Ebook History taking and clinical examination in dentistry: Part 1

History Taking and
Clinical Examination in

DENTISTRY


History Taking and
Clinical Examination in

DENTISTRY
Charu M Marya

BDS MDS PhD

Professor and Head
Department of Public Health Dentistry
Sudha Rustagi College of Dental Sciences and Research
Faridabad, Haryana, India

Foreword
Rahul J Hegde

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History Taking and Clinical Examination in Dentistry
First Edition: 2014
ISBN 978-93-5152-393-2
Printed at


Dedication
I would like to thank my wife Dr Vandana for standing beside
me throughout my career and writing this book. She has

been my inspiration and motivation for continuing to
improve my knowledge and move my career forward.
She is my rock, and I dedicate this book to her.


Contributors
Anil Gupta

MDS

Professor and Head
Department of Pedodontics
SGT Dental College, Hospital and
Research Institute
Gurgaon, Haryana, India

Anirban Chatterjee

MDS PhD

Professor and Head
Department of Periodontology
and Implantology
Oxford Dental College
Bengaluru, Karnataka, India

Avinash J

MDS

Professor and Head
Department of Public Health
Dentistry
Kalinga Institute of Dental
Sciences
Bhubaneswar, Odisha, India

Bhumija Gupta

BDS AEGD GPR

Clinical Faculty
Eastman Institute for Oral Health
University of Rochester
Rochester, New York, USA

Gaurav Sharma

MDS

Reader
Department of Oral Medicine
and Radiology
Sudha Rustagi College of
Dental Sciences and Research
Faridabad, Haryana, India

Hind Pal Bhatia

MDS

Professor and Head
Department of Pedodontics
Manav Rachna Dental College
Faridabad, Haryana
India

Navin Anand Ingle

MDS

Professor and Head
Department of Public Health
Dentistry
KD Dental College and Hospital
Mathura, Uttar Pradesh
India

Pradeep Tangade

MDS

Professor and Head
Department of Public Health
Dentistry
Kothiwal Dental College and
Research Centre
Moradabad, Uttar Pradesh
India

Rajendra Gowda Patil

MDS

Professor and Head
Department of Oral Medicine
and Radiology
Kothiwal Dental College and
Research Centre
Moradabad, Uttar Pradesh
India


viii History Taking and Clinical Examination in Dentistry
SM Kotrashetti

MDS

Professor
Department of Oral and
Maxillofacial Surgery
KLE VK Institute of
Dental Sciences
Belgaum, Karnataka, India

Vandana Dahiya

MDS

Department of Conservative

Dentistry and Endodontics
Haryana Civil Medical Services
Faridabad, Haryana
India


Foreword
It gives me great pleasure to write a foreword for History Taking and
Clinical Examination in Dentistry. The approach adopted by the author
should be a great help to those taking history and doing examination
for diagnosis and treatment planning in dentistry. The idea of taking
symptom complexes and then describing the diagnostic possibilities
with guides to the management both of the disease itself and of the
symptoms will be valuable to all who have to deal with problems of
this sort.
I hope that it will be valuable to all those who have to deal with the
clinical differential diagnosis. It should be of particular use to teaching
faculty, undergraduate and postgraduate dental students and dental
practitioners. It is the sort of book that should be in the hands of
students of dentistry entering the clinics during their clinical postings.
Rahul J Hegde
(Executive Member, Dental Council of India)
Vice-Principal, Professor and Head
Department of Pediatric Dentistry
Bharati Vidyapeeth University Dental College
Navi Mumbai, Maharashtra, India
President, Indian Society of Pediatric Dentistry
Senate Member, Maharashtra University of Health Sciences

Preface
The most important core skills for dental students to master are
history taking and clinical examination. This book has been written
with the philosophy that the acquisition of clinical skills is most
effectively undertaken at the chairside. This book should be used as
a companion, to be taken in the clinics where the information is most
needed. The book begins with a system of history taking followed by
chapters covering clinical examination and diagnosis. Each stage of
the examination starts with a detailed step-by-step description of the
examination method complemented by relevant illustrations, diagrams
and tables. This book is intended primarily for use at the outset of
clinical training; once students have achieved proficiency in the basic
skills of interviewing and examining, the book should also prove useful
for revision.

