1. Chapter 12 Extraoral and Intraoral Examination

2. Copyright © 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 2

3. Copyright © 2017 Wolters Kluwer All Rights Reserved Learning Objectives Explain the rationale Explain the systematic sequence Identify normal anatomy Describe physical characteristics Identify suspicious conditions 3

4. Copyright © 2017 Wolters Kluwer All Rights Reserved Rationale For The Extraoral And Intraoral Examination Early identification To detect cancer Thyroid disorders Eating disorders Nutritional deficiencies Sexually transmitted diseases Systemic conditions 4

5. 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

6. Copyright © 2017 Wolters Kluwer All Rights Reserved I. Types of Examinations Complete Screening Limited examination Follow- up Continuing care/reevaluation 6

7. Copyright © 2017 Wolters Kluwer All Rights Reserved II. Methods for Examination Visual examination Palpation Instrumentation Percussion Electrical test Auscultation 7

8. Copyright © 2017 Wolters Kluwer All Rights Reserved FIGURE 12-1 Bidigital Palpation 8

9. Copyright © 2017 Wolters Kluwer All Rights Reserved FIGURE 12-2 Bimanual Palpation. A: Examination of the buccal mucosa by simultaneous palpation on extraorally and intraorally. B: Examination of the floor of the mouth by simultaneous palpation with fingers of each hand in apposition 9

10. Copyright © 2017 Wolters Kluwer All Rights Reserved FIGURE 12-4 Assessment of the Temporomandibular Joint 10

11. Copyright © 2017 Wolters Kluwer All Rights Reserved III. Signs and Symptoms Signs Objective Symptoms Subjective 11

12. Copyright © 2017 Wolters Kluwer All Rights Reserved IV. Preparation for Examination Review the patient’s histories Examine radiographs Patient understanding Cultural sensitivity 12

13. Copyright © 2017 Wolters Kluwer All Rights Reserved Anatomical Landmarks Of The Oral Cavity I.Oral Mucosa – Masticatory Mucosa – Lining Mucosa – Specialized Mucosa 13

14. Copyright © 2017 Wolters Kluwer All Rights Reserved 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. 14

15. Copyright © 2017 Wolters Kluwer All Rights Reserved Sequence of Examination 1.Overall appraisal of patient 2.Face 3.Skin 4.Eyes 5.Nodes 6.Glands 7.Temporomandibular joint 8.Lips 15

16. Copyright © 2017 Wolters Kluwer All Rights Reserved Sequence of Examination 9.Breath odor 10.Labial and buccal mucosa 11.Tongue 12.Floor of mouth 13.Saliva 14.Hard palate 15.Soft palate, uvula 16.Tonsillar region, throat 16

17. Copyright © 2017 Wolters Kluwer All Rights Reserved FIGURE 12-7 Anatomical Landmarks of the Oral Cavity-Ventral Tongue View 17

18. Copyright © 2017 Wolters Kluwer All Rights Reserved Lymph Nodes 18

19. Copyright © 2017 Wolters Kluwer All Rights Reserved 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). 19

20. Copyright © 2017 Wolters Kluwer All Rights Reserved 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 20

21. Copyright © 2017 Wolters Kluwer All Rights Reserved 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). 21

22. Copyright © 2017 Wolters Kluwer All Rights Reserved Documentation of Findings A. History B. Location and Extent C. Physical Characteristics 22

23. Copyright © 2017 Wolters Kluwer All Rights Reserved Morphologic Categories I.Elevated Lesions II.Blisterform I.Vesicle II.Pustule III.Bulla IV.Nonblisterform I.Papule II.Nodule III.Tumor IV.Plaque 23

24. Copyright © 2017 Wolters Kluwer All Rights Reserved II. Depressed Lesions Ulcer Loss of continuity of epithelium Erosion Shallow Does not extend through epithelium to underlying tissue 24

25. Copyright © 2017 Wolters Kluwer All Rights Reserved III. Flat Lesions Macule Circumscribed Not elevated above surrounding skin or mucosa Identified by color 25

26. Copyright © 2017 Wolters Kluwer All Rights Reserved IV. Other Descriptive Terms Crust Erythema Indurated Papillary Petechiae Pseudomembrane Polyp Punctate Torus Verrucous 26

27. Copyright © 2017 Wolters Kluwer All Rights Reserved Oral Cancer I.Location II.Appearance of Early Cancer – Leukoplakia – Red areas Velvety – Erythroplakia – Ulcers – Masses – Pigmentation 27

28. Copyright © 2017 Wolters Kluwer All Rights Reserved Procedure For Determining when A Suspicious Lesion requires a biospy Brush cytology toluidine blue Diffuse tissue reflectance laser-induced auto fluorescence 28

29. Copyright © 2017 Wolters Kluwer All Rights Reserved I. Exfoliative Cytology A.Cytological Smear B.Liquid-Based Cytology C.Oral Brush Cytology 29

30. Copyright © 2017 Wolters Kluwer All Rights Reserved II. Spectroscopy Laser-Induced Autofluorescence – VELscope Diffuse Reflectance Spectroscopy 30

31. Copyright © 2017 Wolters Kluwer All Rights Reserved 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 31

32. Copyright © 2017 Wolters Kluwer All Rights Reserved Documentation Every detail of the oral examination Recommendations for frequency of exam Review of all lifestyle habits Progress note of first maintenance appt. 32

33. Copyright © 2017 Wolters Kluwer All Rights Reserved 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 33