Methods of examination of a dental patient. Dental examination at a prophylactic appointment

The date: 08.03.2020

Start with inspection vestibule with closed jaws and relaxed lips, lifting the upper lip and lowering the lower lip or pulling the cheek with a dental mirror. First of all, the red border of the lips and the corners of the mouth are examined. Pay attention to the color, the formation of scales, crusts. On the inner surface of the lip, as a rule, a slight bumpy surface is determined, due to the localization of small salivary glands in the mucous layer. In addition, you can see the pinpoint holes - the excretory ducts of these glands. At these holes, when the mouth is fixed in the open position, an accumulation of secretion droplets can be observed.

Then using a mirror inspect the inner surface of the cheeks. Pay attention to the color and moisture of the buccal mucosa. Sebaceous glands (Fordyce's glands) are located along the line of closing of the teeth in the posterior part, which should not be mistaken for pathology. These are pale yellow nodules with a diameter of 1-2 mm, which do not rise above the mucous membrane, and sometimes are visible only when it is pulled. At the level of the upper second large molars (molars) there are papillae on which the excretory ducts of the parotid salivary glands open. (They are sometimes mistaken for signs of disease.) There may be dental prints on the mucous membrane.

It is important to determine the ratio of the dentition - bite. According to the modern classification, all existing types of bite are divided into physiological and pathological (Fig. 4.1).

Following the examination of the oral cavity, gum examination... Normally, it is pale pink, tightly covering the neck of the tooth. The gingival papillae are pale pink, occupying the interdental spaces. A groove is formed at the site of the periodontal junction (previously it was called the periodontal pocket). With the development of the pathological process, the gum epithelium begins to grow along the root, forming a clinical, or periodontal (pathological), periodontal pocket. The condition of the pockets formed, their depth, the presence of tartar are determined using an angular button-like probe or a probe with notches applied every 2-3 mm. Examination of the gums allows you to determine the type of inflammation (catarrhal, ulcerative necrotic, hyperplastic), the nature of its course (acute, chronic, in the acute stage), prevalence (localized, generalized), severity (mild, moderate, severe gingivitis or periodontitis). The papillae may be enlarged due to their swelling, while they cover a significant part of the tooth.

For determining CPITN (index of need for treatment of periodontal diseases), proposed by WHO, it is necessary to examine the surrounding tissues in the area of 10 teeth: 17, 16, 11, 26, 27, which corresponds to teeth 7, 6, 1, 6, 7 on the upper jaw, and 27, 36, 31, 46, 47, which corresponds to 7, 6, 1, 6, 7 teeth on the lower jaw. The results of the examination of this group of teeth make it possible to obtain a complete picture of the state of the periodontal tissues of both jaws. The formula for this group of teeth:

In a special card, the state of only 6 teeth is recorded in the corresponding cells. When examining teeth 17 and 16, 26 and 27, 36 and 37, 46 and 47, codes corresponding to a more severe condition are taken into account. For example, if bleeding is found in the area of tooth 17, and tartar is found in the area of tooth 16, then code 2 is entered into the cell, indicating tartar. If any of these teeth is missing, then the tooth next to it in the dentition is examined. In the absence of this tooth, the cell is crossed out diagonally and this indicator is not taken into account in the summary results.

Periodontal tissues are examined by probing with a special (button-like) probe (Fig. 4.2) to detect bleeding, supra- and subgingival tartar and pathological pocket. The load on the periodontal probe during examination should be no more than 25 g. Practical test to establish this force - pressure with a periodontal probe under the thumbnail without causing pain or discomfort.

Probing force can be divided into two components: working (for determining the depth of the pocket) and sensitive (for detecting subgingival calculus). The pain experienced by the patient during the probing is an indicator of the use of too much force. The number of probes depends on the condition of the tissues surrounding the tooth, however, probing more than 4 times in the area of one tooth is unlikely to be required. Bleeding can appear both immediately after probing and after 30-40 seconds. Subgingival calculus is determined not only when it is clearly present, but also with a barely perceptible roughness, which is revealed when the probe moves along the tooth root along its anatomical configuration.

CPITN is assessed using the following codes:

0 - no signs of disease;
1 - bleeding gums after probing;
2 - the presence of supra- and subgingival calculus;
3 - pathological pocket with a depth of 4-5 mm;
4 - pathological pocket with a depth of 6 mm or more.

Assessment of the hygienic state of the oral cavity- an important indicator of the occurrence and course of pathological processes in it. At the same time, it is important to have not only a qualitative indicator that would make it possible to judge the presence of dental plaque. Many indices have now been proposed to quantify the various components of oral hygiene.

Green and Vermillion (1964) proposed a simplified oral hygiene index (IHI) - determining the presence of plaque and calculus on the buccal surface of the first upper molars, the lingual surface of the first lower molars and the labial surface of the upper incisors: 16, 11, 21, 26, 36 , 46.

In this case, estimates are used in points:

0 - no dental plaque;
1 - plaque covers no more than the surface of the tooth;
2 - plaque covers from Y to at the surface of the tooth;
3 - Plaque covers more at the surface of the tooth.

Plaque Index (PLA) calculated by the formula:

Index 3 indicates unsatisfactory, and 0 indicates good oral hygiene.

Tartar Index (ICC) assessed in the same way as IZN:

0 - no stone;
1 - supragingival calculus at the surface of the tooth;
2 - supragingival stone on 2/3 of the surface of the crown or in certain areas;
3 - the supragingival calculus covers more at the surface of the tooth, the subgingival calculus encircles the neck of the tooth.

In determining Oral hygiene index according to Fedorov-Volodkina(Fig. 4.3) with a solution of iodine and potassium iodide (crystalline iodine 1 g, potassium iodide 2 g, distilled water 40 ml) lubricate the vestibular surfaces of the six anterior (frontal) teeth of the lower jaw. The quantitative assessment is given on a five-point scale:

staining the entire surface of the crown - 5 points;
3/4 of the surface - 4 points;
1/2 surface - 3 points;
1/4 of the surface - 2 points;
lack of staining - 1 point.

The average value of the index is calculated by the formula:

Values 1 - 1.5 reflect good, and values 2-5 - poor oral hygiene.

Podshadley and Haley (1968) suggested oral hygiene efficiency index (IH)... After applying dyes and rinsing the mouth with water, 6 teeth are visually examined: buccal surfaces 16 and 26, lip surfaces 11 and 31, lingual surfaces 36 and 46.

The surface of the teeth is conventionally divided into 5 sections: 1 - medial, 2 - distal, 3 - mid-occlusal, 4 - central, 5 - mid-cervical. At each site, codes are determined:

0 - no staining;
1 - painting any surface.

The calculation is made according to the formula:

where ZN is the sum of codes for all teeth; n is the number of examined teeth. A score of 0 indicates excellent, and 1.7 or more indicates an unsatisfactory hygienic state of the oral cavity.

Tumors and swellings of various shapes and consistencies can form on the gums. The most common abscesses are a sharply hyperemic area of the gums with an accumulation of purulent exudate in the center. After opening the abscess, a fistulous tract occurs. It can also form in the presence of a focus of inflammation at the apex of the root. Depending on the localization of the fistulous tract, its origin can be determined. If the fistulous passage is located closer to the gingival margin, then its formation is associated with an exacerbation of parodontitis, and if it is closer to the transitional fold, then its occurrence is due to a change in the periodontal tissues. It should be remembered that X-ray examination is of decisive importance.

When examining the oral cavity itself, first of all, a general examination is performed, paying attention to the color and moisture of the mucous membrane. Normally, it is pale pink, but it can become hyperemic, edematous, and sometimes acquires a whitish tint, which indicates the phenomenon of para- or hyperkeratosis.

Examining the palate, determine the shape of the hard palate (highly curved, flattened), the mobility of the soft palate, its closure of the nasopharyngeal space (when pronouncing the lingering sound "a-a"), the presence of various kinds of acquired and congenital defects. When examining the tongue, attention is paid to its shape, size, mobility, color, condition of the mucous membrane and the severity of the papillae, the presence of deformities (cicatricial curvatures, adhesions with underlying tissues, tongue defect, compaction, infiltration) and other changes.

Examination of the tongue begins with determining the condition of the papillae, especially if there are complaints of changes in sensitivity or burning and soreness in any areas. There may be a lining of the tongue due to a slowdown in the rejection of the outer layers of the epithelium. This phenomenon may be the result of a violation of the gastrointestinal tract, and possibly pathological changes in the oral cavity with candidiasis. Sometimes there is an increased desquamation of the papillae of the tongue in some area (more often at the tip and lateral surface). This condition may not bother the patient, but pain from irritants, especially chemical ones, may occur. With atrophy of the papillae of the tongue, its surface becomes smooth, as if polished, and due to hyposalivation, it acquires stickiness. Individual areas, and sometimes the entire mucous membrane, can be bright red or crimson. This state of the tongue is observed in malignant anemia and is called Gunther's glossitis (after the name of the author who described it for the first time). Hypertrophy of the papillae may also be noted, which, as a rule, does not cause concern to the patient.

When examining the tongue, one should remember that it is necessary to examine the lateral surfaces of the tongue in the area of the molars and the root of the tongue, where malignant neoplasms are often localized.

When examining the tongue, pay attention to its size, relief. With an increase in size, the time of manifestation of this symptom (congenital or acquired) should be determined. It is necessary to distinguish macroglossia from edema. The tongue can be folded in the presence of a significant number of longitudinal folds, but patients may not be aware of this, since in most cases it does not bother them. Folding is manifested when the tongue is straightened. Patients mistake them for cracks. The difference is that with a crack, the integrity of the epithelial layer is broken, and with a fold, the epithelium is not damaged.

When examining the floor of the oral cavity, pay attention to the mucous membrane

shell. Its peculiarity is compliance, the presence of folds, frenulum of the tongue and excretory ducts of the salivary glands, and sometimes droplets of accumulated secretion. In smokers, the mucous membrane may become dull.

In the presence of keratinization, which manifests itself in areas of grayish-white color, their density, size, adhesion with the underlying tissues, the level of elevation of the focus above the mucous membrane, and soreness are determined.

Palpation. Palpation is understood as a clinical research method that allows, with the help of touch, to determine the physical properties of tissues and organs, their sensitivity to external influences, as well as some of their functional properties. Distinguish the usual and bimanual palpation.

Palpation of the soft tissues of the cheek and floor of the mouth is best done with two hands ( bimanually). The index finger of one hand is palpated from the side of the oral mucosa, and one or more fingers of the other hand are palpated from the outside - from the side of the skin. In the presence of scars, their nature, shape, size are established and it is noted whether they violate the function of the oral cavity organs and what these disorders are.

For palpation of the tongue, they ask the patient to stick it out. Then, with the thumb and forefinger of the left hand, using a gauze napkin, take the tongue by the tip and fix it in this position. Palpation is performed with the fingers of the right hand.

Palpation of the maxillofacial region and adjacent areas is carried out with the fingers of one hand ( normal palpation), and with the other hand

hold the head in the required position for this.

The sequence of palpation of a particular anatomical area is determined by the localization of the pathological process, since palpation should never be started from the affected area. It is recommended to palpate from "healthy" to "sick".

All irregularities, thickening, induration, swelling, soreness and other changes are noted, paying special attention to the condition of the lymphatic system. In the presence of inflammatory infiltration, its consistency (soft, dense), the area of distribution, soreness, adhesion with the underlying tissues, the mobility of the skin over it (whether it folds or not), the presence of foci of softening, fluctuations, the state of regional lymph nodes are determined.

