1. Organization of dental service in Ukraine. Equipment of working place of doctor-dentist. Medical documents of therapeutic examination. Chart of examination of dental patient. Subjective examination. Clinical methods of examination, their role in diagnostics of oral cavity diseases.

1. Organization of dental service in Ukraine. Equipment of working place of doctor-dentist. Medical documents of therapeutic examination. Chart of examination of dental patient. Subjective examination. Clinical methods of examination, their role in diagnostics of oral cavity diseases.

 

METHODS OF DENTAL PATIENT EXAMINATION

The correct diagnosis of the disease can only be based on thorough examination of the patient. Therefore, mastering the complex methods for evaluation of patients with diseases of oral cavity is the basis for establishing the correct diagnosis and further individual effective treatment. As in all fields of clinical medicine, examination of the patient in therapeutic dentistry is divided into two parts:

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

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

TAKING A HISTORY (Anamnesis)

History-taking needs to be tailored to suit the individual patient but it is sometimes difficult to get a clear idea of the complaint. Many patients are nervous, some are inarticulate, others are confused. Rapport is critical for eliciting useful information. Initial questions should allow patients to speak at some length and to gain confidence. It is usually best to start with an ‘open’ question. Medical jargon should be avoided and even regular hospital attenders who appear to understand medical terminology may use it wrongly and misunderstand. Leading questions, which suggest a particular answer, should be avoided because patients may feel compelled to agree with the clinician. It is sometimes difficult to avoid interrupting patients when trying to structure the history for the records. Structure can only be given after the patient has had time to give the information.

Constant note-taking while patients are speaking is undesirable. Questioning technique is most critical when eliciting any relevant social or psychological history or dealing with embarrassing medical conditions. It may be appropriate to delay asking such questions until after rapport has been gained. Some patients do not consider medical questions to be the concern of the dentist and it is important to give reasons for such questions wheecessary (Table 1.1).

During history-taking, the mental and emotional state of the patient should be assessed. This may have a bearing on psychosomatic disease and will also suggest what the patient expects to gain from the consultation and treatment. If the patient’s expectations are unreasonable it is important to try to modify them during the consultation, otherwise no treatment may be satisfactory.

 

 

Demographic details

The age, gender, ethnic group and occupation of the patient should be noted. Such information is occasionally critical. For instance, an elderly woman with arthritis and a dry mouth is likely to have Sjogren’s syndrome, but, a young man with a parotid swelling due to similar lymphoproliferation is far more likely to have HIV infection. Some diseases such as oral submucous fibrosis have a restricted ethnic distribution.

History of the present complaint

Frequently a complaint, such as toothache, suggests the diagnosis. In many cases a detailed history (Table 1.2) is required and sometimes, as in aphthous ulceration, the diagnosis can be made on the history without examination or investigation. If earlier treatment has been ineffective, the diagnosis should be reconsidered. Many patients’ lives have been shortened by having malignant tumours treated with repeated courses of antibiotics.

 

 

Pain is completely subjective and when physical signs are absent special care must be taken to detail all its features (Table 1.3). Especially important are features suggesting a dental cause. A fractured tooth or cusp, dentinal hypersensitivity or occlusal pain are easily misdiagnosed.

 

 

The medical history

A medical history is important as it aids the diagnosis of oral manifestations of systemic disease. It also ensures that medical conditions and medication which affect dental or surgical treatment are identified.

To ensure that nothing significant is forgotten, a printed questionnaire for patients to complete is valuable and saves time. It also helps to avoid medicolegal problems by providing a written record that the patient’s medical background has been considered.

A suggested medical history questionnaire is shown in Table 1.4.

 

 

If the history suggests, or examination reveals, any condition beyond the scope of the dentist’s experience or clinical knowledge, referral for specialist medical examination may be necessary. Medical warning cards may indicate that the patient is, for example, a haemophiliac, on long-term corticosteroid therapy or is allergic to penicillin. It is also worthwhile to leave a final section open for patients to supply any other information that they think might be relevant.

A questionnaire does not constitute a medical history and the information must be checked verbally, verified, and augmented as necessary. It is important to assess whether the patient’s reading ability and understanding are sufficient to provide valid answers to the questionnaire.

A detailed drug history is essential. Drugs can have oral effects or complicate dental management in important ways. In some ethnic groups, enquiry should be made about habits such as betel quid (pan) or smokeless tobacco use.

The dental history

A dental history and examination are obviously essential for the diagnosis of dental pain or to exclude teeth as cause of symptoms in the head and neck region. Symptoms of toothache are very variable and may masquerade as a variety of conditions from trivial to sinister.

