The Sequence of Checking for the physical examination for patients

1. Principles of Physical Examination
• Inspection
• Palpation
– Digital – (lips)
– Bimanual – (floor of the mouth)
– Bilateral – (Comparison)
– Compression
• Percussion – Listen to the resulting sound
– Hard
• high pitch has support by bone
• Low pitch has less support by bone
– Soft
• Auscultation – Listen to the direct sound

2. Radiographic
Interpretations

3. Reading X-ray Films
Use a suitable film mount
Place in proper position with care
Use an illuminator for study
Should be mounted that one views them as
though he were inside the mouth
Clinical examinations are recorded as one
views the mouth from in front of the patient
After diagnosis, the film is kept in s separate
file until treatment is complete and filed with
the case record envelope or folder for future
references.

4. Proper mounting of the x-rays

7. Interpreting X-ray Films
Is the most important work of the dentist in
radiology
It should be done in a systematic manner
Proper consideration given to the age of the
patient
The history
The clinical examination
All findings should be recorded on the
patient’s chart

8. Patients seen for the first time, and
those whose teeth have never been
radiographed should;
Have a routine examination
X-rays of all the teeth includes;
Edentulous spaces
Edentulous jaws
Bitewing are taken when teeth are present

9. If this system is carried out one
will often be surprised to find
definite diseased conditions on
teeth which were not suspected in
the clinical examination.

10. When films are mounted it may be
found that the examinations is not
conclusive in regard to a certain lesion,
or that there is a suspicious place
which requires further investigations
by use of a different angulations or a
different method of exposure or
clinical reexamination.

11. What a radiograph shows and what it
does not;
The radiograph does not picture
disease; it only records on a
photographic film changes in the x-
ray density of the tissues brought
about by pathologic processes, as well
as surgical or medical treatment.

12. An x-ray diagnosis is, therefore
made by drawing deductions from
the picture, and the dentist must
become proficient in associating
radiologic signs with disease
conditions.

13. Through experience, careful
observation, and systematic study of a
large number of similar cases, and in
comparison of x-ray findings with
postoperative findings and the results of
pathologic examinations, it will be
possible to make radiographic
interpretations more accurate

14. Examinations of the following
conditions
 Dental, periodontal, and periapical tissues
1. Departures from normal, such as abnormality in size, outline,
position and number of roots of tooth
2. Pulpless (root-canal filled) teeth, the apices of which are in
close relation with the maxillary sinus
3. Indications of attrition, erosion, abrasion, and caries
4. Conditions of the fillings and other restorations
5. Changes in the pulp canal; pulp stones, denticles, and
adventitious dentin
6. Secondary evidence of pulp disease
7. Quality of the root canal fillings
8. Evidence of resorption or hypercementosis
9. Radiolucent periapical changes
10. Radioopaque pericapical changes
11. Evidence of extensive involvement from osteitis

15. 12. Other marked deviations from normal bone
13. Condition of the alveolar crest, atrophy, widening
of marginal periodontal membrane, and pocket
formation in periodontitis (compared to clinical
pocket): periodontal bone sclerosis due to stress.
14. Evidence of parietal abscesses, especially
between the roots of maxillary molars in
periodontitis.
15. Edentulous sections

16. Bone of Maxilla and Mandible
• In Orthodontics: the relation of occlusal disturbance to facial
abnormalities; disturbance in dentition, presence of cyst, increased or
decrease number f deciduous or permanent teeth.
• In Traumatic injury: both on the injured side and on the opposite jaw,
especially condyle; fracture or luxation of teeth.
• Abnormal conditions causing radiolucent areas or osteolytic defects.
These may be due to infections, cyst, or tumors.
– A. Localized
• With osteitic margin
• With clear-cut margin (puched-out area)
• With cystic margin (cortical bone)
• With bone expansion
• With perforation of bone
• With trabeculated area
– B. Diffuse
• With generalized involvement
• With defined polycystic involvement
• With periosteal new formation
• Abnormal conditions causing radioaque areas due to abnormal
calcified tissues. These may be caused by sequestra, foreign bodies,
sclerosed bone, calcified tumors,such as osteoma, and odontoma.

17. Maxillary Sinuses
• Conditions causing increased density: exudates,
thickened membrane, cyst, tumors.
• Foreign bodies: teeth, roots, osteoma.
• Cases of increased density due to external,
superimposed tumors or inflammatory
conditions such as subperiosteal abscesses and
edema of side of face.

