Intraoral and extraoral

examination
Intraoral and extraoral examination
A complete examination covers the following
three areas:

A. THE GENERAL EXAMINATION

B. THE EXTRAORAL HEAD AND NECK SOFT
TISSUE EXAMINATION
C. THE INTRAORAL SOFT AND HARD TISSUE
EXAMINATION
 General examination
• The general examination begins as soon as the
patient enters the dental office. The patient’s
general appearance may give information that
relates to his or her medical condition. The
clinician will observe the patient’s gait,
mobility, facial asymmetries, lesions or scars.
Extraoral head and neck examination
• The extraoral head and neck soft tissue examination
includes checking for asymmetries, a lymph node
examination and a brief temporomandibular joint
examination.
• 1. Asymmetries
• In order to check for asymmetries, the clinician will
stand in front of the patient to observe the head and
neck, focusing on the area around the jaws. If a
significant asymmetry exists, the clinician will ask the
patient for any known causes, such as previous
surgeries, scars, tumours, and infections.
Extraoral head and neck examination
• 3. TMJ examination
A limited examination of the jaw joints or
temporomandibular joints may also be performed at
the initial dental appointment. This is done by placing
the fingertips over the joints with gentle pressure. The
clinician will note any tenderness, swelling or
redness. Then the patient will be asked to open and
close his or her mouth slowly, several times. He or she
may also be asked to slowly move the lower jaw from
side to side. If an abnormality is noted, further
examination may be needed.
Extraoral head and neck examination
• 2. Lymph node examination
To examine the head and neck lymph nodes and other soft
tissue of the oral region, the clinician will palpate, (which
means feel) the area gently to look for tenderness or
enlargements. Normal lymph nodes are either not
palpable, or may feel like a pea or lentil, and are not tender
when touched. Abnormal lymph nodes are generally larger,
may be tender, and can be an indication of an inflammation
or that drainage of infection has occurred. A non-tender
enlargement may indicate cancer or lymphoma.
• The lymph node examination may include the areas around
the ear, the base of the skull, under the jaw and chin, the
neck and the area above the collar bone.
 Intraoral soft tissue examination
• The intraoral soft tissue examination includes checking
the soft tissues of the mouth, the throat, the tongue
and the gums.
• Lips and labial mucosa
• The clinician will begin by examining the lips and the
mucosa inside the lips called the labial mucosa. The
labial mucosa will be examined by gently turning the
lip out. The labial mucosa should appear wet and
shiny. Scars inside the lower lip are seen frequently as
a result of trauma as a child.
 Blister

Cold sore

Angular Cheilitis
 Intraoral soft tissue examination
• Buccal mucosa and vestibular mucosa
• The clinician will then examine the inside of the
cheeks, called the buccal mucosa, using two
mirrors to retract the buccal mucosa to one
side. This examination will be performed in a
thorough and stepwise manner, moving from one
side to the other. The mucosa should be smooth,
moist and shiny. If the mirror sticks to the
mucosa, xerostomia or dry mouth may be
present.
Intraoral Exam-Melanoma
Inraoral Exam-Melanoma
Melanoma malignum
 Intraoral soft tissue examination
• Hard and soft palate
• Next, the clinician will examine the hard
palate, which is the firm area of the roof of
the mouth and then the soft palate, which is
the soft area behind the hard palate. He or
she will then briefly look at the throat. This is
easier if the patient says “Ahhh”.
Intraoral soft tissue examination
 Intraoral soft tissue examination
• Tongue
The next step is to examine the tongue. The top of the
tongue will be examined first, followed by the sides of the
tongue, which may stretch the tongue slightly. The tip of
the tongue will be held with a piece of gauze and the
tongue moved from one side to the other. If there is any
swelling or ulcers, then the area will be palpated. The
tissue in this area should be soft. The underside of the
tongue will also be examined. Particular attention should
be paid to the sides of the tongue and the floor of the
mouth, as cancers develop in these areas more frequently
than on the top of the tongue or the palate. Oral cancers
may have the appearance of ulcers, masses, red areas, or
white areas.
Intraoral soft tissue examination
 Intraoral soft tissue examination
• Floor of mouth
• Now the clinician will examine the floor of the
mouth. He or she may feel the saliva glands,
which usually feels ropey or lobulated. A
salivary stone in this area would feel
hard. This examination is not painful, but it is
a slightly odd feeling.
Intraoral soft tissue examination
 Intraoral soft tissue examination
• Gingiva and alveolar mucosa
• Finally, the clinician will examine the gums,
which are called the gingiva. Healthy gingiva
is pink, and regular. Some abnormalities
include generalized or localized swelling,
redness, ulceration or bleeding.
Zapalenie dziąseł i przyzębia
Brzeżne zapalenie dziąseł
Zapalenie przyzębia. Sonda periodontologiczna
w kieszeni przyzębnej
Zapalenie dziąseł i próchnica jako wynik
obecności obfitych złogów płytki nazębnej
Ostre martwiczo-wrzodziejące zapalenie dziąseł
przed leczeniem
Ostre martwiczo-wrzodziejące zapalenie dziąseł
po leczeniu
Przerostowe zapalenie dziąseł w przebiegu białaczki
 Normal structures that may be
mistaken for lesions
1. Stensen's duct is the duct of the largest saliva
gland. It opens into the mouth next to the upper
molars and may be flat or slightly raised.
2. Circumvallate papillae form a V-shaped row of
rounded bumps at the back of the tongue.
3. Lingual tonsils are found on the top and back of
the tongue. They may become enlarged with
infections.
4. Plica fimbriata are folds on the underside of the
tongue. These folds may look fringed.
 Variations of Normal

