The oral examination provides valuable information about the health and well-being of the patient and is often an essential component of patient assessment.
Infectious, trauma, congenital abnormalities and reactive processes common causes of problems in the oral cavity. Allergies to various substances and adverse effects of medicine can also affect oral cavity.
Adequate lighting is very important in oral examination and hand-held flashlights or a penlight, are sufficient for the purpose.
Relevant Anatomy of Oral Cavity
The oral cavity is oval shaped and is separated into the oral vestibule and the oral cavity proper.
The oral vestibule is bounded externally by the lips and the cheek mucosa and internally by the alveolar processes and the teeth. Basically, vestibule is the space outer to teeth line.
And oral cavity proper is inside the teeth line. It is the region where tongue is present.
Oral cavity proper is bound by floor of the mouth inferiorly, the oropharynx posteriorly, and the palate superiorly. The oropharynx begins superiorly at the junction between the hard palate and the soft palate, and inferiorly behind the circumvallate papillae of the tongue.
The bony base of the oral cavity is formed by the maxillary and mandibular bones.
Detailed Oral Examination
Oral examination should always begin with extraoral head and neck examination.
The presence of neck lymph node masses can be seen in patients with oral infections or advanced malignancies. The anterior cervical lymph node chain is most commonly affected but other regional lymph nodes may be enlarged as well.
Salivary gland neoplasm such as parotid neoplasms, submandibular masses can be best felt by extra oral palpation
Temporomandibular joint may be examined by placing the tips of the little fingers in the external auditory canals and having the patient open and close the mouth and move the mandible laterally from side to side. Presence of crepitation, clicking, and popping of the temporomandibular joints should be looked for.
The examination of the mouth and throat is conducted with the patient sitting up either in bed, with the head resting comfortable back on pillows, or in a chair. The lips, , gums, tongue, palate, oropharynx and teeth are then examined.
Moving from extraoral to oral examination, lips are examined first.
Look closely at the philtrum for the any scar of a repaired cleft lip suggestive of cleft lip repair. If present, particularly if associated with nasal speech, inspect the palate carefully for signs of a cleft palate.
Observe the corners of the mouth for cracks or fissures. Cheilosis refers to fissuring and dry scaling of the vermilion surface of the lips and angles of the mouth. Riboflavin deficiency, irondeficiency anaemia, infections in children, and ill fitting or deficient dentures can result in cheilosis.
Recurrent scaly cheilitis with small blisters and exfoliation however, is a premalignant condition which may occur on prolonged exposure to the sun wind such as farmers and fishermen.
Desquamation or inflammation of the lips is common in cold weather. It is generally self-limiting condition. Grouped vesicles could be suggestive of herpes.
Carcinoma lesion on the lips usually occurs on the lower lip away from midline. It appears a flat indolent ulcer. The lesion might have induration as well.
Epithelioma is an abnormal growth of the epithelium.
Keratoacanthoma is a lesion due to overgrowth of the stratum granulosum of the skin. It usually present as a firm, rounded nodule sometimes with ulceration. It is more common on the upper lip and heals spontaneously without treatment.
Pyogenic granuloma is a soft red raspberry like nodule on the upper lip following a minor trauma.
The upper lip is the commonest site of an extragenital chancre, which appears as a small, round lesion that is firm and indurated.
Multiple small brown or black spot on the skin around the mouth which may extend on to the lips and buccal mucosa constitutes one the triad of cardinal features of the Peutz-Jeghers syndrome.
Mucosal surfaces of the lips are checked by everting the lips.
Aphthous ulcers are small, superficial, painful ulcers with a white or yellow base and a narrow halo of hyperemia. Such ulcers are also seen on the tongue, buccal mucosa and palate and mucosal surface of lips.
Retention cyst or mucocele are cysts of the mucous glands of the lips and buccal mucosa. These appear as round, elevated, translucent swelling with a characteristic white or bluish appearance.
Oral Cavity Examination
Oral mucosa is described as being salmon-pink in color but variations do occur.
Healthy labial mucosa appears smooth and glistening. Pinpoint mucosal secretions from the minor salivary glands may become apparent when mucosa is wiped.
Labial mucosa is smooth, soft, and well lubricated by the minor salivary glands. Anxiety may result in dryness and in these cases the mucosa becomes tacky to the touch.
Buccal mucosa [cheek inner lining] is examined by asking the patient partially open the mouth and stretching of the buccal mucosa with a mouth mirror or tongue blade.
Fordyce granules are ectopic sebaceous glands present in the majority of patients and manifest as bilateral whitish-yellowish papules on the buccal mucosa or rarely on labial mucosa.
Linea laba is a horizontal ridge on the buccal mucosa at the level of the interdigitation of the teeth. It represents a benign hyperkeratosis secondary to irritation from the teeth cusps.
The orifice of the parotid gland or the Stensen duct can be found as a small punctate soft tissue mass on the buccal mucosa adjacent to first permanent molar teeth.
Gentle palpation of the parotid gland results in the expression of serous saliva from the duct.
The gums are examined most easily with the mouth partially closed and the lips retracted with
Gums adjacent to the crowns of the teeth and appears paler than other oral mucosa. This tissue usually is firm, stippled, and firmly attached to the underlying bone. The alveolar mucosa extends from the attached gingiva to the vestibule. In contrast to the attached gingivae, alveolar mucosa is not keratinized and is darker in color.
Alterations in the clinical appearance of the gingivae [gums] can be an indicator of both localized and systemic disease.
