The evaluation of the neck provides useful information for the dental practitioner by identifying conditions that might contribute with the oral health of the patient and the appropriate function of the masticatory system. At the same time, it constitutes a triage, which allows for a timely referral. There are three elements to consider in the general neck examination: history, clinical examination, and imaging.
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During the interview, the patient should be specifically asked about neck pain, mobility, sounds, and if there is history of any trauma in the head. An example is a whiplash injury produced during a motor vehicle accident. Positive responses might alert the clinician of the possibility of having a patient with cervical arthritis or muscle contractions, with limitations to position the head for dental treatment.
It is also useful to ask about persistent contraction or pain in the shoulders, to identify a patient with stress, who will require some modifications during the regular dental care, such as shorter appointments and behavioral techniques to reduce the anxiety.
Another good question during the examination is the size of the neck. Usually the patients will know that number for clothing purposes. This will allow the clinician to consider the possibility of sleep apnea (17 inches or more might be related with Obstructive Sleep Apnea).
A way to perform the evaluation is to start with neck movements and then address the neck by sections (anterior, lateral and posterior).
Neck Range of Motion
Ask the patient to gently bend forward, rotate the head, and side-bend to each side. Observe if the movements are symmetrical and if the range of motion is near normal parameters. Bending forward or cervical flexion is usually 70-80 degrees; cervical rotation might reach 90 degrees; and side-bending is usually 40-50 degrees). A restriction in the range of motion might indicate pain, muscle contraction, cervical nerve root impingement, or even a neurological condition and the patient has to be referred for proper diagnostic work-up.
Evaluation of the Anterior Section of the Neck
Start in the midline by assessing the thyroid gland, and by palpation identifying position, asymmetry, or enlargement. The patient might have a scar from a surgical procedure. Patients with thyroid problems are more prone to some oral diseases. Interdisciplinary care with the endocrinologist will be required in many cases.
The auscultation of the carotid artery is not a common practice in dentistry, but if palpation of the bifurcation area produces pain, one possible diagnosis is carotidynia, it might be the cause of facial neuralgic pain. In the anterior region, submental and supraclavicular nodes examination would identify tender or enlarge lymph nodes, requiring to rule out infections or neoplasms.
Evaluation of the lateral section of the neck
There are several neck muscles that closely relate to mandibular function and posture, such as the sternocleidomastoid (SCM) and the upper trapezius. During the lateral exam of the neck, palpation of those two muscles might be evidence of referral pain to the face (myofascial pain), being the source of pain that could be confused with odontalgia.
In between the SCM and trapezius, the scalene muscles are in close proximity with the brachial plexus, and some patients might experience a compression of that nerve bundle, producing numbness in the arm and lower pulse rate (thoracic outlet syndrome or TOS).
In the lateral region, the identification of tender or enlarged lymph nodes (cervical or
submandibular) will indicate the possibility of infections or even neoplastic
conditions requiring further evaluation.
An anatomical structure that can be evaluated by palpation is the atlas or first cervical vertebrae. The transverse process is located inferior to the ear between the angle of the mandible and the styloid process of the temporal bone. By asking the patient to move the jaw forward, the clinician can locate the structure and assess if it is symmetric and non-painful. In case of local or referred pain, a physician should assess the patient and physical therapy might be suggested.
Evaluation of the Posterior Section of the Neck
Several muscles can be palpated, starting in the nuchal line and moving the fingers downward to the seventh vertebrae. This group of muscles are post occipital and paracervical muscles and could refer pain to the temporal region. In the nuchal area, the occipital nerves emerge from the skull, and if the patient has an occipital neuralgia, tapping on that area produces pain which travels to the frontal region.
It is important to consider that if the patient has any condition in the posterior neck, the dental chair might need to be adjusted to prevent activation of pain as the patient receives dental care. As with the other regions, the evaluation of tender or enlarged lymph nodes should be performed.
The prescription of any imaging for the neck is not in the scope of practice of dentistry; however, it is important to understand some of the options patients have.
For neck visualization, plain X-ray and ultrasound (US) are a good place to start. Plain images will provide information about general structure, presence of osteophytes, and the integrity of the intravertebral spaces. US will give information of soft tissues. It is the image of choice for salivary glands, thyroid gland, parathyroid, lymph nodes and cysts.
Advanced techniques include CT (usually with contrast) for cervical adenopathy, tumors, and any other condition where anatomic delineation is needed. An MRI will help to assess presence and extension of neurogenic tumors, vascular malformations, neck masses, and angiofibromas.
The dental professional has a great responsibility identifying alterations in the neck that might contribute with orofacial conditions or complicate dental provision.
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