Objectives of Oral Exam (1)
Note Normal Deviations
Oral Cancer Screening
Determine need for postponement of treatment
Early detection of lesions
Objectives of Oral exam (2)
Identify
Identify conditions that may require medical eval
Identify need for treatment adaptation
Objectives of Oral exam (3)
Provide
Provide baseline comparison
Provides info for legal record
Compare: Normal/Normal Deviations/Abnormal
Symmetry/Asymmetry Color Size (mm/cm) Location Shape (define border) Consistency (hard, soft, fluid inside) Texture (rough, smooth) Painful (are they aware) Mobility (deeply rooted, mobile)
History of Lesion
Duration (When first noticed?)
Changes (in size and look)
Sign/Symptoms associated w/ it (differentiate)
Reoccurrence (Did you have it and now it’s back)
Systematic Sequence
Increases patient confidence in you
Prevents overlooking and missing imp. details
Increase efficiency and conserves time
Types of Exams
Complete Screening (limited, classify) Limited (emergency, important to them) Follow-up Maintenance (reoccuring 3,4,6 months)
Method used in Conducting an Oral Exam
Observation, Palpation, Ausculation (clicking/popping), Olfactation, Instrumentation, Percussion (tap to check teeth) Electrical (pulp tester)
Palpation
Digital, Bidigital, Manual, Bimanual, Bilateral, Circular Compression
Most Common Sites in the Oral Cavity for Lesions
Lateral border of tongue Gingiva Soft Palate complex (HPV) Floor of mouth Lower lip (More common in men) Salivary Glands
Oral Cancer Risk Factors
Age, Gender (M>F) Sunlight, Tobacco/Alcohol use (combined as well) Previous malignancy, Area, Environmental/Occupational, Socioeconomic, Specific Disease (HIV), Repeated Trauma
Questions to ask the patient
**Make sure to always ask questions
Are they aware? Do they know when the lesion occured? Have they noticed any changes? Are they having any symptoms? Have they had any testing?
Careful Communication
Be reassuring Don't act alarmed Stress the need for a follow-up Could be normal/treatable Referral just means to get checked out, could be normal/benign
Oral Inspection Form (Extraoral)
General Appearance Skin Eyes Facial Symmetry Lymph Nodes Glands TMJ Breath Odor Lips
Oral Inspection Form (Intraoral)
Labial and Buccal Mucosa Alveolar Ridge Hard Palate (8+9 and back) Soft Palate Floor of mouth Tongue Pharynx Tonsillar region Salivary Ducts Papilla Marginal and attached Gingiva
Sequence of Exam (Extraoral)
Overall appearance, Face, Skin, Eyes, Neck, Nodes
Sequence of Exam, Nodes
Pre/Post auricular Occipital Submental and submandibular Cervical chain Supraclavicular TMJ joint Symmetry Sound Asymptomatic/Symptomatic
Sequence of Exam (Intraoral)
Lips(P), Breath odor(O), labial and Buccal mucosa, Tongue(P), Floor of mouth, Saliva(d), Hard then soft palate(P), Uvula(D), Tonsillar region/throat(D), other
Sequence of Exam (Labial and Buccal Mucosa)
Vestibule (P) Muccobuccal folds (P) Frena (O movement, attachment) Opening of stenson’s duct (Express) Buccal mucosa (P)
Sequence of Exam (Tongue)
Dorsal & Ventral sides (P) Lateral borders (retract, P, use mirror) Base of tongue (O attachment) Extension (describe deviation, sometimes veers)
Where are women most likely to get oral cancer?
