History Taking and

History Taking and
Clinical Examination in
DENTISTRY
History Taking and
Clinical Examination in
DENTISTRY
Charu M Marya BDS MDS PhD

Professor and Head
Department of Public Health Dentistry
Sudha Rustagi College of Dental Sciences and Research
Faridabad, Haryana, India
Foreword
Rahul J Hegde
The Health Sciences Publishers

New Delhi | London | Philadelphia | Panama
Jaypee Brothers Medical Publishers (P) Ltd
Headquarters
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Email: jaypee@jaypeebrothers.com
Overseas Offices
J.P. Medical Ltd Jaypee-Highlights Medical Publishers Inc

83 Victoria Street, London City of Knowledge, Bld. 237, Clayton

SW1H 0HW (UK) Panama City, Panama

Phone: +44 20 3170 8910 Phone: +1 507-301-0496

Fax: +44 (0)20 3008 6180 Fax: +1 507-301-0499

Email: info@jpmedpub.com Email: cservice@jphmedical.com

Jaypee Medical Inc Jaypee Brothers Medical Publishers (P) Ltd

The Bourse 17/1-B Babar Road, Block-B, Shaymali

111 South Independence Mall East Mohammadpur, Dhaka-1207

Suite 835, Philadelphia, PA 19106, USA Bangladesh

Phone: +1 267-519-9789 Mobile: +08801912003485

Email: jpmed.us@gmail.com Email: jaypeedhaka@gmail.com

Bhotahity, Kathmandu, Nepal
Phone: +977-9741283608
Email: kathmandu@jaypeebrothers.com
Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com
© 2014, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and
do not necessarily represent those of editor(s) of the book.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by
any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in
writing of the publishers.
All brand names and product names used in this book are trade names, service marks, trademarks or reg-
istered trademarks of their respective owners. The publisher is not associated with any product or vendor
mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative
information about the subject matter in question. However, readers are advised to check the most current in-
formation available on procedures included and check information from the manufacturer of each product to
be administered, to verify the recommended dose, formula, method and duration of administration, adverse
effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precau-
tions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to
persons or property arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical
services. If such advice or services are required, the services of a competent medical professional should
be sought.
Every effort has been made where necessary to contact holders of copyright to obtain permission to repro-
duce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make
the necessary arrangements at the first opportunity.
Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com
History Taking and Clinical Examination in Dentistry
First Edition: 2014
ISBN 978-93-5152-393-2

Printed at
Dedication
I would like to thank my wife Dr Vandana for standing beside
me throughout my career and writing this book. She has
been my inspiration and motivation for continuing to
improve my knowledge and move my career forward.
She is my rock, and I dedicate this book to her.
Contributors
Anil Gupta MDS Hind Pal Bhatia MDS

Professor and Head Professor and Head
Department of Pedodontics Department of Pedodontics
SGT Dental College, Hospital and Manav Rachna Dental College
Research Institute Faridabad, Haryana
Gurgaon, Haryana, India India
Anirban Chatterjee MDS PhD Navin Anand Ingle MDS

Professor and Head

Professor and Head
Department of Periodontology Department of Public Health
and Implantology Dentistry
Oxford Dental College
KD Dental College and Hospital
Bengaluru, Karnataka, India
Mathura, Uttar Pradesh
Avinash J MDS India

Professor and Head
Department of Public Health Pradeep Tangade MDS

Dentistry Professor and Head
Kalinga Institute of Dental Department of Public Health
Sciences Dentistry
Bhubaneswar, Odisha, India Kothiwal Dental College and
Bhumija Gupta BDS AEGD GPR Research Centre
Moradabad, Uttar Pradesh

Clinical Faculty
Eastman Institute for Oral Health India
University of Rochester
Rochester, New York, USA Rajendra Gowda Patil MDS

Professor and Head
Gaurav Sharma MDS
Department of Oral Medicine

Reader
and Radiology
Department of Oral Medicine
and Radiology Kothiwal Dental College and
Sudha Rustagi College of Research Centre
Dental Sciences and Research Moradabad, Uttar Pradesh
Faridabad, Haryana, India India
viii History Taking and Clinical Examination in Dentistry
SM Kotrashetti MDS Vandana Dahiya MDS

Professor Department of Conservative
Department of Oral and Dentistry and Endodontics
Maxillofacial Surgery Haryana Civil Medical Services
KLE VK Institute of Faridabad, Haryana
Dental Sciences India
Belgaum, Karnataka, India
Foreword
It gives me great pleasure to write a foreword for History Taking and

Clinical Examination in Dentistry. The approach adopted by the author
should be a great help to those taking history and doing examination
for diagnosis and treatment planning in dentistry. The idea of taking
symptom complexes and then describing the diagnostic possibilities
with guides to the management both of the disease itself and of the
symptoms will be valuable to all who have to deal with problems of
this sort.
I hope that it will be valuable to all those who have to deal with the

clinical differential diagnosis. It should be of particular use to teaching
faculty, undergraduate and postgraduate dental students and dental
practitioners. It is the sort of book that should be in the hands of
students of dentistry entering the clinics during their clinical postings.
Rahul J Hegde
(Executive Member, Dental Council of India)
Vice-Principal, Professor and Head
Department of Pediatric Dentistry
Bharati Vidyapeeth University Dental College
Navi Mumbai, Maharashtra, India
President, Indian Society of Pediatric Dentistry
Senate Member, Maharashtra University of Health Sciences
Preface
The most important core skills for dental students to master are
history taking and clinical examination. This book has been written
with the philosophy that the acquisition of clinical skills is most
effectively undertaken at the chairside. This book should be used as
a companion, to be taken in the clinics where the information is most
needed. The book begins with a system of history taking followed by
chapters covering clinical examination and diagnosis. Each stage of
the examination starts with a detailed step-by-step description of the
examination method complemented by relevant illustrations, diagrams
and tables. This book is intended primarily for use at the outset of
clinical training; once students have achieved proficiency in the basic
skills of interviewing and examining, the book should also prove useful
for revision.
This book was written keeping in mind the problems faced in clinics
by undergraduate and postgraduate students regarding history taking,
clinical examination, diagnosis and treatment planning as no book is
available in the market focusing specifically on these topics.
Charu M Marya
Acknowledgments
I would like to express my gratitude to many people who provided

support, read, wrote, offered comments, allowed me to quote their
remarks and assisted in the editing, proofreading and design.
I would like to thank my parents for allowing me to follow my
ambitions throughout my childhood. Ever indebted to my mother
for her encouragement and my father, my guide. My brother Dr Kirti
Mohan Marya for standing by me always and sister Dr Priya Nagpal for
her prayers. I also thank my wonderful children: Akshat and Dewang for
always making me smile. My family, including my in-laws, have always
supported me throughout my career and authoring this book and
I really appreciate it. I want to acknowledge my family’s contribution,
for putting up with my absences, both mental and physical.
Many persons generously gave their time in the preparation
of the first of its kind book History Taking and Clinical Examination
in Dentistry. I would like to convey my grateful thanks to all the
contributors for their cooperation and enthusiasm for the publication
of this book. In addition, special appreciation is to be mentioned for
Dr Ruchi Nagpal, Dr Sukhvinder, Dr Amit Rekhi who provided high
quality logistic and editing support during the preparation of this book.
My thanks also go to my colleagues at the Sudha Rustagi College
of Dental Sciences and Research, Faridabad (Haryana), who have given
encouragement and support at key times in the development of this
book and have contributed for creating a stimulating and congenial
environment for me to work.
I would like to thank Mr Dharamvir Gupta (Chairman), Mr Deepak
Gupta (Secretary), Prof (Dr) Indushekar (Principal) and Dr Vishal
Juneja (CEO), Sudha Rustagi College of Dental Sciences and Research,
Faridabad for their encouragement and support in this venture.
xiv History Taking and Clinical Examination in Dentistry
My due regards to Shri Jitendar P Vij (Group Chairman), Mr Ankit
Vij (Group President) and Mr Tarun Duneja (Director–Publishing) of
M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for
rendering help to come out with this publication in time. I am thankful
to Mrs Samina Khan (Executive Assistant to Director–Publishing), for
being so instrumental and helpful for this publication, and Mr Rajesh
Sharma (Production Coordinator) for extended profound support and
interest in this release.
Contents
1. Introduction 1
Risk Management 3
Confidentiality 4
2. Methods of Recording a Case History 7
3. General Information 10
Patient Registration Number 10
Date 10
Name 10
Age 11
Sex 14
Education 16
Address 16
Occupation 18
Religion 19
4. Chief Complaint 20
5. History of Present Illness 22
Detailed History of a Particular Symptom 23
6. Previous Dental History 61
7. Medical History 64
Relationship Between Systemic and Oral Health 64
Health History Forms 65
Determination of Medical Risk 71
xvi History Taking and Clinical Examination in Dentistry
8. Personal Dental History 81

Oral Habits 81
Thumb and Digit Sucking 82
Pacifier Habits 94
Tongue Thrust Habit 94
Mouth Breathing Habit 99
Bruxism 104
Other Minor Habits 106
Oral Hygiene Habits 107
Adverse Habits 107
Diet History 107
Diet-Diary 108
9. Clinical Examination 116
10. Extraoral Examination 137
Skin 137
Head 138
Face 138
Nose, Paranasal Sinuses, Nasal Mucosa and
External Ear 143
Lips 143
Cheeks 145
Lymph Nodes 145
Temporomandibular Joint 153
Muscles of Mastication 156
Salivary Glands 158
11. Intraoral Examination 165
Soft Tissue Examination 165
Gingivitis 184
Chronic Periodontitis 184
Acute Periodontitis 185
Hard Tissue Examination 191
Arch Forms 192
Contents xvii
Alterations in Number of Teeth 200

Alterations in Size of Teeth 204
Alterations in Shape of Teeth 205
12. Establishing the Diagnosis 230
13. Investigations 232
Conventional Radiographic Investigations 232
Histopathological Investigations 239
Pulp Vitality Testing 241
Hematological Investigations 242
Urine Analysis 250
Microbiological Investigations 250
14. Final Diagnosis 252
15. Formulating a Comprehensive Treatment Plan 254
Phase I: Emergency Phase 255
Phase II: Preventive Phase 255
Phase III: Promotive Phase 255
Phase IV: Curative Phase 256
Phase V: Rehabilitation Phase 256
Phase VI: Maintenance Phase 256
Treatment Planning in Dentistry 258
16. Levels of Prevention 278
ppendices 280
A
Index 343
C H A P T E R 1
Introduction
“Accurate diagnosis of a disease depends on the art of taking

case history.”
Diagnosis is the art and science of recognizing the
presence and nature of disease by an evaluation of its various
distinctive signs, symptoms and characteristics. As modern
rational therapy is based upon the scientific interpretation
of the changes in structure and function of the body tissues,
the importance of an accurate diagnosis is at once evident.
There can be only one true diagnosis and the success of
treatment is dependent upon its establishment.
Professional, ethical and legal responsibilities dictate that
a complete chart and record documenting all the aspects of
each patient’s dental treatment must be maintained. Good
records facilitate the provision of effective dental care and
ensure the continuity and comprehensiveness of oral/dental
health services.
Case history is an important and integral part of treatment.
The principles of practice in dentistry
Responsibilities of a dental professional:

yy Putting patient’s interests first and acting to protect them
yy Respecting patient’s dignity and choices
yy Protecting the confidentiality of patient’s information
yy Co-operating with other members of the dental team and other
healthcare colleagues in the interest of patients
yy Maintaining your professional knowledge and competence
yy Being trustworthy
2 History Taking and Clinical Examination in Dentistry
Case history is defined as planned professional conversation

that enables a patient to communicate his/her feelings, fear
and sequence of events leading to the problem for which the
patient seeks professional assistance, to the clinician so that
patient’s real or suspected illness and mental attitude can be
determined. Ideally case history is taken in a consultation room
or a private office in which the surroundings and the conditions
are entirely friendly and not like the dental operating room.
In many occasions, a properly prepared case history alone is
sufficient to diagnose the disease without examining the patient.
Of all the important diagnostic tools, the art of listening
is the most underrated. Yet careful and attentive listening
establishes patient-dentist rapport, understanding and trust.
Eliciting accurate, detailed and unbiased information from a
patient is a skilled task and not simply a matter of recording
the patient’s responses to a checklist of questions. Avoid
interrupting patients, particularly as they begin to tell you the
story of the presenting features of the illness. Recognizing the
patient’s need to talk without interruption and being a good
listener will greatly help you establish a good relationship
quickly (Fig. 1.1).
A case history is of immense value in the following ways:
•• To provide information regarding etiology and establish
diagnosis of oral conditions.
•• To reveal any medical problem necessitating precautions,
modifications during appointments so as to ensure that
dental procedures do not harm the patient and also to
prevent emergency situations.
•• Evaluation of other possible undiagnosed problems.
•• Discovery of communicable diseases.
•• Gives an insight into emotional and psychological factors.
•• For effective treatment planning. It enables dentists to
obtain information necessary to provide appropriate and
individualized care.
Introduction 3
Fig. 1.1: Listen to the patient
•• Record maintenance for future reference and periodic

follow-up.
•• To prevent medical complications and thus minimize
detrimental effects to the patient and the possibility of
medico-legal complications for the dentist.
RISK MANAGEMENT
In recent years, the requirements for dental records
management have been redefined, especially as they relate to
documentation, release of information and storage. Dentists
are expected to be familiar with current expectations and to
ensure that their staff members understand and adhere to the
updated protocols.
Patient records must be accurate, well-organized, legible,

readily accessible and understandable. If the dentist who
has taken the history and noted the record is not available
to treat the patient for any reason, another dentist should be
able to easily review the chart and carry on with the care of
the patient.
CONFIDENTIALITY
Patients have a right to expect that their dental health
information will be kept confidential.
•• Patients have a right (with a few exceptions) to review and
obtain a copy of their dental records including consultation
reports of other practitioners.
It is appropriate, where patient consent has been obtained,
to share dental and medical records with other health
professionals as necessary to ensure continuity and quality
of care.
•• Every dental team member involved in a patient’s care
should maintain the confidentiality and security of a
patient’s dental records, only sharing them with other
Purposes of records
yy A dental record should provide an accurate picture of the patient’s

general health, as well as oral/dental status and any patient concerns
and requests
yy It should include the proposed treatment plan and any treatment
performed, as well as all supporting documentation
yy Outcome of treatment should be documented and any deviations
from the expected outcomes should be recorded on the patient chart
at the time of service
yy Patients should be advised of compromised results as soon as the
dentist is aware of the situation
yy All the relevant information presented to the patient should be
documented
Introduction 5
healthcare professionals for the purpose of assisting in

providing optimal care.
•• Dental records should only be disposed of in a manner that
ensures the confidentiality of the information is maintained.
According to Dental Recordkeeping Guidelines (2010) by
College of Dental Surgeons of British Columbia (CDSBC):
Essentials of Recordkeeping
The extent of detail required for each record will vary; however,
certain baseline data should be common to all the dental
patients.
This information includes:
•• Accurate general patient information
•• A medical history that is periodically updated
•• A dental history
•• An accurate description of the conditions that are present
on initial examination, including an entry such as “within
normal limits” where appropriate
•• An accurate description of ongoing dental status at
subsequent appointments
•• A record of the significant findings of all the supporting
diagnostic aids, tests or referrals such as radiographs, study
models, reports from specialists
•• All clinical diagnoses and treatment options
•• A record that all reasonable treatment planning options were
discussed with the patient
•• The proposed and accepted treatment plan
•• A notation that informed consent was obtained
•• Assurance that patient consent was obtained for the release
of any and all patient information to a third party
•• A description of all treatment that was performed, materials
and drugs used and, where appropriate, the prognosis and
outcome of the treatment
•• Details about referrals

•• An accurate financial record.
The barriers to obtain a complete medical history by
preprinted forms followed by appropriate in-depth questions
or by direct query of patients include (but are not limited to)
time constraints imposed by busy practices, the unwillingness
of patients to reveal aspects of their medical status, and the
impatience of the dentist while listening to the patients, as
well as a variety of religious and moral issues that may arise.
C H A P T E R 2
Methods of
Recording a Case History
Establishing a good rapport (Fig. 2.1) with the patient

is important for recording a complete history with valid
information. A sincere smile and being a good listener will help
reassure the patient that it is appropriate and safe to divulge
personal information.
The clinician’s manners and demeanor (including his or her
friendliness, empathy, openness and nonjudgmental attitude)
during this process often determine patient’s satisfaction
and compliance. The clinician’s ability to put patients at ease
will come into play during the initial medical interview. To
Fig. 2.1: Establishing a good rapport

System for gathering information (techniques)
yy Give the patient your undivided attention

yy Use language which the patient can understand
yy Let patients tell their problem in their own words
yy Steer patients toward the relevant
yy Use open questions initially and specific (closed) questions later
yy Clarify the meaning of any lay terms or diagnoses used by the patient
yy Remember that the history includes events up to the day of interview
yy Summarize (reflect back) the story for the patient to check
yy Utilize all available sources of information
facilitate this process, the clinician should exhibit an attentive

posture, maintain eye contact, make the patient understand
that the clinician understands the patient’s specific oral health
problem, and recognize the patient’s emotional disposition
toward dental care. The most effective history-taking technique
relies on establishing a dialogue between patient and clinician,
which should provide both with an opportunity to satisfy the
separate agendas each brings to the interview. Although the
clinician will have a scripted agenda, it is important that time
be given to the patient to tell his or her “story”.
Always introduce yourself to the patient and any
accompanying person, and explain, if it is not immediately
obvious, what your role is in helping them. Remember that
patients are (usually) neither medically nor dentally trained,
so use plain speech without speaking down to them. It is
important to adopt a professional appearance and manner,
and introduce oneself clearly and courteously. Factors such
as age, cultural background, understanding and intelligence
of the patient must also be taken into consideration always
while taking the history. It is the clinician’s responsibility to
elicit an accurate history; if that necessitates requirement of
an interpreter, then the clinician must arrange one.
Methods of Recording a Case History 9
The dental history will give an idea of the:

yy Regularity of attendance for dental care
yy Attitude to dental professionals and to treatment
yy Recent relevant dental problems
yy Recent restorative treatment
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.
Sequence of case recording and evaluation:
•• General information
•• Chief complaint
•• History of present illness
•• Previous dental history
•• Medical history
•• Family history
•• Personal history
•• General physical examination
•• Extraoral examination
•• Intraoral examination
•• Provisional diagnosis
•• Investigations
•• Final diagnosis
•• Treatment plan.
C H A P T E R 3
General Information
It is recorded so as to impart knowledge to the investigator

regarding important events in human life, such as: births,
deaths, marriage and migrations. Also, it makes the investigator
familiar with the patient as it does contain personal details of
the patient such as name, age, etc.
PATIENT REGISTRATION NUMBER

It helps the investigator in:
•• Record maintenance
•• Billing purposes
•• Medico-legal aspects
•• Identification of the patient.
DATE
The date is recorded in full for the following purposes:
•• Reference
•• Record maintenance.
NAME
Full name of the patient should be recorded.
Knowing the complete name of the patient while recording
history leads to:
•• Identification
•• Communication
•• Establishing a rapport with the patient
•• Record maintenance
General Information 11
•• Psychological benefit; especially in case of pediatric patient,

if called by nickname
•• Sense of importance and acceptance to the patient
•• Information of patient such as gender and religion.
AGE
The exact date of birth should be written.
Age (date of birth) has a particular significance to the
investigator to decide upon the:
•• Diagnosis
•• Treatment planning
•• Behavior management techniques.
It is also used for maintaining hospital records and to know
the psychology/mental development of the patient which has
a role on his dietary habits, oral hygiene practices and personal
habits.
Diagnosis
Age has a direct bearing on the presence of morbidity and
mortality caused by the medical problems. Increasing age
typically increases a person’s tendency to develop medical
conditions, such as hypertension, heart disease, diabetes and
cancer.
There is a predilection of certain diseases at different age
levels. Based on the disease predilection of age, the patients
are divided into:
•• Newborn: 1 to 28 days
•• Infants: up to 12 months
•• Children: 1 to 10 years
•• Adolescents: 10 to 19 years
•• Young adults: 19 to 24 years
•• Adults: 25 to 60 years
•• Elderly: above 60 years.
So, based on these age groups, one can rule out some of the
dental diseases as well as medical conditions, which, in turn,
relate to dental problems.
For example, Periodontitis is seen generally in old age,
i.e. > 50 years. But if the condition is seen in children and
young adults, one can confirm that it is juvenile periodontitis.
Examples of conditions present at different ages are
mentioned as follows:
Conditions commonly present at birth:
•• Cleft lip and palate •• Facial hemihypertrophy
•• Ankyloglossia •• Facial hemiatrophy
•• Teratoma •• Fissured tongue
•• Hemophilia •• Median rhomboid glossitis, etc.
Conditions commonly present in children and young adults:
•• Papilloma
•• Juvenile periodontitis
•• Scarlet fever, etc.
Conditions commonly occurring in old age:

•• Attrition
•• Periodontitis
•• Pulp stones
•• Root resorption, etc.
Treatment Planning
•• Comparison/correlation of chronological age with dental
age will help to decide the line of treatment for a patient.
Chronological age gives information about the dento-
skeletal development of the person.
•• Growth spurts: It is also important in developmental and
hereditary diseases which occur at the time of birth and
grows up to the puberty or ceases with growth. It is also
important for orthodontics treatment planning.
–– Infantile/childhood growth spurt

–– Mixed dentition/juvenile growth spurt
–– Prepubertal/adolescent growth spurt
•• Calculation of child’s drug dosage.
Based on Age
1. Fried’s Rule for Infants: Fried’s rule is a method of
estimating the dose of medication for a child by dividing
the child’s age in months by 150 and multiplying the result
by the adult dose
Child’s age in months
Pediatric Dose = × Adult dose
150
2. Young’s Rule: It utilizes similar concepts as Fried’s rule
except it is based on the child’s age in years. When given the
adult dose of a medication, it is possible to use this formula
to find the correct pediatric dose.
Child’s age in years
Pediatric Dose = × Adult dose
Child’s age in years + 12 years
Based on Weight
3. Clark’s Rule: The procedure is to take the child’s weight in
pounds, divide by 150, and multiply the fractional result by
the adult dose to find the equivalent child dosage.
Based on body surface area (BSA)
The nomogram method is utilized to determine the correct
pediatric medication dosage based specifically on the patient’s
size. The patient’s size is identified as body surface area (BSA) in
meter square (m2). The average adult client (weighing 150–154
lbs) will have a BSA of 1.73 m2. The nomogram chart can be
used to identify the patient’s BSA based on their height and
weight (in and lbs or cm. and kg.).
Child’s BSA in m 2
Pediatric Dose = × Adult Dosage
1.73 m 2
BSA is determined from a nomogram using the child’s height

and weight.
Example: If the child has a BSA of 0.67 m2 (in meters) and the
adult dose is 40 mg. Then dose for child would be:
0.67
× 40 = 15.8 mg
1.73
Calculation of child’s dosage by BSA is thought to be the
most reliable method.
Behavior Management Techniques

Management of patients of different age groups requires
different behavior modification methods. Example: Tell-show-
do, desensitization, etc.
SEX
Similar to age, certain dental and systemic diseases also show
sex predilection. Some diseases are more specific to females
while some are to males.
Diseases affecting them are as follows:
Females
•• Iron deficiency anemia
•• Pleomorphic adenoma
•• Sjogren’s syndrome
•• Adeno ameloblastoma
•• Myasthenia gravis
•• Sickle cell anemia
•• Thyroid diseases
•• Juvenile periodontitis
•• Peripheral ossifying fibroma
•• Nasoalveolar cyst
• Anorexia nervosa
•
• Parotid gland diseases
•
• Erosion
•
• Aphthous ulcers
•
• Oral lichen planus.
•
Males
• Stomatitis nicotina palati
•
• Hemophilia
•
• Attrition
•
• Carcinoma in situ
•
• Carcinoma of the buccal mucosa
•
• Leukoplakia
•
• Keratoacanthoma
•
• Basal cell carcinoma
•
• Verrucous carcinoma
•
• Adenoid cystic squamous cell carcinoma
•
• Liposarcoma
•
• Hodgkin’s disease
•
• Multiple myeloma
•
• Chondrosarcoma
•
• Herpes simplex
•
• Ewings sarcoma
•
• Ameloblastic fibro-odontoma
•
• Basal cell adenoma.
•
Along with sex predilection of the diseases, gender also helps
to analyze the following:
• Important for the treatment planning in case of orthodontic
•
patients as timing of growth spurts is different in males and
females.
• Esthetic needs of the patient: Girls are more conscious about
•
their esthetics.
• Dosage of drugs: The dosage of drug is affected by certain

•
factors which are discussed below:
– Females require low dosage of drugs than the males as
–
their body weight is less when compared to the males.
– Extraordinary care should be taken while prescribing
–
medicines to patients who are in menstruation,
pregnancy, lactation.
– Drugs given during pregnancy could affect the fetus
–
directly.
– Long-term use of antihypertensive drugs can lead to
–
impotency in males.
– Gynecomastia may be caused in males due to some
–
medications like digitalis, ketoconazole, chlorpromazine,
etc.
• Most of the time, sex is linked to occupation and, in turn,
•
related to occupational hazards.
• Females are sensitive and emotional; hence, care should be
•
taken during the treatment. Sexual abuse or exploitation is
more common in females.
EDUCATION
Education level of the person is recorded to determine:
• Socioeconomic status
•
• Intelligence quotient (IQ) for effective communication
•
• Attitude toward general and oral health.
•
ADDRESS
Complete postal address should be taken in order for
communication and to ascertain geographic distribution. The
recording of the patient’s address, and telephone number;
identification number (e.g. social security number); age
(date of birth); sex; race or ethnicity; name, address and
telephone number of a friend or next of kin; name, address

and telephone number of the referring dentist or physician,
as well as that of the physician(s) and dentist(s) whom the
patient consults for routine problems should be taken. These
records help:
• For future correspondence/recall
•
• To chart out appointments for patients from distant places
•
• Gives a view of the socioeconomic status. For example,
•
diseases such as diabetes, hypertension and dental
caries are more prevalent in high socioeconomic status
persons and diseases such as tuberculosis, chronic
generalized periodontitis are more commonly found in low
socioeconomic status.
• In diagnosis of diseases, since certain diseases are found to
•
be more in particular geographical areas.
For example:

– Fluorosis (as a result of increased level of fluorides in
–
water) is spread differently in various parts of the country.
It is endemic in certain areas.
– Caries are more common in modern industrialized
–
areas, whereas periodontal diseases are more common
in rural areas.
– Filariasis common in Orissa
–
– Leprosy common in West Bengal
–
– Carcinoma of the palate common in Srikakulam, AP
–
• For hospital records/administrative purposes.
•
Factors related to socioeconomic status
Socioeconomic status (SES) is assessed by looking at an individual group’s

housing, occupation, education and income levels in comparison to
their country’s statistical averages from surveys. Socioeconomic status
is typically broken into 3 categories: High SES, middle SES and low SES
to describe the areas a family or an individual may fall into.
OCCUPATION
It is an indicator of socioeconomic status. Also, it shows
predilection of diseases in different occupations described in
Table 3.1.
Table 3.1: Oral manifestations of occupational diseases
according to etiologic agent
Occupation Specific factor Possible oral
manifestations
Cobblers, carpenters, Instruments Localized abrasion
glass blowers, used
musicians prehension
Fishermen, asphalt Tar Stomatitis, caricinoma
and coal tar workers, of lip and mucosa
pavers, pitch roofers,
wood preservers
Bronzers, cement Copper, Staining of teeth,
workers, electrotypers, iron, nickel, pigmentation of
metal grinders, miners, chromium, gingiva, generalized
stone cutters coal, etc abrasion, calculus,
gingivostomatitis,
hemorrhage
Chemical workers, Arsenic Necrosis of bone, blue
electroplaters, metal black pigmentation of
refiners, rubber mixers gingiva
Bismuth handlers, Bismuth Blue pigmentation of
dusting powder makers gingiva, oral mucosa,
gingivostomatitis
Refiners, bakers, Sugar Caries
candy makers
Alcohol, distillery, Amyl acetate Stomatitis
explosives, shellac,
smokeless powder and
shoe factory workers
(Adapted from I Schour and BG Sarnat. Oral manifestations of occupational
origin. JAMA. 1942;120:1197)
Thus, occupation can be an important factor in determining

the source or cause of the disease for further treatment of the
disease.
It helps in planning appointments for the patients as per
their occupation and also determines their affordability in
relation to money and time for the treatment.
It also tells about the socioeconomic status of the patient
and his ability to afford the nutritious food and use of healthy
oral hygiene practices.
RELIGION
Religion has a particular significance to the investigator in:
•• Identifying the festive periods when religious people are
reluctant to undergo treatment procedures
•• Predilection of diseases in specific religions.
C H A P T E R 4
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 answers the question, “Why are you here today?” It
is primarily a statement of the patient’s signs and symptoms.
It is recorded in chronological order of their appearance, and
in the order of their severity. The patient should be questioned
about any other pertinent issues, including medical and dental
history.
The complaint should be documented with the following
information: Duration/progression, domain, character and
relation to physiological function. The chief complaint aids
in the diagnosis and treatment planning and should be given
the first priority.
The chief complaint is a statement of why the patient
consulted the dentist. The verbal complaint may be
accompanied by the patient pointing to the general area of
the problem.
Restatement of the chief complaint by the dentist may be
necessary to clearly define the problem. Many patients are
apprehensive when confronted by a dentist, and if the dentist
appears indifferent or unsympathetic, this can result in barriers
to effective communication, which will simply hinder the
dentist.
The problem that brought the patient to the dentist
is obviously a treatment priority, and the patient’s chief
Chief Complaint 21
complaint should become the dentist’s chief treatment priority.

Otherwise, the patient will seek treatment elsewhere. Pain is
the most common chief complaint that makes patients seek
dental treatment, followed by check-up, esthetic, and teeth
replacement. Esthetic complaint is more common in females
and younger patients.
Common chief complaints include:
•• Pain
•• Bad taste
•• Bleeding from gums
•• Loose teeth
•• Hypersensitivity
•• Burning sensation
•• Recent occlusal problems
•• Temporomandibular disorders
•• Delayed tooth eruptions
•• Dry mouth
•• Swellings
•• Paresthesia and anesthesia
•• Irregular teeth
•• Missing teeth
•• Routine dental check-up.
C H A P T E R 5
History of Present Illness
After establishment and recording of the chief complaint, the

examination process is continued by obtaining a history of the
present illness. A history of the present illness should indicate
the severity and urgency of the problem.
Initially, the patient may not volunteer the detailed
history of the problem. So the examiner has to elicit the
additional information by the possible questionnaire about
the symptoms. The patient’s response to these questions is
termed history of present illness. The conversation should
be directed by the clinician in order to produce a clear
and concise narrative that chronologically depicts all the
necessary information about the patient’s symptoms and the
development of these symptoms.
In order to help elucidate this information, the patient may
be first instructed to fill in a dental history form as a part of the
patient’s office registration. It is a chronological account of the
chief complaint and associated symptoms from the time of
onset to the time the history is taken. The history commences
from the beginning of the first symptom and extends to the
time of the examination. The history of present illness is the
course of the patient’s chief complaint: When and how it began;
what exacerbates and what ameliorates the complaint (when
applicable); if and how the complaint has been treated, and
what was the result of any such treatment; and what diagnostic
tests have been performed.
“Expanding the chief complaint by filling in the dimensions
of the problem identified in the chief complaint provides a
more complete statement—the history of present illness.”
History of Present Illness 23
•• The questions can be asked in the following manner:

–– When did the problem start?
–– What did you notice first?
–– Did you have any problems or symptoms related to this?
–– What makes the problem worse or better?
–– Have any tests been performed before to diagnose this
complaint?
–– Have you consulted any other examiner or dental
professional for this problem?
–– What have you done to treat this problem? etc.
•• In general, the symptoms can be elaborated under:
–– Date of onset
–– Mode of onset
–– Cause of onset
–– Duration
–– Location
–– Progress and referred pain
–– Relapse and remission
–– Treatment taken so far
–– Negative history.
DETAILED HISTORY OF A PARTICULAR

SYMPTOM
Pain
Pain is always subjective. Each individual learns the application of
the word ‘pain’ through experiences related to injury in early life.
The most recent definition by International Association
for the Study of Pain (IASP) defines pain as “an unpleasant
sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage”.
The IASP classification system recommends describing pain
according to the following five categories: Duration and
severity, anatomical location, body system involved, cause, and
temporal characteristics (intermittent, constant, etc.).
Note the following:

•• Anatomical location (site)
•• Origin and mode of onset
•• Severity of pain
•• Type of pain
•• Nature of pain
•• Progression of pain
•• Duration of pain
•• Radiation of pain
•• Precipitating or aggravating factors
•• Relieving factors
•• Associated factors.
Analysis of Pain
The word ‘pain’ is derived from the Latin word ‘poena’ meaning
penalty or punishment. It is a very common symptom and
occurs in response to an injurious stimulus.
Analysis of pain is important so as to reach to the proper
diagnosis. A careful history is an essential prerequisite; else it
may confuse the clinician to frame a wrong diagnosis. There
are various factors to be considered in pain:
If the history of the presenting complaint includes pain, ask

about it using the Mneumonic SOCRATES
yy SITE: Where exactly is this pain?
yy ONSET: When did the pain start; did it start suddenly or gradually?
yy CHARACTER: Describe the pain—sharp, knife-like, gripping, burning,
crushing, sharp, dull, stab, burn, cram or crushing
yy RADIATION: Does the pain spread anywhere; to the ear, jaw, eyes, etc.?
yy ALLEVIATING FACTOR and ASSOCIATIONS: Is the pain accompanied
by any other features?
yy TIMING: Does the pain vary in intensity during the day?
yy EXACERBATING FACTORS
yy SEVERITY: Scale of 1 to 10.
•• Site of Pain: Determining the original site of pain is

important.
The dentist may ask the patient, “Where did the pain start?”
Localization: “Can you point to the offending tooth?”
Although the site of pain may have changed after a short
period, the original site must be known. Localization allows
subsequent diagnostic tests to focus more on this particular
tooth.
•• Origin and mode of onset: “When did the symptoms first
occur?” A patient who is having symptoms may remember
when these symptoms started.
The dentist may ask the patient, “How did the pain start?”
The origin and mode of onset is important to determine the
chronicity of pain. A long continued pain with insidious onset
indicates chronic nature of the disease, whereas a recent
onset of pain with sudden impact indicates acute nature of
the disease.
•• Severity: The perception of pain varies in different
individuals. A mild pain may be severe to others. It often
helps to quantify how much pain the patient is actually
having. The clinician might ask, “on a scale from 1 to
10, 10 being the most severe, how would you rate your
symptoms?”
The severity of pain gives an impression of the acuteness of
the symptoms felt by the patient, thus helping in constituting
a proper diagnosis.
•• Types of pain: There are various types of pain. The most
common are:
–– Vague pain: It is a mild continuous pain, e.g. periodontal
pain
–– Burning pain: Pain usually occurs with the burning
sensation, e.g. reflex oesophagitis
–– Throbbing pain: Type of pressured throbbing sensation
is felt, e.g. in abscesses.
–– Stabbing pain: Sudden, severe, sharp and shortlived pain,

e.g. acute pulpal pain.
–– Shooting pain: Pain increases in severity in a short period,
e.g. trigeminal neuralgia.
•• Nature of pain: Pain may occur continuously or can be
intermittent, with periods of remission in between.
Continuous pain indicates an acute problem or an
exacerbation of chronic problem while intermittent pain
indicates chronicity of the problem.
•• Progression of pain: The clinician asks the patient, “how
is the pain progressing?” The progression of pain from the
time of its onset is to be asked.
•• Duration of the pain: In terms of days/months/years. The
clinician asks, “How long does the pain last?” Pain can be
intermittent or continuous. A continuous pain is the one
which persists for a longer duration. An intermittent pain is
the one which occurs after short intervals of time.
•• Radiation of pain: It is the extension of pain to another site,
while the original site is still painful. The radiating pain has
the same characteristic as that of the original pain.
‘Referred pain’ is a term used to describe the phenomenon
of pain perceived at a site adjacent to or at a distance from
the site of an injury’s origin (Dorland’s Medical Dictionary).
•• Precipitating or aggravating factors: Different factors may
worsen the pain suggesting a specific diagnosis about the
disease. For example, the pain of cracked tooth syndrome
occurs when the patient relieves the occlusal pressure over
the tooth.
•• Relieving factors: Factors which reduce the severity or
frequency of pain are considered important in diagnosis.
For example, in some cases, pain of chronic pulpitis gets
relieved by cold application.
•• Associated symptoms: Pain may occur along with nausea,
vomiting, sweating, flushing and increase in pulse rate.
Table 5.1: Differential diagnosis of odontogenic and

neuropathic pain
Odontogenic Pain Neuropathic Pain
Pain is dull ache or occasionally Pain may be dull, sharp,
sharp shooting or burning
Response to stimuli, such Response to hot, cold or
as hot, cold or percussion, is percussion does not reliably
predictable and proportionate relate to the pain and may be
disproportionate
Pain is usually inconsistent and Pain is persistent and remains
tends to get better or worse unchanged for weeks or months
over time
Pain often disrupts sleep Pain rarely disrupts sleep
There is often an identifiable There is no obvious source of
source (i.e. caries, deep local pathology
restoration, periodontal disease,
fracture line)
Local anesthesia of the suspect Response to local anesthetic is
tooth eliminates the pain ambiguous
Pain may be felt in multiple
areas or teeth
Repeated dental therapies fail
to resolve the pain
(Adapted and Modified from Okessen)
Pain can be either odontogenic or neuropathic (Table 5.1).

Pain can also be classified as neuroalveolar/vascular, dento-
alveolar, muscular/ligamentous/soft tissue (Table 5.2).
Swelling
•• Anatomical location (site)
•• Duration
•• Mode of onset
•• Symptoms
Table 5.2: Classification of orofacial pain
Neurological/ Dentoalveolar Muscular/
vascular ligamentous/soft
tissue
Trigeminal neuralgia Dentinal Temporomandibular
joint (TMJ) pain
Pre-trigeminal Thermal Burning mouth
neuralgia sensitivities
Nerve compression Pulpal Atypical facial pain/
idiopathic orofacial pain
Glossopharyngeal Periodontal Facial arthromyalgia,
neuralgia myofacial pain
Postherpetic Maxillary sinusitis Optic neuritis
neuralgia
Cluster headache Cracked tooth Salivary gland disease
syndrome
Cranial arteritis Internal derangements,
TMJ
Ramsay Hunt Cancer, sinuses,
Syndrome nasopharynx, brain
•• Progress of swelling
•• Secondary changes
•• Impairment of function
•• Recurrence of swelling.
Examination of a swelling should be accompanied by a
complete history of the patient. Following points should be
noted:
•• Site of swelling: The original site where it started must be
assessed (Table 5.3).
•• Duration: The dentist may ask, “When was the swelling
first noticed?” Swellings that are painful and of shorter
Table 5.3: Orofacial soft tissues swelling according to site

Site Type of lesion
Extraoral—Face and neck swellings
Face Seborrheic keratosis, melanoma, squamous cell
carcinoma, basal cell carcinoma, adnexal skin
tumors
Parotid region Sialolithiasis, sialadenitis, salivary neoplasm
Submandibular Sialolithiasis, lymphadenopathy, salivary
region neoplasm
Masseteric Space infection, cellulitis, jaw cysts and tumors,
region masseteric hypertrophy
Lateral neck Lymphadenopathy, lymphoma, mesenchymal
neoplasm, branchial cleft cysts, carotid body
tumor, metastatic carcinoma
Anterior neck Thyroglossal cysts, goiter, thyroid neoplasm
Intraoral
Gingiva Pyogenic granuloma, parulis, gingival cyst,
peripheral fibroma, peripheral ossifying fibroma,
peripheral giant cell granuloma, peripheral
odontogenic tumor, squamous cell carcinoma
Lips and buccal Mucocele, fibroma, salivary tumor, mesenchymal
mucosa tumor, squamous cell carcinoma
Dorsolateral Fibroma, pyogenic granuloma, granular cell
tongue tumor, squamous cell carcinoma
Ventral tongue Ranula, mucocele, lymphoid aggregates,
and oral floor lymphoepithelial cysts, squamous cell
carcinoma, osteocartilaginous choristoma
Palate Abscess, torus, salivary gland tumor
(Modified from Eversole LR, Silverman S. Swellings and tumors of the oral cavity
and face. In Essentials of Oral Medicine)
duration are mostly inflammatory (acute), whereas those

with longer duration and without pain are chronic, e.g. a
chronic periapical abscess.
•• Mode of onset : The dentist may ask, “How did the

swelling start?” The history of any injury or trauma or any
inflammation may contribute to the diagnosis and nature
of the swelling.
•• Other symptoms: Pain, fever, difficulty in swallowing,
difficulty in respiration, disfigurement, bleeding or pus
discharge are the common symptoms associated with
swellings in the orofacial region.
•• Progression: The dentist should ask, “Has the lump
changed in size since it was first noticed?” Benign growths
such as bony swellings grow in size very slowly and may
remain static for a long period of time. If the swelling
decreases in size, this suggests of an inflammatory lesion.
•• Secondary changes: Changes include softening, ulceration,
fungation, inflammatory cysts, etc.
•• Impairment in function: Swellings in the oral cavity can
lead to speech difficulties and problems associated with
chewing of food.
•• Recurrence of the swelling: Many swellings do recur
after removal of the tissue, indicating the presence of
precipitating factor, e.g. ranula.
Swellings can be mentioned according to their palpation
characteristics (Table 5.4). Firm movable masses are usually
neoplasms or granulomas; soft movable masses are fatty or
myxoid tumors; fluctuant masses are cysts, mucoceles or
mucous-duct retention cysts and abscesses; and indurated
fixed masses are probably malignant and may represent
carcinomas, salivary adenocarcinomas, lymphomas and
sarcomas.
The clinical features for the more common mucosal swellings
vary according to each specific entity. It is important that the
dentist take note of the location, coloration, surface texture,
and palpable nature of the mass before attempting to secure
a definitive diagnosis. If the lesion shows the features of an
Table 5.4: Masses according to palpation characteristics

Palpation Mass
characteristics
Soft, nonfluctuant Fibroma, lipoma, organized mucocele
Soft, fluctuant Ranula, mucocele, developmental cysts,
gingival cysts, parulis, sialocysts, space
infections and abscesses
Firm, movable Granulomas, mesenchymal tumors, salivary
adenomas, adnexal skin tumors
Firm, fixed Fibromatosis, keratoacanthoma, seborrheic
keratosis, granular cell tumor
Indurated, fixed Melanoma, sarcomas, lymphomas, basal
cell carcinoma, salivary adenocarcinomas,
squamous cell carcinoma
(Modified from Eversole LR, Silverman S. Swellings and tumors of the

oral cavity and face. In Essentials of Oral Medicine)
abscess, then diagnostic testing for odontogenic or periodontal

origin must be performed by obtaining radiographs, pocket
probing, pulp vitality testing, and identifying pyogenic
suppuration. If no apparent infectious source is uncovered,
then biopsy may be the chief method for procurement of a
definitive diagnosis.
Ulcer (Fig. 5.1)

Oral ulcers may have a great many causes, the principal
causes of oral ulceration are trauma, recurrent aphthous
stomatitis, microbial infections, mucocutaneous disease,
systemic disorders, squamous cell carcinoma and drug therapy,
although, in some cases, no cause is identified. Oral ulcers are
termed “acute” if they persist for less than three weeks’ duration
and “chronic” if they persist for longer than three weeks. They
may be recurrent.
Fig. 5.1: Ulcers
Common types of ulcers in the oral cavity
yy Traumatic ulcer
yy Recurrent aphthous ulcers
−− Bacterial infection
−− Immunologic abnormalities
−− Iron, vitamin B12 or folic acid deficiency
−− Hormonal conditions (premenstrual/postovulation period in
females)
−− Psychic factors (stress)
yy Infections, e.g. Tuberculosis, syphilis, oral candidiasis, HIV
yy Drug-induced aspirin burn, allergic reactions to drugs, Stevens-
Johnson syndrome
yy Malignant: Squamous cell carcinoma
yy Blood dyscrasias: Agranulocytosis, anemia, leukemia
yy Underlying systemic diseases: Behcet’s syndrome, Reiter’s syndrome,
Crohn’s disease, ulcerative colitis
If an ulcer is present, assess whether it is localized or part

of widespread ulceration and whether the surrounding areas
seem inflamed. Note the shape and margins of the ulcer. Feel
for induration of the ulcer and surrounding tissue and ensure
that there is no fixation of mobile tissues such as the tongue.
Note the relation of any prosthesis, sharp teeth, or dental

restorations to an ulcer if present. Extraoral examination to
look for swelling or lymphadenopathy in the head and neck
region should always be performed.
An ulcer is a break in the continuity of epithelium. A proper
history must be taken in case of an ulcer:
•• Mode of onset: The clinician may ask, “How has the
ulcer developed?” The patient may provide significant
information about the nature and etiology of the ulcer such
as any trauma or spontaneously.
•• Duration: The clinician may ask, “How long is the ulcer
present here?” It determines the chronicity of the ulcer. For
example, traumatic ulcers in oral cavity are acute (occurring
for a short period), but if the agent persists, it may become
a chronic ulcer.
•• Pain: The clinician may ask, “Is the ulcer painful?” Most
of the ulcers, being inflammatory in nature, produce pain.
Painless ulcers usually suggest nerve diseases (such as
peripheral neuritis, syphilis, etc.).
•• Discharge: Any blood, pus or serum discharge must be
noted.
•• Associated disease: Any associated generalized systemic
problem may be associated with the ulcers of oral cavity
(such as tuberculosis, squamous cell carcinoma, etc.).
Diagnosis of Oral Ulcers

