Case History

  • History taking is defined as an information gathering process to assess the health status of the patient.

                                                  Or

  • May be define as a planned professional conversation that enables the 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 the nature of the patient’s real and suspected illness and mental attitude of the patient can be determined.

The essential parts of case history includes:-

  1. Biographical and demographical information
  2. Chief complaint and history of present illness
  3. Past dental and medical history
  4. Personal and family history
  5. Reviews of system
  6. Examination of patient
  7. Case summary
  8. Diagnosis
  9. Differential diagnosis
  10. Treatment plan

Biographical and demographical data of patient includes:

  1. Name
  2. Age
  3. Sex
  4. Occupation
  5. Address
  6. Socio-economic status
  1. Personalizes the process of history taking.
  2. It helps in further communication.
  3. Psychological benefit.

Many diseases have certain age predilection:

  1. Infants: Eruption cyst, haemangioma, neuroectodermal tumor, rickets, thalassemia major
  2. Children: Herpes simplex, pulp polyp, childhood infectious disease, Albright disease, cherubism, acute leukemia,
  3. Person under age 40: Hodgkin’s disease, infectious mononucleosis, pyogenic granuloma, palatal tori, mural ameloblastoma, thalassemia major and minor
  4. Person above age 40: Paget’s disease, secondary hyperparathyroidism, leukoplakia, lichen planus, lipoma, lymphoma, desquamative gingivitis, candidiasis

Many diseases have greater predilection for a particular sex.

  1. Female: Desquamative gingivitis, benign mucous membrane pemphigoid, osteoporosis, pyogenic granuloma, peripheral giant cell granuloma, primary hyperparathyroidism, periapical cemental dysplasia, palatal tori
  2. Male: Leukoplakia, erythema multiforme, mucocele, carcinoma in situ, radicular cyst, eosinophilic granuloma, osteomyelitis
  • Indication of socioeconomic status
  • Diseases in different occupation are-
  OccupationPossible oral disease
  Carpenters, musician, cobblerLocalized abrasion
  Fisherman, coal workersStomatitis, carcinoma of lip and mucosa
  Bronzers, cement workers
  Electroplaters, metal refiners
Necrosis of bone, blue pigmentation of the gingiva
  Refiners, bakers, candy makersCaries
  • For future correspondence or recall.
  • To know prevalence of disease like fluorosis, caries, leprosy.
  • Give a view of socio-economic status.
  • A child born in endemic fluoride area later shifted to non-endemic area may show Mottled enamel.
  • Suggest certain disease possibilities.
  • Useful to consider extent of treatment

The chief complaint is the problem for which the patient seeks help for treatment. The chief complaint is recorded in the patients’ own words avoiding technical terms unless used by the patient.

The common chief complaints of patient:  Pain, swelling, ulcers, decayed teeth, bad breath, bleeding from gums.

  1. Location ; to point out area of pain
  2. Onset and duration; sudden or gradual. duration may be in terms of time, days, week, month or year
  3. Nature; may be throbbing, pricking, lancinating, dull, gnawing, boring
  4. Frequency; continuous or intermittent
  5. Intensity ; mild , moderate, severe
  6. Effect on function; effect on function such as extent of mouth opening, mastication, speaking, and swallowing
  7. Aggravating and relieving factor; can be temperature variations , postural variations, diurnal variations, effect of any medication and rest

Duration and progress:

  • Acute or chronic
  • Slow increase in size
  • Moderate or rapid

Associated symptoms: Like pain, fever, difficulty in swallowing, respiration, loss of body weight or changes like softening or ulcerations

Expanding the chief complaint, by filling in the dimension of the problem identified in the chief complaint, provides a more complete statement.

  1. Gives an idea of importance the patient gives to his her oral health and patient’s expectations from the dentist.
  2. Warrants special investigations and alteration in treatment plan.

Helps identify health conditions that could alter complicate or contradicts the treatment plan.

The PMH is usually organized into the following subdivisions:

Serious or significant illnesses.

