case history diagnosis and treatment planning

case history and diagnosis

1. CASE HISTORY,CASE HISTORY,
DIAGNOSIS, AND DIAGNOSIS, AND
TREATMENT PLANNINGTREATMENT PLANNING

2. “A half-educated
physician is not
valuable. He thinks
he can cure
everything.”
-Mark Twain (1891)

3. DefinitionsDefinitions
Case history : the data concerning an individual,
their family, and their environment, including medical
history that may be useful in analyzing and
diagnosing their case or for instructional purposes.
 Signs: objective evidence of the disease detected
and interpreted by the examiner .
 Symptoms: subjective evidence of a
disease as observed by the patient.
SubjectiveSubjective – perceived by the individual only – perceived by the individual only
or not evident to the examiner. Ex:painor not evident to the examiner. Ex:pain
ObjectiveObjective –– viewing events or phenomenon as viewing events or phenomenon as
they exist in the external world. Ex:cyanosisthey exist in the external world. Ex:cyanosis

4. Syndrome: a group of signs and symptoms that
appear together and characterize a specific
disease
Predisposing factors: an inclination that is
present in advance; conditions that make
something liable or susceptible.
 Etiology: the study or theory of the various
causes or origins of a disease.
Pathogenesis: the origin and development of a
disease.

5. Diagnosis- ““Is defined as correct determination, Is defined as correct determination,
discriminative estimation and logical appraisal of discriminative estimation and logical appraisal of
conditions found during examination as evidenced conditions found during examination as evidenced
by distinctive marks, signs that are characteristic by distinctive marks, signs that are characteristic
of health or disease”. -of health or disease”. -

PrognosisPrognosis
–““Predicting the likely outcome of a disease Predicting the likely outcome of a disease
based on condition of patient and action of based on condition of patient and action of
disease”.disease”.

6. Diagnostic procedureDiagnostic procedure

Divided into 4 partsDivided into 4 parts
1) Taking and recording history1) Taking and recording history
2) Examining the patient (physical 2) Examining the patient (physical
examination and supplemental examination and supplemental
examination procedure)examination procedure)
3) Establishing a diagnosis3) Establishing a diagnosis
4) Making a plan of treatment and 4) Making a plan of treatment and
medical risk assessment for dental medical risk assessment for dental
patients.patients.

7. Patient identificationPatient identification
Name-
Age
Gender
Address
Phone number
These information are needed for patient
identification and administrative purpose.
The patients age, gender contribute to the
diagnosis of specific conditions.

8. Chief complaintChief complaint
“why the patient consulted the dentist”
Recorded in patients own words
because it provides insight into the nature
of the problem.
No diagnosis should be included at this
stage
Open-ended, non-leading questions

9. History of present illnessHistory of present illness
Detail patients awareness of the Detail patients awareness of the
problem problem includes :
 Duration of problem
 Prior occurrences
 Previous treatment,
 Effectiveness of past treatment.

10. Specific questions about the nature of the
symptoms experienced:
Inception (When the first time)
Frequency and course (How often)
Intensity (Mild, moderate, or severe)
Quality (Sharp, dull, stabbing,
throbbing)

11. Location (Pointing to the tooth that
hurts)
Provocation factors (heat, cold,
momentary or last longer)
Spontaneous (without provocation)?
Attenuating factors (Anything
relieving the pain)

12. 
Source of pain :Source of pain :
pulpal painpulpal pain
periodontal painperiodontal pain

Quality of pain Quality of pain
– sharp or brightsharp or bright if A delta fibers are if A delta fibers are
functioning.functioning.
(typical of acute tissue injury ) (typical of acute tissue injury )
– dull, boring or throbbingdull, boring or throbbing - severe - severe
damage has occurred damage has occurred
causing C fibers to respond. causing C fibers to respond.

13. Medical historyMedical history
DIVIDED INTO :DIVIDED INTO :

Gait Gait

Past diseasesPast diseases

Characteristic infections and Characteristic infections and
immunizationsimmunizations

HospitalizationsHospitalizations

Allergies and adverse reactions to drugsAllergies and adverse reactions to drugs

Current medical treatment if anyCurrent medical treatment if any

14. Family historyFamily history

Health status of family members.Health status of family members.

