EVALUATION OF THE DENTAL

PATIENT

Dr. Hadi Zahid Rao

Department of Oral and Maxillofacial Surgery
 DIAGNOSIS
 Diagnosis: is a fancy name given to the process of
identifying diseases. It means “through
knowledge” and entails acquisition of data about
the patient and their complaint using the senses :
 . Hearing
 . Observing
 . Touching
 . Sometimes Smelling
 The purpose of making a diagnosis is to be able to
offer the most :

 Effective and safe treatment

 Good prognosis
 Diagnosis is made by the clinical examination,
which comprise the :

 History
 physical examination
 Supplemented in some cases by investigations .
 HISTORY

History taking is part of the initial

communication between the dentist and
patient. It is important to adopt a
professional appearance and manner, and
introduce oneself clearly and courteously.
The history is best given in the patient’s
own words, through the clinician often
needs to guide the patient.
 Important areas:
 General information (name, age, gender, ethnic
origin, place of residence, occupation)
 Presenting “chief” complaint
 History of chief complaint
 Past medical history
 Dental history
 Family history
 Social history.
CHIEF COMPLAINT AND HISTORY OF THE
PRESENTING COMPLAIN

 The chief complaint is established by asking the

patient to describe the problem for which he or she is
seeking help or treatment.
 The chief complaint is recorded in the patient’s own
words as much as possible and should not be
documented in technical (ie, formal diagnostic)
language unless reported in that fashion by the
patient.
Direct and specific questions are used to elicit information about
chief complaint and should be recorded in the patient record in
narrative form, as follows:

Pain:-
 Site
 Time and mode of onset
 Duration
 Severity
 Nature/ character
 Radiation
 Referral
 Progression
 The end of the pain
 Relieving and exacerbating factors
Lump or ulcer:-
 Duration
 First symptom

 Other symptoms

 Progression

 Persistent

 Multiplicity

 Cause
 PAST DENTAL HISTORY
The dental history will give an idea of the:
 past dental visits;

 previous restorative, periodontic, endodontic, or oral surgical

treatment;
 reasons for loss of teeth;

 complications of dental treatment;

 fluoride history;

 attitudes towards previous dental treatment;

 experience with orthodontic appliances and dental prostheses;

 radiation or other therapy for oral or facial lesions.

 MEDICAL HISTORY

 Information about past & present medical

conditions,
 Pertinent social and family histories,
 A review of symptoms by organ system.
 PAST MEDICAL HISTORY

The past medical history includes

information about any significant or serious
illnesses a patient may have had as a child or
as an adult. The patient’s present medical
problems are also enumerated under this
category.
The past medical history is usually organized
into the following subdivisions:

(1) serious or significant illnesses,

(2) hospitalizations,
(3) transfusions,
(4) allergies,
(5) medications, and
(6) pregnancy.
Through a medical history we achieve three important objectives:

 It enables the monitoring of medical conditions and the

evaluation of underlying systemic conditions of which the
patient may or may not be aware.

 It provides a basis for determining whether dental treatment

might affect the systemic health of the patient

 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
 FAMILY HISTORY
 Serious medical problems in immediate family members
should be listed.

 Disorders known to have a genetic or environmental basis

(such as certain forms of cancer, cardiovascular disease
including hypertension, allergies, asthma, renal disease,
stomach ulcers, diabetes mellitus, bleeding disorders, and
sickle cell anemia) should be addressed.

 This type of information will alert the clinician to the patient’s

predisposition to develop serious medical conditions.
 SOCIAL HISTORY
 Different social parameters should be recorded. These
include:
 Marital status (married, separated, divorced, single, or
with a “significant other”)
 Place of residence (with family, alone, or in an
institution)
 Educational level
 Occupation
 Religion
 Tobacco use (past and present use and amount);
 Alcohol use (past and present use and amount);
 Recreational drug use (past and present use, type, and
amount).
 EXAMINATION OF THE
PATIENT
 The examination of the patient represents the
second stage of the diagnostic procedure
 The examination is most conveniently carried out
with the patient seated in a dental chair, with the
head supported.
 Before seating the patient, the clinician should
observe the patient’s general appearance and step
and should note any physical deformities or
handicaps.
 A less comprehensive but equally thorough
inspection of the face and oral and oropharyngeal
mucosa should also be carried out at each dental
visit.

 The tendency for the dentist to focus on only the

tooth or jaw quadrant in question should be
strongly resisted.
The examination procedure in dental office settings
includes the following:

 Registration of vital signs (respiratory rate,

temperature, pulse, and blood pressure).
 Examination of the head, neck, and oral cavity,
including salivary glands, temporomandibular
joints, and lymph nodes.
 Examination of cranial nerve function.
 Special examination of other organ systems.
 Requisition of laboratory studies.
Vital Signs
 PULSE RATE AND RHYTHM
 RESPIRATORY RATE
 BLOOD PRESSURE
 TEMPERATURE
Head, Neck, and Oral Cavity
The examination routine encompasses the
following steps:

 General appearance,
 Evaluate emotional reactions,
 General nutritional state,
 Character of the skin and the presence of petechiae or eruptions,
 Texture, distribution, and quality of the hair,
 Examine the conjunctivae and skin for petechiae, and examine
the sclerae and skin for evidence of jaundice or pallor.
 Determine the reaction of the pupils to light and accommodation,
especially when neurologic disorders are being investigated,
 Palpate for adenopathy. Palpate any swellings, nodules, or
suspected anatomic abnormalities.
 Examine in sequence
 the inner surfaces of the lips,
 the mucosa of the checks,
 the maxillary and mandibular mucobuccal folds,
 the palate,
 the tongue,
 the sublingual space,
 the gingivae,
 and then the teeth and their supporting structures.
 Last, examine the tonsillar and the pharyngeal areas and any
lesion, particularly if the lesion is painful.
 Have the patient extend the tongue for examination
of the dorsum;
 then have the patient raise the tongue to the palate to
permit good visualization of the sublingual space.
 The patient should extend the tongue forcibly out to
the right and left sides of the mouth to permit good
visualization of the sublingual space and to permit
careful examination of the left and right margins.
 A piece of gauze wrapped lightly around the tip of
the tongue helps when manually moving the patient’s
tongue.
 Examine the tonsillar fossae and the oropharynx.
 Use bimanual or bi-digital palpation for examination of
the tongue, cheeks, floor of the mouth, and salivary
glands. Palpation is also useful for determining the degree
of tooth movement. Two resistant instruments, such as
mirror handles or tongue depressors, placed on the buccal
and lingual surfaces of the tooth furnish more accurate
information than when fingers alone are directly
employed.
 Examine the teeth for dental caries, occlusal
relations, possible prematurities, inadequate
contact areas or restorations, evidence of food
impaction, gingivitis, periodontal disease, and
fistulae.
 the general examination of the oral cavity has

been completed, make a detailed study of the

lesion or the area involved in the chief
complaint.