CASE HISTORY

PRESENTED BY: JHUG ISHT

GUIDED BY: DR PAVITRA
INTRODUCTION :

A case history is defined as a planned professional

conversation that enables the patient to communicate
his/her symptoms, feelings, and fears to the clinician
so as to obtain an insight into the nature of the patient’s
illness and his/her attitude to them.

In general, a case history is nothing but an evaluation

of the patient prior to the dental treatment.
A case history is of immense value in the following
ways:

1.to establish the diagnosis.

2. to detect any medical problem
3. evaluation of other systemic problems
4. discovery of communicable diseases.
5. management of emergencies.
6. for effective treatment planning.
STEPS IN THE DIAGNOSTIC PROCEDURE
Taking and recording of the case history.
Physical examination.
Relevant investigation to aid in the diagnosis.
 Establishing a diagnosis after assessing the case
history, physical examination and investigative
procedures.
Outlining the treatment plan of the dental patient.
 Medical risk assessment of the patient.
Prognosis or a clinical evaluation of the most probable
outcome of therapy.
METHODS OF RECORDING A CASE
HISTORY
There is usually a traditional approach in the design of
a case history. The preliminary part of the case history
is usually based on questionnaires. 
Newer techniques of recording a case history are:
 1. Computer aided data gathering.
 2. Open ended interviewing which includes the weed’s problem
oriented record (POR).
 3. Russel’s “condition diagram”.
 4. CD method.
SEQUENCE OF CASE RECORDING AND
EVALUATION 

STATISTICS
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
MEDICAL HISTORY
PAST DENTAL HISTORY
FAMILY HISTORY
GENERAL EXAMINATION
EXTRA ORAL EXAMINATION
INTRA ORAL EXAMINATION
PROVISIONAL DIAGNOSIS
INVESTIGATIONS
FINAL DIAGNOSIS
TREATMENT PLAN 
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.

 Patient registration number

useful for:
-record maintainence
-billing purposes
-medicolegal aspects.
Date:

useful for:
-for reference
-for record maintainence
 Name:
useful for:
-for identification
-for communication
-forming a rapport with patient -
record maintainance
-psychological benefit
-information of patient such as religion.
 Age:
useful for:
-diagnosis
-treatment planning
-behaviour management techniques
AGE
1. Diagnosis: there is a predilection of certain diseases at different age levels.
Eg.

Diseases commonly present at birth:

-cleft lip and palate -ankyloglossia
-teratoma -haemophilia etc.

Diseases commonly present in children and young adults

-papilloma -juvenile periodontits
-scarlet fever etc.

Diseases commonly occuring in adults:

-attrition/abrasion -periodontitis
-pulp stones -root resorption etc.
2. Treatment planning:
- Comparison of chronological age with dental age. Chronologic age – age according
to date of birth
Dental age – age according to last erupted tooth in oral cavity in order of sequence.

- Growth spurts:
1. Infantile / childhood growth spurt
2. Mixed dentition / juvenile growth spurt
3. Prepubertal / adolescent growth spurt

-Calculation of child’s dosage

3. Behavoiur management techniques:

-Management of patients of different age groups require different behaviuor
modification methods. 
SEX
 Knowing the sex of patient is important for:
1. Diagnosis: there is a predilection of different diseases in both sexes.
eg. Diseases more common in females:
-iron deficiency anaemia -sjogren’s syndrome
-myasthenia gravis -juvenile periodontitis
Diseases more common in males:
-attrition -oral carcinoma
-hodgkin’s disease -pernicious anaemia

2. Esthetic: girls are much concious about their esthetics.

3. Child abuse: exploitation is more common in males and sexual abuse in

females. 
 Education: it determines
1. Socio-economic status
2. I.Q. for effective communication
3. Attitude towards general and oral health.

