CLINICAL EXAMINATION OF THE PATIENT AND OBSERVATION SHEET
Faculty of Medicine of Annaba
Department of Dentistry
Oral Pathology and Surgery Department
2nd Year Course
Presented by: Dr Benghersallah
Introduction :
In stomatology, as in all other medical disciplines, it is always necessary to precede treatment by establishing a correct and precise diagnosis allowing for comprehensive care of the patient.
An examination can be defined as the action of looking at, examining with attention beings, things, events, phenomena in order to study them, monitor them and draw conclusions from them.
GOALS :
- To make a diagnosis.
- To establish therapeutic indications
- To clarify the prognosis
Conducting clinical examination in stomatology
The clinical examination corresponds to all the information allowing a diagnosis to be made and a treatment plan to be established.
Practitioner-patient contact includes:
- The interrogation.
- The exo-oral examination.
- The endo-oral examination.
- Additional examinations.
- The diagnosis.
- The treatment plan.
- The interrogation:
The in-depth interrogation allows:
- Recognize a patient for whom a surgical procedure or prescription may carry a risk.
- Relate oral signs from clinical examination to general diseases.
- Protect the dentist and his assistants against a contagious disease.
- Being able to inform and advise the patient on the implementation of a therapeutic plan
Civil status:
First and last name: patient identification.
Age: certain diseases which are related to well-defined age groups, precautions necessary in the event of prescription.
Profession: certain professions can have repercussions on the oral cavity (shoemakers, pastry chefs, seamstresses, etc.)
Address: to discover the endemic regions, example: fluorosis in the south.
Phone or Email:
– to contact the patient
– set appointments.
Reason for consultation:
- Functional: functional discomfort, pain, dental mobility, swelling, etc.
- Orthodontic: eg: piloted extraction to create space in the event of dental overlap.
- Prosthetics: extractions to make a prosthesis.
- Preventive: periodic consultations every 3 or 6 months.
History of the illness: (when, how, medication taken) Example: Onset of pain:
- Nature of the pain (spontaneous or provoked, etc.)
- Seat
- Localized or radiating.
- Association of general disorders: fatigue, fever, weight loss, etc.
- Taking medications and their effects.
Background:
- Personal history: certain pathological conditions requiring special precautions (cardiovascular, endocrine conditions, etc.)
- Family history: looking for certain hereditary diseases.
- Medical history: taking medication that has an impact on hemostasis (anticoagulants) for example.
- Surgical history: Has the patient ever had surgery? If so, when and why.
- Habits: tobacco, alcohol, etc.
- Clinical examination proper:
The patient is comfortably seated in an armchair and is reassured.
Suitable equipment (good quality lighting and specific instrumentation such as tongue depressors, flat mirrors, probes, etc.) is also necessary.
Traditionally, the clinical examination in stomatology is divided into two stages, one intraoral directly concerning the mouth, the other exoral outside the oral cavity.
2.1 Exo-oral examination
A- Inspection:
Assessing facial symmetry , the harmony of the facial whole and of one level in relation to the other actually begins during questioning, with the observation of certain sometimes obvious signs.
However, it must be done methodically.
The cervico-facial sphere is assessed stage by stage
The following are analyzed successively:
- The integuments: coloring, flexibility, presence of possible skin lesions (wounds, tumors, eruptions, scars, etc.)
- The underlying deformations.
B- Palpation: must be gentle and carried out with one or more fingers, one or two hands
Palpation allows us to assess:
- The presence of provoked or diffuse pain
- The integuments, including temperature and mobility relative to the underlying planes
- The underlying tissues: subcutaneous, muscular, lymph nodes, etc., specifying in the event of swelling, the consistency, the mobility in relation to the deep plane.
- To test the sensitivity of various nerve territories.
- ATM:
The existence of joint pain or noises.
– The pain, classically located at the joint space or in the ear, sometimes in the territory of one or more masticatory muscles, can be summarized as headaches variously interpreted by the patient, periorbital pain, otological manifestations (earache, tinnitus, etc.), neck pain, etc.
– Pretragal or endoaural palpation can demonstrate provoked pain.
