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DENTAL HISTORY TAKING AND EXAMINATION

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INTRODUCTION

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A. HISTORY TAKING

1. Presenting Complaint (PC)

• Recorded in the patient's own words (use quotation marks in written records)
• Should state the symptom, NOT a presumptive diagnosis
• e.g., "I have pain in my lower right jaw since 3 days"
• Avoid recording diagnoses like "caries" or "pulpitis" at this stage

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2. History of Presenting Complaint (HPC)

Key dental pain clues:

• Pain on cold = reversible pulpitis
• Pain on heat relieved by cold = irreversible pulpitis
• Continuous throbbing pain worsening at night = acute periapical abscess
• Sharp pain on biting = cracked tooth syndrome
• Pain relieved by eating = peptic ulcer (referred), or reversible pulpitis

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3. Past Dental History (PDH)

• Regularity of dental attendance (regular vs. irregular)
• Previous dental treatments: extractions, fillings, RCT, orthodontics, prosthetics
• Use of local anaesthesia or sedation - any adverse reactions
• Post-extraction haemorrhage (may indicate bleeding diathesis)
• Dental phobia or anxiety levels
• Previous trauma to teeth or jaws

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4. Past Medical History (PMH)

Mnemonic for PMH: MIDWIVES M - Medications, I - Infective endocarditis/Immunosuppression, D - Diabetes, W - Warfarin/bleeding, I - Investigations (recent), V - Valvular disease, E - Epilepsy, S - Steroids/Surgery

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5. Drug History

• All current medications (prescribed, OTC, herbal)
• Clinically important interactions:
  • Warfarin + metronidazole = increased bleeding risk
  • Phenytoin = gingival hyperplasia
  • Bisphosphonates = medication-related osteonecrosis of the jaw (MRONJ)
  • Amlodipine (CCBs) = gingival overgrowth
  • Aspirin + NSAIDs = bleeding risk
  • Steroids (long-term) = adrenal suppression, poor healing

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6. Allergies

• Must be asked and recorded in ALL patients, even if negative
• Specifically ask about:
  • Local anaesthetics (true allergy is rare; often vasovagal)
  • Penicillin/antibiotics
  • Latex (use latex-free gloves)
  • Aspirin/NSAIDs
  • Acrylic (for denture wearers)
• Allergies should be highlighted prominently in clinical records

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7. Family History (FH)

• Genetic conditions: amelogenesis imperfecta, dentinogenesis imperfecta
• Periodontal disease (familial aggressive periodontitis)
• Oral cancer (genetic predisposition)

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8. Social History (SH)

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B. CLINICAL EXAMINATION

General Principles

• Follow the "look, feel, move" principle
• Always proceed from extraoral → intraoral
• Examination should be systematic and bilateral
• Record both positive AND significant negative findings

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1. EXTRAORAL EXAMINATION

A. General Observation (as patient enters)

• General appearance, build, nutritional status
• Gait, speech, mental state
• Signs of systemic disease (pallor, jaundice, lymphadenopathy)
• Smell (e.g., fetor, alcohol)

B. Facial Examination

• Symmetry: note any asymmetry (swelling, atrophy, muscle hypertrophy)
• Skin: colour changes, lesions, scars, sinuses
• Lip competence: competent vs incompetent (relevant in orthodontics)
• Profile: orthognathic, prognathic, retrognathic

C. Temporomandibular Joint (TMJ)

• Palpation: place index fingers anterior to tragus of ear; ask patient to open/close
• Feel for: tenderness, clicking, crepitus, deviation on opening
• Range of movement: normal interincisal opening = 35-45 mm
• Lateral excursions and protrusion

D. Lymph Node Examination

1. Submental nodes
2. Submandibular nodes
3. Pre-auricular nodes
4. Post-auricular nodes
5. Parotid nodes
6. Anterior cervical chain
7. Posterior cervical chain
8. Supraclavicular nodes

