2.Intraoral Examination.pdf

Intraoral Examination Assoc. Prof. Dr. Kader Aydın  Most oral diseases have a local cause and can be recognized fairly readily. Even those that are life- threatening, such as oral cancer in particular, can be detected at an exceedingly early stage. However, even now, oral cancer is so...

Intraoral Examination Assoc. Prof. Dr. Kader Aydın  Most oral diseases have a local cause and can be recognized fairly readily. Even those that are life- threatening, such as oral cancer in particular, can be detected at an exceedingly early stage. However, even now, oral cancer is sometimes overlooked at examination, and the delay between the onset of symptoms of oral cancer and the institution of definitive treatment still often exceeds 6 months  Many systemic diseases, particularly infections and diseases of the blood, gastrointestinal tract and skin, also cause oral signs or symptoms that may constitute the main complaint, particularly, for example, in some patients with HIV, leukopenia or leukaemia  The examination, therefore, should be conducted in a systematic fashion to ensure that all areas are included. If the patient wears any removable prostheses or appliances, these should be removed in the first instance, although it may be necessary later to replace the appliance to assess its fit, function and relationship to any lesion  The lips should first be inspected. The labial mucosa, buccal mucosa, floor of the mouth and ventrum of the tongue, dorsal surface of the tongue, hard and soft palates, gingivae and teeth should then be examined in sequence  Inspection, Palpation and Diascopy are the techniques used for examination of lips. Any colour and texture changes can be determined using visual inspection. Lips seem homogenously 1- pink in colour and there is a sharp border with skin and mucosa. Examination of the Lips Upper and lower lips are removed with mirror and upper and lower labial mucosa are examined. Palpation is used to determine any kind of tumoral enlargements.  Lips: features, such as cyanosis, are seen mainly in the lips in cardiac or respiratory disease; angular cheilitis is seen mainly in oral candidasis or iron or vitamin deficiencies, vertical dimension loss of total prosthesis. Many adults have a few yellowish pinhead-sized papules in the vermilion border (particularly of the upper lip) and at the commissures; these are usually ectopic sebaceous glands (Fordyce spots), and may be numerous, especially as age advances  Labial mucosa normally appears moist with a fairly prominent vascular arcade. Examination is facilitated if the mouth is gently closed at this stage, so that the lips can then be everted to examine the mucosa. In the lower lip, the many minor salivary glands, which are often exuding mucus, are easily visible. The lips, therefore, feel slightly nodular and the labial arteries are readily felt  Lip Examination Herpes simplex Aphtae Mucocele  Lip Examination Melanotic Macule Peutz-Jegher Send. Actinic cheilitis Squamous Cell Ca (SCC)  Lip Examination Angular cheilitis Venous lesion Fordyce granules  Actinic cheilitis lesions may be seen as a result of exceeded amounts of direct sunlight exposure and these lesions are precancerous. Xanthelesma lesions can be seen on the lips. Macrocheilits is the abnormal growth of lips. Cretenism, angio edema, neoplasias, acromegaly, allergic reactions, trauma, amiloidosis, Melkersson- Rosenthal syndrome can be the cause of macrocheilitis.  Melkersson-Rosenthal Syndrome: Recurrent macrocheilitis, Facial Nerve Paralysis, Fissurated tongue findings form the syndrome triad. Growth of the lips are sudden, painless and edematous and the enlargement may last for weeks or months and may decrease spontaneously.  Mucoceles are palpable and soft lesions and are formed by extravasation of saliva. Varicosis are enlarged veins which can be seen in elderly patients.  2- Examination of Buccal Mucosa Cheek (buccal) mucosa is readily inspected if the mouth is held half open. The vascular pattern and minor salivary glands so prominent in the labial mucosa are not obvious in the buccal mucosa, but Fordyce spots may be conspicuous, particularly near the commissures and retromolar regions in adults.  There may be a faint horizontal white line where the teeth meet (linea alba). Place the surface of a dental mirror against the buccal mucosa; it should slide and lift off easily but, if it adheres to the mucosa, then there is probably hyposalivation.  Leucoedema Linea Alba Buccalis Morsicatio Buccarum Fordyce Granules  Pemfigoid Eritema Multiforme Lichen Planus Leukoplakia Leukoplakia Erithroplaki Amalgam Tattoo Fibroma Lichen Planus Aphtae Candida  The floor of the mouth and the ventrum of the tongue are best examined by asking 3- the patient to push the Examination tongue first into the palate and then into each cheek in of the Floor turn. This raises for of the inspection the floor of the Mouth mouth – an area where tumours may start (the coffin or graveyard area of the mouth).  Its posterior part is the most difficult area to examine well and one where lesions are most easily missed. During this part of the examination the quantity and consistency of saliva should be assessed. Examine for the pooling of saliva in the floor of the mouth; normally there is a pool of saliva.  