CASE HISTORY

BY
DR NAMRATA JIDEWAR
DR KAPIL NALADKAR
Contents
 Introduction
 General Information
 Chief Complaint
 History of Present Illness
 Previous Dental History
 Medical History
 Clinical Examination
 Establishing the Diagnosis
 Investigations
 Final Diagnosis
 Formulating a Treatment Plan
 Introduction
 Definition: Case history is defined as the data concerning an individual and his or her family and
environment, including the individual medical his story that maybe useful in analyzing and diagnosing
his or her case or for instructional purposes.(Grossman’s 14th Edition)

 “Accurate diagnosis of a disease depends on the art of taking Case History”

 Case history is defined as planned professional conversation that enables a patient to communicate
his/her feelings, fear and sequence of events leading to the problem for which the patient seeks
professional assistance, to the clinician so that patients’ real or suspected illness and mental attitude of
the patient can be determined.
 Sequence of case recording and
evaluation:
• General • Chief • History of • Medical • Past Dental
Information Complaint Present Illness History History

• Provisional • Intraoral • Extraoral • Personal

• Investigations
Diagnosis Examination Examination History

• Final • Treatment
Diagnosis Plan
General Information
PATIENT REGISTRATION NUMBER
It helps the investigator in:
• Identification of the patient
• Record maintenance
• Billing purposes
• Medicolegal aspects

A Practical Manual of Public Health Dentistry by CM Marya 1st Edition

DATE

The date is recorded for the following purpose:

• Reference
• Record maintenance.

A Practical Manual of Public Health Dentistry by CM Marya 1st Edition

NAME

Knowing the complete name of the patient while recording history leads
to:
• Identification
• Communication General Information
• Establishing a rapport with patient
• Record maintenance
AGE

(date of birth) has a particular significance to the investigator to decide upon:

• Diagnosis
• Treatment planning
• Behavior management techniques.
 SEX

Similar to age, certain dental and systemic diseases also show sex predilection.
Some diseases are more specific to females while some are to males.

 The study conducted by Karuveettil et al reported an increased prevalence of dental

caries among males. While males had 1.26 times the odds of having caries compared to
females in a study done by Kirthiga et al.

 The study by Lukacs in South Asia showed that among the adult population, the
prevalence of caries among males was lower compared to females

Karuveettil, V., Krishna, K., and Ramanarayanan, V. (2022). Is gender a risk factor for oral diseases in India? A metadata
exploration. Public Health and Toxicology, 2(1), 7. https://doi.org/10.18332/pht/145517
EDUCATION

Education level of the person is recorded to determine:

• Socio-economic status
• Intelligence quotient (IQ) for effective communication
• Attitude towards general and oral health.
ADDRESS

Full Postal Address should be taken in order for communication and to ascertain
geographic distribution.
1. For future correspondence/Recall
2. Gives a view of the socioeconomic status.
3. To know prevalence of diseases
4. For hospital records/Administrative purposes.
RELIGION

Religion has a particular significance to the investigator

in:
• Identifying the festive periods when religious people
are reluctant to undergo treatment procedures
• Predilection of diseases in specific religions.
OCCUPATION
It is an indicator of socioeconomic status. Also, it shows predilection of diseases in
different occupations,

(Adapted from I. Schour and B. G. Sarnat. Oral manifestations of occupational origin. JAMA 1942; 120: 1197 )
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.

 It is recorded in patient’s own words as much as possible, and no

documentary or technical language should be used.

 The chief complaint aids in the diagnosis and treatment planning

and should be given the first priority.
 The patient’s chief complaints, or the concerns that initiated the patient’s visit,
should be first recorded verbatim.

 The patient should be encouraged to discuss all aspects of the current problems,
including onset, duration, symptoms, and related factors.

Sturdevants Art & Science of Operative Dentistry 2e south Asian

Common chief complaints include:

• Pain

• Sensitivity

• Decayed tooth

• Swellings

• Food lodgement

• Routine dental check-up.

History of Present Illness
 Initially, the patient may not volunteer a detailed
history of the problem, so the examiner has to elicit
out additional information by the possible
questionnaire about the symptoms.

 The patient’s response to these questions is termed

history of present illness. It is a chronological account
of the chief complaint and associated symptoms from
the time of onset to the time the history is taken.

