CASE HISTORY

Presented by
Sofia Mukhtar
PG IInd Year
 INTRODUCTION

A case history is defined as a planned professional conversation

that enables the patient to communicate his/her symptoms,
feelings and fears to the clinician so as to obtain an insight into
the nature of patient's illness & his/her attitude towards them.
Objectives:-

•To establish a positive professional relationship.

•To provide the clinician with information concerning the
patient's past dental, medical & personal history.
•To provide the clinician with the information that may be
necessary for making a diagnosis.
•To provide information that aids the clinician in makíng
decisions concerning the treatment of the patient.
 COMPONENTS-
Demographic data
 Chief complaint
 History of present illness
1.Medical history
2. Past dental history
3.Family history
4.Personal history
General examination
 Extraoral examination
 Intraoral examination
 Provisional diagnosis
Investigations-
Final diagnosis
Treatment plan
 Statistics/ Demographic data

Patient registration number

Date
 Name
 Age
 Sex
Address
Occupation
Marital status
o PATIENT REGISTRATION NUMBER :
Useful for-
•maintaining a record,
• billing purposes,
• medico legal aspects.
DATE
Useful For-
•Time of admission
• reference during follow up visits
•Record maintenance
NAME
•To communicate with the patient
•To establish a rapport with the patient
• Record maintenance
• Psychological benefits
AGE
For diagnosis
Treatment planning
Behavioral management techniques
 Some diseases are prevalent in particular ages

•DENTAL DISEASES PRESENT SINCE BIRTH OR SEEN IN

INFANCY
•Related to jaw
Agnathia, Facial hemihypertrophy, Macrognathia, Cleft palate
• Related to lip
Commissural pits and fistulae, Double lip, Cleft lip
Related to gingiva
Congenital epulis of the newborn, Fibromatosis gingiva
• Related to tongue
Microglossia, Macroglossia, Aglossia, Ankyloglossia, CIleft tongue,
Fissured tongue, Median rhomboidal glossitis, Lingual thyroid nodule
•Related to teeth
early / delayed eruption, partial/ complete anadontia
• Related to TMJ
Aplasia or congenital hypoplasia of the mandibular condyle
•Systemic Diseases
Congenital heart diseases, Bronchiectasis, Pneumonia
Behavior management technique :

In case of pediatric patients. The dentist has to deal with the

child as well as with the parent; approach is 1:2. In talking to a
child, the dentist must get down patient's level of understanding
based on patient's intelligence.
 SEX
SINGNIFICANCE-
•Some diseases show specific sex predilection. eg:- anorexia is more
common in females while hemophilia may be found exclusively in
males.
•Girls mature faster than boys thus their treatment may be required
earlier.
•Esthetics and emotion is more of a concern in female patients.
•Male patients are more prone to trauma during playing.
•Child abuse of which sexual abuse or exploitation is more common
in case of females.
 ADDRESS
•For future correspondence.

•Gives a view of socio-economic status -to know about the

nourishment, hygiene & payment capacity of the patient.

•Prevalence of diseases like fluorosis as a result off increase

level of fluorides in water are spread differently in various
parts of the country.
 Chief History of
complain present illness

Medical
history

Past dental Personal

history history
 CHIEF COMPLAINT

• The chief complaint is usually the reason for the

patient's visit.
•It is stated in patient's own words in chronological
order of their appearance & their severity.
•The chief complaint aids in diagnosis & treatment
therefore should be given utmost priority.
 COMMON CHIEF
COMPLAINTS
1. Pain
2. Loose Teeth
3. Delayed eruption
4. Caries
5. Swelling
6. Halitosis
7. Maligned Teeth
 HISTORY OF PRESENT ILLNESS

•Elaborate on the chief complaint in detail

•Ask relevant associated symptoms
• The symptoms can be elaborated in terms of:-Mode
& cause of onset
• Duration
• Location-localized ,diffuse ,referred, radiating.
• Progression- continous or intermittent.
• Aggravating & relieving factors
•Treatment taken
 PAIN

a) Anatomical location where the pain felt ?

b) Origin & mode of onset :- activity which inducing the pain should be
taken in consideration.
c) Intensity of pain :- whether the pain is mild , moderate or severe.
d) Nature of the pain :- it can be throbbing , shooting, stabbing, dull,
aching, lancinating, boring, griping, sharp, gnawing, squeezing.
e) Progression of pain:-The patient should be asked 'how is it
progressing
f) Duration of pain- Duration of pain means the period from the time of
onset to the time of pain disappearance.
g) Movement of the pain :- referred, radiating , shifting or migration of
pain.

h) Periodicity of pain-Sometimes an interval of days , weeks, months or

even years may elapse between two painful attack.

