6 PART I PLANNING AND PREPARATION
helpful to have the patient point at the area while the considerable influence in establishing a correct diag-
dentist pays close attention. nosis, prognosis, and treatment plan.
If swelling is present, the location, size, consis-
tency, and color are noted, as well as how long it has
Medical History
been felt and whether it is increasing or decreasing.
An accurate and current general medical history
Function should include any medication the patient is taking,
Difficulties in chewing may result from a local as well as all relevant medical conditions. If neces-
problem such as a fractured cusp or missing teeth; it sary, the patient’s physician or physicians can be
may also indicate a more generalized malocclusion contacted for clarification. The following classifica-
or dysfunction. tion may be helpful:
1. Conditions affecting the treatment methods (e.g.,
Social aspects any disorders that necessitate the use of antibiotic
A bad taste or smell often indicates compromised premedication, any use of steroids or anticoagu-
oral hygiene and periodontal disease. Often social lants, and any previous allergic responses to
pressures prompt the patient to seek care. medication or dental materials). Once these are
identified, treatment usually can be modified as
Appearance part of the comprehensive treatment plan,
Compromised appearance is a strong motivating although some factors may severely limit avail-
factor for patients to seek advice as to whether able options.
improvement is possible (Fig. 1-3). Such patients 2. Conditions affecting the treatment plan (e.g., pre-
may have missing or crowded teeth, or a tooth or vious radiation therapy, hemorrhagic disorders,
restoration may be fractured. Their teeth may be extremes of age, and terminal illness). These can
unattractively shaped, malpositioned, or discolored, be expected to modify the patient’s response to
or there may be a developmental defect. dental treatment and may affect the prognosis.
For instance, patients who have previously
received radiation treatment in the area of a
Personal Details
planned extraction require special measures
The patient’s name, address, phone number, sex, (hyperbaric oxygen) to prevent serious
occupation, work schedule, and marital and finan- complications.
cial status are noted. Much can be learned in a 5- 3. Systemic conditions with oral manifestations.
minute, casual conversation during the initial visit. For example, periodontitis may be modified by
In addition to establishing rapport and developing a diabetes, menopause, pregnancy, or the use of
basis for the patient to trust the dentist, small and anticonvulsant drugs (Fig. 1-4); in cases of gas-
seemingly unimportant personal details often have troesophageal reflux disease, bulimia, or anorexia
nervosa, teeth may be eroded by regurgitated
stomach acid1,2 (Fig. 1-5); certain drugs may gen-
erate side effects that mimic temporomandibular
disorders3 or reduce salivary flow.4,5
Fig. 1-3 Fig. 1-4
Poor appearance is a common reason for seeking restorative Severe gingival hyperplasia associated with anticonvulsant
dental treatment. drug use. (Courtesy of Dr. P. B. Robinson.)
Chapter 1 HISTORY TAKING AND CLINICAL EXAMINATION 7
A B
C D
Fig. 1-5
A, Extensive damage caused by self-induced acid regurgitation. Note that the lingual surfaces are bare of enamel except for a
narrow band at the gingival margin. B, Teeth prepared for partial-coverage restorations. C, Definitive cast. D and E, The completed
restoration.
4. Possible risk factors to the dentist and auxiliary Periodontal history
personnel (e.g., patients who are suspected or The patient’s oral hygiene is assessed, and current
confirmed carriers of hepatitis B, acquired im- plaque-control measures are discussed, as are previ-
munodeficiency syndrome, or syphilis). ously received oral hygiene instructions. The fre-
Dental offices practice “universal precautions” to quency of any previous débridement should be
ensure appropriate infection control. This means recorded, and the dates and nature of any previous
that full infection control is practiced for every periodontal surgery should be noted.
patient; no additional measures are needed when
dentists treat known disease carriers.6 Restorative history
The patient’s restorative history may include only
Dental History simple composite resin or dental amalgam fillings,
Clinicians should be cautious when commenting or it may involve crowns and extensive fixed dental
before a thorough examination is completed. prostheses. The age of existing restorations can help
With adequate experience, a clinician can often establish the prognosis and probable longevity of any
assess preliminary treatment needs during the future fixed prostheses.
initial appointment. However, fairly assessing the
quality of a previously rendered treatment can be dif- Endodontic history
ficult, because the circumstances under which the Patients often forget which teeth have been
treatment was rendered are seldom known. When endodontically treated. These can be readily identi-
such an assessment is requested for legal proceed- fied with radiographs. The findings should be
ings, the patient should be referred to a specialist reviewed periodically so that periapical health can
familiar with the “usual and customary” standard of be monitored and any recurring lesions promptly
care. detected (Fig. 1-6).
