Good morning

Clinical examination

Seminar presentation by: Dr. sapna PG student (1st yr.) Dept. OMDR 06.04.2010

Contents
Introduction Principles of examination General survey Head & neck examination
Extra-oral Intra-oral

Oral examination
Soft tissue examination Hard tissue examination

Approaching pediatric patient, adolescent & older adult. Summary References

INTRODUCTION
The clinical examination is part of gathering information , so a diagnosis can be made. Clinical examination is followed by history taking. In the clinic, it is a good practice to start examining the patient when he walks into the room. The purpose of any examination is to obtain information concerning a patient. From this information one can decide whether or not a problem exists and how it should be managed

The method of obtaining this information may vary from one dentist/physician to another , but the approach selected should be consistent from one patient to the next, so no area is overlooked. The technique used is not as important as that the practitioner be systematic in approach. A systematic approach ensures consistency & completeness for every patient.

PRINCIPLES OF EXAMINATION
INSPECTION PALPATION PERCUSSION AUSCULTATION OTHER ADJUNCTS: DIASCOPY ASPIRATION PROBING

INSPECTION
Visual assessment of the patient and surroundings Findings that may be significant:
Patient hygiene Clothing Eye gaze Body position Skin color Odor

INSPECTION
Brightly lit operatory Mouth mirror to reflect light in dark areas of mouth Visual inspection of the concerning & surrounding area yields important information that may be used later for diagnosis & for evaluation of the progress of treatment.

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 Crepitus And assess skin temperature

Palpation may be either superficial or deep

PALPATION
1. BIDIGITAL When thumb and index finger used to palpate. Nodules of lip, buccal mucosa, helix of the ear. 2. BIMANUAL Manipulation of structures between fingers of one hand and those of another. Submandibular gland, with the index finger of one hand in the floor of mouth and the other pressing against the skin of the submandibular area.

Deep Bimanual Palpation

PERCUSSION
Technique of striking tissue with the finger or instrument. Used to evaluate the presence of air or fluid in body tissues
Sound waves are heard as percussion tones (resonance).

PERCUSSION
EXTRAORALLY: used to detect tenderness in sinus by tapping the finger tips against the finger placed over the sinus. INTRAORALLY: used as a method to evaluate the teeth (tapping the teeth with mirror handle). The tech. may induce pain in areas of inflammation from periodontal disease or pulpitis.ankylosis of teeth in bone (change in sound).

AUSCULTATION
Act of listening sounds within the body Requires a stethoscope
Used to assess body sounds produced by the movement of various fluids or gases in the patient's organs or tissues

Note characteristics of:

Intensity Pitch Duration Quality

AUSCULTATION
Wheezing, clicking of TMJ, clicking of illfitting dentures with porcelain teeth. Monitoring of blood pressure.

DIASCOPY
Tissue examined is compressed by a glass slide or a wafer of clear acrylic to determine whether the reddish or bluishpurple lesion is vascular or otherwise. If on pressing, blood flows through lesion, it will blanch on diascopy and return to its original color on release of the pressure.

PROBING
Probing is palpation with an instrument and is one of the most important diagnostic technique used in dentistry today. Teeth are probed for caries. Periodontal probe : depth of periodontal sulcus. Fistulous tracts can be probed. Lacrimal duct probes: Wartons duct, submandibular gland & Stensens duct of parotid gland.

CLINICAL EXAMINATION IN ORAL MEDICINE

The clinical examination in oral medicine includes:

- General survey - Head & neck examination - Oral examination

GENERAL SURVEY
MENTAL STATUS STATURE NUTRITION GAIT / POSTURE UPPER EXTREMETIES VITAL SIGNS

MENTAL STATUS
The first step in any patient-care encounter is to note:
Patients appearance and behavior Assess level of consciousness

MENTAL STATUS

STATURE
Giantism: familial, hyperpituitrism, klinefelters syndrome. Dwarfism: genetic, turners syndrome, downs syndrome, malnutrition, spinal deformities, skeletal dysplasias, cushings syndrome.

