Clinical diagnosis (Márk Antal DMD - András Forster DMD - Péter Vályi DMD - László Párkányi

DMD)

2.1. Extra-oral examination (Péter Vályi DMD - László Párkányi DMD)

The first step of the clinical examination is extra-oral examination, which is an important part of the stomato-oncological screening. The examination of the patient starts with observation of the patient. Alterations in vital signs (posture, nourishment, gait, voice, hoarseness, respiratory rate, cough, sweating, or hyper-movements) have to be discovered already at that time.

Extra-oral examination follows the steps of the basic physical examination:

ASSESSMENT

1. inspection 2. palpation 3. percussion 4. auscultation

During inspection, all areas of the head and neck region have to be well examined in particular to the face and neck, but disorders on the hair-covered skin should also be analysed. Asymmetries and swellings are easy to discover, but discolorations of the skin, spots, surface alterations (injuries, ulcerations, or blisters) should also be noticed. One of the exceptional regions is the epithelial transition of the lips, where like in other histologically similar regions, neoplasms may develop with a higher chance. Certain movements are evaluated visually, which apply for TMJ disorders in case of the mandible, but movement alterations of the lips, eyelashes, losing of their tone may indicate neurological abnormalities. Examination of the eyes is also very important, the typical symptoms discovered can be exophthalmus, scleral colour changes, and hyper-vascularisation, size alterations of pupils, their reaction to light, or eye movement dysfunction.

Palpation can reveal any resistance, tissue growth, or tissue deficiency. Both bone and soft tissue discrepancies need to be examined. However, palpation by itself is not enough for establishing the diagnosis: fixation, consistence, and tenderness on palpation of the examined volumes are important factors. Palpation can reveal swelling of the lymph nodes, alterations in salivary glands, and part of the temporo-mandibular joint disorders.

Examination can be done by one finger (digital) for detection of torus mandibulae, two fingers on the same hand (bidigital) to examine the lips, one finger on both hands (bimanual) to examine the floor of the mouth, or two sided (bilateral) palpation to examine symmetrical structures on both sides like cervical triangles.

Percussion is used to detect changes in the sinuses. A typical sign of acute inflammation is tenderness or even pain on percussion.

Ausculation signs are also typical for several diseases. No instruments are needed to hear the sounds of temporo-mandibular joint disorders, or broken jaws, or even certain inflammatory reactions. The typical sound is crepitation or clicking. Endoscopes are recommended as well to detect joint disorders.

Besides the above mentioned examination, our nose is also important diagnostic tool. Bad breath (foetor ex ore, malodour) can refer to the presence of oral diseases, but it can also be related to diseases in the lower parts of the digestive tract. Smelling can detect if the patient is smoking, but it can also reveal diabetic acidosis, as it has a typical smell. Alcohol consumption also has typical signs in smell.

Description of disorders

Examinations are done according to regions, and documentation also needs to be done in this manner. The following image shows regions of the head and neck:

ASSESSMENT

Regions of the head and neck

During documentation, the following aspects should be considered, which apply to oral mucosal disorders as well:

• Localisation and distribution

1. anatomical position (anterior-posterior, lateral-medial, inferior-superior, ipsilateral-contralateral) 2. symmetry (unilateral-bilateral, midline)

3. distribution (solitary-multiple, localised-generalised, separated-converging)

• Size and shape

1. size is given in units or in pathological terms (pepper-sized, pea-sized)

2. shape (regular–irregular, sharp–uneven edges, infiltrated, round, oval, etc., the surrounding structure is inflamed, fibrotic, etc.)

• Colour(pink colour can turn into reddish, livid, bluish–purplish. It can be covered by yellowish fibrin, can be adipose, purulent, necrotic, hyperkeratic, etc.)

• Surface structureimportant differential diagnostic factors: crater-like, bark-surfaced, invaginated, papillary, pseudo-membranous, smooth, warty.

• Consistency– resistance of mass: soft, hard, compact, or related to pathological terms: wood-hard, horse fur-like, etc. Regarding liquid content, it can be fluctuating, or empty.

• Spreading and connectivity– it can spread superficially or deeply, can be connected to its base or to a stalk.

• Mobility or fixation– connection to surrounding tissues: mobile or fixed.

ASSESSMENT

• Tenderness– insensitive or painful (the pain can be spontaneous, constant, or develop on palpation)

2.2. Intraoral examination (Péter Vályi DMD - László Párkányi DMD)

During intraoral examination, the oral cavity and its surrounding structures (palate, tongue, floor of the mouth, pharynx, lips, and cheeks) are evaluated. For this, the patient has to be prepared (rinsing with antiseptics, protection of lips and cheeks with non-oil based lubricant, and removal of removable dentures), and appropriate instruments (two dental mirrors, air/water syringe) are needed. Some superficial disorders can only be evaluated after drying the mucosa. A gauze slab is required for the examination and fixation of the tongue.

THE CHEEKS

The inner surface of the cheeks is covered with pink non-keratinized squamous epithelium. The deeper layers, i.e. fat tissues, masticatory muscles, and the parotid glands can be palpated bimanually. The papilla is normally bulky at the excretion ducts of the parotid gland. A typical surface irregularity seen at the line of closure of dental arches is called morsicatio buccarum.

