History taking

history taking principles medical and dental history

CASE HISTORY TAKING
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.
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 making decisions
concerning the treatment of the patient.
Steps in case history taking
1. Assemble all the available facts gathered from
statistics, chief complaint, medical history, dental
history and diagnostic tests.
2. Analyze and interpret the assembled clues to
reach the provisional diagnosis.
3. Make a differential diagnosis of all possible
complications.
4. Select a closest possible choice-final
diagnosis.
5. Plan a effective treatment accordingly.
Methods of obtaining the
patient history
There are 3 methods :-
1) Interview
2) Health questionnaire
3) Combination of these
1) INTERVIEW :- In this the patient is asked about his or her
health in an organized fashion . The patient is allowed to
discussed any problem fully.

The disadvantage include :-

a) Method depends on the dentist skill as an interviewer.
b) The interviewer may skip some important topics.
c) The interviewer requires time to be done well.
2) HEALTH QUESTIONNAIRE :-
The health questionnaire is a printed list of heath related
questions that the patient is requested to answer at the first
appointment.

Advantage :-
1) it takes little of the dentist’s time
2) it offers a standardized approach for each patient.

Disadvantage :-
3) Little time to build rapport with the patient
4) The questions or their format may be interpreted inaccurately
by some patient.
 3)Combination
1. The combined method is considered by the authors to
be the best appropriate technique for history
taking in the routine practice of Dentistry.
2. This approach uses the advantages of both techniques
and reduces the disadvantages after reviewing a completed
health questionnaires, the dentist discusses the
response with the patient.

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COMPONENTS-
⚫ Statistics ⚫ Provisional diagnosis
⚫ Chief complaint ⚫ Investigations
⚫ History of present illness ⚫ Final diagnosis
⚫ Medical history ⚫ Treatment plan
⚫ Past dental history
⚫ Personal history
⚫ General examination
⚫ Extraoral examination
⚫ Intraoral examination
 STATISTICS
⚫ Patient registration number
⚫ Date
⚫ Name
⚫ Age
⚫ Sex
⚫ Address
⚫ Occupation
⚫ Marital status
⚫ Patient registration number
Useful for-
1. maintaining a
record,
2. billing purposes,
3. medico legal aspects.

⚫Date
Useful for-
4. Time
of
admiss
ion
5. refere
NAME
⚫ to communicate with the patient
⚫ to establish a rapport with the patient
⚫ Record maintenance
⚫ Psychological benefits

AGE
⚫ For diagnosis
⚫ Treatment planning
⚫ Behavioral management techniques
⚫ DISEASE MORE ⚫ DISEASE PRESENT
COMMONLY PRESENT IN CHILDREN &
AT BIRTH YOUNG ADULTS
- Micrognathia - Benign migratory
- Cleft lip & cleft plate glossitis
- Ankyloglossia - Juvenile periodontitis
- Predecidous dentition - Pemphigus
- Teratoma - Recurrent apthous
- stomatitis
Hemophilia
- Dental caries
- Dentigerous cyst
- Diptheria
- Rickets
- Infectious
DISEASE PRESENT IN ADULTS & OLDER PATIENTS

- Attrision
- Abrasion
- Gingival recession
- Periodontitis
- Lichen planus
- Ameloblastoma ( 30 – 50)
- Trigeminal neuralgia
- Fibroma
- Verrucous carcinoma
- Iron deficiency anemia
- Diabetes
- Hypertension
- Asthma
⚫ AGE
used to calculate the dose of the
drug.
CHILD DOSE
1) YOUNG RULE = child’s adult dose
age
age + 12
2) CLARK RULE
child age at next birthday adult dose
24

3) DILLING RULE = adult dose

age
20
 SEX
SINGNIFICANCE-Certain diseases are gender specific:

⚫ Diseases common in males:

Attrition, leukolpakia, cancer like squamous cell carcinoma,
melanoma, lymphoma etc

⚫ Diseases common in females:

Iron deficiency anemia, sjogren’s syndrome, osteoporosis, recurrent
apthous ulcers etc

⚫ Drug interaction :- in females, special consideration must be given

to pregnancy & lactation.
 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 of increase

level of fluorides in water are spread differently in various
parts of the country.

.
⚫ OCCUPATION
⚫ To asses the socioeconomic status.
⚫ Predilection of diseases in different occupations for
eg: hepatitis B is common in dentists & surgeons.

