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CASE HISTORY

Introduction
Objectives

Advantages

Diagnostic ProcedureDemographic Features-

Name

Age

Sex
Address

Occupation

ExaminationGeneral Examination

Extra-oral Examination

Intra-oral Examination

Soft-tissue Examination

Hard-tissue Examination

Clinical Diagnosis

Differential Diagnosis

Investigations & Results

Final Diagnosis

Treatment Plan

Summary

Importance of Informed Consent

References

CASE
HISTO
RY

DEFINITION

A case history can be considered to be a planned professional


conversation that enables the patient to communicate their symptoms,
feelings and fears to the clinician so that the nature of the patients real
and suspected illness and mental attitude may be determined.

1.) Purpose of obtaining information and recording it in an orderly


manner is to establish a diagnosis and distinguish one disease from
another.
2.) The database may be compatible with a variety of disease
processes, which constitute the differential diagnosis.
3.) Once data has been accumulated, sufficient information should be
present to determine a definite diagnosis.
4.) A rationale treatment plan can be formulated.

OBJECTIVES

To arrive at a tentative diagnosis of the patients chief complaint.

To determine any systemic factor that might affect the formulation


of a diagnosis.

To determine any systemic condition that requires special


precaution prior to during the dental procedures to protect health
and life of the patient.

ADVANTAGES

Establishment of a written record that serves as a diagnostic


instrument.

Protection from possible disease contact.

Establishment of a basis for future references.

Provision of a document that will serve as a legal evidence for


professional competence.
DIAGNOSTI
C
PROCEDUR
E

Demograph
ic Features

History
Taking

General

Examinatio
n

Provisional
Diagnosis

Extra-oral

Hard- tissue

I. Demographic Features

Name

Age

Sex

Occupation

Address

NAME

Identification

Improves patient-physician relationship.

Investigatio
ns

Final
Diagnosis

Intraoral

Soft- tissue

Children - short names or nick names.

Clue -country, state and religion

AGE

Some problems which set in at childhood are probably congenital in


nature.

Degenerative, vascular and neoplastic disorders are more common in the


middle aged or elderly people.

> CHILDREN- Herpetic Gingivostomatitis, Measles, Rickets.

> AOT- 10-19 years old & rare in people >30years;

> Buccal bifurcation cyst: 5-13years

> Lateral Periodontal Cyst- 5-7th decades of life; rarely in <30years

old.

> Odontoma- average age: 14years old.

> Pagets disease: rarely in <40years old people.

> Adenoid Cystic Carcinoma: rare in people <20years.

SEX

Some diseases are more common in specific genders

Menstrual History, Obstetric History : Females.

MALES

Haemophilia , colour blindness affects males.

Oral Cancer is more common in males.

Warthins Tumour (previously) - Males: Females = 10:1

Orthokeratinized Odontogenic Cyst- Males :Females= 2:1


Necrotising Sialometaplasia- Males :Females= 2:1

FEMALES

Thyroid disorders are more frequently seen in females.

Sjogrens syndrome- Males :Females= 9:1

Adenomatoid Odontogenic Tumour Males :Females= 2:1

Granular Cell Odontogenic Tumour: >70% in females

Pleomorphic Adenoma: Slight female predilection.

ADDRESS

For future correspondence.

Some diseases have geographical distribution.

E.g.: Fluorosis is endemic in some parts of AP,

Filariasis in Orissa,

Leprosy in West Bengal.

Urban Areas- IHD, COPD

Rural Areas -betel nut chewing or Tobacco

People living near factories are liable for pulmonary diseases.

Recent travel should also be noted.

OCCUPATION

Grooving /Notch in the anterior teeth :- Cobblers, carpenters, electricians,


tailors.

Goldsmiths: - Methaemoglobinaemia and resultant cyanosis.

EROSION- exposed to acidic fumes, professional swimmers.

ABRASION persons exposed to atmosphere of abrasive dust.

Hepatitis B Dentists, surgeons, blood bank personnel are more prone to


Hepatitis B.

Flutists & Goldsmiths:- Pneumo parotid[ Air reflux while playing]

Radiologists and technicians:- Radiation Exposure .

Exposure to sun:- Basal Cell Carcinoma is common

GINGIVAL STAINING The strange dark stippling of the marginal gingiva is


seen in persons who work with Pb, Bi & Cd.

O.P. NUMBER

Patient identification

Maintain records

Future recall of patient

For future reference in medico legal cases

Forensic Odontology

DATE

Maintain records k

Chronological order

II. HISTORY TAKING

CHIEF COMPLAINT

HISTORY OF PRESENT ILLNESS

MEDICAL HISTORY

FAMILY HISTORY

PAST DENTAL HISTORY

SOCIAL/PERSONAL HISTORY

TYPES OF QUESTIONS
Open- Ended Questions
Closed- ended Questions
Leading Questions
Contradiction Questions
Indirect Questions

CHIEF COMPLAINT
It is a symptom or symptoms in the patients own words that relates to the
presence of an abnormal condition.

