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Extra Oral Examination of the Dental Patient

Article in Primary Dental Journal · March 2020

DOI: 10.1177/2050168420911016

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911016 PRD Primary Dental JournalVol. xx no. x Month xxxx

Key words Learning Objectives AUTHOR

Medical examination; extra oral
examination in dentistry
•• To understand the importance of Kathleen Fan PhD BDS MBBS FDSRCS
performing extra oral examination in the FRCSEd FRCS OMFS
dental setting Consultant, Oral and Maxillofacial Surgery, King’s
College Hospital NHS Foundation Trust Reader in Oral
•• To understand the association between
and Maxillofacial Surgery, King’s College London
clinical findings on extra oral
examination and associated medical
comorbidities
•• To establish a systematic and
reproducible pattern for extra oral
examination

Kathleen Fan
Prim Dent J. 2020;9(1):21-26

Extra oral examination

of the dental patient
Abstract
The general assessment and extra oral examination of the dental patient can
identify undiagnosed or undisclosed medical conditions, such as malignancies,
endocrine conditions and signs indicating raised cardiovascular or cerebral
vascular risk. This knowledge may influence dental treatment, and could impact
the morbidity and mortality of the patient. This article gives an overview of the
general and extra oral examination of the dental patient.

Introduction problems. Is the patient happy, anxious

Dentists, dental hygienists and therapists
are clinicians forming part of the wider
healthcare team involved in the
management of the dental patient in
totality. Dentists not only diagnose and
treat dental conditions involving the teeth
and the gums; they are also ideally
positioned to examine face, skin, lymph
nodes and the joints and muscles of the
head and neck. The assessment of the
patient can be divided into general
examination and extra oral (head and
neck) examination followed by intra oral
examination. This article will cover the
general and extra oral assessment.
The assessment of the patient commences
the moment they walk into the room.
Information can be obtained from their
general and facial appearance, skin,
mobility and even smell. These aspects
can all be informative and provide clues
to the patient’s medical history.
The general appearance and
demeanour of the patient can also
provide information on their medical
or scared? Do they look tidy, neglected
or unkempt? Note their physical
appearance, their body build (obese,
slim, thin or cachectic). As clinicians,
we almost automatically observe these
features, but it is beneficial to note any
unusual findings.
The following categories are useful to
consider:
•• Signs of distress or anxiety
•• Posture, motor activity, gait
•• Dress, grooming, personal hygiene
•• Skin colour and any obvious lesions
•• Facial expressions
•• Body build
•• Odours (body or breath), e.g. smoker,
alcohol, ketones, renal disease
Gait
As the patient walks in, note the way
they walk (gait), or their need for walking
aids as this can provide information.
A patient who requires a stick or
wheelchair should be asked about the
reason for this need. The medical history
may include a previous stroke, a painful

