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رابعة حديث
lip
Intraoral examination Dr. Mohamed Abdel-Moniem
Intraoral Examination:-
It is the most important and most
direct diagnostic evaluation that
affects the treatment plan.
Examination should involve the
diseased and healthy regions.
To avoid overlooking of any area you
should examine the oral cavity in
systematic approach.
The intraoral examination is classified into:-
1- general appraisal of the patient’s oral
health and chief complain area.
2- examination of the soft tissues and hard
structures (mandible, maxilla and palate).
3- examination of teeth.
4- examination of the gingiva and
periodontal supporting structures.
I- general appraisal of the patient’s oral health and chief complaint area:-
Performed by Inspection
The following informations can be obtained:-
1- general inspection of the area of chief complaint.
2- presence of deposits and stains:- soft (plaque) , hard (calculus), intrinsic stains (amelogenesis imperfecta, porphyria and tetracycline staining) extrinsic stain as (food, chromogenic bacteria, smoking).
3- prevalence of caries or periodontal diseases.
4- Missing teeth and retained deciduous teeth.
5- supernumerary teeth (mesiodense, paramolar and
distomolar).
6- presence of restorations and appliances.
7- presence of halitosis.
These informations will gives idea about:-
1- Chief complaint area and the general techniques which will be used during its examination.
2- The possible diagnostic aids e.g. X-ray, biopsy …… etc.
3- Patients attitudes toward his oral health.
4- Time which will be consumed during examination.
5- The suggested treatment planning (patient with neglected and bad oral hygiene are contraindicated for advanced periodontal surgery, implants and periodontal reconstructive procedures)
Important notes during intraoral examination-
1- examination should be aimed toward
confirming normal findings and detecting
abnormalities.
2- examination should be performed in a
systematic manner to avoid omissions.
3- examination should be performed in a
manner consistent with infection control
recommendations.
The complete examination of the mouth includes
evaluation of:-
1- lips and labial mucosa.
2- Buccal mucosa.
3- Mucobuccal fold.
4- hard palate.
5- soft palate and uvula.
6- oropharynx and nasopharynx.
7- tongue.
8- floor of the mouth.
9- periodontium.
10- examination of the teeth.
1- examination of the lip and
labial mucosa:-
Lips consists of:- Vermilion border and skin.
Vermilion border is the exposed red portion
of the lip and covered by mucous membrane.
Vermilion border is bounded by the labial
mucosa in the mouth and by the
mucocutaneous junction on the face.
Vermilion border does not contain mucous
glands.
The lips are bounded in the face by:-
1- Lateral labial sulcus:- runs from the ala of
the nose downward outward.
2- Mesial labial sulcus:- begins at the corners
of the mouth (also called the commissures) and
runs parallel to the lateral labial sulcus.
3- The mental labial sulcus:- runs parallel to
the mucocutaneous junction of the lower lip.
4- Philtrum:- it is a depression dividing the
upper lip into right and left halves.
In the oral cavity:-
1- The lips are covered by mucous
membrane that has numerous mucous
glands (accessory salivary glands).
2- At the midline, the upper lip has frenum
attaching it to the maxilla and the lower
lip to the mandible.
3- The upper labial frenum in some
patients has a small tissue tag called
fibroepithelial polyp caused by trauma.
The examination of the lip is carried out by
inspection and palpation.
I- Inspection:-
Performed with the patient sitting in a relaxed facial
expression to note the lip morphology and lip seal.
Normally the lips must seal without muscle tension this
occur in normal competent lip morphology.
If the lips are apart at rest this may indicates that there
is a mouth breathing or nasal obstruction.
The part of the teeth that appear during speaking and
smiling should be considered in dental restorations and
prosthesis.
Features obtained by inspection of the lip:-
1- Morphology.
2- Color.
3- Function.
4- Lesions.
5-Texture.
6-Fissuring.
7- scars.
8- others.
A- Morphology:- The lip morphology is changed
if the lips are affected by :-
1- Cheilitis glandularis apostematosa:-
It is uncommon condition caused by chronic exposure to sun, tobacco and emotional disturbances.
It affects the lower lip in which the lip becomes enlarged, firm and finally everted exposing the openings of the accessory or minor salivary glands.
Pitting appear with pressure.
