YENEPOYA DENTAL COLLEGE
DEPARTMENT OF PEDIATRIC AND PREVENTIVE
DENTISTRY
CASE HISTORY
PART-1
Presented by Paul Francis
21D078
CONTENTS
INTRODUCTION
CLINICAL EXAMINATION
CASE HISTORY General Examination
Personal Data Extra Oral Examination
Chief Complaint Facial Height
Past History
Examination of Nose
Pre-Natal,Natal and Post-Natal
Examination of Chin
Family History
Examination of Lips
Drug History
Examination of TMJ
Personal History
Examination of Lymph Node
Behavioural History
CONCLUSION
Diet History
INTRODUCTION
One can treat and cure only those disease
or signs and symptoms that are
diagnosed in the first place
Theart and science of patient
evaluation is the key to treatment planning
Successfuldental treatment for children can
be achieved by recording a detailed
history, a complete clinical
examination, appropriate treatment plan
When clinical data are more complex, the diagnosis
may be established by
a) Reviewing the patients history and physical,
radiographic and laboratory examination data
b) Listing those items that either clearly indicate an
abnormality or that suggest the possibility of a
significant health problem requiring further
evaluation
c) Grouping these items into primary Vs secondary
symptoms, acute Vs chronic problems and high Vs
low priority for treatment
d) Categorizing and labelling these grouped items
according to a standardized system for the
classification of disease
COMPONENTS OF ORAL
EXAMINATION AND DIAGNOSIS
RECORDING THE HISTORY
EXAMINATION OF THE PATIENT
PROVISIONAL DIAGNOSIS
SPECIAL EXAMINATION
FINAL DIAGNOSIS
TREATMENT PLANNING
RECORDING The HISTORY
This can be further categorized for descriptive purpose into:
Vital Statistics
Chief Complaint
History of Present Illness
Family (social) History
Medical History
Drug History
Dental History
Natal,Pre-Natal,Post-Natal History
Behavioural History
Growth and Development
Diet History
TERMINOLOGY
Diagnosis: Determination of the nature of the disease
Differential Diagnosis: Process of listing out two or more
disease, having similar signs and symptoms of which only one
could be attributed to the patients suffering.
Provisional Diagnosis: General diagnosis based on clinical
impression without any laboratory investigation.
Final Diagnosis: Confirmed diagnosis based on all available
data.
Symptoms: Any morbid phenomenon or departure from the
normal in structure, function or sensation experienced by the
patient and indicative of a disease
SEQUENCE OF STEPS
1. Vital Statistics
a) Hospital reg. number with date of first visit
b) Name
c) Age
d) Sex
e) Class and school
f) Parents Name and occupation
g) Address and telephone number
2.Chief Complaint
3. History
a) History of chief complaint
b) Medical History- Pre Natal,Post Natal and Present
History
c) Past Dental History
d) Family History
e) Personal History- Oral hygiene, diet and oral habit
history
4. Examination
General Examination
Local Examination: Extra
Oral Examination
a) Shape of Head
b) Shape of Face
c) Facial Profile
d) Facial Symmetry
e) Facial Divergence
f) Facial Height
g.TMJ
h.Lymph Node
i.Eyes
j.Nose
k.Fore head
l.Naso Labial Angle
m.Lips
n.Mento Labial Sulcus
o.Chin
Local Examination : Intra Oral Examination
a) Soft Tissue Examination
b) Saliva
c) Halitosis
d) Hard Tissue Examination
Teeth Present
Hard Tissue Status
Occlusion: Molar, canine,
incisal relationship
Mobility/Depressibility of
teeth
e. Breathing Pattern
f. Swallowing Pattern
g. Physiologic Spacing
h. Midline
5. Provisional Diagnosis
6. Investigation
7. Final Diagnosis
8. Treatment Planning
a. Medical Phase
b. Systemic Phase
c. Preventive Phase
d. Corrective Phase
e. Maintenance and Recall
HEALTH HISTORY
Health history is a structured format and must be
recorded as such
• Various questions need to be asked depending on the
type of information needed. It may be open-ended
questions or close ended
• To obtain history in infants and children under 5 years of
age , the parent or legal guardian is interviewed
• The questionnaire should be accommodative to the
various problems encountered and not stereotype
• The dentist should be an empathetic listener for the
patients ,may often pour out their grievances to him/her
and this will go a long way in establishing a good rapport
VITAL STATISTICS
Is a systemic approach to collect and compile all the
information related to the vital events like birth,
death, recognition, social structure and legislation
a) Hospital Reg Number
It is recorded for the purpose of organized file
keeping, billing and also legal purposes
b) Date
Records patients first visit which can be referred
back to
c.Name
Children are at ease when they are referred to by
the same name as they are referred at home
Purpose :
• Identification
• To maintain records
• Communication
• To develop rapport with the patient
d.Chronologic Age
It is the age of the child calculated from his/her
birthday
Behavior management techniques that have to be
chosen are definitely age dependent
To relate the eruption and exfoliation sequence of
teeth. It helps to compare the dental age of the
patient with chronological age.
