Procedures in the Assessment and Examination of Patients

Procedures in the Assessment and Examination of Patients

Stephen Dunne and Warren Birnbaum

Introduction

Oral diagnosis, like diagnosis of disease in other parts of the body, is complicated by many factors:

  • Symptoms of quite different diseases may be similar; in some cases exactly similar, for example, pulpitis and atypical odontalgia.
A symptom is defined as any bodily change perceptible to the patient.
  • Signs of different diseases may be similar. An ulcer, for example, may be caused by minor trauma from a sharp tooth or may potentially be a squamous cell carcinoma.
A sign is defined as any bodily change which is perceptible to a trained observer.
  • Signs and symptoms of the same disease, suffered by different patients, may be very different.
For example, an excruciating pain described by one may be perceived as discomfort by another. Signs and symptoms may be hidden.
  • It is the dentist’s task, by careful questioning and observation to render these ‘visible’. Preconceived ideas may cloud the perspective of the patient, who may have decided that the problem is ‘dental’ and has, therefore, sought the advice of a dentist.
In this way the patient may fail to reveal appropriate details to the dentist and non‐dental causes of oral problems may be missed, despite repeated and adequate questions.
  • Common disease (e.g. pulpitis) occurs frequently and must be excluded before the rarity is considered.
However, the rarity will occasionally present, and hence the dentist must learn to expect the unexpected.
  • Some patients may provide the history that they believe the dentist wants to hear, and which is socially acceptable.
For example, patients may underestimate their alcohol, tobacco and sugar consumption, whereas time spent on tooth cleaning may be overestimated. In addition, a history of misuse of drugs, sexually transmitted diseases, eating disorders or child abuse may not readily be admitted to a dentist.
  • Relevant but non‐dental matters may erroneously be considered, by some patients, to be none of the dentist’s business!
For example, the medical history.
  • While the process of diagnosis, quite rightly, begins as soon as a patient enters the surgery, appearances can be deceptive.
A smart suit, for example, does not confer immunity to high alcohol and tobacco use, or dental neglect.
The system of diagnosis of disease involves three main elements:

  1. History.
  2. Examination.
  3. Diagnostic tests.
General considerations:

  • Patients should be respectfully treated as an individual, not as a disease requiring treatment.
  • Always use a methodical approach, avoiding ‘spot’ diagnosis.
While the experienced clinician will appear to diagnose a problem with minimal attention to peripheral details, this technique may lead the inexperienced clinician to guesswork. Experience is gained by practice in the consideration of all details. Only with experience is it possible to reject those enquiries and investigations irrelevant to the particular patient under consideration.
  • During a clinical consultation a third person, such as the dental nurse, should be present at all times.
This chaperone should not be a lay person since emergency procedures may need to be followed and equipment operated.
  • The consent of a parent/legal guardian is required for patients who have not shown the mental capacity to give consent.
See Chapter 5.
  • Children are often more cooperative and communicative if, after the initial introduction, the accompanying parent is asked to return to the waiting area.
  • Establishing rapport with the patient is an essential prerequisite for obtaining a adequate history.
Record keeping
  • The dental record contains important facts.
Neither hide such facts amongst irrelevant details nor omit them.
  • The dental record should be dated, complete, legible and indelible and signed by the clinician. The record should be contemporary.
Contemporary – written at the time of the appointment.
  • The record may be required by other clinicians and occasionally by members of the legal profession.
  • Do not write anything that you would not wish to be read in court.
  • Avoid abbreviations unless universally recognised.
  • Delete errors with a single line and sign and date the correction.
The error must remain readable.
  • Accurate sketches are useful to indicate position, size and shape of lesions.
  • Use headings, where appropriate.
e.g. ‘Medical history’.
  • Where standard layouts/formats exist, use them.
  • Where notes carry on over the page, each page should be dated and the abbreviation ‘Cont’d’ (continued) should follow the date.
  • Records must be safely stored in accordance with the Data Protection Act (or other relevant legislation).
  • Accurate and complete dental records are an essential element of patient care and make a major contribution to diagnosis and planning of treatment.
  • The patient has a legal right to access their dental record.
Do not enter any disparaging remarks.
Establishing rapport
The initial patient interview consists of an exchange of both verbal and non‐verbal information. The dentist’s posture and demeanour can do much to enhance or ruin rapport:
  • The patient should be at the same eye level as the clinician.
Not lying flat.
  • Make eye contact, but do not stare.
This may be intimidating.
  • The patient should be reasonably close to the clinician, approximately one metre away.
Proximity denotes intimacy, whereas excess distance suggests inattentiveness.
  • Likewise, facing the patient indicates attentiveness, while turning away suggests rejection.
  • A smile or confirmative nod of the head shows warmth and concern.
  • Record details of the patient’s close family and any forthcoming social events (e.g. marriages, births) that may be volunteered.
Reference to these, subsequently, establishes personal rapport.
  • The initial interview should be conducted free of any protective eyewear and mask.
Otherwise, facial expressions are concealed and speech is muffled. Protective eyewear should be placed on the patient only when the physical examination begins.
  • Before any investigation or procedure, tell the patient what you will be doing and when and why you will be doing it.
A patient surprised by any action may become frightened, leading to a possible loss of trust.

