SEMINAR

ON
CASE HISTORY
SUBMITTED TO:
The Department of Pedodontics
SUBMITTED BY:
Mandeep kaur
Roll no. 37
BDS IVth Prof
INTRODUCTION
1. CASE HISTORY : is a classic form of documentation which ranges from
clinical sketches to highly detailed and extended accounts that help in
arriving at a diagnosis and formulation of treatment plan of the person
under study.
2. DIAGNOSIS: The process of identifying a disease by careful evaluation
of signs and symptoms.
3. DIFFERENTIAL DIAGNOSIS: The process of listing out two or more
diseases having similar signs and symptoms of which only one could be
attributed to the patients suffering.
4. PROVISIONAL DIAGNOSIS: A general diagnosis based on clinical
impression without any laboratory investigations.
5. FINAL DIAGNOSIS: A confirmed diagnosis based on all available data.
6. SYMPTOM: Any morbid phenomenon or departure from the normal in
structure, function or sensation experienced by the patient and
indicative of a disease.
7. SIGN: Any abnormality indicative of disease, discovered on
examination of the patient.

HISTORY
It includes:
1. Health history
2. Vital statistics
3. Chief complaint
4. Medical history
5. Parent history
6. Prenatal history
7. Birth history
8. Postnatal history
9. Diet history.
HEALTH HISTORY
It is a structured format and must be recorded as such.
The interview conducted should have a few guidelines to be
followed such as:
Various questions need to be asked depending on the type of
information needed.
To obtain history in infants and children, under 5 years of age,
the parent or legal guardian is interviewed.
Often, the symptoms are aptly described by the patient and
should be recorded in his own words (e.g., Doctor, I have a
sudden shooting type of pain).
The dentist should be an good listener as the patients may
often share their grievances to him/her and this will go a long
way in establishing a good rapport.


VITAL STATISTICS
USES
maintain records.
To create administrative standard on health science.
To direct or maintain control during execution of programs.
To disseminate reliable information on health situation and programs.

It includes:
1. Date
2. Hospital number / Case number
3. Name
4. Age
5. Sex
6. Race/Ethnic origin
7. School and class
8. Address
9. Source of information
10.Source of referral.
RACE/ETHNIC ORIGIN
Some diseases may be seen in certain races and oral
hygiene practices may be common in some religions as a
cultural habit.
SCHOOL AND CLASS
To know the economic status and to
communicate with the teacher. It also helps in
assessing the IQ of the child and to establish
effective communication at his own IQ level.
ADDRESS
Communications purpose.
Socioeconomic status.
If the patient is coming from a far distance, the
appointments can be modified to complete
treatment in fewer visits.
Living area may indicate diseases endemic to
that particular region.
SOURCE OF INFORMATION
The source of information (parent or guardian)
and relationship with the child should be
ascertained as the reliability of information.
SOURCE OF REFERRAL
In multidisciplinary set ups, day-to-day referrals
are seen. The chief complaint in these cases
may be non dental. Thus stress on dental
awareness and motivation may be needed.

In certain cases, just an opinion may be
required and the patients treatment can be
carried out only in consultation with pediatrician
or physician. The patient care can be optimized
by being in constant touch with the consultant
(e.g., dental procedures may be performed
under general anesthesia in an uncooperative
child).
CHIEF COMPLAINT
A detailed information of the chief complaint goes a long
way in establishing the diagnosis and it should be recorded
in patients own words.
Several factors need to be evaluated regarding the chief
complaint. For example the most common presenting
illness can be evaluated under:
1. The onset
2. The duration
3. The location
4. The quantity, quality, severity and frequency of
occurrence
5. Aggravating and relieving factors
6. Associated symptoms
MEDICAL HISTORY
History of any medical conditions
should be asked, including recent
hospitalization, blood transfusions, etc.
PARENT HISTORY
A dental visit and the treatment
performed would point towards the
attitudes of the parents.
An unpleasant experience may be
transmitted unknowingly to the child and it
should be kept in mind.
Any genetic/inherited abnormalities
should be interviewed into.
PRENATAL HISTORY
Prenatal history (mainly maternal) may
disclose information that can be linked to
the present condition.
e.g., tetracycline stains on teeth.
BIRTH HISTORY
Suggests if any problems were encountered at
birth, as:
Rh incompatibility: The effects may be seen
in the dentition, with well described entities
such as Hump on the tooth and the
characteristic blue-green discolorations.