Fluctuation (fluctuare - wave-like fluctuations), or ripple - a symptom of finding a liquid in a closed cavity. It is defined as follows. One or two fingers of one hand are placed on the area to be examined. Then, with one or two fingers of the other hand, a sharp push is made in the area of the investigated area. The fluid movement caused by it in the cavity is perceived by fingers applied to the investigated area in two mutually perpendicular directions. A fluctuation perceived in only one direction is false. False fluctuation can be detected in the area of elastic tissues, in soft tumors (for example, lipomas).

If there is a suspicion of a tumor process, special attention is paid to the consistency of the neoplasm (softness, density, elasticity), size, nature of the surface (even, bumpy), mobility in different directions (horizontal, vertical). The most important, and sometimes decisive, is palpation examination of regional lymph nodes.

Palpation of the lymph nodes. The condition of the submental, submandibular and cervical lymph nodes is determined by palpation.

Peripheral lymph nodes are grouped in the subcutaneous tissue of various areas of the body, where they can be detected by palpation, and with significant magnification, also visually. The examination of the lymph nodes is carried out in the symmetrical areas of the same name. The method of superficial palpation is applied. The doctor puts his fingers on the skin of the investigated area and, without lifting the fingers, slides them along with the skin along the underlying dense tissues (muscles or bones), lightly pressing on them. In this case, the movements of the fingers can be longitudinal, transverse or circular. Rolling palpable lymph nodes under the fingers, the doctor determines their number, size and shape of each node, density (consistency), mobility, soreness and adhesion of the lymph nodes to each other, to the skin and surrounding tissues. Visually determine also the presence of skin changes in the area of palpable lymph nodes: hyperemia, ulceration, fistulas. The sizes of the lymph nodes are indicated in cm. If the lymph node has a rounded shape, it is necessary to indicate its diameter, and if it is oval, the largest and smallest dimensions.

Groping submandibular lymph nodes is an important diagnostic technique in the recognition of a number of systemic diseases, oncological processes, as well as inflammatory processes. To palpate the lymph nodes, the doctor stands to the right of the patient, fixes his head with one hand, and probes the lymph nodes with the 2nd, 3rd, 4th fingers of the other hand, brought under the edge of the lower jaw, by careful circular movements.

Getting started with palpation chin lymph nodes, the doctor asks the patient to slightly tilt his head forward and fixes it with his left hand. Places the closed and slightly bent fingers of the right hand in the middle of the chin region so that the ends of the fingers rest on the front surface of the patient's neck. Then, palpating them towards the chin, he tries to bring the lymph nodes to the edge of the lower jaw and determine their properties.

Posterior cervical lymph nodes palpate simultaneously from both sides in the spaces located between the posterior edges of the sternocleidomastoid muscles.

On palpation anterior and posterior cervical lymph nodes the fingers are positioned perpendicular to the length of the neck. Palpation is performed from top to bottom.

Normally, lymph nodes are usually not detected on palpation. If the nodes are palpable, then you should pay attention to their size, mobility, consistency, soreness, cohesion.

Having received, on the basis of an external examination and palpation, data on

changes in the maxillofacial area, proceed to the study of its individual anatomical areas.

Examination of the bones of the facial skeleton, jaws begin with an external examination, paying attention to their shape, size, symmetry of location. Of particular importance is the identification of deformities and changes in various parts of the jaws during deep palpation.

When examining the facial skeleton of a patient with an injury to the maxillofacial region, the symmetry of the external nose, pain on palpation of the nasal bones are noted. The severity of the retraction of the bridge of the nose, the severity of the "step" symptom. Next, an axial load is carried out on the zygomatic arches, the upper jaw, while noting the severity of the pain syndrome and the localization of pain. One should consistently determine the localization of pain during axial load on the lower jaw and the presence of a “step” symptom in the mandibular edge, the severity of crepitus of bone fragments on palpation, and the presence of pathological mobility of bone fragments.

In the presence of a defect or deformation of the maxillofacial region, the nature of the deformity, the localization and boundaries of the defect leading to deformation, and the state of the skin at the border with the defect are described in detail. In the presence of cicatricial deformity, it is necessary to describe its size (in cm), the color of the scar, pain on palpation, the consistency of the scar, the connection with the surrounding tissues.

In the presence of congenital pathology of the face, describe the severity of the Cupid's arc (broken, not broken), the size of the cleft lip, palate along line A; type of cleft: unilateral, bilateral, complete, incomplete, through; the presence of deformation of the alveolar process of the upper jaw; position of the intermaxillary bone.

Examination of the jaws. The difference in the anatomical structure and location of the upper and lower jaws, as well as the unequal degree of their participation in the performance of various functions, cause a different course of pathological processes in them, and, consequently, different signs of their manifestation.

Study of the upper jaw. When treating patients with lesions of the upper jaw, complaints and anamnesis are of great importance. Much more often, symptoms such as pain, nasal discharge, tooth mobility appear in the beginning, and only in a later period there is a deformation of the jaw. However, to establish the pathological process, it is necessary to detail the above symptoms: in case of pain, to determine the place of greatest pain, to identify its intensity and irradiation: in the presence of nasal discharge, their nature (mucous, purulent, bloody, bloody-purulent, etc.), with deformation - its type (protrusion of the wall of the maxillary sinus, its destruction, etc.), size, localization, etc. To identify perforation of the maxillary sinus, among other methods of examination, a nasal test is sometimes performed.

Examination of the lower jaw. When examining the lower jaw, attention is paid to the shape, symmetry of both halves, size, the presence of irregularities, thickenings, acquired and congenital deformities. Palpation determines the nature of the surface of the thickening or tumor (smooth, bumpy), consistency (dense, elastic, soft).

Study of the temporomandibular joint. To a certain extent, the function of the temporomandibular joint can be judged by the degree of mouth opening and lateral movements of the lower jaws.

Normal mouth opening in an adult is 45-50 mm between the incisors. It should be considered more appropriate to measure the individual rate of opening the mouth based on the measurement of the width of the fingers. So, if the patient opens his mouth to the width of his 3 fingers (index, middle and ring), then this can be considered the norm.

Checking the volume of lateral movements of the lower jaw consists in determining the distance in millimeters by which the lower jaw is displaced from the midline of the face when it moves in one direction or another. Then the area of the temporomandibular joint is examined and palpated, noting the condition of the tissues in this area: the presence of swelling, hyperemia, infiltration and soreness. Pressing anteriorly the tragus of the ear, examine the external auditory canal, determining whether there is a narrowing due to the bulging of the anterior wall. In the absence of inflammation, the ends of the little fingers are inserted into the external auditory canals and, when opening and closing the mouth, with lateral movements of the lower jaw, the degree of mobility of the articular heads is established, while the appearance of pain, crunching or clicking in the joint.

Examination of the salivary glands. When examining the salivary glands, first of all, attention is paid to the color of the skin and changes in the contours of tissues in the area of the anatomical location of the glands. If the contours are changed due to swelling, then its size and character are determined (spilled, limited, soft, dense, painful, foci of softening, fluctuations). If the change in the contours of the gland is due to the tumor process, then the exact localization of the tumor in the gland, the clarity of its boundaries, size, consistency, mobility, and the nature of the surface (smooth, bumpy) are established. It is determined whether there is paresis or paralysis of facial muscles and damage to the masticatory muscles. Then the excretory ducts are examined. To examine the orifices of the excretory ducts of the parotid salivary glands, which are located on the mucous membrane of the cheek along the line of closing of the teeth at the level of the second upper molar, the angle of the mouth is pulled forward and slightly outward with a dental mirror or blunt hook. Lightly massaging the parotid salivary gland, observe the secretion from the mouth of the duct, while determining the nature of the secret (transparent, cloudy, purulent) and at least approximately its amount. In order to inspect the excretory duct of the submandibular or sublingual salivary glands, the tongue is pulled backward with a dental mirror. In the anterior part of the hyoid region, the duct outlet is examined. Massaging the submandibular salivary gland, the nature and amount of its secretion is established. By palpation along the duct from back to front, the presence of a stone or an inflammatory infiltrate in the duct is determined. By palpating from the side of the oral cavity and submandibular region (bimanual), the value and consistency of the submandibular and sublingual salivary glands are more accurately established. Under certain indications (suspicion of the presence of a stone, deformation of the duct, its narrowing) and the absence of inflammation, careful probing of the duct can be performed.

Study of the function of the trigeminal, facial, glossopharyngeal and vagus nerves. When examining the functional state of the trigeminal nerve (n.trigemini) assess tactile, pain and temperature sensitivity in the areas innervated by sensory nerves, and the motor function of the masticatory muscles. To test the sensitivity, with the patient's eyes closed, alternately touch the skin of the investigated area with a piece of paper (tactile sensitivity), a needle (pain sensitivity) and test tubes with warm and cold water (temperature sensitivity) and ask the patient to say what he feels. Also check the sensitivity of the cornea, conjunctiva, oral mucosa and nose. Determine the perception of gustatory sensations from the anterior two-thirds of the tongue. By palpating the exit site of the sensory nerves from the skull in the supraorbital arch, in the infraorbital region and in the chin, the presence of pain points is established.

When checking the motor function of the trigeminal nerve, the tone and strength of the masticatory muscles are determined, as well as the correct position of the lower jaw during its movements. In order to determine the tone of the masticatory muscles, the patient is asked to firmly clench and unclench the teeth: at the same time, the well-contoured chewing and temporal muscles are palpated. To check the strength of the masticatory muscles with the patient's mouth open, they cover the chin with the thumb and forefinger of the right hand and ask the patient to close his mouth, while trying to hold the lower jaw by the chin.

Facial nerve (n.facialis ) innervates the facial muscles

tsa, therefore, in the study of its functions, the state of the facial muscles at rest and during their contraction is determined. Observing the state of the muscles at rest, the severity of skin folds (wrinkles) of the right and left sides of the forehead, the width of both eye slits, the relief of the right and left nasolabial folds, and the symmetry of the corners of the mouth are noted.

The contractility of the facial muscles is tested by raising and frowning eyebrows, closing the eyes, bared teeth, puffing out the cheeks and protruding the lips.

When examining a function glossopharyngeal nerve (n.glossopharyngeus) determine the perception of taste sensations from the posterior third of the tongue and observe the implementation of the act of swallowing.

Nervus vagus (n.vagus) is mixed. It contains motor and sensory fibers. Of interest is the study of one of its branches - the recurrent nerve (n.recurens), which supplies motor fibers to the palate muscles, stylopharyngeal muscle, pharyngeal compressors, and laryngeal muscles.

The study of its function consists in determining the timbre of the voice, the mobility of the soft palate and vocal cords, as well as observing the act of swallowing.

Based on the data of the survey, examination and the main research methods (palpation and percussion), a preliminary diagnosis is made. To clarify the diagnosis, in most cases it is necessary to carry out additional research methods.

The purpose of the examination of any patient is to establish a diagnosis based on a thorough analysis of complaints, anamnesis and an objective examination.

Examination of a dental patient includes this complex of studies conducted by a doctor to assess both his general condition and identify the presence of diseases. Based on the obtained research data, a diagnosis is established, general and local etiological and pathogenetic factors of the disease are determined. Diagnosis of the disease is one of the most important components of the medical specialty. The ability to examine a dental patient in the future depends on the diagnosis of various nosological forms of the disease.

When examining a dental patient, the emphasis is on the importance of the sequence of methods for its implementation.

The examination of the patient, as a rule, begins with a survey, clarification of complaints and anamnesis of the disease, past and concomitant diseases, allergic status. The survey data allow the doctor from the very beginning to suggest the correct diagnosis (preliminary) and outline further methods of examination.

Interview. Find out complaints and medical history. During the interview, it is necessary to establish a trusting contact with the patient, to determine his neuropsychic status, intellect and, on this basis, to analyze the complaints, the course of the development of the disease. The doctor with leading questions should help the patient to state the history of the disease.

