Case history

CASE HISTORY
 Under the guidance of :-
 Dr Prerna Taneja (PROF &
HOD)
 Dr Archana nagpal
 Dr Puneeta Vohra
 Presented by-
 Dr Surbhi Singh

• 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.
INTRODUCTION

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
patient.

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
complications.
4. Select a closest possible choice-final diagnosis.
5. Plan a effective treatment accordingly.

Methods of obtaining the patient
history
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
appointment.
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.

3)Combination
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.
8

COMPONENTS-
 Statistics
 Chief complaint
 History of present illness
 Medical history
 Past dental history
 Personal history
 General examination
 Extraoral examination
 Intraoral examination
 Provisional diagnosis
 Investigations
 Final diagnosis
 Treatment plan

STATISTICS
 Patient registration number
 Date
 Name
 Age
 Sex
 Address
 Occupation
 Marital status

 Patient registration number
Useful for-
1. maintaining a record,
2. billing purposes,
3. medico legal aspects.
 Date
Useful for-
1. Time of admission
2. reference during follow up visits
3. Record maintenance.

NAME
 to communicate with the patient
 to establish a rapport with the patient
 Record maintenance
 Psychological benefits
AGE
 For diagnosis
 Treatment planning
 Behavioral management techniques

 DISEASE MORE
COMMONLY PRESENT
AT BIRTH
- Micrognathia
- Cleft lip & cleft plate
- Ankyloglossia
- Predecidous dentition
- Teratoma
- Hemophilia
 DISEASE PRESENT IN
CHILDREN & YOUNG
ADULTS
- Benign migratory glossitis
- Juvenile periodontitis
- Pemphigus
- Recurrent apthous
stomatitis
- Dental caries
- Dentigerous cyst
- Diptheria
- Rickets
- Infectious mononucleosis

DISEASE PRESENT IN ADULTS & OLDER PATIENTS
- Attrision
- Abrasion
- Gingival recession
- Periodontitis
- Lichen planus
- Ameloblastoma ( 30 – 50)
- Trigeminal neuralgia
- Fibroma
- Verrucous carcinoma
- Iron deficiency anemia
- Diabetes
- Hypertension
- Asthma

 AGE
used to calculate the dose of the drug.
CHILD DOSE
1) YOUNG RULE = child’s age adult dose
age + 12
2) CLARK RULE
child age at next birthday adult dose
24
3) DILLING RULE = age adult dose
20

SEX
SINGNIFICANCE-Certain diseases are gender specific:
 Diseases common in males:
Attrition, leukolpakia, cancer like squamous cell carcinoma, melanoma,
lymphoma etc
 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.

ADDRESS
 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.
.

 OCCUPATION
 To asses the socioeconomic status.
 Predilection of diseases in different occupations for eg:
hepatitis B is common in dentists & surgeons.
 MARITAL STATUS
 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.

CHIEF COMPLAINT
 The chief complaint is usually the reason for the
patient’s visit.
 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
 Duration
 Location-localized ,diffuse ,referred, radiating.
 Progression- continous or intermittent.
 Aggravating & relieving factors
 Treatment taken

COMMON CHIEF COMPLAINTS
 Pain
 Swelling
 Ulcer

PAIN
 Original Site of pain
 Origin & mode of onset
 Severity
 Nature of pain
 Progression of pain
 Duration of pain
 Movement of pain
 Periodicity of pain
 Effect of functional activity
 Precipitating factors
 Relieving factors
 Associated symptoms
 Treatment taken

a) Anatomical location where the pain felt ?
b) 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
progressing?
 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
disappears.

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
pain.
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:
• Pallor
• Sweating
• Vomiting
k)Treatment taken-
 Any medication taken by patient & its outcome.

SWELLING
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,
disfiguring.

