The Intraoral and Extraoral Exam

Abstract

This continuing education course is intended for general dentists, hygienists, and dental assistants. This course will introduce the protocol for a complete oral cancer screening with proper techniques for both the intraoral and extraoral exam; provide some patient education information, as well as information on some adjunct considerations that may be utilized in lesion detection and lastly, to suggest that all patients be told they are actually receiving a complete oral screening exam. Overview Overall, oral cancer incidence is decreasing slightly but there are increasing numbers of diagnoses being made at ages younger than 40. Diagnosing the lesions in a pre-malignant or early stage is extremely important in rendering affective treatment for the patient. The prognosis is poor unless lesions are diagnosed and treated in an early stage while the lesion is still in the epithelial layers. Early treatment results in less surgery, radiation, chemotherapy and a better quality of life for the patient. Head and neck surgery can be disfiguring and usually affects the eating/swallowing patterns of an individual. Education regarding the risk factors related to oral cancer is crucial in reducing the risk for all patients, especially for those patients who consume alcohol, use tobacco products and those maintaining a poor quality lifestyle. Teaching patients to become cognizant of any changes in the oral tissues empowers the patient to assess the oral tissues, to become an active participant in their own health, and perhaps to notice any early lesions between dental visits. Using data from the National Health Association, and Nutrition Examination Survey for 1999 through 2004, the Centers for Disease Control and Prevention (CDC) reports that approximately 69 percent of adults ages 20-64 had at least one dental visit during the previous year. However, if fully assessed, only a small percentage of adults report having had an oral cancer screening to detect oral and pharyngeal cancers.

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The Intraoral and Extraoral Exam
This continuin
g
education course is intended
f
or
g
eneral dentists, hy
g
ienists, and dental assistants. This
c
ourse will introduce the protocol
f
or a complete oral cancer screenin
g
with proper techniques
f
or both the
intraoral and extraoral exam; provide some patient education in
f
ormation, as well as in
f
ormation on some
a
d
junct consi
d
erations t
h
at may
b
e utilize
d
in lesion
d
etection an
d
lastly, to su
gg
est t
h
at all patients
b
e tol
d
t
h
ey are actually receivin
g
a complete oral screenin
g
exam
.
Overview
Overall, oral cancer incidence is decreasin
g
sli
g
htly but there are increasin
g
numbers of dia
g
noses bein
g
ma
d
e at a
g
es youn
g
er t
h
an 40. Dia
g
nosin
g
t
h
e lesions in a pre-mali
g
nant or early sta
g
e is extremely
important in renderin
g
a
ff
ective treatment
f
or the patient. The pro
g
nosis is poor unless lesions are
d
ia
g
nose
d
an
d
treate
d
in an early sta
g
e w
h
ile t
h
e lesion is still in t
h
e epit
h
elial layers. Early treatment
r
esults in less sur
g
ery, radiation, chemotherapy and a better quality o
f
li
f
e
f
or the patient. Head and neck
sur
g
ery can be dis
f
i
g
urin
g
and usually a
ff
ects the eatin
g
/swallowin
g
patterns o
f
an individual. Education
r
e
g
ardin
g
the risk
f
actors related to oral cancer is crucial in reducin
g
the risk
f
or all patients, especially
f
or
those patients who consume alcohol, use tobacco products and those maintainin
g
a poor quality li
f
estyle.
Teachin
g
patients to become co
g
nizant o
f
any chan
g
es in the oral tissues empowers the patient to assess
t
h
e oral tissues, to
b
ecome an active participant in t
h
eir own
h
ealt
h
, an
d
per
h
aps to notice an
y
earl
y
lesions
between dental visits. Usin
g
data from the National Health Association, and Nutrition Examination
S
urvey
f
or 1999 throu
g
h 2004, the Centers for Disease Control and Prevention (CDC) reports that approximately
6
9 percent o
f
adults a
g
es 20-64 had at least one dental visit durin
g
the previous year. However, i
f
f
ully
assessed, only a small percenta
g
e o
f
adults report havin
g
had an oral cancer screenin
g
to detect oral and
p
h
aryn
g
eal cancers
.
Nancy W. Burkhart, BSDH, MEd, EdD;
Leslie DeLong, RDH, AS, BSHS, MHA
Continuing Education Units: 3 hours

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Oral squamous cell carcinoma (SCCA) comprises 90% of all oral cancers. The remainin
g
10% are
c
omprised o
f
cancers o
f
the salivary
g
lands, sarcomas and other cancers that are classi
f
ied as rare. In
2006, approximately 31,000 cases of oropharyn
g
eal cancer were dia
g
nosed in the United
S
tates
.
1
T
he
f
ive
y
ear survival rate in the United States is approximatel
y
57%. Case Western Universit
y
presented the
r
esults o
f
a study indicatin
g
that only 53% o
f
hy
g
ienists completed an exam on their patients
.
27
S
everal
studies support the
f
act that oral exams are either not per
f
ormed or poorl
y
per
f
ormed even when the
practitioner is educated or in
f
ormed
.
6
A 2007 stud
y
f
ound that 92 percent o
f
Illinois dentists reported
providin
g
oral cancer screenin
g
examinations, but many were not bein
g
per
f
ormed correctly or at the
appropr
i
ate
i
nterva
l
s
.
12
Additional studies support the
f
act that onl
y
14 percent o
f
dentists per
f
orm all
aspects o
f
the intraoral and extraoral exam
.
2
5
A stud
y
in 1995, indicated that 37 percent o
f
ph
y
sicians did
not believe that early detection was an important means o
f
reducin
g
morbidity and mortality associated with
o
ral-pharyn
g
eal cancer. Not only is a complete oral exam important in the early detection o
f
cancer, there
are other important reasons to do a complete assessment of the patient (see Table 1)
.
The extraoral exam is o
f
ten overlooked as a crucial aspect o
f
the oral cancer screenin
g
. Not only crucial
in
d
etectin
g
enlar
g
e
d
lymp
h
no
d
es t
h
at may in
d
icate metastasis, t
h
e extraoral exam serves to
d
etect ot
h
er
systemic disease states as well as skin cancer.
S
urprisin
g
ly, many patients do not realize that they have
had an oral cancer screenin
g
since practitioners may not even in
f
orm the patient they are per
f
ormin
g
a
c
ancer screen
i
n
g.
8
S
tudies b
y
Patton et al. 2004
,
16
concluded that onl
y
29% of a North Carolina population
c
onsistin
g
o
f
1,096 respondents reported havin
g
had a dental exam when the procedure was described to
them. Additionall
y
, even current and
f
ormer smokers in Mar
y
land were no more likel
y
to have had a dental
exam as anyone in t
h
e
g
eneral population
.
10
D
elay in dia
g
nosis o
f
head and neck cancer is termed “pro
f
essional delay”
.
2
3
S
tudies b
y
Yu found a dela
y
of
as much as 6 months, much lon
g
er than expected,
f
rom the time o
f
the initial examination to the dia
g
nosis/
treatment. This delay results in more late sta
g
e cancers, extensive sur
g
ery, radiation and chemotherapy
f
or
the patient.
S
ome of the more extreme measures ma
y
be minimized or not need to be utilized when oral
c
ancer is
f
ound at its earliest sta
g
e, while con
f
ined to the epithelial layers. Pro
g
ression is rapid in the oral
tissues, because o
f
the rich blood suppl
y
, and detection
f
ollowed b
y
timel
y
treatment is crucial
.
In addition to oral cancer, man
y
chronic disease states ma
y
actuall
y
be discovered in the dental o
ff
ice
since oral mani
f
estations o
f
systemic disease may be observed durin
g
a routine dental exam and oral
c
ancer screenin
g
. With an a
g
in
g
population o
f
baby boomers reachin
g
retirement a
g
e, chronic disease
w
ill continue to increase. B
y
2030 about 20% o
f
all Americans, more than 71 million people, will be older

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Course Contents
•
Introduction and
S
tatistics
•
I - The General Ph
y
sical Appraisal
•
II - T
he
H
e
a
d
an
d
N
e
ck Examinati
on
Cutaneou
s
Area
Lips
E
y
es
L
y
mp
h
No
d
es
Salivar
y
Glands
Th
y
roid Glan
d
Temporoman
d
i
b
ular Joint Evaluatio
n
•
III - T
he
Intra
o
ral Examinati
on
Posterior P
h
aryn
g
eal Wall
Tonsillar Cr
y
p
t
S
oft Palate and Uvula
Har
d
Palat
e
Buccal Muco
s
a
La
b
ial Muco
s
a
Man
d
i
b
l
e
Fl
oo
r
of
th
e
M
o
ut
h
Ton
g
u
e
Attached Gin
g
iva
Salivar
y
Flow and Consistenc
y
Adjuncts for the Oral Cancer Screenin
g
•
Conclu
s
ion
s
•
Appendix A. Your Oral Cancer Screenin
g
Exam
•
Appendix B. Oral Cancer Screenin
g
Form
•
Appendix C. Referral Form for Oral Patholo
g
ist
and/or Oral Sur
g
eo
n
•
Cour
s
e Te
st
•
Re
f
erence
s
•
A
b
out t
h
e Aut
h
or
s
than 65 years old. Oral cancer is a disease associated with a
g
in
g
; however, we have seen a continuin
g
increase o
f
oral cancer dia
g
noses in those patients under a
g
e 40 with no known risk
f
actors
13
al
s
o note
d
in
this a
g
e
g
roup is a si
g
ni
f
icant increase in cancer o
f
the ton
g
ue
.
2
0
The incidence o
f
oral cancer in Europe in
people a
g
ed 20-39 years old has increased 6-
f
old and studies report increased mortality rates
f
or the past
two
d
eca
d
es in Eastern Europe
.
2
6
Practitioners who
f
ocus on patients at hi
g
h risk may miss subtle chan
g
es
in those patients who have no known risk
f
actors or those who do not
f
it the perceived pro
f
ile o
f
oral cancer
susceptibility. Cancer in youn
g
er populations tends to be much more a
gg
ressive with a poorer pro
g
nosis,
i
n
g
enera
l.
The purpose o
f
this paper is multi
f
old:
1
. to introduce the protocol
f
or a complete oral cancer screenin
g
with proper techniques
f
or both the
intraoral an
d
extraoral exam
,
2. to provide some patient education in
f
ormation
,
3
. to provide in
f
ormation on some adjunct considerations that ma
y
be utilized in lesion detection scenarios
an
d
lastl
y,
4. to su
gg
est t
h
at all patients
b
e tol
d
t
h
at t
h
ey are actually receivin
g
a complete oral screenin
g
exam
.
W
e do emphasize the
g
old standard in tissue dia
g
nosis is the so
f
t tissue scalpel biopsy with evaluation by
a patholo
g
ist who will view the tissue under a microscope
f
or a de
f
initive dia
g
nosis. And, as part o
f
tissue
biopsy dia
g
nosis, immuno
f
luorescence is an added adjunct to tissue evaluation in some cases
.
Learning Objectives
U
pon the completion o
f
this course, the dental pro
f
essional will be able to:
•
S
tate ei
g
ht objectives of the intraoral and extraoral exam
.
•
List the sequence o
f
per
f
ormin
g
a total oral cancer screenin
g.
•
List the prime areas
f
or the development o
f
oral cancer
.
•
Describe
f
our adjunct tests/devices & procedures that ma
y
be per
f
ormed in conjunction with the oral
c
ancer screenin
g
w
h
en nee
d
e
d.
•
Discuss t
h
e reasons w
h
y an a
d
junct
d
evice may
b
e use
d
alon
g
wit
h
an oral cancer screenin
g.
•
List
f
ive descriptors that are important in the documentation o
f
oral lesions
.
•
List
f
our risk
f
actors
f
or the development o
f
oral cancer
.
•
De
f
ine the term “Pro
f
essional Dela
y”
•
Name the three classifications of a General Appraisal as part of the extra oral exam
.

