• See Chapters 6, General and Oral Pathology: common conditions and diseases in dental setting; 8, Microbiology and Immunology: vaccinations, infectious diseases; 9, Pharmacology: antibiotic premedication; 10, Medical and Dental Emergencies: medical history, physical status classification (ASA), high blood pressure.

A. Medical history: review of physical health status.

1. Includes statement of chief complaint (CC), history of present and past illness, drug history.

2. Need for medical consult and antibiotic and/or antianxiety premedication require special precautions or antibiotic premedication MUST be assessed.

3. Information obtained by:

a. Questionnaire vs. interview:

(1) Questionnaire: saves time, consistent, potentially MORE thorough; however, inflexible and LACKS opportunity for development of rapport with patient; impersonal.

(2) Interview: flexible and personable; requires good communication skills; enhances the relationship-building process between patient and clinician; time consuming and may cause embarrassment.

(3) Combining BOTH interview and questionnaire achieves practical results and thoroughness by allowing clinician to get additional clarification and information on positive responses.

b. Subjective vs. objective information:

(1) Subjective information: impressions, feelings, attitudes from patient and clinician; patient reports (symptoms), e.g., nausea, and clinician’s observations of patient, e.g., flushed skin.

(2) Objective information: concrete notes, facts, data (signs), test results.

B. Health status: notation of existing and previous conditions.

1. Includes chief complaint (CC) and formation of physical classification status (American Society of Anesthesiologists [ASA]):

a. CC: statement in patient’s own words of why he or she is seeking dental care.

b. Formation of ASA status: reduces risk of emergency occurring during treatment.

c. History of present illness; may influence future treatment options and setting.

(1) Includes description of current complaint and its signs, symptoms, onset, duration, intensity, location, as well as related drug therapies.

(2) May influence or contraindicate certain dental procedures.

d. History of past illness includes:

(1) Diseases that complicate dental treatment or might require special precautions or antibiotic premedication before treatment.

(2) Allergy or untoward reactions to drugs.

(3) Diseases and drugs with oral signs.

(4) Communicable diseases.

(5) Physiological and psychological state.

e. Includes common medical conditions noted on medical history forms; as a result may need medical consult.

(1) Confirming fax is recommended from involved healthcare professionals.

C. Medically compromised patients who can be seen in a dental setting but need major modification of dental treatment and/or need medical consult (drug history discussed next):

1. Patient with cardiovascular disease (CVD):

a. Has inadequate blood circulation to heart muscle, resulting from arteriosclerosis, blocking or narrowing of blood vessels; MUST be ready for an emergency.

b. Possibly reports angina pectoris caused by muscle pain that radiates to left arm and jaw; experiences pain with exertion and anxiety; discomfort is relieved by rest and vasodilator nitroglycerin (NTG, Nitrostat); request that patient bring NTG to dental appointment; have readily available during treatment.

c. May use antihypertensives (includes diuretics, adrenergic blockers) that may result in xerostomia.

d. Patient after myocardial infarction (MI, heart attack): attack resulted from insufficient blood supply to heart muscle caused by atherosclerosis of blood vessel walls; after cardiac episode and/or surgery, requires 4- to 6-week delay before emergency or elective dental procedures.

e. MUST meet 4 metabolic (MET) equivalents to determine functional capacity (FC) to decrease cardiac risk during dental care; continue on CVD drug therapy during treatment.

f. May need to lower amount of vasoconstrictor with local anesthesia.

g. Increased risk of periodontal disease, and if present, may affect CVD.

2. Patient with hypertension (high blood pressure [HBP]): has or had elevated blood pressure; may also report symptoms of headache, dizziness, or nosebleeds:

a. Taking antihypertensive and/or diuretic drug(s); may result in xerostomia.

b. Can progress to arteriosclerosis, impaired renal function, cardiac enlargement, MI, cerebrovascular accident (CVA, stroke); MUST be ready for an emergency.

c. Monitor blood pressure at each visit; refer to physician when blood pressure is stage 1: mild HBP (140 to 159/90 to 99 mm Hg); with stage 2, moderate to severe HBP (>160/>100 mm Hg), may NOT be able to perform elective dental care; may need immediate medical consult.

d. Do NOT provide dental treatment when blood pressure is ≥180/≥110 mm Hg, activate EMS system and treat as emergency.

