DEN 114 Dental Hygiene I Module 5: Oral Facial Assessment / Examination

Oral Cancer Statistics

  • Over 53,000 people will get oral or oropharyngeal cancer this year.

  • Almost 10,000 people will die from oral cancer.

  • Oral cancer rates are rising. This could be attributed to HPV infections.

  • 90% of patients diagnosed with oral cancer are over 40 years old.

  • Males are twice as likely to develop oral cancer compared to females.

  • 85% of oral cancers are linked to tobacco use.

  • The use of alcohol increases the likelihood of developing oral cancer.

  • SCC (Squamous Cell Carcinoma) is typically found more anterior (in the front), while HPV-related cancers tend to be more posterior (in the back).

Oral Cancer Statistics & Risk Factors

  • HPV (Human Papillomavirus) is a significant risk factor for oral cancer.

  • Tobacco products including marijuana use are linked to increased risk.

  • Alcohol use has a consistent correlation with oral cancer risk.

  • Prolonged sun exposure and having fair skin can heighten the risk.

  • Factors such as gender and age also play a role in risk levels.

  • Poor oral hygiene and suboptimal nutrition contribute to risk.

  • A weakened immune system may increase susceptibility to oral cancers.

  • Most common sites affected by oral cancer include the lower lip, lateral borders of the tongue, floor of the mouth, and oropharynx.

Oral Pathology Descriptive Terms

Important descriptive terms used in oral pathology include:

  • Size

  • Color

  • Texture

  • Consistency

  • Shape & Location

  • Characteristics including duration and symmetry

Size

  • Sessile: Lesion with a base that is the same size as the lesion itself.

  • Pedunculated: Lesion with a base that is smaller than the lesion.

Color

  • Erythroplakia: Velvety, deep red patch; typically uncommon and usually indicates severe dysplasia. 90% of these lesions in high-risk areas tend to be carcinomas.

  • Leukoplakia: White or red and white patches; common, and when biopsied, usually show little or no dysplasia. Less than 10% turn out to be cancers. Referral for evaluation is recommended.

  • Pigmented: Refers to dark lesions.

  • Macule: A flat lesion, such as a freckle.

Texture

  • Crater: Central depression in a lesion.

  • Corrugated: Wrinkled surface.

  • Fissured: Exhibiting ridges and irregularities on the surface.

  • Papillomatous: Contains small modulations or elevated projections.

  • Pseudomembrane: Loose surface layer of exudate formed during an inflammatory reaction that contains microorganisms.

  • Purulent: Containing, forming, or discharging pus.

  • Smooth: Deep lesion that stretches the surface tissue.

  • Verrucous: Rough, wart-like texture with multiple irregular folds.

Texture Continued

  • Aphtha: Small white or reddish ulcer.

  • Cyst: A closed epithelial-lined sac (may be normal or pathological) that contains fluid or other material.

  • Exophytic: Lesion growing outward.

  • Idiopathic: Lesion of unknown etiology.

  • Indurated: Pertaining to a hardened or abnormally hard lesion.

  • Petechiae: Very small hemorrhagic spots ranging from pinhead to pinpoint size.

  • Polyp: A mass of tissue projecting outward.

  • Punctate: Marked with points or dots different from the surrounding tissue.

  • Rubefacient: A substance that reddens the skin.

Consistency

  • Blisterform: Filled with fluid (i.e., serum or mucin).

  • Nonblisterform: Solid, not filled with fluid.

Elevated Lesions

  • Usually measured in millimeters using a probe for actual size.

  • Vesicle: ≤ 5mm, contains serum or mucin.

  • Pustule: Contains pus, size does not matter.

  • Bulla: > 5mm, contains serum, mucin, or blood.

  • Plaque: Slightly raised border, broad and flat, with a pasted-on appearance.

  • Papule: < 5mm, solid tissue, can be smooth or corrugated.

  • Nodule: < 1cm, solid tissue.

  • Tumor: ≥ 2cm, solid tissue; can be sessile or pedunculated.

Shape

  • Regular outline: Lesion with a consistent shape.

  • Irregular outline: Lesion with an inconsistent shape

  • Shapes can include circle, oval, etc.

  • Other features may include flat, smooth margin, or raised margin, and may be lobulated.

Visual Inspection

  • A thorough visual inspection provides valuable information to clinicians.

  • Some practices utilize the abbreviation WNL.

  • It is ambiguous whether WNL means "within normal limits" or "we never looked."

  • The OFE (Oral-Facial Examination) is often the first assessment portion that gets curtailed due to time constraints.

Prior to Starting the OFE

  • Clinicians must inform the patient about the procedure.

  • Suggested phrasing: "I am going to take a look at (or assess) your head and neck and everything inside and outside of your mouth."

  • Avoid asking, "Okay?"

  • Inquire about family history of oral cancer and usage of tobacco or nicotine products.