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is t
h
at earl
y
lesions ma
y
b
e
d
etecte
d
at six mont
h
an
d
y
earl
y
maintenance visits. We
h
ave more
o
ne on one contact time wit
h
t
h
e patient t
h
an
o
t
h
er
h
ealt
h
care in
d
ivi
d
uals plus, as an a
dd
e
d
b
onus, we
h
ave a captive au
d
ience
.
PROTOCOL AND SEQUENCE FOR THE
COMPLETE ORAL EXAM
I – The General Physical Appraisal
T
h
e clinician nee
ds
to
d
etermine an overall
impression o
f
the
g
eneral health and physical
w
ell bein
g
o
f
each patient. The
g
eneral appraisal
b
e
g
ins wit
h
t
h
e initial patient contact an
d
c
ontinues durin
g
the entire appointment. The
f
irst
o
pportunity to o
b
serve t
h
e patient’s
g
eneral
h
ealt
h
an
d
p
hy
sical c
h
aracteristics usuall
y
presents as
the patient is escorted to the operator
y
f
rom the
r
eception area. Durin
g
t
h
is walk t
h
e clinician
c
an o
b
serve t
h
e patient’s posture an
d
g
ait an
d
an
y
p
hy
sical limitations w
h
ic
h
ma
y
b
e apparent.
T
h
e
g
eneral appraisal continues as t
h
e clinician
ob
tains or up
d
ates t
h
e me
d
ical an
d
d
ental
histories (Fi
g
ure 1)
.
T
h
e person’s overall cleanliness an
d
personal
appearance may
g
ive t
h
e clinician clues as to t
h
e
abilit
y
o
f
the patient to per
f
orm routine sel
f
-care
proce
d
ures an
d
coul
d
provi
d
e clues a
b
out t
h
eir
emotional/mental
h
ealt
h
s
tatu
s
a
s
well. T
h
e
h
air
should be discreetl
y
observed
f
or cleanliness,
amount and distribution, and the presence o
f
nits
w
hich are indicative o
f
an in
f
e
s
tation with head
l
ice. Be aware a
s
train o
f
head lice ha
s
f
ormed
t
h
at i
s
re
s
i
s
tant to t
h
e mo
s
t common me
d
ication
s
u
sed to eliminate them. An
y
patient suspected o
f
Introduction and Statistics
H
ead and neck cancer
s
evolve becau
s
e o
f
multi
f
actorial cau
s
e
s
. In addition to the known
r
isk
f
actors such as tobacco and alcohol
,
sun exposure, ina
d
equate nutrition,
g
enetic
pre
d
isposition, an
d
viruses suc
h
as t
h
e HPV
1
6, HPV 18 an
d
HIV pla
y
a role in
h
ea
d
an
d
neck cancer. In a
dd
ition
,
alterations in
h
ost
immunit
y
, chronic in
f
lammation as occurs with
mucosal
d
isease states an
d
c
h
ronic p
hy
sical
irritation, ra
d
iation exposure, exposure to
c
arcino
g
ens/c
h
emicals an
d
a
g
enetic propensity
to these
f
actors, may play a si
g
ni
f
icant role in
the development o
f
head and neck cancers
.
19
Patient
s
with known ri
s
k
f
actor
s
s
hould be
screene
d
at every visit an
d
encoura
g
e
d
to
per
f
orm sel
f
-exams and report an
y
abnormalit
y
.
The
f
act that
s
ome individual
s
with oral cancer
s
do not have an
y
known risk
f
actors, support
man
y
o
f
the above mentioned contributors
f
or the
suscepti
b
le in
d
ivi
d
ual
.
The dental pro
f
essional is in a prime position to
assist t
h
e patient in o
b
tainin
g
an
d
maintainin
g
total health. By providin
g
in
f
ormation on health
r
elated topics and re
f
errin
g
patients to specialists
suc
h
as
d
ermatolo
g
ists, internists, nutritionists
an
d
ot
h
er experts, we can assist t
h
e patient
in o
b
tainin
g
quality
h
ealt
h
care. Dentists an
d
h
y
g
ienists are in a prime position to talk to
patients, assess oral tissue – w
h
ic
h
we know
is a
g
ood indicator o
f
total health – and provide
health related in
f
ormation to our patients. We are
pro
b
a
b
l
y
t
h
e sole practitioners w
h
o
h
ave suc
h
a
c
lose view into the health o
f
a person throu
g
h the
assessment o
f
oral tissues. And
,
an added bonus
Figure 1. General appraisal to obtain or update the medical and dental history of the
patient.

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3
. Patholo
g
ic – associated with in
f
ection, trauma,
neoplastic
g
rowt
h
, errors in
d
evelopment
c
ausin
g
f
unctional problems, immune system
d
isor
d
ers
,
an
d
more
.
II – The Head and Neck Examination
T
he
he
a
d
an
d
n
e
ck
e
xaminati
o
n will
e
na
b
l
e
t
he
c
linician to
f
ocu
s
attention on care
f
ul ob
s
ervation
of
the
s
tructure
s
o
f
the head and neck. The
sequence used in per
f
ormin
g
the head and
neck examination an
d
su
b
sequentl
y
t
h
e intraoral
examination is not as important as per
f
ormin
g
eac
h
examination usin
g
t
h
e exact same sequence
ever
y
time. Consistenc
y
enables the clinician to
per
f
orm these examinations quickl
y
and e
ff
icientl
y
w
hile still maintainin
g
the hi
g
hest de
g
ree o
f
awareness in order to identi
fy
abnormal versus
normal con
d
ition
s.
Symmetry and Profile
D
iscreetl
y
observe the patient
f
or
f
acial s
y
mmetr
y
(Fi
g
ure 4) and profile type (Fi
g
ure 5). Obvious
asymmetry may be a red
f
la
g
f
or neoplastic
h
ar
b
orin
g
h
ea
d
lice s
h
oul
d
b
e
d
ismisse
d
an
d
t
h
e
ch
air an
d
surroun
d
in
g
area s
h
oul
d
b
e t
h
orou
gh
ly
c
leaned by vacuumin
g
. A
f
resh headrest cover
f
or every patient is necessary. The
f
ollowin
g
w
eb sites have interestin
g
and timely in
f
ormation
o
n preventin
g
the spread o
f
and treatin
g
lice
in
f
e
s
tation
s
:
H
eadl
i
ce.or
g
an
d
C
enters for
Disease
C
ontrol and Prevention/Head Lice
.
A
s t
h
e
g
eneral appraisal pro
g
resses, any expose
d
s
kin
s
ur
f
ace
s
hould be examined
f
or evidence
of
s
kin cancer or other le
s
ion
s
. The American
C
ancer Society’s ABCD’s of Mali
g
nant Lesions
should be re
f
erenced
f
requentl
y
. This in
f
ormation
is availa
b
le on t
h
e societ
y
’s we
b
site (www.
c
ancer.or
g
). It is eas
y
to identi
fy
lesions, such
as the one seen on the
f
orearm in Fi
g
ure 2, as
abnormal but it is be
y
ond the scope o
f
our practice
to make an
y
ot
h
er assumptions. T
h
e patient
should be re
f
erred to a dermatolo
g
ist or physician
f
or evaluation o
f
an
y
suspicious skin lesions. The
l
esion seen in Fi
g
ure 2 was eventually
d
ia
g
nose
d
as a squamous cell carcinoma. In a
dd
ition to
screenin
g
f
or skin cancer, the clinician should look
f
or any evidence o
f
dermatolo
g
ical mani
f
estations
of
s
y
stemic conditions. Examples would be: skin
d
iseases suc
h
as sclero
d
erma, psoriasis, eczema,
l
upus, lic
h
en planus, pemp
h
i
g
us vul
g
aris, mucous
mem
b
rane pemp
h
i
g
oi
d
, an
d
g
eneral appraisals
of
skin texture, color and
g
eneral health concerns
(Fi
g
ure 2)
.
M
an
y
d
isor
d
ers present wit
h
oral an
d
cutaneous
l
esions and the presence o
f
both ma
y
assist in the
identi
f
ication o
f
an undia
g
nosed condition. Be
f
ore
c
ontinuin
g
wit
h
t
h
e examination,
b
e sure to c
h
eck
the hand
s
f
or evidence o
f
habit
s
s
uch a
s
nail
bitin
g
, HPV in
f
ections, nail in
f
ections, nail pittin
g
,
si
g
ns o
f
arthritis, systemic disease states and
tobacco use (Fi
g
ure 3). Ask the patient questions
a
b
out suspicious areas to
d
etermine t
h
eir
h
istor
y
and possible etiolo
g
y and document your
f
indin
g
s
in t
he
de
ntal r
e
c
o
r
d.
The head and neck and oral examination
s
f
ollow
the
g
eneral appraisal o
f
the patient. Findin
g
s
f
rom the
s
e examination
s
will
f
all into one o
f
three
g
eneral classi
f
ications:
1
. Normal –
f
ound in most individuals
,
2. T
y
pical – not present in all in
d
ivi
d
uals
b
ut still
w
ithin normal limits
(
a variation of normal
),
Figure 2. Diagnosed squamous cell carcinoma.
Figure 3. Check the hands for evidence of habits such as
nail biting, HPV infections, nail infections, nail pitting, signs
of arthritis, systemic disease states and tobacco use.

