oral diagnosis prelims reviewer

7/29/2019 Oral Diagnosis Prelims Reviewer

1/16

ORAL DIAGNOSIS PRELIMS REVIEWER

ORAL DIAGNOSIS

Science of identifying and recognizing the presence

of an oral disease process or condition that may be a

departure from normal

A systemic method of identifying oral disease

Diagnos Greek word meaning distinguishing or

discernment

The discipline of dentistry that is specifically

concerned with the art and science of health

assessment

Includes the evaluation of the patients general

health status orphysical assessment

SCOPE OF REVIEW

Introduction

o Types of diagnosis/prognosis

o Types of clinical exam

o The diagnostic method

o Symptomatology

o Cardinal indicators of diseases

Oral lesions

Patients history

Physical xamniation

Patient assessment

Radiographic interpretation

Clinical laboratory studies

Treatment planning

TYPES OF DIAGNOSIS

DIRECT DIAGNOSIS

o Diagnosis based on inductive logic

o Signs and symptoms presented by the

patient arepathognomatic (unique

features) of a particular disease

o Diagnosis that is mainly utilized for most

dental abnormalities

Eg. Dental caries, malposition of

teeth, dental developmental

abnormalities such as dentogenesis

imperfect

WORKING DIAGNOSIS/ TENTATIVE DIAGNOSIS

o Presumptive diagnosis or clinical impression

o The most likely diagnosis in the order of

diagnostic probability

DEFINITIVE DIAGNOSIS/ FINAL DIAGNOSIS

o All the diagnostic data have been collected

and subjected to evaluation and analysis

o Patients history + clinical exam + analysis

POST-THERAPY/ POST-OPERATIVE DIAGNOSIS

o Diagnosis that confirms or verifies the final

diagnosis

SPOT DIAGNOSIS (IMPROMPTU DIAGNOSIS)

o A form of diagnosis which is primarily based

on the knowledge and experience of the

disease/lesion by the clinician or the

examiner

DIFFERENTIAL DIAGNOSIS

o Comparative diagnostic technique or

diagnosis by elimination

o Type of diagnosis mainly utilized for non-

dental abnormalities

o Eg. Odontogenic tumors like

ameloblastoma. Vesicular lesions like

herpetic gingivostomatitis, white lesions likewhite sponge nevus

PROGNOSIS

Usually expressed in terms of time and tissue

response

Prediction of the possible outcome of the disease as

to:

o Length of time the disease can be

eliminated

o

Degree of tissue damage

o Loss of function

o Susceptibility to recurrence

GRADES OF PROGNOSIS

Good - excellent

Fair

1


2/16

Poor worst

FACTORS AFFECTING THE GIVING OF PROGNOSIS

Severity of the disease

Onset of the disease

Location of the lesion

Age of the patient

Presence of complicating factors

Status of the immune system

Course of the disease

THE DIAGNOSTIC METHOD

Components of the comprehensive dental diagnostic

database

Patient history (case hx)

o Identifying data/ personal record

o Chief complaint (c.c)

o History of chief complaint (hx c.c)

o Medical history

Past medical conditions

Prior hospitalizations

Past infections/ immunizations

Known allergy/ hypersensitivity

Current medical treatment

o Family history (fh)

o Personal, social and economic history

o Review of systems (ros)

o Dental history

Physical/ clinical examination

o General patient appraisal (GPA) and vitalsigns determination

o Extraoral examination

o Intraoral examination

Lips

Labial & buccal mucosa and

vestibule

Hard palate

Soft palate

Oropharyngeal area

Tongue

Floor of the mouth

Teeth

Periodontium

Adjunctive diagnostic information

o Radiographic examination

o Clinical laboratory studies

o Microscopic examination of the tissue

samples

o Consultations/ referrals

PROCEDURAL STEPS OF DIAGNOSTIC METHOD

Collection of diagnostic information

o Patient history

o Physical examination

o Adjunctive diagnostic information

Organization/ analysis of diagnostic information

o Physical assessment of the patients healthstatus

o Classification of abnormalities

Dental abnormalities

Carious lesions

Gingivitis/ periodontitis

Periapical inflammatory

lesions

Dental developmentalanomalies

Non-dental abnormalities

Mucosal lesions

Soft tissue enlargements

Bone lesions

2


3/16

Clinical syndromes

o Formulation of diagnosis including giving of

prognosis

o Formulation and execution of the optimal

treatment plan

Comprehensive treatment plan

(oral rehab)

Alternative treatment plan

o Reassessment of the abnormality following

treatment

TYPES OF CLINICAL EXAMINATION

COMPREHENSIVE DENTAL EXAMINATION

o Complete and thorough type of

examination

o Executive type of examination

o Requires collection of all appropriate

diagnostic information

o All structures of the oral cavity are

examined

o Recommended for patients who request

Total Dental Care (TDC) and who has not

previously undergone such type of

examination

SCREENING TYPE OF EXAMINATION

o Type of examination that serves as a

compromise between thorough/completetype and a less extensive one because of

the practical aspect of reduced:

