Prepared by

(4th batch)

What is case history?

It is a classic form of documentation ranges from clinical

sketches to highly detailed and extended accounts that
help in arriving at a diagnosis and formulation of treatment
plan of a person before treatment
Steps in case history taking
Step 1;assemble all the available facts gathered from chief
complaint, medical history, dental history ,diagnostic tests
and investigations
Step 2:analyse and interpret the assembled clues to reach
the provisional diagnosis
Step3 :make a differential diagnosis of all possible
complications
Step4 ;select a closest possible choice-final diagnosis

GUIDE LINES

Guidelines for taking case

history;

Questions should be open ended (encourage a

detailed explanation). No yes or no questions
Avoid leading questions
Infants under 5yrs parent is interviewed
The questions should be clear and should touch
various aspects of the disease
Symptoms are described by patient should record
in his own words
Doctor should be an empathetic listener
NB: Behavior Shaping of pedo patient should be
started from case history taking or even before

Consent
Esp.

in pediatric patients a written

consent is a must to get adequate
information about the case and to
escape from medico legal
complications

STEPS IN CASE HISTORY

TAKING

Case history taking;

1)VITAL STATISTICS;

a) date;-time of admission
reference during follow up visits
b) out patient number;-maintaining a record, billing , medico
legal considerations
c) name:-to communicate with the patient
-to establish a rapport with the patient
d) age:- 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
eg; primary herpetic gingivostomatitis(6months to 6years)
nursing caries-pre schoolers
-behavior management techniques also varry according to
age

e) sex;-girls mature earlier than boys-require

treatment earlier
-some diseases shows sex predilection
eg: anorexia-females
hemophilia -males
f) race/ethnic origin:-certain religious cultures
depends the etiology of certain diseases.
g) school/class:-to communicate with teacher
-to know the IQ level
h) address;-communication
-to chart out appointments for patients from
distant places
-to know endemic status of disease in the locality
i] socio economic status-to know about the
nourishment, hygiene, $ payment capacity of the
patient

2)Chief complaint:

Always record in patients own words

Mention only the chief problem of the present day in the
order of severity
Follow the chronological order

3)History of the present illness;-it should

indicate the severity and urgency of the problem

detailed history of the chief complaint-eg; dental pain

-quality,-dull, sharp ;throbbing ,constant
-quantity, severity, and frequency
-location-localized ,diffuse ,referred, radiating.
-duration of complaint
-onset; spontaneous, on stimulation, intermittent
-Aggravated by: cold, heat, palpation, percussion
- Relieved by ;cold, heat, any medication ,sleep

MEDICAL HISTORY

4)Medical history
Check list of medical history-by Scully and Cawson
-Anemia
-Bleeding disorders
-Cardio respiratory disorders
-Drug treatment and allergies
-Endocrine disorders
-Fits and faints
-Gastrointestinal disorders
-Hospital admissions and surgeries
-Infections
-Jaundice
-Kidney disease
antibiotic prophylaxis needed in case of bacterial endocarditis

5)Past dental history

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

6)Family history

To know about parental attitude towards the child and towards the dental
treatment
Presence of genetic / inherited abnormalities

7)Personal history

Prenatal history: maternal history of nourishment, usage of drugs etc

eg; tetracycline staining of teeth
phenytoin sodium cleft lips in child
Natal history: birth injuries forceps delivery
premature baby, low birth weight baby
neonatal jaundice-due to rapid destruction of immature
RBCs in liver
Rh incompatibility rh+ father and Rh ive mother

 Post

natal history:
-type of feeding-bottle or breast
feeding
-vaccination
-presence of any habit along with
its onset, duration ,frequency and
intensity should be noted-mouth
breathing, thumb sucking ,tongue
thrusting etc

Nail biting

Tongue thrusting

Mouth breathing

-behavioral status-co-operative or not

-diet chart
-physical and emotional development of the child.
-oral hygiene status of the child-type, method and
frequency of brushing

