Case history for Dental Health care profession CONTENTS: • INTRODUCTION • OBJECTIVES • PERSONAL DETAILS. • CHIEF COMPLAIN . • HISTORY OF PRESENT ILLNESS • DENTAL HISTORY. • MEDICAL HISTORY. • FAMILY HISTORY. • NATAL HISTORY. DIET HISTORY. • CLINICAL EXAMINATION. • PROVISIONAL DIAGNOSIS. • INVESTIGATIONS. • FINAL DIAGNOSIS. • TREATMEN PLANNING. • PROGNOSIS. • FOLLOW UP. • COMPLETE RECORD. INTRODUCTION: Successful dental care for children is best achieved after thorough examination, thoughtful diagnosis and formulation of a proper treatment plan. The interest, warmth and compassion exhibited by dentist are important factors in establishing rapport with and in obtaining meaningful history . A kind and considerate approach is most important in securing and gaining the confidence of the patient. Indicate the patient that you are a friend who is keenly interested in him/her as a professional. Ideally the patient’s history should be taken in a consultation room or a private office in which the décor and the furnishing are quite different from those of the dental operatory . The friendly atmosphere is an important factor in helping the patient to talk freely about his/her problems. OBJECTIVES: • To provide information regarding etiology and establish diagnosis of oral conditions • To reveal any medical problem necessitating precaution modification during appointments so as to ensure that dental procedure do not harm the patient and also to prevent emergency situation • Evaluation of other possible undiagnosed problem • Discovery of communicable disease • Gives an insight into emotional and psychological factor • For effective treatment planning • Record maintenance for future reference and periodic follow up • Act as a evidence in legal matters     DEFINITION A history can be considered to be a planned professional conversation that enables the patient to communicate their symptoms, feeling and fears to the clinician so that the nature of the patient’s real and suspected illness and mental attitudes may be determined. PERSONAL DETAILS OPD NUMBER: It is recorded for the purpose of organized file keeping, billing and also medico legal purpose. • Reference • Record maintenance • Medico legal Issues. DATE: Records patient’s first visit which can be referred back to. • Reference. • Record maintenance NAME: • Recording names are useful in pediatric practice. Children are at ease when they are referred to by the same names as they are referred at home. • Purpose of recording the patient’s name is for; • Identification. • To maintain records • Communication. • Building rapport with patient. AGE: It is one of the important details significant from the fact that a child is in a dynamic state of growth. Some of the reasons why recording age is important are: • Behavior Management Techniques that h

2. 2
Guided By:
Dr. Ashish Saxena
Professor and HOD
Presented By:
Dr. Hage Monju
MDS 1st year
CASE HISTORY AND EXAMINATION OF
CHILDREN

3. CONTENTS:
 Introduction
 Objectives
 Personal Details.
 Chief Complain .
 History Of Present Illness
 Dental History.
 Medical History.
 Family History.
 Natal History.
 Diet History.
 Clinical Examination.
 Provisional Diagnosis.
 Investigations.
 Final Diagnosis.
 Treatment Planning.
 Prognosis.
 Follow Up.
 Complete Record.
3

4. INTRODUCTION:
 Successful dental care for children is best achieved
after thorough examination , thoughtful diagnosis
and formulation of a proper treatment plan.
 The interest, warmth and compassion exhibited by
dentist are important factors in establishing rapport
with and in obtaining meaningful history .
 A kind and considerate approach is most important
in securing and gaining the confidence of the
patient.
 Indicate the patient that you are a friend who is
keenly interested in him/her as a professional to
make them healthy.
4

5. OBJECTIVES:
 To provide information regarding etiology and establish
diagnosis of oral conditions
 To reveal any medical problem necessitating precaution
modification during appointments so as to ensure that dental
procedure do not harm the patient and also to prevent
emergency situation
 Evaluation of other possible undiagnosed problem
 Discovery of communicable disease
 Gives an insight into emotional and psychological factor
 For effective treatment planning
 Record maintenance for future reference and periodic follow
up
 Act as a evidence in legal matters
5
[source: Textbook of Public health dentistry (c.m. marya.)]

