Definition Contents of case history Personal Information General Physical Examination Extra oral examination Intra oral examination Investigations Diagnosis List of references Conclusion

2. IT IS BETTER TO KNOW WHAT KIND OF
PATIENT HAS THE DISEASE THAN WHAT
KIND OF DISEASE THE PATIENT HAS
SIR WILLIAM OSLER

3. CONTENTS
Definition
Contents of case history
Personal Information
General Physical Examination
Extra oral examination
Intra oral examination
Investigations
Diagnosis
List of references
Conclusion

4. Definition:
Case History is a planned professional
conversation between patient and doctor which
enables the patient to express his symptoms, fear
and feelings to the clinician so that the nature of
patient’s real or suspected illness and mental
attitude may be determined.
(Malcolm A. Lynch)

5. To Establish Diagnosis
Assessment Of Systemic Compliance
Prevention of any Possible Medical EMERGENCIES
with known medical History
Effective Treatment Planning

6. The purpose of making a diagnosis is to be able to offer
the most effective and safe treatment
■Accurate prognostication.
Diagnosis is made by the clinical examination, which
comprises the:
■History (anamnesis) – this offers the diagnosis in about
80% of cases
■ Physical examination
■ Supplemented in some cases by investigations.

7. HISTORY
&
SPEECH
APPEARANCE
&
BEHAVIOUR
INDURATION
&
TEMPERATURE
MALODOUR
LISTEN OBSERVE TOUCH SMELL

8. The clinician should use ‘LEAPS’:
■ Listen
■ Empathize
■ Ask
■ Paraphrase
■ Summarize.

9.  PERSONAL INFORMATION
 CHIEF COMPLAINT
 HISTORY OF PRESENT ILLNESS
 MEDICAL HISTORY
 PAST DENTAL HISTORY
 FAMILY HISTORY
 PERSONAL HISTORY
 GENERAL EXAMINATION
 EXTRA ORALEXAMINATION
 INTRA ORALEXAMINATION
 PROVISIONAL DIAGNOSIS
 INVESTIGATIONS
 FINAL DIAGNOSIS
 TREATMENT PLAN

10. 





11.  NAME
Identification
Communication
Forming a rapport with patient
Record maintenance
Psychological benefit
Information of patient such as religion

12.  Age related disorders
 Calculating a suitable dosage
 Treatment plan

13. At birth – congenital cleft lip & palate
1st – 2nd decades – Primary herpetic gingivostomatitis
(6months to 6years), Nursing caries, cherubism,
fibro osseous lesions.
Middle aged – Ameloblastoma, Oral cancer.
Old age – Degenerative osteoarthritis of TMJ, cancer.

14. • Young’s rule =
Child’s age
Age+12 × ADULT DOSE
×ADULT DOSE•Clark’s rule = Child’s weight in lbs
150
Age
• Dilling’s rule = 20 ×ADULT DOSE

15. Sex
In female patients additional questions like
pregnancy, nursing, oral contraceptive pills &
menstruation.
Females – lichen planus ,tmj disorders , iron
deficiency anemia , sjogrens syndrome.
Males – hemophilia, oral cancer, pernicious
anemia

16. Address
Correspondence
Geographical prevalence of dental/oral diseases.
Gives an idea of the socioeconomic status of the
patient.

17. E.g.: Tailors, Beauticians – notching of incisal edges of
upper teeth.
In acidic environment – erosion of teeth.
Musicians - soft tissue trauma ,herpes ,dry mouth,
TMJ pain.
Paint industry- mercury poisoning, lead poisoning.
Mining- silicosis, asbestosis.
Cotton mills – Bysinnosis
Sugarcane industry – Bagassosis.

19. The chief complaint is established by asking the
patient to describe the problem for which he or she
is seeking help or treatment.
Make every attempt to quote the patients own
words
The chief complaint aids in the diagnosis and
treatment planning and should be given the first
priority.

20. It is the record of narrative account of patient’s
problem from the onset to present time listing all
the symptoms, signs, treatment undergone in a
chronological order.