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,
inflammatory changes
7) Recurrence of swelling :- if swelling recurs after
removal,it may indicate malignant changes

ULCER
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
are painless.
3) Discharge :- discharge from ulcer like serum, blood, pus
should be noted down.
4) Associated disease :- like tuberculosis , diabetes &
syphilis

MEDICAL HISTORY
 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
-Anemia
-Bleeding disorders
-Cardio respiratory disorders
-Drug treatment and allergies
-Endocrine disorders
-Fits and faints
-Gastrointestinal disorders
-Hospital admissions and surgeries
-Infections
-Jaundice
-Kidney disease

 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
treatment.
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
noted.
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
medication.
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
birth.
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

POSTNATAL HISTORY
 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
dental treatment.
 History of complications experienced by the patient

FAMILY HISTORY
 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.

PERSONAL HISTORY
 It includes:-
 Diet
 Apetite
 Bowel & micturation habit
 Sleep
 Oral hygiene measures
 Oral habits
 Adverse habits

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.

Habits
a)Oral hygiene method:- poor oral hygiene & improper
brushing technique may leads to dental caries & periodontal
disease. Horizontal brushing technique may leads to cervical
abrasion.
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
development.

GENERAL EXAMINATION
 Analyze the patient entering the clinic for
built, height ,gait, and posture.
 Check for any
pallor, icterus, clubbing, cyanosis, lymphadenopathy &
edema.
 Vital signs like pulse, blood
pressure, temperature, respiratory rate should be noted.

 Pulse
 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.
 Temperature
 normal temp is 98.6 degree F or 37 degree celsius.
 Measured by thermometer.
 Respiratory rate
 Adult rate–16-24 breaths per minute
 Observe
 Feel for chest movement
 Auscultate

 Blood pressure
 Systolic- 110-140 mm Hg
 Diastolic-60-90 mm of Hg
 Measured by Sphygmomanometer.

List of systems reviewed:-
1. Cardiovascular system
2. Respiratory system
3. Central nervous system
4. Gastrointestinal system
5. Genitourinary system
6. Musculoskeletal system
7. Endocrine system

 Every system will be examined under the following
headings:-
 Inspection
 Palpation
 Percussion
 Auscultation

INSPECTION
 Visual assessment of the patient.
 Make sure good lighting is available.
 Position and expose body parts so that all surface can
be viewed.
 Inspect each area of
size, shape, colour, symmetry, position and
abnormalities.
 If possible, compare each area inspected with the same
area on the opposite side of the body.
 Use additional light to inspect body cavities.

PALPATION
 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
palpate for
 –Texture
 –Masses
 –Fluid
 --And assess skin temperature
 Client should be relax and positioned comfortably because
muscle tension during palpation impair its effectiveness.

 Types of Palpation :-
 Light palpation
 Deep palpation
 Bimanual palpation
 Bidigital 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.

 Deep Palpation
 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.
 Bimanual Palpation
 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.

 Bidigital palpation
 It is done by pressing the structure to be examined
between examiner’s thumb & index finger.
 Done for evaluation of nodules, lip etc

PERCUSSION
 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
tissues
 Sound waves heard as percussion tones (resonance)
 Methods of Percussion:-
 Mediate or Indirect Percussion
 Immediate Percussion
 Fist 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.
 Immediate Percussion
 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.

 Fist Percussion
 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.

ASCULTATION
 Auscultation is listening to sound produce by the
body.
 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.

CARDIOVASCULAR SYSTEM
 Cardinal symptoms noted during history taking are:-
 Dyspnea
 Chest pain
 Cough
 Expectoration
 Hemoptysis
 Palpitation
 Syncopal attacks.
 Also history regarding hypertension, coronary heart
disease, hyperlipidemia should be noted.

 INSPECTION
1. Percodium
2. Apex impulse
3. Dilated veins
4. Scars & sinuses
PERCODIUM
 It is the anterior aspect of chest that overlies the
heart.
 Normally it has smooth contour, slightly convex &
symmetrical.

