Case history is one of the most important step before planning and starting patient's treatment. It gives an overall picture of the patient's current and past dental status and his attitude towards treatment outcomes. It also gives the clinician the idea about the affordibility of the patient for the treatment so that alternate treatment options can be provided. It creates a initial good rapport between the clinician and the patient.

1. CASE HISTORY
BY- DR.OINAM MONICA DEVI

2. DEFINITION
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.

3. Objectives
 To establish a positive professional relationship.
 To provide the clinician with information concerning
the patient’s past dental, medical & personal history.
 To provide the clinician with the information that may
be necessary for making a diagnosis.
 To provide information that aids the clinician in
making decisions concerning the treatment of the
patient.

4. CONTENTS

5.  NAME
 AGE/SEX
 OPD NO.
 ADDRESS
 OCCUPATION
 SOCIO ECONOMIC STATUS
 MARITAL STATUS
 CHIEF COMPLAINT
 HISTORY OF PRESENT ILLNESS
 PAST DENTAL HISTORY
 MEDICAL HISTORY
 TREATMENT HISTORY
 FAMILY HISTRY
 PERSONAL HISTORY

6. INDICES
PROVISIONAL DIAGNOSIS
RECORDS
INVESTIGATIONS
FINAL DIAGNOSIS
PROGNOSIS
TREATMENT PLAN
RECALL

7. CLINICAL EXAMINATION
EXTRA ORAL
• SWELLING/ASYMMETRY
• TMJ EXAMINATION
• LYMPH NODES/PARA ORAL STRUCTURES
INTRA ORAL
• MALODOR
• OCCLUSION
• EXAMINATION OF OTHER ORAL STRUCTURES
• SALIVA
• HIGH FRENAL /MUSCLE ATTACHMENT
• HARD TISSUES:TEETH
• SOFT TISSUES:GINGIVA
• PERIODONTAL LIGAMENT EXAMINATION

8. NAME
 to communicate with the patient
 to establish a rapport with the patient
 Record maintenance
 Psychological benefits

9.  AGE/SEX
Disease common in children : tongue tie, cleft lip etc
Diseases common in adults : diabetes, attrition etc
SEX SIGNIFICANCE-
Certain diseases are gender specific:
 Diseases common in males: Attrition, leukopakia, cancer like
squamous cell carcinoma, melanoma, lymphoma etc
Diseases common in females: Iron deficiency anemia, sjogren’s
syndrome, osteoporosis, recurrent apthous ulcers etc
Drug interaction :- in females, special consideration must be
given to pregnancy & lactation.

10. OPD NUMBER
Useful for maintaining a record
billing purposes
medico legal aspects

11. ADDRESS
For future correspondence
Gives a view of socio-economic status -to know about
the nourishment, hygiene & payment capacity of the
patient
 Prevalence of diseases like fluorosis as a result of
increase level of fluorides in water are spread
differently in various parts of the country.

12. OCCUPATION
 To asses the socioeconomic status.
 Predilection of diseases in different occupations for eg: hepatitis B is
common in dentists & surgeons.
MARITAL STATUS
 To see any history of consanguineous marriages
 The high consanguinity rates, coupled by the large family size in
some communities, could induce the expression of autosomal
recessive diseases.

13. CHIEF COMPLAINT
The chief complaint is usually the reason for the patient’s
visit
It is stated in patient’s own words in chronological order of
their appearance & their severity
The chief complaint aids in diagnosis & treatment therefore
should be given utmost priority
Commonly encountered chief complains are pain, gum
bleeding, foul breath, ulcers etc

14. HISTORY OF PRESENT ILLNESS
 Elaborate on the chief complaint in detail
 Ask relevant associated symptoms
 The symptoms can be elaborated in terms of:
 Mode & cause of onset
 Duration
 Location-localized ,diffuse , referred, radiating
 Progression- continuous or intermittent
 Aggravating & relieving factors
 Treatment taken

15. PAST DENTAL HISTORY
The frequency of past dental visits
Previous restorative treatment
Previous periodontic treatment
Previous endodontic treatment
Previous oral surgical treatment
Reasons for loss of teeth
Untoward complications of dental treatment
Fluoride history including supplements & the use of well
water
Attitudes towards previous dental treatment
Experience with orthodontic appliances and dental
prostheses
Radiation or other therapy for oral or facial lesions

