Oral Examination Procedure

Oral Examination Procedure

• Instruct the patient to open their mouth for examination
• Check if dentures or orthodontics fit properly
• Remove any dentures for a comprehensive examination
• Use a penlight to illuminate the mouth for better visibility
• Employ a tongue depressor to move the tongue, allowing visualization of the gums
• Examine the mucosa for color, condition, and any lesions
• Look out for redness, swelling, bleeding, retraction from the teeth, or discoloration
• Take note of the gingiva's condition, including bleeding, retraction, or hypertrophy

Normal Findings in the Oral Cavity

• Gum margins should appear well-defined
• Gums should have consistent color with other mucosa and be intact
• There should be no pockets between the gums and teeth
• Absence of swelling and bleeding should be noted
• Color variations consistent with the patient’s ethnic background are acceptable
• Pale red color is typical in light-skinned individuals
• Patchy brown pigmentation can be found in individuals with dark skin

Gingivitis

• Pale or gray gingivae are indicative of chronic gingivitis

Recession of Gums

• Gum recession or inflammatory gum changes may point to gingivitis, periodontal disease, poor dental hygiene, or vitamin deficiencies

Gum Hyperplasia

• Gum hyperplasia can be a side effect of medications, including dilantin or calcium channel blockers

Leukemia

• Inflamed and bleeding gingivae may indicate leukemia

HIV Periodontitis

• Inflamed, bleeding gingivae can be associated with human immunodeficiency virus (HIV)

Abnormal Findings in the Oral Cavity

• Painful, reddened mucosa, often with mildly adherent white patches, may indicate Candida albicans
• Reddened, inflamed oral mucosa, sometimes accompanied by ulcerations, may indicate allergic stomatitis
• Small, painful vesicles with a reddened periphery and a white or pale yellowish base may be aphthous ulcers (believed to be caused by viral infection, stress, or trauma)
• Nodular, macular, or papular lesions may be Kaposi’s sarcoma, which is associated with acquired immunodeficiency syndrome (AIDS)
• Inflammatory changes may be lichen planus--chronic, gray, lacy patches with or without ulceration that can progress to neoplasm
• Reddened mucosal changes may be erythroplakia which can progress to cancer

Leukoplakia

• White, adherent mucosal thickening that may progress to cancer is leukoplakia

Cancer on the Oral Mucosa

• Cancer can be found on the lips, gums, oral mucosa, or other areas of the mouth
• Oral cancer can be associated with tobacco and alcohol use

Fordyce Granules

• Enlarged sebaceous glands appear as white/yellow raised lesions on the buccal mucosa

Assessing Teeth and Jaw Alignment

• Open and close the mouth to assess teeth in terms of occlusion, number, color, and condition
• Count all upper and lower teeth
• Note teeth's discoloration, looseness/missing teeth, caries, malocclusion, or malformation

Normal Teeth Findings

• Most adults have 28 teeth, or 32 with erupted wisdom teeth
• Teeth should be white, not loose, with good occlusion, in good repair, with smooth edges, proper alignment, and no caries

Overbite

• Overbite is an abnormal finding

Underbite

• Underbite is an abnormal finding

Other Abnormal Teeth Findings

• Loose, poorly anchored teeth, malalignment, and dental caries

Tetracycline Staining

• Tetracycline may discolor teeth gray if administered before puberty

Fluorosis

• Mottled enamel is a sign of fluorosis (excessive fluoride)

Hard and Soft Palate Examination

• The patient should tilt their head back, and open the mouth wide
• Shine the light in the patient’s mouth
• Check their hard and soft palates
• Check for shape, color, presence of lesions or malformations

Normal Hard and Soft Palate Findings

• The palate is intact, smooth, and pink
• Bony, mucosa-covered projections on the hard palate (torus palatinus) or the floor of the mouth (torus mandible) are normal variations

Torus Palatinus

• Torus palatinus is an abnormal finding

Torus Mandible

• Torus mandible is an abnormal finding

Perforation

• Perforation may be congenital or from trauma or drug use

Cocaine Use

• Cocaine use can cause abnormal findings in the mouth

HIV Palatal Candidiasis

• HIV can cause palatal candidiasis

Assessing the Throat

• Patients should tilt their heads back and open mouths wide
• Use the right hand to place a tongue blade on the middle third of the tongue
• Use your left hand to shine light on the back of a patient's throat
• Patients should say "AHHH"
• Observe position, size, color, and general appearance of their tonsils and uvula

Oropharynx

• Inspect the oropharynx for color, lesions, and drainage
• Mucosa should be pink, moist, and intact
• The lymphoid-rich posterior wall may have a slightly irregular surface
• There should be no lesions, erythema, swellings, exudate, or discharge

Abnormal Findings in the Oropharynx

• Yellowish or green streaks on the posterior wall signal postnasal drainage
• Gray membrane/adherent material may indicate diphtheria
• White or pale patches of exudates with erythemic mucosa is infection, either streptococcal or mononucleosis
• Gonorrhea and chlamydia are also associated with exudative pharyngitis
• Erythema is an inflammatory response often associated with infectious pharyngitis, and is common in smokers
• Scattered vesicles/ulcerations can be herpangioma

Herpangioma

• A diagnosis of Herpangioma is an abnormal finding in the Oropharynx

Assessing the Tonsils

• You must assess the tonsils in an oral examination

Normal Tonsils

• Normal tonsils are located posterior to the arches on the sides of the throat
• Note their color, size, and exudate if there is any
• Normal tonsils should be symmetrical, pink, and have clean crypts
• Crypts may have a normal variation of tonsillar pearls, or scant amounts of white cellular debris

Abnormal Tonsils

• Bulges adjacent to the tonsillar pillars indicate potential peritonsillar abscess
• Reddened, hypertrophic tonsils with or without exudates may be acute infections, or tonsillitis
• Other indicators are Lymphoid cobblestoning and Enlarged tonsils with exudates

Tonsilitis

• Tonsilitis is an abnormal finding in the tonsils

Inspecting Salivary Glands

• Stensen's duct inspects the inner aspect of the cheek (buccal mucosa) by the second upper molar
• Patients should lift their tongue when Wharton's duct is being inspected
• The floor of the mouth needs to be inspected

Normal Salivary Glands

• Stensen’s duct should be be intact at the buccal mucosa near the level of the second molars
• Wharton’s Ducts should be visible on either side of the frenulum
• Both ducts should have a moist, pink mucosa with an absence of lesions, swelling, or nodules

Examining the Uvula

• Examining the Uvula is required during an oral examination

Normal Examination of the Uvula

• When a patient says AHHH, the soft palate and the uvula should rise symmetrically, indicating cranial nerves IX and X are intact (glossopharyngeal and vagus)
• A normal Uvula is in the midline, pink, moist, and without lesions
• A gag reflex is expected, but it can be congenitally absent