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Examination of the Oral Cavity. Physical Evaluation. Oral Examination. Many diseases (systemic or local) have signs that appear on the face, head & neck or intra-orally

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Examination of the Oral Cavity


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oral examination
Oral Examination
  • Many diseases (systemic or local) have signs that appear on the face, head & neck or intra-orally
  • Making a complete examination can help you create a differential diagnosis in cases of abnormalities and make treatment recommendations based on accurate assessment of the signs & symptoms of disease
oral examination3
Oral Examination
  • Each disease process may have individual manifestations in an individual patient
  • And there may be individual host reaction to the disease
  • Careful assessment will guide the clinician to accurate diagnosis
scope of responsibility
Scope of responsibility
  • Diseases of the head & neck
  • Diseases of the supporting hard & soft tissues
  • Diseases of the lips, tongue, salivary glands, oral mucosa
  • Diseases of the oral tissues which are a component of systemic disease
equipment
Equipment
  • Assure that you have all the supplies necessary to complete an oral examination
    • Mirror
    • Tissue retractor (tongue blade)
    • Dry gauze
  • You must dry some of the tissues in order to observe the nuances of any color changes
exam of the head neck oral cavity
Exam of the Head & Neck; Oral Cavity
  • Be systematic
  • Consistently complete the exam in the same order
  • See clinic handout for a general guide
extra oral examination
Extra-oral examination
  • Observe: color of skin
  • Examination area of head & neck
  • Determine: gross functioning of cranial nerves
    • Normal vs. abnormal
      • Paralysis
        • Stroke, trauma, Bell’s Palsy
extra oral examination8
Extra-oral examination
  • TMJ
  • Palpate upon opening
    • What is the maximum intermaxillary space?
    • Is the opening symmetrical?
    • Is there popping, clicking, grinding?
      • What do these sounds tell you about the anatomy of the joint?
      • When do sounds occur?
    • Use your stethoscope to listen to sounds
extra oral examination9
Extra-oral examination
  • Lymph node palpation
    • Refer to handout
extra oral examination11
Extra-oral examination
  • Thyroid Gland Palpation
    • Place hands over the trachea
    • Have the patient swallow
    • The thyroid gland moves upward
exam lips
Exam: Lips
  • Observe the color & its consistency-intra-orally and externally
  • Is the vermillion border distinct?
  • Bi-digitally palpate the tissue around the lips. Check for nodules, bullae, abnormalities, mucocele, fibroma
exam lips14
Exam: Lips
  • Evert the lip and examine the tissue
  • Observe frenum attachment/tissue tension
  • Clear mucous filled pockets may be seen on the inner side of the lip (mucocele). This is a frequent, non-pathologic entity which represents a blocked minor salivary gland
slide15

Exam: Lips-palpation

  • Color, consistency
  • Area for blocked minor salivary glands
  • Lesions, ulcers
exam lips16
Exam: Lips
  • Frenum:
    • Attachment
    • Level of attached gingiva
exam lips18
Exam: Lips
  • Palpate in the vestibule, observe color
examination buccal mucosa
Examination: Buccal Mucosa
  • Observe color, character of the mucosa
    • Normal variations in color among ethnic groups
    • Amalgam tattoo
  • Palpate tissue
  • Observe Stenson’s duct opening for inflammation or signs of blockage
  • Visualize muscle attachments, hamular notch, pterygomandibular folds
examination buccal mucosa20
Examination: Buccal Mucosa
  • Linea alba
  • Stenson’s duct
examination buccal mucosa21
Examination: Buccal Mucosa
  • Lesions – white, red
  • Lichen Planus, Leukedema
gingiva
Gingiva
  • Note color, tone, texture, architecture & mucogingival relationships
gingiva23
Gingiva
  • How would you describe the gingiva?
    • Marginal vs. generalized?
    • Erythematous vs. fibrous
  • Drug reactions: Anti-epileptic, calcium channel blockers, immunosuppressant
slide24

Exam: Hard palate

  • Minor salivary glands, attached gingiva
  • Note presence of tori: tx plan any pre-prosthetic surgery
slide25

Exam: Soft palate

  • How does soft palate raise upon “aah”?
  • Vibrating line, tonsilar pillars, tonsils, oropharynx
slide26

Exam: Oropharanyx

  • Color, consistency of tissue
  • Look to the back, beyond the soft palate
  • Note occasional small globlets of transparent or pink opaque tissue which are normal and may include lymphoid tissue
slide27