  • Hospitalizations.
  • Transfusions.
  • Allergies.
  • Medications.
  • Pregnancy.

PERSONAL HISTORY;

  1. Includes obtaining the information about the oral hygiene method, diet, appetite, bowel and micturition, sleep, oral habits.
  2. Patient diet details help in diagnosis of glossitis or angular cheilitis.
  3. Different habits like smoking, alcohol consumption, areca nut chewing etc. can be find out.

FAMILY HISTORY;

Elicit the genetically related disorder like hemophilia, diabetes mellitus, and presence of any communicable diseases.

  • Knowing whether or not a woman of childbearing age is pregnant is particularly important when deciding to administer or prescribe any medication.
  • Patient who believes she could be pregnant but who lacks confirmation by pregnancy test or a missed menstrual period should be treated as though she were pregnant.
  • The number of times a woman has been pregnant (gravida [G]), Given birth (para [P]), Had an abortion (A) is usually recorded in the form of GxPxAx.
  • Tobacco

Form, type, quantity, frequency and duration.

  • Alcohol Consumption:

Quantity, type, frequency.

  1. It is a comprehensive and systemic review of subjective symptoms affecting different parts of body.
  2. Helps dentist to assess all aspects of patient’s health
  3. Helps overall “screening’’ of the patient.
  • General: Weight changes, malaise, fatigue, night sweats.
  • Head: Headaches, tenderness, sinus problems.
  • Eyes: Changes in vision, photophobia, blurring, diplopia, spots, discharges.
  • Ears: Hearing changes, tinnitus, pain, discharge, vertigo.
  • Nose: Epistaxis, obstructions.
  • Throat: Hoarseness, soreness.
  • Respiratory: Chest pain, wheezing, dyspnea, cough, hemoptysis.
  • Cardiovascular: Chest pain, dyspnea, orthopnea (number of pillows needed to sleep comfortably), edema, claudication.
  • Dermatologic: Rashes, pruritus, lesions, skin cancer (epidermoid carcinoma, melanoma).
  • Gastrointestinal: Changes in appetite, dysphagia, nausea, vomiting, hematemesis, indigestion, pain, diarrhea, constipation, melena, hematochezia, bloating, hemorrhoids, jaundice.
  • Genitourinary: Changes in frequency, urgency, dysuria, hematuria, nocturia, incontinence, discharge, impotence.
  • Gynecologic: Menstrual changes (frequency, duration, flow, last menstrual period), dysmenorrhea, menopause.
  • Endocrine: Polyuria, polydipsia, polyphagia, temperature intolerance, pigmentations.
  • Musculoskeletal: Muscle and joint pain, deformities, joint swellings, spasms, changes in range of motion.
  • Hematologic/lymphatic: Easy bruising, epistaxis, spontaneous gingival bleeding, increased bleeding after trauma, swollen or enlarged lymph nodes.
  • Neuropsychiatric: Syncope, seizures, weakness (unilateral and bilateral), changes in coordination, sensations, memory, mood, or sleep pattern, emotional disturbances, history of psychiatric therapy.
  1. Hypertensive patient should not be treated
  2. Medication for hypertension causes dryness, ulceration and gingival enlargement.
  3. Congenital heart disease patient are at risk of infectious endocarditis.
  1. Second phase of diagnostic procedure.
  2. Records objective information.
  3. Aids in confirming physically demonstrable abnormalities.
  4. May reveal some disease which patient is not aware off.
  1. Built
  2. Nutritional status
  3. Gait, posture and body movement
  4. Height and weight
  5. Speech
  6. Pallor
  7. Icterus
  8. Cyanosis
  9. Clubbing
  10. Edema

It is how the body looks like.

Three extremes of body type:

  1. ENDOMORPHIC– Smooth, round body, medium to large joints, high levels of body fat.
  2. MESOMORPHIC– Naturally lean, medium to large size joints.
  3. ECTOMORPHIC– Skinny, linear appearance, low body fat .
  1. By muscle bulk, subcutaneous fat and presence or absence of deficiency signs.
  2. Skin and hair changes are noted
  3. Skin turgor indicates state of dehydration.

