Clinical Examination

The medical and injury history is followed by the clinical examination. The most convenient position to examine the young child, especially with limited cooperative ability, is the knee-to-knee position. The dentist and parent are seated opposite each other with their knees touching. The parent lowers the child’s head into the dentist’s lap, while holding the child’s hands and restraining the legs against his/her body. The dentist stabilizes the head and conducts the clinical examination. The dentist may also conduct the examination with the child in the parent’s lap. The parent restrains the child’s lower body with their legs and the child’s upper body with their arms. Positioning the child in the parent’s lap may comfort the child to the extent they will cooperate for clinical and radiographic examination.2,3

Image: Clinical examination of child patient.

Positioning the child in the parent’s lap may comfort the child to the extent that they will cooperate for clinical and radiographic examination.

Image: Child in the parent's lap in examination chair.
Image: Child in the parent's lap in examination chair.

In the event the child will not cooperate in any of the previous mentioned positions, examination and treatment may have to be performed using a restraining device (Papoose Board®, Olympic Medical).

Image: Child restraining device (Papoose Board).
Image: Child in a restraining device (Papoose Board) for clinical and radiographic examination.

Clinical examination begins with an extraoral examination to rule out injuries to the facial bones. The facial structures should be palpated to determine discontinuities of facial bones. The temporomandibular joints are palpated and any swelling, clicking or crepitus is noted. Mandibular function during excursive movements is checked. Stiffness or pain in the patient’s neck requires immediate referral to a physician to rule out cervical spine injury.

The intraoral examination follows with examination of the soft tissues. Lacerations of the lips and cheeks are checked for the presence of foreign matter such as tooth fragments or gravel. These particles should be removed at the initial visit to prevent infection and tissue fibrosis.

All teeth in the mouth are examined for mobility, displacement and crown fracture and findings are recorded.

Mobility testing determines the extent of loosening, horizontally and vertically. Mobility can be indicative of various injuries, i.e., crown-root fracture, root fracture, subluxation, luxation.

Displacement of the teeth should be noted indicating the position (labially or lingually) and interference with occlusion.

Percussion testing can be performed digitally or with the handle of a dental instrument. Tenderness to percussion is indicative of damage to the periodontal ligament.

Pulpal sensibility testing relates to the assessment of pulpal health. Previously termed "vitality testing" this new terminology stresses the fact neural and vascular components of the pulp tissue need individual consideration. A tooth may not respond to a thermal test but may have an intact blood supply. It is not performed in the primary dentition because of the inability of younger children to cooperate for the test and report their reactions objectively. A recently traumatized tooth may be in shock and may fail to respond accurately. If the tooth does not respond positively to vitality testing emergency treatment may be completed and the tooth retested at the follow-up visit.

The radiographic examination follows the clinical examination. Radiographs allow for detection of root fractures, intrusions, extent of root development, pulp chamber size, periapical radiolucencies, root resorption, degree of tooth displacement, unerupted tooth position, jaw fractures and the presence of tooth fragments and foreign bodies in soft tissue. Although some radiographs may show negative findings at the initial appointment, they are important as baseline comparisons with subsequent radiographs.

Image: All films taken should clearly show the periapical areas of the involved teeth.

All films taken should clearly show the periapical areas of the involved teeth. In cases where root fractures are suspected, second and third radiographs should be taken from slightly different horizontal and vertical angle positions to verify the location of the fracture.

Image: In cases of intruded incisors a lateral view of the anterior region is taken.

In cases of intruded incisors a lateral view of the anterior region is taken. The radiograph is taken either by placing a 3 x 5 inch extraoral film next to the child’s cheek and perpendicular to the radiographic beam or placing a size 1 film intraorally between the buccal surfaces of the primary molars or permanent premolars and the cheek and perpendicular to the radiographic beam. The exposure time for a normal periapical film is doubled.

Image: Radiograph of a lateral view of the anterior region.
Image: To determine the presence of foreign bodies such as tooth fragments and other radio-opaque debris in the soft tissues the radiograph is placed between the hard tissue and the soft tissue of the lip.

Since the orbicularis muscles close tightly around foreign bodies in the lip, palpation of foreign bodies are difficult to palpate. They are best identified radiographically. To determine the presence of foreign bodies such as tooth fragments and other radio-opaque debris in the soft tissues, the radiograph is placed between the hard tissue and the soft tissue of the lip. The exposure time is one fourth of a normal periapical film.