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of
suspicious nevi should be documented. These
an
d
ot
h
er lesions ex
h
i
b
itin
g
t
h
e warnin
g
si
g
ns
associated with the ABCD’s of Mali
g
nant Skin
Le
s
ion
s
s
hould be re
f
erred
f
or
f
urther evaluation.
In a
dd
ition, t
h
e patient s
h
oul
d
b
e a
d
vise
d
to watc
h
f
or chan
g
es in nevi and other pi
g
mented lesions
not exhibitin
g
the warnin
g
si
g
ns o
f
skin cancer.
A
n
y
evidence o
f
ph
y
sical abuse should be noted.
This is especiall
y
relevant in the case o
f
children
w
ho ma
y
not voice an
y
problems.
S
ubsequentl
y
,
c
orrelation
b
etween cutaneou
s
le
s
ion
s
an
d
intraoral lesions
f
ound durin
g
the intraoral
examination
s
hould be made a
s
in the ca
s
e o
f
the
patient wit
h
d
iscoi
d
lupus er
y
t
h
ematosus s
h
own
in Fi
g
ures 6 and 7. The cutaneous lesions o
f
discoid lupus (Fi
g
ure 6) presented concurrently
w
ith the
g
in
g
ival inflammation (Fi
g
ure 7) seen
d
urin
g
t
h
e oral examination
.
Lips
The lips should be examined
f
or s
y
mmetr
y
and
tissue consistenc
y
an
d
texture. Normall
y
t
h
e lip
tissue s
h
oul
d
b
e resilient
,
smoot
h
an
d
h
ave a
homo
g
enous pink color (Fi
g
ure 8). The vermillion
b
or
d
er s
h
oul
d
b
e
d
istinct an
d
even. Earl
y
ultra
g
rowt
h
s, muscle atrop
h
y or
h
ypertrop
h
y, a n
d
neurolo
g
ical pro
b
lems. Asymmetry is also
associate
d
wit
h
temporoman
d
i
b
ular joint
d
y
s
f
unction and malocclusions
.
Cutaneous Area
A
s in t
h
e
g
eneral appraisal, t
h
e expose
d
skin
of
the head and neck
s
hould be examined
f
or suspicious lesions. The skin o
f
the neck
an
d
scalp can
b
e examine
d
w
h
ile t
h
e clinician
is palpatin
g
t
h
e occipital an
d
cervical no
d
es.
T
he
ar
e
a
beh
in
d
an
d
ar
o
un
d
t
he
e
ar can
be
ob
serve
d
w
h
ile palpatin
g
t
h
e auricular no
d
es.
T
h
e patient s
h
oul
d
b
e questione
d
a
b
out t
h
eir
k
nowled
g
e o
f
any lesions discovered durin
g
t
h
e examination an
d
also an
y
lesions t
h
at t
h
e
y
ma
y
h
ave notice
d
t
h
emselves an
y
w
h
ere on t
h
e
bod
y
. In
f
ormation about the histor
y
, and an
y
symptoms such as pain, pruritus (itchin
g
) or other
a
b
normal
s
en
s
ation
s
a
ss
ociate
d
wit
h
t
h
e le
s
ion
s
is crucial in determinin
g
a di
ff
erential dia
g
nosis
and can assist in decidin
g
whether to re
f
er to a
specialist. T
h
e size an
d
p
hy
sical c
h
aracteristics
Figure 4. Facial Symmetry.
Figure 6. Cutaneous lesion of discoid
lupus.
Figure 7. Gingival Inflammation.
Figure 5. Profile Type.

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c
ommon occurrence especiall
y
wit
h
in t
h
e
submandibular
g
roup o
f
lymph nodes. When
examined, these nodes should be small
(
less
than 1 cm
)
, non-tender and mobile. Remember
to correlate
f
indin
g
s
f
rom the medical history
and
g
eneral appraisal o
f
the patient to the
ob
servations ma
d
e
d
urin
g
t
h
e
h
ea
d
an
d
neck
examination. For example, a previous
h
istor
y
of
cancer mi
g
ht cause the clinician to be more
suspicious o
f
newly appearin
g
palpable nodes
than i
f
there is no histor
y
o
f
cancer. I
f
suspicious
no
d
es are
d
iscovere
d
, t
h
e patient s
h
oul
d
b
e
v
iolet
d
ama
g
e may present as an in
d
istinct or
b
roken vermillion
b
or
d
er wit
h
color variation
s
o
r w
h
ite
b
lotc
h
es wit
h
in t
h
e lip tissue. More
advanced si
g
ns o
f
dama
g
e include induration,
pittin
g
and ulceration o
f
the tissues. Patients
w
ith the very early si
g
ns o
f
dama
g
e should be
s
h
own t
h
e area an
d
a
d
vise
d
to limit exposure
to t
h
e sun an
d
use a lip
b
alm wit
h
a sunscreen.
T
h
ey s
h
oul
d
b
e a
d
vise
d
a
b
out t
h
e si
g
ns an
d
appearance o
f
more serious chan
g
es. Patients
should monitor their lips
f
or evidence o
f
these
c
han
g
es. The commissures should be clear o
f
l
esions and should not show si
g
ns o
f
crackin
g
or
dryness (Fi
g
ure 9)
.
C
ommon patholo
g
ical conditions which affect the
c
ommissures include an
g
ular cheilitis, Candida
A
lbicans
,
nutritional de
f
iciencies
,
and Human
H
erpes Virus 1 or 2 lesions
.
Eyes
Observe the e
y
es for an
y
abnormalities. Pa
y
c
lo
s
e attention to the color o
f
the
s
clera and the
size of the pupils (Fi
g
ure 10)
.
Yellow sclera is associate
d
wit
h
jaun
d
ice an
d
ma
y
indicate an undia
g
nosed case of hepatitis (A or
B
), other liver d
y
sfunction or a blood disorder.
B
lue sclera is associate
d
wit
h
osteo
g
enesis
imper
f
ecta which ma
y
include alteration o
f
the
structure o
f
dentin. Pupil size ma
y
help identi
fy
patients who are at risk
f
or medical emer
g
encies
due to ille
g
al dru
g
use.
S
ymblepharon is
associate
d
wit
h
b
eni
g
n mucous mem
b
rane
pemphi
g
oid and lichen planus. A re
f
erral to a
specialist suc
h
as an op
h
t
h
almolo
g
ist is nee
d
e
d
to assess any con
d
ition ex
h
i
b
itin
g
sym
b
lep
h
aron
o
r pterya
gi
m
.
Lymph Nodes
The major l
y
mph nodes o
f
the head and neck
area s
h
oul
d
b
e palpate
d
wit
h
t
h
e patient in
an upri
gh
t position. Fin
d
in
g
s w
h
ic
h
s
h
oul
d
b
e note
d
inclu
d
e enlar
g
e
d
palpa
b
le no
d
es,
f
ixed nodes
,
tender nodes and whether the
palpa
b
le no
d
es are sin
g
le or present in
g
roups.
Fin
d
in
g
s w
h
ic
h
inclu
d
e sin
g
le or multiple, non
-
tender, and
f
ixed nodes are ver
y
suspicious
f
or
mali
g
nancy. Groups of tender nodes usually
o
ccur in conjunction with some t
y
pe o
f
in
f
ection.
Occasionally nodes will remain enlar
g
ed and
palpable a
f
ter an in
f
ection. This is a relativel
y
Figure 8. Normal the lip tissue.
Figure 9. Commissures should be clear of
lesions.
Figure 10. Observe the eyes for any abnormalities.

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•
S
upraclavicular (Fi
g
ure 16) These nodes are
examine
d
usin
g
d
i
g
ital compressions just
superior to t
h
e clavicle
.
•
S
ubmandibular (Fi
g
ure 17) Palpate the
su
b
man
d
i
b
ular no
d
es
b
y pullin
g
or rollin
g
t
h
e
tissues under the chin up and over the in
f
erior
b
o
r
de
r
of
th
e
man
d
ibl
e.
•
S
ubmental (Fi
g
ure 18) Use di
g
ital palpation
to determine the presence o
f
an abnormal
su
b
mental l
y
mp
h
no
d
e
.
Salivary Glands
Palpate the parotid (Fi
g
ure 19) and
submandibular (Fi
g
ure 20) salivary
g
lands usin
g
a
b
ilateral tec
h
nique. Normally t
h
ese
g
lan
d
s
r
e
f
erred to a ph
y
sician
f
or immediate evaluation.
Fi
g
ures 11 t
h
rou
gh
12
d
epict t
h
e examination
techniques
f
or the
f
ollowin
g
lymph nodes
.
•
Occipital nodes (Fi
g
ure 11) Palpate the
o
ccipital no
d
es a
b
out one inc
h
a
b
ove an
d
be
l
o
w t
he
h
airlin
e.
•
Auricular (Fi
g
ures 12 and 13) Palpate the pre
an
d
post auricular no
d
es
b
ilaterally usin
g
t
h
e
pads o
f
the index, middle and rin
g
f
in
g
ers
.
•
Cervical Chain (Fi
g
ures 14 and 15) Palpate
t
h
e no
d
e
s
me
d
ial to t
h
e
s
ternoclei
d
oma
s
toi
d
muscle usin
g
a
b
i
d
i
g
ital tec
h
nique an
d
t
h
e
no
d
es posterior to t
h
e muscle wit
h
a
b
imanual
tec
h
nique
.
Figure 11. Bilateral palpation of the occipital
nodes. Be sure to also observe the skin in this
area.
Figure 14. Palpation of the anterior cervical
nodes.
Figure 12. Postauricular nodes. Figure 15. Palpation of the posterior cervical
nodes.
Figure 13. Preauricular nodes. Figure 16. Bilateral palpation of the
supraclavicular lymph nodes.

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u
sin
g
a
b
imanual tec
h
nique w
h
ere one
h
an
d
supports t
h
e tissue an
d
t
h
e ot
h
er
h
an
d
palpates
t
h
e
g
lan
d
on one si
d
e an
d
t
h
en t
h
e reverse is
done to examine the opposite side o
f
the
g
land
(Fi
g
ure 21)
.
T
h
e normal t
h
yroi
d
g
lan
d
s
h
oul
d
not
b
e visi
b
le
and is most o
f
ten not palpable. In addition,
t
h
e area surroun
d
in
g
t
h
e
g
lan
d
s
h
oul
d
elevate
smoot
h
ly an
d
symmetrically
d
urin
g
swallowin
g
(Fi
g
ure 22)
.
A
ny variation
f
rom these normal
f
indin
g
s should
b
e
d
iscusse
d
wit
h
t
h
e patient an
d
t
h
e patient
should be re
f
erred to their ph
y
sician
f
or
f
urther
e
va
l
uat
io
n
.
s
h
oul
d
not
b
e palpa
b
le. In
d
uration an
d
pain coul
d
be si
g
ns o
f
in
f
ection, blocka
g
e, immune system
d
isor
d
er or a neoplastic process. In a
dd
ition,
non-ten
d
er paroti
d
enlar
g
ement may occur wit
h
alco
h
olism,
d
ia
b
etes, eatin
g
d
isor
d
ers an
d
HIV
in
f
ection. Ask the patient to touch the roo
f
o
f
the
mouth with the ton
g
ue, pressin
g
f
irmly a
g
ainst
t
h
e palate. T
h
is will allow
y
ou to assess t
h
e
muscles an
d
any pat
h
olo
g
y associate
d
wit
h
t
h
e
s
u
b
man
d
i
b
ular no
d
e area
s.
Thyroid Gland
The thyroid
g
land is
f
ound in
f
erior to the larynx
an
d
just superior to t
h
e clavicles on eit
h
er si
d
e
of
the trachea. It is comprised o
f
two lobes
c
onnecte
d
b
y an ist
h
mus. Palpate t
h
e
g
lan
d
Figure 17. Palpate the submandibular lymph
nodes using a cupped hand as shown.
Figure 18. Digital palpation of the submental
lymph nodes.
Figure 19. Palpation of the parotid gland.
Figure 21. Bimanual palpation of the thyroid
gland.
Figure 20. Palpation of the submandibular
glands.
Figure 22. Hold the fingers lightly over the
gland while the patient swallows.

