رابعة حديث

lip

Intraoral examination Dr. Mohamed Abdel-Moniem

Intraoral Examination:-

It is the most important and most

direct diagnostic evaluation that

affects the treatment plan.

Examination should involve the

diseased and healthy regions.

To avoid overlooking of any area you

should examine the oral cavity in

systematic approach.

The intraoral examination is classified into:-

1- general appraisal of the patient’s oral

health and chief complain area.

2- examination of the soft tissues and hard

structures (mandible, maxilla and palate).

3- examination of teeth.

4- examination of the gingiva and

periodontal supporting structures.

I- general appraisal of the patient’s oral health and chief complaint area:-

Performed by Inspection

The following informations can be obtained:-

1- general inspection of the area of chief complaint.

2- presence of deposits and stains:- soft (plaque) , hard (calculus), intrinsic stains (amelogenesis imperfecta, porphyria and tetracycline staining) extrinsic stain as (food, chromogenic bacteria, smoking).

3- prevalence of caries or periodontal diseases.

4- Missing teeth and retained deciduous teeth.

5- supernumerary teeth (mesiodense, paramolar and

distomolar).

6- presence of restorations and appliances.

7- presence of halitosis.

These informations will gives idea about:-

1- Chief complaint area and the general techniques which will be used during its examination.

2- The possible diagnostic aids e.g. X-ray, biopsy …… etc.

3- Patients attitudes toward his oral health.

4- Time which will be consumed during examination.

5- The suggested treatment planning (patient with neglected and bad oral hygiene are contraindicated for advanced periodontal surgery, implants and periodontal reconstructive procedures)

Important notes during intraoral examination-

1- examination should be aimed toward

confirming normal findings and detecting

abnormalities.

2- examination should be performed in a

systematic manner to avoid omissions.

3- examination should be performed in a

manner consistent with infection control

recommendations.

The complete examination of the mouth includes

evaluation of:-

1- lips and labial mucosa.

2- Buccal mucosa.

3- Mucobuccal fold.

4- hard palate.

5- soft palate and uvula.

6- oropharynx and nasopharynx.

7- tongue.

8- floor of the mouth.

9- periodontium.

10- examination of the teeth.

1- examination of the lip and

labial mucosa:-

Lips consists of:- Vermilion border and skin.

Vermilion border is the exposed red portion

of the lip and covered by mucous membrane.

Vermilion border is bounded by the labial

mucosa in the mouth and by the

mucocutaneous junction on the face.

Vermilion border does not contain mucous

glands.

The lips are bounded in the face by:-

1- Lateral labial sulcus:- runs from the ala of

the nose downward outward.

2- Mesial labial sulcus:- begins at the corners

of the mouth (also called the commissures) and

runs parallel to the lateral labial sulcus.

3- The mental labial sulcus:- runs parallel to

the mucocutaneous junction of the lower lip.

4- Philtrum:- it is a depression dividing the

upper lip into right and left halves.

In the oral cavity:-

1- The lips are covered by mucous

membrane that has numerous mucous

glands (accessory salivary glands).

2- At the midline, the upper lip has frenum

attaching it to the maxilla and the lower

lip to the mandible.

3- The upper labial frenum in some

patients has a small tissue tag called

fibroepithelial polyp caused by trauma.

The examination of the lip is carried out by

inspection and palpation.

I- Inspection:-

Performed with the patient sitting in a relaxed facial

expression to note the lip morphology and lip seal.

Normally the lips must seal without muscle tension this

occur in normal competent lip morphology.

If the lips are apart at rest this may indicates that there

is a mouth breathing or nasal obstruction.

The part of the teeth that appear during speaking and

smiling should be considered in dental restorations and

prosthesis.

Features obtained by inspection of the lip:-

1- Morphology.

2- Color.

3- Function.

4- Lesions.

5-Texture.

6-Fissuring.

7- scars.

8- others.

A- Morphology:- The lip morphology is changed

if the lips are affected by :-

1- Cheilitis glandularis apostematosa:-

It is uncommon condition caused by chronic exposure to sun, tobacco and emotional disturbances.

It affects the lower lip in which the lip becomes enlarged, firm and finally everted exposing the openings of the accessory or minor salivary glands.

Pitting appear with pressure.

