Basics of Dentistry

Overview

*Review embryology, anatomy

Dental History

• Biodata
  • Name
  • Age
  • Sex
  • Residence
  • Occupation
• Presenting complaints
  • Should be clear and specific, with duration for each, for example “left-sided lower jaw pain for 3 days” rather than just “jaw pain”
• History of presenting illness
  • Is the patient a referral? From which center?
  • Describe each chief complaint
  • If the chief complaint is pain (very common in dentistry), use SOCRATES to further describe, and establish if pain is typical or atypical dental pain
  • What management if any has been carried out so far, if any
• Dental history
  • Dental habits e.g. tooth brushing, flossing
  • Nutrition and snacking habits – cariogenic diet?
  • Any previous dental visits? If so, why?
  • Any history of tooth extractions under local anesthesia (XLA)
  • Any history of oral surgery? Any associated complications e.g. bleeding?
• Past medical and surgical history
  • History of known chronic illnesses
  • Is the patient currently taking any medication? – e.g. anticoagulants which may cause excessive bleeding in case a procedure is to be carried out
  • History of past admissions
  • History of blood transfusion
  • History of past non-dental surgeries
  • Food or drug allergy and atopy history
• Family and social history
  • Insurance cover – affordability of services; may influence choice of treatment, e.g. MMF over ORIF
  • Occupation
  • Residence
  • Drug and alcohol history – Quantify! Alcohol may be associated with poor oral hygiene (OH), cigarettes and miraa may cause tooth staining, any ingested substances may cause irritation or injury to oral mucosa.
• Review of systems
  • Review CNS, CVS, Respiratory, Gastrointestinal, Genitourinary, Integumentary, Endocrine, Musculoskeletal systems
• Summary of history
  • Create comprehensive summary containing key information captured in history

Dental Examination

• General examination
  • Vital signs
  • Jaunice, pallor, cyanosis, clubbing, edema, lymphadenopathy, etc.
• Local examination
  • Extra-oral examination (head and neck exam)
    • Facial symmetry
    • Lip competence – do lips cover teeth at rest?
    • Cervical lymphadenopathy – palpate all groups of cervical nodes from behind the patient
    • Temporomandibular joint
      • Palpate both simultaneously
      • Have the patient open and close and move joint laterally while feeling for clicking, locking, crepitus (note: clicking may be physiological)
      • Palpate muscles of mastication for spasm and tenderness
    • Any other swellings, masses, deformities (congenital or acquired) – should be inspected, palpated and described
    • In trauma history – signs of head injury or facial trauma – periorbital edema and ecchymosis, battle sign, discharge from ears or nose
  • Intra-oral examination
    • Mouth soft tissues
      • Mucosa
        • Should be pink everywhere (may be pigmented in darker-skinned individuals) – check symmetry of pigmentation; the rule is if it is symmetrical it is most likely normal
        • Any ulcers or growths
        • Candidiasis
      • Tongue
        • Should be moving, with a rough (papillated) upper surface and smooth lower surface
        • May be partially depapillated – e.g. geographical tongue/migratory glossitis which is a normal variant and may be hereditary
        • Extensive depapillation where tongue appears completely smooth may indicate pathologies e.g. atrophic glossitis
        • Any ulcers or growths
        • Candidiasis
      • Gingiva/ periodontal condition
        • Should be pink with varying levels of pigmentation
        • When inflamed appear red or dusky
        • Inflamed gingiva bleed when a blunt instrument is run over them
        • Assess for gingival recession
      • Roof of mouth (hard and soft palate)
        • Assess for patency (cleft-palate, fistulae)
        • Any ulcers or growths
        • Parotid gland duct opening near crown of upper 2nd molars (saliva may be visible dripping/pooling slowly)
      • Floor of the mouth
        • Any swellings
        • Any ulcers or growths
        • Submandibular gland duct openings on either side of lingual frenulum (saliva may be seen shooting out)
      • Palatine tonsils
    • Mouth hard tissues (teeth)
      • Tooth notation
      • Tooth pathologies
        • Caries
          • Name affected tooth/teeth according to above notation
          • If there is pain = ‘caries with acute pulpitis’
        • Tooth deposits
          • Plaque – soft, cream, can be brushed off
          • Calculus – hard, cream/darker, cannot be brushed off (removal by scaling), advancing towards gums hence may be associated with gingival recession
        • Tooth mobility – assess for any increase
      • Jaw occlusion
        • Get patient to close jaws and examine relationship between arches
        • Look at path of closure for any obvious prematurities and displacements
        • Check for evidence of tooth wear/tooth surface loss
    • General assessment of oral hygiene (OH)
  • Summary of oral examination
    • Make a comprehensive list of all extraoral and intraoral findings
• Systemic examination
  • Do a full systemic exam (CNS, CVS, Respiratory, Abdominal, MSK)
  • Thorough CNS exam of extreme importance in trauma to head, e.g. in mandibular fracture. Also rule out any other associated injuries
• Summary of examination
  • Combined summary of local and systemic exams with relevant positives and negatives highlighted

