Conducts a visual examination of the oral cavity. Examination of the oral cavity. Head and neck examination

PAGE 5

METHODOLOGICAL DEVELOPMENT

practical lesson number 2

By section

IV semester).

Topic: Clinical anatomy of the oral organs of a healthy person. Examination and examination of the oral cavity organs. Determination of the clinical condition of the teeth. Inspection and examination of fissures, cervical area, contact surfaces.

Target: Recall the anatomy of the oral cavity of a healthy person. To teach students to examine and examine the organs of the oral cavity, to determine the clinical condition of the teeth.

Place of occupation: Hygiene and prevention room of GKSP No. 1.

Material support:Typical equipment of a hygiene room, a dentist's workplace - prophylaxis, tables, stands, an exhibition of hygiene and prophylaxis products, a laptop.

Duration of classes: 3 hours (117 minutes).

Lesson plan

Stages of the lesson	Equipment	Tutorials and controls	A place	Time in min.
1. Verification of the initial data.	Lesson content plan. Notebook.	Test questions and tasks, tables, presentation.	Hygiene room (polyclinic).
2. Solution of clinical problems.	Laptop, table.	Forms with control situational tasks.	\|\|	74,3%
3. Summing up the results of the lesson. Assignment for the next lesson.		Lectures, textbooks, additional literature, methodological developments.	\|\|

The lesson begins with instructing the teacher about the content and objectives of the lesson. In the course of the survey, find out the initial level of knowledge of the students. In the course of the lesson with students, the concepts are understood: primary, secondary and tertiary prevention, as well as the introduction of primary prevention of dental diseases, in the center of which is the formation of a healthy lifestyle in relation to the organs and tissues of the oral cavity and the body as a whole, is associated with the definition of the level and criteria of health ...

In our opinion, the concept of "healthy child" in dentistry is based on (Leontyev V.K., Suntsov V.G., Gontsova E.G., 1983; Suntsov V.G., Leontiev V.K. and others, 1992), the principle of the absence of any negative influence of the state of the oral cavity organs on the health of the child should lie. Therefore, children with the absence of acute, chronic and congenital pathology of the dentition should be classified as healthy in dentistry. These should include children with no signs of active caries, with sealed carious teeth, in the absence of complicated forms of caries, without periodontal disease, oral mucosa, without any surgical pathology, with cured dentoalveolar anomalies. The index of KPU, kp + KPU should not exceed the average regional values for each age group of children. In every practically healthy person in the oral cavity, one or another abnormality can be found, which, however, cannot be considered manifestations of the disease and, therefore, they are not necessarily subject to treatment. Therefore, in medicine, such an important indicator of health as "norm" is widely used. In practically real conditions, the most often taken as the norm is the interval of indicators determined by statistical means. Within this interval, the body or organs must be in a state of optimal functioning. In dentistry, these average indicators are various indices - kp, KPU, PMA, hygiene indices, etc., which make it possible to quantitatively assess the condition of teeth, periodontium, and oral hygiene.

A healthy lifestyle in relation to the organs and tissues of the oral cavity includes three main sections: hygienic education of the population, carried out through sanitary and educational work; teaching and conducting rational oral hygiene; balanced diet; elimination of bad habits and risk factors in relation to organs and tissues of the oral cavity, as well as correction of the harmful effects of environmental factors.

Determining the level of human dental health is the starting point for planning individual treatment and prevention measures. For this, it is necessary to refine the examination technique with a detailed analysis of the risk zones on the hard tissues of the teeth and soft tissues of the oral cavity. During the examination, attention is paid to the sequence of the examination.

Test questions to identify the initial knowledge of students:

Features of the structure of the oral cavity organs.
Healthy lifestyle concept.
The concept of health and norms in dentistry.
What instruments are used for examining and examining the oral cavity.
Identification and quantitative reflection of the detected pathological abnormalities.

The sequence of examination of the child by the dentist

Stage	Norm		Pathology
Complaints and anamnesis	No complaints The mother's pregnancy went without pathology, breastfeeding, the child is healthy, rational nutrition without excess carbohydrates, regular oral care.		Complaints about aesthetic imperfection, disruption of form, function, pain Toxicosis and illness of the mother during pregnancy, illness of the child, medication, artificial feeding, excess carbohydrates in food, lack of systematic dental care, the presence of bad habits.
Visual inspection:
Emotional condition	The child is calm, benevolent.	The child is agitated, capricious, inhibited.
Physical development	Body length is appropriate for age.	In growth, he is ahead of his peer or lags behind them.
Posture, gait	Direct, energetic, free.	Slouching, sluggish.
Head position	Straight symmetrical.	The head is lowered, thrown back, tilted to the side.
Symmetry of the face and neck	The face is straight, symmetrical.	The neck is pubescent, thrown back, tilted to the side. The face and neck are asymmetrical, the neck is curved and shortened.
Breathing, lip-closing functions	Breathing is carried out through the nose. The lips are closed, muscle tension is not visually and palpable, the nasolabial and chin folds are moderately pronounced.	Breathing is carried out through the mouth, nose and mouth. The nostrils are narrow, the mouth is open, the lips are dry, the bridge of the nose is wide. The lips are open, when they are closed, muscle tension is noted, the nasolabial folds are smoothed.
Speech function	Sound pronunciation is correct.	Violation of pronunciation of sounds.
Swallowing functions	Swallowing is free, movements of facial muscles are invisible. The tongue rests against the hard palate behind the upper incisors (somatic variant).	The facial muscles and muscles of the neck are tense, there is a "thimble symptom", protrusion of the lips, the lower third of the face is enlarged. The tongue rests on the lips and cheeks (infantile version).
Bad habits	Not identified.	Sucks on a finger, tongue, pacifier, bites lips, cheeks, etc.
The condition of the lymphatic apparatus of the maxillofacial region.	not palpable or determined by mobile lymph nodes, painless on palpation, elastic consistency, no more than a pea in size (0.5 × 0.5 cm).	The lymph nodes are enlarged, painful on palpation, sweaty consistency, adhered to the surrounding tissues.
Temporomandibular joint mobility	The movements of the head in the joint are free in all directions, smooth, painless. The amplitude of movement is 40 mm vertically, 30 mm horizontally.	The movements of the lower jaw are limited or excessive, spasmodic, painful on palpation, crunching or clicking is determined.
The shape of the auricle. The condition of the skin along the line of rotation of the maxillary processes with the mandibular.	Correct. The skin is smooth and clean.	Wrong. Along the line of rotation of the processes, in front of the tragus of the ear, deflections of the skin, not changed in color, are determined by palpation, soft, painless (one should look for other symptoms of a violation of the formation of I - II gill arches).
The condition of the skin and the red border of the lips.	The skin is pink in color, moderate moisture, clean, moderate turgor.	The skin is pale or bright pink, dry, turgor is reduced, there are rashes (spots, crusts, papules, pustules, scratching, peeling, scars, blisters, vesicles, swelling).
Oral examination:
The condition of the mucous membrane of the lips and cheeks.	The mucous membrane of the lips is pink, clean, moist, veins are visible on the inner surface of the lips, there are nodular protrusions (mucous glands). On the mucous membrane of the cheeks along the line of closing of the teeth - sebaceous glands (yellowish-gray tubercles). At the level of the second upper molar is the papilla, into the apex of which the parotid duct opens. Saliva flows freely during stimulation, in children 6-12 months. - physiological salivation.	The mucous membrane is dry, bright pink, with a bloom, there are rashes of elements. In place of the mucous gland - a vesicle (blockage of the gland). Along the line of closing of the teeth - their prints or small hemorrhages - traces of biting. On the mucous membrane of the upper molars there are whitish spots. The papilla is swollen, hyperemic. When stimulated, saliva flows out with difficulty, is cloudy, or pus is released. Children over 3 years old have hypersalivation.
Depth of the vestibule of the oral cavity.
The nature of the frenulum of the lips and mucous cords.	The frenum of the upper lip is woven into the gum at the border of the free and attached parts, in children during milk bite - at any level up to the apex of the interdental papilla. The frenum of the lower lip is free - when the lower lip is abducted to the horizontal position, there are no changes in the papilla. Lateral cords or ligaments of the mucous membrane do not change the state of the gingival papillae when pulled.	Low attachment, the bridle is short, wide or short and wide. The frenulum of the lower lip is short; when the lip is retracted to a horizontal position, blanching (anemia) occurs, exfoliation of the gingival papilla from the necks of the teeth. The ligaments are strong, attach to the interdental papillae and cause them to move when pulled.
The condition of the gums.	In schoolchildren, the gum is dense, has a pale pink color, the appearance of a lemon peel. In preschoolers, the gum is brighter, its surface is smooth. The papillae in the area of single-rooted teeth are triangular, in the area of the molars they are triangular or trapezoidal, the gum adheres tightly to the neck of the teeth. No dental plaque. The dentogingival groove (groove) is 1 mm.	The gingival margin is atrophied, the necks of the teeth are exposed. The papillae are enlarged, edematous, cyanotic, the tops are cut off, covered with bloom. The gums flake off from the necks of the teeth. There are supra- and subgingival dental deposits. Physiological periodontal pocket more than 1 mm.
Tongue frenum length	The frenum of the tongue is of the correct shape and length.	The frenum of the tongue is attached to the apex of the interdental papilla and, when pulled, causes it to move. The frenum of the tongue is short, the tongue does not rise to the upper teeth, the tip of the tongue is bent and bifurcated.
The condition of the mucous membrane of the tongue, the floor of the mouth, the hard and soft palate.	The tongue is clean, moist, the papillae are pronounced. The bottom of the oral cavity is pink, large vessels are visible, the excretory ducts of the salivary glands are located on the frenum, salivation is free. The mucous membrane of the palate is pale pink, clear, in the area of the soft palate pink, small-knobby.	The tongue is coated with a bloom, varnished, dry, foci of desquamation of filiform papillae. The mucous membrane of the floor of the oral cavity is edematous, hyperemic, salivation is difficult. The rollers swell sharply. On the mucous membrane of the palate, areas of hyperemia. Elements of defeat.
The condition of the pharyngeal tonsils.	The pharynx is clear, the tonsils do not protrude from the palatine arches. The mucous membrane of the palatine arches is pink, clean.	The mucous membrane of the pharynx is hyperemic, there are elements of the lesion, the tonsils are enlarged, protrude from the palatine arches.
The nature of the bite.	Orthognathic, straight, deep incisal overlap.	Distal, mesial, open, deep, cross.
The condition of the dentition.	The dentition is of the correct shape and length. Teeth of the correct anatomical shape, color and size, correctly positioned in the dentition, individual teeth with fillings, after 3 years - physiological tremors.	The dentition is narrowed or widened, shortened, individual teeth are located outside the dental arch, are absent, there are supernumerary or merged teeth. The structure of hard tissues is changed (caries, hypoplasia, fluorosis).
Dental formula.	Age appropriate, healthy teeth.	Violation of the sequence and parity of teething, cavities, fillings.
The state of oral hygiene.	Good and satisfactory.	Bad and very bad.

