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250
6.3 Examination ofSpecic Sites
inOral Cavity Proper
Sites of Oral Cavity Examination (Fig.6.2)
6.3.1 Cheek andOral Mucosa
(Labial andCheek/Buccal
Mucosa) (Fig.6.2)
Clinical Anatomy
Cheek and cheek mucosa—The cheeks
are a musculo-membranous structure and
are limited superiorly and inferiorly by the
upper and lower gingival buccal sulcus
(vestibules), anteriorly by the labial commissure and posteriorly by the retromolar
trigone and the intermaxillary commissure.
Lip and labial mucosa—This is the
inner lining of the lips or lining of the
eshy folds surrounding the mouth. It is
comprised of the epithelium, basement
membrane, lamina propria mucosae and
lamina muscularis mucosa. This is the
upper and lower labial mucosa.
6 History andExamination ofLip andOral Cavity
How to Examine
Lip and labial mucosa—It is examined
using direct vision by averting the tissues
over the ngers or thumbs followed by bidigital palpation of the tissues of the lips.
The upper and lower labial mucosa are
inspected for swelling, discolouration,
growth, etc.
Cheek and buccal mucosa—It is
inspected by retracting the cheek laterally
with a tongue depressor. The cheek is palpated by the thumb and index or middle
nger.
1. Inspection
(a) Cheek and buccal mucosa—The buccal
mucosa is inspected using direct and indirect vision. Be sure to pull the tissues
away from the retromolar area and stretch
the mucosa away from the upper and
lower mucogingival junctions.
Fig. 6.2 Showing the
sites of the oral cavity
proper
Lip
Teeth
Hard palate
Soft palate
Retromolar
trigone
Tongue
(front two-thirds)
Gingiva (gum)
Uvula
Tonsil
Buccal mucosa
(lip and cheek
lining)
Floor of mouth
6.3 Examination ofSpecic Sites inOral Cavity Proper
251
• Mucosa of cheek—Normal tissues of
the buccal mucosa appear moist and
pink/dark pink. They are soft and pliable on palpation with no discernible
indurations. The dry mucosa is found
in xerostomia, post-radiation and dry
mouth syndrome.
• Discolouration of oral mucosa—The
cheek mucosa is normally pink in
colour, but its colour can be changed.
– White—Leukoplakia oral
candidiasis
– Blue—Haemangioma
– Redish—Erythroplakia
– Black—Melanoplakia
• Parotid duct (Stensen’s duct)—It is an opening against the second upper molar tooth and
should be identied with or without the presence of a parotid papillae (Fig.6.3).
• Swelling/growth
– Type/consistency of swelling—The swell-
ing can be cystic, rm or solid.
Leukoplakia—It is presented with white or greyish
discolouration of the oral cavity mucosa. It is usually
caused by gutkha and tobacco chewing (Fig.6.13c).
The leukoplakia has been classied into homogenous,
non-homogenous and proliferative verrucous.
Erythroplakia—It is a pre-cancerous lesion of the
oral mucosa, usually irregular in outline, although well
dened, and has a bright red velvety surface. It can
also be presented as a red lesion along with white
leukoplakia on oral mucosa (Fig.6.13b).
Melaoplakia—It is the deposition of melanin pigment
in oral cavity mucosa, presented as blackish
discolouration of oral cavity mucosa.
Cystic swelling Solid Firm
Retention cyst,
haemangioma
Fibroma, SCC,
stone in Stensen’s
duct
Buccal
lymph
node
• Growth (Fig.6.15a–c)
(b) Lip and labial mucosa
General appearance
• Normal—Normal lip mucosa tissues are a
homogenous deep pink colour which
changes gradually to a deep red colour
with more prominent vascularity near the
muco-labial vestibule. The tissues should
be moist and have uniform consistency
and thickness when palpated.
• Abnormal
– Abrasions, lacerations—Traumatic
injuries
– Dry, cracked lips
– Angular cheilitis—Human herpes
virus, candida albicans
– Aphthous ulcers
– Neoplastic changes
Fig. 6.3 Shows gingivobuccal mucosa and opening of
parotid duct (blue arrow)
2. Palpation
(a) Cheek and buccal mucosa—The bi-
digital palpation of cheek mucosa is done
with the index nger and thumb. The
cheek should be palpated for tenderness,
consistency, induration and stone.