Investigations in Dentistry

• Local
  • Imaging
    • Radiography and radiology
      • Intra-oral views
        • Periapical (IOPA – intraoral periapical) – shows all of the tooth, root and surrounding periapical tissue
        • Bitewing – shows crowns and crestal bone levels; used to diagnose caries, overhangs, calculus and bone loss <4mm
        • Occlusal – demonstrates larger areas; used for localization of impacted teeth and salivary calculi
      • Extra-oral views
        • Posteroanterior (PA) mandible – used to diagnose/ assess mandibular fracture
        • Panoramic/ DPT (dental panoramic tomograph)/ OPG (orthopantomagram) – accommodates horseshoe shape of the jaws; useful for gross pathology but less so for subtle changes such as early caries
        • Lateral oblique – largely superseded by panoramic views
        • Reverse Townes – used for condyles
        • Occipito-mental
        • Submento-vertex
    • Advanced imaging
      • Computed tomography (CT) – useful for assessing extensive trauma or pathology, and planning surgery
      • Cone beam computed tomography (CBCT) – helpful in planning implant placement and for assessing teeth undergoing endodontic treatment (root canal), in particular if complex root or pulpal anatomy is suspected
      • Magnetic resonance imaging (MRI) – useful for the TMJ and facial soft tissues
      • Ultrasound – used to image the major salivary glands and soft tissue pathology (cysts/abscesses)
      • Doppler ultrasound – used to assess vascularity of lesions and patency of vessels prior to reconstruction
      • Positron emission tomography (PET) – tumor detection
  • Biopsies
  • Swabs for bacteriology – Sputum, pus, nasal, axillary swabs
  • Cytology – smears for candida, FNA for some masses
  • Specific tooth tests
    • Sensibility testing – to investigate integrity of nerve and hence blood supply
    • Application of cold – using endo-frost or ethyl chloride on cotton held against a dry tooth
    • Application of heat – petroleum jelly applied on tooth to be tested to prevent sticking of heated gutta-percha (GP); No response = tooth non-vital, increased response = pulp is hyperaemic
    • Electric pulp tester – prophy or other proprietary lubricant used as conductive medium on a dry tooth
    • Test cavity – drilling into cavity without LA is an accurate but destructive diagnostic test
    • Percussion – carried out by gently tapping adjacent and suspect teeth with end of a mirror handle; positive response indicates tooth is extruded due to exudate in apical or lateral periodontal tissue
    • Tooth mobility – is increased by decrease in bony support, e.g. due to periodontal disease or apical abscess, and also by a fracture of root or supporting bone
    • Palpation – of buccal sulcus near painful tooth can help determine if there is an associated apical abscess
    • Biting on tooth sloth, gauze or rubber – to try elicit pain due to a cracked tooth
    • Local anesthesia – can help localize organic pain
• Systemic
  • Complete blood count (CBC)
  • Urea, electrolytes, creatinine (UECs)
  • Blood cultures
  • Urinalysis