, dental and social history provides essential information to develop an effective personal care plan (see Planning care). 

For children, knowledge of caries experience and dental-related anxiety in parent and siblings gathered as part of the social history may help inform the caries risk assessment and in understanding the ability and motivation of the child and parent/carer to maintain oral health. It is particularly important to ask about toothbrushing and dietary habits as part of the dental history. By including this at the beginning of every dental examination, the importance of brushing and diet is emphasised to both the child and the parent/carer. This may help to assess motivation and enable targeted prevention (see Assessing parent/carer motivation and Caries prevention).

Awareness of the child’s previous experience of dental treatment will help predict how the child might react to treatment and whether the child is likely to accept it. Alternative methods for completing treatment might need to be considered (see Helping the family). For some parent/carers, several visits for preventive and restorative care might present difficulties. Knowledge of all this information will allow tailoring of a personal care plan for the individual child.

For older children, it is important to consider that they might smoke, vape and/or drink alcohol.

Confirm the reason for attendance and begin to assess the oral health expectations and motivation of the child and parent/carer.

Take a full medical and dental history, and ensure this is kept up to date. 

Take a social history, to determine:

  • which adults provide care for the child and need to be included in any caries preventive programme (e.g. regular overnight stays with grandparents, family members, childminders)
  • which days and times are easiest for the parent/carer to bring the child for care
  • the name of the medical practice attended (to facilitate contact with GP and/or Health Visitor) and the name of the nursery or school attended (to facilitate contact with the School Nurse or in relation to Childsmile Nursery/School Programme)

Ask about caries experience in parent and siblings.

Ask about toothbrushing habits. For example:

  • Does the child or the parent/carer brush the child’s teeth?
  • How often does the child brush?
  • What is the fluoride concentration in toothpaste used?
  • Is the child supervised and, if so, who does this?
  • Does the child spit out or rinse after brushing?

Ask about dietary habits. For example:

  • Does the child take a bottle to bed at night and, if so, what is in it?
  • How often does the child drink sugary drinks?
  • Does the child have sugar added to hot drinks?
  • Does the child take regular sugar-containing medication?
  • What does the child eat between meals?
  • What does the child eat at lunchtime at school?
  • How many portions of fruit and vegetables does the child eat each day?

Ask about previous dental experiences. For example:

  • What treatment has been carried out?
  • Does the child have any experience of local anaesthesia?
  • Is the child anxious about visiting the dental surgery?

Consider completing an anxiety questionnaire with the child (refer to Helping the family for behavioural management options).

Ask the parent/carer if there will be any difficulties in bringing the child for dental visits.

Use all of the information gathered to inform your assessment of the child and/or parent/carer’s attitude towards oral health and their ability and motivation to take responsibility for it.