PRESENTED TO-

DR. RITU JINDAL

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)

facial form :
- Straight
- Convex
- Concave




facial symmetry
bilaterally symmetrical/asymmetrical

Lip competency-
competent/incompetent

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

PERMANENT
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

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

EXTRAORAL
RADIOGRAPHS
Ortho pantomographs
Cephalographs


HEMATOLOGICAL INVESTIGATIONS
RBC count
Normal Range- Women: 4.2 to 5.4 million/uL
Men: 4.7 to 6.1 million/uL
Children: 4.6 to 4.8 million/uL

Hemoglobin determination
Hematocrit count
Newborn: up to 60%
Adults: (males): 40- 54%
(Females): 36 46%
Children: varies with age
Platelet count
Normal- 1.5-4 lacs per cmm

Bleeding time
Normal 2-6min

Clotting time
Normal - 3-5min

Tourniquet test
Prothrombin test
White cell count
Normal- 4,300 to 10,800 cells per cubic millimeter (cmm)


Differential leucocyte count
Normal Values-
Neutrophils: 50-70 %
Lymphocytes: 25-35 %
Monocytes: 4-6 %
Eosinophils: 1-3 %
Basophils: 0.4-1 %

OTHER TESTS
Caries activity tests

Biopsy

Vitality tests

Study models

Photographs

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


Internet