Ulcers occur in the mouth with considerable frequency.
Traumatic lesions usually resolve rapidly and, hence, not
usually seen by the dentist. For relatively common conditions,
such as recurrent herpetic vesiculoulcers and aphthous ulcers,
presumptive diagnoses are often made without recourse to
laboratory tests. While the diagnosis of some types of oral
ulcers is facilitated by their association with constitutional signs
and symptoms or lesions on the skin and/or other mucous

membranes, ulcers which are localized to the oral cavity may
be more difficult to identify (Table 5.5).
Most traumatic oral ulcers can be identified by their
association with an identifiable mechanical, chemical, thermal
or radiotherapeutic cause. They may be single or multiple,
symmetrical or irregular in shape, and are usually painful.
Most are of recent onset, but some are chronic. Acute traumatic
Table 5.5: Oral ulcers

Acute Multiple Solitary Chronic
Ulcers, Ulcers
Recurrent
Acute Aphthae Apthae Allergies*
necrotizing Herpes Chancre Bullous
ulcerative simplex virus pemphegoid*
gingivitis
Allergies* Fungi (deep) Epidermolysis
bullosa*
Chemotherapy Gumma Lichen planus*
Erythema Necrotizing Lupus
multiforme* sialometaplasia erythmatosus
Herpangina* Squamous cell Mucous
carcinoma membrane
pemphigoid*
Herpes Trauma Paraneoplastic
simplex virus, pemphigus*
Primary*
Herpes zoster Tuberculosis Pemphigous
virus* vulgaris*
Mucous
patches
Radiotherapy
*Vesicles or bullae may occur in these conditions
ulcers have a removable, yellow-white base and erythematous

borders. Chronic traumatic ulcers may be non-painful with an
indurated base and raised borders; consequently, they may be
indistinguishable from squamous cell carcinomas on the basis
of their clinical features.
Recurrent aphthous stomatitis (RAS) is characterized by
recurrent bouts of one or several shallow, rounded or ovoid,
painful ulcers that recur at intervals of a few days or up to 2–3
months.
The most common site for oral squamous cell carcinoma
is the lateral border of the tongue, followed by the floor of the
mouth. Squamous cell carcinomas of the gums tend to occur
in the molar and premolar regions of the lower jaw. Malignant
oral ulcers have some characteristic features (Table 5.6).
Table 5.6: Clinical features of malignant oral ulcer

Features that should raise suspicion:
yy Age (85% of cases at age >50 years)
yy Male sex (2:1)
yy Non-healing painless ulcer present for >33 weeks
yy Ulcers with rolled thickened edge
yy Induration and lack of inflammation surrounding ulcer
yy No history of previous ulceration
yy No local factor that could potentially cause ulceration
yy No systemic factors that could potentially cause ulceration
yy Previously diagnosed premalignant lesion in the area
yy History of oral squamous cell carcinoma
Features that may reduce suspicion:
yy Multiple ulcers that occur synchronously
yy Recurrent ulceration that heals in between episodes
yy Clustering of ulcers
yy Occurrence in association with systemic diseases, especially
autoimmune
yy Associated sore and bleeding gums
yy Blister formation
yy Identifiable local causes (for example, sharp tooth)
Dentinal Hypersensitivity
Dentinal hypersensitivity may be defined as short, sharp pain
arising from exposed dentine typically in response to chemical,
thermal or osmotic stimuli that cannot be explained as arising
from any other forms of dental defect or pathology (Fig. 5.2)
(Addy M, Urquart E, 1992).
Dentinal hypersensitivity is characterized by a short, sharp pain
in response to stimuli. This stimulus is most commonly thermal,
either hot or cold, but can also be tactile, chemical or evaporative.
Three major mechanisms of dentinal sensitivity have been
proposed in the literature:
•• Neural theory
•• Odontoblastic transduction theory
•• Hydrodynamic theory.
Neural theory, which assumes that changes in tooth surface
temperature are conducted through enamel, dentin and finally
to sensory receptors located at DEJ causing neuron excitation.
Odontoblastic transduction theory, which assumes
external stimulus is transmitted along odontoblasts and
transferred to nerves via synaptic junctions between
Fig. 5.2: Exposed dentinal tubules leading to hypersensitivity

odontoblasts and nerves. But majority of studies have shown

that odontoblasts are matrix forming cells and, hence, they
are not considered to be excitable cells, and no synapses have
been demonstrated between odontoblasts and nerve terminals.
Hydrodynamic theory is the most widely accepted
theory for dentinal hypersensitivity given by Brännström
and coworkers. Brännström and Coworkers (1964) proposed
that dentinal pain is due to hydrodynamic mechanism, i.e.
fluid force. This theory states that stimuli (thermal, chemical,
tactile or evaporative) are transmitted to the pulp surface
due to movement of fluid or semi-fluid within open dentinal
tubules. Anatomically, the areas of the tubules closer to the
pulp chamber are wider and the fluid movement away from the
pulp activates the nerves associated with the odontoblasts at
the end of the tubule; this results in a pain response. The fluid
movement stimulates the small, myelinated A-delta fibers,
which then transmit to the brain and result in the sensation
of well-localized, sharp pain that is associated with dentinal
hypersensitivity.
Etiology of Dentinal Hypersensitivity

The most common causes of hypersensitivity are gingival
recession and enamel loss.
Gingival recession and enamel loss have multiple causes
(Tables 5.7 and 5.8) that result in cementum and/or dentin
exposure (Fig. 5.3). Cementum exposed due to gingival
recession tends to be thin, can easily be abraded or eroded
and may contribute to sensitivity. Gingival recession is more
common as the patient ages.
Patient History
Patients often report with the complaint of a sudden, short,
sharp shock-like sensation in response to cold or hot, sweet
Table 5.7: Causes of gingival recession and attachment loss
yy Anatomy of the labial plate of the alveolar bone
yy Periodontal disease
yy Frenum involvement
yy Toothbrush abrasion
yy Poor oral hygiene
yy Inadequate attached gingiva
yy Periodontal surgery
yy Iatrogenic loss during restorative procedures
yy Aggressive scaling and root planing
yy Acute or chronic trauma
yy Occlusal trauma
yy Excessive oral hygiene
Table 5.8: Factors in enamel loss

yy Abrasion (Fig. 5.3)
yy Attrition
yy Erosion
yy Abfraction (Fig. 5.4)
or sour substances, or touch. This sensation is a hyperactive

pulpalgia and must be elicited by some exciting factors. It is
never spontaneous. Exciting factors are usually cold food or
drink or cold air, contact of two dissimilar metals that will yield
a galvanic shock, or stimulation of the exposed dentin on the
root surface by cold, sweet or sour, vegetable or fruit acid, salt,
or glycerine, or often just touching the surface with a fingernail,
toothbrush or explorer.
Diagnosis
A diagnosis of dentinal hypersensitivity can be a challenge
for dental professionals since patients may not report it
and it may not be obvious. A majority of patients do not
Fig. 5.3: Cervical abrasion
Fig. 5.4: Abfraction

deem it to be a severe oral health condition and may not

seek treatment or even report this condition to the dentist.
Conversely, patients with exposed dentin—a sign that
dentinal hypersensitivity may be present—may or may not
experience sensitivity.
Differential Diagnosis
yy Dental caries yy Fractured restorations

yy Fractured teeth yy Leaking restorations
yy Cracked tooth syndrome yy Pulpal pathology
Through the use of radiographs, conversations with the

patient, and a thorough clinical examination, the dentist
must first exclude these conditions and then define the
diagnosis as one of hypersensitivity. Clinical signs and
symptoms that a dentist should be aware of and inquire
about include sensitivity or pain when a stimulus is applied
(such as hot/cold/sweet/sour/touch) and exposed dentin at
the site of sensitivity.
Bleeding from the Gums

Patients often report with problems of chronic or recurrent
bleeding, which is provoked by mechanical trauma (Fig. 5.5)
(e.g. from toothbrushing, toothpicks or food impaction) or by
biting into solid foods such as apples.
History of Bleeding Gums

•• Duration
•• Amount/quantity
•• Ease with which bleeding can be elicited
•• Associated symptoms (dull pain, sensitivity).
Fig. 5.5: Bleeding from gums
Causes
Chronic or recurrent bleeding: Most common cause is
chronic gingival inflammation.
Acute Bleeding
•• It is caused by injury or can occur spontaneously in acute
gingival disease
•• Acute Necrotizing Ulcerative Gingivitis (ANUG).
Gingival bleeding associated with systemic changes

•• Hemorrhagic disorders (vitamin C deficiency, Schonlein-
Henoch purpura)
•• Platelet disorders (thrombocytopenic purpura)
•• Hypoprothrombinemia (vitamin K deficiency)
•• Other coagulation defects (hemophilia, leukemia, Christmas
disease)
•• Deficient platelet thromboplastic factor (PF3) resulting from

uremia, multiple myeloma and postrubella purpura
•• Excessive intake of drugs (salicylates, anticoagulants—
dicoumarol and heparin).
Dry Mouth (Xerostomia)

The subjective feeling of oral dryness is termed xerostomia. It
is a symptom, not a diagnosis or a disease. It may or may not
be associated with a reduction in salivary output.
Causes of Xerostomia
•• Developmental (aplasia and hypoplasia of the salivary
glands)
•• Drugs (tric yclic antidepressants, antipsychotics,
antihistaminics, atropine, b-blockers) (Table 5.9)
•• Radiation therapy of head and neck
•• Oncologic chemotherapy
•• Infections and inflammatory conditions (parotitis, mumps)
•• Benign or malignant tumors of the salivary glands
Table 5.9: Medications causing xerostomia

Antacids Bronchodilator
Antianxiety Cholesterol reducing
Anticholinergic Decongestant
Anticonvulsant Diuretic
Antidepressant Hormonal replacement therapy
Antiemetic Muscle relaxants
Antihistamines Narcotic analgesics
Antiparkinsonian Sedative
Antihypertensive
Antipsychotic
•• Systemic diseases
–– Sjogren’s syndrome
–– Granulomatous diseases (Sarcoidosis, Tuberculosis)
–– Graft-versus-host disease
–– Cystic fibrosis
–– Bell’s palsy
–– Diabetes
–– Amyloidosis
–– HIV infection
–– Thyroid disease
–– Late stage liver disease
–– Patients on hemodialysis for end-stage renal disease
•• Psychological factors (effective disorders)
•• Malnutrition (anorexia, bulimia and dehydration)
•• Idiopathic disorders
•• Smoking, use of smokeless tobacco products, alcoholism
and caffeine can aggravate dry mouth.
Diagnosis and Evaluation of Xerostomia

•• Patient’s history: Patient complains of dryness of all oral
mucosal surfaces, particularly at night, or of difficulty in
chewing, swallowing and speaking, mucosa may be sensitive
to spicy or coarse foods.
•• Past and present medical history: Assess for medical
conditions or medications known to cause dry mouth.
•• Clinical features: The oral mucosa may be dry and sticky,
lips are often cracked, peeling and atrophic, buccal mucosa
may be pale and corrugated or erythematous due to an
overgrowth of Candida albicans. There may be little or no
pooled saliva in the floor of the mouth, and the tongue may
appear dry with loss of papillation. The saliva may appear
stringy, ropy or foamy. There is often a marked increase
in erosion, dental caries; particularly root caries, mouth
sores, periodontal disease and even cusp tip involvement.

This is because of the loss of bactericidal properties
of saliva encouraging the growth of microbes, such as
Streptococcus mutans, lactobacillus and candida species, lack
of remineralizing action of saliva and decreased flushing
action (natural cleansing action).
Two Additional Indications of Oral Dryness

“Lipstick sign”: Lipstick adheres to the facial surface of
maxillary anterior teeth.
“Tongue-blade sign”: Tongue blade adheres to the buccal
mucosa.
Clinical examination should also include bimanual
palpation of major salivary glands to assess the size, consistency
and tenderness of the glands, and also to determine if saliva can
be expressed via the main excretory ducts. Enlarged, painful
glands are indicative of infection or acute inflammation. The
consistency should be slightly rubbery, but not hard, and
distinct masses within the body of the gland may be indicative
of a salivary gland tumor.
Several office tests and techniques can be utilized to
ascertain the function of salivary glands. Sialometry, or
salivary flow measurement, can determine the salivary output
from the individual major salivary glands or from the whole
saliva. Unstimulated whole saliva flow rate of < 0.1 mL/min
and stimulated whole saliva flow rate of < 1.0 mL/min are
considered abnormally low and indicative of marked salivary
gland hypofunction.
Salivary gland imaging can provide information on salivary
function, anatomic alterations, and space-occupying lesions
within the glands. Various salivary gland imaging modalities
include plain-film radiography, sialography, ultrasonography,
radionuclide salivary imaging, computed tomography and
magnetic resonance imaging. Minor salivary gland biopsy is
often used in the diagnosis of Sjögren’s syndrome (SS), human

immunodeficiency virus causing salivary gland disease,
sarcoidosis, amyloidosis and graft-vs-host disease. Biopsy of
major salivary glands is an option when malignancy is suspected.
Burning Sensations of the Mouth

Burning sensations accompany many inflammatory or
ulcerative diseases of the oral mucosa, but the term ‘Burning
Mouth Syndrome’ is reserved for describing oral burning that
has no detectable cause.
•• Local causes
–– Stomatitis
–– Ulcers
–– Infections (e.g. candidiasis)
–– Dry mouth, salivary gland hypofunction
–– Mucosal disorders (geographic tongue, lichen planus,
etc.)
–– Trauma to oral mucosa (e.g. poorly fitting dentures)
–– Gastroesophageal reflux disease.
•• Systemic causes
–– Vitamin B12, folate, iron deficiencies
–– Medication (e.g. ACE inhibitors such as captopril)
–– Immunologically mediated diseases (e.g. Sjögren’s
disease)
–– Psychogenic disorders (e.g. anxiety, depression, fear of
cancer)
–– Psychosocial stress
–– Diabetes mellitus
–– Menopause/hormonal disturbances.
Diagnosis and Evaluation of Burning Mouth

•• History: When questioned, 10 to 15 percent of post-
menopausal women are found to have a history of oral
burning sensations, and these symptoms are most prevalent

3 to 12 years after menopause. Burning may be intermittent
or constant, but eating, drinking, or placing candy or
chewing gum in the mouth characteristically relieves the
symptoms. Tongue is most frequently involved, followed
by lips and palate. These patients usually are anxious. They
may also have symptoms suggestive of depression.
•• Clinical features and laboratory studies can help eliminate
other causes of burning symptoms of oral mucosa from
burning mouth syndrome. Patients with unilateral
symptoms require thorough evaluation of trigeminal and
other cranial nerves to eliminate a neurological source
of pain. Oral examination for lesions resulting from
candidiasis, lichen planus or other mucosal diseases should
be performed. Salivary gland assessment should be done for
patients complaining of a combination of xerostomia and
burning. When indicated, laboratory tests should be carried
out to detect undiagnosed diabetic neuropathy, anemia or
iron, folate or vitamin B12 deficiencies.
Loose Teeth or Tooth Mobility

Tooth mobility examination is important in planning dental
treatment, as it may give an indication of alveolar bone loss
and the condition of the periodontal ligament. In clinical dental
diagnosis, a manual tooth mobility examination is useful.
However, the determination of tooth mobility is subjective and
depends on the skill and experience of the clinician.
All teeth have a slight degree of physiologic mobility,
which is allowed by the resilience of an intact and healthy
periodontium, when a moderate force is applied to the
crown of the tooth examined. Physiologic tooth mobility
varies for different teeth and at different times of the day.
It is greatest on arising in the morning and it may be due
to slight extrusion of the tooth because of limited occlusal
contact during sleep. Mobility progressively decreases during

the day by chewing and swallowing forces, which intrude the
teeth in the sockets.
Causes
•• Loss of tooth support (bone loss) due to periodontal disease
•• Trauma (physical trauma from a fall or blow to the teeth)
•• Trauma from occlusion
•• Abnormal occlusal habits (bruxism, clenching)
•• Hypofunction
•• Extension of inflammation from the gingival or periapex into
the periodontal ligament results in changes that increase
mobility. For example, spread of inflammation from an
acute periapical abscess may increase tooth mobility in the
absence of periodontal disease
•• Periodontal surgery temporarily increases tooth mobility
•• Mobility may be increased in pregnancy, or sometimes may
be associated with menstrual cycle or use of contraceptive
pills
•• Osteomyelitis of the alveolar bone
•• Cysts/tumors of the jaw.
Symptoms and Diagnosis of Tooth Mobility

Patient complains of discomfort while chewing of food, pain
may accompany the mobility of teeth; the tissues around a
mobile tooth are invariably red, swollen and damaged. At times,
the patient may report with a complaint of loose tooth without
any accompanying symptom.
Halitosis or Oral Malodor

“Halitosis may rank only behind dental caries and periodontal
disease as the cause of the patient’s visit to the dentist.”
Origin may be either oral and extraoral:
Oral
•• Poor oral hygiene
–– Retention of odoriferous food particles on and between
the teeth
–– Coated tongue
–– Artificial dentures
•• Acute necrotizing ulcerative gingivitis
•• Pericoronitis
•• Abscesses
•• Dehydration states
•• Ulceration in the oral cavity
•• Hyposalivation/xerostomia
•• Bone disease (dry socket, osteomyelitis, osteonecrosis and
malignancy)
•• Smoker’s breath
•• Healing oral wounds
•• Chronic periodontitis with pocket formation.
Extraoral (Conditions that can Contribute to the Presence

of Oral Malodor)
•• Sinusitis and other bacterial infections
•• Dry nasal mucosa
•• Blocked nose (which can cause mouth breathing)
•• Tonsillitis/tonsil stones
•• Various carcinomas
•• Infections of the respiratory tract (bronchitis, pneumonia,
bronchiectasis)
•• Alcoholic breath
•• Uremic breath of kidney dysfunction
•• Acetone odor of diabetes.
When a patient presents to the dental office with the
complaint of halitosis, it is important for the dental professional
to eliminate systemic conditions that may be contributing to

the presence of oral malodor. For this reason, it is important to
have an up-to-date medical history of the patient, which should
help the dental professional eliminate any systemic causes for
the presence of oral malodor.
Diagnosis
Diagnosis of this condition is mainly clinical. A full history must
be collected together with a clinical examination. Assessment
of the presence and degree of halitosis can be simply performed
by smelling the exhaled air (organoleptic method) coming from
the mouth and nose and comparing the two.
The clinical assessment of oral malodor is either subjective or
objective. Subjective assessment is based on smelling the exhaled
air of the mouth and nose and comparing the two (organoleptic
assessment). Various scoring systems, such as a 0- to 5-point scale,
and a 0- to 10-point scale can be used to estimate the intensity of
exhaled oral odor, tongue odor and nasal odor, among others.
Organoleptic Scoring Scale
yy Absence of odor
yy Questionable to slight malodor—Odor is deemed to exceed the
threshold of malodor detection
yy Moderate malodor—Odor is definitely detected
yy Strong malodor—Malodor is objectionable but the examiner can
tolerate
yy Severe malodor, Overwhelming malodor—The examiner cannot
tolerate.
Methods for objective measurement of the breath include:

•• Detection of sulfides with an appropriate monitor—simple,
but may fail to detect oral malodor caused by nonsulfide
components. Halimeter is an instrument that can be used
chair-side to measure volatile sulfur compounds in the
exhaled air.
•• Gas chromatography—not applicable for routine clinical

practice.
•• Bacterial detection (such as benzoyl arginine-naphthyla-
mide test (BANA test), polymerase chain reaction, dark field
microscopy)—not applicable for routine clinical practice.
Oral Mucosal Pigmentation

Pigmented lesions are commonly found in the mouth. Such
lesions represent a variety of clinical entities, ranging from
physiologic changes to manifestations of systemic illnesses
and malignant neoplasms.
The mucosal tissues can assume a variety of discolorations in
the course of diseases. Disease processes can culminate in the
formation of pseudomembranes, in increased keratinization
(white lesions), or in increased vascularization (red lesions).
Blue, brown and black discolorations constitute the pigmented
lesions of the oral mucosa.
Oral pigmentation may be exogenous or endogenous in
origin. Exogenous pigmentation is commonly due to foreign-
body implantation in the oral mucosa. Endogenous pigments
include melanin, hemoglobin, hemosiderin and carotene.
Classification of Oral Pigmented Lesions

Exogenous
•• Accidental pigmentation (e.g. Graphite tattoos—due to
pencil points broken off in gingival tissue, if not completely
removed, can cause permanent discoloration)
•• Iatrogenic pigmentation (e.g. Amalgam tattoo)
•• Pigmentation due to drugs and metals (e.g. Bismuth line,
burtonian (lead) line, mercurialism and argyria)
•• Localized pigmentation (e.g. Chlorhexidine stains and hairy
tongue).
Endogenous
•• Kaposi’s sarcoma
•• Hereditary hemorrhagic telangiectasia
•• Brown melanotic lesions
–– Melanotic macule
–– Melanoplakia
a. Due to racial pigmentation
b. May occur due to smoker’s melanosis
c. Peutz-Jegher’s syndrome
d. Addison’s disease
–– Nevi
–– Melanoma
•• Physiological pigmentation
•• Cyanosis
•• HIV oral melanosis
•• Brown heme-associated lesions
–– Ecchymosis and petechiae
–– Hemochromatosis
–– Caratonemia
–– Jaundice
–– Early hematoma.
Drugs Associated with Oral Mucosal Pigmentation

A number of medications may cause oral mucosal pigmentation
(Table 5.10). The pathogenesis of drug-induced pigmentation
varies, depending on the causative drug. It can involve
accumulation of melanin, deposits of the drug or one of its
metabolites, synthesis of pigments under the influence of the
drug or deposition of iron after damage to the dermal vessels.
These pigmentations can be large yet localized, usually to the
hard palate, or they can be multifocal, throughout the mouth.
In either case, the lesions are flat and without any evidence
of nodularity or swelling. The cause is unknown, and the
Table 5.10: Drugs associated with oral mucosal pigmentation
yy Antimalarials: quinacrine, chloroquine, hydroxychloroquine
yy Quinidine
yy Zidovudine (AZT)
yy Tetracycline
yy Minocycline
yy Chlorpromazine
yy Oral contraceptives
yy Clofazimine
yy Ketoconazole
yy Amiodarone
yy Busulfan
yy Doxorubicin
yy Bleomycin
yy Cyclophosphamide
pigment may remain for quite some time after withdrawal of

the incriminated drug.
Guide to Diagnosis and Evaluation of Oral Pigmented

Lesions
Evaluation of a patient presenting with a pigmented lesion
should include a full medical and dental history, extraoral and
intraoral examinations and laboratory tests. The history should
include the onset and duration of the lesion, the presence of
associated skin hyperpigmentation, the presence of systemic
signs and symptoms (e.g. malaise, fatigue and weight loss), use
of prescription and nonprescription medications and smoking
habits. Pigmented lesions on the face, perioral skin and lips
should be noted. The number, distribution, size, shape and
color of intraoral pigmented lesions should be assessed.
In general, benign pigmented lesions show regular borders
and are small, symmetric and uniform in color. They may be
either at surface or slightly elevated. In contrast, irregular borders,
color variation, and surface ulceration suggest malignancy.
Flow chart 5.1: Pigmented Lesions of the Oral Cavity
[Kauzman A, Pavon M, Blanas N, Bradley G. Pigmented Lesions of the Oral

Cavity: Review, Differential Diagnosis, and Case Presentations. J Can Dent
Assoc. 2004; 70(10):682–3]
The algorithm in Flow chart 5.1 can be used as a guide to the

assessment of pigmented lesions of the oral cavity on the basis
of history, clinical examination and laboratory investigations.
Discolored Teeth
Knowledge of the etiology of tooth staining is of importance
to dental surgeons in order to enable a correct diagnosis to be
made when examining a discolored dentition and allows the
dental practitioner to explain to the patient the exact nature
of the condition.
Classification of Tooth Discoloration

Historically, tooth discoloration has been classified according
to the location of the stain, which may be either intrinsic or
extrinsic.
It may also be of merit to consider a further category of
internalized stain or discoloration:
Intrinsic Discoloration
Intrinsic discoloration occurs following a change to the
structural composition or thickness of the dental hard tissues. A
number of metabolic diseases and systemic factors are known
to affect the developing dentition and cause discoloration as a
consequence. Local factors such as injury are also recognized.
•• Alkaptonuria
•• Congenital erythropoietic porphyria
•• Congenital hyperbilirubinemia
•• Amelogenesis imperfecta
•• Dentinogenesis imperfecta
•• Tetracycline staining
•• Fluorosis
•• Enamel hypoplasia
•• Pulpal hemorrhagic products
•• Root resorption
•• Aging.
Extrinsic Discoloration
Extrinsic discoloration is outside the tooth substance and lies
on the tooth surface or in the acquired pellicle. The origin of
the stain may be:
•• Metallic (e.g. lead and iron)
•• Nonmetallic (e.g. tobacco and chromogenic bacteria).
Internalized Discoloration
Internalized discoloration is the incorporation of extrinsic stain
within the tooth substance following dental development.
It occurs in enamel defects and in the porous surface of
exposed dentine. The routes by which pigments may become
internalized are:
•• Developmental defects
•• Acquired defects:
–– Tooth wear and gingival recession
–– Dental caries
–– Restorative materials.
Delayed Tooth Eruption

Delayed tooth eruption (DTE) is the emergence of a tooth into
the oral cavity at a time that deviates significantly from norms
established for different races, ethnicities and sexes.
Conditions Associated with Delayed Tooth Eruption

Local
•• Mucosal barriers—scar tissue: trauma/surgery
•• Gingival bromatosis/gingival hyperplasia
•• Supernumerary teeth
•• Odontogenic tumors (e.g. adenomatoid odontogenic tumors
and odontomas)
•• Nonodontogenic tumors
•• Enamel pearls
•• Injuries to primary teeth
•• Ankylosis of deciduous teeth
•• Premature loss of primary tooth
•• Lack of resorption of deciduous tooth
•• Apical periodontitis of deciduous teeth
•• Regional odontodysplasia
•• Impacted primary tooth
•• Ectopic eruption
•• Arch-length deficiency and skeletal pattern
•• Radiation damage
•• Oral clefts
•• Segmental odontomaxillary dysplasia.
Systemic
•• Nutrition
•• Vitamin D-resistant rickets
•• Endocrine disorders
•• Hypothyroidism (cretinism)
•• Hypopituitarism
•• Hypoparathyroidism
•• Pseudohypoparathyroidism
•• Long-term chemotherapy
•• HIV infection
•• Cerebral palsy
•• Dysosteosclerosis
•• Drugs: Phenytoin
•• Anemia
•• Celiac disease
•• Prematurity/low birth weight
•• Ichthyosis
•• Other systemic conditions: Renal failure, cobalt/lead or
other heavy metal intoxication and exposure to hypobaria
•• Genetic disorders
•• Familial/inherited
•• Idiopathic.
Diagnosis
History: When teeth do not erupt at the expected age, a careful
evaluation should be performed to establish the etiology and
the treatment plan accordingly (Flow chart 5.2). It is important

for the dentist to rule out underlying medical conditions as a
cause. Family information and information from the affected
patients about unusual variations in eruption patterns should
be investigated.
Clinical evaluation: This should be done methodically and
must begin with the overall physical evaluation of the patient.
Although the presence of syndromes is usually obvious, in
the mild forms, only a careful examination will reveal the
abnormalities. Right-left variations in eruption timings are
minimal in most patients, but significant deviations might be
associated with, for example, tumors or hemifacial microsomia
Flow chart 5.2: Diagnostic algorithm for delayed tooth eruption
[Suri L, Gagari E, Vastardis H. Delayed tooth eruption: Pathogenesis,

diagnosis and treatment. A literature review. Am J Orthod Dentofacial
Orthop 2004;126:432-45]
or macrosomia and should alert the clinician to perform further

investigation. Intraoral examination should include inspection,
palpation, percussion, and radiographic examination.
Recent Occlusal Problems

A physiologic occlusion is present when no signs of dysfunction
or disease are present and no treatment is indicated. A
nonphysiologic (or traumatic) occlusion is associated with
dysfunction or disease due to tissue injury and treatment may
be indicated.
Causes
•• Missing or shifting teeth, leading to alterations in arch form
and alignment.
•• Acute occlusal changes—due to iatrogenic changes induced
by faulty restorative dentistry, prosthetic appliances that
interfere with or alter the direction of occlusal forces on teeth.
•• Parafunctional habits—bruxism.
Signs and Symptoms

Signs and symptoms of a nonphysiologic occlusion include
damaged teeth and restorations, abnormal mobility, fremitus,
widened periodontal ligament, pain and a subjective sense of
bite discomfort.
Clinical Evaluation
Clinical evaluation procedures include a screening evaluation
for temporomandibular disorders and intraoral occlusal
evaluation.
This includes assessment of:
•• Intercuspal position stability
–– Light or absent anterior contacts
–– Well-distributed posterior contacts

–– Coupled contacts between opposing teeth
–– Cross-tooth stabilization
–– Forces directed toward long axis of each tooth
•• Excursive movements—smooth excursive movements
without interferences
•• Tooth mobility
•• Attrition.
Temporomandibular Disorders
Temporomandibular disorders (TMDs) refer to a group of
disorders affecting the temporomandibular joint (TMJ),
masticatory muscles and the associated structures. These
disorders share the symptoms of pain, limited mouth opening
and joint noises. Pain associated with TMDs can be clinically
expressed as masticatory muscle pain (MMP) or TMJ pain
(synovitis, capsulitis, or osteoarthritis). TMD pain can be,
but is not necessarily, associated with dysfunction of the
masticatory system (clicking, locking of the TMJ, and limitation
of movement).
TMJ problems
Etiology: TMJ disorders are thought to have a multifactorial
etiology, but the pathophysiology is not well-understood.
Capsule inflammation or damage and muscle pain or spasm
may be caused by abnormal occlusion, parafunctional habits
(e.g. bruxism [teeth grinding], teeth clenching, lip biting), stress,
anxiety or abnormalities of the intra-articular disk. Causes can
be classified into factors affecting the joint itself and factors
affecting the muscles and joint function. The American Academy
of Orofacial Pain has also produced a diagnostic classification.
Symptoms: The three cardinal symptoms of TMJ disorders are:
facial pain, restricted jaw function and joint noise.
•• Pain
–– Located around the TMJ, but may be referred to the head,
neck and ear
–– Pain, located immediately in front of the tragus of the
ear, projecting to the ear, temple, cheek and along the
mandible, is highly diagnostic for TMD
•• Restricted jaw motion
–– May affect mandibular movement in any direction
–– Jaw movements increase the pain
–– Patients may describe a generally tight feeling, which is
probably a muscular disorder, or a sensation of the jaw
‘catching’ or ‘getting stuck’, which usually relates to internal
derangement of the joint
•• Joint noise
–– Clicks and other joint sounds are common; they are not
significant unless there are other symptoms.
Diagnostic Criteria
The Guidelines of the American Academy of Orofacial Pain
(2008) and the Research Diagnostic Criteria (RDCTMD, 1992)
suggest the following criteria:
•• MMP: A complaint of muscle pain in the jaw, temple, face,
or periauricular area, with tenderness on palpation in at
least 3 of 20 predetermined muscle sites
•• TMJ arthralgia: A complaint of pain over the TMJ, including
pain with function or with assisted or unassisted mandibular
movements. Pain on palpation of the joint over the lateral
pole and/or via external auditory meatus. No coarse crepitus.
•• TMJ osteoarthritis has the same criteria as for TMJ arthralgia,
supplemented by coarse crepitus or positive imaging findings.
•• Psychosocial comorbidity in MMP or TMJ pain is rated using
the Graded Chronic Pain Scale and measurement scales for
depression, anxiety, and nonspecific physical symptoms.
C H A P T E R 6
Previous Dental History
Despite its frequent omission from the dental record, the past
dental history (PDH) is one of the most important components
of the patient’s history. This is especially evident when the
patient presents with complicating dental and medical
factors such as restorative and periodontal needs coupled
with a systemic disorder such as diabetes. Significant items
that should be recorded routinely are the frequency of past
dental visits; previous restorative, periodontic, endodontic,
or oral surgical treatments; reasons for loss of teeth; untoward
complications of dental treatment; fluoride history, including
supplements and the use of well water; attitude toward previous
dental treatment; experience with orthodontic appliances and
dental prostheses; and radiation or other therapy for oral or
facial lesions.
It tells the investigator about the attitude of the patient
toward dentistry. It often provides the dentist with valuable
prognostic as well as diagnostic information. A dental history
should be performed that includes the frequency of past dental
visits, a history of dental sensitivity, pain, infection, soft tissue
lesions, bleeding, swelling, age and condition of existing dental
prostheses, and a history of oral and periodontal surgery or any
other dental treatment.
•• Frequency of visits to a dentist: It provides the examiner
with information regarding the interest of the patient in his
dental health.
•• Frequency of dental prophylaxis: It may be valuable guide
in evaluating periodontal conditions which are present as
well as provides the dentist with prognostic information.
•• Past experience during and following local anesthesia: It

may alert the dentist to the necessity for investigation into
possible allergy to the anesthetic agent. It may also allow him
to anticipate possible syncope during the administration of
local anesthesia in future appointments.
•• Past periodontal therapy: Type of treatment and the time
in the past it was received, will help to evaluate the present
status of periodontal structure and planning of future
periodontal treatment for a patient.
•• Past orthodontic treatment: The condition which was
treated, the length of time of active treatment, the nature
of the appliance used, whether a retainer was used
appropriately and is still required can be evaluated.
•• Fixed bridges: The comfort level of the bridge.
•• Surgical procedures in the mouth other than extraction:
Nature of the tissue removed. Manner in which it was
removed and its recurrence should be inquired.
Obtaining past dental records, including radiographs, and
consultation with other dentists involved in the patient’s care
should be considered, especially if the dentist performing the
pretreatment dental evaluation is not the patient’s usual dental
care provider.
The dental history can also give insight into the patient’s
level of dental awareness and motivation to maintain optimum
oral health. Inquiry into the patient’s perceived reasons for lack
of dental care may be predictive of future compliance.
Previous dental history gives a general view about how the
patient is aware about pursuing oral health.
•• It provides a basis for the determination of the caries rate,
the rate of plaque and calculus formation, the susceptibility
to periodontal diseases, the resorption rate of edentulous
ridges
Previous Dental History 63
•• If history of previous bad experience (pain, rude attitude of

dentist, etc.) is present then moulding of behavior is done
using behavior management techniques
•• Significant knowledge can be drawn about the patient’s
previous treatment procedures and it can be helpful toward
the present situation
•• Also the information regarding any complication faced
during the previous treatment/visit can be noted
If this is the patient’s first visit to a dental clinic then reasons
for not visiting the dentist should be inquired:
Patient felt that he/she has:
•• Had no problem
•• Had some problem but thought it will get corrected by itself
•• Due to other reasons, like time factor/no facilities/lack of
affordability, etc.
C H A P T E R 7
Medical History
Obtaining a medical history is an information gathering

process for assessing a patient’s health status. 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.
To conduct a thorough medical history assessment, the
dental healthcare provider must have a methodical plan for
information gathering and review. The plan should prevent
oversights or omissions of important information about the
patient’s medical history.
The main steps in conducting a medical history assessment
are (a) information gathering and (b) determination of medical
risk. One successful approach for obtaining information is to
combine the use of a written questionnaire form filled by
the patient, with an interview of the patient. The interview
provides an opportunity to clarify information and ask follow-
up questions about information on the written questionnaire.
RELATIONSHIP BETWEEN SYSTEMIC AND ORAL

HEALTH
Nield-Gehrig, Jill S suggested that there are many reasons for
conducting a thorough assessment of the patient’s past and
current health status. The most important reason is to protect
the health of the patient.
Medical History 65
There is strong two-way relationship between systemic

health and oral conditions.
•• Medications used to treat systemic diseases and conditions
can produce changes in oral health
•• Systemic diseases and conditions may have oral implications
(e.g. patients with poorly controlled diabetes do not respond
well to dental surgery)
•• Systemic conditions, diseases, or medications may
necessitate precautions to ensure that planned dental
treatment will not be harmful to the patient’s systemic
health
For example, a patient who has a history of heart problem
or diabetes may need certain treatment modifications
•• Oral manifestations may identify conditions that should be
evaluated by a dentist. For example, periodontal disease
that does not respond to treatment may be an indication
of uncontrolled diabetes since this condition increases
susceptibility to infection and results in slower healing
rates
•• Substances, materials, or drugs used in dental treatment
may produce an adverse reaction in certain patients
(e.g. a patient with allergies may be allergic to temporary
restoration or amalgam.)
HEALTH HISTORY FORMS

A health history form is used to gather subjective data about
the patient and explore past and present problems. This form
assists patients in providing an account of their health history.
•• Health history forms are available in many different
languages, formats and lengths
•• Many health history forms include a list of diseases and
medical conditions that help patients in recalling and
remembering their medical history
•• Most forms ask the patient to answer in “yes” or “no” for

each question or item on the form. Some health history
forms have space that allows patients to provide additional
information in response to questions and to list their
medications
•• Many dental offices and clinics design history forms to
meet the desired needs of the office or clinic and its patient
population
•• Regardless of the format or length, the health history form
should provide the dental professional with complete
information regarding the past and present health of each
patient.
The dentist should evaluate a patient’s response to the health
questionnaire from two perspectives: Those medical conditions
and current medications that will necessitate altering the
manner in which dental care will be provided and secondly
those medical conditions that may have oral manifestations
or mimic dental pathosis.
Patients with certain medical conditions may require either
a modification in the manner in which the dental care will be
delivered or a modification in the dental treatment plan:
The medical history also includes biographic and
demographic data used to identify the patient. An appropriate
interpretation of the information collected through a medical
history achieves three important objectives:
1. It enables the monitoring of medical conditions and the
evaluation of underlying systemic conditions of which the
patient may or may not be aware.
2. It provides a basis for determining whether dental treatment
might affect the systemic health of the patient.
3. 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.
Medical History 67
Medical history is the description of the relevant features of

the patient’s health status which influence the oral health from
birth to the moment that the patient enters the office.
Medical history includes:
•• History of past illness
•• Healthcare experience
•• Immunization
•• Diseases or conditions that contraindicate certain kind of
dental treatment
•• Diseases that require special precautions or premedication
prior to dental treatment. For example, myocardial
infarction, hemophilia, radiation, etc.
•• Diseases under treatment of a physician with medication
that contraindicates the use of additional medication. For
example, anticoagulants, steroid therapy, tranquilizers
•• Allergies/untoward reaction toward penicillin/local
anesthesia
•• Diseases that endanger the dentist/other patients. For
example, infectitious diseases like hepatitis, tuberculosis
•• Physiological state of patient. For example, pregnancy, aging.
Checklist for medical history by Scully and Cawson
yy Anemia
yy Bleeding disorders
yy Cardiorespiratory disorders
yy Drug treatment and allergies
yy Endocrine disorders
yy Fits and faints
yy Gastroinstestinal disorders
yy Hospital admissions and surgeries
yy Infections
yy Jaundice
yy Kidney diseases
All diseases suffered by the patient should be recorded in

chronological order. Patients with medical conditions may
require either a modification in the manner in which the
dental care will be delivered or a modification in the dental
treatment plan.
Patient should be evaluated for the following (Table 7.1):
Table 7.1: List of medical problems to be evaluated
CVS yy Heart disease
yy Hypertension angina
yy Syncope
yy Cardiac surgery
yy Rheumatic fever, chorea
yy Bleeding disorder
yy Anticoagulants
yy Anemia
yy High- and moderate-risk categories of endocarditis,
Pathologic heart murmurs
yy Hypertension
yy Unstable angina pectoris
yy Recent myocardial infarction, cardiac arrhythmias
yy Poorly managed congestive heart Failure
GI/Liver yy Celiac disease
yy Crohn’s disease
yy Hepatitis
yy Jaundice
yy Other liver disease
Endocrine yy Diabetes
yy Thyroid
yy Other endocrine disease
CNS yy Cerebrovascular accident
yy Seizure disorders
yy Anxiety
yy Depression and bipolar disorders
yy Presence or history of drug or alcohol abuse
yy Alzheimer’s disease
Contd...
Medical History 69
Contd...
yy Schizophrenia
yy Eating disorders
yy Neuralgias
yy Multiple sclerosis
yy Parkinson’s disease
Respiratory yy Asthma
yy Bronchitis
yy TB
yy Smoker
yy Chronic obstructive pulmonary disease
yy Other chest disease
Genitourinary yy Renal disease
system yy Urinary tract disease
yy Sexually transmitted disease
yy Pregnancy
yy Menstrual problems
Hematologic yy HIV and AIDS
yy Adrenal insufficiency
yy Hyperthyroidism and Hypothyroidism
yy Bleeding disorders
yy Cancer
yy Leukemia
yy Osteoarthritis
yy Rheumatoid arthritis
yy Systemic lupus erythematosis
Allergies To drugs like:
yy Penicillin
yy Anesthetics
yy Doxycycline
yy Aspirin
yy Iodine
yy Or other food items
Drugs yy Current drugs or medical treatment
yy Corticosteroids, anticoagulants
Extremities yy An artificial joint prosthesis
and joints
Patient should be assessed by the questionnaire:

•• Whether he is suffering or has suffered before from any major
illness? The patient should be asked to enumerate illnesses
that required (or require) the attention of a physician or for
which the patient was (or is being) routinely medicated. In
the dental context, specific questions are asked about any
history of heart, liver, kidney, or lung diseases, congenital
conditions, infectious diseases, immunologic disorders,
diabetes or hormonal problems, chemotherapy, blood
dyscrasias or bleeding disorders radiation or cancer and
psychiatric treatment.
•• What is the duration and treatment of the disease?
•• Is the patient on any medication? The types of medications, as
well as changes in dosages over time, often give an indication
of the status of underlying conditions and diseases. The
patient should be asked about any prescription or over-the-
counter (OTC) medications,“alternative” medications, and
other healthcare products the patient is currently taking or
has taken within the previous 4 to 6 weeks. The name, nature,
dose, and dosage schedule of each is recorded.
•• History of all the hospitalizations and their purpose should
be assessed. A record of hospital admissions complements
the information collected on serious illnesses and may
reveal significant events such as surgeries that were not
previously reported. Hospital records are often the dentist’s
best source of accurate documentation of the nature and
severity of a patient’s medical problems, and a detailed
record of hospitalizations.
•• Pregnancy: Knowing whether or not a woman of childbearing
age is pregnant is particularly important when deciding to
administer or prescribe any medication.
Some important examples of diseases (conditions) affecting
the treatment include:
•• Postpone treatment if suffering from acute illness like
mumps or chickenpox
Medical History 71
•• Patient with cardiac diseases needs to get a physician’s report

•• Patient on anticoagulant therapy
•• If asthmatic then Nonsteroidal Anti-inflammatory Drugs
(NSAIDs) are contraindicated
•• Juvenile diabetes mellitus
•• Patient with recent history of stroke
•• Patient having renal disease who is on dialysis
•• Patient who recently had a renal or bone marrow transplant.
DETERMINATION OF MEDICAL RISK

At this stage, the dental healthcare provider must consider
the patient’s medical risk when undergoing dental treatment.
The information gathered from the patient, along with the
clinician’s research on the patient’s medical conditions,
diseases, and medications, are used to determine the need
for precautionary measures before or during dental treatment.
ASA Physical Status

