ByBlessin mathew

CASE HISTORY

Arrive at a tentative diagnosis of patients chief complaint

Written recordProtection from possible disease

contactFuture referenceServes as legal evidence

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SIGNIFICANCE

“ Case history is defined as a planned professional conversation, which enables

the patient communicate his/her symptoms, feelings and fears to the

clinician and recorded in the patient’s own words so as to obtain an insight into the nature of patients illness and his/her

attitudes to them.”

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DEFINITION

Direct interviewPrinted questionnairePrinted check list of information

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METHODS

GUIDELINES FOR TAKING CASE HISTORY •Questions should be open ended

(encourage a detailed explanation). No ‘yes’ or ‘no’ questions•Avoid leading questions•The questions should be clear and should touch various aspects of the disease•Symptoms are described by patient should record in his own words•Doctor should be an empathetic listener

DateO.P. numberNameAgeDate of birthSexAddressRaceReligionEducationOccupationIncome

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PROFORMA

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Contd…Chief complaintHistory of present

illness Medical history Dental historyFamily historyPersonal historyGeneral ExaminationExtra oral ExaminationIntra oral examination

• Provisional diagnosis• Differential diagnosis• Investigations• Final diagnosis• Treatment plan

1.Date• Records the time the patient reported

and can be referred back to , during the following visits

2.O.P. number• To assemble the details of treatment in

follow up visits• Billing• Legal considerations

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SIGNIFICANCE OF FORMAT

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3.Name• Recognize the patient• Develops rapport and healthy

communication between patient and physician

• To maintain records

4. Age• Indicates vital statistics• Age related diseases

Primary Herpes gingivostomatitis (6 mnths-6yrs)Nursing caries in pre-school age groupAttrition , Abrasion , Gingival

recession,Leucoplakia etc.(Adults and Old age)• Surgery and treatment planning• Behavioral management technique• For determining dose

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5. SexCertain diseases are more common in certain

sex Males: Leukoplakia,Carcinoma of buccal

mucosa, Herpes simplex, Smokers palate etc.Females:

Pubertal gingivitis, Juvenile periodontitis etc.

AestheticsEmotionsDoseGifting

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6. Address• Communication purpose• Modifying appointments• Geographical prevalence of dental or oral diseases

Dental caries common in modern industrialized areas Periodontal diseases common in rural areas Dental caries & Mottled enamel depend on fluoride

content of domestic water Habits vary according to residence

• Geographical prevalence of medical diseases Filariasis common in Orissa Leprosy in West Bengal

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7. Race• Some diseases are common in some

races• Oral hygiene practices differ• Tooth mutilations practiced in certain

races

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8.Religion • During Ramzan and other fasting dental

treatments like extractions should be avoided

• Be careful while prescribing medicines during fasting

• Dentist should not force the muslim patients to use mouthwash with excessive alcohol content

• Jains do believe that killing microbes is a sin and they wont brush their teeth because of this.

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9. Occupation

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DISEASE OCCUPATION

Attrition Workers who expose to abrasive dust

Abrasion Carpenters, Tailors

Erosion Sandblasters

Hepatitis BDentists,surgeons,blood bank personal

Gingival staining

Persons work with Lead, Bismuth

• To know about the nourishment and

payment status of the patient

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10.Socio economic status

1.Chief complaint

Always record in patient’s own words

Mention only the chief problem of the

present day in the order of severity

Follow the chronological order

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TAKING AND RECORDING HISTORY

• it should indicate the severity and urgency of the problem

• detailed history of the chief complaint-

eg; dental pain

-quality,-dull, sharp ;throbbing ,constant

-quantity, severity, and frequency

-location-localized ,diffuse ,referred, radiating.

-duration of complaint

-onset; spontaneous, on stimulation, intermittent

-Aggravated by: cold, heat, palpation, percussion

- Relieved by ;cold, heat, any medication ,sleep 17

2)History of the present illness

Check list of medical history -Anemia

-Bleeding disorders

-Cardio respiratory disorders

-Drug treatment and allergies

-Endocrine disorders

-Fits and faints

-Gastrointestinal disorders

-Hospital admissions and surgeries

-Infections, Injuries

-Jaundice

-Kidney disease

-Asthma 18

3.Medical history

History of dental treatment undergone by

the patient ,along with patients experience

before, during and after the dental

treatment

History of complications experienced by the

patient

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4.Dental history

Provides information about the possibility of infective contact as in tuberculosis.

Record of illness with unusual hereditary tendencies like hemophilia is helpful.

Serious medical problems in immediate family members should be listed.

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5.Family history

Disorders with genetic or environmental basis (cancer, cardiovascular disease. Allergy, asthma, renal disease, diabetes, sequential anemia) should be addressed

There are also several inherited anomalies and abnormalities that can affect oral cavity .Eg:congenital missing of lateral incisors , amelogenesis imperfecta, ectodermal dysplasia , cleft lip and palate.

