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Chapter 12

Extraoral and Intraoral Examination

2Copyright © 2017 Wolters Kluwer • All Rights Reserved

Chapter Outline

• Rationale • Components• Landmarks• Sequence• Morphologic Categories• Oral Cancer• Biopsy Determination• Documentation• Everyday Ethics• Factors to Teach the Patient


Learning Objectives

• Explain the rationale• Explain the systematic sequence• Identify normal anatomy• Describe physical characteristics• Identify suspicious conditions


Rationale For The Extraoral And Intraoral Examination

• Early identification• To detect cancer• Thyroid disorders• Eating disorders• Nutritional deficiencies• Sexually transmitted diseases • Systemic conditions

Copyright © 2017 Wolters Kluwer • All Rights Reserved

Components of the Examination

• Concept of total patient being treated

• Examination is all-inclusive– Physical–Mental– Psychological

• Routine, thorough examination• Assessment of health-related risk

factors

5


I. Types of Examinations

• Complete• Screening• Limited examination• Follow- up• Continuing care/reevaluation


II. Methods for Examination

• Visual examination• Palpation• Instrumentation• Percussion• Electrical test• Auscultation


FIGURE 12-1 Bidigital Palpation


FIGURE 12-2 Bimanual Palpation. A: Examination of the buccal mucosa by

simultaneouspalpation on extraorally

and intraorally. B: Examination of the floor

of themouth by simultaneous palpation with fingers of each hand in apposition


FIGURE 12-4 Assessment of the Temporomandibular Joint


III. Signs and Symptoms

• Signs• Objective

• Symptoms• Subjective


IV. Preparation for Examination

• Review the patient’s histories• Examine radiographs• Patient understanding• Cultural sensitivity


Anatomical Landmarks Of The Oral Cavity

I. Oral Mucosa– Masticatory Mucosa– Lining Mucosa– Specialized Mucosa


FIGURE 12-6 Anatomical Landmarks of the Oral Cavity-Dorsal Tongue View. A: View of hard and soft palate. B: View of uvula and oro-pharynx.


Sequence of Examination

1. Overall appraisal of patient2. Face3. Skin4. Eyes5. Nodes6. Glands7. Temporomandibular joint8. Lips


Sequence of Examination

9. Breath odor10.Labial and buccal mucosa11.Tongue12.Floor of mouth13.Saliva14.Hard palate15.Soft palate, uvula16.Tonsillar region, throat


FIGURE 12-7 Anatomical Landmarks of the Oral Cavity-

Ventral Tongue View


Lymph Nodes


I. Extraoral Examination

• . Observe patient during reception and seating to note• physical characteristics and abnormalities, and make an• overall appraisal.• 2. Observe head, face, eyes, and neck, and evaluate the• skin of the face and neck.• 3. Request the patient remove prosthesis prior to performing• the intraoral examination. Explain how this will• improve the ability to inspect all areas of the mouth• adequately.• 4. Palpate the salivary glands and lymph nodes. Figure 12-8• shows the location of the major lymph nodes of the face,• oral regions, and neck. Palpation is a significant component• of the extra-/intraoral examination (Figure 12-9).


I. Extraoral Examination

• Pain or discomfort upon palpation and/or upon• swallowing.• Persistent difficulty swallowing in the absence

of pain.• Any recent noticeable lumps the patient may

have• experienced without pain.• Persistent earache or hoarseness of voice.• Observe mandibular movement and palpate

TMJ


II. Intraoral Examination

• Lips & intraoral mucosa• View/palpate lips, labial and buccal mucosa, and

mucobuccal folds.• Examine and palpate the tongue• Mucosa of the floor of the mouth. • Hard and soft palates, tonsillar areas, and

pharynx • Use a mirror

• oropharynx, nasopharynx, and larynx.6. Note amount and consistency of the saliva and evidence of dry mouth (xerostomia).


Documentation of Findings

A. HistoryB. Location and ExtentC. Physical Characteristics


Morphologic Categories

I. Elevated LesionsII. Blisterform

I. VesicleII. PustuleIII. Bulla

IV. NonblisterformI. PapuleII. NoduleIII. TumorIV. Plaque


II. Depressed Lesions

• Ulcer• Loss of continuity of epithelium

• Erosion• Shallow• Does not extend through

epithelium to underlying tissue


III. Flat Lesions

• Macule• Circumscribed• Not elevated above surrounding skin

or mucosa• Identified by color


IV. Other Descriptive Terms

• Crust• Erythema• Indurated• Papillary • Petechiae• Pseudomembrane• Polyp• Punctate• Torus• Verrucous


Oral Cancer

I. LocationII. Appearance of Early Cancer

– Leukoplakia– Red areas• Velvety

– Erythroplakia– Ulcers– Masses– Pigmentation


Procedure For Determining when A

Suspicious Lesion requires a biospy• Brush cytology

• toluidine blue• Diffuse tissue reflectance • laser-induced auto fluorescence


I. Exfoliative Cytology

A. Cytological SmearB. Liquid-Based CytologyC. Oral Brush Cytology


II. Spectroscopy

• Laser-Induced Autofluorescence– VELscope

• Diffuse Reflectance Spectroscopy


III. Biopsy

• Indications for biopsy• Pathology report

• Class I : Normal• Class II : Atypical, but not suggestive

of malignant cells.• Class III: Uncertain (possible for

cancer)• Class IV: Probable for cancer.• Class V: Positive for cancer


Documentation

• Every detail of the oral examination• Recommendations for frequency of exam• Review of all lifestyle habits• Progress note of first maintenance appt.


Factors to Teach the Patient

• Guidance and support• Self-examination monthly• Dietary and nutritional influences• Oral cavity reflects general health• Warning signs of oral cancer

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