18. Salivary glands (sialographs)
• Infection of gland
• Strictures of ducts
• Salivary stones
• Tumors
Temporomanbular Joint
• Adhesions with obliterations of joint spaces
• Perforation of meniscus
• Displacement of meniscus
• Position of condyle at rest and in function
• Resorption f condyle
• Fractures
• Ankylosis

19. Terms used in X-ray diagnosis
1. X-ray Density - the property of a given tissue to absorb
or prevent the penetration of x-rays. This varies with the
quality and intensity of x-rays.
2. Radiolucent - offering slight resistance to roentgen rays.
Seen in inflammation, cysts, and central soft tissue.
3. Radiopaque - offering great resistance to roentgen x-
rays. Seen in bone sclerosis, and calcified tumors.
4. Osteitic Margin - an indefinite, diffuse margin due to a
gradual change from diseased to normal bone. Seen in
inflammation and infiltrating tumors.
5. Clear-cut Margin - a sharply demarcated, punched-out,
radiolucent area. Seen in perforation of cortex by
periapical infections, central tumors, and rarely surface
erosions from periosteal tumors.

20. 6. Cystic Margin - formed by dense cortical bone
surrounding the area. Seen in crypts around unerupted
teeth, cysts, and benign central osteolytic tumors of the
jaw.
7. Bone expansion - caused by pressure of cystic content
or encapsulated tumor tissue; cortex is resorbed inside and
added to outside by the periosteum. Seen in cysts, benign
giant cell lesions, fibro-osteoma, ameloblastoma, and most
central tumors.
8. Perforation - infiltrating malignant central tumors may
perforate the bone.
9. Trabeculated area - the radiolucent area is generally
cystic in character, often expands to bone, and is
subdivided by septae. Seen in benign giant cell lesions,
central myxoma, central angioma (soap bubble effect), and
central mixed tumors.
10. Localized involvement - the changes are confined to a
definite area in the bone as in most conditions in ostietic
margin, clear-cut margin and cystic margin.

21. 11. Diffused generalized involvement - the entire bone
or a large part of it is involved, without well-defined
limitation. Seen in osteomyelitis, benign giant cell lesionsa,
and locally maglignant tumors.
12. Polycystic involvement - a large part of the bone is
involved by a tumor growing by extension through new
cysts forming at the periphery of the lesion.
13. Periosteal new bone formation - from the
periosteum new bone is formed either parallel to the
surface or vertical to the periphery. The latter is found in
syphilis and as the so-called “sunray effect” in osteogenic
sarcoma.
14. Metaplastic bone formation - bone is formed in
many tumors as a secondary, not a primary, neoplastic
phenomenon.
15. Filling defect - if radiopaque substances are injected
and part of a cavity or gland is not filled with it, we speak
of this as a filling defect. Filling defects are generally due
to the presence of pathologic tissue such as tumors.

22. Laboratory Examinations
• Blood Examination
– Blood test are used for diagnosis of a great
variety of conditions. The test useful as aids in
diagnosis of oral conditions are as follows:
• Blood count
• Hemoglobin estimation
• Test for bleeding time and coagulation time
• Certain chemical test ( Blood Chemistry)
• And similar test (Special Examinations, ex. Kidney,
Liver Functions)

23. • Hemoglobin Estimation - this can be made by various
methods, the Sahli test by acid hematin method is generally
used. The normal hemoglobin value is 14 to 17 gm per
100cc.
• The Color Index - the percentage of hemoglobin
divided by the percentage of red blood cells gives the color
index. The percentage of red blood cells is found by
dividing the number of red blood cells present in a cubic
millimeter of blood by 5,000,000 (the normal number of
cells per cu mm of blood), and multiplying the quotient by
100. Thus, if a person has 2,500,000 red blood cells per
cubic millimeter of blood, he has 50 percent of the normal
red blood cells; if there are 3,500,000, red blood cell count is
70 percent normal. If the individual’s hemoglobin is 40
percent and the percentage of erythrocytes is 50, the color
index is 4 divided by 50, or 0.8. In most anemias the color
index is below 1. In pernicious anemia the typical color
index is above 1.

24. • The Hematocrit Reading and Volume Index
- the hematocrit reading is the percentage of total
blood volume composed of erythrocytes. The
volume of the red blood cells (hematocrit reading)
is determined by rapid centrifuging the blood in a
special tube, and then noting the volume of the
erythrocyte sediment as compared with the liquid
portion of blood. The normal hematocrit value is
42 to 45. The volume index is obtained by dividing
the hematocrit (in percentage of normal) by the
erythrocyte count (in percentage of normal). A
value greater than 1 indicates that the erythrocytes
are larger than normal.

