Intra oral examination

Intra oral examination

1. Dr. Asem Mohammed Kamel Intraoral Examination

2. The dentist should examine? Lip mucosal surface. Labial frenum. Vermilion border. Oral commissures. Vestibules of the mouth. Minor salivary glands. 1--Clinical Examination of Lips & Labial Mucosa

3. Means of clinical examination 1- Inspection Color of the lips and labial mucosa, morphology , function , texture and the presence of abnormal lesion such as ulceration , anatomic or developmental abnormalities as cleft lip, double lip, lip pit and short lip.

4. observe the following: Consistency of the lips and labial mucosa. Pliability of lip surfaces. Indurated lesions of the lips as well as the glandular involvement. Texture of the lip. Size & shape of the lip must be examined for the presence of some pathologic conditions. 2- Palpation

5. Lesions of the Lips and labial mucosa A- Specific chelitis glandularis. chelitis glandularis apostematosa “Melkerson_Rosenthel syndrome”. Lip pits (Congenital sinus of the lower lip). Commissural pit. Double lip. Angular chelitis. Cleft lip.

6. B-common Recurrent herpes labialis. Erythema multiform “Steven Johnson” syndrome. Stomatitis medicamentosa and venenata and angioedema. Smoker’s patch of the lip. Condyloma latum and Condyloma acuminatum . Lichen planus showing white lines “Wickham's stria” on the vermilion border of the lip. Focal epithelial hyperplasia, characterized by appearance of slightly raised multiple papules that could involve the lip, caused by human papilloma virus (Heck’s disease). Malignant lesions of the lip as spindle cell carcinoma and epidermoid carcinoma.

7. Recurrent herpes labialis Erythema multiform Stomatitis medicamentosa Smoker’s patch of the lip Condyloma latum Condyloma acuminatum Focal epithelial hyperplasia

8. Means of clinical examination to see any abnormalities e.g. - Linea alba buccalis - Fordyce's granules - Parotid duct opening - Ulcers - Pigmentation e.g. melanoma 2--Clinical examination of buccal mucosa

9. Linea alba buccalis Fordyce's granules Parotid duct opening Ulcers melanoma

10. Means of clinical examination to feel the consistency and texture of some pathologic conditions as:- leukodema leukoplakia White spongy nevus keratotic lichen planus “papule type” Specked leukoplakia Frictional keratosis Smoker keratosis Indurated ulcers e.g. malignant ulcer Clinical examination of buccal mucosa

11. leukodema leukoplakia White spongy nevus keratotic lichen planus malignant ulcer Frictional keratosis Specked leukoplakia

12. 3--Clinical Examination of Tongue Taste distribution on the tongue surface Sweet tip Sour lateral Salt dorsal Bitter back Nerve supply Anterior two thirds: General sensation by lingual nerve, branch of trigeminal 5th C.N . Taste sensation by chorda tympani, branch of facial 7th C.N. Posterior one third: General and taste sensation by glossopharyngeal 9th C.N. Motor supply By hypoglossal nerve 12th C.N.

13. 1- Active movement Technique: The clinician ask - the patient to raise his tongue against the palate to see the ventral surface. - the patient move the tongue anteriorly and laterally to see the dorsal surface. Movements of the tongue 2- Passive movement Technique: examiner holds tongue with a piece of gaze and moves it up and down and from side to side to detect any abnormalities or any associated pain. 3- Abnormal movement: This movement usually performed by mental patient.

14. Decreased Tongue Coating: (Atrophy) Pernicious anemia “iron deficiency anemia”. Drug allergy. Diabetes mellitus. Lichen planus of the tongue. Chronic atrophic candidiasis. Tertiary syphilis “syphilitic glossitis”. Geographic tongue and median rhomboid glossitis. Sub epithelial vesiculo-bullous lesions.