21. If the patient has pain, a useful mnemonic is
‘SOCRATES’:
S – site (localized ,diffuse ,referred, radiating)
O – onset (spontaneous, on stimulation, intermittent)
C – character (dull, sharp, throbbing, constant)
R – radiation,
A – associations (other symptoms),
T – timing/duration,
E –exacerbating and alleviating factors (cold, heat,
palpation, percussion Relieved by ;cold, heat, any
medication ,sleep)
 S – severity (rate the pain on a visual analogue scale of
1–10).

23. Time and place of alleged assault/injury.
Was the assailant known to the patient?
Was there any loss of consciousness?
Was the patient under the influence of alcohol?
Were there any other injuries to the body?
Were there any witnesses? (In particular, if
consciousness is in doubt.)
What happened immediately after the assault? Are the
police involved or likely to become involved?
Note any ‘old’ injuries, for example a tooth previously
fractured or previous facial injuries.

25. Primary function of PMH is to avoid
complications during dental treatment.
PMH is usually organized in following sub-
divisions:-
Childhood illness
Medical
Surgery
Obsteric
Psychologic

26. • Do you ever have chest pain or
tightness?
• Palpitations?
• Did you suffer from fleeting joint
pains, sore throat or fever?
• Do you have any breathlessness
on exertion?
Cardiovascular system

27. Prophylaxis regimen for Infective Endocarditis
Recommendations from the British Society for Antimicrobial Chemotherapy
(1992) and British National Formulary 2007.

28. Provisional Recommendations from the National
Institute for Clinical Excellence (NICE, 2007)
Antibiotic prophylaxis against infective endocarditis
(IE) is not recommended for patients at risk of
endocarditis undergoing:
• dental procedures.
• ear, nose and throat procedures
• upper respiratory tract procedures

29. Respiratory system:
Are you ever short of breath?
Have you had a cough?
Have you ever coughed up blood?
Wheezing?

30. Gastrointestinal and Hepatic System
Do you have heart burn/acidity/foul taste?
- Peptic ulcer
- Hiatal hernia
 Do you have bouts of nausea, lack of appetite?
 Did you suffer from jaundice/hepatitis?
 Have you noticed any change in your bowel habit
recently?
 Have you ever seen any blood or slime in your stools?

31. Central Nervous System
Pts. with a history of-
 Epileptic attacks
 Paresthesia
 Paralysis
 Syncope.

32. Genitourinary System:
 Do you have to get up at night to pass urine? If so,
how often?
 Have your periods been quite regular?
 Any H/O Prostatic disease,
 Genitourinary infection,
 Renal disease or failure,
 Renal transplant, etc.

33. KIDNEY DISEASE:
Bleeding tendency
Impaired drug excretion
Immunosuppression following kidney transplant
Liability to neoplasia
Cyclosporin causing gingival enlargement

34.  Do you have any pain, stiffness or swelling in
your joints?
 Muscular dystrophy.
 Joint replacements.
 Locomotor difficulties
Musculoskeletal

35. Do you tend to feel the heat or cold more than you
used to?
Have you been feeling thirstier or drinking more
than usual?
Endocrine system

36. Hyperparathyroidism
may cause:
– jaw radiolucency/rarefaction
– loss of lamina Dura
– giant cell granulomas (central)
– hypercalcaemia and hyposalivation.

37. Blood Dyscrasias
Manifestations of most blood Dyscrasias may be seen in
oral cavity.
Any history of prolonged bleeding and easy bruising (
hemophilia/ purpura)
Blood borne viruses, eg. Hepatitis B/C, HIV,
Clotting disorders
Leukemia
Porphyria
Sickle cell anemia

38. MALIGNANT DISEASE:
Patients on radiotherapy and chemotherapy
Pain in associated oral complications
Sensory changes??
Significant morbidity and mortality in some cases

39. PROSTHESIS AND TRANSPLANT PATIENTS:
At a risk of infection, iatrogenic problems like
bleeding, graft-versus-host disease
Transplant patients are liable to complications to
dental treatment- need for steroid cover-liability to
infections
Patients with pacemakers can interfere with
diathermy, electrosurgery, etc

40. Have you ever experienced an unusual reaction to any
drugs/food/materials?
Any unusual reaction to dental anesthetics?

