case history in maxillofacial surgery

2 May 2023 1

GOOD AFTERNOON

CASE HISTORY (133)

2 May 2023 CASE HISTORY 2

CASE HISTORY CHAITANYA DIVI I MDS ORAL & MAXILLOFACIAL SURGERYSIBAR INSTITUTE OF DENTAL SCIENCES

IT IS BETTER TO KNOW WHAT KIND OF PATIENT HAS THE DISEASE THAN WHAT KIND OF DISEASE THE PATIENT HAS

SIR WILLIAM OSLER


CONTENTS Definition Contents of case history Personal Information General Physical Examination Extra oral examination Intra oral examination Investigations Diagnosis List of references Conclusion


Definition: Case History is a planned professional

conversation between patient and doctor which enables the patient to express his symptoms, fear and feelings to the clinician so that the nature of patient’s real or suspected illness and mental attitude may be determined.

(Malcolm A. Lynch)


IMPORTANCE OF TAKING CASE HISTORY

To Establish Diagnosis Assessment Of Systemic Compliance Prevention of any Possible Medical EMERGENCIES

with known medical History Effective Treatment Planning


DIAGNOSIS


The purpose of making a diagnosis is to be able to offer the most effective and safe treatment■ Accurate prognostication.Diagnosis is made by the clinical examination, which comprises the:■ History (anamnesis) – this offers the diagnosis in about 80% of cases■ Physical examination■ Supplemented in some cases by investigations.

SENSES IN DIAGNOSIS


HISTORY&

SPEECH

APPEARANCE&

BEHAVIOUR

INDURATION&

TEMPERATURE

MALODOUR

LISTEN OBSERVE TOUCH SMELL

Communicating with the patient

The clinician should use ‘LEAPS’: ■ Listen ■ Empathize ■ Ask ■ Paraphrase ■ Summarize.


SEQUENCE OF CASE RECORDING PERSONAL INFORMATION

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

MEDICAL HISTORY

PAST DENTAL HISTORY

FAMILY HISTORY PERSONAL HISTORY

GENERAL EXAMINATION

EXTRA ORAL EXAMINATION

INTRA ORAL EXAMINATION PROVISIONAL DIAGNOSIS INVESTIGATIONS

FINAL DIAGNOSIS TREATMENT PLAN


8653

5336

23141234

PERSONAL INFORMATION Patient registration number useful for: Record maintenance Billing purposes Medico-legal aspects. Date for: - Reference Record maintenance.


IDENTIFYING DATA NAME Identification Communication Forming a rapport with patient Record maintenance Psychological benefit Information of patient such as religion


AGE Age related disorders Calculating a suitable dosage Treatment plan


Age related disorders

At birth – congenital cleft lip & palate

1st – 2nd decades – Primary herpetic gingivostomatitis

(6months to 6years), Nursing caries, cherubism,

fibro osseous lesions. Middle aged – Ameloblastoma, Oral cancer. Old age – Degenerative osteoarthritis of TMJ, cancer.


DOSE CALCULATION


Child’s age

• Young’s rule = Age+12 × ADULT DOSE

• Clark’s rule = Child’s weight in lbs ×ADULT DOSE

150

Age • Dilling’s rule = 20 ×ADULT DOSE

Sex

In female patients additional questions like pregnancy, nursing, oral contraceptive pills & menstruation.

Females – lichen planus ,tmj disorders , iron deficiency anemia , sjogrens syndrome.

Males – hemophilia, oral cancer, pernicious anemia


Address Correspondence Geographical prevalence of dental/oral diseases. Gives an idea of the socioeconomic status of the

patient.


Occupation

E.g.: Tailors, Beauticians – notching of incisal edges of upper teeth.

In acidic environment – erosion of teeth. Musicians - soft tissue trauma ,herpes ,dry mouth,

TMJ pain. Paint industry- mercury poisoning, lead poisoning. Mining- silicosis, asbestosis. Cotton mills – Bysinnosis Sugarcane industry – Bagassosis.


CHIEF COMPLAINT


The chief complaint is established by asking the patient to describe the problem for which he or she is seeking help or treatment.

Make every attempt to quote the patients own words

The chief complaint aids in the diagnosis and treatment planning and should be given the first priority.