⚫ MARITAL STATUS
⚫ To see any history of consanguineous marriages.
⚫ The high consanguinity rates, coupled by the large
family size in some communities, could induce
the expression of autosomal recessive diseases.
 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.
 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
 COMMON CHIEF COMPLAINTS
⚫ Pain
⚫ Swelling
⚫ Ulcer
PAIN
⦿ Original Site of pain
⦿ Origin & mode of onset
⦿ Severity
⦿ Nature of pain
⦿ Progression of pain
⦿ Duration of pain
⦿ Movement of pain
⦿ Periodicity of pain
⦿ Effect of functional activity
⦿ Precipitating factors
⦿ Relieving factors
⦿ Associated symptoms
⦿ Treatment taken
a) Anatomical location where the pain
felt ?
b) Origin & mode of onset :- activity which inducing the pain should
be taken in consideration.
c) Intensity of pain :- whether the pain is mild , moderate or severe.
d) Nature of the pain :- it can be throbbing , shooting , stabbing, dull
, aching, lancinating, boring, griping, sharp, gnawing, squeezing.
e) Progression of pain:-The patient should be asked ‘how is
it progressing?
⚫ The pain may begin on a weak note & gradually reach a peak
& then gradually declines.
⚫ It may begin at its maximum intensity & remains at this level
this disappears.
f)Duration of pain-Duration of pain means the period from the time
of onset to the time of pain disappearance.

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.

i) 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.

i)Aggrevating & relieving factor- whether it aggrevates or relieved

with
chewing or any other factors.
j) Associated symptoms-
⦿ Severe pain may be associated with:
• Pallor
• Sweating
• Vomiting
k) Treatment taken-
⚫ Any medication taken by patient & its
outcome.
 SWELLING
1) Duration :- for how many days swelling is present.
2) Mode of onset :-
a)mass that increase in size just before eating :-
salivary gland retention phenomenon.
b) slow growth :- chronic infection cyst, benign tumors
c) rapid growing mass :- abscess, infected cyst,
hematoma
d) mass with accompanying fever :- infection &
lymphoma
3) Symptoms :- like pain, difficulty in respiration
swallowing, disfiguring.
4) Progress of the swelling :- swelling can
increase gradually in size or rapidly
5)Associated symptoms :- fever presence of other swelling
& loss of body weight
6)Secondary changes :- like softening , ulceration,
inflammatory changes
7)Recurrence of swelling :- if swelling recurs after
removal,it may indicate malignant changes
 ULCER
1) Mode of onset :- duration of ulcer should also be noted.
2) Pain :- ulcer associated with inflammation are painful &
ulcers associated with epithelial or basal cell carcinoma
are painless.
3) Discharge :- discharge from ulcer like serum, blood, pus
should be noted down.
4) Associated disease :- like tuberculosis , diabetes &
syphilis
 MEDICAL HISTORY
⚫ The medical history includes the information about past & present
illness.
⚫ All diseases suffered by patient should be recorded in chronological order.
⚫ Check list of medical history-by Scully and Cawson
-Anemia
-Bleeding disorders
-Cardio respiratory disorders
-Drug treatment and allergies
-Endocrine disorders
-Fits and faints
-Gastrointestinal disorders
-Hospital admissions and surgeries
-Infections
-Jaundice
-Kidney disease
⚫ Medical history usually organized into the
following subdivisions : -
1) Serious or significant illness :-In the dental context, ask
about any history of heart, kidney, liver or lung disease.
History of any infection disease, immunologic disorders
radiation or cancer chemotherapy & psychiatric
treatment.
2) Hospitalization :- a record of hospital admission along
with the history of any major surgery.
3) Transfusion :- a history of blood transfusions, including
the date of each transfusion & the number of transfused
blood units. In some instances ,transfusion can be a
source of a persistent transmissible disease.
4) Allergy :- the patient’s record should document any history of
classic allergic reactions such as urticaria, hay fever, asthma
as well as any other adverse drug reaction.
Events reported by the patient as
fainting, stomachache, weakness ,flushing ,rash etc should
be noted.
5) Medications :- an essential component of a medication
history is a record of all the medication a patient is taking.
Identification of medications helps in the recognition of drug
induced disease and oral disorders associated with different
medication.
6) Pregnancy :- knowing whether or not a women of
following age is pregnant is particularly important when
deciding to administer or prescribe any medication &
procedure involving exposure of the pregnant patient to
ionization radiation.
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
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.
 PAST DENTAL HISTORY
⚫ History of dental treatment undergone by the patient,
along with patients experience before, during and after
the dental treatment.
⚫ History of complications experienced by the patient
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 su
congenitally missing lateral incisors, amelogenesis imperfecta , ectodermal dysplasia & cleft li
cleft palate.
PERSONAL HISTORY
⚫ It includes:-
⚫ Diet
⚫ Apetite
⚫ Bowel & micturation habit
⚫ Sleep
⚫ Oral hygiene measures
⚫ Oral habits
⚫ Adverse habits
1) DIET :- whether the diet is vegetarian , mixed or spicy
food.
a) soft diet :- adhere tenaciously to the teeth because of
lack of rough edges leading to more dental caries.
b) coarse diet :- cause more amount of attrition.
c) carbohydrate & vitamin diet :- increase carbohydrate
contents leads to increase risk for dental caries , while
diet deficient in vitamin may cause enamel hypoplasia.