15. Pernicious anemia Drug allergy Lichen planus Chronic atrophic candidiasis Syphilitic glossitis Geographic tongue median rhomboid glossitis Erythema multiform

16. Hairy leukoplakia “AIDs patients”. Mouth breather patients. Vomiting and stomach upset. Smoker patients. Xerostomia. Some tongue lesions as black hairy tongue. Increase Tongue Coating

17. Hairy leukoplakia Black hairy tongue

18. By bidigital palpation to examine - The consistency of tongue lesion. - The resiliency and texture. - The presence of induration, scars and lesions. Palpation of the tongue

19. A-- Congenital anomalies Microglossia and aglossia. Macroglossia. Cleft tongue “bifid tongue”. Fissural tongue . Lingual thyroid nodule. Thyroglossal tract cyst. Ankyloglossia Median Rhomboid glossitis. Diseases of the tongue:

20. Microglossia Aglossia Macroglossia Cleft tongue Fissural tongue Lingual thyroid nodule Ankylogossia Median Rhomboid glossitis

21. Diseases of the tongue: B-- Acquired tongue disease Benign migratory glossitis (geographic tongue). Hairy tongue. Depapillation and atrophic tongue Glossodynia and glossopyrosis. Acquired macroglossia

22. Benign migratory glossitis

23. C- As a manifestation of systemic diseases. Infections e.g. syphilis of tongue “syphilitic glossitis”, gamma of tongue and T.B. ulcer of tongue. Metabolic e.g. Diabetes militius patients showing depapillation and atrophic tongue coating. Hormonal e.g. secondary “acquired” macroglossia that associated with acromegaly and cretinism. Allergy e.g. stomatitis medicamentosa and stomatitis venenata. Hematological e.g. hunter glossitis manifestation of pernicious anemia and decrease tongue coating. Atrophic tongue changes commonly associated with iron deficiency anemia and plumer venison syndrome. Neoplastic e.g. squamous cell carcinoma of the tongue, lymphangioma, Haemangioma and neurofibromatosis which result in secondary macroglossia.

24. Hard palate Soft palate Uvula By using direct and indirect light, visual examination can be performed by observing the following: contour , height , rugae area , incisive papillae and width of the arch . The soft palate should be inspected for color changes , which usually associated with different types of anemia, and the mobility of soft palate must be observed. 4--Clinical examination of Palate 1- Inspection

25. By using one finger of one hand i.e. “Bidigital palpation” the palate can be palpated starting from the anterior region and proceeding posteriorly and laterally. The junction between soft and hard palate should be palpated gently. Any abnormal texture such as egg shell, cracking or fluctuation and swelling must be recorded.

26. The movement of soft palate should be observed by asking the patient to say ahh , this giving idea about the integrity of the 9th and 10th cranial nerves. If paralysis of these nerves occurred the uvula will be shifted toward the unaffected side. The uvula is varying considerably in size from individual to another and examined by means of inspection . It may be congenitally absent or lost during surgery or may appear bifid and represent a form of cleft palate.

27. Cysts of the palate - Incisive canal cyst - Cyst of palatine papilla - Median-palatine cyst - Globulo-maxillary cyst - Naso -palatine cyst White lesions commonly involving the palate - Thermal burn such as pizza burn - Stomatitis nicotina Congenital abnormality of the palate - Cleft palate. - Torus palatinus. Common infections involving the hard palate e.g. - Syphilitic infection during secondary and tertiary stage such as “gamma” - Fungal infection such as moniliasis especially in AIDS patient - Draining sinus from periapical abscess. Tumors of hard palate: - Adenocarcinoma. - Squamous cell carcinoma Lesions of the hard palate

28. Syphilitic perforation of the palate Fungal infection of the palate

29. Incisive canal cyst Cyst of palatine papilla Globulo -maxillary cyst Median-palatine cyst Naso -palatine cyst

30. Herpetic infections of herpes simplex virus (primary and secondary lesions) Herpes zoster Herpangina Recurrent aphthous ulcers Diphtheria. Lesions of the soft palate