I) Effect on functional activity - the effect of various activity such as

brushing, shaving, washing the face, turning the head, lying down
etc. should be noted.

J) Aggrevating & relieving factor- whether it aggrevates or relieved with

chewing or any other factors.
 SWELLING

1) Duration :- for how many days swelling is present.

2) Mode of onset :-
a) mass that increase in size just before eating :- salivary gland
retention phenomenon.
b) slow growth :- chronic infection cyst, benign tumors
c) rapid growing mass :- abscess, infected cyst, hematoma
d) mass with accompanying fever :- infection & lymphoma
3) Symptoms ;- 1like pain, difficulty in respiration swallowing,
disfiguring.
 MEDICAL HISTORY
The medical history includes the information about past & present illiness.
All diseases suffered by patient should be recorded in chronological order.
Check list of medical history-by Scully and Cawscon
Anemia
Bleeding disorders
Cardio respiratory disorders
Drug treatment and allergies
Endocrine disorders
Fits and faints
Gastrointestinal disorders
Hospital admissions and surgeries
Infections
Jaundice
Kidney disease
 PAST MEDICAL AND DENTAL HISTORY
PAST MEDICAL HISTORY
This should include operation, hospitalization, infectious disease, immunization, allergies,
accident, etc.

PAST DENTAL HISTORY

Past dental care and child’s reaction towards it , any previous unpleasent experience, oral
hygine habits, fluoride therapy.
•Any treatment must be postponed if the patient is suffering from acute illness such
as mumps, chicken pox, etc.
•History of rhinitis, repeated cold, adenoidectomy, tonsils should be carefully
examined for evidence of persisting nasal obstruction before undertaking
orthodontic treatment with appliance such as oral screen, activator, etc.
•Patients with cardiac defects should be referred to a pediatrician and antibiotic
prophylaxis must be given prior to any treatment to minimize the risk of
development of subacute bacterial endocarditis (SABE).
•If the child is undergoing anticoagulant therapy, adjustment of anticoagulant
dosage may be required.
•Precaution should be taken to avoid contacting communicable disease.
•Drug allergy or interactions should be noted History of psychological problems
should be obtained. This will help in management of the child's behavior during the
procedure.
 FAMILY HISTORY

•Family members share their genes, as well as their

environment, lifestyles and habits.

•Risks for diseases such as asthma, diabetes, cancer, and heart

disease also run in families.

•There are also several inherited anomalies & abnormalities

that can affect the oral cavity such as congenitally missing lateral
incisors, cleft lip & cleft palate
In case of young patient:-

BIRTH HISTORY :-
Asked from the parents as if any problem were encountered at birth.
1)Rh incompatibility :- may result in the condition termed as
erythroblastosis fetalis". The effect may be seen in the dentition,
with well described entities such as hump on the tooth and the
characteristic blue- green discoloration.
2) Neonatal jaundice:-- the immature RBC's in an infant are rapidly
destroyed in the spleen. This increased bilirubin cannot be
sufficiently cleared by the liver leading to transient jaundice' in the
child.
3) Trauma due to forceps delivery.
 POSTNATAL HISTORY

 In post natal history, significant is attached to the amount of

time the child was breast fed, bottle fed etc.
 Vaccination status needs to be assessed along with the present
illness , if any
Presence of any habit and its duration and frequency.
 Any previous experience with the dentist and what bearing it
have on the present visit.
Progress in the school, how he interact with the children will
indicates the development of the child's emotions.
PERSONAL HISTORY
 Habits
 Diet
Oral hygiene
 HABITS

•It includes recording the frequency intensity and duration of

habits.
•Thumb sucking & lip sucking - anterior proclination of
maxillary incisors.
• Tongue thrusting habit - anterior & posterior open bite.
• Mouth breathing - anterior marginal gingivitis & dental
caries.
DIET HISTORY
•Feeding during infancy- breast milk, bottle, others. The additives and frequency
of feeding is of concern here.
•Diet- vegetarian / non- vegetarian
•Present dietary habits balance diet, snacking in between meals
•Patient should be asked about his complete diet of the past24hrs which should
include the time of the day when food was taken, type of food, frequency of
sugar exposures.
PERSONAL ORAL HYGIENE HABITS

•Number of times and method of brushing.

