case history in detail including objectives, goals, chief complaint, history of present illness, past dental history, medical history, general examination, extraoral examination intraoral examination further dividing into hard and soft tissue examination, provisional diagnosis, differential diagnosis, investigation, final diagnosis, treatment plan, prognosis

1. CASE HISTORY
Under guidance Presented by
DR SHALU RAI (HOD &PROFESSOR) DR PRIYANKA
DR DEEPANKAR MISRA (PROFESSOR)
DR SAHIL KIDWAI (SENIOR LECTURER)
DR SUMAN BISLA ( SENIOR LECTURER)

2. DEFINITION
• CASE HISTORY IS A PLANNED, PROFESSIONAL CONVERSATION BETWEEN THE
PATIENT AND THE CLINICIAN IN WHICH THE PATIENT REVEALS HIS/ HER
SYMPTOMS, FEARS OR FEELINGS TO THE CLINICIAN SO THAT THE NATURE OF
THE REAL OR SUSPECTED ILLNESS AND MENTAL ATTITUDE TO IT MAY BE
DETERMINED.
- ONGOLE
• CASE HISTORY IS PLANNED PROFESSIONAL CONVERSATION THAT ENABLES A
PATIENT TO COMMUNICATE HIS / HER FEELINGS, FEAR AND SEQUENCE OF
EVENTS LEADING TO THE PROBLEM FOR WHICH THE PATIENT SEEKS
PROFESSIONAL ASSISTANCE, TO THE CLINICIAN SO THAT PATIENT’S REAL OR
SUSPECTED ILLNESS AND MENTAL ATTITUDE CAN BE DETERMINED.

3. OBJECTIVES:
• A POSITIVE PROFESSIONAL RELATIONSHIP
• TO PROVIDE THE INFORMATION AND HISTORY OF PATIENT
• TO PROVIDE THE INFORMATION THAT AIDS THE CLINICIAN IN TREATMENT
PLANNING
- STEVEN L. BRICKER 2ND EDITION
•

4. STEPS
• PERSONAL INFORMATION, CHIEF COMPLAINT , HISTORY OF
PRESENT ILLNESS ,PAST DENTAL HISTORY, MEDICAL
HISTORY AND DIAGNOSTIC TESTS
• ANALYZE AND INTERPRET THE ASSEMBLED CLUES -
PROVISIONAL DIAGNOSIS.
• MAKE A D/D
• INVESTIGATE
• FINAL DIAGNOSIS
• TREATMENT PLAN

5. METHODS OF OBTAINING THE PATIENT HISTORY
• INTERVIEW
• HEALTH QUESTIONNAIRE
• COMBINATION OF THESE
-STEVEN L. BRICKER 2ND EDITION

6. INTERVIEW
• PATIENT IS ASKED ABOUT HIS OR HER HEALTH IN AN ORGANIZED FASHION.
• ALLOW HIM/HER TO DISCUSS ANY PROBLEM WITHOUT ANY INTERUPPTION
• DISADVANTAGE:
1. DEPEND ON DENTIST SKILL
2. REQUIRE TIME
3. INFORMATION ACQUIRED MAY BE DISORGANISED

7. HEALTH QUESTIONNAIRE
• PRINTED LIST OF HEALTH RELATED QUESTIONS
• ADVANTAGE:
1. LESS TIME
2. OFFERS A STANDARIZED APPROACH
• DISADVANTAGE:
1. LITTLE TIME TO BUILD RAPPORT
2. QUESTIONS OR FORMAT MAY BE INTERPRETED INACCURATELY
• BASIC QUESTIONS TYPES
1. GENERAL INQUIRY OR DIRECT QUESTIONS
2. FOLLOW UP QUESTION
3. CHECK QUESTION
- STEVEN L. BRICKER 2ND EDITION

8. COMBINATION
• BEST APPROPRIATE TECHNIQUE
• USE ADVANTAGE OF BOTH TECHNIQUE AND REDUCE DISADVANTAGE
• WHATEVER THE RESPONSE , FOLLOWING TOPIC SHOULD BE REVIEWED :
1. ANY KNOWN ALLERGY?
2. ANY HEART OR LUNG PROBLEM ?
3. ANY BLEEDING TENDENCY ?
4. ANY HEPATITIS OR DIABETES HISTORY?
5. ANY MEDICATION
-STEVEN L. BRICKER 2ND EDITION

9. SYMPTOM
• ANY SENSATION OR CHANGE IN BODY FUNCTION
• ONLY EXPRESSED BY PATIENT AND
• ASSOCIATED WITH PARTICULAR DISEASE .
SIGN
• ANY OBJECTIVE EVIDENCE OF DISEASE
• RECOGNISED BY PATIENT OR DENTAL SURGEON
S. DAS

10. THE ART OF HISTORY TAKING
 LISTEN TO YOUR PATIENT
 GOOD COMMUNICATION BETWEEN DOCTOR AND PATIENT
 GOOD CONSULTATION SKILL

11. SEQUENCE OF CASE
RECORDING
• PERSONAL INFORMATION
• CHIEF COMPLAINT
• HISTORY OF PRESENT ILLNESS
• MEDICAL HISTORY
• PAST DENTAL HISTORY
• FAMILY HISTORY
• PERSONAL HISTORY
• GENERAL EXAMINATION
• EXTRA ORAL EXAMINATION
• INTRA ORAL EXAMINATION
• PROVISIONAL DIAGNOSIS
• DIFFERENTIAL DIAGNOSIS
• INVESTIGATION
• FINAL DIAGNOSIS
• TREATMENT PLAN
-CM MARYA

12. PERSONAL INFORMATION
REGISTRATION NUMBER :
• RECORD MAINTENANCE
• BILLING PURPOSE
• MEDICO LEGAL ASPECT
• IDENTIFICATION
DATE :
• REFERENCE
• RECORD MAINTENCE
- STEVEN L. BRICKER 2ND

13. NAME
• IDENTIFICATION
• COMMUNICATION
• FORMING A RAPPORT WITH PATIENT
• RECORD MAINTENCE
• PSYCHOLOGICAL BENEFIT
• INFORMATION OF PATIENT SUCH AS RELIGION
- STEVEN L. BRICKER 2ND

14. AGE
• GROWTH ASSESSMENT PARAMETER
• RECOGNIZE THE DISPARITIES BETWEEN THE DENTAL –
CHRONOLOGICAL AGE
• TREATMENT PLANNING
• DRUG DOSAGE
• FORENSIC ODONTOLOGY
-

15. REFERENCE – WOOD AND GOAZ BOOK 5TH EDITION
INFANTS
1.ERUPTION CYST
2.HEMANGIOMA
3.CLEFT PALATE
4.WHITE SPONGE NEVUS
ADULT ABOVE 40 YEARS
1. CANDIDIASIS
2. LEUKOEDEMA
3. LEUKOPLAKIA
4. LICHEN PLANUS
5. DENTURE STOMATITIS
CHILDREN
1.PULP POLYP
2.ALBRIGHT DISEASE
3.HERPES SIMPLEX
4.DENTAL CARIES
ADULT UNDER 40 YRS
1. CANDIDIASIS
2. HERPES SIMPLEX
3. MUCOCELE
4. PAPILOMA
5. PYOGENIC GRANULOMA

16. • DOSE CALCULATION , BASED ON AGE
YOUNG’S RULE = CHILD’S AGE × ADULT DOSE
AGE+12
COWLING’S RULE = CHILD AGE AT NEXT BIRTHDAY × ADULT DOSE
24
FRIED ’S RULE = AGE ( IN MONTHS ) ×ADULT DOSE
150
K.D PHARMA

17. GENDER
IN FEMALE - ADDITIONAL QUESTIONS LIKE
PREGNANCY,
NURSING,
ORAL CONTRACEPTIVE PILLS &
MENSTRUATION
STEVEN L. BRICKER 2ND

18. REFERENCE – WOOD AND GOAZ BOOK 5TH EDITION
• MALE
1. LEUKOPLAKIA
2. MUCOCELE
3. ORAL CANCER
4. RESIDUAL CYST
5. TOBACCO POUCH
KERATOSIS
6. LYMPHOMA
7. HEMOPHILIA
• FEMALE
1. LICHEN PLANUS
2. PALATAL TORI
3. PYOGENIC GRANULOMA
4. RECURRENT APTHOUS ULCER
5. DENTAL CARIES
6. IRON DEFICIENCY ANEMIA
7. PREGNANCY TUMOR

