CASE HISTORY, CASE HISTORY, EXAMINATION, EXAMINATION, DIAGNOSIS AND DIAGNOSIS AND

TREATMENT PLANINGTREATMENT PLANING

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DefinitionCASE HISTORY

Is defined as planned professional conversation that enables The patient to communicate his symptoms, fears to clinicianSo that nature of patients real or suspected illness & mentalAttitude may be determined.

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OBJECTIVES OF CASE HISTORY

• Tentative diagnosis • Systemic factor that might affect

formulation of a diagnosis• Any systemic condition that requires

special precaution prior to/ during .

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ARMAMENTARIUM REQUIRED

• MOUTH MIRROR• EXPLORER• TWEEZER• PERIODONTAL PROBE• COTTON ROLLS

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Vital Statistics•Date

•Hospital /Case / OP no.•Name

•Age, Sex, Ethnic group•Class & School

•Address , Phone no.•Parent’s occupation

CHIEF

COMPLAINT

History of present illness

Past medical history

Past dental history

Social and family history

FRANKL BEHAVIOR RATING SCALE

Rating Frankl behavior rating Wright modification

1 Definitely Negative: Refusal of treatment, forceful crying, fearfulness, or any other overt evidence of extreme negativism.

( - - )

2 Negative: Reluctance to accept treatment, uncooperativeness, some evidence of negative attitude but not pronounced

( - )

3 Positive: Acceptance of treatment; cautious behavior at times; willingness to comply with the dentist, at times with reservation, but patient follows the dentist'sdirections cooperatively.

( + )

4 Definitely Positive: Good rapport with the dentist, interest in the dental procedures, laughter andenjoyment.

( + +)

PRENATAL HISTORY

Drug intake during pregnancy

Illness during Pregnancy

NATAL HISTORY

Full term / Premature birth

Type of delivery

Birth cry

Feeding

Conginital abnormality if any

Natal teeth

POST NATAL HISTORY

Feeding

Milestones

Vaccination

Major illness during childhood

History of hospitalisation

History of drug intake during childhood

DIET HISTORY

GENERAL PHYSICAL ASSESSMENT

dolicocephalic Mesocephalic Brachychephalic

SHAPE OF HEAD

Females Males Scientific term< 75 < 75.9 dolichocephalic

75 to 83 76 to 81 mesaticephalic> 83 > 81.1 brachycephalic

RING WORM INFECTION

THUMBSUCKING

HANDS

CLUBBING OF FINGERS

THUMBSUCKINGKOILONYCHIA

EXTRA ORAL EXAMINATION

Facial symmetry

TMJ examination

Lymph nodes

Profile

Lip

Swallowing

Speech SUB-MANDIBULAR

CERVICAL

LIPS

ANOMALIES

NOSE

RUNNING NOSE

EPISTAXIS SADDLE NOSE

PERSONAL HISTORY

Other habits

Oral hygiene appraisal

INTRA ORAL EXAMINATION

SOFT TISSUE EXAMINATION

lips, cheek, vestibule, tongue, floor of the mouth, palate

Orifices of salivary gland

Tonsils

Gingiva

BUCCAL MUCOSA

ULCER AMALGAM TATOO

FRENAL ATTACHMENT

LOWERUPPER

TONGUE

SOFT & HARD PALATE

HARD TISSUE EXAMINATION

Teeth present

Occlusion

Overjet

Overbite

Crossbite

Crowding

Deciduous dentition occlusion

• Occlusal relation– Flush terminal plane

• Distal surface of U/L

• Favourable to guide permanent molars

• 59.1%

Deciduous dentition: Development of occlusion

• Mesial step– Distal surface of

lower more mesial to upper

– Favourable

– 19.1%

Deciduous dentition: Development of occlusion

• Distal step– Distal surface of

lower more distal to upper

– Sucking habits

– Prognostically unfavourable

– 4.8%

SIZE & SHAPE OF TEETH

MACRODONTIATRUE & RELATIVEMICRODONTIA

TRUE & RELATIVESHAPE

SCREW DRIVER, CONE SHAPED,

GEMINATION,FUSION, SUBMERGED TEETH

COLOR OF TEETH

EXTRINSICGREENBLACK

BROWN

INTRINSICGREENBROWNYELLOWISHBROWN

RED / PINK

EXTRINSIC STAINS

INTRINSIC STAINS

CARIES

DIAGNOSIS ---IT IS DEFINED – The art or act of identifying a disease from its signs &

symptoms

PROVISIONAL DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

INVESTIGATIONS

FINAL DIAGNOSIS

INVESTIGATIONAIDS

RadiographsCeph

Handwrist etcStudy models Photographs Hematology screening

Histopathological examination

Microbiological investigations

TREATMENT PLAN OBJECTIVES OF TREATMENT : ELIMINATE INFECTIONREPAIR & RETAIN ALL PRIMARY TEETH UNTILL NORMAL EXFOLIATION.RECOGNIZE & IF POSSIBLE CORRECT ANY VARIATION FROM NORMAL.PREVENT & INTERCEPT ANY INCIEPIENT MAL-OCCLUSION.EDUCATE FAMILIES TO CONTROL & PREVENT DISEASE.

TREATMENT PLAN

Step 1 – Emergency phase Step 2 - Immediate phase Step 3 - Plaque control program Step 4 – Restorative phase Step 5 - Orthodontics, Prosthodontics, Oral surgical phase Step 6 - Evaluvation, maintenance and follow up

TREATMENT PROVIDED:RECALLSIGNATURE