Pulp testing,trauma,ulcer & swelling,numbering,
Presented by Dr Surbhi Singh
Under the guidance of : Dr Prerna Taneja (PROF &
Dr Archana nagpal
Dr Puneeta Vohra
• A case
history is defined as a planned professional
conversation that enables the patient to communicate
his/her symptoms, feelings and fears to the clinician so as
to obtain an insight into the nature of patient’s illness &
his/her attitude towards them.
Objectives: To establish a positive professional relationship.
To provide the clinician with information concerning
the patient’s past dental, medical & personal history.
To provide the clinician with the information that may
be necessary for making a diagnosis.
To provide information that aids the clinician in
making decisions concerning the treatment of the
Steps in case history taking
1. Assemble all the available facts gathered from
statistics, chief complaint, medical history, dental
history and diagnostic tests.
2. Analyze and interpret the assembled clues to
reach the provisional diagnosis.
3. Make a differential diagnosis of all possible
4. Select a closest possible choice-final diagnosis.
5. Plan a effective treatment accordingly.
Methods of obtaining the patient
There are 3 methods :1) Interview
2) Health questionnaire
3) Combination of these
1) INTERVIEW :- In this the patient is asked about his or her
health in an organized fashion . The patient is allowed to
discussed any problem fully.
The disadvantage include :a) Method depends on the dentist skill as an interviewer.
b) The interviewer may skip some important topics.
c) The interviewer requires time to be done well.
2) HEALTH QUESTIONNAIRE :The health questionnaire is a printed list of heath related
questions that the patient is requested to answer at the first
Advantage :1) it takes little of the dentist’s time
2) it offers a standardized approach for each patient.
Disadvantage :1) Little time to build rapport with the patient
2) The questions or their format may be interpreted inaccurately
by some patient.
1. The combined method is considered by the authors to be
the best appropriate technique for history taking in the
routine practice of Dentistry.
2. This approach uses the advantages of both techniques and
reduces the disadvantages after reviewing a completed
health questionnaires, the dentist discusses the response
with the patient.
History of present illness
Past dental history
Patient registration number
Patient registration number
Useful for1. maintaining a record,
2. billing purposes,
3. medico legal aspects.
Useful for1. Time of admission
2. reference during follow up visits
3. Record maintenance.
to communicate with the patient
to establish a rapport with the patient
Behavioral management techniques
used to calculate the dose of the drug.
1) YOUNG RULE = child’s age
age + 12
2) CLARK RULE
child age at next birthday
3) DILLING RULE = age
SINGNIFICANCE-Certain diseases are gender specific:
Diseases common in males:
Attrition, leukolpakia, cancer like squamous cell carcinoma, melanoma,
Diseases common in females:
Iron deficiency anemia, sjogren’s syndrome, osteoporosis, recurrent
apthous ulcers etc
Drug interaction :- in females, special consideration must be given to
pregnancy & lactation.
For future correspondence
Gives a view of socio-economic status -to know about the
nourishment, hygiene & payment capacity of the patient
Prevalence of diseases like fluorosis as a result of increase
level of fluorides in water are spread differently in various
parts of the country.
To asses the socioeconomic status.
Predilection of diseases in different occupations for eg:
hepatitis B is common in dentists & surgeons.
To see any history of consanguineous marriages.
The high consanguinity rates, coupled by the large
family size in some communities, could induce the
expression of autosomal recessive diseases.
The chief complaint is usually the reason for the
It is stated in patient’s own words in chronological
order of their appearance & their severity.
The chief complaint aids in diagnosis & treatment
therefore should be given utmost priority.
HISTORY OF PRESENT ILLNESS
Elaborate on the chief complaint in detail
Ask relevant associated symptoms
The symptoms can be elaborated in terms of: Mode & cause of onset
Location-localized ,diffuse ,referred, radiating.
Progression- continous or intermittent.
Aggravating & relieving factors
COMMON CHIEF COMPLAINTS
Original Site of pain
Origin & mode of onset
Nature of pain
Progression of pain
Duration of pain
Movement of pain
Periodicity of pain
Effect of functional activity
a) Anatomical location where the pain felt ?
Origin & mode of onset :- activity which inducing the pain should
be taken in consideration.
c) Intensity of pain :- whether the pain is mild , moderate or severe.
d) Nature of the pain :- it can be throbbing , shooting , stabbing, dull
, aching, lancinating, boring, griping, sharp, gnawing, squeezing.
e) Progression of pain:-The patient should be asked ‘how is it
The pain may begin on a weak note & gradually reach a peak &
then gradually declines.
It may begin at its maximum intensity & remains at this level this
f)Duration of pain-Duration of pain means the period from the time of
onset to the time of pain disappearance.
g)Movement of the pain :- referred, radiating , shifting or migration of
h)Periodicity of pain-Sometimes an interval of days , weeks , months or
even years may elapse between two painful attack.
i) Effect on functional activity :- the effect of various activity such as
brushing , shaving , washing the face, turning the head , lying down
etc. should be noted.
i)Aggrevating & relieving factor- whether it aggrevates or relieved with
chewing or any other factors.
j)Associated symptoms Severe pain may be associated with:
k)Treatment taken Any medication taken by patient & its outcome.
1) Duration :- for how many days swelling is present.
2) Mode of onset :-
a) mass that increase in size just before eating :- salivary
gland retention phenomenon.
b) slow growth :- chronic infection cyst, benign tumors
c) rapid growing mass :- abscess, infected cyst, hematoma
d) mass with accompanying fever :- infection & lymphoma
3) Symptoms :- like pain, difficulty in respiration swallowing,
4)Progress of the swelling :- swelling can increase
gradually in size or rapidly
5) Associated symptoms :- fever presence of other swelling
& loss of body weight
6) Secondary changes :- like softening , ulceration,
7) Recurrence of swelling :- if swelling recurs after
removal,it may indicate malignant changes
1) Mode of onset :- duration of ulcer should also be noted.
2) Pain :- ulcer associated with inflammation are painful &
ulcers associated with epithelial or basal cell carcinoma
3) Discharge :- discharge from ulcer like serum, blood, pus
should be noted down.
4) Associated disease :- like tuberculosis , diabetes &
The medical history includes the information about past & present illness.
All diseases suffered by patient should be recorded in chronological order.
Check list of medical history-by Scully and Cawson
-Cardio respiratory disorders
-Drug treatment and allergies
-Fits and faints
-Hospital admissions and surgeries
Medical history usually organized into the following
subdivisions : 1) Serious or significant illness :-In the dental context, ask
about any history of heart, kidney, liver or lung disease.
