Examination of cranial nerves

3.Occulomotor ,4. Trochlear , 6.Abducent

Pupillory reflexes -------- both pupil on both sides should be constructed

Diplopia ----------- patient see 1 object in 2 objects

Nystagms ---------- pendular movement of the eye or rapid jerking Ptosis -------- the patient can not elevate eyelid completely.

5.Trigeminal nerve
sensory function : examined by light touch with cotton to the area motor function : by exam the muscle of mastication-

- reflexes: Cornal reflex :both eyes should be closed when each corner is stimulate with a piece of cotton.
Jaw jerk : by applying a downward tap on the chin, the tap produce a reflex contraction (( brisk closure)).

7.Facial nerve Motor function: # Ask the patient to wrinkled forehead. # Ask the patient to rise eye brows. # Ask the patient to show his teeth. # Ask the patient blow out his cheeks. Notice any involuntary movement like tics or spasm. Sensory function: test the anterior 2/3 of tongue. 8. The Vestibulocochlear nerve - Examination is done by using of Tuning fork. - The normal patient should equally heard by both ear.

9.Glossopharngael nerve
The patient loss of taste in the posterior third of the tongue or by palatal reflex---- when the soft palate is touch it move upward.

10. Vagus nerve

- The nasal quality of the voice - Drooping of unilateral or bilateral of soft palate.-

- Does the palate move when the patient says ((ah)) for long times, and also tray to observe the palatal movement in bilateral palsies here the palate will not elevate. And in unilateral lesion the one side of the palate remaining immobile.

11.The Spinal accessory nerve

Here we examine the sternomastoid and the trapezius muscle by : - ask the patient to press the chin downward against the resistance of the examiner`s hand. - ask the patient to turn against resistance.

12.Hypoglossal nerve
- Ask the patient to protrude the tongue and carefully see the deviation if there is unilateral weakness it deviated toward the paralysed side. - Ask the patient to move the tongue in- out direction & from one side to other slowly and rapidly.

- Ask the patient to press the cheek with the tongue while the examiner`s finger resist the movement by pressure on the outside the cheek. (any defect in the nerve lead to paralysis, tremor, abnormalities in movement)

TMJ
The dentist should have a sound knowledge of the function anatomy of TMJ and associated structure prior to under taking the examination of the patient.

Inspection
Examination of the TMJ and masticatory muscle should begin by observing the degree of symmetry of the mandible and face, and by observing the path of excursion of the mandible on opening and closing. It is helpful to focus on specific landmark (such as the mesial incisal edge of mandibular central incisor) whilst asking the patient to open and close their mouth in this way any lateral deviation will be noted.

Palpation
In order to examine the joint by palpation the examiner should be in front of the patient so that movement of the mandible may be related to those palpated in the condylar heads. A single finger is placed over each condylar head while the mandibular movement are carried out. Abnormal tenderness associated with the lateral aspect of joint detected by light pressure over the condyle

Intra Oral Examination

The Teeth
Number of teeth, caries and fillings , loose teeth, crowns, discoloration of teeth,.etc

The Gum
The color and texture of the gum are noted, and the standard of oral hygiene classified including the presence of plaque and calculus , recession ,pocketing ,and hyperplastic of the gum is measured, and the mobility of teeth assessed.

The Palate
Inspection of palate : ask the patient to tilt his head Slightly backwards and to open his mouth to his fullest extent. If the height is good the whole palate can be observed. - Ask the patient to say "Ah" loss of movement of half of the soft palate suggest a lesion of the vagus nerve or infiltrating neoplasm of the nasopharynx , while paralysis of the whole soft palate is found in the bulbar form of poliomyelitis.

The floor of Mouth

Ask the patient to put the tip of tongue on the roof of the mouth and bend the head slightly backward and examine the color, texture and presence of swelling or ulceration.

Examination of Mucosa of cheek

Retract the angle of the mouth and the interior is illuminated with a torch to examine the color, texture and presence of swelling or ulceration.

