Dental intro Dr.kavitha
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DENTAL CASE HISTORY
INTRODUCTION
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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.
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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.
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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
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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.
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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.
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7.General eamination
Child-built,height,postureVital signs-temp,blood pressure,pulse,resp rateBody type
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8.Extra oral examination
-shape of head-facial form-facial symmetry -lip competency-tmj-lymph node-salivary gland
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9.Intra oral examination
Soft tissue-tongue palate floor of the mouth gingiva periodontium
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2.Hard tissue examination
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Provisional diagnosis
A general diagnosis based on clinical impression without any lab investigation
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Differential diagnosis
Listing out of two or more diseases having similar signs and symptoms
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Investigation
1.Radiograpic2.laboratory
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Plaque , Calculus
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Gingivitis
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Periodontitis
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Periodontal Abscess
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Dental caries
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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
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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
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