History of any infection disease, immunologic disorders
radiation or cancer chemotherapy & psychiatric
2) Hospitalization :- a record of hospital admission along
with the history of any major surgery.
3) Transfusion :- a history of blood transfusions, including
the date of each transfusion & the number of transfused
blood units. In some instances ,transfusion can be a
source of a persistent transmissible disease.
4)Allergy :- the patient’s record should document any history of
classic allergic reactions such as urticaria, hay fever, asthma as
well as any other adverse drug reaction.
Events reported by the patient as
fainting, stomachache, weakness ,flushing ,rash etc should be
5) Medications :- an essential component of a medication history
is a record of all the medication a patient is taking.
Identification of medications helps in the recognition of drug
induced disease and oral disorders associated with different
6) Pregnancy :- knowing whether or not a women of following
age is pregnant is particularly important when deciding to
administer or prescribe any medication & procedure involving
exposure of the pregnant patient to ionization radiation.
In case of young patient:BIRTH HISTORY :Asked from the parents as if any problem were encountered at
1)Rh incompatibility :- may result in the condition termed as
‘erythroblastosis fetalis’. The effect may be seen in the
dentition , with well described entities such as hump on the
tooth and the characteristic blue – green discoloration.
2) Neonatal jaundice :- the immature RBC’s in an infant are rapidly destroyed in the
spleen. This increased bilirubin cannot be sufficiently cleared
by the liver leading to transient ‘ jaundice’ in the child.
3) Trauma due to forceps delivery
In post natal history , significant is attached to the amount
of time the child was breast fed, bottle fed etc.
Vaccination status needs to be assessed along with the
present illness , if any
Presence of any habit and its duration and frequency.
Any previous experience with the dentist and what bearing
it have on the present visit.
Progress in the school, how he interact with the children
will indicates the development of the child’s emotions.
PAST DENTAL HISTORY
History of dental treatment undergone by the patient,
along with patients experience before, during and after the
History of complications experienced by the patient
Family members share their genes, as well as their
environment, lifestyles and habits.
Risks for diseases such as asthma, diabetes, cancer, and
heart disease also run in families.
There are also several inherited anomalies & abnormalities
that can affect the oral cavity such as congenitally missing
lateral incisors, amelogenesis imperfecta , ectodermal
dysplasia & cleft lip & cleft palate.
It includes: Diet
Bowel & micturation habit
Oral hygiene measures
1) DIET :- whether the diet is vegetarian , mixed or spicy food.
a) soft diet :- adhere tenaciously to the teeth because of lack of
rough edges leading to more dental caries.
b) coarse diet :- cause more amount of attrition.
c) carbohydrate & vitamin diet :- increase carbohydrate
contents leads to increase risk for dental caries , while diet
deficient in vitamin may cause enamel hypoplasia.
2)Appetite :- whether the appetite is regular or irregular.
3) Bowel & micturition habit :- whether it is regular or irregular.
4) Sleep :- sleeping hours should be asked. Insomnia occurs in
case of primary thyrotoxicosis.
a)Oral hygiene method:- poor oral hygiene & improper
brushing technique may leads to dental caries & periodontal
disease. Horizontal brushing technique may leads to cervical
b) oral habits :- pressure habit like thumb sucking lip sucking
leads to anterior proclination of maxillary incisors.Tongue
thrusting habit leads to anterior n posterior open bite. Mouth
breathing leads to anterior marginal gingivitis & dental caries.
c) Deleterious habits :- tobacco, smoking & drinking habit
should be asked as these patient having high risk for cancer
Analyze the patient entering the clinic for
built, height ,gait, and posture.
Check for any
pallor, icterus, clubbing, cyanosis, lymphadenopathy &
Vital signs like pulse, blood
pressure, temperature, respiratory rate should be noted.
Normal pulse rate is 60-80 beeats/min
Average pulse is 72 beats/min
Physiologic increase in infants, after exertion.
Pathologic increase in fever, cardiopulmonary diseases.
normal temp is 98.6 degree F or 37 degree celsius.
Measured by thermometer.
Adult rate–16-24 breaths per minute
Feel for chest movement
Systolic- 110-140 mm Hg
Diastolic-60-90 mm of Hg
Measured by Sphygmomanometer.
List of systems reviewed:1.
Central nervous system
Every system will be examined under the following
Visual assessment of the patient.
Make sure good lighting is available.
Position and expose body parts so that all surface can
Inspect each area of
size, shape, colour, symmetry, position and
If possible, compare each area inspected with the same
area on the opposite side of the body.
Use additional light to inspect body cavities.
A technique in which the hands and fingers are used to
gather information by touch.
Palmar surface of fingers and finger pads are used to
--And assess skin temperature
Client should be relax and positioned comfortably because
muscle tension during palpation impair its effectiveness.
Types of Palpation : Light palpation
Apply tactile pressure slowly, gently and deliberately.
The clinician’s hand is placed on the part to be
examined and depressed about 1-2cm.
It is done after light palpation.
It is used to detect abdominal masses.
Technique is similar to light palpation except that the
finger are held at a greater angle to the body surface and
the skin is depressed about 4-5 cm.
It involve using both hand to trap a structure between
them. This technique can be used to evaluate spleen,
kidney, breast, uterus and ovary.
Sensing hand –Relax & place lightly over the skin.
Active hand –Apply pressure to the sensing hand.
It is done by pressing the structure to be examined
between examiner’s thumb & index finger.
Done for evaluation of nodules, lip etc
Percussion involve tapping the body with the
fingertips to evaluate the size, border and consistency
of body organs and to discover fluid in body cavity.
Used to evaluate for presence of air or fluid in body
Sound waves heard as percussion tones (resonance)
Methods of Percussion:Mediate or Indirect Percussion
Mediate or Indirect Percussion
It can be performed by using the finger on one hand as
a plexor (Striking finger) and the middle finger of the
other hand as a pleximeter (the finger being struck).
Used mainly to evaluate the abdomen or thorax.
Used mainly to evaluate the sinus or an infant thorax.
It can be performed by striking the surface directly
with the fingers of the hand.
Used to evaluate the back and kidney for tenderness.
It involves placing one hand flat against the body
surface and striking the back of the hand with a
clenched fist of the other hand.
Auscultation is listening to sound produce by the
The following characteristics of sound are noted:Frequency or the number of oscillation generated per
second by a vibrating object.