The relationship between symptoms and any dental treatment, or lack of it, should be noted.

The family and social history

Whenever a symptom or sign suggests an inherited disorder, such as haemophilia, the family history should be elicited. Ideally, this is recorded as a pedigree diagram noting the proband (presenting case) and all family members for at least three generations. Even wheo familial disease is suspected, questions about other family members often usefully lead naturally into questions about home circumstances, relatives and social history which can be revealing if, for example, psychosomatic factors are suspected.

OBJECTIVE EXAMINATION

Clinical examination — extra-oral

Medical examination

First, look at the patient, before looking into the patient’s mouth. Anaemia, thyroid disease, long-term corticosteroid treatment, parotid swellings, or significantly enlarged cervical nodes are a few conditions that can affect the facial appearance. The parotid glands, temporomandibular joints (for clicks, crepitus or deviation), cervical and submandibular lymph nodes and thyroid gland should be palpated. Lymphadenopathy is a common manifestation of infection but may also signify malignancy — the cervical lymph nodes are often the first affected by lymphomas. Note the character (site, shape, size, surface texture and consistency) of any enlargement. Press on the maxilla and frontal bone over the sinuses to elicit tenderness if sinusitis is suspected.

 In practice it is usual for dental investigations to be performed first, but the dentist should be capable of performing simple medical examinations of the head and neck. Examination of the skin of the face, hair, scalp and neck may reveal unexpected foci of infection to account for cervical lymphadenopathy or even malignant neoplasms. The eye can readily be inspected for conjunctivitis or signs of mucous membrane pemphigoid, anaemia or jaundice. Examination of the hands may also reveal relevant information. Dentists should be able to examine cranial nerve function but more extensive medical examination by dentists is usually done in hospital.

Symmetry and Profile

Discreetly observe the patient for facial symmetry (Figure 1) and profile type (Figure 2).  Obvious asymmetry may be a red flag for neoplastic growths, muscle atrophy or hypertrophy, and neurological problems.  Asymmetry is also associated with temporomandibular joint dysfunction and malocclusions (Figures 1, 2).

 

 

Cutaneous Area

As in the general appraisal, the exposed skin of the head and neck should be examined for suspicious lesions. The skin of the neck and scalp can be examined while the clinician is palpating the occipital and cervical nodes.  The area behind and around the ear can be observed while palpating the auricular nodes.  The patient should be questioned about their knowledge of any lesions discovered during the examination and also any lesions that they may have noticed themselves anywhere on the body.  Information about the history, and any symptoms such as pain, pruritus (itching) or other abnormal sensations associated with the lesions is crucial in determining a differential diagnosis and can assist in deciding whether to refer to a specialist.  The size and physical characteristics of suspicious nevi should be documented.  These and other lesions exhibiting the warning signs associated with the ABCDE’s of Malignant Skin Lesions should be referred for further evaluation.  In addition, the patient should be advised to watch for changes ievi and other pigmented lesions not exhibiting the warning signs of skin cancer. Any evidence of physical abuse should be noted.  This is especially relevant in the case of children who may not voice any problems.  Subsequently, correlation between cutaneous lesions and intraoral lesions found during the intraoral examination should be made as in the case of the patient with discoid lupus erythematosus shown in Figures 3 and 4.  The cutaneous lesions of discoid lupus (Figure 3) presented concurrently with the gingival inflammation (Figure 4) seen during the oral examination.

 

Eyes

Observe the eyes and the tissues around the eyes  for any abnormalities.  The tissue surrounding the eye is a common area to find lesions associated with sun damage such as basal cell carcinoma.  Always remove the patient’s glasses. Metal frames increase sun damage around the eye area which      could lead to skin cancer. Pay close attention to the color of the sclera and the size of the pupils (Figure 5).

Figure 5. 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.  Blue sclera is associated with osteogenesis imperfecta which may include alteration of the structure of dentin.  Pupil size may help identify patients who are at risk for medical emergencies due to illegal drug use.  Symblepharon is associated with benign mucous membrane pemphigoid and lichen planus.  A referral to a specialist such as an ophthalmologist is needed to asses any condition exhibiting symblepharon or pterygium.

 

Lymphatic nodes

Knowledge of lymphatic drainage pathways from the oral cavity and neck is important with respect to spread of  infection  and  cancer  (Fig. 6 ).  The  lymphatic system provides a mechanism to redirect tissue fluid back into the circulation, passing through a series of lymph  node  “filters’  along  the  way  that  function  in immune surveillance.

