PATIENT’S EXAMINATION.

THE MAIN RULES OF ADDITIONAL

TEST PLANNING. ESTABLISHING
DIAGNOSIS AND TREATMENT
SCHEDULE. PREPARATION OF
PATIENT, OPERATING AREA AND
SURGEON FOR SURGICAL
TREATMENT.

DEPARTMENT OF ORAL SURGERY

LUBLIN MEDICAL UNIVERSITY
 Indications for Oral Surgery
• Extractions of decayed teeth that cannot be restored
• Surgical removal of impacted teeth
• Extraction of nonvital teeth
• Preprosthetic surgery to smooth and contour the
alveolar ridge
• Removal of teeth for orthodontic treatment
• Removal of root fragments
• Removal of cysts and tumors
• Biopsy
• Treatment of fractures of the mandible or maxilla
• Surgical implant procedures
Examination
• In clinical practice, examination of patient
involves four routine procedures:
• Inspection
• Palpation
• Percussion
• Auscultation
Palpation
Fixation or
Consistency Fluctuation indurations -
malignancy

Soft Firm Hard Fluid filled cyst Abscess

Rock hard 
malignancy

Bony  bony lesion

(paget’s , Fibrous
dysplasia, osteoma)

Rubbery  lymph
nodes in Hodgkin’s
disease
Palpation of lymph nodes

Tender  acute infection

Hard not fixed  chronic infection

Rubbery  Hodgkin lymphoma

Fixed  malignancy
Visual examination

Associated
Site Size Shape Color
discharge
Percussion

Is the technique of striking the tissue with fingers

or and instrument e.g., handle of the mirror. The examiner
listens to the resulting sounds and observes the response of the
patient, percussion used extraorally to detect tenderness
in the frontal and maxillary sinuses by tapping the finger tips
against a finger placed over the sinuses.
Percussion used intra orally to evaluate the teeth by tapping
the teeth with the mirror handle; this technique may induce
pain in the area of inflammation from periodontal or periapical
diseases.
Oral Examination
• Many diseases (systemic or local) have signs
that appear on the face, head & neck
or intra-orally
• Making a complete examination can help
you create a differential diagnosis in cases
of abnormalities and make treatment
recommendations based on accurate
assessment of the signs & symptoms
of disease
Oral Examination
• Each disease process may have individual
manifestations in an individual patient
• And there may be individual host reaction
to the disease
• Careful assessment will guide the clinician
to accurate diagnosis
Scope of responsibility
• Diseases of the head & neck
• Diseases of the supporting hard & soft
tissues
• Diseases of the lips, tongue, salivary glands,
oral mucosa
• Diseases of the oral tissues which
are a component of systemic disease
Equipment
• Assure that you have all the supplies
necessary to complete an oral examination
– Mirror
– Dry gauze
– Dental Tweezers

• You must dry some of the tissues in order

to observe the nuances of any color changes
Extra-oral examination
• Observe: color of skin
• Examination area of head & neck

• Determine: gross functioning of cranial

nerves
– Normal vs. abnormal
• Paralysis
– Stroke, trauma, Bell’s Palsy
Extra-oral examination
• TMJ
• Palpate upon opening
– What is the maximum intermaxillary space?
– Is the opening symmetrical?
– Is there popping, clicking, grinding?
• What do these sounds tell you about the anatomy of
the joint?
• When do sounds occur?
– Use your stethoscope to listen to sounds
Extra-oral examination
• Lymph node palpation
– Refer to handout
Extra-oral examination
• Thyroid Gland
Palpation
– Place hands over the
trachea
– Have the patient
swallow
– The thyroid gland
moves upward
Exam: Lips
• Observe the color & its consistency-intra-
orally and externally
• Is the vermillion border distinct?
• Bi-digitally palpate the tissue around the
lips. Check for nodules, bullae,
abnormalities, mucocele, fibroma
Lips
• Evert the lip and examine the tissue
• Observe frenum attachment/tissue tension
• Clear mucous filled pockets may be seen
on the inner side of the lip (mucocele).
This is a frequent, non-pathologic entity
which represents a blocked minor salivary
gland
Exam: Lips-palpation
 Color, consistency
 Area for blocked minor salivary glands
 Lesions, ulcers
Examination: Buccal Mucosa

 Observe color, character of the mucosa

 Palpate tissue
 Observe Stenson’s duct opening
for inflammation or signs of blockage
 Visualize muscle attachments, hamular
notch, pterygomandibular folds
Gingiva
• Note color, tone,
texture, architecture &
mucogingival
relationships
Exam: Hard palate

 Minor salivary glands, attached gingiva

 Note presence of tori
Exam: Soft palate

 How does soft palate raise upon “aah”?