19. ADDRESS
• CORRESPONDENCE
• GEOGRAPHICAL PREVALENCE OF DENTAL/ORAL DISEASES.
HIGH FLUORIDE CONTENT – FLUOROSIS – MEERUT
DENTAL CARIES – MODERN INDUSTRALISED AREA
PERIODONTAL PROBLEM – RURAL AREA
KANGRI CANCER- KASHMIR
SLEEPING SICKNESS- CENTRAL AND WEST AFRICA
PEPTIC ULCER – NORTH WESTERN AND SOUTHERN
GOITRE – SUB HIMALAYAN AREA ( JAMMU KASHMIR ,
PUNJAB , HIMACHAL PRADESH , UP )
• SOCIOECONOMIC STATUS OF THE PATIENT.
-
CM MARYA

20. OCCUPATION
• TAILORS, BEAUTICIANS – NOTCHING OF INCISAL EDGES OF
UPPER TEETH.
• IN ACIDIC ENVIRONMENT – EROSION OF TEETH.
• MUSICIANS - SOFT TISSUE TRAUMA ,HERPES ,DRY MOUTH,
TMJ PAIN.
• PAINT INDUSTRY- MERCURY POISONING, LEAD POISONING.
• HEPATITIS B – DOCTORS/ SURGEONS
• ABRASION – CARPENTER
• VARICOSE VEIN – BUS CONDUCTOR AND TRAFFIC POLICE MAN
CM MARYA

21. CONTACT NUMBER
• TO CHANGE APPOINTMENT
• RECORD
STEVEN L. BRICKER 2ND

22. CHIEF COMPLAINT
• DEFINED AS SYMPTOMS DESCRIBED IN PATIENTS OWN WORDS RELATING TO THE PRESENCE OF ABNORMAL CONDITION
AS FAR AS POSSIBLE NOT PROMOTED BY LEADING QUESTIONS.- SOBEN PETER 6TH EDITION
• AIDS IN THE DIAGNOSIS AND TREATMENT PLANNING
• IN PATIENT’S OWN WORDS IN CHRONOLOGICAL ORDER .
• REASON FOR WHICH THE PATIENT HAS COME TO THE DOCTOR.
• COMMON CHIEF COMPLAINTS : PAIN , SWELLING , ULCER , BLEEDING GUMS, DISCOLORATION, FRACTURED TOOTH ETC.
SOBEN PETER 6TH EDITION

23. HISTORY OF PRESENT ILLNESS
• ELABORATION/DETAILED DESCRIPTION OF THE CHIEF COMPLAINT
• WHEN?
• WHAT DID YOU NOTICED?
• ASSOCIATED FACTOR
• ANY TREATMENT OR MEDICATION
STEVEN L. BRICKER 2ND

24. PAIN
• SITE
• ONSET
• CHARACTER
• SEVERITY
• MOVEMENT
• ASSOCIATIONS
• PERIODICITY
• AGGREVATING AND RELIEVING FACTORS

25. • PAIN SHOULD NOT BE CONFUSED WITH TENDERNESS
• TENDERNESS MEANS PAIN WHICH OCCURS IN RESPONSE TO A STIMULUS GIVEN
BY SOMEBODY ( USUALLY DOCTOR)
• SO PAIN IS A SYMPTOM BUT TENDERNESS IS A SIGN
S DAS 9TH EDITION

26. SWELLING
• ANY ENLARGEMENT OR PROTUBERANCE IN THE BODY DUE TO ANY CAUSE.
• ANATOMICAL LOCATION (SITE)
• DURATION
• MODE OF ONSET
• SYMPTOMS
• PROGRESS OF SWELLING
• ASSOCIATED FEATURES
• SECONDARY CHANGES
• IMPAIRMENT OF FUNCTION
• RECURRENCE OF SWELLING
S DAS 9TH EDITION

27. BLEEDING GUMS
• DURATION
• AMOUNT / QUANTITY
• ASSOCIATED SYMPTOMS
• CAUSE- 1. GINGIVITIS
2. PERIODONTAL DISEASE
3. HARD BRUSHING
4. DEFICIENCY OF VIT C AND VIT K
5. BLEEDING DISORDER
- CM MARYA

28. ULCER
• BREAK IN CONTINUITY OF COVERING EPITHELIUM – SKIN OR MUCOUS MEMBRANE
• MODE OF ONSET
• DURATION
• PAIN
• DISCHARGE- SERUM, BLOOD, PUS
• ASSOCIATED DISEASE- TUBERCULOSIS & SYPHILIS
S DAS 9TH EDITION

29. REPLACEMENT OF MISSING TOOTH:
• REASON
• WHEN
• REASON FOR REPLACEMENT
CM MARYA

30. DECAYED TOOTH
• TIME
• FOOD LODGEMENT
• SENSTIVITY
• ASSOCIATED PAIN

31. DISCOLORATION
• CLASSIFICATION- EXTRINSIC ( STAIN – TOBACCO/ TEA)
INTRINSIC ( TETRACYCLINE / FLUORIDE )
• HOW LONG
• ANY ILLNESS B/W BIRTH & 6 YRS
• FAMILY HISTORY

32. BURNING SENSATION
DURATION
AGGREVATING FACTOR
RELEIVING FACTOR

33. DRY MOUTH
• SYMPTOM, NOT A DIAGNOSIS OR DISEASE.
• HOW LONG
• SMOKING / TOBACCO PRODUCT HISTORY
• DRUG HISTORY
• INFECTION AND INFLAMMATORY CONDITION

34. FRACTURED TOOTH
• CAUSE
• TREATMENT

35. DENTAL HYPERSENSITIVTY
• WASTING DISEASE- ATTRITION, ABRASION, EROSION, ABFRACTION
• GINGIVAL RECESSION
• FENESTRATION AND DEHISENCE
• SENSITIVE TO COLD / HOT / AIR/ SWEET / SOUR SUBSTANCES

36. PAST MEDICAL HISTORY
• PREVIOUS SERIOUS ILLNESS
• CHILDHOOD DISEASE
• HOSPITALISATION
• OPERATIONS
• INJURY TO HEAD AND NECK
• ALLERGY TO ANY MEDICATION OR FOOD
• BLOOD TRANSFUSION
• PREGNANCY
• MEDICATION

37. PAST MEDICAL HISTORY
CHECK LIST OF MEDICAL HISTORY-BY SCULLY AND
CAWSON
• -ANEMIA
• -BLEEDING DISORDERS
• -CARDIO RESPIRATORY DISORDERS
• -DRUG TREATMENT AND ALLERGIES
• -ENDOCRINE DISORDERS
• -FITS AND FAINTS
• -GASTROINTESTINAL DISORDERS
• -HOSPITALADMISSIONS AND SURGERIES
• -INFECTIONS
• -JAUNDICE AND LIVER DISEASES
• -KIDNEY DISEASE

38. PAST MEDICAL HISTORY
1. VARIOUS DISEASES AND FUNCTIONAL DISTURBANCES PREDISPOSES TO ORAL PROBLEMS
EITHER DIRECTLY OR INDIRECTLY.
SYSTEMIC DISEASES ASSOCIATED WITH.. DENTAL PROBLEMS ARE ,
– DIABETES
– ASTHMA
– SJOGREN’S SYNDROME

39. PAST DENTAL HISTORY
• PATIENT’S CURRENT DENTAL STATUS
• RESPONSE OF THE PATIENT
- FREQUENCY OF VISITS TO DENTIST.
- PAST EXPERIENCE.
- PAST DENTAL TREATMENT.
- ANY SURGICAL PROCEDURES
- REASON FOR LOSS OF TEETH

41. FAMILY HISTORY
• CONTAGIOUS INFECTIONS TUBERCULOSIS; HEPATITIS
• HEREDITARY PROBLEMS, SUCH AS AMELOGENESIS IMPERFECTA, HEMOPHILIA
• FAMILIAL CONDITIONS, SUCH AS RECURRENT APTHOUS STOMATITIS ,DIABETES