Conclusion

A relaxed patient and an attentive, thorough and methodical dentist, in a friendly but professional environment, are the foundations of oral diagnosis.

The History

‘Listen to your patient, he is telling you the diagnosis!’ (dia‐gnosis: Greek, ‘through knowledge’).

Objectives:

  • To establish rapport between patient and dentist.
  • To gather sufficient information to arrive at a provisional diagnosis.
  • To gain an understanding of the patient’s wishes and expectations.
The history:

  • Is a personal account of the patient’s problem.
  • Is often the most important component of clinical diagnosis.
  • May occasionally be the only diagnostic factor.
  • Some patients (e.g. young children or those with special needs) may be unable to provide an accurate history.
  • With extreme language difficulties, encourage the patient to bring an interpreter.
In extreme circumstances, questions may be addressed to a parent/guardian/carer.
However, it is usually better to persevere with the patient, even if this means asking leading questions, since it is they who are suffering the problem. A third party may apply yet another interpretation of the problem.
Here again, it is better to persist with the patient wherever possible, although this is clearly often difficult.
The history includes three main stages:

  1. A brief introductory phase.
  2. Listening to the patient’s account.
  3. Structured questioning.
Stage 1. The introductory phase.

  • Greet the patient by name.
  • Introduce yourself by name and describe your role in helping the patient.
  • ‘Break the ice’.
By greeting with an introductory comment about the weather, the patient’s journey or occupation, or a compliment (but avoid excessive flattery).
  • Most patients do not understand medical/dental terminology.
Use plain speech but do not ‘talk down’. A useful ‘rule of thumb’ is to employ only vocabulary that might be found in a popular newspaper.
  • Record the patient’s initial statement.
This may, or may not, relate to their reason for attendance but may often provide important information. The statement, ‘I’m terrified of dentists but the pain forced me here’ has obvious implications for the patient’s management.
  • Record or check biographical data, including:
    • Patient’s name.
    • Gender.
    • Date of birth.
cf. age‐related diseases: most patients with oral cancer are over 40 years old.
    • Address.
Difficulty in attendance, fluoridation of local water supply.
    • Telephone number.
Mobile, daytime and residential.
    • Occupation.
Education; socio‐economic status; exposure to sunlight – skin and lip cancer; chef – caries.
    • Names and addresses of general medical practitioner and general dental practitioner.
Stage 2. Listening to the patient’s account Notes:
The present complaint (CO, Complains Of).
This is the reason the patient is seeking care.

