Transcript 1Examination of dental patient subjective and objective basic and

Examination of dental patient:
subjective and objective basic
and additional methods.
Medical document of
therapeutic dentistry reception.
Hospital chart as medical, legal
and scientific document.
Lecturer: as. Yavors’ka-Skrabut I.M.
Therapeutic dentistry department
DIAGNOSIS
 Diagnosis: is a fancy name given to the process of
identifying diseases. It means “through knowledge”
and entails acquisition of data about the patient and
their complaint using the senses :
 . Hearing
 . Observing
 . Touching
 .sometimes smelling
 The purpose of making a diagnosis is to be able to offer
the most :
 Effective and safe treatment
 Accurate prognostication
 Diagnosis is made by the clinical examination,
which comprise the :
History
physical examination
Supplemented in some cases by investigations .
HISTORY
History taking is part of the initial
communication between the dentist
and patient. It is important to adopt a
professional appearance and manner,
and introduce oneself clearly and
courteously.
The history is best given in the
patient’s own words, through the
clinician often needs to guide the
patient, and may use protocols to
ensure collection of all relevant points.
It is important to cover the following areas:
 General information (name, age, gender, ethnic
origin, place of residence, occupation)
 Presenting “chief” complaint
 History of chief complaint
 Past medical history
 Dental history
 Family history
 Social history.
CHIEF COMPLAINT AND HISTORY OF THE PRESENT
ILLNESS
 The chief complaint is established by asking the
patient to describe the problem for which he or she
is seeking help or treatment.
 The chief complaint is recorded in the patient’s
own words as much as possible and should not be
documented in technical (ie, formal diagnostic)
language unless reported in that fashion by the
patient.
Direct and specific questions are used to elicit information about
chief complaint and should be recorded in the patient record in
narrative form, as follows:
1. When did this problem start?
2. What did you notice first?
3. Did you have any problems or symptoms related to this?
4. What makes the problem worse or better?
5. Have the symptoms gotten better or worse at any time?
6. Have any tests been performed to diagnose this complaint?
7. Have you consulted other dentists, physicians, or anyone
else related to this problem?
8. What have you done to treat these symptoms?
PAST DENTAL HISTORY
 Dental history is one of the most important
components of the patient history.
 The dental history will give an idea of the:
past dental visits; previous restorative, periodontic,
endodontic, or oral surgical treatment; reasons for loss of
teeth; untoward complications of dental treatment;
fluoride history; attitudes towards previous dental
treatment; experience with orthodontic appliances and
dental prostheses; and radiation or other therapy for oral or
facial lesions.
MEDICAL HISTORY
The medical history comprises a
systematic review of the patient’s chief or
primary complaint, a detailed history
related to this complaint, information about
past and present medical conditions,
pertinent social and family histories, and a
review of symptoms by organ system.
PAST MEDICAL HISTORY
The past medical history includes
information about any significant or serious
illnesses a patient may have had as a child
or as an adult. The patient’s present
medical problems are also enumerated
under this category.
The past medical history is usually organized into
the following subdivisions:
(1) serious or significant illnesses,
(2) hospitalizations,
(3) transfusions,
(4) allergies,
(5) medications, and
(6) pregnancy.
An appropriate interpretation of the information
collected through a medical history achieves three
important objectives:
 It enables the monitoring of medical conditions and the
evaluation of underlying systemic conditions of which the
patient may or may not be aware.
 It provides a basis for determining whether dental
treatment might affect the systemic health of the patient
 It provides an initial starting point for assessing the
possible influence of the patient’s systemic health on the
patient’s oral health and/or dental treatment
FAMILY HISTORY
 Serious medical problems in immediate family members
should be listed.
 Disorders known to have a genetic or environmental
basis (such as certain forms of cancer, cardiovascular
disease including hypertension, allergies, asthma, renal
disease, stomach ulcers, diabetes mellitus, bleeding
disorders, and sickle cell anemia) should be addressed.
 This type of information will alert the clinician to the
patient’s predisposition to develop serious medical
conditions.