The examination is carried out in accordance with all the rules of deontology, taking into account the characteristics of the patient's personality.

Clinical research methods are divided into basic and additional. The main ones consist of clarifying complaints, collecting anamnesis, including the development of a present disease, previous treatment, and its effect. All data of anamnesis of life, transferred and concomitant diseases are important. An objective examination of the patient includes an external examination of the face and neck, palpation of the peri-maxillary soft tissues, organs and bones of the face.

cranial and cerebral parts of the skull, determination of the functions of opening and closing the mouth, movements in the temporomandibular joints, examination, palpation of the oral cavity and its components, palpation and percussion of the teeth. Additional include various instrumental and laboratory research methods.

Patient complaints. Patients may present complaints associated with the process in the maxillofacial region and related to concomitant diseases. A thorough and targeted survey of the patient allows the doctor to identify the main and secondary complaints, to assess them professionally.

The most typical of them are complaints of pain, which can be permanent or temporary, acute or dull, localized or diffuse, spontaneous or associated with touching a tooth, part of facial tissues, jaws and other irritations. Such a nature of pain, such as severity, specificity, frequency and other features, may be sufficient for a qualified doctor to make a diagnostic assumption at the first stage of the survey. Pathological processes developing in the maxillofacial region, in most cases, are signs of inflammation, more often of an odontogenic nature. They differ in a certain nature of pain, which may serve as a basis for the differential diagnosis of some diseases. So, with pulpitis, acute pains of a diffuse nature are observed, night pains are frequent, radiating along the nerve branches and trunks. Acute periodontitis is characterized by acute pain localized in the tooth, pain when biting. Over time, they intensify, become permanent and radiate along the branches of the sensory nerves. Acute purulent periostitis of the jaw is manifested by the spread of pain from the causative tooth to the area of the jaw, i.e. the pain is diffuse. Pain in acute osteomyelitis of the jaw, depending on the localization of the process and the length of the bone lesion, are varied: acute, radiating along the nerves, drilling, diffuse. Abscesses, acute lymphadenitis, specific inflammatory processes of the head, neck, jaws are characterized by aching pains in the area of the affected tissues, aggravated by palpation. With phlegmon, adenophlegmon, boils, carbuncles, pain is diffuse, permanent. In the future, the intensity of the pain increases, they become twitching, pulsating. In addition to local pain in inflammatory processes, holo-

clear pain, malaise, loss of appetite, sleep, chills and other manifestations reflecting the degree of intoxication.

Painful sensations can occur when moving the lower jaw, tongue, swallowing, breathing, talking. This is observed in inflammatory, oncological diseases, trauma to the soft and bone tissues of the face, oral organs. Disorders of chewing, swallowing, mouth opening, taste, breathing are possible. Complaints about difficulty swallowing, breathing are formidable symptoms, and in these cases an urgent further examination of the patient is required.

Patients may complain of soreness and swelling of the salivary glands, dry mouth, an unpleasant salty taste associated with food intake, which is characteristic of diseases of the salivary glands.

Patients often complain of a violation of facial symmetry. This can occur due to swelling, neoplasm of tissues of the face, jaws, oral organs. Comparing complaints of pain with the nature of the swelling, in some cases we can talk about diseases of an inflammatory nature, in others - about a tumor or tumor-like formation.

Patients may complain about a defect or deformation of the face, causing functional and aesthetic impairments. In such cases, the nature of the defect or deformity (congenital or acquired) should be clarified. With an acquired defect, it is important to establish its cause (trauma, inflammatory, oncological processes, previously performed operations, etc.).

Medical history. It is important to understand that dental diseases are diseases of the whole organism, and their diagnosis should be based on general clinical principles. This requires deep and versatile knowledge both in the field of dentistry and in other branches of medicine. The methodology for recognizing diseases of the oral cavity and maxillofacial region is based on anamnestic and objective studies, which may become more complicated depending on the nature of the disease, require more complex techniques and the use of new diagnostic research technologies.

When diagnosing, a unified medical approach and the isolation of nosological forms of diseases should be observed according to the International Classification of Dental Diseases, Injuries and Causes of Death based on ICD-10 (1997). According to it, the following classes of diseases should be distinguished.

Class II. Neoplasms emanating from the mucous membrane of the mouth, salivary glands, etc.

Class III. Diseases of the blood, hematopoietic system and certain disorders involving the immune mechanism with lesions in the oral cavity.

Class IV. Diseases of the endocrine system, eating disorders and metabolic disorders in which manifestations in the oral cavity are observed.

Class V. Mental and behavioral disorders: neurotic, stress-related and somatoform disorders (developmental disorders).

Class VI. Diseases of the nervous system. Lesions of individual nerves, nerve roots and plexuses.

Class IX. Diseases of the circulatory system.

Class X. Diseases of the respiratory system.

Class XI. Diseases of the digestive system.

Class XII. Diseases of the skin and subcutaneous tissue.

Class XIII. Diseases of the musculoskeletal system and connective tissue.

Class XVII. Congenital anomalies [malformations] deformations and chromosomal abnormalities. Class XIX. Head trauma.

When diagnosing, one should keep in mind general and local symptoms associated with poisoning with drugs, medicines, biological substances, toxic effects of substances, external causes, as well as those arising from surgical, therapeutic interventions, with the consequences of injuries.

In the course of the survey, the dynamics of the disease is clarified: when the first symptoms appeared, what they were, who noticed them (the patient, those around, the doctor), where the patient turned for help, what treatment was carried out and with what result. You should familiarize yourself with the patient's documentation regarding the examination (an extract from the medical history, data from laboratory and other studies, radiographs, conclusions of consultants).

In case of complaints of pain and swelling in the maxillofacial region, it is necessary to clarify how the process developed and establish the source

infections. With an increase in general and local symptoms of the inflammatory process, hospitalization and, possibly, emergency operations are necessary.

In the presence of specific inflammatory foci, ulcers, defects of the maxillofacial region and oral mucosa, information should be collected about heredity, lifestyle, contacts with sick people, animals to exclude tuberculosis, syphilis, anthrax and HIV infections, and also to clarify the results of examinations, carried out with these diseases.

When the process is localized in the area of the salivary glands from the anamnesis, it is necessary to find out whether there was swelling of the gland, whether it was associated with food intake. It is necessary to clarify the possibility of the development of the disease after operations on internal organs, especially the abdominal cavity, small pelvis, after a viral or other infection, as well as after diseases of the internal organs.

If there is an injury, it is necessary to clarify under what circumstances it occurred, whether the patient lost consciousness and for how long, whether there was nausea, dizziness, vomiting, bleeding from the nose, ears, what help was provided. It is necessary to find out whether the patient was injected with tetanus toxoid or tetanus toxoid, how, when and in what doses. The fact of injury in a state of alcoholic intoxication, drug intoxication requires clarification.

When a patient addresses bleeding associated with trauma, surgical intervention (including tooth extraction), it is imperative to ask about its duration in case of previous operations, cuts, bruises.

For pain that characterizes diseases and damage to the nerves of the face and jaws, you need to know the data of the neurological status. When treating patients with pain and dysfunction of the temporomandibular joints, it is necessary to find out the connection between the process and diseases of the cardiovascular system, musculoskeletal system and connective tissue.

With tumors and tumor-like lesions of the face, jaws, oral cavity organs, it is necessary to find out the connection of the process with other diseases of internal organs, ENT organs, skin, etc., to clarify the features of the growth of the neoplasm (widespread or limited), accompanying symptoms (pain and their nature, violation functions, etc.).

With congenital defects, it is necessary to clarify the data of the family history (heredity), the features of the course of the first half of pregnancy and childbirth, development at an early age and later. In the presence of acquired defects and deformities, it is important to find out their cause - trauma, burns, inflammatory, specific or oncological process, previous operations, etc.

Anamnesis of life. They collect information about the characteristics of childbirth, the health of parents, working conditions, living conditions, nutrition, rest, physical education, alcohol abuse, smoking, drug use, etc. This allows you to get a correct understanding of physical and mental health. It is necessary to find out what diseases the patient suffered, how they proceeded, what treatment was carried out and its results.

It is necessary to identify hereditary diseases and in the future, when diagnosing a dental disease, take into account genetic factors. Genetic history is of great importance in congenital malformations, especially multiple ones. It is necessary to clarify the burdened obstetric history and pay attention to such facts as infertility, miscarriages, stillbirth, early infant mortality, harmful factors affecting the mother's body during pregnancy: smoking, alcohol, drugs.

When collecting anamnesis, it is necessary to find out whether close relatives have had allergic, autoimmune, immunoproliferative diseases, whether there have been malignant tumors in several generations, as well as mental illnesses, including schizophrenia.

It is necessary to clarify with the patient the possible connection of the disease with insect or animal bites, being in natural conditions that predispose to rare infections, their epidemics in the area where the patient was staying.

Accompanying illnesses. Certain attention should be paid to previously transferred diseases, their course, the effectiveness of the treatment.

Particular attention should be paid to patients with hypertension, coronary heart disease, angina pectoris. With these diseases, there is always a risk of complications in the form of a hypertensive crisis, myocardial infarction, an attack of angina pectoris. In addition, one should take into account the presence of diseases such as myocarditis, cardiomyopathy, myocardial dystrophy, cardiac arrhythmias and conduction disorders.

In heart diseases, it is necessary to clarify the relationship of cardiac symptoms with purulent diseases of the skin, internal organs, tooth extraction or other dental interventions, since infectious diseases of the cardiovascular system, especially undiagnosed ones, can be caused by these factors (Debeke H. et al., 1992) ...

Patients with connective tissue diseases, including rheumatic disease, often show signs of it in the oral cavity, maxillofacial region (salivary glands, temporomandibular joints). Systemic connective tissue diseases such as lupus erythematosus, scleroderma, vasculitis, occur with significant violations of immunological reactivity. This should be taken into account when preparing a patient for surgery.

In case of respiratory diseases, it is necessary to clarify the presence of recurrent inflammatory diseases, pulmonary insufficiency, bronchial asthma. These patients are often taking corticosteroids. It should be taken into account when assessing the general, local status and preparing for surgery, both the indicated diseases and the intake of hormonal drugs.

With kidney disease, you need to know what is the degree of acute or chronic failure. It should be borne in mind that in such patients, water-electrolyte and protein metabolism, as well as the function of the blood coagulation system, are disturbed, therefore, a laboratory examination of urine and blood is necessary before the operation.

When interviewing a patient about the state of the endocrine system and the presence of diseases of the hypothalamic-pituitary system, thyroid and parathyroid glands and adrenal glands, special attention should be paid to diabetes mellitus. Purulent processes in the maxillofacial region, boils and carbuncles of the face, including lesions of the lymph nodes and salivary glands, can be associated with this disease.

In women, especially at the age of 50 - 55 years, it is necessary to obtain information about the climacteric period, psychoemotional state. In addition, at this age, women can intensively develop osteoporosis of the bones, including the jaw.

When noticing diseases of the digestive system in a patient, one should bear in mind, on the one hand, diseases of an inflammatory nature, and on the other, allergic ones, often associated with lesions of the salivary glands. Patients with chronic diarrhea, fever, and weight loss should be screened for HIV infection.

Diseases of the blood system in patients should always alert the doctor when diagnosing both a dental disease and the risk of bleeding during surgery. It is necessary to find out if the patient suffers from diseases of the nervous system, organs of vision, ear, throat, nose, as well as other organs and skin. Diseases of the nervous system are often associated with pathology of the sensitive, motor and autonomic nervous apparatus of the face. In addition, the neurological pathology of the dentoalveolar system can be caused by diseases of the ears, paranasal sinuses, eyes, internal organs, musculoskeletal system, including the spine.