Record: size, consistency, tenderness, fixity, mobility

E. Salivary Glands

• Palpate parotid, submandibular, sublingual glands
• Note: swelling, tenderness, discharge from duct orifices

F. Cranial Nerve Assessment (when relevant)

• Especially V (trigeminal) and VII (facial nerve) in trauma and oral pathology

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2. INTRAORAL EXAMINATION

A. Oral Hygiene Assessment

• Plaque levels: use plaque index (Silness and Loe)
• Calculus: supra and subgingival deposits
• Staining: extrinsic (tea, coffee, smoking) vs intrinsic

B. Soft Tissue Examination

For any lesion, describe: site, size, shape, colour, surface, border, consistency on palpation, tenderness, duration, history of change

C. Periodontal Examination

• Basic Periodontal Examination (BPE): screening tool using WHO probe
  • Code 0: healthy
  • Code 1: bleeding on probing
  • Code 2: calculus/overhangs
  • Code 3: pocket 4-5 mm
  • Code 4: pocket ≥ 6 mm
  • Code *: furcation involvement
• Record pocket depths, bleeding on probing, mobility, furcation involvement
• Mobility grading (Miller's classification): Grade I, II, III

D. Dental Examination (Charting)

• Use a standard dental chart (FDI two-digit notation is international standard)
• Examine each tooth for:
  • Caries: visual inspection, probe, transillumination
  • Restorations: integrity, secondary caries, marginal leakage
  • Fractures: crown fractures (Ellis classification), root fractures
  • Tooth wear: erosion, attrition, abrasion, abfraction
  • Colour changes: non-vital teeth (grey), tetracycline staining (banding), fluorosis
  • Vitality testing: cold test (ethyl chloride), heat test, electric pulp tester (EPT)
  • Percussion: vertical (periapical pathology) vs horizontal (periodontal pathology)
  • Mobility: grade I, II, III

E. Occlusal Examination

• Angle's classification of malocclusion (Class I, II, III)
• Overjet and overbite measurement
• Crossbite (anterior/posterior), open bite
• Crowding, spacing
• Path of closure: any premature contacts or displacements
• Evidence of bruxism/parafunctional habits

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C. SPECIAL INVESTIGATIONS

Radiographic Investigations

Laboratory Investigations

• Full blood count (FBC) - anaemia, infection
• Blood glucose - diabetes screening
• Clotting profile (PT, aPTT) - bleeding disorders
• Liver function tests (LFTs) - hepatic disease
• Biopsy (incisional/excisional) - for suspicious mucosal lesions
• Microbiological swabs - specific infections

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D. DIFFERENTIAL DIAGNOSIS AND TREATMENT PLAN

1. Formulate a provisional diagnosis with differentials (ranked by likelihood)
2. List appropriate investigations to confirm/exclude diagnoses
3. Once confirmed, create a phased treatment plan:
   • Phase 1 (Urgent): pain relief, infection control
   • Phase 2 (Disease control): caries removal, periodontal treatment, oral hygiene instruction
   • Phase 3 (Definitive): restorations, prosthetics, surgical procedures
   • Phase 4 (Maintenance): recall schedule, monitoring

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SUMMARY TABLE

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Key examiner points to remember:

• Always ask about allergies even if the answer is negative - document it
• Bisphosphonates and anticoagulants are common exam questions regarding pre-treatment considerations
• The lateral border of the tongue is the most common site for oral squamous cell carcinoma
• Percussion test is positive in periapical pathology; mobility test is positive in periodontal disease
• Vitality tests tell you if the pulp is alive - they do NOT diagnose the condition
• FDI two-digit notation: upper right = 1X, upper left = 2X, lower left = 3X, lower right = 4X

