• Interactive online courses
• Faculty-led hybrid courses
• Hands-on workshops
• A combination of these options

• At-a-Glance
• Instructor’s Guide
• Instructor’s Notes

In this workshop you will learn the skills needed to conduct an oral health examination and an oral cancer screening. You will practice these skills by examining another workshop participant.

At-a-Glance

Topic	The oral examination
Content Source	Smiles for Life, third edition, Course 7: The Oral Examination
Learning Objectives	Conduct an oral examination on an adult patient. Conduct an oral cancer screening on an adult patient.

Instructor’s Notes

Materials provided in the Instructor’s Guide.

• Instructor’s Notes
• Handouts for participants:
  • The Oral Examination Skills Checklist
  • Workshop 1 Evaluation Form

Additional materials needed.

• Smiles for Life Course 7 PowerPoint slides
• Computer, projector, screen
• Surgical mask, examination gloves, 2×2 inch gauze square, and protective eyewear for each participant
• Intraoral mirror and tongue depressor for each participant (optional)

Participant preparation. Participants should review Smiles for Life Course 7: The Oral Examination prior to the workshop. Registration for Course 7 is not required to attend the workshop, but it is required to earn continuing education credit.

Schedule.

• Introduction (5 minutes)
• Live demonstration and slide presentation (25 minutes)
• Peer-to-peer examination (30 minutes)
• Follow-up and documentation (5 minutes)
• Evaluation (5 minutes)

Note: Times may vary depending on the number of participants.

Instructor’s Notes

Introduction (5 minutes). Welcome participants and review the workshop objectives. Explain that participants will develop the skills needed to perform an adult oral examination and oral cancer screening by practicing on each other. Review and distribute protective eyewear, surgical masks, gauze, and examination gloves. Let participants know that following the demonstration, they will be working with a partner to conduct an oral examination and will need to remove any intraoral prosthetics before they begin.

Live demonstration and slide presentation (25 minutes). Ask for a volunteer to be the subject of an oral examination. You will work with the volunteer to demonstrate how to perform both an intraoral and an extraoral examination. As you move through each category (e.g. face, lips), explain what is being visually and manually inspected.

The notes below and the Oral Examination Skills Checklist in this toolkit have been broken into sections to match the presentation slides in Smiles for Life Course 7. Each slide will serve as a prompt for the next step of the oral examination.

• Slide 27, Exam Components. Introduce the components of an oral examination.
• Slide 28, Face and Lips. Instruct the provider to observe the face, ears, and neck of the patient, noting any asymmetry or changes on the skin such as crusts, fissuring, growths, or color variations. The provider should observe the lips with the patient’s mouth both open and closed.
• Slide 29, Common Lip Abnormalities. Review the photographs on this slide.
• Slide 30, Inside Lips. Instruct the provider to observe the inside of the lips with the patient’s mouth partially open. The provider should use gloved fingers to gently lift the upper lip and pull down the lower lip to observe color and texture as well as to note any swelling or other abnormalities of the lip mucosa.
• Slide 31, Buccal Mucosa. The provider should retract the buccal mucosa (cheek) with a gloved finger and examine the right then the left buccal mucosa from the corner of the lip to the back of the throat. Note changes in color and texture, or any other abnormalities.
• Slide 32, Common Mucosal Abnormalities. Review the slide.
• Slide 33, Gums. Instruct the providers to systematically inspect the gums. They should begin at the top right of the mouth and move across the upper teeth to the top left of the mouth before proceeding to the lower left and across the lower arch to the lower right. The lips should be moved up and down and the cheeks retracted to allow a full view of the gums. Providers should look at the color of the gums and note the presence of plaque along the gum line. Pink gums indicate health, and red or erythemic gums indicate inflammation.
• Slide 34, Common Gum Abnormalities. Review the slide.
• Slide 35, Anterior Teeth. Ask providers to briefly examine the anterior or front surface of each tooth looking for signs of tooth decay (discoloration), trauma (chips or breaks), and plaque.
  
