A checklist of past and/or present dental

problems is useful both to ascertain the patient’s

previous dental history, and as a
screen for current problems which may
have yet to be diagnosed. The example
shown in Fig 2.5 has a number of ‘screening’
items for temporomandibular disorders,
as well as dental and periodontal
problems.
• Dietary profile: excessive amounts or high
frequency of intake of fermentable carbohydrates
in the diet are clearly major factors
in dental caries. At the systemic level,
good general health demands a healthy
and balanced diet.
• Oral hygiene habits: what is the patient’s
daily oral hygiene regimen? How often
does the patient brush, and what type of
toothbrush is used? Does the patient use
dental floss and, if so, how often? What
other oral hygiene devices does the patient
use?
MEDICAL HISTORY
The importance of an adequate medical history
before dental treatment cannot be exaggerated.
For the patient’s health and well-being, and for
the dentist’s protection, a thorough medical
history must be obtained and regularly updated.
Contemporary concerns with widespread
communicable and infectious diseases,
and with an aging population, many of whom
are taking multiple medications for a variety
of ailments, make this aspect of data gathering
even more critical.
There is no single answer to the question of
‘how much is enough?’ when taking a medical
history. It is necessary to balance the interests
of time and energy with our need to gather critical
information. Histories that are overly intrusive
or cumbersome in their length and detail
may frustrate or annoy the patient, even to the
point of their withholding critical information.
Histories that fail to identify illnesses or conditions
that clearly impact on dental treatment
can put both patient and dentist at risk. In any
event, when a written history form or questionnaire
is used, it is absolutely essential to review
it verbally with the patient, restating critical
questions and clarifying positive responses or
non-responses.
There are clearly a number of medical issues
that must be addressed in the dental environment;
these include, but are not necessarily limited
to, the following:
PATIENTíS GENERAL HEALTH
When was the last physical examination or
doctor visit, and what were the findings? Is the
patient currently under treatment for any medical
condition? Has the patient been hospitalized
recently (in the past 2–5 years), and for
what reason? Who is the patient’s physician (or
physicians)? This is often a good point at which
to obtain vital signs, generally including pulse,
temperature, respiration, and blood pressure
(Fig 2.6).
What drugs or medications (prescription
or nonprescription) is the patient currently
taking? Answers to these questions, if adequately
explored with the patient, can give
a fairly clear picture of the patient’s general
health status.
Fig 2.6
Vital signs, including blood pressure, are obtained and
recorded.
26 STRATEGIES IN DENTAL DIAGNOSIS AND TREATMENT PLANNING
The issue of medications is particularly critical,
because an ever-growing percentage of the
population is taking one or more (and often
many more) drugs on a daily basis. Some of
these may be prescribed thera-peutics for acute
and chronic illnesses, such as oral agents for
the control of non-insulin-dependent diabetes,
or nonsteroidal antiinflammatory drugs for
chronic inflammatory diseases; some are preventive
in nature such as prescription cholesterol-
lowering agents, or non-prescription lowdose
daily aspirin; some are health- promoting
agents obtained over the counter such as vitamins,
herbal preparations, or nutritional supplements.
The potential for drug interactions among
the many agents being ingested is always
present, and when we add potentially stressful
dental procedures, and additional prescription
or nonprescription medications given in
the course of dental treatment to the mix, the
pharmacologic situation becomes even more
complex. Finally, the patient may not always
tell us about all of the drugs being taken, in
some cases because they are illegal or involve
issues of abuse. Likewise, compli-ance with
prescribed drug regimens is not generally good,
and so some of what the patient tells us about
their medication regimen may be truer in
theory than in practice.
ALLERGIES AND SENSITIVITIES
Has the patient had a reaction to a drug, medication,
or anything else (foods, pollens, insect
bites, etc)? If so, what type of reaction was it? It
is important to differentiate a severe anaphylactic
allergy to penicillin, for example, from ‘heartburn
and gas’ caused by an erythromycin compound.
Latex allergies are a significant and
growing problem, given the widespread use of
latex gloves and dams in dental treatment.
SYSTEMIC DISEASES
A number of systemic conditions have dental
implications. Damaged heart valves may create
a risk of endocarditis if seeded by oral microorganisms.
Diabetes may compromise a
patient’s ability to fight dental infection, or to
heal properly after dental surgery. Active tuberculosis
presents a risk to the dentist and
auxiliary personnel, and cocaine use may precipitate
severe reactions to local anesthet-ics
with vasoconstrictors. (Please refer to the
sources cited for far more comprehensive discussion
of this general topic.) For purposes of
this discussion, the systemic diseases and conditions
in the box, grouped by system, are appropriate
to the dentist’s medical history.