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o
r
f
elt and usuall
y
f
all into one or more o
f
three
major cate
g
ories, clicks, pops an
d
crepitus.
C
licks and pops are associated with articular disk
d
eran
g
ement an
d
crepitus is usually associate
d
w
ith some form of arthritis. Correlate TM joint
f
indin
g
s with the patient’s occlusal classi
f
ication
and other dental
f
indin
g
s such as missin
g
teeth
and poorly
f
ittin
g
partial and/or
f
ull dentures.
Follow-up questions should
f
ocus on the histor
y
o
f
an
y
observed s
y
mptoms and determination o
f
an
y
l
i
f
e st
y
le or dietar
y
modi
f
ications the patient ma
y
have made to alleviate di
s
com
f
ort. Examination
of
the TM joint provides a per
f
ect transition point
fo
r th
e
intra
o
ral
e
xaminati
o
n
.
III – The Intraoral Examination
A
s wit
h
t
h
e
h
ea
d
an
d
neck evaluation
,
t
h
is
examination s
h
oul
d
b
e
d
one usin
g
t
h
e same
sequence ever
y
time. Areas s
h
oul
d
b
e visuall
y
examine
d
t
h
en palpate
d
w
h
erever possi
b
le.
Fin
d
in
g
s s
h
oul
d
b
e t
h
orou
gh
ly investi
g
ate
d
and the in
f
ormation
s
hould be noted in the
patient’s record. Oral cancer ma
y
have multiple
appearances. The
f
irst step in the intraoral
examination is a quick
g
eneral examination o
f
t
h
e c
h
eeks,
h
ar
d
palate, ton
g
ue an
d
g
in
g
iva
l
ookin
g
f
or any contraindications
f
or continuin
g
the evaluation. I
f
there are none
,
start the
e
xam
i
nat
io
n
.
Oropharynx
Examine t
h
e orop
h
arynx
b
y placin
g
a mirror or
ton
g
ue depressor on the dorsal sur
f
ace o
f
the
ton
g
ue applyin
g
g
entle pressure wit
h
out
h
avin
g
t
h
e patient stick t
h
eir ton
g
ue out. You s
h
oul
d
b
e
a
b
le to visualize t
h
e posterior p
h
aryn
g
eal wall,
anterior an
d
posterior pillars an
d
t
h
e tonsillar cr
y
pt
and tonsils, if present (Fi
g
ure 25). These areas
are normall
y
not palpate
d
unless t
h
ere is a nee
d.
Posterior Pharyngeal Wall
T
h
e tissue in t
h
is area s
h
oul
d
appear ver
y
v
ascular
b
ut ot
h
erwise
h
omo
g
enous in color
tendin
g
towards reddish pink. The sur
f
ace may
b
e smoot
h
or appear to
h
ave small coral pink to
translucent,
g
elatin-like, homo
g
enous sur
f
ace
prominences w
h
ic
h
are consistent wit
h
normal
areas of scattered l
y
mph tissues (l
y
mphoid
a
gg
re
g
ates). Patholo
g
ic findin
g
s include:
•
Homo
g
enous an
d
non-ten
d
er eryt
h
ema
associate
d
wit
h
post nasal
d
rip an
d
/or smokin
g
•
Er
y
t
h
ema an
d
purulent exu
d
ate associate
d
Temporomandibular Joint Evaluation
The
f
unction o
f
the TM joint should be evaluated
u
sin
g
a bilateral technique. Place the
f
in
g
ertips
o
ver t
h
e joint an
d
h
ave t
h
e patient open an
d
c
lose slowly (Fi
g
ures 23 and 24), move the jaw to
the left and ri
g
ht (Fi
g
ure 25) and jut the chin out
.
Look
f
or altered openin
g
and closin
g
pathways,
a
b
normal soun
d
s
,
ten
d
erness an
d
limitations in
o
penin
g
. There are two basic types o
f
altered
o
penin
g
pathways, deviations and de
f
lections. An
altere
d
pat
h
way on openin
g
w
h
ic
h
comes
b
ack
to t
h
e mi
d
line at maximum openin
g
is terme
d
a deviation. I
f
the
g
reatest distance
f
rom the
mi
d
line occurs at maximum openin
g
it is calle
d
a de
f
lection. Abnormal sounds ma
y
be heard
Figure 25. Normal anatomy of the
oropharyngeal area.
Figure 24. Have the patient open and close
slowly.
Figure 23. Proper positioning of the fingers.

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palpation is necessar
y
a topical anest
h
etic s
h
oul
d
be used and the palpation should be done
f
rom
the mid line out toward
s
the lateral
s
ur
f
ace
s
.
Normally, t
h
is area is sli
gh
tly less vascular t
h
an
t
h
e orop
h
ar
y
nx an
d
is usuall
y
re
dd
is
h
pink in
c
olor. Observe the area as the patient sa
y
s
“
ah”. The tissue should appear loose, mobile and
symmetrical durin
g
f
unction. The tissue will have
a
h
omo
g
enous, spon
g
y consistency on palpation.
A
typical o
b
servations inclu
d
e yellowis
h
colorin
g
due to increased adipose tissue (especiall
y
in
o
lder patients), excessively lon
g
or short uvulas
an
d
uvulas t
h
at appear sli
gh
tly asymmetrical at
r
est. Occasionall
y
one will discover a bifid (cleft)
u
vula. Patholo
g
ic
f
indin
g
s include:
•
Lesions o
f
an
y
kin
d
•
Loss o
f
f
unction or lack o
f
s
y
mmetr
y
durin
g
f
unction, both o
f
which may indicate
c
ompromise
d
swallowin
g
capa
b
ility an
d
a
hi
g
her risk o
f
aspiration o
f
f
ood and oral
f
luids
into t
h
e lun
g
s
Hard Palate
T
h
e
h
ar
d
palate an
d
maxillar
y
tu
b
erosit
y
areas
are examine
d
usin
g
b
ot
h
d
irect an
d
in
d
irect vision
an
d
illumination. Followin
g
t
h
e visual examination
t
h
e clinician s
h
oul
d
d
i
g
itally palpate t
h
e entire
area usin
g
f
irm non-slidin
g
pressure a
g
ainst the
bone (Fi
g
ure 27)
.
In
g
eneral, t
h
e tissue is a
h
omo
g
enous pale pink
c
olor,
f
irm to palpation towards the anterior and
l
ateral to t
h
e mi
d
line w
h
ile more compressi
b
le
towar
d
s t
h
e posterior an
d
me
d
ial to t
h
e apices
of
the teeth. The normal
s
tructure
s
o
f
the hard
palate should be identi
f
ied:
•
Incisive papilla – protuberance o
f
so
f
t tissue
w
ith pharyn
g
itis (infection of the pharynx) may
c
over portions o
f
the pharyn
g
eal wall
•
Ulcers, erosions or noticea
b
le enlar
g
ements or
g
rowt
h
s
Anterior and Posterior Pharyngeal Pillars
T
h
e anterior an
d
posterior pillars s
h
oul
d
appear
v
ascular, smoot
h
an
d
s
y
mmetrical. At
y
pical
f
indin
g
s one may encounter include lymphoid
a
gg
re
g
ates (as found on the posterior pharyn
g
eal
w
all), areas of pale scarrin
g
in a radial or stellate
pattern
f
rom tonsillectom
y
, or torn or absent
pillars also a result o
f
this sur
g
ery. Patholo
g
ic
f
indin
g
s include:
•
As
y
mmetr
y
, unless
d
ue to tonsillectom
y
•
Lesions o
f
an
y
kin
d
•
Er
y
t
h
ema associate
d
wit
h
ten
d
erness or
exu
d
ate
s
Tonsillar Crypt
T
h
e tonsils are examine
d
usin
g
d
irect
v
isualization. You will o
b
serve rou
gh
, lo
b
ular,
c
oral to li
g
ht pink tissue o
f
varyin
g
amounts
b
etween t
h
e anterior an
d
posterior p
h
aryn
g
eal
pillars. At
y
pical presentations inclu
d
e excessivel
y
l
ar
g
e or asymmetrical tonsils, cratered sur
f
aces
w
ithout evidence o
f
er
y
thema or exudates.
Occasionally, individuals have lar
g
e crypts in
the tonsils (cr
y
ptic tonsils), which collect food
d
e
b
ris an
d
b
acteria. T
h
is matter ma
y
h
ar
d
en
an
d
b
ecome lo
dg
e
d
in t
h
e crypts. T
h
e
h
ar
d
ene
d
matter may
b
e expelle
d
d
urin
g
cou
gh
in
g
. In
a
dd
ition, patients
h
ave reporte
d
pro
b
lems wit
h
halito
s
i
s
. Careful evaluation i
s
needed to rule out
serious
d
isease states inclu
d
in
g
tonsillar cancer.
Tonsillar cancer ma
y
present as a su
b
tle or more
ob
vious c
h
an
g
e in appearance
d
epen
d
in
g
on
the sta
g
e of this type of cancer.
S
ince increases
h
ave
b
een reporte
d
in tonsillar cancer, t
h
is area
is o
f
particular interest and concern. A
f
ter a
tonsillectom
y
one ma
y
o
b
serve resi
d
ual tonsil
tissue or a re
g
rowth o
f
lymph tissue in the area.
Patholo
g
ic
f
indin
g
s include:
•
Dyspha
g
ia (painful or difficult swallowin
g)
•
S
wellin
g
, erythema, and/or surface exudates
(Fi
g
ure 26
)
•
Eryt
h
ema an
d
/ or
d
ysp
h
a
g
ia may also
b
e
associate
d
wit
h
mout
h
b
reat
h
in
g
an
d
may
in
d
icate a na
s
al o
bs
truction
.
Soft Palate and Uvula
T
h
is area is examine
d
usin
g
d
irect vision an
d
is normall
y
not palpated unless necessar
y
. I
f
Figure 26. Streptococcal infection of the tonsils. Note the
purulent exudate.

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molars (Fi
g
ure 30), the tissue should be a
homo
g
enous pink color and
f
irm to palpatio
n
T
h
e torus palatinus is t
h
e most common at
y
pical
f
indin
g
in this area. These tori may ran
g
e in size
f
rom very small to very lar
g
e. They present as
sin
g
le or multilobular masses (Fi
g
ure 31) and
u
suall
y
have a smooth surface texture. Often
t
h
e lar
g
er tori will
h
ave traumatic ulcers or ot
h
er
traumatic le
s
ion
s
on their
s
ur
f
ace
s.
Tori are not usuall
y
consi
d
ere
d
a pro
b
lem unless
prost
h
etic appliances are
b
ein
g
consi
d
ere
d
.
Tori also make it di
ff
icult to expose intraoral
r
adio
g
raphic
f
ilms. Patholo
g
ic
f
indin
g
s include:
•
Pi
g
mente
d
macules – pi
g
mente
d
lesions
l
in
g
ual to t
h
e maxillary central incisors w
h
ic
h
c
overs the incisive
f
oramen and normall
y
appears re
dd
er t
h
an t
h
e surroun
d
in
g
tissues
(Fi
g
ure 28
)
•
Rap
h
e – sli
gh
tly elevate
d
line exten
d
in
g
f
rom the incisive papilla to the so
f
t palate
(Fi
g
ure 28
)
•
Ru
g
ae – corru
g
ate
d
ri
dg
es ra
d
iatin
g
laterally
f
rom the raphe (Fi
g
ure 28
)
•
Vault – relates to the depth and width o
f
the
palate (Fi
g
ure 29
)
•
Maxillar
y
tu
b
erosities – area
d
istal to t
h
e last
Figure 27. Palpating the hard palate. Use firm
pressure and try not to slide the fingers along the
tissue.
Figure 29. Normal structures of the posterior
hard palate. Observe the dimensions (height and
width) of the vault.
Figure 28. Normal structures of the anterior
hard palate.
Figure 30. Normal maxillary tuberosity.
Figure 31. Extreme example of a multilobulated
torus palatinus.
Image contributed by Dr. Alan Coleman