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DENTAL CHIEF COMPLAINTS WITH DIFFERENTIAL DIAGNOSES

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1. Pain (Toothache)
2. Swelling in the mouth/face
3. Bleeding from the gums
4. Oral ulcer
5. Mobile (loose) tooth
6. White/red patch in the mouth
7. Difficulty in opening mouth (Trismus)
8. Dry mouth (Xerostomia)
9. Bad breath (Halitosis)
10. Sensitivity of teeth
11. Broken/fractured tooth
12. Missing teeth / spacing
13. Swelling of salivary gland
14. Facial pain/headache of dental origin

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1. TOOTHACHE / DENTAL PAIN

Differential Diagnoses:

Examiner point: Reversible pulpitis = stimulus-dependent pain that stops quickly. Irreversible pulpitis = spontaneous/lingering pain. Periapical abscess = positive percussion test.

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2. FACIAL / ORAL SWELLING

Differential Diagnoses:

Key distinction: Cellulitis = diffuse, hard, NOT fluctuant. Abscess = localized, soft, FLUCTUANT. This difference guides incision & drainage.

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3. BLEEDING GUMS

Differential Diagnoses:

Red flag: Spontaneous, unprovoked gingival bleeding + pallor + lymphadenopathy = rule out leukaemia. Order FBC urgently.

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4. ORAL ULCER

Differential Diagnoses - "SNAILS" mnemonic:

Examiner rule of 2 weeks: Any ulcer lasting >2 weeks that does not heal = biopsy mandatory to rule out malignancy.

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5. MOBILE (LOOSE) TOOTH

Differential Diagnoses:

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6. WHITE PATCH IN MOUTH

Differential Diagnoses:

Key exam rule: If white patch CAN be wiped off = candidiasis. If CANNOT be wiped off = leukoplakia/other keratotic lesion.

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7. RED PATCH IN MOUTH

Differential Diagnoses:

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8. DIFFICULTY OPENING MOUTH (TRISMUS)

Differential Diagnoses:

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9. SWELLING OF SALIVARY GLAND

Differential Diagnoses:

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10. FACIAL PAIN (NON-DENTAL)

Differential Diagnoses:

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SUMMARY: "RED FLAG" SYMPTOMS TO NEVER MISS

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Theory exam tip: For every complaint, structure your answer as:

1. Definition
2. List of differential diagnoses (at least 5-6)
3. How to differentiate each (clinical features, investigations)
4. Final investigation to confirm (X-ray / biopsy / blood test)

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HoPI OF A LOOSE / MOBILE TOOTH

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DEFINITION

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PRESENTING COMPLAINT (PC)

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HISTORY OF PRESENTING ILLNESS (HoPI)

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1. ONSET

• When did the patient first notice the tooth was loose?
• Was the onset sudden or gradual?
  • Sudden onset → Think: trauma, acute dentoalveolar abscess, acute periapical infection
  • Gradual onset → Think: periodontal disease (most common), cyst, tumour

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2. DURATION

• How long has the tooth been loose?
  • Days → Acute infection, trauma
  • Weeks to months → Periodontal disease, cyst, neoplasm
  • Years → Chronic periodontitis, advanced bone loss

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3. NUMBER OF TEETH INVOLVED

• Is it a single tooth or multiple teeth?
  • Single tooth → Trauma, periapical abscess, root fracture, localized periodontitis, cyst, aggressive periodontitis
  • Multiple teeth → Generalized periodontitis, systemic disease (DM, leukaemia, histiocytosis), drugs (phenytoin gingival overgrowth)

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4. PROGRESSION

• Is the looseness staying the same, getting worse, or improving?
  • Progressive worsening → Periodontitis, malignancy, systemic disease
  • Sudden recent worsening → Secondary infection in an already periodontally compromised tooth

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5. ASSOCIATED SYMPTOMS

A. Pain

• Is there any pain around the loose tooth?
  • Pain on biting → Periapical pathology, root fracture, periodontal abscess
  • Dull aching pain → Chronic periodontitis
  • No pain → Chronic periodontitis (often painless until late), or physiological mobility in pregnancy

