ORAL DIAGNOSIS PRELIMS REVIEWER ORAL DIAGNOSIS Science of identifying and recognizing the presence of an oral disease process

ss or condition that may be a departure from normal A systemic method of identifying oral disease Diagnos Greek word meaning distinguishing or discernment The discipline of dentistry that is specifically concerned with the art and science of health assessment Includes the evaluation of the patients general health status or physical assessment

abnormalities such as dentogenesis imperfect WORKING DIAGNOSIS/ TENTATIVE DIAGNOSIS o o Presumptive diagnosis or clinical impression The most likely diagnosis in the order of diagnostic probability

DEFINITIVE DIAGNOSIS/ FINAL DIAGNOSIS o All the diagnostic data have been collected and subjected to evaluation and analysis Patients history + clinical exam + analysis

POST-THERAPY/ POST-OPERATIVE DIAGNOSIS o Diagnosis that confirms or verifies the final diagnosis

SCOPE OF REVIEW Introduction o o o o o Types of diagnosis/prognosis Types of clinical exam The diagnostic method Symptomatology Cardinal indicators of diseases

SPOT DIAGNOSIS (IMPROMPTU DIAGNOSIS) o A form of diagnosis which is primarily based on the knowledge and experience of the disease/lesion by the clinician or the examiner

DIFFERENTIAL DIAGNOSIS o Comparative diagnostic technique or diagnosis by elimination Type of diagnosis mainly utilized for nondental abnormalities Eg. Odontogenic tumors like ameloblastoma. Vesicular lesions like herpetic gingivostomatitis, white lesions like white sponge nevus

Oral lesions Patients history

o Physical xamniation Patient assessment Radiographic interpretation Clinical laboratory studies Treatment planning PROGNOSIS

Usually expressed in terms of time and tissue response Prediction of the possible outcome of the disease as to: o Length of time the disease can be eliminated Degree of tissue damage Loss of function Susceptibility to recurrence

TYPES OF DIAGNOSIS DIRECT DIAGNOSIS o o Diagnosis based on inductive logic Signs and symptoms presented by the patient are pathognomatic (unique features) of a particular disease Diagnosis that is mainly utilized for most dental abnormalities Eg. Dental caries, malposition of teeth, dental developmental

o o o

GRADES OF PROGNOSIS Good - excellent Fair

Poor worst

Hard palate Soft palate Oropharyngeal area Tongue Floor of the mouth Teeth Periodontium

FACTORS AFFECTING THE GIVING OF PROGNOSIS Severity of the disease Onset of the disease Location of the lesion Age of the patient Presence of complicating factors Status of the immune system Course of the disease

Adjunctive diagnostic information o o o Radiographic examination Clinical laboratory studies Microscopic examination of the tissue samples Consultations/ referrals

THE DIAGNOSTIC METHOD Components of the comprehensive dental diagnostic database Patient history (case hx) o o o o Identifying data/ personal record Chief complaint (c.c) History of chief complaint (hx c.c) Medical history o o o o Past medical conditions Prior hospitalizations Past infections/ immunizations Known allergy/ hypersensitivity Current medical treatment

PROCEDURAL STEPS OF DIAGNOSTIC METHOD Collection of diagnostic information o o o Patient history Physical examination Adjunctive diagnostic information

Organization/ analysis of diagnostic information o Physical assessment of the patients health status Classification of abnormalities Dental abnormalities Carious lesions Gingivitis/ periodontitis Periapical inflammatory lesions Dental developmental anomalies

Family history (fh) Personal, social and economic history Review of systems (ros) Dental history

Physical/ clinical examination o General patient appraisal (GPA) and vital signs determination Extraoral examination Intraoral examination Lips Labial & buccal mucosa and vestibule

o o

Non-dental abnormalities Mucosal lesions Soft tissue enlargements Bone lesions

Clinical syndromes

o o

No set or routine pattern of procedures Priority given to the relief of the chief complaint

Formulation of diagnosis including giving of prognosis Formulation and execution of the optimal treatment plan Comprehensive treatment plan (oral rehab) Alternative treatment plan

PERIODIC HEALTH MAINTENANCE AND RECALL TYPE OF EXAMINATION o Type of examination wherein the results obtained are used to measure any deviations that might have occurred during the interval from the last complete and thorough exam Recall interval may vary from 6 months to 1 year or as long as 2 years