STATURE

HEALTH STATUS

NUTRITION
Protiens- rough skin, later edema of feet & brittle hair Fats- cachexia with hollowing of cheeks, loss of shape of hips, flat abdomen & absent fat over subcutaneous tissue and albows Carbohydrates- difficult to detect

 Vitamins- fatty liver and cirrhosis,glossitis, anaemia, hemorrhagic renal diseases,scurvy. Minerals- iron- koilonychia - calcium- tetany

SKIN COLOR /LESIONS

SKIN & ITS APPENDAGES

SKIN: 1. Colour: pale, flushed, cyanosed, yellow. 2. Hypopigmentation: leprosy, leukoderma, fungal infection 3. Eruptions: macule, papule, nodule, pustules, vesicles, wheal, caf-au-lait patches 4. Hemorrhage: petechiae, purpura, ecchymosis, hematoma

 Types of skin: 1.Dry: dehydration & myxedema 2.Moist: profuse perspiration(shock), crisis of pneumonia, myocardial infarction 3.Thick: myxidema, scleroderma 4.Thin: old people 5.Pinched: dehydration

Jaundice
yellow coloration of tissue & body fluids Inc. in bile pigment Associated : viral hepatitis, malaria, dubin johnson syndrome, gilberts syndrome, cirrhosis of liver, uraemia, SLE, sickle-cell anaemia, snake venom site

Pallor
Paleness of skin & mm (dec. circulating RBC/ dec. blood supply) Anaemia: Hemorrhagic, hemolytic, iron def., aplastic, ch. Infection, pregnancy, malignancy. Vasoconstriction: shock, fright, exposure to cold, syncope. Cutaneous: thick skin & nails, edema

UPPER EXTREMETIES

Hair
1. Falling hair: typhoid 2. Patchy hair loss: syphilis, alopecia areata 3. Loss of outer 3rd of eyebrow: leprosy 4. Absence of axillary, pubic & facial hair: hypopituitrism, hypogonadism 5. Excessive hair growth in women: cushings syndrome, adrenocortical syndrome

Nails
Should be examined for: 1. Pallor 2. Koilonychia: spoon shaped deformity (iron-def. anemia) 3. Onychia: deformity following fungal or tuberculous infections 4. Discoloration: Ag & Hg poisoning 5. Clubbing & cyanosis 6. Hemorrhages: in nail beds (SBE, bleeding dis.) 7. Trophic changes: ribbing, brittleness & often falling of nails (syringomyelia, leprosy & tabes dorsalis)

clubbing
Bulbous Transverse & longitudinal curving of nails Swelling of terminal phalanges- edema & dilation of a& c. Causes: pulmonary, cardiac, alimentary, endocrine, hereditary Pseudoclubbing- hyperparathyroidism (excessive bone resorption, drumstik app. Resembling clubbing)

Cyanosis
Bluish nails increased amount of reduced Hb. Central- CCF, COLD, low p/p of oxygen Peripheral- cold,inc. viscosity of blood, shock Mixed- ALtVF, mitral stenosis Abnormal Pigmentation

 Sites: LPC, tongue, soft palate, palm & nails, other mucosal areas

Edema
Collection of fluid in interstitial spaces or serous cavities. Conditions: Increased capillary permiability: acute infl. Inc. capillary pressure: cardiac failure Decreased osmotic pressure of blood: hypoproteinaemia Damaged lymphatic drainage: filariasis

Site: Venous E: lower limbs Lymphatic E: either limbs/ scrotum (depending upon site involved) Causes: Cardiac: pericarditis Renal: acute nephritis, nephrotic syndrome Hepatic: cirrhosis of liver Venous: inf. Vena cava obstruction Infections: cellulitis, boil, carbuncle

VITAL SIGNS
BLOOD PRESSURE PULSE RATE RESPIRATION RATE TEMPERATURE

Temperature
Body temp. temp. of viscera & tissues of body Hypothalamus 36- 37.5*C Mercury Thermometer

Blood Pressure
120mm Hg, 80mm Hg Sphygmomanometer Most commonly used (along with the stethoscope) to measure systolic and diastolic blood pressure