HISTORY OF PRESENT ILLNESS It is the record of narrative account of patient’s

problem from the onset to present time listing all the symptoms, signs, treatment undergone in a chronological order.


If the patient has pain, a useful mnemonic is ‘SOCRATES’:

S – site (localized ,diffuse ,referred, radiating) O – onset (spontaneous, on stimulation, intermittent) C – character (dull, sharp, throbbing, constant) R – radiation, A – associations (other symptoms), T – timing/duration, E –exacerbating and alleviating factors (cold, heat,

palpation, percussion Relieved by ;cold, heat, any medication ,sleep)

S – severity (rate the pain on a visual analogue scale of 1–10).


Visual analogue scale


History for Patient with injury Time and place of alleged assault/injury. Was the assailant known to the patient? Was there any loss of consciousness? Was the patient under the influence of alcohol? Were there any other injuries to the body? Were there any witnesses? (In particular, if

consciousness is in doubt.) What happened immediately after the assault? Are the

police involved or likely to become involved? Note any ‘old’ injuries, for example a tooth previously

fractured or previous facial injuries.


GLASGOW COMA SCALE


PAST MEDICAL HISTORY

Primary function of PMH is to avoid complications during dental treatment.

PMH is usually organized in following sub-divisions:-

Childhood illness Medical Surgery Obsteric Psychologic



• Do you ever have chest pain or tightness?

• Palpitations?• Did you suffer from fleeting joint

pains, sore throat or fever?• Do you have any breathlessness

on exertion?

Cardiovascular system


Prophylaxis regimen for Infective Endocarditis

Recommendations from the British Society for Antimicrobial Chemotherapy (1992) and British National Formulary 2007.


Provisional Recommendations from the National Institute for Clinical Excellence (NICE, 2007)Antibiotic prophylaxis against infective endocarditis (IE) is not recommended for patients at risk of endocarditis undergoing:• dental procedures.• ear, nose and throat procedures• upper respiratory tract procedures

Respiratory system:

Are you ever short of breath? Have you had a cough? Have you ever coughed up blood? Wheezing?


Gastrointestinal and Hepatic System Do you have heart burn/acidity/foul taste? - Peptic ulcer

- Hiatal hernia Do you have bouts of nausea, lack of appetite? Did you suffer from jaundice/hepatitis? Have you noticed any change in your bowel habit

recently? Have you ever seen any blood or slime in your stools?



Central Nervous System

Pts. with a history of-

Epileptic attacks

Paresthesia

Paralysis

Syncope.


Genitourinary System: Do you have to get up at night to pass urine? If so,

how often? Have your periods been quite regular? Any H/O Prostatic disease, Genitourinary infection, Renal disease or failure, Renal transplant, etc.

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KIDNEY DISEASE:

Bleeding tendency Impaired drug excretion Immunosuppression following kidney transplant Liability to neoplasia Cyclosporin causing gingival enlargement

2 May 2023 CASE HISTORY


Do you have any pain, stiffness or swelling in your joints?

Muscular dystrophy. Joint replacements. Locomotor difficulties

Musculoskeletal


Do you tend to feel the heat or cold more than you used to?

Have you been feeling thirstier or drinking more than usual?

Endocrine system


Hyperparathyroidism may cause:– jaw radiolucency/rarefaction– loss of lamina Dura– giant cell granulomas (central)– hypercalcaemia and hyposalivation.

Blood Dyscrasias

Manifestations of most blood Dyscrasias may be seen in oral cavity. Any history of prolonged bleeding and easy bruising

( hemophilia/ purpura) Blood borne viruses, eg. Hepatitis B/C, HIV, Clotting disorders Leukemia Porphyria Sickle cell anemia


MALIGNANT DISEASE:Patients on radiotherapy and chemotherapyPain in associated oral complicationsSensory changes??Significant morbidity and mortality in some cases


PROSTHESIS AND TRANSPLANT PATIENTS:At a risk of infection, iatrogenic problems like bleeding, graft-versus-host diseaseTransplant patients are liable to complications to dental treatment- need for steroid cover-liability to infectionsPatients with pacemakers can interfere with diathermy, electrosurgery, etc


Allergy:

Have you ever experienced an unusual reaction to any drugs/food/materials?