Reassessment of the abnormality following treatment

TYPES OF CLINICAL EXAMINATION SYMPTOMATOLOGY COMPREHENSIVE DENTAL EXAMINATION o Complete and thorough type of examination Executive type of examination Requires collection of all appropriate diagnostic information All structures of the oral cavity are examined Recommended for patients who request Total Dental Care (TDC) and who has not previously undergone such type of examination Considered to be the descriptive knowledge of the subjective and objective manifestation of disease necessary to carry out th process of oral diagnosis

o o

CLASSIFICATION OF SYMPTOMS SUBJECTIVE SYMPTOMS o Described verbally and felt by the patient Obtained by injury during the taking of case history One that forces the patient to seek dental treatment Subjective symptoms referable to the mouth Pain (odontalgia) Foul breath (halitosis, fetor ex ore) Inability to masticate/open mouth (trismus) Xerostomia (dry mouth; asialorrhea; hyposalivation) Esthetic problems (crowding, discoloration) Sense of unclean mouth Speech problems (dysarhria) Bleeding gums Loss of taste (aguesia) Unpleasant taste (cacoguesia)

o SCREENING TYPE OF EXAMINATION o Type of examination that serves as a compromise between thorough/complete type and a less extensive one because of the practical aspect of reduced: o Time Cost

Skill

Examination that indicates gross disease in broad survey Most popular and widely used method of examination among general dentists

EMERGENCY EXAMINATION o o Incomplete type of examination Type of examination designed to expeditiously manage a chief complaint that requires immediate attention Eg. Avulsion, acute infections, excessive bleeding

OBJECTIVE SYMPTOMS / SIGNS

Those that produce functional and structural changes that may be seen by th naked eye of the patient/examiner Manifested by changes:

Results from Noxious Stimulation that innervates body tissues Localized to affected region Apparent caouse Physical evidence of inflammation Usually acute or episodic Progress in severity types by location and physical findings: headache (cephalalgia) other extraoral and perioral pain pain of pulpal origin (odontalgia) pain of dental supportive tissues and oral mucosa referred pain (projected pain)

o o Size/shape Color Form/ density Number Position Relationship

Gathered during clinical examination and carried out by: Inspection Palpation Percussion Auscultation

o o

Observed by the clinician Ex. LESIONS Primary vesicles Secondary ulcer o

NEUROGENOUS PAIN Pain caused by an abnormality of the nerve itself Localization correspond to affected nerve No apparent cause Inflammation present only with neurotropic viral infections Most are chronic or episodic Severity relatively constant or comparable among episodes Types of neurogenous pain: Neuralgia o Viral (postherpetic neuralgia) Glossopharyng eal Trigeminal (tic douloureux, facial neuralgia,

CARDINAL MANIFESTATOINS OF DISEASE Shortness of breath Swelling of feet and legs Chronic lack of energy

Difficulty sleeping at night due to breathing problems Swollen or tender abdomen with loss of appetite Cough with frothy sputum Increased urination at night Confusion and/or impaired memory

CARDINAL MANIFESTATIONS: PAIN

o o SOMATIC PAIN

fothergills neuralgia, suicide disease) Causalgia o Severe burning pain associated with deformation of nerves by missiles such as bullets that produce high velocity shock waves

Pulmonary disease Chronic obstructive pulmonary disease (COPDs) o o Bronchial asthma Chronic bronchitis emphysema

Hematologic disease Anemia o o IRON DEFICIENCY HEMOLYTIC Sickle cell Thalasse mia

Phantom pain o Pain in a limb that has been amputated

PSYCHOGENIC PAIN Hardest to manage No organic basis/no apparent cause Diffuse or vague distribution No physical evidence of inflammation Chronic course o Variable severity relates to stress or other non somatic factors CARDIOVASCULAR o PALPITATION o o

APLASTIC PERNICIOUS

Leukemia o MONOCYTIC LYMPHOCYTIC

DYSPNEA o Difficulty in breathing/ labored breathing/ shortness of breath Pathologic causes: Cardiovascular disease Ischemic/ coronary heart disease Congestive heart failure (R/L sided) Congenital malformations of the heart o Ventricular and atrial septa defect Valvular heart disease

Undue awareness of a pounding heart Causes: Strenuous physical exercise Stress and anxiety Excessive use or intake of tobacco, coffee, tea and some drugs Disorders of the mechanism of heartbeat or cardiac arrhythmias Functional disorders such as anemia, hypoglycemia and thyrotoxicosis

HYPERTENSION

Episodic or consistent elevation of arterial blood pressure beyond what is considered normal Classification

Difficulty in breathing/labored breathing/ shortness of breath Pathologic causes: o CVD (Cardiovascular Disease) PD (Pulmonary Disease) Hematologic Causes

According to etiology o o Essential/primary type Idiopathi c No underlyi ng o Secondary o With underlyi ng Aka Cardiac Decompression o

