AQ

Extraoral and Intraoral Examination (EOIO)

What is the EOIO exam?

  • EO = Extraoral; IO = Intraoral
  • Performed on each patient at every visit
  • We look, palpate, and listen for anything unusual
  • Rationale: early identification of abnormalities and pathologies, especially oral cancer

Detailed Process of Care: Checklist (Overview)

  • Process of Care includes steps before, during, and after the visit; roles may include Pre-Appointment, Patient, Student, Faculty, and Epic-related tasks
  • Key activities span:
    • Pre-Appointment: review history, x-rays, set up SOAP note, prepare room, and plan for EOIO
    • During setup: wash hands, don PPE, disinfect room with gloves, apply barriers, run water lines (2 minutes)
    • Documentation setup: set up SOAP note, review past notes, med history, x-rays, exams; prepare patient notes and coomings
    • Signoffs and approvals: sign off on med history, medications, and each section; review QA day sheet
    • EOIO-specific steps: complete EOIO; use ABCDT to describe lesions; ensure patient is seated upright for EO check; complete Caries Risk and start dental charting
    • Roles in the sequence: medical history review; medication review; approvals; EOIO check signup; patient seating; EOIO documentation; QA sheet completion
  • Do NOT proceed intraorally until faculty approves the patient
  • Documentation in EPIC: chart steps and EOIO findings; sign and review SOAP notes and QA day sheet

Learning Objectives (from Page 5)

  • List the most common sites for oral cancer
  • Explain the EOIO process prior to beginning the exam
  • Define the four different types of palpation
  • Given a lesion description, match it to the corresponding term (vesicle, pustule, macule, etc.)
  • Describe a lesion using ABCDT descriptors
  • Identify intraoral structures (mucosa, glands, hard/soft palate, etc.)
  • Identify extraoral structures (muscles, glands, lymph nodes, etc.)
  • Complete a full EOIO exam and document correctly in EPIC

Core Assessment Framework

  • Assess | Diagnose | Plan | Document | Evaluate | Implement
  • This framework guides the clinical decision-making cycle during EOIO

Assessing Your Patient (Skills and Senses)

  • Use all senses: Visual, Audible (hearing), Palpable (touch), Smell (halitosis)
  • Do not taste the patient

Rationale for EOIO

  • Essential goal: detect oral cancer at earliest stage
  • Also reveals signs of thyroid disorders, eating/nutritional issues, STDs, and other systemic conditions

Components of Examination: Health-Related Risk Factors

  • History of previous cancer
  • Family history of cancer
  • Tobacco use
  • Alcohol use
  • Cultural/genetic susceptibility
  • Sun exposure
  • Diet
  • Sexual behaviors
  • Abuse history

Types of Examination

  • Comprehensive
  • Screening
  • Limited Examination
  • Follow-up
  • Continuing care / re-evaluation

Methods of Examination

  • Visual
  • Palpation
  • Instrumentation
  • Percussion
  • Electrical Test
  • Auscultation (jaw sounds, e.g., popping/clicking)

Visual Methods for EOIO

  • Direct Observation
  • Radiographic Observation
  • Transillumination

Palpation Methods (Definitions)

  • Digital: single finger palpation
  • Bidigital: finger and thumb of the same hand
  • Bimanual: fingers from each hand
  • Bilateral: two hands examining the same structure on opposite sides

Other Methods (EOIO Tools)

  • Instrumentation: probes, explorers
  • Percussion: tapping on a tooth
  • Electrical Test: vitality testing
  • Auscultation: jaw sounds (popping/clicking)
  • Note: Refer to bilateral palpation of TMJ for related findings

What Are We Looking For?

