Extraoral And IntraOral

Examination

By
Ahmed Amr Hotieba

??Tell me what You see

Well its Actually An

Oreo

O See

Sensations 5

O Hear
O Smell
O Feel
O Taste
?(I dont think we taste our patients, Do we)

See: Inspection
O Its the art of detecting any unusual

changes in the oral cavities, as its

based on vision a light source is of
high need.
O We can see :
Color changes. pigmentation or
caries
Tooth Fracture.
And Different Lesions.
Eg: Erosion.

Feel: Palpation
O This depends on our sense of touch to

feel any abnormalities and to diffrenitte

it from the normal.
O The types as we all know are
O Bidigital P.
O Bimanual P.
O Bilateral P.

O We can detect the different consistency,

temperature, Mobility, indurationetc

Feel: Percussion
O We examine the this by striking an

object on the tooth and evaluate the

produced sound.
O This technique also helps in grading
the tooth mobility and inflammation.

Probing
O This is critically important technique

as it can help detect caries and any

periodontal dieses

Hear: Ausculation
O Depends on the fact we listen to the

normal sounds produced by the

patient
O Wheezing = Respiratory dieses
O TMJ clicking= TMJ disorder

Smell: Odor
O Just by smelling the patient oral

odor, we can help in the differential

diagnosis.
O Acetone odor= Uncontrolled DM
O Foul odor = ANUG

Functional Evaluation
O Simple to evaluate its function:
O E.g. Salvia flow from the glands. Pulp

testing and occulasal relationship are

just a few of the different methods of
evaluation.

Diagnosis sheet

I. Extraoral Examination

. Observe patient during reception and seating to note

physical characteristics and abnormalities, and make an
overall appraisal.
2. Observe head, face, eyes, and neck, and evaluate the
skin of the face and neck.
3. Request the patient remove prosthesis prior to performing
the intraoral examination. Explain how this will
improve the ability to inspect all areas of the mouth
adequately.
4. Palpate the salivary glands and lymph nodes. shows the
location of the major lymph nodes of the face,
oral regions, and neck. Palpation is a significant component
of the extra-/intraoral examination.
13

I. Extraoral Examination
Pain or discomfort upon palpation and/or upon

.swallowing

Persistent difficulty swallowing in the absence

.of pain

Any recent noticeable lumps the patient may

have

.experienced without pain

.Persistent earache or hoarseness of voice

Observe mandibular movement and palpate

TMJ
14

II. Intraoral Examination

Lips & intraoral mucosa

View/palpate lips, labial and buccal mucosa,

.and mucobuccal folds

Examine and palpate the tongue

. Mucosa of the floor of the mouth

Hard and soft palates, tonsillar areas, and

pharynx

Use a mirror

.oropharynx, nasopharynx, and larynx

Note amount and consistency of the saliva. 6 O

.evidence of dry mouth (xerostomia)and
15

Remember
O What ever your Techniques is, it is as

good as how you diagnosed your case.

O To Know to diagnosis is just half the way,
a true doctor must use his diagnosis
capability as tools to pave the way to
identify the problem or Dieses .
O With the proper diagnosis, and
identification the proper action and
treatment plan can be done, and the
prognosis and be seen easily

O The General Physical Appraisal

O The Head and Neck Examination
O Symmetry and Profile
O Cutaneous Area
O Lips
O Eyes
O Lymph Nodes
O Salivary Glands
O Thyroid Gland
O Temporomandibular Joint Evaluation

O The Intraoral Examination

O Oropharynx
O Posterior Pharyngeal Wall
O Anterior and Posterior Pharyngeal Pillars
O Tonsillar Crypt
O Soft Palate and Uvula
O Hard Palate
O Buccal Mucosa
O Labial Mucosa
O Mandible
O Floor of the Mouth
O Tongue
O Attached Gingiva
O Salivary Flow and Consistency

ORAL EXAMINATION AND

DIAGNOSIS
O Following sequence is followed during clinical

examinations
O Inspection
O Palpation
O Percussion
O Auscultation

1)
INSPECTION
O Patient should be observed for :
O unusual gait and habits (may suggest underlying
O
O
O
O
O

systemic disease, drug or alcohol abuse)

Localized swelling,
Presence of bruises,
Abrasions, scars
Signs of trauma
Degree of mouth opening, it should be at least two
fingers