 The history commences from the beginning of the first

symptom and extends to the time of the examination.
• The questions can be asked in the following manner:–
 When did the problem start?–
 What did you notice first?–
 Did you have any problems or symptoms related to this?–
 What makes the problem worse or better?–
 Have any tests been performed before to diagnose this complaint?–
 Have you consulted any other examiner for this problem?–
 What have you done to treat this problem? Etc.
• In general, the symptoms can be elaborated under:–
 Mode of onset–
 Cause of onset–
 Duration--
 progress and referred pain–
 Relapse and remission–
 Treatment–
 Personal History
Habits and addiction: It is an important aspect of
history taking. Many diseases can correlate with particular
habits of the patient.
 Oral hygiene and brushing technique: Bad oral
hygiene and improper brushing techniques may lead
to dental caries and periodontal disease.
 Horizontal brushing technique may lead to cervical
abrasion of the teeth

 Mouth breathing: It may lead to anterior marginal

gingivitis and caries

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
 Bobby pin opening: Seen in teenage girls who open
bobby pins with anterior incisors to place them in the hair.
This results in the notching of incisors

 Bruxism: It may lead to attrition

 Tobacco: Tobacco preparations such as khaini, mawa,
mishri, pan, snuff, zarda, etc. should be asked–
 Smoking: Smoking habits such as bidi, chutta, cigarette,
dhumti, hookah, etc.–
 Drinking habit: Drinking alcohol,
 Patient’s appetite: Whether it is regular or irregular? You should ask the type of
diet (vegetarian, mixed) to the patient

 Soft diet: A soft refined diet adheres tenaciously to the teeth and is not removed
because of lack of rough edges leading to more dental caries than a coarse diet

 Coarse diet: In persons, having a coarse diet, there is more evidence of attrition
 Carbohydrate content: Increased carbohydrate contents leads to increased
prevalence of dental caries.

 Nutritional deficiency: Deficiency of calcium and phosphorus during period of

tooth formation results in enamel hypoplasia and defects of dentin.
 Medical History
 Successful endodontic practice requires complete knowledge about the various
medical conditions and appropriateness in planning treatment as per the need with
effective safety measures.
 Practitioners must be aware of common diseases, and drugs that have an impact in
endodontic treatment and the management options in such cases.
Endodontic Consideration in Hypertensive
Patients

 Hypertension is the medical term for high blood

pressure, meaning that the blood applies too much
force against the blood vessel walls.

 It is estimated that approximately 1 billion people

worldwide
  It is generally accepted that patients with
SBP greater than 180 or DBP greater than
110 should be taken for medical
consultation

 Routine dental treatment should be

deferred until acceptable blood pressure
levels are achieved, and the patient should
be referred for medical evaluation.

Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood
pressure: the JNC 7 report. JAMA. 2003;289(19):2560–72.
 Prolonged use of certain nonsteroidal anti-inflammatory drugs (NSAIDs), such as
ibuprofen, indomethacin, or naproxen, is shown to reduce the effectiveness of
antihypertensive drugs, paracetamol can be used to avoid this side effect

 Excessive bleeding especially is a possibility in hypertensive patients. Therefore,

aggressive dental surgical procedures should be performed with great caution in
these patients
 Endodontic Consideration in diabetic
patients
 According to the International Diabetes Foundation
(2015), diabetes mellitus is now an epidemic with 415
million people affected globally.

 Diabetes is reported to have been responsible for 5

million deaths worldwide in 2015.

 It is characterized by hyperglycemia (increased blood

glucose level) with or without glycosuria resulting from
an absolute or conditional deficiency of insulin
 In patients with controlled diabetes, no
special treatment is required for routine
dentistry including prophylaxis and dental
restorative care.

 Morning appointments are recommended

because cortisol levels are highest at this
time and will provide the best blood glucose
level.
 For patients receiving insulin therapy, appointments should be scheduled so that
they do not coincide with peaks of insulin activity since this is the period of
maximal risk of developing hypoglycemia

 Before the procedure, it has to be ensured that the patient has eaten normally and
taken medication as usual

 Emotional and physical stress increases the amount of cortisol and epinephrine
secretion that induces hyperglycemia. Therefore, if the patient is very
apprehensive, pretreatment sedation should be contemplated
Endodontic Considerations in Patients
with Bleeding Disorders

 Many dental procedures are associated with

postoperative bleeding, which in most cases, is
self-limiting and non-problematic.

