Table Of Contents
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
- Mucosa
- 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
- Caries
- 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)
- Mouth soft tissues
- Summary of oral examination
- Make a comprehensive list of all extraoral and intraoral findings
- Extra-oral examination (head and neck exam)
- 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
- Intra-oral views
- 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
- Radiography and radiology
- 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
- Imaging
- Systemic
- Complete blood count (CBC)
- Urea, electrolytes, creatinine (UECs)
- Blood cultures
- Urinalysis
