History

Biodata

1. Date
2. File number
3. Full name
4. Age/date of birth
5. Gender
6. Contact
7. Physical address
8. Occupation
9. Name of guardian/parent – for children
10. Source of referral (if referred)

Presenting complaint

In patients own words, what is the problem

History of presenting complaint

• S – Site
• O – Onset
• C – Character (throbbing, continuous, dull, acute, sharp)
• R – Radiation (to head)
• A – Associated symptoms (fever, discharge)
• T – Timing (day or night, after eating)
• E – Exacerbating factors (hot/cold food), Alleviating factors (Pain medications)
• S – Scale (scale of 1-10, rate the pain)

Previous treatments concerning the presenting complaint

Past dental history

• Index visit or
• Previous dental treatments done
  • What they were
  • When
  • Where
  • If extraction done – any complications
  • Tolerance to LA

Dental habits

• How many times do they brush their teeth
• How do they brush
• Which toothpaste
• How often they change their brush
• Any interdental cleaning methods used – floss, toothpicks
• Abnormal habits eg. mouth breathing, lip sucking

Past medical history

• History of chronic illness:
  • CHD/CVS, infective endocarditis
  • Respiratory – asthma, bronchitis
  • GIT – peptic ulcers, diarrhea, vomiting, jaundice, hepatitis, gastritis
  • Diabetes
  • CNS disorders
  • Bleeding disorders – hemophilia, anticoagulant therapy
  • Infectious diseases – TB, HIV, Herpes
  • On any medications – NSAID, corticosteroids, anticoagulants, anticonvulsants
• Previous hospital admission – When, where, why, treatment provided
• Food or drug allergy

Obs and gyn history for females

• Last menstruation date and regularity
• Pregnancy status
• Type of contraceptives used

Family social history

• Alcohol – amount and frequency
• Smoking – amount and frequency
• Drugs
• Family status – parents, siblings, chronic illness in family
• Martial status and children
• Water source – borehole or city council

For pediatric and orthopedic patients

Birth history:

Prenatal:

• Health and nutritional status of mother during pregnancy
• Complications during pregnancy:
  • Infections – rubella, TB, syphilis, UTI
  • Pre-eclampsia
  • Hypertension
  • Diabetes
  • Antepartum bleeding
• Drugs
• X-ray
• Rh incompatibility may result in erythroblastosis fetalis – leading to green blue discoloration of dentition. Picture

Natal:

• Full term or premature
• Mode of delivery – Normal/C-section and why?
• Did the baby cry on birth
• Birth weight
• Breast fed or formula milk given

Postnatal:

• Vaccinated
• Developmental history
• Nocturnal feedings/sweetened milk – predisposes to early childhood caries (read more)
• Brushing habits – frequency, by who, supervised?

Habits

• Finger sucking/thumb sucking
• tongue thrusting
• Mouth breathing
• Nail biting – check nails

Diet chart

• 24 hour diet chart
• 7 day diet chart (as investigation)

Family social history

• Name of school
• Class
• Performance in school
• Social or antisocial
• Occupation of parents
• Family history
• Water source

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Clinical examination

General examination

• Anxious or calm
• Build, nourishment – well, poor
• Posture

Vital signs:

• Temperature
• Pulse rate
• Respiratory rate
• Blood pressure

NB: Also measure weight and height for children – to calculate BMI and dosage of LA and drugs

Extra oral examination

• Palpate submental, submandibular and neck lymph nodes
• Facial symmetry – any swellings or asymmetry
• Facial profile
• Scars
• Eyes – jaundice (look down), pallor (look up)
• TMJ movements – clicking or popping sounds, pain, path of closure
• Lips competency
• Hands – examine nails, finger clubbing, cyanosis

Remember it as: J A C C L O W D (Jaundice, anemia, clubbing, cyanosis, lymphadenopathy, oedema, wasting, dehydration)

Intraoral examination

• Oral hygiene status
• Type of dentition: primary, mixed, permanent

Soft tissue examination:

• Gingiva – shape, size, color, bleeding, ulceration, growths, pockets, recession
  • Plaque and gingival score
• Buccal mucosa – color, texture, ulcer, growth, sinus
• Floor of mouth – swellings, ulcer
• Tongue – size, movements, plaque
• Palate – normal, high vault, clefts
• Tonsils – normal, swollen
• Frenal attachments – normal, higher

Hard tissue examination:

• According to quadrants
• Teeth present
• Teeth missing
• DMF
• Palpate, percuss
• Check interproximal caries with floss
• Wear (attrition, abrasion, erosion)
• Discoloration
• Malformation
• Mobility – Millers classification 1950
  • 0 = No detectable mobility
  • 1 = Distinguishable mobility
  • 2 = Horizontal movement > 1mm
  • 3 = Horizontal and vertical movement > 1mm
• Orthodontic assessment
• Fluorosis – TF score for every tooth

Tooth fracture classification

Periodontal assessment

Gingiva:

• Color: Pink, physiologic pigmentation, red, cyanotic
• Size: Mild, moderate, severe inflammed
• Shape: Scalloped, rounded, col – if space between 2 teeth
• Consistency: Firm, flabby
• Texture: Stippling on attached gingiva

Oral hygiene:

• Calculus – presence of supra or subgingival calculus
• Plaque seen with naked eye

Gingival index by Loe and Silness 1963:

• Facial and lingual surface of index teeth: 16, 11, 24 and 36, 31, 44
• Rate:
  • 0 = Normal
  • 1 = minimal inflammation, erythema, no bleeding
  • 2 = Bleed on probing
  • 3 = Spontaneous bleeding
• Find mean score
• GI score:
  • 0-1 = Mild
  • 1-2 = Moderate
  • 2-3 = Severe

