CASE HISTORY

Dr. Abhiram Singamsetti BDS

Contents
Introduction
Diagnosis
History taking and clinical examination
Patient information
History taking
General physical examination
Extra-oral examination
Intra-oral examination
A) Soft tissue examination
B) Hard tissue examination
Provisional diagnosis
Differential diagnosis
Investigations
Final diagnosis
Treatment planning
Prognosis
Introduction
 The case history enables the patients to
communicate symptoms, feelings
and fears and the sequence of events
leading to the problem for which the
patient seeks professional assistance
 “Accurate diagnosis of a disease depends on
the art of taking Case History.”
Diagnosis
 Diagnosis is derived from the Greek word
dia = by and gnosis = knowledge
 Diagnosis –The determination of the
nature of the disease
 History taking and
Clinical Examination
I) Personal information
 Date
–It records the time the patient reported.
–Can be referred back to during the follow- up
visits.
 Case number

–For the purpose of maintaining record

–For billing the individual
–For legal considerations
 Patients name
–To establish a better communication with the patient.
–To establish a rapport with the patient.
–Maintenance of record.
–To elicit the history properly.
–Medico legal purpose.
 Age
The chronological age (date of birth) should be noted.
1)To compare with other ages (dental,skeletal) so as to know
whether the growth and development is normal in the child.
2)Certain diseases are known to occur frequently at particular ages
3)Depending on the age the behavior
– management techniques also vary.
 Sex
–Girls age faster than boys and thus their treatment may be required
earlier.
–Some diseases are more common in females than in males.
–A combination of age and sex can sometimes give an indication of
occurrence of disease
 Address
–It is used for all communications even before the first visit.
–By knowing the locality along with the family income and parent’s
occupation, the socio-economic status can be assessed.
–If the patient is coming from a far distance,the appointments can be
modified to complete treatment in fewer visits.
–It may indicate diseases endemic to the particular areas.
• Socio-economic
status
a) Treatments can be
modified according to the
socioeconomic status.
b) Patients background can
be understood in a better
way.
II) History taking
 Chief complaint
It is defined a symptom or
symptoms, described in
patient own words, related to
the presence of an abnormal
condition.
• History of present illness
Chronological account of the chief complaint and associated symptoms from the
time of onset to the time the history is taken.
The most common presenting illness can be evaluated as,
1) The onset
2) Duration
3) Location
4) The quantity, quality, severity and frequency of occurrence
5) Aggravating and relieving factors
6) Associated symptoms
 Past dental history
a) It gives information about the patients past
dental problems.

b) Frequency of dental visit by the patient which gives

an indication of the patient’s future behavior.

c) Patient’s attitude towards previous dental treatment

d) Any untoward complication of dental treatment.

e) To know about any excessive bleeding in the past

dental treatment.