Action Framework Outline -

examination and examination of the oral cavity organs, filling out medical documentation

Patient examination methodological techniques
Visual inspection.	Attention is drawn to the color of the skin of the face, the symmetry of the nasolabial folds, the red border of the lips, and the chin fold.
Examination of the vestibule of the oral cavity.	We fix attention on the color of the mucous membrane, the condition of the excretory ducts of the parotid salivary glands, the places of attachment and the size of the frenulum of the lips, the shape. Moisture of the periodontal papillae. On the mucous membrane and on the eve of the oral cavity, the frenulum, the gingival groove, the retromolar space are the risk zone.
Inspection of the oral cavity itself.	We begin the examination with the mucous membrane of the cheeks, hard and soft palate, tongue, pay attention to the frenulum of the tongue, and the excretory ducts of the submandibular salivary glands, then proceed to the examination of the teeth according to the generally accepted technique, starting on the right on the lower jaw, then on the left on the lower jaw, on the left on the upper jaw and finally on the right side of the upper jaw. When examining the teeth, we pay attention to the number of teeth, their shape, color, density, we knew the presence of acquired structures of the oral cavity. We pay special attention to the risk zones on the teeth - these are fissures, cervical areas, approximal surfaces.
Filling out medical records.	After the examination, and most often during the examination, we fill out the medical documentation and assess the patient's health level with the appointment of appropriate therapeutic and preventive measures

Situational tasks

A child of 3 years old was born to a healthy mother. In the first half of pregnancy, the mother had toxicosis. Does this child need prophylaxis if no pathology is detected in the oral cavity?
A child of 2.5 years old was born to a mother suffering from chronic pneumonia. During pregnancy, exacerbations of the disease were observed, the mother took antibiotics. The child has multiple caries in the oral cavity. Does this child need prevention?
A four-year-old child was born to a healthy mother with a normal pregnancy, no changes in the oral cavity were found. Does this child need prevention?

List of literature for preparation for classes by section

"Prevention and Epidemiology of Dental Diseases"

Department of Pediatric Dentistry, Omsk State Medical Academy ( IV semester).

Educational and methodological literature (basic and additional with the stamp of UMO), including those prepared at the department, electronic textbooks, network resources:

Preventive section.

A. BASIC.

Children's therapeutic dentistry. National leadership: [with adj. on CD] / ed .: VK Leontiev, LP Kiselnikova. - M .: GEOTAR-Media, 2010 .-- 890s. : ill.- (National project "Health").
Kankanyan A.P. Periodontal disease (new approaches in etiology, pathogenesis, diagnosis, prevention and treatment) / A.P. Kankanyan, V.K. Leontiev. - Yerevan, 1998 .-- 360p.
Kuryakina N.V. Prophylactic dentistry (guide to the primary prevention of dental diseases) / N.V. Kuryakina, N.A. Saveliev. - M .: Medical book, N. Novgorod: Publishing house of the NGMA, 2003. - 288 p.
Kuryakina N.V. Pediatric therapeutic dentistry / ed. N.V. Kuryakina. - M .: N. Novgorod, NGMA, 2001 .-- 744s.
Lukinykh L.M. Treatment and prevention of dental caries / LM Lukinykh. - N. Novgorod, NGMA, 1998 .-- 168p.
Primary dental prophylaxis in children. / V.G. Suntsov, V.K. Leontiev, V.A. Distel, V. D. Wagner. - Omsk, 1997 .-- 315p.
Prevention of dental diseases. Textbook. Manual / E.M. Kuzmina, S.A. Vasina, E.S. Petrina and others - M., 1997 .-- 136s.
Persin L.S. Pediatric dentistry / L.S. Persin, V.M. Himarova, S.V. Dyakov. - Ed. 5th revised and enlarged. - M .: Medicine, 2003 .-- 640s.
Handbook of Pediatric Dentistry: trans. from English / ed. A. Cameron, R. Widmer. - 2nd ed., Rev. And add. - M .: MEDpress-inform, 2010 .-- 391p .: ill.
Dentistry of children and adolescents: Per. from English / ed. Ralph E. McDonald, David R. Avery. - M .: Medical Information Agency, 2003. - 766s .: ill.
Suntsov V.G. The main scientific works of the Department of Pediatric Dentistry / V.G. Suntsov, V.A. Distel and others - Omsk, 2000 .-- 341p.
Suntsov V.G. The use of therapeutic gels in dental practice / ed. V.G. Suntsova. - Omsk, 2004 .-- 164p.
Suntsov V.G. Dental prophylaxis in children (a guide for students and doctors) / V.G. Suntsov, V.K. Leontiev, V.A. Distel. - M .: N. Novgorod, NGMA, 2001 .-- 344p.
Hamadeeva A.M., Arkhipov V.D. Prevention of major dental diseases / A.M. Hamdeeva, V.D. Arkhipov. - Samara, SamSMU - 2001 .-- 230p.

B. ADDITIONAL.

Vasiliev V.G. Prevention of dental diseases (Part 1). Study guide / V.G. Vasiliev, L.R. Kolesnikova. - Irkutsk, 2001 .-- 70s.
Vasiliev V.G. Prevention of dental diseases (Part 2). Study guide / V.G. Vasiliev, L.R. Kolesnikova. - Irkutsk, 2001 .-- 87p.
Comprehensive program of dental health of the population. Sonodent, M., 2001 .-- 35p.
Methodical materials for doctors, educators of preschool institutions, school accountants, students, parents / ed. V.G. Vasilieva, T.P. Pinelis. - Irkutsk, 1998 .-- 52p.
Ulitovsky S.B. Oral hygiene is the primary prevention of dental diseases. // New in dentistry. Specialist. release. - 1999. - No. 7 (77). - 144p.
Ulitovsky S.B. Individual hygienic program for the prevention of dental diseases / S.B. Ulitovsky. - M .: Medical book, N. Novgorod: Publishing house of NGMA, 2003. - 292p.
Fedorov Yu.A. Oral hygiene for all / Yu.A. Fedorov. - SPb, 2003 .-- 112s.

The staff of the Department of Pediatric Dentistry published educational and methodological literature with the stamp of UMO

Since 2005

Suntsov V.G. Guide to practical exercises in pediatric dentistry for students of the pediatric faculty / V.G. Suntsov, V.A. Distel, V.D. Landinova, A.V. Karnitskiy, A.I. Mateshuk, Yu.G. . Khudoroshkov. - Omsk, 2005.211s.
Suntsov V.G. A guide to pediatric dentistry for students of the pediatric faculty / V.G. Suntsov, V.A. Distel, V.D. Landinova, A.V. Karnitsky, A.I. Mateshuk, Yu.G. Khudoroshkov. - Rostov on Don, Phoenix, 2007 .-- 301s.
The use of therapeutic and prophylactic gels in dental practice. A guide for students and doctors / Edited by Professor V.G. Suntsov. - Omsk, 2007 .-- 164p.
Dental prophylaxis in children. A guide for students and doctors / V.G. Suntsov, V.K. Leontiev, V.A. Distel, V.D. Wagner, T.V. Suntsova. - Omsk, 2007 .-- 343p.
Distel V.A. The main directions and methods of prevention of dentoalveolar anomalies and deformities. A guide for doctors and students / V.A. Distel, V.G. Suntsov, A.V. Karnitsky. - Omsk, 2007 .-- 68p.

Electronic tutorials

Program for the monitoring of students' knowledge (preventive section).
Methodical developments for practical training of 2nd year students.
"On increasing the efficiency of providing dental care to children (draft order of 11.02.05)."
Requirements for sanitary-hygienic, anti-epidemic regimes and working conditions of those working in non-state health care facilities and offices of private practicing dentists.
The structure of the Dental Association of the Federal District.
Educational standard for postgraduate professional training of specialists.
Illustrated material for state interdisciplinary examinations (04.04.00 "Dentistry").

Since 2005, the staff of the department has published electronic teaching aids:

Tutorial Department of Pediatric Dentistry, Omsk State Medical Academyunder the section "Prevention and Epidemiology of Dental Diseases"(IV semester) for students of the Faculty of Dentistry / V.G. Suntsov, A.Zh. Garifullina, I.M. Voloshina, E.V. Ekimov. - Omsk, 2011 .-- 300 Mb.

Videos

Colgate training cartoon on teeth cleaning (children's dentistry, prevention section).
"Tell the Doctor", 4th scientific and practical conference:

G.G. Ivanova. Oral hygiene, hygiene products.

V.G. Suntsov, V.D. Wagner, V.G. Bokaya. Problems of prevention and treatment of teeth.

47597 0

The purpose of a clinical examination of a patient is to make the correct diagnosis, which is necessary for the successful treatment of the patient.

In dentistry, various examination methods: collection of anamnesis, examination, temperature diagnostics, electrodontodiagnostics, X-ray examination, as well as laboratory (general clinical analysis of blood, cytological, allergological, etc.) studies and samples. Examination of any patient consists of three stages:

clarification of complaints and anamnesis of the disease;

examination using physical methods (examination, palpation, percussion, auscultation);

research using special methods (laboratory, radiological).

The questioning consists of clarification of complaints and other aspects of the disease, as well as other information about the patient, which makes it possible to make the correct clinical diagnosis and carry out adequate treatment in the future.

Inquiry begins with clarification of complaints. The pain symptom plays an important role in the diagnosis. It is necessary to find out the causes of the onset, the nature (aching, twitching, pulsating), duration (paroxysmal, constant), time of onset (night, daytime), localization or irradiation of pain, which allows you to obtain valuable data for the diagnosis. They learn about the duration of the existence of symptoms, clarify the dynamics of the pathological process. Then you should find out about the treatment being carried out: whether it was carried out at all, and if it was carried out, how effective it was; find out the transferred diseases, working conditions, allergological and epidemiological anamnesis.

Objective examination includes examination, percussion, palpation (basic methods) and a number of additional methods.

Examination schematically consists of an external examination of the patient and examination of the oral cavity.