Bulging Flattened
1. Enlarged heart fibrosis of lung
2. Pericardial effusion congenital deformity
3. Mediastinal tumor
4. Pleural effusion
5. Scoliosis

 APEX IMPULSE
 Apex is lowermost & outermost cardiac impulse.
 It is in 5th left intercoastal space just inside the
midclavicular line.
 It is nt visible in the case of emphysema & pericaedial
effusion.
 DILATED VEINS
 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.

 PALPATION
 APEX BEAT
 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
4. obesity

 PERCUSSION
 It is done to determine the boundaries of heart.
 Left border
 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
beat.
 If it is present outside then it suggests pericardial
effusion.

 Upper border
 Patient is percussed in second & third left intercostal space
in parasternal line, which is the line between mid-
clavicular & 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 :-
2. Aneurysm of aorta
3. Pulmonary hypertension
4. Left atrial enlargement
5. Mediastnal mass

 Right border
 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:-
2. Aneurysm of ascending aorta
3. Right atrial enlargement
4. Dextrocardia
5. Mediastinal mass
6. Right lung base pathology.

 ASCULTATION
 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.

 S1 (lubb)
 The 1st heart sound, marks the beginning of systole
(end of diastole).
 Related to the closure of the mitral and tricuspid
valves.
 Loudest at the apex and lower left sternal border.
Increased S1:
- normally in children
Increased cardiac output
Increased A-V valve flow velocity (acquired mitral
stenosis, but not congenital MS)

 Decreased S1:
Mitral insufficiency
Increased chest wall thickness
Pericardial effusion
Hypothyroidism
S2( DUB)
 The 2nd heart sound, marks the end of systole
(beginning of diastole).
 From closure vibrations of aortic and pulmonary valves
 Loudest at the base.

Abnormal S2
 Loud Second Heart Sound (aortic)
 Systemic hypertension
 Dilated aortic root
 Soft Second Heart Sound (aortic)
 Calcified aortic stenosis
 Loud Second Heart Sound (pulmonary)
 Pulmonary hypertension

RESPIRATORY SYSTEM
 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
history.

Inspection
 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
flattening

 Rate & Rhythm of respiration
Rate of respiration in health (adult)
12-14 breaths/min
 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
equal on
both sides

Palpation
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
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

Percussion
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
the chest
A resonant sound is produced during percussion
The sound and feel of resonance over a healthy
lung has to be learned by practice

Auscultation
 Breath sounds
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
larger bronchi
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
cavity)
- 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)
-

 Added sounds
These are abnormal sounds that arise in the pleura
or lungs
Rhonchi – wheezing sounds (asthma)
Crepitations – bubbling or crackling noises
Pleural rub – creaking or rubbing noises associated
with pain

GASTROINTESTINAL SYSTEM
 Sign & symptoms include
nausea, vomiting, diarrhea, constpation, indigestion, l
oss of appetite & abdominal pain should be noted
while taking the case history.
 Abdomen
 inspection
 Size
 Shape
 Abdomen distention
 Surgical mark
 Movement with respiration

 Palpation
1- Superficial palpation:
 Pain & Tenderness.
 Rigidity
 Superficial swelling.
2- Deep Palpation
 Liver, Spleen, Kidney &
 GB

 Percussion
1- To define the boundaries of abd organs e.g
upper and lower border of the liver, spleen,
urinary bladder.
2- Detection of ascites”
 Shifting dullness.
 Fluid thrill.

 Auscultation
 Minor role.
 Done before palpation and percussion as touching the
abdomen may alter the abdominal sounds.
 Use the warm diaphragm, and listen for 15-20 sec.

GENITOURINARY SYSTEM
 Symptoms associated with this system relate to
menstruation, frequency of urination, pain on
urination, blood or pus in urine.

