Oral Health Wk. 3

systematic

A visual inspection and palpation exam that follows the exact same order every time

extraoral exam features

Head, neck, face, ears, skin, lymph nodes, salivary glands, thyroid, TMJ

screening

a brief, preliminary examination for an initial patient assessment

screening

Which type of examination is done by a hygienist?

comprehensive exam

includes a thorough summary of all the components of the assessment

limited exam

brief examination made for an emergency situation

follow up exam

brief follow-up examination to check healing following a treatment

re-evaluation exam

after a specific period of time following the completion of the care plan and the anticipated restoration to health

medical history, radiographs, prior exams, noted lesions

What should be reviewed prior to the exam?

consent

Can be verbal or nonverbal

Can be a head nod or even just the fact that the patient sat on the chaire

head and neck

Watch for any trouble walking and balance

Assess facial form and symmetry, inspect the skin

lips

Check for color, texture, size

Check for chapping, cracks, blisters, and ulcerations

traumatic lesions, cuts, blisters, irritations

What should be checked when for when looking at the intraoral lips

parafunctional habits

These are things that a patient does daily which may be harming their oral health

Must be documented in the chart

within normal limits

What do we write in the documentation if everything appears to be normal

yes

If a patient has pimples on their skin should it be documented in their chart?

odors

Different ____ mean different things

Ex: sweet or fishy

labial and buccal mucosa

Check for color, texture, and lesions

Observe how much moisture there is

linea alba and fordyce granules

These two landmarks are within normal limits but must still be documented in the chart if found on the patient

vestibule

Check for lesions and check frenums

tongue

Check shape, color, texture, and size

Should not have a white or black coating

light pink

What is the normal tongue color

black hairy tongue

When the dorsal surface of the tongue has a black coating

WNL

What else should we write when we document that either torus palatinus or mandibular tori were found in the patient

hard palate

Check height, contour and color

Check for burns and tori

exostosis

Finger-like bone projections

soft palate

Check color, size and shape

Check for Uvula presence

lymphadenopathy

enlarged lymph nodes

Can be due to infection, inflammatory condition, abscess, or cancer

tonsillar area

Check for presence of tonsils, their size and if infected

thyroid

Check size of ____ gland and for any nodules

TMJ

Check opening and closing, movement forward and back and side to side

Check for popping, clicking, crepitus

palpation

Using compression of about 1/2 inch

Use consistent light pressure and a circular motion

digital

palpation using a single finger

bidigital

palpation using finger and thumb of same hand

bimanual

palpation using a finger or fingers and thumb from each hand applied simultaneously in coordination

bilateral

palpation using two hands are used at the same time on opposite sides of the body

oral exam

ADA recommends a comprehensive ___ ___ be a routine part of each patient’s dental visit

oral cancer

risk increases with age with peak at 55-74

men two times more likely than women

soft tissue lesion

An area of abnormal appearing skin that does not resemble the tissue around it

regular

The border of a lesion resembles a symmetrical circle or oval shape

irregular

The border of a lesion is not uniform or has deviations from a circular or oval shape

smooth

The margin of a lesion is level with the surface of the lesion

raised

The margin of the lesion is above the level of the surface of the lesion

red, white, yellow, and blue

What are the 4 colors a lesion might show up as

leukoplakia

Descriptive term for a white lesion that can’t be wiped off

descriptive

What type of terms are leukoplakia and erythroplakia

discrete configuration

Individual lesions that are separate and distinct from one another

Ex: individual tiny spots of brown pigmentation

grouped configuration

Lesions that are clustered together

confluent configuration

Lesions that have merged together so that the individual lesions are not distinguishable

linear configuration

Lesions that form a line

flat

Surface of the lesion is the same as the normal surface of the skin or mucosa

macule

A smal, flat, discolored spot on the skin or mucosa that doesn’t have a change in skin texture or thickness

Less than 1 cm in size; can be brown, black, or red

patch

A flat, discolored spot on the skin or mucosa

Larger than 1 cm in size

elevated

Lesion in which the surface is raised above the normal level of skin or mucosa

papule

A solid raised lesion that is less than 1 cm in diameter, may be any color

Ex: elevated mole

plaque

A superficial raised lesion often formed by grouped papules

More than 1 cm in diameter, ex: leukoplakia

nodule

A raised marble-like lesion detectable by touch

usually 1 cm or more in diameter, ex: wart

fluid-filled

An elevated lesion filled with clear fluid or puss

vesicle

A small blister filled wit fluid

1 cm or less in diameter

bulla

A large blister filled with fluid

over 1 cm in diameter

pustule

A small raised lesion filled with pus

Ex: acne

ulcer

A crater-like lesion of the skin or mucosa where the top two layers of the skin are lost

Superficial depth, less than 3 mm

depressed

A lesion in which the surface is below the normal level of the skin or mucosa

fissure

A linear crack in the top two layers of the skin or mucosa

erythema

red area of variable size and shape

indurated

A descriptive term that is a synonym for hardened

petechia

miniature hemorrhagic spots ranging from pinhead to pinpoint size

verrucous

Descriptive term for something rough or wartlike

anatomic location, border, color and configuration, diameter and dimensions, type

ABCDT for how to describe a lesion

horizontal, vertical

When measuring the dimensions of a legion we must always write down a ____ and ____ number

milimeter

When documenting a diameter or dimensions of a lesion which measurement should we use

lesion

Dentist must check this (if found on patient) before continuing treatment

patient chart

Where must we document any found lesions or irregularities found during an extra/intraoral examination?

meth mouth, anorexia, and eroded enamel

Other possibilities found during an intra/extraoral exam

clinical notes→ expand all→ choose note→ clinical exams→ EO/IO

How do I document a patient exam on dentrix?

quick letters→ oral pathology→ build/view

How do I access oral pathology referral forms for lesions on dentrix?