Examination of the Oral Cavity2

Examination of Examination of the Oral Cavitythe Oral Cavity

Physical EvaluationPhysical Evaluation

Oral ExaminationOral Examination

Many diseases (systemic or local) Many diseases (systemic or local) have signs that appear on the have signs that appear on the face, head & neck or intra-orallyface, head & neck or intra-orally

Making a complete examination Making a complete examination can help you create a differential can help you create a differential diagnosis in cases of diagnosis in cases of abnormalities and make abnormalities and make treatment recommendations treatment recommendations based on accurate assessment of based on accurate assessment of the signs & symptoms of diseasethe signs & symptoms of disease

Oral ExaminationOral Examination

Each disease process may have Each disease process may have individual manifestations in an individual manifestations in an individual patientindividual patient

And there may be individual host And there may be individual host reaction to the diseasereaction to the disease

Careful assessment will guide the Careful assessment will guide the clinician to accurate diagnosisclinician to accurate diagnosis

Scope of responsibilityScope of responsibility

Diseases of the head & neckDiseases of the head & neck Diseases of the supporting hard Diseases of the supporting hard

& soft tissues& soft tissues Diseases of the lips, tongue, Diseases of the lips, tongue,

salivary glands, oral mucosasalivary glands, oral mucosa Diseases of the oral tissues which Diseases of the oral tissues which

are a component of systemic are a component of systemic diseasedisease

EquipmentEquipment

Assure that you have all the supplies Assure that you have all the supplies necessary to complete an oral necessary to complete an oral examinationexamination MirrorMirror Tissue retractor (tongue blade)Tissue retractor (tongue blade) Dry gauzeDry gauze

You must dry some of the tissues in You must dry some of the tissues in order to observe the nuances of any order to observe the nuances of any color changescolor changes

Exam of the Head & Neck; Exam of the Head & Neck; Oral CavityOral Cavity Be systematicBe systematic Consistently complete the exam Consistently complete the exam

in the same orderin the same order See clinic handout for a general See clinic handout for a general

guideguide

Extra-oral examinationExtra-oral examination

Observe: color of skinObserve: color of skin Examination area of head & neckExamination area of head & neck

Determine: gross functioning of Determine: gross functioning of cranial nervescranial nerves Normal vs. abnormal Normal vs. abnormal

ParalysisParalysis Stroke, trauma, Bell’s PalsyStroke, trauma, Bell’s Palsy


TMJTMJ Palpate upon openingPalpate upon opening

What is the maximum intermaxillary What is the maximum intermaxillary space?space?

Is the opening symmetrical?Is the opening symmetrical? Is there popping, clicking, grinding?Is there popping, clicking, grinding?

What do these sounds tell you about the What do these sounds tell you about the anatomy of the joint?anatomy of the joint?

When do sounds occur?When do sounds occur? Use your stethoscope to listen to soundsUse your stethoscope to listen to sounds


Lymph node Lymph node palpationpalpation Refer to handoutRefer to handout

Thyroid Gland EvaluationThyroid Gland Evaluation


Thyroid Gland Thyroid Gland PalpationPalpation Place hands over Place hands over

the tracheathe trachea Have the patient Have the patient

swallowswallow The thyroid gland The thyroid gland

moves upwardmoves upward

Exam: LipsExam: Lips

Observe the color & its Observe the color & its consistency-intra-orally and consistency-intra-orally and externallyexternally

Is the vermillion border distinct?Is the vermillion border distinct? Bi-digitally palpate the tissue Bi-digitally palpate the tissue

around the lips. Check for around the lips. Check for nodules, bullae, abnormalities, nodules, bullae, abnormalities, mucocele, fibromamucocele, fibroma



Evert the lip and examine the tissueEvert the lip and examine the tissue Observe frenum attachment/tissue Observe frenum attachment/tissue

tensiontension Clear mucous filled pockets may be Clear mucous filled pockets may be

seen on the inner side of the lip seen on the inner side of the lip (mucocele). This is a frequent, (mucocele). This is a frequent, non-pathologic entity which non-pathologic entity which represents a blocked minor salivary represents a blocked minor salivary glandgland

Exam: Lips-palpationExam: Lips-palpation

Color, consistencyColor, consistency Area for blocked minor salivary Area for blocked minor salivary

glandsglands Lesions, ulcersLesions, ulcers


Frenum:Frenum: AttachmentAttachment Level of attached Level of attached

gingivagingiva

Exam: Lips-sun exposureExam: Lips-sun exposure


Palpate in the Palpate in the vestibule, vestibule, observe colorobserve color

Examination: Buccal Examination: Buccal MucosaMucosa Observe color, character of the mucosaObserve color, character of the mucosa

Normal variations in color among ethnic Normal variations in color among ethnic groupsgroups

Amalgam tattoo Amalgam tattoo Palpate tissuePalpate tissue Observe Stenson’s duct opening for Observe Stenson’s duct opening for

inflammation or signs of blockageinflammation or signs of blockage Visualize muscle attachments, hamular Visualize muscle attachments, hamular

notch, pterygomandibular foldsnotch, pterygomandibular folds

Examination: Buccal Examination: Buccal MucosaMucosa Linea albaLinea alba Stenson’s ductStenson’s duct

