6. Case history (case sheet)
Planned professional conversation enables the patient to
communicate his feeling, fear, and sequence of events lead to
the problems for which the patient seeks professional
assistance.
7. Value of a case history
1. Provide info regarding etiology and establish diagnosis.
2. To reveal any medical problem necessitating precaution.
3. Evaluation of other undiagnosed problems.
4. Discover any communicable diseases.
5. Gives an insight in to emotional factors
6. For effective treatment planning.
7. Record maintenance for future reference.
8. Acts as an evidence in legal matters.
8. Components of clinical case sheet
General information
Name : ---------------
Age : -----------------
Gender : -------------
Address : ---------------
Demographic information
9. chief complain C/C
Condition that make patient seeks dental treatment it is recorded
in patient own words as much as possible.
It is the answer for the question “why are you here today?”
Also called presenting complain or complaining of.
if pain is the C/C then we should take HPI (history of present
illness).
10. MEDICAL HISTORY
Information about general body health
• C.N.S
• Growth and development.
• Endocrine system.
• C.V.S.
• Respiratory system.
• G.I.T. system.
• Allergies.
• Medications.
• Hospitalization.
11. If no medical problem is present then we elicited that there is no sign and
symptoms of any systemic disease.
• Symptoms: it is the subjective evidence of a disease perceived by the
patient.
• Sign: it is the objective evidence of a disease elicited by the clinician.
12. Examination
Extra oral examination
Detection of any swelling or
asymmetry in face, extra oral
drainage sinus, pale color of
skin and sclera, and
infection like herpes labialis.
Intra oral examination
Soft and hard tissue
findings.
Oral hygiene, periodontal
condition, carious teeth,
Chart present teeth,
occlusion.
13. Investigation and Final diagnosis
Diagnosis: it is the process of identifying a disease
by its sign and symptoms and also it means
through knowledge.
14. Treatment plan
It is a schedule of procedures and appointments
designed to restore step by step patient’s oral health
and eliminate etiologic factors.
• Treatment of the chief complaint of dental pain will of course
be the priority .
15. Four steps to develop a plan
1. Examination and problem identification
2. Decision to recommend intervention
3. Identification of treatment alternatives.
4. Involve the patient with treatment selection.
16.
17. Basic dental patient examination setup
consists of a
1. mouth mirror.
2. cotton pliers (tweezers).
3. Explorer.
4. cotton dispenser (container)
with cotton.
5. Concentrated sterilized solution.
6. saliva ejector.
7. towels.
8. Mask and gloves.
19. Tooth Numbering Systems
tooth designation systems in general use are
Universal, adopted by the American Dental Association
F.D.I. (or International),the Fédération Dentaire Internationale
Palmer numbering system
European plus / minus system.
20. Universal or ADA System
◦ Permanent Teeth
◦ Start with the right maxillary third molar (number 1) and follow around the
arch to the left maxillary third molar (16); descend to the left mandibular third
molar (17); and follow around to the right mandibular third molar (32).
21.
22. • Primary or Deciduous Teeth
Use continuous upper case letters A through T in the same sequence as for
permanent teeth: right maxillary second molar (A) around to the left maxillary
second molar (J); descend to the left mandibular second molar (K); and around to
the right mandibular second molar (T).
23.
24. International or F.D.I. System
• Permanent Teeth
• Each tooth is numbered by the quadrant (1 to 4) and by the tooth within the quadrant (1 to
8).
• Quadrant Numbers.1 Maxillary right 2 Maxillary left 3 Mandibular left 4 Mandibular right
(clock wise)
• Tooth Numbers Within Each Quadrant Start with number 1 at the midline (central incisor) to
number 8, third molar.
• Designation. The digits are pronounced sepa- rately. For example, ‘‘two-five’’ (25) is the
maxillary left second premolar, and ‘‘four-two’’ (42) is the mandibular right lateral incisor.9
25.
26. Primary or Deciduous Teeth
Each tooth is numbered by quadrant (5 to 8) to continue with the permanent quadrant numbers. The
teeth are numbered within each quadrant (1 to 5).
Quadrant Numbers
5 Maxillary right 6 Maxillary left 7 Mandibular left 8 Mandibular right
Tooth Numbers Within Each Quadrant.
Number 1 is the central incisor, and number 5 is the second primary molar.
Designation. The digits are pronounced sepa- rately. For example, ‘‘eight-three’’ (83) is the
mandibular right primary canine, and ‘‘six- five’’ (65) is the maxillary left second primary molar.
27.
28. Palmer notation
(chevron system)
◦ With number 1 for each central incisor, the teeth in each quadrant are numbered to 8,
the third molar. To identify individual teeth, horizontal and vertical lines are drawn to
indicate the quadrant. For example, the left maxillary first premolar is 4 , the right
mandibular first and second molars are 76 . An entire quadrant may be represented by
the use of the letter Q, for example, the maxillary right quadrant is Q .
29.
30. Primary or Deciduous Teeth
Upper case letters A through E are used instead of the numbers. Examples are the mandibular left canine C
and the maxillary right first primary molar D .
31. European system
(plus/minus system)
◦ This system uses (+) for the maxillary teeth and (-) for the mandibular
teeth for permanent teeth , the teeth of each quadrant are numbered
from 1-8 beginning with central incisor .
◦ In primary teeth, the teeth of each quadrant are numbered from 01,02
to …. 05.