– The noises described by the patient can be found by the practitioner on palpation (jump) or auscultation (noise).
- Masticatory muscles:
Masseter muscle, temporalis muscle, medial pterygoid muscle, lateral pterygoid muscle
- Exploration of the lymph node chains:
Looking for cervical facial adenopathies.
- Location: submental, submandibular, etc.
- Number: single or multiple.
- Consistency: hard or firm
- Sensitivity: painless or sensitive
- Mobile or fixed on the deep plane.
2.2 Intermediate Examination:
– Mouth opening: we assess the path, which must be straight, and the amplitude, which is measured with a caliper between the inter-incisal points (normal in adults: 47 ± 5 mm).
– Mandibular mobility: study of oral opening and closing, propulsion and right and left diductions, measured in millimeters.
2.3 Intraoral examination
The intraoral examination requires the patient to be in a sitting position, with good lighting, using one or two mirrors or tongue depressors, and with gloved hands for palpation.
It must be systematic and involve all regions of the oral cavity.
If the patient has removable dentures, the examination should be performed with and without the dentures in the mouth.
2.3.1 The degree of oral hygiene is assessed for possible motivation and choice of therapeutic mode.
2.3.2 The abundance and consistency of saliva may be taken into consideration in order to detect an underlying pathology or as an aggravating factor.
2.3.3 Soft tissue examination:
The regions to be examined are successively:
● the lips on the mucous surface;
● the endobuccal surface of the cheeks;
● the floor of the mouth and the tongue;
● the palatine vault and the soft palate;
● the periodontium
Upper floor and language.
1. Upper lip, cutaneous side. 2. Inner surface of the upper lip. 3. Anterior upper vestibule. 4. Left lateral upper vestibule. 5. Anterior upper vestibular gingiva. 6. Lateral upper vestibular gingiva. 7. Anterior palate. 8. Gingivopalatine groove. 9. Inner surface of cheek. 10. Hard palate. 11. Veil. 12. Intermaxillary commissure. 13. Retrocommissural area. 14. Base of the tongue. 15. Back of the tongue. 16. Edge of the tongue.
17. Tip of the tongue.
Lower floor.
1. Tip of the tongue. 2. Edge of the tongue. 3. Ventral surface of the tongue. 4. Left lateral floor of the mouth. 5. Anterior floor of the mouth. 6. Left lateral posterior mandibular alveolar ridge. 7. Posterior mandibular alveolar ridge anterior region. 8. Left lateral anterior mandibular alveolar ridge. 9. Anterior mandibular alveolar ridge. 10. Left lateral inferior vestibule. 11. Anterior inferior vestibule. 12. Inner surface of the lower lip. 13. Lower lip.
Examination of the oral mucosa:
Examination of the mucous membranes of the lips
The examination assesses the condition of the mucosa, the labial muscle tone and any shortness of the lip frenulum, which can influence the position of the incisors and the condition of the gum opposite them.
Examination of the mucous membranes of the inner surface of the cheeks
The mirror or tongue depressor is used to expose the bottom of the upper and lower vestibules. The examination assesses the condition of the mucosa and the ostium of the parotid duct located opposite the first maxillary molar.
Simultaneous pressure on the parotid gland allows one to assess the quality and quantity of saliva flowing into the ostium.
Examination of the tongue and floor of the mouth
We assess the appearance of the mucosa, the position of the tongue at rest and in function, the possible existence of dental imprints on the edges of the tongue, reflecting a possible dysfunction, the texture, and even the lingual volume.
The tongue should be examined on its entire dorsal and ventral surfaces. The base of the tongue is accessible to indirect vision in a mirror and to touch.
By pushing back the mobile tongue with a tongue depressor, the floor of the mouth can be examined by completely unfolding the pelvic lingual groove.
The tongue tie is appreciated, the brevity of which can hinder lingual mobility and examination of the anterior floor.
The ostia of the submandibular ducts open on either side of the tongue frenulum.
Bimanual palpation follows the path of each duct in search of possible lithiasis.
The submandibular glands are examined by exerting combined bimanual endo- and exobuccal pressure, with the fingers of the exobuccal hand placed in a hook shape under the mandibular rim.
