History,Exam,Special Tests16

7/28/2019 History,Exam,Special Tests16

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Sara Sarraj

DDS MS MS FGD


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Dent 337

Clinic


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The clinician opinion resulted from the processof evaluating the patient


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Interview Patient

Gather data

Aanalyse Data

Developing Hypotheses Establish Diagnosis

Formulate Tx Paln

Consent form to begins treatment


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S:Subjective information

Objective: Physical findings of the clinician

Analysis : Clinical impression of the condition by

the clinician P:Plan ,recommended management for the

condition1. Specific treatment

2. Referral to specialist3. Dismissal as clinically insignificant


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For consultation with another dentist

To reevaluate current treatment

Only when diagnostic information is available


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Dental

History

AdjunctiveDiagnosticTools

PhysicalExam

Medical History


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Pt Identification

Systemic Disease

Family History

Social History


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Name

Age

Gender

Race Address

Phone# & Email


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Review:

of the medical conditions that have beendiagnosed.

Immunization Hospitalization

Allergies

Current Medications


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1.Is a dynamic document that should be updatedannually and for every new patient

2.Taking medical history makes the pt feel thatthe office provides an optimum treatment.

3.Early recognition of risk improves prognosis,and reduces complications

4.Dental team often first to identify silent

disease(silent killer)


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Standard review of past medical history

Hospitalization: Renal dialysis

Surgery: hip replacement, pace maker, bypass,

Prosthetic heart valve Illness:IE(infective Endocarditis)

Medications: Rx :bisphosphonates, chemotherapy,

anticoagulants,birthcontrol,steroids OTC,herbal,Diet control


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Highest risk People with the followingconditions are considered to be at the highest riskof developing infective endocarditis(IE).Preventive antibiotics are generally

recommended for people with the followingconditions before bleeding induced dentalprocedures A prosthetic heart valve

Valve repair with prosthetic material

A prior history of infective endocarditis

Many congenital (from birth) heart abnormalities


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antibiotic prophylaxismight be useful forpatients who also havecompromised immune

systems (due to, forinstance, diabetes,rheumatoid arthritis,cancer, chemotherapy,and chronic steroiduse), which increasesthe risk of orthopedicimplant infection.


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Chest pain, palpitation, breathlessness(CVD)

Cough, wheeze, breathlessness (RespT)

Bowel Habit: distention, pain, eating And

appetite(Gastrointestinal) Incontinence, straining or drippings

(Genitourinary)

Seizures ,fainting ,headache (central nervous

System)CNS


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Chief Complaint: CC

The statement of why the patient consulted thedentist

It should be in pt own words if possible To assess the dental awareness and the likelihood

of raising it


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Anxiety: How do they feel about dental TX

Florid intake: where do u live

Pt experience with GA and LA: if any complication

in the past Caries rate and erosion: what,s your favorite drink


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Assess motivation:How often to go to dentist

Provide clue about the nature of CC : When did ulast see dentist (RCT)

Motivation: how often do u brush. Gingivalcondition

TMJ: have had any pain or clicking from your jaw

Personality: do grind your teeth , bite nail


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Use introductory words:

What is the problem

When: onset and pattern

How: Frequency What: Exacerbating and relieving factors


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Location: Where

Commencement: When

Character & intensity:

Sharp , shooting ,aching .dull Frequency & Duration

Association : what make them worse or better


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Type

Size

Color

Location Surface Texture

consistency


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General

Extra oral Soft Tissue

Intra Oral Soft Tissue


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General Appearance

Gait

Mobility

Facial Asymmetry Lesion or Scar


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Asymmetry

Lymph Nodes

TMJ


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Visual screening

Palpation screening


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Exam

Extra Oral Exam

palpation

Bilateral

Bimanual

Bidigital

Visualscreening

symmetry


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Surgery Inflammation

Tumors Congenital


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Induration: fixation to the deeper tissues

Roughness or smooth textures of the lesion

Consistency: fluctuant, soft, hard,

Tenderness: if your palpation induces pain Presence of masses and size of them


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Bilateral

Bimanual

Bidigital


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using both hands toboth sides, like

submandibular lymphnodes, TMJ, muscles ofmastication, and thetwo lobes of thyroids


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using both hands toexamine one structurea one side, forsubmandibular

salivary glands to palpate the

buccinators muscleto feel anytenderness


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Using two fingers ofone hand to examineone side, for lips,tongue and for buccalmucosa


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Muscle of mastication Salivary glands

Lymph nodes


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The finger is insertedmedially to the muscleand the muscle ispressed laterally

against the innersurface of themandibular ramus, toelicit tenderness . .