INSPECTION

O During intraoral examination, look at the following

structures systematically
O The buccal, labial and alveolar mucosa
O The hard and soft palate
O The floor of the mouth and tongue
O The retromolar region
O The posterior pharyngeal wall

and facial pillars

O The salivary gland and orifices

INSPECTON (GENERAL
DENTAL STATE)
Oral hygiene status
Amount and quality of restorative work

Prevalence of caries
Missing tooth
Presence of soft or hard swelling
Periodontal status
Presence of any sinus tracts
Discolored teeth
Tooth wear and facets

PALPATON

O Local rise in temperature

O Tenderness
O Extent of lesion
O Induration

O Fixation to underlying tissues

PERCUSSON

O Percussion gives information about the

periodontal status of the tooth

O Percussion of tooth indicates
O inflammation in periodontal ligament which could be

due to
O Trauma
O Sinusitis
O PDL disease

HOW CAN WE DO
?PERCUSSION
O Percussion can be carried out by :
O gentle tapping with gloved finger
O Blunt handle of mouth mirror
O Each tooth should be percussed on all the surfaces

of tooth until the patient is able to localize the tooth

with pain. Degree of response to percussion is
directly proportional to degree of inflammation

PERODONTAL
EVALUATON
Periodontal examination shows change in O
color O
contour O
form O
density O
level of attachment O
bleeding tendency O

O The depth of gingival sulcus is determined by systemic

probing using a periodontal probe

O A sulcus depth greater than 3 mm and the sites that
bleed upon probing should be recorded in the patients
chart
O The presence of pocket may indicate periodontal
disease

PERODONTAL
EVALUATON
:How can we check the mobility of the tooth
The mobility of a tooth is tested by placing a finger or O
blunt end of the instrument on either side of the
crown and pushing it and assessing any movement
with other finger

How to check the mobility of a

tooth?

Mobility grades:
OSlight (normal)
OModerate mobility within a range of 1 mm.
OExtensive movement (more than 1 mm) in mesiodistal
or lateral direction combined with vertical
displacement in alveolus
OAs a general rule, mobility is graded clinically by
applying firm pressure with either two metal
instruments or one metal instrument and a gloved finger
ONormal mobility Grade I: Slightly more than normal
(<0.2mm horizontal movement)
OGrade II :Moderately more than normal (1-2mm
horizontal movement)
OGrade III: Severe mobility (>2mm horizontal or any
vertical movement)

AUSCULTATION
Intra orally of less importance O
But useful in assessing movement of O
Temporomandibular joints

EXAMINATION OF THE
PATIENT
The examination of the patient O
represents the second stage of the
diagnostic procedure
The examination is most conveniently O
carried out with the patient seated in a
.dental chair, with the head supported
Before seating the patient, the clinician O
should observe the patients general
appearance and step and should note
.any physical deformities or handicaps

A less comprehensive but equally O

thorough inspection of the face and
oral and oropharyngeal mucosa
should also be carried out at each
.dental visit
The tendency for the dentist to focus O
on only the tooth or jaw quadrant in
.question should be strongly resisted

The examination procedure in dental office

settings
:includes the following
Registration of vital signs (respiratory rate, . 1
.temperature, pulse, and blood pressure)
Examination of the head, neck, and oral . 2
cavity,
including
salivary
glands,
temporomandibular joints, and lymph
.nodes
.Examination of cranial nerve function. 3
Special examination of other organ. 4
.systems
.Requisition of laboratory studies. 5

Vital Signs
PULSE RATE AND RHYTHM O
RESPIRATORY RATE O
BLOOD PRESSURE O
TEMPERATURE O

PULSE RATE AND RHYTHM

Cardiac rate, rhythm, and strength are O
assessed by taking the radial or carotid
.artery pulse
For the carotid pulse, the first two O
fingers are placed just anterior to the
sternomastoid muscle, posterior to the
larynx, and below the angle of the
.mandible in the region of the carotid bulb
Only light pressure is applied until O
.pulsations are readily detectable

The radial pulse is accomplished by placing the O

first two fingers in the slight trough produced by a
tissue depression between the radius and the
flexor tendons located on the ventral wrist just
proximal to the thumbs thenar eminence
Only light pressure is exerted until pulsations are O
.perceived
The cardiac rate is determined by counting the O
number of beats during 15 seconds and
.multiplying by 4
.Normal heart rate is 60 to 80 beats per minute O

