An important part of a patient’s first visit to a dental office is the examination of the head and neck. The clinician will be checking to see if these tissues are normal or if there are any conditions requiring further investigation. This includes an examination of the soft tissues of the head and neck, as well as the inside of the mouth. This will be performed thoroughly and systematically to ensure that no parts are missed. If an abnormality is seen, the clinician will note details such as the type, size, color, location, surface texture, and consistency of the abnormality.
A complete examination covers the following three areas:
- The General Examination
- The Extraoral Head and neck Soft Tissue examination
- The Intraoral soft tissue examination
A. General examination
The general examination begins as soon as the patient enters the dental office. The patient’s general appearance may give information that relates to his or her medical condition. The clinician will observe the patient’s gait, mobility, facial asymmetries, lesions or scars.
B. Extraoral head and neck examination
The extraoral head and neck soft tissue examination includes checking for asymmetries, a lymph node examination and a brief temporomandibular joint examination.
In order to check for asymmetries, the clinician will stand in front of the patient to observe the head and neck, focusing on the area around the jaws. If a significant asymmetry exists, the clinician will ask the patient for any known causes, such as previous surgeries, scars, tumours, and infections.
2. Lymph node examination
To examine the head and neck lymph nodes and other soft tissue of the oral region, the clinician will palpate, (which means feel) the area gently to look for tenderness or enlargements. Normal lymph nodes are either not palpable, or may feel like a pea or lentil, and are not tender when touched. Abnormal lymph nodes are generally larger, may be tender, and can be an indication of an inflammation or that drainage of infection has occurred. A non-tender enlargement may indicate cancer or lymphoma.
The lymph node examination may include the areas around the ear, the base of the skull, under the jaw and chin, the neck and the area above the collar bone.
3. TMJ examination
A limited examination of the jaw joints or temporomandibular joints may also be performed at the initial dental appointment. This is done by placing the fingertips over the joints with gentle pressure. The clinician will note any tenderness, swelling or redness. Then the patient will be asked to open and close his or her mouth slowly, several times. He or she may also be asked to slowly move the lower jaw from side to side. If an abnormality is noted, further examination may be needed.
C. Intraoral soft tissue examination
The intraoral soft tissue examination includes checking the soft tissues of the mouth, the throat, the tongue and the gums.
Lips and labial mucosa
The clinician will begin by examining the lips and the mucosa inside the lips called the labial mucosa. The labial mucosa will be examined by gently turning the lip out. The labial mucosa should appear wet and shiny. Scars inside the lower lip are seen frequently as a result of trauma as a child.
Buccal mucosa and vestibular mucosa
The clinician will then examine the inside of the cheeks, called the buccal mucosa, using two mirrors to retract the buccal mucosa to one side. This examination will be performed in a thorough and stepwise manner, moving from one side to the other. The mucosa should be smooth, moist and shiny. If the mirror sticks to the mucosa, xerostomia or dry mouth may be present.
Hard and soft palate
Next, the clinician will examine the hard palate, which is the firm area of the roof of the mouth and then the soft palate, which is the soft area behind the hard palate. He or she will then briefly look at the throat. This is easier if the patient says “Ahhh”.
The next step is to examine the tongue. The top of the tongue will be examined first, followed by the sides of the tongue, which may stretch the tongue slightly. The tip of the tongue will be held with a piece of gauze and the tongue moved from one side to the other. If there is any swelling or ulcers, then the area will be palpated. The tissue in this area should be soft. The underside of the tongue will also be examined. Particular attention should be paid to the sides of the tongue and the floor of the mouth, as cancers develop in these areas more frequently than on the top of the tongue or the palate. Oral cancers may have the appearance of ulcers, masses, red areas, or white areas.
Floor of mouth
Now the clinician will examine the floor of the mouth. He or she may feel the saliva glands, which usually feels ropey or lobulated. A salivary stone in this area would feel hard. This examination is not painful, but it is a slightly odd feeling.
Gingiva and alveolar mucosa
Finally, the clinician will examine the gums, which are called the gingiva. Healthy gingiva is pink, and regular. Some abnormalities include generalized or localized swelling, redness, ulceration or bleeding.
The clinician may also palpate the area over the jaws to check for lumps and bumps. This examination may also reveal tenderness that could be the result of infection or inflammation.
Normal structures that may be mistaken for lesions
- Stensen's duct is the duct of the largest saliva gland. It opens into the mouth next to the upper molars and may be flat or slightly raised.
- Circumvallate papillae form a V-shaped row of rounded bumps at the back of the tongue.
- Lingual tonsils are found on the top and back of the tongue. They may become enlarged with infections.
- Plica fimbriata are folds on the underside of the tongue. These folds may look fringed.
Variations of Normal
- Fissured tongue is a common condition. There are multiple grooves on the top or sides of the tongue. This is reported in 2% to 5% of the population.
- Fordyce granules are commonly seen on the upper lip. These are extra sebaceous glands and appear as yellow-beige spots measuring 1 – 3 mm.
- Varicosities are are enlarged veins, commonly seen on the underside of the tongue, usually present in older patients.
Common oral pathologies
- Geographic tongue is a common benign condition seen in 1% to 3% of the population. The cause is unknown. The classic features are multiple circular or semicircular pink or red areas on the top of the tongue, with the red areas partially surrounded by a slightly raised yellow-white rim or border.
- Linea Alba, or white line, is a common condition that appears as a white horizontal line along the buccal mucosa at the level where the teeth meet.
- Benign vascular lesions appear as red or purple areas on the oral mucosa are usually seen in older patients.
- Morsicatio buccarum is cheek biting and appears as a ragged, slightly translucent area on the inside of the cheek. Most patients with morsicatio buccarum, when asked, will admit that they bite their cheek repeatedly.