Patient’s History (Case History) Oral Diagnosis

Ass. Prof Dr/ Baleegh A. Al-kadasi

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Patient’s History (Case History)

Patient`s History (Case History):

- It is the collection of diagnostic information from the patient related to his condition.
- It is often called subjective examination of the patient since it contains information
that the patient tells to the clinician.\

Requirements of ideal patient`s history:

a) It should include all the necessary information.

b) Well organized.
c) Systematic and follows a definite pattern.
d) Brief and concise.

Methods for obtaining case history:

1 – Printed questionnaire:

Using a printed form to collect information.

Advantages:

a) Time saving.
b) Does not require any special skill from the dentist.
c) A standardized form for obtaining information.
d) consistent

Disadvantages:
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Patient’s History (Case History) Oral Diagnosis
Ass. Prof Dr/ Baleegh A. Al-kadasi
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a) Lack in depth.
b) Impersonal and inflexible.
c) Patients may misinterpret questions

2 – Patient interview:

It is a verbal interview between the patient and the dentist.

Advantages:

a) Ability to ask in depth.

b) Personal.
c) Flexibility and the dentist can tailor questions to the individual patient.

Disadvantages:

1) Time consuming.
2) Require a special skill from the dentist.
3) Not consistent.

3- Combination:

- It is clear that a combination of the direct interview and the printed questionnaire
would make use of the advantages of each and tend to minimize their disadvantages.

Methods of presenting questions during the diagnostic interview:

- The patient’s interview is usually the first and often the most important step in
effective diagnosis and treatment planning.

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Patient’s History (Case History) Oral Diagnosis
Ass. Prof Dr/ Baleegh A. Al-kadasi
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- Depending on the patient’s complaint and his personality, different types of questions
can be used during the diagnostic interview.

Types of questions are:

1. Open -ended question:

- This type of question allows the patient to talk freely and answer the question fully
with few interruptions from the dentist.

For example: -

“Can you tell me about your surgery that was performed last year?” The question will
direct the patient to describe the entire topic:

- The problem that required surgery. - The nature of the operation.

- Possible complications. - Duration of hospitalization.

- Response to surgical stress. - Effectiveness of surgery.

Advantages:

a. Less stressful to the patient.

b. Effective method of covering a complicated topic.
c. It calms patients by allowing them to talk in their way.

Disadvantages

a. Time consuming.
b. Patient may deviate from the topic.

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Patient’s History (Case History) Oral Diagnosis
Ass. Prof Dr/ Baleegh A. Al-kadasi
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2. Closed-ended question:

- Simple and specific answers are expected for closed-ended questions.

- The patient answer is limited to a small single sentence or even “Yes”

or “No”.

- After the answer is given the dentist goes quickly to the next

question.

For example: -

 Do you smoke?
 How many cigarettes do you smoke each day?
 For how long have you been smoking?

Advantages:

a. Time saving.
b. Answers are simple and specific.
c. Most effective with unresponsive or unaware patients.

Disadvantages:

a. Patients answer directly without clarifying information.

b. Patients may misinterpret questions.
c. Less effective for responsive and aware patients.

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Patient’s History (Case History) Oral Diagnosis
Ass. Prof Dr/ Baleegh A. Al-kadasi
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3 – Leading question:

- Leading is a technique, which suggests the answer within the question.

For example:-

 The dentist may suspect that recurring morning headache described by the patient
is caused by bruxism.
 The dentist asks the patient: “Do you grind your teeth during sleep”?

Advantages

a. A positive answer confirms the dentist’s doubts.

b. A positive answer increases the patient’s confidence in his dentist.

c. Useful in getting information from unresponsive patients.

Disadvantages

a. Some patients will answer “yes” because it is the expected answer rather
than the actual situation.
b. Dentist’s error in asking a leading question may cause the patient to lose
confidence.

4 – Option question:

In the option question the patient is provided with two or more options.

For example:-

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Patient’s History (Case History) Oral Diagnosis
Ass. Prof Dr/ Baleegh A. Al-kadasi
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«Do you think that recurring morning headache is caused by bruxism or by stress at
your job?».

Advantages:

a. Effective for sensitive topics.

b. Effective with forgetful patients.

