Lesson title: The dental chart (Diagnosis and Treatment planning part 1)

Lesson Objectives:
1. Learn how to fill up the dental chart
2. Learn the proper way of gathering information for dental recording.
3. Learn how to utilize the necessary information for proper diagnosis
4. Learn how to make your own chart.

Productivity Tip:
PRACTICE MEMORY TRICKS. There are memory competitions every year, and despite what you think, the
champions aren’t savants with rare memory gifts. They’re average people like you and me. Here’s a simple
trick you probably already know. Make up a song around things you’re trying to memorize. The same way
you learned the alphabet as a kid will be the same way you can memorize and study for an upcoming quiz or
test. Read and say things repeatedly. Singers cannot master a song by reading the lyrics once unless they
have a photographic memory.

MAIN LESSON Activity 2: Content Notes (13 mins)

EXAMINATION
(Existing Condition)
(General, Extraoral and Intraoral)
In an examination, the clinician uses sight, touch, and hearing to detect abnormal conditions. To
avoid mistakes, it is critical to record what is actually observed rather than to make diagnostic
comments about the condition. For example, “swelling,” “redness,” and “bleeding on probing of gingival
tissue” should be recorded, rather than “gingival inflammation” (which implies a diagnosis).
Thorough examination and data collection are needed for prospective patients who desire fixed
prosthodontic treatment, and more detailed protocols for this effort can be obtained from various
textbooks of oral diagnosis.

General Examination
The patient’s general appearance, gait, and weight are assessed. Skin color is noted, and vital
signs, such as respiration, pulse, temperature, and blood pressure, are measured and recorded.
Middle-aged and older patients can be at higher risk for cardiovascular disease. Relatively inexpensive
cardiac monitoring units are available for in-office use (Fig. 1-8). Patients whose vital sign
measurements are outside normal ranges should be referred for a comprehensive medical evaluation
before definitive prosthodontic treatment is initiated.

THE VITAL SIGNS:

Temperature
Temperature recording gives an indication of core body temperature which is normally tightly
controlled (thermoregulation) as it affects the rate of chemical reactions. Body temperature is
maintained through a balance of the heat produced by the body and the heat lost from the body.
Temperature can be measured from the mouth, rectum, axilla (armpit), ear, or skin. Oral, rectal, and
axillary temperature can be measured with either a glass or electronic thermometer. Note that rectal
temperature measures approximately 0.5 °C higher than oral temperature, and axillary temperature
approximately 0.5 °C less than oral temperature. Aural and skin temperature measurements require
special devices designed to measure temperature from these locations. While 37 °C (98.6 °F) is
considered "normal" body temperature, there is some variance between individuals. Most have a
normal body temperature set point that falls within the range of 36.0 °C to 37.5 °C (96.5–99.5 °F).
A glass thermometer or an electronic thermometer can be used in different areas of the body
(see locations above). When a glass thermometer is taken, the reading is done usually 5mins after. If an
electronic thermometer is used, there is usually a beep sound when it is ready to be read in the LCD
display. If an electronic infrared (gun-type) thermometer is used, it is better to point it (1) inside the ear
or (2) inside the mouth or (3) in the forehead or (4) in the neck for more accurate reading as pointing it
in the wrist since the temperature of the extremities are lower than your core temperature.
The main reason for checking body temperature is to solicit any signs of systemic infection or
inflammation in the presence of a fever. Fever is considered temperature of 37.8 °C or above. It is also
recommended to review the trend of the patient's temperature over time. A fever of 38 °C does not
necessarily indicate an ominous sign if the patient's previous temperature has been higher.

