Extraoral and Intraoral

Exam
Dentalelle Tutoring

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  The head and neck and oral examinations follow the general
appraisal of the patient. Findings from these examinations will fall
into one of three general classifications:
 1. Normal – found in most individuals,
Head and Neck
 2. Typical – not present in all individuals but still within normal
Examinations limits (a variation of normal),
 3. Pathologic – associated with infection, trauma, neoplastic
growth, errors in development causing functional problems,
immune system disorders, and more.

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  The major lymph nodes of the head and neck area should be
palpated with the patient in an upright position. Findings which
should be noted include enlarged palpable nodes, fixed nodes,
tender nodes and whether the palpable nodes are single or
present in groups.
 Findings which include single or multiple, tender, and fixed nodes
are very suspicious for malignancy.
Lymph Nodes  Groups of tender nodes usually occur in conjunction with some
type of infection. Occasionally nodes will remain enlarged and
palpable after an infection. This is a relatively common occurrence
especially within the submandibular group of lymph nodes. When
examined, these nodes should be small (less than 1 cm), non-
tender and mobile. Remember to correlate findings from the
medical history and general appraisal of the patient to the
observations made during the head and neck examination.

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  Occipital nodes - Palpate the occipital nodes about one inch
above and below the hairline.
 Auricular - Palpate the pre and post auricular nodes bilaterally
using the pads of the index, middle and ring fingers.
 Cervical Chain - Palpate the nodes medial to the
sternocleidomastoid muscle using a bidigital technique and the
nodes posterior to the muscle with a bimanual technique.
Nodes  Supraclavicular - These nodes are examined using digital
compressions just superior to the clavicle.
 Submandibular - Palpate the submandibular nodes by pulling or
rolling the tissues under the chin up and over the inferior border of
the mandible. Ask the patient to touch the roof of the mouth with
the tongue, pressing firming against the roof will allow you to
assess the muscles and any pathology associated with the
submandibular lymph node areas.

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Lymph Nodes


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  Digital – single finger
 Bidigital – finger and thumb of the same hand
Palpation  Bimanual – use of finger or fingers and thumb from each hand
 Bilateral – two hands used at the same time

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Salivary Glands

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  The floor of the mouth is examined using direct and indirect vision
followed by bimanual palpation of the entire area. The patient
should be asked to raise the tongue making direct visual
examination of the tissues toward the midline of the floor of the
mouth possible.
 The mirror should be used to examine the areas near the inferior
border of the mandible. The tissues should appear moist and very
vascular. The normal anatomy of the area should be identified
Floor of the including:
 Sublingual caruncle – small rounded projection at the base of the
Mouth lingual frenum which houses Wharton’s duct from the
submandibular salivary gland
 Sublingual folds – two oblique elevations found radiating laterally
away from the lingual frenum on either side of the caruncle which
house the ducts from the sublingual salivary gland
 Lingual frenum – muscle attachment from the ventral surface of
the tongue to the floor of the mouth. This attachment varies in
length from person to person.

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  The clinician should identify the normal anatomy of the tongue
including:
 Dorsal surface – papillae (filiform, fungiform, circumvallate),
median sulcus, sulcus terminalis
 Lateral borders – foliate papillae
 Ventral surface – lingual veins, plica fimbriata, lingual frenum
The Tongue
 Atypical findings on the dorsal surface of the tongue are common.
They include: fissuring, scalloping, benign migratory glossitis and
enlarged papillae, among others. A lingual thyroid may rarely be
found on the posterior dorsal surface at the foramen cecum.
Lingual varicosities are a common finding on the ventral surface of
the tongue, especially in older patients.

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  The tongue is the most common intraoral site for oral cancer.
Therefore, any sign of pathology should be investigated
thoroughly. Some of the pathological findings that are found on
the tongue include:
 Hairy tongue – filiform papilla become elongated due to a variety
The Tongue of reasons from overuse of mouth rinses to not cleaning the
tongue adequately.
 Candidiasis – fungal infection of the tongue often associated with
deeply fissured tongues.
 Glossitis – inflammation of the tongue due to anemia, nutritional
deficiencies and others.

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Oral Cancer

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  Oral cancer is the sixth most form of common cancer in the world with
a 5-year survival rate of less than 50%. The most common causes of
oral cancer are tobacco and alcohol, factors that can be
controlled. Increasingly the Human Papilloma Virus 16 (HPV16) is a
recognized cause of carcinomas in the oropharynx and base of
tongue.
 The presentation of oral cancer is typically as an ulcer, red patch or
white lesion.

Oral Cancer  It is important for the dental health care provider to inspect the
mouth for suspicious lesions and take a biopsy to establish the
diagnosis. Since smaller oral cancers have a better prognosis than
larger ones, early detection plays an important role in reducing both
the treatment associated morbidity and death rate from the disease.
 Oral cancer is a common disease mostly associated with tobacco and
alcohol use. An emerging form of cancer is that occurring in the base
of tongue and oropharynx where the disease is linked to HPV16
infection. All forms of oral cancer are amenable to detection by
dentists and diagnosis by biopsy.