41. Unexpected and sudden onset
• Clinical signs
• Rapid breathing
• Evidence of poor circulation
• Stridor, hoarseness or wheeze
• Tongue swelling
• Pale, clammy, rash, flushed

42. DRUG USE, ALLERGIES ANDABUSE:
Drug use may cause orofacial lesions – hemorrhagic
diathesis caused by decreased prothrombin level (mineral
oil used as a laxative interferes with vit-k absorption)
Drug allergies?? (urticaria, skin rash, angioedema,
respiratory symptoms)
Drug abuse (behavioral problems, cross infection)

43. Corticosteroids- adrenocortical depression
- patients don’t respond to stress, trauma,
operation or infection
- stress causes adrenal crisis and collapse

44. Provides us the basis to evaluate the patient’s
current dental status and how the patient will respond
to the proposed treatment.
Following are the details that should be investigated:
- Frequency of visits to dentist.
- Past experience during and after local anesthesia
, general anesthesia.
- Past experience during and after extraction.
- Past orthodontic treatment.
- Any surgical procedures besides exodontia.

46. This may reveal familial outbreaks of contagious infections
(e.g. herpangina; tuberculosis; hepatitis A)
Hereditary problems, such as amelogenesis imperfecta,
hemophilia or hereditary angioedema, Thalassemia
Familial conditions, such as recurrent apthous stomatitis or
diabetes
Information about siblings’ ages and health status.
Some diseases are more prevalent in certain ethnic groups,
e.g. pemphigus in Jews and Asians;
Behçet syndrome in people from Asia or the Mediterranean
area

47.  It includes:
1) Oral habits
2) Oral hygiene practices
3) Adverse habits

48. DIET:
Excessive use of refined sugar and sticky food.
Nutritional deficiency.

49. Smoking
Alcoholism
Tobacco chewing

50. BUILD
NOURISHMENT
SKIN
HAIR
NAILS

51. Asthenic - lean and underweight
Sthenic - athletic
Pyknic – have enormous amount of body fat compared
to bone and muscle mass, appear rounded
Cachexia – abnormally low tissue mass resulting from
malnutrition or chronic debilitation

52. Indicate development of growth
Quetlet body mass index is used = weight in Kg
( height in meters)2

53. Risk for malnutrition if they meet one or more of the
following criteria:
• Unintentional loss of >10% of usual body weight in
the preceding 3 months
• Body weight <90% of ideal for height
• body mass index (BMI: weight/height in kg/m2) <18.5

54. Pallor
Yellowness
Cyanosis
Blisters (infections, drug eruptions, skin diseases)
Pigmentation ( addison’s disease)
Oedema

56. Alopecia- partial alpoecia seen in xeroderma
pigmentosum and hereditary ectodermal dysplasia
Total alopecia- x-ray irradiation, chemotherapy,
herpes zoster infection

57. Yellow coloured - jaundice
Blue coloured –osteogenesis imperfecta
Osteoporosis
Fetal rickets
Marfan’s syndrome
Ehlers- Danlos syndrome

58. Halitosis (bad breath) is common in patients whose
dental hygiene has been poor
Diabetic ketosis has been described as 'sweet and
sickly
Uremia as 'ammonic or fishy’
Hepatic failure as 'mousy',

59. GAIT (Manner of walking )
These abnormalities relate to neuromuscular
disabilities, fractures
Hemiplegic gait – Hemiplegia
Ataxic gait- Cerebellar lesions, alcohol
intoxication
Propulsive gait- Parkinson’s disease, CO
poisoning, Manganese poisoning
Scissors gait/Spastic gait – Cerebral palsy,
multiple sclerosis,
Waddling gait – Muscular dystrophy

60. PULSE
Pulse rates at rest in health are
approximately as follows:
■ infants, 140 beats/min
■ adults, 60–80 beats/min.