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 Extra oral examination
of the dental patient
gait due to degenerative changes in the
spine, hip or knee or injury. Issues of
mobility are important as they may
influence where it is best to carry out
dental treatment, e.g. on the ground
floor. Does the patient need assistance
into the dental chair? If so, what type of
assistance? A number of pathological
gaits have been described, such as the
classic shuffling gait seen in Parkinson’s
Disease, and ataxic gait, as seen in
cerebellar disease, which some describe
as ‘gait of acute alcohol intoxication’
where there is a clumsy, staggering
movement with legs wide apart. This may
present secondary to a cerebrovascular
accident (CVA). Identifying that the gait is
abnormal allows the awareness of
possible relevant medical history even
before the patient utters a sound.
Skin
The patient may have the yellowish skin
of jaundice or show other signs of liver
disease. It is then important to consider
altered drug metabolism and an increase
in risk of bleeding and malignancy. They
may show signs of sun damage in pale
skin type, such as pigmented or crusted
lesions, that may represent basal cell
carcinomas, squamous cell carcinomas,
or even melanomas.
Facial appearance
A patient’s facial appearance or
expression may provide clues to their
conditions. Moon faces of Cushing
syndrome, mask like faces of
Parkinson’s, or prognathism of
acromegaly. Malar flush may indicate
that the patient has mitral stenosis,
pulmonary hypertension, polycythaemia,
or it may simply be idiopathic.
Clothing/dress
Are they appropriately dressed for the
weather? Patients with hypothyroidism
feel the cold, whilst those with
hyperthyroidism may have thin clothes
on in winter. Patients with bipolar
disorder may attend with bizarre dress
sense, colourful or strange garments.
As the majority of patients with mental
health problems are cared for entirely in
primary care, they are likely to present
in dental practice. These individuals
need to be identified so that their care
can be modified if required1.
Hands
We often shake hands when greeting
patients. Hands can provide clues,
22 Pr i ma r y De n ta l J ou r n a l
not only of medical conditions, e.g.
rheumatoid or osteoarthritis, but also of
the patient’s ability to carry out oral
hygiene. We all recall the numerous
causes of clubbing, including lung
disorders and inflammatory bowel
disorders amongst others.
Communication
The importance of communication skills
and tailoring communication to the
individual cannot be underestimated.
The need to consider the patient is
paramount, be they a child, adult, or
adult with special needs. This is not
covered in this article, but Dougall and
Fiske2 provide useful tips beneficial not
just when treating special care
patients.
Extra oral examination
Assessment of the face
Start by looking at the standing patient.
Assess the symmetry of the face as well
as the head and neck region. This can
also be done if the patient is sat upright
in the dental chair. Most of us have
some asymmetries, but significant
asymmetries on comparison of one side
to the other should be noted. This
asymmetry may be bony or soft tissue in
nature. It may be acute or chronic, or it
may be secondary to previous surgery,
e.g. tumour resection or CVA. It may
have occurred following injury, such as
a fall, and the patient presents to the
dentist with deranged occlusion and
figure 1
Normal anatomy and location of potential
neck lump
Hyoid bone
Thyroid cartilage
Paramidal lobe
of thyroid
Thyroid gland
Sternomastoid
muscle
facial asymmetry due to a mandibular
fracture.
Examination of the eye
Looking at a patient’s eye can give the
dentist an insight into what possible
systemic conditions the patient may have.
Corneal arcus or xanthelasma may
indicate dyslipidaemia and a possible
increased risk of cardiovascular disease,
diabetes or stroke. Proptosis (bulging
eye) may signify endocrine disorder
(Graves’ disease), or occasionally even
malignancy. Acute presentation of
proptosis is less likely at the dental
surgery, but if seen following a facial
injury, it may represent a retrobulbar
haemorrhage. This is an urgent vision
threatening condition, which needs
immediate referral to emergency
department for decompression, usually
by oral and maxillofacial teams. The eye
may show signs of medical conditions
already known to the patient, but if they
are not known, advising the patient to
seek medical attention may influence
their outcome.
Examination of the neck
Inspection of the neck
Medical examination starts with
inspection, followed by palpation and
percussion. Inspect and identify scars
on the neck that may indicate previous
surgery (thyroidectomy, tracheostomy
or neck dissection for head and neck
cancer). Identify any masses in the neck.
Submental node
Submandibular
nodes
Branchial cyst
(or other level II
mass e.g. lymph
node)
Thyroglossal cyst
Thyroid nodules
 figure 2
Neck lump in relation to site

posterior triangle anterior triangle

cystic pulsatile moves with swallowing

cystic hygroma subclavian

yes no
aneuryism
solid cystic solid cystic
solid
thyroid thyroglossal Salivary gland branchial
Lymph node gland cyst Submandibular cyst
level V thyroid Parotid cold abscess
isthmus Lymph Node tuberculossis
Lymph node any level
level VI Parapharyngeal
lesion
Dermoid cyst
cartoid body
tumor

