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Examination of Oral Cavity
https://t.me/med1917
Fig. 10.12: Gingivitis with pigmentation and ulcer.
everted properly to inspect the gums. Proper light is
needed. Gums recede as age advances (Fig. 10.12).
Vincent’s gingivitis/stomatitis (Trench mouth) is an
inflammatory condition with ulcer and pseudomem-
brane in the gums and adjoining mucous membrane.
It is due to Borrelia vincentii and fusiformis fusiformis
bacteria. Purple red lesion may be evident in gums
in cancrum oris. It is commonly observed in molar
or premolar region. Condition has got foul smell.
Cancrum oris (Noma) is an infective gangrene, rapidly
progressing into the bone and soft tissues in cheek
with destruction (Phagaedena). It is common in
children after measles, gastroenteritis, typhoid, and
bronchopneumonia.
Swollen gum is seen in dental abscess. Swelling
in the gums which is localised is called as epulis. Blue
line in gums is observed in those who work in lead
industries. They are better observed using magnifying
lens. Similar bismuth or mercury lines are also seen.
Swollen, livid, spongy, tender bleeding gums with
loose teeth are seen in scurvy. Generalised hyperplastic
progressive gingivitis is seen in children often after
antiepileptic drugs. Hyperplastic gums are also seen
in children with acute leukaemia due to immature
granulocytes and secondary infection. Gums bleed on
touch and there is fever.
Inspection of the Tongue
Tongue is a muscular, glandular, vascular flat organ.
Anterior 2/3rd is termed as body; posterior 1/3rd is
231
base/root. Superior surface is dorsum of the tongue.
It is an essential organ of taste. Tongue is important
in speech, mastication and swallowing. Filiform
papillae are located in anterior 2/3rd of the dorsum
of tongue and are numerous, fine, hair like. Fungiform
papillae are mushroom shaped, deep red, larger,
sparsely located near the tip of the tongue. Large, red,
leaf like foliate papillae are located in posterior third
of tongue on lateral aspect which contains taste buds.
Circumvallate papillae are 8-12 in number mushroom
shaped, arranged in large V shaped row near posterior
third of the dorsum tongue and contains plenty of taste
buds. Small circular opening just posterior to this V
row in the midline is called as foramen caecum which
is the remnant of thyroglossal duct. Shallow groove
just behind the circumvallate papilla on either sides
of the foramen caecum is called as terminal sulcus.
Numerous mucin glands and lymph follicles in the
posterior third of the dorsum of tongue is called as
lingual tonsil. Posterior third of the tongue is difficult
to inspect; it needs headlight, and spatula. It is better
felt than seen. V entral surface is smooth, has a median
fold, frenulum linguae and deep lingual veins on either
side. Lingual frenulum is attached about 10-15 mm
below the mandibular central incisor tooth. In tongue
tie it is only 3-4 mm below the central incisor. It is
congenital short frenulum; which is better seen when
tip of the tongue is rolled upwards. Child may not
protrude the tongue and there may be speech
difficulties. Tongue is examined properly often by
wrapping it with a damp gauze and pulling it out. Its
anterior surface, dorsum, ventral surface, margins
should be inspected (Figs 10.13 and 10.55).
Macroglossia (Megaloglossia/pachyglossia) is a
disorder in which the tongue is larger than normal.
Macroglossia is usually caused by an increase in the
amount (volume) of tissue on the tongue, rather than
by a growth, such as a tumour. It is often seen in haemangioma, lymphangioma, muscular macroglossia (in
cretins), acromegaly , Beckwith-Wiedemann syndrome
(hypoglycaemia, abdominal wall defects, Wilm’s
tumour, macroglossia, adrenal tumour), Down’ s syndrome, mucopolysaccharidoses, primary amyloidosis,
occasionally plexiform neurofibromatosis. Often it
causes functional and cosmetic problems (Fig. 10.14).