To also compare the chronologic age with the
skeletal and mental age
e.Sex
Certain diseases are specific to either of the sexes,
such as hemophilia is common in males or juvenile
periodontitis in female
Timing of eruption sequence also varies b/w male and
female
Behavior management technique may vary depending
on the sexes depending on the likes and dislikes of the
child
f. Class and School
Helpful to correlate the patients chronological age with
mental age
Gives some indication regarding the socio-economic
background of the child
g. Parents Name and Occupation
For communication
Understanding the socio-economic condition
h. Address
Communication purpose
Record purpose
Some areas are endemic to certain disease or
condition
CHIEF COMPLAINT
Reason which prompted the patient to seek dental
treatment
Common reason for seeking treatment includes
pain, swelling and to improve esthetics or may be
referred from other practitioner.
While recording the chief complaint it must be made
in the chronological order, that is what appeared
first should be mentioned first
For example, the ,most common presenting illness
can be evaluated as
1) The Onset
2) The Duration
3) The Location
4) The Quantity: quality , severity and frequency of
occurrence
5) Aggravating and relieving factors
6) Associated symptoms
HISTORY OF PRESENT ILLNESS
It is a detailed description of the chief complaint
It may be in terms of duration, onset, severity,
nature
PAST HISTORY
Includes both medical and dental history and
showed an overview about the general health status
of the patient.
PAST DENTAL HISTORY
It provides clues about the attitude of the patient
towards dentistry/dental treatment
Whether it is his/her first visit or not
If not , the details of previous visit like reason for
seeking treatment , treatment rendered , any
traumatic experience.
MEDICAL HISTORY
History of any medical conditions should be asked
including recent hospitalization, blood transfusion
etc.
Treatment must be postponed if the patient is
suffering from acute illness such as mumps, chicken
pox etc.
Patients with cardiac defects should be referred to a
paediatrician.
Antibiotic prophylaxis must be given prior to any
treatment to minimize the risk of development of
subacute bacterial endocarditis (SABE)
PRE-NATAL HISTORY
Includes history of the mother during her pregnancy
period and includes about
Nutritional Disorder
Drug history: Teratogens may cause abnormal
development of the foetus and some drugs like
tetracycline may cause discolouration of the teeth.
Abnormal foetal position may result in abnormal
pressure on some part of the face leading to facial
symmetry
Accidents/trauma : Trauma may result in oro facial
deformity, due to damage to the growth centers
NATAL HISTORY
Includes history of child at the time of birth
Rh incompatibility that may lead to erythroblastosis
fetalis
Cyanosis at birth may indicate congenital cardiac
disease
Injury to the tempero-mandibular joint at the time of
birth such as may occur during forceps delivery can
affect growth of the condyle and in turn the
mandible
Time of birth-- to rule out pre term birth
POST NATAL HISTORY
It include history of the early infant period of the child
Includes history relating to the type and duration of
feeding habits, nutritional disturbances
Trauma , childhood disease
History of immunization
FAMILY HISTORY
Provides some indication of the hereditarily
influenced development of the patient
Attitude of the parents towards the oral hygiene,
health and dentistry has to be assessed as it may be
reflected in the behaviour of children
Infectious disease in the family such as tuberculosis
should be carefully dealt with.
DRUG HISTORY
Details of the drugs being used for systemic ailments.