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Similarly force isapplied to the subjectsleft jaw to stress theright lateral pterygoid

muscle


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Normal:Not palpabable,feel like a pea or lentil,non tender

Abnormal Lymph Nodes:

Larger,may be tender,inflammation or drainageof infection

Non-tender large lymph nodes:

Cancer

Lymphoma


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Preauricular Tonsilar

Submental

Submandibular Anterior & posterior cervical

suparcalvicular


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Methods of palpation of lymph nodes


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Palpate both joint simultaneously ,GentlePressure : Tenderness, swelling , Redness

Range of movement: open and close slowly manytimes .and from one side to another. Also feel forclicking ,locking ,& crepitus

Palpate the muscle of mastication for spasm &tenderness

Auscultation can be useful too


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There are 2 types of joint sound to look out for: Clicks - single explosive noise

Crepitus - continuos 'grating' noise


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A joint click probably represents the suddendistraction of 2 wet surfaces, symptomatic ofsome kind of disc displacement. The diagnosis ofa joint click, and therefore treatment, varies on

whether the click is left, right or bilateral, painfulor painless, consistent or intermittent. The timingof a click is also significant: a click heard later inthe opening cycle may represent a greater degree

of disc displacement.


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Crepitus is the continuous noise duringmovement of the joint, caused by the articulatorysurfaces of the joint being worn. This occurs mostcommonly in patients with degenerative joint

disease.


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Lateral Range of

Motion


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Temprature (35,5-37,5C)= (95,5-99,5F) post operative,infection,transfusion reaction Shock,hypothermia

Pulse:Adult(60-80 beat/min) Child(up to 140beat/min)

Blood Pressure BP :(120-140/60-90) BP =Age BP =Syncope,Hypovolemia Shock Respiratory Rate=12-18 breath/min, increases in the

following: Chest infection Pulmonary edema shock


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Oral Vestibule Oral cavity proper


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space bounded Laterally by cheek and

lips

Medially by the buccaland labial surfaces ofthe upper and lowerteeth

Posteriorly by theRetromolar area


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The oral


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cavityproper

Bounded

Laterallyby palatal andlingual surfaces of theupper and lower teeth

Superiorlyby the palate(hard & soft)

Inferiorlyby thetongue and or thefloor of the mouth

Posteriorlyby theisthmus of fauces

Superior boundary


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Superior boundary

Palate- PartsIncisive papilla

Palatine Rugae

Median

palatineraphe

Maxillarytuberosity

FoveaPalatina


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InferiorboundaryThe Floor of the mouth

Parts

Ventralsurface of thetongue

LingualFrenum

Sublingualfold

Sublingualcaruncle

Openning of sublingual duct


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Ventral side of the tongue

Plica Fimbriata

Sublingual fold


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D f Th T


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Dorsum of The TongueMedian fissure

fibrous septum

Sulcus terminalis:V-shaped ridge, separates?

Foramen cecum: (blind opening)

at apex of sulcus term.

marks the site of ?

Lingual papillae: 4 types

filiform

smallest & numerousfungiform

tip & marginsvallate

8-12, in front of ?

foliate

linear folds, on the sides

near terminal sulcus


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Exam of lateral side of the


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Exam of lateral side of thetongue(Oral Cancer Screening)


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Soft Tissue of the mouth Throat

Tongue

Gingiva


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Labial mucosa:I nside of the lip Buccal mucosa: Inside of the cheek

Hard Palate: Firm area of the roof of the mouth

Soft Palate: The soft area of the palate


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Linea alba The linea alba isusually presentbilaterally.