- Complain of the patient is recorded.

- Recording of symptoms in the patients own words.

-Current complaint/s; duration of these complaints.

- Record in chronological order.

-Questions like, 1. What are your complaints?


2. What brings you here?

- No leading questions to the patient.

Most common chief complaints


Pain
Swelling
Burning sensation
Bleeding
Loose teeth

Bad breath
Bad taste
Numbness
Dryness of the mouth
ANALYSIS OF PAIN
Chronological account of the chief complaint and associated symptoms from the
time of onset to the time the history is taken.

1. Allow patient to elaborate on the story of his illness; from onset to its
present state.
2. No leading questions
3. Can interrupt to ask for presence of positive or negative symptoms related
to patients current problems.

i.

Date of onset

ii.

Type of onset

iii.

Character

iv.

Location

v.

Relation to other activities(e.g., moving, eating, sleeping, cold, heat, reading)

vi.

Association with complications.

vii.

SITE

viii.

ix.

x.

xii.

Does it stay in one place, or does it move or spread?

May gradually extend or shoot along the distribution of a nerve or


nerve root.

SEVERITY

Does it interfere with daily activities or keep you awake at


night?

If answer is Never, pain is unlikely to be severe.

TIMING & DURATION

xiv.

When did it start? When does it come and when does it go?
Has it changed since it began?

CHARACTER

What is it like?

Descriptions like stabbing, pricking, gnawing, burning.

If pain waxes and wanes or is constant.

OCCURRENCE & AGGRAVATION

xiii.

Note if patient points with a finger to 1 spot or with hands to an area on


the affected body part.

RADIATION

xi.

Where is it?

What brings it on? What makes it worse?

RELIEF

What makes it better?

Pain in pulpal necrosis relieved by cold.

Pain in musculoskeletal system- often relieved by change in position.

ANALYSIS OF SWELLING

DURATION

Acute

Chronic

MODE OF ONSET

Rapid

Slow

Associated with any action such as eating.

SYMPTOMS ASSOCIATED WITH SWELLING

Pain

Difficulty in breathing

Difficulty in swallowing

Fever, loss of weight.

SECONDARY CHANGES

Ulceration

Inflammatory

changes

IMPAIRMENT OF

FUNCTION

Difficulty in eating

Difficulty in opening mouth.

RECURRENCE OF SWELLING

Yes

No

ANALYSIS OF ULCER

Mode of Onset and duration

Pain-

Present/Absent

Discharge-

Serum/Blood/Pus

Associated diseases-

Tb, Syphilis, Diabetes.

MEDICAL HISTORY
Aids in the diagnosis of oral manifestations of systemic disease.

Ensures that medical conditions and medications which affect


dental or surgical treatment are identified..

MEDICAL HISTORY is usually organized into the following subdivisions:

Serious or significant illnesses

Hospitalizations

Transfusions

Allergies

Medications

Pregnancy

SERIOUS OR SIGNIFICANT ILLNESSES:


i.

Illnesses that required attention of a physician

ii.

Necessitated staying in bed for longer than 3 days, or

iii.

for which the patient was (or is being) routinely medicated.

In the dental context any history of :


1.

heart, liver, kidney, or lung diseases;

2.

congenital conditions

3.

infectious diseases

4.

immunologic disorders

5.

diabetes or hormonal problems

6.

radiation or cancer chemotherapy

7.

blood dyscrasias or bleeding disorders

8.

psychiatric treatment.

These questions also serve to remind the patient about medical problems that
can be of concern to the dentist and are therefore worthy of reporting.

HOSPITALIZATIONS:

A record of hospital admissions complements the information


collected on serious illnesses and

May reveal significant events such as surgeries that were not


previously reported.

Hospital records are often the dentists best source of accurate


documentation of the nature and severity of a patients medical
problems

Transfusions:
1. A history of blood transfusions,
2. date of each transfusion
3. Number of transfused blood units

may indicate a previous serious medical or surgical problem :


patients medical status.

Transfusions can be a source of a persistent transmissible


infectious disease.

Allergies:
i.

History of classic allergic reactions, such as urticaria, hay fever,


asthma, or eczema

ii.

Any untoward or adverse drug reaction (ADR)


to medications, local anesthetic agents, foods, or diagnostic
procedures.
Events reported by the patient such as,

fainting,

stomachache,

weakness,

itching,

rash, or

stuffy nose

Events such as,

urticaria
skin rash
acute respiratory difficulties

erythema multiforme
symptoms of serum sickness.
should be differentiated from psychological reactions or aversions
(side effects) to particular medications or foods.
For example, patient claims to be allergic to penicillin should be
questioned as to the type of reaction if it is toxic in nature (nausea,
vomiting) or truly allergic (urticaria, pruritus, respiratory distress, or
anaphylaxis).
It is good practice to record that a patient has no known drug allergies
(NKDA).
Allergic reactions to LATEX are becoming more prevalent. Elicit such
information, prior to instituting a clinical examination.