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SRB’s Clinical Surgery
carcinoma. Glossitis migrans/geographical tongue
can be idiopathic in children or secondary to major
surgery or peritonitis causing bright red colour with
yellowish white margin. Its location and pattern
changes within 2 days. If it is of idiopathic origin it
subsides in 7 days; but in secondary type it subsides
only once patient recovers from main disease (Figs
10.15 and 10.16).
Fig. 10.13: Anatomy of tongue.
Fig. 10.14: Macroglossia in a Down’s syndrome
patient.
Chronic superficial glossitis, leukoplakic patches,
mucous membrane hyperkeratosis causing black hairy
tongue (filiform papillary hypertrophy), discoloured
tongue in Asper gillus fungus infection, fissure, ulcers,
swellings, etc. should be inspected. Congenital fissure
is transverse. It appears at the age of 3 years and persists
later for life. Syphilitic fissure is longitudinal with
denuded intervening epithelium. Carcinoma can
present as a fissure. Median rhomboid glossitis is a
rhomboid mass in the midline posteriorly in front of
the foramen caecum of tongue; probably due to
persistent tuberculum impar; extends deep into the
tongue muscles; with well defined margin; without
any papillae; with slight induration on it mimicking
Fig. 10.15: Severe glossitis.
Ulcer in tongue when present, its size, location,
margin, edge, extension and surrounding area should
be inspected. Inability to protrude the tongue is called
as ankyloglossia. It is seen in carcinoma tongue
infiltrating the floor of the mouth. T ongue may deviate
towards same side (with wasting tongue muscle on
the same side) if there is hypoglossal nerve palsy due
to nodal infiltration or carcinoma tongue infiltrating
the nerve (Figs 10.17 to 10.19).
Leukoplakia (Greek-white plate) in tongue is typical
lesion . Early lesion is thin, crinkled and pearly.
Late lesions are large, creamy white, thick often
desquamated with beefy red colour. Sir Henry Butlin
said, ‘tongue looks as though it had been covered with
white paint that had hardened, dried and cracked’.
Early cases are better inspected by pressing a glass
slide on the surface.
Papilloma, neurofibroma can occur in the tongue.
Size, shape, surface, margin should be mentioned.
Aphthous/dental ulcers are common on the lateral
margin. Tuberculous ulcer is common in tip of the
Examination of Oral Cavity
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233
Fig. 10.16: Congenital fissures of tongue are transverse; syphilitic fissures are longitudinal.
Median rhomboid glossitis is persistent tuberculum impar.
Fig. 10.17: Tongue fissure. It could be a
presentation of carcinoma.
tongue. Syphilitic gummatous ulcer is common on
dorsum of tongue. Carcinoma is common in margin.
Lingual thyroid may be the only thyroid existing in
the region of foramen caecum as a smooth swelling.
T ongue tr emor is checked with tongue inside the oral
cavity (in protruded tongue fasciculation may mimic
the tremor).
Lichen planus in tongue are delicate bluish white
silver nitrate coloured lesion; often difficult to
differentiate from carcinoma; but there are also lesions
over the front of wrists and shin.
Inspection of the Floor of the Mouth
It is U shaped area bounded by lower gum and oral
tongue. It ends posteriorly at the insertion of anterior
tonsillar pillar into the tongue. Sublingual papilla is
present on each side of the frenulum; on summit of
which is the opening of the duct (Wharton’s) of
submandibular salivary gland. Laterally and behind
this papilla, sublingual fold is present which overlies
the sublingual gland. Genioglossus and geniohyoid
muscles are deeper to it. On either side mylohyoid
muscles forms the muscular part of the floor of the
mouth. It arises from mylohyoid ridge of the mandible
extending upto the 3rd molar tooth. Submandibular
salivary gland rests on the external surface of
mylohyoid muscle; only small deeper part extends into
the internal surface. Submandibular salivary duct runs
about 5 cm between sublingual gland and genioglossus
to end in papilla. Lingual and hypoglossal nerves are
closely related to gland and duct. Alveolingual sulcus
is valley shaped space between tongue and mandibular
alveolar bone. Tip of the tongue should be kept upwards
to touch the palate to inspect the floor of the mouth
(Fig. 10.20).