It is restricted to

dentulous areas. It presents an

asymptomatic, linearelevation, with awhitish colour, at thelevel of the occlusalline of the teeth.

l


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Oral Exam

a proper oral exam from your dentist (DDS or DMD) iswarranted at least yearly and should be performed when yourteeth are cleaned during routine visits - the dentist orhygienist should be visually and physically evaluating thetongue's dorsal (top), ventral (bottom), and lateral (side)surfaces through palpations and observations.

A "larger tongue" is termed hyperglossia and the "corrugated"sides of the tongue are termed scalloped tongue, wherethere are indeed what appears to be indents from theadjacent teeth on the lateral borders of the tongue. Both ofthese are common variations of normal that are seen quitefrequently and usually appear together.

Other things that could cause hyperglossia besides beingcongenital (from birth) or medication-induced would be adietary/nutrient insufficiency. Do not hesitate to contact yourdentist or physician, both would be happy to give you anymore information.


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MorsciatioBuccarum

Morsciatio(labiorum)

Morsciatio (linguarum),

Morsciatio labium


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Intraoral:PA,BW,Occlusal Extraoral:Panoramic,Posterior

anterior,cephalometry


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Documenting Periodontal and

periapical disease

Tooth orientation

Root shapes


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X ray

Detects interproximalcaries in both arches

simultaneously Level of crestal bone

Intermediatescreening tools before

taking PA.


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Upper Occlusal

Detecting Palatallesions

Reveal impacted orextra teeth

Document expansionof mandible

Salivary stones in theduct of submandibularduct

Lower occlusal


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Maxillary Occlusal

x ray


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Mandibular Occlusal X ray


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Cover both Jaws Detect developmental abnormalities

Pathological lesion of teeth and bones

Evaluation of edentulous pt before prostheses

Third molar position

Less valuable diagnostic evaluation due to lowerresolution and superimposition of the structures


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Soft tissue Palpation Alveolar hard tissue palpation


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Indicates infalmmation in the periodontalligament.

Cause: could beTrauma,Occlusalprematurities,periodontal disease,extension of

pulpal disease to PDL. Discriminates the affected tooth from its

neighbors, due to the proprioceptive nervereceptors


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Prelude(inform Patient) for the test for moreaccurate results.

The test should be repeated to make sure itsreproducible

This test reflects an advance stage of pulp disease.

It doesnt reflect the tooth vitality


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Simple & reliable methods to indentify individualtooth when group of teeth are involved

Abrupt pressure to the periapical area

Increased intensity of discomfort indicates

inflammation is present Light tap is adequate

Tap normal and suspected teeth

Ankylosed teeth produce different sound than

normalteeth(Trauma,deciduous,ortho,inflammation,reimplantation)


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This test detects the inflammation in the PDL,which results in pain, and the tooth is then calledtender to percussion (TTP)

TTP could be the result of

Toxins from a necrotic pulp reaching PDL

Trauma

Periodontal abscess


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It s an indication of acompromisedperiodontalattachment when

+1>mm . Its a relative exam

Trauma Occlusal trauma

Parafunctional habits

Periodontitis

Root fracture

Rapid orthodonticmovement

PDL Infection ofpulpal origin


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Pulp vitality is defined by the retention of blood supply. Thisshould be differentiated from sensibility Thermal tests Cold test Heat tests

Electric pulp tests Selective anesthesia Test cavity Pulse oximeter Laser doppler flowmetry

Other signs of vitality Color Sinus tract


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Test the suspected tooth Similar tooth controls should be used

Replicate patients symptoms


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To detects incipient cracks Test involved tooth in centric and lateral

occlusion.


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Patients who complain from pain during masticationmay be actually suffering from the wedging force Cracked tooth syndrome Patients usually complain of sharp sporadic pain

while chewing, along with occasional pain from cold

food or drink. Sometimes the patient may indicatethat the pain occurs minutes after chewing or uponreleasing from clenching

Wedging is a test where the patient is asked to bite ona Tooth Slooth on successive cusps until the offending

cusp is located Staining is done by the application of methylene blueor erythrosine dye (cottonwood stick or IRM)


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Flurorescence procedures are based

on illustrating certain fluorescencesubstances like porphyrins, whichgrow in bacterial populated areas.When the area is stimulated withlight of a certain wavelength, themolecules absorb the light energyand release part of the light energywith a different wavelength.