The most common cause of erythema of the gingivae is poor dental hygiene, for example from retained dental plaque and calculus .
Mucocutaneous diseases like , lichen planus, cicatricial pemphigoid, pemphigus vulgaris may affect the gingivae. Gingivae can be affected in HIV infection or may be subjected to bacterial infections.
Few examples of gingival inflammation arenchronic marginal gingivitis and acute herpetic gingivostomatitis due to the simplex virus and Vincent’s gingivostomatitis.
In lead exposure, a stippled blue line can often be observed running along the edge of the gum,
Swollen, irregular in outline, red, spongy gums which bleed easily are found in scurvy.
Gum hypertrophy is noticed in pregnancy and in patients treated for long periods with phenytoin.
Hemorrhages may indicate blood disorders.
Painful alveolar or dental abscess can cause localized swelling of the gum and of the face are sings associated with this condition.
In older patients, ill-fitting dentures can produce a granuloma or an ulcer which needs to be differentiated from malignant lesion.
Ask the patient to protrude the tongue. Inability to do so fully is seen, very rarely, in infants due to tongue tie.
It can be also present in cases of advanced malignancy.
When carcinoma involves the side of the tongue and the floor of the mouth, slight deviation towards the affected side may occur.
In hemiplegia, deviation towards the paralysed side may be found. In lesions of the hypoglossal nerve or its nucleus there may be fasciculation of the affected side; later this side may be wasted and deeply grooved. The tongue is large in acromegaly, cretinism, myxoedema, lymphangioma and amyloidosis.
Tremor of the tongue may be due to nervousness, thyrotoxicosis, delirium tremens or parkinsonism.
Next examine the dorsum of the tongue.
The dorsal surface of the tongue is most easily visualized by having the patient protrude the tongue and attempt to touch the tip of the chin. Grasping the tip of the tongue by the fingers and a gauze sponge. The dorsal surface of the tongue is covered by numerous hairlike filiform papillae interspersed with dozens of mushroom-shaped fungiform papillae, each of which contains one or more taste buds.
8-12 circumvallate papillae are at the junction of the anterior two-thirds and posterior one-third of the tongue. These V-shaped pattern. These also contain numerous taste buds.
Fissuring of the dorsal surface of the tongue has been described in a number of disease states such as , trisomy 21 but fissuring can be clinically insignificant too.
Atrophy of the dorsal surface of the tongue can result from nutritional or oral manifestations of mucocutaneous diseases.
The lateral borders of the tongue are not covered by a large number of papillae. The mucosa is more erythematous and has prominent vertical fissuring.
At the base of the tongue, mucosa colored tissue with a bosselated surface is lymphoid tissue (lingual tonsil) can be present. It is component of the Waldeyer ring and may become enlarged in inflammation, infection, or malignancy.
The ventral surface of the tongue is most easily visualized by having the patient touch the tip of the tongue to the roof of the mouth. The ostia of the submandibular glands, also called (ie, the Wharton ducts) are present as 2 midline papillae on either side of the lingual frenum.
The floor of the mouth, similar to the buccal mucosa, is salmon-pink in color.
The lingual frenum is the primary soft tissue attachment of the tongue to the floor of the mouth. Overattachment of the frenum is called tongue tied and can result in speech problems if untreated.
Both the ventral lateral surface of the tongue and the floor of the mouth are common sites for intraoral squamous cell carcinoma.
Direct visual inspection of the hard palate is accomplished most easily with the use of an intraoral mirror. The hard palate normally is less pink than other oral mucosal sites because of its increased keratinization.
The anterior hard palate is covered by numerous fibrous ridges or rugae.
The hard palate is keratinized and covered by a series of fibrous ridges or rugae. The mucosa overlays a number of minor salivary glands.
Minor salivary glands are abundant in the hard palate and minor salivary gland neoplasms, both benign and malignant may be found in here.
The soft palate is nonkeratinized and salmon-pink in color. It can be visualized better on direct examination by depressing the posterior tongue with a tongue blade and instructing the patient to say “Ahhh.”
Deviation of the soft palate to one side or the other may indicate a neurologic problem or an occult neoplasm.
A look can also be made at oral pharynx when examining soft palate. The tonsillar pillars are visualized most easily by moving the tongue laterally with a tongue blade.
The tonsillar crypts are highly vascular and appear more erythematous than the surrounding tissues. Patients often have accumulations of desquamated epithelial cells, food, and other debris present in the tonsillar crypts.
Ask the patient to grimace so as to show the teeth. If there are dentures, remove ask him or her to remove them and open the mouth widely.
Any number of developmental defects of the teeth may be apparent. Missing teeth and supernumerary teeth are commonly found in a variety of inherited disorders (eg, Gardner syndrome, oral facial digital syndrome). The decay at the gingival margins of the teeth adjacent to the attached gingiva may be the first manifestation of xerostomia. Root surface caries are also commonly observed in geriatric patients with gingival recession.
Yellowish Tartar deposition is noticed on the lingual aspect of the lower incisor and canine teeth. It gets stained brown in smokers. Reddish brown plaques may indicate chewing of betel nuts may also discolour the plaque of teeth a reddish brown. In endemic fluorosis, chalk white patches appear on the teeth
Patients who habitually induce vomiting, e.g. in anorexia nervosa, may show evidence of gastric acid induced erosion of the inner surface of the incisors.
Transverse ridging is sometimes seen in the permanent teeth of those who had vitamin C and D deficiency in infancy.