CLINICAL EXAMINATION OF A PATIENT WITH AN ORAL-DENTAL DISEASE

DIAGNOSIS CONCEPT AND TREATMENT PLAN

I°INTRODUCTION:

II° CLINICAL EXAMINATION 

Different times must be considered to arrive from the clinic to the diagnosis. These are the different stages of the clinical examination.

A) ANAMNESIS or INTERROGATION:

 It involves asking the patient specific questions and letting him express himself using his own terminology while guiding him without influencing him. These questions are:

1/ Civil status:

name, first name, age, profession..

2/ reason for consultation: may be subjective or objective

• Pain
• Embarrassed
• Swelling
• Mucosal lesion (ulceration)
• Hemorrhage

4/ Mode of evolution:

Between the beginning and the current stage:

• How did it evolve?
• With or without treatment?
• Is this the first episode or a repeat?

These questions allow the lesion to be classified according to the acute, subacute or chronic mode.

5/ BACKGROUNDS

This is the patient’s medical history. The history can be local stomatological (extraction, surgery, etc.) or general (diabetes, heart disease, allergy, etc.) of interest to the patient himself or his family members looking for the notion of hereditary disease.

B) GENERAL SIGNS

• Is the general condition satisfactory?
• Is he losing weight? Fever?
• How does the patient behave? Worried? Neglectful?…

 C) FUNCTIONAL SIGNS

E) THE EXO BUCCAL EXAMINATION

1) Inspection  : It must be done in different positions of the head (face, profile, vertical view).

 IT’S NECESSARY :

• NOTE : the symmetry, the harmony of the facial whole but also of one level in relation to the other.
• APPRECIATE : the skin’s color, its suppleness, its hairiness…
• NOTE : holes, connections, flats… Deformation? Disappearances? All anomalies are described, quantified, measured, located according to a reference point.
• EXPLORE : facial expressions by wrinkling the forehead, closing the eyelids, working the lips

 2) Palpation : this phase must be gentle, progressive, using one or more fingers, a or both hands (bimanual).

It’s necessary :

• Specify : the limits of the lesion, its heat, its mobility on the above and below planes.
• Evaluate : its consistency, its volume variations, the noises (crepitations, etc.), the pains (diffuse, exquisite, etc.) triggered by these maneuvers.
• Detect : unusual mobility, jump.
• Palpate : the lymph node areas on each side (adenopathy), the muscles (masseter, temporal, buccinator)
• Test : the sensitivity of the various territories (nerves)

3) EXAMINATION OF MANDIBULAR KINETICS : Ask the patient to open and close the mouth, slowly but several times (ease, difficulty, possibility, etc.)

Note for example:

• On inspection : dental articulation disorders

The appearance of the central inter-incisor line in BF

The path of the lower interincisal point.

• On palpation : The course of the condyles

Glenoid cavity emptiness and mouth opening amplitude in mm 

• On auscultation : joint noises (clicking, cracking)

3°) THE ENDO-ORAL EXAMINATION : Explore one after the other all the elements of the CB in a variable order depending on the case.

a) The dental system :

• the shape of the arches, the number, the position, the coloring, the mobility, the deterioration of the teeth (all faces); axial and transverse percussion; test the vitality of the suspect teeth. 
• Look for inclusions, accidents of development, retained or missing teeth.
• Evaluate the various prosthetic reconstructions

 Study of dental articulation (3 plans)

b) The periodontal system : check the condition of the periodontium for the presence of tartaric deposits and various coatings, particularly tobacco coatings

c) the gingivo-mucosal system : must be explored completely, in all its nooks and crannies, describing, locating and measuring any anomaly 

d) the tongue : requires a special study inside and then outside by pulling it with 2 fingers (compress around its tip). Check each face, each edge, and the grooves.

e) the main salivary system :

Saliva test for quantity and quality

Examination of the salivary gland ostium.