6. DEFINITION
A history can be considered to be a planned professional
conversation that enables the patient to communicate
their symptoms, feeling and fears to the clinician so that
the nature of the patient’s real and suspected illness and
mental attitudes may be determined.
Source: Textbook of oral medicine and radiology-peeyush shivhare

7. Case History is defined as planed professional conversation
that enables a patient to communicate his/her feelings, fear
and sequence of events leading to the problem for which the
patient seeks professional assistance, to the clinician so that
patients’ real or suspected illness and mental attitude of the
patient can be determined.
A Case history is a planned professional conversation that
enables the patient to communicate their symptoms, feeling
and fears to the clinician so that the nature of the patient’s
real and suspected illness and mental attitudes may be
determined.
Source: Textbook of public health dentistry ( C.M. Marya)
Source: Textbook of oral medicine (anil ghom)

8. PERSONAL DETAILS
OPD NUMBER:
 Reference
 Record maintenance
 Medico legal issues
 Billing purposes
DATE:
 Reference.
 Record maintenance
NAME:
 Identification.
 Communication.
 Building rapport with patient.
 Psychological benefit; specially in case of pediatric patient if called by nickname
8

9. AGE:
 Diagnosis
 Treatment planning
 Behavior management techniques
 Hospital records
 Drug dosage:
Young’s Formula:
Age × Adult Dose
= —————————–
Age + 12
Clarke’s Formula:
Body Wt (Kg) × Adult Dose
= —————————————
150 9

10. SEX:
Female:
 Iron Deficiency Anemia
 Juvenile Periodontitis
 Erosion
 Sjogren’s Syndrome.
Male:
 Attrition
 Herpes Simplex
 Ameloblastic Fibro-odontoma
 Stomatitis Nicotina Palati
 Hemophilia.
10

11. EDUCATION:
 Socioeconomic status
 Intelligent quotient(IQ) for effective communication
 Attitude towards general and oral health
11

12. 12
ADDRESS :
• recall
• Future correspondence
• Chart out appointments
• Diagnosis of endemic diseases
eg . fluorosis , caries, filariasis common in orissa, leprosy in west
bengal, carcinoma of the palate seen in srikakulam ( AP)

13. OCCUPATION:
 Its an indicator of socioeconomic status
 Predilection of diseases in different occupation
eg .Cobblers/carpenters= localised abrasion.
Bakers/candy makers=dental caries.
13

14. RELIGION:
 Festive periods when patients reluctant to undergo
treatment.
 Predilection of diseases in specific religions.
14

15. CHIEF COMPLAIN:
 Its the problem the patient/caregiver describes in his/her own
words.
 For two complaints sequential order must be followed with severe
one noted first.
 Must include the onset and duration of the disease
15

16. HISTORY OF PRESENT ILLNESS:
Detailed Elaboration Of Chief Complain:
 Date of onset
 Mode of onset
 Duration
 Progress
 Aggravating factors
 Relieving factor 16

17. PAST DENTAL HISTORY:
Past Dental Experience:
 Frequency of visits to a Dentist
 Frequency of preventive/oral prophylaxis
 Experience Of Local Anaesthesia.
Eg .LA Allergy, Past Orthodontic therapy, Past surgical
procedures
17

18. MEDICAL HISTORY:
 Relationship between systemic and oral health:
 Cardiovascular system . Eg. Congenital heart disease, blood
pressure, rheumatic fever.
 Medication used to treat systemic conditions can produce changes
in oral health .Eg. Tetracycline therapy.
 Systemic diseases may have oral manifestations Eg.Syphilis
patients having peg shaped lateral incisors.
 Hematological disorders 18

