CHAPTER 1 Examination of the Mouth and Other Relevant Structures
A dentist is traditionally taught to perform a complete oral examination of the patient and to develop a treatment plan from the examination findings. The dentist then makes a case presentation to the patient or parents, outlining the recommended course of treatment. This process should include the development and presentation of a prevention plan that outlines an ongoing comprehensive oral health care program for the patient and establishment of the “dental home.”
The plan should include recommendations designed to correct existing oral problems (or halt their progression) and to prevent anticipated future problems. It is essential to obtain all relevant patient and family information, to secure parental consent, and to perform a complete examination before embarking on this comprehensive oral health care program for the pediatric patient. Anticipatory guidance is the term often used to describe the discussion and implementation of such a plan with the patient and/or parents. The American Academy of Pediatric Dentistry has published guidelines concerning the periodicity of examination, preventive dental services, and oral treatment for children as summarized in Table 1-1.
Each pediatric patient should be given an opportunity to receive complete dental care. The dentist should not attempt to decide what the child, parents, or third-party agent will accept or can afford. If parents reject a portion or all of the recommendations, the dentist has at least fulfilled the obligation of educating the child and the parents about the importance of the recommended procedures. Parents of even moderate income usually find the means to have oral health care completed if the dentist explains that the child’s future oral health and even general health are related to the correction of oral defects.
The parent usually makes the first contact with the dental office by telephone. This initial conversation between the parent and the office receptionist is very important. It provides the first opportunity to attend to the parent’s concerns by pleasantly and concisely responding to questions and by offering an office appointment. The receptionist must have a warm, friendly voice and the ability to communicate clearly. The receptionist’s responses should assure the parent that the well-being of the child is the chief concern.
The information recorded by the receptionist during this conversation constitutes the initial dental record for the patient. Filling out a patient information form is a convenient method of collecting the necessary initial information (see Fig. 29-3). Additional discussion of the initial communication with parents is presented in Chapter 29.
Before making a diagnosis and developing a treatment plan, the dentist must collect and evaluate the facts associated with the patient’s or parents’ chief concern and any other identified problems that may be unknown to the patient or parents. Some pathognomonic signs may lead to an almost immediate diagnosis. For example, obvious gingival swelling and drainage may be associated with a single, badly carious primary molar. Although the collection and evaluation of these associated facts are performed rapidly, they provide a diagnosis only for a single problem area. On the other hand, a comprehensive diagnosis of all of the patient’s problems or potential problems may sometimes need to be postponed until more urgent conditions are resolved. For example, a patient with necrotizing ulcerative gingivitis or a newly fractured crown needs immediate treatment, but the treatment will likely be only palliative, and further diagnostic and treatment procedures will be required later.
The importance of thoroughly collecting and evaluating the facts concerning a patient’s condition cannot be overemphasized. A thorough examination of the pediatric dental patient includes assessment of:
|Because each child is unique, these recommendations are designed for the care of children who have no contributing medical conditions and are developing normally. These recommendations will need to be modified for children with special health care needs or if disease or trauma manifests variations from normal. The American Academy of Pediatric Dentistry (AAPD) emphasizes the importance of very early professional intervention and the continuity of care based on the individualized needs of the child. Refer to the text of this guideline for supporting information and references.|
|6–12 mo||12–24 mo||2–6 yr||6–12 yr||12+ yr|
|Clinical oral examination1,2||•||•||•||•||•|
|Assess oral growth and development3||•||•||•||•||•|
|Prophylaxis and topical fluoride4,5||•||•||•||•||•|
|Anticipatory guidance counseling8||•||•||•||•||•|
In certain unusual cases, all of these diagnostic aids may be necessary to arrive at a comprehensive diagnosis. Certainly no oral diagnosis can be complete unless the diagnostician has evaluated the facts obtained by medical and dental history taking, inspection, palpation, exploration (if teeth are present), and often imaging (e.g., radiographs). For a more thorough review of evaluation of the dental patient, refer to the chapter by Glick, Greenberg, and Ship in Burket’s Oral Medicine.2
It is important for the dentist to be familiar with the medical and dental history of the pediatric patient. Familial history may also be relevant to the patient’s oral condition and may provide important diagnostic information in some hereditary disorders. Before the dentist examines the child, the dental assistant can obtain sufficient information to provide the dentist with knowledge of the child’s general health and can alert the dentist to the need for obtaining additional information from the parent or the child’s physician. The form illustrated in Fig. 1-1 can be completed by the parent. However, it is more effective for the dental assistant to ask the questions informally and then to present the findings to the dentist and offer personal observations and a summary of the case. The questions included on the form will also provide information about any previous dental treatment.