Gait refers to the way one walks, it is  a complicated motor activity ultimately controlled by cerebral function influenced by proprioceptive, vestibular and visual feedback.

Types:

  1. Propulsive gait: Seen in Parkinson’s disease or carbon monoxide poisoning
  2. Spastic gait: Stiff, foot dragging walk caused by one sided, long term, muscle contracture.
  3. Scissors gait: Legs flexed slightly at the hips and knees giving the appearance of crouching.
  4. Waddling gait: Duck like walk due to lower limb weakness.
  5. Ataxic gait: Speed and length of the stride vary irregularly with erect posture and separated feet

Posture refers to position of body or it deals with how the body is positioned in relation to another person or group of person.

  1. Tic- sudden repetitive contraction of various muscle groups.
  2. Chorea– involuntary non rhythmic jerky, non-suppressible muscular movement of face and extremities.
  3. Tremors– seen in Parkinson’ s disease.
  4. Tardive dyskinesia– older patients who are on treatment with neuroleptics.

Recorded to assess the physical growth and development of the patient

Abnormalities like lisping associated with tongue tie, inability to pronounce labials associated with cleft lip and palate, malocclusion, ill-fitting denture and macroglossia can be found out.

Paleness of skin and mucous membrane either as a result of diminished circulating red blood cells or diminished blood supply

Checked in– lower palpebral conjunctiva, nail beds, palmer creases, tongue, oral mucosa

Seen in-massive hemorrhage, shock, intense emotions, anemia, syncope, myxedema, exposure to cold

It is yellowish discoloration of skin, sclera and mucous membrane due to excess circulating bilirubin and its accumulation.

Checked in: Sclera of the eyeball, palate, palm and soles, under surface of tongue.

Hypercarotenemia : It is yellow pigmentation due to hypercarotenemia seen in face, palm but not in sclera.

It may arise due to:

  1. Increased bile pigment load to liver
  2. Affection of bilirubin diffusion into the liver cells
  3. Defective conjugation
  4. Defective excretion
  1. Hemolytic jaundice- Due to:
    • Hereditary spherocytosis
    • Hamoglobinopathies
    • Paroxysmal nocturnal hemoglobinuria
  2. Extra corpuscular defects
    • Infections: malaria
    • Drugs: quinine, sulfonamides
    • Physical agents: burns, irradiation
  3. Congenital hyperbilirubinemia
  4. Hepatocellular
    • Infections: Viral hepatitis, septicemia, typhoid
    • Toxic: Halothane agent, phenindione
    • Cirrhosis
  5. Obstructive
    • Inflammatory: Stone, stricture
    • Neoplastic: Carcinoma of head of the pancreas
  • Cyanosis is defined as the diffused bluish coloration of skin and mucus membrane.
  • It is due to the presence of large amount of reduced hemoglobin in the blood.
  • Quantity of reduced hemoglobin should be at least 5 to 7 g/dL in the blood to cause cyanosis.

A. Central cyanosis – Seen in skin and mucous membrane.
Causes: Congenital heart disease, congestive heart disease, collapse and fibrosis of lungs
B. Peripheral cyanosis – Seen only on skin.
Causes: Cold, increased viscosity of blood, shock
C. Cyanosis due to abnormal pigments
Causes: Methemoglobinemia.
D. Mixed
Causes: Acute left ventricular failure, mitral stenosis.

 

 

Central

 

Peripheral

  Mechanismdiminished arterial oxygen  Saturation

diminished flow of blood

to the local part

  Siteson skin and mucous membranes  e.g.; tongue, lips, cheekson skin only
  temperature of limbwarmcold
 Clubbing    and  polycythemiausually associatednot associated
  • In severe anemia
  • Carbon monoxide poisoning

Cyanosis usually occurs only when the quantity of reduced hemoglobin is about 5 g/dL to 7 g/dL. But, in anemia, the hemoglobin content itself is less. So, cyanosis cannot occur in anemia.