B. Bleeding from the Gums

• Does the patient notice bleeding while brushing, eating, or spontaneously?
  • Bleeding on brushing = gingivitis/periodontitis
  • Spontaneous bleeding = ANUG, leukaemia, bleeding disorder

C. Pus / Discharge

• Is there any pus or bad taste coming from around the tooth?
  • Pus from gingival sulcus = periodontal abscess
  • Pus from periapex = sinus tract from periapical abscess

D. Swelling

• Any swelling of the gum or face near the loose tooth?
  • Facial swelling = spreading infection (cellulitis)
  • Localized gum swelling = periodontal/periapical abscess, gingival cyst

E. Bad Taste / Halitosis

• Any bad breath or foul taste?
  • Positive = active infection, ANUG, deep pocketing with food impaction

F. Sensitivity

• Any sensitivity to hot, cold, or sweets?
  • Sensitivity present = vital tooth, possibly exposed root surfaces (recession)
  • No sensitivity = non-vital tooth (dead pulp)

G. Drifting / Migration of Tooth

• Has the patient noticed the tooth moving or drifting outward (flaring)?
  • Labial drifting of upper incisors = sign of advanced periodontal bone loss
  • "Fanning out" of teeth = severe periodontitis

H. Change in Bite

• Any difficulty in chewing or change in how the teeth meet (bite)?
  • Changed occlusion = tooth extrusion, drifting due to bone loss or abscess

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6. HISTORY OF TRAUMA

• Has the patient had any fall, blow, or injury to the face/mouth?
  • Direct blow → luxation injury, root fracture
  • Even old childhood trauma → Late root resorption, ankylosis

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7. PREVIOUS EPISODES

• Has this happened before? Was there a similar episode in the past?
• Did it resolve on its own or was treatment taken?
• Previous tooth extraction for the same reason?

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8. TREATMENT TAKEN

• Has the patient already taken any treatment for this problem?
  • Antibiotics (if yes - partial relief suggests infection)
  • Scaling/cleaning done previously?
  • Splinting or any stabilization?
• Any ongoing dental treatment?

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PAST DENTAL HISTORY (PDH) - Relevant Questions

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PAST MEDICAL HISTORY (PMH) - Systemic Causes of Mobile Teeth

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DRUG HISTORY - Relevant Medications

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SOCIAL HISTORY - Risk Factors

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FAMILY HISTORY

• Any family members with similar tooth loss at early age?
  • Suggests Aggressive (Localized/Generalized) Periodontitis - has strong familial/genetic component
  • Genetic conditions: Papillon-Lefèvre syndrome (palmoplantar keratoderma + severe periodontitis in children)
  • Chediak-Higashi syndrome, Leukocyte adhesion deficiency - all cause severe early periodontitis

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SUMMARY TABLE: HoPI of Loose Tooth

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GRADING OF TOOTH MOBILITY (for Examination section)

Grade III = extraction usually indicated (unless splinting for trauma)

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Theory exam writing tip: When asked "Write HoPI of loose tooth," always follow the structure: Onset → Duration → Number of teeth → Progression → Associated symptoms (pain, bleeding, pus, swelling, drifting) → Aggravating/relieving factors → Previous treatment → PMH (DM, leukaemia, drugs) → Social history (smoking) → Family history This covers all marks systematically and shows the examiner you think clinically.

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HoPI OF BLEEDING FROM GUMS (GINGIVAL BLEEDING)

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DEFINITION

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PRESENTING COMPLAINT (PC)

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HoPI - SYSTEMATIC APPROACH

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1. ONSET

• When was the bleeding first noticed?
• Was it sudden or gradual?

