1. Case History By
Dr.Mohamed Barakat

2. Introduction
* In general , and simple words , case history is nothing but an evaluation of the patient prior to dental treatment
*it is a professional conversation to communicate with the patient as concern symptoms, signs , and nature of the patient illness

3. Introduction
* In general , and simple words , case history is nothing but an evaluation of the patient prior to dental treatment
*it is a professional conversation to communicate with the patient as concern symptoms, signs , and nature of the patient illness

4. Case History By
Dr.Mohamed Barakat

5. A case history is important in order to reach up:-
*establish the diagnosis.
*detect an medical background.
*search for other systemic problem.
*manage emergencies.
*reach up the final and effective .
working treatment plan .

6. Steps of Diagnostic procedures
1) taking and recording the case history .
2) physical examination .
3) relevant investigation to help . reaching the diagnosis .
4) establishing the diagnosis .
5) medical risk assessment of the
case .
6) outlining the treatment plan .
7) prognosis of the case .
8) final working plan

7. Methods Of Recording The Case History
* Traditional approach through
questionnaire
* Newer techniques of case history
recording as:-
. Computer data gathering
. interviewing (problem oriented records)
(POR) .
. CD methods .
. Other methods

8. Sequence of Case Recording and Evaluation
. Statistics .
. Chief Complaint.
. History of chief complaint.
. Medical History .
. Past dental History .
. Family History .
. General Examination

9. . Extra Oral Examination .
. Intra Oral Examination .
. Provisional Diagnosis .
. Prognosis .
. Investigations .
. Final Diagnosis
. Working Treatment .

10. . Behavior management techniques . Statistics
* Defined being a systemic approach to collect all data information to vital events e.g live , birth ,death , social
structures and legalization .
* Patient registration number : -
. Social security number
. Billing purposes
. Insurance
. Medico legal aspect (liability)
* Date :
. For reference
. For records
* Name :
. For identification
. Communication
. Patient records / Statistics
* Age / Sex :
. Treatment planning
. Behavior management techniques
. Statistics

11. Age : - *Age is sometime / most of the time
is an important marker and predilection of certain diseases at
different age levels .
e.g. common disease at birth
. Cleft palate / hair lips
. Hemophilia
. Tongue tie ……. etc

12. * Diseases occur in children and adults:
. Juvenile periodontitis
. Scarlet fever
. Mumps
. Measles

13. .periodontitis / Mobility .Impacted wisdom . Pulp stones
* Diseases commonly occur in adults :
. Attrition / Abrasion
.periodontitis / Mobility
.Impacted wisdom
. Pulp stones
. Root resorption .

14. Sex : Knowing the sex of the patient is important for :
*Diagnosis of different types of diseases having sex predilection to sex :
1)Diseases more common to female :-
. Iron deficiency anemia
.Juvenile periodontal disease
. Oesteoporosis

15. . Oral carcinoma . Hemophilia . Attrition . Diabetes mellitus
Diseases more common to males :
. Oral carcinoma
. Hemophilia
. Attrition
. Diabetes mellitus

16. * Education :
. Socioeconomic status
. I.Q for effective communication
. Attitude towards general oral
health care

17. * Address :
. Socioeconomic level
. Prevalence of diseases/epidemic
. Records
. To follow up case
. Vaccination

18. * Occupation :
. Assessing socioeconomic status
. predilection of some diseases to
occupations
. Hepatitis B- which more likely
related to dentists / surgeons

19. . Predilection of diseases to specific religion
. Festive periods which religious
people seams reluctant to
treatment procedures

20. Chief complaint

21. *Chief complaint is established thru
asking the patient to describe the
problem for which he / she came up
for, seeking help for treatment .
* Chief complaint should be recorded
in patient’s own words as much as
possible wit NO leading questions
or technical language .

22. * The chief complaint aids and helps
to get the diagnosis of the case as
a first priority .

23. ** Common chief complaints
. Pain
. Burning sensation
. Bleeding
. Lose of teeth / Mobility
. Recent occlusal problem
. Delayed teeth eruption
. Xerostomia
. Swelling
. Halitosis/ Bad taste
. Parasthesia / anaesthesia

24. ** History of Present illness Helps the patient to express his
own words describing his present
systemic by possible questionnaire
about his / her symptoms
e.g. :
. when the problem start.
. what did you noticed first
. Did you have problems or symptoms
related to this complaint
. Did you have those symptoms before
. Have you been through any tests
before.
. have you consulted any doctor before
. what have you done to treat this problem

25. In general symptoms can be verified;
as follow :-
* Mode of onset
* Cause of onset
* Duration
* Progress and referred pan
* Remission and exacerbation
* Treatment
* Negative history

26. Past Dental history Past dental history is important to :
* Detect the general attitude of the
patient as concern dentistry/dentist.
* Detect patient awareness about oral
health .
* Detect any previous bad experience
about dental treatment and / also his
behavior against his dentist .
* signifying the patient’s previous
treatment procedures and his attitude
towards his present situation.