  Note: This step can be practiced separately, but once providers become familiar with the process, they should complete this step while examining the gums.
• Slide 36, Lingual Teeth. Providers should ask their patients to tilt their heads back so providers can inspect the lingual (tongue-side or inward-facing) surface of the upper teeth and molars. Then providers should ask patients to tilt their heads down so providers can inspect the inward-facing surface of the lower teeth and molars.
• Slide 37, Common Tooth Abnormalities. Review the slide.
• Slide 38, Hard and Soft Palate. Providers should ask their patients to tilt their heads back so providers can examine the hard and soft palate. The hard palate is the region behind the upper teeth shown in the slide photo. The soft palate, which sits between the hard palate and the throat, should be examined closely as it is a high-risk area for oral cancer.
• Slide 39, Abnormalities of the Palate. Review the slide, then alert participants that another common abnormality of the palate is the presence of bony growths along the inside of the lower jaw or along the cheek side of the upper jaw. These typically benign, hard, bony protrusions are called exostoses. Instruct providers to feel along the gum on the inside of the lower teeth and along the gum on the cheek side of the upper teeth to detect the presence of exostoses.
• Slide 40, Tongue. Instruct each provider to use gauze to grasp the patient’s tongue and inspect the dorsal (top), ventral (bottom), and lateral borders (sides). Emphasize that the lateral borders of the tongue are common areas for oral cancer.
• Slide 41, Video Tongue Exam. Show the video to demonstrate how to inspect the tongue.
• Slide 42, Oral Cancer Screening. Explain that an oral cancer screening should be a routine part of each patient’s general medical examination, especially for those who use tobacco or alcohol excessively. Discuss statistics and review the visual diagram identifying common areas for cancerous lesions.
• Slide 43, Common Tongue Abnormalities. Review the slide.
• Slide 44, Posterior Pharynx. Review the slide. Ask providers to locate the pictured structures on their partners.
• Slide 45, Floor of Mouth. Show the video and explain that the provider should palpate or gently press on the floor of the patient’s mouth.
• Slide 46, TMJ. Instruct providers to remove their gloves and disinfect their hands before performing the temporomandibular joint (TMJ) examination. Show the video.
• Slide 47, Neck Anatomy. Review the slide (optional).
• Slide 48, Neck Palpation. Instruct the provider to palpate the patient’s anterior and posterior triangle and the submandibular area as indicated in the photographs on the slide.
• Slide 27, Exam Components. Return this slide to the screen and leave it there to guide participants as they begin the peer-to-peer examination.

Peer-to-peer examination (30 minutes). After you complete the presentation, ask participants to select a partner. Determine who will act as the provider and who will act as the patient during the first practice oral examination. The provider should wear protective eyewear, a surgical mask, and gloves. The patient should sit down and remove any intraoral prosthetics before the examination begins.

Instruct providers to stand or sit directly in front of their patients. Providers should perform the oral examination using the Oral Examination Skills Checklist as a guide.

When the first examination is complete, ask the participants to switch places so each has a chance to perform the examination. While the oral examinations progress, the instructor should move about the room to answer questions as needed.

Follow-up and documentation (5 minutes). After all participants have performed an oral examination and completed the skills checklist, explain that if a suspicious lesion is found during the oral examination, the provider should take the following steps.

1. Show the lesion to the patient using a hand-held mirror.
2. Ask the patient if he or she is aware of the lesion and if so, how long it has been present. Note: Any lesion that lasts longer than two weeks could indicate a serious condition such as oral cancer. The patient should be referred for evaluation and possible biopsy.
3. Ask the patient if there has been any pain associated with the lesion. Pain or soreness could indicate a cancerous growth.
4. Document the lesion by describing the location, color, size, and presence or absence of pain to the best of your ability (e.g., 2×2 mm white patch on upper right lip, asymptomatic, patient is unsure of how long the lesion has been present).
5. Schedule a follow-up appointment.

Evaluation (5 minutes). Ask participants to evaluate the workshop. You can use the Workshop 1 Evaluation Form provided in this toolkit. If applicable, explain to participants that the next workshop will cover oral health risk assessment and dental referral.

In this workshop you will learn how to conduct both adult and pediatric oral health risk assessments. The pediatric assessment will be simulated using a case study and the AAP Oral Health Risk Assessment Tool. You will practice adult assessment by conducting a risk assessment on another workshop participant while using the ADA Caries Risk Assessment Form (Age >6). You will also learn how to exchange information with dental providers and make referrals.

At-a-Glance

Topic	The oral health risk assessment and dental referral
Content Source	Smiles for Life, third edition, Course 2: Child Oral Health and Course 3: Adult Oral Health
Learning Objectives	Conduct an oral health risk assessment on an adult patient. Learn when and how to provide a dental referral.

Instructor’s Guide

Materials provided in the Instructor’s Guide.

