Chapter 6

Oral Examination and Diagnosis

Ravi GR, Nikhil Marwah, Manju Gopakumar, Vikram Khare

Chapter outline
)) Recording the History )) Specialized Examination
)) Clinical Examination )) Final Diagnosis
)) Provisional Diagnosis )) Comprehensive Treatment Plan

Successful dental treatment for children can be achieved Emphasis on preventive dental care has taken the lead
by recording a detailed history, a complete clinical over the direct restorative intervention. Furthermore,
examination, appropriate investigations, a thoughtful recent information suggests that there is a more intimate
diagnosis, and an appropriate treatment plan. It is very relationship between oral and systemic health. Thus, the
essential to obtain all relevant information about the challenge dentists are facing in the 21st century is a rapidly
patient and family along with an informed consent before growing population of patients who have chronic medical
embarking upon the comprehensive treatment program for conditions, take multiple medications, yet still require
a child patient. In some circumstances, the diagnosis (i.e., routine, safe, and appropriate oral health care. This chapter
an explanation for the patient’s symptoms and identification addresses the rationale and method for gathering relevant
of other significant disease process) may be self-evident.
medical and dental information (including the examination
When clinical data are more complex, the diagnosis may
of the patient) and the use of this information for dental
be established by:
treatment.
™™ Reviewing the patient’s histor y and physical,
radiographic, and laboratory examination data
™™ Listing those items that either clearly indicate an RECORDING THE HISTORY
abnormality or that suggest the possibility of a significant
This can be further categorized for descriptive purposes
health problem requiring further evaluation
into:
™™ Grouping these items into primary versus secondary
™™ Vital statistics
symptoms, acute versus chronic problems, and high
versus low priority for treatment ™™ Chief complaint
™™ Categorizing and labeling these grouped items according ™™ History of present illness
to a standardized system for the classification of disease ™™ Family (social) history
™™ Medical history
Components of oral examination and diagnosis ™™ Drug history
‰‰ Recording the history ™™ Dental history
‰‰ Examination of the patient
‰‰ Provisional diagnosis ™™ Natal, Pre- and postnatal history
‰‰ Special examination ™™ Behavioral history
‰‰ Final diagnosis ™™ Growth and development
‰‰ Treatment plan (including medical referrals)
™™ Diet history
46 Section 2  Diagnosis in Pediatric Dentistry

Vital Statistics variation, any medications, or treatment received

It is a systematic approach to collect and compile all the
information related to the vital events like birth, death,
recognition, social structure, and legislation. Recording
personal details of the child is required for both record
purposes and for communication.
All these details should be entered in the case sheet
prior to the appointment. Details of the patient’s medical
practitioner should also be included (Table 6.1).
Chief Complaint
™™ This is concerned about what made the patient to visit
the dentist or what they are seeking from treatment
™™ It is better to ask the child about his chief complaint
before involving the parent which helps to establish a
good rapport with the child. But, it is mandatory to get
an answer from the parent also regarding the child’s
complaint
™™ It is recommended to record the chief complaint in
patient’s own words. When there are multiple complaints,
they have to be recorded in chronological order.
History of Present Illness
™™ It is the elaboration/detailed description of the chief
complaint
„„ Several factors need to be evaluated regarding
the chief complaint like duration, mode of onset,
severity, nature, aggravating or relieving factors,
associated symptoms, diurnal variation, postural
for the same
„„ Gives an insight toward the possible cause and
nature of disease/condition
„„ Hint toward the possible disease/condition.
Family (Social) History
™™ It provides relevant information about the social
background of the child and his family
™™ It also should include such factors like number of
children in the family, the child’s attendance in
the school, performance in the class, the housing
conditions, and the parent’s occupation
™™ The family history should also include the occurrence
of any genetic diseases, oral, or general
™™ Furthermore, questions regarding family history must
be neither offensive nor intrusive.
Medical History
™™ Various diseases or functional disturbances may directly
or indirectly cause or predispose to oral problems and
may affect the delivery of oral care
™™ A comprehensive medical history should commence
with information relating to pregnancy and birth, the
neonatal period, and early childhood
™™ Details about the previous hospitalization, operations,
illnesses, and traumatic injuries should be recorded
along with the information related to the previous and
current medical treatment.

Table 6.1: Vital statistics of history.