 

 

Fig 6. Lymph nodes of the neck.

 

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.

 

Fig. 7 Palpation of neck lymphatic nodes

 

The anterior cervical chain (Fig. 7) of lymph nodes is frequently involved in both inflammatory oral conditions and metastatic disease. Nodal changes are palpable all along the sternocleidomastoid muscle.

Palpation of Lymph Nodes

The major lymph nodes of the head and neck area should be palpated with the patient in an upright position.  Findings which should be noted include enlarged palpable nodes, fixed nodes, tender nodes and whether the palpable nodes are single or present in groups.  Findings which include single or multiple, non-tender, and fixed nodes are very suspicious for malignancy.  Groups of tender nodes usually occur in conjunction with some type of infection.  Occasionally nodes will remain enlarged and palpable after an infection.  This is a relatively common occurrence especially within the submandibular group of lymph nodes.  When examined, these nodes should be small (less than 1 cm), non-tender and mobile.  Remember to correlate findings from the medical history and general appraisal of the patient to the         observations made during the head and neck examination.  For example, a previous history of cancer might cause the clinician to be more  suspicious of newly appearing palpable nodes than if there is no history of cancer.  If suspicious nodes are discovered, the patient should be referred to a physician for immediate evaluation.  Figures 8 through 15 depict the examination techniques for the following lymph nodes.

► Occipital nodes (Figure 8) Palpate the occipital nodes about one inch above and below the hairline.

Figure 8. Bilateral palpation of the occipital nodes. Be sure to also observe  the skin in this area.

 

► Auricular (Figures    9 and 10)    Palpate the pre and post auricular nodes bilaterally using the pads of the index, middle and ring fingers.

 

 

► Cervical Chain (Figures     11 and 12) Palpate the nodes medial to the sternocleidomastoid muscle using a bidigital technique and the nodes posterior to the muscle with a bimanual technique.

 

►  Supraclavicular (Figure    13) These   nodes are examined using digital compressions just superior to the clavicle.

Figure 13. Bilateral palpation of the supraclavicular lymph nodes.

 

►  Submandibular        (Figure        14)    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.

 

Figure 14. Palpate the submandibular lymph nodes using a cupped hand as shown.

 

►  Submental (Figure   15) Use digital palpation to determine the presence of an abnormal submental lymph node.

 

 

Figure 15. Digital palpation of the submental lymph nodes.

 

Salivary glands

The next most common extraoral mass that may be found on palpation is a salivary gland neoplasm. Parotid neoplasms, in particular, are best detected by careful palpation of the preauricular skin (see image below). Extraoral palpation of the submandibular glands can often reveal enlargement and tenderness; however, bimanual palpation frequently is more effective. Parotid masses (especially in superficial lobe) ( Fig. 16) are easily detected by digital palpation.

 

Fig. 16 Palpation of parotid gland (superficial lobe)

Palpate the parotid (Figure 17) and submandibular (Figure 18) salivary glands using a bilateral technique.  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,         Sjцgren’s syndrome,     eating         disorders,   HIV infection and various malignant/non-malignant states.

 

TMJ

Patients frequently report temporomandibular joint pain and dysfunction. While the origin of such discomfort often is multifactorial and difficult to localize, the presence of crepitation, clicking, and popping of the temporomandibular joints can initially be detected by placing the tips of the little fingers in the external auditory canals and having the patient open and close the mouth and move the mandible laterally from side to side (Fig. 19, 20). Atypical facial pain may be due to causes other than temporomandibular joint dysfunction (eg, myofascial pain dysfunction syndrome, reflex sympathetic dystrophy, tic douloureux, related conditions). The definitive diagnosis of such conditions often is complicated and difficult and requires the combined expertise of physicians, dentists, and other health professionals (eg, physical therapists).

 

 

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. A stethoscope placed anterior to the pinna of the ear can achieve the same result.

                                                                      

Lips

 

 

Examine the lips both visually and by palpation (Fig. 21). The vermilion border should be smooth and pliable (see the picture below). Actinic damage to the lips (actinic cheilitis), especially the lower lip, manifests either as an atrophic change with associated erythema or a leukoplakia with marked thickening of the epithelium. Both of these changes can often be observed simultaneously in adjacent areas of the vermilion border.

Fig. 22  Anatomy of the lips. Note small melanotic macule on the vermillion of the left upper lip near the border as well as physiologic pigmentation of upper lip

 

The vermilion borders of the lips should be smooth and pliable (Fig. 22). Ask female patients to remove any lipstick, which may obscure underlying surface changes.

