Ebook History taking and clinical examination in dentistry: Part 1

(BQ) Part 1 book “History taking and clinical examination in dentistry“ has contents: Introduction, methods of recording a case history, general information, chief complaint, history of present illness, previous dental history, medical history, personal dental history, clinical examination, extraoral examination.

Clinical Examination in DENTISTRY

History Taking and

Clinical Examination in DENTISTRY

Professor and HeadDepartment of Public Health Dentistry

Sudha Rustagi College of Dental Sciences and Research

Faridabad, Haryana, India

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Foreword

Rahul J Hegde

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History Taking and Clinical Examination in Dentistry

First Edition: 2014

ISBN 978-93-5152-393-2

I would like to thank my wife Dr Vandana for standing beside

me throughout my career and writing this book She has been my inspiration and motivation for continuing to improve my knowledge and move my career forward She is my rock, and I dedicate this book to her.

Oxford Dental College

Bengaluru, Karnataka, India

Avinash JMDS

Professor and Head

Department of Public Health

Dentistry

Kalinga Institute of Dental

Sciences

Bhubaneswar, Odisha, India

Bhumija Gupta BDS AEGD GPR

Sudha Rustagi College of

Dental Sciences and Research

Faridabad, Haryana, India

Hind Pal Bhatia MDS

Professor and Head Department of Pedodontics Manav Rachna Dental College Faridabad, Haryana

India

Navin Anand Ingle MDS

Professor and Head Department of Public Health Dentistry

KD Dental College and Hospital Mathura, Uttar Pradesh India

Pradeep Tangade MDS

Professor and Head Department of Public Health Dentistry

Kothiwal Dental College and Research Centre

Moradabad, Uttar Pradesh India

Rajendra Gowda Patil MDS

Professor and Head Department of Oral Medicine and Radiology

Kothiwal Dental College and Research Centre

Moradabad, Uttar Pradesh India

Contributors

India

It gives me great pleasure to write a foreword for History Taking and

Clinical Examination in Dentistry The approach adopted by the author

should be a great help to those taking history and doing examination for diagnosis and treatment planning in dentistry The idea of taking symptom complexes and then describing the diagnostic possibilities with guides to the management both of the disease itself and of the symptoms will be valuable to all who have to deal with problems of this sort.

I hope that it will be valuable to all those who have to deal with the clinical differential diagnosis It should be of particular use to teaching faculty, undergraduate and postgraduate dental students and dental practitioners It is the sort of book that should be in the hands of students of dentistry entering the clinics during their clinical postings.

Rahul J Hegde

(Executive Member, Dental Council of India)

Vice-Principal, Professor and Head Department of Pediatric Dentistry Bharati Vidyapeeth University Dental College

Navi Mumbai, Maharashtra, India President, Indian Society of Pediatric Dentistry Senate Member, Maharashtra University of Health Sciences

Foreword

The most important core skills for dental students to master are history taking and clinical examination This book has been written with the philosophy that the acquisition of clinical skills is most effectively undertaken at the chairside This book should be used as

a companion, to be taken in the clinics where the information is most needed The book begins with a system of history taking followed by chapters covering clinical examination and diagnosis Each stage of the examination starts with a detailed step-by-step description of the examination method complemented by relevant illustrations, diagrams and tables This book is intended primarily for use at the outset of clinical training; once students have achieved proficiency in the basic skills of interviewing and examining, the book should also prove useful for revision.

This book was written keeping in mind the problems faced in clinics

by undergraduate and postgraduate students regarding history taking, clinical examination, diagnosis and treatment planning as no book is available in the market focusing specifically on these topics.

Charu M Marya

Preface

I would like to express my gratitude to many people who provided support, read, wrote, offered comments, allowed me to quote their remarks and assisted in the editing, proofreading and design.

I would like to thank my parents for allowing me to follow my ambitions throughout my childhood Ever indebted to my mother for her encouragement and my father, my guide My brother Dr Kirti Mohan Marya for standing by me always and sister Dr Priya Nagpal for her prayers I also thank my wonderful children: Akshat and Dewang for always making me smile My family, including my in-laws, have always supported me throughout my career and authoring this book and

I really appreciate it I want to acknowledge my family’s contribution, for putting up with my absences, both mental and physical.

Many persons generously gave their time in the preparation

of the first of its kind book History Taking and Clinical Examination

in Dentistry I would like to convey my grateful thanks to all the

contributors for their cooperation and enthusiasm for the publication

of this book In addition, special appreciation is to be mentioned for

Dr Ruchi Nagpal, Dr Sukhvinder, Dr Amit Rekhi who provided high quality logistic and editing support during the preparation of this book.

