CASE HISTORY

Submitted to :
The Department of Pedodontics

Submitted by :- 3rd Year (Old)

Aaditya Gadhvi - Roll no.1
Aarya Parmar - Roll no.2
 INTRODUCTION
The first step towards treating a patient
is to achieve an accurate diagnosis for
which comprehensive history taking and
thorough clinical examination is essential.
 DEFINITIONS
 CASE HISTORY - 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 patient's illness &
his/her attitude towards them.

 DIAGNOSIS – It is the process of identifying a

disease by its signs , symptoms and result of
various diagnostic procedure.
 SYMPTOMS – It is the subjective evidence of
a disease perceived by the patient


SIGNS – Any abnormality indicative of
disease , discovered on examination of the
patient ( an objective symptom of disease).


DIFFERENTIAL DIAGNOSIS – The
process of listing out two or more diseases ,
having similar signs and symptoms of which only
one could be attributed to the patient’s suffering.
PROVISIONAL DIAGNOSIS – A general
diagnosis based on clinical impression
without any laboratory investigation.
 FINAL DIAGNOSIS - A confirmed diagnosis
based on all available data.

 ANTICIPATORY GUIDANCE - It is the term

often used to describe , discuss and
implement diagnosis and treatment plan
with the patient and / or parent.
 HISTORY TAKING
It includes :-
A ) Personal information
B ) Chief complaints
C ) Medical History
D) Dental history
E ) Parent History
F ) Prenatal History
G) Birth History
H) Postnatal History
 PERSONAL INFORMATION

 Date
 Name of the patient
 Age
 Sex
 Hospital number / Case number
 School and Class
 Address
 DATE
It includes the time the patient reported and can
be referred back to during the follow-up visit.

NAME OF PATIENT
 Asking the name is verbal communication
which establishes the rapport with the
patient.
 Give a sense of importance and
acceptance to the patient.
 AGE
 The chronological age ( date of birth ) should be
noted to compare with other ages
(dental ,skeletal)so as to know whether growth and
development is normal in the child.
 Certain diseases are known to occur frequently at
particular ages .
eg :- primary herpetic gingivostomatitis - 6 months
to 6 years.
Nursing caries is seen in preschool age group only.
 SEX

 Girls mature faster than boys and thus their

treatment may be required earlier.
 Some diseases show specific sex predilection.
eg :- anorexia is more common in females while
hemophilia may be found exclusively in males.
 A combination of age and sex can sometimes
give an indication of the occurrence of a
disease.
eg :- pubertal gingivitis in adolescent females
HOSPITAL NUMBER / CASE NUMBER
For the purpose of maintaining a record ,
billing the individual and for legal
considerations.

SCHOOL AND CLASS

 To know economic status and to
communicate with the teacher .
 It also help in assessing the IQ of the
child .
 ADDRESS

 Use for all communications

 Socio-economic status can be assessed
 If the patient coming from a far distance ,
the appointments can be modified to
complete treatment in fewer visits.
 CHIEF COMPLAINTS
 Detailed information of the chief complaints
helps in establishing the diagnosis.
 Always recorded in patients own word.
 Most common presenting illness can be
evaluated under:
1. The onset
2. The duration
3. The location
4. The quantity , quality , severity and frequency of
occurrence.
5. Aggravating and relieving factors.
6. Associated symptoms.
 MEDICAL HISTORY
 It helps to identify conditions relevant to the
patients dental health or which could have an
impact on how treatment is carried out.
eg : conditions which require antibiotic
prophylaxis or prescription of certain drugs.
 History of child being hospitalized , previous
general anesthesia and surgical procedures ,
are traumatic psychological experiences and
may sensitize the young child to dental
procedure.
 DENTAL HISTORY

 Patient’s previous dental history should be recorded.

eg : history of previous treatment and its duration.
 Patient’s present oral hygiene habits and fluoride
exposure should be recorded.

