Examination techniques1

BASIC TECHNIQUES
1. Visual Inspection
- Visual inspection is the systematic observation of the patient. It begins at the first
meeting with the patient in the form of a general appraisal. As the interview is conducted,
one inspects function and form. As the clinical examination begins, this inspection
becomes more detailed.
- Adequate lighting is necessary to perform an examination well. This is achieved by
having a brightly lit operatory and by using the dental mirror to reflect light into dark areas
of the mouth or by using an intraoral source of light.
- Structures to be inspected must not be covered by such items as clothing, cosmetics,
saliva, plaque or other debris. Additionally, eyeglasses, removable partial dentures,
complete dentures, obturators, and other appliances must be removed.
- Some structures may require displacement to adequately inspect them or adjacent
areas. Examples are the ears and hair (for examination of the ears and scalp), the eyelids
(for examination of the conjunctiva) and the tongue (for evaluation of the floor of the
mouth).
- Visual inspection of the skin or mucous membrane yields information concerning color
changes, dryness, and edema. Changes in morphology such as size, shape, symmetry,
deformity, swelling, or abnormal muscular development may also be seen.
- Visual inspection is an aid in the assessment of function by enabling one to note
movement of the eyes, muscles, and joints.
- Measuring devices such as a ruler, a Boley gauge, or fingers are useful adjunctive
instruments that allow observations to be quantified. These are helpful in evaluating
exophthalmia, hypertelorism, mandibular function, and diastemas. Such recordings may
be used later for diagnosis and for evaluation of the progress of treatment.
- Specialized sources of light, such as fiberoptics, are useful to transilluminate the max-
illary and frontal sinuses for the presence of fluids or masses and the teeth for interprox-
imal caries and cracks. Ultraviolet light may be used to detect fluorescence in
tetracycline-stained teeth and that characteristic of erythroblastosis fetalis.
2. Diascopy
- Diascopy is a specific examination technique whereby the tissue examined is com-
pressed by a glass slide or a wafer of clear acrylic.
- The primary objective of this test is to determine whether a reddish or bluish-purple
lesion is vascular in nature or whether it is due to other causes.
1 Oral Diagnosis, Oral Medicine and Treatment Planning by Bricker et al. 1994 pp. 46- 59.
- If blood flows through the lesion, it will blanch on diascopy and return to its original color
on release of the pressure.
- Some examples of conditions that blanch on diascopy include most vascular lesion
such as (some varices, telangiectases, and hemangiomas) and erythroplakia in some
instances.
- If the area does not blanch, it may be due to a variety of other causes; such as
amalgam, carborundum or india ink tatoos, nevi, localized pigmentations and
extravasated blood as (in petechiae, ecchymoses and hematoma).
3. Palpation
- Palpation is a procedure wherein the examiner feels or presses the structures exam-
ined. Palpation gives information about the following :-
a. Texture is best determined through light palpation with the fingertips. Texture defines
the surface of a mass as smooth, rough, or pebbly. The difference between a smooth
enlarged lymph node and one that is lumpy or matted is a difference of texture.
b. Dimension cannot be assessed by the eye alone. Some nodules may have little
dimension in terms of depth; others may be analogous to icebergs. Palpation can reveal
much of the structure’s depth as well as identify the structure’s contours.
c. Consistency is described in terms of compressibility. A lymph node may be described
as soft, rubbery, or indurated.
Both consistency and dimension can be evaluated by pressing the object against
unyielding structures that are deep or lateral to the object palpated. An example is the
rolling with the fingertips of submandibular node against the inferior border of the
mandible. In addition, consistency may be evaluated by pressing the structure between
the examiner’s thumb and index finger, a procedure known as bidigital palpation. An
example is the evaluation of nodules in the lips, buccal mucosa, or helix of the ear.
Manipulation of structures between the fingers of one hand and those of another is called
bimanual palpation. An example is the palpation of the submandibular gland, with the
index finger of one hand in the floor of the mouth and the fingers of the other pressing
against the skin of the submandibular area.
d. Temperature changes are best evaluated using the dorsal or extensor surfaces of the
fingers because the skin is thin and well innervated. Inflamed areas or soft tissues
overlying vascular lesions may be warmer, owing to increasing blood flow to the area.
e. Functional events are any movements that can be detected with the palpating hand. Ex-
amples are the pulsatility or “thrill” of a vascular lesion and the movement of a tooth in its
socket.
f. Although we cannot palpate pain, we may elicit pain with palpation. The palpating hand