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6.Personal history1.Personal habits:

They include smoking use of smokeless tobacco, pan chewing , alcohol consumption etc.

In all these cases number ,frequency and duration is considered

A . Useful and harmful habitsUseful habitsIncludes habits essential for normal function

like proper positioning of tongue ,respiration and normal deglutition.

Harmful habitsIncludes habits that have a deleterious effect

on the teeth and supporting structures like thumb sucking, tongue thrusting etc

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2.Habits related to oral cavity-classifi cation

Empty habitsThese are habits that are not associated

with any deep rooted psychological problems.

Meaningful habitsThese are habits that have a

psychological bearing.

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B.Empty and meaningful habits

Pressure habits• Includes sucking habits such as

thumb sucking, lip sucking, finger sucking, and also tongue thrusting.

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C.Pressure non pressure and biting habits

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FINGER SUCKING

TOUNGE THRUSHING

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Non pressure habits•Habits which do not apply a direct force on the teeth or its supporting structures Eg. Mouth breathing.

Biting habits• Includes habit such as nail biting, pencil biting, and lip biting.

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NAIL BITING

Compulsive habitsThese are deep rooted habits that have

acquired a fixation in the child to the extent that the child retreats to the habit whenever his security is threatened by events which occur around him. The child tends to suffer increased anxiety when attempts are made to correct the habit.

Non compulsive habitsThey are habits that are easily learned and

dropped as the child matures.

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D.Compulsive and non compulsive habits

1.Type of cleaning2.Type of toothbrush3.Method of cleaning4.Materials used5.Frequency of cleaning6.Time of cleaning7.Frequency of changing toothbrush8.Use of other oral hygiene aids

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3.Oral hygiene practices

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Interdental cleaning aidsSUPER FLOSS FLOSS HOLDERS

DENTAL TAPE FLOSS

DOWN

FLOSS UP

FLOSS IN HANDS

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INTERDENTAL BRUSHING INTERDENTAL BRUSHING

END TUFT BRUSH

INTERDENTAL STICKS

Source of waterType of diet: vegetarian, mixed, spicyDietary chart; includes staple diet and nutrition ,sugar exposure Sugar consumption: includes type,

frequency , time of intake, form and consistency

Soft refined food: adheres tenaciously to teeth- leads to dental cariesCoarse diet- attrition of teeth

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4.Dietary habits

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Contd…Increased carbohydrate diet: dental caries increasesIncreased phosphate diet: dental caries preventionDiet deficient in vitamin: enamel hypoplasiaDeficiency of ca and P during teeth formation:

enamel hypoplasia, and defects of dentin.Vitamin D content: reduces caries incidence.Fluoride content: influence caries process.

Tobacco preparation, consumption such as khaini, Manipuri, tobacco, mishi, pan, smut, zandra etc lead to B P variation and also cause staining.

Smoking habits such as bidi, chutta, cigarette etc may lead to cancers that includes oral cavity and lung.

Drinking alcohol, charas, ganja, marijuana, etc may lead to liver toxicity.

Ask duration, frequency, of habit35

7.Addiction

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DIFFERENT FORMS OF TOBACCO

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PIPECIGAR

CIGARETTE

BIDI

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GOZA ,HOOK-AH ,HUBBLE-BUBBLE

SMOKELESS FORMS

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American red man $ Danish Oliver twist

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Tobacco sliced into flakes

Caries, arteriosclerotic heart disease acute appendicitis is more common in middle and high social status individuals.

Periodontitis,tuberculosis, anemia, due to malnourishment is more common in low status individual.

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8.Social status

If he/ she is taking oral contraceptivesObstetric history , miscarriage , therapeutic

abortion.Endocrine diseases accompanied by

abnormalities of pregnancy, labour, lactation.Cardiac failure due to circulatory demand of

pregnancy and labour.Avoid dental treatment in first trimester of

pregnancy.The best time for dental treatment in

pregnant lady is 2nd trimester. 42

9.Menstrual and obstetric history

Having multiple partners may result in sexually transmitted diseases like syphilis which has got significant oral manifestation

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10.Domestic and marital relationship

Significance: to ascertain the possibility of acquiring disease from any epidemic area in which he has travelled .it helps in prevention and early identification of disease

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11.Travel abroad

General examinationa) Height and weight

b) Gait : The way a person walksSpastic gait , Hemiplegic gait , High stepping gait ,Festinant gait , Waddling gait, Gait of cerebellar ataxia

c) Posture : The way a person stands

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EXAMINATION OF THE PATIENT

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d) Body buildAesthetic:

Thin physique- Possess narrow dental archesPlethoric:

Obese persons-Possess large square dental arches

Athletic :Neither obese nor thin-Possess normal sized

dental archesSheldon’s classification

Ectomorphic –Tall and thin physiqueMesomorphic –Average physiqueEndomorphic –Short and obese physique

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MESOMORPH

ENDOMORPHECTOMORPH

Vital signs are; Respiratory rate Temperature PulseBlood pressure

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Vital signs

Respiratory rateNormal-14-20 breathes per minuteRapid breathing- tachypnea, occurs during

fever, shock ,hypoxia, cerebral disturbances, metabolic disturbances etc.