The accessory salivary glands it self becomes enlarged and sometimes nodular.

2- Cheilitis granulomatosa:- It is a diffuse swelling of the lips

especially lower lip.

The lips usually soft and exhibits no pitting upon pressure.

Cheilitis granulomatosa, facial paralysis and fissured tongue referred as Melkersson Rosenthal syndrome.

3- Lip pits:- unilateral or bilateral depression

or pit on the vermilion border commonly on the lower lip.

4- Commissural pits:- Unilateral or bilateral pits at the

corners of the mouth on the vermilion surface.

5- Cleft lips:-

Mandibular clefts are rare condition.

The maxillary cleft lip is the most common.

It may be unilateral or bilateral but not a midline one.

6- Double lip:- It is not an actual duplication of the lip.

It is a groove running between the inner and outer part of the upper lip.

Appear when the patient smiles or talks.

It can be corrected surgically.

Double lip, thyroid enlargement and dropping of the upper eyelid referred as Ascher’s syndrome.

7- Angular chelitis :-

Caused by candidal infection of the lip

commissures.

Characterized by soreness, erythema,

maceration ulceration of the commissures.

8- High attachment of the frenum:-

Labial frenum is a slender midline band

attached at the mucogingival line below the

attached gingiva.

Higher position of the frenum usually

accompanied by gingival recession, diastema

and pocket formation due to tension of the

marginal gingiva during function.

It is examined by gentle pulling of the lip

outward and noticing the retraction of the

marginal gingiva and opening of the sulcus.

Features obtained by inspection of the vermilion

border:-

1- Morphology.

2- Function.

3- Colour.

4- Fissuring.

5-. Texture

6- Lesions

7- scars.

8- others.

B- examination of the function of the lips:-

Dropping of the angle of the mouth

during speaking may be a habitual way of

speaking.

Dropping of the angle at rest may be

facial paralysis, it can be evaluated by

requesting the patient to smile and show

his teeth, blow out the check or whistle.

These functions reflect the integrity of

the 7th cranial nerve.

In facial paralysis the air will pass

through paralytic side and there will

be retention of food and calculus

covering the occlusal surface in the

that side.

Examination of the function of the

mucous glands can be performed by

everting the lip and drying it to notice

the appearance of saliva again.

Features obtained by inspection of the lip:-

1- Morphology.

2- Function.

3- Colour.

4- Lesions.

5- Texture

6-Fissuring

7- scars.

8- others.

C- Color changes of the lips:-

The lip should be retracted to permit thorough inspection of

the labial mucosa.

Common changes in lip color:-

1- pale lip:- in amemia.

2- Caynotic or bluish lip:- in heart diseases and

lung diseases.

3- Browinsh pigmentation:- may be racial or in

Addison,s disease or in hereditary intestinal

polyposis.

4- yellow spots:- in Fordyce,s granules.

5- Bloody crusted appearance:- in erythema multiform.

6- Bluish red spots :- in petechia, ecchymosis

and telangectasia.

7- white color:- in lichen planus.

8- large bluish coloration:- in hematoma due to

trauma.

Features obtained by inspection of the lip:-

1- Morphology.

2- Function.

3- Color.

4- Lesions.

5- Texture

6-Fissuring

7- scars.

8- others.

Angular chelitis and chelosis

occur due to vit. Defeciency,

candidal infection and low

vertical dimension.

Contact allergy:- caused by food,

mouthwashes, cosmetics and

filling materials.

2- Herpes labialis (H.s and H.Z).

Mucocele, mucous retention cyst

and lipoma

Focal epithelial hyperplasia:- multiple

slightly raised papules caused by HPV-

13 or HPV -32.

Lichen plannus

Actinic keratosis:- solar keratosis

occurs due to excessive exposure

to ultraviolet rays.

Angioneurotic edema:- sudden diffuse

swelling, firm and non pitting. Usually

one lip is involved

Smokers patch

II- examination of the lip by palpation:-

It is carried out by bidigital and bimanual palpation.

To detect:-

1- Consistency, pliability, firmness of the underlying

tissues.

2- surface tissue indurations.

3- glandular involvements.

N.B. submucosal nodular or granular sensation

occasionally occur normally in adults due to the

presence of the minor salivary glands.