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  The use of tobacco and alcohol are the two most important risk
factors for cancer of the mouth. Smoking is the single most
important risk factor for oral cancer. The use of tobacco and
alcohol synergistically increase the risk of oral cancer.
 Although it has been suggested that chewing tobacco is a
significant cause of oral cancer, epidemiological studies have
shown that the risk is small.1
Risks  By contrast, the use of pan (areca nut and tobacco leaves soaked
in an alkali solution) is significantly associated with the
development of oral cancer. Although a number of other factors
have been implicated in the development of oral cancer, such as
various bacterial and viral infections, for most oral cancers to date,
none have been conclusively proven.
 For cancer of the lip, the single most important risk factor is heavy
exposure to ultraviolet rays of the sun

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  Herpes Group
The Herpes group of viruses has been implicated in the
development of several cancers in man. Epstein-Barr virus (EBV)
has been strongly associated with African Burkitt’s lymphoma and
nasopharyngeal carcinoma. In oral carcinoma, some authors have
detected Herpes simplex viral proteins in malignant cells whilst
others have shown a co-carcinogenic effect of this virus with other
carcinogens in cell culture studies. The precise oncogenic effects
of HSV on the pathogenesis of oral cancers however, have not
been established.
Viruses 
Human Papilloma Virus (HPV)
Over 100 types of human papilloma virus have been
identified. The wart (verruca vulgaris) is caused by HPV 2 and 4,
whilst condylomata accuminata (genital warts) are caused by HPV
6 and 11. Heck’s disease (Focal epithelial hyperplasia) is
associated with HPV 13 and 32. Of interest is the finding of HPV,
particularly types 16 and and less frequently type 18, associated
with squamous cell carcinoma of the oropharynx (tonsil).

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  If the pathologist reports the lesion as cancer, then the patient
needs to be referred promptly to a cancer treatment centre for
assessment and treatment. An important component of the
assessment is to establish the stage of the disease. Similar to
cancers at other sites in the body, cancer of the mouth is staged
using the TNM system where T stands for tumor size, N for the
presence or absence of tumor involvement in regional lymph
Treatment nodes and M for the presence or absence of distant metastases.
 Generally, the prognosis is better when the tumor is smaller and
has not metastasized to either lymph nodes or other
organs. Staging also plays an important role in determining the
most appropriate therapy for cancer of the oral cavity.

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  Cancer of the oral cavity is treated by:
 Surgery
 Radiation therapy
 Chemotherapy is often added to either treatment.
 For cancers that are restricted to the oral cavity, surgery is generally
the preferred treatment modality. Depending on the site, small
lesions can be excised and closed primarily. Larger lesions may
require more complicated surgical reconstruction using grafting
material taken from the arm or the leg.
Treatment  For patients with bulky tumors or for those with tumor in regional
lymph nodes, the preferred treatment is radiotherapy. In these
instances, radiation is administered in small daily doses (fractions) of
about 2 Grays until a total dose of about 70 Gray has been
administered.
 Radiation therapy has the effect of destroying the salivary glands and
reducing the vascularity to the mandible and maxilla. Hence, patients
who have had radiation therapy to the head and neck have a life-time
risk of developing a form of osteomyelitis, termed osteoradionecrosis
of the jaws.

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  The brush biopsy is considered an adjunct diagnostic tool which
uses a patented spiral shaped stiff brush to remove epithelial cells
for examination by a pathologist.
 The brush is firmly rolled over the lesion until bleeding points are
observed signaling the epithelial tissues have been penetrated.
The cells caught up on the brush are wiped off on a glass slide and
Brush Biopsy sent to the laboratory where pathologists use both computer
assisted and standard methods to evaluate the sample for the
presence of abnormal cells.
 The brush biopsy cannot render a definitive diagnosis, but will give
the practitioner more conclusive evidence of further abnormalities
such as abnormal cells that have been detected.

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  A new cytology technique being used by many hospitals and
gynecology practices in place of the traditional scraped Pap smear
may be used with oral specimens as well.
 Instead of transferring the specimen onto a glass slide, the brush
Cytology used to collect the cell specimen is twirled in a vial containing an
alcohol-based fixative/preservative liquid.
 The brush head remains in the fixative so that no cell is lost during
this process and the entire vial is sent to a laboratory for
microscopic evaluation of the cells.

