Oral and Dental Medicine: Lecture Notes on Patient History (PDF)

Oral and Dental Medicine Oral Diagnosis I Lecture : (Patient history) (Personal data and chief Complain) Dr : Fatma El-Sayed Assistant professor of Oral medicine, periodontology and oral diagnosis ...

Oral and Dental Medicine Oral Diagnosis I Lecture : (Patient history) (Personal data and chief Complain) Dr : Fatma El-Sayed Assistant professor of Oral medicine, periodontology and oral diagnosis  Collecting Diagnostic Information Patient's History: It is the description of past events and related information that contributes to the assessment of the patient's health. It is the back-bone of diagnosis. Diagnostic process: Patient History I. Personal History II.Chief Complain III.History of Chief Complain IV.Medical History V.Dental History VI.Personal and Social Habits VII.Family History A- Patient History 1 Personal History 7 2 Social H. & Chief personal complaint habits Name Age Sex Address Phone 6 Number 3 Family Race H. of chief History complaint Marital Status Occupation Birth place 5 Medical 4 History & Dental Review of History systems Diagnostic process: I. Personal History 1.Name 2.gender 3.Age 4.Race 5.Marital Status: 6.Occupation: 7.Birthplace: 8. Address: 9.Phone Number: 1-Name: Important in: a) Better Communication b) Documentation 2-Age: ✓✓Related diseases, ✓✓ Dose of the drugs  Is important as certain diseases occur generally in certain age group: Infants: Candidiasis. Eruption cyst. 2-Age: Hemangioma (85%by I year of age) Children: Herpetic gingivostomatitis mumps measles, Diphtheria  Persons Under Age 40: ANUG (age 15-35; rare below age 12). Erythema multiforme. Herpes simplex. Hodgkin's disease 9ages 20-40). 2-Age: Infections mononucleosis. Persons over Age 40: Denture stomatitis. Lymphoma. Melanoma. Metastasis carcinoma. Squamous cell carcinoma.  ❑ Names that could be taken for both sexes. e.g. Amal, Esmat. GENDER PREDILECTION SOFT TISSUE LESIONS: i. Squamous cell carcinoma (3: 1 to 2: 1). Male: 3-Sex: i. Erythema multiforme. ii.Leukoplakia. i. Benign mucous membrane pemphigoid (2: 1 ). ii.Geographic tongue (2: 1). Female iii.Lichen planus (2:1 ). iv.Pyogenic granuloma (3:1 ). v.Recurrent aphthous ulcers.  Skin carcinoma in Blond race. Burkit lymphoma in Africa. 4-Race: Lichen planus in blacks. Sickle cell anemia in Mediterranean countries, Jewish are more prone diabetes mellitus and pemphigus.  Which helps in throwing light on 5-Address: the patient's home back ground. 6-Telephone Important for recalling the patient in cases of taking oral biopsy. number: In case of suspected malignancy, the rapid recalling of the patient is important.  Important to detect diseases acquired in children (endemic ds) Dental fluorosis (Libia, Saudi Arabia) Bilharziasis, liver diseases (Egyptian 7-Birth place: Villages) AIDS (Western Africa and Far East) Regional food habits may be the cause of deficiency diseases e.g. Rickets.  Psychological stresses may predispose to certain oral disease. e.g. - Oral lichen planus.- Aphthous ulcerations. 8- Marital status: Source of infection in certain diseases. e.g – T.B. Sexually transmitted diseases. Viral infections  pathologic alteration in patients working with substances such as mercury, arsenic (metallic intoxication). shoe-maker job and sailor job will form notch in the incisal edges of the anterior teeth. Massive destruction of the jawbones in watch 9-Occupation: dial painters who developed radiation necrosis from licking their brushes. sedentary life-style may suffer ischemic heart diseases due to lack of exercise. Patients holding a positions of responsibility, subjected to psychological stresses & psychosomatic diseases. e.g.: hypertension  Diagnostic process: Patient History i. Personal History ii.Chief Complain iii.History of Chief Complain iv.Medical History v.Dental History vi.Personal and Social Habits vii.Family History  II. Chief Complain "Can you tell me why you came to the clinic?" or "Please tell me about your Diagnostic problem." process: written in the patient’s own word with no medical terminology about his problem not his request or treatment expectations  is a symptom or symptoms described by the II. Chief patient in his own words relating to the Complain: presence of an abnormal condition which promoted him to seek treatment.  