SOCIAL HISTORY
 Different social parameters should be recorded. These
include:
 marital status (married, separated, divorced, single, or
with a “significant other”)
 place of residence (with family, alone, or in an institution)
 educational level
 Occupation
 Religion
 Tobacco use (past and present use and amount);
 Alcohol use (past and present use and amount);
 Recreational drug use (past and present use, type, and
amount).
REVIEW OF SYSTEMS
 The review of
systems is a comprehensive and
systematic review of subjective symptoms affecting
different bodily systems.
 Direct questioning of the patient should be aimed at
collecting additional data to confirm or rule out those
disease processes that have been identified by the
clinician as likely explanations for the patient’s
symptoms.
 This type of questioning may also alert the clinician to
underlying systemic conditions that were not fully
described in the past medical history.
A complete review of systems includes
the following categories
1. General
2. Head, eyes, ears, nose, and throat
3. Cardiovascular
4. Respiratory
5. Dermatologic
6. Gastrointestinal
7. Genitourinary
8. Gynecologic
9. Endocrine
10.Musculoskeletal
11. Hematologic-lymphatic
12. Neuropsychiatric
EXAMINATION OF THE PATIENT
 The examination of the patient represents the second
stage of the diagnostic procedure
 The examination is most conveniently carried out with
the patient seated in a dental chair, with the head
supported.
 Before seating the patient, the clinician should observe
the patient’s general appearance and step and should
note any physical deformities or handicaps.
 A less comprehensive but equally thorough inspection
of the face and oral and oropharyngeal mucosa should
also be carried out at each dental visit.
 The tendency for the dentist to focus on only the tooth
or jaw quadrant in question should be strongly
resisted.
The examination procedure in dental office settings
includes the following:
1.
Registration of vital signs (respiratory rate,
temperature, pulse, and blood pressure).
2. Examination of the head, neck, and oral cavity,
including salivary glands, temporomandibular joints,
and lymph nodes.
3. Examination of cranial nerve function.
4. Special examination of other organ systems.
5. Requisition of laboratory studies.
Vital Signs
 PULSE RATE AND RHYTHM
 RESPIRATORY RATE
 BLOOD PRESSURE
 TEMPERATURE
PULSE RATE AND RHYTHM
 Cardiac rate, rhythm, and strength are assessed by
taking the radial or carotid artery pulse.
 For the carotid pulse, the first two fingers are placed
just anterior to the sternomastoid muscle, posterior to
the larynx, and below the angle of the mandible in the
region of the carotid bulb.
 Only light pressure is applied until pulsations are
readily detectable.
 The radial pulse is accomplished by placing the first
two fingers in the slight trough produced by a tissue
depression between the radius and the flexor tendons
located on the ventral wrist just proximal to the
thumb’s thenar eminence
 Only light pressure is exerted until pulsations are
perceived.
 The cardiac rate is determined by counting the number
of beats during 15 seconds and multiplying by 4.
 Normal heart rate is 60 to 80 beats per minute.
RESPIRATORY RATE
 Respiration rate is determined by sitting next to or
standing behind the patient seated in the dental chair
and looking down at the patient’s chest.
 Count the number of times the chest rises and falls for
30 seconds and then multiply by 2.
 A normal respiratory rate is 12 to 15 respirations per
minute.
BLOOD PRESSURE
 Measuring blood pressure assesses pressure within the
arteries during cardiac contraction (systole) and
pressure during cardiac pause (diastole).
 To obtain these values, one must generate an external
pressure that exceeds that within the artery then
slowly lower that pressure until the intra-arterial
pressure exceeds the externally applied pressure,
thereby opening the arteries and being able to detect
the pulse as blood is again pumped through. The
pressure at which the first evidence of a pulse can be
detected is the upper, or systolic pressure, which
normally is about 110 to 130 mm Hg.
 After detecting the systolic pressure, the externally
applied pressure continues to be decreased until
pulsations are no longer detected. This level of
pressure, the diastolic, varies normally from 70 to 90
mm Hg.
TEMPERATURE
 Temperature is recorded using a thermometer or
temperature sensitive disposable oral strips. Either of
these recording devices should be inserted orally, with
the tip placed under the tongue, and left in place for
1.5 to 2.0 minutes. Recall that normal body
temperature is 37°C (98.6°F).