Pulse
The pulse is the rate at which the heart beats while pumping blood through the arteries,
recorded as beats per minute (bpm). It may also be called "heart rate". In addition to providing the
heart rate, the pulse should also be evaluated for strength and obvious rhythm abnormalities. The
pulse is commonly taken at the wrist (radial artery). Alternative sites include the elbow (brachial artery),
the neck (carotid artery), behind the knee (popliteal artery), or in the foot (dorsalis pedis or posterior
tibial arteries). The pulse is taken with the index finger and middle finger by pushing with firm yet
gentle pressure at the locations described above, and counting the beats felt per 60 seconds (or per 30
seconds and multiplying by two). The pulse rate can also be measured by listening directly to the
heartbeat using a stethoscope. The pulse may vary due to exercise, fitness level, disease, emotions,
and medications. The pulse also varies with age. A newborn can have a heart rate of 100–160 bpm, an
infant (0–5 months old) a heart rate of 90–150 bpm, and a toddler (6–12 months old) a heart rate of 80–
140 bpm. A child aged 1–3 years old can have a heart rate of 80–130 bpm, a child aged 3–5 years old a
heart rate of 80–120 bpm, an older child (age of 6-10) a heart rate of 70–110 bpm, and an adolescent
(age 11–14) a heart rate of 60–105 bpm. An adult (age 15+) can have a heart rate of 60–100 bpm.
Conditions with elevated pulse rate (Tachycardia):
Adrenergic storm Dysautonomia Pacemaker mediated Drug related:
Anaemia Exercise Pain Alcohol
Anxiety Fear Pheochromocytoma Stimulants
Atrial fibrillation Hypoglycemia Sinus tachycardia Cannabis (drug)
Atrial flutter Hypovolemia Sleep deprivation Drug withdrawal
Atrial tachycardia Hyperthyroidism Supraventricular tachycardia Tricyclic antidepressants
AV nodal reentrant tachycardia Hyperventilation Ventricular tachycardia Nefopam
Brugada syndrome Junctional tachycardia Wolff–Parkinson–White Opioids (rare)
syndrome
Conditions with low pulse rate (Bradycardia):
Heart tissue damage related to aging
Damage to heart tissues from heart disease or heart attack
Heart disorder present at birth (congenital heart defect)
Infection of heart tissue (myocarditis)
A complication of heart surgery
Underactive thyroid gland (hypothyroidism)
Imbalance of chemicals in the blood, such as potassium or calcium
Heart tissue damage related to aging
 Repeated disruption of breathing during sleep (obstructive sleep apnea)
Inflammatory disease, such as rheumatic fever or lupus
Medications, including some drugs for other heart rhythm disorders, high blood pressure and psychosis

Blood Pressure
Blood pressure is recorded as two readings: a higher systolic pressure, which occurs during the
maximal contraction of the heart, and the lower diastolic or resting pressure. In adults, a normal blood
pressure is 120/80, with 120 being the systolic and 80 being the diastolic reading. Usually, the blood
pressure is read from the left arm unless there is some damage to the arm. The difference between
the systolic and diastolic pressure is called the pulse pressure. The measurement of these pressures is
now usually done with an aneroid or electronic sphygmomanometer. The classic measurement device
is a mercury sphygmomanometer, using a column of mercury measured off in millimeters. In the
United States and UK, the common form is millimeters of mercury, while elsewhere SI units of pressure
are used. There is no natural 'normal' value for blood pressure, but rather a range of values that on
increasing are associated with increased risks. The guideline acceptable reading also takes into account
other co-factors for disease. Therefore, elevated blood pressure (hypertension) is variously defined
when the systolic number is persistently over 140–160 mmHg. Low blood pressure is hypotension.
Blood pressures are also taken at other portions of the extremities. These pressures are called
segmental blood pressures and are used to evaluate blockage or arterial occlusion in a limb.
There are two types of high blood pressure.
Primary (essential) hypertension
For most adults, there's no identifiable cause of high blood pressure. This type of high blood
pressure, called primary (essential) hypertension, tends to develop gradually over many years.
Secondary hypertension
Some people have high blood pressure caused by an underlying condition. This type of high
blood pressure, called secondary hypertension, tends to appear suddenly and cause higher blood
pressure than does primary hypertension. Various conditions and medications can lead to secondary
hypertension, including:
Obstructive sleep apnea
Kidney disease
Adrenal gland tumors
Thyroid problems
Certain defects you're born with (congenital) in blood vessels
Certain medications, such as birth control pills, cold remedies, decongestants, over-the-counter pain relievers
and some prescription drugs
Illegal drugs, such as cocaine and amphetamines

Dental significance: The patient’s physician must be contacted before any dental procedure is done
even if the blood pressure of the patient is normal at the time of the dental visit. The planned
procedure and medications to be given should be discussed with the physician. Appointments and
dental procedures should be as short as possible.