25. The Blood Cell Count
• Apparatus used to make a blood cell count
consist of:
– A microscope
– A blood lancet
– A hemacytometer with a counting chamber with
the Neubauer ruling
• A drop of blood is obtained by the use of
the lancet, the first drop expressed is to be
used for the hemoglobin estimation.

26. • The Red Blood Cell Count
– Blood is drawn into the pipet, diluted and
shaken. A drop is placed in the counting
chamber and 100 of the smallest squares are
counted. The number of red cells in 1 cu mm of
blood is computed. The normal count is
4,000,000 to 5,555,000 per cubic millimeter. A
low count suggests anemia. The anemias are
usually classified on their etiologic basis i.e.
• those due to decreased production of erythrocytes or
hemoglobin,
• those due to excessive destruction of erythrocytes,
• and those due to loss of blood.

27. The size and shape of red blood cells are
ascertained by means of a stained smear.
• Poikilocytsis - there is irregularity of the shape of the cells
(severe anemia and leukemia); sickle cells in large numbers
are also found in anemias.
• Anisocytosis - there is marked irregularity in the size of
the cells
• Normoblast - are nucleated red blood cells found in severe
anemias and various types of leukemias, and make for an
unfavorable prognosis.
• Polychromatophilia - applies to cells which do not stain
uniformity, but take the basic stain.
• Stippling or basophilic degeneration - is a characteristic
of poisoning with lead or other metals.
• Hypochromasia and Anochromasia are sign of normal
degeneration.

28. • The White Blood Cell Count
– Blood is drawn into the pipet, diluted and shaken.
A drop is placed on the ruled counting chamber
and the cells in four of the large squares are
counted. The number of cells counted is divided
by four to obtain an average and multiplied by 200
(dilution 20 times depth of slide 10). This gives the
number of white cells in 1 cu mm of blood. The
white cells have the function of protecting the
human organism. The number may be decreased
through the effects of poisons, increased in case of
need. The normal white cell count is between 5,000
and 10,000 cells per cubic millimeter of adult blood.

29. – The high figure occurs in pregnancy, alimentary
digestion, and people exposed to the elements.
A low count is called “leukopenia”, a high cell
count is called “leukocytosis”, occurs in
infection, leukemia, and severe cachexia. A
mounting cell count means a continuance of
infection towards suppuration or spreading of
the disease. An increase from leukopenia to
normal means improvement. In leukemia an
increase is a bad omen

30. • The differential count gives the proportion
of cell types present, not necessarily an
absolute increase or decrease from normal.
The white cell differential count is made by
smearing a slide, applying special stains,
and counting cell types. Intravital and
supravital staining techniques may also be
used by the hematologist to drive additional
information.

31. Normal Proportions for adults
• Polymorphonuclear neutrophils - 50 – 75 percent
• Polymorphonuclear eosinophils - 1 – 4 percent
• Polymorphonuclear basophils - 0 – 1 percent
• Lymphocytes - 20 – 30 percent
• Monocytes (large mononuclear
lymphocytes, endotheliocytes - 5 – 10 percent

32. • Shift to the left is an expression indicating a
change in the types of the polymorphonuclear
neutrophils. Schilling divided them into four
groups according to their nuclear morphology:
– Myelocytes - immature cells with single rounded
nucleus (0 percent)
– Transitional or young metamyelocytes - with a single
round nucleus somewhat indented (0 -2 percent)
– Older metamyelocytes - with the nucleus deeply
indented but not truly lobulated (3 -5 percent)
– Polymorphonuclear cells - (55 -70 percent)
• A shift to the left means a relative increase of the
first two groups of immature cells; the greater the
shift the poorer becomes the prognosis, especially
if combined with a leukopenia. The appearance of
myelocytes is a grave omen.

33. Blood Cell Sedimentation Test
• This is a macroscopic test used to detect serious
infection. In blood containing an anticoagulant the
cells are allowed to settle, leaving clear plasma.
This is called sedimentation, and is more rapid in
disease than in health.
• Measurement of the time required for the
sedimentation (S.T.) is of value in diagnosis. In
another test the time is fixed and the quantity and
distance of falling are registered (S.R.). Cutler
states that the velocity with which the red blood
cells settle varies from minute to minute, and that
this variation is of extreme importance.