CARDIOVASCULAR DISEASE ISCHEMIC/ CORONARY HEART DISEASE o Demand of Oxygen is greater than supply

CONGESTIVE HEART FAILURE (R/L sided)

CONGENITAL MALFORMATIONS OF THE HEART o Ex. Ventricular and Atrial Septa Defect

According to the course of hypertension o Benign Chronic and long standing Mild effect Doesnt exhibit obvious signs and sympto ms

VALVULAR HEART DISEASE

PULMONARY DISEASE COPD (Chronic Obstructive Pulmonary Disease) o Bronchial asthma (cause of hupersensitivity on allergies) Chronic bronchitis Emphysema

o o

HEMATOLOGIC DISORDERS ANEMIA (reduction in number of circulating RBC and or hemoglobin) faster HR o Types: IRON DEFICIENCY

Malignant Above 200/110 Acute elevatio n of BP Patient prone to cerebrov ascular attack and heart attack HEMOLYTIC Sickle cell (Hereditary; African American) Thalassemia (Cooleys Anemia Mediterranean)

APLASTIC (destruction of red bone marrow) PERNICIOUS (Addison Biermer Anemia)

DYSPNEA

Due to lack of intrinsic factor needed for vitamin BR absorption

o o o

above 200 systolic/ above 110 diastolic acute elevation of BP patient prone to cerebrovascular attack and heart attack

LEUKEMIA o o Monolytic Lymphocytic

CLASSIFICATION OF BP FOR ADULTS AGE 18 AND ABOVE CATEGORY NORMAL PREHYPERTENSI VE HYPERTENSIVE STAGE 1 STAGE 2 SYSTOLIC < 120 120 139 140 159 > 160 DIASTOLIC <80 80 89 90 99 > 100

CARDIOVASCULAR MANIFESTATIONS OF DISEASE PALPATION o Undue awareness of a pounding heartbeat

HPERTENSION o Episodic or consistent elevation of arterial BP beyond what is considered normal

BP FACTS o o o o o 100 110 = best systolic reading 60 70 = best diastolic reading Higher reading in normal old individual has an unknown cause predisposing factors genetics/hereditary lifestyle/habits BP greater than 200/140 mmHg is already considered malignant hypertension 90% of all cases of hypertension have no direct cause. These are referred to as essential hypertension

WEAKNESS Forms: o o Asthenia/ lassitude Faintness

CLASSIFICATION OF HYPERTENSION According to Etiology: essential/primary type o o idiopathic cause no underlying cause

ASTHENIA/ LASSITUDE Generalized muscular weakness/feebleness that is common in the ff. conditions: o o Senility Severe forms of anemia Nutritional deficiencies Thyroid gland disorders (ex. Hyperthyroidism) Disorders of the locomotor system (ex. Osteomyelitis) Endocrine disturbances (ex. Diabetes Mellitus) Malignant neoplasms (ex. Stage 3 & 4 cancer)

secondary o o o with underlying cause o ex. Renal, endocrine diseases (Cushings syndrome) o

According to Cause: benign o o o chronic and long standing o mild effect doesnt exhibit obvious signs and systems CACHEXIA o

malignant

Generalized bodily wasting

FAINTNESS

Recurrent attack of weakness As in the cases of:

Any lymph node enlargement (lymphadenopathy) identified by palpation should be assessed for the ff: o Compressibility Tenderness Mobility

Epilepsy (grand mal type and petit mal type) Hypoglycemia Postural hypotension patients taking antihypertensive drugs Disturbances of cardiac rate/rhythm

o o

o o

JUGULODIGASTRIC LYMPH NODE Movement of the involved in an oral malignancy SINGLE, FIRM, NON-TENDER & MOBILE o Typical of a past infection

o o

Emotional disturbances (anxiety, fear) syncope

BLEEDING/HEMORRHAGE May arise from: o o o Vascular dysfunction leukemia, anemia Blood vessel fragility female with mens Defects in blood coagulation mechanisms thrombocytes, hemophelia Injury to the blood vessels

MULTIPLE, COMPRESSIBLE, TENDER & MOBILE o Indicative of an active infection

MULTIPLE, FIRM, NON-TENDER, NON-MOBILE (FIXED) o Characteristic of regional metastasis of malignant neoplasm

ORAL LESIONS A general term for objective types of symptoms Those that produce structural, morphologic and functional changes clinically

In the oral cavity, bleeding is most commonly associated with gingival disease JAUNDICE ICTERUS Yellowish discoloration of the skin, mucous membrane and sclera of the eyes due to excessive accumulation and inadequate metabolism of BILE PIGMENTS (BILIRUBIN) Mainly due to liver diseases such as HEPATITIS (all types) and LIVER CIRRHOSIS

