General status and skin assessment
The examination begins with assessing the severity of the condition, thermometry, and external inspection. Marked skin pallor is an alarming sign that may indicate intoxication or blood disorders. Attention must be paid to changes in tissue coloration:
- Cyanosis: can be true (heart defects, pulmonary failure), false (gold or silver deposition), and drug-induced.
- Jaundice: indicates liver pathology, hemolysis, or prolonged sepsis.
- Hyperpigmentation: occurs in Addison's disease, thyrotoxicosis, vitamin B12 and PP deficiency, as well as physiologically during pregnancy.
External inspection and palpation of soft tissues
Inspection of the maxillofacial region (MFR) is performed with the patient's head rigidly fixed in a chair or on a table. The relief, facial symmetry, and range of head motion are assessed. In trauma cases, attention is paid to jaw displacement, depression of the nasal bridge or zygomatic bone.
During soft tissue palpation, the boundaries of the pathology are determined:
- Edema: pressing with an instrument leaves a depression (pitting sign).
- Infiltrate: tissues are densified and painful, skin is altered in color (from bright red to purplish-blue), hot to the touch, and poorly gathers into a fold.
The function of cranial nerves is examined separately: the sensitivity of the trigeminal nerve branches (n. trigeminus) and the symmetry of facial muscle activity (facial nerve — n. facialis).
Palpation of regional lymph nodes
Lymph nodes of the neck and face are palpated in a strict sequence, some of them bimanually (facial, parotid). Submandibular nodes are examined by tilting the patient's head down and to the side of palpation.
Differential diagnostics based on node status:
- Acute inflammation: nodes are enlarged, painful, mobility is limited.
- Chronic inflammation (tuberculosis, actinomycosis): nodes are dense and elastic, breakdown with the formation of "cold abscesses" is possible.
- Malignant neoplasms: nodes are dense, fixed, fused with underlying tissues.
- HIV infection: generalized lymph node enlargement is characteristic.
Inspection of the oral cavity and bone structures
Intraoral examination requires a sterile instrument tray (spatula, tweezers, mirror, probe with a button end, and angled probe). Mouth opening is assessed: its limitation occurs due to cicatricial, inflammatory, or tumor contractures of the masticatory muscles, as well as TMJ pathology.
Whitish areas of hyperkeratosis (considered precancerous conditions) are sought on the mucosal membrane, and the lingual papillae are evaluated. A smooth, "polished" tongue indicates atrophy of the papillae (often due to hyposalivation), while a bright red tongue ("Hunter's glossitis") indicates pernicious anemia.
Differential diagnostics of jaw inflammation:
- Acute periostitis: localized painful swelling in the form of an infiltrate along the transitional fold.
- Acute osteomyelitis: infiltration of the alveolar process from three sides simultaneously, purulent discharge from pockets, painful percussion of several teeth, and Vincent's sign.
- Chronic osteomyelitis: dense bone thickening with fistula formation.
Briefly: answers to topical questions
How are the degrees of mouth opening limitation (inflammatory contracture) classified in millimeters?
Inflammatory contracture of the masticatory muscles is classified into grades I, II, and III, although exact values of mouth opening limitation in millimeters are not provided in the sources. Normally, mouth opening is free, painless, and the distance between the central incisors is 5 cm (or three fingerbreadths of the II, III, and IV fingers). With contracture, opening becomes difficult and painful due to muscle involvement in the inflammatory process.
Which groups of regional lymph nodes of the head and neck are subject to mandatory palpation examination?
The following groups of regional lymph nodes of the head and neck are subject to mandatory palpation examination:
- Submandibular lymph nodes — palpated with three fingers, tilting the patient's head down and to the side.
- Submental lymph nodes — examined with the index finger.
- Mastoid lymph nodes — palpated with the 2nd finger from the mandibular ramus to the anterior edge of the sternocleidomastoid muscle (m. sternocleidomastoideus).
- Facial lymph nodes — buccal, nasolabial, zygomatic, and mandibular nodes are palpated bimanually.
- Parotid lymph nodes — examined in the retromandibular region and bimanually along the anterior edge of the gland.
- Lateral cervical lymph nodes — palpated anterior to the sternocleidomastoid muscle.
- Supraclavicular lymph nodes — felt with three fingers on the clavicle.
- Occipital, subclavicular, and axillary lymph nodes — included in the mandatory minimum when alarming symptoms are present.
Which branches of the trigeminal nerve are tested when assessing facial sensitivity, and where are their exit points located anatomically?
When assessing facial sensitivity, the first, second, and third branches of the trigeminal nerve are tested at their exit points (Valle's points):
- First branch (n. ophthalmicus) — the terminal nerve n. frontalis exits through foramen supraorbitalis. The point is projected 0.5 cm above and lateral to the notch along the upper orbital margin.
- Second branch (n. maxillaris) — the terminal nerve n. infraorbitalis exits through foramen infraorbitalis. The point is located 0.5-0.75 cm inferior to the notch along the lower orbital margin.
- Third branch (n. mandibularis) — the terminal nerve n. mentalis exits through foramen mentalis. The point is located at the midpoint of the distance from the intersection of the masseter muscle with the jaw margin to the midline, stepping 0.75 cm upward.
What X-ray signs (presence of sequestra, destruction foci) are characteristic of chronic osteomyelitis of the jaws?
X-ray signs of chronic jaw osteomyelitis depend on its clinical form:
- Destructive form — characterized by the presence of bone tissue rarefaction foci, inside of which the shadow of a formed sequestrum surrounded by a capsule is defined, with a rim of reactive osteosclerosis along the periphery.
- Destructive, rarefying form — manifests as multiple very small foci of rarefaction (small sequestral cavities), between which a zone of reactive osteosclerosis is defined.
- Productive, hyperplastic form — differs by intensive areas of bone tissue compaction and hypertrophic periosteal reaction; rarefaction foci are rare, and signs of sequestration are absent.
Signs of an inflammatory infiltrate: DENSE (tissues are densified), PAINFUL (painful), FUSED (skin does not gather into a fold), HOT (local temperature is elevated), COLORED (skin ranges from pink to cyanotic).
Class and exam questions
How to identify inflammatory edema upon palpation?
Press on the swelling with the blunt end of the instrument. If a depression remains (pit sign), it indicates edema of inflammatory or traumatic origin.
What is Vincent's sign and when does it occur?
This is a sensory disturbance (numbness) of tissues in the innervation zone of the inferior alveolar and mental nerves. It is a characteristic sign of acute and subacute osteomyelitis of the mandible.
How to differentiate scrotal tongue from pathological fissures?
In a plicated (folded) tongue, epithelial integrity is not compromised, and when the tongue is straightened, the folds smooth out. In true fissures, the integrity of the epithelial layer is disrupted.
What else to study on this topic
- Methodology for examining the function of the trigeminal and facial nerves
- Differential diagnostics of masticatory muscle contractures
- Examination in trauma and TMJ pathology
- Specific tongue changes in systemic diseases
- Signs of oncological alertness during the palpation of masses
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Other topics of section "Chapter 16. Methodology of dental patient examination"
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