31. Secondary herpetic stomatitis Herpes zoster Herpangina Recurrent aphthous ulcers Diphtheria

32. floor of mouth can be inspected by asking the patient to raise his tongue to reveal the structures and landmarks such as lingual frenum, orifices of the sublingual and submaxillary salivary gland and lingual vein. The color of the mucosa covering the floor of the mouth must be observed for any pathological lesions such as rannula , mucocele , ulceration and swelling. 5--Clinical examination of Floor of mouth 1- Inspection

33. The Clinician fix the tissues extra-orally by four finger of one hand and the other hand running intra-orally to help in the identification of any pathologic condition involving the floor of mouth such as salivary gland calculi and sub-maxillary lymph node involvement. 2- Bimanual palpation

34. Ranula and mucous retention cyst Hyperkeratotic lesion e.g. leukoplakia Dermoid and epidermis carcinoma Dermoid and epidermoid cyst Salivary gland stone. Ulcer of the floor of the mouth Lesions involving the floor of mouth

35. Ranula

36. 1. gingiva : It divided into free gingival, interdental papilla and attached gingiva. 2. Periodontal ligament (P.L): Principal Collagen Fibers of Periodontal Ligament include Alveolar crestal fibers, Horizontal fibers, Oblique fibers and apical fibers. Periodontal ligament have mechanical, formative, nutritive and sensory functions. 3.The alveolar bone: These processes are composed of cancellous bone covered with cortical bone. The spaces in the alveolar bone that accommodate the roots of the teeth are known alveoli. The alveoli are lined with a layer of bone called alveolar bone proper or cribriform plate. 4.Cementum: It is continuously formed on root surfaces that are in contact with the periodontal ligament or gingival fibers. The width of cementum varies from 16-60um in the coronal half of the root, its much thicker, on the apical third of the root, being 150-200um. 6--clinical Examination Of Periodontium

37. Lamina Dura: it is alveolar bone proper or cribriform plate which appears as white line on the radiograph.

38. crestal lamina Dura: layer of bone covers the crest of the interproximal bone

39. supporting alveolar bone: the cancellous and cortical bone that surrounds the alveolar bone proper

40. interproximal bone or interdental septum: it is The bone located between the roots of the adjacent teeth.

41. inter-radicular bone: it is located between the roots of multirooted teeth.

42. radicular bone: it is the alveolar process located on the facial or lingual surfaces of the roots of teeth

43. Fenestration: it is isolated areas which the root denuded of bone and root surface is covered only by periosteum and overlying gingiva. Dehiscence: it is denuded areas extend through the marginal bone.

44. to determine the following: Whether the patient periodontium is healthy or diseased . The extent of the tissue damaged if pathological change is present. The characteristics of the periodontal disease that well enable the determination of the diagnosis, etiology, prognosis and treatment plan. importance of periodontium examination

45. I- Inspection a. Gingival colour: pink, red, bluish red or other colour variation . b. Gingival contour: “Both marginal and papillary”: normal, rounded, crater or other anatomical variation. c. Gingival size: normal size, gingival enlargement or gingival recession. d. Position of the gingiva: Adjacent to cemento-enamel junction or receded coronal to cement enamel junction. Means of clinical examination

46. II- Palpation a. Gingival consistency: Normal, edematous, fibrotic or fiber edematous. b. Gingival texture “stippling”: normal, decrease, increase or lack of it. c. Tooth mobility: by using the handles of two dental instruments apply alternate pressure on the buccal or lingual surface of each tooth. d. Migration: migration is a pathological movement of the teeth in labial, distal, mesial or supra occlusion. Migration is common feature of some periodontal disease e.g. aggressive periodontal, it may relate to some habit e.g. tongue thrusting.

