wilkins chapter 13 intraoral exam

if lesion is found

use probe to measure height and width

oral examination

systemic inspection of the oral structures

allows for detection of abnormalities and potentially life threatening oral malignancies

site in the mouth with the highest incidence of oral cancer

tongue

risk factors for oral cancer

• age

• gender

• sunlight

• tobacco and alcohol use

what you can do to help diagnose someone with oral cancer

• thorough oral examination

• ask patient about tobacco and alcohol use

• inform

• follow up

leukoplakia

white lesions — possible precursor to cancer

erythroplakia

red lesions — greater potential for becoming cancerous than leukoplakia

symptoms that a patient might report

• soreness

• lump or thickening

• numbness

• hoarseness

• feeling as if something is caught in the throat

• difficulty chewing or swallowing

• ear pain

• difficulty moving jaw or tongue

• jaw selling that causes ill fitting dentures 

management of suspicious lesions

white or red lesions

should be reevaluated in 2 weeks

management of suspicious lesions

is lesions have not resolved in 2 weeks

biopsy is necessary

management of suspicious lesions

any symptom lasting more than 2 weeks indicates

need for a referral to specialist

oral examinations — 7 subgroups

• lips and vermillion border

• oral cavity and mucosal surfaces 

• underlying structures of ;ips and cheeks

• floor of the mouth

• salivary gland function

• tongue

• palate, tonsils and oropharynx

common abnormal findings of lips

• angioedema

• herpes simplex

angioedema

swelling of the lower lip caused by allergy to latex gloves

prep for examinations

• explain procedures to patient

• always inform before you perform

• as patient to remove dentures; female lipstick

• patient in supine position

• intra oral exam — glasses

• extra oral exam — no glasses

inspection of lips and vermillion borders

• visually inspect the lips and vermillion border

• an example of a notable common finding is a herpetic lesion (reappoint)

normal findings on lips/vermillion border

• at rest lips touch

• surface of lips smooth and intact with normal color and texture

• vermillion border is even and not raised

notable findings on lips and vermillion border

• changes in texture or shape

• chapped or cracked lips

• pigment changes or variation in color

• lip pits

• irregular vermillion border

• lips do not meet

• cheilosis at commissures

• herpetic lesions

• soft tissue lesions

• swelling of lips

• trauma, lip biting

• asymmetrical mouth may indicate neurological condition, tumor or infection

parotid duct is the 

papilla duct or stensens duct

on the floor of the mouth is the

• sublingual fold

• sublingual caruncle

oral cavity visual inspection

• inspect entire oral cavity and oropharynx

• use mirror to look for conditions that would cause the exam to be modified, postponed (such as herpetic lesion or red, inflamed throat / tonsils)

anterior floor of the mouth inspection

• ask patient to touch tip of tongue to roof

• visually inspect the anterior portion of floor

posterior region of floor inspection

• ask patient to relax tongue and protrude it

• fold damp gauze square in half; grasp tongue between sides of gauze

• use right hand to pull tongue gently to the left commissure of the lip

floor or mouth palpation

• right index finger on floor of the mouth

• left middle and ring fingers under the chin

• gently move tongue out of way using index finger

• press upward with extraoral fingers and doward with intraoral fingers, trying to make fingers meet