f) Reasons for loss of teeth

• Medical history
This helps in identifying conditions that could alter, complicate or contraindicate
proposed dental procedures.
Does the patient suffer from any of the following at present or in the past?
Congenital diseases
Rheumatic fever
Anemia
Bleeding disorder
Asthma
Diabetes
Hepatitis
Epilepsy
Mental or physical handicap
Sensory deficits
Speech defects
Kidney disorders
Bone & joint problems
Growth and development problems
 Family history
a) It gathers information about diseases that
commonly affects more than one member of a family.
b) Certain disorders that should be inquired are
- Bleeding disorders
- Heart disease
- Diabetes
- Tuberculosis
- Asthma
- Allergies
- Genetic disorders
-Malocclusion
c)Siblings:Number:Order :Sex
 Prenatal history
Should include condition of the mother during
pregnancy
Drug intake during pregnancye.g. tetracycline
administration
 Natal history
Type of delivery- Normal/C-section/Forceps;
Fullterm/Premature
Childs health at birth: Good/Fair/Poor
 Postnatal history
Method of feeding and duration:
Breast fed/Bottle fed/both
Does the child sleep with the bottle?
What are/were the contents of the bottle?
III) General physical
examination
 Height and weight:
Whether normal for the age. If not factors
responsible should be determined.
 Gait:
The way a person walks.
An abnormal gait can be associated with a
particular disease.
 Speech:
Speech disorders can be associated with a
particular disease.
 Body Build(physique)
-Aesthetic
-Plethoric
-Athletic
Classification of general
body build according to
Sheldon
-Ectomorphic
-Mesomorphic
-Endomorphic
IV) Extra-oral examination
 a) Shape of the skull:
It is classified as
-Brachycephalic
-Mesocephalic
-Dolichocephalic
 b) Shape of the face:
Face can be classified in three forms
1) Mesoprosopic-
2) Euryprosopic-
3) Leptoprosopic-
 c) Facial symmetry:
Gross facial asymmetries are seen in
-congenital defects
-hemi facial atrophy/hypertrophy,
-unilateral condylar ankylosis and hyperplasia.
 d) Facial profile:
It can be classified as
-Straight
-Convex
-Concave
 Facial divergence
-Anterior divergent
-Posterior divergent
-Straight or
orthognathic
 Assesment of antero-posterior jaw relationship
 Assesment of vertical skeletal relationship
 Evaluation of facial proportions
 Examination of lips
Competent lips
Incompetent lips
Potentially incompetent lips
Everted lips
 Examination of nose (size,contour,nostrils)
 Examination of chin (mentolabial sulcus,mentalis
activity, chin position and prominence)
 Nasolabial angle
V) Intra-oral examination
 A) Soft tissue
examination
 Labial and Buccal mucosa:
Observe for any changes in
color, texture, pigmentations,
hyperkeratotic
patches,ulcers, swellings,
fistulae, and tenderness.
 Vestibule: Look for the color,
texture, swelling fistulae, and
tenderness.
 Palate: Inspect for swellings,
fistulae, ulcers, burns,
hyperkeratinizations,
tenderness, papules, cleft
palate & also the depth of the
palate.
 Gingiva: The color,
contour,shape, size,consistency,
surface texture, and position is
checked for. Any swellings,
ulcerations, pus discharge, sinus
tracts, erythema is checked for.
 Frenal attachments:
Labial frenum at times can be
thick and may be attached to the
incisive papilla which may cause
midline diastema. Blanch test can
be used for confirmation. Short
lingual frenum can cause
ankyloglossia.
 Tonsils and Adenoids: Enlarged
adenoids should be checked for.
 Tongue: Inspect the dorsum of
the tongue for any swellings
ulcers, coating or variation in size.
 B) Hard tissue examination
1) Teeth present:
2) Type of dentition: Whether primary, permanent or mixed
3) Missing teeth:Note whether the teeth is congenitally missing or
missing following extraction.
4) Caries:
5) Caries with pulp involvement:
6) Root stumps:
7) Filling present:
8) Mobility:Grade of mobility should be mentioned
9) Fractured teeth:
10) Retained teeth:
11) Erupting teeth:
12) Supernumary teeth:
13) Any wasting diseases: Like attrition, abrasion, and erosion
14) Hypoplastic teeth
15) Any other dental anomalies:
 Orthodontic evaluation:
Molar relation:
 Malocclusions
-Terminal plane
relation
-Canine relation
-Overbite
-Overjet
-Crossbite:

-Midline deviation:
-Space loss:
-Ectopic eruption:
-Other significant
findings:
VI) Provisional diagnosis
 A general diagnosis based on clinical
impression without any laboratory
investigations.
VII) Differential diagnosis
 The process of listing out two or more
diseases, having similar signs or
symptoms of which only one could be
attributed to the patient’s suffering.
VIII) Investigations
 Radiographic
investigations
 Vitality tests
 Photographs
 Study models
IX) Final diagnosis
 A confirmed diagnosis based on all
available data.
X) Treatment plan
 A comprehensive treatment plan must be
designed based upon clinical examination
and investigations.
XI) Prognosis
 It is the prediction of the course, duration and
termination of a disease and the likelihood of
its response to treatment.
ThankYou