Time

Cost

Skill

o Examination that indicates gross disease in

broad survey

o Most popular and widely used method of

examination among general dentists

EMERGENCY EXAMINATION

o Incomplete type of examination

o Type of examination designed to

expeditiously manage a chief complaint that

requires immediate attention

Eg. Avulsion, acute infections,

excessive bleeding

o No set or routine pattern of procedures

o Priority given to the relief of the chief

complaint

PERIODIC HEALTH MAINTENANCE AND RECALL

TYPE OF EXAMINATION

o Type of examination wherein the results

obtained are used to measure any

deviations that might have occurred during

the interval from the last complete and

thorough exam

o Recall interval may vary from 6 months to 1

year or as long as 2 years

SYMPTOMATOLOGY

Considered to be the descriptive knowledge of the

subjective and objective manifestation of disease

necessary to carry out th process of oral diagnosis

CLASSIFICATION OF SYMPTOMS

SUBJECTIVE SYMPTOMS

o Described verbally and felt by the patient

o Obtained by injury during the taking of

case history

o One that forces the patient to seek dental

treatment

o Subjective symptoms referable to the

mouth

Pain (odontalgia)

Foul breath (halitosis, fetor ex

ore)

Inability to masticate/open

mouth (trismus)

Xerostomia (dry mouth;

asialorrhea; hyposalivation)

Esthetic problems (crowding,

discoloration)

Sense of unclean mouth

Speech problems (dysarhria)

Bleeding gums

Loss of taste (aguesia)

Unpleasant taste (cacoguesia)

OBJECTIVE SYMPTOMS / SIGNS

3


4/16

o Those that produce functional and structural

changes that may be seen by th naked eye

of the patient/examiner

o Manifested by changes:

Size/shape

Color

Form/ density

Number

Position

Relationship

o Gathered during clinical examination and

carried out by:

Inspection

Palpation

Percussion

Auscultation

o Observed by the clinician

o Ex. LESIONS

Primary vesicles

Secondary ulcer

CARDINAL MANIFESTATOINS OF DISEASE

Shortness of breath

Swelling of feet and legs

Chronic lack of energy

Difficulty sleeping at night due to breathing

problems

Swollen or tender abdomen with loss of

appetite

Cough with frothy sputum

Increased urination at night

Confusion and/or impaired memory

CARDINAL MANIFESTATIONS:

PAIN

o SOMATIC PAIN

Results from Noxious Stimulation

that innervates body tissues

Localized to affected region

Apparent caouse

Physical evidence of inflammation

Usually acute or episodic

Progress in severity

types by location and physical

findings:

headache (cephalalgia)

other extraoral and

perioral pain

pain of pulpal origin

(odontalgia)

pain of dental

supportive tissues and

oral mucosa

referred pain

(projected pain)

o NEUROGENOUS PAIN

Pain caused by an abnormality of

the nerve itself

Localization correspond to affected

nerve

No apparent cause

Inflammation present only with

neurotropic viral infections

Most are chronic or episodic

Severity relatively constant or

comparable among episodes

Types of neurogenous pain:

Neuralgia

o Viral(postherpetic

neuralgia)

o Glossopharyng

eal

o Trigeminal (tic

douloureux,

facial

neuralgia,

4


5/16

fothergills

neuralgia,

suicide

disease)

Causalgia

o Severe burning

pain associated

with deformation

of nerves by

missiles such as

bullets that

produce high

velocity shock

waves

Phantom pain

o Pain in a limb

that has been

amputated

o PSYCHOGENIC PAIN

Hardest to manage

No organic basis/no apparent cause

Diffuse or vague distribution

No physical evidence of

inflammation

Chronic course

Variable severity relates to stress

or other non somatic factors

DYSPNEA

o Difficulty in breathing/ labored breathing/

shortness of breath

o Pathologic causes:

Cardiovascular disease

Ischemic/ coronary heart

disease

Congestive heart failure

(R/L sided)

Congenital malformations

of the heart

o Ventricular and

atrial septa

defect

o Valvular heart

disease

Pulmonary disease

Chronic obstructive

pulmonary disease

(COPDs)

o Bronchial asthma

o Chronic

bronchitis

o emphysema

Hematologic disease

Anemia

o IRON DEFICIENCY

o HEMOLYTIC

Sickle

cell

Thalasse

mia

o APLASTIC

o PERNICIOUS

Leukemia

o MONOCYTIC

o LYMPHOCYTIC

CARDIOVASCULAR

o PALPITATION

Undue awareness of a pounding

heart

Causes:

Strenuous physical

exercise

Stress and anxiety

Excessive use or intake of

tobacco, coffee, tea and

some drugs

Disorders of the

mechanism of heartbeat

or cardiac arrhythmias

Functional disorders such

as anemia, hypoglycemia

and thyrotoxicosis

o HYPERTENSION

5


6/16

Episodic or consistent elevation of

arterial blood pressure beyond

what is considered normal

Classification

According to etiology

o Essential/primary

type

Idiopathi

c

No

underlyi

ng

o Secondary

With

underlyi

ng

According to the course of

hypertension

o Benign

Chronic

and long

standing

Mild

effect

Doesnt

exhibit

obvious

signsand

sympto

ms

o Malignant

Above

200/110

Acute

elevatio

n of BP

Patientprone to

cerebrov

ascular

attack

and

heart

attack

DYSPNEA

Difficulty in breathing/labored breathing/ shortness o

breath

Pathologic causes:

o CVD (Cardiovascular Disease)

o PD (Pulmonary Disease)

o Hematologic Causes

CARDIOVASCULAR DISEASE

ISCHEMIC/ CORONARY HEART DISEASE

o Demand of Oxygen is greater than supply

CONGESTIVE HEART FAILURE (R/L sided)

o Aka Cardiac Decompression

CONGENITAL MALFORMATIONS OF THE HEART

o Ex. Ventricular and Atrial Septa Defect

VALVULAR HEART DISEASE

PULMONARY DISEASE

COPD (Chronic Obstructive Pulmonary Disease)

o Bronchial asthma (cause of hupersensitivity

on allergies)

o Chronic bronchitis

o Emphysema

HEMATOLOGIC DISORDERS

ANEMIA (reduction in number of circulating RBC and

or hemoglobin) faster HR

o Types:

IRON DEFICIENCY

HEMOLYTIC

Sickle cell (Hereditary;

African American)

Thalassemia (Cooleys

Anemia Mediterranean)

APLASTIC (destruction of red bone

marrow)

PERNICIOUS (Addison Biermer

Anemia)

6


7/16

Due to lack of intrinsic

factor needed for vitamin

BR absorption

LEUKEMIA

o Monolytic

o Lymphocytic

CARDIOVASCULAR MANIFESTATIONS OF DISEASE

PALPATION

o Undue awareness of a pounding heartbeat

HPERTENSION

o Episodic or consistent elevation of arterial

BP beyond what is considered normal

o 100 110 = best systolic reading

o 60 70 = best diastolic reading

o Higher reading in normal old individual

o has an unknown cause

o predisposing factors

genetics/hereditary

lifestyle/habits

CLASSIFICATION OF HYPERTENSION

According to Etiology:

essential/primary type

o idiopathic cause

o no underlying cause

secondary

o with underlying cause

o ex. Renal, endocrine diseases (Cushings

syndrome)

According to Cause:

benign

o chronic and long standing

o mild effect

o doesnt exhibit obvious signs and systems

malignant

o above 200 systolic/ above 110 diastolic

o acute elevation of BP

o patient prone to cerebrovascular attack and

heart attack

CLASSIFICATION OF BP FOR ADULTS AGE 18 AND

ABOVE

CATEGORY SYSTOLIC DIASTOLICNORMAL < 120 160 > 100

BP FACTS

BP greater than 200/140 mmHg is already

considered malignant hypertension

90% of all cases of hypertension have no direct

cause. These are referred to as essential

hypertension

WEAKNESS

Forms:

o Asthenia/ lassitude

o Faintness

ASTHENIA/ LASSITUDE

Generalized muscular weakness/feebleness that iscommon in the ff. conditions:

o Senility

o Severe forms of anemia

o Nutritional deficiencies

o Thyroid gland disorders (ex.

Hyperthyroidism)

o Disorders of the locomotor system (ex.

Osteomyelitis)

o Endocrine disturbances (ex. Diabetes

Mellitus)

o Malignant neoplasms (ex. Stage 3 & 4

cancer)

CACHEXIA

Generalized bodily wasting

FAINTNESS

7


8/16

Recurrent attack of weakness

As in the cases of:

o Epilepsy (grand mal type and petit mal

type)

o Hypoglycemia

o Postural hypotension patients taking anti-

hypertensive drugs

o Disturbances of cardiac rate/rhythm

o Emotional disturbances (anxiety, fear)

syncope

BLEEDING/HEMORRHAGE

May arise from:

o Vascular dysfunction leukemia, anemia

o Blood vessel fragility female with mens

o Defects in blood coagulation mechanisms

thrombocytes, hemophelia

o Injury to the blood vessels

In the oral cavity, bleeding is most commonly

associated with gingival disease

JAUNDICE ICTERUS

Yellowish discoloration of the skin, mucous

membrane and sclera of the eyes due to excessive

accumulation and inadequate metabolism of BILE

PIGMENTS (BILIRUBIN)

Mainly due to liver diseases such as HEPATITIS (all

types) and LIVER CIRRHOSIS

URINARY SYMPTOMS

POLYURIA excessive amount of urination

OLIGURIA scanty, limited urine

ANURIA little or no urine

DYSURIA painful urination

HEMATURIA blood in urine

PROTEINURIA cloudy urine

Symptoms suggestive of renal, genitourinary tract

(GUT) disorders: STD, renal stones

LYMPHADENOPATHY(lymphadenitis inflamed lymph)