 However, some people are at an increased risk of

bleeding due to inherited bleeding disorders, in
which even relatively minor invasive procedures
can precipitate a prolonged bleeding episode
 Patients with congenital bleeding disorders require the formulation of a
comprehensive treatment plan with an overall goal of achieving satisfactory
hemostasis.

 It is essential to prevent accidental damage to the oral mucosa when carrying out
any procedure in the mouth by implementing general measures such as careful use
of saliva ejectors and care in the placement of radiographic films
 Endodontic treatment is generally low risk for patients with bleeding disorders.

 Nonsurgical endodontic procedure can be performed without any modification in

anticoagulant therapy

 Periapical surgery may pose a greater challenge for hemostasis therefore, a

consultation with the patient’s hematologist is required in developing an
appropriate treatment plan.
 It is important that the procedure be carried out carefully with the working length
of the root canal calculated to ensure that the instruments do not pass through the
apex of the root canal.

 Sodium hypochlorite should be used for irrigation in all cases, followed by the use
of calcium hydroxide paste to control the bleeding.
 Dental pain can usually be controlled with a minor analgesic such as paracetamol
(acetaminophen) and codeine-based preparations. Aspirin should not be used due
to its inhibitory effect on platelet aggregation.

 The use of any nonsteroidal anti-inflammatory drug (NSAID) must be discussed

beforehand with the patient’s hematologist because of their effect on platelet
aggregation. Antibiotics should only be prescribed if there is local spread or signs
of systemic infection.

 Local hemostatic measures to control bleeding in anticoagulated patients,

atraumatic surgical methods, pressure application, proper wound closure, and
topical clotting agents are some useful here.
Endodontic Considerations in Patients
with Valvular Disease

 An infection on or near the heart valves caused

by a bacteremia is termed as infective or bacterial
endocarditis.

 Patients with valvular disease possess potential

risk for infective endocarditis (IE) and risk of
excessive bleeding in patients on anticoagulant
therapy

 patients with pathologic valve disease are to be

managed in close consultation with their
physicians, especially to determine the need for
antibiotic premedication
 Antibiotic prophylaxis is only recommended for dental procedures that involve
manipulation of the gingival or the periapical tissue.

 In general, procedures associated with nonsurgical root canal treatment such as

local anesthetic injection, placement of the rubber dam, and instrumentation
within the canal system do not place the patient at significant risk for infective
endocarditis.

 Maintaining good oral hygiene and eradicating dental disease is shown to

decrease the frequency of bacteremia from routine daily activities.
 Maintaining good oral hygiene and eradicating dental disease is shown to
decrease the frequency of bacteremia from routine daily activities.

 All the standard infection control protocols should be followed such as

sterilization of instruments, barrier techniques, and disinfecting the dental clinic
and the surgical area, in general maintaining the hygiene of the operatory.

 Antimicrobial mouth rinse (0.2% chlorhexidine) given before any dental

treatment is shown to reduce bacteremia of oral origin
Antibiotic Prophylactic Regimens for Endocarditis, as
recommended by the American Heart Association
Endodontic Considerations in Patients
with Asthma

 Asthma is a respiratory disease that affects the

respiratory system characterized by inflammation and
bronchoconstriction.

 Clinicians should be aware of the potential for dental

materials and products to exacerbate asthma, which
include dentifrices, fissure sealants, tooth enamel dust,
and methyl methacrylate.
 If the patient uses a bronchodilator inhaler, it is essential to advise him/her to
bring the inhaler during each dental visit.

 Anxiety is a trigger and dental treatments often trigger an acute asthmatic attack.
A well-planned and uncomplaining approach of the dentist and dental team
members may help to lessen the anxiety.
 Macrolides (e.g., erythromycin, azithromycin, clarithromycin), ciprofloxacin, and
clindamycin should be avoided in patients taking theophylline due to the risk of
methylxanthine toxicity.

 NSAIDs, barbiturates, and narcotics should be avoided in all asthmatic patients.

 LA-containing epinephrine should be avoided as its sulfite preservative

component may induce acute asthmatic attacks and allergic reactions.
 Improper positioning of suction tips or the use of cotton rolls could trigger a
hyperreactive airway response in sensitive subjects.