16. MEDICAL HISTORY
 Includes the information about past & present illness
 All diseases suffered by patient should be recorded in
chronological order
 It should include
 If patient is under the care of a physician, nature & duration
of problem
 Hospitalizations & operations, complications
 Medications
 Medical problems (eg. Diabetes, Hypertension, Thyroid)
 Any possibility of occupational disease
 Abnormal bleeding tendencies
 Patient’s allergy history
 Onset of puberty & menopause, menstrual disorders,
hysterectomy, pregnancies & miscarriages

17. TREATMENT HISTORY
History of extraction
 restoration
Orthodontic treatment
Surgery

18. FAMILY HISTORY
 Genetic diseases
 Bleeding disorders
 Mental disorders
 Hypertension
 Cardiovascular disease
 Renal diseases
 Diabetes
 Cancer
 Asthma
 Allergies

19. PERSONAL HISTORY
 DIET : Vegetarian or Non Vegetarian
 ORAL HYGIENE HISTORY
 Method of brushing
 Type of toothpaste & toothbrush
 Any interdental aid
 DELETERIOUS HABITS
 Consumption of alcohol, smoker, tobacco chewing etc
 ORAL HABITS
 Bruxism
 Tongue thrusting
 Mouth breathing
 lenching etc

20. CLINICAL EXAMINATION
A) EXTRA-ORAL
1. Swelling/Asymmetry
2. TMJ Examination
 Deviations in the path of the mandible
 Clicking & crepitus
 Tenderness over the joint or masticatory muscles
3. Lymph Nodes/ Para Oral structures

21. LYMPH NODE ENLARGED
PREAURICULAR In External auditory canal infection
POSTAURICULAR In infection of scalp, temporal &
frontal areas.
OCCIPITAL In infection of scalp & syphilis
SUBMENTAL In disorders in the anterior portion of
the mouth and the lower lip.
SUB MANDIBULAR In Infections of head, neck, sinuses,
ears, eyes, scalp
CERVICAL In infection of neck

22. B) INTRA-ORAL EXAMINATION
1. MALODOR
Organoleptic rating, Rosenberg Scale,1992
GRADE CATEGORY DESCRIPTION
O ABSENCE Odor cannot be detected
I QUESTIONABLE Odor is detectable, although the examiner could
not recognize it as halitosis
II SLIGHT Odor is deemed to exceed the threshold of
halitosis recognition
III MODERATE Halitosis is definitely detected
IV STRONG Strong halitosis is detected, but can be tolerated
by the examiner
V SEVERE Overwhelming halitosis is detected and cannot
be tolerated by the examiner

23. 2.OCCLUSION
MOLAR RELATION: Angle’s
classification
CLASS-I:
mesio buccal cusp of the maxillary Ist
molar occludes in the buccal groove of
mandibular Ist permanent molar.
CLASS-II:
Distobuccal cusp of upper first molar
occludes in the buccal groove of lower
first permanent molar
CLASS-III:
mesiobuccal cusp of maxillary first
permanent molar occludes in
interdental space between mandibular
first & second molar.

24. 3.EXAMINATION OF THE OTHER ORAL STRUCTURES
LIPS
Checked for-
• Color
• Texture
• Competency
• Angular or vertical fissures
• Lip pits
• Scars
• Cold sores
• Ulcers
• Scabs
• Keratotic plaques

25. TONGUE
• Size
• Distribution of the papillae
• Any abnormality
• Ulcers
• Tongue tie
• Enlarged tongue due to lymphangioma, hemangioma &
neurofibroma
BUCCAL MUCOSA
checked for any
• Ulcer
• White patch or neoplasia
• Pigmentation

26. FLOOR OF THE MOUTH
checked for:-
• Any swellings
• RANULA: appears as unilateral bluish translucent cyst over Wharton’s
duct
• ANKYLOGLOSSIA: fusion between tongue and floor of the mouth
• CARCINOMAS are common in the floor of the mouth
• Ulcers or red and white patches.