During an external examination, attention is paid to the general appearance of the patient, the presence of swelling, asymmetry of the face configuration; color, the presence of pathological formations on the skin and visible mucous membranes.

Oral examination start by examining the vestibule of the mouth with closed jaws and relaxed lips, lifting the upper and lowering the lower lip or pulling the cheek with a dental mirror. Examine the red border of the lips and the corners of the mouth. Pay attention to the color, the formation of scales, crusts. The level of attachment of the bridles of the upper and lower lip is noted, the depth of the vestibule is measured.

Then, with the help of a mirror, the inner surface of the cheeks, the state of the ducts of the parotid salivary glands and the nature of the secretion secreted by them are examined. Pay attention to the color, moisture content of the mucous membrane. An important role belongs to the determination of the ratio of the dentition in the position of the central occlusion - bite. Following the examination of the oral cavity, the gums are examined. It is normally pale pink in color. Determine the presence or absence of pathological changes, the presence and depth of periodontal pockets.

The hygienic state of the oral cavity is determined using hygienic indices.

When examining the oral cavity itself, attention is paid to the color and moisture content of the mucous membrane. Examine the tongue, the state of its mucous membrane, papillae, especially if there are complaints of changes in sensitivity or burning and soreness. Then the bottom of the oral cavity, the condition of the frenum of the tongue, and the excretory salivary ducts are examined.

Examination of the dentition and teeth: When examining the oral cavity, it is necessary to examine all the teeth. Examination of the teeth is carried out using a set of tools: a dental mirror, probe, spatula. Determine the shape and integrity of the dentition. They pay attention to the shape and size of the teeth, the color of individual teeth, the shine of the enamel, reveal defects in the hard tissues of the teeth of carious and non-carious origin.

D.V. Sharov
"Dentistry"

Examination of the oral cavity organs at all stages of orthopedic treatment plays an important role, since it is on the local manifestation of diseases that medical tactics mainly depend. Having the patient's complaints, the data of his interview and external examination, the doctor mentally puts forward a number of assumptions (working hypotheses), but one should not focus only on confirming the assumptions or searching for evidence of the validity or groundlessness of the patient's complaints.

We consider it necessary to recall that a number of symptoms are signs of various diseases. In the story of patients, subjectively assessed and the most important from his point of view, phenomena often prevail, which, dominating in physiological and psychological perception, can veil other complex diseases of the dentoalveolar system, but occurring without subjective sensations for the patient. It is also important to remember that in the dentoalveolar system there is most often a combination of various diseases and their complications.

When examining the organs of the oral cavity, the doctor always compares what he sees with the physiological options for the structure of this organ. At this stage, it is the comparison that helps to identify a deviation, that is, a symptom of a disease or abnormal development, and to determine the importance and significance of this in the pathological process.

The examination is carried out in the following sequence: 1) assessment of the teeth; 2) assessment of dental arches, defects in them, the relationship of the dentition and movements of the lower jaw;

3) assessment of the oral mucosa, the state of the tongue;

4) assessment of the jaw bones.

Assessment of the condition of the dental crowns. The study of the teeth is carried out using a probe, a mirror and tweezers, combining physical methods of research (examination, palpation, percussion, probing, auscultation). Starting from the right side, all the teeth of the lower jaw are sequentially examined, then they move to the upper jaw and examine the teeth in order in the opposite direction. Evaluation of teeth consists of determining the state of the hard tissues of the crown and root, periodontal tissues, including the periapical region of the state of the dental pulp. The character (caries, hypoplasia, wedge-shaped defects, physiological and pathological abrasion), the topography of the lesion (Black classification) and the degree of damage to hard tissues are described.

Assessment of the characteristic topography and the degree of damage to the hard tissues of the teeth allows not only to establish the presence of diseases, but also to determine the need for orthopedic interventions, and sometimes the type of medical prosthesis. So, with the complete destruction of the coronal part of any tooth, it is necessary to take measures to restore it (stump crowns according to Kopeikin, pin teeth), but this, as a rule, predetermines the need for additional studies - assessing the state of the periapical tissues according to X-ray examination, the correct filling of the canal (canals ) tooth, root wall thickness. However, with general somatic diseases of a chronic and infectious nature of unclear etiology, these indications are narrowed.

Damage to the crown of the tooth in the cervical region (V and I classes according to Black) with the spread of the process under the gum obliges the doctor to decide on the manufacture of a cast metal inlay or crown with an elongated edge and preliminary filling of the cavity with amalgam or filling it with an inlay from the material from which it will be made metal crown. Filling the cavity with plastic materials, as well as using a plastic crown, is contraindicated.

The degree of destruction of hard tissues of the crown and root of the tooth is assessed in two stages - before and after the removal of all softened tissues. It is after the removal of all softened (necrotic) tissues that we can reliably talk about the possibility of preserving the rest of the hard tissues of the teeth and, depending on the topography of the defect, about the type of treatment (filling, inlay, crown, partial and complete resection of the coronal part with its subsequent restoration with pin structures ).

The destruction and preservation of the hard tissues of the filled teeth can only be judged relatively, since it is not possible to determine the volume of tissue excision carried out before the filling. Data on the state of the crown part of the tooth is entered into the odontoparodontogram (Fig. 2, A, B), guided by generally accepted designations.

If the examination reveals teeth that are changed in color or with significant destruction of the coronal part, then even in the absence of subjective sensations, they are subject to electroodontological and X-ray examination. In the same way, it is necessary to examine all teeth with pathological abrasion. The use of these methods is due to the fact that with this type of lesion, the pathological process captures not only hard tissues, but also the pulp and the periapical region. Formed in the pulp denticles can cause the appearance of "pulp" pain, and in combination with obliteration of the canal - aseptic necrosis of the entire neurovascular bundle. The process can also capture the periapical region of the periodontium, where an asymptomatic cystic or cystogranulomatous process is most often determined. Enamel hyperesthesia, which is expressed in the patient's subjective sensations, and upon examination - in the appearance of pain when probing the erased surface, determines a different medical tactics and other complex treatment.

Assessment of dental arches and the relationship of dental arches. When examining the teeth, it is necessary to check the correctness of their position in the dental arch, comparing the data obtained with the norm, in which the inter-cusp grooves seem to pass from the third (second) molar to the premolars, and then to the cutting tubercle and cutting surfaces of the incisors. The deviation of the tooth from this position is one of the diagnostic tests that make it possible, with a comprehensive analysis of subjective sensations and anamnestic data, to establish whether the initial position of the tooth in the arch has changed or whether it is its individual, but abnormal position.

As noted above, the dental arches of the upper and lower jaw have a peculiar structure. Deviation from this location in the formed dentoalveolar system indicates pathological changes in the periodontium or systemic restructuring of the dentition.

Distinguish between displacement of a tooth (teeth) in an intact dentition, displacement of a tooth (teeth) with defects in dentition and displacement of a tooth due to improper eruption (tooth dystopia). The direction of the displacement of the tooth in the formed dentition depends on the nature and direction of the action of the forces of chewing pressure (whether the tooth is located in the zone of a fixed functional center or in the zone of a non-functioning group of teeth). Tooth displacement can be: 1) vestibular or oral; 2) medial or distal; 3) in the vertical direction: supra-occlusal (below the occlusal plane of the dentition) or infra-occlusal (above the occlusal plane of the dentition); 4) rotary (rotation of the tooth around the vertical axis).

Displacement of the tooth in any direction revealed during examination is a symptom of various diseases of the tooth

Rice. 2. Odontoparadontogram. A - prn focal periodontitis (direct traumatic node); B - with focal periodontitis (reflected traumatic node).

jaw system. More research is needed to establish the mechanism of this bias and diagnose the disease. There is a vestibular displacement of the central incisors with the formation of a gap between them (false diastema), displacement of the entire frontal group of teeth, as well as the supra-occlusive position of one of the incisors with varying degrees of rotation, which is pathognomical for a number of diseases - periodontitis, periodontitis (traumatic node). At the same time, the supra- and infra-occlusive position of the teeth is characteristic of the Popov-Godon phenomenon. The appearance of gaps between the teeth against the background of partial adentia (for example, a false diastema and threemias between the frontal teeth in the absence of two or even one first molar) indicates a deep pathological (with varying degrees of compensation) restructuring of the dentition or the entire dento-maxillofacial system.

Continuing the examination of the coronal part of the teeth, it is possible to establish the presence (usually over the age of 25) of the occlusal wear facets, which characterize the contact (occlusal) movements of the lower jaw. Their location depends on the type of bite.

These facets must be distinguished from pathological abrasion, which is characterized by zonal or complete abrasion of the enamel on the occlusal surfaces with exposure of dentin (more yellow than the enamel in color) and its abrasion. In some cases, when the wear is significant, in the areas of dentin corresponding to the horn of the pulp, it is possible to see transparent or whitish, usually round-shaped zones of replacement dentin. It is noted whether the process of abrasion has captured all the teeth (generalized wear) or any group of them (localized). The different type of bite also determines the nature of the loss of hard tissues - horizontal, vertical or mixed form of abrasion. In fact, the facets of occlusal wear should be regarded as physiological wear. If, when examining persons over 25 years of age, these facets are not installed, then there is a delay in abrasion, which can lead to the development of a pathological process in the periodontal tissues, especially when a delay in abrasion is established in individual teeth or a functionally oriented group.

After examining the coronal part of the tooth, they proceed to the examination and instrumental examination of the periodontium, determining the direction and degree of tooth mobility.

At this stage, examination, probing, percussion and palpation are performed.

The examination method determines the presence of inflammation, its length. In chronic processes, it is possible to establish a hypertrophic process in the marginal periodontium, open (on palpation, purulent discharge may come out of them) or healed (whitish, rounded, the size of a pinhead) fistulous passages.

Probing is carried out using an angular dental probe. Its end should be blunt, and notches are made on the surface itself at a distance of 1 mm from each other. The probe is effortlessly inserted into the tooth groove alternately from four sides - vestibular, oral and two proximal. If the probe is immersed in the tooth groove by a fraction of a millimeter, then they speak of the absence of a periodontal (some incorrectly call it periodontal) pocket, especially if no visual inflammatory phenomena have been established.

With inflammation and significant edema of the tissues of the marginal periodontium, as well as with hypertrophic gingivitis, a false impression is created about the formation of a pathological periodontal pocket.