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  The VELscope is a hand held device that excites the tissue causing
it to fluoresce. Normal, healthy tissue will appear pale green when
exposed to the emitted blue light, and when the tissue is not
normal, the color will be darker green to black. No pre-rinse is
used with this adjunct.
 The device has been found useful especially to delineate surgical
Velscope margins that may extend beyond the visible lesion margins.
 When there is a high degree of inflammation, such as in the case
of lichen planus, mucous membrane pemphigoid, pemphigus
vulgaris, lupus, etc. the tissue may appear dark; thereby,
producing a false positive result. Any type of inflammatory
process such as cheek chewing, etc. will also exhibit a darker color
change. (www.velscope.com)

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  The ViziLite device has several components. The patient rinses
with one percent acetic acid for 30-60 seconds followed by the use
of a Chemiluminescence light.
 The light stick is especially beneficial in identifying white and
erythroleukoplakia lesions. After the light stick is broken and
shaken, it is placed next to all visible oral soft tissue surfaces. The
ViziLite device will cause illumination of any leukoplakia and/ or
erythroleukoplakia lesions causing them to appear bright white.
 T-Blue is a part of the plus system and contains pharmaceutical
grade tolonium chloride, which is a toluidine-blue dye that stains
the nuclear cell material blue. The use of the T-Blue assists in
further delineating the extent/margins of any detected lesions.
This is an FDA approved product. (www.vizilite.com)

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  Radiographs and oral photography are important adjuncts which
can be utilized to compare changes in tissue. This is especially
beneficial in cases where severe inflammation is present. Many
mucosal diseases have an inflammatory component and some
adjunct devices do not present any conclusive evidence supporting
anything other than inflammation with a failure to render a clinical
Simple Oral diagnosis.
 Often tissue specimens may return as diagnosed “non-specific
Pathology ulcerative tissue” and crucial areas may be missed due to
excessive inflammation. Being able to compare digital images of
the lesion provides the practitioner the added benefit of actually
seeing the progression or extension of the lesion.
 An added benefit is being able to show the patient any
progression when suggesting they need to have a biopsy.

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  The microscopic examination of desquamated cells for diagnostic
purposes. The cells are obtained from lesions, sputum, secretions,
urine, and other material by aspiration, scraping, a smear of
tissue.
 Steps:
 Prepare the lesion – irrigate and wipe
Exfoliative  Scrape the lesion – scrape with metal spatula several times
Cytology 

Smear on the glass slide – start at center of slide
Fix the cells – flood with alcohol on the slide or spray
 Obtain second smear – duplicate process
 Complete the fixation – leave slides for 30 minutes, after 20
minutes tip slide to slide the remaining alcohol off
 Prepare History or Data Sheet – dentists name (address), patients
name (address), lesion details, other info.

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  Erythroplakia – “Red Lesion”
 Etiology – a significant risk factor to the oral mucosa is chronic exposure to
carcinogenic components found in all types of tobacco. The other common
risk factor is chronic alcohol exposure. Even worse is a combination of both.
 Typical Visual Cues – a circumscribed, or ill-defined, erythematous plaque
that varies in size, thickness and surface configuration. It has a velvety
appearance and occurs most frequently on the floor of the oral cavity, ventral
area of the tongue and the soft palate.
Red Lesion  Useful Clinical Information – a painless and persistent lesion, found more
commonly in adult males and patients who report tobacco exposure.
 Treatment Recommendations – the patient should be counseled in a tobacco
cessation program if biopsies reveal that the lesion is premalignant. Then, a
more extensive therapy is indicated and the patient should be re-evaluated at
regular intervals for other oral mucosal changes.
 Clinical Significance – erythroplakia occurs less frequently than leukoplakia,
but it is much more likely to exhibit microscopic evidence of premaligancy.

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  Etiology – idiopathic (unknown). Risk factors include: tobacco use, alcohol
use, sun radiation, genetic predisposition, nutritional deficiency,
immunosuppression, and infections, such as candidal leukoplakia and human
papillomavirus.
 Typical Visual Cues – a deep-seated ulcerated mass, fungating ulcerated
mass, ulcer margins commonly elevated, adjacent tissues commonly firm to
palpation, and may have residual leukoplakia and/or erythroplakia.
 Useful Clinical Information – more common in adult males, continuous
enlargement, local pain, referred pain often to the ear, and paresthesia often
Squamous Cell of the lower lip.
 Treatment Recommendations – patient should be counseled to stop tobacco
Carcinoma use and given a referral to a local medical treatment facility for appropriate
treatment (surgery, radiation therapy, chemotherapy), and a careful periodic
re-evaluation.
 Clinical Significance – early diagnosis is essential for cure, presence of lymph
node metastasis greatly worsens the prognosis, approximately 50% of
patients have evidence of lymph node metastasis at time of diagnosis (that is
why the extraoral examination is so critical at the time of each intraoral
examination), and patients who have had one cancer are at greater risk of
having a second oral cancer. The overall 5-year survival rate is 45-50%.

