Case history, diagnosis and treatment missing

Case history, diagnosis and treatment planning

1. CASE HISTORY Presented by Sofia Mukhtar PG IInd Year

2. INTRODUCTION A case history is defined as a planned professional conversation that enables the patient to communicate his/her symptoms, feelings and fears to the clinician so as to obtain an insight into the nature of patient's illness & his/her attitude towards them.

3. Objectives:- To establish a positive professional relationship. To provide the clinician with information concerning the patient's past dental, medical & personal history. To provide the clinician with the information that may be necessary for making a diagnosis. To provide information that aids the clinician in makíng decisions concerning the treatment of the patient.

4. COMPONENTS- Demographic data Chief complaint History of present illness 1.Medical history 2. Past dental history 3.Family history 4.Personal history General examination Extraoral examination Intraoral examination Provisional diagnosis Investigations- Final diagnosis Treatment plan

5. Statistics/ Demographic data Patient registration number Date Name Age Sex Address Occupation Marital status

6. o PATIENT REGISTRATION NUMBER : Useful for- maintaining a record, billing purposes, medico legal aspects . DATE Useful For- Time of admission reference during follow up visits Record maintenance NAME To communicate with the patient To establish a rapport with the patient Record maintenance Psychological benefits

7. AGE For diagnosis Treatment planning Behavioral management techniques Some diseases are prevalent in particular ages DENTAL DISEASES PRESENT SINCE BIRTH OR SEEN IN INFANCY Related to jaw Agnathia , Facial hemihypertrophy , Macrognathia , Cleft palate Related to lip Commissural pits and fistulae, Double lip, Cleft lip

8. Related to gingiva Congenital epulis of the newborn, Fibromatosis gingiva Related to tongue Microglossia , Macroglossia , Aglossia , Ankyloglossia , CIleft tongue, Fissured tongue, Median rhomboidal glossitis , Lingual thyroid nodule Related to teeth early / delayed eruption, partial/ complete anadontia Related to TMJ Aplasia or congenital hypoplasia of the mandibular condyle Systemic Diseases Congenital heart diseases, Bronchiectasis , Pneumonia

9. Behavior management technique : In case of pediatric patients. The dentist has to deal with the child as well as with the parent; approach is 1:2. In talking to a child, the dentist must get down patient's level of understanding based on patient's intelligence.

10. SEX SINGNIFICANCE - Some diseases show specific sex predilection. eg :- anorexia is more common in females while hemophilia may be found exclusively in males. Girls mature faster than boys thus their treatment may be required earlier. Esthetics and emotion is more of a concern in female patients. Male patients are more prone to trauma during playing. Child abuse of which sexual abuse or exploitation is more common in case of females.

11. ADDRESS For future correspondence. Gives a view of socio-economic status -to know about the nourishment, hygiene & payment capacity of the patient. Prevalence of diseases like fluorosis as a result off increase level of fluorides in water are spread differently in various parts of the country.

12. CHIEF COMPLAINT The chief complaint is usually the reason for the patient's visit. It is stated in patient's own words in chronological order of their appearance & their severity. The chief complaint aids in diagnosis & treatment therefore should be given utmost priority.

13. COMMON CHIEF COMPLAINTS Pain Loose Teeth Delayed eruption Caries Swelling Halitosis Maligned Teeth

14. HISTORY OF PRESENT ILLNESS Elaborate on the chief complaint in detail Ask relevant associated symptoms The symptoms can be elaborated in terms of:-Mode & cause of onset Duration Location-localized ,diffuse ,referred, radiating. Progression- continous or intermittent. Aggravating & relieving factors Treatment taken

15. PAIN Anatomical location where the pain felt ? Origin & mode of onset :- activity which inducing the pain should be taken in consideration. Intensity of pain :- whether the pain is mild , moderate or severe. Nature of the pain :- it can be throbbing , shooting, stabbing, dull, aching, lancinating , boring, griping, sharp, gnawing, squeezing. Progression of pain:-The patient should be asked 'how is it progressing Duration of pain- Duration of pain means the period from the time of onset to the time of pain disappearance.