• Consistency
– Fibrous—OSMF
– Soft—Cyst, haemangioma
– Hard—Fibroma, stone, carcinoma
252
6 History andExamination ofLip andOral Cavity
• Tenderness
– Traumatic injuries—Thermal burns,
cheek bites, ulcers, traumatic
bromas
– Leukoplakia associated with spit
tobacco
– Neoplastic changes—Erythroplakia,
speckled leukoplakia and pigmented
lesions
– Systemic disease—Oral lichen pla-
nus, pemphigus vulgaris, pemphigoid, lupus, lipomas, aphthous
(b) Lip and labial mucosa
Crohn’s disease, as well as allergyrelated tissue responses
• Tenderness—It is due to furunculosis
and buccal lymphadenitis.
• Swelling—If present, it should be palpated for consistency, tenderness,
mobility, etc.
• Bi-digital palpation—The lip is held
between the thumb and nger and is
palpated for swelling, tenderness and
consistency.
ulcers, erythema multiforme and
Ulcerative/endophytic Proliferative/exophytic Ulceroproliferative
SCC, aphthous ulcer Papilloma, SCC, verrucous CA, papilloma, pyogenic granuloma SCC
6.3.2 Examination ofTeeth, Gum,
Gingivolabial
andGingivobuccal Sulcus
Clinical Anatomy
Gingiva—The gingiva, also known as the
gums, is the pink-coloured keratinized
mucosa that surrounds and protects the
teeth.
Teeth—Teeth make up 20% of the total
surface area of the oral cavity. There are
two types of dentitions that develop in
humans: primary and permanent. Teeth are
classied as maxillary and mandibular, as
incisor, canine, premolar and molar, as
upper and lower.
Lower gingivolabial sulcus
(Fig.6.4a)—It is located between the lower
gum and labial (lip) mucosa.
Upper gingivolabial sulcus
(Fig.6.4b)—It is located at the junction of
the upper gum with the upper labial (lip)
mucosa.
How to Examine
The upper lip is retracted superiorly to
examine the upper gingivolabial sulcus; the
lower lip is retracted to examine the lower
gingivolabial sulcus. The cheek is retracted
laterally with a tongue depressor to examine the lower and upper gingivobuccal sulcus. The gum and teeth are palpated with a
tongue depressor for tenderness.
1. Inspection
(a) Status of teeth—Teeth are inspected for
plaque calculus, loose teeth, missing teeth
and pus discharge with direct inspection
or mirror examination.
(b) Status of gum—The attached gingiva of
the maxillary and mandibular arches is
visually examined using both direct and
indirect vision. The tissues should appear
pale pink and homogenous in colour and
texture. The tissue should feel rm to
touch and tightly attached to the bone.
The most common atypical nding in the
area of the attached gingiva is exostoses.
6.3 Examination ofSpecic Sites inOral Cavity Proper
253
Fig. 6.4 (a, b) Shows
clinical examination of
lower and upper
gingivolabial mucosa
and sulcus
a
• Swelling—Cystic or solid—Gingival
bromatosis, vitamin C deciency,
epulis, tumour, orofacial
granulomatosis
• Gingival hyperplasia, gingival overgrowth, gum enlargement or hypertrophic gingivitis—This is due to calcium
channel blockers, immunosuppressants and systemic causes (HIV, diabetes, anaemia, vitamin deciency).
• Growth—Growth should be inspected
for size, site, type and extension.
Growth may be caused by broma,
pyogenic granuloma, mandibular torus
or oral carcinoma.
• Ulcer—Ulcer may be caused by
trauma, burn abrasion, vitamin deciency, gingivitis and harsh tooth
brushing.
• Bleeding—Trauma, gingivitis, harsh
brushing
• Swelling—Retention cyst, epulis ssuratum or denture irritation hyperplasia
• Pus discharging—Dental abscess,
infected dentigerous cyst
• Mucosal lesion—Lichen planus, pemphigus vulgaris, leukoplakia
(c) Upper and lower gingivobuccal sulcus
• Swelling—The swelling can be either
cystic (abscess, cystic lesion) or solid
(broma, osteoma).