MEDICATIONS:

A record of the medications a patient is taking.


Identification of medications helps in:

the recognition of drug induced (iatrogenic) disease and

oral disorders associated with different medications

1. To avoid untoward drug interactions :


a. When selecting local anesthetics or other medications used
in dental treatment.
2. Types of medications, changes in dosages over time:
a.

Indication of the status of underlying conditions and


diseases.

3.

Prescription or over-the-counter (OTC) medications, alternative


medications, and other health care products:
a.

Currently taking or has taken within the previous 4- 6


weeks.
b. Name, nature, dose, and dosage schedule of each is
recorded.

PREGNANCY:
i.

Important when deciding to administer or prescribe any


medication.

ii.

Benefit v/s potential risk: Procedure involving exposure to ionizing


radiation.

iii.

Patient believes she could be pregnant: But lacks confirmation by


pregnancy test or a missed menstrual period should be treated as
though she were pregnant.

Printed questionnaire?

To ensure that nothing significant is forgotten: a printed


questionnaire for patients
to complete is valuable and saves time.

Helps to avoid medico-legal problems : written record .

FAMILY HISTORY
Whenever a symptom or sign suggests an inherited disorder, such as
HAEMOPHILIA, the family history should be elicited.
Ideally, this is recorded as a PEDIGREE DIAGRAM and all family
members for at least three generations should be considered.
Inherited disorders
hemophilia
diabetes
hypertension
aggressive periodontitis

Dentinogenesis imperfecta
amelogenesis imperfecta

Communicable diseases
hepatitis
Tuberculosis

leprosy

conjunctivitis

Typhoid
Amoebiasis

If no familial disease ask about Family history might lead into questions about
i.) home circumstances,
ii.) relatives
iii.) social history
can be revealing if, for e.g. psychosomatic factors are suspected.

PAST DENTAL HISTORY


List of details investigated in history:
Frequency of visits to a dentist.
Frequency of dental prophylaxis.
Past experience during and after local anaesthetics.
Past experience during and after extractions.
Past periodontal therapy
Past orthodontic treatment.
Dental appliance therapy
Fixed bridges
Root canal fillings.

Surgical procedures
Radiation or other therapy: for oral or facial lesions1. Date, nature of diagnosis
2. Type, anatomic location of T/t.
3. Names, addresses, and telephone numbers of the
physicians and dentists involved
4. Hospital or Clinic where the treatment was given.

PERSONAL HISTORY
i.

Diet:- Mixed/Vegetarian

ii.

Oral hygiene and brushing techniques

iii.

Pressure habits:- Thumb sucking/Mouth breathing/ Tongue


thrusting

iv.

Other habits:- Nail Biting/Lip Biting

a. Tobacco
Type of Smoking tobacco:
Beedi/Cigarette/Any

other

PACK YEARS- =][


Frequency per Day
Smokeless Tobacco???

b. Any other:- ???

Duration of Chewing in yrs.


Frequency of chewing
Do you retain quid in the mouth?
No/Yes

If yes how long:Hour/ >1 hour

Retain quid during sleep:No/ Yes

Other tobacco habits

<1

b. Alcohol Habits:

Non alcoholic*

Occasional Drinker*

Regular Drinker*

Type of Alcohol Consumed No of years since Alcohol used Quantity consumed /week (ml)-

MENSTRUAL HISTORY

Age of Menarche

Duration of each cycle

Regular/Irregular cycle

Age of attainment of menopause

Post menopausal bleeding

OBSTETRIC HISTORY

Conceived No. of times

Pregnancy carried to term No. of times

No. of abortions
1. Spontaneous/therapeutic

No. of living children

Time interval
1. Successive pregnancies/abortions.

Oedema legs, hypertension, seizures1.Antenatal


2.Postnatal

Gestational Diabetes

1.Impaired glucose tolerance during pregnancy


2. H/O giving birth to a large baby.

LIMITATIONS: HISTORY-TAKING

Language difficulties

Mental or psychological disorders

Patient is describing abnormalities of which they have had no

previous personal experience.

Lack of experience limits

patients ability to give a coherent account.

In psychiatric and many neurological disorders there are further


difficulties.

Have sympathy for patients who struggle to find words or


phrases to describe their symptoms; give them time to express
themselves.

