CH 13–14: Extraoral and Intraoral Examination – Study Notes

Module 13–14: Extraoral and Intraoral Examination – Comprehensive Study Notes

  • Informing the Patient (both EO and IO examinations)

    • The purpose of the examination should be explained to the patient prior to beginning the procedure.

    • “Inform before you perform” should be a primary directive for every health-care provider.

    • Prior to performing any procedure, the dental hygienist should provide the patient with:

    • What the procedure is

    • Why it is being done

    • How it will be done

    • Information provided must be appropriate for the patient’s level of understanding.

  • Infection Control (PPE) for EO and IO Examinations

    • The dental hygienist should wear ALL PPE when performing both extraoral and intraoral examinations.

    • Required PPE Includes:

    • Gown

    • Mask

    • Eyewear (Safety Glasses or Loupes)

    • Bonnet

    • Gloves

  • EO/IO Examinations: Overview and General Approach

    • Head and Neck Examination is a physical examination consisting of:

    • A systemic visual inspection of the skin of the head and neck

    • Palpation of the lymph nodes, salivary glands, thyroid, and TMJ

    • Palpation is defined as the use of fingers or hands to feel for texture, size, and consistency of hard and soft tissues.

    • Palpation Techniques include:

    • Bi-lateral Palpation

    • Bimanual Palpation

    • Bi-digital Palpation

    • Digital Palpation

    • General Appraisal of Head and Neck:

    • EO examination begins while greeting and seating the patient.

    • Stand in front of the patient.

    • Complete a general appraisal of the face, head, and neck including inspection of facial form, the skin, and hair.

    • Question the patient about the time of onset, duration, and possible cause of any nodule, ulceration, scars, or other surface variations on the skin.

  • Eyes

    • Stand in front of the patient.

    • Visually inspect the eyes.

    • Note lens opacities, color changes of the sclera, and pupil response to light.

  • Ears: Landmarks and Examination

    • Landmarks: Helix, Antihelix, Entrance to ear canal, Tragus, Lobe.

    • Ears: Stand behind the patient with the head upright; displace the ear forward for visual inspection.

    • Palpation of the mastoid process: Use circular compression; pain on palpation could indicate mastoiditis.

  • Nose Landmarks

    • Ala nasi, Bridge, Tip, Naris, Vestibule.

  • Anatomy Review: Lymph Nodes of the Head and Neck

    • Lymphatic system: a network of lymph nodes connected by lymphatic vessels; plays a role in defense against infection.

    • Lymph nodes: bean-shaped structures that filter and trap bacteria, fungi, viruses, and waste.

  • Lymphadenopathy (enlarged lymph nodes)

    • Nodes enlarge in area of infection. Usually enlarge to
      extsize∈[12,1] inch acrossext{size} \in \left[\frac{1}{2}, 1\right] \text{ inch across}

    • With a virus: often up to ≈ 1 inch1\text{ inch}; with bacterial infection: can enlarge over 1 inch1\text{ inch}; cancer can present as painless enlargement.

    • Lymphatic system can transport cancer cells throughout the body.

  • Correct Palpation Technique for Lymph Nodes

    • Use the fingertips to compress the structure against underlying tissues in a circular motion.

    • Incorrect technique involves lightly “walking” or “dancing” the fingertips over a structure; this is ineffective for detecting nodules, tumors, swelling, or enlarged nodes.

  • Lymph Nodes: Regional Examination Techniques

    • Occipital Lymph Nodes

    • Stand behind the patient; head tipped forward; assist by lifting hair to expose neck.

    • Bilateral palpation via circular compression at the base of the skull from the midline outward to the sternomastoid muscle; cover ~2 inches in width.

    • Postauricular Lymph Nodes

    • Stand behind the patient; hair lifted for neck visibility.

    • Palpate with circular motions against bone of the skull; nodes may be palpated bilaterally.

    • Preauricular Lymph Nodes

    • Stand behind the patient; similar palpation approach as above.

    • Submental Lymph Nodes

    • Compress the area behind and between the midline of the mandible using bi-digital technique (thumb and index finger).

