Chapter 12 Extraoral and Intraoral Examination Chapter Outline

Chapter Outline • • • Rationale Components Landmarks Sequence Morphologic Categories Oral Cancer Biopsy

Learning Objectives • • • Explain the rationale Explain the systematic sequence Identify normal

Rationale For The Extraoral And Intraoral Examination • • Early identification To detect cancer

Components of the Examination • Concept of total patient being treated • Examination is

I. Types of Examinations • Complete • Screening • Limited examination • Follow- up

II. Methods for Examination • • • Visual examination Palpation Instrumentation Percussion Electrical test

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

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

FIGURE 12 -4 Assessment of the Temporomandibular Joint Copyright © 2017 Wolters Kluwer •

III. Signs and Symptoms • Signs • Objective • Symptoms • Subjective Copyright ©

IV. Preparation for Examination • • Review the patient’s histories Examine radiographs Patient understanding

Anatomical Landmarks Of The Oral Cavity I. Oral Mucosa – Masticatory Mucosa – Lining

FIGURE 12 -6 Anatomical Landmarks of the Oral Cavity-Dorsal Tongue View. A: View of

Sequence of Examination 1. 2. 3. 4. 5. 6. 7. 8. Overall appraisal of

Sequence of Examination 9. Breath odor 10. Labial and buccal mucosa 11. Tongue 12.

FIGURE 12 -7 Anatomical Landmarks of the Oral Cavity-Ventral Tongue View Copyright © 2017

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

I. Extraoral Examination • • • • . Observe patient during reception and seating

I. Extraoral Examination • Pain or discomfort upon palpation and/or upon • swallowing. •

II. Intraoral Examination • • • 6. Lips & intraoral mucosa View/palpate lips, labial

Documentation of Findings A. History B. Location and Extent C. Physical Characteristics Copyright ©

Morphologic Categories I. Elevated Lesions II. Blisterform I. Vesicle II. Pustule III. Bulla IV.

II. Depressed Lesions • Ulcer • Loss of continuity of epithelium • Erosion •

III. Flat Lesions • Macule • Circumscribed • Not elevated above surrounding skin or

IV. Other Descriptive Terms • • • Crust Erythema Indurated Papillary Petechiae Pseudomembrane Polyp

Oral Cancer I. Location II. Appearance of Early Cancer – Leukoplakia – Red areas

Procedure For Determining when A Suspicious Lesion requires a biospy • • Brush cytology

I. Exfoliative Cytology A. Cytological Smear B. Liquid-Based Cytology C. Oral Brush Cytology Copyright

II. Spectroscopy • Laser-Induced Autofluorescence – VELscope • Diffuse Reflectance Spectroscopy Copyright © 2017

III. Biopsy • • Indications for biopsy Pathology report • Class I : Normal

Documentation • • Every detail of the oral examination Recommendations for frequency of exam

Factors to Teach the Patient • • • Guidance and support Self-examination monthly Dietary

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Chapter 12 Extraoral and Intraoral Examination

Chapter Outline • • • Rationale Components Landmarks Sequence Morphologic Categories Oral Cancer Biopsy Determination Documentation Everyday Ethics Factors to Teach the Patient Copyright © 2017 Wolters Kluwer • All Rights Reserved 2

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

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 4

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 Copyright © 2017 Wolters Kluwer • All Rights Reserved 5

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 Copyright © 2017 Wolters Kluwer • All Rights Reserved 9

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 Copyright © 2017 Wolters Kluwer • All Rights Reserved 16

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

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 Copyright © 2017 Wolters Kluwer • All Rights Reserved 20

II. Intraoral Examination • • • 6. 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. Note amount and consistency of the saliva and evidence of dry mouth (xerostomia). Copyright © 2017 Wolters Kluwer • All Rights Reserved 21

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

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

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 Copyright © 2017 Wolters Kluwer • All Rights Reserved 31

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

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 Copyright © 2017 Wolters Kluwer • All Rights Reserved 33