  • Use an opening question, such as ‘How can I help you?’
  • If a list of problems is forthcoming, ask ‘What is your main concern?’
Encourage the patient to describe their problem.
In general, do not interrupt the patient.
Encourage the inarticulate by simple questioning.
Direct the ‘talkative’ to more relevant matters.
Record the complaint in the patient’s own words. Particularly in medicolegal cases, the patient’s words may be set in inverted commas.
  • In describing the present complaint, the patient is listing symptoms.
  • Record symptoms in order of severity.
  • If you cannot interpret an adjective describing a symptom it is often useful to ask the patient for a word that describes the opposite to it.
  • Relate the present complaint to the initial statement made by the patient.
Stage 3. Structured questioning
This is subdivided into five headings:

  1. History of the present complaint.
  2. Medical history.
  3. Previous dental history.
  4. Family history.
  5. Social history.
Open‐ended questions, which do not have simple yes or no answers, allow patients more latitude to express themselves.
History of the present complaint (HPC)
  • Is a chronological account of the development of the problem.
  • Include the following questions:
    • When did you first notice the problem?
    • How has it changed since?
Is it getting worse, better, or staying the same?
    • Did (or does) anything cause the problem or make it worse?
e.g. heat, cold or eating may aggravate toothache.
    • Does anything relieve the problem?
e.g. non‐prescription analgesics might relieve mild to moderately severe dental pain.
  • Proceed through questions relating to any additional symptoms and the effectiveness, or otherwise, of any previous treatments.
  • Symptoms may require further clarification.
Pain is a subjective symptom and unlike an ulcer, there may be nothing to assess visually. The history is, therefore, of paramount importance.
  • Avoid ‘leading’ questions.
Suggestible patients may agree to symptoms they did not know they had! Thus, do not ask ‘Do you experience pain with hot and cold foods?’ Instead, ask ‘What causes the pain to start?’
  • If ‘leading’ questions are unavoidable, allow a range of possibilities from which the patient may select.
Medical history (abbreviated MH)
  • May provide important clues to the diagnosis.
  • May greatly modify any treatment plan.
  • An inadequate medical history may put the health of the patient, the dentist and support staff at risk.
  • Is mandatory for medicolegal reasons.
  • If a self‐administered medical history questionnaire is used, answers must be followed up by the dentist.
  • The following questions should be asked:
  • Have you ever had a serious illness or been in hospital?
Hospitalisation often indicates a serious problem.
  • Have you ever had an operation?
May indicate a serious problem or detail information of the patient’s tolerance of an anaesthetic.
  • If so, did you have any problems?
Excessive bleeding, drug reactions etc.
  • Are you presently under the care of a doctor?
May indicate a serious problem.
  • Are you taking any tablets, medicines, pills, drugs or creams?
May suggest the underlying problem. Also, drugs prescribed for dental problems may interact with existing medication. Broad‐spectrum antibiotics may reduce the effectiveness of oral contraceptives, for example, and a barrier method of contraception should be advised.
  • Have you ever had excessive bleeding after cuts or tooth extraction?
May indicate bleeding tendency.
  • Have you ever been turned down as a blood donor?
Blood‐borne viruses, etc.
  • Have you ever had jaundice, hepatitis or any liver problem?
Risk of delayed drug metabolism, bleeding problem.
  • Do you have any heart problems?
Risk of angina/heart attack, general anaesthetic risk.
  • Have you ever had rheumatic fever, a heart murmur, or heart valve problems?
  • Have you ever had high blood pressure?
Risk of stroke or cardiac arrest.
