Case History

1. Case History By Dr.Mohamed Barakat

2. Introduction * In general , and simple words , case history is nothing but an evaluation of the patient prior to dental treatment *it is a professional conversation to communicate with the patient as concern symptoms, signs , and nature of the patient illness

3. Introduction * In general , and simple words , case history is nothing but an evaluation of the patient prior to dental treatment *it is a professional conversation to communicate with the patient as concern symptoms, signs , and nature of the patient illness

4. Case History By Dr.Mohamed Barakat

5. A case history is important in order to reach up:- *establish the diagnosis. *detect an medical background. *search for other systemic problem. *manage emergencies. *reach up the final and effective . working treatment plan .

6. Steps of Diagnostic procedures • 1) taking and recording the case history . • 2) physical examination . • 3) relevant investigation to help . reaching the diagnosis . • 4) establishing the diagnosis . • 5) medical risk assessment of the • case . • 6) outlining the treatment plan . • 7) prognosis of the case . • 8) final working plan

7. Methods Of Recording The Case History * Traditional approach through questionnaire * Newer techniques of case history recording as:- . Computer data gathering . interviewing (problem oriented records) (POR) . . CD methods . . Other methods

8. Sequence of Case Recording and Evaluation • . Statistics . • . Chief Complaint. • . History of chief complaint. • . Medical History . • . Past dental History . • . Family History . • . General Examination

9. . Extra Oral Examination . . Intra Oral Examination . . Provisional Diagnosis . . Prognosis . . Investigations . . Final Diagnosis . Working Treatment .

10. Statistics * Defined being a systemic approach to collect all data information to vital events e.g live , birth ,death , social structures and legalization . * Patient registration number : - . Social security number . Billing purposes . Insurance . Medico legal aspect (liability) * Date : . For reference . For records * Name : . For identification . Communication . Patient records / Statistics * Age / Sex : . Treatment planning . Behavior management techniques . Statistics

11. Age : - • *Age is sometime / most of the time • is an important marker and predilection of certain diseases at • different age levels . • e.g. common disease at birth • . Cleft palate / hair lips • . Hemophilia • . Tongue tie ……. etc

12. * Diseases occur in children and adults: . Juvenile periodontitis . Scarlet fever . Mumps . Measles

13. * Diseases commonly occur in adults : .Attrition / Abrasion .periodontitis / Mobility .Impacted wisdom . Pulp stones . Root resorption .

14. Sex : • Knowing the sex of the patient is important for : • *Diagnosis of different types of diseases having sex predilection to sex : • 1)Diseases more common to female :- • . Iron deficiency anemia • .Juvenile periodontal disease • . Oesteoporosis

15. Diseases more common to males : • . Oral carcinoma • . Hemophilia • . Attrition • . Diabetes mellitus

16. *Education : . Socioeconomic status . I.Q for effective communication . Attitude towards general oral health care

17. * Address : • . Socioeconomic level . Prevalence of diseases/epidemic . Records . To follow up case . Vaccination

18. * Occupation : . Assessing socioeconomic status . predilection of some diseases to occupations . Hepatitis B- which more likely related to dentists / surgeons

19. * Religion : . Predilection of diseases to specific religion . Festive periods which religious people seams reluctant to treatment procedures

20. Chief complaint

21. *Chief complaint is established thru asking the patient to describe the problem for which he / she came up for, seeking help for treatment . * Chief complaint should be recorded in patient’s own words as much as possible wit NO leading questions or technical language .

22. * The chief complaint aids and helps to get the diagnosis of the case as a first priority .

23. ** Common chief complaints . Pain . Burning sensation . Bleeding . Lose of teeth / Mobility . Recent occlusal problem . Delayed teeth eruption . Xerostomia . Swelling . Halitosis/ Bad taste . Parasthesia / anaesthesia

24. ** History of Present illness Helps the patient to express his own words describing his present systemic by possible questionnaire about his / her symptoms e.g. : . when the problem start. . what did you noticed first . Did you have problems or symptoms related to this complaint . Did you have those symptoms before . Have you been through any tests before. . have you consulted any doctor before . what have you done to treat this problem

25. In general symptoms can be verified; as follow :- * Mode of onset * Cause of onset * Duration * Progress and referred pan * Remission and exacerbation * Treatment * Negative history

26. Past Dental history • Past dental history is important to : • * Detect the general attitude of the • patient as concern dentistry/dentist. • * Detect patient awareness about oral • health . • * Detect any previous bad experience • about dental treatment and / also his • behavior against his dentist . • * signifying the patient’s previous • treatment procedures and his attitude • towards his present situation.