Presence of inflamed and palpable lymph nodes

Any lymph node enlargement (lymphadenopathy)

identified by palpation should be assessed for the ff:

o Compressibility

o Tenderness

o Mobility

JUGULODIGASTRIC LYMPH NODE

Movement of the involved in an oral malignancy

SINGLE, FIRM, NON-TENDER & MOBILE

o Typical of a past infection

MULTIPLE, COMPRESSIBLE, TENDER & MOBILE

o Indicative of an active infection

MULTIPLE, FIRM, NON-TENDER, NON-MOBILE

(FIXED)

o Characteristic of regional metastasis of

malignant neoplasm

ORAL LESIONS

A general term for objective types of symptoms

Those that produce structural, morphologic and

functional changes clinically

ORAL MUCOSAL LESIONS WITHOUT ENLARGEMENT

MUCOSAL DISCOLORATION

WHITE MUCOSAL DISCOLORATION

o Those characterized by epithelial

thickening

Lesions undergoing keratinization

(hyperkeratinotic lesions)

Characteristics:

Asymptomatic lesion (not

painful)

Color is opaque white

Surface texture is roughand grainy (nicotinic

stomatitis)

Lesion persists and may progress

Treatment in palliative

o Those characterized by accumulation

of surface materials

8


9/16

Color is opaque white

Symptomatic lesion (painful)

There is a painful raw

bleeding when scraped

Consistency is soft and friable

Condition regress or heals

Examples:

Condition caused by

fungal infections like

CANDIDIASIS caused by

CANDIDA ALBICANS (oral

thrush)

DIABETES MELLITUS

caused by high blood

sugar level due to

insufficient insulin

too much antibiotic and

steroid therapy

a person undergoing

chemotherapy, radiation

therapy

acidic saliva (predisposing

factor)

nocturnal denture wearer

(PF)

acute pseudomembranous type

(white)

o Those characterized by

subepithelial/submucosal change

Asymptomatic lesion (not painful)

Doesnt rub off

Either static or progresses

Color is translucent white

WHITE SPONGE NAEVUS

Naevus spongiosus alvus

mucosae

Cannons disease

White folded

gingivostomatitis

Ex. Fordyces Granules (ectopic

sebaceous gland). Submucosal

fibrosis (premalignant lesions)

DARK MUCOSAL DISCOLORATION

o MACULE

Usually flat, sharply delineated

areas of altered pigmentation (red,

brown or reddish brown)

Can also apply to abnormal focal

loss of melanin pigmentation

ERYTHEMATOUS MACULE

Vascular in origin

Contain blood or blood

pigments

May present as an isolated

lesion or a multifocal or

diffused lesion

PIGMENTED or PIGMENTARY

MACULE

Contains melanin

pigments

May be physiologic or

pathologic

Ex. PEUTZ JEGHERS

SYNDROME SYNDROME

TYPES OF ERYTHEMATOUS MACULES

ERYTHEMA

o Indicates inflammatory redness

o Note: erythmatous skin rashes with multiple

small bumps are termed

MACULOPAPULAR

PETECHIAE

o Reddish subepithelial hemorrhagic

discolorations that are less than 2-3mm in

diameter

ECCHYMOSIS or BRUISES

o Identical to petichiae

ADDISONS

o Insufficiency in adrenal secretions

PIGMENTARY MACULE

9


10/16

ORAL SOFT TISSUE ENLARGEMENT

PAPULE

o Solid focal enlargement less than 1 cm in

diameter

o No fluid

WHEAL

o In an erythematous papule

o Typical appearance of allergic reactions an

insect bites

NODULE

o Solid enlargement between 1 5cm in

diameter

o Enlarged papule

o Ex. PARULIS or GUMBOIL, PYOGENIC

GRANULOMA

TUMORS

o Solid enlargement greater than 5cm in

diameter

o May be reactive or neoplastic in character

o Ex. EPULIS FISSURATUM (reactive)

o Classification as to shape

PEDUNCLE or STEM

Attachment by means ofstem (smaller than

exophytic portion)

SESSILE

Broad base, dome shaped

contour

CYST

o Is an encapsulated semi-solid, fluid-filled

enlargement lined by epithelium

LESIONS CHARACTERIZED BY LOSS OF MUCOSALINTEGRITY

PRIMARY

o Vesicles

o Pustule

o Bullae/blister

SECONDARY

o Came from a primary lesions

o Erosion

o Ulcer

CHARACTERISTIC OF LESION CHARACTERIZED BY LOSS

OF OF MUCOSAL INTEGRITY

Presence of pain

Onset may be acute short duration; gradual

chronic

No geographic findings

o Useless to use radiograph as diagnostic tool

o Impt: clinical and historical findings

Absence of enlargement or swelling

Lesion distribution

o May be single or isolated lesion; most

commonly caused by trauma

Ex. Traumatic ulcer

o May be in cluster appearing in many areas

Ex. Vesicular or bullous

Mostly cause by viral or

autoimmune diseases (pemphigous

vulgaris)