Date Name Nick name Age Details of medical
practitioner
It records the time the patient Knowing the name of ‰‰ To build rapport ‰‰ As growth assessment Helps in
reported to the clinic and can be the child will help in with the child parameter. Example: Dental age diagnosing
referred back during following the following: ‰‰ To alleviate ‰‰ To recognize the disparities medical/
appointments ‰‰ Establish good apprehension between dental age, mental syndromic
rapport with the age, chronological age, and conditions
child skeletal age, if any
‰‰ Communication ‰‰ As an aid in treatment
‰‰ Record purpose planning. Example: Growth
‰‰ Medicolegal issues spurts in girls are ahead of boys
(based on chronological age)
‰‰ Age-related diseases

Sex/gender Address Source of information Occupation of parents Drugs

‰‰ As an aid in treatment ‰‰ Communication To check whether the Reflects the socioeconomic status Helps to ascertain
planning. Example: Growth ‰‰ Record purpose information provided of the family drug interactions
spurts in girls are ahead of boys ‰‰ Medicolegal issues is genuine or not
‰‰ Sex-related diseases. Example: ‰‰ To rule out
Pubertal gingivitis is seen in any endemic
adolescent females conditions
 Chapter 6  Oral Examination and Diagnosis 47
™™ Dental history should also give us explanation for the
Medical history should include
unusual conditions like rampant caries, erosion, and
‰‰ Cardiovascular system (e.g. congenital heart disease, blood
attrition
pressure, rheumatic fever)
‰‰ Central nervous system (e.g. seizures, cognitive delay) ™™ Finally by a thorough dental history, the dentist can
‰‰ Endocrine system (e.g. diabetes) evaluate the attitude of the parent to his or her child’s
‰‰ Gastrointestinal system (e.g. hepatitis) dental treatment
‰‰ Respiratory system (e.g. asthma, upper respiratory tract infections)
‰‰ Hematological disorders (include family history of bleeding Dental history
disorders) ‰‰ Helps in formulation of treatment plan
‰‰ Urogenital system (renal disease). ‰‰ Knowledge about patient’s habits
‰‰ Helps to evaluate attitude of parents toward dentistry
Prenatal, Natal, and Postnatal History ‰‰ Medicolegal purpose
‰‰ In addition, the survey of the previous dental records and radio­
™™ Any infections and systemic conditions during preg­ graphs may give important information for the treatment and
nancy also previous dental records help in medicolegal purposes also.
™™ Immunization status during pregnancy
™™ Whether received antiserum D vaccination or not—in
Behavioral History
case Rh +ve (father) and Rh −ve (mother).
Any clues of negative or unpleasant behavior during the
Natal Events at Birth previous dental visit may call upon the need for behavior
management or shaping.
™™ Time of birth—to rule out preterm birth
™™ Type of delivery—normal/forceps/caesarean
Growth and Development
™™ Vaccinations given at birth
™™ Forceps delivery—predisposed factor for temporo­ Developmental milestones, speech and language develop­
mandibular joint (TMJ) disorder. ment, motor skills, and socialization should be evaluated.

Postnatal Events After Birth Diet History

™™ Developmental milestones—crawling, sitting, walking,
etc.
™™ Development of speech
™™ Immunization schedule.
Drug History
™™ Details of the drugs being used for systemic ailments
™™ Any adverse reaction to drugs
™™ Any drugs already used for the condition.
Dental History
™™ The child’s past experience with the dental treatment
should be assessed
™™ The kind of dental treatment received, including the
pain control measures which has been offered, gives
the dentist important information about the child’s past
behavior for dental treatment which might help us to
modify the treatment appropriately
™™ Dental history should also identify factors that have been
responsible for the existing dental problems and those
which might have an impact on future health
™™ These include day-to-day oral hygiene measures like
frequency of brushing and type of toothpaste used
the type, duration and frequency of sucking habits
and dietary habits which should include duration of
breastfeeding, bottle feeding at bed time, frequency of
snacking between meals
™™ Type of meal (vegetative/mixed) influences the oral
hygiene status
™™ Habits of snacking between meals should be evaluated
as they may be cariogenic
™™ In case of high cariogenic patients, a diet diary with
number of sugar exposures should be noted while taking
diet history
CLINICAL EXAMINATION
The clinical examination not only includes intra- and
extraoral examination but also comprise of complete
general examination.
General Examination
™™ Height and weight—both have a direct relation with
developmental and nutritional status
™™ Gait—look for any abnormality in gait, for example,
waddling gait, limping gait
™™ Posture—look for any abnormality
™™ Stature and built—indicative of any malnutrition or
other abnormality
™™ Vital signs—pulse, heart rate, and respiratory rate differ
in child at different ages till these reach the adult value.
Hence, the clinician should have a thorough knowledge
of these physiological variations
™™ Any other data like illness, malaise.
48 Section 2  Diagnosis in Pediatric Dentistry