34. • The total sedimentation at the end of 60 minutes
expressed in millimeters is called the
sedimentation index (normal for men 2 to 8 mm.,
average 3 to 4 mm., normal for women 2 to 10 mm.,
average 5 to 6 mm., during menstruation as high
as 12 mm.; however, the readings vary greatly with
different methods and require careful
interpretation).
• The sedimentation rate under normal conditions is
relatively constant but is higher and varies more in
women. It may be accelerated in pregnancy or
during menstruation or by pathologic conditions.

35. Bleeding and Coagulation Time
• These are important to the dentist
• If there is a history of undue bleeding from a former
injury or tooth extraction, or if larger surgical
operations are planned, the bleeding and clotting time
should be ascertained.
• These are actually screening tests and more complete
studies by a well qualified physician or internist may
be indicated when the results are not within normal
limits.
• It should be remembered, however, that in many
instances hemorrhages are due to partly severed
blood vessels and other local conditions. The patients
should be questioned as to whether any anticoagulant
is being used for vascular disease, and generally
evaluated clinically.

36. The Bleeding Time
• Normal value 2 to 4 minutes
• Prolonged bleeding time does not always parallel the
clotting time
• There is a slight increase in severe anemias
• A great increase, 10 to 90 minutes, is found in patients with
blood platelets greatly reduced (purpura hemorrhagica,
acute leukemia) and in patients with extremely low
fibrinogen content of the blood (phosphorus poisoning,
destructive liver disease).
• The paradox of prolonged bleeding time and normal
coagulation time is explained by the fact that in such a
disease as thrombocytopenic purpura the number of
platelets is too small to plug the defect in the capillaries but
large enough to intiate the process of coagulation.

37. The Coagulation Time
• Normal value 2 to 8 min
• A coagulation time more than thrice the normal is a danger
signal. It is not a contraindication to surgery, but when present
proper precautions or prophylactic treatment is indicated,
preferably after proper medical evaluation.
• Prolonged coagulation time occurs in hemophilia, in which it
is from one to several hours in anemias, leukemias, in many
infectious diseases, and in jaundice.
• Prolonged coagulation time slightly above the normal may
occur in healthy individuals, and may be cause of prolong
oozing from small blood vessels as in patients who have had
tonsillectomy or operative procedures in the mouth, including
the extraction of teeth.

38. The Clot Retraction Time
• If the blood is normal the clot gradually separates
from the wall of the tube expressing the serum.
The process should be completed after 1 hour.
• By other methods, including incubation, this time
will vary considerably. The retraction is due to the
presence of blood platelets and is independent of
the coagulation time.
– In thrombocytopenia the coagulation time may be
normal but the blood clot will be friable and retracts
very little or not at all, even after several days.
– In hemophilia the blood coagulates very slowly but the
clot when once form has normal retractile power.

39. The Prothrombin Time
• Coagulation time does not differentiate among the various
factors that disturb the clotting mechanism. The deficiency
in prothrombin should be recognized.
• Quick’s test is in common use today. The normal for this
test is 16 to 17 seconds, but the time varies considerably
with the thromboplastin used in the test.
• The prothrombin determination is of value to determine
the state of prothrombinopenia which may be due
– to lack of vitamin K,
– because of dietary deficiency or faulty absorption caused by the
lack of salts such as occurs in obstructive jaundice, biliary fistula,
and sprue, or in persons in whom liver damage has occurred.
– Prolonged use of acetylsalicyclic acid (aspirin) may decrease the
prothrombin time.
• Prothrombinopenia may be corrected in such cases by the
administration of vitamin K. Cahn recommends that 1 mg.
of vitamin K should be prescribed to every 5 grains of
aspirin, if taken constantly.

40. The Tourniquet Test
• This is a test for capillary fragility
• A square 2 by 2 cm. in size is drawn on the inner
aspect of the forearm so that its upper edge is 4
cm. below the crease of the elbow.
• The rubber cuff of a sphygmomanometer is then
applied to the upper arm and inflated until the
pressure is between the systolic and diastolic. After
15 minutes the pressure is released and 5 minutes
later the number of petechiae visible in the
encircled area are counted. The count of 10 or less
petechiae within the square is considered normal.
Counts between 10 and 20 are evidence of a
pathologic condition. Patient with marked
capillary fragility may have counts of 100 or more.