Trans-illumination – suggests mass

figure 3 is fluid filled – e.g. cystic hygroma
Neck lump in relation to site Pulsatility – suggests vascular origin –
e.g. carotid body tumour/aneurysm
midline
Temperature – increased warmth
may suggest inflammatory/infective
moves with swallowing cause
Relation to underlying / overlying
yes no tissue – tethering/mobility (ask to turn
head)
solid cystic
lymph node Auscultation – to assess for bruits –
lipoma e.g. carotid aneurysm
thyroid gland thyroglossal duct cyst sebaceous cyst
thyroid isthmus (elevates on protrusion The location of the lump provides
Lymph node of tongue) clues as to the possible diagnosis.
It is customary to divide the neck in the
central and lateral neck lumps/mass
and a mass or lump in the anterior
The following are key features that are or posterior triangle of the neck
Assessing a neck lump (Figure 1)
important to note for lumps in the face, (Figures 1, 2 and 3). Consideration
neck or intra-oral: Site – can help narrow the differential – of the normal anatomy in terms of
•• Site anterior triangle/posterior triangle mid-line the layers of tissue from superficial
•• Size Size – wi dth/height/depth to deep will help formulate the
•• Shape differential diagnosis: skin (sebaceous
Shape – well defined?
•• Surface cyst), fat (lipoma), bone (osteoma).
•• Colour Surface (overlying skin changes) – Similarly, knowledge of the normal
•• Consistency erythema/ulceration/punctum anatomical structure in the region of
•• Compressibility Consistency – smooth/rubbery/hard/ the lump, mass or swelling will also
•• Temperature nodular/irregular provide clues to the likely diagnosis.
•• Tenderness Enlarged lymph nodes often present
•• Trans illumination Compressibility – e.g. vascular
as multiple palpable lesions,
•• Edge / Margin lesion
whilst most other lesions are usually
•• Pulsatility Fluctuance – if fluctuant, this suggests single (with the exception of thyroid
•• Fixation it is a fluid filled lesion – cyst nodules).

Vol. 9 N o . 1 M a rc h 2020 23
 Extra oral examination
of the dental patient

figure 4
Lymph nodes in anterior and posterior triangle of neck

Preauricular
Posterior auricular
Parotid
Occipital

Superficial cervical Tonsillar

(jugulodigastric)
Lower ear and parotid

Deep cervical Submental

Other nodes of head and neck, occipital Lower lip, floor of mouth,
scalp, ear, back of neck, tongue, apex of tongue
trachea, nasopharynx, nasal cavities,
palate, oesophagus Submandibular
Cheek, side of nose, lower lip,
gums, anterior tongue
Posterior cervical
Supraclavicular
Thorax and abdomen

Palpation of lymph nodes

Examination and palpation of the figure 5
cervical lymph nodes should be carried
out routinely to assess for palpable and
TMJ and muscles of mastication
or tender lymphadenopathy (Figure 4).
Lymph nodes are normally not palpable.
If they are palpable then note the size,
site, number consistency, tenderness and
mobility of the nodes. Look for possible
reasons for the lymphadenopathy, signs
of infection within the drainage pathway
and systemic infection, and always
consider malignancy. Ask about risk
factors (smoking and alcohol intake),
and red flag signs for oral cancer Temporalis muscle
(weight lost, change of voice,
dysphagia, otalgia, night sweats). Condyle of the TM joint
Assess for risk of oral cancer if an adult
presents with an unilateral enlarged Lateral pterygoid muscle
lymph3,4.
Masseter muscle
Ask the patient to sit up in the dental
chair, stand behind them and palpate
the cervical lymph nodes. Patients tend
to try to help by extending their neck,
which makes examination difficult. The
neck should be relaxed and slightly
flexed. Palpate each group in order, Lymph node groups to palpate: •• Cervical chain (upper, middle, lower)
using the pads of the fingertip in a •• Submental •• Supraclavicular
slight rolling motion. The suggestion is •• Submandibular
to palpate each side of the cervical •• Pre-auricular If there is a submandibular mass/
chain independently to avoid the •• Post auricular swelling, bimanual palpation will often
theoretical risk of carotid massage. •• Occipital help to determine if the mass is the

