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methods of clinical examination


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describe the methods of clinical examination to reach the diagnosis

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methods of clinical examination

  2. 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. 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. 4. The common techniques of examination are 1. Inspection 2. Palpation 3. Percussion 4. Probing 5. Auscultation 6. Olfaction 7. Aspiration
  5. 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. 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. 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. 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. 9. Pink Brown
  10. 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. 11. 3- Surface texture:- The surface of a pathologic mass may be:- Smooth. Papillomataus. Ulcerated eroded. Keratinized. Necrotic.
  12. 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. 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. 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. 15. Transillumination is of great value in detection of interproximal caries in anterior teeth by the use of light cure equipment.
  16. 16. The general techniques of examination • 1- Inspection. • 2- Palpation. • 3- Percussion. • 4- Auscultation. • 5- Probing. • 6-Olfaction • 7- Aspiration
  17. 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. 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. 19. Bidigital Using two fingers of one hand. Used usually for lips and buccal mucosa
  20. 20. Bilateral Used to compare symmetrical structures. EXAMPLES: TMJ Muscles of Mastication Lymph nodes Two lobes of Thyroid gland
  21. 21. Features that can be revealed by palpation include • Consistency • Mobility • Extent • Size and shape • Fluctuance • Surface temperature • Vibrational sensation • Diascopic examination
  22. 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. 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. 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. 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. 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.
  27. 27. 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).
  28. 28. 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.
  29. 29. 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.
  30. 30. 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.
  31. 31. Limitations of palpation:- 1- Gives very limited information. 2- Difficult to perform it especially if there is swelling or pain.
  32. 32. The general techniques of examination • 1- Inspection. • 2- Palpation. • 3- Percussion. • 4- Auscultation. • 5- Probing. • 6-Olfaction • 7- Aspiration
  33. 33. 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.
  34. 34. 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.
  35. 35. The general techniques of examination • 1- Inspection. • 2- Palpation. • 3- Percussion. • 4- Probing. • 5- Auscultation. • 6-Olfaction • 7- Aspiration
  36. 36. 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.
  37. 37. 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.
  38. 38. The general techniques of examination • 1- Inspection. • 2- Palpation. • 3- Percussion. • 4- Probing. • 5- Auscultation. • 6-Olfaction • 7-Aspiration
  39. 39. 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.
  40. 40. 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.
  41. 41. The general techniques of examination • 1- Inspection. • 2- Palpation. • 3- Percussion. • 4- Probing. • 5- Auscultation. • 6-Olfaction • 7-Aspiration
  42. 42. 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