Quality Resource Guide l Performance of an Oral and Head and Neck Examination 7th Edition 3 www.metdental.com Following visual examination, palpation of the anatomic triangles proceeds in an orderly fashion, that being the preauricular/postauricular, submandibular, submental, anterior cervical, posterior auricular, posterior cervical and occipital regions. Abnormalities may include tenderness or enlargement of lymph nodes as well as alterations in their degree of mobility (fixation) and changes in consistency (rubbery, doughy, and cystic). Submandibular salivary glands reside within the submandibular triangle along with lymph nodes at either pole of the gland, as well as superiorly and inferiorly. The thyroid gland, with symmetrical right and left lobes connected by a small band of thyroid tissue (isthmus) across the midline resides over the thyroid cartilage. The smooth, even consistency of the gland is characteristic as is an essentially absent profile on visual examination. With a swallowing maneuver the examiner will be able to better evaluate the normally minimally or subtly palpable thyroid gland for nodules, asymmetry, and masses. Submental lymph nodes are next to be palpated. While having the patient press the tongue against the palate, the mylohyoid and floor of mouth muscles will form a firm base allowing ease of lymph node palpation in this region. The largest major salivary glands, the parotid glands, may be palpated at their superior pole over the pre-auricular region. The flattened superficial (lateral) lobe of the gland will be smooth to the touch, non-tender and of even contour. The gland extends inferiorly slightly beyond and posterior to the mandibular angle. Numerous lymph nodes are located along the rim of the gland as well as within the gland itself. In the absence of pathology these lymph nodes are not generally palpable. Following the extraoral/cervical and major salivary gland evaluation, the examination proceeds to the perioral and intraoral phase beginning with the vermilion portion of the lips. Prior to this, however, the patient must remove any partial or complete dentures and eyeglasses. As with the extraoral examination, a consistent sequence should be established. The initial view of the lips should be at an at rest position with removal of lip covering such as lipstick and gloss allowing an examination of texture, color and surface integrity. Particular attention should be paid to the integrity of the junction between the skin and vermilion portion of the lip where a delicate uninterrupted and easily defined junction should be noted. In the open position, evaluation of the commissures is possible where absence of erythema, crusting and fissuring are expected and define the norm. Intraorally, with the patient’s mouth partially open, the upper and lower lips may be sequentially reflected allowing complete visualization of the labial mucosa, frenula and sulcus of each vestibule. This view will allow evaluation of color, surface quality and texture, swellings and abnormalities of the gingiva and alveolar mucosa. Bidigital palpation of the lips for masses or tenderness may then proceed prior to similar evaluation of the cheeks bilaterally with the mouth in a fully opened position. Smooth, glistening surface features should extend from the commissures, posteriorly to the anterior tonsillar pillar bilaterally. The examiner should evaluate for alterations of color as well as changes in surface texture, mobility, and masses by manual palpation. Continuing from the anterior tonsillar pillars, examination of the soft palate and uvula as well as the posterior wall of the oropharynx follows. Symmetrical elevation of the soft palate and depression of the tongue will allow visual inspection of the oropharynx and tonsillar region. Surface abnormalities and asymmetries should be noted. The keratinized mucosa over the hard palate and attached gingiva presents with a firm texture, pink color, and lack of mobility. Palatal contours should be even and symmetrical with gingival architecture showing complete, well-formed interdental papillae. A well-defined junction with the more vascular, distensible, and non-keratinized alveolar gingiva should be seen along the labial and buccal aspects of each quadrant. Sequencing of the examination should begin at the anterior palate, extending posteriorly to the right maxillary tuberosity and alveolar ridge, around the arch to the left maxillary tuberosity. Continuation to the left retromolar region, around the dental arch to the right retromolar area completes the gingival examination. Examination of the tongue begins with a partially opened mouth with the tongue at rest. The dorsum of the tongue should be evaluated Step 2 Step 3 Step 4 Step 5 Step 6 Step 7