    • Submandibular Lymph Nodes

    • Use LEFT hand to move tissue under the chin toward the right side of the neck; palpate with the right hand.

    • Roll tissue up and over the border of the mandible; continue palpation as tissue slowly slides down over mandible.

    • Anterior Cervical Lymph Nodes

    • Examine on each side separately.

    • Stand behind or to the side; head tipped forward and slightly to the left.

    • Palpate the anterior chain on the right by pressing medial to the sternomastoid with fingertips; rotate fingers back and forth along the muscle.

    • Posterior Cervical Lymph Nodes

    • With same head position, palpate cervical lymph in the posterior triangle on the right; apply compression along entire length behind the muscle.

    • Repeat on the left side for both anterior and posterior node chains.

    • Supraclavicular Lymph Nodes

    • Tip the chin down slightly to relax neck muscles.

    • Use index and middle fingers to apply circular compression above the clavicle; palpate both sides.

  • Lymph Nodes: Normal Findings

    • Healthy nodes are usually not detectable (cannot be felt).

    • No tenderness to palpation.

    • Infected nodes: firm, tender, enlarged and warm; bilateral swelling.

    • Nodes should be freely movable from underlying structures.

    • Swollen nodes can feel like a grape; after infection, nodes may remain enlarged (often small ≤ 1 cm1\text{ cm}), non-tender, with rubbery consistency.

  • Temporomandibular Joint (TMJ): Locating and Palpation

    • Locate TMJ by standing behind the patient: place index fingers just in front of the tragus of each ear; instruct patient to open and close.

    • As mouth opens, fingertips drop into the joint spaces.

    • Palpate TMJ: use fingertips to palpate both joints simultaneously; have patient open and close several times; observe the path of opening and note any deviations.

    • ROM and functional assessment include lateral movements and protrusion.

  • TMJ: Notable Findings

    • Abnormal sounds (popping, clicking)

    • Grating sensations during opening/closing

    • Asymmetrical movements

    • Limited range of movement (three fingers may not fit in mouth)

    • Tenderness or pain reported by the patient

  • Temporalis and Masseter Muscles

    • Temporalis: locate by asking patient to clench teeth; palpate bilaterally by compressing tissue against the skull.

    • Masseter: locate by asking patient to clench; palpate bilaterally by compressing the body of the muscle against underlying structures.

  • Parotid Glands

    • Palpate bilaterally by compressing tissue against the cheekbone in circular motions.

    • It is important to palpate the entire surface area of these large glands.

    • The normal gland is difficult to recognize by palpation; however, hyperplastic glands or nodules are palpable.

  • Locating and Palpating Submandibular and Sublingual Glands

    • Submandibular Glands: place index fingers near the angle of the mandible; move fingertips forward along the mandible to locate the slight depression at the border (antegonial notch).

    • Palpate Submandibular Gland: ask patient to press the tip of the tongue against the roof of the mouth; compress the glands upward against the tensed mylohyoid and tongue muscles.

    • Sublingual Glands: performed with similar technique near the caruncles; assess saliva expression.

  • Anatomy: Sternomastoid Muscle

    • Examine the muscle on each side of the neck separately.

    • To locate: ask patient to turn head to one side with chin tipped downward; the muscle is visible along the neck.

    • Support the patient’s head by cupping the chin; patient may assist by holding hair back if needed.

    • Assess origin, body, and insertion.

    • Palpation techniques:

    • Palpate the origin behind the ear using circular compressions.

    • Use bi-digital compression to palpate the body by squeezing the muscle between fingers and thumb.

  • Thyroid and Larynx Location and Function

    • Locating the Thyroid Gland:

    • Normal thyroid is not visible.

    • Have the patient drink water and swallow; the thyroid will move up and down with swallowing.

    • Once located, proceed to palpation.

    • Palpation of Thyroid Gland:

    • Left hand displaces the trachea slightly to the right.

    • Right hand between the Adam’s apple and sternomastoid; rest fingers lightly.

    • Ask patient to swallow; gland will move beneath your fingers.

    • Repeat with trachea displaced to the left.