Ruddy cyanosis is a deep cyanosis with a reddish blue tinge seen in conditions was there is polycythemia with or without hypoxia.

Bulbous enlargement of soft part of terminal phalanges, along with transverse and longitudinal curving of nails.

Grades

  • Grade 1- Softening of nail bed
  • Grade 2 – Obliteration of angle of nail bed
  • Grade 3 –Swelling of subcutaneous tissue. Parrot beak or drumstick appearance.
  • Grade 4- Swelling of fingers in all dimensions

Bronchogenic carcinoma, lung abscess, bronchiectasis, tuberculosis with secondary infection, infective endocarditis, ulcerative colitis, myxedema, acromegaly, crohn’s disease.

When two fingers are held together with nails facing each other, a space is seen at the level of proximal nail fold. Seen in case of clubbing

It is the swelling of tissue caused by the excessive collection of fluid in the subcutaneous tissue.

Types –

    1. Generalized oedema– due to disorders of heart, kidney, liver, gut or in malnutrition.
    2. Localized oedema-Due to allergy and inflammation

Signs-   Pitting on pressure, Skin is pallid and glossy

Bilateral – Pericarditis, acute nephritis, nephrotic syndrome, myxedema, anemia

Unilateral – Filarial, bruises, gout, venous thrombosis, varicose vein.

  1. Temperature
  2. Respiratory rate
  3. Blood pressure
  4. Pulse rate
  5. Weight/Height

Normal body temperature is 98.6 degrees F or 37 degrees C

Increased in – acute infection, hyperthyroid, acute myocardial infections, Addison’s disease, serum sickness, gout, heat stroke.

Decreased in – Hypothyroid, hypoglycemia, exposure to cold, alcoholic intoxication, autonomic dysfunction.

Respiratory rate is the rate at which breathing occurs. A person’s respiratory rate is the number of breaths you take per minute. A respiration rate under 12 or over 25 breaths per minute while resting is considered abnormal.

Normal – 14 to 18 per minute

Increased respiratory rate (TACHYPNEA) – Exercise, nervousness, fever, lung and cardiac disease, metabolic acidosis, pneumonia, congestive heart failure

Decreased respiratory rate (BRADYPNEA) – Pulmonary obstruction, alcohol consumption, cardiogenic shock, obesity, increased intracranial pressure

Normal- 60 to 80 per minute

Increased in– Exercise anxiety, shock, fever and thyrotoxicosis.

Decreased in– Myxedema, heart block

  1. Anacortic pulse – Slow rising pulse, felt in carotids in aortic stenosis
  2. Pulses bisferiens – Rapid rising pulse, seen in- idiopathic hypertrophic sub aortic stenosis.
  3. Dicrotic pulse – Twice beating pulse, seen in- fevers like typhoid, congestive cardiac failure
  4. Pulses parvus et tardus – Slow rising pulse but anacortic wave is not felt, felt in- aortic stenosis
  5. Pulses alternans – Strong and weak beat occurring alternately, seen in- toxic myocarditis, left ventricular failure.
  6. Pulses paradoxus – When systolic BP falls more than 10mmHg during inspiration the pulse is erroneously called pulsus paradoxus. Felt in, asthma, emphysema, pericardial effusion, constrictive pericarditis.
  7. Pulses bigeminus – Coupling of pulse waves in pairs followed by pause, felt in AV block
  8. Thready pulse – Pulse rate is rapid and pulse wave is small, seen in- cardiogenic shock.
  9. Waterhammer pulse – Large bounding pulse, seen in fever, anemia, thyrotoxicosis

Blood pressure is the pressure, measured in millimeters of mercury, within the major arterial system of the body.

Systolic blood pressure is taken while the heart muscle is contracting and pumping oxygen-rich blood into the blood vessels.

