Abstract
A well-conducted clinical examination, with careful history taking, is a fundamental tool for the adequate diagnosis, planning, and determination of the best clinical conduct of oral diseases. The clinical examination is divided into two moments: history taking and physical examination. In this chapter, we discuss important points for the professional to take a careful and complete current and past medical history, as well as to observe clinical signs, symptoms, and maneuvers to diagnose the disease.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Sources
Burgess K. Extraoral and intraoral soft tissue examination. Toronto, Ontario: University of Toronto: Faculty of Dentistry; 2019. https://iits.dentistry.utoronto.ca/extraoral-and-intraoral-soft-tissue-examination. Accessed 15 Nov 2021
Burkhart NW, DeLong L. The intraoral and extraoral exam. Provider. 2012;501:211886. DentalCare.com. https://www.dentalcare.com/en-us/professional-education/ce-courses/ce337/the-intraoral-examination. Accessed 15 Nov 2021
Caton JG, Armitage G, Berglundh T, Chapple ILC, Jepsen S, Kornman KS, Mealey BL, Papapanou PN, Sanz M, Tonetti MS. A new classification scheme for periodontal and peri-implant diseases and conditions–introduction and key changes from the 1999 classification. J Clin Periodontol. 2018;45(Suppl 20):S1–8. https://doi.org/10.1111/jcpe.12935.
Elango KJ, Anandkrishnan N, Suresh A, Iyer SK, Ramaiyer SK, Kuriakose MA. Mouth self-examination to improve oral cancer awareness and early detection in a high-risk population. Oral Oncol. 2011;47(7):620–4. https://doi.org/10.1016/j.oraloncology.2011.05.001. PMID:21646040
Eusterman VD. History and physical examination, screening and diagnostic testing. Otolaryngol Clin N Am. 2011;44(1):1–29, v. https://doi.org/10.1016/j.otc.2010.10.001.
Glass RT, Abla M, Wheatley J. Teaching self-examination of the head and neck: another aspect of preventive dentistry. J Am Dent Assoc. 1975;90(6):1265–8. https://doi.org/10.14219/jada.archive.1975.0254. PMID:1056392
Lingen MW, Abt E, Agrawal N, Chaturvedi AK, Cohen E, D’Souza G, Gurenlian J, Kalmar JR, Kerr AR, Lambert PM, et al. Evidence-based clinical practice guideline for the evaluation of potentially malignant disorders in the oral cavity: a report of the American dental association. J Am Dent Assoc. 2017;148(10):712–727.e10.
Miranda Galvis M, Schausltz Pereira Faustino I, Cabral Ramos J, Dos Santos Silva AR, de Abreu AF, Kowalski LP, Ajudarte LM. Oral cancer adjacent to dental implants mimicking benign lesions: a case series study. Aust Dent J. 2021;66(1):112–8. https://doi.org/10.1111/adj.12793. Epub 2020 Oct 4
Ojha S, Narula A. Carrying out a comprehensive intraoral examination in dental pain. BMJ. 2014;348:g164. https://doi.org/10.1136/bmj.g164.
Oral medicine (stomatology) in Brazil: the first 50 years and counting. Oral Surg Oral Med Oral Pathol Oral Radiol. 2022;134(1):57–64. https://doi.org/10.1016/j.oooo.2022.01.018.
Pigg M. Chronic intraoral pain--assessment of diagnostic methods and prognosis. Swed Dent J Suppl. 2011;220:7–91.
Santos-Silva AR, Lopes MA, Pedroso CM, Ribeiro ACP, Fonseca FP, Brandão TB, Gueiros LAM, Rocha AC, Pires FR, Miranda ÁA, Júnior HM, Alves FA, Marcucci M, Lemos CA, Sugaya NN, Marcucci G, Carrard VC, Martins MD, Cardoso AS, Migliorati CA. Oral medicine (stomatology) in Brazil: the first 50 years and counting. Oral Surg Oral Med Oral Pathol Oral Radiol. 2022;134(1):57–64. https://doi.org/10.1016/j.oooo.2022.01.018. Epub 2022 Feb 2
Scully C, Miller CS, Aguirre Urizar JM, Alajbeg I, Almeida OP, Bagan JV, Birek C, Chen Q, Farah CS, Figueirido JP, Hasséus B, Jontell M, Kerr AR, Laskaris G, Lo Muzio L, Mosqueda-Taylor A, Nagesh KS, Nikitakis NG, Peterson D, Sciubba J, Thongprasom K, Tovaru Ş, Zadik Y. Oral medicine (stomatology) across the globe: birth, growth, and future. Oral Surg Oral Med Oral Pathol Oral Radiol. 2016;121(2):149–157.e5. https://doi.org/10.1016/j.oooo.2015.10.009. Epub 2015 Oct 19
Shah A, Bhushan B, Akhtar S, Kumar Singh P, Garg M, Gupta M. Effectiveness of mouth self-examination for screening of oral premalignant/malignant diseases in tribal population of Dehradun district. J Family Med Prim Care. 2020;9(8):4381–5. https://doi.org/10.4103/jfmpc.jfmpc_535_20. PMID:33110864
Shrestha G, Maharjan L. Mouth self-examination for prevention and control of Oral cavity cancer. JNMA J Nepal Med Assoc. 2020;58(225):360–2. https://doi.org/10.31729/jnma.4910. PMID:32538936
Sonis S.T. (2012) The elements of examination of the Oral cavity. In: Oral mucositis. Springer Healthcare, Tarporley. https://doi.org/10.1007/978-1-907673-46-7_5.
Walsh T, Liu JL, Brocklehurst P, Glenny AM, Lingen M, Kerr AR, et al. Clinical assessment to screen for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults. Cochrane Database Syst Rev. 2013;2013(11):CD010173. https://doi.org/10.1002/14651858.CD010173.pub2. PMID:24258195
Westman EC, Duffy MB, Simel DL. Should physicians screen for oral disease? A physical examination of the oral cavity. J Gen Intern Med. 1994;9(10):558–62. https://doi.org/10.1007/BF02599281.
Warnakulasuriya S, Kerr AR. Oral cancer screening: past, present, and future. J Dent Res. 2021;100(12):1313–20. https://doi.org/10.1177/00220345211014795. Epub 2021 May 26. PMID: 34036828; PMCID: PMC8529297
Acknowledgments
The São Paulo State Research Foundation (FAPESP, São Paulo, Brazil, grant number JFS 19/09419-0) and the Coordination of Training of Higher Education Graduate Foundation (CAPES, Brasilia, Brazil, finance code 001).
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG
About this chapter
Cite this chapter
Scarini, J.F. et al. (2023). History Taking and Physical Examination. In: Santos-Silva, A.R., Lopes, M.A., Scarini, J.F., Vargas, P.A., Almeida, O.P.d. (eds) Clinical Decision-Making in Oral Medicine. Springer, Cham. https://doi.org/10.1007/978-3-031-14945-0_1
Download citation
DOI: https://doi.org/10.1007/978-3-031-14945-0_1
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-031-14944-3
Online ISBN: 978-3-031-14945-0
eBook Packages: MedicineMedicine (R0)