Professional Documents
Culture Documents
Introduction
Objectives
Advantages
Name
Age
Sex
Address
Occupation
ExaminationGeneral Examination
Extra-oral Examination
Intra-oral Examination
Soft-tissue Examination
Hard-tissue Examination
Clinical Diagnosis
Differential Diagnosis
Final Diagnosis
Treatment Plan
Summary
References
CASE
HISTO
RY
DEFINITION
OBJECTIVES
ADVANTAGES
Demograph
ic Features
History
Taking
General
Examinatio
n
Provisional
Diagnosis
Extra-oral
Hard- tissue
I. Demographic Features
Name
Age
Sex
Occupation
Address
NAME
Identification
Investigatio
ns
Final
Diagnosis
Intraoral
Soft- tissue
AGE
old.
SEX
MALES
FEMALES
ADDRESS
Filariasis in Orissa,
OCCUPATION
O.P. NUMBER
Patient identification
Maintain records
Forensic Odontology
DATE
Maintain records k
Chronological order
CHIEF COMPLAINT
MEDICAL HISTORY
FAMILY HISTORY
SOCIAL/PERSONAL HISTORY
TYPES OF QUESTIONS
Open- Ended Questions
Closed- ended Questions
Leading Questions
Contradiction Questions
Indirect Questions
CHIEF COMPLAINT
It is a symptom or symptoms in the patients own words that relates to the
presence of an abnormal condition.
Bad breath
Bad taste
Numbness
Dryness of the mouth
ANALYSIS OF PAIN
Chronological account of the chief complaint and associated symptoms from the
time of onset to the time the history is taken.
1. Allow patient to elaborate on the story of his illness; from onset to its
present state.
2. No leading questions
3. Can interrupt to ask for presence of positive or negative symptoms related
to patients current problems.
i.
Date of onset
ii.
Type of onset
iii.
Character
iv.
Location
v.
vi.
vii.
SITE
viii.
ix.
x.
xii.
SEVERITY
xiv.
When did it start? When does it come and when does it go?
Has it changed since it began?
CHARACTER
What is it like?
xiii.
RADIATION
xi.
Where is it?
RELIEF
ANALYSIS OF SWELLING
DURATION
Acute
Chronic
MODE OF ONSET
Rapid
Slow
Pain
Difficulty in breathing
Difficulty in swallowing
SECONDARY CHANGES
Ulceration
Inflammatory
changes
IMPAIRMENT OF
FUNCTION
Difficulty in eating
RECURRENCE OF SWELLING
Yes
No
ANALYSIS OF ULCER
Pain-
Present/Absent
Discharge-
Serum/Blood/Pus
Associated diseases-
MEDICAL HISTORY
Aids in the diagnosis of oral manifestations of systemic disease.
Hospitalizations
Transfusions
Allergies
Medications
Pregnancy
ii.
iii.
2.
congenital conditions
3.
infectious diseases
4.
immunologic disorders
5.
6.
7.
8.
psychiatric treatment.
These questions also serve to remind the patient about medical problems that
can be of concern to the dentist and are therefore worthy of reporting.
HOSPITALIZATIONS:
Transfusions:
1. A history of blood transfusions,
2. date of each transfusion
3. Number of transfused blood units
Allergies:
i.
ii.
fainting,
stomachache,
weakness,
itching,
rash, or
stuffy nose
urticaria
skin rash
acute respiratory difficulties
erythema multiforme
symptoms of serum sickness.
should be differentiated from psychological reactions or aversions
(side effects) to particular medications or foods.
For example, patient claims to be allergic to penicillin should be
questioned as to the type of reaction if it is toxic in nature (nausea,
vomiting) or truly allergic (urticaria, pruritus, respiratory distress, or
anaphylaxis).
It is good practice to record that a patient has no known drug allergies
(NKDA).
Allergic reactions to LATEX are becoming more prevalent. Elicit such
information, prior to instituting a clinical examination.
