INTRA ORAL

EXAMINATION
- Dr. Kashyap Sawant
Contents
• Introduction
• Preliminary considerations
• Chief complaint
• Examination
• Summary
Introduction
• Intra oral examination is one of the key components of diagnosis and
treatment planning.
Preliminary consideration
• Age , gender and demographics should be recorded
• Should be preceded by extra oral examination
• Dentist must investigate the previous medical history and dental
history
• Remove any dentures if present before examining
• Use visual inspection supplemented by palpation
Patient’s chief complaint
• Patients must be asked to mention their chief complaint
• Patient must describe issues / problems with the previous prosthesis
• Dentist should know what the patient is expecting from the new
prosthesis
• Dentist should not overlook areas other than the area of chief
complaint
EXAMINATION
Terminologies
• Erosion - Erosion - Partial loss of
surface epithelium without
• Papule – small circumscribed
exposure of connective tissue
elevated area
• Ulcer – full thickness loss of
epithelium • Macule – non elevated area of
discoloration
• Vesicle – circumscribed
accumulation of fluid less than 5
mm
• Bulla – circumscribed
accumulation of fluid larger than 5
mm
Colour of the mucosa
• Healthy pink to angry red
• Can be due to ill-fitting denture, infection, underlying systemic disease
or chronic smoking
• White keratotic patches are caused by denture irritation
• Questionable tissue must undergo biopsy and sent to the laboratory
Vermillion border
• Colour should be even
• Demarcation must be sharp between skin and vermillion
• Blurring of the edge – actinic chelitis
• Redness and fissures at the corner of the mouth – angular chelitis
• Record if any hyperkeratosis , ulcers or pigmentation is present
Labial mucosa
• Evert the lip(upper and lower) with index finger and thumb to
examine
• Abnormalities like scar , polyps or ulcers are recorded
Buccal mucosa
• Mouth mirror - retraction
• Examination - from posterior to anterior vestibule
• Mirror sticks to the mucosa – sign of xerostomia
• Swelling is soft – infection or purulent discharge
• Swelling is rigid and hard – tumour
Salivary glands
• Bimanual palpation is done for the submandibular glands and ducts to
detect enlargement, tenderness or calculi.
• Patency of Stenson’s duct and Wharton’s duct is verified with
palpation.
Saliva
• Amount and consistency
• Consistency – from thin, serous type to thick
• IDEAL – serous type consistency
• Dry mouth affects the retention of complete denture
• Excess saliva complicates the impression recording procedure
Residual alveolar ridge
Atwoods Classification
• Order I – Pre extraction
• Order II – Post extraction
• Order III – High well rounded
• Order IV – Knife edge
• Order V – Low well rounded
• Order VI - Depressed
Arch size
• Determines the amount of basal seat area available.
• Greater surface area provides greater retention and support to the
complete denture.
• Discrepancy in upper and lower arch sizes must be noted.
• This poses a difficulty during the teeth arrangement step.
Arch form
• May be square, ovoid or tapered
• Form of the ridge influences the support
• If arch form is different for both arches, some difficulty can be
encountered during teeth arrangement.
Ridge contour
• It can vary widely
• Ideal – high ridge with a flat crest and nearly parallel sides
• Can range from flat, v – shaped to knife edged
• Knife edged can be identified by palpation
• Flat ridge has poor prognosis because of inadequate vertical height
Ridge relation
• Maxillary and mandibular ridges must be observed at vertical
dimension of occlusion
• Amount of interridge distance must be noted
• Excessive amount of space results in poor stability and retention
• Small interridge distance will cause problems during teeth
arrangement and for the maintenance of freeway space
• Ridges that are not parallel will cause movement of bases during
occlusion
Inter arch space
• Class I – ideal space
• Class II – excessive space
• Class III – insufficient space
• Classification of ridge relation
• CLASS I (normal)
• CLASS II (retrognathic)
• CLASS III (prognathic)
Palate
• Red velvety appearance of the palatal mucosa beneath a denture may
indicate denture stomatitis
• Bony enlargement in midline – palatine torus , less resilient than soft
tissue
• Denture-bearing area usually shows decrease in the amount of
keratinization if the patient has a previous complete denture
• Shape must be noted
• U – shaped palatal vault is most favorable
• V - shaped and flat palatal vault are unfavorable
Soft palate
• 3 classifications of soft palate
• Based on degree of flexure of soft palate and width of palatal seal
• Class – I :- horizontal , little muscular movement
• Most favorable, allows more tissue coverage
• Class – II :- has a 45° angle to the hard palate , average muscular
movement
• Class – III :- has a 70° angle to the hard palate, most acute relation of
the soft palate , posterior palatal seal coverage is minimum
• It is the least favorable soft palate form
• V- shaped palatal vault is associated with class – III soft palate
• Flat palatal vault is associated with class- II or class – I soft palate
Palatal throat form
The relationship between the soft palate and the hard palate is called
palatal throat form.
• CLASS I – Large and normal in form, immovable band of tissue of 5 to
12 mm distal to a line drawn across the distal edge of tuberosities.
• CLASS 2 – Medium sized and normal in form, with relatively
immovable resilient band of tissue of 3 to 5mm distal to line drawn
across the distal edge of the tuberosities.
• CLASS 3 – Small maxilla. Curtain of soft tissue turns down abruptly 3
to 5mm anterior to a line drawn across the palate at the distal edge of
tuberosities.
Teeth
• The condition of the existing teeth is important for single complete
denture and tooth supported overdenture.
• Diagnosis must be made regarding the condition and requirement for
extractions
• Extractions must be planned according to requirement.
Tongue
• The tongue is pulled forward to expose the lateral borders
• Reduced mobility should be noted if present
• Tongue size should be noted
• Enlarged tongue – causes tongue biting and crowding of lower
denture base
• Proper tongue movements are necessary for border moulding
Tongue size
•CLASS I: Normal in size, development and function, sufficient
teeth are present to maintain normal form and function.