Skin diseases are often associated with disorders of the internal organs, endocrine and nervous systems. With them, the corresponding symptom complexes can appear in the oral cavity and maxillofacial region.

Often the cause of skin diseases is the irrational use of drugs. Skin diseases can be caused by occupational hazards, genetic factors. It is necessary to keep in mind their relationship with pathological manifestations in the oral cavity and maxillofacial region. The uniformity of pathological symptoms on the skin (including the face), in the oral cavity, the maxillofacial region should alert the doctor. In such cases, syphilis must be ruled out. In addition, pathological changes characteristic of infectious infectious diseases (measles, scarlet fever, diphtheria) can be observed on the skin, which can also affect the oral cavity and oropharynx.

When interviewing a patient about concomitant diseases, one should pay attention to the fact of an increase in lymph nodes, both regional and peripheral, the presence of chronic lung diseases. The latter is especially important at the present time in connection with the increase in the incidence of pulmonary tuberculosis. Patients with lymphadenopathy, fever need examination to exclude HIV infection, tuberculosis.

To assess the functional state of the body, data on immunity play a significant role.

Many diseases of the lungs, heart, digestive system, liver, skin, ear, throat, nose, eyes are of an allergic nature. An allergic history is important both for the diagnosis of a dental disease and for the development of general treatment tactics.

Allergic diseases always lead to impaired immunity, therefore, it is necessary to distinguish between pathology and atypia of the functioning of the immune system. When collecting anamnesis and analyzing data on past and concomitant diseases, hereditary diseases, the following pathology of the immune system should be noted:

1) infectious diseases;

2) allergic and autoimmune diseases;

3) leukoproliferative and neoplastic diseases;

4) congenital defects of the immune system;

5) atypical functioning of the immune system against the background of concomitant diseases, at different age periods, during stress, pregnancy.

The examination of the patient begins with a general examination.

Visual inspection

During an external examination, attention is paid to the general appearance of the patient, the presence of swelling, asymmetry, formations on the red border of the lips. So, with inflammatory processes of the maxillofacial region, tumors, trauma, the configuration of the face changes. It can also change with some endocrine diseases, in particular with myxedema (mucous edema), acromegaly. With hyperfunction of the thyroid gland (Graves' disease), there is a protrusion of the eyeball (exophthalmos), an increase in the thyroid gland (goiter). The configuration of the face can change due to swelling with nephritis, diseases of the cardiovascular system.

The color, swelling of the skin, as well as the presence of pigmentation and the condition of the hair and nails often help the doctor in choosing the correct way of differential diagnosis.

Skin color depends not only on the amount of hemoglobin in the blood, but also on the individually different translucency of the outer layers of the patient's skin. Therefore, in most cases, the degree of coloration of the visible mucous membranes serves as a better indicator of the degree of anemia than skin color. In addition to anemia, pallor of the skin is observed in kidney disease. The pallor of renal patients is caused not only by renal anemia, but also by swelling of the skin and especially poor blood supply to it. The skin is warm, in contrast to the pale, swollen and cold skin of patients with heart disease.

Cyanosis of the face, lips, mucous membranes should be divided into true and false. True cyanosis appears when there is a significant percentage of the restored hemoglobin in the blood.

on, as well as with prolonged use and in large doses of certain chemical medicinal substances (sulfonamides, phenacetin, antifibrin, nitrites, derivatives of aniline, basic bismuth nitrate, analgesics). True cyanosis as a symptom of polyglobulia is observed in congenital and acquired heart defects, in pulmonary insufficiency (pulmonary emphysema, bronchiectasis, etc.).

False cyanosis is observed when silver and gold derivatives are deposited in the skin and mucous membranes.

Skin and mucous membranes with a yellow coloration or tint are observed in liver diseases, hemolytic and pernicious anemias, chronic enterocolitis, protracted septic conditions, in cancer patients, etc.

Pigmentation of the skin and mucous membranes is facilitated by the hormone secreted by the pituitary gland, which stimulates melanophores, which is closely related to the production of ACTH.

Pigment mask or eyeglass hyperpigmentation occurs predominantly in women and is often familial. However, hyperpigmentation can be observed with cirrhosis of the liver, thyrotoxicosis. Pregnancy is often associated with skin pigmentation. Significant skin pigmentation is observed in some diseases: iron deficiency anemia, Addison's disease, hemochromatosis, lymphogranulomatosis, ovarian dysfunctions (after treatment with massive doses of hormones), vitamin deficiencies

IN 12, RR, etc.

Body temperature is noted: subfebrile (fluctuations within 37 - 38 ° C), febrile (from 38 to 39 ° C), pyretic (from 39 to 41 ° C), hyperpyretic (above 41 ° C). Taking into account complaints, anamnesis, individual characteristics of organs and body systems, concomitant diseases and the nature of surgical dental disease and temperature reaction, the patient's condition is determined (satisfactory, moderate, severe and extremely severe).

In a hospital setting, the examination is carried out taking into account all the rules adopted in clinical medicine. In the clinic, the physique of the patient should be assessed, the presence of defects and deformities of the body should be established, the pulse, blood pressure, and mental state should be determined.

If acute infection, syphilis, erysipelas, swelling, HIV infection and other diseases are suspected, the skin of the whole body is examined

(for the presence of rashes, hemorrhages). A doctor should always be alarmed by a pale skin color, as this may indicate intoxication or asthenic syndromes, blood diseases. Palpate the occipital, lateral cervical, subclavian, axillary lymph nodes, examine the pupillary reflex, Kernig's symptom, etc.

Examination of the maxillofacial area includes external examination, palpation, examination of the oral cavity, instrumental examination (probes, blunt and sharp needles, etc.). Clinical examination, if necessary, can be supplemented with scraping, puncture or biopsy, biochemical, microbiological, immunological studies, X-ray, tomography, etc.

Inspection the patient is held in a dental chair. His head should be well fixed on the headrest; you can raise and lower the chair, change the position of the back (straight, at an obtuse angle) and the headrest (the patient's head is thrown back or the chin is close to the chest). In a state of moderate and severe, the patient is examined in bed, on a table in a dressing room or in a dental chair brought to a horizontal position.

For the examination, a tray with sterile instruments is used: a spatula (for abducting the lips, cheeks and examining the vestibule of the mouth and the oral cavity itself, abducting the tongue and examining the sublingual region, tongue body, tonsils, pharynx) and dental or anatomical tweezers (to determine the mobility of the teeth and their percussion). During the examination, a dental mirror is used (for examining the teeth, the hyoid region, the palate), a dental probe, more often at an angle (for probing defects in the crown of teeth, gingival papillae, the gingival margin, the handle of the probe can also be used for percussion of the teeth), a thin Bauman probe, special salivary probes (for probing ducts, fistulous passages), a bulbous probe (for probing wounds, fistulas, perforation messages from the maxillary sinus, palate defects, etc.). It is better to examine the cavity of the nose, pharynx, external ear using a frontal reflector, nasal and ear mirrors.

External examination consists in determining the symmetry of the face: its relief due to the connection of the bones of the facial skeleton, the level of development of the subcutaneous fat layer, the state of the cartilaginous part of the nose, oral and eye fissures, auricles and cutaneous

cover. The normal face is more often symmetrical. It is important to determine the violation of its symmetry due to inflammatory, traumatic, tumor and other changes. In case of diseases and injuries of the maxillofacial region, attention should be paid to the nature of the violation of the proportions of the face and neck (edema, infiltration, tumor-like formation, deformation, etc.).

It is necessary to tilt, turn, throw the head back in order to determine the volume of its movement.

Palpation examination allows you to clarify the boundaries of pathological changes, the texture of tissues, the ability of the skin to fold, the presence of scars, fistulous passages. In the presence of swelling of the peri-maxillary soft tissues, its consistency, the adhesion of the skin with the underlying tissues, and its color are determined. If the blunt end of the instruments leaves a mark under pressure, this indicates an inflammatory edema. It can occur in various inflammatory diseases and trauma to the face and jaws.

If, on palpation, the peri-maxillary soft tissues are compacted, painful, the skin with the underlying tissues is soldered, it is difficult to fold or does not form it, the color is changed from intense pink to bright red or purple-blue, the temperature of the tissues is increased, then this indicates the presence of an infiltrate. All these signs can be observed with abscess, phlegmon, lymphadenitis and other inflammatory diseases of the peri-maxillary soft tissues. In this case, the boundaries of pathological changes should be noted, the areas of greatest pain and fluctuation, the adhesion of the affected tissues with the underlying bones of the facial skeleton, and the presence of fistulas should be determined.

The configuration of the face can be changed due to the displacement of the lower jaw posteriorly, to the side or retraction in the zygomatic region, lengthening of the midface, retraction of the nasal dorsum and other disorders caused by trauma. Pay attention also to bruises, abrasions, wounds, hematomas.

Comparative palpation examination of the bones of the facial skeleton is performed along the bony contours of the face and, mainly, at the junction of the bones, paying attention to atypical unevenness of the bone, pain on palpation.

With a fracture of the jaws, zygomatic bone, the function of opening the mouth is disturbed in the form of a restriction, displacement of the lower jaw to the side, etc.

tav: the head of the condylar process, its articulation with the glenoid cavity, determine the range of motion of the lower jaw when opening and closing the mouth, to the sides.

Palpation determines the sensitivity of the outlet of the peripheral branches of the trigeminal nerve (supraorbital, infraorbital and mental nerves). Various diseases and damage to the nerves of the face and jaws are accompanied by pain, sensory disturbances.

To determine tactile sensitivity, touch the investigated area of the skin with a gauze napkin, a piece of paper. Pain sensitivity is checked with a needle and compared with sensations on the opposite side - the skin or mucous membrane. Temperature sensitivity is tested by applying containers of cold water, ice, or hot water.

Check the sensitivity of the conjunctiva, cornea, nasal mucosa, lips, transitional folds of the vestibule of the mouth. By the strength of movement and tone of the masticatory muscles, the function of the motor branches of the trigeminal nerves is judged. Palpate the actual chewing, temporal muscles, the site of attachment of the internal pterygoid muscles at the inner surface of the mandible angle.

The movements of the facial muscles, the synchronization of their function on both sides of the face are noted. Focus on the formation of skin folds on the forehead, closing the eyelids and the symmetry of the eye slits, nasolabial folds, corners of the mouth. On palpation, pain may increase, an attack may develop. The examination can also reveal a violation of the sensitivity of the facial skin (anesthesia, paresthesia, hypesthesia, hyperesthesia).

If cancer is suspected, deep palpation is performed. Tumors and tumor-like diseases can have a different consistency - doughy, dense elastic, cartilaginous, etc., smooth or bumpy surface, clear or poorly defined boundaries.

They fix the adhesion of the skin with the underlying tissues, its color, using deep and bimanual palpation. In the case of pulsation of the formation, auscultation is performed, which makes it possible to differentiate vascular aneurysms and vascular tumors.

With cancer, symptoms such as pain, discharge from the nasal cavity, nasal congestion and impaired sensitivity of the lower alveolar nerve in the lower jaw should be alarming.

Palpation of regional lymph nodes is important: submandibular, submental, cervical, facial, etc. For palpation of the submandibular lymph nodes, the doctor tilts the patient's head down with his right hand, and with his left hand successively palpates them with three fingers, tilting the patient's head in the appropriate direction; the submental feels in the same position with the index finger, and the mastoid - with the second finger, moving them forward to the posterior edge of the lower jaw branch and posteriorly to the anterior edge of the sternocleidomastoid muscle. Facial lymph nodes (buccal, nasolabial, zygomatic, mandibular) are palpated bimanually - with the fingers of the right hand from the side of the oral cavity and the left - from the outside. The parotid lymph nodes are palpated in the projection of the surface of the branches of the lower jaw, in the posterior jaw region - in the thickness of the salivary gland and bimanually - along the anterior edge of the parotid salivary gland. Lateral cervical lymph nodes are palpated with 2 - 3 fingers anteriorly from the sternocleidomastoid muscle, from the mastoid process downwards - to the clavicle. Further, standing behind the patient, with three fingers (II, III, IV), placed on the clavicle, feel the supraclavicular lymph nodes.