MUSCULOSKELETAL SYSTEM
 Weakness / paralysis / contracture / joint swelling /
pain /other
 Extremity strength
 Symptoms associated with this system include muscle
or bone pain, loss of joint function, muscle weakness
and occasionally multiple bone fracture.

 Spine
 Curvature of spine observe for:-
 Lordosis: Increase lumber curvature
 Scoliosis: Lateral spinal curvature
 Kyphosis: Exaggeration of posterior curvature of
thoracic spine

ENDOCRINE SYSTEM
 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:
 Equilibrium test:
 Sensation test: Pain
 Temperature
 Vibration
 Touch

 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
determined.

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)
 Visual acuity
 snellen’s chart
 Visual field
 Done by confrontation by wiggling fingers 1 foot from
patient ears, asking which they see move.
 Color
 Ishihara chart

 CN III, IV, VI
 Look at pupils: shape, relative size and ptosis.
 Shine light in from the side to see pupils’s light
reaction.
 Ask the patient to follow finger with eyes without
moving head.

 CN V
 Corneal reflex
 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
finger lightly.
 Usually nothing happens, or just a slight closure.
 Facial sensation
 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].
 Motor sensation
 Palpation of the muscle of mastication.

 CN VII
 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
forehead.
 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.
 CN VIII
 Auditory acuity
 Rub hands with noise on side of ear.
 Weber’s test
 Rinne’s test
 Vestibular function
 Romberg test

 Weber Test:
1. 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.
2. Hold the stem against the patient's skull, along an imaginary line
that is equidistant from either ear.
3. 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
brain.
4. 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).
5. 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.

 Rinne Test:
1. Grasp the 512 Hz tuning fork by the stem and strike it
against the bony edge of your palm, generating a
continuous tone.
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.

 CN IX
 Examine the palate for uvular displacement
 Check for gag reflex.
 CN X
 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
upward.
 CN XI
 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.
 CN XII
 Inspect tongue for deviations.

EXTRAORAL EXAMINATION
 SKIN – is looked for
 Appearance-any rashes, sores or itching
 Color-anemia patients have pale skin color, yellow tint is
seen in jaundice patients.
 Pigmentation
 Edema
 Temperature

 FACIAL SYMMETRY–bilaterally
symmetrical/asymmetrical
 LIP COMPETENCY-competent/incompetent
 EYE
 Inspect external eye structure for-
 Position and alignment
 Exophthalmoses
 Strabismus
 Eye lashes : sty.
 Indicator of anemia & jaundice.
 infection of maxillary teeth may extend to orbital region
causing swelling of eyelid & conjunctivitis.

 NOSE
 Size-should be 1/3rd of total facial height.
 Deviated nasal septum in mouth breathers.
 Saddle nose in congenital syphilis.
 JAWS
 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
be examined.

TMJ
 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
the patient.
 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
pressing anteriorly.
 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
abnormalities.
 These muscles are the temporalis,masseter,internal
pterygoid and external pterygoid.

Temporalis muscle
 Origin:In the fossa of the temporal
bone
 Insertion: on the coronoid process
and anterior border of the ramus of
the mandible.
 Palpation
 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
mandible.
 This muscle has a deep and
superficial portion as with the
temporalis muscle, it can be located
when the patients jaws are forcibly
closed.
 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
be palpated.
 Insertion: on the lower medial surface of the
ramus of the mandible .

PALPATION
 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 insertion.
 The body of the muscle can be
palpated by rotating the index
finger upward against the muscle
to near its origin on the
tuberosity.

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.

 PALPATION
 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
evaluation.

LYMPH NODES
 Lymph nodes are oval or
bean-shaped structures found
along lymphatic vessels that
drain body parts.
 Normally, they are non-
tender, 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
region, pinna
 For palpation of
Preauricular lymph
nodes, roll your finger in
front of the ear, against the
maxilla.
 Enlarged - External
auditory canal infection.

 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.

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.

 SUBMENTAL LYMPH
NODE
 Located below the chin.
 Lymphatic drainage: Lower lip,
floor of mouth, teeth, submental
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.