Reveals the possibility of conditions Reveals the possibility of conditions
with a genetic tendency .with a genetic tendency .
e.g. ischemic heart disease, diabetes, e.g. ischemic heart disease, diabetes,
hemophiliahemophilia

Communicable infections also Communicable infections also
suspected on basis of family history.suspected on basis of family history.

15. Social historySocial history

Marital status, Marital status,

Current employment, Current employment,

Level of education number of children, Level of education number of children,

Habits Habits
smoking/pan chewing/alcohol smoking/pan chewing/alcohol

Reflects lifestyleReflects lifestyle

Exposure to specific infections, Exposure to specific infections,

Dental treatment preferences.Dental treatment preferences.

16. Dental historyDental history

Past dental care Past dental care

Unusual dental experiencesUnusual dental experiences

Hygiene practicesHygiene practices

17. Physical examinationPhysical examination

General patient appraisalGeneral patient appraisal

Extraoral examinationExtraoral examination

Intraoral examinationIntraoral examination

18. General patient appraisalGeneral patient appraisal

EVALUATION OF PATIENTSEVALUATION OF PATIENTS
oGeneral appearance General appearance
oGait Gait
oPosturePosture
oSpeechSpeech

MEASUREMENT OF VITAL SIGNSMEASUREMENT OF VITAL SIGNS
oB.P B.P
oPulsePulse
oRespiration Respiration
oBody temperatureBody temperature

19. Extraoral examinationExtraoral examination
HEADHEAD
oEyesEyes
oLips Lips
oEyes Eyes
oSkin Skin
oCheek Cheek
oNose Nose
oLymph nodes Lymph nodes
oTempromandibular Tempromandibular
jointjoint
NECK
•Lymph nodes
•Submandibular
• Submental
• Cervical

20. Intraoral examinationIntraoral examination
GENERAL EXAMINATIONGENERAL EXAMINATION
oBuccal mucosa Buccal mucosa
oTongueTongue
oHard palateHard palate
oSoft palate Soft palate
oFloor of mouth Floor of mouth
oVestibuleVestibule
oOropharynxOropharynx
oSinus tractSinus tract

21. 
PeriodontiumPeriodontium
A)A) Gingival tissue examinationGingival tissue examination
oColorColor : : Normal color of gingiva is pink, change from this is Normal color of gingiva is pink, change from this is
easily visualized in inflammatory conditions. easily visualized in inflammatory conditions.
oContourContour : : change in normal contour (scalloped gingival) change in normal contour (scalloped gingival)
occurs with a swelling. occurs with a swelling.
oConsistencyConsistency : : on inspection (gingiva) appears healthy, on inspection (gingiva) appears healthy,
firm, resilient, while a soft, fluctuant or spongy tissue is more firm, resilient, while a soft, fluctuant or spongy tissue is more
indicative of a pathological state. indicative of a pathological state.

B) Periodontal tissueB) Periodontal tissue
•Periodontal pockets,Periodontal pockets,
•Mobility, Mobility,
•Furcation involvement.Furcation involvement.

22. Hard tissue examinationHard tissue examination
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 88 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 88 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
D= DecayedD= Decayed
M= MissingM= Missing
F= FilledF= Filled

23. Class I – caries involving occlusal surface of premolars and
molars , occlusal 2/3 of buccal and lingual surface of
molars, and lingual surface of upper incisors.
Class II - caries involving one or more proximal surfaces of
premolars and molars
Class III – caries involving proximal surface of anterior
teeth without involving incisal edge.
Class IV - caries involving proximal surface of anterior
teeth involving incisal edge.

