Introduction

"Accurate diagnosis of a disease depends on the art of taking Case History"

Case history is an important and integral part of treatment.

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.
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 patients' real or suspected illness and mental attitude of the
patient can be determined.

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
to 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
• Record maintenance for future reference and periodic follow-up
• Acts as a evidence in legal matters.

Components of Clinical Record Sheet:

• General Information
• History Recording
• Examination of the patient
• Establishment of provisional diagnosis
• Necessary investigations
• Final Diagnosis
• Treatment plan
Methods of Recording a Case History

Establishing a good rapport 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.
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
• Medical History
• Family History
• Personal History
• General Physical Examination
• Extraoral Examination
• Intraoral Examination
• Provisional Diagnosis
• Investigations
• Final Diagnosis
• Treatment Plan

General Information
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:
• Record maintenance
• Billing purposes
• Medicolegal aspects
• Identification of the patient.
DATE
The date is recorded in full for the following purpose:
• Reference
• Record maintenance.

NAME
Knowing the complete name of the patient while recording history leads to:
• Identification
• Communication
• Establishing a rapport with patient
• Record maintenance
• Psychological benefit; specially in case of pediatric patient if called by
nickname
• Sense of importance and acceptance to the patient
• Information of patient such gender and religion.

AGE
Age (date of birth) has a particular significance to the investigator to decide
upon:
• 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 role on his dietary
habits, oral hygiene practices and personal habits.
Diagnosis
There is a predilection of certain diseases at different age levels. Based on the
disease predilection of age patients are divided into:
• Neonatal: At Birth
• 1-3 Yrs: Infancy
• 4-14 Yrs: Child
• 15-20 Yrs: Young Adults
• 21-40 Yrs: Adults
• 40-50 Yrs: Older Adults
• Above 50 Yrs: Old Age

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 yrs.
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
• Fissured tongue
• Teratoma
• 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:
• Attrition/ abrasion
• Periodontitis
• Pulp stones
• Root resorption, etc.

Treatment Planning
• Comparison/Correlation of chronological age with dental age will help to
decide the line of treatment for a patient.
Chronological age gives information about the dento-skeletal development of
the person.
• 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.
- Infantile/childhood growth spurt
- Mixed dentition/juvenile growth spurt
- Prepubertal/adolescent growth spurt

• Calculation of child's dosage.

Based on age
1. Young's Rule

Age adult dose = DOSE FOR CHILD

Age + 12
Based on weight
2. Clark's Rule,
Weight (in lb) adult dose = Dose for infant
150 (average weight for adult in lb)

3. Fried's Rule for Infants

Weight (in months) adult dose = Dose for child
150

Based on body surface area (BSA)

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

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

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.

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:
Females
• Iron Deficiency Anemia
• Pleomorphic Adenoma
• Sjogren's Syndrome
• Adeno Ameloblastoma
• Myasthenia Gravis
• Sickle Cell Anemia
• Thyroid Diseases
• Juvenile Periodontitis
-Peripheral Ossifying Fibroma
• Nasoalveolar Cyst
• Anorexia nervosa
• Parotid gland diseases
• Erosion
• Aphthous ulcers
• Oral Lichen Planus.

Males
• Stomatitis nicotina palate
• Hemophilia
• Attrition
• Carcinoma in Situ
• Carcinoma of the buccal mucosa
• Leukoplakia
• Keratoacanthoma
• Basal Cell Carcinoma
• Verrucous Carcinoma
• Adenoid cystic Squamous cell carcinoma
• Liposarcoma
• Hodgkins Disease
• Multiple Myeloma
• Chondrosarcoma
• Herpes Simplex
• Ewings Sarcoma
• Ameloblastic fibro-odontoma
• Basal cell Adenoma.
Along with sex Predilection of the diseases, Gender also helps to analyze
the following:
1. Important for the treatment planning in case of orthodontic patients as
timing of growth spurts is different in males and females.
2. Esthetic: Girls are more conscious about their esthetics.
3. 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.
4. Most of the times, sex is linked to occupation and in turn, related to
occupational hazards.

EDUCATION

Education level of the person is recorded to determine:

• Socioeconomic status
• Intelligence quotient (IQ) for effective communication
• Attitude towards general and oral health.

