Case History in Periodontics is the first information taken from the patient to help determine and diagnose the patient and his/her condition and plays a major aspect in treatment planning. In Periodontics Case history provides a platform for the patient and dentist to have a conversation helping the patient to convey their symptoms and the Dentist to determine the causes of the present condition. While taking Case history the Dentist and patient can achieve a rapport which can help the patient fell calm and trust the Dentist during the treatment.

It is important to take proper case history and make sure that the patient is revealing all the details as it can help in getting good prognosis and avoids any complications.

Case History in Periodontics:

OP. No:

Date:

Name:

Age:

Occupation:

Address:

Sex:

Chief Complaint:

History of Present illness:

Medical History:

Cardiac History:

  • Chest pain on exertion:
  • Palpitations:
  • Dyspnea:
  • Swelling on ankles:
  • Angina pectoris:

Diabetes:

Hepatitis, Liver disease, Jaundice:

Tuberculosis:

STD:

History of Allergies:

  • Local Anaesthesia:
  • Penicillin or other Antibiotics:
  • Analgesics:
  • Other allergies:

Women:

  • Pregnancy:
  • Breastfeeding:

Past Dental History:

  • Last prophylaxis date:
  • Frequency of Oral prophylaxis:
  • Past treatments done:
  • Frequency of dental treatments:

Family Dental History:

  • History of Periodontal or Caries disease:
  • Loss of teeth in Parents or siblings after loosening of teeth:

Habits:

  • Bruxism
  • Clenching
  • Tongue thrusting
  • Mouth breathing
  • Lip biting, tongue or cheek biting, nail biting
  • Cigarette or pipe smoking
  • Pan, Ghutka or Tobacco chewing

Oral Hygiene: 

  • Method of Brushing: Horizontal, Vertical, Circular
  • Number of times of Brushing
  • Time spent on brushing
  • Type of Brush and frequency of changes
  • Inter dental Aides being used – Dental floss, toothpicks, Inter proximal brushes

Extraoral Examination:

  • TMJ Pain – Clicking or Deviation
  • Symmetry of Face
  • Lymph Nodes – tender or non tender, palpable or not palpable
  •  Lip competence

Intraoral Examination:

Soft Tissue Examination:

  • Buccal and labial mucosa
  • Palate
  • Tongue
  • Floor of mouth
  • Vestibule
  • Mucogingival problems

Case History in Periodontics

Hard Tissue Examination:

  • Number of teeth present:
  • Missing teeth
  • Dental caries
  • Impacted teeth
  • Restored teeth with fillings
  • Attrition
  • Erosion
  • Abrasion

Occlusal Analysis:

  • Angles Classification: Overjet or Overbite
  • Crossbite: Anterior or Posterior
  • Premature contact

Trauma from occlusion:

Fremitus test: Class 1 or class 2 or class 3

Gingival Status: It is usually mentioned quadrant wise by dividing the upper arch into three quadrants and the lower arch into three quadrants – Right posterior, anterior and left posterior.

  • Color:
  • Contour:
  • Size
  • Stippling:
  • Bleeding on Probing:
  • Consistency:
  • Exudation:
  • Width of attached Gingiva:

Case History for Gingival disease or Case History taking in Periodontics is quite different and elaborates mainly on the Gingival health and condition of the underlying bone. You tends to get a diagnosis and also find out the underlying cause of the said condition.