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1. CASE HISTORY,CASE HISTORY,
EXAMINATION,EXAMINATION,
DIAGNOSIS ANDDIAGNOSIS AND
TREATMENT PLANINGTREATMENT PLANING

2. 2
Definition
CASE HISTORY
Is defined as planned professional conversation that enables
The patient to communicate his symptoms, fears to clinician
So that nature of patients real or suspected illness & mental
Attitude may be determined.

3. 3
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 .

4. 4
ARMAMENTARIUM REQUIRED
• MOUTH MIRROR
• EXPLORER
• TWEEZER
• PERIODONTAL PROBE
• COTTON ROLLS

5. 5
Vital Statistics
•Date
•Hospital /Case / OP no.
•Name
•Age, Sex, Ethnic group
•Class & School
•Address , Phone no.
•Parent’s occupation

6. CHIEF
COMPLAINT

7.  History of present illness
 Past medical history
 Past dental history
 Social and family history

8. 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's
directions cooperatively.
( + )
4 Definitely Positive: Good rapport with the dentist,
interest in the dental procedures, laughter and
enjoyment.
( + +)

9. 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

10. POST NATAL HISTORY
 Feeding
 Milestones
Vaccination
Major illness during childhood
 History of hospitalisation
 History of drug intake during childhood
DIET HISTORY

11. GENERAL PHYSICAL ASSESSMENT

13. 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

14. RING WORM INFECTION

15. THUMBSUCKING
HANDS
CLUBBING OF FINGERS
THUMBSUCKING
KOILONYCHIA

16. EXTRA ORAL EXAMINATION
 Facial symmetry
 TMJ examination
 Lymph nodes
 Profile
 Lip
 Swallowing
 Speech
SUB-
MANDIBULAR
CERVICAL

17. LIPS
ANOMALIES

18. NOSE
RUNNING NOSE
EPISTAXIS SADDLE NOSE

19. 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

20. BUCCAL MUCOSA
ULCER AMALGAM TATOO

21. FRENAL ATTACHMENT
LOWERUPPER

22. TONGUE

23. SOFT & HARD PALATE

24. HARD TISSUE EXAMINATION
 Teeth present
 Occlusion
 Overjet
 Overbite
 Crossbite
 Crowding

26. Deciduous dentition occlusion
• Occlusal relation
– Flush terminal plane
• Distal surface of U/L
• Favourable to guide
permanent molars
• 59.1%

27. Deciduous dentition: Development of
occlusion
• Mesial step
– Distal surface of lower
more mesial to upper
– Favourable
– 19.1%

28. Deciduous dentition: Development of
occlusion
• Distal step
– Distal surface of lower
more distal to upper
– Sucking habits
– Prognostically unfavourable
– 4.8%

29. SIZE & SHAPE OF TEETH
MACRODONTIA
TRUE & RELATIVE
MICRODONTIA
TRUE & RELATIVE
SHAPE
SCREW DRIVER, CONE
SHAPED,
GEMINATION,FUSION,
SUBMERGED TEETH

30. COLOR OF TEETH
EXTRINSIC
GREEN
BLACK
BROWN
INTRINSIC
GREENBROWN
YELLOWISHBROWN
RED / PINK

31. EXTRINSIC STAINS

32. INTRINSIC STAINS

33. CARIES

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

35.  PROVISIONAL DIAGNOSIS
 DIFFERENTIAL DIAGNOSIS
 INVESTIGATIONS
 FINAL DIAGNOSIS

36. INVESTIGATION
AIDS
Radiographs
Ceph
Handwrist etc
Study models
Photographs
Hematology screening
Histopathological
examination
Microbiological
investigations

37. TREATMENT PLAN
 OBJECTIVES OF TREATMENT :
 ELIMINATE INFECTION
REPAIR & 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.

38. 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:
RECALL
SIGNATURE