Loudness –Loud or soft
Duration –Length of time that sound vibration last.
Short / medium / long.
Done by stethoscope.
Cardinal symptoms noted during history taking are:Dyspnea
Also history regarding hypertension, coronary heart
disease, hyperlipidemia should be noted.
2. Apex impulse
3. Dilated veins
4. Scars & sinuses
It is the anterior aspect of chest that overlies the
Normally it has smooth contour, slightly convex &
Apex is lowermost & outermost cardiac impulse.
It is in 5th left intercoastal space just inside the
It is nt visible in the case of emphysema & pericaedial
Seen over the chest wall in conditions like intrathoracic
obstruction, superior & inferior vena cava obtruction &
right sided heart failure.
SCRAS & SINUSES
Scars from the previous surgery.
Sinuses mainly seen due to tuberculosis of spine.
the lowest and outermost point of definite cardiac
pulsations can be usually palpated in the 5th intercostal
space within the midclavicular line.
Apex beat absent on left side can be due to:1. Dextrocardia
2. Pericardial effusion
3. Thick chest wall
It is done to determine the boundaries of heart.
Patient must be percussed in fourth & fifth space in
mid axillary line & then medially towards the left
border of heart.
The resonant note of lung becomes dull.
Normally the left border is present along the apex
If it is present outside then it suggests pericardial
Patient is percussed in second & third left intercostal space
in parasternal line, which is the line between midclavicular & lateral sternal line.
Normally there is resonant note in second space & dull
note in third space.
If there is dull note in second space it is suggestive of :1. Pericardial effusion
2. Aneurysm of aorta
3. Pulmonary hypertension
4. Left atrial enlargement
5. Mediastnal mass
Patient is percussed in midclavicular line on the right
side until the live dullness is percussed.
Normally the right border of heart is retrosternal.
If the dullness is parasternal it suggests:1. Pericardial effusion
2. Aneurysm of ascending aorta
3. Right atrial enlargement
5. Mediastinal mass
6. Right lung base pathology.
Though there are four heart sounds recorded, clinically
only two heart sounds are usually audible.
These sounds are ascultated in four areas namely
mitral, tricuspid, pulmonary & aortic areas.
The 1st heart sound, marks the beginning of systole
(end of diastole).
Related to the closure of the mitral and tricuspid
Loudest at the apex and lower left sternal border.
- normally in children
Increased cardiac output
Increased A-V valve flow velocity (acquired mitral
stenosis, but not congenital MS)
Increased chest wall thickness
The 2nd heart sound, marks the end of systole
(beginning of diastole).
From closure vibrations of aortic and pulmonary valves
Loudest at the base.
Before doing the examination of the respiratory system,
general features relevant to the respiratory system should
be assessed such as general appearance to see pallor or
cyanosis & clubbing.
Sign & symptoms like cough, sputum, hemoptysis,
dyspnoea should be recorded while taking the case
Shape of the chest
The normal chest is bilaterally symmetrical and elliptical
in cross section
the transverse diameter > anteroposterior diameter
Comman abnormalities of shape
kyphosis-forward bending of vertebral column
scoliosis- lateral bending of vertebral column
barrel shaped chest- increase in anteroposterior diameter
Rate & Rhythm of respiration
Rate of respiration in health (adult)
Measurement of chest expansion
chest expansion can be measured with a tape
measure around the chest
in a healthy adult it is about 3-5 cm
Symmetry of chest expansion
chest expansion of a healthy adult should be
palpate any part of the chest where the patient complains of
pain or where there is a swelling
Position of the Apex beat and Trachea
In normal subjects the trachea is in the midline and can
be palpated in the suprasternal notch
the apex beat (the lowest and outermost point of definite
cardiac pulsations) can be usually palpated in the 5th
intercostal space within the midclavicular line
Displacement of the apex beat and trachea indicates that
the position of the mediastinum has been altered
This may be due to diseases of the heart, lungs or pleura
Expansion of the chest
Symmetrical or asymmetrical chest expansion can be
assessed by palpation
Vocal fremitus is the vibration detected by palpation
with the palm of the hand on the chest, when the
patient is asked to repeat “ninety nine”
In a normal healthy adult, the vibrations felt in the
corresponding areas on the two sides of the chest are
equal in intensity
The middle finger of the left hand is placed on the
chest and middle phalanx is struck with the tip of
the middle finger of the right hand
Compare the percussion note (resonant) with that
of the corresponding area on the opposite side of
A resonant sound is produced during percussion
The sound and feel of resonance over a healthy
lung has to be learned by practice
There are 2 types of breath sounds:-bronchial breath sounds
- vesicular breath sounds
Bronchial breath sounds
These are produced by the passage of air in the trachea and
In good health, they can be heard only over the trachea
In disease, bronchial breathing may be heard over the area of
lung that is affected (lung collapse, fibrosis or when there is a
- the expiration is long as or longer than inspiration
-the pitch and sound of the expiration is loud or
louder than the inspiratory sounds
-there is a gap between inspiration and expiration
- Vesicular breath sounds
These originate in the larger airways and are produced by
the passage of air in and out of normal lung tissue
In good health, they can be heard all over the chest
-the inspiration is longer than expiration
-the inspiratory sound is intense and louder
than the expiratory sound
-there is no gap between inspiration and expiration
Vesicular breathing with prolonged expiration
example: airway obstruction (asthma)
These are abnormal sounds that arise in the pleura
Rhonchi – wheezing sounds (asthma)
Crepitations – bubbling or crackling noises
Pleural rub – creaking or rubbing noises associated
Sign & symptoms include
nausea, vomiting, diarrhea, constpation, indigestion, l
oss of appetite & abdominal pain should be noted
while taking the case history.
Movement with respiration
1- To define the boundaries of abd organs e.g
upper and lower border of the liver, spleen,
2- Detection of ascites”
Done before palpation and percussion as touching the
abdomen may alter the abdominal sounds.
Use the warm diaphragm, and listen for 15-20 sec.
Symptoms associated with this system relate to
menstruation, frequency of urination, pain on
urination, blood or pus in urine.
Weakness / paralysis / contracture / joint swelling /
Symptoms associated with this system include muscle
or bone pain, loss of joint function, muscle weakness
and occasionally multiple bone fracture.
Curvature of spine observe for: Lordosis: Increase lumber curvature
Scoliosis: Lateral spinal curvature
Kyphosis: Exaggeration of posterior curvature of
The endocrine system involves several glands. Each may be
overactive or underactive.