Swelling or ulcer in floor of the mouth should be
inspected for its extent, size, shape, margin, edge.
Extent from the gum margin, whether crossing midline
or not are important especially in carcinomatous ulcer.
Unilateral bluish localised swelling may be ranula.
Ranula extending into the submandibular region across
mylohyoid is called as plunging ranula. Sublingual
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Figs 10.18A to D: Carcinoma tongue in different patients. Proper inspection and
palpation is essential. Lateral margin is the commonest site – 47%.
Fig. 10.19: Hypoglossal nerve palsy. There is wasting of
tongue muscle on same side with tongue deviating towards
same side.
Fig. 10.20: Inspection of the floor of the mouth. Tip of the
tongue should be kept upwards to touch the palate to inspect
the floor of the mouth.
Examination of Oral Cavity
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dermoid is in the floor of the mouth midline often
extends into submental region externally.
Inspection of the Palate
Roof of the mouth is formed by hard palate and soft
palate. Hard palate is firm anterior part of the roof
of the mouth ending opposite 3rd molars anterior to
fovea palatine. Soft palate is mobile posterior part
of the roof of the mouth. Junction between hard and
soft palate is called as vibrating line. Small rounded
elevation of tissue on the midline behind the central
incisors is called as nasopalatine papilla which is over
incisive foramen through which nasopalatine nerve
traverses to supply anterior hard palate. Slightly
elevated central line is called as palatine raphe. Here
mucosa is firmly adherent to underneath periosteum
without any fat and so it is harder area of hard palate.
Sides of hard palate contain fat and minor salivary
glands (there are around 350 minor salivary glands
in posterior hard palate). Series of elevations in hard
palate are called as palatine rugae useful for food
positioning and aiding tongue to produce specific
sounds. Hard palate is partition between nasal and
oral cavity. Anterior 2/3rd is formed by palatine process
of maxillae; posterior 1/3rd is by horizontal plates
of palatine bones. Anterolateral mar gins continue with
alveolar arches and gums. Posterior margin attaches
to soft palate.
Soft palate is redder than hard palate due to its
vascularity. There is no bone in soft palate behind
vibrating line. Soft palate vibrates or moves. It is mobile
muscular fold. It has got anterior and posterior surfaces,
superior and inferior margins. Uvula is small fleshy
part projecting from centre of the posterior margin
of the soft palate. Pair of pits on either side of the
centre of the soft palate just behind the vibrating line
is called as fovea palatini to which palatine mucus
glands opens. Side of the uvula has got anterior and
posterior folds. Anterior palatoglossal arch conains
palatoglossus muscle ends as anterior pillar of fauces
(in front of tonsils). Posterior palatopharyngeal arch
contains palatopharyngeus muscle ends as posterior
pillar of fauces (behind tonsils). Soft palate contains
mucus glands and taste buds. Soft palate contains
following muscles – tensor veli palati; levator veli
palati; musculus uvulae; palatoglossus; palatopharyngeus. All muscles except tensor palati are
235
supplied through pharyngeal plexus through cranial
part of accessory nerve; tensor palati is supplied by
the mandibular nerve. General sensory nerves are
derived from middle and posterior palatine nerves
which are branches of maxillary nerve and from
glossopharyngeal nerve. Gustatory special sensations
are carried through lesser palatine nerve → greater
petrosal nerve → geniculate ganglion of facial nerve
→ nucleus of solitary tract. Secretomotor fibres are
derived from superior salivatory nucleus through
greater palatine nerve and lesser palatine nerves.
Paralysis of the soft palate (vagus nerve lesions) causes
nasal regurgitation of liquids, nasal twang in voice,
flattening of palatal arch.
Cleft palate is a congenital defect – of uvula, soft
palate or hard palate with nasal septal defect or with
cleft lip should be looked for carefully. Swelling in
the palate may be minor salivary gland tumour. Detailed
inspection of such swelling should be done. Ulcer
palate could be carcinoma/syphilis/tuberculous.
Gummatous ulcer is painless with punched out edge
and often with perforation. Carcinomatous ulcer is
with everted edge; tuberculous is with undermined.