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  Bacterial Plaque Control
 Start oral hygiene instruction at first appointment and emphasize preventive infection control
procedures and potential oral side effects associated with cancer therapy. Toothbrushing
instructions include using a soft or extrasoft toothbrush; a flavored dentifrice may not be
tolerated, but fluoride is essential. Mouthrinses include saline solution to moisten the mucosa
or baking soda rinses for managing oral mucositis. Chlorhexidine gluconate rinsing may also be
recommended for antibacterial properties. Commercial mouthrinses that contain alcohol
should be avoided.
 Daily Fluoride Therapy
 Daily fluoride therapy is indicated for patients about to undergo head and neck radiation
therapy, if the salivary glands are in the field of radiation. Make impressions and fabricate a
Oral custom fluoride tray, advise the patient to apply custom trays lined with prescription neutral
sodium fluoride gel to the teeth for four minutes once daily or use brush-on sodium fluoride
varnish. Advise patient to refrain from eating, drinking, or rinsing for 30 minutes following
Management fluoride application.
 Dietary Instructions
 Instruct the patient in the preparation of foods. Avoid highly cariogenic foods such as
carbohydrates and also spicy foods. A soft, bland diet is recommended. Water is
recommended throughout the day to moisten the oral cavity. Saliva substitutes are also
recommended to decrease the risk of caries.
 Avoid Alcohol and Tobacco Products
 If the patient uses tobacco products, a logical step for the cancer patient is to start tobacco
cessation counseling. See the ADAA continuing education course on tobacco cessation for
further

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The Dentition

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Tooth
Development

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Black’s
Classification

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  Early childhood caries, also known as baby bottle caries, baby
bottle tooth decay, is a disease characterized by severe decay in
the teeth of infants or young children. Early childhood caries (ECC)
is a very common bacterial infection. Its prevalence is epidemic; in
the US its rate is highest in minority and rural populations, at
times infecting over 70% of the children. A large body of scientific
evidence indicates that ECC is an infectious and transmissible
disease, with Streptococcus mutans the primary microbiological
Caries agent in the disease. The disease process begins with the
transmission of the bacteria to the child, usually from the primary
caretaker. Caretakers with untreated dental disease present a very
high risk to their children.
 Root caries – soft, progressive lesion of cementum and dentin.
This can increase with age and gingival recession is necessary.

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  Enamel Hypoplasia – organic enamel hasn’t formed properly.
Enamel is partially or entirely missing. AMELOGENESIS
IMPERFECTA
 Attrition – wearing away of the tooth from constant contact
Non-Carious  Erosion – loss of tooth substance by a chemical process
 Abrasion – mechanical wearing away of tooth substance by forces
other than mastication. At ROOT SURFACES and incisal edges.

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Fracture Types

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  A pulp test is a form of dental treatment. Its primary purpose is tooth
physical health evaluation, particularly, the dentist seats a tool on the
tooth that transmits an electric current, high or cold temperature.
 Certain pulp assessment techniques demand complete usage of the
tooth’s surface area, therefore tooth encased fully with crowns could
be harder to assess compared to uncovered tooth.
 The level to which this electric current generates a reaction in the
tooth can assess possible problems within the tooth. Pulp vitality tests
are important elements of the endodontic evaluation and assist in
revealing the condition of the tooth pulp.
Pulp Testing  These types of pulp tests can easily confirm the demand for dental
interventions such as root canals or tooth extraction. The tooth pulp
test determines the physical health of a tooth’s pulp.
 Once pulp vitality test of a affected tooth implies that pulp is not
active, dentists engage in root canal treatment to eliminate the
lifeless cells and protect against abscess.
 A dead pulp gives NO response. Lingering pain means irreversible
pulpitis, and when pain subsides it means reversible pulpitis.**

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  A carious lesion develops in three stages of demineralization. The
first stage in demineralization of enamel is called the incipient
lesion or “white spot”. This beginning carious lesion can be
reversed with the daily use of fluoride or calcium and phosphate,
persistent oral hygiene care, and a reduction of refined
carbohydrates. The second stage involves the progression of
demineralization leading to the DEJ and into the dentinal layer.
The third stage is the actual cavitation in the dentinal
layer. Neither of the last two stages can be reversed and require
Caries mechanical removal of dental caries.

Development  There are three levels of preventive dentistry that the dental
professional should understand when educating patients in the
dental caries process. The first step is primary prevention. This
prevents the transmission of S. mutans and delays the
establishment of bacteria in infants, toddlers, and young
children. The second step is secondary prevention, which
prevents, arrests, or reverses the microbial shift before any clinical
signs of the disease occur. The third step focuses on limiting or
stopping the progression of the caries process by initiating
remineralization therapy of existing lesions.

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  Once S. mutans and lactobacilli bacteria are established in the oral
cavity, the greater the risk for future caries to develop.
 Where biofilm (plaque) accumulates, the bacterial count is
considered to be higher, as in areas in the oral cavity that are
Prevention difficult to reach during oral hygiene, such as pit and fissures.
 Newly erupted teeth are deficient in mineral content (calcium and
phosphate), making them more susceptible to bacteria. By
introducing antimicrobial agents, such as fluoride the bacterial
count may be significantly reduced.