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bites, ulcers, traumatic fibroma (Fi
g
ure 35
)
•
Leukoplakia associate
d
wit
h
spit to
b
acco
(Fi
g
ure 36
)
•
Neoplastic c
h
an
g
es – eryt
h
roplakia, speckle
d
l
eukoplakia an
d
pi
g
mente
d
lesions
•
Sy
stemic disease states-oral lichen planus,
l
upus, lipomas, ap
h
t
h
ous ulcers, er
y
t
h
ema
multiforme
,
and Crohn’s disease
.
Labial Mucosa
T
h
e la
b
ial mucosa is examine
d
usin
g
d
irect vision
by avertin
g
the tissues over the
f
in
g
ers or thumbs
(Fi
g
ures 37 and 38) followed by bidi
g
ital palpation
of
the tissues o
f
the lips
.
of
an
y
t
y
pe should be identi
f
ied to rule out
melanoma. T
h
e palate is also a common area
f
or unintentional tattoos resultin
g
f
rom pencil
l
ea
d
s
b
ein
g
ja
bb
e
d
into t
h
e tissues w
h
ile
playin
g
wit
h
a pencil or
h
ol
d
in
g
it in t
h
e mout
h.
•
T
h
ermal
b
urns – t
h
e anterior palate is t
h
e
most common area
f
or this t
y
pe o
f
traumatic
injur
y
•
Nicotine stomatitis – whitenin
g
and
f
issurin
g
of
the attached
g
in
g
iva o
f
the hard palate and
in
f
lammation o
f
the minor salivary
g
land ducts
•
Papillary hyperplasia – development o
f
f
in
g
er
-
l
ike projections usually under a poorly
f
ittin
g
f
ull or partial dentur
e
•
Other traumatic lesions – abrasions and
l
acerations resultin
g
f
rom eatin
g
and
f
actitial
injuries
•
Sy
stemic related lesions-lesions related to
l
upus are commonl
y
f
ound in the palate and
the palate is a prime location
f
or the blue
nevu
s.
Buccal Mucosa
T
h
e
b
uccal mucosa is examine
d
usin
g
d
irect an
d
indirect vision
f
ollowed by bi-di
g
ital palpation o
f
t
h
e entire area. Be sure to pull t
h
e tissues awa
y
f
rom the retromolar area and
s
tretch the muco
s
a
away from the muco
g
in
g
ival junction (Fi
g
ures 32
and 33
).
T
h
e
b
uccal mucosa s
h
oul
d
b
e
b
i
d
i
g
itally palpate
d
pressin
g
the tissue between the index
f
in
g
er and
thumb of one hand (Fi
g
ure 34)
.
Normal tissues o
f
the buccal mucosa appear
moist and red. The
y
are so
f
t and pliable on
palpation wit
h
no
d
iscerni
b
le in
d
urations.
S
tensen’s duct should be identified with or without
the presence o
f
a parotid papilla. Linea alba,
For
d
yce’s
g
ranules an
d
leukoe
d
ema are common
atypical
f
indin
g
s on the buccal mucosa. You
ma
y
also
f
eel small papules within the tissues
u
suall
y
indicative o
f
sclerotic or
f
ibrotic minor
salivary
g
lands. Varicosities may o
f
ten present
o
n the buccal mucosa o
f
older patients. The
buccal mucosa is also a prime area
f
or stress
r
elated habits such as cheek chewin
g
(morsicatio
buccarum). Assistin
g
the patient in stress
r
e
d
uction tec
h
niques an
d
provi
d
in
g
awareness
of
the habit is necessary. Patholo
g
ic
f
indin
g
s
a
ss
ociate
d
wit
h
t
h
e
b
uccal muco
s
a inclu
d
e:
•
Traumatic injuries – t
h
ermal
b
urns, c
h
eek
Figure 32. Stretch the tissues making sure you
look under the areas covered by your fingers.
Figure 33. Stretch the tissues away from the
retromolar area.
Figure 34. Palpating the buccal mucosa.

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D
i
g
itally palpate the body o
f
the mandible alon
g
the lin
g
ual and facial surfaces (Fi
g
ure 42)
.
Normal tissues will
b
e a
h
omo
g
enous coral pink
and have a
f
irm consistenc
y
with no visible or
palpa
b
le lesions. Man
d
i
b
ular tori an
d
exostoses
are the most common atypical
f
indin
g
s in this
area. T
h
e retromolar area ma
y
present wit
h
M
ove the ti
ss
ue
s
f
rom
s
ide to
s
ide and vi
s
ualize
the
f
rena. Normal lip tissues are a homo
g
enous
d
eep pink color w
h
ic
h
c
h
an
g
es
g
ra
d
ually to a
d
eep re
d
color wit
h
more prominent vascularit
y
near t
h
e mucola
b
ial ve
s
ti
b
ule. T
h
e ti
ss
ue
s
sh
oul
d
be moist and have uni
f
orm consistenc
y
and
thickness when palpated (Fi
g
ure 39)
.
S
clerotic minor salivary
g
lands are common
atypical
f
indin
g
s as are Fordyce’s
g
ranules.
Patholo
g
ic
f
indin
g
s include the
f
ollowin
g
:
•
Traumatic injuries – a
b
rasions, lacerations
•
Dr
y
, cracke
d
lips
•
An
g
ular c
h
eilitis –
h
uman
h
erpes virus,
C
andida Albican
s
•
Ap
h
t
h
ous ulcers
•
Neoplastic c
h
an
g
es
Mandible
The bod
y
o
f
the mandible will be examined
u
sin
g
direct and indirect vision
f
ollowed by di
g
ital
palpation o
f
the entire structure. The tissues o
f
the
f
loor o
f
the mouth should be stretched awa
y
f
r
o
m th
e
in
fe
ri
o
r b
o
r
de
r
of
th
e
man
d
ibl
e
with a
mouth mirror (Fi
g
ures 40 and 41)
.
Figure 35. Traumatic fibroma associated with
chronic cheek biting. Figure 37. Visual examination of the upper labial
mucosa.
Figure 38. Visual examination of the lower labial
mucosa.
Figure 39. Bidigital palpation of the upper labial
mucosa.
Figure 36. Leukoplakia associated with spit
tobacco.

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Floor of the Mouth
The
f
loor o
f
the mouth is examined usin
g
direct
and indirect vision
f
ollowed b
y
bimanual palpation
of
the entire area. The patient should be asked to
r
aise t
h
e ton
g
ue makin
g
d
irect visual examination
of
the ti
ss
ue
s
toward the midline o
f
the
f
loor o
f
the
mouth possible (Fi
g
ure 44)
.
T
h
e mirror
sh
oul
d
b
e u
s
e
d
to examine t
h
e area
s
n
e
ar th
e
in
fe
ri
o
r b
o
r
de
r
of
th
e
man
d
ibl
e
. Th
e
tissues s
h
oul
d
appear moist an
d
ver
y
vascular.
The normal anatom
y
o
f
the area should be
identified (Fi
g
ure 44) includin
g
:
•
S
ublin
g
ual caruncle – small rounded projection
at the base o
f
the lin
g
ual
f
renum which houses
W
harton’
s
duct
f
rom the
s
ubmandibular
salivary
g
lan
d
•
S
ublin
g
ual folds – two oblique elevations found
r
adiatin
g
laterally away
f
rom the lin
g
ual
f
renum
o
n either
s
ide o
f
the caruncle which hou
s
e the
ducts
f
rom the sublin
g
ual salivary
g
lan
d
•
Lin
g
ual
f
renum – muscle attachment
f
rom the
v
entral sur
f
ace o
f
the ton
g
ue to the
f
loor o
f
the
partially erupted third molars or scarrin
g
f
rom
t
h
ir
d
molar extraction. T
h
is area is also prone
to h
y
perkeratosis
f
rom constant
f
riction
f
rom
masticatory
f
unction. Patholo
g
ic
f
indin
g
s include:
•
Traumatic lesions – ulcers
,
a
b
rasions
•
Infections – pericoronitis (Fi
g
ure 43
)
•
Neoplastic
g
rowt
h
s
•
Leukoplakia associate
d
wit
h
spit to
b
acc
o
Figure 40. Use the mirror to stretch the tissue away
from the inferior border of the mandible.
Figure 41. The mirror is used to visualize the anterior
lingual portion of the mandible.
Figure 42. Use digital palpation pressing the tissues
against the body of the mandible for both the lingual
and the facial aspects.
Figure 44. Visual examination of the floor of the
mouth. Note the normal structures of the area.
Figure 43. Painful pericoronitis surrounding partially
erupted #32.

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•
Traumatic injuries – ulcers (Fi
g
ure 47),
mucoce
l
es
,
•
S
alivary
g
land patholo
g
y – ranula, sialoliths,
en
l
ar
g
emen
t
•
Neoplastic c
h
an
g
es
•
Ankylo
g
lossia – t
h
is is consi
d
ere
d
patholo
g
ic only i
f
it inter
f
eres with the normal
development o
f
proper speec
h
Tongue
T
h
e ton
g
ue is examine
d
usin
g
b
ot
h
d
irect an
d
indirect vision. The most common place
f
or
c
ancer to occur on t
h
e ton
g
ue is t
h
e lateral
border. Grasp the tip of the ton
g
ue with a
g
auze
square an
d
roll t
h
e ton
g
ue over on one si
d
e
to observe the lateral border then repeat
f
or
the other side (Fi
g
ure 48). Use the mirror to
examine the posterior lateral borders i
f
necessar
y
(Fi
g
ure 49)
.
H
ave the patient raise the ton
g
ue to the roo
f
of
the mouth to ob
s
erve the ventral
s
ur
f
ace
(Fi
g
ure 50)
.
mouth. This attachment varies in len
g
th
f
rom
person
t
o person
.
B
imanual intraoral palpation with the index
f
in
g
er
of
the nondominant hand supported extraorall
y
by the
f
in
g
ers o
f
the dominant hand will allow the
c
linician to
f
eel the
s
tructure
s
o
f
the area between
the
f
in
g
ers as they are compressed to
g
ether
g
ently (Fi
g
ures 45 and 46
)
The tissue will be so
f
t on palpation with
f
irmer
areas noted in the area o
f
the suprah
y
oid
muscles (di
g
astric,
g
eniohyoid, mylohyoid).
The sublin
g
ual
f
olds will
f
eel rid
g
e-like and
mo
b
ile. Varico
s
itie
s
are t
h
e mo
s
t common
at
y
pical observation in this area. Other at
y
pical
f
indin
g
s are enlar
g
ed lin
g
ual
f
olds and caruncle
and a short lin
g
ual frenum (ankylo
g
lossia).
A
nkylo
g
lossia is only considered a problem i
f
it
be
g
ins to a
ff
ect the speech development o
f
the
individual. Patholo
g
ic
f
indin
g
s include:
Figure 46. Intraoral view.
Figure 45. Extraoral view of proper palpation
technique.
Figure 47. Traumatic ulcers resulting from intraoral
radiographs.
Figure 48. Examination of the lateral borders of the
tongue.

