Oral Examination Flashcards
Tooth Anatomy
- The outer protective layer of the tooth is enamel, which is extremely hard.
- The middle layer is dentin.
- The pulp is composed of nerves and blood vessels that exit the tooth via the apices.
- The root connects to alveolar bone via the periodontal ligament.
Child
Goals of Exam
Clinicians can perform a thorough and systematic oral, head, and neck exam in a primary care setting.
Goals of the exam are:
* Identify existing problems requiring early dental referral, such as:
* Tooth eruption sequence abnormalities
* Developmental defects
* Caries
* Poor oral hygiene
* Assess risk for future problems
* Provide anticipatory guidance
Child
Primary Dentition
When Do Primary Teeth Erupt?
* Primary teeth (also called baby teeth or deciduous teeth) begin to erupt at age 6 months and this process is complete by 24 and 36 months. There is considerable variation of eruption patterns and the sequence of eruption is more important than the absolute dates.
- There is rarely need to be concerned about lack of eruption unless there is evidence of a syndrome or developmental issues; or if no teeth have erupted by 18 months of age.
- Incisors: 6-12 mo
- First Molars: 1 yr
- Second Molars: 2 yr
- Canines: 1-2 yrs
Child
Knee to Knee Oral Exam
Small children are best examined while lying down. For infants and toddlers, the knee-to-knee oral examination allows you to carefully examine the child’s teeth with assistance from a caregiver.
- Start by having the caregiver hug the child for reassurance.
- Position the child so his or her legs straddle the caregiver. The child can also sit sidesaddle across the caregiver’s lap.
- Next, the caregiver should hold the child’s hands and lean the child back into the examiner’s lap.
- Perform the examination while the caregiver holds the child’s hands and legs.
Child
Exam Components
The key to a successful oral exam is to be systematic. It can be performed in any clinical setting with readily available equipment and supplies.
Observe these features:
* Face and neck
* Gums
* Teeth: all surfaces, including the front, back, and top surfaces
* Eruption sequence of teeth
* Tongue
* Palate and posterior pharynx
* Hygiene
Palpate neck for adenopathy, temporomandibular joint for mobility and floor of mouth for masses.
Child
Face & Neck Exam
- inspect face/neck for symmetry and skin lesions
- palpate neck for adenopathy
Child
Anterior Teeth/Gums
Throughout the exam, reinforce good hygiene practices or teach parents and children where they can do a better job.
- Lift the upper and lower lip to view the gums and anterior surfaces of the teeth.
- Use a tongue depressor or gauze pad to help hold the lips.
- Note the state of oral hygiene including gums, plaque, brown spots, or frank caries.
- Closely inspect the gum line—a high risk area for dental caries with plaque and tartar build up.
Child
Lingual Teeth
The upper front lingual surfaces are at high risk for dental caries as they are not well protected by the tongue and saliva. These areas are often not brushed adequately and problems are harder to detect.
- View the inner (lingual) surfaces of the teeth—a mouth mirror can be helpful but is not mandatory. Most of the lingual teeth can be viewed with changes in examiner position
- If necessary, use a tongue blade or toothbrush to open the mouth.
Child
Tongue and Palate Assessment
- Examine the tongue and palate—a tongue depressor or toothbrush may help open the mouth.
- Assess for tongue lesions, the length of the frenulum, tongue mobility, and contours of the palate.
Adults
Goals of Adult Exam
Primary care clinicians can perform a rapid and complete oral, head, and neck examination of adults in a primary care setting.
Goals of the exam are to:
- Determine the health status of teeth and gums
- Identify abnormal oral lesions and signs of precancer or cancer
- Target anticipatory guidance
Adult
TMJ
- Palpate the temporomandibular joint (TMJ) for crepitus, pain, and tenderness while the patient opens and closes the mouth.
- Watch the point of the chin while the jaw is opening and closing for any lateral deviation.
Adult
Neck Anatomy
The final step in the oral exam is to inspect and palpate the major anatomic divisions of the neck
- The anterior triangle is defined by the mandible superiorly and the sternocleidomastoid posteriorly.
- The posterior triangle is bounded by the sternocleidomastoid anteriorly, the trapezius posteriorly, and the clavicle inferiorly.
- The submandibular area is bounded by the mandible laterally and anteriorly. The floor of the mouth bounds submandibular area superiorly.
Adult
Neck Palpation
Clinicians should examine for adenopathy or abnormal masses. Inspect, then palpate, both sides of the neck in the following regions:
- Anterior triangle (anterior cervical nodes)
- Posterior triangle (posterior cervical nodes)
- Submandibular areas (submandibular and submental nodes)
Adults
Face/Lip Exam
- Identify facial deformities, skin lesions, and peri-oral lesions.
