CASE HISTORY ( Dr. JEENA SEBASTIAN)

Dr. Jeena Sebastian
Reader
Dept of Oral Medicine & Radiology
MINDS, MAHE

Doctors aim is patient management

• Personal information
• Taking & Recording the history
• Examination of the patient
• Provisional diagnosis
• Investigation
• Final diagnosis
• Treatment plan, medical risk assessment

Definition:
A case history can be considered to be a
planned professional conversation that enables
the patient to communicate his symptoms,
feelings and fears to the clinician so that nature
of the patients real or suspected illness and
mental attitudes may be determined.

Objectives:
1. To arrive at a Tentative diagnosis of patient’s chief
complaint
2. To determine any systemic factor that might affect the
formulation of diagnosis
3. To determine any systemic condition that requires
special precautions prior to or during dental procedures
to protect health and life of the patient
4. To obtain written records for documentation, future
reference, referral, research and medico-legal purposes
5. To avoid possible disease contact.

I. PERSONAL INFORMATION
II. CHIEF COMPLAINT:
III. HISTORY OF PRESENT ILLNESS:
IV. PAST DENTAL HISTORY:
V. PAST MEDICAL HISTORY
VI. FAMILY HISTORY:
VII.PERSONAL HISTORY:
VIII.GENERAL PHYSICAL
EXAMINATION
IX. EXTRA ORAL EXAMINATION
X. INTRAORAL EXAMINATION
XI. EXAMINATION OF ANY LOCALISED
LESION:
XII. CHAIRSIDE INVESTIGATIONS:
XIII. CASE ANALYSIS & PROVISIONAL
DIAGNOSIS:
IVX. DIFFERENTIAL DIAGNOSIS
VX. INVESTIGATIONS:
XVI. FINAL DIAGNOSIS
XVII. PHYSICIANS REFERRAL IF
REQUIRED
XVIII. TREATMENT PLAN
CASE HISTORY

 Name
 Age
 Sex
 Address
 Occupation

Name:
1. To recognize the patient
2. To develop rapport and healthy communication
between patient and the physician
3. Communication by means of name gives sense
of importance and acceptance
4. To maintain the records for future references.

Age:
Some diseases are more common in certain age groups
1. Congenital anomalies mostly present since birth. eg:
cleft lip, cleft palate.
2. Also certain diseases are peculiar to particular age. eg;
acute arthritis, acute osteomyelitis found mostly in
infants, sarcomas affect teenagers.
3. Determination of dental age and chronological age for
children in mixed dentition period and for orthodontic
treatment.
4. Determination of drug dosages for children below 12
yrs of age.
5. Determination of treatment modality, co- operation,
duration of procedure and healing process.

Cleft lip
Cleft palate
Ankyloglossia
At /since birth Cystic hygroma
Fordyce's granules
Predeciduous dentition
Erythroblastosis fetalis
Congenital Epulis of newborn
Hemangioma
Fibrosarcoma
Infancy Palatal cyst of newborn
Congenital heart disease
Melanotic ameloblastoma

- Rickets
- NOMA
- Eruption cyst
- Acute arthritis
Children -Acute osteomyelitis
- Nursing bottle caries
- Bacterial sialedenitis
- Juvenile periodontitis
- Juvenile hemangioma
- Papillion-lefevere syndrome

- Hick's disease
- Garre's disease
- Proximal carries
- Kaposis sarcoma
- Ewing's sarcoma
Teenagers - Reiters syndrome
- Hodgkin's disease
- Dentigerous cyst
- Nasoalveolar cyst
- Oral submucous fibrosis
- Infectious mononucleosis

-Asthma
-Attrition
-Abrasion
- Diabetes
- Leukemia
- Candidiasis
- Root caries
- Periodontitis
- Peptic ulcers
- Hypertension
Old age - Erythroplakia
- Lichen planus
- Sjogren's syndrome
-Trigeminal neuralgia
- Basal cell carcinoma
- Malignant melanoma
-Verrucous carcinoma
-Ameloblastic fibroma
- Pleomorphic adenoma
- Gingival cyst of adults
- Mucoepidermoid carcinoma

Sex:
Some diseases are more common in males and females. Eg:
Hemophilia in males.
Disease of thyroid in females.
Hormonal changes:
In females attaining of menarche and menopause.
Pregnancy:
Prescription of drugs: usage of certain drugs are
contraindicated in pregnancy
eg: tetracycline if used results in permanent yellow staining
of teeth.