19. FAMILY HISTORY:
 Genetic predilection of disease
eg. Has any member in family suffered from A similar
problem.
 Siblings :size of family gives an idea about socioeconomic
status.
Eg. Number, age
 Whether the patient can afford for the time and treatment to
know the child psychology which has on effect on his behavior.
19

20. PRENATAL HISTORY:
 Drug intake during pregnancy.(immunization status)
 Whether received antiserum D vaccination or not in case Rh
+ve (father) and Rh-ve (mother)
 Illness during pregnancy.( any infections and systemic
condition)
 Trauma during pregnancy
20

21. NATAL HISTORY:
 Full term/ Premature birth.
 Type of delivery.
 Birth Injury , Cerebral palsy.
 Congenital abnormality.
 Natal teeth/Neonatal teeth
Source:Textbook of pediatric dentistry ,Nikhil Marwah.

22. POST NATAL HISTORY:
 Feeding:
Eg Breast Fed/Bottle Fed/Combination.
 Contents:
Eg. Amount Of Sugar If Added.
 Frequency.
 Any Hospitalisation /Major Illness.
 Vaccination:
Eg. Polio ,BCG.
22

23. 23
Vaccination Schedule-Recommended by the
Indian Academy of Pediatrics(2007)
Source: Textbook of principles and practice of pedodontic(Arathi Rao)

24. HABITS:
• Finger / Thumb sucking
• Nail/Lip biting
• Tongue thrusting
• Mouth breathing
• Bruxism
Source:Textbook of pediatric dentistry ,Nikhil Marwah.

25. DIET HISTORY:
DIET CHART:
 No. Of sugar exposures.
 Quantity of sugar added.
 Type of diet :
veg/non-veg
balanced/unbalanced. 25

26. Operator Area Where The Positioning Of The
Child, Operator And The Parent Resembles
Triangle And Helps In Proper Communication
26
Source:Textbook of principles and practice of pedodontic(Arathi Rao)

27. CLINICAL EXAMINATION:
GENERAL EXAMINATION: :
 BUILT: Eg. Ectomorphic, Endomorphic, Mesomorphic.
 HEIGHT: (IN CMS/FT)
 WEIGHT: (IN Kg’s/pounds).
 GAIT: Eg. Normal, Ataxic ,Antalgic,hemiplegic, Spastic.
 POSTURE: Eg. Lordotic, Fatiqued,normal.
 SPEECH: Eg. Normal, stammering. 27

28. EXTRAORAL EXAMINATION:
SHAPE OF HEAD:
 Mesocephalic: Average Shape Of Head. They posses normal dental
arches.
 Dolicocephalic: Long And Narrow Head. They have narrow dental arches.
 Brachycephalic: Broad And Short Head. They have broad dental arches
Source:Textbook of principles and practice of pedodontic (Arathi Rao)

29. 29
Gross facial assymetries can occur as A result of :
Congenital Defect.
Hemi-facial Atrophy/Hypertrophy.
Unilateral Condylar Ankylosis And Hyperplasia
FACIAL SYMMETRY: Eg.Symmetrical/ Assymetrical.
FACIAL FORM:
• Mesoprosopic: It is an average or normal face form.
• Euryprosopic: it is a broad and short face form.
• Leptoprosopic: It is a long and narrow face form.

30. 30
FACIAL FORM
(C) Mesoprosopic
Source:Textbook of principles and practice of pedodontic (Arathi Rao)
(A)Leptoprosopic (B)Euryprosopic

31. FACIAL DIVERGENCE: It is defined as
an anterior or posterior inclination of the lower face
relative to the forehead. Eg.Straight or
orthognathic,/anterior/posterior divergence.
31
Source: Textbook of Orthodontics The Art and Science S.I. Bhalajhi)

32. Landmarks used
for facial profile
Facial angle Nasolabial angle
32
Source:Textbook of principles and practice of pedodontic (Arathi Rao)

33. FACIAL PROFILE
33
( A)Straight ( B)Convex ( C)Concave
Source:Textbook of principles and practice of pedodontic (Arathi Rao)