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 may induce a painful response from the patient before the finger has actually identifed an
abnormality. During palpation it is important to note the patient’s response.
4. Probing
- Probing is palpation with an instrument. The teeth are probed for caries with the
explorer and the periodontal probe is used to measure the depth of the periodontal
sulcus.
- Lacrimal duct probes are used in the examination of Warton’s duct of the
submandibular gland and Stensen’s duct of the parotid gland.
- Fistulous tracts can be probed with gutta percha points to determine the origin of the
fistula. The gutta percha point can be lubricated with topical anesthetic and gently
inserted and a radiograph made. This is a useful procedure to distinguish flistula arising
from a periapical abscess from a fistula caused by other conditions.
5. Percussion
- Percussion is the technique of striking the tissues with the fingers or an instrument. The
examiner listens to the resulting sounds and observes the response of the patient:
Extraorally, percussion is used to detect tenderness in the frontal and maxillary sinuses
by tapping the fingertips against a finger placed over the sinuses. Intraorally, percussion
is used as a method to evaluate the teeth by tapping with a mirror handle. This technique
may induce pain in areas of inflammation from periodontal disease or pulpitis.
- Ankylosis of teeth in bone produces a change in sound. The presence of occlusal
disharmony may be identified by percussing the mandibular dentition against the maxillary
teeth.
6. Auscultation
- Auscultation is the act of listening for sounds within the body such as wheezing,
popping of the temporomandibular joint, or the clicking of ill-fitting dentures with porcelain
teeth.
- The stethoscope is a useful aid to auscultation. Most stethoscopes have two heads:
The flat diaphragm is used to detect high-frequency sounds, whereas the bell collects
low-pitched sounds.
- Most sounds of interest to the dentist in the head and neck area are high-frequency
sounds, such as; crepitus in the joint area, bruits in the vascular lesions in the jaws and
other sounds such as murmurs that can be heard when the great vessels of the neck are
altered.
- Occasionally fracture lines in the mandible can be located through percussion and
auscultation. The diaphragm of the stethoscope is placed to one side of the site of the
suspected fracture and the other side is percussed with the finger. The presence of a

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 fracture dulls the transmission of the sound.
- One of the most important uses of the stethoscope in dentistry is in monitoring the blood
pressure.
7. Aspiration
- Aspiration is withdrawal of fluids from a body cavity limited to soft tissues or may be
central in bone. The aspirate is the material withdrawn. When nothing can be withdrawn,
the needle tip should be moved to adjacent areas because several attempts may be re-
quired to obtain an aspirate.
- In solid lesions such as neoplasms with minimal vascular content, nothing may be
aspirated. Empty spaces, such as occur in an air embolism or traumatic bone cysts, have
no aspirate or only a small amount of blood-tinted fluid.
- Aspiration of pus indicates an inflammatory process. The aspirate may be used for
culture and sensitivity tests to identity the pathogen and its best treatment.
- Straw-colored or blood-tinted fluid may indicate a cyst, whereas the aspiration of blood
may have several interpretations. If several milliliters of blood are aspirated easily, a
vascular lesion such as a hemangioma should be suspected. If on insertion of the needle,
the plunger is forced out of the syringe by the flow of blood, an arteriovenous shunt
should be suspected. In this instance, there may be difficult in obtaining hemostasis at the
point of the needle puncture.
- Aspiration is performed routinely prior to injection of local anesthetic solution.
- Aspiration of suspected lesions is best performed under local anesthesia with a large
needle of (16 to 20 gauge) because small needles might bend or break and viscous fluids
may not be aspirated through a small needle.
8. Evaluation of Function
a. Tear production and tear drainage can be observed by looking at the eye and tear flow
may be measured by means of the Schirmer tear test. Decreased tear production may be
associated with the use of drugs which have autonomic effects, with Sjogren’s syndrome,
and with rheumatoid arthritis and aging. Tearing may occur following blockage of the
nasolacrimal duct, if there is inability to blink as in Bell’s palsy, or as a physiologic
response to a foreign object in the eye.
b. The function of salivary glands can be assessed to a degree by palpating or “milking”
the glands. As the glands are “milked,” the oral termination should be observed for
amount and character of the saliva, for the presence of pus and for its viscosity. The flow
from the minor or accessory salivary glands can be assessed by everting the lip, drying
the mucosa with a gauze sponge, and observing the beads of saliva that form. This
phenomenon can be observed on most areas of the unattached mucosal surfaces and on

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 the attached mucosa of the hard palate.
c. The tongue is the organ of taste, and its function can be assessed with the use of sat-
urated salt and sour solutions, quinine, and fructose or other sugars.
d. Another function of the oral cavity is mastication. For chewing and swallowing to occur,
some saliva must be present, the muscles of mastication must be coordinated and
functioning, the temporomandibular joint must be free of disease, the teeth and
periodontium must be healthy, the oral and pharyngeal mucosa must be normal, and ade-
quate occlusion of the teeth must exist. Some abnormalities may be accompanied by
masticatory symptoms such as limited jaw opening, inability to move the jaws, pain,
difficulty with swallowing and pain while chewing.
e. The evaluation of neurologic function may be necessary as certain conditions such as
(Bell’s palsy, adenoid cystic carcinoma of the parotid gland and tumors of the jaws)
produce neurologic symptoms such as paresthesia or paralysis.
EXAMPLES OF APPLICATION OF THE TECHNIQUES
Examination of a Nodule
- Once a nodule is located by visual inspection and palpation, it should be evaluated for
its composition. The composition of the nodule can be estimated on the basis of certain
physical signs:
1. Consistency describe the degree of compressability of the nodule between the
palpating fingers. Adjectives used to describe consistency are: indurated (hard), in which
the lump is not compressible; rubbery, referring to a consistency much like a rubber gum
eraser; spongy, which means soft and compressible with some resilience; or soft,
meaning compressible with no resilience.
2. Fluctuation can be assessed by supporting three different quadrants of a nodule
with the thumb and the index and middle fingers of one hand. The fourth quadrant is then
compressed with the index finger of the other hand. A fluid-filled cavity transmits the
increased pressure equally in all directions and is felt by each of the three fingers of the
other hand. A solid mass may or may not bulge out in another direction when pressed but
does not bulge equally in all directions. Smaller nodules may be examined bidigitally.
3. Fluid thrill is the term used for the percussion waves sometimes felt in a fluctuant
nodule. To feel the wave, one side of the nodule is percussed while the other side is
palpated for the transmitted vibration. Fluid thrills are not likely to be detected in small
lumps because the wave moves too quickly.
4. The translucency of a nodule can be evaluated by transillumination with a bright pin-
point light source. Clear fluids transmit light, whereas blood, pus, and solids do not. Nod-
ules containing water, serum, lymph, plasma, and fat show a warm glow in a darkened