Gland Pain Pattern
upper left quadrant or pancreas- generalized epigastric pain
adrenal disorders -myalgia and arthralgia
tenderness in the anterior,inferior aspect of the throat
and neck-thyroid or parathyroid glands
headache or visual disturbances-hypothalamus and pituitary
Clinician should be aware of sign & symptoms of endocrine
diseases such as diabetes mellitus, hypo 0r hyperthyroidism etc
to rule out the diagnosis.
CENTRAL NERVOUS SYSTEM
Orientation –To place / person / time
Level of conscious -confused / alert / restless /
lethargic / comatose
Co-ordination to walk:
Sensation test: Pain
Patients with the history of
convulsions, pain, paresthesia, paralysis or syncope
may have a nervous system disorder.
The location, character, onset, duration & other
symptoms associated with the complaint should be
CRANIAL NERVES EXAMINATION
CN I ( olfactory)
Patency of nasal passage is evaluated bilaterally asking
the patient to breathe in through nostrils while
examiner occludes one nostril at a time.
Once patency is established, ask the patient to close
their eyes and identify the essence of coffee, vanilla,
peppermint dipped in cotton.
Also ask the patient to compare the strength of smell
in each nostril.
CN II (optic)
Done by confrontation by wiggling fingers 1 foot from
patient ears, asking which they see move.
CN III, IV, VI
Look at pupils: shape, relative size and ptosis.
Shine light in from the side to see pupils’s light
Ask the patient to follow finger with eyes without
Touch cotton wool to other side
Look for blink in both eyes.
Jaw jerk reflex
Examiner places finger on tip of jaw.
Grip patellar hammer halfway up shaft and tap examiner’s
Usually nothing happens, or just a slight closure.
Sterile sharp item on forehead, cheek & jaw; then repeat it with dull object & ask the
patient to differentiate.
If abnormal, then test temperature [water-heated/cooled
tuning fork], light touch [cotton].
Palpation of the muscle of mastication.
First look at the patient's face. It should appear symmetric. That is:
There should be the same amount of wrinkles apparent on either side of the
The nasolabial folds (lines coming down from either side of the nose towards the
corners of the mouth) should be equal
The corners of the mouth should be at the same height
Ask the patient to smile. The corners of the mouth should rise to the same height and
equal amounts of teeth should be visible on either side.
Ask the patient to puff out their cheeks. Both sides should puff equally and air should not
leak from the mouth.
Check the taste sensation.
Rub hands with noise on side of ear.
Grasp the 512 Hz tuning fork by the stem and strike it against the
bony edge of your palm, generating a continuous tone. Alternatively
you can get the fork to vibrate by "snapping" the ends between your
thumb and index finger.
Hold the stem against the patient's skull, along an imaginary line
that is equidistant from either ear.
The bones of the skull will carry the sound equally to both the right
and left CN 8. Both CN 8s, in turn, will transmit the impulse to the
The patient should report whether the sound was heard equally in
both ears or better on one side than other (referred to as lateralizing
to a side).
The vibrations are normally perceived equally in both ears because
bone conduction is equal. In conductive hearing loss, the sound is
louder in the abnormal ear than in the normal ear. In sensorineural
hearing loss, lateralization occurs to the normal ear.
1. Grasp the 512 Hz tuning fork by the stem and strike it
against the bony edge of your palm, generating a
2. Place the stem of the tuning fork on the mastoid bone.
3. The vibrations travel via the bones of the skull to CN 8,
allowing the patient to hear the sound.
4. Ask the patient to inform you when they can no longer
appreciate the sound. When this occurs, move the tuning
fork such that the tines are placed right next to (but not
touching) the opening of the ear. At this point, the
patient should be able to again hear the sound. This is
because air is a better conducting medium then bone.
Examine the palate for uvular displacement
Check for gag reflex.
Check for gag reflex
Check for taste alteration in posterior part of tongue.
Ask the patient to open their mouth and say, "ahhhh," causing the soft palate to rise
Check for shrugging of shoulders.
Place your hands on top of either shoulder and ask the patient to shrug while you provide
resistance. Dysfunction will cause weakness/absence of movement on the affected side.
Inspect tongue for deviations.
SKIN – is looked for
Appearance-any rashes, sores or itching
Color-anemia patients have pale skin color, yellow tint is
seen in jaundice patients.
Inspect external eye structure forPosition and alignment
Eye lashes : sty.
Indicator of anemia & jaundice.
infection of maxillary teeth may extend to orbital region
causing swelling of eyelid & conjunctivitis.
Size-should be 1/3rd of total facial height.
Deviated nasal septum in mouth breathers.
Saddle nose in congenital syphilis.
Any deviation in path of closure and opening lateral
movements of mandible.
Tenderness over the joint and muscles of mastication.
Any injuries trauma to the facial bones and jaws should
clicking or popping
Deviation or deflection while opening
pain or tenderness over joint or masticatory muscles.
Maximal interincisal opening (normal is 35-50 mm)
Range of vertical & lateral movements.
PALPATION OF PRE TRAGUS AREA:
The examiner can be positioned either in front of or behind
Patient is asked to slowly open and close the mouth palpating
with index finger, placed in the pre tragus depression.
INTRA AURICULAR PALPATION:
Performed by inserting small finger into the ear canal and
While palpating with this methods check whether condyle
moves symmetrically, with the rotation and translation phase.
Muscle of mastication
Palpation of the muscles of mastication can be helpful
in the determination of temporomandibular joint
dysfunction and in the discovery of other
These muscles are the temporalis,masseter,internal
pterygoid and external pterygoid.
Origin:In the fossa of the temporal
Insertion: on the coronoid process
and anterior border of the ramus of
The muscle can be seen and readily
palpated throughout its entire
length and breadth when the
patients teeth are firmly clenched.
The masseter muscle
Origin: from lower portion of the
zygomatic arch .
Insertion: on the lateral surface of
the angle and coronoid process of the
This muscle has a deep and
superficial portion as with the
temporalis muscle, it can be located
when the patients jaws are forcibly
PALPATION-The body of the
masseter can be palpated with
thumb and the index finger.
Internal pterygoid muscle
Origin:medial side of the lateral pterygoid plate
and the tuberosity of the maxilla and they cannot
Insertion: on the lower medial surface of the
ramus of the mandible .
the anterior part of the insertion
can be palpated by placing the
index finger at a 45 degree angle
in the base of the relaxed tongue.