 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, sinuses, ears, eyes, scalp,
pharynx.

 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
with examiners finger.
 for post chain , fingers are kept
behind the muscle. Palpation starts
from trapizius muscle & moved to
sternomastoid muscle.

INTRAORAL EXAMINATION
 SOFT TISSUE
1) Labial and buccal
mucosa:
2) Lip
3) Floor of mouth
4) Tongue
5) Gingiva
6) Salivary glands
 HARD TISSUE
a) Teeth present
b) Teeth missing
c) Carious teeth
d) Wasting disease
e) Mobility
f) Occlusion

SOFT TISSUE
LABIAL & BUCCAL MUCOSA
 It should be checked for any
 Ulcer
 White patch or neoplasia
 Pigmentation

LIP
 Checked for-
 Color,
 Texture,
 Any surface irregularities,
 Palpate upper lip and lower lip for any thickening
(induration) or swelling.
 Angular or vertical fissures.
 Cleft lip,
 Lip pits,
 Ulcers
 Nodules,
 Keratotic plaque and scars.

Floor of mouth
 It should be checked for:-
 Any swellings
 RANULA: appears as unilateral bluish translucent cyst over
wharton’s duct.
 ANKYLOGLOSSIA: fusion between tongue and floor of
the mouth
 CARCINOMAS are common in the floor of the mouth.
 Ulcers or red and white patches.

Tongue
 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.

INSPECTION:
 COLOR:
 WHITE -Leukoplakia, Oral
Candidiasis
 BLACK - Black Hairy
Tongue(due to hyperkeratosis of
mucous membrane in heavy
smokers)
 COATED TONGUE one
covered with a whitish or
yellowish layer consisting of
desquamated epithelium,
debris, bacteria, fungi, etc.

 FISSURES, CRACKS IN THE
TONGUE:
 CONGENITAL FISSURES>
TRANSVERSE DIRECTION
 SYPHILITIC FISSURES>
LONGITUDINAL
 ANY ULCER:
 Site of ulcer is usually
characteristic
 Carcinomatous ulcers and
traumatic ulcers are common
along lateral border of the
tongue.

PALPATION:
 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
diagnosis.
 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
ulcers.
 Palpate the back of the tongue
for any ulcer or swelling.
123

Gingiva
COLOR:
 Coral Pink,
 Physiological pigmentation may be seen (melanin).
CONTOUR:
 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
lingual surface.
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.

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 .
STIPPLING:
 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.
POSITION:
 refers to the level at which gingival margin is attached to the tooth.

 RECESSION:
 is exposure of root surface by an apical shift in the position of the
gingiva .
 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
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
126

CAUSES: Faulty tooth brushing technique
 Tooth malposition
 High frenal attachment
 Trauma from occlusion
 Orthodontic movement of teeth
127

Salivary glands
 PAROTID GLAND
 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
second molar.
 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
malignancy.

 SUBMANDIBULAR GLAND
 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
painful.
INSPECTION
 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.

 TEST:
 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
duct.
130

BIMANUAL PALPATION:
 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
nodes.
 Submandibular salivary gland enlargement is a single swelling where as nodular swelling
suggests lymph node enlargement .
131

EXAMINATION OF
SWELLING:
 INSPECTION:
 SITUATION: few swellings are
peculiar in their position
 E.G: DERMOID SWELLING:
midline of body
 MEDIAN PALATAL CYST: midline of
hard palate
 GLOBULO MAXILLARY CYST:
between maxillary incisor and
maxillary canine
 MEDIAN MANDIBULAR CYST:
midline of mandible
132

 COLOR:
 BLACK: Benign nevus and melanoma
RED PURPLE: Hemangioma
BLUISH COLOR: Ranula
 SHAPE:
 Shape of the swelling should be noted whether it is
ovoid, pear shaped, and kidney shaped, spherical /
irregular.
 SIZE:
 Always the vertical and horizontal dimensions should
be noted
133

