CASE HISTORY AND PHYSICAL EVALUATION OF DENTAL PATIENTS /prosthodontic courses

CASE HISTORY AND
PHYSICAL EVALUATION OF
DENTAL PATIENTS
INDIAN DENTAL ACADEMY
Leader in continuing Dental Education
www.indiandentalacademy.com

History Physical examination Laboratory studies
Outline Of Components Of Diagnostic Process
Information
Analysis
DIAGNOSIS

INTRODUCTION
• Oral health is an integral part of total health, and oral health care professionals
must adapt to demographic changes and medical advances and shoulder the
responsibility of being part of the patient’s overall health care team.
• Oral medicine is a specialty within dentistry that focuses on the diagnosis and
management of complex diagnostic and medical disorders affecting the mouth
and jaws.

• Clinicians with advanced training in this discipline manage oral mucosal
disease, salivary gland disorders, and facial pain syndromes and also provide
dental care for patients with complicating medical disease.
• However, all general dentists and dental specialists must be aware of oral
medicine and the medical status of their patients in order to provide a high
level of oral health care.
• patients consult all oral health care professionals for management of
problems related to orofacial structures, and the opportunity and the need to
evaluate and assess patient’s overall medical status becomes part of the
responsibility of the dentist.

• This seminar discusses the rationale and method for gathering relevant medical
and dental information , including the examination of the patient, and the use of
this information to provide safe and appropriate oral health care.
• This process is divided into:
1. Obtaining and recording the patient’s medical history
2. Examining the patient
3. Establishing a differential diagnosis
4. Acquiring the additional information required to make a final diagnosis, such as
relevant laboratory and imaging studies and consultations from other clinicians.
5. Formulating a plan of action, including oral health care modifications and
necessary medical referrals.

HISTORY
• A case history is defined as a planned professional conversation that enables
the patient to communicate his/her symptoms, feelings, and fears to the
clinician so as to obtain an insight into the nature of the patient’s illness and
his/her attitude to them.
• In general, a case history is nothing but an evaluation of the patient prior to the
dental treatment.

• The information collected through a medical history achieves several
important objectives; it affords an opportunity for:
– Gathering information necessary for establishing the diagnosis of the patient’s chief
complaint.
– Monitoring known medical conditions.
– Detecting underlying systemic conditions that the patient may or may not be aware of.
– Providing a basis for determining whether dental treatment might affect the systemic
health of the patient.
– Assessing the influence of the patient’s systemic health on patient’s oral health.
– Providing a basis for determining necessary modifications to routine dental care.

METHODS OF RECORDING A CASE HISTORY
There is usually a traditional approach in the design of a case history.
The preliminary part of the case history is usually based on questionnaires.
Newer techniques of recording a case history are:
1. Computer aided data gathering.
2. Open ended interviewing which includes the Weed’s problem oriented
record (POR).
3. Russel’s “condition diagram”.
4. CD method.

Problem Oriented Record (POR)
• The POR focuses on problems requiring treatment rather than on
traditional diagnoses.
• It stresses the importance of complete and accurate collecting of clinical
data, with the emphasis on recording abnormal findings rather than on
compiling the extensive lists of normal and abnormal data that are
characteristic of more traditional method (consisting of narration,
checklists, questionnaire, and analysis summaries).
• Problems can be subjective (symptoms), objective (normal clinical signs)
or otherwise clinically significant (eg. psychosocial) and need not be
described in prescribed diagnostic categories.
• Once the patients problems are identified, priorities are established for
further diagnostic evaluation or treatment of each problem

• The POR is helpful in organizing a set of complex clinical data about an
individual patient, maintaining the up-to-date record of both acute and
chronic problems..

Condition diagram
• The condition diagram uses a standardized approach to categorizing and
diagramming the clinical data, formulating a differential diagnosis,
prevention factor, and interventions
• It relies heavily on graphic or non narrative categorization of clinical data
and provides students with concise strategy for summarizing the “the
universe of patient problem” at a given time.
• It is the graphic method of conceptualizing a patients problems.