 Rubber dams should be used judiciously to avoid possible respiratory

compromise or aggravation. Prolonged supine positioning can also trigger an
asthmatic attack in the dental setting.

 In the event of an acute asthmatic attack during dental treatment, the clinician
should stop the procedure, remove all intraoral implements rule out foreign body
aspiration, and initiate the emergency protocol for managing acute asthmatic
exacerbation.
  LA-containing epinephrine should be avoided as its sulfite preservative
component may induce acute asthmatic attacks and allergic reactions.

 Improper positioning of suction tips or the use of cotton rolls could trigger a
hyperreactive airway response in sensitive subjects.

 Rubber dams should be used judiciously to avoid possible respiratory compromise

or aggravation.

Wynne, C. (2018). Endodontics in Systemically Compromised Patients. In: Jain, P. (eds) Common Complications in Endodontics. Springer, Cham
HIV and Endodontics
 Endodontic treatment prognosis is generally poorer in immunocompromised
patients, like those with HIV infection

 The presence of apical periodontitis exacerbates the challenges in treating such

patients

 Consequently, the compromised immune response in HIV-infected patients may

lead to prolonged or incomplete healing following endodontic treatment, resulting
in a poorer prognosis.
 One of the challenges faced by HIV-positive patients and their dentist is the
potential for adverse drug interactions.

 Many of the medications dentists commonly administer or prescribe may interfere

with the metabolism of the antiretroviral medications

 The dental clinician should know the medications that their HIV-positive patients
are taking, understand the potential drug interactions with medications they
prescribe
 Covid 19 and Endodontics

 Throughout the world, COVID-19 has had a major impact on healthcare

professionals and their day-to-day work.
 The disease has created very challenging conditions and several front-line staff
have become infected and died because of the coronavirus

Provision of dental care

Several criteria have been proposed for the management of dental care during the
COVID-19 pandemic(Abramovitz et al. 2020, Alharbiet al. 2020, Atheret al. 2020,
Penget al. 2020).

Azim AA, Shabbir J, Khurshid Z, Zafar MS, Ghabbani HM, Dummer PM. Clinical endodontic management during the COVID ‐19
pandemic: a literature review and clinical recommendations. International endodontic journal. 2020 Nov;53(11):1461-71.
 It is recommended that patients should also be asked :
 whether they have a fever or flu-like symptoms, respiratory problems, or change
in taste or smell(Chenet al. 2020, Giacomelliet al. 2020)

 whether they have been in contact with individuals who had these symptoms, or
with a confirmed COVID-19-positive patient.

Azim AA, Shabbir J, Khurshid Z, Zafar MS, Ghabbani HM, Dummer PM. Clinical endodontic management during the COVID ‐19
pandemic: a literature review and clinical recommendations. International endodontic journal. 2020 Nov;53(11):1461-71.
Treatment protocol

Azim AA, Shabbir J, Khurshid Z, Zafar MS, Ghabbani HM, Dummer PM. Clinical endodontic
management during the COVID‐19 pandemic: a literature review and clinical
recommendations. International endodontic journal. 2020 Nov;53(11):1461-71.
 Wounds and needle stick injuries following dental procedures resulting in
bleeding and contamination represent the biggest problem concerning potential
viral transmission to clinical staff

 The risk of seroconversion after a needle stick injury with HIV-infected blood is
approx. 0.03%

 In case of deep penetrating injury with accidental exposure to HIV-infected blood

and body fluids, a prophylactic administration of triple antiretroviral therapy
along with immediate referral to a specialist is recommended.
Previous Dental History

It is crucial to understand past experiences to provide optimal care in the future. The
review of the dental history often reveals information about:
 Past dental problems,
 Previous dental treatment,
 Patient’s responses to the treatments.
 Frequency of dental care
 Perceptions of previous care may be indications of the patient’s future behavior.
 If a patient has difficulty tolerating certain types of procedures or has encountered
problems with previous dental care, an alteration of the treatment or environment
might help in avoiding future complications.

 The date and type of available radiographs should be recorded to ascertain the
need for additional radiographs and to minimize the patient’s exposure to
unnecessary ionizing radiation.
Clinical examination
Extra oral
examination

General Intraoral
examination examination

Clinical
examination
 General examination
The following signs should be looked for in general examination
Behavior attitude and posture-
 These include whether the patient is aware of time, place, and person.