Maceration and cracking of the corners of the mouth (angular cheilitis) was traditionally thought to be due to the following:

▲ Localized infection, primarily involving Candida albicans

▲ Nutritional deficiency, especially B vitamin complex

▲ Overclosure of the jaws due to loss of tooth structure (e.g. bruxism, teeth worn and dentures)

While nutritional deficiencies and loss of vertical dimension of the jaws contribute to angular cheilitis, the vast majority of cases respond adequately to topical antifungal agents, often without any additional intervention.

                                        

Fig. 23  Examination of lips’ frenum: its attachment and level of attached gingiva.

 

ORAL EXAMINATION

Oral examination includes examination of vestibule of oral cavity and examination of oral cavity itself.

Together with other portion of the physical examination, the examination of the oral cavity should be conducted in a uniform and consistent manner. For many individuals, the examination of the oral cavity is a clinical skill that is acquired only through repetition. Examination of the oral cavity can only be performed adequately with good light, mirrors and compressed air or other means of drying the teeth. If viscid saliva prevents visualization of the tissues and teeth, a rinse with sodium bicarbonate mouthwash will help.

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. (Fig. 24, 25).

 

Occlusion

Occlusion is examined when dental arches is closed. There are physiological occlusion (such condition when person caormally bite, eat and articulate) and pathological occlusion that do harm in patients feeding and articulating. Occlusion is checked by asking patient to swallow saliva and after evert lips, dental arches should be closed (Fig. 26).

Fig. 26 Determination of occlusion

Gingiva

The gingivae are examined most easily with the mouth partially closed and the lips retracted with the fingers, a tongue blade, or plastic lip retractors. The attached gingiva (i.e. gingiva adjacent to the crowns of the teeth) is keratinized and appears paler than other oral mucosa (Fig. 27).

Fig. 27. Bidigital palpation of attached gingiva and muccolabial fold.

 

This tissue usually is firm, stippled, and firmly attached to the underlying bone. The alveolar mucosa extends from the attached gingiva to the vestibule. In contrast to the attached gingivae, alveolar mucosa is not keratinized and is darker in color (Fig. 28).

Fig. 28 Normal condition of alveolar mucosa, gums tightly overlaps tooth’ neck

The attached gingivae are frequently pigmented, the intensity of which is somewhat proportional to the presence of cutaneous pigmentation. The attached gingiva adjacent to the teeth is keratinized and tightly bound to bone. Healthy noninflamed gingiva is stippled and resembles citrus rind (peau d’ orange).

Alveolar mucosa (Fig. 29) extends from the mucogingival junction to cover the mucobuccal fold (Fig. 30). It is not keratinized and often appears darker than the alveolar mucosa.

 

Persons of color frequently have intraoral pigmentation, including the attached gingiva. The amount of pigmentation generally is proportional to the amount of cutaneous pigmentation. When present, racial pigmentation is bilateral. (Fig. 31)

Fig.31 intraoral pigmentation of attached gingiva

 

Alterations in the clinical appearance of the gingivae can be an indicator of both localized and systemic disease. The most common cause of erythema of the gingivae is poor dental hygiene. Retained dental plaque and calculus result in gingival inflammation and, if not removed, involvement of the underlying supportive structures of the teeth. The presence of retained dental plaque and calculus also serves as initiator for a number of reactive gingival lesions (eg, pyogenic granuloma). The gingivae also frequently are the initial site of occurrence of mucocutaneous diseases (eg, lichen planus, cicatricial pemphigoid, pemphigus vulgaris). Finally, the gingiva is often affected in HIV infection and may be the first indicator of immunosuppression. (Fig. 32, 33)

 

Soft tissues

The soft tissues of the mouth should usually be inspected first. Examination should be systematic to include all areas of the mouth. Care should be taken that mirrors or retractors do not obscure lesions. To ensure complete examination of the lateral tongue and posterior floor of mouth the tongue must be held in gauze and gently extended from side to side. Abnormal-looking areas of mucosa should be palpated for scarring or induration indicating previous ulceration, inflammation or malignancy. Examination should include deeper tissues accessible to palpation, including the submandibular glands. If lesions extend close to the gingiva the gingival crevice or pockets should be probed for any communication. Mucosal nodules, especially those on the gingiva or alveolar mucosa, which suggest sinus openings should be probed to identify any sinus or fistula.

Check the openings of the salivary ducts while expressing saliva by gentle pressure (Fig. 34). Check that saliva flows freely and equally from all glands and is clear in colour.

Fig.  34 Orifice of Stenson duct.