SEQUENCE OF CASE RECORDING AND EVALUATION
Patients information
Chief complaint
History of present illness medical
History
Past medical history
Past dental history
Family history
Personal history
General examination
Extra oral examination
Intra oral examination
Provisional diagnosis
Investigations
Final diagnosis
Treatment plan

STATISTICS/ PATIENT DETAILS
• It is defined as a systemic approach to collect and compile in numerical form
the information related to vital events, live births, deaths, recognition, social
structure and legislation.
Patient registration number useful for:
• record maintainence
• billing purposes
• medicolegal aspects.
Date: useful for:
• for reference
• for record maintainence

Name:
-for identification
-for communication
-forming a rapport with patient
-record maintainence
-psychological benefit
-information of patient such as religion
Age: useful for:
-diagnosis
-treatment planning
-behaviour management techniques

AGE
 Diagnosis: there is a predilection of certain diseases at different age
levels: eg.
 Diseases commonly present at birth:
 cleft lip and palate
 ankyloglossia
 teratoma
 haemophilia etc.
 Diseases commonly present in children and young adults
 papilloma
 juvenile periodontits
 scarlet fever etc.
 Diseases commonly occuring in adults:
 attrition/abrasion
 periodontitis
 pulp stones
 root resorption etc.

• 2. Treatment planning:
• - Comparison of chronological age with dental age
 Chronologic age – age according to date of birth
 Dental age – age according to last erupted tooth in oral cavity in order of
sequence
• - Growth spurts:
 1. Infantile / childhood growth spurt
 2. Mixed dentition / juvenile growth spurt
 3. Prepubertal / adolescent growth spurt
• -Calculation of child’s dosage
• 3. Behavoiur management techniques:
 -Management of patients of different age groups require different behaviuor
modification methods.

SEX
 Knowing the sex of patient is important for:
 1. Diagnosis: there is a predilection of different diseases in both sexes.
 eg. Diseases more common in females:
 -iron deficiency anaemia
 -sjogren’s syndrome
 -myasthenia gravis
 -juvenile periodontitis
 Diseases more common in males:
 -attrition
 -oral carcinoma
 -hodgkin’s disease
 -pernicious anaemia
 2. Esthetic: girls are much concious about their esthetics.
 3. Child abuse: exploitation is more common in males and sexual abuse in females

Education: it determines
 1. Socio-economic status
 2. I.Q. for effective communication
 3. Attitude towards general and oral health.
Address: it is important for
 1. for future correspondence
 2. gives a view of the socio-economic status
 3. prevalence of diseases:
• for eg.
 a) fluorosis as a result of increased level of fluorides in water are spread
differently in vague parts of country.
 b) caries are more common in modern industrialized areas, whereas
periodontal diseases are more common in rural areas

Occupation: it is important for
 1. Assessing the socioeconomic status
 2. Predilection of diseases in different occupations
 eg. 1) Attrition and abrasion are found in industrial workers having an
atmosphere of abrasive dust.
 2) Hepatitis-B is more common in dentists and surgeons .
Religion: it is important for:
 1) Identifying the festive periods when religious people are reluctant to
undergo treatment procedures.
 2) Predliction of diseases in specific religions

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.
 It is recorded in chronological order of their appearance, and in the order of
their severity.
 The chief complaint aids in the diagnosis and treatment planning and should
be given the first priority.

• COMMON CHIEF COMPLAINTS
 1. Pain
 2. Burning sensation
 3. Bleeding
 4. Loose teeth
 5. Recent occlusal problems
 6. Delayed tooth eruptions
 7. Xerostomia
 8. Swellings
 9. Bad taste
 10. Paresthesia and anaesthesia
 11. Halitosis

•
• HISTORY OF PRESENT ILLNESS
• Initially, the patient may not volunteer the detailed history of the problem, so
the examiner has to elicit out the additional information by the possible
questionnaire about the symptoms.
• The patient’s response to these questions is termed history of present
illness.
• The questions can be asked in the manner:
 1. when did the problem start?
 2. what did you noticed first?
 3. did you have any problems or symptoms related to this?
 4. what makes the problem worse or better?
 5. have any tests been performed before to diagnose this complaint
 6. have you consulted any other examiner for this problem?
 7. what have you done to treat this problem?