Respiratory Rate
Average respiratory rates vary between ages, but the normal reference range for people age 18
to 65 is 16–20 breaths per minute. The value of respiratory rate as an indicator of potential respiratory
dysfunction has been investigated but findings suggest it is of limited value. Respiratory rate is a clear
indicator of acidotic states, as the main function of respiration is removal of CO2 leaving bicarbonate
base in circulation.
Conditions with abnormal Respiratory Rate:
Apnea Dyspnea Hyperpnea
Tachypnea Hypopnea Bradypnea
Orthopnea Platypnea Biot's respiration
Cheyne-Stokes respiration Kussmaul breathing

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Extraoral Examination
(TMJ, Muscles of mastication, Lips)
Special attention is given to facial asymmetry because small deviations from normal may hint at
serious underlying conditions. Cervical lymph nodes are palpated, as are the TMJs and the muscles of
mastication.
Temporomandibular Joints Examination
The clinician locates the TMJs by palpating bilaterally just anterior to the auricular tragi while the
patient opens and closes the mouth. This enables a comparison between the relative timing of left and
right condylar movements during the opening stroke. Asynchronous movement may indicate a disk
displacement that prevents one of the condyles from making a normal translatory movement.
Auricular palpation (Fig. 1-9) with light anterior pressure helps identify potential disorders in the
posterior attachment of the disk. Tenderness or pain on movement is noted and can be indicative of
inflammatory changes in the retrodiscal tissues, which are highly vascular and innervated.
Muscles of Mastication examination
Next, the masseter and temporal muscles, as well as other relevant postural muscles, are
palpated for signs of tenderness. Palpation is best accomplished bilaterally and simultaneously. This
allows the patient to compare and report any differences between the left and right sides. Light
pressure should be used (the amount of pressure that can be tolerated without discomfort on one’s
closed eyelid is a good comparative measure), and if any difference is reported between the left and
right sides, the patient is asked to classify the discomfort as mild, moderate, or severe. If there is
evidence of significant asynchronous movement or TMJ dysfunction, the clinician should follow a
systematic sequence for comprehensive muscle palpation as described by Solberg (1976) and Krogh-
Poulsen and Olsson (1966). Each palpation site is scored numerically on the basis of the patient’s
response. If neuromuscular or TMJ treatment is initiated, the examiner can then repalpate the same
sites periodically to assess the response to treatment.
Lip examination
The patient is observed for tooth visibility during normal and exaggerated smiling. This can be
critical in the planning of fixed prosthodontic treatment, especially when the need to fabricate crowns
or fixed dental prostheses is anticipated in the esthetic zone. Some patients show only their maxillary
teeth during smiling. More than 25% do not show the gingival third of the maxillary central incisors
during an exaggerated smile (Fig. 1-13). The extent of the smile depends on the length and mobility of
the upper lip and the length of the alveolar process. When the patient laughs, the jaws open slightly
and a dark space is often visible between the maxillary and mandibular teeth (Fig. 1-14). This has been
called the negative space. Missing teeth, diastemas, and fractured or poorly restored teeth disrupt the
harmony of the negative space and often must be corrected.
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INTRAORAL EXAMINATION
The intraoral examination can reveal considerable information concerning the condition of the
soft tissues, teeth, and supporting structures. The tongue, floor of the mouth, vestibule, cheeks, and
hard and soft palates are examined, and any abnormalities are noted. This information can be
evaluated properly during treatment planning only if objective indices, rather than vague assessments,
are used.

Periodontal Examination
In a periodontal examination, the clinician evaluates the status of bacterial accumulation, the
response of the host tissues, and the degree of reversible and irreversible damage. Long-term
periodontal health is prerequisite for successful fixed prosthodontics. Existing periodontal disease
must be corrected before any definitive prosthodontic treatment is undertaken.

