hey guys welcome back if you don't know us my name is Zoh and i'm a foundation dentist working
here in london and this is ali he's a final year dental student studying at university of
newcastle in this part of the educational series we're going to be covering the examinations and
special investigations that you need to know before you see your patients for the first time
so last week we spoke about how to take a good history so if you haven't watched that yet
we recommend you go back watch that first and then come back to this video where we'll go
through doing a thorough examination and some of the special investigations you might need to do to
be able to reach an accurate diagnosis we're going to cover extraoral and intra-oral examinations
followed by charting and bpe and finishing the examination with some other things that should be
noted we're also going to be talking about which investigations would be appropriate and if you're
here for anything specific then feel free to skip around using the timestamps below we're also going
to include all the information summarized in a document with a link in the description the
document also covers the content from our last video on taking a history as well for completeness
so the exam starts when you see the patient for the first time and you call their name in the
waiting room you want to be looking out for any disabilities breathlessness and their general
appearance the formal examination starts when the history finishes and you receive the implied
consent to proceed by telling them for example i'm going to start by having a feel around your
head and neck to check for any lumps and bumps you start with the extra oral examination by standing
behind the patient and palpating with your fingers on the tmj the muscles of mastication the salivary
glands and the lymph nodes with experience you'll be able to pick up more subtle details
but to help you understand if something is wrong compared to the opposite side and check if there's
any asymmetry there's certain ways you can ask the patient to move to make the tissues you're
examining stick out more so for example the tmj you ask the patient to open and close the jaw
while palpating right in front of their ears and you want to look for any deviation and if there's
a deviation to one side this could indicate some sort of tmj dysfunction you also want to listen
for any clicks or grinding and if there aren't any you want to ask the patient if it hurts
and if it does then this is something you'll need more information about whereas if it doesn't hurt
i would just record an asymptomatic click for example in my nose i would also ask the patient
to bring out their lower jaw and move it side to side and look for any abnormalities there then
from in front of the is i would run my fingers along the zygomatic process to have a feel of the
masseter and as i asked them to open then close then clench i would palpate along the master down
to the mandible then i would move on to palpate the temporalis by asking them to clench again
and placing my fingers higher up near the temporal fossa the reason we palpate the
muscles of mastication is because they can refer pain to other locations in the head and this pain
can be replicated while palpating them they could also give us an indication of someone having a
parafunctional habit like bruxism for example if these muscles are hypertrophic and then when you
later move on to look inside the mouth you might see lots of tooth surface loss from attrition next
you have to populate the parotid and submandibular glands and you can't always feel these impatience
without any pathology but it's important to still check them because if they're large and swollen
then it might indicate that there's some salivary stones there you can find the protein just below
and in front of the ear and you can find the submandibular gland just below the body of the
mandible and above the hyoid bone you also need to check the lymph nodes in the head and neck
region to make sure that there's no infections or cancers in the area which can be spotted by
enlarged red and tender notes the three areas you need to check are the cervical nodes the
submandibular nodes and the submental nodes it's easy to check the cervical nodes by asking the
patient to turn their head away from the side that you're checking so that the sternocleidomastoid
can be pushed out and the cervical nodes are made more obvious when you run your fingers
along their neck the submandibular lymph nodes are just superficial to the submandibular glands
so it's easier to check them both at the same time and finally the submental lymph nodes are
most easily found by tipping the patient's head forward and rolling the nodes along the lower
border of the mandible anteriorly the last thing to watch out for extra orally are skin cancers
like basal cell carcinomas which look like red or pink raised shiny waxy ulcers with irregular blood
vessels and could bleed from any minor traumas if you notice something like this then it's important
that you don't just move on and instead you need to ask the patient how long it's been there
and if it's been hurting them at all basal cell carcinomas grow slowly over a long period of time
and a lot of patients just leave them to grow for years so if you see something suspicious
you should refer them to aura medicine if there's nothing wrong in the notes i just write
tmj mom sg and lg nad and this little circle means that nothing abnormal was detected
now that you've examined the outside of the head it's time to look inside the mouth and
you start by looking at anything abnormal in the soft tissues which consists of the buccal and
labial mucosa the palate the tongue the floor of the mouth and the gingiva on the mucosa for
example you might see white lesions which could be presenting from a range of causes or you might
notice bite marks on the occlusal plane or even red lesions or ulcers or loads of other stuff that
you could pick up from oral med but the important thing is that if you see anything you're unsure
about don't ignore it make sure you mention it to your supervisor or refer to oral med the order i
usually do this is first if the patient is wearing a denture i ask them to take it out and i ask the
patient to open their mouth and using my mirror i start with one side and retract the cheeks
and check the buccal mucosa i then work around clockwise and check the lower label mucosa right
buccal mucosa and then the upper labial mucosa at the same time i'm checking the mucosa i'm
also checking the gingiva as well i then examine the top of the tongue by asking the patient to
stick their tongue out then i look at the lateral borders of the tongue by asking the patient to
stick their tongue to one side and then the other and i check the floor of the mouth and the ventral
tongue by asking the patient to stick their tongue to the roof of their mouth and then i finish off
by using my mirror to check their palette and the tonsils a systematic approach like this will just
ensure that you're doing this on every single patient and you're not missing any bits out
then you want to do an intraoral heart tissue exam which includes charting and a bpe where you record
each tooth in detail noting down anything from caries to missing and i will dry the surfaces
of the teeth while i go around in a systematic order so that it's easier to spot any carries
or well colour matched restorations some people question the use of loops for the examination but
honestly i love it and i feel like i can spot so much more of them on in the future we're going to
