Significance of case record
1. Name
a. Identification of the patient
b. To establish rapport
c. For further communication
d. For medico legal cases
2. Age
a. Identification of the patient
b. Certain diseases are specific to occur in certain age groups
● At birth ( congenital )
1. Cleft palate
2. Cleft lip
3. Congenital epulis of newborn
4. Natal and neonatal teeth
5. Neurofibroma
● Infant
1. Hemangioma
2. Rhabdomyosarcoma
3. Leiomyosarcoma
4. Eruption cyst
● Childhood ( 6-11 years )
1. Primary herpetic gingivostomatitis
2. Nursing bottle caries
3. Pre pubertal periodontitis
4. Papillon- Lefevre syndrome
● Young adult ( teenage )
1. Early onset aggressive periodontitis
2. Recurrent apthous stomatitis
3. Fibrous dysplasia
4. Dentigerous cyst
● Middle aged
1. Lichen planus
2. Pemphigus
3. Chronic periodontitis
4. Systemic lupus erythematosus
● Old aged
1. Paget’s disease
2. Squamous cell carcinoma
3. Metastatic carcinoma
4. Hodgkin’s Lymphoma
, 5. Trigeminal neuralgia
3. Sex
Certain conditons are specific or more prevalent to occur in certain gender
a. Male
1. Warthin’s tumor
2. Adenomatoid odontogenic tumor
3. Paget’s disease
4. Hodgkin’s lymphoma
5. Hemophilia
6. Actinic keratosis
b. Female
1. Sjogren’s syndrome
2. Pyogenic granuloma
3. Lichen planus
4. Pemphigus vulgaris
5. Pemphigoid
6. Systemic lupus erythematosis
7. Puberty tumor
4. Occupation
Certain conditions are prevalent to occur to persons associated with certain occupation
a. Hepatitis B –dentist , blood bank personnel, surgeons.
b. Hepatitis Whitlow- dentist
c. Dental caries- person working in bakery
d. Cancer of blood, skin- personnel working in ionizing radiation environment
e. Discolored nails – photographer & hairdresser
f. Serration of teeth – tailors
g. Blue black gingival enlargement – lead battery workers
5. Address
a. Certain disease are said to be endemic in nature(disease have got geographical
influence )
b. Fluorosis- dependent on fluoride content of the domestic supply water e.g,
krishnagiri district
c. For further communication
d. Reflect the socio-economic status
6. Chief complaint
The following ponts should be remembered
a. It should be written in patient’s own words & not medical terms.
b. In case of multiple complaints, it should follow the chronological order
e.g, patient complaint of pain & swelling, and then it should be written like-
● Patient complaints of pain in the right lower back tooth region of the mouth for past
5 days.
● Patient also complaints of swelling in the right lower third region of face since 3
days.
, ● Since pain was experienced first & later swelling appeared.
c. It should be written as complaint oriented, and not treatment oriented.
e.g, Patient desires to get his teeth cleaned. This should be written like- Patient
complains of deposits in his mouth.
d. Chief complaint should be correlated with the provisional diagnosis.
7. History of presenting illness
The following points should be remembered,
a. It is the elaboration of chief complaint.
b. It should include only symptoms- subjective description about the complaint by the
patient from the day of inception of the chief complaint. Therefore, no technical
language should be used.
c. History of pain :
o Onset- Gradual/ Sudden
o Duration – Specify in days, months, years- indicate acute/chronic
nature of condition.
o Type- Subjective description of pain – lancinating, throbbing, dull
aching, pricking, electric shock like
o Nature- continuous / Intermittent
o Intensity – Mild/ Moderate / Severe
o Aggrevating factors
o Relieving factors
o Radiating nature
d. History of swelling
a. Onset – Gradual / sudden
b. Duration – Specify in days, months, years – Indicate acute/chronic
nature of condition.