16. g ) Movement of the pain :- referred, radiating , shifting or migration of pain. h) Periodicity of pain-Sometimes an interval of days , weeks, months or even years may elapse between two painful attack. Effect on functional activity - the effect of various activity such as brushing, shaving, washing the face, turning the head, lying down etc. should be noted. J) Aggrevating & relieving factor- whether it aggrevates or relieved with chewing or any other factors.

17. SWELLING Duration :- for how many days swelling is present. Mode of onset :- mass that increase in size just before e ating :- salivary gland retention phenomenon. slow growth :- chronic infection cyst, benign tumors rapid growing mass :- abscess, infected cyst, hematoma mass with accompanying fever :- infection & lymphoma 3) Symptoms ;- 1like pain, difficulty in respiration swallowing, disfiguring.

18. MEDICAL HISTORY The medical history includes the information about past & present illiness . All diseases suffered by patient should be recorded in chronological order. Check list of medical history-by Scully and Cawscon A nemia B leeding disorders C ardio respiratory disorders D rug treatment and allergies E ndocrine disorders F its and faints G astrointestinal disorders H ospital admissions and surgeries I nfections J aundice K idney disease

19. PAST MEDICAL AND DENTAL HISTORY PAST MEDICAL HISTORY This should include operation, hospitalization, infectious disease, immunization, allergies, accident, etc. PAST DENTAL HISTORY Past dental care and child’s reaction towards it , any previous unpleasent experience, oral hygine habits, fluoride therapy.

20. Any treatment must be postponed if the patient is suffering from acute illness such as mumps, chicken pox, etc. History of rhinitis, repeated cold, adenoidectomy, tonsils should be carefully examined for evidence of persisting nasal obstruction before undertaking orthodontic treatment with appliance such as oral screen, activator, etc. Patients with cardiac defects should be referred to a pediatrician and antibiotic prophylaxis must be given prior to any treatment to minimize the risk of development of subacute bacterial endocarditis (SABE). If the child is undergoing anticoagulant therapy, adjustment of anticoagulant dosage may be required. Precaution should be taken to avoid contacting communicable disease. Drug allergy or interactions should be noted History of psychological problems should be obtained. This will help in management of the child's behavior during the procedure.

21. FAMILY HISTORY •Family members share their genes, as well as their environment, lifestyles and habits. •Risks for diseases such as asthma, diabetes, cancer, and heart disease also run in families. •There are also several inherited anomalies & abnormalities that can affect the oral cavity such as congenitally missing lateral incisors, cleft lip & cleft palate

22. In case of young patient:- BIRTH HISTORY :- Asked from the parents as if any problem were encountered at birth. 1) Rh incompatibility :- may result in the condition termed as erythroblastosis fetalis ". The effect may be seen in the dentition, with well described entities such as hump on the tooth and the characteristic blue- green discoloration. 2) Neonatal jaundice:-- the immature RBC's in an infant are rapidly destroyed in the spleen. This increased bilirubin cannot be sufficiently cleared by the liver leading to transient jaundice' in the child. 3) Trauma due to forceps delivery.

23. POSTNATAL HISTORY In post natal history, significant is attached to the amount of time the child was breast fed, bottle fed etc. Vaccination status needs to be assessed along with the present illness , if any Presence of any habit and its duration and frequency. Any previous experience with the dentist and what bearing it have on the present visit. Progress in the school, how he interact with the children will indicates the development of the child's emotions.

24. PERSONAL HISTORY Habits Diet Oral hygiene

25. HABITS It includes recording the frequency intensity and duration of habits. Thumb sucking & lip sucking - anterior proclination of maxillary incisors. Tongue thrusting habit - anterior & posterior open bite. Mouth breathing - anterior marginal gingivitis & dental caries.

26. DIET HISTORY Feeding during infancy- breast milk, bottle, others. The additives and frequency of feeding is of concern here. Diet- vegetarian / non- vegetarian Present dietary habits balance diet, snacking in between meals Patient should be asked about his complete diet of the past24hrs which should include the time of the day when food was taken, type of food, frequency of sugar exposures.

27. PERSONAL ORAL HYGIENE HABITS Number of times and method of brushing. A History regarding 'who' brushes the teeth is very important especially in children less than 5 years. Use of fluoridated of non-fluoridated dentifices . Brush: Type of brush and how often it is changed. Other oral hygiene aids used like flossing, rinses, etc. Horizontal brushing technique may leads to cervical abrasion.