 Behaviour (Observed) - Possible descriptors: • Mannerisms, gestures, psychomotor

activity, expression, eye contact, ability to follow commands/requests, compulsions.

 Attitude (Observed) - Possible descriptors: • Cooperative, hostile, open, secretive,

evasive, suspicious, apathetic, easily distracted, focused, defensive.

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Vital signs – pulse, temperature, respiration, and blood pressure
(BP)

 Pulse

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Rate: Fast or slow (normal 60-100 beats/min)

Rhythm: Regular or irregular, irregularly irregular in arterial fibrillation and regularly

irregular in ventricular ectopic.

Volume: High, low and normal volume indicate pulse pressure (normal pulse pressure is
40–60 mm Hg).

Character: Water hammer pulse of aortic regurgitation, pulsus paradoxus of pericardial

effusion, anaerobic pulse (it is a slow rising twice beating pulse where both waves are felt
during systole in carotid artery) in aortic stenosis.

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Temperature

 According to Johns Hopkins normal body temperature can range from

97.8 degrees F (or Fahrenheit, equivalent to 36.5 degrees C, or Celsius) to 99
degrees F (37.2 degrees C) for a healthy adult.

 Body temperature may be abnormal due to fever (high temperature) or

hypothermia (low temperature).

 A fever is indicated when body temperature rises about one degree or more over
the normal temperature of 98.6 degrees Fahrenheit, Hypothermia is defined as a
drop in body temperature below 95 degrees Fahrenheit according to the American
Academy of Family Physicians.
Respiration

 A respiratory rate, or breathing rate, is the number of breaths a person takes in 1 minute
while at rest.

 Respiratory rate can be measured by counting the number of times a person’s chest rises
and falls within a minute.

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
 The normal respiratory rate for children from the age of 1 to 5 years old, normal
respiration is 20 to 30 breaths per minute.

 Children who are from 6 to 12 years old should have a normal respiratory rate
that ranges from 12 to 20 breaths per minute.

 The normal respiratory rate for adults and children over the age of 12 ranges from
14 to 18 breaths per minute.

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Blood Pressure

 It is useful to determine:

 The stroke volume of the heart and stiffness of the arterial vessels.

 To assess severity of hyper and hypotension and aortic incompetence. (normal

level of blood pressure is 120/80 mm of Hg)

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Blood Pressure: AHA guidelines
 Pallor
 Icterus
 Cyanosis
 Clubbing of fingers
 Build and nutrition
 Oedema
 Lymphadenopathy

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Pallor

 Pallor is defined as paleness or a loss of color from your normal skin tone

 Sites to look for pallor: those surfaces of the body which have large number of
superficial blood vessels i.e.:
1. Lower palpebral conjunctiva
2. Tongue and oral mucosa
3. Nail beds
4. Palm

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
 Icterus

 Definition: In jaundice, there is an icteric tint of the

skin, due to the presence of bilirubin, which varies from
the faint yellow of viral hepatitis to the dark olive-
greenish-yellow color of obstructive jaundice

 Site where you should look for icterus: The places where
one should look for icterus are the sclera of the eyeball
(nailbed, lobule of ear, the tip of the nose, and under the
surface of the tongue)

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Cyanosis
 Definition: Cyanosis is the bluish discoloration due to increased
amount of reduced Hb (more than 5 mg%) in capillary blood.

 Types: It can be central, peripheral, cyanosis due to abnormal

pigment or mixed.

 Sites where peripheral cyanosis is looked for: Nailbed, tip of the

nose, skin of the palm and toes

 Sites where central cyanosis is looked for: Tongue and other sites
mentioned above. Tongue is unaffected in peripheral cyanosis

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
 Clubbing of fingers
 Definition: Clubbing is the bulbous enlargement of the
soft part of the terminal phalanges of the nail.
Causes: It includes: –
 Pulmonary causes: Like bronchogenic carcinoma, lung
abscess, bronchiectasis, and tuberculosis with secondary
infection
 Cardiac causes: Like infective endocarditis and cyanotic
congenital heart disease
 Alimentary causes: Like ulcerative colitis, Crohn’s
disease and biliary cirrhosis
 Endocrine causes: Like myxedema and acromegaly

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Build and nutrition

Build It can be described as poorly built, moderately built and well built.
 Asthenic: It appears as lean and underweight
 Sthenic: They are athletic in appearance
 Normosthenic: Normal average body build
 Hypersthenic: Persons have thick muscular and heavy bone structure

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
State of nutrition

 It depends upon distribution of adipose tissue in the body.

