Dr. Abhiram Singamsetti BDS
History taking and clinical examination
General physical examination
A) Soft tissue examination
B) Hard tissue examination
The case history enabIes the patients to
communicate symptoms, feeIings
and fears and the sequence of events
Ieading to the probIem for which the
patient seeks professionaI assistance
"Accurate diagnosis of a disease depends on
the art of taking Case History."
Diagnosis is derived from the Greek word
dia = by and gnosis = knowIedge
Diagnosis -The determination of the
nature of the disease
History taking and
Ì) Personal information
Ìt records the time the patient reported.
Can be referred back to during the follow- up
For the purpose of maintaining record
For billing the individual
For legal considerations
To establish a better communication with the patient.
To establish a rapport with the patient.
aintenance of record.
To elicit the history properly.
edico legal purpose.
The chronological age (date of birth) should be noted.
1)To compare with other ages (dental,skeletal) so as to know
whether the growth and development is normal in the child.
2)Certain diseases are known to occur frequently at particular ages
3)Depending on the age the behavior
management techniques also vary.
Girls age faster than boys and thus their treatment may be
Some diseases are more common in females than in males.
A combination of age and sex can sometimes give an indication of
occurrence of disease
Ìt is used for all communications even before the first visit.
By knowing the locality along with the family income and parent's
occupation, the socio-economic status can be assessed.
Ìf the patient is coming from a far distance,the appointments can
be modified to complete treatment in fewer visits.
Ìt may indicate diseases endemic to the particular areas.
a) Treatments can be
modified according to the
b) Patients background can
be understood in a better
ÌÌ) History taking
Ìt is defined a symptom or
symptoms, described in
patient own words, related to
the presence of an abnormal
W History of present iIIness
Chronological account of the chief complaint and associated symptoms from the
time of onset to the time the history is taken.
The most common presenting illness can be evaluated as,
1) The onset
4) The quantity, quality, severity and frequency of occurrence
5) Aggravating and relieving factors
6) Associated symptoms
Past dentaI history
a) It gives information about the patients past
b) Frequency of dentaI visit by the patient which gives
an indication of the patient's future behavior.
c) Patient's attitude towards previous dentaI treatment
d) Any untoward compIication of dentaI treatment.
e) To know about any excessive bIeeding in the past
f) Reasons for Ioss of teeth
W MedicaI history
This heIps in identifying conditions that couId aIter, compIicate or
contraindicate proposed dentaI procedures.
Does the patient suffer from any of the foIIowing at present or in the
MentaI or physicaI handicap
Bone & joint probIems
Growth and deveIopment probIems
a) Ìt gathers information about diseases that
commonly affects more than one member of a
b) Certain disorders that should be inquired are
- Bleeding disorders
- Heart disease
- Genetic disorders
Should include condition of the mother during
Drug intake during pregnancye.g. tetracycline
Type of delivery- Normal/C-section/Forceps;
Childs health at birth: Good/Fair/Poor
ethod of feeding and duration:
Breast fed/Bottle fed/both
Does the child sleep with the bottle?
What are/were the contents of the bottle?
ÌÌÌ) General physical
Height and weight:
Whether normal for the age. Ìf not factors
responsible should be determined.
The way a person walks.
An abnormal gait can be associated with a
Speech disorders can be associated with a
Classification of general
body build according to
ÌV) Extra-oral examination
a) Shape of the skuII:
Ìt is classified as
b) Shape of the face:
Face can be classified in three forms
c) FaciaI symmetry:
Gross facial asymmetries are seen in
-hemi facial atrophy/hypertrophy,
-unilateral condylar ankylosis and hyperplasia.
d) FaciaI profiIe:
Ìt can be classified as
Assesment of antero-posterior jaw reIationship
Assesment of verticaI skeIetaI reIationship
EvaIuation of faciaI proportions
Examination of Iips
Potentially incompetent lips
Examination of nose (size,contour,nostrils)
Examination of chin (mentolabial sulcus,mentalis
activity, chin position and prominence)
V) Ìntra-oral examination
A) Soft tissue
LabiaI and BuccaI mucosa:
Observe for any changes in
color, texture, pigmentations,
fistulae, and tenderness.
VestibuIe: Look for the color,
texture, swelling fistulae, and
PaIate: Ìnspect for swellings,
fistulae, ulcers, burns,
tenderness, papules, cleft
palate & also the depth of the
Gingiva: The color,
surface texture, and position is
checked for. Any swellings,
ulcerations, pus discharge,
sinus tracts, erythema is
Labial frenum at times can be
thick and may be attached to the
incisive papilla which may cause
midline diastema. Blanch test
can be used for confirmation.
Short lingual frenum can cause
TonsiIs and Adenoids:
Enlarged adenoids should be
Tongue: Ìnspect the dorsum of
the tongue for any swellings
ulcers, coating or variation in
B) Hard tissue examination
1) Teeth present:
2) Type of dentition: Whether primary, permanent or mixed
3) issing teeth:Note whether the teeth is congenitally missing or
missing following extraction.
5) Caries with pulp involvement:
6) Root stumps:
7) Filling present:
8) obility:Grade of mobility should be mentioned
9) Fractured teeth:
10) Retained teeth:
11) Erupting teeth:
12) Supernumary teeth:
13) Any wasting diseases: Like attrition, abrasion, and erosion
14) Hypoplastic teeth
15) Any other dental anomalies:
VÌ) Provisional diagnosis
A generaI diagnosis based on cIinicaI
impression without any Iaboratory
VÌÌ) Differential diagnosis
The process of Iisting out two or more
diseases, having simiIar signs or
symptoms of which onIy one couId be
attributed to the patient's suffering.
ÌX) Final diagnosis
A confirmed diagnosis based on aII
X) Treatment plan
A comprehensive treatment plan must be
designed based upon clinical examination
Ìt is the prediction of the course, duration and
termination of a disease and the likelihood of
its response to treatment.