The accessory salivary glands it self becomes enlarged and sometimes nodular.
2- Cheilitis granulomatosa:- It is a diffuse swelling of the lips
especially lower lip.
The lips usually soft and exhibits no pitting upon pressure.
Cheilitis granulomatosa, facial paralysis and fissured tongue referred as Melkersson Rosenthal syndrome.
3- Lip pits:- unilateral or bilateral depression
or pit on the vermilion border commonly on the lower lip.
4- Commissural pits:- Unilateral or bilateral pits at the
corners of the mouth on the vermilion surface.
5- Cleft lips:-
Mandibular clefts are rare condition.
The maxillary cleft lip is the most common.
It may be unilateral or bilateral but not a midline one.
6- Double lip:- It is not an actual duplication of the lip.
It is a groove running between the inner and outer part of the upper lip.
Appear when the patient smiles or talks.
It can be corrected surgically.
Double lip, thyroid enlargement and dropping of the upper eyelid referred as Ascher’s syndrome.
7- Angular chelitis :-
Caused by candidal infection of the lip
commissures.
Characterized by soreness, erythema,
maceration ulceration of the commissures.
8- High attachment of the frenum:-
Labial frenum is a slender midline band
attached at the mucogingival line below the
attached gingiva.
Higher position of the frenum usually
accompanied by gingival recession, diastema
and pocket formation due to tension of the
marginal gingiva during function.
It is examined by gentle pulling of the lip
outward and noticing the retraction of the
marginal gingiva and opening of the sulcus.
Features obtained by inspection of the vermilion
border:-
1- Morphology.
2- Function.
3- Colour.
4- Fissuring.
5-. Texture
6- Lesions
7- scars.
8- others.
B- examination of the function of the lips:-
Dropping of the angle of the mouth
during speaking may be a habitual way of
speaking.
Dropping of the angle at rest may be
facial paralysis, it can be evaluated by
requesting the patient to smile and show
his teeth, blow out the check or whistle.
These functions reflect the integrity of
the 7th cranial nerve.
In facial paralysis the air will pass
through paralytic side and there will
be retention of food and calculus
covering the occlusal surface in the
that side.
Examination of the function of the
mucous glands can be performed by
everting the lip and drying it to notice
the appearance of saliva again.
Features obtained by inspection of the lip:-
1- Morphology.
2- Function.
3- Colour.
4- Lesions.
5- Texture
6-Fissuring
7- scars.
8- others.
C- Color changes of the lips:-
The lip should be retracted to permit thorough inspection of
the labial mucosa.
Common changes in lip color:-
1- pale lip:- in amemia.
2- Caynotic or bluish lip:- in heart diseases and
lung diseases.
3- Browinsh pigmentation:- may be racial or in
Addison,s disease or in hereditary intestinal
polyposis.
4- yellow spots:- in Fordyce,s granules.
5- Bloody crusted appearance:- in erythema multiform.
6- Bluish red spots :- in petechia, ecchymosis
and telangectasia.
7- white color:- in lichen planus.
8- large bluish coloration:- in hematoma due to
trauma.
Features obtained by inspection of the lip:-
1- Morphology.
2- Function.
3- Color.
4- Lesions.
5- Texture
6-Fissuring
7- scars.
8- others.
Angular chelitis and chelosis
occur due to vit. Defeciency,
candidal infection and low
vertical dimension.
Contact allergy:- caused by food,
mouthwashes, cosmetics and
filling materials.
2- Herpes labialis (H.s and H.Z).
Mucocele, mucous retention cyst
and lipoma
Focal epithelial hyperplasia:- multiple
slightly raised papules caused by HPV-
13 or HPV -32.
Lichen plannus
Actinic keratosis:- solar keratosis
occurs due to excessive exposure
to ultraviolet rays.
Angioneurotic edema:- sudden diffuse
swelling, firm and non pitting. Usually
one lip is involved
Smokers patch
II- examination of the lip by palpation:-
It is carried out by bidigital and bimanual palpation.
To detect:-
1- Consistency, pliability, firmness of the underlying
tissues.
2- surface tissue indurations.
3- glandular involvements.
N.B. submucosal nodular or granular sensation
occasionally occur normally in adults due to the
presence of the minor salivary glands.