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  When refined carbohydrates are introduced into the oral cavity, lactic
acid production occurs as an end product of S. mutans, causing the
saliva pH to drop from a neutral pH of approximately 7 to an acidic
pH of 4.5-5.0. This metabolizing acidogenic bacteria’s lactic acid
production begin to demineralize the enamel.
 The more acidogenic bacteria present, the more lactic acid produced.
 When saliva is released into the oral cavity via the salivary glands, the
pH of the saliva returns to normal or an approximate pH of 7 and a
Demineralization period of remineralization (repair) occurs. This process is facilitated if
fluoride or calcium and phosphate ions are present locally. The
balance between demineralization and remineralization is crucial. If
the balance is not maintained and demineralization occurs too
frequently, then an incipient lesion will occur. This incipient or
‘white spot’ lesion may take up to approximately 9 months or more to
be seen via digital imaging or radiographically as a radiolucency or
dark spot on a bite-wing radiograph.

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  Raw vegetables, such as broccoli, cucumber, lettuce, carrots, peppers.
 Meat, fish, poultry.
 Beans, peas, nuts, natural peanut butter.
 Milk, cheeses, flavored yogurts.
 Corn chips, peanuts, popcorn.
 Fats, oils, butter, margarine.
Low  Non-sugar sweeteners, such as xylitol®, NutraSweet®, aspartame®, saccharin®,
sucralose®.
Acidogenic  Soft drinks, sport drinks, and energy drinks containing sugar are big business in the
United States. Frequent consumption of sugary drinks has long been known to
contribute to dental caries. According to the Centers for Disease Control (CDC),
Foods consumption of soft drinks in the United States has increased over the last 30 years
with both adults and children. Soft drinks have been linked to obesity and type 2
diabetes. Teenagers and young adults consume more sugar drinks than other age
groups. Males consume more soft drinks than females and low-income Americans
consume more soft drinks than those with higher incomes.
 A non-diet soft drink is made from carbonated water, added sugar and
flavors. Each can of soda contains the equivalent of about ten teaspoons, or 40
grams, of sugar. Mountain Dew® is so popular in the United States that the coined
phrase “Mountain Dew Mouth” is a recognized term used by the dental profession
for patients diagnosed with rampant caries and/or erosion.

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 •new carious lesions?
•progression of previous
Oral Risk Factors carious lesions?
•recurrent caries around
restorations?
•plaque present?
•calculus present?
Oral Hygiene
•bleeding on probing > 20%?
•motivation?
•carbohydrate intake?
•including frequency and
Dietary Analysis
texture (sucrose/fructose
drinks, sticky foods)?
Caries Risk •bacterial count?
•xerostomia?
Microbial and •physiological conditions?
Salivary Factors •prescription drugs affecting
saliva rate?
•salivary stones?
•> 5 in-between carbohydrate
meals/day ingested?
Family or Social
•dental fear?
Risk Factors
•cooperation problem?
•parent’s caries history?
•chronic diseases?
Medical Risk
•medically or physically
Factors
challenged?

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Stages of Calculus
Formation

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  Within minutes after brushing or cleaning teeth, a thin membrane
or pellicle, forms on tooth surfaces. This pellicle arises not from
the action of bacteria but from proteins within saliva that naturally
deposits on teeth as a protective coating. Bacteria exploit this
membrane, growing in it as readily as they grow on Petri dishes in
Pellicle a laboratory.
Formation  As the pellicle gains a freight of bacterial colonies, it loses its
solubility; the stabilized film allows more bacterial colonies to
grow on teeth, particularly in fissures and crevices.

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  Bacteria produce their own biofilm (a slippery matrix in which the
microbes grow undisturbed) that adheres to teeth. These biofilm
layers are the earliest stages of plaque formation. Plaque -- a
mixture of bacteria and bacterial waste products -- becomes
visible within hours after tooth-brushing as a whitish paste on
Plaque surfaces within the mouth.

Formation  As these bacterial colonies grow, they produce acidic by-products

that destroy tooth enamel, leading to tooth decay. Brushing and
flossing dislodge immature plaque less than 24 hours old but as
plaque matures it becomes more difficult to remove.

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  Within 24 hours, plaque begins to mineralize into calculus.
Acids and bases interact to form salts; this process forms part of
the composition of calculus as calcium and phosphates in alkaline
saliva interact with acidic bacterial wastes. In its earliest phase of
development, brittle calculus deposits fall away under a
Calculus toothbrush or strand of dental floss.
Formation  If left undisturbed, the mineralization process continues and builds
around defunct bacteria, fossilizing them. Within approximately
twelve days to two weeks, calculus matures.

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  Dentists can readily see mature calculus formations as whitish or
pale yellow structures affixed to teeth. The largest calculus
deposits typically occur on the lingual (nearest the tongue)
surfaces of the lower front teeth but tartar can occur anywhere in
the mouth.

