When examining the oral cavity itself, 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, swollen, and sometimes acquires a whitish tint, which indicates the phenomenon of para- or hyperkeratosis.
When examining the palate, they determine the shape of the hard palate (highly curved, flattened), the mobility of the soft palate, the closure of the nasopharyngeal space by it (when pronouncing the drawn-out sound “a-a”), and the presence of various types of acquired and congenital defects. When examining the tongue, attention is paid to its shape, size, mobility, color, condition of the mucous membrane and the severity of the papillae, the presence of deformation (cicatricial curvature, fusion with underlying tissues, tongue defect, compaction, infiltration) and other changes.
Examination of the tongue begins with determining the condition of the papillae, especially if there are complaints of changes in sensitivity or burning and pain in any areas. A coated tongue may occur due to slower rejection of the outer layers of the epithelium. This phenomenon may be a consequence of disruption of the gastrointestinal tract, and possibly pathological changes in the oral cavity due to candidiasis. Sometimes there is increased desquamation of the papillae of the tongue in some area (usually on the tip and lateral surface). This condition may not bother the patient, but pain may occur from irritants, especially chemical ones. With atrophy of the papillae of the tongue, its surface becomes smooth, as if polished, and due to hyposalivation it becomes sticky. Individual areas, and sometimes the entire mucous membrane, may be bright red or crimson. This condition of the tongue is observed in pernicious anemia and is called Gunther's glossitis (named after the author who first described it). Hypertrophy of the papillae may also be observed, which, as a rule, does not cause concern to the patient.
When examining the tongue, one should remember the need to examine the lateral surfaces of the tongue in the area of the molars and the root of the tongue, where malignant neoplasms are often localized.
When examining the tongue, pay attention to its size and relief. If the size increases, the time of manifestation of this symptom (congenital or acquired) should be determined. It is necessary to distinguish macroglossia from edema. The tongue may be folded if there are a significant number of longitudinal folds, but patients may not know about this, since in most cases it does not bother them. The folding appears 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, but with a fold, the epithelium is not damaged.
When examining the floor of the mouth, pay attention to the mucous membrane
shell. Its peculiarity is its pliability, the presence of folds, the frenulum of the tongue and the excretory ducts of the salivary glands, and sometimes droplets of accumulated secretion. In smokers, the mucous membrane may acquire a matte tint.
In the presence of keratinization, which manifests itself in areas of grayish-white color, their density, size, adhesion to the underlying tissues, the level of elevation of the lesion above the mucous membrane, and pain are determined.
Palpation. Palpation is understood as a clinical research method that allows, using touch, to determine the physical properties of tissues and organs, their sensitivity to external influences, as well as some of their functional properties. Distinguish regular And bimanual palpation.
Palpation of the soft tissues of the cheek and floor of the mouth is best done with both hands ( bimanual). The index finger of one hand is used to palpate from the side of the oral mucosa, and one or more fingers of the other hand is used to palpate from the outside - from the side of the skin. If scars are present, their nature, shape, size are determined and it is noted whether they disrupt the function of the oral organs and what these violations are.
To palpate the tongue, the patient is asked to stick it out. Then, with the thumb and index finger of the left hand, using a gauze napkin, take the tongue by the tip and fix it in this position. Palpation is done with fingers right hand.
Palpation of the maxillofacial area and adjacent areas is carried out with the fingers of one hand ( normal palpation), and with the other hand
keep the head in the required position.
The order of palpation of a particular anatomical area is determined by the localization of the pathological process, since palpation should never begin from the affected area. It is recommended to palpate in the direction from “healthy” to “sick”.
All irregularities, thickenings, compactions, swelling, pain and other changes are noted, paying special attention to the condition of the lymphatic system. In the presence of inflammatory infiltration, its consistency (soft, dense), area of distribution, pain, adhesion to the underlying tissues, mobility are determined skin above it (is going into a fold or not), the presence of foci of softening, fluctuations, the condition of regional lymph nodes.
Fluctuation (fluctuare - oscillate in waves), or ripple - a symptom of liquid being in a closed cavity. It is defined as follows. One or two fingers of one hand are placed on the area to be examined. Then, with one or two fingers of the other hand, a sharp push is made in the area under study. The movement of liquid in the cavity caused by it is perceived by fingers applied to the area under study in two mutually perpendicular directions. A fluctuation perceived in only one direction is false. False fluctuation can be detected in the area of elastic tissues, in soft tumors (for example, lipomas).
If a tumor process is suspected, special attention is paid to the consistency of the neoplasm (softness, density, elasticity), size, nature of the surface (smooth, bumpy), mobility in various directions (horizontal, vertical). The most important, and sometimes decisive, importance is palpation of the regional lymph nodes.
Palpation of lymph nodes. By palpation, the condition of the submental, submandibular and cervical lymph nodes is determined.
Peripheral lymph nodes are grouped in the subcutaneous tissue of various areas of the body, where they can be detected by palpation, and with significant magnification, visually. The examination of lymph nodes is carried out in the same symmetrical areas. The method of superficial palpation is used. The doctor places his fingers on the skin of the area being examined and, without lifting his fingers, slides them along with the skin over the underlying dense tissues (muscles or bones), pressing lightly on them. The movements of the fingers can be longitudinal, transverse or circular. By rolling the palpated lymph nodes under the fingers, the doctor determines their number, size and shape of each node, density (consistency), mobility, pain and adhesion of the lymph nodes to each other, to the skin and surrounding tissues. The presence of skin changes in the area of palpable lymph nodes is also visually determined: hyperemia, ulcerations, fistulas. The dimensions of the lymph nodes are indicated in cm. If the lymph node has a round shape, it is necessary to indicate its diameter, and if it is oval, the largest and smallest dimensions.
Feeling submandibular lymph nodes is an important diagnostic technique in recognizing a number of systemic diseases, oncological processes, as well as inflammatory processes. To palpate the lymph nodes, the doctor stands to the right of the patient, fixes his head with one hand, and uses the 2nd, 3rd, 4th fingers of the other hand, placed under the edge of the lower jaw, to palpate the lymph nodes through careful circular movements.
Starting palpation mental lymph nodes, the doctor asks the patient to slightly tilt his head forward and fixes it with his left hand. Places the closed and slightly bent fingers of the right hand in the middle of the chin area so that the ends of the fingers rest against the front surface of the patient’s neck. Then, palpating them towards the chin, he tries to bring the lymph nodes to the edge of the lower jaw and determine their properties.
Posterior cervical lymph nodes palpated simultaneously on both sides in the spaces located between the posterior edges of the sternocleidomastoid muscles.
On palpation anterior and posterior cervical lymph nodes fingers are placed perpendicular to the length of the neck. Palpation is carried out in the direction from top to bottom.
Normally, lymph nodes are usually not detected by palpation. If the nodes are palpable, then you should pay attention to their size, mobility, consistency, pain, and cohesion.
Having received based on external examination and palpation data about
changes in the maxillofacial region, proceed to the study of its individual anatomical areas.
Study of facial bones, jaws begin with an external examination, paying attention to their shape, size, and symmetry of location. It is especially important to identify, through deep palpation, deformations and changes in various parts of the jaws.
When examining the facial skeleton of a patient with a trauma to the maxillofacial region, the symmetry of the external nose and pain on palpation of the nasal bones are noted. The severity of the retraction of the bridge of the nose, the severity of the “step” symptom. Next, an axial load is applied to the zygomatic arches and upper jaw, noting the severity pain syndrome and location of pain. It is necessary to consistently determine the localization of pain during axial load on the lower jaw and the presence of a “step” symptom in the area of the mandibular edge, the severity of crepitus of bone fragments during palpation, and the presence of pathological mobility of bone fragments.
If there is a defect or deformation of the maxillofacial area, the nature of the deformation, the localization and boundaries of the defect leading to the deformation, and the condition of the skin at the border with the defect are described in detail. If there is a scar deformity, it is necessary to describe its size (in cm), the color of the scar, pain on palpation, the consistency of the scar, and its relationship with surrounding tissues.
In the presence of congenital pathology of the face, describe the severity of Cupid's bow (broken, not broken), the size of the cleft lip, palate along line A; type of cleft: one-sided, two-sided, complete, incomplete, through; the presence of deformation of the alveolar process of the upper jaw; position of the premaxilla.