•A History regarding 'who' brushes the teeth is very important
especially in children less than 5 years.
•Use of fluoridated of non-fluoridated dentifices.
•Brush: Type of brush and how often it is changed.
•Other oral hygiene aids used like flossing, rinses, etc. Horizontal
brushing technique may leads to cervical abrasion.
 Extra oral examination
1. SKIN -is looked for
• Appearance ,any rashes, sores or itching
• Color-anemia patients have pale skin color, yellow tint is
seen in jaundice patients.
• Pigmentation
• Edema
• Temperature
2. Facial symmetry – bilaterally symmetrical/asymmetrical
3. Lip Competency – competent/ incompetent
 JAWS
• Any deviation in path of closure and opening lateral
movements of mandible.
• Tenderness over the joint and muscles of mastication.
• Any injuries trauma to the facial bones and jaws should be
examined.
 TMJ
•clicking or popping sound
•Deviation or deflection while opening
•pain or tenderness over joint or masticatory muscles.
•Maximal interincisal opening (normal is 35-50 mm)
•Range of vertical & lateral movements
•PALPATION OF PRE TRAGUS AREA:
The examiner can be positioned either in front of or
behind the patient
Patient is asked to slowly open and close the mouth
palpating with index finger, placed in the pre tragus
depression.

•INTRAAURICULAR PALPATION:
Performed by inserting small finger into the ear canal
and pressing anteriorty.
While palpating with this methods check whether
condyle moves symmetrically, with the rotation and
translation phase
 LYMPH NODES

Lymph nodes are oval or bean-shaped structures found along lymphatic

vessels that drain body parts.
Normally, they are non-tender, soft and cannot be felt even though they
are present.
tender on palpation ,mobility should be noted.

PREAURICULAR LYMPH NODES

Location- in front of ear
Lymphatic drainage – Eyelids and conjunctivae, temporal
region, pinna
For palpation of Preauricular lymphnodes, roll your finger infront of the ear,
against the maxilla.
Enlarged - Externalauditory canal infection.
•POSTAURICULAR LYMPHNODES
LOCATION- behind the ear, near the insertion of sternomastoid muscle.
Lymphatic drainage: External auditory meatus, pinna, scalp
Digital palpation is done by pressing against the skull.
Enlarged due to infection of scalp, temporal & frontal areas.

OCCIPITAL LYMPH NODES

Location: Located at the junction between the back of the head and
neck.
Lymphatic drainage: Scalp and head.
Enlarged in infection of scalp &Syphilis.
SUBMENTAL LYMPHNODE
Located below the chin.
Lymphatic drainage: Lower lip, floor of mouth, teeth, submental
salivary gland, tip of tongue, skin of cheek.
Roll the fingers below and lingual to the chin, against the
mylohyoid muscle.
Enlarged in disorders in the anterior portion of the mouth and the
lower lip.
SUB MANDIBULAR LYMPH NODE

Located medial to the inferior border of

mandible.
Lymphatic drainage: Tongue, submaxillary
gland, lips and mouth.
Roll your fingers against inner surface of
Mandible with patient's head gently tilted
towards one side
Enlarged in Infections of head, neck,
sinuses, ears, eyes, Scalp, pharynx.
INTRAORAL EXAMINATION
1. SOFT TISSUE 2. Hard tissue
• labial and buccal mucosa • Teeth present
• Lip •Teeth missing
• Floor of mouth •Carious teeth
• Tongue •Mobiltity
• Gingiva •Occlusion
• Salivary glands
LABIAL & BUCCAL MUCOSA
•It should be checked for any
Ulcer, White patch or neoplasia, Pigmentation

LIP
•Checked for
•Color, Texture,
• Any surface irregularities,
• Palpate upper lip and lower lip for any thickening (induration) or
swelling.
• Angular or vertical fissures. Cleft lip, Lip pits,
•Ulcers-Nodules, Keratotic plaque and scars.
FLOOR OF MOUTH
•It should be checked for:-
•Any swellings
•RANULA: appears as unilateral bluish translucent cyst over wharton's duct.
•ANKYLOGLOSSIA: fusion between tongue and floor of the mouth
• CARCINOMAS are common in the floor of the mouth.
•Ulcers or red and white patches.