This book was written keeping in mind the problems faced in clinics
by undergraduate and postgraduate students regarding history taking,
clinical examination, diagnosis and treatment planning as no book is
available in the market focusing specifically on these topics.
Charu M Marya


Acknowledgments
I would like to express my gratitude to many people who provided
support, read, wrote, offered comments, allowed me to quote their
remarks and assisted in the editing, proofreading and design.
I would like to thank my parents for allowing me to follow my
ambitions throughout my childhood. Ever indebted to my mother
for her encouragement and my father, my guide. My brother Dr Kirti
Mohan Marya for standing by me always and sister Dr Priya Nagpal for

her prayers. I also thank my wonderful children: Akshat and Dewang for
always making me smile. My family, including my in-laws, have always
supported me throughout my career and authoring this book and
I really appreciate it. I want to acknowledge my family’s contribution,
for putting up with my absences, both mental and physical.
Many persons generously gave their time in the preparation
of the first of its kind book History Taking and Clinical Examination
in Dentistry. I would like to convey my grateful thanks to all the
contributors for their cooperation and enthusiasm for the publication
of this book. In addition, special appreciation is to be mentioned for
Dr Ruchi Nagpal, Dr Sukhvinder, Dr Amit Rekhi who provided high
quality logistic and editing support during the preparation of this book.
My thanks also go to my colleagues at the Sudha Rustagi College
of Dental Sciences and Research, Faridabad (Haryana), who have given
encouragement and support at key times in the development of this
book and have contributed for creating a stimulating and congenial
environment for me to work.
I would like to thank Mr Dharamvir Gupta (Chairman), Mr Deepak
Gupta (Secretary), Prof (Dr) Indushekar (Principal) and Dr Vishal
Juneja (CEO), Sudha Rustagi College of Dental Sciences and Research,
Faridabad for their encouragement and support in this venture.


xiv History Taking and Clinical Examination in Dentistry
My due regards to Shri Jitendar P Vij (Group Chairman), Mr Ankit
Vij (Group President) and Mr Tarun Duneja (Director–Publishing) of
M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for
rendering help to come out with this publication in time. I am thankful
to Mrs Samina Khan (Executive Assistant to Director–Publishing), for
being so instrumental and helpful for this publication, and Mr Rajesh

Sharma (Production Coordinator) for extended profound support and
interest in this release.


Contents
1. Introduction

Risk Management  3
Confidentiality  4

1

2. Methods of Recording a Case History

7

3. General Information
Patient Registration Number 10
Date  10
Name  10
Age  11
Sex  14
Education  16
Address  16
Occupation  18
Religion  19

10

4. Chief Complaint

20

5. History of Present Illness

Detailed History of a Particular Symptom  23

22

6. Previous Dental History

61

7. Medical History

Relationship Between Systemic and Oral Health  64
Health History Forms  65
Determination of Medical Risk  71

64


xvi History Taking and Clinical Examination in Dentistry
8. Personal Dental History
Oral Habits  81
Thumb and Digit Sucking  82
Pacifier Habits  94
Tongue Thrust Habit  94
Mouth Breathing Habit  99
Bruxism  104

Other Minor Habits  106
Oral Hygiene Habits   107
Adverse Habits  107
Diet History  107
Diet-Diary  108

81

9. Clinical Examination

116

10. Extraoral Examination
Skin  137
Head  138
Face  138
Nose, Paranasal Sinuses, Nasal Mucosa and
  External Ear  143
Lips  143
Cheeks  145
Lymph Nodes  145
Temporomandibular Joint  153
Muscles of Mastication   156
Salivary Glands  158

137

11. Intraoral Examination
Soft Tissue Examination  165
Gingivitis  184

Chronic Periodontitis  184
Acute Periodontitis  185
Hard Tissue Examination  191
Arch Forms  192

165


Contents xvii

Alterations in Number of Teeth  200
Alterations in Size of Teeth  204
Alterations in Shape of Teeth  205
12. Establishing the Diagnosis

230

13.







