EXTRA AND INTRA ORAL EXAMINATION UNCLASSIFIED//REL TO NATO/ISAF

Equipment and supplies Gauze sponges (2x2) Tongue depressor (optional) Mouth mirror Explorer Probe Patient record to document findings

Procedural steps Patient preparation Extraoral features Cervical lymph nodes Temporomandibular joint Indications or oral habits Interior of the lips Oral mucosa and tongue Floor of the mouth Examination of the periodontium Examination of the teeth

Patient preparation When escorting the patient to treatment area, observe the patient’s general apperance Purpose: unusual behavior or apperance Seat the patient in the dental chair in an upright position, put patient personal protection Protection glasses bib

Patient preparation Explain the procedure to the patient. The patient who knows what to expect will be more comfortable and more willing to participate in the procedure.

Extraoral features Examine the face, neck and ears for asymmetry or abnormal swelling Purpose: the two sides of the face should be symmetric

Extraoral features Look for abnormal tissue changes, skin abrasions and discoloration Purpose: unusual bruising, scratches, fistula or cuts may require further evaluation of the area

Extraoral features the vermillon border, the commissures of the lips, the philtrum Normal Abnormal

Extraoral features Evaluate the texture, color and contuinity of the vermillon border, the commissures of the lips, the philtrum Purpose: Lumps, dryness and cracking of the tissues are deviations from the normal that may indicate that further evaluation of the area is required

Extraoral features Document all findings in the patient record

Cervical lymph nodes A lymph node is an oval- shaped organ of the immune system Lymph nodes also have clinical significance. They become inflamed or enlarged in various conditions, which may range from trivial, such as a dental or throat infection, to life- threatening such as cancers.

Cervical lymph nodes Position yourself behind the patient so that you can easily place your fingers just belows the patient’s ears The fingers gently follow the chain of lymph nodes Purpose: you are looking for swelling, abnormal formation and tenderness in the area

Cervical lymph nodes

Cervical lymph nodes Document all findings in the patient record

Temporomandibular joint To evaluate temporomandibular joint (TMJ) mouvement, ask the patient to open and close the mouth normally and then to move the jaw from side to side. To further evaluate the movement of the TMJ, gently place your fingers into the external opening of the ear. Ask the patient to open and close the mouth normally

Temporomandibular joint To determine whether there is noise in the TMJ during movement, listen and feel with your fingers as the patient opens en closes the mouth. A stetoscope may be place on the joint

Temporomandibular joint Dental therapist may be able to more accurately distinguish “normal” from “restricted” mouth opening. However, it must be remembered that this is only one variable, and all aspects of possible dysfunction should be assessed comprehensively before a definitive diagnosis must be made by a stomatologist

Temporomandibular joint Interincisal opening has been defined as “the greatest distance between the incisal edge of the maxillary central incisors to the incisal edge of the mandibular central incisors at the midline when the mouth is open as wide as possible. Normal range of mouth opening in different population studies varies from 40-60mm

Temporomandibular joint normal opening Limited opening

Temporomandibular joint Note in the patient record if normal or any abnormalities or patient comments regarding pain, tenderness or other problems (diminuated opening) related to opening and closing of the mouth

Indications of oral habits Look for indications of oral habits, such as thumb sucking, tongue-thrust swallow, mouth breathing and tobacco use Purpose: these habits can affect the patient’s oral health Look for signs of other oral habits such as bruxism, grinding and clenching. Indications include abnormal wear on the teeth and problems in the TMJ Document any findings in the patient record

Indications of oral habits

Interior of the lips Ask th patient to open his mouth slightly. Examine the mucosa and the labial frenum of the upper lips by gently retracting the lip with the thumbs and the index fingers.

Interior of the lips Examine the mucosa and the labial frenum of the lower lip by gently retracting the lip with the thumbs and the index fingers.

Interior of the lips Palpate the tissues gently to detect lumps or abnormalities

Interior of the lips Abnormalities:

Oral mucosa and tongue Palpate the tissue of the buccal mucosa gently by placing the thumb outside and index inside

Oral mucosa and tongue Examine the tissue that covers the hard palate

Oral mucosa and tongue Torus Normal Normal Gingiva AFAMS Dental Advisor Team

Oral mucosa and tongue abnormalities

Oral mucosa and tongue Visually examine the buccal mucosa and the opening of Stensen’s duct. Purpose: the mouth mirror is warmed to prevent fogging Stensen’s duct

Oral mucosa and tongue Visually examine the buccal mucosa and the opening of Stensen’s duct. Purpose: the mouth mirror is warmed to prevent fogging Normal Abnormal

Oral mucosa and tongue Ask the patient to extend the tongue and to relax it. Using sterile gauze, gently grasp the tip of the tongue and pull it forward.

Oral mucosa and tongue Observe the dorsum (top) of the tongue for color, papillae and abnormalities.

Oral mucosa and tongue Gently move the tongue from side to side to examine the lateral (side) and ventral (underneath) surfaces. Normal Normal

Tongue abnormalities

Floor of the mouth Gently palpate the interior of the mouth by placing the index finger of one hand on the floor of the mouth and by placing the fingers of the other hand on the outer surface under the chin.