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 room when transilluminated.
5. Certain nodules, particularly in the neck are pulsatile with an observable thrill. The
challenge is to determine whether the nodule itself is pulsating or whether it is transmitting
the pulse from an adjacent structure. If in bidigital palpation the fingers are pushed apart,
the nodule itself is expanding and contracting. If the fingers are pushed in the same
direction, the pulsations are often caused by adjacent aneurysms and vascular
neoplasms. A central hemangioma or arterial venous aneurysm may cause an overlying
tooth to pulsate in the socket following compression.
6. Compressibility of a nodule can be determined by bidigital or bimanual palpation.
Solid masses may be slightly compressible, owing to their rubbery consistency, whereas
some fluid-filled masses may be flattened completely. Cysts may distort under pressure
but rebound as soon as the pressure is released, whereas other fluid-filled nodules may
disappear momentarily and then slowly reform. Vascular malformations, in which the
intravascular pressure is low, follow the latter pattern.
7. Bruit is the sound emitted by many vascular nodules that corresponds to the systolic
blood pressure.
8. As the nodule is evaluated for its composition, other features such as its position, color,
shape, size, surface texture, border, and temperature and the presence of tenderness
may be noted.
- If a nodule is located superficially, its relation to a muscle may be ascertained if it
becomes more prominent as the muscle is contracted. If the nodule is deep or within the
muscle, it may become increasingly difficult to be detected on contraction.
- Changes in surface texture may reveal its growth pattern and growth rapidity. Surface
ulceration may be a sign of malignancy, whereas redness may be a sign of inflammation.
- The lymph drainage of the area occupied by the nodule should be inspected for
enlarged and tender lymph nodes, which indicate the nodule may be inflammatory. Pain-
less, matted, indurated nodes may indicate metastatic disease.
Examination of an Ulcer
- Some ulcers are associated with innocuous conditions and some with highly
contagious diseases, whereas others are the clinical manifestation of malignant disease.
Ulcers should be evaluated for the following :
1. The base of the ulcer is the area that occupied the bottom of the lesion. Syphilitic
ulcers have an eschar (slough) in the base that resembles chamois leather. Other
granulomatous ulcers such as tuberculosis and histoplasmosis may have a bluish
granulation tissue resembling a pyogenic granuloma at the base. Ischemic or atrophic
ulcers often have no granulation tissue at the base, which may consist of exposed bone

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 periosteum, or tendon. Redness of the base indicates vascularity and probably an ability
of the ulcer to heal.
2. It is important to note the characteristics of the border of the ulcer. A flat, sloping
edge of a shallow ulcer may be a sign of healing. A punched-out necrotic border involving
the full thickness of the epithelium is seen in syphilitic ulcers when no attempt at repair is
made. An undermined edge may be seen in tuberculosis, whereas a rolled border with
shallow depth is seen often in basal cell carcinomas. A deeper ulcer with an everted edge
overlapping normal skin may be a sign of squamous cell carcinoma.
3. The depth of an ulcer should be noted. A change in depth to more shallow with a
sloping edge is a sign of healing. Often ulcers are of nonspecific origin and are self-
limiting. Definitive procedures such as biopsy may be delayed for a few weeks because
many oral ulcerative conditions will show signs of resolution during that period.
4. An ulcer that fails to respond to treatment and does not clinically appear to be
malignant can be studied further by removing the crust or slough and collecting the
discharge for culture and sensitivity testing. In some instances, histologic examination of
this material may be helpful in detecting nuclear inclusion bodies suggestive of viral
infections; acantholytic (Tzanck) cells seen in pemphigus; and in rare instances malignant
cells may be detected.
5. Other important considerations involve the relationship of the ulcer to
surrounding tissues. If the border is indurated, it is usually a sign of invasion of deeper
tissues by tumor cells particularly seen with basal cell and squamous cell carcinomas.
6. As in the case with nodules, it is important to evaluate the regional lymph nodes.