Endocrine: arthritis, diabetes, thyroid problems
Respiratory: asthma, tuberculosis, shortness of breath
Cardiac: heart disease, rheumatic fever, heart murmur, heart
valve problems, pacemaker, high blood pressure, chest
pains, swollen ankles
Blood: abnormal bleeding, anemia, transfusions, fatiguability
Gastrointestinal/genitourinary: jaundice, hepatitis, liver disease, contact with HIV or
AIDS virus, sexually transmitted disease, kidney disease
Central nervous system: epilepsy, fainting spells, nervous disorder/psychiatric
care
THE PATIENT INTERVIEW 27
Fig 2.7
The medical history can be compact, while addressing many critical issues. The check box items in the first three columns
are arranged by system: endocrine, respiratory, cardiac, blood, gastrointestinal/genitourinary (GI/GU), and central
nervous system (CNS). The right-hand column addresses history of malignancy, joint replacement, habits (tobacco,
alcohol, other drugs), and pregnancy potential.
28 STRATEGIES IN DENTAL DIAGNOSIS AND TREATMENT PLANNING
Fig 2.8
Patient questionnaires can be many pages long. This example is condensed to a single page. Note the specific box for
updates (upper right).
THE PATIENT INTERVIEW 29
ISSUE OF PAST DISEASES, CONDITIONS,
AND TREATMENT
The following issues may have significant dental
implications:
• Malignant and/or non-malignant tumors.
• Radiation therapy.
• Artificial or prosthetic joints.
• Use/abuse of tobacco, alcohol, narcotics,
or other illicit drugs.
• Other past medical conditions, especially
those requiring hospitalization and/or surgery.
• Pregnancy issues: female patients must be
queried as to pregnancy, not only whether
they know themselves to be pregnant, but
whether there is any potential that they
could become so. We may need to prescribe
drugs the safety of which is not established
in pregnancy, or drugs that are clearly contraindicated,
and the patient may not be
cognizant of an unplanned or early pregnancy.
The example medical questionnaire shown in
Fig 2.7 is a reasonable and adequate history
form, but, as with any pre-printed questionnaire,
it would still require verbal review to be
fully effective. You will note that it clusters certain
items to establish a systematic review. It
also includes documentation of subsequent
updates over time.
Combined on a single page, the medical,
dental, and dietary histories provide a compact
instrument for information gathering (Fig 2.8).
Without a doubt, a history form may be considerably
more extensive than suggested here,
and each clinician is entitled to his or her own
opinions as to the breadth and depth of the history.
Geographic locale, type of clinic and patient
population, and the practitioner’s own
judgment will shape the medical history; what
is offered here are minimum guidelines for a
typical general dental practice.
Just as important as a thorough initial history
and review is the regular review and updating
of the information. The dates of such
reviews, and the initials of the person documenting
such updates, are critical, both for
obvious medico-legal reasons and to help cue
the dentist and dental team to perform the function
on a regular basis.
Finally, the importance of verbal review and
reiteration cannot be overstated. The potential
for patients to forget, confuse, or omit important
information is considerable, and can put
both patient and practitioner at risk.5,6
REFERENCES
1. Chambers D, Abrams R, Dental Communication.
OHANA GROUP: Sonoma CA, 1992.
2. Milgrom P, Treating Fearful Dental Patients: A patient
management handbook Reston Publishing
Co. Reston, VA, 1985.
3. Corah NL, Development of a dental anxiety
scale. J Dent Res 1969; 45:569.
4. Ronis D, Hansen C, Antonakos C, Equivalence
of the original and revised Dental Anxiety
Scales. J Dent Hygiene 1995; 69:270–2.
5. Sampson E, Meister F, The importance of verbally
verifying a health history. Wisconsin Dent
Assoc J 1981; 1:15–17.
6. McDaniel T, Miller D, Jones R, Davis M, Assessing
patient willingness to reveal health history
information. J Am Dent Assoc 1995; 126:375.

31
RADIOGRAPHS IN THE
COMPREHENSIVE EXAMINATION
Radiographs are indispensable in dental diagnosis
and treatment. Much of the information
obtained with a radiograph is unobtainable
any other way. Dental radiographs assist
in discovering pathology and non-pathologic
abnormalities, and in confirming normal
healthy conditions. With current technology
and technique, radiographs are a safe and
cost-effective tool in dental diagnosis and
treatment.
TYPES OF DENTAL RADIOGRAPHS AND
THEIR APPLICATION
Intraoral films
• The standard periapical (PA) film is the
most common and versatile radiographic
tool in dentistry. With it, we can image
an entire tooth or several teeth, including
the apex and periapical region. PA
films can be used for an emergency assessment
(usually one or two films), or
regional surveys, or a full mouth survey
(Figs 3.1 and 3.2).
