Before performing an oral examination, review the patients medical and dental history. Note any history of allergies, heart disease, and hepatitis. Note the medications the patient is currently taking. Review and update the patients NAVMED 6600/3, as needed.
When you examine the oral cavity, use a thorough and systematic approach. Some knowledge of the normal dental anatomy is essential to recognize oral diseases. The starting point of the examination is determined by the individual performing it. However, the examination should include the entire orofacial region. The following approach is merely a suggested guideline. First, examine the patients tongue and the floor of the mouth. Check for signs of ulceration, swelling, deviations in normal anatomy and appearance, and lack of papillae on the tongue. To properly visualize these areas, grasp the tongue with a 2 x 2 or 4 x 4 gauze pad, and move the tongue from side to side.
Next examine the buccal mucosa and vestibule areas for signs of ulceration, swelling, or sinus tracts. Examine the hard and soft palates, gingivae, and alveolar mucosa. Record any deviations from normal. Palpate the patients submental, submaxillary, and tonsillar lymph nodes, and record any palpable nodes and whether they are tender, fixed, or mobile.
Using a mirror and an explorer, examine the teeth for caries, chips or fractures, faulty restorations, and other anomalies. Use the mirror and a periodontal probe to check the periodontium for depth of the periodontal sulcus around the teeth. A depth in excess of 3 mm is indicative of periodontal disease, especially if bleeding accompanies gentle probing.
You must now evaluate the chief complaint that brought the patient to seek treatment. If the complaint is a fractured restoration, the exposed dentin may be sensitive to thermal changes, or the sharp edges may irritate the tongue. If the problem is a painful carious lesion, determine the status of the pulp. This is done by percussion in which a painful response may indicate periapical pathology. Sensitivity to heat or cold may indicate pulpal changes, which may be the result of caries, trauma, a new restoration, or a fractured tooth. If pain persists after the stimulus is removed, the pulpal tissue is probably seriously damaged and undergoing degenerative changes.
If the chief complaint is a periodontal problem, evaluate the color, contour, and uniformity of the gingivae. Hemorrhage upon probing indicates periodontal disease. The pain may be related to a pus-filled, fluctuant periodontal abscess. The teeth may be mobile as a result of advanced bone loss or trauma from a recently placed high restoration.
Most emergency dental procedures may be performed without the use of anesthetics. Incising and draining a well-localized soft tissue abscess with a single stab incision, opening the pulp chamber of a painful nonvital tooth, or placing a temporary filling in a carious tooth can usually be performed without a local anesthetic. Often it is disadvantageous to use an anesthetic. For example, if an anesthetic is used when excavating and filling a large carious lesion, you must wait for the anesthesia to wear off before determining whether or not the restoration has eliminated the pain. Placing a temporary sedative filling will usually bring relief without using anesthesia.
Placing a dressing on an exposed vital pulp may require an anesthetic. However, in this case profound anesthesia may not make this procedure pain free. Extensive manipulation of painful tissues, such as irrigation and debridement of an acute pericoronitis, will be more tolerable when you administer an anesthetic. You, the independent duty hospital corpsman, and the patient must decide whether to use an anesthetic.
Pain is perceived differently by patients. One patient may perceive pain as minimal, while another will describe it as excruciating. Fear and anxiety increases the patients perception of pain. It is up to you to reassure the patient to help alleviate this problem.
The problems involved in anesthetizing the mandibular arch are different from those involved in anesthetizing the maxillary arch. In the maxillary arch, most teeth can be effectively anesthetized by injecting 2 ml of anesthetic solution in the loose tissue just above the tooth. It is important to penetrate the loose oral mucosa above the lighter pink attached gingiva that is immediately adjacent to the teeth. The attached gingiva and the similarly attached tissues of the palate are denser, more difficult, and more painful to penetrate. The needle should not penetrate the mucosa more than 5 to 6 mm to approximate the apex of the root of the tooth. Make sure the needle point does not contact the bone,