describe the methods of clinical examination to reach the diagnosis

1. DR. ENAS ELGENDY
ASS. PROF. OF ORAL MEDICINE AND
PERIODONTOLOGY DEPARTMENT
CLINICAL EXAMINATION

2. How to collect diagnostic information =
Methods of collecting information =
Items of diagnostic data base:
I-Patient history
II-Physical examination
III-Adjunctive diagnostic procedures

3. CLINICAL EXAMINATION
• The clinical examination is basis of developing an
accurate diagnosis and successful treatment plan. A
comprehensive examination enables the examiner to
identify the nature of the complaint that promotes the
patient to visit the dental clinic or to discover a disease,
which is unknown to an apparently well patient.
• It is the diagnostic assessment of the patient‘s status.
• Relies on the clinician’s primary senses with the aid of
simple instruments.
• Adjunctive diagnostic methods that require technically
complex as X-ray examination are not considered as
clinical methods.
• Ask for permission before examination.

4. The common techniques of
examination are
1. Inspection
2. Palpation
3. Percussion
4. Probing
5. Auscultation
6. Olfaction
7. Aspiration

5. 1- Inspection
• It is the technique of examination which uses the
visual sense.
• By inspection, many findings could be noticed as:
1- Contour
2-Color
3- Surface texture
4- Inspection by magnifying lenses.
5- Transillumination: is a visual diagnostic method
that relies on the passage of light through
relatively thin, translucent tissues.

6. Proper and successful inspection
requires the following
• Proper positioning of the patient on the dental chair.
• Adequate light source as room light, dental unit light,
and sometime mirror light.
• Complete dryness using compressed air, manual chip
syringe, suction tips and cotton or gauze pieces.
• Retraction could be done by plastic retractors, mirror
top, wooden tongue depressor or even the examiner
fingers.
• Special materials as disclosing tablets could be used to
detect bacterial plaque.

7. 1- Contour:-
Change in contour isn't diagnostic
by itself because many different
diseases produce similar
changes in contour. But;
Alterations from the normal
contour must be noted.

8. 2- Color:-
The examiner should be aware of:-
A- Normal color of each region.
B- Normal variations in color and shadings
of the tissues.
C- Recognize the pathological color changes
in any area.

9. Pink Brown

10. 3- Surface texture:-
The surface of the normal mucosa is smooth
glistening except the rugae area of the
palate and the attached gingiva.

11. 3- Surface texture:-
The surface of a pathologic mass may be:-
Smooth.
Papillomataus.
Ulcerated eroded.
Keratinized.
Necrotic.

12. 4- Inspection by magnifying lenses:-
Can be used to differentiate between lesions with
gross clinical appearance. As leukoplakia and
plaque type of lichen plannus.

13. 5- Transillumination
It is the examination of the maxillary and frontal
sinuses by allowing light to pass through it in a
completely darkened room.
For examination of the maxillary sinuses the light
source is placed in the mouth and the lips are
closed.
 for the frontal sinuses the light is placed in the
upper part of the orbit with the eyelids closed.
A healthy sinus transmits the light, diseased sinus
will appear opaque.

14. The significance of transillumination:-
• Only for detection of diseases extend from teeth
to the maxillary sinuses or vise versa.
• The diagnosis need to be confirmed by other
techniques as x-ray, C.T, MRI, bone scanning.

15. Transillumination is of great value in detection
of interproximal caries in anterior teeth by the
use of light cure equipment.

16. The general techniques of examination
• 1- Inspection.
• 2- Palpation.
• 3- Percussion.
• 4- Auscultation.
• 5- Probing.
• 6-Olfaction
• 7- Aspiration

17. 2- Palpation
Palpation is the examination method
that relies on the sense of touch.
Techniques: The method of palpation
is applied depending upon the area to
be examined.

18. Bimanual
It is the manipulation of the
tissues using two hands or two
fingers of both hands. It is used
for examination of cheeks, floor
of the mouth and to detect the
presence of salivary gland stones.

19. Bidigital
Using two fingers of one
hand.
Used usually for lips and
buccal mucosa

20. Bilateral
Used to compare
symmetrical structures.
EXAMPLES:
TMJ
Muscles of Mastication
Lymph nodes
Two lobes of Thyroid
gland

21. Features that can be revealed by
palpation include
• Consistency
• Mobility
• Extent
• Size and shape
• Fluctuance
• Surface temperature
• Vibrational sensation
• Diascopic examination

22. Consistency
The response of tissue to pressure can be suggestive for diagnosis
of the oral lesion. The following terms are commonly used to
describe the consistency
• Soft: compressible under pressure as lipoma or mucocele.
• Firm: tissues cannot be easily compressed to pressure with
minimal shape alteration occurs in contrast to compressible
tissues. Many benign neoplastic and hyperplastic enlargements
are firm.
• Hard: sensation of bony tissue and implies calcification
• Indurated: means hardness without calcification. Induration is
a feature of many malignant neoplasm’s

23. Consistency
• Doughy: indicates deformity with a degree of resistance
suggesting semisolid contents, then returns slowly to the
original shape. Some cysts are characterized by this
consistency.
• Pitting: tissue respond to pressure then slowly regains
the original contour after release of pressure, e.g. edema
• Collapsing: easily compressible, remains deformed after
the release of pressure.
• Spongy: is the term used when the structure offers minimal
resistance to pressure and quickly regains the original
contour after the pressure is released. Highly vascular
lesions produce this sensation.

24. Mobility
Palpation reveals whether a mass is fixed or mobile in
all direction
• Masses freely movable in all directions benign
lesion, an example of this type of mass is the
epidermoid cyst.
• Masses fixed to the skin but not to the underlying
structures moved freely in all directions by digital
pressure sebaceous cyst which cannot be
moved independent of the skin
• Masses fixed to all layers of tissue
squamous cell carcinoma at this stage fixes the skin
or mucous membrane to the deeper tissues.

25. Extent of the Lesion
• The lesion may have ill defined borders
(malignant lesion that infiltrates adjacent
tissue).
• The lesion may have well defined borders
(encapsulated).
Size and shape of the lesion
- Size can be easily determined by inspection and
millimeter ruler.
- Round or ovoid masses are suggestive for cyst, benign
tumor or lymph nodes. Irregular shapes are suggestive
for malignancy

26. Fluctuance
All soft or rubbery lesions or masses over 1 cm
in diameter should be tested for fluctuance. This
is done by placing one finger of one hand on
one side of the mass to sense the lesion (this
finger is termed sensing finger) and one finger
of the other hand on the other side of the mass
to press the lesion gently (this finger is termed
probing finger). If the sensory finger can detect
a wave passing through the lesion, the mass is
said to be fluctuant.

28. Fluctuance of the lesion is determined
by the following factors
 The mass should contain fluid e.g. cystic lesion.
 The mass must be located in superficial area.
 The mass must not be surrounded by fibrosis.
Chronically infected cyst loses its fluctuance due to
fibrosis around the fluid filled cavity.
The lesion must be in a fluctuant stage: draining
cyst or abscess (discharge through draining sinus).

29. Surface Temperature
• The clinician places the fingers of one hand on
the skin in the area of concern and the fingers
of the other hand on the skin of the other
side.
• The skin has an increased temperature when
it is inflamed or when it overlies an infected or
inflamed area.

30. Vibration sensation
Vibrational sensation within tissue is called
thrill. It results from blood driven by arterial
pressure through large vessels. This is a feature
of some vascular malformations.

31. Diascopic Examination
• It is performed by using glass slide to
compress blood containing lesion. The lesion
blanches if blood is contained within the
vessel e.g. hemangioma, hereditary
hemorrhagic talangecatsia and varicosities.

32. Limitations of palpation:-
1- Gives very limited information.
2- Difficult to perform it especially if
there is swelling or pain.

33. The general techniques of examination
• 1- Inspection.
• 2- Palpation.
• 3- Percussion.
• 4- Auscultation.
• 5- Probing.
• 6-Olfaction
• 7- Aspiration

34. 3- Percussion
It is the striking of the tissues (soft or hard) with
fingers or an instrument.
• Used to evaluate tenderness and pain.
• Striking the tissues with the fingers or an
instrument, the examiner listens to the resulting
sound or watches the patient’s reaction.
• Localize tenderness and pain more exaggerated in
acute rather than chronic cases.
• Three characteristics are noted: tenderness to
percussion, tooth movement and sound.

35. 3- Percussion
• Greater tenderness to precession in an apical
direction suggests apical peridontitis.
• Greater tenderness to percussions in a lateral
direction suggests lateral peridontitis of
gingival origin.

36. The general techniques of examination
• 1- Inspection.
• 2- Palpation.
• 3- Percussion.
• 4- Probing.
• 5- Auscultation.
• 6-Olfaction
• 7- Aspiration

37. 4- Probing
• Probing is the use of a slender device to identify
or determine the extent of a narrow tract or
cavity.
• The dental probe may be:
• Explorer which is sharp ended, curved or
angulated, or
• Periodontal graduated probe with blunt end.

39. 4- Probing
• Examination of carious lesion
1. Decay is detected by repeatedly pressing and
withdrawing the explore tip at each site of
suspected decay. A carious lesion is identified by
the sensation known as a “catch” when the
explorer resists the withdrawals force.
2. Testing local anesthesia.
• Examination of gingival and periodontal tissues:
Blunt graduated periodontal probe is used to
determine the sulcus/pocket depth and the
presence of bleeding in periodontal disease.

40. The general techniques of examination
• 1- Inspection.
• 2- Palpation.
• 3- Percussion.
• 4- Probing.
• 5- Auscultation.
• 6-Olfaction
• 7-Aspiration

41. 5- Auscultation
• Auscultation is the diagnostic process of
listening to sounds made by various body
parts. Abnormal temproamandibular joint
sound is often heard while the patient opens
and closes the mouth.

42. 6- Olfaction
The sense of smell occasionally contributes to
diagnostic information as:
• Fetid odor of bacterial infection ANUG.
• Garlic or bad odor of chronic periodontitis.
• Acetone odor in diabetes.
• Urine smell in renal failure.

43. The general techniques of examination
• 1- Inspection.
• 2- Palpation.
• 3- Percussion.
• 4- Probing.
• 5- Auscultation.
• 6-Olfaction
• 7-Aspiration

44. 7- Aspiration
• Withdrawal of fluids from body cavity.
• Aspirate used for cultures and sensitivity tests
to identify the pathogen
• E.g. Heamangioma bluish blood is aspirated.
• Yellowish white fluid “pus” (associated with
painful fluctuant swelling) abscess.
• Yellowish white fluid pus with “sulphur
granule” Actinomycosis