 SURFACE:
 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,
verrucous carcinoma.
 EDGE:
 edges may be clearly defined or indistinct, sessile or pedunculated.
 NUMBER:
 Some swellings are always multiple e.g. neurofibromatosis, multiple glandular
swelling.
 SOLITARY SWELLINGS: Lipoma, Dermoid Cyst.
134

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
deglutition
Eg thyroid swellings, thyroglossal cyst, pre or para tracheal lymph node
enlargement.
MOVEMENT WITH PROTRUSION OF TONGUE:
 Thyroglossal cyst moves with protrusion of tongue.
135

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
suppuration
 PIGMENTATION OF SKIN seen in moles, nevi or after repeated exposure to
deep x-rays.
 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.
136

 PALPATION:
 TEMPERATURE:
 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.
 TENDERNESS:
 INFLAMMATORY SWELLINGS: TENDER
 NEOPLASTIC SWELLINGS: NON-TENDER
 SIZE
 DEEPER DIMENSIONS OF THE SWELLINGS REMAIN UNKNOWN DURING
INSPECTION.
 SHAPE
 VERTICAL AND HORIZONTAL DIMENSIONS ARE BETTER CLARIFIED BY
PALPATION.
 EXTENT:
 WHETHER MASS IS WELL DEFINED, MODERATELY, POORLY DEFINED.
137

 SURFACE:
 with palmer surface of the fingers the clinician should palpate the surface of
the swelling .
 SMOOTH: cyst
 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.
138

 CHEESY: cyst (sebaceous, dermoid and epidermoid), tubercular node.
 RUBBERY: cyst under
tension, myoblastoma, lymphoma, myxoma, aneurysm.
 FIRM: infection
 benign tumor of soft tissue
 malignancy of soft tissue
 osteosarcoma or chondosarcoma
 inflammation and infection of lymph node.
 BONY HARD: osteoma ,osteogenic sarcoma
 exostosis chondroma,
 chondrosarcoma
 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
139

 FLUCTUATION:
 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
fluctuant.
 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)
140

 FLUID THRILL:
 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
hand.
 In case of small swellings three fingers are placed over other hand, percussion wave
felt by other two fingers on each side.
141

 TRANSLUCENCY:
 swelling can transmit light through it for this it should contain fluid like
 water,
 serum,
 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.
142

 REDUCIBILITY:
 the swelling can be reduced and ultimately disappear as soon as it is pressed
upon. Eg) hernia
 COMPRESSIBILITY:
 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.
143

PULSATALITY:
 A SWELLING MAY BE PULSATILE IF IT
 ARISES FROM THE WALL OF AN ARTERY
 or
 LIES CLOSE TO AN ARTERY
 or
 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
transmitted pulsation.
144

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.
145

ASPIRATION:
146
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

147
5. LYMPH FLUID: color less with high lipid content, appears
cloudy and frothy. it is seen in hygroma and
lymphoma.
6. BLUE BLOOD: seen in early hematoma, hemangioma and
varicosities.
7. BRIGHT RED BLOOD: aneurysm and a-v fistula
8. ASPIRATION OF PAINFUL WARM
FLUCTUANT SWELLING YIELD PUS.
9. ACTINOMYCOSIS: yields pus with few yellow granules in it
(sulfur granules) these are basically bacteria.
10. STICKY CLEAR VISCOUS FLUID – retention phenomenon

 PERCUSSION:
 To elicit slight tenderness like brodies abscess.
 AUSCULTATION:
 all pulsatile swellings are auscultated to exclude presence
of any bruit or murmur.
148

EXAMINATION OF ULCER
 Ulcer is a break in the continuity of the skin and
epithelium.
 INSPECTION:
 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
“WEEPING ULCERS”.
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.
149

 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
ear.
 Malignant ulcers are common on the tongue, and lips.
150