Mouth Floor Examination Examination Normal Ranula Torus  Mouth Floor Examination Lökoplaki SCC Kaposi Melanom  Examination of the floor of the mouth using palpation is made with bimanual palpation. Palpation of the floor of the mouth is important due to neoplastic changes of salivary glands.  Mandibular tori are the bony expansions which can be seen on the lingual part of mandibular canines and premolars. Ranulas are mucoceles that occur in the floor of the mouth and usually involve the major salivary glands. Specifically, the ranula originates in the body of the sublingual gland, in the ducts of Rivini of the sublingual gland, and, infrequently from the minor salivary glands at this location.  The dorsum of the tongue is best inspected by protrusion, when it can be held with gauze. The anterior two Examination thirds is embryologically and of the anatomically distinct from the Tongue posterior third, and separated by a dozen or so large circumvallate papillae  The anterior two-thirds is coated with many filiform, but relatively few fungiform papillae. Behind the circumvallate papillae, the tongue contains several large lymphoid masses (lingual tonsil) and the foliate papillae lie on the lateral borders posteriorly. These are often mistaken for tumours.  The tongue may be fissured (scrotal), but this is a developmental anomaly. A healthy child's tongue is rarely coated, but a mild coating is not uncommon in healthy adults. The voluntary tongue movements and sense of taste should be formally tested. Abnormalities of tongue movement (neurological or muscular disease) may be obvious from dysarthria (abnormal speech) or involuntary movements, and any fibrillation or wasting should be noted. Hypoglossal palsy may lead to deviation of the tongue towards the affected side on protrusion. Normal Yapı Coğrafik Dil Lökoplaki Liken Planus Hemanjiyom Lenfanjiom Fissürlü Dil Romboid Glossit  Siyah Kıllı Dil Kıllı Dil Kıllı Lökoplaki SCC  Dil Bağı Aft Lingual Varis Gorlin Bulgusu  Fissurated (scrotal) tongue is a normal anatomical malformation but it may be related with Melkersson- Rosenthall Syndrome. Varicoceles may be seen on the inferior border of the tongue. Ankyloglossy is the abnormal growth of lingual frenilum and may cause speech disorders.  Hairy tongue is the elongation of filiform and fungiform papillae. Geographic tongue (Erythema Migrans) is the atrophy and desquamation of epidermis of the dorsal tongue. Filiform and fungiforma papillae around the lesion are hyperplastic and white in colour. Generally disease is hereditary.  Median Rhomboid glossitis is the loss of papillae which are anterior to foramen caecum. Generally the lesion is hereditary. Macroglossia is the abnormal growth of tongue and may be related with cretenism, mixedema, acromegaly. Long term edentulous patients’ tongue may enlarge anormally. Examination of Palate and Oropharynx The palate consist of an anterior hard palate and posterior soft palate, and the tonsillar area and oropharynx. The mucosa of the hard palate is firmly bound down as a mucoperiosteum (similar to the gingivae) and with no obvious vascular arcades.  Ridges (rugae) are present anteriorly on either side of the incisive papilla that overlies the incisive foramen. Bony lumps in the posterior centre of the vault of the hard palate are usually tori (torus palatinus). Palpation may be used for the examination of hard palate but soft palate and more posterior areas shall not be palped because of the gagging reflex.  Nikotin Stomatiti Normal Yapı Kaposi Sarkomu Torus  Patients may complain of a lump distal to the upper molars that they think is an unerupted tooth, but the pterygoid hamulus or tuberosity is usually responsible for this complaint. The soft palate and fauces may show a faint vascular arcade. Just posterior to the junction with the hard palate is a conglomeration of minor salivary glands. This region is often also yellowish. The palate should be inspected and movements examined when the patient says ‘Aah’. Using a mirror, this also permits inspection of the posterior tongue, tonsils, oropharynx, and can even offer a glimpse of the larynx. Glossopharyngeal palsy may lead to uvula deviation to the contralateral side. Bifid uvula may signify a submucous cleft palate.  Nikotin Stomatiti Normal Yapı Kaposi Sarkomu Torus  Polip İlaç Pigmentasyonu Siyalometaplazi Pemfigus  El-Ayak-Ağız Hst. Lökoplaki Aft Herpanjina Normal Yapı Tonsilit Farenjit Aft  Examination of Gingiva Gingivae in health are firm, pale pink, with a stippled surface, and have sharp gingival papillae reaching up between the adjacent teeth to the tooth contact point. Look for gingival deformity, redness, swelling, or bleeding on gently probing the gingival margin. The ‘keratinized’ attached gingivae (pale pink) is normally clearly demarcated from the non- keratinized alveolar mucosa (vascular) that runs into the vestibule or sulcus. Bands of tissue, which may contain muscle attachments, run centrally from the labial mucosa onto the alveolar mucosa and from the buccal mucosa in the premolar region onto the alveolar mucosa (fraenae). Healthy gingival sulcus depth must not exceed 1-2 mm. Periodontal