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Treat with Confidence Laser Fluorescence technology

Small lesions can be detected reliably withoutexposure to ionizing radiation

No damage to enamel by sharp-edged probes

Optional Perio-Probe detects calculusconcrements 9mm in periodontal pockets


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DIAGNOdent uses laser technology to detect and quantify hidden orsub-surface caries by measuring laser fluorescence within the toothstructure.

The device operates at a wavelength of 655 nm. At this specificwavelength, clean healthy tooth structure exhibits little or nofluorescence, resulting in very low scale readings on the display.

Altered tooth substances and bacteria, including caries, willfluoresce.

The DIAGNOdent will react with elevated scale readings on thedisplay.

An audio tone allows the operator to hear changes in the scale values.This enables the user to focus on the patient not solely on the

device. The DIAGNOdent is an extremely accurate, reliable and non-

invasive method to aid in caries detection. The device has beensuccessfully used by more than 20,000 dental professionals in theUnited States and is integrated into the curriculum by a growingnumber of dental schools.


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Generally, conventional handinstruments may not be used to probe

within drop-shaped fissures.


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The DIAGNOdent pen offers the

advantage of measuring fluorescencedeep within the fissure pattern, sinceLASER light easily penetrates the enameland is reflected by even the smallestlesion. Measurement is indicated withan acoustic signal and numerical value.


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ionic change across the neural membrane, The circuit is completed via the patient wearing

a lip clip or by touching the probe handle withhis/her hand

individual age, pain perception, tooth surfaceconduction, and resistance

Tip of EPT placed labially within the incisal orocclusal two-thirds of the crown gave moreconsistent results .


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False positive Patient anxiety Saliva conducting the

stimulus to the gingiva Metallic restorations

conducting the stimulus tothe adjacent teeth Liqueficative necrosis

conducting the stimulus tothe attachment apparatus

False negative Premedication with drugs

or alcohol Immature teeth Trauma

Poor contact with the tooth Inadequate media Partial necrosis with vital

pulp remaining in theapical portion of the root

Individual patients withatrophied pulps or highpain thresholds


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unreliable in many instances, producing falseresults in healthy immature teeth . Newly eruptedteeth may take five years before the maximumnumber of myelinated fibres reaches the pulp-dentine border at the plexus of Rashkow. This isalso when apical root maturation occurs

Teeth with pulp canal calcification (PCC) andpatients suffering from primary hyperthyroidismfrequently have an increased sensory response

threshold to EPT. False response healthy pulps undergoing

orthodontic treatment


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Also traumatized teeth when two adjacent teeth have contacting

proximal metallic restorations

Periodontal tissues, breakdown products from

pulps undergoing necrosis, and remnants ofinflamed pulp tissues

Cause false response


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is a last resort in a toothwhere no other meanscan ascertain the pulpstatus .

Cutting into dentine

using a high or low speedbur without localanesthetic

nonetheless consideredinvasive andirreversible,and wouldbe rejected byapprehensive patients


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Mixed responses to vitality tests indicate falsenegative or false positive results

A test cavity is done in a concealed area of thetooth, without anesthesia, where the patient fully

understands the test and knows what to expect Crowned teeth


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This technique has been used to detect vascularintegrity in the tooth.

Relates the absorption of light by a solute to itsconcentration and optical properties at a given lightwavelength. It also depends on the absorbance

characteristics of hemoglobin in the red and infra-redrange. the red region, oxyhemoglobin absorbs lesslight than deoxyhemoglobin and vice versa in theinfrared region].

Oxygenated hemoglobin and deoxygenatedhemoglobin are different in color and thereforeabsorb different amounts of red and infrared light.


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(a) LED-emitting redlight at 660 nm. (b) LEDemitting infrared light at940 nm. (c)Photodetector. (d) Pulseoximeter monitor. (e)

Pulse oximeter sensor.(f) Custom-made pulseoximeter sensor holder.HbO2, oxygenatedhemoglobin; HbR,

deoxygenatedhemoglobin; SpO2,oxygen saturation ofarterial blood


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1.Effective and objective method of evaluating dentalpulp vitality.