ADDRESS
Full Postal Address should be taken in order for communication and to
ascertain geographic distribution.

1. For future correspondence/Recall

2. 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
strata.
3. To know prevalence of diseases: certain diseases are found more in a
particular area.
For example:
a. Fluorosis (as a result of increased level of fluorides in water) is spread
differently in various parts of country. It is endemic in certain areas.
b. Caries are more common in modern industrialized areas, hereas periodontal
diseases are more common in rural areas.
c. Filariasis common in Orissa
d. Leprosy common in West Bengal
e. Carcinoma of the Palate common in Srikakulam AP
4. 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.

OCCUPATION
It is an indicator of socioeconomic status. Also, it shows predilection of
diseases in different occupations, such as:
Thus, occupation can be an important factor in determining the source or
cause of the disease for the further treatment of the disease.
It helps in planning appointments for the patient 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.
CHAPTER 4

Chief Complaint
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 chief complaint aids
in the diagnosis and treatment planning and should be given the first priority.
Common chief complaints include:
• Pain
• Bad taste
• Bleeding from gums
• Loose teeth
• Hypersensitivity
• Burning sensation
• Recent occlusal problems
• Delayed tooth eruptions
• Dry mouth
• Swellings
• Paresthesia and anesthesia
• Irregular teeth
• Missing teeth
• Routine dental check-up.
CHAPTER 5

History of Present Illness

Initially, the patient may not volunteer the detailed history of the problem, so the examiner has to
elicit out the additional information by the possible questionnaire about the symptoms. The
patient's response to these questions is termed history of present illness. 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.
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.
• The questions can be asked in the 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 for this problem?
- What have you done to treat this problem? Etc.
• In general, the symptoms can be elaborated under:
- Mode of onset
- Cause of onset
- Duration
- Progress and referred pain
- Relapse and remission
- Treatment
- Negative history
DETAIL HISTORY OF PARTICULAR SYMPTOM
Pain
The International Association for the Study of Pain (IASP) gives this definition as "an unpleasant
sensory and emotional experience associated with actual or potential tissue damage, or described in
terms of such damage". The IASP classification system recommends describing pain according to
five categories: duration and severity, anatomical location, body system involved, cause, and
temporal characteristics (intermittent, constant, etc.)
Note the following:
• Anatomical location (site )
• Origin and mode of onset
• Intensity of pain
• Nature of pain
• Progression of pain
• Duration of pain
• Movement of pain
• Localization behavior
• Effect of functional activity
• Neurological signs
• Temporal behavior.

Analysis of Pain
The word pain is derived from Latin word 'poena' meaning penalty or punishment. It is a very
common symptom and occurs in response to an injurious stimulus.
Four types of pain are noticed:
1. Superficial: occurs due to direct irritation of the peripheral nerve endings.
2. Segmental: occurs due to irritation of a sensory nerve trunk or root.
3. Deep or visceral: occurs due to irritation of deep structures in the body.
4. Psychogenic or central: pain arises from brain, due to an emotional or hysterical situation.
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:
• Site of pain: determining the original site of pain is important.
The clinician may ask the patient 'where did the pain start'?
Although the site of pain may have changed after a short period, the original site must be known.
• Origin and mode of onset: The clinician 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 disease.
• Severity: The perception of pain varies in different individuals.
A mild pain may be severe to others. The severity of a pain gives an impression of the acuteness of
the symptoms felt by the patient, thus helping in constituting a proper diagnosis.
• Type of pain: There are various types of pain. The most common are:
- Vague pain: It is a mild continuous pain, e.g. periodontal pain
- 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 short-lived pain, e.g. acute pulpal pain.
- Shooting pain: Pain increases in severity in a short period, e.g. trigeminal neuralgia.

• 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 the pain
lasts'? Pain can be intermittant 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 character as 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
application.
some cases, pain of chronic pulpitis gets relieved by cold
• Associated symptoms: pain may occur along with nausea, vomiting, sweating, flushing and
increase in pulse rate.