The quality and quantity of saliva flowing into the ostium is assessed.
Examination of the palatine vault and soft palate:
The mucosa of the roof of the mouth is accessible by direct examination or by indirect vision in a mirror.
The patient’s tongue is loaded with a tongue depressor to be able to examine the soft palate and its dynamics during phonation.
The examination of the oral cavity should end with a finger palpation of all mucosal surfaces.
We will look for damage to the palatine mucosa (ulcerations, wounds).
2.3.4 Examination of hard tissues:
The CAD index: number of decayed, missing and filled teeth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
- Fractures, Cracks
- Anomalies of shape, position, and number
- Abraded teeth, loose teeth, condition of restorations
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
Numbering of temporary dentition
Examination of the causal region (tooth):
Subjective Signs :
The characteristics of the symptoms are noted:
- Pain provoked or spontaneous
- Triggering factors
- The intensity
- The location
- The duration
- Whether it is calmed by taking painkillers or not
Objective Signs:
Visual signs :
- Location of the lesion
- Classification of carious lesion
- State of disrepair, loss of substance
- Tooth staining
- Depth
- Content and nature of affected tissues
In situ signs:
- Pulp Vitality Tests:
Cold test
Hot test
EPT (ELECTRIC PULP TESTING) electrical test
Ultimate Test Milling Test
- Pressure tests
- Axial and transverse percussion tests
- Degrees of tooth mobility
3. Additional examinations:
3.1 Radiological examinations:
- Intraoral images: Retro-alveolar: this is the most used in the dental office because it gives better precision of dental and peridental structures.
- Extra-oral images: the panoramic radiograph is the most requested, giving an overall view of the dental arches.
- Special images: such as CT scans, MRIs.
3.2 Laboratory biological tests:
· The most requested biological tests are: FNS, VS, Glycemia, TP, etc.
– Bacteriological tests: carried out from a sample, often pus, to perform the antibiogram.
4. Diagnosis:
4.1 Etiological diagnosis:
Consists of citing the causes of the disease.
4.2 Differential diagnosis:
Compare conditions that have common points. A definitive diagnosis is reached gradually by gradually eliminating conditions whose clinical and radiological signs resemble the disease in question but which differ in at least one element.
4.3 Positive diagnosis:
This is the definitive diagnosis that will be retained among the probable diagnoses; it consists of detecting the odontostomatological condition.
5. Treatment plan:
Once the diagnosis has been made, the practitioner establishes the therapeutic indication, divided into 4 phases:
- General treatment (preparation): if the patient has a general illness
- Initial treatment: patient motivation for oral hygiene + brushing methods
- Specific treatment: therapy following the diagnosis made
- Comprehensive treatment: as part of the restoration of the oral cavity
6. The prognosis:
This is the outcome of the disease after complete recovery, they require regular and periodic clinical and radiological monitoring of the lesion.
7. Prevention:
It must be the permanent objective of each person, because if it is fundamental to know how to recognize an injury or an illness and to be able to treat it effectively, it is even more desirable to prevent it.
The observation sheet:
At the end of the interview and the clinical examination, a clinical observation is written by the practitioner in a brief, objective and scientific manner, summarizing the results of clinical and additional examinations and is recorded in a clinical file (on paper or electronically).
It is useful for the construction of the diagnosis, the development of patient care and the transmission of information. Furthermore, it is an educational, scientific and medico-legal document.
Conclusion :
The clinical examination must be systematic during any consultation in odontostomatology since it allows us to explore the oral cavity, the very rich pathology of which will require very particular attention.
CLINICAL EXAMINATION OF THE PATIENT AND OBSERVATION SHEET
Early cavities in children need to be treated promptly.
Dental veneers cover imperfections such as stains or cracks.
Misaligned teeth can cause difficulty chewing.
Dental implants provide a stable solution to replace missing teeth.
Antiseptic mouthwashes reduce bacteria that cause bad breath.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush preserves enamel and gums.
