History Taking

and
Clinical Examination

Presentan: Agrippina Maria

Pembimbing: drg. Farisza Gita, Sp.Pros (K)

FIXED
PROSTHODO
NTIC

FIXED
PROSTHODO
NTIC

Comprehensiv
e assessment

Correct
Diagnosi
s

Predictable Success
Fixed Prosthodontic
Treatment

Active
Treatme
nt Phase

Follow
Up Care

 Chief
Complaint
Personal
Details
Medical
History
Dental
History

History

Examinati
on
General
Extraoral
Intraoral
Radiographi
c
Vitality
Testing

Prognosis
Differential
Diagnosis

Diagnosis

General
Factors
Local
Factors

Comfort

Function

Social

Appearance

HISTORY CHIEF COMPLAINT

Nama
Alamat
Nomor telepon
Jenis kelamin
Pekerjaan
Status pernikahan
Keadaan keuangan pasien

HISTORY PERSONAL DETAILS

Condition affecting treatment

method
Condition affecting treatment
plan
Systemic condition with oral
manifestation
Possible risk factor to dentist and
auxillary personel

HISTORY MEDICAL HISTORY

Any disorder needs the use of

antibiotic premedication
Use of steroids or anticoagulants
Previous allergic respons to
medication or dental materials

Condition affecting treatment

method
Condition affecting treatment
plan
Systemic condition with oral
manifestation
Possible risk factor to dentist and
auxillary personel

HISTORY MEDICAL HISTORY

Previous radiation therapy

Hemorrhagic disorders
Extremes of ages
Terminal illness

Condition affecting treatment

method
Condition affecting treatment
plan
Systemic condition with oral
manifestation
Possible risk factor to dentist and
auxillary personel

HISTORY MEDICAL HISTORY

Periodontitis, modified by DM,

menopause, pregnancy, use of
anticonvulsant drugs
Eroded teeth, by regurgitated
stomach acid (Bulimia, anorexia
nervosa, GERD)
Xerostomia, use of certain drugs

Condition affecting treatment

method
Condition affecting treatment
plan
Systemic condition with oral
manifestation
Possible risk factor to dentist and
auxillary personel

HISTORY MEDICAL HISTORY

Suspected or confirmed carriers

of Hepatitis B, AIDS, Syphillis

Periodontal
Restorative
Endodontic
Orthodontic
Removable Prostho
Oral surgical
Radiography
TMJ Dysfunction

HISTORY DENTAL HISTORY

GENERAL - EXAMINATION
General
Appearance
Gait
Weight
Skin Color Anemia/
Jaundice?
Vital Signs

EXTRAORAL EXAMINATION
TMJ

Normal Maximum opening More than

50 mm
Normal Maximum lateral movement
12 mm
Restricted opening movement less
than 35 mm intracapsular changes in

EXTRAORAL EXAMINATION

Muscle of
Mastication

EXTRAORAL EXAMINATION

Muscle of
Mastication

EXTRAORAL EXAMINATION

Lips

EXTRAORAL EXAMINATION

Lips
Negative Space

INTRAORAL EXAMINATION

INTRAORAL EXAMINATION
Periodontal
Examination
Gingiva

INTRAORAL EXAMINATION
Periodontal
Examination
Periodontium - clinical
attachment level

INTRAORAL EXAMINATION
Periodontal
Examination
Periodontium - clinical
attachment level

INTRAORAL EXAMINATION
Periodontal
Examination
Periodontium - clinical
attachment level

INTRAORAL EXAMINATION

Dental Charting
Occlusal Examination
- Initial Tooth Contact
- General Alignment
- Lateral and Protrusive Contacts
- Jaw Maneuverability

INTRAORAL EXAMINATION

Dental Charting
Occlusal Examination
- Initial Tooth Contact
- General Alignment
- Lateral and Protrusive Contacts
- Jaw Maneuverability

INTRAORAL EXAMINATION

Centric Relation

Intercuspal
Position

1. If all teeth come together

simultaneusly at the end of terminal
hinge closure CR=MI
2. If initial contact occurs between
posterior teeth (usually molar) slide
from CR to MI

Dental Charting
Occlusal Examination
- Initial Tooth Contact

INTRAORAL EXAMINATION

Dental Charting
Occlusal Examination
- Initial Tooth Contact
- General Alignment

INTRAORAL EXAMINATION

Dental Charting
Occlusal Examination
- Initial Tooth Contact
- General Alignment
- Lateral and Protrusive Contacts
- Jaw Maneuverability

RADIOGRAPH EXAMINATION

VITALITY TEST EXAMINATION

28-year-old male, no significant medical history; vital signs normal.

Chief complaint: Mesiolingual cusp fracture on tooth # 30. Teeth # 1, # 16, # 17, #
19, and # 32 missing.
Patient reports significant postoperative discomfort after previous molar extraction.
High smile line.
Caries: # 6, mesial; # 12, distal; # 20, mesio-occlusal; and # 30, mesioocclusaldistal.
Tooth # 8 has received previous endodontic treatment.
Generalized gingivitis four posterior quadrants, with recession noted on teeth # 23, #
24, and # 25. 5-mm pockets on teeth # 18, # 30, and # 31.
Radiographic evidence of periapical pathology tooth # 30. Tooth # 30 tests nonvital.

Histor
y
Takin
g

Examinati
on

Diagnosi
s

DIFFERENTIAL DIAGNOSIS

crown-to-root ratios
root angulation and root morphology
Individual tooth mobility
Access for oral hygiene measures
Forces applied of given tooth

Local Factors

Age of Patients
Lowered Resistance of The Oral
Environment
Systemic Problem

General Factors

PROGNOSIS