Examination of the jaws. The difference is anatomical structure and the location of the top and mandible, as well as the unequal degree of their participation in the performance of various functions determine the different course pathological processes in them, and consequently, various signs of their manifestation.
Examination of the upper jaw. When treating patients with lesions of the upper jaw great importance have complaints and medical history. Much more often, symptoms such as pain, nasal discharge, and tooth mobility appear at first, and only in a later period does jaw deformation occur. However, to establish the pathological process, it is necessary to detail the above symptoms: in case of pain - determine the place of greatest pain, identify its intensity and irradiation: in the presence of nasal discharge - its nature (mucous, purulent, bloody, bloody-purulent, etc.), in case of deformation - its type (protrusion of the wall of the maxillary sinus, its destruction, etc.), size, localization, etc. To identify perforation of the maxillary sinus, among other examination methods, a nasal test is sometimes performed.
Examination of the lower jaw. When examining the lower jaw, attention is paid to the shape, symmetry of both halves, size, the presence of irregularities, thickenings, acquired and congenital deformities. Palpation determines the nature of the surface of the thickening or tumor (smooth, lumpy), consistency (dense, elastic, soft).
Examination of the temporomandibular joint. The function of the temporomandibular joint can be judged to a certain extent by the degree of mouth opening and lateral movements of the lower jaws.
Normal mouth opening in an adult corresponds to 45-50 mm between the incisors. It should be considered more appropriate to measure the individual norm of mouth opening based on measuring the width of the fingers. So, if the patient opens his mouth to the width of his 3 fingers (index, middle and ring), then this can be considered the norm.
Checking the volume of lateral movements of the lower jaw consists of determining the distance in millimeters by which the lower jaw moves from the midline of the face when it moves in one direction or another. Then the area of the temporomandibular joint is examined and palpated, noting the condition of the tissues in this area: the presence of swelling, hyperemia, infiltration and pain. By pressing the tragus of the ear forward, the external auditory canal is examined, determining whether it is narrowed due to bulging of the anterior wall. In the absence of inflammation, the ends of the little fingers are inserted into the external auditory canals and when opening and closing the mouth, with lateral movements of the lower jaw, the degree of mobility of the articular heads is determined, the appearance of pain, crunching or clicking in the joint.
Study salivary glands. When examining the salivary glands, first of all, attention is paid to the color of the skin and changes in tissue contours in the area of the anatomical location of the glands. If the contours are changed due to swelling, then its size and character are determined (spread out, limited, soft, dense, painful, areas of softening, fluctuations). If the change in the contours of the gland is caused by a tumor process, then the exact localization of the tumor in the gland, the clarity of its boundaries, size, consistency, mobility, and the nature of the surface (smooth, lumpy) are established. It is determined whether there is paresis or paralysis of the facial muscles and damage to the masticatory muscles. Then the excretory ducts are examined. To examine the mouths of the excretory ducts of the parotid salivary glands, which are located on the mucous membrane of the cheek along the line of closure of the teeth at the level of the second upper molar, the corner of the mouth is pulled forward and slightly outward with a dental mirror or a blunt hook. Lightly massaging the parotid salivary gland, observe the release of secretion from the mouth of the duct, while determining the nature of the secretion (clear, cloudy, purulent) and at least approximately its amount. In order to examine the excretory duct of the submandibular or sublingual salivary glands, the tongue is retracted posteriorly with a dental mirror. In the anterior section of the sublingual region, the outlet of the ducts is examined. By massaging the submandibular salivary gland, the nature and amount of its secretion is determined. By palpation along the duct from back to front, the presence of a stone or inflammatory infiltrate in the duct is determined. By palpating from the oral cavity and submandibular region (bimanually), the size and consistency of the submandibular and sublingual salivary glands can be more accurately determined. For certain indications (suspicion of the presence of a stone, deformation of the duct, its narrowing) and the absence of inflammatory phenomena, careful probing of the duct can be performed.
Study of the function of the trigeminal, facial, glossopharyngeal and vagus nerves. When studying the functional state of the trigeminal nerve (n.trigemini) assess tactile, pain and temperature sensitivity in areas innervated by sensory nerves, and the motor function of the masticatory muscles. To test sensitivity with the patient's eyes closed, they alternately touch the skin of the area under study with a piece of paper (tactile sensitivity), a needle (pain sensitivity) and test tubes with warm and cold water (temperature sensitivity) and ask the patient to say what he feels. The sensitivity of the cornea, conjunctiva, and mucous membranes of the oral cavity and nose is also checked. Determine perception taste sensations from the anterior two-thirds of the tongue. Palpating the exit site sensory nerves from the skull in the area of the superciliary arch, in the infraorbital region and in the chin area, the presence of pain points is determined.
When checking the motor function of the trigeminal nerve, the tone and strength of the masticatory muscles are determined, as well as the correct position of the lower jaw during its movements. In order to determine the tone of the masticatory muscles, the patient is asked to firmly clench and unclench his teeth: while doing this, the well-contoured masticatory and temporal muscles themselves are palpated. To test the strength of the masticatory muscles during open mouth The patient's chin is covered with the thumb and forefinger of the right hand and the patient is asked to close his mouth, while trying to hold the lower jaw by the chin.
Facial nerve (n.facialis ) innervates facial muscles
tsa, therefore, when studying its functions, the state of the facial muscles at rest and during their contraction is determined. Observing the state of the muscles at rest, note the severity of skin folds (wrinkles) on the right and left sides of the forehead, the width of both palpebral slits, the relief of the right and left nasolabial folds, and the symmetry of the corners of the mouth.
The contractility of the facial muscles is tested by raising and frowning the eyebrows, closing the eyes, baring the teeth, puffing out the cheeks and protruding the lips.
When studying the function glossopharyngeal nerve (n.glossopharyngeus) determine the perception of taste sensations from the back third of the tongue and observe the act of swallowing.
Nervus vagus (n.vagus) is mixed. It consists of motor and sensory fibers. It is of interest to study one of its branches - the recurrent nerve (n.recurens), which supplies motor fibers to the muscles of the palate, stylopharyngeal muscle, pharyngeal constrictors, and laryngeal muscles.
The study of its function consists of determining the timbre of the voice, the mobility of the soft palate and vocal cords, as well as observing the act of swallowing.
Based on the data from the survey, examination and basic research methods (palpation and percussion), a preliminary diagnosis is made. To clarify the diagnosis in most cases, additional research methods are necessary.
Oral cancer can be located in any part of the mouth, including the gums, tongue, lips, cheeks, roof of the mouth, and upper throat. However, even if oral cancer is potentially lethal, it is quite possible to detect it on early stages development, when treatment does not yet require such efforts and sacrifices, and is also more effective and efficient than in later stages. To detect oral cancer in a timely manner, it is necessary to regularly conduct self-diagnosis and visit the dentist.
Steps
Self-diagnosis at home
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Check your face, paying attention to any lumps, sores and sores, moles and pigmentation changes. Examine your face carefully in a mirror under bright light, trying to notice any changes that could be symptoms of oral cancer.
- Particular attention should be paid to any changes in skin color, ulcers, moles and birthmarks, as well as any tumors on the face.
- You should also pay attention to whether you have tumors, swellings and “bumps” on one side of your face that are absent on the other half of your face.
- The normal face is almost symmetrical; there should be no serious differences between the left and right halves.
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Palpate the neck for tumors. Using your fingertips, slowly and gently palpate (feel) your neck. Your job is to find any swelling, lumps, lumps, or tender areas that could be symptoms of oral cancer.
- The neck should be palpated both from the sides and from the front.
- Pay special attention to the condition of the lymph nodes - painful, swollen lymph nodes are more than a serious symptom.
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Check to see if your lip pigmentation has changed. Malignant neoplasms affecting the lips often make themselves felt in the first stages of development precisely by changes in pigmentation.
- Pull your lower lip down.
- Check the inside of your lips for red, white, or black patches or sores.
- Continuing to hold the lips apart with your thumb and forefinger, palpate the lips.
- Pay attention to anything unusual, such as tight areas and swelling.