24 Pr i ma r y De n ta l J ou r n a l
submandibular gland. This is carried
out by having one finger inside the
mouth gently palpating the floor of
the mouth. The other hand is pushing
the submandibular mass upwards
and feeling the mass between the
hands. One may feel a salivary stone
if there is a history of meal time
symptoms, such as swelling in
association with food.
TMJ examination (Figure 5)
Examination of joints classically follows
the pattern of LOOK, FEEL, and MOVE.
Look for redness or swelling over the
TMJ. Press gently over the TMJ and ask
if it is painful. Ask the patient to open
and close their mouth and palpate and
listen for clicks or crepitus. Note any
deviation in mouth opening and the
side of the deviation. The mandible
often deviates to the side of pathology.
Record any limitation in mouth opening.
Normal maximum mouth opening is
40-50mm with 35mm opening being an
acceptable range of jaw opening5.
Assess for extent of protrusion and left
and right lateral excursion. Note if one
side is more limited than the other.
Assess the masticatory muscle, the
masseters, temporalis and lateral
pterygoid muscles. Request that the
patient clench and feel the bulk of the
masticatory muscles by direct
palpitation for masseter and temporalis.
Assessment of the inferior head of the
lateral pterygoid muscles is classically
carried out intra-oral by gentle
palpation laterally behind the maxillary
tuberosity. Although this is routinely
carried out by many clinicians, there
is some concern over its validity and
reliability6.
Ask the patent to clench and palpate
the masseter and temporalis muscles
extra-orally. Ask if there is tenderness of
the muscle as you palpate. There may be
trigger points within the muscle that is
more tender. Extra oral palpation of the
masseter muscle provides information on
the superficial fibres, whilst feeling the
bulk of the masseter muscle with a finger
inside the mouth and thumb on the
outside provides additional information
on the deep fibres.
Temporomandibular disorder is
characterised by one or more of
the following features: tenderness on
palpation over the TMJ, joint sounds,
Vol. 9 N o . 1 M a rc h 2020
masticatory muscle tenderness and
deviation mandible, along with signs
of parafunction: scalloping of tongue,
linear able on buccal mucosa, sign of
tooth substance wear and possible
tooth fracture.
Cranial nerve examination
The most likely cranial nerves a
dentist may need to examine are the
trigeminal (V) and facial (VII) cranial
nerves. Infections of the mandible,
including osteomyelitis, may present
with altered sensation. Objective
assessment and documentation of
the neurology will be important as
infection, trauma (fractured
mandible), iatrogenic following
surgery and malignancy are all
possible causes of altered sensation.
Sensory changes due to infection
often improves as the infection
resolves, in contrast to malignancy.
A patient presenting with a swollen Figure 6: Facial nerve examination
face likely to be a parotid swelling
requires examination of the facial nerve
(VII). The most common parotid tumour Safe guarding concerns
is pleomorphic adenoma, which is The initial consultation and examination
a benign tumour. However, facial may raise concerns to the clinician
nerve involvement in association with about the possibility of safeguarding.
a parotid mass would be suggestive of There is a potential link between severe
a malignant tumour. dental decay in children, resulting in the
need for incision and drain, with dental
Trigeminal Nerve (V cranial nerve)
neglect and overall general neglect7.
provides the sensory supply to the face
The safeguarding tool8 has useful
and motor supply to the muscles of
information. For children, concern
mastication. There are three sensory
can be discussed with the GP.
branches of the trigeminal nerve:
ophthalmic, maxillary and mandibular.
Summary
The motor supply is assessed by
A comprehensive general and extra
observing and feeling the bulk of
oral examination of the patient can be
the masseter and temporalis muscles.
performed without undue increase in
Power can be assessed by asking the
time in the dental practice setting.
patient to then open their mouth against
resistance. Although seemingly lengthy, many
aspects of the inspection can be carried
The facial nerve (VII cranial nerve) out as the patient enters the surgery.
supplies motor branches to the This, in conjunction with a thorough
muscles of facial expression. This medical history, will provide information
nerve is assessed by asking the patient to allow the safe and holistic care of
to raise their eyebrows, close their dental patients. Utilisation of preformed
eyes and keep them closed against questionnaires or pre-set fields in
resistance, puff out their cheeks and electronic notes would ease the
reveal their teeth (See Figure 6). documentation. Dentists and dental care
The images show a patient with a left professionals are trained and work
sided lower motor neuron facial nerve within an area where they may identify
palsy as shown by the involvement of unknown medical conditions. They can
the left forehead. There is asymmetry make a difference to a patient’s
in the parotid gland region with prognosis with a timely referral or
concavity on the left side indicative simply advise that they seek medical
of previous surgery. attention.
25

Extra oral examination
of the dental patient
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• dental records • history-taking • full examination • recall visits • consent
• confidentiality • data protection • referrals • electronic records • special situations
The third edition has been fully updated and expanded to reflect technological and regulatory
developments, and the hard copy also includes scenarios to put the guidance into context, as well as
a series of extensive appendices, diagrams, charting notes and template forms for use in practice.
“Relevant, clear, well structured, accessible and an excellent reference tool” British Dental Journal
WWW.FGDP.ORG.UK
MEMBE
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IN PRINT & ONLINE
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practice: A toolkit for dental
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7 Schlabe what to prescribe,
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