The opposite hand can be used
extraorally to palpate the
posterior and inferior portions of
The body of the muscle can be
palpated by rotating the index
finger upward against the muscle
to near its origin on the
EXTERNAL PTERYGOID MUSCLE
Origin: in two parts ,one begins on the greater
wing of the sphenoid bone and the other issues
from the lateral surface of the pterygoid plates.
Insertion:on the neck of the condyle and the
articular disc of the temporomandibular joint.
The muscle is palpated by using
the index or little finger and
placing it lateral to the
maxillary tuberosity and medial
to the coronoid process .
The finger presses upward and
inward and a painful response
can be determined.
Because this procedure is
uncomfortable for the
patient,the response requires
Lymph nodes are oval or
bean-shaped structures found
along lymphatic vessels that
drain body parts.
Normally, they are nontender, soft and cannot be felt
even though they are present.
tender on palpation,
mobility should be noted.
PREAURICULAR LYMPH NODES
Location – in front of ear
Lymphatic drainage - Eyelids
and conjunctivae, temporal
For palpation of
nodes, roll your finger in
front of the ear, against the
Enlarged - External
auditory canal infection.
LOCATION – behind the ear , near
the insertion of sternomastoid
Lymphatic drainage: External auditory
meatus, pinna, scalp
Digital palpation is done by pressing
against the skull.
Enlarged due to infection of scalp,
temporal & frontal areas.
OCCIPITAL LYMPH NODES
Location: Located at the junction
between the back of the head and
Lymphatic drainage: Scalp and
Enlarged in infection of scalp &
Located below the chin.
Lymphatic drainage: Lower lip,
floor of mouth, teeth, submental
salivary gland, tip of tongue, skin
Roll the fingers below and
lingual to the chin, against the
Enlarged in disorders in the
anterior portion of the mouth
and the lower lip.
Located medial to the inferior
border of mandible.
Lymphatic drainage: Tongue,
submaxillary gland, lips and
Roll your fingers against inner
surface of Mandible with patient's
head gently tilted towards one side.
Enlarged in Infections of head,
neck, sinuses, ears, eyes, scalp,
2 chains of lymph nodes present
on either side of sternomastoid
Location – ant. cervical is
located ant to muscle & post
cervical is located posteriorly.
for ant chain pt’s head is tipped
slightly forward & area medial to
sternomastoid muscle is pressed
with examiners finger.
for post chain , fingers are kept
behind the muscle. Palpation starts
from trapizius muscle & moved to
1) Labial and buccal
3) Floor of mouth
6) Salivary glands
a) Teeth present
b) Teeth missing
c) Carious teeth
d) Wasting disease
LABIAL & BUCCAL MUCOSA
It should be checked for any
White patch or neoplasia
Any surface irregularities,
Palpate upper lip and lower lip for any thickening
(induration) or swelling.
Angular or vertical fissures.
Keratotic plaque and scars.
Floor of mouth
It should be checked for: Any swellings
RANULA: appears as unilateral bluish translucent cyst over
ANKYLOGLOSSIA: fusion between tongue and floor of
CARCINOMAS are common in the floor of the mouth.
Ulcers or red and white patches.
Examination is done to check for:-
Volume of tongue- enlarged tongue due to
lymphangioma, hemangioma & neurofibroma.
Integrity of papilla
Any cracks or fissures
Any swelling or ulcers
Presence of tongue tie.
WHITE -Leukoplakia, Oral
BLACK - Black Hairy
Tongue(due to hyperkeratosis of
mucous membrane in heavy
COATED TONGUE one
covered with a whitish or
yellowish layer consisting of
debris, bacteria, fungi, etc.
FISSURES, CRACKS IN THE
Site of ulcer is usually
Carcinomatous ulcers and
traumatic ulcers are common
along lateral border of the
While palpating for indurations on
the base of an ulcer, tongue should be
relaxed and at rest within the mouth.
If it is kept protruded the contracted
muscles may give false impression to
induration and lead to error in
Induration is an important sign in
epithelioma, gummatous ulcers
which is absent in tuberculous ulcer.
Note whether ulcer bleeds on
palpation usually seen in malignant
Palpate the back of the tongue
for any ulcer or swelling.
Physiological pigmentation may be seen (melanin).
Depends on the shape of the teeth and their alignment in the arch,
location and size of the area of proximal contact and dimensions of
facial and lingual embrasures. Scalloped outline on the facial and
Is governed by the contour of the proximal tooth surface and the
location and shape of the gingival embrasures.
SIZE: Corresponds to the sum total of the bulk of cellular and
intercellular elements and their vascular supply.
gingiva is firm and resilient with exception of free gingival margin
gingival fibers contribute to the firmness of the gingival margin.
“orange peel” referred to as being stippled
it can be viewed by drying the gingiva .
will be absent in infancy and old age increases in adulthood.
attached gingiva and central portion of interdental gingiva are stippled;
where as marginal gingiva is not.
stippling is produced by alternate rounded protuberances and
depressions in the gingival surfaces.
refers to the level at which gingival margin is attached to the tooth.
is exposure of root surface by an apical shift in the position of the
RECESSION MAY BE LOCALIZED TO ONE TOOTH OR
GENERALIZED INVOLVING ALL TEETH.
Classification –According to P.D Millers
Class 1 – gingival recession not extending to mucogingival junction
Class 2- gingival recession extending upto or beyond Mucogingival
Class 3 - gingival recession extending upto or beyond mucogingival
junction ,bone & soft tissue loss interdentally
Class 4 - gingival recession extending upto or beyond mucogingival
junction , severe malposition of teeth
CAUSES: Faulty tooth brushing technique
High frenal attachment
Trauma from occlusion
Orthodontic movement of teeth
POSITION: Located below, behind and slightly
in front of the ear.
Swelling of parotid gland obliterates the normal
hollow just below the lobule of the ear.
STENSONS DUCT: opens into the oral cavity on
buccal surface opposite to the crown of maxillary
SUPPURATIVE PAROTITIS: gentle pressure over
the gland will cause purulent saliva to come out
of the duct.
Terminal part of the duct is palpated bi digitally
between the index finger inside the mouth and
the thumb over the cheek.
Blood will come out of the duct in case of
If there is any history of Swelling with pain at the time of meals,
suggests obstruction in the sub mandibular duct. It is tense and
Wharton’s duct is inspected by means of torch on the floor of the
mouth which is situated on either side of lingual frenum.