(Printed with permission from Indiana University–University Pediatric Dentistry Associates.)
Information regarding the child’s social and psychological development is important. Accurate information reflecting a child’s learning, behavioral, or communication problems is sometimes difficult to obtain initially, especially when the parents are aware of their child’s developmental disorder but are reluctant to discuss it. Behavior problems in the dental office are often related to the child’s inability to communicate with the dentist and to follow instructions. This inability may be attributable to a learning disorder. An indication of learning disorders can usually be obtained by the dental assistant when asking questions about the child’s learning process; for example, asking a young school-aged child how he or she is doing in school is a good lead question. The questions should be age-appropriate for the child.
A notation should be made if a young child was hospitalized previously for general anesthetic and surgical procedures. Shaw reported that hospitalization and a general anesthetic procedure can be a traumatic psychological experience for a preschool child and may sensitize the youngster to procedures that will be encountered later in a dental office.3 If the dentist is aware that a child was previously hospitalized or the child fears strangers in clinic attire, the necessary time and procedures can be planned to help the child overcome the fear and accept dental treatment.
Occasionally, when the parents report significant disorders, it is best for the dentist to conduct the medical and dental history interview. When the parents meet with the dentist privately, they are more likely to discuss the child’s problems openly and there is less chance for misunderstandings regarding the nature of the disorders. In addition, the dentist’s personal involvement at this early time strengthens the confidence of the parents. When there is indication of an acute or chronic systemic disease or anomaly, the dentist should consult the child’s physician to learn the status of the condition, the long-range prognosis, and the current drug therapy.
Current illnesses or histories of significant disorders signal the need for special attention during the medical and dental history interview. In addition to consulting the child’s physician, the dentist may decide to record additional data concerning the child’s current physical condition, such as blood pressure, body temperature, heart sounds, height and weight, pulse, and respiration. Before treatment is initiated, certain laboratory tests may be indicated and special precautions may be necessary. A decision to provide treatment in a hospital and possibly under general anesthesia may be appropriate.
The dentist and the staff must also be alert to identify potentially communicable infectious conditions that threaten the health of the patient and others. Knowledge of the current recommended childhood immunization schedule is helpful. It is advisable to postpone nonemergency dental care for a patient exhibiting signs or symptoms of acute infectious disease until the patient recovers. Further discussions of management of dental patients with special medical, physical, or behavioral problems are presented in Chapters 2, Chapter 3, Chapter 14, Chapter 15, Chapter 23, Chapter 24, and Chapter 28.
The pertinent facts of the medical history can be transferred to the oral examination record (Fig. 1-2) for easy reference by the dentist. A brief summary of important medical information serves as a convenient reminder to the dentist and the staff, because they refer to this chart at each treatment visit.
(Printed with permission from Indiana University–University Pediatric Dentistry Associates.)
The patient’s dental history should also be summarized on the examination chart. This should include a record of previous care in the dentist’s office and the facts related by the patient and the parent regarding previous care in another office. Information concerning the patient’s current oral hygiene habits and previous and current fluoride exposure helps the dentist develop an effective dental disease prevention program. For example, if the family drinks well water, a sample may be sent to a water analysis laboratory to determine the fluoride concentration.
Most facts needed for a comprehensive oral diagnosis in the young patient are obtained by a thorough clinical and radiographic examination. In addition to examining the structures in the oral cavity, the dentist may in some cases wish to note the patient’s size, stature, gait, or involuntary movements. The first clue to malnutrition may come from observing a patient’s abnormal size or stature. Similarly, the severity of a child’s illness, even if oral in origin, may be recognized by observing a weak, unsteady gait of lethargy and malaise as the patient walks into the office. All relevant information should be noted on the oral examination record (see Fig. 1-2), which becomes a permanent part of the patient’s chart.