  • It's important to reassure that documentation will be made and checked by a supervisor.

Palpation Techniques

  • Digital palpation: Utilizing one finger, typically on hard tissue.

  • Bidigital palpation: Using the index and thumb with soft tissue in between.

  • Manual palpation: Involving one hand.

  • Bimanual palpation: Using two hands.

  • Bilateral palpation: Employing both hands on both sides of the area being examined.

  • Circular compression: Utilization of fingertip rotation for examining findings, noting to avoid a motion like piano playing.

Extra-Oral Portion: The Face

  • Assess for symmetry.

  • Inspect the color & texture of the skin.

  • Look for discoloration patches, moles, or acne.

  • Move hair to inspect the scalp and evaluate any hair loss areas.

The Eyes

  • Patients should remove glasses for proper evaluation.

  • Indicators of potential issues:

    • Redness: May indicate allergies or alcohol influence.

    • Yellowish tint: May suggest jaundice.

    • Bluish hue: Could indicate chronic oxygen deprivation.

    • Stark white: May signify vasoconstriction.

    • Protrusion: Could indicate adrenal disease.

The Eyes & Pupils (Substance Use)

  • Constriction of pupils could signal alcohol or opioid use.

  • Dilation of pupils may indicate amphetamines, cocaine, or LSD use.

The Lips (External, Visual)

  • Inspect the vermilion borders of the lips.

  • Examine the commissures for abnormalities, and document findings.

The Ears

  • Look for skin abnormalities on the top and sides, especially due to sun exposure.

  • Check behind the ears by gently bending the top forward.

The Neck

  • Ensure to move any hair to inspect the front, sides, and back thoroughly.

The Lymph Nodes (Palpation)

  • Key lymph nodes to palpate include:

    • Pre & Post-auricular

    • Occipital

    • Posterior Cervical

    • Anterior Cervical

    • Supraclavicular

    • Submental

Salivary Glands (Palpation)

  • Palpate major glands:

    • Parotid

    • Submandibular

    • Sublingual

TMJ (Temporomandibular Joint) Palpation

  • Place hands directly in front of the ear.

  • Instruct the patient to open and close their mouth slowly.

  • Listen for sounds and feel for pops and ask the patient if they hear anything or experience pain.

Thyroid Gland Palpation

  • Locate the thyroid cartilage.

  • Palpate the left and right lobes of the thyroid gland, checking for mobility gently.

  • Evaluate the carotid area as well.

Back of Head & Neck Palpation

  • Inspect the occipital area (lymph nodes).

  • Palpate the posterior cervical chains (lymph nodes).

  • Other focuses include preauricular nodes, and all associated glands.

Intra-oral Portion – Inspection and Palpation

  • Inspect the hard palate, palatine rugae, palatine raphe, fovea palatini, maxillary tuberosity, and dorsal surface of the tongue.

  • Palpate the dorsal surface of the tongue using gauze while retracting.

Floor of the Mouth

  • Use light to inspect first.

  • Locate Wharton’s Duct and verbalize the presence of tori.

  • Bimanual palpation is required here, using gloves appropriately.

Oropharynx Examination

  • Move light to inspect the oropharynx first; verbalize findings.

  • Assess anterior and posterior pillars, tonsils, uvula, and the pharynx.

Mallampati Score

  • Patient should open wide and protrude their tongue for scoring the visibility of soft and hard palates and the uvula:

    • Grade I: Shows soft palate and entire uvula.

    • Grade II: Shows soft palate, hard palate, and upper portion of uvula.

    • Grade III: Shows soft palate, hard palate, and base of uvula.

    • Grade IV: Only the hard palate is visible.

Tonsil Size Assessment

  • Operator uses a tongue depressor and asks the patient to say 'ah' while rating the percent of space in the oropharynx occupied by the tonsils:

    • 1: < 25% filled by tonsils

    • 2: 25-50% filled by tonsils

    • 3: 50-75% filled by tonsils

    • 4: 75% + filled by tonsils (kissing tonsils).

  • Tonsil size correlates with breathing ability.

Lips & Frenulum Attachments

  • Inspect the internal lip using light, noting any abnormalities in frena and mucobuccal folds.

  • Bidigital palpation of the lips is necessary.

Buccal Mucosa Assessment

  • Utilize light for inspection bilaterally.

  • Look for Stenson’s duct located on the Parotid Papilla.

  • Thorough bidigital palpation is essential throughout the examination of the buccal mucosa.

Tongue Examination: Dorsal Surface

  • Instruct the patient to extend/stick out their tongue.

  • Move light to visually examine the tongue and gently retract with gauze.

  • Digitally palpate the dorsum while holding the gauze.

Tongue Examination: Lateral Borders

  • Grasp the tongue with a gauze square and gently inspect and palpate from left to right, utilizing a mirror for posterior view.