 Disadvantages:

a. The clinician may receive an incorrect answer if the actual answer is not
provided as an option.
b. The answer of uncertain patients may be variable.

5 – Indirect question:

a) It is used to get information beyond what is requested by the question.

For example:-

“Have you had any complications during or after previous dental treatment?”

This question will clarify complications as well as the patient’s general attitude
toward dental care.

b) Indirect questions may be used to get information about the systemic condition
of the patient.

For example:-

“Have you had chest pain especially following exertion?”

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Patient’s History (Case History) Oral Diagnosis
Ass. Prof Dr/ Baleegh A. Al-kadasi
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If the answer is “Yes” it may reveal heart problem.

 Advantages:

a. Useful in understanding sensitive individuals.

b. Useful in discovering undiagnosed systemic conditions.

 Disadvantages:

a. Time consuming.
b. Indirect approach can be unsuccessful with some individuals.

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Patient’s History (Case History) Oral Diagnosis
Ass. Prof Dr/ Baleegh A. Al-kadasi
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I– Patient identification

- It is the simplest method for the dentist to know the patient.

- The patient should write the information by himself on a printed form toavoid
misspellings and other errors.

Significance of components of the administrative chart

1 – Code number:

- Code number is essential for record keeping and retrieval of the patient’s file.

2 – Date of examination:

- Date of initial presentation helps in retrieval of the file.

- In recall visits, it helps in certain recurring conditions e.g. allergic seasonal diseases,
erythema multiform, aphthous ulcer…etc.

3 – Name:

- Patient’s full name and how he or she prefers to be addressed should be recorded.
Patient’s name is important for:

 Record keeping and retrieval of the file.

 Administrative purposes.
 Better communication between the dentist and the patient.

4 – Date of birth (patient’s age):

- Age is important as certain diseases occur generally in certain age groups and rarely
in others.
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Patient’s History (Case History) Oral Diagnosis
Ass. Prof Dr/ Baleegh A. Al-kadasi
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For example:-

 Primary acute herpetic gingivostomatitis, candidosis, measles and mumps occur

commonly in childhood.
 Squamous cell carcinoma is common in old age.

5 – Sex (gender):

- It is important especially in those who carry names that could be taken for both
sexes e.g. Amal, Esmat…etc.

- Some diseases are common in:

 Males e.g. prostatic carcinoma, leukoplakia and carcinoma of the lip.

 Females e.g. iron deficiency anemia and lupus erythematosis.

6 – Birth place:

- Birth place is important to detect diseases acquired in childhood (endemic

diseases).

For example:-

 Chronic dental fluorosis resulting from drinking water from wells in Libia and
Saudia Arabia.
 Bilharziasis is of common occurrence in Egyptian villages.

7 – Address:

- Address may help in knowing the patient’s social and home background.

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Patient’s History (Case History) Oral Diagnosis
Ass. Prof Dr/ Baleegh A. Al-kadasi
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- Patients living near factories are liable for pulmonary diseases.

- The address may be useful for recalling the patient.

8 – Phone number:

- The telephone number of home, office and mobile is important for recalling the
patient especially after oral biopsy when malignancy is suspected.

9- Occupation:

- In some instances, the diagnosis of some diseases will be based on the knowledge of
the patient’s occupation or the nature of his work.

- Occupational diseases results from the effect of the harmful factors of the working
environment.

A. Acids cause tooth erosion and inflammation of the mucosa.

B. Bacteria from cattles cause cervicofacial actinomycosis.
C. Dusts e.g. ferrous metal cause attrition of teeth.
D. Heavy metals e.g. Lead (water pipes) and Mercury (fluorescent lamp) cause
intoxication.
E. Non – metallic elements e.g. flourine (fertilizers and insectisides) cause
intoxication.
F. Trauma in glass blowers and shoe makers cause notching of incisors.
G. Carcinogenic agents e.g. arsenic and tar

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Patient’s History (Case History) Oral Diagnosis
Ass. Prof Dr/ Baleegh A. Al-kadasi
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10 – Marital status:

- Psychological stress of some married people may predispose to certain oral diseases
such as lichen planus and aphthous ulcers.

- It may be a source of infection in certain diseases such as T. B., AIDS, and other viral
infections.

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