ORAL   EXAMINATION Before   performing   an   oral   examination, review the patient’s 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  patient’s 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  exami- nation should include the entire orofacial region. The  following  approach  is  merely  a  suggested guideline.  First,  examine  the  patient’s  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  patient’s 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. LOCAL  ANESTHESIA 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  patient’s  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, 2-43