Do not mistake anatomical variations  for disease. After examination of the oral mucosa try to visualise the oropharynx and tonsils.

Buccal mucosa

Carefully evaluate the color of the oral mucous membranes. Oral mucosa has traditionally been described as being salmon-pink in color; however, great variation exists in the level of racial pigmentation and vascularity and keratinization. The amount of cutaneous pigmentation present generally is proportional to the amount of oral mucosal pigmentation; however, unanticipated changes in the color of the oral tissues may indicate systemic disease. Evert the lips and inspect the labial mucosa (Fig. 35, 36).

 

The labial mucosa should be smooth and glistening. If the mucosa is wiped dry, pinpoint mucosal secretions from the minor salivary glands may become apparent.

In healthy individuals, the labial mucosa is smooth, soft, and well lubricated by the minor salivary glands. Anxiety regarding the examination may result in a transient xerostomia. In such cases, the mucosa becomes tacky to the touch. The minor salivary glands of the lower lip frequently are palpable. The lower lip is frequently subjected to injury that can cause trauma to the minor salivary gland ducts, resulting in the formation of a mucocele, a lesion most frequently found in this location.

Examination of the buccal mucosa is most easily accomplished by having the patient partially open the mouth, followed by stretching of the buccal mucosa with a mouth mirror or tongue blade. Persons of color frequently have a milky cast to the buccal mucosa that disappears when the cheek is stretched.

Ectopic sebaceous glands (Fordyce granules) are present in the majority of patients and manifest as bilateral whitish-yellowish papules on the buccal mucosa. They may also be observed, albeit with less frequency, on labial mucosa. A horizontal ridge can often be found on the buccal mucosa at the level of the interdigitation of the teeth (ie, the linea alba), which represents a benign hyperkeratosis secondary to mild long-term irritation from the teeth cusps. The orifice of the parotid gland (ie, the Stensen duct) can be found as a small punctate soft tissue mass on the buccal mucosa adjacent to the maxillary 6-year (first permanent) molar teeth. (Fig. 37)

 

 

The linea alba is a horizontal ridge (often hyperkeratinized) that is located bilaterally on the buccal mucosa at the level of the interdigitation of the teeth (Fig. 39). The orifice of the Stensen duct is superior to the linea alba, adjacent to the maxillary 6-year molars. Gentle palpation of the parotid gland results in the expression of serous saliva from the duct. Saliva should be able to be expressed from the duct; however, extraoral massaging of the gland may be necessary. The saliva should be clear and watery, and the patient should not experience any discomfort with the procedure. As with the lips, the buccal mucosa should also be well lubricated with saliva. Minor salivary glands and Fordyce granules may impart a granular texture to the buccal mucosa. With the exception of recurrent intraoral human herpes virus type I lesions, which are limited to keratinized mucosa, vesiculo-erosive diseases most frequently involve the buccal mucosa.

Fig.  39 Linea alba on the buccal mucosa

Tongue

The dorsal surface of the tongue is most easily visualized by having the patient protrude the tongue and attempt to touch the tip of the chin (Fig. 40). Alternatively, the tip of the tongue can be grasped by the fingers and a 2 X 2-in gauze sponge. (Fig. 41)

Fig. 40, 41 Examination of tongue. The patient protrude the tongue and attempt to touch the tip of the chin.

The tip of the tongue is grasped by the fingers and a 2 X 2-in gauze sponge.

 

Interspersed among the filiform papillae are dozens of mushroom-shaped fungiform papillae, each of which contains one or more taste buds, as shown below. The dorsal surface of the tongue is an admixture of thin, keratinized, filiform papillae interspersed with pink mushroom-shaped fungiform papillae (Fig. 42, 43).

 

 

Each of the pink mushroom-shaped fungiform papillae is associated with several taste buds. The circumvallate papillae are at the junction of the anterior two thirds and posterior one third of the tongue. These structures normally are 8-12 iumber and are arranged in a V-shaped pattern. Like the fungiform papillae, the circumvallate papillae also contaiumerous taste buds. The filiform papillae occasionally become elongated (hairy tongue) and collect oral debris, which can lead to halitosis. The elongated papillae can also cause an uncomfortable palatal sensation that may lead to gagging. The presence of fissuring is of no clinical significance in the vast majority of cases.

Atrophy of the dorsal surface of the tongue can result from a variety of causes. Nutritional deficiencies have historically been associated with atrophy of the dorsal surface of the tongue; however, oral manifestations of mucocutaneous diseases often are the underlying cause. In addition to discomfort, patients often report altered taste sensations or complete loss of taste.