3. Patient with congestive heart failure (CHF): occurs when heart muscle is weak and is unable to pump blood at an adequate rate; blood circulation is poor, resulting in congestion and pooling of blood in the organs and lower extremities.

a. Swollen ankles from edema; shortness of breath; fatigue.

b. May be taking digitalis glycoside (digoxin, Lanoxin) and diuretics that usually result in xerostomia.

4. Patient with cardiac dysrhythmia: had or has irregular heartbeat (too slow or fast).

a. May have pacemaker (with or without defibrillator) and report taking digitalis glycoside (digoxin, Lanoxin) or calcium channel blocker such as diltiazem (Cardizem, Dilacor, Tiazac) or nifedipine (Procardia); may have xerostomia and gingival hyperplasia.

b. With pacemaker, do NOT need to avoid use of ultrasonic scalers, since ALL are shielded, AVOID electric pulp testing (EPT) (discussed later).

c. Antibiotic premedication for first 6 months after placement of pacemaker.

5. Patient with valvular heart disorder:

a. Has or had deformity of heart valves because of past infection, drug use (such as phen-fen for weight control), congenital disorder, or heart transplant; artificial replacement of valves may have been performed.

b. Patient with artificial (prosthetic) valve is at high risk for infective endocarditis (IE), infection of lining of heart caused by bacteremia (bacteria in blood) from invasive procedures; requires antibiotic premedication before invasive dental procedures.

6. Patient with diabetes mellitus (DM): has disorder of glucose metabolism resulting from relative or absolute lack of insulin; has vascular component (may have related CVD and/or renal diseases; see later discussion).

a. Two types: type 1, can be severe and unstable; stems from lack of insulin produced from pancreas, and type 2, often NOT as severe but usually stable; develops slowly with age; frequently associated with obesity; pancreas produces adequate insulin but there is insulin insensitivity of the tissue.

b. Dental appointment should be scheduled after meal and insulin therapy if taken; MUST be ready for emergency.

c. Need to know current blood glucose levels: <70 mg/dL, too low; tendency toward hypoglycemia; >240 mg/dL: too high; tendency toward hyperglycemia; medical consult since is a risk for emergency.

d. Risk factor for periodontal disease; MORE frequent maintenance appointments are required, as well as excellent oral hygiene self-care; if periodontal disease is present, may affect DM control.

7. Patient with renal disease: renal function is impaired at various levels, possibly maintained by hemodialysis or kidney transplant.

a. Experiences MORE frequent infections, poor healing, bleeding difficulties.

b. Surgical systemic shunts require antibiotic premedication.

c. Certain drugs remain in circulation longer because of poor renal function (metabolism); care MUST be taken with drugs delivered (such as anesthetics and preventives) and prescriptions given by the dental office.

8. Patient with blood disorder or with history of difficulty with bleeding:

a. Patients include those with anemia, deficiency of red blood cells (RBCs) resulting from vitamin or iron deficiency, bone marrow malfunction, excessive loss of blood, or RBC destruction.

b. Also include patients with leukemia, cancer of white blood cells that do NOT function normally (cells are immature and excessive in number); thrombocytopenia may develop from chemotherapeutic treatment.

c. Prone to infection, weakness, postappointment bleeding, hematomas, or other traumatic vascular lesions; can present with traumatic oral lesions, periodontal disease, xerostomia resulting from chemotherapy.

d. Bleeding levels can be monitored by international normalized ratio (INR); INRs ≤2.5 are safe for invasive dental work.

9. Patient with respiratory infection or disease:

a. May have a cold, flu, or tuberculosis (TB); may have TB oral lesion (highly contagious); if contagious, postpone dental treatment until antibiotic therapy reduces infection that may be transmitted.

b. With emphysema or other forms of chronic obstructive pulmonary disease (COPD), may need oxygen during treatment and to be kept upright.

10. Patient with sexually transmitted disease or infection (STD, STI):

a. Includes patients with syphilis, gonorrhea, and chlamydia acquired through sexual intercourse; note any oral or pharyngeal lesions (highly contagious).

b. If contagious, postpone dental treatment until antibiotic therapy reduces infection that may be transmitted.