• :
• In general, the symptoms can be elaborated under:
 1. mode of onset.
 2. cause of onset.
 3.duration
 4. progress and referred pain
 5. relapse and remission
 6. treatment
 7. negative history

• DETAIL HISTORY OF PARTICULAR SYMPTOM
PAIN:
 anatomical location (site)
 origin and mode of onset
 exacerbating factors
 Relieving factors
 intensity of pain
 nature of pain
 progression of pain
 duration of pain
 movement of pain
 localization behavior
 effect of functional activity
 neurological signs
 temporal behavior

• SWELLING:
 1. anatomical location (site)
 2. duration
 3. mode of onset
 4. symptoms
 5. progress of swelling
 6. associated features
 7. secondary changes
 8. impairment of function
 9. recurrence of swelling
• ULCER
 1. mode of onset
 2. duration
 3. associated pain
 4. discharge
 5. associated diseases

• PAST DENTAL HISTORY
• Gives attitude of the patient towards dentistry.
• Gives a general view about how the patient is aware about pursuing oral
health.
• If history of previous bad experience is present then moulding of behavior is
done using behavior management technique.
• Significant knowledge can be drawn about the patient’s previous treatment
procedures and can be helpful towards the present situation

• : PAST MEDICAL HISTORY
• Recording of past medical history includes history of past illnesses,
hospitalizations and evaluation of the patient’s health based on the history
provided by the patient.
• All diseases suffered by the patient should be recorded in chronological
order.
• Patient should be evaluated for:
 -cardiovascular diseases
 -respiratory diseases
 -gastrointestinal
 -genitourinary
 -endocrine
 -neurological
 -haematological
 -psychiatric
 -allergic reactions
 -extremities and joints

• Patient should be assessed by the questionnaire:
 - whether he is suffering or has suffered before from any major
systemic disease?
 - What is the duration and treatment of the disease? - Is he on any
medication?
 - History of all the hospitalizations and their purpose should be
assessed.
• Some important examples include:
 -Postpone treatment if suffering from acute illness like mumps or
chickenpox
 -Patient with cardiac defects need to get a physician’s report
 -Patient on anticoagulant therapy
 -Asthma
 – NSAID are contraindicated
 -Juvenile diabetes mellitus

• FAMILY HISTORY
• Family history is asked to assess the presence of any inherited disease
pattern or trait.
• It includes:
 -No. of siblings and their age
 -Is there a history of this disease in your family?
• For eg.
 Diseases like
 haemophilia,
 diabetes,
 hypertension recur in families generation after generation.

PERSONAL HISTORY
• It includes:
1) Oral habits
2) Oral hygiene practices
3) Adverse habits

• ORAL HABITS
• 1) Mouth breathing:
• it is the adverse oral habit characterized by habitual respiration of the
patient occurring predominantly through the mouth.
• -It is characterized by presence of narrow arch of maxilla, deep overjet
and overbite, potentially competent or incompetent lips and a tendency to
develop a posterior crossbite.
• 2) Finger and thumb sucking:
• it is the habitual prolonged sucking of the thumb or the finger by the child
patient. It may lead to many dental problems such as hyperactive
mentalis activity, proclination of upper incisors, tendency to posterior
crossbite .
• - it can be diagnosed by assessing the thumb of the child which presents
a shiny, clean area with calculus present at the base of the nail.www.indiandentalacademy.com

• 3) Nail biting:
• it is the constant trimming of the nail parts by the patient at the subconscious
level.
• -it presents with the features as retroclination of the upper incisors, irregular
nail margins, abrasion of lower incisor margins etc.
• 4) Tongue thrusting:
• it is the habitual abnormal function of the tongue which protrudes during the
swallowing pattern to touch the lingual surface of the lower incisors.
• -It is basically the persistence of infantile swallowing.
• It presents with the features: -open bite -marginal gingivitis -potentially
competent/ incompetent lips