42. PERSONEL HISTORY
1. ORAL HYGIENE HISTORY
– METHOD OF CLEANING TEETH
– TYPE OF BRUSH
– METHOD OF BRUSHING
– NO. OF TIMES OF BRUSHING
– OTHER ORAL HYGIENE AIDS
– HOW OFTEN IT IS CHANGED
– TOOTH PASTES
2. DIET HISTORY
VEG/NON-VEG/MIXED DIET
NO. OF MEALS/DAY
CARIOGENIC SNACKS/DAY

43. 3. ADVERSE HABIT
SMOKING – FREQUENCY , DURATION
ALCOHOLISM - FREQUENCY , DURATION
TOBACCO CHEWING - FREQUENCY , METHOD ,DURATION
4. APPETITE
5. SLEEP
6. BOWELAND MICTURITION HABIT
7. NUTRITIONAL STATUS
HABIT – MOUTH BREATHING , THUMB SUCKING, BRUXISM

44. CONCLUSION OF THIS PART :
• LET PATIENTS TELL YOU THEIR STORY FREELY.
• 'LISTEN’.
• ASK THE PATIENT IF THERE'S ANYTHING THEY WANT TO ASK YOU AT THE END OF A CONSULTATION.
• IN ADDITION TO LISTENING , NOTICE THE FACIAL EXPRESSION , BODY LANGUAGE AND VERBAL FLUENCY
OF THE PATIENT
• TELL ALL ORAL FINDING TO THE PATIENT
• - ARTICLE ON HISTORY TAKING BY DR COLIN TIDY, 2019

45. INSPECTION
• VISUAL ASSESSMENT.
• GOOD LIGHTING.
• POSITION AND EXPOSE BODY PARTS SO THAT ALL SURFACE CAN BE VIEWED.
• INSPECT EACH AREA OF SIZE, SHAPE, COLOUR, SYMMETRY, POSITION AND ABNORMALITIES.
• COMPARE EACH AREA INSPECTED WITH THE SAME AREA ON THE OPPOSITE SIDE OF THE BODY.
• USE ADDITIONAL LIGHT TO INSPECT BODY CAVITIES.
• USE DENTAL MIRROR TO REFLECT LIGHT
STEVEN L. BRICKER 2ND EDITION

46. • USE HANDS AND FINGERS- FEEL OR PRESS
• PALMAR SURFACE OF FINGERS AND FINGER PADS
–TEXTURE ( SMOOTH , ROUGH , PEBBLY )
–DIMENSION
–FUNCTIONAL EVENTS
-- ASSESS SKIN TEMPERATURE
-- CONSISTENCY ( SOFT , RUBBERY , INDURATED)
• PATIENT SHOULD BE RELAX AND POSITIONED
COMFORTABLY BECAUSE MUSCLE TENSION DURING
PALPATION IMPAIR ITS EFFECTIVENESS.

47. TYPES OF PALPATION :
1. BIMANUAL PALPATION
2. BIDIGITAL PALPATION
3. BILATERAL PALPATION
S DAS 9TH EDITION

48. BIDIGITAL PALPATION
• PRESSING THE STRUCTURE B/W EXAMINER’S THUMB AND INDEX FINGER
• EG: EVALUATION OF NODULES IN THE LIPS , BUCCAL MUCOSA
• USED FOR THINNER STRUCTURE
STEVEN L BRICKER 2ND EDITION

49. BIMANUAL PALPATION
• MANIPULATION OF STRUCTURE B/W FINGERS OF ONE HAND AND THOSE OF ANOTHER
• EG: PALPATION OF SUBMANDIBULAR GLAND
STEVEN L BRICKER 2ND EDITION

50. BILATERAL PALPATION
• DONE TO DIFFERENTIATE BETWEEN SYMMETRICAL STRUCTURES ON BOTH SIDE OF FACE

51. PROBING
• PROBING IS PALPATION WITH AN INSTRUMENTS .
• THE TEETH ARE PROBED FOR CARIES WITH THE EXPLORER.
• PDL PROBE USED TO MEASURE THE DEPTH OF PERIODONTAL SULCUS.
STEVEN L. BRICKER 2ND EDITION

52. PERCUSSION
• TECHNIQUE OF STRIKING THE TISSUE WITH THE FINGERS OR AN INSTRUMENTS.
• LISTEN TO THE RESULTING SOUNDS AND OBSERVE THE RESPONSE OF THE PATIENT.
• EXTRAORALLY, USE TO DETECT TENDERNESS IN FRONTAL AND MAXILLARY SINUS BY TAPPING FINGER TIPS
AGAINST FINGER PLACED OVER THE SINUS.
STEVEN L. BRICKER 2ND EDITION

53. AUSCULTATION
• ACT OF LISTENING FOR SOUND WITHIN THE BODY.
• EXAMINER MAY LISTEN – WHEZZING, POPPING OF TMJ OR CLICKING SOUND
• THE FOLLOWING CHARACTERISTICS OF SOUND ARE NOTED:
1. FREQUENCY OR THE NUMBER OF OSCILLATION
GENERATED PER SECOND BY A VIBRATING OBJECT.
2. LOUDNESS –LOUD OR SOFT DURATION
3. LENGTH OF TIME THAT SOUND VIBRATION LAST. SHORT /
MEDIUM / LONG.
DONE BY STETHOSCOPE.
STEVEN L. BRICKER 2ND EDITION

54. CASE HISTORY PART -II
• EXAMINATION OF SWELLING
• EXAMINATION OF ULCER

55. EXAMINATION OF SWELLING
• INSPECTION
• PALPATION
• PERCUSSION
• AUSCULTATION
S DAS 9TH EDITION

56. INSPECTION
SITUATION - FEW SWELLINGS ARE PECULIAR IN THEIR POSITION
1. DERMOID SWELLING: MIDLINE OF BODY or ON THE LINE OF FUSION OF
EMBRYONIC
2. MEDIAN PALATAL CYST: MIDLINE OF HARD PALATE
3. GLOBULO MAXILLARY CYST: BETWEEN MAXILLARY INCISOR AND MAXILLARY
CANINE
S DAS 9TH EDITION

57. • COLOR-
BLACK: MELANOMA
RED PURPLE: HEMANGIOMA
BLUISH COLOR: RANULA
• SHAPE:
OVOID,
PEAR SHAPED,
KIDNEY SHAPED,
SPHERICAL
IRREGULAR.
• S DAS 9TH EDITION

58. • SIZE:
VERTICAL AND HORIZONTAL DIMENSIONS
• SURFACE:
1. CAULIFLOWER LIKE SURFACE: SQUAMOUS CELL CARCINOMA
2. IRREGULAR NUMEROUS BRANCHES: PAPILLOMA
S DAS 9TH EDITION

59. • EDGE:
CLEARLY DEFINED OR INDISTINCT,
SESSILE OR PEDUNCULATED.
• NUMBER:
MULTIPLE - NEUROFIBROMATOSIS.
SOLITARY - NEUROFIBROMA, DERMOID CYST.
S DAS 9TH EDITION

60. • PULSATION –
• SWELLING ARISING FROM ARTERIES ARE PULSATILE (ANEURYSM)
EXPANSILE - SWELLING ORIGINATE FROM ARTERIAL WALL
TRANSMITTED - SWELLING LIE JUST ABOVE THE ARTERY & IN CLOSE PROXIMITY.
• S DAS 9TH EDITION

61. • MOVEMENT WITH RESPIRATION:
SWELLINGS THAT ARISE FROM UPPER ABDOMINAL VISCERA MOVE WITH RESPIRATION (LIVER, SPLEEN, STOMACH).
• IMPULSE ON COUGHING:
SWELLINGS WHICH ARE IN CONTINUITY WITH ABDOMINAL CAVITY, PLEURAL CAVITY, CRANIAL CAVITY - IMPULSE ON
COUGHING. ( hernia )
S DAS 9TH EDITION

62. • MOVEMENT WITH DEGLUTITION:
SWELLINGS - FIXED TO LARYNX OR TRACHEA - MOVE DURING
DEGLUTITION
EG- THYROID SWELLINGS,
THYROGLOSSAL CYST,
MOVEMENT WITH PROTRUSION OF TONGUE:
THYROGLOSSAL CYST
S DAS 9TH EDITION

63. •SKIN OVER SWELLING
RED AND EDEMATOUS: INFLAMMATORY SWELLINGS
TENSE, GLOSSY WITH VENOUS PROMINENCE: SARCOMA
SCAR PREVIOUS OPERATION , INJURY
PIGMENTATION MOLES OR AFTER REPEATED EXPOSURE TO DEEP X-RAYS.
S DAS 9TH EDITION