An increase, soreness, limitation of the mobility of the lymph node or their package may indicate an acute inflammation of a bacterial, viral, protozoal or histoplasmoid nature. Increase, dense consistency, disintegration with the formation of "cold" abscesses are characteristic of chronic inflammation and can be with actinomycosis, tuberculosis, syphilis, leprosy, sarcoidosis. Density, immobility, adhesion with the underlying tissues should be alerted to the presence of a malignant neoplasm. Generalized enlargement of lymph nodes, accompanied by general symptoms - fever, diarrhea, weight loss, should raise suspicion of HIV infection.

When deforming the face, it is necessary to note its localization (jaw, lips, nose, peri-maxillary soft tissues) and determine the nature of the changes (increase, decrease, shortening, curvature). Mathematical analysis allows you to obtain objective data on the depth and extent of deformation.

Examination of the oral cavity consists in determining the degree of opening of the mouth, examining the vestibule of the mouth, the oral cavity itself, and the pharynx.

The degree of opening of the mouth is noted (normally it should be 5 cm, or three diameters of II, III, IV fingers inserted between the central incisors), whether the opening is free and painless, whether there is a crunch in the joint, what is the displacement of the lower jaw to the side. Inflammatory processes involving the masticatory muscles make opening the mouth difficult and painful. In such cases, the degree of jaw reduction should be noted (inflammatory contracture of the masticatory muscles of I, II and III degrees).

Restrictions on opening the mouth in combination with soreness, crunching in the temporomandibular joint, its jerky movements, and lateral displacement of the lower jaw is observed when the temporomandibular joint is affected.

Restricted opening of the mouth associated with cicatricial changes in the masticatory muscles occur after pathological processes, more often of an infectious nature, trauma, operations, systemic diseases of the connective tissue. Palpation of the heads of the condylar processes through the external auditory canal determines their mobility and the degree of rocking and lateral movements. This makes it possible to differentiate cicatricial contractures from restrictions on opening the mouth and converging the jaw in case of damage to the temporomandibular joint.

Contraction of the jaw also occurs during a tumor process as a result of the germination of a neoplasm, often malignant, from the jaws, oropharyngeal mucosa into the masticatory muscles.

Oral examination

Start with inspection vestibule with closed jaws and relaxed lips, lifting the upper lip and lowering the lower lip or pulling the cheek with a dental mirror. First of all, the red border of the lips and the corners of the mouth are examined. Pay attention to the color, the formation of scales, crusts. On the inner surface of the lip, as a rule, a slight bumpy surface is determined, due to the localization of small salivary glands in the mucous layer. In addition, you can see the pinpoint holes - the excretory ducts of these glands. At these holes, when the mouth is fixed in the open position, an accumulation of secretion droplets can be observed.

Then using the mirror inspect the inner surface of the cheeks. Pay attention to its color, moisture content. Sebaceous glands (Fordyce's glands) are located along the line of closing of the teeth in the posterior part, which should not be mistaken for pathology. It's pale

yellow nodules with a diameter of 1 - 2 mm, sometimes visible only when the mucous membrane is pulled. At the level of the upper second large molars (molars) there are papillae on which the excretory ducts of the parotid salivary glands open. They are sometimes mistaken for signs of disease. There may be teeth imprints on the mucous membrane.

Following the examination of the oral cavity, examination of the gums. Normally, it is pale pink, tightly covering the neck of the tooth. The gingival papillae are pale pink, occupying the interdental spaces. A groove is formed at the site of the periodontal junction (previously it was called the periodontal pocket). Due to the development of the pathological process, the gum epithelium begins to grow along the root, forming a clinical, or periodontal, periodontal pocket. The condition of the pockets formed, their depth, the presence of tartar are determined using an angular button-like probe or a probe with notches applied every 2 - 3 mm. Examination of the gums allows you to determine the type of inflammation (catarrhal, ulcerative necrotic, hyperplastic), the nature of the course (acute, chronic, in the acute stage), prevalence (localized, generalized), severity (mild, moderate, severe gingivitis or periodontitis) of inflammation. There may be an increase in the size of the papillae due to their edema, when a significant part of the tooth is covered.

Then proceed to the study of the actual oral cavity. First of all, a general examination is performed, paying attention to the color and moisture content of the mucous membrane. Normally, it is pale pink, but it can become hyperemic, edematous, and sometimes acquires a whitish tint, which indicates the phenomenon of para or hyperkeratosis.

Language inspection begin with determining the condition of the papillae, especially if there are complaints of changes in sensitivity or burning and soreness in any areas. There may be a lining of the tongue due to a slowdown in the rejection of the outer layers of the epithelium. This phenomenon may be the result of a violation of the gastrointestinal tract, and possibly pathological changes in the oral cavity with candidiasis. Sometimes there is an increased desquamation of the papillae of the tongue in some area (more often at the tip and lateral surface). This condition may not bother the patient, but pain from irritants, especially chemical ones, may occur. With atrophy of the papillae of the tongue, its surface becomes smooth,

as if polished, and as a result of hyposalivation, it acquires stickiness. Individual areas, and sometimes the entire mucous membrane, can be bright red or crimson. This state of the tongue is observed in malignant anemia and is called Gunther's glossitis (after the name of the author who described it for the first time). Hypertrophy of the papillae may also be noted, which, as a rule, does not cause concern to the patient. Hypertrophy of the papillae of the tongue is often combined with hyperacid gastritis.

When examining the tongue, it should be remembered that at the root of the tongue on the right and left there is a pink or bluish-pink lymphoid tissue. Often this formation is sick, and sometimes even doctors take it for pathological. In the same place, a pattern of veins is sometimes clearly visible due to their varicose expansion, but this symptom has no clinical significance.

Examination of the mucous membrane of the floor of the mouth. A feature of the mucous membrane here is its pliability, the presence of folds, frenulum of the tongue and excretory ducts of the salivary glands, and sometimes droplets of accumulated secretions. In smokers, the mucous membrane may become dull.

The importance of identifying these signs is that sometimes they serve as the basis for active intervention, since foci of hyperkeratosis of the oral mucosa are considered precancerous conditions.

If any changes are detected on the oral mucosa (ulcer, erosion, hyperkeratosis, etc.), it is necessary to exclude or sub-

reiterate the possibility of a traumatic factor. This is necessary for diagnosis and treatment.

Palpation examines the alveolar process of the upper jaw from the vestibular, lingual and palatal sides, the color of the mucous membrane above these areas. When a fistulous passage is detected, pus is released from it, granulation swelling, a probe is used to examine the course, clarify its connection with the jaw bone, the presence of usuria in the bone and further (to the tooth or teeth). Palpating the arch of the vestibule of the mouth, mark the cord along the transitional fold. Such symptoms are characteristic of chronic granulating periodontitis. With this process, there may be a bulging of the bone. However, bone swelling can be observed with a radicular cyst, tumor-like and tumor lesions of the jaw.

If palpation in the area of the vestibular fornix of the vestibule of the mouth or on the lower jaw on the lingual side shows a swelling in the form of a painful infiltrate or in the palate in the form of a rounded infiltrate, one can assume the presence of acute periostitis. Periosteal inflammatory tissue infiltration along the surface of the alveolar processes from the vestibular, lingual and palatal sides, painful percussion of several teeth, suppuration from gingival pockets, fistulas characterize acute, subacute osteomyelitis of the jaw. In the lower jaw at the level of molars and premolars, this may be accompanied by a violation of the sensitivity of the tissues innervated by the lower alveolar and chin nerves (Vincent's symptom). Periosteal dense thickening of the jaw, fistulas on the skin of the face and in the oral cavity are typical for chronic forms of odontogenic osteomyelitis, as well as specific inflammatory lesions. At the same time, with the mobility of the teeth accompanying such clinical symptoms, it is necessary to show oncological vigilance.

The focus of inflammatory changes in the peri-maxillary soft tissues requires clarification of the localization and boundaries of the infiltrate from the side of the mouth. Bimanual palpation is usually used. They reveal a violation of the function of opening the mouth, swallowing, breathing, speech impairment. Particular attention is paid to the root of the tongue, the sublingual, pterygo-mandibular and periopharyngeal spaces.

When massaging the salivary glands, one should pay attention to possible characteristic changes: thick saliva consistency, cloudy color, the presence of flakes, clots, salivary blood clots in it.

In diseases of the salivary glands, probing of the ducts is carried out, which makes it possible to establish their direction, the presence of stenosis, stricture or its complete obliteration, calculus in the duct.

Examination of teeth

When examining the oral cavity, it is necessary to examine all the teeth, and not only the one that, in the patient's opinion, is the cause of pain or discomfort. Violation of this rule can lead to the fact that the cause of the patient's anxiety at the first visit may not be found, because, as mentioned earlier, the pain can radiate. In addition, an examination of all teeth at the first visit is also necessary in order to outline a treatment plan, which ends with a sanitation of the oral cavity.

It is important that during the examination all changes in the tooth tissues are detected. For this purpose, it is recommended to develop a specific inspection system. For example, the examination should always be done from right to left, starting with the teeth of the upper jaw (molars), and then from left to right, the teeth of the lower jaw should be examined.

Examination of the teeth is performed using a set of instruments; the most often used is a dental mirror and probe (always sharp). The mirror allows you to inspect poorly accessible areas and direct a beam of light to the desired area, and the probe is used to check all depressions, pigmented areas, etc. If the integrity of the enamel is not violated, then the probe glides freely over the surface of the tooth, without lingering in the depressions and folds of the enamel. In the presence of a carious cavity in a tooth (invisible to the eye), a sharp probe lingers in it. Especially carefully you should inspect the contact surfaces of the teeth (contact), since it is not easy to find an existing cavity with an intact chewing surface, while probing can detect such a cavity. Currently, the technique of transillumination of tooth tissues is used by supplying light through special light guides. Probing helps to determine the presence of softened dentin, the depth of the carious cavity, communication with the tooth cavity, the location of the canal orifices, and the presence of pulp in them.

Tooth color can make a difference in the diagnosis. Teeth are usually white with many shades (from yellow to bluish). However, regardless of the shade, the enamel of healthy teeth is characterized by a special transparency - "live enamel shine". In a number of conditions, the enamel loses its characteristic shine, becomes dull.

So, the beginning of the carious process is a change in the color of the enamel, the appearance of cloudiness at first, and then a white carious spot. Pulped teeth lose their usual enamel shine, they acquire a grayish tint. A similar discoloration, and sometimes more intense, is observed in teeth in which pulp necrosis has occurred. After necrosis of the pulp, the color of the tooth can change dramatically.

The color of the tooth can also change under the influence of external factors: smoking (dark brown color), metal fillings (staining the tooth in a dark color), chemical treatment of canals (orange color after the resorcinol-formalin method).

Pay attention to shape and the size of the teeth. Deviation from normal shape is due to treatment or abnormality. It is known that some forms of dental anomalies (Hutchinson's, Fournier's teeth) are characteristic of certain diseases.

Percussion- tapping on the tooth - used to determine the state of the periodontium.