Conditions diagnosed by measuring BP: 1.Hypertension (>180/ >110) 2.Hypotension (drop by 20mm Hg) 3.Pulsus paradoxus 4.Pulsus alternas

Stethoscope
Used to evaluate sounds created by the cardiovascular, respiratory, and gastrointestinal systems Position of stethoscope between index and middle fingers

Ophthalmoscope
Used to inspect eye structures:
Retina Choroid Optic nerve disc Macula Retinal vessels

Otoscope
Used to examine deep structures of the external and middle ear

HEAD AND NECK EXAMINATION

HEAD
1. 2. 3. 4. 5. 6. 7. 8. Facial form Skin Hair Ear Preauricular and postauricular lymph nodes Temporomandibular joint Parotid gland Nose and paranasal sinuses

HEAD
1. FACIAL FORM:
 Position of eyes, nose, mouth & ear (size & symmetry)  Facial profile & symmetry  Position of maxilla & mandible in relation to rest of skull  Color of skin  Presence & location of swelling (unilateral or bilateral)

HEAD
2. SKIN:
 Color (caf-au-lait, bruising, jaundice, vascular lesions)  Texture (weather and changes in thyroid activity)  Elasticity (poor hydration, edema)  Question (onset, duration, possible cause of any nodules, ulcerations, scars or other variations)

HEAD
3. HAIR
 Thin & fine (hereditary anhidrotic ectodermal dysplasia)  Color & texture (systemic)  Distribution (sex hormones & genetics)  Question any sudden loss of hair (investigate)

HEAD
4. EARS:
 Normal: origin of helix is in line with outer canthus of eye, pinna is 8-12 cm in size.  Foreign bodies, redness, lesions, discharge & deformity.  Pain on palpation (mastoiditis).

HEAD
5. PREAURICULAR & POSTAURICULAR LYMPH NODES:
 Pre-auricular LN front of the tragus.  Post-auricular behind the ear near the insertion of sterno-mastoid muscle.  Lymph-adenopathy infection of scalp, temporal or frontal areas, eye. Also due to systemic viral infections (German measles, chickenpox, infectious mononucleosis).

HEAD
6. TEMPOROMANDIBULAR JOINT:
 Located in front of tragus, can be found by asking pt. to open & close mouth.  Palpate during function  Palpate both joints at a time.  Notice - pain & deviation  Stethoscope abnormal sounds (dysfunction of masticatory muscles, internal derangements within the capsule of joint).

 Maximum opening: 40 55 mm in an adult.

ABNORMALITIES:

 Popping: reversible, internal derangement, osteophyte or tumor.  Crepitus: irreversible, bone-to-bone contact, later stage of internal derangement.  Pain on palpation: internal derangement, inflammation.

7. PAROTID GLAND:
 Lies against outer border of the ramus of the mandible & extends posteriorly to the sternomastoid muscle.  Normal gland is difficult to localize by palpation.  Swelling: elevates ear lobe (blockage of stensens duct-unilateral.  Facial paralysis may occur if gland is secondarily infected.

HEAD
8. NOSE & PARANASAL SINUSES:
 Parts- bridge , tip, alae, base, septum, external nares separated by thin band of tissue called columella.  Shaped by cartilage within tissue, easy to fracture.  Fracture lead to deviation that causes mouth breathing & associated oral abnormalities.

 Paranasal sinuses : frontal & maxillary sinuses.  Frontal: midline,above the eyes.painful on palpation (inflammed). Fingers placed in canthus of eye, press upwards.  Maxillary: fingers placed either side of nose, below the rim of orbit. No pain on palpation & percussion does not rule out sinusitis.  Excessive discomfort on one side or significant pain suggests sinusitis.

EXAMINATION OF NECK
1. 2. 3. 4. 5. MUSCLES LYMPH NODES THYROID GLAND TRACHEA CAROTID ARTERY

NECK
1. MUSCLES:


  

Sternomastoid: originates from sternum and clavicle & inserts on mastoid process.identified by having the patient rotates his unsupported head. Trepizius: originates on the occipital bone & inserts on the posterior border of the clavicle and scapula. Tenderness: state of tension, MPDS. Tenderness along sternomastoid: occurs may be from muscle itself or from lymph nodes that are pressing against it.