If, in the direction from the anatomical neck of the tooth, the probe is immersed in% of the vertical size of the crown of the tooth, then the depth of the lesion is Y

the length of the wall of the hole of the tooth, if by the size of the crown, then half, if by one and a half the size of the crown part, then% of the vertical size of the wall of the hole. Methods have been developed for determining the depth of a periodontal pocket by introducing four differently configured radiopaque pins into the pockets from four sides or introducing radiopaque liquid substances from a syringe into the pockets in order to obtain an X-ray image. Unfortunately, these highly informative methods have not yet entered the outpatient practice. These data are entered into the odontoparodontogram, and the maximum immersion of the probe from either side of the tooth is entered into it. Recording the depth of the periodontal pocket in the medical history is mandatory, since no doctor is able to remember the condition detected on the day of the examination and, without recording these data, cannot follow the dynamics of the process.

At the same time, the mobility of the teeth is determined by palpation or with the help of tweezers, applying a slight effort in the vestibular, oral, medial, distal and vertical directions. In practice, it is recommended to distinguish four degrees of mobility: in any one direction; 2) in two directions; 3) in the vestibulo-oral and mediodistal directions; 4) in the vertical direction. Pathological mobility is a symptom of a number of diseases - acute periodontitis, periodontitis, acute and chronic trauma. It occurs as a result of inflammatory processes, accompanied by edema of periodontal tissues during resorption of bone tissue and the death of a part of periodontal fibers. Inflammation and edema play a leading role. Data on tooth mobility are recorded in the odontoparodontogram. Special devices make it possible to determine mobility with an accuracy of hundredths of a millimeter (Kopeikin, Martinek, etc.).

When examining and instrumental examination of the teeth, it is possible to establish the absence of teeth. In this case, the method of interrogation, and, if necessary, and radiological should be excluded impacted (unerupted) teeth or primary adentia due to the death of the tooth rudiment. The latter is characterized by a thin, poorly developed alveolar process at the site of the missing tooth.

Percussion (percussion) is carried out using the handle of a tweezers or probe. The state of the periapical tissues is judged by the degree of pain that occurs in response to light blows to the tooth in the vertical direction or at an angle to the coronal part. The force of the blow should be gradually increased, but it should not be too strong and sharp. If the pain appears with a weak blow, then the effort can not be increased.

Sounds when tapping also make it possible to find out the state of the tooth pulp [Entin DA, 1938]. A tooth that is depulpated with a filled canal gives a muffled sound, while an unsealed tooth gives a tympanic sound, reminiscent of the sound when you hit a drum. When a healthy tooth is struck, the sound is clear and loud. To determine the differences in pain and sound vibrations, comparative percussion is performed, i.e. percussion of the teeth of the same name on the right and left sides of the jaw.

Determination of the type of bite and the preservation of occlusal relationships and the surface of the dentition. Features of the relationship of dentition in physiological types of occlusion, as well as the main anomalous forms of development and relationship of dentition are the starting points for determining the symptoms characteristic of diseases of the dento-facial system.

Establishing the type of bite allows you to correctly design a medical device - a prosthesis, to determine medical tactics when changing it and, of course, to correctly judge the pathogenesis of disorders in the dentoalveolar system, to determine the diagnosis and prognosis.

An important role on. This stage of the diagnostic process is played by the knowledge of anthropometric landmarks and the relationship of organs. In this section, we describe the main symptoms of diseases in physiological types of bite and do not touch on the nature of their manifestations in case of developmental anomalies. By this, we aim to not complicate the study of the main symptoms of diseases * since abnormal development is variable and the description of symptoms can complicate the understanding of the diagnostic process. The features of diagnostics for developmental anomalies are described in other manuals.

Evaluation of bite and preservation of occlusal relationships is carried out with closed dentition and with the position of the lower jaw at physiological rest. First of all, the degree of incisal overlap is determined. Normally, with an orthognathic type of bite, this value is 3.3 ± 0.3. If it increases, then this characterizes the presence of another type of bite or pathological changes in the dentition (decrease in occlusal height and distal displacement of the lower jaw), occurring with a number of lesions of the dentition - pathological abrasion of the group of chewing teeth or removal of part or all of this group. Simultaneously with an increase in the degree of incisal overlap due to the distal displacement of the lower jaw, the nature of the occlusal relationship changes: the teeth of the upper and lower jaw are in contact with one antagonist (for example, a canine with a canine). Since the displacement of the lower jaw and a decrease in the occlusal height can cause damage to the muscular system or the temporomandibular joint, it is imperative to determine the depth of the incisal overlap in combination with the establishment of the difference in the size of the lower part of the face during physiological rest of the lower jaw and the central-occlusal relationship. The interocclusal space is also determined - the distance between the dentition at physiological rest of the lower jaw. In the room it is equal to 2-4 mm.

When checking the occlusal contacts, at the same time, you should also study the nature of the movement of the lower jaw when opening and closing the mouth. Normally, the separation of the dentition at the maximum opening of the mouth is 40-50 mm. Opening the mouth can be difficult in acute inflammatory processes, neuralgia, myopathies, and the affected joint. The nature of the displacement is determined by the spatial displacement of the line of the center of the dentition of the lower jaw in relation to the line of the center of the upper dentition at the stages of slow opening and closing of the mouth. Deviation from linear displacement indicates pathological changes in the system.

The mismatch of the center line, the vertical line between the central incisors of the upper and lower jaws can be a symptom of various diseases: damage to the right or left temporomandibular joint, fracture of the jaws, pathological rearrangement in the dentition due to partial loss of teeth, the presence of chewing teeth on one side. For example, acute or chronic arthritis of the right temporomandibular joint causes the lower jaw to shift to the left, thereby relieving pressure on the intra-articular disc.

Finding the cutting edges of the incisors, and sometimes the canines of the upper jaw below the red border of the lips, their significant exposure during conversation indicates their movement vertically or vestibularly due to pathological processes occurring in the periodontium. Differential diagnosis requires hypertrophy of the alveolar ridge with generalized tooth wear. Displacement in the vestibular direction, as a rule, is accompanied by the formation of a bottom and three, and the teeth themselves, as it were, move the lip upward. This displacement can lead to an open bite or cause an upward movement of the lower incisors.

Determination of the preservation of the occlusal surface and in the group of chewing teeth is of great diagnostic value. With orthognathic and biprognathic types of bite and physiological progeny, a smooth curvature of the line of the dentition is observed, starting from the first premolar (Spee curve). On the upper jaw, a line drawn along the vestibular or oral tubercles and the inter-tuberous groove forms a segment of the circumference facing downward. Accordingly, the same curvature is observed in the group of the chewing teeth of the lower jaw. The level of these three curves is different due to the inclination of the crowns of the teeth and the location of the vestibular and oral tubercles in relation to the horizontal plane, which determines the presence of transversal curves. The sagittal curve (Spee's curve) is absent with a direct bite. This must be remembered and not interpreted as a pathology.

A diagnostic symptom should be considered a violation of the smoothness of the curve, caused by the displacement of a tooth or a row of teeth up or down in relation to the adjacent teeth. This phenomenon, called the Popov-Godon phenomenon, is most common when antagonists are lost; on the lower jaw, it occurs less often. It should be remembered that the curvature of the occlusal surface can also occur while maintaining intact dentition, when part of the antagonizing teeth is subject to abrasion (localized form) or the occlusal surface of the teeth is filled with plastic materials. In these cases, simultaneously with the abrasion of hard tissues or filling material, the movement of the antagonizing teeth occurs. A similar symptom of deformation of the dentition can be established when treating partial edentulousness with removable dentures with plastic teeth, plastic bridges, or in cases where the occlusal surface of the metal frame of myoid prosthesis is lined with plastic. To detect deformation of the dentition, the following is carried out: 1) comparison of the levels of the location of adjacent teeth; 2) assessment of the entire occlusal plane when examining the dentition from the side of the anterior teeth.

To assess the occlusal plane, the index fingers move the corners of the patient's mouth to the sides so that the central incisors protrude from behind the red border of the upper lip by at least 0.5 cm, and fix the gaze at the edge of the central incisors (the doctor's eyes are at the level of the patient's half-open mouth) ... In this case, the entire dentition of the upper jaw is in the field of vision of the doctor. The curvature along the occlusal surface (normal) or displacement both downward in relation to this surface and vestibularly in the group of chewing teeth is clearly visible. This method is applicable in the absence of abrasion of the anterior teeth (Fig. 3).

In case of defects in the dentition, the displacement in the vertical direction can be established with closed dentition, when the teeth that have lost their antagonists are below the occlusal surface of the antagonizing dentition (or below the occlusal line of closure of the dentition). In cases of abrasion of antagonistic teeth, lack of abrasion or significantly less abrasion of teeth,

Rice. 3. Violation of the occlusal plane (front view).

deprived of antagonists, the intersection of these teeth with the occlusal line is not evidence of displacement of the tooth (teeth), since deformation of the occlusal surface due to pathological abrasion is diagnosed.

The symptom of deformation of the dentition is the displacement of the teeth in the mediodistal direction with partial defects in the dentition, called convergence. Such deformations are characterized by a complex of symptoms: a change in the axis of inclination of the coronal part of the tooth, a decrease in the distance between the teeth, limiting the defect, the appearance of three between the teeth bordering the defect (more often between the teeth located medially from the defect), violation of the occlusal contacts of the teeth bordering the defect. Sometimes defects in the dentition cause rotational displacement of the teeth, that is, their movement around the long axis with a very variable violation of occlusal contacts.

Violation of occlusal relationships with partial loss of teeth, especially chewing teeth, and their pathological abrasion causes distal displacement of the lower jaw. So, when determining the ratios of the dentition in the occlusion, the doctor notes that the incisal overlap is increased and in some of the teeth there are not two, but one antagonist (the canine of the lower jaw contacts only the canine of the upper jaw). When determining the displacement, the reduction of the incisal overlap and the establishment of the correct (without occlusal contacts) opposition of the canine and other teeth in relation to the antagonists of the upper jaw with the position of the lower jaw in physiological rest are also of diagnostic value, and with slow closure of the dentition, the group of frontal teeth closes ( contact along the closure facets), followed by posterior displacement of the lower jaw and an increase in the incisal overlap.

For diagnostic purposes, it is necessary to distinguish between central occlusion and secondary central occlusion - the forced position of the lower jaw when chewing food due to pathological processes on the occlusal surface of the hard tissues of the chewing teeth, their partial or complete loss.

When diagnosing the distal displacement of the lower jaw, a visual and measuring linear comparison of the relationship between the elements of the temporomandibular joint is necessary on the basis of X-ray images of the joints in the secondary central occlusion and during physiological rest of the lower jaw.