In addition to the clinician’s thorough review of the patient’s
written health questionnaire and research, another helpful
resource for determining the patient’s level of medical
risk during dental treatment is the American Society of
Anesthesiologists (ASA)
Physical Status Classification System is depicted in Tables
7.2 and 7.3.
Family History
Family history is asked to assess the presence of any inherited
disease pattern or trait.
Serious medical problems in immediate family members
(including parents, siblings, spouse, and children) should be
listed.
Table 7.2: The American Society of Anesthesiologists (ASA)
Physical Status Classification System
CLASS I Patient is a completely healthy fit patient
CLASS II Patient has mild systemic disease
CLASS III Patient has severe systemic disease that is not
incapacitating
CLASS IV Patient has incapacitating disease that is a constant
threat to life
CLASS V A moribund patient who is not expected to live
beyond 24 hours with or without surgery
CLASS VI A declared brain-dead patient whose organs are
being removed for donor purposes
The reason a family history can help predict risk is that

families share their genes, as well as other factors that affect
health, like environment, lifestyles and habits. This may
reveal hereditary problems, such as amelogenesis imperfecta,
hemophilia or hereditary angioedema, and familial conditions,
such as diabetes. Some diseases are more prevalent in certain
ethnic groups, e.g. pemphigus in Jews; Behçet’s disease in
people from the Mediterranean area.
There are also several inherited anomalies and abnormalities
that can affect the oral cavity. Many, such as amelogenesis
imperfecta, congenitally missing lateral incisors, ectodermal
dysplasia and cleft lip and/or palate, may have a direct impact
on the type of dental treatment required.
It includes:
•• Number of siblings and their age. This gives an idea of:
–– Size of family and socioeconomic status
–– Whether patient can afford for the time and treatment
–– To know the child’s psychology which has an effect on
his behavior. Children from larger families are more
adjustable, co-operative, willing to face the crisis/face
challenges on their own.
Table 7.3: American Society of Anesthesiologists Physical Status (ASA PS) Classification System and
Treatment Recommendations
ASA Definition Walk up 2 flights Example Treatment recommendations
ps of stairs or 2 city
blocks
1 Normal healthy Patients are able to — No special GREEN
patient walk up one flight precautions FLAG
of stairs or two level
city blocks without
distress
2 Patient with Patients are able to Pregnancy, well- Elective care OK; YELLOW
mild systemic walk up one flight controlled type 2 consider treatment FLAG
disease of stairs or two level diabetes, epilepsy, modification
city blocks, but will asthma, thyroid
have to stop after dysfunction, BP 140-
completion of the 159/90-94 mm Hg
exercise because of
distress
3 Patient with Patients are able to Stable angina Elective care YELLOW
severe systemic walk up one flight pectoris, OK; serious FLAG
disease that of stairs or two level postmyocardial consideration
limits activity city blocks, but will infarction >6 months, of treatment
but is not have to stop enroute post CVA >6 months, modification
incapacitating because of distress exercise induced
Contd...
Medical History 73
Contd...
blocks
asthma, type 1 diabetes
(controlled), epilepsy
(less well-controlled),
symptomatic thyroid
dysfunction, BP 160-
199/95-114 mm Hg
4 Patient with an Patients are unable Unstable Elective care RED
incapacitating to walk up one flight angina pectoris, contraindicated; FLAG
systemic of stairs or two level postmyocardial emergency care:
disease that is a city blocks. Distress infarction <six months, noninvasive (For
constant threat is present even at uncontrolled seizures, example, drugs)
to life rest BP >200/>115 mm Hg or in a controlled
environment
5 Moribund These patients End stage cancer, Palliative care RED

patient not are almost always end stage infectious FLAG
expected to hospitalized, disease, end stage
survive 24 terminally ill patients cardiovascular
hours without disease, endstage
surgery hepatic dysfunction
Contd...
Contd...
blocks
The ASA physical status classification system is adapted with permission of the American Society of Anesthesiologists,
520 N. Northwest Highway, park Ridge, Ill. 60068-2573
Sources: American Society of Anesthesiologists; McCarthy and Malamed.
BP: Blood pressure
Mm hg: Millimeters of mercury
CVA: Cerebrovascular accident
Medical History 75
–– To study the peer influence of dietary and oral hygiene

practice.
•• History of any disease running in the family. For example,
diseases like hemophilia, diabetes, and hypertension recur
in families’ generation after generation.
•• Prenatal, natal and postnatal history should be taken in case
of pediatric patients.
The family history should include:
•• Causes and age of death of parents
•• Details about the health of siblings and children
•• Information about heart disease, hypertension, diabetes,
asthma, allergies & ethnic origin.
Personal and Social History

This documents factors in the person’s lifestyle, environment
and personal habits which can put them at risk from illness or
have a bearing on established disease. This is an opportunity
to discuss how the persons maintain their health (as opposed
to discussing illness) and to consider whether there is a need
for primary or secondary prevention.
Illness may be related to occupation, to environment, or to
being unemployed.
Recent or past travel abroad may have important
implications. Information about contacts with pets and other
animals, which may be relevant to some infectious diseases,
such as cat-scratch disease or toxoplasmosis.
Information to be gathered can include:
•• General well-being
•• Alcohol, smoking, recreational drug use
•• HIV risk factors
•• Housing
•• Family relationships and support
•• Occupation and job security
Medical History 77
•• Social or financial problems

•• Patient’s sexual history, which may be relevant to some
infectious diseases, such as human immunodeficiency
virus (HIV), herpes simplex virus (HSV), papillomavirus
(HPV) and hepatitis viruses A (HAV), B (HBV) and C (HCV)
•• Any occupational problems, which may be relevant to some
disease, and access to care
•• Information about the patient’s diet—dietary fads may lead,
For example, to vitamin deficiencies and glossitis or angular
cheilitis (as in vitamin B12 deficiency in vegans)
It is important to bear in mind that certain aspects of social
history can be private and some patients may find this intrusive.
Personal/social history
yy Marriage/other relationships and outcome: Spouse, partner,

children, number of living children
yy Household composition/living situation: Alone or with others;
relationships; care giving
yy Ethnicity
yy Sources of social support: Friends, community, organizations, pets,
spiritual beliefs or community
yy Personal background: Education, occupation, military, travel,
religion, dwelling, financial, stress
yy Directives for care: Living will, healthcare, Power of attorney, CPR,
transfusions, known health risks
HEALTH HISTORY FORM

Name: Date of birth: Sex:
Address: Phone: Occupation:
Height/weight:
Medical History:
Have you ever had any serious illness or operation? If yes,
describe
_____________________________________________________
Have you ever had blood transfusion? Yes/no
Are you being treated by a doctor at present? Yes/no
(Women) are you pregnant? Yes/no nursing? Yes/no taking
birth control pills? Yes/no
Check (/) if you have or have had any of the following:
•• Anemia •• Cortisone treatments
•• Hepatitis •• Scarlet fever
•• Arthritis •• Cough, persistent
•• High blood pressure •• Shortness of breath
•• Bleeding disorder •• Artificial heart valves
•• HIV/AIDS •• Skin rash
•• Jaw pain •• Artificial joints
•• Asthma •• Diabetes
•• Cancer •• Thyroid problems
•• Back problems fainting •• Glaucoma
•• Headache •• Blood disease
•• Pacemaker •• Swelling of feet or ankles
•• Tonsilitis •• Liver disease
•• Radiation treatment •• Kidney disease
•• Tuberculosis •• Epilepsy
•• Rheumatic fever •• Chemotherapy
Medical History 79
• Ulcer • Heart problems

•
•
• Stroke • Respiratory disease
•
•
List of medications you are currently taking:
_____________________________________________________
Allergies:
• Aspirin • Penicillin
•
•
• Barbiturates • Drugs
•
•
• Codeine • Sulfa
•
•
• Local anesthetic • Latex
•
•
• Metals • Iodine
•
•
• Hay fever animals • Food
•
•
Tobacco History:
Do you currently use tobacco of any type? Yes/no
How many years have you been using tobacco?
_____________________________________________________
How much tobacco do you use in a day?
_____________________________________________________
Were you a tobacco user and have stopped now? Yes/no
Dental History:
Chief complaint:
_____________________________________________________
Date of last dental visit
_____________________________________________________
Date of last dental X-rays
_____________________________________________________
Check (/) if you have had problems with any of the following:
• Bad breath
•
• Sensitivity to hot/cold
•
• Loose teeth or broken fillings

•
• Sores or growths in mouth
•
• Clicking or popping sound
•
• Food collection between teeth
•
• Grinding teeth
•
• Bleeding gums
•
• Sensitivity to sweets
•
• Sensitivity when biting
•
• Periodontal treatment
•
Have you had problems associated with previous dental
treatment? Yes/no
Are you currently experiencing dental pain or discomfort?
Yes/no
Do you wear partial or complete dentures? Yes/no
Have you ever had a serious injury to your mouth or head?
Yes/ no
I certify that i have read and understood the above. I
acknowledge that my questions, if any, about the inquiries
set forth above have been answered to my satisfaction. I will
not hold my dentist, or any other member of his/her staff,
responsible for any errors or omissions that i may have made
in the completion of this form.
Signature of Patient
For completion by dentist
Comments:
_____________________________________________________
_____________________________________________________
C H A P T E R 8

Personal Dental History
Personal dental history includes:

• Oral habits
•
• Oral hygiene habits
•
• Adverse habits
•
• Diet history.
•
ORAL HABITS
Habit
Definition
• A habit can be defined as the tendency toward an act that has
•
become a repeated performance, relatively fixed, consistent
and easy to perform by an individual (Boucher OC).
• A habit can be defined as fixed or constant practice
•
established by frequent repetition (Dorland, 1957).
• Buttersworth (1961) defined habit as a frequent or constant
•
practice or acquired tendency, which has been fixed by
frequent repetition.
• Mathewson (1982) defined that oral habits are learned
•
patterns of muscular contractions.
Various habits are:
• Thumb sucking
•
• Finger sucking
•
• Tongue thrusting
•
• Pacifier or dummy sucking
•
•• Lip biting
•• Nail biting
•• Cheek biting
•• Pencil or foreign object sucking
•• Lip sucking
•• Clenching
•• Mouth breathing
•• Bruxism
•• Occupational habits.
THUMB AND DIGIT SUCKING

It makes up the majority of oral habits. About two-thirds of the
children end this habit by 5 years of age.
•• The types of dental changes that a digit sucking habit may
cause vary with the intensity, duration, and frequency of the
habit as well as the manner in which the digit is positioned
in the mouth.
•• Clinical and experimental evidence suggests that 4 to 6
hours of force per day are probably the minimum necessary
to cause tooth movement.
•• A child who sucks intermittently with high intensity may
not produce much tooth movement at all, whereas a child
who sucks continuously (for more than 6 hours) can cause
significant dental change.
Definition
Thumb sucking is the childhood habit of putting the thumb in
the mouth for comfort or to relieve stress.
Thumb sucking is defined as placement of the thumb or one
or more fingers in varying depths into the mouth (Gellin 1978).
Figure 8.1 shows a child with thumb sucking habit.
Thumb sucking is considered normal upto the second year
of life. Till this time it does not generate any malocclusion.
Personal Dental History 83
Abnormal thumb sucking persists beyond the preschool

period, i.e. after the age of 3 to 4 years.
•• Psychological: Deep rooted emotional reason (insecurity,
neglect, loneliness)
•• Habitual: No psychological bearing; act out of a habit.
Sucking Reflex (Fig. 8.1)

The process of sucking is a reflex occurring in the oral stage of
development and is seen even at 29 weeks of intrauterine life,
and may disappear during normal growth between the ages
of one and three and a half years. It is the first coordinated
muscular activity of the infant.
Finger sucking and tongue thrusting habits are normal
when the child is one and a half year of age and will disappear
spontaneously by the second year with proper attention to
Fig. 8.1: A child sucking thumb

nursing. If it continues beyond three years, malocclusion will

result.
Causative Factors
•• Parent’s occupation
•• Working mother
•• Number of siblings
•• Order of birth of the child
•• Social adjustment and stress
•• Feeding practices
•• Age of the child.
Parents Occupation: It relates to the socioeconomic status of
the family. Families living in a high socioeconomic status are
blessed with ample sources of nourishment. Mothers belonging
to low socioeconomic group are unable to provide the infant
with sufficient breast milk.
Working Mother: Sucking habits are commonly observed to
be present in children with working parents. Such children
brought-up in the hands of care taker may have feelings of
insecurity.
Number of Siblings: The development of the habit can be
indirectly related to the number of siblings.
Order of the Birth of Child: It has been noticed that the later
the sibling rank of a child, greater the chance of having an oral
habit.
Social Adjustment and Stress : Digit sucking has also been
proposed as an emotion based behavior related to the difficulty
with the social adjustment or with stress.
Feeding Practices: A negative relation is also seen between
the breastfeeding and the development of dummy or finger
sucking.
Age of the Child:

•• In the neonate: Primitive demands as hunger
•• During the first week of life: Feeding problems
•• During the eruption of the primary molar: As a teething
device
•• Still later: Release of emotional tension.
Phases of Development of Thumb Sucking

Phase I: Normal/subclinically significant sucking—seen during
first three years of life is considered normal during this phase.
Phase II: Clinically significant sucking—seen during three
to six and half year of age indicates that child is under great
anxiety.
Phase III: Intractable sucking—any thumb sucking that
persists beyond fourth or fifth year of life.
Diagnosis of Digit Sucking

History: It determines the psychological components
involved—questions regarding the frequency, intensity and
duration of habit.
Enquire the feeding patterns, and parental care of the child.
Presence of other habits should be evaluated.
Extraoral Examination
Various key areas to be noted include the following:
The Digit
The digits that are involved in habit will appear reddened,
clean, chapped, short finger nail and with callus formation on
the thumb (Fig. 8.2).
Fig. 8.2: Callus formation on the thumb as a result of sucking habit
The Lip
Chronic thumb suckers are having short, hypotonic upper lip.
Upper lip is passive or incompetent during sucking and
lower lip is hyperactive and this leads to a further increase
in the proclination of the upper anteriors due to its thrust on
these teeth.
Facial form analysis: Check for the mandibular retrusion,
maxillary protrusion, high mandibular plane angle and profile.
Other Features: Active thumb sucker also has higher incidence
of middle ear infections.
Intraoral Examination
Tongue: Examine the oral cavity for size and position of tongue
at rest and tongue action during swallowing.
Dentoalveolar Structure
Individuals with severe finger or thumb sucking habit, where
the digit is applied as anterior superior vector to the upper
dentition and palate, will have flared and proclined maxillary
anteriors with diastemas and retroclined mandibular anteriors
(Fig. 8.3).
Other symptoms are constriction of buccal musculature and
tendency to narrow palates.
Gingiva: Look for the evidence of mouth breathing and
decayed or excessive staining on labial surface of upper central
and lateral incisors.
Effects of Non-nutritive Thumb Sucking

Effects of non-nutritive thumb sucking habits on developing
teeth are minor in infants or children under age three.
Fig. 8.3: Forces acting on the teeth while thumb sucking

Factors Addecting Effects (Fig. 8.4)

•• Intensity is the amount of force that is applied to the teeth
during sucking
•• Duration is defined as the amount of time spent sucking a
digit
•• Frequency is the number of times the habit is practiced
throughout the day.
Features
•• Increased overjet due to proclined maxillary anterior teeth
(Fig. 8.5)
•• Lingual tipping of mandibular anterior teeth
•• Supraeruption of buccal teeth
•• Posterior crossbite due to overactivity of buccinator
compressing the maxilla
•• Narrow and high palatal vault
•• Hypotonic upper lip with the lower part of the face exhibiting
hyperactive mentalis activity
There is a significant association between the prevalence
of class II malocclusion and persisting digit sucking in the
different age groups.
As the duration of the habit increases, the probability of a
child’s developing a class II malocclusion increases.
Fig. 8.4: Factors affecting effects of thumb sucking

Fig. 8.5: Proclination of the upper anterior teeth and anterior

open bite
Emotional difficulties: Some preschoolers who suck their

thumbs may feel ashamed if they are teased by other children.
Parents can cause low self-esteem by ridiculing or punishing
their child for this behavior.
Speech problems: The most common speech problems that
develop because of thumb sucking include mispronouncing
Ts and Ds, lisping, and thrusting out the tongue when talking.
Control of Thumb Sucking

Prevention
•• Motive-based approach: Its prevention should be directed
toward the motive behind the habit.
•• Child’s engagement in various activities: Parents can
be consulted on keeping the child engaged in various
activities.
•• Parent’s involvement in prevention: When the parents are at

home, they should be advised to spend ample time with the
child so as to put away his feelings of insecurity.
•• Duration of breastfeeding: Duration of feeding should be
adequate.
•• Mother’s presence and attention during bottle feeding: It will
promote close emotional union between the mother and
the baby.
•• Use of psychological nipple: Size and number of hole
should be standardized to regulate a slow and steady
flow of milk.
•• Use of dummy or pacifier: Thumb sucking can be prevented
by encouraging the baby to suck a dummy instead.
Treatment Considerations
•• Psychological status of the child: Frequency, duration and
intensity of oral habit are important in evaluating the
psychological status of the child.
•• Age factor: The child having thumb sucking habit at:
–– 3 Years of age:
-- Effect : Damage incurred such as open bite. No
treatment provided in this age group.
–– 4 to 5 years of age:
-- Effect: Self-correction can be expected.
–– 6 years of age:
-- Effect: It will not self correct.
•• Motivation of the child to stop the habit: It is also important
to assess the maturity of child in response to new situation
and to observe the child’s reaction to any suggestion.
•• Parental concern regarding the habit: Negative reinforcements
in the form of threats, nagging and ridicule would only
entrench the habit.
•• Other factors: Self correction again depends on severity of
malocclusion, anatomic variation in the perioral soft tissue,
and presence of other oral habits such as tongue thrusting,

mouth breathing, and lip biting habits.
Management
Psychological Approach
The parents should be consulted to provide the child with
adequate love and affection. They should be advised to divert
the child’s attention to the other things such as play and toys.
•• Dunlop’s beta hypothesis: This hypothesis is the best way to
break a habit.
Child should be asked to sit in front of a mirror and to suck
his thumb, observing himself as he indulges in the habit.
Reminder Therapy
a. Extraoral approaches: It employs hot tasting, bitter flavored
preparations which are distasteful agents that are applied to
thumb, for example, cayenne pepper, quinine or asafoetida.
This is effective only when the habit is not formally
entrenched.
•• Thermoplastic Thumb Post
A thumb device is usually made of nontoxic plastic and is
worn over the child’s thumb (Fig. 8.6).
It is held in place with straps that go around the wrist.
A thumb device prevents a child from being able to suck his
or her thumb and is worn all day.
It is removed after the child has gone 24 hours without
trying to suck a thumb. The device is put back if the child
starts to suck his or her thumb again. Thumb devices need
to be fitted by a health professional.
b. Intraoral approaches:
–– Removable appliances: These are palatal crib, rakes,
palatal arch, lingual spurs, Hawley’s retainer with or
without spur (Fig. 8.7).
Fig. 8.6: Thermoplastic thumb post
Fig. 8.7: Habit crib appliance

–– Fixed appliances: Upper palatal tongue screens appear

to be more effective in breaking these habits.
Mechanotherapy
•• Fixed Intraoral Antithumb Sucking Appliances: Bands fitted
to the primary second molar or first permanent molar. A
lingual arch forms the base of the appliances to which are
added interlacing wires in the anterior portion in the area
of the anterior part of hard palate. This prevents the patient
from putting the palmer surface of the thumb in contact
with palatal gingiva.
Quad Helix (Fig. 8.8)

It prevents the thumb from being inserted and also corrects
malocclusion by expanding the arch.
Fig. 8.8: Quad helix

PACIFIER HABITS
Dental changes created by pacifier habits are largely similar
to changes created by thumb habits, and no clear consensus
indicates a therapeutic difference. Anterior open bite and
maxillary constriction occur consistently in children who suck
pacifiers. Pacifier habits appear to end earlier than digit habits.
TONGUE THRUST HABIT

Definitions
Tongue thrusting is defined as a condition in which the tongue
makes contact with any teeth anterior to the molars during
swallowing.
A tongue thrust is said to be present if the tongue is observed
thrusting between and the teeth do not close in centric
occlusion during deglutition.
— Brauer (1965)
Tongue thrust is the forward movement of the tongue tip
between the teeth to meet the lower lip during deglutition and
in sounds of speech, so that the tongue becomes interdental.
— Tulley (1969)
Tongue thrust is an oral habit pattern related to the
persistence of an infantile swallow pattern during childhood
and adolescence and thereby produces an open bite and
protrusion of the anterior tooth segments.
— Barber (1975)
Tongue thrust is the forward placement of the tongue between
the anterior teeth and against the lower lip during swallowing.
— Schneider (1982)
Etiology of Tongue Thrust
•• Retained infantile swallow
•• Upper respiratory tract infection
•• Mouth breathing
•• Chronic tonsillitis
•• Neurological disturbances
–– Hyposensitive palate
–– Moderate motor disability
–– Disruption of sensory control
•• Due to transient change in anatomy
–– Tongue can protrude when the incisors are missing
•• Bottle feeding
•• Thumb and finger sucking
•• Hypertonic orbicularis oris
•• Macroglossia.
Clinical Manifestations of Tongue Thrust

•• Clinical manifestations depend on:
–– Intensity
–– Duration
–– Frequency and
–– Type of tongue thrust.
Extraoral Findings
•• Lip separation
•• More erratic mandibular movements
•• Speech disorders such as:
–– Sibilant distortions
–– Lisping distortions
–– Problem in articulation of s/n/t/d/l/th/z/v sounds
–– Increase in anterior face height.
Intraoral Findings
•• Jerky and irregular tongue movements
•• Lowered tongue tip because of :
–– Anterior open bite
–– Longer period of time required for tongue tip elevation
•• Malocclusion:
–– Proclination of maxillary anterior results in increased
overjet
–– Generalized spacing between teeth
–– Retroclination or proclination of mandibular teeth
–– Anterior and posterior open bite (depends on posture
of tongue)
–– Posterior teeth crossbite.
Diagnosis of Tongue Thrust

Take History
–– Ask about swallow pattern of siblings and parents to
check for etiologic factor
–– Get information about upper respiratory tract infection,
sucking habits and neuromuscular problems.
Examine
–– Detect perverted swallowing habit and correct it to
facilitate normal development of the palate and dentitions
–– Study the tongue posture
–– Observe tongue movements during swallow.
Treatment Considerations in Tongue Thrust

•• Age: Tongue thrust often corrects itself by 8 or 9 years of
age. Self-correction is due to improved musculature balance
during swallowing.
•• Presence/absence of associated manifestation: Treatment
is not recommended when tongue thrust is present without
malocclusion or a speech problem.
•• Tongue thrust with malocclusion and without speech
defect:
Orthodontic treatment may be carried out.
•• Speech defect with tongue thrust:

–– Speech therapy is indicated
–– Surgery may be done to reduce the size of pharyngeal
lymphoid masses.
•• Treatment of associated habit first: If an associated habit
like thumb sucking is present, it must be treated first.
Treatment of Tongue Thrust

I. Training the tongue for correct swallow and posture:
•• Myofunctional exercise:
–– The child is asked to place the tip of the tongue in the
rugae area for 5 minutes.
–– Orthodontic elastic and sugarless fruit drop exercise.
–– 4s exercise includes:
-- Identifying the spot
-- Salivating
-- Squeezing the spot
-- Swallowing.
–– Ask the child to perform a series of exercises like:
-- Whistling
-- Reciting the count from 60 to 69
-- Gargling or yawning, to tone the respective muscles.
•• Use of appliances to correct position of tongue:
–– Preorthodontic trainer for myofunctional training
(Figs 8.9A and B).
-- Nance palatal arch appliance.
II. Speech therapy:
•• Not indicated before the age of 8 years.
III. Mechanotherapy: Fixed (Fig. 8.10) and removable

appliances can be fabricated to restrain the anterior tongue
movements during swallowing.
•• Force the tongue downward and backward during swallowing
•• Re-educate tongue position.
Figs 8.9A and B: Preorthodontic trainer
Removable Appliance Therapy

•• For posterior open bite, modified habit crib is used.
•• Oral screen
–– Modified acrylic plate
–– Used to control muscle forces both inside and outside
the dental arches
–– Reduces development of malocclusion.
Fig. 8.10: Habit breaking appliance
IV. Correction of Malocclusion

V. Surgical Treatment
•• For retained infantile swallow tongue thrust
•• For reduction of lymphoid tissue size which improves
abnormality to tongue thrust.
MOUTH BREATHING HABIT

Definition
Sassouni (1971): Defined mouth breathing as habitual
respiration through the mouth instead of the nose.
Merle (1980): Suggested the term oronasal breathing instead
of mouth breathing.
Etiology
•• Nasal Obstruction: Nasal obstruction may be due to:
–– Enlarged turbinates
–– Deviated nasal septum
–– Allergic rhinitis
–– Nasal polyps
–– Enlarged adenoids
–– Chronic inflammation of nasal mucosa.
•• Abnormally short upper lip preventing proper lip seal
•• Obstruction in the bronchial tree or larynx
•• Obstructive sleep apnea syndrome
•• Genetically predisposed individuals: Ectomorphic children
having a genetic type of tapering face and nasopharynx are
prone to nasal obstruction.
•• Thumb sucking or other oral habits can be the instigating
agent.
Clinical Features
•• General effects:
–– Pigeon chest
–– Low grade esophagitis
–– Blood gas constituents.
•• Effects on dentofacial structures:
–– Facial form:
-- A large face height
-- Increased mandibular plane angle
-- Retrognathic mandible and maxilla.
–– Adenoid facies characterized by:
-- Long narrow face
-- Narrow nose and nasal passage
-- Flaccid lips with upper lip being short
-- Dolichocephalic skeletal pattern (Figs 8.11A and B)
-- Nose is tipped superiorly in front
A B
Figs 8.11A and B: Dolichocephalic skeletal pattern
-- Expressionless face
-- V-shaped maxillary arch and high palatal vault.
–– Dental defects:
-- Upper and lower incisors are retroclined
-- Posterior cross bite
-- Anterior open bite
-- Narrow palatal and cranial width
-- Flaring of incisors (Fig. 8.12)
-- Decrease in vertical overlap of anterior teeth.
–– Speech defects:
-- Nasal tone in voice.
–– Lips:
-- Short, thick, incompetent upper lip
-- Voluminous curled over lower lip
-- Gummy smile
-- External nares
-- Slit-like external nares with a narrow nose due to
atrophy of lateral cartilage.
Fig. 8.12: Flaring of incisors
–– Gingiva
-- Inflammed and irritated gingival tissue in the anterior
maxillary arch
-- Classic rolled marginal gingiva and enlarged
interdental papilla
-- Interproximal bone loss and presence of deep pockets.
–– Other Effects
-- Otitis Media
-- Dull sense of smell and loss of taste.
Diagnosis
•• History of patient
•• Clinical examination
•• Mirror test: Double-sided mirror is held between nose and
mouth. Fogging on nasal side indicates nasal breathing
while fogging toward oral side indicates oral breathing
•• Cotton test: A butterfly shaped piece of cotton is placed over

upper lip below nostrils.
If cotton flutters down,it indicates nasal breathing.
•• Water test — Patient is asked to fill his mouth with water and
retain it for a period of time.
While nasal breathers accomplish with ease, mouth
breathers find task difficult.
•• Observation — In nasal breathers, external nares dilate
during inspiration.
•• Cephalometric examination.
•• Rhinomanometry.
Management
Elimination of the Cause
Symptomatic Treatment
Interception of the habit: If the habit continues even after
removal of obstruction, then it should be corrected. Correction
can be done by:
•• Physical exercise
•• Lip exercises
•• Maxillothorax myotherapy
•• Oral screen.
Oral Screen (Fig. 8.13): Most effective way to re-establish
nasal breathing is to prevent air from entering the oral cavity.
Oral screen should be constructed with a material
compatible with the oral tissues.
Reduction in the anterior open bite is obtained after
treatment for 3 to 6 months.
Preorthodontic Trainer
It is used in mouth breathers, tongue thruster and thumb
suckers.
Fig. 8.13: Oral screen
Correction of the Malocclusion

Mechanical appliances
•• Children with class I occlusion and anterior spacing—oral
shield appliance
•• Class II division I dentition without crowding—monobloc
activator can be used
•• Class III malocclusion—chin cap can be used.
BRUXISM
Definition
It is defined as the clenching or grinding of teeth when not
masticating or swallowing (Poselt and Wolff ).
Habitual grinding of teeth when the individual is not
chewing or swallowing (Ramfjord 1966).
Nonfunctional contact of teeth which may include clenching,

and tapping of teeth (Rubina 1986).
Etiology
•• Psychological and emotional stresses
•• Occlusal interference or discrepancy between centric
relation and centric occlusion
•• Genetics
•• Magnesium deficiency
•• Allergies
•• Occupational factors.
Clinical Features
•• Occlusal wear facets
•• Fractures of teeth and restorations
•• Mobility of teeth
•• Tenderness and hypertrophy of masticatory muscles
•• TMJ pain and discomfort.
Diagnosis
•• History and clinical examination are sufficient to diagnose
•• Occlusal prematurities can be diagnosed by use of
articulating papers
•• Electromyographic examination to check for hypertrophy
of masticatory muscles.
Treatment
•• Appropriate psychological counseling
•• Hypnosis, relaxing exercises and massage can help relieve
muscle tension
•• Occlusal adjustments need to be carried out to eliminate
prematurities
•• Night guards can be given which cover the occlusal surfaces

of teeth and prevent interferences and wear
•• Biofeedback: Utilizes positive feedback to enable the patient
to learn tension reduction.
OTHER MINOR HABITS

Lip Biting
Lip biting most often involves the lower lip which is turned
inward and pressure is exerted on the palatal surfaces of
maxillary anteriors.
Features
•• Proclined upper anteriors and retroclined lower anteriors
•• Hypertrophic and redundant lower lip
•• Cracking of lips.
Interception
Lip bumpers can be used that not only keep the lips away
but also improve the axial inclination of anterior teeth due to
unrestrained action of tongue.
Nail Biting
It does not produce any gross malocclusion.
Minor local tooth irregularities such as rotation, wear of
incisal edge and minor crowding can occur.
Nut notch is seen which is wear of teeth in the form of notch.
It is seen due to cracking open of hard nuts using incisal edge
of anteriors.
Self-destructive Oral Habits/Masochistic Habits

Include picking at the gingiva with fingers and finger nails,
chewing the inside of the cheek, lip or tongue.
•• Associated with Lesch-Nyhan and de Lange’s syndromes

•• Diverting the child’s attention each time habit is observed,
can solve the problem
•• Restraints, protective padding and sedation can be used in
mentally retarded children.
ORAL HYGIENE HABITS

•• 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 nonfluoridated tooth pastes
–– Type of brush and how often it is changed
–– Use of other oral hygiene aids.
ADVERSE HABITS
•• It includes:
–– Smoking: Record the type, frequency and duration
–– Alcohol consumption: Record the amount, frequency
and duration
–– Tobacco chewing, arecanut chewing/paan chewing:
Record the type, amount, frequency and duration.
DIET HISTORY
Diet Recording
List the sweets and sugar-sweetened foods and the frequency
with which they are consumed in a typical day.
A 5-days diet diary is recommended.
The diary is kept for 5 consecutive days including a weekend
or holiday, to provide a more representative sample of the food
intake.
Place a checkmark in the frequency column for each item

as long as they are eaten at least 20 minutes apart.
(This time is based on the Stephan’s curve that the pH of the
plaque drops and remains below critical level for an average 20
minutes after introduction of sucrose into the mouth).
DIET-DIARY
Name:
Date:
Instructions
1. Each detail about what you eat or drink in the order in
which it is eaten should be recorded with time.
2. The frequency of eating is an important consideration;
therefore between meal-snacks, candies, gum, etc. should
also be included alongwith meals.
3. The following information is essential:
The amount in household measurements such as 8 oz, 1
serving,1/2 cup,1 teaspoon should be recorded.
The food and method of preparation such as fried chicken,
baked apple, raw carrots, etc should be mentioned.
The addition of sugar, syrup or milk to cereal, beverages
such as 1 bowl of cornflakes with 2 teaspoons of sugar and
½ cup of milk.
4. Example:
Wrong Right
Juice ½ cup tomato juice
Sandwich 1 chicken sandwich
Dessert 1 slice chocolate cake
Coffee 1 cup coffee with milk and 2 teaspoons
sugar
Form Frequency Points

Liquid —×5
Solid and sticky — × 10
Slowly dissolving — × 15
Interpretation of sweet score
5 or less excellent
10 good
15 or more “watch out zone” (diet counselling is
indicated)
Diet Analysis
Sugar
The generic term “sugar” usually means sucrose, the
disaccharide caloric white granular substance that is processed
from sugar cane or beets.
Classification of Sugars
•• According to committee on medical aspects of food policy,
sugars can be classified as:
–– Intrinsic sugars: Sugars which are located within the
cellular structures of food and are unavailable for
metabolism by the oral bacteria.
–– Extrinsic sugars: Sugars which are located outside
the cellular structure of the food and are available for
metabolism by the oral bacteria
-- Milk extrinsic sugars
-- Nonmilk extrinsic sugars (NMES).
Pattern of Sugar Consumption

Sugar first became inexpensive and available on a mass scale in
the United States in the mid 9th century, when tariffs on sugar
imports were lifted.
When food distribution methods in the United States became

more efficient after world war I, sugar consumption increased.
Since then, the rate of sugar consumption has continued to
rise; the taste for sweets seems to be insatiable.
The food industry spends large amount of money each
year on the promotion and advertising of sweetened products
(Nielsen 1998) (Fig. 8.14).
Diet and Dental Caries

Dental caries is accepted as being caused by the ingestion of
fermentable carbohydrates particularly sucrose.
Cariogenic potential of food containing sucrose depends on
many variables such as the ability to:
•• Be retained by the teeth
•• Form acids
Fig. 8.14: Expenditure of money on sweetened products in food

industry per year
•• Dissolve enamel
•• Neutralize or buffer acids
–– The solid and retentive sucrose are more cariogenic than
liquid and nonretentive sugars.
–– The frequency and time of ingestion of foods are also
important. The sucrose containing foods become more
dangerous if, it is eaten more frequently. Food eaten at
meals produces less caries than the same eaten between
meals does.
–– In decreasing order of cariogenicity, the food is grouped as:
-- Adherent, sucrose-containing foods eaten frequently
between meals
-- Adherent, sucrose-containing foods eaten during meals
-- Nonretentive (liquid) sucrose-containing beverages
consumed frequently between meals
-- Nonretentive (liquid) sucrose-containing foods
consumed during meals.
Consensus View on Diet and Caries

(Cannon 1992; Department of Health 1989; Rugg-Gunn 1993;
Sheiham 2001; WHO 1990).
•• The influence of the diet is more important after the teeth have
erupted. The preeruptive effect of diet on caries development
is minimal.
•• NMES are highly cariogenic.
•• Frequency of eating/drinking NMES is important in caries
development. However, frequency of intake and amount
consumed are closely related.
•• Intrinsic sugars, as found in for example, fresh fruits and
vegetables and cooked staple starchy foods such as rice and
potatoes, are of low cariogenicity. Milk extrinsic sugars, for
example milk, are virtually noncariogenic.
•• Alternatives or nonsugar sweeteners (bulk and intense) are

non-cariogenic.
Classification of sweets
•• Liquid
•• Solid and sticky
•• Slowly dissolving category.
Sugar in Liquid Form (Figs 8.15A to C)

•• Cold drinks, soda pop, powdered drink mixes, fruit drinks
•• Sweetened condensed milk, syrup
•• Sweetened sauces like chocolate, butterscotch
•• Chocolate milk, hot chocolate
•• Milk shakes and malts.
A B
Figs 8.15 A to C: Sugar in liquid form

A B
Figs 8.16 A to C: Solid and sticky sugar
Solid and Sticky Sugar (Figs 8.16A to C)

•• Cakes, doughnuts, cookie
•• Candies, chocolates
•• Pastries, puddings, sweet rolls, pies
•• Sugar-containing cereals, sugar coated gums
•• Dry fruits— raisins, dates, apricots
•• Food cooked in sugar
•• Ice cream, jam, jellies
•• Sugar containing chewing gums, caramels.
Slowly Dissolving Sugars (Figs 8.17A and B)

•• Hard candies
•• Mints, lollipops, jelly beans
•• Frosting honey, cough syrups, drops.
A B
Figs 8.17 A and B: Slowly dissolving sugar
Diet Counseling
Educate the Patient about the Role of Sugar in Decay
Process
The plaque that forms in the teeth every day contains bacteria.
This metabolizes the sugar present in the food and forms acids.
SUGAR (in food) + PLAQUE/BACTERIA (germs)
TOOTH + ACIDS = DECAY
•• The grand total of time of exposure to acid is used here
to give the patient a rough idea of the risk that his diet is
imposing on his teeth.
Isolate the Sugar Factor

The patient is aided in identification of these foods, whether
they are healthy or harmful choices. Interviewer and patient
together code the record with different colors like red cross for
harmful choices and time and blue cross for good choice and
meal time. Taking this as a game, child is asked to count the
total number of red Xs which are harmful for teeth.
Next, ask the child which X marked food he can eliminate.

Tell him to reduce number of red Xs when he come next time. It
is not fair to cut down all sugar from the diet. Sugar during meal
time and after proper oral hygiene measures is okay. Substitute
should be acceptable to dentist in terms of cariogenicity as
well as to patient as far as taste and preference is concerned.
List of substitute food should be made by the joint effort of
dentist and patient.
List of Substitutes
•• Peanuts, walnuts, pea cans, almonds, other types of nuts
•• Popcorn, corn chips
•• Whole wheat biscuits
•• Unsweetened dry cereals
•• Cold cuts of meats (unsweetened)
•• Cubes of cheese
•• Fresh fruits, salads
•• Vegetables such as carrot slices, celery sticks, cucumber
slices
•• Baked potatoes
•• Unsweetened fruit juices
•• Freshly squeezed fruit juices
•• Sugarless chewing gum.
Recall Visits
Evaluate patient’s performance at regular intervals by means of:
•• Patient’s comments
•• New diet diary
•• Susceptibility tests like Snyder’s test and
•• Clinical judgment
•• Reinforce patient by praising his efforts.
C H A P T E R 9
Clinical Examination
The history and clinical examination are designed to put

the dentist in a position to make a provisional diagnosis, or
a differential diagnosis. Special investigations or tests may
be required to confirm or refine this diagnosis or elicit other
conditions.
The patient has the right to refuse all or part of the
examination, investigations or treatment. A patient has the
right to give or withhold consent to medical examination or
treatment. Patients are entitled to receive sufficient information
in a way they can understand about the proposed investigations
or treatments, the possible alternatives and any substantial risk
or risks involved.
The ability to perform a thorough clinical examination of
the superficial structures of the head, neck and oral cavity is
essential for all dentists. The examination should be carried
out on all the patients, and every dentist must be trained to
effectively diagnose and evaluate the disease.
General examination may sometimes include the recording
of body weight and the ‘vital signs’ of conscious state,
temperature, pulse, blood pressure and respiration. The
dentist must be prepared to interpret the more common and
significant changes.
To perform the examination, a dentist should have:
•• Adequate knowledge of the anatomy and physiology of the
region
•• A well-practiced technique for examination providing
minimal discomfort to the patient
Clinical Examination 117
• Knowledge of the disease process affecting the head and

•
neck region.
The basic techniques of diagnosis are visual inspection,
palpation, olfaction, auscultation, percussion and aspiration.
• Visual inspection: It is a standardized observation of the
•
anatomical landmarks of the head and neck region to ensure
the completeness and accuracy of the examination. Visual
inspection involves evaluating the bilateral completeness
of the facial structures.
• Palpation: It is used to determine the size, texture,
•
consistency, symmetry, temperature, etc which are sensed
by touch. Palpation may be done by either hand or by both
hands (bimanual palpation). Findings related with the
palpation techniques are confirmed with percussion and
auscultatory techniques.
• Olfaction: Some odors can be associated with conditions
•
of the patient such as smoking habits, poor oral hygiene,
sinusitis, metabolic disorders, gastrointestinal disorders, etc.
• Auscultation: It is the listening to sounds. It is performed
•
by the unaided ear or by the assistance of a stethoscope. A
dentist should evaluate the sounds of crepitus or popping
like in case of TMJ, blood pressure sounds, etc.
• Percussion: It is performed by gentle tapping over the area
•
with fingers or an instrument to determine the relative
consistency of the structure with its surroundings. Patient
may even feel pain while the procedure, providing valuable
information about the area percussed.
• Aspiration: It is the removal of whole or a part of fluid from
•
a body cavity. The area aspirated is usually a soft tissue or a
bony lesion having a fluid-filled cavity. The aspirated fluid
is thus evaluated for its consistency and components.
The examination includes the following parts: General
examination and local examination.
Local examination further includes extraoral examination

and intraoral examination.
General examination includes:
• Gait
•
• Posture
•
• Built
•
• Vital signs
•
– Blood pressure
–
– Pulse
–
– Temperature
–
– Respiration
–
• Pallor
•
• Edema
•
• Cyanosis
•
• Icterus
•
• Body mass index (BMI).
•
Gait
Gait is the pattern of movement of the limbs of animals,
including humans, during locomotion over a solid substrate.
Different gaits are characterized by differences in limb
movement patterns, overall velocity, forces, kinetic and
potential energy cycles, and changes in the contact with the
surface (ground, floor, etc).
Antalgic Gait: Painful gait, a limp is adopted to avoid pain on
weight bearing structures (hip, knee, ankle).
Ataxic Gait: An unsteady, uncoordinated walk, a wide base of
support is seen normally due to cerebellar disease.
Festinating Gait: Short, accelerating steps are used to move
forward, often seen in people with Parkinson’s disease.
Four Point Gait: Utilized by crutch users, first on crutch, then
the opposite leg followed by the other crutch and then the
other leg.
Hemiplegic Gait: It involves flexion of the hip because of

inability to clear the toes from the floor at the ankle and
circumduction at the hip.
Spastic Gait: Walk in which the legs are held close together
and move in a stiff manner often due to central nervous system
injuries.
Posture
In humans, posture can provide important nonverbal
communication. Posture deals with how the body is positioned
in relation to another person or group of persons (for example,
leaning stance posture, standing, sitting, etc) and how they are
positioned relative to other various body parts.
Built
It is how the body looks-like.
There are three extremes of
body types.
Endomorph (Fig. 9.1)

• A pear-shaped body
•
• A rounded head
•
• Wide hips and shoulders
•
• Wider front to back rather
•
than side-to-side
• A lot of fat on the body,
•
upper arms and thighs.
Mesomorph (Fig. 9.2)

• A wedge-shaped body
•
• A cubical head
•
• Wide broad shoulders Fig. 9.1: Endomorph body type
•
•• Muscled arms and legs

•• Narrow hips
•• Narrow from front to back rather than side-to-side
•• A minimum amount of fat.
Ectomorph (Fig. 9.3)

•• A high forehead
•• Receding chin
•• Narrow shoulders and hips
•• A narrow chest and abdomen
•• Thin arms and legs
•• Little muscle and fat.
Fig. 9.2: Mesomorph body Fig. 9.3: Ectomorph

type body type
Vital Signs
The word “vital” means “necessary to life.” This is why certain
key measurements that provide essential information about a
person’s health are referred to as vital signs.
Vital signs includes person’s blood pressure, pulse,
temperature and respiration.
Fifth vital sign: In addition to these standard vital signs,
tobacco use has been suggested as the fifth vital sign since
tobacco use is a factor in many medical conditions, as well as
periodontal disease.
Blood Pressure
Blood pressure is the force exerted by the blood on the blood
vessel walls. This force makes a noise called Korotkoff sounds.
When the left ventricle of the heart contracts, blood is forced
out into the aorta and travels through the large arteries to the
smaller arteries, arterioles, and capillaries.
During the course of the cardiac cycle, blood pressure is
changing constantly.
Ta k i n g p a t i e n t s’ b l o o d p re s s u re d u r i n g d e n t a l
examinations is critical to their overall health. High blood
pressure is a proven risk factor for cardiovascular disease,
heart failure, stroke and renal (kidney) disease. The most
common method to measure blood pressure is by using a
manually operated sphygmomanometer and a stethoscope
(Figs 9.4 and 9.5).
Systolic Pressure: Systolic pressure is the peak or highest
pressure. It is caused when the heart muscle contracts. The
normal systolic pressure is less than 120 mm Hg. In patients
over 50 years of age, a systolic reading higher than 140 mm Hg
is more important as a cardiovascular risk factor than a high
diastolic reading.
Fig. 9.4: The sphygmomanometer. a manual sphygmomanometer

consists of: a cuff—an airtight, flat, inflatable bladder (pouch)
covered by a cloth sheath; a bulb, which is squeezed to fill the cuff
with air; a manometer—a gauge that measures the air pressure
in millimeters
Diastolic Pressure: Diastolic pressure is the lowest pressure.

