Case HistoryBy

Dr.Mohamed Barakat

Introduction

*In general , and simple words , case history is nothing but an evaluation of the patient prior to dental treatment

*it is a professional conversation to communicate with the patient as concern symptoms, signs , and nature of the patient illness

Introduction

*In general , and simple words , case history is nothing but an evaluation of the patient prior to dental treatment

*it is a professional conversation to communicate with the patient as concern symptoms, signs , and nature of the patient illness

Case HistoryBy

Dr.Mohamed Barakat

A case history is important in order to reach up-:

* establish the diagnosis.

* detect an medical background.

* search for other systemic problem.

* manage emergencies.

* reach up the final and effective.

working treatment plan.

Steps of Diagnostic procedures

•1 )taking and recording the case history . •2 )physical examination.

•3 )relevant investigation to help . reaching the diagnosis.

•4 )establishing the diagnosis. •5 )medical risk assessment of the

• case. •6 )outlining the treatment plan.

•7 )prognosis of the case. •8 )final working plan

Methods Of Recording The Case History

* Traditional approach through questionnaire * Newer techniques of case history recording as:- . Computer data gathering . interviewing (problem oriented records) (POR) . . CD methods . . Other methods

Sequence of Case Recording and Evaluation

• .Statistics.

• .Chief Complaint.

• .History of chief complaint.

• .Medical History.

• .Past dental History .

• .Family History.

• .General Examination

• .Extra Oral Examination.

• .Intra Oral Examination.

• .Provisional Diagnosis.

• .Prognosis.

• .Investigations.

• .Final Diagnosis• .Working Treatment.

Statistics

*Defined being a systemic approach to collect all data information to vital events e.g live , birth ,death , social

structures and legalization. * Patient registration number - :

. Social security number . Billing purposes

. Insurance . Medico legal aspect (liability)

* Date: . For reference

. For records * Name :

. For identification . Communication

. Patient records / Statistics * Age / Sex:

. Treatment planning . Behavior management techniques

. Statistics

•

Age- :

•*Age is sometime / most of the time

• is an important marker and predilection of certain diseases at

• different age levels. • e.g. common disease at birth

• . Cleft palate / hair lips• . Hemophilia

• . Tongue tie ……. etc•

• •

• *Diseases occur in children and adults:

• . Juvenile periodontitis • . Scarlet fever

• . Mumps• . Measles

• •

• *Diseases commonly occur in adults: •. Attrition / Abrasion

•. periodontitis / Mobility •. Impacted wisdom

• . Pulp stones • . Root resorption

• •.

Sex:

•Knowing the sex of the patient is important for:

•*Diagnosis of different types of diseases having sex predilection to sex:

•1)Diseases more common to female-: • . Iron deficiency anemia

•. Juvenile periodontal disease• . Oesteoporosis

• Diseases more common to males:

• . Oral carcinoma• . Hemophilia

• . Attrition

• . Diabetes mellitus

•* Education: • . Socioeconomic status

• . I.Q for effective communication• . Attitude towards general oral

• health care

• •

•

• *Address: • . Socioeconomic level

. Prevalence of diseases/epidemic . Records

. To follow up case . Vaccination

• •

• *Occupation: • . Assessing socioeconomic status• . predilection of some diseases to

• occupations • . Hepatitis B- which more likely

• related to dentists / surgeons

• *Religion: • . Predilection of diseases to

• specific• religion

• . Festive periods which religious

• people seams reluctant to

• treatment procedures

Chief complaint

•* Chief complaint is established thru • asking the patient to describe the

• problem for which he / she came up • for, seeking help for treatment.

• * Chief complaint should be recorded• in patient’s own words as much as

• possible wit NO leading questions• or technical language .

• * The chief complaint aids and helps

• to get the diagnosis of the case as

• a first priority.

• **Common chief complaints• . Pain

• . Burning sensation • . Bleeding

• . Lose of teeth / Mobility• . Recent occlusal problem

• . Delayed teeth eruption • . Xerostomia

• . Swelling• . Halitosis/ Bad taste

• . Parasthesia / anaesthesia

• **History of Present illness• Helps the patient to express his • own words describing his present• systemic by possible questionnaire

• about his / her symptoms• e.g: .

• . when the problem start.• . what did you noticed first

• . Did you have problems or symptoms • related to this complaint

• . Did you have those symptoms before • . Have you been through any tests

• before .• . have you consulted any doctor before

• . what have you done to treat this problem

• In general symptoms can be verified;

• as follow-:

• * Mode of onset

• * Cause of onset

• * Duration

• * Progress and referred pan• * Remission and exacerbation

• * Treatment• * Negative history

Past Dental history• Past dental history is important to:

• * Detect the general attitude of the • patient as concern dentistry/dentist.• * Detect patient awareness about oral

• health. • * Detect any previous bad experience

• about dental treatment and / also his• behavior against his dentist.