61. Rate :Pulse rate is increased in:
■ exercise
■ anxiety or fear
■ fever
■ some cardiac disorders
■ hyperthyroidism and other disorders.
Rhythm : Regular or irregular
Volume: High, low & normal indicate pulse pressure.
Normal pulse pressure is 40-60 mmHg.
Tension & force: Indicate diastolic & systolic pressures.
Character :Water hammer pulse-aortic regurgitation

63. The temperature is traditionally taken with a thermometer, but
temperature-sensitive strips and sensors are available.
The normal body temperatures are:
Oral 36.6°c;
Rectal or ear(tympanic membrane) 37.4°c;
And axillary 36.5°c.
In most adults, an oral temperature above 37.8°C or a rectal
or ear temperature above 38.3°C is considered a fever
(pyrexia).
A child has a fever when ear temperature is 38°c or higher

64.  Normal 120/80 mm of Hg.
 Systolic controlled by stroke volume of the heart &
stiffness of the arterial vessels.
 Diastolic controlled by peripheral resistance
 Varies with emotion, exercise, meal, alcohol, tobacco,
bladder distension, temperature, anxiety & pain.

65. HYPERTENSION
Etiological factors include:
• Genetic predisposition
• High alcohol intake
• High salt intake
• Smoking
• High body mass index (BMI)
• Impaired tissue response to insulin (insulin resistance)
• Sympathetic overactivity: approximately 40% of
hypertensive patients have raised levels of circulating
catecholamines

68. FACE – Gross asymmetries of face includes diffuse
swellings ,traumatic injuries ,congenital deformities
Shape of the head :
a. Mesocephalic
b. Dolicocephalic
c. Brachycephalic
: average shape of head.
: long and narrow head.
: broad and short head.

70. TMJ: observed for: -
Symmetry: gross derangement in symmetry may reflect
growth disturbances.
-Maximum interincisal opening any deviation in
opening
-Range of vertical movement
-Range of lateral movement
-Listen for clicking and crepitus sounds , tenderness
over joint or masticatory muscles

71. PALPATION OF TMJ
Palpation of pre tragus area
Intra auricular palpation
Auscultation—it is used to study the movement of
TMJ and also used for examination of venous
malformation

73. -know the position
-number of nodes
-tenderness
-fixity to underlying tissues

76. Consistency of lymph nodes:
Soft in consistency
Firm, discrete shotty
Elastic and rubbery
Matted lymph nodes
Stony hard
Inflammatory
Syphilis
Hodgkin’s disease
Periadenitis,
Tuberculosis,
Acute lymphadenitis.
Carcinoma

77. SALIVARY GLAND EXAMINATION
Evaluated for
 Dryness
 Enlargement
 Quantity of secretions

78. HISTORY
1) Mode of onset: trauma , spontaneously.
2) Duration
3) Pain
4) Discharge
LOCAL EXAMINATION
INSPECTION
1) Size & shape
2) Number
3) Position

79. 4)Edge
Sloping—healing non-specific ulcer, venous ulcer.
Undermined—tubercular ulcer.
Raised and everted—squamous cell carcinoma.
Rolled out—rodent ulcer.
Punched out—syphilis
5) Floor
6)Discharge

84. Palpation
Tenderness
Edge & margin
Depth
Bleeding

85. HISTORY
1)Duration
2)Mode of onset
3)Pain
4)Progress of swelling
5)Presence of other lumps
6)Impairment of function

86. INSPECTION
a)Situation
b)Colour
c)Shape
d)Size
e)Edge
f)Number
g)Movement on deglutition & protrusion of tongue

87. PALPATION
1)Temperature
2)Tenderness
3)Size ,surface
4)Edge
5)Consistency
6)Fluctuation
7)Compressibility

88. Hemangioma
Orofacial granulomatosis

89. Fibrous epulis
Cyclosporin-induced gingival swelling

90. Torus palatinus
Dental abscess arising from the
non-vital third molar

91. Tongue cancer, presenting as a
persistent lump that has ulcerated
Fibrous lump

92. Mucocele Parotid salivary gland
enlargement

93. EXTRA ORALEXAMINATION
Inspection of the face for asymmetry.
Inspect open wounds for foreign bodies.
Palpate the entire face.
 Supraorbital and Infraorbital rim
 Zygomatic-frontal suture
 Zygomatic arches
Inspection of scalp for lacerations and contusions
Bleeding points should be arrested

94. Palpate the zygoma along its arch and its
articulations with the maxilla, frontal and
temporal bone.
Check facial stability.