11. Patient with hepatitis A, B, C, D, E: patients ALL have inflammation of the liver resulting from viral infection; causes fatigue, nausea, tender joints, jaundice.

a. Follow recommendations for hepatitis B vaccination for ALL dental providers before treating patients in any clinical setting, since carrier status is frequently unknown.

b. HIGH risk of disease transmission to clinician and then through chain to other patients; however, dental providers MUST follow standard precautions at ALL times when treating ALL patients.

c. May have difficulty with bleeding and metabolism of drugs because of liver damage.

12. Patient with allergy: can have reactions to substance that may be as slight as a skin rash or as severe as fall in blood pressure and anaphylactic shock (airway obstruction from tissue swelling and/or cardiac arrest).

a. Reports reaction to known substance (allergen) such as antibiotics, rubber latex, restorative metals (especially nickel), other allergens; need to AVOID allergen.

b. May have asthma; need to recommend acetaminophen as substitute for its analgesic and antipyretic effects to avoid aspirin-induced attack; may need to alter local anesthetics (AVOID vasoconstrictor or articaine).

c. May use inhaler for acute asthmatic attacks, so should be asked to bring to ALL appointments; instruct to rinse mouth thoroughly after using and expectorate, to reduce systemic absorption, tooth staining, and taste alteration.

d. MUST determine cause and severity of allergic response; MUST be ready for an emergency, which includes having inhalers in emergency kit.

13. Patient with epilepsy: patient can have disturbance of electrical brain activity resulting in seizure (convulsions).

a. Usually reports taking anticonvulsants such as phenytoin (Dilantin); may have related gingival hyperplasia.

b. Appointments should be made when rested; confirm drug compliance and keep appointments short; MUST be ready for an emergency.

14. Patient with total joint replacement:

a. Patient has replacement for ALL surfaces of joint (knee, hip, elbow, fingers) because of past infection or traumatic disorder, osteoporosis, or osteoarthritis.

b. HIGH risk for prosthetic joint infection 2 years after implantation and ALWAYS for immunocompromised (such as diabetics) from bacteremia caused by invasive dental procedures and thus requires antibiotic premedication before invasive dental procedures.

15. Patient with xerostomia: if NOT drug related (such as with patients who have cancer or Sjögren’s syndrome), can recommend use of prescription cholinergic agonist drugs such as pilocarpine (Salagen) and cevimeline (Evoxac); drug-related xerostomia is discussed in next section.

Drug History

Drug history provides information on drugs that may affect oral health, dental treatment, and oral hygiene self-care. Often requires use of reference text and/or online resource, such as Physician’s Desk Reference (PDR), or a medical consult and/or pharmacist consult for further information. PDR lists all drugs by manufacturer’s name, brand name, generic name.

• See Chapters 6, General and Oral Pathology: specific conditions and diseases noted in dental setting; 9, Pharmacology: drugs that affect dental care.

A. Pharmacological record: information regarding drug action, usage, contraindications, adverse reactions, warnings, precautions is reviewed.

1. Includes record of drugs taken (including over the counter [OTC]), noting dosage and condition being treated; note if drug has impact on oral health and any contraindications for dental treatment.

2. Common drug-induced oral side effects:

a. Xerostomia (dry mouth): associated with cracked lips, sore labial commissures, inflamed smooth tongue (glossitis).

(1) MOST common reaction to drugs; MOST commonly to drugs used to treat depression and anxiety, urinary incontinence, Parkinson’s disease, as well as antihistamines, antihypertensives, antidiarrheals, muscle relaxants; BOTH prescription and OTC, such as for colds, flu, allergies.

(2) Results in thick and ropy saliva, altered taste, loss of buffering action; may be associated with burning tongue.

(3) Increases incidence of caries, especially of the root; causes difficulty with chewing, swallowing, speaking, bad breath, denture wearing.

(4) Treatment: relieving symptoms through increased water consumption (sip water), saliva substitutes, tissue lubricants, chewing sugar-free gum (especially with xylitol), air humidification; AVOID alcohol mouthrinses that can dehydrate tissues; to prevent caries, use of home fluoride applications and calcium products for additional remineralization; see earlier discussion if non–drug related.

b. Candidiasis: overgrowth of yeast organism, Candida albicans (see Chapter 8, Microbiology and Immunology):

(1) Increased risk with history of prolonged antibiotics, immunosuppressants, or corticosteroid therapy with immunocompromised health, denture or dental appliance wear.