Depending on the case, complete this assessment with a regional or general examination by directing the patient

III° PARACLINICAL EXAMINATIONS (additional):

1/ the X-ray: 

Radiological incidences will be requested depending on the region to be explored and the nature of the lesion. These may include:

• Standard X-rays:
• Others :

2/ biological examinations:

• Blood tests requested in case of blood clot disorder or in preoperative assessment: FNS-Platelet count-ESR-Glucose level-Hemostasis tests (TP/INR-TS-TCK)
• Bacteriological tests: ECB-Antibiogram
• Serologies: ELISA, VDRL/TPHA, IDR t, HBS, HCV

3/ Anatomopathological examination:

This is done after studying a tissue fragment taken by biopsy in order to specify the histological nature of the lesion.

IV°) CLINICAL EVALUATION=DIAGNOSIS

1° according to the symptomatology:

a)acute mode

• If it is acute and diffuse  : therefore, carefully and quickly look for signs of toxic infection (pale face, shallow breathing, rare urine, etc.), edema, oculomotor nerve deficit.
• If it is acute and localized : note the trismus, the intensity of the pain; specify the stage of development (serous? Suppurative?); The pitting sign. Suppuration is to be feared.

2°) In the face of a traumatic syndrome: incite in particular during:

• The anamnesis will specify the cause, the circumstances, the immediate consequences: loss of consciousness.
• b) Functional signs : impotence, pain, visual disturbances.
• c) Physical signs :

IDENTIFY: bruises, painful points, condition of the joint (deformed, deviated), movements of the condyle when opening and closing the mouth, otorrhagia (fracture of the petrous bone or lesion of the anterior wall of the EAC)

*cerebrospinal fluid rhinorrhea (clear or pink liquid giving an areola on the absorbent support) *The radiological assessment allows the diagnosis of a fracture to be confirmed Other examinations: neurosurgical, ophthalmological, ENT

3°) Faced with a tumor syndrome : the major challenge is to determine the benignity or malignancy of a tumor process. 

•  The anamnesis : specifying the mode of onset and the evolution of the lesion provides information on its malignant (rapid evolution) or benign nature.

• Sensitivity disorders: positive Vincent’s sign?, facial paralysis?
•  physical signs : volume of the lesion – limits (clearTB, impreciseTM) – the base of implantation (softTB, induratedTM), mobility, adhesions, adenopathies

4°) Faced with a painful syndrome : describe:

• The situation
• The character
• Periodicity
• The mode of appearance (trigger zone)
• Irradiations
• Accompanying phenomena
• Previous treatments

5°) In the face of a hemorrhagic syndrome :

The interview will provide information on possible medication (salicylates = Aspirin®) or subsequent surgical intervention (tooth extraction). Laboratory tests are often necessary.

B ACCORDING TO ANATOMICAL REGION  :

Skin, mucous membrane, lymph node, bone or joint, cellular-adipose tissue, vessels or nerve, muscle, salivary gland, etc. sometimes require specific investigations when they are the site of a lesion.

V° TREATMENT:

• Infectious syndrome:

*acute and diffuse: hospitalization

*acute and localized

*chronic and generalized

• Traumatic syndrome:

Technical radiological assessment, SAT, ATB, all orthopedic and/or surgical

• Tumor syndrome:

Benign tumor: surgical treatment (no recurrence)

Malignant tumor: surgery, radiotherapy, chemotherapy (possible recurrence)

• Pain syndrome:

Analgesics, neuroleptics

• Hemorrhagic syndrome:

 Hematological exploration, local hemostasis, blood transfusion.

Conclusion At the end of the clinical examination, the clinician must ask himself 03 questions

• Where ? This is the anatomical or topographical diagnosis . It is essential to know at what level the condition is located: cellular tissue? Bone? Salivary gland? Tongue? ….
• What ? It is the anatomo-pathological diagnosis . Infection, acute or serous or chronic, benign tumor, malignant etc…?
• How? It is the dg etiopathogenesis. Origin of lesion , mechanism of appearance …

CLINICAL EXAMINATION OF A PATIENT WITH AN ORAL-DENTAL DISEASE

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CLINICAL EXAMINATION OF A PATIENT WITH AN ORAL-DENTAL DISEASE