 On this basis individuals are classified as –normal, overweight(fat or
obese), underweight.
 Asthenic: It appears as lean and underweight
 Sthenic: They are athletic in appearance •
 Hypersthenic: Persons have thick muscular and heavy bone
structure

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
 Body mass index

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Lymphadenopathy

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Inspection of lymph node swelling: –

• Position: Position is important, as it will not only give an idea as to

which group of lymph nodes is affected but also help in diagnosis –

• Number: It is important since in some diseases there is generalized

involvement of the lymph nodes like Hodgkin’s disease, lymphatic
leukemia and lymphosarcoma

• Pressure effect: Swelling and venous engorgement of the face and neck
may occur due to pressure effect of the lymph nodes at the root of the
neck

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Palpation:
Extra Oral Examniation

1. Face
a. Face should be assessed, and any abnormal findings noted in the
clinical records. These include swelling, discoloration, and any
asymmetry.

b. Asymmetry can occur due to swellings originating from both

dental and non-dental causes such as infection, neoplastic
growths, and hypertrophy.

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
A subtle visual change such as loss of definition of the nasolabial
fold on one side of the nose may be the earliest sign of a canine
space infection

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Temporomandibular Joint

• History: Medical history of illness, particularly rheumatoid arthritis,

degenerative joint disease, and osteoarthritis should be asked.

• Interincisal opening: The maximum interincisal opening of the mouth

should be determined, which is, normally, in an adult 35–50 mm.

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
• Mandibular movement: Any deviation of the mandible during opening should be
noted, along with its severity.

• The lateral mandibular range of motion is determined by having the patient to

occlude the teeth and then slide the jaw in both directions.

• The range of movement from the midline is measured in mm and any pain along
with location and severity is recorded. Normal lateral movement is usually 8–10
mm

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
 Intraoral Examination
Tongue –
• Color: The white color of leukoplakia, candidiasis, the red
color of the tongue when the leukoplakic plaque gets
desquamated, blue color of venous hemangioma. Black
tongue due to hyperkeratosis of the mucous membrane in
heavy smokers or caused by fungus aspergillus are very
characteristic.

• Swelling and ulcer: Examine the tongue for any swelling or

ulcer

• Mobility of the tongue

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Cheek
• Examine the inside of the cheek for aphthous ulcers, leukoplakia, mucous
cysts, lipoma, mixed salivary tumors, papilloma, and carcinoma

• Pigmented patches: Pigmented patches are seen in Addison’s disease and

Peutz Jegher’s syndrome

• White lesion: It can be seen in pronounced linea alba, leukoedema,

hyperkeratotic patches

• Red lesion: It can be present in ulcers, nodules, scars, and malignancy

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Palate
Inspection
• Point to look for Congenital cleft, perforation, ulceration,
swelling, fistulae, papillary hyperplasia, tori, recent burns,
and hyperkeratinization

• Cleft examination: In case of congenital cleft, note the

extent of the cleft (involving only the uvula, only the soft
palate, or part or whole of the hard palate). Whether the
nasal septum is hanging free or attached to one side of the
cleft

•Point to look for: Tender, fluctuating swelling close to

alveolar process is an alveolar abscess.
Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Salivary Glands

• Parotid Swelling: Keep in mind the position of the parotid gland, which is
below, behind, and slightly in front of the lobule of the ear.

• A swelling of the parotid gland thus obliterates the normal hollow just below
the lobule of the ear. The position is important since many of the lymph node
swellings are mistaken for parotid gland tumors and vice versa.

• Note the extent, size, shape, and consistency. Whether the swelling is fixed to
the masseter muscle or not, is confirmed by asking the patient to clench his
teeth, and mobility is tested over the contracted masseter muscle

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Submandibular Salivary Gland
• History: Swelling with colicky pain at the time of meals suggests
obstruction in a submandibular duct.

• It is tense and painful. Swelling is more often due to lymph node

enlargement rather than salivary gland enlargement.