Maturation  Sub-gingival calculus grows below the gums, while supra-

gingival calculus grows on visible tooth surfaces above the
gums. Although it feels solid, porous calculus plays host to
multiple colonies of bacteria that thrive on the increased
surface area that the mineralized plaque provides.

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  Another question patients ask frequently is, “Do I floss before or after
brushing?” Again, it doesn’t matter. As long as they are flossing properly,
dental professionals are thrilled. The point of brushing and flossing is plaque
removal. By removing the irritant plaque and reducing the bacterial count in
the saliva, the patient is making a significant difference in preventing caries
and periodontal disease.
 There are two flossing methods available to teach your patients. One is the
circle or loop method and the other is the spool method.
 The circle or loop method is preferred for children or any patient with low
manual dexterity. A piece of floss approximately 18 inches long is tied at the
ends to form a loop or circle. The patient uses the thumb and index finger of
each hand in various combinations to guide the floss interproximally through
Flossing the contacts. When inserting floss, it is gently eased between the teeth with a
seesaw motion at the contact point, making sure not to snap the floss and
cause trauma to the gingival papilla. Once through the contact area, gently
slide the floss up and down the mesial and distal marginal ridges in a C-shape
around the tooth directing the floss subgingivally to remove the debris.
 The spool method utilizes a piece of floss approximately 18-24 inches long
where the majority of the floss is loosely wound around the middle finger of
one hand and a small amount of floss around the middle finger of the opposite
hand. The same procedure is followed as the loop method when positioning
the floss interproximally. After each marginal ridge is cleaned, the used floss
is moved or spooled to the other hand until all supragingival and subgingival
areas have been cleaned, including the distal areas of the posterior teeth.

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  If your patients have large diastemas or food impaction areas,
they should be encouraged to utilize interproximal sticks such as
Stim-U-Dents®. Made of balsa wood, Stim-U-Dents® are used to
remove debris and plaque, and are preferred by dental
professionals over standard toothpicks because toothpicks can
splinter into the gingiva and damage the gingival tissue.
 If patients do not have access to floss, they can use the wooden
balsa sticks to remove plaque and stimulate the gingiva.
Tooth Picks
 Interproximal  These small interproximal brushes are attached
to handles and are used for large spaced interproximal areas and
for orthodontic patients to use between their brackets to remove
debris. There are a variety of brushes available, including travel
sizes for pockets and purses. The brushes are tapered for easy
access to difficult areas and patients seem to adapt well to
instructional use.

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Stats

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 Soft Tissue Injuries
 The face is often the most exposed part of the body in athletic competition
and injuries to the soft tissues of the face are frequent. Abrasions, contusions,
and lacerations are common and should be evaluated to rule out fractures or
other significant underlying injury. These usually occur over a bony
prominence of the facial skeleton such as the brow, cheek, and chin. Lip
lacerations are also common.
Fractures
 Fractures of the facial bones present an even more complex problem. One of
the most frequent sites of bony injury is the zygoma (cheekbone). Fractures
Injuries of the zygoma, occurring as a result of direct blunt trauma from a fall, elbow
or fist, account for approximately 10% of the maxillofacial fractures seen in
sports injuries. Like the zygoma, the prominent shape and projection of the
mandible cause it to be frequently traumatized. Approximately 10% of
maxillofacial fractures resulting from sporting activities occur in the mandible
when the athlete strikes a hard surface, another player or equipment. In a
mandibular fracture, airway management is the most important aspect of
immediate care.
 In both children and adults, the condyle is the most vulnerable part of the
mandible. Fractures in this region have the potential for long-term facial
deformity. Recent data suggest that condylar fractures in children can alter
growth of the lower face.

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 TMJ Injuries
 Most blows to the mandible do not result in fractures, yet significant force can be transmitted
to the temporomandibular disc and supporting structures that may result in permanent injury.
In both mild and severe trauma, the condyle can be forced posteriorly to the extent that the
retrodiscal tissue is compressed. Inflammation and edema can result, forcing the mandibular
condyle forward and down in acute malocclusion. Occasionally this trauma will cause
intracapsular bleeding, which could lead to ankylosis of the joint.
Tooth Intrusion
 Tooth intrusion occurs when the tooth has been driven into the alveolar process due to an
axially directed impact. This is the most severe form of displacement injury. Pulpal necrosis
occurs in 96% of intrusive displacements and is more likely to occur in teeth with fully formed
Continued roots. Immature root development will usually mean spontaneous re-eruption. Mature root
development will require repositioning and splinting or orthodontic extrusion.
Crown and Root Fractures
 Crown fractures are the most common injury to the permanent dentition and may present in
several different ways. The simplest form is crown infraction. This is a crazing of enamel
without loss of tooth structure. It requires no treatment except adequate testing of pulpal
vitality. Fractures extending into the dentin are usually very sensitive to temperature and other
stimuli. The most severe crown fracture results in the pulp being fully exposed and
contaminated in a closed apex tooth or a horizontal impact may result in a root fracture. The
chief clinical sign of root fracture is mobility. Radiographic evaluation and examination of
adjacent teeth must be performed to determine the location and severity of the fracture as
well as the possibility of associated alveolar fracture. Treatment is determined by the level of
injury.

