Clinical oral examination
The examination always covers the entire oral cavity, not just the causal tooth that the patient complains about. This is critically important because pain can radiate to other areas, leaving the true source unnoticed. The primary goal is to formulate a plan for complete dental rehabilitation.
The clinician proceeds systematically: on the upper jaw, the examination moves from right to left (starting from the molars), and on the lower jaw, from left to right. A dental mirror is consistently used to illuminate hard-to-reach areas, along with a sharp dental explorer.
- On healthy (intact) enamel, the explorer slides smoothly without catching on any irregularities.
- Inside a carious cavity, even if it is hidden, the tip of the instrument catches.
By means of probing, the clinician determines dentin softening, defect depth, the presence of a communication with the pulp chamber, and the location of root canal orifices. Special attention is paid to the contact surfaces of the teeth, where defects are visually imperceptible.
Assessment of the teeth appearance
Tooth color and shape are essential diagnostic markers. Healthy enamel has a "vibrant luster" and a wide range of shades.
The loss of characteristic luster and dullness indicate an initial carious process. If a tooth has acquired a grayish hue, it has most likely been depulped. A sharp and pronounced darkening of the crown often indicates pulp necrosis. External factors also alter coloration: smoking leaves a dark brown deposit, while root canal treatment using the resorcinol-formalin method imparts a specific orange tint to the tissues.
Tooth shape also matters. Specific deformations (such as Hutchinson's or Fournier's incisors) serve as symptoms of hereditary pathologies and systemic diseases.
Physical examination methods: percussion, palpation, and mobility
Percussion (tapping with tweezers or an explorer) reveals inflammation in the periodontium. The examination always begins with knowingly healthy teeth so that the patient understands the normal response (absence of pain). In vertical percussion, taps are delivered along the axis of the tooth, whereas in horizontal percussion, they are applied laterally. The onset of pain indicates an inflammatory focus.
Tooth mobility is tested by rocking their crowns with tweezers. Physiological micromobility is invisible to the eye. Pathological mobility is divided into three degrees:
- Displacement only back and forth (in the vestibulo-oral direction).
- Sideways mobility (mesio-distal) is added.
- The tooth is displaced in all planes, including vertically (sinking into the socket).
Clinically important: if the mobility of a group of teeth is accompanied by pain during percussion, this warrants oncological vigilance and may be a sign of jaw osteomyelitis.
Electric pulp testing (EPT)
The method is based on the ability of living tissue to react to an electric current. EPT allows for an accurate assessment of pulp vitality. To avoid errors due to current leakage, the clinician wears rubber gloves and uses a plastic spatula instead of a metal mirror. The current intensity is smoothly increased until the first reaction occurs.
Excitability thresholds:
- 2–6 µA: healthy pulp and initial caries.
- 20–40 µA: moderate and deep caries (inflammatory or morphological changes are present in the pulp).
- 60 µA: necrosis of the coronal pulp.
- 100 µA and above: total necrosis of the radicular pulp.
- Over 200 µA: reaction of the pathologically altered periodontium.
If the process in the tooth is localized, sensitivity will be reduced only at a single cusp. In total involvement, readings drop across all cusps of the crown.
Diagnostic radiology
The choice of method depends on the pathology and the clinic's equipment.
- Intraoral radiography: provides a detailed image of roots, canals, and the periodontium. It allows for the visualization of hidden cavities, fractures, and filling quality. The normal periodontium appears as a uniform dark stripe 0.2–0.25 mm thick.
- Orthopantomography (panoramic radiograph): an overview image of both jaws. It is excellent for the initial diagnosis of trauma and tumors, but may produce distortions in the area of the central teeth.
- Computed tomography (CT): creates an accurate three-dimensional model of bones and cavities, making it indispensable for trauma and complex surgical planning.
- Magnetic resonance imaging (MRI): a safe method with no radiation exposure, perfectly displaying soft tissue pathologies (edema, pus, tumors).
Laboratory and functional tests
Prior to surgical intervention in an outpatient setting, the patient must undergo a standard panel of laboratory tests: blood tests for syphilis (RW), HIV, and hepatitis. When treated as an inpatient, the list expands to include an ECG, coagulogram, biochemical blood analysis, blood type and Rh factor determination, and a throat swab for diphtheria.
To assess microcirculation and blood flow in the maxillofacial region, functional methods are employed:
- Biomicroscopy: allows for the visual assessment of mucosal capillaries.
- Rheography: records fluctuations in the electrical resistance of tissues during pulsation.
- Polarography: measures the level of tissue oxygen saturation.
Briefly: answers to topical questions
How is the palpation of regional lymph nodes of the face and neck properly performed during a dental appointment?
Palpation of the regional lymph nodes of the face and neck is performed using gentle circular motions with the fingertips. The core principle is the mandatory comparison of symmetrical areas of the head and neck. During palpation, the following characteristics must be assessed:
- Number — single or multiple.
- Shape — the configuration of the lymph node.
- Size — the dimensions of the lymph node.
- Consistency — soft, firm, or elastic.
- Tenderness — presence of pain upon palpation.
- Mobility — displaceability.
- Adhesiveness — to surrounding tissues or to each other into conglomerates.
What are the distinct visual signs of tooth shape anomalies such as Hutchinson's, Fournier's, and Pflüger's teeth?
The distinct visual signs of Hutchinson's and Fournier's tooth anomalies are associated with crown deformation and enamel hypoplasia, whereas a description of Pflüger's teeth is absent from the sources.
- Hutchinson's teeth — deformation of both upper central incisors, where the neck of the tooth is wider than the cutting edge, and a semilunar notch is present on the cutting surface.
- Fournier's teeth — first permanent molars with shortened crowns and enamel hypoplasia on the occlusal surface.
Which dental indices are used for the quantitative assessment of oral hygiene?
Special hygiene indices are used for the quantitative assessment of the oral hygiene status. The main ones include:
- Fedorov-Volodkina index — assessed by staining the vestibular surfaces of the six lower anterior teeth with Schiller-Pisarev solution, followed by a quantitative evaluation on a 5-point scale.
- Simplified Oral Hygiene Index by J.C. Green and J.R. Vermillion (Green-Vermillion).
- Oral Hygiene Performance Index by Podshadley and Haley.
These methods allow for qualitative and quantitative assessment of the hygiene level.
How is the thermal test (thermometry) of teeth performed, and what do various reactions to cold and hot indicate?
Thermometry is performed using thermal stimuli to assess the response of dental tissues. The technique involves using hot or cold water, a heated instrument, or heated gutta-percha to determine the degree and nature of the response. The purpose of the study is differential diagnosis. The literature does not provide a complete description of reactions to cold and hot, but it is noted that in acute periodontitis, pain may occur after consuming hot food.
Degrees of pathological mobility are easy to remember using coordinate axes: Grade I — displacement along one axis (anteroposterior), Grade II — along two axes (mediolateral added), Grade III — along all axes, including vertical (superoinferior).
What else to study on this topic
- Formula for calculating the true root canal length from a radiograph.
- Indications and contrast agents for sialography.
- Features of angiography in vascular tumors of the maxillofacial region.
- Intraoral radiography techniques (interproximal, occlusal, bite-wing).
- Assessment of the salivary glands: massage, duct probing, and the nature of the secretion.
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Other topics of section "Chapter 16. Methodology of dental patient examination"
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