• ORAL HYGIENE PRACTICES It is important so as to:
 -assess the knowledge of dental care the patient possesses.
 -to determine the level of hygiene maintained by the patient.
• It includes:
 -Regularity of brushing
 -Frequency and method of brushing
 -Use of fluoridated and non fluoridated tooth pastes
 -Type of brush and how often it is changed.
 ADVERSE HABITS It includes:
 -smoking: record the type, frequency and duration
 -alcohol consumption: record the amount, frequency and duration
 -tobacco chewing: record the type, amount, frequency and duration

CASE HISTORY AND
PHYSICAL EVALUATION OF
DENTAL PATIENTS
GUIDED BY:DR.S.S.DEGWEKAR
PRESENTED BY: SWAPNIL MOHODwww.indiandentalacademy.com

PHYSICAL EVALUATION OF DENTAL PATIENTPHYSICAL EVALUATION OF DENTAL PATIENT
Part IIPart II

LEARNING OBJECTIVES
At the end of the seminar learner should be able to :
1. Perform and record a complete medical history
2. Perform and record appropriate aspect of a physical
examination.
3. Order and interpret appropriate laboratory test.
4. Initiate an appropriate medical consultation or referral for the
suspected problem.
5. Evaluate the data base obtained and make appropriate
decision on modification of dental treatments.
6. Interpret the results of physical evaluation to the patient and
explain how these factors will influence dental treatment.

Introduction:
• Because of effect of systemic diseases and medications on dental
procedures as well as the possible effect of dental treatment on systemic
health problems, there is an obvious need for the dentist to be properly
trained in the physical evaluation of the patient
• The term physical evaluation refers to of
- appropriate aspect of performing a physical examination &
- interpreting the laboratory test.
Necessary to obtain a sufficient data base to responsibly plan and carry out
dental therapy and enhance the patient health care.

Basic principles and techniques
• The basic principles of clinical examination are essentially the same for
medicine and for dentistry
• The four classical techniques of physical examination are
– Inspection
– Palpation
– Percussion
– Auscultation
An underlying principle or general guidelines for the dentist’s approach
to clinical examination is to
1. Examine each patient as if the patient had an early stage of cancer
2. Advice and treat each patient as if the patient were your
closest friend or relative.

• Inspection may be considered in two broad categories
1. General observation or gross inspection of the patient
2. Close detailed inspection at close range in the dental chair

Classical techniques
of physical
examination

Inspection
• Inspection it starts as soon as patient enters the clinic.
• It is the simple observation of the patient.
• It makes guidelines for further examination
• It gathers maximum information amongst all techniques.

Palpation
• Palpation is the act of feeling by the sense of touch
• It is usually accomplished through fingertip pressure applied lightly
against the various body tissues.
• To become astute in the art of palpation usually requires much clinical
expirience and the development of manual or digital sensitivity that can
discern many variation in normal and pathological changes.
• The methods of palpation in orofacial region includes
- Bilateral
- Bimanual
- Bidigital

Purcussion
• Percussion is the act of striking a portion of the body with the fingers or
an instrument to evaluate the condition of the underlying structures by
careful attention to the sound or echo produced.

Auscultation
• Auscultation is the act of listening to functional sounds of the body
• Listening can be done with the unaided ear or with the stethoscope.
• In orofacial region
- The clicking or crepitus sounds associated with TMJ
- Squecks or premature contacts related to malocclusions
- Abnormal TM joint sounds inaudible to the unaided ear may be
appreciated by simply listening through a stethoscope placed over the
joint.
- One can some times detect the bruite or vascular pulsation of
developmental lesions, such as arteriovenous fistulas which occurs in the
jaw region.