PARENT HISTORY
 A dental visit and treatment performed would point
towards the attitudes of the parents.
 Any genetic / inherited abnormalities should be
interviewed into.
 PRENATAL HISTORY
 It may disclose information that can be
linked to the present condition.
eg: tetracycline stains on teeth.
• Accident / trauma of the mother during
pregnancy.
Eg : Trauma may result in orofacial deformity.
 BIRTH HISTORY
If any problem were encountered at birth :
 Rh incompatibility - may result in ‘
erythroblastosis fetalis’.
Effects may be seen in dentition as “ HUMP “ on
the
tooth and characteristic “ BLUE-GREEN “
discolorations.
 Other problems :-
1. Neonatorum jaundice
2. Cyanosed or blue baby
3. Trauma due to forceps delivery
4. Premature delivery
 POSTNATAL HISTORY

 It includes the amount of time the child

was breast fed , bottle fed , if the bottle
was misused and type of nipple used etc.
 Vaccination status need to be assessed
along with the present medical illness, if
any.
 Presence of any habit and its duration ,
frequency and intensity need to be
evaluated.
CLINICAL EXAMINATION

1.General examination
2. Extraoral examination
3.Intraoral examination
 GENERAL EXAMINATION

 Child’s stature, gait gives the overview of

the nutrition , general health and
neuromuscular coordination and
development etc.
 EXTRAORAL EXAMINATION

 Head
 TMJ
 Lymph nodes
 SHAPE OF THE HEAD

Cephalic index (CI) = maximum skull width

maximum skull length
Based on the classification by Martin and Saller
(1957),
shape of the head can be classified as :
Mesocephalic – average , cephalic index (CI) is
76.0- 80.9
Dolichocephalic – long & narrow , CI is < 75.9
Brachycephalic – broad & short , CI is 81.0-85.4
Hyperbrachycephalic – CI is > 85.5
 TEMPOROMANDIBULAR JOINT

TMJ function is evaluated by palpating the head

of the mandibular condyle extraorally
and observing the patient while the
mouth is closed and in various
positions of mouth opening.

Any abnormalities detected such as

trismus ,deviation of mandible to
one side , clicking of the joint and
symptoms of pain during mouth
Examination of TMJ
opening should be recorded. during the act of
opening and closing
 LYMPH NODES

Palpation of commonly involved lymph nodes

( submental and submandibular ) shows an acute
or chronic infection.

Examination of Examination of
submandibular cervical
lymph node lymph node
 INTRAORAL EXAMINATION

It includes : -
a. Oral soft tissues
b. Oral hard tissues
 Oral soft tissues EXAMINATION

SKIN / LIPS :- for presence of any sinus / fistula

etc.
MUCOSA :- any ulceration , growth ,pallor of
mucosa indicating anemia ,
yellowish
discoloration.
PALATE :- the hard and soft palate are
inspected for
any developmental anomaly like
clefts and
manifestations of systemic
diseases.
GINGIVA :- normal gingiva in child is different
TONGUE :- should be examined for developmental
anomaly , lesion and swallowing
pattern.
TONSILS / ADENOIDS :- oropharynx should be closely
examined for any enlargement or purulent exudate.

Examination of buccal
mucosa
 ORAL HARD TISSUE
EXAMINATION

The teeth present have to be recorded so

that the dental age can be assessed along
with the stage of development of the
dentition.
 FDI Scoring System
It is one of the commonly used numbering systems.
Quadrants are alloted initial numbers as:
upper right upper left
Primary 5 6
8 7

upper right upper left

Permanent 1 2
4 3

Then the tooth in each quadrant is numbered as:

Primary
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75

Permanent
18 17 16 15 14 13 12 11 21 22 23 24 25 26
27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36
 INDICES

