CHAPTER 1: ART & SCIENCE OF DATA GATHERING

clinical dentistry aims to:

prevent disease

relieve suffering

cure disease

general appraisal

clinicians usually perform only a limited overall physical examination

with careful observation and findings from the health history, the dentist can detect many signs of systemic diseases that could have treatment implications and may suggest referral to a physician

limited overall physical examination

vital signs

exposed skin surfaces

patient posture and gait

cognition and mental acuity

speech and ability to communicate

posture & gait

can affect a patient’s ability to perform adequate oral hygiene

look out for osteoarthritis or have a neurologic problem (Parkinson’s disease or the effects of a stroke)

gait

person’s manner of walking

Posture

the position in which someone holds their body when standing or sitting

cognition

the mental action or process of acquiring knowledge and understanding through thought, experience, and
the senses

mental acuity

intelligence, a person's ability to reason, focus, and recall information at optimum speeds

accurate diagnosis = art + science

science → gathering and analyzing data

art → interpreting data through patient dialogue and observation

purpose of diagnosis

guides proper treatment plan

determine why the problem exists

determine what problem the patient has

5 stages of diagnosis

patient explains why they are seeking advice (chief complaint)

clinician questions the patient about symptoms and history

clinician performs objective clinical tests

correlate subjective (patient) + objective (tests) findings → differential diagnosis

formulate a definitive diagnosis

accurate diagnosis requires:

asking relevant questions

careful listening

clinical tests and interpretation

chief complaint

patient’s statement = important clues for diagnosis

always document patient’s words and chronology of events

patient completes a registration with medical & dental history

sometimes complaints are secondary to:

medical conditions

previous dental treatment

advice from another clinician

medical history

clinician must review every patient’s medical history

update if:

• first visit

• not seen >1 year

• changes in health or medications

Vital Signs

Record BP, pulse, temperature each visit

Indicators: Anxiety, hypertension, infection

Patient may see their dentists twice a year and their physician only once.

It is prudent to take a baseline reading at the patient’s first visit and monitor their vital signs every succeeding visit.

Upon finding any marked changes, inform the patient and refer them to the appropriate health provider if necessary

important considerations

drug allergies, organ transplants, artificial joints

medications interacting with local anesthetics, analgesics, antibiotics

Medical Conditions That Modify Dental Care

pulmonary: COPD, asthma, TB

GI / renal: ESRD, dialysis, hepatitis, liver disease, ulcers, IBD

cardiovascular: Endocarditis risk, heart murmurs, hypertension, arrhythmias, CHF

hematologic / metabolic: Diabetes, adrenal insufficiency, anemia, leukemia, pregnancy

neurologic / psychiatric: Stroke, seizures, anxiety, depression, drug/alcohol abuse, MS, Parkinson’s

medications may cause

stomatitis

petechiae

xerostomia

lichenoid lesions

TB

→ lymph node enlargement

diabetes

→ recurrent abscess

anemia

oral paresthesia

sickle cell anemia

→ bone pain mimicking toothache

dental history

records chronology of events leading to chief complaint

documentation often uses S.O.A.P. format (subjective, objective, appraisal, plan)

includes:

• past & present symptoms

• trauma or procedures related to complaint

5 key directions of questioning

localization → Which tooth is affected?

intensity → Pain scale 1–10; affects treatment urgency

duration → short-lived vs prolonged symptoms → affects treatment choice

provocation/relief → Triggers (cold, heat, chewing), relief (medication, cold water)

commencement → When did symptoms start? (spontaneous, post-trauma, post-dental treatment)

extraoral examination

lymph nodes (tender & firm → likely infection)

palpation (detect firmness, fluctuation, localization)

in general, move cephalocaudally or “head to toe”

observe as patient enters (facial asymmetry, swelling, physical limitations)

swelling in nasolabial fold or upper lip

maxillary canine

swelling in buccal space

upper premolars and molars

lower premolars and first molars

submental or submandibular space

mandibular incisors

intraoral examination

soft tissue (gingiva, mucosa, ulcers, lesions)

swelling (firm vs fluctuant, location indicates tooth/root involved)

sinus tracts (path from infection to gingiva/skin → trace with gutta-percha)