The Tongue
The Tongue will tell the dentist many things, not only by what we hear but by what we see first. Color: because of it`s rich blood supply of the capillary network closed to it`s surface make the color of tongue is dark red and normally it is covered by slight grayish coating. -- Excessive furring will be result from: 1) Local infection either from the mouth or from nose, throat, lung 2) Dehydration either from pyrexia, mouth breathing, smoking.

3) Discoloration of tongue can be occur due to : [a] food [b] iron containing medicine lead to black color [c] antibiotic change in oral flora --- candida infection lead to white color

4) Dry tongue mostly occur due to renal failure , dehydration ,intestinal obstruction, xerostomia , mouth breather.

The dentist have to inspect the dorsum of the tongue for any swelling, ulcer , white lesion & fissure.
-- In anemic patient : depapillated ,smooth ,sore and shiny. -- In cynosis patient : the cynosis of tongue is central in origin. -- In Acromegaly and Mongolsim ----- large and usually fissured in mongolism.

Methods of examination of tongue

(a)Examination of anterior 2/3 of the tongue Ask the patient to put out his tongue and wrapping a piece of gauze around the tip of protruded tongue and moved to left and right side to observed lateral surface, to see any abnormalities present such as large size than normal which may be due to inflammation or muscular hypertrophy (muscular macroglossia diffuse benign neoplasm). Examination of ventral surface (under surface) of the tongue done by asking the patient to rotate the tongue upward toward the rest of his mouth.

(b) Examination of posterior 1/3 of the tongue

Ask the patient to open the mouth widely and press the left index finger firmly into the cheek i.e. it intervenes between the teeth, then palpating the root of the tongue , if patient have gag reflex use spray anesthesia. Palpation of posterior 1/3 of tongue should be undertaken when the patient have : (1) discomfort at the back of the tongue (2) slight dysphasia (3) doubtful ankyloglossia

(c) Neurological examination of the tongue (Examination of hypoglossal nerve ) Inability to protrude the tongue fully may be due to ankyloglossia {in old and middle aged patient suggest advanced neoplastic infiltration of the lingual musculature , while in young patient suggest congenital short frenum}

Examination of salivary glands

The dentist should know the following information prior to examination of S.G 1/ position of S.G and associated structure 2/ clinical features of S.G diseases 3/ investigations required for every symptoms. Clinical examination; During examination the dentist may notice: 1- asymmetry and detectable extra or intra oral swelling 2- sometimes large calculi may be palpable as hardness 3- saliva should be carefully notice if it turbid or mucopurulent

4-pain and skin involve with a firm-rapidly growing mass 5-facial nerve palsy is sinister sign when the parotid mass is detected 6- lymph node detected 7-hypersalivation: this may associated with certain neurological disorder 8-dry mouth

The parotid gland

When dentist notice a swelling in site of parotid gland he should examine it as following:

Inspection The characteristic of the general enlargement is a swelling in front of the tragus extending downward and slightly backward, and obliterating the normal depression below and in front of the ear. Palpation Lay the pulp of finger over the main body of the gland and a ascertain the consistency of the swelling ( tender or not ) Palpate the superior 1/3 of the gland (if there is fullness and if it continue with the main body of the parotid gland) Lay the finger over the inferior 1/3 of the gland ( if the whole parotid gland is enlarge there will be fullness over the posterior-inferior part)

Examination of the orifice of parotid gland (stensen`s duct) which lies opposite the second upper molar by: retract the cheek with a spatula ,with a gentle pressure or massage to the parotid gland and see the saliva if there is gush purulent saliva or drops of thicker pus.

Submandibular S.G
Here the dentist notice a swelling beneath and in front of the angle of the jaw, or if the swelling occur only either just before or during meals this may give an indication that the submandibular S.G is involved. Any swelling at this area should be differentiated from other swelling in this region.