History of present illness (Anamnesis morbi)
Gathering information about the development of the disease is a key criterion for making a provisional diagnosis. Complaints depend on the localization of the lesion (teeth, oral mucosa, masticatory muscles, salivary glands). The physician identifies the suspected cause of the disease, the initial symptoms, and the course of the process.
Special attention is paid to previous treatment:
- Whether the patient attempted self-medication (including traditional medicine).
- What professional care has already been provided (where, when, to what extent).
- Whether there was weight loss during the illness.
- Whether there are occupational hazards (contact with fluoride preparations, heavy metal salts).
The specialist is also required to analyze available documentation: discharge summaries, radiographs, laboratory test results, and consultant reports. In acute inflammatory processes with increasing swelling, the primary task is to find the source of infection. If symptoms progress, hospitalization and emergency surgery are indicated.
Features of patient interview in facial trauma
Acute trauma to the facial bones is accompanied by acute pain, visual and palpation deformity, and severe soft tissue edema. In jaw fractures, pain sharply increases with functional load (chewing, opening the mouth).
When examining an injured patient, the physician must ask three questions:
- When did the injury occur?
- Where did it happen?
- Who is to blame for what happened (causes of the injury)?
The presence of alcohol or drug intoxication, the nature of first aid provided, and tetanus prophylaxis status (doses and timing of toxoid or serum administration) are also clarified. It is important to document the presence of bleeding from ENT organs (nose, ears). If the patient reports nausea, vomiting, or loss of consciousness, these are signs of brain injury requiring consultation with a neurosurgeon or neurologist.
Neoplasms and defects
Complaints in maxillofacial defects are usually associated with functional and aesthetic disorders.
Defects are divided into:
- Congenital: manifest at birth. Examples include cleft lip and palate, underdevelopment of the auricle. Often combined with malformations of other systems.
- Acquired: the consequence of trauma, oncology, burns, jaw osteomyelitis, or purulent otitis in childhood. Require differential diagnosis with syphilis, actinomycosis, noma, and leishmaniasis.
When a benign tumor is suspected, its slow growth (over years), absence of spontaneous pain, and preserved general well-being are taken into account. The physician must clarify whether the formation is subjected to chronic trauma from dentures or teeth, whether its color has changed (important for pigmented neoplasms), and whether there are subjective sensations in this area.
TMJ pathology and secondary adentia
Upon tooth loss, patients complain of aesthetic deficiency, impaired chewing and diction, as well as poor retention of removable dentures.
Temporomandibular joint (TMJ) pathologies manifest as pain, inability to close the mouth, and acoustic phenomena (“clicking”, “crunching” during meals). To clarify the diagnosis, questions are asked:
- Was the onset of clicking preceded by a single acute trauma?
- Have there been any previous dislocations of the mandible?
- What is the chronology of the clicking sound: before or after the use of dentures?
TMJ pain requires the exclusion of diffuse connective tissue diseases and musculoskeletal disorders.
Past medical history (Anamnesis vitae)
The presence of comorbid conditions directly affects examination tactics and the risk of complications. Diseases are classified according to ICD-10.
- Cardiovascular diseases: hypertension, CHD, and arrhythmias require joint preparation with a cardiologist to avoid myocardial infarction in the dental chair.
- Respiratory system: in bronchial asthma, it is important to know whether glucocorticoids are being used. Symptoms such as cough, weakness, and weight loss require alertness for tuberculosis (referral to a phthisiologist).
- Renal failure: impairs water-electrolyte balance and blood clotting; a urologist's clearance is required.
- Rheumatic diseases: rheumatoid arthritis, lupus erythematosus, and Sjögren's syndrome often have local manifestations in the maxillofacial region (salivary glands, joint, mucous membrane).
Briefly: answers to topical questions
Which regional lymph nodes should be palpated during the external examination of the face and neck?
During the external examination of the face and neck, the lymph nodes of the upper neck, as well as nodes classified by levels, are subject to palpation.
- Submental and submandibular (Level I).
- Upper deep cervical (Level II).
- Middle deep cervical (Level III).
- Lower deep cervical (Level IV).
- Posterior triangle nodes of the neck (Level V).
- Anterior cervical (Level VI).
- Upper mediastinal (Level VII).