EXAMINATION

GENERAL EXAMINATION

EXTRA-ORAL EXAMINATION

INTRA-ORAL EXAMINATION

GENERAL EXAMINATION
GENERAL APPRAISAL
MENTAL STATE & INTELLIGENCE
BUILD & STATE OF NUTRITION
ATTITUDE
GAIT
STATURE
CONSTITUTION

EXAMINATION

SKIN

NAILS
HAIR
EXAMINATION
HANDS & FINGERS:

HANDS
FINGERS
NAILS

.FEET & TOES:

FEET
TOES

FACE- FOREHEAD:

EYES
NOSE
EARS

CONSTITUTIONAL FEATURES-

TEMPERATURE
PULSE
BP

PAIN
OEDEMA

GENERAL EXAMINATION
General Examination starts when the patient enters the clinic. It
requires daylight as in artificial light one may miss out the faint yellow
tinge of slight jaundice.
Objective : to obtain a general idea of the patients physical status

GENERAL ASSESSMENT OF ILLNESS:


This is very important and should be assessed in the first opportunity.
In case of severely ill patients one should cut down the wastage of time
to know other less important findings.

THE PHYSICAL ATTITUDE:


The position constantly assumed by the patient at rest or in motion is
referred to as posture or physical attitude.
1.
2.

Vertical Line seen when the patient is standing- Good Posture


Standing posture- S shaped curve- when viewed from the side Poor Posture.

GAIT refers to the way one walks.

Abnormalities: neuromuscular disorders

Posture-refers to the way person stands

Abnormalities: predisposes to malocclusion


MENTAL STATE & INTELLIGENCE:
1. Patients intelligence and mental and emotional state should be
initially assessed.
2. Vocabulary & command of language are generally a good guide.

Mental State (Level of Consciousness) is of particular importance in a


head injury patient:

FIRST STAGE

SECOND STAGE

Semi consciousness(drowsy) but can be awakened.

FOURTH STAGE

Fully conscious paient, with lack of orientation of time and space.

THIRD STAGE

Fully conscious patient, perfect orientation of time, space and


person.

Unconscious( stupor) but responding to painful stimuli

FIFTH STAGE

VITAL SIGNS

Unconscious (stupor) and not responding to painful stimuli

Includes
Temperature
Pulse rate
Respiratory rate
Blood pressure

PULSE- The expansile impulse produced by ventricular ejection &


transmitted along the arteries.
Evidence of Heart rate,Cardiac rhythm,
Character of Cardiac output,
Peripheral Circulation
ANATOMIC LOCATIONS

Radial pulse: Medial ventral wrist

Brachial pulse: Antecubital fossa

Carotid pulse: Inferior and medial to angle of mandible, medial


to Sternocleidomastoid (SCM) muscle,
between larynx & SCM
muscle.

Palpation: Place the tips of index ,middle and ring fingers


along the course of artery
at the pulse point.
CHARACTERISTICS OF PULSE

Normal pulse rate: 60 to 90 beats/min

Rhythm: it reflects cardiac rhythm : regular

Abnormalities in rhythm : Cardiac arrhythmia

Pulse volume: denotes the cardiac output

Pulse character

BLOOD PRESSURE

Respiratory rate

Rate and rhythm.

Normal respiratory rate:- 12-20cycles/min

Counted by rise and fall of chest per minute

Tachypnea: fever, exercise, hypoxia

Temperature

Recorded if the presenting complain involves constitutional


symptoms such as fever.

Normal value:

Causes of fever: Local or systemic infections

37 or 98.6

Abscessed teeth
ANUG
Herpetic gingivostomatitis
Malignant neoplasms
PIGMENTATION OF SKIN
1. Generalised Absence Of Pigmentation
2. Patchy Absence of skin pigmentation
3. Circumscribed hypopigmented lesions.
4. Generalised hyperpigmentation
5. Patchy hyperpigmentation.
6.

Yellow pigmentation of the skin

7.

Bluish discolouration

8.

Ruddy complexion

PALLOR

Pale appearance
1. Skin
2. Mucosa
3. Lower palpebral conjunctiva

4. Finger nails & palms


If patient is ANAEMIC.

Loss of pigmentation of palmar creases of the hands :


<7g% Hb

CLUE:

Look for - Presence of a.) Macules


b.) Papules
c.) Pustules
d.) Scars
e.) Vesicles

Segmental distribution of vesicles-

erythematous base, on one of the body


Zoster.

diagnosis of Herpes

Herpes Zoster involving many segments simultaneously


Immunodeficiency disorder AIDS, DM

I.

BLUISH DISCOLOURATIONPeripheral cyanosis- bluish discolouration of nail bed, tips of


fingers, toes, ears, nose.

II.

CENTRAL CYANOSIS- bluish discolouration

III.

mucous membranes of tongue, lips.


sclera
peripheries

METHAEMOGLOBINAEMIA, Sulphahaemoglobinaemia bluish


discolouration simulating cyanosis.

DERMATOGRAPHIA-

Firm stroking of the skin : Red linear elevation Wheal, surrounded


by diffuse pink flare

RUDDY COMPLEXION- Reddish-hue with a tinge of bluish


discolouration- in patients with POLYCYTHEMIA VERA increased
Hb concentration.
IMPORTANT SKIN MARKERS

CUSHINGS SYNDROMEPurplish striae over the lower, anterior abdominal wall.