Manifestations are plenty

Seen also on other parts of the body

o Ex. Herpetic infection

o Manifestation of systemic conditions; not

caused by trauma

Variety of causes/ variety of etiological factors

o Traumatic injury

o Bacterial infection

Ex Acquired Syphillis (caused by

TREPONEMA PALLIDUM)

Chancre ulcers on lips (single)

Mucous patches cluster, most

infectious stage (multifocal)

10


11/16

Affects the brain; manifests as

GUMMA (single gangrenous lesion

seen on the palate)

o Dermatological

o Autoimmune

o Granulomatous

Tuberculous granulomatous

ulceration on the tongue

PRIMARY LESIONS

Initial presentation of a disease or lesion

Lesions thatare too fragile to exist in the harsh

environment of the oral cavity and predictably

degenerate into ulcer to secondary lesion

Viral lesion start as vesicle or bullae (blister)

Types:

o VESICLE

Composed of serum plasma and

blood

Focal fluid-filled elevation less than

1 cm in diameter

Lesion most often caused by viral

infection those that produce a

cluster of vesicle (zosterform

pattern)

Type 1 herpes simplex waist above (cold sores, recurrent

herpes labialis)

Type 2 herpes simplex genito-anal (cold sores, recurrent

herpes labialis)

Herpes zoster (shingles)

Unilateral, multifocal, vesicular

Secondary manifestation of chicken pox

Caused by VARICELLA ZOSTER

PUSTULE

Vesicels that contain pus

Bacterial rather than viral

BULLA or BLISTER

Fluid-filled elevation greater than 1cm in diameter

Can be single or in clusters

Ex. Pemphigus Vulgaris

Note : Nikolskys sign bullae formation following a

mild lateral pressure to an apparently normal tissue

surface

SECONDARY LESIONS

Stage of the process generally observed by the

dentist

Types:

o EROSION

Focal loss of epithelium

Superficial to basal layer

o ULCER

Loss of epithelial integrity that

extends deep to the basal layers of

the epithelium

1 - due to trauma

2 - due to rupture of primary

lesions

Heals without recurring

o CRUST/SCAB

Loss of epithelial integrity affecting

the skin

Dry collection of blood cells and

plasma proteins

Others:

o FISSURE

A linear defect that extends to the

dermis

A common example caused by

fungal infection known as

athletes foot

Fissuring at the corner of the

mouth known as ANGULAR

CHELITIS (PERLECHE)

SOAP (Subjective Objective Assessment Plan)Patients history is taken from direct interview of the

patientQuestioning should be done methodicallyPROTOCOL GUIDELINES:

1. Adapt a professional appearancea. Look good, dress well, smell good, behave

wellb. Scrub suits can be worn in the clinic

2. Conduct the interview in the privacy of yourclinic

11


12/16

a. Be accommodating, polite and sympatheticb. Have humorc. Explain procedures in laymans term

DEMOGRAPHIC DATA

Give due cognizance or considerations as to the ageof the patient, gender preference, and racial orethnic origin

HECKS DISEASE

Appearance of small popular lesions on lip

Seen in most people who live in Alaska

IMPORTANCE OF CASE HISTORY1. Important diagnostic procedure. A necessary data

to arrive at the provisional or tentative diagnosis ofthe patients chief complaint

2. An important legal procedurea. Serves as evidence of professional evidence

in medico-legal cases3. Factor in improving public relations procedure.

*always ask what the current medication of the patientis*To identify to a systemic condition that may affect theformulation of the diagnosis*identification of systemic condition that necessitatestreatment plan

Methods of Recording Patient History Complete & Thorough Examination- Diagnostic interview

- A verbal exchange between the patient andthe clinician that elicits the patientsknowledge concerning health information

Screening Type of Examination- Combination of diagnostic interview and printed list

of information (Medical History Health Questionnaire)

Elements of the Patients History or Case History1. Patients biographic/demographic data

Name

Age

Address

Gender

Telephone number

Birthday

Race

Referred by whom?2. Chief Complaint

The element of the patients history thatpresents the principal problem as stated inthe patients own words.

What prompted the patient to seek medicalor dental care.

Subjective symptom

Shouldnt be a patients desire3. History of Chief Complaint

Chronologic account of the patients chiefcomplaint from the date of onset untiltreatment

The life story of the chief complaintHistory of Chief Complaint should include theff:

Date of Onset of Complaint

Type of Onset (Acute or chronic)

Character of the Complaint

Location of the Complaint

Relation of the complaint to other activities

Any previous medication, diagnosis ortreatment related to the complaint as givenby other dentists

4. Medical History

Is a description of the relevant features of thepatients health status from birth to the moment thatthe patient enters the dental office.

The most important component of the patientshistory.

Usually divided into the following:

Past Medical Conditions

Past infections / previous immunizations

Prior Hospitalizations due to the following:

Traumatic injuries

Surgical procedures

Blood transfusions

Allergies and adverse reactions to drugs

Current medical treatment

May include special diets,limitations of daily activities andmedications.

