Dental Clinical Diagnosis and Examination Procedures

Diagnosis

Diagnosis: A set of procedures to determine an individual's presented enfermedad (disease).

History

1. History

Questioning: patient information collected verbally and in writing.

Identification Data

A) Identification data:

• Name
• Date of birth
• Place of birth
• Profession
• Address
• Phone

Present Illness

B) Present illness (reason for consultation): what happens, since when, and what the patient attributes it to.

Clinical History

Clinical history: Information that collects all tests on the patient, evolution, and treatments performed. If decay reaches the pulp, the condition progresses. There may be pain that appears with certain stimuli, is located in a tooth, and is not necessarily related to the tooth's position. Depending on the type of pain, it may not disappear once triggers are removed; more diffuse pain can increase when lying down.

Personal and Family History

C) Personal background: any current or past disease (diabetes, etc.), allergies to medicines, and drugs that the patient is currently taking.

D) Family history: diseases present in close relatives.

Clinical Examination

2: Clinical examination: inspection (visual), palpation (manual or with instruments).

Extraoral Examination

A) Extraoral exploration:

• Visual inspection: profile, frontal view — facial asymmetry, changes in color, and shape of the profile.
• Palpation: lymphadenopathy; enlarged lymph nodes in neck.
• Temporomandibular joint (TMJ): pain, noise, sensitivity.
• Clicks: if frequent.
• Crackling: continuous noises.

Intraoral Examination

B) Intraoral exploration: examination of soft tissues and teeth.

• Buccal mucosa: inside the cheeks.
• Alveolar mucosa: lining the mandible and the maxilla.
• Lips and sores: covers the inner side of both lips; inspect for lesions.
• Palate: attached to the underlying bone.
• Floor of the mouth: under the tongue, including the sublingual caruncle.
• Tongue: inspect dorsal and ventral surfaces; papillae and movement — lift the tongue to observe contact with the palate.

Tooth Exploration

Exploration of teeth:

• Mouth mirror: to retract soft tissues and improve visibility.
• Probe: to check for grooves, cavities, or corresponding injuries.
• Two-digit tooth numbering: name each tooth using a code consisting of 2 digits: first digit = quadrant of the mouth, second digit = type of tooth.

Caries: Types and Diagnosis

Caries: destruction of enamel.

Color/staging for diagnosis: 1 — white spot; 2 — dark brown; 3 — brown. Diagnosis is aided by observing the color.

Types of caries by location:

• Pit and fissure grooves: occlusal surfaces of premolars and molars — stained grooves.
• Interproximal (bitewing): mesial and distal surfaces between teeth.
• Smooth surfaces: buccal and lingual surfaces.

Additional Examinations

3) Additional exploration:

• Radiology: commonly used to evaluate enamel, dentin, bone, and cementum.
• Analytical: laboratory tests to detect systemic alterations that affect the mouth.
• Biopsy: a sample of the lesion and adjacent healthy tissue sent to a diagnostic laboratory to assess changes in soft tissues.

Types of Facial Profile

Types of facial profile:

• Straight profile: lip and jaw relationship aligned with the reference line.
• Convex / Retrognathia (mandibular retrusion): the mandible is positioned posteriorly relative to the reference line.
• Concave / Prognathia (mandibular protrusion): the mandible is anterior to the reference line; lips and soft tissues appear forward of the reference line.