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mi
g
ratory
g
lossitis (Fi
g
ure 54) and enlar
g
ed
papillae, amon
g
ot
h
ers. A lin
g
ual t
h
yroi
d
may
r
arel
y
be
f
ound on the posterior dorsal sur
f
ace
at the
f
oramen cecum. Lin
g
ual varicosities are
a common
f
indin
g
on the ventral sur
f
ace o
f
the
ton
g
ue, especially in ol
d
er patients
.
The ton
g
ue is the most common intraoral site
f
or
o
ral cancer. There
f
ore, any si
g
n o
f
patholo
g
y
should be investi
g
ated thorou
g
hly.
S
ome of the
patholo
g
ical
f
indin
g
s that are
f
ound on the ton
g
ue
inclu
de
:
•
Hairy ton
g
ue –
f
ili
f
orm papilla become
elon
g
ated due to a variety o
f
reasons
f
rom
o
veruse o
f
mouth rinses to not cleanin
g
the
ton
g
ue a
d
equately
.
•
Candidiasis – fun
g
al infection of the ton
g
ue
of
ten associated with deeply
f
issured ton
g
ues
.
•
Glossitis – inflammation of the ton
g
ue due to
anemia
,
nutritional de
f
iciencies and others
.
It is also important to note i
f
the ton
g
ue is coated
w
ith dental bio
f
ilm or dental plaque. The ton
g
ue
is home to the hi
g
hest number o
f
bacteria
f
ound
in an
y
w
h
ere in t
h
e oral cavit
y
. Bacteria locate
d
on
t
h
e ton
g
ue
h
ave
b
een associate
d
wit
h
h
alitosis,
increased pH o
f
the saliva, and periodontal
disease. Ton
g
ue cleanin
g
and methods o
f
c
leanin
g
t
h
e ton
g
ue s
h
oul
d
b
e stresse
d
d
urin
g
patient e
d
ucation
.
T
h
e tissues s
h
oul
d
appear pink in color wit
h
a
r
ou
g
h sur
f
ace texture on the dorsal sur
f
ace and a
s
moother
s
ur
f
ace texture on the ventral
s
ur
f
ace.
T
h
e ton
g
ue s
h
oul
d
b
e symmetrical in s
h
ape an
d
in
f
uncti
o
n
.
U
se a
b
i
d
i
g
ital tec
h
nique to palpate t
h
e entire
ton
g
ue between the
f
in
g
er and thumb o
f
one
hand (Fi
g
ure 51)
.
The tissues o
f
the ton
g
ue should
f
eel so
f
t and
r
esilient wit
h
no palpa
b
le in
d
urations or masses.
The clinician should identi
fy
the normal anatom
y
of
the ton
g
ue includin
g
:
•
Dorsal surface – papillae (filiform, fun
g
iform,
c
ircumvallate
)
, median sulcus, sulcus
term
i
na
lis
•
Lateral borders –
f
oliate papilla
e
•
Ventral sur
f
ace – lin
g
ual veins, plica
f
imbriata,
l
in
g
ual
f
renum
A
typical
f
indin
g
s on the dorsal sur
f
ace o
f
the
ton
g
ue are common. They include:
f
issurin
g
(Fi
g
ure 52), scallopin
g
(Fi
g
ure 53), beni
g
n
Figure 49. Proper use of the mirror to aid in the visual
examination of the tongue.
Figure 51. Grasp the tip of the tongue with
gauze while palpating the body of the tongue.
Figure 50. Visually examine the ventral surface of the
tongue.

1
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areas. Less than 1 mm o
f
attached
g
in
g
iva
is consi
d
ere
d
to
b
e ina
d
equate in most
c
ases and the patient should be re
f
erred to a
periodontist
f
or evaluation o
f
the a
ff
ected area
.
•
Muco
g
in
g
ival involvement – areas wit
h
no
attached
g
in
g
iva or areas o
f
extreme recessio
n
•
Frena problems – ti
g
ht
f
renum attachments or
pu
ll
s
•
Traumatic lesions – ulcers
,
a
b
rasions
,
b
urns
•
Mucosal
d
isease states suc
h
as lic
h
en planus,
Attached Gingiva
The attached
g
in
g
iva o
f
the maxillary and
man
d
i
b
ular arc
h
es is visually examine
d
usin
g
b
ot
h
d
irect an
d
in
d
irect vi
s
ion. T
h
e ti
ss
ue
s
s
h
oul
d
appear pale pink an
d
h
omo
g
enous in color
and texture (Fi
g
ure 55). Followin
g
the visual
examination, t
h
e attac
h
e
d
g
in
g
iva is palpate
d
u
sin
g
a
d
i
g
ital tec
h
nique as s
h
own in Fi
g
ure 56
.
The tissue should
f
eel
f
irm to touch and ti
g
htly
attac
h
e
d
to t
h
e
b
one. T
h
e most common at
y
pical
f
indin
g
in the area o
f
the attached
g
in
g
iva is
exostoses (Fi
g
ure 57)
.
Patholo
g
ic
f
indin
g
s include:
•
Inadequate zones o
f
attached
g
in
g
iva – the
c
linician should determine the presence o
f
adequate amounts o
f
attached
g
in
g
iva in all
Figure 52. Fissured tongue.
Figure 55. Normal attached gingiva, facial surfaces of
the maxilla and mandible.
Figure 56. Digital palpation of the mandibular facial
attached gingiva.
Figure 57. Extensive exostoses on the maxillary facial
surfaces.
Figure 53. Scalloped tongue.
Figure 54. Benign migratory glossitis.

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to t
h
e la
b
oratory w
h
ere pat
h
olo
g
ists use
b
ot
h
c
omputer assiste
d
an
d
stan
d
ar
d
met
h
o
d
s to
evaluate the sample
f
or the presence o
f
abnormal
c
ells. The brush biops
y
cannot render a de
f
initive
d
ia
g
nosis,
b
ut will
g
ive t
h
e practitioner more
c
onclu
s
ive evidence o
f
f
urther abnormalitie
s
s
uc
h
a
s
a
b
normal cell
s
t
h
at
h
ave
b
een
d
etecte
d
.
Positive results woul
d
warrant a sur
g
ical
b
iopsy.
(www.oralcdx.com)
Direct
Op
tical Fluorescence Visualizatio
n
Technology
(
VELscope
)
T
h
e VELscope is a
h
an
d
h
el
d
d
evice t
h
at excites
the tissue causin
g
it to
f
luoresce. Normal, healthy
tissue will appear pale
g
reen w
h
en expose
d
to
t
h
e emitte
d
b
lue li
gh
t, an
d
w
h
en t
h
e tissue is not
normal, t
h
e color will
b
e
d
arker
g
reen to
b
lack.
No pre-rinse is use
d
wit
h
t
h
is a
d
junct. T
h
e
d
evice
has been
f
ound use
f
ul especiall
y
to delineate
sur
g
ical mar
g
ins t
h
at may exten
d
b
eyon
d
t
h
e
v
isi
b
le lesion mar
g
ins. W
h
en t
h
ere is a
h
i
gh
de
g
ree o
f
in
f
lammation, such as in the case o
f
l
ic
h
en planus, mucous mem
b
rane pemp
h
i
g
oi
d
,
pemp
h
i
g
us vul
g
aris, lupus, etc. t
h
e tissue may
appear dark; thereby, producin
g
a
f
alse positive
r
esult. An
y
t
y
pe o
f
in
f
lammator
y
process such as
ch
eek c
h
ewin
g
, etc. will also ex
h
i
b
it a
d
arker color
ch
an
g
e. (www.velsco
p
e.com)
Vi
z
i
L
i
te and V
i
z
i
L
i
te Plu
s
w
i
th TBlu
e
T
h
e ViziLite
d
evice
h
as several components.
T
h
e patient rinses wit
h
one percent acetic
acid
f
or 30-60 seconds
f
ollowed b
y
the use o
f
a Chemiluminescence li
g
ht. The li
g
ht stick is
especially bene
f
icial in identi
f
yin
g
white and
erythroleukoplakia lesions. A
f
ter the li
g
ht stick
is
b
roken an
d
s
h
aken, it is place
d
next to all
v
i
s
ible oral
s
o
f
t ti
ss
ue
s
ur
f
ace
s
. The device will
c
ause illumination o
f
an
y
leukoplakia and/or
eryt
h
roleukoplakia lesions causin
g
t
h
em to appear
pemp
h
i
g
us vul
g
aris, mucous mem
b
rane
pemp
h
i
g
oi
d
, lupus, an
d
aller
g
ic type
r
esp
o
nses
.
Salivary Flow and Consistency
S
alivar
y
flow and consistenc
y
will var
y
with
each patient.
S
ome abnormal findin
g
s must
be noted such as
f
roth
y
saliva or thick rop
y
saliva. Xerostomia s
h
oul
d
b
e suspecte
d
b
ase
d
o
n in
fo
rmati
o
n c
o
ll
e
ct
ed
f
r
o
m th
e
m
ed
ical/
de
ntal
histories.
S
ometimes patient’s perception of
d
r
y
ness must
b
e assesse
d
as well. T
h
e patient
ma
y
voice a concern o
f
overall oral dr
y
ness,
w
hile the actual
f
low o
f
saliva appears normal.
The mixture o
f
s
erou
s
and mucou
s
s
aliva
a
ff
ects the perception o
f
dr
y
ness as well. When
problems arise with the parotid
g
land, the
f
low
f
rom
S
tensen’s duct will be diminished. Milkin
g
the salivary
g
lands
f
rom the tail toward the mid
l
ine assists t
h
e clinician in visually assessin
g
t
h
e
S
tensen’s duct orifice found next to the maxillar
y
f
ir
s
t molar
.
Gauze should be used to dr
y
the floor of the
mouth and visuall
y
asses the
f
low
f
rom the
W
harton’
s
duct ori
f
ice and other duct
s
o
f
both the
sublin
g
ual and submandibular
g
lands (Fi
g
ure 58
and 59
).
Adjuncts for the Oral Cancer Screening
OralCDx
®
xx
Brush Test
®
T
h
e
b
rus
h
b
iops
y
is consi
d
ere
d
an a
d
junct
d
ia
g
nostic tool w
h
ic
h
uses a patente
d
spiral
-
shaped sti
ff
brush to remove epithelial cells
f
or
examination by a patholo
g
ist. The brush is
f
irmly
r
olle
d
over t
h
e lesion until
b
lee
d
in
g
points are
ob
serve
d
si
g
nalin
g
t
h
e epit
h
elial tissues
h
ave
b
een penetrate
d
. T
h
e cells cau
gh
t up on t
h
e
brush are wiped o
ff
on a
g
lass slide and sent
Figure 58 and 59. Using gauze to dry the area and watching the flow by pressing above
Stenson’s duct is a good indicator of salivary flow.