5. Family History

Questions concerning the family history are directedto

A. genetic conditions including history of mentaldisease (hemophilia, diabetes, cancer, allergy)

B. communicable infections ( PTB)

C. general health of the family

D. cause of death of parents if deceased

E. history of dental problems in the family6. Personal and Social History

Should include a brief summary of the patientsoccupationmarital and financial status

hobbies/ habitsdaily activitiesemotional adaptation/ type of personality

*NOTE: The two habits of greatest health significance to thedentist are tobacco and alcohol use7. Review of Systems (ROS)

A series of questions that explores the possibility ofundiagnosed disease and the effectiveness of currenttreatment for diagnosed illnesses

Attempts to identify symptoms that are commonlyassociated with organ system dysfunctions

8. Dental History

Provides insight into the patients dental hygienepractices, attitude towards dental care, nature of thepast dental treatment

a. Routine dental care

b. Episodic dental carec. Symptomatic dental care

Physical/ Clinical Exam*Diagnostic evaluation of the patients health status thatrelies mainly on the clinicians primary senses (sight,hearing, touch, smell) and a few simple diagnosticinstruments

General Methods/ Techniques1. Visual Examination

A. Passive Visual Exam (Inspection)B. Active Visual Exam (Extraoral and Intraoral Exam)C. Transillumination to demonstrate the

accumulation of fluid and pus in the Antrum of Highmore

2. Palpation touch and sightA. Presence of pain upon pressure applicationB. Degree of tissue compressibility

A. Compressible B. Non Compressible- Spongy - Bony hard- Doughy - Indurated- Pitting- Collapsing

*Compressible

12


13/16

*Doughy structures offer greater resistance topressure, upon release of pressure it slowlyregains its original form/ contour*Spongy- offers minimal resistance to pressurebut upon release of pressure it quickly regainsits original form / contour* Pitting not usually seen in the oral cavity

(eg. pedal edema of extremities) Collapsing easily compressible

enlargement that remains deformed evenafter pressure release

Eg. Expression of pus from an abscess

*Non compressible* Bony hard- rigid and calcified* Indurated hardness without the rigidsensation associated with calcification. Itcan be compared with squeezing a a dense,solid rubber bowl.Note: Induration is a feature of manymalignant neoplasms

Structures Palpated- Muscles- Bone/teeth- Glandular tissues- Lymph nodes

Techniques of Palpationa) Bimanual Palpation 2 hands, 1 hand

to palpate and the other to support-

Palpating floor of the mouthb) Bidigital Palpation 2 fingers of 1hand

- Palpating thinner tissues like lips, labialand buccal vestibule, tongue

c) Bilateral Palpation- fingers of bothhands are used

- Best technique for palpatingsymmetrical structures on both sides ofthe face; Ex. R and L TMJ, Parotid area,Submandibular and sublingual area,Cervical area of the neck

3. Percussion (sight and hearing)- For localization of inflammation of periodontalmembrane and 2o pulpitis

Structures:

Teeth blunt end of the mouth mirrorFacial Muscles- 2nd and 3rd finger is usedJaw Bones- indirect percussion

Never used as a test for vitality, In general, a tooth with normal support =

high pitch sound whereas less densesupport = lower pitch sound

NOTE: Percussion or tapping over the facialnerve in front of the ears causes twitchingor spasm of the facial muscles as in latenttetany = (+) CHVOSTEKS SIGN

Motor movement of the eyes: III, IV, VI CN Strabismus uncontrolled

squinting of the eyes Diplopia double vision Ptosis drooping of the eyelid

4. Auscultation- Refers to the act of listening to the sound

produced by various body structures- Ex. Heart- heart sound (lub-dub sound)

Lungs- during breathing in and outUsed in Dentistry for:

Examination of TMJ Diagnosis of fractured jaw Blood pressure

measurement5. Probing

Used for:

Detection of carious lesion

Determine depth of periodontal/ crevicularpocket

Diagnostic aspiration or aspiration biopsy

Olfactory Examination discretely done; notan SOP

Evaluation of Functiona. Pulp Vitality Testing using pulp

vitalometer or thermal testb. Determination of occlusal relationship

through the production of diagnostic cast6. Olfactory Examination discretely done; not an

SOP7. Evaluation of Function

a. Pulp Vitality Testing using pulp vitalometer orthermal test

b. Determination of occlusal relationship through theproduction of diagnostic cast

*HOW TO CHECK THE TMJ1. Check for the movement of TMJ

a. By asking the patient to open and close themouth and check for lateral deviations

2. Check the maximum extent of mouth openinga. Extent of the interincisal distance

3. Do palpation in front of the ears just above thecondyles

a. Check for movements and clicking soundsb. Check for tenderness when the patient

opens and closes the mouthc. Posterior part of the TMJ is located at the

External Auditory Meatus*HOW TO EVALUATE MUSCLES OF MASTICATION

MASSETER one finger inside the mouth and one

finger outside

TEMPORALIS ask the patient to clench their teeth

LATERAL & MEDIAL PTERYGOID ask the patientto do lateral excursions

CHORDA TYMPANI

Gustatory sensation

Branch of CN VII5th CN facial sensory8th CN (vestibulocochlear)