NECK
2. LYMPH NODES:
 Submandibular , submental, anterior cervical, posterior cervical, suboccipital, supraclavicular.  Submandibular: in the submandibular triangle, from behind the patient, with patients chin tipped slightly towards the chest,with ones fingers cupped and the tips pressed lightly against the mylohyoid muscle, the tissue is rolled laterally across the inferior border of mandible.on relaxation of pressure, the nodes will be felt to slide across the mandible into the neck.

NECK
 Note for tenderness, enlargement, mobility & attachment to the surrounding tissue.  Submental : palpated in the submental triangle, similarly.  Two chains of lymph nodes are present on either side of sternomastoid m. anterior & posterior cervical chain.  Each chain has superficial and deep components : superficial nodes lie along the external jugular vein, whereas deep nodes lie along the carotid sheath.  Felt by tipping patients head forward to relax the muscles of neck.index finger is placed in the triangle and palpated with a rotatory motion.

NECK
3. THYROID GLAND:
 Located in the midline of neck, made of two lobes connected by isthmus & lies below carotid cartilage. A portion of each lobe lies behind the sternomastoid muscle.right lobe is 25 % larger.gland larger in females.

NECK
 The gland should move vertically as the patient swallows.  Abnormal swelling should be notied.  Palpation: with patients chin slightly lowered, fingers should locate the carotid cartilage; then fingers are placed on either side of trachea, patient asked to swallow repeatedly. As patient swallows, size of the gland can be evaluated, as well as any nodule or swelling.

NECK
4. TRACHEA:
 Trachea is examined above the suprasternal notch to ascertain whether any lateral displacement is caused by thyroid enlargement or a tumor.  Aortic aneurysm tracheal tug

NECK
5. CAROTID ARTERY:
 Palpated in the carotid triangle. One side at a time should be palpated.  Fingers should be placed in carotid triangle, and with gentle pressure, trachea is displaced medially; the pulsation can be felt.  Forceful pulsation: hypertension or thyritoxicosis.  Expansile pulse: aneurysm.

NECK
6. NEUROLOGICAL EXAMINATION:
 Although o comprehensive neurological examination is not within the scope of dental practice, dentist must observe behavioural & physical alterations that may suspect an underlying neurological disorder.  Disorders of cranial nerves are manifested in head & neck : facial nerve paralysis & tic douloureux.  The mental state & speech may be evaluated during initial interview.  Alterations in gait, posture & balance may be induced by neurologic changes.

Mental Status and Speech

A healthy patient should be oriented to person, place, and time Patients should also be able to organize thoughts and converse freely
Provided there are no hearing or speech impediments

Cranial Nerve Assessment

Cranial Nerve I
Olfactory: Test sense of smell with spirits of ammonia

Cranial Nerve II
Optic: Test for visual acuity

Cranial Nerve II and III

Optic and Oculomotor
Inspect size and shape of pupils Test pupil response to light

Cranial Nerve Assessment

Cranial Nerve III, IV, VI
Oculomotor, Trochlear, Abducens
Test extraocular movements by asking patient to look up and down, to the left and right, and diagonally up and down to the left and right

Cranial Nerve V
Trigeminal
Test motor movement by asking patient to clench teeth while palpating temporal and masseter muscles Test sensation by touching forehead, cheeks, jaw on each side

Cranial Nerve Assessment

Cranial Nerve VII
Facial
Inspect the face at rest and during conversation, noting symmetry, or abnormal movements Ask patient to raise the eyebrows, frown, show both upper and lower teeth, smile, and puff out both cheeks Assess strength of facial muscles by asking patient to close eyes tightly so they cannot be opened, and gently attempt to raise the eyelids Observe for weakness or asymmetry