ORAL MUCOSAL LESIONS WITHOUT ENLARGEMENT MUCOSAL DISCOLORATION WHITE MUCOSAL DISCOLORATION o Those characterized by epithelial thickening Lesions undergoing keratinization (hyperkeratinotic lesions) Characteristics: Asymptomatic lesion (not painful) Color is opaque white Surface texture is rough and grainy (nicotinic stomatitis)

URINARY SYMPTOMS POLYURIA excessive amount of urination OLIGURIA scanty, limited urine ANURIA little or no urine DYSURIA painful urination HEMATURIA blood in urine PROTEINURIA cloudy urine

Symptoms suggestive of renal, genitourinary tract (GUT) disorders: STD, renal stones LYMPHADENOPATHY (lymphadenitis inflamed lymph) Presence of inflamed and palpable lymph nodes o

Lesion persists and may progress Treatment in palliative

Those characterized by accumulation of surface materials

Color is opaque white Symptomatic lesion (painful) There is a painful raw bleeding when scraped

Ex. Fordyces Granules (ectopic sebaceous gland). Submucosal fibrosis (premalignant lesions)

DARK MUCOSAL DISCOLORATION o MACULE Usually flat, sharply delineated areas of altered pigmentation (red, brown or reddish brown) Can also apply to abnormal focal loss of melanin pigmentation ERYTHEMATOUS MACULE Vascular in origin Contain blood or blood pigments May present as an isolated lesion or a multifocal or diffused lesion

Consistency is soft and friable Condition regress or heals

Examples: Condition caused by fungal infections like CANDIDIASIS caused by CANDIDA ALBICANS (oral thrush) DIABETES MELLITUS caused by high blood sugar level due to insufficient insulin too much antibiotic and steroid therapy a person undergoing chemotherapy, radiation therapy acidic saliva (predisposing factor)

PIGMENTED or PIGMENTARY MACULE Contains melanin pigments May be physiologic or pathologic Ex. PEUTZ JEGHERS SYNDROME SYNDROME

nocturnal denture wearer (PF)

TYPES OF ERYTHEMATOUS MACULES acute pseudomembranous type (white) ERYTHEMA o o Asymptomatic lesion (not painful) Doesnt rub off Either static or progresses o Color is translucent white WHITE SPONGE NAEVUS Naevus spongiosus alvus mucosae Cannons disease White folded gingivostomatitis ECCHYMOSIS or BRUISES o Identical to petichiae Reddish subepithelial hemorrhagic discolorations that are less than 2-3mm in diameter PETECHIAE Indicates inflammatory redness Note: erythmatous skin rashes with multiple small bumps are termed MACULOPAPULAR

Those characterized by subepithelial/submucosal change

ADDISONS o Insufficiency in adrenal secretions

PIGMENTARY MACULE

ORAL SOFT TISSUE ENLARGEMENT PAPULE o Solid focal enlargement less than 1 cm in diameter No fluid

SECONDARY o o o Came from a primary lesions Erosion Ulcer

o WHEAL o o

CHARACTERISTIC OF LESION CHARACTERIZED BY LOSS OF OF MUCOSAL INTEGRITY In an erythematous papule Typical appearance of allergic reactions an insect bites Presence of pain Onset may be acute short duration; gradual chronic No geographic findings o o Useless to use radiograph as diagnostic tool Impt: clinical and historical findings

NODULE o Solid enlargement between 1 5cm in diameter Enlarged papule Ex. PARULIS or GUMBOIL, PYOGENIC GRANULOMA

o o

Absence of enlargement or swelling Lesion distribution o May be single or isolated lesion; most commonly caused by trauma o Ex. Traumatic ulcer

TUMORS o Solid enlargement greater than 5cm in diameter May be reactive or neoplastic in character Ex. EPULIS FISSURATUM (reactive) Classification as to shape PEDUNCLE or STEM Attachment by means of stem (smaller than exophytic portion)

o o o

May be in cluster appearing in many areas Ex. Vesicular or bullous Mostly cause by viral or autoimmune diseases (pemphigous vulgaris) Manifestations are plenty

Seen also on other parts of the body o o Ex. Herpetic infection Manifestation of systemic conditions; not caused by trauma

SESSILE Broad base, dome shaped contour

CYST o Is an encapsulated semi-solid, fluid-filled enlargement lined by epithelium

Variety of causes/ variety of etiological factors o o Traumatic injury Bacterial infection Ex Acquired Syphillis (caused by TREPONEMA PALLIDUM) Chancre ulcers on lips (single) Mucous patches cluster, most infectious stage (multifocal)

