History taking: Includes patient communication skills, chief complaint, past dental history, medical history and family history, risk assessment associated with common medical conditions with regards to dental extraction. Clinical examination and diagnosis: Components of clinical examination with demonstration of extra oral and intra oral examination (lymph node palpation, TMJ palpation with the focus on the accused tooth/teeth),diagnosis of cases in patients case sheet with regards to dental extraction

1. Dr. Tabark Mohammed Ghadi
History Taking
________________
Al- Iraqia University / Collage of dentistry
Oral Surgery Department
Lab.1

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Personal history
Past dental history
Chief complaint
Component of patient history :
History of the present illness
Past Medical history
Social history
Drug history
8 Family history

4. Personal history ( Biographic data )
• Patient Name ( communication, confidence)
• Age ( disease associated with age)
• Gender
• Occupation ( socio - economic status / education )
• Address (Traveling time to surgery)
• Phone No. ( contact )
• Date

5. Chief Complain (CC)
• In the patient‘s own words .
• Why did you come to see us today?/ what is
the problem?
• The main’s complaint in the Oral surgery clinic
is ( pain , swelling , mobility , ..)
• The aim of (C/C) is : to have provisional
differential diagnose even before examining
the patient .

6. History of present illness (HPI)
 If pain :
1. Onset (when pain is start “ early & late onset ")
2. Duration (How long pain is persist “ seconds , min , hours or continues “ )
3. Nature (sharp , Throbbing , dull ache or electric)
4. Site ( Local or radiated )
5. Interfere with sleeping ( yes / no )
6. Aggravating factors ( cold , sweets & spontaneous)
7. Relieving factors ( after removal of the stimulus / analgesic)
8. Associated phenomena ( headache , nausea , vomiting )

7. Past medical history (PMH) / Systemic review
• Blood Pressure ( Yes / No ? ) , last reading …..
• Diabetes Mellitus ( Yes / No ? ) , last reading ….
• Cardiovascular Disease ( Yes / No ? )
• Respiratory Disease ( Yes/No ? )
• Thyroid Disease ( Yes/No ?)
• Bleeding Disorder (Yes /No ?)
• GIT Disease (Yes/No? )
• Epilepsy (Yes/No?) , last seizure …….
• Previous Hospitalization ? ( Yes /No ? )
• Female : Are you pregnant ? (Yes/No ?) , Which month ……
• Any other medical history ?

8. Drug History
• Allergy : penicillin .
• Regular drugs : anticoagulants , antiplatelets , corticosteroids .
Are you currently on any medication (Yes/No?) , ……….
Are you allergic to penicillin (Yes/No ?) , ……..
Are you allergic to any other medication (Yes/No?) , specify …….

9. Social history
• Habits ( Smoking / Alcohol )
 non smoker
Ex smoker
Smoker : How many cigarette/day ?
Alcohol consumption ?

10. Family history
• Previous extraction ( Yes / No ? )
• Any complications occur at previous extractions . ( Yes / No ? )
• Diabetes , Hypertension , Heart disease , Malignancies , Cause of death

11. Clinical Examination
 Facial swelling
 Facial symmetry
 Lymphadenopathy
 Color of skin
 Color of sclera
 TMJ ( clicking , limitation in
mouth opening , pain ? )
Extra-oral examination
 Oral hygiene (good, fair , poor )
 Gingival & periodontal condition
 Oral Mucosa
 Palate
 Tongue
 Floor of the mouth
Intra-oral examination

13. Investigations
• Viral screen
1. HBV ( Negative , Postive ? )
2. HCV ( Negative , Positive ? )
3. HIV ( Negative , Positive ? )
• Radiogragh
1. Periapical view
2. Panoramic OPG
3. CBCT