X-ray investigation:
1. Contraindicated in pregnant woman because it causes
permanent damages to developing fetus.
2. X-ray investigation could be done using lead Aprons.
Timing of treatment procedures:
1. Any kind of dental treatment should not be attempted in
first trimester of pregnancy {organogenesis}
2. Long duration appointment should be avoided in third
trimester of pregnancy and patient should not be made
to sit in upright position {supine hypotensive syndrome}

Diseasesmorecommoninfemales Diseasesmorecommoninmales
Iron deficiency anemia - Pernicious anemia
Sicklecell anemia - Caries in deciduous teeth
Adenoameloblastoma -Attrition
Torus palatinus - Leukoplakia
Myasthenia gravis - Liposarcoma
Diseases of thyroid - Herpes simplex
Sjogren's syndrome - Osteoid fibroma
Malignant melanoma - Ewing's sarcoma
- Adenolymphoma
Pleomorphic adenoma - Reiter's syndrome
Cicatricial pemphigoid - Hodgkin's disease
Recurrent apthous stomatitis - Multiple myeloma
Central giant cell granuloma - Carcinoma- in- situ
Peripheral ossifying fibroma - Basal cell carcinoma
Central cementifying fibroma -Verrucous carcinoma
Peripheral cemental dysplasia - Benign osteoblastoma
Peripheral giant cell granuloma - Carcinoma of the buccal mucosa

Occupation:
1. To know about occupational diseases and educating regarding the
hazards of his disease.
2. To estimate socio economic status of patient.
3. To estimate emotional behavior of patient.
4. To give appointments according to occupation
5. For identification of risks associated with exposure to chemicals,
physical or biological agents particular to certain occupations
6. To identify groups whose general patterns of life vary because of
different demands made by their occupation
7. Occupational habits like holding of nails in the mouth, thread biting,
the pressure of reed and musical instruments [mouth piece] up on the
teeth have been found to conduce periodontal diseases.

Disease Occupation
Attrition -Workers who expose to abrasive dust
Abrasion - Carpenters, tailors
Erosions - Sand blasters
Hepatitis B - Dentists, surgeons & blood bank personnel
Tennis elbow -Tennis players / cricket players
Varicose veins - Bus conductors & traffic police
Carcinoma of lip - Persons who have to do out door work
Gingival staining - Patients work with Lead, bismuth
Respiratory disorders - Mine workers
Carcinoma of Scrotum - Chimney sweepers
Urinary bladder neoplasm - Aniline die workers

Address:
1. To communicate with the patient
2. To inform changes in appointment
3. To modify appointments to complete treatment
4. Fewer appointments to far distance patients
5. It decides - food habits, Oral changes, Socio
economic status. Provide a clue to desires and
expectations of patients

6. It indicates diseases endemic to particular area
Disease Geographic area
Peptic ulcers - North Western & South India
Kangri cancer - Kashmir
Cystic fibrosis -Children of U.K.
Kaposis Sarcoma - Central European countries
Gallbladder disease -West Bengal
Basal cell carcinoma -Queensland (Australia) -Arizona
(U.S.A)

Dental disease Geographic area
Dental caries - urban areas
Periodontal diseases - Rural areas
Carcinoma of tongue - Mumbai
Oral sub mucous fibrosis - South east countries
Fluorosis & mottled enamel - On the fluoride content of water
7. Geographical prevalence of dental
diseases
Dental fluorosis

Chief complaint:
1. The chief complaint is a symptom or symptoms
described by the patient in his own words relating to the
presence of an abnormal condition.
2. It is his expression of disease and should be limited to
single word, single phrase or single sentence.
3. The complaints of the patients are recorded in a
chronological order of their appearance.
4. It is necessary to determine the patient’s chief
complaint because it is his immediate and chief concern.

Common chief complaints
1. Decay
2. Pain
3. Swelling
4. Bad breath
5. Bad taste
6. Decreased water in the mouth
7. Loose teeth
8. Bleeding gums
9. Burning sensation
10. Irregularly arranged teeth
11. Food impaction
12. Discoloration of teeth
many
more……………………………………..

1. This history commences from the beginning of first
symptoms and extends to the time of examination.
2. It includes
- Mode of onset
- Changes at the site of complaint
- Duration of signs and symptoms
- Associated symptoms

How to record pain history ?
While recording pain history clinician must
include...
1. Site of pain
2. Duration of pain
3. Mode of onset of pain
4. Severity of pain
5. Nature of pain
6. Frequency of pain

7.Progression of pain
8.Factors which relieve the pain
9.Factors which aggravate the pain
10.Radiation of pain to other sites
11. Associated findings

1. Site of pain
- Patient usually point to the site of maximum intensity of
pain, which the clinician will record in specific terms.
2. Duration of pain
- The duration of pain will be known from the time of its
onset.
3. Mode of onset of pain
- History from the patient, whether pain began suddenly
or insidiously, is an important factor. This information
reveals the nature of the condition such as inflammatory
(acute / chronic) or non-inflammatory.