CLINICAL EXAMINATION OF THE PATIENT AND OBSERVATION SHEETCLINICAL EXAMINATION OF THE PATIENT AND OBSERVATION SHEET
Faculty of Medicine of Annaba
Department of Dentistry
Oral Pathology and Surgery Department
2nd Year Course
Presented by: Dr Benghersallah
Introduction :
In stomatology, as in all other medical disciplines, it is always necessary to precede treatment by establishing a correct and precise diagnosis allowing for comprehensive care of the patient.
An examination can be defined as the action of looking at, examining with attention beings, things, events, phenomena in order to study them, monitor them and draw conclusions from them.
GOALS :
- To make a diagnosis.
- To establish therapeutic indications
- To clarify the prognosis
Conducting clinical examination in stomatology
The clinical examination corresponds to all the information allowing a diagnosis to be made and a treatment plan to be established.
Practitioner-patient contact includes:
- The interrogation.
- The exo-oral examination.
- The endo-oral examination.
- Additional examinations.
- The diagnosis.
- The treatment plan.
- The interrogation:
The in-depth interrogation allows:
- Recognize a patient for whom a surgical procedure or prescription may carry a risk.
- Relate oral signs from clinical examination to general diseases.
- Protect the dentist and his assistants against a contagious disease.
- Being able to inform and advise the patient on the implementation of a therapeutic plan
Civil status:
First and last name: patient identification.
Age: certain diseases which are related to well-defined age groups, precautions necessary in the event of prescription.
Profession: certain professions can have repercussions on the oral cavity (shoemakers, pastry chefs, seamstresses, etc.)
Address: to discover the endemic regions, example: fluorosis in the south.
Phone or Email:
– to contact the patient
– set appointments.
Reason for consultation:
- Functional: functional discomfort, pain, dental mobility, swelling, etc.
- Orthodontic: eg: piloted extraction to create space in the event of dental overlap.
- Prosthetics: extractions to make a prosthesis.
- Preventive: periodic consultations every 3 or 6 months.
History of the illness: (when, how, medication taken) Example: Onset of pain:
- Nature of the pain (spontaneous or provoked, etc.)
- Seat
- Localized or radiating.
- Association of general disorders: fatigue, fever, weight loss, etc.
- Taking medications and their effects.
Background:
- Personal history: certain pathological conditions requiring special precautions (cardiovascular, endocrine conditions, etc.)
- Family history: looking for certain hereditary diseases.
- Medical history: taking medication that has an impact on hemostasis (anticoagulants) for example.
- Surgical history: Has the patient ever had surgery? If so, when and why.
- Habits: tobacco, alcohol, etc.
- Clinical examination proper:
The patient is comfortably seated in an armchair and is reassured.
Suitable equipment (good quality lighting and specific instrumentation such as tongue depressors, flat mirrors, probes, etc.) is also necessary.
Traditionally, the clinical examination in stomatology is divided into two stages, one intraoral directly concerning the mouth, the other exoral outside the oral cavity.
2.1 Exo-oral examination
A- Inspection:
Assessing facial symmetry , the harmony of the facial whole and of one level in relation to the other actually begins during questioning, with the observation of certain sometimes obvious signs.
However, it must be done methodically.
The cervico-facial sphere is assessed stage by stage
The following are analyzed successively:
- The integuments: coloring, flexibility, presence of possible skin lesions (wounds, tumors, eruptions, scars, etc.)
- The underlying deformations.
B- Palpation: must be gentle and carried out with one or more fingers, one or two hands
Palpation allows us to assess:
- The presence of provoked or diffuse pain
- The integuments, including temperature and mobility relative to the underlying planes
- The underlying tissues: subcutaneous, muscular, lymph nodes, etc., specifying in the event of swelling, the consistency, the mobility in relation to the deep plane.
- To test the sensitivity of various nerve territories.
- ATM:
The existence of joint pain or noises.
– The pain, classically located at the joint space or in the ear, sometimes in the territory of one or more masticatory muscles, can be summarized as headaches variously interpreted by the patient, periorbital pain, otological manifestations (earache, tinnitus, etc.), neck pain, etc.
– Pretragal or endoaural palpation can demonstrate provoked pain.