20
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Education Course, February 19, 2009
t
h
e i
d
eal clinical environment an
d
expectations
sometimes chan
g
e the
f
urther away we
g
et
f
rom
those formative years. Our sequence may chan
g
e,
o
ur remembrance o
f
key points may become va
g
ue
an
d
t
h
e pressure to keep a sc
h
e
d
ule makes t
h
e
dental exam less likel
y
to be per
f
ormed in total.
This CE course has been presented in a lo
g
ical
sequence wit
h
ke
y
points relate
d
to normal an
d
abnormal
f
indin
g
s
.
W
e
h
ave also inclu
d
e
d
some
d
ocuments t
h
at ma
y
be used in an o
ff
ice to make the patient aware that
a complete exam has been per
f
ormed:
•
A
ppendix A. Your Oral Cancer Screenin
g
E
xa
m
– A
f
orm that may be used statin
g
that
y
our dental pro
f
essional has just per
f
ormed
an oral cancer screenin
g
exam as part o
f
your
dental o
ff
ice visit toda
y.
•
A
ppendix B. Oral Cancer Screenin
g
For
m
–
A
f
orm that ma
y
be used when an abnormal
f
indin
g
needs
f
urther investi
g
ation
f
rom another
spec
i
a
li
st
.
•
App
endix C. Referral Form for Oral
P
atholo
g
ist and/or Oral Sur
g
eo
n
– A
fo
rm that
ma
y
be used when an area o
f
concern should
be
f
urther evaluated b
y
a specialist
.
Ever
y
one will
h
ave t
h
eir own tec
h
niques an
d
approac
h
es to a
d
ental exam;
h
owever, tellin
g
t
h
e
patient what is bein
g
per
f
ormed is a key part o
f
the total exam.
S
ince man
y
patients do not know
t
h
at t
h
ey are
g
ettin
g
an oral cancer screenin
g
, we
believe that this point should be stated.
S
ome
off
ices
g
ive patients a button/brochure statin
g
that
t
h
ey
h
ave
h
a
d
an oral cancer screenin
g
; t
h
ere
b
y,
c
allin
g
attention to the
f
act that the exam is vitally
important. The buttons can be obtained
f
rom the
Oral Cancer Foundation at (www.oralcancer.or
g
)
.
2
8
bri
g
ht white. T-Blue is a part o
f
the plus system
an
d
contains p
h
armaceutical
g
ra
d
e tolonium
ch
lori
d
e, w
h
ic
h
is a tolui
d
ine-
b
lue
dy
e t
h
at stains
the nuclear cell material blue. The u
s
e o
f
the
T-Blue assists in
f
urther delineatin
g
the extent/
mar
g
ins o
f
any detected lesions. This is an FDA
approve
d
pro
d
uct. (www.vizilite.com)
Radiographs and
O
ral Photograph
y
R
a
d
io
g
rap
h
s an
d
oral p
h
oto
g
rap
h
y are important
a
d
juncts w
h
ic
h
can
b
e utilize
d
to compare
c
han
g
es in tissue. This is especially bene
f
icial
in cases where severe in
f
lammation is present.
M
an
y
mucosal diseases have an in
f
lammator
y
c
omponent an
d
some a
d
junct
d
evices
d
o not
present any conclusive evi
d
ence supportin
g
anythin
g
other than in
f
lammation with a
f
ailure to
r
ender a de
f
initive dia
g
nosis. At the same time,
becau
s
e the in
f
lammation i
s
a con
s
tant in
s
ome
c
ases,
f
requent biops
y
ma
y
not be appropriate
eit
h
er since constant
b
iopsies are not t
h
e optimal
f
orm of treatment. Often tissue specimens ma
y
r
eturn as dia
g
nosed “non-speci
f
ic ulcerative
tissue” an
d
crucial areas ma
y
b
e misse
d
d
ue
to excessive in
f
lammation. Bein
g
able to
c
ompare di
g
ital ima
g
es o
f
the lesion provides the
practitioner the added bene
f
it o
f
actually seein
g
the pro
g
ression or extension o
f
the lesion. An
added bene
f
it is bein
g
able to show the patient
any pro
g
ression w
h
en su
gg
estin
g
t
h
ey nee
d
to have a biopsy. Oral photo
g
raphy is hi
g
hly
bene
f
icial as a ke
y
part o
f
the patient’s permanent
r
ecor
d
a
s
well
.
Conclusions
T
h
is course
h
as
b
een presente
d
as an
enhancement to the skills o
f
practicin
g
dentists
and hy
g
ienists. We learn to per
f
orm a complete
exam
d
urin
g
our e
d
ucational pro
g
rams,
b
ut

21
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g
Education Course, February 19, 2009

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
Appendix A. Your Oral Cancer Screening Exam
Appendix B. Oral Cancer Screening Form
The Oral Screenin
g
Form is presented to the patient at the time of an oral cancer screenin
g.

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22
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Oral-B at dentalcare.com Continuin
g
Education Course, February 19, 2009
Appendix C. Referral Form for Oral Pathologist and/or Oral Surgeon

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23
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Course Test Preview
To receive Continuin
g
Education credit for this course, you must complete the online test. Please
g
o to
w
ww.dentalcare.com and find this course in the Continuin
g
Education section.
1. As you examine the TM joint you notice an altered opening pathway which has its greatest
distance from the midline at maximum opening. This defines which one of the following
terms?
a. Crepitus
b
. D
e
viati
on
c
. D
ef
l
e
cti
on
d.
S
ubluxatio
n
e. Deran
g
emen
t
2. Which of the following is associated with arthritis of the TM joint?
a. p
op
b
. click
c
. crep
i
tus
d
.
b
ruxi
s
m
e. missin
g
teet
h
3. All of the following structures would be noted when examining the oropharynx EXCEPT
ONE. Which one is the EXCEPTION?
a. ton
sils
b
. a
d
enoi
ds
c
. tons
ill
ar cr
y
p
t
d
. anterior/posterior pillars
e. posterior p
h
aryn
g
eal wall
4. Which of the following findings is a definitive indication of an infection of the tonsils?
a. post nasal
d
ri
p
b
. enlar
g
e
d
tonsils
c
. cratere
d
ton
s
il
s
d
. purulent exu
d
at
e
e. non-ten
d
er er
y
t
h
ema
5. Diminished swallowing capabilities are associated with a higher risk of which of the
following?
a. bi
f
i
d
uvula
b. lo
ss
o
f
f
unctio
n
c
. aspiration o
f
f
oo
d
d. candida in
f
ection
s
e. excess
i
ve
l
y
l
on
g
uvu
l
a
6. Which of the following techniques would be best for palpating the hard palate?
a.
d
i
g
ital
b
.
b
i
d
i
g
ital
c
.
b
ilat
e
ral
d
.
b
imanual
e. au
s
cu
l
tat
i
o
n

2
4
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7. Which one of the following is a common atypical finding in the area of the hard palate?
a. t
he
rmal
b
ur
n
b
. torus palatinus
c
. muco
s
al a
b
ra
s
io
n
d
. nicotine
s
tomatiti
s
e. papillar
y
hy
perplasia
8. Stensen’s duct is associated with which of the following glands?
a.
b
uccal
b
. paroti
d
c
. su
b
lin
g
ual
d
.
s
u
b
man
d
i
b
ular
e. su
b
lin
g
ual caruncl
e
9. Which one of the following conditions would be considered pathologic?
a. lin
e
a al
b
a
b
. varico
s
itie
s
c
. l
e
uk
oede
ma
d
. er
y
t
h
roplakia
e. For
d
yce’s
g
ranules
10. Which of the following techniques would be appropriate for palpating the buccal and labial
mucosa?
a.
d
i
g
ital
b
.
b
i
d
i
g
ital
c
.
b
ilat
e
ral
d
.
b
imanual
e
. un
il
at
e
ra
l
11. When examining the body of the mandible you would use the mouth mirror to stretch the
mucosal tissues away from the inferior border, BECAUSE you might miss a lesion which is
tucked up into a fold of tissue.
a. Bot
h
t
h
e
s
tatement an
d
t
h
e rea
s
on are correct an
d
relate
d.
b. Both the statement and the reason are correct but NOT related
.
c
. T
h
e
s
tatement i
s
correct
b
ut t
h
e rea
s
on i
s
not
.
d. The statement is NOT correct
,
but the reason is correct
.
e. NEITHER the statement NOR the reason is correct
.
12. All of the following are common atypical findings in the body of the mandible and the
retromolar area EXCEPT one. Which one is the EXCEPTION?
a. t
o
r
i
b
. scarrin
g
c
. per
i
coron
i
t
i
s
d
.
hy
perkeratosis
e. Partiall
y
erupte
d
t
h
ir
d
molars
.
13. Which of the following techniques would be best when palpating the structures of the floor
of the mouth?
a.
d
i
g
ital
b
.
b
i
d
i
g
ital
c
.
b
ilat
e
ral
d
.
b
imanual
e. Fin
g
er and thumb o
f
the same hand
.

25
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Education Course, February 19, 2009
14. Which of the following is the most common intraoral site for oral cancer development?
a. uvu
l
a
b
. ton
g
u
e
c
.
h
ar
d
palat
e
d
.
b
uccal muco
s
a
e
. Fl
oo
r
of
th
e
m
o
uth
.
15. Which of the following findings associated with the tongue is caused by an error in
development?
a.
f
issurin
g
b
. scallopin
g
c
.
h
airy ton
g
u
e
d. plica
f
imbriata
e. lin
g
ual t
h
yroi
d
16. The most appropriate adjunct device to use when determining surgical margins would be:
a. The Orascoptic DK
b. The OralDx
®
Bru
sh
Te
st
c
. ViziLite Plu
s
wit
h
TBlu
e
d
. Visual assessment an
d
t
h
e VELscop
e
e. VELscop
e
17. The perception of dryness may depend upon all of the following except which one?
a. The amount o
f
saliva actuall
y
present
.
b. The amount o
f
s
erou
s
s
aliva
.
c
. The amount o
f
mucou
s
s
aliva
.
d. The salt/calcium composition o
f
the saliva
.
e. The consistenc
y
o
f
the saliva
.
18. The classification of a general appraisal as part of the dental exam is stated in three forms.
The typical form would include which of the following:
a. stipple
d
g
in
g
iva
b
. For
d
yce
g
ranules
c
. l
e
uk
oede
ma
d
.
g
enetic pi
g
mentatio
n
e
. B
o
t
h
b
an
d
c
19. Abnormal findings of the angles of the mouth or commissures, angular cheilitis or Perleche’
may indicate all of the following with one exception: Which is the exception?
a. Nutritional De
f
icienc
y
b. Candida albican
s
c
. Human
h
erpes 1 or
2
d. Lo
ss
o
f
dimen
s
io
n
e. Aller
g
y type responses to
f
oods
.
20. A symblepharon discovered during an extraoral exam would be found in the/on the:
a.
e
ar
b
. no
se
c
. n
e
c
k
d
. e
ye
e.
lip

2
6
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Education Course, February 19, 2009
21. If a symblepharon is discovered, the patient would need to be scheduled with a/ an:
a. Oral Sur
g
eo
n
b. Oral Patholo
g
is
t
c
. Immunolo
g
y
S
pecialis
t
d. Ophthalmolo
g
is
t
e. Dermatolo
g
is
t
22. The most commonly known risk factors for oral cancer that cannot be controlled for with
lifestyle changes is:
a. alc
oho
l
b
. t
ob
acc
o
c
.
d
i
et
d
. a
ge
e. sunli
ght
23. Patients with known risk factors should be screened ____________.
a. at norma
l
ma
i
ntenance v
isi
t
s
b. at more
f
requent intervals
c
. at an
y
time t
h
at an a
b
normalit
y
is notice
d
by
t
h
e patien
t
d
. at
y
earl
y
visits
e. at every visit and encoura
g
ed to per
f
orm sel
f
-exams and report any abnormality
24. A known viral risk factor for oral cancer is:
a. HIV
b
. HPV
c
. HV
C
d
. HVB
e
. B
o
t
h
a an
d
b
25. ______ oropharyngeal cancers are squamous cell carcinomas.
a. 5
0%
b
. 7
0%
c
.
80%
d
.
90%
e. Most orop
h
aryn
g
eal cancers are not squamous cell
.
26. Oral cancer may appear as:
a. a w
h
ite le
s
io
n
b
. a re
d
an
d
w
h
ite le
s
io
n
c
. a pi
g
mente
d
lesio
n
d
. an ulcer-like le
s
ion
s
e. Oral cancer ma
y
have multiple appearances
.
27. Salivary gland tumors, lymphoma, and sarcoma-related cancers comprise what percentage
of oropharyngeal cancers?
a. 1
0%
b
. 2
0%
c
.
30%
d
. 4
0%
e. 5
0%