232

Investigations
Conventional Radiographic Investigations  232
Histopathological Investigations  239

Pulp Vitality Testing  241
Hematological Investigations  242
Urine Analysis  250
Microbiological Investigations  250

14. Final Diagnosis

252

15. Formulating a Comprehensive Treatment Plan
Phase I: Emergency Phase  255
Phase II: Preventive Phase  255
Phase III: Promotive Phase  255
Phase IV: Curative Phase  256
Phase V: Rehabilitation Phase  256
Phase VI: Maintenance Phase  256
Treatment Planning in Dentistry  258

254

16. Levels of Prevention

278

ppendices280
A
Index
343

1

C H A P T E R

Introduction
“Accurate diagnosis of a disease depends on the art of taking
case history.”
Diagnosis is the art and science of recognizing the
presence and nature of disease by an evaluation of its various
distinctive signs, symptoms and characteristics. As modern
rational therapy is based upon the scientific interpretation
of the changes in structure and function of the body tissues,
the importance of an accurate diagnosis is at once evident.
There can be only one true diagnosis and the success of
treatment is dependent upon its establishment.
Professional, ethical and legal responsibilities dictate that
a complete chart and record documenting all the aspects of
each patient’s dental treatment must be maintained. Good
records facilitate the provision of effective dental care and
ensure the continuity and comprehensiveness of oral/dental
health services.
Case history is an important and integral part of treatment.

The principles of practice in dentistry
Responsibilities of a dental professional:
yy Putting patient’s interests first and acting to protect them
yy Respecting patient’s dignity and choices
yy Protecting the confidentiality of patient’s information
yy Co-operating with other members of the dental team and other
healthcare colleagues in the interest of patients

yy Maintaining your professional knowledge and competence
yy Being trustworthy


2 History Taking and Clinical Examination in Dentistry
Case history is defined as planned professional conversation
that enables a patient to communicate his/her feelings, fear
and sequence of events leading to the problem for which the
patient seeks professional assistance, to the clinician so that
patient’s real or suspected illness and mental attitude can be
determined. Ideally case history is taken in a consultation room
or a private office in which the surroundings and the conditions
are entirely friendly and not like the dental operating room.
In many occasions, a properly prepared case history alone is
sufficient to diagnose the disease without examining the patient.
Of all the important diagnostic tools, the art of listening
is the most underrated. Yet careful and attentive listening
establishes patient-dentist rapport, understanding and trust.
Eliciting accurate, detailed and unbiased information from a
patient is a skilled task and not simply a matter of recording
the patient’s responses to a checklist of questions. Avoid
interrupting patients, particularly as they begin to tell you the
story of the presenting features of the illness. Recognizing the
patient’s need to talk without interruption and being a good
listener will greatly help you establish a good relationship
quickly (Fig. 1.1).
A case history is of immense value in the following ways:
•• To provide information regarding etiology and establish
diagnosis of oral conditions.
•• To reveal any medical problem necessitating precautions,

modifications during appointments so as to ensure that
dental procedures do not harm the patient and also to
prevent emergency situations.
•• Evaluation of other possible undiagnosed problems.
•• Discovery of communicable diseases.
•• Gives an insight into emotional and psychological factors.
•• For effective treatment planning. It enables dentists to
obtain information necessary to provide appropriate and
individualized care.