27. Past medical history * Recording of past medical history including
history of past illness , hospitalization ,and
evaluation of his general health .
* All disease experienced by the patient
should be recorded in chronologic order .
* patient should be evaluated for :-
. Cardiovascular disease
. Endocrine disease
. Hematologic diseases
. Allergic reactions
. Neurologic diseases
. Joint disorders .
. Kidney , urinary ,and gastrointestinal diseases
. Respiratory Diseases

28. Personal History THIS INCLUDES : * Oral Habits . *Oral Hygiene .
* Family Histology.
*Adverse Habits.

29. *ORAL HABITS :
. Mouth Breathing
. Upper respiratory Track Problem
. Xerostomia
. Finger / Thumb Sucking
. Nail Biting
. Tongue Thrusting
Those habits my be accompanied by :-
. Open bite / Truma from occlusion
. Deep overbite/Over jet
. Protrusion of anterior teeth
. Generalized marginal gingivitis
Adverse Habits :
. Smoking and tobacco chewing
. Alcohol consumption

30. Family history is important to assess for
any disease that having a family Background
(inherited pattern ) e.g. hemophilia , diabetes ,
hypertension ,and / also to detect any
particular disease among the family

31. General Examination * This includes the vital signs : . Pulse
. Blood pressure
. Body temperature
. Respiration
. Cyanosis

32. Extra Oral Examination
* Skin (colour,texture,odema , pigmentation )
* Facial Symmetry
* TMJ Disorder
* Lymph Nodes
* Eye , Nose , and Ear

33. Intra Oral Examination
** Soft Tissue
.Tongue (volume, integrity,cracks,ulcers
fissures, tongue tie )
. Palate (cleft , perforation, ulceration )
. Floor of the mouth
. Buccal Mucosa
. Parotid gland
. Submandibular / Sublingual Gland

34. . Consistency (firm, resilient, soft)
** GINGIVA
. Color
. Pigmentation
. Contour ( scalloped)
. Shape
. Size
. Consistency (firm, resilient, soft)
. Texture (stippled )
. Size (hypertrophy / hyperplasia )
. Bleeding tendency ( on probing)

35. ** Periodondium * Plaque * Calculus * Pocketing (supra/subgincival)
* Tooth mobility

36. Furcation involvement
*progression of the inflammatory periodontal
diseases may extend to involve bifurcation and
trifurcation multirooted tooth area is called
( Furcation involvement)
* Grades :
. Grade 1: incipient stage, affects soft tissue
with suprabony pocket
. Grade 2: lesion is called “cul-de- sac” having
definite horizontal resorption
. Grade 3: bone is destroyed and detached at
area of furcation with a free pass of the
probe thru furcation area
. Grade 4: complete destruction of interdental bone and
soft tissue

37. Hard tissue examination
** TEETH
. Carious and filled teeth
. Missing rotated teeth
. Milky , mixed and permanent teeth
. Flurosis , root
. Congenital deformities
. Attrition: wear off due to toot to
tooth contact
. Erosion: loss of tooth surface by chemical
or electrochemical agent
. Abrasion: Friction between tooth and exogenous
agent

38. Provisional Diagnosis
* Provisional diagnosis is also called tentative
diagnosis or working diagnosis after
evaluating case history and performing
physical examination
* provisional diagnosis is just temporary one
* Differential Diagnosis should be kept in
mind to reach out the exact and specific
diagnosis
* Final Diagnosis may be possible “ ONLY “
after carrying out further investigation ,
and laboratory investigations

39. Final Diagnosis
Final diagnosis can be reached up by chronologic organization and critical
evaluation of the information that
obtained from patients case history
and physical examination which must
be supported by radiographic and / also
laboratory investigations .

40. Treatment Plan

41. Emergency phase : * Emergency complication is the first
* This is the first and preliminary phase of treatment plan
* Emergency complication is the first
to be treated and managed

42. Preventive phase
This is the second line of treatment involving protection and prevention of high risk factor

43. Preparatory Phase Oral prophylaxis includes .. caries
control, endodontic treatment,as well
as extraction , periodontal surgeries
and orthodontic consultation

44. Corrective Phase Maintenance phase Follow up phase
Permanent restorations and / also
prosthetic replacement, crowns and
bridge construction and space maintainer
Maintenance phase
Follow up phase

45. PROGNOSIS The systemic background of the disease .
Prognosis defined as “fate of the Disease” e.g. the outcome of the disease based on general knowledge of the pathogenesis of the disease and the presence of risk factor and / also
The systemic background of the disease .
Prognosis should be discussed and explained to the patient as concern his awareness and his considerations .
Then the final treatment protocol is now easily determined

46. END