64. ANY PRESSURE EFFECT:
AN AXILLARY SWELLING WITH OEDEMA OF THE UPPER LIMB - SWELLING
ARISING FROM LYMPH NODE
S DAS 9TH EDITION

65. PALPATION OF SWELLING
TEMPERATURE:
 BEST FELT BY DORSAL ASPECT OF THE HAND
 FIRST NOTE SYSTEMIC TEMPERATURE
 FIRST PALPATE ON NORMAL SIDE AND THEN ON
INFECTED SIDE
S DAS 9TH EDITION

66. • TENDERNESS:
INFLAMMATORY- : TENDER
NEOPLASTIC -: NON-TENDER
• SIZE -
DEEPER DIMENSIONS ( CM).
• S DAS 9TH EDITION

67. • SURFACE:
WITH PALMER SURFACE OF THE FINGERS
SMOOTH: CYST
LOBULAR WITH SMOOTH BUMPS – LIPOMA
NODULAR - A MASS OF MATTED LYMPH NODES
IRREGULAR AND ROUGH - CARCINOMA
• S DAS 9TH EDITION

68. • EDGES OR BORDERS:
MARGINS ARE PALPATED WITH THE HELP OF TIP OF THE FINGER.
WELL DEFINED – NEOPLASTIC
SMOOTH MARGINS - BENIGN
IRREGULAR MARGINS- MALIGNANT
ILL DEFINED – INFLAMMATORY.
S DAS 9TH EDITION

69. • CONSISTENCY
 OR DEGREE OF FIRMNESS OF THE LESION IN CONTRAST TO THAT OF ITS SURROUNDING TISSUE.
 VERY SOFT TO VERY HARD
SOFT - LIPOMA
CYSTIC - CYSTS AND CHRONIC ABSCESSES
FIRM - FIBROMA
HARD - CHONDROMA
BONY HARD - OSTEOMA
STONY HARD - CARCINOMA
S DAS 9TH EDITION

70. FLUCTUATION
• FLUCTUATES -- LIQUID OR GAS .
 ONE FINGER OF EACH HAND.
 SUDDEN PRESSURE ON ONE POLE OF SWELLING.
 INCREASE PRESSURE WITHIN THE CAVITY
 TRANSMITTED EQUALLY AT RIGHT ANGLE TO EVERY PART OF ITS WALL.
 FINGER IS PLACED ON OTHER SIDE OF SWELLING
 THE FINGER WILL RAISE PASSIVELY DUE TO INCREASED PRESSURE WITHIN THE
SWELLING.
 THIS MEANS SWELLING IS FLUCTUANT.
• S DAS 9TH EDITION

72. • TWO PLANES AT RIGHT ANGLE TO EACH OTHER.
• KEPT AS FAR AS POSSIBLE AS SIZE OF SWELLING.
• MOVABLE SWELLING – THUMB AND FORE FINGER
• SMALL SWELLING (CAN’T ACCOMMODATE TWO FINGERS,) - PRESSING THE SWELLING AT CENTER.
• THE SWELLING ( FLUID )- SOFTER AT THE CENTER THAN ITS PERIPHERY
• SOLID SWELLING - FIRMER AT CENTER THAN AT ITS PERIPHERY (PAGETS TEST)
• LARGE SWELLING – MORE THAN ONE FINGER OF HAND
S DAS9TH EDITION

73. FLUID THRILL
• SWELLING CONTAINING FLUID ----WHEN ONE POLE OF IT IS TAPPED , PERCUSSION WAVE IS - OTHER POLES
• BIG SWELLING- TAPPING - TWO FINGERS - THE PERCUSSION WAVE - OTHER SIDE OF THE SWELLING WITH PALMAR
ASPECT OF THE HAND.
• SMALL SWELLING- THREE FINGERS - THE MIDDLE FINGER IS TAPPED WITH A FINGER OF THE OTHER HAND
PERCUSSION WAVE IS FELT BY OTHER TWO FINGERS ON EACH SIDE
S DAS 9TH EDITION

74. TRANSLUCENCY
• SWELLING CAN TRANSMIT LIGHT THROUGH IT.
• TRANSLUCENCY - CLEAR FLUID, E.G. WATER, SERUM, LYMPH, PLASMA
• NOT BE TRANSLUCENT - OPAQUE FLUID, SUCH AS BLOOD (DERMOID CYST).
• DARKNESS IS ESSENTIAL. IN DAY TIME,
S DAS 9TH EDITION

75.  THIS CAN BE ACHIEVED BY A ROLL OF PAPER,
 HELD ON ONE SIDE OF THE SWELLING,
 TORCH LIGHT IS HELD ON THE OTHER SIDE
 TRANSMIT THE LIGHT- TRANSLUCENT SWELLING.
S DAS 9TH EDITION

76. IMPULSE ON COUGHING
• GRASPED AND ASKED TO COUGH.
• DUE TO COUGHING, PRESSURE IS INCREASED (ABDOMINAL, PLEURAL AND CRANIAL CAVITIES).
• CHILDREN, THIS EXAMINATION IS PERFORMED WHEN THEY CRY.

77. REDUEIBILITY
• SWELLING REDUCES AND ULTIMATELY DISAPPEARS WHEN IT IS PRESSED UPON.
EG ; -HERNIA
COMPRESSIBILITY
CAN COMPRESS BUT DOES NOT DISAPPEAR
EG – HEMANGIOMA

78. PULSALITY
 EXPANSILE ONE: TWO FINGERS ARE RAISED AND SEPARATED FROM EACH
OTHER
 TRANSMITTED ONE: TWO FINGERS ARE RAISED BUT NOT SEPARATED
S DAS 9TH EDITION

79. FIXITY TO THE OVERLYING SKIN
 PINCH UP THE SKIN OVERLYING THE SWELLING IN DIFFERENT PARTS.
 FIXED - CAN NOT BE PINCHED OFF
 NOT FIXED - PINCHED OFF.
 ORIGINATE FROM THE SKIN ( PAPILLOMA ) – FIXED
S DAS 9TH EDITION

80. PERCUSSION
• TO FIND OUT PRESENCE OF GASEOUS CONTENT WITHIN SWELLING
• EG RESONANT - HERNIA
• HYDATID THRILL – HYDATID CYST ( 3 FINGER TEST )
S DAS 9TH EDITION

81. AUSCULTATION OF SWELLING
• ALL PULSATILE SWELLING SHOULD BE AUSCULTATED TO EXCLUDE THE PRESENCE OF ANY BRUITS.
• EG :’ MACHINERY MURMUR IS HEARD IN ANEURYSMAL VARIX
S DAS 9TH EDITION

82. EXAMINATION OF ULCER
• SIZE AND SHAPE
1. TUBERCULOUS ULCERS - OVAL -IRREGULAR CRESCENTIC BORDER.
2. SYPHILITIC ULCERS - CIRCULAR OR SEMILUNAR -UNITE TO FORM A
SERPIGINOUS ULCER.
3. VARICOSE ULCERS - VERTICALLY OVAL.
SIZE – TIME OF HEALING
• S DAS 9TH EDITION

83. • NUMBER.—
TUBERCULOUS, VARICOSE ULCERS - MORE THAN ONE IN NUMBER.
TRAUMATIC ULCER - SOLITARY
• POSITION
 MEDIAL MALLEOLUS OF A LOWER LIMB - VARICOSE ULCER.
 TUBERCULOUS ULCERS - NECK
 TROPHIC ULCERS - THE HEEL OF THE FOOT
S DAS 9TH EDITION

84. • EDGE
• 'EDGE' SHOULD NOT BE CONFUSED WITH THE TERM 'MARGIN’
1. UNDERMINED EDGE – TUBERCULOSIS
2. PUNCHED OUT – GUMMATOUS ULCER
3. SLOPING EDGE – HEALING TRAUMATIC
ULCER
4. RAISED EDGE- RODENT ULCER
5. EVERTED EDGE – SQUAMOUS CELLED
CARCINOMA
S DAS 9TH EDITION