MEDICATIONS:
3.
PREGNANCY:
i.
ii.
iii.
Printed questionnaire?
FAMILY HISTORY
Whenever a symptom or sign suggests an inherited disorder, such as
HAEMOPHILIA, the family history should be elicited.
Ideally, this is recorded as a PEDIGREE DIAGRAM and all family
members for at least three generations should be considered.
Inherited disorders
hemophilia
diabetes
hypertension
aggressive periodontitis
Dentinogenesis imperfecta
amelogenesis imperfecta
Communicable diseases
hepatitis
Tuberculosis
leprosy
conjunctivitis
Typhoid
Amoebiasis
If no familial disease ask about Family history might lead into questions about
i.) home circumstances,
ii.) relatives
iii.) social history
can be revealing if, for e.g. psychosomatic factors are suspected.
Surgical procedures
Radiation or other therapy: for oral or facial lesions1. Date, nature of diagnosis
2. Type, anatomic location of T/t.
3. Names, addresses, and telephone numbers of the
physicians and dentists involved
4. Hospital or Clinic where the treatment was given.
PERSONAL HISTORY
i.
Diet:- Mixed/Vegetarian
ii.
iii.
iv.
a. Tobacco
Type of Smoking tobacco:
Beedi/Cigarette/Any
other
<1
b. Alcohol Habits:
Non alcoholic*
Occasional Drinker*
Regular Drinker*
Type of Alcohol Consumed No of years since Alcohol used Quantity consumed /week (ml)-
MENSTRUAL HISTORY
Age of Menarche
Regular/Irregular cycle
OBSTETRIC HISTORY
No. of abortions
1. Spontaneous/therapeutic
Time interval
1. Successive pregnancies/abortions.
Gestational Diabetes
LIMITATIONS: HISTORY-TAKING
Language difficulties
EXAMINATION
GENERAL EXAMINATION
EXTRA-ORAL EXAMINATION
INTRA-ORAL EXAMINATION
GENERAL EXAMINATION
GENERAL APPRAISAL
MENTAL STATE & INTELLIGENCE
BUILD & STATE OF NUTRITION
ATTITUDE
GAIT
STATURE
CONSTITUTION
EXAMINATION
SKIN
NAILS
HAIR
EXAMINATION
HANDS & FINGERS:
HANDS
FINGERS
NAILS
FEET
TOES
FACE- FOREHEAD:
EYES
NOSE
EARS
CONSTITUTIONAL FEATURES-
TEMPERATURE
PULSE
BP
PAIN
OEDEMA
GENERAL EXAMINATION
General Examination starts when the patient enters the clinic. It
requires daylight as in artificial light one may miss out the faint yellow
tinge of slight jaundice.
Objective : to obtain a general idea of the patients physical status
FIRST STAGE
SECOND STAGE
FOURTH STAGE
THIRD STAGE
FIFTH STAGE
VITAL SIGNS
Includes
Temperature
Pulse rate
Respiratory rate
Blood pressure
Pulse character
BLOOD PRESSURE
Respiratory rate
Temperature
Normal value:
37 or 98.6
Abscessed teeth
ANUG
Herpetic gingivostomatitis
Malignant neoplasms
PIGMENTATION OF SKIN
1. Generalised Absence Of Pigmentation
2. Patchy Absence of skin pigmentation
3. Circumscribed hypopigmented lesions.
4. Generalised hyperpigmentation
5. Patchy hyperpigmentation.
6.
7.
Bluish discolouration
8.
Ruddy complexion
PALLOR
Pale appearance
1. Skin
2. Mucosa
3. Lower palpebral conjunctiva
CLUE:
diagnosis of Herpes
I.
II.
III.
DERMATOGRAPHIA-
PALMAR ERYTHEMAi.
ii.
iii.
Chronic leukaemias
iv.
Polycythaemia
v.
Rheumatoid arthritis
vi.
Thyrotoxicosis
vii.
XANTHOMAS- Hyperlipidaemia.
