This document provides an overview of how to take a case history for a dental patient. It discusses the importance of gathering demographic data, chief complaints, medical history, dental history and conducting examinations. The key components of a case history are outlined, including the steps of taking a history, examining the patient, making a provisional diagnosis, conducting investigations, reaching a final diagnosis and developing a treatment plan. Taking a thorough case history is important for understanding the patient's condition, making an accurate diagnosis and determining an effective treatment approach.

1. CASE HISTORY
By
Dr.Athul Chandra.M
Dept. Conservative dentistry and endodontics

2. INTRODUCTION
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. Steps in case history taking
•Assemble all the available facts gathered from statistics, chief complaint,
medical history, dental history and diagnostic history and diagnostic tests.
•Analyze and interpret the assembled clues to reach the provisional
diagnosis.
•Make a differential diagnosis of all possible complications.
•Select a closest possible choice-final diagnosis.
•Plan a effective treatment accordingly

5. COMPONENTS-
• Demographic data
• Chief complaint
• History of present illness
1.Medical history
2.Past dental history
3.Family history
4.Personal history
• General examination
• Extraoral examination
• Intraoral examination
• Provisional diagnosis
• Investigations
• Final diagnosis
• Treatment plan

6. Statistics/Demographic data
•Patient registration number
•Date
•Name
•Age
•Sex
•Address
•Occupation
•Marital status

7. ◦ PATIENT REGISTRATION NUMBER
Useful for-
◦ maintaining a record,
◦ billing purposes,
◦ medico legal aspects.
◦ DATE USEFUL FOR-
◦ Time of admission
◦ reference during follow up visits
◦ Record maintenance

8. NAME
• To communicate with the patient
◦ To establish a rapport with the patient
◦ Record maintenance
◦ Psychological benefits
AGE
◦ For diagnosis
◦ Treatment planning
◦ Behavioral management techniques
◦ Some diseases are prevalent in particular ages

9. AGE RELATED ANOMALIES
Commonly present at birth
◦ Micrognathia
◦ Cleft lip & cleft plate
◦ Ankyloglossia
◦ Predecidous dentition
Disease present in children & young adults
◦ Benign migratory glossitis
◦ Juvenile periodontitis
◦ Pemphigus
◦ Recurrent apthous stomatitis
◦ Dental caries

10. Disease present in adults & older patients
◦ Attrition
◦ Abrasion
◦ Gingival recession
◦ Periodontitis

11. SEX
•Significance- Certain diseases are gender specific:
Diseases common in males:
•Attrition,
• leukolpakia,
•cancer like squamous cell carcinoma,
•melanoma,
• lymphoma etc
Diseases common in females:
•Iron deficiency anemia,
• sjogren’s syndrome,
• osteoporosis, recurrent apthous ulcers etc
◦ In females, special consideration must be given to pregnancy & lactation.

12. ADDRESS
•For future correspondence
•Gives a view of socio-economic status
•Prevalence of diseases
Eg-fluorosis as a result of increase level of fluorides in water are spread
differently in various parts of the country.

13. OCCUPATION
•To asses the socioeconomic status.
•Predilection of diseases in different occupations
•eg: . Attrition and abrasion are found in industrial
workers having an atmosphere of abrasive dust
MARITAL STATUS
◦ could induce the expression of autosomal
recessive diseases.

14. 1.Chief
complaint
2.History of
present
illness
3.Medical
history
4.Past dental
history
5.Personal
history
Step 1 - HISTORY TAKING

15. 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

16. HISTORY OF PRESENTING ILLNESS
• 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
• Associated symptoms
• Treatment taken

17. PAIN
PAIN MILD MODERATE SEVERE
QUALITY dull sharp throbbing constant
ONSET
stimulation
required
intermittent spontaneous
LOCATION localised diffuse referred radiating
DURATION secs mins hours constant
INITIATED
BY
cold hot sweet spontaneous mastication supination
keeps
awake at
night
RELIEVED
BY
cold hot Analgesics Narcotics

18. MEDICAL HISTORY
◦ Helps to identify conditions
that would alter ,complicate
or contraindicate proposed
dental procedures.
◦ Communicable diseases
require special precautions or
referral .
◦ Allergies / medications can
contra indicate some drugs.
◦ Systemic diseases, cardiac
abnormalities , joint
replacement etc require
antibiotic coverage

19. PAST DENTAL HISTORY
• History of dental treatment
undergone by the patient,
along with patients experience
before, during and after the
dental treatment.
• History of complications
experienced by the patient

20. ◦ If the patient has difficulty tolerating
certain types of procedure or has
encountered problems with previous
dental care, alteration of treatment or
environment might help in avoiding
future complications.
◦ Past radiographs

21. FAMILY HISTORY
•Family members share their genes, as
well as their environment, lifestyles and
habits.
•Risks for diseases such as asthma,
diabetes, cancer, and heart disease also
run in families.
•There are also several inherited
anomalies & abnormalities that can
affect the oral cavity such as congenitally
missing lateral incisors, cleft lip & cleft
palate

22. PERSONAL HISTORY
◦ Habits-
◦ Diet
◦ Oral hygiene

23. HABITS
◦ Thumb sucking lip sucking leads to anterior proclination of maxillary incisors.
◦ Tongue thrusting habit leads to anterior n posterior open bite.
◦ Mouth breathing leads to anterior marginal gingivitis & dental caries.
◦ Smoking and Alcohol
proclination Anterior open bite

24. Diet-
• soft diet :- adhere tenaciously
to the teeth leading to more
dental caries.
• coarse diet :- cause more
amount of attrition .
– carbohydrate & vitamin diet :-
increase carbohydrate contents
leads to increase risk for dental
caries , while diet deficient in
vitamin may cause enamel
hypoplasia.