- Closely examine sun-exposed areas including the forehead, ears, cheeks, nose and lips for abnormal lesions, paying close attention for potential actinic keratoses, basal cell, or squamous cell cancers.
- In tobacco users, pay close attention to the lips.
Oral Cancer Screening
Cancers most commonly occur on the tongue, floor of mouth, and lower lip vermilion border.
- Oral cancers are the 9th most common cancer in U.S.
- 90% of oral cancers are squamous cell carcinomas.
- 60% of oral cancers are advanced at time of detection.
- Most common in hidden areas: lateral tongue, mouth floor, soft palate, lower lip vermilion border.
- All unexplained lesions in the mouth lasting greater than 2 weeks should be referred for evaluation and biopsy.
- Oral cancers are life threatening and require immediate biopsy and referral for treatment
Adult
Examining Inside Lips
The inner lip exam is particularly important in users of smokeless tobacco because precancerous lesions and cancer occur in these areas where users hold their tobacco.
- Fold the upper lip up and lower lip down to see the inner aspect of the lips
- Mucosa should be smooth, pink, and moist.
- Ulcerations and white patches are cause for concern.
Adults
Buccal mucosa Exam
Buccal mucosal exam is also particularly important in users of smokeless tobacco because precancerous lesions and cancer occur in areas where users park their tobacco.
- With a gloved finger, tongue blade, or mirror inspect the inner (buccal) aspects of the cheeks.
- Mucosa should be smooth, pink, and moist.
- Ulcerations and white patches are cause for concern.
Adult
Common Mucosal Abnormalities
Fibromas are:
* Smooth, pink, and round or oval in shape
* 1mm to 2cm in diameter
* Often result from chronic irritation (sharp tooth margin, biting, irritation from orthodontia or dental appliances)
* Usually asymptomatic
* Treated by surgical excision; recurrence is rare
Linea alba buccalis is:
* Thickened linear, horizontal white line on the buccal mucosa at the level of the occlusal plane extending from the corners of the mouth to the posterior teeth.
* Usually present bilaterally.
* Asymptomatic.
* Associated with the frictional activity of the teeth, cheek biting or bruxism.
* No treatment required
Adults
Gum Examination
This point in the examination presents an opportune time to reinforce regular dental visits. If gum recession is noted, it can be a sign of improper brushing technique and a chance to advise the patient to use either a soft brush or electric oscillating brush in small circular strokes. It is also a good time to reinforce the value of regular flossing.
- Fold the lower lip down and upper lip up to see the anterior gums.
- Use a tongue blade to retract the cheeks and look at the lateral gums.
- Note inflammation, plaque or debris at the gumline, or gingival recession.
- If plaque is noted, this is a teachable moment about daily flossing and more frequent, proper brushing.
Adults
Common Gun Abnormalities
Gingivitis is characterized by erythema and bleeding of the gums, especially with brushing. Gingivitis is very common during pregnancy. Gingivitis is reversible with dental cleaning and improved oral hygiene.
Periodontitis is deep inflammation of the gums, ligaments, and bony structures. It can lead to pain, infection, and tooth loss. It is also associated with severe systemic complications such as heart disease, diabetes, and preterm labor.
Gingival hyperplasia is enlargement of the gums that makes hygiene difficult. It is typically caused by medications such as calcium channel blockers and anticonvulsants.
Adults
Anterior/Lingual Tooth Examination
Anterior
* Examine the anterior surfaces of the teeth for discoloration, caries, trauma, and heavy plaque.
* Inspect the teeth with mouth closed and open noting occlusion and missing, damaged, or decayed teeth.
Lingual
* Ask patients to open their mouths wide to inspect the inner (lingual) aspect of the upper (maxillary) teeth and the molars.
* Use a mouth mirror to help view the inner (lingual) aspect of the teeth and a retractor to help view the molars.
* If you do not have a mirror, you must either advise patients to tilt their heads back or lower your head to see properly.
* Repeat the procedure to examine lingual aspects of the lower teeth and molars.
Adults
Hard/Soft Palate Exam
- Tilt the patient’s head back to examine the hard and soft palate.
- Closely inspect the soft palate for suspicious lesions as this is a high-risk area for cancer.
Adult
Tongue Exam
Dorsal
* Inspect the dorsum of the tongue.
Lateral
* The margins of the tongue are common areas for precancer or cancer and are easily missed by an incomplete examination.
* Retract the cheek with a finger, tongue blade, or mirror.
* Inspect the lateral margins of the tongue as far back as possible.
* Grasp the tip of the tongue with a gauze pad to facilitate this part of the examination.
* Posterolateral tongue margins are cancer-prone areas.
Adults
Posterior Pharynx Exam
The posterior pharynx is familiar territory to primary care clinicians. Observe for size and symmetry of the tonsils and their supporting structures, for erythema, exudate, and ulceration.