4. Severity of pain
- It is a known fact that individuals react differently to
pain. Objectives used by the patient in describing the
pain vary considerably.
- The severity of pain can be expressed in terms of mild,
moderate, severe and excruciating (acute painful)
5. Nature of pain
- Pain may be aching, stabbing (lancinating), burning,
throbbing, electric like.
- An acute abscess can produce throbbing pain

6. Frequency of pain
- whether pain is intermittent or continuous.
7. Progression of pain
- Pain may progress in variety of ways.
- It may begin suddenly at its maximum intensity
and remain at this level until it disappear Ex : Pain
of neuralgia.
- It may increase steadily until it reaches a peak or
conversely may begin at its peak and decline
slowly Ex : Pulpal pain of inflammatory origin.

8. Factors which relieve the pain
- Patients are usually aware of factors that relieve
pain.
- Eg: medications

9. Factors which exacerbate pain
- Patient usually knows anything that makes the pain
worse.
- Lying down also exacerbates acute pain of pulpal origin.
10. Radiation of pain to other sites
- Radiation of pain refers to its extension to another site
while the initial pain persists.
- Pain may appear in one site and then reappear in
another. In this case, both pains are caused by the same
condition. Ex; Headache due to sinusitis or impacted
3rd molars.

11. Course of pain:
- Has the pain changed since the beginning?
13. Associated findings:
- Are they any associated findings such as swelling, fever
etc. when pain occurs?

IV.PAST DENTAL HISTORY:
VI. FAMILY HISTORY:
VII.PERSONAL HISTORY:
EXAMINATION
LESION:
XIII. CASE ANALYSIS & PROVISIONAL
DIAGNOSIS:
VX. INVESTIGATIONS:
REQUIRED
CASE HISTORY

Dental history:
The following is a list of details that should be
investigated in the dental history
• Frequency of visits to dentist
• Nature of treatment procedures undergone. For
eg: oral prophylaxis, restorations, orthodontic
treatment
• Past experience during and following local
anesthesia
• Past periodontal surgery, orthodontic treatment
• Past dental appliance history, fixed bridges and
root canal fillings
• Past experience with surgical procedure: Any
prolonged bleeding, difficult extractions and
healing response.

Past Medical History:
This can be recorded briefly by asking the
following questions.
1. Are you seeing a family doctor for any illness now?
2. Are you taking medications for any health problems?
3. Duration of the illness and medication .
4. Are you allergic to any drugs, medicines, and food ?
5. Were you hospitalized during the last five years for any major
illness, operation, etc?
Dejong KJ(1997) as Medical risk-related history (MRRH).

Cardiovascular System
 H/o MI, stroke, hypertension
 Do you have breathlessness on exertion
like climbing stairs, walking fast, etc.
 Do you have pain on the left side of the
chest on exertion or emotional outburst?
 Did you have any operation of the
Chest?
 Do you get spontaneous dizziness,
palpitation with profuse sweating?
 Did you ever get a stroke
 Did you get sore throat, fever and
fleeting joint pains in recent past?
 Any other complaints.

Respiratory System:
Do you have asthma?
H/o allergy, pneumonia, COPD,etc
Do you have problems of wheezing?
Did you suffer from tuberculosis?
Did you have any sort of breathing problem in recent
times?
Any other (Specify)

Gastrointestinal and Hepatic:
 Do you have heart burn/acidity/ gastritis?
 Have you suffered from jaundice?
 Bouts of nausea, lack of appetite?
 Any liver disorders?
Analgesics – contraindicated in gastritis
patients/ prescribed with precautions

Endocrinal System
 h/o DM,Thyroid disorders, parathyroid disorders,
 Do you have excessive thirst, hunger?
 Do you have to urinate at night disturbing your
sleep
 Do you feel that you have developed
 black patches on the skin, in mouth?
 Have you gained or lost weight excessively in last
three months?
 You feel lethargic and drowsy recently?

Trauma
Did you meet with any major accident
in recent times?
Any sports injury to facial region.
Any other.

Bleeding Disorders:
Do you bleed easily on cutting yourself?
Are you taking any medication, which any
make you bleed more (Anticoagulants?)
Do you bruise easily, get pin-point
bleeding spots on skin or mouth?

VI. PERSONAL HISTORY
(A) Family History
1. Number of family members gives a clue about socio
economic status and nutritional status
2. Many diseases do occur in families such as
 Hemophilia
 Tuberculosis
 Rheumatic fever
 Enamel hypoplasia
 Cleft lip and cleft palate
 Undiagnosed diabetes mellitus

Social status
 Caries, arteriosclerosis heart disease, acute appendicitis
are more common in middle and high social status
individual.
 Periodontitis, tuberculosis, anemia due to
malnourishment is more common in low social status
individual.