Diastolic blood pressure is taken while the muscle is relaxing and refilling with blood.

  • Category

    Systolic Blood Pressure

    (mm Hg)

    Diastolic Blood Pressure

    (mm Hg)

    Nonhypertensive

    Optimal

    < 120 and

    < 80

    Normal

    < 130 and

    < 85

    High normal

    130–139 or

    85–89

    Hypertensive

    Stage 1

    140–149 or

    90–99

    Stage 2

    160–179 or

    100–109

    Stage 3

    ≥ 180 or

    ≥ 110

  • Blood pressure is measured in units of “millimeters of mercury”; written mm Hg for short.
  • Blood pressure measurements are always given in pairs, with the upper (systolic) value first, followed by the lower (diastolic) value.
  • Patient should refrain from smoking or ingesting products containing caffeine within 30 minutes of the blood pressure measure.
  • Seat patient with his or her back supported, arms bare over the biceps and supported at heart level.
  • Patient should rest for 5 minutes in the chair prior to the measure.
  • The bladder of the cuff should encircle at least 80% of the arm.
  • Place the bladder centered over the brachial artery, with the cuff’s lower border 1 to 2 inches above the elbow crease in the anticubital fossa.
  • Palpate the radial pulse.
  • Place a stethoscope on the brachial artery, and listen.
  • Inflate the bladder up to about 20 to 30 mm Hg above the point at which the pulse is no longer palpable (palpable systolic pressure).
  • Both systolic (first appearance of sound or the initial return of palpation of the radial artery) and diastolic (disappearance of sound) blood pressure should be recorded.
  • Two or more readings separated by 2 minutes should be averaged. If the two readings differ by more than 5 mm Hg, two additional readings should be done and averaged.

Signs – Moon face, rough skin, tremors, pigmentation, water hammer pulse, cardiomegaly

Symptoms – Headache, dizziness, epistaxis, angina chest pain, hematuria, syncope

This is a chronic orthostatic hypotension with degeneration of CNS, mainly involving extra- pyramidal tracts, basal ganglia and dorsal nucleus of vagus

Bradycardia is a very slow heart rate less than 60 beats per minute

Causes– increased vagal tone, hypothermia, hypothyroidism, sleep, seizure.

Tachycardia is a very fast heart rate of more than 100 beats per minute

Causes– anemia, exercise, smoking, fever, high or low blood pressure, disease of heart, hyperthyroidism

A. Extra oral examination
Face, skin, hair, eye, ear, nose and Para nasal sinus, salivary gland, temperomandibular joint, lymph node assessment, assessment of cranial nerves
B. Intra oral examination
Soft tissue examination, hard tissue examination, examination of gingival.

  • Facial features indicate health and mental status of an individual.
  • Gives indication of age.

Mesoproscopic– Average facial skeleton

Euryproscopic– Broad face type /low facial skeleton

Leptoproscopic – Narrow face type/high facial skeleton

  1. It determines the disproportions of face in transverse and vertical plane.
  2. Gross facial abnormalities seen in –congenital defects, chronic abscess/cysts/space infection.

Profile assessment helps in diagnosing gross deviation in maxillomandibular relationships.

Types- Straight profile

            Convex profile

            Concave profile

Mesocephalic – Average skull proportions.

Dolicocephalic– Long narrow skull.

Brachycephalic– Short broad skull.

  1. Changes in color, texture, elasticity and presence or absence of oedema should be observed.
  2. Blue red and purple color skin seen in haemangioma, Kaposi sarcoma.
  3. Brown and black color seen in ecchymosis, nevi.
  4. Dehydration is the common cause for elasticity.
  1. Dry skin – Seen in myxedema, dehydration
  2. Moist skin – Seen in myocardial infarction
  3. Thick skin – Seen in myxedema, acromegaly, scleroderma.
  4. Thin skin – Seen in old people
  5. Pinched skin – Suggests dehydration