1. Fissured tongue is a common condition. There

are multiple grooves on the top or sides of the
tongue. This is reported in 2% to 5% of the
population.
2. Fordyce granules are commonly seen on the
upper lip. These are extra sebaceous glands and
appear as yellow-beige spots measuring 1 – 3
mm.
3. Varicosities are are enlarged veins, commonly
seen on the underside of the tongue, usually
present in older patients.
 Common oral pathologies

1. Geographic tongue is a common benign condition seen

in 1% to 3% of the population. The cause is unknown. The
classic features are multiple circular or semicircular pink or
red areas on the top of the tongue, with the red areas
partially surrounded by a slightly raised yellow-white rim or
border.
2. Linea Alba, or white line, is a common condition that
appears as a white horizontal line along the buccal mucosa
at the level where the teeth meet.
3. Morsicatio buccarum is cheek biting and appears as a
ragged, slightly translucent area on the inside of the
cheek. Most patients with morsicatio buccarum, when
asked, will admit that they bite their cheek repeatedly.
 Dental Examination
1. Illumination
2. Dry and clean surface
3. Sharp eyes
4. Explorer
5. X-ray
 Use of explorers

The use of gentle pressure, defined by the force just

required to blanch a fingernail without causing any pain or
damage is highly recommended.

All surfaces of a tooth are cleaned of debris and plaque, the

teeth are dried using an air syringe and examined visually.

If there are suspicious areas, then an explorer is used to

check for the surface texture.
Smooth Surface Caries

Active non-
cavitated carious
lesions on smooth
enamel surfaces
Smooth Surface Caries

If there is visual enamel opacity

under an ostensibly sound marginal
ridge then the enamel is undermined
because of dental caries and the
tooth surface is classified with a non
cavitated carious lesion in dentin
Cavitated Smooth Surface Caries
Caries diagnosis
 Root Caries

Advanced root lesions are soft/leathery with a large surface area

or a cavity (5 millimeter square or larger).
 Reccurent Caries
There are two valid indicators of recurrent (secondary) caries:

Softness at the margin of a filling that is detected using an explorer (gentle

pressure is highly recommended)

Presence of a large defect (a minimum diameter of 0.4 mm) at a margin of a

filling with softness in the area.

Large defects are associated with a high level of colonization with cariogenic
bacteria. Marginal discoloration by itself is not a valid sign for dental caries.
Amalgam Fracture & Secondary Caries
Overhanged Amalgam
Restoration
Cervical Abrasion
Erosion
Dentinal Fluorosis

mild moderate

pitting severe
 Other adjuncts- Magnification
• Loupes

Operating Microscope
Intraoral Camera
 New Technologies:
Digital Radiography

Allows lower dose exposures. Resistance from patients is reduced.

Results are instant.
Patient Education is enhanced as they can see radiographs enlarged in
front of them. Diagnosis may be enhanced.
Essential for online communication with specialists.
Complete offsite backup is possible.
Sensors are larger and placement takes some practice.
 Diagnodent Laser

• This device can give a numerical reading of early decay

in pits.
• With practice, it can be more accurate than visual,
tactile or radiographic examinations.
• Caution is required around hypocalcifications and
existing resins and sealants as the unit may misread.
 New Technologies:
Diagnodent Laser

• Readings under 10 have no decay.

• Readings 10-20 usually have stain or
enamel caries

Readings over 35 generally have

decay in dentin.

Readings of 99 are decayed well into dentin.

Readings 20-35 need individual assessment

Diagnodent Readings alone are not sufficient for diagnosis (See Literature
Review)
 New Technologies:
Diagnodent Pen

Smaller and more portable version released in 2006

Ability to read interproximal lesions
Less fragile cable, less chance of damage
 New Technologies:
DIFOTI (Digital Imaging Fiber-
Fiber-Optic Trans-
Trans-Illumination)
Illumination)

This device creates high

high--resolution digital images of
occlusal, interproximal and smooth surfaces. It enables
dentists to discover or confirm the presence of decay that
cannot be seen radiographically, visually or through use of
an explorer
 New Technologies:
DIFOTI (Digital Imaging Fiber-
Fiber-Optic Trans-
Trans-
Illumination))
Illumination