•CLASS II: Teeth have been absent long enough to permit a change
in the form and function of the tongue.

•CLASS III: Excessively large tongue.

Tongue position
• Wright classified into :-
• Class I – tongue lies in the floor of the mouth with the tip forward and
slightly below the incisal edges of lower anterior teeth
• Class II – tongue is flattened and broadened but the tip is in a normal
position
• Class III – tongue is retracted and depressed into the floor of the
mouth and the tip is curled inward
• Class I is the most favorable for complete denture
Floor of the mouth
• Floor of the mouth and ventral surface of the tongue should be
examined after raising the tongue
• If the floor of the mouth is near to the ridge crest or the movement is
more, the retention and stability will be affected
• Retro mylohyoid space can be a potential space that is partially or
totally obliterated
Lateral throat form
• Neil classified LTF as Class I, Class II,
and Class III depending on the
displaceability of the instrument
placed in the alveolo-lingual sulcus on
protrusion of the tongue.
Redundant tissue
• Maxilla and mandible should be examined for redundant / flabby
tissue
• Excessive flabby tissue causes denture base to shift and move when
force is applied
• Diagnosis has to be made regarding the requirement of surgical
excision
• Large flabby maxillary tuberosity – result of combination syndrome
Hyperplastic tissue
• Can be usually found under ill-fitting denture
• Can be – epulis fissuratum, papillary hyperplasia or hyperplastic folds
under the denture base
• Patient must be told to discontinue denture use
• Tissue conditioners must be applied
• Temporary soft liners can be used
Bony undercuts
• Frequently found on both maxillary and mandibular arches
• Maxillary – undercuts present anteriorly and lateral to tuberosities
• Selective relief has to be provided
• Undercuts do not aid in retention and cause loss of border seal
• If the undercuts are severe, and previous dentures have failed then
surgery should be considered
• Mandibular – Prominent , sharp mylohyoid ridge can cause a problem
Tori
• Torus palatinus and lingual tori are occasionally present
• Maxilla – it can range from a small tuberosity in the mid line to a large
tuberosity which covers entire hard palate
• Mandible – lingual tori can cause a problem with denture
construction
• Either relief should be provided or surgical excision must be planned
Frenum attachments
• Should be examined for favorable or unfavorable position in relation
to residual ridge crest
• Rarely, it is very close to the ridge crest and necessitates surgical
correction
• Usually occurs in maxillary labial frenum and mandibular lingual
frenum
• Class 1 : High in the maxilla or low in the mandible with respect to the
crest of the ridge
• Class 2 : Medium attachment
• Class 3 : encroach on the crest of the ridge may interfere with denture
seal.
Gag reflex
• It is a normal defence mechanism to prevent foreign particles from
entering the airway
• The stimulus is provided by sensation to the posterior pharyngeal
wall, the tonsillar pillars, or the base of the tongue.
• Can be active to the point where it can compromise prosthodontic
treatment
• Effective management can be carried out through clinical techniques,
prosthodontic management, pharmacologic measures, and
psychologic intervention.
Management of gag reflex
• Psychological – distraction techniques such as holding a conversation,
telling the patient to rhythmic concentrated breathing, telling the
patient to activate a certain muscle group such as raising the leg
• Pharmacological - sprays, gels, lozenges, mouth rinses, or injection of
Local anesthetic around the greater palatine foramen
Summary
• The oral examination, medical history, and conversation with the
patient are important in identifying the existence of a problem and
determining the treatment.
• It helps us to assess the current clinical condition and proceed with
the treatment accordingly.
References
1. Section II – Chapter 3,4 Prosthodontic treatment for edentulous patients -
BOUCHER`S 9th Edition.
2. Chapter 6,7 Prosthodontic treatment for edentulous patients – ZARB
BOLENDER 12th Edition.
3. Section II – Chapter 4, 5 Essential of complete Denture Prosthodontics –
SHELDON WINKLER 2nd Edition.
4. Chapter 4 - Textbook of complete denture – Heartwell 4th Edition
5. Sharma K, Shah D, Vaishnav K, Patel P, Joshi R, Patel Z. Comparative
evaluation of the lateral throat form and the border extension of
mandibular complete denture in the distolingual region in gandhinagar
district.