With tweezers or the handle of the probe, tap on the incisal edge or chewing surface of the tooth. If there is no focus of inflammation in the periodontium, percussion is painless. In the presence of an inflammatory process in the periodontium, a painful sensation arises from blows that do not cause discomfort in healthy teeth. When performing percussion, the beats should be light and even. Percussion should be started with obviously healthy teeth, so as not to cause severe pain and to allow the patient to compare the sensation in a healthy and affected tooth.

Distinguish between vertical percussion, when the direction of the blows coincides with the axis of the tooth, and horizontal, when the blows have a lateral direction.

Teeth mobility determined with tweezers by swinging. The tooth has physiological mobility, which is normally almost invisible. However, with damage to the periodontium and the presence of exudate, pronounced tooth mobility arises in it.

There are three degrees of mobility: I degree - displacement in the vestibular-oral direction; II degree - displacement in the vestibular-oral and lateral directions; III degree - displacement and along the axis of the tooth (in the vertical direction).

Examination of the teeth is carried out regardless of the patient's specific complaints and their condition is recorded from right to left, first on the upper, then on the lower jaw. Use a mirror and a sharp probe to

allows you to establish the integrity of the enamel or detect a cavity, mark its depth and dimensions, as well as communication with the tooth cavity. Attention should be paid to the color of the teeth. A grayish and cloudy color of the tooth enamel may indicate pulp necrosis. The shape and size of the teeth are also important, including dental anomalies: the teeth of Hutchinson, Fournier, which may indicate common diseases and hereditary signs of pathology.

Examining the teeth, they are percussed, mobility is determined with tweezers, the presence of supernumerary or milk teeth in a permanent bite is noted, the eruption of the lower wisdom teeth, and the nature of teeth closing is determined. Examine the gingival tubercles, determine the state of the periodontium. The instrument is tapped on the cutting or chewing surface of the tooth (vertical percussion) and on the vestibular surface of the tooth (horizontal percussion). If pain is noted during percussion, this indicates the presence of a peri-apical or marginal focus in the periodontium. They also perform palpation of the teeth - feeling, which makes it possible to establish their mobility and soreness. Grasping the crown of the tooth with dental tweezers, mark the degrees of mobility - I, II and III. Using a dental probe, gingival pockets, their depth, bleeding during probing, discharge from the pockets and their character are determined.

With the mobility of the teeth, it is necessary to clarify whether there is a localized process or diffuse lesion of the periodontium, and also to show oncological alertness. Pathological mobility of a number of teeth, combined with painful percussion, can be one of the symptoms of osteomyelitis of the jaw.

An assessment of the hygiene condition of the oral cavity is mandatory. If urgent surgical operations are required, simple hygienic procedures are performed to reduce the amount of dental plaque. During planned operations, the whole complex of medical procedures is carried out and the hygienic state is assessed according to the Green-Vermillion or Fedorov-Volodkina index, and only with a high hygiene index, the surgical intervention is performed.

The results of the examination of the teeth are recorded in a special scheme (dental formula), where milk teeth are designated by Roman numerals, permanent ones - by Arabic numerals. Currently, it is customary to designate the tooth number according to the international classification.

Clinical examination of the patient should include a number of diagnostic methods and studies. Their type and volume depend on

the nature of the disease or injury to the maxillofacial region and on the conditions of the examination (in the clinic or hospital), as well as on the level of equipment of the medical institution.

X-ray examinations are important for the diagnosis of pathology of the teeth, jaws and other bones of the face and cranial vault, maxillary and frontal sinuses, temporomandibular joints, glands of the oral cavity. Contact intraoral radiography of the teeth, alveolar and palatine processes, the floor of the oral cavity is performed, which makes it possible to clarify the localization and nature of changes in the periodontium, bone, to note the presence of calculus. There are 4 methods of intraoral radiography: radiography of periapical tissues according to the rule of isometric projection; interproximal; bite or occlusal shooting; radiography from an increased focal length with a parallel beam of rays.

Isometric surveys are used to assess the periapical tissues, but they give distortions in magnitude, which can lead to hyper or underdiagnosis. Interproximal radiographs show teeth, periapical tissues, margins of both jaws. Occlusal radiography allows you to take a snapshot of the alveolar process. Most often, this projection gives an idea of the cortical plate of the alveolar process from the vestibular and lingual sides, including the thickness of the periosteum. In another plane, one can judge more accurately about the pathology: cysts, impacted teeth, jaw fracture lines, the presence of a foreign body (calculus) in the submandibular and sublingual salivary glands. Occlusal images are taken in addition to the previous ones.

Long-focus radiography is performed on devices with a more powerful X-ray tube and a long cone localizer. The method is used primarily to display the marginal sections of the alveolar processes, the structure of bone tissue, the shape of the roots and the presence of destructive changes around them.

X-ray examination of teeth, jaws and other bones of the facial skeleton is of fundamental importance for judging the presence of carious dental cavities, the shape of the roots, the degree of filling them with a filling mass, the state of the periodontium, bone, etc.

Tooth enamel gives a denser shade, while dentin and cementum gives a less dense enamel. The cavity of the tooth is recognized by the outline of the contour of the alveoli and the cement of the root - it is determined by the projection of the root of the tooth and the compact plate of the alveoli, which looks like a uniform darker strip 0.2 - 0.25 mm wide.

Bone structure is clearly visible on well-taken radiographs. The bone pattern is due to the presence of bone trabeculae in the cancellous substance and in the cortical layer, or trabeculae, between which the bone marrow is located. The bone beams of the upper jaw have a vertical direction, which corresponds to the force load exerted on it. The maxillary sinus, nasal passages, orbit, and frontal sinus appear as clearly defined cavities. Filling materials due to different density on the film have unequal contrast. So, phosphate cement gives a good image, and silicate cement gives a bad image. Plastic, composite filling materials poorly retain X-rays, and, therefore, a fuzzy image is obtained in the picture.

Radiography allows you to determine the condition of the hard tissues of the teeth (hidden carious cavities on the contact surfaces of the teeth, under the artificial crown), impacted teeth (their position and relationship with the tissues of the jaw, the degree of formation of roots and canals), erupted teeth (fracture, perforation, narrowing, curvature, degree of formation and resorption), foreign bodies in the root canals (pins, broken off burs, needles). On the radiograph, you can also assess the degree of patency of the canal (a needle is inserted into the canal and an x-ray is taken), the degree of filling of the canals and the correctness of the filling, the state of the periapical tissues (expansion of the periodontal gap, rarefaction of bone tissue), the degree of atrophy of the bone tissue of the interdental septa, the correct manufacture of artificial crowns (metal), the presence of neoplasms, sequesters, the state of the temporomandibular joint.

The x-ray can be used to measure the length of the root canal. To do this, an instrument is inserted into the root canal with a limiter set at the estimated length of the canal. An x-ray is then taken. The length of the tooth canal is calculated by the formula:

where i is the actual length of the tool; K 1 - radiologically determined length of the canal; i 1 - radiologically determined length of the instrument.

It is effective to use images on a radiovisiograph during resection of the apex of the tooth root, extraction of teeth (especially impacted ones), and implantation. Radiovisiography gives an image of residual roots, foreign bodies, the position of the implant in relation to the adjacent teeth, the bottom of the maxillary sinus, the nose, the canal of the lower jaw, and the chin foramen. New generations of visiographs provide volumetric, color, and digital data, which make it possible to more accurately judge the amount and structure of the bone, the effect of surgical interventions. Extraoral radiography is used to study the upper and lower jaws, zygomatic, frontal, nasal, temporal and other bones of the skull, maxillary and frontal sinuses, temporomandibular joints. The following projections are used for radiography: direct, lateral, semi-axial, axial, as well as oblique contact and tangential.

Orthopantomography is a promising method of X-ray examination, which allows you to obtain an overview of the teeth and jaws.

Panoramic radiographs have a definite advantage over intraoral images, since with minimal radiation exposure they give an overview of the jaw, teeth, periapical tissues and adjacent sinuses. However, on panoramic radiographs, distortions of the structure of the roots of the teeth, the structure of the bone, the location of individual anatomical formations are possible; the central teeth and the surrounding bone tissue are poorly formed. Side panoramic shots produce less distortion.

Orthopantomography is most effective for the primary diagnosis of inflammation, trauma, tumor, deformity.

When diagnosing pathological processes in the jaws and nasal cavities, orthopantomography, orthopantomography is supplemented with longitudinal tomography and zonography, using direct, lateral, posterior and anterior axial projections. To reduce the radiation exposure, zonograms are also produced with small angles of tube rotation, giving a layer-by-layer image of thicker sections.

In diagnostics, electro-roentgenography is also used, which is very effective for emergency information. However, with this method, the patient receives a large radiation dose.

For diseases and injuries of the salivary glands, bronchiogenic fistulas, chronic osteomyelitis of the jaws, contrast radiography is used using iodolipol and water-soluble

contrast agents. With sialography of the parotid gland, the norm of the contrast agent is 2.0 - 2.5 ml, for the submandibular salivary gland - 1.0 - 1.5 ml. In pathological processes, these numbers can be corrected in the direction of decrease (calculous sialadenitis, interstitial sialadenitis) or increase (parenchymal sialadenitis). With sialography, intraoral zonography is used - direct and lateral and orthopantomography. Sialography allows you to assess the condition of the ducts of the gland, to determine the presence of a salivary stone. The method can be supplemented with pneumosubmandibulography, digital subtraction sialography, radiometry, scintigraphy.

Contrast radiography is also used for chronic osteomyelitis, face and neck fistulas, including congenital (fistulography), jaw cysts, and diseases of the maxillary sinus.

For diseases of the temporomandibular joints, arthrography is used. After intra-articular injection of a contrast agent, tomo or zonograms are obtained at different positions of the condylar process.

Radiography with contrasting arterial and venous vessels of the maxillofacial region is most effective in vascular neoplasms. In some cases, the tumor is punctured, a contrast agent is injected, and radiographs are performed in frontal and lateral projections. In other cases, especially with cavernous hemangioma, the carrying vessel is surgically isolated, and then a contrast agent is injected and a series of radiographs is performed in different projections. Angiography requires special conditions and should be carried out in a hospital, an X-ray operating room, where anesthesia, surgical isolation of the leading tumor vessel, and an approach to the femoral, subclavian, and external carotid arteries are performed. Choose water-soluble contrast agents (verografin, urografin, cardiografin, cardiotrast). More often, serial angiography through the external carotid artery is used to diagnose vascular tumors.

Less commonly, lymphography is used - direct for the diagnosis of lymph nodes, blood vessels.

X-ray computed tomography (RCT) is a promising tool for diagnosing diseases of the maxillofacial region, which makes it possible to obtain two- and three-dimensional layered images.

heads. Thanks to the layered image, RCT determines the true size and boundaries of the defect or deformation, the localization of the inflammatory or tumor process. The high resolution of RKT makes it possible to differentiate pathological processes in bone and soft tissues. This method is very important for trauma and intracranial changes. Establishing the dislocation of brain structures, the localization of brain trauma, the presence of hematomas, hemorrhages helps diagnostics, allows planning interventions and their sequence in the maxillofacial region, the cerebral section of the skull and the brain.

In the diagnosis of pathological processes in the maxillofacial region, magnetic resonance imaging (MRI) is also used. It has a particular advantage as it is not associated with ionizing radiation. MRI detects changes in soft tissues: edema, infiltration, accumulation of exudate, pus, blood, tumor growth, including malignant neoplasms, the presence of metastases.

The combined use of X-ray computed and magnetic resonance imaging makes it possible to obtain a three-dimensional image of the soft and bone tissues of the face and, on the basis of spatial layered anatomical and topographic data, to create graphic computer models. This determines an accurate diagnosis, allows you to plan the proper amount of intervention. X-ray and MRI data also determine the possibility of intraoperative spatial orientation in the maxillofacial region. Especially important is the ability to create three-dimensional graphic images based on these methods for restorative operations in the maxillofacial region.