c. Progression – Slow / Fast
d. Associated symptoms – Pain / pus discharge / Paresthesia
e.History of ulcer
a. Onset- Gradual / sudden
b. Duration – specify in days,months,years- indicate acute/chronic nature
of condition
c. Associated complaint – pain/pus discharge / paresthesia
8. Medical and surgical history
A. Medical history
It contain the most significant information which will help in
1. Name
a. Identification of the patient
b. To establish rapport
c. For further communication
d. For medico legal cases
2. Age
a. Identification of the patient
b. Certain diseases are specific to occur in certain age groups
● At birth ( congenital )
1. Cleft palate
2. Cleft lip
3. Congenital epulis of newborn
4. Natal and neonatal teeth
5. Neurofibroma
● Infant
1. Hemangioma
2. Rhabdomyosarcoma
3. Leiomyosarcoma
4. Eruption cyst
● Childhood ( 6-11 years )
1. Primary herpetic gingivostomatitis
2. Nursing bottle caries
3. Pre pubertal periodontitis
4. Papillon- Lefevre syndrome
● Young adult ( teenage )
1. Early onset aggressive periodontitis
2. Recurrent apthous stomatitis
3. Fibrous dysplasia
4. Dentigerous cyst
● Middle aged
1. Lichen planus
2. Pemphigus
3. Chronic periodontitis
4. Systemic lupus erythematosus
● Old aged
1. Paget’s disease
2. Squamous cell carcinoma
3. Metastatic carcinoma
4. Hodgkin’s Lymphoma
, 5. Trigeminal neuralgia
3. Sex
Certain conditons are specific or more prevalent to occur in certain gender
a. Male
1. Warthin’s tumor
2. Adenomatoid odontogenic tumor
3. Paget’s disease
4. Hodgkin’s lymphoma
5. Hemophilia
6. Actinic keratosis
b. Female
1. Sjogren’s syndrome
2. Pyogenic granuloma
3. Lichen planus
4. Pemphigus vulgaris
5. Pemphigoid
6. Systemic lupus erythematosis
7. Puberty tumor
4. Occupation
Certain conditions are prevalent to occur to persons associated with certain occupation
a. Hepatitis B –dentist , blood bank personnel, surgeons.
b. Hepatitis Whitlow- dentist
c. Dental caries- person working in bakery
d. Cancer of blood, skin- personnel working in ionizing radiation environment
e. Discolored nails – photographer & hairdresser
f. Serration of teeth – tailors
g. Blue black gingival enlargement – lead battery workers
5. Address
a. Certain disease are said to be endemic in nature(disease have got geographical
influence )
b. Fluorosis- dependent on fluoride content of the domestic supply water e.g,
krishnagiri district
c. For further communication
d. Reflect the socio-economic status
6. Chief complaint
The following ponts should be remembered
a. It should be written in patient’s own words & not medical terms.
b. In case of multiple complaints, it should follow the chronological order
e.g, patient complaint of pain & swelling, and then it should be written like-
● Patient complaints of pain in the right lower back tooth region of the mouth for past
5 days.
● Patient also complaints of swelling in the right lower third region of face since 3
days.
, ● Since pain was experienced first & later swelling appeared.
c. It should be written as complaint oriented, and not treatment oriented.
e.g, Patient desires to get his teeth cleaned. This should be written like- Patient
complains of deposits in his mouth.
d. Chief complaint should be correlated with the provisional diagnosis.
7. History of presenting illness
The following points should be remembered,
a. It is the elaboration of chief complaint.
b. It should include only symptoms- subjective description about the complaint by the
patient from the day of inception of the chief complaint. Therefore, no technical
language should be used.
c. History of pain :
o Onset- Gradual/ Sudden
o Duration – Specify in days, months, years- indicate acute/chronic
nature of condition.
o Type- Subjective description of pain – lancinating, throbbing, dull
aching, pricking, electric shock like
o Nature- continuous / Intermittent
o Intensity – Mild/ Moderate / Severe
o Aggrevating factors
o Relieving factors
o Radiating nature
d. History of swelling
a. Onset – Gradual / sudden
b. Duration – Specify in days, months, years – Indicate acute/chronic
nature of condition.
c. Progression – Slow / Fast
d. Associated symptoms – Pain / pus discharge / Paresthesia
e.History of ulcer
a. Onset- Gradual / sudden
b. Duration – specify in days,months,years- indicate acute/chronic nature
of condition
c. Associated complaint – pain/pus discharge / paresthesia
8. Medical and surgical history
A. Medical history
It contain the most significant information which will help in