8 PART I PLANNING AND PREPARATION
simplified by minor tooth movement. When a
patient is contemplating orthodontic treatment, con-
siderable time can be saved if minor tooth move-
ment (for restorative reasons) is incorporated from
the start. Thus, good communication between the
restorative dentist and the orthodontist may prove
very helpful.
Removable prosthodontic history
The patient’s experiences with removable prostheses
must be carefully evaluated. For example, a partial
removable dental prosthesis may not have been worn
for a variety of reasons, and the patient may not even
Fig. 1-6 have mentioned its existence. Careful questioning
Defective endodontics has led to recurrence of a periapical and examination usually elicits discussion concern-
lesion. Re-treatment is required. ing any such devices. Listening to the patient’s
comments about previously unsuccessful removable
prostheses can be very helpful in assessing whether
future treatment will be more successful.
Oral surgical history
Information about missing teeth and any complica-
tions that may have occurred during tooth
removal is obtained. Special evaluation and data col-
lection procedures are necessary for patients
who require prosthodontic care after orthognathic
surgery. Before any treatment is undertaken, the
prosthodontic component of the proposed treatment
should be fully coordinated with the surgical
component.
Radiographic history
Previous radiographs may prove helpful in judging
the progress of dental disease. They should be
Fig. 1-7 obtained if possible, because it is generally better to
Apical root resorption after orthodontic treatment. avoid exposing the patient to unnecessary ionizing
radiation. Dental practices usually forward radi-
ographs or acceptable duplicates promptly on
request. In most instances, however, a current diag-
Orthodontic history nostic radiographic series is essential and should be
obtained as part of the examination.
Occlusal analysis should be an integral part of the
assessment of a postorthodontic dentition. If restora-
tive treatment needs are anticipated, they should be Temporomandibular joint dysfunction history
undertaken by the restorative dentist. Occlusal A history of pain or clicking in the TMJs or neuro-
adjustment (reshaping of the occlusal surfaces of the muscular symptoms, such as tenderness to palpa-
teeth) may be needed to promote long-term tion, may be caused by TMJ dysfunction, which
positional stability of the teeth and reduce or elimi- should normally be treated and resolved before fixed
nate parafunctional activity. On occasion, root prosthodontic treatment begins. A screening ques-
resorption (detected on radiographs) (Fig. 1-7) tionnaire efficiently identifies these problems.
may be attributable to previous orthodontic treat- The patient should be questioned regarding any pre-
ment. As the crown/root ratio is affected, future vious treatment for joint dysfunction (e.g., occlusal
prosthodontic treatment and its prognosis may also devices, medications, biofeedback, or physical
be affected. Restorative treatment can often be therapy exercises).
Chapter 1 HISTORY TAKING AND CLINICAL EXAMINATION 9
EXAMINATION temperature, and blood pressure, are measured and
recorded. Fixed prosthodontic treatment is often
An examination consists of the clinician’s use of indicated in middle-aged or older patients, who can
sight, touch, and hearing to detect conditions outside be at higher risk for cardiovascular disease. Rela-
the normal range. To avoid mistakes, it is critical to tively inexpensive cardiac monitoring units are avail-
record what is actually observed rather than to make able for in-office use (Fig. 1-8). Patients with vital
diagnostic comments about the condition. For sign measurements outside normal ranges should be
example, “swelling,” “redness,” and “bleeding on referred for a comprehensive medical evaluation
probing of gingival tissue” should be recorded, rather before definitive treatment is initiated.
than “gingival inflammation” (which implies a
diagnosis).
Thorough examination and data collection are Extraoral Examination
needed for the prospective fixed prosthodontic Special attention is given to facial asymmetry
patient, and the protocol for this effort can be because small deviations from normal may hint at
obtained from various textbooks of oral diagnosis.7,8 serious underlying conditions. Cervical lymph
nodes are palpated, as are the TMJs and the muscles
of mastication.