27. PALATE
checked for any
•Discoloration
•Swellings and tenderness
•Fistulae
•Papillary hyperplasia
•Tori
•Ulcers
•Recent burns
•Leukoplakia
•Asymmetry of stucture or function

28. VESTIBULE
• Depth
• Overgrowths
• Swellings and tenderness
• Fistulae
• Ulcers
• Recent burns
• White or red patches
• Scars/scabs

29. 4.SALIVA
• Amount:
• mucosa is moist-
• covered with scanty frothy saliva-
• dry-
• Colour
• Consistency

30. 5. HIGH FRENAL/MUSCLE ATTACHMENT
Frenum attachment (Mirko P et al,1974):
 Mucosal
 Gingival
 Papillary
 Papilla penetrating
Variations in normal frenal attachment:( Kakodkar PV et
at,2009)
 Simple frenum with a nodule
 Simple frenum with appendix
 Simple frenum with nuctum
 Bifid labial frenum
 Persistent tectolabial
 Double frenum
 Wider frenum
 absent

31. 6. HARD TISSUES:
TEETH
a. Notation
b. Number of missing teeth
c. Size
d. Colour
e. Wasting diseases
• Abrasion: loss of tooth substance induced by mechanical wear other than
that of mastication.
• Attrition: occlusal wear that results from functional contacts with
opposing teeth
• Erosion: sharply defined wedge shaped depression in cervical area of
facial tooth surface
• Abfraction: results from occlusal loading surfaces tooth flexure,
mechanical microfractures, tooth substance loss in the cervical area

32. f. Fractured teeth
g. dental stains
h. LOBEIN STAIN INDEX
h. Caries/ restorations
i. Calculus
CODE CRITERIA FOR
APPROXIMAL & GINGIVAL
SITES
1 ½ thin line, can be continuous
2 ½ thick line or band
3 ½ covering total area
CODE INTENSITY
0 No stain
1 Light stain
2 Moderate stain
3 Heavy stain

33. j. Proximal contact relationship
• Open contact allows for food impaction
• Abnormal contact relationship may result in
 Midline shift between incisors
 Labial flaring of maxillary canine
 Buccal or lingual displacement of posterior teeth
 Uneven relationship of the marginal ridges
k. Tooth hypersensitivity
• May be located by gentle exploration with a probe or cold air

34. 7. SOFT TISSUES :
GINGIVA
• COLOUR:
 Coral pink is usually the normal color
 Physiologic pigmentation may be seen(melanin)
• CONTOUR:
 Scalloped
 Knife edged

35. • SURFACE TEXTURE
 Orange peel appearance
 Viewed by drying the gingiva under natural light
• SIZE
 Overall increase or decrease depending on the vascularity
and cellular elements

36. • POSITION
 Apical or coronal to CEJ
Miller classified Recession into 4 groups (1985)
CLASS DESCRIOTION
I • Marginal tissue recession not extending to the mucogingival
junction & the underlying alveolar bone
• 100% root coverage can be anticipated
II • Marginal tissue recession which extends to or beyond the
mucogingival junction
• 100% root coverage can be anticipated
III • Marginal tissue recession which extends to or beyond the
mucogingival junction
• Partial root coverage can be anticipated
IV • Marginal tissue recession which extends to or beyond the
mucogingival junction
• Root coverage cannot be anticipated

37. • CONSISTENCY
 Firm & resilient
 Fibrotic & edematous
• TENDERNESS ON PALPATION
• SUPPURATION

38. EASE OF BLEEDING
 bleeding on probing is an earlier sign of inflammation than
gingival colour changes.
 To test for bleeding after probing, the probe is carefully
introduced to the bottom of the pocket and gently moved
laterally along the pocket wall.
 The clinician should recheck for bleeding 30 to 60 seconds
after probing.
 As a single test, bleeding on probing is not a good predictor of
progressive attachment loss; however, its absence is an
excellent predictor of periodontal stability.

39. 8. PERIODONTAL LIGAMENT EXAMINATION
 TOOTH MOBILITY
Mobility is graded clinically by holding the tooth firmly between the
handles of 2 metallic instruments or with 1 metallic instrument & 1 finger.
Miller Classification (1950)
 Grade 0: No detectable movement movement when force is applied other
than what is considered normal (physiologic motion)
 Grade 1: Mobility greater than the normal
 Grade 2: Mobility upto 1mm in a buccolingual direction
 Grade 3: Mobility greater than 1mm in a buccolingual direction combined
with the ability to depress the tooth

40. FURCATION INVOLVEMENT
Glickman [1953]
• Grade I : Pocket formation into the flute, but intact
interradicular bone (incipient).
• Grade II: Loss of interradicular bone and pocket
formation, but not extending through to the opposite side
• Grade III: Through-and-through lesion
• Grade IV: Through-and-through lesion with gingival
recession, leading to a clearly visible furcation area.