Any adverse reaction to drugs
Any drugs already used for the condititon
PERSONAL HISTORY
Details about brushing habits to know the
awareness about oral hygiene
ORAL HABITS HISTORY
It includes recording the frequency, intensity,
duration of the habits such as finger/thumb
sucking, nail biting/lip biting, tongue
thrusting, bruxism, mouth breathing etc.
ORAL HYGIENE HISTORY
It includes history related to the maintenance of oral
hygiene
Number of times and method of brushing
History regarding ‘WHO’ brushes the teeth is very
important especially in children less than years
Use of fluoridated or non-fluoridated dentrifices
Brush: Type of brush and how often it is changed
BEHAVIORAL HISTORY
Any clues of negative or unpleasant behaviour during
the previous dental visit may call upon the need for
behaviour management or shaping
Receptive/Intimidating
DIET HISTORY
Type of meal (vegetative/mixed) influences the oral
hygiene status
Habits of snacking between meals should be evaluated
as they may be cariogenic
In case of high cariogenic patients, a diet diary with
number of sugar exposures should be noted while
taking diet history
DIET CHART (Sample of one day)
TIME FOOD EATEN METHOD OF QUANTITY SUGA
PREPARATION R
7:00 AM Milk, chapathi,jam Boiled with ghee 1 glass yes
2
1 tsp
10:00AM Lassi with sugar _ 1 glass yes
Gulab jamoon fried 2 tsp
2
11:30 AM Burfi Cooked in ghee Small bite piece _
1:00 PM Rice boiled 1 medium bowl yes
Vegetable curry Fried in little oil 1 small bowl
4:30 PM Watermelon juice _ 1 glass+2 tsp Yes
with sugar Baked 4
Glucose biscuits
8:30 PM Rice Boiled 1 medium bowl _
Vegetable curry Fried in little oil 1 small bowl
SUGAR SCORE CALCULATION
value Demineralization
Status
0-12 Healthy tooth
13-24 Beginning of demineralization
>25 Strong demineralization
The sugar score was calculated by classifying each sweet
into liquid, solid and sticky or slowly dissolving categories
The sweet and sugar sweetened foods and the frequency
with which they were consumed were listed
If the sweet were liquids, it was multiplied by 5,
if solid multiplied by 10,
if slowly dissolving multiplied by 15.
The products were written and totalled to obtain the
sugar score
The mineralization status score was obtained by
calibrating and using the DIAGNOdent pen according to
the manufacturers instruction
CLINICAL
EXAMINATION
Most important findings that lead to
diagnostic headway are often detected on
routine examination
GENERAL EXAMINATION
1) General well-being of the child
A brief survey of the entire body is made
2) Height and Weight
Both have a direct relation with developmental and
nutritional status
Possible to determine whether an individuals growth
id progressing normally or abnormally by comparing
his/her height and weight with the standard height
and weight chart
3) Gait
Most common abnormal gait is weak, unsteady gait
of lethargy and malaise in ill patients
Other types of gait-waddling, equines, staggering
etc
4) Posture
Look for any abnormality
5)Stature and Built
Indicative of any malnutrition or other abnormality
Built – William Sheldon categorized human bodies into 3
categories
a) Ectomorph: late mature, tall, thin and fragile long and
slender extremities with minimum subcutaneous fat
and muscle. They have flat chest, lightly muscled body
b) Mesomorph : upright, sturdy, athletic. Muscle, bone and
connective tissue predominate. They have a hard muscular
body.