The lateral borders of the tongue can be examined by grasping the tip of the tongue with a gauze sponge, extending it, and rotating it laterally. The lateral borders of the tongue are not covered by a large number of papillae. The mucosa is more erythematous and, as one moves more posteriorly along the lateral border of the tongue, vertical fissuring becomes more prominent. Collections of mucosal-colored tissue with a bosselated surface can be found at the base of the tongue. This accessory lymphoid tissue (lingual tonsil) is a component of the Waldeyer ring and may become enlarged in the presence of infection or inflammation.

 

Fig. 44 Pathologic formations that you can observe during examination of tongue

 

The lateral border of the tongue occasionally has some associated vertical corrugations (Fig.45), but it may appear smooth and glistening. Lingual tonsils at the posterior-lateral base of the tongue represent the anterior extension of the Waldeyer ring. These tissues may become enlarged secondary to inflammation, infection, or neoplasia.

 

Fig. 45 Vertical corrugations of the tongue

The ventral surface of the tongue is most easily visualized by having the patient touch the tip of the tongue to the roof of the mouth. The sublingual vasculature often is prominent, especially in older individuals. Fronds of tissue, the plica sublingualis, can frequently be observed extending from the ventral surface of the tongue, as shown below. The floor of the mouth, similar to the buccal mucosa, is salmon-pink in color. The ostia of the submandibular glands (ie, the Wharton ducts) are present as 2 midline papillae on either side of the lingual frenum, shown below.

The lingual frenum is the primary soft tissue attachment of the tongue to the floor of the mouth. Overattachment of the frenum may result in speech impediments (“tongue tied”).

 

The orifice of the Wharton ducts, which are located at the base of the lingual frenum, appear as 2 bilateral punctate structures. Mucous saliva can be expressed from the ducts with bimanual palpation of the submandibular glands.

Fig. The orifice of the Wharton ducts

Saliva frequently pools in the floor of the mouth during an oral examination. This pooled saliva is removed most easily with a gauze sponge. Subsequent bimanual palpation of the submandibular glands should result in the expression of saliva from Wharton ducts. This saliva generally is more viscous than that found in parotid glands because of the higher percentage of mucous saliva.

Both the ventral lateral surface of the tongue and the floor of the mouth are common sites for intraoral squamous cell carcinoma. For this reason, the index of suspicion for soft tissue lesions should be heightened, including otherwise innocent appearing red or white lesions. Unless convincing history and compelling clinical evidence exists to the contrary, biopsies should always be obtained from chronic alterations and obvious masses to rule out the possibility of premalignancy or malignancy.

 

Floor of Mouth

Fig. Floor of mouth. Note frenulum (solid arrow), submandibular duct orifices

(broken arrows), and visible prominence of sublingual gland under the mucosa (asterisk)

 

Floor of the oral cavity should be examined thoroughly and palpated bimanually to check for any abnormalities. Lateral border of the tongue and floor of the oral cavity are the favorite areas for development of oral cancer.

 

 

Fig. Squamous Cell Carcinoma of oral cavity floor

The sublingual salivary glands can be palpated laterally and frequently will be seen to bulge into the floor of mouth. The main sublingual duct joints the submandibular (Wharton) duct to empty into the oral cavity at the sublingual papilla near the base of the lingual frenulum.

Fig. Palpation of the floor of the oral cavity.

 

Palate

Direct visual inspection of the hard palate is accomplished most easily with the use of an intraoral mirror. The hard palate, similar to the attached gingiva, normally is less pink than other oral mucosal sites because of its increased keratinization.

Fig. Palate. Note junction of hard and soft palate (dotted line), maxillary tuberosities (thick solid arrows),

palatine fovea (thin solid arrows), rugae (broken arrows), and incisive papilla (asterisk *). The midline raphe is clearly evident.

 

These are the only 2 intraoral sites that are usually affected by recurrent intraoral herpes simplex virus infections. The anterior hard palate is covered by numerous fibrous ridges or rugae, as in the image below.

 

The incisive papillae are immediately posterior to the maxillary incisor teeth. They represent the inferior aspect of the nasopalatine duct and overlay a substantial neurovascular bundle that supplies the anterior hard palate. Minor salivary glands are abundant in the hard palate; because of this, a high incidence of minor salivary gland neoplasms, both benign and malignant, is found in this location. The incisive papillae are immediately posterior to the maxillary incisor teeth on the hard palate. This normal anatomic structure appears as a small firm nodule that is located directly below the ostia of the nasopalatal duct, from which a prominent neurovascular bundle exits the maxilla to supply the palatal mucosa.