(2) Frequently results in painful irritations, creating difficulty in chewing, speaking, wearing dental appliances.

(3) Treatment: antifungals such as nystatin (Mycostatin), clotrimazole (Mycelex), ketoconazole (Nizoral), fluconazole (Diflucan) that may contain sugar, increasing risk of caries; education given on proper denture care (see Chapter 15, Dental Biomaterials).

c. Drug-induced gingival hyperplasia: associated with enlarged, bulbous, and fibrotic gingival tissues:

(1) Results from anticonvulsant phenytoin (Dilantin), calcium channel blocker such as nifedipine (Procardia), or transplant rejection drugs such as cyclosporine.

(2) Can be controlled or prevented through adequate oral hygiene self-care, especially if begun before the drug regimen.

(3) May need surgery to remove excess tissues (see Chapter 13, Periodontology).

d. Additional oral signs of drugs: glossitis, erythema signs, hairy tongue, lichenoid eruptions, trigeminal neuralgia.

3. Common drugs that affect dental treatment:

a. Antihypertensives: used to reduce high blood pressure (HBP) with cardiovascular disease (CVD).

(1) Can cause orthostatic (postural) hypotension (reduced blood pressure): sit patient up slowly and keep seated for several minutes to reduce dizziness of hypotension:

(2) Monitor blood pressure at each visit (see earlier discussion).

(3) Can cause xerostomia (discussed earlier).

(4) Nifedipine (Procardia), calcium channel blocker, can cause gingival hyperplasia (discussed earlier).

(5) May need to alter local anesthetic agent.

(6) Common HBP drugs:

(a) Diuretics: hydrochlorothiazide (Lopressor), furosemide (Lasix) (see next discussion).

(b) Calcium channel blockers: diltiazem (Cardizem, Dilacor, Tiazac), nifedipine (Procardia, Adalat, Nifedical).

(d) Angiotensin converting enzyme (ACE) inhibitors: captopril (Capoten), enalapril (Vasotec), lisinopril (Zestril, Prinivil).

b. Diuretics: used to promote renal excretion in the treatment of CHF and HBP:

(1) Result in frequent urination and xerostomia (see earlier discussion); affects planning of appointment time and length of appointment.

(2) Common drugs: see antihypertensives and diuretics.

c. Anticoagulants and antiplatelets: used for treatment of CVD to increase blood flow by suppressing or delaying coagulation of blood:

(1) Discontinuation of drug may be hazardous because of embolus, thrombus formation.

(2) Side effects can be prolonged; spontaneous internal bleeding can occur; hematoma more likely with some local anesthesia injections (especially inferior alveolar nerve block).

(3) Requires monitoring of bleeding by INR levels (see earlier discussion) and medical consult.

(4) Common drugs: warfarin (Coumadin), clopidogrel (Plavix), aspirin (low dose).

d. Antianginals: used for treatment of angina pectoris to increase oxygen supply to heart muscle through vasodilation:

(1) Usage pattern should be established before each appointment; keep patient’s NTG tablets handy during dental appointment; make dental appointment short and in morning.

(2) When combined with alcohol, can cause severe hypotension.

(3) Common drug: NTG (Nitrostat).

e. Cardiac drugs:

(1) Used with CHF; strengthen myocardial contractility.

(2) May present with swollen extremities and report shortness of breath; seat in upright (45°) position to increase ease of breathing.

(3) Common drugs: digitalis (Lanoxin), enalapril (Vasotec), captopril (Capoten).

f. Anticonvulsant drugs: used to reduce incidence of seizures with epilepsy or Down syndrome.

(1) Stimulate gingival growth, resulting in gingival hyperplasia (see earlier discussion).

(2) Common drugs: phenytoin (Dilantin).

g. Vasoconstrictors: used to alleviate symptoms of asthma and emphysema; taken as inhalants.

(1) Can cause xerostomia (see earlier discussion); frequently associated with inflamed gingival tissues because of mouth breathing (associated with asthma).

