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 Demographic details Anamnesis History of the present complaint The family and social history The medical history The dental history

►Put patients at their ease ►Start with an open question 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 Mild – managed with mild analgesics (e.g. aspirin / paracetamol) Moderate – unresponsive to mild analgesics Severe – disturbs sleep Duration Time since onset. Duration of pain or attacks. Nature Continuous, 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. Localisation The 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 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.

Postauricular nodes. Pre-auricular nodes. Auricular . Palpate the pre and post auricular nodes bilaterally using the pads of the index, middle and ring fingers. Postauricular nodes. Pre-auricular nodes.

Palpation of the anterior cervical 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

Bilateral palpation of the supraclavicular lymph 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 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. 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)

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? 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 pre-prosthetic surgery

Exam: Soft palate How does soft palate raise upon “aah”? Vibrating line, tonsilar pillars, tonsils, oropharynx

Exam: Tongue 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 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 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

Thank you for attention!