• Instructor’s Notes
• Pediatric Case Study – Instructor’s Copy
• Pediatric Case Study Assessment Answers
• Handouts for participants
  • AAP Oral Health Risk Assessment Tool
  • Pediatric Case Study
  • Pediatric Case Study Questionnaire
  • ADA Caries Risk Assessment Form (Age >6)
  • ADA Caries Risk Assessment Instructions
  • Dental Referral Resource List
  • Workshop 2 Evaluation Form

Additional materials needed.

• Surgical mask, examination gloves, 2×2 inch gauze, and protective eyewear for each participant
• Intraoral mirror and tongue depressor for each participant (optional)

Participant preparation. Participants must review Smiles for Life Course 2: Child Oral Health and Smiles for Life Course 3: Adult Oral Health prior to the workshop. Registration in these Smiles for Life courses is not required to attend the workshop, but it is required to earn continuing education credit.

Schedule.

• Introduction (5 minutes)
• Review and discuss case study (20 minutes)
• Peer-to-peer oral health risk assessment (25 minutes)
• Dental referral (10 minutes)
• Evaluation (5 minutes)

Note: Times may vary depending on the number of participants.

Instructor’s Notes

Introduction (5 minutes). Welcome participants and review the workshop objectives. Explain that participants will develop the skills needed to perform an oral health risk assessment and to provide a dental referral. Inform participants that they will review a case study and perform an oral health risk assessment on a partner.

Before you begin, ask participants to note:

• The oral health risk assessment forms presented in this workshop are nationally recognized tools used to determine caries risk.
• Caries risk can change over time and should be reassessed at regular intervals.
• The ADA Caries Risk Assessment Form (Age >6) was developed for use by licensed dental professionals. This workshop is not intended to train other health professionals to recognize all of the clinical conditions listed on the form. It is possible to assess a patient’s risk of developing dental caries without completing the assessment forms provided in this toolkit in their entirety.
• These assessment tools may be used to make other clinical findings as well. Providers may want to use individual sections of each form to prompt and guide dialogue with their patients.

Review and discuss case study (20 minutes). Instruct participants to break into teams of no more than four or five individuals. Each participant should have a Pediatric Case Study, an AAP Oral Health Risk Assessment Tool, and a Pediatric Case Study Questionnaire. The instructor should perform the following steps.

1. Instruct all participants to read through the Pediatric Case Study on their own.
2. Ask each team to complete the Pediatric Case Study Questionnaire and the AAP Oral Health Risk Assessment Tool based on the findings for 4-year old Jacob, the patient in the Pediatric Case Study. Give each team 10 minutes to complete this task.
3. Spend 10 minutes reviewing the answers to the Pediatric Case Study Questionnaire. Ask representatives from each of the teams to share their answers. The questions correspond to each category of the AAP Oral Health Risk Assessment Tool. You may use the instructor’s copy of the case study to assist with this discussion.

Peer-to-peer oral health risk assessment (25 minutes). Distribute protective eyewear, surgical masks, gauze, and gloves and review their use. Then ask participants to select a partner. Explain that one participant will act as the provider and one will act as the patient. The provider should wear the protective eyewear, surgical mask, and gloves during the clinical findings portion of the risk assessment.

Each participant will complete an oral health risk assessment of his or her partner. Some of the questions asked during this role-playing exercise relate to sensitive topics such as cancer treatment and alcohol and drug use. Participants should feel free to provide answers that do not reflect their personal experiences.

Hand out the ADA Caries Risk Assessment Form (Age >6) and the corresponding ADA Caries Risk Assessment Instructions. You will guide participants through the risk assessment using the questions below. These are grouped and numbered as they appear on the assessment form. The ADA Caries Risk Assessment Instructions provide additional guidance related to specific risk factors.

Note: Participants may be unfamiliar with some of the clinical conditions included in the assessment because it was developed for practicing dental professionals. There are no nationally recognized caries risk assessment forms to guide nondental professionals in assessing adolescent and adult patients. If, after reviewing the Smiles for Life slides, participants are unable to recognize some of the clinical conditions, they should skip the corresponding sections of the assessment form.