(2) Need to follow inhaler use instructions (discussed earlier).

(3) May need to alter local anesthetic agent; may need to avoid use with sulfites (vasoconstrictors, articaine).

(4) Common drugs: albuterol (Proventil, Ventolin).

h. Thyroid drugs: treat hypothyroidism (MOST common type) by increasing metabolic rate.

(1) Have NO oral side effects; patient may have goiter or surgical removal of gland.

(2) Common drugs: levothyroxine (Synthroid).

i. Antiinflammatory drugs: depress inflammatory response and treat adrenocortical insufficiency, rheumatoid arthritis (RA), and respiratory disease (emphysema):

(1) High risk for candidal infections (see earlier discussion) and oral ulcerations.

(2) Common drugs: corticosteroids such as prednisone (Deltasone).

k. Tranquilizers: may be taken daily or ONLY for antianxiety premedication because of anxiety and fear of dental care.

(1) Result in CVS depression; may be drowsy, fatigued, or sedated.

(2) May cause xerostomia (see earlier discussion).

(3) Long-term use can cause tardive dyskinesia, involuntary facial movements of facial muscles and/or tongue; may have bruxism with attrition.

(4) Be aware of signs of sucidal or depressive tendencies; refer immediately to physician.

(5) Common drugs: diazepam (Valium), alprazolam (Xanax).

PATIENT ASSESSMENT

Patient assessment is necessary to establish baseline information on general health; includes taking vital signs as well as performing extraoral and intraoral examination and dental and periodontal evaluations. Obtaining baseline information allows determination of treatment needs and subsequent development of treatment plan.

• See Chapter 10, Medical and Dental Emergencies: vital signs.

Patient Examination

Patient examination includes both extraoral and intraoral examination of the soft and hard tissues of the head and neck as part of the assessment of the patient. Recognition of abnormal findings may be critical in preserving the overall health. MUST be recorded in chart (see documentation discussion).

• See Chapters 4, Head, Neck, and Dental Anatomy: head and neck anatomy; 6, General and Oral Pathology: diagnosis.

A. Examination technique: includes visual observation, palpation, auscultation, olfaction.

1. Visual observation, BOTH direct and indirect (mouth mirror), to examine intraoral and extraoral structures:

a. Adopt organized, sequential pattern to AVOID omitting areas.

b. Look for abnormal color (change to red, black, blue, white, dark brown; spread of color), size (change is sudden or ongoing), or change in appearance (irregular margins, elevation, texture becomes scaly, crusty, or ulcerated).

c. Inform patient of the results of examination.

2. Palpation used to examine tissues and underlying structures:

a. Digital: one finger used to examine tissue (hard palate).

b. Bidigital: tissue grasped between finger(s) and thumb (cheeks, alveolar ridges, lips, vestibule, tongue, ducts, floor of mouth, larynx).

c. Manual: all fingers of one hand used to grasp tissue (anterior deep and superficial cervical nodes).

d. Bimanual: finger(s) and thumb from each hand applied simultaneously to examine tissues (floor of the mouth).

e. Bilateral: bilateral structures examined simultaneously to detect differences between sides (temporomandibular joint [TMJ], inferior border of mandible); place fingers on anterior border of jaw, palpate distally on BOTH right and left sides at same time.

f. Circular compression: fingers move in circular motion while applying pressure (occipital nodes); AVOID on palate.

3. Auscultation used to listen to body sounds to determine a change from normal:

a. TMJ sounds, such as clicking, grinding, or popping; make note if pain is associated with sounds.

b. Hoarseness or cough; make note of how long it has persisted.

c. Speech disorders, such as slurred speech, stuttering, or extra loud speech.

4. Olfaction to detect unusual smells:

a. Bad breath (halitosis): poor oral hygiene, necrotizing periodontal disease, GIT difficulties, overconsumption of proteins; MOST comes from coated tongue; encourage tongue cleaning.

b. Acetone breath: indicative of DM, from increased processing of ketones.

c. Alcohol breath: recent alcohol consumption, alcoholism.