    • The Larynx:

    • Place fingers on either side of the larynx and move slowly side to side.

    • Some patients may produce a clicking sound; reassure that this can be normal.

    • Larynx Position and Movement:

    • The larynx should lie at the midline; tumor masses may push the larynx to one side.

    • Inspect for deviation by placing a finger along the larynx and compare spaces with the sternomastoid on both sides.

    • Place fingers over the larynx and ask the patient to swallow; the larynx should rise and fall with swallowing.

  • Documentation and Wrap-Up

    • Upon completion of the extraoral examination, record all findings in the SOAP note in the patient’s EHR and bring them to the attention of the dentist.

  • Intraoral Examination: Overview and Patient Communication

    • Intraoral examination follows a similar principle of informing the patient of purpose and ongoing findings.

    • Throughout the procedure, explain which structures are being inspected and relate the procedure to any patient-specific conditions or interests.

  • Patient Positioning for Intraoral Inspection

    • The patient should be positioned in a supine position for the entire intraoral examination.

    • The dental hygienist works from a seated position.

    • The patient should wear safety glasses; appliances, partial or complete dentures should be removed and placed in water.

    • Examiner should wear ALL required PPE.

    • The oral cavity should be adequately lighted by the unit light and loupes throughout the intraoral examination.

  • Sequence of Intraoral Examination

    • The intraoral examination should be completed in a logical and efficient manner.

    • Involves inspection and/or palpation of the structures of the oral cavity and oropharynx.

    • Helpful to organize the structures to be examined (see EO/IO Sequence):

    • Lips and Vermillion Border

    • Oral Cavity and Mucosal Surfaces (Labial and Buccal)

    • Salivary Gland Function

    • Floor of the Mouth

    • The Tongue

    • Palate, Tonsils and Oropharynx

    • Occlusion

  • Lips and Vermillion Border

    • Visually inspect lips and vermillion border.

    • Evaluate color, texture, and fissuring of vermilion border.

    • Common findings include chapped lips and herpetic lesions.

  • Preliminary and Visual Inspection of Oral Cavity

    • Visually inspect the entire oral cavity and oropharynx.

    • Use a mirror to detect conditions that would modify or postpone exam (e.g., herpetic lesion or red, inflamed throat).

  • Labial Mucosa Inspection and Palpation

    • Labial mucosa of lower lip: visually inspected; use index fingers inside mouth and thumbs outside to palpate (Bi-Digital).

    • Evert and retract the lip fully away from teeth and alveolar ridge.

    • Labial mucosa of upper lip: same procedure.

    • Palpation: move fingers up to the upper lip and compress between index fingers and thumbs (Bi-Digital).

  • Buccal Mucosa Visual Inspection

    • Buccal M mucosa, maxilla: start with right side; stretch right cheek up and away from maxillary teeth; extend tissue so no folds conceal lesions.

    • Buccal M mucosa, mandible: stretch cheek down and away from mandible; inspect left side as well.

    • Palpation: Left hand (middle and ring fingers) extraorally; Right hand (index finger) intraorally; compress tissue along the length of the buccal mucosa.

    • Note: palpation sequence may continue across both sides.

  • Examinations of Parotid Ducts

    • Retract right cheek; dry papilla with gauze.

    • Roll applicator from area slightly above papilla down to papilla while applying pressure; a drop of saliva should be expressed.

    • Repeat on left side.

  • Examinations of Submandibular and Sublingual Ducts

    • Ask patient to raise tongue.

    • Use gauze to gently dry the area.

    • Press gently with applicator in the region of the caruncles; a drop or stream of saliva should be evident.

  • Floor of the Mouth: Anterior and Posterior Inspection

    • Anterior Floor of Mouth:

    • Ask patient to touch the tip of the tongue to the roof of the mouth.

    • Visually inspect the anterior portion of the floor of the mouth; a mouth mirror may reflect light onto the floor.

    • Posterior Floor of Mouth:

    • Ask patient to relax and protrude the tongue.

    • Fold a damp gauze square, grasp tongue between gauze sides, and pull gently to the left commissure of the lip.

    • Then proceed with inspection.

