This document outlines the process and components of taking a thorough case history for a dental patient. It discusses the importance of collecting vital statistics, chief complaints, medical history, dental history, and performing examinations to establish diagnoses and effective treatment plans. Key elements that should be included are a patient's name, age, gender, address, medical conditions, dental history, oral hygiene, habits, and examinations of extra-oral and intra-oral soft tissues. Collecting a comprehensive case history is essential for understanding a patient's full health picture and providing appropriate care.
This document outlines the process and components of taking a thorough case history for a dental patient. It discusses the importance of collecting vital statistics, chief complaints, medical history, dental history, and performing examinations to establish diagnoses and effective treatment plans. Key elements that should be included are a patient's name, age, gender, address, medical conditions, dental history, oral hygiene, habits, and examinations of extra-oral and intra-oral soft tissues. Collecting a comprehensive case history is essential for understanding a patient's full health picture and providing appropriate care.
This document outlines the process and components of taking a thorough case history for a dental patient. It discusses the importance of collecting vital statistics, chief complaints, medical history, dental history, and performing examinations to establish diagnoses and effective treatment plans. Key elements that should be included are a patient's name, age, gender, address, medical conditions, dental history, oral hygiene, habits, and examinations of extra-oral and intra-oral soft tissues. Collecting a comprehensive case history is essential for understanding a patient's full health picture and providing appropriate care.
THE HEAD OF THE DEPARTMENT Presented By:- Mandeep Kaur BDS Prof- 4 th
Roll No- 33
INTRODUCTION o Case history is defined as classic form of documentation which ranges from clinical sketches to highly detailed and extended accounts that help in arriving at a diagnosis and formulation of treatment plan of the person under study.
o In general, a case history is nothing but an evaluation of the patient prior to the dental treatment.
o A case history is of immense value in the following ways: 1) To establish the diagnosis 2) To detect any medical or dental problem 3) Evaluation of other systemic problems 4) Discovery of communicable diseases 5) Management of emergencies 6) For effective treatment planning SEQUENCE OF CASE RECORDING AND EVALUATION Vital Statistics Chief Complaint History of Present Illness Past Dental History Past Medical History Family History Health History Pre- natal History Birth History Post- natal History
Personal History General Examination Extra-oral Examination Intra- oral Examination Provisional Diagnosis Differential Diagnosis Investigations Diagnostic Aids Final Diagnosis Treatment Planning VITAL STATISTICS It is defined as a systemic approach to collect and compile, in numerical form, the information related to vital events, live births, deaths, recognition, social structure and legislation.
Uses Maintain records. To create administrative standard of health activities. To direct or maintain control during execution of programs. To disseminate reliable information on health situation and programs. Date : useful for- Record maintenance Reference
Hospital/Case Number : useful for- Record maintenance Billing Puposes Legal Considerations
Name : useful for- Identification Verbal Communication Establishing a Rapport with the patient Psychological Benefit Record Maintenance
Age : useful for- Diagnosis Treatment Planning Behavior management techniques
The chronological age (date of birth) should be noted to know whether growth and development is normal or not. Occurrence of certain diseases correlated with age : e.g. Primary herpetic gingivostomatitis- from 6months 6 years Nursing caries- Preschool age group
Sex : Girls mature earlier than boys - require treatment earlier. Some diseases shows sex predilection e.g. Anorexia - females Hemophilia - males Pubertal gingivitis Adolescent females Education : It determines- 1) Socio-economic status 2) I.Q . for effective communication
Address : 1) For communication 2) To assess Socio-economic status 3) To chart out appointments for patients from distant places 4) To know endemic status of disease in the locality Socio-economic status : To know about the 1) nourishment 2) hygiene 3) payment capacity of the patient
CHIEF COMPLAINT The chief complaint is established by asking the patient to describe the problem for which he/she is seeking help/ treatment. It is recorded in patients own words. It is recorded in chronological order of their appearance and their order of severity. HISTORY OF PRESENT ILLNESS It should indicate the severity and urgency of the problem. Several factors need to be evaluated regarding the chief complaint : 1) The Onset 2) The Duration 3) The Location 4) The Quantity, Quality, Severity and Frequency Of occurrence 5) Aggravating and relieving factors 6) Associated Symptoms
MEDICAL HISTORY Record of past medical history includes history of past illnesses, hospitalizations and evaluation of the patients health based on the history provided by the patient.
