general examination and local examination

1. General examination and
Local examination

2. Steps involved in examining the patient
1.INSPECTION:
Careful visualization
2.PALPATION:
Touch and feel
3.PERCUSSION: Tap
and feel
4.AUSCULTATION:
Amplify to hear

3. Methods of examination
 The method of examining a pediatric patient depends upon the age of the patient.
 Child younger than 2 years of age: lap-to-lap or knee-to-knee position. The parent
and the dentist sit on either side with the child on their laps.
 2-3 year old child: Patient-over-parent mode
 Patient older than 3 years: examined in the dental chair.

4. General examination
 Gives a primary conclusion of the overall health of the patient.
 Includes assessment of
1. Height and weight
2. Stature
3. Posture
4. Body type
5. Speech
6. Vital signs
7. Structures of ectodermal origin

5. 1.Height and weight
 Why record height and weight?
Dosage of any drug depends on the body surface area of the patient. The
height and weight is required to compute the body surface area.

6. 2.Stature
 Children who are too short or too tall for their age may be suspected for abnormal
developmental patterns.
 Factors leading to abnormal developmental patterns:
1. Hereditary
2. Nutritional intake
3. Socioeconomic environment
4. Developmental anomalies
5. Metabolic disturbances

7. 3.Gait
 The gait or the walking style of the child has to be observed for any abnormality.
 Abnormal gait and their corresponding conditions:
1. Unsteady gait – general weakness of a febrile child
2. Waddling gait – cerebellar dysfunction
3. Equinus gait cerebellar dysfunction
4. Hemiplegic gait – cerebral palsy
5. Shuffling gait – cerebral palsy
6. Wobbly gait – cerebral palsy
7. Staggering gait – cerebral palsy
8. Ataxic gait – cerebral palsy

8. 4.Posture
 Normal: erect posture
 Altered posture is seen in case of:
o Kyphosis(forward bending of spine)
o Scoliosis(lateral bending of the spine)

9. 5.Body type
1. Ectomorphic: tall and thin
2. Endomorphic: short and stout body type
3. Mesomorphic: average body type
 Why determine the body type?
Endomorphs attain puberty earlier than ectomorphs. Hence the
associated growth spurt at puberty is earlier than in ectomorphs.
When myofunctional appliances that target the pubertal growth spurt
are indicated to such children they have to be timed appropriately

10. 6.Speech
 Normally a child starts conversing in sentences by 2 or 3 years of age.
 Speech has to be assessed for any abnormality.
 Common speech disorders:
1. Motor aphasia: Loss of speech secondary to CNS damage
2. Delayed speech: Early hearing loss, intellectual retardation, general developmental
retardation, sensory defects and lack of motivation.
3. Stuttering or repetitive speech: Cerebral palsy, neurodevelopmental disorders and
compulsive disorders
4. Articulatory speech disorders: substitution, omission, insertion and distortion

11. 7.Vital signs
 Temperature
 Heart rate
 Heart rhythm
 Respiratory rate
 pulse

12. 8.Structures of ectodermal origin
 Skin, nails, hair, conjunctiva and teeth are structures of ectodermal origin.
 Developmental disturbances in the skin, nails and conjunctiva can reveal associated
disturbances of teeth as they arise from the same origin

13. A. Skin
 Assessed for abnormalities such as increased temperature, excessive moisture and
dryness
 Hair distribution is also observed
 Inspection for macules, papules, vesicles, ulcerations, crusts and scales.
 If these lesions are found exanthematous diseases, vitamin deficiencies and
developmental disturbances have to be suspected.
 In case of any abnormality the patient should be referred to a physician

14. B. Nails
 Some children may display abnormal oral habits such as nail biting or thumb
sucking.
 Nail biting habit: may be bitten or irregular
 Thumb sucking habit: diligently clean nails and digits with or without callus
 Anemic child: spoon shaped nails, pale nails
 Ectodermal disturbances: pitted, brittle, scaly, thickened or even absent in
ectodermal disturbances
 Cyanotic congenital heart disease: clubbing of digits

15. C. Hair
 Reveals some abnormalities
 Ectodermal dysplasia: scanty and light in colour
 Alopecia: occasionally seen in younger patients
 Ringworm infection: loss of hair or baldness with an indurated and inflamed line
 Hormonal imbalances may cause loss of hair
 Medications resulting in hirsutism:
1. Phenytoin(anticonvulsant)
2. Cyclosporine(immunosuppressant)

16. D. Conjunctiva
 Examined for anemia or jaundice
 Anemia: paleness of conjunctiva
 Jaundice: yellowness of conjunctiva

17. Local examination
pertains to the examination of orofacial apparatus. It encompasses
extraoral and intraoral examination.