Introduction 3

Fig. 1.1: Listen to the patient

•• Record maintenance for future reference and periodic

follow-up.
•• To prevent medical complications and thus minimize

detrimental effects to the patient and the possibility of
medico-legal complications for the dentist.

RISK MANAGEMENT
In recent years, the requirements for dental records
management have been redefined, especially as they relate to
documentation, release of information and storage. Dentists
are expected to be familiar with current expectations and to
ensure that their staff members understand and adhere to the
updated protocols.

4 History Taking and Clinical Examination in Dentistry
Patient records must be accurate, well-organized, legible,
readily accessible and understandable. If the dentist who
has taken the history and noted the record is not available
to treat the patient for any reason, another dentist should be
able to easily review the chart and carry on with the care of
the patient.

CONFIDENTIALITY
Patients have a right to expect that their dental health
information will be kept confidential.
•• Patients have a right (with a few exceptions) to review and
obtain a copy of their dental records including consultation
reports of other practitioners.
It is appropriate, where patient consent has been obtained,
to share dental and medical records with other health
professionals as necessary to ensure continuity and quality
of care.
•• Every dental team member involved in a patient’s care
should maintain the confidentiality and security of a
patient’s dental records, only sharing them with other
Purposes of records
yy A dental record should provide an accurate picture of the patient’s
general health, as well as oral/dental status and any patient concerns
and requests
yy It should include the proposed treatment plan and any treatment
performed, as well as all supporting documentation
yy Outcome of treatment should be documented and any deviations

from the expected outcomes should be recorded on the patient chart
at the time of service
yy Patients should be advised of compromised results as soon as the
dentist is aware of the situation
yy All the relevant information presented to the patient should be
documented


Introduction 5

healthcare professionals for the purpose of assisting in
providing optimal care.
•• Dental records should only be disposed of in a manner that
ensures the confidentiality of the information is maintained.
According to Dental Recordkeeping Guidelines (2010) by
College of Dental Surgeons of British Columbia (CDSBC):

Essentials of Recordkeeping
The extent of detail required for each record will vary; however,
certain baseline data should be common to all the dental
patients.
This information includes:
•• Accurate general patient information
•• A medical history that is periodically updated
•• A dental history
•• An accurate description of the conditions that are present
on initial examination, including an entry such as “within
normal limits” where appropriate
•• An accurate description of ongoing dental status at
subsequent appointments

•• A record of the significant findings of all the supporting
diagnostic aids, tests or referrals such as radiographs, study
models, reports from specialists
•• All clinical diagnoses and treatment options
•• A record that all reasonable treatment planning options were
discussed with the patient
•• The proposed and accepted treatment plan
•• A notation that informed consent was obtained
•• Assurance that patient consent was obtained for the release
of any and all patient information to a third party
•• A description of all treatment that was performed, materials
and drugs used and, where appropriate, the prognosis and
outcome of the treatment


6 History Taking and Clinical Examination in Dentistry
•• Details about referrals
•• An accurate financial record.

The barriers to obtain a complete medical history by
preprinted forms followed by appropriate in-depth questions
or by direct query of patients include (but are not limited to)
time constraints imposed by busy practices, the unwillingness
of patients to reveal aspects of their medical status, and the
impatience of the dentist while listening to the patients, as
well as a variety of religious and moral issues that may arise.


C H A P T E R

2

Methods of
Recording a Case History
Establishing a good rapport (Fig. 2.1) with the patient
is important for recording a complete history with valid
information. A sincere smile and being a good listener will help
reassure the patient that it is appropriate and safe to divulge
personal information.
The clinician’s manners and demeanor (including his or her
friendliness, empathy, openness and nonjudgmental attitude)
during this process often determine patient’s satisfaction
and compliance. The clinician’s ability to put patients at ease
will come into play during the initial medical interview. To

Fig. 2.1: Establishing a good rapport


8 History Taking and Clinical Examination in Dentistry
System for gathering information (techniques)
yy
yy
yy
yy
yy
yy
yy
yy
yy