– The noises described by the patient can be found by the practitioner on palpation (jump) or auscultation (noise).
- Masticatory muscles:
Masseter muscle, temporalis muscle, medial pterygoid muscle, lateral pterygoid muscle
- Exploration of the lymph node chains:
Looking for cervical facial adenopathies.
- Location: submental, submandibular, etc.
- Number: single or multiple.
- Consistency: hard or firm
- Sensitivity: painless or sensitive
- Mobile or fixed on the deep plane.
2.2 Intermediate Examination:
– Mouth opening: we assess the path, which must be straight, and the amplitude, which is measured with a caliper between the inter-incisal points (normal in adults: 47 ± 5 mm).
– Mandibular mobility: study of oral opening and closing, propulsion and right and left diductions, measured in millimeters.
2.3 Intraoral examination
The intraoral examination requires the patient to be in a sitting position, with good lighting, using one or two mirrors or tongue depressors, and with gloved hands for palpation.
It must be systematic and involve all regions of the oral cavity.
If the patient has removable dentures, the examination should be performed with and without the dentures in the mouth.
2.3.1 The degree of oral hygiene is assessed for possible motivation and choice of therapeutic mode.
2.3.2 The abundance and consistency of saliva may be taken into consideration in order to detect an underlying pathology or as an aggravating factor.
2.3.3 Soft tissue examination:
The regions to be examined are successively:
● the lips on the mucous surface;
● the endobuccal surface of the cheeks;
● the floor of the mouth and the tongue;
● the palatine vault and the soft palate;
● the periodontium
Upper floor and language.
1. Upper lip, cutaneous side. 2. Inner surface of the upper lip. 3. Anterior upper vestibule. 4. Left lateral upper vestibule. 5. Anterior upper vestibular gingiva. 6. Lateral upper vestibular gingiva. 7. Anterior palate. 8. Gingivopalatine groove. 9. Inner surface of cheek. 10. Hard palate. 11. Veil. 12. Intermaxillary commissure. 13. Retrocommissural area. 14. Base of the tongue. 15. Back of the tongue. 16. Edge of the tongue.
17. Tip of the tongue.
Lower floor.
1. Tip of the tongue. 2. Edge of the tongue. 3. Ventral surface of the tongue. 4. Left lateral floor of the mouth. 5. Anterior floor of the mouth. 6. Left lateral posterior mandibular alveolar ridge. 7. Posterior mandibular alveolar ridge anterior region. 8. Left lateral anterior mandibular alveolar ridge. 9. Anterior mandibular alveolar ridge. 10. Left lateral inferior vestibule. 11. Anterior inferior vestibule. 12. Inner surface of the lower lip. 13. Lower lip.
Examination of the oral mucosa:
Examination of the mucous membranes of the lips
The examination assesses the condition of the mucosa, the labial muscle tone and any shortness of the lip frenulum, which can influence the position of the incisors and the condition of the gum opposite them.
Examination of the mucous membranes of the inner surface of the cheeks
The mirror or tongue depressor is used to expose the bottom of the upper and lower vestibules. The examination assesses the condition of the mucosa and the ostium of the parotid duct located opposite the first maxillary molar.
Simultaneous pressure on the parotid gland allows one to assess the quality and quantity of saliva flowing into the ostium.
Examination of the tongue and floor of the mouth
We assess the appearance of the mucosa, the position of the tongue at rest and in function, the possible existence of dental imprints on the edges of the tongue, reflecting a possible dysfunction, the texture, and even the lingual volume.
The tongue should be examined on its entire dorsal and ventral surfaces. The base of the tongue is accessible to indirect vision in a mirror and to touch.
By pushing back the mobile tongue with a tongue depressor, the floor of the mouth can be examined by completely unfolding the pelvic lingual groove.
The tongue tie is appreciated, the brevity of which can hinder lingual mobility and examination of the anterior floor.
The ostia of the submandibular ducts open on either side of the tongue frenulum.
Bimanual palpation follows the path of each duct in search of possible lithiasis.
The submandibular glands are examined by exerting combined bimanual endo- and exobuccal pressure, with the fingers of the exobuccal hand placed in a hook shape under the mandibular rim.