34. LIP POSTURE:
34
34
 Competent/incompetent
 Short upper/lower lip
 Everted lower lip
source: assessment of lip(orthodontics the art and sciences.i.bhalajhi)

35. FUNCTIONAL EXAMINATION:
 TMJ:
Eg. Deviation , Clicking Sound.
 Vitals:
Eg. Pulse,respiratory Rate, Temperature,Blood Pressure.
 Lymphnodes.
Eg. Submandibular,cervical.
 Mastication:
Eg. Parafunctions Such As Bruxism And Clenching Also Give
Rise To Masseter Pain ,Lateral Interferences.
 Deglutition: check for any abnormality
35

36. 36
Operator should stand in front of the patient to
observe the path of closer of mandible
Source:Textbook of principles and practice of pedodontic (Arathi Rao),

37. 37
TMJ , Neck & submandibular
examination
Source: Textbook of McDONALD AND AVERY”

38. INTRAORAL EXAMINATION:
SOFT TISSUE EXAMINATION:-
 LIPS:
Eg.Everted/Normal/Flaccid,competent/Incompetent.
 MUCOSA:
Eg. Pigmented/Colour/Texture.
 FRENUM ATTACHMENT:
Eg.High/Normal/Low.
 GINGIVA:
Eg. Colour/Texture,size/Shape,consistency/Contour.
 TONGUE:
Eg.Microglossia/Aglossia/Macroglossia,
Fissured/Normal/Pigmentation /Tongue Tie/ Geographic Tongue.

39. 39
FRENAL ATTACHMENT
Source:Textbook of principles and practice of pedodontic (Arathi Rao),

40. INSPECTION AND PALPATION OF SOFT
TISSUE
40
Source:Textbook of(McDONALD AND AVERY)

41. HARD TISSUE EXAMINATION:
 TEETH PRESENT:
41
The dental arches are divided into quandrants, the upper
and lower, right and left. Each quadrant is denoted by
number as:
ZSIGMONDY-PALMER.
Permanent Dentition
87654321 12345678
87654321 12345678
Deciduous Dentition
EDCBA ABCDE
EDCBA ABCDE

42. FDI (Federation Dentaire Internationale)
 The teeth are numbered as follows:
 Permanent teeth
18,17,16,15,14,13,12,11,21,22,23,24,25,26,27,28
48,47,46,45,44,43,42,41,31,32,33,34,35,36,37,38
 Deciduous teeth
55,54,53,52,51,61,62,63,64,65
85,84,83,82,81,71,72,73,74,75
 Thus the first number denotes the quadrant and
second denotes the tooth. 42

43. OCCLUSION:
DECIDUOS:
• Distal Step
• Mesial Step
• Flush Terminal
43
Source:Textbook of principles and practice of pedodontic (Arathi Rao),

44. CANINE RELATIONSHIP:
44
Source:Textbook of principles and practice of pedodontic (Arathi Rao),
CANINE RELATIONS

45. 45
INCISOR RELATIONSHIP:
• Overjet
• Overbite
• Open bite
• Inscissor liability
Source:Textbook of principles and practice of pedodontic (Arathi Rao),

46. Angle’s molar relation
46
Source:Textbook of principles and practice of pedodontic (Arathi Rao),
PERMANENT TEETH
• Unerupted
• End On
• Angle’s Molar Relation.

47. 47
DENTAL MIDLINE
• Normal
• Shift.
Deviation in the dental midline

48. ARCH LENGTH:
• Adequate
• Inadequate
48
Source:Textbook ofOrthodonticS The Art and Science S.I. Bhalajhi)

49. SUPERNUMERARY TEETH:
• Mesiodens
• Paramolar
• Distomolar
49
Source: Textbook of pediatric dentistry ,Nikhil Marwah.

50.  CONGENITALLY MISSING TEETH.
 ECTOPIC ERUPTION.
 CROSS BITE:
Anterior
Posterior.
 FRACTURED TEETH:
Ellis classification.
50
Source:Textbook of pediatric dentistry ,Nikhil Marwah.