85. • FLOOR
RED GRANULATION TISSUE,- HEALTHY AND HEALING ULCER.
PALE AND SMOOTH GRANULATION TISSUE - SLOWLY HEALING ULCER.
WASH-LEATHER SLOUGH - GUMMATOUS ULCER
BLACK MASS - MALIGNANT MELANOMA.
• DISCHARGE
• A HEALING ULCER - SCANTY SEROUS DISCHARGE,
• SPREADING AND INFLAMED ULCER - PURULENT DISCHARGE.
• TUBERCULOUS ULCER - SERO-SANGUINEOUS DISCHARGE
S DAS 9TH EDITION

86. • SURROUNDING AREA.
• GLOSSY, RED AND OEDEMATOUS- ACUTELY INFLAMED.
• PIGMENTED - VARICOSE ULCER
• A SCAR OR WRINKLING - OLD CASE OF TUBERCULOSIS.
S DAS 9TH EDITION

87. PALPATION OF ULCER
• TENDERNESS
1. ACUTELY INFLAMED ULCER - TENDER.
2. CHRONIC ULCERS - TENDER.
3. VARICOSE ULCERS- MAY OR MAY NOT BE TENDER.
4. NEOPLASTIC ULCERS - NEVER TENDER
• EDGE AND MARGIN
MARKED INDURATION - CARCINOMA.
A CERTAIN DEGREE OF - ANY CHRONIC ULCER, (GUMMATOUS ULCER)
S DAS 9TH EDITION

88. • BASE
1. SLIGHT INDURATION - CHRONIC ULCER
2. MARKED INDURATION - SQUAMOUS-CELLED CARCINOMA
• DEPTH
TROPHIC ULCERS MAY BE DEEP -THE BONE.
• BLEEDING
BLEEDS TO TOUCH OR NOT?
COMMON FEATURE - MALIGNANT ULCER.
S DAS 9TH EDITION

89. • RELATIONS WITH THE DEEPER STRUCTURES.
1. A GUMMATOUS ULCER – OFTEN FIXED .
2. MALIGNANT ULCER – FIXED
• SURROUNDING SKIN
1. INCREASED TEMPERATURE AND TENDERNESS - ACUTE INFLAMMATORY ORIGIN
2. FIXITY TO DEEPER STRUCTURES - MALIGNANT NATURE OF THE LESION.
3. SURROUNDING SKIN IS TESTED FOR NERVE LESION
4. THE ARTERY MAY BE BLOCKED - ARTERIAL ULCER.
S DAS 9TH EDITION

90. CASE HISTORY PART - III
• GENERAL EXAMINATION
• EXTRAORAL EXAMINATION
• INTRAORAL EXAMINATION
• PROVISIONAL DIAGNOSIS
• DIFFERENTIAL DIAGNOSIS
• FINAL DIAGNOSIS
• TREATMENT PLAN
• PROGNOSIS

91. GENERAL EXAMINATION
1. BUILT, HEIGHT ,GAIT, AND POSTURE.
2. ANY PALLOR, ICTERUS, CLUBBING, CYANOSIS & EDEMA.
3. VITAL SIGNS -- PULSE, BLOOD PRESSURE, TEMPERATURE, RESPIRATORY RATE.
.
SCULLY

92. GAIT - PATTERN OF MOVEMENT
• 1. ANTALGIC GAIT – PAINFUL GAIT
• 2. ATAXIC GAIT- UNSTEADY, UNCOORDINATED WALK ( CEREBELLAR DISEASE)
• 3. FESTINATING GAIT – SHORT, ACCELERATING STEPS ARE USED TO MOVE
FORWARD ( PARKINSONS DISEASE)
• 4.FOUR POINT GAIT – CRUTCH USERS
• 5. HEMIPLEGIC GAIT – FLEXION OF HIPS AND CIRCUMDUCTION
• 6. SPASTIC GAIT – LEGS ARE HELD CLOSE TOGETHER (CNS INJURIES )
CM MARYA
CERTAIN DISORDERS CAN ALTER GAIT AND MAY INFLUENCE THE DIAGNOSIS OR TREATMENT PLAN
STEVEN L. BRICKER 2ND EDITION

93. BUILT – HOW BODY LOOKS LIKE
• WILLIAM SHELDON'S-1940
ENDOMORPH- PEAR SHAPED BODY , ROUNDED HEAD
MESOMORPH – WEDGE SHAPED BODY , CUBICAL HEAD, WIDE BROAD SHOULDER ,
NARROW HIPS , MIN AMT OF FAT
ECTOMORPH – HIGH FOREHEAD, NARROW SHOULDER AND HIPS ,THIN ARMS AND LEGS
CM MARYA

94. BUILD - ONGOLE
• BASED ON THE MUSCLE MASS AND SKELETAL FRAME
• ASTHENIC – LEAN AND UNDERWEIGHT
• STHENIC- ATHLETIC IN APPEARANCE
• HYPERSTHENIC – THICK MUSCULAR AND HEAVY BONE STRUCTURE
• PYKNIC – HEAVY AND ROUNDED
• CACHEXIA – ABNORMALLY LOW TISSUE MASS

95. HEIGHT AND WEIGHT
• PHYSICAL GROWTH AND DEVELOPMENT OF PATIENT
• WEIGHT IS PROPORTIONAL TO HEIGHT OF AN INDIVIDUAL , BMI IS USED
BMI = WT IN KG
HEIGHT IN M2
NORMAL RANGE OF INDEX FOR MALE = 10-25
FOR FEMALE = 18-24
- ongole

96. NOURISHMENT
• ASSESSED BY EVALUATING THE PRESENCE AND DISTRIBUTION OF BODY FAT AND MUSCLE BULK
• WELL NOURISHED
• MODERATELY NOURISHED
• POORLY NOURISHED/ MALNOURISED
- ongole

97. SKIN
• EXAMINED FOR
HYDRATION,
PALLOR,
PIGMENTATIONS,
CYANOSIS AND
SKIN ERUPTIONS.

98. ICTERUS ( bilirubin )
• SITE WHERE YOU SHOULD LOOK OF ICTERUS:
• BULBAR CONJUCTIVA ( high affinity to elastin )
• NAILBED,
• LOBULE OF EAR,
• TIP OF THE NOSE AND
• UNDER SURFACE OF TONGUE
IN NEONATES – FOREHEAD OR CHEST

99. SCLERA / BULBAR CONJUNCTIVA
BLUE – OSTEOGENESIS IMPERFECTA ( choroidal vein )
YELLOW – JAUNDICE
CONJUCTIVA :
PALE – ANEMIA
YELLOW – JAUNDICE
RED- CONJUCTIVITIS
EXAMINE PULPEBRAL ( LOWER -PULLED DOWN , LOOK UP
UPPER – LOOK DOWNWARD
BULBAR CONJUCTIVA
S DAS 9TH EDITION

100. PALLOR
PALENESS OR LOSS OF COLOUR FROM THE SKIN AND MUCOUS MEMBRANE .
• RESULT OF REDUCED AMOUNT OF OXYHEMOGLOBIN
• DEPEND ON THICKNESS AND AMT AND QUALITY OF BLOOD IN CAPILLARIES .
• BETTER INDICATOR – ORAL MUCOUS MEMBRANE , PALM AND CONJUCTIVA
SEEN IN ANAEMIA.
S DAS 9TH EDITION

101. CYANOSIS
BLUISH DISCOLORATION OF SKIN AND MUCOUS MEMBRANE AS A RESULT OF INCREASED AMOUNT OF REDUCED
HB LEVEL IN BLOOD
TYPES- CENTRAL – INADEQUATE OXYGENATION OF BLOOD IN THE LUNG
- WARM EXTRIMITIES ( TONGUE ) ( CONGENITAL HEART DISEASE )
PERIPHERAL –DUE TO EXCESSIVE REDUCTION OF OXYHAEMOGLOBIN IN THE
CAPILLARIES WHEN THE BLOOD FLOW IS SLOWED DOWN.
- COLD
- TIP OF NOSE , NAIL BED, SKIN OF THE PALM AND TOES.
RAYNAUD PHENOMENON

103. CLUBBING
• CHARACTERIZED BY – THICKNENING OF NAIL BED ,
OBLITERATION OF ANGLE
SCHAMROTH’S WINDOW TEST – REDUCTION IN GAP
EG : LUNG ABSCESS , INFECTIVE ENDOCARDITIS
S DAS 9TH EDITION

