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

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

3. 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

4. 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

5. 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.

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

7. 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

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

9. 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

10. Extraoral features
Document all findings in the patient record

11. 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.

12. 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

13. Cervical lymph nodes

14. Cervical lymph nodes
Document all findings in the patient record

15. 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

16. 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

17. 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

18. 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

19. Temporomandibular joint
normal opening
Limited opening

20. 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

21. 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

22. Indications of oral habits

23. 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.

24. 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.

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

26. Interior of the lips
Abnormalities:

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

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

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

30. Oral mucosa and tongue abnormalities

31. 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

32. 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

33. 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.

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

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

36. Tongue abnormalities

37. 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.

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

39. 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

40. 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.

41. 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.

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

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

44. Oral cancer screnning
White lesion appearance

45. Oral cancer screnning
red lesion appearance

46. Oral cancer screnning
Mixed red-white lesion appearance

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

48. Gingiva - probe
CFHSTC Clin Perio Crse 0013

49. PSR – periodontal screening and recording
CFHSTC Clin Perio Crse 0013

50. 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

51. 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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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

58. 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

59. 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

60. 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

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