 Address: it is important for

• 1. for future correspondence
• 2. gives a view of the socio-economic status
• 3. prevalence of diseases:
for eg.
a) fluorosis as a result of increased level of
fluorides in water are spread differently in vague parts of
country.

b) caries are more common in modern

industrialized areas, whereas periodontal diseases are more
common in rural areas.
 Occupation: it is important for
• 1. Assessing the socioeconomic status
• 2. Predilection of diseases in different occupations.
eg.
• 1) Attrition and abrasion are found in industrial
workers having an atmosphere of abrasive dust.
• 2) Hepatitis-B is more common in dentists and
surgeons.
 Religion: It is important for:
• 1) Identifying the festive periods when religious
people are reluctant to undergo treatment procedures.
• 2) Predilection of diseases in specific religions 
CHIEF COMPLAINT
The chief complaint is established by asking the
patient to describe the problem for which he or she is
seeking help or treatment.
It is recorded in patient’s own words as much as
possible, and no documentary or technical language
should be used.
It is recorded in chronological order of their
appearance, and in the order of their severity.
 The chief complaint aids in the diagnosis and
treatment planning and should be given the first
priority.
COMMON CHIEF COMPLAINTS
1. Pain
2. Burning sensation
3. Bleeding
4. Loose teeth
5. Recent occlusal problems
6. Delayed tooth eruptions
7. Xerostomia
8. Swellings
9. Bad taste
10. Paresthesia and anaesthesia
11. Halitosis
HISTORY OF PRESENT ILLNESS
 Initially, the patient may not volunteer the detailed history of the
problem, so the examiner has to elicit out the additional information by
the possible questionnaire about the symptoms.

 The patient’s response to these questions is termed history of present

illness.

 The questions can be asked in the manner:

 1. when did the problem start?
 2. what did you noticed first?
 3. did you have any problems or symptoms related to this?
 4. what makes the problem worse or better?
 5. have any tests been performed before to diagnose this complaint?
 6. have you consulted any other examiner for this problem?
 7. what have you done to treat this problem?
In general, the symptoms can be elaborated under:
1. mode of onset.
2. cause of onset.
3. duration
4. progress and referred pain
5. relapse and remission
6. treatment
7. negative history
DETAIL HISTORY OF PARTICULAR SYMPTOM PAIN
 PAIN:
1. anatomical location (site) 2. origin and mode of onset
3. intensity of pain 4. nature of pain
5. progression of pain 6. duration of pain
7. movement of pain 8. localization behavior
9. effect of functional activity 10. neurological signs
11. temporal behavior

 SWELLING:

1. anatomical location (site) 2. duration

3. mode of onset 4. symptoms
5. progress of swelling 6. associated features
7. secondary changes 8. impairment of function
9. recurrence of swelling

 ULCER

1. mode of onset 2. duration

3. associated pain 4. discharge
5. associated diseases
PAST DENTAL HISTORY
Gives attitude of the patient towards dentistry.
Gives a general view about how the patient is
aware about pursuing oral health.
If history of previous bad experience is present
then moulding of behavior is done using behavior
management technique.
Significant knowledge can be drawn about the
patient’s previous treatment procedures and can be
helpful towards the present situation.
PAST MEDICAL HISTORY
Recording of past medical history includes history of past
illnesses, hospitalizations and evaluation of the patient’s
health based on the history provided by the patient.
All diseases suffered by the patient should be recorded in
chronological order.
Patient should be evaluated for:
 cardiovascular diseases respiratory diseases
 gastrointestinal genitourinary
 endocrine neurological
 haematological psychiatric
 allergic reactions extremities and joints
 Patient should be assessed by the questionnaire:
 whether he is suffering or has suffered before from any major
systemic disease?
 What is the duration and treatment of the disease?
 Is he on any medication?
 History of all the hospitalizations and their purpose should be
assessed. etc

 Some important examples include:

-Postpone treatment if suffering from acute illness like mumps or
chickenpox
-Patient with cardiac defects need to get a physician’s report
-Patient on anticoagulant therapy
-Asthma
-NSAID are contraindicated
-Juvenile diabetes mellitus 
PERSONAL HISTORY
It includes:
1) Oral habits
2) Oral hygiene practices
3) Adverse habits
4) Family history
ORAL HABITS
1) Mouth breathing:
it is the adverse oral habit characterized by habitual
respiration of the patient occurring predominantly
through the mouth.

-It is characterized by presence of narrow arch of

maxilla, deep overjet and overbite, potentially competent
or incompetent lips and a tendency to develop a posterior
crossbite. 
2) Finger and thumb sucking:
It is the habitual prolonged sucking of the thumb or the
finger by the child patient. It may lead to many dental
problems such as hyperactive mentalis activity,
proclination of upper incisors, tendency to posterior
crossbite etc.

