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