Chapter 13 Extraoral and Intraoral Examination PDF

Chapter 13 Extraoral and Intraoral Examination  Learning Objectives Explain the rationale for extra- and intraoral examination Explain the systematic sequence Identify normal anatomy Describe physical characteristics Identify suspicious conditions  Compo...

Chapter 13 Extraoral and Intraoral Examination  Learning Objectives Explain the rationale for extra- and intraoral examination Explain the systematic sequence Identify normal anatomy Describe physical characteristics Identify suspicious conditions  Components of Examination Standard of patient care involves the concept of total patient being treated Examination is all-inclusive – Physical, mental, phycological Routine, thorough examination at each continuing care appointment Assessment of health-related risk factors Cancer hx Family cancer hx Tobacco and alcohol use Sun exposure Diet Immunosuppressive conditions Sexual behaviors Cultural/genetic susceptibilities 3  Five Types of Examinations Complete- involves all components of assessment Screening-brief, preliminary exam/usually for pain relief and triage to determine order moving forward Limited examination- brief exam for emergency situation/acute condition Follow- up- brief to check healing after tx Continuing care/reevaluation- After a specific period of time after completion of the care plan – A continuing care examination is a complete reassessment from which a new dental hygiene diagnosis and care plan are derived  Methods for Examination Visual examination- direct, radiographic, transillumination Palpation- digital, bidigital, bimanual, bilateral Instrumentation- periodontal probe, explorer Percussion- tapping on a surface (pt response or sound) Electrical test- detects presence or absence of vital pulp tissue Auscultation- sound Bidigital Palpation of the Lip Bimanual Palpation Bimanual Assessment of the Temporomandibular Joint  Signs and Symptoms General signs and symptoms may occur in various disease conditions (fever) Pathognomonic signs and symptoms are unique to a disease Signs- objective; any abnormality identified by a healthcare professional while examining a patient Symptoms- subjective; is any departure from normal that may be indicative of disease the patient has identified  Preparation for Examination Review health histories and medical record  including risk factors, dental caries, periodontal, and oral cancer risk assessments. Examine radiographs  Dental caries, bone loss, pathologies Explain procedures and their relevance  “I am going to perform an extra-/intraoral examination to look for abnormalities that can affect your oral and overall health.”  Rationale for the Extraoral and Intraoral Examination Early identification of abnormalities and pathologies ORAL CANCER In addition it may reveal signs of: Thyroid disorders Eating disorders Nutritional deficiencies Sexually transmitted diseases A host of systemic conditions Anatomical Landmarks of the Oral Cavity I. Knowing normal anatomy is a must to understanding abnormal in the head and neck II. Oral Mucosa- composed of connective tissue covered with stratified squamous epithelium Masticatory Mucosa Lining Mucosa Specialized Mucosa  Masticatory Mucosa ▶▶ Covers the gingiva and hard palate, the areas most used during the mastication of food. ▶▶ Except for the free margin of the gingiva, the masticatory mucosa is firmly attached to underlying tissues. ▶▶ The normal epithelial covering is keratinized Copyright © 2017 Wolters Kluwer All Rights Reserved 13  Lining Mucosa ▶▶ Covers the inner surfaces of the lips and cheeks, floor of the mouth, underside of the tongue, soft palate, and alveolar mucosa (beyond mucogingival line). ▶▶ These tissues are not firmly attached to underlying tissue. ▶▶ The epithelial covering is Non-keratinized. Copyright © 2017 Wolters Kluwer All Rights Reserved 14  Specialized Lining ▶▶ Covers the dorsum (upper surface) of the tongue. ▶▶ Composed of many papillae; some contain taste buds. Filiform: threadlike keratinized elevations that cover the dorsal surface of the tongue; they are the most numerous of the papillae. Fungiform: mushroom-shaped papillae interspersed among the filiform papillae on the tip and sides of the tongue, appear redder than the filiform papillae and contain variable numbers of taste buds Circumvallate (vallate): the 10–14 large round papillae arranged in a “V” between the body of the tongue and the base. Taste buds line the walls. Foliate: vertical grooves on the lateral posterior sides of the tongue; also contain taste buds. Copyright © 2017 Wolters Kluwer All Rights Reserved 15 Copyright © 2017 Wolters Kluwer All Rights Reserved 16  Sequence of Examination Follow routine order- Table 13-1 Familiarization of anatomic structures critical to understanding abnormal findings- Box 13-1  Sequence of Examination Extra-oral Observations 1. Overall appraisal of patient 2. Face 3. Skin 4. Eyes 5. Nodes 6. Glands 7. Temporomandibular joint 8. Lips Copyright © 2017 Wolters Kluwer All Rights Reserved 19  Sequence of Examination Intra-oral Observations 9. Breath odor 10.Labial and buccal mucosa 11. Tongue 12.Floor of mouth 13.Saliva 14.Hard palate 15.Soft