All the diseases suffered by the patient should be recorded in chronological order.
Patient should be evaluated for following diseases : - Cardiovascular - Respiratory - Gastrointestinal - Genitourinary - Endocrine - Neurological - Hematological - Allergic reactions PAST DENTAL HISTORY Gives attitude of the patient towards the dentistry. 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.
FAMILY HISTORY It is asked to assess the presence of any genetic/inherited abnormalities.
To know about parental attitude towards the child, oral hygiene and towards the dental treatment. HEALTH HISTORY It is a structured format and must be recorded as such.
Guidelines for taking case history: 1) Questions should be open ended (encourage a detailed explanation). No yes or no questions. 2) Avoid leading questions. 3) In Infants under 5yrs, parent is interviewed. 4) The questions should be clear and should touch various aspects of the disease. 5) Symptoms described by the patient should be record in his own words. 6) Doctor should be an empathetic listener. PRENATAL HISTORY o It may disclose information that can be linked to the present condition. e.g. Tetracycline stains on teeth.
BIRTH HISTORY o Birth injuries - forceps delivery premature baby low birth weight baby o Neonatorum jaundice- Due to rapid destruction of immature RBCs in liver o Rh incompatibility May result in the condition Erythroblastis Fetalis.
POSTNATAL HISTORY Type of feeding - bottle or breast feeding.
Vaccination status needs to be assessed.
Presence and evaluation of any habit and its duration, frequency and intensity.
Behavioral Status- cooperative or non- cooperative.
PERSONAL HISTORY Following factors need to be assessed :
Oral Hygiene
Oral Habits
Dietary Habits
ORAL HYGIENE It is important so as to : - assess the knowledge of dental care the patient possesses. - to determine the level of hygiene maintained by the patient.
It includes Regularity of brushing Frequency Twice daily Method of brushing - Circular brushing method or Fones technique Use of fluoridated and non- fluoridated toothpaste Type of brush and how often it is changed. Use power toothbrushes as they cause significant reduction in plaque. ORAL HABITS
CLASSIFICATION Obsessive (deep rooted) Intentional or Meaningful e.g. Nail Biting, Digit Sucking, Lip Biting Masochistic or Self-inflicting Injurious Habit e.g. Gingival stripping Non- Obsessive (easily learned and dropped ) Unintentional or Empty e.g. Abnormal pillowing, chin propping Functional Habits e.g. Mouth Breathing, Tongue Thrusting, Bruxism MOUTH BREATHING :
It is commonly seen in children who have nasal airways impairment which could be a result of - enlarged adenoids - deviated nasal septum - enlarged tonsils, etc. Characterized by - Retrognathic maxilla and mandible - Posterior cross bites - Deep overjet and overbite - Nasal tone in voice - Incompetent upper lip THUMB SUCKING : It is the habitual prolonged sucking of the thumb or the finger by the child patient. Characterized by : - Anterior open bite - Posterior open bite -TMJ problems - Diastemas - Retrusive postioning of the mandible TONGUE THRUSTING : Schneider 1982- It is the forward placement of the tongue between the anterior teeth and against the lower lip during swallowing.
Characterized by : - Anterior open bite - Protrusion of the maxillary incisors - High arched V-shaped palate - Malocclusion - Malformation of the jaws
NAIL BITING : It is the constant trimming of the nail parts by the patient at the subconscious level.
Characteristics : - Retroclination of the upper incisors - Abrasion of lower incisor margins - Irregular nail margins
DIETARY HABITS : Type of diet- Vegetarian or Non-Vegetarian
Quantity and frequency of solids and liquids in meals.