Periodontal index by Turesky et al modified Quigley Hein 1970:

Index teeth and disclosing tablet

• 0 = No plaque
• 1 = Flecks at cervical margin
• 2 = Thin continuous band at cervical margin
• 3 = Band wider than 1mm, < 1/3 of crown
• 4 = Plaque < 2/3 of crown
• 5 = Plaque > 2/3 of crown

Furcation involvement – Glickman classification 1953

• Grade 1 – Incipient, pocket formation into furcation fluting, interradicular bone intact
• Grade 2 – Moderate loss of interradicular bone but not through and through
• Grade 3 – Probe goes through and through, orifice occluded by gingival tissue
• Grade 4 – Exposed furcation

Periodontal charting:

• Draw continuous line of free gingival margin – facial and lingual
• Draw interrupted line indicating bone level on facial side
• Record 6 point pocket depth
• Record tooth mobility
• Record missing teeth (X), open contacts(//) and how many mm, overhang restorations (V)
• Calculate clinical attachment loss (CAL): Gingival recession + pocket depth
  • 1-2mm = Mild
  • 3-4mm = Moderate
  • > 5mm = Severe
  • Localized: < 30% of sites
  • Generalized: > 30% of sites

Orthodontic assessment

• A-P: Molar, canine, incisor relationship – Class I, II, III
• Vertical: Open bite, overbite – deep or open
• Transverse:
  • Crossbite anterior or posterior
  • Midlines
  • Crowding or spacing
  • Rotation or displacement
  • Proclination
• Upper and lower arch form – Normal, V shape, square shape

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Investigations

• Radiological – describing a x-ray:
  • Name and age of patient
  • Date when the x-ray was taken
  • Quality
  • Teeth present
  • Dental age and why
  • Radiolucent/radiopaque lesions
• Microbiological
• Histopathological
• Study model
• Diet chart
• Plaque score
• BMI

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Diagnosis

• Summarize findings: eg. A 5 year old African male with early childhood caries, dentoalveolar abscess secondary to extensive decay on 55, irreversible pulpitis 85 and 75, and occlusal caries on 54, 64, 84, 74

• For periodontal diagnosis: Severity – extent – diagnosis, eg:
  • Mild – localized – chronic periodontitis
  • Moderate – generalized – plaque induced gingivitis secondary to orthodontic treatment and mouth breathing

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Prognosis for periodontology

1. Excellent prognosis:

• No bone loss
• Excellent gingival condition
• Good patient co-operation
• No systemic/environmental factors

2. Good prognosis:

• Adequate remaining bone support
• Adequate control of etiologic factors and maintainable dentition
• Adequate patient co-operation
• No systemic/environmental factors or well controlled

3. Fair prognosis:

• Less than adequate bone support
• Some tooth mobility
• Grade 1 furcation
• Adequate maintenance possible
• Acceptable patient co-operation
• Presence of limited systemic/environmental factors

4. Poor prognosis:

• Moderate-advanced bone loss
• Tooth mobility
• Grade 1 or 2 furcation involvement
• Doubtful patient co-operation
• Presence of systemic/environmental factors

5. Questionable prognosis:

• Advanced bone loss
• Tooth mobility
• Grade 2 or 3 furcation involvement
• Inaccessible areas
• Systemic/environmental factors

6. Hopeless prognosis:

• Advanced bone loss
• Extraction indicated
• Non maintainable areas
• Uncontrolled systemic/environmental factors

NB: Factors affecting prognosis:

• Diagnosis: Disease severity, plaque and calculus
• Systemic factors: DM, puberty, genetic
• Occlusal factors
• Prosthetic and restorative factors: Caries, teeth vitality, abutment selection, subgingival restorations, fixed or removable prosthesis
• Patient factors: Compliance, co-operation, attitude
• Environmental factors: Smoking, alcohol. bruxism

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Treatment objectives

1. To control infection and relieve pain and discomfort
2. To modify attitude to dental care, and behavior to dental treatment
3. To improve oral hygiene
4. To restore integrity and function of the dentition
5. To achieve cariostasis
6. To improve esthetics and correct malocclusion
7. To maintain a healthy oral cavity
8. Diet planning

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Treatment planning

1. Oral hygiene instruction (OHI)
2. Emergency phase: Systemic diseases, infections
3. Etiological phase: Plaque and calculus
4. Restorative phase: Filling, RCT, Prosthetic replacement
5. Maintenance phase: Recall and review

Periodontal treatment planning

1. Preliminary phase: Systemic disease, infections, OHI
2. Etiological phase: FMS, root planing, fluoride treatment, cavity prep and filling
3. Surgical phase: Disimpaction, gingivectomy, implants, open flap debridement, GTR, furcationplasty
4. Restorative phase: Crown, bridge, crown for implant
5. Supportive periodontal therapy/maintenance phase: Review after 2 weeks
   • High risk – recall every 3 months
   • Moderate risk – recall every 6 months
   • Low risk – recall every year

Pediatric treatment planning

1. Systemic phase – Stabilize chronic illness before dental treatment
2. Emergency phase – Antimicrobials
3. Preventive phase – OHI, behavior management, fluoride application, diet counselling, pit and fissure sealants
4. Preparatory phase – Oral prophylaxis, caries control if multiple lesions, preventive orthodontic consultation
5. Corrective phase – Restorations, prosthetic replacement, extractions, Interceptive orthodontic consultation
6. Maintenance phase – Recall and review, 3-6 months

• Significance of oral prophylaxis:
  • Introduction to dental environment/behavior management
  • Oral hygiene education
  • Uncover carious lesion covered in plaque
  • Healthy gingiva