Patient Examination

VICTOR TENGAR PAMOLANGO

 Case Presentation
• Patient (demographics)
• Medical History (general anamnesis)
• Dental History & Chief Complaint (special
anamnesis)
• Examination (status presens)
– Clinical examination
– Radiographic, laboratory examination
• Diagnosis
• Treatment plan
• Treatment
• Prognosis
• Assessment and Evaluation
Patient

• Age
• Gender
• Race/ethnic origin
• Referred by ? to whom or
where? for what?
Medical History

• Systemic conditions that may produce or

affect the patient’s symptoms

• Drugs the patient is taking: identify possible

adverse drug interactions

• Systemic contraindications to treatment

• Need for premedication and prophylaxis

Dental History & Chief Complaint
• What prompted the patient to consult a dentist
in the first place (in the patient’s own words)

• No diagnosis should be included at this stage

• History of present illness/discomfort

• An interview process during which the dentist

attempts to evaluate the patient’s symptoms
accurately, completely, and objectively,
avoiding the temptation to make a premature
diagnosis
Dental History & Chief Complaint

Open-ended, non-leading questions

• ”Tell me about the problem”

• ”I understand you have been

experiencing cold sensitivity in your
upper front teeth for several weeks, is
that correct?”
Dental History & Chief Complaint
Specific questions about the nature of
the symptoms experienced:

• Inception (When the first time)

• Frequency and cource (How often)

• Intensity (Mild, moderate, or severe:

medication, home from work)

• Quality (Sharp, dull, stabbing, throbbing)

Dental History & Chief Complaint
• Location (Pointing to the tooth that hurts)

• Provocation factors (heat, cold, momentary or

last longer)

• Spontaneous (without provocation)?

• Attenuating factors (Anything relieving the

pain
Examination
• Clinical examination
– Extraoral examination
– Intraoral examination

• Radiographic examination
– Dental periapical
– Orthopantomogram in special cases
– CT in special cases
• Laboratory examination
– Routine hematology(Leu, Hb, Tro, Eri, Ht)
– PT, APTT, Glucose level, Na, K, Ur, Cr,
SGOT, SGPT
Intraoral examination
• Any alterations of the color, texture, consistency,
or contour of the soft tissue and hard tissue should
be noted (Tongue, palate, buccal, vestibule, ginggiva,
labii, floor of mouth, tonsil)

• The tooth/teeth in question should be inspected for

color changes, caries and restorative status
– Sondation test
– Percussion test
– Mobility test

• Periodontal examination: gentle probing

Intraoral examination
Thermal pulp tests:

Cold test

• Cold water bath in rubber dam basin

• Ice sticks

• Compressed gasses: ethyl chloride; 1,1,1,2

tetrafluoroethane (Endo-Ice)

• Carbon dioxide snow

Intraoral examination
Thermal pulp tests:

Heat test

• Hot water bath in rubber dam basin

• Warm gutta-percha
Intraoral examination
Electric pulp tests:

• Electric excitation to stimulate the Aδ

sensory fibers within the pulp

• Does not provide any information about the

health or integrity of the pulp; it simply
indicates that there are vital sensory fibers
present within the pulp
Intraoral examination
Special tests:

• Crown removal for inspection

• Test cavity for sensitivity

• Transillumination for caries and physical

defects
 Radiographic examination
• Diagnostic radiography should be used only
after the history is recorded and the clinical
examination is accomplished

Limitations
• Provides a two-dimensional portrayal of a
three-dimensional reality
• Cannot be used to determine the status of
the health and integrity of the pulp
 Diagnosis

Pulpal and
apical periodontal

Other relevant: cyst,

neoplasm, abscess, tmj
disorder, fracture, etc
• Treatment plan
• Short term and long term

• Treatment
• Immediate and permanent
•

• Prognosis
• Endodontic and dental
• Success rate for the relevant diagnosis
and treatment selected
 Discussion: Assessment and
Evaluation
• Assessment of the treatment outcome in this
particular case

• Reasons for making the diagnosis and treatment plan

• Evaluation of the treatment chosen

• Factors influencing the treatment outcome in this

case

• Was there any alternative treatment? And what

would happen if another treatment had been chosen