Case history in maxillofacial surgery

27-Apr-16 CASE HISTORY (133) 1

 IT IS BETTER TO KNOW WHAT KIND OF
PATIENT HAS THE DISEASE THAN WHAT
KIND OF DISEASE THE PATIENT HAS
SIR WILLIAM OSLER
27-Apr-16 CASE HISTORY 3

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

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)

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

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.

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

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

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









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

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

 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.

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

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

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

 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.

 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.

 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.

 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).

 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.

 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

• 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

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

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

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

 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?

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

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.

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

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

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

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

 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

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

 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

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

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

 DRUG USE, ALLERGIES AND ABUSE:
 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)

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

 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.

 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

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

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

 Smoking
 Alcoholism
 Tobacco chewing

 BUILD
 NOURISHMENT
 SKIN
 HAIR
 NAILS

 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

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

 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

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

 √

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

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

 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',

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

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

 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

 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

 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.

 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

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

 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

 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

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

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

SALIVARY GLAND EXAMINATION
 Evaluated for
 Dryness
 Enlargement
 Quantity of secretions

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

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

 Palpation
 Tenderness
 Edge & margin
 Depth
 Bleeding

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

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

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

Hemangioma
Orofacial granulomatosis

Fibrous epulis
Cyclosporin-induced gingival swelling

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

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

Mucocele Parotid salivary gland
enlargement

EXTRA ORAL EXAMINATION
 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

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

 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.

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.

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.

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

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.

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.

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

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.

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

 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 - Displacement of tooth with or without
fracture of crown
 Class 8 - Fracture of crown & mass
 Class 9 - Traumatic injury to deciduous tooth

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

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

Routinely used Hematological
investigations include
 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.

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

 Patch tests
 Intradermal injections
 Prick test
 Modified prick test
 Scratch test

OCCIPITOMENTAL VIEW
STANDARD 00
300

BIOPSY
Incisional Excisional Punch

 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

 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

 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

• 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

 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

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

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

 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

 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.

 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
history recording with no undue time spent will
contribute to a skillful management of any oral
condition.

 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.

Case history in maxillofacial surgery

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