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  Certainly one of the most dramatic sports-related dental injuries is
the complete avulsion of a tooth. Two to sixteen percent of all
injuries involving the mouth result in an avulsed tooth. A tooth
that is completely displaced from the socket may be replaced with
varying degrees of success depending, for the most part, on the
length of time it is outside the tooth socket.
Avulsion  If the periodontal fibers attached to the root surface have not
been damaged by rough handling, an avulsed tooth may have a
good chance of recovering full function. After two hours, the
chance for success is greatly diminished. The fibers become
necrotic and the replaced tooth will undergo resorption and
ultimately be lost.

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  When considering recommendations, an ideal mouthguard:

 protects the teeth, soft tissue, bone structure, and

temporomandibular joints
 diminishes the incidence of concussions and neck injuries
 exhibits protective properties that include high power absorption
Mouthguards and power distribution throughout the expansion
 provides a high degree of comfort and fit to the maxillary arch
 remains securely and safely in place during action
 allows speaking and does not limit breathing
 is durable, resilient, tear resistant, odorless, and tasteless

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  Stock Mouthguards
Stock mouthguards may be purchased from a sporting goods store or pharmacy. They are
made of rubber, polyvinyl chloride or a polyvinyl acetate copolymer. The advantage is that this
mouthguard is relatively inexpensive, but the disadvantages far outweigh the
advantages. They are available only in limited sizes, do not fit very well, inhibit speech and
breathing and require the jaws to be closed to hold the mouthguard in place. Because the
stock mouthguards do not fit well, the player may not wear the mouthguard due to discomfort
and irritation. The Academy of Sports Dentistry has stated that the stock mouthguard is
unacceptable as an orofacial protective device.

Mouth-Formed Protectors
There are two types of mouth-formed protectors: the shell-liner and the thermoplastic
mouthguard. The shell-liner type is made of a preformed shell with a liner of plastic acrylic or
silicone rubber. The lining material is placed in the player’s mouth, molds to the teeth and then
Types is allowed to set. The preformed thermoplastic lining (also known as “boil and bite”) is
immersed in boiling water for 10 to 45 seconds, transferred to cold water and than adapted to
the teeth. This mouthguard seems to be the most popular of the three types and is used by
more than 90 percent of the athletic population
 Custom Made Mouth Protectors
This is the superior of the three types and the most expensive to the athlete. But isn’t it worth
the cost to protect an athlete’s teeth from injury? Most parents will spend quite a bit of money
on athletic shoes, but might not think about protecting their child’s teeth. This mouthguard is
made of thermoplastic polymer and fabricated over a model of the athlete’s dentition. The
mouthguard is made by the dentist and fits exactly to the athlete’s mouth. The advantages
include: fit, ease of speech, comfort and retention. By wearing a protective mouthguard, the
incidence of a concussion by a blow to the jaw is significantly reduced because the condyle is
separated form the base of the skull by placing the mandible in a forward position.

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Landmarks of the Oral
Cavity
Individual Tutoring

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  Masticatory Mucosa: Heavily keratinized tissue that lines the hard
palate and tongue.
 Alveolar Mucosa: Lightly keratinized tissue that lines floor of the
mouth and covers the alveolar processes.
 Labial and Buccal Mucosa: Thinly keratinized tissue that lines the
inner surface of the lips and cheeks
 Oral Vestibule: A pocket formed by the soft tissue of the lips/cheeks
and the gingiva, its deepest point the “muccobuccal fold”.
Landmarks  Frenum: Raised lines of oral mucosa that extend from the alveolar
mucosa to the labial and buccal mucosa.
 Fordyce Granules/Spots: Yellowish sebaceous glands found on the
facial mucosa near the corners of the mouth.
 Linea Alba: A raised white line of keratinized tissue on the buccal
mucosa that runs parallel to the line of the occlusal plane
 Parotid Papilla: Flap of tissue found opposite the maxillary 2nd molar
on the buccal mucosa and contains the terminal end of the Parotid
Duct (Stenson’s Duct).

