DENTAL CASE HISTORY

INTRODUCTION

It is defined as a planned professional conversation that enable the patient to communicate his/her symtoms,feelings,and fears to the clinician so obtain nature of patient illness and his/her attitude to them.-an evalvation of the patient prior to the dental treatment.

1.To establish the diagnosis.2.To detect any medical problems.3.Evalvation of other systemic problems.4.Disovery of communicable diseases.5.Management of emergencies.6.For treatment planning.

Sequence of case history

1.Statistics2.Chief complaint3.HOPA(history of present illness)4.Medical history5.Past dental history6.Family history7.General eamination8.Extra oral examination9.Intra oral examination10.Provisional diagnosis11.Investigation12.Treatment plan

statistics

It is defined as a systemic approaches to collect and compile in numerial form the information related to vital events ,live births,deaths,recognition,social structure and legislation.Pt reg no,age,sex,school/class address,date,name,education,occupation.

1.Chief complaint2.HOPA-quality,quantity,location,duration,aggrevated by,relieved by.3.Medical history-cvd,resp diseases,GI,GU,endorine,neurological,haematological,psyhiatric,allergic reactions.4.Past dental history5.Family history-pre natal,natal,post natal6.Personal history-oral habits=mouth breathing,finger and thumb sucking,nail bitingOral hygiene practices,adverse habits.

7.General eamination

Child-built,height,postureVital signs-temp,blood pressure,pulse,resp rateBody type

8.Extra oral examination

-shape of head-facial form-facial symmetry -lip competency-tmj-lymph node-salivary gland

9.Intra oral examination

Soft tissue-tongue palate floor of the mouth gingiva periodontium

2.Hard tissue examination

Provisional diagnosis

A general diagnosis based on clinical impression without any lab investigation

Differential diagnosis

Listing out of two or more diseases having similar signs and symptoms

Investigation

1.Radiograpic2.laboratory

Plaque , Calculus

Gingivitis

Periodontitis

Periodontal Abscess

Dental caries

Treatment plan

1.systemic phase-stabilize ,medical condition if any ,antibiotic prophylaxis2.preventive phase-caries risk assesment,personal oral hygiene,flouride application,pit and fissure sealant,diet counselling3.preparatory phase-behaviour management,oral prophylaxis,caries control,orthodontic consultation,oral surgical procedure,endodontic therapy

4.corrective phase-restorative dentistry,permanent filling,stainless steel replacement,early orthodontic intervention,minor tooth movement,serial extraction,space management5,maintanence phase-3-6month recall,checkup