B. Documentation (see Chapter 18, Ethics and Jurisprudence):

1. To record findings that may be significant in the overall diagnosis and recommended treatment.

2. As legal record in case of a claim or patient identification (accident or disaster).

3. As baseline data for subsequent examination and future treatment planning.

Extraoral Examination

Patient SHOULD be seated in an upright position for extraoral examination of the head, face, and neck areas, unless NOT able. Good lighting and exposure of the area being assessed are essential (e.g., patient’s collar and tie loosened, glasses removed).

A. Overall physical appearance by visual examination:

1. Unsteadiness of gait: CANNOT walk at a normal pace and maintain balance because of orthopedic disabilities or influence of drugs.

2. Restricted mobility: limps while walking, which may indicate injury to hip, leg, knee, or foot or systemic disease; investigate possible surgery that required pins, joint repair, or prosthesis.

3. Imbalance: CANNOT walk without losing balance; may be due to equilibrium problem, inner ear infection, loss of muscular strength, or damage from CVA.

4. Stature: appears stiff while standing, sitting, or walking; may indicate back problem or arthritis; if assumes a slumped position, may be due to lack of muscle tone resulting from a CVA.

5. Difficulty breathing: appears out of breath while walking or right after walking; may indicate CHF, lung disease, or other systemic disorder.

B. Hair by visual examination and palpation:

1. Unusual amount: loss or thinning may be result of chemotherapy; excessive growth (hypertrichosis) caused by hormone disorder.

2. Unusual distribution: as in alopecia, with loss of hair in patches.

3. Lack of luster: poor nutrition; coarse texture with hypothyroidism.

4. Scalp lesions: psoriasis, previous injury, basal cell carcinoma (BCC); lice: small insects, nits appear as tiny white globules at hair root; spreads easily.

C. Face by visual examination and palpation:

1. General expression can indicate general mood (e.g., happy, sad, angry, indifferent).

2. Asymmetry: facial paralysis (along with lack of blinking) with CVA or Bell’s palsy.

3. Drooling, lack of expression, diminished blinking: Parkinson’s disease.

4. Unusual muscle twitching and loud vocal sounds: Tourette’s syndrome.

5. Bruising, bleeding, or burned areas: physical abuse, anticoagulation therapy, or blood disorder.

6. Pigmentation: Addison’s disease or melanoma.

D. Skin by visual examination and palpation:

1. Color: indicates general health status (e.g., illness, disease, or trauma); note paleness, redness, acne, rosacea, sunburn, patches of pigmentation.

2. Textures: unusual ones should be noted, such as scarring, clamminess, firmness, swelling, acne.

3. Lesions: should be documented, noting color, size, shape, surface texture (note any changes in pigmented nevus).

E. Eyes by visual examination and reaction to light source:

1. Pupil size: normal; dilated or pinpoint may be related to drug abuse.

2. Sclera color: if yellow, may indicate jaundice; if red and crusty, conjunctivitis.

3. Bulging (exophthalmos) or puffy and swollen eyes with edematous eyelids: possible thyroid disorder.

4. Eyes without palpebral fissures and with broad, flat nose and low-set ears: Down syndrome.

F. Nose by visual examination and palpation:

1. Obstructed airway: congestion and/or a structural defect or ulceration related to drug abuse.

2. Secretions: sinus drainage; yellow or green secretion: infection or drug use (constant wiping).

3. Red butterfly-shaped lesion over the nose: systemic lupus erythematosus (SLE).

4. Rhinophyma: overgrowth of sweat and sebaceous glands; appears red and bulbous with increased alcohol consumption.

G. Ears by visual examination and palpation:

1. Hearing loss and use of hearing aids: will require clinician to look at patient while speaking; during use of ultrasonic scaler, patient may need to turn off hearing aid.

2. Infections: may affect ability to hear; may also affect balance.

3. Tinnitus (ringing): may cause humming or buzzing in ear; may result from long-term use of aspirin, infection, or environmental noise trauma.

H. Bones, muscles, lymph nodes, glands using visual and palpation:

1. Parotid glands: bilateral circular compression for pain, swelling, enlargement, hardness; salivary flow observed at opening of duct across from maxillary first molar on buccal mucosa when gland is milked.

2. TMJ: bilateral palpation with BOTH index fingers slightly anterior to outer meatus, have patient open and close several times, slowly; note pain, clicking, popping, grinding, and restriction in opening or closing; note any deviations, including during patient interview; may have TMD.