• * signifying the patient’s previous • treatment procedures and his attitude

• towards his present situation .•

Past medical history • *Recording of past medical history including • history of past illness , hospitalization ,and

• evaluation of his general health. • *All disease experienced by the patient

• should be recorded in chronologic order. • *patient should be evaluated for-:

• . Cardiovascular disease • . Endocrine disease

• . Hematologic diseases• . Allergic reactions

• . Neurologic diseases• . Joint disorders.

• . Kidney , urinary ,and gastrointestinal diseases • . Respiratory Diseases

Personal History • THIS INCLUDES:

• * Oral Habits.

•* Oral Hygiene.

• * Family Histology.

•* Adverse Habits .

•* ORAL HABITS: • . Mouth Breathing

• . Upper respiratory Track Problem • . Xerostomia

• . Finger / Thumb Sucking• . Nail Biting

• . Tongue Thrusting • Those habits my be accompanied by-:

• . Open bite / Truma from occlusion • . Deep overbite/Over jet

• . Protrusion of anterior teeth • . Generalized marginal gingivitis

• Adverse Habits: • . Smoking and tobacco chewing

• . Alcohol consumption

• **Family History:

• Family history is important to assess for • any disease that having a family

Background •( inherited pattern ) e.g. hemophilia ,

diabetes, • hypertension ,and / also to detect any

• particular disease among the family

•

General Examination

• *This includes the vital signs :

• . Pulse

• . Blood pressure

• . Body temperature• . Respiration

• . Cyanosis

Extra Oral Examination

• * Skin (colour,texture,odema , pigmentation )

• * Facial Symmetry• * TMJ Disorder

• * Lymph Nodes

• * Eye , Nose , and Ear

Intra Oral Examination

• **Soft Tissue•. Tongue (volume, integrity,cracks,ulcers

• fissures, tongue tie)

• . Palate (cleft , perforation, ulceration )

• . Floor of the mouth• . Buccal Mucosa

• . Parotid gland • . Submandibular / Sublingual Gland

• ** GINGIVA• . Color

• . Pigmentation• . Contour ( scalloped)

• . Shape• . Size

• . Shape• . Consistency (firm, resilient, soft)

• . Texture (stippled )• . Size (hypertrophy / hyperplasia )• . Bleeding tendency ( on probing)

• **Periodondium•

• * Plaque• * Calculus

• * Pocketing (supra/subgincival)• * Tooth mobility

Furcation involvement•* progression of the inflammatory periodontal

• diseases may extend to involve bifurcation and• trifurcation multirooted tooth area is called

• ( Furcation involvement)• * Grades:

• . Grade 1: incipient stage, affects soft tissue• with suprabony pocket

• . Grade 2: lesion is called “cul-de- sac” having • definite horizontal resorption

• . Grade 3: bone is destroyed and detached at• area of furcation with a free pass of the

• probe thru furcation area• . Grade 4: complete destruction of interdental bone

and• soft tissue

•

Hard tissue examination•

** TEETH•

• . Carious and filled teeth• . Missing rotated teeth

• . Milky , mixed and permanent teeth• . Flurosis , root

• . Congenital deformities• . Attrition: wear off due to toot to

• tooth contact• . Erosion: loss of tooth surface by chemical

• or electrochemical agent• . Abrasion: Friction between tooth and exogenous

• agent•

•

Provisional Diagnosis• * Provisional diagnosis is also called tentative

• diagnosis or working diagnosis after • evaluating case history and performing

• physical examination• * provisional diagnosis is just temporary one

• * Differential Diagnosis should be kept in • mind to reach out the exact and specific

• diagnosis • * Final Diagnosis may be possible “ ONLY“

• after carrying out further investigation, • and laboratory investigations

Final Diagnosis• Final diagnosis can be reached up by

chronologic organization and critical • evaluation of the information that • obtained from patients case history

• and physical examination which must• be supported by radiographic and / also

• laboratory investigations.

Treatment Plan

Emergency phase:

• * This is the first and preliminary phase of treatment plan

• • * Emergency complication is the first

• to be treated and managed

Preventive phase

• This is the second line of treatment involving protection and prevention of high risk factor

Preparatory Phase

•Oral prophylaxis includes .. caries

• control, endodontic treatment,as well

• as extraction , periodontal surgeries

• and orthodontic consultation

Corrective Phase

•Permanent restorations and / also•prosthetic replacement, crowns and

•bridge construction and space maintainer

•Maintenance phase• Follow up phase

•

PROGNOSIS

• Prognosis defined as “fate of the Disease” e.g. the outcome of the disease based on general knowledge of the pathogenesis of the disease and the presence of risk factor and / also

•The systemic background of the disease .

• Prognosis should be discussed and explained to the patient as concern his

awareness and his considerations . •Then the final treatment protocol is now

easily determined

END