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Dentalelle Tutoring 53
  Hard Palate: Bony structure that separates oral cavity from nasal cavity.
 Incisive Papilla: Thick keratinized tissue that covers the incisive foramen.
 Palatine Raphe: Midline ridge of tissue that covers the bony suture of the
palate.
 Palatine Rugae: Irregular ridges or folds of masticatory mucosa that extend
horizontally from either side of the palatine raphe.
 Soft Palate: Forms the posterior section of the palate and is not supported by
Landmarks underlying bone. It can be lifted to meet the posterior pharyngeal wall to seal
the nasopharynx during swallowing and speech.
 Uvula: Small conical mass of tissue that hangs from the palatine velum
 Fauces: The passageway from the oral cavity to the pharynx (throat).
 Pillars of Fauces: Two arches of muscle tissue surrounding posterior oral
cavity. The Anterior Pillar of Fauces is also called palatoglossal arch, the
Posterior Pillar of Fauces is also called the palatopharyngeal arch. They
contract and narrow the fauces during deglutition (swallowing).

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Dentalelle Tutoring 55
  Dorsum of the Tongue: Superior (top) surface of the tongue
 Median Sulcus: A centralized linear indentation on the dorsum of the
tongue running anterior to posterior.
 Ventral Surface of the Tongue: Inferior (underneath) surface of the
tongue. The ventral surface of the tongue is very vascular and
covered with thin, alveolar mucosa.
 Apex of the Tongue: Anterior tip of the tongue.
Tongue  Filiform Papillae: Small cone shaped papillae found in the anterior 2/3
of the dorsum that are responsible for the sense of touch.
 Fungiform Papillae: Mushroom-shaped papillae spread evenly over
the entire dorsum of the tongue. They are deep red in color and each
contains a taste bud.
 Circumvallate Papillae: Cup-shaped papillae that are approximately 1-
2 mm wide and found on the posterior dorsum of the tongue. They
are usually arranged in 2 rows that form a “V-shape”. Each papilla
contains a taste bud.

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Dentalelle Tutoring 57
  Ala: Outer edge (wing) of the nostril.
 Philtrum: Shallow depression between the bottom of the nose and the top of
the upper lip.
 Vermilion Zone: Extraoral reddish portion of the lips.
 Vermilion Border: The border of the lips where the skin of the face meets the
Vermilion zone.
 Nasolabial Sulcus: Linear depression of the face that runs from the ala to the
corner of the mouth.
The Face  Labial Commissures: Corners of the mouth where upper lip meets the lower
lip.
 Tubercle of the Lip: Small projection of tissue in the middle of the upper lip.
 Nasion: Midpoint between the eyes just below the eyebrows.
 Outer Canthus of the Eye: Fold of tissue at the outer corner of the eyelids.
 Inner Canthus of the Eye: Fold of tissue at the inner corner of the eyelids.
 Tragus of the Ear: The triangular cartilage projection anterior to the external
opening of the ear.

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  Lingual Frenum: Midline fold of tissue between ventral surface of
the tongue and floor of the mouth.
 Sublingual Caruncles: Two small, raised folds of tissue found on
either side of the lingual frenum. They each contain a salivary
Floor of the duct opening for Wharton’s Duct (duct leading from the
Submandibular Salivary gland).
Mouth
 Sublingual Folds: Folds of tissue that begin at the Sublingual
Caruncles on either side of the lingual frenum and run backward
toward the base of the tongue. They contain the many ducts from
the sublingual salivary gland.

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  Incisors
 There are four incisors in each arch. Two central incisors and two
Function of lateral incisors.

Teeth - Incisors  Shape – single rooted, crowns are arched and angle toward one
sharp incisal edge.
 Function – to cut or incise food with their thin edges.

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  There are two canines in each arch. They are sometimes referred
to as cuspids.
Canines  Shape – anchored with the longest root, one pointed cusp.
 Function – used for holding, grasping, and tearing food. Referred
to as the cornerstone of the mouth.

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  There are for premolars in each arch. Two first premolars and two
second premolars. They are sometimes referred to as bicuspids.
There are no premolars in the primary dentition.
 Shape – maxillary first premolars have a bifurcated root, all others
Premolars have one root, one prominent cusp with one or two lesser lingual
cusps.
 Function – holding food, like canines because they have cusps;
also to crush food.

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  There are three molars in each arch of the permanent dentition.
Two first molars, two second molars and two third molars. Third
molars are sometimes called wisdom teeth. There are two molars
in each arch of the primary dentition. Two first molars and two
Molars second molars.
 Shape – bifurcated or trifurcated roots, broad chewing surfaces
with four to five cusps.
 Function – grinding food.

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 The primary dentition refers to the first twenty teeth to erupt in
the oral cavity. These teeth are also called deciduous teeth, and
will be exfoliated (shed) to make way for the permanent teeth.
There are 20 teeth in the primary dentition

Primary

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Permanent
Teeth

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Periodontium

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  www.Dentalcare.com
 Clinical Practice of the Dental Hygienist
 http://medicalimages.allrefer.com/large/lymph-tissue-in-the-
head-and-neck.jpg
 Darby and Walsh
 http://graphics8.nytimes.com/images/2007/08/01/health/adam/10
References 95.jpg
 Applegate EJ. The Anatomy and Physiology Learning System,
2nd Edition. Philadelphia: Saunders. p333.

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