It is especially important to evaluate the uniformity and simultaneity of the closure of the dentition with central occlusal contact and the presence of multiple contacts during occlusal movements of the lower jaw. Identification of areas on individual teeth that are the first to come into contact during occlusion is carried out visually with a slow closing of the dentition and a gradual displacement of the lower jaw from the position of the central occlusion to one of the extreme positions of the lateral right or left occlusions, as well as to the extreme anterior position.

The data on the areas of pressure concentration are clarified using the occlusionogram. In the case of establishing uneven contacts along with other symptoms, it is possible to identify the source of the disease or one of the pathological factors of periodontitis, periodontitis, diseases of the temporomandibular joint. The concentration of occlusal contacts (concentration of chewing pressure) can be created due to improperly applied fillings, poor-quality crowns, and bridges. In addition, it occurs with uneven wear of natural teeth, and wear of artificial plastic teeth in dentures.

The presence of premature contacts is pathognomonic for such diseases of the dentoalveolar system as secondary deformities due to partial adentia or periodontal diseases. Premature contacts, that is, contacts on individual points of the teeth or a group of teeth, at the time of occlusion often cause the lower jaw to shift in the opposite direction and change its position in the central-occlusal relationship. Such contacts also determine the transfer of the center of chewing to the opposite side, since, according to the Christensen phenomenon and the provisions on the working and balancing side, the displacement leads to occlusal contacts and separation of the dentition on the other side.

Chewing food on one side or on some teeth can occur not only with the previously mentioned defects in the dentition, but also with untreated caries, pulpitis, periodontitis, localized chronic diseases of the mucous membrane.

Establishing the reasons for the change in occlusal relationships at the time of examination should be considered important in the diagnosis of diseases, since premature contacts or localized foci of pain sources lead to a reflex change in the nature of chewing food, a change in the nature of the contractility of the muscular system, and the position of the lower jaw. Over time, while maintaining the source of irritation, these conditioned reflex reactions can gain a foothold and cause new topographic and anatomical relationships of the organs of the dentoalveolar system and the development of pathological conditions in it.

When conducting a study of the dentition, revealing the nature of occlusal relationships and contacts, it is necessary to assess the nature and presence of contacts between the teeth in the dentition, the severity of the clinical equator of the teeth and their position in relation to the vertical plane (the degree and direction of inclination of the axis of the crown of the tooth). The absence of the equator due to abnormal tooth development or its disappearance due to inclination or change in position can lead to the development of inflammatory processes in the marginal periodontium.

In cases where the presence of treated caries (fillings, artificial crowns), bridgework (prosthesis) is established, it is necessary to assess the condition of the fillings, the quality of artificial crowns and bridges. This allows in many cases to establish the reason for the patient's repeated visit to the dentist, the development of a disease or complications after treatment.

Assessment of the condition of the oral mucosa. Healthy mucous membrane in the gum area is pale pink in color, in other areas it is pink. With pathological processes, its color changes, the configuration is disturbed, various elements of the lesion appear on it. Hyperemic areas indicate inflammation, which is usually accompanied by tissue edema. Sharp hyperemia is characteristic of acute inflammation, a bluish tint - for chronic. An increase in the size of the gingival papillae, the appearance of bleeding gums, a bluish tint or sharp hyperemia indicate the presence of a subgingival calculus, irritation of the gingival margin by the edge of the crown, filling, removable prosthesis, absence of interdental contacts and trauma of the mucous membrane by food lumps. The listed symptoms are observed in various forms of gingivitis, periodontitis. The presence of fistulous passages, cicatricial changes on the gum of the alveolar process indicates an inflammatory process in the periodontium. If there are erosion, ulcers, hyperkeratosis, it is necessary to determine the cause of the injury to this area (sharp edge of the tooth, tilted or displaced tooth, poor-quality prosthesis, metal from which the prosthesis is made). It should be remembered that the injured area may be located away from the injured area of the tongue or gap due to the displacement of tissues or tongue at the time of talking or eating. During the examination, it is necessary to ask the patient to open and close the mouth, move the tongue, which will allow clarifying the traumatic area.

Traumatic injuries (ulcers) must be differentiated from cancerous and tuberculous ulcerations, syphilitic ulcers. Long-term trauma can lead to mucosal hypertrophy - fibroids (single or multiple), soft lobular fibromas, papillomatosis (or papillomatous hyperplasia) are formed.

It should be remembered about chemical, electrochemical damage to the mucous membrane, as well as a possible allergic reaction to the base material, changes in the body during and after menopause.

When detecting petechial rashes on the mucous membrane of the soft and hard palate, even if the patient uses a removable denture, first of all, it is necessary to exclude a blood disease. So, with thrombocytopenic purpura (Verlhof's disease), hemorrhages appear on the mucous membrane in the form of small-point hemorrhages and spots that have a purple, cherry-blue or brown-yellow color.

The mucous membrane of the edentulous area of the alveolar process is subject to a thorough examination by palpation to determine the degree of tactile sensitivity, mobility and compliance. This point is important not only for diagnostics, but also for choosing a method for obtaining impressions, an impression material, and, finally, for choosing the design features of the prosthesis. The fact is that the bone tissue of the alveolar process atrophies after tooth extraction, especially when removed for periodontitis, and is replaced by connective tissue, causing the formation of a mobile, easily displaceable in all directions (the so-called dangling) section of the alveolar edge. Incorrect placement of artificial teeth in removable dentures leads to the same changes.

When wearing removable plastic dentures, chronic atrophic candidiasis can develop, clinically manifested by bright hyperemia, swelling and dryness of the mucous membrane. In some parts of it there are plaques, whitish-gray films that are easily removed or removed with difficulty, as a result of which an eroded surface is exposed. Cracks and weeping corners of the mouth (seizure) occur both under the influence of fungal infections and with a decrease in the occlusal height. Elucidation of the causes of such lesions of the oral mucosa based on specific symptoms and laboratory data allows for differential diagnosis and development of treatment tactics.

It is necessary to pay special attention to such formations as the dental papilla, folds of the hard palate, to determine the severity, mobility and compliance of the tubercle of the lower jaw and tubercles of the upper jaw.

Assessment of the condition of the jaw bones. Palpation of the oral mucosa allows you to assess the condition of the underlying tissues, in particular the bone tissue of the upper and lower jaws. On examination and palpation, the zones of sharp protrusions on the alveolar processes are determined (formed as a result of traumatic tooth extraction and tooth lamination during periodontitis), the topographic relationship of the external and internal oblique lines on the lower jaw with the transitional fold zone, the presence and severity of the palatine ridge. It is important to assess the topography and severity of the arch of the zygomatic bone in the zone of its connection with the upper jaw. Revealing the topographic relationships of these formations with the tissues of the prosthetic bed plays a role not so much in the diagnosis of diseases, but in the choice of the design features of the prostheses and their boundaries. The study of the topographic relationship of the organs and tissues of the mouth, the mucous membrane and the bone skeleton, the exit to the surface of the neurovascular bundles, which during the examination is associated with the topography and the length of the defects in the dentition, can be equated to the analysis and detailing of the area of surgical intervention.

The specificity of the state of the bone skeleton, determined in everyday practice by palpation, can be clarified radiographically. But outpatient examination (examination and palpation to identify the anatomical features of the bone skeleton) is of paramount importance. Below we consider the classification of changes in the jawbone frame. These classifications, that is, the division of disorders into groups with a characteristic degree of preservation of bone tissue after tooth extraction, does not allow assessing the structural features and condition of the facial skeleton with specific lesions of bone tissue (osteodysplasia, osteomyelitis, sarcoma, trauma, etc.). The specificity of changes in bone tissue, as well as other tissues of the dentoalveolar system, in these diseases is described in special manuals.

The study of the muscular system of the maxillofacial region in outpatient settings is carried out both visually and by palpation, taking into account the subjective sensations of the subject.

Palpation of the joint is carried out through the skin anterior to the ear tragus or through the anterior wall of the external auditory canal when the jaws are closed in the central occlusion, as well as during the movements of the lower jaw. With distal displacement of the articular head at the last moment before closing the mouth, pain can be detected.

By palpating the masticatory muscles, one can detect soreness and thickening of them, as well as zones of reflected pain (jaw, ear, eyes, etc.). On palpation of the lower part of the external pterygoid muscle, the index finger is directed along the mucous membrane of the vestibular surface of the alveolar process of the upper jaw distally and upward behind the maxillary tubercle. In the place of attachment of the lower part of the muscle, there is a thin layer of fatty tissue, so the muscle is well felt. For comparison, the muscles on the other side are palpated.

On palpation of the actual chewing muscle, the patient is asked to clench his teeth and determine the anterior edge of the muscle. The thumb is placed on this edge, and the rest - on the posterior edge of the muscle. In this way, the width of the muscle is set. With the index finger of the other hand, palpate the muscle from the skin or mouth. Having found painful areas, compare them with the sensitivity of the opposite side.

The temporalis muscle is palpated extraorally (temple area) and intraorally (place of attachment to the coronoid process). For this, the index finger is placed in the retromolar fossa and moved up and out.

With changes in the dentoalveolar system leading to distal displacement of the lower jaw and joint disease, pain may be detected on palpation of the occipital and cervical muscles, as well as the muscles of the floor of the mouth. The sternocleidomastoid muscle (anterior head) is palpated all the way from the mastoid process to the inner edge of the clavicle when the head is turned in the direction opposite to the muscle being examined. If cervical osteochondrosis is suspected, the right hand is placed on the parietal region and the patient's head is tilted forward with the thumb and forefinger, and the spine is palpated with the left hand with sliding movements.

In the differential diagnosis of joint diseases and lesions of the trigeminal nerve, the points of exit of the branches of the trigeminal nerve from the bone canals are palpated. With facial pain associated with vascular disorders, soreness is detected on palpation: 1) the superficial temporal artery, defined anteriorly and upward from the auricle; 2) the jaw artery from the external carotid artery system (at the edge of the body of the lower jaw, anterior to the corner); 3) the terminal branch of the ophthalmic artery from the system of the internal carotid artery at the upper inner corner of the orbit.

Regardless of the patient's complaints, it is necessary to examine the temporomandibular joint. In a polyclinic, it comes down to palpation and listening without apparatus. In this case, two methods are used: 1) palpation of the area of the joints; 2) the introduction of the little fingers of the examined person into the external auditory holes. The study is carried out when the jaws are closed in the central occlusion and during the main occlusal movements (displacement of the lower jaw forward, right, left, opening and closing the mouth). With a fixed position of the lower jaw, as well as during its movement, palpation can determine the zones and moments of pain. By palpation, it is possible to establish not only the nature and direction of the displacement of the articular heads, but also the rustling, crunching, clicking, speed and direction of displacement that occur during movements.