1. Age. 2. Mental attitude of the patient. 3. Ability of the patient to Factors which may communicate his abnormal govern shaping of the experience to the examiner. complaint by the 4. Degree and type of patient: education. 5. Memory of the patient. 6. The prestige of the dentist.  Chief complaint should be recorded in the patient's own words (nontechnical language) General Do not interrupt the patient. principles to Avoid patient own diagnosis. be followed Allow the patient to express his emotional feelings. during taking Suggest some description without influencing the patient e.g. if patient feel pain (Is it throbbing, sharp, burning, lancinating). the history of The facts should be recorded chronologically. Chief The examiner should summarize off the essential fact. complaint: Analyze the chief or primary complaints in the present illness separately in the order of their development e.g. painful tooth followed by swelling  The patient should be encouraged to describe the main characteristics of the pain; its nature (sharp or 1- Pain: dull), severity, duration, and location; and the precipitating / relieving factors.  Acute pulpitis: Sever sharp, increases at night, relieved temporary by analgesic, increases by Most common cold, chewing causes of pain Chronic pulpitis: Dull, increases only with cold in dental office drink, lasts few seconds are: Periapical infection: Sever, throbbing, spontaneous, continuous, tenderness to pressure & percussion of the tooth  Exposed dentin: Thermal sensitivity, sensitivity to toothbrush and explorer tip. Most common Carious lesions/ Deep decay/ Microleakage of causes of pain restoration: Dull discomfort following exposure in dental office are: to high concentration of sugar, sensitivity to external stimulus.  Neuralgia: Lancinating electrical pain. Reversible pulpitis/ Recent filling/ Traumatic Most common occlusion: Soreness & hypersensitivity to thermal causes of pain stimulation after dental treatment. in dental Tooth fracture: Sharp, stabbing during chewing or office are: biting, sensitivity to percussion, Occlusal trauma: Tooth mobility, periodontal discomfort, pulpitis pain, widening of periodontal ligament space and loss of lamina dura and sensation of fremitus.  Tooth eruption (Teething pain): Soreness of edentulous space, excessive salivation, irritability, tenderness at eruption site, alteration of sleep & Most common mild fever. causes of pain in dental office Orthodontalgia: Tenderness & sensitivity of teeth are: (Orthodontic Treated),tenderness to percussion. Acute maxillary sinusitis: Tenderness to percussion of maxillary posterior teeth.  Sores: mucosal inflammation or ulcers 2- Burning sensation is usually felt in the tongue Sores and and often caused by a thinning or erosion of the surface epithelium. May be caused by: Burning: Burning mouth syndrome. Psychosis. Viral / Fungal infections. Geographic tongue, Fissured tongue Anemia, vit deficiency. Xerostomia.  Intraoral bleeding may be caused by these disturbances: 1. Gingivitis and periodontal disease. 3- Bleeding: 2. Traumatic incidents, including surgery 3. Inflammatory hyperplasia. 4. Deficiencies in hemostasis.  Loss of supporting bone or resorption of roots may result in loose teeth and may indicate the presence of any of the following: 1. Periodontal disease. 4- Loose 2. Trauma. teeth: 3. Normal resorption of deciduous teeth. 4. Pulpo-periapical lesions. 5. Malignant tumors. 6. Benign tumors that may induce root resorption (chondromas, myxomas, hemangiomas). 