Soft palate

In contrast to the hard palate, the soft palate is nonkeratinized and salmon-pink in color. It is easily visible on direct examination by depressing the posterior tongue with a tongue blade and instructing the patient to say “Ahhh.” Deviation of the soft palate to one side or the other may indicate a neurologic problem or an occult neoplasm. Once the posterior tongue has been depressed and the patient has elevated the soft palate, examining the oral pharynx is possible. This can occasionally be complicated in patients who have a hyperactive gag reflex; however, in such cases, the gag reflex can be suppressed through the use of topical anesthetics.

The tonsillar pillars are visualized most easily by moving the tongue laterally with a tongue blade.

The soft palate is not usually keratinized and is more vascular than the hard palate, creating the darker red color.

 

Fig. the soft palate

 

The tonsillar crypts are highly vascular and appear more erythematous than the surrounding tissues. Patients often have accumulations of desquamated epithelial cells, food, and other debris present in the tonsillar crypts, which can lead to a scratchy sensation in the throat and halitosis. Accessory lymphoid tissue on the posterior oral pharynx (adenoids) is normal and appears as pale irregular mucosal papules. These tissues may enlarge in the presence of inflammation or infection. Oral pharyngeal alterations are not uncommon, especially with oral viral infections (eg, herpangina; hand, foot, and mouth disease).

 

 

Fig. raise of soft palate upon “aah”. Vibrating line, tonsilar pillars, tonsils, oropharynx.

Teeth

Examination of the teeth should be the final part of the oral examination. Any number of developmental defects of the teeth may be apparent. Partial anodontia is a common occurrence, especially involving the maxillary lateral incisors. Supernumerary teeth (e.g. mesiodens) also are commonly noted. Missing teeth and supernumerary teeth are commonly found in a variety of inherited disorders (e.g. Gardner syndrome, oral facial digital syndrome). Gross decay of the occlusal (biting) surfaces of the teeth usually appears as discolored cavitations and represents the sequelae of poor oral hygiene. Decay involving the interproximal (e.g. tooth-to-tooth contact) surfaces may not be clinically apparent without the aid of dental radiographs. The decay at the gingival margins of the teeth adjacent to the attached gingiva may be the first manifestation of xerostomia. Root surface caries are also commonly observed in geriatric patients with gingival recession.

As a minimum, the standing teeth with a summary of their periodontal health, caries and restorative state, should be recorded. Tooth wear should be checked for ‘parafunction’. Dental examination should be thorough both for the patient’s sake and for medicolegal reasons. When dental pain is a possibility, full charting, assessment of mobility and percussion of teeth are necessary and further dental investigations will probably be required. However, before any investigations are begun, the patient’s consent must be obtained.

 

► Examine each tooth in turn for caries and examine the integrity of any restorations present.

The functional adequacy of fillings is estimated using following clinical tests: anatomical shape, marginal adhesion to hard dental tissues that surrounds the filling, the state of the contact point, the state and degree of abrasion of the filling’ surface, color of filling that matches the color of tooth, the presence of secondary caries. Dentures are estimated for their cosmetic and functionality. It is mandatory to examine the periodontal tissues around the fillings and dentures. Dentures should be steadily fixed on teeth (removable dentures – should not balance), should restore mastication function, but should not irritate soft tissues of oral cavity.

 ► Occlusion. This should involve not only getting the patient to close together and examining the relationship between the arches, but also looking at the path of closure for any obvious prematurities and displacements. Check for evidence of tooth wear.

 For those patients complaining of pain, a more thorough examination of the area related to their symptoms should then be carried out, followed by any special investigations.

► Percussion is carried out by gently tapping adjacent and suspect teeth with the end of a mirror handle. A positive response indicates that a tooth is extruded due to exudate in apical or lateral periodontal tissues.

 ► Mobility of teeth is ⇑ by ⇓ in the bony support (e.g. due to peridontal disease or an apical abscess) and also by fracture of root or supporting bone.

► Palpation of the buccal sulcus next to a painful tooth can help to determine if there is an associated apical abscess.

 ► Biting on to gauze or rubber can be used to try and elicit pain due to a cracked tooth.

Testing vitality of teeth

The vitality of teeth must be checked if they appear to be causing symptoms. It is also essential to determine the vitality of teeth in the region of cysts and other radiolucent lesions in the jaws at presentation. The information may be essential for diagnosis. To be absolutely certain, several methods may have to be used. Checking hot and cold sensitivity and electric pulp testing are relatively easily performed.

Unfortunately it may not be apparent that a pulp test result is misleading. Care must always be taken to avoid causes of false positive or false negative results.