Contributing conditions:

1. Fluoride exposure
   • Ask the patient about fluoride exposure.
     • What is your primary water source: bottled or tap?
     • Are you on city or well water? (Providers should be familiar with what counties in their area have fluoridated water. Suggest patients on well water have their water tested to determine the fluoride level.)
     • Do you use fluoridated toothpaste or mouthwash?
     • Do you take fluoride supplements or receive a professional fluoride treatment when you visit the dentist?
   • Determine the patient’s risk level.
     • Low risk: Exposed to fluoride through supplements, professional fluoride applications, fluoridated drinking water, or the daily use of fluoridated toothpaste or mouthwash.
     • Moderate risk: Little to no exposure to fluoride.
     • High risk: Lack of fluoride exposure alone does not place a patient at high risk.
2. Sugary foods or drinks
   • Question the patient about diet.
     • How often do you consume sugary drinks such as soda, energy drinks, or juices?
     • How often do you eat foods that are high in sugar?
   • Determine the patient’s risk level.
     • Low risk: Occasional sugary drinks or foods at mealtimes.
     • Moderate risk: Not applicable.
     • High risk: Frequent consumption of sugary drinks or foods, especially prolonged exposure (i.e., sipping a soda throughout the day).
3. Caries experience
   • Note that patients aged 6–14 whose mother, caregiver, or siblings have experienced caries within the last 2 years are at increased risk for caries themselves.
   • For patients over the age of 14, question whether they have had a cavity in the past 2 years and classify accordingly.
   • Determine the patient’s risk level.
     • Low risk: Has not had a cavity diagnosed in over 2 years.
     • Moderate risk: Has had a cavity diagnosed in the past 7–23 months.
     • High risk: Has had a cavity diagnosed in the past 6 months.
4. Dental home
   • Ask whether the patient has a dental home, i.e. a private practice or community health facility where the patient regularly accesses the services of a dental professional. Determine the date of the last dental visit.
   • Determine the patient’s risk level.
     • Low risk: The patient receives regular dental care or has recently visited a dental provider.
     • Moderate risk: The patient does not have a dental provider or reports only seeking dental care when experiencing pain.
     • High risk: The lack of a regular dental provider alone does not place a patient at high risk.

General health conditions:

1. Special health care needs
   • Determine the patient’s age.
     • Patients who are under the age of 14 and have special health care needs are typically considered at high risk.
     • Those over the age of 14 who have a special health care need are, at minimum, considered at moderate risk.
2. Radiation or chemotherapy
   • Determine the patient’s history of exposure to radiation or chemotherapy. Patients undergoing radiation or chemotherapy, or who have a history of radiation or chemotherapy, are considered at high risk.
3. Eating disorders
   • Question the patient about the presence or history of an eating disorder. The presence of an eating disorder puts patients at a minimum of moderate risk for caries.
4. Medications reducing salivary flow
   • Question the patient about medications currently taken.
     • Medications that cause dry mouth put patients at an increased risk of tooth decay.
     • Common medications that reduce salivary flow include antidepressants, antihypertensives, diuretics, allergy medications, and albuterol inhalers.
     • Polypharmacy (the use of many medications) also tends to reduce salivary flow.
     • More information about the oral effects of medication can be found in Smiles for Life Course 3: Adult Oral Health, slide 14, “Oral Effects of Medication.”
     • If you are unsure of whether a patient’s medications reduce salivary flow, consult a database of drug side effects, or ask the patient if he or she experiences dry mouth.
5. Alcohol or drug abuse
   • Question the patient about alcohol or drug use.
     • Alcohol or drug use or abuse can lead to behaviors that put patients at a higher risk for tooth decay. These behaviors include poor food choices while under the influence and lack of proper oral hygiene. Any use of drugs or alcohol places a patient at moderate risk.
     • Substance abuse can also lead to dry mouth, which also increases the risk of tooth decay.
     • More information about the oral effects of alcohol and drug use can be found in Smiles for Life Course 3: Adult Oral Health, slide 18, “Alcohol and Tobacco,” and slide 19, “Meth Mouth.”

Clinical conditions:

1. Cavitated or noncavitated
   • Look for obvious signs of decay when you perform the oral examination.
     • Photographs of decay can be found in Smiles for Life Course 2: Child Oral Health, slides 7–14, and Course 3: Adult Oral Health, slide 8, “Adult Caries.”
     • If decay is noted, the patient is automatically at high risk.
2. Teeth missing due to caries
   • Question the patient about missing teeth. If a missing tooth was lost or pulled in the past 36 months due to tooth decay, then place the patient at high risk.

3. Visible plaque
   • Look for signs of plaque on the teeth and gums.
     • Photographs of plaque and information about its effect on the teeth and gums can be found in Smiles for Life Course 3: Adult Oral Health, slides 7, 9, 10, and 11.
     • If plaque is present, place the patient at moderate risk.

