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CASE HISTORY(1ST PART)

ORAL MEDICINE AND RADIOLOGY

DR.SHALU RAIDR.MANDEEP KAUR

DR. SHIRIN VASHISHTH

PRESENTED BY: DR. SANDEEP KAUR MDS 1ST YEAR

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CASE HISTORY

Case history – It is a planned professional conversation between

doctor and patient followed by accurate recordings of the facts,

symptoms and fear of patient so that the nature,real and

suspected illness and mental attitude of the patient may be

determined.

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TYPE OF CASE HISTORY

ABBREVIATEDCOMPREHENSIVE

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1.COMPREHENSIVE DENTAL EVALUATION It Contains Patient’s history Clinical examination Radiographic and supplemental examinations Diagnostic Summary Treatment planning recommendations

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2.ABBREVIATED EVALUATION 1.SCREENING AND RECALL EVALUATION Consist of: 1. An abbreviated history 2.An abbreviated clinical examination 3.Selected Radiolographic and adjunctive tests 4.A diagnosis 5.Treatment recommendations. 2.EMERGENCY EVALUATION 1.An abbreviated histiory 2.Superficial clinical examination 3.Selected Radoigraphs 4.DIAGNOSIS 5-treatment planning

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OBJECTIVES OF CASE HISTORY

To establish a positive professional relationship To provide the dentist with information

concerning the patient past and present medical,dental & personnel history

To provide the dentist with information that may be necessary for making a diagnosis.

To provide information that aids the dentist in making decision concerning treatment.

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COMPONENTS OF CASE HISTORY 1.Demograhic data 2.Chief complaint and its history 3.Past medical history 4.Past dental history 5.Personal history 6.Family history

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7.Examination -Extraoral -Intraoral-Examination of soft tissue -Examination of hard tissue 8.Summary 9.Provisional diagnosis 10.Differential diagnosis 11. Investigation 12.Final diagnosis 13.Treatment planning 14.Prognosis

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DEMOGRAPHIC DATA

It includes recording of patient 1.Name 2.Age 3.Sex 4.Address 5.Occupation 6.Registration Number 7.Telephone Number.

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1.NAME-Importance

1. For identification of the patient2. Psychological Benefit3. To maintain patient doctor relationship4. To maintain record of the patient5. To know the religion of the patient. 2.AGE-For a.predilection of disease b.chronology c.Medication

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A. PREDILECTION OF DISEASE Certain diseases are common since/at birth Agnathia Facial hemihypertrophy Macrognathia/micrognathia Cleft lip/cleft lip Fissured tongue AplasiaDISEASES MORE COMMON IN CHILDREN AND YOUNG ADULTS Focal epithelial hyperplasia Papilloma Thyroglossal duct cyst Basal cell Carcinoma Burkett’s lymphoma

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DISEASES PRESENT IN INFANCY Palatal cyst of new born Haemangioma Fibrosarcoma Thalassemia Herpe’s syndrome

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DISEASES COMMON IN OLDER PATIENTS Attrision/Abrasion Gingival recession Periodontitis Leukoplakia/lichen planus Cementicles/fibroma Ameloblastoma B.CHRONOLOGY To know the chronology and co relate the dental age with

chronology age

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3.GENDER-Sex related Diseases -dose -Treatment planning A.Certain diseases are predominantly seen in particular sex

such as .DISEASES COMMON IN FEMALES .recurrent apthous stomatitis Central cementifying fibroma Juvenile periodontitis Torus palatinus

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.DISEASES COMMON IN MALES1. Attrision2. Leukoplakia3. Carcinoma in situ4. Benign osteoblastoma5. Ameloblastoma fibroma6. Keratoacanthoma B.DOSE:Females have smaller body weight and requires lower

dose as compared to males In females consideration in dose is given during

mensturation ,pregnancy,lactation

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Drugs given during pregnancy can affect foetus. C.Treatment Planning depends on Gender Females:Cosmetic importance Males:Functional importance

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4.ADDRESS: a.To maintain contact with the patient. b.Certain diseases are common in certain area.Endemic

diseases/geographic prevalence of certain diseases.for eg. In India-cancer of tongue &buccal mucosa-more common In Mumbai,common site affected in cancer is tongue In chennai-Buccal Mucosa Fluorosis in orissa Dental caries- more common in modern industralized

areas.while periodontal diseases are more common in rural areas Gutka in north india(Bihar) Chutta,a form of tobacco in Tamil naidu

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5.OCCUPATION:To know about the financial status of patient since the treatment depends accordingly and certain diseases are occupation related. Foreg

Attrision:workers in industeries exposed to substances like asbestos, coal products,cotton dust,wood dust,welding fumes.