Travel abroad
 Whether the patient has lived abroad and if so whether
he/she was ill there?
 Recent travel, e.g. patient may suffer from malaria if he
has recently traveled from or even through malaria
prone area.
Patient's appetite
 Whether it is regular or irregular?
 Type of diet-vegetarian, mixed, spicy food.

 In persons, having coarse diet there is mere evidence of
attrition.
 Increased carbohydrates lead to increased prevalence of
dental caries.
 Deficiency of calcium and phosphorus during period of
tooth formation results in enamel hypoplasia.
 Vitamin D can reduce the caries incidence. Fluoride
content can influence the caries process
Bowel and micturition habit
 Is it regular or irregular?
Sleep
Insomnia occurs in cases of primary thyrotoxicosis.

Menstrual history:
1. Oral contraceptives
2. Excessive bleeding during childbirth/ menstruation to
confirm hematological disorder.
Smoking:
Type, frequency, duration, reverse/ conventional
 Smoke can alter oral environment in many ways
 It causes brownish discoloration of teeth
 It predisposes to - Candida carriage, candidiasis,
leukoplakia, oral cancers, periodontal diseases etc.

Alcohol:
Increased risk of oral and pharyngeal cancer
Halitosis
It promotes carcinogenesis by
1. Dehydrating effect on the mucosa resulting in increased
permeability
2. Solubilize tobacco constituents
Other oral habits: Tongue thrusting and mouth breathing
habits, bruxism:

IV. PAST DENTAL HISTORY:
VI. FAMILY HISTORY:
VII. PERSONAL HISTORY:
EXAMINATION
LESION:
XIII. CASE ANALYSISPROVISIONAL
DIAGNOSIS:
VX. INVESTIGATIONS:
REQUIRED
CASE HISTORY

GENERAL PHYSICAL EXAMINATION
Objectives:-
 Protection of the patient
 Protect the dentist and auxiliary staff
 Suspecting certain systemic disease

Principles of clinical examination
1. Inspection:
Observation with an unaided eye and aids in systematic
visual assessment of patient under observation.
2. Palpation: It is an act of feeling by sense of touch.

3. Percussion:
It is the act of striking a portion of body with fingers
or an instrument to evaluate condition of underlying
structures by careful attention to sound or echo
produced.
: Inflammation of periodontal ligament
: Character and density of supporting tissues
: Muscle reflex

4. Auscultation:
Act of listening to the sounds produced within the
body
: Abnormal breathing
: Clicking and snapping sounds of TMJ
 Stethoscope is used to listen to sounds

1.BUILT:
Roughly assessed based on the muscle mass &
skeletal framework
 Asthenic –lean & underweight, low bone & muscle mass
 Sthenic –athletic in appearance
 Hypersthenic –thick muscular & heavy bone structures
 Pyknic-enormous amount of body fat compared to bone &
muscle mass
 Cachexia-abnormally low tissue mass resulting from
malnutrition & chronic debilitation

2.NOURISHMENT:
Presence & distribution of body fat & muscle bulk
: Poorly nourished
: Moderately nourished
: Well nourished
3.GAIT (MANNER OF WALKING):
Hemiplegic, Parkinsonian, Scissors, Foot drop etc

4.STATURE:
Relationship of arm length to body length. Trunk is
2/3rd the length of lower extremities.
Tall stature/giant
Hyperpituitarism
Marfan’s syndrome
Short stature/ Dwarf
Down’s syndrome
Hypopitutarism

5. POSTURE:
Kyphosis: Is an exaggerated anterior curvature of the spine
Lordosis: Is an exaggerated anterior curvatures of the lumbar spine
Scoliosis: Lateral curvature of spine.

VITAL SIGNS:
1.Temperature:
Normal body temperature- 36.6 0-37.20 C / 980-990F
Oral, Axilla, Rectal, Aural
Temperature Celsius (C) Farenheit (F)
Normal 36.6-37.2 98-99
Subnormal- <36.6 <98
Hypothermia <35 <95
Febrile >37.2 >99
Hyperpyrexia >41.6 >107

2. Pulse :
Heart rate, cardiac rhythm, cardiac output & peripheral
circulation
Sites: Radial artery, branchial artery, femoral artery, &
carotid artery.

3. Blood Pressure:
It is the lateral pressure exerted by the flowing blood on
the lateral walls of the blood vessels and is designated by
millimeter of mercury (mm of Hg).
Palpatory method
Auscultatory method

Systolic Blood
Pressure
(mm Hg)
Diastolic Blood
Pressure
(mm Hg)
Non hypertensive
Normal < 130 < 85
High normal 130–139 85–89
Hypertensive
Stage 1 140–149 90–99
Stage 2 160–179 100–109
Stage 3 ≥ 180 ≥ 110

4. Respiratory Rate:
It is the measure of one full inspiration &
expiration
• 14-18 cycles/minute
Normal
• > 20 cycles/minute
Tachypnea
• < 14 cycles/minute
Bradyapnea

Increased respiratory rate:
Exertion & excitement
Fever
Hypoxia
Acidosis
Anemia
Poisoning
Shock
Cerebral disturbances.
Decreased respiratory rate:
Narcotic poisoning
e.g.: opium
Brain tumor
Cerebral compression.