It is also very important to carry out palpation examination of the muscles of this area (Fig. 4).

Rice. 4. Palpation examination of the muscles located in the temporomandibular joint according to Schwartz and Hayes.

Comparison of these data with the patient's complaints and the clinical picture of the state of the dentition (topography of defects, their size, the level of the occlusal plane, the presence of prostheses, etc.) serves as the basis for diagnostics.Special research methods make it possible to clarify the diagnosis.

The research methods described above, which have long been established at the present stage of the development of dentistry, are the main diagnostic techniques. Laboratory and machine research methods, which are being improved every year in medicine and especially in dentistry, are resorted to in severe, clinically unclear cases.

Experience allows us to make the following considerations. Clear and simple phenomena, especially those discovered by conventional research methods, can only be symptoms of severe, subjectively and clinically mild diseases. At the same time, a vivid clinical picture according to the patient's description with severe symptoms (acute pain, symptoms of inflammation, a sharp reaction of the patient to polyclinic methods, even to mild and moderate palpation, probing, percussion, etc.) is not proof of the truth of the disease , its severity and even more so the presence of concomitant and aggravating, and sometimes underlying diseases. A disease such as pulpitis, which is very acute, can develop against the background of a long-term and subjectively not felt periodontitis. The same acute subjective symptoms can be observed against the background of precancerous or neoplastic processes.

At the onset of the disease, moments of individualization of the perception of pain always prevail, the degree of which cannot be clarified during an outpatient examination. However, this point is very important, since the doctor's acceptance of the dominant pain factor as the main symptom can lead to an incomplete diagnosis (objective and justified at the time of examination), to the devualization of the main or concomitant disease.

Focusing on the moments of subjectivization of the subject's sensations, we aim to point out that pain is a manifestation of a disease (illness), but pain and subjective sensations cannot be the main criterion for diagnosing a disease. Some individuals are tolerant of pain, while others are intolerant of it.

The listed studies should be considered basic, because only after they are carried out, the doctor can decide what other methods should be used to recognize the disease. In dentistry, X-ray examination and cytodiagnostics are the most developed. In recent years, allergological studies have been developed and carried out. In the event that a doctor is unable to carry out the research necessary from his point of view, he is obliged to send the patient to another medical institution, and if, after receiving the data of these studies, he cannot clarify the diagnosis, then he must organize a consultation or send the patient to the appropriate medical institution. In these cases, the doctor is obliged to indicate the presumptive diagnosis.

Oral examination

Begin by examining the vestibule of the mouth with closed jaws and relaxed lips, lifting the upper lip and lowering the lower lip or pulling the cheek with a dental mirror. First of all, the red border of the lips and the corners of the mouth are examined. Pay attention to the color, the formation of scales, crusts. On the inner surface of the lip, as a rule, an insignificant bumpy surface is determined, due to the localization of small salivary glands in the mucous layer. In addition, you can see the pinpoint holes - the excretory ducts of these glands. At these holes, when the mouth is fixed in the open position, an accumulation of secretion droplets can be observed.
Then, using a mirror, examine the inner surface of the cheeks. Pay attention to its color, moisture content. Sebaceous glands (Fordyce's glands) are located along the line of closing of the teeth in the posterior part, which should not be mistaken for pathology. These are pale yellow nodules with a diameter of 1 - 2 mm, sometimes visible only when the mucous membrane is pulled. At the level of the upper second large molars (molars) there are papillae on which the excretory ducts of the parotid salivary glands open. They are sometimes mistaken for signs of disease. There may be dental imprints on the mucous membrane. Following the examination of the oral cavity, the gums are examined. Normally, it is pale pink, tightly covering the neck of the tooth. The gingival papillae are pale pink, occupying the interdental spaces. A groove is formed at the site of the periodontal junction (previously it was called the periodontal pocket). Due to the development of the pathological process, the gum epithelium begins to grow along the root, forming a clinical, or periodontal, periodontal pocket. The condition of the pockets formed, their depth, and the presence of tartar are determined using an angular button-like probe or a probe with notches applied every 2 - 3 mm. Examination of the gums allows you to determine the type of inflammation (catarrhal, ulcerative-necrotic, hyperplastic), the nature of the course (acute, chronic, in the acute stage), prevalence (localized, generalized), severity (mild, moderate, severe gingivitis or periodontitis) of inflammation. There may be an increase in the size of the gingival papillae due to their edema, when a significant part of the tooth is covered.
Then proceed to the study of the actual oral cavity. First of all, a general examination is performed, paying attention to the color and moisture of the mucous membrane. Normally, it is pale pink, but it can become hyperemic, edematous, and sometimes acquires a whitish tint, which indicates the phenomenon of para or hyperkeratosis.
Examination of the tongue begins with determining the condition of the papillae, especially if there are complaints of changes in sensitivity or burning and soreness in any areas. There may be a lining of the tongue due to a slowdown in the rejection of the outer layers of the epithelium. This phenomenon may be the result of a violation of the gastrointestinal tract, and possibly pathological changes in the oral cavity with candidiasis. Sometimes there is an increased desquamation of the papillae of the tongue in some area (more often at the tip and lateral surface). This condition may not bother the patient, but pain from irritants, especially chemical ones, may occur. With atrophy of the papillae of the tongue, its surface becomes smooth, as if polished, and due to hyposalivation, it acquires stickiness. Individual areas, and sometimes the entire mucous membrane, can be bright red or crimson. This state of the tongue is observed in malignant anemia and is called Gunther's glossitis (after the name of the author who described it for the first time). Hypertrophy of the papillae may also be noted, which, as a rule, does not cause concern to the patient.
Hypertrophy of the papillae of the tongue is often combined with hyperacid gastritis.

When examining the tongue, it should be remembered that at the root of the tongue on the right and left there is a pink or bluish-pink lymphoid tissue. Often this formation is sick, and sometimes even doctors take it for pathological. In the same place, a pattern of veins is sometimes clearly visible due to their varicose expansion, but this symptom has no clinical significance.
When examining the tongue, pay attention to its size, relief. With an increase in size, the time of manifestation of this symptom (congenital or acquired) should be determined. It is necessary to distinguish macroglossia from edema. The tongue can be folded in the presence of a significant number of longitudinal folds, but patients may not be aware of this, since in most cases it does not bother them. Folding is manifested when the tongue is straightened. Patients mistake them for cracks. The difference is that with a crack, the integrity of the epithelial layer is broken, and with a fold, the epithelium is not damaged.
Examination of the mucous membrane of the floor of the mouth. A feature of the mucous membrane here is its pliability, the presence of folds, frenulum of the tongue and excretory ducts of the salivary glands, and sometimes droplets of accumulated secretions. In smokers, the mucous membrane may become dull.
In the presence of keratinization, which manifests itself in areas of grayish-white color, their density, size, adhesion with the underlying tissues, the level of elevation of the focus above the mucous membrane, and soreness are determined.
The importance of identifying these signs is that sometimes they serve as the basis for active intervention, since foci of hyperkeratosis of the oral mucosa are considered precancerous conditions. If any changes are detected on the oral mucosa (ulcer, erosion, hyperkeratosis, etc.) exclude or confirm the possibility of a traumatic factor. This is necessary for diagnosis and treatment.
Palpation examines the alveolar process of the upper jaw from the vestibular, lingual and palatal sides, the color of the mucous membrane above these areas. When a fistulous passage is detected, pus is released from it, granulation swelling with a probe, the course is examined, its connection with the jaw bone, the presence of usuria in the bone and further (to the tooth or teeth) is clarified. Palpating the arch of the vestibule of the mouth, mark the cord along the transitional fold. Such symptoms are characteristic of chronic granulating periodontitis. With this process, there may be a bulging of the bone.
However, bone swelling can be observed with a radicular cyst, tumor-like and tumor lesions of the jaw.
If palpation in the region of the vestibular fornix of the vestibule of the mouth or on the lower jaw on the lingual side shows a swelling in the form of a painful infiltrate or in the palate in the form of a rounded infiltrate, one can assume the presence of acute periostitis. Periosteal inflammatory tissue infiltration along the surface of the alveolar processes from the vestibular, lingual and palatal sides,
painful percussion of several teeth, suppuration from gingival pockets, fistulas characterize acute, subacute osteomyelitis of the jaw. On the lower jaw at the level of molars and premolars, this may be accompanied by a violation of the sensitivity of the tissues innervated by the lower alveolar and chin nerves (Vincent's symptom). Periosteal dense thickening of the jaw, fistulas on the skin of the face and in the oral cavity are typical for chronic forms of odontogenic osteomyelitis, as well as specific inflammatory lesions. At the same time

with the mobility of the teeth accompanying such clinical symptoms, it is necessary to show oncological vigilance.
The focus of inflammatory changes in the peri-maxillary soft tissues requires clarification of the localization and boundaries of the infiltrate from the side of the mouth. Bimanual palpation is usually used. They reveal a violation of the function of opening the mouth, swallowing, breathing, speech impairment. Particular attention is paid to the root of the tongue, the sublingual, pterygo-mandibular and periopharyngeal spaces.
When massaging the salivary glands, one should pay attention to possible characteristic changes: thick saliva consistency, cloudy color, the presence of flakes, clots, salivary blood clots in it.
In diseases of the salivary glands, probing of the ducts is carried out, which makes it possible to establish their direction, the presence of stenosis, stricture or its complete obliteration, calculus in the duct.
Examination of teeth
When examining the oral cavity, it is necessary to examine all the teeth, and not only the one that, in the patient's opinion, is the cause of pain or discomfort. Violation of this rule may lead to the fact that the cause of the patient's anxiety at the first visit may not be found, because,
as discussed earlier, pain can be radiating. In addition, an examination of all teeth at the first visit is also necessary in order to outline a treatment plan, which ends with a sanitation of the oral cavity.
It is important that during the examination all changes in the tooth tissues are detected. For this purpose, it is recommended to develop a specific inspection system. For example, the examination should always be done from right to left, starting with the teeth of the upper jaw (molars), and then from left to right, examine the teeth of the lower jaw.
Examination of the teeth is performed using a set of instruments; the most often used is a dental mirror and probe (always sharp). The mirror allows you to inspect poorly accessible areas and direct a beam of light to the desired area, and the probe is used to check all depressions, pigmented areas, etc. If the integrity of the enamel is not violated, then the probe glides freely over the surface of the tooth, without lingering in the recesses and folds of the enamel. In the presence of a carious cavity in a tooth (invisible to the eye), a sharp probe lingers in it. Especially carefully you should inspect the contact surfaces of the teeth (contact), since it is not easy to find an existing cavity with an intact chewing surface, while probing can detect such a cavity. Currently, the technique of translucent tooth tissues is used by supplying light through special light guides. Probing helps to determine the presence of softened dentin, the depth of the carious cavity, communication with the tooth cavity, the location of the canal orifices, and the presence of pulp in them.
Tooth color can make a difference in the diagnosis. Teeth are usually white with many shades (from yellow to bluish). However, regardless of the shade, the enamel of healthy teeth is characterized by a special transparency - "live enamel shine". In a number of conditions, the enamel loses its characteristic shine, becomes dull.
So, the beginning of the carious process is a change in the color of the enamel, the appearance of cloudiness at first, and then a white carious spot. Pulped teeth lose their usual enamel shine, they acquire a grayish tint. A similar discoloration, and sometimes even more intense, is observed in teeth in which pulp necrosis has occurred. After necrosis of the pulp, the color of the tooth can change dramatically.