2) Appetite :- whether the appetite is regular or irregular.

3) Bowel & micturition habit :- whether it is regular or
irregular.
4) Sleep :- sleeping hours should be asked. Insomnia occurs
in case of primary thyrotoxicosis.
Habits
a) Oral hygiene method:- poor oral hygiene & improper
brushing technique may leads to dental caries & periodontal
disease. Horizontal brushing technique may leads to
cervical abrasion.

b) oral habits :- pressure habit like thumb sucking lip sucking

leads to anterior proclination of maxillary incisors.Tongue
thrusting habit leads to anterior n posterior open bite. Mouth
breathing leads to anterior marginal gingivitis & dental
caries.

c) Deleterious habits :- tobacco, smoking & drinking habit

should be asked as these patient having high risk for
cancer development.
 GENERAL EXAMINATION
⚫ Analyze the patient entering the clinic
for built, height ,gait, and posture.
⚫ Check for any
pallor, icterus, clubbing, cyanosis, lymphadenopathy &
edema.
⚫ Vital signs like pulse, blood
pressure, temperature, respiratory rate should be
noted.
⚫ Pulse
⚫ Normal pulse rate is 60-80 beeats/min
⚫ Average pulse is 72 beats/min
⚫ Physiologic increase in infants, after exertion.
⚫ Pathologic increase in fever, cardiopulmonary diseases.

⚫ Temperature
⚫ normal temp is 98.6 degree F or 37 degree celsius.
⚫ Measured by thermometer.

⚫ Respiratory rate
⚫ Adult rate–16-24 breaths per minute
⚫ Observe
⚫ Feel for chest movement
⚫ Auscultate
⚫ Blood pressure
⚫ Systolic- 110-140 mm Hg
⚫ Diastolic-60-90 mm of Hg
⚫ Measured by Sphygmomanometer.
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 as an oral manifestation

of
a systemic disease or genetic abnormality.

⚫ The sequel of missing teeth may include supra

eruption,tilting,drifting or rotation, all of which may
have an impact on treatment plan.
 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.
 RADIOGRAPHIC METHODS
⚫ BITE WING RADIOGRAPHY:
⚫ To diagnose proximal decay.

⚫ INTRA- ORAL PERI APICAL

RADIOGRAPH:
⚫ To detect the extent of
occlusal caries.
⚫ To assess the periapical area.

⚫ DISADVANTAGES:
⚫ A. To be radiographically
visible, mineral
loss should be more than 20-
⚫ OTHER METHODS:
⚫ Fibro Optic Transilluminator.

⚫ Digital Fibro Optic Transilluminator.

⚫ Fluorescence (acid dissolution of structure).

⚫ Use of caries detector dye e.g. silver nitrate,

methyl red and alizarin stain to detect caries by
color change).
 WASTING DISEASES OF TEETH:
⚫ ATTRITION:
physiologic wearing away of a tooth
as a result of tooth to tooth
contact, as in mastication.

⚫ SITE: occurs on occlusal,incisal

and proximal surfaces of teeth.

⚫ ETIOLOGY: seen in bruxisum,

traumatic occlusion, and also
associated with aging process. It is
an abnormal process.
⚫ ABRASION
⚫ Friction between tooth & an exogeneous agent

⚫ ETIOLOGY:
⚫ use of abrasive dentifrice, tooth floss, tooth picks etc.

⚫ EROSION:
⚫ defined as irreversible loss of dental hard tissue by a
chemical
process that does not involve bacteria.

⚫ SITE: cervical areas of teeth.

⚫ ETIOLOGY:
⚫ INTRINSIC: due to gastro esophageal
reflux and vomiting
⚫ EXTRINSIC: acidic beverages, citrus fruits.
⚫ ABFRACTION
⚫ The pathological loss of enamel and dentine due
to occlusal stresses.
⚫ Occlusal forces which cause the tooth to flex, cause
small enamel flecks to break off, inducing the
abrasive lesions
⚫ These lesions are often diagnosed as toothbrush
abrasion, but they differ as their angles are
sharper
⚫ Common in patients with poor tooth alignment
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.

