1. و ما أوتيتم من العلم الا قليلا
د.برع سلطان
مدرس جراحة الفم والوجه والفكين
BDS , MSc , FICMS

2. Case sheet of the dental patient
The patient case sheet include:
1- history.
2- examination.
3- investigation.
4- diagnosis.
5- treatment plan
6- follow up.

3. What are the essential elements of a patient history ?
1- personal history
2- chief complain CC.
3-history of the present illness (HPI).
4-past medical history.
5- social history .
6-family history.
7-dental history.

4. Case history
Personal history: patients name ,age , sex ,address, date of treatment, telephone number....
Chief complaint C.C :is the reason that the patient seek treatment or care, should be written according to patient own words, usually C.C. Is tooth ache interfering with sleep ,swelling ,ulceration, food impaction between the teeth, and poor esthetic.

6. if the C\C is pain ask about:
History of present illness (H.P.I)
The HPI is a chronologic description of the patients symptoms and should include information about duration ,location ,character, and previous treatment.
if the C\C is pain ask about:
Characteristic of pain :sharp ,dull, throbbing burning.
Severity of pain :mild , moderate, severe according to analgesic intake.

7. Date of onset either at night , during eating drinking hot or cold things.
Is the pain continuous or intermittent?
What are the relieving or aggravating factors?
Area of pain radiation
Any other symptoms like discharge ,bad taste bad odor.....etc
Associated symptoms: fever, chills, anorexia, malaise , weakness

8. If C.C. Is swelling ask about:
Duration
Is it getting larger or smaller.
Any possible cause e.g. Trauma, hypersensitivity.....,etc

9. 4- Past dental history (P. D
4- Past dental history (P.D.H): previous visits & associated complications e.g. bleeding , fainting , difficult extractions.

10. Past medical history (P.M.H.)
Systemic disease: C.V. disease , renal or liver problems.....
Past hospitalization , operation , traumatic injuries...
Medication currently or recently used especially drug allergies.
Description of health related habits like smoking ,alcohol drinking..

11. Date & result of last medical check up or physician visit.
Social history: marital status, smoker , drinker....
Family history: medical history of close relatives e.g. Hemophilia, congenital anomalies....

12. Why is the family history of interest to the dentist?
The family history often provides information about diseases of genetic origin or diseases that have a familial tendency .examples include clotting disorders ,atherosclerotic heart disease ,psychiatric disease and diabetic mellitus .

13. 8. Clinical examination:
Extraoral examination (E.O.E)
Intraoral examination (I.O.E)

16. What techniques are used for physical examination of the patient ?
Inspection : is based on visual examination of the patient .
Palpation :touching and feeling of the patient .
Percussion : differences in sound transmission of structures .
Mobility test : to determine the degree of tooth mobility .

17. E.O.E.: involve
Symmetry of the face
Color of sclera
Sinus or pus discharge.
Mouth opening
Lymph nodes
T.M.J. Clicking or crepitation

18. I.O.E. includes : Patient oral hygiene ( poor , moderate, good )
Condition of the mucous membranes.
Condition of gum ( normal , inflamed , fibrotic)
Carious teeth.
Missing teeth.
Careful examination of the offending tooth.
( Tenderness to percussion , pulp involvement , any
restorations , inclination , malposed , mobility, etc..)

19. investigation
Investigations are adjunctive measures that provide additional information not obtainable by history and physical examination.

20. Investigations : radiograph , pulp testing, Lab
Investigations : radiograph , pulp testing, Lab. Investigations , blood pressure.
Treatment plan: method of tooth removal either closed or open tech. & no. of teeth that will be extracted.

21. The treatment priorities in descending order of importance, are to :
1- relieve pain.
2- relieve swelling.
3- remove dead or diseased tissues.
4- Promote healing.
5- restore function.

26. Extraction of teeth Knowledge of tooth morphology
Application of force related to tooth morphology
Use of forceps
Use of elevators
Position of patient