  • Signs (objective): deviations from normal observed by clinician
  • Symptoms (subjective): patient-reported experiences
  • If unsure whether a finding is normal, document it

Preparation for EOIO Examination

  • Review health histories and medical/dental records
  • Examine radiographs
  • Explain to the patient why EOIO is performed

Anatomy and Mucosa: Key Landmarks

  • Oral Mucosa divided into:
    • Masticatory mucosa: keratinized; covers gingiva and hard palate
    • Lining mucosa: non-keratinized; covers inner lips/cheeks, floor of mouth, underside of tongue, soft palate, alveolar mucosa
    • Specialized mucosa: covers the dorsum of the tongue with papillae (taste buds on some)
  • Palatal and gingival landmarks: provided in lecture visuals (e.g., alveolar mucosa, mucogingival junction, attached gingiva, free gingival groove)
  • Tongue landmarks: dorsal surface (papillae types), ventral surface; base of tongue includes sulcus terminalis and foramen cecum

Anatomical Landmarks: Mouth Surfaces (Ventral and Dorsal Tongue views)

  • Ventral view landmarks: lingual glands, plica fimbriata, sublingual caruncle, submandibular duct, deep lingual veins, sublingual fold, etc.
  • Dorsal view landmarks: filiform, fungiform papillae, fauces, palatine tonsils, median sulcus, uvula, hard/soft palate

Specialized Mucosa and Papillae

  • Filiform papillae: keratinized, most numerous; no taste buds
  • Fungiform papillae: red spots with taste buds
  • Circumvallate, Foliate papillae: taste buds present

Base of the Tongue Structures

  • Sulcus terminalis
  • Foramen cecum

Sequence of Examination (Efficiency and Professionalism)

  • EOIO Sequence overview
    • Extraoral inspection: facial form, eyes, skin, hair, ears, temporomandibular joint (TMJ), major salivary glands (parotid, submandibular, sublingual), neck and lymph nodes
    • Intraoral inspection: lips, labial mucosa, buccal mucosa/folds, parotid glands, floor of mouth, tongue, hard/soft palate, oropharynx and nasopharynx, occlusion
  • IO charting and soft tissue documentation occur concurrently
  • The goal is to maximize efficiency and patient confidence while not overlooking findings

Documentation in EPIC and QA

  • Document EOIO findings using standard descriptors
  • Use the POC (Plan of Care) to guide documentation
  • If no findings: use normal descriptors
  • If notable findings: document precisely using ABCDT descriptors and measurements
  • Sign off on sections and QA day sheet

Explaining EOIO to the Patient (Sample Script)

  • “Mr. Smith, I am now going to complete an exam on your head and neck. I will be examining visually and by touch. I’m looking for unusual lesions, lumps, or bumps. I may ask questions about your history. It is okay if I start this exam?”
  • Response: “Yes, that’s okay.”
  • Encourage questions; invite patient to speak about tenderness or discomfort during the exam
  • If something significant is found, discuss it at the conclusion of the exam; invite questions

Review Questions (Key Concepts)

  • Which palpation uses a single finger? (Digital palpation)
  • Which uses a finger and thumb from the same hand? (Bidigital palpation)
  • Which uses fingers from two different hands? (Bimanual palpation)
  • When is bilateral palpation used? (For symmetrical structures, such as TMJ and lymph nodes)

Intraoral Examination: Areas to Identify

  • Upper and lower vestibules
  • Alveolar mucosa and mucogingival junction
  • Attached gingiva; marginal gingiva; free gingival groove
  • Labial frenum; buccal frenum
  • Parotid papilla
  • Floor of the mouth; sublingual area; submandibular ducts
  • Tongue (dorsal, ventral, base); hard/soft palate; tonsils; pharynx; oropharyngeal region
  • Occlusion (class I, II, III); note occlusion on both sides

Normal and Notable Findings: Intraoral Inspection (Guidance from the slides)

  • Lips: Normal – smooth, intact, vermillion border even, symmetrical; Notable – changes in shape/texture/color, chapping, swelling, asymmetry, failing to meet at rest
  • Labial mucosa: Normal – smooth, intact; Notable – Fordyce granules (normal but document), Linea Alba, swellings, trauma, lesions (describe with ABCDT), pale or reddened mucosa
  • Buccal mucosa and buccal fold: Normal – smooth, intact; Notable – Fordyce granules, Linea Alba, swellings, trauma, lesions (describe with ABCDT), pale/reddened mucosa
  • Parotid glands: Normal saliva flow; Notable – swollen duct, decreased or increased saliva flow
  • Submandibular and Sublingual glands: Normal saliva flow; Notable – swollen duct, altered flow
  • Floor of mouth: Normal – smooth, intact; Notable – color/texture changes, swellings, tenderness; describe lesions with ABCDT
  • Tongue: Normal – moist, pink, papillae present, symmetrical; Notable – coating color (yellow/white/brown), lesions, swelling, asymmetry, ankyloglossia, fissures, geographic changes, dryness, size/color/texture variations
  • Hard & Soft Palate: Normal – smooth, firm, no lesions; Notable – swellings, lesions (describe with ABCDT), cleft palate, uvula changes (missing, deviates, bifid), petechiae
  • Oropharynx and Nasopharynx: Normal – no lesions or discomfort when swallowing; Tonsils – enlarged/inflamed/exudate; Tonsillar pillars – erythematous, discomfort
  • Occlusion: Note Class I, II, III and document bilaterally