- Now repeat the procedure with your upper lip.
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Check the buccal mucosa for changes in pigmentation. Open your mouth as wide as possible and check the inside of your cheeks for early signs of oral cancer.
- Pull your cheek back with your finger to make it easier to see.
- Ulcers and pigmentation changes are a warning sign.
- Now forefinger put it in your mouth, touch your cheek with it. Place your thumb on the outside of the same area.
- Gently run your fingers over your cheek (do not spread them apart), checking for swelling, lumps, rough or painful areas.
- Now repeat this procedure for the other cheek.
- Check also the area between the cheek and teeth, the gums near the lower chewing teeth. All discoloration, swelling and painful sores are warning signs.
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Check your palate. You need to look for the same thing as before. The roof of your mouth can be affected by oral cancer, so being on the safe side is a must. And take a flashlight when you check your palate.
- Gently tilt your head back and open your mouth wider, carefully examining the oral mucosa.
- If you don't tilt your head back and don't use a flashlight, you'll see worse.
- Now use your very fingertips to palpate the palate (you are looking for tumors and lumps, don’t forget).
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Check your language. Open your mouth wide, stick out your tongue and examine it carefully. Changes in the pigmentation or texture of the surface of the tongue may indicate the onset of cancer.
- Check your tongue from all sides - top, bottom, and sides.
- Particular attention should be paid to the sides of the tongue in the part where it is closer to the throat - this is where tongue cancer most often develops.
- Raise your tongue to the roof of your mouth and check the area where the tongue meets the lower jaw.
- Ulcers, pigmentation changes and other abnormal changes are what should attract your attention.
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Check the floor of the mouth. Your “tool” is again palpation. A malignant neoplasm will be revealed by painful areas and compactions.
- You should also pay attention to tumors, lumps, swelling, ulcers and sores.
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Seek professional medical help if you experience any of these worrying symptoms. If you do find abnormal changes in your mouth, ulcers, sores or painful areas that do not heal even after 2-3 weeks, contact your dentist for an oral cavity examination and a cancer screening test.
- The sooner you get a screening test, the better your chances of success in fighting the disease.
- By analogy: the earlier treatment is started, the higher your chances of coping with the disease.
Seeking professional medical help
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Get regular dental checkups to help spot signs of oral cancer. Conducting an examination of the patient's oral cavity at an appointment is one of the dentist's tasks.
- This will give you the opportunity to detect oral cancer at the earliest stages of development.
- In principle, regular dental examinations are the best way to detect any oral disease in the early stages of development.
- If you are at risk of developing cancer (due to smoking, alcohol abuse, frequent exposure to light, or a family history), then your dentist may also perform screening tests.
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Get an oral examination to identify and diagnose any abnormalities and pathologies. During the examination, the doctor will check the condition of the oral mucosa.
- The dentist will palpate the oral cavity (don't worry, his hands will be gloved), including the cheeks, lips, tongue, roof of the mouth, and floor of the mouth, as well as the sides of the tongue, looking for lumps, swelling, and changes in surface tissue texture.
- The dentist will conduct full examination Oral tissues to look for symptoms of cancer, and also examines the mouth, face and neck for changes associated with cancer.
- If the dentist finds any warning signs, he will prescribe additional examinations for you.
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You may need to undergo a biopsy. A biopsy is a lifetime sampling of tissue for analysis, and if the dentist considers it necessary, then you will have to go under a needle.
- During a biopsy, a tissue sample (that is, “from”) will be taken from the suspicious area and examined for the presence of cancer cells.
- Don't be afraid, the biopsy is performed under local anesthesia.
- The resulting tissue sample will be sent to the laboratory for analysis.
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You may also be advised to undergo a needle biopsy. If your dentist finds a tumor in your neck, he or she will have you undergo this procedure to obtain a tissue sample from the tumor for analysis.
- The essence of a puncture biopsy can be described as follows: a needle will be inserted into the tumor, through which its contents will be sucked out into a syringe.
- The resulting material will also be examined for the presence of cancer cells.
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The use of special dyes may also be indicated to detect cancer cells. With their help, those areas where cancer cells form appear to be tinted.
- The essence of the procedure is simple - the dentist will ask you to rinse your mouth with a special product, which will tint all the affected tissues.
- If after rinsing your mouth some areas turn blue, this indicates the presence of cancer cells in that area.
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In addition, light testing can be used for diagnosis. Its meaning is in many ways similar to the use of dyes.
- First, you will need to rinse your mouth with a 1% acetic acid solution.
- This is necessary to clean the mouth and dehydrate the cells, so that the dentist can see and understand more clearly what is going on in your mouth.
- If you have anyone in your family who has been diagnosed with cancer, your chances of being diagnosed with the disease increase.
- Even if you don't have any habits that could put you at risk of developing oral cancer, it won't hurt to get regular oral exams from your dentist.
- Regular dental checkups are the best way to prevent oral cancer because they can detect the disease at the very beginning.
Warnings
- If you develop an ulcer or sore in your mouth that does not heal for three weeks or more, contact your dentist immediately.
Begin by examining the vestibule of the mouth with the jaws closed and the lips relaxed, raising 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 color, formation of scales and crusts. On the inner surface of the lip, as a rule, there is a slight bumpy surface due to the localization of small salivary glands in the mucous layer. In addition, you can see pinholes - the excretory ducts of these glands. At these holes, when the mouth is fixed in an open position, an accumulation of droplets of secretion can be observed.
Then use a mirror to inspect the inner surface of the cheeks. Pay attention to its color and moisture content. Along the line where the teeth meet in the posterior part, there are sebaceous glands (Fordyce glands), 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 stretched. 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 illness. There may be imprints of teeth on the mucous membrane. Following the examination of the oral cavity, the gums are examined. Normally, it is pale pink and tightly covers the neck of the tooth. The gingival papillae are pale pink and occupy the interdental spaces. A groove is formed at the site of the periodontal junction (previously it was called a periodontal pocket). Due to the development of the pathological process, the gingival epithelium begins to grow along the root, forming a clinical, or periodontal, periodontal pocket. The condition of the formed pockets, their depth, and the presence of tartar are determined using an angled button 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 swelling, when a significant part of the tooth is covered.
Then they begin to examine the oral cavity itself. 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, swollen, 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. A coated tongue may occur due to slower rejection of the outer layers of the epithelium. This phenomenon may be a consequence of disruption of the gastrointestinal tract, and possibly pathological changes in the oral cavity with candidiasis. Sometimes there is increased desquamation of the papillae of the tongue in some area (usually on the tip and lateral surface). This condition may not bother the patient, but pain may occur from irritants, especially chemical ones. With atrophy of the papillae of the tongue, its surface becomes smooth, as if polished, and due to hyposalivation it becomes sticky. Individual areas, and sometimes the entire mucous membrane, may be bright red or crimson. This state of the tongue is observed when pernicious anemia and is called Gunther's glossitis (named after the author who first described it). Hypertrophy of the papillae may also be observed, which, as a rule, does not cause concern to the patient.
Hypertrophy of the tongue papillae 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 pink or bluish-pink lymphoid tissue. Often patients, and sometimes even doctors, mistake this formation for pathological. In the same place, the pattern of veins is sometimes clearly visible due to varicose veins, but this symptom has no clinical significance.
When examining the tongue, pay attention to its size and relief. If the size increases, the time of manifestation of this symptom (congenital or acquired) should be determined. It is necessary to distinguish macroglossia from edema. The tongue may be folded if there are a significant number of longitudinal folds, but patients may not know about this, since in most cases it does not bother them. The folding appears 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, but with a fold, the epithelium is not damaged.
Examination of the mucous membrane of the floor of the mouth. The peculiarity 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 secretion. In smokers, the mucous membrane may acquire a matte tint.
In the presence of keratinization, which manifests itself in areas of grayish-white color, their density, size, adhesion to the underlying tissues, the level of elevation of the lesion above the mucous membrane, and pain are determined.
The importance of identifying indicated 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.), it is necessary to exclude or confirm the possibility action of the traumatic factor. This is necessary for diagnosis and treatment.