Head, Neck, and Oral Cavity
The examination routine encompasses the
following eight steps:
1. Note the general appearance of the individual and
evaluate emotional reactions and the general nutritional
state. Record the character of the skin and the
presence of petechiae or eruptions, as well as the
texture, distribution, and quality of the hair. Examine the
conjunctivae and skin for petechiae, and examine the
sclerae and skin for evidence of jaundice or pallor.
Determine the reaction of the pupils to light and
accommodation, especially when neurologic disorders
are being investigated.
2. Palpate for adenopathy. Palpate any swellings,
nodules, or suspected anatomic abnormalities.
3. Examine in sequence the inner surfaces of the lips, the
mucosa of the checks, the maxillary and mandibular
mucobuccal folds, the palate, the tongue, the sublingual
space, the gingivae, and then the teeth and their
supporting structures. Last, examine the tonsillar and the
pharyngeal areas and any lesion, particularly if the lesion
is painful.
4. Completely visualize the smooth mucosal surfaces of the
lips, cheeks, tongue, and sublingual space by using two
tongue depressors or mirrors. Perform a more detailed
examination of the teeth and supporting tissues with the
mouth mirror, the explorer, and the periodontal probe.
5.
Have the patient extend the tongue for examination of the dorsum; then
have the patient raise the tongue to the palate to permit good visualization
of the sublingual space. The patient should extend the tongue forcibly out
to the right and left sides of the mouth to permit good visualization of the
sublingual space and to permit careful examination of the left and right
margins. A piece of gauze wrapped lightly around the tip of the tongue
helps when manually moving the patient’s tongue. Examine the tonsillar
fossae and the oropharynx.
6.
Use bimanual or bi-digital palpation for examination of the tongue,
cheeks, floor of the mouth, and salivary glands. Palpation is also useful for
determining the degree of tooth movement. Two resistant instruments,
such as mirror handles or tongue depressors, placed on the buccal and
lingual surfaces of the tooth furnish more accurate information than when
fingers alone are directly employed.
7. Examine the teeth for dental caries, occlusal
relations, possible prematurities, inadequate
contact areas or restorations, evidence of food
impaction, gingivitis, periodontal disease, and
fistulae.
8. After the general examination of the oral cavity has
been completed, make a detailed study of the
lesion or the area involved in the chief complaint.
FACIAL STRUCTURES
Observe the patient’s skin for color,
blemishes, moles, and other pigmentation
abnormalities; vascular abnormalities such as
angiomas, telangiectasias, nevi, and tortuous
superficial vessels; and asymmetry, ulcers,
pustules, nodules, and swellings. Note the color
of the conjunctivae. Palpate the jaws and
superficial masticatory muscles for tenderness or
deformity. Note any scars formation.
LIPS
Note lip color, texture, and any surface
abnormalities as well as angular or vertical
fissures, lip pits, cold sores, ulcers, scabs,
nodules, keratotic plaques, and scars. Palpate
upper lip and lower lip for any thickening
(induration) or swelling. Note orifices of minor
salivary glands and the presence of Fordyce’s
granules.
CHEEKS
Note any changes in pigmentation and
movability of the mucosa, a pronounced linea alba,
leukoedema, hyperkeratotic patches, intraoral
swellings, ulcers, nodules, scars, other red or white
patches, and Fordyce’s granules. Observe openings
of Stensen’s ducts and establish their patency by
first drying the mucosa with gauze and then
observing the character and extent of salivary flow
from duct openings, with and without milking of the
gland. Palpate muscles of mastication.
MAXILLARY AND MANDIBULAR
MUCOBUCCAL FOLDS
Observe color, texture, any swellings,
and any fistulae. Palpate for swellings and
tenderness over the roots of the teeth and
for tenderness of the buccinator insertion
by pressing laterally with a finger inserted
over the roots of the upper molar teeth.