104. • GRADES OF CLUBBING
GRADES 1:- SOFTENING OF NAIL DUE TO HYPERTROPHY OF TISSUE AT THAT SIDE.
GRADES II:- IN ADDITION TO GRADES I CHANGES, OBLITERATION OF ANGLE BETWEEN NAIL BASE AND ADJACENT SKIN OF
THE FINGERS.
GRADES III:- IN ADDITION TO GRADES II, THE NAIL LOSES LONGITUDINAL RIDGES , BECOMES CONVEX FROM DOWNWARDS
AS WELL AS FROM SIDE TO SIDE . NAIL ASSUME SHAPE “PARROT’S BEAK” AND “DRUM STICK”
GRADES IV:- FINGERS CHANGES ASSOCIATED WITH HYPERTROPHIC PULMONARY OSTEOARTHROPATHY ( PERIOTITIS ,
DIGITAL CLUBBING AND PAINFUL ARTHROPATHY )

105. OEDEMA
• ACCUMULATION OF EXCESS FLUID WITHIN SUBCUTANEOUS TISSUE
• RECOGNISED BY – PRESENCE OF GLOSSY SKIN SURFACE OVER SWOLLEN SITE ,
• PITS ON FINGURE PRESSURE
S DAS 9TH EDITION

106. VITAL SIGN
• BODY TEMPERATURE
• BLOOD PRESSURE
• PULSE RATE
• RESPIRATORY RATE

107. TEMPERATURE
• ORAL 36.6°C OR 98.6 DEGREE F
• . INFECTION - ELEVATED TEMPERATURE;
• HYPERMETABOLIC STATE (HYPERTHYROIDISM) - ELEVATE TEMPERATURE.
• HYPOMETABOLIC STATE – DECREASE IN TEMPERATURE
• , AN ORAL TEMPERATURE - ABOVE 37.8°C OR
A RECTAL TEMPERATURE - ABOVE 38.3°C (A FEVER).
- SCULLY & BRICKER 2ND EDITION

108. BLOOD PRESSURE
• INDIRECTLY – SPHYGMOMANOMETER ANS STETHOSCOPE
• TO DETECT UNDIAGNOSED HYPERTENSION
• TO DETERMINE - WHETHER THE PATIENT MAY HAVE A DISEASE THAT CAUSES
HYPENENSION OR RESULTS FROM HYPERTENSION.
STEVEN L. BRICKER 2ND EDITION

109. • WITH A SPHYGMOMANOMETER THE PROCEDURE IS AS FOLLOWS:
 SEAT THE PATIENT ( SEVERAL MINUTES )
 PLACE CUFF AROUND THE RIGHT UPPER ARM, APPROX 1 INCH ABOVE THE ANTECUBITAL FOSSA;
 PALPATE THE RADIAL PULSE;
 INFLATE THE CUFF UNTIL THE RADIAL PULSE IS NO LONGER PALPABLE

110.  NOTE THE READING AND DEFLATE THE CUFF SLOWLY WHILE LISTENING WITH THE STETHOSCOPE OVER THE
BRACHIAL ARTERY ON ARM BELOW THE CUFF;
 RECORD THE SYSTOLIC PRESSURE - WHEN THE FIRST SOUNDS DETECTED
 DEFLATE THE CUFF – POINT AT WHICH SOUND DISAPPEAR (DIASTOLIC PRESSURE); REPEAT;
 RECORD THE BLOOD PRESSURE AS SYSTOLIC/DIASTOLIC PRESSURES
SYSTOLIC- 110-140 MM HG
DIASTOLIC-60-90 MM OF HG
HYPERTENSIVE – 150/90
(STEVEN L. BRICKER 2ND EDITION

111. PULSE RATE
RATE AT WHICH HEART BEATS PER MINUTE
 NORMAL PULSE RATE IS 60-80 BEEATS/MIN
 AVERAGE PULSE IS 72 BEATS/MIN
 USE THE FINGERTIPS RATHER THAN THE THUMB
STEVEN L BRICKER 2ND EDITION

112. POINTS TO BE NOTED
(A) RATE — FAST OR SLOW,
(B) RHYTHM — REGULAR OR IRREGULAR,
(C) TENSION AND FORCE WHICH INDICATE DIASTOLIC AND SYSTOLIC BLOOD
PRESSURE RESPECTIVELY,
(D) VOLUME WHICH INDICATES PULSE PRESSURE,
(E) CHARACTER – WATER HAMMER IN AORTIC REGUGITATION
(F) CONDITION OF ARTERIAL WALL E.G. ATHEROSCLEROTIC
S DAS 9TH EDITION

113. • THE PULSE CAN BE RECORDED FROM ANY ARTERY, BUT IN PARTICULAR FROM THE FOLLOWING SITES:
 THE RADIAL ARTERY, VENTRAL ASPECT OF WRIST,
 THE CAROTID ARTERY, MEDIAL TO THE STERNOCLEIDOMASTOID MUSCLE ,
INFERIOR AND MEDIAL TO THE ANGLE OF THE MANDIBLE
 THE SUPERFICIAL TEMPORAL ARTERY, JUST IN FRONT OF THE EAR.
 BRANCHIAL ARTERY – MEDIAL TO BICEP TENDON IN ANTECUBITAL FOSSA
SCULLY

114. • PULSE RATE IS INCREASED IN:
■ EXERCISE
■ ANXIETY OR FEAR
■ FEVER
■ HYPERTHYROIDISM
SCULLY

115. RESPIRATORY RATE
• THE NUMBER OF BREATH A PERSON TAKES IN 1 MIN WHILE AT REST
• USUALLY RHYTHMIC BUT NOT ALWAYS REGULAR.
• COUNTED BY WATCHING THE PATIENT'S CHEST RISE AND FALL.
• THE NORMAL RATE -14 TO 18 PER MINUTE.
STEVEN L BRICKER 2ND EDITION

116. EXTRAORAL EXAMINATION
• FACE – FORM, - MESOPROSOPIC
EURYPROSOPIC- BROAD AND SHORT
LEPTOPROSOPIC – LONG AND NARROW
PROFILE – STRAIGHT
CONVEX
CONCAVE
SWELLING, INJURIES, ASYMMETRY, DISCOLORATION OR ANY ABNORMALITY
• HEAD – MESOCEPHALIC
DOLICOCEPHALIC – LONG AND NARROW
BRACHYCEPHALIC -BROAD AND SHORT
CM MARYA

117. • SKIN – PIGMENTATION , SCAR , ULCER , SINUS , EDEMA, TEMPERATURE
• NOSE- SINUS PAIN , DISCHARGE , OBSTRUCTION , PERIORBITAL SWELLING
• EYES- PALLOR, ICTERUS, CONJUCTIVITIS , EXOPHTHALMOSES ( HYPERTHYROIDISM )
• TMJ – DEVIATION , MASS OVER TMJ , MOUTH OPENING, TENDERNESS, SOUNDS
• SALIVARY GLANDS- ENLARGEMENT, DRYNESS, SALIVA QUANTITY AND FLOW
• LYMPH NODES – SITE, SIZE CONSISTENCY, TENDERNESS, FIXITY
CM MARYA

118. TEMPOROMANDIBULAR JOINT EXAMINATION
• LOCATION – IN FRONT OF TRAGUS OF EAR AND FOUND BY ASKING THE PATIENT TO OPEN AND CLOSE MOUTH
• PALPATE BOTH JOINT AT SAME TIME
• NOTICE : PAIN, DEVIATION OR SOUND
•
• NORMAL MOUTH OPENING – 40-55 MM ( ESTIMATED BY USING FINGERS- 3 FINGERS END ON END , NORMAL)
• METHODS OF PALPATION :
1. PRETRAGUS PALPATION
2. INTRAAURICULAR PALPATION
STEVEN L. BRICKER 2ND EDITION

119. PRETRAGUS PALPATION
• THE PATIENT - TO SLOWLY OPEN AND CLOSE THE MOUTH , BILATERALLY PALPATES THE PRETRAGUS
DEPRESSION WITH HIS/ HER INDEX FINGERS

120. INTRAAURICULAR PALPATION
PERFORMED BY INSERTING THE SMALL FINGER INTO THE EAR CANAL AND PRESSING
ANTERIORLY

121. MUSCLE OF MASTICATION
• CLASSIFICATION :
• PRIMARY MUSCLE
1. MASSETER
2. TEMPORALIS
3. LATERAL PTERYGOID
4. MEDIAL PTERYGOID
• ACCESSORY MUSCLE
1. DIGASTRIC
2. STYLOHYOID
3. MYLOHYOID
4. GENIOHYOID
VISHRAM SINGH