Documentation and Lesion Descriptors (ABCDT Framework)

  • A. History: lesion onset, duration, symptoms, prior notices, changes in size/appearance
  • B. Location and Extent: precise location, localized vs generalized; descriptive notation; IO photos if available
  • C. Physical Characteristics: size/shape, color, surface texture, consistency; borders (well-demarcated vs poorly demarcated)
  • D. Diameter/Dimensions: measure with a probe; report length × width; note if circular (diameter)
  • T. Type (Morphologic Categories): elevated, depressed, or flat; matrix of lesion types (macule, patch, papule, plaque, nodule, vesicle, pustule, etc.)
  • Use the Morphologic Descriptors: nonpalpable flat lesions (macule, patch); palpable elevated lesions (papule, plaque, nodule, vesicle, bullae, pustule); loss of surface (erosion, ulcer, fissure)

Lesion Descriptor Worksheet (Descriptors to Use)

  • Anatomic location: head, neck, lips, gingiva, tongue, floor of mouth, palate, oropharynx, etc.
  • Borders: well-demarcated vs poorly demarcated
  • Shape: regular vs irregular
  • Color: red, white, red+white, blue, yellow, brown, black
  • Pattern: discrete, grouped, confluent, linear
  • Size: length × width, or diameter if circular
  • Elevation: non-palpable, palpable, raised, fluid-filled; surface texture: smooth, papillary, fissured, crusted
  • Additional terms: exophytic, endophytic, indurated, papillary

Common Lesion Terminology (Primary Lesions)

  • Macule: flat circumscribed color change < 1 cm
  • Patch: flat color change > 1 cm
  • Papule: solid raised lesion < 1 cm
  • Plaque: flat-topped or superficial raised lesion > 1 cm
  • Nodule: solid, marble-like lesion > 1 cm
  • Vesicle: small blister < 1 cm; contains clear fluid
  • Bullae: larger fluid-filled lesion > 1 cm
  • Pustule: raised lesion with pus
  • Erosion: loss of superficial epithelium
  • Ulcer: crater-like lesion with loss of deeper layers
  • Fissure: linear crack

Other Descriptive Terms for Lesions

  • Surface texture: smooth, irregular (papillary, wart-like, fissured, cracked, crusted)
  • Consistency: soft, spongy, resilient, hard, indurated
  • Exophytic vs Endophytic growth; Papillary surface
  • Crust, Aphthae (apthous ulcers on non-keratinized mucosa), Cyst, Erythema (red area), Petechiae, Pseudomembrane, Polyp, Punctate, Purulent, Rubefaction, Torus, Verrucous growth

Oral Cancer: Key Points

  • Location: lateral borders of the tongue, floor of mouth, lips (lower lip, sun-exposed), soft palate complex are common sites
  • Appearance of early cancer: white areas (leukoplakia), red areas (erythroplakia), ulcers, masses, pigmentation
  • Risk factors: tobacco, alcohol; risk exists even with no risk factors
  • Many cancers are asymptomatic initially; high index of suspicion is important
  • Biopsy is the gold standard for diagnosis; biopsy or cytology adjuncts when biopsy refused or for suspicious lesions

Biopsy and Cytology

  • Biopsy: removal and microscopic examination; definitive diagnosis
  • Indications: inability to identify lesion with certainty or lesions not healing in 2 weeks
  • If the patient refuses biopsy, cytology adjuncts can be considered (but biopsy remains preferred)

Example Measurement (Practice)