The anterior, middle, and posterior lymph nodes of the submandibular triangle, as well as the submental lymph nodes (nodi lymphatici submentales), are also palpated. Palpation assesses their size, consistency, fixation (adhesions), and tenderness.
Which exit points of the trigeminal nerve branches are palpated on the face?
The exit points of the peripheral branches of the trigeminal nerve (n. trigeminus), known as Valle's points, are palpated on the face.
- Supraorbital nerve (n. supraorbitalis) — the terminal nerve of the first branch (n. ophthalmicus), exiting through the foramen supraorbitale.
- Infraorbital nerve (n. infraorbitalis) — the terminal nerve of the second branch (n. maxillaris), exiting through the foramen infraorbitale.
- Mental nerve (n. mentalis) — the terminal nerve of the third branch (n. mandibularis), exiting through the foramen mentale.
Normally, these points are slightly sensitive and painless; pathology causes tenderness and sensory disturbances.
What macroscopic skin changes are evaluated during the external examination of the face?
During the external examination of the face, a number of macroscopic changes and parameters of the skin are evaluated.
- Skin color — pallor, hyperemia, cyanosis, jaundice (icterus), earthy or straw-yellow shades are detected.
- Integrity disruptions — the presence of abrasions, bruises, lacerated-contused wounds, defects, and deformities is recorded.
- Rashes — evaluate for the presence of macules, papules, vesicles, and other rash elements.
- Physical properties — determine moisture level (degree of perspiration or dryness), turgor (tissue elasticity and resilience), and local temperature.
- Structural features — pay attention to the vascular pattern, presence of skin folds, and normal skin lines.
Which masticatory muscles are palpated during external examination to assess their tone and tenderness?
To assess tone and tenderness, the masticatory muscles are palpated.
- Masseter muscle (m. masseter).
- Temporalis muscle (m. temporalis).
- Attachment site of the medial pterygoid muscle (m. pterygoideus medialis) near the inner surface of the mandibular angle.
The condition of the masticatory muscles is assessed by superficial and deep palpation at rest and during function. Movement strength and muscle tone are determined; tenderness of individual muscles may be present.
What clinical symptoms are detected during external examination and palpation in acute facial bone trauma?
During external examination and palpation in acute facial bone trauma, the following clinical symptoms are detected:
- Deformities and changes in facial configuration — elongation of the middle or lower thirds of the face, displacement of the mandible or the midline of the chin, depression of the nasal bridge or zygomatic region, smoothing of the nasolabial folds.
- Soft tissue changes — marked swelling, post-traumatic edema, hemorrhages (including the "raccoon eyes sign"), cyanotic tint or skin hyperemia, abrasions, and wounds.
- Palpatory signs — sharp pain, atypical irregularities, bony step-off, crepitus (a sign of subcutaneous emphysema).
- Specific symptoms of fractures — palpatory (pathological) mobility and displacement of bone fragments, positive load test (tenderness upon pressure), impaired mouth-opening function.
W4H in trauma: Where? When? Who is to blame? — three mandatory questions asked by the physician to a patient with facial injuries.
Class and exam questions
How can a benign tumor be distinguished during the questioning stage?
Benign neoplasms are characterized by slow growth over several years, the absence of spontaneous pain, and no sharp deterioration in general well-being.
Why is it important for a dental surgeon to know about a patient's glucocorticoid use?
The use of hormonal medications (e.g., in bronchial asthma or respiratory diseases) critically affects adrenal function, preoperative planning, and the risks of surgical complications.
What neurological symptoms indicate trigeminal nerve damage in jaw trauma?
Decreased (hypesthesia) or complete loss (anesthesia) of tactile and pain sensitivity of the skin in the zygomatic and infraorbital regions, as well as in the chin and lower lip areas.
What else to study on this topic
- Characteristics of taking a hereditary and antenatal history in congenital malformations of the maxillofacial region.
- Differential diagnosis of specific infections (tuberculosis, syphilis, anthrax).
- Taking a hemorrhagic history and ruling out coagulopathies prior to surgical intervention.
- Neurological status and diagnosis of cranial nerve branch lesions in facial pain.
- The impact of diffuse connective tissue diseases on salivary gland and temporomandibular joint function.
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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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