Check if the duct orifice has swollen or inflamed .
If the gland is infected, slight pressure on the gland will exude pus
through the orifice.
If stone is suspected in one duct saliva will be soon coming out with
normal flow from other orifice while affected duct orifice remains dry.
Tested by putting dry sweets on each orifice and
some lemon juice on dorsum of the tongue, 2
minutes after sweets on one side are taken out.
Sweets on the orifice of the duct where the stone is
impacted will remain dry.
If patient gives history of pain during or after meals
ask the patient to suck little lemon or lime juice. If
swelling appears it indicates stone in submandibular
Patient is asked to open the mouth.
One finger of one hand is placed on the floor of mouth medial to the alveolus and lateral
to the tongue, and pressed on the floor of the mouth as far as possible.
The finger of the other hand on the exterior is placed just medial to the inferior margin
of the mandible.
These fingers are pushed upward as this will help to palpate both the superficial and
deep lobes of submandibular salivary glands.
This also differentiates the enlarged salivary gland from enlarged submandibular lymph
Submandibular salivary gland enlargement is a single swelling where as nodular swelling
suggests lymph node enlargement .
SITUATION: few swellings are
peculiar in their position
E.G: DERMOID SWELLING:
midline of body
MEDIAN PALATAL CYST: midline of
GLOBULO MAXILLARY CYST:
between maxillary incisor and
MEDIAN MANDIBULAR CYST:
midline of mandible
Benign nevus and melanoma
BLUISH COLOR: Ranula
Shape of the swelling should be noted whether it is
ovoid, pear shaped, and kidney shaped, spherical /
Always the vertical and horizontal dimensions should
mucosa will be smooth, ulcerated papillomatous, eroded, keratinized, necrotic.
E.G. CAULIFLOWER LIKE SURFACE: squamous cell carcinoma
IRREGULAR NUMEROUS BRANCHES: surface of papilloma
CORRUGATED OR PAPILLOMATOUS SURFACE: verruca vulgaris,
edges may be clearly defined or indistinct, sessile or pedunculated.
Some swellings are always multiple e.g. neurofibromatosis, multiple glandular
SOLITARY SWELLINGS: Lipoma, Dermoid Cyst.
MOVEMENT WITH RESPIRATION:
Swellings that arise from upper abdominal viscera move with respiration
(liver, spleen, stomach, gall bladder).
IMPULSE ON COUGHING:
Swellings which are in continuity with abdominal cavity, pleural
cavity, spinal cavity, or cranial cavity give rise to impulse on coughing.
MOVEMENT WITH DEGLUTITION:
A few swellings which are fixed to larynx or trachea move during
Eg thyroid swellings, thyroglossal cyst, pre or para tracheal lymph node
MOVEMENT WITH PROTRUSION OF TONGUE:
Thyroglossal cyst moves with protrusion of tongue.
SKIN OVER THE SWELLING:
RED AND EDEMATOUS: inflammatory swellings
SKIN BECOMES TENSE, GLOSSY WITH VENOUS PROMINENCE: sarcoma
with rapid growth
BLACK PUNCTUM OVER THE CUTANEOUS SWELLING: sebaceous cyst.
PRESENCE OF SCAR: indicates previous operation injury or previous
PIGMENTATION OF SKIN seen in moles, nevi or after repeated exposure to
ANY PRESSURE EFFECT: an axillary swelling with edema of the upper limb
means swelling arising from lymph node .
WASTING OF DISTAL LIMB: indicates swelling is a traumatic one.
Best felt by dorsal aspect of the hand
First note systemic temperature
First palpate on normal side and then on infected side
Temperature increased in inflammation as there is increased metabolic rate and
increased vascularity of area.
It is increased in superficial aneurysm a-v shunt and large recent hematoma.
INFLAMMATORY SWELLINGS: TENDER
NEOPLASTIC SWELLINGS: NON-TENDER
DEEPER DIMENSIONS OF THE SWELLINGS REMAIN UNKNOWN DURING
VERTICAL AND HORIZONTAL DIMENSIONS ARE BETTER CLARIFIED BY
WHETHER MASS IS WELL DEFINED, MODERATELY, POORLY DEFINED.
with palmer surface of the fingers the clinician should palpate the surface of
the swelling .
LOBULAR: smooth bumps – lipoma
NODULAR: a mass of matted ln
IRREGULAR AND ROUGH : carcinoma
EDGES OR BORDERS: margins are palpated with the help of tip of the finger.
SMOOTH MARGINS : benign swellings
IRREGULAR MARGINS:malignant swellings
Inflammations in non-encapsulated organ develop ill defined borders.
CONSISTENCY OR DEGREE OF FIRMNESS of the lesion in contrast to that
of its surrounding tissue.
SOFT CONSISTENCY: cyst, warthins tumor, vascular tumor, fatty tumor,
inflammatory hyperplasia, retention phenomenon, cystic hygroma.
CHEESY: cyst (sebaceous, dermoid and epidermoid), tubercular node.
RUBBERY: cyst under
tension, myoblastoma, lymphoma, myxoma, aneurysm.
benign tumor of soft tissue
malignancy of soft tissue
osteosarcoma or chondosarcoma
inflammation and infection of lymph node.
BONY HARD: osteoma ,osteogenic sarcoma
SOFT: easily compressible tissue such as lipoma or mucocele and cyst.
CHEESY: indicates finer tissue that has granular sensation but no rebound
RUBBERY: tissue that is firm but can be compressed slightly and rebound to
normal contour as soon as pressure is withdrawn
firm; fiber tissue that can not be readily compressed
swelling fluctuates when it contains liquid or gas .
TEST: is carried out by one finger of each hand. Sudden pressure is applied on
one pole of swelling.
This will increase pressure within the cavity of the swelling and will be
transmitted equally at right angle to every part of its wall.
If another finger is placed on other side of swelling the finger will raise
passively due to increased pressure within the swelling. This means swelling is
Test is performed in two planes at right angle to each other. Two fingers are
kept as far as possible as size of swelling will allow.
In case of small swelling where it can’t accommodate two fingers, fluctuation is
elicited by pressing the swelling at center.
The swelling containing fluid will be softer at the center than its periphery
while solid swelling will be firmer at center than at its periphery (pagets test)
In case of swellings containing fluid a percussion wave is conducted to its other
poles when one pole of it’s tapped as dome in percussion.
