The General Physical Appraisal
The clinician needs to determine an overall impression of the general health and physical wellbeing of each patient. The general appraisal begins with the initial patient contact and continues during the entire appointment. The first opportunity to observe the patient’s general health and physical characteristics usually presents as the patient is escorted to the operatory from the reception area. During this walk the clinician can observe the patient’s posture and gait and any physical limitations which may be apparent. The general appraisal continues as the clinician obtains or updates the medical and dental histories (Figure 1).
Figure 1. General appraisal to obtain or update the medical and dental history of the patient.
The person’s overall cleanliness and personal appearance may give the clinician clues as to the ability of the patient to perform routine self-care procedures and could provide clues about their emotional/mental health status as well. The hair should be discreetly observed for cleanliness, amount and distribution, and the presence of nits which are indicative of an infestation with head lice. Be aware a strain of head lice has formed that is resistant to the most common medications used to eliminate them. Any patient suspected of harboring head lice should be dismissed and the chair and surrounding area should be thoroughly cleaned by vacuuming. A fresh headrest cover for every patient is necessary. The following web sites have interesting and timely information on preventing the spread of and treating lice infestations: Headlice.org and Centers for Disease Control and Prevention/Head Lice.
In addition to a general appraisal of skin texture, color, and general health, any exposed skin surface should be examined for evidence of skin cancer or other lesions. The American Academy of Dermatology’s ABCDE’s of Malignant Lesions39 should be referenced frequently. This information is available at: (American Academy of Dermatology: Melanoma). It is easy to identify lesions, such as the one seen on the forearm in Figure 2, as abnormal but it is beyond the scope of our practice to make any other assumptions. The patient should be referred to a dermatologist or physician for evaluation of any suspicious skin lesions. The lesion seen in Figure 2 was eventually diagnosed as a squamous cell carcinoma. As the appraisal continues, the clinician should look for evidence of dermatological manifestations of systemic conditions, such as scleroderma, psoriasis, eczema, lupus, lichen planus, pemphigus vulgaris, and mucous membrane pemphigoid, and other general health concerns (Figure 2).
Figure 2. Diagnosed squamous cell carcinoma.
Many disorders present with oral and cutaneous lesions and the presence of both may assist in the identification of an undiagnosed condition. Before continuing with the examination, be sure to check the hands for evidence of habits such as pitting, HPV infections, signs of infections, nail pitting, signs of arthritis, systemic diseases and tobacco use (Figure 3). Ask the patient questions about suspicious areas to determine their history and possible etiology and document your findings in the dental record.
Figure 3. Check the hands for evidence of habits such as nail biting, HPV infections, nail infections, nail pitting, signs of arthritis, systemic diseases and tobacco use.
The head and neck and oral examinations follow the general appraisal of the patient. Findings from these examinations will fall into one of three general classifications:
Normal – found in most individuals,
Atypical – not present in all individuals but still within normal limits (a variation of normal),
Pathologic – associated with infection, trauma, neoplastic growth, errors in development causing functional problems, immune system disorders, and more.