Class V- caries on the facial or lingual surface of cervical
third of anterior and posterior teeth.
Class VI – caries occuring on cusp tips of posterior teeth
and incisal edge of anterior teeth.
G.V BLACKS CLASSIFICATION

24. Examination Of Teeth And RestorationsExamination Of Teeth And Restorations

CLINICAL EXAMINATION FOR CARIESCLINICAL EXAMINATION FOR CARIES
–Good illuminationGood illumination
–Dry conditionsDry conditions
–Using mouth mirror and explorerUsing mouth mirror and explorer
VISUAL CHANGESVISUAL CHANGES

Chalkiness or brownish gray discoloration of pits and Chalkiness or brownish gray discoloration of pits and
fissures or smooth surfacesfissures or smooth surfaces

Frank cavitation confirms diagnosisFrank cavitation confirms diagnosis
Sharp explorer with heavy pressure contraindicated – Sharp explorer with heavy pressure contraindicated –
transfer pathogenic bacteria to non infected areas and transfer pathogenic bacteria to non infected areas and
fracture of enamelfracture of enamel

25. ADDITIONAL AIDSADDITIONAL AIDS

SEPARATION OF SEPARATION OF
TEETHTEETH

FIBROPTIC FIBROPTIC
TRANSILLUMINATIONTRANSILLUMINATION
TRANSILLUMINATION TEST

26. Clinical Examination Of Existing RestorationClinical Examination Of Existing Restoration
EXAMINATION EXAMINATION ::

VisualVisual

TactileTactile

Separation Separation

RadiographsRadiographs
EVALUATE :EVALUATE :
oMarginsMargins
o Structural integrityStructural integrity
o Occlusal Occlusal
o Inter-proximal contactsInter-proximal contacts
o Esthetics Esthetics
o Effects on PeriodontiumEffects on Periodontium

27. Clinical Examination For Other DefectsClinical Examination For Other Defects

AbrasionAbrasion

Erosion Erosion

AbfractionAbfraction

AttritionAttrition

Fracture/craze lines Fracture/craze lines

Developmental anomalies (dens in dente, Developmental anomalies (dens in dente,
amelogenesis imperfectaamelogenesis imperfecta ) )

28. Radiographic examination of teeth Radiographic examination of teeth
and restorationsand restorations

Good quality periapical and bitewing Good quality periapical and bitewing
radiographs helpful in diagnosis.radiographs helpful in diagnosis.

Two dimensional image of three Two dimensional image of three
dimensional object.dimensional object.

29. Differential diagnosisDifferential diagnosis
“Medicine is a
science of
uncertainty and an
art of probability.”
William Osler

30. Differential diagnosisDifferential diagnosis

Distinguishing between Distinguishing between
two or more diseases and two or more diseases and
conditions with similar conditions with similar
symptoms by symptoms by
systematically comparing systematically comparing
and contrasting their and contrasting their
clinical findings, including clinical findings, including
physical signs, physical signs,
symptoms, as well as the symptoms, as well as the
results of laboratory tests results of laboratory tests
and other appropriate and other appropriate
diagnostic procedures.diagnostic procedures.

31. Investigations or adjunctive Investigations or adjunctive
diagnostic procedurediagnostic procedure
RADIOGRAPHS:RADIOGRAPHS:

Intra Oral Peri Apical Intra Oral Peri Apical
(IOPA)(IOPA)

BitewingBitewing

32. VITALITY TESTS-VITALITY TESTS-
Thermal test, electric pulp test, test cavity, Thermal test, electric pulp test, test cavity,
anesthetic test.anesthetic test.
Cold test
Heat test
Electric pulp tester

33. Test cavityTest cavity

34. CLINICAL LAB STUDIESCLINICAL LAB STUDIES ::
-Blood counts -Blood counts
-Microscopic examination-Microscopic examination
SALIVARY TEST-SALIVARY TEST-
-PH-PH
-Buffer-Buffer
-Volume-Volume

35. Final DiagnosisFinal Diagnosis

A final determination reached from A final determination reached from
evaluating signs, symptoms and evaluating signs, symptoms and
laboratory findings. laboratory findings.

Treatments are based on these Treatments are based on these
findings. findings.

36. Treatment PlanTreatment Plan

Planned sequence of therapeutic Planned sequence of therapeutic
measures used to cure or arrest measures used to cure or arrest
patients disease.patients disease.

