Transcript 01. Examination of dental patient

Examination of dental patient:
subjective and objective, basic and
extra methods. Medical document
of therapeutic dentistry reception.
Hospital chart as medical, legal and
scientific document.
Therapeutic dentistry department
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
Anamnesis
Demographic
details
The family and
social history
History of
the present
complaint
The medical
history
The dental
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 history
Characteristic
Informative features
Type
Ache, tenderness, dull pain, throbbing, stabbing, electric shock.
These terms are of limited and the constancy of pain is more useful.
Severity
Duration
Nature
Initiating factors
Mild – managed with mild analgesics (e.g. aspirin / paracetamol)
Moderate – unresponsive to mild analgesics
Severe – disturbs sleep
Time since onset. Duration of pain or attacks.
Continuous, periodic or paroxysmal. If not continuous, is pain
presence between attacks?
Any potential initiating factors. Association with dental treatment or
lack of it is especially important in eliminating dental cause.
Record all and note especially hot and cold sensitivity or pain on
Exacerbating and eating which suggest a dental cause.
relieving factors
Localisation
Referral
The patient should map out the distribution of pain if possible. Is it
well or poorly defined?
Try to determine whether the pain could be referred.
OBJECTIVE EXAMINATION

Clinical examination — extra-oral
Symmetry and Profile
Cutaneous Area
Cutaneous lesion of discoid lup
Lupus erythematosus
Eyes
Observe the eyes for any
abnormalities
Yellow sclera is associated with jaundice and may
indicate an undiagnosed case of hepatitis (A or B),
other liver dysfunction or a blood disorder
Lymphatic nodes
The 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
Occipital nodes.
.Palpate the occipital nodes
about one inch above and
below the hairline.
Bilateral palpation of the occipital
nodes. Be sure to also observe the
skin in this area.
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.
Submandibular lymphatic nodes.
Palpate the submandibular
lymph nodes using a cupped
hand as shown.
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.
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)
Palpation of the submandibular glands.
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.
TMJ

Palpate upon opening
What is the maximum intermaxillary space?
 Is the opening symmetrical?
 Is there popping, clicking, grinding?

What do these sounds tell you about the anatomy of
the joint?
 When do sounds occur?


Use your stethoscope to listen to sounds
TMJ
Proper positioning of the fingers on
the TM joint.
Have the patient open and close
slowly
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
Lips
Bidigital palpation of the
upper and lower labial
mucosa
Exam: 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
Maxillary labial vestibule
showing frenulum
Mandibular labial
vestibule
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
Occlusion


Orthodontic
classification
Interferences
Occlusion
Determination of occlusion
Gingiva
Bidigital palpation of attached
gingiva and muccolabial fold.
Normal condition of alveolar
mucosa, gums tightly overlaps
tooth’ neck
Gingiva

Note color, tone,
texture, architecture &
mucogingival
relationships
Gingiva

How would you describe the gingiva?

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Marginal vs. generalized?
Erythematous vs. fibrous
Drug reactions: Anti-epileptic, calcium channel
blockers, immunosuppressant
Soft tissues
Orifice of Stenson duct
Linea alba on the buccal
mucosa
Examination: Buccal Mucosa


Linea alba
Stenson’s duct
Examination: Buccal Mucosa


Lesions – white, red
Lichen Planus, Leukedema
Exam: Hard palate


Minor salivary glands, attached gingiva
Note presence of tori: tx plan any preprosthetic surgery
Exam: Soft palate


How does soft palate raise upon “aah”?
Vibrating line, tonsilar pillars, tonsils,
oropharynx
Exam: Tongue

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Have the patient stick out their tongue
Wrap the tongue in a dry gauze and gently
pull it from side to side to observe the lateral
borders
Retract the tongue to view the inferior
tissues
Exam: Tongue
Exam: Tongue

You may observe
lingual varicosities
Exam: Tongue

You may observe geographic tongue
(erythema migrans)
Exam: Tongue

You may observe drug reaction
Exam: Tongue

Observe signs of nutritional deficiencies,
immune dysfunction
Exam: Tongue

You may observe oral
cancer
Exam: Floor of mouth

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Visualize, palpate - bimanually
Wharton’s duct
Must dry to observe


Does “lesion” wipe off ?
Where are the two most
likely areas for oral cancer?
lateral border of the tongue
 Floor of mouth

Palpation of the floor of the mouth
Exam: Floor of mouth
Exam: Floor of mouth

Squamous Cell Carcinoma
Exam: Floor of mouth

Squamous Cell Carcinoma
Exam: Leukoplakic area
Edentulous Mandibular Ridge
Systematic Oral Examination
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Done at initial exam & at recalls unless
patient history requires sooner
You must visualize all areas of the oral
cavity
Oral cancer can occur in other places than
the lateral borders of the tongue & the floor
of the mouth
Be complete
Do good, do no harm, do justice, respect
autonomy
Visualize all areas
Breath

Oral odors can indicate:
Infection: caries, periodontal dx
 URT infections
 Chronic G.I. disturbances
 Lung abscess
 Diabetic acidosis
 Uremia, kidney problem
 Liver failure: mousy, musty odor
 Self-medication with alcohol