25. Oral hygiene
◦ Poor oral hygiene & improper brushing technique may lead to dental caries &
periodontal disease.
◦ Horizontal brushing technique may leads to cervical abrasion

26. EXAMINATION
◦ General examination
◦ Built and nourishment
◦ Appearance and gait
◦ Mental status and intelligence
◦ Head to foot examination

27. Extra oral examination
•Facial symmetry
•Facial swelling :yes/no
•Profile :convex/concave
•Lips: competent/incompetent
•Any abnormalities noticed
•Lymph nodes: palpation, tenderness
•TMJ
•Halitosis

28. Intra oral examination
◦ Soft tissue examination
Buccal mucosa
Labial mucosa
Tongue [Dorsal ,Ventral]
Floor of mouth
Hard palate
Soft palate
Gingiva

29. Clinical Examination for Caries:
◦ Dental caries is diagnosed by one or all of the following:
◦ (1) visual change sin tooth surface texture or color,
◦ (2) tactile sensation when an explorer is used judiciously,
◦ (3) radiographs,
◦ (4) transillumination.

30. Basic tools required are:
◦ A good light source,
◦ A mirror,
◦ A sharp explorer and
◦ An air syringe are the most basic tools required

31. Pit and fissures caries
◦ Visual examination +
radiograph enhances
diagnostic sensitivity

32. PROXIMAL CARIES
Proximal surface gingival to the
contact area most susceptible to
caries
Difficult to assess using direct visual
assessment.
Orthodontic separators used to allow
better vision.
Teeth are temporarily separated
using orthodontic rubber rings.
◦ Unwaxed floss:
◦ To detect proximal caries, the floss is
frayed
Bite wing radiographs are used

33. Hard tissue examination
EXAMINATION OF CHIEF COMPLAINT
◦ INSPECTION
◦ PALPATION
◦ PERCUSSSION

34. INSPECTION
Contour
Size, form ,structure and number
Proximal contact relationship
Colour
Erosion ,Abrasion and Attrition
Restorations
Fractures of tooth
Carious lesions

35. Tactile methods:
Explorers are widely used for the detection of carious tooth structure
- Right angled probe- no.6
- Back action probe- no.17
- Shepherd's crook- no. 23
Dental floss

36. Palpation
Detecting any soft tissue swelling
or bony expansion,
The adjacent and contralateral
tissues
Applying firm digital pressure to
the mucosa covering the roots
and apices.
The index finger is used to press
the mucosa against the
underlying cortical bone.
A positive response to palpation
may indicate an active
periradicular inflammatory
process.

37. PERCUSSION
• an indication of
inflammation in the
periodontal ligament
• This inflammation may be
secondary to physical
trauma, occlusal
prematurities, periodontal
disease, or the extension of
pulpal disease into the
periodontal ligament space

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

39. INVESTIGATIONS
◦ VITALITY TEST
◦ RADIOGRAPHIC INVESTIGATIONS

40. DEFINTIVE DAIGNOSIS
• The final diagnosis can usually be reached following chronologic organization
and critical evaluation of the information obtained from
• patient history,
• physical examination and
• the result of radiological and laboratory examination.

41. TREATMENT PLAN
Depends on:
◦ experience of a competent clinician and nature and extent of treatment
facilities available.

42. TREATMENT PLAN SEQUENCING
Urgent phase
Control phase
Reevaluation phase
Definitive phase
Maintence phase

43. Urgent phase
◦ Patient presenting with
◦ swelling,
◦ pain,
◦ bleeding,
◦ or infection these problems managed as soon as possible.

44. Control Phase. :
◦ The goals of this phase are to remove etiologic factors and stabilize the
patient's dental health
(1) eliminate active disease such as caries and inflammation,
(2) remove conditions preventing maintenance,
(3) eliminate potential causes of disease, and
(4) begin preventive dentistry activities
◦ Examples of control phase-extractions; endodontics; periodontal
debridement and scaling; occlusal adjustment

45. Reevaluation Phase
◦ Time between the control and definitive phases that allows for resolution of
inflammation and time for healing.
◦ Home care habits are reinforced, motivation for further treatment is
assessed, and initial treatment and pulpal responses are reevaluated before
definitive care is begun.

46. Definitive Phase
◦ After the dentist reassesses initial treatment and determines the need for
further care, the patient enters the definitive phase of treatment.
◦ This may include endodontic, periodontic, orthodontic, oral surgical, and
operative procedures before fixed or removable prosthodontic treatment.

47. Maintenance Phase
◦ This phase includes regular recall examinations that
◦ 1) may reveal the need for adjustments to prevent future breakdown and
◦ (2) provide an opportunity to reinforce home care.

48. Thank You