Examination of dental Examination of dental patient: subjective and patient: subjective and

objective, basic and extra objective, basic and extra methods. Medical methods. Medical

document of therapeutic document of therapeutic dentistry reception. dentistry reception.

Hospital chart as medical, Hospital chart as medical, legal and scientific legal and scientific

document.document.

Therapeutic dentistry Therapeutic dentistry

departmentdepartment

METHODS OF DENTAL PATIENT EXAMINATION

Taking a history (subjective examination), during which the patient provides doctor with all diagnostic information about itself.

Objective examination (visual examination, palpation, percussion, probing) using basic and extra (laboratory, instrumental) methods.

Subjective examination

The medical history

The dental history

History of the

present complaint

Anamnesis

Demographic details

The family and social history

Table. Essential principles of history-taking technique

►Introduce yourself and greet patient by name►Put patients at their ease

►Start with an open question

►Avoid leading questions

►Avoid jargon

►Explain the need for specific questions

►Assess the patient’s mental state

►Assess the patient’s expectations from treatment

Table 1.4 Taking a pain historyCharacteristic

Informative features

TypeAche, tenderness, dull pain, throbbing, stabbing, electric shock. These terms are of limited and the constancy of pain is more useful.

Severity

Mild – managed with mild analgesics (e.g. aspirin / paracetamol)Moderate – unresponsive to mild analgesicsSevere – disturbs sleep

Duration Time since onset. Duration of pain or attacks.

NatureContinuous, periodic or paroxysmal. If not continuous, is pain presence between attacks?

Initiating factors

Any potential initiating factors. Association with dental treatment or lack of it is especially important in eliminating dental cause.

Exacerbating and relieving factors

Record all and note especially hot and cold sensitivity or pain on eating which suggest a dental cause.

LocalisationThe patient should map out the distribution of pain if possible. Is it well or poorly defined?

Referral Try to determine whether the pain could be referred.

OBJECTIVE EXAMINATION

Clinical examination — extra-oral

Symmetry and Profile

Cutaneous Area

Cutaneous lesion of discoid lupus

Lupus erythematosus

Eyes

Yellow sclera is associated with jaundice and may indicate an undiagnosed case of hepatitis (A or B), other liver dysfunction or a blood disorder

Observe the eyes for any abnormalities

Lymphatic nodesThe presence of neck masses is not an uncommon finding, especially in patients with oral infections or advanced malignancies. The anterior cervical chain is most commonly involved, although other regional lymph nodes may be enlarged as well. Lymphadenopathy secondary to infection generally is both mobile and tender, while metastatic lymphadenopathy is asymptomatic and fixed to the underlying structures; however, a significant amount of variation exists in both subjective and objective findings.

Palpation of Lymph Nodes

Bilateral palpation of the occipital nodes. Be sure to also observe the skin in

this area.

Occipital nodes.

.Palpate the occipital nodes about one inch above and below the hairline.

Auricular . Palpate the pre and post auricular nodes bilaterally using the pads of the index,

middle and ring fingers.

Postauricular nodes.

Pre-auricular nodes.

Cervical Chain. Palpate the nodes medial to the sternocleidomastoid muscle using a bidigital technique and

the nodes posterior to the muscle with a bimanual technique.

Palpation of the anterior cervical nodes.

Palpation of the posterior cervical nodes

Supraclavicular. These nodes are examined using digital compressions just superior to the clavicle.

Bilateral palpation of the supraclavicular lymph nodes.

Palpate the submandibular nodes by pulling or rolling the tissues under the chin up and over the inferior border of the mandible. Ask the patient to touch the roof of the mouth with the tongue, pressing firming against the roof will allow you to assess the muscles and any pathology associated with the submandibular lymph node areas.

Submandibular lymphatic nodes.

Palpate the submandibular lymph nodes using a cupped hand as shown.

Submental lymphatic nodes. Use digital palpation to determine the presence of an abnormal submental lymph node.

Digital palpation of the submental lymph nodes

Salivary glands

Palpation of parotid gland (superficial lobe)

Normally these glands should not be palpable. Induration and pain could be signs of infection, blockage, immune system disorder or a neoplastic process. In addition, non-tender parotid enlargement may occur with alcoholism, diabetes, Sjogren’s syndrome, eating disorders, HIV infection and various malignant/non-malignant states.

Palpation of the submandibular glands.

TMJTMJ

Palpate upon openingPalpate upon opening What is the maximum intermaxillary What is the maximum intermaxillary

space?space? Is the opening symmetrical?Is the opening symmetrical? Is there popping, clicking, grinding?Is there popping, clicking, grinding?

What do these sounds tell you about the What do these sounds tell you about the anatomy of the joint?anatomy of the joint?

When do sounds occur?When do sounds occur? Use your stethoscope to listen to Use your stethoscope to listen to

soundssounds

TMJ

Crepitation, clicking, and popping of the temporomandibular joints are most easily detected by placing the tips of the little fingers in the external auditory canals and having the patient perform a series of excursive mandibular movements

Proper positioning of the fingers on the TM joint.