- it can be diagnosed by assessing the thumb of the child

which presents a shiny, clean area with calculus present at
the base of the nail. 
3) Nail biting:
it is the constant trimming of the nail parts by the patient at the
subconscious level.

-it presents with the features as retroclination of the upper incisors,

irregular nail margins, abrasion of lower incisor margins etc.

4) Tongue thrusting:
it is the habitual abnormal function of the tongue which protrudes
during the swallowing pattern to touch the lingual surface of the
lower incisors. -It is basically the persistence of infantile
swallowing. 
It presents with the features:
-open bite
-marginal gingivitis
-potentially competent/ incompetent lips etc. 
ORAL HYGIENE PRACTICES
 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 and method of brushing
-Use of fluoridated and non fluoridated tooth
pastes
-Type of brush and how often it is changed
ADVERSE HABITS
 It includes:
-smoking: record the type, frequency and duration

-alcohol consumption: record the amount,

frequency and duration

-tobacco chewing: record the type, amount,

frequency and duration 
FAMILY HISTORY
Family history is asked to assess the presence of any
inherited disease pattern or trait.

It includes:
-No. of siblings and their age
-Is there a history of this disease in your family?

For eg. Diseases like haemophilia, diabetes,

hypertension recur in families generation after
generation.
GENERAL EXAMINATION
PULSE: it is an important index of severity of the vascular
system and heart abnormalities.

It is useful to record:
• rate: fast or slow (normal rate is 60-100/min)
• rhythm: regular or irregular
• volume: high, normal or low pulse pressure

(normal pulse pressure is 40-60 mm Hg)

• tension and force
• character : some vascular diseases may show different pulse
character such as ‘water hammer’ pulse in aortic regurgitation,
‘pulsus paradoxicus’ in pericardial effusion etc. 
Blood pressure:
it is useful to determine:
the stroke volume of the heart and stiffness of the
arterial vessels.
to assess severity of hyper and hypotension and
aortic incompetence.
(normal level of blood pressure is 120/80 mm of Hg)
Body temperature
Respiration Cyanosis
EXTRA ORAL EXAMINATION
 SKIN:
skin is looked for:
-appearance
- any rashes, sores or itching may reveal a positive
history
-color : - anaemia patients have a pale skin colour,
yellow tint is seen in jaundice patients etc.
-texture
-signs
-pigmentation
-edema
 Facial symmetry: facial symmetry is important to note so as to
assess the fullness on both the halves of the face and to look for any
gross disorder that may reveal a significant history. It is noted as
symmetrical or asymmetrical.
 TMJ (temporomandibular joint):
observed for:
-symmetry: gross derangement in symmetry may reflect
growth disturbances.
-maximum interincisal opening (normal value- 35-50 mm)
-any deviation in opening
-range of vertical movement
-range of lateral movement
-Listen for clicking and crepitus sounds
-Note for tenderness over joint or masticatory muscles
Palpation of the joint area:
palpation of the pretragus area: the patient should be requested to
slowly open and close the mouth while the doctor bilaterally palpates
the pretragus depression with his/her index fingers.

intra-auricular depression: it is also performed by inserting a small

finger into the ear canal pressing anteriorly.

palpation is also used to detect the tenderness, clicking and crepitus.

-the masseter muscle is examined by simultaneously pressing it both
from inside and outside, termed as bimanual palpation.

the lateral pterygoid muscle is examined by inserting a finger each

behind the maxillary tuberosities, and the medial pterygoid by running
a finger in anteroposterior direction along the medial aspect of
mandible in the floor of the mouth.
LYMPH NODES:
palpation of lymph node is done to:
know the position
number of nodes
tenderness
fixity to underlying tissues

Palpation of the lymph nodes of the neck commonly begins

the most superior nodes and is worked down to the clavicle
to the supraclavicular nodes. 
The superficial and the deep lymph nodes of the neck
are best examined from behind the patient, with the
patient’s head inclined forward and sideways
sufficiently to relax the muscles near the lymph nodes,
and then palpated.

Also look for any distension present in the superficial

veins or any thyroid enlargement 
EYE
-Indicator of the anaemia and jaundice
Infection of the maxillary teeth may extend to orbital
region
 causing swelling of the eyelid and conjuctivitis .

NOSE
Size – should be 1/3rd of total facial height
Deviated nasal septum in mouth breathers
Saddle nose in congenital syphilis
THANK YOU