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2. DURATION

• Days → Acute: ANUG, trauma, acute leukaemia, drug reaction
• Weeks to months → Chronic gingivitis, periodontitis, pregnancy gingivitis
• Long-standing (years) → Chronic periodontitis, haemophilia (since childhood)

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3. NATURE / TYPE OF BLEEDING

A. Provoked vs. Spontaneous

B. Amount of Bleeding

C. Does the Bleeding Stop on Its Own?

• Yes, stops quickly → Local gingival cause (gingivitis, periodontitis)
• No, prolonged bleeding → Systemic cause: bleeding disorder, anticoagulants, liver disease
• Difficult to stop even with pressure → Haemophilia, thrombocytopenia

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4. SITE OF BLEEDING

• Localized (one area) → Local cause: plaque, calculus, sharp restoration, overhanging margin, food impaction, trauma
• Generalized (all areas of mouth) → Systemic cause: leukaemia, thrombocytopenia, scurvy, ANUG, generalised periodontitis

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5. ASSOCIATED SYMPTOMS

A. Pain in the Gums

B. Swelling of Gums

• Generalised swollen, red, oedematous gingiva → Gingivitis, leukaemia, drug-induced gingival overgrowth
• Localised swelling → Abscess, epulis, pyogenic granuloma

C. Ulceration

• Ulceration + bleeding + punched-out interdental papillae = ANUG (Vincent's infection)
• Grey pseudomembranous slough over gingiva = ANUG
• Gingival necrosis = ANUG or Noma (Cancrum oris) in malnourished children

D. Bad Breath (Halitosis)

• Fetor oris (extremely foul smell) = ANUG - pathognomonic
• Moderate halitosis = Periodontitis, food impaction

E. Loose Teeth

• Loose teeth + bleeding gums = advanced periodontitis OR leukaemia, histiocytosis

F. Metallic Taste

• Metallic/altered taste = ANUG

G. Fever / Malaise

• Fever + gingival bleeding = ANUG, acute leukaemia, viral infections (herpetic gingivostomatitis)

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6. AGGRAVATING FACTORS

• Brushing → Gingivitis/periodontitis
• Eating hard food → Inflamed, fragile gingiva
• Minor trauma → Bleeding disorders
• Stress → ANUG is strongly associated with psychological stress and sleep deprivation

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7. RELIEVING FACTORS

• Does it stop with direct pressure? → If yes = local cause; if no = systemic cause
• Any improvement after rinsing with salt water? → Mild gingivitis may improve
• Does it stop between brushings? → Gingivitis (stops; only bleeds on stimulation)

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8. PREVIOUS EPISODES

• Has this happened before?
• Any similar bleeding elsewhere in the body?
  • Bleeding from nose (epistaxis), joints, skin (bruising/petechiae), prolonged bleeding after cuts = suggests systemic bleeding disorder
  • Postoperative bleeding after surgery = haemophilia, platelet disorder

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9. TREATMENT TAKEN

• Any medicines taken (antibiotics, mouthwash, antiseptics)?
• Any previous scaling done? (Relief with scaling = plaque/calculus cause)
• Any change in oral hygiene practices?

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PAST MEDICAL HISTORY - Systemic Causes of Gingival Bleeding

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DRUG HISTORY - Drug Causes of Gingival Bleeding

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SOCIAL HISTORY

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FAMILY HISTORY

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IMPORTANT "RED FLAG" FEATURES IN HoPI

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SUMMARY TABLE: HoPI of Bleeding Gums

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Examiner Tip - How to distinguish Local vs Systemic cause:

Feature	Local Cause (Gingivitis/Periodontitis)	Systemic Cause
Bleeding type	Provoked (on brushing)	Spontaneous
Site	Localized or at gingival margin	Generalized, anywhere
Stops on pressure	Yes	No / prolonged
Other bleeds elsewhere	No	Yes (epistaxis, bruising, joints)
Gingival appearance	Red, swollen, plaque/calculus	May appear relatively normal despite bleeding
Response to scaling	Improves	No improvement

Always order FBC + platelet count + bleeding time + clotting time if systemic cause is suspected.