Any unusual reaction to dental anesthetics?


Anaphylaxis


Unexpected and sudden onset• Clinical signs• Rapid breathing• Evidence of poor circulation• Stridor, hoarseness or wheeze• Tongue swelling• Pale, clammy, rash, flushed

DRUG USE, ALLERGIES AND ABUSE: Drug use may cause orofacial lesions – hemorrhagic

diathesis caused by decreased prothrombin level (mineral oil used as a laxative interferes with vit-k absorption)

Drug allergies?? (urticaria, skin rash, angioedema, respiratory symptoms)

Drug abuse (behavioral problems, cross infection)


Corticosteroids- adrenocortical depression - patients don’t respond to stress, trauma, operation or infection - stress causes adrenal crisis and collapse


PAST DENTAL HISTORY

Provides us the basis to evaluate the patient’s current dental status and how the patient will respond to the proposed treatment.

Following are the details that should be investigated: - Frequency of visits to dentist. - Past experience during and after local anesthesia ,

general anesthesia. - Past experience during and after extraction. - Past orthodontic treatment. - Any surgical procedures besides exodontia.


Family History:


This may reveal familial outbreaks of contagious infections (e.g. herpangina; tuberculosis; hepatitis A)

Hereditary problems, such as amelogenesis imperfecta, hemophilia or hereditary angioedema, Thalassemia

Familial conditions, such as recurrent apthous stomatitis or diabetes

Information about siblings’ ages and health status. Some diseases are more prevalent in certain ethnic

groups, e.g. pemphigus in Jews and Asians; Behçet syndrome in people from Asia or the

Mediterranean area


It includes: 1) Oral habits 2) Oral hygiene practices 3) Adverse habits


PERSONAL HISTORY


DIET: Excessive use of refined sugar and sticky food.Nutritional deficiency.

Adverse habits Smoking Alcoholism Tobacco chewing


GENERAL EXAMINATION

BUILD NOURISHMENT SKIN HAIR NAILS


BUILD:

Asthenic - lean and underweight

Sthenic - athletic

Pyknic – have enormous amount of body fat compared to bone and muscle mass, appear rounded

Cachexia – abnormally low tissue mass resulting from malnutrition or chronic debilitation


HEIGHT & WEIGHT

Indicate development of growth

Quetlet body mass index is used = weight in Kg

( height in meters)2


MALNUTRITION Risk for malnutrition if they meet one or more of the

following criteria: • Unintentional loss of >10% of usual body weight in the

preceding 3 months • Body weight <90% of ideal for height • body mass index (BMI: weight/height in kg/m2) <18.5


SKIN


Pallor Yellowness Cyanosis Blisters (infections, drug eruptions, skin diseases) Pigmentation ( addison’s disease) Oedema

NAILS

√


HAIR:


Alopecia- partial alpoecia seen in xeroderma pigmentosum and hereditary ectodermal dysplasia

Total alopecia- x-ray irradiation, chemotherapy, herpes zoster infection

SCLERA:


Yellow coloured - jaundice Blue coloured –osteogenesis imperfecta Osteoporosis Fetal rickets Marfan’s syndrome Ehlers- Danlos syndrome

ODOUR Halitosis (bad breath) is common in patients whose

dental hygiene has been poor Diabetic ketosis has been described as 'sweet and

sickly Uremia as 'ammonic or fishy’ Hepatic failure as 'mousy',


GENERAL EXAMINATION

GAIT (Manner of walking ) These abnormalities relate to neuromuscular

disabilities, fractures Hemiplegic gait – Hemiplegia Ataxic gait- Cerebellar lesions, alcohol

intoxication Propulsive gait- Parkinson’s disease, CO

poisoning, Manganese poisoning Scissors gait/Spastic gait – Cerebral palsy,

multiple sclerosis, Waddling gait – Muscular dystrophy


VITAL SIGNS

PULSE


Pulse rates at rest in health are approximately as follows:■ infants, 140 beats/min■ adults, 60–80 beats/min.