palate, uvula 16.Tonsillar region, throat Copyright © 2017 Wolters Kluwer All Rights Reserved 21 Copyright © 2017 Wolters Kluwer All Rights Reserved 22 Anatomic Landmarks of the Oral Cavity— Dorsal Tongue View Anatomical Landmarks of the Oral Cavity —Ventral Tongue View Lymph Nodes  Extraoral Examination 1. Observe patient during reception 2. Observe head, face, eyes, neck, lips 3. Request patient remove prosthesis 4. Palpate salivary glands and lymph nodes 5. Observe mandibular movement and palpate temporomandibular joint  Intraoral Examination 1. Preliminary examination of lips and intraoral mucosa 2. View palate, lips, labial and buccal mucosa, and mucobuccal folds 3. Examine and palpate tongue 4. Observe mucosa of floor of mouth 5. Examine hard and soft palates, tonsillar areas, and pharynx 6. Note amount and consistency of saliva  Documentation of Findings History  Whether the lesion is known or not known to the patient; previous evaluation.  If known, when first noticed; if recurrence, previous date when lesion was first noticed.  Duration, symptoms, changes in size and appearance. Location and Extent- use descriptive terms Localized/Generalized Single/Multiple lesion Separate/Coalescing Physical Characteristics Size and shape Color Surface texture Consistency  Morphologic Categories Elevated Depressed Flat  Elevated Lesions (above the plane of the skin or mucosa) Blisterform- (fluid) Vesicle- up to 1 cm or less in diameter fluid filled Pustule- more than or less than 5 mm in diameter and contain pus Bulla- >1 cm It is filled with fluid, usually mucin or serum, but may contain blood Nonblisterform- (solid) Papule-A papule is a small, pinhead to 5 mm in diameter Nodule- larger than a papule 5 mm -2 cm Tumor- 2 cm or greater in width Plaque- slightly raised lesion with a broad, flat top. It is usually larger than 5 mm in diameter Copyright © 2017 Wolters Kluwer All Rights Reserved 31  Depressed Lesions (below the level of the skin or mucosa) Ulcer Loss of continuity of epithelium Erosion Shallow Does not extend through epithelium to underlying tissue Depressed lesions are described as superficial or deep (deep lesion is greater than 3mm) Copyright © 2017 Wolters Kluwer All Rights Reserved 33  Flat Lesions (at the same level of the skin or mucosa) Macule Circumscribed Not elevated above surrounding skin or mucosa Identified by color Copyright © 2017 Wolters Kluwer All Rights Reserved 35  More Descriptive Terms Crust- dry blood, pus, or serum Aphtha- small white or reddish ulcer Cyst- closed epithelial lined sac Erythema- red area Exophytic- growing outward Idiopathic- unknown etiology Indurated- abnormally hardened Papillary- small nipple-shaped projection  An Even More Descriptive Terms Petechiae- tiny hemorrhagic spots Pseudomembrane- loose necrotic membrane Polyp- mass of tissue that projects outward Punctate- marked with points of color, elevated, or texture from surrounding surface Purulent- containing or producing pus Rubefacient- reddening of the skin Torus- bony prominence (palate or mandibular) Verrucous- rough, wart-like growth  Oral Cancer The oral cavity, pharynx, larynx, paranasal sinuses and nasal cavity, and salivary glands are regions of the head and neck where cancer can begin. Cancers of the head and neck begin in the squamous cells that line moist, mucosal surfaces of the mouth, nose, and throat. Salivary glands contain different types of cells that can also become cancerous. Location- The most common sites for oral cancer are the lateral borders of the tongue, floor of the mouth, the lips, and the soft palate complex Appearance of Early Cancer – White areas- Leukoplakia – Red areas- Erythroplakia – Ulcers – Masses – Pigmentation Clinical Recommendations for Evaluation of Oral Lesions Updated histories and extra- and intraoral examination for all adult patients Follow even non-suspicious lesions in adult patients Biopsy for suspicious lesions in adult patients Can perform cytologic adjuncts when patient refuses biopsy or referral, these are like an in between and can motivate the patient to get the biopsy  Biopsy “Gold Standard” of oral cancer diagnosis Removal and microscopic examination of tissue for diagnosis Indications – Any unusual oral lesion that cannot be identified with clinical certainty must be biopsied. – Any lesion that has not healed in 2 weeks is considered suspicious for malignancy until proven otherwise. – A persistent, thick, white, hyperkeratotic lesion and any mass (elevated or not) that does not break through the surface epithelium Pathology report Diagnostic criteria  Documentation Details of the oral examination and follow up procedures Recommendations for frequency of exam for future dental hygiene appointments Review of lifestyle habits Progress note at first maintenance appointment following the biopsy with the results  Role of the Dental Hygienist with Oral Cancer Identification of risk factors Patient education about these risks, especially tobacco cessation, alcohol reduction, and HPV vaccination Professional continuing education and adherence to EB practice guidelines to increase confidence with current recommendations Copyright © 2017 Wolters Kluwer All Rights Reserved 42