Gingiva examination
The gingiva is dried for the examination so that moisture does not obscure subtle changes or
detail. Color, texture, size, contour, consistency, and position are noted. The gingiva is carefully
palpated to express any exudate present in the sulcular area. Healthy gingiva (Fig. 1-15, A) is pink,
stippled, and firmly bound to the underlying connective tissue. The free gingival margin is knife-edged,
and sharply pointed papillae fill the interproximal spaces. Any deviation from these findings is noted.
With the development of chronic marginal gingivitis (see Fig. 1-15, B), the gingiva becomes enlarged
and bulbous, stippling is lost, the margins and papillae are blunted, and bleeding and exudate are
observed. To assess the width of the band of attached keratinized gingiva around each tooth, the
clinician measures the width of the surface band of keratinized tissue in an apico-coronal dimension
with a periodontal probe and subtracts the measurement of the sulcus depth. Alternatively, the
marginal gingiva can be gently depressed with the side of a periodontal probe or explorer. At the
mucogingival junction (MGJ), the effect of the instrument is seen to end abruptly, indicating the
transition from tightly bound gingiva to more flexible mucosa. A third technique is to inject anesthetic
solution into the nonkeratinized mucosa close to the MGJ to make the mucosa balloon slightly.

Periodontium examination
The periodontal probe (Fig. 1-16, A) provides a measurement (in millimeters) of the depth of
periodontal pockets and healthy gingival sulci. The probe is inserted essentially parallel to the tooth
and is “walked” circumferentially through the sulcus in firm but gentle steps; the examiner determines
the measurement when the probe is in contact with the apical portion of the sulcus (see Fig. 1-16, B).
Thus, any sudden change in the attachment level can be detected. The probe may also be angled
slightly (5 to 10 degrees) interproximally to reveal the topography of an existing lesion. Probing depths
(usually six per tooth) are recorded on a periodontal chart (Fig. 1-17), which also contains other data
such as tooth mobility or malposition, open proximal contact areas, inconsistent marginal ridge
heights, missing or impacted teeth, areas of inadequate attached keratinized gingiva, gingival
recession, furcation involvements, and malpositioned frenum attachments).

Clinical Attachment Level

Documenting the level of epithelial attachment helps the clinician quantify periodontal
destruction and is essential for rendering a diagnosis of periodontitis (loss of connective tissue
attachment). This measurement also provides objective information regarding the prognosis of
individual teeth. The clinical attachment level is determined by measuring the distance between the
apical extent of the probing depth and a fixed reference point on the tooth, most commonly either the
apical extent of a restoration or the cementoenamel junction (CEJ). This is recorded on modified
periodontal charts. When the free margin of the gingiva is located on the clinical crown and the level of
the epithelial attachment is at the CEJ, there is no attachment loss, and recession is noted as a negative
number. When the attachment level is on root structure and the free gingival margin is at the CEJ,
attachment loss equals the probing depth, and the recession is scored 0. When increased periodontal
destruction and recession are present, attachment loss equals the probing depth plus the
measurement of recession. Clinical attachment loss is a measure of periodontal destruction at a site,
rather than of current disease activity; it may be considered the diagnostic “gold standard” for
periodontitis and should be documented in the initial periodontal examination. It is an important
consideration in the development of the overall diagnosis, treatment plan, and the prognosis of the
dentition.