 EDGES:
 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
skin.
 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
healthy epithelium.
151

 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
everted edge.
 FLOOR:
 Exposed surface of the ulcer .
 When floor covered with red granulation tissue, ulcer seems to be healthy
and healing.
 PALE AND SMOOTH GRANULATION TISSUE: HEALING ULCER
 WASH LEATHER SLOUGH ON THE FLOOR: GRANULATION ULCER
 A BLACK MASS AT THE FLOOR: MALIGNANT MELANOMA. 152

 DISCHARGE:
 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.
 SURROUNDING AREA:
 If surrounding area of an ulcer is glossy red and edematous, ulcer is actually
inflamed.
 VARICOSE ULCER: surrounding skin is pigmented.
 SCAR OR WRINKLING IN THE SURROUNDING SKIN OF ULCER: old case
of tuberculosis.
153

 PALPATION:
TENDERNESS:
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
in inspection.
Marked induration of edge is the characteristic feature of
carcinoma.
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.
154

 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.
155

TEETH PRESENT
 Size
 Color
 structural changes of teeth
 Eruption status of teeth
 Retained deciduous teeth
 Any trauma to tooth

TEETH MISSING
 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.

CARIOUS TEETH
 The primary examination technique for evaluating the teeth include:
 Visual inspection,
 Probing
 Percussion
 Transillumination
 Basic tools required are:
 A good light source,
 A mirror,
 A sharp explorer and
 An air syringe are the most basic tools required.

RADIOGRAPHIC METHODS
 BITE WING RADIOGRAPHY:
 To diagnose proximal decay.
 INTRA- ORAL PERI APICAL
RADIOGRAPH:
 To detect the extent of occlusal caries.
 To assess the periapical area.
 DISADVANTAGES:
 A. To be radiographically visible, mineral
loss should be more than 20-30%

 OTHER METHODS:
 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
change).

WASTING DISEASES OF TEETH:
 ATTRITION:
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.

 ABRASION
 Friction between tooth & an exogeneous agent
 ETIOLOGY:
 use of abrasive dentifrice, tooth floss, tooth picks etc.
 EROSION:
 defined as irreversible loss of dental hard tissue by a chemical
process that does not involve bacteria.
 SITE: cervical areas of teeth.
 ETIOLOGY:
 INTRINSIC: due to gastro esophageal
reflux and vomiting
 EXTRINSIC: acidic beverages, citrus fruits.

 ABFRACTION
 The pathological loss of enamel and dentine due to
occlusal stresses.
 Occlusal forces which cause the tooth to flex, cause
small enamel flecks to break off, inducing the abrasive
lesions
 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
instruments.
TYPES:
 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.
165

 GRADES OF MOBILITY: (GLICKMAN’S
CLASSIFICATION)
 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-
lingual direction
 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 .
166

OCCLUSION:
MALOCCLUSION
 CLASS-I MOLAR RELATION: mesio buccal
cusp of the maxillary Ist molar occludes in
the buccal groove of mandibular Ist
permanent molar.
 CLASS-II:
 Distobuccal cusp of upper first molar
occludes in the buccal groove of lower first
permanent molar.
 CLASS-III:
 mesiobuccal cusp of maxillary first
permanent molar occludes in interdental
space between mandibular first & second
molar.

PROVISIONAL DIAGNOSIS
 It is also called tentative diagnosis or working diagnosis.
 It is formed after evaluating the case history & performing
the physical examination.
 DIFFERENTIAL DIAGNOSIS
 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
further investigations.