• Growth—The size, site and type of
growth should be noted.
• Ulcer—As described above.
(d) Upper and lower gingivolabial sulcus
• Swelling—The swelling can be either
cystic (mucocele, abscess) or solid
(broma, osteoma).
b
• Growth—The size, site and type of
growth should be noted.
• Ulcer—As described above.
2. Palpation
(a) Teeth
• Teeth are palpated with a tongue
depressor for tenderness and abnormal
movement.
(b) Gum
• Tenderness—Gingivitis, hyperplasia
of gum
• Bleed on touch—Gingivitis, growth
(c) Upper gingivolabial and gingivobuccal
sulcus
• Palpated for tenderness, swelling and
irregularity and conrm the inspection
ndings.
(d) Upper gingivolabial and gingivobuccal
sulcus
• Palpated for tenderness, swelling and
irregularity and conrmed inspection
ndings.
6.3.3 Examination oftheMandible
andLower Alveolus
Clinical Anatomy
Mandible—The mandible has symphysis,
body, angle, ramus, coronoid, condylar
process and alveolar process. It forms the
temporomandibular joint with the temporal
bone. The alveolar process contains teeth,
known as mandibular/lower teeth.
254
How to Examine
Ask the patient to open their mouth, move
the mandible side by side, palpate the lower
border, inspect and palpate the teeth and
palpate the TM joint just anterior to the
external auditory canal in the resting stage
while the patient opens their mouth.
1. Inspection—The body of the mandible is to
be examined using direct and indirect vision
followed by digital palpation of the entire
structure. The tissues of the oor of the mouth
should be stretched away from the inferior
border of the mandible with a mouth mirror.
Normal tissues will be a homogenous coral
pink and have a rm consistency with no visible or palpable lesions.
(a) Mandible
• Lower border of mandible—The lower
border of the mandible is inspected for
swelling, sinus/stula, step ladder
deformity and deformity.
• Occlusal deformity—This is a common sign of a fractured mandible and
other orthognathic deformities.
• Lower gingiva lingual sulcus—
Swelling, laceration, bleeding,
ecchymosis.
• Pre-auricular area for swelling, ecchymosis, swelling.
(b) Lower alveolus
• Flabby ridge—Replacement of bone
by brous tissue
• Teeth—Loose, missing, carries,
broken
• Swelling—Cystic or solid
• Growth—Size, site, type
• Ulcer—Type, size, appearance
• Broken teeth—This is a sign of fractured teeth and fractured mandible.
• Missing teeth—These are signs of
extraction of a tooth, carcinoma, fractured mandible.
6 History andExamination ofLip andOral Cavity
• Step ladder deformity—This is a sign
of fracture.
2. Palpation—Digitally palpate the body of the
mandible along the lingual and facial surfaces. The ramus is to be palpated both orally
and externally.
(a) Mandible
• Step ladder deformity—Run the pulp
of ngers along the lower border of the
mandible, outer surface occlusal line,
to look for any step ladder deformity.
• Tenderness—Tenderness is to be
checked along the lower border, TM
joint area and fracture site.
• Crepitation—This is present at the
fracture site.
• Abnormal movement—The suspected
fracture segments are to be held with
both hands and checked for any abnormal movement.
• Loss of sensation over chin—Fine
touch and coarse touch to be checked
on skin over chin.
(b) Lower Alveolus
• Tenderness—Gingivitis, fracture
• Bleeding on touch
– Traumatic lesions—Ulcers,
abrasions
– Infections—Pericoronitis
– Neoplastic growths.
– Leukoplakia associated with spit
tobacco
– Mandibular tori and exostosis
6.3.4 Examination ofHard Palate
The hard palate and maxillary tuberosity areas
are examined using both direct and indirect
vision and illumination. Following the visual
examination, the clinician should digitally palpate the entire area using rm, non-sliding pressure against the bone.
