Extra/intra-oral exam

Oct. 28, 2005
Reader inquires about tips on how to perform the exams.

Ann-Marie C. DePalma, RDH, BS

Dear RDH eVillage:

I am teaching a first-year dental hygiene class about the intra/extra-oral exams this week, and I wondered if anyone had any good tips or routines that may be helpful for students. I have some basic anatomy to go over, but would like to incorporate the importance of routinely doing these exams for our patients.

Thank you in advance!

Miquette McCanna, RDH, BS

Dear Miquette:

Doing a thorough intra/extra-oral exam is of vital importance for the patient. Many times I have heard stories from hygienists who found "something" that the patient's medical doctor didn't and saved the patient's life. There was a campaign a few years ago by the American Dental Hygienists' Association, "Want to Save a Life, See A Dental Hygienist," and that was so true. As hygienists, we are in a unique situation to view and impart knowledge on a variety of topics to our patients.

With that said, the dental hygiene student must first understand the steps involved in performing an intra/extra oral exam.

These include:

• Inspection (using the eyes to view the patient)

• Palpation (feeling)

• Percussion (the process of striking a body part, such as a sensitive tooth)

• Auscultation (listening to different sounds such as TMJ)

• Olfaction (involves the nose in order to smell odors on the breath)(1)

A systematic approach should be used on all patients, beginning from the moment they enter the operatory (and often as they are walking into the room). The hygienist can view the patient's overall gait and mannerisms and make appropriate observations. The actual head/neck exam can be done in a matter of minutes and can give valuable information.

I would start at the top extraorally and work downwards and then go intraorally. However, as long as the hygienist performs the same assessment in the same manner on all patients, the order is not as important as the actual doing of it.

However, before beginning the process of examination, the hygienist should first explain the procedure to the patient and explain the rationale behind doing the exam. Many patients have never had a comprehensive exam performed and may be apprehensive about it. Reassure the patient, but also request permission to move the patient's hair and to perform needed palpations.

With appropriate PPE donned, starting at the forehead, the hygienist should inspect the overall structure of the patient's face and eyes, noting any asymmetries or skin conditions. This can be viewed from the front of the patient.

The hygienist should then move to behind the patient and evaluate the hair line and behind the ears. From this position, the cervical spine and lymph nodes can also be evaluated by palpation. The hygienist can then palpate the muscles of mastication and TMJ, noting any popping, clicking, or tenderness. The hygienist can then palpate the submandibular nodes and the thyroid gland.

She/he can then rotate to in front of the patient and exam the TMJ again while noting range of motion and listening for any sounds. The thyroid gland can then also be fully evaluated, being careful only to palpate one side at a time as so not to interfere with arterial blood flow in the area.

The examination should proceed down into the clavicular area noting any abnormalities.

All of these examinations should be done bimanually and bilaterally. When done with a light touch by the hygienist in an unhurried manner, most patients find this examination very relaxing and stress-reducing.

After repositioning the patient, the hygienist can then begin to evaluate intraorally. Begin with an overall quick view of the arches and tissues.

Then begin with lips, noting open and closed positioning and palpation. Use both digital and bidigital palpation. Check the patient's breath as well as ask the patient if he/she notices any breath issues, or if they have been approached about it by others.

Palpate and inspect the labial and buccal mucosa, tongue, floor of the mouth, saliva, hard and soft palates/uvula and tonsillar areas. During the examination of the tongue, a wet gauze square is more patient-friendly than a dry one. Use mirror and appropriate reflection where needed.

In addition to the visual, olfactory, and palpation exam, a product known as ViziLite by Zila Pharmacuticals is available to enhance oral cancer detection by dental professionals. After the patient rinses with a dilute acetic acid solution, dense nuclei of abnormal squamous epithelial tissue will appear white when viewed under a diffuse low-energy wavelength light.(2) This procedure takes seconds and has been found to be effective in finding areas of oral cancer that visually were missed.

The next important step during the examination process is to record and inform the patient of findings, both normal and abnormal. If any abnormalities were discovered, appropriate referrals should be provided for the patient. If a referral is made, a good patient/office enhancement would be for the hygienist to personally call the referring office and schedule the appointment for the patient. In addition, if a referral was made, a registered letter with documented findings should be sent to the patient after the patient's appointment.

The hygienist is a vital player in the overall health of patients. Doing a thorough intra/extra-oral exam and fully explaining the procedure to patients will enhance the patient's understanding and appreciation of the professional role of the dental hygienist.


(1) Comprehensive Periodontics for the Dental Hygienist, Mea Weinberg, DMD, et al, Prentice Hall Publishers 2001

(2) ViziLite Product information, Zila Pharmaceuticals , Phoenix Arizona, www. Vizilite.com or 866-945-2776

Information for the article also obtained from Clinical Practice of the Dental Hygienist, 9th edition, Esther Wilkins, DMD Lippencott, Williams and Wilkins Publishers, 2005

Ann-Marie C. DePalma, RDH, BS, is currently a faculty member at Mt. Ida College's dental hygiene program after spending more than 25 years in private practice. She is also pursuing a master's degree in education in instructional design. A member of several professional dental hygiene associations, Ann-Marie has written numerous articles and provides continuing education programs for dental hygienists and dental team members. She can be reached at [email protected].