My thanks also go to my colleagues at the Sudha Rustagi College

of Dental Sciences and Research, Faridabad (Haryana), who have given encouragement and support at key times in the development of this book and have contributed for creating a stimulating and congenial environment for me to work.

I would like to thank Mr Dharamvir Gupta (Chairman), Mr Deepak Gupta (Secretary), Prof (Dr) Indushekar (Principal) and Dr Vishal Juneja (CEO), Sudha Rustagi College of Dental Sciences and Research, Faridabad for their encouragement and support in this venture.

Acknowledgments

My due regards to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Group President) and Mr Tarun Duneja (Director–Publishing) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for rendering help to come out with this publication in time I am thankful

to Mrs Samina Khan (Executive Assistant to Director–Publishing), for being so instrumental and helpful for this publication, and Mr Rajesh Sharma (Production Coordinator) for extended profound support and interest in this release.

1 Introduction 1 Risk Management 3

Detailed History of a Particular Symptom 23

8 Personal Dental History 81

Oral Habits 81

Thumb and Digit Sucking 82

Pacifier Habits 94

Tongue Thrust Habit 94

Mouth Breathing Habit 99

Bruxism 104

Other Minor Habits 106

Oral Hygiene Habits 107

Alterations in Number of Teeth 200

Alterations in Size of Teeth 204

Alterations in Shape of Teeth 205

15 Formulating a Comprehensive Treatment Plan 254

Phase I: Emergency Phase 255

Phase II: Preventive Phase 255

Phase III: Promotive Phase 255

Phase IV: Curative Phase 256

Phase V: Rehabilitation Phase 256

Phase VI: Maintenance Phase 256

Treatment Planning in Dentistry 258

Appendices 280

“Accurate diagnosis of a disease depends on the art of taking case history.”

Diagnosis is the art and science of recognizing the presence and nature of disease by an evaluation of its various distinctive signs, symptoms and characteristics As modern rational therapy is based upon the scientific interpretation

of the changes in structure and function of the body tissues, the importance of an accurate diagnosis is at once evident There can be only one true diagnosis and the success of treatment is dependent upon its establishment

Professional, ethical and legal responsibilities dictate that

a complete chart and record documenting all the aspects of each patient’s dental treatment must be maintained Good records facilitate the provision of effective dental care and ensure the continuity and comprehensiveness of oral/dental health services

Case history is an important and integral part of treatment

1

Introduction

C H A P T E R

The principles of practice in dentistry

Responsibilities of a dental professional:

healthcare colleagues in the interest of patients

Case history is defined as planned professional conversation that enables a patient to communicate his/her feelings, fear and sequence of events leading to the problem for which the patient seeks professional assistance, to the clinician so that patient’s real or suspected illness and mental attitude can be determined Ideally case history is taken in a consultation room

or a private office in which the surroundings and the conditions are entirely friendly and not like the dental operating room

In many occasions, a properly prepared case history alone is sufficient to diagnose the disease without examining the patient

Of all the important diagnostic tools, the art of listening

is the most underrated Yet careful and attentive listening establishes patient-dentist rapport, understanding and trust.

Eliciting accurate, detailed and unbiased information from a patient is a skilled task and not simply a matter of recording the patient’s responses to a checklist of questions Avoid interrupting patients, particularly as they begin to tell you the story of the presenting features of the illness Recognizing the patient’s need to talk without interruption and being a good listener will greatly help you establish a good relationship quickly (Fig 1.1)

A case history is of immense value in the following ways:

• To provide information regarding etiology and establish diagnosis of oral conditions

• To reveal any medical problem necessitating precautions, modifications during appointments so as to ensure that dental procedures do not harm the patient and also to prevent emergency situations

• Evaluation of other possible undiagnosed problems

• Discovery of communicable diseases

• Gives an insight into emotional and psychological factors

• For effective treatment planning It enables dentists to obtain information necessary to provide appropriate and individualized care

• Record maintenance for future reference and periodic follow-up.