47. III- Probing A. Bleeding on probing: No or yes if yes slight, moderate or severe. B. Evaluation of probing depth: By use of the calibrated periodontal probe. C. Furcation involvement: The furcation involvement exists if the periodontal disease extended to involve the alveolar bones i.e. bone resorption as well as attachment loss occurs. The straight periodontal probe adequate to detect buccal and lingual furcation. However special curved probe (Naber’s-1 and Naber’s-2) is helpful for examination of furcation region.

48. Types of periodontal pockets

49. Bi or Tri furcation involvement

50. Glickman (1958): Horizontal classification Grade I : Incipient involvement of furcation with suprabony pocket and no interradicular bone loss. Grade II : Any involvement of the interradicular bone without through-and-through probability   ( cul-de-sac   ) . Grade III : Through-and-through loss of interradicular bone. Grade IV : Through-and through loss of interradicular bone, with total exposure of furcation owing to gingival recession . Classification of furcation involvement

51. Tarnow and Fletcher (1984): vertical classification loss is measured in mm from the roof of the furcation Grade I: Vertical loss of to 3 mm. Grade II: Vertical loss of 4 to 6 mm. Grade III: Vertical loss of 7 mm.

52. The mesial furcation should be probed from the palatal aspect of the tooth. The distal furcation can be probed from either the buccal or the palatal aspect of the tooth. Maxillary molars furcation involvement

53. D. Assessment of attachment level: The attachment level is measured by means of graduated periodontal probe “ mm measurement” from the cemento-enamel junction to the bottom of the gingival sulcus. Probing of attachment levels gives an accurate estimation of the degree of the periodontal tissue destruction and indirectly reflect the levels of the alveolar bony defects .

54. If there is apparent recession clinically i.e. the cemento-enamel junction visible the attachment level is measured directly from the cemento-enamel junction to the bottom of the pocket. In cases of gingival recession the attachment level is greater than pocket depth. Assessment of attachment level

55. If there is no apparent recession i.e. the cemento-enamel junction is covered by the free gingiva. Slide the probe along the tooth surface into the pocket until the CEJ is felt. Then Record in mm from CEJ to the gingival margin. Measure in mm the distance from the gingival margin to the bottom of the pocket. Subtract the mm distance from CEJ to the gingival margin from the total pocket depth to obtain attachment level .

56. E. Bone involvement by using periodontal probe the amount of bone resorption can evaluated by measuring the distance from the dento -gingival attachment to the level of cemento-enamel junction.

57. The patient is anesthetized and the periodontal probe is placed in the sulcus and pushed through the attachment apparatus until the tip of the probe engages alveolar bone. The measurements are made on anterior teeth mid-facially and at the facial/interproximal line angles. Bone sounding procedure

58. Mucogingival assessment

59. It is determined by subtracting the sulcus or pocket depth from total width of gingiva. Width Of Attached Gingiva

60. Mucogingival junction assessed as a scalloped line separating attached gingiva from the alveolar mucosa. Assessed as a borderline between movable and immovable tissue. Tissue mobility is assessed by running a horizontally positioned probe from the vestibule toward the gingival margin using light force. Assessed visually after staining the Mucogingival junction with iodine solution. Attached Gingiva – Keratinized – No glycogen in the superficial layer – Iodine Reactive Negative

61. Inspection of the dentition must be include the following: Discoloration and staining. number . shape and structures. size. Dental caries. Attrition, Abrasion and erosion. Functional relation, proximal contact & occlusion. Teeth vitality. Other problems e.g. tooth fracture. Mobility of the teeth. 7--clinical Examination Of The Teeth Inspection

62. Causes of extrinsic discoloration. - Dental plaque formation. - Food pigments. - Tobacco and smoking. - Chromogenic bacteria. - Medications by drugs.