Abrasion:Shoe maker,carpenter,tailor who hold nails,pins Hepatitis B-dentist,Surgeon Dry Eye Syndrome-Software professionals Gingival Stains:Person working with lead,bismuth&Cadmium

get strange dark stippling of the marginal gingiva.

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6.Registration Number:It is good to give each & every patient a unique registration number & to maintain his/her record under that number . So that when the patient visit the doctor at the later date, the doctor can know the detail of the patient & the treatment done before.

7.Contact Number:Patient/Physician contact number, recall

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CHIEF COMPLAINT: It is established by asking the patient to

describe the problem for which she or he is seeking help or treatment. It is recorded in patients own words

Significance :Pt. knows better about his disease We may underestimate or overestimate the

disease.

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HISTORY OF PRESENT ILLNESS:Patient may or may reveal a detailed history of the problem for which they are seeking treatment and additional information usually needs to be elicited by the examiner. The patient response to these questions may constitute the history of present illness

It is elaboration of patients chief complaint when & how it began,what exacerbates & what ameliorates the complaint.

When and how the complaint has been treated and what was the result of any such treatment and what diagnostic tests have been performed.

Direct and specific questions are used to elicit this information.

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When did this problem start? What did they notice first? Did you have any problems or symptoms related to

this? What makes the problem worse or better? Have the symptoms gotten worse or better at any

time? Have you consulted other dentists, physician? What have you done to treat these symptoms

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If pain in present then,following characteristics are recorded PAIN CHARACTERISTICS Intensity Quality Location Onset Associated events at onset Duration and timing of pain Course of symptoms since onset Activities or experience that increses pain Activities or experience that decrease pain Associated symptoms(eg,altered sensation,swelling) Previous treatments and their effects

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Pain: intensity(sharp,piercing &lancinating or dull, gnawing

&excruciating) quality(diffused or localized), location, mode of onset(sudden or gradual), types of pain(intermittent,recurrent,constant or referred) Associated events with onset,duration and timing of

pain.Altered sensation,swelling or previous treatment and their effects.

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.If swelling is present thenA.Duration & mode of onset.B.Pain & progress of the swellingC.Other Symptoms associated the lump. Some negative answers are more valuable in

arriving at diagnosis and should never be disregarded.

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PAST MEDICAL HISTORY It includes information about any significant or serious illness a patient may had

as a child or as an adult The patient’s present medical problem are enumerated with this category

1.SERIOUS / SIGNIFICANT ILLNESS- -About any heart,lung or kidney diseases Congenital conditions Infectious diseases Immunological disorders Diabetes or hormonal problems Radiation or cancer chemotherapy Blood disperasias or bleeding disorders Psychiatric treatment

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2.HOSPITALISATION: Hospital records are often the dentist best source

of accurate documentation of the nature and severity of the patients medical problem

3.TRANSFUSION: History of blood transfusion including the date of

each transfusion, no. of transfused blood units,may indicate previous history in the evaluation of the patient medical status

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4.Allergies: the patient record should document any h/o –

Classic allergic reactions - urticaria, hay fever, asthma or eczema

Any untoward or adverese drug reaction (ADR) to medications, local

anesthetic agents, foods or diagnostic procedures.

Symptoms of serum sickness should be differentiated from physiological

reactions (urticaria, prutitis, resp. distress or anaphylaxis).

It is good practice to record that a patient has no known drug

allergies(NKDA)

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5.Medication:It is imp. to record all the medicines patient is taking. Ask for their dosage, duration & composition. It helps in recognition of drug induced(iatrogenic) disease and oral

disorders a/w different medication and in avoidance of untoward drug interactions.

Like- Drugs producing lichnoid reaction include oral hypoglycaemic drugs.antihypertensive drugs,Nsaids(Ibrufen,phenylbutazone).