LESIONS CHARACTERIZED BY LOSS OF MUCOSAL INTEGRITY PRIMARY o o o Vesicles Pustule Bullae/blister

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Affects the brain; manifests as GUMMA (single gangrenous lesion seen on the palate)

Ex. Pemphigus Vulgaris Note : Nikolskys sign bullae formation following a mild lateral pressure to an apparently normal tissue surface

o o o

Dermatological Autoimmune Granulomatous Tuberculous granulomatous ulceration on the tongue

SECONDARY LESIONS Stage of the process generally observed by the dentist Types: o EROSION o ULCER Loss of epithelial integrity that extends deep to the basal layers of the epithelium 1 - due to trauma 2 - due to rupture of primary lesions Heals without recurring Focal loss of epithelium Superficial to basal layer

PRIMARY LESIONS Initial presentation of a disease or lesion Lesions thatare too fragile to exist in the harsh environment of the oral cavity and predictably degenerate into ulcer to secondary lesion Viral lesion start as vesicle or bullae (blister) Types: o VESICLE Composed of serum plasma and blood Focal fluid-filled elevation less than 1 cm in diameter

CRUST/SCAB Loss of epithelial integrity affecting the skin Dry collection of blood cells and plasma proteins

Lesion most often caused by viral infection those that produce a cluster of vesicle (zosterform pattern)

Type 1 herpes simplex waist above (cold sores, recurrent herpes labialis) Type 2 herpes simplex genito-anal (cold sores, recurrent herpes labialis) Herpes zoster (shingles) Unilateral, multifocal, vesicular Secondary manifestation of chicken pox Caused by VARICELLA ZOSTER Others: o

FISSURE A linear defect that extends to the dermis A common example caused by fungal infection known as athletes foot Fissuring at the corner of the mouth known as ANGULAR CHELITIS (PERLECHE)

PUSTULE Vesicels that contain pus Bacterial rather than viral

BULLA or BLISTER Fluid-filled elevation greater than 1cm in diameter Can be single or in clusters

SOAP (Subjective Objective Assessment Plan) Patients history is taken from direct interview of the patient Questioning should be done methodically PROTOCOL GUIDELINES: 1. Adapt a professional appearance a. Look good, dress well, smell good, behave well b. Scrub suits can be worn in the clinic 2. Conduct the interview in the privacy of your clinic

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a. Be accommodating, polite and sympathetic b. Have humor c. Explain procedures in laymans term DEMOGRAPHIC DATA Give due cognizance or considerations as to the age of the patient, gender preference, and racial or ethnic origin HECKS DISEASE Appearance of small popular lesions on lip Seen in most people who live in Alaska IMPORTANCE OF CASE HISTORY 1. Important diagnostic procedure . A necessary data to arrive at the provisional or tentative diagnosis of the patients chief complaint 2. An important legal procedure a. Serves as evidence of professional evidence in medico-legal cases 3. Factor in improving public relations procedure. *always ask what the current medication of the patient is *To identify to a systemic condition that may affect the formulation of the diagnosis *identification of systemic condition that necessitates treatment plan Methods of Recording Patient History Complete & Thorough Examination Diagnostic interview A verbal exchange between the patient and the clinician that elicits the patients knowledge concerning health information Screening Type of Examination Combination of diagnostic interview and printed list of information (Medical History Health Questionnaire) Elements of the Patients History or Case History 1. Patients biographic/demographic data Name Age Address Gender Telephone number Birthday Race Referred by whom? 2. Chief Complaint The element of the patients history that presents the principal problem as stated in the patients own words. What prompted the patient to seek medical or dental care. Subjective symptom Shouldnt be a patients desire 3. History of Chief Complaint Chronologic account of the patients chief complaint from the date of onset until treatment The life story of the chief complaint History of Chief Complaint should include the ff: Date of Onset of Complaint Type of Onset (Acute or chronic) Character of the Complaint Location of the Complaint Relation of the complaint to other activities Any previous medication, diagnosis or treatment related to the complaint as given by other dentists 4. Medical History Is a description of the relevant features of the patients health status from birth to the moment that the patient enters the dental office.