It measures the pressure in the arteries between heartbeats
(when the heart muscle is resting between beats and refilling
the blood.) The normal diastolic pressure is less than 80 mm Hg.
Pulse Pressure: Pulse pressure is the difference between
the systolic and the diastolic pressures. The normal or safe
difference is less than 45 mm Hg.
Hypertension and Hypotension
1. Blood pressure measurements indicate if a person is
hypertensive (has abnormally high blood pressure) or
hypotensive (has abnormally low blood pressure).
2. High blood pressure—hypertension—is blood pressure
that stays at or above 140/90 mm of Hg.
Fig. 9.5: Parts of a stethoscope—a stethoscope has the following

parts: earpieces, a brace, binaurals, and an amplifying device. the
amplifying device may be two-sided, with a diaphragm on one side
and a bell on the other.
3. Blood pressure increases when larger blood vessels begin to

lose their elasticity and the smaller vessels start to constrict,
causing the heart to try to pump the same volume of blood
through vessels with a smaller internal diameter.
It is used 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 120/80
mm of Hg).
Procedure to record blood pressure with a

sphygmomanometer (Fig. 9.6)
yy Seat the patient

yy Place the sphygmomanometer cuff on the right upper arm, with about
3 cm of skin visible at the antecubital fossa (Fig. 9.7)
yy Palpate the radial pulse
yy Inflate the cuff to about 200–250 mm Hg or until the radial pulse is
no longer palpable
yy Deflate the cuff slowly while listening with the stethoscope over the
brachial artery on the skin of the inside arm below the cuff
yy Record the systolic pressure as the pressure when the first tapping
sounds appear
yy Deflate the cuff further until the tapping sounds become muffled
(diastolic pressure)
yy Repeat
yy Record the blood pressure as systolic/diastolic pressures (normal
values about 120/80 mm Hg, but these increase with age)
Fig. 9.6: Procedure to record blood pressure with a

sphygmomanometer
Fig. 9.7: Correct arm position for blood pressure assessment.

The patients arm supported passively with antecubital fossa at
midsternum level
Automatic Blood Pressure Equipment

Automatic blood pressure equipment—also called digital or
electronic blood pressure equipment—ranges from the highly
calibrated types used in hospital settings to less advanced
equipment designed for home use (Fig. 9.8).
Electronic Battery-Powered Devices: The most common
types of automatic blood pressure equipment found in the
dental setting are electronic battery-powered devices.
•• These devices use a microphone instead of a stethoscope to
detect the blood pulsing in the artery.
•• The cuff connects to an electronic monitor that automatically
inflates and deflates the cuff when the start button is
pressed. There are two types of cuffs—arm and wrist cuffs.
Fig. 9.8: Automatic blood pressure device. (Courtesy: Omron

healthcare, www.omronhealthcare.com)
•• A monitor displays the blood pressure and pulse reading as

a digital display. The main source of error with automatic
devices is that the cuff has not been positioned at the level
of the heart when the reading is taken.
An abnormally high or low reading obtained with
an automatic device should be verified by retaking the
blood pressure in a few minutes using a traditional
sphygmomanometer and a stethoscope.
Blood pressure measurements are recorded as a fraction
with the systolic reading as the top number and the diastolic
reading as the lower number in the fraction. A typical blood
pressure reading for an adult might be 120/80 mm Hg.
Systolic
BP =
Diastolic
Pulse: When examining the pulse, look for the rate, the rhythm
and the character/volume. The rate of the pulse is the number
of beats per minute. The rhythm is whether the pulse is regular
or irregular. Sometimes an irregular pulse is caused by a heart
block, atrial fibrillation or an extra or additional beat called
an ectopic.
The pulse can be measured automatically or manually (Figs
9.9 and 9.10). The pulse can be recorded from any artery, but
in particular from the following sites: The most commonly
used pulse point is over the radial artery in the wrist.
•• The radial artery, on the thumb side of the flexor surface of
the wrist (Fig. 9.11)
Fig. 9.9: Automatic pulse meter

Fig. 9.10: Measuring pulse manually
The brachial artery is the main artery of the upper arm; it

divides into the radial and ulnar arteries at the elbow. The
brachial artery is used when taking blood pressure.
The radial artery is a branch of the brachial artery beginning
below the elbow and extending down the forearm on the
thumb-side of the wrist and into the hand (Fig. 9.10).
•• The carotid artery, just anterior to the mid-third of the
sternomastoid muscle.
•• The superficial temporal artery, just in front of the ear.
Using the finger pads of the first two or three fingers, the
radial pulse point is located on the thumb side of the patient’s
wrist. Only enough pressure is applied so that the radial artery
can be distinctly felt. Moderate pressure facilitates palpation
of the beats. The pulse is imperceptible with too little pressure,
whereas, too much pressure obscures the pulse.
Fig. 9.11: Anatomy of the brachial and radial arteries of the arm
The thumb is never used to assess the pulse. The thumb has
a pulse; this pulse could be confused with the patient’s pulse.
Sufficient time is needed to assess the rate and characteristics
of the pulse.
Pulse rates at rest in healthy person are approximately as
follows:
•• Infants, 140 beats/minute
•• Adults, 60–80 beats/minute.

It is an important index of severity of the vascular system
and heart abnormalities.
It is useful to record:
•• Rate: Fast or slow (normal rate is 60–100/minute)
•• Rhythm: Regular or irregular
•• Volume: High, normal or low pulse pressure (normal pulse
pressure is 40–60 mm Hg)
•• Tension and force
•• Character: Some vascular diseases may show different
pulse character such as ‘water hammer’ pulse in aortic
regurgitation, ‘pulsus paradoxicus’ in pericardial effusion,
etc.
Pulse rate is increased in:
yy Exercise
yy Anxiety or fear
yy Fever (pyrexia)
yy Some cardiac disorders
yy Hyperthyroidism and other disorders
Body Temperature
The temperature is traditionally taken with a glass thermometer,
but temperature-sensitive strips and sensors and digital
thermometers are available.
Glass thermometers (Fig. 9.12) are cheaper means for
obtaining an accurate oral temperature. Earlier, most glass
thermometers were filled with mercury. Although mercury
Fig. 9.12: Diagram of a glass thermometer filled with mercury

thermometers are not harmful when used properly, they pose

a health threat when broken or disposed of as trash.
Automatic temperature equipment—also called digital
temperature equipment (Fig. 9.13) —ranges from the highly
calibrated types used in hospital settings to less advanced
equipment designed for home use.
The normal core body temperature of a healthy, resting adult
human being is stated to be at 98.6 degrees Fahrenheit or 37.0
degrees Celsius. The normal body temperatures are: oral 36.6°C;
rectal or ear (tympanic membrane) 37.4°C; and axillary 36.5°C.
Body temperature is usually slightly higher in the evenings. In
most adults, an oral temperature above 37.8°C or a rectal or ear
temperature above 38.3°C is considered a fever. A child has a
fever when ear temperature is 38°C or higher.
Temperatures in excess of 101°F (38.3°C) usually indicate
the presence of an active disease process. In most cases,
dental treatment is contraindicated for a patient with an
elevated temperature. The patient should be referred to his
or her primary care physician for evaluation. If an elevated
temperature is due to a dental infection, immediate dental
treatment and antibiotic therapy may be indicated.
Figs 9.13A and B: (A) Digital Thermometer (B) Mercury Thermometer

Variables Affecting Body Temperature
yy Time of Day—temperature varies throughout the day, usually being

lowest in the early morning and rising by 0.5° to 1.0°F (0.3° to 0.6°C)
in the early evening
yy Exercise—temperature may rise by 1°F (0.6°C) or more after strenuous
physical exertion on a hot day
yy Age—the average normal oral temperature for persons over 70 years
of age is 96.8°F (36.0°C)
yy Environment—a cold or hot environment can alter temperature
yy Stress—a stressful situation can cause body temperature to rise
yy Hormones—a woman’s body temperature typically varies by 1°F
(0.6°C) or more throughout her menstrual cycle
yy Hot Liquids—increase oral temperature for approximately 15 minutes
yy Cold Liquids—decrease oral temperature for approximately 15
minutes
yy Smoking—increases oral temperature for approximately 30 minutes
yy Tachypnea (rapid breathing)—decreases oral temperature
yy Infection or Inflammation—increases body temperature
Respiration
A respiratory rate, or breathing rate, is the number of breaths
a person takes in 1 minute while at rest. Respiratory rate can
be measured by counting the number of times a person’s chest
rises and falls within a minute.
Asking the patient to “breathe normally” almost certainly
will cause that person to begin to breathe more slowly
or rapidly. For this reason, the respiratory rate should be
measured immediately after taking a pulse. Counting the
respirations while appearing to count the pulse helps to keep
the patient from becoming conscious of his or her breathing
and possibly altering the usual rate.
The normal respiratory rate for babies from birth to 6 months
is 30 to 60 breaths per minute; after the age of 6 months,
breathing slows down to 24 to 30 breaths per minute. For
Types of Respiration
Normal
The respiratory rate is about 14–20 per minute in adults
Rapid Shallow Breathing
(Tachypnea)
The respiratory rate is greater than 20 per minute; causes include
restrictive lung disease and inflammation of the lungs
Rapid Deep Breathing
(Hyperpnea, Hyperventilation)
Breathing with increased rate and depth; causes include exercise, anxiety,
and metabolic acidosis
Slow Breathing
(Bradypnea)
Breathing with decreased rate and depth; one common cause is diabetic
coma
Obstructive Breathing
The expiration is prolonged because of narrowed airways; causes include
asthma, chronic bronchitis, and chronic obstructive pulmonary disease
(COPD)
children of the age of 1 to 5 years, normal respiration is 20 to

30 breaths per minute. Children who are of 6 to 12 years of age
should have a normal respiratory rate that ranges from 12 to
20 breaths per minute. The normal respiratory rate for adults
and children over the age of 12 ranges from 14 to 18 breaths
per minute.
Pulse and respiration are affected by many factors (Table 9.1).
Table 9.1: Factors affecting pulse and respiration

Factors affecting pulse and respiration
yy Age yy Altitude
yy Medications yy Gender
yy Stress yy Body position
yy Exercise yy Fever
Pallor
Pallor is a reduced amount of oxyhemoglobin in skin or mucous
membrane, a pale color which can be caused by illness,
emotional shock or stress, stimulant use, lack of exposure to
sunlight, anemia or genetics.
Pallor is more evident on the face and palms. It can develop
suddenly or gradually, depending on the cause. It is not usually
clinically significant unless it is accompanied by a general
pallor (pale lips, tongue, palms, mouth and other regions
with mucous membranes). It is distinguished from similar
symptoms such as hypopigmentation. Clinically, the most
accessible site for detecting pallor is the conjunctiva.
Possible causes:
•• Migraine attack or headache
•• Natural genetics
•• Excess estradiol and/or estrone
•• Vitamin D deficiency
•• Weight gain
•• Osteoporosis
•• Emotional response, due to fear, embarrassment, grief
•• Anemia, due to blood loss, poor nutrition, or underlying
disease such as sickle cell anemia
•• Shock, a medical emergency caused by illness or injury
•• Frostbite
•• Cancer
•• Hypoglycemia
•• Leukemia
•• Albinism
•• Panic attack
•• Heart disease
•• Peripheral vascular disease
•• Hypothyroidism
•• Hypopituitarism
•• Scurvy
•• Tuberculosis
•• Sleep deprivation
•• Depression
•• Pheochromocytoma
•• Squeamishness
•• Visceral larva migrans
•• High doses or chronic use of amphetamines
•• Reaction to ethanol and/or other drugs such as cannabis
•• Lead poisoning.
Edema
It is an abnormal accumulation of fluid beneath the skin or
in one or more cavities of the body. Generally, the amount
of interstitial fluid is determined by the balance of fluid
homeostasis, and increased secretion of fluid into the
interstitium or impaired removal of this fluid may cause
edema.
Cutaneous edema is referred to as “pitting” when, after
pressure is applied to a small area, the indentation persists for
sometime after the release of the pressure. Peripheral pitting
edema is the more common type that results from water
retention. It can be caused by systemic diseases, pregnancy
in some women, either directly or as a result of heart failure,
or local conditions such as varicose veins, thrombophlebitis,
insect bites, and dermatitis.
Nonpitting edema is observed when the indentation does
not persist. It is associated with conditions as lymphedema,
lipoedema and myxedema.
Cyanosis
Cyanosis is a physical sign causing bluish discoloration of the
skin and mucous membranes. Cyanosis is caused by a lack of
oxygen in the blood. It is due to the presence of greater than,

or equal to 2.5 g/dL of deoxygenated hemoglobin in blood
vessels near the skin surface. It can be detected by looking at
nails, tongue, lips, cheek, etc.
Icterus
It is defined as a yellow discoloration of mucous membranes
and skin due to high concentrations of bilirubin in blood and
tissues. It is seen in the condition of jaundice.
Jaundice is often seen in liver diseases such as hepatitis and
liver cancer. Clinically, the most accessible site for detecting
icterus is sclera.
Body Mass Index

Body Mass Index (BMI) is a number calculated from a person’s
weight and height. BMI provides a reliable indicator of body
fatness for most people and is used to screen for weight
categories that may lead to health problems.
Calculation of BMI: BMI is calculated the same way for both
adults and children. The calculation is based on the following
formula:
= Weight (in kg)/[Height (in m)]2
With the metric system, the formula for BMI is weight in
kilograms divided by height in meter square.
Table 9.1: Interpretation of BMI

BMI Weight Status
yy Below 18.5 Underweight
yy 18.5–24.9 Normal
yy 25.0–29.9 Overweight
yy 30.0 and Above Obese
C H A P T E R 10
It includes the examination of skin, head, face, nose, paranasal

sinuses, nasal mucosa, external ear, lips, cheeks, lymph nodes,
TMJ, muscles of mastication and salivary glands.
SKIN
Note the general appearance of the individual and the changes
in appearance or any rashes, sores or ulcerations. If present,
is questioned.
Also note for the change in color of the skin as it signifies
anemia and jaundice. Generalized pallor is seen in severe
anemia. Yellowness of skin is seen in carotenemia. Pallor is
seen in hypopituitarism, shock, syncope and left heart failure.
Check out for texture of the skin. Skin becomes dry and
inelastic in dehydration and becomes greasy in acromegaly.
Skin gets atrophied with age and with steroid medications.
Also note for the abnormal signs such as petechial
hemorrhages (e.g. in blood dyscrasias), any eruptions,
erosions, pigmentations (e.g. in Addison’s disease, in Von
Recklinghausen’s disease) or any swelling or edema, if present.
The positive findings denote a specific sign of characteristic
abnormality which is to be questioned.
Drug history is of prime importance with respect to
skin lesions as many of the drugs can cause skin lesions
and eruptions which range from a small patch or vesicle to
widespread involvement of the skin in various morphological
forms.
HEAD
Patient should be evaluated for head region in terms of its
appearance, its circumference, etc.
(Hydrocephalus is suspected when the growth of the head
is abnormal as compared to age and sex of the patient).
Shape of the Head

The shape of the head can be evaluated based on the cephalic
index of the head which was formulated by Martin and Saller
(1957) as (Table 10.1):
Maximum skull width
Cephalic index:
Maximum skull length
Table 10.1: Types of head shapes (Figs 10.1A to C)

Type Description Cephalic index
value
Mesocephalic Average shape of the head. 76.0–80.9
They possess normal dental
arches
Dolicocephalic Long and narrow head. They Less than 75.9
have narrow dental arches
Brachycephalic Broad and short head. They 81.0–85.4
have broad dental arches
Hyperbrachy Extremely wider head More than 85.5
cephalic
FACE
Careful observation and examination of the face should be
done as many of the systemic diseases like hypothyroidism,
thyrotoxicosis, acromegaly, leprosy, Cushing’s syndrome,
Extraoral Examination 139
A B C
Figs 10.1A to C: (A) Meso-cephalic; (B) Dolico-cephalic;

(C) Brachycephalic
Paget’s disease, scleroderma and Bells palsy can manifest with

charactestic ‘facies’ which can be easily identified.
Shape of the Face

A more scientific classification is to classify face into the
following three types by the morphologic “facial index” (FI)
which was given by Martin and Saller (1957) as (Table 10.2):
Morphologic facial height
FI:
Bizygomatic width
Facial Symmetry
Diagnosis of the symmetry of patient’s face is important so
as to determine the disproportions of face in transverse and
vertical planes. No face is ideally symmetrical on both the
sides. Some degree of asymmetry is always considered normal.
Asymmetries that are gross and identifiable should be
noted and recorded. Gross facial abnormalities can occur as
a result of:
•• Congenital defects
•• Hemifacial hypertrophy/hypotrophy
Table 10.2: Shapes of face
Facial form Description Index Shape of the

value arch
Mesoprosopic Average or 84.0–87.9 Normal
normal face form U-shaped
archs
Leptoprosopic Long and narrow 88.0–92.9 Narrow apical
face form basal arches
Hyperleptoprosopic Extremely long Greater
face than 93.0
Europrosopic Face is broad 79.0–83 Broad square
and short arches
Hypereuroprosopic Short with low Less than
facial index 78.9
•• Unilateral condylar ankylosis/hyperplasia

•• Chronic abscesses/presence of a large cyst/space infections
(facial swellings)
•• Facial fractures, etc.
Facial Profile
Profile of the patient is determined by visualizing the patient
from the side. Profile assessment helps in diagnosing gross
deviations in the maxillomandibular relationship.
Three types of facial profiles have been classified:
1. Straight profile: An imaginary line is drawn from the
forehead to the upper lip and another line from the upper
lip to the anterior point of chin. Both these lines when
joined form a nearly straight line (Fig. 10.2A).
2. Convex profile: The two imaginary lines form an angle
with the concavity facing the tissue. This type of profile is
seen in a prognathic maxilla or a retrognathic mandible
(Fig. 10.2B).
A B C
Fig. 10.2: Facial profiles (A) Straight; (B) Convex; (C) Concave
3. Concave profile: The two imaginary lines form an angle

with the convexity toward the tissue. This type of profile is
associated with a prognathic mandible or a retrognathic
maxilla (Fig. 10.2C).
Facial Form (Fig. 10.3)

Facial form is classified according to Leon William’s
classification, 1912 into 3 main types:
1. Ovoid
2. Square
3. Tapered
Other types include:
4. Round
5. Triangular.
Facial Divergence
Facial divergence is the anterior or posterior inclination of
lower face with respect to forehead. It can be assessed by
drawing a line between the forehead and chin and checking
for its inclination.
•• Anterior divergent: A line drawn between forehead and
chin is inclined anteriorly toward chin (Fig.10.4A).
Fig. 10.3: Facial Forms
A B C
Figs 10.4A to C: Facial divergences (A) Anterior divergent

(B) Posterior divergent (C) Straight
•• Posterior divergent: A line drawn between forehead and

chin slants posteriorly toward chin (Fig. 10.4B).
•• Straight: A line drawn between forehead and chin is straight
or perpendicular to floor (Fig. 10.4C).
NOSE, PARANASAL SINUSES, NASAL MUCOSA

AND EXTERNAL EAR
The nasal area should be examined for any sinus pain,
discharge, obstruction, continuous sneezing, periorbital
swelling or inflammation.
Some of the common examples are:
•• An apical abscess of upper tooth may lead to acute sinusitis.
•• Nasal obstruction may lead to mouth breathing habit.
•• Epistaxis (nasal bleeding) is seen in severe conditions like
cerebral hemorrhage.
•• An ear examination is a thorough evaluation of the ears that
is done to screen for ear problems, such as hearing loss, ear
pain, discharge, lumps, or objects in the ear.
•• When examining an ear, it is usually preferable to begin with
the skin around, behind and adjacent to the pinna (mobile
part of external ear also known as auricle). The pinna should
be examined thoroughly, including the top and rear and the
entrance to the ear canal.
•• Examine for any deformity or skin changes and look for
scars or pits in front of, or behind ear. Hearing aids should
be noted then removed. Tug the pinna gently for any
tenderness.
LIPS
The examination begins by examining the lips and the mucosa
inside the lips called the labial mucosa. The labial mucosa
is examined by gently turning the lip out. The labial mucosa
should appear wet and shiny. Scars inside the lower lip are
seen frequently as a result of trauma in a child.
Note the lip color, texture, and any surface abnormalities
as well as angular or vertical fissures, sores, ulcers, nodules,
plaques, scars and swellings. Notice the vermillion border and
the presence of Fordyce’s granules.
Lip posture may be defined as the characteristic way in

which an individual maintains his normal lip position in
repose, i.e. with normal muscular tone and without excessive
muscular contraction. The orolabial soft tissue posture is
characteristic of each individual and under normal conditions,
each individual will achieve a lip seal in the rest position. If a
lip seal does not occur, adaptive postures are used with almost
continual contraction of the circumoral musculature in order
to maintain an adequate lip seal.
Lip Competency/Posture
•• Competent lips: It implies that the lips are able to contact one
another without strain when the mandible is in rest position.
•• Incompetent lips: It implies that the lips are unable to form
an adequate seal under similar unstrained conditions, i.e.
excessive separation of the lips at rest.
•• Potentially competent or pseudo-incompetent: These
are used to describe lip posture when the maxillary incisors
are interposed between the upper and lower lips and the
correction of the incisor relationship will permit normal
lip posture.
•• Everted lips: Lips are often full and everted. This type of
lip morphology is commonly associated with proclination
of both the upper and lower labial segments (bimaxillary
proclination).
Lip Habits
Habits that involve manipulation of the lip and perioral
structures are termed as lip habits. This may include from
wetting of the lips with the tongue and pulling of lips into the
mouth between the teeth. This habit usually involves lower
lip and can cause upper incisors to tip labially and the lower
incisors to collapse lingually with the lower lip wedged between
the upper and lower anterior teeth. This may cause dryness and
inflammation of lip and in severe cases will cause vermillion

hypertrophy and in some case chronic sores.
CHEEKS
Note any changes in pigmentation and linea alba, any
hyperkeratotic or any hyperpigmented patch, swellings,
nodules, scars or ulcers.
LYMPH NODES (FIG. 10.5)

Examination of neck lymph nodes is important, particularly
in head and neck malignancies and a systematic approach
should be followed. Neck lymph nodes are better palpated
Fig. 10.5: Lymph nodes of head and neck

while standing at the back of the patient. Neck is slightly flexed

to achieve relaxation of muscles.
When a node or nodes are palpable, look for the following
points:
•• Location of nodes
•• Number of nodes
•• Size—abnormal nodes
–– Greater than 1.5 cm in jugulo-digastric area (level I, II, III)
–– Greater than 1cm elsewhere
•• Consistency—metastatic nodes are hard; lymphoma nodes
are firm and rubbery; hyperplastic nodes are soft. Nodes of
metastatic melanoma are also soft
•• Discrete or matted nodes
•• Tenderness—inflamed nodes are tender
•• Fixity to overlying skin or deeper structures. Mobility should
be checked both in the vertical and horizontal planes
(Fig. 10.6).
Fig. 10.6: Examination of the neck nodes

Classification of Lymph Nodes

The lymph nodes of head and neck region are classified
according to their position level:
Level I includes
•• IA submental nodes, which lie in the submental triangle, i.e.
between right and left anterior bellies of diagastric muscles
and the hyoid bone.
•• IB submandibular nodes, lying between anterior and posterior
bellies of diagastric muscle and the body of mandible.
Level II: Upper Jugular Nodes

•• They are located along the upper third of jugular vein, i.e.
between the skull base above, and the level of hyoid bone
(or bifurcation of carotid artery) below.
Level III: Middle Jugular Nodes

•• They are located along the middle third of jugular vein, from
the level of hyoid bone above, to the level of upper border
of cricoid cartilage.
Level IV: Lower Jugular Nodes

•• They are located along the lower third of jugular vein; from
upper border of cricoid cartilage to the clavicle.
Level V: Posterior Cervical Group

•• They are located in the posterior triangle, i.e. between
posterior border of sternocleidomastoid (anteriorly),
anterior border of trapezius (posteriorly), and the clavicle
below. They include lymph nodes of spinal accessary chain,
transverse cervical nodes and supraclavicular nodes.
Level VI: Anterior Compartment Nodes

•• They are located between the medial borders of sterno
cleidomastoid muscles (or carotid sheaths) on each side,
hyoid bone above and suprasternal notch below. They
include prelaryngeal, pretracheal and paratracheal nodes.
Level VII
They are located below the suprasternal notch and include
nodes of the upper mediastinum.
Examination of Various Lymph Nodes

•• Submental Nodes (Fig. 10.7): Roll the fingers below the chin
with patient’s head tilted forward.
•• Submandibular Nodes (Fig. 10.8): Roll fingers against
inner surface of mandible with patient’s head gently tilted
on one side.
Fig. 10.7: Examination of submental nodes

•• Parotid (Preauricular) Nodes (Fig. 10.9): Roll the finger in

front of the ear, against the maxilla.
•• Postauricular (Mastoid Nodes) (Fig. 10.10): Roll the fingers
behind the ear.
•• Internal Jugular Chain (Fig. 10.11):
–– Examine the upper, middle and lower groups.
–– Many of them lie deep to sternomastoid muscle which
may need to be displaced posteriorly.
•• Transverse Cervical Nodes
•• Supraclavicular (Scalene Nodes) (Fig. 10.12):
–– Roll your fingers gently behind the clavicles.
–– Instruct the patient to cough or to bear down like they
are having a bowel movement. Occasionally an enlarged
lymph node may pop up.
–– A normal lymph node cannot be felt. If a node is palpable,
it must be abnormal.
Fig. 10.8: Examination of sub-mandibular nodes

Fig. 10.9: Examination of preauricular nodes
Fig. 10.10: Examination of postauricular nodes

Fig. 10.11: Examination of internal jugular chain
Fig. 10.12: Examination of supraclavicular chain

If a node is palpable, record the:

•• Site
•• Size: Measure using Vernier calipers
•• Texture: Soft (in case of infection), rubbery hard (in case
of Hodgkin’s disease), stony hard (in case of secondary
carcinoma)
•• Tenderness to palpation: In case of infection
•• Fixation to surrounding tissues may suggest metastatic
cancer
•• Coalescence in case of tuberculosis
•• Number of nodes: Multiple in case of glandular fever,
leukemia, etc.
Palpable node characteristics:
•• Acute infection: Large, soft, painful, mobile, discrete, rapid
onset
•• Chronic infection: Large, firm, less tender, mobile
•• Lymphoma: Rubbery hard, matted, painless, multiple
•• Metastatic cancer: Stony hard, fixed to underlying tissues,
painless.
Area of Lymphatic Drainage of Face

The face has three lymphatic territories:
1. The upper territory: Including the greater part of the
forehead, the lateral halves of the eyelids, the conjunctiva,
the lateral part of the cheek and the parotid area, drains
into the preauricular (parotid) nodes.
2. The middle territory: Including a strip over the median part
of the forehead, the external nose, the upper lip, the lateral
part of the lower lip, the medial halves of the eyelids, the
medial part of the cheek and the greater part of the lower
jaw, drains into the submandibular nodes.
3. The lower territory: Including the central part of the lower
lip and chin, drains into the submental nodes.
TEMPOROMANDIBULAR JOINT
Temporomandibular joint (TMJ) is the site of articulation
between the mandible and the skull, specifically the area
about the articular eminence of the temporal bone. This
bilateral joint functions to open and close the jaws and
to approximate the teeth of the opposing arches during
mastication. The articulation consists of parts of the mandible
and temporal bones, which are covered by dense, fibrous
connective tissue and are surrounded by several ligaments
(Fig.10.13).
The TMJ is a ginglymoarthrodial joint, a term that is derived
from ginglymus, meaning a hinge joint, allowing motion only
backward and forward in one plane, and arthrodia, meaning
a joint which permits gliding motion of the surfaces. The right
and left TMJ form a bicondylar articulation and ellipsoid
variety of the synovial joints, similar to knee articulation.
Interposed between the two bones is a fibrous articular
disc, compartmentalizing the joint into two separate
synovial-lined cavities. Several pairs of muscles attached to
Fig. 10.13: Anatomy of temporo-mandibular joint

the mandible produce the movements necessary to suckle,

ingest, masticate food, swallow, yawn, and produce speech.
The importance is to determine deviation of jaw from the
midline during the opening and closing of the jaws.
Causes of Jaw Deviation

•• Traumatic injuries of the joint
•• Infection of the jaw
•• Fractures of the jaw
•• Muscular hypertrophy and hypotrophy.
The lateral mandibular range of motion or movement is
assessed “normal 8 to 10 mm” by having the patient to occlude
the teeth and then slide the jaw in both directions. The range
of movement from midline and any pain, location and severity
is recorded.
Maximum interincisal opening: As a general guide, mobility
is considered to be reduced if the subject is unable to open his
or her jaw to the width of two fingers (<30 mm).
Palpation (Figs 10.14 A to C)

•• Palpation of TMJ may be bimanual and bidigital palpation;
may be extra-auricular or intra-auricular.
•• The palpation may reveal pain and irregularities during
condylar movement, described as clicking or crepitus.
Clicking reveals the internal derangement of TMJ.
•• The lateral pole of condyle is most accessible for palpation
during mandibular movements.
•• Palpation just anterior and posterior to the lateral pole
detects pain associated with TMJ capsular ligament.
•• The comparison between both condyles must be assessed
by palpation.
A B
Figs 10.14A to C: TMJ examination: (A) Measuring maximum

interincisal opening; (B) Intra-auricular palpation, the posterior
aspect of TMJ; (C) Palpation of the pretragus area, lateral aspect
of the TMJ
Joint Sounds
There are 2 types of joint sound to look out for:
•• Clicks—single explosive noise
•• Crepitus—continuous ‘grating’ noise.
Clicks
A joint click probably represents the sudden distraction of 2 wet
surfaces, symptomatic of some kind of disc displacement. The
diagnosis of a joint click, and therefore treatment, vary on whether
the click is left, right or bilateral, painful or painless, consistent
or intermittent. The timing of a click is also significant—a click
heard later in the opening cycle may represent a greater degree of
disc displacement. Clicks may frequently be felt as well as heard,
though they are not normally painful.
Crepitus
Crepitus is the continuous noise during movement of the joint,
caused by the articulatory surfaces of the joint being worn.
This occurs most commonly in patients with degenerative
joint disease.
The joint sounds should be listened to with a stethoscope,
preferably a stereo one, as the two sides can be more easily
compared.
MUSCLES OF MASTICATION (FIGS 10.15A TO G)

•• The patient is asked to clench their teeth and, using both
hands, the practitioner palpates the masseter muscles on
both sides, making sure that the patient continues to clench
during the procedure.
•• Palpate the origin of the masseter along the zygomatic arch
and continue to palpate down the body of the mandible
where the masseter is attached.
•• Parafunctions such as bruxism and clenching also give rise
to masseter pain that is frequently associated with pain in
the temporalis muscle.
•• The temporalis is palpated in the same manner to detect
lateral interferences.
A B
C D
E F
Figs 10.15A to G: Examination of muscles of mastication:

(A) Palpation of the masseter muscles; (B) Bimanual palpation of the
masseter muscles; (C) Palpation of the lateral pterygoid muscles;
(D) Palpation of the medial pterygoid muscle; (E) Palpation of
the temporalis muscle; (F) Palpation of the sternocleidomastoid;
(G) Palpation of the trapezius muscles
•• The lateral pterygoid muscle is sometimes painful on

the contralateral side in patients with nonworking side
interferences.
•• In addition, this muscle will be painful whenever there is a
centric slide with an anterior component and the patient is
bruxing or clenching in this anterior position.
•• The lateral pterygoid, despite its commonality in displaying
a spasm, cannot be palpated intraorally.
•• The medial pterygoid muscle is not usually involved in
gnathic dysfunctions but when they are hypertonic, the
patient is usually conscious of a feeling of fullness in the
throat and an occasionally pain on swallowing.
SALIVARY GLANDS
Examination
The salivary glands are exocrine glands that are part of the
digestive system and include three major paired glands: The
parotid, the submandibular, and the sublingual glands (Fig.
10.16). There are also many smaller minor glands in the oral
cavity, pharynx, and larynx.
Diagnosis of diseases of the salivary glands depends on
a careful history and examination of the glands and their
effluent.
The superficial location of the salivary glands allows
thorough inspection and palpation for a complete physical
examination. Initial inspection involves a careful examination
of the head and neck regions, both intraorally and extraorally,
and should be carried out in a systematic way so as to not miss
any crucial signs.
During the initial extraoral inspection, the patient should
stand three to four feet away and directly facing the examiner.
The examiner should inspect symmetry, color, possible
pulsation and discharging of sinuses on both sides of the
Fig. 10.16: Salivary glands

patient. Enlargement of major or minor salivary glands, most
commonly the parotid or submandibular, may occur on one or
both sides. Parotitis typically presents as preauricular swelling,
but may not be visible if deep in the parotid tail or within the
substance of the gland. Submandibular swelling presents just
medial and inferior to the angle of the mandible. Salivary gland
swelling can generally be differentiated from those of lymphatic
origin as being single, larger, and smoother, but the two types
are often easily confused.
During extraoral palpation of the face and neck, the
patient’s head is inclined forward to maximally expose the
parotid and submandibular gland regions. The examiner may
stand in front of or behind the patient. It should be noted that
observable salivary or lymphatic gland swellings do not rise
with swallowing, while swellings associated with the thyroid

gland and larynx do elevate.
Bimanual palpation (extraoral with one hand, introral
with the other) must be performed to examine the parotid
and submandibular glands. One or two gloved fingers should
be inserted within the oral cavity to palpate the glands and
main excretory ducts internally, while using the other hand to
externally support the head and neck. By rolling the hands over
the glands both internally and externally, subtle mass lesions
can be identified. In the submandibular gland, lymph nodes
extrinsic to the gland can often be distinguished from pathology
within the gland itself using this technique.
Physical Examination
The major salivary glands are best examined by palpation and
by observation of the salivary effluent during palpation. Only the
parotid gland and the submandibular glands can be examined
in this way. The parotid gland lies on the lateral surface of the
mandibular ramus and folds itself around the posterior border
of the mandible. It is generally soft and is not usually palpable as
a discrete gland. The anterior border of the gland may be better
defined by having the patient clench his or her teeth together,
which tenses the masseter muscle. The parotid gland lies just
behind the masseter and its consistency may be appreciated
by pressing the gland on its lateral surface against the vertical
mandibular ramus. Parotid secretions are carried to the oral cavity
by Stensen’s duct, which enters the oral cavity in the cheek just
opposite the upper second molar tooth.
The submandibular gland resides just under the inferior
border of the mandibular body and is best palpated bi-
manually with one hand in the lateral floor of the mouth and
the other on the submandibular gland. The gland is usually
soft and mobile and should not be tender to palpation. The
submandibular duct or Wharton’s duct runs superiorly and

anteriorly to empty adjacent to the frenulum of the tongue.
The sublingual glands lie just beneath the mucosa in the
floor of the mouth and empty directly into the mouth or into
the submandibular duct. The gland is not discretely palpable,
nor are the duct openings usually visible.
Radiologic Examination
In patients with these unclear symptoms and no physical signs,
radiographic diagnostic studies, such as sialography, plain-film
radiography, computed tomography, and magnetic resonance
imaging, can play an important role in clarifying the etiology
of such nonspecific symptoms.
Sialography: It relies on the injection of contrast medium
into glandular ducts so that the pathway of salivary flow can
be visualized by plain-film radiographs. The most common
indication for sialography is the presence of a salivary calcu-
lus, which is a deposit of mostly calcium salts that can block
flow of saliva and cause pain, swelling, and inflammation or
lead to infection.
Disorders of salivary glands
I. Developmental disturbances
a. Atresia of the ducts
b. Aplasia
c. Hypoplasia
d. Accessory ducts
e. Aberrant salivary gland duct
II. Inflammatory
a. Sialolithiasis
b. Sjögren’s syndrome—Mikulicz’s disease
c. Necrotizing sialometaplasia
Contd...
Contd...
III. Infective
a. Bacterial parotitis
b. Viral parotitis—mumps
IV. Obstructive disturbances
a. Mucocele—mucous retention type
b. Extravasation type
c. Ranula
V. Functional disturbances
a. Sialorrhea/ptyalism
b. Xerostomia
VI. Neoplastic
a. Benign
1. Pleomorphic adenoma
2. Papillary cystadenoma lymphomatosum—Warthin’s tumor
(parotid only)
3. Oncocytoma
4. Myoepithelioma
5. Hemangioma
b. Malignant
1. Mucoepidermoid carcinoma
2. Adenoid cystic carcinoma
3. Acinic cell tumor
4. Squamous cell carcinoma
5. Clear cell carcinoma
6. Adenocarcinoma
7. Malignant mixed tumor
8. Lymphoma
VII. Idiopathic enlargement—fatty infiltration and salivary gland hypertrophy
a. Malnutrition
b. Alcoholism
c. Obesity
d. Diabetes
Computed tomography (CT): It is now more widely used to

assess the parotid and submandibular glands. The advantage
of CT imaging is the two-dimensional view of the salivary
glands, which can elucidate relationships to adjacent vital
structures as well as to assess the draining cervical lymphatics.
While CT is often utilized as a primary screening tool for the

detection of parotid and submandibular gland abnormalities,
in difficult cases, a higher-sensitivity approach using both CT
and sialography (CT-sialography) can be used.
Magnetic resonance imaging (MRI): It is more often used
for assessment of parapharyngeal space abnormalities. MRI
provides better contrast resolution, exposes the patient to
less harmful radiation and yields detailed images on several
different planes without patient repositioning. This technique
therefore is preferred in the evaluation of parapharyngeal
space masses, especially in discriminating between deep lobe
parotid tumors and other pathology, such as schwannoma and/
or glomus vagale.
Sialendoscopy: It is a minimally invasive technique that
inspects the salivary glands using narrow-diameter, rigid
fiberoptic endoscopes. Lacrimal probes are used to gently
dilate the ductal orifice and then the endoscope is introduced
under direct visualization. During lavage of the glandular
duct of interest, direct inspection of the duct and hilum of
the gland is performed. Thus, in one setting, at the time of
diagnosis, treatment and therapy for benign lesions can be
performed.
Parotid Gland
•• Check for any swelling over the region. Note the extent,
size, shape and consistency of the gland over the area. The
position determination is vital so as to rule out the lymph
node swellings that may be confused with parotid swellings.
•• 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.
The parotid gland duct (Stenson’s duct) opens in the buccal

mucosa opposite to the crown of maxillary second molar.
Retract the cheek for its proper examination.
Submandibular Gland
•• History of the patient is to be noted, e.g. swelling with pain
at the time of meals suggests obstruction in submandibular
duct. Calculi are more common in submandibular gland as
compared to other major salivary glands.
•• Check for any nodal swelling, it may suggest of lymph node
enlargement.
Inspection over the area of the gland should be done to
check the overlying skin color and distension of the mucosa
and the orifice of the Wharton’s duct.
•• 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 upward and palpation is achieved.
If the gland or duct is infected, slight pressure over the gland
will exudate pus from its orifice.
If any obstruction is suspected, it is checked by placing dry
cotton over both the orifices, and the patient is asked to suck
lemon juice for 2 minutes. After 2 minutes, both the cotton
rolls are taken out. The gland that is obstructed will not wet
the cotton on its side.
C H A P T E R 11
Intraoral Examination
SOFT TISSUE EXAMINATION

Examination of Lips and Labial Mucosa
Logically, the intraoral examination begins with the
examination of the lips. The exposed red portion of the lips, or
the vermillion border, forms a transition between the external
skin and the moist mucous membrane of the oral mucosa.
Because the overlying epithelium is thin, a normal lip shows
the characteristic reddish color. Several folds and sulci over the
epithelium of the lip may crease the skin. The thick, pink labial
mucosa that line the internal surfaces of the lips may appear
mildly lumpy or nodular on visual inspection. This is due to
the presence of accessory salivary glands found just beneath
the mucosal surface.
Both the upper and lower lips have a flap of tissue called a
frenum or frenulum, which attaches to the midline mucosa of
the maxillary and mandibular alveolar processes.
The clinical features of normal lips and labial mucosa are:
•• Reddish color over the area
•• Folds and sulci over the surface of lips
•• Absence of any plaque or patchy area
•• Absence of any erosive areas.
The lips and the labial mucosa are examined by the
observation of the patient at rest. The lips are normally in
contact or slightly apart. The lip line, the level of the edge of the
lip should be noted, both at rest and when the patient smiles.
Any abnormalities should be carefully noted and recorded.
A careful evaluation of the lip by bidigital palpation is done
using the index finger and the thumb to gently squeeze the lip
mass. Any abnormalities to sight or feel are carefully recorded.
The lips are thus recorded for:
•• Competency
•• Color
•• Texture
•• Fissuring
•• Shape
•• Presence of any lump or hard tissue.
Some of the common conditions that manifest as lip

abnormalities are:
1. Lip pits and commissural pits: These are congenital defects
of lip and labial mucosa that result in unilateral or bilateral
depression or pit that may occur on the lip region or on the
commissures (angles of mouth).
2. Cleft lip: These are one of the most common developmental
malformations. The incidence of cleft lip varies from 1:500
to 1:2500 in Asians. It presents a unilateral or bilateral
deficiency over the lip area, extending up to the nasal
area. Cleft lip is most common in upper lip. Cleft lip is also
commonly associated with cleft palate (Figs 11.1A and B).
A B
Figs 11.1A and B: (A) Bilateral cleft lip; (B) Unilateral cleft lip
Intraoral Examination 167
3. Angular cheilitis: Inflammatory lesion at the labial

commissure, or corner of the mouth, and often occurs
bilaterally. The condition manifests as deep cracks or splits.
4. Angioedema: Diffuse edematous swelling occurring as a
result of allergic reactions. Spreads to other tissues very
rapidly and should be treated instantly.
Examination of Buccal Mucosa

Buccal mucosa is the internal lining of the cheek region. The
mucous membrane often varies considerably in thickness from
one area to another but it is generally thick and pink like the
labial mucosa with which it is continuous.
Occasionally, there is seen a white line running
anteroposteriorly at the occlusal level, termed as linea alba.
This line is produced by continuous pressing of buccal mucosa
by the teeth due to the action of buccinators. Also, a frequent
observation of small yellow nodules is seen at the posterior
parts of buccal mucosa. These are actually the ectopic sebaceous
glands, termed as Fordyce’s granules. Check for the 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.
Clinically, a normal buccal mucosa presents:
•• Pink to slight reddish surface
•• Occasionally, linea alba may be present
•• Occasional occurrence of Fordyce’s granules.
The buccal mucosa can be best visualized when the patient
partially opens the mouth. A mouth mirror or clinician’s finger
can be used to retract the cheek to expose all the areas. Gauze
should be used to dry the surface of buccal mucosa when
required. Any abnormal finding should be carefully noted
and recorded.
Some of the common conditions in buccal mucosa that

manifest as abnormalities are:
•• White lesions of oral cavity: Such as hyperkeratosis,
leukoplakia, actinic keratosis, candidiasis, chewer’s mucosa,
white sponge nevus, lichen planus, etc.
•• Red lesions of oral cavity: Hemangiomas, varix, erythroplakia,
ecchymosis, etc.
•• Ulcerative lesions of oral cavity: Trauma, apthous stomatitis,
herpangina, Behcet’s syndrome, etc.
Examination of the Floor of Mouth

The floor of the mouth is a narrow, horse-shoe shaped
depression lying between the base of the tongue and alveolar
processes of the mandible. There is present in the midline a
lingual frenulum, connecting the inferior surface of the tongue
with the floor of the mouth.
Clinically, a normal floor of mouth presents:
•• Shiny pink surface
•• Presence of normal lingual frenal attachments
•• Absence of any patchy or ulcerated lesion.
The best view of the floor of the mouth is seen by asking the
patient to raise the tongue to the roof of the mouth and then
using a mouth mirror to further retract the tongue away from
the medial sides of the mandible. The mucosa is gently dried
with gauze.
Palpation is done by gently pressing the floor of the mouth
by index finger of one hand and the opposite hand palpating
from outside of the jaw extraorally, gently pressing up.
Some of the common conditions of floor of mouth that mani-
fest as abnormalities are:
•• Mandibular tori: A physiologic enlargement of alveolar
process on the lingual surface that can be seen while
examining the floor of the mouth.
•• Ranula: A traumatic swelling that occurs on the floor of

mouth as a result of calculi in the duct of salivary gland or
obstruction of minor salivary glands on the surface.
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.
Examination of the Tongue