General observation should begin upon the first visit of patients to the office and
should continue at every opportunity
General observations may yield information specifically in regard to:
1. Stature
2. Body type
3. Posture
4. Gait
5. Mobility
6. Symmetry
7. Color
8. Skin
9. Head, face & neck
10. Hair
11. Hands
12. Responses and functions
13. Dress
14. Cleanliness

GENERAL
EXAMINATION

General examination consists of:
1. General condition
2. Gait
3. Built – average / small
4. Temperature
5. Pulse
6. Respiratory rate
7. Blood pressure
8. Skin
9. Nails
10. Conjunctiva
11. Sclera
12. Edema feet

General condition of patient is evaluated for overall
psychological and bihavioural status of the patient
• Consciousness of the patient
• Co-opration of the patient or resposiveness
• Orientation of the patient towards time, place and person.

Gait
• Observation of patients walk
• Patients are observed for any abnormality in usual smooth movement in
which they move one foot at a time with rhythmic motion.
• Paralytic patients drag their leg
• In patients with leg amputation walk with limp is there
• In tertiary syphilis patients gait is called tabes dorsalis in which the gait is
very halty because they search for ground with each step.

Stature, gait and built
• Stature is strictly defined as the patient’s height.
• Very tall person – giant
• The short as the – dwarf or midget
Average height of
- Men in India – 5.5 feet
- Women in India – 5 feet.
Built
- Average
- Small

Vital signs
• Vital signs are important indicators of health
• “Vital” pertaining to life
• Vital signs are normally measured as a part of physical evaluation
procedure.
• The vital signs include
- Pulse rate
- Respiratory rate
- Temperature
- Blood pressure

PULSE:
• it is an important index of severity of the vascular system and heart
abnormalities.
• It is useful to record:
1. Rate (tachycardia/ bradicardia)
2. Rhythm
- abnormalities in rhythm considered in two main groups
- A. regular irregularity
- B. irregular irregularities
1. Character
- Collapsing or water hammer pulse in aortic regurgitation
Volume
- Observed by pressing index finger
- Full pulse or thready pulse
1. Condition of vessel wall

Respiration
• This includes
1. Rate
Normal rate of respiration 14 to 18 cycles per minute.
1. Rhythem
Kussmauls respiration (heavy or laboured breathing) seen in uncontrolled
diabetic patients who have severe acidosis, because body attempts to
exhale excess acid, the patient breaths frequently and deeply.
Air hunger – may also be seen in renal acidosis or after certain drug
intoxication.

Temprature
• The range of body temperature does not normally exeed
• 98.6 degree F (37 C) by mouth.
• 99.6 degree F (37.5 C) by rectum
• Axillary temperature is usually 97.6 degree F (36.5 C)

• 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 120/80bmm of hg)

Fingers and nails
• The fingers are observed for clubbing
• Clubbing (pulmonary osteoarthropathy) seen in
- Severe coronary or respiratory disease
- Severe ventricular septal defect
- Congenital cerculation problem
- COPD
- Any chronic heart disease that reduces the amount of blood circulated.
• Finger nails : may indicate much about patients medical history
• Classic spinter hemorrhage of endocarditis caused by bacterial emboli in
the finger nail, producing infarction and emboli.
• Extended period of severe illness produce horizontal lines in all the
fingernails.

Skin
• Skin observation is done for
- Any changes in colour
- Texture
- Consistency
- Or symmetry
- Colour of the patients skin need to observed carefully
- Many diseases and physiologic processes produce alteration in skin
pigmentation.
- Hairs are also observe for color, texture, brightness and distribution

Extraoral
examination:

• Facial symmetry:
• facial symmetry is important to note so as to assess the fullness on both the halves
of the face and to look for any gross disorder that may reveal a significant history.
• It is noted as symmetrical or asymmetrical.
• TMJ(temporomandibular joint):
observed for:
 -symmetry: gross derangement in symmetry may reflect growth disturbances.
 -maximum interincisal opening (normal value- 35-50 mm)
 -any deviation in opening -range of vertical movement
 -range of lateral movement
 -Listen for clicking and crepitus sounds
 -Note for tenderness over joint or masticatory muscles

• Palpation of the joint area:
 - palpation of the pretragus area: the patient should be requested to slowly
open and close the mouth while the doctor bilaterally palpates the pretragus
depression with his/her index fingers.
 -intra-auricular depression: it is also performed by inserting a small finger
into the ear canal pressing anteriorly.
 -palpation is also used to detect the tenderness, clicking and crepitus.
 -the masseter muscle is examined by simultaneously pressing it both from
inside and outside, termed as bimanual palpation.
 -the lateral pterygoid muscle is examined by inserting a finger each behind
the maxillary tuberosities, and
 - the medial pterygoid by running a finger in anteroposterior direction along
the medial aspect of mandible in the floor of the mouth.