The alveolar process of the upper jaw is examined by palpation from the vestibular, lingual and palatal sides, the color of the mucous membrane over these areas. If a fistulous tract is detected, pus is discharged from it, granulations bulge, the tract is examined using a probe, its connection with the jaw bone, the presence of an abnormality in the bone and further (to the tooth or teeth) are clarified. By palpating the arch of the vestibule of the mouth, a cord is noted along the transitional fold. Such symptoms are characteristic of chronic granulating periodontitis. With this process, there may be bulging of the bone.
However, bone protrusion can be observed with radicular cyst, tumor-like and neoplastic lesions of the jaw.
If palpation in the area of the vestibular vault of the vestibule of the mouth or on the lower jaw on the lingual side reveals a bulge in the form of a painful infiltrate or on the palate in the form of a rounded infiltrate, the presence of acute periostitis can be assumed. Periosteal inflammatory infiltration of tissue along the surface of the alveolar processes from the vestibular, lingual and palatal sides,
painful percussion of several teeth, suppuration from gum pockets, fistulas characterize acute, subacute osteomyelitis of the jaw. In the lower jaw at the level of molars and premolars, this may be accompanied by a violation of the sensitivity of tissues innervated by the lower alveolar and mental 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 tooth mobility accompanying such clinical symptoms, it is necessary to exercise oncological vigilance.
The focus of inflammatory changes in the perimaxillary soft tissues requires clarification of the localization and boundaries of the infiltrate on the side of the mouth. Bimanual palpation is usually used. Defects in the function of mouth opening, swallowing, breathing, and speech impairment are detected. Particular attention is paid to the root of the tongue, sublingual, pterygomandibular and peripharyngeal spaces.
When doing a massage of the salivary glands, you should pay attention to possible characteristic changes: thick consistency of saliva, cloudy color, the presence of flakes, clots, salivary blood clots in it.
In case of diseases of the salivary glands, probing of the ducts is carried out, which makes it possible to determine their direction, the presence of stenosis, stricture or its complete obliteration, or a stone in the duct.
Dental examination
When examining the oral cavity, it is necessary to examine all teeth, and not just 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 may not be detected on the first visit, because,
as discussed earlier, the pain may radiate. In addition, an examination of all teeth on the first visit is also necessary in order to outline a treatment plan, ending with the sanitation of the oral cavity.
It is important that during the examination all changes in the tooth tissue 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 upper teeth (molars), and then from left to right to examine the lower teeth.
Dental examination is carried out using a set of instruments; the most commonly used are a dental mirror and a probe (necessarily sharp). The mirror allows you to examine poorly accessible areas and direct a beam of light to the desired area, and the probe checks all the recesses, pigmented areas, etc. If the integrity of the enamel is not compromised, the probe glides freely over the surface of the tooth, without lingering in the recesses and folds of the enamel. If there is a carious cavity in the tooth (invisible to the eye), a sharp probe is retained in it. You should especially carefully examine the contact surfaces of the teeth, since it can be difficult to detect an existing cavity with an intact chewing surface, while probing can detect such a cavity. Currently, the technique of translucent dental tissue is used by supplying light through special light guides. Probing helps determine the presence of softened dentin, the depth of the carious cavity, communication with the tooth cavity, the location of the canal mouths, and the presence of pulp in them.
Tooth color can play a role in making a diagnosis. The 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 - “the living shine of the enamel.” In a number of conditions, the enamel loses its characteristic shine and becomes dull.
Thus, the beginning of the carious process is a change in the color of the enamel, the appearance first of cloudiness, and then of a white carious spot. Depulped teeth lose their usual shine of enamel, they acquire a grayish tint. A similar color change, and sometimes even more intense, is observed in teeth in which pulp necrosis has occurred. After pulp necrosis, the color of the tooth can change dramatically.
Tooth color can also change under the influence of external factors: smoking
(dark brown color), metal fillings (coloring the tooth in a dark color), chemical treatment of canals (orange color after the resorcinol-formalin method).
Pay attention to the shape and size of the teeth. Deviation from the usual form is due to treatment or an 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 condition of the periodontium.
Using tweezers or a probe handle, tap the cutting edge or chewing surface of the tooth. If there is no focus of inflammation in the periodontium, percussion is painless. In the presence of inflammatory process In the periodontium, blows that do not cause discomfort in healthy teeth result in a painful sensation. When performing percussion, the blows should be light and uniform. Percussion should begin with teeth that are known to be healthy, so as not to cause severe pain and allow the patient to compare the sensation in a healthy and affected tooth.
A distinction is made 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.
Tooth mobility is determined using tweezers by rocking. The tooth has physiological mobility, which is normally almost invisible. However, when the periodontium is damaged and there is exudate in it, pronounced tooth mobility occurs.
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 along the axis of the tooth (in the vertical direction).
Dental examination 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 to establish the integrity of the enamel or detect a cavity, note its depth and size, as well as its connection with the tooth cavity. You should pay attention to the color of your teeth. A grayish and cloudy color of tooth enamel may indicate pulp necrosis. The shape and size of the teeth are also important, including dental anomalies: Hutchinson’s, Fournier’s teeth, which may indicate general diseases and hereditary signs of pathology.
When examining the teeth, they are percussed, mobility is determined with tweezers, the presence of supernumerary or baby teeth in the permanent dentition is noted, the eruption of lower wisdom teeth is determined, and the nature of teeth closure is determined.
The gingival tubercles are examined and the condition of the periodontium is determined. 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 periapical or marginal lesion in the periodontium. The teeth are also palpated - feeling, which allows one to determine their mobility and soreness. Having grabbed the crown of the tooth with dental tweezers, the degrees of mobility are noted - I, II and III.
Using a dental probe, gum pockets are determined, their depth, bleeding during probing, discharge from the pockets and their nature.
In case of tooth mobility, it is necessary to clarify whether there is a localized process or diffuse periodontal damage, as well as to demonstrate oncological
wariness. Pathological mobility of a number of teeth in combination with pain on percussion may be one of the symptoms of osteomyelitis of the jaw.
It is imperative to assess the hygienic condition of the oral cavity. If emergency is necessary surgical operations carry out simple hygiene procedures that reduce the amount of plaque. During planned operations, the entire range of treatment procedures is carried out and the hygienic condition is assessed using the Green-Vermillion or Fedorov index.
Volodkina, and only with a high hygiene index, surgical intervention is performed.
The results of the dental examination are recorded in a special chart ( dental formula), where baby teeth are designated by Roman numerals, permanent teeth by Arabic numerals. Currently, it is customary to indicate the tooth number according to the international classification.
The clinical examination of the patient should include
b a number of diagnostic methods and studies. Their type and volume depend on the nature of the disease or injury in the maxillofacial area and on the conditions of the examination (in a clinic or hospital), as well as on the level of equipment of the medical institution.
X-ray examinations are important for diagnosing the pathology of 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 teeth, alveolar and palatal processes, and the floor of the mouth is performed, which makes it possible to clarify the location and nature of changes in the periodontium and bone, and to note the presence of calculi. There are 4 methods of intraoral radiography: radiography of periapical tissues according to the rule 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 periapical tissues, but they produce distortions in magnitude, which can lead to over- or under-diagnosis.
Interproximal radiographs show the teeth, periapical tissues, and marginal areas of both jaws. Occlusal radiography allows you to obtain an image of a section 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 the pathology: cysts, impacted teeth, jaw fracture line, the presence of a foreign body (calculus) in the submandibular and sublingual salivary glands. Occlusal photographs are taken in addition to the previous ones.
Long-focus radiography is performed using devices that have 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 the teeth, jaws and other bones of the facial skeleton is of fundamental importance for judging the presence of carious cavities in the teeth, the shape of the roots, the degree of filling them with filling mass, the condition of the periodontium, bones, etc.
Tooth enamel provides a denser shadow, while dentin and cementum provide less dense enamel.
The tooth cavity is recognized by the outline of the alveolus and root cement - determined by the projection of the tooth root and the compact alveolar plate, which looks like a uniform darker strip 0.2 - 0.25 mm wide.
Well-made radiographs clearly show the structure of the bone tissue. The bone pattern is determined by the presence of bone beams, or trabeculae, in the spongy substance and in the cortical layer, 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 densities on the film, have unequal contrast. Thus, phosphate cement gives a good image, but silicate cement gives a poor image. Plastic and composite filling materials do not block X-rays well, and, therefore, the image turns out to be unclear.