• Turned horizontally and held with a cardboard
sleeve or adhesive tab, the bite wing
film is probably the most frequently used
radiograph in dentistry. It can clearly demonstrate
proximal caries and interproximal
periodontal bone levels, as well as many
other findings of clinical crown and crestal
bone (Fig 3.3).
Turned vertically with an adhesive or
mechanical film holder, a vertical bite wing
film can be used to visualize periodontal
bone levels in advanced periodontitis, or
post-periosurgical patients, which may not
be covered by the normal horizontal bite
wing. Figure 3.4a illustrates an acceptable
bite wing film which nevertheless fails to
demonstrate bone crest in the maxillary
molar region. The vertical bite wings (Fig
3.4b) demonstrate the bone level despite
significant periodontal bone loss.
• The occlusal film offers broader coverage to
assess bone trauma and pathology away
from teeth such as cysts, stones, etc (Fig 3.5).
Extraoral films
• Much of the head and facial skeleton is displayed
on panoramic films which are useful
in screening situations to assess trauma (especially
mandibular fractures), demonstrate
cysts, and locate third molars and other notable
findings or conditions that are not in
the usual range of PA films. Panoramic films
can be used instead of PAs for patients who
do not tolerate intraoral films well. Definition
of detail is not as good, however, and
some panoramic formats are non-diagnostic
in the anterior region (Fig 3.6).
• Temporomandibular joint films, including
transcranial, tomograms, and corrected
tomograms, produce images of the condyle
and fossa of varying quality (Fig 3.7). Computed
tomography (CT) can produce
highly detailed images of bony structures,
but both the cost and the radiation dose are
high. Soft tissue derangements are not demonstrable
with any of these films. Arthrography,
with injection of contrast

3 RADIOGRAPHS
32 STRATEGIES IN DENTAL DIAGNOSIS AND TREATMENT PLANNING
Fig 3.3
Standard double bite wing films.
Fig 3.1
The standard single periapical radiograph.
Fig 3.2
Six anterior PAs provide
a wealth of information
regarding both coronal and
apical conditions in this
patient’s mouth.
RADIOGRAPHS 33
Fig 3.4
(a) Standard bite wings of patient’s left posterior, losing the crestal bone in the maxilla, (b) Turned vertically, the crestal
bone is demonstrated.
Fig 3.5
(a) An occlusal film, maxillary anterior, (b) Here standard
PA films are used as occlusal films in a child, with similarly
good results.
34 STRATEGIES IN DENTAL DIAGNOSIS AND TREATMENT PLANNING
media into the joint space(s), is definitive
of soft tissue derangement, but somewhat
invasive (Fig 3.8). Magnetic resonance
imaging (MRI) can demonstrate both bone
and soft tissue joint components and, although
non-invasive, is quite costly, timeconsuming,
and often difficult to interpret
(Fig 3.9).
• Skull projection films, taken at various angles,
can demonstrate specific areas and
problems. Most common in dentistry is the
lateral or frontal cephalometric film, used
to diagnose orthodontic problems and to
predict growth patterns (Fig 3.10).
• Bone scans employing radioactive isotopes,
which accumulate in areas of rapid bone
Fig 3.6
(a) Panoramic radiograph; (b) with some panoramic technology, the image is split at the midline.
Fig 3.7
(a) The head of the condyle is imaged in the glenoid fossa in this transcranial view, (b) Transcranials of both joints in
closed, rest, and open positions.
RADIOGRAPHS 35
metabolism (either osteoblastic or osteoclastic),
can point to bone pathology such
as osteomyelitis in various areas of the head
and neck. Such scans are extraoral in that
the film is not placed in the mouth. The
patient becomes the radiation source, however,
as the isotopes collect and decay in
affected regions.
SELECTION AND USE
HOW MANY?
The extremely low radiation dosage employed
in dental radiography, especially when combined
with collimation and protective leaded
drapes and collars, provides a high degree of
Fig 3.8
Radio-opaque die injected into the joint space helps define
soft tissue joint components in this temporomandibular
joint arthrogram.
Fig 3.9
Magnetic resonance imaging of the joint and fossa region,
Fig 3.10
(a) Oblique extraoral view of mandible, (b) Lateral skull projection, suitable for cephalometric analysis.
36
37
Fig 3.11
Current guidelines for ‘How often?’. (This chart has been adapted and reprinted with permission from Eastman Kodak Company.)
ADA—American Dental Association
AGD—Academy of General Dentistry
AAOMR—American Academy of Oral and Maxillofacial Radiology
AAOM—American Academy of Oral Medicine
AAPD—American Academy of Pediatric Dentistry
AAP—American Academy of Periodontology
FDA—United States Food and Drug Administration
38 STRATEGIES IN DENTAL DIAGNOSIS AND TREATMENT PLANNING
safety and confidence. The dentist may have to
educate patients in this area. The most common
radiographs used in dentistry are also very costefficient.