• LYMPH NODES:
• palpation of lymph node is done to:
 -know the position
 -number of nodes
 -tenderness
 -fixity to underlying tissues
• Palpation of the lymph nodes of the neck commonly begins the most
superior nodes and is worked down to the clavicle to the supraclavicular
nodes
• The superficial and the deep lymph nodes of the neck are best examined
from behind the patient, with the patient’s head inclined forward and
sideways sufficiently to relax the muscles near the lymph nodes, and then
palpated. Also look for any distension present in the superficial veins or any
thyroid enlargement

INTRA ORAL EXAMINATION SOFT TISSUES
• LIP: inspection of lip constitutes:
 - lip color, texture and checking of surface abnormalities
 - cleft lip
 - pigmentation.
 Eg. Pigmentation of lips occurs in adison’s disease and peutz
jegherts syndrome. - any presence of neoplasm or chancre or
diffuse enlargement of lip.
•

• 1. TONGUE: examination should be done to check:
 -volume of the tongue: enlarged tongue may be due to
lymphangioma, hemangioma and neurofibroma.
 -integrity of the papillae: note the distribution and keratosis of the
papillae
 -any cracks or fissures: congenital fissures are mainly transverse
but syphilitic fissures are usually longitudinal.
 -any swellings or ulcers:
 -mobility of the tongue:
 check for the impairment of nerve supply and ankyloglossia.
 - note for presence of cyanosis

 Palpation of the tongue:
 the tongue should be relaxed and at rest within the mouth.
 A protruded tongue may give a false impression because of tensed
muscles.

• BUCCAL MUCOSA: the cheek is retracted using a mouth mirror
and checked for:
 -any ulcer, white patch or neoplasia.
 -pigmentation
 -observe the opening of stenson’s duct and establish their patency.

• FLOOR OF MOUTH:
• patient is asked to open his mouth and to keep the tip of the tongue
upward to touch the palate. This will expose the floor of the mouth.
• Check for:
 -color
 -swelling,
 - any presence of patches.
 -ankyloglossia

 PALATE:
 check for:
-clefts, perforations, ulcerations or any swelling
 -recent burns or hyperkeratinization
-fistulae, tori, papillary hyperplasia etc.

• SALIVARY GLANDS:
• PAROTID GLAND
 -check for any swelling over the region.
 -in case of parotid abscess, the skin over the area becomes edematous with pitting
on pressure.
 -Examine the area for presence of any fistula, and enlargement of lymph nodes or
involvement of facial nerves.
• SUBMANDIBULAR GLAND
 -history of the patient is to be noted: eg swelling with pain at the time of meals
suggests obstruction in submandibular duct.
 -check for any nodal swelling, it may suggest of lumph node enlargement.
 -bimanual palpation
 - in the open mouth, the physician’s finger of one hand is placed on the floor of the
mouth and pressed as far as possible.
• The finger of the other hand is placed on the exterior at the inferior margin of the
mandible. These fingers are pushed upwards and palpation is achieved.

• GINGIVA
• Color: the color of attached and marginal gingiva is normally described as
coral pink.
• In gingivitis, the color changes to reddish blue.
• Pigmentation: present in all normal individuals.
• Size: it is the sum total of cellular and intercllular elements.
• Contour: the contour of gingiva varies differently according to shape of
teeth and alignment in arch.
• Normal contour is termed as scalloped.
• Shape: it is governed by contour of proximal surface and location and shape
of gingival embrasures.
• Consistency: the normal gingiva is firm and resilient, except at the free
gingival margin. In inflammation, it becomed soft and edematous.