Intake of sweetened food e.g. Carbohydrates GENERAL EXAMINATION Analyze while the child is entering the clinic. Built, Height , Weight, Gait and Posture should be noted. BUILT : Ectomorphic (lean) Mesomorphic (normal) Endomorphic (obese)
HEIGHT : Normal Too short Too tall WEIGHT : Normal Underweight Overweight Nourishment of the child. Well- nourished Moderately nourished Poorly nourished Vital signs like temperature, blood pressure, pulse, respiratory rate should be noted TEMPERATURE : Normal Oral Temperature 37 C
BLOOD PRESSURE : Normal- 120/80 mm Hg
PULSE RATE : In Children 80-100 bpm In Adults - 70-80 bpm
RESPIRATORY RATE : In children- 16-20/min In adults - 12-16/min EXTRA-ORAL EXAMINATION Shape of head : -mesocephalic (oval) -brachycephalic (short and broad) -dolicocephalic (long ,thin ,tapering)
TMJ- Following should be noted while jaw movements - clicking sound / crepitus - mandibular deviations - pain / tenderness to palpation
Lymph Nodes : Following should be noted Size Shape Consistency Number Tender on palpation Mobility
INTRA ORAL EXAMINATION ORAL SOFT TISSUES : SKIN / LIPS : For presence of any sinus / fistula, etc. MUCOSA : Any ulcerations, growths, pallor of mucosa, yellowish discoloration. PALATE : The hard and the soft palate are inspected for any developmental anomaly and manifestations of systemic diseases. GINGIVA : Inflammation of gingiva Accumulation of plaque on teeth.
TONGUE : to be examined for- 1) Developmental anomaly 2) Lesion 3) Swallowing pattern 4) Speech
TONSILS / ADENOIDS : to be examined for - 1) Any enlargement 2) Purulent discharge ORAL HARD TISSUES : Teeth Present : determined and noted using FDI coding.
FDI Scoring System : Upper Right Upper Left Primary 5 6 7 8
Upper Right Upper Left Permanent 1 2 3 4 Tooth in each quadrant is numbered as PRIMARY 55 54 53 52 51 61 62 63 64 65 85 84 83 82 81 71 72 73 74 75
INDICES Caries Index Plaque Index Gingival Index CARIES INDEX : WHO Criteria for Primary and Permanent Teeth CONDITION PERMANENT PRIMARY TOOTH CODE TOOTH CODE Sound 0 A Decayed 1 B Filled, with decay 2 C Filled, no decay 3 D Missing as a result of 4 E caries Missing due to any 5 - other reason Sealant, Varnish 6 F Bridge Abutment or 7 G special crown Unerupted Tooth 8 - Excluded Tooth 9 - PLAQUE INDEX ( SILNESS AND LOE, 1964) A specific, highly selective entity resulting from a sequential colonization of microorganisms on the surface of teeth, soft tissues, restorations and appliances.
SCORING CRITERIA : 0- No plaque in gingival area 1- A film of plaque adhering to the free gingival marigns and adjacent area of the teeth. 2- Moderate accumulation of soft deposits within the gingival margin and/or adjacent tooth surface. 3- Abundance of soft matter within the gingival pocket and/or on the gingival margin and adjacent tooth surface. INTERPRETATION SCALE : 0.0 - Excellent 0.1 0.9 - Good 1.0 1.9 - Fair 2.0 3.0 - Poor
GINGIVAL INDEX ( LOE and SILNESS, 1967 ) SCORING CRITERIA : 0- Normal gingiva
1- Mild inflammation slight change in color slight edema no bleeding on probing 3- Moderate inflammation Redness Edema and glazing Bleeding on probing 4- Severe inflammation marked redness and edema ulcerations tendency for spontaneous bleeding INTERPRETATION 0.1 1.0 - Mild 1.1 2.0 - Moderate 2.1 3.0 - Severe
PROVISIONAL DIAGNOSIS A general diagnosis based on the clinical impression without any laboratory Investigations.
DIFFERENTIAL DIAGNOSIS The process of listing out 2 or more diseases having similar signs and symptoms of which only one could be attributed to the patients suffering.
INVESTIGATIONS Radiographs 1) Intraoral type 2) Extraoral type INTRAORAL RADIOGRAPHS Intraoral periapical radiographs Bitewing radiograph Occlusal radiographs
ADVANCED DIAGNOSTIC AIDS DIAGNOSTIC AIDS FOR CARIES : for early detection of caries Fiber Optic Transillumination ( FOTI ) : In dentistry, it was first used as an improved light source for surgical retractors. In 1970, Friedman and Marcus suggested use of FOTI in detection of carious lesions. Useful technique for detection of caries, calculus and soft tissue. It permits a cold, high- intensity light source to be used anywhere in the oral cavity with ease and flexibility. DIAGNOdent : Lussi et al (1998) Patented by KaVo (1999) Based on principle of fluorescence Has a range of -9 to 99 with [-9] being the value where the tooth is the healthiest Advantage- Early, precavitation stage of caries detection Used in determining the amount of caries involvement (decalcification) in different areas of same tooth.