Examination: Buccal Examination: Buccal MucosaMucosa Lesions – white, red Lesions – white, red Lichen Planus, Leukedema Lichen Planus, Leukedema

GingivaGingiva

Note color, tone, Note color, tone, texture, texture, architecture & architecture & mucogingival mucogingival relationshipsrelationships

GingivaGingiva

How would you describe the gingiva?How would you describe the gingiva? Marginal vs. generalized?Marginal vs. generalized? Erythematous vs. fibrousErythematous vs. fibrous

Drug reactions: Anti-epileptic, Drug reactions: Anti-epileptic, calcium channel blockers, calcium channel blockers, immunosuppressant immunosuppressant

Exam: Hard palateExam: Hard palate

Minor salivary glands, attached Minor salivary glands, attached gingivagingiva

Note presence of tori: tx plan Note presence of tori: tx plan any pre-prosthetic surgery any pre-prosthetic surgery

Exam: Soft palateExam: Soft palate

How does soft palate raise upon How does soft palate raise upon “aah”?“aah”?

Vibrating line, tonsilar pillars, Vibrating line, tonsilar pillars, tonsils, oropharynxtonsils, oropharynx

Exam: OropharanyxExam: Oropharanyx

Color, consistency of tissueColor, consistency of tissue Look to the back, beyond the soft Look to the back, beyond the soft

palatepalate Note occasional small globlets of Note occasional small globlets of

transparent or pink opaque transparent or pink opaque tissue which are normal and may tissue which are normal and may include lymphoid tissueinclude lymphoid tissue

Exam: TonsilsExam: Tonsils

Tucked in at base of anterior & Tucked in at base of anterior & posterior tonsilar pillarsposterior tonsilar pillars

Globular tissue that has Globular tissue that has “punched out” appearing areas“punched out” appearing areas

Regresses after adulthoodRegresses after adulthood May see white “orzo rice like” or May see white “orzo rice like” or

“torpedo” shaped white “torpedo” shaped white concretions within the tissueconcretions within the tissue

Exam: TongueExam: Tongue

The tongue and the floor of the The tongue and the floor of the mouth are the most common mouth are the most common places for oral cancer to occurplaces for oral cancer to occur

It can occur other places; so It can occur other places; so visualize all areasvisualize all areas

You may observe:You may observe: Circumvalate papillae, epiglottisCircumvalate papillae, epiglottis


Have the patient stick out their Have the patient stick out their tonguetongue

Wrap the tongue in a dry gauze Wrap the tongue in a dry gauze and gently pull it from side to and gently pull it from side to side to observe the lateral side to observe the lateral bordersborders

Retract the tongue to view the Retract the tongue to view the inferior tissuesinferior tissues



You may observe You may observe lingual lingual varicosities varicosities


You may observe geographic You may observe geographic tongue (erythema migrans)tongue (erythema migrans)


You may observe drug reactionYou may observe drug reaction


Observe signs of nutritional Observe signs of nutritional deficiencies, immune dysfunctiondeficiencies, immune dysfunction


You may observe You may observe oral canceroral cancer

Exam: Floor of mouthExam: Floor of mouth

Visualize, palpate - bimanuallyVisualize, palpate - bimanually Wharton’s duct Wharton’s duct Must dry to observeMust dry to observe

Does “lesion” wipe off?Does “lesion” wipe off? Where are the two mostWhere are the two most

likely areas for oral cancer?likely areas for oral cancer? lateral border of the tonguelateral border of the tongue Floor of mouthFloor of mouth

Palpation of the floor of the Palpation of the floor of the mouthmouth



Squamous Cell CarcinomaSquamous Cell Carcinoma


Squamous Cell CarcinomaSquamous Cell Carcinoma

Exam: Leukoplakic area Exam: Leukoplakic area

Edentulous Mandibular Ridge


Oral Cancer:Oral Cancer: RedRed WhiteWhite Red and WhiteRed and White

Does the patient have important Does the patient have important risk factors for oral cancer?risk factors for oral cancer? Counseling for smoking and alcoholCounseling for smoking and alcohol

Cessation Cessation

Squamous Cell Squamous Cell CarcinomaCarcinoma

Triaging Lesions Triaging Lesions **

Describe it’s characteristicsDescribe it’s characteristics Size, shape, color, consistency, locationSize, shape, color, consistency, location

How long has it been present?How long has it been present? Is it related to a trauma?Is it related to a trauma?

Fractured cusp, occlusal traumaFractured cusp, occlusal trauma Has it occurred before?Has it occurred before? Can you wipe it off? Can you wipe it off? Does the patient have specific risk Does the patient have specific risk

factors for neoplastic lesions?factors for neoplastic lesions?