123. PALPATION OF MUSCLE OF MASTICATION
• TEMPORALIS
PALPATE ENTIRE LENGTH AND BREADTH OF MUSCLE WHEN PATIENT TEETH ARE FIRMLY CLENCHED
• STEVEN L BRICKER

124. • MASSETER
ASK THE PATIENT TO CLOSE HIS /HER JAW
PALPATE BODY OF MASSETER WITH THUMB AND INDEX FINGER

125. • LATERAL PTERYGOID
USING INDEX FINGER, LATERAL TO TUBEROSITY AND MEDIAL TO CORONOID PROCESS

126. • MEDIAL PTERYGOID
USING INDEX FINGER, 45 DEGREE ANGLE IN BASE OF RELAXED TONGUE

127. LYMPH NODE
• 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.
VISHRAM SINGH

128. LEVELS OF LYMPH NODE

129. • PREAURICULAR LYMPH NODES
LOCATION – IN FRONT OF EAR
LYMPHATIC DRAINAGE - EYELIDS AND CONJUNCTIVAE, TEMPORAL REGION, PINNA
FOR PALPATION - ROLL YOUR FINGER IN FRONT OF THE EAR, AGAINST THE MAXILLA.
ENLARGED - EXTERNAL AUDITORY CANAL INFECTION.
VISHRAM SINGH

130. • POSTAURICULAR LYMPH NODES
LOCATION – BEHIND THE EAR , NEAR THE INSERTION OF STERNOMASTOID MUSCLE.
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.
VISHRAM SINGH

131. • OCCIPITAL LYMPH NODES
LOCATION: LOCATED AT THE JUNCTION BETWEEN THE BACK OF THE HEAD AND NECK.
LYMPHATIC DRAINAGE: SCALP AND HEAD.
ENLARGED IN INFECTION OF SCALP & SYPHILIS.
VISHRAM SINGH

132. • SUBMENTAL LYMPH NODE
LOCATED BELOW THE CHIN.
LYMPHATIC DRAINAGE: LOWER LIP, FLOOR OF MOUTH, TEETH, SALIVARY GLAND, TIP OF TONGUE, SKIN OF CHEEK.
ROLL THE FINGERS BELOW AND LINGUAL TO THE CHIN, AGAINST THE MYLOHYOID MUSCLE.
ENLARGED IN DISORDERS IN THE ANTERIOR PORTION OF THE MOUTH AND THE LOWER LIP.
VISHRAM SINGH

133. • SUB MANDIBULAR LYMPH NODE
LOCATED MEDIAL TO THE INFERIOR BORDER OF MANDIBLE.
LYMPHATIC DRAINAGE: TONGUE, SUBMAXILLARY GLAND, LIPS AND MOUTH.
ROLL YOUR FINGERS AGAINST INNER SURFACE OF MANDIBLE WITH PATIENT'S HEAD GENTLY TILTED TOWARDS
ONE SIDE.
ENLARGED IN INFECTIONS OF HEAD, NECK, EARS, SCALP, PHARYNX.
VISHRAM SINGH

134. CERVICAL LYMPH NODES
2 CHAINS OF LYMPH NODES PRESENT ON EITHER SIDE OF STERNOMASTOID MUSCLE.
LOCATION – ANT. CERVICAL IS LOCATED ANT TO MUSCLE & POST CERVICAL IS LOCATED POSTERIORLY.
PALPATION --- FOR ANT CHAIN PT’S HEAD IS TIPPED SLIGHTLY FORWARD &
AREA MEDIAL TO STERNOMASTOID MUSCLE IS PRESSED
--- FOR POST CHAIN , FINGERS ARE KEPT BEHIND THE MUSCLE.
PALPATION STARTS FROM TRAPIZIUS MUSCLE & MOVED TO STERNOMASTOID MUSCLE
VISHRAM SINGH

135. INTRAORAL EXAMINATION
• SOFT TISSUE EXAMINATION
LIPS
LABIAL/ BUCCAL MUCOSA
FLOOR OF MOUTH
TONGUE
PALATE
GINGIVA
SALIVARY GLAND
• HARD TISSUE EXAMINATION
TEETH PRESENT
TEETH ABSENT
CARIES
WASTING DISEASE
MOBILITY
OCCLUSION
DEVELOPMENTAL ANAMOLY

136. LIP
• COLOR,
• TEXTURE,
• ANY SURFACE IRREGULARITIES,
• COMPITENCY
• PALPATE UPPER LIP AND LOWER LIP FOR ANY THICKENING (INDURATION) OR SWELLING. ANGULAR OR VERTICAL
FISSURES.
• ABNORMALITIES
• CLEFT LIP, ULCERS, NODULES, ANGULAR CHEILTIS
• STEVEN L BRICKER 2ND EDITION

137. LABIAL / BUCCAL MUCOSA
ULCERATIONS
SWELLINGS
PIGMENTATION
TEXTURE
LESIONS
ABNORMALITIES ( FORDYCE’S GRANULES , LEUKOEDEMA )
PAROTID PAPILLA
LINEAALBA ( CALICULUS ANGULARIS )
STEVEN L. BRICKER 2ND EDITION

138. VESTIBULE
• FRENUM ATTACHMENT
• SWELLING
• ULCER
• OBLITERATION
• TENDERNESS
STEVEN L BRICKER 2ND EDITION

139. FLOOR OF THE MOUTH
• CHARACTER AND EXTENT OF GLAND SECRETIONS
• SALIVA VISCOSITYAND FLOW
• SWELLINGS(TORI)
• SIALOLITHS
• TENDERNESS
• LINGUAL FRENUM ( SUBLINGUAL CARUNCLE )
STEVEN L BRICKER 2ND EDITION

140. ABNORMALITIES
• RANULA: APPEARS BLUISH TRANSLUCENT CYST OVER WHARTON’S DUCT.
• ANKYLOGLOSSIA: FUSION BETWEEN TONGUE AND FLOOR OF THE MOUTH

141. TONGUE
• MUSCULAR ORGAN – ALMOST FILL MOUTH
• DORSUM SURFACE – TONGUE AT REST AND OPEN MOUTH ( PAPILLA )
STEVEN L. BRICKER 2ND EDITION

142. • PAPILLA
1. FILIFORM PAPILLAE-
 MOST NUMEROUS COVERS THE DORSUM OF THE TONGUE.
 SMALL ,WHITISH ( KERATIN ) ,HAIRLIKE PROJECTION
 DO NOT HAVE TASTE BUDS.
2. FUNGI FORM PAPILLAE-
 NUMEROUS SMALL MUSHROOM SHAPED ELEVATION
 SCATTERED, PROMINENT AT THE LATERAL BORDER (SALTY )& TIP OF THE TONGUE.( SWEET )
 HAVE TASTE BUDS.
STEVEN L BRICKER 2ND EDITION

143. 3. CIRCUMVALATE PAPILLAE:-
 POSTERIORLY ON THE DORSUM OF THE TONGUE( 8-12) LARGE
 ROUND AND HAVE GROOVE AROUND.
 HAVE TASTE BUDS.( BITTER )
4. FOLIATE PAPILLAE:-
 LOCATED IN THE LATERAL BORDERS OF THE TONGUE.
 LEAF LIKE PROJECTIONS
 HAVE TASTE BUDS( SOUR ) .
STEVEN L. BRICKER 2ND EDITION
•

144. • MIDLINE OF THE TONGUE HAS A DEPRESSION OF VARYING DEPTHS CALLED MEDIAN SULCUS IT ENDS IN POSTERIORLY
IN A V & Y SHAPE CALLED TERMINAL SULCUS.

145. PALATE
• THE INCISIVE PAPILLA IS LOCATED IN THE MIDLINE JUST POSTERIOR TO THE MAXILLARY CENTRAL INCISORS
TEETH.
• BEHIND THE INCISIVE PAPILLA & RUNNING TRANSVERSELY ON EITHER SIDE OF THE MIDLINE ARE THE
PALATINE RUGAE.
• IT IS IMPORTANT SPEECH HELPING PARTICULARLY IN “S” SOUND.
•

146. GINGIVA
COLOR
 CORAL PINK
 PHYSIOLOGICAL PIGMENTATION MAY BE SEEN (MELANIN).
CONTOUR
 DEPENDS ON THE SHAPE OF THE TEETH AND THEIR ALIGNMENT IN THE ARCH, .