Bradypnoea-slow and deep respiration seen in cerebral compression.

Paralysis of soft palate causes an inspiratory snoring noise

Expiratory wheezing is heard in bronchitis and asthma.

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Recorded when systemic response secondary to dental infection is suspected

Normal oral temperature-37 degree Celsius

Recent drinking of cold or hot liquid or mouth breathing in a very warm or cold air may alter the oral temperature.

Severe oral infections alter local temperature in mouth without causing fever.

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Temperature

• Normal-60-100 beats per minute• Grossly irregular pulse indicates myocardial disease• Important index of severity of illness abnormalities of heart and vascular system E g; hypertension, hypotension ,

shock , fever etc.

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Pulse

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Blood pressureNormal-systolic 120 to

140 mm Hg and diastolic 80mm of Hg

Accidental intravascular injection or rapid absorption of LA containing epinephrine may cause rise in BP.

BP should be checked before starting dental treatment.

Varies with emotions , exercise, male, alcohol, tobacco, bladder distention, temperature and pain.

Abnormal paleness of skin due to reduced blood flow or lack of normal pigments.

Associated with indoor mode of life, indicate shock, anemia , cancer, etc.

Sites; oral mucosa , tongue, conjunctiva , nail bed, palms and soles.

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Pallor

An icteric tint of skin due to bilirubin Varies from faint yellow to dark olive greenish color.

Site; sclera of eyeball, nail bed, lobule of ear , tip of nose , undersurface of tongue.

First structure involved; sclera.Oral manifestations of jaundice;

-Icterus of oral mucosa on palate and sublingual area

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Icterus

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It is the enlargement of distal segment of fingers and toes due to increase in soft tissue

Causes : disorders of heart ,lungs, GIT etc or may be congenital or hereditary

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Clubbing of fingers and toes

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Negative Schamroth's test for clubbing

Bluish discoloration of skin and mucous membrane due to increased amount of reduced hemoglobin in blood

May be physiological or pathological3 types

Peripheral-on lips, nails, tip of nose, ear lobuleCentral-undersurface of tongue , mucous

membrane of oral cavityMixed-combination of both

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Cyanosis

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Swelling of lymph nodesCauses infiltration of inflammatory cells in

infectionPrimary malignancy that cause

proliferation of lymphocytesInfiltration by metastatic malignant cells

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Lymphadenopathy

Cervical lymphadenopathy

Edema-swelling(Greek)Defined as abnormal and excessive

accumulation of fluid in the interstitial tissue spaces and serous cavities

Sites of edema-legs , thigh , back, face, and limbs

Sclera edema common in bedridden patients

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Edema

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Extra oral examination

1.Mesocephlic : average shape of head, they possess normal dental arches

2.Dolicocephalic:long and narrow head, narrow dental arches

3.Brachycephalic: broad and short head, broad dental arches

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Shape of head

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Mesocephalic

Dolicocephalic

Brachycephalic

Mesofacial: average or normal face formBrachyfacial: broad and short faceDolichofacial: long and narrow face

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Facial form

Examined to determine disproportions of face in transverse and vertical planes

Some degree of asymmetry is considered normal

Gross facial asymmetry can occur as a result of:-

1. Congenital defect 2. Hemi- facial atrophy/hypertrophy. 3. Unilateral condylar ankylosis and

hyperplasia.

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Assesment of facial symmetry

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Examined by viewing patient from side.3 types

StraightConvexconcave

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Facial profile

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Well propotioned face can be divided into 3 equal thirds using 4 horizondal planes.

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Evaluation of facial proportion

Classification

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Examination of lips

Nose size: normally 1/3rd of total facial heightNasal contour: can be straight , convex , or

crooked as a result of injuries.Nostrils: they are oval and bilaterally

symmetrical

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Examination of nose

Mentolabial sulcus Mentalis activityChin position and prominenceNasolabial angle are recorded

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Examination of chin

Patient should be checked for TMJ disordersMaximum interincisal opening-40-45 mmNormal lateral mandibular jaw

movement-8-10 mmJoint is checked for tenderness

clicking, deviation

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TMJ

Usually examined lymph nodes are -Submandibular and submental

-It should be palpated for swelling and tenderness.

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Lymph nodes

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•Parotid, Submandibular and Submental lymph nodes are examined

Salivary glands and muscles of mastication

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