Examined for-

  1. Pallor
  2. Koilonychia- spoon shaped deformity of nails seen in iron deficiency anemia
  3. Onychia – seen in tuberculosis
  4. Discoloration- seen in silver and mercury poisoning
  5. Clubbing and cyanosis
  6. Hemorrhages
  7. Trophic changes

Many condition with oral involvement also effect the eyes like –

  • Sjogren syndrome, Steven- Johnson syndrome, Orofacial granulomatosis,Hyperthyroidism, Hypoparathyroidism, Diabetes mellitus, Porphyria, Cystinosis, Mucopolysaccharidosis, Wilson disease, Systemic lupus erythematosus.
  • Eyes should be examined for-
  • Opacities, infections of eyelids (blepharitis), infection of conjunctiva (conjunctivitis), infection of cornea( keratitis), color changes of sclera, shape and size of the eyeball.
  • For any sinus pain, discharge, obstruction, continuous sneezing, periorbital swelling or inflammation
  • The pattern of distribution, color and texture of hair should be noted
  • Scanty, thin hair seen in ectodermal dysplasia
  • Loss of hairs can be seen in endocrine disorders and fungal disorders affecting the skin
  • To determine deviation of jaw from midline during the opening and closing of jaws
  • To determine the range of vertical and lateral movements
  • Normal maximum interincisal opening of mouth range from 40-45mm
  • Male- 39 to 70mm
  • Female- 36 to 56mm
  • And range of normal lateral jaw movement is 8-10mm
  • Limitation of mouth opening seen in – infection, trauma, fracture, old age

The distance from the incisal edge of upper incisor teeth to the incisal edge of lower incisor teeth is measured using calibrated fiber ruler and findings are recorded in ranges of mm.

Joint is palpated to elicit the clicking, crepitus, and grating during opening and closing of jaw.

  1. Preauricular method- Palpation consists of feeling both the condyles simultaneously with the index finger placed in the pre-tragal area.
  2. Intra auricular method- Palpation is done by inserting the small finger into external auditory meatus.

Preauricular, post auricular, occipital, submandibular, submental, superficial cervical, deep cervical and supra clavicular.

Lymph nodes are assessed for number, size, consistency, tenderness and fixity to the underlying structure.

Enlarged lymph nodes should be palpated with palmer aspect of three fingers. While rolling the fingers against the swellings light pressure is maintained to know the consistency.

  1. Pre auricular lymph nodes are palpated anterior to tragus of the ear.
  2. Post auricular nodes are palpated at the mastoid process or anterior to mastoid.
  3. Occipital nodes they are palpated at the base of skull posteriorly by asking the patient to look down to relax the muscles.
  4. Tonsillar lymph nodes located just below the angle of the mandible.
  5. Submandibular nodes these nodes are palpated at the lower border of the body of the mandible approximating the angle by asking the patient to flex the neck towards the side of the examination.
  6. Sub mental lymph nodes are palpated under the chin. The clinician stands behind the seated patient. Patient is asked to partially flex the neck towards the side that is being examined. Fingers of both the hands should be placed below the chin under the lower border of the mandible and submental lymph nodes should be cupped within the fingers of both the hands.
  7. Anterior superficial cervical lymph nodes lie superficial to the sternocleidomastoid muscle.
  8. Deep cervical lymphnodes lies below the sternocleidomastoid muscle and over the cervical fascia.
  9. Posterior cervical lymphnodes palpated in the posterior triangle of neck close to anterior border of trapezius.
  10. Supraclavicular nodes are palpated in supra clavicular fossae against the clavicle. These nodes are palpated in the supraclavicular fossa bilaterally standing behind the patient.

A.   Infections

·Localized: A response to a local infection such as streptococcal pharyngitis

·Generalized: A response to a systemic infection such as tuberculosis, syphilis, infectious mononucleosis, hepatitis, fungal infection, toxoplasmosis, HIV, etc.

B.   Immunologic conditions:

·Known antigens such as drug reactions or serum sickness.