The dorsum of a healthy tongue is covered by a mucous
membrane, which is rough due to the presence of thousands
of papillae projecting onto the surface. There are three types
of papillae present on the surface:
1. Filiform papillae: These are the most numerous type of
papillae with small, spike-like projections covering most
of the surface of tongue. These papilla do not contain taste
buds and are responsible for surface roughness.
2. Fungiform papillae: These are the second most numerous
papillae containing taste buds, having mushroom-shaped
projections, most commonly on the lateral borders and on
the tip of tongue.
3. Circumvallate papillae: These are 7 to 14 in number,
distinctively present slightly anterior to the sulcus terminalis
(a V-shaped groove on the posterior part of tongue), running
parallel to it. Each circumvallate papilla is surrounded by a
trough or crypt, into which numerous taste buds open.
A normal tongue presents the following characteristics:
•• A moist, reddish mucosa over the dorsal surface
•• Roughness over the dorsal surface indicating the presence
of papilla
•• Absence of any plaque or ulcer.
The dorsal and lateral surfaces of the tongue are best

examined by asking the patient to open his mouth wide and
the tongue thrust forward. Wrap a piece of gauze around the tip
of the protruding tongue to steady it, and lightly press a 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.
All surfaces of the tongue should be carefully inspected and
palpated by running a finger firmly over the surfaces. Care must
be taken not to stimulate the patient’s gag reflex by touching
the soft palate.
Some of the conditions of tongue that manifest as
abnormalities are:
•• Aglossia: Absence of tongue
•• Microglossia: Decrease in size of tongue
•• Macroglossia: Increase in size of tongue
•• Ankyloglossia: It also known as ‘tongue-tie’. A condition,
where lingual frenum attaches overly to the bottom of the
tongue and restricts its free movement (Fig. 11.2)
•• Sprue: A common condition seen in malabsorption
syndrome where tongue becomes severely ulcerated and
inflamed with a painful, burning sensation
•• Iron deficiency anemia: Tongue presents depapillated areas
with erosive lesions
•• Fissured tongue
•• Geographic tongue
•• Ulcers
•• Cleft tongue
•• Black hairy tongue
Fig. 11.2: Ankyloglossia
• Lingual varices
•
• Lingual thyroid nodule
•
• Squamous cell carcinoma
•
• Median rhomboid glossitis
•
• Bluish discoloration of tongue, i.e central cyanosis can occur
•
in many of the cardiovascular and respiratory diseases
• Painful/sore tongue can manifest as a result of local irritants,
•
smoking, candidiasis, vitamin B12 and folic acid deficiency
• Burning mouth syndrome which presents with burning
•
tongue especially in post menopausal women having
multifactorial etiological factors.
Frenum Attachments
Frenal attachments are thin folds of mucous membrane with
enclosed muscle fibers that attach the lips to the alveolar
mucosa and underlying periosteum.
A B
C D
Figs 11.3A to D: Frenum attachments
Depending upon the extension of attachment of fibers, frena

have been classified as:
1. Mucosal: When the frenal fibers are attached up to

mucogingival junction (Fig. 11.3A)
2. Gingival: When fibers are inserted within attached gingiva

(Fig. 11.3B)
3. Papillary: When fibers are extending into inter dental

papilla (Fig. 11.3C); and
4. Papilla penetrating: When the frenal fibers cross the alveolar

process and extend up to palatine papilla (Fig. 11.3D).
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.
Examination of the Hard and Soft Palate

The hard palate forms two-third of the palatal region, lying
between the alveolar processes of the maxilla and palatine
bones. The soft palate is just the posterior one-third of the
palatal region, and is formed by a group of small palatal
muscles covered by a mucous membrane.
The hard palate consists of an incisive papilla, a soft tissue
portion overlying the incisive canal, a median palatine raphe,
which can be distinguished by a shallow depression or a low
ridge extending to the soft palate and palatine rugae, which are
dense ridges of mucosa present on anterior hard palate. The
soft palate consists of a soft tissue projection in the midline
termed as the uvula.
The hard and soft palates can be best visualized when the
patient’s head is tilted back as the patient lies in a supine
position with the mouth wide open. A mouth mirror may be
used for additional help. In addition, the patient is asked to say
‘ahhh’ as the examiner gently depresses the tongue, visualizes
the soft palate function.
There are different shapes of hard palate like (Figs 11.4A to C):
• U-shaped
•
• V-shaped
•
• Flat.
•
The soft palate can be classified into three types, namely
(Fig. 11.5):
• Class I: Soft palate is horizontal and demonstrates little
•
muscular movement
• Class II: Soft palate makes a 45 degree angle to hard palate
•
A B
Figs11.4A to C: Different shapes of hard palate

(A) U-shaped (B) V-shaped (C) Flat
•• Class III: Soft palate makes a 70 degree angle to hard palate

•• Class III: Soft palate is commonly associated with a
V-shaped palatal vault and class I,II with flat palatal vault.
Some of the common conditions of palate that manifest as
abnormalities are:
•• Cleft palate: A common developmental anomaly resulting in
incomplete fusion of the two lateral processes creating a gap
in the palatal shelf. Cleft palate may be complete (involving
the hard and soft palate) or incomplete (involving only the
hard palate or only the soft palate) (Fig. 11.6).
•• Torus palatinus: A slow growing, physiologic, bony
protuberance occurring in the midline area of the palate.
Fig. 11.5: Different types of soft palate
Fig. 11.6: Cleft Palate

Fig. 11.7: Smoker’s palate
•• Smoker’s palate: A common condition where multiple

petechiae are seen over the hard palate, as a result of
inflammation of minor salivary glands and hyperkeratosis
in response to tobacco smoking (Fig. 11.7).
Examination of Swelling
•• Inspection: A good observation of the lump is important for
determining the nature of the swelling. A few points must
be considered:
–– Site of the swelling
–– Shape of the swelling
–– Size of the swelling
–– Surface mucosa
–– Edges
–– Number
–– Movement with deglutition
–– Movement with protrusion of tongue.
•• Palpation: This is the most important part of the physical
examination of the swelling, giving many clues about the
diagnosis. The swelling must be gently palpated to avoid
producing any associated problems. Following points must
be noticed:
–– Surface temperature: Localized temperature may be
raised in cases of increased vascularity as in inflammatory
swellings.
–– Tenderness: If the patient complains of pain while
touching the swelling, it is considered as tender. The
inflammatory swellings are mostly tender.
–– Consistency: The consistency of a swelling indicates the
contents of the swelling and the clue to which anatomical
structure it is derived from. A soft swelling may indicate a
cyst or an acute abscess and a hard swelling may indicate
of a neoplasm or a chronic abscess.
–– Size, shape and extent: On palpation, a general idea can be
taken about the deeper dimensions of the swelling inside
the oral cavity which is not evident from inspection.
–– Fluctuation: To determine a fluctuant swelling, a
sudden pressure is applied at one end of the swelling,
and vibrations are felt at the other end. When a swelling
fluctuates, it indicates the presence of a liquid or a gas,
e.g. in case of lipoma, irritation fibroma, etc.
–– Translucency: The amount of clear fluid (such as water,
serum, plasma, fat globules) present in a swelling decides
the amount of light to pass through it. It is mostly used
to analyze extraoral swellings. A torch is used to produce
light to be transmitted through the swelling, e.g. ranula,
mucocele.
–– Fixity to the skin: Pedunculated swellings (such as

papilloma) or sessile swellings (such as sebaceous cyst)
are assessed.
–– Relation to surrounding structures: The clinician must
try to assess the anatomical structure from which the
swelling has originated and must assess whether it
is confined to that structure or has invaded to other
structures. This is mostly done to rule out malignancies
in the orofacial region.
•• State of the regional lymph nodes: The lymph nodes
associated with the area of swelling should be assessed for
determining chronicity and tenderness.
Examination of Ulcer
•• Inspection: Following points should be considered:
–– Size and shape: Different diseases produce a variety
of ulcers (for example, syphilitic ulcers are circular or
semilunar, carcinomatous ulcers are irregular in shape,
traumatic ulcers take the shape of the injurious agent,
etc).
–– Number: Ulcers of neoplastic origin, tuberculous ulcers,
etc. are solitary while other are numerous in number. For
example, recurrent apthous ulcers.
–– Position: Position of the ulcer over the face or in the oral
cavity itself gives an important clue about the diagnosis
(ulcers of squamous cell carcinoma reside mostly in
the middle third of face, position of traumatic ulcers in
denture wearers gives the idea of the offending artificial
tooth, etc).
–– Edges: It suggests of both the diagnosis and the condition
of the ulcer. Five common types of ulcer edges are seen:
-- Undermined edge: It is seen in tubercular ulcers. The
ulcer spreads and destroys the subcutaneous tissue
faster than skin.
-- Punched out edge: Mostly seen in gummatous or

recent traumatic ulcers. The edge is seen at right angles
to the base of ulcer.
-- Sloping edge: Healing ulcers are mostly present in this
edge. It suggests that the disease is confined within the
ulcer itself, not beyond that.
-- Raised edge: It is a feature of rodent ulcer.
-- Rolled out (averted) edge: It suggests neoplastic
diseases. The fast growing cellular matter heaps up and
spills over the normal skin to produce an everted edge.
–– Floor: This is the major portion of the ulcer and is exposed
to the environment. The presence of granulation tissue
over the base indicates a healing ulcer. A smooth and
shiny base indicates a growing, inflamed ulcer.
–– Discharge: The amount and nature of discharge from the
ulcer should be noted. A spreading and inflamed ulcer will
produce a purulent discharge. Discharge may also be associ-
ated with the etiologic organism associated with the disease.
–– Surrounding area: Generally, the surrounding of an
acute ulcer is inflamed. Wrinkling around the ulcer may
indicate a healing ulcer which may produce a scar.
•• Palpation: Following points should be kept in mind:
–– Tenderness: Acute ulcers are usually found to be more
tender than the chronic ones.
–– Depth: Depth of an ulcer is to be noted.
–– Bleeding: Clinician must see whether the ulcer bleeds on
touching or not. It is a common feature of a malignant ulcer.
–– Surrounding skin: Increased temperature and tenderness
of the adjoining skin are seen in an acute ulcer.
–– Relation with deeper structures.
•• Examination of lymph nodes: The regional lymph nodes
relating to the area of the ulcer must be assessed. In acutely
inflamed ulcers, the lymph nodes become large and tender.
A chronic nonhealing ulcer may too produce an enlarged
lymph node. In malignant ulcers, the nodes are stony hard

and fixed to the surrounding structures.
Periodontal Examination
The periodontal assessment is typically done after the
extraoral and intraoral assessment, and mostly after the dental
assessment. In this way, a number of periodontal abnormalities
can be directly associated to dental hard tissue problems such
as faulty restorations, open contacts, malpositioned teeth,
anatomical variations, etc.
The visual examination of periodontium is difficult
because the appearance of periodontal disease varies widely.
Instruments such as mouth mirror, periodontal probe,
furcation probe, etc. are necessary for the complete assessment
of the periodontium.
The components of the periodontal examination include:
•• Visual characteristics of gingiva
–– Color
–– Contour
–– Consistency
–– Surface texture
–– Shape
–– Size
•• Periodontal pocket assessment
•• Assessment of gingival recession and the level of gingival
attachment
•• Detection of bleeding while probing
•• Detection of suppuration
•• Detection and measurement of furcations.
Gingival Characteristics
•• Color: Healthy gingiva has always been described as being
coral pink, although variable melanin pigmentation between
individuals may differ its appearance. An inflamed gingiva

may appear erythematous or cyanotic or both. Capillary
dilation due to inflammation makes the gingiva appear red
and shiny. Gingival color is not a good indicator of its health
as normal colored gingiva may exhibit deep pockets too.
•• Contour: A healthy gingival contour follows the margin of
underlying bone. In an inflamed gingiva, the connective tissue
is destroyed and hence, the accumulation of extracellular
fluid occurs in it. This edema, swells up the tissue and normal
contour is lost. A rim-like enlargement of gingival margin is
also observed and noted as rolled or rounded.
•• Consistency: Healthy gingiva is firmly bound to underlying
bone and tooth. Inflamed gingiva, being edematous, the
gingiva here loses its firmness and resiliency. The papilla
can be seen retractable, the tissue becomes loose.
•• Surface Texture: Normal gingiva shows an orange peel-
like appearance which is termed stippling. Histologically,
stippling is formed by intersection of epithelial rete pegs and
the interspersing penetration of connective tissue papillae.
Loss of stippling occurs when gingiva loses its resiliency, i.e.
it becomes edematous.
•• Size: A healthy gingiva is flat and not enlarged, fitting snugly
around the tooth. The fitting is because of the attached
gingiva that varies among patients and in different areas of
the mouth from 1 to 9 mm.
In an inflamed gingiva, the size becomes enlarged,
either localized to specific areas or generalized throughout
the gingiva. The amount of false pocket depth also increases.
Size of gingiva increases in:
–– Chronic gingival inflammations
–– Pregnancy associated gingivitis
–– Puberty associated gingivitis
–– Drug-induced gingival reactions.
•• Position: The actual position of the gingiva is at the level
of the attached periodontal tissue, but it can only be
determined by probing. In a fully erupted tooth in an adult,

the apparent position of gingival margin is normally at the
level of, or slightly below, the enamel contour or prominence
of the cervical third of the tooth.
In a diseased gingiva, the margins of gingiva may be
high on the enamel or at a lower level exposing a part of the
cervical area and the root surface.
Conditions producing a high margin:
–– Gingival enlargements
–– Short clinical crowns.
Conditions producing a lower margin:
–– Gingival recessions
–– Trauma from occlusion
–– Supraeruption
–– long clinical crowns.
•• Bleeding on probing: The insertion of probe to the bottom of
the pocket elicits bleeding if the gingiva is inflamed, atrophic
or ulcerated. In most cases, bleeding on probing is an earlier
sign of inflammation than gingival color changes.
To test for bleeding, a blunt periodontal probe is
carefully introduced to the bottom of the pocket along the
long axis of the tooth and is gently moved with a weight
ranging from 20 to 25 grams. The clinician should wait for at
least 30 seconds to check for the presence of any bleeding
(Figs 11.8A and B).
Bleeding on probing occurs when:
–– Gingiva is inflamed
–– Ulcerated
–– Necrosed.
•• Exudate: In a clinically healthy gingiva, there is no exudation
from the gingival sulcus except a slight gingival sulcular
fluid, which cannot be seen by visual observation. But in an
Figs 11.8A and B: Bleeding on probing

inflamed gingiva, the amount of sulcular fluid is increased

and there may be an evidence of suppurative exudation from
the gingival sulcus. Although exudation is an important sign
of inflammation, it does not give any information about the
depth of periodontal pockets.
GINGIVITIS
Definition
Plaque-induced gingivitis is defined as inflammation of the
gingiva in the absence of clinical attachment loss.
Clinical Features
Gingivitis may be characterized by the presence of any of the
following clinical signs:
•• Redness and edema of the gingival tissue
•• Bleeding upon provocation
•• Changes in contour and consistency
•• Presence of calculus and/or plaque
•• No radiographic evidence of crestal bone loss.
CHRONIC PERIODONTITIS
Definition
Chronic periodontitis is defined as inflammation of the
gingiva extending into the adjacent attachment apparatus. The
disease is characterized by loss of clinical attachment due to
destruction of the periodontal ligament and loss of the adjacent
supporting bone.
Clinical features may include combinations of the following
signs and symptoms:
•• Edema
•• Erythema
•• Gingival bleeding upon probing

•• Suppuration
•• Loss of periodontal attachment and loss of alveolar bone
•• Furcation involvement
•• Slight to moderate destruction is generally characterized
by periodontal probing depths up to 6 mm with clinical
attachment loss of up to 4 mm
•• Radiographic evidence of bone loss and increased tooth
mobility may be present.
ACUTE PERIODONTITIS
Definition
Acute periodontal diseases are clinical conditions of rapid
onset that involve the periodontium or associated structures
and may be characterized by pain or discomfort and infection.
They may or may not be related to gingivitis or periodontitis.
They may be localized or generalized, with possible systemic
manifestations.
Clinical Features
Acute periodontal infections include:
•• Gingival abscess
•• Periodontal abscess
•• Necrotizing periodontal diseases
•• Herpetic gingivostomatitis
•• Pericoronal abscess (pericoronitis)
•• Combined periodontal-endodontic lesions.
Gingival Abscess: A localized purulent infection that involves

the marginal gingiva or interdental papilla.
Periodontal Abscess: A localized purulent infection within
the tissues adjacent to the periodontal pocket that may lead
to the destruction of periodontal ligament and alveolar bone.
Necrotizing Periodontal Diseases: Necrotizing ulcerative

gingivitis (NUG) is an acute infection of the gingiva. Where
NUG has progressed to include attachment loss, it has been
referred to as necrotizing ulcerative periodontitis (NUP).
Herpetic Gingivostomatitis: Herpetic gingivostomatitis is a
viral infection (herpes simplex) of the oral mucosa.
Pericoronal Abscess (Pericoronitis): A localized purulent
infection within the tissue surrounding the crown of a partially
or fully erupted tooth.
Combined Periodontal/Endodontic Lesions (Abscesses):
Combined periodontal/endodontic lesions are localized,
circumscribed areas of infection originating in the periodontal
and/or pulpal tissues. The infections may arise primarily from
pulpal inflammatory disease expressed itself through the
periodontal ligament or the alveolar bone to the oral cavity.
They also may arise primarily from a periodontal pocket
communicating through accessory canals of the tooth and, or
apical communication and secondarily infect the pulp.
Periodontal Pocket Assessment

A periodontal pocket occurs as a result of apical migration of
the junctional epithelium in the presence of disease from the
cementoenamel junction. A calibrated periodontal probe must
be used to both detect and measure the depth of pocket. The
periodontal probe consists of a handle connected to a tapered
shank with a working-end marked in millimeters, terminating
in a blunt tip.
The most common probes used for measuring pocket depth
are:
•• Michigan ‘O’ probe: Markings are at 3-6-8 mm
•• The WHO/CPITN probe: Markings are at 0.5-3.5-5.5-8.5-11.5
mm (Fig. 11.9).
Fig. 11.9: CPITN probe
•• William’s periodontal probe: Markings are at 1-2-3-5-7-8-9

mm (Fig. 11.10).
Probing is done by gently inserting the probe into the sulcus
parallel to the long axis of the tooth with a mild force of 20 to
25 grams. At the ‘col’ space, the probe is tilted slightly (up to
10 degrees) to ensure an accurate reading. Measurements
for a tooth are usually made at all the surfaces individually.
The tendency to probe gently in the anterior region and
more forcefully in the posterior region leads to inaccurate
measurements and patient discomfort. A clinically acceptable
healthy gingiva may have a sulcus depth ranging from 1 to 3 mm.
Attachment Loss and Gingival Recession

Probing depth alone does not indicate the amount of
periodontal destruction, assessing the loss of attachment is
Fig. 11.10: William’s periodontal probe
also vital. Loss of attachment and the distance between the

CEJ and the base of the pocket, are the true clinical measures
of the amount of destruction.
Furcation Assessment
The point at which the root trunk on a multirooted tooth
diverges to form more than one root is called a furcation or
furca. Bone loss during the periodontal disease may progress to
the level that results in involvement of the furcation area. Once
a furcation gets involved, the prognosis of the tooth decreases
significantly.
Naber’s probe is the probe of choice for detecting and
measuring furcation areas (Fig. 11.11). It is a double-ended
curved probe with alternate 3 mm markings. While examination,
the tip of the Naber’s probe should be held as parallel as possible
to the long axis of the tooth and the furcation is explored as the
Fig. 11.11: Naber’s probe
probe is moved with a horizontal walking stroke apically and

laterally into the furca.
In 1953, Irving Glickman graded furcation involvement into
the following four classes:
•• Grade I: Incipient furcation involvement, with any
associated pocketing remaining coronal to the alveolar
bone; primarily affects the soft tissue. Early bone loss may
have occurred but is rarely evident radiographically.
•• Grade II: There is a definite horizontal component to the
bone loss between roots resulting in a probeable area, but
bone remains attached to the tooth so that multiple areas of
furcal bone loss, if present, do not communicate.
•• Grade III: Bone is no longer attached to the furcation of the
tooth, essentially resulting in a through-and-through tunnel.
Because of an angle in this tunnel, however, the furcation
may not be able to be probed in its entirety; if cumulative
measurements from different sides equal or exceed the width
of the tooth, however, a grade III defect may be assumed.

In early grade III lesions, soft tissue may still occlude the
furcation involvement, though, making it difficult to detect.
•• Grade IV: Essentially a super grade III lesion, grade IV
describes a through-and-through lesion that has sustained
enough bone loss to make it completely probeable.
Mobility Test
The periodontal attachment surrounding the tooth is evaluated
by using the test. The test is performed by moving the tooth
laterally in its socket either by using a back end of a mirror and
a finger or by using the handles of two instruments.
Mobility is of two types:
1. Pathologic mobility: It results from destruction of attachment
apparatus around the tooth, or by parafunctional habits.
2. Adaptive mobility: It results from anatomic factors such
as short root-crown ratio, or short roots, etc.
Indices to Measure Tooth Mobility

1. According to Glickman:
a. Grade I: Slightly more than normal
b. Grade II: Moderately more than normal
c. Grade III: Severe mobility also in the lateral sides
combined with vertical depression.
2. Lindhes Grading
a. Degree-1: Slight mobility, movement of tooth by
approximately 0.2–1 mm
b. Degree-2: Moderate mobility, movement in horizontal
direction by 1 mm, but no evidence of vertical movement
c. Degree-3: Marked mobility.
3. According to Miller in 1950:
a. 0 – It denotes no detectable movement when force is
applied, except for the normal (physiologic) mobility.
b. 1 – Mobility greater than normal

c. 2 – Mobility upto 1 mm in buccolingual direction
d. 3 – Mobility greater than 1 mm in buccolingual direction
with the ability to depress the tooth.
Check for the presence of any root stump, filled tooth,
defective restorations, the areas devoid of teeth (missing teeth
areas), any supernumerary teeth or any other abnormality
present in the dentition.
Detection of Suppuration
Suppuration is the formation or secretion of PUS. Pus is an
exudate, resulting from inflammatory products consisting of
leukocytes and debris of dead cells and tissue elements. The
presence of suppuration indicates the presence of inflammation
of the periodontium, but does not signify its severity. Notably,
suppuration is not related to pocket depth too.
HARD TISSUE EXAMINATION

A proper hard tissue evaluation involves more than just
reporting the positive findings over the area. Condition
presented in the intraoral examination should be
comprehensively recorded and compared to the results of
the history. The way and order of the comprehensive recording
depend on dentist’s preference.
Dentition
There are different nomenclature systems proposed for naming
each tooth in the oral cavity:
•• FDI (two digit system): This is the most commonly used
system. The first digit in the system indicates the quadrant
number and the second digit denotes the number of tooth
in the quadrant.
Permanent teeth:
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Primary teeth:
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
•• Zsigmondy and Palmer system: The oldest method, divides
the oral cavity into four quadrants.
The deciduous teeth are named by the formula:
EDCBA ABCDE
EDCBA ABCDE
The permanent teeth are named by the formula:
8765432112345678
8765432112345678
•• Universal system: The entire dentition is named by continuous
alphabets/numbers after dividing the quadrants.
Deciduous teeth:
A B C D E FGHIJ
T S R Q P ONMLK
Permanent teeth:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
•• Dane system:
For permanent teeth:
8+ 7+ 6+ 5+ 4+ 3+ 2+ 1+ +1 +2 +3 +4 +5 +6 +7 +8
8– 7– 6– 5– 4– 3– 2– 1– –1 –2 –3 –4 –5 –6 –7 –8
For primary teeth:
05+ 04+ 03+ 02+ 01+ +01 +02 +03 +04 +05
05– 04– 03– 02– 01– –01 –02 –03 –04 –05
ARCH FORMS
There are three main types of arch forms commonly seen:
1. Square arch form: The arch is squarish, most commonly
found in broad face patient and also in class II div 2 patient.
(Fig. 11.12A)
A B
Figs 11.12 A to C: Different types of dental arch forms.

(A)Square (B) Ovoid (C) Tapered
2. Oval arch form: The arch is oval-shaped, most common

arch form found in patients (Fig. 11.12B).
3. Tapered arch form: The arch form is tapered and is mainly
found in long face patients (Fig. 11.12C).
All the three arch forms differ mainly in the dimension of
inter-canine width. The components of arch form are anterior
curvature, posterior curvature and inter-canine width and
inter-molar width.
Dental Caries Assessment

Dental caries: It is an infectious, microbiological disease of
teeth that results in localized dissolution and destruction of
the calcified tissue.
Any type of carious exposure to the patient is examined

and recorded. The caries below an existing restoration are also
carefully checked and recorded.
A tooth is carious if the following conditions are present:
•• Lesion is clinically visible and obvious
•• Discoloration or loss of translucency typical of undermined
or demineralized enamel
•• Definite catch and the explorer tip can penetrate into soft
yielding material.
Classification of Caries
According to EXTENT of lesion:
•• Incipient caries (Initial or primary): Carious lesion appears
as a white opaque region (white spot lesion)
•• Cavitated caries: The enamel surface is broken (not intact)
and the lesion has advanced into enamel/dentin. No
remineralization is possible at this stage.
According to RAPIDITY of caries progression:
•• Acute caries (active): It spreads rapidly invading almost
the entire dentition. It involves several teeth. The carious
lesion is soft and light-colored. For example, rampant caries
appears suddenly in the dentition and progresses rapidly
with early pulp involvement.
•• Chronic caries (slow): Caries spreading slowly over the tooth
surface. The carious lesion is darker in color and harder in
consistency due to repeated phases of demineralization and
remineralization.
According to PREVIOUS treatment:
•• Primary caries: Primary caries is the original carious lesion
of the tooth
•• Recurrent caries (secondary): It occurs at the interface of
tooth and restorative material.
According to the INVOLVING SITES and SURFACES to be

treated:
•• GV Black’s classification:
–– Class 1: Cavities on occlusal surface of premolars and
molars, on occlusal two-thirds of the facial and lingual
surfaces of molars, and on lingual surfaces of molars.
–– Class 2: Cavities on proximal surfaces of posterior teeth.
–– Class 3: Cavities on proximal surfaces of anterior teeth
that do not involve the incisal angle.
–– Class 4: Cavities on proximal surfaces of anterior teeth
that do involve the incisal edge.
–– Class 5: Cavities on the gingival third of the facial and
lingual surface of all teeth.
–– Class 6: Cavities on the incisal edge of the anterior teeth
or occlusal cusp heights of posterior teeth.
According to LOCATION of caries:
•• Pit and fissure caries
•• Smooth surface caries
•• Root surface caries
Percussion Test
This test evaluates the status of periodontium around the
tooth. It is done by two methods: Vertical percussion and
horizontal percussion test. The percussion test is done by
striking the tooth with a quick, moderate blow, first on the
teeth adjacent to the suspected teeth and then in succession
to the last teeth.
If vertical percussion test comes positive, it indicates
periapical pathology and if horizontal percussion test is
positive, it indicates periodontium pathology. Also, the
patient’s response over the striking of the tooth is noted.
Malocclusion
Edward Angle gave the classification for permanent dentition
(1890):
•• Class I: Arch in normal mesiodistal relationship, the mesio-
buccal cusp of the maxillary first permanent molar coincides
with the buccal groove of the mandibular permanent first
molar (Fig. 11.13).
•• Class II: The distobuccal cusp of the upper first permanent
molar coincides with the buccal groove of the lower first
permanent molar (Figs 11.14A and B).
•• Class III: The mesiobuccal cusp of maxillary first permanent
molar coincides with the interdental space between the
mandibular first and second permanent molar (Fig. 11.15).
Fig. 11.13: Class I malocclusion

Figs 11.14A and B: Class II malocclusion: (A) Class II Div 1;

(B) Class II Div 2
Fig. 11.15: Class III malocclusion
Developmental Anomalies of Teeth

Developmental anomalies of teeth are not very rare and can
occur at various stages of tooth development:
•• Dental lamina formation stage: Anodontia (no teeth)
•• Initiation and proliferation (during the formation of tooth
bud): Partial anodontia, supernumerary, geminated/fused
teeth
•• Histo-differentiation: Odontodysplasia
•• Morpho-differentiation: Macro/micro size, dens invaginatus,
dens evaginatus, Hutchinson’s incisors, talon cusp, taurodon-
tism, dilacerations
•• Apposition–matrix formation
–– Amelogenesis imperfecta
–– Dentinogenesis imperfecta
–– Enamel hypoplasia (Fig. 11.16)
Fig. 11.16: Enamel hypoplasia
•• Calcification: Mineralization of the matrix

–– Fluorosis
–– Amelogenesis imperfecta.
•• Alterations in number of teeth
–– Anodontia
–– Supernumerary teeth
•• Alterations in size of teeth
–– Macrodontia
–– Microdontia
•• Alterations in shape of teeth
–– Fusion
–– Gemination
–– Concrescence
–– Dens in dente
–– Dens evaginatus
–– Talon cusp
–– Taurodontism
–– Dilaceration
–– Hypercementosis
–– Enamel pearl
–– Attrition
–– Abrasion
–– Erosion.
ALTERATIONS IN NUMBER OF TEETH

Anodontia
Anodontia denotes congenital absence of all the teeth
because of failure of development of tooth buds (Fig. 11.17).
Total anodontia is a rare condition but partial anodontia
(hypodontia) is more common. Hypodontia (partial anodontia)
denotes congenital absence of one or a few teeth. The affected
teeth are usually the third molars and the maxillary lateral
incisors. Oligodontia refers to the agenesis of numerous teeth.
Fig. 11.17: Congenitally missing maxillary lateral incisors

Anodontia or hypodontia is often associated with a syndrome

known as ectodermal dysplasia. Pseudoanodontia is the
clinical presentation of having no teeth when teeth have either
been removed or obscured by hyperplastic gingiva.
Supernumerary Teeth
Supernumerary teeth (hyperdontia) are additional number
of teeth, over and above the usual number for the dentition.
Supernumerary teeth occur as isolated events but are
also found in Gardner’s syndrome, cleidocranial dysostosis
syndrome, and in cases of cleft palate (or cleft lip).
Supernumerary teeth that occur in the molar area are called
“paramolar teeth”; and, more specifically, those that erupt
distally to the third molar are called “distodens” or “distomolar”
teeth. Also, a supernumerary tooth that erupts ectopically
either buccally or lingually to the normal arch is sometimes
referred to as “peridens” (plural — “peridentes”).
The order of frequency of supernumerary teeth is the
mesiodens, maxillary distomolar (4th molar), maxillary
paramolar (buccal to first molar), mandibular premolar, and
maxillary lateral incisors.
Some clinicians classify additional teeth according to their
morphology:
•• Supernumerary teeth and
•• Supplemental teeth.
Supernumerary teeth are small, malformed extra teeth,
for example mesiodens (Figs 11.18A and B), distomolar and
paramolar. Supplemental teeth are extra teeth of normal
morphology, for example, extra premolars and lateral incisors.
Mesiodens
Mesiodens (plural-mesiodentes) is a supernumerary tooth
that occurs in the anterior maxilla in the midline region near
Figs 11.18A and B: Supernumerary tooth between maxillary

central incisor
the maxillary central incisors (Fig. 11.19). There may be one

or more mesiodentes. The tooth crown may be cone-shaped
with a short root or may resemble the adjacent teeth. It may be
erupted or impacted, and occasionally inverted. Mesiodens is
the most common supernumerary tooth.
Figs 11.19A and B: (A) Presence of two mesiodens;

(B) Single mesiodens
(Courtesy: Department of Pedodontics, Sudha Rustagi, College of Dental
Sciences and Research, Faridabad, Haryana, India)
ALTERATIONS IN SIZE OF TEETH

Macrodontia
Macrodontia (Fig. 11.20) (megadontia) refers to teeth that
are larger than normal. The disorder may affect a single tooth
or may be generalized to all teeth as in pituitary gigantism.
This may be absolute, as seen in pituitary gigantism, or it may
be relative owing to a disproportionately small maxilla and
mandible. The latter results in crowding of teeth and possibly
an abnormal eruption pattern because of insufficient arch
space. Focal, or localized, macrodontia is characterized by
an abnormally large tooth or group of teeth. This relatively
uncommon condition is usually seen with mandibular third
molars. In a condition known as hemifacial hypertrophy, teeth
on the affected side are abnormally large compared with the
unaffected side. Diffuse microdontia occurs in some hereditary
disorders. No specific treatment is indicated for this condition.
Fig. 11.20: Macrodontia

Microdontia
Microdontia refers to teeth that are smaller than normal (Fig.
11.21). Localized microdontia often involves the maxillary
lateral incisors or maxillary third molars. The shape of the tooth
may be altered as in the case of maxillary lateral incisors which
appear as cone-shaped or peg-shaped; hence the term “peg
laterals”. Generalized microdontia may occur in a condition
known as pituitary dwarfism. Typically only a few teeth are
abnormally large. Diffuse macrodontia may occur in pituitary
gigantism. It can be associated with hyperdontia. No specific
treatment is indicated for this condition.
ALTERATIONS IN SHAPE OF TEETH

Fusion (Synodontia)
Fusion is a developmental union of two or more adjacent tooth
germs. Although the exact cause is unknown, it could result
Fig. 11.21: Microdontia

A B
Figs 11.22A to C: Fusion of teeth between mandibular central

and supernumerary incisor (A) Facial view; (B) Lingual view
(C) Radiographic view
from contact of two closely positioned tooth germs which fuse

to varying degrees before calcification or from a physical force
causing contact of adjacent tooth buds. The union between
the teeth results in an abnormally large tooth, or union of the
crowns, or union of the roots only, and must involve the dentin.
The root canals may be separate or fused (Figs 11.22 A to C).
Clinically, a fusion results in one less tooth in the dental arch,
unless the fusion occurred with a supernumerary tooth. The
involvement of a supernumerary tooth makes it impossible
to differentiate fusion from gemination. The cause of this
condition is unknown, although trauma has been suggested.
Gemination
Gemination arises when two teeth develop from one tooth
bud (Fig. 11.23). The incomplete attempt of a tooth germ to
Fig. 11.23: Gemination
divide into two and the resultant tooth has two crowns or a
large crown partially separated, and sharing a single root and
root canal. The pulp chamber may be partially divided or may
be single and large. The etiology of this condition is unknown.
Gemination results in one more tooth in the dental arch. It
is not always possible to differentiate between gemination
and a case in which there has been fusion between a normal
tooth and a supernumerary tooth. Although trauma has been
suggested as a possible cause, the cause of gemination is
unknown. These teeth may be cosmetically unacceptable and
may cause crowding.
Concrescence
Concrescence is a form of fusion occurring after root
formation has been completed, resulting in teeth united by
their cementum (Figs 11.24A and B). This may take place
before or after eruption of teeth and is believed to be related
to trauma or overcrowding. It is developmental in origin. The
involved teeth may erupt partially or may completely fail to
erupt. Concrescence is most commonly seen in association
with the maxillary second and third molars. It can also occur
A B
Figs 11.24A and B: Concrescence of teeth
with a supernumerary tooth. On a radiograph, concrescence

may be difficult to distinguish from superimposed images of
closely positioned teeth, unless additional radiographs are
taken with changes in X-ray beam angulation. This condition
is of no significance, unless one of the involved teeth requires
extraction.
Dens in Dente (Dens Invaginatus, Dilated

Composite Odontome)
Dens in dente, also known as dens invaginatus or tooth within
a tooth, is an uncommon tooth anomaly that is produced by an
invagination of the calcified layers of a tooth into the body of the
tooth (Fig. 11.25). This defect ranges in severity from superficial,
in which only the crown is affected, to deep, in which both the
crown and the root are involved. The permanent maxillary
lateral incisors are most commonly involved, although any
anterior tooth may be affected. Bilateral involvement is
A B
Figs 11.25A and B: (A) Occlusal X-ray showing DE and DI in the

same tooth; (B) IOPA showing dens invaginatus
commonly seen. The cause of this developmental condition is

unknown. Genetic factors are believed to be involved in only
a small percentage of cases. The cavity is usually connected
to the outside of the tooth through a very narrow constriction
which normally opens at the cingulum area. Consequently,
the cavity offers conditions favorable for the development and
spread of dental caries. The infection can spread to the pulp and
later result in periapical infection. Therefore, these openings
should be prophylactically restored as soon as possible after
eruption. The maxillary lateral incisor is the most frequently
affected tooth. Bilateral and symmetric cases are occasionally
seen. Dens in dente can also occur in the root portion of a
tooth from the invagination of Hertwig’s epithelial root sheath.
This anomaly was discovered incidentally on radiographic
examination. Because the defect may often be identified on
radiographic examination before tooth eruption, the patient
can be prepared in advance of the procedure. In cases in which
pulpitis has led to nonvitality, endodontic procedures may
salvage the affected tooth.
A B
Figs 11.26A and B: Dens evaginatus: (A) Dens evaginatus on

maxillary lateral incisor (mirror view); (B) Model of upper arch
Dens Evaginatus
Dens evaginatus (Figs 11.26A and B) is a relatively
developmental condition affecting predominantly premolar
teeth (Leong’s premolars). It exclusively occurs in individuals of
the Mongoloid race (Asians, Eskimos, and Native Americans).
The defect, which is often bilateral, is an anomalous tubercle,
or cusp, located in the center of the occlusal surface. Because of
occlusal abrasion, the tubercle wears relatively quickly, causing
early exposure of an accessory pulp horn that extends into the
tubercle. This may result in periapical pathology in young,
caries-free teeth, often before completion of root development
and apical closure, making root canal fillings more difficult.
Judicious grinding of the opposing tooth or the accessory
tubercle to stimulate secondary dentin formation may prevent
the periapical sequelae associated with this defect.
Talon Cusp
Talon cusp is considered as a type of dens evaginatus (Fig.
11.27). WH Mitchell was the first to describe it and Mellor and
Ripa named the accessory cusp as “talon cusp”.
The talon cusp is an accessory cusp located on the lingual
surface of maxillary or mandibular teeth. Any tooth may be
Fig. 11.27: Talon cusp in upper arch

affected, but usually it is a maxillary central or lateral incisor.

The cusp arises in the cingulum area and may produce
occlusal disharmony. In combination with the normal incisal
edge, the talon cusp forms a pattern resembling an eagle’s
talon.
Taurodontism
Taurodontism is a variation in tooth form in which teeth have
elongated crowns or apically displaced furcations, resulting in
pulp chambers that have increased apical-occlusal height (Fig.
11.28). Taurodont teeth have crowns of normal size and shape
but have large rectangular bodies and pulp chambers which
are dramatically increased in their apico-occlusal heights. The
apically displaced furcations result in extremely short roots
and pulp canals. This developmental anomaly almost always
involves a molar tooth. In an individual, single or multiple
A B
Figs 11.28A and B: Taurodontism (A) IOPA radiograph

(B) Tooth photograph
teeth may be affected either unilaterally or bilaterally. It may

be seen as an isolated incident, in families, and in association
with syndromes such as Down syndrome and Klinefelter’s
syndrome. This anomaly is not recognizable clinically but
on a radiograph, the rectangular pulp chamber is seen in an
elongated tooth body with shortened roots and root canals. No
treatment is required.
Dilaceration
Dilaceration is an extraordinary curving or angulation in the
root of a tooth (Fig. 11.29). Though the exact cause is not known,
it is believed to arise as a result of trauma to a developing tooth
which alters the angle between the tooth germ and the portion
of the tooth already developed. Hereditary factors are believed
to be involved in a small number of cases. Eruption generally
continues without problems. However, extraction may be
difficult. Obviously, if root canal fillings are required in these
teeth, the procedure is challenging.
Fig. 11.29: Dilaceration of root
Hypercementosis
Hypercementosis is evident on a radiograph as an excessive
build-up of cementum around all or part of a root of a tooth.
Surrounding this bulbous enlargement of hypercementosis
is a continuous periodontal membrane space and a normal
lamina dura. In a large majority of instances, hypercementosis
affects vital teeth. Generally no cause can be found, but
occasionally contributing factors are detected such as periapical
inflammation, tooth repair, and teeth that are not in occlusion
(impacted, embedded, or without an antagonist). Generalized
hypercementosis is sometimes associated with Paget’s disease,
acromegaly, and pituitary gigantism. No treatment is required.
Enamel Pearl (Enameloma)

Enamel pearl, also known as enameloma, is an ectopic mass
of enamel which can occur anywhere on the roots of teeth,
Fig. 11.30: Enamel pearl
but is usually found at the furcation area of roots (Fig. 11.30).