Give the patient your undivided attention
Use language which the patient can understand
Let patients tell their problem in their own words
Steer patients toward the relevant
Use open questions initially and specific (closed) questions later
Clarify the meaning of any lay terms or diagnoses used by the patient
Remember that the history includes events up to the day of interview
Summarize (reflect back) the story for the patient to check
Utilize all available sources of information

facilitate this process, the clinician should exhibit an attentive
posture, maintain eye contact, make the patient understand
that the clinician understands the patient’s specific oral health
problem, and recognize the patient’s emotional disposition
toward dental care. The most effective history-taking technique
relies on establishing a dialogue between patient and clinician,
which should provide both with an opportunity to satisfy the
separate agendas each brings to the interview. Although the
clinician will have a scripted agenda, it is important that time
be given to the patient to tell his or her “story”.
Always introduce yourself to the patient and any
accompanying person, and explain, if it is not immediately
obvious, what your role is in helping them. Remember that
patients are (usually) neither medically nor dentally trained,
so use plain speech without speaking down to them. It is
important to adopt a professional appearance and manner,
and introduce oneself clearly and courteously. Factors such
as age, cultural background, understanding and intelligence
of the patient must also be taken into consideration always
while taking the history. It is the clinician’s responsibility to

elicit an accurate history; if that necessitates requirement of
an interpreter, then the clinician must arrange one.


Methods of Recording a Case History 9
The dental history will give an idea of the:
yy Regularity of attendance for dental care
yy Attitude to dental professionals and to treatment
yy Recent relevant dental problems
yy Recent restorative treatment

There is usually a traditional approach in the design of a
case history. The preliminary part of the case history is usually
based on questionnaires.
Sequence of case recording and evaluation:
•• General information
•• Chief complaint
•• History of present illness
•• Previous dental history
•• Medical history
•• Family history
•• Personal history
•• General physical examination
•• Extraoral examination
•• Intraoral examination
•• Provisional diagnosis
•• Investigations
•• Final diagnosis
•• Treatment plan.

C H A P T E R

3

General Information
It is recorded so as to impart knowledge to the investigator
regarding important events in human life, such as: births,
deaths, marriage and migrations. Also, it makes the investigator
familiar with the patient as it does contain personal details of
the patient such as name, age, etc.

PATIENT REGISTRATION NUMBER
It helps the investigator in:
•• Record maintenance
•• Billing purposes
•• Medico-legal aspects
•• Identification of the patient.

DATE
The date is recorded in full for the following purposes:
•• Reference
•• Record maintenance.

NAME
Full name of the patient should be recorded.
Knowing the complete name of the patient while recording
history leads to:
•• Identification
•• Communication

•• Establishing a rapport with the patient
•• Record maintenance


General Information 11
•• Psychological benefit; especially in case of pediatric patient,

if called by nickname
•• Sense of importance and acceptance to the patient
•• Information of patient such as gender and religion.

AGE
The exact date of birth should be written.
Age (date of birth) has a particular significance to the
investigator to decide upon the:
•• Diagnosis
•• Treatment planning
•• Behavior management techniques.
It is also used for maintaining hospital records and to know
the psychology/mental development of the patient which has
a role on his dietary habits, oral hygiene practices and personal
habits.

Diagnosis
Age has a direct bearing on the presence of morbidity and
mortality caused by the medical problems. Increasing age
typically increases a person’s tendency to develop medical
conditions, such as hypertension, heart disease, diabetes and
cancer.
There is a predilection of certain diseases at different age

levels. Based on the disease predilection of age, the patients
are divided into:
•• Newborn: 1 to 28 days
•• Infants: up to 12 months
•• Children: 1 to 10 years
•• Adolescents: 10 to 19 years
•• Young adults: 19 to 24 years
•• Adults: 25 to 60 years
•• Elderly: above 60 years.