Rate :Pulse rate is increased in: ■ exercise ■ anxiety or fear ■ fever ■ some cardiac disorders ■ hyperthyroidism and other disorders. Rhythm : Regular or irregular Volume: High, low & normal indicate pulse pressure. Normal pulse pressure is 40-60 mmHg. Tension & force: Indicate diastolic & systolic pressures. Character :Water hammer pulse-aortic regurgitation


THE TEMPERATURE

The temperature is traditionally taken with a thermometer, but temperature-sensitive strips and sensors are available.

The normal body temperatures are: Oral 36.6°c; Rectal or ear(tympanic membrane) 37.4°c; And axillary 36.5°c. In most adults, an oral temperature above 37.8°C or a

rectal or ear temperature above 38.3°C is considered a fever (pyrexia).

A child has a fever when ear temperature is 38°c or higher


Blood Pressure Normal 120/80 mm of Hg. Systolic controlled by stroke volume of the heart & stiffness

of the arterial vessels. Diastolic controlled by peripheral resistance Varies with emotion, exercise, meal, alcohol, tobacco,

bladder distension, temperature, anxiety & pain.


HYPERTENSION Etiological factors include: • Genetic predisposition • High alcohol intake • High salt intake • Smoking • High body mass index (BMI) • Impaired tissue response to insulin (insulin resistance) • Sympathetic overactivity: approximately 40% of

hypertensive patients have raised levels of circulating catecholamines


Guidelines for BP in Adults



FACE – Gross asymmetries of face includes diffuse swellings ,traumatic injuries ,congenital deformities

Shape of the head : a. Mesocephalic : average shape of head. b. Dolicocephalic : long and narrow head. c. Brachycephalic : broad and short head.


TMJ TMJ: observed for: - Symmetry: gross derangement in symmetry may reflect

growth disturbances. -Maximum interincisal opening any deviation in opening -Range of vertical movement -Range of lateral movement -Listen for clicking and crepitus sounds , tenderness

over joint or masticatory muscles


PALPATION OF TMJ Palpation of pre tragus area Intra auricular palpation Auscultation—it is used to study the movement of

TMJ and also used for examination of venous malformation


-know the position -number of nodes -tenderness -fixity to underlying tissues

LYMPH NODES:


Consistency of lymph nodes: Soft in consistency Inflammatory Firm, discrete shotty Syphilis Elastic and rubbery Hodgkin’s disease Matted lymph nodes Periadenitis,

Tuberculosis, Acute lymphadenitis.

Stony hard Carcinoma


SALIVARY GLAND EXAMINATION Evaluated for Dryness Enlargement Quantity of secretions


EXAMINATION OF ULCER HISTORY

1) Mode of onset: trauma , spontaneously.2) Duration 3) Pain4) Discharge LOCAL EXAMINATION INSPECTION

1) Size & shape2) Number 3) Position


4)Edge Sloping—healing non-specific ulcer, venous ulcer. Undermined—tubercular ulcer. Raised and everted—squamous cell carcinoma. Rolled out—rodent ulcer. Punched out—syphilis 5) Floor 6)Discharge


UNDERMINED EDGE


EVERTED EDGE


ROLLED OUT


PUNCHED OUT EDGE


Palpation Tenderness Edge & margin Depth Bleeding


EXAMINATION OF SWELLING

HISTORY1)Duration2)Mode of onset3)Pain 4)Progress of swelling5)Presence of other lumps6)Impairment of function


INSPECTIONa)Situationb)Colourc)Shaped)Sizee)Edgef)Numberg)Movement on deglutition & protrusion of tongue


PALPATION1)Temperature2)Tenderness3)Size ,surface4)Edge5)Consistency6)Fluctuation7)Compressibility


Swelling in the lips


Hemangioma

Orofacial granulomatosis


Swellings in gingiva

Fibrous epulis

Cyclosporin-induced gingival swelling


Swellings in the palate

Torus palatinus

Dental abscess arising from the non-vital third molar


Swellings in the tongue

Tongue cancer, presenting as a persistent lump that has ulcerated

Fibrous lump

Swellings in the salivary glands


Mucocele Parotid salivary gland enlargement

EXAMINATION OF INJURIES OF BONES & JOINTS


Inspection of the face for asymmetry. Inspect open wounds for foreign bodies. Palpate the entire face.