Radiography makes it possible to determine the condition of hard dental tissues (hidden carious cavities on the contact surfaces of teeth, under an artificial crown), impacted teeth (their position and relationship with jaw tissues, 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). Using an x-ray, you can also evaluate 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 condition 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 condition of the temporomandibular joint.
The length of the root canal can be measured using an x-ray. To do this, an instrument with a limiter set at the expected length of the canal is inserted into the root canal. An x-ray is then taken. The length of the tooth channel is calculated by the formula: where i is the actual length of the tool; K1 - radiographically 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, removal of teeth (especially impacted ones), and implantation.
Radiovisiography provides an image of residual roots, foreign bodies, the position of the implant in relation to adjacent teeth, the bottom of the maxillary sinus, nose, mandibular canal, and mental foramen. New generations of visiographs provide volumetric, color, digital data that makes it possible to judge with greater accuracy the quantity and structure of bone, and 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, and temporomandibular joints. The following projections are used for radiography: direct, lateral, semi-axial, axial, as well as oblique contact and tangential.
Promising method x-ray examination is an orthopantomography, which allows you to obtain an overview image of the teeth and jaws.
Panoramic radiographs have a certain advantage over intraoral photographs, since with minimal radiation exposure they provide a clear image of the jaw, teeth, periapical tissues and adjacent sinuses. However, on panoramic radiographs, distortions in the structure of tooth roots, bone structure, and the location of individual anatomical formations are possible; The central teeth and the surrounding bone tissue are poorly produced.
Lateral panoramic images provide less distortion. For the primary diagnosis of inflammation, injury, tumor, and deformation, orthopantomography is most effective.
When diagnosing pathological processes in the jaws and nasal cavities, orbit, orthopantomography is supplemented with longitudinal tomography and zonography, using direct, lateral, posterior and anterior axial projections. To reduce radiation exposure, zonograms are also produced with small angles of tube rotation, giving a layer-by-layer image of thicker sections.
Electroradiography is also used in diagnostics, which is very effective for urgently obtaining information. However, with this method the patient receives a large radiation dose.
For diseases and injuries of the salivary glands, bronchial fistulas, chronic osteomyelitis of the jaws, it is used contrast radiography using iodolipol and water-soluble contrast agents. For sialography of the parotid gland, the norm of 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 towards a decrease (calculous sialadenitis, interstitial sialadenitis) or an increase (parenchymal sialadenitis). In sialography, intraoral zonography is used - direct and lateral and orthopantomography. Sialography allows you to assess the condition of the gland ducts and determine the presence of salivary stones. The method can be supplemented with pneumosubmandibulography, digital subtraction sialography, radiometry, and scintigraphy.
Contrast radiography is also used for chronic osteomyelitis, fistulas of the face and neck, including those of a congenital nature (fistulography), jaw cysts, and diseases of the maxillary sinus.
Arthrography is used for diseases of the temporomandibular joints.
After intra-articular injection of a contrast agent, tomos or zonograms are obtained at different positions of the condylar process.
Radiography with contrast of arterial and venous vessels of the maxillofacial area is most effective for neoplasms of a vascular nature. In some cases, the tumor is punctured, a contrast agent is injected, and radiographs are taken in frontal and lateral projections. In other cases, especially with cavernous hemangioma, the afferent vessel is surgically isolated, and then a contrast agent is administered and a series of radiographs are taken in various projections. Angiography requires special conditions and should be carried out in a hospital, an X-ray operating room, where anesthesia is performed, surgical isolation of the tumor afferent vessel is carried out, and an approach is made to the femoral, subclavian, and external carotid arteries.
Select water-soluble contrast agents (Verografin, Urografin, Cardiographin, Cardiotrast). More often, serial angiography through the external carotid artery is used to diagnose vascular tumors.
Lymphography is less commonly used - direct for the diagnosis of lymph nodes and vessels.
X-ray is promising in the diagnosis of diseases of the maxillofacial area. CT scan(RCT), which allows you to obtain a two- and three-dimensional layer-by-layer image of the head. Thanks to the layered image
RCT determines the true size and boundaries of the defect or deformation, the localization of the inflammatory or tumor process. The high resolution of X-ray CT allows one to differentiate pathological processes in bone and soft tissues. This method is very important for injuries and the presence of intracranial changes. Establishing the dislocation of brain structures, the localization of brain injury, the presence of hematomas, hemorrhages helps in diagnosis, allows planning interventions and their sequence in the maxillofacial region, the cerebral part of the skull and the brain.
Magnetic resonance imaging (MRI) is also used in the diagnosis of pathological processes in the maxillofacial area. It has the particular advantage of not involving ionizing radiation. MRI reveals changes in soft tissues: swelling, 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, based on spatial layer-by-layer anatomical and topographic data, to create graphic computer models. This determines an accurate diagnosis and 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. Particularly important is the ability to use these methods to create three-dimensional graphic images for reconstructive operations in the maxillofacial area.
Dentistry used for detailed examination of individual areas of the mucous membrane in order to differential diagnosis elements of the lesion, studying the bottom of erosion, ulcers, the surface of verrucous growths, papules, plaques, etc. The efficiency of diagnosis increases when staining the mucous membrane, for example, with Lugol's solution (2%) or toluidine blue (1%).
Photostomatoscopy involves photographing lesions using special devices.
Vital coloring. One such method is staining the discolored tooth surface with a 2% aqueous solution of methylene blue. After thoroughly cleaning the tooth surface from plaque (a 3% solution of hydrogen peroxide can be used), drying it and isolating it from saliva, a swab with a 2% aqueous solution of methylene blue is applied. After 2-3 minutes, the swab is removed, excess paint is removed, and the mouth is rinsed with water. Intact enamel does not stain, but the area of demineralization changes color depending on the degree of damage. To assess the color intensity of dental tissues, a standard scale is used, which provides various shades of blue color from 10 to 100%. The scale is produced by the printing industry.
Schiller-Pisarev test involves lubricating the mucous membrane with a 2% aqueous Lugol's solution. Normally, there is a dark brown coloration of the lips, cheeks, transitional fold, and sublingual area. The remaining areas are iodine negative because they are covered with keratinizing epithelium. Para- and hyperkeratosis of the epithelium, which is normally non-keratinizing, also causes a negative reaction.
Hematoxylin test consists in varying degrees of staining of the mucous membrane depending on its condition. Normal epithelial cells acquire a pale purple color, while atypical ones become dark purple. Areas of hyperkeratosis do not absorb the dye and therefore do not change their appearance. The highest color intensity is characteristic of cancer cells due to the hyperchromicity of the nuclei.
Toluidine blue test produced in a similar way: normal epithelial cells after treating the mucous membrane with a 1% solution look blue, atypical ones become dark blue.
Luminescent methods provide for the use of the fluorescence effect - secondary glow of tissues when exposed to ultraviolet rays (Wood).
Healthy mucosa gives a pale bluish-violet glow; keratosis has a dull yellow tint; a bluish-violet glow is characteristic of hyperkeratosis; bluish-violet - for inflammation; Erosions and ulcers look dark brown. The spot with lupus erythematosus has a snow-white glow.
Luminescent examination is widely used in the diagnosis of hyperkeratoses, as it has a high degree of reliability. It should be remembered that many topical medications also exhibit Wood's luminescence, which may provide false information.
Cytological methods research is widely used in the diagnosis of diseases of the mucous membrane. Material can be collected in various ways. Yasinovsky's test, studying the migration of leukocytes, involves a series of successive washes with subsequent counting of living and dead blood cells - leukocytes. Smear It is performed more often with the mucous membrane of the posterior sections of the cavity; it allows one to evaluate the microflora of the pharynx and other areas. From the surface of the lesion, including from the bottom of the ulcer, cytological material is taken using fingerprint strokes.
If necessary, exploration of deeper layers can be carried out scraping. Puncture allows you to study cells obtained from deep areas of cavitary lesions.
Laboratory studies require special preparation of cytological material (fixation, staining) and subsequent study using technology: from conventional optical devices to sophisticated electron microscopes.