Pallor
Icterus
Cynosis
Clubbing
Lymphad
enopathy
Edema
piccle

Pallor:
Paleness of skin and mucous membrane
Causes: Hemorrhage, anemia, shock &
intense emotion.
Sites: Mucous membrane of lips, cheeks,
lower palpebral conjunctiva, nail beds,
palmer creases.

Icterus:
Yellowish discoloration of body tissues and fluids
Causes: Hepatic causes, hemolytic anemia etc
Sites: Sclera of the eye, nail bed, lobule of the ear, tip
of nose, under surface of tongue

Cyanosis:
Bluish discoloration of skin & mucous membrane as a
result of increased reduced hemoglobin level in the
blood of ≥5gm/dl.
• Due to reduction in oxygen saturation of
arterial blood
• Causes - cardiac & pulmonary diseases
• Sites: tongue, nail bed, tip of the nose, skin
of the palms & toes,
Central
• Due to poor perfusion of the peripheral
vessels.
• Causes- exposure to cold, venous
obstruction, heart failure
• Tongue is unaffected
Peripheral

Clubbing:
Bulbous enlargement of soft part of terminal phalange of the
nail.
Causes: Infective endocarditis, CHD, Emphysema, Lung
abscess, Bronchiectasis, Cohn’s Disease, Ulcerative colitis,
etc
Schamroth’s window test

Grades of clubbing
1. Softening of nail bed
2. Obliteration of angle
3. Parrot beak or drumstick or both
4. Hypertrophic pulmonary osteoarthropathy.

Lymphadenopathy:
Examination of lymph nodes should include:
•Site
•Size
•Shape
•Number
•Tenderness
•Consistency
•Mobility
Consistency of lymph nodes:
•Soft in consistency : Inflammatory
•Firm, discrete& shotty: Syphilis
•Elastic and rubbery : Hodgkin’s disease
•Stony hard : Carcinoma

Edema:
Accumulation of excess fluid within the
subcutaneous tissue
Causes: Soft tissue infection/inflammation,
acute allergy, severe septicemia,
venous & lymphatic obstruction

Skin:
Texture, Hydration, Pallor, Pigmentation, Cyanosis, Skin
eruptions etc
Hair:
Partial alopecia - Hereditary ectodermal dysplasia
Total alopecia – chemotherapy, radiotherapy
Hirsutism- Excessive growth of terminal hair in
females, abundant over chin and lip.

Nails:
Iron deficiency anemia – Brittle, flat, spoon shaped
nails (koilonychia)
Hypoalbunemia - Leukonychia
Extremities and joints :

Face: symmetry, expressions, facial skin, facial profile
Head: shape and size
Microcephaly (small head)
Dolichocephaly/Scaphocephaly – Long narrow face
Brachycephaly – Wide head
Oxycephaly/Turricephaly (pointed/tower skull)
Eyes: Hypertelorism, pallor, icterus, conjunctivitis,
Exophthalmos/ Enophthalmos
Nose: Epistaxis, nasal obstruction

Ear:
Swelling, position of the ears, external ear malformations,
ear discharge or bleeding, parotid gland pathology
Temporomandibular joint examination:
Inspection:
Swelling in preauricular region, deviation/ deflection , Path
of opening
Palpation:
Auscultation:
Lateral/ extra-auricular
Intra-auricular

Muscles Of Mastication:
Neck:
submandibular & sublingual glands, cervical lymph nodes,
mid line structures, and presence of any swellings.
Lymph nodes:
Site
Size
Number
Shape
Surface
Temperature
Tenderness
Consistency
Mobility

Salivary glands: swellings , surface changes etc
Lips: competent/ incompetent
Cranial nerve examination : sensory and motor

 Mouth opening: The maximum opening distance b/w the
incisal edges of upper & lower teeth are measured using a
boley gauge or ruler.
 Normal range: 35-55mm in adults.

Soft tissue examination:
Lips:
 The lips should be inspected & palpated for variations in
color, form, texture & obvious lesions.
 Palpation is carried out bidigitally to determine texture,
flexibility & firmness of underlying surface tissues.
Induration, hyperkeratosis & glandular involvement can be
determined by this procedure.

Labial & buccal mucosa:
 Inspection & palpation of labial surfaces of lip will show
varying degrees of nodularity associated with numerous
mucous glands which are situated in submucous tissue.
 In children, the superior labial frenum is attached to the crest
of alveolar process & forms a raphae that may reach to the
palatal papillae.
 In edentulous patients labial frenum attachment is normally on
the attached gingiva.