Other problems such as:
Cyanosed or blue baby
Trauma due to forceps delivery
Premature delivery etc.

POSTNATAL HISTORY
As discussed elsewhere, significance is attached to the
amount of time child was breast fed, bottle fed, if the bottle
was misused, and the type of nipple used etc.

Vaccination status needs to be assessed along with the
present medical illness, if any.
Presence of any habit and its duration, frequency and
intensity need to be evaluated.

EXAMINATION
It includes:
1. General examination
2. Examination of Head and Neck (extraoral)
3. Local examination (intraoral)
GENERAL EXAMINATION
The general examination and evaluation of the patient
begins with the first appearance of the child along with the
parents.

A child hiding behind the parent, child inquisitively looking at
the equipment, a smiling child, will give a fair indication of the
response to be expected. The child should be checked for the
gait as well.

The built of the child (whether normal for his age), height,
and posture while standing can also be evaluated
simultaneously.
EXAMINATION OF HEAD AND NECK
(EXTRAORAL)
Evaluation of shape of head, facial form and facial
symmetry is carried out after general examination.
Shape of head mesocephalic (oval shaped),
brachycephalic (short and broad ) and dolicocephalic
(long, thin and tapering)
Facial profile i. A straight profile.
ii. A convex profile indicates class II malocclusion
usually from a mandible that is placed too far
posteriorly.
iii. A concave profile indicates class III malocclusion
which may be due to the maxilla too far back or the
mandible too forward.
Lip competency competent or incompetent lips.

TEMPOROMANDIBULAR JOINT
Joint palpation and observing the child in various
position of the jaw can prevent and help in diagnosing
the temporomandibular disorders in children.
Joint sounds like clicks or crepitus, tenderness to
palpation should be noted.
Mandibular deviations during jaw movements or
mastication can signal soreness of muscles or TMJ
dysfunction which should be further evaluated for
required treatment.
LYMPH NODES
Palpation of commonly involved lymph nodes
(submental and submandibular) shows an acute or
chronic infection.
LOCAL EXAMINATION (INTRAORAL)
Local examination of pediatric patient should
be comprehensive:
a)Oral soft tissues
b)Oral hard tissues
ORAL SOFT TISSUES
I. Skin/Lips: For presence of any sinus/fistula etc.
II. Mucosa: Any ulcerations, growths, pallor of mucosa
indicating anemia, yellowish discoloration jaundice.
Systemic manifestations of diseases may be present
(Kopliks spot as in early measles).
III. Palate: The hard and soft palate are inspected for any
developmental anomaly like clefts and manifestations of
systemic diseases.
IV. Gingiva: The normal gingiva in a child is different from an
adult. Inflammation of the gingiva and accumulation of the
plaque on the teeth are seen by respective indices.
V. Tongue: should be examined for developmental
anomalies, lesion and swallowing pattern. If the child is old
enough, speech is also evaluated.
VI. Tonsils/adenoids: oropharynx should be closely
examined for any enlargement or purulent exudate.
ORAL HARD TISSUE EVALUATION
The teeth present have to be recorded so that dental age can be assessed
along with the stage of development of the dentition.

FDI Scoring System
It is one of the commonly used numbering systems. Quadrants are alloted
initial numbers as:
upper right upper left
Primary 5 6
8 7

upper right upper left
Permanent 1 2
4 3
Then the tooth in each quadrant is numbered as:
Primary
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
Permanent
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
INDICES
The most commonly used indices are:

1. Caries index
2. Plaque index (Silness and Loe, 1964)
3. Gingival index (Loe and Silness, 1967)
CARIES INDEX
WHO (1987) criteria for primary and permanent teeth
Permanent tooth code condition/status primary tooth code
0 Sound A
1 Decayed B
2 Filled, with decay C
3 Filled, no decay D
4 Missing as a result of caries E
5 Missing due to any other reason -
6 Sealant, Varnish F
7 Bridge abutment or special crown G
8 Unerupted tooth -
9 Excluded tooth -



PLAQUE INDEX(SILNESS AND LOE, 1964)
Plaque has been defined as a specific, highly selective
entity resulting from a sequential colonization of
microorganisms on the surface of the teeth, soft tissues,
restorations and appliances.