28. Extra oral examination SKIN -is looked for Appearance ,any rashes, sores or itching Color-anemia patients have pale skin color, yellow tint is seen in jaundice patients. Pigmentation Edema Temperature 2. Facial symmetry – bilaterally symmetrical/asymmetrical 3. Lip Competency – competent/ incompetent

29. JAWS Any deviation in path of closure and opening lateral movements of mandible. Tenderness over the joint and muscles of mastication. Any injuries trauma to the facial bones and jaws should be examined. TMJ clicking or popping sound Deviation or deflection while opening pain or tenderness over joint or masticatory muscles. Maximal interincisal opening (normal is 35-50 mm) Range of vertical & lateral movements

30. • PALPATION OF PRE TRAGUS AREA: The examiner can be positioned either in front of or behind the patient Patient is asked to slowly open and close the mouth palpating with index finger, placed in the pre tragus depression. INTRAAURICULAR PALPATION: Performed by inserting small finger into the ear canal and pressing anteriorty . While palpating with this methods check whether condyle moves symmetrically, with the rotation and translation phase

31. LYMPH NODES Lymph nodes are oval or bean-shaped structures found along lymphatic vessels that drain body parts. Normally, they are non-tender, soft and cannot be felt even though they are present. tender on palpation ,mobility should be noted. PREAURICULAR LYMPH NODES Location - in front of ear Lymphatic drainage – Eyelids and conjunctivae, temporal region, pinna For palpation of Preauricular lymphnodes , roll your finger infront of the ear, against the maxilla. Enlarged - Externalauditory canal infection .

32. •POSTAURICULAR LYMPHNODES LOCATION - behind the ear, near the insertion of sternomastoid muscle. Lymphatic drainage : External auditory meatus , pinna , scalp Digital palpation is done by pressing against the skull. Enlarged due to infection of scalp, temporal & frontal areas . OCCIPITAL LYMPH NODES Location : Located at the junction between the back of the head and neck. Lymphatic drainage : Scalp and head. Enlarged in infection of scalp &Syphilis.

33. SUBMENTAL LYMPHNODE Located below the chin. Lymphatic drainage : Lower lip, floor of mouth, teeth, submental salivary gland, tip of tongue, skin of cheek. Roll the fingers below and lingual to the chin, against the mylohyoid muscle. Enlarged in disorders in the anterior portion of the mouth and the lower lip.

34. SUB MANDIBULAR LYMPH NODE Located medial to the inferior border of mandible. Lymphatic drainage : Tongue, submaxillary gland, lips and mouth. Roll your fingers against inner surface of Mandible with patient's head gently tilted towards one side Enlarged in Infections of head, neck, sinuses, ears, eyes, Scalp, pharynx.

35. INTRAORAL EXAMINATION SOFT TISSUE labial and buccal mucosa Lip Floor of mouth Tongue Gingiva Salivary glands 2. Hard tissue Teeth present Teeth missing Carious teeth Mobiltity Occlusion

36. LABIAL & BUCCAL MUCOSA •It should be checked for any Ulcer, White patch or neoplasia , Pigmentation LIP Checked for Color, Texture, Any surface irregularities, Palpate upper lip and lower lip for any thickening ( induration ) or swelling. Angular or vertical fissures. Cleft lip, Lip pits, Ulcers-Nodules, Keratotic plaque and scars.

37. FLOOR OF MOUTH •It should be checked for:- Any swellings RANULA : appears as unilateral bluish translucent cyst over wharton's duct. ANKYLOGLOSSIA : fusion between tongue and floor of the mouth CARCINOMAS are common in the floor of the mouth. Ulcers or red and white patches. TONGUE Examination is done to check for:- Volume of tongue- enlarged tongue due to lymphangioma , hemangioma & neurofibroma . Integrity of papilla Any cracks or fissures , swelling or ulcers Presence of tongue tie .

