patient’s examination in orthopedic dentistry clinic. clinical methods of examination. additional (special) methods of examination. dia
Patient’s examination in orthopedic dentistry clinic.
Clinical methods of examination.
Additional (special) methods of examination.
Diagnostic procedures in orthopedic dentistry.
The general purpose of the lecture:
To introduce the clinical and paraclinical (additional) methods of
patient’s examination in orthopedic dentistry clinic.
To introduce definition and content of the term “Diagnosis” in
The plan of the lecture:
The aim of patient’s examination in orthopedic dentistry clinic.
Clinical methods of patient’s examination.
Additional methods of patient’s examination.
Special methods of patient’s examination and their purpose.
Methods of chewing efficiency determination, their
Definition of term “diagnosis” in orthopedic dentistry.
The insufficient patient examination and incorrect analysis of
examination findings leads to chosen unreasonably treatment. Instead
of disease elimination or process stabilization appear the disease
deterioration, and sometimes organs destruction.
Then thorough and complete the patient examination will be carried
out, the more so goal-directed and effectively treatment will be.
Methods of examination
1) CC – Chief Complaint
2) HPL – History of patient’s life;
3) HPI – History of Present Illness;
4) FH – Family History
II. 1. EXTRAORAL EXAMINATION
– TMJs examination;
– Muscles of Mastication examination;
2. INTRAORAL EXAMINATION:
а) vestibule oral cavity examination;
б) oral cavity proper examination:
- information concerning the condition of teeth;
- information concerning the condition of the dentitions;
- information concerning the condition of the soft tissues (mucosa);
- information concerning the condition of the bones tissues;
- periodontal examination (gingiva, periodontium);
Testing of masticatory pressure;
Masticatory efficiency determination (static methods by Agapov,
Tests of mastication (functional tests: Rubinov test, Gelman test);
Examination of diagnostic models;
Occlusion examination (occlusiogram);
Graphic registration methods of lower jaw motions and the functional
state of muscles (Myography, masticatiography electromyography,
Laboratory tests etc.
The accuracy and significance of the patient's primary reason(s) for
seeking treatment should be analyzed first. This may be just the tip
of the iceberg, and careful examination will often reveal problems and
disease of which the patient is unaware; nevertheless, the patient
perceives the chief complaint as the major problem. Chief complaints
usually fall into one of the following four categories:
• Comfort (pain, sensitivity and swelling)
• Function (difficulty in mastication or speech)
• Social (bad taste or odor)
• Appearance (fractured or unattractive teeth or restorations,
Comfort If pain is present, its location, character, severity, and
frequency should be noted, as well as the first time it occurred, what
factors precipitate it (e.g., hot, cold, or sweet things), and any
changes in its character.
Function Difficulties in chewing may result from a local problem such
as a fractured cusp or missing teeth; it may also indicate a more
generalized malocclusion or dysfunction.
Social A bad taste or smell often indicates compromised oral hygiene
and periodontal disease.
Appearance Compromised appearance is a strong motivating factor for
patients to seek advice as to whether improvement is possible.
PERSONAL DETAILS The patient's name, address, phone number, sex,
occupation, work schedule, and marital and financial status are noted.
Much can be learned in a 5-minute, casual conversation during the
The patient's general appearance, gait, and weight are assessed. Skin
color is noted for signs of anemia or jaundice. Vital signs, such as
respiration, pulse, temperature, and blood pressure, are measured and
recorded. Fixed prosthodontic treatment is often indicated in
middle-aged or older patients, who can be at higher risk for
Special attention is given to facial asymmetry because small
deviations from normal may hint at serious underlying conditions.
Cervical lymph nodes are palpated, as are the TMJs and the muscles of
Temporomandibular Joints. The clinician locates the TMJs by palpating
bilaterally just anterior to the auricular tragus while having the
patient open and close.
Muscles of Mastication. Next, the masseter and temporal muscles, as
well as other relevant postural muscles, are palpated for signs of
tenderness. Palpation is best accomplished bilaterally and
The intraoral examination can reveal considerable information
concerning the condition of the soft tissues, teeth, and supporting
structures. The tongue, floor of the mouth, vestibule, cheeks, and
hard and soft palates are examined, and any abnormalities are noted.
This information can be properly evaluated during treatment planning
only if objective indices, rather than vague assessments, are used.
Periodontal Examination A periodontal examination should provide
information regarding the status of bacterial accumulation, the
response of the host tissues, and the degree of irreversible damage.
Gingiva. The gingiva should be lightly dried before examination so
that moisture does not obscure subtle changes or detail. Color,
texture, size, contour, consistency, and position are noted and
Periodontium. The periodontal probe is one of the most reliable and
useful diagnostic tools available for examining the periodontium. It
provides a measurement (in millimeters) of the depth of periodontal
pockets and healthy gingival sulcus on all surfaces of each tooth.
Additional methods of examination
Electroodontodiagnostics (electric pulp tester) – method of measuring
the response to electrical stimulation the pulp (sensitivity
registration to current intensity). In the norm (in case of intact
teeth) pulp reacts to the 2 – 6 mA current intensity. In carious teeth
pulp reacts to (20 – 40) mA current intensity; in pulpitis – 50 – 60
mA; in periodontitis – over 100 mA.
Occlusion examination (occlusiogram)
Teeth contacts determination by using articulating paper (in central,
frontal, lateral occlusions checking for premature contacts
Diagnostic model - the positive projection of the dentition and jaw,
tissues of prosthetic seat area and mucosa reproduced in a gypsum or
plastic (picture: Shows reduced vertical dimension, direct bite, and
abnormal position of teeth).
Area under investigation:
General scan of teeth and jaws (retained roots, unerupted teeth,
undetected caries cavities, alveolar (tooth) socket atrophy)
Crown of tooth and interdental bone (caries, restorations)
Root and periapical area
Submandibular gland (contrast radiography)
Skull and facial bones
Roentgenography (detailed knowledge of the extent and structure of
bone support and the root morphology of each standing tooth; cyst
presence; periodontium pathology).
provide a sufficiently detailed view for assessing bone support, root
morphology, caries, or periapical pathology.
provide useful information about the presence or absence of teeth,
helpful in assessing third molars and impactions, evaluating the bone
before implant placement, and screening edentulous arches for buried
Computed tomography (CT), magnetic resonance imaging (MRI)
More information can be obtained from serial tomography, arthrography,
Roentgenovisiography (Digital imaging) is a method based on the
digital technologies. With X-rays and computer program it is possible
to get the image of tooth tissues and its surroundings. It is also
possible to print photopictures of the image on the screen. This
technique has been used extensively in general radiology, where it has
great advantages over conventional methods in that there is a marked
dose reduction and less concentrated contrast media may be used.
Ultrasound (US) Ultra-high frequency sound waves are transmitted
through the body using a piezoelectric material. Good probe/skin
contact is required (through gel medium) as waves can be absorbed,
reflected, or refracted. High-frequency (short wavelength) waves are
absorbed more quickly whereas low-frequency waves penetrate further.
US has been used to image the major salivary glands and the soft
Sialography. This is the imaging of the major salivary glands after
infusion of contrast media under controlled rate and pressure using
either conventional radiographic films, or CT scanning.
Arthrography. Just as the spaces within salivary glands can be
outlined using contrast media, so can the upper and lower joint spaces
of the TMJ.
Galvanometry. Pure metals are almost never used in dentistry, because
the physical characteristics are inappropriate. Instead, metal
fillings, crowns, and implants are made up of alloys (metal blends),
and they can contain any combination of “classic” gold crown, for
example, is likely made up of things like gold, platinum, palladium,
silver, copper, and tin.
An electric current, called a “galvanic” current, is generated by the
transportation of metal ions from the dental metals into saliva. This
phenomenon is called “oral galvanism”. First, the electric currents
increase the rate of corrosion (or dissolution) of metal-based dental
restorations and replacements.These ions react with other components
of the body, leading to sensitivity, inflammation, and, ultimately,
autoimmune disease. Second, some individuals are very sensitive to
these internal electrical currents. Oral galvanism can result in local
lesions, nerve shocks, a metallic or salty taste, burning tongue,
unexplained pain, and discoloration.
Finally, there is the concern that oral galvanism directs electrical
currents into brain tissue and can disrupt the natural electrical
current in the brain.
Gnathodynamometry Method of masticatory pressure determination using
different kinds of special device – gnathodynamometer. Masticatory
pressure – developed by masticatory muscles and applied to masticatory
Masticatiography Method of mandible movements’ registration in all
chewing phases: physiological equilibrium; opening the mouth; biting
the chop of food with incisors; grinding with lateral teeth;
swallowing in central occlusion.
Electromyography (EMG). Electromyography, or EMG, involves testing the
electrical activity of muscles. Often, EMG testing is performed with
another test that measures the conducting function of nerves. This is
called a nerve conduction study. During EMG, small pins or needles are
inserted into muscles to measure electrical activity. Patient is asked
to contract your muscles by moving a small amount during the testing.
With nerve conduction studies, small electrodes are taped to patient's
skin or placed around his fingers.
Myotonometry. Method of muscular tonus determination with
myotonometer. It is possible to estimate contractile muscular tonus
and rest muscular tonus.
Rheography. Method of vessels pulse volume determination by means of
graphic registration of electrical tissue resistance alteration.
Allergy Tests. Involves having a skin or blood test to find out what
substance, or allergen, may trigger an allergic response in a person.
Skin tests are usually done because they are rapid, reliable, and
generally less expensive than blood tests, but either type of test may
There are three types of skin tests:
1. Skin prick test.
2. Intradermal test.
3. Skin patch test.
Blood test Allergy blood tests look for substances in the blood called
antibodies. Blood tests are not as sensitive as skin tests but are
often used for people who are not able to have skin tests.
Blood Tests (Hematology)
Red Blood Count (RBC) - the number of red blood cells to evaluate
White Blood Count (WBC) - the number of white blood cells to evaluate
Differential Count - the proportions of the different types of white
blood cells varies in infection, allergies, etc.
Platelet Count - the count of the number of these cells which
participate in blood clotting
Coagulation (clotting) studies - bleeding time, prothrombin time and
other tests determine the clotting process in the blood
Hemoglobin - a measure of the oxygen-carrying capacity of the blood
Sugar (glucose) - the amount of sugar in the blood is a
measurement for diabetes mellitus
Electrolytes (sodium, potassium, chloride and carbon dioxide) -
these substances maintain fluid and blood pressure balance and are
essential for the function of most body systems
Enzymes (CK, LD, AST, ALT) - help to diagnose heart and liver
Cholesterol - high amounts are associated with heart and blood
Urea Nitrogen - test for kidney function
Uric Acid - may indicate gout
Culture - growth of bacteria for the purpose of identification
Smear/Stain - preliminary evaluation of infection
Sensitivity test - testing bacteria with antibiotics to determine
which drug is most effective
Urinalysis Many individual tests make up the urinalysis, such as
glucose, blood, bacteria. The physician gains information about the
kidneys, liver and other body processes from these tests.
Pap smear - microscopic examination of cells to determine abnormal
conditions or malignancy
Sputum - microscopic evaluation for malignancy or other disorders
such as asbestosis
Histology Biopsy - the removal of a small section of tissue to be
studied. The type of cells and their chemical reactions are evaluated.
Immunology AIDS test - positive when a person has the AIDS virus
lmmunohematology (Blood Bank) Blood type and Rh - to identify a
person's blood type which can be O, A, B or AB and Rh which can be
either positive or negative.
Saliva pH assessment Saliva sampling is performed fasting or in 3 – 4
hours after the last meal. The patient rinses his oral cavity with
distilled water and gather all the content into the test tube. After
that the pH instrument is placed into the tube and assessments are
Determination of masticatory efficiency
A diagnosis must be based on adequate information and must account
for the findings from the history and examination. Where findings
cannot be accounted for, further investigation may be incorporated
into the treatment plan, provided such action would not be injurious
to the patient.
Teeth coefficients of masticatory efficiency by N.I. Agapov
Teeth coefficients of masticatory efficiency by I.M. Oxman
Functional methods of masticatory efficiency determination Efficiency
of mastication depends on the following factors:
number of articulating pairs,
presence of teeth with caries and its complications,
state of parodontium and masticatory muscles,
type of bite,
general state of the organism,
saliva discharge and composition of saliva,
size and consistency of food lump.
The method of masticatory apparatus function evaluation was worked out
by Christiansen in 1923. For this purpose it was given three identical
cylinders of a coconut to a patient. After 50 masticatory motions the
oral cavity fluid with the chewed nuts was spited out in a tray,
washed, dry out at the temperature 1000 С during 1 hour and sift
through the special sieve. They judge about efficiency of mastication
through the amount of unsifted particles of the food which remained in
The goal of masticatory tests:
To determine the functional status of masticatory system
To define the indications to the restorations of masticatory
To evaluate the effectiveness of orthopedic treatment.
Physiological masticatory according by I.S. Rubinov
It was determined that in pathological processes of maxilla-facial
region (lost of teeth or other abnormalities) the chewing time to the
swallowing moment is prolonged.
It was also determined the duration of chewing process is equal to 14
c. in case of orthogenetic bite (the rest in the sieve is 0). The
patient is given 0,8 g. of hazelnut and he chews the nut to the
Investigator obtains two measures:
Percentage of pulverized food.
Physiological masticatory according by Gelman
Masticatory efficiency is determined by chewing duration analisis. The
patient is given of 5 g of almonds and he chews it during 50 sec. Then
he spit bolus into the bowl, rinses the oral cavity with boiled water
and also spit the content of his oral cavity. For disinfection purpose
5 – 10 drops of the 5 % sublimate solution is added. All the mass is
filtered with gauze. The remainder is dried using the water bath, then
it is sieved. Received mass is weighted. The result converse into
percentage. Ex.: The rest on the sieve is 2,82 g. Then the percentage
of masticatory efficiency is composed: 5 g. – 100 %; 2,82 – X; X=
(2.82 x 100) / 5 = 56,4 %.
Kurlyandsky offered the more detailed chart of masticatory efficiency
evaluation - Odontoparadontogram
Taking into account functional efficiency of masticatory apparatus for
determining the diagnosis a doctor must use amendments depending on
the state of parodontium. In case of the first degree of parodontium
illnesses and teeth mobility the functional value of teeth decreases
to 25%; in the second degree of mobility - to 50%, in the third degree
- to 100%.
Odontoparadontogram| is a table, which|what| collecting the
information|data| about every tooth and its|its| supporting apparatus.
Information|data| is given as the conditional denotations|designations|,
got|received| as a result of clinical examination, information|data|
of radiographs investigation and gnathodymamometria|. N - without the
pathological changes|changing|; 0 - a tooth is absent|absents|; ¼ (one
fourth) - atrophy of the first degree; ½ (a half (one second)) - it is
atrophy of the second degree; ¾ (three fourth) - atrophy of the third
degree. Atrophy above|over| ¾ belongs to|by| the fourth degree for|after|
which|what| a tooth is held|retained,maintained,deducted| by soft|mild|
tissues and is subject to the extraction.
In odontoparadontogram assessment it is determined:
- Coefficient relations between upper and lower dentitions (in
orthopedic treatment it is necessary to even upper and lover forces);
- Preservation (healthy condition) of supporting apparatus of all the
- Determination of traumatic nodes in the dentition.
Diagnosis - a brief medical report on the pathological conclusion of
the organism, expressed in a common nomenclature and classification of
Diagnosis consists of 2 parts:
Part 1- a main disease and his (its) complications.
Part 2- accompanying diseases (dental and general).
Components of the main disease
1. morphological - reflects the morphological disorders of normal
anatomy (the defects of the crown teeth (classification of the carious
cavities by Blek), classification of defects of dentitions by Kennedy,
types of the toothless mouth by Shreder (upper dentition) and by
Keller (lower dentition), mucosa condition of the prosthetic basal
seat area in full (or total) absence of teeth by Suple;
2. functional - a loss of chewing efficiency by Agapov, Oxman,
distinct speech, swallowing (or deglutition);
3. pathogenetic - causes of pathology: caries, periodontium diseases,
acute and chronic trauma of hard tissues of teeth, etc.
4. aesthetic – disorders of aesthetics’ rates.
Complication of the main disease occur a result in the main disease
(for example, syndrome by Kosten - a result from reduction of the
height of the bite).
To accompanying general somatic diseases follows to refer that, which
necessary to take into account in process of the orthopedic treatment
(the diabetes, hypertonic disease, epilepsy and others.).
To accompanying dental diseases, which must be cure by dentists of
other profiles (e.g., leukoplakia, cancerous diseases of the jaws etc)
Thank you for your attention!