It is also important to check uvular movements and
sensations (Fig. 10.21).
Fig. 10.21: Cleft lip and palate in an adult.
Inspection of Tonsils and Fauces
Inspection of tonsils and fauces should be done to
look for ulcers/tubercles/growth/leukoplakia, etc. (Fig.
10.22).
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A
Fig. 10.22: Inspection of fauces is done
using tongue depressor.
Palpation
Palpation of Lip
Both upper and lower lips should be examined. Usually
carcinoma lip is nontender initially. Later it becomes
stony hard in consistency. Indurated edge is typical.
Extent of lesion should be assessed carefully; whether
it crosses the midline, whether extends into cheek,
angles of mouth are important in deciding the surgical
intervention (Figs 10.23A to 10.24B). Lesion is held
with fingers of one hand and with other hand lip is
held to check the mobility. Carcinoma is always fixed.
Benign lesions like mucus cyst are mobile. Mucus
cyst will be fluctuant and transilluminant. Hunterian
chancre is rubbery hard in consistency.
Palpation of Cheek
Cheek should be palpated for any ulcer, swelling. Ulcer
due to carcinoma will show induration of edge, base
and surrounding area. Its extent should be checked.
Posterior extent is important. If it extends beyond
retromolar trigone, it means it is advanced. Involvement of soft tissues, mandible, and skin over cheek
B
C
Figs 10.23A to C: Examination of lip – methods.
should be checked. Retromolar trigone is the anterior
surface of the ascending ramus of the mandible. It
is triangular in shape with the base being superior
and apex lying inferiorly behind the third molar tooth.
Examination of Oral Cavity
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A
Fig. 10.25: Bidigital palpation of the mandible for tenderness,
thickening, irregularity and fracture site should be done in
all oral carcinoma – to assess the involvement.
237
swelling or ulcer its size, shape, extent, tenderness,
induration, mobility should be checked.
B
Figs 10.24A and B: Palpation of lips carefully to assess
the extent of involvement is essential in carcinoma lip.
How much gap is present between growth and alveolar
margin should be checked. Other part of the oral cavity
should also be palpated. Mandible is palpated using
two fingers. Index finger of one hand is placed inside
the mouth to feel over the lingual surface of the
mandible. Finger of other hand is placed over outer
surface of the mandible. Fingers are run along the
surface of the mandible to feel tenderness, thickening
or any fracture site (features of mandibular involvement
by carcinoma) – bidigital palpation of the mandible.
Mandible is involved by direct extension or through
subperiosteal lymphatic plexus which are communicating with oral lymphatics (Fig. 10.25).
Palpation of Gums
Bleeding from the gums on palpation is an important
finding. It may be due to growth, leukaemia, uraemia,
scurvy, epulis. When any lesion is present either
Palpation of Tongue
T ongue should be palpated with tongue inside because
due to contraction of the tongue muscles protruded
tongue feels harder mimicking induration. Gummatous
ulcer often may be indurated. Tuberculous ulcer is
not indurated (It is painful, tender, often multiple).
Bleeding on palpation, extent of induration, whether
lesion is crossing the midline, tongue movements, floor
of the mouth in relation to the lesion should be checked.
Entire length of lateral margins should be palpated
carefully. Often cheek is retracted using a spatula to
palpate the tongue. Recess between lateral base of
the tongue and anterior pillar of the fauces is examined
(Fig. 10.26).
Palpation of posterior third of the tongue is often
difficult. Often no growth is visible in this site or only
part of the growth is visible. When hyperactive gag
reflex is present local anaesthetic spray can be used
prior to examination. Patient is asked to open the mouth
widely. All left hand fingers of examiner are kept
straight and stiff and are pressed firmly over the
patient’s cheek so that they intervene between upper
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Fig. 10.26: Tongue should be palpated with tongue laid
within the oral cavity. Otherwise induration is difficult to
assess. Protruded tongue will be firm normally while
palpation.