27. Past medical history • * Recording of past medical history including • history of past illness , hospitalization ,and • evaluation of his general health . • * All disease experienced by the patient • should be recorded in chronologic order . • * patient should be evaluated for :- • . Cardiovascular disease • . Endocrine disease • . Hematologic diseases • . Allergic reactions • . Neurologic diseases • . Joint disorders . • . Kidney , urinary ,and gastrointestinal diseases • . Respiratory Diseases

28. Personal History • THIS INCLUDES : • * Oral Habits . • *Oral Hygiene . • * Family Histology. • *Adverse Habits.

29. *ORAL HABITS : . Mouth Breathing . Upper respiratory Track Problem . Xerostomia . Finger / Thumb Sucking . Nail Biting . Tongue Thrusting Those habits my be accompanied by :- . Open bite / Truma from occlusion . Deep overbite/Over jet . Protrusion of anterior teeth . Generalized marginal gingivitis Adverse Habits : . Smoking and tobacco chewing . Alcohol consumption

30. ** Family History : Family history is important to assess for any disease that having a family Background (inherited pattern ) e.g. hemophilia , diabetes , hypertension ,and / also to detect any particular disease among the family

31. General Examination • * This includes the vital signs : • . Pulse • . Blood pressure • . Body temperature • . Respiration • . Cyanosis

32. Extra Oral Examination • * Skin (colour,texture,odema , pigmentation ) • * Facial Symmetry • * TMJ Disorder • * Lymph Nodes • * Eye , Nose , and Ear

33. Intra Oral Examination • ** Soft Tissue • .Tongue(volume, integrity,cracks,ulcers • fissures, tongue tie ) • . Palate (cleft , perforation, ulceration ) • . Floor of the mouth • . Buccal Mucosa • . Parotid gland • . Submandibular / Sublingual Gland

34. ** GINGIVA . Color . Pigmentation . Contour ( scalloped) . Shape . Size . Shape . Consistency (firm, resilient, soft) . Texture (stippled ) . Size (hypertrophy / hyperplasia ) . Bleeding tendency ( on probing)

35. ** Periodondium * Plaque * Calculus * Pocketing (supra/subgincival) * Tooth mobility

36. Furcation involvement • *progression of the inflammatory periodontal • diseases may extend to involve bifurcation and • trifurcation multirooted tooth area is called • ( Furcation involvement) • * Grades : • . Grade 1: incipient stage, affects soft tissue • with suprabony pocket • . Grade 2: lesion is called “cul-de- sac” having • definite horizontal resorption • . Grade 3: bone is destroyed and detached at • area of furcation with a free pass of the • probe thru furcation area • . Grade 4: complete destruction of interdental bone and • soft tissue

37. Hard tissue examination • ** TEETH • . Carious and filled teeth • . Missing rotated teeth • . Milky , mixed and permanent teeth • . Flurosis , root • . Congenital deformities • . Attrition: wear off due to toot to • tooth contact • . Erosion: loss of tooth surface by chemical • or electrochemical agent • . Abrasion: Friction between tooth and exogenous • agent

38. Provisional Diagnosis • * Provisional diagnosis is also called tentative • diagnosis or working diagnosis after • evaluating case history and performing • physical examination • * provisional diagnosis is just temporary one • * Differential Diagnosis should be kept in • mind to reach out the exact and specific • diagnosis • * Final Diagnosis may be possible “ ONLY “ • after carrying out further investigation , • and laboratory investigations

39. Final Diagnosis • Final diagnosis can be reached up by chronologic organization and critical • evaluation of the information that • obtained from patients case history • and physical examination which must • be supported by radiographic and / also • laboratory investigations .

40. Treatment Plan

41. Emergency phase : • * This is the first and preliminary phase of treatment plan • * Emergency complication is the first • to be treated and managed

42. Preventive phase • This is the second line of treatment involving protection and prevention of high risk factor

43. Preparatory Phase • Oral prophylaxis includes .. caries • control, endodontic treatment,as well • as extraction , periodontal surgeries • and orthodontic consultation

44. Corrective Phase • Permanent restorations and / also • prosthetic replacement, crowns and • bridge construction and space maintainer • Maintenance phase • Follow up phase

45. PROGNOSIS • Prognosis defined as “fate of the Disease” e.g. the outcome of the disease based on general knowledge of the pathogenesis of the disease and the presence of risk factor and / also • The systemic background of the disease . • Prognosis should be discussed and explained to the patient as concern his awareness and his considerations . • Then the final treatment protocol is now easily determined

46. END