History, Examination and Diagnosis in Dentistry
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Presented in 2014 by Dr. Rakhshanda and Dr. Jawad Tariq Reference: Contemporary Oral and Maxillofacial Surgery - 6th Edition
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History, Examination and Diagnosis in Dentistry
- 1. 1
- 2. • History and its Components • Significance of History Taking • Clinical Examination and its Components • Significance of Clinical Examination • Questions & Answers 2
- 3. ‘A narrative or record of past events and circumstances that are or may be relevant to a patient's current state of health’ 3
- 4. •Name •Age •Sex •Address •Occupation •Marital Status 4
- 5. 5
- 6. • Obtaining an accurate history is the critical first step in determining the aetiology of a patient's illness • 3 main aspects: Preparation, Initial rapport, and identifying the patient’s problems 6
- 7. 7 • Patients often feel anxiety in clinical setting • Make the environment welcoming and relaxing • Avoid appearing rushed up • Demonstrate from the outset your respect, interest and concern for them
- 8. 8 (Identification of the patient)
- 9. 9 Dig out symptoms that patient ignores or forgets Medical History Surgical History Dental History
- 10. 10 Affordability Anxiety Tension/Depression Oral Hygiene Dietary Habits Abnormal Habits Addiction
- 11. 11 • A large percentage of the time (70%), you will actually be able make a diagnosis based on the history alone • In a paper by Hampton et al*, they showed that after reading the referral letter and taking a history, the definitive diagnosis was reached in 66 of 80 new outpatients. • Proper history could save expensive and anxiety-producing investigations. (*Hampton JR, Harrison, MJG, Mitchell, JRA, Prichard JS, Seymour, C. Relative contributions of history taking, physical examination, and laboratory investigation to diagnosis and management of medical outpatients BMJ 1975 2 4
- 12. 12 ‘A clinical examination is an evaluation of the body and its functions using inspection, palpation, percussion and auscultation’
- 13. • Asymmetry • TMJ • Lymph Nodes • Soft Tissue Examination • Hard Tissue Examination 13 • Patient’s Gait • Asymmetry • Lesions• Mobility • Scars
- 14. 14 • Gives general idea about patient's condition • Gives information about patients general health • Helps to look for any facial asymmetry, previous surgical scars and visible lesion • Gives detail information about facial structures • Gives information about TMJ, Lymph nodes and thyroid status
- 15. 15 • Gives idea about patient's approach towards oral hygiene • Helps to find pathologies of intra oral soft and hard tissues • Helps to identify normal structure that can be mistaken for lesions
- 16. 16 • Diagnostic role 5-10% (Hampton n Peterson et al) • Valuable guide to determine next stage of the investigation • Lets specialists know where to concentrate their efforts • Helps in prevention and prognosis
- 17. 17
- 18. 18
Editor's Notes
- Or History can be simply defined as ‘to know about the patient’s illness as he knows it’
- History of Past Illness: Medical History, Surgical Hx, Dental Hx….
- 1)For example, arrange the patient’s seat close to your…Quiet Room…
- Age: Impaction…certain types of Intraoral cysts and tumours are more prevalent in specific age group, BMS after menopause, Denture Induced Hyperplasia Sex: Tobacco--Nicotinic Stomatitis--Males Address: Flourosis, Trismus due to trauma, Ameloblastomas, GOITRE in hilly… Occupation: Mine workers, Tailors, Farmer and Sailor—Solar Keratosis, socioeconimic status, chemical or radiation exposure. Marital: Pregnancy epulis and gingivitis, Stress in unmarried Female Bruxism,Neuralgia etc
- Systemic Enquiry: Systemic Diseases with Oral manifestations. Past HX: Asthma, HTN, Depression, Recurrence of SCC, Surgical Treatments: Prosthetic Valve, Cyst Rupture, DENTAL HX: Dry Socket,Perioapical Abscess..Experience, Expectation, Willingness, Tolerance. Drug Hx: Reactions/Sensitivity…Side Effects of Drugs Antibiotics- Pseudomem Thrush , Tetracycline-Tooth discoloration…What drugs to prescribe…Penicillin Allergy
- Family: Inherited Disorders – Ginvgivitis, susceptibility to caries…Family approach towards oral hygiene and Treatment… Personal : Abnormal Habits…Bruxism, Pen biting
- Hampton: the physical examination being useful in only 7 patients and laboratory investigations in a further seven. No lab test: income, stress, affordability