SRB’s Clinical Surgery
and lower teeth. Palpation is done using examiner’s
right index finger over posterior part of the tongue.
Left hand fingers prevent biting of the right examining
finger by the patient. By reflex patient may bite only
his pushed cheek (Figs 10.27A to C).
Palpation of the Floor of the Mouth
It is palpated by asking the patient to put the tip of
the tongue on the roof of the mouth with head bending
slightly backwards. Ranula is an extravasation cyst
arising from sublingual or mucus glands. It is smooth,
soft, fluctuant and brilliantly transilluminant. When
it extends into submandibular region across posterior
margin of mylohyoid muscle with cross fluctuation
it is called as plunging ranula. Sublingual dermoid
is usually midline swelling in the floor of the mouth
with extension outside into submental region. It is
smooth, soft, fluctuant but not transilluminant.
Carcinoma floor of the mouth is stony hard with
indurated edge and base. Mandibular thickening may
be felt. It is often fixed.
Palpation of palate: Alveolar abscess is felt as tender
fluctuant swelling near alveolar margin. Gumma may
present as soft swelling in the midline; painless nontender slightly indurated ulcer in the midline (Figs
10.28A and B).
Figs 10.27A to C: Examination of posterior part of the
tongue needs special method (See text).
Palpation of Tonsils and Fauces
It should be done in posterior growths of cheek and
tongue and in tuberculosis. Surface ulcerations,
induration should be looked for. Peritonsillar abscess,
carcinoma tonsil, carcinolymphoma of tonsil should
be kept in mind (Fig. 10.29).
Examination of Oral Cavity
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A
A
Figs 10.28A and B: Palpation of the floor of the
mouth.
239
Examination of Cervical Lymph Nodes
Cervical lymph nodes should be examined. Submental,
submandibular, upper , middle and lower deep cervical
and posterior triangle nodes should be examined. Size,
shape, mobility, fixity , number should be checked. Both
sides should be examined for cervical nodes as
lymphatics cross communicate especially in carcinoma
tongue and floor of the mouth. All levels should be
examined properly (Figs 10.30A to G).
Systemic Examination
Eventhough metastatic (blood spread) disease is rare
in oral carcinomas, respiratory system examination
is important as aspiration pneumonia is common in
oral carcinoma especially in carcinoma tongue.
Melanoma, lymphoma, rarely aggressive carcinoma
can spread to bone, liver through blood. Abdominal
and musculoskeletal system examination should be
completed (Fig. 10.31) .
Investigations
Biopsy of ulcer: Edge biopsy is done. Usually two
biopsies are taken. If it is on the anterior aspect it
can be done under local anaesthesia. Posterior lesions
are biopsied under general anaesthesia. Suction
apparatus should be used during biopsy. Biopsy area
may be apposed using catgut sutures to prevent
Fig. 10.29: Examination of oral cavity should be methodical – lips; gums; cheeks, tongue; floor of the mouth;
palate; posterior aspect of the oral cavity.
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SRB’s Clinical Surgery
A B
D
Figs 10.30A to G: Examination of different levels of
C
E
G
neck nodes – Level Ia; Ib; II; III; IV; V; VI.
F
bleeding. Malignant squamous cells with epithelial
pearls (Keratin pearls) are the histological features
of carcinoma. Broder‘s histological grading–(1) W ell
differentiated: > 75% epithelial pearls; (2) Moderately
differentiated: 50–75% epithelial pearls; (3) Poorly
differentiated: 25–50% epithelial pearls; (4) Very
poorly differentiated: < 25% epithelial pearls.
Orthopantomogram (OPG): OPG is a must in all
oral carcinomas to see mandibular involvement.
Cortical thinning, and bone destruction are looked for.
It is plain X-ray mandible showing entire mandible
in a single plane. It is a rotational tomogram showing
dentition, inner and outer plates of mandible and joints.
It is done in jaw tumours, osteomyelitis of mandible,
fracture mandible and to see spread from carcinoma
oral cavity (Fig. 10.32).
Chest X-ray to see bronchopneumonia.
FNAC of cervical lymph nodes.
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