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.

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

 

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.