URGENT PHASEURGENT PHASE - emergency condition - emergency condition
oPain Pain
oSwellingSwelling
oBleeding Bleeding
oInfectionInfection

37. 
PERIDONTAL TREATMENTPERIDONTAL TREATMENT

EXTRACTIONEXTRACTION

RESTORATIVERESTORATIVE

PROSTHODONTIC REHABLITATIONPROSTHODONTIC REHABLITATION

MAINTENANCE PHASE -MAINTENANCE PHASE - Consists of periodic Consists of periodic
recall of patientrecall of patient

38. HEAD CAPHEAD CAP
INCORRECT CORRECT

39. MOUTH MASKMOUTH MASK
INCORRECT CORRECT

40. PROTECTIVE EYE WEARPROTECTIVE EYE WEAR
INCORRECT CORRECT

41. GLOVING TECHNIQUEGLOVING TECHNIQUE

43. REMOVING THE GLOVESREMOVING THE GLOVES

44. INCORRECT CORRECT

45. FOOT RESTFOOT REST
INCORRECT CORRECT

46. INCORRECT
CORRECT

47. ARM RESTARM REST
INCORRECT PLACEMENT OVER HEAD AND CHEST OF PATIENT

48. PATIENT POSITIONPATIENT POSITION

INCORRECT INCORRECT
PLACEMENT OF PLACEMENT OF
PATIENTS HEAD PATIENTS HEAD
AND DENTIST AND DENTIST
ELBOWELBOW

49. CHAIR SIDE POSITIONCHAIR SIDE POSITION

RIGHT POSITION OR 9 RIGHT POSITION OR 9
O’CLOCKO’CLOCK

FACIAL SURFACES OF FACIAL SURFACES OF
MAXILLARY AND MAXILLARY AND
MANDIBULAR RIGHT MANDIBULAR RIGHT
POSTERIOR TEETH AND POSTERIOR TEETH AND
OCCLUSAL SURFACES OF OCCLUSAL SURFACES OF
MANDIBULAR RIGHT MANDIBULAR RIGHT
POSTERIOR TEETHPOSTERIOR TEETH

OPERATOR DIRECLTY TO OPERATOR DIRECLTY TO
THE RIGHT OF PATIENTTHE RIGHT OF PATIENT

50. RIGHT REAR OR 11 O’CLOCKRIGHT REAR OR 11 O’CLOCK

DIRECT VISION USED DIRECT VISION USED
ON MANDIBULAR ON MANDIBULAR
TEETH ESPECIALLY TEETH ESPECIALLY
LEFT SIDE, LINGUAL LEFT SIDE, LINGUAL
AND INCISAL AND INCISAL
SURFACES OF SURFACES OF
MAXILLARY TEETH MAXILLARY TEETH
VIEWED WITH MOUTH VIEWED WITH MOUTH
MIRRORMIRROR

OPERATOR IS BEHIND OPERATOR IS BEHIND
AND SLIGHTLY AND SLIGHTLY
TOWARDS RIGHT OF TOWARDS RIGHT OF
PATIENT.PATIENT.

51. DIRECT REAR OR 12 O’CLOCK DIRECT REAR OR 12 O’CLOCK
POSITIONPOSITION

OPERATING ON OPERATING ON
LINGUAL SURFACES LINGUAL SURFACES
FOR MANDIBULAR FOR MANDIBULAR
ANTERIOR TEETHANTERIOR TEETH

OPERATOR DIRECTLY OPERATOR DIRECTLY
BEHIND THE PATIENT BEHIND THE PATIENT
AND LOOKS DOWN AND LOOKS DOWN
OVER PATIENTS HEADOVER PATIENTS HEAD

52. RIGHT OR 7 O’ CLOCKRIGHT OR 7 O’ CLOCK

WORKING ON WORKING ON
MANDIBULAR MANDIBULAR
ANTERIOR TEETH, ANTERIOR TEETH,
MANDIBULAR MANDIBULAR
RIGHT POSTERIOR RIGHT POSTERIOR
TEETH AND TEETH AND
MAXILLARY MAXILLARY
ANTERIOR TEETH.ANTERIOR TEETH.

53. Thank you