Floor of the mouth Normal (toris) Abnormal Abnormal (ranula) Abnormal (leukoplasia)

Floor of the mouth Instruct the patient to touch the tongue to the hard palate Purpose: the floor of the mouth, the lingual frenum and the salivary duct can be visually examined

Oral cancer screening The most common site for oral cancers are: Lower lip Tongue Floor of the mouth Soft palate Some oral cancers begin as a white plaque (leukoplakia), red lesion or as a mouth ulcer. Men get oral cancer twice as often as women do, particularly men older than 40.

Cancer screening Smoking and other tobacco use are linked to most cases of oral cancer. Heavy alcool use or long term sun exposure also increases your risk for oral cancer. Other factors that may increase the risk for oral cancer include: Chronic irritation (such as from rough teeth, dentures, or fillings) Human papilloma virus (HPV) infection Taking medications that weaken the immune system (immunosuppressants) Poor dental and oral hygiene Tobacco/Alcohol Use: Tobacco and excessive alcohol use increases the risk of oral cancer. Using both tobacco and alcohol poses a much greater risk than using either substance alone. Sunlight: Exposure to sunlight is a risk factor for lip cancer. Age: Oral cancer is typically a disease of older people, usually because of their longer exposure to risk factors. Incidence of oral cancer rises steadily with age, reaching a peak in persons aged 65–74. For African Americans, incidence peaks about 10 years earlier. Gender: Oral cancer strikes men twice as often as it does women. Race: Oral cancer occurs more frequently in African Americans than in whites.

Oral cancer screening A ulceration, a red or white lesion with no apparent cause can be manage for 10-14 days. Without change after this period, the DT must refer the patient to a stomatolog.

Oral cancer screnning Other finding must be refer to a stomatolog: Non-tender lesion Non-movable swelling Non-symmetry lesion Numbness Lump in throat

Oral cancer screnning White lesion appearance

Oral cancer screnning red lesion appearance

Oral cancer screnning Mixed red-white lesion appearance

Gingiva - Inspection Is the gingiva healthy? Look for: Redness Swelling Recession CFHSTC Clin Perio Crse 0013

Gingiva - probe CFHSTC Clin Perio Crse 0013

PSR – periodontal screening and recording CFHSTC Clin Perio Crse 0013

PSR – periodontal screening and recording The PSR is a good technique for getting an overall idea of the gingival health This should be used for comprehensive treatment planning NOT emergency treatment CFHSTC Clin Perio Crse 0013

Probe teeth Insert probe into gingival sulcus Advance probe with light pressure until resistance Eye the millimeter mark at the level of the gingival margin Repeat this at 6 sites around tooth 4 mm CFHSTC Clin Perio Crse 0013

CLINICAL TESTS Clinical tests: CLINICAL TESTS Palpation Percussion Biting tooth slooth Mobility Periodontal probing Sensitivity Thermal - ice (EPT, gutta percha or air) Clinical tests: Palpation Percussion Biting tooth slooth Mobility Thermal AFAMS Dental Advisor Team

CLINICAL TESTS - thermal Dry teeth Test several teeth Apply refrigerant to cotton pellet - dripping Apply pellet tooth Have patient raise arm when the feel cold Have patient lower arm when the cold goes away CFHSTC Clin Perio Crse 0013

CLINICAL TESTS - thermal Dry teeth Test several teeth Wrap ice stick in gauze Apply ice tooth (make sure water does drip onto other teeth of gingiva) Have patient raise arm when the feel cold Have patient lower arm when the cold goes away CFHSTC Clin Perio Crse 0013

CLINICAL TESTS - percussion First test teeth with finger pressure Use mirror handle and gently tap against tooth Test several teeth CFHSTC Clin Perio Crse 0013

CLINICAL TESTS - mobility Use two instrument handles Mobility: Class 0 – normal Class 1- slightly more that normal Class 2 – up to 1mm in any direction Class 3 – more than 1mm in any direction CFHSTC Clin Perio Crse 0013

CLINICAL TESTS - cracks Tooth slooth Test several teeth Place on cusp and have patient bite Slight rotation to see if you can stimulate pain CFHSTC Clin Perio Crse 0013

CLINICAL TESTS - cracks Transillumination Test several teeth Move overhead light from illuminating the mouth Place fibre-optic light against tooth Look for black lines in symptomatic tooth CFHSTC Clin Perio Crse 0013

Diagnostic Testing 11 +++ + 3mm +- - 21 +/- 2mm … Tooth # Percussion Palpation Probing depth Vitality Mobility Radiograph 11 +++ + 3mm +- - 21 +/- 2mm … Have a standardized format Very important for the follow-up AFAMS Dental Advisor Team

CLINICAL TESTS What is the best test? The one that reproduces the patient’s chief complaint Test all affected teeth, neighboring teeth and and contra-lateral tooth Record and interpret the results AFAMS Dental Advisor Team

UNCLASSIFIED//REL TO NATO/ISAF سوالات؟ Questions? UNCLASSIFIED//REL TO NATO/ISAF