Cranial Nerve VIII

Acoustic: Assess hearing acuity

Cranial Nerve Assessment

Cranial Nerve IX and X
Glossopharyngeal and Vagus
Assess patients ability to swallow with ease; to produce saliva; and produce normal voice sounds Instruct patient to hold breath, and assess for normal slowing of the heart rate Testing for the gag reflex also will test the cranial nerves

Cranial Nerve Assessment

Cranial Nerve XI
Spinal Accessory
Ask patient to raise and lower shoulders and to turn head

Cranial Nerve XII

Hypoglossal
Ask patient to stick out tongue and to move it in several directions

ORAL EXAMINATION
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. LIP AND LABIAL MUCOSA BUCCAL MUCOSA MUCOBUCCAL FOLD HARD PALATE SOFT PALATE AND UVULA OROPHARYNX AND NASOPHARYNX TONGUE FLOOR OF MOUTH PERIODONTIUM EXAMINATION OF TEETH

Intraoral examination
Intrumentarium: 1. Latex gloves 2. Mouth mirror 3. Straight probe 4. Explorer 5. Pulp vitality tester 6. Tongue blade 7. Cheek & lip retractor

LIPS
External portion : vermillion border & skin. Vermillion border: exposed red portion., covered by mucous mem., has no mucous glands. It is bounded by the moist labial mucosa in the mouth and by mucocutaneous junc. Of skin. With age, mucocutaneous junction becomes indistinct & fissures develop running from skin onto the lips. Upper lip is divided into two halves by a depression called philtrum.

LIPS
The interface of the lips has numerous small nodules that can be seen and palpated.they are mucous glands (accessory salivary glands). Evaluation: drying, appearance of small beads of mucous. Upper & lower lips are joined at the commissures of the mouth.

LIPS
The upper and lower lips are attached to maxilla & mandible through frenum. The size & attachment of frena vary among individuals. Frequently, upper labial frenum has a small tag of tissue called fibroepithelial polyp that is a result of trauma.

LIPS
TECHNIQUE:
a. muscular control of lips can be evaluated during conversation. b. At rest, lips touch. If they are apart, indicates mouth breathing, tongue thrusting, nasal obstruction. c. By using bidigital palpation, examine any submucosal nodules, bullae or other abnormalities.

BUCCAL MUCOSA
Lining of the cheek Actual surface of cheek is covered by squamous mucous mem. of varying thickness.thickness partially determines its appearance. Parotid papilla : near 2nd maxillary molar tooth. An elevation containing the opening of Stensens duct from the parotid gland.the opening itself is seen when the gland is pressed.

BUCCAL MUCOSA
Linea alba : a line corresponding to the line of occlusion of teeth. Hyperkeratotic. At the anterior termination of linea alba is a small palpable nodule caliculus angularis.

BUCCAL MUCOSA
The lateral labial frena attaches buccal mucosa to maxilla & mandible. Size, location & attachment vary as in labial frenum. Fordyces granules (ectopic sebaceous glands, small yellow nodules) & leucoedema (wrinkled, whitish, opalescent) are variations of topographic anatomy.

MUCOBUCCAL FOLD
Major structure : labial frena Improper attachment :
Mucogingival problems of periodontal origin. Problems of malposition of maxillary incisors. May disturb prosthesis by dislodging denture bases. Buccal exostosis may be seen impinging on the mucobuccal fold in any area, frequently on max. molar area.

MUCOBUCCAL FOLD
TECHNIQUE :
Inspect visually Palpate, running finger over the bone at the fold,nodules or painful areas can be discovered. In Garres osteomyelitisthe area of mucobuccal fold is elevated, almost to the height of alveolar ridge.

HARD PALATE
Incisive papilla : located in midline, just posterior to the maxillary central incisors. Palatine rugae : behind the incisive papilla & running transversely on either side of the midline . These ridges are important in speech s.

HARD PALATE
TECHNIQUE: Inspect visually It appears pale pink (covered with keratinized epith. with shallow layer of dense conn. Tissue beneath) The rugae shall feel dense & firmly attached near the midline. Contour of palatal vault should be noted due to its importance in speech & denture construction.