Commonly used indices are :-

1. Caries index (Palmer & Knutson,
1938 )
2. Plaque index ( Silness and
Loe ,1964)
3. Gingival index ( Loe and Silness ,
1967)
 CARIES INDEX
W.H.O (1987) criteria for primary and permanent teeth
Permanent tooth code condition/status
primary tooth code
0 Sound A
1 Decayed B
2 Filled, with decay C
3 Filled, no decay D
4 Missing as a result of caries E
5 Missing due to any other reason -
6 Sealant, Varnish F
7 Bridge abutment or special crown G
8 Unerupted tooth -
9 Excluded tooth -
 PLAQUE INDEX
(Silness and LOE,1964)
 PLAQUE has been defined as a specific, highly
selective entity resulting from a sequential
colonization of microorganisms on the surface of
the teeth, soft tissues, restorations and appliances.

 Rather than examining the whole dentition, a few

‘Index teeth’ are selected:
 Permanent dentition - 16, 12, 24, 36, 32, 44
 Primary dentition - 55, 52, 64, 75, 72, 84
 Mixed dentition - 16, 52, 64, 36, 32, 84
Scoring Criteria:
0 -No plaque in the gingival area
1 - A film of plaque adhering to the free gingival
margin and adjacent area of the teeth. Only
running a probe across the teeth surface may
recognize the plaque.
2 - Moderate accumulation of soft deposits
within the gingival margin and/or adjacent tooth
surface that can be seen with naked eye.
3 - Abundance of soft matter within the gingival
pocket and/or the gingival margin and adjacent
tooth surface.
Calculations
A. Plaque index for a tooth =
Add scores from 4 areas of
tooth

--------------------------------------------------
4
B. Plaque index for a individual =
Add scores for each tooth
---------------------------------------------
No. of teeth examined

INTERPRETATION SCALE
1. 0.0 - Excellent
2. 0.1-0.9 - Good
3. 1.0-1.9 - Fair
 GINGIVAL INDEX
(Loe and Silness, 1967)
 It has been developed for the purpose of
assessing the severity of gingivitis and its
location in four possible areas of an individual
tooth.
 Same teeth are examined as in plaque index.
 Each tooth is divided into four parts:
1. Distofacial papilla
2. Midfacial papilla
3. Mesiofacial papilla
4. Entire lingual gingival margin
 Score Criteria
0 - Normal papilla
1 - Mild inflammation, slight change in color,
slight edema; No bleeding on probing.
2 - Moderate inflammation, redness, edema, and
glazing; Bleeding on probing
3 - Severe inflammation, marked redness and
edema, ulcerations; Tendency for spontaneous
bleeding
CALCULATIONS
Gingival index score per tooth =
Total score
---------------------------
4
Gingival index score for a person =
Total of all scores
--------------------------------------
No. of teeth examined

INTERPRETATION
1. 0.1-1.0 Mild
2. 1.1-2.0 Moderate
3. 2.1-3.0 Severe
 PROVISIONAL DIAGNOSIS
 On the basis of history and clinical examination ,
one should arrive at a provisional diagnosis.

DIFFERENTIAL DIAGNOSIS
 The list of most likely and probable diagnosis
based on the available information is called
differential diagnosis.
 It distinguishes one disease from several other
diseases with similar signs and symptoms by
identifying their differences.
 DIAGNOSTIC AIDS
Before arriving at a diagnosis , investigations such
as
• radiographs
• Blood and urine examination
• Biopsy
Should be carried out to confirm the diagnosis.
 TREATMENT PLANNING
After completion of diagnosis , treatment
planning requires careful considerations of the
information assembled after examining the
patient , study models and radiographs.

ADVANTAGES
o Re-diagnosis at every visit is avoided.
o Instruments can be prepared well in advance.
o Total fee estimation can be done.
 PRESENTATION OF TREATMENT PLAN TO
PARENTS

 Good communication is important

 Relaxed environment and informal attitude
 Use of visual aids
 CONTENTS OF PRESENTATION

Includes :-
 Dental need of their child
 Restorative procedure required
 Amount of time required to perform the
treatment
 Total cost
 Preventive measure necessary
THANK
YOU