6.3 Examination ofSpecic Sites inOral Cavity Proper
Clinical Anatomy
The hard palate is a thin horizontal bony
plate made up of two bones of the facial
skeleton, located in the roof of the mouth.
It extends from the upper alveolus to the
soft palate posteriorly. The bones are the
palatine process of the maxilla and the horizontal plate of the palatine bone.
How to Examine
Ask the patient to open the mouth, and the
palate is inspected under direct light. How
to palpate the palate—The clinician should
digitally palpate the entire area using rm,
non-sliding pressure against the bone. The
palate is rm to palpation towards the anterior and lateral to the midline while more
compressible towards the posterior and
medial to the apices of the teeth.
1. Inspection
(a) The general appearance of hard palate—
A healthy palate is whitish in colour, with
a rm texture and irregular transverse
rugae. The tissue over the hard palate is a
homogenous pale pink in colour. The normal structures of the hard palate should
be identied. A few anatomical structures
are as follows:
• Incisive papilla—It is a protuberance
of soft tissue lingual to the maxillary
central incisors which covers the inci-
255
sive foramen and normally appears
redder than the surrounding tissues.
• Raphe—It is a slightly elevated line
extending from the incisive papilla to
the soft palate.
• Rugae—It is corrugated ridges radiating laterally from the raphe.
• Vault—Observe the dimensions
(height and width) of the vault.
• Maxillary tuberosity—This is the
area distal to the last molars that
should be homogenous and pink.
(b) Types of lesions (Table6.31)
(c) Shape of the hard palate
• Dome shaped—Adenoid, Crouzon
syndrome, Down syndrome, Apert
syndrome, Treacher Collins syndrome,
Marfan syndrome.
• Normal shape—It is slightly rounded
and usually smooth.
(d) Position of palate
• Normal—It is slightly rounded
• Abnormal
– High arched—Adenoid hypertro-
phy, Crouzon syndrome, Down
syndrome, Apert syndrome,
Ehlers-Danlos syndrome, Treacher
Collins syndrome, Marfan syn-
drome, allergic rhinitis.
(e) Deformities—The deformities of the pal-
ate may be congenital or acquired—cleft
palate, bid uvula.
(f) Swelling over palate—Size and site to be
noted.
(g) Growth on palate—The size, site, and
type of growth should be noted.
Table 6.31 Showing the D/D of lesions over the hard palate
Type of lesion Denition Differential diagnosis
Pigmented macule Melanoma, pencil lead
Thermal burn Usually present over anterior palate Trauma
Whitening and ssuring Gingiva and inammation of minor
salivary gland
Finger-like projection Under poorly tting denture Papillary hyperplasia
Abrasion and laceration Anterior palate Traumatic injury (eating or factitial
Torus Painless lump over palate Torus palatinus
Nicotine stomatitis
injury)
256
6 History andExamination ofLip andOral Cavity
(h) Ulcer on palate—The site, size, appear-
ance and number of ulcers to be noted.
(i) Denture stomatitis
• Type 1—Localized simple inammation or pinpoint hyperaemia caused by
trauma.
• Type 2—More diffuse erythema
involving a part or the entire denture
covered area.
• Type 3—Granular type involves the
central part of the hard palate and alveolar ridge.
2. Palpation of the hard palate—The palate is
rm on palpation towards the anterior and lateral to midline but compressible towards the
posterior and medial to the apices of teeth.
The examiner rst wears gloves on the right
hand and uses his/her index nger for palpation of the hard palate.
(a) Findings of palpation
• Swelling—The swelling can be cystic,
rm or sloid in consistency (Tables
6.32 and 6.33).
6.3.5 Soft Palate andUvula
Clinical Anatomy
The soft palate consists of muscle bres
and connective tissue covered by a mucus
membrane consisting of a stratied squamous epithelium with secretory salivary
glands. Unlike the hard palate, the soft palate is very exible and does not contain any
bony structures. It is located posterior to
the hard palate and forms the posterior part
of the roof of the oral cavity.
How to Examine
For inspection of the soft palate, the patient
is asked to open their mouth and say aa to
assess the mobility.
