Local examination, Case History, Dentistry

Case history dental

1. Local examination

2. Extraoral Examination Facial symmetry Temporomandibular joint Lymph nodes Salivary gland

3. 1) Facial symmetry Congenital defects Hemifacial hypertrophy Chronic abscesses/ Space infection

4. Temporomandibular joint Inspection : Inspect the joint for swelling or redness. Swelling may manifest as a rounded bulge approximately 1 inch anterior to the external auditory meatus. Swelling, tenderness, and decreased range of motion are indicative of an inflamed joint.

5. TMJ palpation Methods of palpation Pretragus palpation : The patient should be requested to slowly open and close the mouth while the doctor bilaterally palpates the pretragus depression with his/ her index fingers Intra-auricular palpation : It is also performed by inserting the small finger into the ear canal and pressing anteriorly

6. Acc. to American Academy of Orofacial Pain Diagnostic category Diagnosis Cranial bones Congenital and developmental disorders Aplasia Hypoplasia Dysplasia (Hemifacial microsomia, Pierre Robinson syndrome , Treacher Collin Syndrome ) Condylar hyperplasia Acquired disorders Neoplasia Fracture

7. Acc. to American Academy of Orofacial Pain Diagnostic category Diagnosis Temporomandibular joint Deviation in form Disk displacement with / without reduction Masticatory muscle disorders Myofascial pain Myositis Spasm Protective splinting

8. Hypoplasia of the condyle Condylar hyperplasia Bifid condyle Congenital and Development disturbances of TMJ

9. Traumatic disturbances of TMJ Dislocation of condyle Ankylosis(hypomobility) Internal derangement

10. Inflammatory disturbances of TMJ Osteoarthritis Rheumatoid arthritis Arthritis

11. Lymph node examination Lymph node is an elongated or bean-shaped structure , usually less than 3cm long, positioned along the course of lymph vessel often with a slight depression called HILUS on one side .

12. -

13. Skin of head and neck

14. Drainage of oral structures

15. Overlying skin Ferrer R.. Am Fam Physician. 1998;15;58(6):1313-20.

16. Consistency

17. Clinical features to differentiate between benign and malignant lymphadenopathy

18. Salivary gland Parotid Gland Examination: Check for swelling: Note extent, size, shape, and consistency. Determine position to rule out lymph node swellings. Parotid abscess signs: Edematous skin with pitting on pressure. Look for fistula, lymph node enlargement, or facial nerve involvement.

19. Salivary gland Stenson's duct: Opens in buccal mucosa opposite to crown of maxillary second molar. Retract cheek for proper examination.

20. Salivary gland Submandibular Gland Examination: Patient history: Note swelling with pain during meals (suggests duct obstruction). Calculi more common in submandibular gland. Check for nodal swelling indicating lymph node enlargement. Inspection: Check skin color over gland area. Assess mucosa distension and Wharton's duct orifice.

21. Intraoral Examination Soft tissue Lips Labial and buccal mucosa Hard palate and Soft palate Tongue Floor of the mouth Gingiva

22. Lips The clinical features of normal lips and labial mucosa are: • Reddish colour over the area • Folds and sulci over the surface of lips • Absence of any plaque or patchy area • Absence of any erosive areas The lips are thus recorded for: • Competency Color • Texture • Fissuring • Shape • Presence of any lump or hard tissue.

23. Some of the common conditions that manifest as lip abnormalities Lip pits and commissural pits Cleft lip Angular cheilitis Angioedema

24. Labial and Buccal mucosa Clinically, a normal buccal mucosa presents: Pink to slight reddish surface Occasionally, Linea alba may be present Occasional occurrence of Fordyce’s granules

25. Some of the common conditions in buccal mucosa that manifest as abnormalities are: Hyperkeratosis Erythroplakia Lichen planus OSMF Recurrent aphthous ulcers

26. Hard and soft palate Cleft palate Torus palatinus Smoker’s palate

27. Veau’s classification of cleft lip and cleft palate

28. Tongue A normal tongue presents the following characteristics: A moist, reddish mucosa over the dorsal surface Roughness over the dorsal surface indicating the presence of papilla Absence of any plaque or ulcer.

29. Aglossia Microglossia Macroglossia Ankyloglossia Sprue Iron deficiency anemia Fissured Tongue Median rhomboid glossitis Geographic Tongue Squamous Cell Carcinoma Ulcers

30. Floor of the mouth Clinically, a normal floor of mouth presents: Shiny pink surface Presence of normal lingual frenal attachments Absence of any patchy or ulcerated lesion.

31. Some of the common conditions of floor of mouth that manifest as abnormalities are: Mandibular tori Ranula

32. Gingiva Color : Healthy gingiva: coral pink, variable melanin pigmentation. Inflamed gingiva: erythematous or cyanotic, capillary dilation, red and shiny appearance. Note: Gingival color not indicative of health; normal color may still have deep pockets.

33. Consistency : Healthy gingiva: firmly bound to bone and tooth. Inflamed gingiva: edematous , loss of firmness and resiliency, retractable papilla, loose tissue. Contour : Healthy gingiva: follows underlying bone margin. Inflamed gingiva: destruction of connective tissue, edema , loss of normal contour, rim-like enlargement noted as rolled or rounded.

34. Size: Healthy gingiva: flat, not enlarged, snug fit around tooth. Attached gingiva varies from 1 to 9 mm. Inflamed gingiva: enlargement, localized or generalized, increased false pocket depth. Enlargement seen in chronic gingival inflammations, pregnancy-associated gingivitis, puberty-associated gingivitis, drug-induced gingival reactions.