Histological studies in their methods they are close to cytological ones. Tissue collection is performed by biopsy or extended biopsy. The preparations are obtained by the method of thin and ultrathin sections after fixation, followed by staining of the structural elements of the cells. The study of preparations using microscopy methods is a reliable source of data on morphological changes in the mucous membrane.
Histochemical tests with biopsy material are based on the ability of various structural elements of cells, enzyme systems, metabolic products to react to certain dyes. This ability formed the basis for detecting the activity of enzymes (for example, alkaline phosphatase), nucleic acids (RNA, DNA), minerals (calcium), etc.
Bacteriological methods studies involve analysis of microbial and fungal flora obtained from the affected area. Most often, the fingerprint smear method is used to collect material, but scraping, smearing, and other methods can be used. After fixation and staining, bacterioscopy is performed, i.e., the microflora is visually identified by its characteristic color pattern. It is also possible to study the growth activity of bacteria, their sensitivity to medicines. Experimental infection of animals is used to study the pathogenic activity, contagiousness and other properties of microorganisms.
Virological studies are based on serological reactions, the properties of infected cells for agglutination, the ability to fluoresce (immunofluorescence reaction), and the possibility of infecting chicken embryos.
Detection of lesion elements on the oral mucosa often requires general examination sick. In this regard, it is most often prescribed clinical trial blood(extended formula, sugar content),urine. Diagnostic information can be obtained by biochemical blood tests (saturation with vitamins, characteristics of mineral components, etc.), saliva (enzyme activity of lysozyme, calcium, phosphorus content).
Allergy research carried out in case of violation immune status (in vivo patch tests, blood cell counting, tests with a standard set of allergens). Provocative and parenteral tests are excluded from the arsenal of examination methods, since they have a potential risk of complications.
A mandatory assessment of the patient's individual response to the drug should be carried out during the initial use of medications (most often anesthetics), especially for parenteral administration. Sensitivity test It is also placed if the patient has a history of allergic reactions to other medications. In addition, when subjective sensations or objective changes appear on the part of the musculoskeletal system in prosthetic wearers, it is determined the level of metals in the blood, electric currents in the oral cavity, reaction to components of plastic and other materials.
Currently, to provide qualified dental care, doctors need knowledge in related fields of medicine. First of all, this concerns the field of neurology.
The dentist should remember symptoms of allodynia and hyperalgesia, found in many dental diseases.
At allodynia painful sensations arise under conditions of application of non-nociceptive stimuli, i.e. those that in natural conditions are not capable of causing sensations of pain.
At hyperalgesia Painful sensations intensify under conditions of application of nociceptive stimulation. Irradiation of pain, synesthesia occurs (when irritations are felt not only at the site of their application, but also in other areas), polyesthesia (when there is an idea of several irritations, although in fact one was applied), etc.
Term<ноцицептор>introduced by C. Sherrington to designate receptors that respond exclusively to damaging stimuli. The dental pulp is extremely rich in such receptors. The variety of manifestations of pain under the action of damaging stimuli is one of the reasons for their designation as<ноцицептивные>, not painful. The simplest response to a nociceptive stimulus is a reflex. At a certain ratio of the strength of the damaging stimulus (for example, an inflammatory process in the oral cavity) and the excitability of the nociceptive system, sensory signals entering the brain lead to the formation of pain.
During the initial examination of a patient in a dental office, a careful external examination can tell the doctor a lot. A number of pathological phenomena, for example, contractures, atrophy of facial muscles, are noticeable even during an external examination and must be registered in the outpatient card (from a legal point of view, this is important, for example, to avoid conflict situation in case of patient dissatisfaction with the medical treatment provided).
During a special neurological examination, first of all, it is necessary to pay attention to shape and size of pupils. Deformation of the pupils deserves special attention in the sense of suspicion of organic damage to the nervous system. When examining the pupils, it is necessary to evaluate the movement of the eyeballs, especially the presence of nystagmus (twitching of the eyeballs). External examination of the facial muscles is insufficient. It is advisable to ask the patient to wrinkle his forehead, nose, open his mouth wide, and show his teeth. In cases of facial nerve paralysis, tic-like twitching of the affected facial muscles, change in the width of the palpebral fissure, increased mechanical excitability of the muscles. After peripheral paralysis of the lingual muscles, fibrillary twitching with tongue atrophy(this may be a symptom of syringobulbia or amyotrophic lateral sclerosis). Bilateral tongue paresis causes speech disorder type dysarthria. Articulation defects and scanned speech are identified during conversation and questioning of the patient.
The outlined scope of a brief neurological examination requires little time and is simple. Compliance with the examination plan will help the dentist to competently provide assistance to a patient with an intact or damaged nervous system.
| Technique for reading intraoral radiographs |
| I Assessment of the quality of the radiograph: contrast, sharpness, projection distortions - lengthening, shortening of the tooth, completeness of coverage of the area under study. II Determination of the scope of the study: which jaw, group of teeth. III Analysis of the tooth shadow: 1. Condition of the crown (presence of a carious cavity, filling, filling defect, ratio of the bottom of the carious cavity to the tooth cavity); 2. Characteristics of the tooth cavity (presence of filling material, denticles); 3. Condition of roots (number, shape, size, contours); 4. Characteristics of root canals (width, direction, degree of filling); 5. Assessment of the periodontal fissure (uniformity, width), condition of the compact plate of the socket (preserved, destroyed, thinned, thickened). IV Assessment of the surrounding bone tissue: 1. Condition of the interdental septa (shape, height, condition of the compact end plate); 2. The presence of restructuring of the intraosseous structure, analysis of the pathological shadow (area of destruction or osteosclerosis), includes determination of localization, shape, size, nature of the contours, intensity, structure. |
| Diagnostic method in dentistry: profilometry |
| A group of scientists at the University of Toronto, led by Andreas Mandelis, used the most common semiconductor infrared laser with a wavelength of less than 1 micrometer for their experiments. The examined tooth is heated by a laser beam and begins to emit light in the infrared range, which makes it possible to obtain images of the internal structure of the tooth to a depth of up to 5 mm using a computer. The method, called “profilometry,” also provides the possibility of changing the intensity of the laser beam. With high frequency pulsation (about 700 hertz), the method is optimal for identifying surface cracks in tooth enamel, while lower frequencies - less than 10 hertz - can effectively detect cavities inside dental tissue. Researchers believe that their development will soon find wide application in clinical practice For early diagnosis caries. |
Beginning of the form
| What causes pain? | From sour, sweet, cold, hot (may not be) | |
| From everything | ||
| From cold to hot | ||
| When tapping on a tooth | ||
| No pain | ||
| Does a tooth hurt without irritation? | No never | |
| yes, especially at night | ||
| yes/no, sometimes it hurts at night | ||
| Yes, it hurts all the time | ||
| No, if you rinse regularly | ||
| Does it hurt a lot when irritated? | So-so | |
| Very strong, in fits and starts | ||
| Not very good, but hot is quite unpleasant | ||
| Strong | ||
| It may not hurt | ||
| How long does the pain last? | Few seconds | |
| "I walk on the ceiling all day and night" | ||
| It hurts, it doesn't hurt | ||
| Hurts for hours | ||
| Not really, but I remember from time to time | ||
| Where does it hurt? | Specific tooth | |
| I can’t say for sure, but my entire jaw and even the opposite teeth hurt | ||
| A specific tooth, and it seems to me that it has “grown” | ||
| Such a pain? | aching, dull | |
| How a needle was stuck | ||
| Blunt pain | ||
| Acute pain, pulsating | ||
| Virtually none | ||
| When does it hurt or when does the pain get worse? | Only at the moment of irritation | |
| Intensifies at night | ||
| Does not depend on the time of day | ||
| What has changed in my face? | Nothing | |
| There is swelling of the soft tissues on the side of the diseased tooth | ||
| Possible slight swelling of soft tissues on the side of the diseased tooth | ||
| Are there any changes on the gums? | No | |
| The gums are red and swollen in the area of the painful tooth | ||
| Slight redness of the gums, in the area of the root of the diseased tooth on the gum available fistula (a small white blister from which pus periodically leaks) | ||
| How is my tooth different from neighboring healthy ones? | Brown spot, enamel defect, “hole”, pigmentation around the filling | |
| Brown spot, enamel defect, “hole”, pigmentation around the filling. Perhaps you recently had a filling installed and the tooth became sick. | ||
| Enamel defect, “hole”, pigmentation around the filling. Perhaps a filling was recently placed and the tooth became ill. | ||
| Large cavity or filling. It is possible that the tooth was previously “depulped” (they picked it with needles) | ||
| Large cavity or filling. The color of the tooth may be changed. It is possible that the tooth was previously “depulped” (they picked it with needles) | ||
| Does the tooth wobble? | No | |
| Yes | ||
| Does it hurt to bite on it? | No | |
| Perhaps a little | ||
| It hurts so bad it's scary to think about it | ||
Methods for studying the mucous membranes
An examination of the oral cavity is carried out to determine the condition of the mucous membrane, tongue, teeth, salivary glands, changes in which may indicate both local pathology and diseases of other organs and systems.