Have the patient open and close slowly

Lips

Bidigital palpation of the upper and lower labial mucosa

Exam: Lips-sun exposureExam: Lips-sun exposure

ORAL EXAMINATION

examination of vestibule of oral

cavity examination of oral cavity itself

Examination of lips’ frenum: its attachment and level of

attached gingiva

Vestibule of oral cavity—the region between the lips and cheeks and the teeth. The fold of tissue created by the vestibule between the lip and teeth is called the vestibular or mucolabial (mucobuccal) fold

Maxillary labial vestibule showing frenulum

Mandibular labial vestibule

OcclusionOcclusion

Orthodontic Orthodontic classificationclassification

InterferencesInterferences

OcclusionOcclusion

Determination of occlusion

Gingiva

Normal condition of alveolar mucosa, gums tightly overlaps tooth’ neck

Bidigital palpation of attached gingiva and muccolabial fold.

GingivaGingiva

Note color, tone, Note color, tone, texture, texture, architecture & architecture & mucogingival mucogingival relationshipsrelationships

GingivaGingiva

How would you describe the gingiva?How would you describe the gingiva? Marginal vs. generalized?Marginal vs. generalized? Erythematous vs. fibrousErythematous vs. fibrous

Drug reactions: Anti-epileptic, Drug reactions: Anti-epileptic, calcium channel blockers, calcium channel blockers, immunosuppressant immunosuppressant

Soft tissues

Orifice of Stenson duct

Linea alba on the buccal mucosa

Examination: Buccal Examination: Buccal MucosaMucosa Linea albaLinea alba Stenson’s ductStenson’s duct

Examination: Buccal Examination: Buccal MucosaMucosa

Lesions – white, red Lesions – white, red Lichen Planus, Leukedema Lichen Planus, Leukedema

Exam: Hard palateExam: Hard palate

Minor salivary glands, attached Minor salivary glands, attached gingivagingiva

Note presence of tori: tx plan Note presence of tori: tx plan any pre-prosthetic surgery any pre-prosthetic surgery

Exam: Soft palateExam: Soft palate

How does soft palate raise upon How does soft palate raise upon “aah”?“aah”?

Vibrating line, tonsilar pillars, Vibrating line, tonsilar pillars, tonsils, oropharynxtonsils, oropharynx

Exam: TongueExam: Tongue

Have the patient stick out their Have the patient stick out their tonguetongue

Wrap the tongue in a dry gauze Wrap the tongue in a dry gauze and gently pull it from side to and gently pull it from side to side to observe the lateral side to observe the lateral bordersborders

Retract the tongue to view the Retract the tongue to view the inferior tissuesinferior tissues

Exam: TongueExam: Tongue

Exam: TongueExam: Tongue

You may observe You may observe lingual lingual varicosities varicosities

Exam: TongueExam: Tongue

You may observe geographic You may observe geographic tongue (erythema migrans)tongue (erythema migrans)

Exam: TongueExam: Tongue

You may observe drug reactionYou may observe drug reaction

Exam: TongueExam: Tongue

Observe signs of nutritional Observe signs of nutritional deficiencies, immune dysfunctiondeficiencies, immune dysfunction

Exam: TongueExam: Tongue

You may observe You may observe oral canceroral cancer

Exam: Floor of mouthExam: Floor of mouth

Visualize, palpate - bimanuallyVisualize, palpate - bimanually Wharton’s duct Wharton’s duct Must dry to observeMust dry to observe

Does “lesion” wipe off?Does “lesion” wipe off? Where are the two mostWhere are the two most

likely areas for oral cancer?likely areas for oral cancer? lateral border of the tonguelateral border of the tongue Floor of mouthFloor of mouth

Palpation of the floor of the Palpation of the floor of the mouthmouth

Exam: Floor of mouthExam: Floor of mouth

Exam: Floor of mouthExam: Floor of mouth

Squamous Cell CarcinomaSquamous Cell Carcinoma

Exam: Floor of mouthExam: Floor of mouth

Squamous Cell CarcinomaSquamous Cell Carcinoma

Exam: Leukoplakic area Exam: Leukoplakic area

Edentulous Mandibular Ridge

Systematic Oral Systematic Oral ExaminationExamination Done at initial exam & at recalls Done at initial exam & at recalls

unless patient history requires unless patient history requires soonersooner

You must visualize all areas of You must visualize all areas of the oral cavitythe oral cavity

Oral cancer can occur in other Oral cancer can occur in other places than the lateral borders of places than the lateral borders of the tongue & the floor of the the tongue & the floor of the mouthmouth

Be completeBe complete Do good, do no harm, do justice, Do good, do no harm, do justice,

respect autonomyrespect autonomy

Visualize all areasVisualize all areas

BreathBreath

Oral odors can indicate:Oral odors can indicate: Infection: caries, periodontal dxInfection: caries, periodontal dx URT infectionsURT infections Chronic G.I. disturbancesChronic G.I. disturbances Lung abscessLung abscess Diabetic acidosisDiabetic acidosis Uremia, kidney problemUremia, kidney problem Liver failure: mousy, musty odorLiver failure: mousy, musty odor Self-medication with alcoholSelf-medication with alcohol