c) Endomorph : early mature, round shaped, usually stocky
with abundant subcutaneous fat, highly developed
digestive viscera, underdeveloped muscles with soft body
6)SPEECH
Speech disorder can be
a) Aphasia (loss of speech secondary to central nervous
system damage)
b) Delayed speech (due to hearing loss, intellectual
retardation, developmental retardation, poor environmental
stimulation)
c) Stuttering or Repetitive Speech
(where the child repeats some or most of the words and is
due to psychological stresses)
d) Cluttering
- is an unusual type of speech characterisation by
repetition of words or phrases, false starts, changes in
context in the middle of sentence and general verbal
confusion
7) VITAL SIGNS
Pulse, heart rate and respiratory rate differ in child
at different age, till they reach the adult value
LOCAL
EXAMINATION
EXTRA ORAL EXAMINATION
1) Shape of the Head
cephalic index (CI)= max skull width (transverse dimension)
max skull length (antero posterior
dimension)
Classified
a) Mesocephalic: average, CI is 76-80.9
b) Dolichocephalic : long and narrow ,CI is <75.9
c) Brachycephalic: broad and short, CI is 81-85.4
d) Hyper brachycephalic: CI is >85.5
2) Shape of the Face
Morphologic facial index
MFI= morphologic Facial Height
Bizygomatic Width
Classified by Martin and Saller(1957)
a) Dolichoprosopic or Leptoprosopic
high facial skeleton, long and narrow –oval, MFI is 88-
92.9
b. Euryproscopic
low facial skeleton, round, MFI is 79-83.9
c. Mesoprosopic
average, square , MFI is 84-87.9
3) Facial Profile
a) Straight – all the three points in the same
vertical lane, seen in class I malocclusion
b) Convex – if point A is ahead or pogonion is
behind, seen in class II Division I
malocclusion
c) Concave- if point A is behind or pogonion is
front, seen in class III malocclusion
Nasion , point A and the podonion is
considered
4) Facial Symmetry
Is better visualized from above the head,
operator standing behind the patient
Gross asymmetry of face can be due to
First arch syndrome
Parotid enlargement
Hemi facial hypertrophy/atrophy
5) Facial Divergence
Facial angle is used which is formed by NA-Pog soft tissue
line and FH line
3 types
a) Orthognathic: FA is appro. 90 degree
b) Posteriorly divergent: low FA
c) Anteriorly divergent: high FA
6) Facial Height
Upper Facial height
From the bridge of nose to lower border of nose or NA to ANS -
45% of total facial height
Lower facial height
From lower border of the nose to lower border of the chin-
55% of total facial height
7) Temperomandibular Joint
TMJ is palpated by standing in front of the patient.
Helps to visualise the movement of mandible
during opening and closing
It reveals pain on pressure and synchrony of action
of left and right condyle.
Discrepancies of TMJ such as muscular imbalance,
anatomic deviation, trismus, spasm etc can be
noted
8) Examination of Lymph Node
Lymphadenopathy is not uncommon in children due
to frequent viral infection
Ask the patient to bend his neck in forward and
downward position to palpate the lymph node on
the side and to bend it forward to palpate the
submandibular area
A complete examination of neck region including
lymph node is mandatory
9) Examination of Eyes
Eyes should be observed for any inflammation,
swelling or puffiness around the eye
Inflammation of maxillary teeth can cause swelling
of eyelids
10) Examination of Nose
Nose should be examined for any abnormalities in
size, shape or color
Children who encounter nasal discharge indicate
upper respiratory tract infection
Children with chronic upper respiratory tract
infection will develop mouth breathing habit
11) Examination of Fore Head
Profile of face is influenced by shape of the fore
head and nose
Harmonious facial morphology= height of the
forehead should be 1/3 of the entire face height that
it must be as long as the middle and lower third
12) Naso Labial Angle
It is the angle formed b/w lower border of nose to
the upper lip and is 90-110 degree
Increased in retrusive maxilla, retruded upper teeth
Decreased in proclined maxilla, tense upper lip,
prognathic upper teeth
13) Examination of Chin
Prominence of chin and mentalist activity can
indicate habits and malocclusion
14) Examination of Lips
Lips should be examined for the presence of cold
sores, swelling or abnormal coloring
Competent –lips are in contact when musculature is
relaxed
Incompetent – lip seal is not formed in normal
circumstances, only hyper activity of oral
musculature can help in forming closure
15) Mento Labial Sulcus
It is the region b/w lower lip and the mentalis
muscle
Normal – seen in class I occlusion
Deep- seen in class II division I
Shallow – seen in bi maxillary protrusion
CONCLUSION
The provision of dental care for children present
some of greatest challenges in clinical practice.
High on the list of challenge is the need to devise a
comprehensive yet realistic treatment plan for these
young patient
Hence a elaborate case history is of most
importance
REFERENCES
TEXTBOOK of PEDIATRIC DENTISTRY
-Nikhil Marwah (4th edition)
PRINCIPLES OF PEDODONTICS
- Aaithi Rao (2nd edition)
PEDIATRIC DENTISTRY
- Shobha Tandon (1st edition)
Incharge guide: Dr. Raksha Ballal
Presented by: Paul Francis
21D078