SOFT PALATE & UVULA

It is a thin muscular curtain that separates the mouth from the nose. Mucosa of soft palate is thin but overlies thick connective tissue & muscle (redder appearance) Yellow appearance : underlying adipose tissue. Uvula: lies in the midline, on the posterior border of soft palate.

SOFT PALATE & UVULA

Occasionally, median raphe extends posteriorly & divides the uvula into a bifid uvula. Numerous mucous glands, on oral side of soft palate. On the opposite side, it forms covering of pharynx & continues anteriorly in the nose.

SOFT PALATE & UVULA

Inspect visually. Elevate by asking patient to say ahh. Can be palpated using index finger & pressing upwards.avoid touching base of tongue, which elicits gag reflex.

TONGUE
Muscular organ that almost fills the mouth when teeth are in occlusion. Dorsum: covered by oral mucosa, forming 4 types of lingual papillae.
Filiform : most numerous,small whitish hair-like projections (keratin)covers most of tongue, may become elongated or shortened, do not contain taste buds. Fungiform : mushroom-like elevations scattered among filiform papillae, at lateral border & tip of tongue, redder, contain taste buds. Circumvalate : 8-12, large, round, grooved borders, contain taste buds. Foliate : on lateral border of tongue, vertical leaf-like projections, not easily identified, contain taste buds.

TONGUE
Median sulcus : midline of tongue has a depression of varying depths. Additional fissures may be present radiating from the sulcus. Median sulcus may be followed posteriorly to end in a V or Y shape called terminal sulcus.this separates dorsum of tongue from the root.

TONGUE
Lingual tonsil : lie on root of the tongue, posterior to the terminal sulcus. Lingual frenum : located on ventral surface of tongue, attaches to genial tubercle of mandible. Plica fimbriata: on either side of lingual frenum, appears as small line of tissue projections, containing opening of duct fron Blandin & Nuhn.

TONGUE
Ventral surface of tongue has deep seated areas of bluish discoloration, are the lingual veins. With age, these veins may form numerous purple vericocities

TONGUE
TECHNIQUE :
Unusual tumors, shape, size, fissural patterns, length of papillae, changes in color, elevations, depressions & shape of the borders should be noted. A gauze sponge is used to retract. Always palpate bidigitally, avoiding dorsum near the root (gag reflex may be stimulated). Palpate root when suspecious area is noted. May require topical anesthesia

FLOOR OF MOUTH
Lingual frenum divides floor of mouth into two halves. Sublingual caruncles are seen as two small projections on either sides of frenum. They are sites of opening of Wartons duct. from caruncles, the sublingual folds running posteriorly contains parts of sublingual salivary glands & their ducts

FLOOR OF MOUTH
Area between mucous membrane of floor of mouth & skin of submandibular region of neck contains :
Sublingual glands Submandibular glands Mylohyoid muscle Numerous lymph nodes

FLOOR OF MOUTH
TECHNIQUE :
Viewed by having the patient lift the tongue to the roof of mouth. Dry the caruncles, evaluate function of submandibular gland. Bimanual palpation if performed by placing index fingers of one hand in patients mouth & fingers of opposing hand in the submandibular area. Entire floor of mouth should be palpated starting from posterior proceeding anteriorly to opposite side.

PERIODONTIUM
Attached gingiva : bound firmly to alveolar bone Coral pink (keratin) Free gingiva : Closely adapted to necks of teeth Demarcated from attached gingiva by a small depression Freely movable, non-keratinized, redder. Interdental papillae : Fill the embrasure between the teeth

PERIODONTIUM
Retromolar papilla :
Distal to last molar in mandible forms a slight elevation that can cause a pseudopocket. Retromolar pad (rounded, dense pad on ridge) appear distal to retromolar papilla.