INVESTIGATIONS:
CHAIR SIDE INVESTIGATIONS:
 PULP VITALITY TESTS
 PERCUSSION TESTS
 CYTOLOGY
 ASPIRATION
ROUTINE COMPLETE
HEMOGRAM-
 HEMOGLOBIN,
 RED CELL COUNT,
 WBC,
 PLATELET COUNT
 ESR,
 TOTAL LEUKOCYTE COUNT,
 TOTAL DIFFERENTIAL COUNT,
 BLEEDING TIME,
 CLOTTING TIME,
 PLATELET COUNT,
 SERUM IRON,
 CALCIUM,
 PHOSPHORUS AND
 ALKALINE PHOSPHATASE
LEVEL.
169

 PERCUSSION TEST:
 to evaluate the status of the
periodontium surrounding a tooth
 TYPES:
 VERTICAL PERCUSSION TEST –
positive indicates periapical
pathology
 HORIZONTAL PERCUSSION
TEST – positive indicates
periodontium associated problems.
170

RADIOLOGICAL INVESTIGATIONS
INTRAORAL PROJECTIONS;
 -Intra-Oral Periapical,
 Occlusal,
 Bitewing views.
 EXTRAORAL PROJECTIONS;-
 OPG,
 PA view of skull and jaws,
 AP view
 PNS view,
 SUBMENTOVERTEX view,
 TMJ views.
171

OTHER INVESTIGATIONS:-
 URINE EXAMINATION
 Special investigations like:-
 Sialography
 MRI
 CT Scan

 FINAL DIAGNOSIS:
 The final diagnosis can usually be reached following
chronologic organization and critical evaluation of the
information obtained from the,
 patient history,
 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
concurrent problems.
173

TREATMENT PLAN
 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
management.

Treatment phases
1. Preliminary phase
2. Nonsurgical phase
3. Surgical phase
4. Restorative phase
5. Maintainance phase
175

1.Preliminary phase
Treatment of emergencies:
 Dental or periapical
 Periodontal
 Other
Extraction of hopeless teeth and provisional
replacement if needed(may be postponed to a more
convenient time)
176

2.Nonsurgical phase
Plaque control and patient education:
 diet control (in patients with rampant caries)
 Removal of calculas and root planing
 Correction of restorative and prosthetic irritational
factors.
 Excavation of caries and restoration (temporary or
final,depending whether a definitive prognosis for
the tooth has been determind and on the location
of caries)
177

3.Surgical phase
 Periodontal therapy including placement of implants
 Endodontic therapy
4.Restorative phase
 Final restorations
 Fixed and removable prothodontic appliances
 Evaluation of response to restorative procedures
 Periodontal examination
178

5.Maintenance phase
periodic rechecking:
 Plaque and calculas
 Gingival condition(pockets ,inflammation)
 Occlusion,
 Tooth mobility
 Other pathologic changes.
179

 PRESCRIPTION WRITING
 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
label.
 SIGNATURE AND EDUCATIONAL DEGREE OF PRESCRIBING DOCTOR: a
signature is required by law only for certain controlled substance.
180

PROGNOSIS
 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.

 REFERENCES:
 BURKETS ORAL MEDICINE: GREEN BERG, GLICK SHIP- 11TH
EDITION
 ORAL DIAGNOSIS ORAL MEDICINE AND TREATMENT PLANNING:
STEVEN L. BRICKER, ROBERT P. LANGLAIS, CRAIG S. MILLER- 2ND
EDITION.
 ORAL AND MAXILLOFACIAL MEDICINE; SCULLY 1STEDITION.
 PRINCIPAL OF PRACTICAL ORAL MEDICINE & PATIENT
EVALUATION BY PRAMOD JHON R
 PRINCIPLES AND PRACTICE OF MEDICINE, DAVIDSON,
20THEDITION.
 CLINICAL MANUAL ON GENERAL SURGERY, S, DAS,3RDEDITION.
 PRINCIPLES OF PRACTICAL MEDICINE, P.J.MEHTA, 17THEDITION.

 Carranza’s periodontology
 Text book of endodontics-Grossman
 Fundamentals of oral medicine radiology by Durgesh and Bailoor
 Clinical manual for oral diagnosis by Beena Verma

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