RHEUMATIC FEVER- Erythema marginatum
PURPURAS, COAGULATION DEFECTS, LEUKAEMIAS- Petechiae,
ecchymosis.
TUBEROUS SCLEROSIS- a. Adenoma Sebaceum
b. Shagreens patch
c. Ash leaf macules
HAEMANGIOMAS- present externally may also be present in the
CNS.

TELANGIECTASIA1. Multiple telangiectasias- Osler-Rendu-Weber syndrome AV


malformations are found in the lung, liver, CNS and mucous
membranes.
2. spider naevi:. decompensated liver disease, SVC obstruction.

PALMAR ERYTHEMAi.

Decompensated liver disease

ii.

Chronic febrile illness

iii.

Chronic leukaemias

iv.

Polycythaemia

v.

Rheumatoid arthritis

vi.

Thyrotoxicosis

vii.

Chronic alcohol intake

ERYTHEMA NODOSUMNon-specific skin marker in Primary complex


Sarcoidosis
Certain drugs

MULTIPLE NEUROFIBROMAS- von Recklinghausens disease.

XANTHOMAS- Hyperlipidaemia.

MALIGNANT TUMOURS- Squamous Cell Carcinoma, Basal Cell


Carcinoma, Malignant
Melanoma.

PIGMENTATION OF MUCOUS MEMBRANE1. ADDISONS DISEASE


2. PEUTZ-JEGHERS SYNDROME
DIABETES MELLITUSi.
Necrobiosis Lipoidica Diabeticorum
ii.
Diabetic Dermopathy
iii.
Diabetic Bullae
iv.
Diabetic Rubeosis
v.
Carotenoderma
vi.
Granuloma Annulare
vii.
Scleroderma Diabeticorum
viii.
Infections

CHRONIC RENAL FAILURE Uraemic frost

Erythema papulatum uraemicum erythematous nodules over


palm, soles, forearm.

Generalised pruritis

Metastatic calcification

Kyrles disease

Nail changes ( half-half nail Oral manifestations coating of


tongue, xerostomia, ulcerative stomatits)

INTERNAL MALIGNANCY

ACANTHOSIS NIGRICANS

NECROLYTIC MIGRATORY ERYTHEMA

PITYRIASIS ROTUNDA

SIGN OF LESER-TRELAT Sudden eruption of intensely pruritic


multiple seborrhoeic
keratosis in Ca stomach

MIGRATORY THROMBOPHLEBITIS Ca pancreas

CUTANEOUS HAMARTOMA Ca breast, thyroid, GI polyposis,


Cowdens disease
EXAMINATION OF HAIR
Evaluated for pattern of distribution, color & texture.
Texture (fine, normal or coarse).
Thin fine hair is seen in Hereditary Anhidrotic Ectodermal Dysplasia
EXAMINATION OF NAILS

KOILONYCHIA

CCF
HYPOALBUMINAEMI
A
ANAEMIA
DIABETES
MELLITUS

BEAUS LINE

PLUMMER NAIL

WHITE( TERRY) NAIL

BLUE NAIL

BLACK NAIL

SILVER DEPOSITS
WILSONS DISEASE

PEUTZ-JEGHERS
SYNDROME
CUSHINGS
SYNDROME
ADDISONS DISEASE

YELLOW NAIL SYNDROME

NAIL PITTING

PSORIASIS

CLUBBING

CLUBBING

Thickening of the nail bed.


Angle obliteration between nail base & skin of the finger.

Lung Abscess
Bronchiectasis
Infective Endocarditis.

EXAMINATION OF FEET & TOES FEET

GENU VARUM

RICKETS

OSTEOMALACIA

OSTEITIS DEFORMANS( Pagets


Disease)

ACHONDROPLASIA

GENU VALGUM

CONGENITAL

RICKETS

LARGE FEET

ACROMEGALY

SHORT & BROAD FEET

ACHONDROPLASIA

OEDEMA
Collection of excess of fluid in the body interstitium, from the intravascular
compartment.

GENERALISED TYPE
PITTING OEDEMA

LOCALISED TYPE
PITTING OEDEMA

CARDIAC

VENOUS

RENAL

LYMPHATIC

HEPATIC

INFLAMMATORY

NUTRITIONAL

ALLERGIC

IDIOPATHIC

NON-PITTING
OEDEMA

EXAMINATION OF HEAD

SKULL

FACIES

FACIAL FORM

SYMMETRY

EYES

EARS

SCLERODERMA
LYMPHOEDEMA
ANGIONEUROTIC OEDEMA
MYXOEDEMA

NOSE

EXAMINATION OF HEAD SKULL


FACIES
1. ACROMEGALIC

8. CUSHINGOID

2. HYPOTHYROID
HYPERTHYROID

9.