To provide good intraoral examination it’s necessary to know anatomical landmarks under normal condition.

DENTAL CHART

 

Typical instruction for filling in medical chart of dental patient (form № 043/0 MOH Ukraine № 302 from 27.12.99).

 

«Medical chart of dental patient» is filled with the primary facing the patient to the clinic. Passport details: surname, first name, middle name, gender, address and occupation, date of birth of the patient are filled in by nurse (registrar) with a passport that confirms the identity of the patient and his residence.

«Diagnosis» and all subsequent chapters are filled in directly by doctor. Depending on the complaint and initial clinical diagnosis, the physician must direct the patient for laboratory examination, X-rays, obtaining the opinion of experts of corresponding profile, including – somatic, with an extract from the medical history, tests and other medical records. Mentioned documents are inscribed or glued into medical card to the chapter «data of radiological and laboratory tests.»

The chapter ‘diagnosis’ is filled in by the doctor who treats the patient after clinical and laboratory tests and analysis. It is assumed that diagnose could be subsequently clarified, or even changed (date when it was changed or clarified should be mandatory indicated).

The line «Complaints» is recorded according to the patient’ words or his relatives. Complaints that most accurately reflect the patient’s dental condition are filled in chart. In a survey of the patient, physician discovers when appeared spontaneous attack of pain for the first, what preceded the attack of pain, duration of pain attack, are there periods without pain, what are their duration, what causes renewal or increasing of pain or toothache, is there pain at night, what calms the pain, can the patient indicate the painful tooth, was there a nervous breakdown before, mental or physical stress, exacerbation of overall chronic disease or hypothermia.

In the line «Postponed and concomitant diseases» the data according to the patient words are filled in (it is necessary to refer on the patient words), and the data confirmed by experts from other hospitals are filled in as well. It is mandatory to indicate whether the patient has general diseases (hypertension, diabetes mellitus, heart diseases, HIV/AIDS, sexual transmitting diseases, hepatitis B, tuberculosis, etc.).

In the line «Development of the present disease» should be written the time of the first symptoms of the disease, the course of the disease and prior treatment and its effectiveness.

In the line «Objective examination, external examination and the status of hard tissues of teeth and periodontium» the data of external examination, which includes the state of skin, skeleton face, lips, TMJ, lymphatic nodes and so on are filled in. Here you must specify the results of palpation of temporal-mandibular joint, submandibular, parotid salivary glands. Data of oral cavity examination starts with the description of state of hard tissues of teeth and periodontium. The first line of above and beneath schematically pictured teeth is used for denoting condition of coronal part of tooth using symbols, including denoting of prosthetic constructions.

In the line «Occlusion» relationship of dentition is noted: under normal condition, during anomalies, its pathological condition and the relationship between alveolar processes of the jaws without antagonist teeth or complete absence of teeth, focusing on their relationship in a state of relative calm.

In the line «Oral hygiene condition, state of the mucous membrane of the oral cavity, gums, alveolar ridge, palate» the condition of the oral mucosa in accordance to visual inspection, hygiene index HI and papillary-marginal-alveolar index (PMA) is written, which is a measure for assessing symptoms of gingivitis and periodontal index (PI),  that is aimed at detecting advanced forms of pathology.

In the line «Date of training of oral hygiene skills» should be indicated the date when the training that concerns proper brushing of teeth and other oral hygiene habits was done. Doctor must show how to keep your toothbrush, how it should be moved towards the teeth, how to rinse your mouth. The most proper oral hygiene is to brush teeth twice a day –in the morning and evening.

In the line «Date of oral hygiene training control» the date of the training  of oral hygiene skills is put, then assess the state of oral hygiene in accordance with the method described by Yu. Fedorov and V.V. Volodkina (1970).

A special chapter of medical chart is given to a plan of examination and plan of treatment.

Such chapter as «Diary» is used to record patient’ appeals to the doctor, and in the case of appeal with a new disease there reflects the relevant data.

«Epicrisis» (brief description of the treatment results)  it is final chapter of chart where could be noted results of the treatment and recommendation of your doctor. Medical chart should be signed by the doctor who did treatment and finally it is signed by the chief of the department.

«Medical chart of dental patient» as a legal document should be stored in the clinic for about 5 years. After this period, it could be sent to archive.

 

 

 

 

C – caries, F – filling, A – absent(missing) tooth, P – pulpitis, Pt – apical periodontitis, Cr – tooth crown, r – root, Dc – dental calculus

 

 

 

Doctor_________________

Chief of department___________________