Supraorbital and Infraorbital rim Zygomatic-frontal suture Zygomatic arches

Inspection of scalp for lacerations and contusions Bleeding points should be arrested


Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone.

Check facial stability.


Inspect the teeth for malocclusions, bleeding and step-off. Manipulation of each tooth. Check for lacerations.

Palpate the mandible for tenderness, swelling and step-off.


EARS : External auditory meatus should be inspected for blood

and cerebrospinal fluid. Fractures of middle cranial fossa observe for battles

sign and fractured drum appears blue , bulging , exhibiting transmitted pulsation via CSF.


EYES Inspection of eyes for edema of eyelids ,

circumorbital ecchymosis , sub conjunctival hemmorhage.

Assessment of visual acuity in both eyes, Ocular movements , ocular levels should be checked, diplopia carefully recorded.


NOSE Evidence of bleeding from nose. presence or absence of CSF rhinorrhea. Thumb and middle finger of one hand

stabilize the head by gripping temporal region above supraorbital ridge while gently palpating nasal bridge with thumb and index finger of other hand


MIDDLE THIRD OF FACE

Inspection of face in bilateral fracture of maxilla shows bilateral circumorbital ecchymosis, bilateral oedema , lengthening of middle third of face

Infraorbital nerve anaesthesia / paraesthesia.


PALPATION OF ORBITAL REGION Index fingers are placed on either side of nasal bridge

and moved along superior orbital margin Then fingers are passed downwards at frontozygomatic

suture Index and middle fingers are used bilaterally to palpate

zygomatic bone and arch.


MANDIBLE Palpation from behind patient

fingers of both hands palpate both sides of lower border while thumb placed on lateral aspect

TMJ palpation stand infront of patient, presence or absence of movement of condylar head is detected by placing little finger in external auditory meatus and making mandibular movements in all directions


INTRAORAL EXAMINATIONInspection Maxilla fractures inspection for ecchymosis in buccal sulci

near zygomatic prominences or in region of greater palatine foramen Guerin’s sign

Sublingual hematoma is pathognomic of fracture involving lingual plate of mandible

Occlusal plane should be inspected for step defects , gagging of occlusion.


INTRA ORAL EXAMINATION Lip

Tongue

Buccal / Labial mucosa

Gingiva

Palate

Floor of the mouth2 May 2023 CASE HISTORY 105

FRACTURED TEETH – Trauma

ELLIS CLASSIFICATION Class 1 - Enamel with little or no dentin Class 2 - Enamel & dentin without pulp Class 3 - Enamel, dentin & pulp Class 4 - Fracture of non vital tooth with or with

out crown fracture Class 5 - Tooth loss due to trauma Class 6 - Fracture of root with or with out fracture

of crown en-mass Class 7 - Displacement of tooth with or without

fracture of crown Class 8 - Fracture of crown & mass Class 9 - Traumatic injury to deciduous tooth


Diagnosis

Clinical diagnosis. Pathological diagnosis Direct diagnosis Provisional (working) diagnosis Deductive diagnosis Differential diagnosis Diagnosis by exclusion Diagnosis ex-juvantibus Provocative diagnosis


INVESTIGATIONS Hematological investigations Urine analysis Biochemical investigations Radiological investigations Histopathological investigations Microbiological investigations Sialography, Cephalometry, OPG, MRI, CT scan etc


Routinely used Hematological investigations include

Total red blood count Hb concentration Red cell indices Total white cell count Differential white cell count ESR Bleeding and coagulations disorder Partial thromboplastin time.


URINALYSIS

This is routinely performed with ‘dip-sticks’. It may reveal:

Glycosuria Ketonuria Bilirubin or urobilinogen Proteinuria Haematuria


SKIN TESTING

Patch tests Intradermal injections Prick test Modified prick test Scratch test


RADIOGRAPHIC ANALYSIS



Extra oral Radiographs

OPG



SUBMENTO VERTEX


POSTERIOANTERIOR


OCCIPITOMENTAL VIEW

STANDARD 00

300


Reverse Towne's


True lateral skull

HISTOPATHOLOGICAL EXAMINATION

BIOPSY Incisional Excisional Punch


ULTRASOUND

Ultrasound contains waves with a frequency of more than 20,000 cycles/second which the human ears cannot hear.