In big swellings demonstrated by tapping the swelling on one side with two finger
while percussion wave is felt on the other side of swelling with palmer aspect of the
In case of small swellings three fingers are placed over other hand, percussion wave
felt by other two fingers on each side.
swelling can transmit light through it for this it should contain fluid like
lymph or plasma.
for this test, darkness is required
during day time, this can be done by using roll of paper which is held on side
of the swelling while a torch light is held on the other side of the swelling.
the swelling will transmit light if it is translucent.
IMPULSE ON COUGHING: Swelling is grasped and patient is asked
to cough, an impulse is felt by the grasping hand.
the swelling can be reduced and ultimately disappear as soon as it is pressed
upon. Eg) hernia
swelling can be compressed, but could not disappear completely like arterial,
capillary, venous hemangioma.
In compressible swellings, contents are not actually displaced so the swelling
reappears immediately as soon as pressure is taken off.
A SWELLING MAY BE PULSATILE IF IT
ARISES FROM THE WALL OF AN ARTERY
LIES CLOSE TO AN ARTERY
IF THE SWELLING IS A VASCULAR ONE.
PULSATILE ONE: two fingers are raised with each throb of the artery
EXPANSILE ONE: two fingers are raised and separated from each other
TRANSMITTED ONE: two fingers are raised but not separated, called
FIXITY TO THE OVERLYING SKIN:
For this, skin is made to move over the swelling ,
If it is fixed to the skin, the skin will not move.
Try to pinch up the skin overlying the swelling in different parts. If it is
fixed it can not be pinched off
and if not fixed it can be pinched off. Next an attempt is made to
move the mass independent of underlying tissue.
Swelling is freely movable if it is benign, encapsulated mass.
1. STRAW COLORED FLUID:
contain cholesterol crystals e.g. odontogenic
kerato cyst, fissural cyst
2. THICK YELLOWISH WHITE
AND GRANULAR FLUID:
seen in epidermoid and keratocyst in which
lumen is filled with keratin.
3. SEBACEOUS CYST:
contains sebum which is thick homogenous
and yellowish cheesy substance.
4. DARK AMBER COLORED FLUID: thyroglossal duct cyst
5. LYMPH FLUID:
color less with high lipid content, appears
cloudy and frothy. it is seen in hygroma and
6. BLUE BLOOD:
seen in early hematoma, hemangioma and
7. BRIGHT RED BLOOD:
aneurysm and a-v fistula
8. ASPIRATION OF PAINFUL WARM
FLUCTUANT SWELLING YIELD PUS.
yields pus with few yellow granules in it
(sulfur granules) these are basically bacteria.
10. STICKY CLEAR VISCOUS FLUID –
To elicit slight tenderness like brodies abscess.
all pulsatile swellings are auscultated to exclude presence
of any bruit or murmur.
EXAMINATION OF ULCER
Ulcer is a break in the continuity of the skin and
Size and shape:
Tuberculous ulcers are oval in shape but coalesce to form
irregular crescentric borders.
Syphilitic ulcer is circular or semicircular to start with but
unites to form serpiginous ulcer where we call it is as
Carcinomatous ulcers are irregular in shape and size.
To record exact size and shape of ulcer, a sterile gauze is
pressed on to the ulcers to get measurement.
Number: tuberculosis, granulomatous, varicose and soft
chancre may be more than one in number.
Position: is important and gives clue to diagnosis
E.g rodent ulcer, confined to upper part of the face, above
the line joining the angle of the mouth to the lobule of the
Malignant ulcers are common on the tongue, and lips.
IN SPREADING ULCER: the edges are inflamed and edematous
HEALING ULCER: red granulomatous tissue in the centre towards periphery,
will show blue zone (due to thinning of epithelium) and a white zone (due to
fibrosis of scar).
UNDERMINED EDGE: seen in tuberculosis. the disease causing the ulcer
spreads in and destroys the subcutaneous tissue faster than it destroys the
PUNCHED OUT EDGES: Seen in granulomatous ulcer or in a deep tropic
ulcer. The edges drop down at right angle to the skin surface.
SLOPING EDGE: Seen in healing traumatic or venous ulcers. Healing ulcer
always has sloping edge which is reddish purple in color and consist of new
RAISED AND PEARLY WHITE BEADED EDGE: it’s a feature of rodent
ulcer which develops in invasive
Cellular diseases and become necrotic at the centre.
ROLLED (EVERTED EDGES): characteristic features of squamous cell
carcinoma or an ulcerated adenocarcinoma.
Ulcer is caused by fast growing cellular disease. The growing portion at the
edge of the ulcer heaps up and spills over the normal skin to produce an
Exposed surface of the ulcer .
When floor covered with red granulation tissue, ulcer seems to be healthy
PALE AND SMOOTH GRANULATION TISSUE: HEALING ULCER
WASH LEATHER SLOUGH ON THE FLOOR: GRANULATION ULCER
A BLACK MASS AT THE FLOOR: MALIGNANT MELANOMA.
character of discharge its amount and smell.
HEALING ULCER: shows scanty serous discharge
SPREADING AND INFLAMED ULCER: shows purulent discharge
TUBERCULOSIS AND MALIGNANT ULCER: serosanguineous discharge.
If surrounding area of an ulcer is glossy red and edematous, ulcer is actually
VARICOSE ULCER: surrounding skin is pigmented.
SCAR OR WRINKLING IN THE SURROUNDING SKIN OF ULCER: old case
Acutely inflamed ulcer – always very tender
Chronic ulcers -slightly tender
Neoplastic ulcer –never tender
EDGE: in palpation different types of edges are confirmed which are seen
Marked induration of edge is the characteristic feature of
BASE: on which the ulcer rests, whereas floor is exposed surface of ulcer.
Base can be felt where as floor can be seen
If an attempt is made to pick up the ulcer between thumb and index
finger, base will be felt.
Marked induration of the base is an important feature of squamous
cell carcinoma and chancre.
DEPTH: it should be recorded in the examination sheet in millimeter.
BLEEDING: Whether ulcer bleeds on should be checked as
it is a common feature of malignant ulcer.
RELATION WITH DEEPER STRUCTURES:
The ulcer is made to move over the deeper structures to
know whether it is fixed to any of these structures.
GUMMATOUS ULCER: over a subcutaneous tissue or
bone & is often fixed to it.
MALIGNANT ULCER WILL BE FIXED TO DEEPER
STRUCTURES BY INFILTRATION.
structural changes of teeth
Eruption status of teeth
Retained deciduous teeth
Any trauma to tooth
Reason for missing teeth/tooth
History of removal
Co-relation of the missing teeth as an oral manifestation of
a systemic disease or genetic abnormality.