2.Useful in cases of impact injury where the blood

supply remains intact but the nerve supply isdamaged. 3.Pulpal circulation can be detected independent of

gingival circulation. 4.Pulp pulse readings are reproducible.

5.Smaller and cheaper commercial oximeters are nowavailable for routine clinical use in an average dentaloffice


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1.Background absorption associated with venousblood and tissue constituents is notdifferentiated.

2.Probes should be specific for the anatomy of a

tooth as the oxygen saturation values from theteeth routinely register lower than the readingsfrom the patient's finger.


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(LDF) is a noninvasive, painless, electro opticaltechnique, which It measures blood flow even inthe very small blood vessels of themicrovasculature.

estimates the velocity of red blood cells incapillaries


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Red light is emitted from a light source; if thelight beam is scattered-off of stationary tissue orcells, there is no shift in the light spectrum. If,however, the light hits a moving cell in a blood

vessel there is a shift in the light spectrum of thescattered light according to the Dopplerflowmetry


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Accurate Reliable

Reproducible

Non painful

Luxation injuries

Useful in young children whose responses areunreliable and its noninvasive nature helps to

promote patient cooperation and acceptance


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Too expensive The sensor should be maintained motionless and in

constant contact with the tooth for accurate readings.

The laser beam must interact with the moving cells withinthe pulpal vasculature It is generally agreed that LDF assessment for human teeth

should be performed at 4 weeks following the initialtrauma and repeated at regular intervals until 3 months.

Blood pigments within a discolored tooth crown can also

interfere with laser light transmission. Care must be takento ensure that the false positive results are not obtainedfrom the stimulation of supporting tissues.


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Cold Test Hot test


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Simple ,does not need armamentarium, exceptrubber dam to avoid + response

Can be used on Crowned teeth

Has 86%accuracy ,compared with,81%Electric pulp

test,71%heat test. Vital teeth respond quickly, wherase false

postive reading respond more slowly


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Ice Frozen Carbon Dioxide (CO2 )

Refrigerant Spray: tetrafluoroethane which haszero ozone depletion potential

The last two methods are superior to other coldtest


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Utilizes a strong light source which identifiescolour changes that may indicate pulp pathosisand caries.


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It can help to identify cracks in teeth. Limited result in teeth with large restoration


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Detects endodontically involved teeth Should be conducted buccally, labially , and

lingually , palatally.

Reveal s fistulas and swelling


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Used when other test are inconclusive When pain is referred

Start at posterior teeth toward the anterior

PDL injection applied

Mobility test


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y

Handles of mirrors

Other Vitality Test


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y

Color Non-vital teeth may become darker

and less translucent Sinus tract Its presence is a strong evidence of

having a necrotic pulp in a nearbytooth

It usually discharges close to theapex of the offending tooth

Insertion of a gutta percha cone intothe sinus and exposing a radiographtraces the sinus to its origin

Sinus Tract


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Satining


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g

Staining is done by the applicationof methylene blue or erythrosinedye (cottonwood stick or IRM


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Ability of the test to identify diseased tooth 83%Cold test,86% heat test,72% EPT


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The ability of the test to identify healthy tooth 93% cold and EPT

41% heat test


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Periodontal charting: plaque index Probing depth bleeding points

gingival level tooth mobility

charting caries &existingrestorations


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existingrestorations

Palmer 8-1 1-88-1 1-8Letter code UR1-8 UL1-8

LR1-8 LL1-8FDI 1(1-8) 2(1-8)

4(1-8) 3(1-8)Universal 1 16

32 17


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FDI World Dental Federation notation(International System)


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Universal Numbering Systemfor Permanent Dentition Phase

Universal Numbering System

for Primary Dentition Phase


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Contract between Patient & Dentist


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The Art and Science of Operative Dentistry Clifford & John Sturdevant

Oxford Handbook of clinical dentistry

Pickard,s Manual of Operative Dentistry


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20 of July 40 /100

All previous lectures are required

Thank You for Your Attention

Documents

History,Exam,Special Tests16