Electroodontodiagnostics

The use of electric current is based on the well-known fact that any living tissue is characterized by excitability, or the ability to come into a state of excitement under the influence of a stimulus. The minimum force of irritation that causes excitement is called the threshold. It was found that in the presence of a pathological process in the pulp, its excitability changes.

The use of electric current for the purpose of diagnostics is most widespread, since its strength and duration are easily dosed, and it can be used repeatedly without the risk of causing damage.

When conducting this study, usually not limited to one threshold irritation. Having received a positive answer, the current is reduced and the excitability threshold is checked again. To avoid errors associated with electric leakage, the doctor should wear rubber gloves and use a plastic spatula instead of a mirror.

Indicators of the threshold excitation of the pulp in normal and pathological conditions have been established. Healthy teeth react to currents of 2 - 6 μA. In the initial stages of caries, the sensitivity of the tooth does not change. However, even with average caries, and especially with deep, the excitability of the pulp may decrease, which indicates morphological changes in it. A decrease in electroexcitability to 20 -40 μA indicates the presence of an inflammatory process in the pulp. It should be remembered that the electroexcitability index does not characterize the extent of the process. It is possible to speak about the limitedness of the inflammatory process if the excitability is lowered from one mound, and from the rest it is not changed. If the process involves the entire coronal pulp, then excitability will be reduced from all the cusps of the crown.

The pulp response to a current of 60 μA indicates coronal pulp necrosis. If necrosis of the root pulp occurs, the tooth reacts to a current of 100 μA and higher. Normal periodontium is sensitive to currents of 100-200 µA. With pronounced morphological changes in the periodontium, the tooth reacts to currents of more than 200 μA.

Laboratory research in case of diagnostic necessity, it includes a large number of different methods carried out both in a polyclinic and in a hospital. In a polyclinic, their use is limited. As a rule, general blood and urine tests are performed, determination of glucose content in them, cytological and morphological studies. In basic dental and general clinics, they can also additionally conduct bacteriological, immunological, biochemical and other studies. Before the operation in the polyclinic, the doctor must send the patient for blood tests for RW, HIV infection, the presence of hepatitis A, B, C viruses, and, if necessary, other tests of blood, urine, and feces. Before operations in the hospital, in addition to the listed methods, laboratory tests are necessarily carried out: they determine the blood group and Rh factor, glucose in the blood and urine, indicators of coagulation

blood systems, biochemical blood test, prothrombin index; produce ECG, fluorography; examine a smear from the pharynx for diphtheria or receive a document confirming the vaccination. The conclusion of a therapist about the possibility of an operation is required. Some patients may need to study feces for the presence of intestinal flora. In case of a disease against the background of immunity disorders, the immune status is determined (by the immunogram or the results of immune reactions with monoclonal antibodies). In addition, a variety of functional studies are used (rheography, capillarography, electromyography, Doppler sonography). By the method of biomicroscopy, microcirculation in the mucous membrane of the mouth, in the skin of the face is determined, and the blood flow rate in the capillaries is visually measured, the number and type of vessels is established.

Rheography graphically shows the pulse fluctuations in the electrical resistance of the mucous membrane covering the alveolar processes, including the periodontal tissue.

Photoplethysmography allows you to determine local blood flow based on pulse changes in tissue optical density.

Polarography measures the level of tissue oxygenation.

Laser Doppler flowmetry allows you to study the fine mechanisms of the microvasculature of both the outer skin of the face and the mucous membrane of the mouth. The technique helps to assess the vascular system in trauma, after recovery operations, to monitor the effectiveness of drug therapy.

Electromyography provides information on the function of muscles, mainly of the chewing muscles, and is necessary for trauma, reconstructive operations.

In the hospital, during examination and treatment, if there are indications, diagnostic tests can be expanded.

For long-term non-healing ulcers, painless infiltrates, palatal defects, dental anomalies and other disorders, an examination is carried out for tuberculosis, syphilis (serodiagnosis), deep mycosis, and HIV infection.

Important to confirm the nature of the disease are cytological studies: taking smears, prints, scraping, punctate, flushing.

A more reliable answer is obtained when taking the material by the method biopsies- excision of a piece of tissue, which is fixed in

10% solution of neutral formalin and sent to the pathomorphological laboratory with a special accompanying form. Often, in order to clarify the diagnosis in the process of surgery, an emergency biopsy (express biopsy) is performed.

In the conditions of both a hospital and a polyclinic, it is often necessary to conduct microbiological studies. Sowing purulent exudate under aerobic and anaerobic conditions, isolating the main pathogen, determining its properties, obtaining antibioticograms are important for the diagnosis and treatment of inflammatory diseases.

In diseases of the salivary glands, their secretory-excretory function is examined, a qualitative and cytological analysis of saliva is carried out. The results of radio sialography, scanning of the salivary glands, scintigraphy, echosialography, thermovisiography are of great diagnostic importance.

Substantiation of the diagnosis. Based on a comprehensive analysis of complaints, anamnesis of illness and life, an assessment of the functional state of the body and concomitant diseases, a comprehensive study of local symptoms, as well as the results of diagnostic studies, the doctor presents a general picture of the disease. Evaluating subjective and objective symptoms, he analyzes the obvious and latent nonspecific and specific signs of the disease and their pathognomonicity. It should be noted that traditional methods of patient examination are often insufficient. Modern technical improvement of instrumental diagnostics expands the possibilities of disease recognition.

Diagnostics as a scientific discipline is based on methodological principles that allow the use of modern classification schemes developed in accordance with the International Classification of Dental Diseases.

In the course of the diagnostic process (analysis and synthesis of the obtained facts), the specialist must build a logical and didactic scheme, according to which he justifies the diagnosis, draws up a treatment and rehabilitation plan, and also determines the ways of prevention.

A single analytical and thought process on the basis of all the patient's examination data should serve as the basis for establishing a clinical diagnosis: in the first 1-2 days - in the clinic, 1-3 days - in the hospital, in urgent patients - in the first hours of contacting the clinic or admission to hospital. In more complex cases, but not life-threatening to the patient, after the completion of the examination, a final diagnosis is made.

The results of the listed examination methods are entered into the medical history, which is an important legal document, including for forensic medical examination.

Dental Patient Medical Record

Dental Patient Medical Record - Record Form? 043 / U - a document in which passport data, the results of the examination and treatment carried out are registered. By recording, you can judge the effectiveness and correctness of the treatment.

The first section of the medical record is the passport part. This section is filled in at the registry and during the initial visit of the patient to the clinic. All subsequent sections are completed by a doctor.

Column "Diagnosis" is filled in by the attending physician as the final diagnosis after taking anamnesis, examination and, if necessary, additional research methods.

In some cases, the diagnosis can be clarified or even changed, but the date must be indicated. However, in all cases, the diagnosis must be indicated in accordance with existing classifications.

In the column "Development of the present disease" it is necessary to indicate the appearance of the first signs of the disease, the nature of the course, treatment and its effectiveness. The card should include the results of laboratory and other research methods.

A special section of the map is devoted to the preparation of a treatment plan. It is important to do this at the first visit to the patient, which allows for a complete and complex treatment. The presence of a treatment plan is also necessary because the patient, for whatever reason, can get to another doctor.

In the "Diary" section, a short but clear entry is made about the patient's condition and the result of the treatment being carried out.

A medical record as a legal and scientific document is kept in the registry for 5 years and then handed over to the archive.

For the convenience of recording the result of the examination of the teeth, special schemes (dental formula) are used. There are several such schemes. In our country, a diagram is used in which the horizontal line indicates the teeth belong to the upper or lower jaw, and the vertical one indicates the teeth belong to the right or left side. At the same time, it is customary to denote permanent teeth with Arabic numerals:

According to this scheme, the number 1 corresponds to the central incisors, 2 to the lateral incisors, 3 to the canines, 4 to the first small molars (premolars), 5 to the second small molars, 6 to the first large molars (molars), 7 to the second and 8 - the third large molars.

To designate the belonging of a tooth or jaw, the following designations are used:

There are other ways to indicate the formula of teeth. Widespread use has received the designation when the number of the square, which is placed in front of the number of the tooth, is added to the serial number of the jaw tooth from 1 to 8;

With this designation, it is enough to name two numbers to accurately determine the tooth in the arch: 21 - the central incisor of the upper jaw on the left; 44 - the first small molar (premolar) of the lower jaw on the right.

To determine the condition of the tooth, letter designations are used: caries - C, pulpitis - P, periodontitis - Pt, filling - P, a tooth covered with a crown - K, an artificial tooth of a fixed prosthesis - N. Presence of tartar, hypoplasia, fluorosis and other pathological changes marked in the columns below the formula of the teeth. The degree of tooth mobility is indicated by Roman numerals above or below its digital index. In some cases, it becomes necessary to accurately identify the localization of the filling or carious cavity on the tooth surface. For this, the formula of the teeth with the designation of surfaces is applied. Schematically, it looks like the incisors and canines have 4 surfaces, and the small and large molars have 5 surfaces.

In this case, the sequence of the designation of the surfaces must be agreed. For incisors and canines, the labial surface is designated 1, the middle - 2, the lingual - 3, the lateral - 4. On small (premolars) and large molars (molars), counting starts from the chewing surface - 1, then the buccal surface - 2, the front - 3 , lingual - 4, back - 5.

The medical record must indicate the date of admission, the patient's condition, all measures and appointments should be noted.

The card must be filled out immediately after the patient is admitted, and the record must be kept without abbreviations.

When examining a patient, it is also necessary to adhere to deontological principles.

Deontology is a combination of scientific and practical knowledge that ensures successful relationships between people. In medicine, these are the norms of professional duty, the behavior of all medical workers, their relationship with each other and with patients. The goal of deontology is to build patient confidence in the medical staff, which is the key to successful treatment. This goal is provided by the following components: ethical - the patient's conviction in the conscientiousness of the medical staff; business - high qualifications of a doctor, striving for professional growth; psychological - an attitude with understanding, with sympathy. In addition, the appearance of the medical staff, communication skills, the ability to ask questions and listen to the patient matter.

Every doctor should respect his colleagues, not undermine their authority.

The behavior of doctors is incorrect when, after examining the patient in his presence, the previously made diagnosis and treatment are rejected. A doctor should not present his predecessor, who was the first to start treatment, as an ignoramus, who does not understand anything in medicine, but should make the necessary changes, correct mistakes in the most correct form. Wanting to show his erudition, knowledge and great awareness in front of other doctors, he does not think about the patient at all. The patient loses faith in his doctor, which affects his health. This causes the patient to develop iatrogenic diseases, which are very difficult.

Termiatrogeny comes from Greek: iatros- doctor, genes- generated, i.e. caused by a doctor. This is the original meaning of the word. There are various interpretations, definitions of iatrogeny, which have significantly transformed in recent years.

Iatrogenic diseases are called diseases that arise as a result (due to) of a careless word or action of a doctor (health worker), an adverse effect on the patient's psyche (Encyclopedic Dictionary of Medical Terms, 1982). Anglo-American dictionary sources include in the definition of iatrogeny not only mental, but also somatic disorders, introducing

the concept of intent, and determine the stage of the doctor's activity.

The patient can become an unintentional "accomplice" of iatrogenic situations.

I. At the diagnostic stage, this can happen due to:

1) inability or unwillingness to assess their condition;

2) deliberately false presentation of symptoms;

3) concealment of data on existing diseases.

II. At the decision-making stage, this is due to:

1) refusal to consult, additional research methods;

2) "imposing" his own opinion on the doctor;

3) search for the "best doctor".

III. At the stage of treatment - due to:

1) self-medication, fuzzy fulfillment of appointments;

2) refusal of treatment.

In view of the exceptional importance of the section, we present the schemes and algorithm of survey methods.

Diagrams 5.1 and 5.2 show the methods of examination of the patient and the algorithm for their implementation.

Diagram 5.1

Scheme 5.2

DOCTOR'S ACTIONS WHEN EXAMINING A DENTAL PATIENT

Table continuation

The data obtained during the examination are entered into the medical record of the dental patient - registration form? 043 / U - a document of legal significance. In addition to the results of the examination, the diagnosis, the treatment plan, the treatment carried out, the recommendations for the patient on dental rehabilitation and prevention are recorded in the card. A medical record is a legal document that a doctor is responsible for maintaining. The history of an outpatient dental patient makes it possible to ensure the continuity of treatment, since the diagnosis, treatment is clearly recorded in it, and the effectiveness is noted. All actions must be dated.

Examination of the oral cavity.

Condition of teeth. Legend: absent - O, root - R, caries - C, pulpitis - P, periodontitis Pt filled - P, mobility - I, II, III (degree), crown - K, claim. tooth - And

At 6 | the tooth on the anterior surface - a carious cavity of medium depth within the middle layers of dentin, the dentin is pigmented, dense. Probing is painful along the enamel-dentinal junction, percussion is painless, reaction to thermal (cold) stimuli is painful, short-term (disappears after removal of the stimulus) Orthognathic bite

The condition of the oral mucosa, gums, alveolar processes and palate: gingival mucosa in the area 6 | the tooth is bright red, edematous, bleeds easily. Periodontal pocket 3 mm.

DATA OF X-RAY, LABORATORY STUDIES On the radiograph in the area 6 | There are no pathological changes in the periapical tissues of the tooth. Apex of the compact interdental septum plate between 6 | and 5 | teeth missing. Resorption of the interdental septum of the 1st degree is projected.

Examination of the oral cavity organs at all stages of orthopedic treatment plays an important role due to the fact that medical tactics mainly depend on the local manifestations of the disease.

The doctor is already prepared for such an examination. He listened to the complaints and the story of the patient, has data from an external examination, he mentally put forward a number of assumptions - "working hypotheses". However, the doctor should not narrow the examination technique and focus only on confirming assumptions or looking for evidence of the validity or groundlessness of the patient's complaints.

It must be remembered that a number of symptoms are found in various diseases. In addition, in the story of patients, the phenomena that are subjectively assessed by them and the most important from their point of view prevail, which, dominating in physiological and psychological perception, can veil other, very complex diseases of the dentoalveolar system, proceeding without subjective sensations. It is also important to remember that the most common combination of various diseases of the dentition and their complications.

When examining the organs of the oral cavity, the doctor always compares what he sees with the knowledge of the physiological variants of the structure of each organ. At this stage, it is the comparison that will help to find a deviation, that is, a symptom of a disease or abnormal development and determine its importance and significance in the pathological process.

The survey is carried out in the following sequence:

1.) Examination of the condition of the teeth;

2) Examination of the dentition, defects in them, the relationship of the dentition and movements of the lower jaw;

3) Examination of the oral mucosa, tongue;

4) assessment of the jaw bones.

Assessment of the condition of the teeth.

Examination of the condition of the teeth is carried out using a probe, a mirror and tweezers, using research methods (examination, palpation, percussion, probing, auscultation). When examining the teeth, it is suggested to adhere to a certain sequence. First, the teeth of the right side of the lower jaw are examined, then the left and with the transition to the upper jaw, continuing the examination from left to right.

Examining each tooth, pay attention to:

Its provisions;

The condition of the hard tissues of the tooth;

Tooth mobility;

The ratio of the supraalveolar and intraalveolar parts;

Location relative to the occlusal surface of the dentition;

The presence of fillings, artificial crowns, their condition.

When examining the tooth, the dental mirror is held in the left hand, and the probe or tweezers - in the right. The use of a mirror allows you to examine each tooth from all sides (Fig. 5); tweezers determine the mobility of the tooth, probe - the integrity of the surfaces of the crown of the tooth, the sensitivity of the examined area, the depth of the gingival groove, and possibly the periodontal pocket.

Fig. 5. The position of the dental mirror when examining the teeth.

Fig. 6. Change in the shape of the tooth (developmental anomaly.)

Comparing the knowledge of the anatomical shape of the teeth with the data obtained, the correspondence or deviation in the shape of each examined tooth is noted (Fig. 6). At the same time, the color of the tooth is assessed; notice a change in the color of the entire crown or its individual sections. With caries, the color of the tooth changes according to the degree of the process: the disappearance of the natural shine of the enamel, a chalky spot, staining of a carious spot from gray to dark brown tones. If amalgams were used to treat caries, a dark blue color is observed, and if plastic materials are used, a dark brown color. In teeth in which the neurovascular bundle has died or is removed (pulped teeth), the enamel loses its shine and acquires a greyish-yellow tint.

The color of the enamel changes in smokers, workers in acid shops. The color and shape of the tooth can change in a number of diseases (fluorosis, dysplasia).

When examining the crown of a tooth, it is important to correctly direct the beam of light from a lighting lamp or illuminate the area to be examined with a light guide. The areas of interdental contacts, where caries most often develop, are subject to careful examination. The shape of the teeth is disturbed with fluorosis, dysplasia, hypoplasia, wedge-shaped defects, physiological and pathological abrasion of the hard tissues of the tooth (Fig. 7, 8). These are disorders of non-carious origin.

Fig. 7. Violation of the shape of the teeth with hypoplasia.

Fig. 8. Violation of the shape of the teeth with Capdepon's dysplasia.

Most often, the shape of a tooth changes as a result of caries, a pathological process in which demineralization of hard tissues occurs with the subsequent formation of a defect.

Localization and frequency of damage to different groups of teeth are different. Most often, molars and premolars are affected, as a rule, fissures of the occlusal surface and contact surfaces. Black proposed a classification of carious defects depending on the groups of teeth and the surface of the lesion.

By the carious process, the coronal part can be destroyed partially or completely. The examination reveals teeth filled with different materials. In these cases, it is necessary to assess visually and with the help of a probe the quality of the filling, the degree of its adherence to the tooth tissues, to find out whether secondary caries has developed (see Fig. 12, a).

Evaluation of the violation of the shape of the tooth, topography and the degree of damage to the hard tissues of the teeth allows not only to establish the presence of diseases, but also to determine the need for orthopedic interventions. This, as a rule, involves a number of additional studies: assessment of the state of the peri-apical tissues according to X-ray examination data and the correct filling of the dental canal (canals), determination of the thickness of the root walls.

The degree of destruction of hard tissues of the crown and root of the tooth is determined in 2 stages: before and after the removal of all softened tissues. It is after the removal of the softened tissues that we can reliably talk about the possibility of preserving the rest of the hard tissues of the teeth, and taking into account the topography of the defect, about the type of treatment: filling, inlay, artificial crown, partial and complete resection of the coronal part followed by its restoration with pin structures.

Examination of the dentition.

When examining the dentition, we pay attention to the position of each tooth in the dental arch, the nature of the occlusal relationships and contacts between the teeth, the expressiveness of the equator of the teeth relative to the vertical plane, and the shape of the dental arches. Determination of the type of bite is performed by closed jaws, but when assessing the type of bite, difficulties may arise associated with the transferred pathological conditions (fracture of the jaws). In this case, the assessment of the bite is carried out in the position of the lower jaw in a state of physiological rest along the facet of erasure.

Assessment of the state of the oral mucosa

The oral mucosa is pale pink in color. Due to various pathological processes, the color of the mucous membrane changes, its configuration is disrupted, and various elements of inflammation appear.

The reasons for these symptoms are:

Mechanical damage (trauma);

Disturbance of heat transfer of the mucous membrane due to poor thermal conductivity of the plastic prosthesis;

Toxic - chemical effects of plastic ingredients;

Allergic reactions;

Changes in the mucous membrane in some systemic diseases (gastrointestinal tract, endocrine system, vitamin deficiency)

Mycoses;

Diseases of the salivary glands.

Setting the nature of pathological changes in the mucous membrane affects the choice of the method of orthopedic treatment and the material from which the prosthesis should be made.

Assessment of the condition of the jaw bones

Review and palpation of the mucous membrane makes it possible to assess the state of the tissues of the bones of the upper and lower jaws, to reveal the anatomical features of the skeleton of bones: the boundaries of the oblique lines, the topography of the hyoid groove, the chin axis, protrusions (exostoses), the level of atrophy of the alveolar process. Assessment of the condition of the jaw bones, if necessary, can be supplemented by an X-ray examination.

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The purpose of a clinical examination of a patient is to make the correct diagnosis, which is necessary for the successful treatment of the patient.

In dentistry, various examination methods: collection of anamnesis, examination, temperature diagnostics, electrodontodiagnostics, X-ray examination, as well as laboratory (general clinical analysis of blood, cytological, allergological, etc.) studies and samples. Examination of any patient consists of three stages:

clarification of complaints and anamnesis of the disease;

examination using physical methods (examination, palpation, percussion, auscultation);

research using special methods (laboratory, radiological).

The questioning consists of clarification of complaints and other aspects of the disease, as well as other information about the patient, which makes it possible to make the correct clinical diagnosis and carry out adequate treatment in the future.

Inquiry begins with clarification of complaints. The pain symptom plays an important role in the diagnosis. It is necessary to find out the causes of the onset, the nature (aching, twitching, pulsating), duration (paroxysmal, constant), time of onset (night, daytime), localization or irradiation of pain, which allows you to obtain valuable data for the diagnosis. They learn about the duration of the existence of symptoms, clarify the dynamics of the pathological process. Then you should find out about the treatment being carried out: whether it was carried out at all, and if it was carried out, how effective it was; find out the transferred diseases, working conditions, allergological and epidemiological anamnesis.

Objective examination includes examination, percussion, palpation (basic methods) and a number of additional methods.

Examination schematically consists of an external examination of the patient and examination of the oral cavity.

During an external examination, attention is paid to the general appearance of the patient, the presence of swelling, asymmetry of the face configuration; color, the presence of pathological formations on the skin and visible mucous membranes.

Oral examination start by examining the vestibule of the mouth with closed jaws and relaxed lips, lifting the upper and lowering the lower lip or pulling the cheek with a dental mirror. Examine the red border of the lips and the corners of the mouth. Pay attention to the color, the formation of scales, crusts. The level of attachment of the bridles of the upper and lower lip is noted, the depth of the vestibule is measured.

Then, with the help of a mirror, the inner surface of the cheeks, the state of the ducts of the parotid salivary glands and the nature of the secretion secreted by them are examined. Pay attention to the color, moisture content of the mucous membrane. An important role belongs to the determination of the ratio of the dentition in the position of the central occlusion - bite. Following the examination of the oral cavity, the gums are examined. It is normally pale pink in color. Determine the presence or absence of pathological changes, the presence and depth of periodontal pockets.

The hygienic state of the oral cavity is determined using hygienic indices.

When examining the oral cavity itself, attention is paid to the color and moisture content of the mucous membrane. Examine the tongue, the state of its mucous membrane, papillae, especially if there are complaints of changes in sensitivity or burning and soreness. Then the bottom of the oral cavity, the condition of the frenum of the tongue, and the excretory salivary ducts are examined.

Examination of the dentition and teeth: When examining the oral cavity, it is necessary to examine all the teeth. Examination of the teeth is carried out using a set of tools: a dental mirror, probe, spatula. Determine the shape and integrity of the dentition. They pay attention to the shape and size of the teeth, the color of individual teeth, the shine of the enamel, reveal defects in the hard tissues of the teeth of carious and non-carious origin.

D.V. Sharov
"Dentistry"