38. HARD TISSUE TEETH PRESENT Size Color structural changes of teeth Eruption status of teeth Retained deciduous teeth Any trauma to tooth TEETH MISSING Reason for missing teeth/tooth History of removal Co-relation of the missing teeth às an oral manifestation of a systemic disease or genetic abnormality

39. CARIOUS TEETH The primary examination technique for evaluating the teeth Include: Visual inspection, Probing Percussion Transillumination Basic tools required are: A good light source, A mirror A sharp explorer and An air syringe are the most basic tools required

40. RADIOGRAPHIC METHODS BITE WING RADIOGRAPHY To diagnose proximal caries INTRA ORAL PERI APICAL RADIOGRAPH To detect the extent of occlusal caries. To assess the periapical area DISADVANTAGES: A. To be radiographicaly visibie , mineral Ioss should be more than 20-30percent

41. OTHER METHODS: Fibro Optic Transilluminator . Digital Fibro Optic Transilluminator . Fluorescence (acid dissolution of structure). Use of caries detector dye e.g. silver nitrate, methylTed and alizarin stain to detect caries by color change).

42. MOBILITY OF TEETH: To evaluate the integrity of the attachment apparatus surrounding the teeth. •Test is carried out by moving the tooth laterally in the socket or preferably in the handles between two instruments. TYPES: PATHOLOGIC MOVEMENT: it results from inflammatory process, para functional habits. ADAPTIVE MOBILITY: occurs due to anatomic factors such as short roots or poor crown to root ratio. GRADES OF MOBILITY: (GLICKMAN'SCLASSIFICATION) No detectable movement when force is applied other than what is considered normal (physiologic) motion. GRADEI -movement of tooth about I mm in bucco -lingual direction GRADE- II:movement of tooth more than mm 1 bucco -lingual direction and labio palatal direction. GRADE III: depression of tooth in the socket

43. PROVISIONAL DIAGNOSIS It is also called tentative diagnosis or working diagnosis. It is formed after evaluating the case history & performing the physical examination. DIEFERENTIAL DIAGNOSIS The process of listing out of 2 or more diseases having similar signs and symptoms of which only one could be attributed to the patient's suffering A final diagnosis is only possible after carrying out further investigations.

44. INVESTIGATIONS CHAIR SIDE INVESTIGATIONS: Pulp Vitality Tests Percussion Tests Cytology Aspiration ROUTINE COMPLETE HEMOGRAM Hemoglobin, Red Cell Count Wbc Platelet Counts Total Leukocyte Count Total Difeerential Count Bleeding Time Clotting Time Calcium.

45. PERCUSSION TEST: to evaluate the status of theperiodontium surrounding a tooth TYPES: Vertical Percussion Test- positive indicates periapical pathology Horizontal Percussiontest - positive indicates periodontium associated problems RADIOLOGICAL INVESTIGATIONS INTRAORAL PROJECTICONS:- Intra-Oral Periapical , Occlusal Bitewing views. EXTRAORAL PROJECTIONS: OPG PA view of skull and jaws AP viewPNS view SUBMENTOVERTEX view. TMJ views.

46. FINAL DIAGNOSIS: The final diagnosis can usually be reached following chronologic organization and critical evaluation of the information obtained from the, patient history, physical examination and the result of radiological and laboratory examination. The diagnosis usually identifies the diagnosis for the patient primary Complaint first, with subsidiary diagnosis of concurrent problems.

47. TREATMENT PLAN The formulation of treatment plan will depend on both knowledge & experience of a competent clinician and nature and extent of treatment facilities available Evaluation of any special risks posed by the compromised medical status in the circumstance of the planned anesthetic diagnostic or Surgical procedure. Medical assessment is also needed to identify the need of medical consultation and to recognize significant deviation from normal health status that may affect dental management.

48. Systemic phase: Premedication (antibiotic prophylaxis) Preventive phase : Caries risk assessment.- Assessment of preventive measures like fluoride application, pit and fissure sealants, diet counseling. Preparatory phase : Behavior management. Oral prophylaxis. Caries control. Orthodontic consultation. Oral surgery. Endodontic therapy

49. Corrective phase: Restorative dentistry. Prosthetic Rehabilitation. Early orthodontic intervention. Maintenance phase: Frequency depends on child's initial needs, success of therapy, parental cooperation