Swelling
• Anatomical location (site )
• Duration
• Mode of onset
• Symptoms
• Progress of swelling
• Associated features
• Secondary changes
• Impairment of function
• Recurrence of swelling.
Examination of a swelling should be accompanied by a complete history of the patient.
Following points should be noted:
• Duration: The clinician may ask 'when was the swelling first noticed'? Swellings that are
painful and of shorter duration are mostly inflammatory (acute), whereas those with longer duration
and without pain are chronic, e.g. a chronic periapical abscess.
• Mode of onset: The clinician may ask 'how did the swelling start'? The history of any injury or
trauma or any inflammation may contribute to the diagnosis and nature of the swelling.
• Progression: The clinician should ask 'has the lump changed in size since it was first noticed?
Benign growths such as bony swellings grow in size very slowly and may remain static for a long
period of time. If the swelling decreases in size, this suggests of an inflammatory lesion.
• Site of swelling: The original site where it started must be assessed.
• Other symptoms: Pain, fever, difficulty in swallowing, difficulty in respiration, disfigurement,
bleeding or pus discharge are the common symptoms associated with swellings in the orofacial
region.
• Recurrence of the swelling: many swellings do recur after removal of the tissue, indicating
the presence of precipitating factor, e.g. ranula.

ULCER

An ulcer is a break in the continuity of epithelium. A proper history must be taken in case of
an ulcer:
• Mode of onset: The clinician may ask how has the ulcer developed'? The patient may provide
significant information about the nature and etiology of the ulcer such as any trauma or
spontaneously.
• Duration: The clinician may ask 'how long is the ulcer present here'? It determines the chronicity
of the ulcer. For example, traumatic ulcers in oral cavity are acute (occurring for a short period), but
if the agent persists; it may become a chronic ulcer.
• Pain: The clinician may ask 'is the ulcer painful'? Most of the ulcers, being inflammatory in
nature, produce pain. Painless ulcers usually suggest nerve diseases (such as peripheral neuritis,
syphilis, etc).
• Discharge: Any blood, pus or serum discharge must be noted.
• Associated disease: Any associated generalized systemic problem may be associated with the
ulcers of oral cavity (such as tuberculosis, squamous cell carcinoma, etc).
Dental Hypersensitivity
Causes
Exposure of dentinal tubules due to
• Wasting diseases — attrition, abrasion, erosion, abfraction
• Gingival recession
• Following periodontal surgery/root planing due to removal of cementum overradicular dentin.
Patient History
Patients often report with complaint of a sudden, short, sharp shock-like sensation in response to
cold or hot, sweet or sour substances, or touch. This sensation is a hyperreactive pulpalgia and must
be elicited by some exciting factor. It is never spontaneous. Exciting factors are usually cold food or
drink or cold air, contact of two dissimilar metals that will yield a galvanic shock, or stimulation of
the exposed dentin on the root surface by cold, sweet or sour, vegetable or fruit acid, salt, or
glycerine, or often just touching the surface with a fingernail, toothbrush, or explorer.
Bleeding from the Gums
Patients often report with problems of chronic or recurrent bleeding, which is provoked by
mechanical trauma (e.g. from toothbrushing, toothpicks, or food impaction) or by biting into solid
foods such as apples.
History of Bleeding Gums
• Duration
• Amount/Quantity
• Ease with which bleeding can be elicited
• Associated symptoms (dull pain, sensitivity).
Causes
Chronic or recurrent bleeding: Most common cause is chronic gingival inflammation.

Acute bleeding
• Caused by injury or can occur spontaneously in acute gingival
disease
• Acute Necrotizing Ulcerative Gingivitis (ANUG).
Gingival bleeding associated with systemic changes
• Hemorrhagic disorders (Vitamin C deficiency, Schonlein-Henoch purpura)
• Platelet disorders (thrombocytopenic purpura)
• Hypoprothrombinemia (Vitamin K deficiency)
• Other coagulation defects (hemophilia, leukemia, Christmas disease)
• Deficient platelet thromboplastic factor (PF3) resulting from uremia, multiple myeloma,
postrubella purpura
• Excessive intake of drugs (salicylates, anticoagulants — dicoumarol and heparin).
Dry Mouth (Xerostomia)
The subjective feeling of oral dryness is termed xerostomia. It is a symptom, not a diagnosis or a
disease.
Causes of Xerostomia
• Developmental (Aplasia and hypoplasia of the salivary glands)
• Drugs (Tricyclic antidepressants, antipsychotics, antihistaminics, atropine, B-lockers)
• Radiation therapy of head and neck
• Oncologic chemotherapy
• Infections and inflammatory conditions (Parotitis, Mumps)
• Benign or malignant tumors of the salivary glands
• Systemic diseases:
- Sjogren's syndrome
- Granulomatous diseases (Sarcoidosis, Tuberculosis)
- Graft-versus-host-disease
- Cystic fibrosis
- Bell's palsy
- Diabetes
- Amyloidosis
- HIV infection
- Thyroid disease
- Late stage liver disease