Normal variants
 Linea alba buccalis
 Fordyces spots/ granuls
 Leucoedema

Vestibule:
 The vestibule is inspected for any obliteration & palpated for any
tenderness.
Retro molar area:
 Soft tissue prominences present behind the distal molar of upper
& lower arches called retro molar papilla.
 The prominence caused by glands gives the tissue a pad like
appearance & has been called retro molar pad.
 Height of retro molar pad & mucosa covering the retro molar
pad are of importance.

Floor of the mouth:
 Close to the lingual frenum & on each side of it lies a small
round nodule called the sublingual caruncle. It contains openings
of submaxillary gland duct & often those of sublingual gland
duct.
 In the floor of the mouth, one has to observe for – sublingual
folds, sublingual caruncle, lingual frenulum’s position.

 Palpation is done bimanually :
 Lingual surface of the mandible for exostoses, areas of
tenderness, loss of firmness.
 Soft nodular tissue of sublingual glands & submaxillary
duct
 Firm muscles of floor of the mouth
 Contents of sublingual fossa & submaxillary fossa.
 Just posterior to mandibular molar, sometimes lingual nerve
can be palpated

Tongue:
 The tongue should be observed in its normal position & in an
extended position.
 The tip of the tongue is gently grasped with a gauze & pulled
out.
 The lateral border , dorsum can be inspected.
 Papilla is examined for atrophy or hypertrophy.
 Any fissuring or deviation must be noted.

Four types of lingual papillae are:
 Filiform papillae- dorsum of tongue.
 Foliate papillae- lateral borders.
 Circumvallate papillae- dorsal surface posteriorly (in front of
sulcus terminalis).
 Fungiform papillae- lateral surface & tip.

Gingiva:
Color: Coral pink in color.
Color depends on:
 Vascularity of mucosa
 Hb content of blood
 Amount of reduced Hb in blood.
 Density & attachment of connective tissue
 Width of epithelium
 Degree of keratinization
 Pigmentation of epithelium
 Presence or absence of inflammation (reddish pink in inflammation)

Surface: of attached gingiva & interdental papilla is generally
stippled
 Surface of free gingival margin & borders of papilla are
smooth.
 Texture of surface can be readily appreciated when gingiva is
dry.
 The surface stippling is analogus to surface of orange peel.
 It is prominent in young adults.

Position:
 The position of gingival margin on crowns of the teeth varies
with age & degree of eruption.
 Normally it is at the CEJ.
 The depth of the sulcus is normally 2-3mm.

Contour:
It is related to morphology of the crown of the tooth, the spacing of
teeth, the contour of roots of teeth, presence or absence of diseases.
 Normally it is scalloped & it is knife edge when it ends in the
interproximal space.
Consistency:
It is firm & resilient & tightly bound to alveolar process & teeth except
at the free gingival margin & the borders of interdental papilla.
 It is soft & boggy in inflamed gingiva.

Bleeding on probing:
Seen in stage 2 gingivitis.
 Probe is walked around the surface of teeth in gingival sulcus
& checked for bleeding on probing.
 It is a clinical sign of inflammation.
Periodontal pockets:
 Pathologically deepened gingival sulcus is called as pocket.
 Pocket depth is ascertained with a periodontal probe to
evaluate the depth correctly.
 Probe to be walked along the gingival sulcus

Hard & Soft palate:
 Mucous membranes of the palate is firmly attached to the
underlying bone & has some degree of keratinization.
 In the midline of the palate there is a narrow whitish streak
called palatine raphae.
 Radiating from incisive papilla & the anterior portion of
palatine raphae are palatine rugae.

 On each side of the raphae, at the junction of hard & soft palates,
2 small depressions are visible called palatine fovea, into which
palatine glands open.
 Bilateral elevation of soft palate occurs when the patient says
‘ahhh’.
 Palate is palpated & inspected for changes in color, density &
texture & variation in form.

Salivary gland duct orifices:
 Parotid gland duct orifice is palpated at the parotid papilla on the
buccal mucosa opposite to the crown of 2nd maxillary molar
teeth.
 Submandibular & sublingual gland orifices opens in the floor of
the mouth.