The clinical examination, whether the first examination or a regular recall examination, should be all inclusive. The dentist can gather useful information while getting acquainted with a new patient. Attention to the patient’s hair, head, face, neck, and hands should be among the first observations made by the dentist after the patient is seated in the chair.
The patient’s hands may reveal information pertinent to the comprehensive diagnosis. The dentist may first detect an elevated temperature by holding the patient’s hand. Cold, clammy hands or bitten fingernails may be the first indication of abnormal anxiety in the child. A callused or unusually clean digit suggests a persistent sucking habit. Clubbing of the fingers or a bluish color in the nail beds suggests congenital heart disease that may require special precautions during dental treatment.
Inspection and palpation of the patient’s head and neck are also indicated. Unusual characteristics of the hair or skin should be noted. The dentist may observe signs of head lice (Fig. 1-3), ringworm (Fig. 1-4), or impetigo (Fig. 1-5) during the examination. Proper referral is indicated immediately, because these conditions are contagious. After the child’s physician has supervised the treatment to control the condition, the child’s dental appointment may be rescheduled. If a contagious condition is identified but the child also has a dental emergency, the dentist and the staff must take appropriate precautions to prevent spread of the disease to others while the emergency is alleviated. Further treatment should be postponed until the contagious condition is controlled.
(Courtesy Dr. Hala Henderson.)
Figure 1-4 Lesion on forehead above left eyebrow is caused by ringworm infection. Several fungal species may cause the lesions on various areas of the body. The dentist may identify lesions on the head, face, or neck of a patient during a routine clinical examination.
(Courtesy Dr. Hala Henderson.)
Figure 1-5 Characteristic lesions of impetigo on the lower face (A) and on the right ear (B). These lesions occur on various skin surfaces, but the dentist is most likely to encounter them on upper body areas. The infections are of bacterial (usually streptococcal) origin and generally require antibiotic therapy for control. The child often spreads the infection by scratching the lesions.
(Courtesy Dr. Hala Henderson.)
Variations in size, shape, symmetry, or function of the head and neck structures should be recorded. Abnormalities of these structures may indicate various syndromes or conditions associated with oral abnormalities.
Okeson4 published a special report on temporomandibular disorders in children. Okeson indicated that, although several studies include children 5 to 7 years of age, most observations have been made in young adolescent. Studies have placed the findings into the categories of symptoms or signs—those reported by the child or parents and those identified by the dentist during the examination.
One should evaluate TMJ function by palpating the head of each mandibular condyle and observing the patient while the mouth is closed (teeth clenched), at rest, and in various open positions (Fig. 1-6A, B). Movements of the condyles or jaw that are not smoothly flowing or deviate from the expected norm should be noted. Similarly, any crepitus that may be heard or identified by palpation, or any other abnormal sounds, should be noted. Sore masticatory muscles may also signal TMJ dysfunction. Such deviations from normal TMJ function may require further evaluation and treatment. There is a consensus that temporomandibular disorders in children can be managed effectively by the following conservative and reversible therapies: patient education, mild physical therapy, behavioral therapy, medications, and occlusal splints.5
The extraoral examination continues with palpation of the patient’s neck and submandibular area (see Fig. 1-6C, D). Again, deviations from normal, such as unusual tenderness or enlargement, should be noted and follow-up tests performed or referrals made as indicated.
If the child is old enough to talk, speech should be evaluated. The positions of the tongue, lips, and perioral musculature during speech, while swallowing, and while at rest may provide useful diagnostic information.
The intraoral examination of a pediatric patient should be comprehensive. There is a temptation to look first for obvious carious lesions. Certainly controlling carious lesions is important, but the dentist should first evaluate the condition of the oral soft tissues and the status of the developing occlusion. If the soft tissues and the occlusion are not observed early in the examination, the dentist may become so engrossed in charting cariou/>