Occlusal Examination (Initial tooth contacts, General alignment, Lateral and Protrusive contacts)
The clinician starts the occlusal examination by asking the patient to make a few simple openings. and
closing movements, which the clinician carefully observes. The objective is to determine to what extent
the patient’s occlusion differs from the ideal and how well the patient has adapted to any difference
that may exist. Special attention is given to initial contact, tooth alignment, eccentric occlusal contacts,
and jaw maneuverability.
Initial Tooth Contact. The relationship of teeth in both centric relation and the maximum
intercuspation should be evaluated. If all teeth come together simultaneously at the end of terminal
hinge closure, the centric relation (CR) position of the patient is said to coincide with the maximum
intercuspation (MI). The patient is guided into a terminal hinge closure to detect where initial tooth
contact occurs.
The clinician should ask the patient to “close featherlight” until any of the teeth touch and to
have the patient help identify where that initial contact occurs by asking him or her to point at the
location. If initial contact occurs between two posterior teeth (usually molars), the subsequent
movement from the initial contact to the MI position is carefully observed and its direction noted. This
is referred to as a slide from CR to MI. The presence, direction, and estimated length of the slide are
recorded, and the teeth on which initial contact occurs are identified. Any such discrepancy between
CR and MI should be evaluated in the context of other signs and symptoms that may be present: for
example, abnormal muscle tone previously observed during the extraoral examination, mobility (noted
during the periodontal evaluation) on the teeth where initial contact occurs, and any wear facets on the
teeth contacting during the slide.
General Alignment. Any crowding, rotation, supraeruption, spacing, malocclusion, and vertical
and horizontal overlap (Fig. 1-20) are recorded. In many cases, teeth adjacent to edentulous spaces
have shifted slightly. Even minor tooth movement can significantly affect fixed prosthodontic
treatment. Tipped teeth affect tooth preparation design or may necessitate minor tooth movement
before restorative treatment. Supra-erupted teeth are easily overlooked clinically but frequently
complicate fixed dental prosthesis design and fabrication. The relative relationship of adjacent teeth to
planned fixed prostheses is important. A tooth may have drifted into the space previously occupied by
the tooth in need of treatment because a large filling was lost for some time. Such changes in
alignment can seriously complicate or preclude fabrication of a cast restoration for the damaged tooth
and may even necessitate its extraction.

Lateral and Protrusive Contacts. The degree of vertical and horizontal overlap of the teeth is
noted. When asked, most patients are capable of making an unguided protrusive movement. During
this movement, the degree of posterior disclusion (separation of the teeth when the jaw is slightly
opened, a separation of posterior teeth when the lower jaw moves forward, as a natural result of the
alignment of the anterior teeth) that results from the overlaps of the anterior teeth is observed.
Excursive contacts on posterior teeth may be undesirable. The patient is then guided into lateral
excursive movements, and the presence or absence of contacts on the nonworking side and then the
working side is noted. Such tooth contact in eccentric movements can be verified with a thin Mylar strip
(shim stock). Any posterior cusps that hold the shim stock are evident (Fig. 1-21). Teeth subjected to
excessive loading may develop varying degrees of mobility. Tooth movement (fremitus) should be
confirmed by palpation (Fig. 1-22). If excessive occlusal contact is suspected, a finger placed against the
buccal or labial surface while the patient lightly taps the teeth together helps locate fremitus in
maximum intercuspation.

Jaw Maneuverability. The ease with which the patient moves the jaw and the way the mandible
can be guided through hinge closure and excursive movements should be evaluated because this
information is useful for assessing neuromuscular and masticatory function. If the patient has
developed a pattern of protective reflexes, manipulating the jaw in a reproducible hinge movement can
be difficult or impossible. Any restriction in maneuverability is recorded. A patient may move relatively
freely in one lateral excursion but have difficulty moving to the contralateral side. Such limitation in
maneuverability should be considered in the context of comprehensive occlusal and neuromuscular
analysis.

Radiographic Examination
Digital radiographs provide essential information to supplement the clinical examination.
Detailed knowledge of the extent of bone support and the root structure of each standing tooth is
critical for establishing a comprehensive fixed prosthodontic treatment plan. According to radiation
exposure guidelines, the number of radiographs should be limited to only those that will result in
potential changes in treatment decisions; however, a full periapical series (Fig. 1-23) is normally
required for new patients so that a comprehensive fixed prosthodontic treatment plan can be
developed.
 Panoramic films (Fig. 1-24) provide useful information about the presence or absence of teeth.
They are especially helpful in assessing third molars and impactions, evaluating the bone before
implant placement, and screening edentulous arches for buried root tips. However, they do not
provide a detailed view sufficient for assessing bone support, root structure, caries, or periapical
disease.
 Special radiographs may be needed for the assessment of TMJ disorders and a wide variety of
pathologic conditions ranging from bone and mineral disorders to metabolic disorders, genetic
abnormalities, and soft tissue calcifications, such as carotid artery calcification. For assessment of the
TMJs, a transcranial exposure, with the help of a positioning device, reveals the lateral third of the
mandibular condyle and can be used to detect some structural and positional changes. However,
interpretation may be difficult, and more information may be obtained from other images. Cone-beam
imaging is considered prerequisite to most dental implant placements. In this form of imaging, osseous
contours and bone volume are visualized, which improves decision making about the size of implant
fixtures that realistically can be accommodated.
Tooth Vitality Testing
Before any restorative treatment is begun, pulpal health must be confirmed, usually by
assessing the response to thermal stimulation. In vitality tests, however, only the afferent nerve supply
is assessed. Misdiagnosis can occur if the nerve supply is damaged but the blood supply is intact.
Careful inspection of radiographs is therefore essential in the examination of such teeth.
Tooth vitality can be done using different test: Thermal, chemical (less common) and electronic
(using an electronic pulp tester or EPT). The EPT is the most common and is wide used because it is the
most convenient among the methods.