  • Example measurement: 13\,\text{mm} \times 7\,\text{mm} (length × width)
  • For a circular lesion: e.g., a lesion of diameter 3\,\text{mm} would be documented as such; otherwise provide length × width
  • Conversion note: 10\,\text{mm} = 1\,\text{cm}; 13 mm ≈ 1.3 cm

Intraoral Examination: Areas to Inspect (Summary of Page 36–37)

  • Lips; Labial mucosa; Buccal mucosa and buccal folds; Parotid glands and papilla; Floor of mouth; Tongue; Hard and soft palate; Oropharynx and nasopharynx; Occlusion
  • Each area includes both a visual assessment and palpation findings; look for salivary flow changes, color changes, lesions, swellings, and other notable signs
  • Document amount and consistency of saliva and note any lesions using ABCDT descriptors

Extraoral Examination (Overview)

  • Observe: during walking to chair, seating posture, gait, breathing; look at head, face, eyes, neck, and skin
  • Remove prostheses and glasses prior to EO exam to inspect all areas adequately
  • Palpate: salivary glands, lymph nodes, TMJ, and muscles; document symptoms (e.g., discomfort, swallowing difficulty, numbness, etc.)
  • Important ethical note: never tell a patient they have cancer; report findings and refer appropriately for follow-up

Extraoral Structures and Muscles

  • Muscles: masseter, temporalis, medial and lateral pterygoids; mentalis; orbicularis oris; other facial muscles
  • TMJ signs to query: pain, clicking, limited opening, jaw deviation, or locking
  • Lymph nodes: cervical, submental, submandibular, posterior auricular, occipital, supraclavicular; tender nodes can indicate infection or disease process
  • Salivary glands: parotid, submandibular, sublingual and their ducts

Ethical Considerations in EOIO

  • Do not diagnose cancer in a patient; provide findings and refer to appropriate specialists
  • Ensure informed consent and patient education about findings and next steps
  • Document patient education and recommendations for dermatology or medical evaluation when needed

Patient Education and Self-Examination

  • Teach patients to perform self-exams for skin cancer and oral cancer at home
  • Emphasize regular dermatology visits
  • Advise follow-up if a new lesion does not heal within 2 weeks

Intraoral Examination: Quick Reference (Lips to Occlusion)

  • Lips; Labial mucosa; Buccal mucosa and buccal folds; Parotid papilla; Floor of mouth; Tongue; Hard/Soft palate; Oropharynx; Nasopharynx; Occlusion
  • For each area: assess normal descriptors and notable findings; document using ABCDT

Reflection: Using POC for Documentation (Page 57–58)

  • Use your Plan of Care to guide documentation
  • If no findings: use normal descriptors
  • If notable: describe exactly as observed using standard terminology and measurements

The Lesion Descriptor Worksheet (Key Concepts)

  • Head/Neck regions, lip and mucosa locations, gingiva, tongue, floor of mouth, palate, oropharynx
  • Location descriptors: midline, right/left sides, near tooth numbers
  • Lesion properties: border, color, configuration, and pattern; measure length/width; demarcation clarity
  • Macule, Patch, Papule, Plaque, Nodule, Vesicle, Bullae, Pustule, Erosion, Ulcer, Fissure

Practice Question (From Review)

  • 3mm x 2mm left lateral border ulcer, white with red borders, regular borders, well-demarcated, unsure duration, no tobacco/alcohol use
  • Typical clinical approach: document with ABCDT descriptors, measure with a probe, consider differential but biopsy or referral if indicated; this is a hypothetical exercise

Follow-Up Resources

  • EOIO videos and DS intranet resources for additional practice and examples
  • Remember to re-check and monitor lesions over time when appropriate

Quick Reference: Intraoral Areas to Inspect (List)

  • Upper and lower vestibules
  • Mucogingival junction and attached gingiva
  • Marginal/Free gingiva
  • Labial and buccal mucosa; buccal folds
  • Parotid papilla and duct openings
  • Floor of mouth; sublingual folds and caruncles
  • Tongue (dorsal and ventral surfaces; base region)
  • Hard and soft palate; tonsillar region; oropharynx
  • Occlusion: bilaterally assess Class I, II, III