Impact of systemic diseases
Many systemic conditions directly affect the condition of facial and oral tissues, and also determine the physician's tactics:
- Diabetes mellitus. Manifests as purulent processes (furuncles, carbuncles) and salivary gland pathology. Signs of latent diabetes: overweight, enlarged parotid glands, recurrent purulent infections. The main diagnostic method is glucose tolerance testing (glucose tolerance curve).
- Gastrointestinal diseases. Affect the oral mucosa, periodontium, and oral hygiene. Require a gastroenterologist consultation prior to surgery.
- Blood disorders. Present with severe gingival bleeding and ulcerative-necrotic changes. Dangerous due to massive hemorrhages, making a complete blood count mandatory before any intervention.
- HIV infection. Suspected in cases of chronic diarrhea, weight loss, generalized periodontitis, candidiasis, and necrotic oral ulcers.
Examination algorithm
Examination is performed after taking the medical history. The patient's position depends on their severity: from a standard dental chair to an inpatient hospital bed.
- External examination. Assessment of facial expression, constitution, eyes, exposed skin areas, and hemodynamics (pulse, BP).
- Palpation. Examination of soft tissues, cranial bones, lymph nodes, and major salivary glands.
- Oral cavity examination. Examination of the oral vestibule and oral cavity proper using sterile instruments (mirror, probe, tweezers, spatula).
- Additional methods. If necessary, biopsy, puncture, scrape-smears, X-rays, or laboratory tests are prescribed.
Skin and soft tissue assessment
Facial skin color is of great diagnostic importance:
- Pallor indicates intoxication, blood loss, fainting, or blood disorders.
- Ashen complexion is a sign of odontogenic sepsis or malignant tumors.
- Jaundice (icterus) indicates liver or biliary tract pathology.
- Hyperemia and cyanosis accompany cardiovascular or respiratory disorders, or fever.
Acute inflammation is characterized by infiltration and edema. Diffuse redness is typical for phlegmon, while localized redness indicates abscesses. Classic signs of inflammation include swelling (tumor), hyperemia (rubor), local heat (calor), and loss of function (functia laesa).
Traumatic injuries
Traumas alter facial configuration due to bone displacement, edema, or hematomas.
- Mandibular trauma: swelling in the lower third of the face, chin deviation, loss of sensation in the lower lip (in case of n. alveolaris inferior injury).
- Maxillary trauma: edema of the midface (sometimes moon-faced appearance), isolated eyelid hemorrhages.
- Skull base fracture: bilateral eyelid hemorrhages ("raccoon eyes sign") and potential cerebrospinal fluid leakage from the nose (nasal liquorrhea).
- Soft tissue trauma: breach of skin or mucosal integrity, bleeding, bluish discoloration due to subcutaneous hematomas.
Briefly: answers to topical questions
What are the classic local signs of acute inflammation in oral surgery?
The classic local signs of acute inflammation include five main symptoms described by Latin terms.
- Redness (rubor) — caused by inflammatory hyperemia of the skin and mucosa over the lesion.
- Swelling (tumor) — occurs due to tissue edema.
- Pain (dolor) — a result of irritation of sensitive nerve endings.
- Local temperature rise (calor) — determined when the lesion is superficially localized.
- Loss of function (functio laesa) — manifested by impaired swallowing, breathing, and speech.
An additional significant diagnostic sign in the presence of purulent exudate is fluctuation.
What symptoms indicate a skull base fracture in maxillofacial trauma?
A skull base fracture in maxillofacial trauma is indicated by a number of characteristic clinical symptoms.
- Periorbital hematoma («raccoon eyes» sign) — hemorrhage into the loose tissue of both eyelids within the first hours after trauma.
- Mastoid hematoma (Battle's sign) — indicates a fracture of the temporal bone pyramid.
- Liquorrhea — leakage of cerebrospinal fluid from the nose (rhinorrhea) or ears (otorrhea).
- Hemotympanum — accumulation of blood in the tympanic cavity or rupture of the tympanic membrane.
- Neurological disorders — lagophthalmos, facial asymmetry due to peripheral facial nerve palsy.
Bleeding from the nose or ears of varying intensity may also be observed.
Which groups of lymph nodes must be palpated during the examination of the maxillofacial region?
During the examination of the maxillofacial region, regional lymph node groups must be palpated. The physician sequentially examines the following groups:
- Occipital
- Parotid
- Submandibular
- Submental
- Cervical
- Facial (buccal, nasolabial, zygomatic, mandibular)
- Supraclavicular
Facial lymph nodes may be palpated bimanually. The fundamental rule of the examination is that palpation always starts from the opposite (healthy) side away from the pathological process, gradually approaching the lesion. The size, consistency, mobility, and tenderness of the nodes are assessed.
What are the specific manifestations of HIV infection on the oral mucosa?
In HIV infection, the following lesions and changes may be detected on the oral mucosa:
- Oral hairy leukoplakia — painless whitish folds or projections predominantly on the lateral surfaces of the tongue, firmly adherent to the mucosa and cannot be removed by scraping.
- Kaposi sarcoma — a vascular tumor that can affect mucous membranes.
- Candidiasis.
- Ulcerative-necrotic changes of the mucosa.
- Chronic generalized periodontitis.
The combination of chronic diarrhea, fever, weight loss, chronic generalized periodontitis, candidiasis, and ulceronecrotic mucosal lesions is an indication for referring the patient to a specialized medical institution for HIV testing.
What is the technique for palpating the submandibular and sublingual salivary glands?
The technique for palpating the submandibular salivary gland and its duct involves bimanual examination.
- Palpation technique — the examination is performed strictly from back to front.
- Purpose of the technique — to prevent the displacement of a potential calculus into the intraglandular part of the duct.
Bimanual palpation makes it possible to determine the presence of a stone within the gland or along its excretory duct, as well as to assess the consistency of the organ and the presence of swelling. Data on the specific palpation technique for the sublingual salivary glands are not available in the provided materials.
Class and exam questions
What does bright red facial skin resembling "flame tongues" indicate?
This is a pathognomonic (specific) sign of erysipelas.
Why does the chin go numb in a mandibular fracture?
Numbness (loss of sensitivity) of the lower lip and chin occurs due to damage to the inferior alveolar nerve by displaced bone fragments.
What else to study on this topic
- Anthropometric analysis: proportions of the three facial parts
- Risk groups: preparation specifics for menopausal women and elderly patients
- Differential diagnosis of facial lymphadenopathy types
- Ocular manifestations of systemic allergic and autoimmune diseases
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Other topics in "Chapter 3. Features of patient examination in surgical dentistry (M.M. Pozharitskaya, V.V. Afanasyev)"
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