كميونتي

• Dental case history or case sheet


  An important and integral part of disease treatment, enables the clinician to take a proper case history which will lead to a proper diagnosis and a perfect treatment with good prognosis
• "Accurate diagnosis of a disease depends on the art of taking Case History"
• Case history


  A planned professional conversation that enables patients to communicate their feelings, fear and symptoms sequence to the clinician so that patients' real and suspected illness and mental attitude can be determined
• Recognizing the patient's need to talk without interruption particularly as they begin to presenting features of the illness will greatly help the dentist to establish a good relationship quickly
• Ways in which a case history is of immense value


  • To provide information regarding etiology and establish diagnosis of oral conditions
  • To reveal any medical problem necessitating precautions, modifications during appointments to ensure that dental procedures do not harm the patient and to prevent emergency situations
  • Evaluation of other possible undiagnosed problems& discovery of communicable diseases
  • Gives an insight into emotional and psychological factors
  • Record maintenance for future reference and periodic follow-up
  • For effective treatment planning & Acts as evidence in legal matters
• Components of Clinical Record Sheet


  • General Information
  • Chief complaint
  • History Recording
  • Examination of the patient
  • Establishment of provisional diagnosis
  • Necessary investigations
  • Final Diagnosis
  • Treatment plan
• General Information


  Makes the investigator familiar with the patient as it does contain personal details of the patient
• Information included in General Information

  • Patient registration number
  • Date
  • Name
  • Age
  • Gender
  • Education
  • Address, telephone numbers
  • Occupation
• Patient registration number


  Helps the investigator in record maintenance, identification of the patient, billing purposes, medicolegal aspect, survey and studies
• Date


  For the purpose of reference and record maintenance
• Name


  Leads to identification, record maintenance, communication with patient, psychological benefit (especially in case of children)
• Age groups of patients

  • Neonatal: At Birth
  • 1–3 Yrs: Infancy
  • 4–14 Yrs: Child
  • 15–20 Yrs: Young Adults
  • 21–40 Yrs: Adults
  • 40–50 Yrs: Older Adults
  • Above 50 Yrs: Old Age
• Reasons for recording age


  • Know whether he/she is a minor or not
  • Dental appointment time and duration is different for different age groups
  • Method of oral health education & instruction are different for different age groups
  • Diagnosis: Certain diseases occur at certain age groups
  • Treatment planning: Comparison of chronological age with dental age, growth spurts, behavior management techniques
• Gender

  Certain diseases are specific to the gender, timing of eruption sequence of teeth varies, likes and dislikes of child in behavior management technique may vary, drugs indicated/contraindicated during pregnancy, lactation
• Education


  Indicator of socioeconomic status, intelligence quotient (IQ) for effective communication, attitude towards general and oral health
• Address, telephone numbers


  For future communication and it gives a view of the socioeconomic status, presence of fluoride in drinking water, conditions endemic to certain areas
• Occupation


  Indicator of socioeconomic status, predilection of certain diseases
• Chief complaint


  The problem for which the patient is seeking treatment, recorded in patient's own words, aids in the diagnosis and treatment planning
• Common chief complaints


  • Pain
  • Bad taste
  • Bleeding from gums
  • Loose teeth
  • Hypersensitivity
  • Burning sensation
  • Recent occlusal problems
  • Delayed tooth eruptions
  • Swelling
  • Esthetic problems
• Questions to ask for chief complaint

  1. When did the problem start?

  2. What did you notice 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?
• While recording the chief complaint, what appeared first should be mentioned first
• History of present illness


  The history commences from the beginning of the first symptom and extends to the time of the examination, including onset, duration, type (nature) of pain, severity of pain, location and site, prior occurrence, exacerbating factors, relieving factors, associated phenomenon, previous medications
• Past dental history


  Includes the frequency of past dental visits, a history of dental sensitivity, pain, infection, soft tissue lesions, bleeding, swelling, age and condition of existing dental prostheses, and a history of oral surgery or any other dental treatment
• Medical history


  Includes history of past illnesses, diseases or conditions that contraindicate certain kind of dental treatment, diseases that require special precautions or premedication prior to dental treatment, diseases with medication that contraindicates the use of additional medication, allergies, diseases that endanger the dentist/other patients, physiological state of patient, medications or hospitalizations
• Clinical Examination


  Includes adequate knowledge of the anatomy and physiology of the region, a well practiced technique for examination with minimal discomfort to the patient, knowledge of the disease process affecting the head and neck region
• Intraoral Examination


  • Examination of lips and labial mucosa, buccal mucosa, floor of the mouth, tongue, hard and soft palate
  • Periodontal & dental caries examination
  • Developmental anomalies of teeth & enamel hypoplasia and malocclusion
  • Tooth wear (Erosion, Abrasion, Attrition)
  • Dental Fluorosis
  • Oral hygiene evaluation (poor, fair, good)
• Extraoral examination


  • Examination of skin, head, face, nose, paranasal sinuses, external ear, nasal mucosa, lips, cheeks, TMJ, muscles of mastication and salivary glands
  • Asymmetry in lymph nodes
  • General appearance like general petechial or ecchymoses, yellowing (jaundice), cyanosis, pale nail bed
• Establishment of provisional diagnosis


  Reviewing the patient's history and examination data, listing items that may suggest the possibility of a significant health problem, grouping items into primary and secondary, acute and chronic, high priority versus low priority
• Investigations


  • Radiographic investigations
  • Biochemical investigations
  • Histopathological investigations
  • Pulp vitality testing
  • Hematological investigations
  • Urine analysis
  • Microbiological investigations
  • Special investigations like MRI, CT Scan
• Final Diagnosis


  All the records, clinical findings, the provisional diagnosis and investigations are clubbed together to frame the final diagnosis on which treatment is planned, patients must be informed of their diagnosis and the nature, significance and treatment of the health problem that has been clearly diagnosed
• Phases of Comprehensive treatment plan


  • Emergency phase (eliminate pain and manage the acute infections)
  • Preventive phase (control the disease process)
  • Promotive phase (oral health promotion)
  • Curative phase (therapeutic phase)
  • Rehabilitation phase (restore the mouth to full function)
  • Maintenance phase (recall, review and reassessment)
• Gingival Index (GI) of Löe and Silness (1963)


  Index that measures the severity of gingivitis based on color, consistency, and bleeding on probing
• Gingival Index (GI) measurement


  1. Examine each tooth at the mesial, lingual, distal and buccal surface

  2. Dry teeth and gingiva and examine under adequate light, using a mouth mirror and blunt probe

  3. Use a blunt probe to press on the gingiva to determine its degree of firmness, and to run along the soft tissue wall adjacent to the entrance to the gingival sulcus to evaluate bleeding
• Excluded teeth


  • Partially erupted teeth
  • Teeth with periapical lesion
  • Retained roots
• Index teeth


  • 6
  • 2
  • 4
  • 4
  • 2
  • 6
• Score 0


  No inflammation
• Score 1


  Mild inflammation, slight change in color, slight edema, no bleeding on probing
• Score 2


  Moderate inflammation, moderate glazing, redness, edema and hypertrophy, bleeding on probing
• Score 3


  Severe inflammation, marked redness and hypertrophy, ulceration, tendency to spontaneous bleeding
• Gingival Index (GI) interpretation


  • 0.1 - 1: Mild gingivitis
  • 1.1 - 2: Moderate gingivitis
  • 2.1 - 3: Severe gingivitis