They occur most commonly in the bifurcation or trifurcation
of teeth but may appear on single rooted premolar teeth as
well. Maxillary molars are more commonly affected than are
mandibular molars. These deposits are occasionally supported
by dentin and rarely may have a pulp horn extending into them.
This developmental disturbance of enamel formation may be
detected on radiographic examination. It is generally of little
significance except when located in an area of periodontal
disease. In such cases, it may contribute to the extension of a
periodontal pocket because a periodontal ligament attachment
would not be expected and hygiene would be more difficult.
Enamel pearl does not produce any symptom, and when
explored with a dental explorer, it may be mistaken for calculus.
On a radiograph, the enamel pearl appears as a well-defined
round radiopacity.
Defects of Enamel and/or Dentin

• Hypoplasia
•
• Turner’s hypoplasia
•
• Amelogenesis imperfecta
•
• Dentinogenesis imperfecta
•
• Dentinal dysplasia
•
• Odontodysplasia.
•
Hypoplasia
Hypoplastic defects alter the shape of teeth. The most commonly
observed changes are those resulting in a localized loss of enamel.
This loss may take the form of a single pit defect or a series of
pits encircling the tooth horizontally. The pits may coalesce to
form a groove. The more severe forms of hypoplasia are enamel
hypoplasia and enamel hypocalcification. Enamel hypoplasia
occurs as a result of a disturbance in the formation of enamel
matrix and subsequent deficient amount of enamel tissue.
Enamel hypocalcification occurs when a normal amount of
enamel matrix is formed but the matrix is not properly calcified.
Causes of Hypoplasia
• Local:
•
– Trauma (Turner’s hypoplasia)
–
– Infection (Turner’s hypoplasia)
–
• General:
•
– Hereditary
–
- Dentinogenesis imperfecta
-
- Amelogenesis imperfecta
-
– Diseases of genetic or idiopathic origin
–
- Epidermolysis bullosa dystrophica
-
- Cleido-cranial dysostosis
-
- Osteogenesis imperfecta
-
–– Prenatal or congenital syphilis

–– Trophic disturbances
-- Gastro-intestinal disturbances
-- Infantile tetany
-- Vitamin D, calcium and phosphorus deficiency
(rickets)
-- Vitamin C deficiency (infantile scurvy)
-- Exanthematous disease (measles, chicken pox, scarlet
fever)
–– Endemic fluorosis.
Turner’s Hypoplasia
Turner’s hypoplasia, also known as Turner’s tooth, is a term
used to describe a permanent tooth with a hypoplastic defect
to its crown (Fig. 11.31). Localized apical infection or trauma to
a deciduous tooth is transmitted to the underlying permanent
tooth. If the infection or trauma occurs while the crown of
the permanent tooth is forming, the resulting enamel will
Fig. 11.31: Turner’s hypoplasia

be hypoplastic and/or hypomineralized. The mandibular

bicuspids are most often affected by Turner’s hypoplasia,
since the overlying deciduous molars are relatively more
susceptible to infection. Frequently, the maxillary permanent
central incisors are affected because of trauma to the overlying
deciduous incisors.
Amelogenesis Imperfecta
Amelogenesis imperfecta results from a disturbance in the
ectodermal layers of developing teeth. It is a hereditary
abnormality. There are two types of amelogenesis imperfecta:
1. Enamel hypoplasia, in which there is defective formation
of enamel matrix, and
2. Enamel hypocalcification (hypomineralization) in which the
correct amount of enamel is formed, but the mineralization
of the formed matrix is defective. Amelogenesis imperfecta
is hereditary or idiopathic in origin and can affect either the
primary or the permanent dentition. In generalized enamel
hypoplasia, the surface of the enamel may be smooth or
have pitted hypoplastic areas.
The yellowish-brown color of dentin is seen through the
thin enamel.
The crowns of teeth do not have the usual bulbous contour,
resulting in undersized crowns with lack of contact between the
adjacent teeth. The occlusal surfaces of posterior teeth show
occlusal wear caused by abrasion of the thin enamel.
In generalized enamel hypocalcification (hypomineraliza
tion), the crowns of teeth are normal in size and shape when
they erupt, however, with function, the soft enamel starts
to fracture. The hypocalcified enamel and the softer dentin
abrade rapidly, resulting in grossly worn down teeth. The
increased permeability of the hypomineralized enamel gives
it a dark brown color. The enamel has the same radiopacity
as the dentin, and the two often cannot be differentiated on

a radiograph.
Dentinogenesis Imperfecta (Hereditary Opalescent

Dentin)
Dentinogenesis imperfecta is a hereditary abnormality in the
formation of dentin. The clinical appearance of teeth varies
from gray to brownish violet to yellowish brown color, but they
exhibit a characteristic unusual translucent or opalescent hue.
The crowns fracture easily because of abnormal dentinoenamel
junction, and the exposed dentin undergoes rapid attrition.
Radiographically, the teeth exhibit thin, short roots with
constricted cervical portions of the teeth. The pulp chambers
and root canals may be partially or completely obliterated. A
condition called osteogenesis imperfecta has the same dental
characteristics as those of dentinogenesis imperfecta.
Dentinal Dysplasia
Dentinal dysplasia is a hereditary abnormality. It is subdivided
into type I or radicular type; and a more rare type II or coronal
type.
Dentinal dysplasia type I (also known as rootless teeth)
affects primarily the root portion of both the deciduous and
permanent dentitions. The crowns are of normal color and
shape.
On a radiograph, the teeth are seen to have very short
conical roots with a tendency toward pulpal obliteration. The
teeth either exhibit no pulp chambers, or exhibit only residual
small crescent-shaped pulp chambers. An abnormality may not
be suspected until radiographs reveal pulp and root changes.
Frequently, periapical lesions (chronic abscesses,
granulomas, or cysts) occur without any obvious cause that is,
the lesions occur in the absence of caries or trauma to the teeth.
Premature tooth loss may occur because of short roots or

periapical inflammatory lesions.
Dentinal dysplasia type II (also known as coronal dysplasia)
affects primarily the pulp chambers of the deciduous dentition.
The crowns of the deciduous teeth are similar in color, shape
and contour as those seen in hereditary opalescent dentin
(dentinogenesis imperfecta) with premature closure of pulp
chambers and canals. The crowns of the permanent teeth are
normal but their pulp chambers are often extended and may
resemble “thistle-tubes” which frequently contain pulp stones
or may be totally obliterated. The roots of teeth with dentinal
dysplasia type II are of normal shape and proportion. Periapical
radiolucencies are not usually associated with type II, but they
are fairly common in type I.
Odontodysplasia (Odontogenesis Imperfecta, Ghost

Teeth)
Odontodysplasia or “ghost teeth” is a relatively rare
developmental abnormality of unknown cause. It results
in marked hypoplasia and hypocalcification of enamel and
dentin. The cementum is much thinner than normal. The
affected teeth are small and have short roots. They are brittle
and fracture readily, resulting in pulpal infection. Both
dentitions, deciduous and permanent, may be involved. A
single tooth or several teeth in a localized area may exhibit the
abnormality. The maxillary anterior teeth are affected more
than the other teeth. Radiographic appearance shows thin
and poorly mineralized enamel and dentin surrounding large
pulp chambers and wide root canals. This thinness of enamel,
dentin, and cementum gives the teeth the characteristic “egg
shell” appearance and gives rise to the term “ghost teeth”.
Many of these teeth remain unerupted and may, therefore, be
mistaken as teeth undergoing resorption.
Wasting Diseases of Teeth

Tooth wear describes the non-carious loss of tooth tissue as a
result of the interaction of four processes which may occur in
isolation or in combination; attrition, erosion, abrasion and
abfraction.
Erosion is a chemical process in which the tooth surface
is removed in the absence of plaque. Erosive factors may be
either intrinsic or extrinsic. Extrinsic sources include drinks
such as fresh fruit juices, carbonated drinks and alcoholic
beverages; and some foods and industrial processes. Intrinsic
sources include gastro-esophageal reflux and eating disorders
(Fig. 11.32).
Abrasion refers to the loss of tooth structure due to external
agents which have an abrasive effect on the teeth, for example,
toothbrush bristles and dietary factors (Figs 11.33A and B).
Attrition is a process in which tooth tissue is removed as a
result of opposing tooth surfaces contacting during function
or parafunction. Such direct contact occurs at proximal areas,
Fig. 11.32: Dentition showing erosion

Figs 11.33A and B: Abrasion (marked by arrow)
on supporting cusps and on guiding surfaces during empty

grinding movements (Figs 11.34A and B).
Abfraction (stress lesions) has been suggested to be as a
consequence of eccentric forces on the natural dentition. Cusp
flexure causes stress at the cervical fulcrum and results in loss
of the overlying tooth structure. The lesion is typically wedge-
Figs 11.34A and B: Attrition
shaped with sharp line angles, but occlusal abfractions may

present as circular invaginations (Figs 11.35A and B).
Bruxism: It is defined as the grinding of teeth during
nonfunctional movements of the masticatory system. The wear
Figs 11.35A and B: Abfraction (marked by arrows)
is usually uniform when opposing teeth are affected. Bruxism

can also be associated with muscle spasm, fractured teeth and
restorations (Figs 11.36A and B).
Figs 11.36A and B: Bruxism
Enamel Hypoplasia
Enamel hypoplasia is a defect caused by incomplete formation
of enamel, usually because of malnutrition or disease. Enamel
hypoplasia is identified as a horizontal line, a series of pits or
grooves along the outer surface of the tooth. These lines mark
points at which the tooth’s growth was resumed after it had
stopped.
Hypoplasia is most common in the permanent teeth and
represents episodes of arrested growth in infancy or childhood
while these teeth were still developing. Once the enamel forms,
it can no longer be affected (Figs 11.37A and B).
This type of defect may cause tooth sensitivity, may be
unsightly or may be more susceptible to dental cavities. Some
genetic disorders cause all the teeth to have enamel hypoplasia.
Environmental and genetic factors that interfere with tooth
formation are thought to be responsible for enamel hypoplasia.
This includes trauma to the teeth and jaws, infections during
pregnancy or infancy, poor prenatal and postnatal nutrition,
hypoxia, exposure to toxic chemicals and a variety of hereditary
disorders.
Dental Fluorosis
It is important to diagnose the condition. It is difficult to
differentiate between dental fluorosis and other enamel
disturbances. Dental fluorosis is generalized within the
dentition and over the entire tooth surface which makes it
easy to distinguish fluoride-induced enamel changes from
other enamel defects (nonfluoride origin) which may be
symmetrically distributed in the oral cavity.
Due to excessive fluoride intake, enamel loses its lustre.
In its mild form, dental fluorosis is characterized by white,
opaque areas on the tooth surface and in severe form, it is
manifestated as yellowish brown to black stains and severe
pitting of the teeth. This discoloration may be in the form of
spots or horizontal streaks.
Normally, the degree of dental fluorosis depends on the
amount of fluoride exposure up to first six years of life, as
Figs 11.37A and B: Enamel hypoplasia

fluoride stains only the developing teeth while they are being
formed in the jawbones and are still under the gums.
The effects of dental fluorosis may not be apparent if the
teeth are already fully grown prior to the fluoride over exposure.
Therefore, the fact that an adult shows no signs of dental
fluorosis does not necessarily mean that his or her fluoride
intake is within the safety limit.
Trauma from Occlusion

It can be defined as pathologic or adaptive changes which
develop in the periodontium as a result of undue force
produced by the masticatory muscles.
Stillman (1917): A condition where injury results to the
supporting structures of the teeth by the act of bringing the
jaws into a closed position.
WHO (1978): Damage in the periodontium caused by stress
on the teeth produced by the teeth of the opposing jaw.
Trauma from occlusion [TFO] is classified into two
categories:
•• Primary: A tissue reaction, which is elicited around a tooth
with normal height of the periodontium, thus no attachment
loss is seen.
•• Secondary: This is related to situations in which occlusal
forces cause damage in a periodontium of reduced height
(attachment loss present).
The clinical signs that are seen are:
•• Pain
•• Tooth migration
•• Attrition
•• Muscle/joint pain
•• Fractures, chipping
•• Fremitus.
Etiology of TFO
•• Occlusal disharmony
•• Tooth drifting, tipping and overeruption following extraction
of neighboring teeth results in occlusal interference
•• Failure to contour the cusps of restorations
•• Occlusal interference following orthodontic tooth movement
•• Excessive occlusal stress as badly designed partial denture
•• Parafunctional activity, e.g. bruxism
•• Decreased adaptive capacity of the tissues to occlusal
forces.
Tooth Fracture (Fig. 11.38)

Tooth fracture is the break in the continuity of a tooth with
or without any displacements of the fragments. It may be
pathological or by the result of an injury of an already diseased
Fig. 11.38: Tooth fracture

tooth or a healthy one. Tooth fracture can be as a result of many

causes including; sport injuries, automobile accidents, bicycle
falls, physical fighting and chewing of very hard items.
Ellis and Davey have classified tooth fracture according to
the level and severity of fracture:
Class I: Simple fracture of crown involving enamel
Class II: Fracture of crown involving dentin but no pulp
Class III: Extensive fracture of crown involving dentin and
pulp exposure
Class IV: Traumatized tooth becomes nonvital (with or
without loss of tooth structure)
Class V: Tooth lost due to trauma
Class VI: Fracture of root with or without loss of crown
structure
Class VII: Displacement of the tooth without crown or root
fracture
Class VIII: Fracture of crown en mass
Class IX: Fracture of deciduous tooth.
Classification by Garcia Godoy

0– Enamel crack
1– Enamel fracture
2– Enamel, dentin fracture without pulp exposure
3– Enamel, dentin fracture with pulp exposure
4– Enamel, dentin, cementum fracture without pulp exposure
5– Enamel, dentin fracture with pulp exposure
6– Root fracture
7– Concussion
8– Luxation
9– Lateral displacement
10– Intrusion
11– Extrusion
12– Avulsion.
C H A P T E R 12
Establishing the
Provisional Diagnosis
The diagnosis of patient’s symptoms and other significant

disease processes leads to sometimes a self-evident conclusion.
The diagnosis is usually established by:
•• Reviewing the patient’s history and examination data
•• Listing those items that may suggest the possibility of a
significant health problem
•• Grouping items into primary and secondary, acute and
chronic, high priority versus low priority, etc
•• Categorizing the disease on the basis of this grouping.
The purpose of making a diagnosis is to be able to offer the
most effective and safe treatment and accurate prognostication.
Diagnosis is made by the clinical examination, which
comprises the:
•• History (anamnesis): This offers the diagnosis in about 80%
of cases
•• Physical examination
•• Supplemented in some cases by investigations
•• Clinical diagnosis: Made from the history and examination
•• Provisional (working) diagnosis: The more usually made
diagnosis. This is an initial diagnosis from which further
investigations can be planned.
For an effective treatment, insurance and medicolegal
purposes, it is essential that the diagnosis should be written into
the patient’s record after the detailed history and examination
data.
Although, there is no universal accepted system for
identifying and classifying diseases, the diagnosis is often
written for the purpose of accurate understanding of the
Establishing the Provisional Diagnosis 231
disease. Some of the standardization has been done by WHO

under ‘International Classification of Diseases (ICD)’ system,
continuously revised by it.
A descriptive term may be used for describing the probable
health problem, termed as the ‘provisional diagnosis’. The
clinician should always keep in mind about the differential
diagnosis. However, a definite diagnosis cannot be always
made, despite possessing full examination and history data.
The ‘provisional diagnosis’ indicates to list those items that
indicate an abnormality or suggest the possibility of significant
health problems.
C H A P T E R 13
Investigations
The dentist after evaluating the medical history and clinical

examination, generally conducts investigations to arrive at
the final diagnosis. The investigations can also be used for the
prognosis of the condition. The common investigative methods
used in dentistry are:
•• Conventional radiographic investigations
•• Specialized imaging modalities like MRI, CT scan, etc.
•• Histopathological investigations
•• Pulp vitality testing
•• Hematological investigations
•• Urine analysis
•• Microbiological investigations.
CONVENTIONAL RADIOGRAPHIC
INVESTIGATIONS
Conventional (use of radiographic films and use of processing
solutions) radiographic investigations are the most commonly
conducted investigative tests used by dental practitioners.
These are broadly classified into intraoral and extraoral
conventional radiographs.
Clinical situations for which intraoral radiographs may be
indicated are:
•• Positive historical findings like previous periodontal or
endodontic therapy, history of pain or trauma, familial
history of dental anomalies, postoperative evaluation of
healing and presence of implants.
•• Positive clinical signs/symptoms like clinical evidence of
periodontal disease, large or deep restorations, deep carious
Investigations 233
lesions, malposed or clinically impacted teeth, unexplained

sensitivity of teeth, unusual tooth morphology, calcification,
or color and missing teeth with unknown reason.
Intraoral Radiographs
The intraoral radiographs used in dentistry are:
a. Intraoral periapical radiograph
b. Bitewing radiograph
c. Occlusal radiograph.
Periapical Radiograph (Fig. 13.1)

Periapical views show the whole tooth and the surrounding
bone and are very useful for revealing caries, periodontal
and periapical diseases. Intraoral periapical radiographs are
generally taken by two methods: Bisecting (more commonly
Fig. 13.1: Intraoral periapical radiograph

used ) and paralleling technique. These views may be made of

a specific tooth or region or as part of a full mouth examination.
Interproximal Radiograph/Bitewing Radiograph

(Fig. 13.2)
Interproximal views (bitewings) show the coronal aspects of
both the maxillary and mandibular dentition in a region, as
well as the surrounding crestal bone. These views are most
useful for revealing proximal caries and evaluating the height
of the alveolar bony crest.
Occlusal Radiograph (Fig. 13.3)

Occlusal views are intraoral radiographs in which the film
is positioned in the occlusal plane. They are often used in
lieu of periapical views in children because the small size
of the patient’s mouth limits film placement. In adults,
Fig. 13.2: Bitewing radiograph

Investigations 235
Fig.13.3: Occlusal radiograph
occlusal radiographs may supplement periapical views,

providing visualizations of a greater area of teeth and bone.
They are useful for demonstrating impacted or abnormally
placed maxillary anterior teeth or visualizing the region of
a palatal cleft. Occlusal views may also demonstrate buccal
or lingual expansion of bone or presence of a sialolith in the
submandibular duct.
Extraoral Conventional Radiographs

Films are placed outside the mouth. Clinical situations for
which extraoral radiographs are indicated include: Swelling,
evidence of facial trauma, fistula or sinus tract infection,
clinically suspected sinus pathology, growth abnormalities, oral
involvement in known or suspected systemic disease, positive
neurologic findings in the head and neck, evidence of foreign
objects, pain and/or dysfunction of the temporomandibular
joint, facial asymmetry, unusual eruption, spacing, or
migration of teeth.
Panoramic Radiograph (Fig. 13.4)

These radiographs provide a broad view of the jaws, teeth,
maxillary sinuses, nasal fossa and TMJs. They show which
teeth are present, their relative state of development, presence
or absence of dental abnormalities, and many traumatic and
pathologic lesions in bone. Panoramic radiographs are the
technique of choice for initial examinations of edentulous
patients. Panoramic radiographs are also susceptible to
artifacts from improper patient positioning that negatively
affect the image. This system is considered inadequate for
independent diagnosis of caries, root abnormalities, and
periapical changes.
Other less commonly used but important extraoral
radiographs are Water’s view, reverse Towne’s view, lateral
oblique (ramus), lateral oblique (body), submentovertex
view and posteroanterior (PA) view. Water’s view (PNS view)
is indicated for the imaging of paranasal sinuses wheras
reverse towne’s view is indicated for the imaging of condylar
neck fractures. Lateral oblique (ramus) is generally advised
for ramus fractures and submentovertex view is indicated for
zygomatic arches fracture. There are certain TMJ views also
(transcranial view, transpharyngeal view and transorbital view)
that are indicated for TMJ disturbances.
Digital Radiographs (Fig. 13.5)

In digital radiography, digital X-ray sensors are used instead
of traditional X-ray film. Advantages include time efficiency
through bypassing chemical processing and the ability to
digitally transfer and enhance images.The biggest advantage
of digital radiography is lesser radiation exposure as compared
to conventional radiography. Other advantages of digital
radiography are immediate image preview and availability;
elimination of costly film processing steps and the ability
Investigations 237
Figs 13.4A and B: (A) Panoramic X-ray machine;

(B) Panoramic radiograph
Fig. 13.5: Image displayed on monitor taken by a sensor
to modify the image. However, the disadvantages of digital

radiography are its high cost and lack of image clarity as
compared to conventional radiographs. Various digital sensors
used are Charged Couple device (CCD), and Complementary
Metal Oxide Semiconductor (CMOS).
Specialized Imaging Modalities

These include Computed Tomography (CT), Magnetic
Resonance Imaging (MRI), Ultrasonography (USG), nuclear
bone scans.
CT scanning (sometimes called CAT scanning) is a
noninvasive medical test that helps physicians diagnose
Investigations 239
Fig. 13.6: CT scan image
and treat medical conditions. CT scanning combines special

X-ray equipment with sophisticated computers to produce
multiple images or pictures of the inside of the body. These
cross-sectional images of the area being studied can then be
examined on a computer monitor, printed or transferred to a
CD. CT scan provides greater clarity and reveals more details
than regular conventional X-ray exams (Fig. 13.6).
MRI and ultrasonography are however examples of non-
ionizing radiation (i.e. not involving the use of X-rays and thus
not hazardous) that are mainly used for the imaging of the soft
tissues abnormalities. Nuclear bone scan is indicated for the
imaging of metastatic malignancies.
HISTOPATHOLOGICAL INVESTIGATIONS
FNAC (Fine Needle Aspiration Cytology)
It is a safe, rapid, inexpensive and relatively painless diagnostic
procedure where a needle is inserted into the body and small
amount of fluid or tissue is sucked out for examination under
a microscope. It is usually indicated in many of the cysts and
tumors, salivary gland swellings and any other swellings and

lumps in the head and neck region.
Biopsy
Biopsy is the removal and examination of a section of tissue or
other material from the living body for the purpose of diagnosis.
Biopsy is generally indicated for:
•• Any unusual oral lesion that cannot be identified with
clinical certainty
•• Any lesion that has not shown evidence of healing in 2 weeks
should be considered malignant until proven otherwise
•• A persistent, thick, white, hyperkeratotic lesion and any
mass that does not break through the surface epithelium
should be biopsied
•• Any tissue surgically removed must be submitted for
microscopic examination.
Cytologic Smear
The cytologic smear technique is a diagnostic aid in which
surface cells of a suspicious lesion are removed for microscopic
evaluation.
Indications for smear technique are:
•• In general, a lesion for which biopsy is not planned may be
examined by smear. An exception is a keratotic lesion that
is not suitable for exfoliative cytology
•• A lesion that looks-like potential cancer should be examined
by smear if the patient refuses to have a biopsy specimen
taken
•• The smear technique is used for follow-up examination
of patients with oral cancer treated by radiation. The
treated tissue may heal inadequately and cause persistent
ulceration
Investigations 241
•• Cytology is useful for identifying Candida Albicans

organisms in patients with suspected candidiasis
•• Cytology may be useful in identifying herpes virus by taking
a smear from an intact vesicle
•• In mass screening programs for cancer detection, smears
may be taken
•• Research studies to show changes in surface cells, for
example, the effects of topical agents, may use a smear
technique.
Exfoliative Cytology
Stratified squamous epithelial cells are constantly growing
toward the surface of the mucous membrane, where they are
exfoliated. Exfoliated cells and cells beneath them are scraped
off, and when these cells are prepared on a slide, changes
in the cells can be detected by staining and studying them
microscopically. The malignant cells stain differently from
normal cells and take on unusual, abnormal forms.
PULP VITALITY TESTING

Dental pulp tests are investigations that provide valuable
diagnostic and treatment planning information. Pulp
testing combined with information taken from the history,
examination, and other investigations such as radiographs
leads to the diagnosis of the underlying disease. Pulp sensibility
tests include thermal and electric tests, which extrapolate
pulp health from sensory response. With all pulp tests, the
results need to be carefully interpreted as false results can
lead to misdiagnosis leading to incorrect, inappropriate, or
unnecessary treatment.
Cold tests: Ethyl chloride and ice have been popular in
the past, but CO 2 snow and other refrigerants such as
dichlorodifluoromethane (DDM) have been shown to be

effective and superior to ice and ethyl chloride. Ice is the most
common and easiest way for cold test. A common way to make
ice in useful sizes and dimensions involves freezing water in
empty local anesthetic cartridges.
Heat test: Typical methods used include gutta-percha or
compound material heated to melting temperature and directly
applied to the tooth being tested with lubricant in order to
facilitate removal of the material. Heated ball-ended metallic
instruments placed near the tooth (without touching the tooth
surface), battery-powered controlled heating instruments such
as ‘Touch n Heat’.
HEMATOLOGICAL INVESTIGATIONS
A complete blood count (CBC), also known as full blood
exam is generally conducted by the dental practitioner when
there is suspicion of a hematological disorder like anemia,
thrombocytopenia, polycythemia, leukemia and infection.
CBC also helps in monitoring the condition or effectiveness of
treatment being imparted. These tests also assess whether the
patient would be able to tolerate the procedures.
Hematology tests determine specific blood levels of:
•• White blood cell counts (WBC): Total white blood cell
(WBC) count and differential WBC count can be used to
diagnose infection and inflammation, and to monitor
response to chemotherapy or radiotherapy. Normal total
WBC count is 4000–11000 cells/mm3.
•• White blood cell differential: White cell differential
provides more specific information about the immune
system. There are five major types of WBC—neutrophils;
lymphocytes; monocytes; eosinophils; basophils.
•• Neutrophils (50–70%): An increased count of neutrophils
(neutrophilia) is observed in acute bacterial infections,
Investigations 243
leukemia and inflammation whereas a decreased neutrophil

count (neutropenia) is observed in certain bacterial and
viral infections, and drug-induced bone marrow depression.
•• Lymphocytes (20–40%): Lymphocytosis is seen in acute
viral infections (e.g. herpes virus infections) and lymphocytic
leukemia. Lymphocytopenia is seen in autoimmune
disorders and bone marrow damage.
•• Monocytes (2–8%): A high monocyte count is indicative
of subacute bacterial infective endocarditis (SABE) and
tuberculosis.
•• Eosinophils (1–4%): Eosinophilia is observed in parasitic
infections and allergic conditions.
•• Basophils (up to 1%): Basophilia is observed in bone
marrow disorders.
•• Red Blood cell (RBC) Count: The RBC count helps to assess
the blood’s oxygen carrying capacity and diagnose anemia.
Normal RBC count: Male: 4.5–5.5 million cells/mm 3,
female: 4–5 million cells/mm3. A higher RBC count is called
polycythemia whereas a reduced RBC count is known as
anemia.
•• Mean Corpusclar Volume (MCV): 80–100 µm3
•• Mean Corpuscular Hemoglobin (MCH): 26–34 pg.
Mean corpuscular hemoglobin concentration%
(MCHC%): 32–36%.
•• Hemoglobin (Hb): Normal values are in male: 13–18 g/dL;
female: 12–16 g/dL.
•• Hematocrit: Packed cell volume (PCV): In males it is
40–52%, whereas in females, it is 35–47%.
•• Platelets: 150–400 thousand/mm3.
•• Erythrocyte sedimentation rate (ESR): ESR is a sensitive
but nonspecific test. It is commonly the earliest indicator of
disease when other chemical or physical signs are normal.
Using Westergren method, normal value of ESR is 0–10 mm
1st hour in males and 0–20 mm 1st hour in females.
Platelets
Platelets or thrombocytes promote coagulation by providing
phospholipids to the intrinsic clotting pathway, and helping
to form a plug for minor capillary leaks. Bleeding disorders or
bone marrow diseases, such as leukemia, require the dental
healthcare provider to determine the number of platelets
present and/or their ability to function correctly prior to
invasive surgery. For an oral surgical procedure, platelets count
should be greater than 50, 000/mm3.
Liver Function Tests (LFT)

Diseases of liver are very common and range from acute
changes to chronic conditions like hepatitis, cirrhosis and
hepatocellular carcinoma.The oral cavity may show evidence
of liver dysfunction with the presence of hemorrhagic changes,
petechiae, hematoma, jaundiced mucosal tissues, gingival
bleeding, and/or icteric mucosal changes. Glossitis may be seen
with alcoholic hepatitis, especially if combined with nutritional
deficiencies. Ecchymosis and reduced healing after surgery may
also be identified. In some cases, parotid gland enlargement
is evident. Disorders of the liver have many implications for a
patient receiving dental treatment. Dental practitioners should
be aware of the potential for increased bleeding as well as drug
toxicity. It is prudent to discuss the details of the liver disease
with a treating physician in order to provide the patient with
a dental treatment plan that is safe and appropriate for the
medical and dental conditions with which the patient presents.
Quite often, liver disease will result in depressed plasma levels of
coagulation factors that need a careful evaluation of hemostasis
prior to treatment. The following set of tests is commonly used
to diagnose liver disease.
Test: Serum Bilirubin
Investigations 245
Normal value: Total bilirubin = less than 1.5 mg/dl. Bilirubin

is produced by catabolism of aged red blood cells in the tissue
macrophages. It is converted to water-soluble conjugated
bilirubin in the hepatocytes and excreted into bile and lost
with the feces.
Clinical implications: Serum bilirubin level may increase
due to excessive hemolysis of red blood cells (hemolytic or
pre-hepatic jaundice), parenchymal liver disease (hepatic
jaundice) or obstruction in the biliary tree (post-hepatic
jaundice).
Test: Alkaline Phosphatase
Normal Values: 3–13 KA units%
Alkaline phosphatase (ALP) is produced in the liver and
bone, it is also derived from the kidney, intestine, and placenta.
Clinical implications: This test is very useful for diagnosing
biliary obstruction. Even in mild cases of obstructive disease,
this enzyme is elevated. It is not very useful for diagnosing
cirrhosis. If a patient has a concurrent bone disease, this test
may be highly inaccurate, as ALP is also found in bone tissue.
Test: SGOT, SGPT
•• SGPT—Serum glutamic pyruvic transaminase, normal
value: 5–35 U/mL
•• SGOT—Serum glutamic oxaloacetic transaminase, normal
value: 5–40 U/mL.
Estimation of serum enzymes SGOT and SGPT is used to
assess the hepatocellular dysfunction. These enzymes are
normal constituents of hepatocytes. Hepatic cellular damage
results in leakage of the enzymes into blood circulation. These
enzymes are also present in other tissues such as myocardium
and skeletal muscle, but characteristic clinical features of
disorders of these tissues are sufficient to differentiate them
from liver disease.
Clinical implications: Serum SGPT and SGOT tend to be

elevated in almost all types of liver disorders, but very high
levels indicate extensive hepatic necrosis, e.g. severe viral
hepatitis or toxic hepatitis. Serial determinations of the serum
enzymes are used to assess prognosis of hepatic injury.
Thyroid Function Tests (Table 13.1)

Thyroid dysfunction is the second most common glandular
disorder of the endocrine system and the oral cavity is adversely
affected by either an excess or deficiency of these hormones.
An estimated 15% of the general population has abnormalities
of thyroid anatomy on physical examination, and an unknown
percentage of these do not complete a diagnostic evaluation. It
has been suggested that the number of people affected may be
twice as many as the detected cases. This means patients with
undiagnosed hypothyroidism or hyperthyroidism are seen in
the dental chair, where routine treatment has the potential
to result in adverse outcomes. Most of the complications
in patients with hypo- or hyperthyroidism are associated
with cardiac comorbidity. Consultation with a physician is
warranted if any symptom or sign of a thyroid disorder is found
on clinical examination. It has been suggested that all elective
dental surgery be postponed till the thyroid disorder is brought
under control by medication.
Table 13.1: interpretation of thyroid function test
Thyroid Function Test Measurement Normal Range
Total T4 (TT4) Bound and free T4 4.5–11.5 µg/dL
Total T3 (TT3) Bound and free T3 75–200 ng/dL
TSH TSH 0.3–5.0 U/mL
Hypothyroidism is characterized by serum T3 and T4

values below the normal range and elevated serum TSH level.
Hyperthyroidism is characterized by serum T3 and T4 values
above the normal range and subnormal serum TSH.
Investigations 247
Kidney Function Tests

Chronic renal disease (CRD) manifests oral consequences most
frequently. It is defined as a progressive and irreversible decline
in renal function associated with a reduced glomerular filtration
rate (GFR).The importance of CRD for the dental practitioner
lies in the fact that an increasing number of patients with this
disease will probably demand dental treatment, and that up to
90% of them will show oral signs and symptoms related to this
systemic disease. The most frequent causes of CRD are diabetes
mellitus, arterial hypertension and glomerulonephritis. The
most common oral findings in the CRF patients are dry mouth,
pallor, altered taste, and halitosis. These changes are attributed
to metabolic disturbances due to renal failure.
There are also several blood tests that can aid in evaluating
kidney function. These include:
Blood Urea Nitrogen Test (BUN)

Urea is a by-product of protein metabolism. This waste
product is formed in the liver, then filtered from the blood and
excreted in the urine by the kidneys. The BUN test measures
the amount of nitrogen contained in the urea. High BUN levels
can indicate kidney dysfunction, but because blood urea
nitrogen is also affected by protein intake and liver function,
the test is usually done in conjunction with serum creatinine
estimation, a more specific indicator of kidney function.
Normal value is 8–20 mg/dL.
Serum Creatinine
This test measures blood levels of creatinine, a by-product of
muscle energy metabolism that, like urea, is filtered from the
blood by the kidneys and excreted into the urine. Production
of creatinine depends on an individual’s muscle mass, which
usually fluctuates very little. With normal kidney function, the
amount of creatinine in the blood remains relatively constant.

For this reason, and because creatinine is affected very little by
liver function, an elevated blood creatinine is a more sensitive
indication of impaired kidney function than BUN. Normal
value is 0.8–1.2 mg/dL.
Diabetes Mellitus
The most common oral health problems associated with
diabetes are:
•• Tooth decay
•• Periodontal (gum) disease
•• Salivary gland dysfunction
•• Fungal infections
•• Lichen planus and lichenoid reactions (inflammatory skin
disease)
•• Infection and delayed healing
•• Taste impairment.
Patients with poorly controlled diabetes are at risk of
developing oral complications because of their susceptibility
to infection and sequelae, and likely will require supplemental
antibiotic therapy. Anticipation of dento-alveolar surgery
(involving mucosa and bone) with antibiotic coverage may
help prevent impaired and delayed wound healing. Orofacial
infections require close monitoring. Cultures should be
performed for acute oral infections, antibiotic therapy initiated
and surgical therapies contemplated, if appropriate (for
example, incision and drainage, extraction, pulpectomy). In
cases of poor response to the first antibiotic administered,
dentists can select a more effective antibiotic, based on the
patient’s sensitivity test results.
Blood tests are used to diagnose diabetes and prediabetes
because early in the disease, there are no symptoms. Any one
of the following tests can be used for diagnosis:
•• Fasting plasma glucose (FPG)
Investigations 249
•• Oral glucose tolerance test (OGTT)

•• Glysylated hemoglobin (Hb A1C).
Fasting Plasma Glucose Test

The FPG test is used to detect diabetes and prediabetes. The
FPG test has been the most common test used for diagnosing
diabetes because it is more convenient than the OGTT and less
expensive. The FPG test measures blood glucose in a person
who has fasted for at least 8 hours and is most reliable when
given in the morning.
People with a fasting glucose level of 100 to 125 mg/dl are
said to have impaired glucose tolerance, or prediabetes. A
level of 126 mg/dL or above, confirmed by repeating the test
on another day, means a person has diabetes.
Oral Glucose Tolerance Test

The OGTT can be used to diagnose diabetes and prediabetes.
Although OGTT is more sensitive than the FPG test, it is less
convenient to administer. When used to test for diabetes or
prediabetes, the OGTT measures blood glucose after a person
fasts for at least 8 hours and 2 hours after the person drinks 75
grams of glucose dissolved in water.
If the 2 hour blood glucose level is between 140 and 199
mg/dL, the person is said to suffer from impaired glucose
tolerance. A 2 hour glucose level of 200 mg/dL or above means
a person has diabetes.
HbA1c Test
The HbA1c test is a blood test that reflects the average of a
person’s blood glucose levels over the past 3 months. The
HbA1c test is more convenient for patients than the traditional
glucose tests because it does not require fasting and can be
performed at any time of the day. A normal HbA1c level is
below 5.7 percent. People with an HbA1c above 6.0 percent

should be considered at very high-risk of developing diabetes.
A level of 6.5 percent or above means a person has diabetes.
This test is of great value in monitoring the effectiveness of
drug-therapy in known diabetics.
URINE ANALYSIS
There are a variety of urine tests that assess kidney function. A
simple, inexpensive screening test, called a routine urinalysis,
is often the first test administered if kidney problems are
suspected. A small, randomly collected urine sample
is examined physically for color, odor, appearance, and
concentration (specific gravity); chemically for substances
such as protein, glucose, and pH (acidity/alkalinity); and
microscopically for the presence of cellular elements (red blood
cells, white blood cells, and epithelial cells), bacteria, crystals,
and casts (structures formed by the deposit of protein, cells, and
other substances in the kidneys’ tubules). If results indicate a
possibility of disease or impaired kidney function, additional
tests are usually performed for diagnosis of underlying renal
or a systemic disease.
MICROBIOLOGICAL INVESTIGATIONS
There are numerous microbiological tests that are conducted and
individualized for a particular disease. Specimens selected on
the basis of signs and symptoms, should be representative of the
disease process, and should be collected before administration
of antimicrobial agents. The specimen amount and the rapidity
of transport to the laboratory influence the test results.
Direct Examination and Techniques

Direct examination of specimens reveals gross pathology.
Microscopy may identify microorganisms. Immunofluores-
Investigations 251
cence, immuno-peroxidase staining, and other immunoas-

says may detect specific microbial antigens. Genetic probes
identify genus- or species-specific DNA or RNA sequences.
Culture
Isolation of infectious agents frequently requires specialized
media. Nonselective (noninhibitory) media permit the growth
of many microorganisms. Selective media contain inhibitory
substances that permit the isolation of specific types of
microorganisms.
Microbial Identification
Colony and cellular morphology may permit preliminary
identification. Growth characteristics under various conditions,
utilization of carbohydrates and other substrates, enzymatic
activity, immunoassays, and genetic probes are also used.
Sero-diagnosis
A high or rising titer of specific IgG antibodies or the presence
of specific IgM antibodies may suggest or confirm a diagnosis.
Antimicrobial Susceptibility
Microorganisms, particularly bacteria, are tested in vitro to
determine whether they are susceptible to antimicrobial agents.
C H A P T E R 14
Final Diagnosis
There are many types of diagnosis, including:

•• Clinical diagnosis: It is made from the history and clinical
examination.
•• Pathological diagnosis: It is provided from the pathology
results.
•• Direct diagnosis: It is made by observing pathognomonic
features. This is occasionally possible, for example,
in dentinogenesis imperfecta where the abnormally
translucent brownish teeth are characteristic.
•• Provisional (working) diagnosis: It is the more usually made
diagnosis. This is an initial diagnosis from which further
investigations can be planned.
•• Deductive diagnosis: It is made after due consideration of
all facts from the history, examination and investigations.
•• Differential diagnosis: It is the process of making a diagnosis
by considering the similarities and differences between
similar conditions.
•• Diagnosis by exclusion: It is the identification of a disease
by excluding all other possible causes.
•• Diagnosis ex-juvantibus: It is made on the results of
response to treatment. For example, the pain of trigeminal
neuralgia may be atypical, and the diagnosis can sometimes
be confirmed only by a positive response to the drug
carbamazepine.
•• Provocative diagnosis: It is the induction of a condition in
order to establish a diagnosis. This is rarely needed, except
in possible drug reactions or allergies, when the patient may
need to be re-exposed to the potentially culpable substance,
Final Diagnosis 253
but this should always be carried out where appropriate

medical support and resuscitation are available.
All the records, clinical findings, the provisional diagnosis
and investigations are clubbed together to frame the final
diagnosis on which treatment is planned. The final diagnosis is
first made on the chief complaint of the patient and then other
problems are considered.
Patients must be informed of their diagnosis and the results
of the various examinations and tests performed on them.
Also, the patient should be informed of the nature, significance
and treatment of the health problem that has been clearly
diagnosed.
Types of diagnosis
yy Clinical diagnosis
yy Diagnosis ex-juvantibus
yy Differential diagnosis
yy Pathological diagnosis
yy Direct diagnosis
yy Provisional (working) diagnosis
yy Deductive diagnosis
yy Diagnosis by exclusion
yy Provocative diagnosis: Induction of a condition to establish diagnosis
C H A P T E R 15
Formulating a
Comprehensive Treatment Plan
The goal of treatment planning is to devise the best treatment

for the patient. The diagnostic procedures help the clinician
in establishing a suitable treatment plan for the respective
patient. The plan of treatment should also be included in the
record of the patient and explained to the patient in detail.
If the patient has a compromising medical health situation,
the risks for the treatment should be assessed and informed
to the patient.
The decision for or against a medically compromised
patient is usually arrived by the dentist requesting the patient’s
physician to ‘clear the patient for dental treatment’. The plan
of treatment is usually directed toward the severity of patient’s
symptoms, referring to as rational or scientific treatment
planning.
A treatment plan that works effectively in a private practice
as well as teaching institute can be divided into following
phases:
Phases of comprehensive treatment plan
yy Phase I: Emergency phase

yy Phase II: Preventive phase
yy Phase III: Promotive phase
yy Phase IV: Curative phase
yy Phase V: Rehabilitation phase
yy Phase VI: Maintenance phase
Formulating a Comprehensive Treatment Plan 255
PHASE I: EMERGENCY PHASE

It includes the procedures which eliminate pain and manage
the acute infections. The effort should be made to include the
chief complaint in this phase as it addresses the main dental
problem of the patient.
Procedures in this phase include:
•• Treatment of pulpally involved teeth by emergency
endodontics or extraction.
•• Treatment of painful oral conditions such as ANUG, etc
•• Placement of temporary restorations in case of deep caries
threatening pulp exposure.
•• Drainage of abscess.
PHASE II: PREVENTIVE PHASE

In this phase, the effort is made to control the disease process
rather than to provide therapy.
Procedures undertaken in this phase include:
•• Pit and fissure sealants
•• Topical fluoride application
•• Oral screens and other habit breaking appliances
•• Space maintainer and preventive orthodontics.
PHASE III: PROMOTIVE PHASE

Oral health promotion aims to promote overall oral health by
imparting oral health education with respect to oral hygiene
improvement, diet, adverse habits and regular dental visits.
•• Oral hygiene instruction
•• Diet advice/counseling
•• Tobacco cessation.
PHASE IV: CURATIVE PHASE

This phase aims to eliminate all the dental problems of the
patient. This phase is also called as therapeutic phase.
•• Oral prophylaxis and root planing
•• Restoration
•• Endodontic therapy
•• Periodontal therapy
•• Extraction of teeth
•• Oral surgical procedures.
PHASE V: REHABILITATION PHASE

In this phase, the goal is to restore the mouth to full function
using restorative and prosthodontic procedures.
•• Crowns and bridges
•• Implant supported prosthesis
•• Complete or removable partial dentures
•• Reconstruction prosthesis.
PHASE VI: MAINTENANCE PHASE

It includes the steps such as recall, review and reassessment of
the oral conditions of the patient after the treatment.
The recall interval is indeed an important step in dental
care as it helps the clinician to assess the effectiveness of the
treatment and preventive advice provided previously.
The recommended interval for recall should be determined
specifically for each patient and tailored to meet his or her
needs, on the basis of an assessment of disease levels and risk
of or from dental disease (Fig. 15.1).
Fig. 15.1: Factors to consider when deciding on a patient’s recall
•• The beneficial effects of oral hygiene, diet, fluoride use

•• The ill-effects of tobacco, alcohol and pan chewing on oral
health
•• The risk factors that may influence the patient’s oral health,
and their implications for deciding the appropriate recall
interval
•• The outcome of previous care episodes and the suitability
of previously recommended intervals
•• The patient’s ability or desire to visit the dentist at the
recommended interval
•• The financial costs to the patient of having the oral health
review and any subsequent treatments
–– The interval before the next oral health review should
be chosen, either at the end of an oral health review if
no further treatment is indicated, or on completion of a
specific treatment.
–– According to National Institute for Health and Clinical
Excellence, the patient should be assigned a recall
interval of 3, 6, 9 or 12 months if he or she is younger than
18 years, or 3, 6, 9, 12, 15, 18, 21 or 24 months if he or she
is aged 18 years or older.
During a recall visit, the patient record can be updated
in terms of his or her previous treatments, new lesions,
reinforcement of prevention advice, etc.
Periodic maintenance is infact of more importance than
seeking a treatment. If regular evaluation of patient is done
then the need for complex, invasive or surgical procedures
can be eliminated with the help of preventive and promotive
procedures only.
TREATMENT PLANNING IN DENTISTRY

Treatment planning is a critical and fundamental aspect
of dentistry. Treatment planning is preceded by important
steps like a thorough examination, diagnostic work-up and
also a disease control phase. To obtain an accurate and
comprehensive treatment plan, it is important that each of the
above steps to be followed precisely.
Thorough examination as discussed earlier in the book

includes good medical history, vital signs, intraoral and
extraoral exam. This is often followed by diagnostic work-up
which includes radiographs, photographs, and study models.
With the advancement in technology, use of computerized
tomography and cone beam computerized tomography are
also being used for diagnosis and case planning. This phase
is followed by assessing and addressing what are patient’s
immediate needs which can be: Removing source of infections
or active disease, to also restore function in order to reduce
risk for future disease, restoring defective restorations and
poor occlusal function.
Art and Science of Treatment Planning

The phase of treatment planning during which the final draft is
prepared to understand how complex or simple the treatment
needs to be is often the step that requires a lot of information.
Patient’s chief complaint needs to be the most important
question which needs to be addressed, reviewed and revisited
if need be to make sure that the dentist and the patient are
both working like a team toward a similar goal. It is important
not to lose sight of what the patient came to us for, was it only
improvement of function or the patient was also dissatisfied
with the appearance of his teeth? It is also important to set
realistic goals and plans for the patient and once again at
this point it is important to have worked a plan after all initial
information has been understood. The understanding of the
patient’s goal or in other words patient’s chief complaint is
very important step toward also building a relationship with
the patient. A harmonious relationship between a doctor
and dentist cannot be emphasized enough. Extensive dental
work can extend over many appointments which may take
a few months to finish. Trust and agreement between the
dentist and the patient are very important and the foundation
of this relationship is often laid at the treatment planning

appointment. A treatment plan needs to be precisely detailed
in order to address every problem that the patient came in with
and aims toward the patient’s holistic health. The dentist who
explains his treatment plan clearly has the acceptance and
patient agreement.
Tools for successful treatment planning:
•• Good knowledge of the current scientific literature
•• Well-recorded and clearly understood chief complaint of
the patient
•• Thorough intraoral and extraoral exam
•• Good understanding of patient’s medical history,
medications and related comorbidities
•• Patient’s current pictures intraoral and extraoral
•• Patient’s previous pictures, especially in cases of
edentulousness
•• Full mouth series of radiographs
•• Panoramic radiograph, when necessary
•• Computerized tomography and cone beam computerized
tomography especially when extensive work is being
planned like full mouth rehabilitation with implants and
bone grafts, etc
•• Study casts
•• Communication skills.
The definitive treatment phase which commences after the
examination, diagnostic work-up and disease control phase
is essentially the pivot of all dentistry that happens. Following
each of the earlier mentioned steps is extremely crucial in
obtaining an accurate treatment plan. This phase of treatment
often includes:
•• Periodontal therapy
•• Occlusal treatments
•• Orthodontic or surgical correction/orthodontic treatment
•• Restoring individual teeth both functionally and esthetically

•• Doing non-emergency procedures like root canals
•• Removing hopeless teeth
•• Replacing missing teeth.
Periodontal Therapy
A good understanding of the pathogenesis of periodontal
therapy is a very important to be able to control the
disease process. Initial therapy for periodontitis consists of
meticulous scaling, root planning, and instructions for self-
care at home followed by re-evaluation in 2 months. Patients
may often respond well to this therapy but sometimes
pathogens may be more aggressive or the patient’s oral
hygiene is still not adequate, or it may be some systemic
condition that may not respond favorably to the initial phase
of periodontal therapy.
The different method that may be employed in treating a
patient in which periodontitis continues after the initial phase
of treatment often includes:
•• Periodontal surgery: This part of treatment involves raising
a flap and gaining a visual access to the affected area.
Removal of granulation tissue, scaling and root planning.
During this part, bone grafts may be placed, osseous and
soft tissue contours may be corrected.
•• Antibiotic cords/gels placement: Tetracycline or other
antimicrobial agents are often used in the form of cords
or gels and packed into an area of deep pockets or other
affected areas.
•• Bone grafts: Bone grafting is done as a part of regenerative
therapy. Bone grafting materials like freeze dried
demineralized bone which has osseo inductive properties
is placed in the area.
Occlusal Therapy
Occlusal therapy involves taking care of the occlusal
abnormalities which may be detrimental to teeth or the
periodontal tissues. Some of the common findings are mal
positioned teeth, severe loss of tooth structure due to wear,
habits like nail biting, clenching, and also temporomandibular
joint disorders.
During this phase of treatment, occlusal adjustments are
done to bring occlusion to a state of equilibrium. The teeth
are grinded in a selective manner. This technique is employed
also for relieving pain in TMJ. During selective grinding, the
important goal that is being sought is developing an acceptable
centric relation; establishing lateral and protrusive guidance
and also a plane of occlusion.
The fact that grinding away of natural teeth is an irreversible
process, therefore this needs to be evaluated accurately. The
decision for selective grinding can be made based on mounted
diagnostic casts and also intraoral evaluation of occlusion.
Some patients may develop sensitivity where reduction is more,
therefore inform the patient of possible sequels of the grinding.
Others possible ways of managing occlusion is by giving
the patient an appliance like a bite guard or a splint which is
a soft appliance which fits over the teeth. The appliance helps
patients with temporomandibular dysfunction symptoms
and also stabilizes the jaw joints. These appliances are also
noninvasive and reversible which make them extremely
advantageous.
Orthodontic or Surgical (Orthognathic) Correction

