Diagnostic Approach to Oral Lesions
The first dental exam should begin at the time of tooth eruption approximately at a year of age. As the individual ages, the primary objective of the exam will be the same, the maintenance of the structure, function, and cosmetics of the teeth and mouth. The specifics of the exam, however; will vary over time. As in any evaluation of normal and diseased states, obtaining a complete history is paramount and inclusive of both symptomatic and asymptomatic conditions. Specific to the dental exam, symptoms of mucosal bleeding, ear or jaw pain, mastication difficulties and signs of malocclusion, or improper teeth alignment, and the presence of oral growth should be elicited. Tobacco and alcohol have a significant negative impact on dental health; therefore; eliciting information about their use is critical to the completeness of the oral history.
The physical exam begins with evaluation of the face for symmetry, masses, or skin lesions. An examination of the mouth follows, with inspection of the teeth for alignment, mobility, color, and adherent plaque and tartar. Teeth are gently tapped with the mirror handle to assess percussion sensitivity and manually rocked to determine the presence or absence of mobility. The lips are palpated, with an open mouth and a tongue blade used to guide the examination and increase the visibility of the buccal mucosa, vestibules, palate, uvula, and oropharynx. With the tongue extended, the dorsum of the tongue is exposed and examined; side-to-side motion allows for inspection of both posterolateral surfaces. The ventral surface of the tongue and floor of the mouth is examined with an upward motion of the tongue. Palpation of the vestibules, floor of the mouth, and sublingual and submandibular glands is included in the oral examination. Opening and closing of the jaw while palpating the head of the condyle anterior to the external auditory meatus allows for assessment of the temporomandibular joint.
Radiographic x-rays complete the dental examination. A panoramic x-ray is useful for a global assessment of the mouth, including but not limited to the presence of cysts or tumors, abnormally absent teeth, or super-numerary teeth. Assessment for dental caries and of the tooth root and bone requires a full set of x-rays, including 14 to 16 periapical and 4 bite-wing films.