• If the patient gives the history which is suggestive of a stone in the

duct ask the patient to suck a little lemon or lime juice. The swelling
will appear at once

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Gingiva

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Periodontium

• The patient’s teeth and periodontium should be examined in good light under dry
conditions.

• For example, a sinus tract (fistula) might escape detection if it is covered by

saliva or an interproximal cavity may escape notice if it is filled with food.

• Visual examination should include the soft tissue adjacent to the involved tooth,
for the detection of swelling

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
 • A vertical root fracture may often cause a localized narrow periodontal
pocket that extends deep down the root surface. Characteristically, the
adjacent periodontium is usually within normal limits.

• Furcation bone loss can be secondary to periodontal or pulpal disease. The

amount of furcation bone loss, as observed both clinically and
radiographically, should be documented

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Furcation involvement: The term furcation involvement refers to the
invasion of the bifurcation and trifurcation of multirooted teeth by the
periodontal disease.

• Grade I: It is incipient bone loss. Clinically only slight

catch occurs in the furcation area while probing

• Grade II: Partial bone loss. In this case, probe can pass
in the furcation area upto middle

• Grade III: Total bone loss through and through

opening of the furcation. Probe can pass through and through

• Grade IV: It is similar to grade III but with gingival

recession exposing the furcation to view

Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
Hard tissue examination
Inspection

You should look for caries (pit and fissure, smooth surface caries, cervical caries),
defective restoration, or recurrent caries.

Note missing and supernumerary teeth (Mesiodens, paramolar, distomolar). Presence

of root pieces of badly carious fractured teeth.

Also look for over-retained deciduous teeth, impacted teeth, ankylosed teeth, fusion
of teeth, Talon’s cusp, taurodontism, anodontia, enamel hypoplasia, mottled enamel,
neonatal teeth, eruption sequestra, delay eruption, attrition, abrasion,
• Percussion test: This test enables to evaluate the status of the periodontium
surrounding a tooth.
• There are two types of percussion tests carried out, i.e. vertical percussion
and horizontal percussion test.

• Vertical percussion test: If the vertical percussion test is positive, it indicates

periapical pathology, the tooth is struck with a quick, moderate blow,
initially with low intensity by the finger and then with increasing intensity
by using the handle of an instrument, to determine whether the tooth is
tender.
• Firstly you have to tap adjacent teeth and then tap an affected one. The
patient’s response should be taken from the patient body movement, and
reflex reaction of the eye. If a tooth is tender patient will blink his eyes due
to the pain

• Horizontal percussion test: If the horizontal test is positive it indicates

periodontium-associated problems. In the case of the horizontal percussion
test, the procedure is the same but the direction of the blow is in the
horizontal direction
Mobility and depressibility test

• Mobility test: The test consists of moving a tooth laterally in its socket by
using the finger or preferably in the handles to two instruments. The objective
of this test is to determine whether the tooth is firmly or loosely attached to its
alveolus

• Depressibility test: Similarly, the test for depressibility consists of moving a

tooth vertically in its socket. When depressibility test is positive chances of
retaining the tooth range from poor to hopeless
According to Millar: The second method was developed by Millar (1950) in
which the tooth is held firmly between 2 instruments and moves back and
forth and the mobility score is noted as follows:

- 0—It denotes no detectable movement when force is applied other than

what is considered normal (physiologic) motion
- 1—It indicates mobility greater than normal
- 2—Mobility up to 1 mm in a buccolingual direction
- 3—Mobility greater than 1 mm in a buccolingual direction combined with
the ability to depress the tooth.
Examination of Occlusion
Clinical Examination for Caries

• The visual examination is conducted in a dry, well-

illuminated field.

• Direct vision is used to observe how light passes into

the surface of the tooth structure.

• The occlusal surface is diagnosed as diseased if

external chalkiness (enamel caries) subsurface opacity
(dentin caries) or cavitation of tooth structure,
forming the fissure or pit, is seen.
• As noted earlier, sharp explorers previously have been used to evaluate fissures
and pits in an attempt to diagnose fissure/ pit caries. However, numerous studies
have found that the use of a sharp explorer for this purpose did not increase
diagnostic validity compared with visual inspection alone.

