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Dental Case History – General Information

September 30, 2009 by Dr. Varun Pandula 15 Comments

Definition of Case history: The collection of data concerning an individual, their family, and environment, including the medical history, dental history and any other information that may be useful in analyzing and diagnosing the condition or for instructional or research purposes.

  • Case History in Periodontics

This includes all the general information of the Patient which can potentially be helpful in diagnosing any condition which the patient comes to you for. There are many options in Case History which need to be known to not just get a proper diagnosis but also helps in determining a treatment plan and decide the prognosis of the treatment being done.

 

General Information Includes:

  1. Name
  2. Age
  3. Sex
  4. Occupation
  5. Address
  6. Region

 

Case history in Dentistry

Case history in Dentistry

1) NAME:

There are many advantages by the name, the advantages are given below:

Psychological Benefit: It gives a great psychological benefit to the doctor as the patient always likes to be called by his name.

Improves Rapport: It improves personal rapport between the patient and the medical practitioner, mainly helpful in children when called by their short name they respond more than called by their full name.

Specific Identification: It helps in specific identification of the patient on religious, race, Ethnic or Geographic distribution.

2) AGE:

Many diseases show predilection towards Age, Based on the disease predilection of age patients are divided into:

  • Neonatal: At Birth
  • 1-3 Yrs: Infancy
  • 4-14 Yrs: Child
  • 15-20 Yrs: Young Adults
  • 21-40 Yrs: Adults
  • 40-50 Yrs: Post Adolescent
  • Above 50 Yrs: Old Age
So Based on these age groups we can rile out some of the Dental Diseases as well as medical conditions which inturn relate to dental problems.
For Ex: Periodontitis is seen only in Old Age i.e >50yrs But if you can see the condition i Children and Young Adults we can confirm that it is Juvenile Periodontitis.
Not only do they help in ascertaining the age predilection of the disease it also helps in doseage schedule, time of treatment planning, behavior management technique.
Child Dose:
  1. Youngs Law: Child Age / Age+12 X Adult Dose
  2. Clark’s Law: Child age at next Birthday / 24 X Adult Dose
  3. Dilling Law: Age X Adult Dose / 20
It is also important in Developmental and hereditary diseases which occur at the time of birth and grows upto the puberty or ceases with growth.
3) SEX:
Similar to age diseases also show sex predilection. Some are more specific to Females while some are to Males.
Lets see some diseases with the sex predilection:
Females:
  • Iron Deficiency Anemia
  • Pleomorphic Adenoma
  • Sjogrens Syndrome
  • Adeno Ameloblastome
  • Myasthenia Gravis
  • Sickle Cell Anemia
  • Caries
  • Thyroid Diseases
  • Juvenile Periodontitis
  • Peripheral Ossifying Fibroma
  • Naso Alveolar Cyst
Males:
  • Attrition
  • Caries in Decidious Teeth
  • Carcinoma in Situ
  • Carcinoma of the buccal mucosa
  • Leuplokia
  • Keratoacanthoma
  • Basal Cell Carcinoma
  • Verrucous Carcinoma
  • Adenoid cystic Squamous cell carcinoma
  • Liposarcoma
  • Hodgkins Disease
  • Multiple Myeloma
  • Chondrosarcoma
  • Herpes Simplex
  • Ewings Sarcoma
  • Ameloblastic fibro Odontoma
  • Basal cell Adenoma
Along with sex Predilection of the diseases it also helps to analyze the following:
  1. Esthetic Needs whole treating.
  2. Sexual Abuse or Exploitation
  3. Dosage of Drugs
  • Females require low dosage of drugs than the Males as their Body weight is less when comapred to the males.
  • Extraordinary care should be taken while prescribing medicines to patients who are in Mensuration, Pregnancy, Lactation.
  • Drugs given during pregnancy could affect the Fetus directly.
  • Long term use of Anti Hypertensive Drugs can lead to Impotency in Males.
  • Gynecomastia may be caused in males due to some medications like Digitalis, Ketoconazole, Chlorpromazine. . . etc
4) OCCUPATION:
Certain Diseases are predisposed to some particular Occupations:
  1. Tuberculosis: Tobacco factory workers
  2. Pulmonary diseases: People working in Acetic acid plants.
  3. Contact Dermatitis.
  4. Lead Poisoning.
  5. Asbestos Poisoning-  Mesothelioma
  6. Radiation sickness.
  7. Nail Bed infection in Radiographers and Dark Room Assistants.
So thus Occupation can be an important factor in determining the source or cause of the disease for the further treatment of the disease.
5) ADDRESS:
Full Postal Address should be taken in order  for communication and to ascertain geographic distribution.
  • Filariasis common in Orissa
  • Leprosy common in West Bengal
  • Carcinoma of the Palate common in Srikakulam A.P
  • Buccal Carcinoma common in Tamilnadu
  • Sleeping Sickness in South Africans
  • Kangri Cancer in Kashmiris
  • Anemia and Malnutrition severe in Rural Areas.

6) RELIGIOUS:

There are not many religion specific dental conditions which have been researched. The Dental problems might relate to an specific food habits of a particular religion but in general Religion does not play a major role in Dental Case History.

Comments

  1. Urjee says

    October 29, 2009 at 4:47 pm

    It’s so useful, thanks a lot.

  2. rakesh nair says

    March 6, 2010 at 4:08 am

    thanks a lot.i was looking for these informations in the books for quite a lot time……it came really use full i was preparing for a surprise test.

  3. dipak says

    July 3, 2010 at 11:07 am

    thanx its very basic information

  4. Kankia says

    July 25, 2016 at 8:06 am

    Hye dude, this is a freaking good for dentist and other health practitioners… But i urge you put importance of religion…..

  5. hannah says

    September 26, 2016 at 6:58 pm

    wow! you have made my studies easy! thankyu very much. more books lack this info. God bless you

  6. Lakshmi prasadh says

    November 3, 2016 at 3:01 pm

    Thank u so much sir…
    Was very useful to clearly know the basics….

  7. Viral Shah says

    December 26, 2016 at 8:51 am

    what is importance of regilious?

  8. Varun says

    March 6, 2017 at 3:05 pm

    I hope you are asking about – Religion. In some cases there are certain conditions which are religion specific and knowing the religion of the patient can help in Diagnosis of such cases.

  9. helly says

    April 17, 2017 at 6:10 pm

    thank you sir……but why its called case history ?? neither any other name??

  10. Varun says

    April 19, 2017 at 6:32 am

    It is also called as patient history.

  11. Terry M. Quewon says

    March 11, 2018 at 3:14 am

    Thank you for the website, it makes me to learn new this about my patients. But it left me in suspense. it never teach me about why religion was reflected on the record in taking patients identities.

  12. Arati Naik says

    August 7, 2018 at 1:52 am

    Which diseases are religion related??

  13. Isaac says

    February 7, 2019 at 2:31 pm

    This has really helped me in knowing the importance of noting down Demography

  14. Ashutosh says

    August 3, 2019 at 5:53 am

    This is bcz.. for eg
    Muslims do certain rituals when they arr born…so penile cabcers are less common in muslims…
    In Nepal certain communties like Tharus are prone to colour blindness…

  15. Megha says

    July 26, 2020 at 4:54 pm

    Can you please provide the full article for reference

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Varun Pandula

Varun Pandula

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