be making loads of videos on loops so make sure you subscribe so you don't miss any of that out
when it comes to doing a bpe and i had to give one piece of advice
some people stop checking the rest of the sextant when they score a bpe of four
but you shouldn't do that because you might also notice a vacation involvement if you carry on
that would make it a four star pause now if you want to see how the grading system works for a bpe
after you do your bp we think it's a good idea to also make an assessment of any two surface loss
so i suggest you do a bewe which is a basic erosive wear examination and you can pause here
if you want to see what that is at this stage you can also check their occlusion making a note of
their molar relationship and incisor relationship this is the bare minimum you should do but ideally
you would also check their left and right lateral excursions noting whether they have a canine or
group function and i know this sounds like a lot and most likely you won't be doing that on every
single patient when you just start but it's a good idea to get into the habit as early as you can
if they're wearing dentures you can check the occlusion with and without the denture and you
also want to make a general note of the denture states whether they're partial or complete and
whether they're acrylic or cobalt chrome if there are any problems that you notice with the denture
then you can ask the patient more questions now that you've done the charting in bpe you use this
information alongside the patient's complaints to decide which special investigations would be most
appropriate for that patient and here's a list of the main special investigations that you could do
let's go through each one so that you can get a better idea of when to do them first one i
usually think about is what radiographs do i want to do for new patients with no previous
radiographs you instantly think bitewings if they have previous bitewings you need to check how long
it's been since they last had by wings taken the fgdp has guidelines on the intervals and i'm going
to cover that in next week's video on radiographs so subscribe so you don't miss out for periapicals
the list of indications is quite long and i have them on the screen now i'll just go through a few
of them with you for heavily restored teeth the rationale is that you want to get a better idea
of the status of the tooth are there any secondary carries any apical pathologies if it's a crown how
is the marginal fit and if it's an interproximal amalgam is there a ledge has the tooth been root
treated finding out all this information will give you a better idea of all the treatment
that might be needed now or in the future and you can warn your patient about them for perio
you take pas to assess bone levels and to be able to make a diagnosis taking a pa of a tooth
that's non-responsive to sensibility testing might actually give you a reason as to why because you
might see some signs of april periodontitis and you always want to take a pa before any root canal
treatment extractions or indirect restorations to help you with seeing the shape of the roots the
status of the peripheral tissues and to help you plan the treatment and finally the main reasons to
take her dpt would be to assess wisdom teeth and their association to the id canal and they're also
useful for any pathologist like large cysts and for ortho treatment planning you would also need
to consider sensibility testing which could give you an indication of whether the tooth is alive
or not and this is of three types you can have hot cold and electric the most accurate type is
cold sensibility testing where you would place a freezing chemical like endo frost on some cotton
wool and place that on the tooth in question as well as two adjacent teeth the next most accurate
is using electric pulp testing where you'll be asking the patient to hold onto a metal electric
conducting rod and placing toothpaste on the patient's tooth in question and then completing
the circuit by holding the ept device on the tooth through the toothpaste again you would test the
two adjacent teeth as well so that you can see the difference between a possibly healthy tooth and
a diseased tooth this comparison is important because the patient might not be responsive to
sensibility testing at all on any of their teeth because of secondary and tertiary dentine deposits
but if the tooth in question responds in a way that's much different to the healthy tooth then
this is indicative of a disease just remember that this doesn't mean that the tooth is non-vital if
it's non-responsive and you would write in your notes tooth non-responsive to ept as opposed to
the tooth is not vital because the pop could still be alive the last way of sensibility testing is
with hot testing by heating a gutta-percha point and placing it on the tooth but this
is hardly ever used anymore on the screen is a full list of reasons to do sensibility testing
and the same list applies for when you're testing for tender to percussion when you're testing for
tender to percussion be careful of whether you use your finger or a mirror sometimes the patients
come in and they're in excruciating pain and if you tap it with your mirror they might literally
just jump out the chair so with those kind of patients i just used one of my fingers and i
kind of lightly touched the tooth and that would be enough for me to know that the tooth is tender
to percussion when you're testing for ttp make sure you test some of the adjacent teeth as well
so you can have them in for comparison when you have multiple teeth that are causing pain then
i would use a scale so depending on which tooth was causing more pain i would put an extra plus
another special investigation to know about is using a two sleuth and this is used when
the patient presents with a cracked tooth or you suspect that there might be a crack in their tooth
there are two places you should be testing one is the fissures and the other is the individual
cusps and the way you use it is by placing the pointy end on the tooth in question and asking
the patient to bite down hold and then release and asking them at what point did it hurt the
main signs of a crack tooth syndrome is when they get pain on biting and especially pin on release
next is six point pocket charting indicated by bpes of four or persistent bpes of three
even after initial periodontal therapy which by the way is super gingival scaling ohi and
then an 8 to 12 week weight you would also do a plaque score for any perio patient or any
patient with poor oral hygiene another is taking a diet diary for any high caries risk patients
or patients suffering from tooth surface loss and then analyzing this so that you can give dietary
advice when you see them next taking study models is another investigation which helps in monitoring
the progression of tooth surface loss but can also be used in ortho treatments as before and afters
and can also be used to assess space for indirect restoration the last special investigation to
consider is a diagnostic wax up which can help you visualize composite build up cases thanks for
making it this far guys that was everything you need to know about carrying out an examination
with special investigations don't forget to have a look at the document in the description for
their cheat sheet and other useful information you might enjoy other videos on our channel so
feel free to check out some of the suggestions here also if you guys have any questions or
feedback we'd love to see that in the comments section below see you guys in the next video