3. LEONINE

10. ELFIN

4. MYASTHENIC
PARKINSONIAN

11.

5. BELLS PALSY
CIRRHOTIC

12.

6. CRETINOID
TABETIC

13.

7. MASK LIKE FACIES


IN SLE

15. FACE

EXAMINATION OF HEAD FACE


FACIAL FORM

Profile

Straight
Convex
Concave

Positioning :

Maxilla
Mandible

Presence/Location :

Swellings

EXAMINATION OF HEADEYES
1.Ptosis

9. Exophthalmos

2.Pallor

10. Nystagmus

3.Cyanosis

11. Lid Lag

4.Icterus

12. Miosis

5.Bitots Spots

13. Pigmented Pingueculae

6.Phlyctenular Conjunctivitis

14. Interstitial Keratitis

7.Arcus Senilis

15. Argyll- Robertson Pupil

8.Blue Sclera

EXAMINATION OF HEAD NOSE

GROSS DEFORMITY

ACHONDROPLASIA
FRACTURE
LESIONS
SADDLE SHAPE
NOSE OF SYPHILIS

PRESENCE OF DISCHARGE & RELATION TO POST NASAL DRIP

ALLERGY

LESIONS

EPISTAXIS

NASAL OBSTRUCTION

HABIT
TISSUE HYPERTROPHY
POLYPS
FOREIGN OBJECTS
LARGE TURBINATES

ABILITY TO BREATHE THROUGH NOSE

RELATIONSHIP OF NASAL TO MOUTH BREATHING

EXAMINATION OF NECK

EXAMINED FOR:

Lesions

Scars

Lymph node enlargement

Deviations of trachea

Glandular enlargement

Presence of developmental defects

EXAMINATION OF LYMPH NODES

Sub mental

Submandibular

Cervical

Preauricular

Post auricular

Supraclavicular

Lymph nodes are assessed as:

Solitary nodule/ Multiple masses

Unilateral/ Bilateral

Discrete/ Matted

Tender/

Non-tender

Consistency- Hard, Firm or Fluctuant

Submandibular Lymphnodes

Inspection Position & Number

Palpation-

Stand behind the patient, with the patients


chin tipped slightly towards the chest.

With ones fingers cupped and the tips pressed lightly against the
mylohyoid muscle, the tissue is rolled laterally across the inferior border of
mandible.

On relaxation of pressure , the nodes will be felt to slide across the


mandible into the neck.

Pre & Post Auricular Lymph Nodes

1. Digital palpation is done by pressing against skull.


2. Lymphadenopathy is due to infection of scalp, temporal or frontal areas of
the eye.
EXAMINATION OF TMJ

Inspection

Asymmetry

Deflection/deviation

Swelling

Palpation

Tenderness

Crepitus

Intra auricular examination

Extra auricular examination

Hypermobility/hypo-mobility

Auscultation

Bell-end of stethoscope

Mouth opening:

Ask the patient to open as wide as possible without pain.

Distance from upper and lower incisor edges is measured at the midline.

Normal 35 to 50mm

SOFT-TISSUE EXAMINATION

Lips

Buccal mucosa

vestibular sulcus

Gingiva

Hard palate

Soft palate

INTRA ORAL
EXAMINATION

EXAMINATION

uvula

Tongue

Floor of the mouth

Periodontal examination

EXAMINATION

EXAMINATION OF LIPS

Normal colour

: pale pink & homogenous

Labial mucosa : deep pink & homogenous

EXAMINATION OF BUCCAL MUCOSA & VESTIBULAR SULCUS


Anteriorly: Confluent with labial mucosa
and labial commissure.
Posteriorly Pterygomandibular raphe
Normal landmarks- Parotid papilla, Linea
alba, Fordyce's granules
Inspection- Mouth mirror
Palpation- Bidigitally or bimanually for
texture

EXAMINATION OF HARD PALATE

Color: pale pink & homogenous

Normal structures: palatal rugae, median raphe

Inspection: direct- submental VIEW


indirect- using mouth mirror

Abnormalities: Torus palatinus

EXAMINATION OF THE FLOOR OF THE MOUTH

U-shaped space under the tongue

Lingual frenum divides into two halves

Normal color-pink

Inspection ask the patient to touch the tip of the tongue against the anterior
portion of hard palate
Bimanual palpation.

EXAMINATION OF SOFT PALATE &UVULA

Thin muscular structure that separates


the oral cavity from the nasal cavity and
oropharynx

Uvula located on posterior border of soft


palate

Laterally fuse with pillars of fauces

Normally dark pink to red

Inspection

Color Changes

Papillary Growth

Petechial Spots

Bifid Uvula

Deviation

EXAMINATION OF THE TONGUE


Inspection- It can be best seen with the patients mouth wide open.
Shape, size, fissural pattern , length of
papillae, changes in color , elevations ,
depressions, unusual tremors, should be
noted. Palpation:

Gauze sponge is used to retract the


tongue forward, to the left ,to the right
& upward.
Entire body of the tongue can be
palpated bidigitally.

