Intra/Extra Oral Examination

Question 1

Hand relevance to systemic health?

Answer 1

be sure to check the hands for evidence of habits such as nail biting, HPV infections, nail infections, nail pitting, signs of arthritis, systemic disease states and tobacco use

Question 2

Purpose of the extra oral examination?

Answer 2

The examination will enable the clinician to focus attention on careful observation of the structures of the head and neck

• cancer screening
• tmj pain
• patients see their dentist more than their doctor

Question 3

Prostheses? what to look out for?

Answer 3

• Any intraoral prostheses (dentures or partial dentures) are removed before starting the examination.
• These should be examined for any hygiene issues and ask the patient about the fit and function.
• Stored in a receptacle in water until the patient is ready to leave

Question 4

Basics of the extra-oral assessment?

Answer 4

• The extraoral assessment includes an inspection of the face, head, and neck.
• The face, ears, and neck are observed, noting any asymmetry or changes on the skin such as crusts, fissuring, growths, and/or colour change.
• The regional lymph node areas are bilaterally palpated to detect any enlarged nodes, and if detected, their mobility and consistency as well as the TMJ area.

Question 5

Symmetry and profile? Relevance? What it could show?

Answer 5

• Discreetly observe the patient for facial symmetry and profile type .
• Obvious asymmetry may be a red flag for neoplastic growths, muscle atrophy or hypertrophy, and neurological problems.
• Asymmetry is also associated with temporomandibular joint dysfunction and malocclusions.

Question 6

Cuts, scabs and scars? What to do and what they represent?

Answer 6

• As in the general appraisal, the exposed skin of the head and neck should be examined for suspicious lesions.
• The skin of the neck and scalp can be examined discretely while the clinician is palpating the lymph nodes. The area behind and around the ear can be observed while palpating the auricular nodes.
• The patient should be questioned about their knowledge of any lesions discovered during the examination and also any lesions that they may have noticed themselves anywhere on the body.
• Information about the history, and any symptoms such as pain, pruritus (itching) or other abnormal sensations associated with the lesions is crucial in determining a differential diagnosis and can assist in deciding whether to refer to a specialist.

Question 7

The lips and perioral area? relevance, what to look for and what it means?

Answer 7

Lips:

• symmetry
• tissue consistency
• texture
• smooth
• homogenous pink
• vermillion border should be distinct

Perioral:

• viral infections can cause sores to appear
• cracking dry lips (dermatitis)
• Vaseline to coat lips to reduce cracking
• early UV damage present by indistinct or broken border (or colour variation), advice suncream

Should be clear of lesions and not show signs of dryness or cracking

Question 8

Lymph node check? relevance, how and where?

Answer 8

• to palpate, use pads of all four fingertips (most sensitive)
• exam both sides simultaneously, by walking your fingers down the area while applying steady, gentle pressure
  Things to note:
• enlarged palpable nodes, fixed nodes, tender nodes
• whether the nodes are single or present in a group

Findings which include single or multiple, non-tender and fixed nodes are very suspicious for malignancy

Nodes can be tender with some types of infection

Remember to correlate findings from the medical history and general appraisal of the patient to the observations made during the head and neck examination

Question 9

Horizontal/Vertical chain of action when palpating head and neck lymph nodes? Process?

Answer 9

Head: Horizontal
- occipital
- posterior auricular
- preauricular
- parotid
- tonsillar
- submandibular
- submental
Neck: Vertical
- superficial cervical
- deep cervical
- posterior cervical
- supraclavicular

Question 10

TMJ? relevance, how and where?

Answer 10

Place the fingertips over the joint and have the patient open and close slowly, move the jaw to the left and right and jut the chin out. (depression, elevation, lateral excursion, protrusion and of the mandible and back to rest)

Look for altered opening and closing pathways, abnormal sounds, tenderness and limitations in opening.

An altered pathway on opening which comes back to the midline at maximum opening is termed a deviation.

Abnormal sounds may be heard or felt and usually fall into one or more of three major categories, clicks, pops and crepitus.

Clicks and pops are associated with auricular disk derangement and crepitus is usually associated with some form of arthritis.

Question 11

General areas of intra-oral examination?

Answer 11

• Oropharynx (posterior wall, pillars and tonsillar area)
• Soft and hard palates
• Buccal and labial mucosa
• Gingiva
• Mandible and floor of mouth
• Tongue
• Saliva

Question 12

Oropharynx? relevance, how and where?

Answer 12

• Examine by placing a mirror or tongue depressor on the top of the tongue
• Aided by saying aaaaah
• Hopefully be able to see the posterior pharyngeal wall, uvula, anterior and posterior pillars, the palatoglossus folds and the tonsils

Posterior pharyngeal wall:

• appear very vascular and reddish pink
• surface may be smooth and coral pink (gelatin-like)

Anterior and Posterior pillars:

• vascular, smooth and symmetrical
• abnormal findings: lymphoid aggregates, pale scarring (in radial or stellate pattern) and absent landmarks due to surgery

Pathology:

• asymmetry
• lesions
• erythema (exudates)

Question 13

Tonsillar crypts? relevance, how and where?