  • Do you have asthma or any chest or breathing problems?
General anaesthetic risk.
  • Have you ever had tuberculosis?
Risk of cross‐infection.
  • Have you ever had any other infectious diseases?
  • Are you a diabetic?
More susceptible to infection, periodontal disease, risk of collapse if blood sugar falls, general anaesthetic risk.
  • Have you ever had epilepsy?
Risk of seizure
  • Are you pregnant or a nursing mother?
Females only!
  • Do you have any allergies, e.g. hay fever, asthma, eczema or to Elastoplast or latex?
Adverse reaction to drugs, general anaesthetic risk.
  • Have you had any problems with antibiotics, particularly penicillin?
Risk of allergic reaction including anaphylactic shock.
  • Have you had any problems with any tablets or medicines, e.g. aspirin?
Adverse drug reaction.
  • Have you had any problems with dental or general anaesthetics?
Adverse drug reaction.
  • Is there any other medical information that I should know?
General ‘catch all’.
  • Check the medical history at each recall appointment; it may have altered significantly in the interim.
e.g. anticoagulants, heart attack, etc.
  • Contact the patient’s doctor/attending physician or surgeon if in doubt.
  • If the patient is uncertain of the name or type of any medication, ask them to bring the medication to the next appointment.
A medical examination may be required for patients undergoing general anaesthesia or sedation and patients with a positive history about to undergo extensive treatment under local anaesthesia.
Previous dental history (DH)
Ask the following questions:
  • How often did you visit your previous dentist?
Motivation, likely future attendance.
  • When did you last see your dentist and what did your dentist do?
May hint at the present problem.
  • Have you ever had orthodontic treatment?
May indicate good motivation.
  • Have you ever had any problems with previous treatment/anaesthesia?
Anxiety, health problem.
  • How often do you brush your teeth and for how long? Do you use dental floss, or fluoride?
Motivation, knowledge of prevention.
Family history (FH)
  • If a diagnosis involving a hereditary condition is suspected, include details of the health, age and medical history of parents, grandparents, siblings and children.
  • Some diseases such as haemophilia are notably hereditary, while in others a hereditary disposition may be present, including:
  • Non‐insulin dependent diabetes mellitus.
  • Hypertension.
  • Some types of epilepsy.
  • Heart disease.
  • Some psychiatric conditions.
  • Breast cancer.
  • Some other malignancies.
Social history (SH)
The object is to obtain a profile of the patient’s lifestyle, which may exert a major influence on the patient’s dental and general health. Include details of:
  • Diet.
Vegetarian, high acid content, cariogenicity, etc.
  • Exercise.
Anaesthetic risk if sedentary.
  • Alcohol consumption.
Periodontal disease, acute necrotising ulcerative gingivitis (ANUG), oral cancer, liver cirrhosis, bleeding risk.
  • Body weight relative to height.
Eating disorders.
  • Tobacco smoking.
Periodontal disease, anaesthetic risk, ANUG, oral cancer. Alcohol and tobacco use together greatly increase the risk of oral cancer.
  • Tobacco and betel quid chewing.
Oral cancer.
  • Home conditions/partner.
Neglect, stress.
  • Residence abroad.
Tropical diseases.
  • Work.
Physical/psychological stress.
  • Stress.
Psychosomatic disorders.
  • Use of non‐prescription (‘recreational’) drugs
Cross‐infection risk, dental neglect, cardiac risks with cocaine, caries risk with methadone.
Conclusions
The history will often suggest a provisional diagnosis or at the least, the history will allow a different diagnosis. The provisional or differential diagnosis will be confirmed or rejected by clinical examination and diagnostic tests. Note: As a ‘rule of thumb’, a patient’s report of alcohol, tobacco, sugar or non‐prescriptive drug use should be doubled for accuracy, while a patient’s estimate of time spent on oral care should be halved!