Tongue – Ventral Surface

  • Instruct the patient to lift the tongue to the roof of their mouth.

  • Inspect the ventral surface and lingual frenum carefully.

  • Referrals for tongue-ties are essential for any speech or swallowing impediments.

Attached Gingiva & Alveolar Mucosa

  • Inspect both maxillary and mandibular gingiva along with the alveolar mucosa.

  • Digital palpation is necessary for thorough examination.

Palatal Area Inspection

  • Move light to inspect both hard and soft palates.

  • Digital palpation is limited to the hard palate only.

  • Verbalization of findings such as midline maxillary torus is expected.

  • Inspecting and palpating retromolar pads digitally is also necessary.

Occlusion Assessment

  • Applying Angle’s Classification of Occlusion:

    • Examine the molar relationship on both sides:

    • Class I: Normal molar relationship;

    • Class II: Mandible is positioned more significantly than maxilla;

    • Class III: Mandible is positioned less significantly than maxilla.

  • Note that the maxilla remains stable during the assessment, while the mandible's development is crucial for optimal breathing.

Overjet and Overbite Measurement

  • Overjet is measured in millimeters; the distance between the upper and lower incisors when the teeth are in occlusion.

  • Overbite is classified as follows:

    • Slight: Normal (1-2mm).

    • Moderate & Severe: To be noted in records as only moderate and severe are significant.

Anterior Openbite

  • Causes of openbite can include pacifier use and thumb sucking which restrict maxillary growth.

Crossbite Assessment

  • Crossbite can be anterior or posterior, also categorized as complete or partial (anterior only).

Developmental Defects & Tooth Structure

  • Abfraction: Cervical stress lesions caused by tooth flexing under occlusal forces leading to fractures at the crown-root junction.

  • Abrasion: Structural loss from external force effects, like aggressive brushing techniques and stressors such as nails or fishing lines.

  • Attrition: Loss of structure due to tooth contacts, such as grinding or bruxism.

  • Erosion: Chemical loss of structure by acids from diet or conditions like bulimia.

Elevated Lesions Flowchart

  • Localized Elevated Lesions: Above normal plane of mucosa; can be single or multiple.

  • Categories include blisterform (vesicle, bulla, pustule) and nonblisterform (plaque, papule, nodule, tumor).

Depressed Lesions Flowchart

  • Depressed Lesions: Below the normal plane of mucosa often presenting as ulcers.

  • They can be single or multiple with varying margin types & depths.

Flat Lesions Flowchart

  • Flat Lesions: Surface shares the same plane as normal mucosa.

  • Can be single (macule) or multiple (with regular or irregular outline).

Screening Tools for Oral Cancer

  • Items for evaluation and palpation include:

    • Vizilite

    • Velscope

    • OralID

    • Identifi

    • Cytological smear

    • Brush biopsy

    • Biopsy

Clinical Application: Extra-Oral Examination

  • Begin with the patient upright and at eye level.

  • Ensure they remove their eyewear and bonnets.

  • Utilize PPE (Personal Protective Equipment) including gloves and overgloves.

  • Systematic inspection should progress from top of the head to the neck and downwards, assessing and palpating as you proceed.

Clinical Application: Intra-Oral Examination

  • After completing the extra-oral examination, remove the overglove from the dominant hand.

  • Patient put their eyewear back on.

  • Use good light to cover all areas of the mouth, focusing on key ducts and structures like Wharton's duct.

Clinical Application: Soft & Hard Tissues Assessment

  • Recline the patient slightly to a supine position with a neutral head.

  • Inspect soft tissues (lips, buccal mucosa, tongue) as well as hard tissues (attached gingiva, alveolar mucosa, hard palate).

  • Document findings such as abrasion, abfraction, attrition, or erosion.

HPV Vaccine and Cancer Statistics

  • HPV is linked to 70% of cases of oropharyngeal cancer.

  • Rise noted from 1999-2015, with the number of HPV-related throat cancer cases doubling during this period, predominantly in men.

  • Specific symptoms to monitor include persistent sore throat, lumps in the neck or throat, and difficulties with chewing or swallowing.

Family Violence and Reporting

  • Physical neglect: Failure by caregivers to provide essential needs.

  • Emotional abuse: Involves causing mental anguish or controlling behavior.

  • Reporting obligations: Clinicians are mandated to report on any suspected child or elder abuse, with referral systems available.

  • Forensic Dentistry: Application of dental facts to legal issues, requiring certification and is outside the regular dental practice scope.

Summary

  • Understanding oral cancer, the implications of HPV, and assessing various oral lesions is crucial in clinical practice.

  • Practitioners must carry out thorough examinations and document findings to aid in the early detection of conditions like oral cancer.

  • Awareness and training in family violence reporting are essential in dental practice to ensure patient safety.