PERIODONTIUM
TECHNIQUE :
Direct & indirect vision, palpation & probing. Notice change in color from coral pink, ideal sharp edge of free gingiva, form of interdental papilla, presence & degree of gingival inflammation. Palpation : reveals density, may elicit pain, may express pus, may cause bleeding in diseased gingivae. Red acute inflammatory responses Purple red to paler chronicity

PERIODONTIUM
Periodontal probe :
To determine level of attachment , pattern of bone loss & depth of gingival sulcus. Normally, epithelial attachment is approx. 2mm from CEJ. (Ranging from 0.5 to 3 mm). Furcation involvement should be evaluated (class I, II, III) Mobility (grades I, II, III ) Determine whether bone loss is localized, generalized, horizontal or vertical (bone loss pattern is found & help arrive at a diagnosis)

EXAMINATION OF THE TEETH

TECHNIQUES :
visual inspection, transillumination, probing, palpation, percussion & the evaluation of function. Tools : good light source, mirror, a sharp explorer & probe(straight & periodontal) are the most basic tools required. Additional adjuncts : dental floss, articulating paper, electric pulp tester, radiographs & diagnostic casts are additional aids used to make a final diagnosis.

EXAMINATION OF THE TEETH

Visual inspection :
Systematic observation of the entire dentition as a unit. The normal adult dentition consists of 32 teeth.each has a characteristic shape, position, location in arch & a specific eruption pattern.

 Inflammation :
Localized : caries, malaligned teeth, surfaces that are difficult to reach with normal home care, Inflammation adjacent to any restoration: deficiency in contact, overhanging restoration, recurrent caries, poorly contoured restoration.

 Caries pattern :
in adults Usually occurs in pits & fissures (poor home care) Rampant caries noted esp in absence of several local factors (high sucrose diet) Multiple caries on cervical & incisal surface (xerostomia).

 Missing teeth:
History Radiograph locate unerupted or impacted teeth. Correlate with systemic or genetic abnormality. Sequela of missing teeth may include supraeruption, tilting, drifting, rotation (may hav an impact on treatment plan)

 Size:
Dens invaginatus Microdontia Macrodontia

Color:
Enamel- white Dentin- yellow Pulp- pink Amelogenesis imperfecta, dentinogenesis imperfecta, Pulp necrosis, fluorosis/tetracycline, hypoplasia, pink tooth(internal resorption)

 Attrition Abrasion erosion

DETECTION OF PULPAL DISEASES

PULP TESTING:
Check for vitality before performing conservative treatment in case pulpal involvement. Application of heat & ice. Electric pulp testing

Approaching the patient

Pediatric Patient
Remain calm and confident Do not separate the child from the parent unless absolutely necessary Establish rapport with the parents as well as the child Be honest with both child and parent When possible, assign one care giver to stay with the child

Pediatric Patient
Observe the child before the physical examination
If possible, begin the assessment without touching the patient

Note general appearance

Assess behavior

Pediatric Patient
Note particular area of the body that appears painful
If possible, avoid this area until the end of the examination Warn the child before you touch painful area(s)

General Appearance
Best assessed from a distance A child who is seriously ill or injured does not generally attempt to hide or disguise his condition

Adolescents (11 to 18 years)

Generally calm, mature, and helpful Very concerned about modesty, disfigurement, pain, disability, and death If appropriate, make reassurances during the examination Be sensitive to patient's need for privacy If possible, interview privately - away from family and friends Consider alcohol and/or drug use, possibility of pregnancy

Communicating with the Older Adult

Allow extra time to ensure effective communication Stay close to the patient during the interview Repetition of questions may be required Do not to patronize or offend the patient

Physical Examination
Try to ensure patient comfort Offer clear explanations of examination procedures Answer all questions Be alert to chronic pain If transportation to a hospital is necessary
Attempt to calm the patient Reassure the patient that he or she will be well cared for in the hospital

Carefully record all examination findings

Summary
The clinical examination is necessary after a detailed history given by the patient in order to come to the provisional diagnosis and is a necessity before planning treatment for the patient.

References
Steven L. Bricker : Oral diagnosis, oral medicine, and treatment planning (2nd ed.) Wood & Goaz : differential diagnosis of oral and maxillofacial lesions (5th ed.) Hutchisons clinical methods (21st ed.) Cunninghams practical anatomy (head& neck, upper limb, lower limb) P J Mehtas practical medicine (17th ed.) S Das, A manual of clinical surgery (7th ed.)

Thank you
Have a nice day