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Case History Dept of orthodontics Sharad Pawar Dental College Sawangi (Meghe) Wardha

It involves eliciting and recording relevant information from patient and parents to aid in overall diagnosis of the case.

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NAME: - It is very important to know the name of the patients, as he likes to be called by his name & gives psychological benefit to the patient.

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AGE: - Patients chronological age record help in diagnosis and treatment planning certain transient condition occurs during certain age.

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SEX: - Its important in t/t planning as the timing of growth event like growth spurts are different in male and female. www.indiandentalacademy.com


DATE OF BIRTH: - To know the chronological age of the patient which correlates with the bone age, growth spurt. ADDRESS & OCCUPATION: - Help in evaluations of socioeconomic status of the patients and parents and helps in future correspondence to intimate appointments. RELIGION & ETHNIC GROUP: Generally gives us idea of the particular community and the type of face form and occlusion commonly they share. www.indiandentalacademy.com


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FATHER & GUARDIAN NAME: The patient must be accompanied with the parent/ guardian to provide us with all information about history.

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CHIEF COMPLAINT: - It must be directly asked to the patient in a series of leading questions beginning with simple question regarding the need they feel for the treatment and to know the objective of the patient to take treatment. www.indiandentalacademy.com


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PRE NATAL HISTORY: Condition of the mother during pregnancy for e.g. whether the mother was on some medications like thalidomide tetracycline, have an habit of alcohol consumption Regarding the type of delivery e.g. forceps delivery lead to TMJ injuries with marked mandibular growth retardation. The mother must be asked for consumption of few ototoxic drugs like aspirin, streptomycin. After the birth of child information regarding late pregnancy, prematurity, birth injury, anoxia, erythroblastosisfetalis must be asked. www.indiandentalacademy.com


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POST NATAL HISTORY: - Information must be gathered regarding sequence of eruption and relative position of teeth. Gather the information about feeding habit type, duration and frequency Breast feed or/and bottle feed. Milestones of development generally includes walking, crawling, speech and ideal about the first tooth appeared in the oral cavity. It gives us the idea of the normal growth and development of the child. www.indiandentalacademy.com


CHILDHOOD DISEASES: Cleft lip and palate.  Downs Syndrome.  Cerebral palsy.  Asthma.  Cystofibrosis.  Learning disability – mentally retarded.  Fragile X syndrome – (X linked mental disability) have long face, prominent jaw, high arch palate, flat nasal bridge. www.indiandentalacademy.com


Fetal alcohol syndrome associated with malocclusion. Autism associated with disturbed mental and emotional development. Torticollis associated with abnormal muscle forces Cleidocranialdysostosis show maxillary retrusion with mandible prognathic, retarted eruption of permanent teeth with supernumerary tooth in common. Congenital syphilis. www.indiandentalacademy.com


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HABITS: - Includes like tongue interposition, atypical swallowing, suctioning of lips, cheek, thumb, mouth breathing led to orthopedic and orthodontic problems.

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INJURIES: Frequent fall, trauma, accidents leading to nonvitality of tooth, birth injuries like forceps injury, fracture of jaw must be ruled out to know the cause of malocclusion and skeletal deformity pertaining the treatment. GENERAL HISTORY: It mainly includes the reason of taking the orthodontic treatment. Whether it is for esthetic, function, speech or hygiene maintenance. www.indiandentalacademy.com


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FAMILIAL MALOCCLUSION HISTORY: Many malocclusion like skeletal class II, III malocclusion and congenital conditions like cleft lip palate are inherited. Thus it is necessary to know the presence of such condition in parents, brothers or sisters to rule out whether the deformity is development, congenital or acquired.

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PAST DENTAL HISTORY: Ask if the parents had orthodontic treatment this will give us information that of possible hereditary component of problem.

Injury related to facial symmetry.

Did the child have severe toothache / headache before what was the treatment gives.

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Did he undergone only accidents / falls/ blow and any dental treatment. How many times the child brush his tooth. Does he experienced pain and clicking in jaw movements difficulty in opening and closing of the mouth, experience of lock jaw or any previous history of TMJ problem. Does the child have certain habits like lip suking, thumb sucking, mouth breathing etc www.indiandentalacademy.com


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PAST MEDICAL HISTORY: Ask for The socioeconomic state.

Any health problem gives history of trauma

Is the child immunized indicates the need of DPT vaccine.

Ask for birth problems, heart disease, rheumatic fever, anemia. www.indiandentalacademy.com


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Hemophilia, blood transfusion, hepatitis, AIDS, TB liver disease, kidney disease, and diabetes

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Arthritis relates the mandibular growth & development.

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Cancer cerebral palsy, seizers gives idea about uncoordinated muscle activity also determine treatment using radiation and chemotherapy that can alter dental development jaw growth/ somatic growth. www.indiandentalacademy.com


Cleft lip and palate, speech, hearing problem, asthma, and vision, skin problems.

Tonsils, adenoids, sinus problems, evaluates respiratory problems and tooth sensitivity.

Sleep problem, emotional / behavioral problem gives psychological development of the child.

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Any radiation therapy it can greatly alter jaw and selected development, risk of osteo radionecrosis.

Growth problem child can be treated with growth hormones, which can be implicated for growth modification treatment.

Any allergy to drugs / skin reactions

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SOCIAL AND BEHAVIORAL EVALUATION: It explores patient motivation for treatment, expectation as a result of treatment & cooperation of patient. Whether the motivation is by parent / friends or by self.

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PUBERTAL STATUS: Evaluation of pubertal status is needed for the treatment modality. Child in pubertal age can be treated with modification of the growth of jaws with myofunctional but after the puberty treatment modalities changes towards surgery.

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ď‚Ą Pubertal

and adolescent growth spurt occur 2 yrs earlier in girls than boys. So treatment must be done earlier in girls utilizing the adolescent growth spurt. www.indiandentalacademy.com


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