63. Causes of intrinsic discoloration of the teeth Amelogenesis imperfecta. Dentinogenesis imperfecta. Fluorine intoxication, it appears “chalky white”. Severe jaundice, the teeth appear blue or green. Porphyria the teeth appear dark red. Tetracycline administration appear dark brown . Teeth with necrotic pulp, caries or injuries

64. Fluorine intoxication jaundice Tetracycline stain Necrotic pulp

65. 1- Anodontia (Complete or Partial) 2- Supernumaray teeth 3- Predeciduous dentition 4- Post permanent dentition Size of tooth Number of teeth - Macrodontia - Microdontia ( true generalized, relative generalized or localized)

66. Macrodontia Microdontia Supernumerary teeth Supernumaray teeth Predeciduous dentition

67. a- Amelogenesis imperfecta b- Enamel hypoplasia due to - Nutritional deficiency. - Congenital syphilis. - Hypoplasia due to hypocalcaemia. - Hypoplasia due to tooth injuries. - Hypoplasia due to local infection and trauma. - Hypoplasia due to fluoride (Mottled enamel) . c- Enamel and dentin aplasia d- Enamel and dentin hypocalcification. Abnormality of tooth structure.

68. Enamel hypoplasia

69. Anomalies of growth “eruption of the teeth” Attrition, erosion and abrasion of the teeth Function relationship between teeth and jaws: 1- Pathologic migration 2- Open contact (proximal contact) 3- Occlusion abnormalities - Open bite - Cross bite - Edge to edge - Deep over jet - Deep over bite 1- Delayed eruption. 2- Multiple unerupted teeth. 3- Embedded and impacted teeth.

70. Pathologic migration

71. Open contact

72. Open bite

73. Cross bite

74. Edge to edge bite

75. Deep overjet bite

76. Deep overbite

77. Palpation tooth mobility Causes of tooth mobility: 1- Periodontal inflammation 2- Bone loss “bone resorption”. 3- The presence of occlusal trauma Classification of tooth mobility: Grade I: Slight mobility but the patient is not aware of it. Grade II: Moderate mobility but the patient know it and not feel discomfort during eating. Grade III: Severe mobility and the patient feel discomfort during eating.

78. Probing “Exploration of the teeth” detect pulpal exposure, worn teeth and dental caries. Exploration of teeth must be fine and sharp, the clinician should be considered that many areas of the occlusal and proximal portions of the teeth which may be over looked. Exploration is performed with explorer No. (17). All surface of the tooth must be examined before proceeding to the next one.

79. by using light instrument e.g. explorer no. 17 1- Solid sound (vital tooth) 2- Dull sound (non-vital tooth) Percussion of the teeth

80. 1- Dental caries 2- Gemination 3- Concrescence 4- Dilaceration 5- Dens in dent 6- Supernumerary root 7- Ankylosed decidous tooth 8- Impeded and impacted teeth Radiographic examination

81. Dental caries

82. Gemination

83. Concrescence

84. Dilaceration

85. Dens in dent

86. Supernumerary root

87. Ankylosed decidous tooth

88. Impacted teeth

89. General indication of vitality test: Teeth discoloration. Fractured tooth. Deep carious lesion. Dental restoration. Non vital teeth appear clinically as gray, black or bluish black. Causes of non-vital tooth: Trauma, Caries, Accidental exposure Pulp vitality test

90. Vitality pulp examined by 1- Electric pulp testing 2- Thermal pulp test 3- Periapical x- ray film 4- Percussion

91. Indication; It is indicated to determine the presence or absence of vital nerve within the pulp chamber. Test result; The result of electric pulp testing is painful response following stimulation is an evidence of tooth vitality. Advantage of electric pulp testing control stimulation can be applied in gradual increase of the degree so the clinician avoid excessive pain to patient. Electric pulp testing

92. Indication: Painful tooth in which the cause of pain is not clear. Procedures: 1. The tooth surface should be dry. 2. Small piece of cotton sprayed with ethyl chloride is applied on the tooth surface. 3. A hot cylindrical stick of gutta percha may be used. The result of thermal pulp testing Tooth with painful pulpitis will give severe painful response either with hot or cold application than adjacent normal teeth. Thermal pulp testing

93. Thank you