41. Hamp et al [1958]
• Degree I : Horizontal loss of periodontal tissue support
less than 3 mm.
• Degree II: Horizontal loss of periodontal tissue support is
3mm,but not encompassing the total width of the furcation
• DegreeIII: Horizontal through-and-through destruction of
the periodontal tissue in the furcation

42. PATHOLOGICAL MIGRATION
• Contributing factors
 Abnormal forces
 Tongue thrusting habits
 Other habits
• Pathologic migration of anterior teeth in young persons may
be a sign of localised aggressive periodontitis

43. TRAUMA FROM OCLUSION
• Diagnosis of TFO is made from condition of the periodontal
tissues.
• Periodontal findings that suggest presence of TFO include
excessive tooth mobility particularly in teeth that show
radiographic evidence of a widened
 Periodontal space
 Vertical or angular bone destruction
 Infrabony pockets
 Pathologic migration especially in anterior teeth
 FREMITUS TEST
 WAX RECORDS

44. TENDERNESS ON PERCUSSION
PERCUSSION TEST:
to evaluate the status of the periodontium
surrounding a tooth
TYPES:
VERTICAL PERCUSSION TEST – positive
indicates periapical pathology
HORIZONTAL PERCUSSION TEST – positive
indicates periodontium associated problems

45. GINGIVAL INDEX (Loe & Silness in 1963)
16 12 24
44 32 36
INSTRUMENTS USED: mouth mirror ,periodontal probe
4 gingival scoring units: disto-facial papilla,facial margin,mesio-facial papilla &
the entire lingual gingival margin

46. Scoring criteria
Score Criteria
0 Absence of inflammation/ normal gingiva
1 Mild inflammation, slight change in color, slight
edema, no bleeding on probing
2 Moderate inflammation, moderate glazing, redness,
edema & hypertrophy, bleeding on probing
3 Severe inflammation, marked redness &
hypertrophy, ulceration ,tenderness to spontaneous
bleeding
Gingival
scores
Condition
0.1 – 1.0 Mild
gingivitis
1.1 – 2.0 Moderate
gingivitis
2.1- 3.0 Severe
gingivitis
USES:
1. To determine the prevalence & severity of gingivitis in epidemiologic surveys.
2. For assessment of severity of gingivitis in individual dentition.
3. In controlled clinical trials of preventive or therapeutic agents.

47. PLAQUE INDEX (Loe & Silness in 1964)
16 12 24
44 32 36

48. Scoring criteria
Score Criteria
0 No plaque
1 A film of plaque adhering to the free gingival
margin & adjacent area of the tooth
2 Moderate accumulation of soft deposits within the
gingival pocket, on the gingival margin &/or
adjacent tooth surface, which cab be seen by the
naked eye.
3 Abundance of soft matter within the gingival pocket
&/or on the gingival margin & adjacent tooth
surface
Excellent 0
Good 0.1 – 0.9
Fair 1.0 – 1.9
Poor 2.0 – 3.0
USES:
1. A reliable technique for evaluating both mechanical anti-plaque procedures &
chemical agents.
2. Used in epedimiologic studies
Interpretation

49. ORAL HYGIENE INDEX (Green & Vermillion in)
16 Buccal
11 Labial
26 Buccal
36 Lingual
31 Labial
46 Lingual
Surfaces & teeth to be examined
16 17
17 18
11 21
26 27
27 28
36 37
37 38
31 41
46 47
47 48
Substitution for missing teeth
INSTRUMENTS USED:
Mouth mirror, No. 23 explorer (
Shepherd’s Hook)

50. ORAL HYGIENE INDEX SIMPLIFIED (Green & Vermillion in 1964)
16 11 26
46 31 36

51. Scoring criteria
Score Criteria
0 No debris or stain present
1 Soft debris covering not more than one third of the
tooth surface, or presence of extrinsic stains without
other debris regardless of surface area covered.
2 Soft debris covering more than one third but not
more than two thirds , of the exposed tooth surface
3 Soft debris covering more than two thirds , of the
exposed tooth surface

52. B. Calculus Index
16 11 26
46 31 36

53. Scoring criteria
Score Criteria
0 No calculus present
1 Supragingival calculus covering not more than one
third of the exposed tooth surface.
2 Supragingival calculus covering more than one third
but not more than two thirds of the exposed tooth
surface or the presence of individual flecks of
subgingival calculus around the cervical portion of
the tooth or both
3 Supragingival calculus covering more than two
thirds of the exposed tooth surface or continuous
heavy band of subgingival calculus around the
cervical portion of the tooth or both