The sequel of missing teeth may include supra
eruption,tilting,drifting or rotation, all of which may
have an impact on treatment plan.
The primary examination technique for evaluating the teeth include:
Basic tools required are:
A good light source,
A sharp explorer and
An air syringe are the most basic tools required.
BITE WING RADIOGRAPHY:
To diagnose proximal decay.
INTRA- ORAL PERI APICAL
To detect the extent of occlusal caries.
To assess the periapical area.
A. To be radiographically visible, mineral
loss should be more than 20-30%
Fibro Optic Transilluminator.
Digital Fibro Optic Transilluminator.
Fluorescence (acid dissolution of structure).
Use of caries detector dye e.g. silver nitrate, methyl
red and alizarin stain to detect caries by color
WASTING DISEASES OF TEETH:
physiologic wearing away of a tooth
as a result of tooth to tooth
contact, as in mastication.
SITE: occurs on occlusal,incisal
and proximal surfaces of teeth.
ETIOLOGY: seen in bruxisum,
traumatic occlusion, and also
associated with aging process. It is
an abnormal process.
Friction between tooth & an exogeneous agent
use of abrasive dentifrice, tooth floss, tooth picks etc.
defined as irreversible loss of dental hard tissue by a chemical
process that does not involve bacteria.
SITE: cervical areas of teeth.
INTRINSIC: due to gastro esophageal
reflux and vomiting
EXTRINSIC: acidic beverages, citrus fruits.
The pathological loss of enamel and dentine due to
Occlusal forces which cause the tooth to flex, cause
small enamel flecks to break off, inducing the abrasive
These lesions are often diagnosed as toothbrush
abrasion, but they differ as their angles are sharper
Common in patients with poor tooth alignment
MOBILITY OF TEETH:
To evaluate the integrity of the attachment apparatus
surrounding the teeth.
Test is carried out by moving the tooth laterally in the
socket or preferably in the handles between two
PATHOLOGIC MOVEMENT: it results from inflammatory
process, para functional habits.
ADAPTIVE MOBILITY: occurs due to anatomic factors
such as short roots or poor crown to root ratio.
GRADES OF MOBILITY: (GLICKMAN’S
No detectable movement when force is applied other than
what is considered normal (physiologic) motion.
GRADE-I: movement of tooth about
1 mm in bucco-
GRADE-II: movement of tooth more than 1 mm in
bucco-lingual direction and labio palatal direction.
GRADE- III: depression of tooth in the socket .
CLASS-I MOLAR RELATION: mesio buccal
cusp of the maxillary Ist molar occludes in
the buccal groove of mandibular Ist
Distobuccal cusp of upper first molar
occludes in the buccal groove of lower first
mesiobuccal cusp of maxillary first
permanent molar occludes in interdental
space between mandibular first & second
It is also called tentative diagnosis or working diagnosis.
It is formed after evaluating the case history & performing
the physical examination.
The process of listing out of 2 or more diseases having
similar signs and symptoms of which only one could be
attributed to the patient’s suffering
A final diagnosis is only possible after carrying out
CHAIR SIDE INVESTIGATIONS:
PULP VITALITY TESTS
RED CELL COUNT,
TOTAL LEUKOCYTE COUNT,
TOTAL DIFFERENTIAL COUNT,
to evaluate the status of the
periodontium surrounding a tooth
VERTICAL PERCUSSION TEST –
positive indicates periapical
TEST – positive indicates
periodontium associated problems.
EXTRAORAL PROJECTIONS; OPG,
PA view of skull and jaws,
OTHER INVESTIGATIONS: URINE EXAMINATION
Special investigations like: Sialography
The final diagnosis can usually be reached following
chronologic organization and critical evaluation of the
information obtained from the,
physical examination and
the result of radiological and laboratory examination.
The diagnosis usually identifies the diagnosis for the patient
primary complaint first, with subsidiary diagnosis of
The formulation of treatment plan will depend on both
knowledge & experience of a competent clinician and
nature and extent of treatment facilities available.
Evaluation of any special risks posed by the compromised
medical status in the circumstance of the planned
anesthetic diagnostic or surgical procedure.
Medical assessment is also needed to identify the need of
medical consultation and to recognize significant deviation
from normal health status that may affect dental
Treatment of emergencies:
Dental or periapical
Extraction of hopeless teeth and provisional
replacement if needed(may be postponed to a more
Plaque control and patient education:
diet control (in patients with rampant caries)
Removal of calculas and root planing
Correction of restorative and prosthetic irritational
Excavation of caries and restoration (temporary or
final,depending whether a definitive prognosis for
the tooth has been determind and on the location
Periodontal therapy including placement of implants
Fixed and removable prothodontic appliances
Evaluation of response to restorative procedures
SUPERSCRIPTION: general background information regarding the dentist
and the patient and the date of prescription is written.
INSCRIPTION: specific information regarding the drug and the dosage.
SUBSCRIPTION: direction to the pharmacist for filling the inscription.
TRANSCRIPTION: instruction to the patient to be listed on the container
SIGNATURE AND EDUCATIONAL DEGREE OF PRESCRIBING DOCTOR: a
signature is required by law only for certain controlled substance.
It is defined as act of foretelling the course of disease
that is the prospect of survival & recovery from a
disease as anticipated from the usual course of that
disease or indicated by special features of the case.
BURKETS ORAL MEDICINE: GREEN BERG, GLICK SHIP- 11TH
ORAL DIAGNOSIS ORAL MEDICINE AND TREATMENT PLANNING:
STEVEN L. BRICKER, ROBERT P. LANGLAIS, CRAIG S. MILLER- 2ND
ORAL AND MAXILLOFACIAL MEDICINE; SCULLY 1STEDITION.
PRINCIPAL OF PRACTICAL ORAL MEDICINE & PATIENT
EVALUATION BY PRAMOD JHON R
PRINCIPLES AND PRACTICE OF MEDICINE, DAVIDSON,
CLINICAL MANUAL ON GENERAL SURGERY, S, DAS,3RDEDITION.
PRINCIPLES OF PRACTICAL MEDICINE, P.J.MEHTA, 17THEDITION.
Text book of endodontics-Grossman
Fundamentals of oral medicine radiology by Durgesh and Bailoor
Clinical manual for oral diagnosis by Beena Verma