18. Extraoral examination

19. Shape of head:
 Shape is assessed by inspecting over the head.
 Length of the head: anteroposterior dimension from the frontal bone to the
occipital bone.
 Breadth of the head: lateral extent extending from one temporal bone to the other.
 The shape of the head can be one of the following:
1. Dolichocephalic: long and narrow head outline
2. Mesocephalic: average length and breadth
3. Brachycephalic: broad and short head outline

20. Shape of the face
 Corresponds to the shape of the head.
 Can indicate whether the patient is ectomorph, endomorph or mesomorph.
1. Leptoprosopic: long and narrow face corresponds to the dolichocephalic head
pattern indicates ectomorphs
2. Mesoprosopic: average facial dimension corresponding to the Mesocephalic head
pattern indicates mesomorphs
3. Euryprosopic: a broad and short face corresponding to the brachycephalic head
pattern indicates endomorphs

21. Eyes
 Visual impairment or refractive errors of the child have to be recorded.
 Closure of eyelid has to be observed
 Other abnormalities such as swelling or puffiness around the eyes, crusting or
lesions around the eyes, conjunctivitis, excessive lacrimation and hypertelorism
should be noted
 Significance: a child with sensory handicap is classified as a special child.
 Dentoalveolar infection resulting in eye infections and conjunctivitis
 Bechet’s syndrome
 Due to upper respiratory tract infection.

22. Ears
 Hearing impairment must be recorded.
 Earache or any discharge from ears are noted.
 A child wit deafness is considered to be a special child.
 Dentoalveolar pain may be referred to the ear.
 Treacher-Collins syndrome.

23. Nose
 Type of breathing- nasal, oral or combined breathing.
 Water holding test- confirmatory
 Any obstruction of nasal passage
 History of discharge- serous, purulent or blood discharge
 Anatomical defects- depressed nasal bridge, asymmetry of nose, deviated nasal
septum or scars due to trauma or surgery
 Significance:
1. Mouth breathing habit
2. Nasal discharge- ENT referral
3. Cysts and tumors
4. Saddle nose
5. Craniofacial syndrome

24. Lips
 Lips are classified as:
1. Competent: lower lip is able to contact the upper lip effectively.
2. Incompetent: lower lip has to e strained to contact the upper lip.
3. Potentially competent: Dentoalveolar protrusion prevents the lip from being
competent.
 Congenital anomalies- cleft lip, congenital lip pits, double lip
 Hypotonic lip- lip exercises
 Lip trap swallow- excessive overjet
 Puckering of chin

25. Symmetry of the face
 Apparent facial asymmetry must be noted.
 Craniofacial abnormalities
 Cleft lip cleft palate
 Dentoalveolar infections
 Ankylosis of condyle

26. Temporomandibular joint
 Assessed by inspection, palpation and auscultation of the joint region.
 Inspection: mouth opening, tenderness, injury to TMJ during forceps, Ankylosis
must be noted
 Palpation: The condyles are palpated to assess the synchronization of their
movements and tenderness
 Pretragic palpation: dentist stands in front; places the index finger in front of
tragus; patient is directed to open the jaw; anterior and superior surfaces of the
condyles assessed
 Intra-auricular palpation: dentist stands behind; places the little finger intra
auricularly; patient is asked to open and close the mouth; posterior and inferior
surfaces of condyles are palpated
 Auscultation: for crepitus and clicking sounds

27. Intra oral examination
In the oral cavity the soft tissues and the oropharynx have to be assessed
prior to the teeth

28. Soft tissue examination
 The soft tissues of the oral cavity that has to be assessed are:
1. Oral mucosae
2. Gingiva
3. Tongue
4. Hard palate
5. Soft palate
6. Tonsils

29. Oral mucosa
 Colour, consistency, contour and surface consistency
 Normal color- pink ; melanin pigmentation
 Any swelling or mass have to be palpated with thumb and index finger
 Surface lesions are noted
 Significance: Addison's disease and intestinal polyposis
 Salivary gland cyst
 Herpes simplex infections

30. Gingiva
 Gingival color, contour and consistency noted
 Frenum attachment, number, location and position noted
 Significance of gingival examination
 Inflammation
 Herpes simplex infection

31. Tongue
 Shape, size and colour are examined.
 Movement of tongue is examined.
 Swallowing pattern
 Macroglossia
 Depapillation of tongue
 Tongue tie
 Dryness of tongue
 Exanthematous diseases
 Retention cysts
 Swellings and ulcer

32. Palate
 Shape, colour and presence of lesions is observed.
 Scars
 Developmental anomalies
 Colour change

33. Tonsils and soft palate
 Tongue is depressed with mouth mirror to examine tonsils and soft palate
 Enlarged palatine tonsils
 Enlarged pharyngeal tonsils
 Referral to an ENT specialist

34. Hard tissue examination

35. Number of teeth
 Primary dentition comprises five primary teeth in each quadrant
 Anodontia
 Oligodontia
 Supernumerary tooth
 Supplemental teeth

36. Size of teeth
 Microdontia
 Macrodontia

37. Shape of teeth
 Peg-shaped incisors
 Screw-driver shaped incisors
 Turners hypoplasia

38. Colour of teeth
 Normal colour- milk white
 Extrinsic staining
 Intrinsic staining

39. Inter arch and intra arch relations
 Inter arch relations:
1. Primary molar relation- flush terminal plane/mesial step/ distal step
2. Permanent molar relation- angles class I/class II/class III
3. Primary canine relationship- class I/class II/class III
4. Permanent canine relationship-class I/class II/class III
5. Incisor relation
6. Overjet and overbite
 Intra arch relationship
 Crowding, spacing, rotations, malformations and delayed eruption are noted

40. Caries involvement
 Every carious lesion has to be assessed
 Chalky white lesions

41. Indices
 Oral hygiene index simplified
 DMFT and DMFS
 Dean’s fluorosis index/WHO index