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⚫ GRADES OF MOBILITY: (GLICKMAN’S
CLASSIFICATION)

⚫ No detectable movement when force is applied other

than what is considered normal (physiologic) motion.
⚫ GRADE-I: movement of tooth about 1 mm in bucco-
lingual direction
⚫ GRADE-II: movement of tooth more than 1 mm in
bucco-lingual direction and labio palatal direction.

⚫ GRADE- III: depression of tooth in the socket .

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 OCCLUSION:
MALOCCLUSION
⚫ CLASS-I MOLAR RELATION: mesio buccal
cusp of the maxillary Ist molar occludes in
the buccal groove of mandibular Ist
permanent molar.

⚫ CLASS-II:
⚫ Distobuccal cusp of upper first molar
occludes in the buccal groove of lower first
permanent molar.

⚫ CLASS-III:
⚫ mesiobuccal cusp of maxillary first
permanent molar occludes in
interdental space between mandibular
first & second molar.
PROVISIONAL
DIAGNOSIS
⚫ It is also called tentative diagnosis or working diagnosis.
⚫ It is formed after evaluating the case history &
performing the physical examination.

⚫ DIFFERENTIAL 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.
INVESTIGATIONS:
CHAIR SIDE INVESTIGATIONS: ROUTINE COMPLETE
HEMOGRAM-

 PULP VITALITY TESTS  HEMOGLOBIN,

 PERCUSSION TESTS  RED CELL COUNT,
 CYTOLOGY  WBC,
 ASPIRATION  PLATELET COUNT
 ESR,
 TOTAL
LEUKOCYTE
COUNT,
 TOTAL
DIFFERENTIAL
COUNT,
 BLEEDING TIME,
 CLOTTING TIME,
 PLATELET
COUNT,
 SERUM IRON, 57
 CALCIUM,
⚫ PERCUSSION TEST:
⚫ to evaluate the status of the
periodontium surrounding a
tooth

⚫ TYPES:
⚫ VERTICAL PERCUSSION TEST –
positive indicates periapical
pathology
⚫ HORIZONTAL PERCUSSION
TEST – positive indicates
periodontium associated problems.

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RADIOLOGICAL INVESTIGATIONS
 INTRAORAL PROJECTIONS;
 -Intra-Oral Periapical,
 Occlusal,
 Bitewing views.

 EXTRAORAL PROJECTIONS;-
 OPG,
 PA view of skull and jaws,
 AP view
 PNS view,
 SUBMENTOVERTEX view,
 TMJ views. 59
OTHER INVESTIGATIONS:-
⚫ URINE EXAMINATION
⚫ Special investigations like:-
⚫ Sialography
⚫ MRI
⚫ CT Scan
⚫ 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.

173
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.
 Treatment phases
1. Preliminary phase
2. Nonsurgical phase
3. Surgical phase
4. Restorative phase
5. Maintainance phase

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 1.Preliminary phase

Treatment of emergencies:
⚫ Dental or periapical
⚫ Periodontal
⚫ Other

Extraction of hopeless teeth and provisional

replacement if needed(may be postponed to a more
convenient time)

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 2.Nonsurgical phase
Plaque control and patient education:
⚫ diet control (in patients with rampant caries)
⚫ Removal of calculas and root planing
⚫ Correction of restorative and prosthetic irritational
factors.
⚫ Excavation of caries and restoration (temporary or
final,depending whether a definitive prognosis for
the tooth has been determind and on the location
of caries)
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3.Surgical phase
⚫ Periodontal therapy including placement of implants
⚫ Endodontic therapy

4.Restorative phase
⚫ Final restorations
⚫ Fixed and removable prothodontic appliances
⚫ Evaluation of response to restorative procedures
⚫ Periodontal examination

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 5.Maintenance phase
periodic rechecking:

⚫ Plaque and calculas

⚫ Gingival condition(pockets ,inflammation)
⚫ Occlusion,
⚫ Tooth mobility
⚫ Other pathologic changes.

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⚫ PRESCRIPTION WRITING

⚫ SUPERSCRIPTION: general background information regarding the dentist

and the patient and the date of prescription is written.

⚫ INSCRIPTION: specific information regarding the drug and the dosage.

⚫ SUBSCRIPTION: direction to the pharmacist for filling the inscription.

⚫ TRANSCRIPTION: instruction to the patient to be listed on the container

label.

⚫ SIGNATURE AND EDUCATIONAL DEGREE OF PRESCRIBING

DOCTOR: a
signature is required by law only for certain controlled substance.

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PROGNOSIS
⚫ It is defined as act of foretelling the course of
disease that is the prospect of survival & recovery
from a disease as anticipated from the usual course
of that disease or indicated by special features of the
case.
THANK YOU