The area between the lips, attached mucosa and the cheeks is called the vestibule. The connection between the attached gingiva and the non-attached mucosa is described as the muco-gingival junction. Iodine can visually express it. The inferior and superior labial frenula can be found on the inner surfaces of the lips, in the midline, which connect the lips to the attached gingiva. They can be underdeveloped, or can be attached far coronal, this way mobilizing the midline papilla. Similar frenula can be found in the premolar and molar regions as well.

THE GINGIVA

Gingiva is tooth dependent structures which cover the alveolar process, where the teeth are anchored by ligaments. After loosing the teeth, it is called mucosa that covers the edentulous alveolar ridge. Two main parts are the attached gingiva and the marginal gingiva. Its coral-pink colour can have pigmented spots even under healthy conditions. The most common disorders are swelling, discoloration, ulceration, or changes in contour.

Papillae fill the interdental gaps under normal circumstances. Periodontal attachment loss or positional disorders can lead to loss in the papillary structures. The papillae can reside in ulcerative gum diseases. They can go through complete healing or remain in crater like defects in chronic diseases.

THE PALATE AND PHARYNX

The palate can be divided into hard and soft palate depending on the underlying structures. The hard palate is supported by bony base, whereas the soft palate is made up of muscles underneath the mucosa. The soft palate leads towards the pharynx. The hard palate is covered by light pink, keratinized squamous epithelium. The frontal part of the hard palate contains irregular mucosa (rugae palatinae) and papillae indicative of the incisivial foramen behind the central incisors. The hard palate turns into the gingiva of the upper teeth without transition.

The border between the hard and soft palate is well distinguished by making the patient pronounce certain vowels (e.g. while taking an impression). A mucosal tongue-like structure is found in the midline at its distal border. Its swelling or discoloration indicates inflammation, and deviation to one side indicates a neurological disorder. examining the tongue, the inspection of the lower surface and the floor of the mouth are important. Holding the tongue with a gauze slab can provide visual access. Bimanual examination of the tongue can reveal resistance or tissue growth within the tissues. Examining the movements of the tongue can help diagnose some muscular and neurological disorders.

FLOOR OF THE MOUTH

ASSESSMENT

To examine the floor of the mouth, the tongue needs to be retracted in a way previously described. Under healthy conditions, sublingual and submandibular salivary gland excretions can be discovered in the frontal part, which are excreted together as caruncula sublingualis. In the frontal part, mucosal structures continuing on the tongue are visible, besides bluish transparent veins. A hard bony structure on the inner surface of the mandible called torus mandibulae can have a pronounced bulkiness.

2.3. Dental clinical examination (Márk Antal DMD - András Forster DMD)

With the clinical examination, we evaluate the status of the hard dental tissues – erupted through the soft tissues, the possible coronal restorations and the sensibility of the pulp. As a matter of course, examination of the occlusion is also involved, which we discuss in another chapter (3.2.5).

EXAMINATION OF HARD DENTAL TISSUES

Teeth must be dried separately or in groups for the clinical detection of carious lesions. In case of hard tissues, we can use inspection, palpation, and apply different types of dental explorers or transillumination, which is based on the fact that the transmission of light in carious lesions is worse than in sound enamel structures.

We differentiate between carious- and non-carious lesions of hard dental tissues. Non-carious lesions of the enamel are attrition, erosion, hypoplasty, abrasion and any kind of fracture of the hard tissues.

Carious lesions on the smooth, self-cleaning surfaces can be detected easily in an early stage (c. incipient), while the lesions of approximal contact points, even in an early condition, can only be identified with the help of a radiogram (Bite-Wing). By the progrediation of this approximal caries, it is possible to visualise or to palpate with the dental explorer, but only the breakage of the approximal ridge and involvement of the occlusal surface can be considered deep caries. Dental probe is essential to the assessment of fissure caries. Carious lesions are documented according to the surface of the tooth on which they are detected.

Non-carious lesions, in several cases, can relate to severe problems with general health condition of the patient, e.g. an erosion can be intrinsic because of vomiting of patients in pregnancy or eating disorders, while environmental damage or problems with supplement intake can be extrinsic causes of it. Attrition can indicate occlusal alterations, even more the most common sign of bruxism. It provides important information to set the treatment plan up.

Damages of hard dental tissues are classified into 5 groups:

• lesions involving the enamel only

• involving enamel and dentin

• involving enamel, dentin and pulpal tissues

• fracture of the full clinical crown

• fractures spreading under the bone level

Accidental injuries of teeth require special documentation on which the circumstances of the accident, signs, symptoms, the status of the teeth, treatments and check ups are precisely documented.

ASSESSMENT OF THE RESTORATIONS

Marginal integrity and the possible carious lesions along marginal gaps of existing fillings, inlays, partial or total dental crowns should be evaluated. The extended surfaces of the restoration, secondary caries and notes on marginal opening should be documented. It is necessary to examine the anchors of removable dentures as well.

SENSIBILITY TESTS

By the means of sensibility tests it is possible to get information on the current status of the pulp. We evaluate the pain reaction as a response of the test. The stimulus can be thermal, such as cold (cold spray or ice) or heat (by plastic polishing burs), or even electric. These responses reflect more on the status of the circulation than the integrity of the pulpal nerve complex. It can be influenced by the degenerative progresses in the pulp, the