Patient on anticoagulant drugs e.g Aspirin are asked to stop its administration for 7 days prior coming for extraction because of its antiplatelet action as it increases bleeding in patients after extraction

Patient on Antiepileptic drugs (e.g phenytoin) and nitrates e.g nifedipine produces gingival enlargement

Tetracycline produces staining of teeth

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6.PREGNANCY: Knowing whether or not a woman of child

bearing age is pregnant is particularly important when deciding to administer or prescribe any medication

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PAST DENTAL HISTORY The dental history may provide insight into the patient dental I.Q,

priorty given to dental care & fears associated with dentistry.It includes-

1.The frequency of previous dental visits2.The purpose of the past visits &any difficulties a/w it.3.Previous Restorative,periodontal,endodontic or oral surgical treatment.4.Reasons for loss of tooth5.Untoward complication of dental treatment.6.Experience with orthodontic appliance &dental prosthesis7.Radiation or other treatment for past oral & facial lesions

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PERSONAL HISTORY This includes: Place of residence (with family,alone, or in an institution), marital status(marrried, separated,divorced,single) Educational level Habits-oral hygiene -delitorious habits oral habits- Thumb sucking Tongue thrusting- Mouth breathing- Bruxism- Other habits

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A.ORAL HYGIENE: Brushing,flossing,rinsing- ask for type , duration, frequency, composition and choice of preferance. Bad oral hygiene & improper brushing technique- dental caries &periodontal diseases. B.DELITERIOUS HABITS: Tobacco, smoking or chewing habits-affect oral hygiene leads to

leukoplakia,verrucous carcinoma of oral mucosa &nicotine stomatitis Alcohol Use-important consideration in GA& nutritional status of the

patient. -leads to vitamin B complex def.,cirrhosis of liver, - poor patient cooperation

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PRESSURE HABITS: Thumb sucking,lip sucking,finger sucking- Anterior proclination of maxillary anterior teeth NON PRESSURE HABITS Mouth Breathing-Anterior marginal gingivitis,dental caries Biting habits- Nail biting,pencil & lip biting Proclination of upper anterior teeth Retroclination of lower anterior teeth Parafunctional habits Bruxism-Attrision

ORAL HABITS

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FAMILY HISTORY Serious medical problems in immediate family

members should be listed. Cardiovascular diseases including

hypertension,diabetes,bleeding disorders,allergies,asthma,

. Some disorders are genetic in the family should be enquired.

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History about marriage in same family members is asked.When you marry biologically or blood relatives than it is Consanguineous marriage.

Offsprigs are at greater risks of certain genetic disorders. Autosomal recessive disorders can occur in individuals who are

homozygous . Increase in incidence of- -Birth defects -Blinding disorders like retinitis pigmentosa -Blood cancer(ALL). Increase suspectibility to- TB Infectious pathogens HEPATITIS

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EMOTIONAL AND BEHAVIOURAL HISTORY

As the patient is observed and gently questioned,it may become more apparent that individuals have certain personality traits.They may be

extrovertd, introverted, passive, aggrevisive, depressed, apathetic.

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The extroverted person may respond easily Introvert one may be reserved and is more difficult to

develop good rapport or obtain information during the interview.

Patient should be questioned concerning satisfaction with his or her job and family life.

Conditions such as bruxisim,clenching habits,or MPDS are often associated with unhappy situations.

In planning a multidisciplinary approach to these, the emotional component must be assessed.

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GAIT: Refers to the way one walks.Certain disorders can alter

it. .Abnormal gait occurs due to pain,bone & joint

disorder, muscle and neurological diseases. In Limited mobility cases, cause should be determined

so that the visit to dental office may be as comfortable as possible and the degree to which a patient can move from a wheelchair should be established.

