case history, examination, diagnosis and treatment
TRANSCRIPT
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CASE HISTORY, CASE HISTORY, EXAMINATION, EXAMINATION, DIAGNOSIS AND DIAGNOSIS AND
TREATMENT PLANINGTREATMENT PLANING
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DefinitionCASE HISTORY
Is defined as planned professional conversation that enables The patient to communicate his symptoms, fears to clinicianSo that nature of patients real or suspected illness & mentalAttitude may be determined.
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OBJECTIVES OF CASE HISTORY
• Tentative diagnosis • Systemic factor that might affect
formulation of a diagnosis• Any systemic condition that requires
special precaution prior to/ during .
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ARMAMENTARIUM REQUIRED
• MOUTH MIRROR• EXPLORER• TWEEZER• PERIODONTAL PROBE• COTTON ROLLS
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Vital Statistics•Date
•Hospital /Case / OP no.•Name
•Age, Sex, Ethnic group•Class & School
•Address , Phone no.•Parent’s occupation
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CHIEF
COMPLAINT
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History of present illness
Past medical history
Past dental history
Social and family history
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FRANKL BEHAVIOR RATING SCALE
Rating Frankl behavior rating Wright modification
1 Definitely Negative: Refusal of treatment, forceful crying, fearfulness, or any other overt evidence of extreme negativism.
( - - )
2 Negative: Reluctance to accept treatment, uncooperativeness, some evidence of negative attitude but not pronounced
( - )
3 Positive: Acceptance of treatment; cautious behavior at times; willingness to comply with the dentist, at times with reservation, but patient follows the dentist'sdirections cooperatively.
( + )
4 Definitely Positive: Good rapport with the dentist, interest in the dental procedures, laughter andenjoyment.
( + +)
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PRENATAL HISTORY
Drug intake during pregnancy
Illness during Pregnancy
NATAL HISTORY
Full term / Premature birth
Type of delivery
Birth cry
Feeding
Conginital abnormality if any
Natal teeth
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POST NATAL HISTORY
Feeding
Milestones
Vaccination
Major illness during childhood
History of hospitalisation
History of drug intake during childhood
DIET HISTORY
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GENERAL PHYSICAL ASSESSMENT
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dolicocephalic Mesocephalic Brachychephalic
SHAPE OF HEAD
Females Males Scientific term< 75 < 75.9 dolichocephalic
75 to 83 76 to 81 mesaticephalic> 83 > 81.1 brachycephalic
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RING WORM INFECTION
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THUMBSUCKING
HANDS
CLUBBING OF FINGERS
THUMBSUCKINGKOILONYCHIA
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EXTRA ORAL EXAMINATION
Facial symmetry
TMJ examination
Lymph nodes
Profile
Lip
Swallowing
Speech SUB-MANDIBULAR
CERVICAL
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LIPS
ANOMALIES
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NOSE
RUNNING NOSE
EPISTAXIS SADDLE NOSE
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PERSONAL HISTORY
Other habits
Oral hygiene appraisal
INTRA ORAL EXAMINATION
SOFT TISSUE EXAMINATION
lips, cheek, vestibule, tongue, floor of the mouth, palate
Orifices of salivary gland
Tonsils
Gingiva
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BUCCAL MUCOSA
ULCER AMALGAM TATOO
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FRENAL ATTACHMENT
LOWERUPPER
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TONGUE
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SOFT & HARD PALATE
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HARD TISSUE EXAMINATION
Teeth present
Occlusion
Overjet
Overbite
Crossbite
Crowding
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Deciduous dentition occlusion
• Occlusal relation– Flush terminal plane
• Distal surface of U/L
• Favourable to guide permanent molars
• 59.1%
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Deciduous dentition: Development of occlusion
• Mesial step– Distal surface of
lower more mesial to upper
– Favourable
– 19.1%
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Deciduous dentition: Development of occlusion
• Distal step– Distal surface of
lower more distal to upper
– Sucking habits
– Prognostically unfavourable
– 4.8%
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SIZE & SHAPE OF TEETH
MACRODONTIATRUE & RELATIVEMICRODONTIA
TRUE & RELATIVESHAPE
SCREW DRIVER, CONE SHAPED,
GEMINATION,FUSION, SUBMERGED TEETH
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COLOR OF TEETH
EXTRINSICGREENBLACK
BROWN
INTRINSICGREENBROWNYELLOWISHBROWN
RED / PINK
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EXTRINSIC STAINS
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INTRINSIC STAINS
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CARIES
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DIAGNOSIS ---IT IS DEFINED – The art or act of identifying a disease from its signs &
symptoms
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PROVISIONAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
INVESTIGATIONS
FINAL DIAGNOSIS
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INVESTIGATIONAIDS
RadiographsCeph
Handwrist etcStudy models Photographs Hematology screening
Histopathological examination
Microbiological investigations
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TREATMENT PLAN OBJECTIVES OF TREATMENT : ELIMINATE INFECTIONREPAIR & RETAIN ALL PRIMARY TEETH UNTILL NORMAL EXFOLIATION.RECOGNIZE & IF POSSIBLE CORRECT ANY VARIATION FROM NORMAL.PREVENT & INTERCEPT ANY INCIEPIENT MAL-OCCLUSION.EDUCATE FAMILIES TO CONTROL & PREVENT DISEASE.
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TREATMENT PLAN
Step 1 – Emergency phase Step 2 - Immediate phase Step 3 - Plaque control program Step 4 – Restorative phase Step 5 - Orthodontics, Prosthodontics, Oral surgical phase Step 6 - Evaluvation, maintenance and follow up
TREATMENT PROVIDED:RECALLSIGNATURE