3. Masseter and temporalis muscles: bilateral circular compression for pain, swelling, enlargements, unusual hardness; masseter may be enlarged because of bruxism and/or clenching habits.

4. Border of mandible: bimanual palpation from midline to posterior angle for changes in contour and pain.

5. Mentalis muscle: digital palpation, rolling tissue over mandible, for smoothness or restriction in swallowing movement.

6. Lymph nodes: assessed for tenderness or pain, swelling, enlargement, unusual hardness, fixed position:

a. Occipital: bilateral palpation, with head tilted forward.

b. Auricular (anterior and posterior), parotid (superficial), facial: bilateral palpation.

c. Superficial cervical (submental, submandibular, anterior and external jugular): digital palpation with fingers anteriorly from midline of mandible with head down to posteriorly to angle of mandible, rolling tissue over jaw, and then down to and along sternocleidomastoid muscle (SCM), with patient’s head to side.

d. Deep cervical (superior and inferior): palpating deep tissues along SCM with thumb and fingers, with head to side.

e. Accessory and supraclavicular: palpating continuing down into clavicular area, with shoulders up and forward.

7. Submental and submandibular salivary glands: bilateral digital palpation for asymmetry, noncontiguous borders, pain, swelling, enlargement, unusual hardness, difficulty in swallowing.

8. Larynx: bimanual palpation for unrestricted movement.

9. Thyroid gland: displacing gland to one side of neck, then combination of bimanual and manual palpation inferolaterally to cartilage (“Adam’s apple”) while patient sits upright; ask patient to swallow (may need glass of water) to check for mobility; note asymmetry, nodules, enlargement (goiter), or surgical removal.

Intraoral Examination

Patient should be seated in a supine position (see earlier position discussion). Use preprocedural antimicrobial mouthrinse and have client remove any pigmented lipsticks. Apply nonpetroleum lubricant to cracked and dry areas to make examination more comfortable, and remove any removable appliances. Overall, note level of saliva and whether dry mouth (xerostomia) is present.

B. Labial and alveolar mucosa using visual examination and bidigital palpation:

1. Ulcerated lesions: such as herpetic lesions, aphthous ulcers.

2. Tight frenum attachments: can cause gingival defects such as loss of attached gingiva (mucogingival defect).

3. Amalgam tattoo: blue or black macules of varying size on soft tissues.

4. Enlarged mucous retention cyst (mucocele): trauma to duct.

5. Hyperkeratosis: use of lozenges, drugs, or spit (smokeless) tobacco products held in mandibular vestibule; careful evaluation of changes is essential.

6. Smokeless (spit) tobacco lesion: hyperkeratinized tissue; white, sometimes corrugated, in appearance.

7. Torn or lacerated frenum (lingual frenum too): often caused by forced feedings, binding, gagging (abuse).

8. Tissue trauma: biting, abrasion, burns; horizontal bruises at commissures may indicate binding or gagging with abuse.

C. Buccal mucosa using visual examination and palpation:

1. Check parotid (Stensen’s) duct using bilateral palpation: pain, enlargements, tumors, calcified areas; milk the ducts to confirm function.

2. Linea alba: white line paralleling occlusal plane with trauma; also note trauma from toothbrushing, cheek biting (irritation fibroma).

3. Wickham’s striae: thin white lines with lichen planus.

D. Gingiva using visual examination and palpation:

1. Tissue trauma: caused by abrasion, burns, or cuts.

2. Infection, with redness and swelling (inflammation), such as McCall’s festoons (lifesaver marginal gingiva): inadequate dental biofilm removal and presence of periodontal disease, mainly gingivitis, possibly periodontitis.

3. Fibrosis: chronic periodontal disease, drug use, or traumatic toothbrushing.

4. Exostosis (plural, exostoses): small benign bone growths projecting from alveolar process, MAINLY on maxillary facial surface.

5. Recession: loss of periodontal attachment, caused by vigorous toothbrushing, abfraction, or gingival disease or surgery.