35. Types of gingival enlargement Inflammatory enlargement A. Chronic B. Acute Drug-induced enlargement Enlargements associated with systemic diseases A. Conditioned enlargement 1. Pregnancy 2. Puberty 3. Vitamin C deficiency 4. Plasma cell gingivitis 5. Nonspecific conditioned enlargement B. Systemic diseases causing gingival enlargement 1. Leukemia 2. Granulomatous diseases (Wegener's granulomatosis, sarcoidosis, etc ) Neoplastic enlargement (gingival tumors) A. Benign tumors B. Malignant tumors False enlargement

36. Position: Healthy gingiva: at level of attached periodontal tissue, determined by probing. Apparent position in fully erupted adult tooth: at or slightly below enamel contour or cervical third prominence. Diseased gingiva: margins high on enamel or lower, exposing cervical area and root surface. High margin conditions: gingival enlargements, short clinical crowns. Lower margin conditions: gingival recessions, trauma from occlusion, supra eruption, long clinical crowns.

37. Surface Texture : Healthy gingiva: orange peel-like appearance (stippling). Loss of stippling in inflamed gingiva due to loss of resiliency, edema . Bleeding on probing: Insertion of probe elicits bleeding in inflamed, atrophic, or ulcerated gingiva. Bleeding on probing often earlier sign of inflammation than gingival color changes.

38. Intraoral Examination Hard tissue Type of dentition No of teeth present Decayed teeth Missing teeth Filled teeth Wasting disease Occlusion Any prosthesis Others Enamel hypoplasia Fractured /non-vital tooth Supernumerary teeth Stains Periodontal status

39. Type of dentition Primary dentition Permanent dentition

40. No of teeth present

41. Dental Caries Assessment Dental caries: It is an infectious, microbiological disease of teeth that results in localised dissolution and destruction of the calcified tissue.

42. Missing teeth Due to caries / trauma Due to periodontal diseases Due to orthodontic purpose Due to other reasons

43. Filled teeth

44. Wasting diseases of teeth Attrition Abrasion Erosion Abfraction

45. Occlusion

46. Any Prosthesis

47. Enamel hypoplasia

48. Fractured or non vital teeth

49. Periodontal status Periodontal pocket , defined as a pathologically deepened gingival sulcus, s may occur by coronal movement of the gingival margin, apical displacement of the gingival attachment, or a combination of the two processes.

50. Gingival pocket (pseudo pocket): Formed by gingival enlargement without destruction of underlying periodontal tissues. Sulcus deepened due to increased bulk of gingiva. Periodontal pocket: Occurs with destruction of supporting periodontal tissues. Progressive deepening leads to destruction of supporting tissues, tooth loosening, and exfoliation .

51. Two types of periodontal pockets Suprabony ( supracrestal or supraalveolar ) Bottom of the pocket is coronal to underlying alveolar bone. Intrabony (infrabony, subcrestal or intraalveolar) Bottom of the pocket is apical to level of adjacent alveolar bone. Lateral pocket wall lies between tooth surface and alveolar bone .

52. The most common probes used for measuring pocket depth are: • Michigan ‘O’ probe: markings are at 3-6-8 mm. • The WHO/CPITN probe: markings are at 0.5-3.5-5.5-8.5-11.5 mm. • William’s periodontal probe: markings are at 1-2-3-5-7-8-9 mm . B A C

53. Attachment loss and Gingival recession Miller’s classification of gingival recession

54. Furcation assessment : The furcation is an area of complex anatomic morphology, that may be difficult or impossible to be debrided by routine periodontal instrumentation. - Caranza Naber’s probe preferred for detecting and measuring furcation areas.

55. Glickman's Grading of Furcation Involvement (1953): Grade I: Incipient involvement, pocketing remains coronal to bone, primarily soft tissue affected. Grade II: Horizontal bone loss between roots, but bone still attached to tooth, no communication between furcal areas. Grade III: Bone no longer attached, through-and-through tunnel, may not be fully probeable , soft tissue occlusion possible. Grade IV: Advanced through-and-through lesion, fully probeable .

56. Mobility Evaluate periodontal attachment by laterally moving tooth in socket. Test performed using mirror back end and finger or handles of two instruments. Types of Mobility : Pathologic Mobility : Result of attachment apparatus destruction or parafunctional habits. Adaptive Mobility: Due to anatomic factors like short root-crown ratio or short roots.

57. Glickman's Grading: Grade I: Slightly more than normal. Grade II: Moderately more than normal. Grade III: Severe mobility, lateral and vertical depression. Miller's Classification (1950): 0: No detectable movement except normal (physiologic) mobility. 1: Mobility greater than normal. 2: Mobility up to 1 mm in buccolingual direction. 3: Mobility greater than 1 mm in buccolingual direction with ability to depress tooth.

58. Trauma from occlusion Stillman (1917): A condition where injury results to the supporting structures of the teeth by the act of bringing the jaws into a closed position WHO (1978): Damage in the periodontium caused by stress on the teeth produced by the teeth of the opposing jaw.

59. Trauma from occlusion [TFO] is classified into two categories: Primary: A tissue reaction, which is elicited around a tooth with normal of the periodontium, thus no attachment loss is seen. Secondary : This is related to situations in which occlusal forces cause damage in a periodontium of reduced height (attachment loss present). The clinical signs that are seen are: Pain Tooth migration Attrition