27
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Education Course, February 19, 2009
28. The most common reason for the failure to detect oral cancer in a young person is:
a. T
h
e tissue
h
as a varie
d
appearance
d
epen
d
in
g
upon a
g
e
.
b
. Youn
g
people
d
o not seek treatment as rea
d
ily as ol
d
er populations
.
c
. Clinicians do not suspect cancerous chan
g
es in youn
g
individuals
.
d. Cancer does not pro
g
ress as rapidly with youn
g
individuals
.
e. Youn
g
er in
d
ivi
d
uals usually
d
evelop cancer in t
h
e tonsil re
g
ion makin
g
it virtually un
d
etecta
b
le
.
29. Debris found in the tonsil is referred to as:
a. enlar
g
e
d
tonsils
b
. ton
s
illiti
s
c
. streptococca
l
tons
il
s
d
. cr
y
ptic tonsils
e. ton
sill
ar cancer
30. The most common place for cancer to occur on the tongue is:
a. the dor
s
al
s
ur
f
ac
e
b
. t
h
e circumvallate papilla
e
c
. t
he
lat
e
ral
bo
r
de
r
d
. t
h
e ti
p
e. the ventral
s
ur
f
ac
e

28
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Education Course, February 19, 2009
References
1
. American Cancer Society: Cancer Facts and Fi
g
ures. (Accessed on October 25th, 2008)
.
2. Bi
g
elow C, Patton LL, Strauss RP, Wilder RS. North Carolina dental hy
g
ienists’ view on oral cancer
c
ontrol. J Dent Hy
g
. 2007 Fall;81(4):83. Epub 2007 Oct 1
.
3
. Burzynski NJ, Rankin KV, Silverman S Jr, Scheetz JP, Jones DL. Graduatin
g
dental students’
perceptions of oral cancer education: results of an exit surve
y
of seven dental schools. J Cancer
Educ. 2002
S
ummer;17
(
2
)
:83-4
.
4. Delon
g
L, Burkhart N. General and Oral Patholo
g
y for The Dental Hy
g
ienist. Lippincott, Williams &
W
ilkin
s
. Baltimore. 2007
.
5. Forrest JL, Horowitz AM,
S
hmuely Y. Dental hy
g
ienists’ knowled
g
e, opinions, and practices related
to oral and pharyn
g
eal cancer risk assessment. J Dent Hy
g
. 2001 Fall;75(4):271-81
.
6
. Cannick GF, Horowitz AM, Drury TF, Reed SG, Day TA. Assessin
g
oral cancer knowled
g
e amon
g
dental students in South Carolina. J Am Dent Assoc. 2005 Mar;136
(
3
)
:373-8
.
7
. Healthy People 2010 Pro
g
ress Review: Oral Health. (March 17,2004) U.S. Department of Health
and Human
S
ervices
,
Public Health
S
ervice
.
8. Horowitz AM, Siriphant P, Canto MT, Child WL. Maryland dental hy
g
ienists’ views of oral cancer
prevention and early detection. J Dent Hy
g
. 2002
S
ummer;76(3):186-91
.
9
. Horowitz AM, Drury TF, Goodman HS, Yellowitz JA. Oral pharyn
g
eal cancer prevention and early
detection. Dentists’ opinions and practices. J Am Dent Assoc. 2000 Apr;131(4):453-62
.
1
0. Lin
g
H, Gadalla S, Israel E, Lan
g
enber
g
P, et al. Oral cancer exams amon
g
ci
g
arette smokers in
M
ar
y
land. Cancer Detect Prev. 2006;30(6):499-506. Epub 2006 Nov 20
.
1
1. Llewell
y
n CD, Johnson NW, Warnakulasuri
y
a S. Factors associated with dela
y
in presentation
amon
g
youn
g
er patients with oral cancer.Oral Sur
g
Oral Med Oral Pathol Oral Radiol Endod. 2004
Jun;97
(
6
)
:707-13
.
1
2. Lehew CW, Kaste LM. Oral cancer prevention and early detection knowled
g
e and practices of
Illinois dentists--a brief communication. J Public Health Dent. 2007
S
prin
g
;67(2):89-93
.
1
3. Lynch DP, Oral cancer risk and detection. The importance of screenin
g
technolo
g
y. RDH Sept 2007,
10
1
0
-112
.
1
4. Massano J, Re
g
ateiro FS, Januário G, Ferreira A. Oral squamous cell carcinoma: review of
pro
g
nostic and predictive factors. Oral Sur
g
Oral Med Oral Pathol Oral Radiol Endod. 2006
Jul;102(1):67-76. Epub 2006 Jan 10
.
1
5. National Cancer Institute, Surveillance, epidemiolo
g
y, and end results pro
g
ram public-use-data,
1
973-1998. Rockville, Md.: National Cancer Institute, Division of Cancer Control and Population
S
ciences, Surveillance Research Pro
g
ram, Cancer Statistics Branch; 2001
.
1
6. Patton LL, A
g
ans R, Elter JR, Southerland JH, et al. Oral cancer knowled
g
e and examination
experiences amon
g
North Carolina adults. J Public Health Dent. 2004 Summer;64(3):173-80
.
1
7. Sciubba JJ. Oral cancer and its detection. History-takin
g
and the dia
g
nostic phase of mana
g
ement.
J Am Dent Assoc. 2001 Nov;132
S
uppl:12
S
-18
S.
1
8. Tomar
S
L, Lo
g
an HL. Florida adults’ oral cancer knowled
g
e and examination experiences. J Public
H
ealth Dent. 2005 Fall;65
(
4
)
:221-30
.
1
9. Rhodus NL. Oral cancer: Earl
y
detection and prevention. Inside Dentistr
y
, Januar
y
3:1, 2007
.
20. Schantz SP, Yu GP. Head and neck cancer incidence trends in youn
g
Americans, 1973-1997, with a
special analysis for ton
g
ue cancer. Arch Otolaryn
g
ol Head Neck Sur
g
. 2002 Mar;128(3):268-74
.
21. Sie
g
el MA, Kahn MA, Palazzolo MJ. Oral cancer: a prosthodontic dia
g
nosis. J Prosthodont. 2009
Jan;18
(
1
)
:3-10
.
22.
S
ilverman
S
Jr. Demo
g
raphics and occurrence of oral and pharyn
g
eal cancers. The outcomes, the
trends, the challen
g
e. J Am Dent Assoc. 2001 Nov;132
S
uppl:7
S
-11
S.
23. Yu T, Wood RE, Tenenbaum HC. Delays in dia
g
nosis of head and neck cancers. J Can Dent Assoc.
2008 Feb;74
(
1
)
:61
.
24. Warren-Morris D, Wade P. Oral cancer exams: Does
y
our practice pass? Tex Dent J. 2006
Jun;123
(
6
)
:494-9
.
25. Ma
g
uire BT, Roberts EE. Dentists’ examination o
f
the oral mucosa to detect oral cancer. J Public
H
ealt
h
Dent 1994
;
53:115
.

2
9
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re
st
®
Oral-B at dentalcare.com Continuin
g
Education Course, February 19, 2009
26. La Vecchia C, Lucchini F, Ne
g
ri E, Levi F. Trends in oral cancer mortality in Europe. Oral Oncol.
2004 Apr;40(4):433-9
.
27. Case study shows dental hy
g
ienists can be essential to early detection of oral cancer. Case Western
R
eserve Universit
y
. 2004
.
28. The Oral Cancer Foundation
.
About the Authors
Nancy W. Burkhart, BSDH, MEd, EdD
D
r. Burkhart received a Bachelor of
S
cience de
g
ree in dental hy
g
iene from
Fairlei
g
h Dickinson University
S
chool of Dentistry, a Master of Education de
g
ree
f
rom North Carolina State Universit
y
in Occupational Health Education, a Doctor
o
f Education de
g
ree From North Carolina State University in Adult Education/
Interdisciplinar
y
studies.
S
he conducted a one-
y
ear postdoctoral fellowship in the
section of Oral Patholo
g
y at the University of North Carolina School of Dentistry
in Chapel Hill. Her dissertation topic was
“
Oral Lichen Planus Commonalities:
Educational and Psychological Implications.”
Dr. Burk
h
art is an A
d
junct Associate
”
Professor and Educational Consultant in the Department of Periodontics/Stomatolo
g
y at The Baylor
C
olle
g
e of Dentistry where she has been a faculty member since 1997. She is a faculty Co-Host of
the International Oral Lichen Planus Support Group. In addition to foundin
g
the International Support
Group for Oral Lichen Planus, Dr. Burkhart has presented papers both nationall
y
and internationall
y
on
Oral Lichen Planus/ Mucosal Diseases and has published articles in national dental journals. She is
co
-auth
o
r
of
“General and Oral Pathology for the Dental Hygienist”
published in 2007 through Lippincott,
”
W
illiams & Wilkins. She was a 2006 recipient of the ADHA Crest Award throu
g
h Proctor and Gamble.
A
s a columnist
f
or RDH, she writes a monthl
y
column titled,
“Oral Exams”
for the Pennwell publication.
”
E-mail: nburkhart@bcd.tamhsc.ed
u
Leslie DeLong, RDH, AS, BSHS, MHA
Leslie DeLon
g
is an Associate Pro
f
essor o
f
Dental Hy
g
iene at the Lamar Institute o
f
Technolo
g
y in
B
eaumont, Texas.
S
he received an Associate of
S
cience de
g
ree in Dental Hy
g
iene from Middlesex
C
ommunity Colle
g
e, a Bachelor of Science de
g
ree in Health Science from Northeastern University and
a Master of Health Administration de
g
ree from Clark University. She has been the First Year Clinic
C
oordinator for the Dental Hy
g
iene Pro
g
ram at Lamar since 1991. Leslie has tau
g
ht Oral Patholo
g
y and
H
ead and Neck Anatomy and is currently teachin
g
both clinical and didactic sections of the Pre-Clinical
D
ental Hy
g
iene and Introductory Clinic courses. Leslie co-authored
“
Oral Exams: Are You Performin
g
a Complete Exam”
for RDH magazine. She is co-author of
”
G
eneral and Oral Patholo
g
y for the Dental
H
y
gi
en
i
s
t
released in October 2007 through Lippincott, Williams & Wilkins.
t
Lamar Institute o
f
Technolo
g
y
,
A
llied Health and
S
ciences
E-mail: leslie.delon
g
@lit.ed
u
Acknowledgements
Our thanks are extended to the followin
g
individuals for their help in the production of this course
.
•
Ms. Casey Buentello, Senior Dental Hy
g
iene Student at Lamar Institute of Technolo
g
y in Beaumont,
Texas. Ms. Buentello is the patient depicted in most o
f
the ima
g
es
.
•
Ms. Elizabeth Carter, Senior Dental Hy
g
iene Student at Lamar Institute of Technolo
g
y in Beaumont,
Texas. Ms. Carter performed the role of operator in most of the ima
g
es
.
•
Ms. Ruth Fearin
g
-Tornwall, Associate Pro
f
essor o
f
Dental Hy
g
iene at Lamar Institute o
f
Technolo
g
y
in Beaumont, Texas. Ms. Tornwall provi
d
e
d
muc
h
nee
d
e
d
tec
h
nical assistance wit
h
settin
g
up an
d
posin
g
the patient and operator
f
or each o
f
the ima
g
es
.