Differential Diagnosis of Cystic Lesions of the
Oral Cavity
Table 6.32 Shows differential diagnosis of swelling of the palate in adults
Cystic swelling Firm Solid swelling
Median palatine cyst, dental abscess,
developmental cyst, incisive canal
cyst, epidermoid cyst,
haemangioma, lymphangioma,
globulomaxillary cyst, palatal
abscess
Table 6.33 Shows D/D of swelling of the palate in children
Cystic swelling Firm Solid swelling
Palatal abscess, apical abscess,
nasopalatine cyst, mucocele of hard
palate
Papilloma, lymphoma Neurolemmoma, neurobroma,
rhabdomyoma, osteoma,
pleomorphic adenoma, SCC,
rhabdosarcoma, BCC, adenoid
cystic carcinoma, mucoepidermoid
carcinoma
Palatal exostosis, leiomyomatous
hamartoma,
Squamous papilloma
Torus Palatinus
6.3 Examination ofSpecic Sites inOral Cavity Proper
257
1. Inspection—The soft palate and uvula are
inspected on various parameters.
(a) Movement of soft palate and uvula
• Abnormal (lateralized)—U/L paralysis
of the soft palate—Idiopathic, neurological (pharyngeal branch of the
vagus nerve) post-adenoidectomy,
neuromuscular (GB syndrome), infection (diphtheria, poliomyelitis, cranial
vessel pathology, ICA aneurysm, postangiogram) viral infection (measles,
Hepatitis A)
• Normal (centralized)—The uvula
moves upward and remains in the
midline.
• No movement—B/l paralysis of soft
palate—Stroke, traumatic brain injury,
cerebral palsy, neuromuscular
disorder
• Reduced—Fibrosis (OSMF)
(b) Swelling
• Site
– Uvula—Angioedema (Quincke’s
oedema), urticaria, anaphylaxis
– Soft palate—Trauma
• Consistency
– Cystic—Haematoma, oedema,
oedema of uvula
– Solid—Tumour
– Firm—Minor salivary gland
tumour, myoepithelioma
• Colour of swelling
– Blue—Haemangioma
– Pink—Myoepithelioma
(c) Growth—If growth presents its size, site,
and type should be noted.
(d) Ulcer—If present, its size, appearance
and numbers are to be noted.
(e) Movement of uvula—The normal move-
ment of the soft palate is a symmetrical
elevation on saying AA.The movement
may be normal, reduced or absent. In case
of absent movement on one side, there
will be an asymmetrical elevation of the
palate on saying AA.
(f) Position of uvula—Bulging of the soft
palate or pushed antero-inferiorly (JNA).
2. Palpation
(a) Tenderness over palate or over mass/
swelling
(b) Consistency of swelling
• Cystic—Haematoma, oedema, oedema
of uvula
• Solid—Tumour
• Firm—Minor salivary gland tumour,
myoepithelium
6.3.6 Examination oftheFloor
oftheMouth
andGingivolingual Sulcus
Clinical Anatomy
The oor of the mouth is a horseshoeshaped area under the tongue, between the
sides of the lower jawbone (the mandible).
The normal anatomy of the area should be
identied including: the sublingual caruncle, sublingual fold and lingual frenum.
Sublingual caruncle—It is a small round
projection at the base of the lingual frenum
which houses Wharton’s duct from the submandibular salivary gland.
Sublingual fold—These are two oblique
elevations found radiating laterally away
from the lingual frenum on either side of
the caruncle with a house of duct from the
sublingual salivary gland.
Lingual frenum—The muscle attachment from the ventral surface of the tongue
to the oor.
How to Examine
The patient should be asked to raise the
tongue making direct visual examination of
the tissues toward the midline of the oor
of the mouth possible. The oor of the
mouth is examined using direct and indirect vision followed by bimanual palpation
of the entire area.
258
6 History andExamination ofLip andOral Cavity
1. Inspection
(a) Floor of mouth
• General appearance—The tissues
should appear moist and very vascular
• Tongue tie—It is a condition in which
an unusually short, thick or tight band
of tissue (lingual frenulum) tethers the
bottom of the tongue’s tip to the oor
of the mouth.