TONGUE
•Examination is done to check for:-
•Volume of tongue- enlarged tongue due to lymphangioma, hemangioma &
neurofibroma.
•Integrity of papilla
•Any cracks or fissures , swelling or ulcers
•Presence of tongue tie.
 HARD TISSUE
TEETH PRESENT
•Size
• Color
•structural changes of teeth
•Eruption status of teeth
•Retained deciduous teeth
•Any trauma to tooth

TEETH MISSING
•Reason for missing teeth/tooth
•History of removal
•Co-relation of the missing teeth às an oral manifestation of a systemic disease
or genetic abnormality
CARIOUS TEETH
The primary examination technique for evaluating the teeth
Include:
Visual inspection,
Probing
Percussion
Transillumination

Basic tools required are:

A good light source,
A mirror
A sharp explorer and
An air syringe are the most basic tools required
RADIOGRAPHIC METHODS

BITE WING RADIOGRAPHY

To diagnose proximal caries

INTRA ORAL PERI APICAL RADIOGRAPH

To detect the extent of occlusal caries.
To assess the periapical area

DISADVANTAGES:
A. To be radiographicaly visibie, mineral Ioss should be more than 20-
30percent
OTHER METHODS:
Fibro Optic Transilluminator.
Digital Fibro Optic Transilluminator.
Fluorescence (acid dissolution of structure).
Use of caries detector dye e.g. silver nitrate, methylTed and alizarin stain to detect
caries by color change).
MOBILITY OF TEETH:
To evaluate the integrity of the attachment apparatus surrounding the teeth.
•Test is carried out by moving the tooth laterally in the socket or preferably in the handles
between two instruments.

TYPES:
PATHOLOGIC MOVEMENT: it results from inflammatory process, para functional habits.
ADAPTIVE MOBILITY: occurs due to anatomic factors such as short roots or poor crown to root
ratio.

GRADES OF MOBILITY: (GLICKMAN'SCLASSIFICATION)

No detectable movement when force is applied other than what is considered normal
(physiologic) motion.
GRADEI -movement of tooth about I mm in bucco-lingual direction
GRADE-II:movement of tooth more than mm 1 bucco-lingual direction and labio palatal
direction.
GRADE III: depression of tooth in the socket
PROVISIONAL DIAGNOSIS

•It is also called tentative diagnosis or working diagnosis.

• It is formed after evaluating the case history & performing the physical examination.

DIEFERENTIAL DIAGNOSIS
The process of listing out of 2 or more diseases having similar signs and symptoms of which
only one could be attributed to the patient's suffering
A final diagnosis is only possible after carrying out further investigations.
INVESTIGATIONS
CHAIR SIDE ROUTINE COMPLETE
INVESTIGATIONS: HEMOGRAM
•Pulp Vitality Tests •Hemoglobin,
•Red Cell Count
•Percussion Tests
•Wbc
•Cytology •Platelet Counts
•Aspiration •Total Leukocyte Count
•Total Difeerential Count
•Bleeding Time
•Clotting Time
•Calcium.
PERCUSSION TEST:
to evaluate the status of theperiodontium surrounding a tooth
TYPES:
•Vertical Percussion Test- positive indicates periapical pathology
•Horizontal Percussiontest- positive indicates periodontium
• associated problems
RADIOLOGICAL INVESTIGATIONS
INTRAORAL PROJECTICONS:-
•Intra-Oral Periapical,
•Occlusal
•Bitewing views.
EXTRAORAL PROJECTIONS:
•OPG
•PA view of skull and jaws
•AP viewPNS view
•SUBMENTOVERTEX view.
•TMJ views.
FINAL DIAGNOSIS:

•The final diagnosis can usually be reached following chronologic

organization and critical evaluation of the information obtained from the,
patient history,
physical examination and
the result of radiological and laboratory examination.
•The diagnosis usually identifies the diagnosis for the patient primary
Complaint first, with subsidiary diagnosis of concurrent problems.
TREATMENT PLAN
•The formulation of treatment plan will depend on both knowledge &
experience of a competent clinician and nature and extent of treatment
facilities available
•Evaluation of any special risks posed by the compromised medical
status in the circumstance of the planned anesthetic diagnostic or
Surgical procedure.
•Medical assessment is also needed to identify the need of medical
consultation and to recognize significant deviation from normal health
status that may affect dental management.
Systemic phase:
Premedication (antibiotic prophylaxis)

Preventive phase:
Caries risk assessment.- Assessment of preventive measures like
fluoride application, pit and fissure sealants, diet counseling.

Preparatory phase:
a) Behavior management.
b) Oral prophylaxis.
c) Caries control.
d) Orthodontic consultation.
e) Oral surgery.
f) Endodontic therapy
 Corrective phase:
a) Restorative dentistry.
b) Prosthetic Rehabilitation.
c) Early orthodontic intervention.

Maintenance phase:
Frequency depends on child's initial needs, success of therapy,
parental cooperation