Extraoral examination Show Sign and symptoms are essential to identify the etiology and monitor the progression of the disease for which the patient is seeking treatment. Each patient should be evaluated with an extraoral and intraoral examination. [6] The presence of neck swellings is not an uncommon finding, especially in patients with oral infections or malignancies. Lymphatic drainage from oral cavity sites is mainly to submental and submandibular lymph nodes, although other regional lymph nodes may be involved. Lymphadenopathy secondary to infection is generally characterized by both mobile and tender nodes. Patients with oral cancer typically present with non-tender node enlargement, with firm or hard lymph nodes on palpation and fixation (immobility). [7] Salivary gland pathology of the major salivary glands are best detected by careful palpation of the preauricular skin for parotid related diseases (see the second image below). Extraoral palpation of the submandibular and sublingual glands can often reveal enlargement and tenderness; however, bimanual palpation frequently is more effective.  Myofascial and temporomandibular joint (TMJ) pain is commonly encountered in patients. All patients should be examined for possible facial asymmetry and limitation in opening, deviation or guarding. TMJ is palpated for function and tenderness with the mouth closed with the first and second fingers over the joint. The patient is then asked to open and close the mouth repeatedly to assess the presence of any crepitus, symptomatic clicking, or popping. These can also be detected by placing the tips of the fifth finger in the external auditory canals (see the picture below). All muscles of mastication should be palpated for possible tenderness during clenching and at rest (especially the masseter and temporalis which can be palpated extraorally). During the examination, it is important to ask the patient to point out any particular areas of pain (trigger points).The mandibular attachment of the temporalis and medial pterygoid muscles are usually palpated by inserting the second finger into the posterior maxillary vestibule. Both lips should be examined visually and by palpation. The vermilion border is usually smooth and pliable (see the picture below). Intraoral examination As with any other portion of the physical examination, the intraoral examination should be performed in a systematic manner. For many healthcare providers, the examination of the oral cavity is a clinical skill that is acquired only through repetition. Adequate lighting is an essential component for a good oral examination. Dental offices are equipped for such examinations; however, medical practitioners who do not normally utilize fixed or head-mounted examination lights may be forced to rely on hand-held flashlights or a penlight, supplemented by the ambient room lighting. If patients wear removable prostheses these should be removed to perform a thorough intraoral examination. Dentures should be evaluated for fit, general appearance and hygiene. Each anatomic structure should be visually inspected and palpated; possible lesions should be evaluated with respect to size, extent, thickness, texture, color, consistency, and tenderness. The oral mucosa has traditionally been described as salmon-pink in color; however, great variation exists depending on race, vascularity and keratinization. Labial mucosa Evert the lips and inspect the labial mucosa (upper and lower) (see the image below). In healthy individuals, the labial mucosa appears as smooth, soft, and well lubricated by the minor salivary glands. Anxiety regarding the examination (“white coat syndrome) may result in a transient hyposalivation. In such cases, the mucosa may become sticky to the touch. The minor salivary glands of the lower lip frequently are palpable. The lower lip is frequently subjected to injury that can cause trauma to the minor salivary gland ducts, resulting in the formation of a mucocele, a lesion most frequently found in lower labial mucosa/lip. Buccal mucosa Examination of the buccal mucosa is most easily accomplished by having the patient partially open the mouth, followed by stretching of the buccal mucosa with a mouth mirror or tongue blade. The orifice of the parotid gland (ie, the Stensen duct) can be found as a small punctate soft tissue mass on the buccal mucosa adjacent to the first permanent molar teeth. Some patients may present with mild gray-white lacy lines on the buccal mucosa that disappear with stretching of the mucosa (leukoedema). [8] Another common finding of the buccal mucosa or labial mucosa are the Fordyce granules. These represent ectopic sebaceous glands. Linea alba (“white line”) is also often observed on the buccal mucosa as a result from chronic trauma against teeth. Linea alba manifests as a horizontal white streak along the buccal mucosa at the level of the occlusal plane bilaterally. Saliva should be able to be expressed from the duct; however, extraoral massaging of the gland may be necessary. The