Extraoral Examination „„ Euryprosopic—broad and short facial form (Fig. 6.2B)

The extraoral examination should be one of the general
appraisals of the child’s well-being. The clinician should
assess:
™™ Shapes of head (Figs. 6.1A to C) can be classified as
„„ Mesocephalic—average shape of head and arch
(Fig. 6.1A)
„„ Dolichocephalic—long and narrow head; narrow
dental arches (Fig. 6.1B)
„„ Brachycephalic—broad and short head; broad
dental arches (Fig. 6.1C)
™™ Facial forms (Figs. 6.2A to C)—three common facial
forms are
„„ Mesoprosopic—average facial form (Fig. 6.2A)
„„ Leptoprosopic—long and narrow face (Fig. 6.2C)
™™ Facial profile (Figs. 6.3A to C)—this is ascertained by
examining the patient sideways. The three facial profiles
are:
„„ Straight (Fig. 6.3A)
„„ Convex (Fig. 6.3 B)
„„ Concave (Fig. 6.3C)
™™ Facial swelling and asymmetry:
„„ Bacterial or viral infections and trauma are the
principal causes of facial swelling in a child
„„ Pathological facial asymmetry may be produced
by cranial nerve paralysis, fibrous dysplasia, and
familial developmental disturbances

A B C
Figs. 6.1A to C: Head shapes: (A) Mesocephalic; (B) dolichocephalic; (C) Brachycephalic.

A B C
Figs. 6.2A to C: Facial forms: (A) Mesoprosopic; (B) Euryprosopic; (C) Leptoprosopic.
 Chapter 6  Oral Examination and Diagnosis
History and oral examination play a major role in
„„
the diagnosis of any swelling of the face.
™™ Examination of eyes:
„„ Eyes should be observed for any inflammation,
swelling, or puffiness around the eye
„„ Inflammation of maxillary teeth can cause swelling
of the eyelids
„„ Children with upper respiratory tract infection,
sinusitis, and allergy have puffiness of eyelids.
™™ Examination of nose:
„„ Nose should be examined for any abnormalities in
size, shape, or color
„„ Children who encounter nasal discharge indicate
upper respiratory tract infection
„„ Children with chronic upper respiratory tract
infection will develop mouth breathing habit.
49
™™ Examination of skin:
The skin of the face should be evaluated for the
„„
presence of primary and secondary skin lesions
„„ Any scars, bruising, laceration, pallor, and birth
marks should also be documented.
™™ Examination of chin:
„„ Prominence of chin and mentalist activity can
indicate habits and malocclusion.
™™ Examination of lips (Figs. 6.4A and B):
„„ Lips should be examined for the presence of cold
sores, swelling, or abnormal coloring
„„ Competent—lips are in contact when musculature
is relaxed
„„ Incompetent—lip seal is not formed in normal
circumstances, only hyperactivity of oral musculature
can help in forming closure.

A B C

Figs. 6.3A to C: Facial profiles: (A) Straight; (B) Convex; (C) Concave.

A B
Figs. 6.4A and B: Competency of lips.
50 Section 2  Diagnosis in Pediatric Dentistry

A B
Figs. 6.5A and B: Method of examination of TMJ.

™™ Examination of TMJ (Figs. 6.5A and B):
„„ Functional examination should include
palpation and auscultation of TMJ and associated
musculature
„„ The patient should be examined for any clicking
sound, crepitus, pain, deviation, and restricted
opening
„„ Mouth opening is also related to TMJ function and
should also be examined. Normal mouth opening
is 40–45 mm.
TMJ examination
The function of TMJ is examined by palpating the head of
mandibular condyle and observing the patient with mouth closed,
open and during random movements.
™™ Lymph nodes examination (Figs. 6.6A and B):
„„ A complete examination of neck region including
the lymph nodes is mandatory
„„ Lymphadenopathy is not uncommon in children
due to frequent viral infections
„„ Ask the patient to bend his neck in forward and
downward position to palpate the lymph nodes
on the side and to bend it forward to palpate the
submandibular area.
Intraoral examination: Intraoral examination for a young
child should begin with the “tell-show-do” approach, that
is, by explaining the child what are you going to do; show
him the examination instruments followed by intraoral
examination. During and after the intraoral examination,
explain the parents about the intraoral findings and discuss
the treatment plan. This includes the examination of hard
as well as soft tissues.
™™ Soft tissue: It includes examination of the oral mucosa
and examination of periodontal tissues. Complete
inspection and palpation of all soft tissue oral structures
is needed

A B
Figs. 6.6A and B: Examination of lymph nodes.