The Examination

Clinical examination consists of three main stages:

  1. Observation of the patient’s general health and appearance.
  2. Extraoral examination of the head and neck.
  3. Examination of the intraoral tissues.
Note:

  • Observation begins as soon as the patient enters the surgery.
  • During the examination the clinician elicits signs.
  • Like the history, the examination must be thorough and methodical.

Stage 1. General Observation

Note problems such as:
  • Body weight, fit of clothes.
Recent weight loss may indicate serious underlying pathology, e.g. cancer.
  • Very low body weight may suggest an eating disorder. Excessive weight may suggest risk of heart attack or stroke.
Particularly with a general anaesthetic.
  • Breathlessness after minor exertion.
May indicate heart or lung disorder.
  • Physical disability.
  • Obvious illness.
  • Apparent age, relative to chronological age.
  • Complexion.
Pallor with anaemia, yellow with jaundice.
  • Exposed skin areas, including head, neck, hands and nails
Any obvious lesion which may be visible, e.g. finger clubbing.
  • Facial scarring.
Previous surgery or trauma.

Stage 2. Extraoral Examination (EO)

  • Head, face and neck
  • Eyes
  • Lips
  • Lymph nodes
  • Salivary glands
  • Temporomandibular joint
  • Masticatory muscles
1. Head, face and neck
Visually examine the face and neck from the front. Look for obvious lumps, defects, skin blemishes, moles, gross facial asymmetry or facial palsy. Most faces are slightly asymmetric.
To visually examine the neck, ask the patient to tilt the head back slightly to extend the neck. Any swelling or other abnormality is clearly seen in this position. Watch the patient swallow; thyroid swellings move on swallowing.
The patient should then turn the head, still with the neck extended, first to the left and then to the right, to allow visual examination of the submandibular region on each side. Except in the most obese, swellings of the sublingual glands, the lymph nodes and the submandibular glands will be seen.
The neck should then be relaxed to allow bilateral examination of the region of the parotid glands. Note: Unilateral swelling of the parotid salivary glands suggests:

  • Obstruction of the duct.
  • Tumour.
  • Abscess.
  • Retrograde infection of the gland.

Bilateral swelling of the parotid salivary gland suggests:

  • Viral infection, e.g. mumps.
  • Degenerative changes, e.g. sialosis.
2. Eyes (if history suggests)
Look for:

  • Blinking rate
Low frequency staring might indicate a psychological problem, or possibly Parkinson’s disease. High frequency may indicate anxiety or dryness of the eyes, e.g. Sjögren’s syndrome.
  • Limitation of ocular movement or strabismus.
Fractured zygoma.
  • Exophthalmos.
Tumour of orbit or cavernous sinus thrombosis.
  • Bilateral exophthalmos.
Hyperthyroidism – Graves’ disease.
  • Subconjunctival haemorrhage.
Fractured zygoma or nasal arch.
  • Ulceration of conjunctiva.
Behçet’s disease, mucous membrane pemphigoid.
  • Conjunctival pallor.
Anaemia.
  • Blue sclera.
Rarely osteogenesis imperfecta.
  • Yellow sclera.
Jaundice.
  • Corneal scarring.
Mucous membrane pemphigoid.
  • Dry eyes, conjunctivitis.
Sjögren’s syndrome.
3. Lips
Visual examination: note muscle tone. e.g. drooping of the commissure and inability to purse the lips with Bell’s palsy.
Any changes in colour or texture, ulceration, patches, herpetic lesions, angular cheilitis. Note also lip competency/incompetency.
Bimanual palpation: Palpate for lumps, using thumb and forefinger, one intraoral and the other extraoral.
4. Lymph nodes
Important: a normal lymph node cannot be felt. If a node is palpable it must be abnormal.
Lymph node anatomy (Figure 6.1)
The lymph nodes of the head and neck are divided into two main groups:

  1. Circular groups.
  2. Cervical groups.
Line drawing of a human head featuring parotid nodes, facial node, submental node, mastoid node, occipital node, deep cervical nodes, superficial cervical nodes, Jugulo-omohyoid node, and jugulodigastric node.

Figure 6.1 Lymphatic drainage of the head.