The most important component of the patients history. Usually divided into the following: Past Medical Conditions Past infections / previous immunizations Prior Hospitalizations due to the following: Traumatic injuries Surgical procedures Blood transfusions Allergies and adverse reactions to drugs Current medical treatment May include special diets, limitations of daily activities and medications. 5. Family History Questions concerning the family history are directed to A. genetic conditions including history of mental disease (hemophilia, diabetes, cancer, allergy) B. communicable infections ( PTB) C. general health of the family D. cause of death of parents if deceased E. history of dental problems in the family 6. Personal and Social History Should include a brief summary of the patients occupation marital and financial status hobbies/ habits daily activities emotional adaptation/ type of personality *NOTE: The two habits of greatest health significance to the dentist are tobacco and alcohol use 7. Review of Systems (ROS) A series of questions that explores the possibility of undiagnosed disease and the effectiveness of current treatment for diagnosed illnesses Attempts to identify symptoms that are commonly associated with organ system dysfunctions 8. Dental History Provides insight into the patients dental hygiene practices, attitude towards dental care, nature of the past dental treatment a. Routine dental care b. Episodic dental care c. Symptomatic dental care

Physical/ Clinical Exam *Diagnostic evaluation of the patients health status that relies mainly on the clinicians primary senses (sight, hearing, touch, smell) and a few simple diagnostic instruments General Methods/ Techniques 1. Visual Examination A. Passive Visual Exam (Inspection) B. Active Visual Exam (Extraoral and Intraoral Exam) C. Transillumination to demonstrate the accumulation of fluid and pus in the Antrum of Highmore 2. Palpation touch and sight A. Presence of pain upon pressure application B. Degree of tissue compressibility A. Compressible B. Non Compressible Spongy - Bony hard Doughy - Indurated Pitting Collapsing *Compressible

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*Doughy structures offer greater resistance to pressure, upon release of pressure it slowly regains its original form/ contour *Spongy- offers minimal resistance to pressure but upon release of pressure it quickly regains its original form / contour * Pitting not usually seen in the oral cavity (eg. pedal edema of extremities) Collapsing easily compressible enlargement that remains deformed even after pressure release Eg. Expression of pus from an abscess *Non compressible * Bony hard- rigid and calcified * Indurated hardness without the rigid sensation associated with calcification. It can be compared with squeezing a a dense, solid rubber bowl. Note: Induration is a feature of many malignant neoplasms Structures Palpated Muscles Bone/teeth Glandular tissues Lymph nodes Techniques of Palpation a) Bimanual Palpation 2 hands, 1 hand to palpate and the other to support Palpating floor of the mouth b) Bidigital Palpation 2 fingers of 1 hand Palpating thinner tissues like lips, labial and buccal vestibule, tongue c) Bilateral Palpation- fingers of both hands are used Best technique for palpating symmetrical structures on both sides of the face; Ex. R and L TMJ, Parotid area, Submandibular and sublingual area, Cervical area of the neck 3. Percussion (sight and hearing) - For localization of inflammation of periodontal membrane and 2o pulpitis Structures: Teeth blunt end of the mouth mirror Facial Muscles- 2nd and 3rd finger is used Jaw Bones- indirect percussion Never used as a test for vitality, In general, a tooth with normal support = high pitch sound whereas less dense support = lower pitch sound NOTE: Percussion or tapping over the facial nerve in front of the ears causes twitching or spasm of the facial muscles as in latent tetany = (+) CHVOSTEKS SIGN Motor movement of the eyes: III, IV, VI CN Strabismus uncontrolled squinting of the eyes Diplopia double vision Ptosis drooping of the eyelid Auscultation Refers to the act of listening to the sound produced by various body structures Ex. Heart- heart sound (lub-dub sound) Lungs- during breathing in and out Used in Dentistry for: Examination of TMJ Diagnosis of fractured jaw Blood pressure measurement Probing Used for:

Detection of carious lesion Determine depth of periodontal/ crevicular pocket Diagnostic aspiration or aspiration biopsy Olfactory Examination discretely done; not an SOP Evaluation of Function a. Pulp Vitality Testing using pulp vitalometer or thermal test b. Determination of occlusal relationship through the production of diagnostic cast 6. Olfactory Examination discretely done; not an SOP 7. Evaluation of Function a. Pulp Vitality Testing using pulp vitalometer or thermal test b. Determination of occlusal relationship through the production of diagnostic cast *HOW TO CHECK THE TMJ 1. Check for the movement of TMJ a. By asking the patient to open and close the mouth and check for lateral deviations 2. Check the maximum extent of mouth opening a. Extent of the interincisal distance 3. Do palpation in front of the ears just above the condyles a. Check for movements and clicking sounds b. Check for tenderness when the patient opens and closes the mouth c. Posterior part of the TMJ is located at the External Auditory Meatus *HOW TO EVALUATE MUSCLES OF MASTICATION MASSETER one finger inside the mouth and one finger outside TEMPORALIS ask the patient to clench their teeth LATERAL & MEDIAL PTERYGOID ask the patient to do lateral excursions CHORDA TYMPANI Gustatory sensation Branch of CN VII 5th CN facial sensory 8th CN (vestibulocochlear) For hearing and balance 9th & 10th CN Loss of gag reflex 11th CN (Spinal Accessory) No lateral movement of the head No shrugging 12th CN (hypogossal) No motor movement of tongue Cannot protrude tongue General Patient Appraisal (GPA ) Consist of the impressions concerning the patients health status that can be gained by inspection from a comfortable distance Includes the ff: 1. Patients identifying / demographic features a. Age b. Gender c. Race 2. Mental Orientation and emotional status Psychic state of the patient Usually assessed on patients awareness of person, place and time Body size (Habitus), stature (height) and bilateral symmetry (anatomic proportion) Bilateral symmetry

