Folke S, Fridlund B. The subjective meaning of xerostomia – an aggravating misery. International Journal of Qualitative Studies on Health and Well-Being. 2009; 4:245–255.
Examination techniques
Salivary glands can be inspected for symmetry and swelling by examining the face from the anterior. The tissues in the mouth can be inspected for swellings and asymmetry. The glands can be palpated extraorally for masses or tenderness. Intraorally, if the mirror or tongue depressor being used adheres to the mucosa, this may indicate dryness or xerostomia. Also, if you suspect xerostomia, you can administer the cracker test. Obtain a saltine cracker to investigate whether the patient can adequately chew and swallow it. If not, xerostomia may be a problem. The clinician may also attempt to “milk” the glands to assess patency and flow from the parotid duct located in the buccal mucosa bilaterally opposite the upper molar teeth or the submandibular duct, located in the anterior floor of the mouth. Likewise, the anterior lip can be everted, dried with a 2 × 2 gauze, and inspected for flow from the minor salivary glands evident as discrete beads of saliva. Additionally, bimanual palpation of the floor of the mouth can be performed to assess symmetry and locate masses or tenderness.
Vessels
The oral and maxillofacial region is rich in blood supply provided mainly from branches of the external carotid and basilar arteries. The arteries of the head and neck should display a normal pulse without bruits.
Age-related changes
Changes that occur in the vascular system include skin, mucosal, and, rarely, intraosseous. Telangiectasia and angiomas may occur on the skin of the face and neck. Intraorally, the most frequent finding is caviar tongue or lingual varicosities. Intraosseous lesions such as arterio-venous (A-V) malformation may be present. Although rare, tooth removal in the area of an A-V malformation may cause life-threatening blood loss. Temporal (giant cell) arteritis and headaches of various causes are relatively common and may be the result of congestive heart failure, transient ischemia, and increased intracranial pressure.
Examination techniques
Inspection extraorally, intraorally, and radiographically may reveal lesions indicative of vascular pathology. Palpation may reveal mucosal lesions involving the vascular system.
Periodontium
Three important structures comprise the periodontium: alveolar bone, periodontal ligament, and gingival tissues. Alveolar bone is present in both the mandible and maxilla and forms the housing for the teeth. It contains both cortical and cancellous bone. Alveolar bone provides firm support for the teeth, the interface being designated a gomphosis or immobile joint. Surrounding each tooth at the root area is the periodontal ligament, which provides a cushioning effect for the teeth upon occlusion (biting). The ligament runs in several different orientations, counterbalancing vertical and lateral forces placed on the teeth. The gingiva surrounding the teeth is comprised of masticatory and lining musoca and serves to protect the underlying bony and dental structures. The tissues immediately adjacent to the teeth are masticatory and keratinized, and the gingiva below this tissue is lining mucosa and non-keratinized.
Age-related changes
Gingivitis and periodontitis are the two most prominent diseases of the periodontium. These are inflammatory in nature, and the extreme result is tooth mobility or loss. Gingivitis manifests the cardinal signs of inflammation in the gingiva. Periodontitis is an inflammatory-mediated destruction of the periodontium and manifests as bone loss, loose teeth, and generally inflamed gingival tissues. Other presentations of gingival or periodontal disease may occur, such as acute necrotizing ulcerative gingivitis, aggressive periodontitis, and periodontal abscess. There may indeed be substantial bone loss in the apparent absence of local factors (plaque, calculus). Poor control of diabetes and immune deficits also can be contributing factors to the exacerbation of periodontal disease. Systemic illnesses such as leukemia can affect the appearance of the gingival tissues, generally manifesting as hyperplasia, friability, and hemorrhage. Poor oral health and hygiene is a risk for aspiration pneumonia in debilitated patients.[37, 38]
Teeth
There are 20 primary or milk teeth and 32 adult or permanent teeth. There can be additional teeth known as supernumerary. One or more primary teeth can occasionally be retained into adulthood, especially if there is no permanent successor. Teeth are designated as central incisors, lateral incisors, cuspids (canines), 1st and 2nd bicuspids (premolars), and 1st, 2nd, and 3rd molars. There are several methods for numbering teeth, with the military designation being the most common in the United States. The teeth are numbered 1–32 beginning in the upper right, proceeding to the upper left, continuing to the lower posterior left, and proceeding to the lower posterior right. Anterior and posterior are general positional designations for teeth such as the 1st molar, which is the most posterior tooth present. Positional designations for individual teeth are mesial (toward the dental midline), distal (away from the dental midline), lingual (toward the tongue), and facial or buccal (toward the cheek). There are four separate layers of various mineral compositions in dental structure: enamel (90% mineral and the hardest substance in the human body), dentin (70% mineral), cementum (50% mineral), and pulpal tissue (0% mineral; comprised of nerves, blood vessels, and lymphatics). Teeth generally exhibit a white, yellow, or light gray hue of varying chromas. Teeth may also take on the color of the restorative material used to repair lost tooth structure. The teeth should all be present and occlude or fit together smoothly upon closing with no interferences. The upper teeth are generally slightly facial to the lower teeth. Teeth should be clean with minimal plaque, tartar (calculus), or food debris.