Digital FOTI Recent innovation to FOTI introduced by Electro-Optical Sciences, Irvington, New York. Used as a diagnostic tool for early detection of caries without the need to use ionizing radiation. It can detect both early carious lesions and assess their progression.
Videoscope / Endoscope : Endoscope technique is based on observing the fluorescence that occurs when tooth is illuminated with blue light in wavelength range of 400- 500 nm. Allows visualization of small carious lesions in the enamel that are difficult to detect with naked eye or with radiograph. The integration of the camera with the endoscope is called a VIDEOSCOPE.
TACT ( Tuned Aperture Computed Topography ) Is more useful in detection of recurrent caries. A clinician can isolate and examine the individual projections of a region, limiting information to the depth of interest in the radiographic volume.
PERIODONTAL PROBES : Perio temp probe : helps to detect early inflammatory changes in gingiva by detecting temperature rate.
Florida probe : It is a computerized peridontal probe consisting of A Probe Hand piece A digital readout A foot switch A computer interface A computer.
It is used to measure pocket depth. ADVANTAGES : o Constant probing force o Digital readout o High degree of accuracy Foster- Miller Probe : Couples pocket depth determination with detecting of CEJ from which clinical attachment level is automatically assessed. Toronto Automated Probe : To measure clinical attachment levels Sulcus is probed with Ni-Ti wire DNA Probe : helps to identify the organism associated with periodontal disease. OTHER AIDS : Xeroradiography : An X-ray imaging system that uses the xerographic process to record images.
CADIA : Computer Assisted Densitometric Image Analysis System. Video camera measures the light transmitted through radiograph and signals from the camera are converted into gray levels. The camera is interfaced with an image processor and a computer that allows storage and manipulation of images. Computers : help by retention of facts about many patients and selection of relevant facts to give a diagnosis. help in comparative digital study of radiographs. e.g Cephalograms
Ultrasonics : helps in defining Pulp anatomy Shape of soft tissue neoplasms
FINAL DIAGNOSIS
A confirmed diagnosis based on all available data.
TREATMENT PLAN Phases Of Treatment Planning : Systemic Phase Preventive Phase Preparatory Phase Corrective Phase Maintenance Phase
SYSTEMIC PHASE It is the first and the preliminary phase of treatment planning.
A patient with medical history is premedicated before dental treatment.
Premedication is provided in the form of : - Antibiotic Prophylaxis - Sedatives PREVENTIVE PHASE It is the second line of treatment.
Involves assessment of caries risk.
Assessment for various preventive measures : - personal oral hygiene - fluoride application - pit and fissure sealants - diet counselling
PREPARATORY PHASE Behavior management- The childs behavior shaping should start right from the reception itself.
Oral prophylaxis- It presents a clearer view of the caries process which facilitates its diagnosis. It also gives an idea whether the patient will co-operate.
Caries control- Further process of carious lesions should be controlled. Sometimes multiple lesions may need to be temporized.
Orthodontic consultation- Preventive Orthodontic programme should be planned before any orthodontic intervention.
Oral surgical procedure- Unrestorable caries, Orthodontic reasons, etc. may necessitate the extraction of teeth.
Endodontic therapy- If required, a tooth may be saved with an endodontic treatment.
CORRECTIVE PHASE Restorative dentistry- Permanent fillings Stainless steel crowns Prosthetic rehabilitation- Tooth replacement Jacket crowns Early orthodontic intervention- Minor tooth movements Serial Extraction Space Management MAINTENANCE PHASE Depending on the risk of the individual and his oral hygiene status, a 3-6 month recall visit can be established for the following : Review of oral health status by repeating indices and comparing with initial indices Caries activity tests may be repeated Reinforcement of home care measures Motivation and re-counseling of parents if required Follow-up of treatment procedures
BIBLOGRAPHY Text books of pedodontics- Shobha tandon Damle