• To prevent medical complications and thus minimize detrimental effects to the patient and the possibility of medico-legal complications for the dentist

RISK MANAGEMENT

In recent years, the requirements for dental records management have been redefined, especially as they relate to documentation, release of information and storage Dentists are expected to be familiar with current expectations and to ensure that their staff members understand and adhere to the updated protocols

Fig 1.1: Listen to the patient

Patient records must be accurate, well-organized, legible, readily accessible and understandable If the dentist who has taken the history and noted the record is not available

to treat the patient for any reason, another dentist should be able to easily review the chart and carry on with the care of the patient

It is appropriate, where patient consent has been obtained,

to share dental and medical records with other health professionals as necessary to ensure continuity and quality

of care

• Every dental team member involved in a patient’s care should maintain the confidentiality and security of a patient’s dental records, only sharing them with other

Purposes of records

general health, as well as oral/dental status and any patient concerns and requests

performed, as well as all supporting documentation

from the expected outcomes should be recorded on the patient chart

at the time of service

dentist is aware of the situation

documented

healthcare professionals for the purpose of assisting in providing optimal care.

• Dental records should only be disposed of in a manner that ensures the confidentiality of the information is maintained.According to Dental Recordkeeping Guidelines (2010) by College of Dental Surgeons of British Columbia (CDSBC):

Essentials of Recordkeeping

The extent of detail required for each record will vary; however, certain baseline data should be common to all the dental patients

This information includes:

• Accurate general patient information

• A medical history that is periodically updated

• A dental history

• An accurate description of the conditions that are present

on initial examination, including an entry such as “within normal limits” where appropriate

• An accurate description of ongoing dental status at subsequent appointments

• A record of the significant findings of all the supporting diagnostic aids, tests or referrals such as radiographs, study models, reports from specialists

• All clinical diagnoses and treatment options

• A record that all reasonable treatment planning options were discussed with the patient

• The proposed and accepted treatment plan

• A notation that informed consent was obtained

• Assurance that patient consent was obtained for the release

of any and all patient information to a third party

• A description of all treatment that was performed, materials and drugs used and, where appropriate, the prognosis and outcome of the treatment

• Details about referrals

• An accurate financial record

The barriers to obtain a complete medical history by preprinted forms followed by appropriate in-depth questions

or by direct query of patients include (but are not limited to) time constraints imposed by busy practices, the unwillingness

of patients to reveal aspects of their medical status, and the impatience of the dentist while listening to the patients, as well as a variety of religious and moral issues that may arise

Establishing a good rapport (Fig 2.1) with the patient

is important for recording a complete history with valid information A sincere smile and being a good listener will help reassure the patient that it is appropriate and safe to divulge personal information

The clinician’s manners and demeanor (including his or her friendliness, empathy, openness and nonjudgmental attitude) during this process often determine patient’s satisfaction and compliance The clinician’s ability to put patients at ease will come into play during the initial medical interview To

2

Methods of Recording a Case History

C H A P T E R

Fig 2.1: Establishing a good rapport

facilitate this process, the clinician should exhibit an attentive posture, maintain eye contact, make the patient understand that the clinician understands the patient’s specific oral health problem, and recognize the patient’s emotional disposition toward dental care The most effective history-taking technique relies on establishing a dialogue between patient and clinician, which should provide both with an opportunity to satisfy the separate agendas each brings to the interview Although the clinician will have a scripted agenda, it is important that time

be given to the patient to tell his or her “story”

Always introduce yourself to the patient and any accompanying person, and explain, if it is not immediately obvious, what your role is in helping them Remember that patients are (usually) neither medically nor dentally trained,

so use plain speech without speaking down to them It is important to adopt a professional appearance and manner, and introduce oneself clearly and courteously Factors such

as age, cultural background, understanding and intelligence

of the patient must also be taken into consideration always while taking the history It is the clinician’s responsibility to elicit an accurate history; if that necessitates requirement of

an interpreter, then the clinician must arrange one

System for gathering information (techniques)

The dental history will give an idea of the:

There is usually a traditional approach in the design of a case history The preliminary part of the case history is usually based on questionnaires

Sequence of case recording and evaluation:

• General information

• Chief complaint

• History of present illness

• Previous dental history

It is recorded so as to impart knowledge to the investigator regarding important events in human life, such as: births, deaths, marriage and migrations Also, it makes the investigator familiar with the patient as it does contain personal details of the patient such as name, age, etc.