For hearing and balance9th & 10th CN Loss of gag reflex11th CN (Spinal Accessory)

No lateral movement of the head

No shrugging12th CN (hypogossal)

No motor movement of tongue

Cannot protrude tongue

General Patient Appraisal (GPA) Consist of the impressions concerning the patients

health status that can be gained by inspection from acomfortable distance

Includes the ff:

1. Patients identifying / demographic featuresa. Ageb. Genderc. Race

2. Mental Orientation and emotional status- Psychic state of the patient- Usually assessed on patients awareness of

person, place and time

3. Body size (Habitus), stature (height) and bilateralsymmetry (anatomic proportion) Bilateral symmetry

13


14/16

- Refers to the expectation that themidsagittal plane bisects the body into 2 equal partsthat normally corresponds in formAbnormalities in Body Symmetry (Asymmetry)

A. Tissue Deficiency (eg. Physical injury,degenerative disease)

B. Tissue Enlargement (Unilateral facialswelling)

C. Abnormal tissue position (eg. Scoliosis orlateral spine curvature

Classification of Body Built (Habitus)1. Asthenic

- Slender and underweight2. Sthenic- Well proportioned, athletic build3. Hypersthenic (Stocky build)- Heavy bone/ muscular proportion4. Pyknic- heavy, soft and rounded build- Abundance in body fat

Stature or height abnormalities1. Large stature or GIGANTISM

a. ACROMEGALY after pubertygigantism

2. Small stature or DWARFISMa. CRETINISM small stature

with mental retardation due tothyroid gland disorder

4. Facial Form/ Head ShapeA. Normocephalic/ MesocephalicB. Brachycephalic short rounded skull shapeC. Dolichocephalic long narrow head shape

5. Patients gait- Refers to the manner of walkingGait Abnormalities

A. Hemiplegic gait- Characterized by semicircular lateral swing

of the affected leg during strides.- Typical of cerebral damage caused by

strokeB. Ataxic gait (Drunken gait)- Is the staggering , irregular, wide-stance

walk (eg. Alcoholic intoxication, tabes

dorsalis of tertiary syphilis)C. Parkinsonian gait (Freezing gait)- Consists of limited strides, hanging arms

and muscular stiffnessEg. Parkinsons disease (due to dopamine

deficiency)6. Posture, movements and speech

It is simultaneous with gait

May become evident during rest or duringmovement

Patients with endocrine deficiency may manifesttremors

Abnormalities:A. Resting tremors of Parkinsons diseaseB. Intentional tremor of multiple sclerosis

- Often associated with ataxic gait

C. Choreic/ Athetoid movements- Characteristic manifestation of

cerebral palsy- Involves slow, repetitive

movements of the proximalextremities, trunk and face

Speech Abnormalities1. Dysarthria- Slurring of speech2. Aphasia

- Inability to accomplish properverbal expression

* Both abnormalities are non specificindication of intoxication.Neuromuscular Deficiency/ disorders(eg. Stroke, cerebral palsy) and corticaldefects

7. Determination of Vital Signs- Final aspect of general patient

assessmentConsist of:A. Pulse rate/rhythm (60-90/ min)

- QUANTITATIVE - # of pulse per

minute- QUALITATIVE amplitude or

rhythm- NORMAL PR 60-90 bpm- AMPLITUDE force/surge of blood

against the artery*PULSE AMPLITUDE

- 0 = no palpable pulse- 1 = faint pulse (thready pulse)

- Due to:dehydration and/oradvance state ifatherosclerosis

- 2 = normal ulse- 3 = strong pulse manifested

when the persion is in its

active state- 4= bounding pulse

pulse that is easy to find andvery hard to oliterate; seen inpersons who havehyperthyroidism

*PULSE POINTS- RADIAL

- Typically used- Palpated on the

lateral of the wrist- TEMPORAL- CAROTID

- Useful in emergencies- INGUINAL- ANTECUBITAL FOSSA

- Palpated on the

medial- Felt when taking BP

B. Respiration Rate (12-20 breaths/min)- Observe the rise and fall of the

chest- Normal in adults is 12 20/min- Normal in children is 24 30/min- 10 or 30 indicative of

Cardiovascular Disease- TACHYPNEA 7/min; slow- APNEA no breathing- CHEYNE STOKES RESPIRATION

shallow, fast breaths; present inCVD and CHD (coronary heartdisease)

C. Body temperature-

Taken through ears, mouth,axilla

- Normal oral/ear temp is 36.5 C- Person is febrile if temp is 37.8C

or D. Blood pressure - measured usingauscultatory methodE. Height and weight done only in consciouspatients