• The use of the dental explorer for this purpose was found to fracture enamel and
serve as a source for transferring pathogenic bacteria among various teeth.
therefore the use of a sharp explorer in diagnosing pit-and-fissure caries is
contraindicated as part of the detection process.
 DYES
• Stains only the demineralized tooth structure.

 Dyes for enamel caries

 ‘Procion’(Staining is irreversible because the stain

reacts with –OH and _NH2 groups and acts as a fixative.)
 ‘Calcein’(Complexes with calcium and remains
bound in the lesion)

 Dyes for dentinal caries

 0.5% Basic Fuchsin in propylene glycol(carcinogenic)

 Methylene blue
 Acid red

Dr. Anil K Tomer, Dr. Panna Mangat, Dr. Afnan Ajaz Raina, Dr. Faizan Bin Ayub, Dr. Megna Bhatt, Dr. Midhun Ramachandran, Dr. Ashvin G John. Diagnostic aids to detect caries-A review. Int J
Appl Dent Sci 2019;5(2):16-20.
 • 1% acid red in propylene glycol complexes specifically with denatured collagen,
hence used to differentiate infected and affected dentin.

DISADVANTAGES:

Dye staining and bacterial penetration are independent phenomena, hence no actual quantification:

• They also stain food debris, enamel pellicle, and other organic matter
• Dye-aided carious removal- laborious
• Stains DEJ

Pitts NB. Diagnostic tools and measurements—impact on appropriate care. Community Dentistry and Oral Epidemiology
1997; 25 (1):24–35.
Proximal Surfaces

• It also may be detected by careful visual examination after tooth

separation or through fiberoptic transillumination.

• When the caries lesion has progressed through the proximal surface
enamel and has demineralized dentin, a white opaque appearance or a
shadow under the marginal ridge may become evident
 Root caries

• The traditional methods of visual-tactile diagnosis for

root caries can produce a correct diagnosis, but usually
not until the lesion is at an advanced stage.

• Root caries most often occurs supragingivally, at or

close to (within 2 mm) the cemento-enamel junction.

• This phenomenon has been attributed to the location

of the gingival margin at the time conditions were
favorable for caries to occur
The location of root caries has been positively associated with age and gingival recession.

This is consistent with the concept that root caries occurs in a location adjacent to the crest
of the gingiva where dental plaque accumulates.

Root caries occurs predominantly on the proximal (mesial and distal) surfaces, followed
by the facial surface.

Early root caries tends to be diffuse (spread out) and track along the cemento-enamel
junction or the root surface. More advanced root lesions enlarge toward
the pulp

Banting, David W. "The diagnosis of root caries." Journal of dental education 65.10 (2001): 991-996.
 Bite test

• The bite test is useful in identifying a cracked tooth or fractured

cusp when pressure is applied in a certain direction to one cusp or
section of the tooth.

• It is also helpful in diagnosing cases wherein the pulpal pathosis

has extended into the peri-radicular region causing apical
periodontitis.

• The Tooth Sloth and the Frac Finder are the popular commercially
available devices for the bite test
The clinician should note whether the discomfort or pain occurs
during the act of biting or during the release of bite force:
• Pain on biting: Symptomatic apical periodontitis
• Pain on release of biting force: Cracked tooth
References
 A Practical Manual of Public Health Dentistry by CM Marya 1st Edition
 Wynne, C. (2018). Endodontics in Systemically Compromised Patients. In: Jain, P. (eds) Common
Complications in Endodontics. Springer, Cham.
 Textbook of ORAL MEDICINE by Anil Govindrao Ghom Savita Anil Ghom 3 rd Edition
 Banting, David W. "The diagnosis of root caries." Journal of dental education 65.10 (2001):
991-996
 Pitts NB. Diagnostic tools and measurements—impact on appropriate care. Community Dentistry and
Oral Epidemiology 1997; 25 (1):24–35.
 Schour and B. G. Sarnat. Oral manifestations of occupational origin. JAMA 1942; 120: 1197
 Dr. Anil K Tomer, Dr. Panna Mangat, Dr. Afnan Ajaz Raina, Dr. Faizan Bin Ayub, Dr. Megna Bhatt, Dr. Midhun
Ramachandran, Dr. Ashvin G John. Diagnostic aids to detect caries-A review. Int J Appl Dent Sci 2019;5(2):16-20.
Thank You!