Tooth color can also change under the influence of external factors: smoking
(dark brown), metal fillings (dark staining of the tooth), chemical treatment of canals (orange after the resorcinol-formalin method).
Pay attention to the shape and size of the teeth. Deviation from normal shape is due to treatment or abnormality. It is known that some forms of dental anomalies (Hutchinson's, Fournier's teeth) are characteristic of certain diseases.
Percussion - tapping on the tooth - is used to determine the state of the periodontium.
With tweezers or the handle of the probe, tap on the incisal edge or chewing surface of the tooth. If there is no focus of inflammation in the periodontium, percussion is painless. In the presence of an inflammatory process in the periodontium, a painful sensation arises from blows that do not cause discomfort in healthy teeth. When performing percussion, the beats should be light and even. Percussion should be started with obviously healthy teeth, so as not to cause severe pain and to enable the patient to compare the sensation in a healthy and affected tooth.
Distinguish between vertical percussion, when the direction of the blows coincides with the axis of the tooth, and horizontal, when the blows have a lateral direction.
The mobility of the teeth is determined with tweezers by swinging. The tooth has physiological mobility, which is normally almost invisible. However, with damage to the periodontium and the presence of exudate, pronounced tooth mobility arises in it.
There are three degrees of mobility: I degree - displacement in the vestibular-oral direction; II degree - displacement in the vestibular-oral and lateral directions; III degree - displacement and along the axis of the tooth (in the vertical direction).
Examination of the teeth is carried out regardless of the patient's specific complaints and their condition is recorded from right to left, first on the upper, then on the lower jaw.
A mirror and a sharp probe are used, which allows you to establish the integrity of the enamel or detect a cavity, mark its depth and dimensions, as well as communication with the tooth cavity. Attention should be paid to the color of the teeth. A grayish and cloudy color of the tooth enamel may indicate pulp necrosis. The shape and size of the teeth are also important, including dental anomalies: the teeth of Hutchinson, Fournier, which may indicate common diseases and hereditary signs of pathology.
Examining the teeth, they are percussed, the mobility is determined with tweezers, the presence of supernumerary or milk teeth in a permanent bite is noted, the eruption of the lower wisdom teeth, and the nature of teeth closing is determined.
Examine the gingival tubercles, determine the state of the periodontium. The instrument is tapped on the cutting or chewing surface of the tooth (vertical percussion) and on the vestibular surface of the tooth (horizontal percussion). If pain is noted during percussion, this indicates the presence of a peri-apical or marginal focus in the periodontium. They also perform palpation of the teeth - feeling, which makes it possible to establish their mobility and soreness. Grasping the crown of the tooth with dental tweezers, mark the degrees of mobility - I, II and III.
Using a dental probe, gingival pockets, their depth, bleeding during probing, discharge from the pockets and their character are determined.
With the mobility of the teeth, it is necessary to clarify whether there is a localized process or diffuse lesion of the periodontium, as well as to show an oncological

alertness. Pathological mobility of a number of teeth, combined with painful percussion, can be one of the symptoms of osteomyelitis of the jaw.
An assessment of the hygiene condition of the oral cavity is mandatory. If urgent surgical operations are required, simple hygienic procedures are performed to reduce the amount of dental plaque. During planned operations, the whole complex of medical procedures is carried out and the hygienic state is assessed according to the Green-Vermillion or Fedorov index.
Volodkina, and only with a high hygiene index, surgery is performed.
The results of the examination of the teeth are recorded in a special scheme (dental formula), where milk teeth are designated by Roman numerals, permanent ones - by Arabic numerals. Currently, it is customary to designate the tooth number according to the international classification.
The clinical examination of the patient should include a number of diagnostic methods and studies. The type and volume of them depend on the nature of the disease or injury to the maxillofacial region and on the conditions of the examination (in the clinic or hospital), as well as on the level of equipment of the medical institution.
X-ray studies are important for the diagnosis of pathology of the teeth, jaws and other bones of the face and cranial vault, maxillary and frontal sinuses, temporomandibular joints, glands of the oral cavity. Contact intraoral radiography of the teeth, alveolar and palatine processes, the floor of the oral cavity is performed, which makes it possible to clarify the localization and nature of changes in the periodontium, bone, to note the presence of calculus. There are 4 methods of intraoral radiography: radiography of periapical tissues according to the rule of isometric projection; interproximal; bite or occlusal photography; radiography from an increased focal length with a parallel beam of rays.
Isometric surveys are used to assess the periapical tissues, however, they give distortions in magnitude, which can lead to hyper or underdiagnosis.
Interproximal radiographs show teeth, periapical tissues, margins of both jaws. Occlusal radiography allows you to take a snapshot of the alveolar process. Most often, this projection gives an idea of the cortical plate of the alveolar process from the vestibular and lingual sides, including the thickness of the periosteum. In another plane, one can judge more accurately about the pathology: cysts, impacted teeth, jaw fracture lines, the presence of a foreign body (calculus) in the submandibular and sublingual salivary glands. Occlusal images are taken in addition to the previous ones.
Long-focus radiography is performed on devices with a more powerful X-ray tube and a long cone localizer. The method is used primarily to display the marginal sections of the alveolar processes, the structure of bone tissue, the shape of the roots and the presence of destructive changes around them.
X-ray examination of teeth, jaws and other bones of the facial skeleton is of fundamental importance for judging the presence of carious dental cavities, the shape of the roots, the degree of filling them with a filling mass, the state of the periodontium, bone, etc.

Tooth enamel gives a denser shade, while dentin and cementum gives a less dense enamel.
The cavity of the tooth is recognized by the outline of the contour of the alveoli and the cement of the root - it is determined by the projection of the root of the tooth and the compact plate of the alveoli, which looks like a uniform darker strip 0.2 - 0.25 mm wide.
Bone structure is clearly visible on well-taken radiographs. The bone pattern is due to the presence of bone trabeculae in the cancellous substance and in the cortical layer, or trabeculae, between which the bone marrow is located.
The bone beams of the upper jaw have a vertical direction, which corresponds to the force load exerted on it. The maxillary sinus, nasal passages, orbit, and frontal sinus appear as clearly defined cavities. Filling materials due to different density on the film have unequal contrast. So, phosphate cement gives a good image, and silicate cement gives a bad image. Plastic, composite filling materials poorly retain X-rays, and, therefore, a fuzzy image is obtained in the picture.
Radiography allows you to determine the condition of the hard tissues of the teeth (hidden carious cavities on the contact surfaces of the teeth, under the artificial crown), impacted teeth (their position and relationship with the tissues of the jaw, the degree of formation of roots and canals), erupted teeth
(fracture, perforation, narrowing, curvature, degree of formation and resorption), foreign bodies in the root canals (pins, broken burs, needles). The radiograph can also assess the degree of patency of the canal (a needle is inserted into the canal and an x-ray is taken), the degree of filling of the canals and the correctness of the filling, the state of the periapical tissues
(expansion of the periodontal gap, rarefaction of bone tissue), the degree of atrophy of the bone tissue of the interdental septa, the correct manufacture of artificial crowns (metal), the presence of neoplasms, sequesters, the state of the temporomandibular joint.
The x-ray can be used to measure the length of the root canal. To do this, an instrument is inserted into the root canal with a limiter set at the estimated length of the canal. An x-ray is then taken. The length of the tooth canal is calculated by the formula: where i is the actual length of the tool; K1 - radiologically determined length of the canal; i1 is the radiologically determined length of the instrument.
It is effective to use images on a radiovisiograph during resection of the apex of the tooth root, extraction of teeth (especially impacted ones), and implantation.
Radiovisiography gives an image of residual roots, foreign bodies, the position of the implant in relation to adjacent teeth, the bottom of the maxillary sinus, nose, the canal of the lower jaw, and the chin foramen. New generations of visiographs provide volumetric, color, and digital data, allowing more accurate judging of the amount and structure of the bone, the effect of surgical interventions. Extraoral radiography is used to study the upper and lower jaws, zygomatic, frontal, nasal, temporal and other bones of the skull, maxillary and frontal sinuses, temporomandibular joints. The following projections are used for radiography: direct, lateral, semi-axial, axial, as well as oblique contact and tangential.
Orthopantomography is a promising method of X-ray examination, which allows you to obtain an overview of the teeth and jaws.

