Dental case history

Case history ( anamnesis) is an important and integral part of treatment. The treatment of a disease or a condition starts with its proper diagnosis and this can be done successfully only by taking down a proper case history. Accurate diagnosis of a disease depends on the art of taking case history.

Case history is a planned professional conversation that enables the patients to communicate their symptoms, feelings and fear complex to the physician. In many occasions a properly prepared case history alone is sufficient to diagnose the disease without examining the patient.

Steps in case history preparation include the following: general information, history recording, examination of the patient, establishment of provisional diagnosis, necessary investigations, final diagnosis, treatment plan and prognosis.

The interview is the technique used to get a history from the patient. Assessment begins from the moment you make initial contact with the patient, and continues throughout the interview. During the interview you will get information about the patient’s health and feelings – verbally and in writing – while also observing gestures, facial expressions, body posture and changes in voice intonation. In this way there is interaction between you and the patient, which allows you to collect, clarify and expand on meaningful information from the patient’s responses. This type of interview is called the data-collecting interview.

The type of information you get during history taking will depend on the priorities of care and the needs of your patient. A comprehensive history has eight components: 1) demographic details; 2) main complaint or reason for visit; 3) present illness; 4) previous history; 5) history of family illness; 6) systems and body parts; 7) nutritional history; 8) activities of daily living. The following elements should be included in the dental history:

· Past dental visits, including frequency, reasons, previous treatment, and complications

· Oral hygiene practices

· Oral symptoms other than those associated with the chief complaint, including tooth pain or sensitivity, gingival bleeding or pain, tooth mobility, halitosis, and abscess formation

· Past dental or maxillofacial trauma

· Habits related to oral disease, such as bruxing, clenching, and nail biting

· Dietary history

Clinical examination of the patient includes general examination, extraoral examination (skull, the hair, the eyes, the ears, the nose, the symmetry of the face, the lymph nodes, the temporomandibular joint, the neck), intraoral examination (lips, teeth, tooth supporting tissues, oral mucosa, saliva, bones and occlusion). Different techniques of clinical examination are used by the dentist including: visual inspection, palpation, probing, percussion, auscultation, diascopy, aspiration, vitality tests of the teeth and other specific examinations

All bits of information obtained in the history and examination process are called findings. Findings may be normal or abnormal, healthy or pathologic. All findings can generally be grouped as either symptoms (subjective, elicited by history and interview, as described by the patient) or signs (objective, often measurable, discovered by examination).

The written record is the most effective method for transferring permanent data. The written record is a working document of all findings, and all the healthcare givers looking after the patient share this information. Although writing reports is time-consuming, it is efficient because it eliminates the possibility of the data being forgotten and the consequent repetition of data collection.

Diagnosis is an assessment of the findings which specifies what is happening to a patient

and why.

Treatment plan is a written plan of treatment which addresses both disease and etiology; it is the end product of data gathering and diagnosis, and it may take one of two forms: emergency or immediate treatment plan and comprehensive or long range treatment plan.

Ex.8. Find in the text the equivalents for the following words and word-combinations:

План лікування, оцінювання результатів, робочий документ, ділитися інформацією, ефективний метод, причини візиту, виключати можливість, щелепно-лицьова травма, утворення абсцесу, взаємодія, вираз обличчя, кусання нігтів, достатній, мистецтво збору анамнезу, невід’ємна частина лікування.

Ex.9. Answer the following questions:

1. What is a dental case history? 2. What steps does case history preparation include? 3. What kind of information can you get during the data-collecting interview? 4. What are the components of a comprehensive history? 5. What elements should be included in the dental history? 6. What does clinical examination of the patient include? 7. What techniques of clinical examination do you know? 8. How can all findings be generally grouped? 9. What is treatment plan?

Ex.10. Insert the missing words given below:

Collecting _____ is not the only purpose of interviewing. Interviews are also conducted to build up a professional relationship with the ________; promote communication and ensure that the patient understands the purpose of the _________; give the health care practitioner an understanding of the patient’s _________; support the patient during the management and follow-up of the problem.

The data-collecting interview has three ________:

Phase 1. The introduction. Try to put the patient at ease and win the patient’s ____________.

Phase 2. The active data-collecting phase. During this phase, use various interviewing _______ to encourage the patient to talk. This will help you ________ complete and accurate data within the specified time period.

Phase 3. The conclusion. Give direction to the patient by ________what he/she can expect.

Ex.11. Distinguish between symptoms and signs:

Redness, pain, sensitivity to hot or cold, measurable fever, altered taste, molar crossbite, esthetic complaints, bad breath, swelling, inability to chew or to speak clearly, tenderness to palpation, crepitus.

Ex.12. Read the following text and write down all unknown words: