Extraoral Examination

Basic diagnostic protocol suggests that a clinician observe patients as they enter the operatory. Signs of physical limitations may be present, as well as signs of facial asymmetry that result from facial swelling. Visual and palpation examinations of the face and neck are warranted to determine whether swelling is present. Many times a facial swelling can be determined only by palpation when a unilateral “lump or bump” is present. The presence of bilateral swellings may be a normal finding for any given patient; however, it may also be a sign of a systemic disease or the consequence of a developmental event. Palpation allows the clinician to determine whether the swelling is localized or diffuse, firm or fluctuant. These latter findings will play a significant role in determining the appropriate treatment.

Palpation of the cervical and submandibular lymph nodes is an integral part of the examination protocol. If the nodes are found to be firm and tender along with facial swelling and an elevated temperature, there is a high probability that an infection is present. The disease process has moved from a localized area immediately adjacent to the offending tooth to a more widespread systemic involvement.

Extraoral facial swelling of odontogenic origin typically is the result of endodontic etiology because diffuse facial swelling resulting from a periodontal abscess is rare. Swellings of nonodontogenic origin must always be considered in the differential diagnosis, especially if an obvious dental pathosis is not found. This situation is discussed in subsequent chapters.

A subtle visual change such as loss of definition of the nasolabial fold on one side of the nose may be the earliest sign of a canine space infection. Pulpal necrosis and periradicular disease associated with a maxillary canine should be suspected as the source of the problem. Extremely long maxillary central incisors may also be associated with a canine space infection, but most extraoral swellings associated with the maxillary centrals express themselves as a swelling of the upper lip and base of the nose.

If the buccal space becomes involved, the swelling will be extraoral in the area of the posterior cheek. These swellings are generally associated with infections originating from the buccal root apices of the maxillary premolar and molar teeth and the mandibular premolar and first molar teeth. The mandibular second and third molars may also be involved, but infections associated with these two teeth are just as likely to exit to the lingual where other spaces

would be involved. For infections associated with these teeth, the root apices of the maxillary teeth must lie superior to the attachment of the buccinator muscle to the maxilla, and the apices of the mandibular teeth must be inferior to the buccinator muscle attachment to the mandible.

Extraoral swelling associated with mandibular incisors will generally exhibit itself in the submental or submandibular space. Infections associated with any mandibular teeth, which exit the alveolar bone on the lingual and are inferior to the mylohyoid muscle attachment, will be noted as swelling in the submandibular space. Further discussions of fascial space infections may be found in Chapter 14.

Sinus tracts of odontogenic origin may also open through the skin of the face . These openings in the skin will generally close once the offending tooth is treated and healing occurs. A scar is more likely to be visible on the skin surface in the area of the sinus tract stoma than on the oral mucosal tissues. Many patients with extraoral sinus tracts give a history of being treated by general physicians, dermatologists, or plastic surgeons with systemic or topical antibiotics or surgical procedures in attempts to heal the extraoral stoma. In these particular cases, after multiple treatment failures, the patients may finally be referred to a dental clinician to determine whether there is a dental cause. Raising the awareness of physicians to such cases will aid in more accurate diagnosis and faster referral to the dentist or endodontist.

Intraoral Examination

The intraoral examination may give the clinician insight as to which intraoral areas may need a more focused evaluation. Any abnormality should be carefully examined for either prevention or early treatment of associated pathosis. Swelling, localized lymphadenopathy, or a sinus tract should provoke a more detailed assessment of related and proximal intraoral structures.

Soft Tissue Examination

As with any dental examination, there should be a routine evaluation of the intraoral soft tissues. The gingiva and mucosa should be dried with either a low-pressure air syringe or a 2-by-2-inch gauze pad. By retracting the tongue and cheek, all of the soft tissue should be examined for abnormalities in color or texture. Any raised lesions or ulcerations should be docu- mented and, when necessary, evaluated with a biopsy or referral.

Intraoral Swelling

Intraoral swellings should be visualized and palpated to determine whether they are diffuse or localized and whether they are firm or fluctuant. These swellings may be present in the attached gingiva, alveolar mucosa, mucobuccal fold, palate, or sublingual tissues. Other testing methods are required to determine whether the origin is endodontic, periodontic, or a combination of these two or whether it is of nonodontogenic origin.

Swelling in the anterior part of the palate is most frequently associated with an infection present at the apex of the maxillary lateral incisor or the palatal root of the maxillary first premolar. More than 50% of the maxillary lateral incisor root apices deviate in the distal or palatal directions. A swelling in the posterior palate is most likely associated with the palatal root of one of the maxillary molars.

Intraoral swelling present in the mucobuccal fold can result from an infection associated with the apex of the root of any maxillary tooth that exits the alveolar bone on the facial aspect and is inferior to the muscle attachment present in that area of the maxilla. The same is true with the mandibular teeth if the root apices are superior to the level of the muscle attachments and the infection exits the bone on the facial. Intraoral swelling can also occur in the sublingual space if the infection from the root apex spreads to the lingual and exits the alveolar bone superior to the attachment for the mylohyoid muscle. The tongue will be elevated and the swelling will be bilateral because the sublingual space is contiguous with no midline separation. If the infection exits the alveolar bone to the lingual with mandibular molars and is inferior to the attachment of the mylohyoid muscle, the swelling will be noted in the submandibular space. Severe infections involving the maxillary and mandibular molars can extend into the parapharyngeal space, resulting in intraoral swelling of the tonsillar and pharyngeal areas. This can be life threatening if the patient’s airway becomes obstructed.

Palpation

In the course of the soft tissue examination, the alveolar hard tissues should also be palpated. Emphasis should be placed on detecting any soft tissue swelling or bony expansion, especially noting how it compares with and relates to the adjacent and contralateral tissues. In addition to objective findings, the clinician should question the patient about any areas that feel unusually sensitive during this palpation part of the examination.

A palpation test is performed by applying firm digital pressure to the mucosa covering the roots and apices. The index finger is used to press the mucosa against the underlying cortical bone. This will detect the presence of periradicular abnormalities or specific areas that produce painful response to digital pressure. A positive response to palpation may indicate an active periradicular inflammatory process. This test does not indicate, however, whether the inflammatory process is of endodontic or periodontal origin.

Percussion

Referring back to the patient’s chief complaint may indicate the importance of percussion testing for this particular case. If the patient is experiencing acute sensitivity or pain on mastication, this response can typically be duplicated by individually percussing the teeth, which often isolates the symptoms to a particular tooth. Pain to percussion does not indicate that the tooth is vital or nonvital but is rather an indication of inflammation in the periodontal ligament (i.e., symptomatic apical periodontitis). This inflammation may be secondary to physical trauma, occlusal prematurities, periodontal disease, or the extension of pulpal disease into the periodontal ligament space. The indication of where the pain originates is interpreted by the mesencephalic nucleus, receiving its information from proprioceptive nerve receptors. Although subject to debate, the general consensus is that there are relatively few proprioceptors in the dental pulp; however, they are prevalent in the periodontal ligament spaces. This is why it may be difficult for the patient to discriminate the location of dental pain in the earlier stages of pathosis, when only the C fibers are stimulated. Once the disease state extends into the periodontal ligament space, the pain may become more localized for the patient; therefore, the affected tooth will be more identifiable with percussion and mastication testing.

Before percussing any teeth, the clinician should tell the patient what will transpire during this test. Because the presence of acute symptoms may create anxiety and possibly alter the patient’s response, properly preparing the patient will lead to more accurate results. The contralateral tooth should first be tested as a control, as should several adjacent teeth that are certain to respond normally. The clinician should advise the patient that the sensation from this tooth is normal and ask to be advised of any tenderness or pain from subsequent teeth.

Percussion is performed by tapping on the incisal or occlusal surfaces of the teeth either with the finger or with a blunt instrument. The testing should initially be done gently, with light pressure being applied digitally with a gloved finger tapping. If the patient cannot detect significant difference between any of the teeth, the test should be repeated using the blunt end of an instrument, like the back end of a mirror handle . The tooth crown is tapped vertically and horizontally. The tooth should first be percussed occlusally, and if the patient discerns no difference, the test should be repeated, percussing the buccal and lingual aspects of the teeth. For any heightened responses, the test should be repeated as necessary to determine that it is accurate and reproducible, and the information should be documented.

Although this test does not disclose the condition of the pulp, it indicates the presence of a periradicular inflammation.An abnormal positive response indicates inflammation of the periodontal ligament that may be of either pulpal or periodontal origin. The sensitivity of the proprioceptive fibers in an inflamed periodontal ligament will help identify the location of the pain. This test should be done gently, especially in highly sensitive teeth. It should be repeated several times and compared with control teeth.

Mobility

Like percussion testing, an increase in tooth mobility is not an indication of pulp vitality. It is merely an indication of a compromised periodontal attachment apparatus. This compromise could be the result of acute or chronic physical trauma, occlusal trauma, parafunctional habits, periodontal disease, root fractures, rapid orthodontic movement, or the extension of pulpal disease, specifically an infection, into the periodontal ligament space. Tooth mobility is directly proportional to the integrity of the attachment apparatus or to the extent of inflammation in the periodontal ligament. Often the mobility reverses to normal after the initiating factors are repaired or eliminated. Because determining mobility by simple finger pressure can be visually subjective, the back ends of two mirror handles should be used, one on the buccal aspect and one on the lingual aspect of the tooth. Pressure is applied in a facial-lingual direction as well as in a vertical direction and the tooth mobility is scored. Any mobility that exceeds +1 should be considered abnormal. However, the teeth should be evaluated on the basis of how mobile they are relative to the adjacent and contralateral teeth.

Periodontal Examination

Periodontal probing is an important part of any intraoral diagnosis. The measurement of periodontal pocket depth is an indication of the depth of the gingival sulcus, which corresponds to the distance between the height of the free gingival margin and the height of the attachment apparatus below. Using a calibrated periodontal probe, the clinician should record the periodontal pocket depths on the mesial, middle, and distal aspects of both the buccal and lingual sides of the tooth, noting the depths in millimeters. The periodontal probe is “stepped” around the long axis of the tooth, progressing in 1 mm increments. Periodontal bone loss that is wide, as determined by a wide span of deep periodontal probings, is generally considered to be of periodontal origin and is typically more generalized in other areas of the mouth. However, isolated areas of vertical bone loss may be of an endodontic origin, specifically from a nonvital tooth whose infection has extended from the periapex to the gingival sulcus. Again, proper pulp testing is imperative, not just for the determination of a diagnosis but also for the development of an accurate prognosis assessment. For example, a periodontal pocket of endodontic origin may resolve after endodontic treatment, but if the tooth was originally vital with an associated deep periodontal pocket, endodontic treatment will not improve the periodontal condition. In addition, as discussed in, a vertical root fracture may often cause a localized narrow periodontal pocket that extends deep down the root surface. Characteristically, the adjacent periodontium is usually within normal limits.

Furcation bone loss can be secondary to periodontal or pulpal disease. The amount of furcation bone loss, as observed both clinically and radiographically, should be documented . Results of pulp tests (described later) will aid in diagnosis.

Date: 2016-04-22; view: 819