attachment loss msut be kept in mind in depths over 1-2 mm. Gingival sulcus depth measurement is made by using a periodontal probe. Mobility may occur according to periodontal bone loss and mobility of tooth is examined by taking the tooth between the end of probe and mirror. Addison Hastalığı Hidroksiklorokin Tetrasiklin Melanoma  Lösemi Fenitoin Gingival hiperplazi (Kalsiyum Kanal Blokeri) Lenfoma  Gingiva Muayenesi Piyojenik Granülom Gingivit Epulis SCC  Elongation of maxillary and mandibular labial frenilums may cause diastema of the anterior teeth; besides overlength frenulums may cause gingival recessing. Examination of Halitosis and Xerostomia Halitosis, aka fetor oris veya fetor ex ore, fetid halitus defines the condition of bad smell in the exhaled air and this condition disturbes the person and people around. Halitosis also includes nasal bad air. Oral malodor term particularly defines oral bad air.  Classification of Halitosis True halitosis a)physiologic b)pathologic Pseudo Halitosis Halitophobia  For physiologic halitosis there is not a specific or pathologic reason. It may be known as morning breath and originates from the posterior tongue. Dissapears with an effective oral hygiene. Alcohol consumption dehydrates the tissues and may cause physiologic halitosis. Smoking dehydrates the tissues and has a specific bad odour. Overconsumption of odourous food like onion and garlic Overconsumption of food including protein Overconsumption of coffee  Pathologic halitosis can not be eradicated with usual oral hygiene procedures and may originate from intraoral and extraoral pathological conditions. Oral Causes of Halitosis (90 %) Gingival and periodontal diseases Oral cancers Oropharengeal Anomalies Prosthetic problems Dental caries Tartars Xerostomia Accumulation of debris on tongue Chronic tonsil diseases Postnasal flow (sinusitis) Nasal obstruction Extraoral causes of Halitosis Respiratory system diseases (Lung Ca, Tuberculosis etc.) Foreign bodies inside the respiratory tract Gastrointestinal diseases (eusophagus and stomach ca, foreign bodies inside eusophagus, gastritis etc.) Chronic Renal Insufficiency Hematological Diseases Malignities Trimetilaminuria Infectious mononucleosis etc.  Evaluation of Halitosis *Anamnesis- Patient must be with a friend or someone who knows the patient for subjective evaluation. Oral hygiene habits must be learnt. Systemic anamnesis and drugs that the patient uses must be known  Physical evaluation Concordance of prosthesis and restoration margins must be evaluated. Dental caries existence and periodontal health situation must be assessed. Margins of mobile prosthesis must be evaluated. Oral mucosa and tongue evaluation  Debris can be scratched out from the root of the tongue using a tongue press and debris can be smelled to determine if there is an odour. A piece of dental floss may be placed between molar teeth and 45 seconds after the floss’ replacement odour on the floss may be evaluated.  Measurement of Halitosis Organoleptic Method Smelling the expired air 15 cm away from patient’s mouth Spreading the saliva to a petri box and smell after incubation Patient may lick his/her wrist and consequently when the licked place dried, place may be smelled. Chemical Methods Gas chromatography, halimeter, odour sensors, BANA test  Xerostomia (dry mouth) may have local or systemic causes. Generally any obliteration in the orifice of parotid gland is not sufficient for formation of xerostomia. Causes of Xerostomia Congenital- Hipoplasia or Aplasia of Salivary Glands Infections of Salivary Glands (Epidemic Parotitis, Tuberculosis etc.) Dehydratation Sjögren and Mikulicz Syndromes Neoplasms Emotional Disorders Obliteration of salivary gland canals or orifices Central Nervous System Diseases Drugs (Anticolinergics, opiums, ergotamine, sempatomimetics) Atrophy of glands (age related, radiotherapy related) Vitamin deficiencies Diabetes Anemia Menapause  Anamnesis: Complaint of the patient, duration of complaint, consistency of saliva, taste alterations, systemic condition, drug use Physical Examination: Amount and viscosity of saliva, pus discharge. If evident bimanual palpation is used to determine the location and count of sialoliths and if evident palpation of masses. Radiological Evaluation (Occlusal graphies, USG, MRI, CT, sintigraphy, sialography) Biopsy Chemical analysis (Electrolytes)  EVALUATION OF DENTAL HARD TISSUES OTHER NUMBER ANOMALIES – ANADONTIA – ENAMEL HYPOPLASIA – OLIGODONTIA – AMELOGENESIS IMPERFECTA – HYPODONTIA – DENTINOGENESIS – SUPERNUMERARY TEETH IMPERFECTA – GEMINATION – DENTINAL DYSPLASIA – FUSION – TAURODONTISM SHAPE ANOMALIES – RACHITISM – CONCRESCENCE – HYPOPHOSPHATASIA – DENS IN DENTE – REGIONAL – DILACERATION ODONTODISPLASIA – MICRODONTIA – ERUPTION DEFECTS – MACRODONTIA – DISCOLORATIONS – FLUOROSIS  CARIES FRACTURES ATRISION ACQUIRED ABRASION DENTAL EROSION HARD TISSUE DISEASES DECALCIFICATION INTERNAL/ EXTERNAL RESORPTION MALPOSITION HIPERSEMENTOSIS  As a result of the contact of the ATRITTION teeth with each other Chemical dissolution affected by EROSION acid attacks Hard brushing etc. depending on ABRASION physical factors Occurrence in the cervical area due to excessive occlusal ABFRACTION Thank you