GENERAL EXAMINATION
8)General examination: analyze while child entering the clinic
built, height ,gait, and posture should be noted
nourishment of the child
vital signs like temperature, blood pressure, pulse,
respiratory rate should be noted
body type-ectomorphic (lean),mesomorphic (normal),
endomorphic (obese)

EXTRA ORAL EXAMINATION

9)Extra oral examination

Shape of head- mesocephalic (oval), brachycephalic (short

and broad), dolicocephalic (long ,thin ,tapering)
facial form straight, convex (class II), Concave (class III)
facial symmetry bilaterally symmetrical/asymmetrical
Lip competency-competent/incompetent
Soft tissue-color ,contour, consistency, temperature ,size
,extend and shape
TMJ-clicking ,deviation ,pain , crepitation should be noted
while jaw movements
Lymphnodes : size, shape, consistency, number, tender on
palpation, mobility should be noted
Salivary glands- Submandibular gland-bimanual palpation

SALIVARY GLAND

Lymph nodes

INTRA ORAL EXAMINATION

10)Intra oral examination

A) soft tissue examination
-lips-sinus ,fistula ,ulcers, bite marks
-mucosa-(buccal, alveolar, labial); ulcerations, color,
consistency ,kopliks spots in measles ,white lesions,
trauma etc
-hard and soft palate:-developmental anomalies,lesions,
systemic disorders, growths etc
-gingiva- color, contour, consistancy ,size, shape, resiliency,
exudation etc
-Toungue- growth, developmental anomalies, ulcers and
lesions, speech pattern ,trauma
-floor of the mouth-ulcers and lesions, growth etc
-tonsils and adenoids:-inflammatory enlargements
-salivary orifice-flow of saliva,inflammation,exudation

b) Hard tissue examination

Oral hygiene status

Restorations-fractures or failures, over extensions.
Dental caries
Missing teeth
Discolorations,
regressive alterations-attrition ,abrasions, erosions
Periodontal status-bleeding from gums ,mobility (grade ISlight, II-Moderate mobility within a range of 1 mm, IIIExtensive movement more than 1mm both mesiodistal and
vertical) recession ,furcation involvement etc
Class of malocclusion
Crowding, rotations, space loss
Pulpal diseases
Eruption status and development of jaws and teeth
Retained deciduous teeth etc

Pulpal diseases

Occlusal
discrepancies

Faulty
restorations

Dental caries

Periodontal
diseases

spacing

11)Provisional diagnosis

A general diagnosis based on the clinical impression

without any lab. Investigations

12)Differential diagnosis
The process of listing out of 2 or more diseases having similar
signs and symptoms of which only one could be attributed
to the patients suffering

13)Investigations
radiographs, biopsy, $ other tests

14)Final diagnosis
A confirmed diagnosis based on all available data.

TREATMENT PLAN

Treatment plan

A) systemic phase; stabilize the medical condition if any,

antibiotic prophylaxis, sedation, consent
B) preventive phase: caries risk assessment, personal oral
hygiene, flouride application, pit and fissure sealant, diet
counseling
C) preparatory phase: behavior management, oral
prophylaxis, caries control, orthodontic consultation, oral
surgical procedure (extractions) ,endodontic therapy
D) corrective phase: restorative dentistry-permanent fillings,
stainless steel crowns
prosthetic rehabilitation-tooth replacements ,jacket crowns
early orthodontic intervention;-minor tooth
movements,serial extraction, space management

E) Maintanance phase;3-6 month recalls

-review check up of oral health indices
-repeat caries activity tests
-reinforcement of home care measures
-motivation and re-counseling of the parent
-follow up of treatment procedures

Chances only favors trained mind

Louis Pasture

Bibliography

Text books of pedodontics- Shoba tandon

-Damlae
-Pinkham
Text book of pediatric operative dentistryKennedy
text book of oral medicine-Burkette
Carranzas periodontology
Text book of endodontics-Grossman
-Nisha garg

Thank
you.!