 Identification of teeth:
There are different tooth numbering systems available for
identification of teeth.
 Universal notation system:
For primary dentition :
A B C D E F G H I J
T S R Q P O N M L K
Right Left

 For permanent dentition:
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Left
Right

 Zigmondy Palmer system:
For primary dentition:
E D C B A A B C D E
E D C B A A B C D E
For permanent dentition
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Right Left
Right Left

 Federation Dentaire international (FDI) system:
For primary teeth
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
For permanent teeth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 43 41 31 32 33 34 35 36 37 38
Upper right Upper left
Lower right Lower left
Upper right Upper left
Lower right Lower left

 The total number of teeth present in dental arch must be
recorded. Variations in number of teeth are common.
 Anodontia- total lack of tooth development
 Hypodontia- lack of development of one or more teeth.
 Oligodontia- lack of development of 6 or more teeth.
 Hyperdontia- increased number of teeth.
 Supernumerary – additional teeth is termed as supernumerary
 Induced or false anodontia- result of extraction of teeth.
 Pseudoanodontia- multiple interrupted teeth

 Teeth missing in the arch is noted & the reason for it is also
noted.
 Teeth may be missing due to :
1. Congenital:
Most commonly missing teeth are 3rd molars & lateral
incisors.
2. Caries
3. Periodontal diseases
4. Orthodontic extractions
5. Trauma etc.

 Anomalies in size includes Microdontia & macrodontia.
 Microdontia- teeth are smaller than usual.
 Relative microdontia - normal size teeth, appears small when
it is present in the jaws that are larger than normal.
 Macrodontia- teeth are larger than usual size.
Also called as megalodontia or megadontia.
 Relative macrodontia- normal size teeth in a smaller jaw.

 Gemination- attempt of division of single tooth germ by
invagination, with resultant incomplete formation of two
teeth.
 Fusion- union of 2 normally separated tooth germs.
 Concrescence- actually a form of fusion which occurs after
root formation has been completed & the roots are united by
their cementum only.
 Dilaceration- angulation or a sharp bend or curve in the root or
crown of a formed tooth.

 Talons cusp- Anomalous structure projecting lingually from
the cingulum areas of maxillary or mandibular permanent
incisors.
 Dens in dente ( Dens invaginatus)- invagination in the surface
of tooth crown before calcification has occurred.
 Dens evaginatus- accesory cusp or a globule of enamel on the
occlusal surface between the buccal & lingual cusps of
premolars.

 Taurodontism- Bull like teeth in which the body of the tooth is
enlarged at the expense of the root.
 Hutchinsons teeth & mulberry molars seen in congenital
syphylis.
 Hereditary alterations of form include:
 Enamel hypoplasia
 Dentinogenesis imperfecta
 Amelogenesis immperfecta
 Dentin dysplasia

 Primary teeth- bluish white in color
 Permanent teeth- grayish yellow or yellow
 Discoloration of tooth may result from
1. Developmental disturbances
2. Intrinsic pigments
3. Extrinsic pigmentation

 Developmental disturbances result when the normal pattern
of enamel prisms & dentinal tubules is disturbed.
It is present in conditions like
 Amelogenesis imperfecta
 Dentinogenesis imperfecta
 Dental fluorosis– white opaque spots or brown discoloration.

 Intrinsic pigments may result from:
 Jaundice- yellow brown or orange yellow teeth
 Non vital teeth- appears dark grey
 Internally resorbed teeth- pink or black discoloration
 Introduction of medicaments into root canals & pulp chamber
during endodontic treatment.
 Metallic staining due to ingesting or inhaling of metals or
their salts. (eg- in copper, brass or bronze particles)

 Extrinsic pigments may result from:
 Green or red orange– caused by chromogenic bacteria
 Staining due to tobacco.

Attrition:
 Physiologic wearing away of tooth as a result of tooth to tooth
contact as in mastication.
 Flattening of occlusal & incisal surfaces are seen.
 Clinically wear facets will be seen.

Abrasion:
 Pathologic wearing away of tooth material through abnormal
mechanical process.
 Seen as V shaped or wedged shaped ditches at the cervical
margin, caused mostly due to faulty tooth brushing habits.

Erosion:
 Loss of tooth material by chemical process.
 Seen on labial or buccal surface of the teeth.
 Can be seen in
 Persons often consuming carbonated beverages.
 Patients with GERD.
 Persons who constantly vomit.

 Presence of supragingival or subgingival calculus must be
mentioned, grading the severity of the calculus.
 Calculus + indicates supragingival calculus present on the
cervical third of the crown.
 Calculus ++ indicates supragingival calculus extending upto
middle third of the crown
 Calculus +++ indicates supragingival calculus extending
upto incisal or occlusal third of the crown or a thick band of
supragingival calculus surrounding the neck of the tooth.

 For anterior teeth fractures, Ellis system of grading is used.
 For posterior teeth fracture, crown fracture in occlusal or
proximal area is noted.

Ellis grading of fractures:
 Class I- Simple fracture of crown involving enamel.
 Class II- Extensive fracture of crown involving enamel,
considerable dentin but not pulp.
 Class III- Extensive fracture of the crown involving
considerable dentin & exposing the pulp.
 Class IV- Non-vital tooth.