Generalised pruritis
Metastatic calcification
Kyrles disease
INTERNAL MALIGNANCY
ACANTHOSIS NIGRICANS
PITYRIASIS ROTUNDA
KOILONYCHIA
CCF
HYPOALBUMINAEMI
A
ANAEMIA
DIABETES
MELLITUS
BEAUS LINE
PLUMMER NAIL
BLUE NAIL
BLACK NAIL
SILVER DEPOSITS
WILSONS DISEASE
PEUTZ-JEGHERS
SYNDROME
CUSHINGS
SYNDROME
ADDISONS DISEASE
NAIL PITTING
PSORIASIS
CLUBBING
CLUBBING
Lung Abscess
Bronchiectasis
Infective Endocarditis.
GENU VARUM
RICKETS
OSTEOMALACIA
ACHONDROPLASIA
GENU VALGUM
CONGENITAL
RICKETS
LARGE FEET
ACROMEGALY
ACHONDROPLASIA
OEDEMA
Collection of excess of fluid in the body interstitium, from the intravascular
compartment.
GENERALISED TYPE
PITTING OEDEMA
LOCALISED TYPE
PITTING OEDEMA
CARDIAC
VENOUS
RENAL
LYMPHATIC
HEPATIC
INFLAMMATORY
NUTRITIONAL
ALLERGIC
IDIOPATHIC
NON-PITTING
OEDEMA
EXAMINATION OF HEAD
SKULL
FACIES
FACIAL FORM
SYMMETRY
EYES
EARS
SCLERODERMA
LYMPHOEDEMA
ANGIONEUROTIC OEDEMA
MYXOEDEMA
NOSE
8. CUSHINGOID
2. HYPOTHYROID
HYPERTHYROID
9.
3. LEONINE
10. ELFIN
4. MYASTHENIC
PARKINSONIAN
11.
5. BELLS PALSY
CIRRHOTIC
12.
6. CRETINOID
TABETIC
13.
15. FACE
Profile
Straight
Convex
Concave
Positioning :
Maxilla
Mandible
Presence/Location :
Swellings
EXAMINATION OF HEADEYES
1.Ptosis
9. Exophthalmos
2.Pallor
10. Nystagmus
3.Cyanosis
4.Icterus
12. Miosis
5.Bitots Spots
6.Phlyctenular Conjunctivitis
7.Arcus Senilis
8.Blue Sclera
GROSS DEFORMITY
ACHONDROPLASIA
FRACTURE
LESIONS
SADDLE SHAPE
NOSE OF SYPHILIS
ALLERGY
LESIONS
EPISTAXIS
NASAL OBSTRUCTION
HABIT
TISSUE HYPERTROPHY
POLYPS
FOREIGN OBJECTS
LARGE TURBINATES
EXAMINATION OF NECK
EXAMINED FOR:
Lesions
Scars
Deviations of trachea
Glandular enlargement
Sub mental
Submandibular
Cervical
Preauricular
Post auricular
Supraclavicular
Unilateral/ Bilateral
Discrete/ Matted
Tender/
Non-tender
Submandibular Lymphnodes
Palpation-
With ones fingers cupped and the tips pressed lightly against the
mylohyoid muscle, the tissue is rolled laterally across the inferior border of
mandible.
Inspection
Asymmetry
Deflection/deviation
Swelling
Palpation
Tenderness
Crepitus
Hypermobility/hypo-mobility
Auscultation
Bell-end of stethoscope
Mouth opening:
Distance from upper and lower incisor edges is measured at the midline.
Normal 35 to 50mm
SOFT-TISSUE EXAMINATION
Lips
Buccal mucosa
vestibular sulcus
Gingiva
Hard palate
Soft palate
INTRA ORAL
EXAMINATION
EXAMINATION
uvula
Tongue
Periodontal examination
EXAMINATION
EXAMINATION OF LIPS
Normal colour
Normal color-pink
Inspection ask the patient to touch the tip of the tongue against the anterior
portion of hard palate
Bimanual palpation.