• palpate right posterior floor. repeat on left side

• BIMANUAL

floor of the mouth notable findings

• changes in color and texture

• lesions or other abnormalities

• swelling, especially unilateral swelling

• mucocele or ranula

• salivary calculi or stones that obscure flow of saliva

• leukoplakia on floor of mouth

• hard area of discomfort

wharton ducts

submandibular/ sublingual ducts

submandibular/ sublingual ducts locating 

• ask patient to raise tongue

• use gauze to gently dry

• press down gently with applicator in region of caruncles

• a drop or stream of saliva should be evident 

parotid salivary ducts examined

• retract right cheek

• dry papilla with gauze

• roll applicator from area slightly above papilla while applying pressure

• a drop of saliva will be expressed from papilla

• repeat on left side

salivary glands normal findings

normal flow of saliva

salivary glands notable findings

xerostomia — decreased salivary flow

swelling in floor of the mouth due to blocked salivary glands/ducts or trauma

inspecting lower lip

• visually inspect

• use index fingers inside the mouth and thumbs on the outside

• evert and retract lip fully away from teeth and alveolar ridge

inspecting upper lip

• visually inspect

• use index fingers inside the mouth and thumbs on outside

• evert and retract lip fully away from teeth and alveolar ridge

buccal mucosal/ maxilla inspection

• begin with right side of the mouth

• stretch cheek up and away from maxillary teeth

• extend tissue so that no folds remain to conceal a lesion or abnormality

buccal mucosa/ mandible inspection

• stretch cheek down and away from mandible

• next inspect the buccal mucosa on left side of the mouth

mucosal surfaces normal findings

• smooth, intact tissue

• coral pink or pigmented color

• no lesions

• intact frenum on both arches

• normal variation: fordyce granules

• linea alba

mucosal surfaces notable findings

• changes in color or texture

• swelling

• trauma

• lesions

• pale or reddened mucosa

• dry mucosa

• leukoplakia

• lichen planus

• halitosis

lower lip palpated

• palpate lower lip by compressing the tissues between your index fingers and thumbs

• next reposition your fingers to palpate the right cheek

right cheek palpated

• left hand - middle and ring finger extraorally

• right hand - index finger intraorally

• compress tissues between fingers

• palpate entire length of buccal mucosa

• use fingertips, not back of hand

• parotid gland too

upper lip palpated

• move fingers up to upper lip

• compress lip between index fingers and thumbs

lips and cheeks normal findings

• firm tissue

• moist tissue

• intact tissue

• minor salivary glands in the lips feel like small beads when palpated

lips and cheeks notable findings

• swellings or nodules

• changes in texture

• tenderness upon palpation

dorsal surface of the tongue consists of

• filiform papillae

• fungiform papillae

• foliate papillae

• circumvallate papillae

filiform papillae

hairlike, cover anterior 2/3 surface if tongue, taste sensitive to sweet/salt

fungiform papillae

mushroom shaped, sour tasting

foliate papillae

on lateral border of the posterior 1/3 of tongue, 3 to 5 large red projections

circumvallate papillae

v-shaped row of 8 to 12 large papillae on posterior surface, bitter

ventral surface of the tongue contains

• lingual frenulum

• lingual vein

• ducts of submandibular glands

common variation of the tongues appearance

pigmentation

example of a notable finding with tongue

ankyloglossia (tongue tied)

ventral surface of tongue inspection

ask patient to touch tongue to roof of mouth and visually inspect ventral surface

dorsal surface of the tongue inspection

• grasp with damp gauze

• visually inspect entire surface

• gently pull on tongue not to injure the frenum

inspecting lateral borders of the tongue

• gently pull to left commissure

• evert to obtain clear view

• repeat to inspect other side

• use a mirror to see posterior portion

tongue palpation

• between index finger and thumb

• be alert for swellings or nodules

tongue normal findings

• moist, pink, freckled pigmentation

• symmetrical

• lingual veins on ventral surface

• media groove on dorsum

• three types of papillae on dorsum

• foliate papillae on lateral surface

• scalloped edges

tongue notable findings

• ulceration

• lesions

• swelling

• variation in color

• black, hairy

• variation in texture

• asymmetrical shape

• dry mouth

• denuded

• fissured

• geographic

• macroglossia

• ankyloglossia

example of notable finding with uvula

bifid uvula (spilt in two)

example of notable finding with tonsils

tonsillitis

visual inspection of the palate

perform preliminary visual inspection of the hard and soft palate, uvula, tonsils and oropharynx

palpating hard/ soft palate

• avoid sliding finger across soft palate

• use intermittent pressure with index against palate

tonsils/ oropharynx inspected

• mirror (reflecting down)

• as patient to say ahhh

• apply firm downward and forward pressure with mirror

palate/ oropharynx normal findings

• pale pink color

• palatine raphae and rugae

• firm

• palatine torus

• soft palate is symmetrical

• absent, small, or large ronsils

• uvula at midline

palate/ oropharynx notable findings

• swelling

• lesions

• tumors

• client palate

• changes in color

• changes in texture

• snuff or tobacco chew pouch

• petechiae

• ulcerations

• inflamed or enlarged tonsils

• pus balls on tonsils

• red and sore throat

• deviated uvula