Orthodontic teeth movements are often a consideration in
young patients, especially in adolescent population. But
orthodontic treatment is also becoming more acceptable
option for helping with malocclusion, uprighting tipped teeth
before fabricating fixed dentures and shifting wisdom teeth into

a missing second molar area or pulling an impacted canine
into the dental arch. It is important to have these treatment
options as a part of the treatment plan and discuss with the
patient the use of this treatment modality when addressing
their comprehensive care.
Comprehensive orthodontic treatment generally involves
moving several teeth with the use of bands and brackets. The
orthodontic treatments have a predictable outcome most of
the times, but may also have some negative effects on teeth
like periodontitis, gingivitis, gingival recession and blunting
of the roots.
Orthognathic Surgery
Orthognathic surgery is considered as an option when
patients have severe skeletal abnormality or deficiencies. The
surgical treatment is most often done before or after regular
orthodontic treatment. Some problems that are experienced
after orthognathic surgery that a patient should be aware of are
nerve damage which may result in numbness of the involved
teeth, lips, tongue and other structures.
Restoring Individual Teeth both Functionally and

Esthetically
Loss of tooth structure happens most commonly due to caries,
tooth fracture, erosion, attrition, abrasion and abfraction. The
single tooth restoration is often done to improve function,
aesthetics, and normal contour of the teeth. Sometimes existing
restorations are also replaced when they are either faulty or
leaking. Most commonly used materials are amalgam and
composites for intracoronal restorations. When the whole tooth
is broken down, an extracoronal restoration is done, commonly
a crown or a veneer.
The other restorative materials used in dentistry are glass

ionomer and, pit and fissure sealants.
Glass ionomer: Glass ionomer releases fluoride and may
benefit in reduction of caries. Glass ionomer can also be used
in class IV cavities because it bonds to dentin and enamel both.
Pit and fissure sealants: Pit and fissure sealants are unfilled
resins which are used to prevent caries in the pit and fissure
areas. It was initially used in children, but has now gained
popularity in all ages. Pit and fissure sealants have a benefit
of arresting and preventing decay. The application process is
a technique sensitive and requires a dry field for sealant to be
efficacious.
Composite resin: Composite resins are direct filled tooth
colored restoration. Composite are commonly used for most
intra coronal restorative procedures. Composites have excellent
color matching and newer composites also have better wear
resistance and strength. Composites are self-cured and light-
cured. The common disadvantage of composites is micro
leakage, staining and also extremely treatment sensitive, and
therefore requires dry field.
Amalgam: Dental amalgam is an inexpensive, easy to handle
non-technique sensitive restorative material. Amalgam is a
material of choice for large restoration. Amalgams are preferred
for posterior restorations. The disadvantage of amalgam is that
they can fail because of fracture, secondary decay and there
can be leakage in the amalgam restoration.
Cosmetic or Esthetic Dentistry

As the patient population is moving toward enhancing their
appearance so is dentistry advancing toward more and
improved means and methods for improving how the teeth look.
Figs 15.2 A and B: Before and after non-vital bleaching on tooth 23

which had an endodontic treatment and “walking bleach” treatment
We have some excellent materials today which can be used to

improve the color, shape, reduce or eliminate stains, etc.
Some techniques commonly employed are microabrasion
which is removal of intrinsic discoloration on the enamel
surface. Bleaching teeth which is vital as well as for non-vital
teeth. Veneers for extremely heavily stained/discolored or
poorly shaped teeth (Fig. 15.2).
Diastema closure is also being done in many patients who
have a large gap in between their upper central incisors. This
treatment enhances the patient’s appearance quite significantly
(Figs 15.3A and B).
Removing Hopeless Teeth

Hopeless or compromised teeth are teeth that cannot be
salvaged because they are restoratively or periodontology
compromised. Sometimes a decision to extract a tooth rather
than trying to salvage a tooth is made due to patient’s financial
and/or motivation reasons. Wisdom teeth extraction is also
a common aspect in routine dentistry. Common reasons for
extracting teeth are inadequate space, decay of second molar,
crowding of anterior teeth, pericoronitis, decay of third molar
itself, and cysts and tumors.
Other reasons for extracting hopeless teeth are before
fabrication of removable partial dentures.
Preprosthetic surgeries are also needed for patients
especially before planning teeth replacements with dentures.
Some of the reasons for surgery are removal of toris and
exostoses, ridge augmentation and bulbous tuberosities.
Smile Analysis
An important evaluation is that of the smile. Smile can often
be classified based on the display of gums and teeth. It can be
low, medium or high smile line (Figs 15.4 A to C).
Figs 15.3A and B: Before and after diastema closure
Esthetic changes being suggested to the patient should

be done based on the patient’s smile line and accessing the
outcome of the treatment being suggested. Examples of a few
red flag situations are patient requiring replacement of 11, 12
A B
Figs 15.4A to C: Types of smiles (A) Medium (B) High (C) Low
teeth and has a high smile line.The option being considered is

bone and soft tissue graft and eventually implants. The tissue
contour may or may not heal perfectly in this area which may
lead to appearance of the black triangles. These aspects have to
be undertood and discussed in great details with the patient to
avoid future dissatisfaction and disharmony with the patient.
Discussion of the smile and its analysis is in itself a whole
chapter, so for the sake of including this important aspect, we
have only touched upon this aspect. It can be studied in much
greater detail. The take home message is that the anterior area
of the mouth requires extremely careful planning, especially
when the patient has come to the dentist to restore his/her
appearance.
Replacing Missing Teeth

The option of missing teeth can be a fixed or removable.
Removable/fixed dentures require a significant amount of
Figs 15.5A and B: Restoring patient’s smile and function after

extracting hopeless teeth
planning with regards to understanding anatomy of every

individual patient, the needs and the expectations of the
patient. Removable dentures tend to be less expensive as
compared to the fixed alternative and less invasive (Figs 15.5A
and B), they though are not for everyone. It improves quality of
life, appearance and function to go along with an individual’s
lifestyle. With the advent of implant dentistry, patients can

function very effectively and comfortably with dentures which
do not affect the quality of life.
Communication Skills
Communication skills are though at the bottom of the list, but
the significance to it is no less than any other part of the list.
Communication is often described as a transfer of signals/
messages between a sender and a receiver through various
methods (written words, nonverbal cues, spoken words). It is
also the method used to establish and modify relationships. In
the patient dentist situation, communication is an important
aspect of a successful relationship. A few aspects of effective
communication are speaking and listening. Some key points to
remember about effective communication are maintaining eye
contact, using gestures, listening effectively and completely,
not sending mixed messages. The attitudes one brings to
communication will have a huge impact on the way one
composes himself and interacts with others. Choose to be
honest, patient, optimistic, sincere, respectful, and accepting of
others. Be sensitive to the patient’s feelings, be empathetic and
don’t be shy of expressing that. Patients notice very quickly and
easily when the doctor is not paying attention or not listening
completely. This often builds distrust in the patient. It may not
hurt to paraphrase or ask the person to repeat what they said for
better clarity and understanding. Communication carried out
effectively is often the basis for long-term successful trusting
relationships.
Ethical Considerations of Treatment Planning

Some ethical considerations to be carefully evaluated are:
•• Provider is placing the patient’s interest and well-being
as the most important criteria: The goal of the treatment
will improve patient’s health and condition. The motivation

for the provider should not be a financial gain but the
enhancement of patient’s wellbeing.
•• No harm will be done to the patient: this is an important
aspect to the treatment planning; the provider ensures
that the treatment being offered is safe and scientifically
supported. Not requiring excessive radiation exposure or
use of materials that have toxic effects on human body. The
use of all components and parts are safe, true and tested.
•• To be truthful to the patient: All aspects of treatment
planning should be discussed with the patient explaining
to the patient the pros and cons of the treatment option
that is being discussed. No beneficial effects should
be overemphasized and no harmful effects should be
underplayed. A patient should understand every aspect of
the treatment clearly and should be able to make a decision
based on the information provided to him.
•• No pressure on the patient: There should be no pressure
or any other method used in which the patient feels he/she
is being forced into making a decision about the treatment.
Discussing Treatment Plan with the Patient

As important as it is to plan the treatment and its phases
accurately, it cannot be underestimated how important is
the presentation of the treatment plan to the patient. The
treatment plans which are extensive require from the patient
a lot of motivation, commitment and as these are financially
involved have to be presented in a manner in which patient’s
acceptance will be high.
The important points to remember for treatment planning
are that as a provider, the goal is to guide and educate the
patient to be able to make an educated decision. This is
the provider’s ethical responsibility to never overtreat,
over diagnose or to undermine a disease. The results of

all the examinations need to be expressed truthfully and
accurately. A patient is a partner during the treatment and
his/her commitment and acceptance of responsibility will
play an important role in the success and achieving the final
outcome.
Let’s discuss treatment planning by looking at a few
examples. The cases mentioned in example are showing the
information that is gathered from a patient before a plan is
made and how the information is then used toward a successful
treatment planning process.
Example: Mr. Smith is a 63 years old male. His chief complaint
is “I want to replace my teeth”. Intraoral exam shows (Fig.
15.6): 16, 13, 12, 11, 21, 23, 25 on the upper arch (Figs
15.7 and 15.8) are grossly decayed. The teeth on the lower
Fig. 15.6: Dental charting

Figs 15.7A and B: Upper Arch
Fig. 15.8: IOPA X-rays of upper arch

arch are 31, 32, 33, 34, 41, 42, 44 (Figs 15.9 and 15.10).
Periodontal condition is moderate to advanced periodontitis.
Mucosa: Pale pink in color, hard palate: multilobular palatal
tori, soft palate: tongue, floor of the mouth is within normal
limits. The gingiva is thick, biotype, color reddish-pink. Poor
oral hygiene. Multiple missing teeth. Extraoral exam: Head and
Fig. 15.9: Lower arch
Fig. 15.10: IOPA X-rays of lower anterior

neck have no facial asymmetry, TMJ has no signs of pathology.

Lymph nodes appear normal and no signs/symptoms of any
extraoral swelling/pain/tenderness.
Health history: Diabetes, smoker (1 pack cigarettes/day),
hypertension.
Medications: Metformin and Lisinopril.
Social history: Smokes one pack of cigarettes/day and drinks
alcohol socially.
Let’s evaluate the radiographs and pictures to formulate a
diagnosis and then build a treatment plan.
Patient’s goal: He wants function and esthetic and wants to
replace his teeth.
Treatment Plan: Phase 1: Initial therapy—scaling and
root planing + prophylaxis + oral hygiene instructions and
re-evaluation (6–8 weeks)
Phase 2: Surgical Phase
Phase 3: Restorative phase
Phase 4: Maintenance phase.
Option 1: Maxillary arch.
Initiative treatment: Scaling and root planing, detailed evalu-
ation of oral hygiene habits followed by new recommendations.
Surgical phase: Maxillary tori removal.
Extraction of teeth: 11, 12, 14, 18, 23, 25.
Restorative phase: Fabricate a maxillary complete denture.
Option 1: Mandibular Arch.
Initiative treatment: Scaling and root planning.
Restorative phase: Fabrication of lower cast partial denture.
Option 2 for Maxillary Arch
Surgical phase: Extraction of 11, 12, 14, 18, 23, 25.

D efinitiv e Treatment : B one graft, Possible r idg e
augmentation?? Implant placement of teeth 15, 12, 21, 24 and
fabrication of implant supported overdenture.
Option 2 for Mandibular Arch
Definitive phase: Placing implants in 36, 46 and fabricating an
implant supported partial denture.
The above described treatment plan is based on patient’s
chief complaint and his needs which are function and esthetics.
The patient was presented with both treatment options and the
cost of each treatment plan was also provided to the patient.
The supporting scientific literature was carefully evaluated
before formulation of such a treatment plan. It was also very
important to know the success rate of implant treatment in
diabetic and smoker both of which this patient happens to be.
After a good assessment of the literature, it was explained
to the patient that implant success rate is slightly lower in a
smoker and a diabetic as compared to a non-smoker and non-
diabetic. The patient makes a decision on either of the options
based on his financial comfort and his overall goal.
It is the responsibility of a good clinician to provide the
patient with the all possible options for their treatment.
To educate, help and guide the patient to understand the
treatment being suggested is also important. Dental treatment
can be very expensive and may require to be phased out, so
that the patient can plan to do the treatment over a period of
time to be able to afford it. We as providers should be able to
accommodate and formulate such treatment plans. This not
just enhances the level of comfort for the patient financially

but also improves patient-dentist relationship.
SUMMARY
The few important points from this chapter are:
•• Treatment planning has to be individual to each patient.
•• Treatment plan needs to be formulated based on current
science.
•• Patient should be offered treatments which are true and
tested. Not experimental or a treatment that may potentially
be hazardous.
•• Treatment plans should also be based on patient’s need and
most importantly the “chief complaint”. It should enhance
patient’s function and esthetic.
•• Treatment plan needs to be ethical.
•• Patient whenever possible should be offered a few options
which are based on the patient’s needs. This helps patient
decide on the option they choose based on their financial
comfort level and also what their personal goal is.
•• Whenever possible, lay a treatment plan out in phases
especially when it is an extensive one, it helps the patient
adhere to it more easily and affordably.
•• Most importantly: Do no harm.
C H A P T E R 16
Levels of Prevention
In modern day, concept of prevention has become ‘broad

based’.
Four levels of prevention can be identified in relation to
natural history of disease (Table 16.1):
•• Primordial prevention
•• Primary prevention
•• Secondary prevention
•• Tertiary prevention.
Table 16.1: Levels of prevention
Levels of Primordial Primary Secondary Tertiary
prevention
Priorities of Before Disease Disease Loss of
prevention emergence Initiation progression function
of risk and
factors recurrence
Taxonomy of Prepathosis Prepathosis Intervention Replacement
prevention
Preventive Individual Health Early Disability
services and mass promotion diagnosis limitation
education specific and prompt rehabilitation
protection treatment
Primordial prevention consists of actions and measures

that inhibit the emergence of risk factors in the form of
environmental, economic, social, and behavioral conditions
and cultural patterns of living etc.
Primary prevention is defined as the action taken prior to
onset of disease which removes the possibility that a disease
will ever occur.
Levels of Prevention 279
Secondary prevention is defined as the action which halts

the progress of disease in its incipient stage and prevents
complications.
Tertiary prevention is defined as all measures available
to reduce or limit impairments and disabilities, minimize
suffering caused by existing departures from good health to
promote patient’s adjustment to irremediable conditions.
Appendices
Appendix 1:
Case History Proforma for Department of Pedodontics
OPD NO: ______________________ Date:___________
SOCIAL HISTORY
Name: ___________________ Nick name: ___________________
Age: _____________________ Sex _________________________
Address: ______________________________________________
Tel No.: __________________ Mother tongue: _______________
DOB: ________________________________________________
Name of the parent/guardian: ___________________________
Occupation: ___________________________________________
Relationship with guardian: _____________________________
Referred by____________________________________________
Chief complaint: _______________________________________
_______________________________________________________
History of Present Illness:
Relevant history:
Medical history:
Previous dental history & experience:
Good/bad: Any complications:
Social and family history:
Appendices 281
Frankl behavior rating scale:

Management problems, if any:
PRENATAL HISTORY
Drug intake during pregnancy:
Illness during pregnancy:
NATAL HISTORY
Full term/Premature birth
Type of delivery: Normal/Forceps/Caesarian
Birth cry: Immediate/Delayed
Birth injury:
Feeding: Breast Fed or Bottle Fed.
Combination & contents:
Congenital abnormality, if any:
Natal Teeth/Neonatal teeth:
Other:
POSTNATAL HISTORY
Feeding: Breast fed/Bottle fed/Combination
Contents:
Duration:
Frequency:
Weaning:
Milestones: Normal/Delayed
If delayed reasons:
Vaccination: Completed/Incomplete
Any major illness during childhood:
History of hospitalization/or care under pediatrician:
Present history of drug intake:

Immunization:
DIET HISTORY
Add diet chart
EXTRAORAL EXAMINATION:
General physical assessment

Built: Ear, nose and throat:
Height: Weight:
Gait: Hair:
Fingers: Nails:
Vital Signs
Pulse rate: BP:
Respiratory rate: Temperature:
Shape of the head:
Somatotypes (Sheldon’s):
Facial symmetry:
TMJ Examination
Inspection: Palpation:
Deviation: Ankylosis:
Hypermobility: Tenderness:
Trismus: Clicking:
Appendices 283
Lymph nodes: Tenderness:

Enlargement:
Other:
Profile:
Lip:
Others:
Swallowing:
Speech:
PERSONAL HISTORY
Brushing:
Oral hygiene appraisal:
Mode of oral hygiene practice: Guided by parent/Not
Frequency:
Other habit:
Finger or thumb sucking, lip or nail biting, mouth breathing,
tongue thrusting, bruxism, none
Any other (in detail):
Duration:
Frequency:
Intensity:
INTRAORAL EXAMINATION
Soft tissue examination
Lip:
Cheek:
Tongue:
Vestibule:
Floor of the mouth:
Palate:
Mucosa:
–– Normal:
–– Ulcer:
–– Linea alba:
–– Fordyce’s granules:
–– Any other details:
Orifices of salivary glands: Normal/inflamed
Oropharynx: Tonsils:
Gingiva
Color:
Size
Form:
Texture:
Sinus/Fistula:
Frenum Attachment
Labial:
Lingual:
Hard tissue examination
Teeth present (FDI system only)
Decayed teeth:
Mobility Physiological
Pathological Tenderness
Appendices 285
Restored teeth: GI/Ag/MM/Composite/Temporary

stainless steel crowns/Others
Pathologic migration:
Trauma: Ellis Classification
Discoloration:
Wasting: Attrition/Abrasion/Erosion
Teeth missing: Congenital/Extracted/Exfoliated
Other anomalies: Microdontia/Macrodontia/Talon’s

cusp/Supernumerary tooth
Eruption status:
Other abnormality:
Oral hygiene appraisal :
Stains Extrinsic Intrinsic
Calculus
OHIS Index
DMFS Index
Occlusion
Right Left
Molar: Primary dentition:
Permanent dentition:
Anterior: Canine relation Over jet Overbite
Midline
Cross bite: Posterior
Anterior
Crowding: Posterior
Anterior
PROVISIONAL DIAGNOSIS:
Investigations:
Intraoral:
Extraoral:
Other special investigations:

Blood examination:
Urine examination:
Other:
DIFFERENTIAL DIAGNOSIS:
FINAL DIAGNOSIS
TREATMENT PLAN
Emergency Phase:
Immediate Phase:
Preventive Phase:
Restorative Phase:
Surgical Phase:
Appendices 287
Endodontic Phase:
Orthodontic Phase:
TREATMENT PROVIDED
RECALL:
SUMMARY:
Student Signature: Staff Signature:

Appendix 2:
Case History Proforma for Department of Orthodontics
PERSONAL DETAILS
Name: ___________________ Age: ________________________
Sex ______________________ Religion: ____________________
Ethnic origin: _____________ Occupation: _________________
Address: ______________________________________________
Temporary: _______________ Permanent: _________________
Vegetarian or non-vegetarian:
RECORDS MADE
Study models: Lateral Cephalogram:
Intraoral X-rays: PA Cephalogram:
Periapical
Bitewing Facial photographs
Occlusal
Any other: Hand wrist X-rays
OPG
Chief Complaint:
History of chief complaint:
Family history:
Prenatal history:
Informer:
Condition of mother during pregnancy:
Delivery: Term: Type:
Postnatal history:
Type of feeding:
Childhood diseases:
Appendices 289
Nutritional deficiencies:
Milestones of development:
Trauma / accidents:
MEDICAL HISTORY
Problems at birth:
Any known systemic diseases:
Any drug allergies or food allergies:
Any history of trauma:
Snoring while sleeping:
Chewing or swallowing difficulties:
Cold or stuffy nose:
Tonsillitis or adenoid problems:
Puberty attained:
Any emotional or behavioral problems:
DENTAL HISTORY
History:
Dental trauma:
Toothaches:
Restorations:
Extractions:
Orthodontic treatment:
Gingival or periodontal problems:
History of habits:
Intensity: Duration: Frequency:
Thumb sucking:
Finger sucking:
Nail biting:
Lip biting:
Grinding of teeth:
Mouth breathing:
Any other:
Brushing habits:
GENERAL EXAMINATION
Built of patient: Ectomorphic Endomorphic Mesomorphic
Appearance and attitude: Good Poor
Posture: Lordotic Fatigued Normal
Gait: Normal Shuffling Lameness
Speech: Normal Abnormal
EXAMINATION OF HEAD AND FACE

Cephalic index:
Head type: Dolicocephalic Mesocephalic
Brachycephalic
Face type: Leptoprosopic Mesoprosopic
Euryprosopic
Facial form: Round Angular
Oval Triangular
Symmetry of the face: Symmetrical/Asymmetrical
Profile analysis:
AP relation: Convexity Concavity
Straight
Appendices 291
Facial divergence: Straight Posterior divergent

Anterior divergent
Mandibular plane angle: Average Steep
Flat
Chin button contour:
SOFT TISSUE EXAMINATION

Lip competence: Competent Incompetent ……mm
Lip posture: Normal Short Curled
Upper
Lower
Color of lips: Dry scaly Moist red
Upper
Lower
Mentolabial sulcus: Normal Shallow Deep
Nasolabial angle: Acute Obtuse Right angled
Examination of hard tissues
Teeth present clinically:
Radiographic evaluation:
Maxillary Mandibular
Arch form:
Size of tooth v/s arch length:
Symmetry of arch:
Midline coincidence:
Anomalies:
Shape:
Position of individual teeth:
Size:
Restorative status: D M F
Soft tissue examination

Oral hygiene status:
Color Texture Consistency Position
Gingiva:
Mucogingival junction:
Palate:
Floor of mouth:
Tonsils and adenoids:
Fauces:
Frenal attachments: Lingual Labial
Upper
Lower
Gingival and periodontal status:
Evaluation of occlusion:
Transverse AP Vertical
Molar relation:
Canine relation:
Incisor relation:
Overjet: ……mm
Overbite: …...mm
Curve of spee:
Freeway space:
Midline coincidence:
FUNCTIONAL ANALYSIS
Examination of TMJ
Right Left
History of pain
Appendices 293
Limited mobility:
Clicking sounds:
Tenderness on palpation:
Range of motion:
Maximum opening:
Right excursion:
Left excursion:
Protrusion:
Path of closure: Normal Anterior shift
Posterior shift Lateral
Any occlusal interference:
Freeway space:
Type of breathing: Normal Mouth Both
Speech: Normal Abnormal
Examination of tongue:
Size: Shape:
Position of tongue at rest:
Position of tongue during: Deglutition Speech
Type of deglutition: Simple Complex
Infantile Normal
Muscle function:
Hypertonic Hypotonic Normal
Upper lip:
Lower lip:
Masseter:
Temporalis:
Internal pterygoid:
External pterygoid:
Mentalis:
MODEL ANALYSIS
Classification of occlusion:
Overjet Overbite
Palatal contour:
Sagittal Transverse
Teeth clinically present:
Right Left
Upper
Lower
Teeth measurements (in mm):
Upper
Lower
Arch form and symmetry:
Upper
Lower
Bolton’s tooth ratio analysis
Sum of maxillary 12 Sum of maxillary 6
Sum of mandibular 12 Sum of mandibular 6
Overall ratio Overall anterior Ratio
Diagnosis:
Amount of maxillary/mandibular excess
Inference:
Amount of maxillary/mandibular anterior excess
Inference:
Ashley Howe’s analysis
Total tooth material (TTM):
Premolar diameter (PMD):
Premolar basal arch width (PMBAW):
Appendices 295
PMBAW
PMBAW% = × 100
TTM
Inference:
1.
2.
Arch perimeter analysis Carey’s arch perimeter analysis
Maxillary arch length: Mandibular arch length:
Maxillary tooth material: Mandibular tooth material:
Discrepancy: Discrepancy:
Inference: Inference:
Cephalometric Analysis
Skeletal Analysis
Parameters Norm Pt. Value Inference
MAXILLA
SNA
N Pr. To A (mm)
Eff. Mx. Length (mm)
MANDIBLE
SNB
N Pr. To Pog (mm)
Eff. Mn length (mm)
MX-MN
Wits AO / BO (mm)
ANB
Angle of convexity
Mx - Mn diff (mm)
VERTICAL
FMA
SN Go Gn
Y-axis
Jarabaks ratio (%)
LAFH
Parameters Norm Pt.Value Inference

Saddle angle
Articular angle
Gonial angle
(U)
(L)
OTHERS
FH - SN
Base plane angle
Inclination angle
Cant of occ.
Dental Analysis

MAXILLARY INCISORS
U. incisor to NA (deg/mm)
U. incisor to A vert. (mm.)
U. incisor to A Pog (mm.)
U. incisor to FH
U. incisor to SN
MANDIBULAR INCISORS
L incisor to NB (deg/mm)
L. incisor to Mn. plane
L. incisor to Occ.plane
L. incisor to A - Pog (mm.)
MX – MAN
Interincisal Angle
Overjet (mm)
Appendices 297

VERTICAL PLANE
Overbite(mm.)
C. of Spee(mm.)
Soft Tissue Analysis
Parameters Pt. Value Inference

Naso-labial angle
Lip strain (mm.)
L. lip to E- line (mm.)
L. lip to S- line (mm.)
U. lip to S-line (mm.)
Any other analysis (specify):

Diagnosis:
Treatment objectives:
Treatment plan:
Treatment time:
Retention time:
Appendix 3:
Case History Proforma for Department of Periodontics
Doctor’s Name: _____________ Case No.: ___________________
CASE HISTORY
Name _____________________ Age/Sex: ____________________
OPD No.: _________________ Occupation: _________________
Address: ______________________________________________
Date: __________________ Chief complaint: _______________
Present dental history:
Past dental history:
MEDICAL HISTORY
Does the patient suffer/suffered from any of the following
diseases:
Disease Yes No
Cardiovascular disease
Diabetes
Hemorrhagic disorders
Blood dyscrasias
Epilepsy
Pregnancy/menopause
Renal disease
Pulmonary disease
Infectious disease
Others
Appendices 299
History of previous and present medications:
Disease Yes No
Cardiac therapy
Anti-diabetic therapy
Anti-hemorrhagic
Immunosuppressants
Anti-asthamatics
Anti-hypertensive
Anti-epileptic
Oral contraceptives
Anti-depressants
Others
SUMMARY:
PERSONAL HISTORY
Oral hygiene habit:
Type of Brush: Super Soft / Soft / Medium / Hard
Dentifrice:
Frequency of brushing:
Technique:
Others:
Personal habits
Pan Chewing:
Smoking:
Alcohol:
Others:
Extraoral examination
Symmetry of face:
Lymph nodes:
TMJ:
Intraoral examination
Oral mucous membrane:
Buccal mucosa:
Labial mucosa:
Palate:
Tongue:
Vestibule:
Floor of the mouth:
Appendices 301
HALITOSIS
Local Causes:
Systemic Causes:
ORAL HYGIENE STATUS

(Green and Vermillion 1964)
DEBRIS INDEX CALCULUS INDEX
6 1 6 6 1 6
TOTAL DI SCORE = TOTAL CI SCORE =

TOTAL OHIS SCORE per person = DI – S + CI – S =
PLAQUE CONTROL RECORD

(O’ Leary T.J. 1972)
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
No. of teeth with plaque × 100

=%
No. of teeth present × 4
GINGIVAL STATUS
Others
Abscess
Exudate
Position
Contour
Bleeding on
probing
Surface
texture
Consistency
Shape
Size
Color
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Color
Size
Shape
Consistency
Surface
texture
Bleeding on
probing
Contour
Position
Exudate
Abscess
Others
Appendices 303
PERIODONTAL STATUS
Pathologic
Migration
Furcation
Mobility
Cal
Pockets
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Pockets
Cal
Mobility
Furcation
Pathologic
Migration
PERIOPLASTIC PROBLEMS
Gingival recession:
Width of attached gingiva soft tissue ablation:
Depth of vestibule:
Frenal attachment:
Mucosal/gingival/papillary/papilla penetrating:
Gingival pigmentation index:
Interdental papillary index:
DENTAL STATUS
No. of teeth present:
Missing teeth:
Caries:
Extrusion:
Over fillings:
Plunger cusps:
Hypersensitivity:
Food impaction:
WASTING DISEASE
Attrition:
Abrasion:
Erosion:
OCCLUSAL ANALYSIS
Type of malocclusion:
Overbite:
Overjet:
Crossbite:
Open contacts:
Wear patterns:
Fremitus test:
HABITS
Lip seal:
Mouth breathing:
Tongue thrusting:
Bruxism:
DIAGNOSIS
Differential diagnosis:
Appendices 305
Provisional:
Final diagnosis:
PROGNOSIS
Overall:
Individual:
TREATMENT PLAN
Emergency phase:
Extraction:
Others:
Phase I:
OHI:
Scaling and polishing:
Root planing:
Restoration:
Occlusal therapy:
Provisional splinting:
Others:
Phase II:
Periodontal surgery:
Curettage Periodontal flap Gingivectomy
Gingivoplasty Osseous Vestibuloplasty

surgery
Frenectomy/ Grafting (soft/ Perio – endo lesion

frenotomy hard)
Perio–plastic surgery ( others)
TREATMENT PLAN
Phase III: Rehabiltation:
Implants:
Conservative:
Prosthodontics:
Orthodontics:
Phase IV:
Appendices 307
Appendix 4:
Case History Proforma for Department of Prosthodontics
DIAGNOSIS CHART & TREATMENT RECORD FOR

COMPLETE DENTURE PATIENT
Patient’s name: _________________________________________
Age: __________Sex: __________ Out Patient No.:____________
Address: ______________________________________________
_______________________________________________________
Dept. case no.:____________________ Date :_________________
Phone No.: ____________________
Fee charged after concession: i) Rs._________ ii) Rs._________
Occupation: ___________________ Hobbies: ________________
Fee charged: i) Rs. _________ ii) Rs. _________
Fee paid: i) Rs. _________ ii) Rs. _________
Habits: ______________________ Receipt no.: i) _____ ii) _____
INSTRUCTOR HEAD OF THE DEPARTMENT
Chief complaint: ________________________________________

_______________________________________________________
H/O Major illness: ______________________________________
H/O Minor illness: ______________________________________
H/O Dental illness: _____________________________________
1. General Dental Health:
Good ____________ Fair ___________ Poor ____________
2. Causes of loss of teeth:

Caries_______Gum problems________Accident_______
3. Sequence of loss of teeth:
Irregular_______Anterior 1st______Posterior 1st________
Right side teeth 1st________ Left side teeth 1st_________
4. Duration of edentulousness:_______________________
5. Denture wearer:
Yes ______ No ______ If yes, duration__________________
6. Patient’s opinion & complains on existing previous
denture/s: _______________________________________
GENERAL EXAMINATION
Constitution:
Robust ____________ Frail ____________ Average ___________
Nutritional status:
Balanced _________________ Undernourished ______________
General resistance:
Poor_____________ Fair_____________ Good________________
Psychological attitude:
Co-operative _________ Exacting ________ Indifferent _______
Unco-operative ________________ Operative _______________
Patient’s expectancy:
Normal ________ Optimistic ________ Pessimistic ___________
Motivation for denture:
Mastication ________ Esthetics ________ Phonetics_________
On his own ___________ Somebody’s suggestion ___________
DENTAL EXAMINATION
1. Extraoral Examination
a. TMJ:
No abnormality detected _________ Abnormal ________
Crepitus_____________
Appendices 309
Asymmetrical movement _________ Tenderness ______

b. Maxilla-mandibular relation:
Ortho _________ Retro __________ Prognathic _________
c. Skin:
i. Complexion: Fair ______ Medium ______ Dark ______
ii. Wrinkles: Present ____________ Absent _____________
d. Facial feature:
Rugged _________ Delicate _________ Average ________
Square _________ Ovoid __________ Tapering _________
e. Face profile:
Convex ________ Concave _________ Straight _________
f. Facial musculature:
Tense ___________ Flaccid _________ Normal _________
g. Lips:
Short ___________ Long __________ Average __________
2. Intraoral Examination
a. Oral Mucosa:
No abnormality detected _________ Inflamed ________
Other abnormalities_______________________________
b. Hard palate:
Deep _________________ Flat average ________________
c. Palatine torus:
Normal ________________ Prominent ________________
Requiring relief ___________________________________
Severe undercuts requiring surgery _________________
d. Soft palate:
Width of posterior palatal seal:
Wide _________ Narrow _________ Average _________
Compressibility:
Compressible _________ Non-compressible ________
Gagging reflex:
Normal _________________ Excessive ______________
e. Tongue:
Size:
Large ___________________ Normal ________________
Gagging Reflex:
Normal _______________ Excessive ________________
Other abnormalities _____________________________
f. Floor of mouth:
No abnormality detected _________ Abnormal ________
g. Vestibule: Normal ____________ Abnormal ___________
h. Freni: Normal ______________ Abnormal _____________
i. Residual Ridges:
i. Arch form:
Upper: Square ______ Ovoid ______ Tapering _____
Lower: Square ______ Ovoid ______ Tapering _____
ii. Ridge size:
Upper: Favorable ________ Non-favorable _______
Lower: Favorable ________ Non-favorable _______
iii. Ridge form:
Upper: U-shaped __________ V-shaped __________
Knife edge ___________
Flat _________ Uneven ________ Smooth _________
Lower: U-shaped __________ V-shaped __________
Knife edge __________
Flat _________ Uneven ________ Smooth _________
iv. Mucosa:
Well-keratinized ________ Smooth & thin ________
Firm ______________ Hypermobile ______________
Other abnormalities ___________________________
v. Undercuts (location): Upper _______ Lower ______
vi. Ridge relation:
Class I _________ Class II ________ Class III _______
Appendices 311
vii. Interridge space:

mm approximately, average ____________________
Excessive _______________ Deficient ________________
j. Saliva:
Thick ____________ Thin ___________ Normal _________
Excessive ________ Deficient ______ Normal _________
k. X-ray advised: ___________________________________
X-ray report: ____________________________________
l. Operator’s opinion on existing denture: _____________
m. Pre-extraction records: ____________________________
DIAGNOSIS: ___________________________________________
TREATMENT PLAN:
1. Corrective measures:
Systemic: ___________________________________________
Local: ______________________________________________
2. Relief required over: _________________________________
(Mention the area)
3. Denture fabrication technique and materials
a. Primary impression: _______________________________
b. Secondary impression: ____________________________
c. Denture base: ____________________________________
d. Teeth:
Mold: __________________________________________
Shade: _________________________________________
Make: __________________________________________
e. Specify if any other materials/technique: ____________
_________________________________________________
PROGNOSIS: Poor ____________________ Fair ______________
INSTRUCTOR
TREATMENT RECORD
Sr. No. Date Work Done Sign of Staff

1. Primary Impression Upper
Lower
2. Secondary Impression Upper
Lower
3. Jaw relation
4. Try-in
5. Correction required
6. Denture delivery
Correction required
7. Check up
Correction done
8. Treatment Evaluation
Patient’s approval: Denture delivery:

Try-in:
INSTRUCTOR HEAD OF THE DEPARTEMENT

Appendices 313
Appendix 5: Case History Proforma for Department of

Conservative and Endodontics
CASE SHEET
OPD NO: _______________________ Date: __________________
Patient’s Name: ____________________ Age/Sex: ____________
Occupation: ___________________________________________
Address: _______________________________________________
_______________________________________________________
Telephone no.: _________________________________________
Chief complaint:
History of present illness:
Dental history:
Relevant drug/medical history:
Personal habits:
EXAMINATION
General Examination
Vital Signs:
Blood pressure:
Temperature:
Pulse rate:
Respiration rate:
Lymph nodes:
Temporomandibular joint:
Any swelling:
Intraoral Examination:
A. Soft tissue:
Lips and cheeks:
Vestibule:
Buccal mucosa:
Gingiva:
Any swelling/sinus tract:
B. Hard tissue: Teeth
Total no.:
Form/Morphology
Color:
Carious lesions:
Attrition/Abrasion/Erosion:
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Proximal relationships (contact and contours):

Occlusion:
Fracture:
Status of old restorations, if present:
Percussion test:
Palpation test:
Mobility:
Vitality testing:
Radiographic evaluation:
Any other diagnostic aids, if required:
Appendices 315
Clinical diagnosis:
Prognosis:
Treatment plan:
Patient’s consent:
Tooth Canals Working Final Reference

number length with working point
instrument length
Date Work done Staff sign.

Appendices 317

Oral and Maxillofacial Surgery
Name of Patient: ___________________ Date: __________________

Age/Sex: ___________________________ Time: ______________
Occupation: ___________________________________________
Address: _______________________________________________
_______________________________________________________
Chief complaint:
History of present illness:
Medical history:
Dental history:
Personal history:
Family history:
EXAMINATION
General examination
Built: Gait:
Speech:
Psychological status:
Vital signs
Blood pressure: Heart rate:
Temperature: Respiratory rate:
EXTRAORAL EXAMINATION
Inspection
Face:
Skin and soft tissues:
Skull:
Eyes:
Nose:
Malar and paranasal regions:
Ears:
Lips:
PALPATION
TMJ:
Lymph nodes:
Salivary glands:
Swelling:
Appendices 319
Muscles of mastication:
Interincisal opening:
Buccal/labial/alveolar mucosa:
Hard and soft palate:
Floor of the mouth:
Tongue:
Retromolar region:
Posterior pharyngeal wall:
Faucial pillars:
Salivary gland and their orifices:
Dentition and occlusion:
Provisional diagnosis:
INVESTIGATIONS
Radiographic investigations:
Laboratory investigations:
TREATMENT PLAN
Appendices 321

Public Health Dentistry
Date: ______________________ OPD No. ___________________

Student’s name: _______________________________________
Patient’s name: ________________________ Age/Sex: ___________
Date and place of birth: ___________________________________
________________________________________________________
Education: _________________ Occupation: _________________
Total income of family per month: ________________________
Per capita income: ________________________________________
Address: _______________________________________________
_______________________________________________________
Contact no: ______________________________________________
I. CHIEF COMPLAINT:
____________________________________________________
____________________________________________________
II. HISTORY OF PRESENT ILLNESS:
____________________________________________________
____________________________________________________
III. MEDICAL HISTORY:
Diabetes:
Hypertension:
Blood dyscrasias:
Hospitalizations:
Blood transfusions:
Medications:
Asthma:
Drug allergies:
Others:
IV. DENTAL HISTORY:
V. FAMILY HISTORY:
a. Siblings: Number ______________ Age________________

Has any family member suffered from a similar problem?
__________________________________________________
Do you know of any illness that runs in your family?
__________________________________________________
b. Marital status: Married
Unmarried
c. Children (if any) Number Age: _________
VI. PERSONAL HISTORY:
a. Personal Habits: Number Frequency Duration
1. Smoking:
2. Smokeless tobacco:
(with/without pan
chewing)
3. Pan chewing:
4. Alcoholism:
b. Habits related to oral cavity:
Mouth Thumb Tongue Bruxism Lip/Nail/Pencil
Breathing sucking thrusting biting
Duration: ___________________________________________
__________________________
c. Oral hygiene practices:
1. Type of cleaning:
Toothbrush Finger
Stick Any other (specify)
2. Method of cleaning:
Vertical Horizontal
Circular
3. Materials used:
Toothpaste Tooth powder
Charcoal Sand
Appendices 323
Brick powder other

4. Frequency of cleaning:
Once Twice Thrice
5. Time of brushing:
Before meals After meals
6. Frequency of changing the toothbrush:
_______________________________________________
7. Use of other oral hygiene aids:
Flossing Inter-dental aids
Oral mouth rinse
d. Dietary habits:
1. Vegetarian Mixed
2. Dietary chart: (Staple diet)
Time item Sugar Exposure
__________ ________________ _________________
__________ ________________ _________________
__________ ________________ _________________
__________ ________________ _________________
__________ ________________ _________________
__________ ________________ _________________
3. Sugar consumption (per day):
- Type:
Fermentable Less fermentable
- Frequency:
Once Twice
Thrice
Please specify, if more:
_____________________________________________
- Time of intake:
With meals Without meals
- Form and consistency:
Solid Liquid
Sticky Non-sticky
VII. GENERAL EXAMINATION:

Gait: ________________________ Pallor: ____________________
Posture: _____________________ Cyanosis: _________________
Built: _______________________ Edema: _________________
Blood pressure: ______________ Icterus: _________________
Pulse: _______________________ Height: _________________
Temperature: ________________ Weight: __________________
Respiratory rate: _____________ BMI: ____________________
VIII. LOCAL EXAMINATION:
a. Extraoral:
Symmetry: __________________________________________
TMJ: ______________________________________________
Lymph nodes: ______________________________________
b. Intraoral:
1. Soft tissue:
- Tongue ________________________________________
- Buccal mucosa _________________________________
- Labial mucosa _________________________________
- Gingiva:
Color ______________________________________
Contour ____________________________________
Consistency _________________________________
Size ________________________________________
Shape ______________________________________
Texture _____________________________________
Position ____________________________________
Bleeding on probing ____________________________
- Palate _________________________________________
- Floor of mouth _________________________________
- Alveolar mucosa _______________________________
2. Hard tissue:
Dentition:
Deciduous Mixed
Permanent
Appendices 325
Number of teeth present:

Teeth absent and reason for loss:
Root stumps:
Dental caries:
Non-cavitated:
Cavitated:
Filled teeth:
Any prosthesis (mention tooth):
Crown:
Bridge:
RPD/Implant:
Wasting disease:
Generalized Localized (mention tooth)
Attrition:
Abrasion:
Erosion:
Enamel Hypoplasia:
Generalized
Localized (Mention Tooth)
Fluorosis:
Generalized
Localized (Mention tooth)
Supernumerary teeth:
Any other anomaly please specify:
Malocclusion:
Trauma from occlusion:
Fractured/Non-vital tooth:
Stains: Extrinsic Intrinsic
3. Periodontal status:
Generalized Localized (Mention Tooth)
Gingivitis
Periodontal pocket
Mobility of teeth
Gingival recession
4. ORAL HYGIENE STATUS:
Dental deposits
Plaque Stains Calculus
Good Fair Poor
IX. PROVISIONAL DIAGNOSIS:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
X. INVESTIGATION:
_______________________________________________________
_______________________________________________________
_______________________________________________________
XI. DIAGNOSIS:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
XII. TREATMENT PLAN:
1. Emergency phase
_________________________________________________
_________________________________________________
_________________________________________________
2. Preventive phase
_________________________________________________
_________________________________________________
_________________________________________________
Appendices 327
3. Promotive phase
_________________________________________________
_________________________________________________
_________________________________________________
4. Curative or therapeutic phase
_________________________________________________
_________________________________________________
_________________________________________________
5. Rehabilitation
_________________________________________________
_________________________________________________
_________________________________________________
6. Maintenance phase
1. Recall
_______________________________________________
_______________________________________________
2. Review
_______________________________________________
_______________________________________________
3. Reassessment
_______________________________________________
_______________________________________________
XIII. COMMUNITY TREATMENT PLAN:
_______________________________________________________
_______________________________________________________
_______________________________________________________
Teacher’s signature
Appendix 8: Terminologies
Abfraction The pathologic loss of hard tooth substance caused

by biomechanical loading forces. Such loss is
thought to be due to flexure and chemical fatigue
degradation of enamel and/or dentin at some
location distant from the actual point of loading.
Ablation 1: Separation or detachment; extirpation; eradication.
2: Removal of a part, especially by cutting.
Abrasion 1: The wearing away of a substance or structure
(such as the skin or the teeth) through some unusual
or abnormal mechanical process. 2: An abnormal
wearing away of the tooth substance by causes
other than mastication.
Abscess Localized collection of purulent exudates (pus) in a
cavity formed by the disintegration of tissues.
Abutment Tooth, root, or implant used to support and/or anchor
a fixed or removable prosthesis.
Acute apical An inflammatory reaction to pulpal infection and
abscess necrosis characterized by rapid onset, spontaneous
pain, tenderness of the tooth to pressure, pus
formation and swelling of associated tissues.
Acute A response that is abrupt in onset and short in
inflammation duration characterized by the exudation of fluid,
serum proteins, inflammatory mediators and cells,
mainly polymorphonuclear leukocytes into the area
of injury; may become chronic if the injurious agent
persists.
Adhesion 1: The property of remaining in close proximity,
as that resulting from the physical attraction of
molecules to a substance or molecular attraction
existing between the surfaces of bodies in contact.
2: The stable joining of parts to each other, which
may occur abnormally. 3: A fibrous band or structure
by which parts abnormally adhere.
Appendices 329
Amalgam 1: An alloy of mercury 2: Dental amalgam is an alloy

of mercury, silver, copper, and tin, which may also
contain palladium, zinc, and other elements to improve
handling characteristics and clinical performance.
Analgesia Absence of sensibility to pain, designating particularly
the relief of pain without loss of consciousness.
Analgesic Pharmacological agent used to reduce sensibility to pain.
Anaphylac- A severe, sometimes fatal, immediate allergic reaction,
tic shock usually occurring seconds to minutes after exposure to
an antigen and is mediated via histamine.
Anaphylaxis Immediate hypersensitivity response to antigenic
challenge, mediated by IgE and mast cell histamine
release, typically life-threatening.
Anesthesia The loss of feeling or sensation as a result of an
anesthetic agent to permit diagnostic and treatment
procedures.
Ankyloglos- The binding of the tip of the tongue to the floor of
sia the mouth or the alveolar ridge due to abnormal
attachment of the lingual frenum.
Anomaly An aberration or deviation from normal anatomy,
development or function.
Anticoagu- Any substance or agent that inhibits or prevents the
lant coagulation of blood.
Apexifica- A method used to induce a calcified barrier in a
tion root with an open apex or the continued apical
development of an incompletely formed root in teeth
with necrotic pulps.
Apexogen- A vital pulp therapy procedure performed to encourage
esis continued physiological development and formation
of the root end; frequently used to describe vital pulp
therapy performed to encourage the continuation of
this process.
Appliance Any item that is attached to the teeth by the orthodontist
to move the teeth or change the shape of the jaw.
Arch, dental The curved composite structure of the natural dentition
and the alveolar ridge, or the residual bone after the loss
of some or all of the natural teeth.
Aseptic Free from infection.