54. USES:
1. Studies of epidemiology
of periodontal disease
2. Evaluation of dental
health education
programs in public
school systems
3. Evaluating the cleansing
efficiency of tooth
brushes
4. Evaluate an individual’s
level of oral cleanliness

55. P.D
C.A.L
G.M.L
Buccal
Lingual
Buccal
Lingual
Buccal
Lingual
FULL MOUTH CHARTING
18 16
17 15 12
13
14 11 21 22 23 24 25 27
26 28
P.D
C.A.L
G.M.L
Buccal
Lingual
Buccal
Lingual
Buccal
Lingual
48 46
47 45 42
43
44 41 31 32 33 34 35 37
36 38

56. 9. PROVISIONAL DIAGNOSIS
 It is also called tentative diagnosis or working diagnosis.
 It is formed after evaluating the case history & performing
the physical examination.

57. 10. RECORDS
DIFFERENTIAL DIAGNOSIS
 Clinical Photographs
 Color photographs are useful for recording the appearance of tissue before
& after treatment
 Depict gingival morphological changes
 Study Casts
 Useful adjuncts during oral examination
 Indicate the position of the gingival margins, position & inclination of teeth,
proximal contact relationships, food impaction areas.
 Important record of the dentition before it is altered by treatment
 Provide a view of lingual-cuspal relationship
 Serve as visual aids during discussion
 Helpful to determine position of implant placement if the case requires it

58. 11. INVESTIGATIONS
A. X-RAY EXAMINATION
Intra-Oral
• Minimum 14 intraoral films + 4 posterior bite wing films
 Bite Wing : to examine proximal surfaces of teeth
 Periapical
Extra-Oral
 OPG

59. B. HEMATOLOGICAL INVESTIGATIONS
 Hb
 TLC
 DLC
 BT
 CT
 ESR
 BLOOD SUGAR
 Fasting
 Post Prandial
C. ROUTINE URINE EXAMINATION
D.EXFOLIATIVE CYTOLOGY
E. BIOPSY

60. 12. FINAL DIAGNOSIS:
reached following chronologic
evaluation of the information obtained from the,
• patient history,
• physical examination
• result of radiological
• laboratory examination

61. 13. PROGNOSIS
It is a prediction of the probable course, duration and outcome of a disease based on
a general knowledge of the pathogenesis of the disease and the presence of risk
factors for the disease.
It depends on : depends on:
 The adequacy of the diagnosis.
 The quality of the treatment, including home care and recall maintenance.
Factor that may influence prognosis:
 The extent and significance of mucogingival problems.
 The extent of furcation lesions.
 The combined periodontal and endodontic lesions.
 The presence of the hopeless teeth.
a) Overall/Individual
b) Tooth Associated
c) Site Associated

63. EXCELLENT PROGNOSIS
GOOD PROGNOSIS
FAIR PROGNOSIS
POOR PROGNOSIS
QUESTIONABLE PROGNOSIS
HOPELESS PROGNOSIS

64. 14. TREATMENT PLAN
 EMERGENCY TREATMENT
 Dental or periapical abscess
 Periodontal abscess
 Splinting
 Extraction of hopeless teeth

65.  PHASE I THERAPY (ETIOTROPIC PHASE)
 Removal of calculus and root planing
 Correction of restorative & prosthetic factors
 Temporary & final restorations
 Antimicrobial Therapy
 Occlusal therapy
 Minor orthodontic movements
 Provisional splinting & prosthesis
EVALUATION/MAINTENANCE

66.  PHASE II THERAPY (SURGICAL PHASE)
 Endodontic Therapy
 Periodontal Therapy
• Pockets
• Gingival recession
• Furcation involvement
• Others
EVALUATION/MAINTENANCE

67.  PHASE III THERAPY (RESTORATIVE PHASE)
 Final restorations
 Fixed or removable prosthetics
EVALUATION/MAINTENANCE

68.  PHASE IV THERAPY (MAINTENANCE PHASE)
periodic checking for
 Plaque & calculus
 Ginvival conditions (pockets,inflammation)
 Occlusion
 Tooth mobility
 Other pathologic changes
15. RECALL
after 6 months

69.  RFERENCES
1.South asian 2nd edition Carranza’s clinical
periodontology
2.13th edition Carranza’s clinical periodontology
3. Burket’s book of oral medicine 12th edition
4.S. Das book of surgey 10th edition

70. THANK YOU