General Examination
The patient’s general appearance, gait, and weight Temporomandibular joints
are assessed. Skin color is noted for signs of anemia The clinician locates the TMJs by palpating bilater-
or jaundice. Vital signs, such as respiration, pulse, ally just anterior to the auricular tragi while the
Characteristics of the pulse
Common ECG findings
Sinus tachycardia
Fast
⬎100/min Ventricular tachycardia
Regular Rate Normal Normal sinus rhythm
60-100/min
Sinus bradycardia
Slow
⬍60/min Heart block
Rhythm
Early beats Atrial premature contraction
Irregular Pattern
Skipped beats Premature ventricular contraction
Regularly irregular Sinus arrhythmia
Totally irregular Atrial fibrillation
Fig. 1-8
Cardiac monitoring printout. (Courtesy of Dr. T. Quilitz.)
10 PART I PLANNING AND PREPARATION
patient opens and closes the mouth. This permits minimal click, because very little soft tissue lies
a comparison between the relative timing of left between the fingertips and the mandibular bone.
and right condylar movements during the opening A maximum mandibular opening resulting in
stroke. Asynchronous movement may indicate an less than 35 mm of interincisal movement is
anterior disk displacement that prevents one of the considered restricted, because the average opening
condyles from making a normal translatory move- is greater than 50 mm.9,10 Such restricted movement
ment (see Chapter 4). Auricular palpation (Fig. 1-9) on opening can be indicative of intracapsular
with light anterior pressure helps identify potential changes in the joints. Similarly, any midline devia-
disorders in the posterior attachment of the disk. tion on opening and/or closing is recorded.
Tenderness or pain on movement is noted and can The maximum lateral movements of the patient
be indicative of inflammatory changes in the can be measured (normal is about 12 mm)
retrodiscal tissues, which are highly vascular and (Fig. 1-10).
innervated. Clicking in the TMJ is often noticeable
through auricular palpation but may be difficult to Muscles of mastication
detect in palpation directly over the lateral pole of Next, the masseter and temporal muscles, as well
the condylar process, because the overlying tissues as other relevant postural muscles, are palpated
can muffle the click. Placement of the fingertips on for signs of tenderness (Fig. 1-11). Palpation is
the angles of the mandible helps identify even a best accomplished bilaterally and simultaneously.
This allows the patient to compare and report any
differences between the left and right sides. Light
pressure should be used (the amount of pressure one
can tolerate when gently pushing on one’s closed
eyelid without feeling discomfort is a good compar-
ative measure), and if any difference is reported
between the left and right sides, the patient is asked
to classify the discomfort as mild, moderate, or
severe. If there is evidence of significant asynchro-
nous movement or TMJ dysfunction, a systematic
sequence for comprehensive muscle palpation
should be followed as described by Solberg9 and
Krogh-Poulsen and Olsson.11 Each palpation site is
given a numerical score based on the patient’s
response. If neuromuscular or TMJ treatment is ini-
tiated, the examiner can then repalpate the same
Fig. 1-9 sites periodically to assess the response to treatment
Auricular palpation of the posterior aspects of the temporo-
mandibular joints.
(Fig. 1-12).
Lips
The patient is observed for tooth visibility during
normal and exaggerated smiling. This can be critical
in fixed prosthodontic treatment planning,12 espe-
cially for margin placement of certain metal-ceramic
crowns. Some patients show only their maxillary
teeth during smiling. More than 25% do not show the
gingival third of the maxillary central incisors during
an exaggerated smile13 (Fig. 1-13). The extent of the
smile depends on the length and mobility of the
A B upper lip and the length of the alveolar process.
When the patient laughs, the jaws open slightly and
a dark space is often visible between the maxillary
and mandibular teeth (Fig. 1-14). This has been
called the negative space.14 Missing teeth, diastemas,
Fig. 1-10 and fractured or poorly restored teeth disrupt the
Maximum opening of more than 50 mm (A) and lateral move- harmony of the negative space and often require
ment of about 12 mm (B) are normal. correction.15