EXAMINATION OF THE GINGIVA


Attached gingiva: is coral pink in color, free
gingiva is reddish in appearance.
Examination of gingiva: Direct or Indirect vision,
palpation & probing.

Inspection: Changes in color, shape of the


interdentaL papillae, presence & degree of gingival
inflammation can be noted.
Palpation: reveals density may elicit pain ,pus & bleeding in diseased gingiva.

Acute inflammatory responses are red whereas , the more the chronic , the
paler the coloration because of ensuing fibrosis of gingiva.

Inflamed gingiva also has changes in shape &


texture.

DEBRIS & CALCULUS


Grading is done using OHI-S index
Score 0
Score 1
Score 2
Score 3
FURCATION INVOLVEMENT

The progress of inflammatory periodontal disease to bifurcation or


trifurcation of multirooted teeth

Measured using Nabers probe

Grade 1- Incipient stage

Grade 2- Cul-de-sac
Grade 3- Through and through passage of probe
Grade 4- Interdental bone is completely destroyed
and soft tissues have receded completely

PERIODONTAL POCKET

Pathological deepening of the gingival sulcus.

Can be: true pocket or false/ Pseudo pocket

Assessed by: Walking the probe technique

GINGIVAL RECESSION
Apical migration of the gingival margin resulting in exposure of the root surface
Factors to be examined

Presence of local factors

Malposition teeth

High frenal attachment

Ablation

Mode of brushing

TOOTH MOBILITY

Physiologic mobility

Pathologic mobility

Checked USING - mouth mirror or straight probe

Millers classification of tooth mobility

Grade 0- physiologic mobility

Grade 1- movement in faciolingual direction

Grade 2- faciolingual and mesiodistal


movement of tooth

Grade 3-movement in apical direction

HARD-TISSUE EXAMINATION

Teeth present

Decayed teeth

Missing teeth

Filled teeth

Root stumps

Grossly decayed teeth

Fractured teeth

Discoloration and staining

Mobility

Tenderness on percussion

Wasting diseases

Occlusal relation

TEETH PRESENT

ZSIGMONDY PALMER SYSTEM


DECIDUOUS
PERMANENT
DENTITION
DENTITION
EDCBA ABCDE
EDCBA ABCDE

87654321 12345678
87654321 12345678

FDI SYSTEM

DECIDUOUS TEETH
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75

PERMANENT TEETH
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

DECAYED TEETH
Record carious teeth
Location of decay
1.
2.
3.
4.

Detected with an
explorer
Tactile Examination
Smooth surface caries- Place the No.5 explorer in the interproximal
area and walking it up the tooth to the contact point.

MISSING TEETH

Absent teeth

Reason for absence

Congenitally missing teeth

Anodontia

Hypodontia

Oligodontia

FRACTURED TEETH
Class 1
fracture of enamel involving little or no dentin
Class 2

fracture of enamel and considerable dentine not involving the pulp

Class 3

Extensive fracture of the enamel and dentine and exposing the dental
pulp
Class 4

Traumatized
tooth becomes
non-vital.

Class 5

Tooth lost due to


trauma

Class 6

Fracture of the
root with or
without loss of
the crown

Class 7
Displacement of
the tooth with or without the fracture of the tooth structure.
Class 8
Fracture of the crown en masse
Class 9
Fracture of the deciduous teeth

WASTING DISEASES

Attrition

Abrasion

Erosion

Abfraction

OCCLUSAL RELATIONSHIP

For permanent dentition

Angles classification of molar relation

ESTABLISHING A
DIAGNOSIS
DefinitionThe process of
establishing the nature
of an abnormality or
disease that produces
signs &
symptoms is called
diagnosis.

CLINICAL

PATHOLOGICAL

Made by observing pathognomic features

PROVISIONAL

Provided from pathology results

DIRECT

Made from history and examination

Initial diagnosis from which further investigations can be planned

DEDUCTIVE

DIFFERENTIAL

Identify the disease by excluding other possible causes.

DIAGNOSIS EX-JUVANTIBUS

Diagnosis made by considering the similarities & differences


between similar conditions.

DIAGNOSIS BY EXCLUSION

Made after considering all facts from history, examination &


investigations.

Made on the results of response to treatment

PROVOCATIVE DIAGNOSIS

Induction of a condition to establish a diagnosis.

INVESTIGATIONS & RESULTS


Accurate diagnosis is the only true cornerstone on which a rationale treatment
plan can be built.
- C. Noyek

Make or Confirm diagnosis & prognosis


Exclude some diagnosis

LABORATORY INVESTIGATIONS
It helps in final diagnosis. The common methods are

Hematological investigations

Urine analysis

Biochemical investigations

Radiological investigations

Histo pathological investigations

Microbiological investigations

Special investigations Sialography, MRI, Pulp testing etc..