saliva should be clear and watery, and the patient should not experience any discomfort with the procedure. As with the lips, the buccal mucosa should also be well lubricated with saliva. Minor salivary glands and Fordyce granules may impart a granular texture to the buccal mucosa. Tongue and floor of the mouth All surfaces of the tongue should be examined including the dorsum, sides and ventral tongue. The dorsal surface of the tongue is most easily visualized by having the patient protrude the tongue and attempt to touch the tip of the chin. Alternatively, the tip of the tongue can be grasped by the fingers and a 2 X 2-in gauze. The dorsal surface of the tongue is uniformly covered by numerous filiform papillae, as shown below. Interspersed among the filiform papillae are dozens of mushroom-shaped fungiform papillae, each of which contains one or more taste buds, as shown below. The circumvallate papillae are at the junction of the anterior two thirds and posterior one third of the tongue. These structures normally are 8-12 in number and are arranged in a V-shaped pattern anterior to the foramen cecum, a shallow depression which represents a developmental remnant of the thyroglossal duct. Like the fungiform papillae, the circumvallate papillae also contain numerous taste buds. Coated or hairy tongue is characterized by hyperplastic filiform papillae and accumulation of keratin due to increased retention and reduced exfoliation secondary to dehydration. Patients may complain of bad breath and even gagging especially if the coating is localized to the posterior tongue near the circumvallate papillae. Fissuring of the dorsal surface of the tongue has been described in dry mouth or syndromic patients (e.g., trisomy 21); however, the presence of fissuring is of no clinical significance in the vast majority of cases. Atrophy of the dorsal surface of the tongue can be secondary to nutritional deficiencies, some medications (e.g., hydroxyurea), erythematous candidiasis and other mucocutaneous diseases. In addition to discomfort, patients often report altered taste sensations. Foliate papillae are structures present on the posterolateral aspect of the tongue and contain additional taste buds. These can be often mistaken for abnormal tissue as they may vary in size and appearance. The lateral borders of the tongue can be examined by grasping the tip of the tongue with a gauze sponge, extending it, and rotating it laterally. [9] The lateral borders of the tongue are not covered by a large number of papillae. The mucosa is more erythematous and, as one moves more posteriorly along the lateral border of the tongue, vertical fissuring becomes more prominent. Collections of mucosal-colored tissue with a bosselated surface can be found at the base of the tongue. This accessory lymphoid tissue (lingual tonsil) is a component of the Waldeyer ring and may become enlarged in the presence of infection or local inflammation. The ventral surface of the tongue is most easily visualized by having the patient touch the tip of the tongue to the roof of the mouth. The sublingual vasculature often is prominent, especially in older individuals. Fronds of tissue, the plica sublingualis, can frequently be observed extending from the ventral surface of the tongue, as shown below. The floor of the mouth, similar to the buccal mucosa, is salmon-pink in color. The orifices of the submandibular glands (ie, the Wharton ducts) are present as 2 midline papillae on either side of the lingual frenum, shown below. Saliva frequently pools in the floor of the mouth during an oral examination. This pooled saliva is removed most easily with a gauze. Subsequent bimanual palpation of the submandibular and sublingual glands should result in the expression of saliva from the Wharton ducts. This saliva generally is more viscous than the one from the parotid glands because of the higher percentage of mucous saliva. Both the ventral/lateral surface of the tongue and the floor of the mouth are common sites for oral cancer. An incisional biopsy remains the gold standard to rule out dysplasia or invasive squamous cell carcinoma. Hard palate The palate is divided into the soft palate posteriorly and the hard palate anteriorly. Direct visual inspection of the hard palate is accomplished most easily with the use of an intraoral mirror. The hard palate, similar to the attached gingiva, normally is less pink than other oral mucosal sites because of its increased keratinization (see image below). The anterior hard palate is covered by numerous fibrous ridges or rugae, (see second image below) and many individuals may present with a prominent midline incisive papilla anteriorly (the opening of the incisive canal). Minor salivary glands are abundant in the hard palate; because of this, a high incidence of minor salivary gland neoplasms, both benign and malignant, is found in this location. Soft palate and oro-pharynx In contrast to the hard palate, the soft palate is nonkeratinized and salmon-pink in color. It is easily visible on