HARD PALATE AND SOFT PALATE
Illuminate the palate and inspect for
discoloration, swellings, fistulae, papillary
hyperplasia, tori, ulcers, recent burns,
leukoplakia, and asymmetry of structure or
function. Examine the orifices of minor
salivary glands. Palpate the palate for
swellings and tenderness.
THE TONGUE
 Inspect the dorsum of the tongue (while it is at rest) for any swelling,
ulcers, coating, or variation in size, color, and texture. Observe the
margins of the tongue and note the distribution of filiform and
fungiform papillae, crenations and fasciculations, depapillated areas,
fissures, ulcers, and keratotic areas. Note the frenal attachment and
any deviations as the patient pushes out the tongue and attempts to
move it to the right and left.
 Wrap a piece of gauze around the tip of the protruding tongue to
steady it, and lightly press a warm mirror against the uvula to
observe the base of the tongue and vallate papillae; note any ulcers or
significant swellings. Holding the tongue with the gauze, gently
guide the tongue to the right and retract the left cheek to observe the
foliate papillae and the entire lateral border of the tongue for ulcers,
keratotic areas, and red patches.
 Repeat for the opposite side, and then have the
patient touch the tip of the tongue to the palate to
display the ventral surface of the tongue and floor of
the mouth; note any varicosities, tight frenal
attachments, stones in Wharton’s ducts, ulcers,
swellings, and red or white patches.
 Gently palpate the muscles of the tongue for nodules
and tumors, extending the finger onto the base of the
tongue and pressing forward if this has been poorly
visualized or if any ulcers or masses are suspected.
Note tongue thrust on swallowing.
FLOOR OF THE MOUTH
With the tongue still elevated, observe
the openings of Wharton's ducts, the
salivary pool, the character and extent of
right and left secretions, and any swellings,
ulcers, or red or white patches. Gently
explore and display the extent of the lateral
sublingual space, again noting ulcers and
red or white patches.
GINGIVAE
Observe color, texture, contour, and
frenal attachments. Note any ulcers,
marginal
inflammation,
resorption,
festooning, Stillman’s clefts, hyperplasia,
nodules, swellings, and fistulae.
TEETH AND PERIODONTIUM
Note missing or supernumerary teeth,
mobile or painful teeth, caries, defective
restorations, dental arch irregularities,
orthodontic anomalies, abnormal jaw
relationships, occlusal interferences, the
extent of plaque and calculus deposits,
dental hypoplasia, and discolored teeth.
TONSILS AND OROPHARYNX
Note the color, size, and any surface
abnormalities of tonsils and ulcers, tonsilloliths, and
inspissated secretion in tonsillar crypts. Palpate the
tonsils for discharge or tenderness, and note
restriction of the oropharyngeal airway. Examine the
faucial pillars for bilateral symmetry, nodules, red
and white patches, lymphoid aggregates, and
deformities. Examine the postpharyngeal wall for
swellings, nodular lymphoid hyperplasia, hyperplastic
adenoids, postnasal discharge, and heavy mucous
secretions.
Macule
A macule is a change in surface color, without elevation
or depression and, therefore, nonpalpable, well or illdefined, variously sized, but generally considered less
than either 5 or 10mm in diameter at the widest point.
Patch
A patch is a large macule equal to or greater than either
5 or 10mm, depending on one's definition of a macule.
Patches may have some subtle surface change, such as a
fine scale or wrinkling, but although the consistency of
the surface is changed, the lesion itself is not palpable
Papule
A papule is a circumscribed, solid elevation of skin with
no visible fluid, varying in size from a pinhead to either
less than 5 or 10mm in diameter at the widest point.
Nodule
A nodule is morphologically similar to a papule, but is
greater than either 5 or 10 mm in both width and depth, and
most frequently centered in the dermis or subcutaneous fat.
The depth of involvement is what differentiates a nodule
from a papule.
Vesicle
A vesicle is a circumscribed, fluid-containing, epidermal elevation
generally considered less than either 5 or 10 mm in diameter at the
widest point.
Bulla
A bulla is a large vesicle described as a rounded or irregularly shaped
blister containing serous or seropurulent fluid, equal to or greater than
either 5 or 10 mm, depending on one's definition of a vesicle.