4.

3.

5.

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Refers to the expectation that the midsagittal plane bisects the body into 2 equal parts that normally corresponds in form Abnormalities in Body Symmetry (Asymmetry) A. Tissue Deficiency (eg. Physical injury, degenerative disease) B. Tissue Enlargement (Unilateral facial swelling) C. Abnormal tissue position (eg. Scoliosis or lateral spine curvature Classification of Body Built (Habitus) 1. Asthenic Slender and underweight 2. Sthenic Well proportioned, athletic build 3. Hypersthenic (Stocky build) Heavy bone/ muscular proportion 4. Pyknic heavy, soft and rounded build Abundance in body fat Stature or height abnormalities 1. Large stature or GIGANTISM a. ACROMEGALY after puberty gigantism 2. Small stature or DWARFISM a. CRETINISM small stature with mental retardation due to thyroid gland disorder 4. Facial Form/ Head Shape A. Normocephalic/ Mesocephalic B. Brachycephalic short rounded skull shape C. Dolichocephalic long narrow head shape 5. Patients gait - Refers to the manner of walking Gait Abnormalities A. Hemiplegic gait Characterized by semicircular lateral swing of the affected leg during strides. Typical of cerebral damage caused by stroke B. Ataxic gait (Drunken gait) Is the staggering , irregular, wide-stance walk (eg. Alcoholic intoxication, tabes dorsalis of tertiary syphilis) C. Parkinsonian gait (Freezing gait) Consists of limited strides, hanging arms and muscular stiffness Eg. Parkinsons disease (due to dopamine deficiency) 6. Posture, movements and speech It is simultaneous with gait May become evident during rest or during movement Patients with endocrine deficiency may manifest tremors Abnormalities: A. Resting tremors of Parkinsons disease B. Intentional tremor of multiple sclerosis Often associated with ataxic gait C. Choreic/ Athetoid movements Characteristic manifestation of cerebral palsy Involves slow, repetitive movements of the proximal extremities, trunk and face Speech Abnormalities 1. Dysarthria Slurring of speech 2. Aphasia Inability to accomplish proper verbal expression

* Both abnormalities are non specific indication of intoxication. Neuromuscular Deficiency/ disorders (eg. Stroke, cerebral palsy) and cortical defects 7. Determination of Vital Signs Final aspect of general patient assessment Consist of: A. Pulse rate/rhythm (60-90/ min) QUANTITATIVE - # of pulse per minute QUALITATIVE amplitude or rhythm NORMAL PR 60-90 bpm AMPLITUDE force/surge of blood against the artery *PULSE AMPLITUDE 0 = no palpable pulse 1 = faint pulse (thready pulse) Due to: dehydration and/or advance state if atherosclerosis 2 = normal ulse 3 = strong pulse manifested when the persion is in its active state 4= bounding pulse pulse that is easy to find and very hard to oliterate; seen in persons who have hyperthyroidism *PULSE POINTS RADIAL Typically used Palpated on the lateral of the wrist TEMPORAL CAROTID Useful in emergencies INGUINAL ANTECUBITAL FOSSA Palpated on the medial Felt when taking BP B. Respiration Rate (12-20 breaths/min) - Observe the rise and fall of the chest - Normal in adults is 12 20/min - Normal in children is 24 30/min - 10 or 30 indicative of Cardiovascular Disease - TACHYPNEA 7/min; slow - APNEA no breathing - CHEYNE STOKES RESPIRATION shallow, fast breaths; present in CVD and CHD (coronary heart disease) C. Body temperature - Taken through ears, mouth, axilla - Normal oral/ear temp is 36.5 C - Person is febrile if temp is 37.8C or D. Blood pressure - measured using auscultatory method E. Height and weight done only in conscious patients *when unconscious, only take BP, RR & PR