4. Unusual tooth morphology
   • Note the shape and alignment of the teeth.
     • Teeth that are oddly shaped or out of alignment can be difficult to clean.
     • Patients who show unusual tooth morphology are at a higher risk for decay.
5. Interproximal restorations
   • Look for interproximal restorations. These are fillings placed between a patient’s teeth.
     • These types of fillings can make it difficult to floss, creating a higher risk for recurrent tooth decay.
     • The presence of one or more interproximal restorations places a patient at a higher risk for tooth decay.

6. Exposed root surfaces
   • If root exposure is obvious, note that here.
     • Photographs of root exposure are provided in Smiles for Life Course 3: Adult Oral Health, slide 9, “Root Caries.”
     • Root exposure is problematic because the root is not protected by enamel, making it more prone to tooth decay.

7. Restorations with overhangs or open margins
   • Overhangs and open margins are terms used to describe a problem with a dental restoration (commonly called a filling). The presence of overhangs and open margins places patients at high risk for tooth decay.
   • Nondental providers are not expected to recognize an overhang or an open margin.
8. Dental or orthodontic appliances
   • Determine if the patient has braces or a removable appliance such as a mouth guard. If so, then he or she is at a moderate risk, at minimum.

9. Severe dry mouth
   • Question the patient about the presence of severe dry mouth.
     • The presence of severe dry mouth puts the patient at a higher risk for tooth decay.

To determine patient’s caries risk, follow this guidance from the ADA Caries Risk Assessment Form (age>6).

• Low risk: only conditions in low risk column present.
• Moderate risk: only conditions in low and moderate risk columns present.
• High risk: one or more conditions in the high risk column present.
• The clinical judgment of a dental professional may justify a change of the patient’s risk level (increased or decreased) based on review of this form and other pertinent information. For example, missing teeth may not be regarded as high risk for a follow-up patient, or other risk factors not listed may be present.

Dental referral and follow-up (10 minutes). Participants should understand when and how to provide a dental referral and when it is necessary to schedule a follow-up appointment with a patient. Encourage participants to reach out to dental providers in their communities to build relationships. This will assist participants in making appropriate and informed referrals.

• When to refer. All patients should be asked if they have a dental home. According to the American Academy of Pediatric Dentistry, “the dental home is oral health care…that is delivered in a comprehensive, continuously accessible, coordinated and family-centered way by a licensed dentist.” Who should be referred to a dental professional for a consultation?
  • Individuals who lack a dental home.
  • Individuals whose oral examinations indicate a high risk for caries. If a patient is at moderate to high risk for caries and has a dental home, the provider is responsible for communicating with the patient’s dental provider to coordinate care.

• Making the referral.
  • Know your local dental providers and know which of those providers accept government-issued insurance. The Dental Referral Resource List in this toolkit will assist you in locating these dental practices in your area.
  • Ask your local dental practices if they can provide you with referral forms that you can keep on file to dispense to your patients.
  • Create a handout for your patients with contact information for area dental providers.
  • Give dental referrals to patients before they leave the office. During the consultation, the provider should explain the reason for the referral and try to ascertain whether the patient understands why a visit with a dental provider is recommended and where the dental provider is located. It is good practice to call the dental provider’s office yourself to schedule an appointment if the patient has an urgent need (e.g., an infected tooth or dental pain).
• When a dental home is not available. For pediatric patients, the American Academy of Pediatric Dentistry recommends that the primary care provider perform an oral health risk assessment at every well-child visit when a dental home is not available.

• Follow-up. If you identify an oral health condition or make a dental referral, ask the patient to schedule a follow-up appointment to ensure proper care coordination. You might also want to schedule a follow-up appointment to make sure the patient received a dental consultation. In some cases, you may be unsure if a dental referral is indicated (e.g., when a patient presents with an oral lesion that is less than two weeks old). In such cases, schedule a follow-up visit to determine if the lesion has healed before issuing a dental referral.

Evaluation (5 minutes). Ask participants to evaluate the workshop. You can use the Workshop 2 Evaluation Form provided in this toolkit.

• AAP Oral Health Risk Assessment Tool
• ADA Caries Risk Assessment Form (age>6)
• ADA Caries Risk Assessment Instructions
• Dental Referrals Resources
• Pediatric Case Study
• Pediatric Case Study Assessment Answers
• Pediatric Case Study Instructor Copy
• Pediatric Case Study Questionnaire
• Workshop 1 and 2 Evaluation Form
• Workshop 1 Skills Checklist