95. Inspect the teeth for malocclusions, bleeding and
step-off.
Manipulation of each tooth.
Check for lacerations.
Palpate the mandible for tenderness, swelling and
step-off.

97. EARS :
External auditory meatus should be inspected for blood
and cerebrospinal fluid.
Fractures of middle cranial fossa observe for battles
sign and fractured drum appears blue , bulging ,
exhibiting transmitted pulsation via CSF.

98. EYES
Inspection of eyes for edema of eyelids ,
circumorbital ecchymosis , sub conjunctival
hemmorhage.
Assessment of visual acuity in both eyes, Ocular
movements , ocular levels should be checked,
diplopia carefully recorded.

99. NOSE
Evidence of bleeding from nose.
presence or absence of CSF rhinorrhea.
Thumb and middle finger of one hand
stabilize the head by gripping temporal region
above supraorbital ridge while gently palpating
nasal bridge with thumb and index finger of
other hand

100. MIDDLE THIRD OF FACE
Inspection of face in bilateral fracture of maxilla
shows bilateral circumorbital ecchymosis, bilateral
oedema , lengthening of middle third of face
Infraorbital nerve anaesthesia / paraesthesia.

101. PALPATION OF ORBITAL REGION
Index fingers are placed on either side of nasal bridge
and moved along superior orbital margin
Then fingers are passed downwards at frontozygomatic
suture
Index and middle fingers are used bilaterally to palpate
zygomatic bone and arch.

102. MANDIBLE
Palpation from behind patient
fingers of both hands palpate both sides of lower
border while thumb placed on lateral aspect
TMJ palpation stand infront of patient, presence or
absence of movement of condylar head is detected by
placing little finger in external auditory meatus and
making mandibular movements in all directions

103. INTRAORAL EXAMINATION
Inspection
Maxilla fractures inspection for ecchymosis in buccal sulci
near zygomatic prominences or in region of greater
palatine foramen Guerin’s sign
Sublingual hematoma is pathognomic of fracture involving
lingual plate of mandible
Occlusal plane should be inspected for step defects ,
gagging of occlusion.

104.  Lip
 Tongue
 Buccal / Labial mucosa
 Gingiva
 Palate
 Floor of the mouth

105. FRACTURED TEETH – Trauma
ELLIS CLASSIFICATION
Class 1 - Enamel with little or no dentin
Class 2 - Enamel & dentin without pulp
Class 3 - Enamel, dentin & pulp
Class 4 - Fracture of non vital tooth with or with
out crown fracture
Class 5 - Tooth loss due to trauma
Class 6 - Fracture of root with or with out fracture
of crown en-mass
Class 7
Class 8
Class 9
- Displacement of tooth with or without
fracture of crown
- Fracture of crown & mass
- Traumatic injury to deciduous tooth

107. Clinical diagnosis.
Pathological diagnosis
Direct diagnosis
Provisional (working) diagnosis
Deductive diagnosis
Differential diagnosis
Diagnosis by exclusion
Diagnosis ex-juvantibus
Provocative diagnosis

108. Hematological investigations
Urine analysis
Biochemical investigations
Radiological investigations
Histopathological investigations
Microbiological investigations
Sialography, Cephalometry, OPG, MRI, CT scan etc

109. Routinely used Hematological
investigations include
109
Total red blood count
Hb concentration
Red cell indices
Total white cell count
Differential white cell count
ESR
Bleeding and coagulations disorder
Partial thromboplastin time.