Astringent An agent that causes contraction of tissues, arrests
secretion or controls bleeding.
Asymmetry Absence or lack of symmetry or balance;
dissimilarity in corresponding parts or organs on
opposite sides of the body.
Asymptomatic Inflammation and destruction of apical period
apical ontium that is of pulpal origin, appears as an apical
Periodontitis radiolucent area, and does not produce clinical
symptoms.
Asymptomatic A clinical diagnosis based on subjective and
irreversible objective findings indicating that the vital inflamed
pulpitis pulp is incapable of healing. Additional descriptors:
No clinical symptoms but inflammation is produced
by caries, caries excavation and trauma.
Atrophy 1: A wasting away 2: A diminution in size of a cell,
tissue, organ or part.
Attachment The distance from the cemento-enamel junction to
level, clinical the tip of the periodontal probe during periodontal
diagnostic probing.
Attrition The physiologic wearing away of a substance or
structure, such as a tooth, in the course of normal
use or parafunctional habits.
Atypical facial A syndrome characterized by a long-term
pain continuous aching or throbbing pain that does not
follow established neural pathways and a clinical
examination that does not reveal an apparent
cause. Multiple etiologies have been suggested.
Avulsion The complete separation of a tooth from its
(exarticulation) alveolus by traumatic injury; most commonly used
in reference to dental injuries resulting from acute
trauma.
Biofilm The colonization and proliferation of micro-
organisms at a surface and solution interface.
Appendices 331
Biopsy The removal of tissue for histologic examination

and diagnosis.
Bleaching The use of a chemical agent, sometimes in com-
bination with heat, to remove tooth discolorations.
Bracket A metal or ceramic part that is glued onto a tooth
and serves as a means of fastening the arch wire.
Bruxism An oral habit consisting of rhythmic or spasmodic
nonfunctional grinding or clenching of teeth.
Bruxomania The grinding of teeth occurring as a neurotic habit
during the waking state.
Calculus, A hard concretion that forms on teeth or dental
dental (tartar) prostheses through calcification of bacterial plaque.
Canal, pulp A passage or channel in the root of the tooth
(root canal) extending from the pulp chamber to the apical
foramen; may be narrow, have lateral branches and/
or exhibit irregular morphology.
Candidiasis An infection with a fungus of the genus Candida,
(thrush) usually C. albicans, that is associated with several
predisposing factors including the use of broad
spectrum antibiotics, pregnancy, xerostomia, diabetes
mellitus, and suppression of the immune system.
Clinical features include soft, white, curd-like plaques
that can be wiped away leaving an erythematous
area.
Carcinoma A malignant growth of epithelial cells, tending to
infiltrate the surrounding tissues, giving rise to
metastases.
Caries, dental A localized and progressive bacterial infection
that results in the disintegration of a tooth, usually
beginning with the dissolution of enamel and
followed by bacterial invasion.
Cavernous Blood clot that may arise from a maxillary apical
sinus infection and settles in the cavernous sinus.
thrombosis
Cavitation The formation of submicroscopic voids as a result

of shearing a fluid medium by the alternating high
frequency movement of an instrument tip; creates
shock waves that propagate throughout the medium
when voids implode.
Cellulitis A symptomatic edematous inflammatory process
that spreads diffusely through connective tissue
and fascial planes; frequently associated with
an infection by invasive microorganisms with
subsequent breakdown of connective tissue.
Chlorhexidine A bis-biguanide antiseptic agent used to prevent
colonization of microbes and to kill or inhibit
microorganisms on surfaces; known for its substantivity.
Chronic An inflammatory reaction to pulpal infection and
apical necrosis characterized by gradual onset, little or no
abscess discomfort, and the intermittent discharge of pus
through an associated sinus track.
Chronic A response that is slow in onset and of long-
inflammation standing duration characterized by proliferation
of fibroblasts and vascular endothelium and an
influx of lymphocytes, plasma cells, macrophages
and inflammatory mediators. It may be primary or
preceded by acute inflammatory response.
Clicking With respect to temporomandibular articulation, a
snapping or cracking noise is evident on movement
of one or both mandibular condyles.
Coagulation The process of changing from liquid to solid,
(clotting) especially of blood.
Composite An organic, polymerizable resin mix that typically
contains inorganic particles treated with a bonding
or coupling agent polymerized by light or chemical
mechanisms.
Concussion A traumatic tooth injury characterized by tenderness
to percussion and no mobility or displacement.
Appendices 333
Condensing Diffuse radiopaque lesion representing a localized

osteitis bony reaction to a low-grade inflammatory stimulus,
usually seen at apex of tooth.
Cracked tooth A phenomenon involving posterior teeth in which
fractures usually involve the marginal ridges;
primarily in minimally restored mandibular first
and second molars; symptoms may vary but pain
to chewing and thermal sensitivity are common.
Cross bite The bite that occurs when some of the upper teeth
are inside the lower teeth during the biting process.
Crowding Discrepancy between tooth sizes and arch length
and/or tooth positioning that results in malalignment
and abnormal contact relationships between teeth.
Deep bite An excessive overbite.
Dentinal The short, exaggerated, painful response elicited
hypersensitivity when exposed dentin is subjected to certain
thermal, mechanical, or chemical stimuli.
Denture An artificial substitute for missing natural teeth and
adjacent tissues.
Diagnose To recognize or determine the nature of a disease
or abnormal state or condition by study and
consideration of the signs and symptoms and their
manifestation.
Diastema A space between two adjacent teeth in a dental arch.
Edema An accumulation of fluid in a tissue.
Emphysema, An accumulation of air or other gas in tissue spaces;
subcutaneous in endodontics, usually results from injection of
air through the root canal into surrounding soft
tissues or from air-driven dental handpieces used
in surgical procedures.
Emphysema A pathological accumulation of air or gas in tissue
spaces. In the oral and facial regions, it may be
caused by an air syringe, an air-driven dental
handpiece, coughing, or blowing the nose.
Epithelium, The tissue serving as the lining of the intraoral

oral surfaces. It extends into the gingival crevice and
adheres to the tooth at the base of the crevice.
Erythema Redness of the skin or mucous membranes
produced by congestion of the capillaries.
Etiology The study of the causes of disease; alternately, the
cause of a disease.
Exfoliation 1. The shedding of something, such as epithelial
cell from the surface of the body. 2. In dentistry, the
physiological loss of the primary dentition; the loss
of implanted materials.
Exostosis A benign, bony growth projecting outward from the
surface of a bone.
Extrusion Movement of a tooth in an incisal or occlusal
direction; can be intentional, physiologic or
traumatic; also extension of obturating materials
beyond the apical foramen.
Exudates Fluid, cells and plasma proteins that have escaped
from the vascular system and accumulated in a
tissue or tissues; usually the result of inflammation.
Facial profile The outline form of the face from a lateral view.
Fascial space Microbes and their products expanding into potential
infection anatomic spaces between structures.
Fetor oris Foul, offensive odor from the oral cavity.
Fistula An abnormal canal joining the cavities of two hollow
organs or the cavity of an organ and the surface of
the body.
Flap, surgical A section of tissue, such as gingival mucosa, that
has been partially detached from the underlying
tissue but retains uninterrupted blood supply
through an intact base.
Flare-up An acute exacerbation of an asymptomatic pulpal
and/or periradicular pathosis after the initiation or
continuation of root canal treatment.
Appendices 335
Fluctuant A tactile sensation of fluid motion noted during

palpation of a mass or swelling such as an abscess.
Fluorosis, A form of enamel hypoplasia. Mottling and
dental discoloration of enamel results from ingestion of
excessive amounts of fluoride during the apposition
phase of tooth development.
Food The forceful wedging of food into the interproximal
impaction space by chewing pressure (vertical impaction)
or the forcing of food interproximally by tongue or
cheek pressure (horizontal impaction).
Fracture A split or break in bone, cartilage or tooth structure.
Freeway The space between the maxillary and mandibular
space teeth when the mandible is suspended in the
postural position.
Furcation The anatomic area of a multi rooted tooth where
the roots diverge.
Gingiva The fibrous investing tissue, covered by keratinized
epithelium, that immediately surrounds a tooth and
is contiguous with its periodontal ligament and with
the mucosal tissues of the mouth.
Halitosis Breath that is offensive to others, caused by a
variety of reasons including but not limited to
periodontal disease, bacterial coating of tongue,
systemic disorders, and different types of food.
Hematoma A localized collection of extravasated blood, usually
clotted, that forms in a tissue, organ or space.
Hypertrophy The enlargement or overgrowth of an organ or part
due to an increase in size of its constituent cells.
Iatrogenic Resulting from the activity of the clinician; applied
to disorders induced in the patient by the clinician.
Impacted tooth An unerupted or partially erupted tooth so positioned
that complete eruption is unlikely.
Implant Material inserted or grafted into the tissues of a host.
Impressions The process of making a mold of the teeth; bite

impression is taken in a container filled with a
substance that hardens to produce a mold of
the teeth.
Infection Invasion and proliferation of pathogenic micro
organisms in body tissues and the reaction of the
tissues to their presence.
Informed An agreement by the patient to have treatment
consent rendered by the provider after the risks of the
treatment, the results of no treatment, the alternatives
to treatment and prognoses have been explained.
Leukoplakia A non-specific white patch in the oral cavity which
will not rub off.
Lichen planus An inflammatory mucocutaneous disorder
characterized by discrete skin papules with a
keratinized covering which often appears in the
form of adherent scales.
Luxation Displacement of a tooth from its original position
in the alveolus, without total avulsion, resulting
from acute trauma.
Malocclusion Any deviation from a physiologically-acceptable
relationship of opposing teeth.
CLASS I The normal mesiodistal relation of the maxillary
(Neutrocclusion) and mandibular teeth with the mesiobuccal cusp
of the maxillary first permanent molar occluding
in the buccal groove of the mandibular first
permanent molar.
CLASS II The dental relationship wherein the mandibular
(DistoccIusion) dental arch is posterior to the maxillary arch; the
mandibular first molar is located distal to that seen
in neutrocclusion.
CLASS III The dental relationship wherein the mandibular
(Mesiocclusion) dental arch is anterior to the maxillary arch; the
mandibular first molar is located mesial to that
seen in neutrocclusion.
Appendices 337
Mastication The process of chewing food in preparation for

swallowing and digestion.
Materia alba Loosely adherent, white curds of matter composed
of dead cells, food debris, and other components
of the dental plaque found on the tooth.
Mouth The process of breathing primarily through the
breathing oral cavity rather than the nasal passages. May
be associated with gingival enlargement and
inflammation.
Mouthguard A removable device used to protect the teeth and
mouth from injury caused by sporting activities.
The use of a mouthguard is especially important
for orthodontic patients.
Mucocele A cyst or cyst-like structure that contains mucous
glycoproteins.
Mucositis Inflammation of a mucous membrane.
Myositis Inflammation of a muscle.
Nightguard A removable appliance worn at night to help an
individual minimize the damage or wear while
clenching or grinding teeth during sleep.
Nodule A small, solid, collection of tissue.
Normal apical Teeth with normal periradicular tissues that are not
tissues sensitive to percussion or palpation testing. The
lamina dura surrounding the root is intact and the
periodontal ligament space is uniform.
Normal pulp A clinical diagnostic category in which the pulp
is symptom-free and normally responsive to pulp
testing.
Open bite A malocclusion in which teeth do not make contact
with each other. With an anterior open bite, the
front teeth do not touch when the back teeth are
closed together. With a posterior open bite, the
back teeth do not touch when the front teeth are
closed together.
Osteoporosis A metabolic bone disease of variable etiologies that

results in a net decrease in bone mass; characterized
by disproportionate osteoclastic activity in cells.
Over-filling A solid or semi-solid core root canal filling extending
beyond the apical foramen; commonly used to imply
that the root canal space is completely obturated.
Overbite Vertical overlapping of the mandibular incisors by
the maxillary incisors when the jaws are in centric
(habitual) occlusion.
Pain A multifactorial noxious experience that involves
not only the sensory response but also modification
by cognitive, emotional and motivational influences
related to past experience.
Palpation The use of the sense of touch to examine tissue for
diagnostic reasons, such as to determine texture,
rigidity and tenderness.
Paresthesia A sensation such as burning, prickling or partial
numbness caused by neural injury; sometimes
follows acute traumatic injuries or infection to the
teeth and jaws, root-end resection or overfilling of the
root canal with impingement upon a nerve.
Periodontitis Inflammation of the supporting tissues of the teeth.
Usually a progressively destructive change leading to
loss of bone and periodontal ligament. An extension
of inflammation from gingiva into the adjacent bone
and ligament.
Periodontium The tissues that invest and support the teeth including
the gingiva, alveolar mucosa, cementum, periodontal
ligament, and alveolar and supporting bone.
Pigmentation The deposition of coloring matter; coloration or
discoloration of a part by a pigment.
Plaque An organized mass, consisting mainly of
microorganisms, that adhere to teeth, prostheses,
and oral surfaces and is found in the gingival crevice
and periodontal pockets.
Appendices 339
Pocket A pathologic fissure between a tooth and the

crevicular epithelium, and limited at its apex
by the junctional epithelium. It is an abnormal
apical extension of the gingival crevice caused
by migration of the junctional epithelium along the
root as the periodontal ligament is detached by a
disease process.
Previously A clinical diagnostic category indicating that
initiated the tooth has been previously treated by partial
therapy endodontic therapy (e.g. pulpotomy, pulpectomy).
Previously A clinical diagnostic category indicating that the
treated tooth has been endodontically treated and the
canals are obturated with various filling materials
other than intracanal medicaments.
Probing depth The distance from the soft tissue (gingiva or alveolar
mucosa) margin to the tip of the periodontal probe
during usual periodontal diagnostic probing.
Prophylaxis, The removal of plaque, calculus, and stains from
oral the exposed and unexposed surfaces of the teeth
by scaling and polishing as a preventive measure
for the control of local irritational factors.
Pulp necrosis A clinical diagnostic category indicating death of
the dental pulp. The pulp is usually non-responsive
to pulp testing.
Pulpotomy The removal of the coronal portion of a vital pulp as
(pulp a means of preserving the vitality of the remaining
amputation) radicular portion; may be performed as emergency
procedure for temporary relief of symptoms or
therapeutic measure, as in the instance of a Cvek
pulpotomy.
Pus A product of inflammation consisting of leukocytes,
degenerated tissue elements, tissue fluids, and
microorganisms.
Pyorrhea An archaic term for several periodontal diseases.
Ranula Forms in the floor of the mouth as a result of trauma

or blockage of a salivary gland duct. It may be lined
with epithelium.
Recession Location of marginal periodontal tissues apical to
the cemento-enamel junction.
Removable An orthodontic appliance that can be removed from
appliance the mouth by the patient. Removable appliances
are used to move teeth, align jaws and to keep
teeth in their new positions when the braces are
removed (retainers).
Resorption A condition associated with either a physiologic or
a pathologic process resulting in a loss of dentin,
cementum and/or bone.
A loss of substance from tissues that normally are
calcified, such as the dentin or cementum of teeth,
or of the alveolar process. The condition may be
physiologic or pathologic.
Reversible A clinical diagnosis based upon subjective and
pulpitis objective findings indicating that the inflammation
should resolve and the pulp returns to normal.
Sextant One of the six relatively equal sections into which
the dental arches can be divided. Anterior sextants
contain the incisor teeth and canines; posterior
sextants include the premolar and molar teeth.
Sinus tract A pathway from an enclosed area of infection to
an epithelial surface; opening or stoma may be
intraoral or extraoral and represents an orifice
through which pressure is discharged; usually
disappears spontaneously with elimination of the
causative factor by endodontic treatment.
Space A fixed appliance used to hold space for an
maintainer unerupted permanent tooth after a primary (baby)
tooth has been lost prematurely, due to accident
or decay.
Appendices 341
Stain 1: A soiled or discolored spot; a spot of color in

contrast to the surrounding area 2: A preparation
used in staining 3: In dentistry, the discoloration of
a tooth surface or surfaces as a result of ingested
materials, bacterial action, tobacco, and/or other
substances.
Stippling The pitted, orange-peel appearance frequently
seen in attached gingiva.
Stomatitis Inflammation of the soft tissues of the oral cavity.
Supernumerary A genetic occurrence in which there are more
teeth teeth than the usual number. These teeth can be
malformed or erupt in abnormal position.
Symptom Subjective evidence of disease or physical
disturbance; something that indicates the presence
of a bodily disorder.
Symptomatic Inflammation, usually of the apical periodontium,
apical producing clinical symptoms including a painful
periodontitis response to biting and/or percussion or palpation.
It may or may not be associated with an apical
radiolucent area.
Symptomatic A clinical diagnosis based on subjective and
irreversible objective findings indicating that the vital inflamed
pulpitis pulp is incapable of healing. Additional descriptors:
Lingering thermal pain, spontaneous pain, referred
pain.
Transudate Any fluid substance that has passed through a
membrane or tissue surface; sometimes associated
with inflammation.
Traumatogenic An occluding of the teeth that is capable of
occlusion producing injury to oral structures.
Wires Also known as arch wires, they are held in the
brackets using small elastic o-rings or stainless
steel wire ligatures. Wires are used to move the
teeth.
Index
Page numbers followed by f refer to figure and t refer to table
A American Society of
Aberrant salivary gland duct 161 Anesthesiologists 71
Abfraction 38, 39f, 223f, 328 Amiodarone 52
Ablation 328 Amyloidosis 43, 45
Abrasion 38, 200, 221f, 328 Analgesia 329
Abscess 29, 48, 140, 185, 328 Anaphylactic shock 329
Accessory ducts 161 Anaphylaxis 329
Acinic cell tumor 162 Anemia 32, 56, 67, 68, 78
Acquired defects 55 Anesthesia 329
Addison’s disease 51 Angioedema 167
Adenoameloblastoma 14 Angular cheilitis 167
Adenocarcinoma 162 Ankyloglossia 12, 170, 171f, 329
Adenomatoid odontogenic Anodontia 199, 200
tumors 55 Anorexia 43
Adhesion 328 nervosa 15
Adnexal skin tumor 29, 31 Antalgic gait 118
Adrenal insufficiency 69 Anticoagulants 68, 329
Aglossia 170 Anxiety 45, 68
Agranulocytosis 32 Apexification 329
Albinism 134 Apexogenesis 329
Alcohol consumption 107 Aphthous stomatitis, recurrent
Alkaptonuria 54 35
Allergic reactions 32 Apical abscess
Allergies 34, 69 acute 328
Alveolar bone, osteomyelitis chronic 332
of 47 Apical periodontitis 330
Alzheimer’s disease 68 Aplasia 161
Amalgam 264, 329 Aphthae chancre 34
Ameloblastic fibro-odontoma Arch 192, 329
15 length deficiency and
Amelogenesis imperfecta 54, skeletal pattern 56
198, 199, 215, 217 Arthritis 78
Aspiration 117 gums, history of 40
Aspirin 69, 79 recurrent 41
Asthma 69, 78, 133 Bleomycin 52
Ataxic gait 118 Blood
Atrophy 330 disease 78
Attachment loss and gingival dyscrasias 32
recession 187 pressure 118, 121
Attrition 12, 15, 200, 222f, 227,
urea nitrogen test 247
330 Bluish discoloration of tongue
Atypical facial pain 28, 330 171
Auscultation 117 Body
Automatic blood pressure mass index, calculation of
device 126f 118, 136
equipment 125 surface area 13
Automatic pulse meter 127f temperature 130
Avulsion 330 Bone
disease 48
B grafts 261
Bacterial infection 32 Bottle feeding 95
Bacterial parotitis 162 Brachial and radial arteries of
Barbiturates 79 arm, anatomy of 129f
Basal cell Bracket 331
adenoma 15 Bradypnea 133
carcinoma 29, 31, 15 Brain 28
Basophils 243 Branchial cleft cysts 29
Behçet’s Breastfeeding, duration of 90
disease 72 Breath, shortness of 78
syndrome 32 Fibromatosis, gingival 55
Bell’s palsy 43, 139 Bronchiectasis 48
Benzoyl arginine- Bronchitis 48, 69, 133
naphthylamide test (BANA) Brown heme-associated lesions
50 51
Bilateral cleft lip 166f Brown melanotic lesions 51
Biopsy 240, 331 Bruxism 82, 222, 104, 224f, 331
Black hairy tongue 170 Bruxomania 331
Bleaching 331 Buccal mucosa
Bleeding carcinoma of 15
chronic 41 examination of 167
disorder 67-69, 78 Bulimia 43
Index 345
Bullous pemphegoid 34 Christmas disease 41

Busulfan 52 Circumvallate papillae 169
Clear cell carcinoma 162
C Cleft
Cancer 28, 69, 78, 134 lip 12, 166
fear of 45 palate 12, 174, 175f
Candida albicans 43, 241 tongue 170
Carotenemia 51 Cleido-cranial dysostosis 215
Carcinoma 331 Clofazimine 52
adenoid cystic 162 Cluster headache 28
in situ 15 Codeine 79
Cardiorespiratory disorders 67 Cold tests 241
Caries Combined periodontal/
acute 194 endodontic lesions 185, 186
chronic 194 Compartment nodes, anterior
classification of 194 148
recurrent 194 Competent lips 144
Carotid Complete blood count 242
artery 128 Composite resin 264
body tumor 29 Computed tomography 162, 238
Cavernous sinus thrombosis Condensing osteitis 333
331 Congenital erythropoietic
Celiac disease 56, 68 porphyria 54
Cellulitis 29, 332 Congenital hyperbilirubinemia
Cephalic index 138 54
Cerebral palsy 56 Congenital syphilis 216
Cerebrovascular accident 68 Congestive heart failure 68
Cervical abrasion 39f Cotton test 103
Charged couple device 238 Cough 78
Chemotherapy 34, 78 Cracked tooth 333
Chest disease 69 syndrome 28, 40
Chicken pox 216 Cranial arteritis 28
Child sucking thumb 83f Crohn’s disease 32, 68
Chipping 227 Cross bite 333
Chlorhexidine 332 Cyanosis 51, 118, 135
Chloroquine 52 Cyclophosphamide 52
Chlorpromazine 52 Cystic fibrosis 43
Chondrosarcoma 15 Cysts 29, 31, 47
D Dilated composite odontome

208
Dane system 192
Discolored teeth 53
De Lange’s syndromes 107
Dolichocephalic skeletal pattern
Deciduous teeth
101f
ankylosis of 55
Doxorubicin 52
apical periodontitis of 55
Doxycycline 69
Deep bite 333
Drug-induced aspirin burn 32
Dehydration 43
Dry
Delayed tooth eruption 21, 55,
mouth 21, 42, 45
57
nasal mucosa 48
Dens
socket 48
evaginatus 199, 210, 210f
Ducts, atresia of 161
in dente 199, 208
Dunlop’s beta hypothesis 91
invaginatus 208, 209f
Dysosteosclerosis 56
Dental
caries 40, 55, 193
assessment 193 E
charting 272f Eating disorders 69
fluorosis 225 Ectopic eruption 56
prophylaxis, frequency of 61 Edema 118, 135, 184, 333
Dentinal Electronic battery-powered
dysplasia 215, 218 devices 125
hypersensitivity 36, 333 Emphysema 333
etiology of 37 Enamel
Dentinogenesis imperfecta 54, hypoplasia 54, 198, 199f,
198, 215, 218 224, 226f
Dentoalveolar structure 87 pearl 55, 200, 213, 214f
Dentures, artificial 48 Enameloma 213
Depression 45 Endemic fluorosis 216
Developmental cysts 31 Endocarditis, categories of 68
Diabetes 43, 68, 78 Endocrine
acetone odor of 48 disease 68
mellitus 45, 248 disorders 56, 67
Diabetic coma 133 End-stage renal disease 43
Diastema 333 Eosinophils 243
Diastolic pressure 122 Epidermolysis bullosa 34
Digit sucking, diagnosis of 85 dystrophica 215
Digital thermometer 131f Epilepsy 78
Index 347
Erosion 15, 38, 200 Fixed appliances 93

Erythema 184, 334 Fixed bridges 62
multiforme 34 Fixed intraoral antithumb
Erythrocyte sedimentation rate sucking appliances 93
243 Floor of mouth, examination
Everted lips, evaluation of 144 of 168
Ewings sarcoma 15 Fluorosis 54, 199, 335
Exanthematous disease 216 Folic acid deficiency 32
Exfoliation 334 Fordyce’s granules 143
Exogenous 50 Fractures 227, 335
Exostosis 334 Fremitus 227
Extrinsic discoloration 54 Frenum attachments 171
Extrusion 334 Fried’s rule 13
Exudates 334 Frostbite 134
Fungiform papillae 169
F Furcation 335
Face, shape of 139, 140t assessment 188
Facial Fusion 199, 205
arthromyalgia 28
divergence 141, 142f G
fractures 140 Gait 118
hemiatrophy 12 Gastroesophageal reflux disease
hemihypertrophy 12 45
index 139 Gastrointestinal
space infection 334 disorders 67
swellings 140 disturbances 216
symmetry 139 Gemination 199, 206
Fasting plasma glucose 248, 249 Genetic disorders 56
Fetor oris 334 Genitourinary system 69
Fibroma 29, 31 Geographic tongue 45, 170
Fibromatosis 31 Ghost teeth 219
Filiform papillae 169 Giant cell granuloma, peripheral
Fine needle aspiration cytology 29
(FNAC) 239 Gingiva 87, 102, 335
Finger sucking 81 Gingival recession and
Fissured tongue 12, 170 attachment loss, causes of
Fistula 334 38t
Fits and faints 67 Gingivitis 184
Glass ionomer 264 Hemiplegic gait 119
Glaucoma 78 Hemochromatosis 51
Glomerular filtration rate 247 Hemoglobin 243
Glossopharyngeal neuralgia 28 Hemophilia 12, 15, 41
Glysylated hemoglobin 249 Hemorrhagic disorders 41
Goiter 29 Hepatitis 68, 78
Graft-versus-host disease 43 viruses A 77
Granular cell tumor 29, 31 Hereditary
Granulomas 31 hemorrhagic telangiectasia
Granulomatous diseases 43 51
GV Black’s classification 195 opalescent dentin 218
Herpangina 34
H Herpes simplex virus 34, 77
Habit breaking appliance 99f Herpes zoster virus 34
Habit crib appliance 92f Herpetic gingivostomatitis 185,
Halitosis 47, 335 186
Hard High blood pressure 78
and soft palate, examination HIV 32
of 173 and AIDS 69, 78
tissue examination 191 infection 43, 56
Hawley’s retainer 91 oral melanosis 51
Hay fever animals 79 Hodgkin’s disease 15, 152
HBA1C test 249 Human immunodeficiency virus
Head 45, 77
and neck, lymph nodes of Hydrodynamic theory 37
145f Hydroxychloroquine 52
shape 138 Hypercementosis 200, 213
types of 138t Hyperplasia, gingival 55
Headache 78, 134 Hyperpnea 133
Healing oral wounds 48 Hypersensitivity 21
Heart Hypertension 68, 122
disease 68, 134 angina 68
valves, artificial 78 Hyperthyroidism 69
Heat test 242 Hypertonic orbicularis oris 95
Hemangioma 162 Hypertrophy 335
Hematoma 335 Hyperventilation 133
Hemifacial hypertrophy/ Hypofunction 47
hypotrophy 139 Hypoglycemia 134
Index 349
Hypoparathyroidism 56 J
Hypopituitarism 56, 134
Jaundice 51, 67, 68
Hypoplasia 161, 215
Jaw
causes of 215
cysts 29
Hypoprothrombinemia 41
deviation, causes of 154
Hyposalivation 48
fractures of 154
Hyposensitive palate 95
infection of 154
Hypotension 122
pain 78
Hypothyroidism 56, 69, 134
Joint
artificial 78
I noise 60
Ichthyosis 56 prosthesis, artificial 69
Icterus 118, 136 sounds 155
Idiopathic disorders 43 Juvenile
Idiopathic orofacial pain 28 diabetes mellitus 71
Impacted tooth 335 periodontitis 12, 14
Inadequate attached gingiva 38
Incisors, flaring of 102f K
Infantile
Kaposi’s sarcoma 51
scurvy 216
Keratoacanthoma 15, 31
tetany 216
Ketoconazole 52
Infection 32, 45, 67, 215, 336
Kidney
Inflammation
disease 67, 78
acute 328
dysfunction, uremic breath
chronic 332
of 48
Internal derangements 28
function tests 247
Internal jugular chain 149
examination of 151f
Internalized discoloration 55 L
International classification of Late stage liver disease 43
diseases (ICD) system 231 Lateral pterygoid muscles,
Intrinsic discoloration 54 palpation of 157f
Iodine 69 Lead poisoning 135
Iron 32 Lesch-Nyhan syndrome 107
deficiency anemia 14, 170 Leukemia 32, 41, 69, 134
Irregular teeth 21 Leukoplakia 15, 336
Irreversible pulpitis, Lichen planus 34, 45, 336
asymptomatic 330 Lingual thyroid nodule 171
Lip 86, 143 Mandibular tori 168
and labial mucosa, Masseter muscles
examination of 165 bimanual palpation of 157f
biting 82, 106 palpation of 157f
competency/posture 144 Masseteric hypertrophy 29
habits 144 Mastication, muscles of 156
pits and commissural pits Mastoid nodes 149
166 Materia alba 337
sucking 82 Matrix, mineralization of 199
Lipoma 31 Maxillary
Liposarcoma 15 and mandibular
Lipstick sign 44 mucobuccal folds 169
Lisping distortions 95 central incisor 202f
Liver lateral incisor, dens
disease 68, 78 evaginatus on 210f
function tests 244 sinusitis 28
Loose teeth 21, 46 Maximum interincisal opening
Lower jugular nodes 147 154
Lupus erythematosus 34 Mean corpuscular
Luxation 336 hemoglobin 243
Lymph nodes 145 volume 243
classification of 147 Measles 216
examination of 148, 179 Mechanotherapy 93, 97
Lymphadenopathy 29 Medial pterygoid muscle,
Lymphatic drainage of face, area palpation of 157f
of 152 Median rhomboid glossitis 12,
Lymphocytes 243 171
Lymphoepithelial cysts 29 Melanoma 29, 31
Lymphoid aggregates 29 Melanoplakia 51
Lymphoma 29, 31, 162 Melanotic macule 51
Mercury thermometer 131f
M Mesenchymal neoplasm 29
Macrodontia 199, 204, 204f Mesenchymal tumor 29, 31
Macroglossia 95, 170 Mesiodens 201
Magnetic resonance imaging Mesomorph 119
163, 238 Metastatic carcinoma 29
Malnutrition 43, 162 Microdontia 199, 205, 205f
Malocclusion 96, 196, 336 Microglossia 170
correction of 99, 104 Middle jugular nodes 147
Index 351
Migraine attack 134 Nasoalveolar cyst 14

Mikulicz’s disease 161 Nasopharynx 28
Milk extrinsic sugars 109 Neck nodes, examination of
Minocycline 52 146f
Missing teeth 21 Neuropathic pain 27, 27t
Mixed tumor, malignant 162 Neutrophils 242
MMP 60 Nodes
Mobility test 190 location of 146
Moderate motor disability 95 number of 146
Monocytes 243 Nonodontogenic tumors 55
Mouth Nonsteroidal anti-inflammatory
breathing 82, 94, 337 drugs (NSAIDs) 71
burning sensation of 45 Nuclear bone scans 238
guard 337
Mucocele 29, 31, 162, 337 O
Mucoepidermoid carcinoma Obstructive
162 breathing 133
Mucosal disorders 45 pulmonary disease, chronic
Mucositis 337 69, 133
Mucous membrane pemphigoid Occlusal
34 therapy 262
Multiple trauma 38
myeloma 15, 42 treatments 260
sclerosis 69 Odontoblastic transduction
Muscle theory 36
of mastication, examination Odontodysplasia 215, 219
of 157f Odontogenesis imperfecta 219
pain 59 Odontogenic tumor 29, 55
Muscular hypertrophy and Odontomas 55
hypotrophy 154 Open bite 337
Myasthenia gravis 14 Optic neuritis 28
Myoepithelioma 162 Oral
Myofacial pain 28 candidiasis 32
Myositis 337 cavity, pigmented lesions of
53
N clefts 56
Naber’s probe 189f contraceptives 52
Nail biting 82, 106 glucose tolerance test 249
hygiene instruction 255 Papillomavirus 77
lichen planus 15 Paraneoplastic pemphigus 34
malodor 47 Paresthesia 21, 338
mucosal pigmentation 50 Parkinson’s disease 69, 118
pigmented lesions, Parotid gland 163
classification of 50 diseases 15
screen 104f duct 164
ulcers 34t Parotid nodes 149
diagnosis of 33 Parulis 29, 31
malignant 35t Pemphigous vulgaris 34
Organoleptic scoring scale 49 Penicillin 69, 79
Orofacial Percussion test 195
pain, classification of 28t Pericoronal abscess 185, 186
soft tissues swelling 29t Pericoronitis 48, 185, 186
Orthognathic surgery 263 Periodontal
Ossifying fibroma 14, 29 abscess 185
Osteoarthritis 69 disease 38
Osteocartilaginous choristoma examination 180
29 pocket assessment 186
Osteogenesis imperfecta 215 surgery 38, 261
Osteomyelitis 48 therapy 260, 261
Osteonecrosis 48 Periodontitis 12, 338
Osteoporosis 134, 338 acute 185
Paget’s disease 139 chronic 48, 184
Pain 21, 23, 60, 227, 338 Periodontium 338
analysis of 24 Peutz-Jegher’s syndrome 51
duration of 24, 26 Pheochromocytoma 135
nature of 24, 26 Pigmentation 338
progression of 24, 26 Pit and fissure
radiation of 24, 26 caries 195
site of 25 sealants 264
types of 24, 25 Platelet 243, 244
disorders 41
P Pleomorphic adenoma 14, 162
Pallor 118, 134 Pneumonia 48
Palpation 117, 154, 177, 179, 338 Polymerase chain reaction 50
Panic attack 134 Poor oral hygiene 38, 48
Papillary cystadenoma Postauricular nodes,
lymphomatosum 162 examination of 150f
Index 353
Postherpetic neuralgia 28 occlusal 233, 234, 235f

Post-rubella purpura 42 panoramic 236, 237f
Preauricular nodes 149 Radiotherapy 34
examination of 150f Ramsay Hunt syndrome 28
Prenatal syphilis 216 Ranula 29, 31, 162, 169, 340
Preorthodontic trainer 98f, 103 Rapid deep breathing 133
Primary tooth, premature loss Rapid shallow breathing 133
of 55 Recent myocardial infarction 68
Pseudohypoparathyroidism 56 Red blood cell count 243
Psychogenic disorders 45 Regional odontodysplasia 56
Psychological nipple, use of 90 Reiter’s syndrome 32
Psychosocial stress 45 Removable appliance therapy
Pulp 98
amputation 339 Renal
necrosis 339 disease 69, 247
stones 12 failure 56
vitality testing 241 Replacing missing teeth 268
Pulpal Resorption 340
hemorrhagic products 54 Respiration 118, 132
pathology 40 types of 133
Pulpotomy 339 Respiratory tract, infection of 48
Pulse 118, 127 Restricted jaw motion 60
pressure 122 Retained infantile swallow 94
Pyogenic granuloma 29 Reversible pulpitis 340
Pyorrhea 339 Rheumatic fever 68, 78
Rheumatoid arthritis 69
Q Root
Quad helix 93, 93f resorption 12, 54
Quinacrine 52 surface caries 195
Quinidine 52
S
R Salivary
Radial artery 127 adenocarcinomas 31
Radiograph adenomas 31
bitewing 233, 234, 234f gland 158, 159f
digital 236 disease 28, 45
interproximal 234 hypofunction 45
intraoral 233 tumor 29
disorders of 161 Soft palate, types of 175f

neoplasm 29 Soft tissue examination 165

tumor 29 Space infection 29

Sarcoidosis 43, 45 Spastic gait 119
Sarcomas 31 Sphygmomanometer 122f, 124f
Scalene nodes 149 Squamous cell carcinoma 29,
Scar tissue 55 31, 32, 34, 162, 171
Scarlet fever 12, 78, 216 adenoid cystic 15

Schizophrenia 69 Stabbing pain 26
Schonlein-Henoch purpura 41 Stenson’s duct 164
Scleroderma 139 Stethoscope, parts of 123f
Scurvy 135 Stevens-Johnson syndrome 32
Seborrheic keratosis 29, 31 Stippling 341
Segmental odontomaxillary Stomatitis 45, 341
dysplasia 56 nicotina palati 15

Seizure disorders 68 Streptococcus mutans 44
Sexually transmitted disease 69 Submandibular
Shooting pain 26 gland 164

Sialadenitis 29 nodes 148

Sialendoscopy 163 Sub-mandibular nodes,
Sialocysts 31 examination of 149f
Sialography 161 Submental nodes 148
Sialolithiasis 29, 161 examination of 148f

Sialorrhea 162 Sucking reflex 83
Sibilant distortions 95 Superficial temporal artery 128
Sickle cell anemia 14 Supernumerary teeth 55, 199,
Sinus tract 340 201, 202f, 341
Sjögren’s Supraclavicular chain,
disease 45 examination of 151f

syndrome 14, 43, 45, 161 Sweet score, interpretation of

Skin rash 78 109
Sleep deprivation 135 Swelling 21, 27, 78
Slow breathing 133 examination of 176

Smiles, types of 268f progress of 28

Smoker’s recurrence of 28, 30

breath 48 shape of 176

melanosis 51 site of 28, 176

palate 176, 176f Syncope 68

Smooth surface caries 195 Synodontia 205
Inde 355
x
Syphilis 32 treatment of 97

Systemic lupus erythematosis examination of 169

69 Tonsil stones 48
Tonsillitis 48, 78, 95
T Tooth
Tachypnea 133 discoloration, classification

Talon cusp 199, 210, 211f of 54

Teeth, concrescence of 208f eruption 55

Temporomandibular fracture 228, 228f

disorders 21, 59 migration 227

wear and gingival recession

joint 59, 153

55

anatomy of 153f
Toothbrush abrasion 38

pain 28
Torus palatinus 174

Teratoma 12
Tetracycline 52 Translucency 177
staining 54 Transverse cervical nodes 149
Trauma 34, 215

TFO, etiology of 228
Thermal sensitivities 28 acute 38

Thermoplastic thumb post 91, chronic 38

92f Traumatic ulcer 32, 35
Throbbing pain 25 Traumatogenic occlusion 341
Thrombocytopenic purpura 41 Trigeminal neuralgia 28
Thumb and Trophic disturbances 216
digit sucking 82 Tuberculosis 32, 34, 43, 78, 135
Tumor of jaw 47

finger sucking 95
Turner’s

Thumb sucking 81
control of 89 hypoplasia 215, 216

tooth 216

development of 85

Two digit system 191

Thyroglossal cysts 29
Thyroid 68
disease 14, 43 U

function test 246, 246t Ulcer, examination of 178

neoplasm 29 Ulceration in oral cavity 48

TMJ arthralgia 60 Ulcerative colitis 32
Tongue 86 Ulcers 31, 32f, 45, 170
blade sign 44 aphthous 15, 52

diagnosis of 96 Universal system 192

etiology of 94 Unstable angina pectoris 68

Upper arch 273f W
model of 210f Warthin’s tumor 162

Upper Wasting diseases of teeth 220
jugular nodes 147 Water test 103

respiratory tract infection 94 Weight gain 134

Urinary tract disease 69 White blood cell counts 242
William’s periodontal probe 187
V
Vague pain 25 X
Vascular disease, peripheral 134 Xerostomia 42, 43, 48, 162
Verrucous carcinoma 15 causes of 42
Viral parotitis 162

Visceral larva migrans 135 Y
Vital signs 118, 121
Young’s rule 13
Vitamin
B12 32, 45
Z

C deficiency 41, 216

D deficiency 134 Zidovudine 52

D resistant rickets 56 Zsigmondy and palmer system

K deficiency 41 192

History Taking and

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

History Taking and

Uploaded by

Copyright:

Available Formats

History Taking and

Charu M Marya BDS MDS PhD

The Health Sciences Publishers

Anil Gupta MDS Hind Pal Bhatia MDS

SM Kotrashetti MDS Vandana Dahiya MDS

It gives me great pleasure to write a foreword for History Taking and

I would like to express my gratitude to many people who provided

8. Personal Dental History 81

Alterations in Number of Teeth 200

“Accurate diagnosis of a disease depends on the art of taking

The principles of practice in dentistry

Responsibilities of a dental professional:

Case history is defined as planned professional conversation

Fig. 1.1: Listen to the patient

•• Record maintenance for future reference and periodic

Patient records must be accurate, well-organized, legible,

yy A dental record should provide an accurate picture of the patient’s

healthcare professionals for the purpose of assisting in

•• Details about referrals

Establishing a good rapport (Fig. 2.1) with the patient

Fig. 2.1: Establishing a good rapport

System for gathering information (techniques)

yy Give the patient your undivided attention

facilitate this process, the clinician should exhibit an attentive

The dental history will give an idea of the:

There is usually a traditional approach in the design of a

It is recorded so as to impart knowledge to the investigator

PATIENT REGISTRATION NUMBER

•• Psychological benefit; especially in case of pediatric patient,

Conditions commonly occurring in old age:

–– Infantile/childhood growth spurt

BSA is determined from a nomogram using the child’s height

Behavior Management Techniques

• Dosage of drugs: The dosage of drug is affected by certain

telephone number of a friend or next of kin; name, address

Socioeconomic status (SES) is assessed by looking at an individual group’s

Thus, occupation can be an important factor in determining

The chief complaint is established by asking the patient to

complaint should become the dentist’s chief treatment priority.

After establishment and recording of the chief complaint, the

•• The questions can be asked in the following manner:

DETAILED HISTORY OF A PARTICULAR

Note the following:

If the history of the presenting complaint includes pain, ask

•• Site of Pain: Determining the original site of pain is

–– Stabbing pain: Sudden, severe, sharp and shortlived pain,

Table 5.1: Differential diagnosis of odontogenic and

Pain can be either odontogenic or neuropathic (Table 5.1).

Table 5.3: Orofacial soft tissues swelling according to site

duration are mostly inflammatory (acute), whereas those

•• Mode of onset : The dentist may ask, “How did the

Table 5.4: Masses according to palpation characteristics

(Modified from Eversole LR, Silverman S. Swellings and tumors of the

abscess, then diagnostic testing for odontogenic or periodontal

Ulcer (Fig. 5.1)

Fig. 5.1: Ulcers

Common types of ulcers in the oral cavity

If an ulcer is present, assess whether it is localized or part

Note the relation of any prosthesis, sharp teeth, or dental

Diagnosis of Oral Ulcers

and symptoms or lesions on the skin and/or other mucous

Table 5.5: Oral ulcers

ulcers have a removable, yellow-white base and erythematous