RESPIRATORY RATE
Respiration rate is determined by O
sitting next to or standing behind the
patient seated in the dental chair
and looking down at the patients
. chest
Count the number of times the chest O
rises and falls for 30 seconds and
.then multiply by 2
A normal respiratory rate is 12 to 15 O
.respirations per minute

BLOOD PRESSURE
Measuring blood pressure assesses pressure O
within the arteries during cardiac contraction
(systole) and pressure during cardiac pause
.(diastole)
To obtain these values, one must generate an O
external pressure that exceeds that within the
artery then slowly lower that pressure until the
intra-arterial pressure exceeds the externally
applied pressure, thereby opening the arteries
and being able to detect the pulse as blood is
again pumped through. The pressure at which the
first evidence of a pulse can be detected is the
upper, or systolic pressure, which normally is

After detecting the systolic pressure, O

the externally applied pressure
continues to be decreased until
pulsations are no longer detected.
This level of pressure, the diastolic,
varies normally from 70 to 90 mm
.Hg

TEMPERATURE
Temperature is recorded using a O
thermometer
or
temperature
sensitive disposable oral strips.
Either of these recording devices
should be inserted orally, with the tip
placed under the tongue, and left in
place for 1.5 to 2.0 minutes. Recall
that normal body temperature is
.37C (98.6F)

Head, Neck, and Oral

Cavity

The examination routine

encompasses the following eight
:steps
Note the general appearance of the individual and
evaluate emotional reactions and the general
nutritional state. Record the character of the skin
and the presence of petechiae or eruptions, as
well as the texture, distribution, and quality of the
hair. Examine the conjunctivae and skin for
petechiae, and examine the sclerae and skin for
evidence of jaundice or pallor. Determine the
reaction of the pupils to light and accommodation,
especially when neurologic disorders are being
.investigated
Palpate for adenopathy. Palpate any swellings,
.nodules, or suspected anatomic abnormalities

.1

.2

Examine in sequence the inner surfaces of the lips,

the mucosa of the checks, the maxillary and
mandibular mucobuccal folds, the palate, the
tongue, the sublingual space, the gingivae, and
then the teeth and their supporting structures. Last,
examine the tonsillar and the pharyngeal areas and
. any lesion, particularly if the lesion is painful
Completely visualize the smooth mucosal surfaces
of the lips, cheeks, tongue, and sublingual space by
using two tongue depressors or mirrors. Perform a
more detailed examination of the teeth and
supporting tissues with the mouth mirror, the
.explorer, and the periodontal probe

.3

.4

Have the patient extend the tongue for examination of the .5

dorsum; then have the patient raise the tongue to the
palate to permit good visualization of the sublingual space.
The patient should extend the tongue forcibly out to the
right and left sides of the mouth to permit good
visualization of the sublingual space and to permit careful
examination of the left and right margins. A piece of gauze
wrapped lightly around the tip of the tongue helps when
manually moving the patients tongue. Examine the
.tonsillar fossae and the oropharynx
Use bimanual or bi-digital palpation for examination of the
tongue, cheeks, floor of the mouth, and salivary glands.
Palpation is also useful for determining the degree of tooth
movement. Two resistant instruments, such as mirror
handles or tongue depressors, placed on the buccal and
lingual surfaces of the tooth furnish more accurate
.information than when fingers alone are directly employed

.6

Examine the teeth for dental caries, .7

occlusal relations, possible prematurities,
inadequate contact areas or restorations,
evidence of food impaction, gingivitis,
.periodontal disease, and fistulae
After the general examination of the oral .8
cavity has been completed, make a
detailed study of the lesion or the area
.involved in the chief complaint

FACIAL STRUCTURES
Observe the patients skin for color,
blemishes, moles, and other pigmentation
abnormalities; vascular abnormalities such
as angiomas, telangiectasias, nevi, and
tortuous
superficial
vessels;
and
asymmetry, ulcers, pustules, nodules, and
swellings.
Note
the
color
of
the
conjunctivae.
Palpate
the
jaws
and
superficial
masticatory
muscles
for
tenderness or deformity. Note any scars
.formation