·Unknown antigens such as in sarcoidosis.

·Connective tissue disease such as rheumatoid arthritis, systemic lupus erythematosus.

C.   Miscellaneous: Giant lymph node hyperplasia, dermatopathies, lymphadenitis, immunoblastic lymphadenopathy.

D.  Malignant processes:

·Diffuse involvement, as in lymphomas and leukemias

·Diffuse invasion, as in diffuse carcinomatosis

·Localized invasion, as in head and neck tumors

E.   Lipid storage diseases

F.   Miscellaneous: Graves’ and Addison’s diseases

Acute infection:

  1. Tender
  2. Mobile
  3. Enlarged

Chronic Infection

  1. Nontender
  2. Mobile
  3. Enlarged

Tuberculosis

  1. Matted
  2. Non tender

Squamous cell carcinoma

  1. Fixed
  2. Enlarged

Lymphomas

  1. Rubbery
  2. Enlarged

Calcified lymphnodes can be seen in histoplasmosis, tuberculosis, coccidioidomycosis
and aspergillosis, and non-infectious causes such as silicosis.

  • Parotid and submandibular gland are examined.
  • Enlarged parotid gland will alter the facial contour and lift the ear lobe.
  • Enlarges sub mandibular gland may distend the skin over the submandibular triangle.

Submandibular salivary gland is best palpated bimanually. Patient is asked to open the mouth. One finger of one hand is placed on the floor of the mouth medial to alveolus and lateral to the tongue and is pressed on the floor of the mouth as far back as possible. The fingers of the other hand in the exterior are placed just medial to inferior margin of mandible. These fingers are pushed upwards. This helps to palpate both superficial and deep lobes of salivary glands.

This examination also differentiates an enlarged salivary gland from enlarged submandibular lymph nodes. The finger inside the mouth can feel the deep part of salivary gland but not the lymph node as the former is situated above the mylohyoid muscle and latter below the muscle.

  1. Olfactory nerve– can be tested by asking the patient to identify familiar odor such as coffee, tobacco. Ammonia and acetic acid should not be identified as it stimulates the fifth cranial nerve.
  1. Optic nerve– Tested for visual activity and visual field.
  2. Oculomotor nerve– Movement can be tested by asking the patient to follow the examiner’s finger 20 inches away toward right, left, upwards and downwards
  3. Trochlear nerve– Patient is asked to roll the eyeball upward and laterally
  4. Trigeminal nerve– Sensory division testing done by a pin prick and light touch of a cotton tipped applicator, motor division is elevated by assessing the strength of contraction of muscles of mastication.
  5. Abducen nerve– Can be tested by asking the patient to rotate  the eye laterally and in downward direction
  6. Facial nerve– Asking the patient to puff out the cheeks , wrinkle forehead, pucker the lips, smile, close the eyes tight
  7. Auditory nerve- Hearing can be tested using Weber test or Rinne test
  8. Glossopharyngeal nerve– Assess by checking the taste sensation
  9. Vagus nerve- Tested by observing the movement and symmetrical elevation of soft palate and gag reflex
  10. Accessory nerve- Ask the patient to rotate the head and lift the shoulder
  11. Hypoglossal nerve- ask the patient to protrude the tongue and move it left and right
  1. Lips should be examined for changes in color, texture, fissures, and presence of any lesions on the vermillion border, mucocutaneous junction and the labial mucosa are noted.
  2. Lips are common site for recurrent herpes infections.
  3. Crusting of the lip favors the diagnosis of erythema multiforme.
  4. Lips can be classified as competent, incompetent, potentially competent, everted lips
  5. Buccal mucosa variations in the normal topographical anatomy are seen in conditions like linea alba, fordyces granules and leukoedema
  1. Alveolar and vestibular mucosa is examined for any changes in color and presence of swelling and sinus openings.
  2. Loss of vestibular depth is a sign of pathological change in the underlying soft tissue or bone.