41. Normal Values of Blood

42. Normal Values Normal range values Normal Values Normal range values
Prothrombin Time 10 – 13 sec Erythrocytes 4 – 5. 5 x 107 g/L
Bleeding Time 1 – 3 minutes Platelets 2 – 4 x 105 per cu.
mm. of blood
Clotting Time 3 – 6 minutes (Slide)
8 – 15 minutes
(Lee/White)
Coagulation Time 2 – 8 minutes
Platelet count 140 – 440 x 109 Clot retraction time 1 hour
Hemoglobin M – 140 – 160
F – 120 - 140
Partial Thromboplastin
Time
29 – 34 sec
Hematocrit M – 40 – 54
F – 37 - 47
WBC 5 – 10 x 10 g/L
Sedimentation Rate Adult 0 – 30mm/hr
Children 0 – 145
mm/hr

43. Differentiation of Hemorrhagic Disorders
• Coagulation time prolonged, bleeding time and
platelet count normal:
– Hemophilia
– Vitamin K deficiency
– Severe liver injury
– Idiopathic hypoprothrombinemia
– Presence of anticoagulants in the blood
– Pseudohemophilia
• Coagulation and bleeding time prolonged,
platelet count normal:
– Same conditions as I
– Fibrinogenopenia

44. • Prothrombin time prolonged, Coagulation and
bleeding time and platelet count normal:
– Hemorrhagic disease of new born
– Vitamin K deficiency
– Severe liver injury
– Idiopathic hypoprothrombinemia
• Bleeding time prolonged, coagulation time and
platelet count normal:
– Hereditary hemorrhagic diathesis
• Bleeding time prolonged and presence of
thrombocytopenia:
– Idiopathic purpura hemorrhagica
– Symptomatic thrombocytopenic purpura, due to
poisoning by chemical, vegetable and animal agents

45. Blood Chemistry
There are a number of blood chemistry test
which are of diagnostic interest in certain
diseases. The blood for such tests is taken from
a vein, sodium citrate solution is added, and
the specimen is sent to a laboratory. Generally
specific test are indicated for a specific
diagnosis.

46. Substance Normal range
values
Increase Decrease
Glucose Substance 4.2 – 6.4 m mol/L Diabetes mellitus Hyperinsulinism,
Addison’s disease
Urea Nitrogen
Substance
3.2 – 6.8 m mol/L Prostatic or intestinal
obstruction, shock
Severe liver damage
Creatinine Substance 44 – 106 u mol/L Nephritis, metallic
poisoning, prostatitis
Fever, acidosis, diabetes,
vomiting, gastrointestinal
disturbance
Uric Acid Substance 178 – 440 u mol/L Arthritis, nephritis Severe liver damage
Cholesterol Substance 3.4 – 6.1 m mol/L Diabetes, nephrosis,
xanthomatosis
Severe liver damage
Alkaline Phosphatase 9 – 35 lu/L Hyperparathyroid,
rickets, liver disease,
Paget’s osteomalacia
LDH - L 109 – 193 lu/L
Triglycerides
Substance
Up to 2.4 m mol/L
Calcium Substance 2.1 – 2.5 m mol/L Hyperparathyroid Hypoparathyroid,
Uremia

47. Spinal Fluid
• Spinal fluid may be examined for syphilis. When reaction to
the serologic Wassermann test is negative the spinal fluid
may give a positive results, especially in neurosyphilis.
Urinalysis
• The urine is examined as a routine procedure in all
hospitals before administration of an anesthetic. Primarily
it gives information regarding renal diseases, but it is also
of importance in the study of irregularities or deficiencies
in metabolism, which in turn may have a direct relation to
oral conditions. The quantity of urine (normal amount
1,000 to 2,000 cc. or 1 to 2 qts. in 24 hours) and frequency of
urination should be noted by the clinician; they often give
important information.

48. • Albumin - the presence of albumin is seen in fever,
pregnancy (toxic), and nephritis, especially if cast are
present. Sometimes albumin is present in urine of patients
with marked dental infection.
• Sugar - Detection may be made by Benedict’s test, simple
screening test packets are available. More than 0.2 percent
of sugar is found in persons having diabetes mellitus, and
also in those with renal diabetes, which is temporary as a
rule and frequency due to the excessive use of alcohol,
starch, or sugar, or to nervous strain. The presence of
excessive sugar in the urine suggest the need for thorough
medical study.
• Acetone - this is found in the urine of patient’s with
acidosis due to the incomplete metabolism of fat. It occurs
in association with diabetes mellitus and may indicate
cachexia, starvation or coma.
• Urea - The quantitative test gives information regarding
the body metabolism or the amount of nitrogen excreted,
which is eliminated mostly by the kidneys in a form of urea.
Urea is usually excreted in amounts of 15 to 40 gms. per 24
hours. It is increased in toxic goiter.