• Surface texture:
 the normal gingiva gives an orange peel appearance and is called as
stippled. It occurs in attached gingiva.
 Stippling is a form of adaptive specialization or reinforcement for function.
 Position: it refers to the level at which the gingival margin is attached to the
tooth.
• Bleeding on probing:
 It is a method to check gingival inflammation. The insertion of a probe to
the bottom of the pocket elicits bleeding if the gingiva is inflamed and the
pocket epithelium is atrophic or ulcerated.
 The probe is carefully introduced into the bottom of the pocket and gently
moved laterally along the pocket wall. After inserting the examiner should
wait for 30-60 seconds.

• PERIODONTIUM PLAQUE AND CALCULUS:
• the dental tissues are carefully inspected for the presence of plaque and
calculus.
• PERIODONTAL POCKETS: a pocket is defined as a pathological
deepening of gingival sulcus. The examination includes assessing the
surface of the tooth, the pocket depth and the type of the pocket. A
periodontal probe is used for the assessment in a ‘walking’ fashion.
• TOOTH MOBILITY: all teeth have a slight amount of physiologic mobility.
The destruction of periodontium makes the tooth loose in the socket. Tooth
mobility is graded as:
 grade I- slight mobility, upto 0.5 mm.
 grade II- moderate mobility, more than 0.5 mm but less than 1 mm.
 grade III- severe mobility, tooth is movable both mesiodistally and
labiolingually and may be depressible in the socket.

• FURCATION INVOLVEMENT:
• the progress of inflammatory periodontal disease to the bifurcation or
trifurcation of multirooted teeth is called as furcation involvement.
• It is graded as:
 grade I – incipient stage, the pocket is suprabony and primarily affects
the soft tissues.
 grade II – lesion is called ‘cul-de-sac’, having a definite horizontal
component.
 grade III – the destruction has progressed and the bone is not attached
to the dome of the furcation, the probe can be passed completely
through the furcation.
 grade IV – interdental bone is completely destroyed, and the soft tissues
have receded completely.

• HARD TISSUE EXAMINATION TEETH –
• A)NUMBER
• B)NOTATION: by any of the three methods of notation:
 1) FDI Primary/Deciduous teeth
 2) Zsing mondy/palmer method
• 3) UNIVERSAL SYSTEM
• C) Caries assessment: count the total number of caries and the tooth
number is to be noted.
• D) Filled teeth
• E) Any defected/fractured restoration
• F) Attrition, erosion and abrasion: Attrition is defined as the wear caused
by tooth to tooth contact. A certain amount of attrition is normal called as
physiologic attrition. Erosion: Tooth surface loss caused by chemical or
electrochemical action is termed “corrosion.” Abrasion: Friction between a
tooth and an exogenous agent causes wear called “abrasion”
• G) Root stumps.
• H) Fluorosis: it is an endemic disease in geographic areas where the
content of fluoride ion in the drining water exceeds 2 ppm. Fluorosis is
estimated by the dean’s fluorosis method.
• i) Any congenital deformity

DIAGNOSIS
• The word diagnosis is derived from Greek words dia (thorough) gnosis
(knowledge).
• It can be defined as the process of determining the nature of an
abnormality or disease that is producing signs or symptoms or both.
Types of diagnosis are:
1. Working or tentative diagnosis.
2. Clinical diagnosis.
3. Radiographic diagnosis.
4. Differential diagnosis.
5. Final diagnosis.(definitive diagnosis)

• Provisional Diagnosis
 Provisional diagnosis is also called as tentative diagnosis or working
diagnosis and is arriver at after evaluating the case history and performing
the physical examination.
 Provisional diagnosis is just a temporary The dentist shoulde keep in mind
the differential diagnosis.
 The postive findings are listed down and the possibility of a specific
diagnosis is evaluated.

