EXTRAORAL AND INTRAORAL EXAMINATIONS

The following is a concise overview of the components of the extraoral and intraoral examination. It stresses a systematic and consistent approach to these examinations. (The order of the examination steps as described herein, is the systematic sequencing that the author uses. The order of the examination steps may vary depending individual clinician-determined protocols.)

Systematic Extraoral Examination 
A review and assessment of the systemic health and pharmacological status of the patient is always done prior to any dental examination. The extraoral examination continues with observation of the head and neck, as well as observation of the sound of the patient's voice and eye movements commencing from when the patient is first seated in the treatment room (Figure 1). Hoarseness in the voice may warrant further investigation if it has been persistent, since this may be an indication/suspicion of a growth within the larynx/oropharynx. Abnormal breathing may be a sign of anxiety or fatigue. Pupil size may signify a reaction to drugs or state of emergency as well as an indication of a disease state or inflammatory presence. The appearance of the face is further evaluated noting any asymmetry, swelling or discoloration. Inspection of the skin includes the color, texture, the presence of eruptions or swellings, or any abnormal growth. Observe all areas of exposed skin, paying particular attention to areas behind the ears and the back of the head and neck. Most people will have freckles, birthmarks, or moles; irregularities or a change in the shape, edge, color, and/or size can be a warning sign of skin cancer thus warranting further investigation. 
Have your patients remove their eyeglasses to make certain there are no hidden growths or developments that would have otherwise gone unnoticed. The areas along the hairline and under the eyeglasses will require tactile palpation in order to discern or identify any swellings/growths. 

Figure 1. Initial observation of head and neck, speech, and eye movements.	Figure 2. Examination of the temporomandibular joint.
Figure 3. Bilateral palpation of parotid  salivary glands.	Figure 4. Bilateral palpation of submental nodes.
Figure 5. Bilateral palpation of submandibular nodes.	Figure 6. Bilateral palpation of cervical lymph nodes.
Figure 7. Bilateral palpation of supraclavicular nodes.	Figure 8. Bilateral palpation of occipital nodes.
Figure 9. Bilateral palpation of postauricular nodes.	Figure 10. Bilateral palpation of preauricular nodes.

Next is the examination of the temporomandibular joint, utilizing a bilateral examination technique (Figure 2). This is accomplished by placing your finger pads over the joint just anterior to the ear; instructing the patient to open and close as well as move the jaw to the left and right; checking for any limitations or deviations upon opening, subluxation, any tenderness, sensitivity or any noises such as a grating, clicking, or popping. 
The next area to be examined is the parotid salivary glands (Figure 3). The extraoral palpation of the parotid salivary glands is best examined using a bilateral technique, employing light pressure and placing fingers at the angles of the mandible over the parotid glands. Compare the bilateral findings for symmetry. Normal parotid glands are not palpable and exhibit no tenderness. Abnormal salivary glands may be painful, swollen, and indurated. 
The lymph nodes are examined next with the clinician behind the patient and the patient's chin slightly elevated. Areas of particular concern in a systematic examination can be found in the Table.
It is important to inform the patient as to the relevance of the examination of the lymphatics of the head and neck before commencing this portion of the extraoral examination. In addition, one should indicate what areas of the head and neck will be examined. Due to the diverse multiculturalism that exists within our patient population, we must be culturally aware and sensitive to the different possible comfort levels of our patients. 
Evaluation of the lymph nodes is done by a gentle rolling motion of the fingers, using the bilateral palpation technique. Note any enlargement, tenderness, lack of mobility, hardness, or asymmetry. If enlargement is detected, the examiner should determine the mobility and consistency of the nodes. Enlargement or lymphadenopathy may be attributed to either an infectious or inflammatory process or a malignant neoplasm. Clinical characteristics can help discern the difference.
In the broadest clinical terms, the enlarged node, if related to infection, is most often soft, freely movable, and painful. Also, the patient may have presented with an infection (or presence of inflammation) and may occasionally possess some knowledge of the etiology. Malignant neoplasm related nodes are normally fixed, particularly in the later stages, and they are generally not painful. One could compare the consistency of an infection related node to a blueberry or pea, whereas a malignant neoplasm related node is normally firmer in consistency, like a stone. 
Next, submental and submandibular nodes should be examined carefully. With the patient's head back slightly, first examine the submental nodes (Figure 4). Instruct the patient to bite together lightly and place the tongue into palatal vault. This results in a tensing of the mylohyoid muscle, allowing for easier palpation of submental glands. Moving posterior toward the angle of the mandible and palpating directly below the line of the mandible are the submandibular glands (Figure 5). 
Another area to examine are the cervical nodes; both superficial and deep nodes. This set forms a complex chain of numerous nodes. Instruct the patient to turn the head in order to reposition the sternocleidomastoid muscle for ease of palpation and better access of both the superficial/deep cervical nodes (Figure 6). 
The supraclavicular nodes are palpated next, found superior to the clavicle in the hollow area or supraclavicular fossa directly above the collarbone (Figure 7). They drain a part of the thoracic cavity and abdomen. Virchow's node is a left supraclavicular node, which receives the lymph drainage from most of the body (especially above the abdomen) via the thoracic duct; this node may serve as an early site of metastasis for various malignancies. 
The next nodes to be palpated are the occipital nodes (Figure 8). These are associated with the occipital artery at the posterior base of the skull. Using a bilateral technique, palpation is done directly below the base of the occipital bone. Reclining the patient's head to the front, exposing the occipital area may facilitate better access for palpation of the occipital nodes. 
The posterior auricular, or postauricular, nodes are next in the systematic order of lymph node palpation and are usually 2 in number (Figure 9). The anterior auricular or preauricular nodes are from one to 3 in number and lie immediately in front of the tragus (Figure 10). Both pre- and postauricular nodes' efferent vessels drain into the superior deep cervical nodes. 
The thyroid gland, normally not detected by palpation, is examined next.
An abnormal gland could be indurated, enlarged on one or both sides, or contain palpable nodes. When using bilateral palpation, palpation is done on both sides of the gland, noting any nodules or masses (Figure 11). Instruct your patient to swallow, which in turn will elevate the thyroid gland; allowing for an abnormality to become more apparent. Asymmetrical movement of the thyroid cartilage during swallowing might indicate that the gland is fixed to underlying tissues. If the patient is obese, it may be easier to palpate this area positioned behind the patient, having him or her turn the head toward the examining side. Suspicious thyroid gland findings should be referred to your patient's physician for further evaluation.