147. SHAPE
• 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.

148. CONSISTENCY
 GINGIVA IS FIRM AND RESILIENT WITH EXCEPTION OF FREE GINGIVAL MARGIN
 GINGIVAL FIBERS CONTRIBUTE TO THE FIRMNESS OF THE GINGIVAL MARGIN.
SURFACE TEXTURE
 “ORANGE PEEL” REFERRED TO AS BEING STIPPLED
 IT CAN BE VIEWED BY DRYING THE GINGIVA .

149. STIPPLING:
 ABSENT IN INFANCYAND OLD AGE INCREASES IN ADULTHOOD.
 ATTACHED GINGIVAAND CENTRAL PORTION OF INTERDENTAL GINGIVAARE STIPPLED; WHERE AS MARGINAL GINGIVA IS
NOT.
 ALTERNATE ROUNDED PROTUBERANCES AND DEPRESSIONS IN THE GINGIVAL SURFACES.
POSITION:
 REFERS TO THE LEVEL AT WHICH GINGIVAL MARGIN IS ATTACHED TO THE TOOTH.

150. • RECESSION
CLASSIFICATION –ACCORDING TO P.D MILLERS
CLASS 1 – GINGIVAL RECESSION NOT EXTENDING TO MUCOGINGIVAL JUNCTION
CLASS 2- GINGIVAL RECESSION EXTENDING UPTO OR BEYOND MUCOGINGIVAL JUNCTION
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

151. • POCKET
• FURCATION INVOLVEMENT

152. TEETH PRESENT
• COLOR
• NUMBER
• ANY TRAUMA
• OCCLUSION

153. NOMENCLATURE
1) FDI
2) ZSING MONDY/PALMER METHOD •
3) UNIVERSAL SYSTEM

154. TEETH MISSING
• REASON FOR MISSING TEETH/TOOTH
• HISTORY OF REMOVAL
• THE SEQUEL OF MISSING TEETH MAY INCLUDE SUPRA
ERUPTION,TILTING,DRIFTING OR ROTATION, ALL OF WHICH
MAY HAVE AN IMPACT ON TREATMENT PLAN.

155. CARIES ASSESSMENT
• GV BLACK CLASSIFICATION
 CLASS I – OCCLUSAL SUFACE
 CLASS II- PROXIMAL SURFACE ( POSTERIOR TEETH)
 CLASS III – PROXIMAL SURFACE ( ANTERIOR TEETH WITHOUT INVOLVE INCISAL EDGE )
 CLASS IV - PROXIMAL SURFACE ( ANTERIOR TEETH INVOLVING INCISAL EDGE
 CLASS V – GINGIVAL THIRD
 CLASS VI- INCISAL EDGE OR OCCLUSAL CUSP
STURDEVANT 1ST EDITION

157. RECURRENT CARIES
FRACTURED TOOTH/ RESTORATION
RESTORED TOOTH
ROOT STUMP
MOBILITY
PERCUSSSION
MALOCCLUSION

158. WASTING DISEASE
• ATTRITION
• ABRASION
• EROSION
• ABFRACTION

159. PROVISIONAL DIAGNOSIS
 IT IS ALSO CALLED TENTATIVE DIAGNOSIS OR CLINICAL DIAGNOSIS.
 IT IS FORMED AFTER EVALUATING THE CASE HISTORY & PERFORMING THE PHYSICAL EXAMINATION.

160. DIFFERENTIAL DIAGNOSIS
• REARRANGING LIST OF POSSIBLE DIAGNOSIS WITH MOST PROBABLE LESION RANKED AT TOP AND LEAST
LIKELY TO BE AT BOTTOM

161. FINAL DIAGNOSIS
• ALL THE RECORDS, CLINICAL FINDING , PROVISIONAL DIAGNOSIS AND INVESTIGATION ARE CLUBBED
TOGETHER TO FRAME FINAL DIAGNOSIS ON WHICH TREATMENT IS PLANNED
• FIRST MADE ON CHIEF COMPLAINT OF PATIENT AND THEN OTHER PROBLEMS ARE CONSIDERED.

162. TREATMENT PLAN
• GOAL – BEST TREATMENT FOR PATIENT
• IN RECORD AND EXPLAINED TO PATIENT
• TREATMENT PHASES
1. PRELIMINARY PHASE
2. NONSURGICAL PHASE
3. SURGICAL PHASE
4. RESTORATIVE PHASE
5. MAINTAINANCE PHASE

163. PRELIMINARY PHASE
• TREATMENT OF EMERGENCY
• MANAGEMENT OF PAIN AND ACUTE INFECTION USING ANALGESIC AND ANTIBIOTIC
• INCISION AND DRAINAGE OF ABSCESS, PALLIATIVE PULPOTOMY
• EXTRACTION OF HOPELESS TEETH AND PROVISIONAL REPLACEMENT IF NEEDED

164. NON SURGICAL PHASE
• PLAQUE CONTROL AND PATIENT EDUCATION
• DIET CONTROL ( RAMPANT CARIES PT )
• REMOVAL OF CALCULUS AND ROOT PLANNING
• CORRECTION OF RESTORATIVE AND PROSTHETIC IRRITATIONAL FACTOR
• EXCAVATION OF CARIES AND RESTORATION

165. SURGICAL PHASE
• PERIODONTAL THERAPY
• ENDODONTIC THERAPY
• BIOPSIES
• ENUCLEATION OF CYST
• RESECTION OF TUMOR

166. RESTORATIVE PHASE
• FINAL RESTORATION
• FIXED AND REMOVABLE PROSTHODONTIC APPLIANCE
• EVALUATION OF RESPONSE TO RESTORATIVE PROCEDURE
• PERIODONTAL EXAMINATION

167. MAINTENANCE PHASE
• PERIODIC RECHECKING:
• PLAQUE AND CALCULUS
• GINGIVAL CONDITION ( POCKET, INFLAMMATION )
• OCCLUSION
• TOOTH MOBILITY
• OTHER PATHOLOGIC CHANGE

168. FACTORS THAT INFLUENCE TREATMENT PLANS
• PATIENT’S HEALTH
• PATIENT’S AGE
• EXPECTATION OF THE PATIENT
• PSYCHOLOGICAL FACTOR
• PROGNOSIS OF PROPOSED DENTAL TREATMENT

169. PROGNOSIS
• ACCORDING TO SOBEN PETER
• DEFINED AS PREDICTION OF THE COURSE , DURATION AND TERMINATION OF THE DISEASE AND ITS RESPONSE TO
TREATMENT.
• TYPES –
1. EXCELLENT
2. GOOD
3. FAIR
4. POOR
5. QUESTIONABLE

170. EXCELLENT
• NO BONE LOSS
• EXCELLENT GINGIVAL CONDITION
• GOOD PATIENT COOPERATION
• NO SYSTEMIC ENVIRONMENTAL FACTOR

171. GOOD PROGNOSIS
• ONE OR MORE OF THE FOLLOWING
• ADEQUATE REMAINING BONE SUPPORT
• ADEQUATE POSSIBILITIES TO CONTROL ETIOLOGICAL FACOR
• ADEQUATE PATIENT COOPERATION
• NO SYSTEMIC ENVIRONMENTAL FACTOR

172. FAIR PROGNOSIS
• LESS THAN ADEQUATE REMAINING BONE SUPPORT
• TOOTH MOBILITY
• FURCATION INVOLVEMENT
• ADEQUATE MAINTENECE POSSIBLE
• ACCEPTED PATIENT COOPERATION
• PRESENCE OF LIMITED SYSTEMIC / ENVIRONMENTAL FACTOR

173. POOR PROGNOSIS
• MODERATE TO ADVANCED BONE LOSS
• TOOTH MOBILITY GRADE I & II
• FURCATION INVOLVEMENT
• DIFFICULT TO MAINTAIN AREA &/OR DOUBTFUL PATIENT COOPERATION
• PRESENCE OF SYSYTEMIC / ENVIRONMENTAL FACTOR

174. QUESTIONABLE PROGNOSIS
• ADVANCED BONE LOSS
• GRADE II & III MOBILITY
• FURCATION INVOLVEMENT
• PRESENCE OF SYSYTEMIC / ENVIRONMENTAL FACTOR