    • Posterior Floor of Mouth (continued):

    • Use the left hand to apply gentle upward pressure against the submandibular gland; this makes the posterior floor of mouth more visible.

    • Visually inspect; repeat on left side.

  • Palpation: Floor of the Mouth

    • Right index finger on floor of mouth; Left middle and ring fingers under the chin.

    • Gently move tongue out of the way with the index finger.

    • Then:

    • Press upward with extraoral fingers and press downward with your index finger; as if trying to bring the fingers to meet.

    • Palpate the right posterior floor; repeat on the left.

  • The Tongue: Significance and Surface Anatomy

    • The tongue is the site with the highest incidence of oral cancer.

    • Landmarks (reference diagram): dorsum with lingual tonsil, vallate papillae, filliform papillae, epiglottis, fungiform and foliate papillae, palatine tonsil, and related structures.

    • Ventral surface and anterior floor of mouth landmarks: lingual frenulum, lingual vein, and ducts of submandibular glands.

    • Notable finding: Ankyloglossia (tongue-tie).

  • Tongue Inspection and Palpation Procedures

    • Ventral surface: ask patient to touch tongue to roof; visually inspect.

    • Dorsal surface: ask patient to protrude slightly; grasp tongue with damp gauze; pull forward; visually inspect entire dorsal surface.

    • Lateral borders: gently pull tongue to the left commissure; evert to view lateral surface; inspect both sides using direct and indirect vision.

    • Palpation of Tongue: Bi-Digitally palpate the entire body of the tongue for swellings or nodules.

  • Hard and Soft Palate, Tonsils, and Oropharynx

    • Landmarks include posterior and anterior columns, hard palate, soft palate, uvula, pharynx, and tongue.

    • Visual Inspection of Hard and Soft Palate: perform direct inspection and with a mouth mirror.

    • Palpation of Hard and Soft Palate: use index finger; intermittent firm upward pressure; avoid sliding finger across the palate (note: GAG!).

    • Oropharynx Inspection: use mouth mirror with reflecting surface down; ask patient to say “ahhhh”; apply firm downward and forward mirror pressure.

    • Nasopharynx Inspection: depress tongue with mirror (reflecting surface up); place mirror in the back of the oropharynx close to the pharyngeal wall.

  • SOAP and Final Documentation

    • Upon completion of the intraoral examination, record all findings in the SOAP note in the patient’s EHR and inform the dentist.

  • Quick Reminders and Practical Tips

    • Maintain a logical and systematic approach to EO/IO examinations to avoid omissions.

    • Ensure patient comfort and understanding at every step.

    • Use proper lighting, magnification (loupes), and appropriate PPE throughout.

    • Always compare bilaterally and document normal versus abnormal findings with specific descriptions.

  • LaTeX Summary of Key Measurements and Concepts

    • Normal lymph node size for benign processes when enlarged: up to 1 cm1\text{ cm}; viral infections often cause nodes up to 1 cm1\text{ cm}; bacterial infections can exceed this.

    • Lymph node enlargement in cancer may be painless and persistent; swollen nodes may be rubbery or firm depending on etiology.

    • Mouth opening assessment example: extthreefingersext{three fingers} width indicates ROM limitations when patient cannot fit three fingers between incisal edges.

  • References to Materials

    • EO/IO Sequence document referenced as EOIO_Sequence.docx for standardization of sequence (no single fixed order).

    • Video access instructions via the DS Intranet (dserver.uthscsa.edu) under Dental School Streaming Server → Dental Hygiene → select video.

  • Quick Cheat Sheet (for exam use)

    • Always begin EO with patient greeting and general facial/head/neck inspection.

    • Use circular, gentle compressions for palpation; avoid light, sweeping finger motions.

    • For thyroid: swallow to observe movement; palpate with trachea displaced left and right.

    • For TMJ: check opening path, deviations, and sounds; note lateral movements and protrusion.

    • In IO exam, inspect and palpate lips, labial mucosa, buccal mucosa, floor of mouth, tongue, hard/soft palate, tonsils, and oropharynx; evaluate salivary duct function and occlusion where relevant.

  • End of Notes