GENERAL PHYSICAL EXAMINATION

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TYPES OF GAIT: HEMIPLEGIC OR CIRCUMDUCTION GAIT SPASTIC GAIT ATAXIC GAIT PARKINSONIAN GAIT SLAPPING GAIT

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STATURE AND NUTRIONAL STATUS: Stature refers to height and build,whereas nutritonal status is an

evaluation of the degree of obesity or emaciation . Simple recording of height and weight help in evaluating the

nutritional status. BODY BUILT Aesthetic-thin physique -Usually posses narrow dental arches Pletoric –person who are obese -Have large square dental arches Atheletic-Normally built being neither thin nor obese -Have normal sized dental arches

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-Body built is also classified as STHENIC-good bone & muscle structure -HYPERSTHENIC-short and stocky -HYPOSTHENIC-thin with poor muscle -ASTHENIC-slighter build than

hyposthenic

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VITAL SIGNS

Vital signs include: 1.Blood pressure, 2.Pulse rate, 3.Resp.rate 4.oral temperature. 1.Blood pressure is taken indirectly, using a sphygmomanometer and a

stethescope. Measurement of the blood pressure is used to detect undiagnosed

hypertension as well as to determine whether the patient may have a disease that causes hypertension or result from hypertension.

If a patient is being treated for hypertension, then determination is made whether it is controlled

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.Blood pressure recording technique includes placement of cuff, SUPPORT ARM AT THE level of heart palpation of radial artery and placement of stethoscope,disappearance of

sounds to measure diastolic B.P.. Take two measurements at each visit.

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Normal range-120/80mmHg Hypertensive-Systolic Diastolic Stage 1 140-149 90-90 Stage 2 160-179 100-109 Stage 3 >180 >110 HIGH B.P-Causes RENAL DISEASES- Renal vascular diseases ENDOCRINE DISEASES-hyperparathyroidism - Thyrotoxicosis - Primary hypothyroidism -Cushing syndrome

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LOW B.P-Causes - Severe aortic stenosis -Hypertrophic obst.cardiomyopathy -Arrhythmia

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2.PULSE RATE:Pulse rate can be taken as the dentist palpates the radial artery for the blood pressure reading.

When taking the pulse,the examiner should use the fingertips rather the thumb.

The pulse rate is recorded in beats per minute and the normal value is 72.

Pulse rate-Bradycardia <60bpm -Normal 60-100bpm -Tachycardia >100bpm

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NORMAL PULSE RATES INFANTS AT BIRTH -140bpm 1 yr age -90 to170bpm AGE 1-2yr -90 to 140bpm AGE 3-5yr -80 to 110bpm AGE 6-12 -75 to 105bpm AGE 13-18yr -60 to 100bpm

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RAPID PULSE CAUSES- 1.Recent exercise 2.Excitement 3.shock (eg bleeding) 4.fever ,thyrotoxicosis SLOW PULSE CAUSES- 1.Severe hypothyroidism. 2.Complete heart block

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3. RESPIRATORY RATE: The rate of respiration is the number of inspirations recorded during 1 minute. Respiration is usually rhythmic but not always regular. The rate should be counted by watching the patient’s chest rise and fall. The normal rate for an adult is approximately 14 to 18 per minute. The normal respiration has regular rhythum with inspiration longer than

expiration. Irregular respiration may be of the following types: A.cheyne-stokes respiration B.kussmaul’s respiration C.Biot’s respiration D.Stridor E.Wheezing.

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Normal breathing in males and some females is abdominothoracic i.e both the abdomen and thorax are moving during the act of respiration but the abdominal movements are more prominent.

Normal breathing in majority of females is thoracoabdominal i.e the thoraic movements are more prominent than abdominal movements:

1.Thoracic breathing:thoracic movements are predominant and abdominal movements are minimal.

Occurs in- diaphragmatic paralysis,peritonitis -severe ascites 2.Abdominal breathing:abdominal movements are predominant and

thoracic movements are minimal. Occurs in: Pleurisy Collapse of the lung.

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A.Increased respiratory rate(tachypnea)1.Exertion and excitement2.Fevers e.g pneumonias3.Anoxemia and acidosis.4.Anemia and poisoning.5.Pain whilst breathing e.g pleurisyB.Decreased respiratory rate(bradypnea)1.Narcotic poisoning e.g opium2.Brain tumour3.Dyspnea:Breathlessness

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4. TEMPERATURE: Patient oral temperature should be recorded.This is

accomplished using an oral thermometer .Normal oral temp. is 98.6 F +/- 0.5. Infection- common cause of elevated temperature; a hypermetabolic

state such as hyperthyroidism can also elevate the patient’s temp. and

Hypothermia /decrease in temp. can be associated with a hypometabolic state such as myxedema.