51. ANY DISCOLORATION:
51
Source:Textbook of principles and practice of pedodontic (Arathi Rao),
Hypoplasia.
Fluorosis

52.  DENTAL CARIES:
VISUAL INSPECTION OF CARIES (WHO CRITERIA)
 ANY ASSOCIATED SWELLING:
 MOBILITY :
According to glickman:
Grade I
Grade II
Grade III.
 RESTORATIONS.
 STAINS/ CALCULUS.
 POCKETS/ BLEEDING GUMS.
52
Source:Textbook of pediatric dentistry ,Nikhil Marwah.

53. Provisional diagnosis:
Provisional diagnosis is a general diagnosis based on clinical impression
without any laboratory investigation.
BASED ON CLINICAL EVALUATION
 Fabrication of differential diagnosis.
 Differential diagnosis is the process of listing out two or more diseases,
having similar signs and symptoms of which only one could be
attributed to the patient’s suffering.
53

54. PROCEED WITH INVESTIGATIONS:
CLINICAL INVESTIGATIONS:
 IOPA
 OPG
 Lateral Cephaloghram
 CT SCAN.
 Heat Test
 Cold Test
 Pulp Test
54
Source :Textbook of Mcdonald and avery’s dentistry for the child and Adolescent.

55. LABORATORY INVESTIGATIONS:
 Biopsy.
 Blood tests:
Eg: Hb , CBC
55

56. FINAL DIAGNOSIS:
 Final diagnosis is a confirmed diagnosis based on all available data.
 Its the diagnosis made after investigations.
 Helps in the fabrication of treatment plan.
56

57. TREATMENT PLANNING;
 Medical Treatment; Referral To Physician
 Systemic Treatment; Premedication , Therapy For Oral Infection
 Preparatory Treatment; Oral Prophylaxis, Caries Control, Orthodontic
Consultation, Oral Surgery, Endodontic Therapy.
 Corrective Treatment; Operative Dentistry, Prosthetic Dentistry, orthodontic
Therapy.
 Alternate Treatment Plan;
 Revisions Of Treatment Plan;
 Periodic Recall Examination And Maintainance Treatment;
57

58. PROGNOSIS:
DEFINITION:
The prognosis 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.
 Predictable Treatment Outcome.
 Result Of The Treatment.
.
58

59. COMPLETE RECORDS:
 Study models.
 X-rays: IOPA/Bitewing/ OPG.
 Cephalograms.
 Photoggraphs- intraoral/ extraoral
59

60. CONCLUSION:
One can treat and cure only those diseases or signs and symptoms
that are diagnosed in the first place. This art and science of the
patient evaluation is the key to treatment planning.
Accurate diagnosis can only be achieved by systematic and
methodical collection and evaluation of data.
A clinician can be successful in rendering a comprehensive
treatment by means of updating his knowledge timely.
Nevertheless the role of examination, diagnosis and treatment
planning still play the pivotal role in rendering the same even with
the constant development of the science and technology. All the
latest techniques do not yield the desired results if these three
fundamentals are ignored. 60

61. REFERENCES:
Textbook of kerr. Ash. Millard -oraldiagnosis.
Textbook of pedodontic, shobha tandon.
Textbook of pediatric dentistry ,Nikhil Marwah.
Textbook of malcolma lynch , oral medicine and radiology- peeyush
shivhare.
Textbook of pediatric dentistry s.G. Damle.
Textbook of pediatric dentistry arathi rao.
61

62. Textbook of oral medicine and radiology ANIL GHOM.
Textbook of public health dentistry (c.m. marya.)
Textbook of carranza’s clinical and periodontology.
Textbook of Orthodontics The Art and Science S.I.Bhalajhi.
Textbook of Mcdonald and avery’s dentistry for the child and
Adolescent.(jeffery A.Dean, DDS,MSD)
62

63. 63