- Patients on hemodialysis for end-stage renal disease

• Psychological factors affective disorders)
• Malnutrition (anorexia, bulimia, dehydration)
• Idiopathic disorders
• Smoking, use of smokeless tobacco products, alcoholism and caffeine can aggravate dry mouth.
Diagnosis and Evaluation of Xerostomia
• Patient history: Patient complains of dryness of all oral mucosal surfaces, particularly at night,
or of difficulty chewing, swallowing and speaking, mucosa may be sensitive to spicy or coarse
foods.
• Past and present medical history: Assess for medical conditions or medications known to
cause dry mouth.
• Clinical features: The oral mucosa may be dry and sticky, lips are often cracked, peeling and
atrophic, buccal mucosa may be pale and corrugated or erethamatous due to an overgrowth of
Candida albicans. There may be little or no pooled saliva in the floor of the mouth, and the tongue
may appear dry with loss of papillation. The saliva may appear stringy, ropy or foamy. There is
often a marked increase in erosion and dental caries, particularly root caries and even cusp tip
involvement.
Two Additional Indications of Oral Dryness
"Lipstick sign" - Lipstick adheres to the facial surface of maxillary anterior teeth.
"Tongue-blade sign" - Tongue blade adheres to the buccal mucosa.
Clinical examination should also include bimanual palpation of major salivary glands to assess the
size, consistency and tenderness of the glands, and also to determine if saliva can be expressed via
the main excretory ducts. Enlarged, painful glands are indicative of infection or acute inflammation.
The consistency should be slightly rubbery, but not hard, and distinct masses within the body of the
gland may be indicative of a salivary gland tumor.
Several office tests and techniques can be utilized to ascertain the function of salivary glands.
Sialometry, or salivary flow measurement can determine the salivary output from the individual
major salivary glands or from the whole saliva. Unstimulated whole saliva flow rates of < 0.1
mL/min and stimulated whole saliva flow rates of < 1.0 mL/min are considered abnormally low and
indicative of marked salivary gland hypofunction.
Salivary gland imaging can provide information on salivary function, anatomic alterations, and
space-occupying lesions within the glands. Various salivary gland imaging modalities include
plain-film radiography, Sialography, Ultrasonography, Radionuclide Salivary Imaging, Computed
Tomography and Magnetic Resonance Imaging. Minor salivary gland biopsy is often used in the
diagnosis of Sjögren's syndrome (SS), human immunodeficiency virus-salivary gland disease,
sarcoidosis, amyloidosis and graft-vs-host disease.
Biopsy of major salivary glands is an option when malignancy is suspected.

Burning Sensation of the Mouth

Burning sensations accompany many inflammatory or ulcerative diseases of the oral mucosa, but
term Burning Mouth Syndrome is reserved for describing oral burning that has no detectable cause.
• Local causes
- Stomatitis
- Ulcers
- Infections (e.g. Candidiasis)
- Dry mouth, salivary gland hypofunction
- Mucosal disorders (Geographic tongue, lichen planus, etc.)
- Trauma to oral mucosa (e.g. Poorly fitting dentures)
- Gastroesophageal reflux disease.