PATIENT REGISTRATION NUMBER

It helps the investigator in:

Full name of the patient should be recorded

Knowing the complete name of the patient while recording history leads to:

• Psychological benefit; especially in case of pediatric patient,

if called by nickname

• Sense of importance and acceptance to the patient

• Information of patient such asgender and religion

AGE

The exact date of birth should be written

Age (date of birth) has a particular significance to the investigator to decide upon the:

• Diagnosis

• Treatment planning

• Behavior management techniques

It is also used for maintaining hospital records and to know the psychology/mental development of the patient which has

a role on his dietary habits, oral hygiene practices and personal habits

Diagnosis

Age has a direct bearing on the presence of morbidity and mortality caused by the medical problems Increasing age typically increases a person’s tendency to develop medical conditions, such as hypertension, heart disease, diabetes and cancer

There is a predilection of certain diseases at different age levels Based on the disease predilection of age, the patients are divided into:

So, based on these age groups, one can rule out some of the dental diseases as well as medical conditions, which, in turn, relate to dental problems.

For example, Periodontitis is seen generally in old age, i.e > 50 years But if the condition is seen in children and young adults, one can confirm that it is juvenile periodontitis.Examples of conditions present at different ages are mentioned as follows:

Conditions commonly present at birth:

• Cleft lip and palate • Facial hemihypertrophy

• Ankyloglossia • Facial hemiatrophy

• Teratoma • Fissured tongue

• Hemophilia • Median rhomboid glossitis, etc

Conditions commonly present in children and young adults:

• Papilloma

• Juvenile periodontitis

• Scarlet fever, etc

Conditions commonly occurring in old age:

• Growth spurts: It is also important in developmental and hereditary diseases which occur at the time of birth and grows up to the puberty or ceases with growth It is also important for orthodontics treatment planning

– Infantile/childhood growth spurt

– Mixed dentition/juvenile growth spurt

– Prepubertal/adolescent growth spurt

• Calculation of child’s drug dosage

Based on Age

1 Fried’s Rule for Infants: Fried’s rule is a method of

estimating the dose of medication for a child by dividing the child’s age in months by 150 and multiplying the result

by the adult dose

Pediatric Dose = Child’s age in months Adult dose

2 Young’s Rule: It utilizes similar concepts as Fried’s rule except it is based on the child’s age in years When given the adult dose of a medication, it is possible to use this formula

to find the correct pediatric dose

Pediatric Dose = Child’s age in years

Child’s age in years + 12 years×Adult ddose

Based on Weight

3 Clark’s Rule: The procedure is to take the child’s weight in pounds, divide by 150, and multiply the fractional result by the adult dose to find the equivalent child dosage

Based on body surface area (BSA)

The nomogram method is utilized to determine the correct pediatric medication dosage based specifically on the patient’s size The patient’s size is identified as body surface area (BSA) in meter square (m2) The average adult client (weighing 150–154 lbs) will have a BSA of 1.73 m2 The nomogram chart can be used to identify the patient’s BSA based on their height and weight (in and lbs or cm and kg.)

Pediatric Dose = Child’s BSA in m

1.73 m2 Adult Dosage

2

×

BSA is determined from a nomogram using the child’s height and weight.

Example: If the child has a BSA of 0.67 m2 (in meters) and the adult dose is 40 mg Then dose for child would be:

0 67.1.73 × 40 = 15.8 mg

Calculation of child’s dosage by BSA is thought to be the most reliable method

Behavior Management Techniques

Management of patients of different age groups requires different behavior modification methods Example: Tell-show-

do, desensitization, etc

SEX

Similar to age, certain dental and systemic diseases also show sex predilection Some diseases are more specific to females while some are to males

Diseases affecting them are as follows:

• Basal cell adenoma.

Along with sex predilection of the diseases, gender also helps

to analyze the following:

• Important for the treatment planning in case of orthodontic patients as timing of growth spurts is different in males and females

• Esthetic needs of the patient: Girls are more conscious about their esthetics

• Dosage of drugs: The dosage of drug is affected by certain factors which are discussed below:

– Females require low dosage of drugs than the males as their body weight is less when compared to the males.– Extraordinary care should be taken while prescribing medicines to patients who are in menstruation, pregnancy, lactation

– Drugs given during pregnancy could affect the fetus directly

– Long-term use of antihypertensive drugs can lead to impotency in males

– Gynecomastia may be caused in males due to some medications like digitalis, ketoconazole, chlorpromazine, etc

• Most of the time, sex is linked to occupation and, in turn, related to occupational hazards

• Females are sensitive and emotional; hence, care should be taken during the treatment Sexual abuse or exploitation is more common in females

EDUCATION

Education level of the person is recorded to determine:

• Socioeconomic status

• Intelligence quotient (IQ) for effective communication

• Attitude toward general and oral health

ADDRESS

Complete postal address should be taken in order for communication and to ascertain geographic distribution The recording of the patient’s address, and telephone number; identification number (e.g social security number); age (date of birth); sex; race or ethnicity; name, address and

telephone number of a friend or next of kin; name, address and telephone number of the referring dentist or physician,

as well as that of the physician(s) and dentist(s) whom the patient consults for routine problems should be taken These records help:

• For future correspondence/recall

• To chart out appointments for patients from distant places

• Gives a view of the socioeconomic status For example, diseases such as diabetes, hypertension and dental caries are more prevalent in high socioeconomic status persons and diseases such as tuberculosis, chronic generalized periodontitis are more commonly found in low socioeconomic status

• In diagnosis of diseases, since certain diseases are found to

be more in particular geographical areas

For example:

– Fluorosis (as a result of increased level of fluorides in water) is spread differently in various parts of the country

It is endemic in certain areas

– Caries are more common in modern industrialized areas, whereas periodontal diseases are more common

in rural areas

– Filariasis common in Orissa

– Leprosy common in West Bengal

– Carcinoma of the palate common in Srikakulam, AP

• For hospital records/administrative purposes

Factors related to socioeconomic status

Socioeconomic status (SES) is assessed by looking at an individual group’s housing, occupation, education and income levels in comparison to their country’s statistical averages from surveys Socioeconomic status

is typically broken into 3 categories: High SES, middle SES and low SES

to describe the areas a family or an individual may fall into.

It is an indicator of socioeconomic status Also, it shows predilection of diseases in different occupations described in Table 3.1

Table 3.1: Oral manifestations of occupational diseases

according to etiologic agent

Occupation Specific factor Possible oral

and coal tar workers,

pavers, pitch roofers,

wood preservers

of lip and mucosa

Staining of teeth, pigmentation of gingiva, generalized abrasion, calculus, gingivostomatitis, hemorrhage Chemical workers,

electroplaters, metal

refiners, rubber mixers

black pigmentation of gingiva

Bismuth handlers,

gingivostomatitis Refiners, bakers,

Alcohol, distillery,

explosives, shellac,

smokeless powder and

shoe factory workers

(Adapted from I Schour and BG Sarnat Oral manifestations of occupational origin JAMA 1942;120:1197)

Thus, occupation can be an important factor in determining the source or cause of the disease for further treatment of the disease.

It helps in planning appointments for the patients as per their occupation and also determines their affordability in relation to money and time for the treatment

It also tells about the socioeconomic status of the patient and his ability to afford the nutritious food and use of healthy oral hygiene practices

RELIGION

Religion has a particular significance to the investigator in:

• Identifying the festive periods when religious people are reluctant to undergo treatment procedures

• Predilection of diseases in specific religions

The chief complaint is established by asking the patient to describe the problem for which he or she is seeking help or treatment It is recorded in patient’s own words as much as possible, and no documentary or technical language should

be used It answers the question, “Why are you here today?” It

is primarily a statement of the patient’s signs and symptoms

It is recorded in chronological order of their appearance, and

in the order of their severity The patient should be questioned about any other pertinent issues, including medical and dental history

The complaint should be documented with the following information: Duration/progression, domain, character and relation to physiological function The chief complaint aids

in the diagnosis and treatment planning and should be given the first priority

The chief complaint is a statement of why the patient consulted the dentist The verbal complaint may be accompanied by the patient pointing to the general area of the problem

Restatement of the chief complaint by the dentist may be necessary to clearly define the problem Many patients are apprehensive when confronted by a dentist, and if the dentist appears indifferent or unsympathetic, this can result in barriers

to effective communication, which will simply hinder the dentist

The problem that brought the patient to the dentist

is obviously a treatment priority, and the patient’s chief

4

Chief Complaint

C H A P T E R

complaint should become the dentist’s chief treatment priority Otherwise, the patient will seek treatment elsewhere Pain is the most common chief complaint that makes patients seek dental treatment, followed by check-up, esthetic, and teeth replacement Esthetic complaint is more common in females and younger patients.