 Vibrating line, tonsilar pillars, tonsils,
oropharynx
Oropharanyx

 Color, consistency of tissue

 Look to the back, beyond the soft palate
 Note occasional small globlets of transparent
or pink opaque tissue which are normal
and may include lymphoid tissue
Exam: Tongue
• The tongue and the floor of the mouth are
the most common places for oral cancer to
occur
• It can occur other places; so visualize all
areas
Exam: Tongue
• Have the patient stick out their tongue
• Wrap the tongue in a dry gauze and gently
pull it from side to side to observe
the lateral borders
• Retract the tongue to view the inferior
tissues
Exam: Tongue
 Visualize,
palpate -
bimanually

Wharton’s
duct

Must dry
to observe

Where are
the two
most

likely areas
• lateral border
for oral of the tongue
cancer?
• Floor of mouth
Exam: Floor of mouth
 Oral Cancer:
 Red
 White

 Red and White

 Does the patient have important risk factors

for oral cancer?
 Counseling for smoking and alcohol
 Cessation
Triaging Lesions *

Describe it’s Is it related to

characteristics a trauma?
•Size, shape, •Fractured cusp,
color, occlusal trauma
consistency, Does the
location patient have
How long has Has it
Can you wipe specific risk
it been occurred
it off? factors for
present? before?
neoplastic
lesions?
Triaging Lesions *
• Lesions due to infectious
processes would have
Any lesion that healed in that time frame
is suspicious • If it remains, the lesions
should be re- should be biopsied
evaluated in 2
weeks
Occlusion
Systematic Oral Examination

Done at initial exam & at recalls unless patient history requires sooner

You must visualize all areas of the oral cavity

Oral cancer can occur in other places than the lateral borders of the
tongue & the floor of the mouth

Be complete

Do good, do no harm, do justice, respect autonomy

Breath

• Infection: caries, periodontal dx

Oral • URT (upper respiratory tract) infections
• Chronic G.I.(gastrintestinal) disturbances
odors • Lung abscess
• Diabetic acidosis
can • Uremia, kidney problem
• Liver failure: mousy, musty odor
indicate: • Self-medication with alcohol
IMAGING RESULTS

• Record any relevant diagnostic imaging

results that are immediately available to you
(e.g.radiographs, CT scan, MRI, bone scan).
LABORATORY RESULTS

• Record any relevant lab results that are

immediately available to you.
INR and APTT ratio
• A laboratory test called an INR(International Normalized
Ratio) measures the time it takes for blood to clot and
compares it to an average.
• Therapeutic unfractionated heparin is monitored by APTT
(Activated Partial Thromboplastin Time) ratio.
The therapeutic ratio is 1.5 - 2.5 times control. The range will
be given as seconds. The laboratory will give the reference
therapeutic range quoted with the results. For example APTT
50s (therapeutic range 43 - 73s).

Coagulation screen Reference ranges:

(INR and APTT ratio) INR: 0.8 - 1.2
APTT ratio: 0.8 - 1.
ASSESSMENT/IMPRESSION/DIAGNOSIS
Information gathered from the history and physical examination is analyzed to develop
working hypotheses. Problem solving is begun at the time of the initial patient interview.

Once symptoms are recorded and the patient is examined, several diagnostic possibilities
may occur, although one or two might seem most likely. The most common
diseases/diagnoses are considered first.

The assessment is the formulation of a working diagnosis using cognitive and intellectual
skills.

Clinical judgment is used to weigh diagnostic possibilities in order to arrive atthe most
likely conclusion.

When many diagnoses explain the symptoms and events of the present chief complaint
or illness, a differential diagnosis is made. The current medical status is taken into
consideration.
PLAN

• Once all of the diagnostic possibilities are

recorded, a plan for each is initiated.
• These plans may include additional
laboratory studies, diagnostic imaging
studies, consultations, patient education,
monitoring, medications, physiotherapy,
dental rehabilitation, or surgery.
• The plan must take in to consideration the
patient as a whole.
ANY QUESTIONS?
THANK YOU FOR
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EMERGENCY PROCEDURES IN DENTAL
PRACTICE – SYNCOPE, EPILEPSY,
CARDIAC INFARCTION.