Age-related changes
Although poor oral hygiene may be present at any age, an elderly individual may be more prone to this due to loss of manual dexterity, visual deficit, or cognitive decline. Teeth may be lost due to caries, periodontitis, or fracture. As a result of loss of teeth, a poor occlusal or interdigitating relationship may occur, leading to tipped, rotated, or increased spacing between teeth. Besides dental caries and periodontal disease, a variety of factors can lead to tooth structure loss, including attrition, abrasion, erosion, and abfraction. Attrition is loss of tooth structure due to tooth-to-tooth contact. Abrasion is loss of tooth structure due to dietary or environmental materials (e.g., sand or dust, coarse dietary components, tobacco, etc.).
Examination techniques
The teeth should be inspected for the presence of calculus, plaque, and food debris. Plaque only requires about 24 hours to form, and tartar (calculus) can form in as few as three days. The teeth can be inspected for caries, wear, and fractured cusps or other tooth components. The teeth can be palpated for tenderness or looseness. A tongue blade may be used to push on the teeth from several directions for this assessment. The teeth can be percussed to assess for tenderness as well. To assess for tooth fracture, a tongue blade may be applied over the tooth in question, and a bite force can be applied to elicit any tenderness. The general occlusion of the teeth can be assessed by having the patient bite the teeth together. Normally there is an overjet (maxillary teeth project out over the mandibular teeth) and overbite (maxillary teeth overlap the mandibular teeth), and the teeth fit together evenly and symmetrically.
Prosthetics
A variety of prosthetic devices may be present in the mouth. These devices may be permanently affixed to the mouth or removable. Appliances may be worn to aid in mastication and for aesthetics. These appliances should be well adapted and not painful. Appliances may be worn to aid in protecting the dentition due to grinding or bruxism, to position the jaw in a certain way, or to straighten the teeth. Dental implants affixed to the jaw should be immobile and well functioning. Any prosthetic devices should allow for smooth, symmetrical, and pain-free closure and functioning. All prosthetic devices used for whatever purpose should be clean and free of plaque, calculus, or food debris.
Age-related changes
There are myriad prosthetic devices that may be present in the mouth for a variety of reasons. It is critical for patients to be followed closely by their dental professional if they wear a prosthetic device. However, if there is minimal follow-up the device may become ill-fitting due to changes and loss of oral structures.[39] Fixed prosthetics, if preventive measures are not in place, can gather plaque, calculus, and infectious organisms. Patients may then suffer from recurrent or new caries around the device at the margins between the prosthesis and the natural tooth.
Furthermore, nutritional deficiencies can affect the tissues’ response to trauma from prosthetic devices. Moreover, poor oral and prosthesis hygiene may be present. Oral mucosal lesions (epulis and papillary hyperplasia) can be associated with removable prosthetic devices. Fungal infections appearing as either beefy red areas or as curdlike plaques that wipe off easily are relatively common under removable appliances. A potassium hydroxide staincan confirm this diagnosis. If there are lesions associated with the prosthetics, both the prosthesis and the attendant tissue must be treated for full resolution. Individuals wearing removable prosthesis should keep the prosthesis out of their mouth for at least six hours a day to allow the tissues to breathe and minimize infection (such as fungal).
Examination techniques
Removable prosthetic devices should be removed upon examination of the mouth. They should be inspected for cleanliness and integrity. Once placed in the mouth, they should be inspected for proper general fit and function. Of course, a subjective history from the patient may also alert the practitioner to potential problems with the prosthesis. Fixed devices (crowns, bridges, implants, etc.) should be inspected for cleanliness, as well as the condition of the periodontium surrounding them.
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