In medical sonography, frequencies used are commonly 2-10 MHz


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CT SCAN

Good definition of soft tissue structures in any plane Useful for areas of complex anatomy such as maxilla or base of skull

Definition further improved by use of contrast media Density of tissues is numbered as Hounsfield Number

(HN) • Water—Zero HN • Air—Minus 1,000 • Bone—Plus 1,000


DOPPLER

Doppler effect is a change in the perceived frequency of sound emitted by a moving source. So it measures blood flow.

Spectral Doppler wave form and ultrasound image are combined in Duplex scanning.

Uses To study cardiovascular system. To study vascularity of tumours. To study blood flow and velocity in arterial diseases


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MAGNETIC RESONANCE IMAGING (MRI)


• Produces clear tomograms in any plane without superimposition

• Particularly good for soft tissue lesions. • Better than CT• No X-ray dose• Clear definition of bones and teeth

POSITRON–EMISSION TOMOGRAPHY(PET scan)

It is a non-invasive diagnostic method to assess the biochemical and physiological status of a tissue.

It is used in complimentary with CT scan and MRI.

Short-life radioactive isotope used to identify biochemical activity, usually glycolysis, to identify putative tumor size, location or metastasis

Good for identifying unsuspected metastases Helps identify neoplasms when post-surgical

artifact or inflammation obscure CT or MRI Also available as a combined PET-CT scan


Endoscopy


Endoscopy is typically performed with flexible fibre-optic endoscopes, under local analgesia, sometimes with conscious sedation or general anaesthesia. Relevant endoscopic proceduresinclude:■ Nasendoscopy■ Oesophagoscopy■ Bronchoscopy■ Panendoscopy usually refers to triple endoscopy (nasendoscopy, oesophagoscopy and bronchoscopy)■ Gastroscopy (the oesophagus, stomach and duodenum)■ Sialoendoscopy■ Colonoscopy

FINAL DIAGNOSIS:

This indicates that a definitive diagnosis has been made on the basis of all necessary observations and laboratory investigations


TREATMENT PLAN PHASE 1- EMERGENCY PHASE: Management of pain & acute infections by antibiotics &

analgesics .Incision & drainage, reduction of fractures PHASE 2 –SURGICAL : Extraction, Biopsy,

Enucleation, Resection. PHASE 3 – PROPHYLACTIC : Scaling& root planning,

& bone graft , bone curettage. PHASE 4 – RESTORATIVE : Restoration PHASE 5 – CORRECTIVE : Prosthesis & ortho

correction Phase 6 – RECALL & REVIEW


PROGNOSIS The prognosis is the prediction of the probable course,

duration, and outcome of a disease based on a general knowledge of the pathogenesis of the disease and the presence of risk factors for the disease. The prognosis is evaluated and informed to the patient.


CONCLUSION

Comprehensive & valuable write–up of case history elicits good basic Knowledge of oral diseases so that the interviewer is able to trace out leads given by patient during interview. Thereby case history forms the basis of diagnosis & all the treatment of any condition. There is no substitute for a good case history , aiding at correct diagnosis & appropriate treatment modalities. Thus careful attention paid to a tactful case history recording with no undue time spent will contribute to a skillful management of any oral condition.


Reference Hutchison's Clinical Methods - An Integrated Approach to Clinical

Practice, 22nd Edition Kumar & Clark’s Clinical Medicine 8th edition. 2013 CURRENT Medical Diagnosis & Treatment. 52nd edition oral radiology- principles and interpretation-white-pharoah 6th edition Oral and Maxillofacial Medicine The Basis of Diagnosis and

Treatment, 3e Crispian Scully Bates' Guide to Physical Examination and History-Taking (11th Ed.) Burket’s oral medicine 11th ed Davidson's Principles and Practice of Medicine (21st Ed.) Macleods.Clinical.Examination.12th.Edition Differential diagnosis of oral & maxillofacial lesions wood & goaz 5ed Cawson’s essentials of oral pathology and oral medicine 8th ed. Common medical conditions – A guide for dental treatment.



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case history in maxillofacial surgery

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