The survey allows us to identify complaints of pain in the mouth when talking, eating, swallowing, which is often associated with pathology of the trigeminal, glossopharyngeal or upper laryngeal nerves, pterygopalatine node, tongue, with the presence of aphthae, erosions, ulcers on the mucous membrane. Possible impairment of diction caused by defects in the mucous membrane, cleft palate, macroglossia, and errors in the manufacture of dentures. Dry mouth (xerostomia) may indicate dysfunction of the salivary glands. Bad breath is characteristic of ulcerative-necrotizing gingivitis, periodontitis, and periodontitis. Complaints of burning, paresthesia, and changes in taste sensations are observed with stomalgia and glossalgia. A feeling of sore throat may appear in connection with pathology caused by occupational hazards - acid necrosis, cervical necrosis of hard tissues.
When examining, pay attention to the color, shine, relief of the mucous membrane, the presence of aphthae, erosions, ulcers, and fistulas. The normally pink mucous membrane acquires a bright red color in acute infectious processes, blood diseases, and also in smokers; its pale or bluish color is a sign of a number of diseases of the cardiovascular system; a yellow tint is often associated with liver pathology.
Loss of shine of the mucous membrane and the appearance of whitish spots are observed with hyperkeratoses, such as leukoplakia. The presence of swelling of the mucous membrane, which can be observed both in the pathology of the R. p. itself and can be a symptom of other diseases, is judged by the imprints of the teeth, which are often determined on the lateral surface of the tongue or along the line of closure of the teeth. In order to detect hidden edema under the epithelium of the mucous membrane, 0.2 ml isotonic solution sodium chloride (blister test). The resulting bubble normally resolves within 50-60 min; With swelling, the resorption time increases.
To identify diseases of the mucous membrane, especially those that are accompanied by increased keratinization, examination of the R. p. is carried out in the rays of a Wood's lamp (fluorescent diagnostics).
In order to establish the causes of a number of lesions of the mucous membrane, it is necessary additional examination, including allergy tests with bacterial and non-bacterial antigens, cytological (for the diagnosis of pemphigus, viral infections, cancer, precancerous diseases), bacteriological (to detect fungal infections and in ulcerative-necrotic processes), immunological (if syphilis is suspected - Wasserman's reaction, for brucellosis - Wright's reaction, etc.) studies. All patients with pathology of the oral mucosa undergo a clinical blood test.
Pathology oral cavity includes malformations, injuries, diseases, tumors. This includes pathology teeth , salivary glands , jaws , language , lips, palate and oral mucosa.
Developmental defects. A significant place among developmental defects is occupied by congenital cleft lips, caused by both hereditary factors and disorders intrauterine development. The formation of a cleft may be associated with impaired fusion of the mandibular processes (median cleft of the lower lip), maxillary and median nasal processes (the so-called cleft lip). The size of the clefts ranges from a slight notch in the area of the red border to its complete connection with the opening of the nose. When tissue splitting is limited to the muscle layer, a hidden cleft occurs in the form of retraction of the skin or mucous membrane. Clefts of the upper lip can be unilateral or bilateral; in approximately half of the cases they are combined with clefts of the alveolar process of the upper jaw and palate. Complete clefts are accompanied by difficulty sucking, as well as breathing problems (frequent, superficial), which often leads to pneumonia.
Possible absence of lips (acheilia), fusion of the lips in the lateral sections (syncheilia), shortening of the middle part of the upper lip (brachycheilia), thickening and shortening of the frenulum, limiting the mobility of the upper lip. Hypertrophy of mucous glands and fiber leads to the formation of folds of the mucous membrane (the so-called double lip). Treatment for malformations of the lips is surgical. For clefts and other tissue defects it is used different kinds plastic surgeries using local tissues, free skin grafts, Filatov stem, etc. Operations are performed in the first three days after birth or in the third month of the child’s life (after immunological restructuring of the body). If the frenulum is deformed, it is excised; in case of a double lip, excess tissue is removed.
Most frequent vices development of the palate are congenital clefts (the so-called cleft palate), often combined with cleft lips. They can be through (pass through the alveolar process of the upper jaw, hard and soft palate) and non-through, in which the alveolar process has a normal structure. Through cleft palate can be unilateral or bilateral; non-through clefts - complete (passes through the entire hard and soft palate) and partial (affects only part of the hard and soft palate). There are hidden clefts, in which the palate defect is covered by an unchanged mucous membrane. Cleft palates, especially through ones, sharply disrupt the breathing and sucking function of newborns (when sucking, milk enters the nasal passages, resulting in aspiration). With age, speech disorders develop, a nasal tone appears, and the shape changes. individual parts faces. Treatment of cleft palate is surgical, however, unlike cleft lips, it should be performed at the age of 4-7 years. Until this age, obturators are used to ensure normal breathing and nutrition - special devices that separate the oral and nasal cavities.
There are also narrow high palates, in which orthodontic or (if ineffective) surgical treatment; underdevelopment of the soft palate requiring plastic surgery.
Damage. Damage to both the oral mucosa and underlying tissues is possible. Isolated damage to the mucous membrane is most often associated with mechanical, thermal or chemical trauma. Long-term trauma to it can lead to the formation of erosions, ulcerations, and the development of precancerous diseases and cancer. Damage to the lips occurs as a result of blows and wounds. Wounds (bruised, cut, gunshot) can be superficial, deep, through, torn, with or without a tissue defect. They are accompanied by rapid development of edema and significant bleeding. The characteristic gaping of the wound often creates the impression of a larger defect than in reality. Damage to the palate can occur when it is injured by a sharp object, as a result of gunshot wounds. The latter are usually accompanied by simultaneous damage to the nasal cavity, maxillary sinus, and upper jaw.
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An examination of the oral cavity is carried out in a dental chair. Parents can hold small children (under 3 years old) in their arms.
The patient sits or lies in a chair, the doctor is located opposite the patient (at the 7 o'clock position) or at the head of the chair (at 10 or 12 o'clock). To examine the oral cavity, good lighting is necessary. The vestibule of the oral cavity is examined by holding and retracting the upper lip with the first and second fingers of one hand, and the lower lip with the second finger of the other hand. The cheeks are retracted with the third and fourth fingers, with the third fingers in contact with the buccal surfaces of the teeth and the corners of the mouth; The corner of the mouth can be shifted no further than the level of the first molars.
To examine the oral cavity, use a dental mirror, a dental probe, and, if conditions permit, an air gun.
A dental mirror is necessary to focus light; it provides a magnified image and allows you to see surfaces of teeth that are not directly visible. A right-handed doctor holds a mirror in his right hand if this is the only instrument used for examination; if a mirror and a probe are used at the same time, then the mirror is held in the left hand.
The mirror should be held by the tips of the first and second fingers by the upper part of the handle. To obtain an image of various points of the oral cavity, the mirror is tilted in a pendulum-like motion (the angle of the handle with the vertical should not exceed 20°) and/or the mirror handle is rotated around its axis, while the hand remains motionless.
A dental probe is most often used to remove food particles from the surface of a tooth that interfere with examination, as well as to assess the mechanical properties of objects of study: dental tissues, fillings, dental plaque, etc. The probe is held with the first, second and third fingers of the right hand by the middle or lower third of its handle; when examining teeth, the tip is placed perpendicular to the surface being examined.