Circular groups (arranged around base of skull)
These are subdivided into outer and inner circular groups:
  • Outer circle:
  • Submental.
Behind the chin, lying on the mylohyoid muscle.
  • Submandibular.
Between the mandible and the submandibular salivary gland.
  • Facial (buccal).
On the buccinator muscle, anterior to the insertion of the masseter muscle.
  • Mastoid (post‐auricular).
On the mastoid process.
  • Parotid (pre‐auricular).
In front of the tragus of the ear.
  • Occipital.
Around the occipital artery.
  • Inner circle (not illustrated in Figure 6.1). Named nodes include:
    • Retropharyngeal.
    • Pre‐tracheal.
    • Para‐tracheal.
The circular groups drain into the deep cervical chain.
Cervical groups
Superficial cervical nodes. Distributed around the external and anterior jugular veins. These drain into the deep cervical chain.
Deep cervical chain. Distributed along the internal jugular vein.
Important named nodes include:
  • Jugulodigastric.
Between the angle of the mandible and the anterior border of the sternomastoid muscle.
  • Jugulo‐omohyoid.
Just behind the internal jugular vein, above the inferior belly of omohyoid, under cover of the posterior border of sternomastoid).
Drainage (see Figure 6.1)
Submandibular nodes (unilateral drainage). These drain the centre of the forehead, frontal and maxillary sinuses, upper lip, external nose, related cheek, upper and lower teeth and gums, anterior two thirds of the tongue (except the tip) and floor of the mouth. The submandibular node, in turn, drains into the jugulo‐omohyoid and jugulodigastric nodes.
Facial (buccal) nodes. Drain part of the cheek and lower eyelid. The facial node drains into the deep cervical chain.
Parotid (pre‐auricular) nodes. Drain the forehead, temple, vertex, eyelids and orbit. The parotid nodes drain into the superficial cervical and deep cervical chain
Occipital and mastoid (post‐auricular). Drain the scalp.
Retropharyngeal nodes. Drain the soft palate and drain into the deep cervical chain.
Submental nodes (drain bilaterally). Drain the tip of the tongue, lower lip, chin and incisor teeth and gum area. The submental nodes drain to the submandibular nodes or directly into the jugulo‐omohyoid node.
Jugulo‐omohyoid nodes. Drain the posterior third of the tongue.
Clinical examination of the lymph nodes
Most lymph nodes should be examined by extraoral, bimanual palpation from behind the patient. Expose the neck by asking the patient to loosen relevant clothing. Do not extend the neck because sternomastoid must be relaxed. Use the pulp of the finger tips and try to roll the gland against adjacent harder structures.
Submental. Tip the head forward and try to roll the node against the inner aspect of the mandible.
Submandibular. Same as above but with the patient’s head tipped to the side being examined (Figure 6.2).
Jugulodigastric. Move the anterior border of sternomastoid back.
Line drawing of a face tipped to the left side assisted by hands on top and below the chin.

Figure 6.2 Palpation of submandibular lymph nodes.

Jugulo‐omohyoid. Move the posterior border of sternomastoid forward.
If a node is palpable, record the:

  • Site
  • Size
Measure using vernier callipers.
  • Texture
Soft (infective), rubbery hard (possible Hodgkin’s), stony hard (secondary carcinoma).
  • Tenderness to palpation
Infection.
  • Fixation to surrounding tissues
May suggest metastatic cancer.
  • Coalescence
e.g. tuberculosis.
  • Number of nodes
Multiple – glandular fever, leukaemia, etc.
If more than one node is found, refer for examination of the rest of the body for generalised lymphadenopathy and blood tests.
Palpable node characteristics
Acute infection. Large, soft, painful, mobile, discrete, rapid onset.
Chronic infection. Large, firm, less tender, mobile.
Lymphoma. Rubbery hard, matted, painless, multiple.
Metastatic cancer. Stony hard, fixed to underlying tissues, painless.
If a non‐dental cause is suspected, refer urgently for medical assessment. Suspect metastatic cancer or lymphoma until proven otherwise.
5. Salivary glands
Parotid salivary gland
View from the front. The lower part of the ear lobe may be turned outwards if the gland is swollen. Palpate the glands for enlargement or tenderness.
The gland is located mainly distal to the ascending ramus of the mandible. Occasionally a better view of the parotid gland may be obtained from the back of the patient.
Submandibular salivary gland
Bimanual palpation (Figure 6.3). Use index and middle finger of one hand intraorally and the same fingers of the other hand extraorally.
Palpate the gland above and below mylohyoid and do not neglect to examine the ducts of the glands for calculi.
Line drawing of a face in side view with the index and middle finger of one hand intraorally and the same fingers of the other hand extraorally.

Figure 6.3 Bimanual palpation of the submandibular gland.