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Extraoral Exam Physical Examination of Specific Extraoral Structures 1. Facial forms/ symmetry examined by inspection and palpation in the ff. perspective/ view A. Frontal view Pupil alignment Midline location of the nose Symmetry/ contour of the zygoma, ears and mandible B. Submental visualizes the anatomic triangles of the neck Ask the patient to tilt the head upward Under the jaw, anatomic triangles of the neck a) Submental b) Submandibular c) Cervical Ask the patient to move head on the side a) Cervical lymph nodes Anterior, medial, lateral, superficial, deep b) Jugulodigastric & juguloomohyoid lymph nodes Can be felt when there is tonsillar infection or when there are malignancies c) Clavicular lymph nodes C. Lateral- reveals the profile of the facial bones D. Supraorbital- achieved by looking down the patients face from above and behind the head Effective position to observe deviation of mandible during opening 2. Skin of face/neck 3. Eyes/ear/nose *Eyes - Abnormalities of the eyes can suggest the ff: A. Developmental abnormalities eg. Strabismus, ptosis (drooping of the upper eyelid) - Diplopia (double vision) B. Inflammatory disease eg. Erythema of the palpebral conjunctiva is a sign of conjunctivitis C. Manifestations of Systemic disease eg. Jaundice/ icterus of the sclera is indication of liver disease Exophthalmos/ bilateral protrusion of the eyeballshyperthyroidism Photophobia (intense aversion to bright light) is a sign of porphyria *Ears - condition affecting the ears that are of diagnostic significance are: A. Developmental origin Congenital defects of the middle and inner ear resulting to deafness B. Inflammatory Origin Eg. Otitis media (middle ear infection) -tenderness elicited by palpation of the mastoid process is indicative of mastoiditis Intraoral Exam *GUIDELINES/PROTOCOL: 1. Perform the intraoral exam in a systematic/procedural manner/routine 2. Proper positioning of the patient, proper illumination/lighting and proper use of clean basic instruments 3. Practice proper infection control 4. Whatever findings seen in intraoral exam must be checked with the other findings

a.

Must be analyzed, checked and examined all together

Examination of the Oral Soft Tissue 1. Lips bidigital palpation inspection and bidigital palpation Common Abnormalities includes: a. Ulcers b. Rough surface texture c. Patchy homogenous thickening 2. Buccal mucosa and vestibule -inspection/ palpation (bidigital) 3. Hard/Soft Palate Bidigital palpation Indirect inspection using the mouth mirror Direct visual inspection from the submental perspective with the patients mouth wide open and head hyperextended Common abnormality of the hard palate in adults is a bony hard enlargement at the midline called torus palatinus Reaction of bone to stress Bony exostosis Not pathologic because it stops growing after it reaches its saturation point Removed under 3 circumstances: If it interferes with speech If it interferes with mastication If it interferes with placement of prosthesis 4. Oropharynx Visualization (inspection of the oropharynx by depressing the tongue with a mouth mirror while patient responds to the request to say ah Palpation not routinely performed unless an abnormality is visually apparent 5. Tongue Visualization of the dorsal, ventral surfaces and lateral borders of the tongue Bidigital palpation to reveal its muscular consistency DORSAL Muscular upon bidigital palpation Ant. 2/3 must be rough (should not be smooth nor coated) due to the presence of the papilla Filiform Fungiform Foliate Circumvallate VENTRAL Raise tongue (put the tip of the tongue on the lingual surface of the maxillary incisors) ANKYLOGLOSSIA Tongue-tied Short or no lingual frenum ANKYLOTOMY Surgical procedure done to lengthen the lingual frenum LINGUAL VARICOSITIES dilated veins 6. Floor of the mouth Inspection (visualization) at the same time the ventral surface of tongue is examined Bimanual palpation SUBLINGUAL CARUNCLE

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Small elevations found on either side of the lingual frenum at the floor of the mouth Marks the opening of the Whartons duct

Examination of Teeth 2 stage process 1. Dental orientation examination of the teeth by visual inspection without specific efforts to remove saliva / food debris; Includes: a. Number of teeth present b. Quality of oral hygiene c. General extent of calcular deposits d. Presence of extensive decay e. Dental developmental malformations and malalignment f. Dental discolorations g. 2. Comprehensive Examination of each tooth by visualization, probing for carious lesions, palpation and percussion for signs of mobility, tenderness and fracture h. Periodontium- visualization, periodontal pocket probing and palpation 2. Comprehensive Examination of each tooth by visualization, probing for carious lesions, palpation and percussion for signs of mobility, tenderness and fracture Periodontium Visualization periodontal pocket probing palpation

-Rosette Go

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