LIPS
Note lip color, texture, and any surface
abnormalities as well as angular or
vertical fissures, lip pits, cold sores,
ulcers,
scabs,
nodules,
keratotic
plaques, and scars. Palpate upper lip
and lower lip for any thickening
(induration) or swelling. Note orifices
of minor salivary glands and the
.presence of Fordyces granules

CHEEKS
Note any changes in pigmentation and
movability of the mucosa, a pronounced linea
alba, leukoedema, hyperkeratotic patches,
intraoral swellings, ulcers, nodules, scars,
other red or white patches, and Fordyces
granules. Observe openings of Stensens ducts
and establish their patency by first drying the
mucosa with gauze and then observing the
character and extent of salivary flow from duct
openings, with and without milking of the
.gland. Palpate muscles of mastication

MAXILLARY AND MANDIBULAR

MUCOBUCCAL FOLDS
Observe
color,
texture,
any
swellings, and any fistulae. Palpate
for swellings and tenderness over
the roots of the teeth and for
tenderness of the buccinator
insertion by pressing laterally with
a finger inserted over the roots of
.the upper molar teeth

HARD PALATE AND SOFT

PALATE
Illuminate the palate and inspect
for
discoloration,
swellings,
fistulae, papillary hyperplasia, tori,
ulcers, recent burns, leukoplakia,
and asymmetry of structure or
function. Examine the orifices of
minor salivary glands. Palpate the
palate
for
swellings
and
.tenderness

THE TONGUE
Inspect the dorsum of the tongue (while it is at rest) for any O
swelling, ulcers, coating, or variation in size, color, and texture.
Observe the margins of the tongue and note the distribution of
filiform and fungiform papillae, crenations and fasciculations,
depapillated areas, fissures, ulcers, and keratotic areas. Note
the frenal attachment and any deviations as the patient pushes
.out the tongue and attempts to move it to the right and left
Wrap a piece of gauze around the tip of the protruding tongue O
to steady it, and lightly press a warm mirror against the uvula
to observe the base of the tongue and vallate papillae; note
any ulcers or significant swellings. Holding the tongue with the
gauze, gently guide the tongue to the right and retract the left
cheek to observe the foliate papillae and the entire lateral
border of the tongue for ulcers, keratotic areas, and red
.patches

Repeat for the opposite side, and then have the O

patient touch the tip of the tongue to the palate to
display the ventral surface of the tongue and floor
of the mouth; note any varicosities, tight frenal
attachments, stones in Whartons ducts, ulcers,
.swellings, and red or white patches
Gently palpate the muscles of the tongue for O
nodules and tumors, extending the finger onto the
base of the tongue and pressing forward if this
has been poorly visualized or if any ulcers or
masses are suspected. Note tongue thrust on
.swallowing

FLOOR OF THE MOUTH

With the tongue still elevated,
observe the openings of Wharton's
ducts, the salivary pool, the character
and extent of right and left
secretions, and any swellings, ulcers,
or red or white patches. Gently
explore and display the extent of the
lateral sublingual space, again noting
.ulcers and red or white patches

GINGIVAE
Observe color, texture, contour,
and frenal attachments. Note
any
ulcers,
marginal
inflammation,
resorption,
festooning, Stillmans clefts,
hyperplasia, nodules, swellings,
.and fistulae

TEETH AND
PERIODONTIUM
Note missing or supernumerary
teeth, mobile or painful teeth, caries,
defective restorations, dental arch
irregularities, orthodontic anomalies,
abnormal jaw relationships, occlusal
interferences, the extent of plaque
and
calculus
deposits,
dental
.hypoplasia, and discolored teeth

TONSILS AND OROPHARYNX

Note the color, size, and any surface
abnormalities
of
tonsils
and
ulcers,
tonsilloliths, and inspissated secretion in
tonsillar crypts. Palpate the tonsils for
discharge or tenderness, and note restriction
of the oropharyngeal airway. Examine the
faucial pillars for bilateral symmetry, nodules,
red and white patches, lymphoid aggregates,
and deformities. Examine the postpharyngeal
wall
for
swellings,
nodular
lymphoid
hyperplasia, hyperplastic adenoids, postnasal
.discharge, and heavy mucous secretions

Some Weird Stuff in Egypt