You should remember the possible harm of probing:
. the probe can mechanically damage tissue (immature enamel, enamel in the area of initial caries, tissue in the subgingival area);
. probing the fissure can facilitate the introduction of plaque, i.e. infection of its deep parts;
. probing may cause pain (this is especially likely when probing open carious cavities);
. the sight of a needle-like probe often frightens anxious patients, which destroys psychological contact with them.
For these reasons, the probe is increasingly giving way to an air gun, which allows you to dry the surface of the teeth from oral fluid that distorts the picture, and free the surface of the teeth from other unrelated objects.
Clinical examination of the oral cavity is carried out in the following order:
1. Examination of the oral mucosa:
. mucous membrane of the lips, cheeks, palate;
. condition of the excretory ducts of the salivary glands, quality of discharge;
. mucous membrane of the back of the tongue.
2. Study of the architectonics of the oral vestibule:
. depth of the vestibule of the oral cavity;
. lip frenulum;
. lateral buccal cords;
. frenulum of the tongue.
3. Assessment of periodontal condition.
4. Assessment of the condition of the bite.
5. Assessment of dental condition.
Examination of the oral mucosa.
Normally, the oral mucosa is pink, clean, and moderately moist. In some diseases, elements of damage to the mucous membrane may appear, reducing its elasticity and moisture.When examining the excretory ducts of the major salivary glands, salivation is stimulated by massage of the parotid area. Saliva should be clean and liquid. With some diseases of the salivary glands, as well as somatic diseases, it can become scanty, viscous, and cloudy.
When examining the tongue, pay attention to its color, the severity of the papillae, the degree of keratinization, the presence of plaque and its quality. Normally, all types of papillae are present on the back of the tongue, the keratinization is moderate, and there is no plaque. At various diseases The color of the tongue and the degree of its keratinization may change, and plaque may accumulate.
Study of the architectonics of the oral vestibule.
The examination begins with determining the height of the attached gum: for this, the lower lip is retracted to a horizontal position and the distance from the base of the gingival papilla to the line of transition of the attached gum into the mobile mucous membrane is measured. This distance must be at least 0.5 cm. Otherwise, there is a risk for the periodontium of the lower anterior teeth, which can be eliminated with plastic surgery.The frenulum of the lips is examined by retracting the lips to a horizontal position. The place where the frenulum is woven into the tissues covering the alveolar process (normally, outside the interdental papilla), the length and thickness of the frenulum (normally, thin, long) are determined. When the lip is retracted, the position and color of the gums should not change. Short frenulums intertwined with the interdental papillae are stretched during eating and talking, changing the blood supply to the gums and injuring it, which can subsequently lead to pathological irreversible changes in the periodontium.
A powerful frenulum of the lip, intertwined with the periosteum, can cause the presence of a gap between the central incisors. If a pathology of the frenulum is detected, the patient’s lips are referred for consultation to a dental surgeon to decide on the advisability of cutting or plastic surgery of the frenulum.
To examine the lateral (buccal) cords, the cheek is taken to the side and attention is paid to the severity of the folds of the mucous membrane running from the cheek to the alveolar process. Normally, buccal cords are characterized as mild or moderate. Strong, short cords intertwined with the interdental papillae have the same negative effect on the periodontium as short frenulums of the lips and tongue.
Inspection of the frenulum of the tongue is carried out by asking the patient to lift the tongue or by lifting it with a mirror.
Normally, the frenulum of the tongue is long, thin, and one end is woven into middle third tongue, others - into the mucous membrane of the floor of the mouth distal to the sublingual ridges. In pathology, the frenulum of the tongue is powerful, intertwined with the anterior third of the tongue and the periodontium of the central lower incisors. In such cases, the tongue does not rise well; when the patient tries to stick out the tongue, its tip may bifurcate (the “heart” symptom) or bend downwards. A short, powerful frenulum of the tongue can cause dysfunction in swallowing, sucking, speech (impaired pronunciation of the sound [p]), periodontal pathology and occlusion.
Assessment of periodontal condition.
Normally, the gingival papillae are well defined, have an even pink color, a triangular or trapezoidal shape, and fit tightly to the teeth, filling the interdental embrasures. A healthy periodontium does not bleed either on its own or when touched lightly. The normal gingival groove in the front teeth has a depth of up to 0.5 mm, in the lateral teeth - up to 3.5 mm.Deviations from the described norm (hyperemia, swelling, bleeding, the presence of lesions, destruction of the gingival groove) are signs of periodontal pathology and are assessed using special research methods.
Assessment of the state of occlusion.
The bite is characterized by three positions:Jaw ratio;
. shape of dental arches;
. position of individual teeth.
The jaw relationship is assessed by fixing the patient's jaws in the position during swallowing central occlusion. The main relationships of key antagonist teeth are determined in three planes: sagittal, vertical and horizontal.
Signs of orthognathic bite are as follows:
In the sagittal plane:
— the mesial cusp of the first molar of the upper jaw is located in the transverse fissure of the tooth of the same name in the lower jaw;
— the canine of the upper jaw is located distal to the canine of the lower jaw;
— the incisors of the upper and lower jaws are in tight oral-vestibular contact;
In the vertical plane:
— there is a tight fissure-tubercle contact between the antagonists;
— incisal overlap (the lower incisors overlap the upper ones) is no more than half the height of the crown;
In the horizontal plane:
- the buccal cusps of the lower molars are located in the fissures of the upper molars of the antagonists;
- the central line between the first incisors coincides with the line between the first incisors of the lower jaw.
The assessment of the dentition is carried out with the jaws open. In an orthognathic occlusion, the upper dental arch has the shape of a semi-ellipse, the lower - a parabola.
The position of individual teeth is assessed with the jaws open. Each tooth should occupy a place corresponding to its group affiliation, ensuring the correct shape of the dentition and smooth occlusal planes. In an orthognathic dentition, there must be a point or plane contact point between the proximal surfaces of the teeth.
Assessment and recording of dental condition.
During the clinical examination, the condition of the tissues of the crown of the teeth and, in appropriate situations, the exposed part of the root is assessed.The surface of the tooth is dried, after which the following information is obtained using visual and, less commonly, tactile examination:
About the shape of the tooth crown (normally corresponds to the anatomical standard for a given group of teeth);
. about the quality of enamel (normally, enamel has an apparently integral macrostructure, uniform density, is painted in light colors, translucent, shiny);
. about the presence and quality of restorations, orthodontic and orthopedic fixed structures and their effect on adjacent tissues.
It is necessary to examine every visible surface of the tooth crown: oral, vestibular, medial, distal, and in the group of premolars and molars - also occlusal.
In order not to miss anything, a certain sequence of dental examinations is followed. The examination begins with the upper right, last tooth in the row, examines all the teeth of the upper jaw one by one, goes down to the lower left last tooth and ends with the last tooth on the right half of the lower jaw.
In dentistry, symbols have been adopted for each tooth and the main conditions of the teeth, which greatly facilitates record-keeping. The dentition is divided into four quadrants, each of which is assigned a serial number corresponding to the examination sequence: from 1 to 4 for permanent occlusion and from 5 to 8 for temporary occlusion (Fig. 4.1).
Rice. 4.1. Dividing the dentition into quadrants.
Incisors, canines, premolars and molars are assigned conventional numbers (Table 4.1).
Table 4.1. Conventional numbers of temporary and permanent teeth 
The designation of each tooth consists of two numbers: the first number indicates the quadrant in which the tooth is located, and the second number is the conventional number of the tooth. Thus, the upper right central permanent incisor is designated as tooth 11 (should be read: “tooth one one”), the lower left second permanent molar is designated as tooth 37, and the lower left second temporary molar is designated as tooth 75 (see Fig. 4.2).
Rice. 4.2. Dentition of permanent (top) and temporary (bottom) bite.
For the most common dental conditions, WHO offers the symbols shown in Table 4.2.
Table 4.2. Symbols of dental condition 
In dental documentation there is a so-called “dental formula”, when filling it out all accepted designations are used.
T.V. Popruzhenko, T.N. Terekhova