• DIFFERENTIAL DIAGNOSIS :
• A differential diagnosis is a list, in order or probability beginning with
the most likely, of all the possible diseases that should be
considered.
 If the diagnosis is not conclusive for a definite disease process, a list
of probable diagnoses is recorded in the patient’s case history.
 These diseases may have a similar course, progress, or signs and
symptoms. A final diagnosis may be possible only after carrying out
further investigation.

Supplemental diagnostic aids

RADIOGRAPHS
• A) OCCLUSAL
• B) IOPA
• C) BITEWING
• D) OPG (ORTHOMOPENTOGRAM) RADIOGRAPHIC
INVESTIGATIONS.
• LABORATORY INVESTIGATIONS :
• LABORATORY INVESTIGATIONS It helps to come to the final
diagnosis
• b) BIOCHEMICAL INVESTIGATIONS
• c) BLOOD EXAMINATION
• d) URINE EXAMINATION
• E) SPECIAL INVESTIGATIONS LIKE SIALOGRAPHY, MRI

• FINAL DIAGNOSIS :
• Usually reached by chronologic organization and critical evaluation
of the information obtained from patients case history, physical
examination and the result of radiological and laboratory
examinations. it usually identifies the chief complaint first and then
the subsidiary diagnosis of other problems

• TREATMENT PLAN
• 1. EMERGENCY
 PHASE this is the first and the preliminary phase of treatment planning. The
emergency complication is the first thing to be treated and managed.
 For eg. Ludwigs angina involves high morbidty due to airway obstruction,
thus trecheostomy is the first procedure to be performed.
 Also, in cases of acute pulpal abcess, access opening is done so as to
immediately relieve the pressure within the root canal.

• 2. PREVENTIVE PHASE
 This is the second line of treatment. The preventive phase involves
protection and prevention of the high risk factors such as sticky,
sugary diet, calculus retentive factors, deep pits and fissures etc.
 for eg. In cases of caries risk assessment i.e. high caries risk/low
caries risk, preventive phase is achieved by: Dietary Counseling:
Add more cereals ,pulses ,milk & dairy product and poultry Pit and
fissure Sealant Application.
 Indication Age more than 6 year Fluoride Treatment : Age less than
6 year –Varnish application Age more than 6 year – fluride gel

• 3. PREPRATORY PHASE:
• Oral prophylaxis Caries control Endodontic Treatment Extraction
Orthodontic consultation
• 4. CORRECTIVE PHASE : Permanent Restoration and other
prosthetic replacement Stainless steel crown Space maintainer
• 5. MAINTAINANCE PHASE : a follow up is essential.

• PROGNOSIS :
• PROGNOSIS:
• The prognosis is the prediction of the probable course, duration,
and outcome of a disease based on a general knowledge of the
pathogenesis of the disease and the presence of risk factors for the
disease.
• The prognosis is evaluated and informed to the patient. The final
treatment protocol is then determined.

Summary
• The physical evaluation of a dental patient before the provision of dental
treatment, either in the office or hospital settings is the legal
responsibility of the dentist.
• Some form of pre treatment medical history is essential for all patients
• A physical evaluation should be developed to the depth necessary. The
degree of history taking and examination will depend on the answer to
the initial questions concerning the patients health status; for example, a
patient with the history of chronic debilitating disease who is taking
multiple medications will clearly need a much more detailed medical
history and evaluation than a person with no history of medical disorder.
• The dentist is in very favorable position to detect early disease of which
patient may be unaware by simple screening measures.

“Elephant and five blind men”

• References :
• Burket’s oral medicine 11th
edition; 2008 BC Decker Inc Hamilton
• K. Ciarocca, M. Greenberg: Burket’s oral medicine 10th
edition; 2004
BC Decker Inc Hamilton
• Physical evaluation of dental patients , charls l. halsted, the C.V.
mosby company 1982
• Principles of Practical Oral Medicine and Patient Evaluation, by
pramod john R. Endodontic practice, by louis I, grossman, 11th
edition.
• Femin. A. Carranza.Clinical periodontology, 10th edition

Thank you.

CASE HISTORY AND PHYSICAL EVALUATION OF DENTAL PATIENTS /prosthodontic courses

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