The quality and quantity of saliva flowing into the ostium is assessed.
Examination of the palatine vault and soft palate:
The mucosa of the roof of the mouth is accessible by direct examination or by indirect vision in a mirror.
The patient’s tongue is loaded with a tongue depressor to be able to examine the soft palate and its dynamics during phonation.
The examination of the oral cavity should end with a finger palpation of all mucosal surfaces.
We will look for damage to the palatine mucosa (ulcerations, wounds).
2.3.4 Examination of hard tissues:
The CAD index: number of decayed, missing and filled teeth
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
- Fractures, Cracks
- Anomalies of shape, position, and number
- Abraded teeth, loose teeth, condition of restorations
55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75
Numbering of temporary dentition
Examination of the causal region (tooth):
Subjective Signs :
The characteristics of the symptoms are noted:
- Pain provoked or spontaneous
- Triggering factors
- The intensity
- The location
- The duration
- Whether it is calmed by taking painkillers or not
Objective Signs:
Visual signs :
- Location of the lesion
- Classification of carious lesion
- State of disrepair, loss of substance
- Tooth staining
- Depth
- Content and nature of affected tissues
In situ signs:
- Pulp Vitality Tests:
Cold test
Hot test
EPT (ELECTRIC PULP TESTING) electrical test
Ultimate Test Milling Test
- Pressure tests
- Axial and transverse percussion tests
- Degrees of tooth mobility
3. Additional examinations:
3.1 Radiological examinations:
- Intraoral images: Retro-alveolar: this is the most used in the dental office because it gives better precision of dental and peridental structures.
- Extra-oral images: the panoramic radiograph is the most requested, giving an overall view of the dental arches.
- Special images: such as CT scans, MRIs.
3.2 Laboratory biological tests:
· The most requested biological tests are: FNS, VS, Glycemia, TP, etc.
– Bacteriological tests: carried out from a sample, often pus, to perform the antibiogram.
4. Diagnosis:
4.1 Etiological diagnosis:
Consists of citing the causes of the disease.
4.2 Differential diagnosis:
Compare conditions that have common points. A definitive diagnosis is reached gradually by gradually eliminating conditions whose clinical and radiological signs resemble the disease in question but which differ in at least one element.
4.3 Positive diagnosis:
This is the definitive diagnosis that will be retained among the probable diagnoses; it consists of detecting the odontostomatological condition.
5. Treatment plan:
Once the diagnosis has been made, the practitioner establishes the therapeutic indication, divided into 4 phases:
- General treatment (preparation): if the patient has a general illness
- Initial treatment: patient motivation for oral hygiene + brushing methods
- Specific treatment: therapy following the diagnosis made
- Comprehensive treatment: as part of the restoration of the oral cavity
6. The prognosis:
This is the outcome of the disease after complete recovery, they require regular and periodic clinical and radiological monitoring of the lesion.
7. Prevention:
It must be the permanent objective of each person, because if it is fundamental to know how to recognize an injury or an illness and to be able to treat it effectively, it is even more desirable to prevent it.
The observation sheet:
At the end of the interview and the clinical examination, a clinical observation is written by the practitioner in a brief, objective and scientific manner, summarizing the results of clinical and additional examinations and is recorded in a clinical file (on paper or electronically).
It is useful for the construction of the diagnosis, the development of patient care and the transmission of information. Furthermore, it is an educational, scientific and medico-legal document.
Conclusion :
The clinical examination must be systematic during any consultation in odontostomatology since it allows us to explore the oral cavity, the very rich pathology of which will require very particular attention.
CLINICAL EXAMINATION OF THE PATIENT AND OBSERVATION SHEET
Early cavities in children need to be treated promptly.
Dental veneers cover imperfections such as stains or cracks.
Misaligned teeth can cause difficulty chewing.
Dental implants provide a stable solution to replace missing teeth.
Antiseptic mouthwashes reduce bacteria that cause bad breath.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush preserves enamel and gums.
CLINICAL EXAMINATION OF THE PATIENT AND OBSERVATION SHEET