Therefore, the answer to ‘how many?’
is ‘enough,’ that is, we must obtain a sufficient
number of good quality radiographs to make
accurate diagnoses. This is a professional, ethical,
and legal standard of care. On the other
hand, we must also take care not to take more
radiographs than are needed simply to fill up
slots on the mount. Radiographs should always
be based on diagnostic need, rather than any
routine protocol.
Example 1. An 18-year-old male patient is seen
as an emergency after a blow to the
chin (sports accident). There is
swelling and bruising on lip and
chin, and two lower incisors are
very loose. What radiographs are
indicated?
Answer. As this is an emergency and not
a fully comprehensive examination,
only the areas of immediate
concern need to be imaged. This
would include PA views of the
loosened anterior teeth, and
panoramic or other extraoral images
of the mandible to diagnose
or rule out fracture either at the
site of the trauma or elsewhere
within the mandible. The
condyles need to be imaged, because
the neck region is the thinnest
portion of the bone, and most
at risk of fracture.
Example 2. A 57-year-old new female patient
(missing all bicuspids and molars)
needs general dental care, including
upper and lower distal extension
partial dentures. What radiographs
are indicated?
Answer. A combination of panoramic film
and anterior PAs to image the teeth
and surrounding bone will provide
good coverage. As an alternative to
the panoramic film, holding devices
of various types can be used
to image posterior edentulous areas.
Example 3. A 34-year-old fully dentulous male
with numerous visible carious lesions
and fractured teeth is seen for
a new patient examination. He recalls
having bite wing radiographs
a year or so ago. What radiographs
are indicated?
Answer. The presence of active dental disease
calls for current and accurate
diagnostic data. A full mouth series,
including periapicals of all teeth and
double bite wings, is indicated.
HOW OFTEN?
Frequency is another issue involving both cost
and exposure. Here again routine protocols
(bite wings every 6 months) based solely on
time interval are not acceptable. Current guidelines,
developed by a panel of experts representing
the ADA, AGD, AAOMR, AAOM,
AAPD, AAP, under the sponsorship of the FDA
are outlined in Fig 3.11.
Example 1. A 12-year-old boy with eight proximal
carious lesions visible on radiograph
will be placed on 6-
month recalls for examination,
cleaning, and fluoride. When
would you next take bite wing radiographs?
Answer. As a result of the high caries rate
and likelihood of undetectable incipient
caries, follow-up bite wings
at the 6-month recall are indicated.
Based on findings at that time, continued
monitoring at 6–12 month
intervals may be indicated.
Example 2. A 40-year-old new female patient
has no pathology or abnormality
visible in full-mouth radiographs.
No dental treatment is needed,
other than routine cleaning. When
would you next take a full series
of radiographs?
Answer. Assuming that regular check-ups
reveal no pathology, and no symptoms
arise, this patient could easily
go 3–5 years or more before another
full series is taken.
Example 3. A pregnant 24-year-old female patient
is seen on emergency with an
acute dental abscess. She agrees to
endodontic therapy, and two addiRADIOGRAPHS
39
tional appoint-ments are scheduled.
What radiographs would you take?
Answer. Using appropriate shielding, there
is no contraindication to dental radiographs
in pregnancy. This clinical
situation calls for periapical diagnostic
and measurement films
appropriate to endodontic therapy.
Sensitivity to patient concerns and
careful education may be required
to allay fears.
The general operative principle in the selection
and use of dental radiographs is to obtain
whatever films are necessary for diagnosis
and treatment planning consistent with
radiation safety and cost-effectiveness. All
dental radiographs must meet minimum
standards for quality, that is, they must be ‘diagnostic’
films, properly aligned, exposed, and
processed.
Inadequate radiographs can seriously compromise
dental and oral diagnosis, and lead to
inappropriate or untimely treatment. The
reader is encouraged to consult the many excellent
reference works for specific details regarding
dental radiography.
Digital radiography, employing a radiationsensitive
receiver in place of the X-ray film, can
produce digital images on a computer monitor
almost instantaneously. It has the advantage of
lower radiation exposure as a result of the great
sensitivity of the receiver, and having images
available immediately is a great convenience
and time saver. Applications in endodontic
treatment and surgery, especially for measurement
and assessment of work in progress, are
obvious. Drawbacks at this time include the
high cost of the technology, difficulty in archival
storage which requires considerable computer
capacity, and problems from the medicolegal
standpoint. As digital images can be
altered without a trace, their use as evidence
can be questioned. These problems may well
be addressed with advances in technology in
years to come.