Inspection-

  1. Site of swelling
  2. Shape of swelling
  3. Size of swelling
  4. Surface mucosa, edges
  5. Movement and deglutition
  6. Movement and protrusion of tongue.

Palpation

Gives clue about the diagnosis, following points should be noted:

  1. Surface temperature
  2. Tenderness
  3. Consistency
  4. Size, shape and extent
  5. Fluctuation
  6. Translucency
  7. Fixity to skin
  8. Relation to surrounding structure

State of regional lymph nodes determines chronicity and tenderness.

Inspection

  1. Size and shape
  2. Number of ulcer
  3. Position
  4. Edges
  5. Surrounding area
  6. Discharge

Palpation

  1. Tenderness
  2. Depth
  3. Bleeding
  4. Surrounding skin

Examination of regional lymph nodes

Lymph nodes become large and tender

  1. Characteristics of gingiva
  2. Periodontal pocket assessment
  3. Assessment of gingival recession and level of gingival attachment
  4. Bleeding on probing
  5. Mobility
  6. Furcation involvement
  1. Color- Normal colour of gingival is coral pink
    1. Bright red in acute gingivitis
    2. Bluish red in chronic gingivitis
  2. Contour- Normal contour is scalloped
    1. Changes seen in case of gingival enlargement
  3. Consistency- Normal is firm and resilient
    1. Destructive and reparative changes seen in chronic gingivitis
  4. Surface texture – Normally orange peel appearance or presence of stippling
    1. In inflammation loss of stippling is there
  5. Bleeding on probing-
    1. Important objective sign of acute gingival inflammation
  6. Position- Normal position of gingiva is at level of attached periodontal tissue.
    1. Condition producing high margins: Gingival enlargement, short clinical crowns
    2. Conditions producing lower margins: Gingival recession, trauma from occlusion, long clinical crown.
    3. Recession – exposure of tooth by apical migration of gingiva.

Normal is 0.005 to 0.10mm on application of 100mg of force.

Grade 1:   Slightly more than normal

Grade 2:   Moderately more than normal

Grade 3:  Severe mobility faciolingually and mesiodistally with vertical displacement

Probe should be inserted parallel to the vertical axis of tooth and walked circumferentially around each surface of the tooth.

  1. Eruption pattern
  2. Missing teeth
  3. Development disorders
  4. Dental caries
  5. Wasting disease – Abrasion, erosion, attrition, abfraction
  6. Occlusion(molar relation)
  7. Fractured teeth: Cracked tooth syndrome, Ellis classification for fractured anterior teeth

Incomplete fractures through the body of the tooth may cause pain of idiopathic origin. This referred to cracked tooth syndrome. Patient complains of pain at the initiation or release of biting pressure.

The diagnostic summary is obtained by listing all the findings which indicate the presence of disease. It helps in arriving at a provisional and comprehensive diagnosis

Diagnosis is the establishment of the disease after eliciting history and clinical examination supplemented by radiographical studies.

When clinical data are more complex, the diagnosis may be established by:

  • Reviewing the patient’s history and physical, radiographic, and laboratory examination data.
  • Listing those items that either clearly indicate an abnormality or that suggest the possibility of a significant health problem requiring further evaluation.
  • Grouping these items into primary versus secondary symptoms, acute versus chronic problems, and high versus low priority for treatment.
  • Categorizing and labeling these grouped items according to a standardized system for the classification of disease.

Types of diagnosis:

  1. Provisional diagnosis-Based on clinical impression without any investigations.
  2. Emergency diagnosis-Made in situation like accidental injuries.
  3. Therapeutic diagnosis– Arrived after beneficial effects of therapy.
  4. Final diagnosis– Made after necessary investigations are taken out.
  5. Comprehensive diagnosis-Diagnosis of all the problems after detailed examination of all organ systems

Process of identifying a condition by differentiating it from other pathological processes that may produce similar symptoms of lesion

  1. To address the chief complaint.
  2. To eliminate or control the disease.
  3. Restoration of function and aesthetics.
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