Baseline of tongue
Sequence of Exam (Floor of mouth)
Ventral surface of tongue (P) Whartons duct(Express) Mucosa(palpate, use mirror) Frena (attachment)
Occlusal Screening/Oral habits
Angle’s Classification
Habits
Occlusal Discrepancies
Periodontal Exam
Papilla
Marginal Gingiva
Attached Gingiva
Periodontal Summary Statement
AAP Case Type
Describing and Documenting SF
Size and Shape, Color, Location and Configuration, Texture, attachment and depth, consistency, mobility, symptomatology
Size and shape (SF)
Determined by L,W,H
Margin traits: Smooth/flat, raised/elevated/depressed
Contour of the border: Regular/irregular
Color (SF)
Most common: red, white,red and white, pink
Others: yellow, black, brown or blue
Location and Configuration (SF)
Generalized or localized
Discrete, grouped, confluent, or coalescing, linear
Flat Lesions
Are on the same level as the normal skin and oral mucosa
Macule or patch
Macule
Small flat, discolored spot that exhibits no change in skin texture or thickness
Less than 1 cm in size
Color: brown, black, red, or any color lighter than skin
EX: freckles, petechia
Patch
Flat, discolored area on skin or mucosa
Greater than 1 cm in size
EX:Snuff patch, Birth marks
Elevated Lesions-Nonblisterform
Area where surface of the lesions are raised above the normal level of the skin or oral mucosa
Denser/Firmer cell filled
EX: Papules, Plaque, Nodule, Tumor
Papule
A solid raised lesions that is usually less than 1 cm in diameter
Ex: moles and skin tags
Plaque
Superficial raised lesion often formed by the coalescence of closely grouped papules. Greater than 1 cm in diameter and slightly raised by still flat
Ex: leukoplakia, psoriasis
Nodule
Raised marble-like lesion dectectable by touch usually 1 cm or more in diameter- hard mass
Ex: wart, enlarged lymph node
Tumor
General swelling or enlargement, 2 cm or greater in width
Fluid Filled Lesions-Blisterforms
Elevated lesions filled with clear fluid or pus
Softer, more fluctuant
EX: Vesicle, Bulla, Pustule, Wheal
Vesicle
Small blister filled with a clear fluid, Usually less than 1 cm in diameter
Bulla
Large blister filled with clear fluid. Greater than 1 cm in diameter
EX: Burn blister
Pustule
Small raised lesion filled with pustule
EX: acne, boil, abscess
Wheal
Raised, irregular area of localized edema. Usually from an allergic reaction lasting 24 hours
EX: Mosquito bite, Hives
Depressed Lesions
Surface of the lesion is below the normal level of the skin or oral mucosa. Can be superficial or deep
EX: Ulcer, Erosion
Ulcer
Crater-like Lesion of the skin or mucosa where the top of 2 layers of skin are lost
Superficial is less than 3 mm depth
Deep ulcer is greater than 3 mm depth
Erosion
Shallow, depressed lesion that does not extend through the epithelium to the underlying tissue
(usually 1st layers, lip pickers)
Linear Cracks
Crack
Fissure
Crack
Long narrow break in the surface of the skin or mucosa
EX: lips crack
Fissure
Linear crack in the top two layers of skin or mucosa
EX: corners of mouth
Other Descriptive Terms
Exophytic (growing outside)
Petechiae (pinpoint red dot)
Sclerosis (hardening)
Verrucous (wartlike)
DBCTA
Diameter, Border, Color, Type, Anatomic Location
Oral Cancer
Devastating when detected late
50% survival rate w/n 5 years after treatment
Squamous cell carcinoma makes up 90% of all malignant neoplasms in oral cavity. Associated with sun, tobacco, alcohol, and HPV
Appearance of Early Cancer
White area, Red area, Red and White area, Ulcers, Masses, Pigmentation (Doesn’t need to be all, can be just one)
Diagnostic Aids
Toluidine Blue
Chemiluminescence
Toluidine Blue
Identify changes in mucosa that could be malignant. Rinse or painted on. Rinsed w/ acetic acid and the retaining dye should be biopsied.
Chemiluminescence
Rinse w/ 1% acetic acid and used light which will help detect abnormal cells
Checking Suspicious lesions
Biopsy
Exfoliative cytology
Cytologic Smear
Biopsy
Total or partial removal of the lesion by excision means so the tissue can be examined for the purpose of diagnosis (Best Method)
Exfoliative Cytology
Diagnostic Aid in which cells are removed from the lesion and slides fixed and mailed in for results.
Usually comes back as suspicious so need biopsy anyway
Cytologic Smear
Diagnostic aid in which cells are removed from the lesion for microscopic evaluation.
Can get false positives, not reliable
Healthy Characteristics of Gingiva
Pink, Flat, Knife-like edge, Stippling (looks like an orange peel)
Unhealthy Characteristics of Gingiva
Erythemic, Bulbous, and Rolling (on marginal)
Cratered (Blown up with fluid), Irregular border, Blunted, Smooth, Smooth/Shiny (w/ a lot of edema)
Papilla Healthy
Pink, Melatonic, Flat, Firm, Stippled
Can be either healthy/unhealthy: Pointed, Shiny, Smooth
Papilla Unhealthy
Erythemic, Cyanotic, Bulbous, Blunted, Cratered, Edematous, Irregular, Fibrotic
Marginal Gingiva Healthy
Pink, Melatonic, Flat, Firm, Shiny, Smooth
Marginal Gingiva Unhealthy
Erythemic, Cyanotic, Rolled, Festooned, Recessed, Clefting, Edematour, Stippled, Irregular, Fibrotic
Angiodema
Swollen on lower lip
Bells Palsy
Affects one side