Triaging Lesions Triaging Lesions **

Any lesion that is suspicious Any lesion that is suspicious should be re-evaluated in 2 should be re-evaluated in 2 weeksweeks Lesions due to infectious processes Lesions due to infectious processes

would have healed in that time would have healed in that time frameframe

If it remains, the lesions should be If it remains, the lesions should be biopsiedbiopsied

Exam: Maxilla & Exam: Maxilla & MandibleMandible• size, shape, contour

• pre-prosthetic treatment

•Tori removal

• tuberosity reduction

•Soft or hard tissue or both

Exam: Maxilla & Exam: Maxilla & MandibleMandible

Exam: Maxilla & Exam: Maxilla & MandibleMandible

Exam: Maxilla & Exam: Maxilla & MandibleMandible Evaluate for Evaluate for

Epulis fissuratumEpulis fissuratum

If you make a If you make a new denture will new denture will the excess tissue the excess tissue resolve?resolve?

OcclusionOcclusion

Orthodontic Orthodontic classificationclassification

InterferencesInterferences

OcclusionOcclusion

Systematic Oral Systematic Oral ExaminationExamination Done at initial exam & at recalls Done at initial exam & at recalls

unless patient history requires soonerunless patient history requires sooner You must visualize all areas of the You must visualize all areas of the

oral cavityoral cavity Oral cancer can occur in other places Oral cancer can occur in other places

than the lateral borders of the tongue than the lateral borders of the tongue & the floor of the mouth& the floor of the mouth

Be completeBe complete Do good, do no harm, do justice, Do good, do no harm, do justice,

respect autonomyrespect autonomy

Visualize all areasVisualize all areas

BreathBreath

Oral odors can indicate:Oral odors can indicate: Infection: caries, periodontal dxInfection: caries, periodontal dx URT infectionsURT infections Chronic G.I. disturbancesChronic G.I. disturbances Lung abscessLung abscess Diabetic acidosisDiabetic acidosis Uremia, kidney problemUremia, kidney problem Liver failure: mousy, musty odorLiver failure: mousy, musty odor Self-medication with alcoholSelf-medication with alcohol

Documentation: Documentation: NomenclatureNomenclature Infection Control ICInfection Control IC No change in medical No change in medical

status status NCMH NCMH Mesial Mesial

MM DistalDistal D D Lingual/PalatalLingual/Palatal L L Facial FFacial F Buccal BBuccal B IncisalIncisal I I Occlusal OOcclusal O

Amalgam Amalgam AmAm

Composite Composite CpCp

RestorationRestoration Rest Rest Calcium hydroxide Calcium hydroxide

CaOHCaOH Cement base Cement base

CBCB Zinc Phos. Cement Zinc Phos. Cement

CMTCMT Glass Ionomer Cemnt Glass Ionomer Cemnt

GIGI LidocaineLidocaine Lido Lido

Documentation: Documentation: NomenclatureNomenclature Epinephrine EpiEpinephrine Epi BridgeBridge

BrdgBrdg Crown Crown

CrnCrn Post & corePost & core P&C P&C Gutta Percha Gutta Percha

GPGP Partial denture Partial denture

RPDRPD Complete denture F/FComplete denture F/F EndodonticsEndodontics Endo Endo

Open & Drain Open & Drain O/DO/D

Prophylaxis Prophylaxis ProphyProphy

Scaling & Rt Plan. Scaling & Rt Plan. ScRpScRp

Broken Appointment Broken Appointment BABA

Canceled Appt.Canceled Appt. CA CA Extraction Extraction

ExtExt Non-vital Non-vital

NVNV

ChartingCharting

Symbols:Symbols: Restorations + missing teeth: Restorations + missing teeth:

blue/blackblue/black Pathology, abnormalities Pathology, abnormalities

radiographic findings:radiographic findings: redred

ChartingCharting

Restorations:Restorations: RedRed DecayDecay Red outlineRed outline Faulty restorationFaulty restoration Blue/blackBlue/black AmalgamAmalgam Black outlineBlack outline Resin/compositeResin/composite ~~ Black~~ Black Fissure sealantFissure sealant Black /// through crownBlack /// through crown Crown/inlay/onlayCrown/inlay/onlay ImplantImplant

ChartingCharting

Pathology:Pathology: RedRed DecayDecay Food impactionFood impaction

^ Furcation^ Furcation 3mm 3mm

OpenContact/DiastemaOpenContact/Diastema X over rootX over root Missing tooth-part of Missing tooth-part of

fixed prosthetic fixed prosthetic applianceappliance

ChartingCharting

Pathology:Pathology: Uneven marginal ridgesUneven marginal ridges D D DriftDrift D D D D ExtrudedExtruded 0 or 0 or Periapical area Periapical area

(abscess, surgery)(abscess, surgery) over toothover tooth Tooth to be Tooth to be

extractedextracted

ChartingCharting Remember: the dental chart is a legal Remember: the dental chart is a legal

documentdocument Failure to document means it didn’t Failure to document means it didn’t

happenhappen Use blue or black inkUse blue or black ink Do not use “white out”; if error-cross out Do not use “white out”; if error-cross out

with a single strike through and initialwith a single strike through and initial Document:Document:

Visits, meds prescribed, meds taken, Visits, meds prescribed, meds taken, conversations w/ physicians, other health conversations w/ physicians, other health care workerscare workers

Example of Dental Example of Dental ChartingCharting

Documents

Examination of the Oral Cavity2