• Systemic causes
- Vitamin B.12, folate, iron deficiencies
- Medication (e.g. ACE inhibitors such as Captopril)
- Immunologically mediated diseases (e.g. Sjogren's disease)
- Psychogenic disorders (e.g. Anxiety, depression, fear of cancer)
- Psychosocial stress
- Diabetes mellitus
- Menopause/hormonal disturbances.
Diagnosis and Evaluation of Burning Mouth
• History: When questioned, 10 to 15 percent of postmenopausal women are found to have a history
of oral burning sensations, and these symptoms are most prevalent 3 to 12 years after menopause.
Burning may be intermittent or constant, but eating, drinking, or placing candy or chewing gum in
the mouth characteristically relieves the symptoms. Tongue is most frequently involved, followed
by lips and palate. These patients usually are anxious, they may also have symptoms suggestive of
depression.
• Clinical features and laboratory studies can help eliminate other causes of burning symptoms of
oral mucosa from burning mouth syndrome. Patients with unilateral symptoms require thorough
evaluation of trigeminal and other cranial nerves to eliminate a neurological source of pain. Oral
examination for lesions resulting from Candidiasis, lichen planus or other mucosal diseases should
be performed. Salivary gland assessment should be done for patients complaining of a combination
of xerostomia and burning.
When indicated, laboratory tests should be carried out to detect undiagnosed diabetic neuropathy,
anemia or iron, folate or Vitamin B12 deficiencies.
Loose Teeth or Tooth Mobility
Causes
• Loss of tooth support (bone loss) due to periodontal disease
• Trauma (physical trauma from a fall or blow to the teeth)
• Trauma from occlusion
• Abnormal occlusal habits (bruxism, clenching)
• Hypofunction
• Extension of inflammation from the gingival or periapex into the periodontal ligament results in
changes that increase mobility.
For example, spread of inflammation from an acute periapical abcess may increase tooth mobility
in the absence of periodontal disease
• Periodontal surgery temporarily increases tooth mobility
• Mobility may be increased in pregnancy, or sometimes may be associated with menstrual cycle
or use of contraceptive pills
• Osteomyelitis of the alveolar bone
• Cysts/tumors of the jaw.
Symptoms and Diagnosis of Tooth Mobility
Patient complains of discomfort while chewing of food, pain may accompany the mobility of teeth;
the tissues around a mobile tooth are invariable red, swollen and damaged. At times, patient may
report with complaint of the loose tooth without any accompanying symptom.

Halitosis or Oral Malodor

"Halitosis may rank only behind dental caries and periodontal disease as the cause of the patient's
visit to the dentist."
Origin may be either -
Oral
• Poor oral hygiene
- Retention of odoriferous food particles on and between the teeth
- Coated tongue
- Artificial dentures
• Acute Necrotizing ulcerative gingivitis
• Pericoronitis
• Abscesses
• Dehydration states
• Ulceration in the oral cavity
• Hyposalivation/ Xerostomia
• Bone disease (Dry socket, Osteomyelitis, Osteonecrosis and malignancy)
• Smoker's breath
• Healing oral wounds
• Chronic periodontitis with pocket formation.

Extraoral (Conditions that can Contribute to Presence of Oral Malodor)

• Sinusitis and other bacterial infections
• Dry nasal mucosa
• Blocked nose (which can cause mouth breathing)
• Tonsillitis/tonsil stones
• Various carcinomas
• Infections of the respiratory tract (bronchitis, pneumonia, bronchiectasis )
• Alcoholic breath
• Uremic breath of kidney dysfunction
• Acetone odor of Diabetes
When a patient presents to the dental office with the complaint of halitosis, it is important for the
dental professional to eliminate systemic conditions that may be contributing to the presence of oral
malodor. For this reason, it is important to have an up-to-date medical history of the patient, which
should help the dental professional eliminate any systemic causes for the presence of oral malodor.
The clinical assessment of oral malodor is either subjective or objective. Subjective assessment is
based on smelling the exhaled air of the mouth and nose and comparing the two (organoleptic
assessment). Various scoring systems, such as a 0- to 5-point scale (Table 1), and a 0- to 10-point
scale can be used to estimate the intensity of exhaled oral odor, tongue odor and nasal odor, among
others.
ORGANOLEPTIC SCORING SCALE
• Absence of odor
• Questionable to slight malodor. Odor is deemed to exceed the threshold of malodor detection
• Moderate malodor. Odor is definitely detected
• Strong malodor. Malodor is objectionable but examiner can tolerate
• Severe malodor. Overwhelming malodor. Examiner cannot tolerate