 Class V- Tooth lost as a result of trauma.
 Class VI- Fracture of root with or without loss of crown
structure.
 Class VII- Displacement of tooth without fracture of crown or
root.
 Class VIII- Fracture of crown en masse.
 Class IX- Traumatic injuries to deciduous teeth.

 The surfaces of the teeth must be examined for chalky white or
dark discoloration or cavitation.
 A catch felt during probing the surface indicates definitive
evidence of decay. A fine sharp explorer is used for this.

 Proximal evaluation of caries or overhanging restoration may be
done with a dental floss.
 Thin round unwaxed nylon floss is used. It should pass through
the contact area without being torn or shredded.
 Tearing or shredding- obstruction indicative of dental caries or
overhanging restoration.
 Teeth extensively decayed creates a clinical suspicion of pulpal
involvement. All such teeth must be percussed & any tenderness
present must be noted.

 Sometimes extensive carious lesions invade the crown
completely & no crown structure is clinically evident.
 Based on the clinical sites for caries initiation, caries may be
on:
1. Pit & fissures
2. Smooth enamel surfaces
3. Root surfaces.

 Generally local deposits & poor periodontal health cause mobility
of teeth.
 Trauma, traumatic occlusion poorly fabricated partial dentures
causing tooth mobility must be analysed.
 Mobility is checked with:
Ends of two slender mouth mirrors
Use of end of a mouth mirror or a probe & the clinicians finger.

 Class I – Tooth can be moved less than 1mm in a buccolingual
direction or mesiodistal direction.
 Class II – Tooth can be moved 1 mm or more in buccolingual or
mesiodistal direction but does not exhibit mobility in
occlusoapical direction.
 Class III – Tooth can be moved 1 mm or more in both
buccolingual or mesiodistal direction & occlusoapical direction.

Molar relation :
 Angles system of classification can be used when evaluating
molar relationship in permanent dentition.
 The normal molar relationship : Mesiobuccal cusp of
maxillary first permanent molar occludes in the buccal groove
of the mandibular first permanent molar.

Angles class I malocclusion:
 The mesiobuccal cusp of maxillary first permanent molar
occludes in the buccal groove of mandibular first permanent
molar along with dental irregularities such as crowding of
teeth, spacing b/w teeth, rotated teeth etc.

Angles class II malocclusion:
 The distobuccal cusp of maxillary first molar occludes in the
buccal groove of mandibular first permanent molar.
 Angles class II division I:
Class II molar relationship with a proclined maxillary
incisors with a resultant increase in overjet.
Short hypotonic upper lip & narrow upper arch is present.

 Angles Class II div 2:
Class II molar relationship with palatal inclination of
maxillary central incisors & labially tipped maxillary lateral
incisors over the maxilllary central incisors.
Deep anterior overbite is present.
 Angles class II subdivision:
Patient has class I molar relationship on one side & class II
molar relationship on the other side.

Angles class III malocclusion:
 The mesiobuccal cusp of maxillary first permanent molar
occludes in the interdental space between the mandibular 1st &
2nd molars.
 True class III malocclusion:
Skeletal relationship caused by an excessively large
mandible or smaller than normal maxilla or combination of
both.

 Pseudo Class III malocclusion:
Also called habitual or postural class III malocclusion.
Functional disturbance that cause this malocclusion due to
habitual forward positioning of the mandible.
 Class III sub division:
Presence of class I on one side & class III on the other side.

 Class I canine relation:
The mesial incline of the upper permanent canine overlaps
the distal incline of the lower canine.
 Class II canine relation:
The upper permanent canine is placed forward. The distal
incline of upper canine contacts the mesial incline of lower
canine.
 Class III canine relation:
The lower permanent canine is placed forward in relation to
upper canine & there is no overlap.

 The relationship b/w distal surfaces of maxillary & mandibular
2nd deciduous molar is evaluated.
 Flush terminal plane:
The distal surface of maxillary & mandibular 2nd deciduous
molar are in straight plane.
 Mesial step:
The distal step of the mandibular 2nd molar is more mesial
to that of the maxillary second molar.
 Distal step:
The distal surfaces of mandibular second molar is more
distal to the maxillary 2nd molar.

 Burket’s –Text book of Oral Medicine, 8th
Edition, 12th Edition
 SHAFER’S –TEXT BOOK OF ORAL
PATHOLOGY- 7th edition
 Ker Ash Millard –Oral diagnosis- 1st Edition
 Ravikiran Ongole -Clinical Manual -1st edition
 Steven L bricker Bricker – Oral Diagnosis, Oral
Medicine AndTreatment Planning - 2nd
edition

CASE HISTORY ( Dr. JEENA SEBASTIAN)

CASE HISTORY ( Dr. JEENA SEBASTIAN)

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