Palpation

Detect soft tissue swelling or bony expansion

Compare with adjacent/contralateral teeth

Ask patient about sensitivity

percussion

detect inflammation in periodontal ligament (symptomatic apical periodontitis)

procedure:

• tell patient what to expect

• start with contralateral/control teeth

• percuss occlusal → buccal → lingual

• repeat to ensure reproducibility

mobility

method: mirror handles on buccal & lingual

indicates compromised periodontal attachment, not pulp vitality

causes of mobility

trauma

pulp infection

occlusal forces

periodontal disease

recording mobility:

+1 → slight movement

+2 → <1 mm horizontal movement

+3 → >1 mm horizontal, possible rotation or vertical

periodontal examination

step probe around tooth in 1-mm increments

furcation involvement: document as class I–III

measure pocket depth (gingival margin → attachment)

isolated vertical bone loss → may indicate endodontic etiology

pulp tests

determine responsiveness of pulpal sensory neurons

methods → thermal (cold/heat), electric, blood flow devices

• clinical tests = indirect

• histology = only definitive method

thermal testing

heat:

• for hot-sensitivity pain → isolate teeth, apply heated water/gutta- percha

cold:

• primary method → use CO2 sticks, ice, or skin refrigerant

in multirooted teeth → some roots may be vital while others are necrotic

normal

sensation felt, disappears immediately

abnormal

no response

lingering pain or immediate sharp pain

lymph nodes

mobile and non-tender in the head and neck area

should be palpated gently to look for tenderness or enlargements

interpretations:

• abnormal → generally larger, fixed, tender

• normal → either not palpable or it can feel like a small pea

• tenderness generally → inflammation or drainage of infection

critical factors in assessing a mass or swelling

mobility

tenderness

consistency

size (solitary or multiple)

duration of enlargement

location (unilateral → represent pathology, bilateral → rarely)

key points for diagnosis and treatment

verify that the problem is of dental origin.

determine if pulpal tissues are pathologically involved

identify cause of pulp disease (caries, trauma, restoration)

decide on the appropriate treatment

diagnosis is based on testing, questioning, and reasoning, not just radiographs or symptoms.

tongue depressor

used for examining the throat and gauze is used to hold the tongue for examination.

areas of the tongue to inspect:

dorsal surface → from tip to circumvallate papillae and lingual tonsils, palpate for irregularities.

lateral aspects → requires careful retraction with 2×2 gauze. High incidence of oral malignancy here.

ventral surface → check lingual frenum, submandibular salivary ducts, and typical varicosities.

areas to inspect:

uvula

tonsils

pharynx

soft palate

anterior and posterior pillars

pharyngeal & soft palate examination

with mouth open, ask the patient to say “ah” or yawn

use a tongue blade or mouth mirror to gently depress the mid-tongue for visualization

avoid pressing too far back to prevent gagging

note color, symmetry, swelling, exudates, ulcerations, or tonsillar enlargement

palpate suspicious areas for induration or tenderness

be aware that tonsils have crypts where whitish spots of normal exfoliating epithelium may appear.

record all findings

hard palate examination

inspect and palpate digitally, moving from one side to the other.

do not palpate the soft palate to avoid gagging or vomiting.

• note:

  • color and surface texture

  • consistency

  • swellings, nodes, or lesions

  • patient-reported pain or tenderne

general dental examination

midline shifts → Is the dental midline aligned with the facial midline?

wear patterns → Look for excessive attrition (wear), erosion, or abrasion

marginal ridges and occlusal plane → Are teeth even? Any teeth extruded (too high) or intruded (too low)?

tooth migration → Have teeth moved mesially (forward) or distally (backward) into edentulous spaces?

Occlusal Examination

Maximum intercuspal position (MIP):

• Instruct patient to bite fully.

• Evaluate overbite (vertical overlap) and overjet (horizontal overlap) in the anterior region.

Angle Classification:

• Examine canine relationship (maxillary vs mandibular canines).

• Examine first molar relationship (maxillary vs mandibular first molars).

Functional movements:

• Ask the patient to move the mandible laterally (side to side) and protrusively/retrusively (forward and backward).

• Observe which teeth guide the occlusion in lateral and protrusive excursions.

Note any open bite or cross-bite.