7. Hypophosphatasia. 8. Histocytosis x. 9. AIDS.  A- Over-contoured restorations. B-Periodontal disease. 5-Recent C-Traumatic injury (fracture of bone or occlusal tooth root). problem: D-Pericemenitis or periapical abscess. E-Cysts or tumors  Delayed eruption of a tooth may be related to any of the following: 1.Malposed or impacted teeth. 6- Delayed 2.Cysts or tumors. tooth 3.Odontomas, supernumerary teeth. eruption: If there is a generalized delay, the clinician should consider the possibilities of adontia, cleidocranial dysostosis, or hypothyroidism  Etiology: a) Physiologic as sleeping or speaking for longtime b) Pathologic: Local: ❑Oral cavity: smoking, mouth breathing 7- Dry-mouth ❑Salivary glands: developmental, (xerostomia): obstructive, infection, degenerative, chemotherapy, radiation, Autoimmune disease. Systemic: ❑Drugs: tranquilizers, antihistamines, antihypertensives, diuretics. ❑Endocrine: diabetes mellitus, diabetes insipidus, hyperthyroidism.  Etiology: 8-Too much ❑Insertion of a new denture Saliva ❑Increase or decrease of V. D. (Sialorrhea): ❑Young patient with large tongue ❑Mental retardation ❑Infections as ANUG, AHGS ❑Drugs: expectorants, pilocarpine. ❑Psychosomatic.  Inflammations and Infections Cysts 9-Swellings: Retention Phenomena Inflammatory Hyperplasia Benign and/or Malignant tumors.  Aging changes Heavy smoking Poor Oral hygiene 10- Bad Dental caries Taste: Periodontal necrotizing ulcerative gingivitis (ANUG) Diabetes and Uremia Medications  11-Halitosis: A. Extraoral causes: d) Uremia. a) Infections e) Diabetic crisis. i. laryngcaTonsillitis. f) Liver diseases. ii. Pharyngitis. g) Odoriferous substance in iii. Nasal infection. the blood stream iv. Sinusitis and sinus eliminated in the expired infection. air as spicy food, garlic and b) tumors. onions. c) Gastric problems.  11-Halitosis: A. Intraoral causes: a) Poor oral hygiene. b) Periodontal disease. c) Growth dental caries. d) Poor denture hygiene. e) Pericoronitis. f) Post-oral surgery. 12-Esthetic problem: Gummy Recession. Crowding. smile. Teeth Prognathism colour.  Injury to regional nerves or jaw Malignancies. fracture or surgical procedure. 13-Paresthesia and Medications e.g. Sedatives. Diabetes. anesthesia: Pernicious anemia. Psychosis.  Diagnostic process: Patient History i. Personal History ii.Chief Complain iii.History of Chief Complain iv.Medical History v.Dental History vi.Personal and Social Habits vii.Family History III. The History of Chief complaint: 1. Onset: 2. Course: 3. Character: 4. Nature: 5. Associated phenomena: 6. Precipitating factors: 7. Relieving factors: History of pain should include: Onset: sudden or gradual. Course: progressive or regressive & continuous or intermittent. Duration: e.g week, month. Character: e.g radiating/ localized. Nature: burning, dull, stabbing, lancinating, sharp shooting, throbbing, Associated phenomena: e.g. Pain + swelling (Dentoalveolar abscess) Pain + bleeding+fetid odor (ANUG) Precipitating factors: substances which increase the feeling of pain. e.g cold or hot Relieving factors: e.g drugs (antibiotic or analgesics) or hot fomentation. III. The History of Chief complaint: History of ulcers: History of missing teeth: onset, duration, when and why were history of recurrence, they extracted? history of remission and exacerbation, precipitating and relieving factor.  ✓Onset: sudden or gradual. (Acute / Chronic). ✓Course: progressive (acute) or regressive or stationary (chronic). ✓ Duration: e.g week, month (long time: chronic). History of ✓Associated phenomena: e.g. Lymphadenitis, Pain, loss of function. Swellings ▪ Mandible expansion + numbness of the lip (osteoporosis & pagets disease). should ▪ Swelling + discharge + bad taste or salty taste include: (Draining abscess or cyst). ✓Precipitating factors: substances which increase the feeling of pain. ✓e.g cold or hot ✓Relieving factors: e.g drugs (antibiotic or analgesics) or hot fomentation