Rather than examining the whole dentition, a few Index
teeth are selected:
Permanent dentition - 16, 12, 24, 36, 32, 44
Primary dentition - 55, 52, 64, 75, 72, 84
Mixed dentition - 16, 52, 64, 36, 32, 84
Scoring Criteria:

0-No plaque in the gingival area
1-A film of plaque adhering to the free gingival margin and
adjacent area of the teeth. Only running a probe across the
teeth surface may recognize the plaque.
2-Moderate accumulation of soft deposits within the gingival
margin and/or adjacent tooth surface that can be seen with
naked eye.
3-Abundance of soft matter within the gingival pocket and/or
the gingival margin and adjacent tooth surface.


Calculations
A. Plaque index for a tooth =
Add scores from 4 areas of tooth
--------------------------------------------------
4
B. Plaque index for a individual =
Add scores for each tooth
---------------------------------------------
No. of teeth examined
INTERPRETATION SCALE
1. 0.0 - Excellent
2. 0.1-0.9 - Good
3. 1.0-1.9 - Fair
4. 2.0-3.0 - Poor
GINGIVAL INDEX (LOE AND SILNESS, 1967)
It has been developed for the purpose of assessing
the severity of gingivitis and its location in four possible
areas of an individual tooth.
Same teeth are examined as in plaque index.
Each tooth is divided into four parts:
1. Distofacial papilla
2. Midfacial papilla
3. Mesiofacial papilla
4. Entire lingual gingival margin

Score Criteria
0 - Normal papilla
1 - Mild inflammation, slight change in colour,
slight edema; No bleeding on probing.
2 - Moderate inflammation, redness, edema,
and glazing; Bleeding on probing
3 - Severe inflammation, marked redness and
edema, ulcerations; Tendency for
spontaneous bleeding

CALCULATIONS
Gingival index score per tooth =
Total score
---------------------------
4
Gingival index score for a person =
Total of all scores
--------------------------------------
No. of teeth examined

INTERPRETATION
1. 0.1-1.0 Mild
2. 1.1-2.0 Moderate
3. 2.1-3.0 Severe
PHASES OF TREATMENT PLANNING
It includes:

1. Systemic phase
2. Preventive phase
3. Preparatory phase
4. Corrective phase
5. Maintenance phase



1. Systemic phase:

A patient with a history of medical disease
may require the condition to be stabilized
before dental treatment commences. In this
respect the patient may have to be referred to
the pediatrician.
Keeping in mind the systemic condition,
premedication(as in antibiotic prophylaxis,
sedation) needs to be given to the child, with
the consent of the pediatrician.
Preventive phase:
Caries risk assessment and
assessment for various
preventive measures (personal
oral hygiene, fluoride
application, pit and fissure
sealant, diet counseling).

3. Preparatory phase:
a) Behavior management - The childs behaviour shaping
should start right from the reception itself.
b) Oral prophylaxis It presents a clearer view of the
caries process which facilitates its diagnosis. It also
gives an idea whether the patient will cooperate.
c) Caries control Further progress of carious lesions
should be controlled. Sometimes multiple lesions may
need to be temporized.
d) Orthodontic consultation Preventive orthodontic
programme should be planned before any orthodontic
intervention.
e) Oral surgical procedure Unrestorable caries,
orthodontic reasons etc. may necessitate the extraction
of teeth.
f) Endodontic therapy If required, a tooth may be saved
with endodontic treatment.
4. Corrective phase:
a) Restorative dentistry Permanent fillings,
stainless steel crowns etc.
b) Prosthetic rehabilitation Tooth replacement,
jacket crowns etc.
c) Early orthodontic intervention Minor tooth
movements, serial extraction, space
management etc.

.
5. Maintenance phase:
Depending on the risk of the individual and
his oral hygiene status, a 3-6 month
recall visit can be established for the
following:
Review of oral health status by
repeating indices and comparing with
initial indices.
Caries activity tests may be repeated
Reinforcement of home care measures
Motivation and re-counseling of parents
if required
Follow-up treatment procedures