Answer 13

• Direct visualisation
• Observe rough, lobular and coral to light pink tissue
• Atypical: excessively large or asymmetrical and cratered surfaces without erythema or exudates

Large tonsillar crypts can trap food debris
(cryptic tonsils - could cause halitosis)

Pathological findings:

• dysphagia (difficult swallowing)
• swelling, asymmetry, erythema and exudates
• mouth breathing (nasal obstruction)

Question 14

Soft palate and uvula? relevance, how and where?

Answer 14

• Direct vision (not palpable unless necessary, needs topical anaesthetic)
• Slightly less vascular (than oroph) and reddish pink in colour
• Should appear loose, mobile and symmetrical (spongy consistency)
• Atypical: yellowish due to increased adipose, excessively long or short uvulas (asymmetry)
• Pathological: lesions and loss of function/symmetry (show compromised swallowing capabilities)

Question 15

Hard palate? relevance, how and where?

Answer 15

• Direct and indirect vision (and illumination)
• Homogenous pale pink, firm to palpate towards anterior and lateral to midline (while more compressible towards the posterior and medial apices of the teeth
• Incisive papilla: protuberance of soft tissue lingual to maxillary central incisors (covers incisive foramen)
• Raphe: elevated line extending from the incisive papilla
• Rugae: corrugated ridges

Maxillary tuberosities:
- distal to last molar and should be pink and frm to palpate

Torus palatinus: most common atypical finding;

• vary in size and be single or multilobular
• may possess lesions

Question 16

Buccal mucosa? relevance, how and where?

Answer 16

• Direct and indirect vision followed by bi-digital palpation
• Stretch the tissues away from the retromolar area (mucogingival junction)
• Palpation via the index finger and thumb
• Soft with no discernible induration
• Stensen’s duct identification
• Fordyce’s granules (common atypical finding)
• Small papules indicative of sclerotic or fibrotic minor salivary glands
• Assist patient with stress reducing techniques
• Traumatic injuries: thermal burns, cheek bites, ulcers and fibroma

Question 17

Labial mucosa? relevance, how and where/

Answer 17

• Direct vision by averting the tissues over the fingers and thumbs followed by bidigital palpation of the lips
• Move the tissues from side to side
• Look deep pink colour with gradual change to a deep red, with more prominent vascularity
• Should be moist and have uniform consistency and thickness

Pathological:

• abrasions and lacerations
• cracked lips
• angular cheilitis (herpes)
• ulcers

Question 18

Gingiva? What to look at?

Answer 18

• Examine buccal, labial, palatal and lingual aspects

Question 19

Mandible? relevance, how and where?

Answer 19

• Direct and indirect vision followed by digital palpation of entire structure
• Tissues of the floor of mouth should be stretched away from the inferior border (with mouth mirror)
• Should be coral pink and form consistency with no visible lesions
  Atypical findings:
• tori and exostoses

Lesions can be present from third molar

Pathological:
- lesions, ulcers and abrasions

Question 20

Floor of the mouth? relevance, how and where? Key landmarks?

Answer 20

The floor of the mouth is examined using direct and indirect vision followed by bimanual palpation of the entire area. The patient should be asked to raise the tongue making direct visual examination of the tissues toward the midline of the floor of the mouth possible

Mirror should be used to examine the areas near the inferior border of the mandible. The tissues should appear moist and very vascular. The normal anatomy of the area should be identified including:

• Sublingual duct– small rounded projection at the base of the lingual frenum which houses Wharton’s duct from the submandibular salivary gland
• Sublingual folds – two oblique elevations found radiating laterally away from the lingual frenum on either side which house the ducts from the sublingual salivary gland
• Lingual frenum – muscle attachment from the ventral surface of the tongue to the floor of the mouth. This attachment varies in length from person to person.

Question 21

The tongue? relevance, how and where?

Answer 21

• The tongue is examined using both direct and indirect vision.
• Grasp the tip of the tongue with a gauze square and roll the tongue over on one side to observe the lateral border then repeat for the other side.
• Use the mirror to examine the posterior lateral borders if necessary
• Have the patient raise the tongue to the roof of the mouth to observe the ventral surface
• The tissues should appear pink in color with a rough surface texture on the dorsal surface and a smoother surface texture on the ventral surface.
• The tongue should be symmetrical in shape and in function.
• The tissues of the tongue should feel soft and resilient with no palpable indurations or masses

Dorsum of the tongue:
- Atypical findings on the dorsal surface of the tongue are common.They include: fissuring, scalloping, benign migratory glossitis – geographic tongue and enlarged papillae, among others.

Question 22

Salivary flow? relevance, how and where?

Answer 22

Atypical findings on the dorsal surface of the tongue are common. They include: fissuring ,scalloping , benign migratory glossitis – geographic tongue and enlarged papillae, among others