Inspection
Color Changes
Papillary Growth
Petechial Spots
Bifid Uvula
Deviation
Acute inflammatory responses are red whereas , the more the chronic , the
paler the coloration because of ensuing fibrosis of gingiva.
Grade 2- Cul-de-sac
Grade 3- Through and through passage of probe
Grade 4- Interdental bone is completely destroyed
and soft tissues have receded completely
PERIODONTAL POCKET
GINGIVAL RECESSION
Apical migration of the gingival margin resulting in exposure of the root surface
Factors to be examined
Malposition teeth
Ablation
Mode of brushing
TOOTH MOBILITY
Physiologic mobility
Pathologic mobility
HARD-TISSUE EXAMINATION
Teeth present
Decayed teeth
Missing teeth
Filled teeth
Root stumps
Fractured teeth
Mobility
Tenderness on percussion
Wasting diseases
Occlusal relation
TEETH PRESENT
87654321 12345678
87654321 12345678
FDI SYSTEM
DECIDUOUS TEETH
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
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
DECAYED TEETH
Record carious teeth
Location of decay
1.
2.
3.
4.
Detected with an
explorer
Tactile Examination
Smooth surface caries- Place the No.5 explorer in the interproximal
area and walking it up the tooth to the contact point.
MISSING TEETH
Absent teeth
Anodontia
Hypodontia
Oligodontia
FRACTURED TEETH
Class 1
fracture of enamel involving little or no dentin
Class 2
Class 3
Extensive fracture of the enamel and dentine and exposing the dental
pulp
Class 4
Traumatized
tooth becomes
non-vital.
Class 5
Class 6
Fracture of the
root with or
without loss of
the crown
Class 7
Displacement of
the tooth with or without the fracture of the tooth structure.
Class 8
Fracture of the crown en masse
Class 9
Fracture of the deciduous teeth
WASTING DISEASES
Attrition
Abrasion
Erosion
Abfraction
OCCLUSAL RELATIONSHIP
ESTABLISHING A
DIAGNOSIS
DefinitionThe process of
establishing the nature
of an abnormality or
disease that produces
signs &
symptoms is called
diagnosis.
CLINICAL
PATHOLOGICAL
PROVISIONAL
DIRECT
DEDUCTIVE
DIFFERENTIAL
DIAGNOSIS EX-JUVANTIBUS
DIAGNOSIS BY EXCLUSION
PROVOCATIVE DIAGNOSIS
LABORATORY INVESTIGATIONS
It helps in final diagnosis. The common methods are
Hematological investigations
Urine analysis
Biochemical investigations
Radiological investigations
Microbiological investigations
FINAL DIAGNOSIS
Final diagnosis is usually reached after chronologic organisation & evaluation of
the information obtained from the patient history , physical examination &
laboratory examination.
PROGNOSIS
FACTORS DETERMINING PROGNOSIS
Systemic/environmental factors
Local factors
Prosthetic/restorative factors
TREATMENT PLAN
Any treatment plan should be arranged into a logical and prioritized series of
management procedures designed to solve the patients oral problems.
Phase 1 :
emergency phase
Phase 2 : surgical
phase
Phase 3 :
prophylactic phase
Phase 4 :
restorative phase
Phase 5 : corrective
phase
Phase 6 : recall and
review
CASE ANALYSIS AND SUMMARY
A brief case summary is written at the end of the case highlighting the positive
findings.
The characteristic features of the case are written emphasizing on the
investigatory process and diagnosis.
The treatment plan is explained.
Subjective standard:
In general, the patient's presence in the hospital ward, ICU or clinic does
not represent implied consent to all treatment and procedures.
The patient's wishes and values may be quite different than the values of
the physician's.
body, the principle of beneficence may require you to act on the patient's
behalf when his life is at stake.
REFERENCES
Oral diagnosis by Kerr, Ash & Millard , 6th edition