direct examination by depressing the posterior tongue with a tongue blade and instructing the patient to say "Ahhh." Deviation of the soft palate to one side or the other may indicate a neurologic problem or an occult neoplasm. Once the posterior tongue has been depressed and the patient has elevated the soft palate, examining the oral pharynx is possible. This can occasionally be complicated in patients who have a hyperactive gag reflex; however, in such cases, the gag reflex can be suppressed through the use of topical anesthetics. The tonsillar pillars are visualized most easily by moving the tongue laterally with a tongue blade. The tonsillar crypts are highly vascular and appear more erythematous than the surrounding tissues. Patients often have accumulations of desquamated epithelial cells, food, and other debris present in the tonsillar crypts, which can lead to a scratchy sensation in the throat and halitosis. Accessory lymphoid tissue on the posterior oral pharynx (adenoids) is normal and appears as pale irregular mucosal papules. These tissues may enlarge in the presence of inflammation or infection. Oral pharyngeal alterations are not uncommon, especially with oral viral infections (eg, herpangina; hand, foot, and mouth disease). Gingivae The gingivae are examined most easily with the mouth partially closed and the lips retracted with the fingers, a tongue blade, or plastic lip retractors. The attached gingiva (ie, gingiva adjacent to the crowns of the teeth) [10] is keratinized and appears paler than other oral mucosa (see the first image below). This tissue usually is firm, stippled, and firmly attached to the underlying bone. The alveolar mucosa extends from the attached gingiva to the vestibule. In contrast to the attached gingivae, alveolar mucosa is not keratinized (see the second image below). The attached gingivae are frequently pigmented, the intensity of which is somewhat proportional to the presence of cutaneous pigmentation; however, alveolar mucosa is rarely pigmented (see the third image below). Alterations in the clinical appearance of the gingivae can be an indicator of gingivitis or a systemic disease. The most common cause of gingival erythema is poor dental hygiene. Deposits of dental plaque and calculus result in gingival inflammation and, if not removed, involvement of the underlying supportive structures of the teeth. The presence of retained dental plaque and calculus also serves as a nidus for a number of reactive gingival lesions (eg, pyogenic granuloma). The gingiva is also the initial site of occurrence of mucocutaneous diseases (such as lichen planus, mucous membrane pemphigoid, pemphigus vulgaris). Dentition Examination of the teeth should be the final part of the oral examination. The pediatric or primary dentition consists of a total of 20 teeth (2 molars, 1 canine, and 2 incisors per quadrant). The adult, or secondary, dentition includes 32 teeth (3 molars, 2 premolars, 1 canine, and 2 incisors per quadrant). Any number of developmental defects of the teeth may be apparent. Partial anodontia is a common occurrence, especially involving the maxillary lateral incisors. Supernumerary teeth (eg, mesiodens) may be also noted. Missing teeth and supernumerary teeth are commonly found in a variety of inherited disorders (eg, Gardner syndrome, oral facial digital syndrome). Gross decay of the occlusal (biting) surfaces of the teeth usually appears as discolored cavitations and represents the sequelae of poor oral hygiene. Decay involving the interproximal (ie, tooth-to-tooth contact) surfaces may not be clinically apparent without the aid of intraoral radiographs. Cervical decays (the decay at the gingival margins of the teeth adjacent to the attached gingiva) may be the first manifestation of dry mouth. Root surface caries are also commonly observed in geriatric patients with gingival recession [11, 12, 13, 14, 15, 16] How do you palpate the temporomandibular joint?Palpate directly over the joint while the patient opens and closes the mandible, and the extent of mandibular condylar movement can be assessed. Normally, condylar movement is easily felt. Have the patient close slowly, and you will feel the condyle move posteriorly against your finger.
Which instruction to the client will facilitate examination of the temporomandibular joint by the nurse?Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? While performing the assessment of the temporomandibular joint, the nurse should ask the client to open the mouth. This gives an easy access to the joint.
Why do we perform head and neck assessment?The information gathered from the physical examination of the head and neck. Peritonsillar Abscess , along with the information from the history, is used by the physician to generate a differential diagnosis and treatment plan for the patient.
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What action would a nurse have a patient perform in order to palpate the temporomandibular joint?
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