Activity 3: Skill-building Activities (18 mins + 2 mins checking)

Create your own Dental record chart that shows general, extraoral and intraoral examination
guidelines or checklist. Scour the internet for more samples but do not copy and paste. Use the
table below page to write on.
 Example Examination Chart Guidelines/Checklist
General Examination Guidelines
1. Check patient’s general appearance:
Skin condition/color -
Gait -
Weight -
2. Check patient’s vital signs:
Blood Pressure -
Respiratory Rate -
Pulse Rate -
Temperature -

Extraoral Examination Guidelines

1. Check the TMJ for abnormalities
2. Check the Muscles of mastication (4 muscles) for abnormalities
3. Check the …
Continue …
Intraoral Examination Guidelines
1. Check the gingiva for color, texture, size, contour, consistency, position (any abnormalities)
Continue …

Activity 4: What I Know Chart, part 2 (2 mins)

Reviewing the questions in the What I Know Chart from Activity 1 and write your answers to the
questions based on what you now know in the third column of the chart.

Activity 5: Check for Understanding (5 mins)

 Describe briefly how a body temperature is taken using a glass thermometer. (No rectal Yadz!).

Describe briefly how a pulse is taken.

Describe briefly how respiratory rate is taken.

LESSON WRAP-UP

Activity 6: Thinking about Learning (5 mins)

A. Work Tracker

You are done with this session! Let’s track your progress. Shade the session number you just
completed.

B. Think about your Learning

1. Rate from 0-5 were 0 means “Hard as rock” and 5 means “Easy – like a hot knife slicing
through butter “, How difficult was this module?

5
 2. Was our learning target/objective met? Refer to objective/s and answer yes or no

5 C.

 This module will be collected at a designated time and place for checking and grading.
 Download this module in pdf or docx and answer in the same format using Microsoft word
or pdf editor. Save the file. Rename the file in this format Ebua.Allan.FPD.Mod.1.docx or
Ebua.Allan.FPD.Mod.1.pdf send it to the email address provided below.
 Convert to pdf if the file is too large. Modules/files can be placed in archived file format
containers/compression like .7z or .zip or .rar (use file name compression container in this
example “Ebua.Allan.FPD.Mod1-10.zip”)
 Please do not give me a link to your google drive.
 Phone calls/virtual calls/chat/ to students will be scheduled for work monitoring, providing
guidance, answering questions and checking understanding.

Contact Information
Dr. Allan Rotello Sia Ebua
 Mobile:
 Facebook/Messenger:
 Messenger Chat group:
 Email: For submission of modules, use email below (look for your appropriate section):
+63-929-886-1569
https://www.facebook.com/alexstrasz/
https://www.facebook.com/dr.allan.ebua
FPD A1 1st Sem 2022 2023 (look for your appropriate sec)
FPD A2 1st Sem 2022 2023
FPD A3 1st Sem 2022 2023
FPD A4 1st Sem 2022 2023
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…and so on…
dr.ebua.fpda1@gmail.com (for sec A or A1)
dr.ebua.fpda2@gmail.com (for sec B or A2)
dr.ebua.fpda3@gmail.com (for sec C or A3)
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…and so on…