Panoramic radiographs have a definite advantage over intraoral images, since with minimal radiation exposure they provide an overview of the jaw, teeth, periapical tissues and adjacent sinuses. However, on panoramic radiographs, distortions of the structure of the roots of the teeth, the structure of the bone, the location of individual anatomical formations are possible; the central teeth and the surrounding bone tissue are poorly formed.
Side panoramic images give less distortion.Orthopantomography is most effective for the primary diagnosis of inflammation, trauma, tumor, deformation.
When diagnosing pathological processes in the jaws and nasal cavities, orthopantomography, orthopantomography is supplemented with longitudinal tomography and zonography, using direct, lateral, posterior and anterior axial projections. To reduce the radiation exposure, zonograms are also produced with small angles of tube rotation, giving a layer-by-layer image of thicker sections.
In diagnostics, electro-roentgenography is also used, which is very effective for emergency information. However, with this method, the patient receives a lot of radiation exposure.
For diseases and injuries of the salivary glands, bronchiogenic fistulas, chronic osteomyelitis of the jaws, contrast radiography is used using iodolipol and water-soluble contrast agents. With sialography of the parotid gland, the norm of the contrast agent is 2.0 - 2.5 ml, for the submandibular salivary gland - 1.0 - 1.5 ml. In pathological processes, these numbers can be corrected in the direction of decrease (calculous sialadenitis, interstitial sialadenitis) or increase (parenchymal sialadenitis). With sialography, intraoral zonography is used - direct and lateral and orthopantomography. Sialography allows you to assess the condition of the ducts of the gland, to determine the presence of a salivary stone. The method can be supplemented with pneumosubmandibulography, digital subtraction sialography, radiometry, scintigraphy.
Contrast radiography is also used for chronic osteomyelitis, face and neck fistulas, including congenital (fistulography), jaw cysts, and diseases of the maxillary sinus.
For diseases of the temporomandibular joints, arthrography is used.
After intra-articular injection of a contrast agent, tomo or zonograms are obtained at different positions of the condylar process.
Radiography with contrasting arterial and venous vessels of the maxillofacial region is most effective in vascular neoplasms. In some cases, the tumor is punctured, a contrast agent is injected, and radiographs are performed in frontal and lateral projections. In other cases, especially with cavernous hemangioma, the carrying vessel is surgically isolated, and then a contrast agent is injected and a series of radiographs is performed in different projections. Angiography requires special conditions and should be carried out in a hospital, an X-ray operating room, where anesthesia, surgical isolation of the leading tumor vessel, and an approach to the femoral, subclavian, and external carotid arteries are performed.
Choose water-soluble contrast agents (verografin, urografin, cardiografin, cardiotrast). Serial angiography through the external carotid artery is most often used to diagnose vascular tumors.

Less commonly, lymphography is used - direct for the diagnosis of lymph nodes, blood vessels.
X-ray computed tomography (RCT) is a promising tool in the diagnosis of diseases of the maxillofacial region, which makes it possible to obtain two- and three-dimensional layered images of the head. Thanks to the layered image
RCT determines the true size and boundaries of the defect or deformity, the localization of the inflammatory or tumor process. The high resolution of RKT makes it possible to differentiate pathological processes in bone and soft tissues. This method is very important for trauma and intracranial changes. Establishing the dislocation of cerebral structures, the localization of brain trauma, the presence of hematomas, hemorrhages helps diagnostics, allows planning interventions and their sequence in the maxillofacial region, the cerebral region of the skull and the brain.
In the diagnosis of pathological processes in the maxillofacial region, magnetic resonance imaging (MRI) is also used. It has a particular advantage as it is not associated with ionizing radiation. MRI detects changes in soft tissues: edema, infiltration, accumulation of exudate, pus, blood, tumor growth, including malignant neoplasms, the presence of metastases.
The combined use of X-ray computed tomography and magnetic resonance imaging makes it possible to obtain a three-dimensional image of the soft and bone tissues of the face and, on the basis of spatial layered anatomical and topographic data, create graphic computer models. This determines an accurate diagnosis, allows you to plan the proper amount of intervention. RCT data and
MRI also determines the possibility of intraoperative spatial orientation in the maxillofacial region. Especially important is the ability to create three-dimensional graphic images based on these methods for restorative operations in the maxillofacial region.

Start with inspection vestibule with closed jaws and relaxed lips, lifting the upper lip and lowering the lower lip or pulling the cheek with a dental mirror. First of all, the red border of the lips and the corners of the mouth are examined. Pay attention to the color, the formation of scales, crusts. On the inner surface of the lip, as a rule, an insignificant bumpy surface is determined, due to the localization of small salivary glands in the mucous layer. In addition, you can see the pinpoint holes - the excretory ducts of these glands. At these holes, when the mouth is fixed in the open position, an accumulation of secretion droplets can be observed.

Then using a mirror inspect the inner surface of the cheeks. Pay attention to the color and moisture of the buccal mucosa. Sebaceous glands (Fordyce's glands) are located along the line of closing of the teeth in the posterior part, which should not be mistaken for pathology. These are pale yellow nodules with a diameter of 1-2 mm, which do not rise above the mucous membrane, and sometimes are visible only when it is pulled. At the level of the upper second large molars (molars) there are papillae on which the excretory ducts of the parotid salivary glands open. (They are sometimes mistaken for signs of disease.) There may be dental prints on the mucous membrane.

It is important to determine the ratio of the dentition - bite. According to the modern classification, all existing types of bite are divided into physiological and pathological (Fig. 4.1).

Following the examination of the oral cavity, gum examination... Normally, it is pale pink, tightly covering the neck of the tooth. The gingival papillae are pale pink, occupying the interdental spaces. A groove is formed at the site of the periodontal junction (previously it was called the periodontal pocket). With the development of the pathological process, the gum epithelium begins to grow along the root, forming a clinical, or periodontal (pathological), periodontal pocket. The condition of the pockets formed, their depth, and the presence of tartar are determined using an angular button-like probe or a probe with notches applied every 2-3 mm. Examination of the gums allows you to determine the type of inflammation (catarrhal, ulcerative-necrotic, hyperplastic), the nature of its course (acute, chronic, in the acute stage), prevalence (localized, generalized), severity (mild, moderate, severe gingivitis or periodontitis). The papillae may be enlarged due to their swelling, while they cover a significant part of the tooth.

For determining CPITN (index of need for treatment of periodontal diseases), proposed by WHO, it is necessary to examine the surrounding tissues in the area of 10 teeth: 17, 16, 11, 26, 27, which corresponds to teeth 7, 6, 1, 6, 7 on the upper jaw, and 27, 36, 31, 46, 47, which corresponds to 7, 6, 1, 6, 7 teeth on the lower jaw. The results of the examination of this group of teeth make it possible to obtain a complete picture of the state of the periodontal tissues of both jaws. The formula for this group of teeth:

In a special card, the state of only 6 teeth is recorded in the corresponding cells. When examining teeth 17 and 16, 26 and 27, 36 and 37, 46 and 47, codes corresponding to a more severe condition are taken into account. For example, if bleeding is found in the area of tooth 17, and tartar is found in the area of tooth 16, then code 2 is entered into the cell, indicating tartar. If any of these teeth is missing, then the tooth next to it in the dentition is examined. In the absence of this tooth, the cell is crossed out diagonally and this indicator is not taken into account in the summary results.

Periodontal tissues are examined by probing with a special (button-like) probe (Fig. 4.2) to detect bleeding, supra- and subgingival tartar and pathological pocket. The load on the periodontal probe during examination should be no more than 25 g. Practical test to establish this force - pressure with a periodontal probe under the thumbnail without causing pain or discomfort.

Probing force can be divided into two components: working (for determining the depth of the pocket) and sensitive (for detecting subgingival calculus). The pain experienced by the patient during the probing is an indicator of the use of too much force. The number of probes depends on the condition of the tissues surrounding the tooth, however, probing more than 4 times in the area of one tooth is unlikely to be required. Bleeding can appear both immediately after probing and after 30-40 seconds. Subgingival calculus is determined not only when it is clearly present, but also with a barely perceptible roughness, which is revealed when the probe moves along the tooth root along its anatomical configuration.

CPITN is assessed using the following codes:

0 - no signs of disease;
1 - bleeding gums after probing;
2 - the presence of supra- and subgingival calculus;
3 - pathological pocket with a depth of 4-5 mm;
4 - pathological pocket with a depth of 6 mm or more.

Assessment of the hygienic state of the oral cavity- an important indicator of the occurrence and course of pathological processes in it. At the same time, it is important to have not only a qualitative indicator that would make it possible to judge the presence of dental plaque. Many indices have now been proposed to quantify the various components of oral hygiene.

Green and Vermillion (1964) proposed a simplified oral hygiene index (IHI) - determining the presence of plaque and calculus on the buccal surface of the first upper molars, the lingual surface of the first lower molars and the labial surface of the upper incisors: 16, 11, 21, 26, 36 , 46.

In this case, estimates are used in points:

0 - no dental plaque;
1 - plaque covers no more than the surface of the tooth;
2 - plaque covers from Y to at the surface of the tooth;
3 - Plaque covers more at the surface of the tooth.

Plaque Index (PLI) calculated by the formula:

Index 3 indicates unsatisfactory, and 0 indicates good oral hygiene.

Tartar Index (ICC) assessed in the same way as IZN:

0 - no stone;
1 - supragingival calculus at the surface of the tooth;
2 - supragingival stone on 2/3 of the surface of the crown or in certain areas;
3 - the supragingival calculus covers more at the surface of the tooth, the subgingival calculus encircles the neck of the tooth.

In determining Oral hygiene index according to Fedorov-Volodkina(Fig. 4.3) with a solution of iodine and potassium iodide (crystalline iodine 1 g, potassium iodide 2 g, distilled water 40 ml) lubricate the vestibular surfaces of the six anterior (frontal) teeth of the lower jaw. The quantitative assessment is given on a five-point scale:

staining the entire surface of the crown - 5 points;
3/4 of the surface - 4 points;
1/2 surface - 3 points;
1/4 of the surface - 2 points;
lack of staining - 1 point.

The average value of the index is calculated by the formula:

Values 1 - 1.5 reflect good, and values 2-5 - poor oral hygiene.

Podshadley and Haley (1968) suggested oral hygiene efficiency index (IH)... After applying dyes and rinsing the mouth with water, 6 teeth are visually examined: buccal surfaces 16 and 26, lip surfaces 11 and 31, lingual surfaces 36 and 46.

The surface of the teeth is conventionally divided into 5 sections: 1 - medial, 2 - distal, 3 - mid-occlusal, 4 - central, 5 - mid-cervical. At each site, codes are determined:

0 - no staining;
1 - painting any surface.

The calculation is made according to the formula:

where ZN is the sum of codes for all teeth; n is the number of examined teeth. A score of 0 indicates excellent, and 1.7 or more indicates an unsatisfactory hygienic state of the oral cavity.

Tumors and swellings of various shapes and consistencies can form on the gums. The most common abscesses are a sharply hyperemic area of the gums with an accumulation of purulent exudate in the center. After opening the abscess, a fistulous tract occurs. It can also form in the presence of a focus of inflammation at the apex of the root. Depending on the localization of the fistulous tract, its origin can be determined. If the fistulous passage is located closer to the gingival margin, then its formation is associated with an exacerbation of parodontitis, and if it is closer to the transitional fold, then its occurrence is due to a change in the periodontal tissues. It should be remembered that X-ray examination is of decisive importance.