FINAL DIAGNOSIS
Final diagnosis is usually reached after chronologic organisation & evaluation of
the information obtained from the patient history , physical examination &
laboratory examination.

PROGNOSIS
FACTORS DETERMINING PROGNOSIS

Overall clinical factors: age, disease severity

Systemic/environmental factors

Local factors

Prosthetic/restorative factors

TREATMENT PLAN
Any treatment plan should be arranged into a logical and prioritized series of
management procedures designed to solve the patients oral problems.

Phase 1 :

emergency phase
Phase 2 : surgical
phase
Phase 3 :
prophylactic phase
Phase 4 :
restorative phase
Phase 5 : corrective
phase
Phase 6 : recall and
review
CASE ANALYSIS AND SUMMARY
A brief case summary is written at the end of the case highlighting the positive
findings.
The characteristic features of the case are written emphasizing on the
investigatory process and diagnosis.
The treatment plan is explained.

IMPORTANCE OF INFORMED CONSENT


What is informed consent?
Informed consent is the process by which a fully informed patient can participate
in choices about his/her health care. It originates from the legal and ethical right
the patient has to direct what happens to his/her body and from the ethical duty
of the physician to involve the patient in his/her health care.
How much information is considered "adequate"?

Reasonable physician standard:

Physician can determine what information is appropriate to disclose.

the typical physician tells the patient very little.

Standard is considered inconsistent focus is on the physician


rather than on what the patient needs to know.

Reasonable patient standard:

focuses on what a patient would need to know in order to


understand the decision at hand.

Subjective standard:

What patient needs to know and understand in order to make an


informed decision?

Most challenging to incorporate into practice, since it requires


tailoring information to each patient.

What are the elements of a complete informed consent?

Goal of informed consent-

Patient should have an opportunity to be an informed participant in his


health care
decisions.

Complete informed consent includes a discussion of the following


elements:

1. Nature of the decision/procedure.


2. Alternatives to the proposed intervention, relevant risks, benefits, and
uncertainties related to each alternative.
3. Assessment of patient understanding.
4. Acceptance of the intervention by the patient.

3. When is it appropriate to question a patient's ability to participate in


decision making?

Most cases, its clear if patient is competent to make their own


decisions.
Occasionally not so clear. Patients are under an unusual amount of stress
during illness and can experience anxiety, fear, and depression. Stress
associated with illness should not preclude one from participating in
one's own care.
Precautions to ensure the patient does have the capacity to make
good decisions.

Dentist should assess the patient's ability to:


1. Understand his or her situation,

2. Understand the risks associated with the decision at hand, and


communicate a
decision-based on that understanding.
3 .When this is unclear, a psychiatric consultation can be helpful.
3. What about the patient whose decision making capacity varies from day to
day?
Patients can move in and out of a coherent state as their medications or
underlying disease processes ebb and flow.
You should do what you can to catch a patient in a lucid state
even lightening up on the medications if necessary in order to include
him in the decision making process.
4. What should occur if the patient cannot give informed consent?

Patient is determined to be incapacitated/ incompetent to make health


care decisions a surrogate decision maker must speak for him/her.

Specific hierarchy of appropriate decision makers defined by state law .

If no appropriate surrogate decision maker is available Physicians are


expected to act in the best interest of the patient until a surrogate is
found or appointed.

5. Is there such a thing as presumed/implied consent?


Patient's consent only "presumed", rather than obtained, in emergency
situations when patient is unconscious or incompetent and no surrogate
decision maker is available.

In general, the patient's presence in the hospital ward, ICU or clinic does
not represent implied consent to all treatment and procedures.

The patient's wishes and values may be quite different than the values of
the physician's.

The principle of respect for person obligates you to do your best to


include the patient in the health care decisions that affect his life and

body, the principle of beneficence may require you to act on the patient's
behalf when his life is at stake.

REFERENCES
Oral diagnosis by Kerr, Ash & Millard , 6th edition

Principles of Oral Diagnosis by Coleman and Nelson, 1st edition

Textbook of Oral Medicine, Diagnosis and Treatment by, Burket ,


10th edition.

Essentials of Oral Pathology and Medicine by Crispian Scully, 1 st


edition.

Textbook of Oral Medicine & Radiology by, Dr. Ravikiran Ongole,


1st edition.

Textbook of Clinical Medicine, by Hutchinson

Textbook of Clinical Medicine by, Alagappan, 2nd edition.

Textbook of Oral Pathology by Neville, 3rd edition

Textbook of Periodontology by, Carranza 11th edition

Textbook of General Surgery by, S. Da, 2nd edition

Textbook of Pediatric Dentistry by, Mac Donald