Exam: Tonsils

  • Tucked in at base of anterior & posterior tonsilar pillars
  • Globular tissue that has “punched out” appearing areas
  • Regresses after adulthood
  • May see white “orzo rice like” or “torpedo” shaped white concretions within the tissue
exam tongue
Exam: Tongue
  • The tongue and the floor of the mouth are the most common places for oral cancer to occur
  • It can occur other places; so visualize all areas
  • You may observe:
    • Circumvalate papillae, epiglottis
exam tongue29
Exam: Tongue
  • Have the patient stick out their tongue
  • Wrap the tongue in a dry gauze and gently pull it from side to side to observe the lateral borders
  • Retract the tongue to view the inferior tissues
exam tongue31
Exam: Tongue
  • You may observe lingual varicosities
exam tongue32
Exam: Tongue
  • You may observe geographic tongue (erythema migrans)
exam tongue33
Exam: Tongue
  • You may observe drug reaction
exam tongue34
Exam: Tongue
  • Observe signs of nutritional deficiencies, immune dysfunction
exam tongue35
Exam: Tongue
  • You may observe oral cancer
slide36

Exam: Floor of mouth

  • Visualize, palpate - bimanually
  • Wharton’s duct
  • Must dry to observe
    • Does “lesion” wipe off?
  • Where are the two most

likely areas for oral cancer?

    • lateral border of the tongue
    • Floor of mouth
slide39

Exam: Floor of mouth

  • Squamous Cell Carcinoma
slide40

Exam: Floor of mouth

  • Squamous Cell Carcinoma
exam leukoplakic area
Exam: Leukoplakic area

Edentulous Mandibular Ridge

slide42

Exam: Floor of mouth

  • Oral Cancer:
    • Red
    • White
    • Red and White
  • Does the patient have important risk factors for oral cancer?
    • Counseling for smoking and alcohol
      • Cessation
triaging lesions
Triaging Lesions *
  • Describe it’s characteristics
    • Size, shape, color, consistency, location
  • How long has it been present?
  • Is it related to a trauma?
    • Fractured cusp, occlusal trauma
  • Has it occurred before?
  • Can you wipe it off?
  • Does the patient have specific risk factors for neoplastic lesions?
triaging lesions45
Triaging Lesions *
  • Any lesion that is suspicious should be re-evaluated in 2 weeks
    • Lesions due to infectious processes would have healed in that time frame
    • If it remains, the lesions should be biopsied
slide46

Exam: Maxilla & Mandible

  • size, shape, contour
  • pre-prosthetic treatment
    • Tori removal
    • tuberosity reduction
      • Soft or hard tissue or both
slide49
Evaluate for Epulis fissuratum

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

Exam: Maxilla & Mandible

occlusion
Occlusion
  • Orthodontic classification
  • Interferences
slide52

Systematic Oral Examination

  • Done at initial exam & at recalls unless patient history requires sooner
  • You must visualize all areas of the oral cavity
  • Oral cancer can occur in other places than the lateral borders of the tongue & the floor of the mouth
  • Be complete
  • Do good, do no harm, do justice, respect autonomy
breath
Breath
  • Oral odors can indicate:
    • Infection: caries, periodontal dx
    • URT infections
    • Chronic G.I. disturbances
    • Lung abscess
    • Diabetic acidosis
    • Uremia, kidney problem
    • Liver failure: mousy, musty odor
    • Self-medication with alcohol
documentation nomenclature
Infection Control IC

No change in medical status NCMH

Mesial M

Distal D

Lingual/Palatal L

Facial F

Buccal B

Incisal I

Occlusal O

Amalgam Am

Composite Cp

Restoration Rest

Calcium hydroxide CaOH

Cement base CB

Zinc Phos. Cement CMT

Glass Ionomer Cemnt GI

Lidocaine Lido

Documentation: Nomenclature
documentation nomenclature56
Epinephrine Epi

Bridge Brdg

Crown Crn

Post & core P&C

Gutta Percha GP

Partial denture RPD

Complete denture F/F

Endodontics Endo

Open & Drain O/D

Prophylaxis Prophy

Scaling & Rt Plan. ScRp

Broken Appointment BA

Canceled Appt. CA

Extraction Ext

Non-vital NV

Documentation: Nomenclature
charting
Charting
  • Symbols:
    • Restorations + missing teeth: blue/black
    • Pathology, abnormalities

radiographic findings: red

charting58
Charting
  • Restorations:
    • Red Decay
    • Red outline Faulty restoration
    • Blue/black Amalgam
    • Black outline Resin/composite
    • ~~ Black Fissure sealant
    • Black /// through crown Crown/inlay/onlay
    • Implant
charting59
Charting
  • Pathology:
    • Red Decay
    • Food impaction
    • ^ Furcation
    • 3mm OpenContact/Diastema
    • X over root Missing tooth-part of

fixed prosthetic appliance

charting60
Charting
  • Pathology:
    • Uneven marginal ridges
    • D Drift
    • D D Extruded
    • 0 or Periapical area (abscess, surgery)
    • over tooth Tooth to be extracted
charting61
Remember: the dental chart is a legal document

Failure to document means it didn’t happen

Use blue or black ink

Do not use “white out”; if error-cross out with a single strike through and initial

Document:

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

Charting