Common chief complaints include:

After establishment and recording of the chief complaint, the

examination process is continued by obtaining a history of the present illness A history of the present illness should indicate

the severity and urgency of the problem

Initially, the patient may not volunteer the detailed history of the problem So the examiner has to elicit the additional information by the possible questionnaire about the symptoms The patient’s response to these questions is termed history of present illness The conversation should

be directed by the clinician in order to produce a clear and concise narrative that chronologically depicts all the necessary information about the patient’s symptoms and the development of these symptoms

In order to help elucidate this information, the patient may

be first instructed to fill in a dental history form as a part of the patient’s office registration It is a chronological account of the chief complaint and associated symptoms from the time of onset to the time the history is taken The history commences from the beginning of the first symptom and extends to the time of the examination The history of present illness is the course of the patient’s chief complaint: When and how it began; what exacerbates and what ameliorates the complaint (when applicable); if and how the complaint has been treated, and what was the result of any such treatment; and what diagnostic tests have been performed

“Expanding the chief complaint by filling in the dimensions

of the problem identified in the chief complaint provides a more complete statement—the history of present illness.”

5

History of Present Illness

C H A P T E R

• The questions can be asked in the following manner:

– When did the problem start?

– What did you notice first?

– Did you have any problems or symptoms related to this?– What makes the problem worse or better?

– Have any tests been performed before to diagnose this complaint?

– Have you consulted any other examiner or dental professional for this problem?

– What have you done to treat this problem? etc

• In general, the symptoms can be elaborated under:

– Progress and referred pain

– Relapse and remission

– Treatment taken so far

Note the following:

• Anatomical location (site)

• Origin and mode of onset

Analysis of pain is important so as to reach to the proper diagnosis A careful history is an essential prerequisite; else it may confuse the clinician to frame a wrong diagnosis There are various factors to be considered in pain:

If the history of the presenting complaint includes pain, ask

about it using the Mneumonic SOCRATES

y SITE: Where exactly is this pain?

y ONSET: When did the pain start; did it start suddenly or gradually?

y CHARACTER: Describe the pain—sharp, knife-like, gripping, burning,

crushing, sharp, dull, stab, burn, cram or crushing

y RADIATION: Does the pain spread anywhere; to the ear, jaw, eyes, etc.?

y ALLEVIATING FACTOR and ASSOCIATIONS: Is the pain accompanied

by any other features?

y TIMING: Does the pain vary in intensity during the day?

y EXACERBATING FACTORS

y SEVERITY: Scale of 1 to 10.

• Site of Pain: Determining the original site of pain is

• Origin and mode of onset: “When did the symptoms first occur?” A patient who is having symptoms may remember

when these symptoms started

The dentist may ask the patient, “How did the pain start?”

The origin and mode of onset is important to determine the chronicity of pain A long continued pain with insidious onset indicates chronic nature of the disease, whereas a recent onset of pain with sudden impact indicates acute nature of the disease

• Severity: The perception of pain varies in different

individuals A mild pain may be severe to others It often helps to quantify how much pain the patient is actually having The clinician might ask, “on a scale from 1 to

10, 10 being the most severe, how would you rate your symptoms?”

The severity of pain gives an impression of the acuteness of the symptoms felt by the patient, thus helping in constituting

– Burning pain: Pain usually occurs with the burning

sensation, e.g reflex oesophagitis

– Throbbing pain: Type of pressured throbbing sensation

is felt, e.g in abscesses

– Stabbing pain: Sudden, severe, sharp and shortlived pain,

e.g acute pulpal pain

– Shooting pain: Pain increases in severity in a short period,

e.g trigeminal neuralgia

• Nature of pain: Pain may occur continuously or can be

intermittent, with periods of remission in between

Continuous pain indicates an acute problem or an exacerbation of chronic problem while intermittent pain indicates chronicity of the problem

• Progression of pain: The clinician asks the patient, “how

is the pain progressing?” The progression of pain from the time of its onset is to be asked

• Duration of the pain: In terms of days/months/years The

clinician asks, “How long does the pain last?” Pain can be

intermittent or continuous A continuous pain is the one which persists for a longer duration An intermittent pain is the one which occurs after short intervals of time

• Radiation of pain: It is the extension of pain to another site,

while the original site is still painful The radiating pain has the same characteristic as that of the original pain

‘Referred pain’ is a term used to describe the phenomenon

of pain perceived at a site adjacent to or at a distance from the site of an injury’s origin (Dorland’s Medical Dictionary)

• Precipitating or aggravating factors: Different factors may

worsen the pain suggesting a specific diagnosis about the disease For example, the pain of cracked tooth syndrome occurs when the patient relieves the occlusal pressure over the tooth

• Relieving factors: Factors which reduce the severity or

frequency of pain are considered important in diagnosis For example, in some cases, pain of chronic pulpitis gets relieved by cold application

• Associated symptoms: Pain may occur along with nausea,

vomiting, sweating, flushing and increase in pulse rate