6. Mucogingival defects:

a. Lack of attached gingiva: tooth positioning, hereditary factors, oral habits, poor oral hygiene.

b. Stillman’s clefts (comma shaped): poor oral hygiene and occlusal trauma.

c. High frenum attachments: muscle pull on attached gingiva.

E. Hard and soft palate using visual inspection and digital palpation:

1. Torus (plural, tori): hard protruding bony structure (benign exostosis), NOT of significance unless partial or full denture is being constructed, then may need to be reduced or removed.

2. Ulcerations: fluid-filled lesions surrounded with red halo with aphthous ulcers, burns, viral infection, or autoimmunity (broken blisters).

3. Trauma: mechanical or chemical irritation; should heal within 10 days, if not, further investigation needed to rule out pathological condition or child abuse.

4. Stomatitis: ranges from small, red, petechia-like lesions (nicotine and denture stomatitis) to generalized and granular (denture stomatitis) to ulcerative (aphthous stomatitis) to intense redness with focal bone loss (necrotizing stomatitis).

5. Petechiae: small red dots on mucous membranes, caused by trauma or systemic disease (mononucleosis on palate).

6. Fistulas: pimplelike lesions with periodontal or periapical abscess.

7. Soft palate: high-risk area for oral cancer, with red and/or white lesions, bleeding, ulceration; also area for trauma from abuse.

F. Floor of mouth using visual inspection and palpation:

1. Check submandibular (Wharton’s) duct: can become blocked with mucous plugs or sialoliths (present on occlusal radiograph).

2. Varicosities: often found sublingually on elderly.

3. Large mucous retention cyst (ranula): blocked or traumatized ducts of submandibular and sublingual glands; soft, sessile, slowly enlarging mass on one side of floor of mouth; painless; once removed, may recur.

4. Limited tongue movement: ankylosis of tongue; may lead to swallowing and speech disorders.

5. High-risk area for oral cancer, with red and/or white lesions, bleeding, ulceration.

G. Tongue using visual examination and palpation:

1. Coating: varying degree of keratinization of filiform lingual papillae; food, drugs, bacteria (halitosis); staining caused by tobacco use; tongue cleaning needed.

2. Fissuring: presence of numerous grooves and crevices on dorsal surface and lateral borders of tongue; entrap food and bacteria; tongue cleaning needed; MORE common with Down syndrome.

3. Varicosities: often found on ventral surface on elderly.

4. Lateral border and ventral surface: high-risk area for oral cancer, with red and/or white lesions, bleeding, ulceration.

5. Other common lesions of the tongue:

a. Ulcers: aphthous is MOST common, with systemic disease such as viral infections or autoimmunities or with smoking cessation.

b. Irritation fibroma: trauma.

c. Geographic: common benign condition involving filiform lingual papillae found on dorsum and borders; lesions are red areas with white borders; outline of lesions changes, heals, reappears in different area.

d. Median rhomboid glossitis (central papillary atrophy): flat or lump benign lesion on dorsum, NO filiform present; related to chronic candidiasis.

e. Tongue thrust (during swallowing): anterior portion pushes between teeth; ideally SHOULD be positioned on palate behind maxillary central incisors while swallowing; retraining may be necessary if thrusting causes speech disorders or tooth positioning problems (malposed teeth).

f. White plaques: lichen planus, candidiasis, or other systemic disease; definitive diagnosis is needed.

g. Black hairy tongue: elongation of filiform with dark staining: long-term use of certain drugs or tobacco; long-term rinsing with undiluted hydrogen peroxide.

h. Hairy leukoplakia: hyperkeratosis of filiform caused by Epstein-Barr virus (EBV); results in white corrugated appearance on lateral borders; associated with HIV/AIDS.

i. Hemangiomas and lymphangiomas: developmental benign tumors creating enlargements.

j. Macroglossia: symmetrical enlargement; developmental abnormality, cretinism, acromegaly; may be scalloped from pushing against the teeth.

CLINICAL STUDY

Age	27 YRS	SCENARIO
Sex	Male Female	The patient has minimal calculus and dental biofilm with slight gingival inflammation.
Height	5’2”
Weight	135 LBS
BP	110/65
Chief Complaint	“I know I have to keep my mouth healthy, since it impacts all of my health.”
Medical History	Hemophilia Contracted AIDS 15 years ago from blood transfusion