110. This is routinely performed with ‘dip-sticks’. It may
reveal:
Glycosuria
Ketonuria
Bilirubin or urobilinogen
Proteinuria
Haematuria
110

111. Patch tests
Intradermal injections
Prick test
Modified prick test
Scratch test
111

112. 112

113. 113

114. 114

115. 115

116. 116

117. OCCIPITOMENTAL VIEW
STANDARD 00
117
300

118. 118

120. BIOPSY
Incisional Excisional Punch

121. Ultrasound contains waves with a frequency of more
than 20,000 cycles/second which the human ears
cannot hear.
In medical sonography, frequencies used are
commonly 2-10 MHz

122. Good definition of soft tissue structures in any plane
Useful for areas of complex anatomy such as maxilla or
base of skull
Definition further improved by use of contrast media
Density of tissues is numbered as Hounsfield Number
(HN)
• Water—Zero HN
• Air—Minus 1,000
• Bone—Plus 1,000

123. Doppler effect is a change in the perceived frequency
of sound emitted by a moving source. So it
measures blood flow.
Spectral Doppler wave form and ultrasound image are
combined in Duplex scanning.
Uses
To study cardiovascular system.
To study vascularity of tumours.
To study blood flow and velocity in arterial diseases

124. • Produces clear tomograms in any plane
without superimposition
• Particularly good for soft tissue lesions.
• Better than CT
• No X-ray dose
• Clear definition of bones and teeth

125. It is a non-invasive diagnostic method to
assess the biochemical and physiological
status of a tissue.
It is used in complimentary with CT scan and
MRI.
Short-life radioactive isotope used to identify
biochemical activity, usually glycolysis, to
identify putative tumor size, location or
metastasis
Good for identifying unsuspected
metastases
Helps identify neoplasms when post-surgical
artifact or inflammation obscure CT or MRI
Also available as a combined PET-CT scan

126. Endoscopy is typically performed with flexible fibre-optic
endoscopes, under local analgesia, sometimes with
conscious sedation or general anaesthesia. Relevant
endoscopic procedures
include:
■Nasendoscopy
■Oesophagoscopy
■Bronchoscopy
■Panendoscopy usually refers to triple endoscopy
(nasendoscopy, oesophagoscopy and bronchoscopy)
■Gastroscopy (the oesophagus, stomach and duodenum)
■Sialoendoscopy
■Colonoscopy

127. FINAL DIAGNOSIS:
This indicates that a definitive diagnosis has been
made on the basis of all necessary observations and
laboratory investigations

128. PHASE 1- EMERGENCY PHASE:
Management of pain & acute infections by antibiotics &
analgesics .Incision & drainage, reduction of fractures
PHASE 2 –SURGICAL : Extraction, Biopsy,
Enucleation, Resection.
PHASE 3 – PROPHYLACTIC : Scaling& root planning,
& bone graft , bone curettage.
PHASE 4 – RESTORATIVE : Restoration
PHASE 5 – CORRECTIVE : Prosthesis & ortho
correction
Phase 6 – RECALL & REVIEW

129. PROGNOSIS
The prognosis is the 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. The prognosis
is evaluated and informed to the patient.
130

130. Comprehensive & valuable write–up of case history
elicits good basic Knowledge of oral diseases so that
the interviewer is able to trace out leads given by
patient during interview. Thereby case history forms
the basis of diagnosis & all the treatment of any
condition. There is no substitute for a good case
history , aiding at correct diagnosis & appropriate
treatment modalities. Thus careful attention paid to a
tactful case undue timewith no
skillful management of
spent
any
will
oral
history recording
contribute to a
condition.

131. Hutchison's Clinical Methods - An Integrated Approach to Clinical
Practice, 22nd Edition
Kumar & Clark’s Clinical Medicine 8th edition.
2013 CURRENT Medical Diagnosis & Treatment. 52nd edition
oral radiology- principles and interpretation-white-pharoah 6th edition
Oral and Maxillofacial Medicine The Basis of Diagnosis and
Treatment, 3e Crispian Scully
Bates' Guide to Physical Examination and History-Taking (11th Ed.)
Burket’s oral medicine 11th ed
Davidson's Principles and Practice of Medicine (21st Ed.)
Macleods.Clinical.Examination.12th.Edition
Differential diagnosis of oral & maxillofacial lesions wood & goaz 5ed
Cawson’s essentials of oral pathology and oral medicine 8th ed.
Common medical conditions – A guide for dental treatment.

132. 27-Apr-16 CASE HISTORY 133