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NORMAL RANGE OF TEMPERATURE Oral temp.-98.6F/37.0C Axillary-97.6F/36.3C Rectal-99.6F/37.7C Aural-99.6F/37.7C Digital thermometer used in the auditory canal are

popular and accurate. Thermometer is one of the common method of

recording temperature.

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UPPER EXTREMITIES: SKIN HAIR FINGERNAILS

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SKIN: The skin is examined by observation and palpation. Color,texture,elasticity,and presence or absence of edema should be

noted. The pigmentation varies in each individual and in diff.areas like

elbows,nuckles,creases and palm of hands. The texture of skin is evaluated by light palpation.Edematous tissue

doesnot usually rebound when depressed with a finger and normal skin does

Bluish pigmentation - seen in bruising,cyanosis Yellow- in jaundice Red - in vascular lesions

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FINGERNAILS: Fingernails can reveal indications of systemic disease,the

changes found are not pathognomic for specific diseases. The nail is composed of the cuticle,the nail bed or matrix,a

pale semicular configuration at the base of the matrix called the lanula,and the nail itself.

The angle of the nail to the skin should not exceed 160DEG. This is called LOVIBOND’S ANGLE . And it determines whether a nail is clubbed.

CLUBBING-due to overgrowth of nail bed in which levibond angle >160 or almost straight.

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In clubbing:nails are curved like a watch glass and the finger tip is bulbous and enlarged.Its causes include

Pulmonary causes-like lung abscess -Bronchiectasis Tuberculosis with sec. infections In koilonychia:nails have a spoon shape and are concave. -seen in Iron def. anaemia Pallor of nails:may indicate presence of several conditions. Specific diseases of nails- Onychomycosis –fungal infection of nail Onycholysis-keratin deposition beneath nail bed -Occurs in psoriasis

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HAIRS: The hair should be evaluated for the pattern of

distribution,color,and texture.Dry and brittle hair may be due to hypothyroidism.

In hyperthyroidism –hair texture is fine In hypothyroidism-amount of hair decreases.

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PALLOR: Pallor of the skin seen in- Massive haemorrhage, shock & intense emotions. Anaemic patients are also pale. One should look at- the lower palpebral conjuctiva mucous membrane of the lips and cheeks, nail beds palmar creases .

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CYANOSIS:bluish or purplish tinge of the skin or mucous membrane which results from the p/o excessive amount of reduced Hb in the underlying blood vessels.

Types-Central -Peripheral

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CENTRAL CYANOSIS: Occurs due to inadequate oxygenation of blood to the lungs. Causes- Cardiac causes like-congenital abnormalities of heart - Cong.cardiac failure & cong.cyanotic heart diseases. Pulmonary causes- -like chronic obst. lung diseases -Pulmonary obstruction -High altitude due to low pressure of oxygen. SITES: Tongue Tip of nose Nail bed Skin of palm & toes

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PERIPHERAL CYANOSIS: It is due to excessive reduction of oxyHb in the capillaries

when the blood flow is slowed down. This happens on exposure to cold (cold induced vasoconstriction).

Peripheral cyanosis is looked for in the nail bed, tip of the nose, skin of the palm toes.

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ICTERUS : In JAUNDICE- there is icteric tint of the skin due to presence of

bilirubin which varies from faint yellow of viral hepatitis to dark olive greenish yellow of obstructive jaundice. The places where one should look for jaundice are:

1. sclera of the eyeball- for this the patient is asked to look at his feet while the surgeon keeps the palpebral fissure wide open by pulling up the eyelid.

2. nail bed, 3. lobule of the ear, 4. tip of the nose, 5. under surface of the tongue.

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Oral Medicine diagnosis and treatment-Burket’s (10th Edition) Oral Diagnosis,medicine &treatment

planning-Bricker/langlais/Miller (2nd Edition) Treatment Planning in Dentistry-Stefanac Nesbit Clinical Surgery-S.Das Clinical Medicine-Davidson Clinical Manual-Hutchison Textbook of oral pathology-Shafers Textbook of orthodontic-Balaji

REFRENCES