6. Examination of articulatory system (if history indicates)
Temporomandibular joints (TMJ)
Investigate the following:

  • Range of movement.
  • Tenderness.
  • Sounds.
  • Locking.
  • Muscle tenderness.
  • Bruxism
  • Head/neck ache.
  • Occlusion.
Range of movement
Measure the maximum pain‐free jaw opening, then measure the maximum opening possible, at the central incisor tips. Identify whether limitation is caused by pain or physical obstruction. Observe any lateral deviation.
Notes:

  • Any lateral deviation on opening is usually towards the affected (i.e. painful) side.
  • The lower limit for normal maximum inter‐incisal opening is 35 mm (female), 40 mm (male) (approximately 2 patient finger‐widths).
  • Measurement in millimetres, using a rule or calliper, is preferable to measurement of mouth opening in terms of the number of the patient’s fingers that can be inserted.
  • Trismus is the inability to open the mouth (see later in this section).
Next, measure the extent of lateral excursion, both pain‐free and forced. Measure from the centre lines.
Notes:

  • The lower limit for normal lateral excursion is 8 mm, in either direction.
  • If the left TMJ is painful, the right lateral excursion is usually reduced.
Mandibular movement may be limited by:

  • Trauma, e.g. third molar surgery, local anaesthetic injection, fracture of mandible, middle third of face or zygomatic arch, laceration of masticatory muscles.
  • Infection, e.g. pericoronitis, submasseteric, pterygomandibular, infratemporal or parapharyngeal space infections, tonsillitis, mumps, osteomyelitis.
  • Scar tissue formation, e.g. post irradiation, burns, submucous fibrosis, scleroderma.
  • Temporomandibular joint disorders.
  • Central nervous system disorders, e.g. tetanus, meningitis, Parkinson’s disease.
  • Medication/poisons, e.g. phenothiazine group of drugs, strychnine.
  • Neoplasm, e.g. nasopharyngeal, carcinoma, coronoid hyperplasia.
  • Psychological factors, e.g. hysteria.
TMJ tenderness
Use bimanual palpation by pressing over the lateral aspect of the joint. Follow this by intra‐auricular palpation by placing the little fingers into the external auditory meatus and gently pressing forwards (Figure 6.4).
TMJ sounds
Clicks are caused by sudden movement of the disc relative to the condyle.
Clicks may be early (i.e. in the early part of jaw opening), late (may indicate greater disc displacement and are often louder), reciprocal (on opening and closing), single (usual), multiple (unstable or perforated disc), loud, quiet, painful or not, and may occur with crepitus.
Line drawing of a face with the mouth wide open, with the pinky fingers inserted to both ears.

Figure 6.4 Intra‐auricular palpation of the temporomandibular joint.

Fifty per cent of the population experience clicking during their life. It is usually of limited duration and if not causing problems should remain untreated.
Crepitus is a prolonged, continuous, grating or crackling noise. Crepitus occurs with degenerative diseases and acute inflammation (e.g. after trauma).
TMJ locking
Locking is due to malposition, distortion or perforation of the disc, which allows the condyle to rotate but not translate. The jaw may open up to 20 mm and then ‘stick’. Rarely, the jaw may open but fail to close easily.
Dislocation
The condyle is displaced over the articular eminence. This may be caused by trauma (e.g. following a difficult tooth extraction) or, very rarely, on yawning. Bilateral dislocation will cause anterior open bite where none existed previously. Unilateral dislocation will lead to cross bite where none existed previously.
Muscles of mastication
Examine for tenderness:
  • Muscles should be tested where they attach to bone. The body of a muscle is not usually tender.
  • Masseter: Originates from the anterior two thirds of the zygomatic arch and inserts into the outer aspect of the angle of the mandible.
Use bimanual palpation, with the finger of one hand intraoral, index and mid finger of the other hand on the cheek. Palpate the origin and insertion.
  • Temporalis: Originates from the superior and inferior temporal lines above the ear and inserts into the coronoid process and anterior border of the ascending ramus.
Palpate the origin extraorally and insertion intraorally.
  • Lateral pterygoid: Originates from the lateral surface of the lateral pterygoid plate and inserts into the anterior border of the condyle and disc. It is inaccessible to palpation
Attempts to palpate behind the maxillary tuberosity are unreliable. Resistance provided by the operator’s hand to attempted lateral excursion by the patient may elicit lateral pterygoid pain, and is a more reliable guide.
  • Medial pterygoid:
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Jan 22, 2018 | Posted by in General Dentistry | Comments Off on Procedures in the Assessment and Examination of Patients
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