– Type I (anterior): The frenulum is
thin and elastic and anchors the tip
of the tongue to the ridge behind
the lower teeth.
– Type II (posterior): The frenulum is
ne and elastic, and the tongue is
anchored 2–4 mm from the tip to
the oor of the mouth close to the
ridge behind the lower teeth.
• Tongue mobility
– Normal—Tongue can be moved in
all directions and twist on itself.
– Restricted or xed—This is the
sign of intrinsic muscle involvement by carcinoma, OSMF.
• Swelling over the oor of the mouth
– Site
– Anterior—Ranula, plunging ran-
ula, sublingual gland, stone in the
submandibular duct, dermoid cyst,
sublingual choristomas
– Posterior—Sialoadenitis, sialolithi-
asis, salivary gland tumour,
Ludwig’s angina, submandibular
space infection.
– Type
– Solid—Solitary brous tumour
– Cystic—Ranula, plunging ranula
– Firm—Sialolithiasis, brous
histiocytoma
• Growth
– Proliferative/exophytic—SCC
– Ulcerative—SCC
• Ulcer—Described above.
(b) Gingivolingual sulcus—This sulcus
should be inspected for Ulcer, growth,
swelling, growth and pus discharging.
2. Palpation—Bimanual intraoral palpation
with the index nger of the nondominant hand
supported extraorally by the ngers of the
dominant hand will allow the clinician to feel
the structures of the area between the ngers
as they are compressed together gently. A submandibular gland is palpable while a submandibular lymph node is not. The tissue will be
soft on palpation with rmer areas noted in
the area of the suprahyoid muscles (digastric,
geniohyoid, mylohyoid). The sublingual folds
will feel ridge-like and mobile.
(a) Differential diagnosis of a tumour of the
oor of the mouth (Table6.34).
Table 6.34 Shows differential diagnosis of lesions of the oor of the mouth
Tumour Benign tumour Slow growing, smooth surface,
displaces the adjacent structure
Malignant tumour Ulcerative surface, invasion of
adjacent structure, metastatic lymph
node
Mucous extravasation phenomenon Ranula Bluish translucent colour
Metastatic lymph node
Embryonic abnormalities Dermoid cyst Swelling midline oor of the mouth,
slow growing and painless
Others Lipoma
Traumatic injuries Ulcers, mucoceles Self-inicted trauma
Salivary gland pathology Sialolithiasis, secondary node Tender swelling, bimanually
palpable
6.3 Examination ofSpecic Sites inOral Cavity Proper
6.3.7 Examination ofRetromolar
Trigone
Clinical Anatomy of Retromolar Trigone, Retromolar Fossa, Retromolar Space or Retromolar Gap
It is a hidden area of the oral cavity that lies between the last molars, the pterygo mandibular
raphe and the ascending ramus of the mandible. The mucosa of the retromolar trigone covers
the anterior border of the ascending ramus of the mandible. Its base lies posterior to the last
molar and its apex anterior to the tuberosity of the maxilla.
259
How to Examine
The mouth should be wide open, the cheek
should be retracted with one tongue depressor and the tongue should be retracted with
another tongue.
1. Inspection—This is the hidden area to be
examined carefully for any growth, ulcer or
swelling.
2. Palpation—The index nger is to be used for
palpation purposes. The palpation is done to
elicit tenderness, which is the sign of fracture,
of the ascending ramus of the mandible and
infection of the last molar tooth.
6.3.8 Examination ofTongue
Clinical Anatomy
The normal tongue should appear moist
and pink in colour with a rough surface texture on the dorsal surface and a smoother
surface texture on the ventral surface. The
tongue should be symmetrical in shape and
in function. There is normally a very thin
‘coat’, but liform, fungiform and circumvallate papillae are visible.
Fungiform papillae—They are located
in the anterior two-thirds of the tongue.
People have an average of 33 fungiform
papillae with approximately 114 buds per
papilla. Innervation is through cranial
nerve (CN) VII via the chorda tympani.
Circumvallate papillae—They are
located in the posterior two-thirds of the
tongue, consisting of 8–12 papillae,
(continued)