*when unconscious, only take BP, RR &PR

14


15/16

Extraoral ExamPhysical Examination of Specific Extraoral Structures1. Facial forms/ symmetry examined by inspection andpalpation in the ff. perspective/ view

A. Frontal view- Pupil alignment- Midline location of the nose- Symmetry/ contour of the zygoma, ears and

mandibleB. Submental visualizes the anatomic triangles

of the neck- Ask the patient to tilt the head upward- Under the jaw, anatomic triangles of the

necka) Submentalb) Submandibularc) Cervical

- Ask the patient to move head on theside

a) Cervical lymph nodes

Anterior, medial,

lateral, superficial,deep

b) Jugulodigastric &juguloomohyoid lymph nodes

Can be felt whenthere is tonsillarinfection or when

there aremalignancies

c) Clavicular lymph nodesC.Lateral- reveals the profile of the facial bonesD. Supraorbital- achieved by looking down the

patients face from above and behind the head- Effective position to observe deviation of

mandible during opening2. Skin of face/neck3. Eyes/ear/nose*Eyes - Abnormalities of the eyes can suggest the ff:

A. Developmental abnormalitieseg. Strabismus, ptosis (drooping of the uppereyelid)- Diplopia (double vision)

B. Inflammatory disease

eg. Erythema of the palpebral conjunctiva is a sign ofconjunctivitisC. Manifestations of Systemic disease

eg.Jaundice/ icterus of the sclera is indication ofliver diseaseExophthalmos/ bilateral protrusion of the eyeballs-hyperthyroidismPhotophobia (intense aversion to bright light) is asign of porphyria

*Ears - condition affecting the ears that are of diagnosticsignificance are:

A. Developmental origin- Congenital defects of the middle and inner ear

resulting to deafnessB. Inflammatory Origin

Eg. Otitis media (middle ear infection)-tenderness elicited by palpation of the mastoid

process is indicative ofmastoiditis

Intraoral Exam*GUIDELINES/PROTOCOL:

1. Perform the intraoral exam in asystematic/procedural manner/routine

2. Proper positioning of the patient, properillumination/lighting and proper use of clean basicinstruments

3. Practice proper infection control4. Whatever findings seen in intraoral exam must be

checked with the other findings

a. Must be analyzed, checked and examinedall together

Examination of the Oral Soft Tissue1. Lips bidigital palpation

- inspection and bidigital palpation

Common Abnormalities includes:a. Ulcersb. Rough surface texturec. Patchy homogenous thickening

2. Buccal mucosa and vestibule-inspection/ palpation (bidigital)3. Hard/Soft Palate

- Bidigital palpation- Indirect inspection using the mouth mirror- Direct visual inspection from the submental

perspective with the patients mouth wide open andhead hyperextended

- Common abnormality of the hard palate in adults is abony hard enlargement at the midline called toruspalatinus

Reaction of bone to stress

Bony exostosis Not pathologic because it stops growing

after it reaches its saturation point

Removed under 3 circumstances:

If it interferes with speech

If it interferes with mastication

If it interferes with placement ofprosthesis

4. Oropharynx- Visualization (inspection of the oropharynx by

depressing the tongue with a mouth mirror whilepatient responds to the request to say ah

- Palpation not routinely performed unless anabnormality is visually apparent

5. Tongue- Visualization of the dorsal, ventral surfaces and

lateral borders of the tongue- Bidigital palpation to reveal its muscular consistency- DORSAL

- Muscular upon bidigital palpation- Ant. 2/3 must be rough (should not be

smooth nor coated) due to the presence ofthe papilla

- Filiform- Fungiform- Foliate- Circumvallate

- VENTRAL- Raise tongue (put the tip of the tongue on

the lingual surface of the maxillary incisors)- ANKYLOGLOSSIA

- Tongue-tied-

Short or no lingual frenum- ANKYLOTOMY

- Surgical procedure done to lengthen thelingual frenum

- LINGUAL VARICOSITIES dilated veins

6. Floor of the mouth- Inspection (visualization) at the same time the

ventral surface of tongue is examined- Bimanual palpation- SUBLINGUAL CARUNCLE

15


16/16

- Small elevations found on either side of thelingual frenum at the floor of the mouth

- Marks the opening of the Whartons duct

Examination of Teeth

2 stage process1. Dental orientation examination of the teeth by visualinspection without specific efforts to remove saliva / fooddebris; Includes:

a. Number of teeth presentb. Quality of oral hygienec. General extent of calcular deposits

d. Presence of extensive decaye. Dental developmental malformations and

malalignmentf. Dental discolorationsg. 2. Comprehensive Examination of each

tooth by visualization, probing for cariouslesions, palpation and percussion for signsof mobility, tenderness and fracture

h. Periodontium- visualization, periodontalpocket probing and palpation

2. Comprehensive Examination of each tooth by visualization,probing for carious lesions, palpation and percussion for signsof mobility, tenderness and fracture

Periodontium

Visualization

periodontal pocket probing

palpation

-Rosette Go

16

oral diagnosis prelims reviewer

Documents